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BICOL CHRISTIAN COLLEGE OF MEDICINE

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PSYCHIATRY • Agoraphobia may coexist as a consequence of the Panic
Disorder
Recognizing Panic Disorder and Treatment Options • The panic attack are not due a direct physiological effects
Gregorio S. Tan, MD DPBP FPPA FPCAM of a substance or a GMC
• The panic attack is not better accounted for a by another
Objective and Purpose of this Lecture mental disorder
• Panic Disorder often creates a confusing clinical picture
to us doctors especially if we do not include it as one of DSM IV Diagnostic Criteria for Panic Attack
our diagnostic options - A discreet period of intense fear or discomfort in which
• It may coexist with a medical condition and thus may four (or more) of the following symptoms developed
complicate the diagnosis management and prognosis of abruptly and reached a peak within ten minutes
the coexisting medical condition 1. Palpitations, pounding heart or accelerated heart rate
• Objective and Purpose of This Lecture 2. Sweating
• Panic Disorder often creates a confusing clinical picture 3. Trembling or shaking
to us doctors especially if we do not include it as one of 4. Sensations of shortness of breath
our diagnostic options 5. Feeling of choking
• It may coexist with a medical condition and thus may 6. Chest pain or discomfort
complicate the diagnosis management and prognosis of 7. Nausea or abdominal distress
the coexisting medical condition 8. Feeling dizzy, unsteady or lightheaded
• Unrecognized panic disorder may lead to both psychiatric 9. Feelings of unreality or being detached from oneself
and medical complications 10. Fear of losing control or going crazy
• However, with proper understanding of this disorder, it is 11. Fear of dying
easy to recognize and treatment options becomes readily 12. Paresthesias (numbness or tingling sensations)
apparent 13. Chills or hot flushes
14. Stress related or tension headache is also common
What Is Panic Disorder? (neuromuscular headache)
• Panic Disorder is a type of Anxiety Disorder
• Anxiety Disorders as a group is characterized by a state Diagnostic issues and challenges
of anxiety whose severity and frequency causes
significant impairment in function and distress to the Panic Disorder vs. A Legitimate Medical Condition
patient • A real medical condition such as a cardiovascular
• The state of anxiety is characterized by a feeling of dread disease or a pulmonary disorder should always be ruled
and accompanied by somatic signs that indicate a out by appropriate physical examination history and
hyperactive autonomic nervous system. diagnostic tests
• It is differentiated from fear which is an appropriate • However the presence of an array of autonomic
response to a known threat, anxiety is a response to a symptoms not consistent with a specific clinical syndrome
threat that is unknown, vague, conflictual or ambivalent and associated with intense fear is highly suggestive of a
• It has an acute onset of episode Panic Disorder most especially so if associated with
Agoraphobia
• It causes the most severe form of emotional distress and
fear of death
Coexisting Panic Disorder and a Medical Condition
• It usually presents as a medical emergency
• The presence of Panic Disorder does not exclude the
possibility of a medical condition, Likewise the
Examples of Anxiety Disorders
confirmation of a medical condition does not exclude the
• Generalized anxiety disorder presence of a Panic Disorder. In fact both these
• Obsessive-compulsive disorder* conditions coexist very often and may worsen each
• Phobias other's symptomatology and even prognosis
• Panic Disorder w/ Agoraphobia • If the autonomic symptoms exceeds that of which is
• Panic Disorder w/o Agoraphobia expected for the coexisting medical condition, there is
• Posttraumatic Stress Disorder* intense fear of dying and there are other panic symptoms
• Acute Stress Disorder* not part of the medical condition then a comorbid panic
disorder and a GMC should be considered
• However, Panic Disorder is unique among the different
types of Anxiety Disorders and of special interest to the The Following Mental Disorders May Confused for Panic
non-psychiatrist for the following reasons: Disorder
• Other forms of Anxiety Disorder
Diagnosis of Panic Disorder Is Based on the Following: • Psychotic Disorders
• Recurrent Unexpected Panic Attacks • Somatoform disorders
• Persistent concern about having additional attacks • Adjustment Disorder with anxiety
• Worry about the implications of the attack or its
consequences The Following Mental Disorder Often Coexist With Panic
• Significant change of behavior related to the attacks Disorder
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• Mood Disorders
• Personality Disorders
• Sleep Disorders
• All forms of anxiety disorder

Treatment options
• Treatment options is best understood by looking at the
Biopsychosocial etiology of Panic Disorder
• As in any mental or medical condition the causes are
often multifactorial or biopsychosocial thus treatment
should also be biopsychosocial

