Have you been depressed over the past 2 weeks?

Have you lost interest in doing things that you

enjoyed previously over the past 2 weeks?
IF YES to either question

How does your depressed mood affect your everyday life?

Criteria for Major Depression

Have you got any problems with sleep?

Any changes in appetite or weight?
Any changes in energy or ability to focus/concentrate?
Any guilt feelings?
Anybody notice that you are slower than usual?
Do you have thoughts or plans of hurting yourself?

Screen for hypomanic/manic episode

Have you ever felt the opposite e.g. abnormally happy?

Have you ever felt high level of energy running through your body?

If NO

Have you had sadness like this in the past?

 Screen for past or current manic or anxiety
symptoms.
 Evaluate the physical (hypothyroidism, B12
deficiency, folate deficiency, behavioural
symptoms and severity of psychological
symptoms e.g. pseudodementia, psychotic
features).
 Any h/o drug or alcohol abuse?
 Any suicidal ideation/plan or attempt?
[currently or past attempt]
 Psychotherapy
counseling
problem solving
cognitive behaviour therapy
 Pharmacotherapy
SSRI
Tricyclics
tetracyclics
Choice of antidepressants:

 If she had an episode in the past and

responded to drug ‘A’, then restart drug ‘A’ if
there is no contraindication.

 If it’s second episode or more, it takes a

longer duration to respond.
 A 42 year old woman c/o insomnia.
 5 weeks of insomnia associated with LOA,
LOW, easily fatigue and low mood. She
continues to work but socializes less
than usual.
 20 years ago she had similar episode and
sought a brief course of counseling.
 Her symptoms improved over several
months.
 SSRI – sedative e.g. Fluvoxamine, sertraline
[least sedative: Fluoxetine]
 Tricyclics (TCA) : Amitriptyline, Imipramine,
Dothiepin
 Sleep hygiene!

If pt is suicidal, only SSRI as TCAs can be fatal in

overdose.
 SSRI TCA
Sexual +++ ++
dysfunction
Weight gain + ++
sedation +/- +++
cardiac - +++
 May or may not.
 Add if your patient is anxious, no previous
history of adverse effects with
benzodiazepine esp when you use SSRI.
 First 2 weeks of SSRI use: paradoxical anxiety
 Caution: effects of BDZ can be potentiated by
fluvoxamine
 2nd episode: continue antidepressants for 2-3
years after remission.

 1st episode: 6-9 months after remission

 3rd episode: lifelong
 Antidepressant SSRI – low dose initially
 Mood stabilizer Lithium, lamotrigine
 Close monitoring.

 Quetiapine
 Counselling
 Supportive therapy [counselling with problem
solving]
POSTPARTUM DISORDERS
 Postpartum Blues
 Within the first 2 weeks after delivery
 Depressed mood, irritability, mood
swings, crying spells, fatigue and
anxiety.
 Self limiting : rarely more than a few
weeks
 Reassurance and monitoring.

POSTPARTUM DEPRESSION
 Postpartum Depression

 Within the first 4-6 weeks after childbirth

Depressed mood
Loss of pleasure / interest
 Similar to major depressive disorder but
Change in appetite
tend /toweight
experience more mood
Feelings of worthlessness
fluctuation and prominent anxiety
Excessive guilt
symptoms.
Sleep changes
Diminished  Disinterest in the newborn / fearful of
concentration
being left alone with the baby.
Restless or slowness
Fatigue  Increased risk of suicide, neglect of the
newborn and infanticide
Treatment

ECT
Antidepressants :
Fluoxetine (SSRI)
Dothiepin (TCA)
 Postpartum Psychosis

 Primiparous / history of perinatal complications

 Begins within the first 2 weeks following
delivery.
 Early stages: reminiscent of the postpartum
blues: depressed mood, irritability, mood
swings, crying spells, fatigue and anxiety
FRANK PSYCHOSIS e.g. suspiciousness,
incoherent, delusions, hallucinations
Postpartum Psychosis – cont.

 Delusional beliefs may involve the child :

child is dead, child is being possessed or
evil or the child is defective
 May have impulses to harm the child
 Agitated, poor sleep
 Hallucinations: command the mother to
harm herself or the baby
 Treatment

