Major Depressive Disorder 1. 2. 3. 4. 5. MOOD DISORDERS At least 5 of the following symptoms have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood) - Depressed mood: For children and adolescents, this can also be an irritable mood - Diminished interest or loss of pleasure in almost all activities (anhedonia) - Significant weight change or appetite disturbance: For children, this can be failure to achieve expected weight gain - Sleep disturbance (insomnia or hypersomnia) - Psychomotor agitation or retardation - Fatigue or loss of energy - Feelings of worthlessness - Diminished ability to think or concentrate; indecisiveness - Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide The symptoms cause significant distress or impairment in social, occupational or other important areas of functioning. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder There has never been a manic episode or a hypomanic episode Mnemonics: SI*G E* CAPS + Low mood* - Sleep - Interest - Guilt - Energy - Concentration - Appetite - Psychomotor - Suicidal ideation. Specify, Severity (ICD-10) (* consider major criteria) - Mild: 2-3 major + 2 minor (medications rarely indicated) Moderate: 2-3 major + 3-4 minor Severe: 3 major + ³ 4 minor Specify, presence of psychotic features Identify, - Predisposing factors (e.g. family history of psychiatric illness, poor socioeconomic status, broken family) - Precipitating factors (e.g. recent stressful event) - Maintaining factors (e.g. substance use) Treatment (Bio-Psycho-Social) Non pharmacological: - Risk management Assess suicidal risk: • • • Before (Idea/ plan) o Stressor o Planning o Suicide notes o Last act During (intention) o Lethality o Intention of act o Precautions against discovery o Intervention After o Help seeking behaviour o Regret after - Psychoeducation Lifestyle modification: exercise, diet, sleep hygiene, stop alcohol/ caffein/ substance misuse Treat underlying medical illness Problem solving treatment, self-help strategies CBT Family/ couple therapy Pharmacological: - Antidepressant, starts low and go slow. (i) 2nd generation antidepressant: SSRI (preferred e.g Sertraline, escitalopram) / SNRI/ Atypical antidepressant/ serotonin modulators (ii) 1st generation antidepressant – TCA/ MAOIs. - Change antidepressant if no response in 6 – 12 weeks. Usually patient will see the effect within the first 2 weeks (reduction > 20% of baseline symptoms) - Adjunct with anxiolytics in patient with anxiety and/ or insomnia with (i) Benzodiazepines (BDZ) (e.g clonazepam 0.5mg to 2mg ON or divided bd dose) (ii) (iii) Non BDZ hypnotics (e.g. zolpidem) 2nd generation antipsychotic (e.g. quetiapine and aripriprazole) < 5 : close monitoring 5-6 : consider admission ³ 7: Admit Screening: 1. Edinburgh Postnatal Depression Scale. 2. Patient Health Questionnaire-9 3. Postpartum Depression Screening Scale Treatment: SSRI (Sertraline). Persistent Depressive Disorder (Dysthymia) Adjustment disorder (Class: Trauma and stressor-related disorder) 1. Depressed mood for most of the day, for more days than not, as indicated by subjective account or observation by others, for at least 2 years. 2. Presence while depressed of two or more of the following: - Poor appetite or overeating. - Insomnia or hypersomnia. - Low energy or fatigue. - Low self-esteem. - Poor concentration or difficulty making decisions. - Feelings of hopelessness 3. During the 2 year period of the disturbance, the person has never been without symptoms from the above two criteria for more than 2 months at a time. 4. Criteria for MDD may be continuously present for 2 years, in which case patients should be given comorbid diagnoses of persistent depressive disorder and MDD 5. There has never been a manic episode, a mixed episode, or a hypomanic episode and the criteria for cyclothymia have never been met. 6. The symptoms are not better explained by a psychotic disorder. 7. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse or a medication) or a general medical condition. 8. The symptoms cause clinically significant distress or impairment in important areas of functioning. 1. Onset of emotional or behavioural symptoms must occur in response to identifiable stressors, and within 3 months of the stressor 2. These symptoms are clinically significant, marked by: - Marked distress that is out of proportion to the severity or intensity of the stressor, taking into account the external context and the cultural factors that might influence symptom severity and presentation. “Rules of 2”: 2 or more depressive symptoms, for 2 years (most of days), not without symptoms ³ 2 months. Precipitant: stressful life event (e.g. marital conflict, job loss, academic failure, persistent painful illness) Course: Onset within a month; 60% resolve (self-limiting) , 20% mild depression, 20% moderate-severe depression. Significant impairment in social, occupational, or other important areas of functioning 3. The disturbance does not meet the diagnostic criteria for another mental disorder (e.g. major depressive disorder or another depressive disorder), and is not an exacerbation of a pre-existing disorder. 4. The symptoms do not represent a normal bereavement 5. Symptoms do not last for more than 6 additional months after the stressor or its consequences have been resolved - Uncomplicated bereavement 1. Symptoms persist for at least 2 months after the individual’s loss: - The individual feels guilty about the death of their loved one(s), unrelated to or in addition to his or her thinking they could have done more to save the deceased individual. - He or she has consistent thoughts about his or her own death, unrelated to or in addition to his or her belief that it should have been them that died. - The individual becomes preoccupied with feelings of worthlessness. - He or she experiences and displays impaired psychomotor skills. - The individual’s everyday functioning is impaired. - He or she has hallucinations, unrelated to or in addition to ones of the deceased individual Adjustment disorder is diagnosed only if symptoms do not meet criteria for another specific disorder, e.g. MDD). If not fulfil MDD, but has low mood; Adjustment disorder with depressed mood. Treatment: Non pharmacological: - Psychotherapeutic counselling - Life style modification: sleep hygiene, balance diet, exercise. Pharmacological (short term symptomatic treatment): - Insomnia: short term BZD (< 2 weeks) - Antidepressant (if failed therapy) Normal grief usually lasting within 6 months. Abnormal grief either prolonged than 6 months, or abnormal content. Stages of normal grief: DADBA 1. Shock and denial: unable to ‘take-in’ what has happened, ‘numb’. 2. Anger: towards others (e.g. medical staffs), they should have saved life or prevented unwanted outcome. 3. Disengagement from usual activities (e.g. self-care, eating, hobby and from social-contact, except a few intimate friends. 4. Searching for the lost objects: usually by imagining we hear or we see the deceased person and pseudo-hallucination is common 5. Bargaining: can accompany the severe restlessness , both motor and psychological and yearning. 