Psych Interns - Manual

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Departmentof Psychiatryand BehavioralMedicine

Universityof the Philippines- PhilippineGeneral Hospital
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TABLE OF CONTENTS
IA. PsychiatricHistoryTaking
18. History Taking in Consultation-LiaisonPsychiatry 1

II. Objective Examinationin Psychiatry 4
111
. Proc~ss of Diagnosis in Psychiatry and Biopsychosocial Formulation 6
IV. Overview of PsychiatricConditions 9
V. Modalities of Treatmentin Psychiatryand Introductionto Psychotherapy 12

VI. Process of Treatment in Psychiatry 16
VII. Psychosis 19
VIII. Depression 21
IX. Bipolar Disorder 23
X. Delirium 24
XI. Substance Related Disorders 25
XII. Suicide 26
References 27
28
Appendix I. Common PsychotropicMedicationsand Their Usual Dose
29
Appendix II. Mini M~ntal Status Examination
30
AppendixIll. SamplePsychiatryChartEntry(forC-L)
31
Preparedby: ConstantineL. Yu Chua, MD; Oct 2016

For the exclusiveuseof UP-PGHmedical interns.
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IA. PsychiatricHistory Taking
FORMAT OF DOCUMENTATION IN PSYCHIATRY
Subjective: Objective:
o Chief Complaint and Informants o Physical Examination
o Pre-morbid personality, or o Neurologic Examination
baseline level of psychological o Mental Status Examination
and occupational functioning o Standardized tests (e.g.,
o History of Present Illness MMSE)
o Review of Systems Assessment: DSM-5 diagnosis if
o Past Medical History applicable, may provide short
o Family Medical History formulation/explanation
o Substance History Plan: biological , psychological, and
o Anamnesis social interventions/recommendations
Chief Complaint and Informants

Chief complaint is written verbatim as much as possible, both "according to patient" and "according to
companion (specify who)" .Their reliability levels are also noted (good/fair/poor or through percentages) .
Premorbid personality
This is a statement of the patient's usual personality prior to the history of present illness (HPI) . For
purposes of medical charting in the ER or ward , at least the baseline level of psychological and socio-
occupational functioning should be indicated (e.g., previously well with no psychiatric symptoms , able to
interact well and has average school performance) . This will situate the HPI.
History of Present Illness (HPI)

Elicit details regarding onset and quality of symptoms, as guided by the common diagnos tic
syndromes in the DSM. The best way to document is to label the symptoms using psychiatric
terminology then describe (e.g., patient presented with auditory hallucinations , such that he
would hear a voice telling him to kill himself which would cause him anxiety but he was able to
ignore). This way , it would be easy to "match" the symptoms with the DSM criteria .
Aside from the history of symptoms , the psychiatric history must include the F.A.C .T.S. :
o .E unctionality
• Knowing the patient's level of function during the onset of symptoms and during the
interim will be useful for diagnosis (e.g., presence cognitive decline and subtle
residual symptoms in chronic schizophrenia, history of hypomanic episodes in bipolar
depression , etc .) and goal setting (i.e., what can be a realistic goal for treatment
based on patient's baseline) .
o Abuse of substances / Another medical condition
• These always have to be ruled out because these may be a significant comorbid of
the patient or may even be the etiology of the psychiatric symptoms .
o friteria for admission
• During the interview, the clinician should already an idea if the patient needs to be
adm itted to the hospital or not. (see Part VB - treatment process in psychiatry)
o Irauma or triggers
• Identifying a traumatic event or triggering situation for the episodes will aid in
diagnosis (e.g., adjustment disorder, post-traumatic stress disorder , specific phobia),
prognosis , and treatment planning (i.e., addressing the trigger) .
• The discont inuation of a medication is a very common "trigger· for relapse and this
should be noted, as with the reason for stopping so it can be addressed .
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o §creening
• The clinician can run down common symptoms in five major criteria of psychiatric
disorders to ensure completeness. Thereby, it is important to include pertinent
negatives.
FIVE CLUSTERSOF SYMPTOMSFOR "PSYCHSCREENING"

1. Psychotic symptoms
2. Depressive symptoms
3. Manic symptoms
4. Anxiety symptoms
5. Delirium or encephalopathy symptoms - especially those with medical comorbids,
abnormal ROS/PE/NE, acute onset of psychiatric symptoms, or atypical age of onset.
TABLE I. COMMON MISTAKES IN PSYCHIATRIC HISTORY TAKING AND HOW TO CORRECT THEM
CommonMistake Correction
Focusing too much on external As muchas possible, explorethe internal experienceand ~Sl£Chiatric
events or acts. SJlmptoms of the patients.
Example: asidefromjust mentioning agitation, indicatewhat the patient
thoughtor felt that led him to becomeagitated?Was he paranoid?Was he
irritable?Was he disorientedand anxious?
Eliciting only non-specific Althoughtheseare importantto assessseverityof the disorder, they do not
symptoms such as "behavioral contributevery muchto diagnosis.
change", agitation, sleep Example:asidefromjust mentioning "behavioralchanges·, run down
disturbance, or withdrawal. characteristic symptomsseenin the DSM- hallucinations, delusions,
mooddisturbances , grandiosity, unfoundedguilt, suicidal thoughts, etc_
Eliciting insufficient symptoms to Makesureto run throughsymptomscomprehens ively (e.g., 5 for
meet any diagnosis. psychosis , 9 for depression , and so forth). Mention pertinent negatives to
showthat all symptomswereexplored. The pertinentnegatives are also
importantto distinguish normal emotionalstatesversuspathologic ones.
Taking interpretations by Patientsandfamiliesoftenmisuseterms. The interview shoulddescribe
informants as is (e.g. "na- whatthe informantsmeanby the termsthey use. Theycan be assisted
depress kasi siva"). with close-endedquestions regardingsymptoms.
Failing to note pertinent Partof DSMcriteriafor a particular disorder is the exclusion of other
negatives. conditions , so be sureto includenegatives. It is also important for patients
who undergomentalhealth screenino.
Failing to elicit and describe A priordiagnosismuststill be describedto confirmif it is correct or if
previous episodes OR just phenomenology of the condition has shifted(e.g., somepatientswho
stating "known case of __ " initiallypresentas depressedmay actually havea prodrome of
schizophren ia or are actuallybipolar, etc).
An endorsementof "knownschizophrenia" thenzeroing in to the current
episodeis NOTacceptable .
Taking a "story-telling" tone in Althoughdetailsare helpful, theyshouldbe labeledwith formalterminology
documenting the HPI as with otherspecialties of medicine. Usingpsychiatric termswill help the
clinicianmatchit to the list of symptoms in the DSM.
Alwaysrememberthat the psychiatric documentationis partof the medical
chartandshouldbe statedin a wav befittino it.
Past medical history
llli Aside from medical conditions, hospitalizations,surgeries, and allergies, include psychiatric consults.
admissions, and history of psychotropic intake (identify the specific drugs, doses, effects, compliance and
reason for shifting if possible). Also include accidents, especially head trauma.
Family medical history

Aside from medical conditions, this should include psychiatric illnesses, substance abuse, and suicidal
behavior in the family. These predispose the patient both neurogenetically and psychologically.
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Include all other components of history taking as applicable: 08-GYN history, developmental and
immunization history, etc.
Substance-use history
Includeage of initiation,frequency, quantity, responseduringintoxication, and the presence of
withdrawal.Featuresof substanceuse disorder(see Part XI) should also be elicited.
Anamnesis
The usualpersonal-socialhistoryis alreadycoveredin the anamnesis, includingthe HEADSSS part in
adolescents. In short, there is no need for a "personal-socialhistory" part. Anamnesis refers to the "life
story" of the patient.As a guide, the anamnesisgives us an idea of the patient's P.A.S.T.:
f ersonality
• This includesthe patient'sway of perceivingthe self and the world and how he reacts to this.
Track the continuityfrom childhoodto adulthood- if there are significantchanges and how these
changescame about.Some things to be watchfulfor include:
o Borderlinepersonalitydisorderfor personswho have multiplesuicide attempts.
o Antisocialpersonalitydisorderfor drug abusersand perpetratorsof violence.
o Dependentor avoidantpersonalitypatternsin personswith depression.
• Patternsof impulsiveness,criminality, difficultymaintainingrelationships, low self-esteem, and
the like shouldbe elicited.
• Usual coping styles shouldalso be elicited.
_Activities
• This would includethe patient'sinvolvementand aptitudein school, home and community
activities, leisure, and work. Some thingsto be watchfulfor include:
o Patternsof underachievementor over-involvement.
o Occupationalproblemssuchas truancy, bullyingor being bullied, running away from
home,terminationfrom work, etc.
o Legalconflict (e.g., historyof arrests,havinga lawsuit)
§,ocialrelationships
• This would includethe qualityof relationshipsthe patient has with his family, peers, friends, and
intimatepartners. Some things to be watchfulfor include:
o Who he/she is currentlylivingwith.
o Sourcesof social support
o Who raisedthe patient and how
o Complicatedor problematicrelationshippatterns
o Uniquesocial situations(e.g., being adopted, parents havinga divorce, growing up with
multiplecaregivers,having a same-sexpartner, etc).
o Possibleneglector abuse, whetherphysicalor emotional
Iraumatic events or turningpoints

• Examplesof traumaticeventsare child abuse, neglect, exposureto violence, bullying, sexual
assault, verbalabuse, participationin military activities, and the like.
• Also note turning points in the patient'slife such as when he/she got started into illegal drugs,
began criminalactivities, joined an organization, etc. Explorehis motivationsbehind these.
The anamnesisis importantin the establishmentof a biopsychosocialformulation. Management-wise, it

will guide the doctor regardingthe type of psychotherapymost suited for the patient as well as social
interventionsthat need to be enacted. In a more diagnosticpoint of view, some differential diagnosesmay
not always be evident in the HPI but can be elicitedthrough an anamnesis, such as personalitydisorders.
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18.HistoryTakingin Consultation-Liaison
Psychiatry
Consultation-Liaison(C-L) psychiatryis a subspecializationof psychiatryfocusing on the interface

betweengeneral medicineand psychiatry/mentalhealth. In the hospital, the C-L section sees patients
confined in other wards who have psychologicalor psychiatricconcerns. History taking in C-L psychia!ry
is unique in the followingways:
1) "Reasonfor referral"is indicatedat the beginning.

This will guide the psychiatristin what to answer or addressfor the primary service, being a
consultationservice.
2) Medicaldiagnosisand medicaltreatmentplan are reviewedand noted in the start
3) Most important:Medicaland psychiatrichistoryare unified.

Do not limit the history to the medicalaspectbecausethe primary service already knows this. The
usual kinds of patientsreferred, and the generalstructureof the history is as follows:
A. Knownpsychiatricpatientswho incur a medicalproblem.

}> Discussthe psychiatrichistory as usual
}> Discussthe developmentof the medicalillness
}> FOCUS: How did the medical illnessaffect the chronic psychiatricconditionand vice versa?
• Did it causean exacerbationof symptoms?
• Did the patienthave adversepsychologicalreactionsto the illness as a stressor?
• Did the psychiatricconditionand/orits treatmentcontributeto the developmentof the
medicalillness(e.g., self-neglect, side-effectof medications, etc)?
B. A patientwith severemedicalconditionwho may haveadversepsychological/behavioral reactionsto it.