ECT
Antipsychotics

CONTRACEPTIVE METHOD: Non hormonal

 SUICIDE
Causes and Risk Factors
• Difficult to predict suicide.
• Clinically we need to estimate the risk of suicide.
• Identification of factors that may increase a
patient’s level of suicide
• One risk factor will not determine suicide
independently. Think of the factors present in
aggregate and view them within the context of
patient’s experience.
 Risk Factors for Suicide
• Patient demographics: age and gender
• Past and current suicidality
• Psychiatric diagnosis and psychiatric symptoms
• Individual history: Medical history, family
history, psychosocial history
• Personality strengths and weaknesses.
 Age
• Generally suicide rates increase with increasing
age.
[trend now : 2 population groups i.e.
adolescents/young adults and the elderly]
The increase of suicide during adolescents
Suicide rates rise
and young sharply parallels
adulthood in late adolescence
the rise in the
and early adulthood
incidence before levelling
of mental illness. Manyoffmajor
through
midlife
mental and risinghave
disorders afteronset
againtheir age 70.
in
adolescence, As severe mental disorders
(Depression, bipolar disorder, schizophrenia)
increase so do suicide rates.
• Highest suicide rates : elderly
[Suicide attempts are more common in the
younger age groups]

• Completed suicide.
 Reasons for the rise in suicidal
behaviours in the elderly
• Less physical resilient: suffering from physical illness.
• More likely to have access to medication: overdose
• Poverty and isolation: less likely to be rescued
• Generally demonstrate a greater determination to die
as they give few warning signs
• Involve greater planning and use more lethal
methods.
 Gender
• Rates of suicides in older adulthood are higher for men.
Reasons:
 Men are less likely to seek help for emotional problems.
 Men are more impulsive than women.
 Men are less socially embedded than women.
 Men may choose more lethal methods
PROTECTIVE FACTORS FOR WOMEN
Pregnancy
Presence of young children
 Risk factors unique for women
• Intimate partner/spouse abuse
• Gender inequalities in some society/within the
family.
[poisoning in China and self burning in Middle
East]
• Severe psychiatric illness following delivery e.g.
postpartum depression and postpartum
psychosis.
 Past history of suicide attempt
• Up to 50% of those die of suicide have made at
least one previous attempt.

• Suicide attempts are 10-20 times more prevalent

than suicide.
 Characteristics of past attempts that
increase future risk:
 Presence of longstanding medical problems
 Psychiatric illness esp depression, alcohol abuse

 Social isolation / poor support

 Past attempt with adverse consequences e.g. disability

 high intent

 Use of highly lethal means

 Measures taken to avoid discovery
 Current suicidal ideation
Higher risk if :
the magnitude of suicidal thoughts is greater and
persistent.
The intent is higher (patient’s expectation to die)
Detailed and specific suicide plan
 Aspects of suicide plan that is
associated with higher lethality
i. Method: higher lethality method is associated with
higher suicide risk.
ii. Patient’s belief about the lethality of the method (high
intent)
iii. Low chance of rescue
iv. Steps taken to enact plan: hoarding pills, plan the
time and setting, ensuring isolation and low chance of
discovery.
v. Preparedness of death: making a will, writing letters to
loved ones, suicide notes.
 Psychiatric symptoms associated
with suicide
• Mood disorder esp depression
• hopelessness
• Psychotic disorder with command hallucinations
• Impulsivity
• aggression
• Panic disorders Protective factors
• Personality disorders Optimism
• Substance abuse and dependence Religiosity
• Anger High life satisfaction
• Side effects of Rx e.g., akathisia
 Psychiatric symptoms associated
with suicide

• A higher risk is associated with individuals who

are also socially isolated, with maladaptive
coping and experiencing significant loss (e.g.
financial)
 Psychiatric diagnosis
• Mood disorders
• Psychotic disorders
• Anxiety disorders
• Alcohol and substance abuse
• Personality disorders
 Personality Disorders
• Borderline personality disorders

1. Frequent displays of inappropriate anger

2. Recurrent acts of crisis such as wrist cutting,
overdosing, or self-mutilation
3. Feelings of emptiness and boredom
4. Intolerance of being alone
5. Impulsiveness with money, substance abuse,
sexual relationships, binge eating, or shoplifting
 Personality Disorders
• Antisocial personality disorders

1. failure to conform to social norms

2. repeated lying or conning others for personal
profit or pleasure
3. impulsivity
4. irritability and aggressiveness, as indicated by
repeated physical fights or assaults
5. reckless disregard
for safety of self or
others
6. consistent
irresponsibility
7. lack of remorse, as
indicated by being
indifferent to or
rationalizing having
hurt, mistreated, or
stolen from another
 Medical History
• Esp illnesses associated with functional
impairments, cognitive impairments, pain,
disfigurement and decreases in hearing or vision.
• Neurological disorders: epilepsy, multiple
sclerosis, Huntington disease, brain and spinal
cord injury.
• Chronic illness
• Risk is higher if associated with depression
 Family History
• Suicide
• Psychiatric disorder
 Psychosocial History
Marital Status

• Generally being married : protective

• Conflictive and abusive marriages
• Divorced, separated, widow: 4-5x higher
• Single adults : 2x higher
 Psychosocial History
Employment Status

