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Study Notes in Psychiatry (2008) Dr.

Roger Ho

Table of Content Page
Ch. 1 Introduction 2

Ch.2 Signs & symptoms 2
Acute management
Study Notes in Ch. 3 Schizophrenia 3
Psychiatry Ch. 4 Delusional disorder 6

Ch. 5 Bipolar disorder 7
(For MBBS III to V)
Ch. 6 Depressive disorder 9

Ch. 7 Obsessive compulsive 10
disorder
Ch. 8 Anxiety, Panic, Phobia 11

Ch. 9 Post traumatic stress 12
Dr. Roger Ho disorder, Acute stress, grief
MBBS (HK), DPM( Ireland), MMed (Psych) Ch. 10 Alcoholism 13

Assistant Professor Ch. 11 Drug Dependence 14
Department of Psychological
Medicine, NUS Ch. 12 Old age psychiatry 15

Email: pcmrhcm@nus.edu.sg Ch. 13 Consultation Liaison 16
Psychiatry
Version: May 2008 Ch. 14 Perinatal Psychiatry 18

Ch. 15 Eating disorder and 19
impulse control disorders
Ch. 16 Suicide and DSH 21

Ch. 17 Personality Disorder 22

Ch. 18 Psychiatric 23
emergencies
Ch. 19 Sleep disorders 24

Ch. 20 Child Psychiatry 25

Ch. 21 Learning disability 28

Ch. 22 Legal aspect 29

Ch. 23 Psychotherapy 30

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Chapter 1 Introduction completing it, starts movement, even
The purpose of writing this set of notes is to the opposite after the stimulus is
provide a concise summary of psychiatry and to movement withdrawn
help medical students to have rapid review for
Neologisms Metonyms
examination.
The patient uses Use of ordinary
Ch. 2 Definitions of signs and symptoms words or phrases words in unusual
The MCQ exam often confuses you with the invented by himself ways
following terms (Levi, 1998): Obsessions Delusions
Recurrent, persistent A false belief with
Echolalia Echopraxia thoughts, impulses, the following
Repetition by the Imitation by the images that the characteristics firmly
patient of the patient of the patient regards as held despite
interviewer’s words interviewer’s absurd and alien evidence to the
or phrases movements. while recognising as contrary; out of
Stereotypy Mannerism the product of his keeping with the
Regular, repetitive Abnormal, repetitive own mind. Attempts person’s education &
non goal-directed goal-directed are made to resist cultural background,
movement movement (of some or ignore them content often bizarre
(purposeless) functional Verbigeration Vorbeireden
significance) (word salad) (talking past point)
Waxy flexibility Mitmachen Disruption of both The patient seems
Patient’s limb can be Patient’s body can the connection always about to get
placed in an be placed in any between topics and near to the matter in
awkward posture posture; when finer grammatical hand but never
and remain fixed in relaxed, patient structure of speech quite reaches it.
position for long time returns to resting Occurs in SZ Occurs in SZ
despite asking to position Loosening of Flight of ideas
relax; occurs in associations
Schizophrenia (SZ) Loss of the normal Patient’s thoughts
Catalepsy Cataplexy structure of and conservations
Motor symptom of Symptom of thinking. Muddled move quickly from
schizophrenia, same narcolepsy in which and illogical one topic to another,
as waxy flexibility there is sudden loss conservation that the links between
of muscle tone cannot be clarified these rapidly
leading to collapse, Occurs in SZ changing topics are
occurs in emotional understandable
state. Associated with
Automatic Gegenhalten rhyming, punning &
obedience (opposition) clang associations.
Patient does The patient will Depersonalisation Derealisation
whatever the oppose attempts at A change in self A change in self
interviewer asks of passive movement awareness such that awareness such that
him irrespective of with a force equal to person feels unreal the environment
the consequences that being applied. feels unreal
Mitgehen Negativism Bipolar I Bipolar II
An extreme form of Extreme form of Mania Hypomania
mitmachen in which gegenhalten, Affect Mood
patient will move in motiveless Emotional state at a Emotional state over
any direction with resistance to moment a longer period
very slight pressure suggestion/ attempts Euphoria Euthymia
at movement. Sustained and A normal mood state
Ambitendence Preservation unwarranted Neither depressed or
The patient beings to The senseless cheerfulness mania
make a movement repetition of a
but before previously requested

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Chapter 3 Schizophrenia 3) α1 – adrenergic overactivity.
4) Glutaminergic hypoactivity: ketamine,
3.1 Types of schizophrenia NMDA antagonist, induce SZ symptoms
- Paranoid schizophrenia: prominent well – 5) GABA hypoactivity which leas to
systematised persecutory delusions or overactivity of dopamine, serotonin,
hallucinations. More common with noradrenaline.
increasing age.
Environmental factors:
- Catatonic schizophrenia: WRENCHES - Complications of pregnancy, delivery.
W – Waxy flexibility; catalepsy - Maternal influenza in pregnancy, winter
R – Rigidity births
E – Echopraxia, echopraxia - Non – localising soft signs in childhood:
N – Negativism astereognosis, dysgraphaesthesia, gait
C – Catalepsy abnormalities, clumsiness.
H – High level of motor activity - Disturbed childhood behaviour
E – Echolalia - Degree of urbanisation at birth
S - Stupor
Other features: automatic obedience, 3.4 Pathogenesis (Appendix 3a/3b)
stereotypy; ambitendence, mannerism; 1) Neurodevelopmental hypothesis
mitmachem; mitgehen. 2) Thickening of corpus callosum
3) Ventricular enlargement
3.2 Epidemiology
Median age of onset: 3.5 Clinical features (appendix 3c)
Male Female - First rank symptoms/ Positive
23 years 26 years - Negative symptoms
(earlier onset) (later onset) - Neologisms, Metonyms

Sex: equally between men & women 3.6 Diagnosis (DSM – IV)
Social class: increased prevalence in lower - At least 2 of the following for at least 1
social class month: (ABCD + PLANT V)
Season of birth: increased incidence in - Social / occupational dysfunction
winter months - Post – schizophrenic depression is
Prevalence rate: 1% of general population common
Incidence: 15/100 000
3.7 Differential diagnosis:
3.3 Aetiology Young adults Older patients
- Genetics: Heritability: 60-80% - Drug induced - Acute organic
- Family studies show the prevalence rates psychosis syndrome:
of schizophrenia in relatives as follows: - Temporal lobe encephalitis
Relationship to SZ Prevalence rate epilepsy - Dementia
Parent of a SZ 5% - Diffuse brain
Sibling of a SZ/ DZ Twin 10% disease
Child of one SZ parents 14% Other DDX: psychotic depression, paranoid
Child of two SZ parents 45% personality disorder
Monozygotic twins of SZ 45%
3.8 PE and Investigation
Biochemical theories: - Full neurological examination: gait and
1)) Dopamine over-activity: high level of motor
dopamine within mesolimbic cortical - Cognitive examination: MMSE
bundle. (eg amphetamine increase - Blood: FBC, LFT, RFT, TFT, glucose.
dopamine release; Haloperidol reduces its - CT or MRI brain
release). - Urine drug screen
2) Serotonergic overactivity: LSD, inc - EEG if suspects of TLE
5HT, leads to hallucination, clozapine has
serotonergic antagonism.

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Management: idiosyncratic effects
3.9 Conventional antipsychotics - High incidence of EPSE
Typical antipsychotics:
-Chlorpromazine: more antiadrenergic & 3.10 Atypical antipsychotics
antihistaminergic (100 – 400mg daily) Risperidone: 1-2mg ON ($1/mg)
- Haloperidol: more EPSE (5 – 10mg daily) Higher affinity of D2 in mesolimibic and less
- Trifluperazine: more EPSE: 5 – 10mg in nitrostriatal; higher affinity for 5HT2 and
daily α1 receptors.
Block mesolimbic Antipsychotic action
cortical bundle Side effects:
Blk Nigrostriatal Extrapyramidal - EPSE (if high dose like 4mg daily)
effects - Elevation of prolactin (strongest
Blk Tubero- Galactorrhoea among atypicals)
infundibular activity - Antiadrenergic side effects

Side effects of typical antipsychotics: Other preparations of risperidone:
PO Risperdal quicklet: quickly dissolve in
1) Extrapyramidal side effects (EPSE): mouth
-Acute dystonia: treated by IM PO Risperdal solution: 1mg/ml $70/ bottle.
antimuscarinic (congentin 2mg) IM Risperdal consta – only atypical depots
- Akathisia: restlessness: treated by Start with IM 25mg, increase to 37.5mg
propanolol 10mg TDS every 2 weeks
- Pseudoparkinsonism: oral antimuscarinic:
benhexol 2mg BD Olanzapine: 5- 10mg ON ($1/mg)
- Tardive dyskinesia Moderate for D2; High affinity for 5HT2 and
2) Hyperprolactinaemia muscarinic receptors
3) Antiadrenergic: sedation, postural
hypotension, failure of ejaculation Side effects:
4) Anticholinergic: dry mouth, urinary - Weight gain and increase appetite
retention, constipation - Sedation
5) Antihistaminergic: sedation - Antiadrenergic side effects
6) Antiserotonergic: depression - Prolongation of QT interval on ECG
- Hyperprolactinemia (transient)
More on Tardive dyskinesia (TD)
- After chronic use of antipsychotic Quetiapine: 100 – 800mg daily ($2/100mg)
- Due to upregulation of postsynaptic Weak for D2, High affinity for 5HT2 and α1
Dopamine receptors in Basal Ganglia
- More common in female Side effects:
- History of chronic brain disease: risk factor - Antiadrenergic side effects like
-slow writhing movement (athetosis) postural hypotension
-Sudden involuntary movements - Prolong QT interval
- Oral lingual region (chorea) - Almost no EPSE (same as placebo)
- Temporary raise the dose may give - No ↑ in prolactin (same as placebo)
immediate relief; try to maintain minimum
effective dose in long run Sulpiride 200mg – 400mg ON (IMH)
- Change to atypical antipsychotics - Low dose: block D3 and D4: negative
- Vitamin E may prevent deterioration symptoms
- Anticholinergic will worsen TD. - High dose: block D2 and D1: positive
symptoms
Conventional depot antipsychotics - Fewer EPSE, less sedation, cause
IM Flupentixol 20 – 40mg 4 weekly galactorrhoea.
(Fluanxol) Other Modecate, Clopixol
- Long acting depot injection for non Clozapine: more active at D4, 5HT2, α1 &
compliant patients. muscarinic receptors
- To give a test dose to ensure no

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- for treatment resistant SZ.(failure of 2 Causes of relapse:
antipsychotics with adequate dose) 1) Iatrogenic relapse: reduction of dose by
doctor
Side effects include: 2) Non compliance
- Life threatening agranulocytosis 2-3%; 3) High expressed emotion
needs regular FBC under clozaril
patient monitoring programme (IMH) 3.14 Complications of SZ
- Hypersalivation - Water intoxication in chronic
- Anticholinergic and antiadrenergic. schizophrenia, leading to hypanatraemia.
- Fewer EPSE
- Suicide is the most common cause of
3.11 Psychological treatment: death of SZ, 10-38% of all deaths of SZ.
-Psychoeducation can prevent relapse by
enhancing insight - SZ and violence: controversial: senior
-Cognitive Behavioural therapy (CBT) to psychiatrists say no but recent findings
challenge delusions. support the association. In exam, safer to
-Social skill training: improve relationship say no association.
- Behavioural: positive reinforcement of
desirable behaviour. Schizoaffective disorder

