Lecture Notes on Psychiatry

Study Notes in Psychiatry (2008)

Study Notes in Psychiatry (For MBBS III to V)

Dr. Roger Ho

Table of Content Ch. 1 Introduction

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Ch.2 Signs & symptoms Acute management Ch. 3 Schizophrenia

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Ch. 4 Delusional disorder

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Ch. 5 Bi Bipolar disorder

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Ch. 6 Depressive disorder

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Ch. 7 Obsessive compulsive disorder Ch. 8 Anxiety, ety, Panic, ic, Ph Phobia

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Ch. 9 Post traumatic stress disorder, Acute stress, grief Ch. 10 Alcoholism

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Assistant Professor Department of Psychological Medicine, NUS

Ch. 11 Drug Dependence

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Ch. 12 Old age psychiatry

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Email: [email protected]

Ch. 13 Consultation Liaison Psychiatry Ch. 14 Perinatal Psychiatry

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

Version: May 2008

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

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Ch. 17 Pers ersonality Dis Disorder rder

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Ch. 18 Psychiatric emergencies Ch. 19 Sl Sleep disorders

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Ch. 20 Child Psychiatry

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Ch. 21 Learning disability

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Ch. 22 Legal aspect

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Ch. 23 Ps Psychotherapy

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Chapter 1 Introduction The purpose of writing this set of notes is to provide a concise summary of psychiatry and to help medical students to have rapid review for examination. Ch. 2 Definitions of signs and symptoms The MCQ exam often confuses you with the following terms (Levi, 1998):

Echolalia Repetition by the patient of the interviewer’s words or phrases Stereotypy Regular, repetitive non goal-directed movement (purposeless) Waxy flexibility Patient’s limb can be placed in an awkward posture and remain fixed in position for long time despite asking to relax; occurs in Schizophrenia (SZ) Catalepsy Motor symptom of schizophrenia, same as waxy flexibility

Automatic obedience Patient does whatever the interviewer asks of him irrespective of the consequences Mitgehen An extreme form of mitmachen in which patient will move in any direction with very slight pressure Ambitendence The patient beings to make a movement but before

Echopraxia Imitation by the patient of the interviewer’s movements. Mannerism Abnormal, repetitive goal-directed movement (of some functional significance) Mitmachen Patient’s body can be placed in any posture; when relaxed, patient returns to resting position

Cataplexy Symptom of narcolepsy in which there is sudden loss of muscle tone leading to collapse, occurs in emotional state. Gegenhalten (opposition) The patient will oppose attempts at passive movement with a force equal to that being applied. Negativism Extreme form of gegenhalten, motiveless resistance to suggestion/ attempts at movement. Preservation The senseless repetition of a previously requested

Dr. Roger Ho

completing it, starts the opposite movement Neologisms The patient uses words or phrases invented by himself Obsessions Recurrent, persistent thoughts, impulses, images that the patient regards as absurd and alien while recognising as the product of his own mind. Attempts are made to resist or ignore them Verbigeration (word salad) Disruption of both the connection between topics and finer grammatical structure of speech Occurs in SZ Loosening of associations Loss of the normal structure of thinking. Muddled and illogical conservation that cannot be clarified Occurs in SZ

Depe Depers rson onal alis isat atio ion n A change in self awareness such that person feels unreal Bipolar I Mania Affect Emotional state at a moment Euphoria Sustained and unwarranted cheerfulness

movement, even after the stimulus is withdrawn Metonyms Use of ordinary words in unusual ways Delusions A false belief with the following characteristics firmly held despite evidence to the contrary; out of keeping with the person’s education & cultural background, content often bizarre Vorbeireden (talking past point) The patient seems always about to get near to the matter in hand but never quite reaches it. Occurs in SZ Flight of ideas

Patient’s thoughts and conservations move quickly f rom rom one topic to another, the links between these rapidly changing topics are understandable Associated with rhyming, punning & clang associations. Dere Dereal alis isat atio ion n A change in self awareness such that the environment feels unreal Bipolar II Hypomania Mood Emotional state over a longer period Euthymia A normal mood state Neither depressed or mania

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Chapter 3

Schizophrenia

3.1 Types of schizophrenia - Paranoid schizophrenia: prominent well – systematised persecutory delusions or hallucinations. More common with increasing age. - Catatonic schizophrenia: WRENCHES W – Waxy flexibility; catalepsy R – Rigidity E – Echopraxia, echopraxia N – Negativism C – Catalepsy H – High level of motor activity E – Echolalia S - Stupor Other features: automatic obedience, stereotypy; ambitendence, mannerism; mitmachem; mitgehen. 3.2 Epidemiology Median age of onset: Male Female 23 years 26 years (earlier onset) (later onset) Sex: equally between men & women Social class: increased prevalence in lower social class Season of birth: increased incidence in winter months Prevalence rate: 1% of general population Incidence: 15/100 000 3.3 Aetiology - Genetics: Heritability: 60-80% - Family studies show the prevalence rates of schizophrenia in relatives as follows: Relationship to to SZ SZ Prevalence ra rate Parent of a SZ 5% Siblin bling g of of a SZ/ DZ DZ Tw Twin 10% 10% Child of of on one SZ SZ parents 14% Child of two SZ parents 45% Mono Monozy zygo goti tic c twin twins s of SZ 45% 45% Biochemical theories: 1)) Dopamine over-activity: high level of dopamine within mesolimbic cortical bundle. (eg amphetamine increase dopamine release; Haloperidol reduces its release). 2) Serotonergic overactivity: LSD, inc 5HT, leads to hallucination, clozapine has serotonergic antagonism.

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3) α1 – adrenergic overactivity . 4) Glutaminergic hypoactivity : ketamine, NMDA antagonist, induce SZ symptoms 5) GABA hypoactivity which leas to overactivity of dopamine, serotonin, noradrenaline. Environmental factors: - Complications of pregnancy, delivery. - Maternal influenza in pregnancy, winter births - Non – localising soft signs in childhood: astereognosis, dysgraphaesthesia, gait abnormalities, clumsiness. - Disturbed childhood behaviour - Degree of urbanisation at birth 3.4 Pathogenesis (Appendix 3a/3b) 1) Neurodevelopmental hypothesis 2) Thickening of corpus callosum 3) Ventricular enlargement 3.5 Clinical features (appendix 3c) - First rank symptoms/ Positive - Negative symptoms - Neologisms, Metonyms 3.6 Diagnosis (DSM – IV) - At least 2 of the following for at least 1 month: (ABCD + PLANT V) - Social / occupational dysfunction - Post – schizophrenic depression is common 3.7 Differential diagnosis: Young adults Older patients - Drug induced - Acute organic psychosis syndrome: - Temporal lobe encephalitis epilepsy - Dementia - Diffuse brain disease Other DDX : psychotic depression, paranoid personality disorder 3.8 PE and Investigation - Full neurological examination: gait and motor - Cognitive examination: MMSE - Blood: FBC, LFT, RFT, TFT, glucose. - CT or MRI brain - Urine drug screen - EEG if suspects of TLE

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Dr. Roger Ho

Management: 3.9 Conventional antipsychotics Typical antipsychotics: -Chlorpromazine: more antiadrenergic & antihistaminergic (100 – 400mg daily) - Haloperidol: more EPSE (5 – 10mg daily) - Trifluperazine: more EPSE: 5 – 10mg daily Block mesolimbic Antipsychotic action cortical bundle Blk Nigrostriatal Extrapyramidal effects Blk TuberoGalactorrhoea infundibular activity

idiosyncratic effects - High incidence of EPSE

Side effects of typical antipsychotics:

Other preparations of risperidone: PO Risperdal quicklet: quickly dissolve in mouth PO Risperdal solution: 1mg/ml $70/ bottle. IM Risperdal consta – only atypical depots Start with IM 25mg, increase to 37.5mg every 2 weeks

1) Extrapyramidal side effects (EPSE): -Acute dystonia: treated by IM antimuscarinic (congentin 2mg) - Akathisia: restlessness: treated by propanolol 10mg TDS - Pseudoparkinsonism: oral antimuscarinic: benhexol 2mg BD - Tardive dyskinesia 2) Hyperprolactinaemia 3) Antiadrenergic: sedation, postural hypotension, failure of ejaculation 4) Anticholinergic: dry mouth, urinary retention, constipation 5) Antihistaminergic: sedation 6) Antiserotonergic: depression More on Tardive dyskinesia (TD) - After chronic use of antipsychotic - Due to upregulation of postsynaptic Dopamine receptors in Basal Ganglia - More common in female - History of chronic brain disease: risk factor -slow writhing movement (athetosis) -Sudden involuntary movements - Oral lingual region (chorea) - Temporary raise the dose may give immediate relief; try to maintain minimum effective dose in long run - Change to atypical antipsychotics - Vitamin E may prevent deterioration - Anticholinergic will worsen TD. Conventional depot antipsychotics IM Flupentixol 20 – 40mg 4 weekly (Fluanxol) Other Modecate, Clopixol - Long acting depot injection for non compliant patients. - To give a test dose to ensure no

3.10 Atypical antipsychotics Risperidone: 1-2mg ON ($1/mg) Higher affinity of D2 in mesolimibic and less in nitrostriatal; higher affinity for 5HT2 and α1 receptors.

