PRIMARY CARE

PSYCHIATRY
THE LIMA WAY
PSYCHOTIC
DEPRESSED
SUBSTANCE ABUSE

CHILD AND
ADOLESCENT MENTAL
ILLNESSES

ANXIOUS

4/2/2011

16

Dr. M PARAMESHVARA DEVA

1

PRIMARY CARE
PSYCHIATRY
THE LIMA WAY
PSYCHOTIC
DEPRESSED
SUBSTANCE ABUSE

CHILD AND
ADOLESCENT MENTAL
ILLNESSES

ANXIOUS

4/2/2011

16

Dr. M PARAMESHVARA DEVA

Professor of Psychiatry, Faculty of Medicine and Health Sciences

THIS BOOK IS NOT FOR SALE and an AFPA contribution to improvement in mental health training.
Copies and e Copies of this and related books may be obtained by writing to the author at
parameshvara24@yahoo.com
COPYRIGHT 1986 Reserved
No part of this book may be copied in any form without written permission of the author
Published by OPHIR MEDICAL SPECIALISTS, 2 Jalan Pos Bahru, 41300 Kelang Malaysia
Printed by BOON YIN ENTERPRISERS PRINTERS, 16, 2/16 Section 2, 40000 SHAH ALAM MALAYSIA
FIRST EDITION 1 May 2014

The word LIMA means five or hand in numerous countries from Madagascar to Easter Island albeit with different pronunciations

CONTENTS
Chapter 1

Making a Paradigm Shift in Managing Stress Disorders

Chapter 2

Locked cells, Steel bars - or Medicines

Chapter 3

LIMA method of understanding Stress illnesses and Treatments

10

Chapter 4

Basics of Stress related illnesses (clerking Sheets p21)

16

Chapter 5

Anxiety Disorders

35

Chapter 6

Depressive illnesses, Bipolar illnesses Suicides, Parasuicides

37

Chapter 7

Psychotic Disorders Psychogenic, organic

43

Chapter 8

Substance Abuse Disorders

45

Chapter 9

Child and Adolescent Disorders

47

Chapter 10

WHO Essential Medicines List

48

CHAPTER 1

MAKING A PARADIGM SHIFT IN

DETECTING AND MANAGING STRESS DISORDERS
Most medical and nursing students are not very keen to learn about mental illnesses and not a few
laugh uneasily and the prospect of seeing the mentally ill as patients in their clinics or wards. The
fear and uneasiness is the result of ignorance about mental illness- from top to bottom of medical
and nursing professions and the resultant prejudice . Not long ago they were taught about mental
illnesses by lecture-demonstrations of the severely mentally ill in mental institutions. The jail like
atmosphere of psychiatric hospitals and wards for decades and even now all over the world sadly
perpetuate the fear students have long before they enter training.

Health is defined by the WHO as a state of physical, mental and social wellbeing and not the
absence of disease or infirmity-WHO Constitution Page 1 Para 1 Line 2, July 22 1946
Mental health is defined by the WHO as a state of well-being in which every individual
realizes his or her own potential, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to her or his community.
Health includes mental health and mental health is part of health although by default both health
care professionals and the public have been wrongly led to believe that mental illnesses are not part
of health and related to madness not included in general health care as they see in mental hospitals.
But the truth as discovered in the past 70 years is that Psychiatric or Mental illnesses are,
1.not limited to the few with psychoses in locked mental institutions
2.present in 20-30 percent of all primary care clinic patients
3.commonly anxiety illnesses, depressive illness forming over 60% of all mental illnesses
4.very treatable in most cases with medicines counselling and social management as outpatients
5.largely not detected by doctors or nurses in PHC clinics because their behaviour is not psychotic

So Why does the ignorance, fear and prejudice and stigma of mental illnesses continue ?
Because unlike other frightening and stigmatising illnesses like Leprosy, Tuberculosis, Polio, HIV
AIDS, whose management has been effective, resources spent by Ministries of Health, hospitals and
clinics on Mental illnesses through effective training , effective treatment strategies, public
education and extensive treatment facilities is not enough. Many mentally ill receive poor diagnosis ,
treatments and counseling support. Just look at TB and Leprosy which have been almost eliminated
in most countries including poor ones which had large leper and TB asylums which have closed
decades ago.
Hence the need to learn about PHC mental illnesses, their diagnoses and management
Many efforts such as slogans, walkathons, publicity campaigns do not succeed in improving
management of mental illnesses because of archaic jail like wards manned by inadequately trained
staff and resort to cells instead of pills locked asylums instead of short stay stress management or
day treatments and charity or welfare aid instead of rehabilitation programmes.

CHAPTER 2

LOCKED CELLS, STEEL BARS - OR MEDICINES

Perpetuating human wrongs, preventing human rights

Discovered 1954

Still Used 2014

7

Available since 1960s

Basic and Essential Psychotropics available all over the world and inexpensive

PSYCHOSES
DEPRESSIONAntidepressants,
counseling

Anti psychotics
rehabilitation

SUBSTANCE
ABUSE DISORDERS
rehabilitation, medicines

CHILD AND ADOLESC

DISORDERS counseling,

ANXIETY

medicines

Anxiolytics, Counseling

YOUR DIAGNOSIS AND TREATMENTS

ARE IN YOUR HANDS

WHAT
ALL
PRIMARY
PROFESSIONALS,

MUST KNOW

HEALTH

CARE

History taking and interviewing skills, accurate

assessment of mental status and cognitive functions, recognition of behaviour

related to anxiety, depression, psychoses in any setting, Diagnostic skills, LIMA
Classification - anxiety, depressive disorders including parasuicides, suicides,
Bipolar Disorders psychotic disorders and basic medication use (EML WHO) and
counseling skills and basic rehabilitation principles. Psychiatric illnesses in all
non-psychiatric clinical settings

SHOULD KNOW

Substance Abuse and Child and Adolescent

disorders Signs symptoms diagnoses and basic management

CONSIDER NICE TO KNOW
Forensic psychiatry, social psychiatry,
sexual disorders eating disorders, psychotherapy, Newer treatments, latest
discoveries in psychopharmacology
CLINICAL CRITERIA FOR DETECTING
SYCHOLOGICAL STRESS PROBLEMS IN PHC SETTINGS
1. All with HEADACHE, but especially those looking distressed
2. All who KEEP ATTENDING CLINICS for headache, stomachache, backache,
chest pains despite so many tests done repeatedly AND YET NO DIAGNOSIS
3. All patients with INSOMNIA BUT NO PAIN OR PHYSICAL DISEASE
4. All patients whom nurses, doctors and nurses see as "MALINGERERS" for
frequent medical leave requests
5. All patients with Essential Hypertension without complications

6. ANY Patients who have been given PLACEBO for complaints without a proper
diagnosis
7. Any Patient with past history of "MENTAL PROBLEM

CHAPTER 3

SIMPLI

LIMA
Depression
Antidepressants

Psychosis
Personality, Subs
Antipsychotics Abuse, addictions

Child and Adolescent

problems

Anxiety
Anti-anxiet y
medicines

COMMONEST MENTAL
PROBLEMS IN PRIMARY CARE
@ copyright reserved

Dr. M P Deva
MB;BS,FAMM, FRANZCP, FRCPsych DPM Eng

Professor of Psychiatry, Faculty of Medicine, University Tunku Abdul Rahman, Malaysia

parameshvara24@yahoo.com
parameshvara@utar.edu.my

10

SIMPLI
SIMPLIFIED MANAGEMENT OF PSYCHIATRIC AND
RELATED ILLNESSES
Pre-requisite : Get Good History, Do GOOD Asessment, PLEASE
!!
No Psychiatric illness can be managed by guess work, prejudice
and casual poor shoddy clinical skills learnt by observation,
ONLY !!

