Q = MANIFESTATION OF INSANITY

GRADUAL ONSET
1= loss of sleep
Loss of appetite
Dyspepsia and dysphagia
2=person is unaware about his habit, ideas, and manners the person becomes
unconventional and this condition is called eccentrism
3= emotion for his friends and families Are lost
4= intellectual loss
5= memory loss
6= judgement power is weak
7=hallucination
8= irritablilty
Q CLASSIFICATION OF ANXIETY
1=AMENTIA
2=DEMENTIA
3= FUNCTIONAL PSYCHOSES
4= INSANITY ASSOCIZATED WITH ORGANIC DISEASE
1= AMENTIA=.IT is incomplete development of mind before age of
18years arising from inherent causes or by disease or injury
3 GRADES OF AMENTIA
1-=IDIOCY
2= IMBECILILE
3= MORON
Q INTELLECTUAL QUOTIENT(IQ)
Intellectual capacity of an individual is expressed in term of IQ.

1
It is ratio between mental age(determioned by various tests) divided by
actual age and expressed as percentage
Maximum adult age taken for this purpose is 16years
FOR IDIOCY
Mental age is 0-3years
So IQ is 3/15 multiply by 100 =20%
FOR IMBECILE
Mental age=3-7 years
So IQ is 5/15 multiply by100=33%
FOR MORON =
Mental age is =9
IQ Is 9/15 multiply by 100=60%
Before age of 18 years incomplete development is called as amentia
Q DEMENTIA=
It is form of anxiety produced by degeneration of mental facilities after they
have fully developed
Symptoms may appears as sudden or gradual
Q PRESENILE DEMENTIA
Before old age and usually recent memory is affected
Q SENILE DEMENTIA
At onset of old age or due to cerebral atherosclerosese
Pt loses his memory and becomes child lish ,silly and some times perverted
in behaviur
ORGANIC=dementia due to organic lesion in brain
Q =IN MANIA WE SEE EXCITEMENT AND IN DEPRESSION WE
SEE DEPRESSION
Q =MANIA=
2
CONDITION OF EXCITATION AND FEELING OF WELBEING
AND manifests as increase physical and mental activity
Mania may manifest as 1=hypomania
2=acute mania 3= chronic mania
Q HYPOMANIA=
Mild form of exaggerated sense of self importance
B=acute mania=
Attack is gradual
1= headache, malaise, restlessness ,insomnia and concentration defects
C= chronic mania= manifestation of acute mania becomes chronic
Q MELANCHOLIA=
It is opposite to mania and thinking depressed and decrease physical and
mental activity . it may be simple,acute or chronic and affects females more
than males
Q DELUSIONAL INSANITY
IT IS A FORM of insanity characterized by fixed systematized delusions
and hallucination.it may be acute or chronic
It effects adults in both sexes
Self control is lost and may commit suicide
Q SOCIAL EVILS=
1=PROSTITUTION
2= male prosthitutes(homosexual and gays)
3= beggary
4=drug addiction
5= karo kari
6= child abuse
7=kidnaping and thieving
3
Q == ATYPICAL DEPRESSION
Differs from classic form of depression characterized by
hypersomnia,increase apetite,increase weight gain
Most common subtype of depression
Treatment with MAOI or SSRI
Q overvalued ideas= described by wernick and it is comprehenssible
and undrerstandable ideas which is persuid beyond bound of reason
It share some of characteristics of delusion
Overvalued ideas vary from delusion in two ways
1= content of overvalued ideas is understandable but bizarre in
delusion
2=them is common and structurally acceptable
Overvallued ideas must also be distinguishable from obsession
This is usually easier than difference from delusion
Since there is no sense of intrusiveness or senselessness of thought nor is
there resistance to it
Disturbances of thinking process
Disturbances of theme of thought
In disturbanses of theme of thought amount and speed of thinking is changed
In pressure of thought ideas arise in unusual varety and abundance and pass
thru mind rapidly
In poverty of thought pt has few thought
Pressure of thought occur in ,,mania
Poverty of thought in depression ,pressure and poverty of thought may occur
in schyzooprenia
Q THOUGHT BLOCK =
Interuption of steam of thought
4
Observer notice suden intereption in pt speech and pt see that his mind has
gone blank and may occur repeatedly .thought block suggest schyzoprenia
Q DISORDER OF FORM OF THOUGHT
Also called formal thought disorder recognized from speech and writing
Several kind of formal thought disorder
Preservation is persistent inappropriate repetition of same thought in
response to series of simple question pt may give correct answer to first
quesuion but continue to give same anmswer to subsequent question
And preservation occur in dementia and frontal lobe injures
Q Flight of ideas=
Thought and speech move quickly from one topic to another so that one train
of thought is not carried to completion before another takes place
Q Loosening of associastion=loss of normal structure of thinking and
three characteristic kind of lloosening off association have been
described and occur in schyzoprenia
1= in talking past the point
2=knight movement and derailment = refer to transition from one topic to
another
3=verbigeration= is said to be present when speech is reduced to senseless
repetetion of words and phrase and occur in association with expressive
aphasia and occers in schyzoprenia
Q Word salad= when verbegeration is abnormal and extreme it is
word salad
Q Overinclusion=refers to widening of bounrderies of concept such as
such that there ideas are grouped together which are not normally close
together

5
Q Neologism= occur in schyzioprenia are words or praises invented by pt
to describe morbid experience
Neologism must be distinguished friom incorrect pronounciation the wrong
use of word by people with limited education
Q depersonalization and derealization=recurrent feeling of being
detached from ones mental process accompanied by intact sence of reality
Etiology-=psychological stress
Prevalence= episode of depersionalization common
Onset =usually in adult
Key symptoms =depersonalization often described as out of body experience
Derealization= feeling of being detached from physical surrounding and
envoroment and is often strange
Jamavu= a sence of familiar thing being strange
Dejavu= a sense of unfamiliar thing being familiar
Tx=psychotheraphy decrease anxiety
Ddx
Substance induced mental disorder with dissiociative symptoms inckluding
intoxication ,withdrawalhallucination including persisting perception
disorder,panic disorder a nd PTSD
Q shyzoaffective disorder
Symptom of schyzoprenia for two weeks and presence of mood symptoms
Prognoses=better diagnoses than pt of schyzopenia but worse progoses than
pt with affective disorders
Tx hospitalize
Antidepressents and anticonvuisants to control mood symptoms
Antipsychotic medication
Shyzopreniform disorder= hallucination delusion disorganized speech
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Negative symptoms
Socoial or occupational symptoms
Symptom present for more than I month and less than 6month
Most of pt return to there base line of functioning
Risk factors
After resolution of psychtric symptoms depressive pt at risk ‘of suicide
Tx hospitalize for safety of function from suicide
Antipsychotic medication for 3-6yr
Individual psychotheraphy
Dellusoinal disorder= symptoms not bezar for atleast one month .no
impairment in level of functioning
Types= 1=Erotomanic
2= Jealous
3= Grandiose
4= Somatic
5= Mixed 6= unspecific

Important handy points

Q 1=some handy points=abnormal behaviuor =it describe person covert
and overt activities that are deviating from normal behavior
2 Abreaction=emotion release after recalling a painful experience
3 Adiadokinesia==inability to perform rapid alternating movement
4 Affect = observed expression of emotion
5 Aggression =forceful goal directed action that may ne verbal or
physical

7
6 Agitation=severe anxiety asocited with motor restlessness
7 Agnosia=inability to recognize and interpret the significance of
sensory experience
8 Alexithymia-=inability in describing ones emotion or mood
9 Ambivalence=coexistance of two opposing impulses toward same thing
in same person at same time
10Amnesia= inability to recal past experiences
11Anhedonia=inability to experience pleasure in any activity
12 Anosognosia=ignorance of illness
13 Anterograde amnesia=amnesioa for events ocuuring after a point in
time
14 Apathy =lack of feeling or emotion
15 Apraxia=inability to carry out certain specific task
16Ataxia =failure of muscle coordionation
17 Behavior=all overt and covert activities of human beings that can be
observed
18 Blunted affect-=a disturbance in affect that is manifested by severe
reduction in intensity of external feeling
19 Cataplexy=temporary loss of tone due to emotional state
20 Catalepsy=maintenance of immobilile position
21Catharses=release that occur when pt is encouraged to talk about
things that bother much
22Cognition=the mental process characterized by knowing thinking ,
learning and judging
23Conflict= clashes of two opposite interests
24 Coma=profound degree of unconsciousness

8
25 Clang association=association of words similar in sounds but not in
meanings
26 Distraactability=inability to concentrate attention
27Disprosidy=loss of normal speech melody
28 Dysarthtria= difficulty in articulation
29 Echolalia=psychopathogical repeating of words of one person by
another
30Echopraxia=patghilogical imitation of movement of one person by
another
31Hallucinoses=hallucination associtedwith chronic alcohol abuse
32Hypervigilance=excesssive focus and attention on all internal and
external stimuli usually secondry to paranoid or delusional state
33Insight=Abilty of pt to understand ytrue cause and meaning of
sitruation
34Mood swings=oscilation between euporia and depression
35Mutism = voiceless ness without stryuctural abnormalities
36Neologism =pt invented newwords
37 Seclusion =separation of pt from other usually in a safe enviromnt\
38Somnolence-== abnormal drowsinwss
39Somnombolism = sleep walking
40Qfcps=HYPNOGOGIC HALLYUCINATION=
Vivid dream like hallucination at onset of sleep
41HYPNOPOMPIOC HALLUCINATION =
Vivid dream like hallucination on awakening from sleep
42KINESTHETIC HALLUCINATION=
Hallucination involving sense of bobily movements
43LILIPUTIAN HALUCINATION=
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WHEN thing and peoples looks smaller
Than they are in reality
Q44 serotonergic syndrome
A no of drug that potentite brain 5ht2 function can produce severe
neurotoxicity when combined with maoi
Some symptoms resemble NMS
Q 45egocentric -=preoccupied by own thought
46Animastic thinking=
Behaviuor is control, by soul
47Fixated = always thinking and talking abt something
48Envy=desire to have another qualities for one self
49 Oepidal complex= sexual attraction for opposite sex parent and
aggressive toward same sex parent
50 Self esteem=self care
51Fragile x syndrome=
X linked syndrome with on long arm of x chromosomre associated with MR,
enlarge testes, long ears and enlarge jaw
52 Ret syndrome=
Progressive disorder of grey matter of female since birth and features
are autism, ataxia dementia and seizure
53Asperger syndrome
Overdevelopment of ones mental faculty in an autistic person
54Fidgeting=Moving hands feet
55Shuning by peer =avoidance by peers
56Labile mood =unstable mood
57 Impulsivity= tendancy to have blind disobedance to internal drives
58Bulyiing=Person frighting weak people bby showing their strength
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59Vandalism= crime of destroying public property deliberately
60Defiant behavior=openly refusing to obey some one
61Vindictiveness= trying harm someone who harm u
62 Escalate-=more serious
63Emotional turmoil = a state of great anxity
64Despair =lost all hope
65Pressured speech =excessive rapid speech in manic episode of bipolar
disorder
66Dysthymia = chronic depressed mmod for more than two yr
67Cyclothymiia=chronic disorder with bolth depressed mood and hypomanic
mood for more than 2yr
68Guilt unhappy feeling by thinkling that u have done something wrong
69Postpartum blues or blue baby
Deign after birth and last uptoo 2week
70Mumbling= speech to himself
71Intrusive thought=
72Disturbing thought
73Saccading eye movement= small jerky movement of both eyes
simultaneously
74Hypervigilant= note sign of danger
75Factitious disorder=conscious production of sign and symptom of both
medical and mentel disorder
76Disheveled=unorganized
77Detrailment=to leave the right path
78Grooming= clear appearance
79Escorted=
Person who walk with someone to protect him
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80Embarresment=feelling ashamed
81Flash backs =to show some one to impress others
82Histrionic pd=attention seekimng excitable behaviuor
83Flaws==mistake in someone which is not correct
84Conversion disorder
= dx in which individual experiences one or more neurologic symptoms
that cannot be explained by any medical and neurologic disorder
85 Malingering = conscious production of sign and symptoms for obvious
gain likely money and avoidance
86See most frequently in prison and militry
87Agnosia=falilure to identify peoples
88Apraxia=failure to ability btio bexhecte ccomplex motor behavior
89Stupor= reduced responsueness
90Asterixis= sign of hepatic coma
91Seizure= abnormal n electrical activity I n brain which may mmanifest
ass1=abnormal motor
2=abnormal sensory
3=abn psychomotor experiences
92Epilepsy= recurrent seizures
93Myoclonus=type of seizure in which brain jerks e,.g plate go away like
jerk
94Dissociation = separation of aspects of consciousness incliuding memory
,identity and perception
95Dissociative fuge=sudden un expected travel accompanied by inability to
tremembre one past
96Depersonalization= recurrent feeling of being detached from ones mental
process with intact sence of reality
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97Derealization feeling detached from environmemt
98Jamavu=under familiar
99Déjà vu=overfamiliarity
100Adjustment disorder=maladaptive reaction to psychosocial stressor
101Beellingerance=agressive and hostile behavior
102Apathy=feeling of not being interested in anything
103Impulse control dispoorders a disorder in which pt is unable to reseist an
impulse
Before disorder increase anxiety and reduce anxiety after act
104Ego syntonic=aspects of pt thought that are felt to be acceptable and
consistent with rest of his personality
105Kleptomania=psycchtric wealthy pt steal object that he does not need
and act of stealing is the goal ,increase anxiety before act and decrease after
act
106Arson=deliberate fireseetting to building
107Pyromania= a deliberate fire seeting on more than one occasion
Increased anxierty before act and decrease after act
108Pathologic gambling= a disorder characterized by recreant gambling
behaviuor that include preoccuoation of gambling and need to gamble with
more money.illegal act to search money for gambling
109Confession= a statemment that person makes and states that they are
guilty of crime
110Trichotolomania= characrteriozed by pulling one own or another person
hair
111Concordance= a state of being similar to ssomethuing
112Ood =strange
113Ecstacy= very great happiness

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114Plotting= a person who makes secret plan to harm somebody
115Eccentric=considered by other people to be very unusual
116Rem latency-= period lasting frm moment you fall asleep to first rem
period,some disorder decrease rem latency to usually 90min
117Rem latency decrese in depression and latency
118Sleep latency=time needed before u fall asleep(15min)in insomnia this
may be abniormal
119Narcolepsy= excessive day time sleepiness and abnormalities of rem
sleep for a period of more than 3months and rem sleep occur in less than
10min
Pt feel refreshed after awakening
120Cataplexy=pathognomoc sign of sudden loss of muscle tone which has
been precipitated by intense emotion
121Sleep paralyses
During awakening pt cannot move limbs
122Sleep apnea= cessation of airflow at nose mouth during sleep episode last
more than one seconds.loud noise followed bby heavy pause.consider
pathologic if 30 episide in night or 5 episode in one hr ;in severe cases pt
may experienced more than 300 episode during night
123Yawning-= to open mouth widely and breath deeply becoz u tired
124Night mare=Dream that is very frightening
125Cataplexy=sudden loss of tone without loss of consiuosness
126Syncoup==loss of consiousnes
127Fantasy= unreality
128Vanigisnmus= involuntary constriction of outer thrd of vagina that
interfere with sexual act
129Disrobed=to take off your clothes for an official ceremony
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130Aversive conditioning=learning in which punishment is is used to be
asocisaate with undesirable response
131Types of parapilias
132=exhibitionism=recurent behavior to expose oneself to strangers
133Fetcism= sexual use of nonliving oobject
134=frotherism= touching against non consenting partener
135pedophilia= recurrent urges toward prepubisent children most common
parasplia
136=voyeurism= involvuing act of observing a person who is engaging in
sexual activity
137Masochism= act of humiliation and feeling ashamed
138Sadism= recurrent behaviuor in which pphysical or psychological
suffering of a victim is exciting to pt
139Trannsvestic fetcism= recurrent urges or behaviuor invololving cross
dressing
Q140 tx of premature ejaculation
Typically consist of behaviuoral techniqes aimed at prolonging time before
ejaculation occurs
Squeeze and go techniques
Q141 two most common causes of impotence
Diabtes mellitus and alcoholism
Q 142dx impotency by pleythysmography
And postage stamp
Q 143 dilaters used for vaginismis
Q 144 spasm of various muscle group is dystonia
Q145 motor restlessness iss akathesia
Q 146tardive dyskinesia
15
Movement often occur first in tongue and finger and at last trunk
Q 147chemical denervation hypersensitivity is most common cause of
tardive dyskinesia
Q 148labile mood is unstable mood
Emotion and mood may vary in relation to pt circumstances ,increase
variation are called lability of mood
Q149 emotional incontinence= extreme variation in mood
150Blunting and flattening = it is reduce variation in mood and mostly occer
in depression and schyzoprenias if severe then apathy
Q 151incongruent mood= emotion anmd mood may vary in a way that is
not according to pt circumstances
Q 152irritability= readiness to become angry
Q 153 phobia is severe irrational fear of situation or object
Q 154anticipatory anxiety= phobia people not only fear in presence of object
but also whem thinnkling about it
Q155 depression and grief=Grief is normal response to misfortune
And also called mourning
Depression may be abnormal when it is out of proportion to misfortune
Depression is associated with loss of self care negative thinkling and
anhedonia
Q156 psychomotor retardation=In depressed pt level of arousal is reduced
Q157 elated mood = extreme degree of elated mood
Q158 perception =process of becoming aware of external environment thru
sense organs
Q159 imagery= is awareness of percept generated in mind
Q 160illusion -= misinterpretationof external stimulus
Q161 hallucination=feeling something which is not there
16
Q 162pseudohallucination= term used to experience that are similar to
hallucination but which does not meet all requirements of hallucination
Q163 derailment = move from one topic to another
Q164 verbigeration= is said to be present when speech is reduced
Q 165tics = irregular repeated involving a group of musle e,g sideway
movement of head and raising of one shoulder
Q166 mannerism =repeated movement that appears to have some
functional significance like saluting
Q167 stereotyped movements= repeated movements that have no
significance
Rocking to and fro
Q 168catatonia= increase muscle tone that affects flexion and extension
and abolished by voluntary movements
169Catalepsy= tone in catationia is called catalepsy
Catalepsy should not be confiused with cataplexy
Q170 posturing =adoption of unusual posture for a long time e.g stooped
posture in parkinsonism
Q171 negativism=When pt do opposite of what they asked and resist
efforts to persuade them
Q 172echpraxia= imitates interviewer movement even when asked not to
do so
Q173 Phantom limb= psychological pain in limb even if limb
amputation have been done
Q174 hemisomatognosia= unilateral lack of awareness or neglect
usually following stroke
Q 175asnissognosia= lack of awareness of loss of function even in
hemiplegia
17
Q 176reduplication phenomenon= pt feels that he has either 2 left arm
or three leg ,seen in migraine temporal lobe epilepsy or in shyzioprenia
Q177 parasomnis is distiortion of memory
Q 178=immediate memory is retention of information iver a short
period measured in minutes
Q 1709recent memory= retension of memory of events over a few days
Long term memory over a long period of time
Q180 consciousness =awareness of self and envieronment .level of
consiuosness can vary extreme of alertness and coma
181Coma-= most extreme form of impaired consiuosnerss
182Clouding of consciousness is impaired consiuosnesds
Q183 stupor= condition in which pt is immobile mute and
unresponsiveness
184Confusion= inability to think clearly
185Attention= ability to focus on matter
186Concentration =ability to maintain that focus
187Impairment = pathlogical defect e.g hemiparesis after stroke
188DISABILITY= IMPairnment that causes loss of function both
physically and psychologically e.g difficulty in self care caused by
hemipatreses
Q189 handicapped= social dysfunction and unable to work due to
hemiparesis in above example is called handicapped
Q 190dying death and betreavement
Stages of dying
According to Elizbath Ross stages of dying involve 5 stages.they may
occur simultaneously or in order
191Denial= pt refuses to believes that he is dying
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192Anger= pt anger may displace onto physicisan and hospital staff
193Bargaining= pt may try to strike a bargain with GOD e.g I promise
to go to mosque every day if I get rid of this disease
194Depression= pt becom preoccupied with death and may become
emotionally detached .I feel less hopefull and helpless
Acceptance= the pt is calm and accept his faith
195Bereavement after loss of a loved one or loss of body part .
196normal grief reaction that must be distinguished from depression
which is pathological
Q197 psychopathic personality is who satisfies himself and not society
is known as psych pathic personality
198Psychotic personality = a person who satisfies neither society nor
himself
Q199 doping = substance medicinal or nonmedicinal taken by atheletes
to enhances there performance in there profession
e.g cocaine ,ephedrine. Alcohol,stimoulants , antii fatyigue medication
Q 200sensitivity=ability of test to identify correctly all those have a
disease that is true positive
e.g 90% sensitivity means that 90% cases have a true positive disease
remaining 10% false negative
201specificity=ability of test to identify all those who does not have
disease 90% spesisificity show true negative and does not have disease
10% are false positive
202predictive accuracy = performance of test is by predictive value
which is diagnostic power of a test
203positive predicive value= the probebilty of test that individual who
test positive for disease actually have a disease
19
negative predicted value= probability that individual who test negative
for a disease are really disease free
MOTOR SYMPTIOMS AND SIGNS
204 TICS= irregular repeated movements of group of musckles such as
sideway movemenyts of head or raising of one shoulder
205Mannerism= repeated movements that have functional significance
such as saluting
205Stereotyped= repeated movements which are regular (unlike tics)
And have no functional significance (unlike mannerism)
206Catatonia=State of increase muscle tone that effect flexion and
extensuion
207Catalepsy=waxy flexibilityTerm used to describe tone in catatonia
and detected when pt limb can be placed in a position in which they
remaine for prolong period
While at same time muscle tone is increased
Catalepsy should not be confused with cataplexy
208Posturing =adoption of unusuall body posture for prolong period
and like standing on on one leg and no functional significance
209Negativism= pt do opposite of what is asked
210Echopraxia-= pt imitates intereviever movement automatically even
when asked not to do so
211Ambitendence= is state when they alternate between two movements
Disturbance of body image= specific abnormalities of body image occur
in neurological disease
212Phantom limb = pain In limb after amputation
Unilateral lack of awareness
213In stroke
20
Hemoisomatognosia
Feels incorrectly that limb is missing
214Anosognosia= hemiplegic lack of awareness of loss of function
215General distortion of body image= occur in anorexia nervosa that pt
suspects that she is obese even when pt is underweight
216Reduplication phenomenon pt suspsects that he has two limbs and
occur in migraine , temporal lobe epilepsy and shyzoprenia
217Disturbence of self=
Disturbance concerned with activities
Pt with delusion oof control and loss of this awareness
218Distrbances of awareness of unity of self =pt with dissociative
identity disoreder have experience of existence as two or more selves
219Disturbances of unity of self= e.g in schyzoprenia pt may say that he
is different from one existing before this disorder
220Distrbance of boundres of self= experienced is that pt may report
that he felt as if they were dissolving
222Parasomnias is distortion of memory and occur in psychoses
223immediate memory= retension of information over short period of
time
224Recent memory=Memory of last few days occur in dementia and
delirium
225Long term memory over long periods
In dementia it usually progreses with time and becomes sevare
226=Some organic condition give rise to interesting partial effect known
as amnestic disdorer
In which pt unable to rememmber event occured a few minutes before
227Disturbances of recognition =1=jama vu and 2=dehja vu
21
3= confabulation is confident recounting of quite false memiories for
recent events and is charactreistic of amnesa
4=psychogenic amnesia 5= false memory syndrome
5 Disturbance of consiuosness= consiuosness= is awreness of self aand
environmmet level of consiuosness can vary between alertness and
comma
228Coma = most extreme form of impaired consiuosness
229Clouding of consciousness Seen in delirium
Impairment of consuiosness is seen in thinking,attention, are impaired
in mania depression anxiety scyzoprenia and organic disorder
231Insight = awareness of morbid change in oneself ability to act
appropriately and self respect
Lack of insight was said to be a feature that distinguish between
psychoses( absent insight) and neuroses( intact)
232 intelectual insight= refer to capacity to formulate this understanding
234Emotional insight is is capacity to feel and response to
understanding
235Stupor= pt is mute immobile and unresponsive
And stupor occur in catatonia
236Confusion= inability to think clearly seen in state of impaired
consiuosnes
Other state of impaired state are oneiroid state and torper
237Disturbance of attention= attention = ability to focus on matter in
hand
238Concentration is ability to maintain that focus
239What is shizoid personality=they are socially withdrawn . they like to
live in isolated life
22
240They donot I nteract with other peoples
They appear uninterested in their surrounding
Most of them develop schyzoprenIA

Intermediate module exam scenarios

Q what is intelligence ?
Answer-= worldwide(global) capacity of individual to act firmly to think
sensibly and deal effectively with environment
IQ= MA /CA MULTIPLY BY 100=result
For adults we use WAISR
FOR CHILDREN we use WISC –III
STANFORD BINET INTELLIGENCE SCALE
Q =components of emotional assessment =
In 1990 john and salway suggest that definition of emotional intelligence
includes abilities in five main areas
1= Self awareness
2= Emotional intelligence
3= Motivating oneself
4= Recognizing emotion in other
5= Handling relationship
Q EMOTIONAL INTELLIGENCE AND IQ=
In a sentence human brain contain two minds and two different types of
emotional intelligence 1= Rational 2= Emotional
These two different modes of consciousness interact to constitute our mind
Emotional and rational mind are semi dependant faculties. The working of
limbic system and neocortex, amygdale and prefrontal lobe means each is

23
full partner in mental life. when theses partners work well both emotional
intelligence and intellectual abilities are enhanced
Q HOW TO IMPROVE EMOTIONAL INTELLIGENCE=
Like any other scale it is a set of skills that can be measured, learned ,and
enhanced,
Observe how peoples react to peoples
Do you rush to judgment before you know all facts?
Do you stereotype?
How you think and interact with people
Try to put yourself at their place
Look at your work and environment
Do you seek attention for before your accomplishment.
Domains of emotional intelligence=
1= Motivate yourself
2= Know your emotion
3=Manage your emotion
4= Recognize and know other emotion
5= Manage emotion of others
Emotional intelligence can be defined as understanding ones own feeling,
(empathy)sympathy for feeling of others and regulation of emotion in a way
that enhances living
1-=Self awareness = Know your emotion
2=Self management= Manage your emotion
3= Social awareness= Understanding emotion of other peoples
4=relationship management=managing other emotion
Q = name 4 neurological and medical condition that can present with
delusion
24
Anser=MENTAL CAUSES= 1=delusional disorder
2= organic disorder
3--=schizophrenia ‘
4-==mania
Medical causes meningitis and encephalitis
Q = Serotonin hypothesis= serotonin modulators help to control excess
dopamine
Some believe excess serotonin contributes to schizophrenia
Structural abnormalities-==
Many pt have structural abnormalities in brain, enlarged ventricles
Founded that people with schizophrenia has less brain tissue and csf
Positron emission tomography studies suggest diminished glucose
metabolism and oxygen in brain
Research show decrease brain volume and abnormal brain function in frontal
and temporal areas of brain of person of schizophrenia, may be related to
brain damage
Also linked to abnormal blood flow in brain smaller temporal, frontal lobes
and less grey matter
Viral infection= may result from prenatal exposure to certain viruses
Mother of schizophrenic pt report more instances of flue during winter
Increase level of antibodies to certain viruses found in blood of
schyzioprenic pt
No specific to type 1 or type 2
Psychological theories=
Stress= increase level of stressful. life events probably triggering effect on
onset of schizophrenia in predisposed individual
Family theories=

25
Schizophrenic mother, lack of real parents depending on mother , anxious
mother
Information processing hypotheses=
Disturbances in attention, inability to maintain a set and inability to
assimilate and integrate percept are common findings in schizophrenia
Psychoanalytic theories=
According to Freud there is (Repression)suppression to preoral , oral stage
of psychosexual development
With use of defence mechanism of denial, reaction formation and projection
Sociocultutral= social influences like poverty, abuse, conflict in family affect
an individual mental functioning
It affect course of disease
Sociocultural stresses have role in schizophrenia
Q PERSONALITY=
DEF= sum total of all physical., mental and psychological characteristic of
human being
1=intelligence
2=feeling(emotions)
3=instincts
Psychological treatments
Q important viva question=RELAXATION TECHNIQUES =guidelines for
progressive muscle relaxation=
In progressive relaxation, each muscle or group of muscle is tensed for 10seconds
and then relaxed for 20seconds
Repeat the cycle
Four muscle group are covered in this order1=hand forearm and biceps
2= head, face, throat and shoulder

26
3= chest abdomen and lower back
4=thigh buttock and calves and feet using this procedure
Practice progressive relaxation while seated in chair with feet firmly on floor
Begin active relaxation by tightening right fist for ten seconds and paying
attention to tension
Allow muscle of right fist to relax while noticing the pleasant difference
Do same with left fist tensing, relaxing and noticing difference
Do same with second third and fourth group of muscles
Q=25yr old house wife refuses to leave her home fearing that she will
suffocate in market . however remains symptom free at home
What is most likely diagnoses
Ans= agoraphobia
Q =in above case what are non pharmacological intervention likely to
explain her?
Ans= CBT=Continue progressive relaxation techniques and graduated
imagined exposure to feared stimulus desensitization has been used
Systematic desensitization works by principle of reciprocal inhibition which
asserts that sympathetic response associated with anxiety is incompatible
with and thus inhibited by parasympathetic response that occurs during deep
muscle relaxation
Exposure= prolong and repeated in vivo exposure to feared stimulus is by
far the most studied and effective form of treatment for specific phobia ,
cognitive restructuring phobia.
Specific irrational thought may contribute to development of phobia ,
maintain avoidance behavior and contribute to physiological symptoms

27
Cognitive restrictive treatments help pt to monitor irrational thoughts and
change underlying belief so that they are better able to enter feared
situation
Q = list steps you will put into place to treat her using behavior
theraphy
Ans=steps=
1=steps = systematic desensitization=management of phobia
(IRRATIONAL FEAR)
2= aversive conditioning
Management of paraphilias (e.g pedopilias)
And addiction such as smoking
3= flooding and implosion=
Management of phobias
4=token economy= to increase the behavior in person who is severely
disorganized e.g psychoses, autism and mentally retarded
5= biofeed back = to manage HTN , Reynaud’s disease, migraine , tension
headache , chronic pain, fecal incontinence and temporomandibular joint pain
6=CBT to manage mild to moderate depression, somatoform disorders and
eating disorders
Q =cognitive triad and its examples
Negative view of self e,g I am ineffective
Negative view of future e.g nothing will work out
Negative view of world e.g world is hostile
Q handy point==cognitive theories are widely used as an effective
psychotherapy
Q=what are basic principles of CBT=
Ans=1= distraction and focusing attention away from distressing thought
28
2= neutralizing e.g. my heart is beating fast because I feel anxious and not
because I have heart diseases
3=challenging belief =
Therapist produces evidence that contradicts pt belief
4--=reassuring pt responsibility by constructing a pie chart that show all
determinants
Q COUNSELLING STEPS
Q counseling=IS TECHNIQUES THAT AIMS TO HELP people help
themselves by development of special relationship between counselor
and pt and his family members a colleague or any body who seek
counsel
Counseling session are aimed at
1=establishing a relationship of mutual trust and caring and pt feels secure
2=give pt a chance to seek clarification and explanation of issue
3= providing opportunity to pt to freely express feeling
4=provision of reassuring
5= achieving a deeper and clear understanding b of a health related issue
6 making a decision that is consider a more suitable
7= seeking support for counselor for mobilization of resources required to
implement the solution 8=learning necessary skill to deal
with issue
Q what are don’t of counseling
1-=don’t ask why question they imply interrogation(QUESTIONING)
2= don’t use should and ought they imply moralization
3= don’t blame(HOLD RESPONSIBLE) the pt
4=don’t automatically compare pt experience with your own
5=don’t invalidated pt feeling
29
Q enumerate 4 skill taught in dialectical behavioral therapy
It is for borderline personality disorder
Skill taught include
1cbt 2=dialectical way of thinking about problem
3-=mindfulness 4= saying(aphorism)
Q= 6 therapeutic factior in group theraphy
Ans=1=Universality
This help pt to realize that they are not isolated and other have similar
problems and experiences, hearing about other experience is more
convincing and helpful than reassurance frm therapist
2=Altruism(self sacrifice and humanity)
Helping other improve self esteem of person giving support as well as
helping receiver
Mutual support is one of factor leading to sense of belonging to group
3=Group cohesion=For isolated pt
Socialization aquision of social skill
4=IMITATION=LEARNING From other
5=INTERPERSONAL THERAPHY
Learning from interaction within a group and from practicing new ways of
interaction and IPT is imp component of group therapy
6=RECAPITIULATION OF FAMILY GROUP
Q WHAT IS PSYCHOLOGICAL TREATMENT OF CHOICE=
ANS= EXPOSURE WAS FIRST Behavioral treatment for agoraphobia ,
it was shown to be effective but more so when combined with anxiety
management
In short term cbt is as effective as medication but in long term CBT is
more effective than medication
30
Q in above case how you will use modeling=
Is a type of observational learning e.g. an individual behaves in a manner
similar to that of some one she admires
Q = what is meant by exposure and response prevention=
Ans = this is for obsession rituals
The procedures is based on observation that urges to carry out rituals,
decreases if rituals can be resisted for long period usually about one hour
The steps are=1= therapist explains rationale for treatment and agrees target
for exposure with pt e,,g. a target might be to touch a contaminated object
such as door handle and not to wash hand for next hour
2= the therapist may demonstrate necessary exposure him or herself this
procedure is known as modeling
3= at first therapist accompanies and support pt while they strive to prevent
rituals later pt does this on their own
4= when necessary restrains has been achieved the urge to carry out ritual is
made greater by persuading pt to enter situation that provoke this urge
since these situation have previously been avoided this procedure is called
exposure
The obsession thought that accompany ritual usually improves as ritual
are brought under control
Obsession thought that occur without rituals are more difficult to treat.
Habituation training is a form of mental exposure treatment for treating
observed thought
Thought stopping techniques is also used for obsessional thoughts
Q = 65 yr old retired person is admitted into your ward after being
brought by his wife with history of falling memory for last 6 months
Q = name six lab tests=

31
B12, Folate, RPR, CBC with SMA and TFTs
Q = name radiological tests= 1=EEG may show focal abnormalities
2= Feldstein minim mental state is used
3=Neuroanatomic findings
Cortical atrophy, flattened sulci and enlarged ventricles
Histopathology=Senile plaques, Neurofibrilory tangles,
Neuronal loss
Synaptic loss, Granulovacuolar degeneration of neurons
Q= list 4 psychometric test you would request for to rule out orgaicity
in this case-=
Ans=1=TFTs 2=ct scan 3=MRI 4= spect and pet
Q =name 4 techniques that are to be used by therapist in this case
Ans=1= Distractibility or focusing away from distressing thought
2=Neutralizing 3= challenging belief
4=Reassuring pt responsibility
Anxiety management is a general term for anxiety disorders it has six stages
1=assessment of frequency and severeity of symptoms situation in which
they occur
2= information about physiology of anxiety 3= explanation of various visual
circles of anxeity
4= relaxation training as a mean of controlling anxiety
5= exposure to situation that provoke anxiety
6=distraction to reduce impact of anxiety provoking thoughts
Q = 35 yr old chronic scyzoprenic illiterate , married , with no issue is
being discharged after 8wk stay in your ward he has stabilized on
flupenthixol deconuaste fortnightly
A= what intervention can you offer to such pt beyond drug treatment?
32
Ans-= psychosocial approaches=
1=family therapy 2-=CBT 3= social skill
management and illness self management
4= treatment of cognitive impairment 5= dynamic psychotherapy
6= interaction of drugs and psychosocial treatment
Q 27=LABELL EACH OF FOLLOWING THOUGHT WITH
COGNITIVE DISTORTION?
1= my complexion is dark and ugly so no body looks at my long hairs
and green eyes=
Ans= selective abstraction
2= I m sure my treatment is bound to fail I may actually go mad while
trying to thinking about my feelings
Ans=selective abstraction
3=you have arrived late to undertake psychotherapy because you know
it is useless to treat me
Ans= overgeneralization
4= I know deep in your heart you consider me evil person
Ans =all or nothing thinking
5= it does not matter that I got highest marks in school in six subjects
but it is not terrible that I was second in two subjects
Ans-=selective abstraction
Q28=What essential activities that you would organize in a typical
CBT section midway in treatment of this patient?
Ans=cognitive techniques=
Four methods are used to bring about changes in cognition
1= distraction=

33
Focus attention away from distressing activity and by engaging in
demanding mental activity
2= neutralizing =
Emotional aspects of anxiety provoking thoughts can be reduced by
reassuring response
E.G. my heart is beating fast because I m anxious and I have no heart
disease
3=CHALLENGING BELIEF=
Therapist produces evidence that challenge pt belief and thus also
attempt to change illogical ways of thinking
4=REASSURING PT RESPONSIBILTY=
Pt can be helped to reassess their responsibility by constructing pie chart
that show all determinants for example mother who feels responsible for
ensuring that every member of family is happy and successful
Q =25 yr old female was suffering from ocd for more than a year was
referred to you by a district hospital psychiatrist for cbt
The pt was on proper pharmacological treatment but showing partial
response
What necessary information you will provide on efficacy and
procedure of cognitive behavioral treatment
Answer=CBT
Q =what is exposure with response prevention
Answer=obsessional rituals usually improves with a combination of
response prevention with exposure to any environmental cues that increase
the symptoms.
About 2/3 of pt with moderately severe rituals can be expected to
improve substantially although not completely. When rituals respond to
34
this treatment the accompanying obsessional thought usually improves as
well. The result seems to be at least comparable with those of treatment with
clomipramine and ssri. Behavioral treatment is much less effective for
obsessional thought that occur without rituals. The techniques of thought
stopping has been used for many years but there is no good evidence that
it has a specific effect. Indeed sternat al found an effect which did not
differ from that of thought stopping directed toward irrelevant talk
Cognitive theraphy= seeks to reduce and avoid obsessional thoughts as
such attempts have been shown to Increase rather than decrease the
frequency of these thought
The pt is helped to record frequency of obssessional thought in order to
compare effects of suppression and distraction.
As suppression and avoidance appears to be driven by conviction that to
think something to make it happen .
Attempts are made to weaken this conviction by reviewing the evidence
for and against it .
These techniques may be combined with exposure to an audio recorder
repetition of thought and discussion of other cognitive distortion along
general lines of cognitive therapy
It is not certain whether cognitive therapy improves effect of behavioral
therapies in an consistent way but current treatment generally incorporates
elements of both approaches
Q COGNITIVE behavioral therapy in depressive disorder?
DEVELOPED BY AORON BECK as first effective form of cognitive
therapy
It is a complex procedure intended to alter 3 aspects of thinking of depress
patients
35
Negative thought ,belief and assumption that make ordinary situation
stressful
Monitoring is of three kinds
1=pt identify these thoughts
2=therapeutist uncover dysfunctional beliefe
3=pt record their activity and marks each one
P→if it was pleasurable
m→if sence of mastery
procedure
weekly for 15-25 weeks. person is helped to identify there distorted negative
thoughts about him or herself
.the person replaces these negative thought with positive
Symptoms improve

Q HUMANISTIC PERSONALITY THEORY BBY CARL ROGAR

AND ITS THERAPEUTIC APPROACH .CARL ROGAR IS
CONSIDERED AS Father of psychotherapy in America and founded
humanistic approach to psychology, his theory was baased on
phenomenological field personality theory and have a extension and
elaborated theory
prepositives
1=all individual in this world exist as centre of world
2=organism react to field as it is experienced and perceived
3=organism react to phenomenological field as an organized whole
4= a portion of total perception becomes differentiated ass self
Q = name five behaviuoral methods that are likely to be effective in
this case= of obsessive compulsive disorder
36
Ans= 1-= Relaxation techniques 2= Guided imagery ‘
3= Exposure 4= Paradoxical intent
5= response prevention 6- thought stopping techniques and modeling
Q define counselling
MEANS giving advice here it donates a wider procedure concerned as
much with emotion as with knowledge
Q Enlist different model of counselling
Counselling for specific purposes
1= Debriefing 2= counselling for relationsip problem
3=Grief counselling 4=Counselling about risk 5= counseeling in
primary care
Q=indication of CBT
1= treatment for anxiety disorder 2= depressive illness
3= bulimia nervosa 4=hypochondriases
5=schzpoprenia 6=personality disorder
7= dialectical beaviuoral theraphy for border line personality disorder
Q PSYCHOLOGICAL Techniques=

Family therapy uses a range of counseling and other techniques including:

Structural therapy - Identifies and Re-Orders the organisation of the family

system

Strategic therapy - Looks at patterns of interactions between family members

Systemic/Milan therapy - Focuses on belief systems

Transgenerational Therapy - Transgenerational transmission of unhelpful

patterns of belief and behaviour.

