Schizophrenia (Dx Criteria)
A) 2 or more of the following, each present to
significant portion of time, for at least 1 month, at
least one of them must be (1), (2) or (3).
1) Delusion
2) Hallucination
3) Disorganized speech
4) Grossly disorganized/ catatonic behaviour
5) Negative sx
B) During a sig portion of time after onset of the sx,
the level of functioning in one/more major areas
is markedly below the level achieved prior to the
onset.
C) Continuous sn of disturbance for at least 6
months. This 6 months period include 1 month
period of sx that meet criterion A & may include
prodromal & residual phase(negative sx or
attenuated form of sx listed in criterion A)
D) Schizoaffective d/o & depressive/bipolar d/o have
been ruled out becoz either
(i) there is no major depressive/manic
episode occur concurrently with
schizophrenia sx.
(ii) if there is mood episode, they have been
present for minority of the total duration
of the illness.
E) The disturbance is not attributable to
substance/another medical condition.
F) If there is hx of autism spectrum d/o or
communication d/o of childhood onset, an
additional dx of schizophrenia is made only if
prominent delusion/hallucination in addition of
other acquired sx have been present for at least 1
month.
Active
Residual
Prodromal Prodromal
Positive sx: exaggeration of N mental fn
Negative sx: diminution of N mental fn
Schneider 1st rank sx
3 auditory hallucinations
- Thought echo
- Running commentary
- Third person
3 thought alienation
- Thought insertion
- Thought withdrawal
- Thought broadcasting(people know about what u think,
see & conversation wout u tell them)
3 delusion of control (aka Passivity phenomena)
- Made action(smting enter body & control actn)
- Made impulse(suddenly did action which he didn’t want)
- Made feeling(laugh at funeral)
Somatic passivity(body ache d/t ext force)
Delusional perception(N stimulus with delusional
misinterpretation eg: traffic light change, CIA is after me)
Negative Sx
- Alogia(poverty of speech)
- Avolition(lack of physical activity)
- Asocial(social withdrawal)
- Apathy(lack of motivation)
- Anhedonia(lack of interest/pleasure)
- Affective blunting
Management
Ix:
1) Biological
– FBC(wbc), LFT(drug metabolised by liver),
RP(baseline)
– ECG
– Urine for drugs(rule out subst induce)
– Thyroid fn test(tro hyperthyroidism if pt
aggressive)
– Fasting blood glucose & lipid profile
(antipsychotic aw metabolic synd)
– CT scan(1st time pt tro SOL)
2) Psychological
- Brief psychiatric rating scale for psychosis
- Personality test(Bipolar)
 3) Social (IM fluphenazine 25mg, IM flupenthixol, IM
- trace old notes zuclopenthixol)  every 1-3wk
- Collateral hx with family members IM risperidone  every 2 wk
IM paliperidone  every 1/12
Tx- so that pt can be like premorbid fn. IM aripiprazole
Pharmacological:
1) Acute- if pt is aggressive, EPS sx

- IM haloperidol/IM olanzapine/IM ziprasidone - Acute

i) Dystonia(spasm of ms)
IM haloperidol (typical) Torticollis(scm), oculogyric crisis(sup
Cannot be given if pt had hx of neuroleptic malignant rectus of eye), opisthothonus(back),
synd(ms rigidity, hyperpyrexia, autonomic disturbance
blepharospasm(orbicularis oculi),
w increase creatinine phosphokinase CPK)
laryngeal ms.
IM Olanzapine (atypical)(waffle type) ii) Akathisia (motor restlessness, unable to
– contraindicated w bdz(don’t give 24hr b4 & after) sit still)*x give anticholinergicworsened. Give
bdz
IM Ziprasidone iii) Parkinsonism (pill rolling tremor,
–aw QT’s prolongation (arrythmia)
cogwheel rigidity, akinesia, postural
++(Typical Antipsy aka Tranquilizer : IM Haloperidol, Chlorpromazine, instability)
perphenazine, trifluoperazine,IV diazepam)
- Late
++(Atypical AntiPsy: IM olanzapine, risperidone, quetiapine)
i) Tardive dyskinesia (irreversible orobuccal
2) Long term: movement/involuntary movements of
- Atypical antipsychotic (less SE & EPS than typical, mouth,tongue, face, limbs)
and improve sx better)
Eg: ++SE:
- Olanzapine (wt gain, inc appetite, - antiCholiEff: dry mouth,blurred vision, constipate,
hyperglycemia, inc lipid, sedation). sedation
- Quetiapine (orthostatic hypotension, same w - orthostat hypotension, ,hyperPRL.
olanzapine).
- Risperidone (wt gain, galactorrhea, sedation, Emergency SE : Neuroleptic M9 Synd
menstrual irregularity)
- Cogwheel rigidity
# Tx resistant schizophrenia - Fever
- Fluctuate BP
- Pt failed to response to 2 types of medication - Tachycardia
which are geven enough doses & enough - ↑CK
durations (4-6 weeks).
- Pre-workout b4 start clozapine: baseline BMI, FBC, What to do?
FBGluc, ECG, CK, BP, not allergy, absent contraind.
- Use clozapine (agranulocytosis, sialorrhea, wt  Stop antipsychotic
gain, myocarditis, orthostatic hypotension).  Change to another w less EPS
12.5mg starting dose.  Prescribe anticholinergic : artane
- Augmentation w other antipsychotic if pt failed to  Give BDZ(akithisia)
respond to clozapine.
- Consider ECT.

