Table Of Contents
M
a
tering
!!!!!! iatry:!
Psych
A"core"textbook"for"undergraduates!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!(!!!4!!!t!!h!! !!E!!!d!!!!ition)
!
"
"
"
Melvyn"WB"Zhang"
Cyrus"SH"Ho"
Christopher"CS"Cheok"
Ng"Beng"Yeong"
Lee"Cheng"
Rohit"Shankar"
Sanjeev"Sockalingam"
Michael"Cheng"
Roger"CM"Ho""
""
Mastering*Psychiatry*
A*core*textbook*for*Undergraduates*
4rd*edi9on*
Lead%Author:%
Melvyn*WB*Zhang*
MBBS%(Singapore)%
%Diploma%(Cl%Psychiatry)%%(RCP&S%Ireland),%MRCPsych%(UK)%
Resident*(Psychiatry)*
Na9onal*Healthcare*Group*
Cyrus*SH*Ho*
MBBS%(Singapore)%,%%
Diploma%(Cl%Psychiatry)%%(RCP&S%Ireland),%MRCPsych%(UK)%
Specialist*Registrar*
Na9onal*University*Healthcare*Systems*
Local&collaborators:&
Christopher*Cheok*Cheng*Soon*MBBS,%MMed%(Psychiatry)%%
Senior*Consultant*&*Vice*Chairman*Medical*Board*(Na9onal*Addic9ons*Management*Service),*Ins9tute*of*Mental*Health*
*
Lee*Cheng*MBBS,%MMed%(Psychiatry)%%
Senior*Consultant*&*Vice*Chairman*Medical*Board*(Clinical),*Ins9tute*of*Mental*Health*
*
Ng*Beng*Yeong*MBBS%,%MMed%(Psychiatry)%
Senior*Consultant,*Singapore*General*Hospital*
*
Overseas%Collaborators:%
Rohit*Shankar*
MBBS%%
DPM,%MRCPsych(UK),%CCT,%PGCIResearch,%PGCIAsperger’s%syndrome%
Consultant*in*Adult*Developmental*NeuroPsychiatry*(Cornwall*Partnership*NHS*Founda9on*Trust)*
Hon.*Associate*Professor*–*Exeter*Medical*School,*UK*
Innova9on*Lead*–*South*West*Division*RCPsych,*Deputy*Research*governance*Director*CFT,*Beddoes*Fellow*
*
Sanjeev*Sockalingam*
MD,%FRCPC%%
Deputy*Psychiatrist*in*Chief*(TGH*&*PMH)*
Director,*Con9nuing*Professional*and*Prac9ce*Development*/*Assistant*Professor,*Department*of*Psychiatry*
University*of*Toronto*
*
Michael*Cheng*
MD,%FRCPC%(C)%%
Psychiatrist,*Children’s*Hospital*of*Eastern*Ontario*
*
Associate*Professor,*Faculty*of*Medicine,*University*of*O[awa
EditorIinIChief:%
Roger*CM*Ho*
MBBS%(Hong%Kong),%DPM%(Psych)%(Ireland)%%
Diploma%(Cl%Psychiatry)%%(RCP&S%Ireland),%DIP%(Psychotherapy)%(NUS),%%
%MMed%(Psych)%(Singapore),%MRCPsych%(UK),%FRCPC%%
Assistant*Professor*and*Consultant*Psychiatrist*
Department*of*Psychological*Medicine*
Yong*Loo*Lin*School*of*Medicine*
Na9onal*University*of*Singapore*
*
Illustrated*by*
Anna*Chua*
BSc%(NUS)%
Research*Assistant*
Department*of*Psychological*Medicine*
Yong*Loo*Lin*School*of*Medicine*
Na9onal*University*of*Singapore*
*
*
*
First published in Singapore in 2012 by
Melvyn WB Zhang and Roger CM Ho, Department of Psychological Medicine, Level 9, NUHS Tower Block
1E Lower Kent Ridge Road, Singapore 119 228.
2nd Edition published in Singapore in July 2013
3rd Edition published in Singapore in July 2014
4th Edition published in Singapore in July 2015
© 2015 Melvyn WB Zhang, Cyrus SH Ho, Rohit Shankar, Sanjeev Sockalingam, Michael Cheng & Roger CM Ho
Copyright endorsed with The Screenwriters Association Singapore & Samuel Seow Law Corporation
Serial Number: ASR2012/0006
All rights reserved. No part of this publication or electronic resource may be reproduced, stored in a retrieval system,
or transmitted in any form such as electronic, mechanical, photocopying, recording without prior permission of the
copyrighted owners.
