Study Notes in Psychiatry (2008

)

Dr. Roger Ho

Table of Content Ch. 1 Introduction Ch.2 Signs & symptoms Acute management Ch. 3 Schizophrenia Ch. 4 Delusional disorder Ch. 5 Bipolar disorder Ch. 6 Depressive disorder Ch. 7 Obsessive compulsive disorder Ch. 8 Anxiety, Panic, Phobia Ch. 9 Post traumatic stress disorder, Acute stress, grief Ch. 10 Alcoholism Ch. 11 Drug Dependence Ch. 12 Old age psychiatry Ch. 13 Consultation Liaison Psychiatry Ch. 14 Perinatal Psychiatry Ch. 15 Eating disorder and impulse control disorders Ch. 16 Suicide and DSH Ch. 17 Personality Disorder Ch. 18 Psychiatric emergencies Ch. 19 Sleep disorders Ch. 20 Child Psychiatry Ch. 21 Learning disability Ch. 22 Legal aspect Ch. 23 Psychotherapy

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Study Notes in Psychiatry (For MBBS III to V)

Dr. Roger Ho
MBBS (HK), DPM( Ireland), MMed (Psych)

Assistant Professor Department of Psychological Medicine, NUS Email: pcmrhcm@nus.edu.sg
Version: May 2008

Study Notes in Psychiatry (2008)

Dr. Roger Ho

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

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

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 salad) Disruption of both the connection between topics and finer grammatical structure of speech Occurs in SZ Loosening of associations Loss of the normal structure of thinking. Muddled and illogical conservation that cannot be clarified Occurs in SZ

movement, even after the stimulus is withdrawn Metonyms Use of ordinary words in unusual 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

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

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

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Study Notes in Psychiatry (2008)

Dr. Roger Ho

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.

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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5HT2. try to maintain minimum effective dose in long run . postural hypotension.To give a test dose to ensure no idiosyncratic effects . less sedation.More common in female .History of chronic brain disease: risk factor -slow writhing movement (athetosis) -Sudden involuntary movements .Sedation .EPSE (if high dose like 4mg daily) . increase to 37.Haloperidol: more EPSE (5 – 10mg daily) .Prolong QT interval .10mg ON ($1/mg) Moderate for D2. Roger Ho Management: 3.Pseudoparkinsonism: oral antimuscarinic: benhexol 2mg BD .Elevation of prolactin (strongest among atypicals) .9 Conventional antipsychotics Typical antipsychotics: -Chlorpromazine: more antiadrenergic & antihistaminergic (100 – 400mg daily) .Antiadrenergic side effects .Prolongation of QT interval on ECG . α1 & muscarinic receptors 4 .Change to atypical antipsychotics .Long acting depot injection for non compliant patients.Hyperprolactinemia (transient) Quetiapine: 100 – 800mg daily ($2/100mg) Weak for D2.Vitamin E may prevent deterioration .High incidence of EPSE 3.Study Notes in Psychiatry (2008) Dr.Antiadrenergic side effects like postural hypotension .Low dose: block D3 and D4: negative symptoms .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) . failure of ejaculation 4) Anticholinergic: dry mouth.Fewer EPSE. Conventional depot antipsychotics IM Flupentixol 20 – 40mg 4 weekly (Fluanxol) Other Modecate. IM Risperdal consta – only atypical depots Start with IM 25mg.Anticholinergic will worsen TD.Antiadrenergic side effects Other preparations of risperidone: PO Risperdal quicklet: quickly dissolve in mouth PO Risperdal solution: 1mg/ml $70/ bottle.Almost no EPSE (same as placebo) .Tardive dyskinesia 2) Hyperprolactinaemia 3) Antiadrenergic: sedation.High dose: block D2 and D1: positive symptoms .5mg every 2 weeks Olanzapine: 5. higher affinity for 5HT2 and α1 receptors. High affinity for 5HT2 and muscarinic receptors Side effects: . High affinity for 5HT2 and α1 Side effects: . urinary retention.Temporary raise the dose may give immediate relief. cause galactorrhoea. Side effects: .Oral lingual region (chorea) . .Akathisia: restlessness: treated by propanolol 10mg TDS .10 Atypical antipsychotics Risperidone: 1-2mg ON ($1/mg) Higher affinity of D2 in mesolimibic and less in nitrostriatal.Due to upregulation of postsynaptic Dopamine receptors in Basal Ganglia . Clopixol . Clozapine: more active at D4. constipation 5) Antihistaminergic: sedation 6) Antiserotonergic: depression More on Tardive dyskinesia (TD) .Weight gain and increase appetite .After chronic use of antipsychotic .No ↑ in prolactin (same as placebo) Sulpiride 200mg – 400mg ON (IMH) .

Behavioural: positive reinforcement of desirable behaviour.Family history of affective disorder . leading to hypanatraemia. Schizotypal personality disorder .11 Psychological treatment: -Psychoeducation can prevent relapse by enhancing insight -Cognitive Behavioural therapy (CBT) to challenge delusions. enlarged ventricles.14 Complications of SZ .ECT is for catatonic schizophrenia Indications for Hospital admission: • Suicide / violent • Severe psychosis • Severe depression • Catatonic schizophrenia • Non – compliance • Failure of outpatient treatment 3.Female sex .Marked mood disturbance . critical comments from family.Hypersalivation .Water intoxication in chronic schizophrenia.Acute onset . needs regular FBC under clozaril patient monitoring programme (IMH) . Treatment: Antipsychotics + antidepressant or mood stabilizer.Poor prognosis: 50% develop schizophrenia Schizoid personality disorder – introspective’ prone to engaged in an inner world of fantasy rather than take action.13 Prognosis Rules of quarters 25% 25% Complete Good Remission recovery Causes of relapse: 1) Iatrogenic relapse: reduction of dose by doctor 2) Non compliance 3) High expressed emotion 3.Fewer EPSE 3.Rehabilitation (IMH) to enhance self care.Living in a developing country .12 Other treatments: . Schizoaffective disorder It is a disorder in which the symptoms of schizophrenia and affective disorder are present in approximately in equal proportion. In exam. over-involvement.Life threatening agranulocytosis 2-3%.Suicide is the most common cause of death of SZ. Roger Ho - for treatment resistant SZ. ICD 10 requires both psychotic and mood episode are simultaneously present and equal prominent. hence reduce relapse rate) 3. compliance and insight. aloof and 25% Partial recovery 25% Downhill course Good prognosis: .(failure of 2 antipsychotics with adequate dose) Side effects include: . Family therapy: to reduce expressed emotion (EE). . -Social skill training: improve relationship .Anticholinergic and antiadrenergic.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 . . self sufficient and detached. safer to say no association. lack of emotional warmth and rapport.Study Notes in Psychiatry (2008) Dr.SZ and violence: controversial: senior psychiatrists say no but recent findings support the association. (High EE include hostility.Good premorbid adjustment Poor prognosis: adolescence or early onset. 10-38% of all deaths of SZ. . . 5 .

Somatic: delusion belief about body (abnormal genitalia) to infestation: (worms crawling in the body) . loss hallucinogen) .Dementia.9 Management . 2004) 4. usually female.Paranoid personality disorder (Less clearly circumscribed delusion) 4. make effort to contact important person. low social status.advanced age.Persecutory: Most common type. Erotomania more common in female 4. . incapable of expressing tenderness or affection.Morbid jealousy (Othello syndrome): fixed belief that their spouse has been unfaithful. to obtain legal recourse . 4.Admission to hospital if there is a risk to self or violence to others. . sensory impairment.3 Risk factors and aaetiology .Delirium: change in delusion (mood consciousness before delusion) .Usually equal in M and F.Schizophrenia (less .03% .Study Notes in Psychiatry (2008) Dr.Mean age: 40 – 49 years . premorbid personality disorder. often eccentric.Cognitive techniques: gently challenge delusion .Cortical damage: paranoid delusion .1 Types of delusional disorder (DSM IV) .Folie a deux: one dominant and one submissive partner in a relationship 4.Separation from source or focus of delusion . Morbid jealousy more common in alcoholic male.Temporal lobe epilepsy. shy.OCD: reality testing hallucination) is intact . ability.025 – 0. .Supportive psychotherapy: to establish therapeutic alliance without confronting . 10 Prognosis Remission Improvement 33-50% 10% Persisting 33-50% 6 . collect evidence for sexual activity & restrict partner’s activity.4 Pathogenesis: . may result in violence.Both risperidone and Haloperidol have liquid form: for those refusing tablets .Mood disorder with .Substance induced . . family history.4 Delusional Disorder (Oxford Handbook.Grandiose: special role.Delusions are highly implausible.5 Clinical features: .Benzodiazepine to treat anxiety Psychological treatment .Basal ganglia – less cognitive disturbance . history of Head Injury. . .7 Differential diagnosis Young patients Old patients .huge impact on behaviour.Improving risk factors: sensory deficits.8 Assessment A thorough history and MSE Collateral history from 3rd party To rule out organic causes Document risk assessment - 4.abnormal process in arriving conclusion 4.Folie a deux – shared delusion between husband and wife (close relationship) 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.Antipsychotics: atypical: less side effect . .Uncommon: 0. relationship.Erotomanic (de Clerambault syndrome): Important person like PM is secretly in love with them.Late onset elaborated delusion) psychosis (with . ill – at – ease in company Ch.memory (stimulant. substance abuse. isolation 4.with evidence of systematization (better organized than SZ delusion).2 Epidemiology . isolation. Immigration . insensitive. Roger Ho humourless.Social skill training . others are attempt to harm. involved in religion.6 Diagnosis: DSM IV requires > 1 month duration 4.