Side effects: - EPSE (if high dose like 4mg daily) - Elevation of prolactin (strongest among atypicals) - Antiadrenergic side effects

Olanzapine: 5- 10mg ON ($1/mg) Moderate for D2; High affinity for 5HT2 and muscarinic receptors

Side effects: - Weight gain and increase appetite - Sedation - Antiadrenergic side effects - Prolongation of QT interval on ECG - Hyperprolactinemia (transient) Quetiapine: 100 – 800mg daily ($2/100mg) Weak for D2, High affinity for 5HT2 and α1

Side effects: - Antiadrenergic side effects like postural hypotension - Prolong QT interval - Almost no EPSE (same as placebo) - No ↑ in prolactin (same as placebo) Sulpiride 200mg – 400mg ON (IMH) - Low dose: block D3 and D4: negative symptoms - High dose: block D2 and D1: positive symptoms - Fewer EPSE, less sedation, cause galactorrhoea. Clozapine: more active at D4, 5HT2, α1 & muscarinic receptors

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for treatment resistant SZ.(failure of 2 antipsychotics with adequate dose)

Side effects include: - Life threatening agranulocytosis 2-3%; needs regular FBC under clozaril patient monitoring programme (IMH) - Hypersalivation - Anticholinergic and antiadrenergic. - Fewer EPSE 3.11 Psychological treatment: -Psychoeducation can prevent relapse by enhancing insight -Cognitive Behavioural therapy (CBT) to challenge delusions. -Social skill training : improve relationship - Behavioural: positive reinforcement of desirable behaviour. Family therapy: to reduce expressed emotion (EE). (High EE include hostility, over-involvement, critical comments from family; hence reduce relapse rate) 3.12 Other treatments: - Rehabilitation (IMH) to enhance self care, compliance and insight. - ECT is for catatonic schizophrenia

Causes of relapse: 1) Iatrogenic relapse: reduction of dose by doctor 2) Non compliance 3) High expressed emotion 3.14 Complications of SZ - Water intoxication in chronic schizophrenia, leading to hypanatraemia. - Suicide is the most common cause of death of SZ, 10-38% of all deaths of SZ. - SZ and violence: controversial: senior psychiatrists say no but recent findings support the association. In exam, safer to say no association. Schizoaffective disorder

It is a disorder in which the symptoms of schizophrenia and affective disorder are present in approximately in equal proportion. ICD 10 requires both psychotic and mood episode are simultaneously present and equal prominent. Treatment: Antipsychotics + antidepressant or mood stabilizer.

Indications for Hospital admission: Suicide / violent Severe psychosis Severe depression Catatonic schizophrenia Non – compliance Failure of outpatient treatment

Schizotypal personality disorder

3.13 Prognosis Rules of quarters 25% 25% Complete Good Remission recovery

U – unusual perception: eg telepathy F – Friendless O – Odd belief and odd speech

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- There is familial relationship between schizotypal personality disorder & schizophrenia

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25% Partial recovery

25% Downhill course

Good prognosis: - Marked mood disturbance - Family history of affective disorder - Female sex - Living in a developing country - Acute onset - Good premorbid adjustment Poor prognosis: adolescence or early onset, enlarged ventricles.

Clinical features: UFO RIDE

R – Reluctant to engage I – Idea of reference D – Doubtful of others E – Eccentric behaviour - Poor prognosis: 50% develop schizophrenia Schizoid personality disorder – introspective’ prone to engaged in an inner world of fantasy rather than take action; lack of emotional warmth and rapport; self sufficient and detached; aloof and

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humourless; incapable of expressing tenderness or affection; shy; often eccentric; insensitive; ill – at – ease in company Ch.4 Delusional Disorder (Oxford Handbook, 2004) 4.1 Types of delusional disorder (DSM IV) - Erotomanic (de Clerambault syndrome): Important person like PM is secretly in love with them; usually female; make effort to contact important person. - Morbid jealousy (Othello syndrome): fixed belief that their spouse has been unfaithful; collect evidence for sexual activity & restrict partner’s activity; may result in violence. - Persecutory: Most common type; others are attempt to harm; to obtain legal recourse - Grandiose: special role, relationship, ability, involved in religion. - Somatic: delusion belief about body (abnormal genitalia) to infestation: (worms crawling in the body) - Folie a deux – shared delusion between husband and wife (close relationship) Delusional misidentification syndrome: Capgras delusion Fregoli delusion Other have been Someone they know identified by identical in disguise and or near identical harming him imposter 4.2 Epidemiology - Uncommon: 0.025 – 0.03% - Mean age: 40 – 49 years - Usually equal in M and F; Morbid jealousy more common in alcoholic male; Erotomania more common in female 4.3 Risk factors and aaetiology - advanced age, isolation, low social status, premorbid personality disorder, sensory impairment, substance abuse, family history, history of Head Injury, Immigration

- Temporal lobe epilepsy, 4.4 Pathogenesis: - Cortical damage: paranoid delusion - Basal ganglia – less cognitive disturbance - Folie a deux: one dominant and one submissive partner in a relationship

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- Delusions are highly implausible, - with evidence of systematization (better organized than SZ delusion); - huge impact on behaviour, - abnormal process in arriving conclusion 4.6 Diagnosis: DSM IV requires > 1 month duration 4.7 Differential diagnosis Young patients Old patients - Substance induced - Dementia- memory (stimulant, loss hallucinogen) - Mood disorder with - Delirium: change in delusion (mood consciousness before delusion) - Schizophrenia (less - Late onset elaborated delusion) psychosis (with - OCD: reality testing hallucination) is intact - Paranoid personality disorder (Less clearly circumscribed delusion) 4.8

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Assessment A thorough history and MSE Collateral history from 3rd party To rule out organic causes Document risk assessment

4.9 Management - Admission to hospital if there is a risk to self or violence to others. - Separation from source or focus of delusion - Antipsychotics: atypical: less side effect - Both risperidone and Haloperidol have liquid form: for those refusing tablets - Benzodiazepine to treat anxiety Psychological treatment - Supportive psychotherapy: to establish therapeutic alliance without confronting - Cognitive techniques: gently challenge delusion - Social skill training - Improving risk factors : sensory deficits, isolation 4. 10 Prognosis Remission Improvement 33-50% 10%

Persisting 33-50%

4.5 Clinical features:

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Ch. 5

Better prognosis if it is acute; Poor prognosis if delusional disorder last longer than 6 months. Bipolar disorder

5.1 The affective spectrum - Dysthymia – not meeting criteria of depression - Depression - Atypical depression: hypersomnia, hyperphagia - Psychotic depression - Recurrent depression - Bipolar II – Hypomania - Bipolar I – Mania - Rapid cycling > 4 episodes per year - Ultra – rapid cycling: very rapid changes 5.2 Epidemiology - Lifetime prevalence: 0.3 – 1.5% - M = F in prevalence - Bipolar II / rapid cycling: more common in Female - Mean age of onset: 21 years old 5.3 Aetiology - Genetics: 1st degree relative are 7x more likely to develop this condition. - Children of a parent with bipolar disorder have a 50% chance of developing psychiatric disorder - MZ:DZ 45%: 23% 5.4 Pathogenesis - Noradrenaline, dopamine, serotonin, & glutamine have all been implicated. - Antidepressant induced mania or hypomania is common. 5.5 Clinical features Hypomanic episode: MANIAC (Clinical skill training)

For mania, on top of MANIAC, they also have: - severe enough to interfere social & occupation function. - Psychotic features related to grandiosity. - Flight of idea, Pressure of speech - Racing thought - Behaviours with serious consequences: reckless spending, inappropriate sexual encounters, careless investment.

Dr. Roger Ho

DSM IV diagnosis - Bipolar I disorder: occurrence of 1 or more manic episode with or without history of 1 or more depressive episode. - Bipolar II disorder – occurrence of 1 or more depressive episode accompanied by at least 1 hypomanic episode. 5.7 DDX: - Substance abuse (if young) - Organic: thyroid, cushing, SLE, head injury - Psychotic disorders (if psychotic features) - Schizoaffective disorder (prominent psychosis) - Anxiety disorders 5.8 Investigation - FBC, ESR - LFT, RFT, TFT, glucose - VDRL - Urine drug screen - CT/MRI to rule out space occupying lesion, infarction, haemorrhage - EEG to rule out epilepsy

Other tests: - ANF to rule out SLE in ladies - Urinary copper to rule out Wilson disease 5.9 Setting of Treatment:

Usually require admission for manic episode; ward has to be calm with less stimulation. Indications for admission include: - High risk of suicide or homicide - Lack of capacity to cooperate with treatment - Poor psychosocial supports - Severe psychotic symptoms - Severe depressive symptoms - Rapid cycling - Failure of outpatient treatment Goals of outpatient treatment - Establish & maintain therapeutic alliance - monitor psychiatric status - Psychoeducation for bipolar disorder - Enhancing treatment adherence - Monitoring side effects of medication - Promoting regular sleep and activity - Identify new episodes early

5.6 Diagnosis

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Dr. Roger Ho

- For rapid cycling disorder 5.9 Pharmacological Management Acute treatment of manic phase : By antipsychotics:

Haloperidol 5-10mg daily; Risperidone 2- 4mg daily Olanzapine (more sedative & good for mood symptoms but expensive): 5- 10mg daily Then add on mood stabilizer after blood investigations. Lithium CR (500mg – 1000mg $0.3-0.6) Before starting lithium, RFT & TFT have to be normal. Mechanism of action : - By stimulating Na/K pump, stimulates entry of Na into the cells where intracellular Na is reduced in manic state; stimulates exit of Na from cells where intracellular Na is elevated in depressed state. - Inhibits both cyclic AMP and inositol phosphate second messenger system in the membrane. Indications: - For depression, manic states - Prophylaxis of bipolar disorder - not useful for rapid cycling Adverse effects: - Short term side effects : GI disturbances (nausea, vomiting, diarrhea) - Long term side effects : nephrogenic diabetes insipidus due to blockage of ADH sensitive adenyl cyclase, hypothyroidism and cardiotoxicity - Toxic effects (refer to appendix 5a): Lithium overdosage can be fatal. - Ebstein anomaly in foetus. Sodium valporate (Epilim) (400mg – 1000mg) ($0.5 – 1) Before starting Valporate, check LFT Mechanisms - mediate its therapeutic effect by indirect inhibitions on GABAergic systems. Indications: - Treatment of depressive and manic episodes - Prophylaxis of bipolar affective disorder

Adverse effects: - Slight risk of liver, pancreatic toxicity - Haematological disturbance of platelet function; Neural tube defect in foetus Carbamazepine 400– 800mg ($0.2-0.4) Check FBC before starting carbamazepine Mode of action: - Mediate its therapeutic effect by inhibiting kindling phenomena in the limbic system Indications: - Depression - Prophylaxis of bipolar affective disorder Adverse effect: - Drowsiness and dizziness - Leucopenia and other blood disorders Lamotrigine 50 – 150mg 100mg = $3 For bipolar disorder with depressive episodes 5.10 Psychological Management - Cognitive therapy to challenge grandiose thought - Behavioural therapy to maintain regular pattern of daily activities - Psychoeducation on bipolar disorder - Family therapy: Psychoeducation for family & techniques to cope with patient’s illness - Relapse drills: to identify symptoms and to formulate a plan to seek help in early manic phase. - Support group for bipolar patients. 5.11 Other treatment - ECT: Best for acute mania, failure to drug treatment, for pregnancy (to avoid teratogenic effects) 5.12 Course and Prognosis: -Extremely variable -First episode may be hypomanic, manic, mixed, or depressive - Length of time between subsequent episodes may begin to narrow but stabilize at 4th to 5th decade. - Untreated patients have > 10 episodes in a lifetime. - Treated patients have better prognosis 5.13 Complication:

