Study Notes in Psychiatry (2008) Dr.

Roger Ho
Study Notes in
Psychiatry
(For MBBS III to V)
Dr. Roger Ho
MBBS (HK), DPM( Ireland), MMed
(Psych)
Department of Psychological
edicine! N"S
#mail$ pcmrhcm%nus.edu.sg
Tabe o! "ontent Page
1
Study Notes in Psychiatry (2008) Dr. Roger Ho
"h. # Introduction $
"h.$ Signs % sy&'to&s
(cute &anage&ent
$
"h. ) Schi*o'hrenia )
"h. + Deusiona disorder ,
"h. - Bi'oar disorder .
"h. , De'ressi/e disorder 0
"h. . 1bsessi/e co&'usi/e
disorder
#2
"h. 3 (n4iety5 Panic5 Phobia ##
"h. 0 Post trau&atic stress
disorder5 (cute stress5 grie!
#$
"h. #2 (cohois& #)
"h. ## Drug De'endence #+
"h. #$ 1d age 'sychiatry #-
"h. #) "onsutation 6iaison
Psychiatry
#,
"h. #+ Perinata Psychiatry #3
"h. #- 7ating disorder and
i&'use contro disorders
#0
"h. #, Suicide and DSH $#
"h. #. Personaity Disorder $$
"h. #3 Psychiatric
e&ergencies
$)
"h. #0 See' disorders $+
"h. $2 "hid Psychiatry $-
"h. $# 6earning disabiity $3
"h. $$ 6ega as'ect $0
"h. $) Psychothera'y )2
"ha'ter # Introduction
&he purpose of 'riting this set of notes is to
pro(ide a concise summary of psychiatry and to
help medical students to ha(e rapid re(ie' for
e)amination.
"h. $ De!initions o! signs and sy&'to&s
The MCQ exam often confuses you !th the
follo!n" terms (#e$!, %&&')(
7choaia 7cho'ra4ia
Repetition *y the
patient of the
inter(ie'er+s 8ords
or 'hrases
,mitation *y the
patient of the
inter(ie'er+s
&o/e&ents.
Stereoty'y Manneris&
Regular! repetiti(e
non goal-directed
mo(ement
('ur'oseess)
.*normal! repetiti(e
goal-directed
mo(ement (o! so&e
!unctiona
signi!icance)
9a4y !e4ibiity Mit&achen
Patient+s lim* can *e
placed in an
a'/'ard posture
and remain fi)ed in
position for long time
des'ite as:ing to
rea4; occurs in
Schi0ophrenia (S1)
Patient+s *ody can
*e placed in any
posture; 8hen
rea4ed5 'atient
returns to resting
'osition
"atae'sy "ata'e4y
otor symptom of
schi0ophrenia! same
as 'a)y fle)i*ility
Symptom of
narcoe'sy in 'hich
there is sudden loss
of muscle tone
leading to collapse!
occurs in emotional
state.
(uto&atic
obedience
<egenhaten
(o''osition)
Patient does
'hate(er the
inter(ie'er as/s of
him irrespecti(e of
the conse2uences
&he patient 'ill
oppose attempts at
passi(e mo(ement
'ith a force e2ual to
that *eing applied.
Mitgehen Negati/is&
.n e)treme form of
&it&achen in 'hich
patient 'ill mo(e in
any direction 'ith
(ery slight pressure
#)treme form of
gegenhaten5
moti(eless
resistance to
suggestion3 attempts
at mo(ement.
(&bitendence Preser/ation
&he patient *eings to
ma/e a mo(ement
*ut *efore
completing it! starts
&he senseless
re'etition of a
pre(iously re2uested
&o/e&ent5 e(en
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Study Notes in Psychiatry (2008) Dr. Roger Ho
the o''osite
&o/e&ent
after the stimulus is
'ithdra'n
Neoogis&s Metony&s
&he patient uses
8ords or 'hrases
in/ented *y himself
"se of ordinary
'ords in unusal
'ays
1bsessions Deusions
Recurrent! persistent
thoughts! impulses!
images that the
patient regards as
absurd and alien
'hile recognising as
the product of his
o'n mind. .ttempts
are made to resist
or ignore them
. !ase beie! 'ith
the follo'ing
characteristics firmly
held despite
e(idence to the
contrary4 out o!
:ee'ing 'ith the
person+s education 5
cultural *ac/ground!
content often *i0arre
Verbigeration
(8ord sad)
Vorbeireden
(ta:ing 'ast 'oint)
Disruption of *oth
the connection
*et'een topics and
finer grammatical
structure of speech
6ccurs in S1
&he patient seems
al'ays a*out to get
near to the matter in
hand *ut ne/er
=uite reaches it.
6ccurs in S1
6ossening o!
associations
Fight o! ideas
6oss o! the nor&a
structure of
thin/ing. uddled
and illogical
conser(ation that
cannot *e clarified
6ccurs in S1
Patient+s thoughts
and conser(ations
mo(e =uic:y !rom
one topic to another!
the lin/s *et'een
these ra'idy
changing to'ics are
understanda*le
.ssociated 'ith
rhyming! punning 5
clang associations.
De'ersonaisation Dereaisation
. change in self
a'areness such that
'erson feels unreal
. change in self
a'areness such that
the en/iron&ent
feels unreal
Bi'oar I Bi'oar II
ania Hypomania
(!!ect Mood
#motional state at a
moment
#motional state o(er
a longer period
7u'horia 7uthy&ia
Sustained and
un'arranted
cheerfulness
. normal mood state
Neither depressed or
mania
"ha'ter ) Schi*o'hrenia
).# Ty'es o! schi*o'hrenia
> Paranoid schi*o'hrenia$ prominent 'ell 7
systematised persecutory delusions or
hallucinations. ore common 'ith
increasing age.
> "atatonic schi*o'hrenia? 9R7N"H7S
8 7 8a)y fle)i*ility4 catalepsy
R 7 Rigidity
# 7 #chopra)ia! echopra)ia
N 7 Negati(ism
9 7 9atalepsy
H 7 High le(el of motor acti(ity
# 7 #cholalia
S - Stupor
6ther features$ automatic o*edience!
stereotypy4 am*itendence! mannerism4
mitmachem4 mitgehen.
).$ 7'ide&ioogy
Median age o! onset?
Mae Fe&ae
2: years
(earlier onset)
2; years
(later onset)

Se4$ e2ually *et'een men 5 'omen
Socia cass$ increased pre(alence in lo'er
social class
Season o! birth? increased incidence in
'inter months
Pre/aence rate? <= of general population
Incidence? <>3<00 000
).) (etioogy
> <enetics? Herita*ility$ ;0-80=
> Fa&iy studies sho' the pre(alence rates
of schi0ophrenia in relati(es as follo's$
Reationshi' to S@ Pre/aence rate
Parent of a S1 >=
Si*ling of a S13 D1 &'in <0=
9hild of one S1 parents <?=
9hild of t'o S1 parents ?>=
ono0ygotic t'ins of S1 ?>=
Bioche&ica theories?
#)) Do'a&ine o/er>acti/ity? high le(el of
dopamine 'ithin &esoi&bic cortica
bunde. (eg amphetamine increase
dopamine release4 Haloperidol reduces its
release).
$) Serotonergic o/eracti/ity? @SD! inc
>H&! leads to hallucination! clo0apine has
serotonergic antagonism.
)) A# B adrenergic o/eracti/ity.
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Study Notes in Psychiatry (2008) Dr. Roger Ho
+) <uta&inergic hy'oacti/ity$ /etamine!
ND. antagonist! induce S1 symptoms
-) <(B( hy'oacti/ity 'hich leas to
o(eracti(ity of dopamine! serotonin!
noradrenaline.
7n/iron&enta !actors?
- 9omplications of pregnancy! deli(ery.
- aternal influen0a in pregnancy! 'inter
*irths
> Non 7 localising soft signs in childhood$
astereognosis! dysgraphaesthesia! gait
a*normalities! clumsiness.
- Distur*ed childhood *eha(iour
- Degree of ur*anisation at *irth
).+ Pathogenesis ((''endi4 )aC)b)
#) Neurode/eo'&enta hy'othesis
$) Thic:ening o! cor'us caosu&
)) Ventricuar enarge&ent
).- "inica !eatures (a''endi4 )c)
> First ran: sy&'to&sC Positi/e
> Negati/e sy&'to&s
> Neoogis&s5 Metony&s
)., Diagnosis (DSM B IV)
- .t least 2 of the follo'ing for at least <
month$ (.A9D B P@.N& C)
- Social 3 occupational dysfunction
- Post 7 schi0ophrenic depression is
common
).. Di!!erentia diagnosis?
Doung aduts 1der 'atients
- Drug induced
psychosis
- &emporal lo*e
epilepsy
- .cute organic
syndrome$
encephalitis
- Dementia
- Diffuse *rain
disease
1ther DDE$ psychotic depression! paranoid
personality disorder
).3 P7 and In/estigation
- Dull neurological e)amination$ gait and
motor
- 9ogniti(e e)amination$ S#
- Alood$ DA9! @D&! RD&! &D&! glucose.
- 9& or R, *rain
- "rine drug screen
- ##E if suspects of &@#
Manage&ent?
).0 "on/entiona anti'sychotics
Ty'ica anti'sychotics?
-"hor'ro&a*ine$ more antiadrenergic 5
antihistaminergic (<00 7 ?00mg daily)
- Hao'erido$ more #PS# (> 7 <0mg daily)
- Tri!u'era*ine$ more #PS#$ > 7 <0mg
daily
Aloc/ mesolim*ic
cortical *undle
.ntipsychotic action
Al/ Nigrostriatal #)trapyramidal
effects
Al/ &u*ero-
infundi*ular acti(ity
Ealactorrhoea
Side e!!ects o! ty'ica anti'sychotics?
#) 74tra'yra&ida side e!!ects (7PS7)?
-.cute dystonia$ treated *y ,
antimuscarinic (congentin 2mg)
- ./athisia$ restlessness$ treated *y
propanolol <0mg &DS
- Pseudopar/insonism$ oral antimuscarinic$
*enhe)ol 2mg AD
- &ardi(e dys/inesia
2) Hy'er'roactinae&ia
:) (ntiadrenergic? sedation! postural
hypotension! failure of eFaculation
?) (ntichoinergic? dry mouth! urinary
retention! constipation
>) (ntihista&inergic? sedation
;) (ntiserotonergic? depression
More on Tardi/e dys:inesia (TD)
> .fter chronic use of antipsychotic
- Due to upregulation of postsynaptic
Dopamine receptors in Basa <angia
- ore common in !e&ae
- History of chronic *rain disease$ ris/ factor
-slo' 'rithing mo(ement (athetosis)
-Sudden in(oluntary mo(ements
- 6ral lingual region (chorea)
- &emporary raise the dose may gi(e
immediate relief4 try to maintain &ini&u&
e!!ecti/e dose in long run
- 9hange to aty'ica anti'sychotics
- Vita&in 7 may pre(ent deterioration
- .nticholinergic 'ill 'orsen &D.
"on/entiona de'ot anti'sychotics
, Dlupenti)ol 20 7 ?0mg ? 'ee/ly
(Dluan)ol) 6ther odecate! 9lopi)ol
- @ong acting depot inFection for non
compliant patients.
- &o gi(e a test dose to ensure no
idiosyncratic effects
- High incidence of #PS#
4
Study Notes in Psychiatry (2008) Dr. Roger Ho
).#2 (ty'ica anti'sychotics
Ris'eridone? #>$&g 1N (F#C&g)
Higher affinity of D2 in mesolimi*ic and less
in nitrostriatal4 higher affinity for >H&2 and
G< receptors.
Side effects$
- #PS# (if high dose li/e ?mg daily)
- #le(ation of prolactin (strongest
among atypicals)
- .ntiadrenergic side effects
1ther 're'arations o! ris'eridone?
P1 Ris'erda =uic:et? 2uic/ly dissol(e in
mouth
P1 Ris'erda soution? <mg3ml HI03 *ottle.
IM Ris'erda consta 7 only atypical depots
Start 'ith , 2>mg! increase to :I.>mg
e(ery 2 'ee/s
1an*a'ine? -> #2&g 1N (F#C&g)
oderate for D24 High affinity for >H&2 and
muscarinic receptors
Side effects$
- 9eight gain and increase a''etite
- Sedation
- .ntiadrenergic side effects
- Prolongation of J& inter(al on #9E
- Hyperprolactinemia (transient)
Guetia'ine? #22 B 322&g daiy (F$C#22&g)
8ea/ for D2! High affinity for >H&2 and G<
Side effects$
- (ntiadrenergic side e!!ects li/e
postural hypotension
- Proong GT inter/a
- .lmost no #PS# (same as place*o)
- No K in prolactin (same as place*o)
Su'iride $22&g B +22&g 1N (IMH)
> @o' dose$ *loc/ D: and D?$ negati(e
symptoms
- High dose$ *loc/ D2 and D<$ positi(e
symptoms
- De'er #PS#! less sedation! cause
galactorrhoea.
"o*a'ine? more acti(e at D?! >H&2! G< 5
muscarinic receptors
- for treatment resistant S1.(failure of 2
antipsychotics 'ith ade2uate dose)
Side effects include$
- @ife threatening agranulocytosis 2-:=4
needs regular DA9 under clo0aril
patient monitoring programme (,H)
- Hypersali(ation
- .nticholinergic and antiadrenergic.
- De'er #PS#
).## Psychoogica treat&ent?
>Psychoeducation can pre(ent relapse *y
enhancing insight
-"ogniti/e Beha/ioura thera'y ("BT) to
challenge delusions.