Biologic Causes of Panic Disorder

• Excessive autonomic reaction with increased sympathetic
tone
• Increased release of cathecolamines
• Increased activity of the temporal cerebral cortex
• Neurotransmitter imbalance (decreased GABA and
serotonin, increased dopamine)
• Dysregulated and hyperactive locus ceruleus Pharmacotherapy
Benzodiazepines
Biopsychosocial Causes of Panic D/O Example: Alpraxolam (Xanor)
• Compromise formation gives way to symptom formation ➢ Advantages: Faster onset of clinical response, Ideal for
(failure of defenses mechanisms to ward off anxiety) acute treatment and in controlling severe distress
• Social learning theory ➢ Disadvantages: Psychological and physical dependence
may develop, may be lethal in overdose, no
• Faulty and distorted patterns of cognitive thinking
antidepressant properties
• Underlying Personality Disorder
Tricyclic Antidepressants
• A conditioned response to stress Examples: Dothiepen, Clomipramine
➢ Advantages: Affordable, has both antidepressant and
A VICIOUS CYCLE ACTUALLY OCCURS IN PANIC DISORDER anxiolytic effect
➢ Disadvantages: may cause sedation and has
anticholinergic effects, some cardiac effects
EXTERNAL
PROCESSING Addictive Potential of Benzodiazepines
CAUSES
• Due to the fact that it only relieves the symptoms
• The compound itself has addictive properties
THE • Both physical and psychological dependence can occur
PANIC • May be used as a recreational drug
RESPONSE SSRI
ACTIVATION Examples: Setraline (Zoloft)
SIGNS AND ➢ Advantages: less adverse effects, not lethal in overdose,
SYMPTOMS OF LOCUS also are antidepressants
CERELEUS ➢ Disadvantages: may be anxiogenic in the first two weeks,
may take 4 weeks before anxiolytic properties sets in
expensive

Exception to the anxiogeneic effect may be Escitalopram

SSRI's has a BLACK BOX warning

- Ironically it has an increase suicide risk among
teenagers

Mirtazepine (off label)

➢ Advantages: less adverse effects, not lethal in overdose,
also are antidepressants, no initial anxiogenic effect
➢ Disadvantages: may take 2 weeks before clinical effect
becomes apparent especially for the depressive
component if present, expensive
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Psychotherapy
• Supportive Psychotherapy
• Insight Oriented Psychotherapy
• Cognitive Psychotherapy
• Psychodynamic Psychotherapy
• Group Psychotherapy
• Behavioral Psychotherapy

Address External Sources of Stressors

• Remove or modify stressors if possible
• Always look into the family dynamics

Additionally, The APA Practice Guidelines for Panic Disorder

Recommends the Following:
• Psychoeducation
• Slow Breathing Exercise
• Continuous Panic monitoring
• Correction of catastrophic interpretation of bodily
sensations

A patient with panic disorder who experiences intense fear of

death, hyperactive nervous system, cardiovascular
complications, overall distress, and loss of productivity and
valuable resources…

…may eventually lead a normal functional life where he can be

productive and put his resources such as time, money, skills
and effort to good use.

