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1
Psychiatric evaluation
Perpetuating factor
what are the factors that may prevent him from getting better?
Knowing the patient
poor social support
Predisposing factor
poor pre-morbid level of functioning
why did the patient develop this disorder? poor insight
significant family history late treatment
personality disorder or traits co-morbid substance use
traumatic childhood experiences criminal record
chronic stress unemployment
substance use
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Comprehension of speech Abstract reasoning and concrete thinking: explain a proverb,
similarities between table and chair
Mood and Affect
General knowledge: capital city of Malaysia, Independence Day
Current mood Judgment: in a burning house, burglar in the house
Labile mood Insight: awareness, attribution and acceptance of condition
Congruent affect
Physical examination
Thought content - to rule out medical causes for the symptoms
Delusions - to check for side effects from psychiatric medications
Obsessions
Concerns - to look for co-morbid medical disorders
Suicidal thoughts
Depressive thoughts
Phobias Multiaxial diagnosis
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Liaison psychiatry - relationship between the psychological and physical aspects of the case
Classification of psychiatric illness encountered in liaison - patient's attitude towards psychiatric intervention
setting - staff attitude towards patient
- Psychiatry provoking ill-health
Treatment
Liaison case summaries
nature
- reason for referral side-effects
- psychiatric diagnosis uncertainty of outcome
need for self-care
- physical disease and patient's reaction to it
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Patient Implications for assessment
psychological vulnerability Characteristics of "at-risk" patients
social circumstances systematic review of patients, looking for psychiatric problems
other stresses (chronic and acute) presence of key symptoms
reactions of others information from relatives
implications for treatment
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Illness behaviour Depression
- describes the actions of the patient and his attitude towards medical Risk factors for depressive disorders in physical illness
personnel - female gender
- eg stoical, restrained, histrionic, dramatizing, hostile, suspicious, - being unmarried
flirtatious, pleading, aloof, excessively cooperative and agreeable
- living alone
- relentless search for causes and cures coupled with inability to accept
reassurance from doctors even when this has been given clearly plus Depression in physically ill
appropriate investigation done
- co-morbid disorders continue after discharge
- inability to accept the suggestion that non-physical factors may be
relevant to one's condition - often goes undetected
- disability out of proportion to detectable organic disease - depressive disorders co-occurring with physical illness complicate
treatment of both disorders
- reinforcement of illness behaviour by family, disability payments and
health care providers - predicts readmission
- inappropriate response to physical disorder - either excessive disability - postponing treatment of depressive disorder worsens prognosis of both
or denial of need of treatment/limitation of activities
- high healthcare costs
- adoption of lifestyle around the sick role with repertoire of behaviours
- poor quality of life
to sustain sick role
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Possible mechanism of co-morbidity Anxiety
- effect on neurotransmitters - causes increased vulnerability to cardiac events
- effect on immune system - phobic anxiety and generalised anxiety are predictors of MI and cardiac
death
- side effects of medications
Post-stroke depression
Organic anxiety syndromes
- up to 50% of patients develop post-stroke depression in acute post-
stroke period - cardiovascular system: angina, arrhythmia, congestive cardiac failure
- left anterior brain lesions (especially caudate nucleus) - neurologic disorders: seizure disorder, akathisia
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Medications that cause anxiety-like symptoms Meaning of cancer to the patient
Stimulant intoxication: caffeine, nicotine, cocaine, - loss of physical strength and well being
methamphetamines, phencyclidine
- loss of independence
Sympathomimetics: pseudoephedrine, methylphenidate,
- loss of role
amphetamines, beta agonists
- loss of personal relationships
Dopaminergics: amantadine, bromocriptine, levodopa
- loss of life expectancy
Anticholinergics: benztropine, diphenhydramine, meperidine
- loss of control - the younger patient, the greater the impact
Miscellaneous: ephedrine, indomethacine, steroids
- impact is greater if cancer is detected unexpectedly in an apparently Factors contributing to psychological problems
healthy person
- concern about prognosis and welfare of relatives
- uncertainty when patient first comes to clinic may be so stressful that
- poorly controlled physical symptoms eg pain, nausea, breathlessness
they develop anxiety while waiting for the investigation results
- vulnerable personality - poor coping with stress
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- fear of being abandoned as the disease progresses Risk factors for anxiety
- lack of confiding relationships - harbouring underground fears about illness or its treatment and too
frightened to share with the staff
- other life events or difficulties not related to cancer
- seeks out more information than they can handle
- around time of initial diagnosis and while waiting for results for Denial
suspected relapse - unconscious refusal to acknowledge certain distressing aspects of reality
10
Suspect denial when Maladaptive denial
- looks for another physician in the hope of getting a "better explanation" - poor compliance
- asks for repeated investigations, partially knowing that the original - blocked communication with relatives
diagnosis is correct
- they may talk briefly about the reality of their situation before indicating
their inability to look at it realistically any longer (daydream, fantasies,
talking about brighter things which contradict what he said earlier)
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Anger Management of anger
- transient anger is a normal phase in the adjustment process - listen to patient, dont be defensive and dont make judgments
- some patients may obtain relief through the spontaneous free - offer consistent professional care although the patient is ungrateful
expression of anger before they move on towards acceptance
- facilitate a full blown expression of anger by a neutral counsellor
- family and nurses find it hard to cope because anger is displaced at all
directions and projected at random - responding to criticisms of other doctors and nurses
- anger can be more marked in the relatives - colluding with the blame on colleagues is unwise and unfair
- staff or family member should not react personally because it feeds into - encourage redirection of anger and re-chanelling the energy elsewhere
the patient's hostile behaviour eg exercise, music, creative activity and cancer-related charity work
- medication: psychotropics
Types of anger
- free floating: angry about the unfairness of the illness, blaming fate or Depression in cancer
God - usually associated with a great sense of loss
- displaced: towards healthcare staff - financial burden
- justified: delay in making diagnosis - loss of job due to frequent absences or inability to function
- suppressed: not co-operative and leads to depression - drugs: cytotoxics, steroids
Why anger?
