Schizophrenia (Dx Criteria)
Schizo affect 1% people over lifetime
Men: 20yo
Women: 30 yo age presentation
Strong genetic predispotion
- 50% monozygotic
- 40% both parent schizo
- 12% if 1st degree relative
Downward drift hypothesis
Lower socioeco gp, higher rate schizo.
A) 2 or more of the following, each present to
significant portion of time, for at least 1 month, at
least one of them must be (1), (2) or (3).
1) Delusion
2) Hallucination
3) Disorganized speech
4) Grossly disorganized/ catatonic behaviour*not
approved by people
5) Negative sx(Avolition, Affective blunted)
B) During a sig portion of time after onset of the sx,
the level of functioning in one/more major areas
is markedly below the level achieved prior to the
onset.
C) Continuous sn of disturbance for at least 6
months. This 6 months period include 1 month
period of sx that meet criterion A & may include
prodromal & residual phase(negative sx or
attenuated form of sx listed in criterion A)
D) Schizoaffective d/o & depressive/bipolar d/o have
been ruled out becoz either
(i) there is no major depressive/manic
episode occur concurrently with
schizophrenia sx.
(ii) if there is mood episode, they have been
present for minority of the total duration
of the illness.
E) The disturbance is not attributable to
substance/another medical condition.
F) If there is hx of autism spectrum d/o or
communication d/o of childhood onset, an
additional dx of schizophrenia is made only if
prominent delusion/hallucination in addition of
other acquired sx have been present for at least 1
month.
Active
Residual
Prodromal Prodromal
Positive sx: exaggeration of N mental fn
Negative sx: diminution of N mental fn
Schneider 1st rank sx
3 auditory hallucinations
- Thought echo
- Running commentary
- Third person
3 thought alienation
- Thought insertionthought spoken out loud
- Thought withdrawal
- Thought broadcasting(people know about what u think,
see & conversation wout u tell them)
3 delusion of control (aka Passivity phenomena)
- Made action(smting enter body & control actn)
- Made impulse(suddenly did action which he didn’t want)
- Made feeling(laugh at funeral)
Somatic passivity(body ache d/t ext force)Somatic hallucination
+delusion of control
Delusional perception(N stimulus with delusional
misinterpretation eg: traffic light change, CIA is after me)
Negative Sx
- Alogia(poverty of speech)
- Avolition(lack of physical activity)
- Asocial(social withdrawal)
- Apathy(lack of motivation) may lead to anhedonia
- Anhedonia(lack of interest/pleasure)
- Affective blunting
Management
Ix:
1) Biological
– FBC(wbc), LFT(drug metabolised by liver),
RP(baseline)
 – ECG - Pt failed to response to 2 types of medication
– Urine for drugs(rule out subst induce) which are geven enough doses & enough
– Thyroid fn test(tro hyperthyroidism if pt durations (4-6 weeks).
aggressive)(rare) - Pre-workout b4 start clozapine: baseline BMI, FBC,
– Fasting blood glucose & lipid profile FBGluc, ECG, CK, BP, not allergy, absent contraind.
(antipsychotic aw metabolic synd) - Use clozapine (agranulocytosis, sialorrhea, wt
– CT scan(1st time pt tro SOL) gain, myocarditis, orthostatic hypotension).
2) Psychological 12.5mg starting dose.
- Brief psychiatric rating scale for psychosis - Augmentation w other antipsychotic if pt failed to
- Personality test(Bipolar) respond to clozapine.
3) Social - Consider ECT.
- trace old notes
Non-compliant pt
- Collateral hx with family members
- Use depot injection:
Tx- so that pt can be like premorbid fn. (IM fluphenazine 25mg, IM flupenthixol 40mg, IM
Pharmacological: zuclopenthixol 200mg)  every 2-4wk
1) Acute- if pt is aggressive, IM risperidone 25-50 every 2 wk
IM paliperidone  every 1/12
- IM haloperidol/IM olanzapine/IM ziprasidone
IM aripiprazole
IM haloperidol (typical)
EPS sx
Cannot be given if pt had hx of neuroleptic malignant
synd(ms rigidity, hyperpyrexia, autonomic disturbance
- Acute
w increase creatinine phosphokinase CPK)
i) Dystonia(spasm of ms)
IM Olanzapine (atypical)(waffle type) Torticollis(scm), oculogyric crisis(sup
– contraindicated w bdz(don’t give 24hr b4 & after) rectus of eye), opisthothonus(back),
- range 5-20mg, average 10 mg bd. blepharospasm(orbicularis oculi),
IM Ziprasidone laryngeal ms.
–aw QT’s prolongation (arrythmia) ii) Akathisia (motor restlessness, unable to
sit still)*x give anticholinergicworsened. Give
++(Typical Antipsy aka Tranquilizer : IM Haloperidol, Chlorpromazine,
bdz
perphenazine, trifluoperazine,IV diazepam)
++(Atypical AntiPsy: IM olanzapine, risperidone, quetiapine) iii) Parkinsonism (pill rolling tremor,
cogwheel rigidity, akinesia, postural
2) Long term: once given, if suitable(responsive & no SE), continue instability)
lifelong.Never taper up dose as this is long term maintenance.
- Late
- Atypical antipsychotic (less SE & EPS than typical,
i) Tardive dyskinesia (irreversible orobuccal
and improve sx better) coz METABOLIC
movement/involuntary movements of
SYNDROME (central obesity, ↑BP, ↑fasting
mouth,tongue, face, limbs)
blood gluc, ↑triglyceride)
*change tx to clozapine (↓EPSE)
Eg:
- Olanzapine (wt gain, inc appetite, ++SE:
hyperglycemia, inc lipid, sedation).
- Quetiapine (orthostatic hypotension, same w - antiCholiEff: urinary retention,dry mouth,blurred
olanzapine). vision, constipate, sedation
- Risperidone (wt gain, galactorrhea, sedation, - orthostat hypotension, ,hyperPRL.
menstrual irregularity) strong effect, not for elderly.
Emergency SE : Neuroleptic M9 Synd
# Tx resistant schizophrenia
- Cogwheel rigidity
 - Fever 3) Nigrostriatal: Substantia nigra(pars compacta) to
- Fluctuate BP striatum(caudate & putamen)
- Tachycardia - Stimulation of purposeful movement
- ↑CK - Dz antagonism induce EPS.
4) Tuberoinfundibular: Hypothalamus(arcuate &
What to do? periventricular nuclei) to infundibular rgn(median
 Stop antipsychotic eminence).
- Dopamine inhibit PRL release.
 Change to another w less EPS
- Dz antagonism inc PRL release 
 Prescribe anticholinergic : artane
Hyperprolactinaemia.
 Give BDZ(akithisia only)

Psychosocial
Catatonia (3 out of 12)AbN movement/behaviour d/t disturbed mental state.
1) Psychoeducation (nature & course, sx & sn,
- Stuporslow motor activity to point of immobile
necessity of tx, SE tx, cx, relapse rate, prognosis)
- Catalepsyimmobile position that constantly maintained
2) Sheltered workshop
- Waxy flexibilityCan be moulded into position & maintain
3) Group therapy: to get support from peers.
- Mutismquiet
4) Rehabilitation: Occupational therapy : ↑self esteem
- Negativismresistance to all attempt to be moved
5) Family intervention – family support, identify
- Posturinginappropriate/bizarre posture
early warning sn.
- Mannerism involuntary repetitive goal directed actvt
6) Assertive community team (case manager,home
- StereotypyNon-Goal directed
visit & check for compliance, remind the pt to
- Agitation in absence of ext stimuli
come for f/up)
- Grimacingfacial expression show pain
7) Social skill training
- Echolaliarepetition other’s word
8) Cog Remediation Therapyfor cog dysfn, ex: help in prob solving
- Echopraxiaimitation movement other person

++Route for Olanzapine & risperidone

# clozapine (agranulocytosis) - Tab

- Im
- Check fbc every wk for 4-6 wk - Syrup
- Every 2 wk until 4 months - Zydis wafer(dissiolve in mouth)
- Every month
++SLUDGE Synd for cholinergic SE