REFERENCE:
• PPT
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PSYCHIATRY – LECTURE NOTES • Concomitant benzodiazepines as initial therapy in the short
GENERALIZED ANXIETY DISORDERS term may be useful.
Generalized Anxiety Disorder • 8–12 weeks of pharmacotherapy at optimum doses may be
• Generalized anxiety disorder is defined as excessive anxiety and needed to assess efficacy.
worries about several events or activities most of the time for at • Good evidence for the benefit of maintenance treatment at
least 6 months. least up to 6 months.
The worry is difficult to control and is associated with somatic symptoms,
such as:
1. muscle tension PSYCHOTIC DISORDERS
2. irritability Positive Symptoms
3. difficulty sleeping Hallucinations
4. restlessness 1. Auditory hallucinations
• The worry usually involves a broad swath of everyday life, such 2. Voices commenting
as simple daily activities, timeliness, finances, or health. These are 3. Voices conversing
ordinary worries for many people. 4. Somatic or tactile hallucinations
• However, patients with a generalized anxiety disorder worry about 5. Olfactory hallucinations
them to the point where catastrophe seems possible, likely, and 6. Visual hallucinations
imminent. Delusions
• Another feature is that these concerns cannot be prioritized or put 1. Persecutory delusions
aside to deal with more pressing matters that may pop up. 2. Delusions of jealousy
• This inability to prioritize is a key feature that contributes to the 3. Delusions of guilt or sin
pathologic effect that this disorder has on functioning. 4. Grandiose delusions
5. Religious delusions
6. Somatic delusions
7. Delusions of reference
Generalized Anxiety Disorder
8. Delusions of being controlled
DSM 5 ICD 10
9. Delusions of mind reading
Diagnostic Generalized Anxiety Generalized 10. Thought broadcasting
name Disorder Anxiety 11. Thought insertion
Disorder 12. Thought withdrawal
Duration ≤6 mo Bizarre behavior
Symptoms ✓ Excessive Persistent anxiety 1. Clothing and behavior
anxiety/worry Anxiety 2. Social and sexual behavior
✓ Difficulty characterized by: 3. Aggressive behavior
controlling/ • Shaking 4. Repetitive or stereotyped behavior
managing • Muscle tension Positive formal thought disorder
worry • Sweating 1. Derailment
Anxiety characterized • 2. Tangentiality
by: Lightheadedness 3. Incoherence
• Restlessness • Palpitations 4. Illogicality
• Fatigue • GI symptoms 5. Circumstantiality
• Poor concentration 6. Pressure of speech
• Irritability 7. Distractible speech
• Muscle tension 8. Clanging
• Insomnia
Required First two criteria and Negative Symptoms
number 3+ of the specific Affective flattening or blunting
of symptoms symptoms 1. Unchanging facial expressions
Psychosocial Marked distress 2. Decreased spontaneous movement
consequences and/or impairment 3. Paucity of expressive gesture
of symptoms 4. Poor eye contact
Exclusions (not • Another mental Anxiety not 5. Affective nonresponsivity
result of): disorder associated 6. Inappropriate affect
• Substance use with an object, 7. Lack of vocal inflections
• Another medical event, Alogia
condition or situation 1. Poverty of speech
2. Poverty of content of speech
3. Blocking
Pharmacotherapy of Anxiety Disorders: Key Pointers 4. Increased latency of response
• SSRIs are the first-line option. Avolition—apathy
• Start low and go slow. 1. Grooming and hygiene
• Routine increase to higher doses not recommended, but a 2. Impersistence at work or school
subgroup might benefit. 3. Physical anergia
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Anhedonia—asociality Symptom With catatonia, Paranoid
1. Recreational interests and activities Specifiers defined as presence of schizophrenia
2. Sexual interest and activities three or more of the —primarily defined
3. Intimacy and closeness following: by delusions. Less
4. Relationships with friends • ↓ psychomotor activity/ or no disturbance
Attention stupor of affect or volition.
1. Social inattentiveness • Catalepsy (holding a Hebephrenic
2. Inattentiveness during testing posture for an extended schizophrenia
period) —negative affect
Schizophrenia • Waxy flexibility (hold a with inappropriate
DSM 5 ICD 10 position but movable to mood, social
Diagnostic Schizophrenia Schizophrenia a new posture as if isolation and
name made of wax) unpredictable
Duration Symptoms present • Mutism behavior
continuously for • Negativism Catatonic
at least 6 mo • Posturing schizophrenia
Symptoms ✓ Delusions Thought • Odd mannerisms —psychomotor
✓ Hallucinations distortions • Stereotypic behaviors changes, such as
✓ Disorganization Perceptual • Agitation posturing, odd
of speech disorders • Grimacing mannerisms/affect,
✓ Disorganization Negative affect, • Echolalia (imitating stupor vs. agitation
of behavior or often blunted another’s speech) Undifferentiated
catatonia Possible cognitive • Echopraxia (imitating Schizophrenia
✓ Negative dysfunction another’s movements) Residual
symptoms Other possible schizophrenia
symptoms: —chronic illness
• Thought echo and cognitive
• Thought insertion changes resulting
or from a prolonged
withdrawal psychotic illness
• Thought Simple
broadcasting schizophrenia—
• Delusional slow progressive
perception development of
• Delusions of changes in
control, behavior and
influence, or functioning,
passivity affective blunting
• Hallucinatory without preceding
voices psychotic
• Disordered symptoms
/disorganized Other
thinking Schizophrenia
• Negative Schizophrenia
symptoms unspecified
Required ≥2, including at least 1 Defined by the first Course First episode,
number of the first 3 listed three specifiers currently in acute
of symptoms listed, although the episode
other First episode,
symptoms are currently in partial
considered remission:
common currently less symptoms
Psychosocial Functional than needed for
consequences impairment diagnosis
of symptoms First episode,
Exclusions Substances Other neurologic currently in full
(not Other medical diseases remission:
better conditions Schizoaffective 0 symptoms
explained by): Other psychiatric disorder Multiple episodes,
conditions Epilepsy currently in acute
Psychoactive episode:
substances ≥2 episodes
Multiple episodes,
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currently in partial MSE in psychosis
remission - Has lack of insight
Multiple episodes,
currently in full PE
remission - Meningitis (+ Brudzinski, + Kernig sign), encephalitis
Continuous - Saccadic eye movement (jerking of eye back and
Unspecified forth)

NOTES BIOLOGIC CAUSES

Signs and symptoms Problems in the:
1. Hallucinations – perceptual experiences that is not real 1. Temporal
2. Delusions – false beliefs 2. Prefrontal cortex
➢ Bizarre – “aliens” “I am superman” 3. Limbic area
➢ Grandiose 4. Caudate nucleus
➢ Persecutory 5. Neural network (important)
3. Disorganized behavior
Others:
DSM-4 (schizophrenia) - Widening of ventricles (there is volume loss → cortical
➢ Paranoid type atrophy)
➢ Catatonic - Brain asymmetry
➢ Disorganized - Problems with electric impulses (micro seizures;
➢ Undifferentiated temporal seizures; absence seizures)
DSM-5 (schizophrenia spectrum) ➔ Associated with violence (poor impulse control)
➢ Brief – less than 1 month - Neurotransmitters (DOPAMINE, serotonin, norepi,
➢ Schizopreniform – 1 to 6 months GABA)
➢ Schizophrenia – more than 6 months - Genetics
➢ Father has the disease (40%)
Delusional disorders – only delusions (systematized) and very ➢ Monozygotic twin (50%)
realistic. ➢ First degree relative (symptom)

1st symptom of psychosis Seasonal pattern of experiencing schizophrenia

- Person is still under investigation ➔ May be due to viral diseases
- Exposed mother to virus → child may be at risk to
History and physical examination: schizophrenia.
Q: is being poor a risk factor of having psychosis? ➢ Pregnancy at 3rd trimester infection (brain
A: it can be a risk factor, but it can also be the outcome. development is during the third trimester)