37
communication theory
media and communications psychology
psychoeducation
psychotherapy
relationship counseling
relationship education
systemic coaching
systems theory
reality therapy
attachment-focused family therapy
Q you have arrived late to under take psychotherapy session becoz u
actually know that it is useless to treat me
Ans=arbitrary inferences
Q I know deep in my head u consider me an evil person
Answer=arbitrary inferences
Q it does not matters that I got highest marks in six subjects in school
but it is not that I was second in two subjects
Answer=selective abstraction
Q types of cognitive distortion
1=Arbitrary inferences=drawing a specific conclusion without sufficient
evidence
2=DICHOTIMOUS THINKING=tendency to categorize experience as all or
none
3=overgeneralization=forming and applying a general conclusion based on
an isolated events
4=magnification and minimization=over or under valuing the significance of
a particular event
38
Q WRITE NOTE ON COGNITIVE BEHAVIUOR THERAPHY?
INTRODUCTION =is a psychotherapeutic approach that aims to solve
problems concerning dysfunctional emotions , behaviuor and cognition
thru a goal oriented systematic procedure .CBT combines the cognitive
theraphy developed by aoren beck and behavioural therapy techniques.
Thought causes feeling and behavior .emphases based on current
behavior .
Cbt is the collaborative effort between therapist and clients
---client role ---define goal, express concern ,learn and implement learning
----therapist--- help client define goal ,listen ,teach and encourage
Q=What essential activities that you would organize in a typical CBT
section midway in treatment of this patient?
Ans=cognitive techniques=
Four methods are used to bring about changes in cognition
1= Distraction=
Focus attention away from distressing activity and by engaging in
demanding mental activity
2= Neutralizing =
Emotional aspects of anxiety provoking thoughts can be can be reduced by
reassuring response
E.G. my heart is beating fast because I m anxious and I have no heart
disease
3=CHALLENGING BELIEF=
Therapist produces evidence that challenge pt belief and thus also attempt
to change illogical ways of thinking
4=REASSURING PT RESPONSIBILTY=

39
Pt can be helped to reassess their responsibility by constructing pie chart
that show all determinants for example mother who feels responsible for
ensuring that every member of family is happy and successful
Q TOPIC TO BE CONSIDERED DURING ASSESSMENT FOR CBT
1=A Brief description of each problem including behavior, thought, emotion
associated with it
Where it occur most often
Common prior events’
Pt response to these events ‘
What following problems
2=factors that alleviate or worsen a problem
3=maintaining factors
Include
Avoidance
Safety behavior
Selective attention
Way of thinking and response of others
Q =business man with 6 month history of GAD, now he feels difficult
to give presentation in board meeting due to tremor, blushing and loss of
confidence and difficulty in organizing his thought,he remains
preoccupied with negative thought that his proposal will be turn down
and peoople will laugh at him , he often feels heaviness on chest and
suffocation.
His medical ward cleared him physically. Manage anxiety in this case
Anser=Behavioral psychotherapies includes relaxation training, biofeed back
.Pharmacotherapy includes SSRI,, venlafaxine, buspirone, benzodiazepine
Q=General characteristics od CBT=
40
Answer= for depressive illness essential aim of ect is to change way of
thinking.
There are many studies of CBT in acute depression that have been reviewed
recently by NICE
NICE conclusion currently are following
CBT is superior to other waiting list control in depressive illness
CBT is not generally superior to IPT
CBT is effective as pharmacological treatment
Combined CBT and pharmacological therapy is better than
pharmacological treatment alone
Q=What are psychosocial intervention for schizophrenia?
1=Family therapy
(psycho education)
2=CBT
3= cognitive remediation=Cognitive remediation therapy (CRT), also
called cognitiveenhancement therapy (CET), is designed to
improve neurocognitive abilities such as attention, working
memory, cognitive flexibility and planning, and executive
functioning which leads to improved social functioning.
4= social skill training
5= supported employment
6= illness management skills
7= integrated management for co morbid cannabis misuse
8= assertive community treatment
Q= enlist three evidence based 3 SSRI and three psychological option
available for pt of PTSD?
1=counseling 2=CBT
41
3=eye movement desensitization and reprocessing
Medication such as benzodiazepine should be avoided
SSRI includes 1=Escitalopram
2= Paroxetine 3=Flouxetine
SSRI and maoi and tca have shown efficacy in clinical trial
Antipsychotic like olanzapine
Q =Application of behavioral techniques to medicine
A=systematic desensitization = is a behaviuoral technique based on
clinical conditioning and use to eliminate phobia
B=token economy=
C= cognitive therapy
Is one of behavioral theraphy used to deal with depression and anxiety
D=biofeed back = involves learning to gain control over measurable
physiological problem and is based on operant conditioning and require
high degree of motivation and practice
Therapeutic uses==1=peptic ulcer 2=asthma 3=migraine 4=
tension headach
Q =NAME THERAPEUTIC FACTORDS IN GROUP THERAPHY
1=UNIVERSALITY
(SHARED EXPERIENCES)
2=ALTRUISM(practice of concern for welfare of others)
3=GROUP COHESION
4 SOCIALIZATION
5=IMITATION
6=INTERPERSONAL LEARNING
7=RECAPITULATION OF FAMILY GROUP
Problems in group therapy
42
Certain problems commonly arises in course of group theraphy
Formation of sub groups
Membres who talk too m,uch
Conflicts between members
Avoidance of present
Q =what non pharmacological intervention are likely to help her?
Ans= CBT
Systematic desensitization
aggressive training
Exposure
C=q list steps you will put Into place to treat her using behavior
theraphy?
SYSTEMATIC DESENSITIZATION=
For management of phobia
Aversive conditioning=Paraphilias (pedophilia) and addiction like smoking
Flooding and implosion=Phobia
Token economy= for disorganized psychoses , autistic and mentally
retarded
Feed back = hypertension , raynauds disease, tension headache
Cbt= depression, somatioform disorder and eating disorders
Q =pt with abdominal pain but surgeon says that thre is no
intraabdominal pathology and surgeon refers pt to psychiatrist
Diagnioses is hypochondrioase
Q WHAT is psyhiatric response to above patient
Answer=psychotherapy to help relieve stress and help cope with illness .
Frequent regular schedules visits to patient medical doctor
Q =Examples of illogical thinking
43
And cognitive distortion
1=overgeneralization =pt draw general conclusion from single instance
2= selective abstraction = pt focus on a single unfavorable aspects and
ignore favorable aspects
3=personalization = pt blames itself for consequences of action of other
people
4=all or nothing thinking=pt view people or situation in black and white
terms
Q Enumerate four skills taught in dialectical behaviuoral theraphy for
borderline personality disorder=
1=cognitive behaviuoral techniques
2= dialectical ways of thinking about problems
3=mindfulness
4= aphorisms(a brief statement of scientific principle)
Q =Examples of illogical thinking
And cognitive distortion
1=overgeneralization =pt draw general conclusion from single instance
2= selective abstraction = pt focus on a single unfaviuorable aspects and
ignore favourable aspects
3=personalization = pt blames itself for consequences of action of other
people
4=all or nothing thinking=pt view people or situation in black and white
terms
Q enumerate four skills taught in dialectical behavioral theraphy for
borderline personality disorder=
1=cognitive behavioral techniques
2= dialectical ways of thinking about problems
44
3=mindfulness
4= aphorisms
CHILDHOOD DISORDERS have not been classified in a easy
satisfactory way these includes
CLINICAL PSYCHTRIC SYNDROMES
SPEIFIC DELAY IN DEVELOPMENT IN INTELLECTUAL AND
MEDICAL AND SOCIAL SITUATION
Q– = cognitive distortion triad=
Ans= Negative view of self e,g I am uneffective
Negative view of future= e,g = nothing wil work
Negative view of world e.g= world is hostile
Q=What psychosocial intervention can you offer to support drug
treatment in persecutory delusions
Answer= psychological management including individual ,family and group
psychotherapy is useful to provide long term support and to foster
adherence to drug regimen.
Q = Cognitive behavioural theraphy

All psychiatric disorder have cognitive and behavioural components and these
features have to change if pt is to recover .

With other treatment changes comes about indirectly

For example mood varies with antidepressants therapy

CBT aims to change cognition and behavior directly

Behavioral therapy is concerned with factor that provoke abnormal behavior e.g
in bulimia nervosa episode of excessive eating may be provoked by situation
that cause to pt to feel inadequate

One of frequent maintaining factors is a avoidance

45
In phobia and anxiety it is important

Cognitive therapy generally focus on two kind of abnormal thinking

Intrusive thought are automatic thought and dysfunctional belief and attitudes

Intrusive thought provoke an immediate emotional reaction usually of anxiety

and depression

Dysfunctional beliefs and attitude determines the way in which situation are
perceived and interpreted

3 factors are thought to maintain dysfunctional attitude and behavior

1=attending selectively to evidence that confirm them and ignoring evidence that
contradict them .In social phobia attend more to critical behavior

2=thinking illogically

Examples are

A=Overgeneralization

Pt draw general conclusion from single instance e.g he does not love me so no
one will ever love me

B =Selective abstraction

Pt focuses on an single unfavorable aspect of situation and ignore favorable aspect

C=Personalization

Pt blame themselves for consequences of action of other peoples

D=All or nothing thinking

Pt believe people or situation In black or white terming pt is seen as wholly good

or wholly bade rather having mixture of good and bad qualities

3=Safety seeking behavior

Which occur because it is believed to reduce immediate threat

46
Q GENERAL FEATURES OF CBT

Pt takes an active part in treatment and therapist acting as expert adviser who ask
questions

Attention to provoking and maintaining factor

This type of assessment is called as abc approach

A=antecedent

B=behavior and

C=consequences

Attention to way of thinking

Treatment as investigation

Homework assignment and behavioral assessment

Highly structured session

Monitoring of progress

Treatment manual

Q TOPIC TO BE CONSIDERED DURING ASSESSMENT FOR CBT

1=A Brief description of each problem including behavior, thought, emotion

associated with it

Where it occur most often

Common prior events’

Pt response to these events ‘

What following problems

2=factors that alleviate or worsen a problem

3=maintaining factors

47
Include Avoidance, Safety behavior

Selective attention
Way of thinking and response of others

Q Enlist various models of counsellings

Ans=1=Debriefing

2=Counseling for relationship problems

3=Grief counseling

4= Counseling about risks

5=Counseling in primary care

Q SELF ACTUALIZATION
INTRIODUCED by kurt gold stein
All behaviuoral techniques aims to increase pt control over their own
behavour .self controlled techniques are based on operant conditioning
principles ..
Self controlled training is usually part of wider cognitive behaviouir
programs forexample in treatmrent of eating disorder
3stages
1=self monitioring
2=self evaluation
3=sellf reward
Q COLLECTIVE UN CONSCIOUS
Is introduced bby carl jung . it is a term of analytical psycology .it is
considered to be a part of unconscious mind

48
And all life forms with nervous system in humanity
Jung distinguish the collective unconscious from personal unconsuoius
Q PSYCHOTHERAPHY in depression
Several types of psychotheraphy available for depression
Types include
1= cognitive behavioural therapies
2=interpersonal theraphy
For severe depression we use both IPT AND CBT
For mild to moderate depression we use only IPT OR CBT
COGNITIVE BEHAVIUORAL THERAPHY
Used to correct negative thinking and negative behaviour associated with
depression and to control behaviuoral disturbances that leads to there
illnesses
INTERPERSONAL THERAPHY
In this type of psychotheraphy we improve troubled personal relations and
other factors that have been associated with depression
Q= describe projective personality assessment= test used
(ambiguous)unclear stimuli, needs clinical experience, not diagnostic
roshash test(ink blot), thematic apperception test and sentence
completion drawing
Q describe Roshasch test and name clinical condition in which it would
we use this
Ans= it is most commonly used projective personality test, used to identify
thought disorder and defence mechanism
Pt are asked to understand ten bilaterally symmetrical ink blot designs e.g
describe what you see in this shape

49
Q =who started classical conditioning and who started operant
conditioning?
Ans= classical conditioning by Pavlov and operant conditioning by b. f.
skinner
Q = behavioral therapy= involve changing behavior of pt to reduce
dysfunction and improve quality of life .
The principle of behavioral therapy are based on early studies of
classical conditioning by pavlow and operant conduitioning by skinner
Classical conditioning is learning of involuntary response by pairing a
stimulus that normally causes a particular response with a new neutral
stimulus after enough pairing , the new stimulus will also cause response to
occur
Q = you are treating 20 yr old girl one of your friend approaches you
to inquire about her illness as his younger brother is getting married to
her
Briefly describe how you will handle this situation
Ans= we will maintain (confidentiality)secrecy because although physician
are expected ethically to maintain pt confidentiality they are not required
to do so if 1= there pt is a suspected case of child or elder abuser
2= there pt has a significant risk of suicide
3-= there pt poses a serious threat to another person
4= there pt poses a risk to public safety e,g impaired DRIVER
B =involvement by physician if poses a threat
1 the physician must determine reliability of threat or danger
2= if danger is likely physician must inform suitable law enforcing officials
or social welfare agency and warn the intentional sufferer (tarasoff decision)
Q =what are various determinants of intelligence
50
Briefly discuss to what extent they affect Intelligence?
Ans=intelligence and mental age=1= intelligence is defined as ability to
understand summary(abstract) concepts, reasons, understand, remember,
explore and organize information and meet special need of new situation
Intellectual(mental ) age is defined by Alfred binet reflects a person level of
intellectual functioning
(chronological)in order age is person actual age in years
IQ= MA/CA multiply by 100-=result
An IQ of 100 means that person mental and chronological age are equal
The highest chronological age used to determine IQ is 15yrs
IQ =is determined to a large extent by (genetics)inheritance
However poor nutrition and illness during development can negatively
affect an IQ.
The result of IQ test are influenced by person cultural background and
emotional responses to testing situation.
IQ is relatively stable thru out life
In absence of brain pathology an individual IQ is essentially same in old
age as in childhood
Normal intelligence= as stated above an IQ of 100 means MA and CA are
approximately same
Average or normal IQ is in range of 90-109
Standard deviation in IQ SCORE Is 15
A person with an IQ of that is more than 2SD below mean (iq= 70)
Is usually considered mentally retarded
Q Classification of mental retardation
Mild IQ= 50-70
MODERATE IQ =35-55

51
SEVERE IQ= 20-40
PROFOUND IQ -= LESS THAN 20
A score between 70-84 indicates borderline intellectual functioning
The person with an IQ more than 2SD means iQ of 70 has superior
intelligence
Weshler intelligence test and Vineland adaptive behavior scale=
WAIS-IV is most commonly used IQ test
wais-R has four index score
1=spoken(verbal) comprehension index
2=working memory index
3=perceptual reasoning index
4=processing speed index
Vic and WMI together make up verbal IQ
PSI and PRI together make up performance IQ’ . Full IQ score is generated
by all four index scores
WISC is used to test intelligence in children 6-16and half yr age
Weshler preschool and primary scale of intelligence scale is used to test
intelligence in 4-6 yr age.
Vinland adaptive behavior scales are used to evaluate skill for daily living
e.g. dressing using telephone in people with MR and other challenges e.g
those with impaired vision or hearing
Q : Enlist three salient characteristics of defense mechanism
Answer: 3 salient characteristics
1= (unconscious)insensible responses to external stressor
2= As well as to anxiety, anxiety arising from internal conflicts
Originally defense mechanism was described by sigmoid fried

52
In response to stressful circumstances most frequently defense mechanism
are represented by denial, displacement, projection, and regression
Defense mechanism are unconscious process .concept of defense
mechanism are useful in understanding of psychiatric people under stress
Also Freud used defense mechanism to explain the etiology of mental
disorders
Q =types of defense mechanism
1=Projection= attributing your own wishes ,thought or feeling onto some
illness .e.g.i am sure my wife is cheating on me
2=DENIAL(rejection)= used to avoid becoming aware of some painful
aspect of actuality,e.g. I know I do not have cancer
3= Splitting-= external objects are divided into all good or bad
E,g. morning staff is much better than evening staff
4=BLOCKING= temporary block in thinking
e.g. I cannot seem to remember his name
5=Regression(deterioration)=return to an earlier stage of development, most
immature
e.g. ever since my divorce my 5yr old son has begun to wet bed
6=Somatization= psychic derivatives are converted into bodily symptoms
e.g. just thinking of exam I get butterflies in my stomach,
7=Introjections= features of external ward are taken and made part of
self.e.g. resident physician dresses like attending
8=Displacement= an emotion or drive is shifted into another that resembles
like original in some aspects e.g. I had to get rid of my dog since my
husband kicked it every time we had an argument.
9-=Repression(suppression)= an idea is with held from consciousness, an
unconscious forgetting e.g I do not remember having had a dog
53
10=Intellectualization= excessive use of intellectual processes to avoid
(affective)emotional (expression)look e.g it is interesting to note specific
skin lesion which seems to arise as a consequence of my end stage disease
11= Isolation= separation of an idea from affect that accompanies it ,as she
arrived to identify dead body she appeared to show no emotion
12=Rationalization(good reason)= rational explanation are used to justify
unacceptable attitudes or behavior e.g. I did not pass test because it was
very difficult
13=Reaction formation= an unacceptable impulse is transferred into its
opposite results in formation of characteristic behavior e.g listen to him tell
his family he was not afraid when I saw him crying
14= Undoing==acting out=reverse of an unacceptable behavior ,consists of
an act e.g I need to wash my hand whenever I have these thoughts
15=Acting out=emotional or behavioral outbursts e.g. I cannot explain why
he has those annoyance and bad temper
16= Humor=permits expression of feeling without personal discomfort
17=Sublimation=most mature of defenses, impulse gratification has been
achieved but aim or objective has been changed from unacceptable to
acceptable
e.g jack ripper becomes a surgeon
18=Suppression =conscious forgetting, only conscious defense e.g.i would
rather forget that my dog was run over by a car
19=Dissociation=splitting of brain from conscious awareness e.g I donot
know where I live
Q USEFULNESS OF DEFENCE MECHANISM=
The way and mean Ego(self esteem and self worth) ward off anxiety and
control instinctive urges and un pleasant affects and emotion

54
Defense mechanism are unconsciousness ( except suppression which is
conscious)
(discrete)separate, (dynamic)active and irreversible, adaptive or maladaptive
Q =clinical assessment of patient with behavioral symptoms=
Overview of psychological assessment=
Psychological assessment test are used to assess intelligence, achievement
and personality and psychopathology. These test are classified by functional
areas evaluated
Q INDIVIDUAL VERSES GROUP TESTING
Intelligence tests
IQ test= MA/CA multiply by 100= result of IQ TEST
WAIS-IV
WAIS-R has four index scores
1=verbal comprehension index
2=working memory index
3-=perceptual reasoning index
4=processing speed index
Verbal comprehension index
Working up memory index
ACHIEVEMENT TESTS=
Used to evaluate reading and mathematics
SPECIFIC ACHIEVEMENT TEST=
1=Scholastic(educational) aptitude(ability) test
2=Medical college admission test
3=USMLE test
Q OBJECTIVE PERSONALITY TEST=
1=MMPI=Minnesota multiphase personality (inventory)register
55
2=million clinical multiaxial inventory
Q PROJECTIVE PERSONALITY TEST=
1=Rosasch test
2=Thematic apprehension
Q OBJECTIVE RATING SCALE FOR DEPRESSION=
1=Hamilton 2=Raskin
3=Jung 4=Beck scale
In Hamilton and raskin examiner rates patient
In jung and beck pt rates himself
Q NAME IMPORTANT NEUROPSYCHOLOGICAL TESTS=
1=BENDER GESTALT 2=LURIA NEBRASKA 3= HALTED REITAN
,THESE TESTS USED TO DETECT ORGANICITY FROM ANY
PSYCHIATRIC DISORDER.
Q=what are psychosocial intervention for schizophrenia?
Answer= Family therapy(psycho education), CBT
Cognitive remediation , social skill training
Supported employment , Illness management scale
Integrated treatment for co morbid misuse , assertive community
treatment
Q discuss DIAGNOSTIC CRETERIA FOR POST TRAUMATIC
DISORDER
ANS=Diagnostic criteria is similar in both ICD-10 AND DSM –IV
DSM-IV includes two criteria that are not present in ICD-10
According to DSM-IV symptoms must be present for at least one month and
may cause impaired social impairment
As a result of these differences’ concordances between diagnoses of PTSD
using the criteria is 35%

56
By convention PTSD can be diagnosed in people who have a history of
psychiatric disorder before stressful event.
Deferential diagnoses include following
1=Stress induced exacerbation of previous anxiety or mood disorder
2=Acute stress disorder distinguished by time course
3=Adjustment disorder distinguished by different pattern of symptoms
4=Enduring(stable and continuing) personality changes after disastrous
experience
PTSD may present as deliberate self-harm or substance abuse which have
developed as maladaptive coping strategies
Q seven medical condition as DDx=of panic disorder
1=shortness of breath and smothering sensation
2=palpitation and accelerated heart rate
3=chest pain
4=dizziness and fainting
5= nauseas and abdominal suffering
6=fear of dying and fear of going mad
7=numbness and tingling sensation
8=sweating, flushing and chills
Q DIAGNOSTIC CRETERIA FOR PANIC DISORDER
In DSM-IV the diagnoses is made when 1=panic attack occur unexpectedly
And 2=more than 4episode occur in less than one month
3=worry about heart attack
Diagnostic criteria is similar in ICD-10
Q= Enlist few drugs that are known to raise serum lithium level
Answer=1=diuretics 2=NSAIDS 3=ACE inhibiters 4=ARBS 5=antibiotics
like metronidazole
57
Q = what is organic basis of anxiety?
Answer=increase norepineprine ,decrease serotonin , decrease GABA
Locus ceruleans (site of noradrenergic neurons)
Raphe nucleus(site of serotonergic neurons)
Caudate nucleus(particularly in OCD)
Frontal cortex is involved in anxiety disorder
Increase caffeine intake, substance abuse, hyperthyroidism, vita B 12
deficiency, hypo and hyperglycemia, cardiac arrhythmias, anemia and
pheochromocytoma.if etiology is primarily organic diagnoses substance
abuse anxiety disorders by a general medical condition may be appropriate
Q =give a brief account of no benzodiazepine treatment for anxiety
disorder
Answer= anti anxiety agents including BZD, buspiron, beta blockers are used
to treat symptoms of anxiety.
Buspirone is a non benzodiazepine anti anxiety agents
1= because of its low abuse possible buspirone is used as long term
maintenance therapy for pt with Gen.anxiety disorder.
2=because it takes two weeks buspirone has little immediate effect on
anxiety symptoms
BETABLOCKERS=
Propranolol are used to control autonomic symptoms such as tachycardia in
anxiety disorders particularly for anxiety about performing in public or taking
an examiner
ANTIDEPRESSENTS=MAOI, TCA, especially SSRI such as paroxetine,
fluoxetine and setraline are most effective long term maintenance theraphy
for panic disorder and OCD,and have shown efficacy also in PTSD.recently
SSRI such as escitalopram,SNRI such as venlafaxine and duloxetin were

58
approved to treat GAD. Paroxetine and setraline and venlafaxine now also
are indicated in management of social phobia.
PSYCHOLOGICAL MANAGEMENT
1=systematic desensitization and CBT for phobia is used as an addition to
pharmacotherapy in other anxiety disorder
Q =30 yr old female is brought to psychiatric patient clinic . On
detailed interview she says that she is chosen by some power or by
destiny for a special purpose.because of her unusual talent.she thinks
that she is able to read peoples thru and that she is much clever than
any one.
Q=What phenomenogy stands for above mentioned symptoms?
Answer= GRANDIOSE DELUSION showing mania
Q = How manage this pt (mania)
Answer=ACUTE TREATMENT OF MANIA=
MEDICATION=
Antipsychotic drugs like typical antipsychotic like chloropromazine and
haloperidol
Atypical antipsychotics like aripiprazole, olanzapine, quetiapine and
respiridone.
MOOD STABILIZERS=
LITHIUM , Carbamazepine, valproate, benzodiazepine, ECT
Q=LONG TERM TREATMENT OF MOOD DISORDER=
PREVENTION OF RELAPSE OF MOOD DISORDERS
Treatment to prevent relapse should be called continuation treatment and
treatment to prevent recurrence should be called prophylactic or
maintenance theraphy,. Carbamazepine, valproate should be given
DRUG TREATMENT OF UNIPOLAR DEPRESSION=
59
Continuation treatment and maintenance treatment
DRUG TREATMENT FOR BIOLAR DISORDER=
Continuation treatment , maintenance treatment
Psychotherapy and interpersonal therapy
Q =38 yr old lady brought to ER crying that I m going crazy(mad).she
states that for last two months when she was going to northern areas
she has sudden episodes of palpitation, sweating and
trembling(tremulous) ,ecg and other physical signs are normal what is
most likely diagnoses?
Answer=panic disorder
Q =What will be most likely appropriate step for acute treatment?
Answer=pharmacological intervention includes SSRI,
(FLUOXETINE),alprazolam, clonazepam,imipramine,and MAOI e,g
phenelzine
Psychotherapeutic intervention includes relaxation training for panic attack
and systemic desensitization for agoraphobic symptoms
Q =what is psychoanalyses explanation for this condition?
Answer=1=psychoanalyses related therapies such as psychodynamics
theraphy are psychotherapeutic treatment based on freud concept of
unconsiuos mind.
Defense mechanism and transfer reaction=
2-=central strategies of these therapy is to uncover experiences that are
repressed in unconscious mind and integrate them into pt unconscious mind
and personality
B= techniques used to recover repressed experiences includes
1= free association

60
A=in psychoanalyses person sits on a sofa in a reclined position facing away
from therapist and says whatever comes into mind(free association)
B =in therapies related to psychoanalyses person sits in a chair and talks
while facing therapist
2=interpretation of dreams is used to examine an unconscious conflict and
impulses
3= analyses of transfer reaction
Person unconscious response to therapist is used to examine important past
relationship
C=peoples who are fit for psychoanalyses and related therapy should have
following characteristics
1=are younger than 40years
2=are intelligent and not psychotic
3=have a good relationship within other e.g.no evidence of antisocial or
border line personality disorder
4= have a stable life situation and not in midst of divorce
5=have time and money to spend on treatment
D= in psychoanalyses people receive treatment 5 times weekly for
4years,related therapies are brief and more directly
(brief psychodynamic psychotherapies is limited to 12- 40 week session)
Q = middle aged man reported to you with a history of being irritable,
labile mood and increasingly forgetfulness following head injury
Name five neuropsychological tests to rule out organic basis of illness
Answer=1=structural brain imaging with CT or MRI or PET
2= neuropsychological testing 3=EEG 4=CSF examination
5= genetic testing 6= brain biopsy
Q =name language components of minimental state examination?
61
Answer=language component
See minimental state examination
Q= pt with history of bipolar affective disorders is brought in
emergency with acute disturbances of behavior and violent gestures,
informant is not offering any useful information
What you think has caused acute disturbances of behavior in this case?
ANS= due to bipolar affective disorder current episode mania we see acute
disturbance of behavior and violent gestures
Q ;enumerate 4 common side effects of two mood disorders each which
leads to poor compliance.
Answer= side effects of lithium =
1=tremors 2= nephrogenic diabetes insipid us 3= GIT distress
4=memory problem
5= acne exacerbation
Q SIDE EFECTS OF VALPROIC ACID=
1-=Sedation 2= ataxia and tremors
3=GIT distress 4=thrombocytopenia
Q Idiosyncratic reaction of valproic acid are;
1=fatal hepatotoxicity 2; fulminant pancreatitis 3=agranulocytoses
Due to these side effects we see poor compliance
Q What are priority management steps that you will consider in this
case
TREATMENT OF BIPOLAR DISORDER=
Must assess pt safety to determine need for hospitalization
Pharmacotherapy includes 1=mood stabilizer
2=BZD
3=antipsychotics both typical and atypical
62
Individual psychotherapy also indicated.
Q;60 year old lady report to you with history of being paranoid ,
irritable, confused, unsteadiness of gait and urinary incontinence also
history of forgetfulness and aimless wandering and she improved
markedly remarkably after neurosurgical intervention
Q enlist 3 differential diagnoses in above case.
Answer;1=Normal pressure hydrocephalus
2=Parkinsonism
3= Alzheimer disease
Q ;what is most likely diagnoses?
Answer; Normal pressure hydrocephalus
Q =name five relevant investigation with detailed finding of one
1=EEG 2= neuroimaging
3; neuropsychological testing 4;TFTS
5; FOLSTEIN Mental state examination
6; b12 and folate
On CT SCAN we see enlarged and dilated cerebral ventricles but normal
pressure so it is diagnosed as such but no cortical atrophy
Q;Name neurosurgical intervention in normal pressure hydrocephales
Answer; shunt placement
Manage acute deterioration; ventricular drainage ventriculoatrial or
ventriculo peritoneal shunt
Gradual drainage
Ventriculoperitoneal shunt
Complication of shunt=1= infection
2=subdural hematoma
3= shunt obstruction
63
Q Health belief model developed to explain and calculate health related
behavior in regard to uptake of health services
HBM was developed in 1950 by social psychologist at us public health
service and remained one of most well known and widely used theory in
health behavior research
HBM suggest that people belief about health problem, perceived benefit of
action and barrier to action and self efficacy explain engagement in health
promoting behavior
A stimulus or clue to action must also be present in order to trigger health
promoting behavior
Q Abstract reasoning
Ability to analyze information and solve problem on a complex thought
based level is sometime reffered to as abstract reasoning
And it involves skills such as theories about nature of object , ideas ,
processes and problem solving ,understanding subjects on a complex level
thru analyses and evaluation
Ability to apply knowledge in problem solving using theory about
understanding relationship between verbal and non verbal cues
Q Rage= Feeling of intense violent anger
Associated with flight fright responses and often activated in response to
external cues such as an event that impact negative person
Q Verbal reasoning = is understanding and analysis concept framed in
words .it aims at evaluating ability to think constructively
Large graduate training schemes are increasingly using verbal reasoning test
to distinguish between applicants
Q = Ten year old girl brought with history of frequent brief disruption
of consciousness
64
She gets blanked ,pale, dazed and unresponsiveness for a while .eyes
assumed a glazed appearance.soon she starts talking where she had left
and resumes normal activity
A=what is likely diagnoses and how would you differentiate it from
schyzoprenic thought block
Answer=Epilepsy(typical absence seizure),generalized anxiety disorder?
While thought block is symptom of schizophrenia, first rank shnedder
symptoms and in this thought block there is temporary block in thinking
e.g. I cannot seem to remember his name
In schizophrenia along with thought block we also see positive and negative
symptoms
Absence seizures occur in childhood while schizophrenia occurs in young
or old age pt.
Q = name one relevant investigation with one finding
Answer= EEG may help establish and characterized type of epilepsy.
Determination of type is necessary and important for determining most
appropriate anticonvulsant drug with which to start treatment,
If pt is having frequent seizure EEG may confirm the presence of seizures
by demonstrating spikes or sharp waves even in interictal period
Q = name 3 drugs used for absence seizures
Answer=first line =Etthosuximide 2nd line=valproate
3rd line=Lamotrigine and Clonazepam
Q= Enumerate various pharmacological agents which may be used in
treating tardive dyskinesia
Answer=1=stop older antipsychotics 2=olanzapine trial or quetiapine trial
3=vitamin E

65
Q =Declarative memory can be subdivided into working memory and
long-term memory.
Q =MAOIs: indications MAOI'S:
Ans=Melancholic [classic name for atypical depression]
Anxiety
Obesity disorders [anorexia, bulimia]
Imagined illnesses [hypochondria]
Social phobias
Listed in decreasing order of importance.
Q Serotonin Syndrome Causes .

Some illegal drugs, such as LSD and cocaine, and dietary supplements, including
St. John's wort and ginseng, can also lead to serotonin syndrome when combined
with antidepressants that affect serotonin.

Q Serotonin Syndrome Diagnosis

There is no single test to diagnose serotonin syndrome. Your health care provider
will ask about your medical history, including medication, supplement, and
recreational drug use, and perform a physical exam. Other conditions may cause
symptoms that are similar to serotonin syndrome. Tests to exclude other causes of
symptoms may be ordered.

Q=For past 10years memory of 74 year old women has progressively

declined and forgetfulness and she cannot remember how to cook his
favorite recipes and disoriented and confused at night, her muscle
strength and balance are normal
Q = what is most likely diagnoses=

66
Answer-=Alzheimer disease
B Q =give features of this disease?
Answer= it occupies more than 50% of pt of nursing home beds
Found in 50% of pt of dementia
Risk factors= female , family history, head trauma and down syndrome
Neuroanatomic findings= cortical atrophy; flattened sulci, enlarged
cerebral ventricles.
Histopathology findings= senile amyloid plaques
Neurofibrilory tangles , neuron loss , synaptic loss
Granulovacuolar degeneration of neuron
Associated with chromosome 21(gene for amyloidal precursor protein)
Decreased ach and NEP
Gradual deterioration and death after 8years
Focal neurologic symptoms are rare
Q Classification of Mental disorders=ICD-10
F00-F99 MENTAL AND BEHAVIOURAL DISORDERS
F00-F09= ORGANIC MENTAL DISORDERS
F10-F19= mental disorders due to psychoactive substance use
F20- f29= schyzoprenia-shyzotypal and delusuional disorders
F30- f39=mood disorders
F40-f 48 neurotic, stress related and somatoform disorders
F50-f 59= Behavioral syndromes associated with physiological
disturbances
F60-f69= disorder of adult personality and behavior
F70- f79= mental retardation
F80- f89=disorders of psychological development

67
F90- f98= behavioral and emotional disorders with onset usually occurring
in childhood and adolescence
F99= unspecified mental disorders
Q DSM –IV CLASSIFICATION OF MENTAL DISORDER
DSM IS published by American psychiatric association
It has five dimensions as described below
AXIS 1=CLINICAL SYNDROMES
=this is what we think of as diagnoses like depression and scyzoprenias
AXIS II= DEVELOPMENTAL AND PERSONALITY DISORDERRS
DEVELOPMENTAL disorders includes
Autism, MR.
Personality disorders includes paranoid , antisocial, ,borderline personality
disorders
AXIS III=PHYSICAL CONDITION MAY PLAY ROLE IN
DEVELOPMENT AND EXCERBATIONODF AXIS 1 and AXIS 2
Physical condition such as brain injury and hive –aids can result in
symptoms of mental illnesses
AXIS IV= SEVERTY OF PSYCHOSOCIAL DISORDRS=events in person
life such as death of loved ones can cause disorders in axis 1 and axis 2
Q = 4 year medical student has long standing grudge against a hard
working and successful classfellow but he finds it hard to admit the
reality to himself.
Instead he tell his friend the said fellow is jealous of my intelligence
Q- =what is most likely defense mechanism in this case
Answer= projection
Q = ELEMENTS OF FAMILY INTERVENTION IN SCHYZOPRENIA
Answer-=1=education about schizophrenia 2=improving communication
68
3=lowering expressed emotion 4=expanding social networks
5=adjusting expectation 6=reducing no of hours of daily
contact
Q = name psychometric tests useful for assessing progress of
schizophrenia?
Answer=
1=structural brain changes 2=structural imaging such as CT, MRI ,PET
3=neuropathology 4=functional brain Imaging
5= cerebral blood flow 6=neuropsychological EEG, SENSORY
EVOKED POTENTIAL POTENTIAL , EYE TRACKING
7=NEUROCEMICAL FINDINGS=dopamine, glutamate,GABA,serotonine
Q =Incidence= is a ratio of number of individual in population who
develops an illness in a given time period(of one year)
Divided by total number of individual at risk for illness during that
time period e.g. no of iv drug abuses newly diagnosed with aids divided
by iv drug abuser in population
Q Prevalence= is ratio of no of individual in population who have an illness
divided by total no of individual at risk for illness. Point prevalence= is ratio
of no of individual who have an illness at a specific point in time
Period prevalence=is ratio of no of individual who have an illness during
specific time period divided by total population who could have an illness
Q =Echopraxia=
Answer= pt imitates(copies) interviewer movement involuntarily even
when asked not to do so.
Q =LOOSENING OF ASSOCIATION=
Loss of normal structure of thinking.

69
3 characteristic kinds of loosening of association and have been described
and occurs in schizophrenia
1==in taking past the point
2= knight movement and derailment=refer to transition from one topic to
another
3=verbigeration=is said to be present when speech is reduced to senseless
repetition of words and phrases and occur in association with expressive
aphasia and occur in schyzoprenia
Q =young doctor is planning to conduct a research study on efficacy of
a new drug for depression.
He consult his supervisor for advice regarding appropriate study design
for his research. What would be most appropriate study design in this
situation n?
Answer=case control study
Q=what are hierarchy(ladder or chain of command) of quality of
research about treatment
Answer=
1 a=evidence from a systematic review of randomized control trial
1b=evidence from atleast one RCT
II a= evidence from at least one controlled study without randomization
Ii b=evidence from at least one other type of quasi experimental study=
Iii=evidence from non experimental descriptive studies such as
comparative study ,correlation studies and case control study
Iv=evidence from expert committee reports or options and clinical
experience of respected authorities
Q =What is criteria for assessing strength of treatment studies?
Answer= key criteria for validity in treatment studies is randomization.
70
In addition clinician who are entering pt into a therapeutic trial should be
aware of treatment group to which their pt are being allotted , this is usually
refered to as concealment of randomization list.
Without concealed randomization the validity of study is questionable and
its result may be misleading
Other points to consider when assessing the validity of a study include
following
Were all of pt who entered the trial accounted for its conclusion?
Were pt analyzed in group to which they were allocated(so called intension
to treat analyses)
Were pt and clinician blind to treatment received (a different question to
that of blind allocation)?
Apart from experimental treatment were the group treated equally?
Did the randomization process results in the group being similar at baseline?
Q=psychometric tests are standardized ,psycho logic and measurement
of knowledge, abilities and personality disorder are widely used in
commercial and educational setting for centuries and their population
has continued to increase
TYPES OF PSYCHOMETRIC TESTS=
1=numerical reasoning 2=verbal reasoning
3=inductive reasoning 4= personality questionnaire
5=sale questionnaire
Employers use psychometric test for multiple reasons
1= job performance 2=organizational performance
3=convenience
Q = ethical problems in psychiatric practice
Answer:

71
(1) Doctor patient relationship (transferase and counter transference)
(2) Confidentiality
(3) Consent
(4) Compulsive treatment
(5) Research
Doctor patient relationship is based on ethical principles
1=respect for autonomy(self sufficiency) 2= beneficence
(and non malevolence)
4=justice
Q ABUSE OF RELATIONSHIP
1=impose own values and belief on patient
2=put interest of third parties before those of patient
3=take advantage of pt sexually 4=take advantage of
pt for financial gain
The bond which form in relationship can take three forms
1=vertical model 2=teacher student model
3= mutual participation horizontal model
Q Psychological reaction in doctor pt relationship
1-=transference 2= counter transference 3=resistance
Q= you are called by your colleagues in medicine department who have
recently joined his post graduate training ,you were requested by
physician for help, to break bad news to a recently diagnosed young
man with HIV positive report
Q=name different models of breaking news
1=biopsychosocial model 2=individualized disclosure model
3=full disclosure model 4=paternalistic disclosure model
5= non disclosure model

72
Q =what is best and why=
Answer= Biopsychosocial model is best because it provides clear crisp
evidence based information on pt condition
the bad news is broken using principles of effective communication and
counseling and information
q =what steps are followed in breaking news
Answer=1=steps 1=seating and setting environment
Involvement of significant others
Seating arrangement , be attentive and calm
listening mode availability
step 2=pt perception step 3=invitation step
4=knowledge
step 5=empathy(sympathy) step 6=summarize step
7=plan of action
Q= perception=
Definition= is process of becoming aware of what is presented thru sense
organs.
Perception can be attended or ignored but it cannot be terminated by an
effort of will
Q Imagery is awareness of percept that has been generated within mind and
cannot be called up and terminated by an effort of will
Percept may vary in intensity and in quality, anxious people may
experience sensation as more intense than usual e.g. they may be unusually
sensitive to noise
In mania perception seems more vivid than usual, depressed pt may
experience perception as dull and life less. Our motives (needs and
drives)may determine what we perceive

73
A=motivation and perception B=attention and perception
C=basic perceptual abilities
a=pattern and constancies B=pattern perception
C=perceptual constancies D=shape constancies
E=size constancies F=depth perception G=depth
perception
H= binocular cues I=monocular constancies
J=perception of movement
D =ABNORMALITIES OF PERCEPTION
I=ILLUSION is misinterpretation of external stimulus
2=hallucination
3=pseudo hallucination
E=EXTRA SENSORY PERCEPTION
1= clairvoyance=The term clairvoyance (from French clair meaning"clear"
and voyance meaning "vision") is used to refer to the ability to gain
information about an object, person, location or physical event
throughmeans other than the known senses, i.e., a form of extrasensory
perception.

2=telepathy=the supposed communication of thoughts or ideas by

means other than the known senses
3=precognition=foreknowledge of an event, especially as a form of
extrasensory perception.
4=psychokineses=psychic ability allowing a person to influence
a physical system without physical interaction
Q =what you understand by term biopsychosocial model of health care
and who statrted it?

74
Ans= GEORGE ANGEL in 1970 for first time
started
BIOPSYCHOSOCIAL MODEL
George angel in 1970 for first time started to stress the importance of
integrating the traditional biological (path
physiological or
sciences(sociology, psychology and structural) aspects of medicine
with
behavioral anthropology) and put forward the concept of biopsychosocial
perspective of health and disease
Using system theory(an individual is composed of a complex integrated
system of interacting subsystem of elements of mind , body, spirit and social
relationships and all having feedback loops. He proposed a triad in which the
biological system ensure a structural ,biochemical and a molecular study of
a disease, the psychological system provides an insight into the role of
personality, attitudes, attributes, other dynamic factors whereas a social
system emphasizes the impact of family, social forces, culture and melee on
etiology, presentation and management of illnesses.
It stresses on understanding and manipulation of psychosocial environment
of patent in same way as study of path physiological processes and method of
treatment is used to reverse them.
The death of significant other, grief, loss of self-esteem, a threat to one’s life,
a property or integrity, even victories and reunions were proposed by Engel
as events that can trigger a medical, surgical or psychiatric condition
The biopsychosocial model therefore provides a comprehensive clinical
approach toward practice of holistic medicine. This approach lays great
emphases on doctor pt relationship, psychosocial assessment,
use of
communications skills, informational care, counseling crises intervention
and expansion of care to family. The doctor pt relationship is discussed in
section B while psychosocial assessment is part of section E.

75
One of significant contribution of bps model In health care is emphases it
assigns to use of intervention that does not involve surgery or drugs, the non-
pharmacological interventions
Q =organize a psychiatric medical camp In town of half million
population with a town medical centre having no psychiatric facility
Write down four priority objectives that that you will address during
this camp=
Ans=1=advising and training GPs and their staff 2=assessing and
referring
3=assessing and treating 4=shared care 5=laison meeting
Q =steps involved to achieve these objectives
1=classification of psychiatric disorders in Primary care
2=identification of psychiatric disorders in primary care
3= disorders that are treated in primary care
Person seeking help
↓
Primary care
↓
Specialist care
4=disorders that are referred from primary care to psychiatric services
5= treatment provided by primary care team for acute disorders
6= improving access to psychological therapies
7= treatment provided by primary care team for chronic disorders
8= work in primary care by psychiatric team
Q =state Hippocratic oath
Ans= whatever in my connection to professional practice or not in
connection with it, I see or hear in life of men which should not to be

76
spoken in a foreign country , I will not make known , as estimate that all
such should be kept secret
It was restated in 1948 in declaration of Geneva.
Q =You are posted as a psychiatrist in a flood hit district of southern
Punjab keeping in view the disastrous situation in area
Q In above case what would be most frequent psychological reaction in
affectees
Ans= Crises (intervention)inteinterference
Q =what are common causes of mental handicap in northern Pakistan
Ans=Etiology of mental handicap=
1= Inborn error of metabolism e.g .lipidoses, aminoaciduria and glycogen
storage disease
2-= Chromosomal anomalies like cri du cat syndrome, down syndrome and
fragile x syndrome
3-= TORCH infection like CMV
4=intrauterine exposure to toxins and other insults such As alcohol , hypoxia
and malnutrition
5=post natal exposure to toxin and infection, poor prenatal care, postnatal
exposure to heavy metal , physical trauma and social deprivation
6= amniocentesis= may reveals chromosomal abnormalities associated with
mental retardation in high risk pregnancy in mother more than 35 yrs
Q =what are various complication that you would screen pt with mental
handicap if you are working as a district psychiatrist?
In above case what are various differential diagnoses in above case?
Ans=1= learning and communication disorders,2=sensory impairments ,
3=autistic disorders 4=borderline intellectual functioning in IQ in range of
70-100
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5=environmental disorder
Q =psychosocial aspect of disease=
Psychological aspects of illness and hospitalization .
Diseases and hospitalization are a source of major stress to pt. the severity of
stress and individual response to it have a major role in suffering of pt and
prognoses of illness
Stress due to illness=
Change of role , Financial loss
Stigmatization , loss of self esteem
Fear of being handicapped or of disfigurement , uncertain
prognoses
Intervention= most of factors listed above require a mere explanation and
reassurance based on facts and scientific data and information furnished in
a language best understood by subject and have a major impact on
prognoses of disease and a greater pt satisfaction
2=stress of hospitalization= hospital is a place associated with disease
disability and death that we learn to dread
The word hospital is synonymous with bad news and thus a source of
major stress
Q Anatomy and physiology of stress=
In layout , architecture and design of hospital particularly in public sector
setting is unfortunately far from aesthetic and pleasant,.
The most dreadful and traumatic parts such as traumatic centers , emergency
and intensive care unit are set at very front thus becomes face of hospital.
Stresses relating to hospitalization are thus over and above those of illness .
the common stressor includes , Loss of privacy
Loss of autonomy , Separation from dear ones

78
Need of seeking, , Approval of doctors
The issue of handing over his health matter to group of total stranger
Threat of social dysfunction of family, Unsatisfactory
information
Q =38yr old pt of chronic schyzoprenia , illiterate , married with no
issue is being discharged after 8week stay in your ward , he has
stabilized on flupenthioxol deaconate fortnightly.
A=what intervention can you offer to such a pt beyond drug
treatment?
Answer-= although medication are corner stone of schizophrenia treatment
once psychoses recedes psychosocial treatment also are important these may
includes social skill training= includes focuses on important communication
and social interaction
Family theraphy=
Support and education to families dealing with schizophrenia
Vocational rehabilitation and supported employment=Focuses on helping
people with schizophrenia find and keep jobs
Individual therapy=
Learning to cope with stress and identify early warning signs of relapse and
can help people with schizophrenia manage their illness
Q= a young house officer usually attends educational seminars only if
there is a post seminar lunch or if he knows that there will be a photo
session with chief guest otherwise he either gets himself posted at ER
on that day or reports sick ‘
Explain the behavior of house officer according to b f skinner theory
Ans=this is also known as instrumental conditioning and was established by
work of bf skinner operant conditioning occurs when a behavior that is not
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part of person natural response is learned or unlearned by consequences
for individual in form of reward and punishment
Whereas classical conditioning involves innate or instinctual reflexes.
Operant conditioning explain the learning of voluntary behavior such as
motor action
The famous skinner box demonstrated operant conditioning by placing a
rat in box in which pressing of a small bar produces food .
Skinner showed that rat eventually learns to press bar regularly to obtain
food, this experiment shows that a behavior will occur frequently if given
positive reinforcement and will decrease in frequency by punishment .
master A who was described in beginning of section was instrumentally
conditioned to remain dry by use of buzzer.
The reward that he got in form of chocolate was a positive reinforcement
whereas act of getting up and washing his clothes was a negative
reinforcement
Q Principles of operant conditioning =
1= behavior is determined by its consequences for individual . the
consequences(reinforcement or punishment) occurs immediately following
a behavior
In operant conditioning a behavior that is not part of individual natural
repertoire can be learned thru reinforcement.
The likelihood that a behavior will occur is increased by positive or
negative reinforcement and decreased by punishment and extinction .
Types of reinforcement includes positive (reward) is introduction of a
positive stimulus that result in an increase in rate of behaviuor
Negative reinforcement (escape) is removal of an aversive stimulus that
also results in an increase in rate of behavior

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Punishment=is introduction of an aversive stimulus aimed at reducing rate
of unwanted behavior
Extinction= in an operant conditioning is gradual disappearance of a
learned behavior when reinforcement (reward ) is with held
Q =concept of normality in psychiatry=the difficulty in distinguishing
normal from abnormal behavior has lead to a diversity of approaches
for devising a precise, scientific definition of abnormal behavior
1= an abnormality as deviation from average
2= abnormality as deviation from ideal
3= abnormality as sense of individual discomfort
4=abnormality as an inability to function effectively
Legal definition of abnormality
According to law distinction between normal and abnormal behavior rest
oon definition of insanity which is legal but not psychological
Q =25yr old house wife refuses to leave her home fearing that she will
suffocate in market . however remains symptom free at home
What is most likely diagnoses
Ans= Agoraphobia
Q =in above case what are non pharmacological intervention likely to
explain her?
Ans= CBT=Continue progressive relaxation techniques and graduated
imagined exposure to feared stimulus desensitization has been used
Systematic desensitization works by principle of reciprocal inhibition which
asserts that sympathetic response associated with anxiety is incompatible
with and thus inhibited by parasympathetic response that occurs during deep
muscle relaxation

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Exposure= prolong and repeated in vivo exposure to feared stimulus is by
far the most studied and effective form of treatment for specific phobia ,
cognitive restructuring phobia.
Specific irrational thought may contribute to development of phobia ,
maintain avoidance behavior and contribute to physiological symptoms
Cognitive restrictive treatments help pt to monitor irrational thoughts and
change underlying belief so that they are better able to enter feared
situation
Q = List steps you will put into place to treat her using behavior
theraphy
Ans=Steps=
1=Steps = systematic desensitization=management of phobia
(IRRATIONAL FEAR)
2= Aversive conditioning
Management of paraphilias (e.g pedopilias)
And addiction such as smoking
3= Flooding and implosion=
Management of phobias
4=Token economy= to increase the behavior in person who is severely
disorganized e.g psychoses, autism and mentally retarded
5= Biofeed back = to manage HTN , Reynaud’s disease, migraine , tension
headache , chronic pain, fecal incontinence and temporomandibular joint pain
6=CBT to manage mild to moderate depression, somatoform disorders and
eating disorders
Q =What are neuropathlogical finding in brain in pt with dementia of
Alzheimer dementia?

