psychiatry simplified for medical students (dsm iv-tr)

7/25/2019 Psychiatry Simplified for Medical Students (DSM IV-TR)

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PSYCHIATRY

Ida


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Content

Title Page Number

Psychiatric Evaluation 2iaison Psychiatry !

Personality "isorders #$

Stress "isorders #%

Childhood "isorders #&

Eating "isorders 2'

Substance Abuse 2%

Schi(o)hrenia* "e)ression and +i)olar ,ood "isorder '%

Suicide and "eliberate Sel-.harm $2

An/iety "isorders $!

Pregnancy.related "e)ression $0

Cognitive "isorders !1

Psychotro)ic treatment !0

EPS and N,S %

,alaysian Psychiatry %0

Note: This book follows the diagnostic criteria from DSM-IV-TR

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Psychiatric evaluation

3no4ing the )atient

Predis)osing -actor 4hy did the )atient develo) this disorder5

signi6cant -amily history

)ersonality disorder or traits

traumatic childhood e/)eriences

chronic stress

substance use

Preci)itating -actor

4hy develo) at this )oint in time5

Protective -actor

4hat are the -actors that 4ill hel) him recover5

good social su))ort

good )re.morbid level o- -unctioning

good insight

early intervention

no substance use including alcohol no criminal behaviour

Per)etuating -actor

4hat are the -actors that may )revent him -rom

getting better5

)oor social su))ort

)oor )re.morbid level o- -unctioning )oor insight

late treatment

co.morbid substance use

criminal record

unem)loyment

,ental State E/amination

A))earance and behaviour

Abnormal behaviour

+uilt

Cleanliness* consciousness* coo)eration

"istractibility* dressing

Eye contact

7acial e/)ressions

S)eech

anguage s)o8en Ade9uate

Coherent

Relevant

Com)rehension o- s)eech

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,ood and A:ect

Current mood

abile mood

Congruent a:ect

Thought content

"elusions

;bsessions

Concerns

Suicidal thoughts

"e)ressive thoughts

Phobias

Perce)tion

Hallucinations

Illusions

Cognitive -unctions

orientation to time* )lace and )erson

memory< immediate =immediate recall o- ! ob>ects?*

recent =recall the ! ob>ects a-ter ! minutes* eventsthat ha))ened last 2$ hours?* remote =IC number*

address?

Attention and concentration< serial * @;R"

bac84ards

Abstract reasoning and concrete thin8ing< e/)lain a

)roverb* similarities bet4een table and chair

eneral 8no4ledge< ca)ital city o- ,alaysia*

Inde)endence "ay

Budgment< in a burning house* burglar in the house

Insight< a4areness* attribution and acce)tance o-condition

Physical e/amination

. to rule out medical causes -or the sym)toms

. to chec8 -or side e:ects -rom )sychiatric medications

. to loo8 -or co.morbid medical disorders

,ultia/ial diagnosis

A/is I< Psychiatric disorder

A/is II< "evelo)mental or )ersonality disorder

A/is III< eneral ,edical condition

A/is I< Presence o- ongoing )sychosocial stressors

A/is < lobal Assessment o- 7unctioning

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iaison )sychiatry

Classi6cation o- )sychiatric illness encountered in

liaison setting

. Psychiatry )rovo8ing ill.health

. Psychiatry as conse9uence o- organic disease

. )sychiatric sym)toms as )resenting sym)toms

. cerebral com)lications o- organic disease

. abuse o- alcohol and drugs

. deliberate sel-.harm

. se/ualDrelationshi) )roblems and eating disorders

. )sychiatric disorder e/acerbate )hysical illness

. )hysical sym)toms 4ithout organic basis

. )sychiatric and )hysical illness occurring by chance

iaison case summaries

. reason -or re-erral

. )sychiatric diagnosis

. )hysical disease and )atients reaction to it

. evidence o- abnormal illness behaviour

. relationshi) bet4een the )sychological and )hysical

as)ects o- the case

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. )atients )ersonality co)ing strategies

. )atients attitude to4ards )sychiatric intervention

. sta: attitude to4ards )atient

Psychiatric disorder in )hysical illness

7actors a:ecting )revalence o- )sychiatric disorder in

)hysical illness

Illness

sym)toms

threat to li-e

course =acute* rela)sing* chronic?

duration

disability

cons)icuousness

Treatment

nature

side.e:ects

uncertainty o- outcome

need -or sel-.care

Patient

)sychological vulnerability

social circumstances

other stresses =chronic and acute?

reactions o- others

7actors associated 4ith a )articularly high ris8 o-

)sychiatric )roblems

Severe illness

un)leasant

threatening

acute rela)sing or )rogressive illness

Fn)leasant treatment

ma>or surgery

radiothera)y

chemothera)y

ulnerable )atients

history o- )revious )sychiatric )roblems

current )sychiatric disorder

adverse social circumstances lac8 o- )ersonal and emotional su))ort

Im)lications -or assessment

Characteristics o- Gat.ris8G )atients

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systematic revie4 o- )atients* loo8ing -or )sychiatric