Family therapy: to reduce expressed It is a disorder in which the symptoms of
emotion (EE). (High EE include hostility, schizophrenia and affective disorder are
over-involvement, critical comments from present in approximately in equal proportion.
family; hence reduce relapse rate) ICD 10 requires both psychotic and mood
episode are simultaneously present and
3.12 Other treatments: equal prominent.
- Rehabilitation (IMH) to enhance
self care, compliance and insight. Treatment:
Antipsychotics + antidepressant or mood
- ECT is for catatonic schizophrenia stabilizer.
Indications for Hospital admission: Schizotypal personality disorder
• Suicide / violent
• Severe psychosis - There is familial relationship between
• Severe depression schizotypal personality disorder &
• Catatonic schizophrenia schizophrenia
• Non – compliance
• Failure of outpatient treatment Clinical features: UFO RIDE

3.13 Prognosis U – unusual perception: eg telepathy
Rules of quarters F – Friendless
25% 25% 25% 25% O – Odd belief and odd speech
Complete Good Partial Downhill
Remission recovery recovery course R – Reluctant to engage
I – Idea of reference
Good prognosis: D – Doubtful of others
- Marked mood disturbance E – Eccentric behaviour
- Family history of affective disorder
- Female sex - Poor prognosis: 50% develop
- Living in a developing country schizophrenia
- Acute onset
- Good premorbid adjustment Schizoid personality disorder –
introspective’ prone to engaged in an inner
Poor prognosis: adolescence or early world of fantasy rather than take action; lack
onset, enlarged ventricles. of emotional warmth and rapport; self
sufficient and detached; aloof and

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Study Notes in Psychiatry (2008) Dr. Roger Ho

humourless; incapable of expressing - Delusions are highly implausible,
tenderness or affection; shy; often eccentric; - with evidence of systematization (better
insensitive; ill – at – ease in company organized than SZ delusion);
Ch.4 Delusional Disorder (Oxford - huge impact on behaviour,
Handbook, 2004) - abnormal process in arriving conclusion
4.1 Types of delusional disorder (DSM IV) 4.6 Diagnosis: DSM IV requires > 1 month
- Erotomanic (de Clerambault syndrome): duration
Important person like PM is secretly in love
with them; usually female; make effort to 4.7 Differential diagnosis
contact important person. Young patients Old patients
- Morbid jealousy (Othello syndrome): - Substance induced - Dementia- memory
fixed belief that their spouse has been (stimulant, loss
unfaithful; collect evidence for sexual activity hallucinogen)
& restrict partner’s activity; may result in - Mood disorder with - Delirium: change in
violence. delusion (mood consciousness
before delusion)
- Persecutory: Most common type; others - Schizophrenia (less - Late onset
are attempt to harm; to obtain legal recourse elaborated delusion) psychosis (with
- Grandiose: special role, relationship, - OCD: reality testing hallucination)
ability, involved in religion. is intact
- Paranoid
- Somatic: delusion belief about body personality disorder
(abnormal genitalia) to infestation: (worms (Less clearly
crawling in the body) circumscribed
- Folie a deux – shared delusion between delusion)
husband and wife (close relationship)
4.8 Assessment
Delusional misidentification syndrome: - A thorough history and MSE
Capgras delusion Fregoli delusion
- Collateral history from 3rd party
Other have been Someone they know
- To rule out organic causes
identified by identical in disguise and
- Document risk assessment
or near identical harming him
imposter
4.9 Management
- Admission to hospital if there is a risk to
4.2 Epidemiology self or violence to others.
- Uncommon: 0.025 – 0.03% - Separation from source or focus of
- Mean age: 40 – 49 years delusion
- Usually equal in M and F; Morbid jealousy - Antipsychotics: atypical: less side effect
more common in alcoholic male; Erotomania - Both risperidone and Haloperidol have
more common in female liquid form: for those refusing tablets
- Benzodiazepine to treat anxiety
4.3 Risk factors and aaetiology
- advanced age, isolation, low social status, Psychological treatment
premorbid personality disorder, sensory - Supportive psychotherapy: to establish
impairment, substance abuse, family history, therapeutic alliance without confronting
history of Head Injury, Immigration - Cognitive techniques: gently challenge
delusion
- Temporal lobe epilepsy, - Social skill training
- Improving risk factors: sensory deficits,
4.4 Pathogenesis: isolation
- Cortical damage: paranoid delusion
- Basal ganglia – less cognitive disturbance 4. 10 Prognosis
- Folie a deux: one dominant and one Remission Improvement Persisting
submissive partner in a relationship 33-50% 10% 33-50%
4.5 Clinical features:

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- Better prognosis if it is acute;
- Poor prognosis if delusional disorder DSM IV diagnosis
last longer than 6 months. - Bipolar I disorder: occurrence of 1 or
more manic episode with or without history
Ch. 5 Bipolar disorder of 1 or more depressive episode.
- Bipolar II disorder – occurrence of 1 or
5.1 The affective spectrum more depressive episode accompanied by
- Dysthymia – not meeting criteria of at least 1 hypomanic episode.
depression
- Depression 5.7 DDX:
- Atypical depression: hypersomnia, - Substance abuse (if young)
hyperphagia - Organic: thyroid, cushing, SLE, head injury
- Psychotic depression - Psychotic disorders (if psychotic features)
- Recurrent depression - Schizoaffective disorder (prominent
- Bipolar II – Hypomania psychosis)
- Bipolar I – Mania - Anxiety disorders
- Rapid cycling > 4 episodes per year
- Ultra – rapid cycling: very rapid changes 5.8 Investigation
- FBC, ESR
5.2 Epidemiology - LFT, RFT, TFT, glucose
- Lifetime prevalence: 0.3 – 1.5% - VDRL
- M = F in prevalence - Urine drug screen
- Bipolar II / rapid cycling: more common in - CT/MRI to rule out space occupying lesion,
Female infarction, haemorrhage
- Mean age of onset: 21 years old - EEG to rule out epilepsy

5.3 Aetiology Other tests:
- Genetics: 1st degree relative are 7x more - ANF to rule out SLE in ladies
likely to develop this condition. - Urinary copper to rule out Wilson disease
- Children of a parent with bipolar disorder
have a 50% chance of developing 5.9 Setting of Treatment:
psychiatric disorder
- MZ:DZ 45%: 23% Usually require admission for manic
episode; ward has to be calm with less
5.4 Pathogenesis stimulation.
- Noradrenaline, dopamine, serotonin, &
glutamine have all been implicated. Indications for admission include:
- Antidepressant induced mania or - High risk of suicide or homicide
hypomania is common. - Lack of capacity to cooperate with
treatment
5.5 Clinical features - Poor psychosocial supports
Hypomanic episode: MANIAC (Clinical skill - Severe psychotic symptoms
training) - Severe depressive symptoms
- Rapid cycling
For mania, on top of MANIAC, they also - Failure of outpatient treatment
have:
- severe enough to interfere social & Goals of outpatient treatment
occupation function. - Establish & maintain therapeutic alliance
- Psychotic features related to grandiosity. - monitor psychiatric status
- Flight of idea, Pressure of speech - Psychoeducation for bipolar disorder
- Racing thought - Enhancing treatment adherence
- Behaviours with serious consequences: - Monitoring side effects of medication
reckless spending, inappropriate sexual - Promoting regular sleep and activity
encounters, careless investment. - Identify new episodes early

5.6 Diagnosis

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- For rapid cycling disorder

5.9 Pharmacological Management Adverse effects:
- Slight risk of liver, pancreatic toxicity
Acute treatment of manic phase : - Haematological disturbance of platelet
By antipsychotics: function; Neural tube defect in foetus

Haloperidol 5-10mg daily; Carbamazepine 400– 800mg ($0.2-0.4)
Risperidone 2- 4mg daily Check FBC before starting carbamazepine
Olanzapine (more sedative & good for mood Mode of action:
symptoms but expensive): 5- 10mg daily - Mediate its therapeutic effect by inhibiting
Then add on mood stabilizer after blood kindling phenomena in the limbic system
investigations.
Indications:
Lithium CR (500mg – 1000mg $0.3-0.6) - Depression
Before starting lithium, RFT & TFT have to - Prophylaxis of bipolar affective disorder
be normal.
Adverse effect:
Mechanism of action : - Drowsiness and dizziness
- By stimulating Na/K pump, stimulates - Leucopenia and other blood disorders
entry of Na into the cells where intracellular
Na is reduced in manic state; stimulates exit Lamotrigine 50 – 150mg 100mg = $3
of Na from cells where intracellular Na is For bipolar disorder with depressive
elevated in depressed state. episodes
- Inhibits both cyclic AMP and inositol
phosphate second messenger system in 5.10 Psychological Management
the membrane. - Cognitive therapy to challenge grandiose
thought
Indications: - Behavioural therapy to maintain regular
- For depression, manic states pattern of daily activities
- Prophylaxis of bipolar disorder - Psychoeducation on bipolar disorder
- not useful for rapid cycling - Family therapy: Psychoeducation for family
& techniques to cope with patient’s illness
Adverse effects: - Relapse drills: to identify symptoms and
- Short term side effects: GI disturbances to formulate a plan to seek help in early
(nausea, vomiting, diarrhea) manic phase.
- Long term side effects: nephrogenic - Support group for bipolar patients.
diabetes insipidus due to blockage of ADH
sensitive adenyl cyclase, hypothyroidism 5.11 Other treatment
and cardiotoxicity - ECT: Best for acute mania, failure to drug
- Toxic effects (refer to appendix 5a): treatment, for pregnancy (to avoid
Lithium overdosage can be fatal. teratogenic effects)
- Ebstein anomaly in foetus.
5.12 Course and Prognosis:
Sodium valporate (Epilim) (400mg – -Extremely variable
1000mg) ($0.5 – 1) -First episode may be hypomanic, manic,
Before starting Valporate, check LFT mixed, or depressive
- Length of time between subsequent
Mechanisms episodes may begin to narrow but stabilize
- mediate its therapeutic effect by indirect at 4th to 5th decade.
inhibitions on GABAergic systems. - Untreated patients have > 10 episodes in a
lifetime.
Indications: - Treated patients have better prognosis
- Treatment of depressive and manic
episodes 5.13 Complication:
- Prophylaxis of bipolar affective disorder