• Unemployment, financial and legal difficulties

• Employed: Health care professionals higher risk
esp. physicians and dentists
 Psychosocial History
Past abuse
• Childhood sexual or physical abuse

Cultural and religious beliefs

• Protective factor: religion or culture that view
suicide as sinful or criminal act
 30 yr old woman c/o feeling fearful and
anxious when leaving the house.
 Pounding heart and feeling shaky
 At home, she also experience sudden and
unexpected attacks
 “I feel like I’m going to pass out”
 She would stay near an exit in public
places, just in case “I need to get out of
there”.
 Anxiety = excessive worrying, nervousness or
feeling on edge.
 ADAPTIVE – motivates one to complete a task.

 PATHOLOGIC – excessive and creates

disability, avoidance behaviour.
 Impairment in social, occupational and ADL.
 “What have you given up because of your
symptoms?”

 “have your symptoms prevented you from

doing something you wanted to?”
1. Medical conditions with anxiety-like
symptoms
2. Medications & substances that cause anxiety
like symptoms
3. Co morbidity with other psychiatric disorder
e.g. depression
4. Suicidal intention or ideation
 Cardiovascular: coronary artery ds, CCF,
arrhythmias
 Pulmonary: asthma, COPD
 Endocrine: thyroid dysfunction, menopause,
Cushing ds, pheochromocytoma
 Hematologic: anemia
 Neurologic: seizure, encephalitis, essential
tremor
 Substance abuse
 Stimulant intoxication:
caffeine, nicotine, cocaine, metamphetamines,
phencyclidine
 Sympathomimetics:
pseudoephedrine, methylphenidate, amphetamines, beta agonists
 Dopaminergics:
amantadine, bromocriptine, levodopa
 Anticholinergics:
benztropine, diphenhydramine, meperidine
 Miscellaneous:
ephedrine, indomethacine, steroids
 Drug withdrawal:
alcohol, BDZ, opiates
 ANXIETY
DISORDERS

SITUATIONAL SITUATIONAL
TRIGGER TRIGGER
Present Absent

PANIC
SOCIAL ANXIETY PTSD OCD GAD
DISORDER

Recurrent Anticipatory
Spontaneous anxiety:
panic
and unexpected perpetuates
attacks the disability
Relaxation therapy
 Deep breathing
Stress: short, shallow breaths and only the upper
chest would be filled up with oxygen
 Deep breathing increases oxygen intake.
 Deep breathing reduces tension.
 Lie on your back with
your feet slightly apart.
 Breathe in slowly
through your nose.
Keep the tip of your
tongue gently touching
the roof of your
mouth.
 Count to 5 as you
inhale. Abdomen
expands.
 Hold the breath as you
count to 5 again.
 Exhale slowly with a whoosh of sound, count
of 5.

 Pause a second or two , then repeat.

 Increase your counts from 5 to 10 when you

are more relaxed.
 Tensing and releasing groups
of muscles one at a time to
relax your entire body.
 Lie on your back.
 Breathe in deeply.
 Tense your entire body.
 Hold the tension for few
seconds, noticing how it feels.
 Then let go while exhaling,
notice the difference.
 Now tense each part of
your body one by one,  Make your hands into
starting with your feet. fists, then let go.
 Point your toes forward  Press your arms
then up. against the floor, then
relax them.
 Tense your calf  Shrug your shoulders,
muscles, then relax. then release.
 Move on to your  Tense the muscles in
thighs, then your your face (wrinkle your
stomach muscles. brow, clench your
 Now arch your back teeth, open your
slightly, then press it mouth wide).
into the floor.  When you’ve finished,
lie quietly for a few
 Continue tensing minutes.
individual muscle  Your whole body
groups. should feel at rest.
 OTHER RELAXATION
 Counselling
 CBT
 Behaviour
modification
esp agoraphobia
  Initial activation:
1. SSRI nervousness
dose dependent and time limited
BDZ dependence to the first 1-2 wks.
Co morbidity with depression  GIT side effects:
transient nausea- very common

2. Tricyclics 
Slower titration
Sexual side effects:
delayed ejaculation, delayed or
3. Short term absent orgasm

Benzodiazepine:
Alprazolam
Clonazepam
 A 28 year old man with a diagnosis of
GERD [gastro-oesophageal reflux ds]
presents with continuing worry about his
illness.
 On Rx and some improvement [for GERD]
but he cont. to worry
 “It’s the way that I’ve always been”
 He wishes that he could ‘just relax’
 ANXIETY
DISORDERS