First Level

IS THE PRESENTING PROBLEM

NORMAL
BEHAVIOUR

ABNORMAL
BEHAVIOUR

Counsel complainant
Manage anxiety
Psychosis

Depression

Anxiety

Second
WAY

Level

THE

Personality, Suns
Abuse, addictions

Child and Adolescent

problems

COMMONEST MENTAL
PROBLEMS IN PRIMARY CARE

LIMA

SIMPLI

------------------------------------------------------------------------1.Anxiety 2.Depression 3.Psychoses 4.Substance

5.Child
Related
Related
Related Abuse/personality Adolescent
Disorders
Anxiolytics
Counselling

Disorders
Anti-depressants
Counselling

Disorders
Disorders
Anti Psychotics Rehab, Meds
Rehabilitation Counseling

11

Disorders
Family Therapy
some medicines

The commonest psychological illnesses in the clinic setting are anxiety, depression and stress
related emotional reactions that occur in 20-30% of all general or Primary Health Care
patients clinic patients. But these psychological conditions are very seldom detected by
primary care clinic staff as their symptoms of anxiety or depression (see details below) such
as stomach pains, headache, chest pains, are also similar to symptoms of physical conditions.
Together they form over 80% of all mental illnesses but remain poorly detected- and very
poorly treated. Their recognition is poor because of poor training of all health care staff. They
are often present in chronic clinic attenders in whom definite diagnoses are unclear.
Psychosis

Depression

Anxiety

Details of Second Level

Personality, Suns
Abuse, addictions

Child and Adolescent

problems

COMMONEST MENTAL
PROBLEMS IN PRIMARY CARE

1.Anxiety is a psycho-physiological response to a psychosocial threat. Anxiety

is normal and gets us ready to fight or flight when we face threats. But when that
psycho-physiological problem is not resolved it may become a disease called Anxiety
Disorder. Anxiety disorders make up over 60% of mental illnesses and present with
symptoms of
Worry, tension
Recent poor sleep
Preoccupation with headache, gastric, chest, heart symptoms and worry about disease
Headache, neck ache, backache, stomach ache
BUT, on examination and investigations, are essentially normal
Worry of serious disease, despite reassurances, resulting in doctor shopping
Symptoms started after onset of psycho-social threat. (history is difficult to elicit-)
Treatments.
Understand source of worries, (Get good History) reduce symptoms with Anxiolytic
medicines, like diazepam, teach relaxation exercises, try and overcome conflicts, through
Counselling process. Behaviour modification to reduce problem behaviours. Prolonged
anxiety can be associated with depressive symptoms.

2.Depression can be defined as a Psycho-physiological response to a Loss.

When a person loses something dear and near to himself or herself there is a negative effect
on the emotion. First there is worry overcome but when it is clear that the loss cannot be
overcome sadness, then depression sets in. The symptoms occur soon after a loss. Depression
like anxiety causes both mental and physical symptoms. Depression in one form or another
accounts for 20% of all mental illnesses
Feeling sad, miserable, moved to tears. In acute depression there may be selfharm
(Parasuicide)
Decreased interest in work, pleasurable activities and social commitments
Neglect of personal needs, grooming, dressing
Rational and coherent but negative in thoughts and speech
Tendency to avoid others, keeping to oneself , seen crying
Negative ideas, leave job, go far away
In late stages thinking of ending it all, of suicide

12

Loss of good sleep , difficulty going to sleep, very early awakening and inability to sleep
again
Sometimes excess sleep
No interest work, recreation, no interest in food, lack of appetite, leading to loss of weight
Depressive problems and illnesses can be mild, moderate, or severe
1 Mild -brief adjustment problems like recent loss in but able to go on with work, social life
Acute but mild depressive reactions include failing exams, loss of a relationship, death of a
loved one. In acute loss of a relationship there may be attempts at suicide (self- harm) but
these for the most part resolve and do not progress to severe depression. Symptoms of sleep,
appetite problems are short lasting from a few days to a few weeks.. These usually do not
require anti-depressant medicines and do well usually with anti-anxiety medicines and
counselling
2 Moderate, - longer depressive symptoms affecting sleep appetite, loss of weight work and
social life result from difficulty in overcoming acute losses and last many weeks and include
sleep problems, appetite problems and loss of weight
3 Severe, -much longer, affecting sleep, eating, bowel movements, sexual function, work,
social life, with suicidal ideas occur with unresolved acceptance of the loss. They may be not
working for some time before they present themselves for assessment
4 Some depressed persons although basically depressed may present with psychotic
behaviour agitation, irritability, hyper-excitability, talkativeness or even violence
These are often features of Bipolar Affective Disorders (see below)
Treatments.
Most milder illnesses will need only Anxiolytic medicines and counselling.
Those with moderate to severe illnesses will need Anti-depressant medicines and when
better, counselling. Cognitive Behaviour Therapy has an important role for those
recovering from Depressive illnesses Bipolar disorders are best managed by use of mood
stabilisers.For treatments of psychotic depressive illnesses see below

3 Psychoses are psycho-physiological responses to inability to cope with stress in

vulnerable persons. The Psychoses commonly seen are
a. Psychogenic psychoses schizophrenia, manic depressive psychoses (Bipolar
disorder) paranoid illnesses
b. Organic psychoses, such as due to physical diseases, toxic substances, infections
of the brain, head injury, endocrine problems or dementias .
Psychoses are usually easy to recognise as they present with :
Abnormal thoughts such false beliefs that people are going to harm them
Abnormal perceptions such as hearing voices, seeing things that are not there
Abnormal behaviour, such as talking, laughing to ones self for no reason
Occasional restlessness and rarely aggression and more rarely violence
Psychoses are rare in the community occurring in less than 1% of the population
In Bipolar Affective disorders there are 2 phases
one of depression usually severe with delusions and paranoid ideas and occasionally hearing
voices asking him to die, or accusing him etc. and
two of cheerful overactive behaviour with abnormal talkativeness, confidence and racing
thoughts.
These 2 phases of the same psychotic illnesses may alternate in presentation in the same person

13

Treatments for psychoses

Anti-Psychotic medicines such as haloperidol, depot anti-psychotics and Rehabilitation.
For bipolar disorders mood stabilisers such as sodium valproate, carbamazepine or lithium
with properly monitored blood levels are used with or without anti-psychotic medicines.
Counselling.
4.Personality, substance abuse and deviation- related disorders
are
conditions
Characterized by what society sees as difficult behaviours that are on the whole very difficult
to treat with medicines and counselling . Although some medicines such as naltrexone for
opioid addiction or antabuse for alcoholism are available along with counselling the success
rate is far below that of the treatments for anxiety, depression or psychoses. The main
features are prolonged and recurrent behaviour problems with possible physical and long
term complications. There are many persons with depression or anxiety disorders who also
abuse drugs or abuse alcohol in attempts at self-treatments and may end up with 2 diseases
rather than one. For chronic opioid addiction, maintenance on such drugs as methadone is
nowadays preferred.

