Study Notes in Psychiatry (2008) Dr.Roger Ho
Study Notes in Psychiatry
(For MBBS III to V)
Dr. Roger Ho
MBBS (HK), DPM( Ireland), MMed (Psych)
Department of Psychological Medicine, NUS
Email:
Table of Content / PageCh. 1 Introduction / 2
Ch.2 Signs & symptoms
Acute management / 2
Ch. 3 Schizophrenia / 3
Ch. 4 Delusional disorder / 6
Ch. 5 Bipolar disorder / 7
Ch. 6 Depressive disorder / 9
Ch. 7 Obsessive compulsive disorder / 10
Ch. 8 Anxiety, Panic, Phobia / 11
Ch. 9 Post traumatic stress disorder, Acute stress, grief / 12
Ch. 10 Alcoholism / 13
Ch. 11 Drug Dependence / 14
Ch. 12 Old age psychiatry / 15
Ch. 13 Consultation Liaison Psychiatry / 16
Ch. 14 Perinatal Psychiatry / 18
Ch. 15 Eating disorder and impulse control disorders / 19
Ch. 16 Suicide and DSH / 21
Ch. 17 Personality Disorder / 22
Ch. 18 Psychiatric emergencies / 23
Ch. 19 Sleep disorders / 24
Ch. 20 Child Psychiatry / 25
Ch. 21 Learning disability / 28
Ch. 22 Legal aspect / 29
Ch. 23 Psychotherapy / 30
Chapter 1Introduction
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 / EchopraxiaRepetition by the patient of the interviewer’s words or phrases / Imitation by the patient of the interviewer’s movements.
Stereotypy / Mannerism
Regular, repetitive non goal-directed movement (purposeless) / Abnormal, repetitive goal-directed movement (of some functional significance)
Waxy flexibility / Mitmachen
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) / Patient’s body can be placed in any posture; when relaxed, patient returns to resting position
Catalepsy / Cataplexy
Motor symptom of schizophrenia, same as waxy flexibility / Symptom of narcolepsy in which there is sudden loss of muscle tone leading to collapse, occurs in emotional state.
Automatic obedience / Gegenhalten
(opposition)
Patient does whatever the interviewer asks of him irrespective of the consequences / The patient will oppose attempts at passive movement with a force equal to that being applied.
Mitgehen / Negativism
An extreme form of mitmachen in which patient will move in any direction with very slight pressure / Extreme form of gegenhalten, motiveless resistance to suggestion/ attempts at movement.
Ambitendence / Preservation
The patient beings to make a movement but before completing it, starts the opposite movement / The senseless repetition of a previously requested movement, even after the stimulus is withdrawn
Neologisms / Metonyms
The patient uses words or phrases invented by himself / Use of ordinary words in unusal ways
Obsessions / Delusions
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 / 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
Verbigeration (word sald) / Vorbeireden (talking past point)
Disruption of both the connection between topics and finer grammatical structure of speech
Occurs in SZ / The patient seems always about to get near to the matter in hand but never quite reaches it.
Occurs in SZ
Lossening of associations / Flight of ideas
Loss of the normal structure of thinking. Muddled and illogical conservation that cannot be clarified
Occurs in SZ / Patient’s thoughts and conservations move quickly from one topic to another, the links between these rapidly changing topics are understandable
Associated with rhyming, punning & clang associations.
Depersonalisation / Derealisation
A change in self awareness such that person feels unreal / A change in self awareness such that the environment feels unreal
Bipolar I / Bipolar II
Mania / Hypomania
Affect / Mood
Emotional state at a moment / Emotional state over a longer period
Euphoria / Euthymia
Sustained and unwarranted cheerfulness / A normal mood state
Neither depressed or mania
Chapter 3Schizophrenia
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 / Female23 years
(earlier onset) / 26 years
(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 SZ / Prevalence rateParent of a SZ / 5%
Sibling of a SZ/ DZ Twin / 10%
Child of one SZ parents / 14%
Child of two SZ parents / 45%
Monozygotic twins of SZ / 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.
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 psychosis
- Temporal lobe epilepsy / - Acute organic syndrome: encephalitis
- Dementia
- Diffuse brain disease
OtherDDX: 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
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 cortical bundle / Antipsychotic actionBlk Nigrostriatal / Extrapyramidal effects
Blk Tubero-infundibular activity / Galactorrhoea
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
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 α1 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 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
-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
Remission / Good recovery / Partial recovery / 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.
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 humourless; incapable of expressing tenderness or affection; shy; often eccentric; insensitive; ill – at – ease in company
Ch.4Delusional 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 delusionOther have been identified by identical or near identical imposter / Someone they know in disguise and harming him
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 ersponality 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 submissivepartner in a relationship
4.5 Clinical features:
- 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 (stimulant, hallucinogen)
- Mood disorder with delusion (mood before delusion)
- Schizophrenia (less elaborated delusion)
- OCD: reality testing is intact
- Paranoid personality disorder (Less clearly circumscribed delusion) / - Dementia- memory loss
- Delirium: change in consciousness
- Late onset psychosis (with hallucination)
4.8Assessment
-A thorough history and MSE
-Collateral history from 3rd party
-To rule out organic causes
-Document risk assessment
4.9Management
- 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 / Persisting33-50% / 10% / 33-50%
-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
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
5.9 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.
LithiumCR (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 memberane.
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
- For rapid cycling disorder
Adverse effects:
- Slight risk of liver, pancreatic toxiciety
- 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)
5.12Course 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
5.13Complication:
- 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: