Study Notes in Psychiatry (2008)
Study Notes in
Psychiatry
(For MBBS III to V)
Dr. Roger Ho
MBBS (HK), DPM( Ireland), MMed
(Psych)
Department of Psychological
Medicine, NUS
Email: pcmrhcm@nus.edu.sg
Dr. Roger Ho
Table of Content
Ch. 1 Introduction
Page
2
Ch.2 Signs & symptoms
Acute management
Ch. 3 Schizophrenia
2
Ch. 4 Delusional disorder
6
Ch. 5 Bipolar disorder
7
Ch. 6 Depressive disorder
9
Ch. 7 Obsessive compulsive
disorder
Ch. 8 Anxiety, Panic, Phobia
10
Ch. 9 Post traumatic stress
disorder, Acute stress, grief
Ch. 10 Alcoholism
12
Ch. 11 Drug Dependence
14
Ch. 12 Old age psychiatry
15
Ch. 13 Consultation Liaison
Psychiatry
Ch. 14 Perinatal Psychiatry
16
Ch. 15 Eating disorder and
impulse control disorders
Ch. 16 Suicide and DSH
19
Ch. 17 Personality Disorder
22
Ch. 18 Psychiatric
emergencies
Ch. 19 Sleep disorders
23
Ch. 20 Child Psychiatry
25
Ch. 21 Learning disability
28
Ch. 22 Legal aspect
29
Ch. 23 Psychotherapy
30
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1
Study Notes in Psychiatry (2008)
Chapter 1
Introduction
The purpose of writing this set of notes is to
provide a concise summary of psychiatry and to
help medical students to have rapid review for
examination.
Ch. 2 Definitions of signs and symptoms
The MCQ exam often confuses you with the
following terms (Levi, 1998):
Echolalia
Repetition by the
patient of the
interviewer’s words
or phrases
Stereotypy
Regular, repetitive
non goal-directed
movement
(purposeless)
Waxy flexibility
Patient’s limb can be
placed in an
awkward posture
and remain fixed in
position for long time
despite asking to
relax; occurs in
Schizophrenia (SZ)
Catalepsy
Motor symptom of
schizophrenia, same
as waxy flexibility
Automatic
obedience
Patient does
whatever the
interviewer asks of
him irrespective of
the consequences
Mitgehen
An extreme form of
mitmachen in which
patient will move in
any direction with
very slight pressure
Ambitendence
The patient beings to
make a movement
but before
Echopraxia
Imitation by the
patient of the
interviewer’s
movements.
Mannerism
Abnormal, repetitive
goal-directed
movement (of some
functional
significance)
Mitmachen
Patient’s body can
be placed in any
posture; when
relaxed, patient
returns to resting
position
Cataplexy
Symptom of
narcolepsy in which
there is sudden loss
of muscle tone
leading to collapse,
occurs in emotional
state.
Gegenhalten
(opposition)
The patient will
oppose attempts at
passive movement
with a force equal to
that being applied.
Negativism
Extreme form of
gegenhalten,
motiveless
resistance to
suggestion/ attempts
at movement.
Preservation
The senseless
repetition of a
previously requested
Dr. Roger Ho
completing it, starts
the opposite
movement
Neologisms
The patient uses
words or phrases
invented by himself
Obsessions
Recurrent, persistent
thoughts, impulses,
images that the
patient regards as
absurd and alien
while recognising as
the product of his
own mind. Attempts
are made to resist
or ignore them
Verbigeration
(word sald)
Disruption of both
the connection
between topics and
finer grammatical
structure of speech
Occurs in SZ
Lossening of
associations
Loss of the normal
structure of
thinking. Muddled
and illogical
conservation that
cannot be clarified
Occurs in SZ
Depersonalisation
A change in self
awareness such that
person feels unreal
Bipolar I
Mania
Affect
Emotional state at a
moment
Euphoria
Sustained and
unwarranted
cheerfulness
movement, even
after the stimulus is
withdrawn
Metonyms
Use of ordinary
words in unusal
ways
Delusions
A false belief with
the following
characteristics firmly
held despite
evidence to the
contrary; out of
keeping with the
person’s education &
cultural background,
content often bizarre
Vorbeireden
(talking past point)
The patient seems
always about to get
near to the matter in
hand but never
quite reaches it.
Occurs in SZ
Flight of ideas
Patient’s thoughts
and conservations
move quickly from
one topic to another,
the links between
these rapidly
changing topics
are understandable
Associated with
rhyming, punning &
clang associations.
Derealisation
A change in self
awareness such that
the environment
feels unreal
Bipolar II
Hypomania
Mood
Emotional state over
a longer period
Euthymia
A normal mood state
Neither depressed or
mania
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Study Notes in Psychiatry (2008)
Chapter 3
Schizophrenia
3.1 Types of schizophrenia
- Paranoid schizophrenia: prominent well –
systematised persecutory delusions or
hallucinations. More common with
increasing age.
- Catatonic schizophrenia: WRENCHES
W – Waxy flexibility; catalepsy
R – Rigidity
E – Echopraxia, echopraxia
N – Negativism
C – Catalepsy
H – High level of motor activity
E – Echolalia
S - Stupor
Other features: automatic obedience,
stereotypy; ambitendence, mannerism;
mitmachem; mitgehen.
3.2 Epidemiology
Median age of onset:
Male
Female
23 years
26 years
(earlier onset)
(later onset)
Sex: equally between men & women
Social class: increased prevalence in lower
social class
Season of birth: increased incidence in
winter months
Prevalence rate: 1% of general population
Incidence: 15/100 000
3.3 Aetiology
- Genetics: Heritability: 60-80%
- Family studies show the prevalence rates
of schizophrenia in relatives as follows:
Relationship to SZ
Prevalence rate
Parent of a SZ
5%
Sibling of a SZ/ DZ Twin 10%
Child of one SZ parents
14%
Child of two SZ parents
45%
Monozygotic twins of SZ 45%
Biochemical theories:
1)) Dopamine over-activity: high level of
dopamine within mesolimbic cortical
bundle. (eg amphetamine increase
dopamine release; Haloperidol reduces its
release).
2) Serotonergic overactivity: LSD, inc 5HT,
leads to hallucination, clozapine has
serotonergic antagonism.
Dr. Roger Ho
3) α1 – adrenergic overactivity.
4) Glutaminergic hypoactivity: ketamine,
NMDA antagonist, induce SZ symptoms
5) GABA hypoactivity which leas to
overactivity of dopamine, serotonin,
noradrenaline.
Environmental factors:
- Complications of pregnancy, delivery.
- Maternal influenza in pregnancy, winter
births
- Non – localising soft signs in childhood:
astereognosis, dysgraphaesthesia, gait
abnormalities, clumsiness.
- Disturbed childhood behaviour
- Degree of urbanisation at birth
3.4 Pathogenesis (Appendix 3a/3b)
1) Neurodevelopmental hypothesis
2) Thickening of corpus callosum
3) Ventricular enlargement
3.5 Clinical features (appendix 3c)
- First rank symptoms/ Positive
- Negative symptoms
- Neologisms, Metonyms
3.6 Diagnosis (DSM – IV)
- At least 2 of the following for at least 1
month: (ABCD + PLANT V)
- Social / occupational dysfunction
- Post – schizophrenic depression is
common
3.7 Differential diagnosis:
Young adults
Older patients
- Drug induced
- Acute organic
psychosis
syndrome:
- Temporal lobe
encephalitis
epilepsy
- Dementia
- Diffuse brain
disease
Other DDX: psychotic depression, paranoid
personality disorder
3.8 PE and Investigation
- Full neurological examination: gait and
motor
- Cognitive examination: MMSE
- Blood: FBC, LFT, RFT, TFT, glucose.
- CT or MRI brain
- Urine drug screen
- EEG if suspects of TLE
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Study Notes in Psychiatry (2008)
Management:
3.9 Conventional antipsychotics
Typical antipsychotics:
-Chlorpromazine: more antiadrenergic &
antihistaminergic (100 – 400mg daily)
- Haloperidol: more EPSE (5 – 10mg daily)
- Trifluperazine: more EPSE: 5 – 10mg
daily
Block mesolimbic
Antipsychotic action
cortical bundle
Blk Nigrostriatal
Extrapyramidal
effects
Blk TuberoGalactorrhoea
infundibular activity
Side effects of typical antipsychotics:
1) Extrapyramidal side effects (EPSE):
-Acute dystonia: treated by IM
antimuscarinic (congentin 2mg)
- Akathisia: restlessness: treated by
propanolol 10mg TDS
- Pseudoparkinsonism: oral antimuscarinic:
benhexol 2mg BD
- Tardive dyskinesia
2) Hyperprolactinaemia
3) Antiadrenergic: sedation, postural
hypotension, failure of ejaculation
4) Anticholinergic: dry mouth, urinary
retention, constipation
5) Antihistaminergic: sedation
6) Antiserotonergic: depression
More on Tardive dyskinesia (TD)
- After chronic use of antipsychotic
- Due to upregulation of postsynaptic
Dopamine receptors in Basal Ganglia
- More common in female
- History of chronic brain disease: risk factor
-slow writhing movement (athetosis)
-Sudden involuntary movements
- Oral lingual region (chorea)
- Temporary raise the dose may give
immediate relief; try to maintain minimum
effective dose in long run
- Change to atypical antipsychotics
- Vitamin E may prevent deterioration
- Anticholinergic will worsen TD.
Conventional depot antipsychotics
IM Flupentixol 20 – 40mg 4 weekly
(Fluanxol) Other Modecate, Clopixol
- Long acting depot injection for non
compliant patients.
- To give a test dose to ensure no
idiosyncratic effects
Dr. Roger Ho
- High incidence of EPSE
3.10 Atypical antipsychotics
Risperidone: 1-2mg ON ($1/mg)
Higher affinity of D2 in mesolimibic and less
in nitrostriatal; higher affinity for 5HT2 and
α1 receptors.
Side effects:
- EPSE (if high dose like 4mg daily)
- Elevation of prolactin (strongest
among atypicals)
- Antiadrenergic side effects
Other preparations of risperidone:
PO Risperdal quicklet: quickly dissolve in
mouth
PO Risperdal solution: 1mg/ml $70/ bottle.
IM Risperdal consta – only atypical depots
Start with IM 25mg, increase to 37.5mg
every 2 weeks
Olanzapine: 5- 10mg ON ($1/mg)
Moderate for D2; High affinity for 5HT2 and
muscarinic receptors
Side effects:
- Weight gain and increase appetite
- Sedation
- Antiadrenergic side effects
- Prolongation of QT interval on ECG
- Hyperprolactinemia (transient)
Quetiapine: 100 – 800mg daily ($2/100mg)
Weak for D2, High affinity for 5HT2 and α1
Side effects:
- Antiadrenergic side effects like
postural hypotension
- Prolong QT interval
- Almost no EPSE (same as placebo)
- No ↑ in prolactin (same as placebo)
Sulpiride 200mg – 400mg ON (IMH)
- Low dose: block D3 and D4: negative
symptoms
- High dose: block D2 and D1: positive
symptoms
- Fewer EPSE, less sedation, cause
galactorrhoea.
Clozapine: more active at D4, 5HT2, α1 &
muscarinic receptors
- for treatment resistant SZ.(failure of 2
antipsychotics with adequate dose)
4
Study Notes in Psychiatry (2008)
Dr. Roger Ho
Side effects include:
- Life threatening agranulocytosis 2-3%;
needs regular FBC under clozaril
patient monitoring programme (IMH)
- Hypersalivation
- Anticholinergic and antiadrenergic.