- loss of control
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Clinical presentation Management of depression
- physical symptoms seem to be out of proportion to the stage of cancer - let patient express their feelings of sadness and anger
progression eg weight loss, anorexia, fatigue
- foster a 'fighting' spirit, but if patient is very depressed, it can
- insomnia especially morning awakening accentuate the sense of shame and failure
- suicidal thoughts
Acceptance
- a stage where the patient is neither depressed nor angry about his 'fate'
Types of depression
- almost void of feelings
- reactive depression
- as if the struggle is over
encouragements and reassurances
- patient prefers to be left alone
- preparatory grief
- not in a talkative mood
takes into account impending losses
- communications become more non-verbal than verbal
allow patient to express their sorrow
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Personality Disorders Social learning in childhood for antisocial behavior
Paranoid - from poor ability to sustain attention and other impediments to learning
Schizotypal
Antisocial Narcissistic
- Lack of concern for other's feelings, transient relationships, - Grandiose self-important, exploits others, requires excessive admiration,
irresponsible, impulsive and irritable, lack guilt and remorse, fail to learn envious and expects to be envied, lacks empathy
from adverse experience
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CLUSTER C: Anxious OTHERS
Avoidant Passive-aggressive
- feels socially inferior, preoccupied with possibility of rejection, avoids - Passive resistance when given demands for adequate performance
involvement with new experiences and people, avoid risk, avoid social
activity, restraint in intimate relationship from fear of being shamed or
ridiculed, inhibited in new personal situations due to feelings of Depressive
inadequacy
- Persistently gloomy, strong sense of duty, little capacity for enjoyment,
unsatisfied with their life
Dependent
Obsessive-compulsive Cycloid
- Preoccupied with details/rules, inhibited by perfectionism, over- - Extremes of depressive and hyperthymic personality disorders
conscientious, excessively concerned with productivity, rigid and
controlling, miserly, cannot discard worthless or worn-out objects
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Stress Disorders - symptoms
- defence mechanisms: denial, displacement, regression -reassurance that the condition is frequent and short-lived
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PTSD - hyperarousal by >2 of
- significant distress or impaired social functioning for >1 month - management: counselling, CBT, if patient prefers or if psychotherapy
unavailable then give SSRI or TCA and continue for a year if good
- re-experience by >1 of
response
flashbacks
dreams
trauma re-enactment
distress or reactivity to cues resembling an aspect of the event
thoughts
activities
inability to recall
reduced interest
'numbness'
restricted affect
sense of foreshortened future
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Childhood disorders - hyperactivity disorder: persistent of at least 6 months of > 6 symptoms
of
- attention-deficit disorder: persistent for at least 6 months of > 6 - some symptoms that caused impairment were present before 7 years
symptoms of old
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Autism
- more frequent in boys
- qualitative impairment in social interaction, impairment in - associated with congenital rubella, phenylketonuria, tuberous sclerosis
communication, restricted repetitive and stereotyped patterns of - may be due to immunological incompatibility with mother (maternal
behaviour/interests antibodies directed at fetus) or perinatal complications
- due to neuroanatomical or biochemical factors
- onset < 3 years of age of delays or abnormal functioning in > 1 area - management: target behaviours that will improve their abilities to
(social interaction, language used in social communication, symbolic or integrate into schools, develop meaningful peer relationships and
imaginative play) increase the likelihood of maintaining independent living as adults
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- onset of all of the following after the period of normal development: >2 of qualitative social impairment
deceleration of head growth between ages 5 and 48 months, markedly abnormal non-verbal communicative verbal gestures,
loss of previously acquired purposeful hand skills between ages 5 failure to develop peer relationships,
and 30 months with the subsequent development of stereotyped lack of social or emotional reciprocity,
hand movements, impaired ability to express pleasure in other person's happiness
loss of social engagement early in the course,
appearance of poorly coordinated gait or trunk movements,
severely impaired expressive and receptive language >1 of restricted interest and patterns of behaviour
development with severe psychomotor retardation
preoccupation with one or more stereotyped and restricted
patterns of interest abnormal in intensity/focus,
apparently inflexible adherence to specific non-functional
- symptomatic management: physiotherapy for muscular dysfunction,
routines or rituals,
anticonvulsants for seizures, behaviour therapy and medication for
control of self-injurious behaviours stereotyped and repetitive motor mannerisms,
persistent preoccupation with parts of objects
Asperger's syndrome
- no clinically significant delay in cognitive development or in the
development of age-appropriate self-help skills, adaptive behaviour and
curiosity about the environment in childhood
- impairment and oddity of social interaction and restricted interest and
behaviour - no language delay, cognitive delay or adaptive impairment
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Oppositional defiant disorder - management:
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- presence of >3 criteria in past 12 months with >6 months of at least one - mild: few if any conduct problems in excess of those required to make
