Assessment & Specific Managements

Alcohol Use
Biological

- Liver Failure, Cirrhosis, Liver Cancer

- Malnutrition  Prone to Infection
- GI Cancers
- Wernicke’s Encephalopathy
- Karsakoff Syndrome – Variable Retrograde Amnesia

Psychological

- Dependence, Tolerance, Withdrawal Symptoms

Social

- Inability to keep up with social responsibilities, work, school, relationships etc.

Complications of Chronic Alcoholism

CNS/PNS - Wernicke-Korsakoff Syndrome
- Optic Neuropathy
- Alcohol Related Cognitive Impairment (Alcoholic Dementia)
- Haemorrhagic Stroke
- Cerebellar Degeneration
GI - Alcoholic Hepatitis
- Alcoholic Steatosis
- Pancreatitis
- Peptic Ulcer
- Gastritis
- Cancers
CVS - Arrhythmia
- Hypertension
- Ischaemic Heart Disease
Immunodeficiency - Infection Risk
Endocrine - Hypoglycaemia
- Hyperlipidaemia
- Hypertriglyceridemia
- Hyperuricemia
MSK - Gout
- Avascular Necrosis
- Myopathy
Reproductive - Sexual Dysfunction
- Fetal Alcohol Syndrome
Trauma - Head Injury
- Fractures
- Soft Tissue Injuries
Haematology - Red Cell Macrocytosis
- Anaemia
Delirium Tremens
Clinical Features

- Acute Confusion 2˚ Alcohol Withdrawal

- 5% of Episodes of Withdrawal
- Onset 1-7 days after Last Drink
- Features of Uncomplicated Withdrawal
o Coarse Tremor, Sweating, Insomnia, Tachycardia, NV, Psychomotor Agitation, Generalized
Anxiety
- Additional Features
o Clouding of Consciousness
o Disorientation
o Amnesia for Recent Events
o Hallucination (Liliputian)
o Marked Fluctuations in Severity, Hour by Hour, Usually Worse at Night
- Severe Cases
o Heavy Sweating, Fear, Paranoid Delusions, Agitation, Suggestibility, Raised Temperature,
Sudden CVS Collapse

Management

- Care in Well Lighted, Quiet Room

- Hydration
- Long-Acting Benzodiazepines (e.g. Chlordiazepoxide)
- Give thiamine to prevent progression into Wernicke’s Encephalopathy
- Check for Complications of Alcohol, e.g. GI Bleeding
- Rule out Organic Causes
- Long Term Plan:
o Detoxification (BZD Reducing Regiment) (e.g. Chlordiazepoxide)
o Regular Follow up for Complications of Alcohol, Compliance of Chlordiazepoxide

Detoxification for Alcohol Withdrawal

1. Decide on Setting: in patient or out patient
2. Assess need for BZD reducing regiment (Chlordiazepoxide)
o Consider Need for Other Medications
 Antipsychotics
 Supplementary Vitamins: Thiamine
 Wernicke-Korsakoff Syndrome
 or Evidence of Malnourishment
o Find Lowest Possible Dose that Suppresses Withdrawal Symptoms
o Taper Off over 1 week
3. Provide Verbal and Written Advice
o how to quit education
4. Inform GP of Plans
5. Give Patient a Contact in case of an Emergency
6. Decide on adequate follow up time
- Outpatient for most uncomplicated cases
Indication for Inpatient Detox

- Past History of Complicated Withdrawals (Seizures or Delirium)

- Current Symptoms of Confusion or Delirium
- Comorbid Mental/Physical Illness, Polydrug Misuse, Suicide Risk
- Symptoms of Wernicke-Karsakoff Syndrome
- Severe NV, Severe Malnutrition
- Lack of Stable Home Environment

Alcohol Withdrawal Syndrome

Uncomplicated Alcohol Withdrawal Syndrome

- 4-12hrs after last drink

Somatic Coarse Tremors

Nausea, Vomiting
Autonomic – Sweating, Tachycardia, Hypertension, Pupil Dilatation
Psychomotor Agitation
Insomnia
Perceptio Hyper-Acusis
n Hallucinations (any modality), Illusions, Delusions
Mood Anxiety, Depression

w/ Seizures (Rum Fit Seizures)

- 5-15% complicated by Grand Mal Seizures

- 6-48hrs after last drink
- Predisposing Factors: Previous History, Idiopathic Epilepsy, Hx of Head Injury, Hypokalaemia

Management Alcohol Misuse

- Psychoeducation  Involve Family
- Motivational Interview  State of Change
- Plan intervention  Continue VS Cut down
o Abstinence vs Controlled Drinking
- Life Style Modification
o Avoid High Risk Settings when Drinking
o Avoid Heavy Drinking Acquaintances
o Set Limit
o Self-Monitoring
o Reward System
o Rate Control, Spacer Drink
o Eat Before or During
- Residential Abstinence can be considered
- Pharmacological
o Thiamine
o Aversion: Disulfiram
 Irreversible Inhibition of Aldehyde Dehydrogenase
 Unpleasant Symptoms when drinking
o Anti-Craving (for once abstinence achieved)
  Acamprosate
 Reduces Alcohol Craving
 Act Through Enhancing GABA Transmission in Brain
 S/E: GI Upset, Pruritus, Rash, Altered Libido
 Naltrexone
 Antagonizes Effects of Endogenous Endorphins Released by Alcohol
Consumption
 Diminishes both desirable experience and loss of control
- Group
o Alcoholic Anonymous
- Psychological
o CBT
 Invite for Collaboration
 Set Goals
 Coping Styles
 Cognitive Restructuring
o Social Skills Training
o Relaxation Training
o Problem-Solving Skills
o Anger Management
o Relapse Prevention
- Social
o Medical Social Worker to help enlist in appropriate social support resources
 E.g. Housing, financial aid

Wernicke-Korsakoff Syndrome

Wernicke Encephalopathy
Clinical Features

- Acute Confusion State

- Ocular Sign (Ophthalmoplegia, Nystagmus)
- Ataxia
- Associated: Peripheral Neuropathy, Resting Tachycardia, Nutritional Deficiency

