DEPARTMENT OF PSYCHIATRY

School of Medical Sciences, Universiti Sains Malaysia

GMT 409
STUDENT GUIDE BOOK
PHASE II - YEAR 4
ACADEMIC SESSION 2017/2018

Checked and Confirmed by:

........................................
(Signature )

DR. SHARIFAH ZUBAIDIAH SYED JAAPAR

Year 4 Posting Coordinator
Department of Psychiatry
Academic Session 2017/2018
ext: 6701 e-mail : zubaidiah@usm.my

05/07/2017
Date : ................................

1
 CONTENTS

PAGE

1. INTRODUCTION 3

2. PHASE II – UNDERGRADUATE PSYCHIATRY PROGRAMME

- GENERAL OBJECTIVES 4

- SPECIFIC OBJECTIVES 5

3. GUIDELINES FOR PSYCHIATRIC ASSESSMENT

A. PSYCHIATRIC HISTORY 9

B. MENTAL STATUS EXAMINATION 19

C. EXAMINATION OF NON-COOPERATIVE OR 27
STUPOROSE PATIENTS

4. CASE FORMULATION 30

5. INSTRUCTION TO STUDENT 33

6. GUIDELINE FOR PREPARING CASE WRITE-UP 37

7. ASSESSMENT 40

9. READING LIST 42

2
1 INTRODUCTION

Welcome to psychiatric posting!

In this posting students will be exposed to proper psychiatric interviews,
case clerkings, clinical presentations and theoretical understanding of
psychiatric disorders.

Many students found this posting interesting simply because it has a

difference. First and foremost, psychiatry is a branch of medicine that focus
on the understanding of the process of thinking, emotion and behaviour.
Secondly, psychiatry if not treated like any other subjects in medicine would
appear to be loose and abstract. It is suggested that the beginner sticks to a
methodology used in clinical medicine. As one said, insanity is a disease that
affect the brain. Therefore it has to be studied in a similar manner one study
medicine. The difference perhaps is on the holistic approach, the
authoritative and negotiative style in managing cases.

Remember that in psychiatry, systematic history taking and mental status

examination must be supplemented with empathic understanding and good
doctor-patient relationship. Only then one would be able to produce a good
diagnosis and treatment modality.

To excel in psychiatric study, group discussion is encouraged on top of

individual study alone. This is because in understanding the psychiatric terms
and phenomena, there will always be a different interpretation on a similar
phenomena. Similarly, different books will say differently and different
classification systems will classify disorders differently. The beginners will be
confused if they do not get proper guidance from teachers or well-informed
peers.

Last but not least, it is our hope that this posting would be a memorable one
that students will remember throughout their entire medical career.

3
2 UNDERGRADUATE PSYCHIATRIC PROGRAMME

GENERAL OBJECTIVES

The phase II psychiatric academic programme has been structured such that
the student, when he/she graduates at the end of phase II, should be able
to:
1.1 Understand the scientific basis of psychiatry and its application to
patient care.
1.2 Acquire a satisfactory standard of clinical competence relating to
the following parameters:
1.2.1 Able to interview and obtain a satisfactory case history.
1.2.2 Perform a mental status examination and carry out simple
clinical procedures.
1.2.3 Able to diagnose common psychiatric conditions and acute
emergencies and formulate their solutions which entail the
institution of first line management before referral for
specialist treatment whenever necessary.
1.2.4 Acquire satisfactory behavioural and communications skills,
necessary for instituting patient management.

1.3 Understand and appreciate the socio-cultural background of the

patient and his/her environment in formulating a plan of
management including long term management and follow-up.
1.4 To understand the broader role and responsibilities of psychiatrists
in society and play the role of the leader in the mental health care
team and the community.
1.5 To utilize the knowledge acquired to pursue continuing medical
education.

4
SPECIFIC OBJECTIVES

2.1 At the end of phase III, the student is expected to be able to

demonstrate KNOWLEDGE of:-
2.1.1 The aetiology, psychopathology (including defense mecha-
nism), clinical features and management of the following:
2.1.1.1 Neurodevelopmental disorders
2.1.1.2 Psychotic disorders
2.1.1.3 Mood disorders
2.1.1.4 Anxiety disorders
2.1.1.5 Obsessive-compulsive and related disorders
2.1.1.6 Trauma-and stressor-related disorders
2.1.1.7 Dissociative disorders
2.1.1.8 Somatic symptoms and related disorders
2.1.1.9 Feeding and eating disorders
2.1.1.10 Elimination disorders
2.1.1.11 Sleep-wake disorders
2.1.1.12 Sexual dysfunction
2.1.1.13 Gender dysphoria
2.1.1.14 Disruptive, impulse-control, and conduct
disorders
2.1.1.15 Substance-related and addictive disorders
2.1.1.16 Neurocognitive disorders
2.1.1.17 Personality disorders
2.1.1.18 Paraphilic disorders
2.1.1.19 Transcultural psychiatry

5
2.1.2 Pharmacological treatment including neuroleptics,
antidepressants, anxiolytics and mood stabilisers.

2.1.3 Physical treatment including electroconvulsive therapy,

trans-cranial magnetic stimulation and deep brain
stimulation.