)roblems

)resence o- 8ey sym)toms

in-ormation -rom relatives

im)lications -or treatment

A:ective disorder

. 4orsens )rognosis o- stro8e and ,I

Positive )sychological changes

. enhanced a))reciation o- li-e

. less concern -or trivial or material things

. more tolerance to4ards others

. im)roved sel-.4orth

Sic8 role

. sic8 individual is obliged to see8 the a))ro)riate hel)*

coo)erate 4ith assessment* acce)t a diagnosis and com)ly

4ith the treatment

. legitimate ado)tion o- this role re9uires sanction -rom

relatives* medical )ractitioners* em)loyers and others in

authority

Illness behaviour

. describes the actions o- the )atient and his attitude

to4ards medical )ersonnel

. eg stoical* restrained* histrionic* dramati(ing* hostile*

sus)icious* irtatious* )leading* aloo-* e/cessively

coo)erative and agreeable

Abnormal illness behaviour

. uncom-ortable a4areness o- bodily events much o- the

time together 4ith e/cessive -ears and concerns about

health and disease

. relentless search -or causes and cures cou)led 4ith

inability to acce)t reassurance -rom doctors even 4hen this

has been given clearly )lus a))ro)riate investigation done

. inability to acce)t the suggestion that non.)hysical

-actors may be relevant to ones condition

. disability out o- )ro)ortion to detectable organic disease

. rein-orcement o- illness behaviour by -amily* disability

)ayments and health care )roviders

. ina))ro)riate res)onse to )hysical disorder . either

e/cessive disability or denial o- need o-

treatmentDlimitation o- activities

. ado)tion o- li-estyle around the sic8 role 4ith re)ertoire o-behaviours to sustain sic8 role

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"e)ression

Ris8 -actors -or de)ressive disorders in )hysical illness

. -emale gender

. being unmarried

. living alone

. )revious de)ressive e)isodes

. certain medical treatments

. severe -orms o- )hysical illness

"e)ression in )hysically ill

. co.morbid disorders continue a-ter discharge

. o-ten goes undetected

. de)ressive disorders co.occurring 4ith )hysical illness

com)licate treatment o- both disorders

. )redicts readmission

. )ost)oning treatment o- de)ressive disorder 4orsens

)rognosis o- both

. high healthcare costs

. )oor 9uality o- li-e

Possible mechanism o- co.morbidity

. e:ect on neurotransmitters

. e:ect on immune system

. side e:ects o- medications

. )hysical se9uelae o- suicide attem)ts

. )ossible common genetic )redis)osition

Post.stro8e de)ression

. u) to !1 o- )atients develo) )ost.stro8e de)ression in

acute )ost.stro8e )eriod

Ris8 -actors -or )ost.stro8e de)ression

. le-t anterior brain lesions =es)ecially caudate nucleus?

. dys)hasia

. living alone

. )ast history o- ma>or de)ressive e)isodes

. )revious history o- )yschiatric andDor cerebrovascular

disorder

. -amily history o- mood disorders


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An/iety

. causes increased vulnerability to cardiac events

. )hobic an/iety and generalised an/iety are )redictors o-

,I and cardiac death

Antici)atory an/iety

. )er)etuates the disability

;rganic an/iety syndromes

. cardiovascular system< angina* arrhythmia* congestive

cardiac -ailure

. endocrine system< hy)erthyroidism* )haeochromocytoma*meno)ause

. metabolic disorders< hy)oglycemia* hy)o/ia

. neurologic disorders< sei(ure disorder* a8athisia

. gastrointestinal system< )e)tic ulcer disease

. res)iratory system< asthma* C;P"

. immunologic disorder< ana)hyla/is* SE

,edications that cause an/iety.li8e sym)toms

Stimulant into/ication< ca:eine* nicotine* cocaine*

metam)hetamines* )hencyclidine

Sym)athomimetics< )seudoe)hedrine*

methyl)henidate* am)hetamines* beta agonists

"o)aminergics< amantadine* bromocri)tine*

levodo)a

Anticholinergics< ben(tro)ine* di)henhydramine*

me)eridine

,iscellaneous< e)hedrine* indomethacine*

steroids

"rug 4ithdra4al< alcohol* +"J* o)iates

Cancer

. )sychological im)act o- diagnosis de)ends on the 4ay the

disease )resents

. im)act is greater i- cancer is detected une/)ectedly in an

a))arently healthy )erson

. uncertainty 4hen )atient 6rst comes to clinic may be so

stress-ul that they develo) an/iety 4hile 4aiting -or the

investigation results

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,eaning o- cancer to the )atient. loss o- )hysical strength and 4ell being

. loss o- inde)endence

. loss o- role

. loss o- )ersonal relationshi)s

. loss o- li-e e/)ectancy

. loss o- control . the younger )atient* the greater the

im)act

"evelo)ment o- emotional )roblems

. no )sychiatric disorder< !1

. ad>ustment reaction< '1

. -ormal )sychiatric diagnosis< 21

7actors contributing to )sychological )roblems. concern about )rognosis and 4el-are o- relatives