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- Morbidity and Mortality rates are high: lost
work, lost productivity, divorce, attempted 6.6 Pharmacological Management:
suicide 25-50% & committed suicide: 10% Selective serotonin reuptake inhibitors SSRI
Ch. 6 Depressive Disorder -Fluoxetine (Prozac) 20mg OM ($0.2) for
retarded depression; adverse effect:
Restlessness; Long half life, avoid in elderly with
6.1 Epidemiology
a lot of medication; (first line nowadays)
Age: Women, highest prevalence between 35
and 45 years; Men increases with age
- Fluvoxamine (Faverin) 50mg -100mg ON; $0.5
Sex: F:M = 2:1
Sedative; high incidence of nausea & vomiting in
Social class: more common in I (rich), II and V
first few days.
(poor)
More common among divorced, separated
- Paroxetine CR (Seroxat) 25mg ON, $2: good
Prevalence: 5%
for mixed anxiety & depression; more withdrawal
symptoms
6.2 Aetiology:
- Genetics: Prevalence in first rate relatives: 10-
- Escitalopram (lexapro) 10mg ON, $1.5; less
15%
drug interaction, good for elderly
- Monoamine theory of depression: depletion
- Setraline (Zoloft) 50 – 150mg ON; $1.8
of monoamine such as 5HT & NA
-Noradrenergic and specific serotonergic
- Endocrine abnormalities: hypersecretion of
antidepressants (NaSSas): Mirtazepine
cortisol, decreased TSH
(Remeron) 15-30 mg ON ($1-2); 5HT-2 and 5HT-
3 postsynaptic receptor antagonist & anti-
Psychological theory:
histamine effects.
- Maternal deprivation when young
- Learned helplessness: highly aversive
- good for depression and insomnia
outcomes are possible.- Cognitive distortions:
- drowsiness and weight gain
1) Arbitrary inference: drawing conclusion when
- No serotonin related side effects: sexual
there is no evidence.
dysfunction, insomnia, agitation, nausea
2) Selective abstraction – ignore important
- No cardiovascular or anticholinergic side effects
feature
3) Over-generalisation from single incident
- Serotonin & Noradrenaline reuptake
4) Minimisation positive and magnitification of
inhibitor: Venalfaxine (Efexor) 75 mg BD $5.6;
negative
second line, high dose  hypertension
Social theory: for women, (Brown & Harris) Duloxetine(Cymbalta) 60mg ON for pain &
-3 or more children under 15 yr of age depression
-not working outside
-lack of supportive relationship from hd. - TCA: amitriptyline 50 – 100mg ON,
-loss of mother/separation before age 11 cardiotoxicity when overdose, anticholinergic side
-Threatening life event before depression effects; MAOI: seldom used

6.3 Clinical features: - ECT: for actively suicidal patients, not eating &
- DEPESSION – refer to clinical skills drinking, treatment resistant depression
-Severe depression may have psychotic features: -ECT has wide range effects on monoamine
-Delusions concerned with themes of -Absolute contraindication: raised ICP
worthlessness, guilt, ill-health, poverty -Relative contraindications: cerebral aneurysm,
-Persecutory delusion: people are about to take recent MI, cerebral haemorrhage, retinal
revenge on him detachment.
- Hallucination: second person auditory
hallucination: repetitive words & phrases -Early side effects: loss of short term
(retrograde) memory, headache, confusion,
6.4 DDX: muscle aches
- Is it mixed anxiety & depression?
- Is it bipolar disorder? -Late side effect: long term memory loss
- Endocrine: hypothyroidism Mortality of ECT: 2/100, 000
- Medication related: antihypertensive, steroid
- Alcohol abuse 6.7 Psychological Treatment

6.5 Investigations: FBC, ESR, B12, Folate, CBT: Cognitive: Identify cognitive dysfunctions
RFT, LFT, TFT from dysfunctional thought diary; patient will

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Study Notes in Psychiatry (2008) Dr. Roger Ho

examine evidence for and against them; cognitive - Anxiety disorders
restructuring to change distorted thought; - Phobic anxiety disorders
Behavioural: increase pleasurable activities. - Psychotic disorders
Ch. 7 Obsessive Compulsive Disorder - Organic disorders
- Depressive disorders
7.1 Epidemiology
- Onset is most commonly in early adult life 7.5 Pharmacological treatment
- Equally common among men and women
- SSRIs are indicated in the treatment
- Prevalence 0.05%
of OCD. OCD require higher doses
of SSRIs compared to depression.
7.2 Aetiology
- Fluvoxamine (Faverin) 150mg –
- Genetic: MZ: DZ 80%: 25%
200mg
- Organic factor: during epidemic of
- Fluoxetine (Prozac) 40mg – 60mg
encephalitis lethargica
- Paroxetine CR (Seroxat) 25mg –
- Premorbid personality: 70% of OCD
75mg: for very anxious patients.
patients have obsessive compulsive
personality trait- cleanliness, orderliness,
7.6 Psychological treatment
rigid, checking
Cognitive therapy: to use dysfunctional
thought diary to record obsessions and
7.3 Pathogenesis
gently challenge obsessional thought.
- Dysregulation of the 5HT system
- Cell immediated autoimmune factors
Behavioural therapy: Exposure and
- CT/ MRI: bilateral reduction in caudate
response prevention. This technique
nucleus.
involves exposing patient to situations they
- Psychological explanation: OCD patients
avoid such as dirty places and the patient is
have defective arousal system and inability
subsequently prevented from carrying out
to control unpleasant internal states.
the usual compulsive cleansing rituals until
Obsessions (fear of dirt) are stimuli
the urge to do it has passed (response
associated with anxiety provoking events
prevention)
where compulsions (such as hand washing)
are learned to reduce anxiety.
Thought stopping: The patient is asked to
ruminate and upon doing so, the therapist
7.3 Clinical features
shouts “stop” to teach the patient to interrupt
OBSESSION – DIRT
the obsessional thought. The patient then
Doubts: repeating themes expressing
learns to internalize the “stop” order so that
uncertainty about previous actions: turned
thought stopping can be used outside
off the tap or not
therapy situation.
Impulses – Repeated urges to carry out
actions that are usually embarrassing or
Rehabilitation
undesirable e.g shout obscenities in church
- to maintain functional capacity;
Ruminations – repeated worrying themes
- Maintain their strengths
of more complex thought – the end of the
- Promote adaptation to everyday
world.
living.
Thought – repeated and intrusive words or
phrases
7.7 Social treatment
Obsessional patients often involve other
Compulsions – Cs (refer to clinical skills
family members in their rituals. In planning
training)
treatment, it is essential to interview
A compulsion is usually associated with an
relatives and encourage them to adopt a
obsession as if it has the function of
firm but sympathetic attitude to the patient.
reducing the distress caused by obsession.
E.g obsessional thought with hand
7.8 Prognosis
contamination, associated with handwashing
- Poor prognosis: Giving in to compulsions,
compulsion.
longer duration, early onset, bizarre
obsession & compulsion, comorbid delusion
7.4 DDX:
and depression

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- Good prognosis: good premorbid,function 2 peaks in women: 15-24 yr; 45-54 yr
a precipitating event.
OCD does not associate with suicide.
Ch. 8 Anxiety Disorders (Ox handbook) Aetiology:
- Genetics: 30-40% heritability
8.1 Generalised Anxiety Disorders -Supersensitivity of 5HT1A receptors
Epidemiology: - Increased adrenergic activity
-Lifetime prevalence: 2.5-6.4% - Decreased in GABA – inhibitory
-Female> Male - Fear network in brain: amygdala
- Early onset: with childhood fears
- Late onset: stressful life events Clinical features
-Palpitations, SOB, choking, shaking
Aetiology: - Autonomic arousal
- Genetics: Heritability: 30% - Fear of losing control
- Increase ANS responsiveness -Concerns of death from cardiac &
- Loss of control of cortisol respiratory problems
- ↓ GABA activity
- dysregulation of 5HT activity DDX/Investigations: similar to GAD
- Unexpected negative events eg early
death of parent Psychological Management:
- Chronic stressors Behavioural: use of relaxation & control of
hyperventilation
Clinical features (at least 4) Cognitive method: teaching about bodily
-Autonomic arousal: sweating, shaking responses associated with panic attack
-Physical: breathing difficulty, choking,
nausea, swallowing difficulty Pharmacological:
-Mental: dizzy, fainting, derealisation, -SSRI: paroxetine, fluoxetine, fluvoxamine
depersonalization are recommended drug of choice
-General: numbness, tingling - BZDs: alprazolam 0.5mg for acute attack
-Tension: muscle,ache, keyed up
-Other: mind going blank, poor concentration Hyperventilation Syndrome (HVS):
- Very common; more common in Female
DDX: - 50-60% of patients with panic disorder
- normal worries have HVS
- mixed anxiety and depression - Hyperventilation;chest pain;dizziness;
- Alcohol & drug abuse bloating; acute hypocalcaemia
- Organic: Thyroid disorder, Arrhythmia, - Treatment: establish normal breathing
Asthma, Temporal lobe epilepsy, pattern, benzodiazepine; breathing into
hypoglycemia. paper bag is not recommended nowadays
as CO2 can trigger more anxiety.
Investigation: FBC, LFT, RFT, TFT,
glucose, ECG Agoraphobia: (housebound housewife)
Management: 15-35 yr old; more common in women
-Psychological: relaxation therapy. Fear of shops, markets, bus, MRT, crowd,
-Pharmacological: short term place that cannot be left suddenly
benzodiazepine, SSRI (avoid fluoxetine),
propranolol for palpitation Social phobia
17-30; M = F; avoid situations that can be
Course: observed by others (presentation, hawker
-Chronic and disabling, low remission rate centre, MRT) & worries of humiliating or
-Can lead to alcohol abuse. embarrassing

8.2 Panic disorder Management: short term benzodiazepine,
Epidemiology: SSRI
Lifetime prevalence: 4.2% Systematic desensitization: imagine or
Women: 2-3 times higher than men expose to anxiety provoking situations,

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Study Notes in Psychiatry (2008) Dr. Roger Ho

progress through hierarchy, neutralize by - Anxiety symptoms: 2 weeks alprazolam
relaxation technique until patient habituates 0.25mg TDS

Chapter 9 Post traumatic stress disorder 9.7 Complication
9.1 Epidemiology - 50% recover 1st year; 30%: chronic
- After traumatic event, 8-13% for men, 20
-30% for women develop PTSD Acute Stress Reaction (hrs to days):
- Lifetime prevalence 8%. A transient disorder (hrs or days) that occur
- F:M = 2:1 as immediate response to exceptional
stress, accident, assault, fire, bereavement).
9.2 Aetiology Clinical features: depression and anxiety.
- Genetic: higher concordance in MZ than
DZ twins Acute Stress disorder (2d – 4 weeks)
- Reduced right hippocampal volume, Similar to acute stress reaction, but more
enhanced reactivity to stimulation & memory dissociative symptoms
deficits Similar to PTSD, but less than 4 weeks
- Dysfunction amygdala lead to enhanced duration.
fear response
Adjustment disorder (3 mo – 6 mo)
Risk factors: Protective factors It occurs within 3 months of a particular
-Low education - High IQ stressor & should not last longer than 6
-Lower Social class - High social class months after the stressor is removed.
-Female gender - Male Manifested as depression and anxiety (no
-Low self esteem - Chance to view psychotic features).
-Family history of body of dead person
psychiatric disorders Treatment of above disorders:
- Previous trauma Supportive psychotherapy to enhance
capacity to cope, understand meaning of
9.3 Clinical features (Appendix 9a) stressors.
- PTSD is a severe psychological Pharmacological: SSRI, short term BZD
disturbance following a traumatic event
characterized by involuntary re-experiencing Normal and abnormal grief reactions
of the events, with symptoms of - Bereavement: any loss event
hyperarousal, avoidance and flashbacks of
events. Longer than 4 weeks. - Normal grief: refer to appendix 9a
Mean duration: 6 months.
9.4 DDX
- Acute stress reaction - Adjustment disorder - Abnormal grief:
1) Intense
9.5 Psychological treatment 2) Prolonged> 1 year
- CBT: education about PTSD, anxiety 3) Delayed grief
management, anger management, cognitive 4) Absent grief
restructuring for trauma experience, gradual Other features: thoughts of death, excessive
exposure to stimuli avoided guilty, marked psychomotor retardation,
- Psychodynamic therapy: understand the prolonged impairment of function,
meaning of trauma, to resolve unconscious hallucination.
conflict.
- Eye movement desensitization & Management:
reprocess: Using voluntary multi-saccadic - Short term benzodiazepine:
eye movements to reduce anxiety (limited alprazolam 0.25mg TDS for 2 weeks
experience in Singapore, don’t mention it in - Antidepressant if there are
oral exam) depressive symptoms
- Look for alcohol abuse - Supportive psychotherapy:
enhance coping
9.6 Pharmacological treatment
- Depressive symptoms: SSRI

