Psychiatry Cases

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Contents
1. History taking in psychiatry 02

2. Mental state examination 04

3. The patient with psychotic symptoms – Schizophrenia 06

4. The patient with low mood – Depression 17

5. The patient with elevated mood – Bipolar affective disorder 26

6. The patient with anxiety – GAD, agoraphobia, social phobia and panic attacks 33

7. The patient with obsessions and compulsions – OCD 37

8. The patient with a reaction to stress – Acute stress reaction, 40

adjustment disorder, PTSD

9. The patient with unexplained weakness – Dissociative disorder 42

10. The patient with decline of cognitive function – Dementia 44

11. Substance abuse – Alcohol, illicit drugs 50

12. Deliberate self harm 61

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History taking in psychiatry

 Introduction to the patient

o Name
o Age
o Marital state and number of children
o Occupation
o Mode of referral

 Presenting complaint

 History of presenting complaint

o Onset
o Duration
o Progression
o Relevant associated symptoms to establish diagnosis or exclude D/D
o Exacerbating/ relieving factors
o Severity
o Distress due to symptoms
o Impact on day to day life
o Etiology of disease
o The Predisposing, Precipitating and Perpetuating characteristics of the disease.

 Family history
o Family history of psychiatric illness, DSH, suicide
o Details of the family members
o Significant events in the family
o Relationship of patient with family members-if relevant

 Past psychiatric history – details of previous psychiatric illness and treatment given

 Past medical history – specially neurological and endocrine disease and other systemic disease
which could be relevant to drug therapy

 Personal history
o Birth and anti natal history-if relevant
o Early development- significant events, illness
o Educational history
o Occupational history
o Relationships, sexual, marital history
o Children

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 o Social circumstance – living conditions
o Forensic history
o Gyn. History, menstrual history

 Drug history

 Alcohol and drug use

 Pre morbid personality

o Attitudes
o Relationships
o Leisure activities
o Habits
o Religious and moral values
o Coping skills

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Mental state examination
The mental state examination should be done as early as possible. Try to do this after the history of
presenting complaint. Most of the information required should be gathered in the history itself. The
mental state examination can reflect the patient’s condition within the last 24 hours.

 Appearance and behavior

o General – Ill/well looking
Build
Hair
Clothes
Signs of self neglect
Self harm
o Facial expression
o Posture
o Movements – involuntary/ other
o Behavior
Appropriateness of behavior
Activity
Anxiety
Aggression
Distractibility
Eye contact
Rapport
o Violence

 Speech
o Rate
o Spontaneous/ not
o Amount
o Volume
o Coherence
o Difficulty in speaking which could reflect a neurological problem- dysphasia,
dysarthria
o Continuity/flow of speech
o Neologisms – New words invented by the patient

 Mood
o Describe prevailing mood - Subjective and objective assessment
o Fluctuation of mood – labile, blunted/ flattened
o Appropriateness of mood
o Suicidal ideas, homicidal ideas

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 Thinking
o Abnormalities of the content of thought
Preoccupations – thoughts that recur frequently but can be controlled

Obsessional and compulsive thoughts

Delusions – belief held firmly on inadequate grounds not affected by rational

argument or evidence to the contrary which a person could not be expected to hold,
based on his or her cultural background.

o Abnormality in amount and speed of thought

Pressure of thought – unusually rapid, abundant and varied

Poverty of thought

Thought block

o Form of thought ( how ideas are linked together)

Flight of ideas

Loosening of associations

Perseveration – persistent and inappropriate rep. of the same sequence of thought.

 Perception
o Illusions – misperception of an external stimulus
o Hallucination – perception experienced on the absence of an external stimulus to a
corresponding sense organ

 Cognitive function
o Orientation (time, place, person)
o Attention and concentration ( SERIAL 7S TEST, days of the week forwards and
backwards)
o Short term memory
o Memory for recent events
o Remote memory
o Intelligence

 Insight
o Awareness that others think these symptoms are abnormal
o These symptoms are not caused by others
o Acceptance that it is due to a physical/ mental illness
o Awareness that treatment is needed

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The patient with psychotic symptoms – Schizophrenia

A 20 year old woman is brought by her family members as she is increasingly getting isolated and is
locking herself up in her room. She admits that she also hears voices telling discussing her actions and
also telling her that she is a very bad person. She does not eat any food prepared at home as she
believes that her family members are poisoning her food.

History

Introduction

Keep in mind the age of onset of schizophrenia for males is about 23 years and that for females is about
26 years.

Presenting complaint

History of the presenting complaint- Should have 4 important points

1. Describe the presenting complaint in detail and go on to describe the key features of psychotic
illness. For these key symptoms encountered in the history describe the,

 Onset
 Duration
Outline of the history  Progression
 Chronological order of development of symptoms
 Describe the  Impact on day to day life
presenting complaint
 Establish features of
psychotic disease
2. Ask for the key features of psychotic illness. These are,
 Exclude D/D
 Identify the  Disorders of perception
precipitating,  Disorders of thought
predisposing and  Negative symptoms
perpetuating factors  Psychomotor
 Poor insight
of the disease
 Describe the social
support and living
conditions of the
patient Remember not to use technical terms when describing the
following symptoms. Always describe using the patient’s
own words

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Disorders of perception – Ask in detail about the following.

 Auditory hallucinations

 1st person - The patient admits to hear thoughts spoken out loud as he thinks them or repeats them
immediately after he has thought them. The latter is known as thought echo.

 2nd person -The patient hears voices talking to them or commanding them

 3rd person- Voices speaking about the patient, commenting about his/her actions, discussing the
patient.

 Visual hallucinations

 Not a typical feature of psychotic disease. However autoscopic hallucinations where the patient sees
himself or herself in external space may occur in psychotic illness.

 Other – Tactile, olfactory, gustatory, somatic

Disorders of thought – Asking about these is a very important aspect of the history

Ask about delusions according to themes

 Persecutory delusions – People or organizations trying to inflict harm on the patient. Family
members poisoning food is an example.

 Delusions of reference – objects, events, or actions of other people have special significance for
the patient. For example the patient may believe that items on the television are directly
referring to him.

 Delusions of control – Here the patient believes that his thoughts and actions are being
controlled by an outside person or organization

 Delusions of thought possession- thought insertion, thought withdrawal, thought broadcasting

( The patient believes his thoughts are made aware to other people.)

 Grandiose delusions – Here the patient believes that he has special powers

 Other bizarre delusions

Negative symptoms

 Under activity
 Lack of drive

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  Social withdrawal
 Emotional apathy
 Thought disorder

Psychomotor symptoms
Poor insight

3. At the end of this consider the possible D/D. And ask relevant direct questions. Also try to perform a
quick mental state examination at this point. These are,
 Schizophrenia
 Schizoaffective disorder – Ask about symptoms of depression and mania
 Depression/mania with psychotic symptoms
 Delusional disorder – Usually has systematized delusions
 Substance abuse – especially about cocaine
 Organic brain pathology – TLE, SLE, endocrine disease- Cushing, thyroid, metabolic disease,
Infections.

4. Describe the risks to the patient and to others

Go through the next part of the history and assess the risk both to themselves and others. Ask about
suicidal thoughts. Complete the history with the other components. These are important in
estimating the prognosis.

Family history - schizophrenia or other serious mental illness

Past psychiatric history – Ask for past episodes and describe the basic presentation of each. Then the
management, drug side effects, compliance to therapy, ECT and inter episode functional status.

Past medical history – Important to decide the management. Ask about DM, IHD, HT

Personal history and social support for the patient – Give a detailed description. Look for predisposing,
precipitating and persisting factors for the disease. For schizophrenia the following have been identified
as predisposing factors

o Complications of pregnancy, delivery and the neonatal period

o Delayed walking and neuro-developmental difficulty

Describe the social support and living conditions of the patient in detail

Pre morbid personality – Ask for odd beliefs and thinking, belief in supernatural forces

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Mental state examination
Appearance and behavior
 May be normal
 Look for signs of self neglect which may indicate social withdrawal
 Look for abnormal movements – Extrapyrimidal side effects of drug therapy
 May have variable patterns of behavior

Speech
 Pressure of speech
 Poverty of speech

Mood
 Describe prevailing mood
 Fluctuation of mood – labile, blunted/ flattened
 Appropriateness of mood
 Suicidal ideas

Thinking
 Abnormalities of thought content
Delusions
Persecutory, control, thought insertion, withdrawal and thought broadcasting
 Abnormality in amount and speed of thought
Pressure of thought – unusually rapid, abundant and varied
Poverty of thought
Thought block
 Abnormalities in the flow of thought
Flight of ideas
Loosening of associations
Perseveration – persistent and inappropriate rep. of the same sequence of thought.