. )oorly controlled )hysical sym)toms eg )ain* nausea*

breathlessness

. vulnerable )ersonality . )oor co)ing 4ith stress

. direct e:ects o- illness to the brain

. side e:ects o- drugs

. metabolic disturbances such as liver -ailure

. -ear o- being abandoned as the disease )rogresses

. lac8 o- con6ding relationshi)s

. other li-e events or diKculties not related to cancer

Prevention o- emotional )roblems

. o:er in-ormation about illness and its treatment . may be

re)eated later

. allo4 the )atient to e/)ress emotional distress

. )rovide ongoing care

"etection o- emotional )roblems

. sim)le screening 9uestionnaire re)eated at regular

intervals

. as8 )atient -rom time to time ho4 they have been co)ing

4ith the emotional side o- illness and let them discuss theircurrent concerns

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An/iety

. may be mi/ed 4ith de)ression

. around time o- initial diagnosis and 4hile 4aiting -or

results -or sus)ected rela)se

Ris8 -actors -or an/iety

. harbouring underground -ears about illness or its

treatment and too -rightened to share 4ith the sta:

. see8s out more in-ormation than they can handle

. inaccurate in-ormation -rom non.medical )ro-essionals

. )ersonality

E:ect o- an/iety on cancer treatment

. chronically an/ious )atients 4ould consult doctors

-re9uently and become hy)ochondriacal once the diagnosis

is con6rmed

. -alse alarms about s)read o- disease

. very concerned about treatment and its side e:ects

. avoidance o- treatment

. may 8ee) their sym)toms a secret* resulting in a delayed

diagnosis

. inter-ere 4ith treatment and diagnostic test

"enial

. unconscious re-usal to ac8no4ledge certain distressing

as)ects o- reality

. to )rotect themselves -rom an/iety and un)leasantness in

daily li-e

. usually lasts not more than a -e4 days

Sus)ect denial 4hen

. reactions

. loo8s -or another )hysician in the ho)e o- getting aGbetter e/)lanationG

. as8s -or re)eated investigations* )artially 8no4ing that

the original diagnosis is correct

. -ail to reali(e their diagnosisD)rognosis

. -ails to as8 9uestions about the illness

. -orgets the in-ormation given

. ma8ing unrealistic )lans -or the -uture

. understands the matters in intellectual sense 4ithout

a))ro)riate emotional distress

Ada)tive denial

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. denial acts as a bu:er a-ter une/)ected ne4s* allo4ing

)atient to collect himsel- and mobili(e other resources

. denial is a tem)orary de-ense and 4ill be re)laced by

)artial acce)tance

. it enables )atients to ac8no4ledge their cancer andacce)t necessary treatment at one level o- conscious

a4areness

. at another level they )lay do4n the seriousness o- the

illness

. they may tal8 briey about the reality o- their situation

be-ore indicating their inability to loo8 at it realistically any

longer =daydream* -antasies* tal8ing about brighter things

4hich contradict 4hat he said earlier?

,alada)tive denial

. delays cancer diagnosis

. )oor com)liance

. bloc8ed communication 4ith relatives

,anagement o- denial

. Collusion

going along 4ith the )atients vie4

8ind to the )atients but the sta: -eels uncom-ortable

. Con-rontation

challenging the )atient 4ith the truth

sta: -eels better but causes great distress to the

)atient

. ,iddle a))roach

am)le o))ortunity -or )atient to as8 9uestions but

never -orcing un4anted in-ormation u)on them

Anger

. transient anger is a normal )hase in the ad>ustment

)rocess

. some )atients may obtain relie- through the s)ontaneous

-ree e/)ression o- anger be-ore they move on to4ards

acce)tance

. -amily and nurses 6nd it hard to co)e because anger is

dis)laced at all directions and )ro>ected at random

. anger can be more mar8ed in the relatives

. sta: or -amily member should not react )ersonally

because it -eeds into the )atients hostile behaviour

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Ty)es o- anger

. -ree oating< angry about the un-airness o- the illness*

blaming -ate or od

. dis)laced< to4ards healthcare sta:

. >usti6ed< delay in ma8ing diagnosis

. su))ressed< not co.o)erative and leads to de)ression

@hy anger5

. com)aring sel- 4ith others . limited activity

. as8ing -or attention to ma8e sure that he is not -orgotten

. loss o- control

,anagement o- anger

. listen to )atient* donLt be de-ensive and donLt ma8e

>udgments

. o:er consistent )ro-essional care although the )atient is

ungrate-ul

. -acilitate a -ull blo4n e/)ression o- anger by a neutral

counsellor

. res)onding to criticisms o- other doctors and nurses

. colluding 4ith the blame on colleagues is un4ise and

un-air

. encourage redirection o- anger and re.chanelling the

energy else4here eg e/ercise* music* creative activity and

cancer.related charity 4or8

. medication< )sychotro)ics

"e)ression in cancer

. usually associated 4ith a great sense o- loss

. 6nancial burden

. loss o- >ob due to -re9uent absences or inability to

-unction

. drugs< cytoto/ics* steroids

Clinical )resentation

. )hysical sym)toms seem to be out o- )ro)ortion to thestage o- cancer )rogression eg 4eight loss* anore/ia*