- Salivation
- Lacrimation
Dopaminergic Pathway - Urination
- Diaphoresis
1) Mesolimbic : VTA(ventral tegmental area) to - GI upset
NA(nucleus accumbens) of limbic. - Emesis
- Increase mesolimbic pathway
 Motivation, rewards, emotions, +ve sx Indication for ECT (applicable for Schizo/Bipolar/MDD)
schizophrenia.
- Refused oral intake
2) Mesocortical : VTA to cortex(prefrontal cortex)
- High suicidal risk
- Cognitive & executive fn (dorsolateral
- Catatonia
prefrontal cortex)
- Post-partum onset(...e.g:psychosis)
- Emotions & affects(ventralateral
- Severe aggressive behaviour
prefrontal cortex)
- Hypofn  cognitive & negative sx Brief psychotic d/o : <1month
schizophrenia. Schizophreniform d/o: 1<x<6month
Dx criteria Schizoaffective d/o
- Major mood d/o occur concurrently with criteria
A schizophrenia.
- Delusion/hallucination occur for 2wk/more in
absence of mood episode.
- Sx that meet criteria for major mood episode are
present for majority of total duration of illness.
- Not attributable to eff of substance or another
medical disorder.
Delusional d/o
- 1 or more delusion w duration more than
1month
- Criteria A schizophrenia x met
- Despite delusion, fn is not impair &
behaviour still normal.
- If MD episode/manic occur,it is brief
compared to delusion.
- X d/t substance, x better explain by other
mental illness.
Bipolar Disorder
Epidemiology
- Life time prev: 0-2.4% (bipolar I), 0.3-4.8%
(bipolar II) *annual incidence:<1%
- Equal in male & female, male high of
manic, female high of depressive, female
high rate of rapid cyclers(>4 manic in a yr)
- Age : 5/6-50 w mean age=30 yo.
- Marital status: common in divorce &
single person.
- Socioeconomic : more common in high
socioeconomic gp.
Comorbidity
- Substance-use-d/o, panic d/o, OCD.
Etiology
1) Biological
- ↑HPA
- ↑somatostatin → ↓GH
2) Genetic factors
- Family hx of mood d/o
- 70-90% in monozygotic twins
- Chromosome 18q & 22q
3) Psychodynamic factors
- Defence against u/l depression
Dx criteria for bipolar I & bipolar II
Bipolar I Disorder
A) Criteria have been met for at least 1 manic
episode.
B) The occurrence of manic and major depressive
episode are not better explained by other mental
disorder.
Bipolar II Disorder
A) Criteria have been met for at least 1 hypomanic
episode and at least 1 major depressive episode.
B) There has never been manic episode.
C) The hypomanic and major depressive d/o is not
better explained by oher mental d/o.
Manic episode(ada sig loss of fn)
A) A distinct period of abnormally & persistently
elevated, expansive or irritable mood &
abnormally & persistently inc in goal-directed
activity or energy, lasting at least 1 week &
present most of the day, nearly everyday (or any
duration if require hospitalization)
B) During period of mood disturbance & increased of
energy or activity. 3 or more of the following (4
only if irritable mood) are present to significant
degree & represent a change from usual
behaviour.
1) Inflated self esteem
2) ↓need for sleep
3) More talkative than usual/ pressure to keep
talking.
4) Flights of ideas/thoughts are racing
5) Distractibility.
6) ↑in goal directed activity/psychomotor
agitation.
7) Excessive involvement in activities which have
painful consequences.(sexual indiscretion, buying
spree, foolish business investment)
Mood elevated
Energetic
Distractibility
Indiscriminate
Grandiosity+↑self esteem
Flight of ideas
 A:↑goal-directed activity
S:↓need for sleep
Talkative
C) The mood disturbance is sufficiently severe to
cause impairment in social/ occupational
functioning or to necessitate hospitalization to
prevent harm to self or others, or there is
psychotic feature.
D) The episode is not attributable to substance or
other medical condition.
Criteria A-D: manic episode.
Hypomanic episode(xde sig loss of fn,selalunya x dtg hosp
sbb happy & org x complain tentang pt)
A) A distinct period of abnormally & persistently
elevated, expansive or irritable mood &
abnormally & persistently inc in goal-directed
activity or energy, lasting at least 4
consecutive day & present most of the day,
nearly everyday. (4 to 6 daysDr Ang)
B) During period of mood disturbance &
increased of energy or activity. 3 or more of
the following (4 only if irritable mood) are
present to significant degree & represent a
change from usual behaviour.
1) Inflated self esteem
2) ↓need for sleep
3) More talkative than usual/ pressure to
keep talking.
4) Flights of ideas/thoughts are racing
5) Distractibility.
6) ↑in goal directed activity/psychomotor
agitation.
7) Excessive involvement in activities which
have painful consequences.
C) The episode is aw unequivocal change in
functioning that is uncharacteristic of
individual when not symptomatic.
D) The mood disturbance & change in
functioning are observable by others.
E) The mood disturbance is not severe enough
to cause marked impairment in functioning,
to necessitate hospitalization, or has
psychotic features. (clear change in fn but no
marked impairment )
F) The episode is not attributable to substance
or other medical condition.
Criteria A-F: hypomanic episode
Depressive episode
A) 5 or more of following present in same 2 wk
period and represent a change from prev
functioning; at least 1 of sx is either (i) depressed
mood or (ii) loss of interest of pleasure.
1) Depressed mood most of the day/ irritable
mood in children/adolescence.
2) Markedly diminished of interest/pleasure in
all, or almost all activities most of the day.
3) Sig wt loss/ wt gain (5% in a month), or ↑/↓
of appetite.
Nearly
4) Insomnia/hypersomnia.
5) Psychomotor agitation/retardation.
6) Fatigue/loss of energy
7) Feeling worthlessness/ excessive or
inappropriate guilt.
8) Diminished ability to think/concentrate/
indecisiveness.
9) Recurrent thought of death/ suicidal
intention/ suicidal attempts
B) The sx cause clinically sig distress/ impairment in
functioning.
C) The episodes is no attributable to substance or
other medical conditions.
Criteria A-C : depressive episodes
Mx
I would like to admit this pt for:
- Perform thorough ix
- Tro ddx
- Plan tx
1) Biological
- FBC, LFT(if going to start antipsychotic
sodium valproate), Renal profile(Lithium,
carbamazepine)
- TFT(tro hypothyroidism, check baseline
for starting lithium becoz lithium can coz
hypoth)
- Fasting blood glucose & lipid
profile(antipsychotic)
- Serum Ca level(lithium coz
hyperparathyroidism)
2) Psychological
 - Young mania rating scale - Steady state: 2.5-3days
- Hamilton rating scale for depression - Sodium
- Montgomery asberg depression rating Valproatethrombocytopenia/cbmzpancytopenia(SE:
scale. GI upset, sedation, wt gain, raised liver
- Beck Depression Inventory test enzyme, neural tube defect(spina bifida),
- Personality test steven-johnson syndrome(rashes))
3) Social: Trace old notes, collateral hx from family
members & colleagues.  or haloperidol(as tranquilizer tx agitation, not mood
stabilizer)
Tx :  or atypical antipsychotic: increase enzyme
actvt(later need to ↑dose)
Acute- if pt is aggressive,
 or combination
- IM haloperidol/IM olanzapine(as tranquilizer x
 consider ECT: severe depression/suicidal
mood stabilizer)
attempt/manic→very agitated.
2) Acute Depression:
1) Acute mania:
 Monotherapy of lithium/ Quetiapine(SE:
Mood stabilizer
orthostatic hypotension, wt gain, dizziness,
 Lithium
somnolence, dyslipidemia, hyperglycemia)
- Acute: 600-1800mg/day in divided dose
 Combination therapy of lithium, valproate,
- Maintenance: 300-1200mg/day
SSRI, olanzapine, bupropion.
- Narrow therapeutic index-need blood
 ECT
monitoring
- Half-life:1day
- Steady state: clearance=4-5day halflife
acute=0.8-1.2mg 3) Long term
maintenance=0.4-0.8mg  1st line lithium as monotherapy, regularly f/up
>1.5=toxic side effect(toxic for 6 month.
encephalopathy/delirium, cerebellar or
sn/DASHING)Dysdiadochokinesia,ataxia,slurred  Lamotrigine(depressive)- (skin rash, insomnia,
speech,hypotonia, intentional tremor,nystagmus,gait steven-Johnson’s synd, blurred vision,
>2.0 confusion, coma, death diplopia)
Revert by dialysis or
- SE:  Monotherapy of olanzapine, quetiapine,
1. Short term:GI upset, polyuria, valproate, risperidone injection, aripiprazole.
polydipsia, wt gain, metallic taste *Rapid cyclers resistance to lithium.
in mouth.
Psychological
2. Long term: hypothyroidism,
hyperparathyroidism, Diabetes 1) Psychoeducation
insipidus, Renal failure 2) Interpersonal social rhythm therapy
- Absolute contraindicated in pregnancy & - Improve medication adherence
breastfeeding. - Technique to manage stressful life events
- Lithium toxicity: delirium+cerebellar sn. - Reduces disruption in social rhythm
 or Sodium - Improve sleep
valproate(epilim)/carbamazepineind: mixed episode 3) Family session.
& rapid cycler(>4x in 1 yr)
4) Cognitive Behavioural Therapy: challenge thought,
- Epilim acute phase=600-2500mg/day 5) Exercise therapy
- Maintenance=400-2000mg/day
- Blood monitor:347-693ɥmol/L *DANGER: Lithium+Carbamazepine
 Lamotrigine+Carbamazepine - Feeling of guilty
- Problems thinking & making decision
- Recurring thought of death/suicide.
++Hx:
D SIGE CAPS
- Mood: irritable→got into argument Depressed
- Distractibility:cant concentrate during Suicidal thought
Interest/pleasure loss
reading newspaper or watching tv.
Guilty
Dev emotional & behave sx in response to Energy loss
identifiable stressor. Concentration poor
- Grandiosity:felt superior than other, have Appetite loss/↑
Psychomotor retardation/agitation
special power.
Sleep disturbance
- Activity increase: ask why don’t need
sleep, +according to theme of grandiosity.
Epidemiology:
Dr Aaron:
Always find out the stessor/precipitant.(Identify the
sn & educate the pt that these are yr early warning sn & - Lifetime prevalence: 5-17%
do not wait until call police). - Sex: female 2X greater than
Non-compliance: explain about illness properly & male(hormonal diff, childbirth, learned
convince them that by compliance to medication can help helplessness)
tx illness.
- Age of onset: 20-50yr w mean age=40yr
- Marital status: common in wout close
Cyclothymic D/O relationship/divorce/separated
- Cultural/socioeconomic: more common in
A) For at least 2yr, numerous period of hypomanic rural area than urban.
episode & numerous period depression that do
not meet criteria MDD. Comorbidity:
B) During 2 yr period, depressive & hypomanic have
- Substance use d/o, panic d/o, OCD, social
present for half time & has not been wout sx for 2
anxiety d/o,eating d/o.
month.
C) Criteria for MDD, manic & hypomanic are not met Etiology:
D) Sx critereia not better explain by (other mental
d/o) schizophrenia, schizophreniform d/o... 1) Biological
E) Sx not attributable to substance or another - ↓monoamine neurotransmitter:
medical cond (norepinephrine, serotonin, dopamine)
F) Sx cause clinically sig distress/impairment in - Monoamine-acetylcholine imbalance:
sociooccupational fn. ↑acetylcholine
- ↓γ-aminobutyric acid(GABA)
- Altered glutamatergic transmission
(mood=pervasive/sustained - ↑HPA activity
Major Depressive Disorder
emotion) - ↓Thyroid hormone
- ↓Somatostatin→↑GH
Definition: Sx of either depressed mood or loss of - ↑nondominant hemispheric activity
pleasure in activity lasting at least 2 wk with 4 or more 2) Genetic
from list of sx: - Family hx mood d/o
- Change in appetite/wt - 70-90% in monozygotic twins
- Change in sleep&activity 3) Psychosocial factor
- Lack of energy - Losing of parents b4 11 yr
 - Losing of spouse C) The episode is not attributable to substance/other
- Unemployment medical condition.
- Guilt *A-C=major depressive d/o
4) Psychodynamic D) The episode is not better explained by other
- Disturbance in the infant mother during mental condition.
oral phase(10-18 month of life) E) There has never been a manic/hypomanic
- Real/imagined object loss episode.
- Introjections of object loss
- The loss of object is a mixture of love & Differences between bereavement & MDD
hate, feeling of anger are directed at the Bereavement:
self.
5) - cognitive triad about self, environment & future. - Feeling emptiness/loss
- learned helplessness. - ↓as time passed by & come in wave
when remind of deceased.
Biological sx - Able to have +ve emotion.
Diurnal mood variation(worse morning, mild evening)
- Have self-esteem.
Loss libido
Fatigue - Thought of dying as joining deceased.
Constipation
Amenorrhea MDD:
Appetite ∆
Sleep ∆ - Depressed mood/inability to anticipate
pleasure.
Diagnostic criteria of major depressive d/o - Persistent & not tied with thought
- Not have +ve emotion
A) 5 (or more) of following sx have been present for - Feeling of worthlessness
the same 2 week period & represent change from - Thought of dying as feeling of
previous functioning; at least 1 of sx is either worthlessness
(1)Depressed mood or (2)loss of interest or
pleasure. Clinical feature:
1) Depressed mood of the day/irritable mood in
- Depressed mood
children/adolescence
- Loss of interest/pleasure
2) Markedly diminished Interest pleasure in all
- Contemplate suicide(2/3), commit
or almost all activity, most of the day.
early everyday3) Sig wt loss/wt gain(5% in a month), ↑/↓ in suicide(10-15%)
- Social withdrawal
Appetite.
- ↓in energy(97%)
4) Insomnia/hypersomnia
- Trouble in sleeping, early morning
5) Psychomotor agitation/retardation
awakening, multiple awakening at night.
6) Fatigue/loss of Energy
- Change in appetite & weight
7) Feeling worthlessness/excessive,
- Anxiety
inappropriate Guilt
- Alcohol abuse
8) Diminished ability to think or
- Somatic complaint
Concentrate/indecisiveness.
- Inability to think/concentrate
9) Recurrent thought of death, suicidal
- Poor academic performance
ideation/Suicidal attempt.
- Truancy
B) Sx cause clinically significant distress/ impairment
- School phobia In adolescents
in fn.
- Running away
MSE b) To complete dx evaluation: investigate &
tx pt in holistic manner(whether had
- Psychomotor retardation, downcast, other d/o)
averted gaze. c) For tx plan.
- ↓rate, vol, amnt speech. 2) Biological
- Thought block, poverty of content. a) Antidepressant(SSRI, TCA, MAOI, atypical
- Impaired concentration & antidep: SNRI,SARI,NaSSA)
forgetfulness(depressive b) CHOICE: Selective Serotonin Reuptake
pseudodementia) Inhibitor
Investigation i) Sertraline(zoloft) 50-200mg/day
ii) Fluvoxamine(luvox)100-
1) Biological 200mg/day(max 300)
- FBC, LFT(SSRI metabolized in liver), iii) Fluoxetine(Prozac)20mg/day
RP(baseline) iv) Paroxetine(paxil)
- TFT(tro hypothy) v) Escitalopram(lexapro)10-20mg/day
- Urine for drug(tro substance induce) c) Reason give SSRI:
- Lipid profile (if pt obese) i) Less SE(anticholinergic &
2) Psychological cardiotoxicity)
- Beck Depression inventory, ii) Safer in overdose
- Montgomery-Asberg depression rating (↓cardiotoxicity)
scale iii) No food restriction (like in MAOI-
3) Social tyramine eg:chocolate cheese
- Collateral hx w family member soysauce)
- Trace old note d) Educate about SE
i) Git disturbance
# Suicidal risk assessment(SADPERSON) ii) Headache GI disturbance
iii) Sex dysfn Anxiety
- Sex: Male↑risk Dry mouth
iv) Anxiety Insomnia
- Age: <20 or >40
v) Dry mouth Sex dysfn
- Depression Headache
vi) Insomnia
- Prev attempt
B) In the ward
- Ethanol abuse
- Suicidal caution chart(every 30 min).
- Rational thinking lose
- Start SSRI: Sertraline, fluoxetine,
- Social support lack
fluvoxamine, escitalopram.
- Organized plan
i) SE: Gi disturbance,
- No spouse
agitation, anxiety,
- Sickness
insomnia, headache,
*7-10 hospitalization
tremor, sex dysfn.
Mx/tx - +/-BDZ becoz pt is anxious. eg:lorazepam,
alprazolam
A) Acute mx - If pt has psychotic feature, atypical
1) Admit pt to ward: antipsychotic: risperidone, olanzapine.
a) For pt safety - Suicidal thought: give ECT
i) if pt had suicide attempt &
intention to die high, put pt on Psychological
suicidal chart.
- 1) Psychoeducation:explain sn sx, nature dz,
ii) If comorbid w alcohol dependent,
imp medication, cx.
put pt on withdrawal chart.
 - Family session Course & Prognosis
- Group therapy(in ward)
- Supportive therapy: - 50% relapse if 1 episode
i)provide emotional support: care abt him - 70% if 2
ii)ventilation: let pt talk out prob. - 90% if 3
- Cog Behavioural Therapy(coping skills) - 15% commit suicide.
mainstate tx for MDD. Help identify cognitive error,
++Hx
challenge the thought & correct it. Help w +ve
therapy, interpersonal therapy(tx his prob that he x
+Biological sx
realise).