Perception
 Hallucination – auditory, especially 3rd person

Cognitive function – This is important as cognitive function is usually impaired in these patients
o Orientation (time, place, person)
o Attention and concentration ( SERIAL 7S TEST)
o Short term memory
o Memory for recent events
o Remote memory
o Intelligence
Insight – Impaired

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Schizophrenia

Management

Outline of the management plan

 Making a diagnosis
 Decide prognosis
 Emergency management of a restless patient (if necessary)
 Early management – Setting, observation and pharmacological
management
 Long term management

 Complete the assessment based on the history and MSE.

 Make a diagnosis

Diagnostic criteria

Symptoms > 1 month

ICD -10

1 or more

o Thought echo, thought insertion, or withdrawal + thought broadcasting

o Delusions of control, influence or passivity, delusional perception
o Auditory hallucinations – (3rd person running commentary), other types of hallucinatory
voices coming from other parts of the body
o Bizarre delusions
2 or more

o Other persistent hallucinations that occur every day for weeks and associated with
fleeting delusions, persistent overvalued ideas
o thought disorganization
o catatonic
o negative symptoms
o change in personal behavior

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  If possible classify according to the subtypes. (Not essential. Given below are some salient
features of subtypes of schizophrenia)

Paranoid Hebephrenic Catatonic Residual

Commonest Prominent thought Prominent motor Prominent negative
Characterized by disorganization. symptoms such as symptoms for a
persecutory delusions Associated with early stupor, excitement, duration of at least 1
and by persecutory negative symptoms posturing, negativism, year
auditory hallucinations. rigidity, waxy flexibility
Thought
disorganization,
catatonic and negative
symptoms not
prominent

 Other subtypes also present

 Make an assessment of the prognostic factors
 Identify the predisposing, precipitating and perpetuating factors

Good prognostic factors Poor prognostic factors

Sudden onset Insidious onset
Short episode Long episode
No previous psychiatric history Previous psychiatric history
Paranoid type Hebephrenic
Prominent negative symptoms
Older age at onset Young age at onset
Female Male
Married Single
Good psychosexual adjustment Poor
Good previous personality Abnormal pre morbid personality
Good work record Poor work record
Good social relationships Social isolation

Make the decision to admit the patient or not. Admission should be considered especially if there is

o High risk of suicide or homicide

o Illness related behavior that endangers relationships, reputation or assets
o Severe psychotic symptoms
o Catatonic symptoms
o Lack of social support

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Emergency management

Manage severe behavioral disturbance if present as given below

 Safety
 Restrain the patient
 Pharmacological management

Pharmacological management options

 IM haloperidol 10mg and IM promethazine 25mg

 Diazepam 10mg IV
 IM chlorpromazine 25-100mg
 IM zuclopenthixol acetate 50-150mg
 IM olanzapine may also be used

Monitor pulse, respiratory rate, blood pressure and side effects of drug therapy.

Early management

 Once the patient has been admitted

 Observation
Appetite, self care, behavior, suicidal attempts, interactions
 Pharmacological
 The treatment of choice is to commence the patient on an atypical antipsychotic drug.
Atypical antipsychotics are preferred as they have better effect on the negative symptoms and
cognitive dysfunction seen in schizophrenia.
 Drug doses

Risperidone – Start with 2mg and increase up to 4mg/d – 6mg/d. Maximum dose is 16mg/d
Olanzapine – 10mg/d and maximum is 20mg
Haloperidol 3-5mg, 2-3 a day. Maximum is 30mg

 Before commencing medication basic investigations should be performed such as FBS, FBC,
LFT, lipid profile, urea and electrolytes.
 CT scan may be done if a neurological disease is suspected

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Antipsychotic drugs

Drug class Examples Side effects

Typical antipsychotics Haloperidol Extrapyrimidal side effects

Flupenthixol Acute dystonia
Zuclopenthixol Akathasia
Chlorpromazine Parkinsonism
Fluphenazine Tardive dyskinesia
Trifluoperazine
Anticholinergic side effects
Dry mouth
Reduced sweating
Urinary hesitancy and retention
Constipation
Blurred vision

Antiadrenergic effects
Sedation
Postural hypotension
Inhibition of ejaculation

Other effects
Cardiac arrhythmias
Weight gain and diabetes
Amenorrhoea
Galactorrhoea
Neuroleptic malignant syndrome
Atypical antipsychotics Risperidone Less extra pyramidal side effects
Olanzapine But can have more metabolic side
Quetiapine effects
Zotepine
Amisulpride

Side effect profile of specific antipsychotic drugs

Conventional

 Chlorpromazine – Prominent anti-adrenergic effects such as postural hypotension, pronounced

sedative effect
 Fluphenazine, trifluoperazine – Pronounced EPS, fewer sedative effects and fewer
antimuscarinic effects
 Haloperidol - EPS

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Atypical

 Risperidone – Most likely of the atypicals to cause EPS

 Olanzapine – Most likely to cause metabolic syndrome
 Zotepine – Cardiac toxicity

 Remember that the extra pyramidal symptoms are more with typical antipsychotics. Although
the atypical antipsychotics were thought to have minimal side effects they have endocrine and
metabolic side effects.
 Observe for response to medication. If there is no response after 3-4 weeks consider changing
the drug or adding another antipsychotic.
 For patients with low compliance depot preparations can be considered in the management.
Some of the available drug preparations are listed below.

o Flupenthixol decanoate
o Fluphenazine decanoate
o Haloperidol decanoate
o Zuclopenthixol decanoate
o Risperidone

 ECT is used in some occasions especially in catatonic schizophrenia

Continuing management

 Education of the family members and if possible the patient about the disease, drug, side effects
of medication and importance of compliance.
 Cognitive behavioral therapy
 Commence a rehabilitation plan. This should include
Self care skills, social skills training, communication skills, cognitive function improvement,
leisure and recreation, work skills and vocational training and creative skills
 Optimize the antipsychotic medication
 Plan discharge and follow up.

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Follow up

 The patient should be followed up at an outpatient clinic initially weekly then once in 2 weeks
and later once a month. The following aspects should be looked into at follow up.

 Medical
o MSE
o Side effects, compliance of drug therapy
o BMI
o Assess response to drug therapy
o Conduct relevant investigations
o Recent life events or current stressors, suicidal or homicidal ideas
o Relevant investigations
 Psychological
o Education
o Supportive treatment
 Social
o Social skills
o Rehabilitation progress
o Support

An assessment of the patient can be made with a scale such as the PANSS (Positive And Negative
Symptoms Scale)

Duration of treatment – 1st episode for 2 years, 2nd episode for 5 years and 3rd episode lifetime

Management of treatment resistant schizophrenia

Definition

 Failure to respond to 2 or more antipsychotic medications given in therapeutic doses for 6

weeks or more

Management

 Clarify diagnosis
 Address co morbidities such as substance abuse
 Compliance with medication

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 Start clozapine. When starting this drug it is extremely important to monitor with FBC as it can
cause fatal agranulocytosis, ECG and Echo for myocarditis, cardiomyopathy.
When starting the patient on clozapine 12.5mg and gradually increase the dose. Maximum dose
900mg. If dose is omitted for 48h the dosing should be started from 12.5 mg.
 Monitor WBC weekly for 18 weeks from commencement of therapy. Then once in 2 weeks for
the next year. After this the WBC is monitored once a month. Stop drug if WBC less than 3000
or neutrophill count less than 1500.
 Rehabilitation
 Patients on Clozapine are followed up in the Clozapine clinic.
 When a patient attends the clozapine clinic the following is carried out
o Measurement of height, weight and BMI
o Measurement of blood pressure
o Assessment of the symptomatology
o PANSS
o Drug compliance and side effects
o Look at the investigations – FBC as necessary, LFT every 6 months, FBS every 6 months,
lipid profile every 6 months to 1 year
o Make modifications of the dose as necessary
o Follow up on the rehabilitation

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The patient with low mood - Depression

A 42 year old man presents with difficulty in sleeping over the last 3 months. He also admits that he is
always tired and does not feel like engaging in his day to day activities and has refrained from going to
work during the last few weeks.