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- Grief therapy: explore the meaning - Tremulous hands
of the loss, let go of the past and - Truncal ataxia
move towards the future. - Autonomic overactivity
Ref: Oxford Handbook, 2004
Alcoholic hallucinosis
Ch. 10 Alcohol dependence -occurs in clear consciousness
10.1 Definition of dependence: -voices utter insults or threats,
1) Subjective awareness of compulsion to - Causes anxiety in patients
drink Inx: FBC, LFT, U&E, GGT, CXR, glucose
2) Stereotyped pattern of drinking
3) Increased tolerance to alcohol 10.5 Management
4) Primacy of drinking over other activities Detoxification: managing withdrawal
5) Repeated withdrawal symptoms - Diazepam 5mg TDS, Vitamin, thiamine
6) Relief drinking 30mg OM, B12, Rehydration.
7) Reinstatement after abstinence
Motivation interviewing to help patient to
10.2 Epidemiology change.
Age: men in their early twenties Stages of change: precontemplation,
Sex: More common in male; increasing contemplation, preparation, action,
incidence in females. maintenance, relapse
Social class: lowest prevalence in middle - Refer to CAMP, IMH
social blass
Marriage: more common in Pharmacological agents used for
divorce/separated maintenance:
Occupation: high risk: directors, doctors. - Disulfiram: an aversive stimulus, inducing
nausea if patient drinks alcohol
10.3 Aetiology: - Acamprostate: works on GABA/glutamate
- Genetic factors: MZ > DZ twins, adoption system, for maintenance
study also proves genetic links. - Naltrexone: opiate receptor antagonist,
- Abnormal neurotransmitter mechanism
- Learning factors: learn from peer / parents Psychological treatment:
- Personality factors: chronic anxiety, Behavioural therapy: keep diary log &
feeling inferior. tackle drinking behaviour.
- Other illness: anxiety disorder, depression
Social treatment:
10.4 Clinical features (appendix 10) - Goal orientated treatment plan:
Alcohol intoxication: explosive outbursts Total abstinence: > 40, heavily dependent,
of aggression, short term amnesia after physical damage, failed controlled drinking
heavy drinking, idiosyncratic reactions to Controlled drinking:< 40, not dependent
alcohol, pathological drunkenness: acute on alcohol, no physical damage, early stage
psychosis induced by small amount of - Alcoholic anonymous: observe &
alcohol mirroring, develop coping strategies
General withdrawal symptoms: 12-24 hr - Half way house: rehabilitation, counselling
- Acute tremulousness in hands (the shake)
- Agitation, sweating 10.6 Complications
- Nausea Nutritional or toxic disorders
- Perceptual distortions & hallucinations Wernicke’s Korsakoff’s
- Convulsions encephalopathy psychosis
Delirium tremens: 3-4days Ophthalmoplegia Impairment of recent
- Clouding of consciousness Nystagmus memory
- Disorientation in time & place Clouding of Confabulation
- Impairment of recent memory consciousness Retrograde amnesia
- Illusions & Hallucinations Memory disturbance Disorientation
- Fearful affect Ataxia Euphoria
- Prolonged insomnia - Alcohol dementia
- Depression and suicidal behaviours

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- Polysubstance abuse - Chronic use can lead to paranoia
- Social complications: job, marriage - Hostility & aggression
10.6 Prognosis: good prognosis in - Persecutory delusions
motivated, socially stable, no antisocial - Auditory, visual, tactile hallucination
personality disorder - Clear consciousness

Ch. 11 Drug Dependence 11.5 Cannabis
Effects Chronic
11.1 Definition: effects
It is a state, resulting from the interaction -Exaggerating existing Chronic
between a human and a drug, characterized mood amotivational
by behavioural and other responses that -Distortion of time & space syndrome.
include a compulsion to take the drug on a -Intensification of visual
continuous or periodic basis to experience perception & visual Flashback
its psychic effects & to avoid discomfort. hallucination phenomena
-Reddening of eye
11.2 Physical and psychological -Irritation of respiratory Psychotic
dependence tract reactions

Drugs Physical Psychological 11.6 Cocaine
Heroin Yes Yes Formication (cocaine bugs) – exam classic:
Hallucinogen No Yes a tactile hallucination as feeling insects
Amphetamine No Yes crawling under the skin.
Cannabis No Yes
Cocaine No Yes Treatment of above disorders: may need
BZD Yes Yes antipsychotics to treat psychotic experience.

11.2 Opiates – eg Heroin 11.7 Benzodiazepine
Chronic use Withdrawal
Constipation Pilo-erection, e.g. Dormicum (Midazolam), Alprazolam
Constricted pupils shivering (Xanax)
Weakness -Abdominal cramps Chronic use Withdrawal
Impotence -Lacrimation Unsteady gait Rebound insomnia
Tremors - Dilated pupils Dysarthria Anxiety
- Intense crave for Drowsiness Appetite disturbance
drugs Nystagmus Sweating, convulsion
- Agitation Confusion,
Delirium tremens
Treatment:
- Methadone: 20mg solution form, Treatment: switch to long acting
supervised treatment. benzodiazepines such as diazepam 5mg
- Buprenorphine (Subutex) was listed as TDS and slowly cut down the dose.
illegal drug & withdrawan from Singapore.
May need in-patient detoxication if using
11.3 Hallucinogens – LSD (lysergic acid high dose benzodiazepine.
diethylamide)
- Effects occur after 2 hours of consumption. Psychological treatment:
- Synaethesia: confusion between senses - Supportive psychotherapy: educate
e.g hearing images patients on complications of drug
- Out of body experience dependence and cope with day to day
- Anxeity and depression problems.
- Can lead to unpredictable & dangerous - Group therapy: observe their own
behaviour. problems mirrored in other drug abusers;
work out for better coping
11.4 Amphetamines

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Study Notes in Psychiatry (2008) Dr. Roger Ho

- Behavioural therapy: keep a diary of drug Acetylcholinesterase inhibitors: $$$
use and explore mood and feelings at the MMSE > 12 points
time of drug use with therapist and to reduce
the number of drug intake. Donepezil 5-10mg/day: (5mg=$5) long half
- Rehabilitation in CAMP, IMH: to leave the life, once daily dosage with GIT side effects,
drug subculture, support by counselor. not for asthma patients
Rivastigmine 3-6mg BD: ($2.6/3mg) short
Ch. 12 Old Age Psychiatry half life, GIT side effects and safe in asthma.
12.1 Alzheimer’s disease
-most common cause of dementia (70%) Galantamine: 4-12mg BD (8mg = $4.5);
also works on nicotinic Ach receptors.
Epidemiology
-1% at 60, doubles every 5 years; 40% at 85 Memantine: NMDA receptors partial
yr old antagonist (10mg = $3)
-M:F = 4:1
- Other risk factor: Down syndrome, head Low dose antipsychotics such as risperidone
injury, hypothyroid 1mg ON for delusion of theft

Genetics: Behavioural techniques for changing
- Chromosome 21 for amyloid precursor negative behaviour
protein
- Chromosome 19 for apolipoprotein E4 Poor prognosis: Male, Onset < 65, Parietal
- Chromosome 14 for presenilin 1 lobe damage, prominent behavioural
- Chromosome 1 for presenilin 11 problems, Depression

Cholinergic hypothesis: degeneration of 12.2 Other causes of dementia
cholinergic nuclei in nucleus of Meynert
- Dementia with Lewy body (with
Pathophysiology parkinsonism)
-Amyloid plagues in hippocampus, - Fronto – temporal dementia with
amygdale and cortex personality changes
-Neurofibrillary tangles in cortex, - Vascular dementia with neurological signs
hippocampus of stroke

Clinical features 12.3 Reversible causes of dementia –
Early symptoms: increasing forgetfulness Appendix 12a

Amnesia 12.4 Pseudo dementia: always say, “I
Aphasia (word finding difficulty) don’t know”
Apraxia (cannot dress) - Previous history of depression
Agnosia (cannot recognize body parts) - Islands of normality
Poor visual spatial skill - Response to antidepressant

Delusion of theft against maid in S’pore 12.5 Psychosis in elderly
Hallucination 10% Less than 1%; F:M 5:1
Family history of schizophrenia; sensory
Behavioural disturbance: aggression, impairments, social isolation
wandering, sexual disinhibition
Persecutory delusions: 90%
Mini-mental state exam < 24 /30 Auditory hallucinations: 75%
Visual hallucination 13%
Investigations: FBC, B12, Folate, LFT,
RFT, VDRL, CT or MRI brain Treatment: relieve isolation & sensory
deficits; low dose atypical antipsychotics:
Management: risperidone 1mg ON / quetiapine 50mg ON

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Study Notes in Psychiatry (2008) Dr. Roger Ho

12.6 Depression in elderly - Exclude histrionic personality disorder.
- more psychomotor retardation Investigation: no demonstratable organic
- nihilistic delusion (Cotard syndrome) findings
- Monitor suicide risk Management:
- Treatment of choice: escitalopram 10mg Psychological treatment:
ON - reassurance and suggestion
Ch. 13 Consultation Liaison Psychiatry - exploratory psychotherapy about his past
13.1 Dissociative / Conversion Disorders life.
Definition
- Dissociation – an apparent dissociation Social treatment: to eliminate factors that
between different mental activities. are reinforcing symptoms.
- Conversion - Mental energy can be
converted into certain physical symptoms. Biological treatment: Abreaction: IV
injection of small amount of diazepam to put
Epidemiology: patient into resting state and encouraged to
- Onset usually before the age of 35 relieve stressful life event (last to mention in
- More common among women exam)
- More common in lower social class Prognosis: If the course is longer than 1
- Occurs in national servicemen year, it is likely to persist for many years.