C) Long term
1) SSRI cont for 1 month & BDZ taper off after
>2wk.
2) Reassess after 3 wk, sx sn depress (D SIGE
CAPS)
If same, check adherence/compliance
If no response at all, ∆ drug group e.g ssri to
snri.
If no change, combine drug but risk SE higher.
If no change, augmentation(increase efficacy
of drug by using drug that is not indicated for
the illness e.g: +lithium)
3) If reach remission, continue for 1 year if single
episode, 2-5 years for 2nd episode, life long for
3rd episode.
4) If insufficient response, titrate the dose
upward & cont for 2 more wk, switch to other
antidepressant if no response.
*The need for continuing antidepressant should be
depend on:
- no of episode
- Sx(residual)
- Stressor
*Other type of antidepressant
i) SNRI: venlafaxine 75-225mg/day(max 375mg),
duloxetine.
ii) TCA: Amitriptyline, Clomipramine, Imipramine
anticholinergic SE
iii)MAOI: Meclobemide high effective
antidepressant & anxiolytic.
iv)Noradrenergic Selective Serotonin
Antidepressant(NaSSA): Mirtazapine 15-45mg/day
Anxiety D/O
Epid:
- more common in woman
- low socioeco status
Etiology:
- Biological
- Psychoanalytic
- Learning theory
Social Anxiety D/O(Fear that people will –vely evaluated )
Lifetime prevalence: 3-13%
A) Marked fear/anxiety about one or more social
situation in which the individual is exposed to
possible scrutiny by others.
B) The individual fear that he/she will act in a
way/show sx that will be –vely evaluated.
C) The social situation almost always provoke fear/
anxiety.
D) The social situation is avoided/endured with
intense fear/anxiety.
E) The social anxiety is out of proportion to the
actual threat by social situation or the
sociocultural context.
F) Fear, anxiety or avoidance is persistent, typically
lasting >6month.
G) Fear, anxiety or avoidance cause clinically sig
distress/impairment in functioning.
H) Fear, anxiety or avoidance is not attributable to
substance/another medical condition.
I) Fear, anxiety or avoidance is not better explained
by other mental d/o.
 J) If another medical condition present, fear anxiety General Anxiety D/O
or avoidance is clearly unrelated/is excessive.
A) Excessive anxiety/worry occurring more days than
Cognitive Behavioural Therapy not for at least 6 month, about a no of
events/activities.
- Graded exposure B) The individual find it difficult to control the worry.
Panic d/o(1st 2nd attack occur wout any trigger, fear attack come C) The anxiety & worry is associated with 3 or more
again, nocturnal panic attack) of the following 6 sx (at least some of them have
been present for >6months).
A) Recurrent unexpected panic attack in which 1. Restlessness/feeling keyed up on the edge
abrupt surge of intense fear/discomfort which 2. Being easily fatigue
reach peak within minutes & 4 or more of the 3. Difficulty concentrating/mind going blank
following sx occur. 4. Irritability
1. Palpitation, pounding heart, accelerated heart 5. Muscle tension
rate. 6. Sleep disturbance
2. Sweating D) The anxiety/worry/physical sx cause clinically sig
3. Trembling/shaking distress/impairment in fn.
4. Sensation of SOB/smothering E) The anxiety/worry is not attributable to
5. Feeling of choking substance/another medical condition
6. Chest pain/discomfort F) The anxiety/worry is not better explained by
7. Nausea/abdominal distress other mental d/o.
8. Feeling dizzy, unsteady, lightheaded or faint.
9. Chills/heat sensation WATCHERS
Worry
10. Paraesthesia
Anxious
11. Derealization/depersonalization Tension ms
12. Fear of losing control/going crazy Concentration poor
13. Fear of dying Hyperarousal
Easily fatigue
B) At least one of attack is followed by one month(or
Restlessness/feel keyed up
more) of 1 or both following: Sleep disturbance
1) Persistent concern/worry about additional
panic attack/their consequences. Cognitive intervention
2) A sig maladaptive change in behaviour related
to panic attack. - Re-appraisal of unrealistic belief.
C) The disturbance is not attributable to - Re-assesssment of likelihood of –ve
substance/another medical condition. outcome
D) The disturbance is not better explained by other - Address intolerance of
mental d/o. uncertainty/perfectionalism.

