Paradoxical Response

1. At 4, he hardly sits still. Methylphenidate is given when he goes to preschool only. Recently he got 2 weeks’ break, and he didn’t take any medicine. Upon restarting the drug, hyperactivity seems to be worsening, a phenomenon of paradoxical hyperactivity.

2. The aunt noticed some form of physical aggression toward animals. He threw away two rabbits to the ground till both died on the spot. His emotion was labile and unstable.

3. The aunt wants mum to confirm with the doctor does Methylphenidate cause aggression. The truth is Methylphenidate-induced agitation, hostility and depression are known side-effects. But at the same time, Mum confirmed that the acts have had just occurring even before he was started with medication. The best part is: he is manageable now!

4. Methylphenidate is a great drug. Managing it is difficult. In a small group discussion among few of us, very recently, we shared some interesting views on Ritalin. A friend said: ‘The contradiction is, a fat guy needs smaller doses but a thin chap needs higher doses’. Of course, those are not necessarily true, but the point is you can’t predict the response.

5. Perhaps this is what I would now call personalized medicine phenomena. Either it is due to slow and fast metabolizers in regard to cytochrome activities or differential tenancy of genetic makeup which involved in drug metabolism and excretion.

6. We reminded ourselves to explain and caution patients and their parents before starting the medication. This is to emphasize that Methylphenidate when use with caution is safe and beneficial especially to patients with hyperactivity.

7. The objective of our meeting? Group in the making: MyCAPS – Malaysia Association of Child and Adolescent Psychiatry. Bravos.

What the Guidelines Say About Hormone Replacement Therapy?

Women in general need to be educated on Hormone Replacement Therapy.

Indications for the use of Hormone Therapy include the following situations related to menopause:

– relief of vasomotor symptoms (hot flushes, sweating)

– relief of joint and muscle aches and pains+

– relief of sleeplessness and other sleep disturbances+

– relief of depressed mood

– relief of urogenital symptoms (vaginal dryness)

– relief of sexual dysfunction, such as decrease libido

– maintaining and improvement of quality of life.

(+ commonest complaints in Asian postmenopausal  women)

– As a prevention for bone loss and fractures in postmenopausal  women

Contraindications to Hormone Therapy include:

– history of breast cancer

– history of thromboembolism and stroke

– undiagnosed uterine bleeding

– significant cardiovascular disease

– hypersensitivity to oestrogen


Best start between 50-59 years or within 10 years of menopause


Lowest effective dose of estrogen with corresponding low dose of progestogen.

(Source: Clinical Practice Guidelines AMM, MOH + CO&GM)

Magical Thinking

1. One fine day, a splendid splash of idea run through your mind like a flash of light, a scene of a man in a motorbike speeding and finally hit in a motor vehicle accident. You are puzzled and ask what is happening. Your innerself explain that is the vengeance of speeding. You are asking if you keep on counter-talking you are going to look absurd.

2. Magical thinking may be a normal phenomenon in children. It is a belief in adults. Unfortunately, the implication of the belief is beyond normal cause and effect. If the innerself is indeed a ‘perception that comes without any stimulus’ than you are indeed facing a problem then. If not, you are safe.

3. Magical thinking is quite normal in people with stress and to people dealing with helplessness and worthlessness. OCD with a lot of rumination might end up with some kind of magical thinking. Narcissistic, borderline and schizotypal are not spared to have magical thinking. Way beyond; no doubt, is psychosis.

4. In schizotypal, the odd thinking is like having a funny communication with the ruh, something normal to the bomoh and pawang. Don’t tell me bomoh and pawang are psychotics.

5. In borderline personality, the thoughts are believed to cause events in the context when the person devalue themselves and their environment.

6. The magical thinking in persons with the narcissistic trait is when they would fully believe that whatever happens they will prevail and those good things will happen to them forever.

7. Finally, I am now settling down with the final diagnosis. Am writing a referral to my colleague in Hospital Ipoh. Dear colleague,….


1. PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections.

2. Common in the West but quite rare in our practice. Reasons: (i) acute condition, most acute cases are referred, treated and discharged. A week or 2 later patients developed neuropsychiatric disorders, waxing and waning with subsequent reinfection  (ii) diagnosis is controversial; not classified in DSM/ICD (iii) temporal relationship between beta hemolytic strep infection and neuropsychiatric manifestation is unclear.

3. Childhood-onset neuropsychiatric disorder is widely used to describe a disorder caused by antineuronal antibodies which appear to arise in response to group A [beta]-hemolytic streptococcal (GABHS) infections and to cross-react with cells within the central nervous system (CNS).

4. Based on clinical observations of children with Sydenham’s chorea, Tourette’s syndrome (TS), and/or obsessive-compulsive disorder (OCD), scientists hypothesize that neuroimmunological dysfunction secondary to anti-neuronal antibodies may result in behavioral disturbances, such as:


-emotional lability,

-obsessive-compulsive symptoms,

-hyperactivity, and inattention,

-sleep disturbances; and

-neurological abnormalities, such as motor and phonic tics, ballismus, chorea, and choreiform movements.

4. Unlike Rheumatic Fever, treatment using antibiotic prophylaxis is inconclusive. Symptomatic treatment for tics and OCD is warranted.