SITUATIONAL SITUATIONAL
TRIGGER TRIGGER
Present Absent

GAD
PANIC
SOCIAL ANXIETY PTSD OCD
DISORDER

Muscle
Excessive
lack of central free floating tension, Chronic Duration at
worries over
trigger anxiety restlessness insomnia least 6 months
trivial matters
and fatigue
 SSRI:
Escitalopram, Sertraline

 Propanolol

 TCA
Some efficacy
 BDZ
 28 year old man, working as a mechanic
 Late to work
 Spent long hours in the bathroom.
 Minimum: 1 hour
 Checking tyres and kept on tightening
the screw many times
 Very slow in his work
 ANXIETY
DISORDERS

SITUATIONAL SITUATIONAL
TRIGGER TRIGGER
Present Absent

OCD
PANIC
SOCIAL ANXIETY PTSD GAD
DISORDER

Common theme: COMPULSIONS

OBSESSIONS
contamination,
recurrent & repeated doubts,need ritualistic behaviours
unwanted intrusive for order, horrific carried out in response
ideas, thoughts, thoughts and sexual to an obsession e.g.
imagery. handwashing, checking
impulses or images.
Distress to pt of locks, counting.
 Onset after age 35: prompt a complete
neurologic evaluation
 Co therapist
 Relaxation therapy
 Behaviour modification
thought stopping
response prevention
 Antidepressants
SSRI:
Fluvoxamine (150-
300mg/day)
Fluoxetine (40-60mg/day)
Sertraline (100-200mg/day)
 Benzodiazepine
short term esp
during behaviour
therapy

Tricyclics:
Clomipramine (75-
125mg/day)
 40 year old lady met an accident and sustained
broken pelvis and spent few weeks in the
hospital.
 After D/C, she could not face travelling in a
car again.
 She c/o poor sleep with early morning
awakening.
 She was also troubled with recurrent
nightmares about the crash.
 She was also haunted by sudden visual images
of the accident coming into her mind.
 She has stopped watching TV as most programmes
repeatedly feature cars.
 ANXIETY
DISORDERS

SITUATIONAL SITUATIONAL
TRIGGER TRIGGER
Present Absent

PTSD
PANIC
SOCIAL ANXIETY OCD GAD
DISORDER

exposure to Symptoms of
re-
Avoidance Increasing Sx resolves within 1
highly (avoiding
experiences autonomic month following the
traumatic conversations,
(flashbacks, arousal traumatic event = ACUTE
event as a activities or
nightmares, STRESS DISORDER
victim or people assoc
intrusive
witness with the event
memories) Sx persist >1 month =
PTSD
 Antidepressants:
SSRI
Tricyclics
Continue for a year if the response is good.
 A 29 yr old woman turned up at parent
teacher meeting for her daughter.
 She turned up late and left with a
headache.
 She could not remember what was
discussed.
 She has similar concerns when attending
social functions.
 ANXIETY
DISORDERS

SITUATIONAL SITUATIONAL
TRIGGER TRIGGER
Present Absent

PANIC

SOCIAL DISORDE
PTSD OCD GAD

ANXIETY

Pathologic Fear that they will be

Specific negatively evaluated by
shyness situation: public others eg ‘say something
Fear of speaking / stupid’ or others will
notice that they are
embarrassment or social functions
blushing, sweating or
humiliation in front
shaking.
of others.
 SSRI
Paroxetine
Sertraline

 Benzodiazepine
clonazepam
alprazolam
 Global impairment of intellect without
impaired consciousness.
 Interferes with social & occupational
functioning

Delirium is an acute organic mental condition with

global cognitive impairment and loss of
consciousness. Delirium is often reversible & brief.
 syndrome characterized by multiple
impairments in cognitive functions without
impairment of consciousness.

 cognitive functions affected :

◦ memory
◦ orientation
◦ Attention / concentration
◦ judgment
◦ language and problem solving.
◦ Abstract thinking.
 Age > 65 yrs old (primarily)
◦ 5 % have severe dementia.
◦ 15 % have mild dementia.
◦ 20% > 80 years
 50 - 60 % have Alzheimer's type dementia.
 15 - 30 % vascular dementia.
Reversible dementias Irreversible
 Common causes: dementias
◦ Hypothyroidism  Common causes:
◦ Vit B12 deficiency ◦ Alzheimer's disease
◦ Subdural haematoma ◦ Vascular dementia
◦ Uremia ◦ AIDS
◦ Normal pressure
hydrocephalus
◦ Syphilis
 Cognitive changes, daily functions (ADL),
behaviour, neurologic signs and symptoms.
 Severity of symptoms
 Psychiatric history e.g. mood disorder/psychotic
features
 Medication history
 Social support and safety issues (home, driving,
financial)
Have you noticed:
 Being more forgetful?
 Losing your train of thought?
 Problems trying to find the right word?
 Difficulty following conversations?
 Forgetting to turn things off such as the
lights or stove?
 Keeping track of time?
 Others expressing concern about your
memory?
 COGNITIVE SAMPLE TESTS
DOMAINS
Attention Spell ‘world’ backwards
Serial 7
State months of the year of days
of week backwards
Baseline IQ Vocabulary, educational
achievements
Memory Remote : childhood history
Short term : recall 3 objects, digit
span
Aphasia Comprehension: ability to follow simple
commands
Expressive: pt’s speech, quality of expressions
“No ifs, ands or buts”
Any missed or mispronounced words
Anomia (naming objects) or nominal aphasia