PANICS D Anxiety d/o

Palpitation
Abd distress - Reassurance & psychoeducation (nature,
Nausea,numbness sx, role of body(fight &flight)), necessity
Intense fear lose control,crazy,death of tx, +ve response, SE of tx).
Choking,chill heat sensation,chest pain
- Relaxation technique (progressive ms
Sweating,sob,shaking
Dizziness, depersonalization, derealisation. relaxation & abdominal breathing)
- SSRI + BDZ(SE:drowsiness, sedation, respiratory
depression, dependence Withdrawal: rebound anxiety,
for 2wk, then titrate up SSRI taper
seizure)
off bdz.
Agoraphobia - GAD-7 test
3) Social
A) Marked fear/anxiety about 2(or more) of - Trace old notes of pt
following 5 situation: - Collateral hx from family member/friends
1. Using public transportation
2. Being in open space A) Acute mx
3. Being in enclosed space 1) Admit pt to ward:
4. Standing in line/being in crowd a) For pt safety
5. Being outside of the home alone iii) if pt had suicide attempt &
B) The individual fear/avoid these situation becoz of intention to die high, put pt on
thought that escape/help might be not available suicidal chart.
in event of dev panic-like sx/ incapacitating/ iv) If comorbid w alcohol dependent,
embarrassing sx. put pt on withdrawal chart.
C) The agoraphobic situation almost always provoke b) To complete dx evaluation: investigate &
fear/anxiety. tx pt in holistic manner(whether had
D) The agoraphobic situation are actively other d/o)
avoided/require presence of companion/ are c) For tx plan.
endured with intense fear/anxiety. 2) Biological
E) The fear/anxiety is out of proportion to the actual a) Antidepressant(SSRI,BDZ, TCA, MAOI)
danger posed by the agoraphobic situation & to b) CHOICE: Selective Serotonin Reuptake
the sociocultural context. Inhibitor(SSRI)
F) The fear/anxiety/avoidance is persistent, typically
*usu give BDZ for 2-4 wk if pt dev SE anxiety. SE from SSRI
lasting >6 months i) Sertraline(zoloft)
G) The fear/anxiety/avoidance cause clinically ii) Fluvoxamine(luvox)
significant distress/impairment in functioning. iii) Fluoxetine(Prozac)
H) If another medical condition present, the fear/ iv) Paroxetine(paxil)*good for Panic d/o
anxiety/avoidance is clearly excessive. v) Escitalopram(lexapro)
I) The fear/anxiety/avoidance is not better
vi) Citalopram(celexa)
explained by other mental d/o. vii) Venlafaxine(Effexor)
Cog Behav Therapy c) Reason give SSRI:
i) Less SE(anticholinergic &
- Graded Exposure cardiotoxicity)
ii) Safer in overdose
Mx
(↓cardiotoxicity)
Investigation iii) No food restriction (like in MAOI)
d) Educate about SE
1) Biological i) Git disturbance(nausea)
a) Perform simple investigation to det baseline ii) Anxiety
- FBC iii) Dry mouth
- RP iv) Insomnia
- LFT v) Sex dysfn
- RBS vi) Headache
- Urine test(check for drug toxicity) e) Benzodiazepine(bdz) (↓no & intensity
- Lipid profile(if pt obese) attack)
2) Psychological #Short Act= Alprazolam,Clonazepam, Lorazepam
- Beck-anxiety inventory (BAI)testmild<17- #LongAct=Diazepam

moderate-<24 Severe
 i) Alprazolam(xanac)*effective panic #PhysiologyofAnxiety
d/o& anxiety & depression
Fight&flightresponse→activSympatheticNS
ii) Midazolam Short act 6-8hr
→↑adrenaline & cortisol production →
iii) Lorazepam(ativan)
cause palpitation,tremor, parasthesia,
iv) Clonazepam(klonopin) long act 11-
15hr
chillhot, abdominal distress, ms tension,
v) Diazepam(valium) vasoconstriction.