Treatment

- High Potency Parenteral Thiamine Replacement and Multivitamin

o Avoid Carbohydrate Load Prior to Thiamine Replacement Completion
o 30 mins twice daily for 3-7 days
- Assess for Alcohol Problems, and need for Detox
- Assess and Treat for Alcohol Withdrawal Syndrome

Korsakoff Syndrome
Clinical Feature

- Variable Length of Retrograde Amnesia

- Working Memory Unimpaired
- Procedural and “Emotional” Memory Unimpaired
Treatment

- Continue Oral Thiamine Replacement and Multivitamin Supplementation

o For up to 2yrs
- Treat Psychiatric Comorbidity
- OT Assessment, Cognitive Rehabilitation

Bipolar Affective Disorder

Pharmacological

- Mood Stabilizer – Lithium (1st line)

Psychotherapy

- Psychoeducation
- CBT – Coping Strategies, Facilitate Compliance
- Interpersonal and Social Rhythm Therapy (IPT/SRT)
o Reduce lability of mood
o Maintain Regular Pattern of Daily Activities
- Family Therapy
- Support Group

Manic Episode
Pharmacological

- Mood Stabilizers, as Acute Treatment as well as Prophylaxis

o Lithium (1st line)
o w/ Psychotic Symptoms
 + Antipsychotics
 ECT is Severe
o w/ Catatonia
 admit to Hospital
 Treat w/ ECT and/or BZD
o w/ Suicide Risk – admit for ECT
o w/ Violence Risk – Admit
o w/ Substance-Related Disorders
 Address Misuse Issue
 Detoxification as Required
 Admit to Hospital
- If Severe Behavioural Disorder
o Haloperidol + Clonazepam (or Lorazepam/Diazepam)
- Stop Antidepressants if Any

Depressive Episode
Pharmacological

- Patient on Prophylaxis Already

o Optimize, Check Serum Levels
 o Consider & R/O, Other Conditions
o Consider adding Antipsychotic
 Quetiapine, Licensed to Treat Depression in BAD
 Olanzapine-Fluoxetine Combination (Licensed)
o Or SSRI
- If Evidence of Recent Mood Instability
o (1st line) Increase or Recommence Anti-Manic Agents
o (2nd Line) Lamotrigine
- If No Response to SSRI
o Alternative Antidepressant
o Or Add Quetiapine/Olanzapine
- If Life Threatening – ECT
- Once Remitted – Taper Off after 8wks maintenance treatment
o Continue Mood Stabilizer to Prevent Relapse

Childhood Psychiatric Diseases

- ADHD (Methylphenidate, Atomoxetine)
- Tic Disorder (Anti-psychotics, Clonidine)
- Enuresis (TCA, DDAVP)
- ASD (Aripiprazole, Risperidone, Melatonin)
- Depression
o 1st Line: Fluoxetine
o 2nd Line: Sertraline, Citalopram
- Social Phobia (SSRI)

ADHD
Treatment

- Psychoeducation
o Advice and support to parents and teachers
- Family Therapy
- Liaison with Schools for support, as well as with family
- Medication: Methylphenidate, Atomoxetine
- Behavioural Intervention:
o Encourage realistic expectations
o Positive reinforcement
o Consistent Contingency Management at Home and at school
o Break Down Tasks
o Reduce Distractions
- Treat any comorbidities

Out of Home Care

- For when Child’s condition is caused by a family situation
- OR when the family cannot care for the child
- AND every action has been tried to improve family situation, but to no avail
- A Last Resort
Setting: Foster Care, Children’s Home, Boarding School

Increased Risk for

- Psychopathology
- Conduct Disorder
- Substance Abuse
- Criminality

Delirium
Aetiology

- Infection (Sepsis, Bacterial Endocarditis, Chest Infection, Wound Abscess)

- Metabolic (Anaemia, Hypoglycaemia, DKA, Electrolyte Disturbances, Hepatic Encephalopathy)
- Vascular (CVA)
- Traumatic (Contusions)
- Inflammatory (Lupus)
- Endocrine (Thyroid, Adrenal)
- Substance and Withdrawal (Alcohol-Wernicke’s Encephalopathy, BDZ)

DELIRIUM

- Drugs
- Electrolyte and Metabolic Imbalance
- Lack of Drugs, or Withdrawals
- Infective
- Reduced Sensory Input
- Intracranial
- Urinary or Fecal Problems
- Myocardial (Heart) and Lungs

Management

1. Solve Precipitating Cause

2. Environmental Modification
o Isolated Environment
o Remove Triggers
o Restrains to prevent fall/injury
o Put up large clock and a calendar
o Removal of Nearby Dangerous Objects
3. Drug
o Haloperidol for Psychotic Control
o BZD (only if case of BZD or alcohol withdrawal)
4. Regular Clinical Assessment
o Close Monitoring by Staff

Vs Dementia
- Main Difference:
 o Impairment in Consciousness
o Sudden Onset

Dementia

BPSD Assessment
BPSD: 6 Domains (Apathy, Aggression, Agitation, Depression, Anxiety, Psychosis)

- Mood – Fluctuating? Low/High

- Personality
- Violence Risk, Safety Issues, Self-Neglect, Self Harm
- Psychotic Symptoms – Delusions, Persecutions, Hallucinations
- Behaviours – Sleep, likes taking walks

Specific Cognitive Impairment

- Learning and Memory

- Perceptive Motor
- Language
- Complex Attention
- Executive Function
- Social Cognition

Screen

- Vascular – Stroke, Hemiplegia/Numbness

- Parkinsonism – Tremors
- SA/A
 - Head Injury
- Carer Stress

Management

Alzheimer’s disease
- Life Expectancy: 10 years

Investigations

- Physical Exam, for Focal Neurological Signs (Poorer Prognosis, e.g. Apraxia)
o R/o Parkinson’s Disease
- Blood Tests
o FBC, LFT, U&E, Fasting Glucose, TFT, CaPO4, Magnesium
o VDRL, HIV Antibody
o Vitamin B12, Folate
o CRP, ESR
- EEG (exclude Delirium, CJD)
- Brain Imaging:
o CT, MRI

Psychotherapy

- Reality Orientation
- Refer to OT: Cognitive Stimulation Programme 認知訓練
- Behavioural Interventions