2.1.4 Psychological treatment including cognitive behaviour

therapy, group therapy, and grief work.

2.1.5 Psychiatric emergency including suicidal, aggressive,

neuroleptic malignant syndrome and delirium tremens

2.1.6 Emotional problems associated with physical illness.

2.1.7 Psychiatry and the law - Mental Health Act and criteria for
certification.

2.1.8 Ethical issues involved in the management of psychiatric

patients.

2.1.9 Psychiatric services available in Malaysia and outline of the

organization of the mental health services in Malaysia.

2.1.10 Role of para-medical personnel in the management of

psychiatric patients

6
2.2 SKILLS:
The students are expected to be able to make a complete patient
assessment by:
2.2.1 Communicating effectively with patient and family.
2.2.2 Eliciting description of patients‟ problems from them.
2.2.3 Recognizing the signs and symptoms, their relationship and
their relationship with patient‟s past, family and personal,
social background or with his medical illness.
2.2.4 Demonstrating the ability to effectively communicate this
recognition through a detailed problem - oriented record,
formulation of differential diagnosis, diagnosis and plan of
management including investigations.
2.2.5 Demonstrate ability to ask for relevant psychodiagnostic
testing and also to carry out and interpret simple basic
bedside psychometry.
2.2.6 Demonstrating these recognitions also in case-presentation,
writing a problem oriented medical record, summary and
discharge/referral letter.
2.2.7 Undertake basic psychotherapeutic techniques and
counseling.
2.2.8 Participating in simple physical treatment procedure e.g.
electroconvulsive therapy.
2.2.9 Participating in basic management and therapeutics of
psychiatric patient

7
2.3 ATTITUDES

2.3.1 Empathize with patients about their problems.

2.3.2 Establish rapport with patients and their family.

2.3.3 Be sensitive and attentive to the patients‟ problem.

2.3.4 Be sincere and predictable in relating to patient.

2.3.5 Inspire rational hope, confidence and trust in relationships.

2.3.6 Maintain confidentiality about professional communication.

2.3.7 Develop sufficient degree of awareness about your own

feelings, values and attitudes as they affect doctor patient
relationship.
2.4.8 Recognize the limitations, willingness to refer.

2.4.9 Collaborate with colleagues in related fields e.g., social

worker, occupational therapist, psychotherapist or
psychologist.

8
3 GUIDELINES FOR PSYCHIATRIC ASSESSMENT

A. PSYCHIATRIC HISTORY
1. Preliminary Identification
● Name, age, marital status; sex; occupation; language if other
than English; race, nationality, and religion in so far as they are
pertinent; previous admissions to a hospital for the same or a
different condition; with whom the patient‟s lives. There should
also be comment on the sources of information and the
reliability of history.

2. Chief complaint (s)

● exactly why the patient come to the psychiatrist, preferably in
the patient‟s own words; if information does not come from the
patient, note who supplied it. Note that one important function
of the chief complaint is to provide possible differential
diagnosis based on your description.
3. History of presenting illness
● This should be started with a very brief description about the
patient‟s past psychiatric illness (if applicable) and time of the
last discharge, followed by the time when the patient has
become ill this time. This is important in order to put your
history in context especially for patients with chronic relapsing
illnesses like Schizophrenia or Bipolar Disorder.

● Next, elaborate the chronological background and development

of the symptoms of behavioural changes that culminated in the
patient‟s seeking assistance; patient‟s life circumstances at the
time of onset; personality when well: how illness has affected
life activities and personal relations – changes in personality,
interests, mood, attitudes towards others, dress, habits, level
of tenseness, irritability, activity, attention, concentration,
memory, speech.

9
 ● Elicit psycho-physiological symptoms – nature and details of
dysfunction, location, intensity, fluctuation; whether anxieties
are generalized and nonspecific (free floating) or specifically
related to particular situations, activities, or objects, or
object; how anxieties are handled – repeated avoidance of
feared situation, use of drugs or other activities for
distraction.
 This should then be followed by a section highlighting
important negatives and ruling out of the other differential
diagnosis presumed from the chief complaint.

4. Previous illnesses

● Past psychiatric history

- Emotional or mental disturbance – extent of incapacity,

admissions and type of treatment, names of hospitals,
length of illness, effect of treatment.
- If there has been several admissions, try to summarize
the main events / presentations. There is no need to
give a too detailed account of past episodes.
 Past medical or surgical history- Elaborate when relevant.

5. Systemic Review
 Keep a brief review of various systems to ensure that you
have not missed out any possible organic cause for the
patient‟s presentation.

6. Family history

● Family tree
● Elicited from patient and from reliable informants, since quite
different description may be given of the same people and
events: ethnic, national, and religious traditions
● Other people in the home, descriptions of them – personality
and intelligence – and what has become of them since
patient‟s childhood.

10
 ● Descriptions of different household lived in; present
relationships between patient and those who were in family;
role of illness in the family; history mental illness.

7. Past Personal History

● History (anamnesis) of the patient‟s life from infancy to the
present to the extent it can be recalled, including age of onset,
duration, and impact of significant medical illness on patient;
gaps in history as spontaneously related by the patient;
emotions associated with those life periods – painful, stressful,
conflicting etc.
● Components
1. Prenatal history – nature of mother‟s pregnancy and
delivery: length of pregnancy, spontaneity and normality
of delivery, birth trauma, whether patient was planned
and wanted, birth defects.

2. Early childhood (through age 3)

a. Feeding habits: breast-fed or bottle-fed, eating
problem
b. Maternal deprivation, early development –
language development, motor development, signs of
unmet needs, sleep pattern, object constancy,
stranger anxiety, separation anxiety.
c. Toilet training: age, attitude of parents, and feelings
about it.
d. Symptoms of behaviour problems: thumb
sucking, temper tantrums, tics, head banging,
rocking, night-terrors, fears, bed wetting or bed
soiling, nail biting, masturbation.
e. Personality as a child: shy, restless, overactive,
withdrawn, studious, outgoing, timid, athletic,
friendly, patterns of play, reactions to siblings.
f. Early or recurrent dreams or fantasies

11
3. Middle childhood (ages 3 to 11)
● early school history – feelings about going to school,
early adjustment, gender identification, conscience
development, punishment.

4. Later childhood (from pre-puberty through

adolescence
a. Social relationships: attitudes toward siblings and
playmates, number and closeness of friends, leader or
follower, social popularity, participation in group or
gang activities, idealized figures; patterns of
aggression, passivity, anxiety, antisocial behavior
b. School history: how far the patient went,
adjustment to school, relationships with teachers –
teacher‟s pet or rebellious – favourite subjects of
interests, particular abilities or assets, extracurricular
activities, sports, hobbies, relationships of problems or
symptoms to any school period
c. Cognitive and motor development: learning to
read and other intellectual and motor skills, minimal
cerebral dysfunction, learning disabilities – their
management and effects on the child
d. Particular adolescent emotional or physical
problems: nightmares, phobias, masturbation, bed
wetting, running away, delinquency, smoking, drug or
alcohol use, weight problems, feeling of inferiority
e. Psychosexual history
i. Early curiosity, infantile masturbation, sex play.
ii. Acquiring of sexual knowledge, attitude of
parents toward sex.
iii. Onset of puberty, feelings about it, kind of
preparation, feelings about menstruation,
development of secondary sexual characteristics.

12
 iv. Adolescent sexual activity: crushes, parties,
dating, petting, masturbation, wet dreams and
attitudes toward them
v. Attitudes toward opposite sex: timid, shy,
aggressive, need to impress, seductive, sexual
conquests, anxiety
vi. Sexual practices: sexual problems, homosexual
experiences, paraphilias, promiscuity
F. Religious background: strict, liberal, mixed
(possible conflicts), relationship of background to
current religious practices

5. Adulthood
a. Occupational history: choice of occupation,
training, ambitions, conflicts; relations with authority,
peers, and subordinates; number of jobs and
duration: changes in job status; current job and
feelings about it.
b. Social activity: does patient have friends; is he or
she withdrawn or socializing well; kind of social,
intellectual, and physical interests; relationships with
same sex and opposite sex; depth, duration, and
quality of human relations.
c. Adult sexuality
i. Premarital or extra – marital sexual relationships
ii. Marital history: common-law marriages, legal
marriages, description of courtship and role
played by each partner, age at marriage, family
planning and contraception, names and ages of
children, attitudes toward the raising of children,
problems of any family members, housing
difficulties if important to the marriage, sexual
adjustment, areas agreement and disagreement,
management of money, role of in-laws.
iii. Sexual symptoms: anorgasmia, impotence,
premature ejaculation etc.

13
 iv. Attitudes toward pregnancy and having children;
contraceptive practices and feelings about them
v. Sexual practices: paraphilias
d. Forensic History: any involvement with the law or
criminal offences.

8. Current social situation:

● Where does patient live - neighborhood and particular
residence of the patient; is home crowded; privacy of family
members from each other and from other families; sources of
family income and difficulties in obtaining it; public assistance,
if any, and attitude about it; will patient lose job by remaining
in the hospital; who is caring for children.

9. Premorbid Personality
● In this description of the personality prior to the beginning of
the mental illness, do not be satisfied with a series of
adjectives and epithets, but give illustrative anecdotes and
detailed statements. Aim at a picture of an individual, not a
type. The following is merely a collection of hints, not a
scheme. It will not be possible to cover all the items listed in
the course of the first interview, but an attempt should be
made, particularly in case of neurosis or affective disorder, to
elicit evidence about all aspects of pre-morbid personality in
the course of explorations extending over a period. Of course,
presence of a reliable informant is crucial to get an accurate
account of the patient‟s Premorbid personality.For the ease of
remembering, remember the acronym:
C H A R2 M S I F
1. Character

● Attitude to work and responsibility; welcomes or is

worried by responsibility; makes decisions easily or
with difficulty; haphazard an slapdash or methodical
and meticulous; rigid or flexible; cautious, foresightful
and given to checking or impulsive and slipshod;
persevering and determined or easily bored and
discouraged