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- Morbidity and Mortality rates are high: lost work, lost productivity, divorce, attempted suicide 25-50% & committed suicide: 10% Ch. 6 Depressive Disorder 6.1 Epidemiology Age: Women, highest prevalence between 35 and 45 years; Men increases with age Sex: F:M = 2:1 Social class: more common in I (rich), II and V (poor) More common among divorced, separated Prevalence: 5% 6.2 Aetiology: - Genetics: Prevalence in first rate relatives: 1015% - Monoamine theory of depression: depletion of monoamine such as 5HT & NA - Endocrine abnormalities: hypersecretion of cortisol, decreased TSH Psychological theory: - Maternal deprivation when young - Learned helplessness: highly aversive outcomes are possible.- Cognitive distortions: 1) Arbitrary inference: drawing conclusion when there is no evidence. 2) Selective abstraction – ignore important feature 3) Over-generalisation from single incident 4) Minimisation positive and magnitification of negative Social theory: for women, (Brown & Harris) -3 or more children under 15 yr of age -not working outside -lack of supportive relationship from hd. -loss of mother/separation before age 11 -Threatening life event before depression 6.3 Clinical features: - DEPESSION – refer to clinical skills -Severe depression may have psychotic features: -Delusions concerned with themes of worthlessness, guilt, ill-health, poverty -Persecutory delusion: people are about to take revenge on him - Hallucination: second person auditory hallucination: repetitive words & phrases 6.4 DDX: - Is it mixed anxiety & depression? - Is it bipolar disorder? - Endocrine: hypothyroidism - Medication related: antihypertensive, steroid - Alcohol abuse 6.5 Investigations: FBC, ESR, B12, Folate, RFT, LFT, TFT

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6.6 Pharmacological Management: Selective serotonin reuptake inhibitors SSRI -Fluoxetine (Prozac) 20mg OM ($0.2) for retarded depression; adverse effect: Restlessness; Long half life, avoid in elderly with a lot of medication; (first line nowadays) - Fluvoxamine (Faverin) 50mg -100mg ON; $0.5 Sedative; high incidence of nausea & vomiting in first few days. - Paroxetine CR (Seroxat) 25mg ON, $2: good for mixed anxiety & depression; more withdrawal symptoms - Escitalopram (lexapro) 10mg ON, $1.5; less drug interaction, good for elderly - Setraline (Zoloft) 50 – 150mg ON; $1.8 -Noradrenergic and specific serotonergic antidepressants (NaSSas): Mirtazepine (Remeron) 15-30 mg ON ($1-2); 5HT-2 and 5HT3 postsynaptic receptor antagonist & antihistamine effects. - good for depression and insomnia - drowsiness and weight gain - No serotonin related side effects: sexual dysfunction, insomnia, agitation, nausea - No cardiovascular or anticholinergic side effects - Serotonin & Noradrenaline reuptake inhibitor: Venalfaxine (Efexor) 75 mg BD $5.6; second line, high dose  hypertension Duloxetine(Cymbalta) 60mg ON for pain & depression - TCA: amitriptyline 50 – 100mg ON, cardiotoxicity when overdose, anticholinergic side effects; MAOI: seldom used - ECT: for actively suicidal patients, not eating & drinking, treatment resistant depression -ECT has wide range effects on monoamine -Absolute contraindication: raised ICP -Relative contraindications: cerebral aneurysm, recent MI, cerebral haemorrhage, retinal detachment. -Early side effects: loss of short term (retrograde) memory, headache, confusion, muscle aches -Late side effect: long term memory loss Mortality of ECT: 2/100, 000 6.7 Psychological Treatment CBT: Cognitive: Identify cognitive dysfunctions from dysfunctional thought diary; patient will

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examine evidence for and against them; cognitive restructuring to change distorted thought; Behavioural: increase pleasurable activities.

Ch. 7 Obsessive Compulsive Disorder 7.1 Epidemiology - Onset is most commonly in early adult life - Equally common among men and women - Prevalence 0.05% 7.2 Aetiology - Genetic: MZ: DZ 80%: 25% - Organic factor: during epidemic of encephalitis lethargica - Premorbid personality: 70% of OCD patients have obsessive compulsive personality trait- cleanliness, orderliness, rigid, checking 7.3 Pathogenesis - Dysregulation of the 5HT system - Cell immediated autoimmune factors - CT/ MRI: bilateral reduction in caudate nucleus. - Psychological explanation: OCD patients have defective arousal system and inability to control unpleasant internal states. Obsessions (fear of dirt) are stimuli associated with anxiety provoking events where compulsions (such as hand washing) are learned to reduce anxiety. 7.3 Clinical features OBSESSION – DIRT Doubts: repeating themes expressing uncertainty about previous actions: turned off the tap or not Impulses – Repeated urges to carry out actions that are usually embarrassing or undesirable e.g shout obscenities in church Ruminations – repeated worrying themes of more complex thought – the end of the world. Thought – repeated and intrusive words or phrases Compulsions – Cs (refer to clinical skills training) A compulsion is usually associated with an obsession as if it has the function of reducing the distress caused by obsession. E.g obsessional thought with hand contamination, associated with handwashing compulsion. 7.4 DDX:

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Anxiety disorders Phobic anxiety disorders Psychotic disorders Organic disorders Depressive disorders

7.5 Pharmacological treatment - SSRIs are indicated in the treatment of OCD. OCD require higher doses of SSRIs compared to depression. - Fluvoxamine (Faverin) 150mg – 200mg - Fluoxetine (Prozac) 40mg – 60mg - Paroxetine CR (Seroxat) 25mg – 75mg: for very anxious patients. 7.6 Psychological treatment Cognitive therapy: to use dysfunctional thought diary to record obsessions and gently challenge obsessional thought. Behavioural therapy: Exposure and response prevention. This technique involves exposing patient to situations they avoid such as dirty places and the patient is subsequently prevented from carrying out the usual compulsive cleansing rituals until the urge to do it has passed (response prevention) Thought stopping: The patient is asked to ruminate and upon doing so, the therapist shouts “stop” to teach the patient to interrupt the obsessional thought. The patient then learns to internalize the “stop” order so that thought stopping can be used outside therapy situation. Rehabilitation - to maintain functional capacity; - Maintain their strengths - Promote adaptation to everyday living. 7.7 Social treatment Obsessional patients often involve other family members in their rituals. In planning treatment, it is essential to interview relatives and encourage them to adopt a firm but sympathetic attitude to the patient. 7.8 Prognosis - Poor prognosis: Giving in to compulsions, longer duration, early onset, bizarre obsession & compulsion, comorbid delusion and depression

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- Good prognosis: good premorbid,function a precipitating event. OCD does not associate with suicide. Ch. 8 Anxiety Disorders (Ox handbook) 8.1 Generalised Anxiety Disorders Epidemiology: -Lifetime prevalence: 2.5-6.4% -Female> Male - Early onset: with childhood fears - Late onset: stressful life events Aetiology: - Genetics: Heritability: 30% - Increase ANS responsiveness - Loss of control of cortisol - ↓ GABA activity - dysregulation of 5HT activity - Unexpected negative events eg early death of parent - Chronic stressors Clinical features (at least 4) -Autonomic arousal: sweating, shaking -Physical: breathing difficulty, choking, nausea, swallowing difficulty -Mental: dizzy, fainting, derealisation, depersonalization -General: numbness, tingling -Tension: muscle,ache, keyed up -Other: mind going blank, poor concentration DDX: - normal worries - mixed anxiety and depression - Alcohol & drug abuse - Organic: Thyroid disorder, Arrhythmia, Asthma, Temporal lobe epilepsy, hypoglycemia. Investigation: FBC, LFT, RFT, TFT, glucose, ECG Management: -Psychological: relaxation therapy. -Pharmacological: short term benzodiazepine, SSRI (avoid fluoxetine), propranolol for palpitation

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2 peaks in women: 15-24 yr; 45-54 yr Aetiology: - Genetics: 30-40% heritability -Supersensitivity of 5HT1A receptors - Increased adrenergic activity - Decreased in GABA – inhibitory - Fear network in brain: amygdala Clinical features -Palpitations, SOB, choking, shaking - Autonomic arousal - Fear of losing control -Concerns of death from cardiac & respiratory problems DDX/Investigations: similar to GAD Psychological Management: Behavioural: use of relaxation & control of hyperventilation Cognitive method: teaching about bodily responses associated with panic attack Pharmacological: -SSRI: paroxetine, fluoxetine, fluvoxamine are recommended drug of choice - BZDs: alprazolam 0.5mg for acute attack Hyperventilation Syndrome (HVS): - Very common; more common in Female - 50-60% of patients with panic disorder have HVS - Hyperventilation;chest pain;dizziness; bloating; acute hypocalcaemia - Treatment: establish normal breathing pattern, benzodiazepine; breathing into paper bag is not recommended nowadays as CO2 can trigger more anxiety. Agoraphobia: (housebound housewife) 15-35 yr old; more common in women Fear of shops, markets, bus, MRT, crowd, place that cannot be left suddenly

Course: -Chronic and disabling, low remission rate -Can lead to alcohol abuse.