- Change in the religion may be a risk factor in EPIDEMIOLOGY

developing psychosis. Male = Female
0.6% to 1.4% (average 1%) has schizophrenia
Risk factors: ✓ in males – peak is during 20s
1. Major changes ✓ in females – peak is during 25 to 30 and 30 to 40
2. Changes in culture
3. Change in religion psychosis at 60s
4. Low socioeconomic status check if its:
5. Alcohol use - stroke
6. Illicit drug use - cerebrovascular disease
7. Major loss

MSE in Schizophrenia Diseases associated with psychosis

- Disorganized speech • Infectious disease (important)
- Flat affect • Hyperthyroidism
• In bipolar → labile (affect)
- (+) delusions Infectious disease
- (+) hallucinations Bacteria
- Salmonella
Paranoid ideations (personality disorder) vs. paranoid - Syphilis
(schizopsychosis) Virus
Paranoid ideations – has false belief but if corrected, it may ➢ Almost all viruses (they love the neural network)
change. - Herpes zoster virus
Paranoid (schizopsychosis) – cannot be corrected. - Herpes simplex virus (1 and 2)
- CMV
- EBV
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- HIV
- Rabies (important) → negri bodies Superego Lacunae (in psychotic patients)
- They cannot control the Id
DRUGS that cause psychosis
1. Coffee 5. Lack of interpersonal skills
2. Meth 6. Too much positive and negative comments
3. Cocaine
TREATMENT AND MANAGEMENT
DOPAMINE TRACT Biologic
VTA (ventral tegmental area) → NA (nucleus accumbens) 1. Treat bacterial and viral disease
- Mesolimbic tract 2. Antipsychotics
- Causes positive symptoms - Typical (effective but has side effect of EPS)
MTA → PFA - Atypical (expensive; less EPS)
- Mesocortical tract EPS
- Causes negative symptoms Nigostrial tract controls fine motor movements → when
Substantia nigra → striatum blocked or inhibited → causes uncontrolled fine motor
- Nigrostriatal tract movements (EPS)
- EPS (controls fine motor movement)
Hypothalamus → infundibulum (pituitary) SE of antipsychotics
- Tuberoinfundibular tract ➢ For women
- hyperprolactinemia - Lactation (increased prolactin)
- Increased breast size
➢ For men
- Gynecomastia

EPS only in TYPICAL AP → tardive dyskinesia

POTENCY VS. EFFICACY

Potency – amount of drug required to make or cause effect
Efficacy – effect of the drug (therapeutic effectiveness)

AE of antipsychotics
• Increases blood sugar → DM (olanzapine,
risperidone)
• Agranulocytosis (clozapine)
• Increased uric acid (Aripiprazole)

Chlorpromazine → hepatotoxic (avoid in patients taking TB

drugs)
- Monitor → before and after taking the medication

ADJUNCT THERAPHY
CARAMAZEPINE
- For seizures

!!! do not give 2 antipsychotic drugs together.

✓ Typical Antipsychotics – NEUROLOGIC SE

✓ Atypical Antipsychotics – METABOLIC SE

Psychosocial
1. Behavioral therapy
2. Cognitive therapy
3. Psychotherapy

!!! do not do psychotherapy during an active episode

AFTER TREATMENT (RISK)

PSYCHOSOCIAL CAUSES ➔ !!! patient may have increased suicide risk
1. Freudian concepts (Id, Ego, Superego)
2. Psychoanalytic (trust vs mistrust)
3. Child upbringing
4. Maller (object permanence)
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MOOD DISORDERS PSYCHOSOCIAL CAUSES
Treatment is individualized 1. Marital status (divorced or single)
2. Increased or decreased socioeconomic status
MSE in mood disorders 3. Learned helplessness
1. Depressed mood 4. Major loss (loved one, separation, material, money,
2. Cognitive deficits (forgetfulness) plans)
3. Alteration in the ability to concentrate Psychodynamic issues – related to the growth and development
4. Disoriented of the patient.
5. *pseudo dementia
6. Functional impairment Mgt: RESOLVE ISSUES
7. History of mania
COGNITIVE DISTORTIONS IN MOOD DISORDERS
MANIA 1. Disorganized thoughts
- Hyperproduction speech 2. Problems in jumping into conclusions
- Talkative 3. All or nothing form of thinking
4. Focus on specific things (Tx: reframing – focusing
DEPRESSIVE MOOD on other good things in his/her life)
- Should be at least 2 weeks
MANAGEMENT
Symptoms (Depression): Psychosocial
- Loss of interest For losses:
- Insomnia / hypersomnia - Oriented psychotherapy (talk about the loss)
- Suicidal thoughts - Behavioral psychotherapy
- Cognitive behavioral therapy
✓ Most anti-depressants are sedating except for Prozac - Mindfulness
(non-sedating anti-depressant)
Biologic
❖ PERVASIVE DEPRESSIVE MOOD (DYSTHYMIA) 1. TCA antidepressants
- (+) Depression (but not severe enough to cause a - Clomipramine
functional impairment) 2. SSRI’s (will take effect after 2 weeks)
❖ DOUBLE DEPRESSION - Inhibits the uptake
- Dysthymia but occasionally has major depressive - Serotonin is neutralized
episode.
❖ PSYCHOTHYMIA Prozac
➢ Non-sedating
BIOLOGIC CAUSE ➢ Half-life: 72 hours
1. Endocrine problems Mirtazapine
2. Hypothalamus – pituitary axis problems ➢ Earlier onset
3. Adrenal problems
4. Hyperactivity of neural networks 3. LITHIUM
5. Decreased metabolic function - GOLD STANDARD for treatment of mood disorders
On PET scan C/I: for pregnant patients?
➢ Left – Depression
➢ Right – Mania Adjunctive therapy:
1. Valproic acid for manic episodes
6. Abnormality in the amygdala and limbic system - liver function test first
7. Genetic (chromosome 18 and 21: genetic cause for - toxic to the liver
depression and mood disorders) - avoid giving to women -> may cause PCOS
8. Anatomy of the brain
9. Imbalance in the neurotransmitters
• Norepi – increased activity
• Dopamine – increased (causes psychotic
symptoms) (specifiers – mild, moderate, severe)
• Acetylcholine
• GABA