14
 ● Interpersonal relationships; self-confident or shy and
timid; insensitive or touchy and sensitive to criticism;
trusting or suspicious and jealous emotionally
controlled or quick-tempered an irritable; tactful or
outspoken; enjoys or shuns self-display; quiet and
restrained or expressive and demonstrative in speech
and gesture; interest and enthusiasms sustained or
evanescent; tolerant or intolerant of others; adaptable
or not adaptable.
● Standards in moral, religious, social and health
matters: level of aspiration high or low; perfectionist
and self-critical or complacent and self approving in
relation to own behaviour and achievement; steadfast
in face of difficulties or intolerant of frustration; selfish
and egotistical or unselfish and altruistic; given too
much or little concern about own health
● Energy, initiative: energetic or sluggish; output
sustained or fitful. Fatigability: and regular or irregular
fluctuations in energy or output
2. Habits: eating (fads); alcohol consumption; self-
medication with drugs or other medicines. Specify
amounts taken recently and earlier. Tobacco
consumption; sleeping; excretory function
3. Attitudes: towards self and others – optimistic,
pessimistic, stingy, paranoid towards others etc.
4. Relationships: to family (attachment, dependence); to
friends, groups; to work and workmates (leader or
follower, organizer, aggressive, submissive, ambitious,
adjustable, independent)
5. Religion: the patient‟s religion, attitude towards it,
piousness, anxiety and the role of religion as the source of
solace in times of stress.
6. Mood: bright and cheerful or despondent; worrying of
placid; strung-up or calm and relaxed; optimistic or
pessimistic; self-depreciative or satisfied; mood stable of
unstable (with or without any occasion)

15
 7. Social activities: these include involvements in social
events like feasts, societies or even recreational activities
including sports and clubbing.

8. Intellectual activities, hobbies and interests: books,

plays, movies preferred; memory, observation, judgment,
critical faculty

9. Fantasy life: frequency and content of daydreaming

10. Events Chart

● It is very helpful to provide a summary of events which

illustrates the main events of the patient‟s history in simple
graphic style for easy viewing. The contents of the chart should
be concise, precise and striking. Example is in chart 1.

● For mood disorder patients especially those with repeated

episodes e.g. bipolar disorder on recurrent depressible
disorder, a mood chart will also be very helpful. Example is in
chart 2.

16
 CHART 1

LIFE EVENT CHART

Started Stopped Noted to be Smiling Seen Aggresive, Brought

SPM exam 1/2 withdrawn and bomoh throwing to HUSM
way laughing things
to self

12/11/01 16/11 early Dec Feb 02 mid Feb 2/3/02 6/3/02

Please note that as far as possible, all major events are charted to give a
“summarized” graphic account of events leading to the current presentation
(either to the ward or outpatient clinic). This may be extended to several
years back for patients suffering from chronic recurring or relapsing
disorders like Schizophrenia, Bipolar Disorder or sometimes, certain neurotic
disorders.

17
 CHART 2

MOOD CHART

SSRI Lithium Risperidone and

Treatment (Fluoxetine) Sodium Valproate

Severe
Mania

Moderate

Mild Apr „97 Sep „„97 May „00

Dec „97 Feb „00

Mild
Depression

Moderate

Severe

Recurrence
Precipitating Precipitated by ? SSRI induced
following stoppage
Poor
Factor father‟s death hypomania of Lithium compliance?

Admission

18
B. MENTAL STATUS EXAMINATION

Mental Status : sum total of the examiner‟s observations and impressions

derived from the initial interviews.

1. GENERAL APPEARANCE AND BEHAVIOUR:

● Posture, state of personal hygiene, abnormal involuntary
movements, mannerism, hyper / hypo activity, physical signs
of anxiety, like sweating of hands, wide eyes, frequently
changing posture and frequent swallowing or depressive signs
like stooped posture, vacant look apathy to surrounding.
 Attitude (towards the examiner) - co-operative, communicative,
domineering, withdrawn, interfering, evasive, guarded, hostile,
rapport.

2. SPEECH :
● Language, relevance
● Amount - Normal / increased / decreased
● Volume - Normal / increased / decreased
● Speed - Normal / increased / decreased; pressure of
speech / poverty of speech
● Tone - Normal / monotonous

3. MOOD AND AFFECT

● MOOD
 A pervasive and sustained emotion that colors the person‟s
perception of the world

 This is a subjective and longitudinal emotional state.

 Question : How have you been feeling lately.

19
 ● AFFECT

 Emotional expression in response to a given situation. This

is an objective and cross-sectional emotional state.
 Affect is characterized in several ways
1. By the type of emotion expressed and observed :
anger, sadness elation, etc.
2. By the intensity / depth of emotion expressed :
normal, blunted or flat. In flat affect, there is no
expression of feeling; the face is immobile and the
monotonous. In blunted effect, the expression of
feeling is severely reduced.
3. By the range of emotion shown : Broad affect
describes the normal condition in which a full range of
feelings is expressed. Restricted or constricted affect
is when it is limited in expression.
4. By it appropriateness : Inappropriate affect is
apparent emotion discordant with accompanying
thought or speech (e.g., laughing while telling a story
most people would find horrifying).
5. By consistency or liability of emotion : labile
affect shifts rapidly between different emotional states
such as crying, laughing, and anger.