Apraxia Constructional : pentagons or CDT

Ideomotor: brushing teeth, combing hair

Agnosia Prosopagnosia: impaired recognition of familiar

faces
Astereognosis: impaired recognition of familiar
objects via tactile exploration
Finger agnosia: identify finger by touch
(Identify each digit)
Executive Ability to plan and sequence steps of
function drawing a clock (CDT)
Ability to reproduce rhythm with finger
tapped out by examiner

Function 4 IADL
(Instrumental Activities of Daily Living)
Ask caregiver whether pt needs
assistance in these areas:
a) Money management
b) Medication management
c) Telephone use
d) Traveling
Suspect dementia with increased need
of assistance
ADLs
– Bathing
– Finances
– Dressing
– Self-medication
– Grooming
– Transportation
– Toileting
– Shopping
– Ambulation
– Food preparation
– Transfer
– Housekeeping
 Most common dementing disorder.
 Represents >50% of all dementia cases in the
elderly.
 Suggestive of Alzheimer’s disease:
◦ progressive impairment in recall for recent
events
◦ decreased fluency in speech
◦ spatial disorientation in unfamiliar surroundings
◦ patient tends to minimize or rationalize errors
◦ inability to plan
 Suggestive of Vascular dementia
◦ abrupt onset and stepwise course
◦ focal neurologic signs
◦ Imaging evidence of cerebrovascular disease
– Memory impairment
– At least one of:
aphasia
apraxia
agnosia
disturbance in executive functions
– Impairment in occupational or social
functioning
– Decline from previous level of functioning
– Not occurring exclusively during the course
of delirium
 Age (most cases after the age of
65)
Prevalence doubles every 5 years after 60
years of age
(4% at 75, 16% at 85 and 32% at 90)
 Genes
Having a first degree relative with AD e.g.
parent or a sibling, increases the risk of
getting AD by 3½ times.
It increases with the number of affected
relatives.
 Early onset AD
 Most people with the early onset of AD
(before the age of 60) show an autosomal
dominant inheritance and mutations on
chromosomes 1(-secretase),14 (β-
secretase) and 21(assoc with the increased
production of β-amyloid)

 40 % of early onset AD are linked to

chromosome 14.
 Headtrauma with loss of
consciousness and vascular
damage.
Brain injury may trigger the
production of β-amyloid.
Increased of β-amyloid in the
areas of previous trauma.
 Menopause
Loss of estrogen.
Role of estrogen: promotes neural growth,
reduction of APOE4, anti-inflammatory,
antioxidant effects and increased cerebral
blood flow.

 Less intelligence and less formal education

Less synaptic connections.

 Individuals with less physical and mental

activity
 Loss of neurons
 Atrophy of brain tissue
 Widened ventricles
 Collection of neuritic plaques and
neurofibrillary tangles (pathologic collections
of cellular debris)
 Extraneuronal deposition of -amyloid
protein

 Intraneuronal destabilization of tau protein

 Amyloid precursor protein(APP)
(normally found in the cell membranes of neurons
throughout the brain)

Altered metabolism by
Metabolize by
-secretase  and -secretase
(NORMAL)
Protein fragment of 42 amino acids
(-amyloid)
Accumulate into insoluble sheets (-
pleated sheets) in spaces between
neurons
NEURITIC PLAQUE FORMATION
 Amyloid viewed with
fluorescence microscopy
 Normal: cytoskeleton (cell’s main support
structure) and the transport system composed of
microtubules. The structure is stabilized by tau
protein.