-Socia s:i training$ impro(e relationship
- Beha/ioura$ positi(e reinforcement of
desira*le *eha(iour.
Fa&iy thera'y? to reduce e4'ressed
e&otion (77). (High 77 incude hostility!
o(er-in(ol(ement! critical comments from
family4 hence reduce relapse rate)
).#$ 1ther treat&ents?
- Rehabiitation (IMH) to enhance
self care! compliance and insight.
- 7"T is for catatonic schi0ophrenia
Indications !or Hos'ita ad&ission?
• Suicide 3 (iolent
• Se(ere psychosis
• Se(ere depression
• 9atatonic schi0ophrenia
• Non 7 compliance
• Dailure of outpatient treatment
).#) Prognosis
Rues o! =uarters
$-H $-H $-H $-H
9omplete
Remission
Eood
reco(ery
Partial
reco(ery
Do'nhill
course
<ood 'rognosis?
- ar/ed mood distur*ance
- Damily history of affecti(e disorder
- Demale se)
- @i(ing in a de(eloping country
- .cute onset
- Eood premor*id adFustment
Poor 'rognosis? adolescence or early
onset! enlarged (entricles.
"auses o! rea'se?
#) Iatrogenic rea'se? reduction of dose *y
doctor
2) Non co&'iance
5
Study Notes in Psychiatry (2008) Dr. Roger Ho
:) High e4'ressed e&otion
).#+ "o&'ications o! S@
> 9ater into4ication in chronic
schi0ophrenia! leading to hypanatraemia.
> Suicide is the most common cause of
death of S1! <0-:8= of all deaths of S1.
> S@ and /ioence? contro(ersial$ senior
psychiatrists say no *ut recent findings
support the association. ,n e)am! safer to
say no association.
Schi*oa!!ecti/e disorder
,t is a disorder in 'hich the symptoms of
schi0ophrenia and affecti(e disorder are
present in appro)imately in e2ual proportion.
,9D <0 re2uires *oth psychotic and mood
episode are simultaneously present and
e2ual prominent.
Treat&ent?
.ntipsychotics B antidepressant or mood
sta*ili0er.
Schi*oty'a 'ersonaity disorder
- &here is familial relationship *et'een
schi0otypal personality disorder 5
schi0ophrenia
"inica !eatures? IF1 RID7
" 7 unusual perception$ eg telepathy
D 7 Driendless
6 7 6dd *elief and odd speech
R 7 Reluctant to engage
, 7 ,dea of reference
D 7 Dou*tful of others
# 7 #ccentric *eha(iour
- Poor prognosis$ >0= de(elop
schi0ophrenia
Schi*oid 'ersonaity disorder 7
introspecti(e+ prone to engaged in an inner
'orld of fantasy rather than ta/e action4 lac/
of emotional 'armth and rapport4 self
sufficient and detached4 aloof and
humourless4 incapa*le of e)pressing
tenderness or affection4 shy4 often eccentric4
insensiti(e4 ill 7 at 7 ease in company
"h.+ Deusiona Disorder (14!ord
Handboo:5 $22+)
+.# Ty'es o! deusiona disorder (DSM IV)
> 7roto&anic (de "era&baut syndro&e)?
,mportant person li/e P is secretly in lo(e
'ith them4 usually female4 ma/e effort to
contact important person.
- Morbid Jeaousy (1theo syndro&e)?
fi)ed *elief that their spouse has *een
unfaithful4 collect e(idence for se)ual acti(ity
5 restrict partner+s acti(ity4 may result in
(iolence.
- Persecutory? ost common type4 others
are attempt to harm4 to o*tain legal recourse
- <randiose? special role! relationship!
a*ility! in(ol(ed in religion.
- So&atic? delusion *elief a*out *ody
(a*normal genitalia) to in!estation$ ('orms
cra'ling in the *ody)
- Foie a deu4 7 shared delusion *et'een
hus*and and 'ife (close relationship)
Deusiona &isidenti!ication syndro&e?
"a'gras deusion Fregoi deusion
6ther ha(e *een
identified *y identical
or near identical
imposter
Someone they /no'
in disguise and
harming him
+.$ 7'ide&ioogy
- "ncommon$ 0.02> 7 0.0:=
- ean age$ ?0 7 ?L years
- "sually e2ual in and D4 or*id Fealousy
more common in alcoholic male4 #rotomania
more common in female
+.) Ris: !actors and aaetioogy
- ad(anced age! isolation! lo' social status!
premor*id ersponality disorder! sensory
impairment! su*stance a*use! family history!
history of Head ,nFury! ,mmigration
- &emporal lo*e epilepsy!
+.+ Pathogenesis?
- 9ortical damage$ paranoid delusion
- Aasal ganglia 7 less cogniti(e distur*ance
- Dolie a deu)$ one dominant and one
su*missi(e partner in a relationship
+.- "inica !eatures?
- Delusions are highly implausi*le!
- 'ith e(idence of systemati0ation (*etter
organi0ed than S1 delusion)4
6
Study Notes in Psychiatry (2008) Dr. Roger Ho
- huge impact on *eha(iour!
- a*normal process in arri(ing conclusion
+., Diagnosis? DS ,C re2uires M < month
duration
+.. Di!!erentia diagnosis
Doung 'atients 1d 'atients
- Su*stance induced
(stimulant!
hallucinogen)
- ood disorder 'ith
delusion (mood
*efore delusion)
- Schi0ophrenia (less
ela*orated delusion)
- 69D$ reality testing
is intact
- Paranoid
personality disorder
(@ess clearly
circumscri*ed
delusion)
- Dementia- memory
loss
- Delirium$ change in
consciousness
- @ate onset
psychosis ('ith
hallucination)
+.3 (ssess&ent
- . thorough history and S#
- 9ollateral history from :
rd
party
- &o rule out organic causes
- Document ris/ assessment
+.0 Manage&ent
- .dmission to hospital if there is a ris/ to
self or (iolence to others.
- Separation from source or focus of
delusion
- .ntipsychotics$ atypical$ less side effect
- Aoth risperidone and Haloperidol ha(e
li2uid form$ for those refusing ta*lets
- Aen0odia0epine to treat an)iety
Psychoogica treat&ent
- Su''orti/e 'sychothera'y$ to esta*lish
therapeutic alliance 'ithout confronting
- "ogniti/e techni=ues$ gently challenge
delusion
- Socia s:i training
- I&'ro/ing ris: !actors$ sensory deficits!
isolation
+. #2 Prognosis
Re&ission I&'ro/e&ent Persisting
::->0= <0= ::->0=
- Aetter prognosis if it is acute4
- Poor prognosis if delusional disorder
last longer than ; months.
"h. - Bi'oar disorder
-.# The a!!ecti/e s'ectru&
- Dysthymia 7 not meeting criteria of
depression
- Depression
- .typical depression$ hypersomnia!
hyperphagia
- Psychotic depression
- Recurrent depression
- Aipolar ,, 7 Hypomania
- Aipolar , 7 ania
- Rapid cycling M ? episodes per year
- "ltra 7 rapid cycling$ (ery rapid changes
-.$ 7'ide&ioogy
- @ifetime pre(alence$ 2.) B #.-H
- N D in pre(alence
- Aipolar ,, 3 rapid cycling$ more common in
Demale
- ean age of onset$ $# years od
-.) (etioogy
- <enetics? <
st
degree relati(e are I) more
li/ely to de(elop this condition.
- 9hildren of a parent 'ith *ipolar disorder
ha(e a >0= chance of de(eloping
psychiatric disorder
- 1$D1 ?>=$ 2:=
-.+ Pathogenesis
- Noradrenaline! dopamine! serotonin! 5
glutamine ha(e all *een implicated.
- (ntide'ressant induced mania or
hypomania is common.
-.- "inica !eatures
Hypomanic episode$ .N,.9 (9linical s/ill
training)
Dor mania! on top of .N,.9! they also
ha(e$
- se(ere enough to interfere social 5
occupation function.
- Psychotic features related to grandiosity.
- Dlight of idea! Pressure of speech
- Racing thought
- Aeha(iours 'ith serious conse2uences$
rec/less spending! inappropriate se)ual
encounters! careless in(estment.
-., Diagnosis
DSM IV diagnosis
7
Study Notes in Psychiatry (2008) Dr. Roger Ho
- Bi'oar I disorder? occurrence of < or
more manic episode 'ith or 'ithout history
of < or more depressi(e episode.
- Bi'oar II disorder 7 occurrence of < or
more depressi(e episode accompanied *y
at least < hypomanic episode.
-.. DDE?
- Su*stance a*use (if young)
- 6rganic$ thyroid! cushing! S@#! head inFury
- Psychotic disorders (if psychotic features)
- Schi0oaffecti(e disorder (prominent
psychosis)
- .n)iety disorders
-.3 In/estigation
- DA9! #SR
- @D&! RD&! &D&! glucose
- CDR@
- "rine drug screen
- 9&3R, to rule out space occupying lesion!
infarction! haemorrhage
- ##E to rule out epilepsy
6ther tests$
- .ND to rule out S@# in ladies
- "rinary copper to rule out 8ilson disease
-.0 Setting o! Treat&ent?
"sually re2uire admission for manic
episode4 'ard has to *e calm 'ith less
stimulation.
Indications !or ad&ission incude?
- High ris/ of suicide or homicide
- @ac/ of capacity to cooperate 'ith
treatment
- Poor psychosocial supports
- Se(ere psychotic symptoms
- Se(ere depressi(e symptoms
- Rapid cycling
- Dailure of outpatient treatment
<oas o! out'atient treat&ent
- #sta*lish 5 maintain therapeutic alliance
- monitor psychiatric status
- Psychoeducation for *ipolar disorder
- #nhancing treatment adherence
- onitoring side effects of medication
- Promoting regular sleep and acti(ity
- ,dentify ne' episodes early
-.0 Phar&acoogica Manage&ent
(cute treat&ent o! &anic 'hase ?
By anti'sychotics?
Haloperidol >-<0mg daily4
Risperidone 2- ?mg daily
6lan0apine (more sedati(e 5 good for mood
symptoms *ut e)pensi(e)$ >- <0mg daily
&hen add on mood sta*ili0er after *lood
in(estigations.
6ithiu& "R (-22&g B #222&g F2.)>2.,)
Be!ore starting ithiu&5 RD& 5 &D& ha(e to
*e normal.
Mechanis& o! action ?
- By sti&uating NaCK 'u&'5 stimulates
entry of Na into the cells 'here intracellular
Na is reduced in manic state4 stimulates e)it
of Na from cells 'here intracellular Na is
ele(ated in depressed state.
- Inhibits both cycic (MP and inosito
'hos'hate second messenger system in
the mem*erane.
Indications?
- Dor depression! manic states
- Prophyla)is of *ipolar disorder
- not useful for rapid cycling
(d/erse e!!ects?
> Short ter& side e!!ects$ E, distur*ances
(nausea! (omiting! diarrhea)
> 6ong ter& side e!!ects$ nephrogenic
dia*etes insipidus due to *loc/age of .DH
sensiti(e adenyl cyclase! hypothyroidism
and cardioto)icity
> To4ic e!!ects (refer to appendi) >a)$
@ithium o(erdosage can *e fatal.
- 7bstein ano&ay in foetus.
Sodiu& /a'orate (7'ii&) (+22&g B
#222&g) (F2.- B #)
Aefore starting Calporate! chec/ @D&
Mechanis&s
- mediate its therapeutic effect *y indirect
inhi*itions on E.A.ergic systems.
Indications?
- &reatment of depressi(e and manic
episodes
- Prophyla)is of *ipolar affecti(e disorder
- Dor rapid cycling disorder
8
Study Notes in Psychiatry (2008) Dr. Roger Ho
(d/erse e!!ects?
- Slight ris/ of li(er! pancreatic to)iciety
- Haematological distur*ance of platelet
function4 Neura tube de!ect in foetus
"arba&a*e'ine +22B 322&g (F2.$>2.+)
9hec/ DA9 *efore starting car*ama0epine
Mode o! action?
- ediate its therapeutic effect *y inhi*iting
/indling phenomena in the lim*ic system
Indications?
- Depression
- Prophyla)is of *ipolar affecti(e disorder
(d/erse e!!ect?
- Dro'siness and di00iness
- @eucopenia and other *lood disorders
6a&otrigine -2 B #-2&g #22&g L F)
Dor *ipolar disorder 'ith depressi(e
episodes
-.#2 Psychoogica Manage&ent
- "ogniti/e thera'y to challenge grandiose
thought
- Beha/ioura thera'y to maintain regular
pattern of daily acti(ities
- Psychoeducation on *ipolar disorder
- Damily therapy$ Psychoeducation for family
5 techni2ues to cope 'ith patient+s illness
- Rea'se dris$ to identify symptoms and
to formulate a plan to see/ help in early
manic phase.
- Su''ort grou' for *ipolar patients.
-.## 1ther treat&ent
- 7"T? Aest for acute mania! failure to drug
treatment! for pregnancy (to a(oid
teratogenic effects)
-.#$ "ourse and Prognosis?
-#)tremely /ariabe
-Dirst episode may *e hypomanic! manic!
mi)ed! or depressi(e
- @ength of time *et'een su*se2uent
episodes may *egin to narro8 *ut sta*ili0e
at ?
th
to >
th
decade.
- "ntreated patients ha(e M <0 episodes in a
lifetime.
- &reated patients ha(e *etter prognosis
-.#) "o&'ication?