-atigue

. insomnia es)ecially morning a4a8ening

. an/iety

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. diKcult to control )ain

. suicidal thoughts

Ty)es o- de)ression

. reactive de)ression

encouragements and reassurances

. )re)aratory grie-

ta8es into account im)ending losses

allo4 )atient to e/)ress their sorro4

E:ect on cancer treatment. )atient may consider themselves too 4orthless to get

hel)

. they do not com)lain

. )oor 9uality o- li-e

,anagement o- de)ression

. let )atient e/)ress their -eelings o- sadness and anger

. -oster a 6ghting s)irit* but i- )atient is very de)ressed* it

can accentuate the sense o- shame and -ailure

. i- de)ression )ersists a-ter sim)le discussion* more

s)ecialised treatment such as )sychothera)y and

antide)ressants 4ill be re9uired

Acce)tance. a stage 4here the )atient is neither de)ressed nor angry

about his -ate

. almost void o- -eelings

. as i- the struggle is over

. )atient )re-ers to be le-t alone

. not in a tal8ative mood

. communications become more non.verbal than verbal

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Personality "isorders

CFSTER A< ;dd

Paranoid

. Sus)icious* sensitive* mistrust-ul* resent-ul* sel-.im)ortant

Schi(oid

. Cold* detached* lac8 en>oyment* intros)ective

Schi(oty)al

. socially an/ious* cognitive and )erce)tual distortions*

oddities o- s)eech* ina))ro)riate a:ective res)onse*

eccentric behaviour

CFSTER +< "ramatic

Antisocial

. ac8 o- concern -or others -eelings* transient

relationshi)s* irres)onsible* im)ulsive and irritable* lac8

guilt and remorse* -ail to learn -rom adverse e/)erience

Social learning in childhood -or antisocial behavior

. through gro4ing u) in an antisocial -amily

. through lac8 o- consistent rules in the -amily

. learnt as a 4ay o- overcoming another )roblem

. -rom )oor ability to sustain attention and other

im)ediments to learning

+orderline

. Identity disturbance* intense unstable relationshi)s*

e:orts to avoid abandonment* recurrent suicidal behavior*transient stress.related )aranoid ideation* im)ulsive*

diKculty controlling anger* unstable a:ect* history o-

conduct disorder be-ore #!

Histrionic

. Sel-.dramati(ation* suggestible* shallo4 and labile a:ect*

see8s attention and e/citement* ina))ro)riately seductive*

over.concerned 4ith )hysical attractiveness* e/cessively

im)ressionistic s)eech* considers relationshi)s moreintimate than they are

Narcissistic

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. randiose sel-.im)ortant* e/)loits others* re9uires

e/cessive admiration* envious and e/)ects to be envied*

lac8s em)athy

CFSTER C< An/ious

Avoidant

. -eels socially in-erior* )reoccu)ied 4ith )ossibility o-

re>ection* avoids involvement 4ith ne4 e/)eriences and

)eo)le* avoid ris8* avoid social activity* restraint in intimate

relationshi) -rom -ear o- being shamed or ridiculed*

inhibited in ne4 )ersonal situations due to -eelings o-

inade9uacy

"e)endent

. Allo4s others to ta8e res)onsibility* unduly com)liant 4ith

4ishes o- others* -eels unable to care -or themselves* -ear

o- being le-t to care -or themselves* diKculty initiating

)ro>ects* goes to e/cessive lengths to obtain su))ort*

urgently see8s a su))ortive relationshi)

;bsessive.com)ulsive

. Preoccu)ied 4ith detailsDrules* inhibited by )er-ectionism*

over.conscientious* e/cessively concerned 4ith

)roductivity* rigid and controlling* miserly* cannot discard

4orthless or 4orn.out ob>ects

;THERS

Passive.aggressive

. Passive resistance 4hen given demands -or ade9uate

)er-ormance

"e)ressive

. Persistently gloomy* strong sense o- duty* little ca)acity

-or en>oyment* unsatis6ed 4ith their li-e

Hy)erthymic

. Habitually cheer-ul and o)timistic* )oor >udgement* >um)s

to conclusion* )eriods o- irritability

Cycloid

. E/tremes o- de)ressive and hy)erthymic )ersonality

disorders

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Stress "isorders

Acute stress reaction

. 7ree(e* 6ght* ight

. Avoidance and denial should recede as an/iety diminishes

to allo4 coming to terms 4ith the stress-ul e/)erience

Acute stress disorder

. onset 4hile or a-ter e/)eriencing the distressing event

. asts M2 days but $ 4ee8s

. co)ing strategy< avoidance o- reminders* use o- alcohol or

drugs

. de-ence mechanisms< denial* dis)lacement* regression

"iagnosis

. stressor

e/)osure to event involving actualDthreatened

deathDserious in>ury to sel- or others e/)erience o- -earDhel)lessnessDhorror or

disorgani(edDagitated behaviour in children

. sym)toms

re.e/)eriencing o- the event

avoidance o- stimuli that arouse recollections o- the

trauma

mar8ed sym)toms o- an/iety or hy)erarousal

signi6cant distress or im)aired social -unctioning

M' o-< sense o- numbingDdetachment* reduced

a4areness o- surroundings* dereali(ation*

de)ersonali(ation* dissociative amnesia

,anagement

. assess by acute stress disorder intervie4* acute stress

disorder scale. Critical incident stress debrie6ng< -acts* thoughts*

-eelings* assessment* education

.reassurance that the condition is -re9uent and short.lived

.short.term an/iolytic =i- an/iety is severe? and hy)notic =i-

severely disru)ted slee)?