5.Child and adolescent emotional problems are emotional and behavioural

problems of children and adolescents resulting from
a. Developmental difficulties of childhood such as dyslexia, learning disorders,
spasticity
b. Behaviour problems of childhood and adolescent such as bedwetting, Attention
Deficit Hyperactivity Disorder (ADHD) stealing, violence, truancy often resulting
from stresses in family, and school the child or adolescent is unable to cope with
c. Psychoses of childhood such as Autism, schizophrenia
Treatments for Child and adolescent disorders
Treatment are largely family counselling for the developmental problems and remedial
help for the child, and overcoming the behaviour problems through family and
individual counselling for behaviour problems. For the more severe illnesses medicines
and behaviour modification by trained staff may be needed
Principles of Management of All Emotional problems
Medicines for distressing symptoms
Counselling for psychological aspects of distress
Psychosocial rehabilitation using Psychological, Social and Occupational methods
Medication maintenance Relapse prevention
Prognosis (chances of recovery), depend on
1. Early detection
2. Accurate history taking, accurate diagnosis
3. Appropriate medicines, as advised
4.Effective counselling to overcome psychosocial problems, conflicts
5.Effective Relapse Prevention Strategies, Family involvement.
*Note: Please see Latest edition of Essential Medicine List of W.H.O. for details of medicines mentioned in these
notes.

14

CHAPTER 4
BASICS OF STRESS RELATED ILLNESSES
A. CAUSES OF MENTAL ILLNESSES

BIO-PSYCHO-SOCIAL
BIOLOGICAL
Functions of the Brain and body that have been affected by
Psychological and Social stresses, Physical Stresses
PSYCHOLOGICAL and SOCIAL
Thoughts, worries related to self, family, work, relationships,
finances, instability in country, natural calamity political and
other man made calamities such as war and in later life, ones
health ,
PREDISPOSING FACTORS
PRECIPITATING FACTORS
PERPETUATING FACTORS
B. MANAGING,
TREATING
MENTAL ILLNESSES

AND

REHABILITING

A. ACCURATE HISTORY (HIS-STORY) AND THEIR STORY

FROM FAMILY
B. CAREFUL ACCURATE MENTAL STATUS EXAMINATION
C. IMMEDIATE AND LONGER TERM MEDICAL TREATMENT
FOR DISTRESSING SYMPTOMS
D. WHEN SYMPTOMS IMPROVE, START COUNSELING
PROCESS TO IMPROVE COPING
E. REHABILITATION FOR RECOVERY PROCESS WHEN
ILLNESS HAS BEEN MODERATE TO SEVERE
15

LESSON # 1
MEDICINES ONLY CONTROL SYMPTOMS DO NOT
OVERCOME THE PSYCHOSOCIAL STRESSES THAT HAD
CONTRIBUTED TO START OF THE SYMPTOMS
A 27 year old girl becomes depressed and sleepless after discovering a week ago that her live
in boyfriend of 2 years has been having an affair with another woman and many quarrels that
followed. She is likely to benefit from sedative anxiolytics for her symptoms of sleeplessness
but still needs help with being with her psycho-social stress. No medicine exists that can cure
psycho social stresses. Stresses often cause symptoms such as palpitation, headache, stomach
ache, poor sleep and poor concentration. Medicines can reduce the symptoms of stress but not
the causes of stress. Stresses are experienced when a person reacts adversely to
uncomfortable events, relationships, demands made on the person and inability or
unwillingness to accept changes. Most people like to be in their comfort zone and any
change makes them uneasy, uncomfortable and feel stressed. Most people can cope with
minor stresses with time often by avoiding the stressful demands for example.

LESSON #2

But if the source of that intrusion into their comfort zone intensifies the minor irritant gets
worse producing more reactions such as insomnia, headache, stomach-ache, backache, poor
concentration at work or chest pain.
The mechanism that triggers off the physical reactions in the form of physical symptoms are
related to our readiness to Fight or Flight. In the reaction reminiscent of our ancient animal
beginnings when we perceive a danger (loss of boyfriend for example) the reaction is not
dissimilar to fear and our body gets ready for fight or flight. This is an autonomic reaction of
the brain and autonomic nervous system that triggers off all mechanisms under autonomic
control - such as heart, muscles, digestive system which go into overdrive and even affect
sleep. In our ancient development the body got ready for a real threat of a sabre toothed
16

tigers roar we heard and our stomach went into hyperactivity producing more gastric juice to
digest more food to send more glucose to the muscles which was done by the heart working
hard to pump blood to muscles for FIGHT or FLIGHT both of which needed excess
activity of these vital organs. The overwork caused blood pressure to rise, the pulse rate to go
up and the body to produce more heat which in turn triggered more sweat to cool the body,
dryness of the mouth. Some times these action stations reaction to the threat caused
frequency of micturition, even hypermotility of the intestines, even causing nervous
diarrhoea.
Fortunately the threats these days are not from wild animals but from family related
stresses, such as disagreements , quarrels, financial problems disciplining of children
poor school performance, work related stresses, such as rivalry, unequal promotions,
financial stresses.
But getting at rather personal problems facing the person suffering from stress is not easy.
Very few volunteer to their doctor they have a quarrelsome boss, wife or disobedient children
or that they have lost out on promotion. These require painstaking his-story taking.
Unfortunately taking a good history and teaching of good clinical communication skills
are not well done in medical schools or nursing schools of the 21 st century The symptoms
that torture the suffering patient are all so clearly physical but all investigations show no
physical illness whatever. Taught wrongly that only physical pathology causes physical
symptoms most doctors including cardiologists, gastroenterologists, and neurologists, miss
out the psychosocial stresses rather that physical causes of the symptoms. Patients who
suffer from emotional stress make up over 25% of all clinic attenders in Primary care and
confound the nurses and doctors by their resistance to all treatments except psycho social
ones they are not offered. Sadly the patient goes on suffering and spending more on treatment
with no way out until you as students relive them one day from their suffering !

REMEMBER.

17

SO, IS THERE A PILL FOR EVERY DISEASE ?

18

IS THERE A SCANNER FOR EVERY STRESS THAT HIDES INSIDE

NO!
GET A GOOD HISTORY AND MENTAL STATUS EXAMINATION !

19

USE HUMAN HIS-STORY AND MSE SCANNER !

THE HUMAN SCANNER SHOULD ELLICT ACCURATE HIS-STORY

Preliminary data
Personal history
Family History
Current Mental state
Tests of Cognitive Function
And
Do a good physical examination

But costs less and does work no MRI, CT, PET, SPECT can scan . Trainee Human
scans can learn to be good scanners with dedication and concern for patients.