Non-compliant pt

- Use depot injection:

Psychosocial Catatonia (3 out of 12)

1) Psychoeducation (nature & course, sx & sn, - Stupor

necessity of tx, SE tx, cx, relapse rate, prognosis) - Cataplexy
2) Rehabilitation: Occupational therapy - Waxy flexibility
3) Family therapy – family support - Mutism
4) Assertive community team (case manager,home - Negativism
visit & check for compliance, remind the pt to - Posturing
come for f/up) - Mannerism
5) Social skill training - Stereotypy
- Agitation in absence of ext stimuli
- Grimacing
# clozapine (agranulocytosis) - Echolalia
- Echopraxia
- Check fbc every wk for 4-6 wk
++Route for Olanzapine & risperidone
- Every 2 wk until 4 months
- Every month - Tab
- Im
- Syrup
- Zydis wafer(dissiolve in mouth)
Dopaminergic Pathway
++SLUDGE Synd for cholinergic SE
1) Mesolimbic : VTA(ventral tegmental area) to
- Salivation
NA(nucleus accumbens) of limbic. - Lacrimation
- Increase mesolimbic pathway - Urination
 Motivation, rewards, emotions, +ve sx - Diaphoresis
schizophrenia. - GI upset
- Emesis
2) Mesocortical : VTA to cortex(prefrontal cortex)
- Cognitive & executive fn (dorsolateral
prefrontal cortex)
- Emotions & affects(ventralateral
prefrontal cortex)
- Hypofn  cognitive & negative sx
schizophrenia.
3) Nigrostriatal: Substantia nigra(pars compacta) to
striatum(caudate & putamen)
- Stimulation of purposeful movement
- Dz antagonism induce EPS.
4) Tuberoinfundibular: Hypothalamus(arcuate &
periventricular nuclei) to infundibular rgn(median
eminence).
- Dopamine inhubit PRL release.
- Dz antagonism inc PRL release 
Hyperprolactinaemia.
Bipolar Disorder
Epidemiology
- Life time prev: 0-2.4% (bipolar I), 0.3-4.8%
(bipolar II) *annual incidence:<1%
- Equal in male & female, male high of
manic, female high of depressive, female
high rate of rapid cyclers(>4 manic in a yr)
- Age : 5/6-50 w mean age=30 yo.
- Marital status: common in divorce &
single person.
- Socioeconomic : more common in high
socioeconomic gp.
Comorbidity
- Substance-use-d/o, panic d/o, OCD.
Etiology
1) Biological
- ↑HPA
- ↑somatostatin → ↓GH
2) Genetic factors
- Family hx of mood d/o
- 70-90% in monozygotic twins
- Chromosome 18q & 22q
3) Psychodynamic factors
- Defence against u/l depression
Dx criteria for bipolar I & bipolar II
Manic episode(ada sig loss of fn)
A) A distinct period of abnormally & persistently
elevated, expansive or irritable mood &
abnormally & persistently inc in goal-directed
activity or energy, lasting at least 1 week &
present most of the day, nearly everyday (or any
duration if require hospitalization)
B) During period of mood disturbance & increased of
energy or activity. 3 or more of the following (4
only if irritable mood) are present to significant
degree & represent a change from usual
behaviour.
1) Inflated self esteem
2) ↓need for sleep
3) More talkative than usual/ pressure to keep
talking.
4) Flights of ideas/thoughts are racing
5) Distractibility.
6) ↑in goal directed activity/psychomotor
agitation.
7) Excessive involvement in activities which have
painful consequences.
C) The mood disturbance is sufficiently severe to
cause impairment in social/ occupational
functioning. or to necessitate hospitalization to
prevent harm to self or others, or there is
psychotic feature.
D) The episode is not attributable to substance or
other medical condition.
Criteria A-D: manic episode.
Hypomanic episode(xde sig loss of fn,selalunya x dtg hosp
sbb happy & org x complain tentang pt)
A) A distinct period of abnormally & persistently
elevated, expansive or irritable mood &
abnormally & persistently inc in goal-directed
activity or energy, lasting at least 4
consecutive day & present most of the day,
nearly everyday.
B) During period of mood disturbance &
increased of energy or activity. 3 or more of
the following (4 only if irritable mood) are
present to significant degree & represent a
change from usual behaviour.
1) Inflated self esteem
2) ↓need for sleep
3) More talkative than usual/ pressure to
keep talking.
4) Flights of ideas/thoughts are racing
5) Distractibility.
6) ↑in goal directed activity/psychomotor
agitation.
7) Excessive involvement in activities which
have painful consequences.
C) The episode is aw unequivocal change in
functioning that is uncharacteristic of
individual when not symptomatic.
D) The mood disturbance & change in
functioning are observable by others.
E) The mood disturbance is not severe enough
to cause marked impairment in functioning,
 to necessitate hospitalization, or has
psychotic features.
F) The episode is not attributable to substance
or other medical condition.
Criteria A-F: hypomanic episode
Depressive episode
A) 5 or more of following present in same 2 wk
period and represent a change from prev
functioning; at least 1 of sx is either (i) depressed
mood or (ii) loss of interest of pleasure.
1) Depressed mood most of the day/ irritable
mood in children/adolescence.
2) Markedly diminished of interest/pleasure in
all, or almost all activities most of the day.
3) Sig wt loss/ wt gain (5% in a month), or ↑/↓
of appetite.
4) Insomnia/hypersomnia.
5) Psychomotor agitation/retardation.
6) Fatigue/loss of energy
7) Feeling worthlessness/ excessive or
inappropriate guilt.
8) Diminished ability to think/concentrate/
indecisiveness.
9) Recurrent thought of death/ suicidal
intention/ suicidal attempts
B) The sx cause clinically sig distress/ impairment in
functioning.
C) The episodes is no attributable to substance or
other medical conditions.
Criteria A-C : depressive episodes
Bipolar I Disorder
A) Criteria have been met for at least one manic
episode.
B) The occurrence of manic and major depressive
episode are not better explained by other mental
disorder.
Bipolar II Disorder
A) Criteria have been met for at least one hypomanic
episode and at least one major depressive
episode.
B) There has never been manic episode.
C) The hypomanic and major depressive d/o is not
better explained by oher mental d/o.
Ix
1) Biological
- FBC, LFT(if going to start antipsychotic
sodium valproate), Renal profile(Lithium,
carbamazepine)
- TFT(tro hypothyroidism, check baseline
for starting lithium becoz lithium can coz
hypoth)
- Fasting blood glucose & lipid
profile(antipsychotic)
- Serum Ca level(lithium coz
hyperparathyroidism)
2) Psychological
- Young mania rating scale
- Hamilton rating scale for depression
Nearly everyday
- Montgomery asberg depression rating
scale.
3) Social: Trace old notes, collateral hx from family
members & colleagues.
Tx :
1) Acute mania:
 Lithium
- Acute: 600-1800mg/day in divided dose
- Maintenance: 300-1200mg/day
- Narrow therapeutic index-need blood
monitoring
- Half-life:1day
- Steady sate: clearance=4-5day halflife
acute=0.8-1.2mg
maintenance=0.4-0.8mg
>1.5=toxic side effect(toxic
encephalopathy/delirium, cerebellar
sn/dashing)
>2.0 confusion, coma, death
Revert by dialysis
- SE: GI upset, polyuria, polydipsia, wt gain,
hypothyroidism, hyperparathyroidism)
- Absolute contraindicated in pregnancy &
breastfeeding.
- Lithium toxicity: delirium+cerebellar sn.
 or Sodium valproate(epilim)/carbamazepine
- Epilim acute phase=600-2500mg/day
- Maintenance=400-2000mg/day
 - Blood monitor:347-693ɥmol/L
- Sodium Valproate(SE: GI upset, sedation,
wt gain, thrombocytopenia, raised liver
enzyme, neural tube defect(spina bifida))