EPIDEMIOLOGY
• Female > Male
• Increase in divorced or separated individuals
• Increased in single individuals
• Increased socioeconomic status (mania)
• Decreased socioeconomic status (depression)
 PSYCHIATRY II
PERSONALITY TRAITS AND DEFENSES IN THE MEDICALLY ILL
Gregorio Tan, MD | 24 May 2021
3.01
OBJECTIVES: II. PERSONALITY TRAINTS IN THE MEDICAL
1. UNDERSTAND THE ROLE OF PSYCHIATRY AMONGST SETTING
MEDICAL SURGICAL/PATIENTS
2. APPLY THE BIOPSYCHOSOCIAL APPROACH IN DEALING WITH HISTRIONIC
ALL PATIENTS DESCRIPTION/TRAITS:
3. RECOGNIZE THAHT THERE MAY BE DIFFICULT PATIENTS - Dramatic, vivid, likable, anxious, involved
EVEN AMONG NON-PSYCHIATRIC PATIENTS REACTION TO ILLNESS:
4. BE FAMILIAR WITH THE PSYCHODYNAMICS INVOLVED IN - Were an attack to masculinity or femininity
THE DIFFICULT PATIENT SUGGESTED MANAGEMENT:
5. UTILIZE KNOWLEDGE TO OPTIMIZE THE PROGNOSIS, - Appreciation of attractiveness/courage
IMPROEV QUALITY OF CARE AND OVERALL OUTCOME OF OUR - Ventilation of fears
MEDICAL/SURGICAL PATIENTS. - Supportive but not detained explanations

I. CONSULTATION-LIAISON PSYCHIATRY OBSESSIVE

DESCRIPTION/TRAITS:
CL Psychiatry stand between psychiatry and the rest of - Orderly, dull, likable, anxious, involved
medicine. REACTION TO ILLNESS:
To medicine it interprets what is happening in psychiatry and - As if illness were a punishment for letting things get
behavioral science, and at the same time, to psychiatry it out of control
interprets what is happening to the rest of medicine SUGGESTED MANAGEMENT:
- Detailed “scientific explanations”, and make the
❖ Consultation, with its emphasis on patient partner in the therapeutic process.
• Diagnosis
• Assessment NARCISSISTIC
• Recommendations for management SUGGESTED MANAGEMENT:
• Is the heart of liaison psychiatry - Supporting strength and integrity of the self by
making patient equal independent partner in own
❖ On the other hand, consultation without liaison is care.
• Much more time consuming
• Probably less efficient ORAL
• Because it eliminates the education of DESCRIPTION/TRAITS:
physicians/nurses/staff about the biopsychosocial - Clinging, demanding, attention
factors in illness REACTION TO ILLNESS:
- As if illness posed the threat of abandonment
❖ Consultation-liaison psychiatry proc=vides a SUGGESTED MANAGEMENT:
biopsychosocial approach to patients who are - Warm support but firm limits on undue neediness
treated in hospitals and clinics outside of the and manipulativeness.
psychiatric setting
MASOCHISTIC
❖ Disease can not be explained only by DESCRIPTION/TRAITS:
understanding pathophysiology at the cellular - Long suffering, depressed, help rejecting
and molecular level but by the social, and REACTION TO ILLNESS:
internal psychodynamic factors as well that play - As if illness were deserved, expected punishment of
in the PRECIPITATION, PROLONGATION, and worthlessness
RECOVERY FROM ILLNESS. SUGGESTED MANAGEMENT:
- Appreciation of courage in suffering without undue
FOCUS reassurance or optimism; appeal to altruism
• The health care provider (includes the primary
physician and other doctors, nurses, social worker, SCHIZOID
therapist, etc.) DESCRIPTION/TRAITS:
• The patient - Remote, unsociable, uninvolved
REACTION TO ILLNESS:
• The family and community
- As if illness threatened a dangerous invasion of
• The environment (includes the hospital setting and
privacy
home)
SUGGESTED MANAGEMENT:
- Muted interest in patient but respect need for privacy
PATIENTS IN THE NON-PSYCHIATRIC HOSPITALS MAY
and distance.
BE DIVIDED INTO THE FOLLOWING:
1. Those with physical illness with comorbid psychiatric
PARANOID
illness
DESCRIPTION/TRAITS:
2. Those with behavioral symptoms 2nd to a medical
- Wary, suspicious, aggrieved, querulous, blaming,
condition
hypersensitive
3. Difficult patients
REACTION TO ILLNESS:
4. Normal individuals in very stressful or abnormal
- As if illness were an annihilating assault coming from
situation
everywhere outside of self.
5. Patient with physical disorders for which no cause
SUGGESTED MANAGEMENT:
can be found.
- Honest, simple, full, repeated, explanations;
accusation neither disputed nor confirmed but