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Ans= on gross examination= brain is shrunken with widened sulci and
enlarged ventricles .brain weight is reduced
On microscopic examination= cardinal diagnostic features are neurofibrillry
tangles and senile amyloidal plaques in cerebral cortex and many subcortical
regions
Selective loss of neurons in hippocampus and entorinal cortex , glioses
(which is proliferation of astrocytes and loss of synapses which leads to
impairment hirano bodies and granulovacuolar accumulation
Q =18yr old male brought to causality by his family for disruptive
behavior at home and increase use of alcohol threaten to harm you if
you try to examine him
Ans=protect your self , donot approach alone
Call for assistance to manage any situation ,reassure pt , restrain
This should be used as a last resort but when needed it must not be
delayed and must not be attempted in half hearted way
Restraint is usually followed by compulsory hospitalization
And parental medication
It is rarely necessary to continue for more than a few hours
Assess nutritional state and if there is dehydration iv fluids are essential ,
sedation
The most effective drugs are inj chloropromazine 100mg
Inj haloperidol 10-20 mg , Inj diazepam 10mg
Q = What psychosocial issue are experienced in a typical coronary
care unit settings?
Ans= Coronary artery disease is common in people with type A personality
traits who have a characteristics combination of time urgency , excessive
competitiveness and hostility
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It is more in person with high environmental stress and life dissatisfaction
There are chances of more of coronary artery disease in person with less
social mobility and those with personal loss.
These pt when hospitalize to CCU find themselves faced with a situation
when their health and environment is not in their control
For a pt CCU may appear as a chamber of horror and further complicate
his psychological state
However there will be other pt who feel calm and protected in same setting .
The common psychological reaction in pt in CCU setting is 1=anxiety
2=fear
3=distress 4=gloom
This is known to lead into clinical depression in upto one third of pt who
may present with weeping spells , low mood decrease sleep and decrease
appetite and even in no cardiac chest pain. Some of depress pt may however
use defense mechanism of denial ,elated, talkative and found cracking jokes
The co morbid depression and anxiety may delay recovery and adversely
affects short and long term outcome in term of morbidity and mortality. The
long term use of benzodiazepines in cardiac pt as a routine may also
result in bzd misuse, abuse and dependence.
At a social level attendant and family member may be equally anxious and
distress
Their anxiety is often on account of lack of information and awareness
about events taking place inside CCU hidden from their eyes.
INTERVENTION= all CCU should be comfortable, dedicated waiting room
And rest room for family members and attendants
A regular flow of information about pt status and progressed based on
scientific data should be ideally ensured thru a MO or a senior nurse who is
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trained in principles of effective communication, counseling, informational
care
A MO in CCU must actively look for above psychological reaction , make
clinical notes and promptly start treatment and make a referal for
psychiatric opinion
Use of informational care session , counseling and ventilation session
training with pt and family members and progressive muscular relaxation,
hypnoses , meditation and biofeed back for pt are psychological intervention
that can greatly enhance effectiveness of biological treatment and improve
clinical outcome in ccu setting
Opportunity for stable PT IN CCU to interact in group with each other and
share there experience have tremendous therapeutic value.
Group session conducted by doctor , cardiologist to educate pt and for
behavior modification strategies regarding smoking , anger, and stress.
Management can also enhance therapeutic outcome and prevention of
future cardiac events
Q = Enlist various neuro imaging techniques?
ANS = 1 CT 2=MRI
3=PET 4= SPECT
5=EEG 6= EVOKED EEG
Q =What are indication of MRI ?
ANS=1= Brain tumors 2=brain infarction
3=brain hemorrhage 4= lesion of posterior fossa
5 = in spinal cord mri show tumors 6=syringomyelia
7= cord compression 8= vascular malformation
Q = Adverse effects of clozapine ?

85
Ans= 1= in 2% pt leucopenia and then progresses to agranulocytoses and
provide chances for severe infection,
2= at first weekly we check leucocyte count for at least 18 weeks and then 2
weekly and then per monthly
3= hypersalivatiion 4= drowsiness
5= postural hypotension 6= weight gain
7= hyperthermia 8= seizure
9= respiratory and cardiovascular embarrassment
10= myocarditis and myopathy 11= weight gain and
diabetes
Q = Conflict resolution=
Def= are defined as state where two equal strong forces oppose each
other
They arise in situation where individual and group find that they are not
getting what they want or needed e.g. marital conflicts , conflict between
two colleagues
Conflict are inevitable situation and are usually seen in setting where there
is poor communication, power seeking . conflict has the quality to divert
attention from main activities,. Conflict can sometimes be productive
when they are raised in spirit to clarify and sort out important problems
and issues
Q COMMON CAUSES OF CONFLICT IN HEALTH SETTINGS =
1= needs and wants not being met
2= values are being tested e.g .a well female pt reluctant to allow a
male student to examine her 3= perception are
being questioned

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4= assumption are being made e.g doctor assumes that pt knows that his
absence from ward and inability to attend him is on account of
unavoidable academic commitment like attending an international
conference
5= knowledge is minimum 6= expectation are too high
7= personality , race , gender or social class differences exist
Q Methods of conflict resolution =
1= meets conflicts head on
2= set goals that lead to a win situation for both parties in conflict rather
than a victory of one party at expense of other
3= plan for resolving conflict thru free communication
4= be honest about concern and verbalize them as early as possible
5= agree to disagree
6= get individual ego out of negotiation and avoid serving or pleasing one
individual
7= if you are one coordinating dialogue let negotiating team creat
solution rather than vertically handing over solution
People support what they create
8= discuss differences in value openly
Q ==Maslow hierarchy(ladder) of needs=
1= basic physiological needs=
Biological needs for food shelter, water ,sleep, oxygen , sexual expression
2= safety= avoiding harm and attaining security , order and physical safety
3= love and belonging=
Giving and receiving affection , companionship and identification within a
group

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4=esteem and recognition= self esteem and respect of others, success at
work , prestige
5= self actualization
Fulfillment of unique potential
Q = Paget stages of cognitive development=
ans= jean piaget believed that intelligence was an expansion of biologic
adjustment and had a reliable structure
His theory consisted on how children and adolescents think and acquire
knowledge
Stage 1=Sensor motor stage= birth -2yrs
Infant begins to learn thru sensory observation and gain control of motor
function thru activity investigation and operation of environment .
Objective performance is achieved
Stage 2= Preoperational stage= 2-7yrs
Child uses symbols and language more extensively
Children are self-centered and careless for feeling of others , use animistic
thinking , and have a sense of impending justice
Death reversible and lack law of conservation
Stage 3= Concrete operational stage 7-11yr
self-interest is replaced by complete thought therefore they can see things
in other probable
Have the law of conservation death is irreversible at age of 10yr
Stage 4= Formal operational stage= 11- end of adolesenscece= ability to
think conceptually, reason deductively and define concepts , characterized
by hypothetical thinking and deductive reasoning
Q = Name three prominent psychologist who have contributed to
developmental theories
88
Ans= 1 -= Erik Erikson 2= jean Paget 3= Sigmund
Freud
Q = 55 yr old male present to you as an out door patient , you are not
having much of time and ask him to draw a clock which is an
important component of psychometric testing , what interpretation can
draw from this simple test
A ns = it is used for dementia (Alzheimer disease) and cognitive impairment
Q = What other test can you employ to assess organi city in this man?
Ans=1= ct scan
2= T3,T4 and TSH
3= test for Wilson disease
Q = a pt comes to you in opd
He is complaining of that he hear voices from and experiencing ants
crawling under his skin .Can see scorpion on and can smell a foul
odor while drinking water . identify experience of pt in
phenomenological term
Ans=1= auditory hallucination
2= tactile hallucination
3= olfactory hallucination
Q =40 yr old man comes to your opd to say that he is fed up with his
problem of alcoholism and wants to leave it
A= How you will assess that he is dependant on substance=
Ans= electrical levels of in body fluids such as blood and urine
Q =In above case 3 days after you admit him he stats becoming
confused and disoriented he says he can see spiders crawling over
walls what is most likely diagnosis and how you will treat him

89
Ans= Delirium tremens = is a life threatening condition and mortality rate
is 20%
Ans= Medical treatment= it consist of detoxification and treatment of alcohol
dependence
Detoxification= is treatment of alcohol withdrawal symptoms the best way
to stop alcohol is to stop it suddenly
Aim = of detoxification is symptomatic management of emergent
withdrawal symptoms
Drug of choice =
Chlorodiezepoxide 80-200mg daily , Diazepam 40-80mg per day
The dose should be decreased every day before being stopped usually on
tenth day
Vit b 100mg iv bd for five days followed by oral vit b 1 for at least six
months plus antacids
Q Treatment of alcohol dependence= behavioral therapy=
Relaxation techniques=self forceful skill training , self control
Positive reinforcement =
Film of their own drinking pattern is taken and are shown to them
The therapy helps to modify behavior pattern and increase coping ability
and assertiveness in life
Supportive psychotherapy
Individual psychotherapy detergent agents causes sensitization to alcohol
Drug = disulpram 250 –500 mg per day in first week ‘
250 mg per day maintenance dose
Other detergents includes citrated calcium carbonate , antipsychotics
, antidepressants, Lithium , Carbamazepine and narcotics
Q = What is role of amygdale in fear?
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Identify various important nuclei that connect amygdale into a=
papez circuit
B = expression of rage and anger
Ans= Neurobiological mechanism involved in generalize anxiety disorder
are presumably those that mediate normal anxiety
Studies in animals have indicated a key role for amygdala which receives
sensory information both directly from thalamus and from a longer pathway
involving somatosensory cortex and anterior cingulated cortex
Hippocampus is believed to have an important role in regulation of anxiety
Q Papez circuit=
Cingulated gyrus
↓ ↑
Hippocampus ↑
↓ Thalamus
Mamilory bodies ↑
Abnormal activity in amygdale and prepiriform area and psychomotor and
temporal lobe epilepsy and are associated with increase aggression
Poor new learning concerned specifically in Alzheimer disease
Q Kluver buchy syndrome (decrease violent behavior, increase hyper
sexuality and hyper orality )
Decrease conditioned fear response
Q = List five steps which you should follow before administering
rapid tranquilizers for an acutely disturbed and violent patient=
De-escalation techniques used to prevent violence=
1= one staff member should take charge of situation
2= move pt to suitable room to help to reduce arousal
3= make sure that sufficient staff are available
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4= explain to pt what staff are doing and how they hope to resolve
situation
5= attempt to establish rapport show concern and listen attentively ask
open questions
Monitor your own verbal and nonverbal behavior
6= if weapon is involved ask for it to be put in a neutral location rather
than handed over.
Q = 70 yr old man is brought by his family member with a 2yr history
of increasing forgetfulness , irritability and withdrawal , you suspect
that he may have dementia
Q= how confirm your diagnoses=
Ans= screening test for dementia
COGNITIVE FUNCTION= mini mental state examination
Six item cognitive impairment test, seven minute screen
Clock drawing test, Hopkins verbal learning test
Mental test score, Alzheimer disease assessment scale
Cambridge examination for mental disorders of elderly, cognitive section
INVESTIGATION FOR ESTABLISHING CAUSE OF DEMENTIA=
IN PRIMARY CARE= FBC and ESR
UREA AND ELECTROLYTES, LFT
CALCIUM AND PHOSPHATE TFTS, VIT B 12 and folate
In secondary care= MRI or ct brain
Urinalyses, Syphilis serology
HIV scan , Chest radiograph
Neuropsychological assessment
Genetic testing, EEG

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Q = what features in history , physical examination and investigation
are specific to vascular dementia?
Ans =vascular dementia or multi infarct dementia=
Found in 15-30 % pt of dementia
Risk facters= male , advance age, HTN or other cardiovascular problem
affects small and medium sized vessels
Examination may reveal carotid bruit, fundoscopy abnormalities and
enlarged cardiac chambers
MRI may reveal hyper intensities and focal atrophy suggestive of old
infarction
Deterioration may be step wise or gradual depending on underlying
pathology
Focal neurologic symptoms (pseudo bulbar palsy, dysarthria and
dysphagia are most common), abnormal reflexes and gait
disturbances are often present
Treatment is directed toward underlying condition and lessening cell
damage
Control of risk factors such as HTN , smoking , DM , hypercholesterolemia
and hyperrlipidemia is useful. For some pt cardiovascular pathology ,
endarterectomy , correction of sources of emboli and anticoagulant therapy
may be indicated
Thrombolytic agents such as TPA are often given in hope of decreasing
cellular ischemia during first hour of acute ischemia during first hour of
an acute ischemic stroke
Q = 24 yr old student who lives in hostal is brought by his parents .
they report that since past one year he has left off studies and is not

93
taking care of himself as he used to and keep saying that his roommates
are spying on him by listening to him thru electrical outlets
What is most likely diagnoses=
Ans= Schyzoprenia
Q= 134you decide to admit him and start him on antipsychotics , two
days after later he becomes mute and stuprous .Physical examination
reveals high grade fever bp=150/100mmhg
And rigidity, what is diagnoses and how you will treat him
Ans= Diagnoses is Neuroleptic malignant syndrome
Treatment= immediate discontinuation of medication, and physiologic
supportive measures , dantroline and bromocriptine may be used
Q = 50 yr old individual who has been using regularly using
benzodiazepines for last 10yr presents with forgetfulness
The family also reveals that he tends to tell fantastic stories that are
difficult to substantiate
What are possible causes of such a presentation
Identify the path physiological basis of impairment of memory
Ans-= underlying problem is pre senile dementia
Causes are
1=BZD 2= Age over 50yr
Q handy point= = Gerstmane syndrome= confusion , alexia, dyscalculia
and dysgrapia
Q = name two neurological examination for each of them
1=Non dominant parietal lobe=involvement characteristically give rise to
visuo spatial difficulties , with neglect to contra lateral space and
constructural and dressing apraxia
Q Dominant parietal lobe=

94
Receptive aphasia , limb apraxia , body image disorders, right and left
disoreantation, dyscalculia, finger agnosia and agrapia
Q Temporal lobe lesion=
1=Primary auditory cortex = bilaterally leads to deafness and unilaterally
leads to slight hearing loss
2=Wernicks area=
Receptive and fluently aphasia
3= Hypocampus bilaterally leads to inability to convert short term into
long term memory loss
4=Amygdale= kluver bucky syndrome= hyperphagia, hypersexuality
and visual agnosia
5=Olfactory bulb leads to ipsilateral anosmia
6= Myer loops=contra lateral upper quadratonopia
Q =what is meant by culture bound syndrome?
Ans= certain pattern of unusual behavior and restricted to certain culture
have been thought to reflect psychological mechanism of dissociation, some
of these behavior can be classified as culture bound syndrome
This has been criticized because of its ethnocentric implication that all
mental disorder are understood only from a European viewpoint
It is applied to syndrome which is not found in particularly in western
culture e.g eating disorders, chronic fatigue syndrome examples of cultural
syndrome are latah(Malaysia) is characterized by echolalia, echopraxia and
follows a frightening experience.
QAmok(indoneshias and malayshia)= it begins with period of brooding
followed by voilant behaviier and sometimes dangerous use of weapons
plus amnesia is reported afterwards
Some suffer from dissociative disorders

95
Some from mania, schizophrenia or a post epileptic state
Arctic hysteria=(Inuit)= and in women
Pt tears clothes , screams and cries, runs about in distress and may
endanger life by exposure to cold and some time violent behavior
Q =Erik Ericson theory of human development
Determine by adult and childhood experiences and covers infancy to old
age
Crises are turning point of stages
Stage 1=basic trust versus mistrust
Birth to 1yr
Infant develop trust if want satisfied and if mother not attentive mother
will learn to mistrust
Stage2= autonomy versus shame and doubt
Children have a sence of mastery over themcselves and there drives ,they
can be cooperative and stuborn they gain a sence of separation from other
Stage 3 initive versus guilt 3-5yr
Inites both motor and intelectual activity and sexual curiosty present and
sibling jealousy
Stage4= industry versus inferiorty6-11
Child enter program of learning
= Able to work and acquire adult skill and able to master and complete a task
Stage 5 identity versus role diffusion
Group identity , deal with morality and ethics .identity crises occur at end of
this stage which paged call normative
Stage 6= intimacy versus isolation
21-40 YR

96
INTIMACY OF SEXUAL RELATION SHIP AND ALL DEEP
RELATIONSHIP AND ABLE TO CARE SHARE WITHOUT FEAR OF
LOSING SELF
STAGE7= GENERATIVITY VERSES STAGNATION 40-65
HAVING AND RAISING CHILDREN AS WELL ASS OTHER INTEREST
OUTSIDE HOME IF CHILDLESS DEVEPMENT OF ALTRUISM AND
CREATIVITY
STAGE8=INTEGRITY VERSUS DESPPAIR
OUR65YR
A SENSE OF SATISFACTION WITH ONE LIFE, ALLOW FOR A
ACCEPTANCE OF ONES PLACE IN LIFE CYCLE
Q = BASED ON CONTENTS CLASSIFY DELUSION
1=PARANOID, ,REFERENCE,, GRANDIOSE , BIZZARE
,GUILT,NIHILISTIC ,HYPOCHONDRIAL,JEALOUS ,RELIGIUOS ,
CONCERNING POOSSESSION OF THOUGHT,
THOUGHT INSERTION, WITHDRAWAL AND BROADCASTING
Q DELLUSIONAL PERCEPTION IS INCLUDED IN SHNEDER
FIRST
RANK SYMPTOMS
Q PROGNOSES OF SCHYZOPRENIA
REPEATED PSYCHOTIC EPISODE AND CHRONIC DOWNHILL
COURSE
ILLNESS OFTEN STABILIZES IN MIDLIFE
SUICIDE COMMON
50% ATTEMPT SUICIDE DUE TO POST PSYCHOTIC DEPRESSION OR
HAVING HALLUCINATION COMMANDING THEM TO HARM THEM
AND 10 % DIE IN THOSE ATTEMPT
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PROGNOSES IS BETTER THE SUICIDE RISK IS LOWER IF PT IS
OLDER IN ONSET OF ILLNESS ,IS MARREOID ,HAS SOCIAL
RELATIONSHIP,IS FEMALE V AND HAS A GOOD EMPOLIYMENT
HX ,HAS MOOD SYMPTOMS HAS FEW NEGATIVE SYMPTOMS AND
HASS FEW RELAPSES
Q = Stupor used in psychiatry refer to a condition in which pt is
immobile, mute, unresponsive but appear to be full conscious in that eye
are usually open and follow external objects, if eye close pt resist
attempts to open them
Reflexes are normal and resting posture is maintained stupor may
occur in catatonia
Q =Theories of human development
1= chase and Thomas showed that there are endogenous difference in
temperaments of infant and that remain quite stable for first 25yr of life
These difference include such characteristics as reactivity to stimuli
responsive to people and attention span , Early children are adaptable to
change ,show regular eating and sleeping pattern and have a positive mood
B=different children show behavior opposite to those of easy children
C =slow to warm children show behavior of different children at first but
then improve and adapt with increase contact with others
2=sigmoid Freud=
Development in term of part from which most pleasure is derived at each
stage of development
3=Erik Eriksson=Development in term of vital period for achievement of
social goal
If specific goal at specific time not achieved at specific age difficulty in
achieving goal in future
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4=jean piaget development in term of learning capabilities of child at each
age
Jean piaget believed that intelligence was an extension of biologic
adaptation and had a logical structure
His theory consisted on how children and adolescence develop and think?
Stage 1= sensor motor stage birth to 2yr
Infant begin to learn thru sensory observation and gain control over
function motor thru active exploration and manipulation of environment
Object performance is achieved
Stage 2= preoperational 2-7yr
Child uses symbols and language
And egocentric and uses animistic thinking. Death is reversible
STAGE3= CONCRETE OPERATIONAL STAGE7-11YR
OPERATIONAL THOUGHT REPLACE EGOCENTRICITY
HAVE A LAW OF CONSERVATION AND DEATH IS IREVERSIBLE AT
10YR
STAG 4= FORMAL OPERTIONAL STAGE 11- END OF ADOLESENCE
conceptual THINKING AND DEFINE CONCEPT
HYPOTHETICAL THINKING AND DEDUCTIVE REASONING
Q =Objective and projective personality test
For assessment of pd
Objective=MMPI, MMCI, Projection= Roshash
test
TAT test, Sentence completion test
Q pervasive developmental disorder
Gp of disorder in which abnormalities in communication
Social interaction
99
Restricted activities
And interest
And occur in wide range situation and is usually abnormal since infancy
and manifested before 5yr
Q Etiology of Autism
CNS damage . encephalitis
Rubella maternal.
PKU, tuberous scleroses
Fragile x syndrome
Perinatal anoxia
Q =Clinical features of Autism
Qualitative impairment in social interaction , communication, imagination
and interest
Social=lack of peer relationship
Failure to use nonverbal cues
Communication strange speech and MR 75% abnormal EEG seizure
abnormal brain morphology
Course
30% autistic become semi dependants in adulthood
Seizure in 25%
Physical exam
Self injuries due to heads banging and biting
QTreatment
Family counseling, Special education
Newer antipsychotic to control severe agitation and self harming behavior
Ddx MR
Hearing impairment Selective mutism

100
Rett syndrome Asperger syndrome
Q pt with Hiv Aids Psychological stressor Aids pt must deal with
particular physiological stressor not seen together with other disorder
These stress include fatal illness
1=feeling guilty about how they contract illness sex with multiple partners
,iv drug and about infecting others and being met with fear of contagious
from medical personnel, family and friend
2= HIV pt who as homosexual may come out n
3= medical and psychological testing can reduce psychological and medical
risk
4=mental Illness may result from due to infection of brain while other
opertunistc infection liker cryptococal meningitis and cerebral lymphoma
B=contagious
1=if they comply with acceptable method of infection control hiv positive
physician do not risk transmit virus to there pt
2=few health worker have contracted hv frm pt
Needle transmisssiion is most common way of transmission
Q =what is clasiccal conditioning and who describe it
Ans=1 =Robert 2= Nicolas 3=shepherd Siegel
Q =Describe classical conditioning
In classical conditioning a natural or reflex response (behavior )is
elicited by a learned stimulus this type of learning is called associative
learning hippocampus and cerebellum are involved in classical
conditioning
Elements of classical conditioning are 1=unconditioned stimulus
2=unconditioned response
3= conditioned stimulus
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4= conditioned response
Q = what are schedules of reinforcement=
ans=1=continuous=presented after every response 2=fixed ratio=
presented after a selected number of responses
3= fixed interval = presented after chosen amount of time
4=variable ratio=presented after a random number of responses
5= variable interval = presented after random amount of time
Q = 7yr old boy who has not been able to to progress in school studies
is brought for assessment.,
What psychometric test you would advice what is likely clinical profile
of a child with an iq of 70?
Ans= psychometric test= intelligence test IQ measures academic
performance
IQ = MA/CA multiply by 100= result
Mean iQ-=100
SD= 15
Adult weshler adult intelligence scale revised (wais –R)
Children -= weshler intelligence scale for children revised (wisc –r)
Stanford binet test
Personality test use simple stimuli, do not needs much clinical
experience=Minnesota multiphase personality
inventory(mmpi)projective test use ambiguous stimuli need clinical
experience .not diagnostic.
Rascal test=inkblot test
Thematic apperception test (tat)
Sentence completion drawing

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Neuropsychological tests= used to detect organ city from any
psychiatric disorder=bender gestalt
Lutia –Nebraska
Halted- reitan
Clinical profile of child with an IQ OF 70
ANS= mild MR WITH IQ OF 50-70
Attains academic skill upto sixth grade level, often live independently in
community or with minimal supervision may have a problem with impulse
control and self esteem and may have associated conduct disorders,
substance related disorders and ADHD
Q mother bring her four yr old child that has been found talking to
furniture .it seems that he thinks that he thinks table and chair are like
human being and can be good or bad
Keeping in mind the cognitive developmental theory of piaget hich stage
is child in ?
What are features of stages to follow?
Ans=child lies in preoperational stage FEATRURES OF STAGE
FOLLOWING ARE STAGE 3 CONCRETE OPERATIONAL STAGE AND
STAGE 4 FORMAL OPERATIONAL STAGE
Q =you have seen a pt suffering from depression who does not wants to
be treated by drugs and wants psychological treatment
What psychotherapy would you give him
Keeping the evidence born in mind which is ideal choice of treatment
that you will offer , how you will make individual understand this
disease using format base of therapy
Ans=Prognoses=psychotic features =worse prognoses
Atypical features= increase weight , increase apetite and increase sleep
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Treatment=must first secure safety of pt given that suicide is such a high
risk pharmacotherapy includes antidepressants such as SSRI,TCA or MAO
ECT may be indicated if pt is worried about side effects from medication
Individual psychotherapy is indicated to help pt deals with conflict or sense
of loss etc
Another form of therapy is cognitive therapy which will change pt hazy
thoughts about self future and world etc
DD= Medical disorders-=1= Hypothyroidism
2=Parkinsonism 3 =Dementia and pseudo dementia
4=Tumors and CVA
Mental disorders=
Mood disorders and substance disorders and grief
Q INTELIGENCE=
Capacity to interpret experience and learn from it and to modify behavior
in light of it
Q INTELIGENT QUITIENT
= mental age/chronological age multiply by 100
Weshler adult intelligence scale
It is standard and most widely used intelligence test
It was founded by weshler
Q ALCOHOLICS
Are defined by WHO as those excessive drinkers whose dependence upon
alcohol has attained such a degree that interfere with bodily and mental
health and social and economic functioning
Both alcoholics and heavy drinker are social problems and are economical
burden to society

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True alcoholic is unable to stop his alcohol drinking because of inner
feeling compel him to drink alcohol
Q CRAVING=Is term used for inner feeling which compels alcoholic to
drink alcohol
Q CAUSE OF ALCOHOLISM=
1= Environmental and social causes 2= Drinking
campaigns
3= Frustration at work 4=Drinking at
social drinking
5=Domestic problems
Q ALCOHOL RELATED PROBLEMS
1=Crimes 2-=Traffic accidents
3=Broken family
4= Absentism(non-attendance)
Q CHILD ABUSE
1=physical violence 2=sexual abuse
3=neglect and deprivation 4= mental and emotional
treatment
Q Contributing facters of child abuse are 1=poverty
2=alcohol 3=loneliness
4=immaturity
Q PREVENTION OF CHILD ABUSE
1=STUDIES have shown that provision of supportive home visitors can
stop child abuse from happening 2=
increase legal help

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3= education, postponing the children until they are sufficient mature
so that they may be adequate parents 4= support
individual and families
Q JUVENILE DELINQUENCY
A delinquency means child who has done crime
Juvenile means boy who has not attained age of 16yr or girl who has
not attained a age of 18years
Juvenile delinquency is not merely juvenile crime
Also include all deviation from normal behavior and include adults who are
habitually disobedient and they leave their home and desert there home and
mix with immoral peoples and they also have antisocial and behavioral
problems
Q CAUSES of juvenile delinquency=
1=BIOLOGICAL CAUSES=
Hereditary defects , Physical defects
Glandular imbalance
Chromosomal anomalies might be associated with tendency for JD and
crimes especially XYY men suffers from severe disturbance of whole
personality
SOCIAL CAUSES
Broken home e.g. death of parents , separation of parents
Poverty Alcoholism
Parental neglect too many children’s
ABSENCE OF RECREATION, URBANIZATION
INDUSTRIALIZATION, CINNEMAS AND TELEVISION
Q PREVENTIVE MEASURES
1= IMPROVE FAMILY LIFE
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2= HEALTHY TEACHERS
AND CHILD RELATION becoz school comes next to home in determining
the behavior of children
3=SOCIAL WELFERE SERVICES
A=RECREATION FACILITIES B=CHILD GUIDANCE AND
EDUCATION TO PREVENT CRIMES
Q BATTERED BEBY SYNDROME
A clinical condition in which young children received non accidental
trauma or injury on one or more occasion and may be minimal as well as
fatal trauma either due to parental deprivation or guardian deprivation of
nutrition and care
Q GENETICS= science that deals with underlying causes of
resemblances and differences
Over 2300 disease are genetically determined
Father of genetics is Mendel
Q CLASSIFICATION OF GENETIC DISORDERS
1=CHROMOSOMAL ABNORMALITIES
2= UNIFACTORIAL DISEASE
3 =MULTIFACTORIAL DISEAES
1=CHROMOSOMAL DISORDERS= INCLIUDE
DOWN .TURNER AND KNILFILTER SYNDROME AND SUPER
FEMALE AND XYY SYNDROME
2= UNIFACTORIAL DISEASE
AUTOSOMAL DOMINANT INCLUDES
PCKD
Autosomal recessive is Maple syrup urine disease
Sex linked dominant = Rickets
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SEX RECESSIVE = HEMOLPHLIAS
MULTIFACTORIAL DISORDER
HTN , DM . SCHYZOPRENIA AND PEPTIC ULCER
Q GENETIC COUNSELLINGS=
1=perspective= FIRST identify heterozygous individual for a defect and
then prevent the marriage of heterozygote like in thalaesmia and sickle cell
disease
2=retrospective
Hereditary disorder has already occurred in families
Method suggested at genetic counseling centers are
1=contraception
2=pregnancy
3-=termination
4=sterilization
Q Consanguinity=
Prevention of cousin marriages are called consanguinity and these cousin
marriages should be avoided
LATE MARRIAGES ARE AVOIDED
Q EUTHENICS=
1=IMPROVEMENT OF ENVIROMENTAL CONDITION
2=IMPROVEMENT OF GENOTYPE
Q REHABILITATION= it means to train the disable person to make
the best use of what has remained over after disability
AIMS= to restore to near normal functioning capacity
1=medical rehabilitation=
Means restoration of function. if TB has spread to knee joint physiotherapy
and surgery are done to restore and correct it
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2= vocational rehabilitation=Restoration of capacity to earn livelihood
3=social rehabilitation= restoration of family and social relationship
4=PSYCHOLOGICAL REHABILITATION= restoration of confidence
and encourage to return to normal capacity
Q LEGAL COMPETENCE
DEFINITION=1 TO BE LEGALLY COMPETENT to make health care
decision the pt must understand risks , benefits, and likely outcome of such
decision
2 all adults above 18yr are assumed to be legally competent to make
health care decision for themselves
Minor=is person younger than 18yr are not considered legally competetent
Emancipated minor are people under 18yr who are considered legally
competent adult and can give consent for their own medical care
3=to be considered an emancipated minor individual must meet at least
one of following criteria
A=Be self supportive
b= Be in military
c= Be married
D=Have a child to whom she cares
C= Question of decision making capacity and competence
1= in an adult competence is in question e.g. a person with MR or dementia
a pysicain involved in this case can evaluate and testify to capacity of pt to
make health care decision however only a judge ( with input from pt family
and physician ) can make the legal determination of competence
2=if decision to be found to be incompetent a legal guardian will be
appointed by court to make decision for that person .the legal guardian may
be or may not be a family member

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3= a person may meet a legal standard for competence to accept or reject
medical management even if she is mentally ill has MR or is inconsistent in
other areas of her life e.g finances
4=mmse correlates to some extent with clinical evaluation of pt capacity
while a total score of 23 or higher suggest competence and a total score of 18
or lower sugest incompetence the mmse score alone cannot be used to make
a determination of legal competence
Q =Death ,dying and bereavement
Based on stages developed by Elizbath Kobler Rose.she believes that
dying person did not follow a regular series of responses that could be early
identified
These stages do not occur in order
1=Shock and denial 2=Anger 3=Bargaining
4= Depression 5= Acceptance
STANFORD BINET CALCULATE IQ AS =
MA/CA MULTIPLY BY 100= RESULT
Q SIMPLE LEARNING=
INCLUDES-= HABITUATION AND SENSITIZATION
HABITUATION =REPEATED STIMULATION LEADS TO DECREASE
RESPONSE
SENSITIZATION=
REPEATED STIMULATION LEADS TO INCREASE RESPONSE
Q CLASSICAL CONDITIONING== to learn classical conditioning we
have Pavlov experiments with dogs
In this experience first of all Pavlov present food along with bell .later on
simple bell ring may cause dog to increase salivation
This is a type of learning

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Q OPERANT CONDITIONING
It is also a type of learning
In this particular action gives reward
Two type
1=positive reinforcement 2= negative reinforcement
Positive reinforcement= desire award produces action
NEGATIVE REINFORCEMENT= removal of aversive stimulus elicits
behavior
PUNISHMENT=Application of aversive stimulus finishes unwanted
behaviuor
EXTINCTION=Discontinuation of reinforcement eliminates behavior
types of reinforcement cause production of desired action and remove
unwanted behavior
q imm=REINFORCEMENT SHEDULES=
Continue = reward received after every response and rapidly extinguishing
VARIABLE RATIO=
Reward received after random numbers of responses =slowly extinguished
TRANSFERANCE=
Pt projects feeling of imp formation on doctor
COUNTER TRANSFERANCE=
In doctor projects feeling about important formation on another person on
pt
Q FREUD STRUCTURAL THEORY OF MIND=
Aim of Freud==Central goal of Freud was to make pt aware of what was
hidden in his or her unconsciousness
Id means drives instincts
1=primal urges 2=sex and aggression 3=food

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Entirely subconscious
EGO= mediator between primary urges and behavior in reality
SUPEREGO=
MORAL VALUES AND IS IN CONSIUOSNES AND CAN lead to self
blam And ATTACK ON EGO
Q INSTINCTS= IS COMPLEX OF UNLEARNED RESPONSES THAT
IS CHARATERISTIC OF SPECEAS
Id derives instincts present at birth.
There can be only two derives, sex and aggression
EGO= defense mechanism, judgment , relation to reality and develops
shortly after birth
SUPEREGO=
Conscious formed during latency period
Q DEFENCE MECHANISM=
THE WAY IN WHICH EGO PROTECTS against anxiety and control
instinctive urges and unpleasant emotion
Defense mechanism are unconscious(suppression which is conscious
processes) and discrete ,dynamic and adaptive and maladaptive
Q TYPES OF DEFENSE MECAHNISM=
Attributing own thought and feeling on someone else
e.g. I m sure that my wife is cheating on me
or it is defined as an un acceptable internal stimulus is attributed to
external stimulus
for example= a man who wants another women thinks his wife cheating on
him
DENIAL= common reaction to pt of AIDS OR CANCER PATIENTS

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DEFINITION= used to avoid becoming aware of some painful aspect of
reality
SPLITTING=External objects are divided into all good and all bad
e.g morning staff is good than evening staff
some one believes that all nurses are cold and all doctor are warm and
friendly .seen also in borderline personality disorders
BLOCKING=Temporary block in thinking
e.g. I cannot seems to remember his name
REGRESSION=Return to earlier stages of development
Which is immature stage seen in children at under stress for example
bedwetting
SOMATIZATION=
PSYCHICS STRUCTURES ARE converted to physical symptoms e.g just
thinking if exam I got butter flies in my stomach
INTROJECTION=Features of external world are taken and converted to
bodily symptom e.g resident physician dresses like an attendant
DISPLACEMENT=
Process where by avoided ideas and feeling are transferred to some neutral
person e.g mother places blame on child because she is angry on his
husband

REPRESSION=
An idea is removed from conscious to unconscious
e.g I don’t remember having had a dog
INTELLECTUALIZATION
Excessive use of intellectual process to avoid affective expression

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e.g pt suffering from end stage disease says that specific symptoms of skin
developed due to end stage disease
ISOLATION OF AFFECT-= separation of feeling from ideas or events
e.g as she arrived to station to identify body she appear to show no emotion
RATIONALIZATION-=
Rational explanation are used to some extent to avoid self blam e,g I did not
pass test as it was very difficult
REACTION FORMATION=
DEFENCE MECHANISM IN WHICH person assumes attitude
reverse of his wishes
e.g. listen to him tell his family he was not afraid when I saw him crying
ACTING OUT
Behavioral and emotional outbursts e,g I cannot explain why he has those
temper tantrums
UNDOING= acting out reverse of an unacceptable behaviuor
e.g I need to wash my hands whenever I have these thought
HUMOR=
Appreciating assuming nature of adverse situation
e.g nervous medical student jokes about boards
SUBLIMATION=it is most mature of defenses
Defense mechanism in which consciously unacceptable drives are
converted in to personality and socially acceptable channels
SUPPRESSION= conscious forgetting only conscious defense mechanism
e.g. I would rather forget that my dog
DISSOCIATION= splitting of brain from its consiuios awareness,e.g I
don’t know where I live
Q -=THEORIES ON HUMAN DEVELOPMENT
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Erik Eriksson=
HE believed that human personality was determined by childhood and
adult experiences
His theories of human development cover infancy to old age
His stages are determined by crises which are turning point of stages
STAGE1= BASIC TRUST VERSUS MISTRUST
Infant develops feeling of trust if these wants and needs are satisfied. if
mother is not attentive infant will learn to mistrust from birth to 1year
STAGE 2= AUTONOMY VERSUS SHAME AND DOUBT(1YR -3YR)
Children have sense of mastery over themselves
They can be cooperative and stubborn
They gain there sense of separation from others
STAGE 3= INITIATIVE VERSUS GUILT(3-5YRS)
Children initiates both motor and intellectual activity
Sexual curiosity is present ( curiosity means that they want to know about
sex)
Sibling rivalry (it is competition between brothers and sisters and friends)
STAGE 4 INDUSTRY VERSUS INFERIORITY(6-11 YEARS)
Child enters into learning and wants to acquire adult skills children learn
they are able to master
STAGE 5= IDENTITY VERSUS ROLE DIFFUSION(11- END OF
ADOLESENCE) THEY identify and deals with morality and ethics
Normative =identity crises occur at end of this stage which paiget called
normative
STAGE 6=INTIIMACY VERSUS ISOLATION(21-40YR)they develop
intimacy ,friendship relation and ability to share without fear of losing self
STAGE7=GENERATIVITY VERSUS STAGNATION=(40-65)

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Having and raising children as well as other interest outside home
If childless development of altruism and creativity
STAGE8=INTEGRITY VERSUS DESPAIR=(ABOVE 65) sense of
having satisfaction in ones life

Q PIAGET has theorized that how children and adolescents think and
acquire knowledge
STAGE 1= SENSORIMOTOR STAGE(BIRTH TO 2YEARS)
INFANT BEGINS TO LEARN THRU SENSORY OBSERVATION AND
GAIN CONTROL THRU MOTOR FUNCTION THRU ACTIVITY
Stage2=PREOPREATIONAL STAGE(2-7 years) child uses symbols
and ,language more extensively
Children are egocentric use animistic thinking( egocentric means
preoccupied with ones own thoughts) and animistic thinking means
behavior is control by soul and say death is reversible
STAGE 3= CONCRETE OPERATIONAL STAGE(7-11YR)
egocentricity is replaced by operational thought
Death is irreversible
STAGE 4=FORMAL OPERATION STAGE
Ability to think conceptually reasoning and define concepts
Q SIGMEUD FREUD=
HE believed that child is influenced by sexual drives
Stage1=oral stage(birth-18month) mouth is main site for deriving
pleasure and is manifested by chewing, biting and sucking
STAGE 2= ANAL STAGE
AT this stage anus is site of obtaining pleasure
They can control their bowel and bladders
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If harsh toilet trained they become anally fixated(obsessive compulsive
personality disorder)
STAGE3=PALLIC STAGE(3-5 YEARS)
Penis is stage of gratification
They fear of castration at this stage
Increase in penile masturbation with fantasies involving opposite sex
parents=oepidel complex
STAGE 4= LATENCY STAGE=5-12 YEARS
Formation of super ego and resolution of oepidal complex
STAGE 5= GENITAL STAGE 12- ADULTHOOD)
Capacity for true relationship
Q LEARNING DISORDERS= IS condition in which learning in specific
areas are below average and below expectation
Etiology=1= cerebral palsy 2=lead poisonings 3= fetal
alcohol syndrome
PRESENTING SYMPTOMS
5% of school children, conduct disorder
Opposite defiant disorder , ADHD
1=poor self esteem 2= social immaturity
3= behavioral disturbances 4 -= occupational dysfunction if persists
into adult hood ‘
Q DIAGNOSES=IQ PLUS ACADEMIC ACHIEVEMEMNT TEST
TREATMENT=1=SPECIAL EDUCATION 2=PARENT
COUNSELLING
TO IMPROVE SELF ESTEEM AND SOCIAL BEHAVIUOR
Differential diagnoses=1= Mentally retarded
2= HEARING AND VISION IMPAIRMENT

117
Q = Explain following defence mechanism with examples=
A =Displacement= an emotion is shifted into another that resembles original
in some aspects e.,g I had to get rid of dog since my husband kicke it every
time we had an argument
RATIONALIZATION= rational explanation are used to justify un
acceptable attitudes , beliefs or behavior
E,g= I did not pass test because it was very difficult
REPRESSION= an idea is withheld from consciousness ,an unconscious
forgetting e.g. I do not remember having had a dog
Reaction formation= an un acceptable impulse is transferred into its
opposite resulting in formation of character traits e,g listen to him tell his
family he was not afraid when I saw him crying
Projection = attributing own feeling onto someone else
E.g. I am sure my wife is cheating on me
Q =You see a 16yr old pregnant girl who discloses that she murdered
a person last year
now she appeared in court and judge ask you to break confidentiality
a=Will it be ethical to break confidentiality
ans=yes
b= what are situation when you break confidentiality?
Ans=if pt is a threat to self or other physician must break confidentiality
Duty to warn and duty to protect(tarasoff decision)
Suicide , homicide and abuse are obvious threat
C= Q =can you break confidentiality after death of a person
Ans =No
D =Q =she does not want tell her parent about pregnancy . will you tell
her parents without her permission ?