Pharmacotherapy

- Drugs and Compliance Therapy (Alzheimer’s Disease)

o AChEIs – NVD, Bradycardia, Bronchoconstriction (for AD w/ MMSE > 10)
 Donepezil (Long Half Life)
 GIT Side Effects at High Dose
 Bradycardia
 GIT Bleed (Rare)
 Contraindicated in Asthmatics
 No Liver Toxicity
 Rivastigmine (Short Half Life) (Patch form)
 Local Irritation
 Not Metabolized by Liver
 Less Drug-Drug Interactions
o NMDA – Receptor Partial Antagonist
 Memantine
 For DAT, Vascular, Mixed Dementia
- Psychiatric Medications for BPSD 心理／行為

Social

- Home Safety
o Electric Stove Instead
 o Avoid Clutter (Fall Risk)
- Promote Protective Factors
o Environmental Cues – Large Calendars, Clocks, Reminders
o Don’t give too much money at once
o Avoid Changes to the Environment
o Encourage Exercise
o Cognitive Stimulating Activities – Learn Things, Mah-jong
o Avoid Conflicts
- Occupational Therapy, Maintenance of ADL
- Social Worker: Elderly Home Referral
o Day Centre: 老人中心
- Psychosocial Support for Carer Stress
o Refer to Appropriate Community Facilities
o Screen Mental Health

Dementia with Lewy Bodies

- Antipsychotics – Avoid/Use with Great Caution
o Severe Sensitivity, e.g. Irreversible Parkinsonism, Impairment of consciousness, NMS
- AChEIs, not yet recommended by UK Guidelines
- No clear Evidence for Antidepressants, Anticonvulsants or BZDs

Fronto-Temporal Dementia (FTD) (Pick’s Disease)

- No specific Treatment
- AChEIs – Unlikely to be beneficial
- SSRIs – Limited Benefits for Behavioural Symptoms

Vascular Dementia
- Establish Causative Factors
- Early Medical or Surgical Treatment
- Daily Aspirin May Delay Course of Disease
Depression

Depression and Grief

Depression Grief
Trigger Any Loss of Someone
Duration ≥ 2 weeks < 12 months
Differentiatin Preoccupation with: Preoccupation with Diseased
 g Symptom - Worthlessness
- Guilt
- Suicidal Thought
Progression Static/Chronic or Worsens Progressive Improvement (Transient decline on
special days)
Stages None Parke’s or Kubler Ross
- excessive guilt - Disbelief, shock, numbness, feeling of
o about other things, unreality
rather than those - Anger
surrounding death - Feeling of guilt
- Psychomotor Retardation - Sadness & Tearfulness
- prolonged period of inability to - Insomnia
function - Disturbed Appetite
- Hallucination, not of the - Seeing/hearing voice of deceased
deceased - Can still experience positive emotions
- "Mummification" - e.g. laying - Thoughts more related to deceased
place setting, or not changing - Less Functional Impairment
house at all - Treatment mainly psychological

Parke’s – Alarm, Numbness, Pinning, Denial & Depression, Recovery & Reorganization

Kubler Ross – Denial, Anger, Blaming, Depression, Acceptance

Management
- SSRI
o Depends on Age, Sex, S/E Profile, Previous Response, Medical Condition of the Patient,
Symptomatology
- Antipsychotic if Psychotic Symptoms
- Psychotherapy
o Psychoeducation – Coping Strategies
o Self Help
o CBT
o Exercise Therapy
- Initial Follow-up will be Fairly Frequent (2-4 weeks), monitor treatment response
o Monitoring of Unwanted Side-Effects

w/ Psychotic Features

- (1st Line) ECT

- Combination Treatment (Antidepressant + Antipsychotic)
o Start Antipsychotic First for a few days
 Allow for Assessment to Exclude Primary Psychotic Disorder

Maintenance Therapy

- First Episode
o Continue Effective Treatment for 6mths to 1yr after remission, taper off slowly
o If during Tapering, Symptoms Re-emerge  Effective dose for ≥ 4-6mths
- Recurrent Episodes
o If Period between episode < 3y or Severe Episode  Prophylactic Treatment Maintained for ≥
5yrs
 Postpartum Depression
- Develops within 6mths after childbirth
- Depressive Symptoms
- Typical Anxious Preoccupation related to baby

Management

- Early Identification and Close Monitoring

- Education and Support
- Pharmacological: Antidepressants ± Brief CBT
- Hospital Admission if Risk

Puerperal Psychosis
- 1.5/1000 live births
- Peak occurrence at 2weeks postpartum

3 common Presentations

- Prominent Affective Symptoms (80%) – Mania or Depression w/ Psychotic Symptoms

- Schizophreniform Disorder (15%)
- Acute Organic Psychosis (5%)

Common Features

- Lability
- Insomnia
- Perplexity, Bewilderment, Disorientation
- Suicide or Infanticide

Risk Factors

- Personal/Family History of Major Psychiatric Disorder

- Lack of Social Support
- Single Parenthood
- Previous Postpartum Psychosis
Management

- Identification, Education, Support

- Treatment
o Admission
o ECT, Mood Stabilizers
o Antidepressants – if depressed
o Usual Protocol for Antipsychotics – if psychotic features

Serotonin Syndrome
Clinical Features

- Neuromuscular: Tremor, Rigidity, Myoclonus, Hyper-reflexia

- Autonomic Dysfunction: Hyperthermia, GI Upset, Tachycardia, Hypertension
- Mental: Confusion, Agitation, Coma

Management

- Emergency: Activated Charcoal, Gastric Lavage

- Supportive:
o IV Fluid  Correct Volume, reduce risk of rhabdomyolysis
o If Rhabdomyolysis  IV Sodium Bicarbonate to maintain urine output
o Reduce Temperature  Cooling Blanket, Ice Packs
- Pharmacological:
o BZD (Lorazepam) for Seizure, Agitation, Rigidity, Myoclonus
o Anti-hypertensives  Hypertension
o Serotonin Receptor Antagonist  Cyproheptadine

Treatment Resistance
- Failure to response to 2 antidepressants at adequate dose and duration (≥ 4 weeks)