Antidepressant induced mania or hypomania is common. cushing.7 DDX: . dopamine.1 The affective spectrum . inappropriate sexual encounters.2 Epidemiology .M = F in prevalence .Severe psychotic symptoms .Psychotic features related to grandiosity.Genetics: 1st degree relative are 7x more likely to develop this condition.Urinary copper to rule out Wilson disease 5. RFT.4 Pathogenesis .Anxiety disorders 5.FBC. infarction. Indications for admission include: . on top of MANIAC.ANF to rule out SLE in ladies .Psychotic depression . Roger Ho Ch. they also have: . Pressure of speech .CT/MRI to rule out space occupying lesion. TFT.Rapid cycling . ESR . haemorrhage .3 Aetiology . .Behaviours with serious consequences: reckless spending.Promoting regular sleep and activity .5 Clinical features Hypomanic episode: MANIAC (Clinical skill training) For mania.8 Investigation . careless investment. . hyperphagia .Poor psychosocial supports .Children of a parent with bipolar disorder have a 50% chance of developing psychiatric disorder .Bipolar I – Mania .MZ:DZ 45%: 23% 5. . . & glutamine have all been implicated.Organic: thyroid.Bipolar II disorder – occurrence of 1 or more depressive episode accompanied by at least 1 hypomanic episode.Rapid cycling > 4 episodes per year .Ultra – rapid cycling: very rapid changes 5.Bipolar II – Hypomania .Lack of capacity to cooperate with treatment .Psychotic disorders (if psychotic features) .severe enough to interfere social & occupation function.6 Diagnosis DSM IV diagnosis .Mean age of onset: 21 years old 5. 5.Lifetime prevalence: 0.Study Notes in Psychiatry (2008) Dr.3 – 1.Recurrent depression .VDRL . ward has to be calm with less stimulation.LFT. serotonin.Schizoaffective disorder (prominent psychosis) . 5. SLE.High risk of suicide or homicide .Urine drug screen .Failure of outpatient treatment Goals of outpatient treatment .Establish & maintain therapeutic alliance .Noradrenaline. Poor prognosis if delusional disorder last longer than 6 months.Substance abuse (if young) .Flight of idea. head injury . .9 Setting of Treatment: Usually require admission for manic episode.Racing thought .5% .monitor psychiatric status .Depression .Atypical depression: hypersomnia.Dysthymia – not meeting criteria of depression .Psychoeducation for bipolar disorder .Bipolar I disorder: occurrence of 1 or more manic episode with or without history of 1 or more depressive episode. 5. glucose .Identify new episodes early 7 . 5 Better prognosis if it is acute.Enhancing treatment adherence .Bipolar II / rapid cycling: more common in Female .EEG to rule out epilepsy Other tests: .Monitoring side effects of medication .Severe depressive symptoms . Bipolar disorder 5.

Toxic effects (refer to appendix 5a): Lithium overdosage can be fatal.Ebstein anomaly in foetus. failure to drug treatment. pancreatic toxicity . 5.6) Before starting lithium.Psychoeducation on bipolar disorder .Cognitive therapy to challenge grandiose thought .Long term side effects: nephrogenic diabetes insipidus due to blockage of ADH sensitive adenyl cyclase.13 Complication: 8 .10 Psychological Management .By stimulating Na/K pump.Depression .Treated patients have better prognosis 5. check LFT Mechanisms . or depressive .Untreated patients have > 10 episodes in a lifetime. RFT & TFT have to be normal.Relapse drills: to identify symptoms and to formulate a plan to seek help in early manic phase.2-0.Inhibits both cyclic AMP and inositol phosphate second messenger system in the membrane.10mg daily Then add on mood stabilizer after blood investigations. mixed.Prophylaxis of bipolar disorder .Behavioural therapy to maintain regular pattern of daily activities .4) Check FBC before starting carbamazepine Mode of action: . Lithium CR (500mg – 1000mg $0. Roger Ho .Haematological disturbance of platelet function.Slight risk of liver. diarrhea) .Length of time between subsequent episodes may begin to narrow but stabilize at 4th to 5th decade. Risperidone 2. Sodium valporate (Epilim) (400mg – 1000mg) ($0.Short term side effects: GI disturbances (nausea.mediate its therapeutic effect by indirect inhibitions on GABAergic systems. .Treatment of depressive and manic episodes . Neural tube defect in foetus Carbamazepine 400– 800mg ($0.For depression.Prophylaxis of bipolar affective disorder Adverse effects: . vomiting.4mg daily Olanzapine (more sedative & good for mood symptoms but expensive): 5. Indications: . manic.Prophylaxis of bipolar affective disorder Adverse effect: .Drowsiness and dizziness .12 Course and Prognosis: -Extremely variable -First episode may be hypomanic. for pregnancy (to avoid teratogenic effects) 5.Family therapy: Psychoeducation for family & techniques to cope with patient’s illness . . .Support group for bipolar patients. .Leucopenia and other blood disorders Lamotrigine 50 – 150mg 100mg = $3 For bipolar disorder with depressive episodes 5.Study Notes in Psychiatry (2008) Dr. stimulates exit of Na from cells where intracellular Na is elevated in depressed state. Mechanism of action : .not useful for rapid cycling Adverse effects: . Indications: . . stimulates entry of Na into the cells where intracellular Na is reduced in manic state. hypothyroidism and cardiotoxicity .ECT: Best for acute mania.9 Pharmacological Management Acute treatment of manic phase : By antipsychotics: Haloperidol 5-10mg daily.3-0. manic states .5 – 1) Before starting Valporate.11 Other treatment .For rapid cycling disorder 5.Mediate its therapeutic effect by inhibiting kindling phenomena in the limbic system Indications: .

drowsiness and weight gain . RFT.No serotonin related side effects: sexual dysfunction..2) for retarded depression. MAOI: seldom used . not eating & drinking.3 Clinical features: . 2) Selective abstraction – ignore important feature 3) Over-generalisation from single incident 4) Minimisation positive and magnitification of negative Social theory: for women.6 Pharmacological Management: Selective serotonin reuptake inhibitors SSRI -Fluoxetine (Prozac) 20mg OM ($0. steroid . guilt. less drug interaction. recent MI.Is it bipolar disorder? . ill-health.Hallucination: second person auditory hallucination: repetitive words & phrases 6. $1. attempted suicide 25-50% & committed suicide: 10% Ch. (Brown & Harris) -3 or more children under 15 yr of age -not working outside -lack of supportive relationship from hd.Setraline (Zoloft) 50 – 150mg ON.Learned helplessness: highly aversive outcomes are possible.7 Psychological Treatment CBT: Cognitive: Identify cognitive dysfunctions from dysfunctional thought diary. cerebral haemorrhage. separated Prevalence: 5% 6. decreased TSH Psychological theory: .5 Investigations: FBC.1 Epidemiology Age: Women.Monoamine theory of depression: depletion of monoamine such as 5HT & NA . anticholinergic side effects. agitation. Roger Ho . high incidence of nausea & vomiting in first few days.Maternal deprivation when young .Paroxetine CR (Seroxat) 25mg ON.4 DDX: . second line. more withdrawal symptoms . 5HT-2 and 5HT3 postsynaptic receptor antagonist & antihistamine effects. Long half life. II and V (poor) More common among divorced.Alcohol abuse 6. highest prevalence between 35 and 45 years.Fluvoxamine (Faverin) 50mg -100mg ON. insomnia. confusion. headache.Escitalopram (lexapro) 10mg ON.2 Aetiology: . lost productivity.5.good for depression and insomnia .Serotonin & Noradrenaline reuptake inhibitor: Venalfaxine (Efexor) 75 mg BD $5.6.Study Notes in Psychiatry (2008) Dr.No cardiovascular or anticholinergic side effects . treatment resistant depression -ECT has wide range effects on monoamine -Absolute contraindication: raised ICP -Relative contraindications: cerebral aneurysm.Endocrine abnormalities: hypersecretion of cortisol.Cognitive distortions: 1) Arbitrary inference: drawing conclusion when there is no evidence. divorce. -Early side effects: loss of short term (retrograde) memory.Genetics: Prevalence in first rate relatives: 1015% . ESR.Endocrine: hypothyroidism . (first line nowadays) .DEPESSION – refer to clinical skills -Severe depression may have psychotic features: -Delusions concerned with themes of worthlessness.8 -Noradrenergic and specific serotonergic antidepressants (NaSSas): Mirtazepine (Remeron) 15-30 mg ON ($1-2). Men increases with age Sex: F:M = 2:1 Social class: more common in I (rich).ECT: for actively suicidal patients. . $1.TCA: amitriptyline 50 – 100mg ON. poverty -Persecutory delusion: people are about to take revenge on him .Morbidity and Mortality rates are high: lost work. adverse effect: Restlessness. TFT 6.Is it mixed anxiety & depression? . $2: good for mixed anxiety & depression. -loss of mother/separation before age 11 -Threatening life event before depression 6.5 Sedative. avoid in elderly with a lot of medication. retinal detachment. LFT. $0.Medication related: antihypertensive. good for elderly . muscle aches -Late side effect: long term memory loss Mortality of ECT: 2/100. Folate. cardiotoxicity when overdose. . 000 6. nausea . high dose  hypertension Duloxetine(Cymbalta) 60mg ON for pain & depression . B12. patient will 9 . 6 Depressive Disorder 6.

Fluoxetine (Prozac) 40mg – 60mg .Study Notes in Psychiatry (2008) Dr. . Ch.SSRIs are indicated in the treatment of OCD.8 Prognosis .1 Epidemiology . . E. .Poor prognosis: Giving in to compulsions. it is essential to interview relatives and encourage them to adopt a firm but sympathetic attitude to the patient.Premorbid personality: 70% of OCD patients have obsessive compulsive personality trait.Paroxetine CR (Seroxat) 25mg – 75mg: for very anxious patients.Psychological explanation: OCD patients have defective arousal system and inability to control unpleasant internal states. checking 7.7 Social treatment Obsessional patients often involve other family members in their rituals.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. 7. The patient then learns to internalize the “stop” order so that thought stopping can be used outside therapy situation. 7.Equally common among men and women .Prevalence 0. cognitive restructuring to change distorted thought. Roger Ho examine evidence for and against them.CT/ MRI: bilateral reduction in caudate nucleus.Maintain their strengths .3 Pathogenesis . bizarre obsession & compulsion. 7. Behavioural therapy: Exposure and response prevention. 7 Obsessive Compulsive Disorder 7.Dysregulation of the 5HT system . 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.Cell immediated autoimmune factors . 7.Organic factor: during epidemic of encephalitis lethargica .6 Psychological treatment Cognitive therapy: to use dysfunctional thought diary to record obsessions and gently challenge obsessional thought. associated with handwashing compulsion. Obsessions (fear of dirt) are stimuli associated with anxiety provoking events where compulsions (such as hand washing) are learned to reduce anxiety.5 Pharmacological treatment .05% 7. OCD require higher doses of SSRIs compared to depression. rigid.Promote adaptation to everyday living.2 Aetiology . In planning treatment. the therapist shouts “stop” to teach the patient to interrupt the obsessional thought. Rehabilitation .g obsessional thought with hand contamination.cleanliness. comorbid delusion and depression 10 . 7.Onset is most commonly in early adult life . 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. early onset.g shout obscenities in church Ruminations – repeated worrying themes of more complex thought – the end of the world. longer duration. Behavioural: increase pleasurable activities.to maintain functional capacity.Genetic: MZ: DZ 80%: 25% .Fluvoxamine (Faverin) 150mg – 200mg . orderliness.4 DDX: - Anxiety disorders Phobic anxiety disorders Psychotic disorders Organic disorders Depressive disorders 7.

Asthma.Loss of control of cortisol .Autonomic arousal .dizziness. more common in women Fear of shops. ECG Management: -Psychological: relaxation therapy.2% Women: 2-3 times higher than men 2 peaks in women: 15-24 yr. hawker centre. acute hypocalcaemia .Fear network in brain: amygdala Clinical features -Palpitations. markets.Unexpected negative events eg early death of parent .Hyperventilation.↓ GABA activity . Roger Ho . hypoglycemia. crowd.2 Panic disorder Epidemiology: Lifetime prevalence: 4. MRT. TFT. breathing into paper bag is not recommended nowadays as CO2 can trigger more anxiety. MRT) & worries of humiliating or embarrassing Management: short term benzodiazepine. poor concentration DDX: . nausea. derealisation. fainting. shaking -Physical: breathing difficulty. choking.Early onset: with childhood fears .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.Good prognosis: good premorbid.5-6. 8 Anxiety Disorders (Ox handbook) 8. tingling -Tension: muscle.function a precipitating event. fluoxetine.Decreased in GABA – inhibitory . glucose. SSRI (avoid fluoxetine). place that cannot be left suddenly Social phobia 17-30.Treatment: establish normal breathing pattern. 8. low remission rate -Can lead to alcohol abuse.Increased adrenergic activity .Very common. bloating. OCD does not associate with suicide.Alcohol & drug abuse .BZDs: alprazolam 0. shaking . Agoraphobia: (housebound housewife) 15-35 yr old. SSRI Systematic desensitization: imagine or expose to anxiety provoking situations.Chronic stressors Clinical features (at least 4) -Autonomic arousal: sweating.ache. propranolol for palpitation Course: -Chronic and disabling. avoid situations that can be observed by others (presentation. -Pharmacological: short term benzodiazepine. Arrhythmia. choking. fluvoxamine are recommended drug of choice . depersonalization -General: numbness. 11 . Temporal lobe epilepsy.Genetics: 30-40% heritability -Supersensitivity of 5HT1A receptors . benzodiazepine.1 Generalised Anxiety Disorders Epidemiology: -Lifetime prevalence: 2. swallowing difficulty -Mental: dizzy. 45-54 yr Aetiology: .4% -Female> Male .chest pain.Genetics: Heritability: 30% .normal worries .dysregulation of 5HT activity . RFT.Late onset: stressful life events Aetiology: . LFT. Ch.Study Notes in Psychiatry (2008) Dr.50-60% of patients with panic disorder have HVS .Increase ANS responsiveness . more common in Female . keyed up -Other: mind going blank. M = F. SOB. bus.5mg for acute attack Hyperventilation Syndrome (HVS): .mixed anxiety and depression .Organic: Thyroid disorder. Investigation: FBC.

Genetic: higher concordance in MZ than DZ twins . assault. understand meaning of stressors. Manifested as depression and anxiety (no psychotic features). Acute Stress disorder (2d – 4 weeks) Similar to acute stress reaction. with symptoms of hyperarousal.Supportive psychotherapy: enhance coping 9.Study Notes in Psychiatry (2008) Dr. 9. to resolve unconscious conflict. accident.High social class .Eye movement desensitization & reprocess: Using voluntary multi-saccadic eye movements to reduce anxiety (limited experience in Singapore.Male .Look for alcohol abuse 9. don’t mention it in oral exam) . but more dissociative symptoms Similar to PTSD.3 Clinical features (Appendix 9a) . bereavement).25mg TDS 9.Short term benzodiazepine: alprazolam 0.25mg TDS for 2 weeks . Clinical features: depression and anxiety.High IQ .50% recover 1st year. neutralize by relaxation technique until patient habituates Chapter 9 Post traumatic stress disorder 9. avoidance and flashbacks of events. short term BZD Normal and abnormal grief reactions . hallucination.PTSD is a severe psychological disturbance following a traumatic event characterized by involuntary re-experiencing of the events.Previous trauma Protective factors .7 Complication .Acute stress reaction .F:M = 2:1 9.Normal grief: refer to appendix 9a Mean duration: 6 months.CBT: education about PTSD.Chance to view body of dead person . Management: .After traumatic event.Depressive symptoms: SSRI 12 .Reduced right hippocampal volume. Roger Ho progress through hierarchy. cognitive restructuring for trauma experience. excessive guilty. Pharmacological: SSRI. 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.Lifetime prevalence 8%. gradual exposure to stimuli avoided . but less than 4 weeks duration. . Longer than 4 weeks. anxiety management. 30%: chronic Acute Stress Reaction (hrs to days): A transient disorder (hrs or days) that occur as immediate response to exceptional stress.2 Aetiology . anger management. 20 -30% for women develop PTSD .Anxiety symptoms: 2 weeks alprazolam 0.1 Epidemiology .6 Pharmacological treatment . Treatment of above disorders: Supportive psychotherapy to enhance capacity to cope.Adjustment disorder 9.Abnormal grief: 1) Intense 2) Prolonged> 1 year 3) Delayed grief 4) Absent grief Other features: thoughts of death. prolonged impairment of function. 8-13% for men. enhanced reactivity to stimulation & memory deficits . marked psychomotor retardation. .4 DDX . .Bereavement: any loss event .Psychodynamic therapy: understand the meaning of trauma. fire.Antidepressant if there are depressive symptoms .5 Psychological treatment .Dysfunction amygdala lead to enhanced fear response Risk factors: -Low education -Lower Social class -Female gender -Low self esteem -Family history of psychiatric disorders .