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Ans = yes
E=Q = will you inform police about her murder
Ans= yes
Q = Ethical problem in psychiatric practice=
Or Ethical dilemmas in doctor life=
In this we shall discuss ethical problem related to 1-=doctor pt relationship
2= confidentiality 3-=consent 4= compulsory treatment
5= research
Doctor pt relationship= it is a relationship of trust between doctor and
pt and is basis of ethical medical problems this is on basis of four
principles
1=autonomy 2=beneficence 3=non malevolence 4=justice
Abuse of relationship
1= impose their own values and belief on pt
2= put Interest of third parties before those of pt
3=take advantage of pt sexually 4= take advantage of pt for financial
games
5= accepting gift from pt
6= charges and fee pt , colleagues’ , teachers and medical students
7= E- consultation and telemedicine
8=media and medicine
9=euthanasia and physicians assisted suicide
10 relationships with pharmaceutical company
Q = what are types of tests to assess personality=
Ans=1=objective test
2=projective
Q -=what are three projective test to assess personality?

119
Anns=1= Rosarsh test also called as ink blot test
2= Thematic apperception test
3= Sentence completion test
Q = how do projective test far as regard their reliability and validity=
Ans= projective test use unclear stimuli, needs clinical experience, not
diagnostic
Q = comment on use of projection test in diagnoses of mental illness
Ans== 1=dementia
2=achievement
3=academic performance
4= intelligence
Q = young man laborer residing in unhygienic condition suddenly
developed headache, moderate fever and in a few days become drowsy
His neck is rigid reflexes’ are intact with planters down going
temperature 101 f pulse 100 and resp rate -=21/min
Systemic examination NAD SKIN NO RASH peripheral blood
examination TLC= 8000. Normal DLC., platelets are 25000000 esr =
12mm/ist hour
Csf examination shows protein 30mg % glucose 50%
Microscopy reveals predominantly lymphocytic picture what is most
likely diagnoses== ANS=viral meningitis
Q = justify diagnoses=
Ans= since pt is residing in unhygienic condition so its may be tuberculoses
TBM
But sudden history shows viral since glucose is raised and protein is also
raised these are showing viral meningitis also csf shows lymphocyte there

120
can be two DDx tuberculous or viral but viral meningitis is most probable
diagnoses
DD INCLUDES
1= BACTERIAL meningitis includes TBM and meningococcal meningitis
2= viral encephalitis 3= cerebral malaria
Q = how you will investigate to come to a final diagnoses and give
likely finding of each investigation?
Ans = 1=CT brain 2= MRI 3=CSF RE and LP
BACTERIAL = GLUCOSE DECREASED protein Increased neutropilias
Viral = glucose incressed , Protein decreased, Lymphocytes
raised
Tbm = glucose decreased , Protein increased and lymphocytes raised
Q =senarios in which treatment for OCD presented in ER for a
sustained conjugate deviation of eyes upward to one side .conditon is
painful and uncomfortable
Answer DDx include 1 =acute dystonia 2=bradykinesia
3=akathesia
4 tardive dyskinesia 5=NMS
6=blephrospasm
7=torticollis 8=writer cramp
Q Managment of Acute dystonia
1=Antcholinergic such as benztropine , Trihexyphenoidyl
Q = 30yr old man was brought to psychiatric opd with history of
change in behavior he says American CIA was after him and thought of
him as terrorist they were taping his telephone and cameras were
placed in his room to monitor his activities

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He suspected that certain news in newspaper was in fact about him
and he felt endangered about his life, he also sometimes heard them
talking about him .
He had low mood decrease sleep decrease appetite
On physical examination and systyemic examination NAD. He did not
admit to have taken any psychoactive drugs
Q = give three differential diagnoses
1=Delusional disorders 2= Organic states 3= Affective disorders
4= schizophrenia
Q = what psychoactive drug of abuse can cause such a clinical picture
of hallucination in pt
Ans hallucinogens 1-= LSD 2= Mescaline 3= Psiloyibaiin
4=MDMA
Q = name three psychometric test that you employ in this case
Ans= PANNS SCALE, IQ TEST, MMSE
NEUROPSYCHIOLOGICAL TESTS
Q = briefly describe freud stages of psychosexual development?
Ans=sigmeud freud= freud beleived that children were influenced by sexual
drives
He noted that infant were capable of sexual activity from birth, initial
stages being non congenital
Stage 1= oral stage (birth – 18 months)
The mouth is main site of gratification and is manifested by chewing, biting
and sucking
Stage 2-=anal stage 2=(1-3 years)

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The anus and surrounded areas are main site of gratification primarily
involved in bowel function and bladder control, if harsh toilet training child
may become anally fixated (ocd personality disorder)
Stage 3=phallic stage (3-5 yrs)
Genital area is main site of gratification,
Penis envy and fear of castration are evident during this stage , Increase in
genital masturbation with fantasies involving opposite sex parents, oepidel
complex
Stage 4-=latency stage 4=(5-13yr)
Formation of super ego, resolution of oedipal complex , sexual interest
during this period are believed to be quiescent. Sublimation of sexual
energy into energetic learning and for playing activities
Stage 4= genital stage= (11- to adolescence)
Capacity for true intimacy
Q = what Is perseveration of thought?
Ans= is persistent and inappropriate repetition of same thought.
This disorder is detected by examining person words
Thus in response to series of simple question the person may give correct
answer to first question but continue to give same answer to subsequent
questions
Perseveration occurs in dementia and frontal lobe injury
Q -=echolalia= psychopathological repeating of words or phrases of
one person by another
Q = what are overvalued ideas
It is a comprehensible and understandable idea which is pursued beyond
bound of reason. It may preoccupy a person life for many years and affect
there action

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Q = Delusional perception= some time delusion is attached to normal
percept e,g the position of letter that has been left on pt desk may be
interpreted as a signal that he is to die
Q = Incongruency of mood = The delusion that is out of keeping with
prevailing mood is mood incongruent mood and is suggestive of
schizophrenia
Q ==waxy flexilbity= Part of body can be placed in position that will be
maintained for long period of time even if very uncomfortable
Q = depersonalization= a dissociative disorder characterized by trouble
feeling of detachment from ones body or thought not secondary to
another mental disorder
Q =Reflex hallucination= is a rare phenomenon in which a stimulus in
one sensory modality results in a hallucination in another e.g. music
may provoke visual hallucination
Q ABSTARCT THINKING=
ANSWER= similarities and proverb understanding
Q 30 yr old man came with his wife who is a pt of scyzopreninia its
genetic transmission so that plan to have a child. What will be your
response in light of genetic theories of etiology of schyzoprenia?
Ans= genetic bases of schyzoprenia already discussed in previous scenarios
Q = young women presented at ER with his eyes rolled upward ,
tongue protruded and with spasm of neck muscles, and unable to sit at
one place.
He was taking one milligram of trifluperazine for last one week
What is most probable diagnoses?
Answer= EPS (ACUTE DYSTIONIA )
Q = what is neurological basis of this condition
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Answer= older antipsychotics are associated with high incidence of extra
pyramidal syndrome, newer antipsychotic medication causes minimal or
no eps
Low potency antipsychotics medication( chlorpromazine and theoridazine
cause less EPS than high potency older antipsychotics medication but has
more sedative effects
Q = list 4 intervention in order of priority that you may use to
manage this condition .
Ans=1= stop older antipsychotic and if TARDIVE DYSKINESIA
develops use newer antipsychotic medication
2= anticholinergic like benztropine and diphenhydramine 3=diazepam
4=kempro (procyclidine) 5=ECT
Q =echopraxia= pathological imitation of movement of one person by
another
Q = you are treating a pt with bipolar disorder, you opt for lithium
carbonate for long term prophylaxes A=what protocol should
followed before starting treatment
Ans= do TFT, SERUM UREA, SERUM CREATI NNE, GFR, ECG
,PREGNANCY TEST
Q = how you will manage this ?
Ans= give thyroxin 50ug per day and maintain lithium below 1.5 meq per
litre
Q = 35 YR OLD MO present with two month history of feeling of
impending disaster and as if he will go mad ,. The episode often wake
him up around 4;00 am this is first time that he has experienced these
episodes
Q= what will be DD In this case?
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1=panic disorder 2=generalize anxiety disorder 3= night mare
4=phobia 5=hyperthyroidism
B =list five investigation that you will request for?
Ans=1=TFTs 2-= RBS 3= CATECHOLAMINES
4= ECG 5=ECHO
Q = list five suggestion
Ans=1=Relaxation techniques 2=Deep brain stimulation
3=Prolong muscle relaxation 4= Inderal 5= Benzodiazepines
Q = 40 yr old male is being treated with 40 mg thioridazine daily, he is
now suicidal and is being prepared for ect under GA,
A= What necessary work up is required before started before ect?
Answer =stop thioridazine and then give ect
B -= what machine setting will you change if pt was on 40 mg of
flouxetine
Ans= decrease seizure threshold so decrease millicoulombs
Q = middle aged recently married presented with history of inability
to accomplish marriage? What are key areas in history and examination
that you will assess?
Answer= assessment of sexual dysfunction= define problem (ask both
parteners) origin and course , ,
Prior base line sexual function
With other partners? , Sexual
drives
Knowledge and fears , Socially
relationship generally
Relationship between partners ,
Psychiatric disorder
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Substance misuse ,
Medical illness , medical or surgical treatment
Why seek help now?
Physical examination
Laboratory tests
Q = Psychological causes of erectile dysfunction in an individual ?
Ans=Stress or anxiety from work or family responsible, concern about
sexual performance, conflict in relationship with partners
Depression or anxiety unresolved, sexual orientation issues ., previous
traumatic sexual or physical experience, body image and self problems
Q = 47 yr old lady presents with severe headache for last six months,
episodic in nature and at times pt feels nauseas and photophobia when
headache becomes severe
Q = what are likely differential diagnose?
1-=Migraine 2= SAH 3= Meningitis and
encephalitis
4= Subdural hemorrhage 5= Tension headache 6= Cluster
headache
Q Treatment of headache=
Treatment of migraine, paracetamol 1gm
Or aspirin 900 mg , Ibuprofen 400-600 mg
Antiemetic metochlopreramide 10 mg , Or domperidone 10 mg
Sumatriptan 25-100mg at onset of headache, Zolmitriptane 2.5 mg at
onset
Syp mosegar , Tab inderal 10 mg tds upto 40 mg
tds

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Q = 35 yr old married lady presented with history of in ability to
complete house hold work in time , excessive thinking about trivial
matters and feels that a disaster wil strike if she did not give a
hundred every day to a bagger.
Her husband informed that she hides kitchen knives because that
she may hurt her children
Q = what is this behavioral called phenomenological term
Ans= paranoid delusion
Q =list four clinical disorders which presents with such phenomenon
1=delusional disorder 2=schizophrenia 3=organic state
4=severe affective disorder
Q = what clinical features you will see in opium abuse?
Ans= clinical features= lack of interest in any thing, dysphonic, pupillory
constriction, drowsiness, slurred speech , impairment in memory, coma
and death
Treatment of intoxication=
Naloxone . 4 mg till pupil dilates
Treatment of withdrawal = clonidine and methadone
Q =Factors associated with dangerousness and violent behavior in
psychiatry ward?
Answer=Psychotic disorder like schizophrenia, mania, paranoid and
post partum psychoses
Organic mental disorders like delirium , drug intoxication and
withdrawal
Personality disorders like antisocial and paranoid personality disorder.
Brain disorders like seizures , brain injury, encephalitis asnd MR swith
behavior problems
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Q = 65 yr old retired person is admitted into your ward after being
brought by his wife with history of falling memory for last 6 months
Q = name six lab tests=
B12, Folate, RPR, CBC with SMA and TFTs
Q = Name radiological tests= 1=EEG may show focal abnormalities
2= Feldstein minim mental state is used
3=Neuroanatomic findings
Cortical atrophy, flattened sulci and enlarged ventricles
Histopathology=Senile plaques, Neurofibrilory tangles,
Neuronal loss
Synaptic loss, Granulovacuolar degeneration of neurons
Q List 4 psychometric test you would request for to rule out orgaicity
in this case-=
Ans=1=Tfts 2=CT scan 3=MRI 4= SPECT AND
PET
Q = 30 yr old female pt is receaving 4mg of risperidione medication.
After a few days she reports that milk is coming out of her nipple
What specific lab test you will request forf ?
Ans-= plasma prolactine levels
Q =What could be pathological basis of this clinical condition?
Answer- antipsychotics block dopamine and resulting loss of inhibition of
dopamine results In hyperprolactenemia resulting in gynaecomaia ,
galactorea, and amenorea
C= treatment of hyperprolactinemmia is bromocriptine , dopamine
agonoist ,
Replace risperidone with prolactin sparing aripiprazole

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Q = What information will you give about nature and prognoses of
disease to family
Answer= Deterioration is gradual with average during from onset to death
being 8yr .downhill course
B = What advice you will give to make best use of pt existing
capabilties
Ans= correction of underlying pathology is essential,. Medication that
further impair cognition should be avoided
Provision of familiar surroundings, reassurance, emotional support is often
helpful
Provide light job
Q = Name four medicines given in alzeimer dementia
Ans=1-= Tacrine, 2= Donepozil
3=Rivastigmine
4=Memantine
5=Galantaminne
Q= Nurse ask you at end of lecture why there is need for pt to have 6-
8yr of sleep every day
Psychiatrist may be asked to see pt whose main problem is either
difficulty in sleeping or less often excessive sleep..Many other pt also
complain about sleep problem as one of there symptoms , however
sleep disturbances are often overlooked or misdiagnosed.
Sleep problems are important for several reasons
They may represent primary sleep disorders
They may be causes of psychological problems
They may be symptoms of psychiatric disorders like mood disorders
Sleep problems can also occur in a stage of medical disorders
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Many pt who sleep badly complains of tiredness and mood disturbances
during day
Although prolong sleep deprivation leads to some impairment of
intellectual performance and disturbances of mood , loss of sleep on
occasional night is of little significance except in those whose
responsibilities or activities require maximum alertness . the day time
symptom of people who sleep badly are propably related more to cause of
their insomnia itself
B =list four normal physiological condition that can cause disturb sleep
Ans= 1= Night mare 2=Night terror 3=Sleep walking disorder
4= Rem sleep behavior disorder
Q = 40 yr old female pt of schizophrenia taking olanzapine 10mg daily
for atleast one yr was admitted in medical ward for complain of
burning feet excessive urination and ten kg weight gain during last ten
months
A= what will be your specific diagnoses
Ans= Olanzapine induced diabetes mellitus
B = what specific test you will request for
Ans= RBS
Treatment of diabetes=replace olanzapine with aripipprazole
q =25 yr old pregnant admitted with one day history of weakness of her
right leg
She has past history of admissions with complain of blindness In one
eye, to rule out organic causes plan to advice ct scan , mri beside other
investigation
a-== which of two (ct or mri brain )will you prefer in this case and why?
Ans=MRI is good for spinal cord lesion
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Q = consultant has to asked to take consent from relatives of a chronic
schyzopreia to start clozapine .
What information you will provide about clozapine
Ans=we will provide information about adverse effects of clozapine
1=leucopenia in 2% cases and progresses to agranulocytoses
2=weekly blood count for first 18 weeks of treatment and then 2week
interval are mandatory
After one year I monthly blood count
Hyper salivation, weight gain,
Drowsiness, postural hypotension
, seizures , myocarditis , and myopathy,
Weight gain responsible for diabetes mellitus
Q C T SCAN = identify anatomically based brain changes such as
enlarged brain ventricles seen in cognitive disorder such as Alzheimer
disease as well as schizophrenia
MRI= identify demyelinating disease like multiple scleroses showing
biochemical condition of neural tissue with out pt exposing to ionizing
radiation.
Q = you are posted as a psychiatrist in a flood hit district of southern
Punjab keeping in view disastrous situation in area
A= what would be most frequent psychological reaction in affectees
Ans= crises intervention
Q =which psychiatric illness you could expect most frequent
Ans= ask
Q =lot of parents visit psychiatric clinic having complain of erogant
behavior of their teens age children . how would you explain this

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phenomenon in light of developmental theory of erik erikson , freud
and jean piaget
Ans= sigmoid Freud= describe development in term of parts of body from
which most pleasure is derived at each stage of development e,g, oral stage
occurs during first year of life’
Erik erikson = described development in term of critical period for
achievement of specific goal. If specific goal is not achieved at a specific
age the individual will have difficulty in achieving goal in future. For
example in erik eriksion stage of basic trust versus mistrust ,child must
learn to trust other during first year of life or they will have trouble
forming close relationship as adults
Jean Paget-= describe development in term of learning capabilities of child
at each stage
Q=what are common cause of mental handicap in pakistran
List four of them you will consider If you were working in northern
Pakistan ?
Ans=1-= Inborn error of metabolism like lipidoses, amino acids and
glycogen storage disease
2= Chromosomal disorders like cri du cat and down syndrome 3=Torch
infection
4=Alcohol 5= Hypoxias’ or malnutrition
DD= Learning and communication disorders, Sensory impairment,
autistic disorder
Border line intellectual functioning , environmental deprivation
Q = 35 yr old chronic scyzoprenic illiterate , married , with no issue is
being discharged after 8wk stay in your ward he has stabilized on
flupenthixol deconuaste fortnightly
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A= what intervention can you offer to such pt beyond drug treatment?
Ans-= Psychosocial approaches=
1=Family therapy 2-=CBT 3= Social skill
management and illness self management
4= Treatment of cognitive impairment 5= Dynamic psychotherapy
6= Interaction of drugs and psychosocial treatment
Q = note on Health belief model=
Is a psychological health behavior change model developed to explain and
predict health related behavior particularly in regard to uptake of health
services. Health belief model was developed in 1950 by US social
psychologists public health service and remained most well known and
widely used theories in health belief researches.
Prevention of illness and promotion of health depends largely upon an
individual attitude toward help seeking.
HBM contains a no of variables all of which contribute to some extent to
health behavior. These factors includes interest with health matters, belief
toward susceptibility to illness severity, benefits and cost of caring out action
and belief about how well those actions will work
Typically psychiatric disorders are seen in our part of world as spiritual
illnesses that are result of nazar or evil eye, possession by evil spirits and
jins and satanic changes ,this thought determines the pathway that a
psychiatric pt consequently follows
He or she therefore must first be taken to a faith healer or pir or clergy man
Even after an eventual consultation with psychiatrist tweeze , degas, dum
durood must continue as adjunctive to psychiatric intervention
A sensitive doctor will ensure compliance to treatment and provide
informational care on scientific bases of disease.

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Scientific doctor chooses a strategy of running awareness campaigns thru
media to enhance and improve understanding about psychiatric illness.
And remove myths and misconception in community by replacing their
existing understanding with evidence based scientific thought
Following questions can be asked to assess to pt explanatory model of
illness
What do you call your problem?
What name does it have?
What caused your problem?
What is onset and course of disease?
What type of treatment u should receive?
These questions can form basis of informational care session in health
settings.
Q=what are different stages of memory=
1=Encoding 2=Storage 3=Retrieval system
Q =Methods to improve memory=
Answer=1= Knowledge of results or feed back 2 =Attention and focus
on study
3==Reading and retrieval 4=Organizing study
5=Selective study 6=Serial position effect 7= Mnemonics
8= Attach emotions 9=over learning 10=spaced practice
11= Whole versus part learning 12=sleeping 13=Review
Q =Motivational forgetting
The theory of emotional forgetting was introduced by sigmeud freud
when he describe a key concept of psychoanalyses versus repression
Repression refers to have tendency of people to have difficulty in
recalling anxiety provoking Information, this helps to explain why
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people generally remember pleasant events more often than they do
un pleasant ones
This feature should encourage to make ones learning a lot of funs ,enjoying
your study and clinical work rather than making it painful and burden ,
this will happen if you leave your exam preparation to few days prior to
exam only
Q =30 yr old man single drop out from intermediate college, changed
several jobs presently working as a sales man on a shop; presented
with history of impulsivity , anger and conduct disorder= he mostly
remember isolated often behaving like a female and unable to make
intimate relation, Keeping in mind the erikson theory of psychosocial
development , In which stage of development he is at present?
Answer-=stage 6=intimacy versus isolation
Q =what future stages of development will be affected
Answer=stage 7 and stage 8
Q =TRANSTHEORITICAL MOODEL OF CHANGE
ANSWER=1=precontemplation 2=contemplation
3=preparation 4=action 5=maintenance 6 =relapse
Q = give a brief account of Alfred adler theory of individual psychology
and how he differs from his teacher sigmoid freud
Answer-= according to adler the foremost source of human motivation is a
striving for superiority. In his view this striving does not necessarily translate
into pursuit of dominance
Adler saw striving for superiority as a universe drive to adapt ,improve
oneself and master life challenges .He noted that young children
understandably feels week and helpless in comparison with more competent
old children and adults.

136
These early inferiority feeling supportedly motivate them to acquire new
skills and develop new talents, thus adler maintained that striving for
superiority is prime goal of life rather than physical gratification(as
suggested by freuds)
Adler asserted that everyone has to work to overcome some feeling of
inferiority a process he called compensation. Compensation involves efforts
to overcome imagined or real inferiorities by developing ones abilities.
Inferiority feeling can become excessive resulting in what is widely
known today as a inferiority complex. Exaggerated feeling of weakness and
inadequacy . adler thought that either parental neglect could cause an
inferiority complex. It was adler who first focused attention on possible
importance of birth order as a factor governing facility
Q =what is difference between psychodynamic theory and
psychoanalytical theory
Answer=they are similar but not same thing
Psychoanalyses is subset of psychodynamic theory
According to American psychiatric association Psychoanalyses is a part of
psychodynamic theory created by freud that is focused on unconscious
motivation and conflict..It is usually very long and intensive (some time
3-5 times per week )
Psychodynamic theory is a broad therapeutic orientation that consists of
self psychology, object relation, ego psychology and a couple more
Behavior is explained in term of past experiences and motivational forces
Action are viewed as stemming from inherited instincts ,biological drives
and attempts to resolve conflict between personal needs and social
requirements
Q what are types of memories ?

137
Ans=1-= Sensory memory for sensations like sight ,sounds and taste and
last one to two seconds
2=Short term memory can be stored as images and sounds and act as
temporary store house for small amount of information
3= Important and meaningful information is transferred to permanent store
house of long term memory
Q = anatomical areas involved in memories?
ans=short term memory by hippocampus . Long term memory by
amygdale
Other structures involved are. Hypothalamus, mammillory
bodies, and thalamus
Q =parents of 21 year college students came for counseling of their son
because there son prefer to live alone and avoids gathering and has no
close friends?
Q= What are types of personality disorders in this pt ?
ANS= 1=SHYZOTYPAL 2= PARANOID
3= AVOIDANT PD
Q= In above case name psychometric test that you wil require in such
case?
Ans= projective tests and objective tests=
Projective includes HTP, Rosach test,
And objective Includes MMPI,16PT
Q=A renowned social worker often has to leave her child under
supervision of house mad .she told that she is going abroad alone for 4
month training and wants to know the possible impact of her absent
on her child

138
Explain the expected behavior of child after 4months training in light
of bowlbay theory of attachment
Ans=John bowlbay showed that rearing abilities of care giver plays an
important role in giving infant a secure emotional attachment which has
great role in development of interpersonal attachment
Q=what psychiatric disorder can appear in this child due to frequent
absence of her mother?
Ans=Insecure emotional attachment can increase risk of various types of
psychopathologies like depression
Q= mother of pt of schizophrenia has to give informed consent for use
of child
What are her rights?
Ans=Full consent requires that pt has received understand five pieces of
information
1= Nature of procedure
2=Purpose of procedure
3= Benefits
4=Risks
5=Alternative procedures
Q=Write three conditions in which informed consent is not required?
Ans=few exception to informed consent
1= Emergency
2== Waiver by patient(expression by patient)
3= Pt is incompetent
4= Therapeutic privilege ( unconscious , confused, physician deprives pt of
autonomy In interest of health )

139
Q= write 3 condition which may legally impair capacity of mother of
pt to give informed consent?
Ans=1=schizophrenia 2= Alzheimer disease 3= dementia 4= delirium
Q = You have to plan a trial for antipsychotics ?
Q= what instruments you wil use to screen population?
ANS= General health quesionare and BPRS
Q= what Instrument you will use to recommend to measure the
response to antipsychotics ?
Answer= PANNS scale
Q=what instrument you will use to measure efficacy of of medications
in drug trial?
Ans=PANNS scale
Q =what are determinants of mental health and prevention of mental
problems In Pakistan ?
Ans=determinents of mental health in pakistan =Determinents of
,mental health in Pakistan =1=Genetic illness =
A number of mental health disorders are genetically determined
If father is ill then sibling will have 20%chances of mental illness
If mother then also 20% chances of mental illness in sibling
If both parents 40% chances
2= stresses and pressures of life = due to stress subnormal personality
becomes totally abnormal especially in schyzoprenias and depression
3= type A personality=will have will power and determination and they are
hard workers and cross borderline from subnormal to normal
4= Extrinsic causes=
Infection, brain trauma, alcoholic intoxication, Lack of vitamin b12

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5=Psychosocial stressers=loss of loved person , loss of friends and great
finantial losses
Q =prevention of mental health disorders in Pakistan
Goal of prevention is to decrease onset and sunsequent residual
disability of mental disorders
Primary prevention=1= remove causative agents
2 Increase resistance and immunity
3=control mode of disease prevention 4= education about mental
health
SECONDARY PREVENTION=
1= search for mental case by door to door services and give support
2= take mental case to mental health services
TWO TYPES OF CENTRES ARE=1=day centres
2=24hour centers
With proper treatment and proper counseling and proper support these pt
can be treated
3= TERTIARY PREVENTION= goal is to decrease residual disability and
give balanced personality to community and to care so that to able those
mentally ill to reach high level of functioning.
Q =as regards heroin dependence list symptoms of dependence with
recepters and brain regions involved
Ans= 3 types of Recepters=
Mue,kappa and delltas recepters
And limbic system is predominantly involved
Q= pt presented with complaInts of restlessness apprehesnsion ,
palpitation and sweating, , she has five episodes in which she has
pounding heart, trembling of hands, these episodes lasts 15min

141
What is diagnoses?
Answer=Panic disorders
Q=what medical and psychiatric disorders would you consider in
differential diagnoses?
Ans=1=Agoraphobia 2=Depression 3=Generalized anxiety 4=Substance
abuse
Q=list psychometric and biological investigation that you would
undertake in this case
Answer=1= BLI 2=TFTs 3=LFT
4=UREA AND CREATIINE
Q=LIST pharmacological and psychological intervention that you will
prescribe in this case
Ans=Pharmacological intervention includes
SSRI like (fluoxetine ) alprazolam , Clonazepam ,imipramine, , mao e,g
phenelzine
Psychotherapeutic intervention=
Relaxation training for panic attacks and systemic desensitizing for
agoraphobic symptoms
Q=A 42 years old patent of BIPOLAR DISORDERS, stabilized on
lithium for past six years presents with complaints, lethargy, dry coarse,
cold intolerance, weight gain , and menstrual irregularities for past
2months
What is diagnoses?
ANS=LITHIUM INDUCED HYPOTHYRIOIDISM
Q=TOXICITY MANAGEMENT=
Keep plasma levels below 1.5meq/litre

142
Dehydration and hyponatremia predisposes to lithium toxicity by increasing
lithium levels
Tremor at therapeutic levels may respond to decrease dosage
Divided doses or slow release preparation minimize dose related
untoward effects by decreasing peak plasma levels
Q= what is recommended prelithium work up and monitoring
during course of treatment
Ans=Before starting on lithium physicial examination including
measurements of bp.and weight pt And BMI,
ALSO Do serum electrolytes, GFR, FBC, TFT ECG AND PREGNANCY
TESTS
If these tests show no contraindication to lithium, doctor should also check
that pt is not taking any drug that may interact with lithium like diuretics
and ace inhibiters, metronidazole and decrease lithium levels with
theopyline and sodium bicarbonate.
Q= 40 YEAR female teacher lost her husband two year before in
accident and demise of her mother nine year old and her father died
when she was at age 20year
And has now sleep disturbances, late insomnia, decrease appetite and
weight loss
List differential diagnoses in this case?
1= hypothyroidism 2=parkinsoniosm 3=pseudementioa 4=cva 5=mood
disorders
6= substance abuse 7 =greif
Q=what are risk factors=
Ans= major depression is seen more frequently in women due to hormonal
differences, great stress and bias. Typical age of onset is 40 years

143
There is also higher incidence in those who has no close interpersonal
relationship, or are divorced or separated, Abnormalities in serotonin and
nor epinephrine, and dopamine
Other factors includes family history ,,exposure to stressors, and behavioral
reasons such as learned helplessness
TREATMENTS=must also secure safety of patient given the suicide is a
high risk
SSRI, TCA and MAOI,
Electroconvulsive therapy may be indicated if pt is suicidal or worried
about side effects from medication,. Individual psychotherapy is Indicated
to help pt to deal with conflicts, sense of loss etc Another form of therapy is
cognitive therapy which will change pt distorted thoughts about self ,future
and world etc
Q = ONE MONTH after CVA pt is complaining of crying spells ,
fatigue, anhedonia, and suicidal ideation,
He has no prior psychiatric history but does have hypertension and
urinary hesitancy
Diagnoses is post CVA depressive illness
What treatment you would advice ?
Ans= give sertraline 50mg in morning and avoid TCA because it causes
ant cholinergic effects and cardio toxicity (arrhythmia ) and suicidal risk
with increase doses
Q = 70 year female with forgetfulness , frequent loss of temper and
gradual change in her personality. she has been pt of HTN and has
been drinking alcohol for long period of time
What is diagnose ?
Ans= alzeimer dementia

144
Q = what structural changes in mri you will see in this patient?
Ans= gross anatomical brain changes are
1= enlargement of brain ventricles 2= diffuse atrophy 3= flattening of
sulci
Microscopic anatomical brain changes are
1= Amyloidal plaques 2= Neurofibrilory tangles 3= loss of cholinergic loss
in basal forebrain
4= Neuronal loss and synaptic loss
Q = NAME MOST RELEVENT FIVE LABORTORY TESTS
Ans=primary care = fbc, esr, urea and electrolytes, LFT, TFT, B12 and folate
Secondary care= mri ,ct, urinalyses, syphilis and hiv status, chest
radiograph , neuropsychological changes and neuropsychological assessment
Q = LIST FIVE PSYCHOMETRIC TESTS IN ALZEIMER
DISEASE=1=MINNIMENTAL STATE EXAMINATION
2= SIX TEM COGNITIVE ASSESSMENT TEST 3=SEVEN
MINUTE SCREEN
4= CLOCK DRAWING TEST
5= ALZEIMER DSEASE ASSESSMENT SCALE-COGNITIVE
SUBSCALES
Q=65YR old diabetic pt is having forgetfulness and diabetic
neuropathy ,he is tearful and sad and has unable to fall asleep for last
two months due to careless attitude of his wife
He attempted suicide once but was saved by his sons
Q = what are differential diagnoses?
1= Alzheimer dementia
2= depression

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Q = BIOLOGICAL INVESTIGATION FOR ALZEMER DEMEMTIA
ARE
Fbc,ESR, urea and electrolytes, LFTs, calcium and po4,tft.,vit b12 ad
folate,
Psychological investigation are= minimental state examination, six item
cognitive impairment test, seven mionute screen , clock drawing
test,Hopkin verbal learning scale, mental test score
Alzheimer disease assessment scale
Cambridge examination for mental disorders for elderly
Q=Biological and psychological Investigation for depression=
1=cornwel scale 2= geriatric depression rating scale 3= global
assessment
4 clinical dementia rating(CDR)
Abnormal biological tests are
Dexamethasone suppression scale ,Thyrotropine releasing hormone test
Q=WHAT BIOPSYCHOSOLOGICAL TREATMENT WILL YOU
OFFER=
WE ACCORDINGLY WILL OFFER TREATMENT ACCOTRDING
TO UNDERLYING CAUSE
BIO=MEDICATION
PSYCHO=CBT
SOCIAL = FAMILY THERAPHY AND TO PROVIDE CARE AND JOB
TO PT
Q= Pt is suicidal and suffer from depression. Step that you will place
before administering treatment.
Ans-= STEPS IN ECT= involving induction of a generalize seizures lasting
25-65seconds by passing an electric current across brain , prior to seuizure
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induction pt is premedicated with atropine. General anaesthetic propofol is
given and muscle relaxant such as suucinyl choline is given
–Q= Name five situation in which ect may be advantageus over other
treatments
Ans=1= when depression is associated with life threatning illness such as
refusal of food and fluids and a high suicidal risk
2=for depressive illness associated with stupor ,marked psychomotor
retardation or delusion or hallucinations
3= ect is used as second and third line of treatment that is not responsive to
antidepressants
4=ect may be used in mania associated with life threatening exhaustion or
no response to drugs
5= ect may be used as a fourth line of treatment for treatment resistant
schizophrenia
After treatment with 2 antipsychotic have proven ineffective and then
clozapine proved in effective
6= ECT may be used in catatonia when benzodiazepines are ineffective
Q= CONTRAINDICATION of ECT=
1= respiratory illnesses 2=heart disease 3=pyrexia
4=sickle cell trait
Q=SIDE EFFECTS OF ECT=
1= anxiety 2=headache 3= retrograde and antero grade amnesia
4=disorientation 5=damage to tongue , teeth and lips
6= crush fractures of vertebrae7= cardiac arrhythmias’ 8=aspiration
pneumonia
9=cva 10=status epilepticus

147
Q = what is single photon emission tomography and how it differs
from positron emission tomography?
Answer=SPECT= obtaining similar data to PET
But is more practical for clinical use because it uses a standard gamma
camera rather than a cyclotron
PET=localizes area of brain that are physiologically active during specific
task by characterizing and measuring metabolism of glucose in neural
tissue
Also measures specific neurotransmitters receptors Requires use of
cyclotrons
QPsychosurgery
Definition= use of neurosurgical procedure to modify symptom of
psychiatric
illnesses by operating on either nuclei in brain or white matter
Psychosurgery began in 1936 with work of egas whose operation consisted on
extensive cut in white matter of frontal lobe which was called frontal leucotomy
This operation was modified by freeman who added that operation of incision
should be in frontal lobe thru lateral burr holes
This procedure is widely used in uk initially pt were improved but
later on
adverse effects were founded such ad intellectual impairment,
emotional
lability , disinhibition, incontinence and obesity and epilepsy
Later on some progress was made particularly with incorporation of stereotactic
techniqyues
Current approaches=the term psychosurgery is now often replaced by phrase
neurosurgery for mental disorder
This change is intended to emphasize that
1=the techniques involved now involve placement of localize lesion in specific
cerebral sites

148
2= the techniques iis for specific psychiatric condition (such as
treatment
resistant depression and obsessive compulsive disorders) not for
primary
behavioral disturbances
Indications=1= major depression 2=obsessive compulsive disorder
Types of operations=nowadays the older blind operations have been replaced by
stereotactic procedures that allow the lesion to be placed more accurately
In uk current procedures are limited to anterior capsulotomy and anterior
cingulectomy
The lesion are produced by
1=radiofrequency thermo coagulation 2= gamma radiation
Effectiveness=A report by royal college of psychiatrists foun a marked
improvement rate in 63% of patients of major depression and in 58% of patients
of obsessive compulsive disorders
QAdverse effects Acute effects=1=operative mortality rate of o.1%
2= hemorrhage and hemiplegia 3=transient confusion and lethargy
Long term effects= 1=epilepsy 2=weight gain
3=frontal lobe syndrome 4= mild personality changes
QStereotactic procedures used in psychosurgery=
1=sub caudate tractotomy= lesion made beneath the head of each caudate
nucleus in rostral part of orbital cortex
2=anterior cingulotomy=
Bilateral lesion within cingulated bundles
3=limbic leucotomy=subcaudate tractotomy combined with cingyulotomy
4= anterior capsulotomy=
Bilateral lesion in anterior part limb of internal capsule
Q 45 yr old man was referred from prison for hearing strange voices and
disruptive behavior for two weeks .

149
He at times starts talking very loudly ,use strange words and make
gestures as if talking with imaginary peoples
How can you differentiate that hallucination he heard were genuine or
faked?
Answer=since there are many phenomenological pathologies like 1=
auditory hallucination
2=disorganized behavior
3=neologism
4==visual hallucination
There are multiple symptoms so most these were genuine and not faked
Q =42yrold business man presented at a psychiatric department with
one month history of disturbed biological function, anhedonia ,
reduced physical energy, ideas of worthlessness and pessimism(negative
though to every thing) .
Detailed history revealed that he has tried to kill himself two weeks
earlier by hanging himself with a rope but was saved in time by his
family members
Further inquiry revealed that he has been taking alcohol for last one
year and was once detoxified in a local mental health facility six month
back?
A=what is most likely diagnosis?
Answer=major depressive disorder
B =list factors associated with Increase risk of suicide?
Answer= etiology and risk factors
Etiology= clients with psychiatric disorder such as depression, schizophrenia,
substance abuse ,PTSD, borderline personality disorder
Chronic medical condition like cancer, hiv, head and spinal cord injury

150
Environmental facters like isolation, any recent loss, lack of social support,
divorse, unemployment ,
Behavioral factors= impulsivity and unexplained changes from usual
behavior , unstable life style
Risk factors= the risk of completed suicide increases in sad persons
S =sex male
A=age adolescence age more than 40years
D =depression = 25% more common in depressed than normal pt
P=previous history of suicidal attempts
E=ethanol =alcohol or drug dependence history
R=rational thinking loss due to mental illness
S=severe illness
O=organized plan
N=no partner
S= social isolation
Q Prevention of suicide?
Answer= better and more accessible psychiatric services, Restriction of
means of suicide
Encouragement of responsible reporting, Educational program
Improved care for high risk group,. Crises centers and
telephone hotlines
Q =components and principles of management of schyzoprenia=
Answer=1= therapeutic partnership with pt and carers
2=integrated multidisciplinary working ,involving primary and secondary
care
3= antipsychotics drugs for treatment and propylaxes

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4= trial of clozapine for all pt who meets creteria 5 =CBT 6=family
intervention
7=early intervention 8= cognitive remediation
9= assertive outreach for vulnerable pt 10=regular assessment of
needs
11=crises resolution and home treatment teams as alternative to admission
12= maintain realistic therapeutic optimism
Q = what is single photon emission tomography and how it differs
from positron emission tomography?
Answer=SPECT= obtaining similar data to PET , But is more practical for
clinical use because it uses a standard gamma camera rather than a
cyclotron
PET=localizes area of brain that are physiologically active during specific
task by characterizing and measuring metabolism of glucose in neural
tissue
Also measures specific neuro transmitters receptors,. Requires use of
cyclotron
Q =42yrold business man presented at a psychiatric department with
one month history of disturbed biological function, anhedonia ,
reduced physical energy, ideas of worthlessness and pessimism .
Detailed history revealed that he has tried to kill himself two weeks
earlier by hanging himself with a rope but was saved in time by his
family members
Further inquiry revealed that he has been taking alcohol for last one
year and was once detoxified in a local mental health facility six month
back?
A=what is most likely diagnosis?

152
Answer=major depressive disorder
B =list factors associated with Increase risk of suicide?
Answer= etiology and risk factors
Etiology= clients with psychiatric disorder such as depression,
schizophrenia ,substance abuse ,ptsd, borderline personality disorder
.Chronic medical condition like cancer, hiv, head and spinal cord injury.
Environmental factors like isolation, any recent loss, lack of social support,
divorce, unemployment ,
Behavioral factors= impulsivity and unexplained changes from usual
behavior , unstable life style
QPrevention of suicide?
Answer= better and more accessible psychiatric services
Restriction of means of suicide. Encouragement of responsible reporting
Educational program .Improved care for high risk group
Crises centers and telephone hotlines
Q =components and principles of management of schyzoprenia=
Answer=1= therapeutic partnership with pt and corers
2=integrated multidisciplinary working ,involving primary and secondary
care
3= antipsychotics drugs for treatment and prophylaxes
4= trial of clozapine for all pt who meets criteria
5=cbt 6=family intervention 7=early intervention
8= cognitive remediation
9= assertive outreach for vulnerable pt
10=regular assessment of needs
11=crises resolution and home treatment teams as alternative to admission
12= maintain realistic therapeutic optimism

153
Q management of hallucinogen toxicity
1= supportive counseling and bzd
Q -== lady refer to you by gynaes after delivery of baby rapid
development of behavioral changes. she harm her baby and hates .her
pulse 100 bp 145/95
Temp 100
Ddx post partum psychoses and depression
Treatment of post partum psychoses is antidepressants and antipsychotic
and mood stabilizers
Treatment of postpartum depression is anti depressants
Q screening test
Is process of using test to permit early detection of risk factors
asymptomatic infection or early stages of clinical disease thus permitting
early dx and early intervention and tx
Screening is generally applied to population of apparently well individual
illness if present is asymptomatic (subclinical, inapparent screening test
allow for early detection dx ,.hopefully .Earlier treatment will affect a more
favorable clinical course
Screening test results are classified as positive (presumed by test to be
disease or negative presumed by test to be well
Q Sensitivity
Proportion of people with disease who are correctly classified by
screening test as positive
Sensitivity
Tp/ all people with disease
Tp/tp plus FN
Q Specifity

154
The proportion of well individual who are correctly classified by
screening test as negative
Specificity=TN /TN plus FP
Q SENAREIOS OF 10 YR BABY BY MOTHER BECOZ OF
REPEATED BED WETTING AND decrease academic performance
decreased mood decrease speech monotonous
Ddx
1= nocturnal enuresis=Treat with imipramine and clomipramine
2= depression =ssri and tca 3= hypothyroidism
4= UTI tx by floroquinolones
Important investigations
T3 t4 and tsh
Q HANDY POINT= PT HAVE NO RIGHT TO KILL HIMSELF
Q CAUSES OF SUICIDE
1-=DEPRESSION 2= BAD 3= SCHYZIOPRENIA
4= ANOREXIA NERVOSA
5 BULEMIA NERVIOSA
Q =Role of dopamine in cns and its pathologies=
Answer= Nigrostriatal tract is involved in regulation of muscle tone and
movement nigrostriatal tract degenerates In parkinsonism .
Treatment with antipsychotics block postsynaptic dopamine receptors
receiving
From nigrostraital tract can result in Parkinson like symptoms
Dopamine receptors acts tubuloinfundibular tract to inhibits secretion of
prolactin from anterior pituitary

155
Q = a chronic schizophrenic pt started biting other pt and staff .
several option were tried but staff were unavailable to control his
behavior
A board of three doctors decided that because pt is dangerous to other
all his teeeths should be removed .the dental surgeon removed his teeths
and provided a dentuire which could be used at time of taking
food.when relatives visited they got angry and went in a court of law
where after proper hearing 3 doctor of board and dental surgeon was
declared guilty
What are principles of medical ethics and in this case what principles
are violated?
Answer-=three ethical principles are widely adopted in medical ethics
1= respect for autonomy= involving pt in health care decision, informing
them so that they can make decision and respecting their views
2= beneficence and nonmalevolence= doing what is best for pt and not doing
harm ,
In practice this usually means doing what body of professional opinion
judges to be best
3= justice=acting fairly and balancing interest of different peoples
Ethical principles can and do regular conflict with each other
In above principles no malevolence was principles but this was violated and
thus malevolence was observed
Q = what is single photon emission tomography and how it differs
from positron emission tomography?
Answer=SPECT= obtaining similar data to PET
But is more practical for clinical use because it uses a standard gamma
camera rather than a cyclotron
156
PET=localizes area of brain that are physiologically active during specific
task by characterizing and measuring metabolism of glucose in neural
tissue
Also measures specific neurotransmitters receptors
Requires use of cyclotron
Q =25 yr old female was suffering from ocd for more than a year was
referred to you by a district hospital psychiatrist for cbt
The pt was on proper pharmacological treatment but showing partial
response
What necessary information you will provide on efficacy and
procedure of cognitive behavioral treatment
Answer=CBT
Q = 45 yr old man was referred from prison for hearing strange voices
and disruptive behavior for two weeks .He at times starts talking very
loudly ,use strange words and make gestures as if talking with
imaginary peoples
How can you differentiate that hallucination he heard were genuine or
faked?
Answer=since there are many phenomenological pathologies like 1= auditory
hallucination
2=disorganized behaviuor 3=neologism 4==visual hallucination
There are multiple symptoms so most these were genuine and not faked
Q =42yrold business man presented at a psychiatric department with
one month history of disturbed biological function, anhedonia ,
reduced physical energy, ideas of worthlessness and pessimism .

