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1. Predisposing factors
a. Genetic (family history)
b. Social
c. Substance abuse (Cannabis)
d. Environment
e. History of childhood central nervous system infection
f. History of obstetric complication
2. Schneiders First rank Symptoms
a. Thought Insertion
b. Thought withdrawal
c. Thought broadcast
d. Delusional perception
e. Delusion of control
f. Auditory hallucination
g. Somatic passivity
3. DSM IV Criteria
a. Two or more must be present for at least 1 month
i. Delusions
ii. Hallucinations
iii. Disorganized speech
iv. Disorganized behaviour
v. Negative symptoms
b. Social / occupational dysfunction
c. At least 6 months (including prodromal or residual periods when above
criteria is not met)
d. Symptoms not due to medical, neurological or substance induced disorder
4. Negative symptoms
a. Affect (flat)
b. Alogia
c. Anhedonia
d. Attention (poor)
e. Avolition
5. Differential diagnosis
a. Schizophreniform disorder
b. Schizoaffective disorder
c. Brief psychotic disorder
6. Management
a. Hospitalization
i. Risk of harm to self or others
ii. Deterioration in psychosocial functioning
iii. Serious / life threatening drug reactions
b. Antipsychotics
i. Dopamine receptor antagonists (Typical psychotics)
ii. Serotonin-dopamine antagonists (Atypical antipsychotics)
c. Electroconvulsive therapy
i. Catatonic schizophrenia
ii. Cannot tolerate side effect of drugs / not responding to drugs
iii. Has previous improvement with ECT
d. Psychosocial intervention
i. Supportive psychotherapy
ii. Psychoeducation
iii. Social skills training
e.
f.
g.
h.
2. DSM IV Criteria
a. 5 or more symptoms present during the same 2 weeks;
i. Low mood throughout the day
ii. Anhedonia
iii. Loss of appetite with significant weight loss
iv. Insomnia or hypersomnia
v. Psychomotor agitation or retardation
vi. Fatigueness
vii. Feeling worthlessness or inappropriate guilt
viii. Diminished attention and concentration
ix. Recurrent thoughts of death and suicide
b. Symptoms do not meet criteria for mixed episode
c. Symptoms must cause clinically significant distress or impairment in
social, occupational or other important areas of functioning
d. Symptoms cannot be due to substance abuse or medical conditions
e. Symptoms are not accounted for by bereavement
3. Suicide risk assessment
a. Current history
i. Seriousness of attempt
1. Suicidal attempt
2. Suicidal note
3. Doing it alone
ii. Regrets about attempt
iii. Current intent or wish to die
b. Preventers
i. Any loved ones
ii. Support from family or other people
iii. Future prospect or plan
c. Past history
i. Previous self-harm
ii. Previous or current mental illness
iii. Any drugs or alcohol intake
d. Candidates opinion of current risk
e. Candidates immediate plan
f. How candidate react and handle patients reaction during interview
4. Management
a. Hospitalization
i. Risk of suicide or homicide
ii. Unable to care for self
iii. Rapidly progressing symptoms
iv. Diagnostic procedures
b. Antidepressants
i. SSRI
ii. TCA
iii. MAOI
c. Antipsychotics
i. If patient displayed psychotic features
d. Electroconvulsive therapy
i. Unresponsive to pharmacotherapy
ii. Cannot tolerate with drugs adverse effects
iii. Desire rapid reduction of symptoms (in suicidal patients)
e. Psychotherapy
i. Cognitive therapy
ii. Interpersonal therapy
iii. Supportive therapy
iv. Family therapy
5. Differential diagnosis
a. Adjustment disorder with depressed mood
b. Hypothyroidism
BIPOLAR DISORDER
Bipolar Type 1
1. DSM IV Criteria for Manic Episode
a. Distinct period of abnormally and persistently elevated, expansive or
irritable mood lasting at least 1 week
b. During the period, three (or more) of the following symptoms have
persisted (four if the mood is only irritable);
i. Inflated self-esteem or grandiosity
ii. Decreased need for sleep
iii. Pressure of speech
iv. Flight of ideas
v. Distractibility
vi. Increase in goal directed activity
vii. Excessive involvement in pleasurable activities that have a high
potential for painful consequences (shopping sprees, etc)
c. Symptoms do not meet criteria for a mixed episode
Bipolar Type 2
1. DSM V Criteria for hypomanic episode
a. A distinct period of abnormally and persistently elevated, expansive, or
irritable mood and abnormally and persistently increased activity or
energy, lasting at least 4 consecutive days and present most of the day,
nearly every day.
b. During the period of mood disturbance and increased energy and activity,
three (or more) of the following symptoms have persisted (four if the
mood is only irritable), represent a noticeable change from usual
behaviour, and have been present to a significant degree:
i. Inflated self-esteem or grandiosity.
ii. Decreased need for sleep (e.g., feels rested after only 3 hours of
sleep).
iii. More talkative than usual or pressure to keep talking.
iv. Flight of ideas or subjective experience that thoughts are racing.
v. Distractibility (i.e., attention too easily drawn to unimportant or
irrelevant external stimuli), as reported or observed.
c. Increase in goal-directed activity (either socially, at work or school, or
sexually) or psychomotor agitation.