- or*idity and ortality rates are high? lost
'or/! lost producti(ity! di(orce! attempted
suicide 2>->0= 5 committed suicide$ <0=
"h. , De'ressi/e Disorder
,.# 7'ide&ioogy
(ge? 8omen! highest pre(alence *et'een :>
and ?> years4 en increases 'ith age
Se4? D$ N 2$<
Socia cass? more common in , (rich)! ,, and C
(poor)
ore common among di(orced! separated
Pre(alence$ >=
,.$ (etioogy?
- <enetics$ Pre(alence in first rate relati(es$ <0-
<>=
- Monoa&ine theory o! de'ression$ depletion
of monoamine such as >H& 5 N.
- 7ndocrine abnor&aities$ hypersecretion of
cortisol! decreased &SH
Psychoogica theory?
- Materna de'ri/ation 'hen young
- 6earned he'essness? highly a(ersi(e
outcomes are possi*le.- "ogniti/e distortions?
<) .r*itrary inference$ dra'ing conclusion 'hen
there is no e(idence.
2) Selecti(e a*straction 7 ignore important
feature
:) 6(er-generalisation from single incident
?) inimisation positi(e and magnitification of
negati(e
Socia theory? for 'omen! (Aro'n 5 Harris)
-: or more children under <> yr of age
-not 'or/ing outside
-lac/ of supporti(e relationship from hd.
-loss of mother3separation *efore age <<
-&hreatening life e(ent *efore depression
,.) "inica !eatures?
> D#P#SS,6N 7 refer to clinical s/ills
-Se(ere depression may ha(e psychotic features$
-Delusions concerned 'ith themes of
'orthlessness! guilt! ill-health! po(erty
-Persecutory delusion$ people are a*out to ta/e
re(enge on him
- Hallucination$ second person auditory
hallucination$ repetiti(e 'ords 5 phrases
,.+ DDE?
- ,s it mi)ed an)iety 5 depressionO
- ,s it *ipolar disorderO
- #ndocrine$ hypothyroidism
- edication related$ antihypertensi(e! steroid
- .lcohol a*use
,.- In/estigations? DA9! #SR! A<2! Dolate! RD&!
@D&! &D&
,., Phar&acoogica Manage&ent?
Seecti/e serotonin reu'ta:e inhibitors SSRI
9
Study Notes in Psychiatry (2008) Dr. Roger Ho
-Fuo4etine (Pro*ac) 20mg 6 (H0.2) for
retarded depression4 ad(erse effect$
Restlessness4 @ong half life! a(oid in elderly 'ith
a lot of medication4 (first line no'adays)
- Fu/o4a&ine (Fa/erin) >0mg -<00mg 6N4 H0.>
Sedati(e4 high incidence of nausea 5 (omiting in
first fe' days.
- Paro4etine "R (Sero4at) 2>mg 6N! H2$ good
for mi)ed an)iety 5 depression4 more 'ithdra'al
symptoms
- 7scitao'ra& (e4a'ro) <0mg 6N! H<.>4 less
drug interaction! good for elderly
- Setraine (@oo!t) >0 7 <>0mg 6N4 H<.8
-Noradrenergic and s'eci!ic serotonergic
antide'ressants (NaSSas)? irta0epine
(Remeron) <>-:0 mg 6N (H<-2)4 >H&-2 and >H&-
: postsynaptic receptor antagonist 5 anti-
histamine effects.
- good for depression and insomnia
- dro'siness and 'eight gain
- No serotonin related side effects$ se)ual
dysfunction! insomnia! agitation! nausea
- No cardio(ascular or anticholinergic side effects
- Serotonin % Noradrenaine reu'ta:e
inhibitor? Vena!a4ine (7!e4or) I> mg AD H>.;4
second line! high dose  hypertension
Duo4etine("y&bata) ;0mg 6N for pain 5
depression
- T"(? a&itri'tyine >0 7 <00mg 6N!
cardioto)icity 'hen o(erdose! anticholinergic side
effects4 M(1I? seldom used
- 7"T$ for acti(ely suicidal patients! not eating 5
drin/ing! treatment resistant depression
-#9& has 'ide range effects on monoamine
-.*solute contraindication$ raised ,9P
-Relati(e contraindications$ cere*ral aneurysm!
recent ,! cere*ral haemorrhage! retinal
detachment.
-7ary side e!!ects$ loss of short term
(retrograde) memory! headache! confusion!
muscle aches
>6ate side e!!ect$ long term memory loss
ortality of #9&$ 23<00! 000

,.. Psychoogica Treat&ent
"BT? "ogniti/e$ ,dentify cogniti(e dysfunctions
from dysfunctional thought diary4 patient 'ill
e)amine e(idence for and against them4 cogniti(e
restructuring to change distorted thought4
Beha/ioura? increase pleasura*le acti(ities.
"h. . 1bsessi/e "o&'usi/e Disorder
..# 7'ide&ioogy
- 6nset is most commonly in early adult life
- #2ually common among men and 'omen
- Pre(alence 0.0>=
..$ (etioogy
- Eenetic$ 1$ D1 80=$ 2>=
- 6rganic factor$ during epidemic of
encephalitis lethargica
- Premor*id personality$ I0= of 69D
patients ha(e o*sessi(e compulsi(e
personality trait- cleanliness! orderliness!
rigid! chec/ing
..) Pathogenesis
- Dysregulation of the >H& system
- 9ell immediated autoimmune factors
- 9&3 R,$ *ilateral reduction in caudate
nucleus.
- Psychological e)planation$ 69D patients
ha(e defecti(e arousal system and ina*ility
to control unpleasant internal states.
6*sessions (fear of dirt) are stimuli
associated 'ith an)iety pro(o/ing e(ents
'here compulsions (such as hand 'ashing)
are learned to reduce an)iety.
..) "inica !eatures
1BS7SSI1N B DIRT
Doubts? repeating themes e)pressing
uncertainty a*out pre(ious actions$ turned
off the tap or not
I&'uses 7 Repeated urges to carry out
actions that are usually em*arrassing or
undesira*le e.g shout o*scenities in church
Ru&inations 7 repeated 'orrying themes
of more comple) thought 7 the end of the
'orld.
Thought 7 repeated and intrusi(e 'ords or
phrases
"o&'usions B "s (refer to clinical s/ills
training)
. co&'usion is usually associated 'ith an
o*session as if it has the function of
reducing the distress caused *y o*session.
#.g o*sessional thought 'ith hand
contamination! associated 'ith hand'ashing
compulsion.
..+ DDE?
- .n)iety disorders
- Pho*ic an)iety disorders
- Psychotic disorders
10
Study Notes in Psychiatry (2008) Dr. Roger Ho
- 6rganic disorders
- Depressi(e disorders
..- Phar&acoogica treat&ent
- SSRIs are indicated in the treatment
of 69D. 69D re2uire higher doses
of SSR,s compared to depression.
- Dlu(o)amine (Da(erin) <>0mg 7
200mg
- Dluo)etine (Pro0ac) ?0mg 7 ;0mg
- Paro)etine 9R (Sero)at) 2>mg 7
I>mg$ for (ery an)ious patients.
.., Psychoogica treat&ent
"ogniti/e thera'y$ to use dysfunctional
thought diary to record o*sessions and
gently challenge o*sessional thought.
Beha/ioura thera'y$ #)posure and
response pre(ention. &his techni2ue
in(ol(es e)posing patient to situations they
a(oid such as dirty places and the patient is
su*se2uently pre(ented from carrying out
the usual compulsi(e cleansing rituals until
the urge to do it has passed (response
pre(ention)
Thought sto''ing$ &he patient is as/ed to
ruminate and upon doing so! the therapist
shouts PstopQ to teach the patient to interrupt
the o*sessional thought. &he patient then
learns to internali0e the PstopQ order so that
thought stopping can *e used outside
therapy situation.
Rehabiitation
- to maintain functional capacity4
- aintain their strengths
- Promote adaptation to e(eryday
li(ing.
... Socia treat&ent
6*sessional patients often in(ol(e other
family mem*ers in their rituals. ,n planning
treatment! it is essential to inter(ie'
relati(es and encourage them to adopt a
firm *ut sympathetic attitude to the patient.
..3 Prognosis
- Poor 'rognosis? Ei(ing in to compulsions!
longer duration! early onset! *i0arre
o*session 5 compulsion! comor*id delusion
and depression
- <ood 'rognosis$ good premor*id!function
a precipitating e(ent.
69D does not associate 'ith suicide.
"h. 3 (n4iety Disorders (14 handboo:)
3.# <eneraised (n4iety Disorders
7'ide&ioogy?
-@ifetime pre(alence$ 2.>-;.?=
-DemaleM ale
- #arly onset$ 'ith childhood fears
- @ate onset$ stressful life e(ents
(etioogy?
- Eenetics$ Herita*ility$ :0=
- ,ncrease .NS responsi(eness
- @oss of control of cortisol
- R E.A. acti(ity
- dysregulation of >H& acti(ity
- "ne)pected negati(e e(ents eg early
death of parent
- 9hronic stressors
"inica !eatures (at east +)
-.utonomic arousal$ s'eating! sha/ing
-Physical$ *reathing difficulty! cho/ing!
nausea! s'allo'ing difficulty
-ental$ di00y! fainting! derealisation!
depersonali0ation
-Eeneral$ num*ness! tingling
-&ension$ muscle!ache! /eyed up
-6ther$ mind going *lan/! poor concentration
DDE?
- normal 'orries
- mi)ed an)iety and depression
- .lcohol 5 drug a*use
- 6rganic$ &hyroid disorder! .rrhythmia!
.sthma! &emporal lo*e epilepsy!
hypoglycemia.
In/estigation$ DA9! @D&! RD&! &D&!
glucose! #9E
Manage&ent?
-Psychological$ rela)ation therapy.
-Pharmacological$ short term
*en0odia0epine! SSR, (a(oid fluo)etine)!
propranolol for palpitation
"ourse?
-9hronic and disa*ling! lo' remission rate
-9an lead to alcohol a*use.
3.$ Panic disorder
7'ide&ioogy?
@ifetime pre(alence$ ?.2=
8omen$ 2-: times higher than men
2 pea/s in 'omen$ <>-2? yr4 ?>->? yr
11
Study Notes in Psychiatry (2008) Dr. Roger Ho
(etioogy$
- Eenetics$ :0-?0= herita*ility
-Supersensiti(ity of >H&<. receptors
- ,ncreased adrenergic acti(ity
- Decreased in E.A. 7 inhi*itory
- Dear net'or/ in *rain$ amygdala
"inica !eatures
-Palpitations! S6A! cho/ing! sha/ing
- .utonomic arousal
- Dear of losing control
-9oncerns of death from cardiac 5
respiratory pro*lems
DDECIn/estigations? similar to E.D
Psychoogica Manage&ent?
Beha/ioura? use of rela)ation 5 control of
hyper(entilation
"ogniti/e &ethod? teaching a*out *odily
responses associated 'ith panic attac/

Phar&acoogica?
-SSR,$ paro)etine! fluo)etine! flu(o)amine
are recommended drug of choice
- A1Ds$ alpra0olam 0.>mg for acute attac/
Hy'er/entiation Syndro&e (HVS)?
- Cery common4 more common in Demale
- >0-;0= of patients 'ith panic disorder
ha(e HCS
- Hyper(entilation4chest pain4di00iness4
*loating4 acute hypocalcaemia
- &reatment$ esta*lish normal *reathing
pattern! *en0odia0epine4 *reathing into
paper *ag is not recommended no'adays
as 962 can trigger more an)iety.
(gora'hobia? (housebound house8i!e)
<>-:> yr old4 more common in 'omen
Dear of shops! mar/ets! *us! R&! cro'd!
place that cannot *e left suddenly
Socia 'hobia
<I-:04 N D4 a(oid situations that can *e
o*ser(ed *y others (presentation! ha'/er
centre! R&) 5 'orries of humiliating or
em*arrassing
Manage&ent? short term *en0odia0epine!
SSR,
Syste&atic desensiti*ation? imagine or
e)pose to an)iety pro(o/ing situations!
progress through hierarchy! neutrali0e *y
rela)ation techni2ue until patient ha*ituates
"ha'ter 0 Post trau&atic stress disorder
0.# 7'ide&ioogy
- .fter traumatic e(ent! 8-<:= for men! 20
-:0= for 'omen de(elop P&SD
- @ifetime pre(alence 8=.
- D$ N 2$<
0.$ (etioogy
- <enetic$ higher concordance in 1 than
D1 t'ins
- Reduced right hi''oca&'a /ou&e5
enhanced reacti(ity to stimulation 5 memory
deficits
- Dysfunction amygdala lead to enhanced
fear response
Ris: !actors? Protecti/e !actors
-@o' education
-@o'er Social class
-Demale gender
-@o' self esteem
-Damily history of
psychiatric disorders
- Pre(ious trauma
- High ,J
- High social class
- ale
- 9hance to (ie'
*ody of dead person
0.) "inica !eatures ((''endi4 0a)
- P&SD is a se(ere psychological
distur*ance follo'ing a traumatic e(ent
characteri0ed *y in(oluntary re-e)periencing
of the e(ents! 'ith symptoms of
hyperarousal! a(oidance and flash*ac/s of
e(ents. @onger than ? 'ee/s.
0.+ DDE
- .cute stress reaction - .dFustment disorder
0.- Psychoogica treat&ent
> "BT$ education a*out P&SD! an)iety
management! anger management! cogniti(e
restructuring for trauma e)perience! gradual
e)posure to stimuli a(oided
- Psychodyna&ic thera'y? understand the
meaning of trauma! to resol(e unconscious
conflict.