criteria of the diagnosis and conduct problems cause only minor harm to others
aggression to people and animals - moderate: number of conduct problems and effect on others
intermediate between mild and severe
bullies/threatens/intimidates others,
initiates physical fights, - severe: many conduct problems in excess of those required to make the
used a weapon that can cause serious physical harm to others, diagnosis or conduct problems cause considerable harm to others
physically cruel to people/animals,
stolen while confronting a victim,
forced someone into sexual activity, - good prognosis is predicted for mild conduct disorder in the absence of
coexisting psychopathology and the presence of normal intellectual
destruction of property functioning
deliberately engaged in fire setting with the intention of causing - those with severe conduct disorder are most vulnerable to comorbid
serious damage, disorders later in life such as mood disorders and substance use disorders
deliberately destroyed others' property,
deceitfulness or theft
- management:
broken into someone else's house/building/car,
lies to obtain goods or favours or to avoid obligations, multimodal treatments using behavioural interventions where
stolen items of nontrivial value without confronting a victim, rewards are earned for prosocial and nonaggressive behaviours,
social skills training,
serious violations of rules family education and therapy
stays out at night despite parental prohibitions before age of 13,
run away from home overnight at least twice while living in
parental or parental surrogate home or once without returning
for a lengthy period,
truant from school before 13 years old
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Eating disorders Types
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erosion of dental enamel (especially of front teeth) with - admission to hospital is indicated if
corresponding decay
the patient's weight is dangerously low
there is severe depression and suicidal risk
outpatient care has failed
- the disorder may run a chronic course but recovery can occur even after
many years
- monitor the patient's physical state regularly and prescribe vitamin - non-purging: uses other inappropriate compensatory behaviours such as
supplements if indicated excessive exercise, but has not regularly engaged in self-induced vomiting
or the misuse of laxatives, diuretics or enemas
- eating as an inpatient should be supervised by a nurse who has to
reassure the patient that she can eat without the risk of losing control
over her weight, to be clear about agreed targets and to ensure that the
- usually of normal weight
patient does not induce vomiting or take purgatives
- most are female and often have normal menses
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- some may have a history of a previous episode of anorexia nervosa - antidepressant drugs such as SSRIs decrease the frequency of binge
eating and purging and improve mood
- there is an initial period of dietary restriction which, after a variable
length of time, breaks down with increasingly frequent episodes of - the patient is more likely to wish to recover and a good working
overeating relationship can often be established
- as the overeating becomes more frequent, the body weight returns to a there is no need for weight restoration
more normal level
- it is necessary to assess the patient's physical state and to measure
- episodes of bulimia may be precipitated by stress or the breaking of self- electrolyte status in those who are vomiting frequently or misusing
imposed dietary rules, or may occasionally be planned laxatives
- voracious eating at first brings relief from tension but relief is soon
followed by guilt and disgust
Binge eating disorder
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Substance abuse
Substance dependence: maladaptive pattern of substance use leading to
clinically significant impairment and developing within 12 months >3 of:
Abuse and dependence
tolerance: defined as need for markedly increased amounts to
achieve desired effect/ markedly diminished effect with
continued use of same amount
Substance abuse: maladaptive pattern of substance use leading to
withdrawal manifested as characteristic withrdwal of the
clinically significant impairment and developing within 12 months >1 of:
substance/ the same substance is taken to relieve or avoid
recurrent substance use resulting in a failure to fulfil major role withdrawal symptoms
obligations at work/ school/ home the substance is taken in larger amounts or over a longer period
recurrent substance use in situations in which it is physically than intended
hazardous persistent desire or unsuccessful efforts to cut down substance
recurrent substance-related legal problems use
continued substance use despite having persistent or recurrent great deal of time spent in activities necessary to obtain the
social or interpersonal problems caused or exacerbated by the substance or recover from its effects
effects of the substance important social, occupational or recreational activities given up
or reduced because of substance use
substance use continued despite knowledge of persistent physical
or psychological problem likely caused or exacerbated by the
substance
Withdrawal symptoms
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Alcohol stupor
Excessive consumption of alcohol: weekly intake of alcohol exceeding 21 Aetiology: genetic factors, abnormalities in alcohol dehydrogenase
units for men and 14 units for women leading to less sensitivity to acute intoxication effects, learning factors,
personality factors (risk taking, novelty seeking, chronic anxiety)
Have you ever felt you ought to Cut down on drinking? - >2 of
Have people Annoyed you by criticizing your drinking? automomic hyperactivity,
Have you ever felt Guilty about your drinking? hand tremors,
Have you ever had a drink first thing in the morning as an Eye- insomnia,
opener to steady your nerves or get rid of a hangover?