157
Detailed history revealed that he has tried to kill himself two weeks
earlier by hanging himself with a rope but was saved in time by his
family members
Further inquiry revealed that he has been taking alcohol for last one
year and was once detoxified in a local mental health facility six month
back?
A=what is most likely diagnosis?
Answer=major depressive disorder
B =Q list facters associated with Increase risk of suicide?
Answer= etiology and risk factors
Etiology= clients with psychiatric disorder such as depression,
schizophrenia ,substance abuse ,ptsd, borderline personality disorder
Chronic medical condition like cancer, hiv, head and spinal cord injury
Environmental factors like isolation, any recent loss, lack of social support,
divorcé, unemployment ,
Behavioral factors= impulsivity and unexplained changes from usual
behavior , unstable life style
Q Prevention of suicide?
Answer= better and more accessible psychiatric services
Restriction of means of suicide, .Encouragement of responsible reporting
Educational program .Improved care for high risk group
Crises centers and telephone hotlines
Q =Enumerate Neuro psychiatric sequelae associated with HIV aids
Answer= neuropsychiatric disorder are common both secondory to
complication of immune suppression and direct effects of hiv on brain
1=minor cognitive disorders are frequent
2=aids dementia complex

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3=hiv encephalopathy
4=sub acute encephalitis
5=progression to profound dementia
6=delirium may occur when there is cerebral malignancy
Q = enumerate risk behavior that contribute to aquision of hiv
Answer=1=Blood transfusion 2=Sexual intercourse
3=thru razor and blade 4=Torch infection 5=Tooth brush
Q =while giving lecture on ECT to undergraduate students you are
asked in which clinical condition ect is ineffective,
How you will respond to question
Ans=1=transiently Increased intracranial pressure2=space occupying lesion
Intracranial lesion require a caution
Q = Give briefly advantages and disadvantages of typical antipsychotics
medication
1=psychomotor agitatation
2= schyzoprenia
3=other psychotic disorders such acute psychoses, schyzopreniform disorder
4=mood disorder
5= sedation when benzodiazepine are In effective
6=movement disorders 7= hiccups
8=tourett syndrome
Q Disadvantages of antipsychotic agents
1=sedation due to antihistamine activity
2=hypotension due to alpha adrenergic blockage
3=endocrine effects such as gynacomastia ,
Galactorea, and amenorrhea

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4=dermal and ocular syndrome =photosensitivity , cataract and abnormal
pigmentation
5=cardiac conduction abnormalities with theoridazione and agranulocytoses
with clozapine
6=extrapyramidal syndrome like acute dystonia, bradykinesia, akathesia,
tardive dyskinesia, and neuroleptic malignant syndrome
B=name one potentially fatal hazard of typical antipsychotic drugs
How you would diagnose it?
Answer=1=EPS 2=NMS
EPS includes acute dystonia , bradykinesia, akathesia, tardive
dyskinesia and NMS
We recognized acute dystonia because of spasm of various muscle groups
Bradykinesia=there will be slow volitional movement, increase muscle tone
and resting tremor
AKATHESIA= motor restlessness
TARDIVE DYSKINESIA= there will be choreoathetoid movements and
other involuntary movements
Movement often occurs in tongue, finger and later involve trunk.
Use newer antipsychotic medication and stop older antipsychotic drugs
We will do CPK in EPS and fever and history of high dose of
antipsychotics in past
Usually NMS is associated with high dosages of high potency antipsychotic
medication
Q What are difference between icd10 and DSM –IV.Which of two is
socioculturaly relevant for use in Pakistan ?
Justify your answer= origin of icd-10 is international and origin of DSM
–IV is American psychiatric association
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Presentation of icd 10 is that different version for clinical work
research and use in primary care in icd -10-
A single documents in dsm iv
In ICD- 10 available in all widely spoken languages
Dsm -iv English version
Structure in icd 10 = part of overall icd framework is single axis in chapter
5
in dsm iv multiaxial system available
contents of icd 10= guidelines and criteria do not include social
consequences of disorders
dsm iv diagnostic criteria include significant impairment in social function
Q = identify the psychosocial issue at level of pt ,his family and the
community that arises after diagnoses of schizophrenia is established
in an adult male in a typical Pakistani rural family?
Answer= concept of stigma= the tendency to stigmatize seems to be deeply
rooted in human nature as a way of responding to people who appear or
behave differently
Stigmatization is based on fear that those who seems differently may
behave in threat or unpredictable ways and it is reduced when it becomes
clear that the stigmatize person is unlikely to behave in ways that were
expected
Stigma in psychiatry=people with mental illness and they stigmatize those
who are affected by it
Psychosocial issues at level of pt , family and community
1=socially rejected
2=increase difficulties
3=families are rejected by societies
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4=stress on pt and families
5=popular misconception
Q=10 yr old boy is brought with history of refusal to go to school every
morning, he started feel abdominal pain whenever he sees school bag.
His mother starts to shout at him , father beats him , initially the boy
started to go to school as a result of his parental reaction and then
stoped going to school
A = what are various types of learning theories that are playing role in
this scenarios ?
Ans=1=habituation
2=sensitization
Classical conditioning=
Elements of classical conditioning are an unconditioned stimulus
An unconditioned response
A conditioned stimulus
A conditioned response
Response aquision , extinction, and stimulus generalization
Aversive conditioning
Learned helplessness
Imprinting
Operant conditioning
Positive and negative reinforcement
Punishment and extinction
Q=List four learning techniques that you may employ to improve
behavior of child?
Answer=operant conditioning
a-=positive reinforcement
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b= negative reinforcement
c- =punishment and extinction
Features =the likelihood that a behavior will occur is increased by positive
or negative reinforcement and decreased by punishment and extinction
Types of reinforcement includes
Positive reinforcement is introduction of a positive stimulus that results in
an increase in rate of behavior
Negative reinforcement is removal of an aversive stimulus that also result in
an increase in rate of behavior
Punishment= is Introduction of an aversive stimulus aimed at reducing rate
of unwanted behavior.
Extinction= in operant conditioning is gradual disappearance of learned
behavior when reinforcement is with held.
Q =Enumerate 10 question which can be asked in routine clinical
assessment of personality
List response to each in case of schizoid personality disorders
Answer=assessment of personality
Relationship
Spare time activities
Current mood and emotional attitude
Attitude and standard
Ultimate concern
Personality test are used to evaluate psychopathology and personality
characteristics and are categorized by wether Information is gathered
objectively or projectively

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B= objective personality tests e.g Minnesota multiphase personality
inventory and million clinical multiaxial inventory are based on question
that are easily scored and statistically analyzed
Projective personality tests=Include
Rorschach test, thematic apperception test
And sentence completion test require the subject to interpret question
Responses are assessed to be based on subject motivational state and
defense mechanism
Minnesota multiphase personality inventory= the most common objective
personality test are useful for primary care physician because no training is
required for administration and scoring
Evaluate attitude of pt toward taking test
Rosh ash test= is most commonly used projective personality test.
Used to identify thought disorder and defender mechanism
Projective personality test
Thematic apperception test= stories are used to evaluate unconscious
emotional conflict
It is projective test
Sentence completion test= used to identify worries and problem solving
Verbal association
Q = identify list of psychometric test that a tertiary care mental health
facility should ideally have
Justify your choice of test
Answer-= Rating of depressive symptoms=
Hamilton rating scale for depression
Beck depressive inventory
Montgomery as berg depression rating scale
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Pt heath questionnaire
Q Rating of anxiety symptoms=
Hamilton anxiety scale
Clinical anxiety scale
State trait anxiety scale
Q RATING OF obsessive compulsive disorder=
Yale brown obsessive compulsive scale
Mania= young mania rating scale
Motor symptoms =rating of motor symptoms
Q Rating used in assessment of cognitive impairment and dementia’
Schizophrenia
positive and negative syndrome scale
rating of broad group of symptoms =
general health questionnaire
brief psychiatric rating scale
Global rating scale=
global assessment of function
Clinical global impression’
Quality of life scale
health of nation outcome scale
Q EXPLICIT MEMORY is a memory that can be intentionally and
consciously recalled. it has been typically divided into two main
categories itself
1=EPISODIC MEMORY= personal events that can be recalled. Example is
your first day in college , birthday and your patient clinical state.

165
2=Semantic=facts and figures that can be recalled .it is our store of general
and specific knowledge. Examples water boils at 100centigrade,Pakistan is in
asia and heart is on left side.
Q IMPLICIT MEMORY/PROCEDURAL MEMORY
Is experiential or functional form of recalled. they have been linked to
subconscious or unconscious mechanism .this memory is used in making
responses and skilled actions .examples remembering how to dissect ,pass a
nasogastric tube, play a tennis and drive a car .
Q what you know about MOTIVATED FORGETTING
The theory of motivated forgetting was introduced by sigmoid Freud when
he described a key concept of psychoanalysis viz repression. Repression
refers to the tendency of people to have difficulty in recalling anxiety
provoking or threatening information. this helps to explain why people
generally remembers pleasant events more often than they do unpleasant
ones. the unpleasant have been repressed. this aspects should encourage to
make ones learning a lot of fun, enjoying your study and clinical work
rather than making it painful and a burden. this will happen if u leave your
exam preparation to the few days prior to exam only .
Q Explain briefly about psychiatric assessment?
PHYSICIAN IMPRESSION OF PT ABLILITY TO to accurately assess
his situation
OTHER COMPONENTS OF PSYCHATRIC ASSESSMENT
1=physical examination
2=laboratory investigation
3 psychological assessments
4=neuropsychological assessment
B=Physical assessment provides 3kinds of information in assessment
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.it may show diagnostically useful signs e.g. Goiter or absent reflexes. it is
therefore particular important in diagnosis and exclusion of organic disorders
Psychiatric drugs may produce physical side effects such as parkinsonism
due to antipsychotic drugs which needs to be measure.pt general health.
Nutritional state may all be affected by psychiatric disorders .for above
reason physical examination is an important part of psychiatric assessment
In case of out pt pt may be refereed to psychiatrist from another doctor
who ,may have recently carried out an appropriate examination of physical
examination
In case of inpatient psychiatrist is generally responsible for both physical
examination and mental health
FUND OF INFORMATION AND KNOWLEDGE
Calculating ability and name past presidents
IMPULSE CONTROL
Estimated from history and behavior during interview
JUDGEMENT AND INSIGHT
Ability to act appropriately and self respect
RELIABIILITY
LABORTORY INVESTIGATION
Depends on 1=nature of differential diagnosis
2= treatment needs to be given
3=resources available
If there is a strong suspicion of a treatable organic disorder such as dementia
the CT, MRI, cranial ultrasound , genetic testing and biochemical screening
may be needed
.by convention we do base line investigation in almost all pt such as FBC,
electrolytes , LFT And TFTs are usually carried out on admission.

167
PSYCHOLOGICAL ASSESSMENT
Clinical psychologist and psychological testing can contribute to psychiatric
assessment in several ways
NEUROPSYCHOLOGICAL ASSESSMENT
There are many psychometric tests available which measured different
aspects of neuropsychological assessment, .in learning disability IQ measure
severity of learning disability
In dementia also IQ test
If decline in performance from premorbid abilities is suspected a
discrepancy may be seen between verbal and performance IQ
E.G .schizophrenia there are persistent impairment in specific domains of
memory and attention and these predict poor outcome
COGNITIVE ASSESSMEENT
Refers to assessment of pt thoughts and pattern of thinking
NEUROPSYCHIATRIC EXAMINATION
LANGUAGE
DYSARTRIA is difficulty in production of speech by speech organs
DYSPHASIA
Is partial failure of language function of cortical origin . it can be expressive
(broacas aphasia)and receptive aphasia (wer nick aphasia)
RECEPTIVE APHASIA
Can be detected by asking pt to read and hear and comprehend spoken
words and to explain them
EXPRESSIVE DYSPHASIA
Is detected by asking pt to name objects such as watch key and pen and
some of there parts such as face of watch .language disorders point to left
hemisphere in right handed person

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Expressive aphasia suggest anterior lesion
Receptive aphasia suggest posterior lesion
AUDITORY DYSPHASIA
Temporal lobe lesion
VISUAL DYSPHASIA
Most posterior lesion
CONSTRUCTIONAL ABI,LITIES
APRAXIA is inability to perform a desire act even though motor system
and sensoriaium are sufficiently intact for person to do so
Apraxia can be tested in several ways
CONSTRUCTIONAL APRAXIA is tested by asking pt to draw simple
figures such as house or clock
DRESSING APHASIA
Is tested by asking pt to, put on some of their clothes
IDEOMOTOR APRAXIA is tested by asking pt to perform increasingly
complicated tasks to command
Apraxia especially if pt fails to complete left side of figure or dressing in
left side suggest a a right handed lesion in posterior parietal region
AGNOSIA is inability to understand the significance of sensory stimuli
even though sensory pathway and sensorium are sufficiently intact for
person to be able to do so
Agnosia cannot be diagnosed until there is good evidence that sensory
pathway are intact and consciousness is not impaired
ASTEREOGNOSIS
Is failure to identify 3dimentional form
It is tested by asking pt to identify objects placed in there hands such as key
or coins of different size

169
ATOPOGNOSIAS is inability to localize position of objects on skin
FINGER AGNOSIA
Is pt cannot identify which of there finger has been touched when there eyes
are closed
AGRAPHOGNOSIA
Is failure to identify letter written on skin
Anosognosia
Is failure to adentify functional defects caused by disease .it is seen most
often as unawareness of left sided weakness and sensory inattention after
right parietal lesion
AGNOSIAS
Points to lesion of association areas of primary sensory receptive areas
BEHAVIOURAL ASSESSMENT
Is necessary preliminary to behavioral therapy, behavioral assessment is
also used to evaluate the component of pt disorder e.g .in phobia of
avoidance and coping strategies and there relationship to stimuli in
environment and crowded places
PERSONALITY ASSSESSMENT
In past detailed personality testing including use of projective tests such as
rosharch test was often part of psychiatric assessment .these are no longer
widely used
Q = BRIEFLY DESCRIBE HEALTH BELIEF MODEL?
Is a psychological health behavior change model developed to explain and
predict health related behavior particularly In regard to uptake of health
services. health belief model model was developed in 1950 by social
psychologist at us public health service and remained most well known
and widely used theories in health belief research .prevention of illness and

170
promotion of health depends in large part upon an individual attitude toward
help seeking
HBM contains a no of variables all of which contribute to some extent to
health behavior .these factors include interest with health matters, belief
toward susc eptibility to illness severity, benefits and costs of carrying out
certain action and belief about how well those actions will work .typically
those actions will work. typically psychiatric disorders are seen in our part
of world as spiritual illnesses that are result of nazar or evil eye ,possession
by evil spirits and jins and satanic changes, this thought determines the
pathway that a psychiatric pt consequently follows.he or she therefore must
first be taken to a faith healer or pir or clergy man
Even after an eventual consultation with psychiatric tweeze daga dum
durrood must continues as adjunctive to psychiatric intervention
A sensitive doctor wil ensure strict compliance to treatment and provide
Informational care on scientific basis of disease. Sensitive dr choose a
strategy of running awareness’ campaigns thru media to enhance and
improve understanding about psychiatric disorders
And remove myths and misconception in community by replacing their
existing understanding with evidence based scientific thought
Following questions can be asked to assess pt explanatory model of illness
What do u call ur problem ?
What name does it have?
What caused ur problem?
What is onset and course of disease?
What type of treatment u should receive?
These questions can form basis of informational care session in health
settings

171
Q scenarios in which parent of 21yr old boy come to u for counseling
about their son .there son is recently admitted in university in another
alone and avoids gathering
They say that there son prefers to live alone and has no close friends
Ans=type of personality disorder is avoidant personality disorder
Q which psychomotor scale you would use
PANSS
Q HUMANISTIC PERSONALITY THEORY BBY CARL ROGAR
AND ITS THERAPEUTIC APPROACH .CARL ROGAR IS
CONSIDERED AS Father of psychotherapy in America and founded
humanistic approach to psychology, his theory was baased on
phenomenological field personality theory and have a extension and
elaborated theory
prepositives
1=all individual in this world exist as centre of world
2=organism react to field as it is experienced and perceived
3=organism react to phenomenological field as an organized whole
4= a portion of total perception becomes differentiated ass self
Q= list four distinctive features of each clinical condition
Ans=a=delusional disorder
1=fixed delusion And persistent
2=examples poaranoid in persecutory types and romantic in erotomanic type
3= few if any other thought disorder
B=organic states=
1-== types are delirium, dementia and amenesia
Delirium is characterized by confusion and clouding of connsiuosness
that result from CNS impairment

172
It usually occurs in course of acute medical illness such as encephalitis ,
meningitis but also seen in drug abuse and withdrawal from alcohol
(delirium tremens)
Q Dementia= involves gradual loss of intellectual abilities without
impairment of consciousness
Q =22yr old police man presents with 3 month history of seeing flashes
of light , feeling undue familiarity for strength often leaving police
station suddenly without reason and returning after few minutes with
a very sketchy memory of events that took place during this period of
time
He often had no explanation for his action
A= what is most likely diagnoses and differential diagnoses and
differential diagnoses
Dd = 1= dissociative disorder with depersonalization and dearealization
Further DD include
1 =TEMPORAL LOBE EPILEPSY
2 =conversion disorder
3=substance related disorder
4= panic disorder
5=PTSD
We diagnose patient on symptom occurred during episodes
Q KEY SYMPTOMS= IN ABOVE CASE
Depersonalization often described as an out of body experience
Derealization= perception of event is often distorted or strange during
episode of depersonalization accompanied by feeling of being detached
from physical surrounding

173
Jamais-vu(a sense of familiar things being strange,), déjà vu(a sense of
unfamiliar things being familiar and other forms of perceptual distortion
may occur)
TREATMENT=
1=psychotherapy directed at decreasing anxiety
2= hypnosis
3= drug assisted interview as well as long term psychoanalytically oriented
psychotherapy to recover lost memories of disturbing emotional experiences
Q=48 yrs old man suffering from bipolar affective disorder type 1 for
last 18 yrs is on prophylactic lithium therapy since from years.now for
last few months he feels that he has become slow and has developed
intolerance to cold ?
Q=what is likely cause of this clinical picture
Ans=Lithium induce hypothyroidism .
Some patient especially women gain some weight when taking drugs.
Persistent fine tremor mainly affected hand of patient but coarse tremor
suggest that plasma conc of lithium has reached toxic level .
Propranolol is given upto 40 mg TDS may reduce symptom but hair loss
and coarsening of hair texture can occur .
Thyroid gland enlargement occur in 5% of patient who are taking lithium .
thyroid shrinks again if thyroxin is given while lithium is continued and it
generally returned to normal a month or two after lithium has been stopped .
lithium interfere with thyroid production and hypothyroidism occur upto 20
% of women patient with compensatory rise in TSH . we shall do TSH ,T3,
T4, every six months to help to detect these changes . other clinical signs
include lethargy and substantial weight gain. If hypothyroidism develops

174
and reason for lithium treatment are stil strong thyroxin treatment should be
added
Q = what specific investigation will you will undertake to reach
diagnoses
Ans=T3, T4 AND TSH
And lithium every 6 months
Q =what management steps for above pt
Ans= in above question already mentioned
Q = 25 yr old male is diagnosed to be suffering from obsessive
compulsive disorder
A =what specific steps would you ensure in Informational care session
and and what treatment option would you offer him ?
Ans= seven question in informational care session
1=what is wrong with me?(diagnoses)
2= why I have developed this disease (etiology)
3= is there any effective treatment to my problem ?
Is treatment safe?
Are there any serious side effects?
4=how long will take to recover?
(Prognoses)?
5= is there any restriction in diet?
6-= is there a risk of illness being spread to those who are around me or
passing it to my offspring’s?
7= how will illness and treatment affect my functioning?
Can I continue to work or rest?
What will happen to my sex , sleep and appetite?
Q = what treatment option would you offer him?
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Ans=1= pharmacological
2=psychological treatment=
B = behavioral psychotherapy=
Relaxation training, guided imagery , exposure, paradoxical inventory,
response prevention , thought stopping techniques and modeling
Pharmacotherapy includes ssri e.g flovoxamine, clomipramine
Q = name five behaviuoral methods that are likely to be effective in
this case= of obsessive compulsive disorder
Ans= 1-= Relaxation techniques 2= Guided imagery ‘
3= Exposure 4= Paradoxical intent
5= response prevention 6- thought stopping techniques and modeling
Q = enumerate types of delusion which may bbe found in pt suffering
from major depressive disorder with psychotic feature
(both mood congruent and mood incongruent)
Ans=psychotic depression
That type of depression in which there are features of delusion and
hallucination both
Type of delusion includes
1= delusion of guilt
2= hypochondriac delusion
3= persecutory delusion
4= delusion of impoverishment
5= nihilistic delusion
6= costarred delusion in which pt says that his intestine are block but no
evidence of disease in abdomen
7= delusion of guilt

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Q = what are difference between delusion in schizophrenia and affective
disorder
Ans= in scyzoprenia we see paranoid delusions . in affective disorder we
see grandiose delusion .Associated symptoms with paranoid delusion will
be suspiciousness , auditory hallucination, social withdrawal , lack of self
esteem
In mania we see grandiose delusion. Other symptoms of mania will be
present like distractibility, irresponsible , flight of ideas, Social withdrawal ,
over talkative, pressured speech
Q = you have seen a 30 yr old pt who has presented with tremors, and
other involuntary movements
There is a strong family history of similar illness
You suspect a genetic basis of inheritance
What is most likely diagnoses and what is mode of inheritance
Answer= diagnoses=Huntington disease with chorea
Mode of inheritance is autosomal dominant
List principles of governing this mode of inheritance?
Autosomal dominant inheritance is associated with structural lesion
Q =you are managing a pt on ward who is threatening to kill himself
what factors you wil consider in assessing risk of suicide?
What steps will you take to prevent him from community suicide on
ward?
Ans= risk factors=
The risk of completed suicide increase in sad persons
Already discussed in suicide risk
Q Prevention of suicide=
1= service changes

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2-= better and more accessible psychiatric services
3= restriction of means of suicide
4= encouragement of responsible reporting
5= educational program
6= improving care for high risk group
7= crises centers and telephone hot lines
8= reducing means of availability of methods of suicide
9= more responsible media reporting
Q = you have seen a 22yr old presented with 3yr history of gradual
deterioration of functioning level , social isolation, self neglect and self
talking
What is most likely diagnoses
Ans= schizophrenia
Q =what other sign and symptoms he likely to harbor
Illustrate each with how it will present clinically in pt language
1= hallucination(mostly auditory hallucination)
Pt will say that when he is alone he hear voices that you are to be killed
and and kill some one or attack on some one
Delusion= mostly bizarre that my intestine are blocked and I cannot
defecate
Disorganized speech and behavior=
Poor grooming and disheveled appearance
Negative symptoms = impairment in social interaction, communication
and lack of motivation
Q First rank symptoms of schneder will be present
1= hearing thought spoken a loud
2= hallucination in form of commentary
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3= auditory hallucination
4= delusional perception
5= thought Insertion
6= thought withdrawal or thought broadcasting
7= somatic hallucination
8=delusion of control
9= delusion of reference
Q = you have been treating a pt suffering from depression , you have
prescribed foluxetine, 20mg per day
After 8weeks pt reports no improvement
What are most likely causes of this out come?
1= lack of compliance
2= dose needs to be increased
3= some pt donot respond to specific drug
B=Q what treatment option you would consider in this situation
Ans = 1= dose needs to be increased
Maximum dose is 80mg per day
We may try another SSRI
SSRI such as paroxetine , setraline or flovoxamine or escitalopram or tca
or mao
We may give venlafaxine or add some antipsychotics for augmentation
therapy of antidepressant medication, we may start pt on mirtazapine(15mg
upto 45mg)we may add add following in addition to ssri 1=bupropion ,
2=buspiron 3=lithium 4=thyroxin
When we add lithium or thyroxin we must moniter their levels in blood.
Q = you have seen a 22 yr old male who has 2 yr history of repeated
episodes of unconsciousness
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Ans =1=Epilepsy 2= Diabetic ketoacidoses
3=Hypertension 4= Stroke 5= Electrolytes imbalance
Q Diagnoses of epilepsy
Take a detailed history from pt and
Interview an eye witness who has observed an attack
Specific questions=
Events leading up to attacks
Sleep deprivation, drugs alcohol and near tv screen
Time of day and night
Symptoms of aura and duration
Abnormal movements
Limb stiffness, jerking and automatism
Salivation and cyanoses
Tongue biting and incontinence
Limb pain, headache and drowsiness
Q Examination in epilepsy=
Auscultation of neck and eyes for bruit
Pulse blood pressure and heart for auscultation
Skin for lesion of neurofibromatosis
Visual field, and optic fundi
Limbs for evidence of hemiparesess and hypereflexia
Q=pt came to you and says he cannot go to sleep and ask for
prescription of hypnotics
Before prescribing hypnotics
a--= what further inquiries will you make before suggesting a
treatment?

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Assessment= requires a full psychiatric and medical history together
with detailed inquiries about sleep complaints
Transient insomnia occurs at time of stress or as jet lag
Short term Insomnia is associated with personal problems for example
illness and Bereavement, relationship difficulties or stress at work
Insomnia in clinical practice is usually secondary to other disorders notably
painful physical condition, depressive disorders and anxiety disorders
It also occurs with excessive use of alcohol, caffeine and in dementia
Sleep may be disturbed for several weeks after stopping heavy drinking
Sleep problems are also common in association with many medical illness
that results in any significant pain or discomfort or is associated with
metabolic disturbances
They may also be provoked by prescribed drugs ‘
In about 15 % of cases of insomnia, no cause can be found(primary
insomnia)
Peoples vary in there amount of sleep that they require and some of those
who complains of insomnia may be having enough sleep without realizing it
Sleep studies are rarely used
Q = what sleep hygiene you will ensure?
Ans= Sleep environment should be familiar and comfortable
Dark
Quite
Encourage bed time routine
Consistent time for going to bed and walking up
Going to bed only when tired
Thinking about problem before going to bed
Regular exercise
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AVOID= overexcitment before going to bed
Late evening exercise
Caefine containing drinks late in day
Excessive alcohol and smoking
Excessive day time sleep
Large late meals
Too much timing In bed lying awake
Q Treatment for insomnia=
Non pharmacological treatments =
Sleep hygiene
Cognitive therapy
Stimulus control therapy
Sleep restriction
Progressive muscle relaxation
Pharmacological treatment
Short acting benzodiazepine such as temazepam
Z drugs like zolpidem , zoleplon or zopiclone
Low dose sedating antidepresents such as trazodone
Metformine
Q =you are asked to see a 65 yr old man presenting with 3 day history of
disoreantation, fluctuating level of consciousness , visual hallucination,
labile affect and agitation
Q= what is most likely diagnoses
Ans=delirium
Q what physical Investigation will you carry out ?
Ans=Physical examination=

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Motor abnormalities commonly present includes incoordination, tremor
,asterixis and nystagmus
Incontinence is common
There is often evidence of underlying general medical condition or
substance specific syndrome.
Diagnostic test=EEG often shows either generalized slowing of activity , fast
wave activity or focal abnormalities. Abnormal finding from neuroimaging
and neuropsychological testing may be required
Q = in above questions briefly describe management(delirium)?
Ans= treatment=
1= correction of physiological problem is essential
2= frequent orientation and reassurance are helpful
3=protective use of physical restraints and high potency antipsychotic
medication for dangerous medication should be considered
DDs=1=dementia
2=substance intoxication and withdrawal
3=psychotic disorders are major rule outs
Q =you are treating a pt suffering from schizophrenias, he has not
responded to a trial of typical antipsychotics
Q =in above case what atypical antipsychotics are available in Pakistan
Ans= atypical antipsychotics which are available in Pakistan are
1=clozapine 2=olanzapine
3=quetiapine 4-=ziprasidone 5=aripiprazole
Q =what are indication of clozapine use?
Ans=treatment resistant schyzoprenia
Q = what is most severe side effects of clozapine

183
Ans=1= in 2%pt leucopenia which progresses to agranulocytoses
2=myocarditis
Q =What is maximum dose of clozapine?
A ns= 900mg per day
Q =what is meant by metabolic syndrome?
ANS= many psychotropic drugs appears to affect energy balance in body
leading to weight gain and potentially metabolic syndrome(obesity, insulin
resistance and hyper lipidemia)
The most problematic agents in this regard are olanzapine and clozapine
although all atypical antipsychotics and some mood stabilizers(lithium and
valproate) are associated with increase body mass and may precipitate
diabêtes
Mechanism is unclear.some antipsychotics appear to increase apetite,
sometime substantially and they also decrease metabolism
Generally benefit of antipsychotics therapy for psychotic disorders
outweight risk of metabolic effects. Pt and family should be Informed of risk
prior to therapy initiation. Base line body measurements and fasting lipids
and glucose should be checked at initiation and periodically during treatment
Q =what investigation you will do to rule out metabolic syndrome?
Ans= baseline body measurement
And fasting lipids and glucose should be checked at initiation and
periodically during treatment.
Q =you are treating a pt suffering from depression and is seriously
suicidal and you decide to administer ect,
Q =in above case what are steps you will put into place before
administering treatment?
Ans= investigate pt for any medical illness
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Do LFTS, RFTs, SERUM ELECTROLYTES,CBC, EC G in each pt , also do
other investigation according to need e.g. chest x ray pa view, CT brain
Advice ect according to updated guidelines keeping in view comorbid
condition if any and discuss possible wanted and unwanted effects of ECT
with pt or attendant
Stop or decrease dose of any medication that can increase seizure threshold
e.g mood stabilizers, bzd, barbiturates for sufficient time before ECT,
according to their pharmacokinetics e.g elimination rates and half life
Take written consent
Keep NBM, for at least 6hr before ect
If any medication needed too much then can take with sips of water
Patient should have clean oral cavity(with tooth brush) and remove any
artificial changeable denture
Check vitals of pt b.p, pulse, temp, and weight
Q = what are steps of administering ect under general anaesthesia?
Ans=pass iv line
Inj propofol iv in dose of 1.5mg /kg along with atropine (. 5-1mg)
But resembles always give lowest possible dose of anaesthetic , just to
induce hypnoses in pt because it also increase seizure threshold
Iv suxamethonium iiv in dose of 1mg per kg to 2mg per kg (maximum
about 150mg) in same cannula after above
Place plastic or wooden block clenched between teeth of pt ,
Apply bilateral electrode over 3cm above midpoint of line drawn
between extrernal angle of orbit and external auditory meatus
Electrical stimulus should be 1.5 times of seizure threshold in bilateral
electrode methods
If seizure is observed for at least 15 seconds then well and good
185
If not then restimulate 45 seconds after permission from anaesthetist
3 ect per week for 3 week so maximum only 12 ect in one session of
treatment
Q Adverse effects of ECT=
Adverse effects of ECT by itself are rare and mostly due to anaesthetics and
other agent used in ECT
1= alteratrion of bp and cvs complication in ischemic heart disease
2= death due to anaersthesia in pt with comorbid medical condition
3= dental and oral treatment
4=pain and muscle ache
5= prolong apnea and aspiration pneumonia
6= skin burn at site of application of electrode but rare when water saline
soaked swabs are used over electrodes
7= antegrade and retrograde amnesia
Q =name psychiatrist who contributed toward development of
current criteria of schyzoprenia
Ans=1=vignettes 2=kurt shnedre
3=crow 4=liddle 5-=kaeplon
6=grisengwr’
7= eugen gubler 8=cart jung
9= lamherd

Q =pst partum depression senarios

name an d write briefly scales you would use

ans= edinberg post natal rating scale

186
Q Concept of preventive psychiatry=

1=primary prevenmtion

2-=secondory prevention

3= tertiary prevention

Primary prevention= aims at promotion of mental health and prevention of

mental disorder i.e reduction of occurrence of new cases of mental disorders

The community mental health nurse has a significant role in primary prevention

Promotion of mental health can be done by nurse by educating members of

community on principles of mental health and mental hygiene by providing them
healthy coping mechanism in handling day to day stresses in life etc

Secondry prevention= it focus on early identification and effective treatment for

those suffering with mental disorders

Tertiary prevention=

It aims to reduce the rate of disability due to longer duration of suffering from
mental disorder

It aims to help pt in readjustment with family and community from where he

comes thru rehabilitation

187
Q SENARIOS OF epigastric pain
Dd include 1 Dudenal ulcer
2=Gastritis
3=Gastric carcibnoma
4=GERD
Q IMPORTANT investigation for duodenal ulcer
1=Endoscopy 2=Barium meal
3=Manometry
Q MANAGEMENT PLAN
1= H2 RECCEOPTER ANTAGONOIST
2= BISMITH CHELATER
3= SUCRALFATE 4=OMEPRAZOLE
5=PIRENZAPINE AND ANTACID
Q pt with one day history of severe loss of vision in one left eye and
optic disc swelling on ophthalmoscopy and pt is anxious asnd worried
and past show that 6month back she was admitted for lower limb
weakness
Dd 1=amarorous fugax
2=clouding of normality
3=transparent eye structure
4=Central retinal vein occlusion
5=Central retinal artery occlusion
6= ABNORMALITIES OF RETINA AND NERVE
Q INVESTIGATION
1=MRI OR CT OR USG FOR CAROTID ARTERY FOR TIA OR FOR
AMAROUS FUGAX
2=EEG =continuous monitoring of heart rythm
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3=ESR measurement
4=CRP and platelets
5=examination by doctor
Treatment option
Disorder causing loss of vision is treated as early as possible although
treatment may not be able to save vision
However prompt treatment may decrease risk of same process in other
eye .sudden loss of vision is emergency so should go to hospital
.Presence or absence of pain help indicate whaty causes are most likely
If vision returns early on its own TIA or ocular migraine are among likely
causes
Q = discuss Investigation of epileptic fits occurring in a 28yr old man
with no history of seizure
Ans=investigation=
FBC
Urea and creatinine
Lumber puncture
Urine for toxin and blood for calcium ,magnesium and phosphate
Lfts
Brain imaging
1=CT scan or MRI to rule out structural lesion
2= PET and SPECT is used to evaluate when medical theraphy is in effective
EEG is suggestive but not diagnostic
Chest x ray is used after age of 20 for seeing because it is most common site
for primary and seccondry neoplasms
Q = five most common causes of medical and physical causes of sexual
DYSFUNCTION?
189
ANS=1=Endocrine causes suchnaS DIABETES MELLITUS ,hyperthyroidism
,myxedema and Addison disease
2=Gynecological causes= such as vaginitis and endometrioses
3= CVS such as angina ,MI..peripheral vascular disease
4=Respiratory such as asthma and copd
5=Arthritis and renal failure
Q BIOPSYCHOSOCIAL MODEL
George angel in 1970 for first time started to emphasize the importance of
integrating the traditional biological (pathophysiological or
sciences(sociology, psychology and structural) aspects of medicine with
behavioral anthropology) and put forward the concept of biopsychosocial
perspective of health and disease
Using system theory(an individual is composed of a complex integrated
system of interacting subsystem of elements of mind ,body, spirit and social
relationships and all having feedback loops. He proposed a triad in which the
biological system ensure a structural ,biochemical and a molecular study of
a disease, the psychological system provides an insight into the role of
personality, attitudes, attributes,other dynamic factors whereas a social
system emphasizes the impact of family, social forces, culture and melee on
aetiology, presentation and management of illnesses.
It stresses on understanding and manipulation of psychosocial environment
of patent in same way as study of pathophysiological processes and method
of treatment is used to reverse them.
The death of significant other, grief, loss of self-esteem, a threat to one’slife,
a propertyor integrity, even victories and reunions were proposed by Engel as
events that can trigger a medical, surgical or psychiatric condition

190
The biopsychosocial model therefore provides a comprehensive clinical
approach toward practice of holistic medicine. This approach lays a great
emphases on doctor pt relationship, psychosocial assessment, use of
communications skills, informational care, counselling crises intervention
and expansion of care to family. The doctor pt relationship is discussed in
section B while psychosocial assessment is part of section E.
One of significant contribution of bps model in health care is emphases it
assigns to use of intervention that does not involve surgery or drugs, the non-
pharmacological interventions
Q =you have been asked to see a 25yr old female who has attempted to
commit suicide by taking overdose of medication
a-= which people you are going to include in assessment of this patient?
Ans=if married then partner and kids
If unmarried then sister and brothers for risk assessment
Give your management plan
Ans already discussed
Q =NEUROCOGNITIVE DISORDERS
1=Delirium
2=Dementia also called as major neurological disorder
3=Mild neurocognitive disorder
Q SUBSTANCE RELATED AND ADDICTION DISORDER
Intoxication and psychoses
Withdrawal
Gambling disorder
NEUROSES AND NON PSYCHOTIC DISORDERS
Is a mixed bag of disease?

191
GENERALIZE ANXIETY DISORDERS is characterized by continues
anxiety without any reason
Q TRAUMATIC STRESS D ISORDER
Follow exposure to a traumatic event such as involvement in war or rape
Q Factitious disorder
In which patient pretends illness
Q DELIRIUM=
ACUTE CONFUSIONAL STATE which occurs in high fever,
alcohol,,delirent poisoning and mental stresses
Manifestation=
1= clouding of consciousness
2=disorientation
3=hallucination
4=delusion
5-=in coordination
Pt may commit suicide
He therefore not responsible for such act if he has lost consciousness to
such an extent that prevent him from knowing the nature of act.
This condition last from few hours to few days and end with partial or full
recovery
Q;Causes of schizophrenia § Cannabis and Long-term effects of cannabis §
Schizophrenia

According to some studies, the more often cannabis is

used the more likely a person is to develop a psychotic
illness with frequent use being correlated with twice the
risk of psychosis and schizophrenia. While cannabis use is
accepted as a contributory cause of schizophrenia by
some, it remains controversial, with pre-existing

192
vulnerability to psychosis emerging as the key factor that
influences the link between cannabis use and psychosis.
Some studies indicate that the effects of two active
compounds in cannabis, tetrahydrocannabinol (THC)
and cannabidiol (CBD), have opposite effects with respect
to psychosis. While THC can induce psychotic symptoms in
healthy individuals, CBD may reduce the symptoms caused
by cannabis.

Cannabis use has increased dramatically over the past few

decades whereas the rate of psychosis has not increased.
Together, these findings suggest that cannabis use may hasten
the onset of psychosis in those who may already be predisposed
to psychosis.] High-potency cannabis use indeed seems to
accelerate the onset of psychosis in predisposed patients. A 2012
study concluded that cannabis plays an important role in the
development of psychosis in vulnerable individuals, and that
cannabis use in early adolescence should be discouraged.

Q classification of childhood psychiatric disorders according to ICD - 10

Ans= f8 disorders of psychological development

Specific developmental disorder of scholastic(educational ) skills

Specific developmental disorders of motor function

Specific developmental disorders of speech and language

Pervasive developmental disorder

F9=behavioral and emotional disorders

With onset usually in childhood and adolescence

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Hyper kinetic disorder

Conduct disorder

Mixed disorder of conduct and emotional disorders

Emotional disorders with onset usually in specific to childhood

Tic disorder

Other behavioral and emotional disorder with onset usually IN CHILD HOOD
AND ADOLESENCE INCLUDES elimination disorders and feeding disorders

Multi axial system have been proposed=icd 10 Has six axes

1=clinical psychiatric syndromes

2= specific delay in development

3 = intellectual level

4= medical condition

5= abnormal sociall situation

6=level of adaptive functioning

Q Functionof blood brain barrier

The blood–brain barrier acts very effectively to protect the brain from many
common bacterial infections. Thus, infections of the brain are very rare.
Infections
of the brain that do occur are often very serious and difficult to treat.
Antibodies are too large to cross the blood–brain barrier, and
only

194
certain antibiotics are able to pass. In some cases a drug has to be administered
directly into the cerebrospinal fluid (CSF) However, drugs delivered directly to
the
CSF do not effectively penetrate into the brain tissue itself, possibly due to the
tortuous nature of the interstitial space in the brain. The blood–brain barrier
becomes more permeable during inflammation. This allows some antibiotics
and phagocytes to move across the BBB. However, this also allows bacteria and
viruses to infiltrate the BBB. An exception to the bacterial exclusion is the
diseases
caused by spirochetes, such asBorrelia, which causes Lyme disease, Group B
streptococci which causes meningitis in newborns and Treponema pallidum, which
causes syphilis. These harmful bacteria gain access by releasing cytotoxins like
pneumolysin which have a direct toxic effect on
brain
microvascular endothelium and tight junctions.

There are also some biochemical poisons that are made up of large molecules that
are too big to pass through the blood–brain barrier. This was especially important
in more primitive times when people often ate
contaminated
food. Neurotoxins such as botulinum in the food might affect peripheral nerves, but
the blood–brain barrier can often prevent such toxins from reaching the central
nervous system, where they could cause serious or fatal damage.

4 Parts of the Brain Not Protected by the Blood Brain Barrier

Some parts of the brain are not protected by the blood-brain barrier, which
prevents
toxins and large molecules from entering the brain.

The blood-brain barrier prevents toxic substances, large molecules, and

neurotransmitters released in the blood from entering the brain. Four areas of the
brain are not protected by the blood-brain barrier. These areas include the

195
posterior pituitary gland, pineal gland, the median eminence of the
hypothalamus and the area postrema.

Q =how flouxetine differs from duloxetine pharmacodynamically

=fouxetine is sssri while duloxetine is snri

Q =copropraxia= complex motor ticks tend to be slower .

Q four psychotropic for treatment of tourete syndrome

Ans=1= pimozide 2=haloperidol 3-=risperidone 4=clonidine

Q Thought disorder

Thought disorder (TD) or formal thought disorder (FTD) refers to

disorganized thinking as evidenced by disorganized speech. Specific thought
disorders include derailment,poverty of
speech, tangentiality, illogicality, perseveration, neologism, and thought
blocking.

Psychiatrists consider formal thought disorder as being one of two types of

disordered thinking, with the other type being delusions. The latter involves
"content" while the former involves "form". Although the term "thought
disorder" can refer to either type, in common parlance it refers most often to
a disorder of thought "form" also known as formal thought disorder.

Q NEROLOGICAL CONDITION AFFECTING PERSONALITY

196
Causes

There are several possible causes for Organic Personality Syndrome. Frequently it
is the consequence of structural brain damage from neoplasms (tumors), head
trauma, or cerebrovascular disease involving the upper part of the brain and its
blood vessels. Less commonly, it may be caused by endocrine disorders such as
thyroid and adrenocortical (outer part of adrenal gland) disease, or by ingesting
certain psychoactive substances (drugs that affect the mind or behavior). The
syndrome may be of short duration if caused by medications, drug abuse, or certain
types of tumors that are surgically removed. It may be of long duration if it is
secondary to structural brain damage

Q Physical causes of erectile dysfunction

In most cases, erectile dysfunction is caused by something physical. Common

causes include:

Heart disease
Blocked and congested blood vessels (atherosclerosis)
High cholesterol
High blood pressure
Diabetes
Obesity
Metabolic syndrome — a condition involving increased blood pressure, high
insulin levels, body fat around the waist and high cholesterol
Parkinson's disease
Multiple sclerosis
Peyronie's disease — development of scar tissue inside the penis

197
Certain prescription medications
Tobacco use
Alcoholism and other forms of substance abuse
Sleep disorders
Treatments for prostate cancer or enlarged prostate
Surgeries or injuries that affect the pelvic area or spinal cord
Q =comment on relevance of model that you prefer ion practice of
psychiatry in in pakistan
Ans= biopsychosocial model

Q =Classification of people by ernst keshmer=

Kretschmer divided personality into two "constitutional groups": Schizothymic,

which contain a "Psychaesthetic proportion" between sensitive and cold poles,
and Cyclothymic which contain a "Diathetic" proportion betweengay and sad. The
Schizoids consist of the Hyperesthetic (sensitive) and Anesthetic (Cold)
characters,
and the Cycloids consist of the Depressive (or "melancholic")
and Hypomanic characters.