6. Acceptance: resolution of the grief 7. Future episodes of grief. Persistent complex bereavement disorder, DSM-5 / Prolong Grief disorder, ICD 11/ Complicated grief 1. Death of someone close 2. Since the death, at least one of the following on most days to a clinically significant degree for at least 12 months after the death: - Persistent yearning or longing for the deceased person - Intense sorrow and emotional pain in response to the death - Preoccupation with thoughts or memories of the deceased person. - Preoccupation with the circumstances of the death. 3. Since the death, at least 6 of the following symptoms to a clinically significant degree for most days to a clinically significant degree for at least 12 months after the death; - Marked difficulty accepting the death - Disbelief or emotional numbness over the loss - Difficulty with positive reminiscing about the deceased. - Bitterness or anger related to the loss. - Maladaptive appraisals about oneself in relation to the deceased or the death (e.g. self-blame) - Excessive avoidance of reminders of the loss - A desire to die to be with the deceased - Difficulty trusting other people since the death - Feeling alone or detached from other people since the death - Feeling that life is meaningless or empty without the deceased or the belief that one cannot function without the deceased Confusion about one’s role in life or a diminished sense of one’s identity - Difficulty or reluctance to pursue interests or to plan for the future (e.g. friendship, activities) since the loss 4. Clinically significant distress or impaired functioning (personal, family, social, educational, or occupational) 5. The duration and intensify of the grief response exceeds expected social, cultural, or religious norms for the bereaved individual’s social context and culture 6. The symptoms are not the result of another psychiatric disorder (e.g. unipolar major depressive, or post-traumatic stress disorder), a substance (e.g. medication or alcohol), or a general medical disorder - Manic episode BIPOLAR AND RELATED DISORDER 1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently goal-directed behaviours or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). 2. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviours: - Inflate self-esteem or grandiosity - Decrease need for sleep (feel rested after only 3 hours of sleep) - More talkative than usual, or pressure to keep talking - Flight of ideas or subjective experience that thoughts are racing Mnemonic: DIG FAST - Distractibility - Indiscretion, pleasurable activities with painful consequences - Grandiosity - Flight of ideas/ subjective racing thoughts - Activity increased or psychomotor agitation - Sleep need decreased - Talkativeness. Treatment: Acute Mania 1) Bio Distractibility (i.e attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed - Increased in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. - Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). 3. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. 4. The episode is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or another medical condition. - Check if patient on any antidepressant. If yes, STOP - Check if patient on any antimanic medication. If no, (i) start on antipsychotic (haloperidol, quetiapine, risperidone or olanzapine). (ii) Start low dose and titrate up to optimum maximal dose with tolerable side effect. Work in 5-7 days. (iii) If not enough, augment with mood stabilizer (lithium/ valproate) - If already on antimanic mediations, (i) Antipsychotic: check compliance, titrate up and if needed, add on mood stabilizer (ii) Litihium/ valproate: check plasma level, titrate to therapeutic range, and if needed add on antipsychotic 2) Psycho - Risk management - Psychoeducation - CBT - Family therapy - Interpersonal therapy - Supportive therapy 3) Social - Acute Depression 1) Bio - Start on Fluoxetine, at lower dose and titrate up to maximal optimum dose. Educate : it work to balance NT in the brain (serotonin, NA, dopamine) and thus elevate the symptoms. 2) Social - Risk management - Psychoeducation - CBT - Interpersonal therapy - Coping skills counselling - Supportive therapy Hypomanic episode 1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. 2. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behaviours, and have been present to a significant degree: - Inflate self-esteem or grandiosity - Decrease need for sleep (feel rested after only 3 hours of sleep) - More talkative than usual, or pressure to keep talking - Flight of ideas or subjective experience that thoughts are racing - Distractibility (i.e. attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed Increased in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation. - Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment). Criteria have been met for at least one manic episode. The manic episode may have been preceded by and may be followed by hypomanic or major depressive episodes. The occurrence of the manic and major depressive episode(s) is not better explained by schizoaffective disorder, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. - 3. 4. 5. 6. Bipolar I disorder 1. 2. Note: Major depressive episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Note: Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. Bipolar II Disorder Cyclothymic disorder 1. Criteria have been met for at least one hypomanic episode and at least one major depressive episode 2. There has never been a manic episode. 3. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder. 4. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 1. For at least a two year period, there have been episodes of hypomanic and depressive experiences which do not meet the full DSM-5 diagnostic criteria for hypomania or major depressive disorder. 2. The above criteria had been present at least half the time during a two year period, with not more than two months of symptom remission. 3. There is no history of diagnoses for manic, hypomanic, or a depressive episode. 4. The symptoms are cannot be accounted for by a psychotic disorder, such as schizophrenia, schizoaffective disorder, schizophreniform disorder, or delusional disorder. 5. The symptoms cannot be accounted for by substance use or a medical condition. 