nausea,
>2 positive replies implies alcohol misuse
transient visual/ auditory/ tactile hallucination,
psychomotor agitation,
anxiety,
Alcohol intoxication:
grand mal seizures
- recent ingestion of alcohol
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Alcohol dependence: >3 for 12 months Biological dysfunction
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alcoholic hallucinosis: distressing auditory hallucinations which total abstinence vs controlled drinking
may be followed by persecutory delusions, happens when normal prevent major complications of withdrawal
blood alcohol levels drop, responds to antipsychotics group therapy, couple therapy, cognitive-behavioural therapy
cerebellar degeneration - severe limb ataxia + dysarthria + slurred
speech + nystagmus due to toxic effect on Purkinje cells of
cerebellar cortex Abstinence maintenance:
Marchiafava-Bignami syndrome: demyelination and necrosis of
middle 2/3 of corpus callosum disulfiram: blocks oxidation of alcohol causing acetaldehyde
depressive disorder accumulation, anticipation of unpleasant reaction deters from
impulsive drinking
pathological jealousy
sexual dysfunction acamprosate: stimulate inhibitory effect of GABA and decrease
excitatory effect of glutamate, to remain alcohol-free after
detoxification
naltrexone: reduce craving, short-term treatment
Delirium tremens
motivational interviewing
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Recreational drugs - (in pregnancy) low birth weight, small head circumference, early
gestational age, growth retardation
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Amphetamine withdrawal: Cannabis
- cessation of/ reduction in amphetamine use that has been heavy or
prolonged
Cannabis and similar substances:
- dysphoric mood and >2 of
- marijuana, grass, weed, pot, tea, Mary Jane, hemp, chasra, bhang, ganja,
fatigue dagga, sinsemilla
vivid unpleasant dreams
insomnia or hypersomnia - smoked
increased appetite
psychomotor retardation or agitation
Cannabis intoxication:
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- (long-term) cerebral atrophy, lowered threshold for seizure, - (life-threatening) non-haemorrhagic cerebral infarctions, seizures,
chromosomal damage, birth defect, impaired immune reactivity, myocardial infarctions, arrhythmias, respiratory depression
alteration in testosterone concentration, dysregulation of menstrual cycle
Cocaine intoxication:
Cocaine
- recent use of cocaine
Cocaine side-effects:
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Cocaine withdrawal: Hallucinogens
- cessation of cocaine use that has been heavy and prolonged
- lasts for 18h in mild to moderate use, 1 week in heavy use Hallucinogens and similar substances:
- dysphoric mood and within a few hours >2 of - LSD, mescaline, MDMA (ecstasy), morning glory, DMT
fatigue
vivid unpleasant dreams
insomnia or hypersomnia Hallucinogen use:
increased appetite - tablets, blotter acid
psychomotor retardation or agitation
- symptoms: increased deep tendon motor reflexes, increased muscle
tension, ataxia, increased respiration, increased blood pressure,
decreased appetite, salivation, synesthesia, visual hallucinations, intense
Cocaine-induced psychotic disorder symptoms:
transient emotions, increased suggestibility
- paranoid delusions, auditory hallucinations, formication, grossly
- lasts 8 to 12 hours
inappropriate sexual and generally bizarre behaviour
- treatment: diazaepam (20mg oral)
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Hallucinogen intoxication: Opioid
- recent use of a hallucinogen
- clinically significant maladaptive behavioural or psychological changes Opioid and similar substances:
- perceptual changes occurring in a state of full wakefulness and alertness - morphine, heroin, methadone, codeine, vicodin
- >2 of
blurring of vision
drowsiness or coma
slurred speech
impairment in attention or memory
34
Opioid withdrawal symptoms:
- >3 of
dysphoric mood
nausea or vomiting
muscles aches
lacrimation or rhinorrhea
pupillary dilation or piloerection or sweating
diarrhea
yawning
fever
insomnia
- onset within 8-12 hours after last dose, peak at 24-48 hours and
subsides over 10 days
Treatment
35
Schizophrenia, depression and bipolar mood disorder Types
Auditory hallucinations
Broadcasting of thoughts
Control delusions (control by an external force)
Delusional perception
36
Good prognostic indicators for schizophrenia Schizophreniform psychosis
Female >2 of
Late onset
Good premorbid level of functioning delusions
No family history hallucinations
Acute onset disorganized speech
Prominent positive symptoms disorganized or catatonic behaviour
Good social relationships negative symptoms
Duration of untreated psychosis is less than a year
37
Depression Types
- depressed mood/ loss of interest with >4 of - mild: worse in the evening, start at time of misfortune and ends when
fortune changes
change in appetite or significant weight loss
insomnia or hypersomnia - moderate: worse in the morning, neglected grooming
observed psychomotor agitation or retardation - severe: inattention to basic hygiene and nutrition, complete loss of
fatigue or loss of energy social/ occupational function
feelings of worthlessness or guilt
diminished ability to think or concentrate
recurrent thoughts of death or suicidal ideation Dysthymia
- present >2 weeks - chronic depressive state
38
Management - Duration of treatment
SSRI Anti-depressants may take 2-4 weeks for visible effects but must
TCA be taken continuously without stopping
Start with low dose but may have to increase dose for optimal
- Insomnia
response
SSRI sedative eg Fluvoxamine, sertraline Benzodiazepine is for short-term, will need to be stopped once
TCA amitriptyline, imipramine the anti-depressants begin to work
Sleep hygiene The anti-depressants must be taken for at least 6 months (in first
episode of depression)
- Add benzodiazepine There may be a relapse after which the duration of treatment will
If patient is anxious with no history of adverse effects with be longer
benzodiazepine, esp when using SSRI The medication needs to be tapered down gradually. Avoid
First 2 weeks of SSRI use can cause paradoxical anxiety abruptly stopping medication (to avoid SSRI discontinuation
syndrome)
- Indications for ECT
39
Depression in elderly Baseline investigations before starting therapy (FBC, RBS, lipid
profile, RP, LFT, ECG)
- Declining senses/cognitive deficit/sexual changes
- Medical cause: Distress due to illness/side effect of medication/
painful procedures/dependency
Indications for admission
- Social cause: Retirement, multiple bereavements, empty nest
syndrome, isolation/loneliness, physical/emotional abuse, Risk of harm to self