Social phobia 17-30; M = F; avoid situations that can be observed by others (presentation, hawker centre, MRT) & worries of humiliating or embarrassing

8.2 Panic disorder Epidemiology: Lifetime prevalence: 4.2% Women: 2-3 times higher than men

Management: short term benzodiazepine, SSRI Systematic desensitization: imagine or expose to anxiety provoking situations,

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Dr. Roger Ho

progress through hierarchy, neutralize by relaxation technique until patient habituates

- Anxiety symptoms: 2 weeks alprazolam 0.25mg TDS

Chapter 9 Post traumatic stress disorder 9.1 Epidemiology - After traumatic event, 8-13% for men, 20 -30% for women develop PTSD - Lifetime prevalence 8%. - F:M = 2:1

9.7 Complication - 50% recover 1st year; 30%: chronic

9.2 Aetiology - Genetic: higher concordance in MZ than DZ twins - Reduced right hippocampal volume, enhanced reactivity to stimulation & memory deficits - Dysfunction amygdala lead to enhanced fear response Risk factors: -Low education -Lower Social class -Female gender -Low self esteem -Family history of psychiatric disorders - Previous trauma

Protective factors - High IQ - High social class - Male - Chance to view body of dead person

9.3 Clinical features (Appendix 9a) - PTSD is a severe psychological disturbance following a traumatic event characterized by involuntary re-experiencing of the events, with symptoms of hyperarousal, avoidance and flashbacks of events. Longer than 4 weeks. 9.4 DDX - Acute stress reaction - Adjustment disorder 9.5 Psychological treatment - CBT: education about PTSD, anxiety management, anger management, cognitive restructuring for trauma experience, gradual exposure to stimuli avoided - Psychodynamic therapy: understand the meaning of trauma, to resolve unconscious conflict. - Eye movement desensitization & reprocess: Using voluntary multi-saccadic eye movements to reduce anxiety (limited experience in Singapore, don’t mention it in oral exam) - Look for alcohol abuse

Acute Stress Reaction (hrs to days) : A transient disorder (hrs or days) that occur as immediate response to exceptional stress, accident, assault, fire, bereavement). Clinical features: depression and anxiety. Acute Stress disorder (2d – 4 weeks) Similar to acute stress reaction, but more dissociative symptoms Similar to PTSD, but less than 4 weeks duration. Adjustment disorder (3 mo – 6 mo) It occurs within 3 months of a particular stressor & should not last longer than 6 months after the stressor is removed. Manifested as depression and anxiety (no psychotic features). Treatment of above disorders: Supportive psychotherapy to enhance capacity to cope, understand meaning of stressors. Pharmacological: SSRI, short term BZD Normal and abnormal grief reactions - Bereavement: any loss event

- Normal grief: refer to appendix 9a Mean duration: 6 months. - Abnormal grief: 1) Intense 2) Prolonged> 1 year 3) Delayed grief 4) Absent grief Other features: thoughts of death, excessive guilty, marked psychomotor retardation, prolonged impairment of function, hallucination. Management: - Short term benzodiazepine: alprazolam 0.25mg TDS for 2 weeks - Antidepressant if there are depressive symptoms - Supportive psychotherapy: enhance coping

9.6 Pharmacological treatment - Depressive symptoms: SSRI

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Grief therapy: explore the meaning of the loss, let go of the past and move towards the future. Ref: Oxford Handbook, 2004 Ch. 10 Alcohol dependence 10.1 Definition of dependence: 1) Subjective awareness of compulsion to drink 2) Stereotyped pattern of drinking 3) Increased tolerance to alcohol 4) Primacy of drinking over other activities 5) Repeated withdrawal symptoms 6) Relief drinking 7) Reinstatement after abstinence 10.2 Epidemiology Age: men in their early twenties Sex: More common in male; increasing incidence in females. Social class: lowest prevalence in middle social blass Marriage: more common in divorce/separated Occupation: high risk: directors, doctors. 10.3 Aetiology: - Genetic factors: MZ > DZ twins, adoption study also proves genetic links. - Abnormal neurotransmitter mechanism - Learning factors: learn from peer / parents - Personality factors: chronic anxiety, feeling inferior. - Other illness: anxiety disorder, depression

10.4

Clinical features (appendix 10) Alcohol intoxication: explosive outbursts of aggression, short term amnesia after heavy drinking, idiosyncratic reactions to alcohol, pathological drunkenness: acute psychosis induced by small amount of alcohol General withdrawal symptoms: 12-24 hr - Acute tremulousness in hands (the shake) - Agitation, sweating - Nausea - Perceptual distortions & hallucinations - Convulsions Delirium tremens: 3-4days - Clouding of consciousness - Disorientation in time & place - Impairment of recent memory - Illusions & Hallucinations - Fearful affect - Prolonged insomnia

Dr. Roger Ho

- Tremulous hands - Truncal ataxia - Autonomic overactivity Alcoholic hallucinosis -occurs in clear consciousness -voices utter insults or threats, - Causes anxiety in patients Inx: FBC, LFT, U&E, GGT, CXR, glucose 10.5 Management Detoxification: managing withdrawal - Diazepam 5mg TDS, Vitamin, thiamine 30mg OM, B12, Rehydration. Motivation interviewing to help patient to change. Stages of change: precontemplation, contemplation, preparation, action, maintenance, relapse - Refer to CAMP, IMH Pharmacological agents used for maintenance: - Disulfiram: an aversive stimulus, inducing nausea if patient drinks alcohol - Acamprostate: works on GABA/glutamate system, for maintenance - Naltrexone: opiate receptor antagonist, Psychological treatment: Behavioural therapy: keep diary log & tackle drinking behaviour. Social treatment: - Goal orientated treatment plan: Total abstinence: > 40, heavily dependent, physical damage, failed controlled drinking Controlled drinking:< 40, not dependent on alcohol, no physical damage, early stage - Alcoholic anonymous: observe & mirroring, develop coping strategies - Half way house: rehabilitation, counselling 10.6 Complications Nutritional or toxic disorders Wernicke’s Korsakoff’s encephalopathy psychosis Ophthalmoplegia Impairment of recent Nystagmus memory Clouding of Confabulation consciousness Retrograde amnesia Memory disturbance Disorientation Ataxia Euphoria Alcohol dementia - Depression and suicidal behaviours

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-

Dr. Roger Ho

Polysubstance abuse Social complications: job, marriage 10.6 Prognosis: good prognosis in motivated, socially stable, no antisocial personality disorder

- Chronic use can lead to paranoia - Hostility & aggression - Persecutory delusions - Auditory, visual, tactile hallucination - Clear consciousness

Ch. 11 Drug Dependence

11.5 Cannabis Effects

11.1 Definition: It is a state, resulting from the interaction between a human and a drug, characterized by behavioural and other responses that include a compulsion to take the drug on a continuous or periodic basis to experience its psychic effects & to avoid discomfort. 11.2 Physical and psychological dependence Drugs Heroin Hallucinogen Amphetamine Cannabis Cocaine BZD

Physical Yes No No No No Yes

Psychological Yes Yes Yes Yes Yes Yes

11.2 Opiates – eg Heroin Chronic use Withdrawal Constipation Pilo-erection, Constricted pupils shivering Weakness -Abdominal cramps Impotence -Lacrimation Tremors - Dilated pupils - Intense crave for drugs - Agitation Treatment: - Methadone: 20mg solution form, supervised treatment. - Buprenorphine (Subutex) was listed as illegal drug & withdrawan from Singapore. 11.3 Hallucinogens – LSD (lysergic acid diethylamide) - Effects occur after 2 hours of consumption. - Synaethesia: confusion between senses e.g hearing images - Out of body experience - Anxeity and depression - Can lead to unpredictable & dangerous behaviour.

-Exaggerating existing mood -Distortion of time & space -Intensification of visual perception & visual hallucination -Reddening of eye -Irritation of respiratory tract

Chronic effects Chronic amotivational syndrome.

Flashback phenomena Psychotic reactions

11.6 Cocaine Formication (cocaine bugs) – exam classic: a tactile hallucination as feeling insects crawling under the skin.

Treatment of above disorders: may need antipsychotics to treat psychotic experience. 11.7 Benzodiazepine

e.g. Dormicum (Midazolam), Alprazolam (Xanax) Chronic use Withdrawal Unsteady gait Rebound insomnia Dysarthria Anxiety Drowsiness Appetite disturbance Nystagmus Sweating, convulsion Confusion, Delirium tremens Treatment: switch to long acting benzodiazepines such as diazepam 5mg TDS and slowly cut down the dose.

May need in-patient detoxication if using high dose benzodiazepine. Psychological treatment: - Supportive psychotherapy: educate patients on complications of drug dependence and cope with day to day problems. - Group therapy: observe their own problems mirrored in other drug abusers; work out for better coping

11.4 Amphetamines

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- Behavioural therapy: keep a diary of drug use and explore mood and feelings at the time of drug use with therapist and to reduce the number of drug intake. - Rehabilitation in CAMP, IMH: to leave the drug subculture, support by counselor. Ch. 12 Old Age Psychiatry 12.1 Alzheimer’s disease -most common cause of dementia (70%) Epidemiology -1% at 60, doubles every 5 years; 40% at 85 yr old -M:F = 4:1 - Other risk factor: Down syndrome, head injury, hypothyroid

Dr. Roger Ho

Acetylcholinesterase inhibitors: $$$ MMSE > 12 points Donepezil 5-10mg/day: (5mg=$5) long half life, once daily dosage with GIT side effects, not for asthma patients Rivastigmine 3-6mg BD: ($2.6/3mg) short half life, GIT side effects and safe in asthma. Galantamine: 4-12mg BD (8mg = $4.5); also works on nicotinic Ach receptors. Memantine: NMDA receptors partial antagonist (10mg = $3)

Low dose antipsychotics such as risperidone 1mg ON for delusion of theft

Genetics: - Chromosome 21 for amyloid precursor protein - Chromosome 19 for apolipoprotein E4 - Chromosome 14 for presenilin 1 - Chromosome 1 for presenilin 11

Behavioural techniques for changing negative behaviour

Cholinergic hypothesis: degeneration of cholinergic nuclei in nucleus of Meynert

12.2 Other causes of dementia

Poor prognosis: Male, Onset < 65, Parietal lobe damage, prominent behavioural problems, Depression

Pathophysiology -Amyloid plagues in hippocampus, amygdale and cortex -Neurofibrillary tangles in cortex, hippocampus

- Dementia with Lewy body (with parkinsonism) - Fronto – temporal dementia with personality changes - Vascular dementia with neurological signs of stroke

Clinical features Early symptoms: increasing forgetfulness

12.3 Reversible causes of dementia – Appendix 12a

Amnesia Aphasia (word finding difficulty) Apraxia (cannot dress) Agnosia (cannot recognize body parts) Poor visual spatial skill