 or haloperidol/atypical antipsychotic
 or combination
 consider ECT
2) Acute Depression:
 Monotherapy of lithium/ Quetiapine(SE:
orthostatic hypotension, wt gain, dizziness,
somnolence, dyslipidemia, hyperglycemia)
 Combination therapy of lithium, valproate,
SSRI, olanzapine, bupropion.
 ECT

3) Long term
 1st line lithium as monotherapy, regularly f/up
for 6 month.
or
 Lamotrigine(depressive)- (skin rash, insomnia,
steven-Johnson’s synd, blurred vision,
diplopia)
or
 Monotherapy of olanzapine, quetiapine,
valproate, risperidone injection, aripiprazole.
*Rapid cyclers resistance to lithium.

Psychological

1) Psychoeducation
2) Interpersonal social rhythm therapy
- Improve medication adherence
- Technique to manage stressful life events
- Reduces disruption in social rhythm
- Improve sleep
3) Family session.
Stimulant Related Disorder-Amphetamine, 6) Continued stimulant used despite having
Metamphetamine, Cocaine persistent/recurrent social/interpersonal
problem caused/exacerbated by stimulant.
Administration & action 7) Important social/occupational/recreational
1) Amphetamine(less addictive than cocaine) activity are given up becoz of stimulant use.
- Orally (effects within 1 hr) 8) Recurrent stimulant use in situation which are
- IV(immediate effect) physically hazardous.
- Snorting(inhaled) 9) Continued stimulant use despite knowledge
- ↑catecholamine(dopamine & of having persistent/recurrent
norepinephrine) and serotonin physical/psychological problem that is likely
 ↑dopaminergic pathway(reward to have been caused by stimulant use.
circuit 10) Tolerance, as defined as either of the
pathway/mesolimbic+mesocortical following:
pathway) i) A need markedly increase in amnt of
2) Cocaine(aw CVA, cardiac death) stimulant use to achieve
- Orally (very rare) intoxication/desire effect.
- Inhaling(snorting) ii) A markedly decrease in effect with
- SQ/IV continued use of same amnt of
- Smoking(crack) most dangerous stimulant.
method. 11) Withdrawal, defined as either of following
i) A characteristic withdrawal syndrome
CVA of stimulant.
- Blockade of dopamine reuptake ii) Stimulant is used to avoid/relieve
→↑dopamine withdrawal sx.
- Immediate effect & last for 30-60 mins. *Amphetamine- paranoid ideas with cont used.
- Can be present in urine & blood up to 10 *Cocaine- irritability, impaired ability to
days. concentrate, compulsive behaviour, severe
Comorbidity (cocaine related disorder) insomnia, wt loss, nasal congestion.