SE: dependant,withdrawal synd if discont.

#ShortAct will coz withdrawal synd faster GAD

esp large dose.
- Continuous
- Worry abt activities e.g house, health, finance
f) TCA- imipramine (tofranil),
Amitryptiline(aventyl), Panic D/O
Clomipramine(anafranil)
SE: anticholinergic, cardiotoxicity, - Episodic
lethality if overdose (arrythmia). - Worry/fear of next spontaneous attack.
g) MAOI- phenelzine(Nardil)
Tranylcypromide(parnate)
SE: hpt crisis 2nd ingestion Avoidance anxiety
tyramine.
- More severe
- At any place
- Low self esteem, feeling inferior/inadequacy,
fear of rejection,fear judge/criticised
A) In the ward - Want to have friend(schizoid:x want friend)
- Suicidal caution chart(every 30 min).
Social AnxD/O
- Start SSRI: Sertraline, fluoxetine,
fluvoxamine, escitalopram. - Less severe
ii) SE: Gi disturbance, - Only in public
- Fear being scrutinized/-vely evaluated
agitation, anxiety,
insomnia, headache,
tremor.
- +/-BDZ becoz pt is anxious. eg:lorazepam,
alprazolam Obsessive Compulsive D/O
- If pt has psychotic feature, atypical
antipsychotic: risperidone, olanzapine. Epidemiology
- Suicidal thought: give ECT
- Lifetime prev: 2-3%
Psychosocial - Adults: male=female
- Adolescence: Male>female
- Cog Behavioural Therapy(coping skills) (1. - Male had younger age of onset
challenge thought2.ms relaxation,deep breathing,
- Mean age: 20
systemic desensitization) mainstate tx for
- More common in single
MDD. (*not for elderly pt(Prof hamidin))
- Graded exposure Comorbidity
- Breathing exercise
- Psychoeducation - MDD (67%)
- Family session - Social phobia (25%)
- Group therapy (in ward) - Alcohol use d/o, gen anxiety d/o, specific
phobia, panic, eating d/o
Etiology
- Genetic: relative w OCD 3-5X higher than
control.
- Behavioural : learning theory
Diagnostic criteria:
A) Presence of obsession, compulsion, or both
Obsession is defined by 1 or 2:
1) Recurrent & persistent thought, urge, or
image that are experienced as intrusive &
unwanted which is causing markedly
anxiety/distress.
2) The individual attempt to ignore/suppress
those thought, urge or image or to neutralize
them by performing compulsion
Compulsion are defined by 1 or 2:
1) Repetitive behaviour/mental acts that
individual feel driven to perform in response
to an obsession or according to rule that must
be applied rigidly.
2) Those behaviour or mental acts are aimed to
prevent/reduce anxiety/distress or to prevent
dreaded/situation, but those behaviour/
mental acts are not connected in realistic way
with what they are design to prevent or
neutralize, or are clearly excessive.
B) The obsession/compulsion are time consuming or
cause clinically sig distress/impairment in
functioning.
C) The obsessive-compulsive sx are not attributable
to substance/other medical condition.
D) The obsessive compulsive sx are not better
explained by other mental d/o.
*1) Good/Fair insight
Clinical feature
2) Poor insight
3) Absent insight
Symptom patterns:
1) Contamination: obsession of contamination
followed by compulsion of washing
hands/avoidance.
2) Pathological doubt: obsession of doubt with
compulsion of checking.
3) Intrusive thought: intrusive obsessional thought
without compulsion, thought of sexual/aggressive
act/suicidal ideation.
4) Symmetry: with compulsion of slowness
5) Others: religious obsession, compulsive hoarding,
compulsive hair pulling/nail-bitting, masturbation,
counting, blasphemysaying offensive about god/religion
Course & Prognosis
- >50% had sudden onset, 50-70% after
stressful life event
- 20-30% sig improvement, 40-50%
moderate improvement, 20-40%
remain/worsen
- Good prognosis- good social &
occupational adjustment, presence of
precipitating event, episodic nature of sx.
- Poor prognosis: yielding to compulsion,
childhood onset, bizarre compulsion,
need for hospitalization, MDD, delusion,
overvalued ideas & personality d/o.
Treatment
1) Pharmacological:
- SSRI(high dose, sertraline)
- clomipramine,
- BDZ.
2) Psychological
- Psychoeducation(family session & patient)
- Behaviour therapy(Exposure & response
prevention)
- Relaxation technique(breathing exercise,
progressive muscular relaxation)
- Family therapy
- Group therapy
Stimulant Related Disorder-Amphetamine,
Metamphetamine, Cocaine.
Amphetamine
- Dextroamphetamine(dexedrine)
- Methylphenidate(Ritalin)
- Methamphetamine(desoxyn,ice,crank,speed,crystal
meth)
Substitute Amph
- MDMA(MethyleneDioxyMethamphetamine) ecstasy
 - MDEA(MethyleneDioxyEthylAmphetamine)
Administration & action
1) Amphetamine(less addictive than cocaine)
- Orally (effects within 1 hr)
- IV(immediate effect)
- Snorting(inhaled)
- ↑catecholamine(dopamine &
norepinephrine) and serotonin release &
block reuptake.
 ↑dopaminergic pathway(reward
circuit
pathway/mesolimbic+mesocortical
pathway)
2) Cocaine(aw CVA, cardiac death)
- Orally (very rare)
- Inhaling(snorting)
- SQ/IV
- Smoking(crack) most dangerous
method.
CVA
- Blockade of dopamine reuptake
→↑dopamine
- Immediate effect & last for 30-60 mins.
- Can be present in urine & blood up to 10
days.
Comorbidity (cocaine related disorder)
- Mood d/o, anxiety d/o, antisocial
personality d/o, alcohol related d/o.
Diagnostic criteria of Stimulant use disorder
B) A pattern of amphetamine-type substance,
cocaine or other stimulant use leading to clinically
sig distress/impairment, as manifested by 2 or
more of following in 12 month period.
1) Stimulant always taken in larger amnt/longer
period than was intended.
2) Persistent desire/unsuccessful effort to
control/cut down stimulant use.
3) A great deal of time spent to
obtain/use/recover from its effect.
4) Craving/strong desire/urge to use stimulant.
5) Recurrent stimulant use leading to failure to
fulfill major role at work/school/home.
eve
6) Continued stimulant used despite having
persistent/recurrent social/interpersonal
problem caused/exacerbated by stimulant.
7) Important social/occupational/recreational
activity are given up becoz of stimulant use.
8) Recurrent stimulant use in situation which are
physically hazardous.
9) Continued stimulant use despite knowledge
of having persistent/recurrent
physical/psychological problem that is likely
to have been caused by stimulant use.
10) Tolerance, as defined as either of the
following:
i) A need markedly increase in amnt of
stimulant use to achieve
intoxication/desire effect.
ii) A markedly decrease in effect with
continued use of same amnt of
stimulant.
11) Withdrawal, defined as either of following
i) A characteristic withdrawal syndrome
of stimulant.
ii) Stimulant is used to avoid/relieve
withdrawal sx.
*Amphetamine- paranoid ideas with cont used.
*Cocaine- irritability, impaired ability to
concentrate, compulsive behaviour, severe
insomnia, wt loss, nasal congestion.
Cocaine coz death 2nd to cardiac arrhythmia, MI,
seizure, resp depress.
Diagnostic criteria of Stimulant Intoxication.
A) Recent use of stimulant.
B) Clinically sig problematic behavioural/
psychological change develop during/ shortly
after stimulant use.
C) >2 of the following develop during/shortly after
stimulant use:
1) Tachycardia/Bradycardia
2) Pupillary dilation Major
3) Elevated/lowered blood pressure Sn
4) Perspiration of chills
5) Nausea/vomiting
6) Evidence of wt loss
7) Psychomotor agitation/retardation
 8) Muscular weakness/respiratory depress/chest 3) Mood d/o: intoxication with manic/mixed;
pain/cardiac arrhythmia withdrawal with depression.
9) Confusion/seizure/dyskinesia/dystonia/coma 4) Anxiety d/o
D) The sx/sn are not attributable to other medical 5) OCD
condition/not better explained by other mental 6) Sexual dysfn
d/o. 7) Sleep d/o

