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Important things to know

MSE (ASEPTIC) Appearance (any self neglect)


Speech: quantity, rate, volume, quality (enunciation, fluency),
appropriateness, spontaneity bipolar = pressured speech (manic
phase)
Emotions: Affect (what you see), Mood (what patient say)
Perception (?hallucinations, illusions, depersonalization,
derealization)
Thoughts: content (eg delusions), form (structure/process of
thought), stream (production of thought, rate),
Insight (how do they view their condition) and judgment (ability to
make sound/measured/responsible decisions)
Cognition- level of consciousness, memory (working, ST, LT)
Where you will do MMSE to evaluate
MMSE (quantitative estimation of severity of cognitive impairment)
- dementia
1. Orientation (date 5pts place 5pts)
2. Memory (state 3 unrelated objects, ask patient to repeat 3pts,
at end of exam ask patient to recall again 3pts)
3. Concentration (serial 7s/ spell WORLD backwards 5pts)
4. Language
Name 2 objects 2 pts
Repeat sentence NO IFS ANDS OR BUTS 1 pt
Read CLOSE YOUR EYES and do as it says 1pt
Write a sentence 1pt
Copy intersecting pentagon 1pt
Complete a 3 stage command 3pt
Estimate persons sensorium (alert, drowsy, stupor, coma)
TOTAL SCORE 30
<24: probable impairment
<17: definite impairment
Impairment VS Disability VS Handicap
Impairment: Loss or abnormality in psychological functioning
Disability: any restriction or lack of ability to perform ADL
(physical)
Handicap: Disorder due to impairment/ disability that limits or
prevents fulfillment of persons social role normally expected of the
individual given age/sex/cultural expectation

Substance dependence VS Substance


abuse
Substance dependence (WALTER P)
DSM IV
-Pattern of use that results in significant impairment, disability,
handicap over past 12 months and have 3 or more of
1. Repeated withdrawal
2. Abandon important social/occupational/recreational activities
3. Larger amount taken than intended
4. Increased tolerance
5. Excessive time spent obtaining/using/ recovering from
substance
6. Repeated failure to cut down
7. Continued use despite knowing of persistent physical or
psychological illness caused/worsened by it
8. Taking substance to avoid withdrawal
Substance abuse (LOSS)
-Past 12 months, 1 or more of
1. Recurrent substance related legal problem
2. Recurrent use and failure to fulfill role and obligation at
work/school/home
3. Recurrent use under physically hazardous situation
4. Continued use despite recurrent or persistent social or
interpersonal relation caused or increased by substance
*might be useful to just remember CAGES

MOOD DISORDERS
Adjustment disorder VS MDD VS Dysthymia
Adjustment disorder
Occur within 3 months of the stressor onset (biological or
psychosocial)
Symptoms not more than additional 6 months once stressor
terminates
Involve symptoms and levels of disability and handicap+
marked distress more than normally expected
Symptoms must not represent bereavement (depressed
symptoms begin 2/12 of loss of loved one and dont go

beyond 2 months, no marked functional impairment, no


worthlessness or suicidal ideation/psychomotor
retardation/psychotic symptoms, behavior expected due to
death of loved ones)
Can be of depressed mood/anxiety or mixed
MDD (SAD A FACES)
Persistent symptoms 2 or more weeks of
Depressed mood/Anhedonia
+
4 or more of
Sleep disturbance (insomnia/hypersomnia)
Appetite changes ----think of weight gain/loss
Fatigue/loss of energy
Psychomotor agitation or retardation
Concentration poor/indecisive
Esteem low, worthlessness, guilt
Suicidal ideation
*Must exist a change from previous level of functioning
2 main types
1) Melancholic features (more severe): 3 or more of
Marked psychomotor retardation, agitation
Early morning awakening
depression regularly worse in morning
Weight loss significant
Excessively inappropriate guilt
Loss of pleasure in all or most activities
Lack of reactivity to usually pleasurable stimuli
Distinct quality of depressed mood
2) Atypical features
Mood reactivity: improves when positive event happen
2 or more of :
significant weight gain/ increased appetite
hypersomnia
leaden paralysis
long standing pattern of interpersonal rejection
sensitivity causing significant social or occupational
impairment
Postnatal depression
onset in postnatal period up to 6 months , longer than
that= MDD
VS Postpartum blues: transient, self limiting, hours-days,
emotional lability

TX ANTIDEPRESSANTS
SSRI
5HT1A: antidepressant, anxiolytic
5HT2: agitation, akathisia, anxiety, insomnia, sexual dysfunction (SE
of SSRI)
5HT3: GIT SE (nausea, diarrhea), headache
Dont use with TCA, MAOI: serotonin toxicity
TCA
-nonselective reuptake inhibitor of NA/5HT
-NA: mostly used to improve biological symptoms: retardation, loss
of appetite, loss of libido, drive to do things
-5HT: more of the emotional aspect
-not used in <16yo (lower therapeutic range increase chance of
OD)
-main SE: anticholinergic (dry mouth, blurred vision, constipation etc
SNRI
SSRI+SNRI
MAOAI: moclobemide
-competitively reversibly inhibit MAOA, increase level of 5HT and NA
and Dopamine
- Dopamine: pleasure, sex, psychomotor activity
MAOI:
-Inhibit MAOA, B, irreversible
-Avoid tyramine (Cheese, marmite, alcohol)HTN crisis as intestinal
MAO inhibited, causing tyramine absorption (sympathomimetic)
*Remember most take 2 weeks to work
May have initial worsening of symptoms because initially when
presynaptic symptoms exposed to increased 5HT/NA will act to
decrease its release, but eventually the constant exposure will
cause downregulation of these presynaptic receptors
presynaptic 5HT1B, 2A: decrease 5HT release
presynaptic alpha2 receptors: decrease NA release
Mirtazapine: block presynaptic Alpha2 receptors, increase
adrenergic transmission, indirectly increase serotonergic
transmission as remove block of postsynaptic 5HT receptors
TX NON PHARMACOLOGICAL: Psychoeducation, CBT, MDT Support
TX FOR SEVERE: ECT/ TMS, may be good for those with psychotic
features etcccc, not too important to know at all
Dysthymia
Chronic low grade depressive symptoms