Management

- Review Diagnostic Formulation

- Address Comorbidities
- Check Compliance
- Continue Monotherapy at Max Tolerable Dose
- Consider:
o Change Antidepressant (different class)
o Augment w/ Mood Stabilizer
o Additional Augmentative Agents (T3, Tryptophan)
o Combining Antidepressants from Different Classes
o ECT

STAR*D Trial
The Sequence Treatment Alternatives to Relieve Depression Trial

- For Non-Psychotic Major Depression

 Level 1 Citalopram
Level 2 Switch to
- Bupropion, Sertraline, Venlafaxine XR or Cognitive Therapy
OR Augment Citalopram w/
- Bupropion, Buspirone or Cognitive Therapy
Level 2a If Cognitive Therapy Alone or + Citalopram
- Add or Switch to Bupropion or Venlafaxine XR
Level 3 Switch to
- Nortriptyline or Mirtazapine
OR Augment w/
- Lithium or T3
Level 4 Switch to
- Tranylcypromine
OR
- Venlafaxine XR + Mirtazapine

Eating Disorder

Anorexia Nervosa
- Some may have Sexual Assault in the past
o Those would require more rigid treatment, and longer Psychotherapy

Management

- Most as Out-Patients
o In Patient if:

Extremely Rapid/Excessive Weight Loss

Severe Electrolyte Imbalance

Serious Physiological Complications
 e.g. Temperature < 36˚C, Fainting due to Bradycardia
 Cardiac Complications or other Acute Medical Disorders
 Severe Malnutrition  Marked Changes in Mental State
 Psychosis, Suicide Risk
- Combined Approach is best:
o Psychological:
 Family Therapy
 As patients may refuse eating not due to fat phobia, but instead be a
“protest” of sorts
 Individual Therapy
 CBT (May improve long term outcome) (Less Evidence)
o Pharmacological
 No drug treatment that is properly approved with good evidence
 Fluoxetine ± Olanzapine (but patients tend to reject due to weight gain)
o Education
 Nutritional Education (Challenge over-valued ideas)
 Self Help Manuals (Bibliotherapy)

Re Feeding Risk
 - Cardiac Decompensation – Myocardium cannot withstand Stress of Increased Metabolic Demand

Poor Prognostic Factors – Rule of Thirds (1/3 recover, 1/3 partial, 1/3 chronic)

- Chronic
- Late age Onset
- Bulimic Features (BP)
- Anxiety
- Excessive Weight Loss
- Male
- Poor Childhood Social Adjustment
- Fat Phobic
- Poor Parental Relationship

Bulimia Nervosa
Management

- Usually Managed as Outpatient

o Unless suicidal, Physical Problem, Extreme Refractory, or Pregnancy
- Psychological
o CBT (Best evidence)
 Highly Evidence Base as Psychotherapy for BN
 3 meals per day
 enough per meal
 starvation is the major sure step to developing BN
 No Snacking
 Stimulus Control (e.g. Don’t Buy Snacks)
 Binge Eating requires the right stimulus and the right environment cues
o E.g. alone, no one watching, feeling low
 Self-Monitoring (Diary)
 Exploring the Positives and Negatives
- Pharmacological
o SSRI
 Fluoxetine is the only evidence based Pharmacological Treatment
 20mg, titrate up to 80mg
 Usually High Dose (60mg) – Long Term Treatment Necessary (>1y)

Prognosis

- Generally Good, Unless Poor self-esteem or concurrent PD

Neurotic

GAD
Psychological

- Generally, Less Effective than other Anxiety Disorders (lack of Situational Triggers)
- CBT, Relaxation and Psychoeducation
Pharmacological

- Buspirone (For Psychic Symptoms)

o Anxiolytic, but not GABA related, hence less dependence issues
- BZDs (for Somatic Symptoms)
o Lorazepam, Diazepam
- Antidepressants
o SSRI (Low Dose) e.g. Escitalopram (Licensed)
o SNRI (Licensed) – Duloxetine, Venlafaxine
o Trazodone (Licensed)
- β-blocker (Cardiovascular or Autonomic Symptoms)

Alternatives/Additional

- Beta blocker, Pregabalin

- BZD if necessary

Prognosis
Poor Factors

- Functional Impairment
- Comorbidities
- Family History
- Premorbid Personality
- Social Support

Chronic and Distressing, Generally Poor Prognosis w/ Low Remission Rate

- 30% Remission w/ treatment for 3 years

OCD
Psychological

- CBT – Exposure and Response Prevention (ERP)

- Behavioural Therapy – to prevent Ritualistic Behaviour

Pharmacological

- Antidepressants
o (1st Line) SSRI – Escitalopram, Paroxetine, Sertraline, Fluoxetine for ≥ 12 wks
o (2nd Line) Clomipramine – Specific Anti-Obsessional Effects
o High Doses for the above (low dose for other things using SSRI, High for Eating Disorder)
- Antipsychotic (Risperidone, Haloperidol)
o As Augmentation
o For if Psychotic Features, Tics, or Schizotypal Traits
- If Marked Anxiety – Buspirone/Short-Term Clonazepam

Physical

- ECT (if suicidal or severely incapacitated)

 Panic Disorder w/ Agoraphobia
Management

- Psychological
o CBT
 Behaviour Therapy, to Treat Phobic Avoidance by Exposure
 Use of Relaxation to control Hyperventilation
 Exposure Therapy
 Educate Model of Panic Cycle, Break cycle by rejecting false assumptions
o Psychodynamic – Panic Focused
- Pharmacological
o (1st Line) SSRIs – Citalopram, Escitalopram, Paroxetine, Sertraline (NOT Fluoxetine)
o BZDs – only to cover symptomatic relief in combination with antidepressants
 For 1-2 weeks
o If Successful: Continue for 12-18mths before trial discontinuation
 Tapering over 2-4mths
 If Recur – Continue for ~1y before Trial Discontinuation

Prognosis
- Untreated  Chronic
- w/ Treatment
o 25-75% Recovery within 1-2 years
o 10-30% within 5 years
o 50% in long term w/ mild symptoms

Poor Factors

- Severe Initial Symptoms

- Marked Agoraphobia
- Low Social Status
- Less Education
- Long Duration of Untreated state