- Fewer EPSE
3.11 Psychological treatment:
-Psychoeducation can prevent relapse by
enhancing insight
-Cognitive Behavioural therapy (CBT) to
challenge delusions.
-Social skill training: improve relationship
- Behavioural: positive reinforcement of
desirable behaviour.
Family therapy: to reduce expressed
emotion (EE). (High EE include hostility,
over-involvement, critical comments from
family; hence reduce relapse rate)
3.12 Other treatments:
- Rehabilitation (IMH) to enhance
self care, compliance and insight.
- ECT is for catatonic schizophrenia
Indications for Hospital admission:
 Suicide / violent
 Severe psychosis
 Severe depression
 Catatonic schizophrenia
 Non – compliance
 Failure of outpatient treatment
3.13 Prognosis
Rules of quarters
25%
25%
Complete Good
Remission recovery
25%
Partial
recovery
25%
Downhill
course
Good prognosis:
- Marked mood disturbance
- Family history of affective disorder
- Female sex
- Living in a developing country
- Acute onset
- Good premorbid adjustment
Poor prognosis: adolescence or early
onset, enlarged ventricles.
Causes of relapse:
1) Iatrogenic relapse: reduction of dose by
doctor
2) Non compliance
3) High expressed emotion
3.14 Complications of SZ
- Water intoxication in chronic
schizophrenia, leading to hypanatraemia.
- Suicide is the most common cause of
death of SZ, 10-38% of all deaths of SZ.
- SZ and violence: controversial: senior
psychiatrists say no but recent findings
support the association. In exam, safer to
say no association.
Schizoaffective disorder
It is a disorder in which the symptoms of
schizophrenia and affective disorder are
present in approximately in equal proportion.
ICD 10 requires both psychotic and mood
episode are simultaneously present and
equal prominent.
Treatment:
Antipsychotics + antidepressant or mood
stabilizer.
Schizotypal personality disorder
- There is familial relationship between
schizotypal personality disorder &
schizophrenia
Clinical features: UFO RIDE
U – unusual perception: eg telepathy
F – Friendless
O – Odd belief and odd speech
R – Reluctant to engage
I – Idea of reference
D – Doubtful of others
E – Eccentric behaviour
- Poor prognosis: 50% develop
schizophrenia
Schizoid personality disorder –
introspective’ prone to engaged in an inner
world of fantasy rather than take action; lack
of emotional warmth and rapport; self
sufficient and detached; aloof and
humourless; incapable of expressing
tenderness or affection; shy; often eccentric;
insensitive; ill – at – ease in company
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Study Notes in Psychiatry (2008)
Ch.4 Delusional Disorder (Oxford
Handbook, 2004)
4.1 Types of delusional disorder (DSM IV)
- Erotomanic (de Clerambault syndrome):
Important person like PM is secretly in love
with them; usually female; make effort to
contact important person.
- Morbid jealousy (Othello syndrome):
fixed belief that their spouse has been
unfaithful; collect evidence for sexual activity
& restrict partner’s activity; may result in
violence.
- Persecutory: Most common type; others
are attempt to harm; to obtain legal recourse
- Grandiose: special role, relationship,
ability, involved in religion.
- Somatic: delusion belief about body
(abnormal genitalia) to infestation: (worms
crawling in the body)
- Folie a deux – shared delusion between
husband and wife (close relationship)
Dr. Roger Ho
- huge impact on behaviour,
- abnormal process in arriving conclusion
4.6 Diagnosis: DSM IV requires > 1 month
duration
4.7 Differential diagnosis
Young patients
Old patients
- Substance induced - Dementia- memory
(stimulant,
loss
hallucinogen)
- Mood disorder with - Delirium: change in
delusion (mood
consciousness
before delusion)
- Schizophrenia (less - Late onset
elaborated delusion) psychosis (with
- OCD: reality testing hallucination)
is intact
- Paranoid
personality disorder
(Less clearly
circumscribed
delusion)
4.8
Delusional misidentification syndrome:
Capgras delusion
Fregoli delusion
Other have been
Someone they know
identified by identical in disguise and
or near identical
harming him
imposter
4.2 Epidemiology
- Uncommon: 0.025 – 0.03%
- Mean age: 40 – 49 years
- Usually equal in M and F; Morbid jealousy
more common in alcoholic male; Erotomania
more common in female
4.3 Risk factors and aaetiology
- advanced age, isolation, low social status,
premorbid ersponality disorder, sensory
impairment, substance abuse, family history,
history of Head Injury, Immigration
- Temporal lobe epilepsy,
4.4 Pathogenesis:
- Cortical damage: paranoid delusion
- Basal ganglia – less cognitive disturbance
- Folie a deux: one dominant and one
submissive partner in a relationship
4.5 Clinical features:
- Delusions are highly implausible,
- with evidence of systematization (better
organized than SZ delusion);
-
Assessment
A thorough history and MSE
Collateral history from 3rd party
To rule out organic causes
Document risk assessment
4.9
Management
- Admission to hospital if there is a risk to
self or violence to others.
- Separation from source or focus of
delusion
- Antipsychotics: atypical: less side effect
- Both risperidone and Haloperidol have
liquid form: for those refusing tablets
- Benzodiazepine to treat anxiety
Psychological treatment
- Supportive psychotherapy: to establish
therapeutic alliance without confronting
- Cognitive techniques: gently challenge
delusion
- Social skill training
- Improving risk factors: sensory deficits,
isolation
4. 10 Prognosis
Remission
Improvement
33-50%
10%
-
Persisting
33-50%
Better prognosis if it is acute;
Poor prognosis if delusional disorder
last longer than 6 months.
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Study Notes in Psychiatry (2008)
Ch. 5
Bipolar disorder
5.1 The affective spectrum
- Dysthymia – not meeting criteria of
depression
- Depression
- Atypical depression: hypersomnia,
hyperphagia
- Psychotic depression
- Recurrent depression
- Bipolar II – Hypomania
- Bipolar I – Mania
- Rapid cycling > 4 episodes per year
- Ultra – rapid cycling: very rapid changes
5.2 Epidemiology
- Lifetime prevalence: 0.3 – 1.5%
- M = F in prevalence
- Bipolar II / rapid cycling: more common in
Female
- Mean age of onset: 21 years old
5.3 Aetiology
- Genetics: 1st degree relative are 7x more
likely to develop this condition.
- Children of a parent with bipolar disorder
have a 50% chance of developing
psychiatric disorder
- MZ:DZ 45%: 23%
5.4 Pathogenesis
- Noradrenaline, dopamine, serotonin, &
glutamine have all been implicated.
- Antidepressant induced mania or
hypomania is common.
5.5 Clinical features
Hypomanic episode: MANIAC (Clinical skill
training)
For mania, on top of MANIAC, they also
have:
- severe enough to interfere social &
occupation function.
- Psychotic features related to grandiosity.
- Flight of idea, Pressure of speech
- Racing thought
- Behaviours with serious consequences:
reckless spending, inappropriate sexual
encounters, careless investment.
5.6 Diagnosis
Dr. Roger Ho
- Bipolar I disorder: occurrence of 1 or
more manic episode with or without history
of 1 or more depressive episode.
- Bipolar II disorder – occurrence of 1 or
more depressive episode accompanied by
at least 1 hypomanic episode.
5.7 DDX:
- Substance abuse (if young)
- Organic: thyroid, cushing, SLE, head injury
- Psychotic disorders (if psychotic features)
- Schizoaffective disorder (prominent
psychosis)
- Anxiety disorders
5.8 Investigation
- FBC, ESR
- LFT, RFT, TFT, glucose
- VDRL
- Urine drug screen
- CT/MRI to rule out space occupying lesion,
infarction, haemorrhage
- EEG to rule out epilepsy
Other tests:
- ANF to rule out SLE in ladies
- Urinary copper to rule out Wilson disease
5.9 Setting of Treatment:
Usually require admission for manic
episode; ward has to be calm with less
stimulation.
Indications for admission include:
- High risk of suicide or homicide
- Lack of capacity to cooperate with
treatment
- Poor psychosocial supports
- Severe psychotic symptoms
- Severe depressive symptoms
- Rapid cycling
- Failure of outpatient treatment
Goals of outpatient treatment
- Establish & maintain therapeutic alliance
- monitor psychiatric status
- Psychoeducation for bipolar disorder
- Enhancing treatment adherence
- Monitoring side effects of medication
- Promoting regular sleep and activity
- Identify new episodes early
DSM IV diagnosis
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Study Notes in Psychiatry (2008)
5.9 Pharmacological Management
Acute treatment of manic phase :
By antipsychotics:
Haloperidol 5-10mg daily;
Risperidone 2- 4mg daily
Olanzapine (more sedative & good for mood
symptoms but expensive): 5- 10mg daily
Then add on mood stabilizer after blood
investigations.
Lithium CR (500mg – 1000mg $0.3-0.6)
Before starting lithium, RFT & TFT have to
be normal.
Mechanism of action :
- By stimulating Na/K pump, stimulates
entry of Na into the cells where intracellular
Na is reduced in manic state; stimulates exit
of Na from cells where intracellular Na is
elevated in depressed state.
- Inhibits both cyclic AMP and inositol
phosphate second messenger system in
the memberane.
Indications:
- For depression, manic states
- Prophylaxis of bipolar disorder
- not useful for rapid cycling
Adverse effects:
- Short term side effects: GI disturbances
(nausea, vomiting, diarrhea)
- Long term side effects: nephrogenic
diabetes insipidus due to blockage of ADH
sensitive adenyl cyclase, hypothyroidism
and cardiotoxicity
- Toxic effects (refer to appendix 5a):
Lithium overdosage can be fatal.
- Ebstein anomaly in foetus.
Sodium valporate (Epilim) (400mg –
1000mg) ($0.5 – 1)
Before starting Valporate, check LFT
Mechanisms
- mediate its therapeutic effect by indirect
inhibitions on GABAergic systems.
Indications:
- Treatment of depressive and manic
episodes
- Prophylaxis of bipolar affective disorder
- For rapid cycling disorder
Dr. Roger Ho
Adverse effects:
- Slight risk of liver, pancreatic toxiciety
- Haematological disturbance of platelet
function; Neural tube defect in foetus
Carbamazepine 400– 800mg ($0.2-0.4)
Check FBC before starting carbamazepine
Mode of action:
- Mediate its therapeutic effect by inhibiting
kindling phenomena in the limbic system
Indications:
- Depression
- Prophylaxis of bipolar affective disorder
Adverse effect:
- Drowsiness and dizziness
- Leucopenia and other blood disorders
Lamotrigine 50 – 150mg 100mg = $3
For bipolar disorder with depressive
episodes
5.10 Psychological Management
- Cognitive therapy to challenge grandiose
thought
- Behavioural therapy to maintain regular
pattern of daily activities
- Psychoeducation on bipolar disorder
- Family therapy: Psychoeducation for family
& techniques to cope with patient’s illness
- Relapse drills: to identify symptoms and
to formulate a plan to seek help in early
manic phase.
- Support group for bipolar patients.
5.11 Other treatment
- ECT: Best for acute mania, failure to drug
treatment, for pregnancy (to avoid
teratogenic effects)
5.12 Course and Prognosis:
-Extremely variable
-First episode may be hypomanic, manic,
mixed, or depressive
- Length of time between subsequent
episodes may begin to narrow but stabilize
at 4th to 5th decade.
- Untreated patients have > 10 episodes in a
lifetime.