6. The symptoms cause distress or significant impairment in social or occupational functioning PSYCHOTIC DISORDER Brief Psychotic disorder 1. The patient must have 1 or more of the following symptoms: delusions, hallucinations, disorganized speech (e.g., frequent derailment or incoherence), and grossly disoriented or catatonic behaviours; 1 or more of the first 3 symptoms must always be present; a symptom should not be included if it is a culturally sanctioned response 2. The duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning 3. The disturbance cannot be better explained by major depressive or bipolar disorder with psychotic features or by another psychotic disorder (e.g., schizophrenia or catatonia), nor can it be attributed to the physiologic effects of a substance or medication or another medical condition *The specific trigger of BPD, if present, must be specified as follows: - Brief psychotic disorder with marked stressor(s) is also referred to as brief reactive psychosis. It is the onset of psychotic symptoms that occur in response to a traumatic event that would be stressful for anyone in similar circumstances in the same culture - Brief psychotic disorder without marked stressor(s) is the onset of psychotic symptoms that occur in the absence of a traumatic event that would be stressful for anyone in similar circumstances in the same culture - Schizophrenia Brief psychotic disorder with postpartum onset is defined as the onset of psychotic symptoms that occur within four weeks postpartum 1. Characteristic symptoms: ³2 of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): - Delusions - Hallucinations - disorganized speech (e.g., frequent derailment or incoherence) - grossly disorganized or catatonic behaviour - negative symptoms (i.e. diminished emotional expression or lack of motivation to do or complete task/ activities that has an end goal) *Only one symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behaviour or thoughts, or two or more voices conversing with each other. (refer to notes#) 2. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement) 3. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion 1 (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. The strongest risk factor for developing a psychotic disorder is family history - Monozygotic twin: 50% - Parent: 10-15% - Sibling: 10% - No fhx: 1% Prodromal syndrome (present before the positive symptoms) - like changes on his behaviour or deterioration in his studies (e.g. grades going drop e.g. lazy, no bullies) Notes# Positive psychotic symptoms (at least 1 of clear symptoms or ³ 2 less clear symptoms): (1) Clear : - Delusions that are culturally inappropriate and completely impossible (e.g. being able to control the weather) (i) Delusions of reference: beliefs that random external events in his/her life or wider society (details from a news item, song or TV programmed) relate in a special way to him/her During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion 1 present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). 4. Schizoaffective and mood disorder exclusion: Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. 5. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 6. Relationship to a pervasive developmental disorder: If there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). (ii) - Delusions of thought interference: others can hear, read, insert or steal their thoughts (iii) Passivity phenomenon: beliefs and/or perceptions that others are able to control their will, limb movements, bodily functions, or feelings. (iv) Thought echo: hearing one’s own thoughts spoken aloud. Hallucination : running commentary or discussing the patient amongst themselves, or voice coming from other part of the body. (2)Less clear: Hallucination, other than mentioned above Thought disorders: breaks in the train of thought (thought block), overinclusive and concrete thinking, neologism. Catatonic behaviours. Negative psychotic symptoms (includes in less clear symptoms) • Apathy: blunted affect • Flat affect: emotional withdrawal • Odd/ incongruous affect (smile while recounting sad events) • Lack of attention to self-care • • • Poor rapport: reduced verbal or non-verbal communication (e.g. eye contact) Lack of spontaneity Difficulty in abstract thinking (e.g. explaining proverbs, or common saying) Treatment: Non-pharmacological: - Psychosocial interventions: CBT, family-based intervention. Pharmacological: Preferred: 2nd generation antipsychotic Agitation + insomnia: antipsychotic with prominent sedating effect. E.g. olanzapine, haloperidol (+ benztropine/ diphenhydramine) ± BDZ Schizophreniform disorder 1. ³2 of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (i), (ii), or (iii): (i) Delusions (ii) Hallucinations (iii) disorganized speech (e.g., frequent derailment or incoherence) (iv) grossly disorganized or catatonic behaviour (v) negative symptoms,(i.e., diminished emotional expression or avolition). 2. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When diagnosis must be made without waiting for recovery, it should be qualified as “Provisional.”) 3. Schizoaffective and mood disorder exclusion: Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. 4. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. Schizoaffective disorder 1. An uninterrupted duration of illness during which there is a major mood episode (manic or depressive) in addition to criterion 1 for schizophrenia; the major depressive episode must include depressed mood. 2. Hallucinations and delusions for two or more weeks in the absence of a major mood episode (manic or depressive) during the entire lifetime duration of the illness. 3. Symptoms that meet the criteria for a major mood episode are present for most of the total duration of both the active and residual portions of the illness. 4. The disturbance is not the result of the effects of a substance (e.g., a drug of misuse or a medication) or another underlying medical condition. *The following are specifiers based on the primary mood episode as part of the presentation. Bipolar type: includes episodes of mania and sometimes major depression. Depressive type: includes only major depressive episodes. PRIMARY ANXIETY DISORDER Pathological anxiety is distinguished from normal stress responses by being disproportionate (i.e out of keeping with the situation), prolonged and severe enough to interfere with normal functioning. Acute stress reaction Development of specific fears behaviours that last from 3 days to Precipitant: stressful life event 1 month after a traumatic event. Course: Onset immediately after event, resolves without intervention within hours or days Post-traumatic stress disorder 1. Exposure to actual or threatened death, serious injury, or Precipitant: life-threatening event (PTSD) sexual violence in one or more of the following ways: - Directly experiencing the traumatic event Screening question: “Some people have terrible - Witnessing, in person, the event as it occurred to experiences happen to them (give example, others personal trauma, sexual assault, or seeing - Learning that the traumatic event (must be violent or someone badly injured or killed). Has anything like accidental event) occurred to a close family member this ever happened to you?”. If yes, or close friend. - Experiencing repeated or extreme exposures to “ Have you ever had recurrent dreams or aversive details of the traumatic event (e.g. first nightmares about this experience, or recurrent responders collecting human remains, police offices thoughts or flashbacks?” repeatedly exposed to detail of child abuse) – not through electronic media, movies, pictures. Course: Rarely resolve spontaneously; frequent comorbid depression. 2. Presence of ³1 of the following intrusion symptoms associated with the traumatic event, beginning after the traumatic event occurred: - Recurrent, involuntary and intrusive distressing memories of the traumatic event. - Recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event. - Dissociative reactions (e.g. flashback), in which the individual feels or acts as if the traumatic event was recurring. - Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. - Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event. 