PTSD
Functional Impairment

- Household/Family
- Occupational
- Childcare
- Social/Interpersonal Function
- ADL

Treatment

- Build Rapport
- Bio – Pharmacological
o SSRI (Paroxetine, Sertraline, etc.)
o For Hyperarousal: Buspirone, BZD (If necessary)
o Propranolol
 o SGA
- Psycho
o CP for Trauma-Focused CBT
 Psychoeducation
 Graded Exposure to Targets of Avoidance
 Relaxation Therapy, Breathing Exercises
o Eye Movement Desensitizing and Reprocessing
 Saccadic Eye Movement while thinking about memories associated with trauma
 To reduce associated anxiety and reprocess emotions
o Hypnotherapy
o Psychodynamic Therapy
o Supportive Therapy
- Social
o CPN
o Social Worker, for CSSA, if cannot work
o Functional Rehab
o Caregiver Support

Prognostic Factors

Pre-Trauma Coping Behaviour, Personality, History of Psychiatric Co-Morbidities

Peri-Trauma Involvement, Nature, Duration, Severity, Disfiguration or Physical Harm
Post-Trauma Mal-Adaptive Behaviour, Health Seeking Behaviour, Severity of PTSD, Blaming, Guilt,
Functional Impairment, Social Support

Social Anxiety Disorder

Psychological

- (1st Line) CBT – Individual or Group

o Relaxation Training
o Social Skills Training
o Integrated Exposure Method

Pharmacological

- SSRI – Escitalopram (Licensed), Sertraline (Licensed)

- SNRI – Venlafaxine (Licensed)
- or MAOI (Unlicensed)
- β-blocker (e.g. Atenolol) – reduce autonomic arousal

Psychosis

Schizophrenia Management
- Psychological
o Psychoeducation, to family as well
o Family Therapy, Carer’s Stress
o CBT (Less Evidence)
- Pharmacological
 o SGA  (if First Episode) continue for 1-2 years
o BZD/IM Haloperidol if disruptive behaviour
- Social
o Social Work and Housing Involvement  for enlisting into adequate social resources
o Community Psychiatric Nurses  Educate & Monitor

Negative Symptoms
- Lack of Volition
o Lack of incentive to do daily tasks
- Flattening of Affect
o Inability to experience different emotions
- Alogia
o Slowing of thoughts
o Lack of spontaneous thoughts

Neuroleptic Malignant Syndrome

- After Use of Antipsychotic
- Not Dose Related
- Insidious onset of 4-11 days after Dose Increase or Initiation
- Lasts for 7-10 days after stopping, 21 days after depot injection

Presentation

- Neuromuscular: Rigidity, cramps, tremors, bradykinesia, stiff pharyngeal/thoracic muscles (Dysphagia,

Dyspnea), Bradyreflexia
- Autonomic Dysfunction: Hyperthermia, Hypo/Hypertensive, Tachycardia, Sweating, Salivation, Urinary
Incontinence
- Acute Mental Confusion, Stupor, Coma, Delirium, Agitation

Biochemical Changes

- Raised WCC, CK, ALT

- Hypertensive Crisis and Metabolic Acidosis

Pathophysiology

- Blockade of D2 Receptor in Nigrostriatal Tracts  Neuromuscular abnormalities

- Release of Intracellular Calcium  Muscle Rigidity, Rhabdomyolysis  Raised, WCC, CK, ALT

Complications

- Pneumonia
- Renal Failure
- CVS Collapse
- Thromboembolism

Investigation

- Urine Toxicology
- Urine Myoglobin, Serum CK
 - ABG  Acidosis
- PT/PTT  DIC
- CBC, LRFT, CaPO4

Risk Factors

- Young
- Agitated, Bipolar
- Dehydrated
- Self-Neglect
- But mostly Idiopathic
- SGA can also cause NMS

Can be Mimicked by Serotonin Syndrome  Rapid Onset, but Less Muscle Rigidity, with Hyperkinesia

Management

- Refer to Medical ICU (Cannot manage in Psychiatry)

o Emergencies: Respiratory Failure, Renal Failure
- Supportive as in Delirium
o Move to Isolated Room
o Remove Stimulus and Triggers
o Put up Large Clock and Calendar to Help with Orientation
o Remove Dangerous Objections
- Close Monitoring: BP, HR, RR, SaO2, MSE
- Pharmacological
o Don’t give IM Injections
o BZD for Disruptive Behaviour
o Stop the Antipsychotics
o To Reduce Rigidity: Dantrolene
- Supportive
o Hydration  IV Fluid
o Oxygen
o Reduce Temperature – Cooling Packs
o Rhabdomyolysis:
 Urine Alkalization by IV Sodium Bicarbonate (Prevent ARF)
- Pharmacological (for Rigidity)
o 1st line Dentrolene, Lorazepam
o 2nd line Bromocriptine/Amantidine
o 3rd line ECT/Nifedipine

Prognostic Factors for Schizophrenia

Good
- Marked Mood Disturbance, Especially
Elation, During Initial Presentation
- Family History of Affective Disorder
- Female
- Living in Developing Country
- Good Response to Treatment
Poor
- Poor Premorbid Adjustment
- Insidious Onset
- Onset in Childhood/Adolescence
- Cognitive Impairment
- Enlarged Ventricles
- Co-morbidities
 - Sudden Onset - Male
- Presence of a Stressor
o 20% Remission
o 40% Relapse
o 40% Chronic

Schizophrenia vs Alcoholic Hallucinosis

Schizophrenia Alcoholic Hallucinosis
Age of Onset <40 >40
Onset Insidious Acute
Duration Chronic Three Months
Heavy Drinking -ve +ve
Delusions Any 2˚ to AH
Thought disorder +ve -ve
Affect Blunted/Incongruent Appropriate
Family History Schizophrenia Alcoholism

Schizophrenia vs Schizoaffective vs Affective Disorder with Psychotic Features

Schizoaffective

- Look at temporal relation between affective symptoms and psychotic features

- Presence of ≥ 2 months of psychotic features in the absence affective symptoms

Schizophrenia

- Prodromal Negative Symptoms

- Disorganized Speech and Behaviour

Affective w/ Psychotic Features

- Mood Congruent Affect and mood congruent psychotic features

Look into FHx as well

Treatment Resistance Schizophrenia

- Failure to respond to ≥ 2 antipsychotics given in therapeutic dose for ≥ 6 weeks