- Treated patients have better prognosis
5.13 Complication:
- Morbidity and Mortality rates are high: lost
work, lost productivity, divorce, attempted
suicide 25-50% & committed suicide: 10%
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Study Notes in Psychiatry (2008)
Ch. 6 Depressive Disorder
6.1 Epidemiology
Age: Women, highest prevalence between 35
and 45 years; Men increases with age
Sex: F:M = 2:1
Social class: more common in I (rich), II and V
(poor)
More common among divorced, separated
Prevalence: 5%
6.2 Aetiology:
- Genetics: Prevalence in first rate relatives: 1015%
- Monoamine theory of depression: depletion
of monoamine such as 5HT & NA
- Endocrine abnormalities: hypersecretion of
cortisol, decreased TSH
Psychological theory:
- Maternal deprivation when young
- Learned helplessness: highly aversive
outcomes are possible.- Cognitive distortions:
1) Arbitrary inference: drawing conclusion when
there is no evidence.
2) Selective abstraction – ignore important
feature
3) Over-generalisation from single incident
4) Minimisation positive and magnitification of
negative
Social theory: for women, (Brown & Harris)
-3 or more children under 15 yr of age
-not working outside
-lack of supportive relationship from hd.
-loss of mother/separation before age 11
-Threatening life event before depression
6.3 Clinical features:
- DEPESSION – refer to clinical skills
-Severe depression may have psychotic features:
-Delusions concerned with themes of
worthlessness, guilt, ill-health, poverty
-Persecutory delusion: people are about to take
revenge on him
- Hallucination: second person auditory
hallucination: repetitive words & phrases
6.4 DDX:
- Is it mixed anxiety & depression?
- Is it bipolar disorder?
- Endocrine: hypothyroidism
- Medication related: antihypertensive, steroid
- Alcohol abuse
6.5 Investigations: FBC, ESR, B12, Folate, RFT,
LFT, TFT
6.6 Pharmacological Management:
Selective serotonin reuptake inhibitors SSRI
Dr. Roger Ho
-Fluoxetine (Prozac) 20mg OM ($0.2) for
retarded depression; adverse effect:
Restlessness; Long half life, avoid in elderly with
a lot of medication; (first line nowadays)
- Fluvoxamine (Faverin) 50mg -100mg ON; $0.5
Sedative; high incidence of nausea & vomiting in
first few days.
- Paroxetine CR (Seroxat) 25mg ON, $2: good
for mixed anxiety & depression; more withdrawal
symptoms
- Escitalopram (lexapro) 10mg ON, $1.5; less
drug interaction, good for elderly
- Setraline (Zoloft) 50 – 150mg ON; $1.8
-Noradrenergic and specific serotonergic
antidepressants (NaSSas): Mirtazepine
(Remeron) 15-30 mg ON ($1-2); 5HT-2 and 5HT3 postsynaptic receptor antagonist & antihistamine effects.
- good for depression and insomnia
- drowsiness and weight gain
- No serotonin related side effects: sexual
dysfunction, insomnia, agitation, nausea
- No cardiovascular or anticholinergic side effects
- Serotonin & Noradrenaline reuptake
inhibitor: Venalfaxine (Efexor) 75 mg BD $5.6;
second line, high dose  hypertension
Duloxetine(Cymbalta) 60mg ON for pain &
depression
- TCA: amitriptyline 50 – 100mg ON,
cardiotoxicity when overdose, anticholinergic side
effects; MAOI: seldom used
- ECT: for actively suicidal patients, not eating &
drinking, treatment resistant depression
-ECT has wide range effects on monoamine
-Absolute contraindication: raised ICP
-Relative contraindications: cerebral aneurysm,
recent MI, cerebral haemorrhage, retinal
detachment.
-Early side effects: loss of short term
(retrograde) memory, headache, confusion,
muscle aches
-Late side effect: long term memory loss
Mortality of ECT: 2/100, 000
6.7 Psychological Treatment
CBT: Cognitive: Identify cognitive dysfunctions
from dysfunctional thought diary; patient will
examine evidence for and against them; cognitive
restructuring to change distorted thought;
Behavioural: increase pleasurable activities.
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Study Notes in Psychiatry (2008)
Ch. 7 Obsessive Compulsive Disorder
7.1 Epidemiology
- Onset is most commonly in early adult life
- Equally common among men and women
- Prevalence 0.05%
7.2 Aetiology
- Genetic: MZ: DZ 80%: 25%
- Organic factor: during epidemic of
encephalitis lethargica
- Premorbid personality: 70% of OCD
patients have obsessive compulsive
personality trait- cleanliness, orderliness,
rigid, checking
7.3 Pathogenesis
- Dysregulation of the 5HT system
- Cell immediated autoimmune factors
- CT/ MRI: bilateral reduction in caudate
nucleus.
- Psychological explanation: OCD patients
have defective arousal system and inability
to control unpleasant internal states.
Obsessions (fear of dirt) are stimuli
associated with anxiety provoking events
where compulsions (such as hand washing)
are learned to reduce anxiety.
7.3 Clinical features
OBSESSION – DIRT
Doubts: repeating themes expressing
uncertainty about previous actions: turned
off the tap or not
Impulses – Repeated urges to carry out
actions that are usually embarrassing or
undesirable e.g shout obscenities in church
Ruminations – repeated worrying themes
of more complex thought – the end of the
world.
Thought – repeated and intrusive words or
phrases
Compulsions – Cs (refer to clinical skills
training)
A compulsion is usually associated with an
obsession as if it has the function of
reducing the distress caused by obsession.
E.g obsessional thought with hand
contamination, associated with handwashing
compulsion.
7.4 DDX:
- Anxiety disorders
- Phobic anxiety disorders
- Psychotic disorders
Dr. Roger Ho
-
Organic disorders
Depressive disorders
7.5 Pharmacological treatment
- SSRIs are indicated in the treatment
of OCD. OCD require higher doses
of SSRIs compared to depression.
- Fluvoxamine (Faverin) 150mg –
200mg
- Fluoxetine (Prozac) 40mg – 60mg
- Paroxetine CR (Seroxat) 25mg –
75mg: for very anxious patients.
7.6 Psychological treatment
Cognitive therapy: to use dysfunctional
thought diary to record obsessions and
gently challenge obsessional thought.
Behavioural therapy: Exposure and
response prevention. This technique
involves exposing patient to situations they
avoid such as dirty places and the patient is
subsequently prevented from carrying out
the usual compulsive cleansing rituals until
the urge to do it has passed (response
prevention)
Thought stopping: The patient is asked to
ruminate and upon doing so, the therapist
shouts “stop” to teach the patient to interrupt
the obsessional thought. The patient then
learns to internalize the “stop” order so that
thought stopping can be used outside
therapy situation.
Rehabilitation
- to maintain functional capacity;
- Maintain their strengths
- Promote adaptation to everyday
living.
7.7 Social treatment
Obsessional patients often involve other
family members in their rituals. In planning
treatment, it is essential to interview
relatives and encourage them to adopt a
firm but sympathetic attitude to the patient.
7.8 Prognosis
- Poor prognosis: Giving in to compulsions,
longer duration, early onset, bizarre
obsession & compulsion, comorbid delusion
and depression
- Good prognosis: good premorbid,function
a precipitating event.
OCD does not associate with suicide.
10
Study Notes in Psychiatry (2008)
Ch. 8
Anxiety Disorders (Ox handbook)
8.1 Generalised Anxiety Disorders
Epidemiology:
-Lifetime prevalence: 2.5-6.4%
-Female> Male
- Early onset: with childhood fears
- Late onset: stressful life events
Aetiology:
- Genetics: Heritability: 30%
- Increase ANS responsiveness
- Loss of control of cortisol
- ↓ GABA activity
- dysregulation of 5HT activity
- Unexpected negative events eg early
death of parent
- Chronic stressors
Clinical features (at least 4)
-Autonomic arousal: sweating, shaking
-Physical: breathing difficulty, choking,
nausea, swallowing difficulty
-Mental: dizzy, fainting, derealisation,
depersonalization
-General: numbness, tingling
-Tension: muscle,ache, keyed up
-Other: mind going blank, poor concentration
DDX:
- normal worries
- mixed anxiety and depression
- Alcohol & drug abuse
- Organic: Thyroid disorder, Arrhythmia,
Asthma, Temporal lobe epilepsy,
hypoglycemia.
Investigation: FBC, LFT, RFT, TFT,
glucose, ECG
Management:
-Psychological: relaxation therapy.
-Pharmacological: short term
benzodiazepine, SSRI (avoid fluoxetine),
propranolol for palpitation
Course:
-Chronic and disabling, low remission rate
-Can lead to alcohol abuse.
8.2
Panic disorder
Epidemiology:
Lifetime prevalence: 4.2%
Women: 2-3 times higher than men
2 peaks in women: 15-24 yr; 45-54 yr
Dr. Roger Ho
Aetiology:
- Genetics: 30-40% heritability
-Supersensitivity of 5HT1A receptors
- Increased adrenergic activity
- Decreased in GABA – inhibitory
- Fear network in brain: amygdala
Clinical features
-Palpitations, SOB, choking, shaking
- Autonomic arousal
- Fear of losing control
-Concerns of death from cardiac &
respiratory problems
DDX/Investigations: similar to GAD
Psychological Management:
Behavioural: use of relaxation & control of
hyperventilation
Cognitive method: teaching about bodily
responses associated with panic attack
Pharmacological:
-SSRI: paroxetine, fluoxetine, fluvoxamine
are recommended drug of choice
- BZDs: alprazolam 0.5mg for acute attack
Hyperventilation Syndrome (HVS):
- Very common; more common in Female
- 50-60% of patients with panic disorder
have HVS
- Hyperventilation;chest pain;dizziness;
bloating; acute hypocalcaemia
- Treatment: establish normal breathing
pattern, benzodiazepine; breathing into
paper bag is not recommended nowadays
as CO2 can trigger more anxiety.
Agoraphobia: (housebound housewife)
15-35 yr old; more common in women
Fear of shops, markets, bus, MRT, crowd,
place that cannot be left suddenly
Social phobia
17-30; M = F; avoid situations that can be
observed by others (presentation, hawker
centre, MRT) & worries of humiliating or
embarrassing
Management: short term benzodiazepine,
SSRI
Systematic desensitization: imagine or
expose to anxiety provoking situations,
progress through hierarchy, neutralize by
relaxation technique until patient habituates
11
Study Notes in Psychiatry (2008)
Chapter 9 Post traumatic stress disorder
9.1 Epidemiology
- After traumatic event, 8-13% for men, 20 30% for women develop PTSD
- Lifetime prevalence 8%.
- F:M = 2:1
9.2 Aetiology
- Genetic: higher concordance in MZ than
DZ twins
- Reduced right hippocampal volume,
enhanced reactivity to stimulation & memory
deficits
- Dysfunction amygdala lead to enhanced
fear response
Risk factors:
-Low education
-Lower Social class
-Female gender
-Low self esteem
-Family history of
psychiatric disorders
- Previous trauma
Protective factors
- High IQ
- High social class
- Male
- Chance to view
body of dead person
9.3 Clinical features (Appendix 9a)
- PTSD is a severe psychological
disturbance following a traumatic event
characterized by involuntary re-experiencing
of the events, with symptoms of
hyperarousal, avoidance and flashbacks of
events. Longer than 4 weeks.
9.4 DDX
- Acute stress reaction - Adjustment disorder
9.5 Psychological treatment
- CBT: education about PTSD, anxiety
management, anger management, cognitive
restructuring for trauma experience, gradual
exposure to stimuli avoided
- Psychodynamic therapy: understand the
meaning of trauma, to resolve unconscious
conflict.