vagrancy Psychotic symptoms
Inability to care for self
Lack of impulse control
Suicide risk Danger to others
S Sex (male)/single/separated/divorced/widowed/schizophrenia
U Unemployment SAD PERSONS SCALE risk assessment
I Illicit drug use
Sex
C Chronic medical condition with poor symptom control Age
Depression
I Inheritance (Family history of suicide)/intend to die
Prior history
D Depression Ethanol abuse
A Attempted before/anxiety disorder/age >40 Rational thinking
Support system loss
L Life event Organized plan
No significant other
Sickness
Investigations
- 0-2 no real problem
TFT, VDRL, ESR
Urine screening for drugs esp amphetamine-type stimulants - 3-4 send home but check frequently
CT brain if focal neurological deficit present/suspected SOL - 5-6 consider hospitalization if assured that patient will return for review
EEG suspected seizure disorder
- 7-10 definitely hospitalization
40
Bipolar mood disorder excessive involvement in pleasurable activities with painful
consequences
Typical age of onset is 21 years
grandiosity
decreased need for sleep Treatment for mania
pressured speech sodium valproate,
flight of ideas olanzapine,
distractible chlorpromazine,
goal-oriented activity haloperidol,
excessive involvement in pleasurable activities with painful quetiapine,
consequences aripiprazole,
risperidone,
ECT
Hypomania
41
Maintenance Factors predicting a greater risk of future episodes
Severe insomnia - interval between episodes becomes progressively shorter with both age
Self neglect and the number of episodes
Memory impairment
Agitation
Panic attacks
Pessimism
Despair
Anhedonia,
Morbid guilt.
Declared intent
Preparation
Past history of Deliberate self-harm
Severe depression
Schizophrenia
Substance abuse,
The use of a potentially lethal method.
42
Suicide and Deliberate Self-harm Reasons for higher suicide rates in men
Risk factors for suicide Men may choose more lethal methods
Past and current suicidality (50% more likely) Risk factors for suicidal behaviours in women
Individual history: Medical history, family history, psychosocial Gender inequalities in some society/within the family.
history
Severe psychiatric illness following delivery e.g. postpartum
Personality strengths and weaknesses. depression and postpartum psychosis.
Reasons for higher suicidal behaviours in the elderly Characteristics of past attempts that increases future risk
Less physical resilient: suffering from physical illness. Presence of longstanding medical problems
More likely to have access to medication: overdose Psychiatric illness esp depression, alcohol abuse
Poverty and isolation: less likely to be rescued Social isolation / poor support
Generally demonstrate a greater determination to die as they Past attempt with adverse consequences e.g. disability
give few warning signs
high intent
Involve greater planning and use more lethal methods.
Use of highly lethal means
43
Risk of successful suicide in current suicidal ideation Psychiatric symptoms associated with suicide
the magnitude of suicidal thoughts is greater and persistent. Mood disorder esp depression
Detailed and specific suicide plan Psychotic disorder with command hallucinations
Impulsivity
Method: higher lethality method is associated with higher suicide Panic disorders
risk.
Personality disorders
Patients belief about the lethality of the method (high intent) Substance abuse and dependence
Low chance of rescue Anger
Steps taken to enact plan: hoarding pills, plan the time and Side effects of Rx e.g., akathisia
setting, ensuring isolation and low chance of discovery.
higher risk is associated with individuals who are also socially
Preparedness of death: making a will, writing letters to loved isolated, with maladaptive coping and experiencing significant
ones, suicide notes. loss (e.g. financial)
Optimism
Religiosity
High life satisfaction
44
Deliberate Self-Harm Management
Psychoeducation
Cognitive behavioural therapy
Predisposing factors
To die
To escape from unbearable anguish
To get relief
To change the behaviour of others
To escape from a situation
To show desperation to others
To get back at others/make them feel guilty
To get help
45
Anxiety disorders - Worry about the meaning or consequences of attacks
Fear is a response to a known, external, definite, or non-conflictual threat - With or without agoraphobia
- can be due to
Anxiety is a response to a threat that is unknown, internal, vague, or dysfunction of noradrenergic neurons of the locus ceruleus,
conflictual panic-inducing substances,
pathological involvement in the temporal lobes,
classic conditioning or from parental behaviour,
Panic disorder unsuccessful defences against anxiety-provoking impulses
palpitations, Agoraphobia
sweating,
trembling,
SOB, - anxiety about being alone in situations or places which are perceived as
chest pain, being difficult to get help if a subsequent panic attack occurs
air hunger,
dizzy,
derealization, - Marked and consistently manifests fear in or avoidance of >2 of
nausea,
numbness, crowds,
chills public places,
traveling alone
- Persistent concern of future attacks traveling away from home
46
- >2 anxiety symptoms present together in the feared situation on at least - >2 anxiety symptoms manifested at some time since the onset of the
1 occasion since the onset of the disorder and 1 of the symptoms are disorder together with >1 of
Specific phobia
- Presence of either fear of being the focus of attention or behaving in a
way that will be embarrassing or avoidance of being the focus of
attention/situations where there is fear of behaving in a way that will be
- Marked and persistent fear or avoidance of a specific object that is
embarrassing
excessive or unreasonable
47
- Recognition that the fear is excessive or unreasonable Generalized anxiety disorder
- Symptoms restricted to the feared situation or contemplation of the - Excessive anxiety and worry about a number of events or activities
feared situation (future oriented), occurring more days than not for at least 6 month
- due to persistence of childhood fears, conditioning, stimulation in the - Worry is difficult to control
anterior cingulate cortex/amygdala/hippocampus
- Worry is associated with >3 of
restlessness,
- management: exposure, benzodiazepines for short term relief easily fatigued,
difficulty concentrating,
irritability,
Obsessive-Compulsive disorder muscle tension,
sleep disturbance
48
Separation anxiety disorder
- >3 of
- management:
reduce stressors,
talk about their worries,
psychoeducation,
anxiolytic drugs for short-term if very severe anxiety
49
Pregnancy-related depression - Disinterest in the newborn / fearful of being left alone with the baby.