.7ollo4.u) 4ithin # month

. )revention< cognitive behavioural intervention 2.4ee8s

)ost.trauma* )re)are individuals at ris8 =eg E,S andmilitary? by training to remain calm and ob>ective* avoid

identi-ying 4ith victims* e/)ress emotional reactions

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PTS"

. traumatic event< e/)erienced* 4itnessed or con-ronted

4ith an event that involved actual or threatened death or

serious in>ury or a threat to the )hysical integrity o- sel- orothers

. etiology< -ear conditioning* hy)othalamic.)ituitary.adrenal

a/is abnormalities* or adrenergic e:ect on amygdala

. )re.dis)osing -actors< 4omen* -amily history o- )sychiatric

disorder* )ersonal history o- mood and an/iety disorder*

)revious history o- trauma* lo4er intelligence* lac8 o- social

su))ort

. signi6cant distress or im)aired social -unctioning -or M#

month

. re.e/)erience by M# o-

ashbac8s

dreams

trauma re.enactment

distress or reactivity to cues resembling an as)ect o-

the event

. avoidance o- reminders by M' o-

thoughts

activities

inability to recall

reduced interest

numbness

restricted a:ect

sense o- -oreshortened -uture

. hy)erarousal by M2 o-

insomnia

irritability

)oor concentration

hy)ervigilance

e/aggerated startle res)onse

. assess by clinician.administered PTS" scale =gold

standard? or )ost.traumatic stress diagnostic scale

. management< counselling* C+T* i- )atient )re-ers or i-

)sychothera)y unavailable then give SSRI or TCA and

continue -or a year i- good res)onse

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Childhood disorders

Attention.de6citDhy)eractivity disorder

. )attern o- diminished sustained attention and higher

levels o- im)ulsivity in a child or adolescent than e/)ected

-or someone o- that age and develo)mental level

. more )revalent in boys

. attention.de6cit disorder< )ersistent -or at least % months

o- M % sym)toms o-

-ailing to give close attention to details or ma8es

careless mista8es in activities*

o-ten has diKculty sustaining attention in tas8s or

)lay activities*

o-ten does not seem to listen 4hen s)o8en to

directly*

o-ten does not -ollo4 through on instructions and

-ails to 6nish chores*

o-ten has diKculty organi(ing tas8s*

o-ten avoidsDdisli8esDreluctant to engage in tas8s

that re9uire sustained mental e:ort*

o-ten loses things necessary -or tas8s*

o-ten easily distracted by e/traneous stimuli* o-ten

-orget-ul in daily activities

. hy)eractivity disorder< )ersistent o- at least % months o-

M % sym)toms o-

o-ten 6dgets 4ith handsD-eet or s9uirms in seat* o-ten leaves seat in situations in 4hich remaining

seated is e/)ected*

o-ten runs about or climbs e/cessively in situations

in 4hich it is ina))ro)riate*

o-ten has diKculty )laying or engaging in leisure

activities 9uietly*

o-ten Gon the goG or acts as i- Gdriven by a motorG*

o-ten tal8s e/cessively

. some sym)toms that caused im)airment 4ere )resent

be-ore years old

. cognitive testing including a continuous )er-ormance tas8

=the child is as8ed to )ress a button each time a )articular

se9uence o- letters or numbers ashes on the screen?

. 6rst.line management< CNS stimulants methyl)henidate

and de/troam)hetamine

. second.line management

nore)ine)hrine u)ta8e inhibitor Atomo/etine*

antide)ressant venla-a/ine*

al)ha.adrenergic rece)tor agonist clonidine

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Autism

. 9ualitative im)airment in social interaction* im)airment in

communication* restricted re)etitive and stereoty)ed

)atterns o- behaviourDinterests

. due to neuroanatomical or biochemical -actors

. onset ' years o- age o- delays or abnormal -unctioning

in M # area =social interaction* language used in social

communication* symbolic or imaginative )lay?