 In AD: tau protein becomes

hyperphosphorylated producing paired helical
filaments destabilize microtubules system
aggregate into clumps i.e.
NEUROFIBRILLARY TANGLES
Microscopic view of neurofibrillary tangles. Adapted from Karolinska Institute Library
 In the cerebral cortex there is fragmentation of
neurites (neuronal processes) within gray matter producing the
characteristic "senile plaques." These are degenerative presynaptic
endings.
Alzheimer's disease leads to cerebral atrophy. Shown here is the
external surface of the brain with widened sulci and narrowed gyri,
mostly over the frontal and parietal regions, gross.
 DISEASE TRIGGERS
Genetic mutations
Risk factors

NEURITIC PLAQUE FORMATION

NEUROFIBRILLARY TANGLES

NEUROTOXICITY

INFLAMMATION
Cerebral atrophy

CHOLINERGIC DEFICITS

SYMPTOMS OF AD
Mild Symptoms

Confusion and memory loss

Disorientation

Problems with routine tasks

Moderate Symptoms
 Difficulties with activities in daily living such
as dressing, bathing and shopping

 Anxiety, aggression, agitation and

suspiciousness

 Sleep disturbances

 Wandering, pacing

 Difficulty recognizing familiar people

Severe Symptoms

Loss of speech

Loss of appetite and weight

loss

Loss of bladder and bowel

control
Stage 1 Normal

Stage 2 Very mild

Memory problem reported but
not evident in clinical interview.
Stage 3 Mild impairment in memory,
concentration and
occupational performance
Stage 4 Moderate impairment in
memory, knowledge retrieval
and complete tasks
Stage 5 Mod to severe impairment in recent
and remote memory, frequent
disorientation to time and place,
impairments of ADL
Stage 6 Severe cognitive impairment with
inability to tend to ADL without
assistance
Stage 7 Very severe impairment in
cognition, language and motor
skills
* Complete blood
count
* Thyroid function
 ECG
* Vitamin B12 and
folate  Chest X-ray
* Syphilis serology  CT scan
* BUN and creatinine
* Calcium
* Glucose
* Electrolytes
* Urinalysis
* Liver function tests
 The Clock Drawing Test

 Time: 5.00
 normal
Time: 'no real time'
Impaired possibly dementia
12

1
2
3
 The score is influenced by a number of
factors:
Educational background
Visual and hearing integrity
 Quantifying cognitive failures.

AGE CUT-OFF SCORES

40s 29
50s 28
60s 28
70s 28
80s 26

 For practical purposes, consider score

<26 out of 30 as abnormal.
 Score 1 for correct answer
 Memory
1. I want you to remember this number.Can you
repeat after me (for example, 4517)? (1)
I shall be testing you again in 10 minutes.

2. How old are you? (1)

3. When is your birthday? Or What year were

you born? (1)
 Orientation and information
4. What is the day of the week today? (1)

What is the date today?

5. day (1)
6. month (1)
7. year (1)
8. What is this place called (for example,
clinic or hospital)? (It is not necessary to
give the name of the place) (1)
9. What is his or her job (for example,
pointing to a nurse or doctor)? (1)
Memory recall
10. Can you recall the number again? (1)

Total :

Cut off point for case 5/6

Cut off point for non case 6/7
 Eliminate non-essential drugs
that could interfere with cognition
 Monitor driving ability and safety
in use of household appliances
 Refer to local AD Association for
information and support groups
 General treatment
◦ supportive medical care.
◦ emotional support for patient and family.
◦ Provide an environment that provides frequent cues
for orientation
◦ Supportive therapy & group therapy
 Symptomatic treatment.
◦ nutritious diet, proper exercise, attention to visual
and auditory problems.
 Pharmacological treatment for specific
symptoms.
 Ideally inhibit the formation or the effects
of β-amyloid.
Secretase inhibitors
Under study
Neotrofin?
decrease the β-amyloid levels in cell
cultures but improvement in humans not
statistically significant

 Prevent destabilization of tau protein

 Memantine:
blocks glutamate receptor and NMDA (n-
methyl-D-aspartate) receptor

less neuronal injury

 Inhibitors of AchE
increase the level of Ach
delays the progression of AD
**Tacrine : hepatotoxic

 Donepezil
 Rivastigmine
 Galantamine
SUBSTANCE
MISUSE
TYPES OF SUBSTANCE MISUSE:

At-risk consumption
intake associated with increased risk of harm

Abuse
associated with health and social
consequences, but without dependence

Dependence
psychological dependence & withdrawal
 CONCEPT OF DEPENDENCE:
 Physiological, behavioural and cognitive features
arising from sustained use of alcohol or drugs
 a compulsion to take the substance
 tolerance
the need for increasing doses of the substance
to achieve the same subjective effect
 withdrawal symptoms
 WITHDRAWAL SYMPTOMS:

Physiological reaction to lack of the

substance depended upon

e.g. alcohol withdrawal include tremor,

retching, sweating and muscle cramps.
 ASSESSMENT

 Ask screening questions

E.g. CAGE for alcohol
Have you ever felt you ought to cut down on your
drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt guilty about your drinking?
Have you ever had a drink first thing in the morning (an
Eye-opener)?
 MANAGEMENT:
 Depends on the severity
 Identify at-risk consumption and harmful use
early
 In dependency, facilitate withdrawal
(detoxification).
 Rx complications : septicaemia in IDU
Psychosis secondary to amphetamines
 Rehabilitation
 Prevention
 HARMFUL EFFECTS OF ALCOHOL:
 MEDICAL
liver damage,CVS diseases, GIT- ulcer, pancreatitis, liver / oesophageal
neoplasms, anaemia
 NEUROLOGICAL & NEUROPSYCHIATRIC
Blackouts, Epilepsy, Neuropathy, Delirium tremens, Wernicke’s
syndrome, Cerebellar degeneration, Head injury
 PSYCHIATRIC
Alcoholic hallucinosis, Morbid jealousy, dementia,depression,sexual
dysfunction
 SOCIAL
Accidents, relationship problems, domestic abuse, empployment
difficulties, crime
 CLINICAL FEATURES:
Diagnosis of alcohol dependence

 Feeling compelled to drink

 Primacy of drinking over other activities such as eating,
family life, work and health
 Increased tolerance to alcohol
 Relief drinking
 Stereotyped pattern of drinking
 Unable to give up alcohol for long
 Drinking despite awareness of harmful consequences
 Withdrawal symptoms
 MAIN FEATURES OF ALCOHOL
WITHDRAWAL:
 Tremulousness
 agitation
 nausea and retching
 sweating
 craving
Relieved by ALCOHOL
If untreated, the symptoms may last for
several days
 Withdrawal symptoms often occur on
waking as the blood concentration falls
during sleep

 Delirium tremens
 Wernicke’s syndrome
 Associated medical disorder
 Associated psychiatric disorder
 DELIRIUM TREMENS:
 Onset 24-48 hours after stopping heavy, prolonged
drinking
 delirium
 visual hallucinations
 delusions- persecutory
 transient misidentification of people
 fear & agitation
 coarse tremor
 seizures
 PR BP
 insomnia
 dehydration
 electrolyte disturbance
 Management
 Monitor vital signs
 Rehydrate patient
 Thiamine
 Parentrovite
 Folic acid
 BDZ : diazepam
 Correct any electrolyte imbalance
 Treat any infection
 Antipsychotic : if necessary
 Anticonvulsants if necessary
 WERNICKE’S SYNDROME:

 Delirium
 ataxia
 nystagmus
 Opthalmoplegia (6th nerve palsy)

 due to THIAMINE DEFICIENCY

 may progress to Korsakov’s syndrome
 MANAGEMENT OF ALCOHOL
PROBLEMS:
 Detection and diagnosis
 Assess accurately the amount consumed
 Assess the extent of harm
 Advice(tailor accordingly) for at-risk consumption
 Detoxification- for alcohol dependence
 Maintaining abstinence- Alcoholics Anonymous group
 Rx underlying psychiatric disorder e.g. depression,
anxiety
 Role of NALTREXONE / ACAMPROSATE
 Treat associated medical/neurological disorders
 OPIOIDS/OPIATES:
(Heroin, Morphine,Codeine)

 Very addictive

 Modes of use
intravenous
inhalation (chasing the dragon)
“snorting” -sniff fine powder

Codeine: cough syrup

 CLINICAL FEATURES:

 Main effect:euphoria, analgesia

 Less pleasant features:chronic malaise, anorexia, loss of

libido, impotence,pinpoint pupils and constipation

 Tolerance: rapid

 Because of tolerance, pain management in opioid user is

difficult
 WITHDRAWAL:
 Craving
 restlessness & insomnia
 myalgia
 sweating
 abdominal pain, vomiting and diarrhoea
 dilated pupils, running nose and eyes
 tachycardia
 yawning
 ‘goose bumps’
ONSET:8-12 HRS. AFTER THE LAST DOSE
PEAK: 24-48 HRS. LATER
SUBSIDING OVER 10 DAYS
 MANAGEMENT:

 RAPID DETOXIFICATION AND ABSTINENCE

Inpatient detoxification
use Clonidine or Naltrexone

 HARM REDUCTION AND MAINTENANCE THERAPY

reduce injecting
stabilize drug use and lifestyle
reduce criminal behaviour
reduce death rate
 Substitution therapy
 Methadone (opioid agonist)
 Buprenorphine
 SUBOXONE (buprenorphine and naloxone)
sublingual film. It contains buprenorphine
and naloxone HCl dihydrate. Available in
four dosage strengths, 2 mg buprenorphine
with 0.5 mg naloxone, 4 mg buprenorphine
with 1 mg naloxone, 8 mg buprenorphine
with 2 mg naloxone and 12 mg
buprenorphine with 3 mg naloxone.
 STIMULANTS:
(3,4 METHYLENEDIOXYMETHAMPHETAMINE-
MDMA,ECSTASY)
 Synthetic amphetamine analogue with the alerting
actions of amphetamines and some hallucinogenic
effects
 usually in the club
 Tolerance
 The best experience is said to be the first
 Adverse reactions: hyperpyrexia, acuterenal failure
 Acute psychosis
 Depression and impulsivity: lowered central 5-HT level
 CANNABIS:
(MARIJUANA, GANJA)
 Most widely used
 Cannabis sativa
 Main active ingredient: delta-1-tetrahydrocannabinol
 usually smoked
 Effects:
exaggeration of pre-existing mood
distortion of sense of space and time
reddening of eyes
impairment of motor performance
anxiety and paranoid ideas
delirium(occasionally)
 Does not cause dependence or withdrawal

 some tolerance occur - psychological dependence

 Chronic users-’amotivational state’ :unproven

 risk factor for Schizophrenia

 SOLVENTS:
(GLUE SNIFFING / PETROL)
 Adolescent male

 rapid in onset

 euphoria, disinhibition, blurred vision, ataxia,

hallucination

 medical complications: cardiac dysrhythmias, inhalation

of vomit, coma
 BENZODIAZEPINES:
(ROCHE, UPJOHN)
 Diazepam, Alprazolam
 as part of multiple drug misuse
 as an opioid substitute
 Intoxication:
behavioural disinhibition(hostile/aggressive)
worse when taken together with alcohol
 Withdrawal:
anxiety, dysphoria, intolerance for bright lights and
loud noises, nausea, sweating, muscle twitching,
seizures.
Louis Wain (5 August 1860 – 4 July 1939) was an
English artist best known for his drawings.
Louis Wain started to draw cats to
amuse his wife who had cancer,
then he became popular for his
cats drawings and postcards.

At first, he was drawing cats

doing stuff human beings do,
then his drawings evolved as his
schizophrenia was getting worst.
His cats became more and more
abstract and tortured.

His work is often displayed as an

example of schizophrenic artist.
Louis Wain (5 August 1860 – 4 July 1939)
Louis Wain (5 August 1860 – 4 July 1939) was an
English artist best known for his drawings.
Possible signs of psychological
deterioration

One of many pieces Wain produced at the

Bethlem Royal Hospital. This piece is not
broadly representative of his work there.
 Acute Schizophrenia

Lack of insight
Auditory hallucination
Ideas of reference
Suspiciousness
Flatness of affect
 Chronic syndrome
Under activity
Lack of drive
Social withdrawal
Emotional apathy
Social behaviour – deteriorate
Affect – blunted/ incongruent
Hallucinations – as in acute syndrome
 Aetiology-genetic

Siblings 10%

Children (both parents schizophrenic) 45%

Monozygotic twins 45%

Dizygotic twins 10%

 Biochemical abnormalities
**Dopamine hypothesis
Dopamine overactivity in mesolimbic
pathways D2 and D4
 Serotonin (5-HT)
Serotonin
modulatory effect on dopamine

Serotonin and dopamine neurons project from

brain stem to basal ganglia
 Good prognostic factors
Sudden onset Married (good support)
Short episode Good previous
personality
No past h/o psychiatric
disorder Good work record
Prominent affective Good social
symptoms relationships
Paranoid type Good compliance
Older age of onset
 Antipsychotics
Typical/conventional
positive symptoms
EPS> atypical
Dopamine pathways

Atypical
Positive and negative symptoms
Serotonin and dopamine pathways
 Typical
Parenteral
1. Depot
a. i.m. Fluphenazine decanoate (modecate)
b. i.m. Flupenthixol decanoate (fluanxol)
c. i.m. Zuclopenthixol decanoate (clopixol)

2. Acute (shorter half life)

a. i.m. haloperidol
b. i.m. Zuclopenthixol acetate (clopixol acuphase)
 Typical
Oral
Haloperidol
Chlorpromazine
Trifluoperazine
Perphenazine
Typical antipsychotics usually associated with EPS

Acute dystonia
ANTICHOLI-
Pseudoparkinsonism NERGICS
Neuroleptic malignant syndrome

Tardive dyskinesia
 Anticholinergics
Parenteral
i.m. ophenedrine
i.m. procyclidine
i.m. benztropine

Oral
Artane

Alternative: BDZ
 Atypical
Parenteral
L.A.I Risperidone (risperdal consta)

Oral
Clozapine
METABOLIC SYNDROME
Risperidone Monitor :
Olanzepine •FBS
•Serum lipid
Quetiapine
 Mood Stabilizer
Lithium carbonate
FBC, ECG, Renal profile, TFT, UPT *

Sodium valproate
Carbamazepine
Lamotrigine