Aetiology: Pseudoseizure:
- Premorbid personality: 15% has premorbid - Inconsistent neurological sign
histrionic personality traits. - Can recall the seizure episode & avoid
- Emotionally charged ideas lodged in the injury
unconscious at some time in the past. There - no increase in serum prolactin (increases
is a conversion of psychic energy into in genuine epilepsy)
physical channels.
13.2 Hypochondriasis
Pathogenesis Hypochondriasis is the preoccupation with
- Primary gain: anxiety arising from a the fear of having a serious disease which
psychological conflict is excluded from persists despite negative investigation.
patient’s conscious mind
- Secondary gain: symptoms confer Epidemiology
advantage to patient: exempted from NS. More common among elderly, equal sex
incidence, lower social class
Clinical features:
Dissociation Conversion Aetiology:
- Psychogenic - Paralysis - History of childhood illness, parental
amnesia - Fits illness, excessive medical attention seeking
- Psychogenic fugue - Blindness in parents, childhood sexual abuse
(wandering) - Deafness - Tendency to misattribute body symptoms
-Somnambulism - Aphonia. - Medical reassurance provides temporary
(sleep walking) - Anaethesia relief of anxiety which acts as a reward for
- Multiple personality - abdominal pain more medical attention.
- Disorder of gait
Clinical features:
La Belle indifference: less than the -Preoccupation with the idea of having a
expected amount of distress often shown by serious medical condition, which will lead to
patients with hysterical symptoms. death and serious disability.
- Patient will seek medical advice but is
DDX: unable to be reassured by negative
- Exclude organic causes: temporal lobe investigations;
epilepsy, cerebral tumour, general paralysis - Anxiety & depression are common.
of insane dementia - It is usually in the form of overvalued idea.
- Exclude malingering: conscious aware of
what he or she is doing, making up illness Management

16
Study Notes in Psychiatry (2008) Dr. Roger Ho

- Allow patient to ventilate their problems Capacity to give consent
- Explain negative test, reassurance, no 1) Patient must be informed about the
further investigation, procedure, risk and benefit
- Aim to improve function 2) Can patient understand the info?
- Break cycle of repeat consultation 3) Can patient retain info?
- Family education 4) Can patient balance the risk or benefit?
- CBT: challenge & replace misinterpretation 5) Can patient arrive at a conclusion?
- Exposure to illness cue & response 6) Further assessment of cognitive function
prevention e.g mini mental state examination.
- Depression: use SSRI like fluoxetine 7) Having a psychiatric illness like
Schizophrenia does not mean lack of
Somatisation disorder capacity to give consent.
A chronic disorder of multiple medically
unexplained symptoms, affecting multiple Delirium/ Acute confusional state
organ systems presenting before the age of It is a clinical syndrome of fluctuating global
40. It is associated with significant cognitive impairment with behavioural
psychological distress. abnormalities due to variety of insults.

Aetiology - More family members with Epidemiology
somatisation disorder; similar to aetiology of 10% of medical & surgical inpatients.
hypochondriasis.
Risk factors: elderly, dementia, blind &
Epidemiology: - 0.2%; F:M 5:1; age of deaf, postoperative, burn victims, alcoholic.
onset: childhood to 30s
Aetiology
Clinical features: -Intracranial: CVA, head injury, CNS
Pain: right iliac, back and head infection
CVS: dyspnoea, chest pain, palpitation, BP - metabolic: electrolyte disturbance, hepatic
GI: heartburn, nausea, flatulence, dysphagia encephalopathy, hypoxia
Sweating or body odour - endocrine: Pituitary, thyroid, PTH, adrenal
- Infection: UTI, chest infection, abscess
Management: - Substance intoxication and withdrawal
Initial:
-Acknowledge symptom severity & as real Clinical features: - Fluctuating course
-Attempt to reframe symptoms as emotional -impaired consciousness and attention
- Disorientation, impaired recent memory
Ongoing management: - Nocturnal worsening of symptoms
-Regular review by single doctor, planned - Psychomotor agitation & emotional lability
visit, avoid AED & unnecessary investigation - illusions, visual hallucinations (big insect)
- Investigate objective signs only - Poorly formed paranoid idea (other
- Symptom re-attribution patients want to harm him)
- CBT
DDX: - Psychotic illness
Body dysmorphic disorder - Post ictal confusion
(Dysmorphophbia): Preoccupation that - Dementia
some aspect of physical appearance (body
image) is grossly abnormal & refuses to Management:
accept medical explanation. Treated by 1) Identify & treat precipitating cause
SSRI and CBT. It can lead to depression, 2) Provide calm environment with
suicide, & functional impairment. reality orientation (big clock)
3) Low dose antipsychotics:
Factitious disorder / Munchausen’s Haloperidol 2.5mg/ risperidone 1mg
syndrome: falsify symptoms & fabricate 4) Regular review and follow up
signs (use ketchup for blood) for medical 5) Educate family about delirium
attention
Depression in chronic medical illness

17
Study Notes in Psychiatry (2008) Dr. Roger Ho

- Common, Look for non somatic - Family history of psychiatric disorder
symptoms: guilt, concentration, low - Lack of social support
mood
- Assess suicide risk Clinical features:
- Use escitalpram as it has less drug -Prominent affective features (80%): mania /
interactions. depression
Ch. 14 Perinatal Psychiatry - Psychosis, paranoid idea about safety of
baby
14.1 Baby blues - Insomnia, perplexity, disorientation
- Look for suicide & infanticide risk
¾ of new mothers will experience a short
lived period of tearfulness and emotional Management:
lability starting 2-3 days after birth.
Treatment in hospital – KK women hospital /
Due to pospatrum reductions of oestrogen, In the UK, admit to special mother – baby
progesterone and prolactin. unit

No need for treatment. ECT is useful

14.2 Postnatal depression Antipsychotics is needed ( to avoid breast
feeding)
Epidemiology:
- 10-15% of women 14.4 Premenstrual Syndrome (PMS)
- Peak: 3-4 weeks of delivery
PMS is a constellation of menstrually
Risk factors: related, chronic, cyclical, physical and
- Family history of depression; emotional symptoms in the luteal phase.
- Poor relationship with own mother
- Ambivalence towards pregnancy Symptoms: Breast tenderness, fatigue,
- Poor social support cramping, bloating, irritability, depression,
- Previous postpartum depression poor concentration, food cravings, lethargy,
libido changes.
Clinical features
- Depression + worries about baby’s health Prevalence: 40% of women of reproductive
and ability to look after baby age, severe impairment in 5%
- 90% last less than 1 month
Investigation: Charting of daily symptoms
Management: for at least 2 menstrual cycle may aid in
- Prevention by education confirming cyclical pattern.
- Enhance support
- If severe, SSRI (to avoid breast Treatment:
feeding) Conservative management: Low salt and
- CBT fat diet, less caffeine, reduce alcohol and
tobacoo intake, to reduce stress
14.3 Postpatrum psychosis
Consider medication: to try SSRI if fails to
Epidemiology conservative treatment.
1.5/1000 live births
Peak: 2 weeks postpartum Refer to O and G if above measures fail

Aetiology
Reduce of oestrogen, leading to dopamine
super-sensitivity, cortisol levels or Ref: Oxford Handbook, 2004
postpartum thyroiditis

Risk factors:

18
Study Notes in Psychiatry (2008) Dr. Roger Ho

Dry skin/brittle hair
Loss of brain volume
Cerebral atrophy
Ventricle
enlargement

Ch. 15 Eating disorder Elevated hormones Reduced
hormones
15.1 Anorexia Nervosa Growth hormone T3 and T4
Prolactin Oestradiol
Epidemiology Cortisol Testoesterone
- Usually Females; F:M = 10:1 FSH and LH
-Onset between 16-17
- More common in upper social class Investigation
- 1% of middle class adolescent girls. FBC, RFT, LFT, glucose, TFT, cholesterol,
- Increasing incidence: 0.5% LH, FSH

Aetiology DDX:
-Genetics: MZ: DZ 65%:32%;6-10% of Functional illness Organic disorder
female siblings of patients also suffer from OCD Hypopituitarism
this condition Depressive disorder Thyrotoxicosis
-Hypothalamic dysfunction Diabetes Mellitius
- Social: Exam stress in S’pore, occupations Brain tumour
group: ballet students, atheletes Malabsorption
-Individual pathology: dietary problems in
early life, lack of a sense of identity
Management:
- Family pathology: enmeshment, rigidity,
overprotectivieness, lack of problem solving
Admission to hospital:
-Extremely rapid or excessive weight loss
Clinical features
-Severe electrolyte imbalance
- Cardiac complications
Core clinical features - RAPID
- Marked change in mental status
-A body weight more than 15% below the
- Risk of suicide
standard weight or BMI 17.5 or less
- Failure of outpatient treatment
- Self induced weight loss: vomiting, purging,
excessive exercise, appetite suppressant
Feeding and refeeding syndrome
-Body image distortion- dread of fatness,
-Consult medical/dietitian
overvalued idea
- Refeeding syndrome: Cardiac
-Endocrine disorder: HPA axis,
decompensation can occur within first 2
amenorrhoea, reduced sexual interest,
weeks: myocardium cannot withstand the
raised cortisol, altered TFTs
stress of increased metabolic demand;
- Delayed and arrested puberty.
slowly increase dietary intake by 200kcal per
day and monitor RFT closely
Complications:
Secondary to Consequences of
Psychological treatment:
starvation vomiting &
-Supportive psychotherapy: to improve
laxative
interpersonal relationships and sense of
Hypothermia Hypokalaemia personal effectiveness.
Constipation Hyponatraemia - Behavioural therapy: regimen of
Low BP, anaemia Prolonged QT refeeding, to set target weight, positive
Bradycardia Cardiac arrhythmia reinforcement with privileges such as outing,
Amenorrhoea Dental caries movie etc
Leucopenia - Cognitive therapy, after gaining some
Hypercholesterolemia weight, aims at changing attitude towards
Delayed in growth
Osteoporosis

19
Study Notes in Psychiatry (2008) Dr. Roger Ho

eating, reappraisal of self image and life - Admission only for suicidality and physical
circumstances. problems
-Family therapy - Higher dose of SSRI: fluoxetine up to 60
mg
Pharmacological: Olanzapine may be used - Cognitive behavioural therapy
to promote weight gain (controversial not to
mention in exam) Poor prognosis: severe personality
disorder or low self esteem.
Prognosis of AN
15.3 Pathological gambling
Rules of one third: It is a persistent and recurrent maladaptive
1/3 1/3 1/3 patterns of gambling behaviour.
Recover fully Recover Chronically
partially disabled. Relatively common and may lead to
significant personal, family and occupational
Factors associated with a poor prognosis difficulties.
- Chronic illness
- Late age of onset Clinical features
- Bulimic features - Preoccupation with gambling
- Anxiety when eating with others - Tolerance: need to gamble with
- Excessive weight loss larger amounts of money
- Poor childhood social adjustment - Fail to cut down
- Poor parental relationships - Chasing losses (like chasing the
- Male sex dragon in drug addicts)
- Lying to others about gambling
Bulimia Nervosa - Committing illegal acts to finance
gambling.
Epidemiology: 1% of women - Losing or jeopardizing familial
relationship
Aetiology:
Family history of affective disorder Treatment:
Serotonergic dysregulation - CBT to reduce preoccupation with
gambling
Clinical features: - SSRI (fluoxetine)
-Persistent preoccupation with eating - Support group
-Irresistible craving for food - Credit card debt counseling via
-binges: episodes of overeating MSW
- Attempts to counter the fattening effects of
food: self induced vomiting, purging 15.4 Kleptomania
Failure to resist impulses to steal items that
BN is different from AN. In BN, are not needed nor sought for personal use.
- Patients are more eager for help e.g A men stole 10 female T shirts, same
- Menstrual abnormalities less than style but different colours.
half of the patients
- Body weight within normal limits Usually women, mean age 36, 16 years of
illness
Comorbidity: Multiple dyscontrol
behaviours: DDX: shoplifting (well planned and
- Cutting / burning motivated by need and monetary gain),
- Overdose OCD and depression
- Alcohol / drug misuse
- Promisuity Treatment:
- CBT
Management - SSRI
- Usually managed as outpatient
15.5 Trichotillomania