Management

- Review Diagnostic Formulation

- Address Comorbidity – e.g. Comorbid Substance Misuse
- Check Compliance – Psychoeducation, Compliance Therapy, Family Therapy
- Pharmacological – Clozapine
o If Clozapine Resistance
 Switch to Previously Untried SGA
 Augmentation of Clozapine with Benzamides (Sulpiride, Amisulpride) and
Anticonvulsants (Lamotrigine)
 ECT – may be useful, no strong evidence

Substance Abuse
 Opioid
Withdrawal (HAM SCONE)

- Tachycardia, Hypertension (H)

- Abdominal Pain (A)
- Joint Pain, Muscle Cramps (M)
- Sweating (S)
- Piloerection (C)
- Watering Eyes and Nose, Yawning (O)
- NVD (N)
- Dilated Pupil (E)

Substance Induced Psychosis vs Schizophrenia

Substance Induced Schizophrenia
Onset Acute Insidious
Duration - During Intoxication Chronic
- During Withdrawal
- Residual afterwards
Delusions Secondary to Hallucinations Any, can be Separate from
Hallucinations
Thought Control Absent Can be Present
Negative Symptoms Absent Can be Present
Hallucinations Present (Visual Dominant) Can be Present
Substance Abuse History Precedes Psychotic Features Can be a Genuine Comorbidity
The Primary Cause
Family History +ve for SA +ve for Schizophrenia
Treatment Duration 6 months Usually Life Long
Condition Self-limiting once
abstinent

General Managements
History

- Affective Symptoms
- Psychotic Symptoms
- Recent Stressors
- Risk Assessment – Self-harm, suicidality, violence, maladaptive coping strategy
- Substance Abuse, Alcohol Abuse
- Functional Impairment – Self-care, Child care, social, occupational
- (Neurotic)
- (Dementia and BPSD)

Physical Examination

- Pupil Dilatation – Substance Abuse

- Autonomic s/s for Substance Abuse
- Neurological Exam
- Signs of Self Harm
 - Endocrine Examination: Thyroid Status
- Nutrition, Hydration Status

Investigation

- CBC (Anaemia)
- LRFT
- TFT
- CaPO4
- B12, Folate (Mainly for Dementia)
- Fasting Glucose, Lipid Profile
- ECG
- CT Brain
- (HIV Antibody, VDRL)
- Urine Toxicology – Especially if suspected Toxicity (e.g. NMS, SS)

Acute Management

- Compulsory Admission if Risk

- Environment:
o Quiet Single Room, Free of Hazardous Objects
o Comforting Staff
- Pharmacological:
o IM Haloperidol 5mg if w/ Psychotic Behaviour
o IM Lorazepam 2mg (Medium to Long Acting BZD)
- Physical: (If Pharmacological Fails)
o Safety Vest

Management

- Social Support “Optimize Social Functioning to Enhance Protective Factors”

o Integrated Community Care for Mental Wellness (ICCMW) – Depression, Psychosis
 For Daytime Activities
o Community Psychiatric Nurse Visits – Urgent Crisis Intervention (Form 12)
 Help to Provide Information/Education to Family
 Monitor Early Signs of Relapse
o Day Hospital or Day Care Centre
 Hospital  Professional Healthcare Services, Monitor Disease Progress
 Care Centre  Rehabilitation Activities, No Medical Professions, Mild and Better
Patients
o Medical Social Worker
 Enlist Appropriate Social Resources (i.e. Financial Benefits, Accommodation)
 Supervised Living Environment
o Supported Hostel
o Halfway House
o Long Stay Care Home
 Comprehensive Social Security Assistance
o Occupational Therapist  Functional Rehabilitation and Assessment
 Psychosis
  Dementia
 Affective
o Alcoholics Anonymous
o Encourage Family Participation
o Family/Marriage Counselling
- Bio – Pharmacological
o Sleep: Antihistamine (Piriton), Z-Drug, BZD, Melatonin
o Removal of Stressor for Temporary Relief
o Liaise w/ Medical if on Medication that induces Psychiatric Disorders (Steroids)
o Medication for Psychiatric Disorder
o Treat any Comorbidities (e.g. SA)
- Psycho – Psychotherapy
o CBT – Neurosis, Affective, BN
 Coping Strategies – Affective, Alcohol, Neurosis (PTSD)
o Supportive Therapy
 Social Skills Training – Affective, Alcohol, SAD
 Problem-Solving Skills – Alcohol, Neurosis, Affective
 Anger Management – Alcohol
 Relaxation Training – Neurosis, Affective
 Exercise Therapy – Depression
o Cognitive Remedial Therapy – Schizophrenic
o Psychodynamic Therapy – Depression, Panic Disorder
o Family Therapy – AN, Psychosis, Affective, Alcohol
o Interpersonal and Social Rhythm Therapy – Affective
 Structured Daily Routine; Sleeping pattern, adequate physical activities
 Avoid Excessive Stimulation & Reduce activities
 Delay Important Decisions
o Psychoeducation
 Risk Detection, Contingency Plan in Emergency, awareness of signs of relapse
 Encourage Participation, Guidance, Support
 Instil Insight, emphasize important of compliance

Admission
- High Risk of Suicide or Homicide
- Other Illness Related Behaviour, endangering relationships, reputation, assets
- Severe Psychotic, Depressive, Rapid Cycling or Catatonic Behaviour
- Lack or Loss of Appropriate Psychosocial Supports
- Failure of Out-patient Treatment
- Non-Compliance with Treatment Plan
- Lack of Capacity to Cooperate with Treatment
o Directly due to Illness
o Or 2˚ to Availability of Social Support/Outpatient Resources
- Significant Changes in Medication for Patient at High Risk of Relapse
- Treatment Resistance
- Initiation of ECT
- Need to Address Comorbid Conditions
 o Inpatient Detoxification
o Physical Problems
o Serious Medication Side Effects