People use stimulants becoz of the characteristic effect: Management

- Elation(excitement) Ix
- Euphoria
- Perceived improvement on mental & 1) Biological
physical tasks - FBC, LFT, RP
- ECG
- ↑self-esteem
- Urine for drugs
Diagnotis criteria for Stimulant Withdrawal→crash - Fasting blood glucose, lipid profile
2) Psychosocial:
A) Cessation of/Reduction of prolonged stimulant - Collateral hx with family members/friends
use.
- Check the forensic record
B) Dysphoric mood and >2 of the following develop
within few hours to several days after criterion A: Treatment:
1) Fatigue
2) Vivid, unpleasant dreams(↑REM) 1) Pharmacological:
3) Insomnia/hypersomnia - IM Haloperidol for agitated patient
4) ↑in appetite - Diazepam
5) Psychomotor retardation/agitation - Symptomatic tx(Respective gp of drugs for
C) The sx of criterion B causes clinically sig respective sx)
e.g: antiemetic, antispasmodic,...
distress/impairment in functioning.
2) Psychological
D) The sx/sn are not attributable to other medical
- Psychoeducation: nature & course, sx &
condition/not better explained by other mental
sn, SE, necessity of tx, relapse.
d/o.
- Motivational Enhancement Therapy: to
Clinical feature of stimulant withdrawal: ↑motivation.
(adv&disadv taking drugs, adv of
 Anxiety, tremor, headache, profuse sweating, stopping)
muscle cramp, stomach cramp & the above to identify stage of change pt:
sx in criterion B. -precontemplation b
 peak in 2-4 days and resolved in a week. -contemplation
-preparation
 Depression(most severe sx) can cause suicidal
-Action
ideation/attempts. -Maintenance
- Cognitive behavioural therapy
Stimulant Related Disorder
i) Coping skill
1) Delirium ii) Relapse prevention therapy (how
2) Psychotic disorder: to say no, avoid cues to take
- Paranoid delusion, auditory hallucination, drugs)
visual hallucination. - Narcotic anonymous for cocaine.
- Tactile hallucination(bugs crawling - Therapeutic community
beneath skin) common with cocaine. - Supportive psychotherapy(only for pt in
- Tx: short term haloperidol crisis)
++Dr Ang:Stimulant
-Cardiac arrhythmia
-increase temp(NMS)→ ↑ms breakdown→ myoglobinuria→ AKI→ Die.
Opiod Related D/O-heroin, morphine, codeine,
methadone
Lifetime prevalence: 1%
May coz resp distress d/t cns depressant eff.
Administration
- IV
- Smoking(catching the dragon)
- Snorting
*Endogenous opiod: endorphine, dynorphine,
enkephaline
- orally
Action on opioid receptor
- *MMu-analgesia, resp depression, constipation,
dependence*
- KKappa-analgesia, diuresis, sedation
- ∆Delta-analgesia
-interaction w reward circuit pathway
-interaction w noradrenergic neuronewithdrawal sx
-cause tolerance & dependence after long time use.
-withdrawal occur when abrupt stop or administration of
opioid antagonist(eg: naltrexone).
Comorbidity
- Mood d/o, anxiety d/o, antisocialaggressive
personality d/o, accohol related d/o.
Dx criteria for opioid use d/o
A) Aproblematic pattern of opioid use leading to
clinically sig distress/impairment, manifested as 2
or more of following in 12 month period.
1) Opioid taken in large amount/longer period
than was intended
2) Persistent desire/unsuccessful effort to cut
down/control opioid use.
3) A great deal of time is spent to
obtain/use/recover from its effect
4) Craving/a strng desire/urge to use opioid
5) Recurrent opioid use leading tofailure to fulfil
major role at work.
6) Continued opioid use despite having
persistent/recurrent social/interpersonal
problem caused/exacerbated by opioid use.
7) Important social/occupational/recreational
activity are given up because of opioid use.
8) Recurrent use opioid in situation which is
physically hazardous.(driving, accident)
9) Continued opioid use despite knowledge of
having persistent/recurrent
physical/psychological problem that is likely
to have been caused/exacerbated by opioid
use.
10) Tolerance, defined as either of the following:
- A need of markedly increase in amnt of
opioid use to achieve intoxication/desire
effect.
- A markedly diminished effect of continue
use of same amnt of opioid
11) Withdrawal, manifested either of following:
- A characteristic withdrawal sx of opioid
- Opioid is taken to relieve/avoid
withdrawal sx
Diagnostic Criteria for Opioid Intoxication
A) Recent use of opioid
B) Clinically sig problematic behavioural/
psychological change dev during/shortly after
opioid use.
C) Pupillary constriction (pupillary dilation d/t anoxia
from severe overuse) & >1 of following develop
during/shortly after opioid use
- Drowsiness/coma
- Slurred speech
- Impairment in attention/memory
D) The sx are not attributable to another medical
condition/not better explained by other mental
d/o.
Dx criteria for Opioid Withdrawal
A) Presence of either of following
1) Cessation of/reduction in heavy prolonged
opioid use.
 2) Administration of opiod antagonist after a - Methadone(once daily)(w pt had
period of opiod use. withdrawal):
B) >3 of following dev within minutes to few days i) can cause dependance, sedation,
after criteria A. resp distress.
1) Dysphoric mood ii) Can be given to pregnant lady.
2) Nausea/vomiting - Buprenorphine(w pt had withdrawal):
3) Muscle ache i) can be given to pt w resp
4) Lacrimation/rhinorrhea problem.
5) Pupillary dilation/piloerection/sweating - Naltrexone:
6) Diarrhoea i) Given when pt no longer had
7) Yawning withdrawal.
8) Fever ii) Reduce the craving.
9) Insomnia c) Psychological:
C) The sx in criterion B causes clinically sig - Psychoeducation
distress/impairment in functioning. - Motivational enhancement therapy
D) The sx are not attributable to another medical - Cog Behav Therapy
condition/ not better explained by other mental i) Coping skills
d/o. ii) Relapse prev therapy
- Therapeutic community
*Morphine & heroin: withdrawal begin 6-8 hours
- Narcotic anonymous
after last dose, peak in 2-3days, subside during next 7-
10 days, but some sx persist >6months. Cannabis related D/O Marijuana, pot, weed, grass

*Methadone: begin 1-3 days after last dose, end in Dx criteria for opioid use d/o
10-14 days.
A) A problematic pattern of cannabis use leading to
Clinical features clinically sig distress/impairment, manifested as 2
or more of following in 12 month period.
- Euphoria, feeling of warmth, heaviness of 1) Cannabis taken in large amount/longer
extremities, dry mouth, itchy face, facial period than was intended
flushing, sedation
2) Persistent desire/unsuccessful effort to cut
- Resp depression down/control cannabis use.
- Opioid Overdose: coma, pinpoint pupil, 3) A great deal of time is spent to
resp depression obtain/use/recover from its effect
Mx: 4) Craving/a strng desire/urge to use cannabis
5) Recurrent cannabis use leading tofailure to
1) Investigation fulfil major role at work.
a) Biological: FBC, RP, LFT, Urine for drug 6) Continued cannabis use despite having
b) Psychososial: collateral hx from family persistent/recurrent social/interpersonal
member & friends problem caused/exacerbated by cannabis use.
2) Treatment 7) Important social/occupational/recreational
a) Acute(overdose): activity are given up because of cannabis use.
- Sustain airway 8) Recurrent use cannabis in situation which is
- Administration of naloxone(opioid physically hazardous.
antagonist) at slow rate with 0.8mg/70kg 9) Continued cannabis use despite knowledge of
of patient. Beware sn of withdrawal. having persistent/recurrent
b) Long term physical/psychological problem that is likely
 to have been caused/exacerbated by cannabis D) The sx are not attributable to another medical
use. condition/ not better explained by other mental
10) Tolerance, defined as either of the following: d/o.
- A need of markedly increase in amnt of
Medical use Marijuana:
cannabis use to achieve - nausea for pt on chemo
intoxication/desire effect. -LOA in pt aids
- A markedly diminished effect of continue -↓intraocular pressure
use of same amnt of cannabis -ms spasm

11) Withdrawal, manifested either of following:

- A characteristic withdrawal sx of cannabis
Alcohol use & related D/O
- Cannabis is taken to relieve/avoid
withdrawal sx Activate GABA, - glutamate→ CNS depression

Diagnostic Criteria for Cannabis Intoxication Diagnostic criteria for alcohol use d/o