Acamprostate: works on GABA/glutamate system.Causes anxiety in patients Inx: FBC. Vitamin. relapse .Genetic factors: MZ > DZ twins. develop coping strategies . increasing incidence in females.Personality factors: chronic anxiety. contemplation. counselling 10. Motivation interviewing to help patient to change. Stages of change: precontemplation.2 Epidemiology Age: men in their early twenties Sex: More common in male.4 Clinical features (appendix 10) Alcohol intoxication: explosive outbursts of aggression.Prolonged insomnia 13 .Study Notes in Psychiatry (2008) Dr. adoption study also proves genetic links. thiamine 30mg OM. glucose 10.Convulsions Delirium tremens: 3-4days .Half way house: rehabilitation. preparation. 2004 Ch.Fearful affect . depression - . pathological drunkenness: acute psychosis induced by small amount of alcohol General withdrawal symptoms: 12-24 hr . CXR.Acute tremulousness in hands (the shake) . 10. GGT. not dependent on alcohol. 10 Alcohol dependence 10. physical damage.Alcoholic anonymous: observe & mirroring.Learning factors: learn from peer / parents .Nausea . feeling inferior.Perceptual distortions & hallucinations .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.Goal orientated treatment plan: Total abstinence: > 40. . idiosyncratic reactions to alcohol. heavily dependent.Other illness: anxiety disorder. sweating .5 Management Detoxification: managing withdrawal .Abnormal neurotransmitter mechanism . Ref: Oxford Handbook.Illusions & Hallucinations . .Agitation. failed controlled drinking Controlled drinking:< 40. U&E. let go of the past and move towards the future. maintenance. for maintenance . doctors. short term amnesia after heavy drinking. Social treatment: .Tremulous hands .Truncal ataxia .3 Aetiology: . B12.Refer to CAMP. Rehydration.Disorientation in time & place . early stage . inducing nausea if patient drinks alcohol . IMH Pharmacological agents used for maintenance: .Depression and suicidal behaviours 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 . LFT.Disulfiram: an aversive stimulus.Autonomic overactivity Alcoholic hallucinosis -occurs in clear consciousness -voices utter insults or threats. Social class: lowest prevalence in middle social blass Marriage: more common in divorce/separated Occupation: high risk: directors.Naltrexone: opiate receptor antagonist.Clouding of consciousness . Psychological treatment: Behavioural therapy: keep diary log & tackle drinking behaviour. Roger Ho Grief therapy: explore the meaning of the loss. no physical damage. .Impairment of recent memory . action.Diazepam 5mg TDS.

g hearing images . work out for better coping 11. 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.Effects occur after 2 hours of consumption.Intense crave for drugs . .Methadone: 20mg solution form. supervised treatment. Constricted pupils shivering Weakness -Abdominal cramps Impotence -Lacrimation Tremors .1 Definition: It is a state. Delirium tremens Treatment: switch to long acting benzodiazepines such as diazepam 5mg TDS and slowly cut down the dose. Alprazolam (Xanax) Chronic use Withdrawal Unsteady gait Rebound insomnia Dysarthria Anxiety Drowsiness Appetite disturbance Nystagmus Sweating. Roger Ho Polysubstance abuse Social complications: job.Can lead to unpredictable & dangerous behaviour.Out of body experience .6 Cocaine Formication (cocaine bugs) – exam classic: a tactile hallucination as feeling insects crawling under the skin.Chronic use can lead to paranoia . no antisocial personality disorder Ch. socially stable. 11.Group therapy: observe their own problems mirrored in other drug abusers.Persecutory delusions . Dormicum (Midazolam).Synaethesia: confusion between senses e. convulsion Confusion.Anxeity and depression . Psychological treatment: . tactile hallucination .g.Auditory.4 Amphetamines 14 .Dilated pupils .Clear consciousness 11. marriage 10. May need in-patient detoxication if using high dose benzodiazepine.7 Benzodiazepine e.2 Physical and psychological dependence Drugs Heroin Hallucinogen Amphetamine Cannabis Cocaine BZD Physical Yes No No No No Yes Psychological Yes Yes Yes Yes Yes Yes - . Treatment of above disorders: may need antipsychotics to treat psychotic experience. 11 Drug Dependence 11. 11.5 Cannabis Effects -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.Agitation Treatment: .2 Opiates – eg Heroin Chronic use Withdrawal Constipation Pilo-erection.Study Notes in Psychiatry (2008) Dr. 11.Hostility & aggression . visual.6 Prognosis: good prognosis in motivated.Supportive psychotherapy: educate patients on complications of drug dependence and cope with day to day problems. . 11.Buprenorphine (Subutex) was listed as illegal drug & withdrawan from Singapore. .3 Hallucinogens – LSD (lysergic acid diethylamide) . resulting from the interaction between a human and a drug. Flashback phenomena Psychotic reactions 11.

Galantamine: 4-12mg BD (8mg = $4. Onset < 65. Depression 12. sensory impairments. once daily dosage with GIT side effects.6/3mg) short half life. 40% at 85 yr old -M:F = 4:1 .5 Psychosis in elderly Less than 1%.Vascular dementia with neurological signs of stroke 12. CT or MRI brain Management: Acetylcholinesterase inhibitors: $$$ MMSE > 12 points Donepezil 5-10mg/day: (5mg=$5) long half life.Chromosome 14 for presenilin 1 . IMH: to leave the drug subculture. B12.Fronto – temporal dementia with personality changes .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. GIT side effects and safe in asthma. 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. prominent behavioural problems. Roger Ho . amygdale and cortex -Neurofibrillary tangles in cortex. not for asthma patients Rivastigmine 3-6mg BD: ($2.Chromosome 19 for apolipoprotein E4 .Dementia with Lewy body (with parkinsonism) . wandering. LFT. hypothyroid Genetics: . 12 Old Age Psychiatry 12. . Ch. also works on nicotinic Ach receptors. low dose atypical antipsychotics: risperidone 1mg ON / quetiapine 50mg ON 15 . VDRL. doubles every 5 years. RFT. support by counselor. Memantine: NMDA receptors partial antagonist (10mg = $3) Low dose antipsychotics such as risperidone 1mg ON for delusion of theft Behavioural techniques for changing negative behaviour Poor prognosis: Male.5).Study Notes in Psychiatry (2008) Dr. sexual disinhibition Mini-mental state exam < 24 /30 Investigations: FBC.2 Other causes of dementia .3 Reversible causes of dementia – Appendix 12a 12.Other risk factor: Down syndrome.4 Pseudo dementia: always say. head injury. social isolation Persecutory delusions: 90% Auditory hallucinations: 75% Visual hallucination 13% Treatment: relieve isolation & sensory deficits. F:M 5:1 Family history of schizophrenia.1 Alzheimer’s disease -most common cause of dementia (70%) Epidemiology -1% at 60. Folate.Chromosome 21 for amyloid precursor protein . “I don’t know” Previous history of depression Islands of normality Response to antidepressant 12.Rehabilitation in CAMP.Chromosome 1 for presenilin 11 Cholinergic hypothesis: degeneration of cholinergic nuclei in nucleus of Meynert Pathophysiology -Amyloid plagues in hippocampus. Parietal lobe damage.

equal sex incidence.More common in lower social class .Emotionally charged ideas lodged in the unconscious at some time in the past.Study Notes in Psychiatry (2008) Dr. Clinical features: -Preoccupation with the idea of having a serious medical condition. .abdominal pain . Epidemiology More common among elderly.exploratory psychotherapy about his past life.Secondary gain: symptoms confer advantage to patient: exempted from NS.It is usually in the form of overvalued idea.Conversion . childhood sexual abuse . cerebral tumour.Paralysis . making up illness 16 . Social treatment: to eliminate factors that are reinforcing symptoms.reassurance and suggestion .Patient will seek medical advice but is unable to be reassured by negative investigations.Dissociation – an apparent dissociation between different mental activities.Anxiety & depression are common.Aphonia.Anaethesia .Tendency to misattribute body symptoms .6 Depression in elderly .2 Hypochondriasis Hypochondriasis is the preoccupation with the fear of having a serious disease which persists despite negative investigation. . 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.History of childhood illness.Primary gain: anxiety arising from a psychological conflict is excluded from patient’s conscious mind . .Occurs in national servicemen Aetiology: . Pseudoseizure: .Exclude histrionic personality disorder.Psychogenic fugue (wandering) -Somnambulism (sleep walking) . Management La Belle indifference: less than the expected amount of distress often shown by patients with hysterical symptoms.Mental energy can be converted into certain physical symptoms. excessive medical attention seeking in parents. Investigation: no demonstratable organic findings Management: Psychological treatment: . Roger Ho 12.nihilistic delusion (Cotard syndrome) .1 Dissociative / Conversion Disorders Definition . . which will lead to death and serious disability. lower social class Aetiology: .Premorbid personality: 15% has premorbid histrionic personality traits.Inconsistent neurological sign .Monitor suicide risk .Exclude organic causes: temporal lobe epilepsy.more psychomotor retardation . 13 Consultation Liaison Psychiatry 13.Medical reassurance provides temporary relief of anxiety which acts as a reward for more medical attention.More common among women .Treatment of choice: escitalopram 10mg ON Ch.Onset usually before the age of 35 .Exclude malingering: conscious aware of what he or she is doing. parental illness.Can recall the seizure episode & avoid injury .Blindness . DDX: .no increase in serum prolactin (increases in genuine epilepsy) 13. .Multiple personality Conversion . Pathogenesis . general paralysis of insane dementia .Disorder of gait .Fits . .Psychogenic amnesia . it is likely to persist for many years. Epidemiology: . Clinical features: Dissociation .Deafness . There is a conversion of psychic energy into physical channels.