Whilst the advice and information in this book are believed to be true and accurate at the date of going to press,
neither the authors nor the printer can accept any legal responsibility or liability for any errors or omissions that may be
made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check
drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly
being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug
companies' printed instructions before administering any of the drugs recommended in this book.
National Library of Singapore Cataloguing in Publication Data.
A catalogue record for this book is available from the National Library of Singapore
ISBN (Book): 978-981-07-0163-5
ISBN (DVD): 978-981-07-0164-2
ISBN (International): 978-1-105-93719-4
1 2 3 4 5 6 7 8 9 10
Editors: Melvyn WB Zhang, Cyrus SH Ho, Rohit Shankar, Sanjeev Sockalingam, Michael Cheng & Roger CM Ho
Cover Design: Melvyn WB Zhang
Images: Anna Chua
Printed and bound in Singapore
Authorized Printers: E-Print(Singapore), Campus Suppliers (NUS), Xorex Press (Singapore)
Preface
_____________________________________________________
Psychiatry is a branch of medicine that focuses on the diagnosis, treatment and prevention of mental and
emotional disorders. Psychiatry offers medical students a unique experience because psychiatric
diagnosis is established by clinical interview but not based on a laboratory test or an X-ray. Medical
students may need time to adjust to this specialty because it involves treatment modality such as
psychotherapy or electroconvulsive therapy which are not found in other medical or surgical disciplines.
The duration of undergraduate posting in psychiatry is 6 weeks and it poses a challenge for medical
students to master psychiatric knowledge and skills in a short period of time. The old ideology was to study
a large psychiatric textbook. Medical students often realise that much time has elapsed without
consolidating their knowledge prior to the examination, leading to panic attacks. Some students study
textbooks published in the UK and US but these books may contain treatment recommendations which are
not relevant to the Singapore context. We believe that this new book, Mastering Psychiatry: A core
Textbook for Undergraduates will be one of the most accessible, creative and practical
books in undergraduate psychiatry to bridge the gaps of revision and application of knowledge in the
examinations and future practice . The skilful organisation comes through on every page and candidates
can revise psychiatry in an efficient manner.
The chapters in this book are based on the common syllabus of most medical schools worldwide. We also
incorporate the guidelines from the Ministry of Health (Singapore) and the National Institute of Clinical
Excellence (NICE) (United Kingdom). The materials of this book are based on the undergraduate course
taught and the wealth of clinical experience gathered by RH at the National University Hospital. Whenever
possible, the concepts are supplemented with diagrams and sample exam questions, where the readers
may gain a deeper insight, so whilst the materials are easily absorbable, they also provide a stepping
stone to the OSCE examination. We believe that the preparation for OSCE is based on clinical videos and
a DVD is provided to help candidates to prepare for the OSCE. Furthermore, the OSCE grid helps to
consolidate knowledge in a practical and memorisable manner. This book also contains important
information required for the theory papers. We hope that we have produced an affordable book that lives
up to the high expectations from the readers and yet to revise psychiatry in an enjoyable and informative
way.
We have striven to make Mastering Psychiatry: A core textbook for undergraduates an interesting,
enjoyable and useful. We would welcome constructive criticism and comments (email to
[email protected]) directed at making improvements to future editions. We believe that
readers putting effort into learning psychiatry through this book would be in a strong position to impress the
examiners and their colleagues.
Roger Ho
Melvyn Zhang
Cyrus SH Ho
Singapore 2015*
*
*
To%people%with%mental%illnesses,%their%families%and%mental%health%workers%
who*ba[le*with*mental*illnesses*and*devote*their*lives*to*improve*the*quality*of*psychiatric**
care.*
*
To%medical%students%
who*strive*for*excellence*and*determine*to*pursue*a*medical*career*with*9reless*effort.*
Thanks*for*the*tremendous*support*for*our*book*in*from*2012*to*2015.***
*
R.H.**
M.Z*
C.H.*
Our%InternaRonal%EducaRonal%Leads%/%CoIauthors%
Dr Rohit Shankar (Co-author / UK Lead)
Deputy Director - Research and Innovation, Cornwall Partnership NHS Foundation Trust
Dr Rohit Shankar (MBBS, DPM, MRCPsych, CCT, PGC-Cl. Research. PGC –Aspergers) is a Consultant
Developmental Neuropsychiatrist working for Cornwall Partnership NHS Foundation Trust and an Hon. Associate
Professor to the Exeter Medical School.