3. Persistence avoidance of stimuli associated with the traumatic event, beginning after the traumatic event occurred, as evidence by 1 or both of the following: - Avoidance of or effort to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event - Avoidance of or an efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic events. 4. Negative alterations in cognition and mood associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidence by ³ 2 of the following: - Inability to remember an important aspect of the traumatic events (due to dissociative amnesia) - Persistent or exaggerated negative beliefs or expectations about oneself, others, or the world - Persistent, distorted cognitions about the cause or consequences of the traumatic event that lead the individuals to blame himself/ herself or others. - Persistent negative emotional state (e.g. fear, horror, anger, guilt or shame) - 5. 6. 7. 8. Specific phobias 1. 2. 3. Markedly diminished interest or participation in significant activities. - Feeling of detachment or estrangements from others - Persistent inability to experience positive emotions (e.g. inability to experience happiness, satisfaction, or loving feelings) Marked alterations in arousal and reactivity associated with the traumatic event, beginning or worsening after the traumatic event occurred, as evidenced by ³2 of the following: - Irritable behaviour and angry outburst (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects - Reckless or self-destructive behaviour - Hypervigilance - Exaggerated startle response, - Problems with concentration - Sleep disturbances. Duration of disturbance (Criteria 2 – 4) is ³ 1 month The disturbances causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbances is not attributable to the physiological effects of substance, or other medical conditions. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood). The phobic object or situation almost always provokes immediate fear or anxiety. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. Treatment: Non pharmacological: Exposure-based-CBT Pharmacological: - SSRI: Paroxetine 4. The phobic object or situation is actively avoided or endured with intense fear or anxiety. 5. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 6. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. 7. The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder). Agoraphobia *Specify types: - Animal Type (e.g., spiders, insects, dogs) - Natural Environment Type (e.g., heights, storms, water) - Blood-Injection-Injury Type (e.g., needles, invasive medical procedures) - Situational Type (e.g., airplanes, elevators, enclosed places) - Other Type (e.g., phobic avoidance of situations that may lead to choking, vomiting, or contracting an illness; in children, avoidance of loud sounds or costumed characters) 1. A marked fear or anxiety at ³ 2 of the following 5 situations: - Using public transportations - Being in open spaces Agoraphobia: The individual fears or avoids these situations because thoughts that escape may be difficult or help might not be available in the 2. 3. 4. 5. Panic disorder (Episodic paroxysmal anxiety) ± Agoraphobia ** Panic disorder + agoraphobia (maladaptive behaviours) 1. - Being in enclosed spaces (e.g shops, theatre, cinemas) - Standing in line or being in a crowd - Being outside the home alone The agoraphobic situations almost always provoke fear or anxiety The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context The fear, anxiety or avoidance is persistent, typically lasting ³ 6 months. The fear and anxiety usually lead to avoidance causes clinically significant distress or impairment in important areas of functioning. Panic attack: abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time ³ 4 of the following symptoms occur - Palpitation, pounding heart or accelerated heart rate - Sweating - Trembling/ shaking - Sensation of shortness of breath - Feeling of choking - Chest pain or discomfort - Nausea or abdominal distress - Feeling dizzy, unsteady, lightheaded or faint - Derealization (feeling of unreality) or depersonalization (being detached of oneself) - Fear of losing control, or “going crazy” - Paraesthesia - Chills or hot flushes event of developing panic-like symptoms or other incapacitating or embarrassing symptoms. Treatment: SSRI Precipitant: variability of exposures to anxiety, sometimes none. Unpredictable Screening question: “Did you ever have a spell or an attack when all of a sudden you feel frightened, anxious, or very uneasy?” Maladaptive: - Anticipatory anxiety - Avoidance behaviours - Increase in illness behaviours - Use alcohol or other sedatives to relieve distress (‘self-medication’) - Repeatedly seeking medical opinions for somatic anxiety, despite repeatedly normal investigations - Escape behaviour Course: Treatable but relapse is common 2. Recurrent and unexpected panic attacks, ³ 1 attack has been followed by ³1 month by one or both of the following - Persistent concern about additional attacks or their consequences - A significant maladaptive change in behaviour related to the attacks (e.g. agoraphobia*) 3. The disturbance is not attributable to the physiological effect of substance or another medical conditions 4. The disturbances is not better explained by another mental disorder (e.g. the panic attack do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsession, as in OCD; in response to reminders of traumatic events, as in PTSD; or in response to separation from attachment figures, as in separation anxiety disorder) Generalized anxiety disorder (GAD) 1. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performances) 2. The individual finds it difficult to control the worry. 3. The anxiety and worry are associated with 3 or more of the following 6 symptoms (with at least some symptoms having been present for more than not for more days than not for the past 6 months) - Restlessness, feeling keyed up or on edge - Being easily fatigue - Difficulty in concentrating or mind going blank - Irritability - Muscle tension - Sleep disturbances Treatment: Non-pharmacological treatment: 1. Patient’s education: Explain the nature of the physical symptoms (it’s never fatal). Reassure about the benign course of panic disorder. 2. Lifestyle modification 3. Breathing and relaxation techniques ± graded exposure. 4. CBT (works better than medication provided it carried out by trained personal) Pharmacological treatment: 1. 1st line: SSRI 2. Treatment resistant, 2nd line: Bupropion 3. Beta-blockers (symptomatic) Precipitant: no immediate precipitant Screening question: “Would you say that you have been bothered by “nerves” or feeling anxious or on edge?” Course: Usually present by teenage years and run a chronic relapsing course Treatment: Non pharmacological: CBT Pharmacological: Preferred SSRI Illness- anxiety disorder (Hypochondriasis) 4. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupation, or other important areas of functioning. 