CBT: challenge & replace misinterpretation .Study Notes in Psychiatry (2008) Dr. palpitation.endocrine: Pituitary.Post ictal confusion . F:M 5:1.Exposure to illness cue & response prevention . 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. alcoholic. dementia. Delirium/ Acute confusional state It is a clinical syndrome of fluctuating global cognitive impairment with behavioural abnormalities due to variety of insults. visual hallucinations (big insect) . 7) Having a psychiatric illness like Schizophrenia does not mean lack of capacity to give consent. impaired recent memory .Explain negative test.Break cycle of repeat consultation . affecting multiple organ systems presenting before the age of 40. 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.Investigate objective signs only . abscess .metabolic: electrolyte disturbance. It can lead to depression. PTH. BP GI: heartburn. CNS infection . Risk factors: elderly. Epidemiology: . hypoxia .Allow patient to ventilate their problems .Symptom re-attribution .Psychotic illness . nausea.Psychomotor agitation & emotional lability .Disorientation. It is associated with significant psychological distress. hepatic encephalopathy. flatulence. .Dementia Management: 1) Identify & treat precipitating cause 2) Provide calm environment with reality orientation (big clock) 3) Low dose antipsychotics: Haloperidol 2.Family education .2%. postoperative. blind & deaf.5mg/ risperidone 1mg 4) Regular review and follow up 5) Educate family about delirium Depression in chronic medical illness 17 .Nocturnal worsening of symptoms . avoid AED & unnecessary investigation . suicide.g mini mental state examination.illusions. Roger Ho . adrenal .Depression: use SSRI like fluoxetine Somatisation disorder A chronic disorder of multiple medically unexplained symptoms. Aetiology . chest pain. age of onset: childhood to 30s Clinical features: Pain: right iliac. Treated by SSRI and CBT.0.Substance intoxication and withdrawal Clinical features: . Epidemiology 10% of medical & surgical inpatients. & functional impairment. chest infection. thyroid. reassurance. no further investigation. risk and benefit 2) Can patient understand the info? 3) Can patient retain info? 4) Can patient balance the risk or benefit? 5) Can patient arrive at a conclusion? 6) Further assessment of cognitive function e. similar to aetiology of hypochondriasis.Infection: UTI.CBT Body dysmorphic disorder (Dysmorphophbia): Preoccupation that some aspect of physical appearance (body image) is grossly abnormal & refuses to accept medical explanation. burn victims.More family members with somatisation disorder.Fluctuating course -impaired consciousness and attention . Aetiology -Intracranial: CVA.Aim to improve function .Poorly formed paranoid idea (other patients want to harm him) DDX: . back and head CVS: dyspnoea. planned visit. head injury.

Prevention by education . cramping.2 Postnatal depression Epidemiology: . cyclical.3 Postpatrum psychosis PMS is a constellation of menstrually related. less caffeine. No need for treatment. leading to dopamine super-sensitivity. poor concentration. Look for non somatic symptoms: guilt. Ch. chronic. Roger Ho Common. paranoid idea about safety of baby . Refer to O and G if above measures fail Epidemiology 1. severe impairment in 5% Investigation: Charting of daily symptoms for at least 2 menstrual cycle may aid in confirming cyclical pattern. bloating. fatigue.CBT 14.10-15% of women .5/1000 live births Peak: 2 weeks postpartum Aetiology Reduce of oestrogen. physical and emotional symptoms in the luteal phase. SSRI (to avoid breast feeding) . concentration. disorientation .Previous postpartum depression Clinical features .1 Baby blues - - Family history of psychiatric disorder Lack of social support Clinical features: -Prominent affective features (80%): mania / depression . Symptoms: Breast tenderness. lethargy. progesterone and prolactin.Insomnia. cortisol levels or postpartum thyroiditis Risk factors: Ref: Oxford Handbook.90% last less than 1 month Management: .Poor relationship with own mother . Treatment: Conservative management: Low salt and fat diet.Look for suicide & infanticide risk Management: Treatment in hospital – KK women hospital / In the UK. libido changes. to reduce stress Consider medication: to try SSRI if fails to conservative treatment. reduce alcohol and tobacoo intake. depression. perplexity.Ambivalence towards pregnancy . 2004 18 .Depression + worries about baby’s health and ability to look after baby . . food cravings.4 Premenstrual Syndrome (PMS) ¾ of new mothers will experience a short lived period of tearfulness and emotional lability starting 2-3 days after birth. low mood . Prevalence: 40% of women of reproductive age. 14. admit to special mother – baby unit ECT is useful Antipsychotics is needed ( to avoid breast feeding) 14.Use escitalpram as it has less drug interactions. 14 Perinatal Psychiatry 14.Family history of depression.Assess suicide risk .Poor social support .Peak: 3-4 weeks of delivery Risk factors: .Psychosis.If severe.Enhance support . Due to pospatrum reductions of oestrogen. irritability.Study Notes in Psychiatry (2008) Dr.

15 Eating disorder Elevated hormones Growth hormone Prolactin Cortisol Reduced hormones T3 and T4 Oestradiol Testoesterone FSH and LH 15.Social: Exam stress in S’pore.Usually Females. LH. overvalued idea -Endocrine disorder: HPA axis. purging.Cardiac complications .dread of fatness.More common in upper social class .Marked change in mental status . TFT.Family pathology: enmeshment. raised cortisol. occupations group: ballet students. rigidity.5% Aetiology -Genetics: MZ: DZ 65%:32%. lack of problem solving Clinical features Core clinical features .Delayed and arrested puberty. Complications: Secondary to starvation Hypothermia Constipation Low BP. F:M = 10:1 -Onset between 16-17 . anaemia Bradycardia Amenorrhoea Leucopenia Hypercholesterolemia Delayed in growth Osteoporosis Consequences of vomiting & laxative Hypokalaemia Hyponatraemia Prolonged QT Cardiac arrhythmia Dental caries Investigation FBC. to set target weight.Increasing incidence: 0.Risk of suicide . movie etc .Cognitive therapy. excessive exercise. reduced sexual interest. aims at changing attitude towards 19 . amenorrhoea.6-10% of female siblings of patients also suffer from this condition -Hypothalamic dysfunction .Behavioural therapy: regimen of refeeding. LFT.RAPID -A body weight more than 15% below the standard weight or BMI 17.5 or less . Roger Ho Dry skin/brittle hair Loss of brain volume Cerebral atrophy Ventricle enlargement Ch. altered TFTs . RFT. 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 . cholesterol. after gaining some weight. 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. atheletes -Individual pathology: dietary problems in early life. glucose.Study Notes in Psychiatry (2008) Dr. positive reinforcement with privileges such as outing.1% of middle class adolescent girls. .1 Anorexia Nervosa Epidemiology . lack of a sense of identity . .Failure of outpatient treatment Feeding and refeeding syndrome -Consult medical/dietitian . overprotectivieness.Self induced weight loss: vomiting. appetite suppressant -Body image distortion.Refeeding syndrome: Cardiac decompensation can occur within first 2 weeks: myocardium cannot withstand the stress of increased metabolic demand.

Body weight within normal limits Comorbidity: Multiple dyscontrol behaviours: .Overdose .Tolerance: need to gamble with larger amounts of money .Menstrual abnormalities less than half of the patients .Lying to others about gambling .Losing or jeopardizing familial relationship Treatment: .Credit card debt counseling via MSW 15.SSRI (fluoxetine) .Fail to cut down .Chasing losses (like chasing the dragon in drug addicts) . mean age 36. purging BN is different from AN. . Clinical features .4 Kleptomania Failure to resist impulses to steal items that are not needed nor sought for personal use.Chronic illness . 16 years of illness DDX: shoplifting (well planned and motivated by need and monetary gain).CBT to reduce preoccupation with gambling .Excessive weight loss . Relatively common and may lead to significant personal.Poor parental relationships .5 Trichotillomania Factors associated with a poor prognosis . e.SSRI 15.3 Pathological gambling It is a persistent and recurrent maladaptive patterns of gambling behaviour.Cutting / burning . Usually women.Study Notes in Psychiatry (2008) Dr.Alcohol / drug misuse . .Usually managed as outpatient 20 .Cognitive behavioural therapy Poor prognosis: severe personality disorder or low self esteem.Support group .Anxiety when eating with others .Higher dose of SSRI: fluoxetine up to 60 mg .Attempts to counter the fattening effects of food: self induced vomiting. 15.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 .CBT .Promisuity Management . . reappraisal of self image and life circumstances.Preoccupation with gambling .Late age of onset .Admission only for suicidality and physical problems . family and occupational difficulties.Patients are more eager for help . -Family therapy 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 1/3 Chronically disabled.g A men stole 10 female T shirts.Committing illegal acts to finance gambling.Bulimic features . In BN.Poor childhood social adjustment . same style but different colours. Roger Ho eating. OCD and depression Treatment: .