History
Presenting complaint

History of presenting complaint

 Describe the symptoms in the presenting complaint as follows

 Is the patient a diagnosed patient with mental illness?
 Onset – Describe any specific triggering factor in detail
 Duration and progression over time
 Chronological order of development of symptoms

Then it is important to ask questions related to D/D. Especially when asking the symptoms of depression
relate to day to day life. Also always try to associate these with the effect on day to day life.

 Ask for the typical symptoms of depression based on the diagnostic criteria (ICD 10). These are,
o Low mood and diurnal variation of the mood
o Markedly diminished interest or pleasure in all or almost all activities most of the
day, nearly every day (anhedonia)
o Reduced energy leading to increased fatiguability and diminished activity, marked
tiredness after slight effort
o Reduced concentration and attention
o Reduced self esteem and self confidence
o Ideas of guilt and unworthiness
o Bleak and pessimistic view of the future
o Ideas or acts of suicide or self harm
o Difficulty in sleeping and waking early morning before the usual time and have
depressive thoughts
o Loss of appetite and associated weight loss (patients may have the opposite)

Other associated symptoms (somatic). Some somatic symptoms overlap with the symptoms given
above.

o Loss of libido
o Lack of emotional reactivity to normally pleasurable surroundings and events

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 o Agitation and irritability
o Unexplained physical symptoms – headache, abdominal pain, menstrual
disturbances

Apart from these typical symptoms the patient may also have psychotic symptoms when depression is
severe. Therefore try to ask these in the history.

Delusions - Delusions of guilt, hypochondriacal, delusions of impoverishment, nihilistic delusions

persecutory delusions

Hallucinations

Note that these are mood congruent psychotic features unlike those in other psychotic disorders

Exclude other D/D

 Reaction to stress
Adjustment disorder
Pathological grief
In these disorders there will be a specific triggering stressful event
 Depression in BAD
Ask for features of a manic episode previously
 Recurrent depressive disorder
Ask for past history of similar episodes. Recurrent depressive disorder is characterized by 2 or
more episodes lasting a minimum of 2 weeks separated by several months.
If this is the diagnosis ask in detail on diagnosis and severity, investigations, management
response to management and drug compliance related to the following
1st episode
Last episode
Number of episodes and duration
 Dysthymia
This is characterized by chronic depressed mood without fluctuations
 Negative symptoms of schizophrenia
Look for features of schizophrenia
 Schizoaffective disorder
Should have the diagnostic features of schizophrenia and depression in the same episode
 Substance abuse and drug history
 Organic pathology
Ask for features of neurological disease, endocrine disease such as hypothyroidism, history of
malignancy and other systemic complaints.

After this describe in detail any risks to the patient or others (suicide and homicide).

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Family history

Depression, DSH and suicides, major psychiatric illness

Past psychiatric history

Ask for past episodes of similar symptoms, the treatment given, compliance with the treatment and
inter episode functioning.

Personal history

Use this to identify predisposing, precipitating and maintaining factors of the disease. Also identify the
social support available for the patient.

 Parental separation
 Relationships with the parents
 Abuse as a child
 Stressful life events
 Life difficulties

Pre morbid personality

May have been a dependent person with poor coping and problem solving skills

Mental state examination

Appearance and behavior

 Dress and grooming may be neglected

 Facial features – Downturned corners of the mouth, vertical furrowing of the center of the
brow, rate of blinking is reduced, shoulders are bent and the head is inclined forwards. The
direction of gaze is downwards.

Speech

 Slow
 Non spontaneous

Mood

 The patient is usually miserable

 Subjective and objective assessment of the mood
 Reactivity
 Congruence

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Thoughts

 Poverty of thought
 Depressive cognition – This means that the patient has gloomy thoughts about the past, present
and future
Thoughts concerned about the present – The patient sees the unhappy side of every event and
thinks he is a failure at everything he does
Thoughts concerned about the future – He sees a very bad future for himself
Thoughts concerned about the past – Unreasonable guilt and self blame about minor matters
 Delusions
Persecutory
Nihilistic

Perception

 Auditory hallucinations
 Olfactory hallucinations – Bad smells

Cognition

 Cognitive decline

Management

Outline of the management

 Diagnosis and classification

 Acute management and
pharmacological therapy
 Psychotherapy
 ECT if required
 Long term therapy

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 The first step in the management is to make a diagnosis based on the ICD 10 criteria. These have
been covered in the history.

o Depressed mood
o Anhedonia
o Lack of energy leading to increased fatigability

 Lack of attention and concentration

 Reduced self esteem and self confidence
 Ideas of guilt and worthlessness
 Bleak and pessimistic views on the future
 Ideas or acts of suicide or self harm
 Disturbed sleep
 Diminished appetite

Somatic symptoms

 Markedly diminished interest or pleasure in all or almost all activities most of the day,
nearly every day.
 Lack of emotional reactivity to normally pleasurable surroundings and events
 Waking 2 hours or more before usual time in the morning
 Depression worse in the morning
 Objective evidence of psychomotor retardation or agitation
 Marked loss of appetite
 Loss of 5% or more of body weight in past month
 Marked loss of libido

Psychotic symptoms

 Delusions, hallucinations or stupor

 The next step is to classify depression. This based on severity and presence or absence of
somatic symptoms.

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Mild With somatic syndrome 2 of A+ at least 2 of B + at least 4
of somatic symptoms
Without somatic syndrome 2 of A + at least 2 of B
Moderate With somatic syndrome 2 of A + at least 3 of B + at least 4
of somatic symptoms
Without somatic syndrome 2 of A + at least 3 of B
Severe With psychotic symptoms All of A + at least 4 of B +
psychotic symptoms
Without psychotic symptoms All of A + at least 4 of B

 Do relevant investigations
 Decide on hospital admission. Consider the following
 Serious risk of suicide
 Serious risk of harm to others
 Significant self neglect
 Severe depressive symptoms
 Psychotic symptoms
 Poor social support
 Once the patient is admitted monitor behavior, interactions with others, suicidal attempts,
appetite, sleep, symptoms of depression and side effects of drug therapy
 Initiate treatment
 There are 2 categories of treatment. These are psychotherapy and pharmacological
management.
 Mild depression is treated with psychotherapy alone whereas moderate and severe depression
is treated with a combination of psychotherapy and pharmacological therapy.
 ECT is also an option for management
Severe episode
Depressive stupor
Unresponsive
Side effects of drug therapy

Pharmacological therapy

Choosing an antidepressant

 Several drug classes are available

 Efficacy is the same in all drug classes
 Monotherapy is preferred over polytherapy

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 Choice is made based on the following characteristics
o Symptoms
o Safety and side effect profile
o Risk in overdose
o Comorbidities
o Drug interactions
o Availability and cost

 Once a drug is started the therapeutic effect begins after about 1-2 weeks. Full effect is reached
after about 6 weeks. From this time drugs are continued up to 6 months after the symptoms
have subsided
 The drug of choice in moderate depression is an SSRI. The most commonly used drug is
fluoxetine 20mg mane. This can be increased after 3-4 weeks. Maximum dose is 60mg.
 However in severe depression a TCA should be considered in the management
Imipramine is the drug of choice dose – 75mg/d up to 150-200mg/d
 Venlaflaxine can also be considered. The dose 75mg/d with the maximum being 375mg/d
 When starting an antidepressant start at a low dose and gradually increase.
 If there is failure to respond to initial treatment there are several options which can be
considered
o Reconsider the diagnosis
o Increase antidepressant to maximum tolerated dose
o Try different class of antidepressant
o Combination of antidepressants is best avoided due to the risk of serotonin syndrome
o Augmentation therapy with lithium

 Then drugs are tailed off over 6 – 8 weeks.