- 7ye &o/e&ent desensiti*ation %
re'rocess? "sing (oluntary multi-saccadic
eye mo(ements to reduce an)iety (limited
e)perience in Singapore! don+t mention it in
oral e)am)
- @oo/ for alcohol a*use
0., Phar&acoogica treat&ent
- Depressi(e symptoms$ SSR,
- .n)iety symptoms$ 2 'ee/s alpra0olam
0.2>mg &DS
12
Study Notes in Psychiatry (2008) Dr. Roger Ho
0.. "o&'ication
- >0= reco(er <
st
year4 :0=$ chronic
(cute Stress Reaction (hrs to days)$
. transient disorder (hrs or days) that occur
as immediate response to e)ceptional
stress! accident! assault! fire! *erea(ement).
9linical features$ depression and an)iety.
(cute Stress disorder ($d B + 8ee:s)
Similar to acute stress reaction! *ut more
dissociati(e symptoms
Similar to P&SD! *ut less than ? 'ee/s
duration.
(dJust&ent disorder () &o B , &o)
,t occurs 'ithin : months of a particular
stressor 5 should not last longer than ;
months after the stressor is remo(ed.
anifested as depression and an)iety (no
psychotic features).
Treat&ent o! abo/e disorders?
Supporti(e psychotherapy to enhance
capacity to cope! understand meaning of
stressors.
Pharmacological$ SSR,! short term A1D
Nor&a and abnor&a grie! reactions
- Berea/e&ent? any loss e(ent
- Nor&a grie!? refer to appendi) La
ean duration$ ; months.
- (bnor&a grie!?
<) ,ntense
2) ProlongedM < year
:) Delayed grief
?) .*sent grief
6ther features$ thoughts of death! e)cessi(e
guilty! mar/ed psychomotor retardation!
prolonged impairment of function!
hallucination.
Manage&ent?
- Short ter& ben*odia*e'ine?
alpra0olam 0.2>mg &DS for 2 'ee/s
- .ntidepressant if there are
depressi(e symptoms
- Su''orti/e 'sychothera'y$
enhance coping
- <rie! thera'y? e)plore the meaning
of the loss! let go of the past and
mo(e to'ards the future.
Ref$ 6)ford Hand*oo/! 200?
"h. #2 (coho de'endence
#2.# De!inition o! de'endence?
<) Su*Fecti(e a'areness of co&'usion to
drin/
2) Stereoty'ed 'attern of drin/ing
:) ,ncreased toerance to alcohol
?) Pri&acy of drin/ing o(er other acti(ities
>) Repeated 8ithdra8a sy&'to&s
;) Reie! drin:ing
I) Reinstate&ent after a*stinence
#2.$ 7'ide&ioogy
(ge$ men in their early t'enties
Se4$ ore common in male4 increasing
incidence in females.
Socia cass$ lo'est pre(alence in middle
social *lass
Marriage$ more common in
di(orce3separated
1ccu'ation? high ris/$ directors! doctors.
#2.) (etioogy?
- <enetic !actors? 1 M D1 t'ins! adoption
study also pro(es genetic lin/s.
- .*normal neurotransmitter mechanism
- @earning factors$ learn from peer 3 parents
- Personaity !actors? chronic an)iety!
feeling inferior.
- 6ther illness$ an)iety disorder! depression
#2.+ "inica !eatures (a''endi4 #2)
(coho into4ication? e)plosi(e out*ursts
of aggression! short term amnesia after
hea(y drin/ing! idiosyncratic reactions to
alcohol! pathological drun/enness$ acute
psychosis induced *y small amount of
alcohol
<enera 8ithdra8a sy&'to&s? #$>$+ hr
- .cute tremulousness in hands (the sha/e)
- .gitation! s'eating
- Nausea
- Perceptual distortions 5 hallucinations
- 9on(ulsions
Deiriu& tre&ens? )>+days
- 9louding of consciousness
- Disorientation in time 5 place
- ,mpairment of recent memory
- ,llusions 5 Hallucinations
- Dearful affect
- Prolonged insomnia
- &remulous hands
- &runcal ata)ia
- .utonomic o(eracti(ity
(cohoic haucinosis
13
Study Notes in Psychiatry (2008) Dr. Roger Ho
-occurs in clear consciousness
-(oices utter insults or threats!
- 9auses an)iety in patients
In4? DA9! @D&! "5#! EE&! 9SR! glucose
#2.- Manage&ent
Deto4i!ication? &anaging 8ithdra8a
- Dia0epam >mg &DS! Citamin! thiamine
:0mg 6! A<2! Rehydration.
Moti/ation inter/ie8ing to help patient to
change.
Stages o! change? precontemplation!
contemplation! preparation! action!
maintenance! relapse
- Re!er to "(MP5 IMH
Phar&acoogica agents used !or
&aintenance?
- Disu!ira&? an a(ersi(e stimulus! inducing
nausea if patient drin/s alcohol
- (ca&'rostate$ 'or/s on E.A.3glutamate
system! for maintenance
- Natre4one? opiate receptor antagonist!
Psychoogica treat&ent?
Beha/ioura thera'y$ /eep diary log 5
tac/le drin/ing *eha(iour.
Socia treat&ent?
> <oa orientated treat&ent 'an?
Tota abstinence$ M ?0! hea(ily dependent!
physical damage! failed controlled drin/ing
"ontroed drin:ing$T ?0! not dependent
on alcohol! no physical damage! early stage
- (cohoic anony&ous? o*ser(e 5
mirroring! de(elop coping strategies
- Ha! 8ay house? reha*ilitation! counselling
#2., "o&'ications
Nutritiona or to4ic disorders
9ernic:eMs
ence'hao'athy
Korsa:o!!Ms
'sychosis
6phthalmoplegia
Nystagmus
9louding of
consciousness
emory distur*ance
.ta)ia
,mpairment of recent
memory
9onfa*ulation
Retrograde amnesia
Disorientation
#uphoria
- .lcohol dementia
- Depression and suicidal *eha(iours
- Polysu*stance a*use
- Social complications$ Fo*! marriage
#2., Prognosis? good prognosis in
moti(ated! socially sta*le! no antisocial
personality disorder
"h. ## Drug De'endence
##.# De!inition?
,t is a state! resulting from the interaction
*et'een a human and a drug! characteri0ed
*y *eha(ioural and other responses that
include a compulsion to ta/e the drug on a
continuous or periodic *asis to e)perience
its psychic effects 5 to a(oid discomfort.
##.$ Physica and 'sychoogica
de'endence
Drugs Physica Psychoogica
Heroin Ues Ues
Hallucinogen No Ues
.mphetamine No Ues
9anna*is No Ues
9ocaine No Ues
A1D Ues Ues
##.$ 1'iates B eg Heroin
"hronic use 9ithdra8a
9onstipation
9onstricted pupils
8ea/ness
,mpotence
&remors
Pilo-erection!
shi(ering
-.*dominal cramps
-@acrimation
- Dilated pupils
- ,ntense cra(e for
drugs
- .gitation
Treat&ent?
> Methadone? 20mg solution form!
super(ised treatment.
> Bu'renor'hine (Subute4) 'as listed as
illegal drug 5 'ithdra'an from Singapore.
##.) Haucinogens B 6SD (ysergic acid
diethya&ide)
- #ffects occur after 2 hours of consumption.
- Synaethesia$ confusion *et'een senses
e.g hearing images
- 6ut of *ody e)perience
- .n)eity and depression
- 9an lead to unpredicta*le 5 dangerous
*eha(iour.
##.+ (&'heta&ines
- 9hronic use can lead to paranoia
- Hostility 5 aggression
- Persecutory delusions
- .uditory! (isual! tactile hallucination
- 9lear consciousness
14
Study Notes in Psychiatry (2008) Dr. Roger Ho
##.- "annabis
7!!ects "hronic
e!!ects
-#)aggerating e)isting
mood
-Distortion of time 5 space
-,ntensification of (isual
perception 5 (isual
hallucination
-Reddening of eye
-,rritation of respiratory
tract
9hronic
amoti(ational
syndrome.
Dlash*ac/
phenomena
Psychotic
reactions
##., "ocaine
Dormication (cocaine *ugs) 7 e)am classic$
a tactile hallucination as feeling insects
cra'ling under the s/in.
&reatment of a*o(e disorders$ may need
antipsychotics to treat psychotic e)perience.
##.. Ben*odia*e'ine
e.g. Dormicum (ida0olam)! .lpra0olam
(Sana))
"hronic use 9ithdra8a
"nsteady gait
Dysarthria
Dro'siness
Nystagmus
Re*ound insomnia
.n)iety
.ppetite distur*ance
S'eating! con(ulsion
9onfusion!
Delirium tremens
Treat&ent? s'itch to long acting
*en0odia0epines such as dia0epam >mg
&DS and slo'ly cut do'n the dose.
ay need in-patient deto)ication if using
high dose *en0odia0epine.
Psychoogica treat&ent?
> Su''orti/e 'sychothera'y? educate
patients on complications of drug
dependence and cope 'ith day to day
pro*lems.
- <rou' thera'y? o*ser(e their o'n
pro*lems mirrored in other drug a*users4
'or/ out for *etter coping
- Beha/ioura thera'y? /eep a diary of drug
use and e)plore mood and feelings at the
time of drug use 'ith therapist and to reduce
the num*er of drug inta/e.
- Rehabiitation in "(MP5 IMH? to lea(e the
drug su*culture! support *y counselor.
"h. #$ 1d (ge Psychiatry
#$.# (*hei&erMs disease
-most common cause of dementia (I0=)
7'ide&ioogy
-<= at ;0! dou*les e(ery > years4 ?0= at 8>
yr old
-$D N ?$<
- 6ther ris/ factor$ Do'n syndrome! head
inFury! hypothyroid
<enetics?
- 9hromosome 2< for amyloid precursor
protein
- 9hromosome <L for apolipoprotein #?
- 9hromosome <? for presenilin <
- 9hromosome < for presenilin <<
"hoinergic hy'othesis? degeneration of
cholinergic nuclei in nucleus of eynert
Patho'hysioogy
-.myloid plagues in hippocampus!
amygdale and corte)
-Neurofi*rillary tangles in corte)!
hippocampus
"inica !eatures
#arly symptoms$ increasing forgetfulness
.mnesia
.phasia ('ord finding difficulty)
.pra)ia (cannot dress)
.gnosia (cannot recogni0e *ody parts)
Poor (isual spatial s/ill
Delusion of theft against maid in S+pore
Hallucination <0=
Beha/ioura disturbance$ aggression!
'andering! se)ual disinhi*ition
Mini>&enta state e4a& N $+ C)2
In/estigations? DA9! A<2! Dolate! @D&!
RD&! CDR@! 9& or R, *rain
Manage&ent?
(cetychoinesterase inhibitors? FFF
MMS7 O #$ 'oints
Done'e*i ->#2&gCday? (-&gLF-) long half
life! once daily dosage 'ith E,& side effects!
not for asthma patients
Ri/astig&ine )>,&g BD? (F$.,C)&g) short
half life! E,& side effects and safe in asthma.
15
Study Notes in Psychiatry (2008) Dr. Roger Ho
<aanta&ine? ?-<2mg AD (8mg N H?.>)4
also 'or/s on nicotinic .ch receptors.
Me&antine? ND. receptors partial
antagonist (<0mg N H:)
@o' dose antipsychotics such as risperidone
<mg 6N for delusion of theft
Beha/ioura techni=ues for chaging
negati(e *eha(iour
Poor 'rognosis? ale! 6nset T ;>! Parietal
lo*e damage! prominent *eha(ioural
pro*lems! Depression
#$.$ 1ther causes o! de&entia
- Dementia 'ith @e'y *ody ('ith
par/insonism)
- Dronto 7 temporal dementia 'ith
personality changes
- Cascular dementia 'ith neurological signs
of stro/e
#$.) Re/ersibe causes o! de&entia B
(''endi4 #$a
#$.+ Pseudo de&entia? a8ays say5 PI
donMt :no8Q
- Pre(ious history of depression
- ,slands of normality
- Response to antidepressant
#$.- Psychosis in edery
@ess than <=4 D$ >$<
Damily history of schi0ophrenia4 sensory
impairments! social isolation
Persecutory delusions$ L0=
.uditory hallucinations$ I>=
Cisual hallucination <:=
&reatment$ relie(e isolation 5 sensory
deficits4 lo' dose atypical antipsychotics$
risperidone <mg 6N 3 2uetiapine >0mg 6N
#$., De'ression in edery
- more psychomotor retardation
- nihilistic delusion (9otard syndrome)
- onitor suicide ris/
- &reatment of choice$ escitalopram <0mg
6N
"h. #) "onsutation 6iaison Psychiatry
#).# Dissociati/e C "on/ersion Disorders
De!inition
- Dissociation 7 an apparent dissociation
*et'een different mental acti(ities.
- "on/ersion > ental energy can *e
con(erted into certain physical symptoms.
7'ide&ioogy?
- 6nset usually *efore the age of :>
- ore common among 'omen
- ore common in lo'er social class
- 6ccurs in national ser(icemen
(etioogy?
- Premor*id personality$ <>= has premor*id
histrionic personality traits.
- #motionally charged ideas lodged in the
unconscious at some time in the past. &here
is a con(ersion of psychic energy into
physical channels.
Pathogenesis
- Pri&ary gain? an)iety arising from a
psychological conflict is e)cluded from
patient+s conscious mind
- Secondary gain? symptoms confer
ad(antage to patient$ e)empted from NS.
"inica !eatures?
Dissociation "on/ersion
- Psychogenic
amnesia
- Psychogenic fugue
('andering)
-Somnam*ulism
(sleep 'al/ing)
- ultiple personality
- Paralysis
- Dits
- Alindness
- Deafness
- .phonia.