. total o- M % items 4ith

M2 -rom 9ualitative im)airment in social interaction

lac8 o- eye contact* -acial e/)ression and gestures*

no -riends*

lac8 o- social and emotional reci)rocity

M # -rom 9ualitative im)airments in communication

delay or lac8 o- develo)ment o- s)o8en language*

diKcult to initiate and sustain a conversation* stereoty)e and re)etitive use o- language or

idiosyncratic language

M# o- restricted* re)etitive and stereoty)ed )atterns o-

behaviourDinterestDactivities

adherence to s)eci6c routines or rituals*

stereoty)ed and re)etitive motor mannerisms

. more -re9uent in boys

. associated 4ith congenital rubella* )henyl8etonuria*

tuberous sclerosis

. may be due to immunological incom)atibility 4ith mother

=maternal antibodies directed at -etus? or )erinatal

com)lications

. management< target behaviours that 4ill im)rove their

abilities to integrate into schools* develo) meaning-ul )eer

relationshi)s and increase the li8elihood o- maintaininginde)endent living as adults

Retts syndrome

. )rogressive condition o- develo)mental deterioration 4ith

onset a-ter several months o- a))arently normal

develo)ment

. a))arently normal )renatal and )erinatal develo)ment

. a))arently normal )sychomotor develo)ment through the

6rst ! months a-ter birth

. normal head circum-erence at birth

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. onset o- all o- the -ollo4ing a-ter the )eriod o- normal

develo)mentor de)ressive e)isode M# 4ee8

Ra)id cycler< M$ mood s4ings in # year

Treatment -or mania

sodium val)roate*

olan(a)ine*

chlor)roma(ine* halo)eridol*

9uetia)ine*

ari)ira(ole*

ris)eridone*

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ECT

Treatment -or de)ression

SSRI 7luvo/amine

amotrigine*

o-e)ramine =A;I" i- suicidal?*

ECT

,aintenance

lithium*

carbama(e)ine =es) ra)id.cycling?

lamotrigine

High ris8 clinical -actors -or suicide includeor de)ressive disorder but tend toe/)erience more mood uctuation and )rominent an/iety

sym)toms

. "isinterest in the ne4born D -ear-ul o- being le-t alone 4ith

the baby

. Increased ris8 o- suicide* neglect o- the ne4born and

in-anticide

. Treatment includes antide)ressants 7luo/etine =SSRI? or

"othie)in =TCA?* ECT and )sychothera)y

. Ris8 o- recurrence is !1

Post)artum )sychosis

. ;nset usually 4ithin the 6rst month

. usually in )rimi)arous or 4hen there is a history o-

)erinatal com)lications

. Early stages similar to )ost)artum blues* )rogress to

-ran8 )sychosis 4ith sus)iciousness* delusions*

hallucinations 4hich may involve the child

. may have im)ulses to harm the child

. agitated* )oor slee)

. Treatment includes ECT* anti)sychotics 4ith mood

stabili(ers i- bi)olar in )resentation and anti)sychotics 4ith

antide)ressants i- de)ressed

. Advice on non.hormonal contrace)tion

. Ris8 o- recurrence is 1

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Cognitive disorders

"elirium

. Acute global cognitive im)airment in the setting o-

clouded consciousness =)atient is a4a8e but has reduced

a4areness o- environment and is unres)onsive?

. o-ten reversible and brie-

Predis)osing -actors

age M%!*

male*

cognitive im)aired =dementia* de)ression?*

-unction im)airment =-unctional de)endence*

immobility?*

sensory im)airment*

decreased oral inta8e*

substance use*

coe/isting medical conditions

Preci)itating -actors

drugs =narcotics* )oly)harmacy?*

)rimary neurological disease*

intercurrent illness*

surgery*

environmental =)hysical restraint* ICF admission*

multi)le )rocedures?

Patho)hysiology

cholinergic de6ciency*

do)amine =regulates acetylcholine?*

changes in +++

"iagnosis

disturbance o- consciousness 4ith reduced ability to

-ocus* sustainDshi-t attention*

change in cognition or develo)ment o- )erce)tual

disturbance*

develo)ment o- disturbance over a short )eriod o-

time =hours to days? and uctuates

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Ty)es

"elirium due to a general medical condition

=evidence -rom history* PE or laboratory 6ndings? egmeningitis* head in>ury* stro8e* FTI* chest in-ection*

PE* ,I* arrhythmia* he)atic ence)halo)athy*

hy)erDhy)oglycemia in diabetes* e)ile)sy*

malignancy

delirium due to into/ication =sym)toms develo)ed

during substance into/ication* medication use is

etiologically related to the disturbance* cognitive

sym)toms are in e/cess o- into/ication syndrome? eg

insulin* digo/in* lithium* o)iates* ben(odia(e)ines

delirium due to substance 4ithdra4al =sym)toms

develo)ed during or shortly a-ter a 4ithdra4al

syndrome* cognitive sym)toms in e/cess o-

4ithdra4al syndrome?*

delirium due to multi)le etiology*

delirium not other4ise s)eci6ed

Investigations

"elirium Rating Scale evaluates tem)oral onset o-

sym)toms* uctuation* )erce)tual disturbances andhallucinations*

Con-usion Assessment ,ethod tool =re9uires acute

onset and uctuating course 4ith inattention and

either disorgani(ed thin8ing or altered level o-

consciousness?