 If symptoms recur continue for another 6 months.
 If recurrent depressive episodes treat as following
Two episodes for 2 years
More than 2 episodes – 5 years

If depression with psychotic features are present

 Initially start the patient on an antipsychotic and then start an antidepressant a few days later
 Monitor carefully for side effects
 ECT is also an option

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Antidepressants

Drug class Mechanism of action Side effects Advantages and

disadvantages

TCA Inhibits the pre synaptic Anti cholinergic Advantages

Imipramine uptake of serotonin, Dry mouth Well studied
Clomipramine noradrenaline and dopamine Urinary retention No serious long term
Amitriptyline Constipation toxicity at therapeutic
Sexual dysfunction doses
Useful sedative effect
Anti adrenergic
Postural hypotension

Cardio toxicity
Conduction defects Disadvantages
Arrhythmias Anti cholinergic side
effects
Other Cardio toxic- dangerous
Weight gain in overdose
Drowsiness Cognitive impairment
Cognitive dysfunction Weight gain during long
Seizures term use
SSRI Selective inhibition of the Gastrointestinal Advantages
Fluoxetine uptake of serotonin Nausea Less disabling side
Fluvoxamine Loss of appetite effects
Sertraline Dyspepsia Not toxic in overdose
Citalopram Diarrhea
Constipation

CNS Disadvantages
Headache May not be useful in
Insomnia severe depression
Anxiety
Fatigue

Other
Delayed orgasm

MAOI Inhibition of the MAO-A Multiple interactions Not used clinically

Phenelzine enzyme system with food and drugs
Moclobemide
Isocarboxazid

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Other Inhibition of the reuptake of Similar to SSRI Advantages
SNRI serotonin and noradrenaline No anti cholinergic side
Venlaflaxine effects
No cognitive
impairment

Disadvantages
Expensive
GI and sexual problems

Psychological management

 Supportive and problem solving methods

 Cognitive behavior therapy
In CBT the following cognitive abnormalities are altered
 Intrusive thoughts of self depreciation
 Logical errors such as exaggeration (magnifying small mistakes), catastrophizing
(expecting serious consequences of minor problems, overgeneralization (thinking that
the bad outcome of one event will be repeated in every single event in the future) and
ignoring the positive
 Maladaptive assumptions
 Activity schedule
 Dealing with life stressors and other stressful events

Long term management and follow up

 This is done with the objective of preventing relapse and recurrence

 Psychological management is a first line option
 Rehabilitation and social integration

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The patient with an elevated mood – Bipolar affective disorder

A 28 year old man is brought by his wife to the ward. She says that he has not slept more than 2 hours a
day for about 3 weeks duration. He has also become extremely irritable and talkative and is spending a
large amount of money on clothes and other personal items.

History

Introduction to the patient

Presenting complaint

History of presenting complaint

o Onset
o Duration
o Progression
o Impact on day to day life
o Chronological order of development of symptoms

Ask for features of a manic episode

 Elevated mood
 Increased energy which is usually reflected in symptoms such as over activity, reduced need for
sleep, increased appetite, increased libido and rapid varied thoughts
 Increased self esteem which is reflected in excessive optimism, grandiosity, reduced social
inhibitions.
 Reduced attention/increased distractibility
 Tendency to engage in behavior that could have serious consequences, for example spending
recklessly, inappropriate sexual encounters
 Irritability, aggression
 Marked disruption of work, usual social activities and family life
 Ask for psychotic symptoms – Delusions of grandiosity, persecutory delusions
 Ask for suicidal/homicidal ideas

Once the symptoms have been described in detail think of the differential diagnosis and ask direct
questions based on them.

 Manic episode with or without psychotic symptoms

 Hypomania

27
 Has similar symptoms to mania but these are less prominent. Also do not significantly disrupt
work or lead to social rejection
 Bipolar affective disorder
Requires at least 2 episodes with one being hypomanic, manic, mixed or depressive
 Schizophrenia and Schizoaffective disorder
Ask for auditory hallucinations and other typical features of schizophrenia
 Substance abuse
Hallucinogens, stimulants, opiates
 Side effects of drugs
 Medical conditions
Thyroid disease, Cushing’s syndrome, SLE, brain tumors

Past psychiatric history

Describe the past episodes of mania/ depression based on the following points.

 Presentation and diagnosis made

 Treatment given – drugs, ECT
 Response to treatment
 Inter episode functioning

Past medical history

Family history

Personal history – Take a routine personal history and identify the predisposing, precipitating and
maintaining factors of the disease. Also identify the social supports for the patient

Pre morbid personality

Mental state examination

Appearance and behavior

 The patient will usually wear bright colored clothes

 Facial expressions
 May be aggressive or irritable
 May be over familiar or disinhibited
 Distractible

28
Speech

 Rate and volume may be increased

 Pressure of speech

Mood

 Elated
 Irritable

Thought

 Content
Grandiose ideas, grandiose delusions, persecutory delusions
 Flight of ideas
 Loosening of associations

Perception

 Can have hallucinations or illusions

Cognitive functions

Insight

 Usually impaired

29
Bipolar affective disorder

Outline of the management

 Setting
 Manage if restless
 Manage presenting episode – Mania/depression
 Consider prophylaxis
 Long term managment

Management

 Proper assessment – Make a proper diagnosis, assess the severity, identify the predisposing,
precipitating and maintaining factors of the disease and the social supports available to the
patient
 ICD – 10 criteria for diagnosis
 Treat the current episode

Treatment of the manic episode

Immediate

 Decide treatment setting. Decide on admission if the following are present

o High risk of suicide/ homicide
o Illness related behavior that endangers relationships, reputation or assets
o Lack of social support
o Poor compliance to treatment
o Severe symptoms especially psychotic symptoms
o Mixed states or rapidly cycling
 Manage acute disturbance if required
 Monitor behavior, appetite, sleep, suicidal/homicidal attempts
 Pharmacological management
Antipsychotics – Consider the use of atypical antipsychotics such as Olanzapine
Lithium
Benzodiazepines- To improve sleep and diminished sleep
 ECT

30
Continuation treatment

 Continue antipsychotics for about 2-3 months and tail off over 2 weeks
 Continue lithium for about 6 months and tail off once the patient has been asymptomatic for
about 8 weeks

Management of a bipolar depressive episode

This can be challenging as there is a risk of precipitating a manic episode or inducing a rapidly cycling
mood disorder.

Immediate management

 Decide the setting of management

 Look into the drugs the patient is taking
 Antidepressant treatment – An SSRI such as fluoxetine is preferred over a TCA as there is less
chance of inducing a manic episode
Fluoxetine 20mg mane
 Mood stabilizers – Lithium is the 1st line choice. If the patient is already on lithium consider the
addition of a 2nd mood stabilizer such as sodium valproate, carbamezapine or lamotrigine
Lithium – 1 to 1.5g daily
 Antipsychotics – Consider Olanzapine. Combination therapy with fluoxetine has been shown to
reduce relapses
Olanzapine 10mg/d
 ECT – In severe cases
 Duration of treatment should be shorter than that for unipolar depression

Consider prophylactic treatment

Indications

Any patient who has had at least 2 episodes in the last 5 years

 Lithium is the 1st line treatment

 Starting dose 200-400mg daily
 Anticonvulsants such as sodium valproate, carbamezapine and lamotrigine can also be
considered.

31
Lithium

 Preparation for starting lithium

o Physical examination including measurement of the weight, BMI and blood pressure
o Blood investigations – FBC, serum electrolytes, renal function tests, thyroid function
tests
o ECG
o Look for drugs which could cause interactions with lithium (Diuretics, NSAIDS, ACEI)
o Patient advice
 Monitoring of lithium levels
One week after commencement of therapy 12 hours after the last dose.
Following this weekly for 3 weeks
Until stabilization of lithium levels - once every 6 weeks
Once levels are stable once in every 3 months
 Maintain levels at 0.8 – 1.0 for the treatment of acute mania and 0.4-0.7 for prophylactic
management
 Follow up with FBC, serum electrolytes, renal function tests, thyroid function tests every 6
months – 12 months
 Educate on adverse effects of lithium

GIT/hepatic Altered taste, anorexia, nausea, vomiting,

diarrhea, weight gain
Neurological Tremor, weakness, dysarthria, ataxia, impaired
memory
Renal Polyuria, polydipsia
Endocrine Hypothyroidism
Hematological Leukocytosis
Dermatological Acne, hair loss
Cardiovascular T wave flattening/inversion or widening of the QRS
duration

Lithium overdose

Identification
 Early signs and symptoms
Marked tremor, anorexia, nausea and vomiting, diarrhea with associated dehydration and
lethargy
 Late symptoms
Severe neurological manifestations – Restlessness, myoclonic jerks, choreoathetoid movements,
hypertonicity and progression up to coma
Cardiovascular manifestations – Hypotension and cardiac arrhythmias

32
  Identify precipitating events
 Stop the drug and immediately come to hospital

Long term management

 Patient education
 CBT
 Rehabilitation

Follow up

 Assess the present state of symptoms

 Drug treatment and compliance to medication especially with regard to lithium
 Side effects of drug therapy
 Review investigations done
 Present state of rehabilitation and social re integration of the patient
 Treatment with lithium is continued for a minimum of 2 years. If the decision is made to stop
the drug tail off over a few weeks.