2 or more years in adult, 1 or more year in adolescent/child


May not be present every day but cant be without it for 2 or
more months
Persistent anhedonia absent
Symptoms typically worse later in the day
2 or more of: appetite change, sleep disturbance, fatigue, self
esteem low, poor concentration, indecisive, hopeless (dont
have psychomotor retardation, or suicidal tendencies); not as
severe (cf MDD)
Other definitions
Anhedonia: cant experience pleasure from activities usually
enjoyable
Alexithymia: cant sense and describe mood states, disconnection
from feelings
Bipolar disorder
Swings unpredictably from mania to depression
At least 1 maniac episode
Abnormally increased or irritable mood and labile
affect for at least 1 week
3 or more of / 4 or more if only irritable mood present
(MAD FASTS)
decreased need for sleep
inflated self esteem
increased energy
pressured speech, more talkative
flight of ideas: increased thought flow,
excess involvement in pleasurable activity
that potentially may cause adverse effects
(sexual, business, shopping)
distracted poor judgment for negative
consequence
psychomotor agitation, increased goal
directed activity
if >4 episodes of depression/mania/mixed/hypomania per
year= rapid cycling
I: have at least 1 manic episode/ mixed ep (mania+ MDD
symptoms nearly met everyday for 1+ week and occur
simultaneously in quick succession)
II: only hypomania and MDD
Onset usually peak in early adult life, if occur for first time
>40yo: think of drugs effect (PD meds/Corticosteroid) or
Medical illness (Cushings, hyperthyroidism, brain tumor,
Huntington)
Mania severity

Hypomania: dont suffer marked disruption in occupational social


functioning, no psychotic features, symptoms less severe and
shorter, needs to last minimum of 4 days, dont usually need
hospitalisation
VS Mania (psychotic features usually like grandiose delusions,
paranoia)
Cyclothymia: chronic more than 2 years, low grade, alternating
hypomania and depressive symptoms
TX
Lithium
Sodium Valproate
Carbamazepine
Delay onset 1-2 weeks , so treat ST behavioral disturbance with
benzodiazepine
Contradicted with antidepressant

PSYCHOTIC ILLNESSES
Positive symptoms (mesolimbic DA hyperactivity)
Hallucinations, delusions, disorganized
thinking/speech/behavior/formal thought disorder (loss of normal
flow of thinking seen in speech and writing, tangentlity, loose
association, incoherence)
Negative symptoms (mesocortical DA deficit)
Avolition, self neglect, blunted affect, alogia, social withdrawal,
poverty of thought)
Important definitions
Delusions: False idea about reality
Hallucination: False perception about reality
Brief psychotic disorder:
- >1 week, <1month
- Positive symptoms of schizo predominate
- Proceed from a clearly identifiable psychosocial stress
Schizophreniform disorder:
- Acute, rapid onset, no prodromal period
- Features schizo but shorter (resolved in less than 6 months,
but at least 1 month duration)
- Unlikely to suffer decreased social and occupational
functioning

- Negative symptoms less common


Schizoaffective disorder:
- Prominent mood symptoms on top to core schizo symptoms
- schizo symptoms: delusions and hallucinations must be
present for at least 2 week in absence of mood symptoms
- Mood symptoms can be bipolar or depressive type
Delusional disorder
- Non bizarre delusions for at least 1 month
- Auditory or visual hallucination (not prominent)
- Less impairment than schizo
- Occur in 40s
Schizophrenia
- 2 or more symptoms present for significant portion of time in
1 month period(only 1 needed if bizarre (ie impossible)
delusions or hallucinations have running commentary or
voices conversing): delusions, hallucination, disorganized
speech, grossly disorganized/catatonic behavior, negative
symptoms
- Continuous sign of disturbance persist at least 6 months
- Schneiders 1st rank symptoms
- Types: Paranoid, Disorganized, Catatonic, undifferentiated,
residual
- Prodromal period could lasts up to 2 years, mostly have
cognitive changes, mood changes, behavioral changes
TX: Antipsychotics: Block D2 receptors
1st gen: (typical)
High potency: Haloperidol : causes EPSE
Low potency: Chlorpromazine: more sedative, hypotensive,
anticholinergic (dry mouth, blurred vision, constipation, urinary
retention)
2nd gen (atypical): olanzapine, quetiapine
1ST LINE
- tend to also provide 5HT2 receptor blockade, SE: weight gain
- more selective for D2R in the limbic system rather than those
in the frontal/ prefrontal cortex which are responsible for the
negative symptoms and cognitive dysdunction
EPSE
-

(due to D2 blockade in basal ganglia)


Acute dystonia: involuntary slow muscle contraction, h-day
Akathisia: inner restlessness, restless leg, agitation, wks
Parkinsonian: TRAP, drooling, hypersalivation, wks
Tardive dyskinesia: involuntary movement of face/tongue,
months-yrs, irreversible often
- TX: Benztropine, mainly for dystonia, may worsen tardive
dyskinesia

Sedation likely to decrease over 1-2 weeks of TX

Serious Psychosis: Clozapine SE: agranulocytosis, neutropenia,


metabolic symptoms

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