50
Cognitive disorders Precipitating factors
cholinergic deficiency,
dopamine (regulates acetylcholine),
Predisposing factors changes in BBB
age >65,
male,
cognitive impaired (dementia, depression), Diagnosis
function impairment (functional dependence, immobility), disturbance of consciousness with reduced ability to focus,
sensory impairment, sustain/shift attention,
decreased oral intake, change in cognition or development of perceptual disturbance,
substance use, development of disturbance over a short period of time (hours to
coexisting medical conditions days) and fluctuates
51
Types Non-pharmacological management
Delirium due to a general medical condition (evidence from avoid extremes of sensory input,
history, PE or laboratory findings) eg meningitis, head injury, relief of distress,
stroke, UTI, chest infection, PE, MI, arrhythmia, hepatic control agitation and prevent exhaustion,
encephalopathy, hyper/hypoglycemia in diabetes, epilepsy, psychosocial support
malignancy
delirium due to intoxication (symptoms developed during
substance intoxication, medication use is etiologically related to Pharmacological management
the disturbance, cognitive symptoms are in excess of intoxication
syndrome) eg insulin, digoxin, lithium, opiates, benzodiazepines ensure drug treatment for underlying physical problem is the
delirium due to substance withdrawal (symptoms developed minimum required
during or shortly after a withdrawal syndrome, cognitive antipsychotics for agitated patients with perceptual disturbances,
symptoms in excess of withdrawal syndrome), treatment of specific etiologies
delirium due to multiple etiology,
delirium not otherwise specified
Dementia
Investigations
- global impairment of intellect without impaired consciousness
Delirium Rating Scale evaluates temporal onset of symptoms,
fluctuation, perceptual disturbances and hallucinations, - cognitive functions affected include memory, orientation, perception
Confusion Assessment Method tool (requires acute onset and and attention, judgment, language and problem solving and abstract
fluctuating course with inattention and either disorganized thinking
thinking or altered level of consciousness)
- score of <23 out of 30 in MMSE is suggestive of cognitive impairment
Abbreviated Mental Test Score to establish cognitive deficits
present on admission and for a baseline score for assessing - interferes with social and occupational functioning
progress
- patients may have episodes of violence or abuse towards others and
self-harm in advanced dementia
52
Reversible causes of dementia Function
53
Vascular dementia - criteria for Alzheimers dementia
Memory impairment
At least one of: aphasia, apraxia, agnosia, disturbance in
- comprise 25% of all dementias executive functions
- large vessel disease: multi-infarct dementia, strategic infarct dementia Impairment in occupational or social functioning
Decline from previous level of functioning
- small vessel disease: lacunar state, Binswanger disease (subcortical Not occurring exclusively during the course of delirium
arteriosclerotic encephalopathy, may have small infarcts of white matter
with sparing of cortical regions) - risk factors
- effects occur in a stepwise progression (ie memory plateaus then Age >65
worsens after a further stroke) First degree relative with Alzheimers (increases risk of early
onset Alzheimers)
- linked to a history of multiple strokes or TIAs
Head trauma with loss of consciousness and vascular damage
- remains at a fixed MMSE (Brain injury may trigger the production of -amyloid.)
Menopause (Loss of estrogen which promotes neural growth)
Less intelligence and less formal education
Alzheimer's dementia (Less synaptic connections.)
Individuals with less physical and mental activity
- patients show deficits of visual-spatial skill, memory, and cognitive - antipsychotic drugs for severe non-cognitive features such as psychosis
and severe challenging behaviour which is a risk to the patient and others
capabilities e.g. problem solving, word finding and speech, navigation,
arithmetic, writing or reading. - MMSE drops by 3 points every year without treatment
- diagnosis is made by excluding treatable dementias - MMSE drops 1-2 points every year with treatment
54
Mild symptoms Frontotemporal dementia
Confusion and memory loss
Disorientation
Problems with routine tasks - umbrella term for uncommon disorders primarily affecting the frontal
and temporal lobes of the brain
Severe symptoms
- In depression the cognitive deficit (if present) is typically acute and
Loss of speech recent (while Alzheimer's disease is typically insidious)
Loss of appetite and weight loss
- The depressed patient will often communicate a sense of distress and
Loss of bladder and bowel control
agitation, and the depression will be associated with typical features e.g.
positive diurnal mood variation and early morning waking.
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Wernickes encephalopathy variant form often presents with an extended neuropsychiatric
prodrome with mood disturbance or other psychiatric symptomatology.
- variant CJD in young adults has been linked with exposure to beef
infected with the bovine spongiform encephalopathy agent. This new
56
Elderly Cognitive Assessment Questionnaire MMSE
- This is the most widely used instrument for assessing severity of the
dementia. However it can only assess the domains of cognitive deficit.
- A score of 7 or more is indicative of normal memory and a score of 4 and
The maximum score is 30. The lower the score, the more severely
below indicate probable dementia. This is useful for routine screening.
demented the patient is.
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Geriatric Depression Scale
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Clock drawing test Stage 1 Normal
Stage 2 Very mild
Memory problem reported but not evident in clinical
interview.
- This is used as a measure of constructional apraxia and may also reflect
Stage 3 Mild impairment in memory, concentration and
frontal and temporoparietal functioning
occupational performance
Stage 4 Moderate impairment in memory, knowledge retrieval
and complete tasks
Stage 5 Mod to severe impairment in recent and remote
memory, frequent disorientation to time and place,
impairments of ADL
Stage 6 Severe cognitive impairment with inability to tend to ADL
without assistance
Stage 7 Very severe impairment in cognition, language and
motor skills
Management of dementia
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Psychotropic treatment - provides the patient with skills to approach future problems
- helps to change how you think ('Cognitive') and what you do - indications
('Behaviour') anxiety and panic disorders,
- focuses on the 'here and now' problems and difficulties. depression and bipolar mood disorders,
phobias (including agoraphobia and social phobia),
- Instead of focusing on the causes of your distress or symptoms in the stress disorders,
past, it looks for ways to improve your state of mind now. bulimia,
- requires commitment and cooperation from the patient obsessive compulsive disorder,
psychosis
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Relaxation therapy Breathe in deeply.
Deep breathing Hold the tension for few seconds, noticing how it feels.
- increases oxygen intake Then let go while exhaling, notice the difference.
- reduces tension Now tense each part of your body one by one, starting with your
feet.
- Method:
Point your toes forward then up.
Lie on your back with your feet slightly apart.
Tense your calf muscles, then relax.
Breathe in slowly through your nose. Keep the tip of your tongue
gently touching the roof of your mouth. Move on to your thighs, then your stomach muscles.
Count to 5 as you inhale. Abdomen expands. Now arch your back slightly, then press it into the floor.
Hold the breath as you count to 5 again. Continue tensing individual muscle groups.
Exhale slowly with a whoosh of sound, count of 5. Make your hands into fists, then let go.
Pause a second or two, then repeat. Press your arms against the floor, then relax them.
Increase your counts from 5 to 10 when you are more relaxed. Shrug your shoulders, then release.
Tense the muscles in your face (wrinkle your brow, clench your
teeth, open your mouth wide).
Progressive muscle relaxation
When youve finished, lie quietly for a few minutes.
- Tensing and releasing groups of muscles one at a time to relax your
entire body. Your whole body should feel at rest.
- Method:
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ANTI-DEPRESSANT - side effects: headache, somnolence, dry mouth
TCA MAOI
RIMA
SSRI - reversible inhibitor of monoamine oxidase
- selective serotonin reuptake inhibitor - moclobemide
- fluoxetine, sertraline, paroxetine, citalopram, fluvoxamine - side effects: dry mouth, headache, insomnia
- indications: depression, panic disorder, social phobia, OCD
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Azapirone
ANXIOLYTICS HYPNOTIC
- Caution: effects of benzodiazepine can be potentiated by Others - Chloral hydrate, Clomethiazole edisylate
fluvoxamine/alcohol, in patients with COPD
- Antidote: Flumazenil
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ANTIPSYCHOTIC - Clozapine
- side effects
Anti-parkinsonian
Atypical (2nd gen)
- biperiden, procyclidine, benzhexol, orphenadrine, benztropine
- serotonin/dopamine antagonist
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Depot Prematurity and small- Avoid if possible - toxic syndrome
for-dates babies Continue if risk of toxic encephalopathy causing delirium
discontinuation in
cerebellar signs: Dysdiachokinesis, Ataxia, Nystagmus, Intentional
schizophrenic is highly
tremor, Slurred speech, Hypotonia
significant
treat with osmotic diuretics or haemodialysis
MOOD STABILIZER
Sodium valproate
Lamotrigine
Lithium - indication: bipolar depression
- indications: acute mania, bipolar relapse prevention, treatment- - side effects: maculopapular rash, headache, blurred vision
resistant depression
- becomes toxic in sodium-depleting states eg dehydration, vomiting, - side effects: somnolence, dizziness, fatigue, nystagmus
diarrhea, renal impairment
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Lithium 10% risk of Fetal echo at 16-20 weeks ECT
congenital if prescribed in first
abnormality trimester
Higher risk in later Avoid in pregnancy - electroconvulsive therapy
trimesters
- indications: severe depressive illness, catatonia, prolonged/ severe
Sodium Neural tube defects Avoid if possible in women manic episode
valproate 22% risk of impaired of childbearing age
cognition Folate 5mg/day 12 weeks - contraindications: space-occupying lesion in the brain, recent MI,
prior to conception arrhythmias, raised ICP, recent stroke,
Lamotrigine Increased risk of oral Slow reduction in dosage - side-effects: short-term retrograde amnesia, anterograde amnesia,
cleft over last month with transient post-ictal confusion, status epilepticus, headache
reinstatement after
delivery - The decision to initiate electroconvulsive therapy and the number of
treatment sessions on any patient in any psychiatric hospital shall be
made by a psychiatrist.