Advice which should be given to a patient taking lithium

 Disease that the patient is having

 Name of the drug, the dose and how and when to take it
 Importance of good compliance to drug therapy
 Information on storage of the drug
 Education on side effects of the drugs and the routine investigations which should be done
 Drink more the 2.5l of water per day
 Advice on how to recognize lithium toxicity and to stop the drug and come to hospital if he has
any of these symptoms
 To stop the drug and seek medical advice during bouts of infection, diarrhea, vomiting
 Always tell other doctors that you are on lithium
 Planned pregnancy

33
The patient with anxiety

History

Introduction to the patient

Presenting complaint

The patient will present with features of abnormal anxiety.

 Ask for associated psychological symptoms such as fear, irritability, restlessness, worrying
thoughts and poor concentration
 Ask for physical symptoms such as palpitations, chest discomfort, and difficulty in breathing,
tremor, and muscle tension.
 The key feature is that these symptoms will be out of proportion to the stimulus and also the
patient will be extremely concerned about them.
 Also ask about secondary fears of dying, losing control or going mad

History of the presenting complaint

 Describe the onset and progression of symptoms

 Duration
 Define the circumstances of the symptoms of anxiety. Is the anxiety present in only well defined
circumstances or is there no such association?
 Consider the D/D
Anxiety disorders
These can be classified as
Phobic anxiety disorders - Social phobia, agoraphobia, specific phobias
Other anxiety disorders – Panic disorder, GAD, mixed anxiety and depressive disorder
Look for features of the following disorders if anxiety is present in defined circumstances

34
Agoraphobia Social phobia
 Anxiety is restricted to  Anxiety is restricted to social situations
crowds, public places, travelling away from such as speaking in public, attending public
home and travelling alone events, speaking with the opposite sex

 Anxiety is reduced when accompanied by a  Associated with low self esteem, a fear that
trusted companion he/she will be criticized by others and that
they are being continuously observed by
 Avoidance of the phobic situation others

 Anticipatory anxiety  They may also have a fear that they will
vomit
 Panic attacks
 Avoidance of the situation

 Isolated phobias
 If the anxiety is not situational consider GAD or panic disorder
In GAD the patient has symptoms of anxiety most days for at least several weeks at a time, and
usually for several months
In panic disorder there are recurrent attacks of severe anxiety with the patient being relatively
symptom free between attacks
 Exclude other D/D
o Reaction to stress – Acute stress reaction
o Anxiety occurring secondary to major psychotic illness – Ask a few symptoms of mood
disorders and schizophrenia
o OCD – Ask for a few features of OCD
o Substance misuse – This may trigger anxiety or an anxious person may consume alcohol
for relief from his symptoms
o Medical illness
o Drugs for medical illness
 Describe the severity of these symptoms and how it affects the patient’s day to day life

Past psychiatric history

Past medical history

Family history

Personal history

 Childhood experiences
 Relationships – These should be well described if social phobia is suspected
 Look for predisposing, precipitating and maintaining factors

35
Pre morbid personality

 Coping skills
 Relationships
 Social interactions
 Impulsive/aggressive
 Self confidence
 Anxious-avoidant personality
 Apart from this if social phobia is suspected look for the following
Excessively high standards for social performance
Negative belief about the self
Excessive monitoring of his/her performance in social situations

Mental State Examination

Do a routine MSE.

Management

Generalized anxiety disorder

 Decide setting of management. GAD is usually managed on an outpatient basis

 Explanation of the diagnosis to the patient
 Reassurance that the symptoms of anxiety are not brought about by any physical illness
 Discuss the management plan with the patient
 Relaxation therapy
 Cognitive behavioral therapy
 Pharmacological management
Short course of benzodiazepines – less than 3 weeks (Diazepam 5mg bd)
Buspirone
Beta blockers for severe symptoms
If long term management is required consider an antidepressant

Panic disorder

 Decide on the setting of management. This is usually outpatient management

 Explain the diagnosis to the patient
 Reassurance that the symptoms of anxiety are not brought about by any physical illness
 Discuss the management plan with the patient
 CBT
Educate on the vicious cycle of a panic attack

36
  Pharmacological management
SSRI is the drug of choice at a dose of 20-60mg/day. However TCA such as imipramine or
clomipramine can be used for the management
BDZ (alprozolam, clonazepam) can be used as a short course for 1-2 weeks until the
antidepressant takes effect
 Continue medication for about 1 year

Phobic anxiety disorders

 Decide on the setting of management. This is usually outpatient management

 Explain the diagnosis to the patient
 Reassurance that the symptoms of anxiety are not brought about by any physical illness
 Discuss the management plan with the patient
 CBT
Behavioral techniques
Exposure with the objective of desensitization
Here a hierarchy of events is constructed from the least anxious to the most anxious. The
hierarchy should contain a minimum of 10 items. The patient is gradually exposed to these
items on the hierarchy
A diary may be used to record these events
Relaxation techniques are also employed

Cognitive techniques
These are used to alter the cognitions of
Fear of fear
Fear of symptoms
Fear of negative evaluation in patients with social phobia

 Social skills training

 Pharmacological management
Antidepressant – SSRI
Benzodiazepines

37
The patient with obsessions and compulsions - OCD

A 2o year old girl presents with recurrent thoughts of being dirty or unclean. Due to these thoughts she
spends about 5 hours in the shower. She has a particular order of showering which must be followed.
She knows that these thoughts are abnormal and feels anxious and distressed about it.

Given the above presenting complaint it is likely that this patient has obsessions and compulsions. The
1st priority in the history is to establish the basic features of an obsession.

History of the presenting complaint

Elicit the following in the history

Obsession

 Thoughts, images or impulses

 Which are a formed by the patient’s own mind
 Are resisted unsuccessfully (At least 1 thought)
 The thought of carrying out the act in itself is not pleasurable and may be distressing

The next step would be to establish the type of obsessional symptoms the patient has

 Obsessional thoughts – These can be based on various themes such as dirt and contamination,
orderliness, sexual practices. (This patient has obsessional thoughts based on dirt and
contamination)
 Obsessional rumination – Internal debates in which arguments for and against even the
simplest actions are reviewed endlessly
 Obsessional doubts – Repeated worrying themes where the patient is uncertain about previous
actions. For example whether he has closed the tap or turned off the lights.
 Obsessional impulses – Repeated urges to carry out actions, usually actions which are
aggressive, dangerous or socially embarrassing. For example the urge to harm his child, jump in
front of the train, to stab another person). The person has no wish to carry out the impulses and
does not act on them.
These impulses may lead to obsessional phobia. An example of this is a patient with an
obsessional impulse to stab a person with a knife may cause a person to be afraid of going to the
kitchen.

The next step is to elicit compulsions the patient has

Compulsions

 Repetitive and seemingly purposeful behavior

38
  Performed in a stereotyped way
 In response to an obsession and can be connected or not connected, the person may get a
temporary relief of the obsession
 The patient recognizes this behavior to be irrational and tries to resist

Compulsions are of various themes, these are

 Checking rituals – For example checking again and again if the tap is closed
 Cleaning rituals
 Counting rituals
 Dressing rituals – The patient lays out clothes or puts them on in a particular way or order

(In the case given above the patient’s compulsion is a cleaning ritual in response to her obsessional
thought of dirt and contamination)

After the obsessions and compulsions in the patient are well described it is important to describe the
progression of the symptoms over time. Also ask about any triggering factors

The next step is to explain in detail using the history the effect of these symptoms on the day to day
activities of the person. Especially features of anxiety and depression due to these symptoms.

Look for suicidal and homicidal ideas

The next step in the history is to exclude certain differential diagnosis in patients with obsessions and
compulsions.