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 PSYCHIATRY II
PERSONALITY TRAITS AND DEFENSES IN THE MEDICALLY ILL
explained as coming from illness rather than • Anticipation
someone trying to injure the patient. • Sublimation

III. THEORETICAL HEIRARCHY OF ADAPTIVE EGO Transference and Counter-transference issues

DEFENSES • Patients may hate you for no apparent reason and
vice versa
NARCISSISTIC DEFENSES • Patients may idolize you and vice versa
• Common in healthy individuals before 5 years of age • These are normal phenomena but should be dealt
and in adult dreams and fantasy; such mechanism with in a professional manner
alter reality for the user and appear “crazy” to the • If severe you may refer the patient to another health
beholder, refractory to change by conventional worker.
psychotherapeutic interpretation but are altered y
change in reality (such as antipsychotic meds and Finally,
removal of stressor) - Look at your own personality traits as well
- Sometimes it is the health worker that may have
EXAMPLES OF NARCISSISTIC issues or problems
• Delusional projection - Look at the dynamics of the working group/health
• Psychotic denial team
• Distortion - Address flaws or deficiencies

IMMATURE DEFENSES
• Common in “healthy” individuals between ages 3-16 REFERENCES:
years, in “character” and affective disorders, and in
individuals in psychotherapy, such mechanism 1. PPT
mitigate “dangers” of interpersonal intimacy for the
user but for the beholder they appear socially
undesirable; they may be altered by prolonged
relationship with intuitive, mature individual.

EXAMPLES OF IMMATURE DEFENSES

• Projection
• Schizoid fantasy
• Hypochondriasis
• Passive aggression
• Acting out

NEUROTIC DEFENSES
• Common in “healthy” adults with neurotic disorders
and when mastering acute distress; such mechanism
alters private feelings or instinctual expression
(sexual or aggressive) of the user but to the beholder
appear as quirks or “hang ups”; often they can be
dramatically changed by conventional supportive
therapy and clarification of unconscious wishes or
fears.

EXAMPLES OF IMMATURE DEFENSES

• Intellectualization
• Aggression
• Displacement
• Reaction formation
• Dissociation

MATURE DEFENSES
• Common in healthy adults during optimal function;
they are often regarded as so adaptive and
conscious as to be not defenses but rather “coping
mechanisms”; for the user these mechanisms
integrate conscious reality, interpersonal
relationships, and private feelings; to the beholder
they appear as convenient virtues; under increasing
stress may change to less mature defenses.

EXAMPLES OF IMMATURE DEFENSES

• Altruism
• Humor
• Suppression

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 PSYCHIATRY II
PRACTICAL AND SIMPLIFIED APPROACH FOR PARENTS AND TEACHERS IN DEALING WITH
CHILDREN WITH BEHAVIORAL DISABILITIES
Gregorio Tan, MD | 24 May 2021
3.02
PRACTICAL AND SIMPLIFIED APPROACH FOR PARENTS AND - corporal or a physical punishment is a NO
TEACHERS IN DEALING WITH CHILDREN WITH BEHAVIORAL - instead, temporarily withholding benefits or additional
DISABILITIES constructive homework is preferred
- reprimand is also in order using the guidelines
THERE ARE MORE THAN 25 TYPES OF DISABILITIES
mentioned earlier
- have a high index of suspicion but leave the
- positive affirmation is preferred.
diagnosis up to the experts
- experts use very strict diagnostic criteria to make a
POSITIVE REINFORCEMENT
diagnosis such as ICD 10 and DSMIV TR
- good behavior should always be noticed and
- included in this discussion are children with no
acknowledge more than the bad behavior
disabilities but are difficult to handle
- “I am glad you did not bully anyone today and I am
confident you are not going to bully anyone anymore”
CHILD ABUSE IS ONE OF THE MOST COMMON FORM OF
or better still say: “I noticed you are friendly and nice
COMPLICATION IN CHILDREN WITH BEHAVIORAL
to everyone, that makes you and me happy”.
DISABILITIES
- the abuse can be emotional or physical
REWARD SYSTEM
- active assault or by deprivation
- Star reward
- no one is exempt for being at risk as a perpetuator
- Tokens for a reward system should never be
regardless of the social status or educational
excessive
background
- It should be weaned, to pleasing parents and
- focus is on the parents and teachers or care giver
teachers as the reward itself.
- Final goal is for the child to realize that a good deed
there is a need for parents, teachers and caregivers to be
is a reward in itself.
debriefed, counseled, educated to prevent child abuse
so, attention and treatment should be directed not only
PROVIDE STRUCTURE
the child alone but to the parents or caregiver as well
- Structure allows a child to adjust to the school or
home environment rather than expecting the
ISSUES TO BE RESOLVED BY PARENTS OR TEACHERS
environment or people around to adjust to him
INCLUDE:
- This is utmost importance to both children with
- guilt
disabilities and the normal ones.
- need to blame
- embarrassment or shame
Manipulations are the means that a child will try to
- coping
destroy the structure you have provided.
- absence or availability of resources
- denial
Common ways a child can manipulate a parent or teacher
- own personality factors
- Tantrums, threat, temper
- ignorance
- Appeal for pity, looking sad
- other conflicts
- Making you feel guilty and on the spot “you don’t
really love me”
the less conflict filled the parents or caregiver are, the
- Bargaining
better it is for the child with behavioral disabilities.
- Being nice to get what he wants
“Check yourself first”
ADDITIONALLY
DO NOT COMPARE
- Pool resources
- comparing can lead to frustration and even guilt
- Be honest and straightforward
- even within the same disabilities no two children are
- Don’t discriminate nor should you play favorites
the same
- Communicate with all parties involved
- instead compare the child with himself, his struggle,
- Ask or help in a timely manner
his achievements over time
FINALLY
DO NOT LABEL
- Give a lot of unconditional love
- labeling is very reinforcing and may even create a life
long image for the child
- if you are to label, make it a positive one but even REFERENCES:
this should be done with caution. 1. PPT

