Study Notes in Psychiatry (2008) Dr.

Roger Ho

Table of Content Page

Ch. 1 Introduction 2

Ch.2 Signs & symptoms 2

Acute management
Study Notes in Ch. 3 Schizophrenia 3
Psychiatry Ch. 4 Delusional disorder 6

Ch. 5 Bipolar disorder 7

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

Ch. 7 Obsessive compulsive 10

disorder
Ch. 8 Anxiety, Panic, Phobia 11

Ch. 9 Post traumatic stress 12

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

Assistant Professor Ch. 11 Drug Dependence 14

Department of Psychological
Medicine, NUS Ch. 12 Old age psychiatry 15

Email: pcmrhcm@nus.edu.sg Ch. 13 Consultation Liaison 16

Psychiatry
Version: May 2008 Ch. 14 Perinatal Psychiatry 18

Ch. 15 Eating disorder and 19

impulse control disorders
Ch. 16 Suicide and DSH 21

Ch. 17 Personality Disorder 22

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

Ch. 20 Child Psychiatry 25

Ch. 21 Learning disability 28

Ch. 22 Legal aspect 29

Ch. 23 Psychotherapy 30

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Chapter 1 Introduction completing it, starts movement, even

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provide a concise summary of psychiatry and to movement withdrawn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

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Study Notes in Psychiatry (2008) Dr. Roger Ho

Chapter 3 Schizophrenia 3) 1 adrenergic overactivity.

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

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

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Study Notes in Psychiatry (2008)
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 Tubero- Galactorrhoea
infundibular activity
Side effects of typical antipsychotics:
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
Dr. Roger Ho
idiosyncratic effects
- High incidence of EPSE
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
1 receptors.
Side effects:
- EPSE (if high dose like 4mg daily)
- Elevation of prolactin (strongest
among atypicals)
- Antiadrenergic side effects
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
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 1
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, 1 &
muscarinic receptors
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Study Notes in Psychiatry (2008)
- 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
Indications for Hospital admission:
Suicide / violent
Severe psychosis
Severe depression
Catatonic schizophrenia
Non compliance
Failure of outpatient treatment
3.13 Prognosis
Rules of quarters
25% 25% 25% 25%
Complete Good Partial Downhill
Remission recovery recovery 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.
Dr. Roger Ho
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.
Schizotypal personality disorder
- There is familial relationship between
schizotypal personality disorder &
schizophrenia
Clinical features: UFO RIDE
U unusual perception: eg telepathy
F Friendless
O Odd belief and odd speech
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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Study Notes in Psychiatry (2008) Dr. Roger Ho

humourless; incapable of expressing - Delusions are highly implausible,

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

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Study Notes in Psychiatry (2008)
- Better prognosis if it is acute;
- Poor prognosis if delusional disorder
last longer than 6 months.
Ch. 5 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.
5.6 Diagnosis
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
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Study Notes in Psychiatry (2008)
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
Dr. Roger Ho
- For rapid cycling 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 patients 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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Study Notes in Psychiatry (2008)
- 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: 10-
15%
- 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
Dr. Roger Ho
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 5HT-
3 postsynaptic receptor antagonist & anti-
histamine 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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Study Notes in Psychiatry (2008) Dr. Roger Ho

examine evidence for and against them; cognitive - Anxiety disorders

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

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Study Notes in Psychiatry (2008)
- 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
Course:
-Chronic and disabling, low remission rate
-Can lead to alcohol abuse.
8.2 Panic disorder
Epidemiology:
Lifetime prevalence: 4.2%
Women: 2-3 times higher than men
Dr. Roger Ho
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
Social phobia
17-30; M = F; avoid situations that can be
observed by others (presentation, hawker
centre, MRT) & worries of humiliating or
embarrassing
Management: short term benzodiazepine,
SSRI
Systematic desensitization: imagine or
expose to anxiety provoking situations,
11
Study Notes in Psychiatry (2008)
progress through hierarchy, neutralize by
relaxation technique until patient habituates
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
9.2 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: Protective factors
-Low education - High IQ
-Lower Social class - High social class
-Female gender - Male
-Low self esteem - Chance to view
-Family history of body of dead person
psychiatric disorders
- Previous trauma
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, dont mention it in
oral exam)
- Look for alcohol abuse
9.6 Pharmacological treatment
- Depressive symptoms: SSRI
Dr. Roger Ho
- Anxiety symptoms: 2 weeks alprazolam
0.25mg TDS
9.7 Complication
- 50% recover 1st year; 30%: chronic
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
12
Study Notes in Psychiatry (2008) Dr. Roger Ho

- Grief therapy: explore the meaning - Tremulous hands

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
- 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
Wernickes Korsakoffs
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

13
Study Notes in Psychiatry (2008) Dr. Roger Ho

- Polysubstance abuse - Chronic use can lead to paranoia

- Social complications: job, marriage - Hostility & aggression
10.6 Prognosis: good prognosis in - Persecutory delusions
motivated, socially stable, no antisocial - Auditory, visual, tactile hallucination
personality disorder - Clear consciousness

Ch. 11 Drug Dependence 11.5 Cannabis

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

Drugs Physical Psychological 11.6 Cocaine

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

11.2 Opiates eg Heroin 11.7 Benzodiazepine

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

14
Study Notes in Psychiatry (2008)
- 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 Alzheimers 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
Genetics:
- Chromosome 21 for amyloid precursor
protein
- Chromosome 19 for apolipoprotein E4
- Chromosome 14 for presenilin 1
- Chromosome 1 for presenilin 11
Cholinergic hypothesis: degeneration of
cholinergic nuclei in nucleus of Meynert
Pathophysiology
-Amyloid plagues in hippocampus,
amygdale and cortex
-Neurofibrillary tangles in cortex,
hippocampus
Clinical features
Early symptoms: increasing forgetfulness
Amnesia
Aphasia (word finding difficulty)
Apraxia (cannot dress)
Agnosia (cannot recognize body parts)
Poor visual spatial skill
Delusion of theft against maid in Spore
Hallucination 10%
Behavioural disturbance: aggression,
wandering, sexual disinhibition
Mini-mental state exam < 24 /30
Investigations: FBC, B12, Folate, LFT,
RFT, VDRL, CT or MRI brain
Management:
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
Behavioural techniques for changing
negative behaviour
Poor prognosis: Male, Onset < 65, Parietal
lobe damage, prominent behavioural
problems, Depression
12.2 Other causes of dementia
- Dementia with Lewy body (with
parkinsonism)
- Fronto temporal dementia with
personality changes
- Vascular dementia with neurological signs
of stroke
12.3 Reversible causes of dementia
Appendix 12a
12.4 Pseudo dementia: always say, I
dont know
- Previous history of depression
- Islands of normality
- Response to antidepressant
12.5 Psychosis in elderly
Less than 1%; F:M 5:1
Family history of schizophrenia; sensory
impairments, social isolation
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
Study Notes in Psychiatry (2008)
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
patients conscious mind
- Secondary gain: symptoms confer
advantage to patient: exempted from NS.
Clinical features:
Dissociation Conversion
- Psychogenic - Paralysis
amnesia - Fits
- Psychogenic fugue - Blindness
(wandering) - Deafness
-Somnambulism - Aphonia.
(sleep walking) - Anaethesia
- Multiple personality - 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
Study Notes in Psychiatry (2008)
- 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 / Munchausens
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
17
Study Notes in Psychiatry (2008)
- 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
of new mothers will experience a short
lived period of tearfulness and emotional
lability starting 2-3 days after birth.
Due to pospatrum reductions of oestrogen,
progesterone and prolactin.
No need for treatment.
14.2 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 babys 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
Risk factors:
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:
Treatment in hospital KK women hospital /
In the UK, admit to special mother baby
unit
ECT is useful
Antipsychotics is needed ( to avoid breast
feeding)
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
18
Study Notes in Psychiatry (2008) Dr. Roger Ho

Dry skin/brittle hair

Loss of brain volume
Cerebral atrophy
Ventricle
enlargement

Ch. 15 Eating disorder Elevated hormones Reduced

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

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

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

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

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

Stereotyped recurrent pulling of hair 8. Other associations :

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

21
Study Notes in Psychiatry (2008)
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
A Affect: unstable
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
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 patients 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
Psychological treatment
-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
22
Study Notes in Psychiatry (2008)
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.
Incidence: 0.2%
F: M = 2:1
Risk factors
- Drug nave patient receiving high potency
antipsychotics
- Dehydration
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
More rapid onset, rapid progression and less
rigid than NMS.
Investigations: same as NMS, add in CXR
to rule out aspiration, ECG to look for
prolonged QTc
23
Study Notes in Psychiatry (2008) Dr. Roger Ho

- Chronic significant insomnia 6%

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

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

Long acting Diazepam Initiating, - Social skill training

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

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

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

25
Study Notes in Psychiatry (2008)
- 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 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)
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
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.
26
Study Notes in Psychiatry (2008)
20.5 Approaches to the Child
- Establish the rapport and gaining
the childs confidence
- Begin with subjects well away from
the presenting problem (interests,
hobbies, friends and siblings, school
and holidays)
- Progress to enquire about the
childs 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
20.6 School refusal
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
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
Dr. Roger Ho
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
Treatment
an early return to school is important
discussion with teachers is needed
depressive disorder should be treated
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.
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 Tourettes syndrome
27
Study Notes in Psychiatry (2008) Dr. Roger Ho

Multiple motor and vocal tics for a year, with

distress and impairment function.