>" Indicatethe developmentof symptoms
>" FOCUS: How did the patientrespondor cope to this? Followthe "A.B.C.":
• ~ffect (feelings)
• §ehavior (copingstrategies)
• fognit ion (thoughts).
>" Run-downcommonpsychiatricsymptoms,especially regardingdepressionand anxiety. Make
sure to note pertinentnegatives.
}> When did he/sheknowthe diagnosis(e.g., malignancy)?
}> Does he/sheunderstandthe diagnosisand its implications(treatment,prognosis)?What was
the psychologicalresponseto this knowledge?
J> What does he/sheexpectfrom the diseaseand its treatment?Is this realistic?
}> What is the most difficultpart of the condition?What is the source of strengthor support?
}> What are his/herplansthroughthe courseof the condition?
C. A patientwho has psychiatricsymptomsdirectlybecauseof a medicalproblem(e.g., delirious patient).

l> Describethe medicalhistoryand adequatelysituate in the timcline when the very first
psychiatricmanifestationsoccurred. ....
}> Note of introductionof medications,as these may also cause psychiatric disturbances.
>" Make a specialnote reviewinglaboratoryfindings.
>" Take specialnote of the featuresof delirium (see Part X)
4) Short "coursein the wards"or the patient'scurrentstatus should be included after the HPI
proper. Indicate if there are problemssuch as:
• Agitation
• Non-adherence
to treatment
• Hostilitytowardsstaff or watchers
• Inabilityto sleep/ poor intake
• Overlydependent behavior
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5) Assessment can be an answer to a query the primary service has presented , depending on the
reason for referral.
• "No psychopathology" denotes a normal reaction to an illness . Indicators include :
having no DSM diagnosis or frank psychiatric symptoms, use of mature defense
mechanisms to cope with illness , adequate familial support , and adequate resources for
treatment.
• Ability to provide informed consent means that the patient is able to fully understand
his/her condition, the indication of the procedure , risks and benefits , alternative
treatments, resources needed, prognosis, and post-procedural care . The patient should
have not been coerced by anyone . Usual events that impair ability to provide informed
consent include severe psychosis , intellectual disability, and neurocognitive disorder such
as in delirious states, among others .
6) For purposes of endorsing in the C-L conference, state the psychiatric diagnosis first then
the medical diagnosis.
7) "Recommendations"which address the primary's concern may be included in the plan . This
need not be limited to diagnostics and medications .
See Appendix 3 for an example of psychiatry chart entry.
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II. ObjectiveExaminationin Psychiatry
Physical Examinationand NeurologicExaminationare performedas usual.
Format of the NeurologicExamination:

o Sensorium (GCS score), higher cortical functions (aphasia, apraxia , other descriptions)
o Cranial nerve examination
o Motor examination (muscle tone and strength)
o Sensory examination
o Deep tendon reflexes and primitive reflexes
o Cerebellar examination
o Meningeals
I. Mental Status Examination
Format of Documentingand Reportingthe MSE:
I o
o
o
General survey (appearance and behavior, speech, eye contact, attitude)
Mood and affect
Thought process
o Thought content
I o
o
Perception
Sensorium and cognition
I • The clinician may elicit findings from the patient in any sequence. In fact , most of the items in the
MSE can be noted already by simply talking with the patient without need for formal testing . Try to
be as "smooth" as you can in eliciting MSE findings as you progress in training .
• Pertinent negatives should always be stated.
I •
•
If an item cannot be assessed , the clinician may write this down and explain the reason for it. Do
not confuse this with a negative finding .
The clinician is not limited to the terms used below. In fact, it is encouraged to give a qualitative
I description or explanation of the findings.
General Survey
1. Appearance
1· a. Apparent physical features: presence of wounds, deformities , medical contraptions such
as NGT , IV line, foley catheter, splint, use of wheelchair , etc.
b. Manner of dressing: appropriate/inappropriate for age/sex/situation
I c. Personal hygiene: kempUunkempt

d. Psychomotor symptoms: restlessness, psychomotor retardation/agitation , tics ,
compulsions , extrapyramidal symptoms , involuntary movements , etc .
2. Eye contact: good/fair/poor , shifting, fixed, etc.
I 3. Speech
a. Production : unresponsive, uses gestures only, hypoproductive , normoproductive ,
pressured speech (cannot be interrupted), incoherent
b. Tone or rate: slow/normal/fast , monotonous, dramatic/theatrical, etc .
I- c. Volume : sofUnormal/loud
d. Other details: child-like , highfaluting, etc.
4 . Attitude toward the interviewer: cooperative , hostile, evasive, dismissive , overly familiar , etc.
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Mood and affect

1. Mood:
0 Refers to how the patient feels, regardless of expression .
0 Euthymic, elevated/elated/euphor ic, depressed, anxious , irritable, dysphoric , labile
2. Affect:
0 Refers to the emotional expression of the patient.
0 Full (100%) "? constricted (-75% , can be normal in those who are wary to show how they
feel)"? blunted (-50%, not considered normal anymore) "? flat (0%)
0 Congruent or incongruent with mood.
Thought Process
o Refers to the flow of thoughts in the patient's mind, which is best reflected through his speech
and manner of answering questions .
o Common disorders includes :
1. Circumstantiality - patient answers are only partially connected with the question , usually
involving irrelevant details.
2. Tangentiality - patient's answers are totally disconnected from the quest ion.
3. Flight of ideas - patient has a lot of ideas which are connected to each other but are coming
in and out of his/her mind too fast for completion .
4. Looseness of associations - patient's ideas are no longer connected to each other or do not
follow conventional logic.
5. Thought blocking - when an otherwise cooperative patient does not answer particular
questions (as if not hearing anything), usually questions of more personal content
* Tangentiality and looseness of association denotes a disorganization of thought commonly
attributed to psychosis ; circumstantiality and flight of ideas are commonly attr ibuted to man ia.
Thought Content
o Refers to the things that the patient thinks about or believes .
o Common disorders includes :
1. Delusions: fixed , false beliefs not amenable to logical explanat ion
a. Bizarre: things which cannot happen even in the extremes of reality; includes thought
control, withdrawal, insertion , and broadcasting , among others . Connotes a greater
degree of disordered thought. Examples: having microch ip in the brain, abducted by
aliens, family replaced by impostors, etc.
b. Non-bizarre: things which can happen in the extremes of reality but are simply not
true; includes persecutory, jealous, erotomanic (romantic). grand iose. and somat ic
types.
A common mistake is for the interviewer to report that the patient ·denies" delusions .
Instead, the interviewer should report if delusions were elicited because this is not a yes-
or-no category but elicited through conversation .
2. Preoccupations: predominant themes of thought ; religious or sexual themes are the most
common but other themes can be included such as family problems , going home, safety , etc.
3. Obsessions : this refers to repetitive, specific, and intrusive thoughts most often with
distressing content. May or may not be coupled with compulsions . Example : obsession of
having germs which will cause illness , that mother will die, repetitive images of unwanted
incest, etc.
I 4. ldeations : suicidal , homicidal, escape , assault or revenge .
.J
For patients who have attempted suicide, the content of the suicide inqu iry (see Part VIII)
should be reflected here. It is vital to elicit this in all clinical encounters , and is not
contraindicated in any way (e.g., it will not "put ideas " in the patien t's mind) .
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Perceptual Disturbances
o Hallucinations are false perceptual experiences that arise from no stimul i. Note the details of the
hallucination as enumerated below:
o Sensory modality : auditory, visual, tactile, olfactory
• Auditor~ is most common in primary psychiatric disorders
• Visual is most common in organic brain disorders and delirium
• Tactile can sometimes be noted in substance use ("formication " or sensation of
ants crawling under the skin)
o Content: familiar/unfamiliar, command, commentary, derogatory , etc. Specify verbatim .
o Patient's reaction: ignores, follows, converses, becomes anxious , etc.
o Illusions are distorted perceptions of existing stimuli, more common in psychiatric conditions
associated with other medical conditions.
o Hallucinatory gestures describe actions of a patient that may point out to hallucinations (even i.f
denied) such as talking by himself, laughing without reason, fixed eye contact on a particular
place without stimulus, etc.
Sensorium and Cognition

o Sensorium is the wakefulness of the patient: awake, drowsy, obtunded , stuporous, or comatose .
o Cognition refers to the mental processes in a person's mind. This includes :
a. Orientation : to time, to place, and to person
b. Memory : immediate , recent, and remote
c. Concentration - tested using serial 7's. The rule is that the patient should do the whole
process continuously without verbal cues from the interviewer . Alternatively , serial 3's or
spelling WORLD/MUNDO backwards can be done for those who have lower education .
d. Other higher cognitive skills
i. Judgment - tested by giving a situation such as smelling smoke in a cinema .
ii. Abstract thinking - tested by asking the patient to interpret a proverb or stafing
the similarities between two objects.
e. Insight
• Refers to the patient's awareness of having a mental disorder and requiring help.
• This can be elicited by questions such as
• What is the reason you came here?
• How can a psychiatrist help you?
• What do you know about your condition?
• How do you feel about your confinement?
• Do you agree with your diagnosis?
• The levels of insight are:
1. Total denial of the illness
2. Slight awareness of being sick but denies it at the same time
3. Attribution of the illness to an external source , other people , or
unspecified medical causes
4. Intellectual insight - awareness of the disease as existing but without
application.
5. True emotional insight - awareness and understanding with application
such as changes in coping mechanisms .
The Mini-Mental State Examination (MMSE) can be performed for patients who are suspected to have
mild or major neurocognitive disorder("dementia
") - see Appendix2.
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Ill. Process of Diagnosis in Psychiatry
1. Classify the condition following the DSM-5 categories

o The Diagnostic and Statistical Manual for Mental Disorders 5th Edition or DSM 5 is the basis for
diagnosis for psychiatry .
o Primarily, the DSM is descriptive in nature , such that the basis for classification will be the actual
signs and symptoms the patient presents (etiology comes secondary) .
o Before anything else, always consider that the patient may have a normal mental state ("no
psychopathology")which is not uncommon in psychiatric consultations . It is important to avoid
over-diagnosis to avoid possibly stigmatizing labels and over-prescription .
o The DSM 5 also lists adverse life situations as part of the diagnosis and are called "other
conditions that may be a focus of clinical attention ".
• These are sometimes termed "V-codes" because these are officially indexed in the DSM
as official diagnoses under letter V of ICD-10 .
• This highlights that the patient may have no neurob iological illness but is not necessarily
in a situation of optimal mental health , and may warrant psychosocial intervent ion .
• In a social and community psychiatry framework , this serves to avoid over-diagnosis ,
recognizing "normal patients in abnormal situations ".
• Nonetheless, these diagnoses can co-exist with psychiatric disorder (e.g., person w ith a
bipolar disorder who also has "relationship distress with intimate partner ") .
o The most common classifications are as follows . Refer to specific chapters for details.
• Psychos is
• Bipolar disorder
• Depressive disorder
• Anxiety I trauma related / obsessive-compulsive
• Delirium
2. Determine the etiology

o After classifying the type of disorder the patient has, the etiology has to be determined .
• Due to another medical condition
• Due to substance intoxication or withdrawal
• Primary psychiatric disorder
o It is important to analyze the review of systems , past medical history , substance history , phys ical
and neurologic exam , and laboratory results prior to committing to a primary psychiatr ic disorder .
o Medical conditions which can present with psychiatric symptoms :
• Neurologic conditions : seizures, CNS infection, stroke , neurodegenerative disorders
• Endocrine conditions : thyroid pathology, hypercortisolemia , pheochromocytoma
• Autoimmune diseases
• Rheumatologic/physiatric : can present pain syndromes which may overlap with
somatoform disorders .
• Encephalopathies
• Refers to a global disruption of brain funct ion due to physiolog ic derangements
• Will equate to a psychiatric diagnosis of delirium
• Refer to delirium chapter for details (Part X).
o Substances that can cause psychiatric symptoms - refer to substance use chapter (Part XI).
3. If primary psychiatric , specify the disorder .