20
Study Notes in Psychiatry (2008) Dr. Roger Ho

Stereotyped recurrent pulling of hair 8. Other associations :
a) history of DSH (1/3- ½ of
DDX: OCD, Tourette syndrome, Autism, completers)
factitious disorder
Suicide and mental illness
Treatment: behavioural modification, • all psychiatric illness (except OCD)
SSRI,if fail consider risperidone or lithium increase risk by 90-95 %
• Depression (risk 3.6 - 8.5 % = 30 x
Ref: Oxford Handbook, 2004
general population risk)
Ch.16 Suicide and DSH Trickcyclist, UK
Schizophrenia (risk 5 - 10 %)
16.1 Suicide
Alcohol dependence (risk 3.4 - 6.7 %)
Epidemiology
• completers are more often : Neurosis: panic disorder/ PTSD
• male
• psychiatric disorder Special populations
• have made a plan
• used a dangerous method Elderly
Prevalence • rate increasing
• lifetime prevalence (USA): • 80-90 % of elderly suicides have
• 21 % morbid thoughts depressive illness
• 10.2 % suicidal thoughts • often first episode of depression
• 2.9 % attempted suicide • DSH is more closely associated with
• GP : (2,500 patients) completed suicide
• 1 suicide every 4 years • denial of suicide more common
• Psychiatrist (catchment area 50,000)
• 1 suicide every 3 months Inpatients Highest risk :
• first week of admission
Sociodemographic correlates of suicide • early stages of recovery
1) Age, Sex • between shifts of staff
a) M:F = 3:1; males > females • on leave (patients and staff)
for all groups • bank holidays
b) suicide pacts more common • discharge (premature)
in the elderly • risk is increased 30 x in the
2. Marital status : month after discharge
a) divorced > widowed > single
3. Employment : Aetiology
a) unemployed / retired / living
alone Genetics
4. Social Class :
a) Higher in lowest social • suicidal behaviour clusters in family
groups & professional • MZ : DZ = 11.3 % : 1.8 % (Roy et al.
b) lowest in middle groups 1991)
5. Religion :
a) strong religious affiliation is Neurochemical
a protective factor 1)Serotonin : serotonin deficiency
6. Occupation :
a) higher risk groups are 16.2 Deliberate self harm (DSH)
doctors, lawyers, hotel and A deliberate, non fatal act, whether physical,
bar trade owners drug overdose, or poisoning, done in the
7. Chronic Physical illness : knowledge that it was potentially harmful.
terminal illness / malignancies More common in female
a) chronic pain

21
Study Notes in Psychiatry (2008) Dr. Roger Ho

Motives: A cry for help; An attempt to - Low 5HT levels in impulsive violent individuals
influence others; escape from stress; to feel
pain in personality disorder Childhood development
- Difficult infant temperament
- Harsh and inconsistent parenting
Factors of DSH predicting suicidal risk - Conduct disorder in childhood
• Isolation; timing
Clinical features: “CALLOUS”
• precautions to avoid intervention
• suicide note Conduct disorder < 15
• anticipatory acts Antisocial Act and aggression
• ‘dangerousness’ of state of mind Lies frequently
Ch. 17 Personality disorder Lack superego
Obligations not honoured
Deeply ingrained, maladaptive patterns of Unstable and cannot plan ahead
behaviour; recognisable in early adulthood, Safety of self or others ignored
continuing throughout most of adult life; there is
an adverse effect on the individual or society.
Prognosis:
17.1 Borderline Personality Disorder May commit crime
May show Improvement by 5th decade
Prevalence: 1.5 – 2%
Management of Personality Disorder
Childhood development
- Childhood trauma – sexual abuse, Making the diagnosis of personality disorder
divorce - Assess patient’s enduring and pervasive
- Playing primitive defence mechanisms patterns of emotional expression,
such as splitting or projective interpersonal relationships, social
identification functioning
- Obtain collateral information from family
Clinical features: “I RAISE A PAIN” and past psychiatric history
- Explore relationships, self concept and
I – Identity disturbance functional assessment

R- Relationship: unstable Admission to hospital
A – Abandonment fear of - They benefit little from prolonged
I – Impulsive admission.
S – Suicidal gesture - Admission is indicated for specific crisis
E – Emptyiness - Treatment plan aims to set limits and to
achieve realistic goal
A – Affect: unstable
Psychological treatment
P – Paranoid idea / psychosis: transient
A – Anger -Supervision and support are often beneficial
I - Idealisation and Dealisation
N - Negativistic CBT:
- Educate them about the schema
Prognosis: 1/3 continue to have Borderline - Empathetic challenging their core beliefs
Personality disorder after 10 – 20 years. - Goal directed problem solving approach

Poor prognosis: Dialectical behavioural therapy for borderline
- Severe repeated self-harm personality disorder

- Focus on a detailed CBT approach to self harm
17.2 Antisocial Personality Disorder - Then focus on tolerance of distress, emotional
regulation and interpersonal skills
Prevalence: 2-3.5% - To process trauma
- Develop self esteem and realistic future goals
Neurophysiology:
Pharmacological treatment:
-immature EEG in posterior temporal lobe as - SSRI antidepressant can improve mood and
slow waves reduce impulsivity

22
Study Notes in Psychiatry (2008) Dr. Roger Ho

Outcome of personality disorder Clinical signs and symptoms:
- High rates of accident, suicide and - Hyperthermia
violent death. - Muscular rigidity
- Confusion / agitation
- Tachycardia
- Hyper or hypotension
- Tremor
- Incontinence
Ref: Oxford Handbook, 2004 - ↑ CK level
Investigations: FBC, LFT, RFT, Ca and
Chapter 18 Psychiatric Emergency
PO4, serum CK, CXR, CT
18. 1 Acute disturbed patient
Aetiology DDX: lethal catatonia, malignant
- Alcohol and drug dependence hyperthermia, meningitis, heat exhaustion,
- Illicit drugs rhabdomyolysis
- Metabolic disturbance
- Head injury Management:
- Schizophrenia - Stop antipsychotics
- Mania - Medical emergency, refer to medical
- Personality disorders - IV fluids, reduce temperature
- Benzodiazepine for acute
Treatment of acute disturbed patient or behavioural disturbance
crisis: - To give bromocriptine
It requires immediate action:
Mortality: 5-20% die, it can lead to acute
1) De-escalation verbally in calm and renal failure.
consistent environment.
2) Oral medication: PO Haloperidol 18.3 Serotonin syndrome:
5mg stat or PO lorazepam 1mg stat A rare but potentially fatal syndrome
occurring in the context of initiation of
3) IM medication: IM Halperidol 5mg serotonergic agent, characterised by altered
stat; IM lorazepam 2mg (in IMH); no mental state, agitation, tremor, shivering,
IM diazepam due topoor absorption diarrhoea, hyperreflexia, myoclonus and
4) Close monitoring on vital sign hyperthermia.
5) If chemical restraint fails, consider
physical restraint 1% of patients on SSRI
18.2 Neuroleptic Malignant Syndrome Pathophysiology: due to increase in
serotonin.
It is a rare life threatening reaction to
antipsychotic medication characterised by Clinical features:
fever, muscular rigidity, altered mental Autonomic: hyperthermia, nausea,
status and autonomic dysfunction. diarrhoea, mydriasis, tachycardia,
hyper/hypotension
Due to blockade of D2 receptors leading to
impaired calcium mobilisation and leads to Neuromuscular: myoclonus, rigidity and
muscle rigidity. tremors, hyperreflexia, ataxia
Incidence: 0.2% More rapid onset, rapid progression and less
F: M = 2:1 rigid than NMS.
Risk factors Investigations: same as NMS, add in CXR
- Drug naïve patient receiving high potency to rule out aspiration, ECG to look for
antipsychotics prolonged QTc
- Dehydration

23
Study Notes in Psychiatry (2008) Dr. Roger Ho

- Chronic significant insomnia – 6%
Treatment:
- Consult medical, it is a medical Aetiologies:
emergency. Intrinsic causes:
- IV access, to allow volume correction to - Psychophysiological insomnia
reduce the risk of rhabdomyolysis associated with anxiety
- Prescribe benzodiazepine to control - Sleep state misperception (constant
agitation, seizure and muscle rigidity. monitoring of sleep)
- Idiopathic insomnia
Course and prognosis: - Sleep apnoea syndrome
- Resolve with 24 – 36 hours - Periodic limb movement disorder
- Mortality < 1 in 1000
Chapter 19 Sleep disorders Extrinsic causes:
- Inadequate sleep hygiene
19.1 Normal sleep – stages and cycle - Dependency related sleep disorder
- A typical night’s sleep has 4 or 5 cycles of like hypnotics
stages, each lasting 90 – 110 minutes. - Nocturnal eating and drinking
- As night progresses, the amount of time
spent in delta sleep decreases with Medical and Psychiatric causes:
consequent increase in REM sleep. - Pain
- Total sleep time in adult is between 5 – 9 - Respiratory (COPD)
hours. - Parkinson disease
- Endocrine: Addison, Cushing
Stage 1 Light sleep, with slow theta - Depression, bipolar disorder
and delta waves - Anxiety disorder, PTSD
Stage 2 K complexes - Schizophrenia
Stage 3 & 4 Delta wave, slow wave
sleep Management:
REM Low voltage, - Address underlying problem (drug
desynchronised EEG dependency)
activity - Education: stages and cycles.
- Sleep hygiene measures: Good
Assessment of sleep disorders: sleep habits and stimulus control
Present Onset, duration, course, - Relaxation training
compliant frequency, stressors - Use of hypnotics if unresponsive to
Daily routine Waking, daily activities, bed above
time
Description Behaviour during sleep, Length of Examples Comments
of sleep dream, wakening, action
satisfaction Ultra –short Zolpidem Non – BZD
Daytime Level of alertness, effect on (Stilnox) Facilitate onset
somnolence work, 2 hr of sleep
Drug & Regular hypnotics 10mg ON Also has
alcohol Caffeine containing drugs $1.80 potential of
dependency,
19.2 Insomnia cause rebound
Insomnia involves difficulty to fall asleep, insomnia
maintaining sleep and poor quality of sleep Intermediate Lorazepam Initiating,
as persistent problem 3 days per week for Ativan maintaining,
one month. 6 hours 1mg ON Consolidating
sleep
Epidemiology
- Common problem Zopiclone Non BZD
- F>M Imovane Bitter taste
- Greater in elderly 7.5mg ON

24
Study Notes in Psychiatry (2008) Dr. Roger Ho

Long acting Diazepam Initiating, - Social skill training
Valium maintaining, - Parent management training
> 12 hours 5-10mg Consolidating - Education and remedial intervention
sleep - Stimulant: Methylpenidate 5-10mg
Flurazepam OM: increase Dopamine &
Dalmadorm noradrenaline which can increase
NUH only Hang over concentration & attention, side effect
15-30mg effect on the include growth retardation which
morning requires drug holiday.
Midazolam (Dormicum) has very fast onset
of action and high potency, it has high Outcome
potential for dependency. It is not - 20% develop antisocial personality
recommended for regular oral usage. disorder
Ch. 20 Child Psychiatry - 20% develop substance abuse
20.1 Attention Deficit & Hyperkinetic disorder
Disorder (ADHD)
ADHD is a persistent pattern of inattention 20.2 Conduct disorder
+/- hyperactivity that is developmentally A repetitive and persistent pattern of
inappropriate. The symptoms should have behaviour in which the basic rights of others
an onset in childhood. or major age appropriate societal norms are
violated.
Epidemiology:
- USA: 3-5% (over-diagnosis) Epidemiology
- UK: 1% - Earlier onset and is more common in boys
- M:F = 3:1 than in girls.