Diagnosis Features
OCD At least 2 weeks of genuine obsessions and
compulsions.
Depressive disorder Obsessive-compulsive symptoms occur
simultaneously with, or after the onset of
depressive features.
Also these obsessions and compulsions are mood
congruent
Schizophrenia Presence of other features of schizophrenia

39
Other D/D

 Anxiety disorders
 Personality disorder
 Hypochondriacal disorders

Family history

Past psychiatric history

Past medical history

Personal history

Pre morbid personality

Obsessional personality

Mental state examination

This is as usual but elicit obsessional thoughts in the thought content

Management

 Patient education
 Psychotherapy
Behavioral therapy – Exposure with response prevention using a hierarchy of events
Cognitive therapy – Seeks to reduce the attempts to suppress and avoid the obsessional
thoughts
 Pharmacotherapy
Clomipramine – 25mg/d increased over 2 weeks to 100-150mg/d
SSRI – Fluoxetine 20mg mane
Benzodiazepines to relieve anxiety

40
The patient with a reaction to a stressful event

 Identify and describe the stressful event in detail. Describe what the patient says and put them in a
chronological order
 Think of the D/D and ask for the relevant symptoms

Acute stress reaction Adjustment disorder Post traumatic stress disorder

Clinical Emotional response Emotional response Emotional response

features Intense anxiety
Panic attacks Somatic symptoms Intrusions
Restlessness and irritability Other Intense intrusive imagery
Purposeless activity Feeling of inability to cope Flashbacks
Impaired concentration Plan ahead Recurrent distressing dreams
Insomnia Feeling of inability to continue in the about the event
Depersonalization and present situation
derealization Avoidance
Considerable impact on day to day life Difficulty in recalling stressful
Somatic symptoms events at will
Dissociative symptoms Avoidance of reminders of the
Numbing event
Difficulty in recall Detachment
Dazed effect Coping strategies Numbness
May be maladaptive
Coping strategies Onset within 1 month of the stressor Coping strategies
May be maladaptive and usually do not exceed 6 months May be maladaptive
Duration less than 4 weeks Onset is after an exceptionally
traumatic event
There is usually a latent period
Management Psychological Psychological Psychological
Usually no specific treatment Counseling and supportive therapy CBT
required Ventilation of problems Dynamic psychotherapy
Counseling and supportive Improvement of coping skills
therapy Pharmacological Pharmacological
Pharmacological Antidepressants and anxiolytics Treat prominent symptoms
Anxiolytics if anxiety symptoms In failure of psychological therapy
predominate

41
Management of grief and bereavement

Normal grief reaction

Stage Features
Stage 1 Denial, disbelief
Hours to days Numbness
Stage 2 Waves of grief, guilt
Weeks to months Blame on others
Anxiety symptoms
Disturbed sleep, diminished appetite
Somatic complaints
Hallucinations
Social withdrawal
Stage 3 Readjustment, acceptance
Can take about 6 months

 The person in stage 3 can switch into stage 3 on anniversaries and other important events of the
deceased person’s life. This is known as an anniversary reaction

Abnormal grief

Grief is considered abnormal if;

 It is prolonged
 If it is abnormally intense and meet the criteria of a depressive episode or the patient has
suicidal ideas
 Prolonged grief more than 6 months
 Delayed grief – When the 1st stage does not appear until more than 2 weeks after the death
 Inhibited or distorted grief – Marked hostility, over activity and extreme social withdrawal

Management

 Consider the setting of management

 Grief counseling. The important principles are,
Identify the stage of grief
Help the patient ventilate his/her emotions
Accept that the loss is real by creating a cognitive dissonance
Work the patient through the cycle of grief
Utilize family and social support
Adjust to life without the deceased
 Pharmacological management of a depressive episode
 Support groups and family

42
The patient with unexplained weakness – Dissociative disorder

History

Introduction to the patient

Presenting complaint

The patient will be usually referred from a medical ward for weakness of the limbs.

History of the presenting complaint

 Describe the onset of the symptoms

 Progression over time
 Duration of symptoms
 Ask for other features
Sensory impairment or associated parasthesia or hyperesthesia
Bladder and bowel incontinence
Visual impairment
Diplopia
Hearing impairment
Vertigo
Dysphagia
 Ask for associated seizures
 Ask the patient about the investigations and management done up to now with a description of
the results

D/D

 Neurological disease
 Dissociative disorder – Ask for a recent stressful event, problems or disturbed relationships
 Malingering
 Factitious disorder

 Look for evidence of the primary gain and secondary gain

 Personal history – Look for stressful factors at home, in the workplace or at other circumstances
 Pre morbid personality

43
Mental State Examination

Look for la belle indifference – Here the patient will not seemed troubled by his/her weakness or
paralysis

Relevant physical examination is extremely important especially a full neurological examination. In

dissociative disorders the neurological examination findings will not be compatible with any anatomical
distribution

Also look for Hoover’s sign

Hold your hand under the weak limb and ask the patient to extend the other leg off the bed against
resistance. If you feel pressure from the weak heel, the weakness is likely organic. If no pressure is felt,
the patient is likely suffering from non-organic limb weakness.

Management of dissociative disorders

 Make a proper diagnosis of dissociative disorder based on the ICD 10 guidelines

 The setting of management is usually ward based
 Observation
 Education of the patient and reassurance
 Educate the staff on the patient and ask them not to give wrong information to the patient
 Acknowledge the patient’s problem
 Arrange for physiotherapy
 Create a structured plan and set goals for the patient’s recovery.
 Psychotherapy
Explanation
Give the patient help to resolve his current stressors
Improve coping ability and problem solving skills
Relaxation therapy
Give positive reinforcement for improvement. Do not reinforce the symptoms
 Medication is usually not required unless the patient is having a co morbid psychiatric disorder

44
The patient with decline of cognitive function - Dementia
A 69 year old man presents with problems of memory and disorganized behavior for the last few
months.

History

Introduction to the patient

Outline of the history Presenting complaint

 Describe the History of the presenting complaint

presenting complaint
The 1st step in the history is to take a detailed history of
 Ask for other cognitive
the presenting complaint and also to inquire in detail on
functions
other cognitive functions. As usual give a chronological
 Exclude D/D
account of the development of symptoms.
 Look for cause
 Severity and effect on
day to day life
 Personal history
 Social support for the
patient

 Memory
Ask the details of this memory impairment. What exactly does the patient forget?
o Ask about retention of new information such as newly learned names addresses and
telephone numbers.
o Forgetting names, places, appointments, daily household activities, self care, taking
medicines etc.
o Ask about long term memory – Can he remember important events in his life?

 Decline in language skills

Ask for difficulty in naming objects and understanding what is being said
 Loss of executive function
Loss of ability to plan and carry out various activities. Therefore the patient will get more and
more disorganized

45
  Loss of orientation
 Personality and behavioral change
Ask for restlessness, waking at night, aggression, wandering, decline of self care
 Agnosia
Ask if the patient has difficulty in recognizing familiar objects such as clothing, faces, and familiar
places. The patient may admit that he has trouble finding his way home
 Apraxia
Ask if the patient has difficulty in carrying out skilled motor activities such as dressing himself.
 Also ask for impairment of calculation and writing skills
 Also ask for associated psychiatric symptoms. Ask about the mood as depression can be
associated. Ask for delusions especially on a persecutory theme and hallucinations.

Exclude D/D and establish a diagnosis of dementia. Do a quick mental state examination at this point
especially an assessment of the cognitive function.

The D/D would be

 Dementia
 Delirium
 Amnesic syndromes
 Depression with pseudo dementia

Delirium Dementia
Acute onset Insidious onset
Fluctuating Chronic progressive course
Impaired consciousness Consciousness intact
Thinking disorganized Thinking impoverished
Disorders of perception common Rare
Alertness impaired Alert

 Amnesic syndromes may be excluded as they do not have alteration of other cognitive functions
apart from memory.
 Depression with pseudo dementia is difficult to exclude.

Once a diagnosis of dementia is likely the next step in the history is to determine the cause. Given
below are possible causes. Most points have been covered in the history earlier.

 Primary neurodegenerative disease

 Alzheimer’s disease
 Dementia with Lewy bodies
 Fronto- temporal dementia
 Huntingdon’s disease

46
  Vascular
 Following stroke

Alzheimer’s DLB FTD Vascular

Insidious onset Fluctuating course Insidious onset Past history of stroke
Progressive Visual hallucinations Progressive Signs of cerebro-
Short term memory loss Parkinsonism Loss of social conduct vascular disease
Loss of language skills Recurrent falls Prominent behavioral Emotional and
Dyspraxia changes personality changes
Behavioral changes
Restlessness at night
Wandering
Psychiatric features
Delusions
Hallucinations

 Inflammatory and autoimmune –SLE and other vasculitis with CNS involvement
 Traumatic – Ask for history of repeated head injury
 Infections -HIV, Neurosyphillis. Therefore ask for history of sexually transmitted disease
 Neoplastic – Brain tumors- Ask for early morning headache, vomiting and visual disturbances
 Metabolic and endocrine -Organ failure, Hypothyroidism, Vitamin B12 deficiency, chronic
alcohol abuse
 Other - Normal pressure hydrocephalus – Ask for incontinence and difficulty in walking.