4. PERCEPTUAL DISTURBANCE

a. Definition
 Hallucination - Sensory perception without an
objective stimulus
 Illusion - Sensory misinterpretation of an
objective stimulus

20
b. Types True Pseudo
Hallucination Hallucination

a. Spatial relationship Objective Subjective

space Space

b. Sensory modality + +
involved
c. Clarity + +
d. Voluntary Control Absent Present
e. Insight Absent Present

c. Modalities - Auditory, visual, olfactory, gustatory, tactile.

 Auditory Hallucination

Second person

● When the voice addresses the patient directly as “you”

or commands him to do things.

Third person

● When 2 voices converses and refer the patient as third

person eg.„he‟, „she‟ etc.

● When a voice gives a running commentary of the

patients activities

d. Description - Continuous / Intermittent

 Depersonalization - Sense of unreality pertaining to the

self with a quality of “as if”.

 Derealization - Sense of unreality pertaining to the

surrounding with a quality of “as if”.

21
5. THINKING

a. Disorders Of Form
● Form refers to the meaningfulness or understandability of
the speech. Normally ideas, associations and symbols are
connected meaningfully to reach a reality oriented
conclusion.
● Fantasy thinking – the connections may be meaningful but
the conclusions reached are unrealistic.
● Autism – may be present as thinking is less responsive
to external stimuli
● Neologism – presents with highly personalized
meaning being attached to newly formed words

● Association disturbance

● Looseness – may be association / incoherence –

inability to logically understand the jumps from one
topic to another.
● Flight of ideas – it is based on rhyming, punning etc.
leading to vague wooly thinking and word salad.
Presence of pressure of speech is also necessary (see
below).NB: prolixity is flight of ideas without the
pressure of speech.
● Conceptual thinking – evidence of abnormal
overgeneralization / concretization (mainly through
proverbs / similarity / differences tests)
● Circumstantiality / tangentiality
b. Flow
● Productivity and continuity of speech/thought.
● Increased productivity (pressure of speech) may give rise
to flights of ideas and circumstantiality.

22
 ● Decreased productivity gives rise to thought retardation
 Disturbance of continuity produces either perseveration or
thought block

c. Content
 If refer to the content of thinking per se. It includes
primary delusions, secondary delusions, preoccupations,
overvalued ideas and also obsessional or repeated
thoughts.

d. Possession
 Normally the subject experiences his thinking as his own
i.e. he has a sense of possession. Disorder of possession
means the subject thinks that his thoughts are no longer
his own or no more under his control eg. thought
insertion, broadcasting, withdrawal and obsessions and
compulsions. Note that the disorders of thought
possession are also delusions. So, you need to attempt at
challenging these believes as well.

● Thought Insertion
 Q. Do you think other people / force are putting their
thoughts in to your mind/head against your wish?

● Thought broad casting

 Q. Do you think others can know your thoughts
without you telling so

● Thought withdrawal
 Q. Do you think somebody / some force snatches your
thoughts away against your wish.

23
6. COGNITION
a. Orientation
● Time - does patient identify the date correctly; can be
approximate date, time of day if he is in a hospital, does
he know how long he has been there; does patient behave
as if he is oriented to the present?
● Place: does patient know where he is?
● Person: self and others. Does the patient know the
identity of himself and the examiner, does he know the
roles or names of the persons with whom he is in contact.

b. Attention And Concentration :

● Serial Subtraction Test
i) 100 - 7 (N - 120 sec.)
ii) 40 - 3 (N - 60 sec.)
iii) 20 - 1 (N - 15 sec.)
● Days of the week and months forward and backward.

c. MEMORY:
● Efforts made to cope with impairment - denial,
confabulation, catastrophic reaction, circumstantiality;
whether the process of registration, retention, or
recollection of material is involved.
(i) Immediate memory - Digit span test
● Digit forward (DF) & digit backward (DB)
● Instruction to the patient with example.
● Read digits one per sec.
● The following digits may be used

24
 5-7-3

6-3-8-2

1-6-4-9-5

3-8-1-7-9-6

7-2-5-9-4-8-3

4-7-2-9-1-6-8-5

The normal range for DF is 7 (±2) and DB is

5(±2).NB: Avoid using consecutive numbers or
numbers with a familiar pattern (e.g. 2,4,6,… or
1,3,5,7,…) in the list. Also, do not use the same
set of digits for both DF and DB.

(ii) Recent memory:

● The past few days; what did patient do
yesterday, the day before; what did he have
for breakfast, lunch, dinner, object recall test
- (2 dissimilar objects, one address - name,
house number, street, city) after 3 minutes
of distraction.

(iii) Remote memory: Personal like birthday, dates of

graduation, employment, marriage, no. of children,
I.C. No. and impersonal like old events like the
Independence Day, the May-13 incident, the Agung‟s
installation.

d. INFORMATION AND INTELLIGENCE

(i) Comprehension
(ii) General Knowledge
(iii) Arithmetic
(iv) Vocabulary

25
e. ABSTRACT THINKING :
● disturbances in concept formation; manner in which the
patient conceptualizes or handles his ideas;

1. Proverb test - Proverbs known to the patient.

2. Test of similarity }
} 2 to 3 each
3. Test of difference }

f. JUDGEMENT
● Social judgment: behaviours harmful to self and others
and or against all social norms.