He was a finalist in the Health Service Journal awards 2012 and 2013, RCPsych Public Educator of the year Award
2013 and the British Medical Journal awards 2012. He was the recipient of the Royal College of Psychiatrists
southwest division innovation award for 2009 and 2011 and runners up in 2012, BMA ‘highly commended’ book award
2011 and international Medical Futures Award 2007 for the BeSMART program. He received the public health
Beddoes fellowship in 2010 to use radio as a medium to raise public awareness and insight while reducing stigma.
He is the Innovation lead for the Royal College of Psychiatrists south west division, Associate member of the health
service research board (NIHR), the Trust research governance deputy director and CPD coordinator.
He has an active interest in research and in the last 5 years over forty publications, oral and poster presentations in
peer reviewed journals and conferences. In the last 3 years he has received over £100,000 worth of various grants
for research, innovation and teaching. He has developed training DVDs for psychiatrists and GPs and an online
website to foster safer epilepsy care which has been supported by the Joint Epilepsy Council and leading epilepsy
charities.
Dr. Sanjeev Sockalingam (Co-author / Toronto Lead)
He is currently the Deputy*PsychiatristbinbChief,*Department*of*Psychiatry,*University*Health*Network*and*also*the*Director,*
Bariatric*Surgery*Psychosocial*Program,*Toronto*Western*Hospital.*He*is*also*the*Head*for*Hepatology*and*Mental*Health*
Service,*University*Health*Network*
He*is*also*the*Director*for*Con9nuing*Professional*and*Prac9ce*Development,*Department*of*Psychiatry,*University*of*Toronto*
He*holds*the*posi9on*of*Assistant*Professor*at*the*Department*of*Psychiatry,*University*of*Toronto.*
Dr. Michael Cheng (Co-author / Ottawa Lead)
He is a psychiatrist as the Children’s Hospital of Eastern Ontario and also holds the position of Associate Professor
with the Faculty of Medicine, University of Ottawa.
He is one of the pioneers to launch a mental health website in Canada. The website is available at
www.ementalhealth.ca.
Disclaimers*
1) The purpose of Mastering Psychiatry is to provide a free textbook and free access to
a website which contains simulated videos. This is a dedication, lead by Dr. Melvyn
WB Zhang and Dr. Roger Ho in 2012, to medical students from the Yong Loo Lin
School of Medicine, NUS especially those students with financial difficulty and cannot
afford a foreign textbook. Students can photocopy and reproduce in any format which
they prefer because the authors would like to share their knowledge with medical
students in the most direct and convenient way.
2) The authors do not receive any income from this book. This book is a humble setup
without access to full typesetting service and no publisher was involved in the publication
process. As a result, this book does not have continuous page numbering and an index
at the back for cross-reference and cannot be comparable with a book published by a
publisher.
3) There are various psychiatry textbooks in the market. University students are
expected to have the wisdom to choose their preferred textbooks. Different textbooks are
written in different styles and they are not mutually exclusive. Mastering Psychiatry
follows the format of British revision notes for medical students. It aims to be concise and
written in short sentences or point-forms.
4) There have been significant discoveries in psychiatric knowledge. The authors have
tried their very best to include the most updated information in this book which is relevant
to clinical practice in Singapore. This book aims to be a companion for undergraduate
studies and a reference book for future practice. The authors have highlighted mistakes
and clarified queries raised by previous medical students. You can find those information
in the website.
5) This book is not intended to replace clinical clerkship. Students are advised to see
patients and link their clinical observation with the book content. In examination, there
are questions based on clinical scenarios. Students are advised to use their clinical
reasoning to select the best answers. It should not not a direct recall from any textbook
without clinical reasoning.
6) We welcome constructive feedbacks and queries on Mastering Psychiatry. You could
send your feedback and enquiries to [email protected] , or contact any
one of the Singapore Lead Authors.