o In the DSM, specific disease entities include criteria such as: signs/symptoms , time frame, and
inclusion or exclusion statements .
o Descriptorsor modifiersof diagnosesare also listedin the DSM and help the clinicianhavea
better picture of the patient's condition (e.g., "bipolar 1 disorder+ most recent episode manic+
with psychotic features) .
o If the symptoms of the patient apparently falls in a certa in category , but not in any of the specific
diseases listed under it, there is a provision for the follow ing :
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• "Other specified __ disorder": clinician chooses to indicate the details of the

condition ; usually done for atypical presentations (e.g., other specified anxiety disorder -
panic attacks in the context of distressing memories).
• "Unspecified_ disorder": clinician chooses not to indicate the details of the cond ition;
usually due to lack of reliable data due to unavailable informants .
4. Formulate a biopsychosocial formulation

o Mental conditions differ from physical conditions such that it is difficult to pinpoint and exact
cause . Instead of a causative model, it is recognized that there are multiple factors that
contribute to a state of poor mental health (as a spectrum , instead of categorically having or
not having a mental illness), spanning the biological, psychological, and social .
o The biopsychosocial formulation is a way of holistically explaining the mental status of the
patient in a more clinically -relevant and comprehensive manner than the DSM diagnosis .
• Biological - centers mainly on the factors that affect the brain as the physical
organ of the mind, whether directly or indirectly .
• Psychological - describes the internal state of the person , which involves cognitive
and emot ional reactions and intrapsychic events (e.g. , conflicts , emotional loss , self-
esteem, sense of security , etc) . This can be a result of the reaction to a social factor .
• Social - describes the external environment of the person , which involves familial ,
social, economic , occupational , and spiritual contexts and events that occur in the
person's life.
o Also, psychiatric conditions are seen in a longitudinal viewpoint, such that they do not arise
acutely , but involve a process of development.
• Predisposing - explains the overall vulnerability of the patient to having the
psychiatric condition, present even before the onset of the symptoms .
• Precipitating - identifies the factors that trigger the psychiatric syndrome .
• Perpetuating - identifies factors that hinder recovery or the factors that "feed " the
psychiatric condition .
• Protective - identifies factors which help the person recover or are good prognostic
factors for quality of life or functionality .
o Treatment, likewise , will follow a biopsychosocial approach as guided by the formulat ion .
Notes on making a complete and comprehensive diagnosis/assessment:

o Co-occurring psychiatric disorders are common due to neurobiological and psychological connections .
Examples include:
o Combined features as one diagnosis: schizoaffective disorder (psychotic disorder with bouts
of mood disorder symptoms) due to shared neurobiological processes- overlapping genes
affected , same excessive neurotransmitters .
o Dual diagnoses: substance use disorder and major depressive disorder (as two separate
diagnoses). The patient is depressed and tries to ·self-medicate " w11hsubstances .
o An acute condition over an underlying condition: delirium in a person with Alzheimer 's type
neurocognitive disorder; major depressive disorder in a patient with borderline personality
disorder. The chronic condition in itself is a predisposing factor for the acute one .
o Co-occurring medical problems are also included in the complete diagnosis, not only due to its effect
on psychiatric treatment, but also for holistic care of the patient. Oftentimes, psychiatrists would also
be the primary healthcare providers of patients with chronic mental conditions.
o Metabolic syndrome (diabetes, obesity, hypertension, dyslipidemia) can be triggered or
exacerbated by some psychotropic medications.
o Persons with psychiatric disorders may have poor self-care which predispose them to
infections, lifestyle conditions, nutritional problems, and physical trauma.
o Pregnancy, renal problems, and hepatic problems will all require adjustment in medications.
o Simply put, persons with mental disorders are not immune to the usual medical illnesses
everyone gets; however, they require a more integrated approach to healthcare .
o Note that "multiaxial diagnosis" is no longer the format used in DSM V.
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TABLE 2. THE BIOPSYCHOSOCIAL

FORMULATIONMATRIX
Biological Psychological Social
Predisposing Genet ic background Temperament and personality Dysfunctional parental ,
factors that cause baseline family, and school/work
Prior neurologic insults (e.g., suboptimal mental health settings as patient grew up .
chronic substance use , (e.g., low self-esteem ,
impaired brain development insecure attachment patterns , Negative social situations
such as in those with extremely high self- (e.g., bullying, discrimination ,
intellectual disability and expectat ions, repressed pressure, etc)
chronic early life stress , etc) needs and emotions , etc) .
Precipitating Effect of substance Response to a stressor Overwhelming , adverse life
intoxication or withdrawal Describe the psychological events that led to the
reaction or process, not the psychological event (e.g .,
Physiologic derangements event itself. Describe what trauma, social conflict ,
and illness affecting CNS . the social event represented failure, etc) .
and meant to the patient.
Part of the disease process in
itself - In the absence of Usually represents
psychological or social intrapsychic/emotional loss
triggers, the biological and consequent maladaptive
component is strong . defense mechanism .
Perpetuating Poor medication adherence . Maladapt ive coping skills Lack of social support ,
regarding the illness and life stigma, economic or
Other comorbid illnesses . situation . occupational difficulties ,
sociocultural issues .
Cogn itive decline and Difficulty accepting condition
residual symptoms and working through it. Can be the same social
associated with condition conditions which predisposed
(e.g., schizophrenia). the patient to the illness.
Suboptimal biolooical control.

Protective Adherence to medications Healthy coping mechanisms . Social support .
and good response to it.
'
Good biological prognostic
factors specific to the illness .
EXAMPLE:A MEDICALCLERKWITH MAJOR DEPRESSIVEDISORDER

Biological Psychological Social
Predisposing Family history of major Uncertainty regarding Competitive environment
depressive disorder. decision to go into medical Financial difficulty, pressure
school. to mainta in scholarship
Excessive self-expectation
and perfectionist tendencies.
Depressive temperament
since childhood .
Precipitating Chronic disruption of sleep Feelings of helplessness and Highly stressful environment
pattern . meaninglessness . in the hospital.
Defense mechanism of
introjection , repression ,
reaction formation in
response to anger of being in
this situation .
Perpetuating Continued physical stress Limited range of interests, Fam ily , although supportive ,
from hospital work. tends to isolate self in times is located in Mindanao and is
of stress difficult to access .
Difficulty of balancing health
and school requirement.
Protective Good and prompt response to High level of intelligence and Cons istent set of friends .
standard dose of SSRI , good psychological mindedness . Presence of psychiatry
physical health. Good candidate for therapy _ service within the hospital.
11
PSYCHIATRY
IV. Overview of Psychiatric Conditions
Categories of Psychiatric Disorders

1. Neurodevelopmental disorders
o Inborn conditions of the CNS that affects a person 's behavior , emotional and cognitive
functioning through the course of development.
o Common conditions include :
• Attention deficit/hyperactivity disorder (ADHD) - triad of inattention, hyperact ivity,
and/or impulsivity.
• Autism spectrum disorder- characterized by social impairment and stereotypic
behaviors .
• Intellectual disability (formerly called "mental retardation ") - impairments in adaptive
functioning + documented subpar intellect, usually via IQ testing
• Specific learning disorders such as reading impairment (formerly called "dyslexia ")
2. Neurocognitive disorders
o Conditions affecting the CNS that impacts a person's cognitive capacity , which includes
memory, language, attention , perception, and executive functions which are not part of the
developmental process .
o Delirium - corresponds to the neurologic diagnosis of "encephalopathy " - a global disruption
of brain function . Delirium is the behavioral syndrome of encephalopathy . (see part X)
o Neurocognitive disorder (former ly called dementia)
• Describes a long-term cognitive decline , which primarily affects learning , memory,
and executive functions rather than sensorium and attention.
• Includes the following etiologies:
• Alzheimer's disease
• Frontotemporal neurocognitive disorder
• Vascular dementia
• Traumatic Brain Injury
• Secondary to HIV (AIDS-dementia complex)
• Secondary to Prion Disease
• Secondary to Parkinson's Disease, Huntington's Disease, Lewy Body Disease
1·
3. Personality disorders
o Refers to an enduring pattern of inner experience and behav ior that is inflex ible. pervasive.
causes distress or dysfunction and is stable in late adolescence /early adulthood onwards .
o For a formal diagnosis, several number of criteria must be fulfilled which differs per subtype .
However , it would be helpful to be aware of personality types with or without a formal DSM V
diagnos is. A person may have traits across different disorders .
o Disordered personality types includes :
• Cluster A("odd and eccentric ") - has a tendency towards psychosis ; may represent
the prodrome or residual symptoms of schizophrenia .
• Paranoid - suspicious and distrusting .
• Schizoid - detached and lacking in emotion.
• Schizotypal - distorted and magical thinking.
• Cluster .8 ("emotional and erratic ") - has a tendency towards mood disorders .
• Histrionic - attention-seeking and emotional.
• Narcissistic - self-important, lacking in empathy , needing admiration .
• Antisocial -d isregard for laws and rights of others ; with evidence of conduct
disorder before 15 years of age.
• Borderline - unstable sense of self; tends to be impulsive ; associated with
self-harm, turbulent relationsh ips, and emotional outbursts .
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University of th e Philippines - Philippine General Hospital
• Cluster C ("fearful and anxious ") - has a tendency towards anxiety disorders .
• Dependent - clingy and submissive .
• Avoidant - socially inhibited with feelings of inadequacy .
• Obsessive Compulsive - perfectionist and rigid; note that this is different
from obsessive compulsivedisorder.
4. Psychosis - discussed in Part VII.
5. Depressive disorders-discussed in Part VIII.
6. Bipolar disorders- discussed in Part IX.
7. Anxiety disorders
o Anxiety as a phenomenon can include two components :
• Fear, wh ich is mediated by the amygdala and is connected to the sympathetic
nervoussystem.
• Worrying, which is a cognitive processes mediated by the cortico-striato-thalamo-
cortical tract.
o Specific conditions include :
• • Panic disorder
• A panic attack is a spontaneous episode of severe anxiety characterized by
a combination of psychological and physiologic symptoms .
o Psychological : derealization. fear of losing control or "going crazy" ,
fear of dying
o Physiologic : palpitations, tachycard ia, trembling , shortness of
breath, choking , chest pain, nausea, abdominal distress , dizziness .
chills/heat sensation, paresthesia .
• The presence of panic attacks + 1 month or more of persistent worrying or
maladaptive change in behavior in response to the attacks = panic disorder
• Panic attack alone ~- not a psychiatric diagnosis.
• Specific phobia
• Severe anxiety resulting rom exposure to a specific and normally harmless
object or situation
• Generalized anxiety disorder (GAD .)
• Excessive anxiety and worry (usually about the future and possible negative
events) occurring for most days than not in a span of at least 6 months .
• This is characterized by: restlessness , being easily fatigues , difficulty
concentrating or mind going blank, irritability , muscle tension , and sleep
disturbances .
• Agoraphobia
• This used to be a modifier for a panic disorder but is now a stand-alone
diagnosis
• It is characterized by marked fear or anxiety in situations where escape is
deemed difficult (public transportation , open spaces : enclosed spaces .
crowds, and being outside alone) .
• These situations are avoided or endured with intense fear .
• Social anxiety disorder
• Consistent fear or anxiety about social situations in wh ich the individual is
subject to the possibility of scrutiny by others (conversat ions , meeting new
people, being observed by other people , and performing) .
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PSYCHIATRY
TABLE 3. SUMMARYOF ANXIETY DISORDERS