20

Remember most failures in diagnoses are the result of poor history taking skills

HISTORY TAKING FORMAT

PSYCHOLOGICAL AND BEHAVIOURAL MEDICINE
FACULTY OF MEDICINE
CONFIDENTIAL
1.

PRELIMINARY DATA

Name:

Hospital / Clinic Number

Sex:

Identity Card Number

D.O.B.

Current Age:

Ethnic group:

Religion

Single/Married/ Divorced/Widowed /Separated/Live in relationship

Occupation:

Current employment status

Current address

Home address, phone, work address

Language spoken
(translated/not)
2.

HIS-TORY OF ILLNESS INTERVIEW - INTERNAL-VIEW

Chief complaints 1

duration

duration

duration

History of Present illness (from patient)

History of Present illness (from relative/friend)
(relationship to patient)

Sleep, Work ability

Brief history of past illness (psychiatric)
nature, duration
treatment source
admissions
1
2
3
History of past illness, admissions/ brief notes
sleep problems
Self-care - able or not
appetite
agitated/violent or not
suicidal or not

21

3.

FAMILY AND PERSONAL HISTORY

THE GENEOLOGICAL CHART filled accurately IS A MUST as it helps understand the background
of the ill person and also helps in the psychosocial management
Family history
Genealogical chart

- ----------------------------------------------------I
------------------------------------------------I
I
I
I
I

See attached sample

Family history
Family history of ,
mental illness
any other significant and family history

Personal History
Brief birth history
born where, normal delivery or not
schooling - primary where
performance
- secondary where
performance
- exam results Std 6
SRP
SPM

Post-school education up to what grade

Results, distinctions
Work record

1st job, when, where, what, salary

other jobs
current job
reasons for change of job(s)

Sexual history masturbation

heterosexual or
homosexual
girlfriends, boyfriends
who, where, how close
how many, currently
Marital history - when
to whom, courtship
or arranged
Children (chart) school, work, married
problems in marriage, outside relationships
Alcohol, cigarettes, drugs - when started
current consumption, any psychological
or social effects Other habits, gambling
Pre-morbid personality (history by relatives )
H/O MEDICAL illnesses, admissions
Any history of police charge- details

22

4.

PSYCHIATRIC EXAMINATION

a.Current Mental State

General Appearance and Behavior
Dress grooming, cooperative or not,
restless or aggressive
Talk, speech
sample of speech
language, coherence, relevance
abnormal speech e.g. pressure
loose association, mute, slow
Mood, Affect
anxious, depressed, flat, normal
labile, elated
Thought content
Perceptual disturbances
hallucination, auditory, visual
others
Delusions, paranoid grandiose
nihilistic, somatic
Obsessional thoughts
recurrent dreams, ideas
nightmares, preoccupations
b. Tests of Cognitive Function
Orientation, to time, day, date, month, year
place, person
Memory, immediate recall
short term 5 min memory test, medium term,
long term
Attention and concentration
serial 7s, serial 5s, test ,digit span
Intelligence - brief school record
exams passed, simple arithmetic,
Judgment
Insight

Events Chart (see attached sample)

This a chronological events chart from birth to present including birth, early childhood schooling, significant
events related to family and schooling, marriage or not children or not and work record Events Chart
(sample)
Seen mumbling to self 2008 1Sept
Nov 21
----------------------------------------------------------------------------------------------------------------------------- -----I
I
I
I
I
I
1989
04 Std 6
F3 Failed
Dropped out F4
Worked
Adm
Born FTND age 13
Age 16
Age 17
for uncle
Age 20
Ceras
Poor results
often absent
smoking, fights
mechanic
Violent
(age 19)

23

5.SUMMARY OF PHYSICAL EXAMINATION

List of Differential Diagnoses

1
2
3
FORMULATION: (One paragraph of not more than 10 lines)
Mr. SCA is a 43 year old married printing technician from Sg. Buloh who was well till 4 th of May 2012 when
driving to work on Federal highway he suddenly felt chest pain and afraid he was going to die.
Provisional Diagnosis AXIS I Psychiatric Diagnosis
To Include
AXIS II Personality Diagnosis
AXIS III Physical Diagnosis
AXIS IV Psychosocial Stressors
AXIS V Level of Functioning in past month
Investigations suggested
Provisional treatment and other orders for patient care
Name of Student/ Doctor ___________________Signature.---------------------------------------Date--------------

MPDCS/2013UTAR
Revised April 2014

24

History Taking Sheet a must for clerking any patient who has stress related illness
IF YOU TAKE A GOOD HISTORY YOU DESERVE A BOQUET, AND THE
UNDYING GRATITUDE OF THE PATIENT, HIS/HER FAMILY AND DOCTOR. IF
NOT, CONTINUE IN THE PAST MISMANAGEMENT OF THE MENTALLY ILL

25

Although many mentally ill may look uneasy, distressed or even disturbed many will not
admit it easily. There is a natural tendency to deny human problems that cause stress and
produce distressing symptoms . The reasons for this are many, but most of all is a very
human reaction not to look weak or seen by others as having failed in any way. The resort to
explanations for the distress that having nothing to do with failure is a common reaction.
Thus supernatural causes, biochemical causes or symptoms caused by enemies, jealousy are
fairly common. Many a person bearing pain, distress disappointment and pain puts on a
brave front that throws the well meaning healer, nurse or doctor or medical student off
course. Many a patient desperately in need of help for emotional pain and indeed having
faced painful disappointment actually denies he or she is facing any problem and even
emphasising he or she is actually happy and well except for the persistent headache (or
stomachache no doctor with expensive investigations can discover. No amount of reassurance
by doctors that he is physically well helps. Many a suffering patient with emotional pain
hunts for a bodily disease that no one can discover and spends heavily in the process. It is
indeed , a disease no specialist of internal medicine nor sophisticated investigating can
discover

Commonest complaints of heart symptoms, stomach complaints are NOT physical in origin.
The autonomic nerve supply of both organs also trigger heart pain, stomach pain when there
is emotional Heartache someone is giving her or the patient cannot stomach emotional
pain .

26

Physical illnesses usually show up on lab and other physical tests and must be done routinely.
But) are of emotional origin. when the tests are repeatedly negative, it may mean the patients
symptoms (stomach ache, heart ache, headache are of emotional origin.. About 25% of all
PHC patients heartaches, stomachaches, headaches and backaches are emotional distressrelated. AND need a good History taking Scan.
Look at the patients face- does he look anxious, distressed, depressed

There is no Scizo-coccus

or

Depresso-lesterol discovered yet !

This Treadmill Stress Test is for Muscles of Heart and Does not Show Stresses of Life

27

EVERYTHING

-Ve ?

EVEN MRI NEGATIVE !

but still has many

physical complaints . Do not jump to conclusion he is malingering. He may be anxious or

depressed or both.

LOOK AT HIS FACE (NOT your Facebook))

DOES IT LOOK NORMAL ??