- indications: narcolepsy, ADHD, refractory depressive disorder (combine Careful attention to obstetric Elevation of patients right hip
with antidepressant), elderly depressed with concomitant medical illness and anaesthetic factors
66
- Provide strict cooperation between gynecologists, neonatologists, and
pediatricians in order to warrant optimal maternal antenatal cares and
promptly diagnose and manage eventual perinatal complications during
the first hours after delivery
Prescribing in pregnancy - Provide regular follow-up of children exposed in utero to either FGAS
and SGAs in order to diagnose and manage possible signs of
neurodevelopmental delay
- Antipsychotic therapy should be considered mandatory in pregnant
patients with psychotic features
Breastfeeding issues
- When a planned or unplanned pregnancy occurs during antipsychotic
treatment, privilege the choice to continue the previous therapy, if - All psychotropic medication passes into breast milk at 1% of maternal
known as effective Pregnancy is not the best period to experiment the serum level
effectiveness of drugs - Reduced fetal withdrawal symptoms if psychotropes taken antenatally
- In the case of occurrence of psychotic symptoms in drug-nave pregnant - Avoid drugs or breastfeeding if baby is vulnerable
patients, privilege the drug showing the highest number of reassuring
reports and the lowest reported number of fetal anomalies (eg, - Premature
chlorpromazine) - Renal/hepatic/cardiac/neurological impairment
- Provide strict gynecological surveillance (tritest, regular clinical follow- - Close monitoring of babys behaviour
up, and ultrasound monitoring) during therapy with both first-generation - Avoid sedating medications
antipsychotics (FGAs) and second-generation antipsychotics (SGAs)
- Time feeds to avoid peak levels
- Provide strict endocrinological surveillance (Hb1Ac, glycemia,
cholesterol and triglycerides serum levels, bodyweight gain) during
therapy with FGAs but, especially, with SGAs
- Take into consideration the possibility to taper both FGAs and SGAs
Symptoms of neonatal withdrawal
during the last trimester in order to reduce the risk of neonatal
extrapyramidal reactions and seizures Match this decision with the risk of - Irritability
a relapse of psychotic symptoms - Constant crying
67
- Tremor
- Poor feeding
68
EPS and NMS Dystonia
Tardive dyskinesia
- may be irreversible
69
Neuroleptic Malignant Syndrome
- life-threatening
- treatment
70
Malaysian Psychiatry Form 5:
Form 1:
Form 8:
Form 4: Order by Board of Visitors to detain
Recommendation by Medical officer/Registered Medical Valid for 6 months
Practitioner to detain patient
Valid for 24 hours
Form 9:
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Form 10:
Form 11: No minor patient below the age of twelve shall be subjected to
physical means of restraint or seclusion in psychiatric hospitals.
Information to court of discharge of patient under Section 55/73
The privacy and safety of a patient shall be observed at all times
during the restraint or seclusion procedures.
No physical or chemical means of restraint or seclusion shall be
Form 12:
applied to patients in any psychiatric nursing home or community
Order to transfer patient from Psychiatric Hospital to another mental health centre, except during an emergency and the
Psychiatric Hospital by Director General/Authorized Person patient shall then be transferred to psychiatric hospitals without
delay.
If the period of physical means of restraint of a patient exceeds
Patients Rights eight hours, a psychiatrist shall review the patient on the need for
further restraint.
No seclusion shall be carried out on a patient for more than eight
1. The reasons of his admission and detention and means of hours consecutively or for more than twelve hours intermittently
discharge, leave or transfer over a period of forty eight hours, without an independent review
2. Treatment, information, confidentiality, personal identity, privacy by a psychiatrist.
3. Adequate accommodation
4. Recreational activities
5. Practice gender identity Restraint area
6. Practice religious belief of their choice There shall be a designated restricted area with a dedicated
7. Communicate with persons outside observation bay manned by a qualified, trained and experienced
8. Receive visitors staff for the purpose of monitoring of patients.
9. Have access to a second psychiatric opinion
The area shall be adequately lit and ventilated.
10. Obtain legal representation and appeal to the Board of Visitors or
the Director General for discharge
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Physical restraint
Equipment that may be used as physical means of restraint
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Seclusion
Removal of physical means of restraint
Decision to remove the restraints shall be made by the psychiatric Indications for seclusion
nurse on-duty.
The medical officer or registered medical practitioner must be A patient in a psychiatric hospital may be kept in seclusion only if
informed of the termination of restraints. it is necessary for the protection, safety or well-being of the
patient or other persons with whom the patient would otherwise
be in contact.
Other less restrictive method of treatment to calm the patient
Chemical restraint
has not been successful.
74