Triaaer Timing Response
Panic disorder None Episodic + baseline worrying "Panic attack "
about havina attacks .
Specific phobia Particular object Episodic (upon exposure) Panic-like
Generalized None Persistent Low-level anxiety
anxiety disorder (NOT panic level)
Agoraphobia Situations of difficult Baseline worrying + acute Variable
escape/assistance episodes aiven exposure
Social anxiety Social situations Baseline worrying + acute Variable
disorder episodes given exposure
8. Trauma or stressor-related disorders

o Acute stress disorder and post-traumatic stress disorder (PTSD)
• There is an exposure to actual or threatened death, serious injury , or sexual violence
which triggers the following symptoms :
• Intrusion symptoms - memories, dreams
• Negative mood / cognitive changes - inability to experience positive
emotions
• Dissociative symptoms - depersonalization, derealization
• Avoidance symptoms - avoids anything that reminds them of the event
• Arousal symptoms - sleep disturbance , irritability , angry outbursts ,
hypervigilance, problems with concentration, exaggerated startle response .
• Acute : 3 days to 1 month
• Post-traumatic : more than 1 month, involves more long-term negative alterations to
cognitive schemes and mood and may be delayed in manifestation .
o Adjustment disorder - refers to the development of out-of-proportion emotional or behavioral
symptoms in response to an identifiable stressor (not necessarily life threatening) within 3
months of its onset. This represents poor coping mechanisms . It can have the following
modifiers :
• With depressed mood
• With anxiety
• With mixed anxiety and depressed mood
• With disturbance of conduct
o Psychosis is never a normal response to any stressor. Regardless of trigger, a patient
presenting with psychosis receives a diagnosis falling under the psychosis cat~gory.
o Similarly, if the patient develops full blown depression even in the presence of a trigger , the
diagnosis is Major Depressive Disorder.
o Dual diagnosis with psychosis/depression is possible .
9. Substance use disorders- see Part XI
10. Somatic symptom and related disorders

o Somatic symptom disorder - formerly called "somatoform disordern, this involves one or more
bodily complaints + having excessive thoughts , behav iors, or feelings related to this that
interferes with daily functioning . This is no longer defined by having symptoms which are "not
organically explained ".
o Conversion disorder or functional neurological symptom disorder - development of neurologic
deficits incompatible with recognized neuromedical cond itions .
o Illness anxiety disorder - formerly called "hypochondriasis ", this involves preoccupation with
__, having a serious illness despite having minimal symptoms .
o Psychological factors affecting other medical conditions
14
11
II PSYCHIATRY LEARNINGMODULE FORMEDICALINTERNS
u • A psychologicalor behavioralfactor adverselyaffects the medical condition of a

person by directly influencingcourseof medicalillness, interiering with treatment, or
adding health risks.
If •
•
•
A commoncause of referralto consultation-liaisonpsychiatry.
Practitionersregardlessof field shouldbe wary for this.
This does NOT includeformal psychiatricdisorders.
• Classifications:
It • Mild: increasesmedicalrisk
• Moderate: aggravatesunderlyingmedicalcondition
• Severe: results in medicalhospitalization/ERconsult
d • Extreme: life-threateningrisk
TABLE 4. SOMATICSYMPTOMSDISORDERVS. FACTITIOUSDISORDERVS. MALINGERING:

Motivation
d. Somatic s m tom dso.
Factitious disorder
d 11. Obsessive-compulsive disorder

o Obsessionsare recurrent,intrusive,specific, and distressingthoughts, bringing about anxiety
to the patient.
• o Compulsionsare repetitiveactions, whethermentalor actual,which the patient cannot stop

doing and is usuallya way for him or her to controlthe anxiety brought about by obsessions. It
is usually not a logicalresponseto the contentof the obsession.
•
o Aside from OCD,other disorderswithin this spectrumwill include hoarding disorders,
excoriationdisorder,body dysmorphicdisorder,and trichotillomania.
Other Categories of Psychiatric Disorders
•
'
• DissociativeDisorders
• Feeding and Eating Disorders
• Elimination Disorders
•
• Sleep-WakeDisorders
• Sexual Dysfunctions
• Gender Dysphoria
• Disruptive, ImpulseControl,and ConductDisorders
•• •
•
Paraphilic Disorders
Other ConditionsThat May Be a Focusof ClinicalAttention
•
••
I
•
•
• 15
PSYCHIATRY
University of the Philippines - Philippin e General Hospital
V. Modalities of Treatment in Psychiatry and Introduction to Psychotherapy
Principles of Treatment
o Psychiatry utilizes a combination of biological, psychological, and social treatment that corresponds
with the biopsychosocial formulation .
o Biological treatment involves medications and other interventional techniques such as
electroconvulsive therapy (ECT) , transcranial magnetic stimulation (TMS) , and deep brain
stimulation (DBS).
o Psychological treatments involve psychotherapy .
o Social treatment involves rehabilitative approaches to reintegrate the person in the
community, restore functionality, and improve social support .
o Milieu therapy refers to using the environment of the ward to promote restoration of ego function and
psychological well-being . This is done by having consistent and structured schedules , rules, and
therapeutic activities .
Psychopharmacology
• Medications and physical modalities in psychiatry mainly affect the neurotransmitters in the brain . They
are geared towards resolving symptoms and as prophylaxis for future episodes .
• Psychiatric medications are used for indications beyond their traditional labels (e.g., "antipsychotics "
are used for bipolar, "antidepressants" are used for anxiety disorders) because different psychiatric
conditions have ·overlapping neurotransmitter imbalances . The medications were labeled based on
their target disease in a time where neurotransmitter targets were not yet elucidated .
• These drugs do no address faulty synaptic networks in the brain (representing faulty schema and
learning) and therefore cannot replace psychotherapy. However , drugs are sometimes needed before
psychotherapy to make the person more conducive to such processes .
• Specific drugs will be discussed under the psychiatric disorder they are used in.
I • Psychotherapy
• Psychotherapy is a clinical process involving therapist-patient interaction which is geared to improve
psychological functioning and well-being .
• Differs from counseling , such that it does not only revolve around giving sound advice or merely
listening and encouraging (although these are aspects of therapy) , but focuses on producing lasting
change in the person's psychological functioning .
• Psychotherapy should be tailored to the intellectual and psychological capacity , motivation , and
symptomatology of the patient. It is not "one-size-fits-all".
• There is no need to stick only to one type of psychotherapy. Most psychotherapy utilizes an eclectic
(combined) approach as applicable for the patient.
1. Psychoeducation - teaching the patient and family about the psychiatric condition helps them cope
with the psychiatric illness.
o This includes :
• Name, signs and symptoms, and medications of the patient's cond ition
• The nature of psychiatric disorder - misconceptions have to be corrected : that it is
not contagious , not a spiritual punishment , not a result of being weak -willed , not a
matter of shame, etc.
• The importance of medication adherence and check-ups , medication side-effects
• Signs of an exacerbation or beginning relapse
• Prognosis for remission and occupational functioning
• For the family, how to appropriately interact with the patient
o For patients with impaired reality testing , psychoeducat ion can begin by expla ining why they
are confined or treated in ways which are relevant to their concerns (e.g., to help you feel
more calm , more in control , sleep better, etc)
o If the patient is not amenable to explanation , there is no need to force psychoeducat ion
prematurely .
16
PSYCHIATRY
I University of the Philippines - Philippine General Hospital
I 2. Support ive psychotherapy

o Uses direct measures to 1) ameliorate symptoms and 2) maintain , restore , or improve self-
esteem and ego functions , and 3) foster adaptive skills.
o Techniques can include clarification , expansion of awareness , reframing , empathic validation
I and affirmation .
o Example : a patient with depression due to failure in school -
• Empathic validation of his feelings of loss, and that this sadness is not an object of
I •
shame .
Relabeling of the problem , from "being a failure" to "failing one subject and pass ing
many others".
I •
•
Expanding awareness that he has failed not because of "incompetence" but also
because he has chosen to focus on other things such as caring for his family
The wrong notion of everything being "too late already" is reframed - that there is no
time limit to things . Realistic examples are given and strategies are discussed .
I • He is taught to cope by reaching out instead of withdrawing from others, with

perspective-taking exercises on how others realistically see him (that they will want to
help him as friends and not criticize him).
I o This works on objective reality and is not simply telling the patient that "he/she is okay " or
"everything will be alright".
3. Behavioral therapy
I o Works under the premise that behaviors are conditioned .

o Modifying antecedents (triggers), teaching replacement behaviors , and manipulating
consequences of behaviors can shape the behaviors of a person {A-B-C model).
o Example : a person with alcohol use disorder -
1- • A: Trigger situations such as passing by the bar or meeting with certain people are
avoided . Environmental stressors which lead to the drinking are also addressed.
Psychotherapy can be used to address negative cognitive and emotional states that
I •
lead him to want to drink .
B: Healthier ways to cope with stress are taught such as sports and other leisure .
Symptoms such as anxiety or insomnia are addressed more correctly using
appropriate pharmacologic agents. These are called replacement behaviors.
• C: The patient is given disulfiram, a drug which creates an unpleasant reaction similar
f. to a hangover shortly when alcohol is drank. The patient eventually learns to avoid
alcohol because the consequence of pleasure is removed . The patient is also given
activity incentives the longer he stays alcohol free.
4. Cognitive therapy
o Addresses automatic thoughts, faulty schemas (ways of looking at oneself and the world), and
cogn itive distortions which causes the person to feel distressed or act in maladaptive ways .
o Uses techniques that challenge automatic thoughts and facilitate healthy cognition such as :
asking for proof, asking for best/worst case scenarios, asking for realistic predictions of
likelihood, alternative explanations , asking "so what" questions , etc . The patient does most of
the thinking and the therapist is just a guide to facilitate this {as against support ive
psychotherapy wherein the therapist tends to "lend his/her thinking to the patient ")
o Usually involves "homework" by the patient, listing down his/her automatic thoughts , the
emotionit causes,alternativethoughts,andchangesin emotion.
o Mostly combined with behavioral techniques {called cognitive behavioral therapy or CST).
o Example : a perfectionist who is frequently anxious in school -
• Through guided questioning , patient is led to a realistic appraisal of the possible
consequences of small mistakes - that it is more likely that people will ignore it and
not make a fuss out of it, as against his automatic thought that people will notice it.
• The cognitive distortion of "catastrophizing " mistakes is brought to awareness - that
he works under the construct that mistakes are irreversible and always of high
impact , with underpinnings of underestimating his capability for problem solving .
17
PSYCHIATRY
• Situations wherein he was able to troubleshoot mistakes or wherein his classmates

were supportive instead of critical are discussed to improve his sense of control.
• He is asked for the percentage wherein he went to class and made mistakes - seeing
how small it actually is will disprove his notion that he "always makes mistakes".
Sample Basic CBT Matrix :