Contents & Abridged Index
_____________________________________________________
The authors
Preface
Foreword
Dedications
More about Co-authors
Disclaimers
1. Psycho-pathology
Perceptions – 1
Illusions – 1
Hallucinations – 2
Thought process and speech – 3
Delusions – 4
Psychopathology in movement – 4
Common Psychiatric syndromes – 5
2. Clinical Interview, formulation and management
Psychiatric history- 10
Mental state examination – 13
Physical examination – 15
Diagnosis and hierarchy of diagnosis – 16
Formulation – 16
Investigations, Management and multidisciplinary approach -17
3. Schizophrenia, antipsychotics and related disorder
Schizophrenia – 19
Diagnostic criteria – 22
Physical Exam, Differentials – Page 27
Management - 28
Antipsychotics – 31
EPSE – 38
Psychosocial intervention – 39
Prodromal Psychosis – 41
Catatonia – 42
Schizoaffective disorder – 42
Brief Psychotic Disorder – 43
Delusional disorder – 44
4. Mood disorders
Depressive disorder – Page 52
Diagnostic criteria – 54
Differentials, Investigations, Questionnaires – 58
Management – 59
Antidepressants – 59
ECT & RTMS – 64
Bipolar disorder – 68
Diagnostic criteria – 70
Investigations, Questionnaire & Management – 73
Mood stabilizers – 75
Suicide and DSH - 78
*
*
Contents & Abridged Index
_____________________________________________________
5. Anxiety, phobia and stress related disorder
Learning theory – 86
Epidemiology of all Anxiety disorders – 88
Generalized anxiety disorder – 90
Panic disorder – 92
Social phobia – 94
Specific phobia – 94
Obsessive compulsive disorder – 97
Acute stress reaction and adjustment disorder – 101
Post traumatic stress disorder – 102
Depersonalization and derealisation - 105
6. Personality and impulse control disorder
Borderline personality disorder – 112
Obsessive compulsive personality disorder – 116
Avoidant personality disorder – 117
Schizotypal personality disorder -118
Antisocial personality disorder – 119
Narcissistic personality disorder – 121
Schizoid personality disorder – 123
Paranoid personality disorder – 124
Histrionic personality disorder – 125
Dependent personality disorder – 127
Impulse control disorder - 128
7. Substance misuse and dependence
Alcohol misuse and dependence – 132
Opioid misuse and dependence – 141
Stimulants – 143
Nicotine and smoking – 147
Solvents, sedatives, caffeine and steroids – 149
Caffeine – 151
Steroids – 152
Gambling disorder – 152
Internet addiction – 153
8. Eating disorders
Anorexia Nervosa – 157
Bulimia Nervosa – 160
Binge eating disorder – 161
Metabolic syndrome – 164
9. Psychiatric emergencies
Neuroleptic malignant syndrome – 170
Serotonin syndrome – 172
Suicide / Deliberate Self Harm – 173
Drug overdose – 177
*
*
Contents & Abridged Index
____________________________________________________
10. Psychotherapies
Transference, Countertransference and Defence Mechanisms – Page 183
Psychodyamic psychotherapy – 185
Cognitive behavioral therapy – 186
Dialectical behavioral therapy – 187
` Interpersonal therapy – 188
Family therapy – 188
Group therapy – 189
Couple therapy – 190
EMDR – 191
Grief Counseling, Motivational Interview and Mindfulness – 191
11. Sleep disorders
Assessment of sleep disturbances – 195
Insomnia – 196
Hypersomnia and excessive daytime sleepiness – 198
Narcolepsy – 199
Parasomnia – 200
REM / NREM sleep – 202
12. Psychosexual disorders
Premature ejaculation, Organmisc dysfunction – 205
Failure of genital response, Loss of sexual desire, Several aversion – 206
Non-organic vaginismus, Non organic dyspareunia – 207
Abnormal sexual preference and paraphilia – 209
Gender dysphoria disorder – 210
13. Somatoform & Dissociative disorders
Somatic symptoms disorder – 214
Health anxiety disorder – 218
Body dysmorphic disorder – 219
Dissociative and conversion disorder – 221
14. Consultation liaison psychiatry
Delirium – 229
Common problems in CL Psychiatry -232
Cardiovascular disorder – 233
Liver impairment – 235
Renal Impairment – 235
Electrolytes disturbances and Psychiatric manifestations – 236
Endocrinology – 236
Psycho-oncology – 238
HIV infections – 240
Post concussion syndrome / NP SLE – 242
Women’s mental health - 243
15. Old age psychiatry
Normal aging & overview of dementia – 252
Alzheimer’s dementia – 259
Vascular dementia – 262
Fronto-temporal dementia – 263
Lewy body dementia – 264, Other psychiatric disorders - 265
*
*