The three types

Sheldon's "somatotypes" and their associated physical and psychological traits can
be characterized as follows:

198
comparison of body types
Ectomorphic: characterized as linear, thin, usually tall, fragile, lightly muscled,
flat
chested and delicate;.
Mesomorphic: characterized as hard, strong, rectangular, athletically built with
well developed muscles, thick skin and good posture;.
Endomorphic: characterized as round, usually short and soft with under-developed
muscles and having difficulty losing weight
Q =HEALTH BELIEF MODEL OF PARENTS AND FACTORS
AFFECTING CHOICE OF TREATMENT FOR THERE SON?
Prevention of illness and promotion of health depends in large part upon on
individual attitude toward help seeking and value of health
The health belief model contains a number of variables all of which
contribute to some extent to health behavior,these factors include interest
and concern with health matters,belief about susceptibility to illness,ideas
about illness,severirity ,benefits and cost of carrying out certain action and
belief about how well those actions will work.
Elaboration of HBM HAS ALSO empasised importance of opinion of
respected peoples in Individual life and perceived amount of personal
control that people perceive they have over events
Typically psychiatric disorders are seen in our part of llnes as spiritual
illnesses that are result of nazar or evil eye,possession by evil spirits and
satanic changes.this thought
Determines the pathway that a psychiatric pt consequently follows.he or she
must first be taken to a faith healer,a pir or a clergy man even after an
eventual consultation with a psychiatrist , taweez, dagha, dum, darood must
continue as adjunctive to psychiatric intervention.

199
A sensitive doctor will ensure strict compliance to treatment and gives an
informational care on scientific basis of disease.he is however not expected to
challenge or try and alter health belief model of patient and or his family
thru a process of confrontation.
He may instead choose a strategy of running awareness campaigns thru
media and to enhance and improve the understanding about psychiatric
disorder and remove myths and misconception in community by replacing
their existing understanding with evidence based scientific thoughts
.changing attitude and hence behavior is not just a question of telling people
what to do, it is to show them the benefit without shaking or challenging
their conventional wisdom.
The following questions can be asked to assess pt explanation model of
illness
Q what do u call ur illness?
Q what name does it have?
Q What do u think has caused your problems ?
Qhow do u think it started and what course do u think will it take?
Q what type of treatment do u think u should receave?
Qwhat do u think can illness do to u and those around you? These questions
can form the basis of an informational care session in health care settings
Q MOTHER OF A 2YR OLD child a renowned social worker often has
to leave her child under supervision of house maid.she told that she is
going abroad alone for four months training and wants to know possible
impact impact of her frequent absence on her child?
Answer=separation anxiety disorder
Failure to thrive

200
John bowlbey showed that nurture abilities of main care giver plays an
important role in giving the infant a secure emotional attachment which is
of critical importance in development of satisfactory inter personal
relationship. insecure attachment can increase risk of various kinds of adult
psychopathology including depression
Q write3conditions in which informed consent is not required
Answer=1=Emergency
2=Waiwer by pt 3=Pt is incompetent
4=Theapeutic privileged (unconscious confused physician deprives pt of
autonomy in interest of health)
Q write three conditions which illegally impair capacity of mother for
informed consent?
Answer=1=Schizophrenia 2=Alzemers disease 3= Delirium
Q you have to plan trial for antipsychotics what measure u wil use to
screen population?
Answer=BPRS
Q what measure u will use to measure a response to antipsychotics
PANNS SCALE
Q what measure u will use to measure efficacy of medication in drug
trial
Answer=PANNS
Q scenarios of panic disorder with apprehension, palpitation,
sweating, restlessness
Answer= panic disorder
QDDx of panic disorder=1=agoraphobia
2=depression 3-= generalize anxiety disorder
4= substance abuse
201
Q list psychometric and psychological intervention you would
undertake in this case
Answer=psychometric tests=1 =Hamilton anxiety scale
2=HAD 3=BDI
Biological investigations =BLI,TFT,CALCIUM AND PO4,LFT AND RFT
Q TREATMENT OF PANIC DISORDER=
PHARMACOLOGICAL INTERVENTION
1=SSRI such as
fluoxetine,SETRALINE,VENLAFAXINE,PAROXETINE,ESCITALOPRA
M
2=alprazolam , clonazepam, imipramine and clomipramine ,MAOI such as
phenelzine
PSYCHOTHERAPEUTIC INTERVENTION INCLUDE
1=RELAXATION TRAINING FOR PANIC ATTACKS
2= DESENSETIZATION FOR AGORAPHOBIC SYMPPOMS
Q 42yr old pt of bipolar disorder stabilize on lithium for past six
years presents with complains of lethargy ,dry coarse skin ,cold
intolerance, weight gain, menstrual irregularities for past 2 months
,Diagnosis is lithium toxicity
Management =keep plasma level below 1.5meq/liter
Dehydration and hyponartremia predispose to lithium toxicity by
increasing serum lithium levels
Tremors at therapeutic levels may respond to decrease dosage
Divided dosage or slow release effects by decreasing peak plasma levels
Q 40YR teacher whose two daughter moved to Karachi for university
education lost her husband in accident 2yr ago .personal history reveal
demise of hr mother when pt was 9yr old ,her father died when she was
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20yr ,for last one yr se feels sad and fatigue easily most of time has
sleep disturbances and late insomnia decreseapetite and decrease weight
DD include
1=Hypothyroidism 2=parkinsonism
3=Pseudodementtia 4=cva
5=Mood disorder 6=substance disorder 7=grief
Q RISK FACTORS FOR MAJOR DEPRESSION=
MAJOR depression is seen in women due to several factres
1=hormonal differences
2=great stress
3=simply bias in diagnosis
Typical age of onset is 40yrs
There is higher incidence in those who have no close interpersonal
relationship or are divorced or separated .
ECT CT
Family history of depression , exposure to stress
Behaviuoral reasons such as learned helplessness
Q MANAGEMENT OF MAJOR DEPRESSION
Must first secure safety of pt because suicidal risk is very high
1=SSRI
2=TCA 3=MAOI
4=ECT 5=INDIVIDUAL PSYCHOTREAPHY
AND CBT
Q = screening of post CVA depression
Answer=sertraline 50mg od at morning
Becoz TCA can cause anticholinergic effect and arrhythmia and
cardiotoxicity and suicide with increase dose
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Q Scenario’s of ocd pt was washing hand repeatedly ?
Answer=psychological terms include obsession and compulsion
Q scenarios with short term and long term memory loss. what are
anatomical areas involved in these memories ?
Short term memory is thru Hypocampus while long term memory thru
amygdala .Both are embedded under temporal lobe
Q parents of 21yr old boy came for counselling of their son in which
son prefer to live alone
Answer=1 shizotypal personality disorder 2; avoidant personality and
antisocial Pd.and paranoid pd
Q a history student complains that although he is good in
remembering short events in history but he has problem in
remembering names and years
.identify types of memory
Ans short term and long term memory
Q give psycho physiological basis?
Answer 1=Facilitates potentiating of memory
2=NMDA receptors role of glutamate to increase influx of calcium inflow
3 =Increase sensitivity to nerve cells to acetylcholine
Q enumerate scales psychometric scale that you will require in such a
case of personality disorder?
1 PANSS MMPI
Projective tests such as HTP AND ROSASCH TEST
Objective tests include MMPI
Q yield = amount of previously unrecognized that is dx as a result of
screening test
It depends on sensitivity , specificity and prevalence

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e.g by limiting a diabetes screening program to person over 40yr we can
increase yield of screening test
high yield population usually selected for screening
Q somatoform disorder
Presentation of physical symptoms with no medical explanation
Symptoms interfere with social or occupational functioning
somatization disorder a disorder consisting of multiple symptom affecting
multiple organs
Etiology=affects women
Low socioeconomic status
begin by 30 yr of age
genetic linkage
within families male relatives have antisocial pd and female histrionic pd
Physical and psychiatric symptoms= many physical symptoms affecting
multiple organ and no medical explanation
long complicated medical histories
interpersonal and psychologic symptoms are usually present
at least 4 symptoms
2 gastrointestinal
1 sexually
One pseudo neurologic symptoms
For dx 4 symptoms should be there
Commonly associated with depression pd and substance related disorders
Tx single physician as primary care taker
Individual psychotherapphy is needed to cope with symptoms
Ddx
Medical disorders
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Multiple sceleroses,
MR , SLE , THYROID
PSYCHIATRIC=1=MDD
2=GENERALIIZE ANXIETY DISORDER
Q what are types of memories ?
Ans=1-= sensory memory for sensations like sight ,sounds and taste and last
one to two seconds
2=short term memory can be stored as images and sounds and act as
temporary store house for small amount of information
3= important and meaningful information is transferred to permanent store
house of long term memory
Q= Anatomical areas involved in memories?
ans=short term memory by hippocampus
Long term memory by amygdale
Other structures involved are
Hypothalamus, mamilory bodies, and thalamus
Q=parents of 21 year college students came for counseling of their son
because there son prefer to live alone and avoids gathering and has no
close friends?
Q= What are types of personality disorders in this pt ?
ANS= 1=SHYZOTYPAL 2= PARANOID
3= AVOIDANT PD
Q= In above case name psychometric test that you wil require in such
case?
Ans= projective tests and objective tests=
Projective includes htp,rosach test,
And objective Includes MMPI,16PT
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Q= mother of pt of schizophrenia has to give informed consent for use
of child
What are her rights?
Ans=full consent requires that pt has received under stand five pieces of
information
1= nature of procedure
2=purpose of procedure
3= benefits
4=risks
5=alternative procedures
Q= write 3 condition which may legally impair capacity of mother of
pt to give informed consent?
Ans=1=schizophrenia 2= Alzheimer disease
3= dementia 4= delirium
Q Medical guideline

A medical guideline (also called a clinical guideline, clinical

protocol or clinical practice guideline) is a document with the aim of
guiding decisions and criteria regarding diagnosis, management, and
treatment in specific areas of healthcare. Such documents have been
in use for thousands of years during the entire history of medicine.
However, in contrast to previous approaches, which were often based
on tradition or authority, modern medical guidelines are based on an
examination of current evidence within the standard patern
of evidence-based medicine. They usually include
summarized consensus statements on best practice in healthcare. A
healthcare provider is obliged to know the medical guidelines of his
or her profession, and has to decide whether or not to follow the
recommendations of a guideline for an individual treatment.

Q = what antipsychotic you will prescribe in pregnancy=

Ans-= Aripiprazole

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Q which antipsychotic drug you will give in old age
Ans ==we should give same drugs in old age but should give in low dose
Q what antipsychotic we wil give in childs below 12yr
Ans= we give syrup and also in low dose
Q psychomotor tools in Alzheimer disease=

COGNITIVE FUNCTION
Minimental state examination
Six item cognitive impairment test
Seven minute screen
Clock drawing test
Hopkins verbal learning test
Alzheimer disease assessment scale and cognitive sub scale
Cambridge examination for mental disorders of elderly cognitive section
Behavioral and psychological features
Neuropsychological inventory
MOUSE PAD
BEHAVE AID
COHEN MANS FIELD AGRESSION INVENTORY
ACTIVITIES OF DAILY LEARNING
Bristol scale
Alzheimer disease functional and change scale.
Disability assessment for dementia
DEPRESSION
Cornel scale geriatric depression rating scale
GLOBAL ASSESSMENT
Clinical dementia rating scale

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Q =STRESS AND COPING
Definition=the concept of stress as borrowed by physiology and
psychology from physics where it generally refer to a force acting
against some resistance. Hans ley introduced the concept of stress into
physiology
He defined stress as rate of wear and tear in body and also stated another
definition as the state manifested by a specific syndrome which consist of
all nonspecific induced changes within a biological system
Another definition of stress is is any stress which brings about response or
changes within a nervous system
Stress is how the body reacts to a stressor ,a real or imagined, a stimulus
that causes stress
Stressor is stimuli precipitating a change
Stress may be linked to external factors such as
The state of world , country and any community to which you belong
Unpredictable EVENTS
Environment in which you live or work .
Work itself
Family
STRESS can also come from your own
Irresponsible behavior
Poor health habit
Negative attitude and feelings
Unrealistic expectation
Perfectionism
Q MODEL OF STRESS=GENERAL ADAPTATION SYNDROME
MODEL
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HEN SELY labelled universal response to stressor as general
adaptation model(GAS)
Physiological response occurs in three stages
1=alarm reaction
Alarm is a first stage, when stressor is realized ,body stress response is a state
of alarm
During this stage adrenaline is produced in order to bring about the flight or
fight response
2=stage of resistance=
Resistance is second stage .if stressor persist it becomes necessary to
attempt mean of coping with stress although the body begins to try to adapt
to demands of environment body cannot keep this up indefinitely
Q =PERSONALITY DISORDERS=
PERSONALITY=THERE ARE MANY DEFINITION OF
PERSONALITY
GOOD EXAMPLE IS PERSONALIY is those features which
determines individual unique response to environment ( human and non
human)
So studies add that personality is life long and persistent although
personality changed somewhat over time, the natural maturation process
can be changed thru sustained psychotherapy
Personality features influences individual way of thinking, feeling and
behaving
Freud said that healthy personality was demonstrated by ability to love and
work
Personality features obey normal distribution curve with majority of
population in middle of graph and a few individual at extremes

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Q define Health= according to WHO = a state of complete mental and
physical wellbeing
Q =Personality disorder=
Is enduring patern of inner experiences and behavior that deviate
markedly from expectation from individual culture
Has an onset in early adulthood and is stable overtime and leads to
impairment and distress
Individual with personality disorder like antisocial personality disorder
generates distress in other thru failed relationship
Q =SARVANT SYNDROME=
Labuan down described a group of mentally handicapped children’s
who exhibit special facilities
Down eventually became known for this description of down syndrome
Servant occurs in individual who are severely handicapped
Q EMOTIONAL INTELLIGENCE=
Is defined as is capacity to put emotion under control of reason
Emotional intelligence can be divided into four areas
1= capacity to perceive emotion
2= capacity to use emotion to facilitates thinking
3= capacity to understand emotional meaning
4= capacity to manage emotions
To be emotionally intelligent is to have personal skills that characterize a
rich and balanced personality
Aristotle said that the rare ability to be angry with right person ,to right
degree,at right time ,for right purpose and in right way
Emotional intelligence is measured by emotional quotient
Q Components of emotional assessment=
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In 1990 john and salovey suggest that definition of emotional intelligence
includes abilities in five main areas
1= self awareness=
2-= emotional intelligence
3=motivating oneself
4-= recognizing emotion in others
5= handling relationship
Q KEY POINTS OF GOLDMAN MODEL
Most widely used in discussing EQ
This model describes EQ in term of 5 domain that are split into 4
quadrant
Two of domain are related to personal competence and two are for social
competence
Using emotion→recognizing emotion Leads to understanding emotion=
regulating emotion
Q CRETERIA FOR GOOD MENTAL HEALTH=
There are six criteria of mentrally healthy individual proposed by dr maree
1= self confident, self reliant and self respecting
2=his degree of self actualizing is such that that motivational process can
be characterized as growth motivation
3= he cannot resist stress and his psychic process are in flexible b balance
4= he is relatively independent of social influences and is autonomous
5= he is able to perceive world and other person with relative freedom
from distortion that may originate in his own needs
6= he is adapted to his environment, displaying a creative capacity for love
work and play
Q CAUSES OF MENTAL DISORDR-=

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BIOLOGICAL FACTORS
BIOCHEMICAL = RELATED to abnormal balance of
chemicals=neurotransmitters
GENETICS (HEREDITRY)
THRU GENES AND have family history
INFECTION=
BRAIN INJURRY OR DEFECTS
PRENATAL DAMAGE= loss of oxygen to brain may be a facter in
development of autism like condition
SUBSATANCE ABUSE= long term use of has been linked to anxiety
,depression and paranoia
Other facters=
Poor nutrition and exposure to toxins like leads
PSYCHOLOGICAL FACTERS
Severe psychological trauma in form of emotional. Physical or sexual abuse
Loss of parents
Neglect
Poor ability to relate with others
Environmental factors
Death or divorce
Poverty
Dysfunctional family life
Feeling of inadequacy, low self esteem ,anxiety, anger, loneliness
Changing jobs and schools
Social or cultural expectation
Substance abuse by person or person parents
Q TRANSFER REACTION ARE
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Transfer and counter transference are unconscious mental attitude based on
past personal relationship e.g with parents
These phenomenon increase emotionality and may thus alter judgment and
behavior in pt relationship with their doctor that is transference and doctor
relationship with pt that is counter transference
B= transfrence
In positive transference pt has confidence in dr.
If intense pt may over idealize doctor or develop sexual feeling toward doctor
Pt may become agree to doctor if pt desired and expectation are not realized
and leads to poor adherence to medical advice
C=in counter transfersance
feeling ABOUT PT WHO REMINDS U DOCTOR OF CLOSE FRIEND
CAN INTERFERE WITH DOCTOR MEDICAL JUDGEMENTE
QFUNCTION OF TEMPORAL LOBE
1=EMOTIONS
2= ATTENTION 3=FEEDING 4= MATCHING BEHAVIUOR
Q 495CLINICAL FEATURES OF KLUVER BUKY SYNDROME
IT RESULTS FROM BILATERAL LESION OF AMYGDALA
AND HYPOCAMPUS
1=PLACIDITY is little emotional reaction to external stimuli
2 ; psychiatric blindness
3 ;hyperorality and hyper sexuality
DEPERSONLIZATION AND DEREALIZATION
Q WHAT ARE PSYCHOMOTOTR SYMPTOMS IN THIS DISORDER
1=GAD
2=PHOBIC ANXIETY
3=DEPRESSION

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4= SCHZPORENIA
5 TEMPORAL LOBE EPILEPSY
Q OOD BEHAVIOUR FOR SIX MONTHS,HE DID NOT EAT FOOD
HE BELIEVES someone has mixed poison and sometimes talking to
himself he gradually avoiding his friends
Dd are schizophrenia and delusional disorder
Management of schizophrenia are
Hospitalization and antipsychotic medication if other medication fail then
clozapine and supportive psychotherapy
Treatment of delusional disorder
Hospitalization antipsychotic and individual psychotherapy
Q = What is most common psychiatric presentation of brain tumors
Answer cognitive impairment
Q some causes of cognitive impairment in cancer pt
Mass effect
Diffuse infiltration
Paraneoplastic limbic encephalitis anti NMDA receptor antagonist
Metabolic derangement
Acidosis
Hypoglycemia
Radio and chemotherapy
Q =how does olanzapine differ from haloperidol on its effect on
dopamine receptors
Ans= haloperidol are high potency older typical antipsychotics while
olanzapine is atypical antipsychotic and blocks D4,D2 and serotonine
recepors.

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Q – what is effect of cocaine, nicotine and ampetamine on dopaminergic
system ?
ANS=amphetamine works primarily by increasing availability of dopamine
and release of dopamine
Cocaine blocks reuptake of dopamine leads to euphoria and psychotic
symptoms like schizophrenia.
Nicotine does not have role in dopaminergic system instead on cholinergic
system .
Q = young man who was taking treatment for OCD was presented at
ER with a sustained conjugate deviation of eyes upward and to one
side and its condition is quite uncomfortable and painful started few
hour ago after taking his treatment . he is visiting his psychiatrist
yesterday who increased dose of paroxetine and added aripiprazole
5mg in this prescription.what may be your differential diagnoses?
Answer=1=acute dystonia
2=torticollus 3= laryngeal dystonia
4=occupational dystonias
5=writers cramps 6= blephrospasm
Q = name three drugs other than neuroleptic that can induce this
reaction
Answer=1= benztropine 2= diphenhhydramine
3=trihexyphenidyl
Q = name three risk factors NMS
Answer=1=young age 2=male sex 3= increase dose of dopamine
Q =how would you manage dystonias?
answer= treatment of idiopathic torsion dystonia includes
1=levodopa 2=carbamazepine 3=anticholenergics
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Q Treatment of spasmotic torticolliolis includes 1= haloperidol 2-=
anticholinergics such as benztropine
Inj of botulinum toxin may be helpful .
Q= 28 YR female presented with 5yr history of episode of extreme
happiness in which she used to have party every day and felt as if she
was full of energy and sometime depressed for no apparent reason
Q what is your diagnoses
Answer= cyclothymiacs disorders
Q =what are treatment option ?
ANSWER=anti manic drugs like lithium , carbamazepine and valproic acids
are typically drug of choice
Psychotherapy will focus on helping the patient gain an insight into their
illness and how to cope with it
Q=what is prognoses
Answer=prognoses is not good
Q = You are requested to see a young lady who delivered her first child
one week back .she has not feeling well and has been upset on seeing
her newborn child . she thinks that child is not healthy and dark in
complexion and feels that she may not be able to take adequete
care.she becomes tearful ,exibit low mood and describe suicidle and
homocidal thoughts
A= what would be your most probable diagnoses with justification
Answer=postpartum depression and psychoses because suicidal and
homocidal ideation are present and has low mood and tearful
Q =what is treatment of above case
Answer=1=antidepressants 2=psychotherapy 3=mood stabilizers and
antipsychotics
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Q =name and write breifly the scales you know
Answer=1=Edinburgh postnatal rating scale
2=Hamilton rating scale for depression
3= beck depressive Inventory
4=Montgomery asberg depression rating scale
Q = psychatric traineee has been called to see a 40 yr old man with
three day history of severe epigastric pain especially when hungry and
at times nauseas and vomiting ,he would wake up in middle of night due
to severe epigastric pain .on examination he point with a single finger to
epigastrium at site of pain . he told that he used to take antacid on and
off for last six months keeping in mind some serious stressess at job .last
week his GP prescribed him tab escitalopram 10mg od
Tab cemitidine 200mg bd
Syp antacid
Ans=senarios of epigastric pain
DD includes=1=duodenal ulcer 2=gastritis
3= gastric carcinoma 4= GERD
Q =Important Investigation for duodenal ulcer
1= endoscopy 2= barium meal
3= manometery
Q =management plan
Answer=1= H 2 receptor antagonist
2=bismuth chelate
3=sucralfate
4=omeprazole
5=pirenzapine and antacids

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Q = girl with one day history of severe loss of vision in left eye.nothing
abnormality was detected on her physical examination except mild optic
disk swelling on ophthalmoscopy .pt is anxious and has low mood
,worried about her illness.her past history showed that she was admitted
in hospital six months back for left lower .limb weakness which was
improved after treatment
Answer=DD =1= AMAROUSES FUGAX
2=Clouding of normality 3-= transparent eye structure
4=central retinal vein occlusion and 5= central retinal artery occlusion
6=abnormalities of retina and nerves
Q =name three investigation
1= MRI or CT SCAN or USG FOR CAROTID ARTERY FOR TIA OR
AMAROUS FUGAX
2=EEG continuos monitoring of heart rhythm
3= ESR measurement 4= CRP and platelets 5=examination by
doctor
Q 507imm =write three treatment option according to your diagnoses
Answer=treatment option= disorder causing loss of vision is treated as
early as possible although treatment may not be able to save vision
However prompt treatment may decrease risk of same process in other
eye.
Sudden loss of vision is emergency so should go to hospital
Presence or absence of pain helps indicates what causes are most likely
If vision returns early on its own TIA or ocular migrain are among likely
causes

219
Q =obese lady presented with typoe 2 diabetes mellitus and
hypertension for several years,she developed depression after an attack
of acute coronary syndrome.
She is now physically stable and is now refered to you for treatment of
depression
Her past history shows that during childhood she developed febrile
fits
Q = name antidepressants you choose write down dose and reason of
selection
Answer= tab setraline 50mg in morning and up to 150 mg we can give. It is
used because of better profile and good and efficient
Q = adverse effects of SSRI =
1= SSRI are less cardiotoxic than TCA and have less anticholenergic side
effects and safe in overdose as compared to TCA
2= Gastrointestinal nauseas, vomiting and diarhea, bloating , flatulance and
dyspepsia
3= neuropsychiatric side effects=
Insomnia,agitation, tremor , restlessness and seizure. EPSE common with
ssri . parkinsoniosm and akasthesia more common than tca.
4=sexual dysfunction=
Ejaculatory delay, anorgasmia ,sweating,dry mouth, skin rashes, self harm ,
behaviuoral side effects and suicidal behaviour
Q =business man with 6 month history of GAD, now he feels difficult
to give presentation in board meeting due to tremor, blushing and loss of
confidence and difficulty in organizing his thought,he remains
preoccupied with negative thought that his proposal will be turn down

220
and peoople will laugh at him , he often feels heaviness on chest and
suffocation.
His medical ward cleared him physically. Manage anxiety in this case
Answer=Behavioral psychotherapies includes relaxation training, biofeed
back .
Pharmacotherapy includes SSRI,, venlafaxine, buspirone, benzodiazepine
Q= =female graduate student is suffering from major depressive illness
presents in psychiatric OPD .
Consultant decides to admit her but she is reluctant to be admitted.
She is stating multiple stresses in her mind due to illness and
hospitalization.
a= enlist four stressess due to illness experienced by this patient?
answer= 1=common psychological complaints in hospitalized patients
includes anxiety, sleep depression, and disorientation, often as a result of
delirium and depression
2= pt who are at great risk for such problems includes those undergoing
surgery or renal dialyses or those being treated in intensive care unit or
coronary care unit in all groups ,elderly patents are at great risk
3= patient undergoing surgery who are at greatest psychological and medical
risk are those who believe that they will not survive surgery as well as those
who do not admit that they are worried before surgery
4= psychological and medical risk can be reduced by enhancing sensory and
social input e.g. placing the patient bed near a window encouraging the pt to
talk ,providing information on what the pt can expect during and after a
procedure and allowing pt to control the environment e.g. lightening, pain
medication as much as possible

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Q =Transsexualism = desire to live as opposite sex often thru surgery or
hormonal treatment
Q =Transvestism =
=parapilias
Wearing clothes of opposite sex
Q =what are risk facters for major depressive disorders
1= hormonal differences 2=great stress
3= no close personal and interpersonal relationship 4= divorced
5= separation 6=family history 7= exposure to stress
8=behaviural resons such as learned helplessness
Q =BREAKING BAD NEWS
Any news that adversely and seriously affects an individual view of his or
her future is considered as bad news
Many clinical situation where bad news has to be communicated to pt and
there relatives e.g. disclosing the diagnoses of cancer or birth of malformed
baby or death of a loved ones
Breaking bad news is an unpleasant task and can be learned from senior
physician most pt or relatives expect full closure delivered with empathy,
kindness.there are five different school of thought
It is BPS model that has least no of limitation and is ter strongly
recommended fo se in health care setting
Q BIOPSYCHOSOCIAL MODEL
Provides clear crisp evidence based information on pt condition
The bad news is broken using principle of effective communication
and counselling and informational care
Bps model suggest following steps and aims at breaking bad news
Step1=seating and setting environment

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Exclusivity =the environment where bad news is being broken can have
serious effect on outcome of interview
INVOLVEMENT OOF SIGNIFICANT OTHERS
Some pt like to have family members or friends around them when they
receave bad news
SEATING ARRANGEMENT
Interview should take place with both doctor and pt comfortably and
respectively seated next to each other preferably at a distance of an arms
ength
BE ATTENTIVE AND CALM
LISTENING MODE
AVALILABILITY
STAGE2=PT PERCEPTION
The principle involved in this step is before u tell and ask
Before u break the bad news to pt try to ascertain as accurately as possible
the pt perception of his or her medical condition
Obtaining this information depends on your own communication style
Step3=INVITATION
Most pt want to know all about there illness
Some examples to address this are
Are you the kind of person who likes to know all the detail about what is
going on ?
How much information would you like me to give you about your
diagnoses and treatment?
STEP 4=KNOWLEGDE
Before you break bad news give your pt a warning of some sort of help to
prepare for himself eg unfortunately I have a bad news to tell you mr x
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When giving your pt bad news use the same language that he uses
Avoid scientific and technical language
Step5=empathy
For most drs responding to our pt emotion is one of most difficult parts while
breaking bad news. The technique that is most useful is termed as empathic
response
In empathic response one need to listen and identify the emotion or mixture
of emotion that pt is experiencing and offer an acknowledgement for that
Step6 summarize
Before discussion ends recapitulate the information in a short summary of
all that has been discussed
Step7=plan of action
You and your pt should go away interview with a clear plan for next steps
B=individualized disclosure model
In this model amount of information openly stating and its rate of its
opening are according to desire of individual pt by doctor pt talk
Together they will clarify what information pt wants and then will become
doctor task to impart it in a way that pt understands
This is an ongoing and developing procedure
The distinguishing feature of this model are that it takes time and skill which
the busy physician may feel that he or she does not have and its assumption
are supported by evidence
C=full disclosure model
This model involves full information to every pt as soon as it is known
It is argued that it promotes doctor pt trust and communicates and facilitates
mutual support within family .The underlying assumption in this model are

224
that pt has a right to full information about himself and doctor has an
obligation to give it
All pt want to know bad news about themselves and pt themselves should
decide what treatment is best for them. The disadvantage of this model is that
disussing of option in detail may frighten and confuse some pts
PATERNALISTIC DISCLOSURE MODEL
This model implies that information about pt disease is right of doctor and he
delivers information in a sugar coating to minimize pain and distress of pt
and expression of sympathy. It is not recoverable any more
NONDISCLOSURE MODEL
This model is based on that under no circumstances should pt be informed
that they have acquired a lethal disease. Advantages of following this model
are it is easier and less time consuming for doctor and suits those people who
prefers not to know there condition
This model is fast falling out of favor and is widely rejected by modern
day doctors as well as patient and their families
Q HOW SHOLUD BAD NEWS BE DELIVERED
1= ADVANCE PREPARATION
2=BUILT A GOOD ENVIROMENT AND RELATIONSHIP
3=COMMUNICATE WELL
4=DEAL WITH FAMILY REACTION AND DEAL WITH PT
5=ENCOURAGE AND VALIDATE EMOTION
6= FINAL COMMENT
Q = enumerate 4 reaction to illness and hospitalization
1=anger 2=depression 3= dependence
4=denial
Q imm=general characteristics od CBT=

225
Answer= for depressive illness essential aim of ect is to change way of
thinking.
There are many studies of CBT in acute depression that have been reviewed
recently by NICE
NICE conclusion currently are following
CBT is superior to other waiting list control in depressive illness
CBT is not generally superior to IPT
CBT is effective as pharmacological treatment
Combined CBT and pharmacological therapy is better than
pharmacological treatment alone
Q WHAT ARE OUTCOMES OF DELIBERATE SELF HARM
ANSWER=1=repetition of self harm 2= suicide following deliberate self
harm
Q imm = stages of psychoanalytic theory of development
It is based on freud concept that behaviors is determined by forces derived
from unconscious mind
Q Psychoanalytic theories are psychotherapy based on this concept
Freud theory of mind= to explain his ideas freud developed early in his
carrier the topographic theory of mind and later in his carrier structural
theory
Topographic theory of mind
In this three levels1=unconscious
2=preconscious 3=conscious
Unconscious mind contain repressed thought and feeling that are not
available to mind and uses primary process of thinking .
A=primary process= is a type of thinking associated with primitive
derives, wish full illness and pleasure thinking.

226
Primary thinking process is seen in young children .
B =dreams represent gratification of unconscious instinctive impulses
and wish full filillness.
2=preconsiuios mind=
Contain memories that while not imediately available can be assessed easily
3=conscious mind=contain thought that person is currently aware of it
And it operates in close conjunction with preconscious mind but does not
have access to unconscious mind
The conscious mind uses secondary process of thinking(logical and mature)
and can delay gratification.
B =structural theory of mind= mind contains three parts id , ego,
superego
Id=unconscious
Ego=unconscious
Preconscious
Conscious
Superego= unconscious, preconscious and conscious techniques used to
recover repressed experiences includes
1=free association= in psychoanalyses person lies in a ccouch in a
reclined position facing away from therapist and says whatever comes
to mind.
In therapies related to psychoanalyses person sits in a chair and talks
while facing therapist.
2=interpretation of dreams used to examine an unconscious impulses
3= analyses of transference reaction= people who are appropriate to
psychoanalysis and related therapies should have following
characteristics
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1= younger than 40yrs
2= are intelligent and not psychotics
3=have a stable life situation
4= have a good relationship with others
5= have time and money to spend on treatment
In psychoanalyses people receives 4-5 weekly for 3-4yrs. Related
therapies are briefer and more direct
1=self actualization, fulfillment of unique potential
2=esteem and recognition .self esteem and respect of other
Success at work
3=love and belonging .giving and receiving affection ,companionship,
identification with a group
4=safety and avoiding self harm .attaining security order And physical
safety
5=basic physiological needs
Biological needs for food ,shelter, water and sleep, oxygen and sexual
expression
Q =you are asked to see a young man who is recently diagnosed as a
case of malignant carcinoma.tests to detect following issues
Q=should we inform pt about diagnoses?
Answer= yes
Q =what physiological issues are expected during management of this
patient?
Answer=1=dependence 2=denial
3=anger 4=depression
Q = PREVALENCE= number of new and old cases

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Point prevalence= number of new and old cases at a particular point in
time
Period prevalence= number of new and old cases at a particular period
of time
Q= transplant of organs=
1=psychosocial aspect of this intervention are often ignored
2=while recipient is of prime significance on account of severe illness .
Donor must never be forgotten
3= donor must be cared for
4= other than physical care of wound ,surgical and medical risk that he may
carry ,he or she is looking for approval and support from medical staff
5=profuse and repeated thankful to his behavior is the least that we can do
This aspect is left for family of recipient
As a medical student it is important that you ask for donor, visit him and
use priciples of communication such as understanding for emotion, active
listening and empathy in interacting with him . A single interaction of this
kind can lift his psychological state and may be enough to comfort him. It is
also important to give detailed information care session to remove myths and
misconception. and reassure him that he is not a disabled individual after
donating a kidney and can leads to a full and productive life particular
emphases needs to be given to impact on his diet, sleep ,sexual life, return to
work and adresss his concern about his perhaiz.
Q =BIOPSYCHOSOCIAL MODEL OF HEALTH
George engel in 1970 started this model
It states that biological, psychological(which entails thought, behaviuor and
emotion) and social(socioeconomic ,socioenviromental,and cultural) facters
all play a significant role in human functioning in context of disease or

229
illness .it posits that health is best understood in term of combination of
biological, psychological and social factors rather than purely in medical
terms
This is in contrast to biomedical model of medicine that suggest every
disease process can be explained in term of an underlying deviation from
normal function such as viruses ,gene ,developmental abnormalities or injury
.the concept is used in fields such as medicine, health psychology as well as
sociology and particularly more in psychiatry and clinical psychology
The bps paradigm is a technical term for popular concept of mind body
connection which addresses philosophical arguments between bps and
biomedical model rather than there empirically exploration and clinical
application
Novelty, acceptance and prevalence of bps model varies across cultures.
Q =SALIENT FEATURES OF DESTIGMATIZATION OF
PSYCHIATRIC DISORDERS
REDUCING STIGMA=
1= campaign to reduce stigma is to provide information about
understanding of mental illness and only minority people have dangerous
behavior
2= encourage mental illness to speak publically about their experiences
3= young people should be educated during campaigns
Stigma can be reduced gradually
In past epilepsy and autism were considered mental illness and were
stigmatize but there increased treatment attitude of people changed .now
epilepsy and autism are much less stigmatized but schyzoprenic is still
stigmatize but need of ongoing public compaigns to reduce fear and

230
misunderstanding of mental illness again .diagnoses of schyzoprenia should
be prohibited
Q= 10yr old boy reported with recent onset of bed wetting following
death of his mother in a road traffic accident
Q= what is most likely diagnoses?
Answer= Nocturnal enuresis
Q=which mechanism is she using?
Answer=Regression
Q=enlist five common defense mechanism ?
Answer=1=projection= attributing your own wishes, feeling and thoughts
onto some one else e.g I am sure my wife is cheating on me
2= denial= used to avoid becoming aware of some painful aspect of reality
e.g I know I don’t have a cancer
3= splitting= external objects are divided into all good or all or bad e.g
morning staff is much better than evening staff.
4=blocking=temporary block in thinking e.g I cannot seems to remember his
name
5=introjections= features of external world are taken and made part of self
e.g resident physician dresses like attending.
Q =what are psychosocial intervention for schizophrenia?
1=family therapy
(psycho education)
2=CBT
3= cognitive remediation=Cognitive remediation therapy (CRT), also
called cognitiveenhancement therapy (CET), is designed to
improve neurocognitive abilities such as attention, working

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memory, cognitive flexibility and planning, and executive
functioning which leads to improved social functioning.
4= social skill training
5= supported employment
6= illness management skills
7= integrated management for co morbid cannabis misuse
8= assertive community treatment
Q= name psychometric instrument that can be used for assessing
progress of diseases
Answer=PANNS scale
Q = what is diagnostic creteria for PTSD?
Answer=diagnostic criteria is similar in both ICD-10 AND DSM-IV
DSM –IV includes two criteria that are not present in ICD -10.
According to DSM –IV symptoms must be present for at least one month
and may cause social impairment. As a result of these differences
concordance between diagnoses of PTSD is using criteria is 35%.By
convention PTSD can be diagnosed in people who have a history of
psychiatric disorders before stressful event
DD includes following 1= stress induced exacerbation of previous anxiety
and mood disorders 2= acute stress disorder distinguished by time course
3= adjustment disorders distinguished by different pattern of symptoms
4=enduring personality changes after a catastropic experience.
PTSD may present as deliberate self harm or substance abuse which have
developed as maladaptive coping strategies
Q = write three risk facters for PTSD
Answer=1= traumatic event precipitate ASD and PTSD
2= premorbid factors such as personality trait plays an uncertain role
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3=re experience of traumatic events 4=night mares
Essential features of PTSD are following
1= hyper arousal 2= reexperience of aspect of stressful events
3= avoidance of reminder
Q= enlist three evidence based 3 SSRI and three psychological option
available for pt of PTSD?
1=counseling 2=CBT
3=eye movement desensitization and reprocessing
Medication such as benzodiazepine should be avoided
SSRI includes 1=escitalopram
2= paroxetine 3=flouxetine
Ssri and mao and tca have shown efficacy in clinical trial
Antipsychotic like olanzapine
Q= 20 yr old female had been behaving in an odd way for last 29 days
He said that he beleived That police has conspired with his university
teacher to harm and take away his thought.in light of facts and finding
presented
Answer= paranoid delusion
Diagnoses is acute and transient psychoses
Q= young female emaciated depressed with sunken eyes and atropied
muscles presents to psychiatric OPD
Attendant mentioned that she denies taking proper meal insisting that
she is getting fatty
She is constipated and gives a history of amenorrhea
Q=what is most likely diagnoses and justify that?
Answer= Anorexia nervosa and all symptoms are compatable with anorexia
nervosa
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ABNORMALITIES ON PHYSICAL INVESTIGATION OF
ANOREXIA NERVOSA=
Endocrine abnormalities=
Decrease LH, decrease FSH and decrease t3 and T4, Increase cortisol and
growth hormone
CARDIOVASCULAR ABNORMALITIES=
ECG , QT INTERVAL AND CONDUCTION DEFECTS
Gastrointestinal abnormalities=delayed gastric emptying and decrease
colon motility
HEMATOLOGIICAL Abnormalities
Moderate normocytic nornmochrominc anemia ,leucopenia,
thrombocytopenia other metabolic abnormalities includes increase
hypercholesterolemia
Q= 42 yr old comes to ER and says that men are following me, he also
complains of hearing voices telling him to hurt others.he tells examiner
that new anchorman gives him message about state of world every
night thru television
What are phenomenological terms in above case
1= paranoid delusion
2= auditory hallucination
3=delusion of reference
Q=define delusion, illusion and loosening of asssociation
Answer= delusion= false belief which is held by pt tightly inspite of
evidence to contrary and which should not originate from pt
socioculturoreligious back ground
Define illusions=
Misinterpretation of external stimulus
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Illusion have no diagnostic significance
Define=loosening of association=
Shift of idea from one topic to another in an unrelated way.
Neologism is inventing new words
Tangentiality is getting further away from point as speaking continues
Circumstantialities=
Inclusion of too much detail
Q= pt hospitalized for his three episodes of psychoses,
He complained of recent onset of difficulty focusing his thought, bizare
ideas and auditory hallucination. he lost his job due to these symptoms
.
MSE reveals pressured speech , loosening of association, occasional
idiosyncratic word usage. his previous 2 episodes remitted completely
within a few months .For current episode his symptoms gradually
cleared after several weeks of treatment with antipsychotics
Q = what is most likely diagnoses=
Answer=schizophrenia=
Q=what duration of symptoms required for diagnoses
6months
Q =are mood disorders associated with schyzoprenia?
Answer= sometimes mood disorders are associated with schyzoprenia
resulting in schizoaffective disorders
Q =has it any etiology?
ANSWER-=high level of dopamine and serotonin
Q = what is prognoses of such patients?
Answer= schizophrenia involves repeated psychotic episodes and a chronic
downhill course over year and illness stabilizes in mid life
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Suicide is common in pt with schizophrenia and more than 50% attempt
suicide more often during post psychotic depression or when having
hallucination commanding them to harm themselves and 10% of those die in
suicide
3= prognoses=prognoses is better and suicide rate is low in elderly and in
married person and has social relationship and in female and has mood
symptoms, has few negative symptoms and has few relapses
Q =Application of behavioral techniques to medicine
A=systematic desensitization = is a behaviuoral technique based on
clinical conditioning and use to eliminate phobia
B=token economy=
C= cognitive therapy
Is one of behavioral theraphy used to deal with depression and anxiety
D=biofeed back = involves learning to gain control over measurable
physiological problem and is based on operant conditioning and require
high degree of motivation and practice
Therapeutic uses==1=peptic ulcer 2=asthma 3=migraine 4=
tension headach
Q = six year old boy brought to psychiatrist becoz of increasingly
disturbing mannerism ,has frequent outbursts of obsene language plus
grunting and occassionaly unintereupted sounds. Tics involving head ,
tarso and limb are noted
Q what is most likely diagnoses?
Answer=tourete syndrrome
Q=enlist three differential diagnoses?
Answer=1=ADHD 2=OCD
3=Abnormalities in dopamine and adrenergic symptoms
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Q =differentiate between echolalia and coprolalia
Echolalia is psychopathologic repeating of words or phrases of one
person by another
Coprolalia= is compulsive utterence of obsene words
Q=differentiate between echopraxia and copropraxia?
Answer=echopraxias= pathologic imitation of movement of one person
by another?
Copropraxia=discussed next pages
Q handy point= recurrent urge to steal objects
Kleptomania
Q handy point=setting fire of neibour garbage repeatedly
Piromania
Q anorexia nervosa dehydration by severe laxative induced diarhea
and worried about wt gain and she is thin and amenorea
Q= =enlist four psychotropic drugs for treatment of this disorders?
Answer=1=pimozide 2=haloperidol 3=risperidone 4=clonidine
5=clonazepam
Q=young man came to ER on numerous occasion with severe abdominal
pain with no physical or organic cause.he is felt to have a strange affect
and was very anxious .doctor gave him a talets of phenobarbitonee.he
return to emergency room a short time later with even worse
complaints.he improved with a shot of petidine.
His father had similar complaints and underwent abdominal surgery.
Father also exibited several psychiatric manifestation
Enlist three important differntial diagnoses
1=irritable bowel syndrome
2==ulcerative colitis
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3=crohn disease
4= tuberculous enteritis .most likely diagnoses is irritable bowel syndriome
Q =what is etiology ?
Answer= cause of irritable bowel syndrome is uncertain although there
appears to be disturbances of bowel function and sedation. depressive and
anxiety disorders are common among people who attend gastroenterology
clinic with irritable bowel syndrome especially among those who fails to
respond to treatment
Q =give psychiatric symptoms of this IBS syndrome?
Answer=1=disturbance of bowel function and sensation
2= depression 3=anxiety
4=fails to respond to treatment
Q =genetics of schyzoprenia-=
General population 1%
Monozygotic twins 47%
Dizygotic twins 12%
One schyzoprenic parents 12%
Two schyzoprenic parents 40%
First degree relatives 12%
Second degree relatives 6%
Q= name and outline theories of mode of inheritance of schyzoprenioa?
Answer=
Genes includes 2NF 304 A and neurogulin1
Enviromental facters examples are perinatal infection ,birth complication
And early canabis misuse
Social and structural facters are also involved
Functional imaging
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Neuro physiological
Neur ochemical
Psycho logical
Hypotheses
Q = name five syndrome leading to learning disability with there
respective chromosomal abnormalities
Answer= trisomies=down syndromes, edward syndrome , turner
syndrome XO, klinfelter syndrome XXY
Angel man syndrome
Prader willi syndrome
Fragile x syndrome
Q = enlist 3 types of chromosomal abnormalities attributed to down
syndrome
Answer= trisomy 21 due to failure of disjunction during meioses and
increase maternal age. 5% cases are translocation involving 21%
chromosomes or due to mosaisism
Q = at what age of mother down syndrome is most common amongst
there childrens
Answer= it occurs in 1 out of 700birth and accounts for 10% of mentally
retarded children
Etiology=high maternal age (age more than 35years)
Q = Enumerate 4 long acting antipsychotics and there pharmakokinetic
properties
1=flupeenthixol deconuate =
Time to peak plasma level is 3-7 days
Time to steady state is 8weeks
Licensed dosing interval is 2-4weeks
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Typical clinical dose per two week is 60mg
2=flupenazine deconuate
Time to peak plasma level is 1-2 days
Time to steady state is 8weeks
Licensed dosing interval is 2-5 weeks
Typical clinical dose per 2 weeks is 50mg
3=haloperidol deaconate
Time to peak plasma level is 7 days
Time to steady state 8-12weeks
Licensed dosing interval is 2-4 weeks
Typical clinical dose per 2weeks is 100mg
4=zuclopenthixol deconate
Time to peak plasma levels is 7days
Time to steady state= 8weeks
Licensed dosing interval is 1-4 weeks
Typical clinical dose per 2 weeks =300mg
Q WHAT ARE OUTCOMES OF DELIBERATE SELF HARM
ANSWER=1=repetition of self harm
2= suicide following deliberate self harm
Q =42 year old lady of bipolar Affective disorder stabilized on lithium
for past six years presents with complaints of lethargy, dry coarse
skin, cold intolerance, weight gain and menstrual irregularities for past
two months.
Q= mother of 7yr boy told her gp that her boy shout at top of his voice
whenever his demand are not fulfilled .She told yesterday he woke up
at 5 am and start shouting and demanded that he wants to eat pizza.To