5. The disturbances is not attributable to the physiological effect of a substance (e.g. drug abuse) or other medical illnesses (e.g. hyperthyroidism) 6. The disturbance is not better explained by another medical/psychiatric disorder (e.g. the panic attack do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsession, as in OCD; in response to reminders of traumatic events, as in PTSD; or in response to separation from attachment figures, as in separation anxiety disorder) 1. Preoccupation with having or developing a serious illness. 2. Somatic symptoms are mild or non-existent. If a general medical illness is present or the risk for acquiring a medical illness is high (e.g, strong family history), the preoccupation is clearly excessive 3. Substantial anxiety about health and a low threshold for becoming alarmed about one’s health 4. Either of the following: - Excessive health related behaviours, such as repeatedly checking oneself for signs of illness - Maladaptive avoidance of situations (e.g visiting sick family members, doctor appointments, or hospital), or activities (eg exercise) that are thought to represent health threat. 5. Preoccupation with illness is present for at least 6 months Precipitant: health anxieties, worried about severe diagnosis (e.g. cancer) Course: varies, can be trait or state, but always context dependant Somatic symptoms disorder (Somatization disorder) 6. The illness preoccupation is not better explained by other mental disorders such as somatic symptoms disorder or somatic type of delusional disorder 1. ³ 1 somatic symptoms that cause distress or psychosocial impairment 2. Excessive thoughts, feelings, or behaviours associated with the somatic symptoms, as demonstrated by ³ 1 of the following: - Persistent thought about the seriousness of the symptoms - Persistent, severe anxiety about the symptoms or one’s general health - The time and energy devoted to the symptoms or health concerns is excessive Precipitant: Worried about symptoms • • • Obsessive-Compulsive disorder (OCD) Mild: 1 features of above Moderate: ³2 features Severe: ³2 features + multiple somatic symptoms (e.g. fatigue, dizziness, GI distress), or one very severe somatic symptoms 3. Although the specific somatic symptoms may change, the disorder is persistent (usually ³ 6 months) 1. Presence of obsessions, compulsions, or both: Obsessions are defined by: - Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. Precipitant: intrusive thoughts (obsession = thought, compulsion = behaviours) Course: lifelong, with relapse; frequent comorbid depression; can be as disabling as schizophrenia. Treatment: Non pharmacological: - The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by: - Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. - The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. 2. The obsessions or compulsions are time consuming (e.g. take more than 1 hour/ day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 3. The disturbances is not better explained by the symptoms of another mental disorder (e.g. excessive worries, as in GAD; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possession as in hoarding disorder; hair pulling as in trichotillomania; skin pricking as in excoriation; ritualized eating behaviour as in eating disorder; preoccupation with substance or gambling, as in substance-related and addictive disorder; sexual urges or fantasies as in - CBT, ERP form (Exposure Response Prevention) is 1st line treatment for mildmoderate symptoms. CBT, mindfulness-based cognitive therapy (e.g. meditation and breathing technique) Pharmacological (in severe case with CBT) - SSRI. paraphilic disorder; impulses as in disruptive, impulse control and conduct disorder; guilty rumination as in MDD; thought insertion or delusional as in schizophrenia etc) *Specify if: - with good or fair insight: the individuals recognizes that the OC beliefs are definitely or probably not true or that they may or may not be true - with poor insight: the individuals thinks OCD beliefs are probably true - with absent insight/ delusional belief: the individual is completely convinced that OCD beliefs are true Separation anxiety disorder *Specify if: Tic related. (current or past hx of tic disorder) 1. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: - Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. - Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. - Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. - Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. - Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. - Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. - Repeated nightmares involving the theme of separation - Repeated complaints of physical symptoms (such as headaches, stomach-aches, nausea, or vomiting) when separation from major attachment figures occurs or is anticipated 2. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults. 3. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. 4. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder. Delirium MEDICAL 1. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention. Mnemonic aetiologies: I WATCH DEATH - Infection - Withdrawal 2. Change in cognition (e.g. memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a pre-existing, established, or evolving dementia. 3. The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. 4. Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause. - Acute metabolic (hypoglycaemia, the 4failures) Trauma CNS lesion Hypoxia Deficiency (general, thiamine, Vit B12, folate) Endocrine (thyroid, parathyroid, adrenal) Acute vascular (CVA) Toxins (drugs, esp sedatives) Heavy metal (leads, mercury) SUBSTANCE USE DISORDER Nicotine addiction Screening: Fagerstrom’s Score Options: 1. Motivational interviewing 2. Nicotine replacement therapy (NRT), i.e nicotine gum, nicotine patch for 8-12 weeks 3. Non-nicotine replacement therapy (NNRT), i.e. Varenicline or buproprion for 12 weeks Alcoholic drinker status 1. Social drinker: Individual sticks to the recommended levels for safe drinking: - Male: 2 standard drink/ day - Female: 1 standard drink/ day 2. Binge drinking: pattern of alcoholic consumption that brings the BAC (blood alcohol concentration) level to 0.08% within 2 hours; - Male: ³5 standard drinks - Female: ³ 4 standard drinks 3. Heavy drinking - Male: ³ 15 standard drinks/ week - Female: ³ 8 standard drinks/ week 1 standard drink = 10gm of pure alcohol. = amount of drink (litre) x %ABV x 0.789 e.g. 500mls of beer ABV 5% = 0.5 x 5 x 0.789 = 1.975 standard drink = 2 Alcohol Use Disorder (AUD) *In DSM-5, no more separation between alcohol abuse and alcohol dependence. AUD can be specified as mild, moderate and severe. *Alcohol abuse in DSMIV = Mild AUD *Alcohol dependence in DSM-IV = moderate to severe AUD Addiction 4C’s Control Compulsion Craving Continuous use (despite consequences) A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12 months period;= 1. Alcohol is often taken in larger amounts or over a longer period than was intended 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effect 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfil major role obligation at work, school, or home 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problems that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: - A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. 