Abbreviated ,ental Test Score to establish cognitive

de6cits )resent on admission and -or a baseline

score -or assessing )rogress

Non.)harmacological management

avoid e/tremes o- sensory in)ut*

relie- o- distress*

control agitation and )revent e/haustion*

)sychosocial su))ort

Pharmacological management

ensure drug treatment -or underlying )hysical

)roblem is the minimum re9uired

anti)sychotics -or agitated )atients 4ith )erce)tual

disturbances*

treatment o- s)eci6c etiologies

"ementia

. global im)airment o- intellect 4ithout im)aired

consciousness

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. cognitive -unctions a:ected include memory* orientation*

)erce)tion and attention* >udgment* language and )roblem

solving and abstract thin8ing

. score o- 2' out o- '1 in ,,SE is suggestive o- cognitive

im)airment

. inter-eres 4ith social and occu)ational -unctioning

. )atients may have e)isodes o- violence or abuse to4ards

others and sel-.harm in advanced dementia

. )atients are vulnerable to )hysical* mental and 6nancial

abuse by others

Reversible causes o- dementia

Hy)othyroidism

it +#2 de6ciency

Subdural haematoma Fremia

Normal )ressure hydroce)halus

Sy)hilis

Irreversible causes o- dementia

Al(heimers disease

ascular dementia

AI"S

Ouestions to elicit ty)e o- memory diKculties

+eing more -orget-ul5

osing your train o- thought5

Problems trying to 6nd the right 4ord5

"iKculty -ollo4ing conversations5

7orgetting to turn things o: such as the lights or

stove5

3ee)ing trac8 o- time5

;thers e/)ressing concern about your memory5

7unction

$ instrumental activities o- daily living

. As8 caregiver 4hether )t needs assistance in these areasugate ga(e disorder are ty)ical?

. Thiamine de6ciency may be secondary to alcoholism*

vomiting during )regnancy* dietary insuKciency or gastric

carcinoma

. Treatment is 4ith urgent intravenous thiamine* but the

ma>ority 4ill develo) a chronic 3orsa8o: syndrome

Creut(-eldt.Bacob disease

. characteri(ed by a ra)idly )rogressive dementia*

myoclonus and distinctive electroence)halogra)hic and

neuro)athologic 6ndings

. The in-ectious agent causing CB" is uni9ue in being a

con-ormationally abnormal )rion )rotein ie contains no

genetic material

. The dementia can be accom)anied by signs o-

involvement o- any )art o- the central nervous system* but

myoclonus is )articularly common

. Although ty)ically occurring s)oradically in middle.aged

adults* a -amily history may be )resent in &.#1

. variant CB" in young adults has been lin8ed 4ith

e/)osure to bee- in-ected 4ith the bovine s)ongi-orm

ence)halo)athy agent This ne4 variantL -orm o-ten

)resents 4ith an e/tended neuro)sychiatric )rodrome 4ithmood disturbance or other )sychiatric sym)tomatology

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Secondary causes o- dementia

. ,etabolic< thiamine de6ciency* vitamin +#2 de6ciency*

hy)othyroidism* Cushings syndrome* @ilsons disease

. ascular< Cerebrovascular disease* subdural haematoma

. Neo)lastic< )rimary CNS tumours* metastases

. Inammatory< SE

. "rugs and to/ins< Anticholinergics* heavy metal e/)osure

. In-ection< Sy)hilis

Elderly Cognitive Assessment Ouestionnaire

. A score o- or more is indicative o- normal memory and a

score o- $ and belo4 indicate )robable dementia This is

use-ul -or routine screening

,,SE

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. This is the most 4idely used instrument -or assessing

severity o- the dementia Ho4ever it can only assess the

domains o- cognitive de6cit The ma/imum score is '1 The

lo4er the score* the more severely demented the )atient

is

eriatric "e)ression Scale

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. A short #!.item 9uestionnaire is used to assess the

de)ression in dementia The )atient has )ossible

de)ression i- the score is ! or more

Cloc8 dra4ing test

. This is used as a measure o- constructional a)ra/ia and

may also reect -rontal and tem)oro)arietal -unctioning

lobal "eteroration scale

. -or staging o- dementia

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Stage # NormalStage 2 ery mild

,emory )roblem re)orted but not evident in

clinical intervie4Stage ' ,ild im)airment in memory* concentration

and occu)ational )er-ormance

Stage $ ,oderate im)airment in memory* 8no4ledgeretrieval and com)lete tas8s

Stage ! ,od to severe im)airment in recent and

remote memory* -re9uent disorientation to

time and )lace* im)airments o- A"Stage % Severe cognitive im)airment 4ith inability to

tend to A" 4ithout assistanceStage ery severe im)airment in cognition*

language and motor s8ills

,anagement o- dementia

Eliminate non.essential drugs that could inter-ere

4ith cognition

,onitor driving ability and sa-ety in use o- household

a))liances

Re-er to local A" Association -or in-ormation and

su))ort grou)s

eneral treatmento su))ortive medical careo emotional su))ort -or )atient and -amily

o Provide an environment that )rovides -re9uentcues -or orientation

o Su))ortive thera)y U grou) thera)y

Sym)tomatic treatment

o nutritious diet* )ro)er e/ercise* attention to

visual and auditory )roblems

Pharmacological treatment -or s)eci6c sym)toms

Psychotro)ic treatment

Psychoeducation

. )sychothera)eutic intervention

. educate the )atient and their -amilies about the illness*

the cause and course o- the illness and the role o-

medication

. hel)s im)rove )atients insight* com)liance* lo4er rate o-

rela)se and better sym)tom control

. enhances su))ort -rom -amily members

Cognitive +ehavioural Thera)y

. a 4ay o- tal8ing about ho4 you thin8 about yoursel-* the

4orld and other )eo)le and ho4 4hat you do a:ects your

thoughts and -eelings. hel)s to change ho4 you thin8 =Cognitive? and 4hat you

do =+ehaviour?