- Eye movement desensitization &
reprocess: Using voluntary multi-saccadic
eye movements to reduce anxiety (limited
experience in Singapore, don’t mention it in
oral exam)
- Look for alcohol abuse
9.6 Pharmacological treatment
- Depressive symptoms: SSRI
- Anxiety symptoms: 2 weeks alprazolam
0.25mg TDS
Dr. Roger Ho
9.7 Complication
- 50% recover 1st year; 30%: chronic
Acute Stress Reaction (hrs to days):
A transient disorder (hrs or days) that occur
as immediate response to exceptional stress,
accident, assault, fire, bereavement).
Clinical features: depression and anxiety.
Acute Stress disorder (2d – 4 weeks)
Similar to acute stress reaction, but more
dissociative symptoms
Similar to PTSD, but less than 4 weeks
duration.
Adjustment disorder (3 mo – 6 mo)
It occurs within 3 months of a particular
stressor & should not last longer than 6
months after the stressor is removed.
Manifested as depression and anxiety (no
psychotic features).
Treatment of above disorders:
Supportive psychotherapy to enhance
capacity to cope, understand meaning of
stressors.
Pharmacological: SSRI, short term BZD
Normal and abnormal grief reactions
- Bereavement: any loss event
- Normal grief: refer to appendix 9a
Mean duration: 6 months.
- Abnormal grief:
1) Intense
2) Prolonged> 1 year
3) Delayed grief
4) Absent grief
Other features: thoughts of death, excessive
guilty, marked psychomotor retardation,
prolonged impairment of function,
hallucination.
Management:
- Short term benzodiazepine:
alprazolam 0.25mg TDS for 2 weeks
- Antidepressant if there are
depressive symptoms
- Supportive psychotherapy:
enhance coping
- Grief therapy: explore the meaning
of the loss, let go of the past and
move towards the future.
Ref: Oxford Handbook, 2004
12
Study Notes in Psychiatry (2008)
Ch. 10 Alcohol dependence
10.1 Definition of dependence:
1) Subjective awareness of compulsion to
drink
2) Stereotyped pattern of drinking
3) Increased tolerance to alcohol
4) Primacy of drinking over other activities
5) Repeated withdrawal symptoms
6) Relief drinking
7) Reinstatement after abstinence
10.2 Epidemiology
Age: men in their early twenties
Sex: More common in male; increasing
incidence in females.
Social class: lowest prevalence in middle
social blass
Marriage: more common in
divorce/separated
Occupation: high risk: directors, doctors.
10.3
Aetiology:
- Genetic factors: MZ > DZ twins, adoption
study also proves genetic links.
- Abnormal neurotransmitter mechanism
- Learning factors: learn from peer / parents
- Personality factors: chronic anxiety,
feeling inferior.
- Other illness: anxiety disorder, depression
10.4
Clinical features (appendix 10)
Alcohol intoxication: explosive outbursts
of aggression, short term amnesia after
heavy drinking, idiosyncratic reactions to
alcohol, pathological drunkenness: acute
psychosis induced by small amount of
alcohol
General withdrawal symptoms: 12-24 hr
- Acute tremulousness in hands (the shake)
- Agitation, sweating
- Nausea
- Perceptual distortions & hallucinations
- Convulsions
Delirium tremens: 3-4days
- Clouding of consciousness
- Disorientation in time & place
- Impairment of recent memory
- Illusions & Hallucinations
- Fearful affect
- Prolonged insomnia
- Tremulous hands
- Truncal ataxia
- Autonomic overactivity
Alcoholic hallucinosis
Dr. Roger Ho
-occurs in clear consciousness
-voices utter insults or threats,
- Causes anxiety in patients
Inx: FBC, LFT, U&E, GGT, CXR, glucose
10.5
Management
Detoxification: managing withdrawal
- Diazepam 5mg TDS, Vitamin, thiamine
30mg OM, B12, Rehydration.
Motivation interviewing to help patient to
change.
Stages of change: precontemplation,
contemplation, preparation, action,
maintenance, relapse
- Refer to CAMP, IMH
Pharmacological agents used for
maintenance:
- Disulfiram: an aversive stimulus, inducing
nausea if patient drinks alcohol
- Acamprostate: works on GABA/glutamate
system, for maintenance
- Naltrexone: opiate receptor antagonist,
Psychological treatment:
Behavioural therapy: keep diary log &
tackle drinking behaviour.
Social treatment:
- Goal orientated treatment plan:
Total abstinence: > 40, heavily dependent,
physical damage, failed controlled drinking
Controlled drinking:< 40, not dependent
on alcohol, no physical damage, early stage
- Alcoholic anonymous: observe &
mirroring, develop coping strategies
- Half way house: rehabilitation, counselling
10.6
Complications
Nutritional or toxic disorders
Wernicke’s
Korsakoff’s
encephalopathy
psychosis
Ophthalmoplegia
Impairment of recent
Nystagmus
memory
Clouding of
Confabulation
consciousness
Retrograde amnesia
Memory disturbance Disorientation
Ataxia
Euphoria
Alcohol dementia
- Depression and suicidal behaviours
- Polysubstance abuse
- Social complications: job, marriage
10.6
Prognosis: good prognosis in
motivated, socially stable, no antisocial
personality disorder
13
Study Notes in Psychiatry (2008)
Ch. 11 Drug Dependence
11.5 Cannabis
Effects
11.1 Definition:
It is a state, resulting from the interaction
between a human and a drug, characterized
by behavioural and other responses that
include a compulsion to take the drug on a
continuous or periodic basis to experience
its psychic effects & to avoid discomfort.
11.2 Physical and psychological
dependence
Drugs
Heroin
Hallucinogen
Amphetamine
Cannabis
Cocaine
BZD
Physical
Yes
No
No
No
No
Yes
Dr. Roger Ho
Psychological
Yes
Yes
Yes
Yes
Yes
Yes
11.2 Opiates – eg Heroin
Chronic use
Withdrawal
Constipation
Pilo-erection,
Constricted pupils
shivering
Weakness
-Abdominal cramps
Impotence
-Lacrimation
Tremors
- Dilated pupils
- Intense crave for
drugs
- Agitation
Treatment:
- Methadone: 20mg solution form,
supervised treatment.
- Buprenorphine (Subutex) was listed as
illegal drug & withdrawan from Singapore.
11.3 Hallucinogens – LSD (lysergic acid
diethylamide)
- Effects occur after 2 hours of consumption.
- Synaethesia: confusion between senses
e.g hearing images
- Out of body experience
- Anxeity and depression
- Can lead to unpredictable & dangerous
behaviour.
11.4 Amphetamines
- Chronic use can lead to paranoia
- Hostility & aggression
- Persecutory delusions
- Auditory, visual, tactile hallucination
- Clear consciousness
-Exaggerating existing
mood
-Distortion of time & space
-Intensification of visual
perception & visual
hallucination
-Reddening of eye
-Irritation of respiratory
tract
Chronic
effects
Chronic
amotivational
syndrome.
Flashback
phenomena
Psychotic
reactions
11.6 Cocaine
Formication (cocaine bugs) – exam classic:
a tactile hallucination as feeling insects
crawling under the skin.
Treatment of above disorders: may need
antipsychotics to treat psychotic experience.
11.7 Benzodiazepine
e.g. Dormicum (Midazolam), Alprazolam
(Xanax)
Chronic use
Withdrawal
Unsteady gait
Rebound insomnia
Dysarthria
Anxiety
Drowsiness
Appetite disturbance
Nystagmus
Sweating,
convulsion
Confusion,
Delirium tremens
Treatment: switch to long acting
benzodiazepines such as diazepam 5mg
TDS and slowly cut down the dose.
May need in-patient detoxication if using
high dose benzodiazepine.
Psychological treatment:
- Supportive psychotherapy: educate
patients on complications of drug
dependence and cope with day to day
problems.
- Group therapy: observe their own
problems mirrored in other drug abusers;
work out for better coping
- Behavioural therapy: keep a diary of drug
use and explore mood and feelings at the
time of drug use with therapist and to reduce
the number of drug intake.
- Rehabilitation in CAMP, IMH: to leave the
drug subculture, support by counselor.
14
Study Notes in Psychiatry (2008)
Ch. 12 Old Age Psychiatry
12.1 Alzheimer’s disease
-most common cause of dementia (70%)
Epidemiology
-1% at 60, doubles every 5 years; 40% at 85
yr old
-M:F = 4:1
- Other risk factor: Down syndrome, head
injury, hypothyroid
Genetics:
- Chromosome 21 for amyloid precursor
protein
- Chromosome 19 for apolipoprotein E4
- Chromosome 14 for presenilin 1
- Chromosome 1 for presenilin 11
Cholinergic hypothesis: degeneration of
cholinergic nuclei in nucleus of Meynert
Pathophysiology
-Amyloid plagues in hippocampus,
amygdale and cortex
-Neurofibrillary tangles in cortex,
hippocampus
Clinical features
Early symptoms: increasing forgetfulness
Amnesia
Aphasia (word finding difficulty)
Apraxia (cannot dress)
Agnosia (cannot recognize body parts)
Poor visual spatial skill
Delusion of theft against maid in S’pore
Hallucination 10%
Behavioural disturbance: aggression,
wandering, sexual disinhibition
Mini-mental state exam < 24 /30
Investigations: FBC, B12, Folate, LFT,
RFT, VDRL, CT or MRI brain
Management:
Acetylcholinesterase inhibitors: $$$
MMSE > 12 points
Donepezil 5-10mg/day: (5mg=$5) long half
life, once daily dosage with GIT side effects,
not for asthma patients
Dr. Roger Ho
Rivastigmine 3-6mg BD: ($2.6/3mg) short
half life, GIT side effects and safe in asthma.
Galantamine: 4-12mg BD (8mg = $4.5);
also works on nicotinic Ach receptors.
Memantine: NMDA receptors partial
antagonist (10mg = $3)
Low dose antipsychotics such as risperidone
1mg ON for delusion of theft
Behavioural techniques for chaging
negative behaviour
Poor prognosis: Male, Onset < 65, Parietal
lobe damage, prominent behavioural
problems, Depression
12.2 Other causes of dementia
- Dementia with Lewy body (with
parkinsonism)
- Fronto – temporal dementia with
personality changes
- Vascular dementia with neurological signs
of stroke
12.3 Reversible causes of dementia –
Appendix 12a
12.4 Pseudo dementia: always say, “I
don’t know”
- Previous history of depression
- Islands of normality
- Response to antidepressant
12.5 Psychosis in elderly
Less than 1%; F:M 5:1
Family history of schizophrenia; sensory
impairments, social isolation
Persecutory delusions: 90%
Auditory hallucinations: 75%
Visual hallucination 13%
Treatment: relieve isolation & sensory
deficits; low dose atypical antipsychotics:
risperidone 1mg ON / quetiapine 50mg ON
12.6 Depression in elderly
- more psychomotor retardation
- nihilistic delusion (Cotard syndrome)
- Monitor suicide risk
- Treatment of choice: escitalopram 10mg
ON
15
Study Notes in Psychiatry (2008)
Ch. 13 Consultation Liaison Psychiatry
13.1 Dissociative / Conversion Disorders
Definition
- Dissociation – an apparent dissociation
between different mental activities.
- Conversion - Mental energy can be
converted into certain physical symptoms.
Epidemiology:
- Onset usually before the age of 35
- More common among women
- More common in lower social class
- Occurs in national servicemen
Aetiology:
- Premorbid personality: 15% has premorbid
histrionic personality traits.
- Emotionally charged ideas lodged in the
unconscious at some time in the past. There
is a conversion of psychic energy into
physical channels.
Pathogenesis
- Primary gain: anxiety arising from a
psychological conflict is excluded from
patient’s conscious mind
- Secondary gain: symptoms confer
advantage to patient: exempted from NS.