3. Management
a. Hospitalization
i. Risk of bringing harm to self or others
ii. Marked psychotic symptoms
iii. Delirium
iv. Total inability to function
v. Medical conditions that warrant medication monitoring (eg,
substance withdrawal / intoxication)
b. Pharmacotherapy
i. Mood stabilizers
1. Lithium
2. Carbamazepine
3. Valproate
4. Lamotrigine
ii. Anti-psychotics
c. Psychotherapy
i. Cognitive behavioural therapy
ii. Interpersonal and social rhythm therapy
iii. Behavioural family therapy
ANXIETY DISORDER
Panic Attack
1. DSM IV Criteria for panic attack
a. A discrete period of intense fear or discomfort, in which 4 (or more) of the
following symptoms developed abruptly and reached a peak within 10
minutes:
i. Palpitations
ii. Sweating
iii. Trembling or shaking
iv. Sensations of shortness of breath
v. Feeling of choking
vi. Chest pain or discomfort
vii. Nausea or abdominal distress
viii. Feeling dizzy, unsteady, lightheaded or faint
ix. Derealization (feeling of unreality)
x. Fear of losing control or going crazy
xi. Fear of dying
xii. Parasthesias
xiii. Chills or hot flushes
2. DSM IV Criteria for panic disorder without agoraphobia
a. Both (1) and (2)
5. Treatment
a. Pharmacotherapy
i. Selective serotonin reuptake inhibitors
ii. Benzodiazepines
b. Psychotherapy
i. Applied relaxation
ii. Cognitive therapy
iii. Respiratory training
iv. Insight-oriented psychotherapy
Generalized Anxiety Disorder
1. DSM IV criteria for GAD
a. Excessive anxiety and worry occuring more days than not for at least 6
months, about a number of events or activities.
b. The person finds it difficult to control the worry.
c. The anxiety and worry are associated with 3 (or more) of the following 6
symptoms:
i. Restlessness or feeling keyed up or on edge
ii. Being easily fatigued
iii. Difficulty concentrating or mid going blank
iv. Irritability
v. Muscle tension
vi. Sleep disturbance
d. The focus of anxiety and worry is not confined to features of Axis 1
disorder.
h. The anxiety, worry or physical sufficiently severe to cause marked
impairment in occupational and social functioning
i. Symptoms are not due to direct physiological effects of a substance or a
general medical condition
2. Treatment
a. Pharmacotherapy
i. Antidepressant
1. SSRI
2. Buspirone
ii. Benzodiazepines
Obsessive Compulsive Disorder
1. DSM IV criteria for OCD (Obsessions a to d, Compulsions e to f)
a. Recurrent and persistent thoughts, impulses, or images that are intrusive
and inappropriate, causing marked anxiety or distress.
b. The thoughts, impulses, or images are not simply excessive worries about
real-life problems.
c. The person attempts to ignore or suppress them with some other thought
or action.
d. The person recognizes that those are product of his or her own mind.
e. Repetitive behaviors or mental acts that the person feels driven to perform
in response to an obsession, or according to rules that must be applied
rigidly.
f. The behaviors or mental acts are aimed at preventing or reducing distress
or preventing some dreaded event or situation; however, these behaviors
or mental acts are not connected in a realistic way with what they are
designed to neutralize or prevent or are clearly excessive.
2. Treatment
a. Pharmacotherapy
i. SSRI
ii. TCA
b. Psychotherapy
i. Behaviour therapy
Acute Stress Disorder
1. DSM IV Criteria
a. Exposure to actual or threatened death, srious injury or sexual violation in
one or more of following ways:
i. Direct exposure to the event
ii. Witnessing, in person.
iii. Indirectly, close relative or close friend was exposed to trauma.
iv. Repeated or extreme exposure to aversive details of the event(s).
b. Presence of 9 or more of following symptoms from any 5 categories of
intrusion, negative mood, dissociation, avoidance and arousal
i. Intrusion
1. Recurrent, involuntary & intrusive distressing memories
2. Traumatic nightmares, traumatic distressing dreams
3. Dissociative reactions (eg: flashback)
4. Intense or prolonged distress after exposure to internal or
external cues that symbolize or resemble the traumatic
event.