- Mood d/o, anxiety d/o, antisocial Diagnostic criteria of Stimulant Intoxication.

personality d/o, alcohol related d/o. A) Recent use of stimulant.
Diagnostic criteria of Stimulant use disorder B) Clinically sig problematic behavioural/
psychological change develop during/ shortly after
A) A pattern of amphetamine-type substance, stimulant use.
cocaine or other stimulant use leading to clinically C) >2 of the following develop during/shortly after
sig distress/impairment, as manifested by 2 or stimulant use:
more of following in 12 month period. 1) Tachycardia/Bradycardia
1) Stimulant always taken in larger amnt/longer 2) Pupillary dilation Major
period than was intended. 3) Elevated/lowered blood pressure Sn
2) Persistent desire/unsuccessful effort to 4) Perspiration of chills
control/cut down stimulant use. 5) Nausea/vomiting
3) A great deal of time spent to 6) Evidence of wt loss
obtain/use/recover from its effect. 7) Psychomotor agitation/retardation
4) Craving/strong desire/urge to use stimulant. 8) Muscular weakness/respiratory depress/chest
5) Recurrent stimulant use leading to failure to pain/cardiac arrhythmia
fulfill major role at work/school/home. 9) Confusion/seizure/dyskinesia/dystonia/coma
 D) The sx/sn are not attributable to other medical 5) OCD
condition/not better explained by other mental 6) Sexual dysfn
d/o. 7) Sleep d/o

People use stimulants becoz of the characteristic effect: Management

- Elation(excitement) Ix
- Euphoria
- Perceived improvement on mental & 1) Biological
physical tasks - FBC, LFT, RP
- ↑self-esteem - ECG
- Urine for drugs
Diagnotis criteria for Stimulant Withdrawal→crash - Fasting blood glucose, lipid profile
2) Psychosocial:
A) Cessation of/Reduction of prolonged stimulant - Collateral hx with family members/friends
use.
B) Dysphoric mood and >2 of the following develop Treatment:
within few hours to several days after criterion A:
1) Fatigue 1) Pharmacological:
2) Vivid, unpleasant dreams(↑REM) - IM Haloperidol for agitated patient
3) Insomnia/hypersomnia - Diazepam
4) ↑in appetite - Respective gp of drugs for respective sx
5) Psychomotor retardation/agitation 2) Psychological
C) The sx of criterion B causes clinically sig - Psychoeducation: nature & course, sx &
distress/impairment in functioning. sn, SE, necessity of tx, relapse.
D) The sx/sn are not attributable to other medical - Motivational interview: to ↑motivation
condition/not better explained by other mental (adv&disadv taking drugs, adv of
d/o. stopping)
- Cognitive behavioural therapy
Clinical feature of stimulant withdrawal: i) Coping skill
ii) Relapse prevention therapy (how
 Anxiety, tremor, headache, profuse sweating, to say no, avoid cues to take
muscle cramp, stomach cramp & the above drugs)
sx in criterion B. - Narcotic anonymous for cocaine.
 peak in 2-4 days and resolved in a week.
 Depression(most severe sx) can cause suicidal
ideation/attempts.

Stimulant Related Disorder

1) Delirium
2) Psychotic disorder:
- Paranoid delusion, auditory hallucination,
visual hallucination.
- Tactile hallucination(bugs crawling
beneath skin) common with cocaine.
- Tx: short term haloperidol
3) Mood d/o: intoxication with manic/mixed;
withdrawal with depression.
4) Anxiety d/o
 (mood=pervasive/sustained
Major Depressive Disorder - Guilt
emotion)
4) Psychodynamic
Definition: Sx of either depressed mood or loss of - Disturbance in the infant mother during
pleasure in activity lasting at least 2 wk with 4 or more oral phase(10-18 month of life)
from list of sx: - Real/imagined object loss
- Change in appetite/wt - Introjections of object loss
- Change in sleep&activity - The loss of object is a mixture of love &
- Lack of energy hate, feeling of anger are directed at the
- Feeling of guilty self.
- Problems thinking & making decision 5) - cognitive triad about self, environment & future.
- Recurring thought of death/suicide. - learned helplessness.