Clinical features:
Dissociation
- Psychogenic
amnesia
- Psychogenic fugue
(wandering)
-Somnambulism
(sleep walking)
- Multiple personality
Conversion
- Paralysis
- Fits
- Blindness
- Deafness
- Aphonia.
- Anaethesia
- abdominal pain
- Disorder of gait
La Belle indifference: less than the
expected amount of distress often shown by
patients with hysterical symptoms.
DDX:
- Exclude organic causes: temporal lobe
epilepsy, cerebral tumour, general paralysis
of insane dementia
- Exclude malingering: conscious aware of
what he or she is doing, making up illness
- Exclude histrionic personality disorder.
Investigation: no demonstratable organic
findings
Management:
Psychological treatment:
- reassurance and suggestion
Dr. Roger Ho
- exploratory psychotherapy about his past
life.
Social treatment: to eliminate factors that
are reinforcing symptoms.
Biological treatment: Abreaction: IV
injection of small amount of diazepam to put
patient into resting state and encouraged to
relieve stressful life event (last to mention in
exam)
Prognosis: If the course is longer than 1
year, it is likely to persist for many years.
Pseudoseizure:
- Inconsistent neurological sign
- Can recall the seizure episode & avoid
injury
- no increase in serum prolactin (increases
in genuine epilepsy)
13.2
Hypochondriasis
Hypochondriasis is the preoccupation with
the fear of having a serious disease which
persists despite negative investigation.
Epidemiology
More common among elderly, equal sex
incidence, lower social class
Aetiology:
- History of childhood illness, parental illness,
excessive medical attention seeking in
parents, childhood sexual abuse
- Tendency to misattribute body symptoms
- Medical reassurance provides temporary
relief of anxiety which acts as a reward for
more medical attention.
Clinical features:
-Preoccupation with the idea of having a
serious medical condition, which will lead to
death and serious disability.
- Patient will seek medical advice but is
unable to be reassured by negative
investigations;
- Anxiety & depression are common.
- It is usually in the form of overvalued idea.
Management
- Allow patient to ventilate their problems
- Explain negative test, reassurance, no
further investigation,
- Aim to improve function
- Break cycle of repeat consultation
- Family education
16
Study Notes in Psychiatry (2008)
- CBT: challenge & replace misinterpretation
- Exposure to illness cue & response
prevention
- Depression: use SSRI like fluoxetine
Somatisation disorder
A chronic disorder of multiple medically
unexplained symptoms, affecting multiple
organ systems presenting before the age of
40. It is associated with significant
psychological distress.
Aetiology - More family members with
somatisation disorder; similar to aetiology of
hypochondriasis.
Epidemiology: - 0.2%; F:M 5:1; age of
onset: childhood to 30s
Clinical features:
Pain: right iliac, back and head
CVS: dyspnoea, chest pain, palpitation, BP
GI: heartburn, nausea, flatulence, dysphagia
Sweating or body odour
Management:
Initial:
-Acknowledge symptom severity & as real
-Attempt to reframe symptoms as emotional
Ongoing management:
-Regular review by single doctor, planned
visit, avoid AED & unnecessary investigation
- Investigate objective signs only
- Symptom re-attribution
- CBT
Body dysmorphic disorder
(Dysmorphophbia): Preoccupation that
some aspect of physical appearance (body
image) is grossly abnormal & refuses to
accept medical explanation. Treated by
SSRI and CBT. It can lead to depression,
suicide, & functional impairment.
Factitious disorder / Munchausen’s
syndrome: falsify symptoms & fabricate
signs (use ketchup for blood) for medical
attention
Capacity to give consent
1) Patient must be informed about the
procedure, risk and benefit
2) Can patient understand the info?
3) Can patient retain info?
4) Can patient balance the risk or benefit?
Dr. Roger Ho
5) Can patient arrive at a conclusion?
6) Further assessment of cognitive function
e.g mini mental state examination.
7) Having a psychiatric illness like
Schizophrenia does not mean lack of
capacity to give consent.
Delirium/ Acute confusional state
It is a clinical syndrome of fluctuating global
cognitive impairment with behavioural
abnormalities due to variety of insults.
Epidemiology
10% of medical & surgical inpatients.
Risk factors: elderly, dementia, blind & deaf,
postoperative, burn victims, alcoholic.
Aetiology
-Intracranial: CVA, head injury, CNS
infection
- metabolic: electrolyte disturbance, hepatic
encephalopathy, hypoxia
- endocrine: Pituitary, thyroid, PTH, adrenal
- Infection: UTI, chest infection, abscess
- Substance intoxication and withdrawal
Clinical features: - Fluctuating course
-impaired consciousness and attention
- Disorientation, impaired recent memory
- Nocturnal worsening of symptoms
- Psychomotor agitation & emotional lability
- illusions, visual hallucinations (big insect)
- Poorly formed paranoid idea (other
patients want to harm him)
DDX: - Psychotic illness
- Post ictal confusion
- Dementia
Management:
1) Identify & treat precipitating cause
2) Provide calm environment with
reality orientation (big clock)
3) Low dose antipsychotics:
Haloperidol 2.5mg/ risperidone 1mg
4) Regular review and follow up
5) Educate family about delirium
Depression in chronic medical illness
- Common, Look for non somatic
symptoms: guilt, concentration, low
mood
- Assess suicide risk
- Use escitalpram as it has less drug
interactions.
17
Study Notes in Psychiatry (2008)
Ch. 14 Perinatal Psychiatry
14.1
Baby blues
¾ of new mothers will experience a short
lived period of tearfulness and emotional
lability starting 2-3 days after birth.
Due to pospatrum reductions of oestrogen,
progesterone and prolactin.
Dr. Roger Ho
-Prominent affective features (80%): mania /
depression
- Psychosis, paranoid idea about safety of
baby
- Insomnia, perplexity, disorientation
- Look for suicide & infanticide risk
Management:
Treatment in hospital – KK women hospital /
In the UK, admit to special mother – baby
unit
No need for treatment.
ECT is useful
14.2
Postnatal depression
Epidemiology:
- 10-15% of women
- Peak: 3-4 weeks of delivery
Risk factors:
- Family history of depression;
- Poor relationship with own mother
- Ambivalence towards pregnancy
- Poor social support
- Previous postpartum depression
Clinical features
- Depression + worries about baby’s health
and ability to look after baby
- 90% last less than 1 month
Management:
- Prevention by education
- Enhance support
- If severe, SSRI (to avoid breast
feeding)
- CBT
14.3
Postpatrum psychosis
Epidemiology
1.5/1000 live births
Peak: 2 weeks postpartum
Antipsychotics is needed ( to avoid breast
feeding)
14.4
Premenstrual Syndrome (PMS)
PMS is a constellation of menstrually related,
chronic, cyclical, physical and emotional
symptoms in the luteal phase.
Symptoms: Breast tenderness, fatigue,
cramping, bloating, irritability, depression,
poor concentration, food cravings, lethargy,
libido changes.
Prevalence: 40% of women of reproductive
age, severe impairment in 5%
Investigation: Charting of daily symptoms
for at least 2 menstrual cycle may aid in
confirming cyclical pattern.
Treatment:
Conservative management: Low salt and
fat diet, less caffeine, reduce alcohol and
tobacoo intake, to reduce stress
Consider medication: to try SSRI if fails to
conservative treatment.
Refer to O and G if above measures fail
Aetiology
Reduce of oestrogen, leading to dopamine
super-sensitivity, cortisol levels or
postpartum thyroiditis
Ref: Oxford Handbook, 2004
Risk factors:
- Family history of psychiatric disorder
- Lack of social support
Clinical features:
18
Study Notes in Psychiatry (2008)
Dr. Roger Ho
enlargement
Ch. 15
Eating disorder
15.1 Anorexia Nervosa
Epidemiology
- Usually Females; F:M = 10:1
-Onset between 16-17
- More common in upper social class
- 1% of middle class adolescent girls.
- Increasing incidence: 0.5%
Aetiology
-Genetics: MZ: DZ 65%:32%;6-10% of
female siblings of patients also suffer from
this condition
-Hypothalamic dysfunction
- Social: Exam stress in S’pore, occupations
group: ballet students, atheletes
-Individual pathology: dietary problems in
early life, lack of a sense of identity
- Family pathology: enmeshment, rigidity,
overprotectivieness, lack of problem solving
Clinical features
Core clinical features - RAPID
-A body weight more than 15% below the
standard weight or BMI 17.5 or less
- Self induced weight loss: vomiting, purging,
excessive exercise, appetite suppressant
-Body image distortion- dread of fatness,
overvalued idea
-Endocrine disorder: HPA axis,
amenorrhoea, reduced sexual interest,
raised cortisol, altered TFTs
- Delayed and arrested puberty.
Complications:
Secondary to
starvation
Hypothermia
Constipation
Low BP, anaemia
Bradycardia
Amenorrhoea
Leucopenia
Hypercholesterolemia
Delayed in growth
Osteoporosis
Dry skin/brittle hair
Loss of brain volume
Cerebral atrophy
Ventricle
Consequences of
vomiting &
laxative
Hypokalaemia
Hyponatraemia
Prolonged QT
Cardiac arrhythmia
Dental caries
Elevated hormones
Growth hormone
Prolactin
Cortisol
Reduced
hormones
T3 and T4
Oestradiol
Testoesterone
FSH and LH
Investigation
FBC, RFT, LFT, glucose, TFT, cholesterol,
LH, FSH
DDX:
Functional illness
OCD
Depressive disorder
Organic disorder
Hypopituitarism
Thyrotoxicosis
Diabetes Mellitius
Brain tumour
Malabsorption
Management:
Admission to hospital:
-Extremely rapid or excessive weight loss
-Severe electrolyte imbalance
- Cardiac complications
- Marked change in mental status
- Risk of suicide
- Failure of outpatient treatment
Feeding and refeeding syndrome
-Consult medical/dietitian
- Refeeding syndrome: Cardiac
decompensation can occur within first 2
weeks: myocardium cannot withstand the
stress of increased metabolic demand;
slowly increase dietary intake by 200kcal per
day and monitor RFT closely
Psychological treatment:
-Supportive psychotherapy: to improve
interpersonal relationships and sense of
personal effectiveness.
- Behavioural therapy: regimen of
refeeding, to set target weight, positive
reinforcement with privileges such as outing,
movie etc
- Cognitive therapy, after gaining some
weight, aims at changing attitude towards
eating, reappraisal of self image and life
circumstances.
-Family therapy
19
Study Notes in Psychiatry (2008)
Dr. Roger Ho
Pharmacological: Olanzapine may be used
to promote weight gain (controversial not to
mention in exam)
Prognosis of AN
Rules of one third:
1/3
1/3
Recover fully Recover
partially
Poor prognosis: severe personality
disorder or low self esteem.
15.3
Pathological gambling
It is a persistent and recurrent maladaptive
patterns of gambling behaviour.
1/3
Chronically
disabled.
Factors associated with a poor prognosis
- Chronic illness
- Late age of onset
- Bulimic features
- Anxiety when eating with others
- Excessive weight loss
- Poor childhood social adjustment
- Poor parental relationships
- Male sex
Bulimia Nervosa
Epidemiology: 1% of women
Aetiology:
Family history of affective disorder
Serotonergic dysregulation
Clinical features:
-Persistent preoccupation with eating
-Irresistible craving for food
-binges: episodes of overeating
- Attempts to counter the fattening effects of
food: self induced vomiting, purging
BN is different from AN. In BN,
- Patients are more eager for help
- Menstrual abnormalities less than
half of the patients
- Body weight within normal limits
Comorbidity: Multiple dyscontrol
behaviours:
- Cutting / burning
- Overdose
- Alcohol / drug misuse
- Promisuity
Management
- Usually managed as outpatient
- Admission only for suicidality and physical
problems
- Higher dose of SSRI: fluoxetine up to 60
mg
- Cognitive behavioural therapy
Relatively common and may lead to
significant personal, family and occupational
difficulties.