● Test judgment: patient‟s prediction of what he would do

in imaginary situations - what he would do if he found a
stamped, addressed letter in the street.

● Personal judgment: future plans after discharge

g. INSIGHT: The awareness of having mental illness and the

necessity for the treatment

26
C. EXAMINATION OF NON-COOPERATIVE OR STUPOROSE PATIENTS
(KIRBY, 1521)

The difficulty of getting information from non-cooperative patients should not

discourage the physician from making and recording certain observations.
These may be of great importance in the study of various types of cases and
give valuable data for the interpretation of different clinical reactions. It is
hardly necessary to say that the time to study negativistic reactions is during
the period of negativism, the time to study a stupor is during the stuporose
phase.

To wait for the clinical picture to change or for the patient to become more
accessible is often to miss an opportunity and leave a serious gap in the
clinical observation. Obviously it is necessary in the examination of such cases
to adopt some other plan than that used in making the usual “mental status”.
The following guide was devised to cover in a systemic way the most
important points for purposes of clinical differentiation.
1. GENERAL REACTION AND POSTURE
i) Attitude: voluntary or passive
ii) Voluntary postures: comfortable, natural, constrained or
awkward
iii) What does the patient do if placed in awkward or uncomfortable
positions
iv) Behaviour toward physicians and nurses: resistive, evasive,
irritable, apathetic, compliant
v) Spontaneous acts: any occasional show of playfulness,
mischievousness or assaultiveness. Defensive movements when
interfered with or when pricked with pin. Eating and dressing.
Attention to bowels and bladder. Do the movements show only
initial retardation or are they consistent throughout?
vi) To what extent does the attitude change? Is the behaviour
constant or variable from day to day? Do any special occurrences
influence the condition?

27
2. FACIAL EXPRESSION
i) Alert, attentive, placid, vacant, serious, sulky, scowling,
perplexed, distressed, etc.
ii) Any play of facial expression or signs of emotion: tears, smiles,
flushing, perspiration. On what occasions?

3. EYES
i) Open or closed. If closed, resist having lid raised.
ii) Movement of eyes: absent or obtained on request; give
attention and follow the examiner or moving objects; or show
only fixed gazing, furtive glances or evasion. Rolling of eyeballs
upward. Blinking, flickering, or tremor of lid. Reaction to
sudden approach of threat to stick pin in eye. Sensory reaction
of pupils (dilation from painful stimuli or irritation to skin of
neck).

4. REACTION TO WHAT IS SAID OR DONE

i) Commands: show tongue, move limbs, grasp with hand
(clinging, clutching, etc).
ii) Motions slow or sudden. Reaction to pin-pricks.
iii) Automatic obedience: tell patient to protrude to tongue to have
pin stuck into it.
iv) Echopraxia: imitation of actions of others

5. MUSCULAR REACTIONS
i) Test for rigidity: muscles relaxed or tense when limbs or body
is moved.
ii) Catalepsy, waxy flexibility. Negativism shown by movements in
opposite direction or springy or cogwheel resistance.
iii) Test head and neck by movements forward and backward and
side to side.

28
 iv) Test also the jaw, shoulders, elbows, fingers and the lower
extremities.
v) Does distraction or command influence the reactions?
vi) Closing of mouth, protrusion of lips, holding of saliva, drooling.

6. EMOTIONAL RESPONSIVENESS.
i) Is feeling shown when talked to of family of children?
ii) Or when sensitive points in history are mentioned or when
visitors come?
iii) Note whether or not acceleration or respiration or pulse occurs;
also look for flushing, perspiration, tears in eyes, etc. Do jokes
elicit any response?
iv) Effect of unexpected stimuli (clap hands, flash of electric light).

7. SPEECH.
i) Any apparent effort to talk, lip-movements, whispers,
movements of head.
ii) Note exact utterances with accompanying emotional reaction
(may indicate hallucinations).

8. WRITING.
i) Offer paper and pencil.
ii) Irresponsive or partially stuporose patients will often write
when they fail to talk.

29
 CASE FORMULATION
1. Summary

 Demographic details (eg. 28 year old Malay gentleman, single,

unemployed, from Pasir Tumbuh
 PMH/ PSH/ P. PSY. HX/ F.HX. (with no past medical/ surgical or
psychiatric history and no family history of any mental
illnesses……..
 Presented with ……….
● Characterized by ………
● No evidence to indicate organicity/ affective disorder/
anxiety/ substance abuse
● No evidence of gross behavioral disturbances or hearing of
voices
 Mental status examination revealed ………
 Physical examination revealed ………

2. Diagnosis
 Provisional and differential diagnoses – with justifications
 Diagnostic classification according to the Diagnostic And Statis-
tical Manual of Mental Disorders 5th Edition (DSM-5)

3. Aetiology
 Predisposing factors (bio/psycho/social)
 Precipitating factors (bio/psycho/social)
 Perpetuating factors (bio/psycho/social)

30
4. Investigations
Biological Blood tests, urine tests, EEG, CT Scan etc.,
laboratory tests, tests of other medical conditions,
reading comprehension and handwriting tests, tests
for aphasia
Psychological Psychological tests e.g. personality, intelligence and
neuropsychological testing
Social Trace old notes, speak to relatives, staffs‟
observation, specialized reports

5. Management
● Biological/ Psychological/ Social
● Treatment plan – modalities of treatment recommended, role
of medication,inpatient or outpatient treatment, frequency of
sessions, probable duration of therapy; individual, group, or
family therapy; type of psychotherapy; symptoms or problems
to be treated.