- .naethesia
- a*dominal pain
- Disorder of gait
6a Bee indi!!erence? less than the
e)pected amount of distress often sho'n *y
patients 'ith hysterical symptoms.
DDE?
- #)clude organic causes$ temporal lo*e
epilepsy! cere*ral tumour! general paralysis
of insane dementia
- #)clude malingering$ conscious a'are of
'hat he or she is doing! ma/ing up illness
- #)clude histrionic personality disorder.
In/estigation? no demonstrata*le organic
findings
Manage&ent?
Psychoogica treat&ent?
- reassurance and suggestion
- e)ploratory psychotherapy a*out his past
life.
16
Study Notes in Psychiatry (2008) Dr. Roger Ho
Socia treat&ent? to eliminate factors that
are reinforcing symptoms.
Bioogica treat&ent? (breaction$ ,C
inFection of small amount of dia0epam to put
patient into resting state and encouraged to
relie(e stressful life e(ent (last to mention in
e)am)
Prognosis? ,f the course is longer than <
year! it is li/ely to persist for many years.
Pseudosei*ure?
- ,nconsistent neurological sign
- 9an recall the sei0ure episode 5 a(oid
inFury
- no increase in serum prolactin (increases
in genuine epilepsy)
#).$ Hy'ochondriasis
Hy'ochondriasis is the preoccupation 'ith
the fear of ha(ing a serious disease 'hich
persists despite negati(e in(estigation.
7'ide&ioogy
ore common among elderly! e2ual se)
incidence! lo'er social class
(etioogy?
- History of childhood illness! parental
illness! e)cessi(e medical attention see/ing
in parents! childhood se)ual a*use
- &endency to misattri*ute *ody symptoms
- edical reassurance pro(ides temporary
relief of an)iety 'hich acts as a re'ard for
more medical attention.
"inica !eatures?
-Preoccupation 'ith the idea of ha(ing a
serious medical condition! 'hich 'ill lead to
death and serious disa*ility.
- Patient 'ill see/ medical ad(ice *ut is
una*le to *e reassured *y negati(e
in(estigations4
- .n)iety 5 depression are common.
- ,t is usually in the form of o(er(alued idea.
Manage&ent
- .llo' patient to (entilate their pro*lems
- #)plain negati(e test! reassurance! no
further in(estigation!
- .im to impro(e function
- Area/ cycle of repeat consultation
- Damily education
- 9A&$ challenge 5 replace misinterpretation
- #)posure to illness cue 5 response
pre(ention
- Depression$ use SSR, li/e fluo)etine
So&atisation disorder
. chronic disorder of multiple medically
une)plained symptoms! affecting multiple
organ systems presenting *efore the age of
?0. ,t is associated 'ith significant
psychological distress.
(etioogy - ore family mem*ers 'ith
somatisation disorder4 similar to aetiology of
hypochondriasis.
7'ide&ioogy? - 0.2=4 D$ >$<4 age of
onset$ childhood to :0s
"inica !eatures?
Pain$ right iliac! *ac/ and head
9CS$ dyspnoea! chest pain! palpitation! AP
E,$ heart*urn! nausea! flatulence! dysphagia
S'eating or *ody odour
Manage&ent?
Initia?
-.c/no'ledge symptom se(erity 5 as real
-.ttempt to reframe symptoms as emotional
1ngoing &anage&ent?
-Regular re(ie' *y single doctor! planned
(isit! a(oid .#D 5 unnecessary in(estigation
- ,n(estigate o*Fecti(e signs only
- Symptom re-attri*ution
- 9A&
Body dys&or'hic disorder
(Dys&or'ho'hbia)? Preoccupation that
some aspect of physical appearance (*ody
image) is grossly a*normal 5 refuses to
accept medical e)planation. &reated *y
SSR, and 9A&. ,t can lead to depression!
suicide! 5 functional impairment.
Factitious disorder C MunchausenMs
syndro&e? falsify symptoms 5 fa*ricate
signs (use /etchup for *lood) for medical
attention
"a'acity to gi/e consent
<) Patient must *e informed a*out the
procedure! ris/ and *enefit
2) 9an patient understand the infoO
:) 9an patient retain infoO
?) 9an patient *alance the ris/ or *enefitO
>) 9an patient arri(e at a conclusionO
17
Study Notes in Psychiatry (2008) Dr. Roger Ho
;) Durther assessment of cogniti(e function
e.g mini mental state e)amination.
I) Ha(ing a psychiatric illness li/e
Schi0ophrenia does not mean lac/ of
capacity to gi(e consent.
Deiriu&C (cute con!usiona state
,t is a clinical syndrome of fluctuating glo*al
cogniti(e impairment 'ith *eha(ioural
a*normalities due to (ariety of insults.
7'ide&ioogy
<0= of medical 5 surgical inpatients.
Ris: !actors$ elderly! dementia! *lind 5
deaf! postoperati(e! *urn (ictims! alcoholic.
(etioogy
-Intracrania? 9C.! head inFury! 9NS
infection
- &etaboic? electrolyte distur*ance! hepatic
encephalopathy! hypo)ia
- endocrine? Pituitary! thyroid! P&H! adrenal
- In!ection? "&,! chest infection! a*scess
- Substance into4ication and 8ithdra8a
"inica !eatures? - Dluctuating course
-impaired consciousness and attention
- Disorientation! impaired recent memory
- Nocturnal 'orsening of symptoms
- Psychomotor agitation 5 emotional la*ility
- illusions! (isual hallucinations (*ig insect)
- Poorly formed paranoid idea (other
patients 'ant to harm him)
DDE? > Psychotic illness
- Post ictal confusion
- Dementia
Manage&ent?
1) ,dentify 5 treat precipitating cause
2) Pro(ide calm en(ironment 'ith
reality orientation (*ig cloc/)
3) @o' dose antipsychotics$
Haloperidol 2.>mg3 risperidone <mg
4) Regular re(ie' and follo' up
5) #ducate family a*out delirium
De'ression in chronic &edica iness
- 9ommon! @oo/ for non somatic
symptoms$ guilt! concentration! lo'
mood
- .ssess suicide ris/
- "se escitalpram as it has less drug
interactions.
"h. #+ Perinata Psychiatry
#+.# Baby bues
V of ne' mothers 'ill e)perience a short
li(ed period of tearfulness and emotional
la*ility starting 2-: days after *irth.
Due to pospatrum reductions of oestrogen!
progesterone and prolactin.
No need for treatment.
#+.$ Postnata de'ression
7'ide&ioogy?
- <0-<>= of 'omen
- Pea/$ :-? 'ee/s of deli(ery
Ris: !actors?
- Damily history of depression4
- Poor relationship 'ith o'n mother
- .m*i(alence to'ards pregnancy
- Poor social support
- Pre(ious postpartum depression
"inica !eatures
- Depression B 'orries a*out *a*y+s health
and a*ility to loo/ after *a*y
- L0= last less than < month
Manage&ent?
- Pre(ention *y education
- #nhance support
- ,f se(ere! SSR, (to a(oid *reast
feeding)
- 9A&
#+.) Post'atru& 'sychosis
7'ide&ioogy
<.>3<000 li(e *irths
Pea/$ 2 'ee/s postpartum
(etioogy
Reduce of oestrogen! leading to dopamine
super-sensiti(ity! cortisol le(els or
postpartum thyroiditis
Ris: !actors?
- Damily history of psychiatric disorder
- @ac/ of social support
"inica !eatures?
-Prominent affecti(e features (80=)$ mania 3
depression
18
Study Notes in Psychiatry (2008) Dr. Roger Ho
- Psychosis! paranoid idea a*out safety of
*a*y
- ,nsomnia! perple)ity! disorientation
- @oo/ for suicide 5 infanticide ris/
Manage&ent?
&reatment in hospital 7 WW 'omen hospital 3
,n the "W! admit to special mother 7 *a*y
unit
#9& is useful
.ntipsychotics is needed ( to a(oid *reast
feeding)
#+.+ Pre&enstrua Syndro&e (PMS)
PS is a constellation of menstrually
related! chronic! cyclical! physical and
emotional symptoms in the luteal phase.
Sy&'to&s$ Areast tenderness! fatigue!
cramping! *loating! irrita*ility! depression!
poor concentration! food cra(ings! lethargy!
li*ido changes.
Pre/aence? ?0= of 'omen of reproducti(e
age! se(ere impairment in >=
In/estigation? 9harting of daily symptoms
for at least 2 menstrual cycle may aid in
confirming cyclical pattern.
Treat&ent?
"onser/ati/e &anage&ent? @o' salt and
fat diet! less caffeine! reduce alcohol and
to*acoo inta/e! to reduce stress
"onsider &edication? to try SSR, if fails to
conser(ati(e treatment.
Re!er to 1 and < i! abo/e &easures !ai
Ref$ 6)ford Hand*oo/! 200?
"h. #- 7ating disorder
#-.# (nore4ia Ner/osa
7'ide&ioogy
- "sually Demales4 D$ N <0$<
-6nset *et'een <;-<I
- ore common in upper social class
- <= of middle class adolescent girls.
- ,ncreasing incidence$ 0.>=
(etioogy
-Eenetics$ 1$ D1 ;>=$:2=4;-<0= of
female si*lings of patients also suffer from
this condition
-Hypothalamic dysfunction
- Social$ #)am stress in S+pore! occupations
group$ *allet students! atheletes
-,ndi(idual pathology$ dietary pro*lems in
early life! lac/ of a sense of identity
- Damily pathology$ enmeshment! rigidity!
o(erprotecti(ieness! lac/ of pro*lem sol(ing
"inica !eatures
"ore cinica !eatures > R(PID
-. *ody 'eight more than <>= *elo' the
standard 'eight or A, <I.> or less
- Self induced 'eight loss$ (omiting! purging!
e)cessi(e e)ercise! appetite suppressant
-Aody image distortion- dread of fatness!
o(er(alued idea
-#ndocrine disorder$ HP. a)is!
amenorrhoea! reduced se)ual interest!
raised cortisol! altered &D&s
- Delayed and arrested pu*erty.
"o&'ications?
Secondary to
star/ation
"onse=uences o!
/o&iting %
a4ati/e
Hypothermia
9onstipation
@o' AP! anaemia
Aradycardia
.menorrhoea
@eucopenia
Hypercholesterolemia
Delayed in gro'th
6steoporosis
Dry s/in3*rittle hair
@oss of *rain (olume
9ere*ral atrophy
Centricle enlargement
Hypo/alaemia
Hyponatraemia
Prolonged J&
9ardiac arrhythmia
Dental caries
7e/ated hor&ones Reduced
19
Study Notes in Psychiatry (2008) Dr. Roger Ho
hor&ones
Ero'th hormone
Prolactin
9ortisol
&: and &?
6estradiol
&estoesterone
DSH and @H
In/estigation
DA9! RD&! @D&! glucose! &D&! cholesterol!
@H! DSH
DDE?
Functiona iness 1rganic disorder
69D
Depressi(e disorder
Hypopituitarism
&hyroto)icosis
Dia*etes ellitius
Arain tumour
ala*sorption
Manage&ent?
(d&ission to hos'ita?
-#)tremely rapid or e)cessi(e 'eight loss
-Se(ere electrolyte im*alance
- 9ardiac complications
- ar/ed change in mental status
- Ris/ of suicide
- Dailure of outpatient treatment
Feeding and re!eeding syndro&e
-9onsult medical3dietitian
- Refeeding syndrome$ 9ardiac
decompensation can occur 'ithin first 2
'ee/s$ myocardium cannot 'ithstand the
stress of increased meta*olic demand4
slo'ly increase dietary inta/e *y 200/cal per
day and monitor RD& closely
Psychoogica treat&ent?
>Su''orti/e 'sychothera'y? to impro(e
interpersonal relationships and sense of
personal effecti(eness.
- Beha/ioura thera'y? regimen of
refeeding! to set target 'eight! positi(e
reinforcement 'ith pri(ileges such as outing!
mo(ie etc
- "ogniti/e thera'y! after gaining some
'eight! aims at changing attitude to'ards
eating! reappraisal of self image and life
circumstances.
-Fa&iy thera'y
Phar&acoogica? 6lan0apine may *e used
to promote 'eight gain (contro(ersial not to
mention in e)am)
Prognosis o! (N
Rues o! one third$
#C) #C) #C)
Reco(er fully Reco(er
partially
9hronically
disa*led.
Factors associated 8ith a 'oor 'rognosis
- 9hronic illness
- @ate age of onset
- Aulimic features
- .n)iety 'hen eating 'ith others
- #)cessi(e 'eight loss
- Poor childhood social adFustment
- Poor parental relationships
- ale se)
Bui&ia Ner/osa
7'ide&ioogy? <= of 'omen
(etioogy?
Damily history of affecti(e disorder
Serotonergic dysregulation
"inica !eatures?
-Persistent preoccupation 'ith eating
-,rresisti*le cra(ing for food
-*inges$ episodes of o(ereating
- .ttempts to counter the fattening effects of
food$ self induced (omiting! purging
BN is di!!erent !ro& (N. In BN5
- Patients are more eager for help
- enstrual a*normalities less than
half of the patients
- Aody 'eight 'ithin normal limits
"o&orbidity? Muti'e dyscontro
beha/iours?
- 9utting 3 *urning
- 6(erdose
- .lcohol 3 drug misuse
- Promisuity
Manage&ent
- "sually managed as outpatient
- .dmission only for suicidality and physical
pro*lems
- Higher dose of SSR,$ fluo)etine up to ;0
mg
- 9ogniti(e *eha(ioural therapy
Poor 'rognosis$ se(ere personality
disorder or lo' self esteem.