Exasperated Me

1. Getting so exasperate when a final year student can’t even talk to the patient and ask open-ended questions.

2. The inquisitive mind is basically what it is needed from medical professionals. In order to be inquisitive, proper technique of questioning, different ways of maneuvering the interview has to be mastered to the maximum.

3. A student can’t be too naive to accept answers and explanations. He/She would have to think the follow-up questions, restate right paraphrases and most important evaluate answers in term of rationality, relevancy, and congruity. All those processes have to occur in seconds. Hence, the student has to stay alert and keep thinking all the time during the interview. It is an active and dynamic process.

4. Trying to assuage pain and suffering quickly at the initial interview stage will hinder information gathering and result in poor history taking. To my mind, to a certain extent, Kelantanese language are peacemaking, tolerant and pleasing. Sometimes, students who converse in Kelantanese language avoid hurting patients’ feeling, but they are acquiescent and chose to agree without critical thinking.

5. I used to remind my students to be careful with the agreeableness attitude with patients giving the example of a patient coming to casualty following a motor vehicle accident without obvious physical injury and the doctor concurs by saying: ‘Ok deh’. ‘Deh’ is a suffix which is usually used in Kelantan language to present a sentence as rather light-going and not so serious and it has no specific meaning. The obvious reply the doctor gets is: OK; failing to realize (and examine) the patient would have suffered intracranial or intraabdominal injury.

6. Students were told that doctors do not please their patients all the time. It is a matter of balancing the critical thinking, acting, and empathetic feeling which to some students is difficult to master.

Global Burden of Depression

1. The Australian study conducted by Australian Institute of Health and Welfare shows depression as no 1 disease that causes disability in Australia. 4% males and 7% females are affected.

2. 62% of cases do not get any mental health intervention.

3. 75% of those who do receive care are dealt with in primary care.

4. Disability-adjusted life -years (DALY) is a measure of the years of ‘healthy’ life lost due to illness or injury (one DALY is a one-lost year of ‘healthy’ life). Depression contributes to 3.7% of DALY.

5. In the younger persons, those with alcohol, tobacco and cannabis abuse at high risk to develop co-morbidities with depression whereas the older ones are those with vascular diseases and cognitive impairment.

6. Problem with our patients and services are:  i) poor access to risky patients esp the young and the old, ii) lack of funding for atypical antidepressants, iii) poor recognition by the society and family members, iv) non-compliance to standard treatment, v) denial by society at large, vi) traditional belief in emphasis on religious-based treatment, vii) lack of proper in-patient facility to treat depressive patient, viii) lack of continuous care and support, ix) lack of integrated medical care between medical and psychological services x) little recognition of management of comorbid substance abuse

Inquiry About Virginity

1. Many a time we encounter people come to be examined on virginity. A 2-year-old child was found to have some question marks on vulva areas; the mum suspected foul play and wanted to find out what went wrong.

2. Are we going to dismiss maternal instinct, even without a trace of evidence and vehement suspicion?

3. The world has become the unsafe place for indefensible folks. People are not just being robbed of their property but their feeling and dignity. That was what Wardina Safiyyah said in MHI early morning today.

4. Yes, as inquisitive clinicians, we will investigate…



1. When parental divorce happens, children used to become the scapegoat. When a mom starts to be suspicious of her ex-husband, everything is being questioned.

2. The truth that prevails, at last, is a big NO. No evidence of abuse.

Chicken and Egg

1. Sleep is the most frequent question we ask when enquiring about psychological problems. Sleep a lot or having less sleep will always be indicator for psychological problem. Circadian rhythm is like an internal clock that works 24 hours a day.

2. Now we know if one has difficulty sleeping, his circadian rhythm is altered. But which one comes first? (chicken-and-egg question)

3. Perhaps, agomelatine has the answer. No bias, please!

4. Since agomelatin activates kinases (which involve in intracellular signaling that took part in the survival of newly formed neurons) and therefore influence clock gene expression and hence sleep-wake cycle, then it is safe to say that the circadian rhythm affects sleep not the other way round….

5. Wonder if I just learned a new thing or an old fact that has just been turn-around?

A Child with Horrifying Imagination

1. She presented with scary feeling, seen ghost, stories full of horrifying imagination. At 7 years, sleeping with mum and dad on the same bed. Mum complained she was quite restless at night, keep changing position until the end of the bed. Due to unnoticed insomnia, she required extra day sleep, making her wake up till 12.00 noon. In the daytime, she was over-active and had abundance eating as if she is discharging unfulfilled wishes.

2. Mum claimed she was easily fatigued and lethargic. Slightly overweight since young, she has had rhinitis, sinusitis when she was five. Nasal Spay was prescribed and she recovered. Until around September when she had developing sleep problem associated closely with abnormal behavior.

3. Obstructive sleep apnoea in young children is rare and most of the time overlook by physician treated children for sinusitis and tonsillitis. Most doctors do not ask about sleep pattern in children. They assume children sleep soundly especially when they are sleeping with their parents.

4. This kid has sleep deprivation characterized by symptoms of fatigue, listlessness and overactive behavior the next morning, the mom noticed she was moving and turning in bed. Sometime children who do not get enough sleep would show moodiness and tantrums behavior.

5. In most cases, removing the tonsil or adenoid would solve the problem. Medical treatment for sinusitis and URTI help in the minority of cases on a temporary basis as illustrated earlier on in this case. CPAP machine can be quite intimidating for children in the beginning. Proper diagnosis needs to be done in sleep lab before starting CPAP.