Epidemiology: Diagnostic criteria of major depressive d/o

- Lifetime prevalence: 5-17%
- Sex: female 2X greater than
male(hormonal diff, childbirth, learned
helplessness)
- Age of onset: 20-50yr w mean age=40yr
- Marital status: common in wout close
relationship/divorce/separated
- Cultural/socioeconomic: more common in
rural area than urban.
Comorbidity:
Nearly everyday
- Substance use d/o, panic d/o, OCD, social
anxiety d/o,eating d/o.
Etiology:
1) Biological
- ↓monoamine neurotransmitter:
(norepinephrine, serotonin, dopamine)
- Monoamine-acetylcholine imbalance:
↑acetylcholine
- ↓γ-aminobutyric acid(GABA)
- Altered glutamatergic transmission
- ↑HPA activity
- ↓Thyroid hormone
- ↓Somatostatin→↑GH
- ↑nondominant hemispheric activity
2) Genetic
- Family hx mood d/o
- 70-90% in monozygotic twins
3) Psychosocial factor
- Losing of parents b4 11 yr
- Losing of spouse
- Unemployment
A) 5 (or more) of following sx have been present for
the same 2 week period & represent change from
previous functioning; at least 1 of sx is either
(1)Depressed mood or (2)loss of interest or
pleasure.
1) Depressed mood of the day/irritable mood in
children/adolescence
2) Markedly diminished Interest pleasure in all
or almost all activity, most of the day.
3) Sig wt loss/wt gain(5% in a month), ↑/↓ in
Appetite.
4) Insomnia/hypersomnia
5) Psychomotor agitation/retardation
6) Fatigue/loss of Energy
7) Feeling worthlessness/excessive,
inappropriate Guilt
8) Diminished ability to think or
Concentrate/indecisiveness.
9) Recurrent thought of death, suicidal
ideation/Suicidal attempt.
B) Sx cause clinically significant distress/ impairment
in fn.
C) The episode is not attributable to substance/other
medical condition.
*A-C=major depressive d/o
D) The episode is not better explained by other
mental condition.
E) There has never been a manic/hypomanic
episode.
Differences between bereavement & MDD - Impaired concentration &
forgetfulness(depressive
Bereavement: pseudodementia)
- Feeling emptiness/loss Investigation
- ↓as time passed by & come in wave
when remind of deceased. 1) Biological
- Able to have +ve emotion. - FBC, LFT(SSRI metabolized in liver),
- Have self-esteem. RP(baseline)
- Thought of dying as joining deceased. - TFT(tro hypothy)
- Urine for drug(tro substance induce)
MDD: 2) Psychological
- Depressed mood/inability to anticipate - Beck Depession inventory, Montgomery-
pleasure. Asberg depression rating scale
- Persistent & not tied with thought 3) Social
- Not have +ve emotion - Collateral hx w family member
- Feeling of worthlessness # Suicidal risk assessment(SADPERSON)
- Thought of dying as feeling of
worthlessness - Sex: Male↑risk
- Age: <20 or >40
Clinical feature: - Depression
- Depressed mood - Prev attempt
- Loss of interest/pleasure - Ethanol abuse
- Contemplate suicide(2/3), commit - Rational thinking lose
suicide(10-15%) - Social support lack
- Social withdrawal - Organized plan
- ↓in energy(97%) - No spouse
- Trouble in sleeping, early morning - Sickness
awakening, multiple awakening at night. *7-10 hospitalization
- Change in appetite & weight Mx/tx
- Anxiety
- Alcohol abuse A) Acute mx
- Somatic complaint 1) Admit pt to ward:
- Inability to think/concentrate a) For pt safety
- Poor academic performance i) if pt had suicide attempt &
- Truancy intention to die high, put pt on
- School phobia In adolescents suicidal chart.
- Running away ii) If comorbid w alcohol dependent,
put pt on withdrawal chart.
b) To complete dx evaluation: investigate &
MSE tx pt in holistic manner(whether had
other d/o)
- Psychomotor retardation, downcast, c) For tx plan.
averted gaze. 2) Biological
- ↓rate, vol, amnt speech. a) Antidepressant(SSRI, TCA, MAOI, atypical
- Thought block, poverty of content. antidep: SNRI,SARI,NaSSA)
 b) CHOICE: Selective Serotonin Reuptake 3) If insufficient response, titrate the dose &
Inhibitor cont for 2 more wk, switch to other
i) Sertraline(zoloft) antidepressant if no response.
ii) Fluvoxamine(luvox)
iii) Fluoxetine(Prozac) *Other type of antidepressant
iv) Paroxetine(paxil) i) SNRI: venlafaxine, duloxetine
v) Escitalopram(lexapro)
c) Reason give SSRI: ii) TCA: Amitriptyline, Clomipramine, Imipramine
i) Less SE(anticholinergic & anticholinergic SE
cardiotoxicity)
iii)MAOI: Meclobemide
ii) Safer in overdose
(↓cardiotoxicity) iv)Mirtazapine
iii) No food restriction (like in MAOI)
d) Educate about SE Course & Prognosis
i) Git disturbance
- 60% relapse if 1 episode
ii) Anxiety
- 70% if 2
iii) Dry mouth
- 90% if 3
iv) Insomnia
- 15% commit suicide.
v) Sex dysfn
vi) Headache
B) In the ward
- Suicidal caution chart(every 30 min).
- Start SSRI: Sertraline, fluoxetine,
fluvoxamine, escitalopram.
i) SE: Gi disturbance,
agitation, anxiety,
insomnia, headache,
tremor.
- +/-BDZ becoz pt is anxious. eg:lorazepam,
alprazolam
- If pt has psychotic feature, atypical
antipsychotic: risperidone, olanzapine.
- Suicidal thought: give ECT