Facial tics as initial symptoms

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

Onset: 7 years old M:F = 3:1

Prevalence: 5/10,000

Genetics factors: AD
Involves dopamine system and Basal
Ganglia

Comorbidity: depression, OCD

Treatment: Haloperidol 1.5mg-5mg, CBT

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

Most common genetic cause of LD CNS: behaviour problems: hyperactive,

Trisomy of chromosome 21 sleep problems, poor visual acuity, hearing
loss, language deficits.
IQ most often below 50
Develop Alzheimers disease at 40s and 50s Other: ASD, VSD, renal hypoplasia.

Clinical features of Down syndrome

28
Study Notes in Psychiatry (2008)
22 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
1) 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.
Example:
Assume you are the AED medical officer
working in a general hospital. A 29 year old
Dr. Roger Ho
male suffers from paranoid schizophrenia
was brought in to your AED. He has been
violent at home and attacks his parents. He
has poor insight and has defaulted his
treatment for 3 months.
He refuses to be admitted to your general
hospital psychiatric unit (or your psychiatric
ward is full)
In this case, you can send the patient to IMH
for assessment. (You need to call the IMH
registrar on call at 6389 2000)
The IMH medical officer or registrar will sign
the Form 1 of Mental Disorder and
Treatment Act: compulsory admission for 72
hours.
22.2 Driving and Psychiatric illness
(Based on UK law, Singapore does not
have clear guideline on this)
For schizophrenia, bipolar disorder:
Driving must cease during acute illness
Re-licensing for private car:
- 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 dialysis. 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.
29
Study Notes in Psychiatry (2008) Dr. Roger Ho

First, we have to determine whether the Techniques:

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

30
Study Notes in Psychiatry (2008)
ve belief or emotion to a second
Identific person. Then, there is another
ation 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.
Reactio The expression externally of
n attitudes and behaviours which
formati are the opposite of the
on unacceptable internal impulses.
Displac Transferring the emotional
ement response to a particular person,
event, or situation to another
where it doest belong but carries
less emotional risk.
Rational Justifying behaviour or feelings
isation with a plausible explanation after
the event, rather than examining
unacceptable explanation.
Sublima Regarded as healthy defence
tion mechanism, The external
expression of unacceptable
internal impulse in socially
acceptable way.
Ch. 24 Glossary
Alexithymia: The inability to describe ones
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 patients 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.
Dj 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 ones
skin is infested by multiple, tiny, mite like
animals.
Delusion of reference: A delusional belief
that external events or situations have been
31
Study Notes in Psychiatry (2008)
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 (Knights 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
ones home and environment. Due to
organic disorder, schizophrenia, OCD.
Dysarthria Impairment in ability to
properly articulate speech
Dyslexia Inability to read at the level
normal for ones age or
intelligence
Dysphasia Impairment in producing or
understanding speech
(expressive dysphasia -
Brocas and receptive
dysphasia - Wernicke)
related to cortical
abnormality
Dysphoria An emotional state
experienced as unpleasant,
secondary to depression
Dyspraxia 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 ones
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
patients 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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 Study Notes in Psychiatry (2008)
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.
Synaethesia: A stimulus in one sensory
modality is perceived in a fashion
characteristic of an experience in another
sensory modality (tasting sounds).
Appendix
Appendix 3a Neurodevelopmental Hypothesis of Schizophrenia
From: Your questions answered series Schizophrenia, Churchill Livingstone
Appendix 3b Brain abnormalities of Schizophrenia
Dr. Roger Ho
Tangentiality: Producing answers which
are only very indirectly related to the
question asked by the examiner.
Trichotillomania: Compulsion to pull ones
hair out.
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
- 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.
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Study Notes in Psychiatry (2008) Dr. Roger Ho

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

Appendix 3C

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

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

Appendix 5a - Toxic effect of lithium

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

Appendix 9a PTSD and Grief

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

Appendix 10

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Study Notes in Psychiatry (2008) Dr. Roger Ho

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

Appendix 12a

36
Study Notes in Psychiatry (2008) Dr. Roger Ho

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

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

Disorder Mnemonic Breakdown of Mnemonic

Negative 5As and aPathy
symptoms of PLANT aLogia

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Study Notes in Psychiatry (2008) Dr. Roger Ho

schizophrenia aFfective flattening

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

Everything else decreases

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