Chronic Physical illness : terminal illness / malignancies a) chronic pain 8. Other associations : a) history of DSH (1/3.8 % (Roy et al. Employment : a) unemployed / retired / living alone 4.7 %) 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 : • 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. Sex a) M:F = 3:1.2 % suicidal thoughts • 2. Occupation : a) higher risk groups are doctors.if fail consider risperidone or lithium Ref: Oxford Handbook.000) • 1 suicide every 3 months Sociodemographic correlates of suicide 1) Age. or poisoning. Social Class : a) Higher in lowest social groups & professional b) lowest in middle groups 5.500 patients) • 1 suicide every 4 years • Psychiatrist (catchment area 50. hotel and bar trade owners 7. Marital status : a) divorced > widowed > single 3. lawyers. 2004 Ch. whether physical. UK 16.10 %) Alcohol dependence (risk 3. SSRI. More common in female 21 .2 Deliberate self harm (DSH) A deliberate. Roger Ho Stereotyped recurrent pulling of hair DDX: OCD. factitious disorder Treatment: behavioural modification. Tourette syndrome.½ of completers) Suicide and mental illness • all psychiatric illness (except OCD) increase risk by 90-95 % • Depression (risk 3. done in the knowledge that it was potentially harmful.3 % : 1.6. 1991) Neurochemical 1)Serotonin : serotonin deficiency 16.4 .1 Suicide Epidemiology • completers are more often : • male • psychiatric disorder • have made a plan • used a dangerous method Prevalence • lifetime prevalence (USA): • 21 % morbid thoughts • 10.Study Notes in Psychiatry (2008) Dr.6 . Autism. drug overdose. Religion : a) strong religious affiliation is a protective factor 6.16 Suicide and DSH Trickcyclist. non fatal act.8.5 % = 30 x general population risk) Schizophrenia (risk 5 . males > females for all groups b) suicide pacts more common in the elderly 2.9 % attempted suicide • GP : (2.

5% Neurophysiology: -immature EEG in posterior temporal lobe as slow waves 22 . there is an adverse effect on the individual or society.Negativistic Prognosis: 1/3 continue to have Borderline Personality disorder after 10 – 20 years.Develop self esteem and realistic future goals Pharmacological treatment: . 17 Personality disorder Deeply ingrained.Severe repeated self-harm 17.Then focus on tolerance of distress. self concept and functional assessment Admission to hospital They benefit little from prolonged admission. divorce Playing primitive defence mechanisms such as splitting or projective identification Clinical features: “I RAISE A PAIN” I – Identity disturbance R. timing • • • • precautions to avoid intervention suicide note anticipatory acts ‘dangerousness’ of state of mind Ch.SSRI antidepressant can improve mood and reduce impulsivity Prevalence: 2-3. maladaptive patterns of behaviour.To process trauma .Study Notes in Psychiatry (2008) Dr.5 – 2% Childhood development Childhood trauma – sexual abuse. social functioning Obtain collateral information from family and past psychiatric history Explore relationships. continuing throughout most of adult life. An attempt to influence others. emotional regulation and interpersonal skills .2 Antisocial Personality Disorder - Educate them about the schema Empathetic challenging their core beliefs Goal directed problem solving approach Dialectical behavioural therapy for borderline personality disorder .Idealisation and Dealisation N .Focus on a detailed CBT approach to self harm . 17. recognisable in early adulthood. to feel pain in personality disorder Factors of DSH predicting suicidal risk .Relationship: unstable A – Abandonment fear of I – Impulsive S – Suicidal gesture E – Emptyiness A – Affect: unstable P – Paranoid idea / psychosis: transient A – Anger I .1 Borderline Personality Disorder Prevalence: 1. 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 CBT: • Isolation. Roger Ho Motives: A cry for help. interpersonal relationships. escape from stress. Poor prognosis: .Low 5HT levels in impulsive violent individuals Childhood development Difficult infant temperament Harsh and inconsistent parenting 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.

Confusion / agitation . nausea. it can lead to acute renal failure.Stop antipsychotics .Benzodiazepine for acute behavioural disturbance .Hyperthermia .IV fluids. IM lorazepam 2mg (in IMH). 2) Oral medication: PO Haloperidol 5mg stat or PO lorazepam 1mg stat 3) IM medication: IM Halperidol 5mg stat.Schizophrenia .Incontinence . Roger Ho Outcome of personality disorder High rates of accident. 1% of patients on SSRI Pathophysiology: due to increase in serotonin.Mania . ataxia More rapid onset. mydriasis. Due to blockade of D2 receptors leading to impaired calcium mobilisation and leads to muscle rigidity. malignant hyperthermia. meningitis. tachycardia. tremor.Illicit drugs .3 Serotonin syndrome: A rare but potentially fatal syndrome occurring in the context of initiation of serotonergic agent. rigidity and tremors. CXR. hyperreflexia. consider physical restraint 18. characterised by altered mental state. Incidence: 0. reduce temperature .Dehydration 23 . ECG to look for prolonged QTc 18.Tachycardia .2% F: M = 2:1 Risk factors . Ref: Oxford Handbook. CT DDX: lethal catatonia. serum CK.Tremor .Personality disorders Treatment of acute disturbed patient or crisis: It requires immediate action: 1) De-escalation verbally in calm and consistent environment. diarrhoea. suicide and violent death.Head injury . altered mental status and autonomic dysfunction. refer to medical . rhabdomyolysis Management: .Medical emergency. hyper/hypotension Neuromuscular: myoclonus.2 Neuroleptic Malignant Syndrome It is a rare life threatening reaction to antipsychotic medication characterised by fever. add in CXR to rule out aspiration. agitation. shivering. Clinical features: Autonomic: hyperthermia. Investigations: same as NMS.Alcohol and drug dependence . no IM diazepam due topoor absorption 4) Close monitoring on vital sign 5) If chemical restraint fails. 2004 Chapter 18 Psychiatric Emergency Clinical signs and symptoms: . diarrhoea.Study Notes in Psychiatry (2008) Dr. muscular rigidity. 1 Acute disturbed patient Aetiology . LFT. myoclonus and hyperthermia.Drug naïve patient receiving high potency antipsychotics . RFT. hyperreflexia.Muscular rigidity . rapid progression and less rigid than NMS.To give bromocriptine Mortality: 5-20% die.Metabolic disturbance . 18. heat exhaustion.Hyper or hypotension .↑ CK level Investigations: FBC. Ca and PO4.

course. effect on somnolence work. compliant frequency.Endocrine: Addison.2 Insomnia Insomnia involves difficulty to fall asleep. of sleep dream. desynchronised EEG activity Chronic significant insomnia – 6% Aetiologies: Intrinsic causes: .Dependency related sleep disorder like hypnotics . . wakening.Nocturnal eating and drinking Medical and Psychiatric causes: . seizure and muscle rigidity. Epidemiology . Drug & Regular hypnotics alcohol Caffeine containing drugs 19. with slow theta and delta waves K complexes Delta wave. satisfaction Daytime Level of alertness. Consolidating sleep Non BZD Bitter taste Assessment of sleep disorders: Present Onset. .Resolve with 24 – 36 hours .As night progresses.Sleep hygiene measures: Good sleep habits and stimulus control .Relaxation training .5mg ON 24 .1 Normal sleep – stages and cycle .Mortality < 1 in 1000 Chapter 19 Sleep disorders 19.Common problem .Pain .Psychophysiological insomnia associated with anxiety .Periodic limb movement disorder Extrinsic causes: .Idiopathic insomnia .F>M . Cushing .Prescribe benzodiazepine to control agitation.Total sleep time in adult is between 5 – 9 hours.Greater in elderly Intermediate 6 hours Lorazepam Ativan 1mg ON Zopiclone Imovane 7. Stage 1 Stage 2 Stage 3 & 4 REM Light sleep.Use of hypnotics if unresponsive to above Length of action Ultra –short 2 hr 10mg ON $1.Anxiety disorder.Address underlying problem (drug dependency) . . cause rebound insomnia Initiating. it is a medical emergency. maintaining sleep and poor quality of sleep as persistent problem 3 days per week for one month.Sleep state misperception (constant monitoring of sleep) .Depression. bipolar disorder .Sleep apnoea syndrome . daily activities.Schizophrenia Management: .Inadequate sleep hygiene . Roger Ho Treatment: . bed time Description Behaviour during sleep. the amount of time spent in delta sleep decreases with consequent increase in REM sleep. .Consult medical. to allow volume correction to reduce the risk of rhabdomyolysis .A typical night’s sleep has 4 or 5 cycles of stages.IV access.Parkinson disease . each lasting 90 – 110 minutes. stressors Daily routine Waking. Course and prognosis: .Education: stages and cycles.Study Notes in Psychiatry (2008) Dr. maintaining. slow wave sleep Low voltage.80 Examples Zolpidem (Stilnox) Comments Non – BZD Facilitate onset of sleep Also has potential of dependency.Respiratory (COPD) . PTSD . duration.