12.4 Pseudo dementia: always say, “I

Delusion of theft against maid in S’pore Hallucination 10%

12.5 Psychosis in elderly Less than 1%; F:M 5:1 Family history of schizophrenia; sensory impairments, social isolation

Behavioural disturbance: aggression, wandering, sexual disinhibition Mini-mental state exam < 24 /30 Investigations: FBC, B12, Folate, LFT, RFT, VDRL, CT or MRI brain Management:

-

don’t know” Previous history of depression Islands of normality Response to antidepressant

Persecutory delusions: 90% Auditory hallucinations: 75% Visual hallucination 13% Treatment: relieve isolation & sensory deficits; low dose atypical antipsychotics: risperidone 1mg ON / quetiapine 50mg ON

15


12.6 Depression in elderly - more psychomotor retardation - nihilistic delusion (Cotard syndrome) - Monitor suicide risk - Treatment of choice: escitalopram 10mg ON Ch. 13 Consultation Liaison Psychiatry 13.1 Dissociative / Conversion Disorders Definition - Dissociation – an apparent dissociation between different mental activities. - Conversion - Mental energy can be converted into certain physical symptoms. Epidemiology: - Onset usually before the age of 35 - More common among women - More common in lower social class - Occurs in national servicemen Aetiology: - Premorbid personality: 15% has premorbid histrionic personality traits. - Emotionally charged ideas lodged in the unconscious at some time in the past. There is a conversion of psychic energy into physical channels. Pathogenesis - Primary gain: anxiety arising from a psychological conflict is excluded from patient’s conscious mind - Secondary gain: symptoms confer advantage to patient: exempted from NS. Clinical features: Dissociation - Psychogenic amnesia - Psychogenic fugue (wandering) -Somnambulism (sleep walking) - Multiple personality

Conversion - Paralysis - Fits - Blindness - Deafness - Aphonia. - Anaethesia - abdominal pain - Disorder of gait

La Belle indifference: less than the expected amount of distress often shown by patients with hysterical symptoms. DDX: - Exclude organic causes: temporal lobe epilepsy, cerebral tumour, general paralysis of insane dementia - Exclude malingering: conscious aware of what he or she is doing, making up illness

Dr. Roger Ho

- Exclude histrionic personality disorder. Investigation: no demonstratable organic findings Management: Psychological treatment: - reassurance and suggestion - exploratory psychotherapy about his past life. Social treatment: to eliminate factors that are reinforcing symptoms. Biological treatment: Abreaction: IV injection of small amount of diazepam to put patient into resting state and encouraged to relieve stressful life event (last to mention in exam) Prognosis: If the course is longer than 1 year, it is likely to persist for many years. Pseudoseizure: - Inconsistent neurological sign - Can recall the seizure episode & avoid injury - no increase in serum prolactin (increases in genuine epilepsy) 13.2 Hypochondriasis Hypochondriasis is the preoccupation with the fear of having a serious disease which persists despite negative investigation. Epidemiology More common among elderly, equal sex incidence, lower social class Aetiology: - History of childhood illness, parental illness, excessive medical attention seeking in parents, childhood sexual abuse - Tendency to misattribute body symptoms - Medical reassurance provides temporary relief of anxiety which acts as a reward for more medical attention. Clinical features: -Preoccupation with the idea of having a serious medical condition, which will lead to death and serious disability. - Patient will seek medical advice but is unable to be reassured by negative investigations; - Anxiety & depression are common. - It is usually in the form of overvalued idea. Management

16


- Allow patient to ventilate their problems - Explain negative test, reassurance, no further investigation, - Aim to improve function - Break cycle of repeat consultation - Family education - CBT: challenge & replace misinterpretation - Exposure to illness cue & response prevention - Depression: use SSRI like fluoxetine Somatisation disorder A chronic disorder of multiple medically unexplained symptoms, affecting multiple organ systems presenting before the age of 40. It is associated with significant psychological distress. Aetiology - More family members with somatisation disorder; similar to aetiology of hypochondriasis. Epidemiology: - 0.2%; F:M 5:1; age of onset: childhood to 30s Clinical features: Pain: right iliac, back and head CVS: dyspnoea, chest pain, palpitation, BP GI: heartburn, nausea, flatulence, dysphagia Sweating or body odour Management: Initial: -Acknowledge symptom severity & as real -Attempt to reframe symptoms as emotional Ongoing management: -Regular review by single doctor, planned visit, avoid AED & unnecessary investigation - Investigate objective signs only - Symptom re-attribution - CBT Body dysmorphic disorder (Dysmorphophbia): Preoccupation that some aspect of physical appearance (body image) is grossly abnormal & refuses to accept medical explanation. Treated by SSRI and CBT. It can lead to depression, suicide, & functional impairment. Factitious disorder / Munchausen’s syndrome: falsify symptoms & fabricate signs (use ketchup for blood) for medical attention

Dr. Roger Ho

Capacity to give consent 1) Patient must be informed about the procedure, risk and benefit 2) Can patient understand the info? 3) Can patient retain info? 4) Can patient balance the risk or benefit? 5) Can patient arrive at a conclusion? 6) Further assessment of cognitive function e.g mini mental state examination. 7) Having a psychiatric illness like Schizophrenia does not mean lack of capacity to give consent. Delirium/ Acute confusional state It is a clinical syndrome of fluctuating global cognitive impairment with behavioural abnormalities due to variety of insults. Epidemiology 10% of medical & surgical inpatients. Risk factors: elderly, dementia, blind & deaf, postoperative, burn victims, alcoholic. Aetiology -Intracranial: CVA, head injury, CNS infection - metabolic: electrolyte disturbance, hepatic encephalopathy, hypoxia - endocrine: Pituitary, thyroid, PTH, adrenal - Infection: UTI, chest infection, abscess - Substance intoxication and withdrawal Clinical features: - Fluctuating course -impaired consciousness and attention - Disorientation, impaired recent memory - Nocturnal worsening of symptoms - Psychomotor agitation & emotional lability - illusions, visual hallucinations (big insect) - Poorly formed paranoid idea (other patients want to harm him) DDX: - Psychotic illness - Post ictal confusion - Dementia Management: 1) Identify & treat precipitating cause 2) Provide calm environment with reality orientation (big clock) 3) Low dose antipsychotics: Haloperidol 2.5mg/ risperidone 1mg 4) Regular review and follow up 5) Educate family about delirium Depression in chronic medical illness

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Common, Look for non somatic symptoms: guilt, concentration, low mood - Assess suicide risk - Use escitalpram as it has less drug interactions. Ch. 14 Perinatal Psychiatry 14.1

Baby blues

¾ of new mothers will experience a short lived period of tearfulness and emotional lability starting 2-3 days after birth.

Dr. Roger Ho

-

Family history of psychiatric disorder Lack of social support

Clinical features: -Prominent affective features (80%): mania / depression - Psychosis, paranoid idea about safety of baby - Insomnia, perplexity, disorientation - Look for suicide & infanticide risk Management:

Due to pospatrum reductions of oestrogen, progesterone and prolactin.

Treatment in hospital – KK women hospital / In the UK, admit to special mother – baby unit

No need for treatment.

ECT is useful

14.2

Antipsychotics is needed ( to avoid breast feeding)

Postnatal depression

Epidemiology: - 10-15% of women - Peak: 3-4 weeks of delivery Risk factors: - Family history of depression; - Poor relationship with own mother - Ambivalence towards pregnancy - Poor social support - Previous postpartum depression Clinical features - Depression + worries about baby’s health and ability to look after baby - 90% last less than 1 month Management: - Prevention by education - Enhance support - If severe, SSRI (to avoid breast feeding) - CBT 14.3

Postpatrum psychosis

Epidemiology 1.5/1000 live births Peak: 2 weeks postpartum Aetiology Reduce of oestrogen, leading to dopamine super-sensitivity, cortisol levels or postpartum thyroiditis

14.4

Premenstrual Syndrome (PMS)

PMS is a constellation of menstrually related, chronic, cyclical, physical and emotional symptoms in the luteal phase. Symptoms: Breast tenderness, fatigue, cramping, bloating, irritability, depression, poor concentration, food cravings, lethargy, libido changes. Prevalence: 40% of women of reproductive age, severe impairment in 5% Investigation: Charting of daily symptoms for at least 2 menstrual cycle may aid in confirming cyclical pattern. Treatment: Conservative management: Low salt and fat diet, less caffeine, reduce alcohol and tobacoo intake, to reduce stress Consider medication: to try SSRI if fails to conservative treatment. Refer to O and G if above measures fail

Ref: Oxford Handbook, 2004

Risk factors:

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Dr. Roger Ho

Dry skin/brittle hair Loss of brain volume Cerebral atrophy Ventricle enlargement Ch. 15

Eating disorder

15.1 Anorexia Nervosa Epidemiology - Usually Females; F:M = 10:1 -Onset between 16-17 - More common in upper social class - 1% of middle class adolescent girls. - Increasing incidence: 0.5% Aetiology -Genetics: MZ: DZ 65%:32%;6-10% of female siblings of patients also suffer from this condition -Hypothalamic dysfunction - Social: Exam stress in S’pore, occupations group: ballet students, atheletes -Individual pathology: dietary problems in early life, lack of a sense of identity - Family pathology: enmeshment, rigidity, overprotectivieness, lack of problem solving Clinical features Core clinical features - RAPID -A body weight more than 15% below the standard weight or BMI 17.5 or less - Self induced weight loss: vomiting, purging, excessive exercise, appetite suppressant -Body image distortion- dread of fatness, overvalued idea -Endocrine disorder: HPA axis, amenorrhoea, reduced sexual interest, raised cortisol, altered TFTs - Delayed and arrested puberty. Complications: Secondary to starvation

Hypothermia Constipation Low BP, anaemia Bradycardia Amenorrhoea Leucopenia Hypercholesterolemia Delayed in growth Osteoporosis

Consequences of vomiting & laxative Hypokalaemia Hyponatraemia Prolonged QT Cardiac arrhythmia Dental caries

Elevated hormones

Growth hormone Prolactin Cortisol

Reduced hormones T3 and T4 Oestradiol Testoesterone FSH and LH

Investigation FBC, RFT, LFT, glucose, TFT, cholesterol, LH, FSH DDX: Functional illness OCD Depressive disorder

Organic disorder Hypopituitarism Thyrotoxicosis Diabetes Mellitius Brain tumour Malabsorption

Management: Admission to hospital: -Extremely rapid or excessive weight loss -Severe electrolyte imbalance - Cardiac complications - Marked change in mental status - Risk of suicide - Failure of outpatient treatment Feeding and refeeding syndrome -Consult medical/dietitian - Refeeding syndrome: Cardiac decompensation can occur within first 2 weeks: myocardium cannot withstand the stress of increased metabolic demand; slowly increase dietary intake by 200kcal per day and monitor RFT closely Psychological treatment: -Supportive psychotherapy: to improve interpersonal relationships and sense of personal effectiveness. - Behavioural therapy: regimen of refeeding, to set target weight, positive reinforcement with privileges such as outing, movie etc - Cognitive therapy, after gaining some weight, aims at changing attitude towards

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Dr. Roger Ho

eating, reappraisal of self image and life circumstances. -Family therapy Pharmacological: Olanzapine may be used to promote weight gain (controversial not to mention in exam)

- Admission only for suicidality and physical problems - Higher dose of SSRI: fluoxetine up to 60 mg - Cognitive behavioural therapy Poor prognosis: severe personality disorder or low self esteem.