20
Study Notes in Psychiatry (2008) Dr. Roger Ho
#-.) Pathoogica ga&bing
,t is a persistent and recurrent maladapti(e
patterns of gam*ling *eha(iour.
Relati(ely common and may lead to
significant personal! family and occupational
difficulties.
"inica !eatures
- Preoccupation 'ith gam*ling
- &olerance$ need to gam*le 'ith
larger amounts of money
- Dail to cut do'n
- 9hasing losses (li/e chasing the
dragon in drug addicts)
- @ying to others a*out gam*ling
- 9ommitting illegal acts to finance
gam*ling.
- @osing or Feopardi0ing familial
relationship
Treat&ent$
- 9A& to reduce preoccupation 'ith
gam*ling
- SSR, (fluo)etine)
- Support group
- 9redit card de*t counseling (ia
S8
#-.+ Ke'to&ania
Dailure to resist impulses to steal items that
are not needed nor sought for personal use.
e.g . men stole <0 female & shirts! same
style *ut different colours.

"sually 'omen! mean age :;! <; years of
illness
DDE? shoplifting ('ell planned and
moti(ated *y need and monetary gain)!
69D and depression
Treat&ent?
- 9A&
- SSR,
#-.- Trichotio&ania
Stereotyped recurrent pulling of hair
DDE? 69D! &ourette syndrome! .utism!
factitious disorder
Treat&ent? *eha(ioural modification!
SSR,!if fail consider risperidone or lithium
Ref$ 6)ford Hand*oo/! 200?
"h.#, Suicide and DSH Tr!c)cycl!st, *K
#,.# Suicide
7'ide&ioogy
• completers are more often $
• male
• psychiatric disorder
• ha(e made a plan
• used a dangerous method
Pre(alence
• l!fet!me +re$alence ("S.)$
• 2< = mor*id thoughts
• <0.2 = suicidal thoughts
• 2.L = attempted suicide
• EP $ (2!>00 patients)
• < suicide e(ery ? years
• Psychiatrist (catchment area >0!000)
• < suicide e(ery : months
Sociode&ogra'hic correates o! suicide
%) ,"e, Sex
a) $D N :$<4 males M females
for all groups
*) suicide pacts more common
in the elderly
-. Mar!tal status (
a) di(orced M 'ido'ed M single
/. 0m+loyment (
a) unemployed 3 retired 3 li(ing
alone
1. Soc!al Class (
a) Higher in lo'est social
groups 5 professional
*) lo'est in middle groups
2. 3el!"!on (
a) strong religious affiliation is
a protecti(e factor
4. 5ccu+at!on (
a) higher ris/ groups are
doctors! la'yers! hotel and
*ar trade o'ners
6. 9hronic Phys!cal !llness (
terminal illness 3 malignancies
a) chronic pain
'. 5ther assoc!at!ons (
a) history of DSH (<3:- X of
completers)
Suicide and &enta iness
• all psychiatric illness (e)cept 69D)
increase ris/ *y L0-L> =
21
Study Notes in Psychiatry (2008) Dr. Roger Ho
• Depression (ris/ :.; - 8.> = N :0 )
general population ris/)
Schi0ophrenia (ris/ > - <0 =)
.lcohol dependence (ris/ :.? - ;.I =)
Neurosis$ panic disorder3 P&SD
S'ecia 'o'uations
#lderly
• rate increasing
• 80-L0 = of elderly suicides ha(e
depressi(e illness
• often first episode of depression
• DSH is more closely associated 'ith
completed suicide
• denial of suicide more common
,npatients Highest ris/ $
• first 'ee/ of admission
• early stages of reco(ery
• *et'een shifts of staff
• on lea(e (patients and staff)
• *an/ holidays
• discharge (premature)
• ris/ is increased :0 ) in the
month after discharge
(etioogy
<enetics
• suicidal *eha(iour clusters in family
• 1 $ D1 N <<.: = $ <.8 = (Roy et al.
<LL<)
Neurochemical
%)Seroton!n ( serotonin deficiency
#,.$ Deiberate se! har& (DSH)
. deli*erate! non fatal act! 'hether physical!
drug o(erdose! or poisoning! done in the
/no'ledge that it 'as potentially harmful.
ore common in female
Moti/es? . cry for help4 .n attempt to
influence others4 escape from stress4 to feel
pain in personality disorder
Factors o! DSH 'redicting suicida ris:
• ,solation4 timing
• precautions to a(oid inter(ention
• suicide note
• anticipatory acts
• Ydangerousness+ of state of mind
"h. #. Personaity disorder
Deeply ingrained! maladapti(e patterns of
*eha(iour4 recognisa*le in early adulthood!
continuing throughout most of adult life4 there is
an ad(erse effect on the indi(idual or society.
#..# Borderine Personaity Disorder
Pre/aence? <.> 7 2=
"hidhood de/eo'&ent
- 9hildhood trauma 7 se)ual a*use!
di(orce
- Playing primiti(e defence mechanisms
such as splitting or proFecti(e
identification
"inica !eatures? PI R(IS7 ( P(INQ
, 7 ,dentity distur*ance
R- Relationship$ unsta*le
. 7 .*andonment fear of
, 7 ,mpulsi(e
S 7 Suicidal gesture
# 7 #mptyiness
. 7 .ffect$ unsta*le
P 7 Paranoid idea 3 psychosis$ transient
. 7 .nger
, - ,dealisation and Dealisation
N - Negati(istic
Prognosis? <3: continue to ha(e Aorderline
Personality disorder after <0 7 20 years.
Poor 'rognosis?
- Se(ere repeated self-harm
#..$ (ntisocia Personaity Disorder
Pre/aence? 2-:.>=
Neuro'hysioogy?
-immature ##E in posterior temporal lo*e as
slo' 'a(es
- @o' >H& le(els in impulsi(e (iolent indi(iduals
"hidhood de/eo'&ent
- Difficult infant temperament
- Harsh and inconsistent parenting
- 9onduct disorder in childhood
22
Study Notes in Psychiatry (2008) Dr. Roger Ho
"inica !eatures? P"(661ISQ
9onduct disorder T <>
.ntisocial .ct and aggression
@ies fre2uently
@ac/ superego
6*ligations not honoured
"nsta*le and cannot plan ahead
Safety of self or others ignored

Prognosis?
ay commit crime
ay sho' ,mpro(ement *y >
th
decade
Manage&ent o! Personaity Disorder
Ma:ing the diagnosis o! 'ersonaity disorder
- .ssess patient+s enduring and per(asi(e
patterns of emotional e)pression!
interpersonal relationships! social
functioning
- 6*tain collateral information from family
and past psychiatric history
- #)plore relationships! self concept and
functional assessment
(d&ission to hos'ita
- &hey *enefit little from prolonged
admission.
- .dmission is indicated for specific crisis
- &reatment plan aims to set limits and to
achie(e realistic goal
Psychoogica treat&ent
-Super(ision and support are often *eneficial
"BT?
- #ducate them a*out the schema
- #mpathetic challenging their core *eliefs
- Eoal directed pro*lem sol(ing approach
Diaectica beha/ioura thera'y !or borderine
'ersonaity disorder
- Docus on a detailed 9A& approach to self harm
- &hen focus on tolerance of distress! emotional
regulation and interpersonal s/ills
- &o process trauma
- De(elop self esteem and realistic future goals
Phar&acoogica treat&ent?
- SSR, antidepressant can impro(e mood and
reduce impulsi(ity
1utco&e o! 'ersonaity disorder
- High rates of accident! suicide and
(iolent death.
Ref$ 6)ford Hand*oo/! 200?
"ha'ter #3 Psychiatric 7&ergency
#3. # (cute disturbed 'atient
(etioogy
- .lcohol and drug dependence
- ,llicit drugs
- eta*olic distur*ance
- Head inFury
- Schi0ophrenia
- ania
- Personality disorders
Treat&ent o! acute disturbed 'atient or
crisis?
,t re2uires immediate action$
<) De-escalation (er*ally in calm and
consistent en(ironment.
2) 6ral medication$ P6 Haloperidol
>mg stat or P6 lora0epam <mg stat
:) , medication$ , Halperidol >mg
stat4 , lora0epam 2mg (in ,H)4 no
, dia0epam due topoor a*sorption
?) 9lose monitoring on (ital sign
>) ,f chemical restraint fails! consider
physical restraint
#3.$ Neuroe'tic Maignant Syndro&e
,t is a rare i!e threatening reaction to
antipsychotic medication characterised *y
fe(er! muscular rigidity! altered mental status
and autonomic dysfunction.
Due to boc:ade o! D$ rece'tors leading to
impaired calcium mo*ilisation and leads to
muscle rigidity.
Incidence? 0.2=
D$ N 2$<
Ris: !actors
- Drug naZ(e patient recei(ing high potency
antipsychotics
- Dehydration
"inica signs and sy&'to&s?
- Hyperthermia
- uscular rigidity
- 9onfusion 3 agitation
- &achycardia
23
Study Notes in Psychiatry (2008) Dr. Roger Ho
- Hyper or hypotension
- &remor
- ,ncontinence
- K 9W le(el
In/estigations? DA9! @D&! RD&! 9a and
P6?! serum 9W! 9SR! 9&
DDE? lethal catatonia! malignant
hyperthermia! meningitis! heat e)haustion!
rha*domyolysis
Manage&ent?
- Stop antipsychotics
- edical emergency! refer to medical
- ,C fluids! reduce temperature
- Aen0odia0epine for acute
*eha(ioural distur*ance
- &o gi(e *romocriptine
Mortaity? >-20= die! it can lead to acute
renal failure.
#3.) Serotonin syndro&e?
. rare *ut potentially fatal syndrome
occurring in the conte)t of initiation of
serotonergic agent! characterised *y altered
mental state! agitation! tremor! shi(ering!
diarrhoea! hyperrefle)ia! myoclonus and
hyperthermia.
<= of patients on SSR,
Pathophysiology$ due to increase in
serotonin.
"inica !eatures?
(utono&ic? hyperthermia! nausea!
diarrhoea! mydriasis! tachycardia!
hyper3hypotension
Neuro&uscuar? myoclonus! rigidity and
tremors! hyperrefle)ia! ata)ia
ore rapid onset! rapid progression and less
rigid than NS.

In/estigations? same as NS! add in 9SR
to rule out aspiration! #9E to loo/ for
prolonged J&c
Treat&ent?
- 9onsult medical! it is a medical emergency.
- ,C access! to allo' (olume correction to
reduce the ris/ of rha*domyolysis
- Prescri*e *en0odia0epine to control
agitation! sei0ure and muscle rigidity.
"ourse and 'rognosis?
- Resol(e 'ith 2? 7 :; hours
- ortality T < in <000
"ha'ter #0 See' disorders
#0.# Nor&a see' B stages and cyce
- . typical night+s sleep has ? or > cycles of
stages! each lasting L0 7 <<0 minutes.
- .s night progresses! the amount of time
spent in delta sleep decreases 'ith
conse2uent increase in R# sleep.
- &otal sleep time in adult is *et'een > 7 L
hours.
Stage < @ight sleep! 'ith slo' theta
and delta 'a(es
Stage 2 W comple)es
Stage : 5 ? Delta 'a(e! slo' 'a(e
sleep
R# @o' (oltage!
desynchronised ##E
acti(ity
(ssess&ent o! see' disorders?
Present
compliant
6nset! duration! course!
fre2uency! stressors
Daily routine 8a/ing! daily acti(ities! *ed
time
Description
of sleep
Aeha(iour during sleep!
dream! 'a/ening!
satisfaction
Daytime
somnolence
@e(el of alertness! effect on
'or/!
Drug 5
alcohol
Regular hypnotics
9affeine containing drugs
#0.$ Inso&nia
,nsomnia in(ol(es difficulty to fall asleep!
maintaining sleep and poor 2uality of sleep
as persistent pro*lem : days per 'ee/ for
one month.
7'ide&ioogy
- 9ommon pro*lem
- DM
- Ereater in elderly
- 9hronic significant insomnia 7 ;=
(etioogies?
Intrinsic causes?
- Psychophysiological insomnia
associated 'ith an)iety
- Sleep state misperception (constant
monitoring of sleep)
24
Study Notes in Psychiatry (2008) Dr. Roger Ho
- ,diopathic insomnia
- Sleep apnoea syndrome
- Periodic lim* mo(ement disorder
74trinsic causes?
- ,nade2uate sleep hygiene
- Dependency related sleep disorder
li/e hypnotics
- Nocturnal eating and drin/ing
Medica and Psychiatric causes?
- Pain
- Respiratory (96PD)
- Par/inson disease
- #ndocrine$ .ddison! 9ushing
- Depression! *ipolar disorder
- .n)iety disorder! P&SD
- Schi0ophrenia
Manage&ent?
- .ddress underlying pro*lem (drug
dependency)
- 7ducation? stages and cycles.
- See' hygiene &easures? Eood
sleep ha*its and stimulus control
- Rea4ation training
- "se of hypnotics if unresponsi(e to
a*o(e
Mida*oa& (Dor&icu&) has (ery fast onset
of action and high potency! it has high
potential for dependency. ,t is not
recommended for regular oral usage.
"h. $2 "hid Psychiatry
$2.# (ttention De!icit % Hy'er:inetic
Disorder ((DHD)
.DHD is a persistent pattern of inattention
B3- hyperacti(ity that is de(elopmentally
inappropriate. &he symptoms should ha(e
an onset in childhood.
7'ide&ioogy?
- "S.$ :->= (o(er-diagnosis)
- "W$ <=
- $D N :$<
(etioogy?