. -ocuses on the here and no4 )roblems and diKculties

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. Instead o- -ocusing on the causes o- your distress or

sym)toms in the )ast* it loo8s -or 4ays to im)rove your

state o- mind no4

. re9uires commitment and coo)eration -rom the )atient

. )rovides the )atient 4ith s8ills to a))roach -uture

)roblems

. ma8e sense o- over4helming )roblems by brea8ing them

do4n into smaller )artsected to )hysical means o- restraint or seclusion

in )sychiatric hos)itals

The )rivacy and sa-ety o- a )atient shall be observed

at all times during the restraint or seclusion

)rocedures

No )hysical or chemical means o- restraint or

seclusion shall be a))lied to )atients in any)sychiatric nursing home or community mental

health centre* e/ce)t during an emergency and the

)atient shall then be trans-erred to )sychiatric

hos)itals 4ithout delay

I- the )eriod o- )hysical means o- restraint o- a

)atient e/ceeds eight hours* a )sychiatrist shall

revie4 the )atient on the need -or -urther restraint

No seclusion shall be carried out on a )atient -or

more than eight hours consecutively or -or more

than t4elve hours intermittently over a )eriod o-

-orty eight hours* 4ithout an inde)endent revie4 bya )sychiatrist

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Restraint area

There shall be a designated restricted area 4ith a

dedicated observation bay manned by a 9uali6ed*

trained and e/)erienced sta: -or the )ur)ose o-

monitoring o- )atients

The area shall be ade9uately lit and ventilated

Physical restraint

Indications -or )hysical means o- restraint

A restraint is -or the )ur)ose o- the medical

treatment o- the )atient

To )revent the )atient -rom causing in>ury to himsel-

or any other )erson To )revent the )atient -rom )ersistently destroying

)ro)erty

@hen other less restrictive method o- treatment to

calm the )atient has not been success-ul

E9ui)ment )rohibited to be used as )hysical means o-

restraint

Strings* ro)es and raKaW

Handcu:s* shac8les

+ody restraintW

Strait >ac8etW

Chains =-rom 4hatever material?W

@ireW

+andageW

E9ui)ment 4ith tears* )rotruding metal )arts or any

de-ect that may endanger )atient

E9ui)ment that may be used as )hysical means o- restraint

Restraint bedW

Restraint chairW

Padded restraints made o- either calico cloth orcotton * leather * nylon* vinyl * )olyurethane* silicone

or rubber based materialsW and

Any other e9ui)ment a))roved by the "irector

eneral

A))lication o- )hysical means o- restraint

carried out or su)ervised by 9uali6ed* trained and

e/)erienced )ersonnel

a))lied only to the limbs o- a )atient It shall not be necessary to obtain a )ersonLs

consent to the a))lication o- )hysical means o-

restraint

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No )hysical restraint is allo4ed in the )sychiatric

nursing home and community mental health centre*

EVCEPT at the time o- Trans)ortation o- )atients to a

)sychiatric hos)ital

I- the )atient is acutely disturbed* a member o- the

nursing sta: shall visit at intervals o- not more than

6-teen minutes A medical oKcer or registered medical )ractitioner

shall e/amine the acutely disturbed )atient at

intervals o- not more than -our hours

Removal o- )hysical means o- restraint

"ecision to remove the restraints shall be made by

the )sychiatric nurse on.duty

The medical oKcer or registered medical )ractitioner

must be in-ormed o- the termination o-

restraints

Chemical restraint

A))lication o- chemical means o- restraint

Consent -or chemical means o- restraint consent

shall be obtained -rom a voluntary )atient )rior to

chemical means o- restraint

I- the )atient is acutely disturbed* a member o- the

nursing sta: shall visit at #! minutes interval

A medical oKcer or registered medical

)ractitioner shall e/amine the acutelydisturbed )atient at intervals o- not more than $

hours

Seclusion

Indications -or seclusion

A )atient in a )sychiatric hos)ital may be 8e)t in

seclusion only i- it is necessary -or the )rotection*

sa-ety or 4ell.being o- the )atient or other )ersons

4ith 4hom the )atient 4ould other4ise be in

contact

;ther less restrictive method o- treatment to calmthe )atient has not been success-ul

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A))lication o- seclusion

It is not necessary to obtain a )ersonLs

consent -or his seclusion to him or her

A member o- the nursing sta: shall visit an acutely

disturbed )atient at intervals o- not more than

6-teen minutes

A medical oKcer or registered medical

)ractitioner shall visit the )atient under

seclusion at intervals o- not more than -our hours$

The )atient may re9uest to communicate 4ith others

4hile under the seclusion

psychiatry simplified for medical students (dsm iv-tr)

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