Situation AutomaticThoughts Emotional Alternative Thoughts Emotion After
Reaction
Myfriend ignored me. She is angry at me. Sadness of 8/10. She may be busy or Sadness decreased
I don't get along well preoccupied . to 3/10 .
with people. There is no reason for Sadnessmore
I'm socially inept. herto be angryat me. relatedto missingmy
I haveotherfriendswho I friend .
get along with.
She would sometimes
initiateinteractions with
me.
5. Psychodynamic psychotherapy
o A way of thinking about the patient through unconscious conflict, deficits and distortions of the
psychic apparatus and internal object relations. Defense mechanisms, which are unconscious
ways that the ego avoids anxiety, are also highlighted .
o Works under the premise that insight (knowledge of the unconscious factors that influence
one's current state) and working through conflicts help the person be more in control of his/her
present.
o Additionally, psychodynamic psychotherapy holds the therapeutic relationship in importance
such that it can be internalized by the patient to be a template for healthier view of self and
more stable attachments to other people. The way the patient interacts with the therapist can
also reflect his attachment patterns to other people (awareness of transference and counter-
transference) .
o Its theoretical background is based on different schools of thought, namely :
1) Ego psychology
2) Object relations theory
3) Self psychology
4) Attachment theory
o Techniques such as interpretation, observation, and confrontation are used as appropriate . It
may initially start on the more supportive end of the spectrum .
o Example: a teenager who tends to be very bossy, such that it affects friendships -
• Through a subtle, gradual process, made aware of how she is utilizing a reaction
formation to feelings of inferiority and helplessness, rooting from insecurity with her
sibling and lack of validation from her parents.
• Through this insight, the patient becomes more in control of her actions, and can find
better ways of developing her self-esteem .
• The therapist's validation and warmth is internalized by the patient as a template of
relationships - that it is safe to be vulnerable and people can react in a loving manner
if she allows herself to be loved. Note that this process is not necessarily conscious
such that the patient can probably not verbalize this .
18
PSYCHIATRY
LEARNING
University of the Philipp ines - Philippine General Hospital
VI. Processof Treatmentin Psychiatry
1. Decide whether the patient needs to be admitted or not.
Absolute psychiatric indications for admission :

1. Harm to self
2. Harm to others
3. Non -compliance to medications
4 . Social emergencies -victims of abuse with perpetrators living in same house , etc.
• Other indications for admission include need for work-up, declining self-care status ,
or having active medical/surgical comorbids.
2. Address immediate needs and urgent symptoms .

• Agitation (severe restlessness, violence, forceful attempts to escape , forceful refusal to take
medications, extreme verbal aggression/threats, etc)
o Ensure safety - do NOT attempt to chase, restrain , or engage an agitated patient.
Call trained personnel and alert the hospital staff.
o Attempt talking with the patient if safety is not compromised .
• Keep in control and do not panic.
• Ask the patient what can be done to make him feel better. Do not compromise
the patient's sense of ~ontrol and agency as this will worsen agitation .
• At the same time, set clear limits of rules inside the hospital.
• Do not use threats, shout, or argue as it will trigger more agitation .
• Do not try to argue against hallucinations and delusions .
o Physical restraints may be warranted , administered by trained personnel. Four-
point restrained using non-abrasive material is usually done . Any weapon or items of
potential harm are removed.
o Chemical restraint involves provision of rapid acting agents to calm the patient
down . If safety is not compromised , these may be administered without physical
restraints to avoid much discomfort for the patient. However , if safety is
compromised , it is usually done after physical restraint.
• Agitation, unless willful and premeditated, would represent surge in limbic system
activity - treatment would be to re_
gulate this upsurge .
• Antipsychotics can block the excessive dopaminergic activity in the mesolimbic
tract.
• Benzodiazepines can also promote inhibition of the limbic system by stimulating
the inhibitory neurotransmitter GABA
• Sedatives are also given as adjunct to put the patient to sleep .
• Preferred route is intramuscular or through the use of orodispersible tablets
(dissolves in the mouth but still passes through the enteral route) .
• See Appendix 1 on the most common agents used for agitation.
• Suicidality - see part XII.
• Severe insomnia
• Severe malnutrition
• Severe anxiety
2. Control symptoms .
• Initiate medications as warranted (see chapters on specific conditions for basic
psychopharmacologic regimens) .
• Tailor milieu therapy to the patient's needs, including nursing interventions and individual and
group occupational therapy .
19
PSYCHIATRY
University of the Philippin es - Philippine General Hospital
o The primary goal is to restore a "normalizing " structure to the patient , which will
encourage self-control and minimize anxiety from ambiguity .
o Occupational therapy in the inpatient setting also helps the patient transition from
inpatient to outpatient setting, focusing on important tasks such as self-care,
medication compliance, and proper interaction with the family .
• Psychoeducation and supportive psychotherapy are initiated . The inpatient setting is where
rapport between the psychiatrist and the patient should begin and will influence adherence to
outpatient-based treatment.
3. Maintain remission and proceed to recovery.

• Remission would pertain to the absence of symptoms, while recovery in addition would
involve maximizing quality of life and occupational performance.
• As much as possible, contemporary psychiatric practice discourages institutionalization and
promoted community reintegration.
• Follow-up check-ups, continued medication, and psychotherapy are done in an outpatient
basis.
• Social and occupational interventions are enacted. Referral to occupational therapy and
social work services may sometimes be beneficial.
.J
f.
!
..
{
r
,/
20
.,_.-- . ~~ ;. ·. 'I..,,. : - - • - · : ·... , ...
PSYCHIATRY
LEARNING
University of the Philippines- Philippine General Hospital
VII. Psychosis
Diagnosis
o Psychosis was classically described as "impaired reality testing" and is called a "disorder of
thought ".
SYMPTOMS OF PSYCHOSIS:
1. Hallucinations
2. Delusions
3. Disorganized behavior
4 . Disorganized speech
5. Negative symptoms : flattening of affect, avolition, alogia, extreme social withdrawal.
o In general , two out of five symptoms must be fulfilled for a psychotic disorder .
o The first two are called "positive symptoms" because it adds something that should not be there
to the patient's experience of life.
Pathophysiology
• Psychosis is a result of dopamine dysregulation in the brain. Dopamine is influenced by serotonin
and glutamate .
• Positive symptoms result from increased dopamine in the mesolimbic tract. The patient develops
a difficulty in distinguishing thoughts from reality, thus perceiving subjective phenomenon as facts
and actual sensory experiences . In this way, the content of hallucinations and delusions may be
reflective of a patient's intrapsychic state (sometimes reversed or projected by the ego 's
defensive apparatus).
• Negative symptoms result from decreased dopamine in the mesocortical tract. To illustrate, it is
not usually seen in acute methamphetamine-intoxicat ion psychosis wherein dopamine is simply
elevated . The presence of negative symptoms is most common in schizophrenia . Common
differentials to negative symptoms include depression, catatonia, and a "tuning off of external
stimuli (such as the interviewer) due to severe positive symptoms .
• Dopamine is also found in the niqrostriatal tract which is involved in modulating movement as a
functional part of the basal ganglia. Blockade of dopamine in this tract causes extrapyramidal
symptoms which include rigidity and tremors.
• Dopamine also inhibits prolactin release in the tuberoinfundibular tract. Blockade of dopamine in
this tract can cause hyperprolactinemia which can lead to amenorrhea-galactorrhea syndrome
and gynecomastia.
'
I
Sub-types
• Schizophrenia spectrum I
Time frame Description Treatment
Brief psychotic 1 day to 1 Usually, but not always, an isolated Short-course
disorder month episode associated with a stressor (thus anti psychot ics
it was formerly called "brief reactive (-1 month )
....I
psychosis"). Not usually associated with
negative symptoms.
Schizophreniform 1 month to 6 Around 2/3 progress into schizophrenia . Variable
disorder months
Schizophrenia Greater than 6 More likely to see negative symptoms . Long-term
months , with 1 More likely to have gradual cognitive maintenance with
month of active and functional decline related to chron ic anti-psychot ics .
symptoms . neurodegenerative process
21
PSYCHIATRY
• Schizoaffective disorder :
o Presence of two or more weeks of psychotic symptoms alone with the eventual
development of a major mood episode (which fulfills criteria for MOD/bipolar) still in the
temporal context of the psychos is.
o Classified as depressed type or bipolar type.
o This is different from a mood disorder with psychotic features , wherein the mood disorder
occurs first, and episodes of psychosis just develops eventually -still within the mood
problem .
o Schizoaffective is usually treated with a combination of antipsychotics and
antidepressanUmood -stabilizer . The former is maintained long-term while the latter is
eventually tapered off. The reverse is done for a mood disorder with psychotic features .
• Delusional disorder - psychosis which only has delusions as its primary symptom. It more
commonly involves non-bizarre delusions .
• Substance or medication induced psychosis :
o Methamphetamine and other stimulant intoxication .
o Alcohol intoxication and withdrawal.
o According to some studies, cannabis can trigger an exacerbation or advance the onset of
psychosis in those with latent schizophrenia .
o Steroids can induce psychosis ("roid rage").
• Psychosis secondary to another medical condition- can arise from epilepsy , systemic lupus
erythematosus andthyroid pathology, among others . Note that it is no longer called "secondary to
a general medical condition" because psychosis in itself is a medical condition .
Treatment
• The first line treatment is the use of antipsychotic medication.
• Psychotherapy plays an adjunctive role to improve insight, coping skills , medication compliance,
interpersonal relations , and quality of life. It may help in relapse prevention.
• Psychosocial intervention is done with the goal of reintegrating them into society , as against the
obsolete model of chronic institutionalization .
Anti-psychotics
Mechanism Examples Notable side effects