Roger Ho Long acting > 12 hours Diazepam Valium 5-10mg Flurazepam Dalmadorm NUH only 15-30mg Initiating.Gang involvement .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 .Large family size .School failure Assessment: .Earlier onset and is more common in boys than in girls. getting up & down.Genes: 5.Neuroimaging: frontal hypometabolism .Collateral info from school Treatment: .Cruelty to people and animals .Interview with parents: developmental history . .Deceitfulness or theft . Aetiology Biological factors . Jumping the queue Inattention symptoms Cannot sustain attention Poor task completion Making mistakes when task require attention Social skill training Parent management training Education and remedial intervention Stimulant: Methylpenidate 5-10mg OM: increase Dopamine & noradrenaline which can increase concentration & attention.Low socioeconomic status and poverty .Study Notes in Psychiatry (2008) Dr. . 6. maintaining.UK: 1% .CBT: behavioural techniques Clinical features: .20% develop antisocial personality disorder . 20 Child Psychiatry 20. 2x increase in siblings .USA: 3-5% (over-diagnosis) .Aggression . Consolidating sleep - - Hang over effect on the morning Midazolam (Dormicum) has very fast onset of action and high potency.hyperactivity that is developmentally inappropriate.M:F = 3:1 Aetiology: Genetics: . 11 are implicated.20% develop substance abuse disorder 20.Harsh and inconsistent parenting . Epidemiology: .Substance abuse in parents . It is not recommended for regular oral usage.Low IQ .Brain injury Psychosocial .Parental criminality . climbing on desks Blurting out answers. moving.Ensure the safety of the child .Destruction of property .Serious violation of rules .Domestic chaos and violence . Outcome .50% risk in MZ twins.Observe attachment style and level of activity of child . side effect include growth retardation which requires drug holiday.Early loss and deprivation .Family history of antisocial behaviour or substance abuse. it has high potential for dependency.CBT problem solving skill 25 . Ch.Low CSF serotonin . The symptoms should have an onset in childhood.Dopamine & 5HT dysregulation in prefrontal cortex Clinical features: Hyperactivity symptoms Fidgeting.1 Attention Deficit & Hyperkinetic Disorder (ADHD) ADHD is a persistent pattern of inattention +/.Lack of empathy Management: .

Increase in brain size .Abnormal communication/play: lack of language.Socially and emotionally inappropriate behaviour and interpersonal interaction . hyperactivity. low IQ. .Male predominance . IQ and language are normal or superior. abnormal gaze Physiological: abnormal response to pain. .Increase in lateral and 4th ventricle . poor parenting. . Behavioural: irritability.CD is often chronic and unnameable. Newton and Einstein may have AS Epidemiology .1 in 300 Clinical features . hyperactivity.3 Autism Neurological: tics.A qualitative abnormality in communication and play . Clinical features: . self – injury. . family criminality. attentional problems. .Rating scale: Autism Behavioural Checklist It is characterised by the triad of symptoms: .Restricted interests or activities: non functional routines or rituals (bus schedule) Treatment: .Toxic agents .Narrow interests and preoccupation of a subject . abnormal temperature regulation.Restricted. interests and activities Epidemiology: .Extensive logical or technical patterns of thought . repetitive behavioural patterns and restricted interests.Onset is typically before age 3.Antisocial PD in adults <50% Poor outcome: Early onset < 10 year old.Requires Multidisciplinary approach .Peculiarities in speech and language . Mild motor clumsiness and family history of autism may be present.Frontal & cerebellar abnormalities .Speech and language therapy 20.Problems with non verbal communication .Abnormal social relatedness .Family interventions .Study Notes in Psychiatry (2008) Dr.Abnormal purkinje cells in cerebellar vermis.Genetic . Roger Ho - Parent management training Family therapy Academic & social support referral - Course and outcome: .Repetitive behaviours or rituals . repetitive and stereotyped behaviour. 20. temper tantrums.Education & vocational interventions .Obstetric complications .Abnormal limbic architecture.Prevalence: 5-10/1000 Aetiology: . aggression Assessment: .4 Asperger Syndrome (AS) Severe persistent impairment in social interactions.Behavioural interventions .M:F = 3-4:1 . 26 .Association with tuberous sclerosis Pathophysiology MRI: . difficulty to initiate conversation. increase in head circumference. poor school achievement.Clumsy and uncoordinated motor movements.Pre/postnatal infections.Abnormal social relatedness: poor eye contact and no peer relationship .

Paraphilias .Borderline personality disorder . or vague complaints of feeling ill – these 27 . overprotective mother in combination with a weak.5 - Approaches to the Child Establish the rapport and gaining the child’s confidence Begin with subjects well away from the presenting problem (interests. 14 years and older. restrict fluid at night Medication: imipramine (TCA) 20. passive. hobbies. 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.PTSD . age 5 (starting school) 2. 7 years (change to junior school) 3.g. obstructive uropathy.Dissociative disorder . diarrhoea.Conversion disorder .6 • • Epidemiology • • • prevalence of 1-2 % slightly more common in boys more common during three periods in school life: 1.Substance abuse 20. neurological problems. Primary enuresis: never dry Secondary enuresis: previously dry Behavioural modification is important treatment: starchart to reward patient. 75% have family history of enuresis To rule out UTI. friends and siblings.9 Tourette’s syndrome 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.Depression . when there is often associated depression and difficulties in school an early return to school is important discussion with teachers is needed depressive disorder should be treated Prognosis • • worse prognosis in older children higher incidence of psychiatric disorders (e.Study Notes in Psychiatry (2008) Dr.8 Consequence of child abuse: . abdominal pain. ineffectual. Roger Ho 20. 7 Enuresis Voluntary/involuntary voiding of urine at night for child > 5 yr old. school and holidays) Progress to enquire about the child’s view of the problems Observe the level of activities and attention during the interview Try to interview the child and family together to observe family dynamics School refusal • - - 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 • 20. agoraphobia) in adult life 20. sickness. 11 years (starting secondary school) 4.

Psychiatry – An illustrated colour text. motor impairment Very limited language & basic skills Lesley Stevens. thin upper lip Growth deficits: Small overall length.Caused by maternal alcohol use. Other: ASD.2 – 3 per 1000 live births . Ian Robin. Due to effect of alcohol on NMDA receptors which affects cell proliferation Clinical features: Alcohol withdrawal: irritability. hypotonia. renal hypoplasia. language deficits. small maxillae and mandibles. sleep problems.0. CBT Ref: Oxford Handbook.3 Foetal Alcohol Syndrome . simple work Lower level of work. short palpebral fissure. Churchill livingstone 2001 21. with distress and impairment function.Study Notes in Psychiatry (2008) Dr. Facial tics as initial symptoms Vocal tics: meaningless sounds to clear words and coprolalia Tic wax and wane.Major causes of learning disability . Roger Ho Multiple motor and vocal tics for a year. 21. VSD.1 IQ and learning disability (LD) LD Mild Moderate Severe Profound IQ 50-69 35-49 20-34 Below 20 Features Independent self care Some deficit in language. small eye fissures. hearing loss. tremor and seizures Facial features: Microcephaly. 2004 21 Learning Disability/ Mental Retardation 21. cleft palate.2 Down Syndrome 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 28 .5mg-5mg. poor visual acuity. CNS: behaviour problems: hyperactive. exacerbations due to stress Onset: 7 years old M:F = 3:1 Prevalence: 5/10. joint deformities. OCD Treatment: Haloperidol 1. epicanthic folds.000 Genetics factors: AD Involves dopamine system and Basal Ganglia Comorbidity: depression.

22.Regain of insight For professional driver: bus driver.Compliant with treatment . Singapore does not have clear guideline on this) For schizophrenia. you can send the patient to IMH for assessment. He has poor insight and has defaulted his treatment for 3 months. disorientation. 22. Suffering from schizophrenia does not mean the patient has no capacity to decide on her dialysis. She wants to stop dialysis. bipolar disorder: Driving must cease during acute illness 22 22.has remained well and stable for at least 3 months . Example: Assume you are the AED medical officer working in a general hospital. A 29 year old Re-licensing for private car: . He refuses to be admitted to your general hospital psychiatric unit (or your psychiatric ward is full) In this case.1 Legal & Ethical Aspects Mental Disorder and Treatment Act . (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. 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. 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. Roger Ho male suffers from paranoid schizophrenia was brought in to your AED. The renal team is very concerned as she may die and they want to seek your opinion.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.Study Notes in Psychiatry (2008) Dr.Free from adverse effects of medication . 29 . He has been violent at home and attacks his parents. lack of insight and judgement are not fit to drive.3 Dialysis and Schizophrenia You have a 58 year old lady suffering from chronic schizophrenia and end stage renal failure.2 Driving and Psychiatric illness (Based on UK law.