Psychological

- Psychoeducation
- Family session
- Group therapy(in ward)
- Cog Behavioural Therapy(coping skills)
C) Long term
1) SSRI cont for 1 month & BDZ taper off after
>2wk.
2) If reach remission, continue for 1 year if single
episode, 2-5 years for 2nd episode, life long for
3rd episode.
Social Anxiety D/O(Fear that people will –vely evaluated )
Lifetime prevalence: 3-13%
A) Marked fear/anxiety about one or more social
situation in which the individual is exposed to
possible scrutiny by others.
B) The individual fear that he/she will act in a
way/show sx that will be –vely evaluated.
C) The social situation almost always provoke fear/
anxiety.
D) The social situation is avoided/endured with
intense fear/anxiety.
E) The social anxiety is out of proportion to the
actual threat by social situation or the
sociocultural context.
F) Fear, anxiety or avoidance is persistent, typically
lasting >6month.
G) Fear, anxiety or avoidance cause clinically sig
distress/impairment in functioning.
H) Fear, anxiety or avoidance is not attributable to
substance/another medical condition.
I) Fear, anxiety or avoidance is not better explained
by other mental d/o.
J) If another medical condition present, fear anxiety
or avoidance is clearly unrelated/is excessive.
Cognitive Behavioural Therapy
- Graded exposure
Panic d/o(1st 2nd attack occur wout any trigger, fear attack come
again, nocturnal panic attack)
A) Recurrent unexpected panic attack in which
abrupt surge of intense fear/discomfort which
reach peak within minutes & 4 or more of the
following sx occur.
1. Palpitation, pounding heart, accelerated heart
rate.
2. Sweating
3. Trembling/shaking
4. Sensation of SOB/smothering
5. Feeling of choking
6. Chest pain/discomfort
7. Nausea/abdominal distress
8. Feeling dizzy, unsteady, lightheaded or faint.
9. Chills/heat sensation
10. Paraesthesia
11. Derealization/depersonalization
12. Fear of losing control/going crazy
13. Fear of dying
B) At least one of attack is followed by one month(or
more) of 1 or both following:
1) Persistent concern/worry about additional
panic attack/their consequences.
2) A sig maladaptive change in behaviour related
to panic attack.
C) The disturbance is not attributable to
substance/another medical condition.
D) The disturbance is not better explained by other
mental d/o.
General Anxiety D/O
A) Excessive anxiety/worry occurring more days than
not for at least 6 month, about a no of
events/activities.
B) The individual find it difficult to control the worry.
C) The anxiety & worry is associated with 3 or more
of the following 6 sx (at least some of them have
been present for >6months).
1. Restlessness/feeling keyed up on the edge
2. Being easily fatigue
3. Difficulty concentrating/mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance
D) The anxiety/worry/physical sx cause clinically sig
distress/impairment in fn.
E) The anxiety/worry is not attributable to
substance/another medical condition
F) The anxiety/worry is not better explained by other
mental d/o.
Cognitive intervention
- Re-appraisal of unrealistic belief.
- Re-assesssment of likelihood of –ve
outcome
- Address intolerance of
uncertainty/perfectionalism.
Anxiety d/o
- Reassurance & psychoeducation (nature,
sx, role of body(fight &flight)), necessity
of tx, +ve response, SE of tx).
 - Relaxation technique (progressive ms
relaxation & abdominal breathing)
- SSRI + BDZ(SE:drowsiness, sedation, respiratory
depression, dependence Withdrawal: rebound anxiety,
for 2wk, then titrate up SSRI taper
seizure)
off bdz.

Agoraphobia

A) Marked fear/anxiety about 2(or more) of

following 5 situation:
1. Using public transportation
2. Being in open space
3. Being in enclosed space
4. Standing in line/being in crowd
5. Being outside of the home alone
B) The individual fear/avoid these situation becoz of
thought that escape/help might be not available
in event of dev panic-like sx/ incapacitating/
embarrassing sx.
C) The agoraphobic situation almost always provoke
fear/anxiety.
D) The agoraphobic situation are actively
avoided/require presence of companion/ are
endured with intense fear/anxiety.
E) The fear/anxiety is out of proportion to the actual
danger posed by the agoraphobic situation & to
the sociocultural context.
F) The fear/anxiety/avoidance is persistent, typically
lasting >6 months
G) The fear/anxiety/avoidance cause clinically
significant distress/impairment in functioning.
H) If another medical condition present, the fear/
anxiety/avoidance is clearly excessive.
I) The fear/anxiety/avoidance is not better
explained by other mental d/o.

Cog Behav Therapy

- Graded Exposure
Opiod Related D/O-heroin morphine, codeine 7) Important social/occupational/recreational
Lifetime prevalence: 1% activity are given up because of opioid use.
8) Recurrent use opioid in situation which is
Administration physically hazardous.
- IV 9) Continued opioid use despite knowledge of
- Smoking(catching the dragon) having persistent/recurrent
- Snorting physical/psychological problem that is likely
to have been caused/exacerbated by opioid
*Endogenous opiod: endorphine, dynorphine, use.
enkephaline 10) Tolerance, defined as either of the following:
- A need of markedly increase in amnt of
- orally
opioid use to achieve intoxication/desire
Action on opioid receptor effect.
- A markedly diminished effect of continue
- *M-analgesia, resp depression, constipation, use of same amnt of opioid
dependence* 11) Withdrawal, manifested either of following:
- K-analgesia, diuresis, sedation - A characteristic withdrawal sx of opioid
- ∆-analgesia - Opioid is taken to relieve/avoid
withdrawal sx
-interaction w reward circuit pathway
Diagnostic Criteria for Opioid Intoxication
-interaction w noradrenergic neuronewithdrawal sx

