Manic

Mania and bipolar affective disorder

Signs of mania include

1. Mood : irritability, euphoria, lability

2. Cognition : grandiosity, flight of ideas, racing thoughts, distractibility, poor concentration, confusion, lack of insight

3. Behaviour : Rapid speech, hyperactivity, insomnia, hypersexuality, extravagance

4. Psychotic : delusions, hallucinations

*Less severe state: hypomania
*Occur alternative with depression: bipolar affective disorder

Causes:

1. Physical: Infections, hyperthyroidism, SLE, thrombotic thrombocytopenic purpura, stroke, ECT

2. Drugs : Amphetamine, cocaine, antidepressants, cimetidine, captoril, steroids, L-dopa, baclofen

Treatment:

1. Olanzapine 10mg PO / sodium valproate 250mg/8h PO: acute moderate/severe mania

2. Lithium carbonate: prophylaxis

3. If lithium doesn’t give good control; consider lamotrigine (if mostly depression) or cabamazepine (if mostly manic)

Mnemonic for bipolar diagnosis: INSPIRE

I ncrease activity
N eed for sleep is reduced
S peed of thought increase
P ressure of words
I ncrease self-esteem / grandiosity
R educed inhibition
E asily distracted

Reference:

1. Oxford Handbook of Clinical Specialty

2. Mnemonics for Medical Undergraduates (PasTest)

Schizo!

Schizophrenia

Mnemonics involving schizophrenia

1. Diagnosis of Schizophrenia: DEAD

D isordered thoughts – withdrawal, insertion, broadcasting

E xperience passivity

A uditory hallucination

D elusion

2. +ve symptoms for Schizophrenia: THREAD

T hought disorder

H allucination

R educed reality contact

E motional disturbance

A rousal

D elusion

3. –ve symptoms for Schizophrenia: LESS

L oss of activeness

E motional flatness

S peech reduced

S lowness in psychomotor

Better prognosis if: sudden onset, supportive home, no negative symptoms, marked mood disturbance

Rx: Antipsychotics [Typical: chlorpromazine, haloperidol; atypical: risperidone, olanzepine, clozapine]

Reference:

1. Oxford Handbook of Clinical Specialty

2. Mnemonic for Medical Undergraduates

3. Schizophrenia and Antipsychotic Lecture by Dr. David Hayward

Anxiety

Neurosis refers to maladaptive psychological symptoms not due to organic causes or psychosis and usually precipitated by stress.

Generalized anxiety disorder: anxiety which present for more than 6 months with associated somatic symptoms and causing functional impairment

Symptoms of anxiety include tension, agitation, and feeling of impending doom, trembling, collapse, insomnia, poor concentration, goose flesh, hyperventilation, sweating, palpitation, poor appetite, nausea, and difficulty getting to sleep.

Causes could be stress, life events, genetic predisposition or faulty learning

Treatment would involve

1. Symptom control: listening is a good way to decrease anxiety

2. Regular exercise; meditation; relaxation

3. Cognitive behavioural therapy

4. Anxiolytics – diazepam, paroxetine, buspirone, beta-blocker, SSRI

*Easy Mnemonics to remember

Patient complain of PPI:

Panic Attacks, Pervasive apprehension, Impending doom

Abnormal worry: POOR

Painful, Out of proportion, Out of control, Recognisable

Reference:

1. Oxford Handbook of Clinical Specialty

2. Neurotic Conditions Lecture by Dr. David Hayward

3. Mnemonics for Medical Undergraduates (PasTest)

Mental State Examination

Mental State Examination

1. Appearance and Behaviour
It include the physique, clothes, cleanliness, hair, makeup and whether it is appropriate for the age, sex, cultural group and social class of the patient. It is important to pick up signs of self-neglect (poor hygiene, body odour, stained clothes)
Look at the manner the patient act towards the interviewer (anxiety, friendly, cooperative, complaining, suspicious, or critical)
Take note of the psychomotor activity which includes facial expression, posture and gait. (Too little movement; too much movement; involuntary movement)

2. Speech
Look at the rate, rhythm, volume and tone of speech. Also note the quantity and quality of the speech.
Retardation is a delay in starting to speak and rate of speech. Mutism is total absence of speech. Pressure of speech describes rapid outpouring ideas that are often difficult to interrupt. Flight of ideas describes the speech of manic patient move rapidly from one subject to another, usually with some discernible association.

3. Mood and Affect
Mood is the overall impression of mood over the duration of interview while affect is moment to moment variability and responsiveness.

Subjective mood – How have you been feeling recently?
Objective mood – sadness, anxiety, or happiness conveyed through facial expression, posture and motility (weeping, euphoria, irritability)
Autonomic activity – Sweating, palpitation, dry mouth, hyperventilation, and increased frequency of micturition associated with anxiety, acute or chronic schizophrenia

4. Cognition
Orientation – Time, place, person
Attention
Concentration
Short and long term Memory
*basically use MMSE and MSQ

5. Thoughts
Suicidal ideas or self harm – ask about plans, attempts, preparation, perception of the event and perceived fatality
Flow – flight of ideas, word salad, circumstantial
Content – unusual beliefs/ overvalued ideas/ delusions
Alienation – Insertion, broadcast, withdrawal, blocking

6. Insight
Describing patient’s beliefs regarding their symptoms and treatment. It is an understanding of the presence, nature of mental illness and its causes.
*What does the patient believe is the problem? What does the patient believe will help?

7. Perception
*Have you heard voices of people that you couldn’t see? have you noticed any changes in yourself or your surroundings that you can’t account for?
Illusions – misinterpretation of external stimuli
Hallucination – perceptions that are not based on external stimuli; perceived as real
Pseudohallucination – lack the quality of vividness and reality that are possed by normal perceptions and hallucination; often have an ‘as if’ quality

Reference:
1. Mental State Examination Tutorial by Dr. Sharon Butler
2. Oxford Handbook of Clinical Specialties 8th Edition
3. Psychiatry in Medical Practice 3rd Edition