28

LESSON #3
LEARNING NORMAL FROM ABNORMAL EMOTIONS IS THE KEY
TO UNDERSTANDING STRESS (MENTAL) ILLNESSES
Is he as normal as you ??? Is he Anxious, Depressed, (or rarely Psychotic)
If So,

USE LATEST MODEL SCAN CALLED

HISTORY TAKING

Getting a good history that addresses the problems that present with difficult to understand
symptoms, is a fine art that students can learn given interest in healing the patient in distress.
One has to delve deep into the tunnel of psychosocial history and an examination of the
mental state and cognitive functions. Guesswork based on prejudice do not have a place in
history taking. Similarly a pretty face or good looks can hide moutains of emotional pain.

A Face may mislead and not always reveal as as much as a physical examination of an
abdomen in a physical illness.

29

Behind a smiling face may be a sack full of problems, worries, tragedies and losses that
caused abdominal symptoms,
or chest pains that no
COMMON SOURCES OF PSYCHOSOCIAL STRESS
automated tests can reveal.
STUDIES STRESS, FORCED TO TAKE UP COURSE HE DOES NOT
LIKE , BOYFRIEND, GIRLFRIEND, (OR NO BF/GF)JEALOUSY,
CHEATING, MONEY PARENTS, FINANCIAL SIBLING RIVALRY
BROKEN LOVE AFFAIRS, FOUND OUT SHE OR HE HAVE BEEN
CHEATING , UNMARRIED LEFT ON SHELF, MARRIED TO WRONG
PERSON, HANDSOME BUT HAS TRAIL OF GIRLFRIENDS, IN LOVE
BUT HE IS GAY, MARRIED BUT UNHAPPY HUSBAND WIFE
PROBLEMS, DOMINEERING SPOUSE INFIDELITY,BUDGETING
PROBLEMS, LAZY NOT RESPONSIBLE, UNABLE TO COPE WITH
WORK AND HOUSE KEEPING, CHILD CARE, WORK RIVALRY,
PROMOTION PROBLEMS..ETCETCETCETC

Unfortunately physical symptoms are triggered by both physical pathology and

psychopathology but cannot show the mess in the list and picture above and below

STUDIES STRESS, FORCED TO TAKE UP COURSE HE DOES NOT LIKE , BOYFRIEND, GIRLFRIEND, (OR NO
BF/GF)JEALOUSY, CHEATING, MONEY PARENTS, FINANCIAL SIBLING RIVALRY BROKEN LOVE AFFAIRS, FOUND OUT SHE OR HE HAVE BEEN
CHEATING , UNMARRIED LEFT ON SHELF, MARRIED TO WRONG PERSON, HANDSOME BUT HAS TRAIL OF GIRLFRIENDS, IN LOVE BUT HE IS
GAY, MARRIED BUT UNHAPPY HUSBAND WIFE PROBLEMS, DOMINEERING SPOUSE INFIDELITY,BUDGETING PROBLEMS, LAZY NOT
RESPONSIBLE, UNABLE TO COPE WITH WORK AND HOUSE KEEPING, CHILD CARE, WORK RIVALRY, PROMOTION
PROBLEMS..ETCETCETCETC

THERE IS NO
EXAMINATION

SUBSTITUTE

FOR

GOOD

HISTORY

TAKING

AND

There is no ECG, LAB TEST, CT, MRI or PET scan that can take a good history, so do
it !

30

ECG of STRESS STORY

Predisposing 2 weeks Suspected he has another girlfriend. c/o Cannot sleep, , chest pain
saw doctor ECG done Normal Reassured sent home with sleeping tablets (No Psych Diag)
Precipitating Broke up with BF found him in bed with other girl

Suicidal Attempt

Admitted HKL Seen by MS

Depression 1 month

Tries to rationalise

Becomes Depressed, sleepless Suicidal

Found Hanged in her room

ECG Normal
31

ECG SHOWS HEALTHY CONDUCTION SYSTEM

BUT

NOT THE TORTURE HEART

IS EXPERIENCING

Headache, Stomach ache Chest Pains are in more than 55% are NOT Physical in origin
. If the results of tests for these symptoms are negative do take a good look at the
patients face and take a good psycho-social history to broaden your differential
diagnoses .
A Big problem with many anxious and depressed patients (who are not grossly abnormal in
behaviour and clearly not psychotic) is that at first contact many if not most deny they have
any stress, worries or problems(not keen to wash dirty linen in public) and yet are referred
or come for distressing problems of sleep difficulties, chest pain or physical symptoms for
which no pathology is evident. It is easy for the nurse or doctor to be confounded by a
distressed patient who is not physically ill and denies emotional distress. So how does one
proceed ??
The two tools the mental health professional has are
The geneological chart accurately obtained
An events chart obtained in detail

32

-----------------------------------Mother nurse 68 Technician died MVA age 64 two yr.agoMI

Diabetic Retired.
Retired - treated 3 years for Depression
Doted on son, who was his pet but very
Disappointed he was sacked for theft 4y ago

______________________________
O

34 M

32 M

O
28S*

31M

Bank exec

Engineer

Lawyer

Univ. Graduate

Univ. graduate

Univ. Graduate School Cert only,truancy,indiscpl.

clerk , Patient depressed

A picture is worth a thousand words and this chart tells more than a chapter of
denials, no I have no problems
This simple genealogical chart shows at once some clear issues
He is the only boy,
All sisters are graduates
He is not a graduate of University and earns less than them
All are married except him
Father died when Patient was 25
Mother is older than Father by 2 years
Father treated for depression for 3 years. what is the loss ?
Could these be significant in his present illness ? (normal or abnormal stresses)
The purpose of getting a detailed family history is to understand circumstances that could
have a bearing on his present illness. No illness occurs in isolation or out of the blue
including physical illnesses. Cancers result from years of damage done to the organs.
Tuberculosis results from tuberculosis bacteria attacking the body which is weak so that
factors of weakness and exposure to the bacteria act to affect the persons health Smoking of
one cigarette will not lead to cancer but repeated smoking may. Similarly the stresses that
underlie a persons emotional illness relate to many years of repeated stresses or a lifestyle
over years that makes a person more likely to develop the mental illness
(BIO_PSYCH_SOCIAL) One needs to look at circumstances that may have contributed to
the likelihood of emotional illness starting. Thus family stress, frequent quarrels, desertion,
divorce or death can and does affect the life of children and the spouse.. Significant mental
illnesses in the family too show the likelihood that there is stress in the family environment.
.But what are these ? How does one find out what is upsetting the person or family. A big
problem in understanding persons with emotional problems is that many are very reluctant to
tell the whole story, the true story, or the real underlying difficulties in their lives in the first
interview no matter how distressed they are . Common responses to questioning are,

33

1. I have headache I cannot sleep I feel unwell I need medical leave to rest and when
asked if they have any stress most will reply
2. I have no problems. I am happy No, I have no problems with my husband or children
3. Did you have any problems before this complaint started ? No I was perfectly well
4. Have you had any worries
5. No I never have worries
6. Do you quarrel with your wife ? even small quarrels
7. Never, not even once in my 15 years of marriage
8. Any problems with your children . do you ever punish them ?
9. Never. They are wonderful children
10. (sometimes tears will well up when asking these questions) but client will deny she is
upset or crying and even say its not tears but only dirt in both her eyes
This kind of response with no problems whatsoever and yet despite all investigations being
negative, for months , complaining of sleeplessness or headache often means that there may
be an attempt on the part of the client to deny (not tell) the whole story that is distressing her.
The way to overcome this barrier in understanding the client and problems is to look at an
age-wise problem check list like the following.