A) Recent use of cannabis A) A problematic pattern of alcohol use leading to

B) Clinically sig problematic behavioural/ clinically sig distress/impairment, as manifested
psychological change dev during/shortly after by 2 or more of following in 12 month period:
opioid use. (impaired motor coordination, euphoria, anxiety, 1) Alcohol is always taken in larger amnt/longer
impaired judgement, social withdrawal) period than was intended.
C) 2 or more of following develop within 2 hr after 2) Persistent desire/unsuccessful effort to cut
cannabis use: down/control alcohol use.
- Conjunctival injection 3) A great deal of time is spent to
- ↑appetite obtain/use/recover from its effect.
- Dry mouth 4) Craving/A strong desire/urge to use alcohol.
- Tachycardia 5) Recurrent alcohol use causing failure to fulfil
D) The sx are not attributable to another medical major role at home/school/work.
condition/not better explained by other mental 6) Continued alcohol use despite having
d/o. persistent/recurrent social/ interpersonal
problem that is caused/exacerbated by
Dx criteria for Cannabis Withdrawal
alcohol.
A) Cessation ofcannabis use that has been heavy & 7) Important social/occupational/ recreational
prolonged. activity are given up because of alcohol use.
B) >3 of following dev within 1 week after criteria A. 8) Recurrent use of alcohol in situation which is
1) Irritable, anger or aggression physically hazardous(drive, racing, stole).
2) Nervousness or anxiety 9) Continue alcohol use despite knowledge of
3) Sleep difficulty.(insomnia) having persistent/recurrent
4) ↓appetite/wt loss physical/psychological problem that is likely
5) Restlessness to have been caused/exacerbated by alcohol.
6) Depressed mood 10) Tolerance, defined as either of the following:
7) At least 1 of following cause sig discomfort: a) A need of markedly increase in amnt of
Abd pain, shakiness/tremor, sweating, fever, alcohol use to achieve desire
chill or headache. effect/intoxication.
C) The sx in criterion B causes clinically sig b) A markedly diminished effect with
distress/impairment in social, occupational continue use of same amnt of alcohol.
functioning. 11) Withdrawal, manifested by either of
following:
 a) A characteristic withdrawal synd of Mod: Diaphoresis, tachycard, fever, hpt, disorientation.
Severe: Tonic-clonic seizure, Delirium tremens, hallucination
alcohol.
b) Alcohol is taken to relieve/avoid Delirium Tremen:
withdrawal sx. Male 5x than female
Delirium a/w hallucination, gross tremor, autonomic instability.
ACT DOC GHK TW
Management:
Diagnostic criteria of alcohol Intoxication.
Blood alcohol level>100, obv sn>150mg/dL Ix:
A) Recent ingestion alcohol 1) Biological:
B) Clinically sig problematic behaviour/psychological - FBC(polycythemia), LFT(chronic use of
change alcohol & the drugs might be given
C) 1 or more of following develop during or shortly metabolised by liver), renal
after alcohol use: profile(electrolyte imbalance).
1) Slurred speech - Blood alcohol level.
2) Incoordination - Random blood glucose(alcohol use aw
3) Unsteady gait hypoglycemia)
4) Nystagmus - Fasting lipid profile(prolong alcohol use
5) Impairment in attention/memory aw increased in triglyceride)
6) Stupor/coma. - Urine for drugs(tro substance use)
SIGN IS 2) Psychosocial
D) The sx/sn are not attributable by other medical - Collateral hx from family member(tro
condition/not better explained by oyher mental depression).
d/o. - Trace old notes if any.
Diagnostic criteria of alcohol withdrawal Treatment: (DO NOT GIVE BDZ WHEN PT INTOXICATED)
A) Cessation of/Reduction in prolonged & heavy 1) Pharmacological:
alcohol use. a) Acute: IM Haloperidol/clonazepam/lorazepam
B) 2 or more of following sx dev within several hours to sedate pt.
to a few days after criteria A: b) In the ward:
1) Autonomic hyperactivity(sweating, ↑pulse (prevent seizure & delirium tremens*(acute
rate) psychotic cond involve tremor,
2) ↑hand tremor hallucination,disorientation) which can cause
3) Insomnia death)
4) Nausea/vomiting - Diazepam(10mg tds):
5) Transient visual/tactile/auditory hallucination i) to ↓ & control withdrawal sx.
/delusion ii) high dose initially, ↓dose by 20%
6) Psychomotor agitation every 2 days.
7) Anxiety - IM/IV/oral thiamine 100mg per day to
8) Generalized tonic clonic seizure prevent Wernicke Korsakoff syndrome.
C) Criterion B cause clinically sig distress/impairment i) Wernicke encephalopathy
in functioning. (acute): confusion, ataxia,
D) Sx & sn not attributable by other medical ophthalmoplegia.
condition/not better explained by other mental ii) Korsakoff syndrome(chronic):
d/o. inability to form new memory,
memory loss, confabulation,
EtOH withdrawal sx
Mild: irritability, tremor, insomnia hallucination.
 iii) Wernicke can proceed to - Family hx
korsakoff if left untreated. - Adverse experience in childhood
- IV dextrose if pt hypoglycaemic - Loss father since child
- Provide high caloric food.
c) Rehabilitation: Precipitating:
- DisulfiramAntabuse(pt cannot take alcohol 12 - Recent trigger/stressful event
hr b4 & after taking this)
- Naltrexone(↓craving) Perpetuating:
- Acamprosate(not in M’sia)
- Non-compliance
2) Psychological
- Poor insight
a) Psychoeducation
- Poor family support
b) Motivational interview
c) Alcohol anonymous Sleep D/O
d) Cog Behavioural Therapy
- Coping skills Insomnia
- Relapse prevention. A)Dissatifaction sleep quality & quantity.
B)3night/wk for 3month.
++preg women x drink alcohol, can coz fetal alcohol synd.
C)coz soc/occup impairment
Substance use d/o hx: D)X d/t physical/mental cond
E)X d/t substance
1. What- name of substance
When- start & last Hypersmnolence d/o
Why- reason to use A)excessive sleepiness despite main sleep period at least
How- tablet, chase, iv, im, snorting 7hr.
Freq- start & nowadays B)At least 1 - recurrent sleep on same day
Amnt- how much ringgit/gram - prolonged main sleep >9hr that unrefreshing
-start & nowadays - difficult fully awake after abrupt awakening
Intoxification sx C)3X/wk for at least 3month
Stop taking-tried b4 D)X better explain by other sleep d/o
-how long mx to stop E)X d/t substance
-any withdrawal sx F)coexist medical problem inadequate to explain
Caught by police hypersomnolence.
Go jail/rehab centre Nightmare d/o
Methadone/any tx Repeated awakening d/t frighten dream
++Dx criteria = 11 Occur during REM
2. Additional: WIPAP Freq at end of night
Withdrawal Upon awakening, rapidly alert & orientated.
Intoxication Sx dev during/soon after Tx: tca,bdz
Persist for long period of time
After cessation of acute withdrawal/severe intoxication. NonREM sleep arousal d/o
Preceded the amnt substance use. Recurrent incomplete awakening during stage 3/4 with
Dr Ang..
Must ask motivation of pt to stop..(stage of 1)sleep terror or
change) 2)sleep walking
No detail dream recall
Morning amnesia
Coz sig distress, socfn impairment
Predisposing: X d/t substance
X d/t medical/mental d/o - Hypnotics
- Inhalant
Sleep talking=somniloque - Opioid

Narcolepsy Post Traumatic Stress Disorder

A)Recurrent period need to sleep, lapse to sleep or nap DWLE MDFP ACA
within same day. Occur 3x/wk for at least 3month.
B)Presence 1 of following A) Exposure to actual threatened death/serious injury/
- cataplexy(sudden loss ms tone or spontaneous jaw open sexual violence. 1≥of following
w tounge thrusting) - Direct
- Hypocretin deficiency - Witness
- Polysomnography REM sleep latency <15mins - Learning it occur to close one
- Experienced repeatedly
Dx Ix: Polysomnography
Tx: Force nap at reg time, stimulant(Ritalin) B) Intrusion syndrome associated with traumatic event
(≥1).
- Memories(recurrent)
Breathing Related Sleep D/O
- Dreams
1) OSAhypopnea - Flashback
-Polysomnography show atleast 5 - Psychological - distress
apnea/hypopnea per hr w either following - reaction when exposed to
i)snoring,gasping,breathing pause during sleep. internal /external cue.
ii)daytime sleepiness,fatigue,unrefreshing despite
sufficient sleep, & not d/t medical/mental d/o. C) Avoidance(≥1)
-15 or more hypopnea/apnea per - avoiding distressing memory, thought, feelings.
hr(polysomnography) - avoid external cues(place, people).