11. Withdrawal, as manifested by either of the following: - The characteristics withdrawal syndromes for alcohol (refer below) - Alcohol ( or a closely related substance, such as benzodiazepine), is taken to relieve or avoid withdrawal symptoms. *1-4: previously in DSM-IV to diagnose “abuse” * 5-11: previously in DSM-IV to diagnose “dependence”. (10 =. Tolerance) *Specify severity: - Mild: 2-3 symptoms - Moderate: 4-6 symptoms - Severe: > 6 symptoms Alcohol withdrawal 1. Cessation or reduction in alcohol use that has been heavy and prolonged, AND 2. ³ 2 of the following , developing within several hours to a few days after the cessation of (or reduction in) alcohol use AND; - Autonomic hyperactivity (sweating, tachycardia - Increased hand tremors - Insomnia - Nausea and vomiting - Transient visual, tactile or auditory hallucination - Psychomotor agitation - Anxiety - Generalized tonic clonic seizure - 6-12 hours: tremor, sweating, tachycardia, anxiety 12-24 hours: Alcoholic hallucinosis (visual, auditory, tactile) 24- 48 hours: seizures 48-72 hours: delirium tremens ( classical triad: clouding of consciousness + tremors + vivid visual hallucination) Treatment : - Monitoring & supportive treatment. - Benzodiazepine ± phenobarbitone if seizures Medical-related complications of alcoholism 3. The signs and symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning AND, 4. The signs and symptoms are not attributable to another medical condition and are not better explained by other mental disorder, including intoxication or withdrawal from another substances. 1) Wernicke’ encephalopathy (COAT) - Confusion - Ophthalmoplegia - Ataxia - Thiamine deficiency (Vit B1) 2) Korsakoff’s syndrome (RACK) – consequences of untreated Wernicke’s encephalopathy - Retrograde amnesia - Anterograde amnesia - Confabulation - Korsakoff’s psychosis 3) Vit B12 deficiency - Neurological features: peripheral sensory loss (loss of joint position and vibration sense), ataxia gait, upgoing plantar, optic neuritis (sudden unilateral vision loss) 4) Folate deficiency - Progressive cognitive impairment 5) Pneumonia: Klebsiella pneumonia Withdrawal symptoms of commonly misused substances Attention Deficit Hyperactive Disorder (ADHD) CHILDREN/ ADOLESCENT Symptoms and/or behaviours that have persisted ³ 6 months in ³ 2 settings (e.g. school, home, church). Symptoms have negatively impacted academic, social, and/or occupational functioning. In patients aged < 17 years old, ³6 symptoms are necessary; in those ³17 years, ³5 symptoms are necessary 1. Inattentive type diagnosis criteria - Displays poor listening skills - Loses and/or misplaces items needed to complete activities or tasks - Side-tracked by external or unimportant stimuli - Forgets daily activities - Lacks of ability to complete schoolwork and other assignments or to follow instructions - Avoids or is disciplined to begin homework or activities requiring concentration - Fails to focus on details and/or makes thoughtless mistakes in schoolwork or assignments. 2. Hyperactive/ Impulsive type diagnosis criteria (i) Hyperactive symptoms - Squirm when seated or fidgets with feet/hand - Marked restlessness that is difficult to control - Appears to be driven by a “ motor” or is often “on the go” - Lacks ability to play and engage in leisure activities in a quiet manner - Incapable of staying seated in class - Overly talkative (ii) Impulsive symptoms - Difficulty waiting turn Mnemonic ATTENTION - Attention difficulty - Trouble listening - Task that require sustained mental efforts are difficult - Easily distracted - Necessary things for tasks are lost - To finish what he/she starts is difficult - Is forgetful in daily activity - Organisational skills lacking - Not concerned about details or makes careless mistakes RUN FIDGET - Runs, climbs or restless - Uninhibited in conversation - Not able to play quietly - Fidgets or squirms in seats - Interrupts or intrudes on others - Difficulty waiting his/her turns - Get going or acting as if driven by a motor - Evacuates seat unexpectedly - Talks excessively Treatment: Pharmacological: - 1st line: CNS stimulants, methylphenidate (brand name: Ritalin) - Interrupts or intrudes into conversations and activities of others - Impulsively bursts out answers before questions completed. 3. Additional requirement for diagnosis - Symptoms present prior to age 12 years - Symptoms not better accounted for by a different psychiatric disorder (e.g. mood disorder, anxiety disorder) and do not occur exclusively during a psychotic disorder (e.g. schizophrenia) - Symptoms not exclusively a manifestations of oppositional behaviours. 4. Classification: - Combined type: patient meets both inattentive and hyperactive/ impulsive criteria for the past 6 months - Predominantly inattentive type: patient meets inattentive criterion, but not hyperactive/impulse criterion, for the past 6 months - Predominantly Hyperactive/ Impulsive type: Patient meets hyperactive/ impulse criterion, but not inattentive criterion, for the past 6 months. Autism Spectrum Disorder *Symptoms may be classified as mild, moderate, or severe based on symptom severity. 1. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive, see text): - Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing - Side effect: Decreased appetite (give meds pre meal) , poor growth (drugs holiday), dizziness (try longer acting) , insomnia (sleep hygiene), mood lability, rebound, tics. 2nd line: SNRI (Atomoxetine) 3rd line: clonidine and TCA - - of interests, emotions, or affect; to failure to initiate or respond to social interactions. Deficits in nonverbal communicative behaviours used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Specify current severity: Severity is based on social communication impairments and restricted repetitive patterns of behaviour. 2. Restricted, repetitive patterns of behaviour, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text): - - Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behaviour (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day). - - Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest). Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Specify current severity: Severity is based on social communication impairments and restricted, repetitive patterns of behaviour. 3. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life). 4. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. 5. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently cooccur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. Oppositional defiant disorder 1. A pattern of angry/irritable mood, argumentative/defiant behaviour, or vindictiveness (Disorder Class: Disruptive, Impulse-Control, and Conduct Disorders) - - - Conduct disorder (Disorder Class: Disruptive, Impulse-Control, and Conduct Disorders) lasting at least 6 months as evidenced by at least four symptoms of the following categories, and exhibited during interaction with at least one individual who is not a sibling: Angry or irritable mood (1) Often loses temper (2) Is often touchy or easily annoyed (3) Is often angry and resentful. Argumentative/ defiant behaviours (4) Often argues with authority figures or, for children and adolescents, with adult (5) Often actively defies or refuses to comply with requests from authority figures or with rules (6) Often deliberately annoys others (7) Often blames others for his or her mistakes or misbehaviours. Vindictiveness (8) Has been spiteful or vindictive at least twice within the past 6 months. 1. A repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: - Aggression to people and animals: (1) often bullies, threatens, or intimidates others (2) often initiates physical fights (3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) (4) has been physically cruel to people (5) has been physically cruel to animals (6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) (7) has forced someone into sexual activity - Destruction of property (8) has deliberately engaged in fire setting with the intention of causing serious damage (9) has deliberately destroyed others’ property (other than by fire setting) - Deceitfulness or theft (10) Has broken into someone else’s house, building, or car (11) often lies to obtain goods or favours or to avoid obligations (i.e., “cons” others) (12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) - Serious violations of rules (13) often stays out at night despite parental prohibitions, beginning before age 13 years (14) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) (15) is often truant from school, beginning before age 13 years 2. The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning. 3. If the individual is ³18 years, criteria are not met for Antisocial Personality Disorder. Disruptive mood dysregulation disorder ((Disorder Class: Disruptive, Impulse-Control, and Conduct Disorders) 1. Recurrent and severe temper tantrums or outbursts - The tantrums/outbursts may be expressed verbally and/or behaviourally (physical aggression towards other people or property). The tantrums/outbursts are considered out of proportion (in duration and intensity) to the situation or triggering event The tantrums/outbursts are inconsistent with the child’s developmental level The tantrums/outbursts occur three or more times per week, on average 2. Persistent irritability or anger - The irritable/angry mood occurs nearly every day, for most of the day The irritable/angry mood is observable by others (peers, parents, teachers, etc.) The recurrent temper tantrums and persistent irritability/anger have been present for 12 months or longer Throughout the 12 months of ongoing temper tantrums and irritability/anger, the child has not had a period lasting 3 or more consecutive months without all of the diagnostic symptoms. 3. Symptoms are present in at least two of three primary settings, either home, school, or in social situations. - Symptoms are severe in at least one of the three primary settings. 4. DMDD diagnosis should not be assigned before age 6 or after age 18. 5. The age of onset of disruptive mood dysregulation disorder is before 10 years old. 6. The symptoms are not better explained by another mental illness, such as depression, posttraumatic stress disorder, or autism School-related problems Motivation Associated features Anorexia nervosa Truancy (ponteng) Surreptitious absences, motivated by pleasure, not anxiety-based, lack of emotional distress Parent role Linked with delinquency, academic problems, or social problems such as homelessness or poverty Always try to conceal absences from parent Function Increased positive emotions. Example Excitement of skipping class to play videogames or smoking EATING DISORDERS 1. Restriction of energy intake relative to requirements, leading to a significant low body weight in the context of the age, sex, developmental trajectory, and physical health (less than minimally normal/expected). School refusal Severe emotional distress. More concerned with not being at school than being at home. Goal is not just to “blow-off” school. Would like to feel more comfortable at school and being able to attend Separation, generalized or social anxiety, somatic complains and/or depression. Not related to socio-economic status or academic ability Parents aware, child usually persuades parents to try to not make them go Escape, avoidance, or relief negative emotions or unpleasant physical sensations. Avoiding possibility of having a panic attack at school Complications: - Reduced: HypoK, FSH, LH, T3, Estrogen, Testosterone 2. Intense fear of gaining weight or becoming fat or persistent behaviour that interferes with weight gain. 3. Disturbed by one’s body weight or shape, selfworth influenced by body weight or shape, or persistent lack of recognition of seriousness of low bodyweight. *Specify types: - Restricting type: During the last 3 months, has not regularly engaged in binge-eating or purging. - Binge-eating/purging#type: During the last 3 months, has regularly engaged in binge-eating or purging # purging is self-induced vomiting or misuse of laxatives, diuretics, or enemas. *Specify current severity: Bulimia Nervosa Mild: BMI more than 17 Moderate: BMI 16- 16.99 Severe: BMI 15-15.99 Extreme: BMI less than 15 1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both: - Eating in a discrete period of time (e.g. within any 2 hours period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances - Raised G & C: growth hormones, glucose, salivary gland, cortisol, cholesterol, carotenimia. - A sense of lack of control over eating during the episodes (e.g. feeling that one cannot stop eating or control what or how much one is eating). 2. Recurrent inappropriate compensatory behaviours to prevent weight gain, such as selfinduced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise 3. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months 4. Self-evaluation is unduly influenced by body shape and weight 5. The disturbances does not occur exclusively during the episode of anorexia nervosa Binge-eating disorder 1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both: - Eating in a discrete period of time (e.g. within any 2 hours period), and amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances. - A sense of lack of control over eating during the episodes (e.g. feeling that one cannot stop eating or control what or how much one is eating) 2. Binge eating episodes are associated with 3 or more of the following: - Eating much more rapidly than normal - Eating until feeling uncomfortably full - Eating large amounts of food when not feeling physically hungry - Eating alone because feeling embarrassed on how much one is eating - Feeling disgusted with oneself, depressed or very guilty afterwards. 3. Marked distress regarding binge eating is present 4. The binge eating occurs, on average, at least once a week for 3 months 5. The binge eating is not associated with the recurrent use of inappropriate compensatory behaviours as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. *Specify current severity: - Mild: 1-3 binge eating/ week - Moderate: 4-7 - Severe: 8-13 - Extreme: ³ 14 Somatization disorder S for symptoms - HypoChondrial disorder C for cancer (worried about worst diagnosis) - Conversion disorder - - - - Dissociative disorder - Munchhausen’s syndrome - Malingering - UNEXPLAINED SYMPTOMS (SIMPLIFIED) Multiple physical SYMPTOMS present for at least 2 years Patient refuses to accept reassurance or negative test result Persistent belief in the presence of an underlying serious DISEASES. Patient refuses to accept reassurance or negative test results Typically involves loss of motor or sensory function The patient doesn’t consciously feign the symptoms (factitious disease) or seek material gain (malingering) Patient may be indifferent to their apparent disorder. Dissociation is process of ‘separating off’ certain memories from normal consciousness In contrast to conversion disorder involves psychiatric symptoms e.g. amnesia, fugue, stupor Also known as factitious disorder The intentional production of physical or psychological symptoms Fraudulent stimulation or exaggeration of symptoms with the intention of financial or other gain. Refer Primary Anxiety disorder for full DSM 5 Refer Primary Anxiety disorder for full DSM 5 Scenario: 16 years old is brought for review by her father. She is a talented violinist and is due to start music college in a few weeks’ time. Her parents are concerned she has had a stroke as she is reporting weakness on her right side. Neurological examination is inconsistent and you suspect a non-organic cause for her symptoms. Despite reassurance about the normal examination findings, the girl remains unable to move her right arm. Scenario: 24 years old male admitted to ETD complaining of severe abdominal pain. On examination, he is shivering and rolling around the trolley. He has previously been investigated for abdominal pain and no cause has been found. He states that unless he is given morphine for the pain, he will kill himself. Dementia Onset Duration Course Insidious Months/ years Gradually progressive Alertness Orientation Memory Normal Usually impaired for time and place Impaired recent and sometimes remote memory Slowed, perseverance Thoughts Perception Emotion Sleep Others Often normal, visual hallucination in 3040% Apathetic, labile, irritable Disturbed, nocturnal wondering and confusion Screening using MMSE ELDERLY Depression (Pseudodementia) Gradual Weeks/ months Worse in morning and improve at night No interest. Responds as “don’t know” Usually normal Recent may be impaired. Remote intact Slowed, preoccupied, sad and hopeless 20% with mood congruent hallucination Flat, sad, unresponsive. May be irritable Early morning awakening Past history or family history of mood disorder Delirium Acute Hours/ days/ weeks Fluctuates, worse at night, with lucid period. Fluctuates Always impaired Recent impaired Often out of touch with reality Visual and auditory hallucination are common Irritable, aggressive or fearful Nocturnal confusion Other physical disease obvious Screening using Geriatric depression scale. PERSONALITY DISORDER • • • Personality is the way people thinking, feeling and behaving Present since teenagers, consistent overtime and recognised by relatives and friends So personality disorder cause severe disturbance (eccentric) deeply ingrained in the character and behavioural tendencies causing maladaptive patterns of thinking, feelings and behaviours that deviated markedly from normal causing problems (to them self or others) • • Personality disorder is not considered mental illness or psychiatric disorder Most primary personality disorder do not seek treatment Antisocial - Psychopath - Avoidant Borderline Dependent - Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest. More common in men. Deception, as indicated by repeatedly lying, use of aliases, of conning others for personal profit or pleasures. Impulsiveness or failure to plan ahead. Irritability and aggressiveness, as indicated by repeated physical fights or assaults Reckless disregard for safety of self or others. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviours or honour financial obligations. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection Unwillingness to be involved unless certain of being likes. Preoccupied with ideas that they are being criticised or rejected in social situations. Restraint in intimate relationships due to the fear of being ridiculed. Reluctance to take personal risks due to fear of embarrassment. Views self as inept and inferior to others Social isolations accompanied by a craving for social contact. Efforts to avoid real or imagined abandonment Unstable interpersonal relationships which alternate between idealization and devaluation Unstable self-image Impulsivity in potentially self-damaging area (e.g. spending, sex, substance abuse) Recurrent suicidal behaviours Affective instability Chronic feeling of emptiness Difficulty controlling temper Quasi psychotic thoughts. Difficulty making everyday decisions without excessive reassurance from others Need for others to assume responsibility for major areas of their life Difficulty expressing disagreement with others due to fears of losing support Histrionic Drama queen Narcissistic Obsessive-compulsive Paranoid Antivaxxx - Lack of initiative Unrealistic fears of being left to care for themselves Urgent search for another relationships as source of care and support when a close relationship ends Extensive efforts to obtain support from others Unrealistic feelings that they cannot care for themselves Inappropriate sexual seductiveness Need to be the centre of attention Rapidly shifting and shallow expression of emotions Suggestibility Physical appearance used for attention seeking purposes Impressionistic speech lacking detail Self-dramatization Relationship considered to be more intimate than they are. Grandiose sense of self importance Preoccupation with fantasies of unlimited success, power or beauty Sense of entitlement Taking advantage of others to achieve own needs Lack of empathy Excessive need for admiration Chronic envy Arrogant and haughty attitude Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone. Demonstrate perfectionism that hampers with completing task Is extremely dedicated to work and efficiency to the elimination of spare time activities. Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things Takes on stingy spending style towards self and others, and shows stiffness and stubbornness. Hypersensitivity and an unforgiving attitude when insulted Unwarranted tendency to questions the loyalty of friends Reluctance to confide in others Preoccupation with conspiration beliefs and hidden meaning Schizoid Schizotypal Bomoh style - Unwarranted tendency to perceive attacks on their character. Indifference to praise and criticism Preference for solitary activities Lack of interest in sexual interactions Lack of desire for companionship Emotional coldness Few interest Few friends or confidants other than family Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviours Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent.