Age 1-15
Age 15-17
Age 17-21
Age 21-25
Age 25-35
Age 35-45
Age 45-55
Age 55-65
Age >65

Stresses in school, studies family, parents siblings, home

Stresses in school, opposite sex, relationships, family, siblings
Stresses in college studies, opposite sex, new job, relationships
Stresses in studies, relationships with opposite sex, work, bosses
Stresses, marriage, in-laws, children, money, work
Stresses in work, money, children, spouse
Stresses with children, spouse, work, money, health
Stresses with children, money (retired) Spouse
Stresses with health money, children, grandchildren widowhood ?

Asking about particular areas relevant to age will be a useful place to start by asking
Tell me about your children what are they doing ? How are they doing in school.
Tell me about your husbands work, salary, is that enough, do you have debts ?
Are there quarrels between you and your husband about money, his coming home late..
Usually by the time the main phase of the interview is over The interviewer has a fairly good
idea of the kind of emotional problems the client has and a fairly good idea how this present
stress is related to the symptoms.

34

CHAPTER 5

WORRY DISORDERS

ANXIETY DISORDERS
ANXIETY is a normal psychological and physical response to a threat of uncertainty or
insecurity. Awaiting examination results, uncertainty about outcome of an interview or worry
about the delay in arrival of a loved one can make a person worried. The worry is manifest by
a sense of expecting the worst, palpitation, sweating, dryness of the mouth, tremors feeling
of butterflies in the stomach, headache and, poor sleep sometimes chest pains. In most
cases the normal worry diminishes and ends once the source of the worry is resolved. But if
the source of the worry persists the response or symptoms may continue and become a source
of more worry. p These persistent symptoms often make the person more worried as he now
thinks each symptom is a sign of a real physical disease and the original psychological threat
multiples and becomes a preoccupation with many aspects of psychial illness and health that
does not exist. Persisting that the physical symptoms are real the patient goes from doctor to
doctor despite being reassured there is no physical illness. The lack of adequate training of
nurses and doctors in understanding the nature of anxiety and the psycho-physiological
nature of the causes of anxiety and taking a good psychosocial history and helping the
patient overcome the stresses through a counseling process.

35

But before counseling can help the patient the distressing physical symptoms of heart,
stomack, head and others of a physical nature need to be overcome. Managing anxiety
disordersdepends on ,
1.Recognising anxiety as the main problem underlying the numerous physical symptoms
2.Excluding physical causes of illnesses with similar symptoms
3.Getting an accurate and detailed history of psychosocial stressors
4.Identifying main sources of the stresses
5.Prescribing anti-anxiety medicines to reduce distressing symptoms of anxiety and ,
improving sleep. The relief provided by the anti-anxiety medicines id very fast if given in
adequate doses.
6.If untreated or poorly for a long time an anti depressant medicine should be started to
overcome depression- although the depression itself will take not less than about 3 weeks to
improve.
7.Once the symptoms subside a process of helping the individual to overcome the
psychosocial problems he or she faces, throgh counseling can begin. Counseling is not advice
giving. It is an opportunity for the individual to work out solutions for the problems with
support from the counselor.
8. Having said that some persons are unable to make the transition from worry to resolving
problems that continue to worry them. Personality and other factors may make resolution
difficult. Thus several marital problems continue unresolvedfor decades and either side
cannot come to terms witg the difficulty contributing to prolonged anxiety and depression
despite medicines and counseling.
Essential Medicines:
depressant

Diazepam or lorazepam as anxiolytic and Fluoxetine as anti

36

CHAPTER 6

DEPRESSIVE DISORDERS
Depressive disorders that are psycho-physiological responses to Loss. . It is not a feeling of
sadness that all experience at seeing or hearing of a sad situation but more sustained
following a loss. The loss may contribute mild moderate or severe depressive illnesses and in
some a bipolar depressive illness.

I am my worst enemy, Its all my fault, I am solely to blame Its no use going on are some
signs of severe depressive illness. The physical syptoms of depression are slowing of actions,
disinterest in food, loss of appetite work and daily activities, and in prolonged depressive
illness there may be constipation, loss of weight and slowing of thinking and speech.

37

Many with depressive illnesses do not cry openly in an interview. Many who are not
seriously depressed cry during an interview. Crying itself is not a reliable indicator of a
depressive illness, although many nurses and doctors consider it so. Reaction to being told
that a person has a serious illness or that a family member has died will often bring tears to
the eyes of the patient but that is not instant depression. It is a depressive reaction not a
disease, yet. The reaction is often termed sadness. Sadness when it persists and deepens
following a loss may lead to a depressive illness. It is important to distinguish between the
feeling of sadness all experience often (and which dissapears with no treatment) and the
illness called Depressive illness which has clear signs and symptoms both psychological and
psysical, and which needs treatment. Many symptoms of a depressive illness which is very
treatable are missed as the person is labelled lazy shirker and the person told to pull
yourself together. Some communities consider depression as a sign of weakness and
persons with depression do not like to be told that they have a depressive illness. Depressive
illness are a sign of reaction to a serious loss that the person cannot accept. The biological
signs and symptoms of depression such as insomnia, loss of appeite, loss of energy, loss of
concentration, interest in work, play, loss of weight are best treated with medicines and when
they improve counseling can be started to help overcome the psycho social losses
experienced .
Psychological Symptoms(like looking through a tinted glass even the sunny day looks grey)

Everything is down !
Not feeling usual self, seeing only negative side of everything
Feeling miserable, gloomy, negative thoughts, easily tearful
Poor interest in normal work, play, concentration
Poor sleep
The loss is a often personal one that reflects poorly on himself and his standing in society

Physical symptoms
Lack of energy, not interested in games usual physical activity

38

Preoccupied with physical health, worried about illness- tends to exaggerate minor physical
problems- expecting the worst.- goes investigating +, doctor shopping +
Loss of interest in food, reduced appetite, eating less- loss of weight
Even constipation and poor interest in sexual activity and poor sexual function
Persons who drink and smoke may resort to these in excess to sleep better, feel better, and
improve their mood have better sexual function

Classifying Depressive Reactions and Illnesses

Mild
With anxiety

moderate

Severe

with anxiety

Grief, parasuicides

Without

With Psychoses

psychoses

Unipolar

Bipolar

Manic
Phase

Depressive
Phase

Treatments
counseling, anxiolytics

anxiolytics

antidepressants
anxiolytics

anti depressants

mood stabilisers

anti psychotics anti

depressants
ECT if severe

counseling
Parasuicide risk

SUICIDE RISK best managed by psychiatrist in hospital

All depressive reactions and illnesses are serious conditions needing urgent asessment , Rx

Bipolar illnesses are essentially psycho-physiological reactions to losses. Almost all

bipolar illnesses start with a depressive phase that may not always be noticed by those
around the person as there may be a brief lowering of mood which may be followed
1. suddenly by an elevated mood- one of excess jollity and unusual happiness or
2. in some cases irritability argumentativeness , unreasonableness, boisterousness
3. In others there may be a mixture of both,
39