 Obtain the other components of the history

 Family history
 Past medical and surgical history
 At the end in the personal history describe in detail how the patient attends to his/her
activities of daily living and the family and social support available to the patient.
ADL should include
Washing, cleaning, eating, dressing etc.

Examination

 Mental state examination

Appearance and behavior – Look for signs such as self neglect, restlessness, abnormal behavior
and disinhibition
Speech – Look for decreased language skills which are a typical feature of dementia
Mood – Look for associated depression

47
 Thought – Look for persecutory delusions
Perception – Hallucinations
Cognition
Insight

 MMSE
 Extended cognitive functions
Frontal lobe
Speech and verbal fluency
Digit span test
Abstract reasoning
Sequencing

Parietal lobe
Dominant hemisphere
Drawing
Calculation
Praxis
Non dominant hemisphere
Neglect

Temporal lobe
Memory

Investigations

Blood investigations – FBC, ESR, Urea and electrolytes, serum creatinine, liver function tests, thyroid
function tests, VDRL, HIV screening

Urine

Neuro imaging – CT/MRI, Further investigations may be carried out as necessary

Outline of management

 Assessment
 Care giver education and support
 Non pharmacological management
 Pharmacological management

48
Management

 Make a proper assessment. The objectives of this assessment should be to

o Make a diagnosis of dementia
o Identify the cause
o Identify the associated medical and psychiatric co morbidities
o Assess the risk to the patient and caregivers
o Assess the activities of daily living
o Social support available to the patient
 Scales used for assessment
Cognitive function – NuCOG, ADAS-Cog, CAMCOG, Hopkins verbal learning test, mental test
score
Behavioral and psychological features – MOUSEPAD, BEHAVE-AD
Activities of daily living – Bristol scale, Disability assessment for Dementia
Depression – Hamilton scale, Cornell scale
 Setting
 Manage any coexisting medical illness
 Non pharmacological management
This should be considered under several themes. These are given below. Non pharmacological
management is a very critical aspect of the management.
Care giver education and support
Day to day activities
o Training on activities of daily living such as cleaning, eating, washing and dressing if
these are significantly impaired.
o Planning of activities based on a simple routine
o Memory aids such as a large calendar and clock, schedules of daily routine, memory
books, medicine reminders
o Physical exercise and outdoor activities
o The patient may have trouble sleeping. This may be minimized by increasing daytime
activity, avoiding sleep during daytime
o Complete unfinished family responsibilities

Modifications in the home environment

o Remove barriers, obstacles and risk areas and appliances

o Ensure good lighting
o Paint walls in a light color
o Prevent wandering
o Marking the way around the house with sign boards
o Toileting
o Make a simple indoor arrangement

49
 o Keep pictures which remind the person of friends and family and important events at
various places in the house

Sensory stimulation using music

Behavioral management

 Pharmacological
Pharmacological management should be started by a specialist. There are several options. These
drugs are only used if a clear diagnosis of Alzheimer’s disease is made
AChEI – Donepezil, Rivastigmine (Can only be used if the MMSE is greater than or equal to 12.
NMDA receptor partial antagonist memantine can be given at MMSE 3-14

Dose of Rivastigmine – 1.5mg/bd increased in steps of 1.5mg up to 3-6mg/bd. Can cause GI side
effects

50
The patient with alcohol use problems

 Presenting complaint and history of presenting complaint – The patient may present with a
medical or surgical condition related to abuse of alcohol or with an alcohol induced psychiatric
disorder. Therefore describe this event in detail.

 History of drinking
o When did the patient start? Also state the duration that the patient has been consuming
alcohol
o Type of alcohol
o Why did he start to drink?
o Amount and frequency over time
o Any change in the type of alcohol consumed?
o Why did the patient continue to take alcohol?

 Usual drinking pattern

o Describe the present drinking pattern
o Any change from the usual drinking pattern?
o Last drink, any period of abstinence from alcohol and the circumstances

 Features of alcohol dependence based on the ICD 10 criteria

 Ask the following from the patient

o Strong desire to take the substance

o Difficulty in controlling substance taking behavior- onset, termination, level of use
o Withdrawal state (Asked in detail later during the assessment)
o Tolerance
o Progressive neglect of alterative pleasures or interests
o Use despite clear evidence of harm

 Look for 3 or more of the above during the last year

 Other features may suggest alcohol dependence
 These are relief drinking, where the patient takes more and more drinks to avoid withdrawal
symptoms. They also may become secretive about the amount consumed. Also they develop a
stereotyped pattern of drinking.

 The next step is to elicit the complications of alcohol abuse

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 Neuropsychiatric

History of intoxication (Severe): Disturbed level of consciousness

Significant behavioral change
Memory blackouts
History of withdrawal: Ask for these symptoms in periods of abstinence from alcohol
In the 1st 48 hours: Tremulousness
Agitation
Nausea, sweating, retching
Disorders of perception, such as auditory and/or visual
hallucinations
Epileptic seizures

After about 48 hours Delirium tremens

Altered consciousness, abnormal cognition
Gross tremors
Autonomic disturbances (sweating, palpitations)
Insomnia
Hallucinations – visual hallucinations (threatening animals such
as snakes, Lilliputian hallucinations)
Dehydration

Wernicke’s encephalopathy: Impaired consciousness

Diplopia
Ataxia
Korsakoff’s syndrome: Impaired recent memory
Confabulations

Psychiatric disorders Depression

Anxiety
Homicide
Suicide
Pathological jealousy
Sexual dysfunction
DSH

 Physical
Do an extensive systemic review and past medical history to identify co morbidities

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  Social problems
Violence at home, emotional and conduct disorders in children, effects on relationships, work
place, legal and financial problems
 Willingness to change and goals
 Past history of interventions done and the outcome of these interventions
 Other substance use
 Personal history and social support
History of childhood problems
Occupation
Relationships
Forensic history – i.e. driving under the influence of alcohol
 Pre morbid personality
Look for an anxious personality, low self esteem and self confidence, poor coping skills in day to
day life, antisocial personality, impulsive.
Also leisure activities, religious and moral values

Examination
Mental state examination

Appearance and behavior

 Describe the appearance of the patient well
 Look for tremors
 Behavior – irritable and anxious

Speech
 Slurring of speech

Mood
 Subjective and objective assessment. Look for associated depression
 Suicidal ideas

Thinking
 Attitudes on taking alcohol
 Persecutory delusions
 Delusions of jealousy

Perception
 Illusions
 Hallucinations – Alcoholic hallucinosis

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Cognitive functions
 Orientation may be impaired due to withdrawal and Wernicke- Korsakoff syndrome
 Short term memory may be impaired due to Wernicke – Korsakoff syndrome
 Multiple losses of cognitive function may indicate alcohol induced dementia.

Insight

Do a relevant physical examination

Assessment and management

 Make a proper assessment based on the history and examination and identify

o Is there a problem?
o How severe is the problem? – features of alcohol dependence
o Identify associated physical and psychological co morbidities
o State of change of the patient. (Pre contemplation, contemplation etc.)
o Resources for change

 Consider use of the brief intervention. This is not useful in severe cases of alcohol misuse i.e. in
alcohol dependence. The main components are

o Identify risks and discuss consequences

o Provide medical advice
o Solicit patient commitment
o Identify goal—reduced drinking or abstinence
o Give advice and encouragement

Motivational interviewing

In more severe cases the technique of motivational interviewing is used. The principles are as follows.

o Give a feed back on his assessment

o Non judgmental approach
o Expressing empathy
o Roll with resistance
o Develop discrepancy between how the client wants to be and how they are now

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 o Develop a change in the patient based on the advantages and disadvantages of his
behavior.
o Support self efficacy
o Move the client through the cycle of change

Interventions based on the cycle of change

Usually the patient will be in the state of pre contemplation or contemplation. Given below are the
specific points which should be stressed during the interview

o Improve the knowledge of the patient

o Improve self efficacy
o Change the patient’s concept of being content with the present. Use a table similar to
the one given below.