Dopamine receptor Haloperidol, chlorpromazine • Extrapyramidal symptoms
antagonists (ORA) or • Akathisia - a subjective feeling
typical antipsychotics Fluphenazine and flupenthixol of restlessness
( decanoate or depot drugs • Tardive dyskinesia - a
injected monthly) hyperkinetic disorder due to
upregulation of D2 receptors
resulting from chron ic ORA use .
• Neuroleptic malignant syndrome
(NMS): fever , gncephalopathy,
Yitals unstable , glevated muscle
enzymes, Rigidity (F.E.V.E.R.)
Serotonin and dopamine Risperidone , olanzapine , • Mostly metabolic syndrome and
antagonists (SDA) or quetiapine, clozapine, sedation , with less EPS.
atypical antipsychotics amisulpride , aripiprazole , • Clozapine can lower seizure
asenapine , paliperidone threshold and has idiosyncratic
reaction of agranulocytosis , thus
* This class of drug is noted to be is NOT first line despite its
more effective for negative effectiveness .
symptoms than typicals . • Olanzapine is known for having
the highest weight gain .
22
PSYCHIATRY
LEARNING
VIII. Depression
Diagnosis
• Diagnosed if the patient fulfills at least five of nine symptoms for a span of at least two weeks :
SYMPTOMS OF MAJORDEPRESSION
o Two core symptoms
• Depressed mood
• Anhedonia - inability to find pleasure in anything
o Three psychological symptoms
3. Recurrent thoughts of death or suicidality
4 . Feelings of worthlessness or inappropriate guilt
5. Difficulty in concentration
o Four somatic or body-related symptoms
6. Disturbances in appetite or weight
7. Disturbances in sleer2
8. Psychomotor retardation or agitation
9. Fatigue
• The core symptoms are called such because it perpetuates the cycle of depression (i.e ., the
depressed mood cannot be counteracted with pleasurable activity , thus perpetuating it) .
• The seven other associated symptoms would differentiate it from normal sadness .
Pathophysiology
• Biologically speaking, this is influenced by hypofunctioning of the serotonergic , dopaminergic, and
norephinephrinergic circuits of the brain . This is not necessarily just a lack of those
neurotransmitters but may be a receptor/secondary messenger dysfunction as well . Nonetheless,
an increase in serotonergic function is found to be helpful for many patients . The biological
component of depression - the brain changes it entails - takes time to develop .
• Psychological and social factors play a big role in depression and may be the ones responsible
for the biological changes in the brain especially in those genetically vulnerable through
epigenetic and neurohormonal factors .
• Subtypes of major depression include : with atypical features, with melancholic features , with
anxious distress, with psychotic features, with catatonia, with postpartum onset , and with
seasonal pattern (formerly called "seasonal affective disorder") .
Treatment
• Mild depression , especially those without somatic symptoms, may be treated with psychotherapy
alone depending on the patient's preferences .
l
• Moderate or severe depression is treated with combined pharmacology and psychotherapy . 11
I
• Severedepressionrefractoryto treatment,with.contraindications
to medications, or with severe I
suicidality and psychosis may be treated with electroconvulsive therapy (ECT). ECT is proven
safe and effective and is usually done under anesthesia , as against its portrayal in media.
Anti-depressants
Mechanism Examples Notable side effects
Serotonin selective reuptake Escitalopram, sertraline, GI disturbances, headache, restlessness
inhibitor (SSRI) fluoxetine, paroxeline
"'Duloxetine: SNRI
Tricyclic antidepressants lmipramine, clomipramine, Prolongationof the QT interval in the ECG,
amytriotvlline leading to arrhythmias.
Monoamine Oxidase (MAO) lsocarboxazid Combiningthis with tyramine-containing food
inhibitors such as cheese will cause hypertensive crisis.
23
PSYCHIATRY
LEARNING
IX. BipolarDisorder
Diagnosis
• Bipolar 1 disorder is diagnosed if the patient has a single manic episode . A depressive episode
preceding or following the manic episode is common , but is NOT necessary for diagnosis .
• A manic episode is when a person has abnormally and persistently elevated, expansive, or
irritable mood for a period of at least one week + three of the following symptoms (but four is
required if the mood is only irritable) :
SYMPTOMS OF MANIA: Mood elevation or irritability+

1. Inflated self-esteem or grandiosity
2 . Decreased need for sleep
3. Pressured speech
4 . Flight of ideas or racing thoughts
5. Distractibility
6. Increased goal-directed activity or psychomotor agitation
7. Excessive involvement in activities with high potential for adverse consequences (e .g. ,
sexual indiscretions , foolish gambling or sprees , daredevil stunts , etc)
• Bipolar 2 disorder is diagnosed if the patient has at least one hypomanic episode + at least one
major depressive episode .
• A hypomanic episode has the same symptoms as mania but is not severe enough to warrant
hospitalization or severe functional impairment, minimum of 4 days duration .
• Bipolar disorder should always be a differential for all cases of depression .
Pathophysiology
• Biologically, bipolar disorder involves dysregulation of the monoamine neurotransmitters which
include dopamine, serotonin, and norepinephrine.
• Because of the overlap with elevated dopamine in psychosis, it is not uncommon to see psychotic
features , most commonly mood-congruent positive symptoms, in individuals with mania .
• Bipolar disorder, unlike schizophrenia, usually does not involve cognitive and functional decline.
There is return to baseline functioning during the interim, at least in the neurobiological aspect.
Treatment
• Mood-stabilizers are the first-line treatments for bipolar disorder. However, this is commonly
augmented with atypical antipsychotics (which antagonizes serotonin and dopamine) .
• For pregnant patients, atypical antipsychotics may be used to avoid teratogenic effects .
• Antidepressants are used with caution because it can theoretically push a depressed person with
bipolar disorder into a manic episode . If used, they areusually coupled with a mood stabilizer.
• Psychotherapy can be used to address issues that cause depression and to improve insight,
adherence to medications, and quality of life.
Mood Stabilizers
Drug Mechanism Notable Side Effects
Lithium Proposed to have modulatoryeffects on Cheap and effectivebut has a narrow therapeutic
intracellular secondarymessengersof range (0.8 to 1.2 mEqs). Toxicity includes:GI
monoamineneurons. disturbances,tremors, delirium, acne, weight
gain, diabetes insipidus, hypothyroidism, kidney
damage and teratogenesis(Ebstein's anomaly).
Valproic acid Antiepilepticdrug that preventsovertiring Has a wider therapeutic range than lithium, but is
of monoamineneurons by stabilizing the also teratogenic: neural tube anomalies.
membrane.
Other AEDs commonly used as mood-stabilizersinclude lamotrigineand carbamazepine.
24
PSYCHIATRY
LEARNING
Universityof the Philippines- Philippine General Hospital
X. Delirium
Diagnosis
Delirium, the neurobehavioral sequelae of a physiologic derangement that affects global brain
functions, should always be ruled out for patients with psychiatric symptoms , especially those
with medical comorbidities .
This corresponds to the neurologic diagnosis of encephalopathy .
FEATURES OF DELIRIUM
The core of delirium is disturbance in sensorium and cognition and all its behavioral sequelae .
o May be hyperactive or hypoactive type.
o Changes in sensorium (e.g., drowsiness, reversed sleep-wake pattern} are seen in
severe cases . This is not present in primary psychiatric disorders.
o Impairment in attention and presence of disorientation are common .
o It may also involve psychotic symptoms (which are usually disorganized or having no
specific theme and involve visual hallucinations, as against that in primary psychosis) .
o These may result to agitation, although agitation is a non-specific symptom .
Delirium tends to develops over a short period of time (acute) and tends to fluctuate through the
day (e.g., the symptoms are intermittent, or there are periods of improvements and exacerbat ions
within the same day}. These characteristics are NOT common in primary psychiatric disorders .
Delirium is a direct physiological consequence of other medical conditions , substances or

medication, or multiple etiologies. It is important to correlate mental state with PE/NE findings and
laboratory findings to see the cause of delirium.
Patients with chronic psychiatric disorders (e.g., schizophrenia, dementia} are more prone to
delirium than other patients with normal CNS make-up.
COMMON PRECIPITANTS OF DELIRIUM

• Uremia
• Hepatic encephalopathy
• Hypoxia, including severe anemia
• Metabolic derangements (electrolytes, glucose, etc}
• Sepsis
• Substance toxicity/withdrawal, including anesthetics
Treatment
If the underlying etiology is corrected, the delirium would resolve within a few days .
Psychotropics are given to control the delirium symptoms which may be very distressing or even
dangerous for the patient.
o Atypical antipsychotics are usually given at low doses to minimize agitation , decrease
positive symptoms, and improve sleep.
o Benzodiazepines may also be given for anxiolysis and sedation .
In delirious patients, medications should be given judiciously :
o Too much sedation can interfere with monitoring of sensorium (for neurologic patients) .
o Some antipsychotics can have cardiac side-effects and are not ideal for cardiac patients
or those in shock .
o Some antipsychotics can worsen metabolic derangements such as blood sugar and
lipids .
o Antipsychotic metabolism (renal or hepatic) should be considered and adjusted to dose
depending on the patient's ability to clear the drug.
25
PSYCHIATRY
LEARNING
XI. Substance Related Disorders
o When assessing clients with history of substance use, three dimensions are evaluated :
1. Acute effects: would include substance-induced psychiatric syndromes , whether in intox ication or
withdrawal , such as psychosis , depressive disorder, bipolar disorder, anxiety , delirium, etc .
Common pictures of substance abuse:

Intoxication Withdrawal
Stimulants (e.g ., Psychosis, mood disturbances, Mood disturbances such as
cocaine, sympathetic signs - dilated pupils, depression/dysphoria when stimulants
methamphetamine) hypertension, tachycardia/ arrhythmia , are withdrawn . Stimulant withdrawal
profuse sweating restlessness tremors psychosis is not common .
Alcohol , sedative- Stupor, coma, psychosis and moor Tremors, agitation , delirium, seizures ,
hypnotics, and other disturbances, discoordination - slurred psychosis , mood and sleep
depressants speech, ataxia, nystagmus. disturbances .
Wernlcke Korsakoff syndrome: triad of

ophthalmoplegia , confusion, and ataxia
caused by thiamine deficiency from
chronic alcoholism .
Cannabis Conjunctiva! injection , increased appetite, Irritability . anxiety, sleep difficulty .
(hallucinogen) dry mouth, tachycardia , perceptual decreased appetite , restlessness .
disturbance such as hallucinations . depressed mood , tremors .
Linked to precipitating latent
schizophrenia.
Other substances of abuse: nicotine, caffeine , opioids, inhalants.
2. Pattern of substance use: the following characterize a substance use disorder (i.e., a disordered
pattern of using the substance, as against just simply "trying it out"):
1) Tolerance
2) Withdrawal
3) Craving
4) Failed attempts to cut down
5) Taken in larger amounts or longer than intended.
6) Great deal of time is spent to obtain the substance .
7) Failure to fulfill major role obligations at work, school, or home.
8) Important occupations are given up because of substance use.
9) Recurrent use in situations where it is physically hazardous .
1C) Use is continued despite knowledge of having a persistent or recurrent physical or
psychological problem caused by the substance.
11) Continued use despite social problems (interpersonal or legal conflict) .
o Mild use disorder has 2-3 symptoms, moderate has 4-5 symptoms , severe has 6 or more .
o Early remiss ion is 3-12 months off the substance . Sustained remission lasts greater than 1 year.
o Substances of abuse include: alcohol, caffeine, cannabis, hallucinogens , inhalants, opioids,
sedative-hypnotics
or anxiolytics(benzodiazepines)
, stimulants,tobacco,and other substances.
3. Underlying psychiatric disorder or psychosocial disturbance leading to substance use .