Clinical features
- Preoccupation with gambling
- Tolerance: need to gamble with
larger amounts of money
- Fail to cut down
- Chasing losses (like chasing the
dragon in drug addicts)
- Lying to others about gambling
- Committing illegal acts to finance
gambling.
- Losing or jeopardizing familial
relationship
Treatment:
- CBT to reduce preoccupation with
gambling
- SSRI (fluoxetine)
- Support group
- Credit card debt counseling via
MSW
15.4
Kleptomania
Failure to resist impulses to steal items that
are not needed nor sought for personal use.
e.g A men stole 10 female T shirts, same
style but different colours.
Usually women, mean age 36, 16 years of
illness
DDX: shoplifting (well planned and
motivated by need and monetary gain),
OCD and depression
Treatment:
- CBT
- SSRI
15.5
Trichotillomania
Stereotyped recurrent pulling of hair
DDX: OCD, Tourette syndrome, Autism,
factitious disorder
20
Study Notes in Psychiatry (2008)
Treatment: behavioural modification,
SSRI,if fail consider risperidone or lithium
Dr. Roger Ho
Suicide and mental illness
Ref: Oxford Handbook, 2004
Ch.16 Suicide and DSH Trickcyclist, UK
 all psychiatric illness (except OCD)
increase risk by 90-95 %
 Depression (risk 3.6 - 8.5 % = 30 x
general population risk)
16.1 Suicide
Schizophrenia (risk 5 - 10 %)
Epidemiology
Alcohol dependence (risk 3.4 - 6.7 %)
 completers are more often :
 male
 psychiatric disorder
 have made a plan
 used a dangerous method
Prevalence
 lifetime prevalence (USA):
 21 % morbid thoughts
 10.2 % suicidal thoughts
 2.9 % attempted suicide
 GP : (2,500 patients)
 1 suicide every 4 years
 Psychiatrist (catchment area 50,000)
 1 suicide every 3 months
Neurosis: panic disorder/ PTSD
Special populations
Elderly
 rate increasing
 80-90 % of elderly suicides have
depressive illness
 often first episode of depression
 DSH is more closely associated with
completed suicide
 denial of suicide more common
Inpatients Highest risk :
Sociodemographic correlates of suicide
1) Age, Sex
a)
M:F = 3:1; males > females
for all groups
b)
suicide pacts more common
in the elderly
2.
Marital status :
a)
divorced > widowed > single
3.
Employment :
a)
unemployed / retired / living
alone
4.
Social Class :
a)
Higher in lowest social
groups & professional
b)
lowest in middle groups
5.
Religion :
a)
strong religious affiliation is
a protective factor
6.
Occupation :
a)
higher risk groups are
doctors, lawyers, hotel and
bar trade owners
7.
Chronic Physical illness :
terminal illness / malignancies
a)
chronic pain
8.
Other associations :
a)
history of DSH (1/3- ½ of
completers)







first week of admission
early stages of recovery
between shifts of staff
on leave (patients and staff)
bank holidays
discharge (premature)
risk is increased 30 x in the
month after discharge
Aetiology
Genetics
 suicidal behaviour clusters in family
 MZ : DZ = 11.3 % : 1.8 % (Roy et al.
1991)
Neurochemical
1)Serotonin : serotonin deficiency
16.2 Deliberate self harm (DSH)
A deliberate, non fatal act, whether physical,
drug overdose, or poisoning, done in the
knowledge that it was potentially harmful.
More common in female
Motives: A cry for help; An attempt to
influence others; escape from stress; to feel
pain in personality disorder
21
Study Notes in Psychiatry (2008)
Factors of DSH predicting suicidal risk





Isolation; timing
precautions to avoid intervention
suicide note
anticipatory acts
‘dangerousness’ of state of mind
Ch. 17 Personality disorder
Deeply ingrained, maladaptive patterns of
behaviour; recognisable in early adulthood,
continuing throughout most of adult life; there is
an adverse effect on the individual or society.
17.1
Borderline Personality Disorder
Prevalence: 1.5 – 2%
Childhood development
Childhood trauma – sexual abuse,
divorce
Playing primitive defence mechanisms
such as splitting or projective
identification
Clinical features: “I RAISE A PAIN”
I – Identity disturbance
R- Relationship: unstable
A – Abandonment fear of
I – Impulsive
S – Suicidal gesture
E – Emptyiness
A – Affect: unstable
P – Paranoid idea / psychosis: transient
A – Anger
I - Idealisation and Dealisation
N - Negativistic
Dr. Roger Ho
-
Conduct disorder in childhood
Clinical features: “CALLOUS”
Conduct disorder < 15
Antisocial Act and aggression
Lies frequently
Lack superego
Obligations not honoured
Unstable and cannot plan ahead
Safety of self or others ignored
Prognosis:
May commit crime
May show Improvement by 5th decade
Management of Personality Disorder
Making the diagnosis of personality disorder
Assess patient’s enduring and pervasive
patterns of emotional expression,
interpersonal relationships, social
functioning
Obtain collateral information from family
and past psychiatric history
Explore relationships, self concept and
functional assessment
Admission to hospital
They benefit little from prolonged
admission.
Admission is indicated for specific crisis
Treatment plan aims to set limits and to
achieve realistic goal
Psychological treatment
-Supervision and support are often beneficial
Prognosis: 1/3 continue to have Borderline
Personality disorder after 10 – 20 years.
CBT:
-
Poor prognosis:
- Severe repeated self-harm
Dialectical behavioural therapy for borderline
personality disorder
17.2
Antisocial Personality Disorder
Prevalence: 2-3.5%
Neurophysiology:
-immature EEG in posterior temporal lobe as
slow waves
- Low 5HT levels in impulsive violent individuals
Childhood development
Difficult infant temperament
Harsh and inconsistent parenting
Educate them about the schema
Empathetic challenging their core beliefs
Goal directed problem solving approach
- Focus on a detailed CBT approach to self harm
- Then focus on tolerance of distress, emotional
regulation and interpersonal skills
- To process trauma
- Develop self esteem and realistic future goals
Pharmacological treatment:
- SSRI antidepressant can improve mood and
reduce impulsivity
Outcome of personality disorder
High rates of accident, suicide and
violent death.
22
Study Notes in Psychiatry (2008)
Ref: Oxford Handbook, 2004
Chapter 18
Psychiatric Emergency
18. 1 Acute disturbed patient
Aetiology
- Alcohol and drug dependence
- Illicit drugs
- Metabolic disturbance
- Head injury
- Schizophrenia
- Mania
- Personality disorders
Treatment of acute disturbed patient or
crisis:
It requires immediate action:
1) De-escalation verbally in calm and
consistent environment.
2) Oral medication: PO Haloperidol
5mg stat or PO lorazepam 1mg stat
3) IM medication: IM Halperidol 5mg
stat; IM lorazepam 2mg (in IMH); no
IM diazepam due topoor absorption
4) Close monitoring on vital sign
5) If chemical restraint fails, consider
physical restraint
18.2
Neuroleptic Malignant Syndrome
It is a rare life threatening reaction to
antipsychotic medication characterised by
fever, muscular rigidity, altered mental
status and autonomic dysfunction.
Dr. Roger Ho
- Tachycardia
- Hyper or hypotension
- Tremor
- Incontinence
- ↑ CK level
Investigations: FBC, LFT, RFT, Ca and
PO4, serum CK, CXR, CT
DDX: lethal catatonia, malignant
hyperthermia, meningitis, heat exhaustion,
rhabdomyolysis
Management:
- Stop antipsychotics
- Medical emergency, refer to medical
- IV fluids, reduce temperature
- Benzodiazepine for acute
behavioural disturbance
- To give bromocriptine
Mortality: 5-20% die, it can lead to acute
renal failure.
18.3
Serotonin syndrome:
A rare but potentially fatal syndrome
occurring in the context of initiation of
serotonergic agent, characterised by altered
mental state, agitation, tremor, shivering,
diarrhoea, hyperreflexia, myoclonus and
hyperthermia.
1% of patients on SSRI
Pathophysiology: due to increase in
serotonin.
Clinical features:
Autonomic: hyperthermia, nausea,
diarrhoea, mydriasis, tachycardia,
hyper/hypotension
Due to blockade of D2 receptors leading to
impaired calcium mobilisation and leads to
muscle rigidity.
Neuromuscular: myoclonus, rigidity and
tremors, hyperreflexia, ataxia
Incidence: 0.2%
F: M = 2:1
More rapid onset, rapid progression and less
rigid than NMS.
Risk factors
- Drug naïve patient receiving high potency
antipsychotics
- Dehydration
Investigations: same as NMS, add in CXR
to rule out aspiration, ECG to look for
prolonged QTc
Clinical signs and symptoms:
- Hyperthermia
- Muscular rigidity
- Confusion / agitation
Treatment:
- Consult medical, it is a medical emergency.
- IV access, to allow volume correction to
reduce the risk of rhabdomyolysis
23
Study Notes in Psychiatry (2008)
Dr. Roger Ho
- Prescribe benzodiazepine to control
agitation, seizure and muscle rigidity.
Course and prognosis:
- Resolve with 24 – 36 hours
- Mortality < 1 in 1000
Chapter 19
Sleep disorders
19.1 Normal sleep – stages and cycle
- A typical night’s sleep has 4 or 5 cycles of
stages, each lasting 90 – 110 minutes.
- As night progresses, the amount of time
spent in delta sleep decreases with
consequent increase in REM sleep.
- Total sleep time in adult is between 5 – 9
hours.
Stage 1
Stage 2
Stage 3 & 4
REM
Light sleep, with slow theta
and delta waves
K complexes
Delta wave, slow wave
sleep
Low voltage,
desynchronised EEG
activity
Assessment of sleep disorders:
Present
Onset, duration, course,
compliant
frequency, stressors
Daily routine Waking, daily activities, bed
time
Description
Behaviour during sleep,
of sleep
dream, wakening,
satisfaction
Daytime
Level of alertness, effect on
somnolence work,
Drug &
Regular hypnotics
alcohol
Caffeine containing drugs
19.2
Insomnia
Insomnia involves difficulty to fall asleep,
maintaining sleep and poor quality of sleep
as persistent problem 3 days per week for
one month.
Epidemiology
- Common problem
- F>M
- Greater in elderly
- Chronic significant insomnia – 6%
Aetiologies:
Intrinsic causes:
- Psychophysiological insomnia
associated with anxiety
-
Sleep state misperception (constant
monitoring of sleep)
Idiopathic insomnia
Sleep apnoea syndrome
Periodic limb movement disorder
Extrinsic causes:
- Inadequate sleep hygiene
- Dependency related sleep disorder
like hypnotics
- Nocturnal eating and drinking
Medical and Psychiatric causes:
- Pain
- Respiratory (COPD)
- Parkinson disease
- Endocrine: Addison, Cushing
- Depression, bipolar disorder
- Anxiety disorder, PTSD
- Schizophrenia
Management:
- Address underlying problem (drug
dependency)
- Education: stages and cycles.