Prognosis of AN Rules of one third : 1/3 1/3 Recover fully Recover partially

1/3 Chronically disabled.

Factors associated with a poor prognosis - Chronic illness - Late age of onset - Bulimic features - Anxiety when eating with others - Excessive weight loss - Poor childhood social adjustment - Poor parental relationships - Male sex Bulimia Nervosa Epidemiology: 1% of women Aetiology: Family history of affective disorder Serotonergic dysregulation Clinical features: -Persistent preoccupation with eating -Irresistible craving for food -binges: episodes of overeating - Attempts to counter the fattening effects of food: self induced vomiting, purging BN is different from AN. In BN, - Patients are more eager for help - Menstrual abnormalities less than half of the patients - Body weight within normal limits Comorbidity: Multiple dyscontrol behaviours: - Cutting / burning - Overdose - Alcohol / drug misuse - Promisuity Management - Usually managed as outpatient

15.3 Pathological gambling It is a persistent and recurrent maladaptive patterns of gambling behaviour.

Relatively common and may lead to significant personal, family and occupational difficulties. Clinical features - Preoccupation with gambling - Tolerance: need to gamble with larger amounts of money - Fail to cut down - Chasing losses (like chasing the dragon in drug addicts) - Lying to others about gambling - Committing illegal acts to finance gambling. - Losing or jeopardizing familial relationship Treatment: - CBT to reduce preoccupation with gambling - SSRI (fluoxetine) - Support group - Credit card debt counseling via MSW 15.4 Kleptomania Failure to resist impulses to steal items that are not needed nor sought for personal use. e.g A men stole 10 female T shirts, same style but different colours.

Usually women, mean age 36, 16 years of illness DDX: shoplifting (well planned and motivated by need and monetary gain), OCD and depression Treatment: - CBT - SSRI 15.5

Trichotillomania

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Stereotyped recurrent pulling of hair

Dr. Roger Ho

8.

Other associations :

a)

history of DSH (1/3- ½ of completers)

DDX: OCD, Tourette syndrome, Autism, factitious disorder

Suicide and mental illness Treatment: behavioural modification, SSRI,if fail consider risperidone or lithium

Ref: Oxford Handbook, 2004 Ch.16 Suicide and DSH Trickcyclist, UK 16.1 Suicide Epidemiology

completers are more often : male psychiatric disorder have made a plan used a dangerous method Prevalence lifetime prevalence (USA): • 21 % morbid thoughts 10.2 % suicidal thoughts 2.9 % attempted suicide GP : (2,500 patients) 1 suicide every 4 years Psychiatrist (catchment area 50,000) 1 suicide every 3 months •

•

•

all psychiatric illness (except OCD) increase risk by 90-95 % Depression (risk 3.6 - 8.5 % = 30 x general population risk)

Schizophrenia (risk 5 - 10 %) Alcohol dependence (risk 3.4 - 6.7 %) Neurosis: panic disorder/ PTSD

• •

Special populations

• •

Elderly • •

•

rate increasing 80-90 % of elderly suicides have depressive illness often first episode of depression DSH is more closely associated with completed suicide denial of suicide more common

•

•

•

•

•

•

•

Inpatients Highest risk :

•

•

first week of admission early stages of recovery between shifts of staff on leave (patients and staff) bank holidays discharge (premature) risk is increased 30 x in the month after discharge •

Sociodemographic correlates of suicide 1) Age, Sex a) M:F = 3:1; males > females for all groups b) suicide pacts more common in the elderly 2. Marital status : a) divorced > widowed > single 3. Employment : a) unemployed / retired / living alone 4. Social Class : a) Higher in lowest social groups & professional b) lowest in middle groups 5. Religion : a) strong religious affiliation is a protective factor 6. Occupation : a) higher risk groups are doctors, lawyers, hotel and bar trade owners 7. Chronic Physical illness : terminal illness / malignancies a) chronic pain

• • • • • •

Aetiology Genetics •

•

suicidal behaviour clusters in family MZ : DZ = 11.3 % : 1.8 % (Roy et al. 1991)

Neurochemical 1)Serotonin : serotonin deficiency 16.2 Deliberate self harm (DSH) A deliberate, non fatal act, whether physical, drug overdose, or poisoning, done in the knowledge that it was potentially harmful. More common in female

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Motives: A cry for help; An attempt to influence others; escape from stress; to feel pain in personality disorder Factors of DSH predicting suicidal risk • • • • •

Isolation; timing precautions to avoid intervention suicide note anticipatory acts ‘dangerousness’ of state of mind

Ch. 17 Personality disorder Deeply ingrained, maladaptive patterns of behaviour; recognisable in early adulthood, continuing throughout most of adult life; there is an adverse effect on the individual or society. 17.1

Borderline Personality Disorder

Prevalence: 1.5 – 2% Childhood development Childhood trauma – sexual abuse, divorce Playing primitive defence mechanisms such as splitting or projective identification Clinical features: “I RAISE A PAIN” I – Identity disturbance R- Relationship: unstable A – Abandonment fear of I – Impulsive S – Suicidal gesture E – Emptyiness

Dr. Roger Ho

- Low 5HT levels in impulsive violent individuals Childhood development Difficult infant temperament Harsh and inconsistent parenting Conduct disorder in childhood Clinical features: “CALLOUS” Conduct disorder < 15 Antisocial Act and aggression Lies frequently Lack superego Obligations not honoured Unstable and cannot plan ahead Safety of self or others ignored Prognosis: May commit crime May show Improvement by 5th decade Management of Personality Disorder Making the diagnosis of personality disorder Assess patient’s enduring and pervasive patterns of emotional expression, interpersonal relationships, social functioning Obtain collateral information from family and past psychiatric history Explore relationships, self concept and functional assessment Admission to hospital They benefit little from prolonged admission. Admission is indicated for specific crisis Treatment plan aims to set limits and to achieve realistic goal

A – Affect: unstable Psychological treatment P – Paranoid idea / psychosis: transient A – Anger I - Idealisation and Dealisation N - Negativistic Prognosis: 1/3 continue to have Borderline Personality disorder after 10 – 20 years. Poor prognosis: - Severe repeated self-harm 17.2

Antisocial Personality Disorder

Prevalence: 2-3.5% Neurophysiology: -immature EEG in posterior temporal lobe as slow waves

-Supervision and support are often beneficial CBT:

-

Educate them about the schema Empathetic challenging their core beliefs Goal directed problem solving approach

Dialectical behavioural therapy for borderline personality disorder - Focus on a detailed CBT approach to self harm - Then focus on tolerance of distress, emotional regulation and interpersonal skills - To process trauma - Develop self esteem and realistic future goals Pharmacological treatment: - SSRI antidepressant can improve mood and reduce impulsivity

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Outcome of personality disorder High rates of accident, suicide and violent death.

Ref: Oxford Handbook, 2004 Chapter 18

Psychiatric Emergency

18. 1 Acute disturbed patient Aetiology - Alcohol and drug dependence - Illicit drugs - Metabolic disturbance - Head injury - Schizophrenia - Mania - Personality disorders Treatment of acute disturbed patient or crisis: It requires immediate action:

1) De-escalation verbally in calm and consistent environment. 2) Oral medication: PO Haloperidol 5mg stat or PO lorazepam 1mg stat 3) IM medication: IM Halperidol 5mg stat; IM lorazepam 2mg (in IMH); no IM diazepam due topoor absorption 4) Close monitoring on vital sign 5) If chemical restraint fails, consider physical restraint 18.2

Neuroleptic Malignant Syndrome

It is a rare life threatening reaction to antipsychotic medication characterised by fever, muscular rigidity, altered mental status and autonomic dysfunction. Due to blockade of D2 receptors leading to impaired calcium mobilisation and leads to muscle rigidity.

Dr. Roger Ho

Clinical signs and symptoms: - Hyperthermia - Muscular rigidity - Confusion / agitation - Tachycardia - Hyper or hypotension - Tremor - Incontinence - ↑ CK level Investigations: FBC, LFT, RFT, Ca and PO4, serum CK, CXR, CT DDX: lethal catatonia, malignant hyperthermia, meningitis, heat exhaustion, rhabdomyolysis Management: - Stop antipsychotics - Medical emergency, refer to medical - IV fluids, reduce temperature - Benzodiazepine for acute behavioural disturbance - To give bromocriptine Mortality: 5-20% die, it can lead to acute renal failure. 18.3 Serotonin syndrome: A rare but potentially fatal syndrome occurring in the context of initiation of serotonergic agent, characterised by altered mental state, agitation, tremor, shivering, diarrhoea, hyperreflexia, myoclonus and hyperthermia.

1% of patients on SSRI Pathophysiology: due to increase in serotonin. Clinical features: Autonomic: hyperthermia, nausea, diarrhoea, mydriasis, tachycardia, hyper/hypotension Neuromuscular: myoclonus, rigidity and tremors, hyperreflexia, ataxia

Incidence: 0.2% F: M = 2:1

More rapid onset, rapid progression and less rigid than NMS.