<enetics?
- >0= ris/ in 1 t'ins! 2) increase in
si*lings
- Eenes$ >! ;! << are implicated.
- Neuroimaging$ frontal
hypometa*olism
- Dopamine 5 >H& dysregulation in
prefrontal corte)
"inica !eatures?
Hy'eracti/ity
sy&'to&s
Inattention
sy&'to&s
Didgeting! mo(ing!
getting up 5 do'n!
clim*ing on des/s
Alurting out ans'ers!
[umping the 2ueue
9annot sustain
attention
Poor tas/ completion
a/ing mista/es
'hen tas/ re2uire
attention
(ssess&ent?
- ,nter(ie' 'ith parents$
de(elopmental history
- 6*ser(e attachment style and le(el
of acti(ity of child
- 9ollateral info from school
Treat&ent?
- 9A&$ *eha(ioural techni2ues
- Social s/ill training
- Parent management training
- #ducation and remedial inter(ention
- Stimulant$ ethylpenidate >-<0mg
6$ increase Dopamine 5
noradrenaline 'hich can increase
concentration 5 attention! side effect
include gro'th retardation 'hich
re2uires drug holiday.
25
Study Notes in Psychiatry (2008) Dr. Roger Ho
1utco&e
- 20= de(elop antisocial personality
disorder
- 20= de(elop su*stance a*use
disorder
$2.$ "onduct disorder
. repetiti(e and persistent pattern of
*eha(iour in 'hich the *asic rights of others
or maFor age appropriate societal norms are
(iolated.
7'ide&ioogy
- #arlier onset and is more common in *oys
than in girls.
(etioogy
Bioogica !actors Psychosocia
- Damily history of
antisocial *eha(iour
or su*stance a*use.
- @o' 9SD serotonin
- @o' ,J
- Arain inFury
- Parental criminality
- Su*stance a*use in
parents
- Harsh and
inconsistent
parenting
- Domestic chaos
and (iolence
- @arge family si0e
- @o' socio-
economic status and
po(erty
- #arly loss and
depri(ation
> School failure
"inica !eatures?
- .ggression
- 9ruelty to people and animals
- Destruction of property
- Deceitfulness or theft
- Serious (iolation of rules
- Eang in(ol(ement
- @ac/ of empathy
Manage&ent?
- #nsure the safety of the child
- 9A& pro*lem sol(ing s/ill
- Parent management training
- Damily therapy
- .cademic 5 social support referral
"ourse and outco&e?
- 9D is often chronic and
unnamea*le.
- .ntisocial PD in adults T>0=
Poor outco&e? #arly onset T <0 year old!
lo' ,J! poor school achie(ement! attentional
pro*lems! hyperacti(ity! family criminality!
poor parenting.
$2.) (utis&
It is characterised by the triad o!
sy&'to&s?
- .*normal social relatedness
- . 2ualitati(e a*normality in
communication and play
- Restricted! repetiti(e and
stereotyped *eha(iour! interests and
acti(ities
7'ide&ioogy?
- 6nset is typically *efore age :.
- $D N :-?$<
- Pre(alence$ >-<03<000
(etioogy?
- Eenetic
- 6*stetric complications
- &o)ic agents
- Pre3postnatal infections.
- .ssociation 'ith tu*erous sclerosis
Patho'hysioogy MRI?
- ,ncrease in *rain si0e
- ,ncrease in lateral and ?
th
(entricle
- Drontal 5 cere*ellar a*normalities
- .*normal pur/inFe cells in cere*ellar
(ermis.
- .*normal lim*ic architecture.
"inica !eatures?
- (bnor&a socia reatedness$ poor
eye contact and no peer relationship
- (bnor&a co&&unicationC'ay?
lac/ of language! difficulty to initiate
con(ersation.
- Restricted interests or acti/ities?
non functional routines or rituals
(*us schedule)
- Neuroogica? tics! increase in head
circumference! a*normal ga0e
- Physioogica? a*normal response
to pain! a*normal temperature
regulation.
- Beha/ioura? irrita*ility! temper
tantrums! self 7 inFury! hyperacti(ity!
aggression
(ssess&ent?
- Re2uires ultidisciplinary approach
26
Study Notes in Psychiatry (2008) Dr. Roger Ho
- Rating scale$ .utism Aeha(ioural
9hec/list
Treat&ent?
- 7ducation % /ocationa
inter/entions
- Beha/ioura inter/entions
- Fa&iy inter/entions
- S'eech and anguage thera'y
$2.+ (s'erger Syndro&e ((S)
Se(ere persistent impairment in social
interactions! repetiti(e *eha(ioural patterns
and restricted interests.
,J and language are normal or superior.
ild motor clumsiness and family history of
autism may *e present.
Ne'ton and #instein may ha(e .S
7'ide&ioogy
- ale predominance
- < in :00
"inica !eatures
- Narro' interests and preoccupation
of a su*Fect
- Repetiti(e *eha(iours or rituals
- Peculiarities in speech and
language
- #)tensi(e logical or technical
patterns of thought
- Socially and emotionally
inappropriate *eha(iour and
interpersonal interaction
- Pro*lems 'ith non (er*al
communication
- 9lumsy and uncoordinated motor
mo(ements.
$2.- (''roaches to the "hid
- #sta*lish the rapport and gaining
the child+s confidence
- Aegin 'ith su*Fects 'ell a'ay from
the presenting pro*lem (interests!
ho**ies! friends and si*lings! school
and holidays)
- Progress to en2uire a*out the
child+s (ie' of the pro*lems
- 6*ser(e the le(el of acti(ities and
attention during the inter(ie'
- &ry to inter(ie' the child and family
together to o*ser(e family dynamics
$2., Schoo re!usa
7'ide&ioogy
• pre(alence of <-2 =
• slightly more common in *oys
• more common during three periods in
school life$
<. age > (starting school)
2. I years (change to Funior school)
:. << years (starting secondary school)
?. <? years and older! 'hen there is
often associated depression and
difficulties in school
(etioogy
• associated 'ith se+arat!on anx!ety
especially in younger children
• may occur after a minor life e(ent$
illness
• some older children ha(e depression
• increased incidence of an)ious!
o(erprotecti(e mother in com*ination
'ith a 'ea/! passi(e! ineffectual! or
a*sent father
• children are often emotionally immature
and ha(e not learned to accept
frustration
"inica !eatures
• there are often somatic symptoms such
as headache! a*dominal pain!
diarrhoea! sic/ness! or (ague
complaints of feeling ill 7 these
complaints occur on school days *ut not
at other times
• the final refusal may occur after se(eral
e(ents$
• follo'ing a period of increasing
difficulty
• after an enforced a*sence such as
respiratory infection
• after an e(ent at school such as
change of class
• follo'ing a pro*lem in the family
such as illness of another family
mem*er
27
Study Notes in Psychiatry (2008) Dr. Roger Ho
Treat&ent
• an early return to school is important
• discussion 'ith teachers is needed
• depressi(e disorder should *e treated
Prognosis
• 'orse prognosis in older children
• higher incidence of psychiatric disorders
(e.g. agorapho*ia) in adult life
$2. . 7nuresis
Coluntary3in(oluntary (oiding of urine at
night for child M > yr old.
I>= ha(e family history of enuresis
&o rule out "&,! neurological pro*lems!
o*structi(e uropathy.
Pri&ary enuresis$ ne(er dry
Secondary enuresis$ pre(iously dry
Aeha(ioural modification is important
treatment$ starchart to re'ard patient!
restrict fluid at night
edication$ imipramine (&9.)
$2.3 "onse=uence o! chid abuse?
- P&SD
- Dissociati(e disorder
- 9on(ersion disorder
- Aorderline personality disorder
- Depression
- Paraphilias
- Su*stance a*use
$2.0 TouretteMs syndro&e
ultiple motor and (ocal tics for a year! 'ith
distress and impairment function.
Facia tics as initial symptoms
Voca tics? meaningless sounds to clear
'ords and coprolalia
&ic 'a) and 'ane! e)acer*ations due to
stress
6nset$ I years old $D N :$<
Pre(alence$ >3<0!000
Eenetics factors$ .D
,n(ol(es dopamine system and Aasal
Eanaglia
9omor*idity$ depression! 69D
&reatment$ Haloperidol <.>mg->mg! 9A&
Re!? 14!ord Handboo:5 $22+
$# 6earning DisabiityC Menta
Retardation
$#.# IG and earning disabiity (6D)
6D IG Features
Mid -2>,0 ,ndependent self
care
Moderate )->+0 Some deficit in
language! simple
'or/
Se/ere $2>)+ @o'er le(el of
'or/! motor
impairment
Pro!ound Beo8
$2
Cery limited
language 5
*asic s/ills
$#.$ Do8n Syndro&e
ost common genetic cause of @D
&risomy of chromosome 2<
,J most often *elo' >0
De(elop .l0heimer+s disease at ?0s and >0s
"inica !eatures o! Do8n syndro&e
28
Study Notes in Psychiatry (2008) Dr. Roger Ho
Lesley Stevens, Ian Robin, Psychiaty ! "n
ill#state$ colo# te%t, &h#chill livin'stone 2001
$#.) Foeta (coho Syndro&e
- aFor causes of learning disa*ility
> 0.2 7 : per <000 li(e *irths
- 9aused *y maternal alcohol use.
Due to effect of alcohol on ND. receptors
'hich affects cell proliferation
"inica !eatures?
(coho 8ithdra8a$ irrita*ility! hypotonia!
tremor and sei0ures
Facia !eatures? icrocephaly! small eye
fissures! epicanthic folds! short palpe*ral
fiussure! small ma)illae and mandi*les! cleft
palate! thin upper lip
<ro8th de!icits? Small o(erall length! Foint
deformities.
"NS? *eha(iour pro*lems$ hyperacti(e!
sleep pro*lems! poor (isual acuity! hearing
loss! language deficits.
1ther? .SD! CSD! renal hypoplasia.
$$ 6ega % 7thica (s'ects
$$.# Menta Disorder and Treat&ent (ct
- 9an only apply at ,H (8ood*ridge
hospital) in Singapore
"riteria !or co&'usory ad&ission at IMH
1) &he person suffers from a mental
disorder of a nature or degree 'hich
ma/es it appropriate for the person
to recei(e psychiatric treatment in
,H.
2) .dmission is li/ely to alle(iate or
pre(ent deterioration in a psychiatric
condition (Schi0ophrenia! Aipolar
disorder)
3) ,t is necessary for the health or
safety of the patient or for the
protection of other persons that the
person should recei(e such
treatment and it cannot *e pro(ided
unless he is compulsory admitted.
74a&'e?
.ssume you are the .#D medical officer
'or/ing in a general hospital. . 2L year old
male suffers from paranoid schi0ophrenia
'as *rought in to your .#D. He has *een
(iolent at home and attac/s his parents. He
has poor insight and has defaulted his
treatment for : months.
He refuses to *e admitted to your general
hospital psychiatric unit (or your psychiatric
'ard is full)
,n this case! you can send the patient to ,H
for assessment. (Uou need to call the ,H
registrar on call at ;:8L 2000)
&he ,H medical officer or registrar 'ill sign
the Dorm < of ental Disorder and
&reatment .ct$ compulsory admission for I2
hours.
29
Study Notes in Psychiatry (2008) Dr. Roger Ho
$$.$ Dri/ing and Psychiatric iness
(Based on IK a85 Singa'ore does not
ha/e cear guideine on this)
For schi*o'hrenia5 bi'oar disorder?
Dri(ing must cease during acute illness
Re-licensing for pri(ate car$
- has remained 'ell and sta*le for at
least : months
- 9ompliant 'ith treatment
- Dree from ad(erse effects of
medication
- Regain of insight
Dor professional dri(er$ *us dri(er! ta)i dri(er
or lorry dri(er$ Re-licensing may *e possi*le
if 'ell and sta*le for a minimum of : years
'ith minimum dosage of medication and no
significant li/elihood of recurrence
De&entia?
&hose 'ith poor short term memory!
disorientation! lac/ of insight and Fudgement
are not fit to dri(e.
$$.) Diaysis and Schi*o'hrenia
7ou ha$e a 2' year old lady suffer!n" from
chron!c sch!8o+hren!a and end sta"e renal
fa!lure. She ants to sto+ d!alys!s. The renal
team !s $ery concerned as she may d!e and
they ant to see) your o+!n!on.
Suffering from schi0ophrenia does not mean
the patient has no capacity to decide on her
dialysis.
Dirst! 'e ha(e to determine 'hether the
patient has the capacity to ma/e the
decision to 'ithhold dialysis. ,n order to
sho' that she has the capacity! she must *e
a*le to understand and *elie(e that she
suffers from end stage renal failure4 dialysis
is used to treat #SRD and she 'ill die if she
stops dialysis.
8e need to consider the follo'ing$
,t is good to e)plore the psychological
aspects of dialysis$ se)ual dysfunction is
common4 they are more isolated and costs
of dialysis may reduce their 2uality of life
and anaemic can cause fatigue.
"raemia can lead to impaired mentation!
lethargy! multifocal myoclonus.
Dialysis can lead to neuropsychiatric
symptoms such as dialysis dementia!
delirium and depression.
8e may need to treat patient+s
neuropsychiatric symptoms *y
antidepressant or antipsychotics and
reassess her capacity later.
$) Psychothera'y
"o&&on 'sychothera'ies 'ractised in
Singa'ore incude?
$).# Su''orti/e Psychothera'y
.ims to offer practical and emotional
support! opportunity for (entilation of
emotions! and guided! pro*lem sol(ing
discussion.
#)amples include counselling and general
psychiatric follo' 7 up.
$).$ Brie! 'sychodyna&ic
'sychothera'y
,t is an acti(e therapy 'here the therapist
attempts to guide free association on more
focused topics.
Rationae?
- Shorter time scale of long term
psychoanalysis (too e)pensi(e and difficult
for patient to stay in therapy for so long)
Indication?
- ,ndi(iduals 'ith emotional pro*lems
in psychological terms.
- Docal conflicts
-
Techni=ues?
- <oa setting$ tac/le an)iety3
defence
- Focus choosing? repetiti(e
*eha(iour to a single transference
figure
- (cti/e inter'retation
Trans!erence "ountertrans!erence
Patient+s feeling
to'ards therapist
&herapist+s feeling
to'ards patient
Phases o! treat&ent
- Initia? setting treatment contract!
formulation of the case
- 7ary session$ ,dentify central issue
- Midde session? e)plore transference
- "osing$ anticipate termination!
arrangement of aftercare.
30
Study Notes in Psychiatry (2008) Dr. Roger Ho
$).) "BT
Aeha(iours and emotions are determined *y
person+s cognitions. Some pathological
emotions are as a result of cogniti(e errors.
,f the person can *e helped to understand
the connection *et'een cogniti(e errors and
distressing emotion! they can try methods to
change.
&he therapist aims to assist the patient to
monitor cognitions! identify cogniti(e errors!
understand maladapti(e schema! e)plore
'ith strategies and challenge and e)amine
the resultant effects.
Beha/ioura
techni=ues
"ogniti/e
techni=ues
.cti(ity scheduling
Eraded assignment
#)posure3 response
pre(ention
Rela)ation training
Psychoeducation
,dentify automatic
thoughts
Role play
&houghts diary
#)amine e(idence
De!ence &echanis&s
Re'ress
ion
"nconscious forgetting of pain
memory and impulse.
Regress
ion
Re(ert to functioning of a
pre(ious maturational point.
Denia Refusal to consciously
ac/no'ledge e(ents or truths
'hich are o*(ious.
ProJecti
on
.ttri*uting one+s o'n
unaccepta*le ideas or impulses
to another person.
ProJecti
/e
Identi!ic
ation
6ne person proFects a thought!
*elief or emotion to a second
person. &hen! there is another
action in 'hich the second
person is changed *y the
proFection and *egins to *eha(e
as though he or she is in fact
actually characteri0ed *y those
thoughts or *eliefs that ha(e
*een proFected.
Reactio
n
!or&ati
on
&he e)pression e)ternally of
attitudes and *eha(iours 'hich
are the opposite of the
unaccepta*le internal impulses.
Dis'ac
e&ent
&ransferring the emotional
response to a particular person!
e(ent! or situation to another
'here it does+t *elong *ut carries
less emotional ris/.
Rationa [ustifying *eha(iour or feelings
isation 'ith a plausi*le e)planation after
the e(ent! rather than e)amining
unaccepta*le e)planation.
Subi&a
tion
Regarded as healthy defence
mechanism! &he e)ternal
e)pression of unaccepta*le
internal impulse in socially
accepta*le 'ay.
"h. $+ <ossary
(e4ithy&ia? &he ina*ility to descri*e one+s
su*Fecti(e emotional e)periences (er*ally.
(&nesia (nterograde? the period of
amnesia *et'een an e(ent and the
resumption of continuous memory. &he
length of anterograde amnesia is correlated
'ith the e)tent of *rain inFury.
Retrograde? &he period of amnesia
*et'een an e(ent and the last continuous
memory *efore the e(ent.
(utochthonous deusion? . primary
delusion 'hich appears to arise fully formed
in the patient+s mind 'ithout e)planation.
(utosco'y? (Phantom irror image)
&he e)perience of seeing a (isual
hallucination or pseudohallucination of
oneself.
"on!abuation? &he process of descri*ing
plausi*ly false memories for a period for the
patient has amnesia. 6ccurs in Worsa/off
psychosis! dementia.
"o'roaia? . forced (ocalisation of
o*scene 'ords or phrases. &he symptoms
is largely in(oluntary *ut can *e resisted for
a time! at the e)pense of mounting an)iety.
6ccurs in &ic disorder
"ou/ade syndro&e? . con(ersion
symptom seen in partners of e)pectant
mothers during their pregnancy.
DRJS /u . sense that e(ents *eing
e)perienced for the first time ha(e *een
e)perienced *efore. .n e(eryday e)perience
*ut also a non specific symptoms of a
num*er of disorders including temporal lo*e
epilepsy! schi0ophrenia and an)iety
disorders. ,n contrast! Ta&is Vu is the
sensation that e(ents or situations are
31
Study Notes in Psychiatry (2008) Dr. Roger Ho
unfamiliar! although they ha(e *een
e)perienced *efore.
Deusiona &e&ory
. primary delusion 'hich is recalled as
arising as a result of a memory (eg patient
'ho remem*ers his parents ta/ing him to
hospital for an operation as a child
*ecoming con(inced that he had *een
implanted 'ith monitoring de(ices 'hich
ha(e *ecome acti(e in his adult life)
Deusiona &ood? . primary delusion 'hich
is recalled as arising follo'ing a period 'hen
there is an a*normal mood state
characterised *y anticipatory an)iety! a
sense of something a*out to happen and an
increased sense of significance of minor
e(ents.
Deusiona 'erce'tion? . primary delusion
'hich is recalled as ha(ing arisen as a result
of perception. &he percept is a real e)ternal
o*Fect.
Deusion o! guit? . delusional *elief that
one has committed a crime or other
reprehensi*le act. ,t is a feature of psychotic
depressi(e illness.
Deusion o! in!estation (7:bo&
syndro&e)? . delusional *elief that one+s
s/in is infested *y multiple! tiny! mite li/e
animals.
Deusion o! re!erence? . delusional *elief
that e)ternal e(ents or situations ha(e *een
arranged in such a 'ay as to ha(e particular
significance for or to con(ey a message to
the affected indi(idual.
De'ersonaisation? .n unpleasant
su*Fecti(e e)perience 'here the patient
feels as if they ha(e *ecome unreal.
Derai&ent (KnightMs &o/e thin:ing)?
schi0ophrenic thought disorder in 'hich
there is total *rea/ in the chain of
association *et'een the meaning of
thoughts.
Dereaisation$ .n unpleasant su*Fecti(e
e)perience 'here the patient feels as if the
'orld has *ecome unreal.
Digenes syndro&e$ Hoarding of o*Fects!
usually of no practical use and neglect of
one+s home and en(ironment. Due to
organic disorder! schi0ophrenia! 69D.
Dysarthria ,mpairment in a*ility to
properly articulate speech
Dyse4ia ,na*ility to read at the le(el
normal for one+s age or
intelligence
Dys'hasia ,mpairment in producing or
understanding speech
(e)pressi(e dysphasia -
Arocas and recepti(e
dysphasia - 8ernic/e)
related to cortical
a*normality
Dys'horia .n emotional state
e)perienced as unpleasant!
secondary to depression
Dys'ra4ia ,na*ility to carry out comple)
motor tas/s (dressing!
eating)
7dietic i&agery$ Particular type of
e)ceptionally (i(id (isual memory. Not a
hallucination. ore common in children.
74traca&'ine haucination
. hallucination 'here the percept appears to
come from *eyond the area usually co(ered
*y he senses (eg a patient in 9lementi
hearing (oices seeming to come from a
house in 9hangi)
<anser sy&'to&s$&he production of
appro)imate ans'ers. Here the patient gi(es
repeated 'rong ans'ers to 2uestions 'hich
are nonetheless in the right *allpar/. 8hat is
2B2O N >. ore common in alingering.
<obus Hytericus? &he sensation of a lump
in the throat occurring 'ithout oesophageal
structural a*normality.
Hy'nagogic haucination? . transient
false perception e)perienced 'hile on the
(erge of falling asleep
Hy'no'o&'ic haucination? &he same
phenomenon e)perienced 'hile 'a/ing up
Iusion? . false type of false perception in
'hich the perception of a real 'orld o*Fect is
com*ined 'ith internal imagery to produce a
false internal percept.
32
Study Notes in Psychiatry (2008) Dr. Roger Ho
6ii'utian haucination? . type of (isual
hallucination in 'hich the su*Fect sees
miniature people or animals. .ssociated 'ith
organic state li/e delirium tremens.
6oosening o! associations$ @ac/ of
meaningful connection *et'een se2uential
ideas.
Magica thin:ing? . *elief that certain
actions and outcomes are connected
although there is no rational *asis for
esta*lishing a connection.
Maingering? Deli*erately falsifying the
symptoms of illness for a secondary gain.
Mirror sign? @ac/ of recognition of one+s
o'n mirror reflection 'ith the perception that
the reflection is another indi(idual 'ho is
mimic/ing your actions.
1/er/aued idea? . form of a*normal *elief.
&hese are ideas 'hich are reasona*le and
understanda*le in themsel(es *ut 'hich
come to unreasona*ly dominate the
patient+s life.
Preser/ation? 9ontinuing 'ith a (er*al
response or action 'hich 'as initially
appropriate after it ceases to *e apposite.
Do you /no' 'here you areO ,n the
hospitalO Do you /no' 'hat day is itO ,n the
hospital.
Russe Sign$ s/in a*rasions! small
lacerations and the calluses on the dorsum
of the hand o(erlying the
metacarpophalangeal and interphalangeal
Foints found in patients 'ith symptoms of
*ulimia. 9aused *y repeated contact
*et'een incisors and the s/in of the hand
'hich occurs during self induced (omiting.
Synaethesia? . stimulus in one sensory
modality is percei(ed in a fashion
characteristic of an e)perience in another
sensory modality (tasting sounds).
Tangentiaity? Producing ans'ers 'hich are
only (ery indirectly related to the 2uestion
as/ed *y the e)aminer.
Trichotio&ania? 9ompulsion to pull one+s
hair out.
Re!erences?
<) @e(i. Aasic Notes in Psychiatry. Radcliffe
Pu*lishing @td <LL8.
2) D. Semple! R. Smith! [ Aurns! R. DarFee!
.. clntosh. 6)ford Hand*oo/ of
Psychiatry. 6)ford "ni(ersity Press. 200?
:) '''.tric/cyclists.co.u/
Appendix
Appendix 3a – Neurodevelopmental Hypothesis of Schizophrenia
33
- &here is an e4cess o! obstetric
co&'ications in those 'ho de(elop the
disorder.
- .ffected su*Fects ha(e &otor % cogniti/e
'robe&s 'hich precede the onset of
illness.
- Schi0ophrenia su*Fects ha(e abnor&aities
o! cerebra structure of <
st
presentation.
- .lthough the *rain is a*normal! giosis is
absent 7 suggesting that differences are
possi*ility ac2uired in utero.
(o)* +o# ,#estions ans-ee$ seies ! Schi.o/henia, &h#chill Livin'stone
Study Notes in Psychiatry (2008) Dr. Roger Ho
Appendix 3b – Brain abnormalities of Schizophrenia
Lesley Stevens, Ian Ro$in ! Psychiaty an ill#state$ te%t, &h#chill Livin'stone0 2001
"//en$i% 3&
34
Study Notes in Psychiatry (2008) Dr. Roger Ho
Lesley Stevens, Ian Robin, Psychiaty ! "n ill#state$ colo# te%t, &h#chill livin'stone 2001
Appendix 5a - oxic effect of lithium
Lesley Stevens, Ian Robin, Psychiaty ! "n ill#state$ colo# te%t, &h#chill livin'stone 2001
Appendix !a "S# and $rief
35
Study Notes in Psychiatry (2008) Dr. Roger Ho
Lesley Stevens, Ian Robin, Psychiaty ! "n ill#state$ colo# te%t, &h#chill livin'stone 2001
"//en$i% 10
Lesley Stevens, Ian Robin, Psychiaty ! "n ill#state$ colo# te%t, &h#chill livin'stone 2001
36
Study Notes in Psychiatry (2008) Dr. Roger Ho
Appendix %&a
Lesley Stevens, Ian Robin, Psychiaty ! "n ill#state$ colo# te%t, &h#chill livin'stone 2001
Mne&onics in Psychiatry (Mne&onics !or MR"P5 P(ST7ST5 $22,)
37
Study Notes in Psychiatry (2008) Dr. Roger Ho
Disorder Mne&onic Brea:do8n o! Mn&onic
Negati(e
symptoms of
schi0ophrenia
>.s and
P@.N&
aPathy
a@ogia
aDfecti(e flattening
aNhedonia
a&tentional deficit
Depression D#PR#SS,6N Depressed mood
#nergy loss
Pleasure loss
Retardation$ psychomotor
#ating change
Sleep distur*ance
Suicidal ideation
, am a failure
6nly me to *lame N guilt
No concentration
.N,. .N,.9 ood increase
.cti(ity 3 energy increase
No inhi*ition
,nsomnia
.l'ays thin/ing M Pressure of speech! flight of ideas
9onfidence e)cess  grandiose
#ating disorder R.P,D Refusal to maintain 'eight
.menorrhoea
Preoccupation 'ith food and 'eight
,nduction of diarrhoea and (omiting
Distur*ance in the 'ay 'eight and si0e are percei(ed
Worsa/off
psychosis
.DD,9& .mnesia
Disorientation
,nsight loss
9onfa*ulation
&hiamine deficiencies
#ating disorder ,ncreases in
the follo'ing
Nuclei .cid *ases$
E 7 Ero'th hormone
9 7 cortisol and cholesterol
. 7 .mylase
& 7 &ransaminase
" 7 "rea and 9reatinine
#(erything else decreases
38