- Sleep hygiene measures: Good
sleep habits and stimulus control
- Relaxation training
- Use of hypnotics if unresponsive to
above
Length of
action
Ultra –short
Examples
Comments
Zolpidem
(Stilnox)
Non – BZD
Facilitate onset
of sleep
Also has
potential of
dependency,
cause rebound
insomnia
Initiating,
maintaining,
Consolidating
sleep
2 hr
10mg ON
$1.80
Intermediate
6 hours
Long acting
> 12 hours
Lorazepam
Ativan
1mg ON
Zopiclone
Imovane
7.5mg ON
Diazepam
Valium
5-10mg
Flurazepam
Dalmadorm
NUH only
Non BZD
Bitter taste
Initiating,
maintaining,
Consolidating
sleep
Hang over
24
Study Notes in Psychiatry (2008)
15-30mg
effect on the
morning
Midazolam (Dormicum) has very fast onset
of action and high potency, it has high
potential for dependency. It is not
recommended for regular oral usage.
Ch. 20
Child Psychiatry
20.1
Attention Deficit & Hyperkinetic
Disorder (ADHD)
ADHD is a persistent pattern of inattention
+/- hyperactivity that is developmentally
inappropriate. The symptoms should have
an onset in childhood.
Epidemiology:
- USA: 3-5% (over-diagnosis)
- UK: 1%
- M:F = 3:1
Aetiology:
Genetics:
- 50% risk in MZ twins, 2x increase in
siblings
- Genes: 5, 6, 11 are implicated.
- Neuroimaging: frontal
hypometabolism
- Dopamine & 5HT dysregulation in
prefrontal cortex
Clinical features:
Hyperactivity
symptoms
Fidgeting, moving,
getting up & down,
climbing on desks
Blurting out answers,
Jumping the queue
Inattention
symptoms
Cannot sustain
attention
Poor task completion
Making mistakes
when task require
attention
Assessment:
- Interview with parents:
developmental history
- Observe attachment style and level
of activity of child
- Collateral info from school
Treatment:
- CBT: behavioural techniques
- Social skill training
- Parent management training
- Education and remedial intervention
- Stimulant: Methylpenidate 5-10mg
OM: increase Dopamine &
noradrenaline which can increase
concentration & attention, side effect
Dr. Roger Ho
include growth retardation which
requires drug holiday.
Outcome
- 20% develop antisocial personality
disorder
- 20% develop substance abuse
disorder
20.2
Conduct disorder
A repetitive and persistent pattern of
behaviour in which the basic rights of others
or major age appropriate societal norms are
violated.
Epidemiology
- Earlier onset and is more common in boys
than in girls.
Aetiology
Biological factors
- Family history of
antisocial behaviour
or substance abuse.
- Low CSF serotonin
- Low IQ
- Brain injury
Psychosocial
- Parental criminality
- Substance abuse
in parents
- Harsh and
inconsistent
parenting
- Domestic chaos
and violence
- Large family size
- Low socioeconomic status and
poverty
- Early loss and
deprivation
- School failure
Clinical features:
- Aggression
- Cruelty to people and animals
- Destruction of property
- Deceitfulness or theft
- Serious violation of rules
- Gang involvement
- Lack of empathy
Management:
- Ensure the safety of the child
- CBT problem solving skill
- Parent management training
- Family therapy
- Academic & social support referral
Course and outcome:
- CD is often chronic and unnameable.
- Antisocial PD in adults <50%
25
Study Notes in Psychiatry (2008)
Poor outcome: Early onset < 10 year old,
low IQ, poor school achievement, attentional
problems, hyperactivity, family criminality,
poor parenting.
20.3
Autism
It is characterised by the triad of
symptoms:
- Abnormal social relatedness
- A qualitative abnormality in
communication and play
- Restricted, repetitive and
stereotyped behaviour, interests and
activities
Epidemiology:
- Onset is typically before age 3.
- M:F = 3-4:1
- Prevalence: 5-10/1000
Aetiology:
- Genetic
- Obstetric complications
- Toxic agents
- Pre/postnatal infections.
- Association with tuberous sclerosis
Pathophysiology MRI:
- Increase in brain size
- Increase in lateral and 4th ventricle
- Frontal & cerebellar abnormalities
- Abnormal purkinje cells in cerebellar
vermis.
- Abnormal limbic architecture.
Clinical features:
- Abnormal social relatedness: poor
eye contact and no peer relationship
- Abnormal communication/play:
lack of language, difficulty to initiate
conversation.
- Restricted interests or activities:
non functional routines or rituals
(bus schedule)
- Neurological: tics, increase in head
circumference, abnormal gaze
- Physiological: abnormal response
to pain, abnormal temperature
regulation.
- Behavioural: irritability, temper
tantrums, self – injury, hyperactivity,
aggression
Dr. Roger Ho
-
Treatment:
- Education & vocational
interventions
- Behavioural interventions
- Family interventions
- Speech and language therapy
20.4
Asperger Syndrome (AS)
Severe persistent impairment in social
interactions, repetitive behavioural patterns
and restricted interests.
IQ and language are normal or superior.
Mild motor clumsiness and family history of
autism may be present.
Newton and Einstein may have AS
Epidemiology
- Male predominance
- 1 in 300
Clinical features
- Narrow interests and preoccupation
of a subject
- Repetitive behaviours or rituals
- Peculiarities in speech and
language
- Extensive logical or technical
patterns of thought
- Socially and emotionally
inappropriate behaviour and
interpersonal interaction
- Problems with non verbal
communication
- Clumsy and uncoordinated motor
movements.
20.5
-
Assessment:
Requires Multidisciplinary approach
Rating scale: Autism Behavioural
Checklist
Approaches to the Child
Establish the rapport and gaining
the child’s confidence
Begin with subjects well away from
the presenting problem (interests,
hobbies, friends and siblings, school
and holidays)
Progress to enquire about the
child’s view of the problems
26
Study Notes in Psychiatry (2008)
-
Observe the level of activities and
attention during the interview
Try to interview the child and family
together to observe family dynamics
Dr. Roger Ho


discussion with teachers is needed
depressive disorder should be treated
Prognosis
20.6
School refusal
Epidemiology



prevalence of 1-2 %
slightly more common in boys
more common during three periods in
school life:
1. age 5 (starting school)
2. 7 years (change to junior school)
3. 11 years (starting secondary school)
4. 14 years and older, when there is
often associated depression and
difficulties in school
Aetiology





associated with separation anxiety
especially in younger children
may occur after a minor life event:
illness
some older children have depression
increased incidence of anxious,
overprotective mother in combination
with a weak, passive, ineffectual, or
absent father
children are often emotionally immature
and have not learned to accept
frustration
Clinical features


there are often somatic symptoms such
as headache, abdominal pain, diarrhoea,
sickness, or vague complaints of feeling
ill – these complaints occur on school
days but not at other times
the final refusal may occur after several
events:
 following a period of increasing
difficulty
 after an enforced absence such as
respiratory infection
 after an event at school such as
change of class
 following a problem in the family
such as illness of another family
member
Treatment



worse prognosis in older children
higher incidence of psychiatric disorders
(e.g. agoraphobia) in adult life
20. 7 Enuresis
Voluntary/involuntary voiding of urine at
night for child > 5 yr old.
75% have family history of enuresis
To rule out UTI, neurological problems,
obstructive uropathy.
Primary enuresis: never dry
Secondary enuresis: previously dry
Behavioural modification is important
treatment: starchart to reward patient,
restrict fluid at night
Medication: imipramine (TCA)
20.8 Consequence of child abuse:
- PTSD
- Dissociative disorder
- Conversion disorder
- Borderline personality disorder
- Depression
- Paraphilias
- Substance abuse
20.9
Tourette’s syndrome
Multiple motor and vocal tics for a year, with
distress and impairment function.
Facial tics as initial symptoms
Vocal tics: meaningless sounds to clear
words and coprolalia
Tic wax and wane, exacerbations due to
stress
Onset: 7 years old M:F = 3:1
Prevalence: 5/10,000
Genetics factors: AD
Involves dopamine system and Basal
Ganaglia
Comorbidity: depression, OCD
an early return to school is important
27
Study Notes in Psychiatry (2008)
Treatment: Haloperidol 1.5mg-5mg, CBT
Ref: Oxford Handbook, 2004
21
Learning Disability/ Mental
Retardation
Dr. Roger Ho
- Major causes of learning disability
- 0.2 – 3 per 1000 live births
- Caused by maternal alcohol use.
Due to effect of alcohol on NMDA receptors
which affects cell proliferation
Clinical features:
21.1 IQ and learning disability (LD)
LD
Mild
IQ
50-69
Moderate
35-49
Severe
20-34
Profound
Below
20
Features
Independent self
care
Some deficit in
language,
simple work
Lower level of
work, motor
impairment
Very limited
language &
basic skills
21.2 Down Syndrome
Alcohol withdrawal: irritability, hypotonia,
tremor and seizures
Facial features: Microcephaly, small eye
fissures, epicanthic folds, short palpebral
fiussure, small maxillae and mandibles, cleft
palate, thin upper lip
Growth deficits: Small overall length, joint
deformities.
CNS: behaviour problems: hyperactive,
sleep problems, poor visual acuity, hearing
loss, language deficits.
Other: ASD, VSD, renal hypoplasia.
Most common genetic cause of LD
Trisomy of chromosome 21
IQ most often below 50
Develop Alzheimer’s disease at 40s and 50s
Clinical features of Down syndrome
Lesley Stevens, Ian Robin, Psychiatry – An
illustrated colour text, Churchill livingstone 2001
21.3 Foetal Alcohol Syndrome
28
Study Notes in Psychiatry (2008)
22
Legal & Ethical Aspects
22.1
Mental Disorder and Treatment Act
- Can only apply at IMH (Woodbridge
hospital) in Singapore
Criteria for compulsory admission at IMH
1) The person suffers from a mental
disorder of a nature or degree which
makes it appropriate for the person
to receive psychiatric treatment in
IMH.
2) Admission is likely to alleviate or
prevent deterioration in a psychiatric
condition (Schizophrenia, Bipolar
disorder)
3) It is necessary for the health or
safety of the patient or for the
protection of other persons that the
person should receive such
treatment and it cannot be provided
unless he is compulsory admitted.
Example:
Assume you are the AED medical officer
working in a general hospital. A 29 year old
male suffers from paranoid schizophrenia
was brought in to your AED. He has been
violent at home and attacks his parents. He
has poor insight and has defaulted his
treatment for 3 months.
He refuses to be admitted to your general
hospital psychiatric unit (or your psychiatric
ward is full)
In this case, you can send the patient to IMH
for assessment. (You need to call the IMH
registrar on call at 6389 2000)
The IMH medical officer or registrar will sign
the Form 1 of Mental Disorder and
Treatment Act: compulsory admission for 72
hours.
Dr. Roger Ho
Re-licensing for private car:
- has remained well and stable for at
least 3 months
- Compliant with treatment
- Free from adverse effects of
medication
- Regain of insight
For professional driver: bus driver, taxi driver
or lorry driver: Re-licensing may be possible
if well and stable for a minimum of 3 years
with minimum dosage of medication and no
significant likelihood of recurrence
Dementia:
Those with poor short term memory,
disorientation, lack of insight and judgement
are not fit to drive.
22.3 Dialysis and Schizophrenia
You have a 58 year old lady suffering from
chronic schizophrenia and end stage renal
failure. She wants to stop dialysis. The renal
team is very concerned as she may die and
they want to seek your opinion.
Suffering from schizophrenia does not mean
the patient has no capacity to decide on her
dialysis.
First, we have to determine whether the
patient has the capacity to make the
decision to withhold dialysis. In order to
show that she has the capacity, she must be
able to understand and believe that she
suffers from end stage renal failure; dialysis
is used to treat ESRF and she will die if she
stops dialysis.