240
pacify him she has to take him to pizza outlet at airport as no outlet
was opened in vicinity at this time
Child have above average intelligence and was not suffering from any
physical or mental disorders
Based on your knowledge of behavioral psychology write behavior of
child and what measures you will suggest to her mother?
Answer=use principles of classical conditioning and positive and
negative reinforcement
Q =PSYCHIOLOGICAL ISSUES OF AGING
1-= DEMOGRAPHICS=6% OF POPUKLATION IS ABOVE 65YEAR
14% OF POPULATION IS IN DEVELOPING COUNTRIES
4% OF POPULATION IN LESS DEVELOPED COUNTRIES
Q =PHYSICAL CHANGES IN BRAIN
1=WEIGHT of human brain decrease progressively from infancy to
adulthood and then to elderly age 2=ventricles in brain
3=meninges thickened
4= MRI show changes in white and grey matter
5= lipofuscin which is present in cytoplasm of neurons and increase in
neurons
6=senile plaques and Neurofibrilory tangles accumulate in human brain
in alzeimer diseases
7=genetic changes in DNA also
Q=INFERIORITY COMPLEX= is a lack of self worth and uncertainity
It is often subconsiuos. Alder was scientist who introduced inferiority
complex
Classical ALDER psychology makes a difference between primary and
secondry inferiority feeling. Primary inferiority feeling is said to be rooted

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in young child original experience of weakness and helplessness.
Secondory inferiority feeling related to adult experiences of being unable to
reach a subconscious goal
Q = scenario of short attention span and inability to sit quietly in class
Dx is ADHD
Q 20yr college student is reffered to psychiatrist he fail several classess
and he is undisturbed by this and also failed in sports plus psychomotor
agiitastion
Dx is bipolar disorder
Q = pt complains of low appetite , low energy, poor concentration for
more than 2yr
Dx is dysthymic disiorder
Qmr aslam has experienced hx of feeling great followed by feeling lousy
for 5yrs
Dx = cyclothymia
Q pt depressed mood sleep every winter but absent In summer
Dx seasonal affective disorder
Q=depressed pt must be assessed for suicidal thought and must be given
respiridone as initial theraphy
Q 25yr man cover window with aluminum foil becoz they were after
his idea when asked who they are he looks to sky and point away to a
fareway plannet
Dx Paranoid dellusion of schizophrenia
Q SCHYZOPRENIA DISORGANIZED TYPE BEZARRE
BEHAVIUOR AND wearing many layer of clothes , child like
appearance and frequently barks at others ad admit auditory
hallucination

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Q schizophrenia catatonic has been in hospital for few months mute
and does not respond to questions
Q homeless men was taken to hospital after accident dr question him
note that thought are illogical blunt emotion poor grooming
Dx schizophrenia residual type
Q chineese immigrant found wandering in street shout loudly telling
someone was name of some person died
Dx acute and transient psychoses
Q mr aslam married for 10yr and thinking ,most of time he believed
his wife trying to poison him
To get his money and stomach aches hich he believed due to poison . his
wife is rich
Dx deliusional disorder
Q suspiciousness about neibours and needs to be treated by risperidone
If symptom does not improve she might develop schyzopreniform
disorder from acute psychoses
Q = YOU ARE COUNSELLING 2O YR old medical student for
adjustment disorder for one month .he continue to show conduct
disorder at home .his symptoms are aggravatecd by conflicts of his
parents in which his father frequently deals harshly with his
mother .his mother accompanies him in a session .she acts out and
shouts at you saying that her son is not improving due to your fault
Name two defence mechanism are =\
1=projection
2= acting out
List two defence mechanism for following
1= obsessive compulsive disorder
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A= undoing b=isolation and reaction formation
2=dissociation disorder
A=displacement and denial
3= delusional disorder
Projection and acting out
Q =PT SAYS THAT VARIUOS TV channels ARE CONTINOUSLY
talking about this in news
Answer= delusion of grandiosity
Delusion of reference
Q IN WHICH psychiatric disorder these symptom can be present
1=mania and 2= SCHYZOPRENIA
Q = PT with 10yr history of restless all the time symptoms of restless
irritable bowel , muscle tension, dry mouth, fine tremors , she has
been taking diazepam orally for 5 yrs and now inspite of taking a dose
more than prescribed by her family .she cannot get relief from anxiety
Answer=generalize anxiety disorder
Q psychiatric assessment=Informant can be seen separately from pt or
is invited to join interview but pt must give their consent .few cases in which
pt permission is not required before interviewing relatives e.g. if pt is a child
or adult pt with mutism and confusion. in other cases doctor should inform
the pt for reason of interviewing information for treatment permission must
be obtained, interviewer begin by explaining purpose of interview and may
need to reassure informants, a relative may fear that interviewer will view
them as responsible in some way for pt problem. If informant have been
interviewed separately from pt psychiatrist should not tell pt about interview
with informants unless permission have been obtained. This is imp even
without permission of informant’s interview should not be disclosed.

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Q = CRISIS INTERVENTION
Can be used either to cope with crises in their life or to use the crisis as an
entry to long term problem this approach has been used after the break up
of relationship after natural disorder of floods and earthquake
FOURTH STAGE OF COPING BASE ON KAPLAN VIEW
1=emotional arousal with efforts to solve the problem
2=if these fails greater arousal leading to disorganized behavior
3=trial of alternative way of coping
if there is still no resolution exhaustion and decomposition occur
The word crisis is derived from Greek word meaning decision making
Chinese language has an expression for it in two words danger and
oportunity
Crisis is therefore a situation which holds potential for great individual
growth provided that appropriate decisions are taken
Crisis intervention seeks to limit the reaction to first stage or if this has
been passed before person seeks help to avoid fourth stage
Q =what are PROBLEMS LEADING TO CRISIS
1=loss and separation such as divorce as bereavement
2==role change such as marriage And parenthood
3=relationship problems such as those between sexual partners
4=conflict
Q CRISIS INTERVENTION
Treatment immediate brief and collaborative
Stage1=
Reduce arousal
Focus on current problem
Encourage self help

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Stage2=assess problem consider solution and test solution
Stage3= consider future coping methods
CRISIS INTERVENTION
The methods resemble interpersonal counselling and and problem solving
counselling although with great emphases on reducing arousal
Treatmernt starts as soon as possible after the crisis and is brief usually
consisting of a few sezssion over a period of days
Q =discuss physical examination for psychiatric assessment
Physical examination provides 3kinds of information in assessment
1= it may reveal diagnostically useful signs such as goiter or absent
reflexes’
It is therefore particularly important in diagnosis and exclusion of organic
disorders
Neurological ,CVS ,and endocrine system most commonly require detailed
examination
2=psychotropic drugs may produce physical side effects which needs to be
measured such as htn
3=pt general health, nutritional status and self care may all be affected by
psychiatric disorders
For above 3 reasons physical examination is an integral part of psychiatric
assessment
Q =INDICATION OF ECT (NICE)
It is recommended that ect is used only to achieve rapid and short term
improvement of severe symptoms after an adequate trial of other treatments
options have proved ineffective and when condition is considered to be
potentially life threatening in individual with 1=severe depressive illness
2=catastonia

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3=severe manic epidsode

Q =INDICATION OF ECT
Royal college of physician
In severe depressive illness ect may be treatment of choice when illness is
associated with life threatening illness becoz of refusal of food and fluids
and high suicidal risk
ECT may be considered for treatment of severe depressive illness associated
with stupor, delusion and hallucinations
EC T may be considered as second or third line treatment of depressive
illness that is not responsive to antidepressants
ECT may be considered for treatment of mania that has not responded to
Appropriate drug treatment
ECT may be considered for treatment of acute schizophrenia as a fourth
line option for treatment resistant schizophrenia after treatment with 2
antipsychotics and clozapine has proved ineffective
ECT for catatonia where treatment with other bzd usually lorazepam
proved ineffective
Q = describe CONFIDENTIALITY
Physician can not tell any one any thing about there pt without pt
permission although physician are expected ethically to maintain pt
confidentiality they are not required to do so if 1=their pt is a suspected
case of child or elder abuse
Q when BREAK OF CONFIDENTIALITY
THEY ARE not required to do so if
1=their pt is a suspected case of child or elder abuse
2=their pt is a significant risk of suicide

247
3==there pt poses a serious threat to another person
4=there pt poses a risk to public safetye,g . impaired driver
Intervention by physician if pt poses a threat
1= physician must first ascertain credibility of danger or threat
2=if threat or danger is convincing physician must identify law enforcement
officials or social service agency and warn the intended victim(TorSatoff
decision)
Q IN WHICH psychiatric disorder these symptom can be present
1=Mania AND 2= SCHYZOPRENIA
Q = PT with 10yr history of restless all the time symptoms of restless
irritable bowel ,muscle tension, dry mouth, fine tremors ,she has been
taking diazepam orally for 5 yrs and now in spite of taking a dose more
than prescribed by her family .she cannot get relief from anxiety
Answer=generalize anxiety disorder
Q ASSESSMENT OF SOME ETHICAL ISSUES RELATING TO
RESEARCH
SCIENTIFIC MERITS
WILL FINDING BE OF VALUES ?
ARE METHODS AND SIZE OF GROUPS LIKELY TO ACHIEVE
AIMS?
What are sources of financial and other support and are there any
potential conflicts of interest?
Are there any potential conflicts of interest for any of investigation?
Could aim be achieved in an ethically better way?
SAFETY
Are the procedure safe?
If theris a risk are all of necessary precaution being taken?
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Is assessed level of risk acceptable to investigation subjects and
relatives?
CONSENT
Will subject be competent to give consent?
Will subjects receive clean and sufficient information?
Will they have adequate time to consider and should they wish to do so and
to withdraw consent?
Will it be clear that refusal wil not affect quality and quantity of care
provided?
Is any payment to subjects for expenses likely to exceed these and therefore
acts as an incentive to consent?
Is the researcher under any pressure to recruit subjects e,g, receiving
payment from a sponsoring company?
CONFIENTIALITY
Have subjects consented to use of confidential information in research?
Will the data from research be kept sincerely?
Q= You have to interview 40yr old divorced lady wearing a very
provocative dress and showing seductive behavior. During initial
introduction while telling her address she invited you for a cup of tea at
her house
How you wil manage her seductive behavior?
Answer=Reassure lady of ethical issues and don’t attend invitation and is
the violation of boundaries of ethics
Q= name ten specific interviewing techniques you may like to use?
Answer=1=open ended question 2=close ended question 3=facilitation
4=confrontation
5= reassurance

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6= leading
Q INVESTIGATION YOU administer MMSE
1=ALZEMER AND
MENTAL ILLNESS
MAIN COMPONENTS 1= APEARANCE2=BEHAVIUOR 3=ATTITUDE
4= LEVAL OF CONSIOUSNESS
5= COGNITION
6=MOOD
7=AFFECT
8=THOUGHT 9=PERCEPTION
10= JUGDEMENT AND INSIGHT
11=RELIABILITY
Q 7yr boy brought by mother and restless and cannot sit at one place
and disturbing thought and fail to listen
And talkative
Answer=dx according to icd 1o is 1=conduct disorder and adhd
Common associated problems 1=low self esteem mood labiality, conduct
disorder , , learning disorder, communication disorder, drug abuse,
school failure, and physical trauma as a result of impulsivity
Treatment of ADHD
Physiological social and educational intervention
Specialize educational techniques
Immediate reinforcement for learning
Pharmacotherapy Methyl phenidate , Amphetamine
Antidepressants and clonidine
Q some heading for court report

250
A statement of psychiatric full name , qualification and present
appointment (WETHER THEY ARE APPROVED UNDER SECTION
12 of mental health act)
Where and when interview was conducted and wether any third pt was
present
Sources of information including documents that have been examined
Family and personal history of defendant
Present mental state
Mental health at time of relevant events
Conclusion a summary of key finding
Q= YOU are planning to give ect in male suffering from chronic
schizophrenia and pt had not responded to several antipsychotics
included clozapine in therapeutic doses for sufficient period of time
Answer=according to royal college of psychiatrist ECT is used for
schizophrenia as a fourth line of treatment
Q=DIAGNOSTIC CRETERIA FOR POST TRAUMATIC DISORDER
ANS=diagnostic criteria is similar in both ICD-10 AND DSM –IV
DSM-IV includes two criteria that are not present in ICD-10
According to DSM-IV symptoms must be present for at least one month and
may cause impaired social impairment
As a result of these differences ’concordances between diagnoses of PTSD
using the criteria is 35%
By convention PTSD can be diagnosed in people who have a history of
psychiatric disorder before stressful event.
Deferential diagnoses include following
1=stress induced exacerbation of previous anxiety or mood disorder
2=acute stress disorder distinguished by time course
251
3=adjustment disorder distinguished by different pattern of symptoms
4=enduring personality changes after catastrophic experience
PTSD may present as deliberate self-harm or substance abuse which have
developed as maladaptive coping strategies
Q seven medical condition as d/dof panic disorder
1=shortness of breath and smothering sensation
2=palpitation and accelerated heart rate
3=chest pain
4=dizziness and fainting
5= nauseas and abdominal distress
6=fear of dying and fear of going crazy
7=numbness and tingling sensation
8=sweating, flushing and chills
Q =CLINICAL ASSESSMENT OF PT WITH BEHAVIOURAL
SYMPTOMS
OVER VIEW OF PSYCHOLOGICAL TESTING
TYPES OF TESTS
Psychological assessment tests are used to assess intelligence
,achievement personaslity and psychopathology ,these tests are classified
by functional areas evaluated
INDIVIDUAL VERSES GROUP TESTING
Psychological tests administered to one individual at a time allow
carefull observation and evaluation of that particular person .a test
battery looks at functioning of an individual n in a number of different
functional areas
Group testing .

252
Test administered to a group of people simultaneously have advantage
of efficient administration grading and statistical analyses
Q INTELLIGENCE TESTS
INTELLIGENCE AND MENTAL AGE IS DEFINED ABILITY TO
UNDERSTAND DIFFICULT CONCEPT,REASONS AND
ASSIMILATION RECALL AND ANASLYZE
MENTALL AGE
IS defined by Alfred binet shows a person level of intellectual
functioning
CHRONOLOGICAL AGE
Is person actual age in years
Q INTELLECTUAL QUOTIENT
Is ratio of mental age and chronological age multiplied by 100
MA/CA X1OO==IQ
AN IQ OF 100 Means that person mental and chronological ages are
equivalent.highest CA used to determine IQ is 15yrs
IQ is determined to a large extent by genetics. However poor nutrition
and illness during development can negatively affects IQ
Results of IQtest are influenced by person cultural background
IQ is relatively STABLE THRU OUT LIFE.IN ABSENCE OF
BRAINpathology an individual IQ is essentially same in old age as in
childhood
NORMAL INTELLIGENCE
An IQ of 100 means that MA AND CA are approximately same.
Normal IQ is in range of 90-109

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Standard deviation in IQ sore is 15.a person with IQ that is more than 2
standard deviation below mean(IQ=70)is usually considered as mentally
retarded
Q CLASSIFICATION OF MENTAL RETARDATION
Mild IQ 50-70
MODERATE IQ 35-55
Severe IQ 20-40
Profound less than 20
A person score between 71-84 indicates borderline intellectual functioning
A person with an IQ of more than 2SD above mean that is mean above 130
has super intelligence
Weshler intelligence test and Vineland adaptive behavior scale
1=the weshler adult intelligence scale fourth edition (WAIS-IV) is most
commonly used IQ test
2==the WAIS-R has four index score 1= verbal comprehension index
2=working memory index
3= perceptual reasoning index
4=processing speed index
Vci and wmi
Verbal comprehension index and working up
Perceptual reasoning index and processing speed index together make up
performance Iq
Full scale IQ is generated by all four index scores
Weshler intelligence scale for children (WISC) Is used to test intelligence in
children of 4-6 yr of age

254
Vineland adaptive behavior scales are used to evaluate skill for daily living
e.g. dressing and using telephon in people with mental retardation and
other challenges such as impaired vision
Q ACHIEVMENT TEST
USES evaluate how well an individual has mastered specific subject areas
such as reading and mathematics
These test used for evaluation in schools and industries
SPECIFIC ACHIEVEMENT TEST
Achievement tests include scholastic aptitude test, medical college
admission test and united states medical licensing examination .wide range
achievement test which which is often used clinically evaluate arithmetic
,reading and spelling skills and also Stanford test of achievement
Personality tests are used to evaluate psychopathology and personality
characteristics and are characterized by whether information is gathered
objectively or projectively
Q OBJECTIVELY PERSONALITY TESTS
Include minisota multiphasic personality inventory and million clinical
multiaxial inventory are based upon question that are easily scored and
statistically analyzed
Projective personality test
Rosasch test, thematic apperception test and sentence completion test require
subject to interpret questions
Responses are assumed to be based on subject motivational state and
defence mechanism
MINISOATA MULTIPHASIC PERSONALITY INVENTRY

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USES=the most commonly used objective personality test used for primary
care physician because no training is required for administration and scoring
evaluate attitude of pt toward taking the test,
Clinical scales include depression paranoia schizophrenia
and
hypochondriacs
ROSASCH TEST
Most commonly used projective personality test used to identify thought
disorder and defense mechanism.
Pt are asked to interpret 10 bilaterally symmetrically ink
blot
designs(describe what u see in this figure)
THEMATIC APERCEPTION TEST
USES=stories are used to evaluate unconscious emotions and conflicts
Sentence completion test
Projective used to identify worries and problem solving verbal
association .pt completes sentences started by examiner
Q Reasons given for deliberate self harm
Answer=1=to die 2=to escape from unbearable anguish
3=to obtain relief
4=to change the behavior of others
5=to=to escape from situation
6=to show desperation to others
7=to get back at other people /make them feel guilty
8=to get help
Q WHAT ARE OUTCOMES OF DELIBERATE SELF HARM
ANSWER=1=repetition of self harm
2= suicide following deliberate self harm

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Q PHARMACOLOGICAL TREATMENT OF BEHAVIUORAL AND
PSYCHOLOGICAL SYMPTOMS
Dementia can be treated by long acting cholinesrterase inhibiters like
tacrine and donepizel
Antipsychotic like risperidine may be helpful in low doses to decrease
agitation
Q =PHYSICAL EVALUATION OF PATEEINT WITH EMOTIONAL
SYMPTOMS
Psychiatric history is taken as part of medical history .the psychiatric history
include questions about mental illness. drug and alcohol use, sexual activity
and sources of stress
Q =MENTAL STATUS EXAMINATION RELATED IINSTRUMENTS
Is a structured interview that is used to evaluate individual current state
of mental functioning
OBJECTIVE RATING SCALE OF DEPRESSION that are conmmonly
used include Hamilton ,raskin ,jung,beck scale .
In Hamilton and raskin scales an examiner rates pt
In jung and beck the pt rates himself (measures include sadness,guilt and
social withdrawn
VARIABLES EVALUATED ON MSE
Appearance
Behaviouir
Attitude
Cognition
Orientation
Mood and affect
Thought form and content

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Perception
Jugdement and insight
Q =PT SAYS THAT VARIUOS TV channels ARE CONTINOUSLY
talking about this in news
Answer= delusion of grandiosity
Delusion of reference
Q IN WHICH psychiatric disorder these symptom can be present
1=mania AND 2= SCHYZOPRENIA
Q = PT with 10yr history of restless all the time symptoms of restless
irritable bowel ,muscle tension, dry mouth, fine tremors ,she has been
taking diazepam orally for 5 yrs and now inspite of taking a dose more
than prescribed by her family .she cannot get relief from anxiety
Answer=Generalize anxiety disorder
Q =what medical problem u will rule out before making diagnoses of
GAD
Answer= Hyperthyroidism
Treatment of generalize anxiety disorder
1=behavioral psychotherapy
Q=WHAT dopamine tracts are involved in effects and side effects of
haloperidol
Answer=Nigrostriatal tract is involved in regulation of muscle tone and
movement
Nigrostriatal tract are degenerate in parkinsonism
Treatment with antipsychotics block postsynaptic dopaminer receptor
receaving input from nigrostratral tract can result in Parkinson like
symptom

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Dopamine acts on tuberoinfundibular to inhibit secreation of prolactin
from anterior pituitary
Blockage of dopamine recepters by antipsychotic prevent inhibition of
prolactin and results in elevated prolactin Resulting in galactorea, breast
enlargement and sexual dysfunction .
Q =CONCEPT OF HOLISTIC MEDICINE
TRADITIONAL VERSUS HOLISTIC MEDICINE
HOLISTIC MEDICINE IS derived from theory of holicism which
states that all living matter is made up of unified wholes that are greater than
sum of their parts.
Each subparts is linked with other in a dynamic way
Holistic medicine denies the separation of mind and body in traditional
medicine
Holistic medicine consider mind, body and spirit as subparts which form the
person a whole which is greater than sum of its parts
The traditional ALLOPATHIC MEDICINE TREATS The diseased part of
human being
The holistic medicine aims at restoring health and wellness to person as a
whole rather than focusing on disease part alone
To do so a physican commited to holistic medicine is expected to
understand following elements of this approach
PERSON =
A human being has three essential and well integrated elements mind ,body
and spirit held in a dynamic balance
ENVIRONMENT
A set of external forces such as family ,community ,culture, socioeconomic
resources acess to health care quality and type of health care providers as

259
well as attitude toward and belief about health that support or disrupts the
dynamic balance of mind body and spirit of a peson
Health= a dynamic state of mind body and spirit balance that bring the best
out of person that help realize his or her full potential
PHYSICIAN=
THE person who support health rather than one who merely treat disease.
A physician believes that health is a dynamic interactive and integrative
phenomenon that can result from dynamic relationship between person
environment and physician
The holistic medicine demands that a physician must be a person who has
following characteristics
Belief in a potential of healing aact
Capacity to learn
Respects for dignity of human being
Tolerance for difference of opinion
A gentle spirit
Ability to mix creative thinking AND scientific thought
The knowledge of physical sciences along with anatiomy, physiology and
biochemistry provides adequate basis for practice of traditional allopathic
medicine
The practice of holistic medicine however demands the knowledge of
holistic medicine
Q =Biopsychosocial model
Scientist George in early 1970 for first time started emphasize the
importance of integrating traditional biological(path physiological
structure)

260
Aspect of medicine with the behavioral sciences and put forwarded the
concept biopsycho social concept of health and disease
Using system theory (an individual is composed of complex integrated
subsystem elements of mind body and spirit, social relationship all having
feedback loops
BIOPSYCHOSOCIAL FORMULATION
BUIOLOGICAL FACTORS
Disease
Physiology
PSYCHOLOGICAL FACCTRES
Cognition
Mood
Beauvoir
SOCIAL FACTORS
Interpersonal
Social occupational and relating to health care system
George proposed a triad of following above diagram
The biopsychosocial model therefore provides a comprehensive clinical
approach of toward practice of holistic medicine
This approach lays a great emphases on doctor pt relationship, psychosocial
assessment , use of communication skills ,informational care,
counselling,crisis intervention and extension of care to family
Doctor pt relationship is discussed in section b while psychosocial
assessment is part of section e
One of significant contribution of BPS model in health care is the e mpases
it assigns to use of intervention that does not inviolve surgery or drugs ,the
non pharmacological interventions

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Q 3MONTH history of voilance against wife And daughter
Pt suspect sexual involment with neibour
He also plan to remove daughter name from his name becoz he thinks
that features resemble that of neibiour. pt denies any illness
DD 1=delusional disorder
2=schizophrenic 3= anxiety
4= depressive illness5= mood disorder
Q =INDICATION OF ECT (NICE)
It is recommended that ect is used only to achieve rapid and short term
improvement of severe symptoms after an adequate trial of other treatments
options have proved ineffective and when condition is considered to be
potentially life threatening in individual with 1=severe depressive illness
2=catatonia
3=severe manic episode
Q =INDICATION OF ECT
Royal college of physician
In severe depressive illness ect may be treatment of choice when illness is
associated with life threatening illness becoz of refusal of food and fluids
and high suicidal risk
ECT may be considered for treatment of severe depreesive illness assocated
with stupor, delusion and hallucination
EC T may be considered as second or third line treatment of depreesive
illness that is not responsive to antidepressants
ECTmay be considered for treatment of manuia that has not responded to
Appropriastre drug treatment

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ECT may be considered for treatment of acute schyzoprenia as a fourth
,line option for treatment resistant schizophrenia after treatment with 2
antipsychotics and clozapine has proved ineffective
ECT for catatonia where treatment b with other bzd usually lorazepam
proved ineffective
Q = PT with 10yr history of restless all the time symptoms of restless
irritable bowel ,muscle tension,dry mouth,fine tremors ,she has been
taing diazepam orally for 5 yrs and now inspite of taking a dose more
than prescribed by her family .she cannot get relief from anxiety
Answer=generalize anxiety disorder
Q =what are characteristic of a typical mentally healthy individual ?
Answer= criteria for good mental health=
Six criteria of mentally health individual proposed by dr marie in her
monograph.
Current concept of positive mental health .
1= he is self reliant, self conflict And self expecting
2= his degree of self actualization is such that his motivational process
can be characterized by growth motivation rather than need motivation
3= he can resist stress
4= he is autonomous
5= he is able to perceive world and other person with relative freedom
from distortion that can originate in his own need
6=he is adopted to his environment, displaying a creative capacity for
love ,work and play
Q YOU ARE BEING ASKED TO TRAIN SOME VOLUNTEERS FOR
COUNSERLLING OF FLOOD VICTIMS TAKING THE
OPPURTUNITY YOU OBTAIN DATA ABOUT THESE
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VOLUNTEERS AT START OF TREATMENT AND AT END ALL
DATA IS IN MEASURABLE FORM
A=NAME ANY TEST OF STATISTICAL SIGNIFICANCE THAT CAN
BE APPLIED FOR DATA?
Answer=chi square test
Q = ENUMERATE different types of study designs used in medical
research
REASEARCH STUDY DESIGN
Research studies identify relationship between factor and variables
Types
Research studies include cohort, case control ,and cros sectional studies
A= cohort studies
1=begin with specific population (cohort)who are free of illness under
investigation at start of study
2=following assessment of exposure to a risk factors (smoking)
Incidence rate of illness between between exposed and unexposed members
of cohort are compared
An example of cohort study would be one that followed healthy adults from
early adulthood thru middle age to compare the health of those who smoke
verses those who do not smoke 3=cohort studies can be perspective(taking
place in present time) or historical(some activities taken place in past)
4=a clinical treatment trial is a special type of cohort study in which
members of a cohort with A special illness are given one treatment and other
members of cohort are given placebo or second treatment the result of two
treatment are then compared

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An example of a clinical treatment trial would be one in which difference
in survival rates between men with prostate care who recieva a new drug
and men with a prostate cancer who receave a standard drug are compared
B=CASE CONTROL STUDY
It begins with identification of subjects who have a specific disorder(cases)
and subjects who do not have that disorder(control)
Information on prior exposure of cases and control to risk factors is then
obtained
An example of a case control study would be one in which smoking
history of women with and without breast cancer are compare
C=CROSS SECTIONAL STUDIES
It begins when information is collected from a group of individual who
provide a snapshot in time of disease activity
Such studies can provide information on relation shop between risk facter
and health status of a group of individual at one specific point in time(e.g.
random telephone sample conducted to determine if male smokers are
more likely to have upper respiratory infection then male smokers
They can also be used to calculate prevalence of a disease in a population
Q =MOTIVATIONALL INTERVIEWING
ANSWER=EXPRESS EMPATHY
AVOID ARGUING AND DON’T BE JUDGEMENTAL
DETECT AND ROLL WITH RESISTANCE
POINT OUT DISCREPAANCIES IN PT HISTORY
RAISED AWARENESS ABOUT CONTRAST BETWEEN
SUBSTANCE USER AIMS AND BEHAVIOUR
Q =discuss physical examination for psychiatric assessment
Physical examination provides 3kinds of information in assessment
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1= it may reveal diagnostically useful signs such as goiter or absent
reflexes’
It is therefore particularly important in diagnosis and exclusion of organic
disorders
Neurological , CVS, and endocrine system most commonly require detailed
examination
2=psychotropic drugs may produce physical side effects which needs to be
measured such as HTN
3=pt general health, nutritional status and self care may all be affected by
psychiatric disorders
For above 3 reasons physical examination is an integral part of psychiatric
assessment
Q =what are physical and psychological manifestation of stress
Ans= both sympathetic and parasympathetic system may go into overdrive
when faced with stress,
Sympathetic system comes into play when stress is of acute nature and
manifest in form of tachycardia , midraises, dry mouth , piloerrection,
increase bp , when this stress is sustained for a prolong period of time.
stress mainly affects 3 target or organs namely stomach , heart and blood
vessels but spares none
Consequently there is increase acid secretion in stomach, increase gastric
mptying, nausea, and hypertension and muscle aches
Parasympathetic system is stimulate when there is chronicity of stress
It causes anger , delayed gut motility, constipation.
Both system operate thru hypothalamic pituitary adrenal axis which is a
physiological tract involved in stress response

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Recent evidence indicates chronic psychological stress can lead to
increase production of proinflamatory cytokines particularly interleukin il
-6
Proinflamatory cytokines have been implicated in a range of disease in
older adult that can be traced to inflammation including cvs disease,
osteoporoses, ,and diabetes mellitus , certain cancers including multiple
myeloma , non Hodgkin lymphoma and chronic lymphocytic leukemia and
Alzheimer dementia
Il -6=production of c reactive protein= risk of MI.
Examples= cardiovascular= htn , angina, MI, arrhythmia, C coronary
artery disease
GASTROINTESTINAL= irritable bowel syndrome, duodenal ulcer,
gastric ulcer
Ulcerative colitis,
Hormonal =hypoglycemia, dm , hypothyroidism , hypoparathyroidism ,
and hyper thyroidism
Immune= SLE , RA, hashimoto thyroidoitis, myasthenia gravis
Neuro muscular = chronc pain , sacroiliac pain, TMJ, raynauds
diasease
Skin= psoriases , urticaria, pruritus
Respiratory= asthma, hyperventilation, TB

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Q EMOTIONAL MANIFESTATION OF STRESS People who respond
to sympathetic reaction tends to show anxiety, fear, avoid stressor by

showing fright or flight response

Hyper vigilance, hyper arousal are emotional manifestation of these
Individual. Parasympathetic response tend to show guilt , guilt , sadness ,
depression, feeling of being abandoned and isolates
Q = 25yr old house wife refuses to leave her home fearing that she
will suffocate in market ,. She however remains symptom free at home
Q what is the likely diagnoses in this pt
Ans= agorapohobia
Q =FACTORS ASSOCIATED WITHH RISK OF REPETETION
ATTEMPTED SUICIDE ?
1=PREVIOUS ATTEMPT
2=PERSONAL DISORDER

268
3=ALCOHOL OR DRUG ABUSE
4=PREVUIOS PSYCHOTIC TREATMENT
5=UNEMPOLYMENT 6=LOW SOCIAL Class
7=criminal records
8=history of voilance
9=age 25 –50yr
10== single , divorced and separated
Q =what non pharmacological intervention are likely to help her?
Ans= CBT
Systematic desensitization
aggressive training
Exposure
C= list steps you will put Into place to treat her using behavior
theraphy?
SYSTEMATIC DESENSITIZATION=
For management of phobia
Aversive conditioning=Paraphilias (pedophilia) and addiction like smoking
Flooding and implosion=Phobia
Token economy= for disorganized psychoses , autistic and mentally
retarded
Feed back = hypertension , raynauds disease, tension headache
Cbt= depression, somatioform disorder and eating disorders
Q Married man with severe depression plus 30pounds weight loss in last
2months and refuses to eat and does not change clothes and death wishes
Answer=ect is indicated in major depressive illness which does not respond
to antidepressants
B=HOW would u convince to proceed with your treatment of choice
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Answer=discus that ect is good and rapid long term treatment
Q WHAT ARE PT CHARACTERISTICS THAT MAKE
COMMUNITY CARE DIFFICULT
ANSWER=risk of harm to self and others
Unpredicted behavior and liability to relapse
Substance misuse
Poor motivation and poor capacity for self management
Lack of insight into need for treatment
Low public acceptably
Q = what are ETHICAL ISSUES INVVOLVING HIV PATIENT
HIV POSITIVEE DOCTORS
Physicians are not required to inform either pt or medical establishment
about a another physician hiv positive status
Since if physician follows procedure for self control he or she does not
poses a risk to patients
HIV POSITIVE PATEINTS
1=ETHICALLY A Physician cannot refuse to treat hiv positive pt becoz of
fear of infection
2=a pregnant pt at high risk for hiv infection cannot be tested or treated for
virus with zidovidine and nevrapine against her will even if fetus could be
adversely affected by such refusal
.after child is born however their mother cannot refuse to allow child to
be tested and treated for virus
3=if health care provider is exposed to body fluids if pt who may potentially
be infected with hiv
It is acceptable to test the pt with hive even if pt refuses to consent to test

270
4 = physician are not required to maintain confidentiality when hiv pt
habitually b puts an identifying person at risk by engaging in unprotected sex
Q INVOLUNTRY AND VOLUNTRY HOSPITALIZATION
A= under certain circumstances pt
In psychiatric emergency situation who will not or cannot agree to be
hospitalized may be hospitalized against their will or without
consent(involuntary hospitalization)with certificate by one or two
physician .such pt may be hospitalized for upto 90 days depending on state
law e a court befor a court hearing
B=even if psychiatric pt chooses voluntary to be hospitalized he or she may
require to wait 24-48hr before permission to sign out against medical advice
C=pt who are confined to mental health facilities whether voluntary or
involuntary have the right to receive treatment and to refuse
treat(medical,ect.
Pt who are actively or suicidal however generally cannot refuse treatment
aimed at stabilizing their condition
Q describe briefly TRANSFERENCE REACTIONS
DEFINITION =transference and counter transference which are
unconsois mental atitudes based on important past personal relationship
e.g with parents .these phenomenon increased emotionally and may thus
alter judgment and behavior in pt relationship with their doctor(transference)
and doctor relationship with their pt(counter transference)
TRANSFERENCE= positive and negative transference
Positive transference=pt has confidence in doctor if intense pt may over
idealize the doctor or develop social feeling toward doctor

271
NEGATIVE TRANSFERANCE= PT MAY become angry toward
doctor if pt desire and expectations are not realized this may lead to poor
adherence to medical advice
COUNTER TRANSFERANCE
Feeling about pt who reminds doctor of a close friend or b relative can
interfere with doctor medical judgment
Q FRONTAL LOBE SYNDROME is impairment of frontal lobe that
occurs due to disease or head trauma. The frontal lobe of brain plays a key
role in higher mental function such as motivation .planning and social
behavior and speech production
CAUSES=
1= head trauma
2= tumors
3=degenerative disease
4=neurosurgery
5= cerebrovascular disease
Diagnosis= on recognition of typical signs ,use of simple screening tests
and specialist neurological testing
PATHOLOGY=
1=foster klenedy syndrome
2=foster disinhibition syndrome,Rett syndrome and ADHD
3=frontal abulic syndrome
Clinical features of frontal lobe syndrome
1=cognitive
Short attention span
Poor working and short term memory
Difficulty in planning and reasoning
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2=emotional-=depression
Anger
Frustration and sadness
3=behavioral
Per severable behavior
Sexual behavior
4=frontal release signs
Grasp reflex , palmo mental reflex and rooting reflex
Q IN WHICH psychiatric disorder these symptom can be present
1=mania AND 2= SCHYZOPRENIA
Q PT with 10yr history of restless all the time symptoms of restless
irritable bowel ,muscle tension,dry mouth, fine tremors ,she has been
taing diazepam orally for 5 yrs and now in spite of taking a dose more
than prescribed by her family .she cannot get relief from anxiety
Answer=generalize anxiety disorder
Q =BRIEFLY DISCUSS REPETETION OF SELF HARM
A systematic review of 90 studies concluded that among people who
have engage in DSH
A=about one sixth repeats DSH within one year
B=about one fourth repeats DSH within 4yrs
Q =FACTORS ASSOCIATED WITHH RISK OF REPETETION OF
ATTEMPTED SUICIDE ?
1=PREVIOUS ATTEMPT
2=PERSONAL DISORDER
3=ALCOHOL OR DRUG ABUSE
4=PREVUIOS PSYCHOTIC TREATMENT
5=UNEMPOLYMENT 6=LOW SOCIAL Class
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7=criminal records
8=history of voilance
9=age 25 –50yr
10== single ,divorced and separated
Q ASSESSMENT OF SOME ETHICAL ISSUES RELATING TO
RESEARCH
SCIENTIFIC MERITS
WILL FINDING BE OF VALUES ?
ARE METHODS AND SIZE OF GROUPS LIKELY TO ACHIEVE AIMS?
What are sources of financial and other support and are there any potential
conflicts of interest?
Are there any potential conflicts of interest for any of investigation?
Could aim be achieved in an ethically better way?
SAFETY
Are the procedure safe?
If theris a risk are all of necessary precaution being taken?
Is assessed level of risk acceptable to investigation subjects and relatives?
CONSENT
Will subject be competent to give consent?
Will subjects receave clean and sufficient information?
Will they have adequate time to consider and should they wish to do so and
to withdraw consent?
Will it be clear that refusal wil not affect quality and quantity of care
provided?
Is any payment to subjects for expenses likely to exceed these and therefore
acts as an incentive to consent?

274
Is the reasearcher under any pressure to recruit subjects e,g, receiving
payment from a sponsoring company?
CONFIENTIALIYTY
Have subjects consented to use of confidential information in research?
Will the data from research be kept sincerely?
Also SAD PERSON MNEMONIC
Q =MENTAL STATUS EXAMINATION AND RELATED
INSTRUMENTS
1=MSE IS A STRUCTURED ITERVIEW THAt IS USED TO
EVALUATE INDIVIDUAL CURRENT STATE OF MENTAL
FUNCTIONING
2=OBJECTIVE RATING SCALE OF DEPRESSION THAT ARE
COMMONLY USED ARE HAMILTON ,RASKIN, ZUNG AND BECK
SCALES
A=IN HAMILTON AND RASKIN SCALE AN EXAMINER RATES PT
B=IN ZUNG AND BECK PT RATES HIMSELF AND MEDASURES
INCLUDE SADNESS,GUILT, SOCIAL WITHDRAWAN AND SELF
BLAM
EACH ITEM CAN BE SCORED FROM O to 3.total score of 30 to
63indicates severety of depression scores of 5 to 9 indicate little or no
depression
Q ASSESSMENT OF SOME ETHICAL ISSUES RELATING TO
RESEARCH
SCIENTIFIC MERITS
WILL FINDING BE OF VALUES ?
ARE METHODS AND SIZE OF GROUPS LIKELY TO ACHIEVE AIMS?