4. Over dressing, make up, flirtation and provocativeness in females

The manic phase of the bipolar illnessis frequently missed even by doctors abnd even
psychiatrists as cheerfulness is missed for genuine happiness and the irritability and
argumentativeness as a sign of schizophrenic illness. Some patients have repeated

Excess drinking and smoking generate more problems though giving the drinker and
smoker temporary happiness. It is not uncommon to find depressed people using alcohol as
a self treatment to elevate their mood and many an alcoholic has become dependent on
alcohol after sufferuing from poorly treated or untreated depression. Alcohol brings with it
real problems of
Accidents,falls injuries
Problems of drunken behaviour, violence,
Problems with the law, MVA, drunkeness disorderliness
Domestic violence, relationship problems, marital problems child and spouse abuse
Work related problems, absenteeism, poor work performance
Frequent leave taking
Financial problems
Managing Bipolar (Manic-Depressive) illnesses
While using anti depressants for the depressive phase and anti psychotics for the manic phase
has been the norm for treatment of bipolar illnesses, the use of anti convulsants such as
sodium valproate in the past decade has improved management of acute phases of the illness
and help in prevention of relapses. Bipolar illnesses are difficult to manage and often require
specialist help . Following stabilisation counseling and social intervention help overcome
underlying stressors and precipitating factors.
40

Deliberate Self Harm or parasuicides are not uncommon occurences in acute depressive
crises or spells but less common in moderate to severe depressive illnesses. Both depressive
illnesses and alcoholism are conditions with risk of suicide and parasuicide. Methods used to
harm ones self vary from one culture to another. Thus in Malaysia use of pills , medicines,
detergents, poisonous liquids are much more common than slashing of wrists. For
copmpleted suicides, use of hanging is commoner in many countries, guns in others where
gun control is not strong and falling from high rise buildings more common in some urban
societies. Suicide itself is rare in muslim and catholic communities but high in some other
societies
Features

Para Suicides

Suicides

Frequency

very common

rare

Gender

>female

>male

Age

16-35

> 40

Religion

Most

Rare in Muslim,Catholic

Stress

Acute

Chronic

Illness

Rare

Depressive, Schizo,Alcoh

<Fatal

> fatal

Method used

Suicide is the action taking of ones own life in which death results
Parasuicide is self harm where death very rarely occurs
Accidental suicides occur when a parasuicide attempter uses a fatal method (viz Paraquat)
Unsuccessful Suicides occur when a fatal method used fails- fell from great height but landed
on an awning and had minor injuries.
Treatments for Parasuicides : Remove poisonous substance by stomach washout, stabilise
injuries treat in safe ward with medical/psychiatric management, and suicidal caution,
interview relatives , obtain good history of stresses. Counseling. Treat anxiety, depression if
needed. Follow up
Managing Potential or failed suicides: manage in safe ward. Suicidal Caution. Interview
patient and family to elicit especially recent losses and details of mood. Counseling.

41

Counseling for emotional Distress

Counseling is a word used very often in medical treatment and management discussions but
without
clear
understanding
of
what
is
involved
in
Counseling.
Counseling is NOT giving advice or heavy handed persuasion through instilling fear or
threats. Thus smokers are sent for counseling, patients with obesity are sent for counseling
hypertensives and medication defaulters are sent for counseling with the belief that by
merely being advised by a doctor or social worker or nurse the bad behaviour will change.
Counseling is a PROCESS by which a trained counselor gives an opportunity to the
counselee to understand the problem and work out a solution by himself with support of the
counsellor. It is an opportunity to develop personal growth through the process of working
out a solution.
Pre determined concepts of the counselee facing the problem because of laziness,
stubbornness, being spoilt or stupid , by the counselee are unacceptable in counseling
process. The counselor has to be a very good LISTENER, who learns from the patient his
problems and affords opportunities through asking questions(rather than giving answers)for
the counsellee to work out a solution. It is a fairly long process and cannot be achieved in a
few sessions of advice giving as many unfortunately believe.
In psychiatry counseling, psychotherapy and group therapies use similar principles by
allowing the individual to work out a solution and achieve personal growth with support
(but not advice) from the counsellor or the psychiatrist.
Most Counseling is between the counselor on a one to one basiss. However several other
useful counseling methods such as Group Counseling for a number of stressed persons who
meet with a counselor in a group on a regular basis have the added advantake of the clients
learning from each other. Marital counseling focuses on counseling of couples with marriage
related stresses. Family therapy used counseling for a fmaily with stresses where counseling
may require all members to be counselled together.

42

CHAPTER 7

PSYCHOTIC ILLNESSES
Psychoses is a generic term used to define Psycho-physiological illness that occurs in
vulnerable persons mostly of psychogenic origin characterised by abnormal behaviour,
speech, moods and perceptions and sometimes mental ability ; brain diseases can present with
organic psychoses which present with significant cognitive impairment

Psychoses

Psychogenic

Organic
Paranoid

Schizophrenia

Psychotic Depression

Trauma Toxic Infectious Endocrine.

..Degenerative, Neoplastic

Unipolar

Bipolar

( can be Acute, Subacute, Chronic)

Psychogenic Psychoses
Abnormal behaviour, dressing, cleanliness, cooperativeness
Abnormal speech strange words, way of speaking
Abnormal mood flat, elated, preoccupied speaking to himself, smiling, laughing to self
Abnormal Perceptions- auditory occasionally visual
Abnormal Thoughts- Delusions, paranoid, grandiose, feels brain being controlled thoughts
being inserted, ideas of reference
Poor Functioning ability

43

Organic Psychoses (in addition to those of Psychogenic psychoses) may have

Visual , tactile, olfactory, gustatory and
Cognitive deficits in,
Orientation
Short term memory with less commonly medium to longer term memory
Attention and concentration
Judgement
Insight
In delirium or acute organic brain syndromes the symptoms and signs of psychoses come on
suddenly (e.g. delirium tremens in alcoholic withdrawal) and recede with or without
treatment .
Schizophrenia starts in late teens and is a deteriorating condition and after several years of
illness ability to function, progress in school, college work all deteriorate. Cognitive
functions usually are not affected till much later.
It is clinically very rare to see onset of schizophrenia after the late 20s.
It is almost unknown to see schizophrenic patients go through school college successfully get
married and hold jobs successfully before getting the illness. In most of the cases of onset of
psychotic illness after the twenties the diagnosis is more likely an affective disorder missed
by poor history taking skills.
Studies have shown the likelihood of schizophrenics having had neurological soft signs from
birth and poor social skills and awkwardness in early years.
Psychoses of a schizophrenic type with deterioration in functioning are also seen in children
with learning disabilities who are put under undue stress in school systems that do not cater to
their needs in a special needs school.
Managing Psychoses
Distinguish type of psychoses by accurate history and mental status and cognitive tests
Start on antipsychotic suitable for positive symptoms (restless aggressive behaviour ) or
negative symptoms (withdrawn, preoccupied). Use injectable anti psychotics for chronic
defaulters. (look up Essential Medicines list of W H O on internet- www.who.int)
When stabilised, Psychological, Social, Occupational Medical rehabilitation and relapse
prevention strategies at a day rehabilitation centre will work to improve functioning.