Risk factors - Drug naïve patient receiving high potency antipsychotics - Dehydration

Investigations: same as NMS, add in CXR to rule out aspiration, ECG to look for prolonged QTc

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Dr. Roger Ho

Treatment: - Consult medical, it is a medical emergency. - IV access, to allow volume correction to reduce the risk of rhabdomyolysis - Prescribe benzodiazepine to control agitation, seizure and muscle rigidity. Course and prognosis: - Resolve with 24 – 36 hours - Mortality < 1 in 1000 Chapter 19 Sleep disorders 19.1 Normal sleep – stages and cycle - A typical night’s sleep has 4 or 5 cycles of stages, each lasting 90 – 110 minutes. - As night progresses, the amount of time spent in delta sleep decreases with consequent increase in REM sleep. - Total sleep time in adult is between 5 – 9 hours.

Stage 1 Stage 2 Stage 3 & 4 REM

Light sleep, with slow theta and delta waves K complexes Delta wave, slow wave sleep Low voltage, desynchronised EEG activity

Assessment of sleep disorders: Present Onset, duration, course, compliant frequency, stressors Daily routine Waking, daily activities, bed time Description Behaviour during sleep, of sleep dream, wakening, satisfaction Daytime Level of alertness, effect on somnolence work, Drug & Regular hypnotics alcohol Caffeine containing drugs 19.2 Insomnia Insomnia involves difficulty to fall asleep, maintaining sleep and poor quality of sleep as persistent problem 3 days per week for one month. Epidemiology - Common problem - F>M - Greater in elderly

Chronic significant insomnia – 6%

Aetiologies: Intrinsic causes: - Psychophysiological insomnia associated with anxiety - Sleep state misperception (constant monitoring of sleep) - Idiopathic insomnia - Sleep apnoea syndrome - Periodic limb movement disorder Extrinsic causes: - Inadequate sleep hygiene - Dependency related sleep disorder like hypnotics - Nocturnal eating and drinking Medical and Psychiatric causes: - Pain - Respiratory (COPD) - Parkinson disease - Endocrine: Addison, Cushing - Depression, bipolar disorder - Anxiety disorder, PTSD - Schizophrenia Management: - Address underlying problem (drug dependency) - Education: stages and cycles. - Sleep hygiene measures: Good sleep habits and stimulus control - Relaxation training - Use of hypnotics if unresponsive to above Length of action Ultra –short

Examples

Comments

Zolpidem (Stilnox)

Non – BZD Facilitate onset of sleep Also has potential of dependency, cause rebound insomnia Initiating, maintaining, Consolidating sleep

2 hr 10mg ON $1.80

Intermediate 6 hours

Lorazepam Ativan 1mg ON Zopiclone Imovane 7.5mg ON

Non BZD Bitter taste

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Long acting > 12 hours

Diazepam Valium 5-10mg

Initiating, maintaining, Consolidating sleep

Flurazepam Dalmadorm NUH only 15-30mg

Hang over effect on the morning Midazolam (Dormicum) has very fast onset of action and high potency, it has high potential for dependency. It is not recommended for regular oral usage. Ch. 20 Child Psychiatry 20.1 Attention Deficit & Hyperkinetic Disorder (ADHD) ADHD is a persistent pattern of inattention +/- hyperactivity that is developmentally inappropriate. The symptoms should have an onset in childhood. Epidemiology: - USA: 3-5% (over-diagnosis) - UK: 1% - M:F = 3:1 Aetiology: Genetics: - 50% risk in MZ twins, 2x increase in siblings - Genes: 5, 6, 11 are implicated. - Neuroimaging: frontal hypometabolism - Dopamine & 5HT dysregulation in prefrontal cortex Clinical features: Hyperactivity symptoms Fidgeting, moving, getting up & down, climbing on desks Blurting out answers, Jumping the queue

Inattention symptoms Cannot sustain attention Poor task completion Making mistakes when task require attention

Assessment: - Interview with parents: developmental history - Observe attachment style and level of activity of child - Collateral info from school Treatment: - CBT: behavioural techniques

Dr. Roger Ho

-

-

Social skill training Parent management training Education and remedial intervention Stimulant: Methylpenidate 5-10mg OM: increase Dopamine & noradrenaline which can increase concentration & attention, side effect include growth retardation which requires drug holiday.

Outcome - 20% develop antisocial personality disorder - 20% develop substance abuse disorder 20.2 Conduct disorder A repetitive and persistent pattern of behaviour in which the basic rights of others or major age appropriate societal norms are violated. Epidemiology - Earlier onset and is more common in boys than in girls. Aetiology Biological factors - Family history of antisocial behaviour or substance abuse. - Low CSF serotonin - Low IQ - Brain injury

Psychosocial - Parental criminality - Substance abuse in parents - Harsh and inconsistent parenting - Domestic chaos and violence - Large family size - Low socioeconomic status and poverty - Early loss and deprivation - School failure

Clinical features: - Aggression - Cruelty to people and animals - Destruction of property - Deceitfulness or theft - Serious violation of rules - Gang involvement - Lack of empathy Management: - Ensure the safety of the child - CBT problem solving skill

25


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Parent management training Family therapy Academic & social support referral

Course and outcome: - CD is often chronic and unnameable. - Antisocial PD in adults <50% Poor outcome: Early onset < 10 year old, low IQ, poor school achievement, attentional problems, hyperactivity, family criminality, poor parenting. 20.3

Dr. Roger Ho

-

Neurological: tics, increase in head circumference, abnormal gaze Physiological: abnormal response to pain, abnormal temperature regulation. Behavioural: irritability, temper tantrums, self – injury, hyperactivity, aggression

Assessment: - Requires Multidisciplinary approach - Rating scale: Autism Behavioural Checklist

Autism

It is characterised by the triad of symptoms: - Abnormal social relatedness - A qualitative abnormality in communication and play - Restricted, repetitive and stereotyped behaviour, interests and activities Epidemiology: - Onset is typically before age 3. - M:F = 3-4:1 - Prevalence: 5-10/1000 Aetiology: - Genetic - Obstetric complications - Toxic agents - Pre/postnatal infections. - Association with tuberous sclerosis Pathophysiology MRI: - Increase in brain size - Increase in lateral and 4th ventricle - Frontal & cerebellar abnormalities - Abnormal purkinje cells in cerebellar vermis. - Abnormal limbic architecture. Clinical features: - Abnormal social relatedness : poor eye contact and no peer relationship - Abnormal communication/play: lack of language, difficulty to initiate conversation. - Restricted interests or activities: non functional routines or rituals (bus schedule)

Treatment: - Education & vocational interventions - Behavioural interventions - Family interventions - Speech and language therapy

20.4

Asperger Syndrome (AS)

Severe persistent impairment in social interactions, repetitive behavioural patterns and restricted interests. IQ and language are normal or superior. Mild motor clumsiness and family history of autism may be present. Newton and Einstein may have AS Epidemiology - Male predominance - 1 in 300 Clinical features - Narrow interests and preoccupation of a subject - Repetitive behaviours or rituals - Peculiarities in speech and language - Extensive logical or technical patterns of thought - Socially and emotionally inappropriate behaviour and interpersonal interaction - Problems with non verbal communication - Clumsy and uncoordinated motor movements.

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20.5

Dr. Roger Ho

Approaches to the Child •

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-

-

Establish the rapport and gaining the child’s confidence Begin with subjects well away from the presenting problem (interests, hobbies, friends and siblings, school and holidays) Progress to enquire about the child’s view of the problems Observe the level of activities and attention during the interview Try to interview the child and family together to observe family dynamics

•

•

•

•

Treatment •

20.6

School refusal

complaints occur on school days but not at other times the final refusal may occur after several events: following a period of increasing difficulty after an enforced absence such as respiratory infection after an event at school such as change of class following a problem in the family such as illness of another family member

• •

an early return to school is important discussion with teachers is needed depressive disorder should be treated

Epidemiology • • •

prevalence of 1-2 % slightly more common in boys more common during three periods in school life: 1. age 5 (starting school) 2. 7 years (change to junior school) 3. 11 years (starting secondary school) 4. 14 years and older, when there is often associated depression and difficulties in school

Prognosis • •

worse prognosis in older children higher incidence of psychiatric disorders (e.g. agoraphobia) in adult life

20. 7 Enuresis Voluntary/involuntary voiding of urine at night for child > 5 yr old.

75% have family history of enuresis To rule out UTI, neurological problems, obstructive uropathy.

Aetiology •

•

• •

•

associated with separation anxiety especially in younger children may occur after a minor life event: illness some older children have depression increased incidence of anxious, overprotective mother in combination with a weak, passive, ineffectual, or absent father children are often emotionally immature and have not learned to accept frustration

Clinical features •

there are often somatic symptoms such as headache, abdominal pain, diarrhoea, sickness, or vague complaints of feeling ill – these

Primary enuresis: never dry Secondary enuresis: previously dry

Behavioural modification is important treatment: starchart to reward patient, restrict fluid at night Medication: imipramine (TCA) 20.8 Consequence of child abuse: - PTSD - Dissociative disorder - Conversion disorder - Borderline personality disorder - Depression - Paraphilias - Substance abuse 20.9

Tourette’s syndrome

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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 Ref: Oxford Handbook, 2004 21 Learning Disability/ Mental Retardation 21.1 IQ and learning disability (LD) LD Mild

IQ 50-69

Moderate

35-49

Severe

Profound

20-34

Below 20

Features Independent self care Some deficit in language, simple work Lower level of work, motor impairment Very limited language & basic skills

21.2 Down Syndrome

Most common genetic cause of LD Trisomy of chromosome 21 IQ most often below 50 Develop Alzheimer’s disease at 40s and 50s

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

21.3 Foetal Alcohol Syndrome - Major causes of learning disability - 0.2 – 3 per 1000 live births - Caused by maternal alcohol use. Due to effect of alcohol on NMDA receptors which affects cell proliferation Clinical features: Alcohol withdrawal: irritability, hypotonia, tremor and seizures Facial features: Microcephaly, small eye fissures, epicanthic folds, short palpebral fissure, small maxillae and mandibles, cleft palate, thin upper lip Growth deficits: Small overall length, joint deformities. CNS: behaviour problems: hyperactive, sleep problems, poor visual acuity, hearing loss, language deficits. Other: ASD, VSD, renal hypoplasia.