2) Central sleep apnea D) Negative alternation of cognitive + mood(≥2).

-5 or more central sleep apnea per hr sleep - inability to remember important aspect of an event.
-not d/t other sleep d/o - negative belief to self/others.
- blame self + others.
Sleep hygiene technique (ASLEEP) - persistent negative emotion.
Alcohol, nicotine caffeine avoided - ↓interest to participate in activity,
Sleep & sex the only use of bed - persistent inability to experience +ve emotion.
Laptop, tv, paperwork out of bedroom - feeling detachment/estrangement from others
Exercise reg but not 2-3 hr b4 sleep
Early rising, avoid daytime nap E) Arousal sx (≥2) RICHES
Plan for bedtime - Reckless behaviour
- Irritable behaviour
Stimulant - Concentration difficulty
- Stimulant - Hypervigilance(↑careful watch for danger)
- Cannabis - Exagerated(startle response to shock)
- Caffeine - Sleep disturbance.
- Nicotine
F) Duration of disturbance B,C,D,E is > 1 month.
Depression
G) cause socio-occupational impairment.
- Alcohol
H) X substance, X medical condition. Her younger sister is 39 years old and opens her own saloon. Her
younger brother is 37 years old and works as a teacher at secondary
PTSD(for <6years) school.

A) same Patient is close to all her siblings.

B) same
There was no other medical or psychiatry illness run in her
C) ≥1 of intrusion, avoidance, negative alteration
family.
cognitive.
Intrusion=same She married for 20 years already and blessed with 5 chidren.
Avoidance=same Her husband works as an occupational health officer in private
cognitive→ - ↑freq –ve emotion
company. Her eldest child is 19 years old and youngest child is 13 years
- ↓interest to participate activity.
old.
- socially withdrawn
- persistent ↓in expression of +ve There was no other suicidal ideation, medical or psychiatry
emotion. illness run in her family.
D) Arousal sx=same
E) same PERSONAL HISTORY
F) same Prenatal history

G) same
Otherwise, there was no history of manic symptom (such as persistent
elevated mood, increase in goal-directed activities, inflated self-
Patient could not remember about his prenatal history.
Early Childhood: Patient could not remember much about his early
childhood live. But generally he was cheerful and he did not have
disease such as asthma or febrile fit.
Middle & Late Childhood: He was not enjoy going to school and he had

esteem, decrease need of sleep, more talkative) depressive symptom only few friends who only have the same interest like him. His

(such as depressed mood, irritable, markedly loss of interest in all
activity, significant loss of weight, insomnia, suicidal thought), anxiety
symptom (such as restlessness, easily fatigue, excessive anxiety, worry)
or drug abuse.
PAST PSYCHIATRIC HISTORY
He had no psychiatric illness previously.
PAST MEDICAL/SURGERY HISTORY
He did not have history of medical illnesses.
On May 2015, he involve in motor vehicle accident. His lung and
intestine were severely injured. He claimed to undergo operation for
lung and intestine transplant which was donated by Tengku Jalil. He
was admitted into Intensive Care Unit for 2 months & surgical ward for
another 2 month. After being discharged, he defaulted the follow up
because he thought that he was well already.
FAMILY HISTORY
Patient’s father is 70 years old with underlying ischemic heart
disease. Her mother currently is 67 years old with underlying
hypercholestrolemia. She has 3 siblings and she was the eldest child.
academic performance was poor but he was active in sport activities
such as football. He claimed having discipline problems during school
time which are truant and smoking which started during Standard 6. His
SPM result was 1b 1c 7d.
Adulthood: After finish secondary school, he went to work as a horse
trainer at Istana Pasir Pelangi Johor. He claimed to start drinking
alcohol on that time after being offered by people in the minibar in the
palace. He never change job until January 2016 when he ran away to
KL and change his job to security at Maybank Perkeso.
DRUG & ALLERGY HISTORY
He was not on any medication or TCM. There was no allergy towards
drugs or food.
SOCIAL HISTORY
He is a single young man and currently staying in hostel with his friends
near the Maybank. He works as security guard at Maybank Perkeso. He
was a smoker and smoke 1 pack for 2-3 days since 12 years old. He only
took alcohol drink occasionally. He denied any history of drugs abuse.
PREMORBID PERSONALITY
Patient claimed himself as a quiet & relax person. He does not easily He only had mild delusion of persecutory. However, there was no
irritated or angry. He did have hobby which is playing polo. Otherwise, overvalued idea, preoccupation or suicidal thoughts.
he did not have any obvious trait such as having odd belief, excessive Possession
social anxiety, low self confidence or anxious./ She described herself as No thought broadcasting thought withdrawal, or thought insertion
a happy and cheerful person before she had depression. She did not noted.
have problem to socialize with friends. The had no problem with her
boyfriend and relationship with family also good. COGNITION
Orientation
He was not orientated to time because he didn’t know the day and the
MENTAL STATE EXAMINATION date of interview. He didn’t realize that he is in HKL and unable to
GENERAL APPEARANCE AND BEHAVIOR recognize me as student.
Mr Rizan , Malay male, was sitting comfortably on a chair with normal = He was not oriented to time, person and place.
posture (no mannerism, stereotypy, tremor or stupor), wearing Attention
hospital attire with moderate personal hygiene (neat & clean shirt, He unable to perform subtraction of 7 in 120 seconds. His has poor
short and messy hair and wearing slipper). Upon interviewing, patient attention.
was conscious, cooperative and able to communicate well with good Memory
rapport. He also established good eye contact and not easily distracted. a)immediate memory
Otherwise, there was no sign of depress(depressed mood, loss of He able recall 7 digit forward and 5 digit backward.
interest, agitated, vacant look apathy to surrounding or stooped b)recent memory
posture) or sign of anxiety(restlessness, chill/heat sensation, sweaty He able to recall 5 objects (ayam, kucing, ikan, meja, kerusi) out of 5 in
hand, frequent swallowing, frequent posture changing). 5 minutes
c)remote memory
SPEECH He able to recall his IC number and birthday date.
He able to speak in Malay fluently. The speech was relevant and Thus, he has good memory.
coherent with normal volume, speed amount and tone(↑if bipolar).
INFORMATION & INTELLIGENCE
Comprehension
MOOD AND AFFECT
Good.Patient understood all the questions being asked in the interview
The mood was 5 (0:depress, 5:euthymic, 10:elated) and answered accordingly.
His affect was appropriate, broad and congruent to thought. No labile General knowledge
Good. She was able to tell the name of our current prime minister.
affect noted.
Dato seri Najib Tun Razak.
Arimethic
PERCEPTUAL DISTURBANCES Good.
Question: If you have RM3.00 and you buy a plate of nasi lemak which
There was no auditory hallucination, depersonalization, derealization
costs you RM 1.80, how much money is left?
or illusions were revealed. Her answer was correct, which was RM1.20.
Vocabulary
THINKING Patient had good vocabulary.

Form Abstracts thinking(schizo poor)

His form of thought was able to understand and meaningful. There a)Proverb test
were no preservation, loosening of association(schizo) or flights of He didn’t know the meaning of “ulat buku” and “bagai isi dengan kuku”
ideas(bipolar). b)Similarity Test
Flow apple and grape = fruit
Flow of thought was normal where there were no thought block, c)Difference Test
poverty of thought or pressure of thought. chicken, cat & orange = orange
Content = The abstract thinking was poor.
Judgment :
(i)Social judgment “If person talks loudly in a library, what
are you going to do?”
“I will told that person to silent”
(ii) Test judgment “If this building is on fire, what you will
do?”
“I will switch on fire alarm”
(iii) Personal judgment “What you plan to do after being
discharge?”
“I want to go back home, repair
motorcycle, riding it at his residential area & smoking”
= The judgment was good.

Insight:
He is not aware that he is having psychiatric illness and didn’t know the
symptom & result of not being treated. He only takes medication
because the staffs ask him to do so./compliance Thus, his insight was
poor.

PHYSICAL EXAMINATION
Patient was alert, conscious & not in resp distress. He was sitting
comfortably on the bed. He was not pale, jaundiced or cyanosed.
Hydrational status was normal. There was no abnormal movement
noted.
Temperature : 36.8°C
Pulse rate(PR) : 70/minutes
Respiratory rate(RR) : 17/minutes
Blood pressure(BP) : 122 / 77mmHg

Examination of other system was unremarkable

Prognostic factors: GAM PC FC

Gender
Age
Marital status
Premorbid fn
Chronic illness
Freq relapse
Compliance to medication