Aetiology: Aetiology
Genetics: Biological factors Psychosocial
- 50% risk in MZ twins, 2x increase in - Family history of - Parental criminality
siblings antisocial behaviour - Substance abuse in
- Genes: 5, 6, 11 are implicated. or substance abuse. parents
- Neuroimaging: frontal - Low CSF serotonin - Harsh and
hypometabolism - Low IQ inconsistent
- Dopamine & 5HT dysregulation in - Brain injury parenting
prefrontal cortex - Domestic chaos
and violence
Clinical features: - Large family size
Hyperactivity Inattention - Low socio-
symptoms symptoms economic status and
Fidgeting, moving, Cannot sustain poverty
getting up & down, attention - Early loss and
climbing on desks Poor task completion deprivation
Blurting out answers, Making mistakes - School failure
Jumping the queue when task require
attention Clinical features:
- Aggression
Assessment: - Cruelty to people and animals
- Interview with parents: - Destruction of property
developmental history - Deceitfulness or theft
- Observe attachment style and level - Serious violation of rules
of activity of child - Gang involvement
- Collateral info from school - Lack of empathy

Treatment: Management:
- CBT: behavioural techniques - Ensure the safety of the child
- CBT problem solving skill

25
Study Notes in Psychiatry (2008) Dr. Roger Ho

- Parent management training - Neurological: tics, increase in head
- Family therapy circumference, abnormal gaze
- Academic & social support referral - Physiological: abnormal response
to pain, abnormal temperature
Course and outcome: regulation.
- CD is often chronic and - Behavioural: irritability, temper
unnameable. tantrums, self – injury, hyperactivity,
- Antisocial PD in adults <50% aggression
Poor outcome: Early onset < 10 year old, Assessment:
low IQ, poor school achievement, attentional - Requires Multidisciplinary approach
problems, hyperactivity, family criminality, - Rating scale: Autism Behavioural
poor parenting. Checklist
20.3 Autism

It is characterised by the triad of Treatment:
symptoms: - Education & vocational
- Abnormal social relatedness interventions
- A qualitative abnormality in - Behavioural interventions
communication and play - Family interventions
- Restricted, repetitive and - Speech and language therapy
stereotyped behaviour, interests and
activities
20.4 Asperger Syndrome (AS)
Epidemiology:
- Onset is typically before age 3. Severe persistent impairment in social
- M:F = 3-4:1 interactions, repetitive behavioural patterns
- Prevalence: 5-10/1000 and restricted interests.

Aetiology: IQ and language are normal or superior.
- Genetic
Mild motor clumsiness and family history of
- Obstetric complications autism may be present.
- Toxic agents
- Pre/postnatal infections. Newton and Einstein may have AS
- Association with tuberous sclerosis
Epidemiology
Pathophysiology MRI: - Male predominance
- Increase in brain size - 1 in 300
- Increase in lateral and 4th ventricle
- Frontal & cerebellar abnormalities Clinical features
- Abnormal purkinje cells in cerebellar - Narrow interests and preoccupation
vermis. of a subject
- Abnormal limbic architecture. - Repetitive behaviours or rituals
- Peculiarities in speech and
Clinical features: language
- Abnormal social relatedness: poor - Extensive logical or technical
eye contact and no peer relationship patterns of thought
- Abnormal communication/play: - Socially and emotionally
lack of language, difficulty to initiate inappropriate behaviour and
conversation. interpersonal interaction
- Restricted interests or activities: - Problems with non verbal
non functional routines or rituals communication
(bus schedule) - Clumsy and uncoordinated motor
movements.

26
Study Notes in Psychiatry (2008) Dr. Roger Ho

complaints occur on school days but not
20.5 Approaches to the Child at other times
• the final refusal may occur after several
- Establish the rapport and gaining events:
the child’s confidence • following a period of
- Begin with subjects well away from increasing difficulty
the presenting problem (interests, • after an enforced absence
hobbies, friends and siblings, school such as respiratory infection
and holidays) • after an event at school
- Progress to enquire about the such as change of class
child’s view of the problems • following a problem in the
- Observe the level of activities and family such as illness of another
attention during the interview family member
- Try to interview the child and family
together to observe family dynamics Treatment
• an early return to school is important
20.6 School refusal • discussion with teachers is needed
• depressive disorder should be treated
Epidemiology
• prevalence of 1-2 %
Prognosis
• slightly more common in boys
• more common during three periods in • worse prognosis in older children
school life: • higher incidence of psychiatric disorders
1. age 5 (starting school) (e.g. agoraphobia) in adult life
2. 7 years (change to junior
school) 20. 7 Enuresis
3. 11 years (starting Voluntary/involuntary voiding of urine at
secondary school) night for child > 5 yr old.
4. 14 years and older, when
there is often associated depression 75% have family history of enuresis
and difficulties in school To rule out UTI, neurological problems,
obstructive uropathy.
Aetiology
Primary enuresis: never dry
• associated with separation anxiety
Secondary enuresis: previously dry
especially in younger children
• may occur after a minor life event: Behavioural modification is important
illness treatment: starchart to reward patient,
• some older children have depression restrict fluid at night
• increased incidence of anxious,
overprotective mother in combination Medication: imipramine (TCA)
with a weak, passive, ineffectual, or
absent father 20.8 Consequence of child abuse:
- PTSD
• children are often emotionally immature
- Dissociative disorder
and have not learned to accept
- Conversion disorder
frustration
- Borderline personality disorder
- Depression
Clinical features
- Paraphilias
• there are often somatic symptoms such - Substance abuse
as headache, abdominal pain,
diarrhoea, sickness, or vague 20.9 Tourette’s syndrome
complaints of feeling ill – these

27
Study Notes in Psychiatry (2008) Dr. Roger Ho

Multiple motor and vocal tics for a year, with
distress and impairment function.

Facial tics as initial symptoms
Vocal tics: meaningless sounds to clear
words and coprolalia
Tic wax and wane, exacerbations due to
stress

Onset: 7 years old M:F = 3:1
Prevalence: 5/10,000

Genetics factors: AD
Involves dopamine system and Basal
Ganglia

Comorbidity: depression, OCD

Treatment: Haloperidol 1.5mg-5mg, CBT
Lesley Stevens, Ian Robin, Psychiatry – An
Ref: Oxford Handbook, 2004 illustrated colour text, Churchill livingstone 2001
21 Learning Disability/ Mental
Retardation 21.3 Foetal Alcohol Syndrome
- Major causes of learning disability
21.1 IQ and learning disability (LD) - 0.2 – 3 per 1000 live births
- Caused by maternal alcohol use.
Due to effect of alcohol on NMDA receptors
LD IQ Features
which affects cell proliferation
Mild 50-69 Independent self
care
Clinical features:
Moderate 35-49 Some deficit in
language, simple
Alcohol withdrawal: irritability, hypotonia,
work
tremor and seizures
Severe 20-34 Lower level of
work, motor Facial features: Microcephaly, small eye
impairment fissures, epicanthic folds, short palpebral
Profound Below Very limited fissure, small maxillae and mandibles, cleft
20 language & palate, thin upper lip
basic skills
Growth deficits: Small overall length, joint
21.2 Down Syndrome deformities.

Most common genetic cause of LD CNS: behaviour problems: hyperactive,
Trisomy of chromosome 21 sleep problems, poor visual acuity, hearing
loss, language deficits.
IQ most often below 50
Develop Alzheimer’s disease at 40s and 50s Other: ASD, VSD, renal hypoplasia.

Clinical features of Down syndrome

28
Study Notes in Psychiatry (2008) Dr. Roger Ho

male suffers from paranoid schizophrenia
was brought in to your AED. He has been
violent at home and attacks his parents. He
has poor insight and has defaulted his
treatment for 3 months.

He refuses to be admitted to your general
hospital psychiatric unit (or your psychiatric
ward is full)

In this case, you can send the patient to IMH
for assessment. (You need to call the IMH
registrar on call at 6389 2000)

The IMH medical officer or registrar will sign
the Form 1 of Mental Disorder and
Treatment Act: compulsory admission for 72
hours.

22.2 Driving and Psychiatric illness
(Based on UK law, Singapore does not
have clear guideline on this)

For schizophrenia, bipolar disorder:
Driving must cease during acute illness

Re-licensing for private car:
22 Legal & Ethical Aspects - has remained well and stable for at
least 3 months
22.1 Mental Disorder and Treatment Act - Compliant with treatment
- Free from adverse effects of
- Can only apply at IMH (Woodbridge medication
hospital) in Singapore - Regain of insight

Criteria for compulsory admission at IMH For professional driver: bus driver, taxi driver
or lorry driver: Re-licensing may be possible
1) The person suffers from a mental if well and stable for a minimum of 3 years
disorder of a nature or degree which with minimum dosage of medication and no
makes it appropriate for the person significant likelihood of recurrence
to receive psychiatric treatment in
IMH. Dementia:
2) Admission is likely to alleviate or Those with poor short term memory,
prevent deterioration in a psychiatric disorientation, lack of insight and judgement
condition (Schizophrenia, Bipolar are not fit to drive.
disorder)
3) It is necessary for the health or 22.3 Dialysis and Schizophrenia
safety of the patient or for the You have a 58 year old lady suffering from
protection of other persons that the chronic schizophrenia and end stage renal
person should receive such failure. She wants to stop dialysis. The renal
treatment and it cannot be provided team is very concerned as she may die and
unless he is compulsory admitted. they want to seek your opinion.

Example: Suffering from schizophrenia does not mean
Assume you are the AED medical officer the patient has no capacity to decide on her
working in a general hospital. A 29 year old dialysis.