Clinical features of Down syndrome

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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

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Legal & Ethical Aspects

22.1

Mental Disorder and Treatment Act

- Can only apply at IMH (Woodbridge hospital) in Singapore Criteria for compulsory admission at IMH

The person suffers from a mental disorder of a nature or degree which makes it appropriate for the person to receive psychiatric treatment in IMH. 2) Admission is likely to alleviate or prevent deterioration in a psychiatric condition (Schizophrenia, Bipolar disorder) 3) It is necessary for the health or safety of the patient or for the protection of other persons that the person should receive such treatment and it cannot be provided unless he is compulsory admitted. 1)

Example: Assume you are the AED medical officer working in a general hospital. A 29 year old

Re-licensing for private car: - has remained well and stable for at least 3 months - Compliant with treatment - Free from adverse effects of medication - Regain of insight For professional driver: bus driver, taxi driver or lorry driver: Re-licensing may be possible if well and stable for a minimum of 3 years with minimum dosage of medication and no significant likelihood of recurrence Dementia: Those with poor short term memory, disorientation, lack of insight and judgement are not fit to drive. 22.3 Dialysis and Schizophrenia You have a 58 year old lady suffering from chronic schizophrenia and end stage renal failure. She wants to stop d ialysis. The renal team is very concerned as she may die and they want to seek your opinion.

Suffering from schizophrenia does not mean the patient has no capacity to decide on her dialysis.

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First, we have to determine whether the patient has the capacity to make the decision to withhold dialysis. In order to show that she has the capacity, she must be able to understand and believe that she suffers from end stage renal failure; dialysis is used to treat ESRF and she will die if she stops dialysis. We need to consider the following: It is good to explore the psychological aspects of dialysis: sexual dysfunction is common; they are more isolated and costs of dialysis may reduce their quality of life and anaemic can cause fatigue. Uraemia can lead to impaired mentation, lethargy, multifocal myoclonus. Dialysis can lead to neuropsychiatric symptoms such as dialysis dementia, delirium and depression. We may need to treat patient’s neuropsychiatric symptoms by antidepressant or antipsychotics and reassess her capacity later. 23 Psychotherapy Common psychotherapies practised in Singapore include: 23.1 Supportive Psychotherapy Aims to offer practical and emotional support, opportunity for ventilation of emotions, and guided, problem solving discussion.

Examples include counselling and general psychiatric follow – up. 23.2 Brief psychodynamic psychotherapy It is an active therapy where the therapist attempts to guide free association on more focused topics. Rationale: - Shorter time scale of long term psychoanalysis (too expensive and difficult for patient to stay in therapy for so long) Indication: - Individuals with emotional problems in psychological terms. - Focal conflicts -

Dr. Roger Ho

Techniques: - Goal setting: tackle anxiety/ defence - Focus choosing: repetitive behaviour to a single transference figure - Active interpretation Transference Patient’s feeling towards therapist

Countertransference Therapist’s feeling towards patient

Phases of treatment - Initial: setting treatment contract, formulation of the case - Early session: Identify central issue - Middle session: explore transference - Closing: anticipate termination, arrangement of aftercare. 23.3 CBT Behaviours and emotions are determined by person’s cognitions. Some pathological emotions are as a result of cognitive errors. If the person can be helped to understand the connection between cognitive errors and distressing emotion, they can try methods to change. The therapist aims to assist the patient to monitor cognitions, identify cognitive errors, understand maladaptive schema, explore with strategies and challenge and examine the resultant effects. Behavioural techniques Activity scheduling Graded assignment Exposure/ response prevention Relaxation training

Cognitive techniques Psychoeducation Identify automatic thoughts Role play Thoughts diary Examine evidence

Defence mechanisms Repress Unconscious forgetting of pain ion memory and impulse. Regress Revert to functioning of a ion previous maturational point. Denial Refusal to consciously acknowledge events or truths which are obvious. Projecti Attributing one’s own on unacceptable ideas or impulses to another person. Projecti One person projects a thought,

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ve Identific ation

Reactio n formati on Displac ement

Rational isation

Sublima tion

Ch. 24

belief or emotion to a second person. Then, there is another action in which the second person is changed by the projection and begins to behave as though he or she is in fact actually characterized by those thoughts or beliefs that have been projected. The expression externally of attitudes and behaviours which are the opposite of the unacceptable internal impulses. Transferring the emotional response to a particular person, event, or situation to another where it does’t belong but carries less emotional risk. Justifying behaviour or feelings with a plausible explanation after the event, rather than examining unacceptable explanation. Regarded as healthy defence mechanism, The external expression of unacceptable internal impulse in socially acceptable way. Glossary

Alexithymia: The inability to describe one’s subjective emotional experiences verbally. Amnesia Anterograde: the period of amnesia between an event and the resumption of continuous memory. The length of anterograde amnesia is correlated with the extent of brain injury. Retrograde: The period of amnesia between an event and the last continuous memory before the event. Autochthonous delusion: A primary delusion which appears to arise fully formed in the patient’s mind without explanation. Autoscopy: (Phantom Mirror image) The experience of seeing a visual hallucination or pseudohallucination of oneself. Confabulation: The process of describing plausibly false memories for a period for the patient has amnesia. Occurs in Korsakoff psychosis, dementia.

Dr. Roger Ho

Coprolalia: A forced vocalisation of obscene words or phrases. The symptoms is largely involuntary but can be resisted for a time, at the expense of mounting anxiety. Occurs in Tic disorder Couvade syndrome: A conversion symptom seen in partners of expectant mothers during their pregnancy. Déjà vu A sense that events being experienced for the first time have been experienced before. An everyday experience but also a non specific symptoms of a number of disorders including temporal lobe epilepsy, schizophrenia and anxiety disorders. In contrast, Jamis Vu is the sensation that events or situations are unfamiliar, although they have been experienced before. Delusional memory A primary delusion which is recalled as arising as a result of a memory (eg patient who remembers his parents taking him to hospital for an operation as a child becoming convinced that he had been implanted with monitoring devices which have become active in his adult life) Delusional mood: A primary delusion which is recalled as arising following a period when there is an abnormal mood state characterised by anticipatory anxiety, a sense of something about to happen and an increased sense of significance of minor events. Delusional perception: A primary delusion which is recalled as having arisen as a result of perception. The percept is a real external object. Delusion of guilt: A delusional belief that one has committed a crime or other reprehensible act. It is a feature of psychotic depressive illness. Delusion of infestation (Ekbom syndrome): A delusional belief that one’s skin is infested by multiple, tiny, mite like animals. Delusion of reference: A delusional belief that external events or situations have been

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arranged in such a way as to have particular significance for or to convey a message to the affected individual. Depersonalisation: An unpleasant subjective experience where the patient feels as if they have become unreal. Derailment (Knight’s move thinking): schizophrenic thought disorder in which there is total break in the chain of association between the meaning of thoughts. Derealisation: An unpleasant subjective experience where the patient feels as if the world has become unreal. Digenes syndrome: Hoarding of objects, usually of no practical use and neglect of one’s home and environment. Due to organic disorder, schizophrenia, OCD. Dysarthria Dyslexia

Dysphasia

Dysphoria

Dyspraxia

Impairment in ability to properly articulate speech Inability to read at the level normal for one’s age or intelligence Impairment in producing or understanding speech (expressive dysphasia Brocas and receptive dysphasia - Wernicke) related to cortical abnormality An emotional state experienced as unpleasant, secondary to depression Inability to carry out complex motor tasks (dressing, eating)

Edietic imagery: Particular type of exceptionally vivid visual memory. Not a hallucination. More common in children. Extracampine hallucination A hallucination where the percept appears to come from beyond the area usually covered by he senses (eg a patient in Clementi hearing voices seeming to come from a house in Changi) Ganser symptoms:The production of approximate answers. Here the patient gives repeated wrong answers to questions which

Dr. Roger Ho

are nonetheless in the right ballpark. What is 2+2? = 5. More common in Malingering. Globus Hytericus: The sensation of a lump in the throat occurring without oesophageal structural abnormality. Hypnagogic hallucination: A transient false perception experienced while on the verge of falling asleep Hypnopompic hallucination: The same phenomenon experienced while waking up Illusion: A false type of false perception in which the perception of a real world object is combined with internal imagery to produce a false internal percept. Lilliputian hallucination: A type of visual hallucination in which the subject sees miniature people or animals. Associated with organic state like delirium tremens. Loosening of associations: Lack of meaningful connection between sequential ideas. Magical thinking: A belief that certain actions and outcomes are connected although there is no rational basis for establishing a connection. Malingering: Deliberately falsifying the symptoms of illness for a secondary gain. Mirror sign: Lack of recognition of one’s own mirror reflection with the perception that the reflection is another individual who is mimicking your actions. Overvalued idea: A form of abnormal belief. These are ideas which are reasonable and understandable in themselves but which come to unreasonably dominate the patient’s life. Preservation: Continuing with a verbal response or action which was initially appropriate after it ceases to be apposite. Do you know where you are? In the hospital? Do you know what day is it? In the hospital. Russell Sign: skin abrasions, small lacerations and the calluses on the dorsum

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Dr. Roger Ho

of the hand overlying the metacarpophalangeal and interphalangeal joints found in patients with symptoms of bulimia. Caused by repeated contact between incisors and the skin of the hand which occurs during self induced vomiting.

Tangentiality: Producing answers which are only very indirectly related to the question asked by the examiner.

Synaethesia: A stimulus in one sensory modality is perceived in a fashion characteristic of an experience in another sensory modality (tasting sounds).

References: 1) Levi. Basic Notes in Psychiatry. Radcliffe Publishing Ltd 1998. 2) D. Semple, R. Smith, J Burns, R. Darjee, A. Mclntosh. Oxford Handbook of Psychiatry. Oxford University Press. 2004 3) www.trickcyclists.co.uk

Trichotillomania: Compulsion to pull one’s hair out.

Appendix Appendix 3a – Neurodevelopmental Hypothesis of Schizophrenia

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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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Dr. Roger Ho

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

Appendix 3C


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Dr. Roger Ho

Appendix 5a - Toxic effect of lithium


Appendix 9a PTSD and Grief

Lesley Stevens, Ian Robin, Psychiatry – An illustrated colour text, Churchill livingstone 2001 Appendix 10

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Dr. Roger Ho


Appendix 12a

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Dr. Roger Ho


Mnemonics in Psychiatry (Mnemonics for MRCP, PASTEST, 2006) Disorder Negative symptoms of

Mnemonic 5As and PLANT

Breakdown of Mnemonic aPathy aLogia

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Lecture Notes on Psychiatry

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