Shorter time scale of long term psychoanalysis (too expensive and difficult for patient to stay in therapy for so long) Indication: . 23 Psychotherapy Common psychotherapies practised in Singapore include: 23. 30 . Dialysis can lead to neuropsychiatric symptoms such as dialysis dementia.Initial: setting treatment contract.Middle session: explore transference .1 Supportive Psychotherapy Aims to offer practical and emotional support. Some pathological emotions are as a result of cognitive errors. The therapist aims to assist the patient to monitor cognitions. 23.2 Brief psychodynamic psychotherapy It is an active therapy where the therapist attempts to guide free association on more focused topics.Closing: anticipate termination.Active interpretation Transference Patient’s feeling towards therapist Countertransference Therapist’s feeling towards patient Phases of treatment . We may need to treat patient’s neuropsychiatric symptoms by antidepressant or antipsychotics and reassess her capacity later. Roger Ho First. Examples include counselling and general psychiatric follow – up. Projecti One person projects a thought. Rationale: .Individuals with emotional problems in psychological terms. opportunity for ventilation of emotions. and guided. they can try methods to change. We need to consider the following: It is good to explore the psychological aspects of dialysis: sexual dysfunction is common.Focus choosing: repetitive behaviour to a single transference figure .Goal setting: tackle anxiety/ defence . 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. Denial Refusal to consciously acknowledge events or truths which are obvious. lethargy. dialysis is used to treat ESRF and she will die if she stops dialysis. 23. Projecti Attributing one’s own on unacceptable ideas or impulses to another person. If the person can be helped to understand the connection between cognitive errors and distressing emotion. In order to show that she has the capacity. multifocal myoclonus. Uraemia can lead to impaired mentation. delirium and depression. formulation of the case . they are more isolated and costs of dialysis may reduce their quality of life and anaemic can cause fatigue.Early session: Identify central issue . arrangement of aftercare. problem solving discussion.Study Notes in Psychiatry (2008) Dr. understand maladaptive schema.3 CBT Behaviours and emotions are determined by person’s cognitions. we have to determine whether the patient has the capacity to make the decision to withhold dialysis.Focal conflicts - Techniques: . Regress Revert to functioning of a ion previous maturational point. identify cognitive errors. explore with strategies and challenge and examine the resultant effects. . she must be able to understand and believe that she suffers from end stage renal failure.

Delusion of reference: A delusional belief that external events or situations have been Ch. a sense of something about to happen and an increased sense of significance of minor events. The external expression of unacceptable internal impulse in socially acceptable way. 24 Alexithymia: The inability to describe one’s subjective emotional experiences verbally. Occurs in Tic disorder Couvade syndrome: A conversion symptom seen in partners of expectant mothers during their pregnancy. Transferring the emotional response to a particular person. Glossary Coprolalia: A forced vocalisation of obscene words or phrases. 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 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. although they have been experienced before. Confabulation: The process of describing plausibly false memories for a period for the patient has amnesia. 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. dementia. Delusional perception: A primary delusion which is recalled as having arisen as a result of perception. 31 . at the expense of mounting anxiety. event. Déjà vu A sense that events being experienced for the first time have been experienced before. The symptoms is largely involuntary but can be resisted for a time. Occurs in Korsakoff psychosis. An everyday experience but also a non specific symptoms of a number of disorders including temporal lobe epilepsy. The length of anterograde amnesia is correlated with the extent of brain injury. Then. Delusion of guilt: A delusional belief that one has committed a crime or other reprehensible act. The percept is a real external object. In contrast. It is a feature of psychotic depressive illness. Roger Ho ve Identific ation Reactio n formati on Displac ement Rational isation Sublima tion belief or emotion to a second person.Study Notes in Psychiatry (2008) Dr. Retrograde: The period of amnesia between an event and the last continuous memory before the event. Justifying behaviour or feelings with a plausible explanation after the event. tiny. schizophrenia and anxiety disorders. or situation to another where it does’t belong but carries less emotional risk. rather than examining unacceptable explanation. Amnesia Anterograde: the period of amnesia between an event and the resumption of continuous memory. Jamis Vu is the sensation that events or situations are unfamiliar. Regarded as healthy defence mechanism. there is another 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. The expression externally of attitudes and behaviours which are the opposite of the unacceptable internal impulses. Delusion of infestation (Ekbom syndrome): A delusional belief that one’s skin is infested by multiple. mite like animals.

Here the patient gives repeated wrong answers to questions which 32 . Russell Sign: skin abrasions. small lacerations and the calluses on the dorsum Dysphoria Dyspraxia Edietic imagery: Particular type of exceptionally vivid visual memory.Wernicke) related to cortical abnormality An emotional state experienced as unpleasant. Dysarthria Dyslexia Dysphasia Impairment in ability to properly articulate speech Inability to read at the level normal for one’s age or intelligence Impairment in producing or understanding speech (expressive dysphasia Brocas and receptive dysphasia . usually of no practical use and neglect of one’s home and environment. Not a hallucination. schizophrenia. Lilliputian hallucination: A type of visual hallucination in which the subject sees miniature people or animals. OCD. More common in Malingering.Study Notes in Psychiatry (2008) Dr. eating) are nonetheless in the right ballpark. secondary to depression Inability to carry out complex motor tasks (dressing. Overvalued idea: A form of abnormal belief. 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. More common in children. 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. Associated with organic state like delirium tremens. What is 2+2? = 5. Preservation: Continuing with a verbal response or action which was initially appropriate after it ceases to be apposite. Digenes syndrome: Hoarding of objects. Globus Hytericus: The sensation of a lump in the throat occurring without oesophageal structural abnormality. Do you know where you are? In the hospital? Do you know what day is it? In the hospital. 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. Malingering: Deliberately falsifying the symptoms of illness for a secondary gain. Derailment (Knight’s move thinking): schizophrenic thought disorder in which there is total break in the chain of association between the meaning of thoughts. Loosening of associations: Lack of meaningful connection between sequential ideas. Roger Ho arranged in such a way as to have particular significance for or to convey a message to the affected individual. Derealisation: An unpleasant subjective experience where the patient feels as if the world has become unreal. These are ideas which are reasonable and understandable in themselves but which come to unreasonably dominate the patient’s life. Magical thinking: A belief that certain actions and outcomes are connected although there is no rational basis for establishing a connection. Due to organic disorder. Depersonalisation: An unpleasant subjective experience where the patient feels as if they have become unreal.

Oxford Handbook of Psychiatry. Although the brain is abnormal.Study Notes in Psychiatry (2008) Dr. A. Schizophrenia subjects have abnormalities of cerebral structure of 1st presentation. Trichotillomania: Compulsion to pull one’s hair out. References: 1) Levi. R.uk Appendix Appendix 3a – Neurodevelopmental Hypothesis of Schizophrenia - There is an excess of obstetric complications in those who develop the disorder. Radcliffe Publishing Ltd 1998. Synaethesia: A stimulus in one sensory modality is perceived in a fashion characteristic of an experience in another sensory modality (tasting sounds). Churchill Livingstone Appendix 3b – Brain abnormalities of Schizophrenia 33 . Affected subjects have motor & cognitive problems which precede the onset of illness. Roger Ho of the hand overlying the metacarpophalangeal and interphalangeal joints found in patients with symptoms of bulimia. Tangentiality: Producing answers which are only very indirectly related to the question asked by the examiner. gliosis is absent – suggesting that differences are possibility acquired in utero. Oxford University Press. Darjee. 2) D. Smith. R.co. Caused by repeated contact between incisors and the skin of the hand which occurs during self induced vomiting.trickcyclists. J Burns. From: Your questions answered series – Schizophrenia. Semple. Basic Notes in Psychiatry. 2004 3) www. Mclntosh.

Churchill Livingstone. 2001 Appendix 3C Lesley Stevens. Ian Robin. Roger Ho Lesley Stevens.Study Notes in Psychiatry (2008) Dr. Psychiatry – An illustrated colour text. Ian Rodin – Psychiatry an illustrated text. Churchill livingstone 2001 34 .

Psychiatry – An illustrated colour text. Ian Robin. Churchill livingstone 2001 Appendix 9a PTSD and Grief Lesley Stevens. Ian Robin. Roger Ho Appendix 5a .Toxic effect of lithium Lesley Stevens. Psychiatry – An illustrated colour text.Study Notes in Psychiatry (2008) Dr. Churchill livingstone 2001 Appendix 10 35 .

Churchill livingstone 2001 Appendix 12a 36 .Study Notes in Psychiatry (2008) Dr. Ian Robin. Roger Ho Lesley Stevens. Psychiatry – An illustrated colour text.

Ian Robin. 2006) Disorder Negative symptoms of Mnemonic 5As and PLANT Breakdown of Mnemonic aPathy aLogia 37 . Psychiatry – An illustrated colour text. Roger Ho Lesley Stevens. Churchill livingstone 2001 Mnemonics in Psychiatry (Mnemonics for MRCP. PASTEST.Study Notes in Psychiatry (2008) Dr.

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 38 . Roger Ho schizophrenia Depression DEPRESSION MANIA MANIAC Eating disorder RAPID Korsakoff psychosis ADDICT Eating disorder Increases in the following 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.Study Notes in Psychiatry (2008) Dr.

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