6. Prognosis (short-term and long-term)

● From own experience
● From papers
● Dependent also on patient‟s
● Previous history
● Personality
● Compliance
● Characters
● Response to medication
● Social support
● Skills and coping mechanisms

31
Glossary

- Some additions are

 Empathy Understand the emotion of other person‟s

emotion

 Sympathy Sharing or feeling the same emotion as the

other person

 Rapport Ability to empathize or understand other‟s

emotion

 Apathy Dull emotional tone associated with

detachment or individual difference.

32
 6 INSTRUCTION TO STUDENTS

1. Tutorials

Students are expected to read on the topic before the session

starts. The presenters are expected to read from established
textbook so that they could explain to the rest in greater depth.
They are also expected to meet the lecturer in-charge of the
seminar 1 week earlier so that the material presented is relevant to
the topic.

2. Clinical teaching

Format of the clinical teaching will depends on the individual

lecturer. Some lecturers prefer only one case presented and would
like to discuss the case in great detail while others would like to
conduct like in the ward round so as to allow as many people to
present. The leader would have to see the individual lecturer for
confirmation.

3. Clinic/Ward

Students are encouraged to clerk and present cases to lecturers or

medical officers in the clinic/ward. Students need to ask permission
from patient and/or relative to interview patient. Students may ask
their phone number in case students want to inquire further history.
Students need to get signature from doctors or staff-in-charge of
the ward/clinic as a proof for the attendance. The attendance
should be at least 80%.

4. Case presentation during journal club

The case presentation will be held with postgraduate case presenta-

tion and journal club. The undergraduate students will present the
history, the physical and mental status examination, the problem
list, diagnosis (provisional and differential) and management. All
presentation should use Power Point. LCD and computers provided
by the department.

33
5. Briefing on the ward/clinic

The group leader would have to arrange briefing on ward and clinic
with the Sisters. This should be done on the first day of the posting.
Since our wards are consider secured, students must try to enter in
batches. Having said that individual entry is also allowed. Security
must not be taken for granted and is one‟s own responsibility.

Some do‟s and don‟t:

 Do not bring valuable property when enter the ward.

 Always suspicious and on the look for possible attacker.

 Distance yourself when talking to patients. Avoid quiet area.

 Do not enter the toilet or pantry unaccompanied with staffs.

 Stop the interview, use excuse tactfully when confronted with

irritable patients.

 Request for chaperone when needed.

 Get a company when on call.

6. Ward round

Different lecturers conduct their ward round on different days.

Students have to see their respective lecturers and arrange time
when to follow ward round. On the rest of the days, students
should follow MOs round.

34
7. Case write ups

Students need to identify one psychotic case and one non-psychotic

case for their write up. Students need to clerk, manage and follow-
up the cases. No similar cases are allowed for write up. Students
need to make sure that cases are not taken by others yet. Stu-
dents are required to pass up one case by the end of the third week
and the second case by the end of the sixth week. The lecturer in-
charge can fail students who haven‟t pass their work before the last
day of the posting. The write up must be accompanied by a
standard form provided by the department. It has to be certified by
the lecturer or MOs treating the patient. When pass up the write up
to the department, make sure students sign in a form available at
the department. The Dean has reminded students not to copy other
people works through cut & paste method. Serious action will be
taken if the students are found guilty of plagiarism.

8. Procedures

Students must observed/performed procedures listed in the

logbook before they finish the posting. Failing to do so will cause
their MCQ result to be withold and students will fail their posting.

9. Visit to Drug Rehabilitation Centre

Students will visit Cure and Care Clinic guided by a lecturer from
the department. The program will start with a short briefing given
by the Komandan in-charge followed by a short tour to observe
rehabilitation activities in the centre. Finally, students will present a
seminar on Substance Related and Addictive Disorders . Please
discuss with the lecturer in-charge, Dr. Mohd. Azhar Mohd. Yassin.

35
10. Psychosocial rehabilitation

Students need to observe and participate in psychosocial rehabilita-

tion of psychiatric patients. Students can do that by visiting MEN-
TARI at second floor of trauma center, car wash workshop and café
at fifth floor. Students can observed and perform some of the pro-
cedures there. Please discuss with the lecturer in-charge, Dr
Raishan Safini Bakar or the Occupational Therapist-in-charge, En
Fadzli bin Sajeli.

11. HRPZII Posting

Students need to do posting at Psychiatry Department, HRPZII in

Week 3 and 4. Students need to arrange the transport there. Stu-
dents need to contact and make arrangement with the Head of
Department, Dr Haji Mohd Ariff bin Mohd Noor. White coats and
name tag needs to be wear all the time.

12. Mental Health Advocacy Project

Each group of psychiatry posting needs to do one project on mental

health advocacy at the end of posting. A lecture on Mental Health
Advocacy will be given by Dr Raishan Safini Bakar and she will su
pervise the project. Each student needs to fill in the logbook and
the point(s) learned need to be an individual opinion.