29
Study Notes in Psychiatry (2008) Dr. Roger Ho

First, we have to determine whether the Techniques:
patient has the capacity to make the - Goal setting: tackle anxiety/
decision to withhold dialysis. In order to defence
show that she has the capacity, she must be - Focus choosing: repetitive
able to understand and believe that she behaviour to a single transference
suffers from end stage renal failure; dialysis figure
is used to treat ESRF and she will die if she - Active interpretation
stops dialysis.
Transference Countertransference
We need to consider the following:
Patient’s feeling Therapist’s feeling
It is good to explore the psychological
towards therapist towards patient
aspects of dialysis: sexual dysfunction is
common; they are more isolated and costs
of dialysis may reduce their quality of life Phases of treatment
and anaemic can cause fatigue. - Initial: setting treatment contract,
formulation of the case
Uraemia can lead to impaired mentation, - Early session: Identify central issue
lethargy, multifocal myoclonus. - Middle session: explore transference
- Closing: anticipate termination,
Dialysis can lead to neuropsychiatric arrangement of aftercare.
symptoms such as dialysis dementia,
delirium and depression. 23.3 CBT
Behaviours and emotions are determined by
We may need to treat patient’s person’s cognitions. Some pathological
neuropsychiatric symptoms by emotions are as a result of cognitive errors.
antidepressant or antipsychotics and If the person can be helped to understand
reassess her capacity later. the connection between cognitive errors and
23 Psychotherapy distressing emotion, they can try methods to
Common psychotherapies practised in change.
Singapore include: The therapist aims to assist the patient to
monitor cognitions, identify cognitive errors,
23.1 Supportive Psychotherapy understand maladaptive schema, explore
Aims to offer practical and emotional with strategies and challenge and examine
support, opportunity for ventilation of the resultant effects.
emotions, and guided, problem solving
discussion. Behavioural Cognitive
techniques techniques
Examples include counselling and general Activity scheduling Psychoeducation
psychiatric follow – up. Graded assignment Identify automatic
Exposure/ response thoughts
23.2 Brief psychodynamic prevention Role play
psychotherapy Relaxation training Thoughts diary
It is an active therapy where the therapist Examine evidence
attempts to guide free association on more
focused topics. Defence mechanisms
Repress Unconscious forgetting of pain
Rationale: ion memory and impulse.
- Shorter time scale of long term Regress Revert to functioning of a
psychoanalysis (too expensive and difficult ion previous maturational point.
for patient to stay in therapy for so long) Denial Refusal to consciously
acknowledge events or truths
Indication: which are obvious.
- Individuals with emotional problems Projecti Attributing one’s own
in psychological terms. on unacceptable ideas or impulses
- Focal conflicts to another person.
- Projecti One person projects a thought,

30
Study Notes in Psychiatry (2008) Dr. Roger Ho

ve belief or emotion to a second
Identific person. Then, there is another Coprolalia: A forced vocalisation of
ation action in which the second obscene words or phrases. The symptoms
person is changed by the is largely involuntary but can be resisted for
projection and begins to behave a time, at the expense of mounting anxiety.
as though he or she is in fact Occurs in Tic disorder
actually characterized by those
thoughts or beliefs that have Couvade syndrome: A conversion
been projected. symptom seen in partners of expectant
Reactio The expression externally of mothers during their pregnancy.
n attitudes and behaviours which
formati are the opposite of the Déjà vu A sense that events being
on unacceptable internal impulses. experienced for the first time have been
Displac Transferring the emotional experienced before. An everyday
ement response to a particular person, experience but also a non specific
event, or situation to another symptoms of a number of disorders
where it does’t belong but carries including temporal lobe epilepsy,
less emotional risk. schizophrenia and anxiety disorders. In
Rational Justifying behaviour or feelings contrast, Jamis Vu is the sensation that
isation with a plausible explanation after events or situations are unfamiliar, although
the event, rather than examining they have been experienced before.
unacceptable explanation.
Sublima Regarded as healthy defence Delusional memory
tion mechanism, The external A primary delusion which is recalled as
expression of unacceptable arising as a result of a memory (eg patient
internal impulse in socially who remembers his parents taking him to
acceptable way. hospital for an operation as a child
becoming convinced that he had been
Ch. 24 Glossary implanted with monitoring devices which
have become active in his adult life)
Alexithymia: The inability to describe one’s
subjective emotional experiences verbally. Delusional mood: A primary delusion which
is recalled as arising following a period when
Amnesia Anterograde: the period of there is an abnormal mood state
amnesia between an event and the characterised by anticipatory anxiety, a
resumption of continuous memory. The sense of something about to happen and an
length of anterograde amnesia is correlated increased sense of significance of minor
with the extent of brain injury. events.

Retrograde: The period of amnesia Delusional perception: A primary delusion
between an event and the last continuous which is recalled as having arisen as a result
memory before the event. of perception. The percept is a real external
object.
Autochthonous delusion: A primary
delusion which appears to arise fully formed Delusion of guilt: A delusional belief that
in the patient’s mind without explanation. one has committed a crime or other
reprehensible act. It is a feature of psychotic
Autoscopy: (Phantom Mirror image) depressive illness.
The experience of seeing a visual
hallucination or pseudohallucination of Delusion of infestation (Ekbom
oneself. syndrome): A delusional belief that one’s
skin is infested by multiple, tiny, mite like
Confabulation: The process of describing animals.
plausibly false memories for a period for the
patient has amnesia. Occurs in Korsakoff Delusion of reference: A delusional belief
psychosis, dementia. that external events or situations have been

31
Study Notes in Psychiatry (2008) Dr. Roger Ho

arranged in such a way as to have particular are nonetheless in the right ballpark. What is
significance for or to convey a message to 2+2? = 5. More common in Malingering.
the affected individual.
Globus Hytericus: The sensation of a lump
Depersonalisation: An unpleasant in the throat occurring without oesophageal
subjective experience where the patient structural abnormality.
feels as if they have become unreal.
Hypnagogic hallucination: A transient
Derailment (Knight’s move thinking): false perception experienced while on the
schizophrenic thought disorder in which verge of falling asleep
there is total break in the chain of
association between the meaning of Hypnopompic hallucination: The same
thoughts. phenomenon experienced while waking up

Derealisation: An unpleasant subjective Illusion: A false type of false perception in
experience where the patient feels as if the which the perception of a real world object is
world has become unreal. combined with internal imagery to produce a
false internal percept.
Digenes syndrome: Hoarding of objects,
usually of no practical use and neglect of Lilliputian hallucination: A type of visual
one’s home and environment. Due to hallucination in which the subject sees
organic disorder, schizophrenia, OCD. miniature people or animals. Associated with
organic state like delirium tremens.
Dysarthria Impairment in ability to
properly articulate speech Loosening of associations: Lack of
Dyslexia Inability to read at the level meaningful connection between sequential
normal for one’s age or ideas.
intelligence
Dysphasia Impairment in producing or Magical thinking: A belief that certain
understanding speech actions and outcomes are connected
(expressive dysphasia - although there is no rational basis for
Brocas and receptive establishing a connection.
dysphasia - Wernicke)
related to cortical Malingering: Deliberately falsifying the
abnormality symptoms of illness for a secondary gain.
Dysphoria An emotional state
experienced as unpleasant, Mirror sign: Lack of recognition of one’s
secondary to depression own mirror reflection with the perception that
Dyspraxia Inability to carry out complex the reflection is another individual who is
motor tasks (dressing, mimicking your actions.
eating)
Overvalued idea: A form of abnormal belief.
Edietic imagery: Particular type of These are ideas which are reasonable and
exceptionally vivid visual memory. Not a understandable in themselves but which
hallucination. More common in children. come to unreasonably dominate the
patient’s life.
Extracampine hallucination
A hallucination where the percept appears to Preservation: Continuing with a verbal
come from beyond the area usually covered response or action which was initially
by he senses (eg a patient in Clementi appropriate after it ceases to be apposite.
hearing voices seeming to come from a Do you know where you are? In the
house in Changi) hospital? Do you know what day is it? In the
hospital.
Ganser symptoms:The production of
approximate answers. Here the patient gives Russell Sign: skin abrasions, small
repeated wrong answers to questions which lacerations and the calluses on the dorsum

32
Study Notes in Psychiatry (2008) Dr. Roger Ho

of the hand overlying the Tangentiality: Producing answers which
metacarpophalangeal and interphalangeal are only very indirectly related to the
joints found in patients with symptoms of question asked by the examiner.
bulimia. Caused by repeated contact
between incisors and the skin of the hand Trichotillomania: Compulsion to pull one’s
which occurs during self induced vomiting. hair out.

Synaethesia: A stimulus in one sensory References:
modality is perceived in a fashion 1) Levi. Basic Notes in Psychiatry. Radcliffe
characteristic of an experience in another Publishing Ltd 1998.
sensory modality (tasting sounds). 2) D. Semple, R. Smith, J Burns, R. Darjee,
A. Mclntosh. Oxford Handbook of
Psychiatry. Oxford University Press. 2004
3) www.trickcyclists.co.uk

Appendix
Appendix 3a – Neurodevelopmental Hypothesis of Schizophrenia

- There is an excess of obstetric
complications in those who develop the
disorder.
- Affected subjects have motor & cognitive
problems which precede the onset of
illness.
- Schizophrenia subjects have abnormalities
of cerebral structure of 1st presentation.
- Although the brain is abnormal, gliosis is
absent – suggesting that differences are
possibility acquired in utero.

From: Your questions answered series – Schizophrenia, Churchill Livingstone

Appendix 3b – Brain abnormalities of Schizophrenia

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Lesley Stevens, Ian Rodin – Psychiatry an illustrated text, Churchill Livingstone. 2001

Appendix 3C

Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001

34
Study Notes in Psychiatry (2008) Dr. Roger Ho

Appendix 5a - Toxic effect of lithium

Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001

Appendix 9a PTSD and Grief

Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001

Appendix 10

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001

Appendix 12a

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001

Mnemonics in Psychiatry (Mnemonics for MRCP, PASTEST, 2006)

Disorder Mnemonic Breakdown of Mnemonic
Negative 5As and aPathy
symptoms of PLANT aLogia

37
Study Notes in Psychiatry (2008) Dr. Roger Ho

schizophrenia aFfective flattening
aNhedonia
aTtentional deficit
Depression DEPRESSION Depressed mood
Energy loss
Pleasure loss
Retardation: psychomotor
Eating change
Sleep disturbance
Suicidal ideation
I am a failure
Only me to blame = guilt
No concentration
MANIA MANIAC Mood increase
Activity / energy increase
No inhibition
Insomnia
Always thinking > Pressure of speech, flight of ideas
Confidence excess  grandiose
Eating disorder RAPID Refusal to maintain weight
Amenorrhoea
Preoccupation with food and weight
Induction of diarrhoea and vomiting
Disturbance in the way weight and size are perceived
Korsakoff ADDICT Amnesia
psychosis Disorientation
Insight loss
Confabulation
Thiamine deficiencies
Eating disorder Increases in Nuclei Acid bases:
the following G – Growth hormone
C – cortisol and cholesterol
A – Amylase
T – Transaminase
U – Urea and Creatinine

Everything else decreases

38