Antipsychotics

SGA
- Pros
o Effective in Controlling Symptoms, Less EPSE, Wider therapeutic range
- Cons
o More Metabolic Side Effects, Therapeutic Effect Dependent on Compliance, NMS risk

Side Effects
Metabolic/Weight Gain

- Clozapine > Olanzapine > Quetiapine > Risperidone > Aripiprazole

Hyperprolactinaemia

- Risperidone > Olanzapine > Rest

ESPE

- FGA > Risperidone > Aripiprazole > Olanzapine > Quetiapine > Clozapine

Sedation

- Quetiapine > Olanzapine

o Olanzapine has the best Sleeping affect

Heart Stuff

- Avoid Clozapine
o Caution for 1st year Post-MI
- Avoid Phenothiazine (e.g. Chlorpromazine)
- Olanzapine Generally Recommended (Avoid High Doses)

Antidepressants
Pregnancy - Fluoxetine
- Nortriptyline
Lactating - Sertraline
- Paroxetine
Liver Disease - Imipramine
- Paroxetine, Citalopram (Avoid Sertraline) (SSRI Increase Bleeding
Risk)
AN/BN - Fluoxetine (Most Evidence for BN)
- Family Therapy/CBT (Repsectively 1st Line)
Fluoxetine

- Longer Half Life

 o Safer for those with high risk of overdosing – Suicidal

TCA Side Effects

- Antihistamine: Weight Gain, Sedation
- Anticholinergic: Dry Mouth, Blurred Vision, Urinary Retention, Constipation
- Anti-Adrenergic: Postural Hypotension, Sexual Dysfunction, Drowsiness
- Cardiotoxicity: Prolonged QT Interval, ST Elevation, Arrhythmia, Heart Block

SSRI Side Effects

Initial: Insomnia, Anxiety, Agitation, Suicidality
GI: NVD
Others: Headache, Weight-loss, Hyponatraemia (SIADH in elderly), Sexual Dysfunction, Fatigue

Benzodiazepine (BZD)
Dose Reduction

- Cut Dose by ~1/8th of total dose each fortnight

o Low Dose by 2.5mg fortnightly
o High dose 5mg fortnightly
- If Substantial Symptoms re-emerge  Review and halt or Temporarily Increase

Cognitive Behavioural Therapy

A Structured, effective, time-limited psychotherapy between psychiatrist and patient, to Balance the pros and
cons and weigh the automatic thoughts, to identify the dysfunctional thinking, associated emotions and correct
it, resulting in improvements towards the recovery goal.

- GAD: Relaxation Technique

- Phobic Disorder CBT: Graded Exposure Therapy
- OCD CBT: Exposure with Response Prevention
- Trauma CBT
- Eye Movement Desensitization and Reprocessing
- Delusion CBT: Reality Testing & Reframing, Insight Orientation

Behavioural Therapy

- Concerned with the factors that provoke symptoms and abnormal behaviours
- As well as the Maintaining factors for such symptoms and behaviours

Cognitive Therapy

- Identifies and attempts to correct the intrusive thoughts, Dysfunctional Believes and Attitudes
- which provoke the symptom/behaviours

Dysfunctional Thinking

- Overgeneralization
- Dichotomous Thinking
- Magnification
 - Arbitrary Inference
- Personalization
- Cognitive Deficiency

Delivery of CBT

- A Systemic Rational Restructuring

1. Presentation of Rationale
2. Overview of Irrational Assumptions (Common Irrational Assumptions)
3. Identify Clients Irrational Assumptions, Analysis of Client’s Problems, in Rational Emotive Terms
4. Teach Client to Modify such believes, by self talk, and putting it into practice

Steps

1. Every 6-8 weeks

2. Invite Patient’s Collaboration
3. Highly Structured: Set Agenda, Review Last Weeks Progress.
4. Attention to Provoking and Maintaining Factors
5. Present Ellis’ ABC Model
6. Attention to Ways of Thinking
7. Record Associated Thoughts/Mood with behaviour or emotional disturbance, and the provoking
situation
8. Homework Assignment
9. Practice New Behaviour with Therapist

Graded Exposure Therapy

- Treatment for Phobic Disorders

Desensitization

- Construct Hierarchy, making list of situations that provoke anxiety

- Enter or Imagine Entering Situations until done without anxiety
- Use relaxation methods while entering or imagine entering
- Repeat with each item

Flooding

- Enter situation near tip of hierarchy form start of treatment

- Remains there until anxiety diminished

Exposure in every day practice

- Sessions of 45mins
- Enter feared situation every day

OCD CBT: Exposure with Response Prevention

- For Obsessional Rituals
- Explain Rational for Treatment, Set and Agree on Agenda
- Modelling: Patient Demonstrate Necessary Exposure
- First Therapist Accompanies and Support patient to Prevent Rituals
 - Later Patient Alone
- Once Restraint Achieved  Increase Provocative Factor

Trauma CBT
- Psychoeducation
- Graded Exposure for Target of Avoidance
- Breathing Exercises and Relaxation Therapy

Eye Movement Desensitization and Reprocessing

3 Components

- Saccadic Eye Movement: while patient thinks about memories associated with incident
- Exposure: Imagine Scenes of Traumatic Event
- Cognitive: Replace Negative Thoughts associated with images

CBT for Panic Disorder

- Exposure Therapy – for phobic avoidance
- Breathing Exercise for Hyperventilation
- Educate on Panic Cycle, attempt to Break cycle by rejecting dysfunctional thoughts

CBT for Social Anxiety Disorder

Group or Individual

- Relaxation Training, Anxiety Management

- Social Skills Training
- Integrated Exposure Training
- Cognitive Restructurion

Cognitive Remediation Therapy

Designed to Improve Neurocognitive Abilities, such as: Attention, Working Memory, Executive Function,
Cognitive Flexibility, Planning, Executive Function, Leading to Improvement in Psychosocial Functioning

- Set of Cognitive Drills or Compensatory Interventions

- Designed to Enhance Cognitive Functioning
- Engages the participant in a learning activity to enhance neurocognitive skills relevant to overall
recovery goals

Mainly for Schizophrenia, Recent Attention towards Anorexia Nervosa

- By Becoming aware of problematic cognitive styles, patient can reflect on how these affect everyday
lives
- Learn to develop new strategies