DISSECT
- learn to dissect behavior from the person
Example: instead of saying you are a bad person (labeling),
say: “what you did was bad”.
Example: instead of saying I am angry at you, say: “I am
angry at what you did”.

TIMING IS VERY IMPORTANT

- everything should be done in a timely manner

PUNISHMENT

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 PSYCHIATRY II
NSSI: NON-SUICIDAL SELF INJURY
Gregorio Tan, MD | 14 June 2021
3.03
DISTINCT FROM THE SUICIDAL PATIENT Underlying PD, Mood Disorder and Suicidal thoughts still
- Intentional self-inflicted harm without the intention of has to be ruled out
ending one’s life
- Distinct from the suicidal patient • While NSSI is distinct on its own personality disorders
- Overlap may occur such as borderline PD and Obsessive-Compulsive
- Traditionally presumed as suicidal Personality Disorders has to be ruled out
• While in NSSI there is no desire to end one’s life it is
Epidemiology still a risk factor for future suicide as the person may
- Often seen as part of suicidal behavior, personality be “desensitizing”.
disorders and mood disorders
- Emerging condition that may one day warrant a DSM- Treatment
5 diagnosis on its own • Biologic treatments
- Life time prevalence in adults 4-6 percent. - SSRIs, Aripiprazole
- Difference in prevalence rates may be due to different • Psychologic treatments
definition and criteria - Behavioral therapy
- More women than men is consistent finding but - Emotion Regulation Group Therapy
recently been questioned - Cognitive Therapy
- More on the younger age group but rare before • Address underlying factors and comorbid conditions
puberty • Family education
- Self-cutting common in women whole other forms
common in men

• Onset between 12 to 4 years old

REFERENCES:
• Prevalence is 7.5 to 46.6 percent among adolescents 1. PPT
• 38.9 percent among university students
• 4-23 percent among adults

Includes:
1. Cutting
2. Burning
3. Scratching
4. Self-hitting
5. Severe rubbing
6. Combination
Cutting is the most common

• More prevalent now though there were reported cases

and descriptions as early as 1938 termed “partial
suicide”
• Various terms has been used since then,
➢ Syndrome of self-cutting 1969
➢ Deliberate self-harm 1983
➢ Self-wounding 1992
➢ Self-mutilation 2002

Changes in knowledge
- No longer considered as attention seeker
- Not exclusive to personality disorders especially
borderline PD and Mood disorders although
comorbidity is still very high
- Child abuse not an exclusive etiology

Etiology
- Childhood maltreatment
- Sexual abuse (conflicting studies)
- Insecure paternal attachment
- Maternal and paternal neglect
- Maternal rejection
- Childhood separation
- Low emotional expressiveness
- Emotional dysregulation
- Alleviate intense negative emotions
- Increase EE (expressed emotions) in the family
- Need to react or “do something”/ task completion
- Lack of options or venue to express
themselves/escape internal states.