Advantages Disadvantages
Using
Stopping

Once the patient is in the determination phase

o Reinforce and strengthen the commitment to change and improve self efficacy
o Help the patient devise a plan to change
 Identify what has and what has not worked previously
 Identify the internal and external triggers for the behavior such as mood,
special occasions and celebrations
 Seek the patients idea about strategies for avoiding or dealing with triggers and
replacing the benefits brought on by the undesired behavior
 Suggest social support, self reward, environmental change as possible helpful
options
 Advise the patient to use available social support
 Go through the plan with the patient and understand strengths and
weaknesses of the plan
o Arrange follow up

Detox the patient

o Decide setting
Outpatient: Uncomplicated alcohol withdrawal

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 Patient living close to the hospital
Good family and social support

Inpatient: Past history of complicated alcohol withdrawal

Current symptoms of confusion
Co morbid physical/ mental illness
Suicide risk
Lack of social and family support

Management of alcohol withdrawal

o Observation and monitor pulse rate, respiratory rate and blood pressure
o Also observe sleep, appetite, behavior, suicidal attempts
o Ensure proper hydration
o Proper nutrition and vitamin supplementation-Thiamine 100mg IM for 4 days then 10mg/ day
orally for 3 months
o Look for clinical features of withdrawal – prodromal features and features of delirium tremens
o Chlordiazepoxide fixed dose regimen – dose depends on the patient, tail off over 7 days
otherwise the patient can develop dependence.
o The dose can also be calculated based on a formal scale such as the CIWA scale. But this is not
usually done
o Manage other complications as necessary
 Seizures – benzodiazepines
 Psychosis – haloperidol 5-10mg oral

 Maintenance with counseling, problem solving skills, relaxation training, anger management,
group therapy. This is done at institutions such as Mal Medura.
 Pharmacological treatment to maintain alcohol abstinence

Disulfiram
Acamprosate – Dose 666mg 3 times daily. Can cause GI side effects.

Naltrexone

Follow up

o Review the effectiveness of the plan and critically review the strengths and
weaknesses.
o Modify the plan as necessary

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Relapse

o Make the patient realize that a relapse is normal

o Identify the precipitating cause for the relapse and why the patient could not face up
to it
o Improve self efficacy
o Reassess the current stage and act accordingly

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The patient with use of illicit drugs

Introduction to the patient

Presenting complaint and reason for consultation

History of the substance use

o When did the patient start? Also state the duration that the patient has been using the
substance
o Type of substance and route of administration
o Method of administration
o Why did he start to use the substance
o Amount and frequency over time
o Describe the use in terms of money spent
o Periods of abstinence in the past and why?
o Any change in the type of substance or any other substances consumed?
o Why did the patient continue to use the substance

Current drug use pattern

o Describe the present pattern

o Where does he obtain the substance from?
o Any change from the usual pattern?
o Last use and period of abstinence

Features of dependence based on the ICD 10 criteria

Ask the following from the patient

o Strong desire to take the substance

o Difficulty in controlling substance taking behavior- onset, termination, level of use
o Withdrawal state
o Tolerance
o Progressive neglect of alterative pleasures or interests
o Use despite clear evidence of harm

Look for 3 or more of the above during the last year

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Complications due to use of the substance

Physical

o History of overdose
o Hepatitis B and C
o HIV
o Infective endocarditis
o Local infection

Psychiatric

o Depression – Look for features of depression

o Anxiety
o Ask for suicidal ideas and episodes of deliberate self harm

Social problems related to the use of drugs

Previous treatment episodes

Present attitude to change his behavior

Family history
Family history of drug use/ alcohol problems, psychiatric illness

Personal history
Was anyone in the family a drug addict?
Childhood experiences with substance abuse
Education level
Relationships with the family members
Sexual relationships
Problems in the family

Forensic history
Was he in prison for use and possession of illicit drugs?

Pre morbid personality

Look for an anxious personality, low self esteem and self confidence, poor coping skills in day to day life,
antisocial personality, impulsive.
Also for leisure activities
Religious attitudes

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Examination

MSE

Do a routine MSE especially with the aim of identifying substance induced psychiatric symptoms and
also coexisting problems such as depression.

Investigations

 Urine drug screen – Amphetamines, benzodiazepines, cocaine metabolites, codeine/morphine,

cannabis
 FBC, LFT, HIV and hepatitis screening if required

General principles of management

 Motivational interviewing based on the state of change model by Prochaska and Diclemente
 Treatment setting
 Look for physical complications of drug therapy
Local
Systemic
 Detoxification
 Psychological therapy
 Rehabilitation

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 Heroin Cocaine Cannabis
Active substance and Opioid. Blocks reuptake of 9-delta-
mechanism of action Acts through stimulation dopamine into pre tetrahydrocannibinol
of the opioid receptors synaptic terminal
Methods of use Oral, inhalational, Inhalational, parenteral Inhalational
parenteral
Effects Euphoria, analgesia Increased energy, Mild euphoria, sense of
Nausea, vomiting, euphoria, grandiosity, enhanced well being,
constipation disinhibition, paranoid relaxation
Constipation psychosis with violent
Dependence behavior Anxiety, depressive illness
Feeling as if bugs are Can precipitate an episode
crawling under the skin of schizophrenia
Can cause arrhythmias,
myocarditis and
cerebrovascular disease
Withdrawal features Intense craving for the After acute use
substance, sweating, Anhedonia, fatigue,
dilated pupils, anxiety, hypersomnolence
tachycardia,
hypertension, After prolonged use
piloerection, rhinorrhea, Intense craving for the
abdominal cramps, and drug, depression, suicidal
nausea and vomiting. ideation
Disturbance of
temperature control

Management Follow general principles Follow general principles Follow general principles
Management of
withdrawal

Manage the features of

withdrawal on a
symptomatic basis

Pain with PCM

Diarrhoea with
Loperamide
Nausea and vomiting with
Metaclopramide
Rhinorrhea with
clophenaramine
Psychotic symptoms with
haloperidol

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Deliberate self harm

History

Introduction to the patient

Presenting complaint and mode of referral

This will usually be a referral from a medical ward after ingestion of organophosphates, kaneru seeds or
pharmacological substances such as paracetamol

History of the presenting complaint

 Describe the precipitating event for the act in detail – i.e. After a broken love affair
 How did the patient react to this event? Describe the details up to the point of the actual
suicidal act
 Look for features of psychiatric illness during this period – depression, stress reaction
 Evaluate the actual suicidal intent. The points are given below
 Ask about circumstances related to the event
o Degree of planning
o Suicide note
o Any final acts carried out by the person in response to death
o Precautions against discovery and/or intervention
o Communication of intent before act
o Acting to gain help before or during the intervention
o Isolation
o Timing of event
o Purpose of the event
 Also ask on
o Expectations regarding the fatality of the act
o Conception on the lethality of the method
o Seriousness of the attempt
o Ambivalence towards living
o Conception of reversibility
o Degree of premeditation
 Evaluate the further risk of suicide
o Ask if the patient still believes he should end his life
o Look for the presence of psychiatric illness – Depression, psychotic illness
o Ask for further stressors

Past psychiatric history

 Past suicidal attempts and their circumstances

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  Past history of psychiatric illness

Past medical history

Substance use

Family history – DSH, suicide, mood disorders

Personal history

The main objective of this is to highlight any predisposing, precipitating and maintaining factors

 Childhood stressors
 Relationships with parents
 Education level
 Marriage and other relationships
 Work place
 Financial status
 It is very important to evaluate and describe the social support available to the patient

Pre morbid personality

 Coping skills
 Relationships
 Social interactions
 Impulsive/aggressive
 Self confidence
 Religious beliefs
 Hobbies
 Habits

MSE

Do a routine MSE especially looking for features of psychiatric illness

Management

 Do a detailed assessment using the history and mental state examination. This assessment
should give the following details
Suicidal intent of the act – Use a suicidal intent scale such as Beck’s suicidal intent scale
Present state of suicidal ideation
Current problems

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 Is there a psychiatric disorder?
The resources of the patient – both personal and social support

 Decision to admit - Look for any indications for admission

Current suicidal ideation
Symptoms of psychiatric illness
Poor social support
 If admitted monitor the patient closely in ward – Appetite, sleep, behavior, suicidal attempts,
psychiatric symptoms and signs
 Manage psychiatric illness if present
 Psychotherapy
Help the patient cope with the current stressor
Improve general coping skills
Improve problem solving skills with problem solving counseling – In this method the patient is
asked to make a list of problems that he or she is currently encountering and prioritize them.
After this the counselor helps to discuss various solutions to the problem. After finding the best
solution he or she is asked to try it out. The results are then discussed at a follow up session.
 Family discussion and educate the family

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