44

CHAPTER 8

SUBSTANCES OF ABUSE
Numerous substances have been used by every culture for stimulation, recreation and
dependence for thousands of years. It is said every culture has used and abused alcohol.
Although the present epidemic of abuse of substances has close links in trafficking and street
level pushing for largely monetary gain the biggest cause is the ease with which trade and
communication have spread in the past 2 centuries. The following is a brief introduction to
substances of abuse popular at present

CNS SEDATIVES
OPIOIDS

Non OPIOIDS

Natural

Artificial

Opium

Pethidine

Barbiturates
Non-barbiturates

Morphine Methadone
Heroin

Alcohol
Benzodiazepines

CNS STIMULANTS
Natural cafein, nicotine
cocaine
Artificial- amphetamine
methamphetamine

HALLUCINOGENS
Natural-cannabis,
poisonous mushrooms
nutmeg, morning glory
seeds
Artificial PCP, LSD,

Mostly psychological
dependence producing with
less physical addiction

Nitrous Oxide
Psychological depence
producing

ALL are Physically Addictive with physical

symptoms of withdrawal

IMPORTANT NOTES
1 Physical dependence producing CNS sedatives were the most widely used substances of
potential abuse. Alcohol has both social roles and have been abused widely. Cirrhosis of the
liver, heart diseases, road accidents, violence and social and domestic strife result from
alcohol dependence often misused as a self treatment for stress, and depressive illness

45

2.Opioids like heroin smoked, or chased (chasing the dragon) produces calmness and sense
of well being but when injected intravenously have the very high risk of carrying bacterial,
viral infections due to unsterile needles (HIV-AIDS, Hepatitis B, C, bacterial endocarditis,
osteomyelitis, brain abcess)
3 CNS Stimulants like methamphetamines produce a sense of alertness, excitement but in
excess can produce paranoid ideas
4 Hallucinogens affect the sensory modalities and may distort perception of time, space,
colours, sounds and can be very dangerous to safety.
5.Many substance abusers are multi drug abusers
6 Social, family and occupational decline, crimes medical consequences and risk of HIVAIDS are serious consequences of chronic substance abuse.
7 Use of medicines such as methadone maintenance regimes and naltrexone do not guarantee
abstinence and the 2 year drug rehabilitation centres have limited success rate

46

CHAPTER 9

CHILD AND ADOLESCENT DISORDERS

Despite psychiatrys rapid advance in the psychopharmacological field in the past half a
century very little has been discovered to help childhood and adolescent mental problems.
Nonetheless the growing recognition that children too face stresses and illnesses due to
emotional problems and intellectual problems has been a breakthrough in psychiatry. The late
recognition has meant few specialists in child and adolescent psychiatry worldwide and more
so in developing economies. Training in child psychiatry has been difficult to obtain resulting
in poor recognition of signs and symptoms at the level of families and schools and even
health care clinics.
Childhood psychological disorders

Developmental

Behavioural

Learning disorders

problems of childhood & adolescence

Birth related

behaviour at home, behavior in school

Behaviour in society, violence, crime
Attention Deficit Hyperactivity Disorders (ADHD)

Management
Assessment of child, Family circumstances, School performance
Identification of source of stress
Therapy for family, child
Medicines where needed

47

Psychoses
Childhood autism
Childhood Schizophrenia

CHAPTER 10
Essential Medicines List of WHO 2009
24. PSYCHOTHERAPEUTIC MEDICINES
24.1 Medicines used in psychotic disorders
chlorpromazine
Injection: 25 mg (hydrochloride)/ml in 2ml ampoule.
Oral liquid: 25 mg (hydrochloride)/5 ml.
Tablet: 100 mg (hydrochloride).
fluphenazine Injection: 25 mg (decanoate or enantate) in 1ml ampoule.
haloperidol
Injection: 5 mg in 1ml ampoule Tablet: 2 mg; 5 mg.
Complementary List [c]
chlorpromazine
Injection: 25 mg (hydrochloride)/ml in 2ml ampoule.
Oral liquid: 25 mg (hydrochloride)/5 ml.
Tablet: 10 mg; 25 mg; 50 mg; 100 mg (hydrochloride).
haloperidol
Injection: 5 mg in 1ml ampoule.
Oral liquid: 2 mg/ml.
Solid oral dosage form: 0.5 mg; 2 mg; 5 mg.
24.2 Medicines used in mood disorders
24.2.1 Medicines used in depressive disorders
amitriptyline Tablet: 25 mg (hydrochloride).
fluoxetine Solid oral dosage form: 20 mg (present as hydrochloride).
Complementary List [c]
fluoxetine a
Solid oral dosage form: 20 mg (present as hydrochloride).
a >8 years.
24.2.2 Medicines used in bipolar disorders
carbamazepine Tablet (scored): 100 mg; 200 mg.
lithium carbonate Solid oral dosage form: 300 mg.
valproic acid Tablet (entericcoated): 200 mg; 500 mg (sodium valproate)
24.3 Medicines used in generalized anxiety
diazepam Tablet (scored): 2 mg; 5 mg.
24.4 Medicines used for obsessive compulsive disorders and panic attacks
clomipramine Capsule: 10 mg; 25 mg (hydrochloride).
24.5 Medicines used in substance dependence programmes
nicotine replacement therapy (NRT)
Chewing gum: 2 mg; 4 mg.
Transdermal patch: 5 mg to 30 mg/16 hrs; 7 mg to 21 mg/24 hrs.
Complementary List
methadone*
Concentrate for oral liquid: 5 mg/ml; 10 mg/ml (hydrochloride).
Oral liquid: 5 mg/5 ml; 10 mg/5 ml.
* The square box is added to include buprenorphine. The medicines
should only be used within an established support system
World Health Organisation Geneva (look up latest revision in www.who.int )

48

TREATMENTS IN PSYCHIATRY
If Psychiatric illnesses are caused by BIO-PSYCHO-SOCIAL causes then treatments need to include

BIOLOGICAL agents like medicines, taken orally, injections. or operations to remove or repair damage
PSYCHOLOGICAL methods such as counseling to help person comes to terms with anxiety loss etc.
SOCIAL methods such as improving social living conditions , income. Relationships and coping with changes

Physical injury can heal by preventing infection and allowing cells to help healing and controlling pain
Psychological injury in many under stress needs psychological healing, social help
By prescribing only medicines one only helps relieve distressing symptoms but not the emotional pain of loss
and worry . Basic Counseling skills and social assistance through a variety of agencies such as employment
agencies, skills training or re-training for those with poor work skills contributing to depression are essential
for primary care providers.

------------------------------------------------------------

The Author. Dr. M Parameshvara Deva is Professor of Psychiatry at

Faculty of Medicine and Health Sciences at the Universiti Tunku Abdul Rahman, Malaysia
and has worked in many Pacific Island Countries since 1999 for the WHO and as a volunteer
for the Asian Federation of Psychiatric Associations, AFPA that he founded in 2005.

parameshvara24@yahoo.com

parameshvara@utar.edu.my

49

Heliconia Blossoms of the Pacific in Suva Market Fiji

50