• Substance use can be a form of "self-medication ": anxious patients use alcohol to calm
themselves down , depressed patients use MAP to temporarily alleviate symptoms , patients
with ADHD use stimulants to boost their attention span, etc.
• Substance use can be a maladaptive coping mechanism to psychosocial problems .
• Social factors such as peer pressure and easy accessib ility of substances can contribute to
the pattern of use.
26
PSYCHIATRY LEARNINGMODULEFORMEDICALINTERNS
XII. Suicide
• Patients who had a suicide attempt are referred to psychiatry. The role of the psychiatrist as
an evaluator is to:
1. Determinethe presenceof comorbidpsychiatricdisorders

At the minimum,there is an adjustmentdisorder because suicidal behavior is never
considereda normal responseto any situation.
• Common differentialsinclude: major depression, psychosis, bipolar disorder,
borderline personalitydisorder,substance-inducedpsychosis or mood disorder, and
adjustmentdisorder.
2. Evaluate risk for another attempt

• Significant risk factors can be summarizedas "D.E.A.D.":
• Qiseases- severe psychiatricdisorders and debilitating or "terminal" medical
illnesses
• gxtreme behaviorssuch as history impulsiveness, violence, etc.
• previous~ttempts (explore lethalityand context)
• Qrugs and other substances, which may disinhibit a person or worsen
psychiatriccomorbids I,I I
• + lack of protectivefactors
• Protectivefactors can include:
• Psychosocialsupports like a partner and friends
• Positivetherapeuticrelationshipwith a therapist
• Evidenceof coping skills and flexibility of actions
• Sense of responsibilityto family, having children
• Religiousprohibition(e.g., does not want to commit the "sin" of suicide)
• Full-timeemployment
• Ability to cite reasonsfor living and optimism - plan for the future can be
elicited in the interview.
• The psychiatrist will then determine appropriate management based on the evaluation. If the
patient is high-risk,the patient may be admitted. For example, those with:
Psychosis and other major psychiatriccomorbids
Violent, near-lethal, premeditatedattempt,with attempt to prevent rescue
Patient expresses regret that he/she survived; plan or intent still persists
Evident impulsiveness,agitation, poor judgment, or refusal of help
Poor social support, especially having no responsiblewatcher at home
With changes in mental status that require further work-up
Cannot cooperate with outpatient treatment
• Asking about suicide is a must for any psychiatric patient. Inquiry does NOT "give the patient
ideas" . It involves asking about the following:
1. Ideation
• Does the person think of suicide as a recourse?Note that this is different from fleeting
thoughts of death.
• How severe and persistent are these ideations?
• Sometimes, this can be subtle such as "not wanting to wake up" or "wanting to push an
off button".
27 I
I
PSYCHIATRY
LEARNING
Universityof the Philippines - Philippine GeneralHospital
2. Intent
• What is the desired outcomefor the attempt?Doesthe patient really seek death?
• What is the motivationbehindthe attempt?This can includeescape from a problem,
reuniting with a dead loved-one,inducingguilt on others, seeking attention, fantasies of
rebirth, etc.
3. Plan
• Is there a specific plan or just a vaguenotion?
• For an attempt, was it premeditatedor "spur-of-the-moment"?
4. Behavior
• How lethal is the plan or attempt?
• Is there an attempt to preventdiscoveryor rescueby others?
• Are there prerequisitesteps alreadycarried out? This can include purchasing a firearm or
poison, making a will, giving away prizedobjects,saying farewell, etc.
5. History
• Were there previousattemptsof suicide?In what contextwere these done (ask the
above questionsregardingthe previousattempts).
• The suicide inquiry, risk factors, and protective factors, should be reflected in the
documentation. The risk assessment and psychiatric diagnoses are both included in the
assessment.
References:
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 2013. VA: American Psychiatric
Publishing
• Stahl S. Stahl's EssentialPsychopharmacology , Fourth Edition. 2013. UK: University Printing House
• Sadock B, Sadock V, Ruiz P. Kaplan &Sadock's Synopsis of Psychiatry, Eleventh Edition. 2015.
USA: Lippincott Williams & Wilkins
28
PSYCHIATRY
LEARNING
Universityof the Philippines- PhilippineGeneralHospital
,
Appendix I. CommonPsychotropicMedicationsand Their Usual Doses
Antipsychotics
Typical
Chlorpromazine 200mg, 1 tab HS to BID
Depot drugs (typical)

Fluphenazinedecanoate 25mg/ml, 1ml IM every month
Flupentixol 20mg/ml , 1ml IM every month
*The use of depot drugs does not alwayseliminatethe need for oral medications but may decreases oral
dose requirements and circumvent adherence issues.
For EPS/akathisia
Biperiden 2mg tab, 1 tab OD PRN
Atypical
Risperidone 2mg tab, 1 tab HS to BID
Olanzapine 10mg tab, 1 tab HS to BID
Clozapine 100mg tab, 1-3 tabs HS or divided through the day(slowly uptitrated, for treatment resistant
psychosis; serial CBCs must be done)
Antidepressants
Escitalopram 10mg tab, 1 tab OD
Sertraline 50mg tab, 1 tab OD
Fluoxetine 20mg tab, 1 tab OD
* It will take about 2-4 weeks before it begins to take effect.
** A higher dose is usually given for anxiety disorders or OCD.
Bipolar I disorder
Na Valproate + valproic acid (or divalproex sodium) 500mg tab, 1 tab BID to TID
Lithium carbonate 450mg tab, 1 tab BID (lithium assay should be done especially in higher doses)
* Atypical antipsychotics may initially be warranted if there are psychotic features and for faster response
Other symptoms
• For agitation: Haloperidol lactate 5mg +/- diphenhydramine50mg cocktail IM PRN
• Note:diphenhydramine may precipitate delirium in geriatric patients because of its
anticholinergic effects.
• For delirium: Haloperidol lactate 5mg IV PRN. Note that the definitive treatment is still to correct
underlying physiologic derangements. BP and ECG precautions apply.
• For insomnia:
1. Clonazepam 2mg tab, ¼ to ½ tab PRN (this requires a yellow prescription or triplicate
prescription as it is potentially addictive and exhibits withdrawal phenomenon)
2. Diphenhydramine 50mg tab, ½ to 1 tab HS PRN
3. Quetiapine 25mg tab, 1 tab HS can also be given - this is significantly lower than the
mood-stabilizing/antipsychoticdose, which is around 300 - 800 mg/ day.
29
PSYCHIATRY
LEARNING
Universityof the Philippines - Philippine General Hospital
Appendix 2. Mini Mental State Examination
• This is usuallydone for patientssuspectedof havinga neurocognitivedisorder, particularly

Alzheimer's dementia.
• The term "mini-MSE"is a misnomer. This DOESNOT representa summarizedmentalstatus
examination as it focuses on cognitiononly.
• No specific study has been madeto validatea Filipinoversion but for practical purposes, it is
acceptableto translatedependingon the patient'sneeds.
Max Score Task/Question

.
5 Orientation to Time: Year, month,date, day, and season
5 Orientation to Place: Country,state/reQion
, city/town, building, floor
3 Registration: Repeatthree objects immediatelyafter interviewer says
them.
5 Attention and calculation: Serial Ts or spelling WORLD backwards.
Do not give verbal remindersin between.
3 Recall: Ask for the 3 objects stated in registration.
language
2 Name a pencil and watch.
1 Repeat the following: "no ifs, ands, or buts" or "walanangperoperopa"
3 Follow a three-stagecommand:"take a paper in your writing hand, fold it
in half, and put it in the floor'. Do when the three steps are mentioned
and do not give reminders.
1 Read quietly and follow: "Closeyour eyes"
1 Write a complete sentence
1 Visuospatial ability: Copy the design below -
GD
Assess for the overlappingrectanglebetween two pentagons.
TOTAL A score of 25 or below may be indicative of a neurocognitive
30 points disorder.
Take note of educational/culturalissues, sensory impairment, and
cooperation issues which may skew results.
30
PSYCHIATRY
LEARNING
MODULE
FOR MEDICAL
INTER
NS
Appendix 3. SamplePsychiatryChart Entry (for CL)
l> (Reason for referral) Referred by rehab med for refusal of patient to join physical therapy and
poss ible MOD.
l> (Medical review) Noted to be diagnosed with : Congestive heart failure, functional class Ill-IV ,
secondary to valvular heart disease ; Acute respiratory failure secondary to COPD, s/p
tracheostomy (Feb 20, 2016 , PGH).
l> Chief complaint:

o Accord ing to patient: "Kinakabahan " (good reliability)
o According to watcher (son) : "Hindi sumasali sa therapy " (good reliability)
l> Premorbid status: Patient was previously well without any psychiatric symptoms and was able
to perform her tasks as a homemaker.
}> History of present illness (combined medical and psy chiatric): 1 year prior to consult , patient
began to exper ience progressive progressive shortness of breath upon exertion, eventua lly eve n
during her usual chores . This required her to be taken care of by her children as she wouldn 't be
able to do house cleaning , cooking , or laundry. They consulted regard ing her state and she was
informed about her condition and its chronicity and possible progress ion. She understood this and
this made her feel anxious but she drew strength from the support of her children and the fact that
she raised them as capable and responsible adults. She also prays frequent ly which relieves her
anxieties . She was compliant with check-ups and medications . She has bouts of depressed mood
when she contemplates on her health status but has( -) sleep disturbances , appetite
disturbances , suicidal ideations, panic attacks, or persistent , unmanageab le anxiety . She was still
able to do her self-care activities . 1 week prior to consult, patient began to have worsen ing of
dyspnea even at rest. No sensorial or cognitive changes were noted at this time. Eventually they
observed noisy breathing and restlessness , prompt ing consult at the PGH-ER.
}> (Short course in the wards) The patient was treated for 2 weeks in the General Medicine ward
and underwent tracheostomy and was transferred to the rehabil itation wa rd for recond itioning .
Currently , the patient has no agitation , has good sleep, is conversant and pleasant to the staff , is
compliant with medical treatment but refuses to jo in physical therapy allegedly due to dyspnea .
She was noted to selectively join therapy depending on the watcher at the time.
l> ROS: (+) dyspnea at rest, (+) weight loss, -10% over 6 months
l> Past medical history: (-) previous psychiatric conditions, (+) hypertens ion
l> Family medical history:(-) psychiatric conditions in the family
}> Substance history: (-) illicit drug use, alcohol, cigarette smoking
> 08-GYN: G2P2 (2002) , menopausal
}> Anamnesis : Patient is the 1st of 5 siblings from a low-income , rural, nuclear family . As a child,
she was shy and soft-spoken but was able to play and make friends . She had average school
performance , no disciplinary problems, and had harmon ious relationships with her fam ily and
classmates . Her parents were strict and would use corporal punishment but she was rarely
subject to it as she was very obed ient in general. She stopped school after graduating grade
school due to financial constraints and then worked to help with the ir fam ily farming . At age 18,
she had her first boyfriend whom she married after 6 months of courtship . He was a school
teacher who was 15 years older than her. They moved to Manila and she became a homema ker
from then on and had two children . The trans ition to the city was diffic ult for her but she was able
to cope by interacting with her neighbors who became her friends . She had good relat ionships
31
PSYCHIATRY
LEARNING
with her family and enjoyed being a housewife. 3 years ago, her husband died due to myocardial
infarction. Although she was able to acceptthis as part of old age, she was visibly more
frequently worried about her health and that of her childrenfrom then on. At this time, she insisted
that her younger child and his wife live with her. The latter consented, althoughwith hesitation, to
keep the patient company and eventuallyto take care of her when she got sick. They get along
well in general although the patient'sdaughter-in-lawfeels that their life and plans on having a
child became on hold becauseof the patient'scondition.
>" [Physical and NeurologicExamination]
>" Mental Status Examination(for CL, also elucidateon her illness experienceand perception)
The patient was seen recliningon the bed,with mild dyspneaat rest, appropriately dressed and
well-kempt, with tracheostomyin place,with good eye contact, would communicatewillingly and
coherently through writing, and was cooperativeall throughout.She reportedanxious mood dueto
dyspnea and has constrictedaffect. She had linear thought process. She has no delusions, no
ideations, but was preoccupiedregardingher dyspnea. She thinks it is a sign that she is nearing
death, the same way her husbanddied. She feels that therapywill aggravateher condition and is
dangerous for her. She understoodher illnessas a terminaldiagnosis. She was fully awake,
oriented to three spheres,with intact immediate, recent,and remote memory, good concentration,
good abstract thinking, good judgment,and fair insightsuch that she knew that she was
undergoing "psychologicaldifficulty" but was unawareof its nature.
j:,, Assessment:
o Not highly consideringmajor depressivedisorder
o Patient's refusal to join therapymay be due to anxietyover her dyspnea, uncertainty
regarding her condition,and learnedmanipulativebehaviorfrom her very permissive
watcher.
>" Plan:
o No additional diagnostics or psychotropicswarrantedfor now.
o Supportive psychotherapyinitiated. Patient's worries were validatedand discussed. She
was assured that she is safe in the hospitaland that she will be monitored closely by
trained therapists.
o Patient was taught the use of pulseoximeterfor biofeedbackand assured that dyspnea is
a normal part of initial rehabilitation.
o Watcher advised regardingappropriatebehavioralapproachesto patient's manipulative
behavior.
o Recommendations:
• Suggestto refer to occupationaltherapyfor incorporationof leisure and
behavioralmanagementtechniq~esinto rehab.
• Suggest primary serviceto outline the course of rehabilitation, prognosis, and
explain to patient for her to adjust her expectationsaccordingly.
o Will follow-up. Refer PRN. Thankyou.
32
I
•I I. WARD ROTATION
PSYCHIATRYROTATION:THINGSTO DO
A Non-duty (usual schedule)
7:30 AM to Perfonn daily MSE on SIC patientspriorto ward meeting