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 PSYCHIATRY II
NSSI: NON-SUICIDAL SELF INJURY
Gregorio Tan, MD | 14 June 2021
3.03
PSYCHOSOCIAL ETIOLOGY
SUICIDE • Durkheim’s theory: egoistic suicide, altruistic suicide
- Intentional self-inflicted death and anomic suicide
- The conscious act of self-induced annihilation, best • Menninger’s theory: the person’s anger/frustration is
understood as multidimensional malaise in a needful directed towards himself
individual who defines as issue for which the act is • Related fantasies
perceived as the best solution • Related hopelessness
- Not a random or pointless act • Group dynamics
EPIDEMIOLOGY BIOLOGIC ETIOLOGY
• 35,000 successful suicides per year in the U.S. or Genetics
100 per day • 8 times higher in 1st degree relatives of psychiatric
• These numbers exclude “chronic suicides” and patients than in normal control
accidents of unknown causes. • Higher concordance rate among monozygotic twins
• 8th overall cause of death in the USA decade ago than dizygotic twins
now 10th but not due to increased prevention. Ut • A longitudinal study in Amish community found 26
because pneumonia and kidney disease has suicides in just 4 families all of whom also exhibited
entered the picture heavy genetic loading for a mood disorder.
• 25 to 1 ration between suicide attempt and Neurochemistry
completed suicide. • Serotonin deficiency measured by a decrease om the
• Men commit suicide 3x more than women metabolism of 5-hydroxyindolacetic acid (5-HIAA) are
• However, women are 4x more likely to attempt found in depressed patients who commit suicide
suicide than men (may be dependent to the • The lower the 5-HIAA in the CSF the more violent the
methods used) method used
• Suicide rates increased by age. Structural
• Ventricular enlargement with abnormal EEG’s
M= completed suicide peaks after 45
F= completed suicide peaks after 55 MANAGEMENT OF THE SUICIDAL PATIENT
• Recognize risk factors from the story (ex. Aside from
• Elderly account for 25% od suicide although they depression and mental illness, in alcohol dependence
make up only 10% of the general population. suicide rate is 50x higher than the non-alcohol
• Suicide rate is rapidly increasing in the young dependent)
• The third leading cause of death in the 15 to 34 years • Assess for other risk factors from current medical and
old after accidents and homicides social circumstances
• 15 to 24 years old have 1 to 2 million attempted • Always do an MSE in high-risk patients
suicides annually. • Always ask about suicide ideation
• 2x greater in whites than colored Remember:
• Lowest in Catholics historically and even today - Eight out of ten persons who eventually kill
• Divorced/Widowed > Single > Married > Married with themselves give warning signs of their intent
children - Fifty percent say openly that they want to die

Of special interest: Physician Suicide HISTORY, SIGNS, AND SYMPTOMS OF SUICIDE RISK
- Physician suicide highest among professionals • Previous attempt or fantasized suicide
- 400 physicians commit suicide each year in the • Anxiety, depression or exhaustion
United States • Availability of means of suicide
- In U.K., the rate for male M.D.’s is 2 to 3 times than • Concern for effect of suicide to family
the general male population • Verbalized suicide ideation
- The rate for unmarried female M.D.’s is 2.5x the
• Preparation of a will, resignation after an agitated
unmarried female in the general population
depression
- No data from the Philippines but anecdotal stories
• Proximal life crisis such impending surgery
are common.
• Family history of suicide
• Pervasive pessimism and hopelessness
• High correlation to physical health in 11 to 50% of all
suicide victims
FACTORS ASSOCIATED WITH SUICIDE RISK
• Postmortem studies shows that a serious physical
illness is present in 25 to 75%
• 50% of men with cancer who commit suicide do so
within a year
• No seasonal correlation
• Mental health have the highest correlation with suicide
• 95% of those who commit or attempt suicide have a
diagnosable mental disorder
• Depressive disorders account for 80%, schizophrenia
for 10%, and 5% from delirium and dementia
• 25% among all mental diagnosis have co morbid
alcohol dependence or abuse

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 PSYCHIATRY II
NSSI: NON-SUICIDAL SELF INJURY
EVALUATION OF SUICIDE RISK behavior, presence or absence of suicide plan of
action.
- Give antipsychotics or antidepressant as indicated
- Treat comorbid conditions (ie. Alcohol dependence)
- Sedate highly agitated or violent patient
- Restrain if necessary
- Inform patient and relatives of long-term medical
effects of the suicidal act.
- Search patient belongings
- Maximize observation y nursing staff
- Support psychotherapy
- Group psychotherapy
- Family therapy
- Don’t hesitate to use ECT when indicated

SCHNEIDMAN’S PRACTICAL PREENTIVE MEASURES

FOR DEALING WITH A SUICIDAL PERSON (FOR NON-
PSYCHIATRIST)
• Reduce the psychological pain by modifying the
patient’s stressful environment, enlisting the aid
of the spouse, employer or friend
• Build realistic support by recognizing that the
patient may have a legitimate complaint
• Offer alternatives to suicide

LEGAL AND ETHICAL CONSIDERATIONS

• What the court require is not that suicide never occur
but that the patient be periodically evaluated for
suicidal risk, that a treatment plan be formulated and
the staff members follow the treatment plan.
• Some states consider suicide and suicide attempt as
a felony and as a misdemeanor respectively.

REFERENCES:
1. PPT

OTHER DANGER SIGNS:

- Patients admits a plan of action
- Patient who has been threatening suicide becomes
quite and less agitated than in the past faulty
judgement and poor impulse control

To hospitalize or treat on an outpatient basis?

When to discharge?
GUIDELINES AND POINTERS
- Not all suicidal patient require hospitalization some
can be managed on a out-patient basis or can be
discharged once medically/surgically stable
- Major considerations are the presence or lack of
strong social support system, severity of impulse

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