-cause tolerance & dependence after long time use. A) Recent use of opioid
B) Clinically sig problematic behavioural/
-withdrawal occur when abrupt stop or administration of psychological change dev during/shortly after
opioid antagonist. opioid use.
Comorbidity C) Pupillary constriction (pupillary dilation d/t anoxia
from severe overuse) & >1 of following develop
- Mood d/o, anxiety d/o, antisocial during/shortly after opioid use
personality d/o, accohol related d/o. - Drowsiness/coma
- Slurred speech
Dx criteria for opioid use d/o
- Impairment in attention/memory
A) Aproblematic pattern of opioid use leading to D) The sx are not attributable to another medical
clinically sig distress/impairment, manifested as 2 condition/not better explained by other mental
or more of following in 12 month period. d/o.
1) Opioid taken in large amount/longer period
Dx criteria for Opioid Withdrawal
than was intended
2) Persistent desire/unsuccessful effort to cut A) Presence of either of following
down/control opioid use. 1) Cessation of/reduction in heavy prolonged
3) A great deal of time is spent to opioid use.
obtain/use/recover from its effect 2) Administration of opiod antagonist after a
4) Craving/a strng desire/urge to use opioid period of opiod use.
5) Recurrent opioid use leading tofailure to fulfil B) >3 of following dev within minutes to few days
major role at work. after criteria A.
6) Continued opioid use despite having 1) Dysphoric mood
persistent/recurrent social/interpersonal 2) Nausea/vomiting
problem caused/exacerbated by opioid use. 3) Muscle ache
4) Lacrimation/rhinorrhea
 5) Pupillary dilation/piloerection/sweating i) Given when pt no longer had
6) Diarrhoea withdrawal.
7) Yawning ii) Reduce the craving.
8) Fever c) Psychological:
9) Insomnia - Psychoeducation
C) The sx in criterion B causes clinically sig - Motivational interview
distress/impairment in functioning. - Cog Behav Therapy
D) The sx are not attributable to another medical i) Coping skills
condition/ not better explained by other mental ii) Relapse prev therapy
d/o. - Therapeutic community
- Narcotic anonymous
*Morphine & heroin: withdrawal begin 6-8 hours after
last dose, peak in 2-3days, subside during next 7-10
days, but some sx persist >6months.

*Methadone: begin 1-3 days after last dose, end in

10-14 days.

Clinical features

- Euphoria, feeling of warmth, heaviness of

extremities, dry mouth, itchy face, facial
flushing, sedation
- Resp depression
- Opioid Overdose: coma, pinpoint pupil,
resp depression

Mx:

1) Investigation
a) Biological: FBC, RP, LFT, Urine for drug
b) Psychososial: collateral hx from family
member & friends
2) Treatment
a) Acute(overdose):
- Sustain airway
- Administration of naloxone(opioid
antagonist) at slow rate with 0.8mg/70kg
of patient. Beware sn of withdrawal.
b) Long term
- Methadone(once daily)(w pt had
withdrawal):
i) can cause dependance, sedation,
resp distress.
ii) Can be given to pregnant lady.
- Buprenorphine(w pt had withdrawal):
i) can be given to pt w resp
problem.
- Naltrexone:
Obsessive Compulsive D/O
Epidemiology
- Lifetime prev: 2-3%
- Adults: male=female
- Adolescence: Male>female
- Male had younger age of onset
- Mean age: 20
- More common in single
Comorbidity
- MDD (67%)
- Social phobia (25%)
- Alcohol use d/o, gen anxiety d/o, specific
phobia, panic, eating d/o
Etiology
- Genetic: relative w OCD 3-5X higher than
control.
- Behavioural : learning theory
Diagnostic criteria:
A) Presence of obsession, compulsion, or both
Obsession is defined by 1 or 2:
1) Recurrent & persistent thought, urge, or
image that are experienced as intrusive &
unwanted which is causing markedly
anxiety/distress.
2) The individual attempt to ignore/suppress
those thought, urge or image or to neutralize
them by performing compulsion
Compulsion are defined by 1 or 2:
1) Repetitive behaviour/mental acts that
individual feel driven to perform in response
to an obsession or according to rule that must
be applied rigidly.
2) Those behaviour or mental acts are aimed to
prevent/reduce anxiety/distress or to prevent
dreaded/situation, but those behaviour/
mental acts are not connected in realistic way
with what they are design to prevent or
neutralize, or are clearly excessive.
B) The obsession/compulsion are time consuming or
cause clinically sig distress/impairment in
functioning.
C) The obsessive-compulsive sx are not attributable
to substance/other medical condition.
D) The obsessive compulsive sx are not better
explained by other mental d/o.
*1) Good/Fair insight
Clinical feature 2) Poor insight
3) Absent insight
Symptom patterns:
1) Contamination: obsession of contamination
followed by compulsion of washing
hands/avoidance.
2) Pathological doubt: obsession of doubt with
compulsion of checking.
3) Intrusive thought: intrusive obsessional thought
without compulsion, thought of sexual/aggressive
act/suicidal ideation.
4) Symmetry: with compulsion of slowness
5) Others: religious obsession, compulsive hoarding,
compulsive hair pulling/nail-bitting, masturbation,
counting.
Course & Prognosis
- >50% had sudden onset, 50-70% after
stressful life event
- 20-30% sig improvement, 40-50%
moderate improvement, 20-40%
remain/worsen
- Good prognosis- good social &
occupational adjustment, presence of
precipitating event, episodic nature of sx.
- Poor prognosis: yielding to compulsion,
childhood onset, bizarre compulsion,
need for hospitalization, MDD, delusion,
overvalued ideas & personality d/o.
Treatment
1) Pharmacological:
- SSRI(high dose, sertraline)
- clomipramine,
- BDZ.
2) Psychological
- Psychoeducation(family session & patient)
- Behaviour therapy(Exposure & response
prevention)
- Relaxation technique(breathing exercise,
progressive muscular relaxation)
-- Family
Family therapy
therapy
- Group therapy
 - Group therapy
Alcohol use & related D/O
Diagnostic criteria for alcohol use d/o
A) A problematic pattern of alcohol use leading to
clinically sig distress/impairment, as manifested
by 2 or more of following in 12 month period:
1) Alcohol is always taken in larger amnt/longer
period than was intended.
2) Persistent desire/unsuccessful effort to cut
down/control alcohol use.
3) A great deal of time is spent to
obtain/use/recover from its effect.
4) Craving/A strong desire/urge to use alcohol.
5) Recurrent alcohol use causing failure to fulfil
major role at home/school/work.
6) Continued alcohol use despite having
persistent/recurrent social/ interpersonal
problem that is caused/exacerbated by
alcohol.
7) Important social/occupational/ recreational
activity are given up because of alcohol use.
8) Recurrent use of alcohol in situation which is
physically hazardous.
9) Continue alcohol use despite knowledge of
having persistent/recurrent
physical/psychological problem that is likely
to have been caused/exacerbated by alcohol.
10) Tolerance, defined as either of the following:
a) A need of markedly increase in amnt of
alcohol use to achieve desire
effect/intoxication.
b) A markedly diminished effect with
continue use of same amnt of alcohol.
11) Withdrawal, manifested by either of
following:
a) A characteristic withdrawal synd of
alcohol.
b) Alcohol is taken to relieve/avoid
withdrawal sx.
Diagnostic criteria of alcohol Intoxication
A) Recent ingestion alcohol
B) Clinically sig problematic behaviour/psychological
change
C) 1 or more of following develop during or shortly
after alcohol use:
1) Slurred speech
2) Incoordination
3) Unsteady gait
4) Nystagmus
5) Impairment in attention/memory
6) Stupor/coma.
D) The sx/sn are not attributable by other medical
condition/not better explained by oyher mental
d/o.
Diagnostic criteria of alcohol withdrawal
A) Cessation of/Reduction in prolonged & heavy
alcohol use.
B) 2 or more of following sx dev within several hours
to a few days after criteria A:
1) Autonomic hyperactivity(sweating, ↑pulse
rate)
2) ↑hand tremor
3) Insomnia
4) Nausea/vomiting
5) Transient visual/tactile/auditory
hallucination /delusion
6) Psychomotor agitation
7) Anxiety
8) Generalized tonic clonic seizure
C) Criterion B cause clinically sig distress/impairment
in functioning.
D) Sx & sn not attributable by other medical
condition/not better explained by other mental
d/o.
Management:
Ix:
1) Biological:
- FBC(polycythemia), LFT(chronic use of
alcohol & the drugs might be given
metabolised by liver), renal
profile(electrolyte imbalance).
- Blood alcohol level.
- Random blood glucose(alcohol use aw
hypoglycemia)
- Fasting lipid profile(prolong alcohol use
aw increased in triglyceride)
- Urine for drugs(tro substance use)
 2) Psychosocial
- Collateral hx from family member(tro
depression).
- Trace old notes if any.

Treatment: (DO NOT GIVE BDZ WHEN PT INTOXICATED)

1) Pharmacological:
a) Acute: IM Haloperidol to sedate pt.
b) In the ward:
(prevent seizure & delirium tremens*(acute
psychotic cond involve tremor,
hallucination,disorientation) which can cause
death)
- Diazepam(10mg tds):
i) to ↓ & control withdrawal sx.
ii) high dose initially, ↓dose by 20%
every 2 days.
- IM/IV/oral thiamine 100mg per day to
prevent Wernicke Korsakoff syndrome.
i) Wernicke encephalopathy(acute):
confusion, ataxia,
ophthalmoplegia.
ii) Korsakoff syndrome(chronic):
inability to form new memory,
memory loss, confabulation,
hallucination.
iii) Wernicke can proceed to
korsakoff if left untreated.
- IV dextrose if pt hypoglycaemic
- Provide high caloric food.
c) Rehabilitation:
- Disulfiram(pt cannot take alcohol 12 hr b4
& after taking this)
- Naltrexone(↓craving)
- Acamprosate(not in M’sia)
2) Psychological
a) Psychoeducation
b) Motivational interview
c) Alcohol anonymous
d) Cog Behavioural Therapy
- Coping skills
- Relapse prevention.