8:00AM
8:00 AM to MON/THURS:WARD MEETING
9:00AM 1. Presentward census(projected)
2. SOAP endorsementof newadmissions
3. MSE and updatesfor old patients- but still knowtheir histories!
a. FollowMSE fom1atin the handouts
o Updates: sleep, behavior, interaction, complianceto meds,
participationin OT, activity level, self-care, etc.
4. Theoreticalswill be discussedas well.
WEDNESDAY- CL Roundswith consultant(resident~ .will present)

FRIDAY- ER Conferencewith consultant(residents willpresent)
9:00AM to I. Do SIC work for Ward 7 patients.
3:00 PM 1. Handwrittenincomingnotes for old patients is highlyrecommended.©
2. Printed incomingSOAPnotesfor new admissions(same_as the ER notes). j
3. Handwrittenclinicalabstract, dischargesummary, and PHIS fom1sfor all
patients.
4. Conductions,monitoring, and proceduresas applicable
5. Updateward censusas applicable, updateyour own patientplease.
.I
II. Do C-L psychiatrywork in the otherwards.
6. See new and old patients
i. Old patients: MSEand updates- but still knowtheir histories!
ii. New patients: SOAPendorsement
7. ManageC-L referrals
i. Checkthe C-L logbookfor new referrals.
ii. Deckthe C-L patient to an intern.
iii. lnfonn C-L residentof newreferralthroughtext.
iv. Updateyour own patientin the C-L census.
v. Other infom1at ion:
• NO NEEDTO SEE CHILDREFERRALS . Just infonn Dr
Tanafor child referrals: 0943368 1498then leave it.
• Cut-offrule: if before3pm, seewithin the day; if after 3pm,
see on the next working day
• If there are emergencyreferrals in the C-L logbook, just give
the misplaced paper to any first year resident. NO NEEDTO
SEE ER REFERRALSIN THE CL LOGBOOK.
Ill . Study handouts,references,and patients'cases.

IV. Interactwith your patients.
3:00 PM or C-L PSYCHIATRY ROUNDS
4:00 PM 1. PresentC-L census(projected).
2. EndorseSOAP of new patients, updatesand MSE of old patients
• Followthe C-L historyfonnat in the handouts.
3. Theoreticalswill be discussed.
5:00 PM MGH ©
8 . Duty
1. Text your name to the duty phone at 7AM: 0922 841 2865
2. Wait for calls from the residentsregardingER consults

a. 1st year resident for adults- usually, you will chart togetherwith them
b. 2nd/3rd year residentfor childrenand sexualassault- usually,they will ask you to
chart first then text if finished.
* For SA, if patient is uncomfortable , you can focusthe interviewon the watcher
* Inform RIC at once if patient is agitatedor violentand DEFERinterviewespeciallyif
RIC is not with you. Do NOT attemptto chaseescapingpatients, restrainpatients, etc.
3. For every consult:

a. Make SOAP notes: - don't just copy the resident'sentry
i. If patient is admitted, printthe notes and attach in chart+ email. This will
already serve as the incomingnotes.
ii. If patient is not admittedto W7. just email.
b. Update the batch ER censusfor your tour of duty
4. At the end of the duty, pleasetext DISPOSITION/LOCATION

of patientsand backlogsto
duty phone and next 100.
Minimum:
Last name- location (e.g., Smith- OPD; Johnson-W4; Anderson- HAMA;
Brown - still at ACU Sx3)
Any other informationto includeis of your own good will ©
5. Update the Ward Census if you have new admissions.
6. Be ready to consult your new admissionsin the next ward meeting.
7. Do monitoring and other clinical tasks after hoursas applicable.
Other reminders:
a. Usual non-dutywork is still done as usual. (Statusis only duty and non-duty)
b. Stay in the call room during your duty. ©
c. Discuss cases with the RIC/RODfor maximum learning.
11.OPD ROTATION
1. Fill-up the screeningform as you interviewand examineyour deckedscreeningpatient.
2. Write a summarizedSOAP of the patienton a healthmanagementsheet+ carbonpaper

copy (availableat the OPD).
3. Discuss the patient with the residentscreeneror child psychiatryfellow. Maximizethis

time for learning.Ask questionsand try to volunteeryour own assessmentand plan.
4. Email a computerizedversionof your SOAPto pghpsychiatry@gmail.com

withinthe
day.
5. Do one PHL as a group.
a. Schedule this on a Mondayor Tuesdaywhenthereare the mostpeoplein the

waiting area. Confirmyour schedulewith the residentscreener(OPDteam
captain for the week) at leastone day before.
b. Topic: usuallychooseyour own, but have it confirmedwith the residentscreener
first at least one day before. Choosepracticaltopicsfor lay persons.
I
l
c. Method of delivery is up to you. l
I
I
Other reminders:
o Come on time at 7AM and sign the logbookpromptly.
o You are often dismissedvery early (12nn)so you can emailthe SOAPnotes right
after you leave. Do not procrastinatethis as you will finish this task at around1PM
and still have lots of time the rest of the day. Considerit part of the duty. © It will be
a hassle to be chasedfor these requirementswhen you are alreadyin IM.
o No OPD screeningon weekendsand officialholidays.
RECAPOF EMAILS:
1. SOAP- OPD, duty, and new CL
2. CENSUS- Ward, CL, and weeklyER
pghpsychiatry@gmail
.com

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Departmentof Psychiatryand BehavioralMedicine

18. History Taking in Consultation-LiaisonPsychiatry 1

V. Modalities of Treatmentin Psychiatryand Introductionto Psychotherapy 12

Preparedby: ConstantineL. Yu Chua, MD; Oct 2016

IA. PsychiatricHistory Taking

FORMAT OF DOCUMENTATION IN PSYCHIATRY

Chief Complaint and Informants

History of Present Illness (HPI)

FIVE CLUSTERSOF SYMPTOMSFOR "PSYCHSCREENING"

Past medical history

Family medical history

Iraumatic events or turningpoints

The anamnesisis importantin the establishmentof a biopsychosocialformulation. Management-wise, it

Consultation-Liaison(C-L) psychiatryis a subspecializationof psychiatryfocusing on the interface

1) "Reasonfor referral"is indicatedat the beginning.

2) Medicaldiagnosisand medicaltreatmentplan are reviewedand noted in the start

3) Most important:Medicaland psychiatrichistoryare unified.

A. Knownpsychiatricpatientswho incur a medicalproblem.

B. A patientwith severemedicalconditionwho may haveadversepsychological/behavioral reactionsto it.

C. A patientwho has psychiatricsymptomsdirectlybecauseof a medicalproblem(e.g., delirious patient).

See Appendix 3 for an example of psychiatry chart entry.

II. ObjectiveExaminationin Psychiatry

Physical Examinationand NeurologicExaminationare performedas usual.

Format of the NeurologicExamination:

I. Mental Status Examination

Format of Documentingand Reportingthe MSE:

I description or explanation of the findings.

I c. Personal hygiene: kempUunkempt

Mood and affect

Sensorium and Cognition

Ill. Process of Diagnosis in Psychiatry

1. Classify the condition following the DSM-5 categories

2. Determine the etiology

3. If primary psychiatric , specify the disorder .

• "Other specified __ disorder": clinician chooses to indicate the details of the

4. Formulate a biopsychosocial formulation

Notes on making a complete and comprehensive diagnosis/assessment:

TABLE 2. THE BIOPSYCHOSOCIAL

Suboptimal biolooical control.

EXAMPLE:A MEDICALCLERKWITH MAJOR DEPRESSIVEDISORDER

IV. Overview of Psychiatric Conditions

Categories of Psychiatric Disorders

4. Psychosis - discussed in Part VII.

5. Depressive disorders-discussed in Part VIII.

6. Bipolar disorders- discussed in Part IX.

TABLE 3. SUMMARYOF ANXIETY DISORDERS

8. Trauma or stressor-related disorders

9. Substance use disorders- see Part XI

10. Somatic symptom and related disorders

u • A psychologicalor behavioralfactor adverselyaffects the medical condition of a

TABLE 4. SOMATICSYMPTOMSDISORDERVS. FACTITIOUSDISORDERVS. MALINGERING:

d 11. Obsessive-compulsive disorder

• o Compulsionsare repetitiveactions, whethermentalor actual,which the patient cannot stop

Other Categories of Psychiatric Disorders

V. Modalities of Treatment in Psychiatry and Introduction to Psychotherapy

I University of the Philippines - Philippine General Hospital

I 2. Support ive psychotherapy

I • He is taught to cope by reaching out instead of withdrawing from others, with

I o Works under the premise that behaviors are conditioned .

• Situations wherein he was able to troubleshoot mistakes or wherein his classmates

Sample Basic CBT Matrix :