Compliance
Medication Factor Disease Factor Patient Factor
- Complicated Regime, - Chronic, Remitting - Poor Insight
Polypharmacy Course - Poor Social Support
 - Intolerable S/E - Occupation
- Delayed Onset of
Therapeutic Effects

Compulsory Admission
Indication

- Harm to Self or Others

- Complications/Comorbidity
- Delirium

Mental Health Ordinance Cap 136

- Form 1: Social Worker/Family/Doctor

- Form 2: Another Doctor
- Form 3: District Judge

Crisis Intervention
- Offer assertive community outreach service to patients presenting high complexity level of risk for
harm reduction and to prevent the occurrence of community violence
- Signing of Form 12
- Before Intervention:
o Liaise with family for plan
 Informing need to recall patient to hospital in view of high violent risk
 Which family member are involved on day of crisis
 Who open the key of front gate?
 Remove potential weapons at home e.g. knife
 Look out for any rooms without window frame/any doors that can be locked from
the inside

ECT
No Absolute Contraindication

- Limit Use in:

o Cerebral Aneurysm, Intracerebral Haemorrhage
o Recent MI, Cardiac Arrhythmias, Unstable Vascular Aneurysm or Malformation
o Acute/Impending Retinal Detachment
o Phaeochromocytoma
o High Anaesthetic Risk

Procedures

- Fasting overnight
- GA
- Muscle Relaxants
 - Induce Generalized Tonic-Clonic Seizure
- Monitor: BP/P, SaO2, ECG, EEG

Side Effects

- Short Term Retrograde Amnesia, usually resolves completely

- Headaches
- Temporary Confusion
- Clumsiness
- Myalgia

Mortality: 2/100,000

Alternatives:

- CBT, Augmentation

Lithium Toxicity
Causes

- Dehydration (VD) (Infection)

- Hyponatraemia
- Renal Failure
- Suicidal Overdose
- Drug Interactions (NSAIDs, Diuretics, ACEI)

Symptoms: Dose-Related

- Low Dose, Early signs: Coarse Tremors, NVD, Anorexia, Dehydration, Lethargy
- High Dose:
o Neuromuscular: Restlessness, Myoclonus, Choreoathetoid Movement, Fasciculation
o Neurological: Nystagmus, Ataxia, Dysarthria, Hyperreflexia, Convulsion
o Renal: Oliguria
o Cardiovascular: Hypotension, Arrhythmia, Collapse
o Mental: Drowsiness, Confusion, Coma, Delirium
o Permanent Neurological Impairment, Death

Management

(Immediate)

- Stop Medication, Consult Medical!!!

(Investigation)

- CBC
- Blood Glucose
- RFTs & Electrolytes
- TFT
- ECG
(Monitor)

- Monitor Renal & Electrolyte Balance

- Serum Lithium (Q2-4H)

(Treatment)

- Supportive
o Hydration
o Correct Electrolyte Imbalance
- GI Decontamination (within 2-4hrs of Ingestion)
o Whole Bowel Irrigation w/ PEG Solution
o Via NG tube until Rectal Effluent Clear
o Not for Confusion/Lethargy
- Rapid Steps to Reduce Serum Lithium
o Forced Diuresis
 IV Isotonic Saline
o Serum [Li] ≥ 4, Severe Toxicity, Renal Insufficiency
  Haemodialysis
- Anticonvulsants for Seizure

Mood Stabilizers
Lithium:

- Polyuria/Polydipsia, Hypothyroidism, Renal Impairment, Weight Gain, Hair Loss, Sedation, Benign
Leukopenia, Oedema, Epstein’s Anomaly

Valproate:

- GI: NVD, Hepatotoxicity

- CNS: Sedation, Dizziness, Tremor
- Teratogenicity: Neural Tube Defect for Pregnancy, Cognitive Defect, Limb Defect

Carbamazepine:

- Dizziness, Diplopia, Sedation, Blood Dyscrasia, SJS, Neural Tube Defect

Lamotrigine:

- Cleft Palate, SJS, NV, Headache, Sedation, Dizziness, Aggression, Irritability, Agitation, Ataxia, Blurred
Vision, Diplopia

Neural Tube Defect – Prevention: Prophylactic Folic Acid

Antipsychotics:

- Antiadrenergic, Anticholinergic, Ant-Histaminergic: e.g. Weight gain

- Macrosomia due to GDM
MSE
- Appearance and Behaviour
- Speech
- Thoughts & Beliefs
- Perception
- Mood and Affect
- Insight

Risk Assessment
Past - Previous Attempts
- Method
- Remorse
- Maladaptive Coping Skills
- Protective/Risk Factors
o Demographic
o Psychiatric Disorder
o Medical Disorder
Present - Remorse
- Any Psychotic Features (Overvalued Ideas/Delusions)
- Precipitating
o Pre-existing Psychiatric Conditions
o Organic Causes
o Substance Abuse
- Plan
o Avoid being discovered
o Writing down will
- Impulsivity
- Preparation
o Lethality of method
o Access to Method
- Final Act
- Stressor – Is it Ongoing?
Future - Future Plans/Intentions
- Specific Targets
- Outlook in Life

SSRIs
Indications:

- Depression
- GAD, Social Anxiety Disorder, Panic Disorder
- OCD – High dose
- PTSD
- BN

Side Effects

- Initial Paradoxical Increase in Anxiety, Agitation or Even Suicidality

o Increased Suicidal Risk in Adolescent
 o Delayed Effect (2-3wks)  Clinical Effect takes time and are preceded by S/E
- Loss of Appetite/Libido
- Insomnia e.g. Fluoxetine
- Sedation e.g. Sertraline
- NVD
- Headache, dizziness, Tremor

Stimulants in Children
- Amphetamine
- For Psychotherapy Resistant ADHD
- Works by Enhancing Noradrenaline and Dopamine Transmission
- Improves Inattention, not Hyperactivity and Impulsivity
- 2/3 responsive
- Long Term Therapy Often Needed

Side Effects

- Nausea
- Insomnia
- Anorexia
- High Dose: Aggression, Seizures, Psychosis