We need to consider the following:
It is good to explore the psychological
aspects of dialysis: sexual dysfunction is
common; they are more isolated and costs
of dialysis may reduce their quality of life
and anaemic can cause fatigue.
Uraemia can lead to impaired mentation,
lethargy, multifocal myoclonus.
22.2 Driving and Psychiatric illness
(Based on UK law, Singapore does not
have clear guideline on this)
Dialysis can lead to neuropsychiatric
symptoms such as dialysis dementia,
delirium and depression.
For schizophrenia, bipolar disorder:
Driving must cease during acute illness
We may need to treat patient’s
neuropsychiatric symptoms by
29
Study Notes in Psychiatry (2008)
antidepressant or antipsychotics and
reassess her capacity later.
23
Psychotherapy
Common psychotherapies practised in
Singapore include:
23.1
Supportive Psychotherapy
Aims to offer practical and emotional support,
opportunity for ventilation of emotions, and
guided, problem solving discussion.
Examples include counselling and general
psychiatric follow – up.
23.2
Brief psychodynamic
psychotherapy
It is an active therapy where the therapist
attempts to guide free association on more
focused topics.
Rationale:
- Shorter time scale of long term
psychoanalysis (too expensive and difficult
for patient to stay in therapy for so long)
Indication:
- Individuals with emotional problems
in psychological terms.
- Focal conflicts
Techniques:
- Goal setting: tackle anxiety/
defence
- Focus choosing: repetitive
behaviour to a single transference
figure
- Active interpretation
Transference
Patient’s feeling
towards therapist
Countertransference
Therapist’s feeling
towards patient
Phases of treatment
- Initial: setting treatment contract,
formulation of the case
- Early session: Identify central issue
- Middle session: explore transference
- Closing: anticipate termination,
arrangement of aftercare.
23.3
CBT
Behaviours and emotions are determined by
person’s cognitions. Some pathological
emotions are as a result of cognitive errors.
If the person can be helped to understand
the connection between cognitive errors and
Dr. Roger Ho
distressing emotion, they can try methods to
change.
The therapist aims to assist the patient to
monitor cognitions, identify cognitive errors,
understand maladaptive schema, explore
with strategies and challenge and examine
the resultant effects.
Behavioural
techniques
Activity scheduling
Graded assignment
Exposure/ response
prevention
Relaxation training
Cognitive
techniques
Psychoeducation
Identify automatic
thoughts
Role play
Thoughts diary
Examine evidence
Defence mechanisms
Repress Unconscious forgetting of pain
ion
memory and impulse.
Regress Revert to functioning of a
ion
previous maturational point.
Denial
Refusal to consciously
acknowledge events or truths
which are obvious.
Projecti Attributing one’s own
on
unacceptable ideas or impulses
to another person.
Projecti One person projects a thought,
ve
belief or emotion to a second
Identific person. Then, there is another
ation
action in which the second
person is changed by the
projection and begins to behave
as though he or she is in fact
actually characterized by those
thoughts or beliefs that have
been projected.
Reactio The expression externally of
n
attitudes and behaviours which
formati
are the opposite of the
on
unacceptable internal impulses.
Displac
Transferring the emotional
ement
response to a particular person,
event, or situation to another
where it does’t belong but carries
less emotional risk.
Rational Justifying behaviour or feelings
isation
with a plausible explanation after
the event, rather than examining
unacceptable explanation.
Sublima Regarded as healthy defence
tion
mechanism, The external
expression of unacceptable
internal impulse in socially
30
Study Notes in Psychiatry (2008)
acceptable way.
Ch. 24
Glossary
Alexithymia: The inability to describe one’s
subjective emotional experiences verbally.
Amnesia Anterograde: the period of
amnesia between an event and the
resumption of continuous memory. The
length of anterograde amnesia is correlated
with the extent of brain injury.
Retrograde: The period of amnesia
between an event and the last continuous
memory before the event.
Autochthonous delusion: A primary
delusion which appears to arise fully formed
in the patient’s mind without explanation.
Autoscopy: (Phantom Mirror image)
The experience of seeing a visual
hallucination or pseudohallucination of
oneself.
Confabulation: The process of describing
plausibly false memories for a period for the
patient has amnesia. Occurs in Korsakoff
psychosis, dementia.
Coprolalia: A forced vocalisation of
obscene words or phrases. The symptoms
is largely involuntary but can be resisted for
a time, at the expense of mounting anxiety.
Occurs in Tic disorder
Couvade syndrome: A conversion
symptom seen in partners of expectant
mothers during their pregnancy.
Déjà vu A sense that events being
experienced for the first time have been
experienced before. An everyday
experience but also a non specific
symptoms of a number of disorders
including temporal lobe epilepsy,
schizophrenia and anxiety disorders. In
contrast, Jamis Vu is the sensation that
events or situations are unfamiliar, although
they have been experienced before.
Delusional memory
A primary delusion which is recalled as
arising as a result of a memory (eg patient
who remembers his parents taking him to
Dr. Roger Ho
hospital for an operation as a child
becoming convinced that he had been
implanted with monitoring devices which
have become active in his adult life)
Delusional mood: A primary delusion which
is recalled as arising following a period when
there is an abnormal mood state
characterised by anticipatory anxiety, a
sense of something about to happen and an
increased sense of significance of minor
events.
Delusional perception: A primary delusion
which is recalled as having arisen as a result
of perception. The percept is a real external
object.
Delusion of guilt: A delusional belief that
one has committed a crime or other
reprehensible act. It is a feature of psychotic
depressive illness.
Delusion of infestation (Ekbom
syndrome): A delusional belief that one’s
skin is infested by multiple, tiny, mite like
animals.
Delusion of reference: A delusional belief
that external events or situations have been
arranged in such a way as to have particular
significance for or to convey a message to
the affected individual.
Depersonalisation: An unpleasant
subjective experience where the patient
feels as if they have become unreal.
Derailment (Knight’s move thinking):
schizophrenic thought disorder in which
there is total break in the chain of
association between the meaning of
thoughts.
Derealisation: An unpleasant subjective
experience where the patient feels as if the
world has become unreal.
Digenes syndrome: Hoarding of objects,
usually of no practical use and neglect of
one’s home and environment. Due to
organic disorder, schizophrenia, OCD.
Dysarthria
Dyslexia
Impairment in ability to
properly articulate speech
Inability to read at the level
31
Study Notes in Psychiatry (2008)
Dysphasia
Dysphoria
Dyspraxia
normal for one’s age or
intelligence
Impairment in producing or
understanding speech
(expressive dysphasia Brocas and receptive
dysphasia - Wernicke)
related to cortical
abnormality
An emotional state
experienced as unpleasant,
secondary to depression
Inability to carry out complex
motor tasks (dressing,
eating)
Edietic imagery: Particular type of
exceptionally vivid visual memory. Not a
hallucination. More common in children.
Extracampine hallucination
A hallucination where the percept appears to
come from beyond the area usually covered
by he senses (eg a patient in Clementi
hearing voices seeming to come from a
house in Changi)
Ganser symptoms:The production of
approximate answers. Here the patient gives
repeated wrong answers to questions which
are nonetheless in the right ballpark. What is
2+2? = 5. More common in Malingering.
Globus Hytericus: The sensation of a lump
in the throat occurring without oesophageal
structural abnormality.
Hypnagogic hallucination: A transient
false perception experienced while on the
verge of falling asleep
Hypnopompic hallucination: The same
phenomenon experienced while waking up
Illusion: A false type of false perception in
which the perception of a real world object is
combined with internal imagery to produce a
false internal percept.
Lilliputian hallucination: A type of visual
hallucination in which the subject sees
miniature people or animals. Associated with
organic state like delirium tremens.
Dr. Roger Ho
Loosening of associations: Lack of
meaningful connection between sequential
ideas.
Magical thinking: A belief that certain
actions and outcomes are connected
although there is no rational basis for
establishing a connection.
Malingering: Deliberately falsifying the
symptoms of illness for a secondary gain.
Mirror sign: Lack of recognition of one’s
own mirror reflection with the perception that
the reflection is another individual who is
mimicking your actions.
Overvalued idea: A form of abnormal belief.
These are ideas which are reasonable and
understandable in themselves but which
come to unreasonably dominate the
patient’s life.
Preservation: Continuing with a verbal
response or action which was initially
appropriate after it ceases to be apposite.
Do you know where you are? In the
hospital? Do you know what day is it? In the
hospital.
Russell Sign: skin abrasions, small
lacerations and the calluses on the dorsum
of the hand overlying the
metacarpophalangeal and interphalangeal
joints found in patients with symptoms of
bulimia. Caused by repeated contact
between incisors and the skin of the hand
which occurs during self induced vomiting.
Synaethesia: A stimulus in one sensory
modality is perceived in a fashion
characteristic of an experience in another
sensory modality (tasting sounds).
Tangentiality: Producing answers which
are only very indirectly related to the
question asked by the examiner.
Trichotillomania: Compulsion to pull one’s
hair out.
References:
1) Levi. Basic Notes in Psychiatry. Radcliffe
Publishing Ltd 1998.
32
Study Notes in Psychiatry (2008)
Dr. Roger Ho
2) D. Semple, R. Smith, J Burns, R. Darjee,
A. Mclntosh. Oxford Handbook of Psychiatry.
Oxford University Press. 2004
3) www.trickcyclists.co.uk
Appendix
Appendix 3a – Neurodevelopmental Hypothesis of Schizophrenia
-
-
-
-
There is an excess of obstetric
complications in those who develop the
disorder.
Affected subjects have motor &
cognitive problems which precede the
onset of illness.
Schizophrenia subjects have
abnormalities of cerebral structure of
1st presentation.
Although the brain is abnormal, gliosis
is absent – suggesting that differences
are possibility acquired in utero.
From: Your questions answered series – Schizophrenia, Churchill Livingstone
Appendix 3b – Brain abnormalities of Schizophrenia
Lesley Stevens, Ian Rodin – Psychiatry an illustrated text, Churchill Livingstone. 2001
33
Study Notes in Psychiatry (2008)
Dr. Roger Ho
Appendix 3C
Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001
Appendix 5a - Toxic effect of lithium
Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001
34
Study Notes in Psychiatry (2008)
Dr. Roger Ho
Appendix 9a PTSD and Grief
Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001
Appendix 10
35
Study Notes in Psychiatry (2008)
Dr. Roger Ho
Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001
Appendix 12a
Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001
36
Study Notes in Psychiatry (2008)
Dr. Roger Ho
Mnemonics in Psychiatry (Mnemonics for MRCP, PASTEST, 2006)
Disorder
Negative
symptoms of
schizophrenia
Mnemonic
5As and
PLANT
Depression
DEPRESSION
MANIA
MANIAC
Eating disorder
RAPID
Korsakoff
psychosis
ADDICT
Eating disorder
Increases in
the following
Breakdown of Mnmonic
aPathy
aLogia
aFfective flattening
aNhedonia
aTtentional deficit
Depressed mood
Energy loss
Pleasure loss
Retardation: psychomotor
Eating change
Sleep disturbance
Suicidal ideation
I am a failure
Only me to blame = guilt
No concentration
Mood increase
Activity / energy increase
No inhibition
Insomnia
Always thinking > Pressure of speech, flight of ideas
Confidence excess  grandiose
Refusal to maintain weight
Amenorrhoea
Preoccupation with food and weight
Induction of diarrhoea and vomiting
Disturbance in the way weight and size are perceived
Amnesia
Disorientation
Insight loss
Confabulation
Thiamine deficiencies
Nuclei Acid bases:
G – Growth hormone
C – cortisol and cholesterol
A – Amylase
T – Transaminase
U – Urea and Creatinine
Everything else decreases
37