13. Examination

Exam will be held at the end of the posting. Clinical exam will be
taken by the respective lecturer. The last weeks is always allocate
for clinical assessment. There will be one long case with one hour
clerking and half an hour presentation. Students also need to per-
form and comment a MSE in front of the supervisor within 20
minutes.

36
7 GUIDELINES FOR PREPARING CASE WRITE-UPS

1. History

A. Demographic details
B. Presenting complaints/ reasons for referral
C. History of presenting illness
D. Past psychiatric history
● Previous illness : diagnoses – medication / treatment –
outcome – precipitants
● Admissions : diagnoses – medication / treatment –
outcome – precipitants
E. Past medical / surgical history
● Admissions : diagnoses – medication / treatment -
outcome – precipitants
● Medication and allergies
F. Family history
● Family tree
● Family history of medical or psychiatric illness
● Home atmosphere / degree of closeness of the family /
degree of support
G. Personal history
● Early development and childhood
● Later childhood / adolescence
● Employment / occupation
● Psychosexual (sexual adjustments and marriage)

37
 ● Present social situations
● Forensic history
● Habits / abuse of substance / recreational drugs

H. Premorbid personality

2. Mental Status Examination

A. Appearance and Behaviour
B. Speech
C. Mood and affect
D. Thought Disturbance
E. Perceptual Disturbances
F. Cognitive function
● Orientation
● Attentions / concentration
● Memory
1. Immediate
2. Short term / recent
3. Remote
● Information and intelligence
a) Comprehension
b) General knowledge
c) Arithmetic / calculations
d) Vocabulary
● Abstract thinking
● Judgment
● Social / Test / Personal

G. Insight

38
3. Summary (refer to formulation section)

4. Diagnosis
a. Provisional diagnosis
b. Differential diagnosis
(with some discussion to explain or justify your provisional
diagnosis and differential diagnoses)

5. Management
a. Include both investigation and treatment according to the
usual bio-psycho-social principle)

6. Discussion
a. Discussion about the case as a whole particularly relation to the
patient in question

b. Should include at least discussion about

- Possible etiological factors
- Reasons for the choice of treatment given
- Prognosis
- Issues that you found interesting about the case

7. Progress

8. Prognosis

39
8 ASSESSMENT

The end of posting assessment will consist of the following.

A. Continuous Assessment

This part of the assessment is very important and it is mandatory

that students pass this section first before he/she can proceed to
the other forms of assessment.
1. Case Write Up (10%)
2. Logbook (20%)

B. Examination

Clinical exam(42%) at the end of posting and will be done

by the supervisors. It consists of one long case and one MSE.

Theory (28%) will be at the end of semester.

40
C. Satisfactory discipline and attitude ; and satisfactory
comment by supervisor

● For example in terms of punctuality for attendance to teaching

sessions, behaviour (courteous and respectful) and acceptable
attire / tidiness throughout the posting

● Overall satisfactory comment from supervisor which includes

the following areas
 Attendance
 Knowledge
 Ability to communicate with patients, relatives and
lecturers.
 Attitude and interest shown by students towards his work
and patients.
 Attitude is assessed as part of Continuous Assessment of a
student:

1. Attendance to ALL scheduled classes are

COMPULSORY. Absence in ONE class is considered as
absence for ONE WHOLE DAY.

2. Students are expected to wear lab-coats at all time

while attending the clinic and wards.

3. Students are expected to maintain good and

professional relationship with all staff members and
patients.

4. Any form of cheating e.g. signing of attendance,

copying of log books and case write-up will result in
automatic failure of the posting and notify to the Dean
for action.

5. Students who fail the Continuous Assessment will be

deemed to have failed the posting irrespective
whether or not they passed the other components of
the assessment.

41
9 READING LISTS

 Andrew Sim Symptoms In The Mind. An introduction to Descriptive

Psychopathology.5th Edition. WB Sanders Co Ltd

 Diagnostic And Statistical Manual of Mental Disorders Fifth Edition (DSM

5) American Psychiatric Association June 2013

 Gelder M., Andreasen N.,Lopez-Ibor J & Geddes J. (2012). New Oxford

Textbook of Psychiatry.2nd Edition. OUP Oxford

 Johnstone E.C., Cunningham Owen D.G., Lawrie S.M., Freeman C.P.L,

(2010), Companion to Psychiatric Studies. 8th Edition. Churchill
Livingstone

 Rashid Zaman, AkmalMakhdum, Churchill's Pocketbook of Psychiatry,

Churchill Livingstone

 Rita L. Atkinson, Richard C. Atkinson, Edward E. Smith, Daryl J. Bern

Introduction to Psychology. Harcourt Brace Jovanovich College
Publishers

 Saddock B.J. &Saddock V.A. (2010).Kaplan &Sadock's Pocket Handbook

Of Clinical Psychiatry.5thEdition. Lippincott Williams & Wilkins

 Saddock B.J., Saddock V.A. & Ruiz P. (2015).Kaplan and Sadock‟s

Synopsis of Psychiatry.11th edition. Lippincott Williams & Wilkins

Typeset & layout : azie\akademikPPSP\August’14

42
43