5. Marked physiologic reactivity after exposure to traumarelated stimuli.
ii. Negative mood
1. Persistent inability to experience positive emotion
iii. Dissociative symptoms
1. Altered sense of reality of ones surrounding
2. Inability to remember an important aspect of traumatic event
iv. Avoidance symptom
1. Effort to avoid distressing memories, thoughts or feelings
2. Effort to avoid external reminders
v. Arousal symptoms
1. Sleep disturbance
2. Irritable behavior and angry outburst
3. Hypervigilance
4. Problem with concentration
5. Exaggerated startle response
c. Duration of disturbance is 3 days to 1 month after trauma exposure
d. Clinically significant distress or impairment in important areas of
functioning as a result of the event
e. Disturbance cannot be attributed to a substance or another medical
condition and cannot be better explained as brief psychotic disorder
2. Treatment
a. Pharmacological
i. Antidepressants
ii. Anticonvulsants
b. Psychotherapy
i. Cognitive behavioral therapy
ii. Family therapy
iii. Group therapy
1. Carbamazepine, valproate
b. Psychotherapy
i. Supportive psychotherapy
ii. Insight oriented psychotherapy
iii. Behaviour therapy
iv. Cognitive therapy
v. Group therapy
ANTIPSYCHOTICS
Typical
1. Examples
a. Haloperidol
b. Fluphenazine (IM)
c. Flupenthixol (IM)
d. Zuclopenthixol (IM)
2. Indications
a. Psychotic symptoms
3. Adverse effects
a. Extrapyrimidal side effects
i. Parkinsonism
ii. Akathisia
iii. Dystonia
b. Hyperprolactinemia
c. Anti-HAM effect
i. Anti-histaminic = causes sedation
ii. Anti-adrenergic = orthostatic hypotension, cardiac abnormalities,
sexual dysfunction
iii. Anti-muscarinic = tachycardia, dry mouth, urinary retention,
constipation, blurry vision
d. Weight gain
e. Neuroleptic malignant syndrome
f. Tardive dyskinesia
Atypical
1. Examples
a. Clozapine, Risperidone, Quetiapine, Olanzapine
2. Indications
a. Psychosis in schizophrenia and schizoaffective disorders
b. Acute treatment of manic or mixed episodes in bipolar disorder
c. Psychoses of all types; secondary to head trauma, dementia or drug
induced psychosis
3. Adverse effects
a. Agranulocytosis in Clozapine
b. Prolactinemia in Risperidone
c. Weight gain in Olanzapine
d. Postural hypotension in Quetiapine
MOOD STABILIZERS
Lithium
1. Brand name = LLiconate
2. Indication
a. Bipolar disorder
b. Explosive outburst in mental retardation & conduct disorder
3. Adverse effects
a. Nausea
b. Vomiting
c. Headache
d. Hypothyroid
e. Weight gain
Carbamazepine
1. Brand name = Tegretol
2. Indications
a. Bipolar disorder (effective in those do not respond to lithium)
b. Explosive outburst in mental retardation & conduct disorder
3. Adverse effects
a. Nausea
b. Drowsiness
c. Vertigo
Valproate
1. Brand name = Epilim / Epilim Chrono
2. Indications
a. Bipolar disorder
b. Explosive outburst in mental retardation & conduct disorder
3. Adverse effects
a. Nausea
b.
c.
d.
e.
Vomiting
Sedations
Weight gain
Hair loss
Lamotrigine
1. Brand name = Lamictal
2. Indications
a. Bipolar disorder
b. Anticonvulsant
3. Adverse effects
a. Skin rash
b. Stevens Johnson syndrome
c. Toxic epidermal necrolysis
ANTIDEPRESSANTS
Selective Serotonin Reuptake Inhibitor
1. Examples
a. Citalopram
b. Fluoxetine
c. Sertraline
d. Paroxetine
2. Indications
a. Depression
b. OCD
c. Panic disorder
d. GAD
e. PTSD
f. Social anxiety disorder
3. Adverse effects
a. Headache
b. Nausea
c. Vomiting
d. Weight gain
e. Insomnia
f. Loss of libido
g. Anorgasmia
4. Serotonin syndrome
a. Symptoms = restlessness, excessive sweating, insomnia, hyperthermia
symptoms
b. Causes
i. SSRI overdose
ii. SSRI + MAOI
iii. MAOI + synthetic narcotics
Tricyclic Antidepressants
1. Examples
a. Amitriptylline
b. Clomipramine
2. Indications
a. MDD
b. Panic disorder with agoraphobia
c. GAD
d. OCD
e. Neuropathic pain
f. Childhood enuresis
3. Adverse effects
a. Muscarinic receptor blockage
i. Dry mouth, tachycardia, blurred vision, constipation, urinary
retention, sexual dysfunction
b. Adrenoreceptor blockade
i. Drowsiness, postural hypertension, sexual dysfunction
c. H1 receptor blockade
i. Drowsiness, weight gain
d. Membrane stabilizing properties
i. Rash, oedema, leukopenia, elevated liver enzymes
Monoamine oxidase inhibitors
1. Examples
a. Irreversible non-selective inhibitors
i. Tranylcypromine, Phenelzine
b. Reversible inhibitors of MAO-A (RIMA)
i. Moclobemide
c. Reversible inhibitors of MAO-B
i. Selegiline
2. Indications
a. Depression
b. Bipolar depression
c. Panic disorder & social phobia
d. Bulimia nervosa
e. PTSD
f. ADHD
3. Adverse effects
a. Serotonin syndrome
i. Initial = lethargy, restlessness, tremor
ii. Later = hyperthermia, renal failure, convulsion, coma, death
b. Hypertensive crisis
i. When MAOI taken with tyramine rich foods (red wine, cheese,
chicken liver, fava bean)
ii. Chest pain, headache, mydriasis
c. Others
i. Orthostatic hypotension, blurred vision
Atypical antidepressants
1. Bupropion
2. Mitazapine
3. Nefazodone