275
What are sources of financials and other support and are there any portential
conflicts of interest?
Are thereany potential conflicts of interest for any of investigation?
Could aim be achieved in an ethically better way?
SAFETY
Are the procedures safe?
If theris a risk are all of necessary precaution being taken?
Is assessed level of risk acceptable to investigation subjects and relatives?
CONSENT
Will subject be competent to give consent?
Will subjects receave clean and sufficient information?
Will they have adequate time to consider and should they wish to do so and
to withdraw consent?
Will it be clear that refusal wil not affect quality and quantity of care
provided?
Is any payment to subjects for expenses likely to exceed these and therefore
acts as an incentive to consent?
Is the researcher under any pressure to recruit subjects e,g, receiving
payment from a sponsoring company?
CONFIENTIALIYTY
Have subjects consented to use of confidential information in research?
Will the data from research be kept sincerely?
Q 3MONTH history of voilanc against wife And daughter
Pt suspect sexual involment with neibour
He also plan to remove daughter name from his name becoz he thinks
that features resemble that of neibiour. pt denies any illness
DD 1=delusional disored
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2=schizophrenic 3= anxiety
4= depressive illness5= mood disorder
Q =CLASSIFICATION OF ANXIETY
1=PHOBIC ANXIETY DISORDER
2=PANIC DISORDER
3=GENERALIZED ANXIETY DISORDER
Q =COPING WITH DEATH
Death is ultimate test which has to be faced by every body in world.
And we have to cope with it
Death is a great loss.
It may represent failure or success, ending or beginning ,a disaster or
triumph.
We may try to improve our way of caring but whatever circumstances death
must never become routine
When peoples are coming close to death
Professional may have little or no control over what is happening.
Scientific medicine can help us to improve and relieve some of pain of
dying but with all our knowledge 100% of our pt will still die
Despite this pt and families continue to turn us for help.
Death is a social event, it affects the lives of many people
In this circle of people pt are centre of care as long as they are alive but their
troubles will be soon over, those of families may just be beginning
The traditional training of doctor and nurses does little to prepare us for
challenges of terminal and bereavement care
We are so preoccupied with saving life but we are at a loss what to do
when life cannot be saved .some of us deal with problem thereby denying its
existence

277
We insist on fighting for care until bitter ends
Other acknowledge to themselves that pt is dying but attempt to conceal it
from pt
If they succeed the pt may die in blissful ignorance but they often fail
As disease progresses pt looks in mirror and realizes that that some body is
lying
At a time when they most need to trust their medical attendant they realizes
that they have been deceived
In either case the family who survive are denied the opportunity to say
good bye and to conclude any un finished psychological business with pt
Off course it is not only professional staff who find it hard to cope with
people who are dying even friends and family members are equally at loss.
they may deal with their own feeling of inadequacy by putting pressure on us
to continue our treatment long after it can do good and we have to conceal
the true situation from patient.you would not tell him he is dying, will you
doctor? it would kill him if he found out .such remarks occasionally be
justified, they are more likely to reflect the in formant own inability to cope
with truth rather than that of patient
Q Dopaminergic tracts and role of dopamine in cns and its pathologies
Nigrostriatal tract is involved in regulation of muscle tone and movement
Nigro striatal tract degenerates in Parkinson disease
Treatment with antipsychotics drugs which blocks post synaptic dopami n
receptor receaving input from nigrostriatal tract can result in Parkinson like
symptoms
Dopamine acts on tubule infundibular tract to inhibit secretion of prolactin
from anterior pituitary

278
Blockage of dopamine recepters by antipsychotics prevent inhibition of
prolactin release and results in elevated prolactin levels
This elevation in turn results in symptoms like breast
enlargement,galactiorea and sexual dys function
Mesolimbic and mesocortical tract is associasted with psychotic disorders
This tract may have role in expression of emotion si nce it perojects into
limbic system and prefrontal cortex
Hyperactivity of mesolimbic system is associated with positive symptoms
like schyzioprenia and hypoacttivity of mesocortical tract is associated with
negative symptoms like apathy(lack of interest in any thing) in schyzoprenia
Q DEFENCE MECHANISM=
DEFINITION =
Are un conscious mental techniques used by ego to keep conflicts out of
conscious mind thus decreasing anxiety and maintaining a person sense of
safety and equilibrium and self esteem. they can be helpful in dealing with
difficult life situation such as medical illness but when used to excess can
become a barrier to seeking care or adhering to treatment recommendation
SPECIFIC DEFENCE MECHANISMS=
Some defense mechanism are immature like child like manifestation
Mature defence mechanism such as altruism, humor, sublimation and
suopression ,when used in moderation ,directly help the patient or others
Repression, pushing unacceptable emotion into unconscious is the basic
defense mechanism on which all others are based
Q TRANSFERANCE REACTION=
Definition=transference and counter transference are unconscious mental
attitudes based on important past personal relationship e.g with parents

279
These phenomenon increase emotionality and alter judgment and behavior
in pt relationship with their doctors(transference) and doctor relationship with
there pts(coyunter transference)
Transference include positive and negative transference
In positive transference pt has confidence in doctor ,if intense the pt may
over idealize docter or develop sexual feeling toward doctor
In negative transference pt may angry toward doctor if pt desires and
expectations are not realized, this leads to poor adherence to medical advice
In counter transference feeling about pt who reminds doctor of a close
friend or relative can interfere with doctor medical judgment.
Q =GENERALIZE ANXIETY DISORDER
Excessive poorly controlled anxiety about life circumstances about life
circumstances that continues for more than 6months
Both physiologic and psycho logic components will be present
Psycho logic components include worries and restless and difficulty in
concentrating
Physiologic components include autonomic instability and motor tension
Clinical features=prevalence is 5% in especially females and have chronic
course
Associated symptoms include depression
Etiology=genetic predisposition
Treatment=1=relaxation techniques
2=biofeed back
3=psychopharmacology includes ssri, venlafine,buspirone and
benzodiazepines
SYMPTOMS OF GENERALIZE ANXIETY DISORDER
Worries plus apprehension, Muscle spasm

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, Autonomic hyperactivity , Psychological arousal
Sleep disturbances
Other features are depression and depersonalization
Q DEVELOPMENTAL PSYCHOPATHOLOGY
BEHAVIOURAL CHANGES
During development we learn that how we know that at specific stage child
is normal or abnormal,. if child starts urination at age of 3years then it is
normal but if child urinates at age of 7yrs then it is abnormal
LIFE EVENTS
Another important developmental factor is that if child under 6months if
passess to some one else show little disturbance but if child above 3yr passes
to another care giver
Then show separation anxiety .this shows that life events differs as child
grows
PSYCHOPATHOLOGICAL CHANGES=
Some disease are in childhood such as anxiety disorders in children while
in adults depressive disorders and conduct disorders are common
EFFECT OF GENES FOR PRODUCING DISEASE
Especially in autism and adhd
EFFECT OF ENVIROMENTS
Environmental changes may predispose to some disorder and may even
protect person from depression
Q EMOTIONAL ABUSE
Severe neglect sufficient to retard child development
Some times this term is used for verbal abuse which retard child
development
Other varieties of abuse may be along with emotional abuse

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Q =EFFECTS OF EMOTIONAL ABUSE ON CHILD
1=failure to thrive physically
2=psychological impairment
3=emotional and conduct disorders
DIAGNOSES=
BY parents behavior toward child .one or both child may have personality
disorder or psychiatric disorders
Doctor should assess parent mental status
Treatment =of EMOTIONAL ABUSE=
1= parents should be taught to control their emotional problems
2=parent should interact with child
3= in case parents are rejecting the social services be taken into account for
safety of child and steps required for care of child
Q =DIVIDING LINE BETWEEN AND ABNORMAL
CONTINUITIES AND DISCONTINUITIES
Some psychological problems in child persists into Adulthood while some
disorder like anxiety disorders less likely to progress to adulthood
PARENT CHILD INTERACTION
Childs usually learns from parents especially mothers
Q =CLASSFICATION OF PSYCHATRIC DISORDERS IN
CHILDREN AND ADULTHOOD
SEVEN MAIN DISORDERS
1=ADJUSTMENT DISORDER
2=PERVASIVE DEVELOPMETAL DISORDER
3=SPECIFIC DEVELOPMENTAL DISORDER
4==CONDUCCT OR ANTISOCIAL DISORDER
5=ADHD

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6=EMOTIONAL DISORDER
7=SYMPTOMATIC DISORDER
CHILDHOOD DISORDERS have not been classified in a easy
satisfactory way these includes
CLINICAL PSYCHTRIC SYNDROMES
SPEIFIC DELAY IN DEVELOPMENT IN INTELLECTUAL AND
MEDICAL AND SOCIAL SITUATION
Q = Stages of memory= human memory resembles a computer in that
it consist of an information processing system that has three separate
stages
1= ENCODING= sensory information is received into neural impulse that
can be processed further or stored for later use
2-= storage= information is then stored in memory system
3= retrieval = when we recall memory into consciousness we have
retrieved this recal process is known as memory retrieval
Q =erik erikson =
Ans=stage 1= basic trust versus mistrust
Stage 2= autonomy versus shame and doubt
Stage 3=initiative versus guilt
Stage 4= industry versus inferiority
Stage 5= identity versus role diffusion
Stage 6=intimacy versus isolation
Stage 7= generativity versus stagnation
Stage 8= Integrity versus despair
Q = what test are available for assessment of intelligence=
Ans= iQ test = MA / CA multiply BY 100 =
WESHLER ADULT INTELLIGENCE SCALE
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WESHLER INTELLIGENCE SCALE FOR CHILDREN -III
Assessment of IQ includes assessment of mathematics , verbal , spatial
and mechanical proficiency.
Q = breaking bad news
biopsychosocial model=
Step one= seating and setting exclusively
Involvement of significant other
Seating arrangement
Be attentive and calm
Listening mode available
Step 2= pt perception
Step 3= invitation
Step 4= knowledge
Step 5= empathy
Step 6--= summarize
Step 7= plan of action
B = individualized disclosure model
C= full disclosure model
D= paternistic disclosure model
E= nondisclosure model
Q = management of voilance=
Ans=protect yourself,
Do not approach alone
Call for assistance to manage any situation, Reassure pt, Restraint
This should be used as a last resort but when needed it must not be
delayed and must not be attempted in half hearted way

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Restraint is usually followed by compulsory hospitalization and parenteral
medication,
It is necessary to continue restraint for more than few hour. Assess
nutritional status and if there is dehydration iv fluids are essential,
Sedation
The most effective drugs are inj chlorpromazine 100 mg
Inj haloperidol 10 -20mg, Inj diazepam 10mg
Q = 23 yr old male has been brought by his family with six months
history of self neglect. Academic decline, staying aloof and isolated, and
refuses to leave home
Further inquiry reveals that he believes that he may be abducted by
Taliban who are constantly watching his action thru hidden camera
A= what is most likely diagnose
Ans= persecutory delusion
Q = what will be your first line of management
Give two alternatives
Justify thru current guidelines
Ans=treat underlying cause
Q= what psychosocial intervention can you offer to support drug
treatment in persecutory delusions
Answer= psychological management including individual ,family and group
psychotherapy is useful to provide long term support and to foster
adherence to drug regimen.
Q =15yr old unmarried girl presented with history of extreme concern
about shape and weight, loss of weight About 15yr and secondary
amenorrhea and frequent vomiting
What is most probable diagnoses
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Answer-= Anorexia nervosa
Q =I = give important classical signs and investigation with
justification
Ans= Diagnostic test
Signs of malnutrition=
Normocytic normochromic anemia, elevated liver enzymes
, abnormal electrolytes, low estrogen and testosterone levels, sinus
bradycardia, reduce brain mass and abnormal EEG
Signs of purging=Metabolic alkaloses, Hypochlorite
By emesis
Metabolic alkaloses caused by laxative abuse’
Investigation as such no investigation are available
We do physical examination
Outcome= long term mortality rate of individual hospitalize for anorexia
nervosais 10 perrcent resulting from effects of starvation and purging or
suicide
Physical examination=
Signs of malnutrition includes emaciation. Hypotension, bradycardia,
lanugo(i.e. fine hairs on trunk)
And peripheral edema
Signs of purging include eroded dental enamel caused by emeses and
scarred or scratched hands from self gagging to induce emesis
There may be evidence of general medical condition caused by abnormal
diet, starvation and purging
Q Medical complication of eating disorders caused by multiple
behavior
Binge eating= causes gastric dilation or rupture and obesity
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Vomiting causes= esophageal rupture, parotiditis with hyperamylasia
Hypokalemic , hypochloremic metabolic acidoses with cardiac
arrhythmias
Ipecac toxiocity= cardiac and skeletal myopathies
Dehydration
Electrolyte imbalance and Starvation cause= leucopenia, anemia,
hypotension, bradycardia, edema, hypercholesterolemia, dry skin,
lanugo hairs
Q =TREATMENT OF Generalized anxiety disorder= IS =behavioural
psychotherapy include relaxation training , and biofeed
back.pharmacotheraphy includes ssri, venlafaxine,busppirone, and bzd Imm
Q=

Q =INFORMATIONAL CARE

It is provision of information to patients using principles of communication

regarding disease, drugs and doctors(3D),that concern him
This helps to fill the gap in patient knowledge and understanding in these
areas,using the language that pt understands
During ill health patient as well as the concerned others feel a desperate
needs to know what is exactly wrong, how is it being or will be managed,
how all will deliver care and how?
The amount of information provided, timing ,language and setting in which
informational care is imparted has to be tailored according to individual need
of patient, the stage of recovery and questions that bother the patient much
Q SEVEN QUESTINS needs to be asked in in informational care
session includes
1=what is wrong with me? pt seeks diagnoses
2=why have u developed this disease? what is etiology

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3=is there any effective treatment to my problem? Is the treatment safe? Are
there any serious side effects?
4=how long will it take to recover(what is prognoses?5=is there a perhaz?
restriction in diet
6=is there a risk of illness being spread ton those around me or passing it on
to my offspring?
7=how will illness and treatment affect my functioning? can I continue to
work or rest? What will happen to my sex, sleep,appetite?
Q SEVEN ESSENTIALS IN INFORMATIONAL CARE
Physician must set aside certain time within consultation to give a
reasonable ,evel of information to patient and his family about disease and
treatment
1= the ic session must take place in language that pt can understand
2-=it must start with pt knowledge ,understanding,and expectation
3=he doctor must then remove any myths and misconception that pt
mention in his description .these misconceptions must be immediately
replaced with scientific bases and evidence basis
4=the task of giving information must be professionalized, meaning
thereby that evidence based facts are provided without fear of causing a
negative reaction in patient or relatives
It must however be done with compassion, empathy and sensitivity
Vague statements and building false hopes should be avoided
5=both aspects of disease and treatment ,negative and positive should be
communicated to patients but information overload should be avoided
6=use of simple figures, diagrams and sketches are often helpful to
understand pt understanding(most pt or relatives may like to keep sketches

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at end of session which consolidates the interest and utility of IC exercises
in therapeutic process
7=the IC session ends with pt briefly summarizing his new understanding of
3D
This helps to evaluate how much of information has been retained? the
doctor finally reassures that any future concerns and clarification that are
needed will also be addressed
Q briefly describe TRADITIONAL VERSUS HOLISTIC MEDICINE
Holistic medicine is inspired which states that states that reality (living
organism ) is made up of unified wholes that is greater than sum of
there parts linked by dynamic balance
Holistic medicine denies the separation of mind and body as is seen in
traditional medicine
It consider mind body and spirits as sub parts which forms person . a
whole than greater than sum of its parts and denies there sepatration
of mind and body
Traditional medicine treats the disease part of body
Holistic medicine aims at restoring health wellness to person as a whole
rather than focusing on disease part alone
To do so physician committed to holistic medicine is expected to
understand following elements of this approach
PERSON=Human being has three essential elements ,mind body and spirit
held in a dynamic balance
ENVIROMNENT=
A SET OF EXTERNAL FORCES like culture ,family or community and
attitude toward and belief that support or disrupt balance of mind body
and spirit of a person
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HEALTH =
A dynamic state of mind body and spirit balance bring about best out of a
person and help him realize his full potential
PHYSICIAN =
The person who support health and rather than one who merely treats
disease
Holistic medicine demands that a physician must have following
characteristics
Belief in potential of healing act
Capacity to listen and emphasize
Respect for dignity of human being ‘
Tolerate for difference of opinion
Gentle spirit
Ability to mix creative thinking and with scientific thought
Will never give hope even against heavy oods
The knowledge of physical sciences along with anatomy ,physiology and
biochemistry provide adequate bases for practice of traditional allopathic
medicine
Practice of holistic medicine however demands the knowledge of
behavioral sciences
INTELLIGENCE= the global capacity of individual to act
purposefully ,to think rationally and to deal effectively with
environment
IQ= MA/CA×1OO= RESULT
FOR ADULT WE USE WAISR
FOR CHILDEREN WE USE WISC-III
EXTTREME OF INTELLIGENCE
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In 5% population we see extreme of intelligence either above 130 or below
70 scores are seen
And are designated as exceptional
Score below are mentally handicapped and also have deficit s in self care,
social skills and communication
Diagnose of handicapped also requires that condition occur before age of
18year
Also head injury have role in this low score
Individual with score above140 may be identified as gifted or genius
Q ABUSE OF DOCTOR PT RELATIONSHIP DURING
PSYCHOTHERAPY

ANSWER=1=IMPOSE OWN VALUES AND BELIEVES ON PATIENT

2=SEXUALLY ABUSE PT

3=EXPLOIT PT FOR FINANTIAL GAIN

4=PUT THE INTEREST OF THIRD PARTY AGAINST INTEREST OF

PATIENT

Q SENARIOS OF ALZEMERS DISEASE pt of 77yr old with history of

gradual loss of recent memory for a few months
Answer=biological investigation
IN PRIMARY CARE Full blood count
ESR
Urea and electrolytes LFTS
Calcium and phosphate TFt Vitamin b12 and folate
IN SECONDERY CARE
MRI CT BRAIN
URINALYSIS SYPILIS SEROLOGY

291
CXR RADIOGRAPH
NEUROPSYCHOLOGICAL ASSESSMENT
GENETIC TESTING AND EEG
Q HOW PREVENT DRUG ABUSE=PREVENTION OF DRUG
ABUSE=
1=PREVENTION= use social pressure against use of drugs
2= detoxification
Given medication to minimize effects of drugs and its withdrawal
3= substitution therapy
Use methadone in place of heroin
4= anxiolytic and antidepressants drugs
Q DEFINE ORIENTATION= pt ability to know about time , place
and person
Order of loss 1=time 2=place 3=
person
Q Common causes of loss of oreintation
1-= alcohol 2= electrolyte disturbances
3= drugs 4= hypoglycemia 5= head trauma
Q DEFINE KORSAKOFF AMNESIA
=Classical anterograde amnesia caused by thiamin deficiency ,leads
to bilateral destruction of mamillory bodies
Thiamine deficiency leads to anterograde amnesia seen in alcoholics
and associated with confabulation
Q =BIOPSYCHOSOCIAL MODEL OF HEALTH
George engel in 1970 started this model
It states that biological, psychological(which entails thought,behaviuor and
emotion) and social(socioeconomic ,socioenviromental,and cultural) factors
292
all play a significant role in human functioning in context of disease or
illness. It posits that health is best understood in term of combination of
biological, psychological and social factors rather than purely in medical
terms
This is in contrast to biomedical model of medicine that suggest every
disease process can be explained in term of an underlying deviation from
normal function such as virus, gene, developmental abnormalities or injury.
the concept is used in fields such as medicine ,health psychology as well as
sociology and particularly more in psychiatry and clinical psychology
The bps paradigm is a technical term for for popular concept of mind body
connection which addresses philosophical arguments between bps and
biomedical model rather than there empirically exploration and clinical
application
Novelty, acceptance and prevalence of bps model varies across cultures
Q WRITE A DETAIL NOTE ON PSYCHOTRAUMA
IS result of extraordinary stressful events that shatters person sense of
security making him feel hopeless and vulnerable in a dangerous world
Psycho trauma is a wound to psyche due to an experience which has
endangered ones life and threatens one s identity, integrity ,honors and
property
The experience is understood as a threats to n ones physical and
psychological wellbeing and is a sharp confrontation with death or a
challenge to life
A traumatic experience leaves scar on mind and body of a human being
Traumatic experience often involve a threat to life or safety but any
situation that leaves a person feeling frightened and alone can be traumatic,
even if it does not involve physical harm
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Experiences such as verbal abuse, or any major loss can be just as
traumatizing as a life threatening event especially when they happen during
childhood
Wether the threat is physical or psychological trauma results when an
experience e is so overwhelming that a person goes numb or disconnects
from what’s happening
While this automatic response may be protective for a short while it also
prevent a person from moving on
Not all potentially traumatic events leads to psycho trauma
Some people rebound quickly from even the most tragic experiences
other are devastated by experiences that on a surface appears to be less
upsetting it is not the magnitude of a catastrophe that determines whether an
event is traumatic but a person subjective emotional experience of an event.
The more endangered,helpless and unprepared a person is ,the more likely
that he will be traumatized
CAUSES=
Emotional trauma can be caused by one time occurrences such as house
fire,a plane crash or earthquake psychological and emotional trauma can be
caused by experience of ongoing and continue stress such as fighting in a
war, living in a dangerous neibhuorhood,or struggling with the life
threatening disease
Though people respond differently to stressful experiences, a traumatic
event is likely to result in negative effects if it is
Inflicted by humans, Repeated and ongoing
Unexpected, Intentionally cruel
Experienced in childhood

294
People are more likely to be traumatized as adults if they have a history of
childhood trauma or if they are already experiencing a lot of stress
Q DEVELOPMENTAL TRAUMA
Stressful experiences in childhood whether a one time event such as a car
accident or an ongoing situation caused by a negligent parent can be
traumatizing
Developmental or attachment trauma results from anything that disrupts a
child sense of safety and security
This can include unsafe environment ,separation n from parent
Developmental trauma is more severe when it involves harms at hands of a
care giver
This trauma has a negative impact on child physical ,emotional and social
development
Child who has been traumatized see the world as a dangerous and
frightening place
When childhood trauma Is not resolved this sense of fear and helplessness
can carry over into adulthood , setting the stage for further trauma
Q Normal resposes to traumatic events=
It is more important to distinguish between normal reaction to traumatic
events and symptoms of more serious and persistent problem
Following a traumatic event most people experience a variety of emotion
like shock ,fear, anger, and relief to be a live
Often they think or talk of nothing else than what happened to them
Some become depressed
COMMON REACTION TO TRAUMA=
Guilt Self blame
Anxiety Mood swing and irritability
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Feeling disconnected Distressing memories
Social withdrawal Loss of appetite
Feeling sad Difficulty in concentration
These feeling symptoms typically last from a few days to few months
And gradually fading as one process the trauma
Recovery from trauma takes time and every one heals at his own place
Professional help is required if a person has
Problems at work or home
Living with persistent fear and anxiety’
Avoiding more and more things that reminds one of trauma
Q POST TRAUMATIC STRESS DISORDERS=
Is a condition that result from severe kind of trauma,
It is characterized by intrusive memories, flashbacks, avoiding things
that reminds one of traumatic event and living in a constant state of red
alert
Q MANAGING PSYCHOTRAUMA=
The process of healing of emotional trauma is slow and complex
It involves facing and resolving unbearable b feeling and memories which
a person has long avoided
The healing journey involves processing of memory of trauma thru various
techniques
Q POST TRAUMATIC GROWTH
Though idea of trauma is most frequently thought off in negative terms it
have positive aspects as well
Q The term post traumatic GROWTH WAS COINED BY
PSYCHOLOGIIST in 1996 by Richard

296
He describes a post traumatc change in how many people think of
themselves, their relationship with others including all of humanity as well
as profound philosophical, spiritual or religious changes
According to these psychologists trauma can lead to growth they say that
reports of growth experiences in aftermath of traumatic event far outnumber
report of psychiatric disorders
Post traumatic growth can manifest I n form of improved relationship, new
possibilities for one life ,a greater appreciation for life,a great sense of
personal strength and spiritual development
Their losses can produce valuable gain and they may find themselves
becoming more comfortable with intimacy and having a greater sence of
compassion for other who experiences life difficulties
Q =OBESITY= causes and consequences=
def= more than 20% over ideal weight on basis of common height
and weight charts or having a body mass index of thirty or higher’
At least 25 % of adults are obese and an inc reasingly no of children
are overqweight at or abiove 95 % of BMI for age in united states
Obesity is not an eating disorder
Genetic factors are most important in obesity.
Adult weight is closer to biologic rather than adoptive parents
Obesity is more common in low socioeconomic group and its associated
with increase risk for cardio respiratory , sleep and orthopedic problems ,
hypertension and diabetes mellitus.
Management= most weight loss achieved using commercial dieting and
weight loss program is regard within a 5 yr period
Q : Write what is your concept about stigma in psychiatric patient?
CONCEPT OF STIGMA
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Peiople stigmatize others mentally ill pt.the tendency to stigmatize is deeply
rooted in humans nature as a way of responding to people who appear or
behave differently
Stigmatization is based on fear that those who seems different may behave in
threatning way
And is reduced when it becomes clear
Q STIGMA IN PSYCHIATRY
People fear mental illness and they stigmatize those who behave in different
ways. Peoples with mental illness a nd cannot control their behaviuor and
they act in odd and possibly voilant ways
Thus they are seen as directly threatning also indirectly threatning becoz
their lack of control threatens ouir belief in our ability to control our action
Diagnosis such as leprosy and aids have the potential to be stigmatizing
It is suggested that stigma of mentall illness would be reduced if diagnosis
such as schyzioprenia were abandoned
To reduce stigma it is neessary to reduce fear and this require accurate
information about mentall illness and better understanding of mentally ill
people
.psychatric stigma arises frm a no of false belief e.g. concern about
dangerousness is a major component of psychotic stigma.other important
illnesses are ideas such as
People witnh mentrally ill are unpredictable
People with mental illness feel different frm rest of us
People of mental illness are hard to talk and relate to
Mentall illnesds cannot br cured and people with mental illness do not
recover

298
Those belief make people draw back froom thos with menal illness and
discoourage them from engaginging in social relationship with mentally ill
people
People do not learn that there assumption are wrong .in this way fear of
stigma adds greatly to problem of people off mentall illness
Stigma has wider social effects it make harder for mentally ill people tgo
obtain work
Q : How would you reduce stigma in psychiatric patient?
REDUCING STIGMA
Compaigns to reduce stigma genetrally include information about nature of
mental illness and low frequency of dangerous behavoipor.encouregement
to persuade public figures who have had a mental illness to speak
publically about there experience
A focus on young people whose attitude may be less fixed than those of
there elders
Although stigma can be reduced this cannot be done quickly or early .in
past people of epilepsy were stigmatized as knowledge spread as treatment
improved attitude gradually changes ,changes are now beginning to be seen
in stigma attached to some but not all psychotic disorders
Q : Expain psychometric tools for assessing various mental illnesses?
INSTRUMENTS FOR MEASURING SYMPTOMS
RATING FOR DEPRESSIVE SYMPTOMS
1=HAMILTON RATING SCALE
2=BECK DEPRESSION INVENTRY
3=MONTGOMERY ASBERG DEPRESSION RATING SCALE
4=PATIENT HEALLTH QUESIONASRE
RATING OF ANXIETY SYMPTOMS
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1=HAMILTON ANXIETY SCALE
2=CLINICAL ANXIETY SCALE
3= STATE TRAIT ANXIETY INVENTRY
RATING OF OTHER SYMPTOMS
1=YALE BROWN OBSSEDSSIVE COMPULSIVE SCALE
2=YOUNG MANIA RATING SCALE
3=RATING OF MOTOR SYMPTOMS
4=RATING USED IN ASSESS,MENT OF COGNITIVE IMPAIRMENT
AND DEMENTIA
RATING OF SYMPTOMS OF SCHYZOPRENIA
PANNS SCALE
RATING OF PERSONALITY AND ITS DISORDERS
Q HOW PREVENT DRUG ABUSE=PREVENTION OF DRUG ABUSE=

1=PREVENTION= use social pressure against use of drugs

2= detoxification

Given medication to minimize effects of drugs and its withdrawal

3= substuitution theraphy

Use methadone in place of heroin

4= anxiolytic and antidepresents drugs

Q DEFINE ORIENTATION= pt ability to know about time , place and

person

Order of loss

1=time

2=place

3= person

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Q Common causes of loss of orientation

1-= alcohol

2= electrolyte disturbances

3= drugs

4= hypoglycemia

5= head trauma

Q DEFINE KORSAKOF AMNESIA=

Classical anterograde amnesia caused by thiamin deficiency ,leads to bilateral

destruction of mamilary bodies

Thiamine deficiency leads to anterograde amnesia seen in alcoholics and

associated with confabulation

Q =DISSOCIATIVE AMNESIA=

Inability to recall important personal information usually subsequent to trauma

Q WHAT IS MANIA AND MANIC EPISODES=

Episode of abnormally elevated mood lasting at least one week

Diagnioses require 3 or more of following are present during mood disturbances

(MANICS DIG FAST)

1=DISTRACTIBILITY=

2=IRESPONSIBILITY( SEEKS PLEASURE WITHOUT REGARD TO

CONSEQUENCES)

3=GRANDIOSITY(INCREASE SELF ESTEEM )

4=FLIGHT OF IDEAS

5-=INCREASE IN PSYCHOMOTOR AGITATION

6=DECREASE B NEED FOR SLEEP

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7= TALKATIVENESS OR PRESSURED SPEECH

Q == ATYPICAL DEPRESSION

Differs from classic form of depression characterized by hypersomnia,increase

apetite,increase weight gain

Most common subtype of depression

Treatment with MAOI or ssri

Q =PANIC DISORDER=

Episode of intense fear, peaking in 10min, and have at least 4 of following

P=palpitation and paresthesia

A=abdominal discomfort

N=nausea=

I=intense fear and light headedness

C=chest pain,chills and chocking

S =sweating and shortness of breath

Strongly genetically inherited

Treatment = CBT

Also=SSRI,TCA, BENZODIAZEPINES

Q =Transsexualism = desire to live as opposite sex often thru surgery or

hormonal treatment

Q =Transvestism ==parapilias

Wearing clothes of opposite sex

Q =DELIRIUM TREMONS=

IS one of life threatening alcoholic withdrawal that peaks v2-5 days after last
drink

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SYMPTOMS=

1= AUTONOMIC HYPERACTIVITY LIKE TACHYCARDIA,TREMORS,

SEIZURES

2-= PSYCHOTIC SYMPTOMS LIKE HALLUCINATYION AND DELUSION

3= CONFUSION

TREATYMENT =BENZODIAZEPINES

Q =PERSONALITY DISORDERS=

PERSONALITY=THERE ARE MANY DEFINITION OF PERSONALITY

GOOD EXAMPLE IS PERSONALIY is those features which determiners

individual unique response to environment ( human and non human)

So studies add that personality is life ling and persistent although personality
changed somewhat over time, the natural maturation process can be changed
thru sustained psychotherapy

Personality features influences individual way of thinking feeling and behaving

Freud said that healthy personality was demonstrated by ability to love and work

Personality features obey normal distribution curve with majority of population

in middle of graph and a few individual at extrenme

Q define Health= according to WHO = a state of complete mental and

physical wellbeing

Q =Personality disorder=

Is enduring patern of inner experiences and behavior that deviate markedly from
expectation from individual culture

Has an onset in early adulthood and is stable overtime and leads to impairment
and distress

Individual with personality disorder like antisocial personality disorder

generates distress in other thru failed relationsip

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Q= What are methods used for suicide?

Ans=poisoning, hanging,drowning,,jumping,and burning

Q =What social ,envoromental and situational facters are involved in

offending and aggression ?

ANS= CAUSES OF CRIMINOLOGY=

GENETICS AND PHYSIOLOGICAL BEHAVIOUR

Studies of twins suggest that concordance rate for crimes are more in
monozygotic twins than dizygotic twins

Genetic factors are well established for conduct disorders in children and and
continuity in aggressive antisocial behaviuor

Psychosocial factors for offending=

Individual factors=

Hyperactivity and impulsivity

Low intelligence

Child rearing poor supervision

Teenager mother

Parent conflict and separation

Criminal parents

SOCIAL FACTERS=

Socioeconomic deprivation

Peer influences ,school influnceds and criminal influences

PSYCHiATRIC CAUSES=

Psychiatric causes and offending

Psychotic people aquire more voilance than normal people by a factors of 10

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 Antisocial personality and substance misuse are having more offending than
psychotic peoples

Q SCHYZOPRENIA AND OFFENDING

The paranoid psychotic pt are having more voilant behaviors and also non
voilant offending behavior

Q what will be effect of watching aggression on viewer behaviors?

Ans=as we know that criminal influences, peer influences and school influences
are having more role in offending aggression so these can aggravate and precipitate
aggression

Q=a young girl developed a strong emotional reaction on watching her

fiancé with another girl in a shoping mall?what wil be effect of emotional
arousal on thinking and what physiologic and iimmunological changes it can
causes?

Ans=1it can interfere with efforts to cope with cope in stress,

2= interefere with attention and memory recall and rehearsal of memory

3=impair judgement and decision making

Q=write note on biopsychosocial model?

George angel In 1970 empisize the importance of integrating traditional

biological with behaviuoral sciences and put forward the concept of bps
model

Bps model provides a comprehensive clinical approach toward practice of

holistioc medicine

And lays great emphaseson doctor pt relationship, psychosocial assessment,

communication skills and informational care , crises intervention, and expansion
of care to family

Q Social determinants of aggression=

Poverty ,frustration, low socioeconomic stress

305
Q Biological determinants of aggression=

Hormones and anabolic steroids and estrogens and progesterone

Substance abuse

Amphetamine and phencyclidine

Q NUEURAL BASIS OF AGRESSION=

SEROTONINE AND GABA decrease aggression and dopamine and

norepinephrine facilitates it

Abnormal activity of brain especially amygdala ,prepyriform cortex,frontal lobe

and hypothalamus

Q =What is diagnostic creteria for post traumatic stress disoreder?

Diagniostic creteria is similar in ICD 0-10 AND DSM –IV

DSM –IV ASSIGNS MORE IMPORTANCED TO NUMBING

DSM –I V require two creteria that are not present in icd 10

According to icd -10 symptoms must be present for at least 1month and may
cause v social impairment

As a result of these differences the concordance between the diagnoses of these

two sets of cretyeria is 35%

By convention n PTSD can be diagnosed in people having a history of psychtric

disorders before the stressful events

Differential diagnoses includes following

1=stress induced exacerbation of b anxiety or mood disorders

2= acute stress disorders diagnosed by time course

3=adjustment disorders

4= enduring personality changes after catastrophic experiencers

306
Q = Seven medical condition as differential diagnoses of panic disorders=

1=SOB and smothering sensation

2=palpitation and tachycardia

3=chest pain

4=dizziness and faintness

5= numbness and tingling sensation

6= fear of dying

7=fear of going crazy

Q=PT states that he heared a voice of GOD as her clocked ticked ,shwe
heared voices coming from running tape in a way the voices were audible
simultaneously .she sees someone standing behind her

Ans= reflex hallucination

q=pt hears voices of GOD giving him direction whenever he sees amber
light at traffic signals,sometimes he seea phantom mirror image of herself

Ans= autoscopic hallucination

Q= pt hears animal noises at onset of sleep and at awakening from sleep?

ANS=HYPNOPOMPIC AND HYPNOGOGIC HALLUCINATION

Q=Senarios of pt on antipsychotics inj zuclopentihixol 3days ago brought

to emergency in confusion ,febrile ,bp changes from lying to standing
position

Q=what is most likely diagnose?

Ans=neuroleptic malignant syndrome

Q =in this condition you will see what specific clinical signs on physical
and mental status examination

Ans= 1= muscle stiffness ,cog wheel rigidity

307
2=hyperthermia

3= autonomic instability

4= delirium

Q What specific investigation you would undertake in NMS?

ANS=1= LEUKOCYTOSES

2= crp gradually increase

3-= secondary complication includes pneumonia,., thromboembolism , renal

failure, cvs collapse

Q PROGNOSES=10% MORTALITY RATE

And declining over several years

DD =includes 1= encephalitis

2=heat stroke

Q = Manage NMS=

1= Immediately discontinue drugs

2= symptomatic treatment

3-=cold sponging

4= intercurrent infections

5= for muscle stiffness give dyzepam

6= malignant hypertension is treated by dantroline

7= severely ill pt are admitted in icu and intubated and deals with renal; failure

Complication of NMS=1= secondary pneumonia 2= thromboe mbolism

3= cvs collapse 4= renal failure

Q what is Memory?

308
Definition=memory is most important extraordinary phenomenon of human brain.

Our brain are modified and reorganized by our experiences and perceptions.

The most strange aspect of human memory is that it stores events as videos along
with emotions .it is this phenomenon that makes our feeling as pleasant and
unpleasant.

In all our higher mental functions like speech ,thinking and perception as well as
psychomotor skill are based on our memory phenomenon.

Indeed without memory there can be no mind .

Q what are stages of memory?

human memory resembles a computer in that it consists of an information

processing system that has three separate stages

1=encoding

2=storage

3=retrieval system

1=encoding

Sensory information is received and transformed into neuro impulses that can be
processed and stored for later use

2=storage of information

Must be stored in memory system.

The information which is used only once are stored for temporary basis .while
information which is like telephone numbers are stored on permanent basis

3=memory retrieval

Human memory work like computer system. It can be recall up by its name and
used again. When we recall or bring a memory into its consciousness.

This recall process of stored memory is called memory retrieval.

309
Q what are Types of memory

1=sensory memory

Is a memory and storage of sensory events such as sounds ,sight and taste with
no further processing.sensory information tend to last only briefly about one half
to one second depending on which sensory system involved

The information which we see last for one and half second. The information which
you hear last only for upto 2seconds.

2=short term memory

Not everything seen or heard is kept in memory. Let say a tv commercial is

running in the background as your friend reads his notes on pharmacology. We
usually don’t remember tv commercial becoz our attention was toward notes and
information moves on to short term memory. short term memory are also s and
sounds. short term memory is brief but longer than sensory memory.

Short term memory can be stored as of images and sounds. short term memory can
acts as temporary store house for small amount of information. important news is
stored while unimportant is lost from short term memory.

3=long term memory

Important and meaningful information is transferred to third memory system

called long term memory. long term memory acts as permanent store house for
information.

Short term memory store information on basis of sound images or words while
long term memory store permanently that information.

And which is stored on basis of meaning and importance. Hippocampus is brain

structure responsible for storing memory for long term basis.

310
Flow diagram how information converted to long term memory.

4=Rehearsal

it consists of repeating items in short term memory silently or aloud .

Rehearsal transfers information from short term to long term memory. Majority of
great peoples have great memory is dependent on their rehearsal of memory.

Q Two types of rehearsal

1=maintenance rehearsal. Peoples who going to do study by going over and over
does not succeed in transfer of short term memory into long term memory.

2=elaborative rehearsal is an active process which is repeating the information

either silently or aloud and thus succeed in transferring short term memory into
long term memory.

5=forgetting

Is apparent loss of information already encoded and stored in long term memory
or loss of information due to lack of attention may not have reached from sensory
311
memory to short term memory. Information forgotten is dependent on following
factors

A=interference=some of experiments suggests that early memory in brain leads to

interfere with new memory. Similarly new memory interfere with past memory.

Retrieval problems

Reppetetion helps in long term memory while rehearsal and epetetion problems
leads to forgetting of long term memory.

Q Motivated forgetting

Theory of motivational forgetting was introduced by sigmeud freud when he

described a key concept of psychoanalysis vs repression.

QRepression

Is a tendency of majority of peoples to have difficulty in retrieving anxiety

provoking or un pleasant events.

Thus leads to concept that people usually have memory and remembers pleasant
events ant forget unpleasant events.

Q Anatomy and biochemistry of memory

Short term memory is thru hippocampus while long term memory is thru
amygdala.hypocampus and amygdala are essential in receaving information and
storing it.both hippocampus and amygdala are embedded under temporal
lobe.diencephalon also contains a number of structures the most important of
which for memory being mammillary body ,thalamus and hypothalamus.lesions of
mamilory bodies hypothalamus and thalamus results in problems in encoding and
storing of new information. Many have shown that physiologic basis of memory
and learning on long term potentiation which is process in which repeated
stimulation of nerve cells in brain can lead tpo long term memory.studies also
indicate that a specific type of recepters nmdareceptor just like calcium have a
role in long term memory.certain studies show that memory depends on increase in
sensitivity of nerve cells to acetylcholine.
312
Q Methods to improve memory

some great peoples have specific techniques thru which that facilitates there
memory and learning of new information.

1=knowledge of results

Or feedback. Learning occurs most effectively when knowledge of results. When

answers questions correctly and receive reward and when u have bad study then u
try to correct ur deficiency and leads to more practice and study.

2=attention and focus on study increased in good setting

3=recitation and rehearsal

This means repeating to ureself what u have learnt .when u studying text book we
should stop and frequently and remembers what u have read thus it leads to
increase and improve memory.

4=organize

Study in organize way improve memory

5=selective study

One scholar said that good memory is like a fisher man net. it should keep all big
fishes and lets small fishes to escape. Big ideas should be underlined thus
selective
study improves our memory

6=serial position

Whenever u must learn something. aware of the serial position effect. if u are
remembering the long line of people .u will fprgett names of middle ones so u will
do extra efforts to remember those in middles

7=mnemonics=medical students often invent mnemonics for memorizing the

names of cranial nerves and amino acids and remember these long lists for long
term basis. Basics principles for formations of mnemonics are a=use mental
pictures’=makes things meaningful=makes information familiar.

8=attach emotions and feeling for increase retention by using mental pictures

313
9=over learning. Many studies indicate that memory is greatly improved when stuy
is beyond bare mastery.

10=spaced practice

Is superior method of learning and memory .Three 20min sessions with spacing is
better than one hour of continues study.

11=whole versus part learning

Try to learn the longest meaningful amount of information possible at one time.

Selective notes especially self made notes are of benefit and for succeesss.

12=sleeping

Sleep after study is helpful and decreases interference

13=review

Revision before exam is helpful. One should avoid the tendency to memorize new
inform at that time

Q =PERSONALITY DISORDERS=

PERSONALITY=THERE ARE MANY DEFINITION OF PERSONALITY

GOOD EXAMPLE IS PERSONALIY is those features which determiners

individual unique response to environment ( human and non human)

So studies add that personality is life ling and persistent although personality
changed somewhat over time, the natural maturation process can be changed
thru sustained psychotherapy

Personality features influences individual way of thinking feeling and behaving

Freud said that healthy personality was demonstrated by ability to love and work

Personality features obey normal distribution curve with majority of population

in middle of graph and a few individual at extreme

314
 Q define Health= according to WHO = a state of complete mental and physical
wellbeing

Q =Personality disorder=

Is enduring pattern of inner experiences and behavior that deviate markedly

from expectation from individual culture

Has an onset in early adulthood and is stable overtime and leads to impairment
and distress

Individual with personality disorder like antisocial personality

disorder
generates distress in other thru failed relationship

Q = What are methods used for suicide?

Ans=poisoning, hanging ,drowning,, jumping,and burning

Q =a young girl developed a strong emotional reaction on watching her

fiancé with another girl in a shoping mall?what wil be effect of emotional
arousal on thinking and what physiologic and iimmunological changes it can
causes?

Ans=1it can interfere with efforts to cope with cope in stress,

2= interfere with attention and memory recall and rehearsal of memory

3=impair judgment and decision making

Q = Seven medical condition as differential diagnoses of panic disorders=

1=SOB and smothering sensation

2=palpitation and tachycardia

3=chest pain

4=dizziness and faintness

315
5= numbness and tingling sensation

6= fear of dying

7=fear of going crazy

Q=What are neuropsychiatric and behavouoral symptpoms in multiple

scleroses

1-= chronic neurological disability

2-=seven time risk in suicidal risk

3=depression

Depression is also due to use of beta interferon in multiple scleriposes

4= cognitive impairment in 40%patients

5= intellectual deterioration

Q =PT states that he heared a voice of GOD as her clocked ticked ,shwe
heared voices coming from running tape in a way the voices were audible
simultaneously .she sees someone standing behind her

Ans= reflex hallucination

Q =pt hears voices of GOD giving him direction whenever he sees amber
light at traffic signals,sometimes he seea phantom mirror image of herself

Ans= autoscopic hallucination

Q = pt hears animal noises at onset of sleep and at awakening from sleep?

ANS=HYPNOPOMPIC AND HYPNOGOGIC HALLUCINATION

Q =Senarios of pt on antipsychotics inj zuclopentihixol 3days ago brought

to emergency in confusion ,febrile ,bp changes from lying to standing
position

Q=what is most likely diagnose?

Ans=neuroleptic malignant syndrome

316
 Q =in this condition you will see what specific clinical signs on physical
and mental status examination

Ans= 1= muscle stiffness ,cog wheel rigidity

2=hyperthermia

3= autonomic instability

4= delirium

Q What specific investigation you would undertake in NMS?

ANS=1= LEUKOCYTOSES

2= crp gradually increase

3-= secondary complication includes pneumonia,., thromboembolism , renal

failure, cvs collapse

PROGNOSES=10% MORTALITY RATE

And declining over several years

DD =includes 1= encephalitis

2=heat stroke

Q= Manage NMS=

1= Immediately discontinue drugs

2= symptomatic treatment

3-=cold sponging

4= intercurrent infections

5= for muscle stiffness give diazepam

6= malignant hypertension is treated by dantroline

7= severely ill pt are admitted in ICU and incubated and deals with renal; failure

317
Complication of NMS=1= secondary pneumonia 2= thromboembolism

3= cvs collapse 4= renal failure

Q =What social ,envoromental and situational facters are involved in

offending and aggression ?

ANS= CAUSES OF CRIMINOLOGY=

GENETICS AND PHYSIOLOGICAL BEHAVIOUR

Studies of twins suggest that concordance rate for crimes are more in
monozygotic twins than dizygotic twins

Genetic factors are well established for conduct disorders in children and and
continuity in aggressive antisocial behaviuor

Psychosocial factors for offending=

Individual factors=

Hyperactivity and impulsivity

Low intelligence

Child rearing poor supervision

Teenager mother

Parent conflict and separation

Criminal parents

SOCIAL FACTERS=

Socioeconomic deprivation

Peer influences ,school influences and criminal influences

PSYCHTRIC CAUSES=

Psychiatric causes and offending

Psychotic people acquire more violence than normal people by a factors of 10

318
 Antisocial personality and substance misuse are having more offending than
psychotic peoples

SCHYZOPRENIA AND OFFENDING

The paranoid psychotic pt are having more violent behaviors and also non
violent offending behavior

Q n what will be effect of watching aggression on viewer behaviors?

Ans=as we know that criminal influences, peer influences and school influences
are having more role in offending aggression so these can aggravate and precipitate
aggression

Q =a young girl developed a strong emotional reaction on watching her

fiancé with another girl in a shoping mall?what wil be effect of emotional
arousal on thinking and what physiologic and immunological changes it can
causes?

Ans=1it can interfere with efforts to cope with cope in stress,

2= interfere with attention and memory recall and rehearsal of memory

3=impair judgment and decision making

Q=What is diagnostic creteria for post traumatic stress disoreder?

Diagniostic creteria is similar in ICD 0-10 AND DSM –IV

DSM –IV ASSIGNS MORE IMPORTANCE TO NUMBERING

DSM –I V require two creteria that are not present in icd 10

According to icd -10 symptoms must be present for at least 1month and may
cause v social impairment

As a result of these differences the concordance between the diagnoses of these

two sets of criteria is 35%

By convention n PTSD can be diagnosed in people having a history of psychtric

disorders before the stressful events

319
Differential diagnoses includes following

1=stress induced exacerbation of anxiety or mood disorders

2= acute stress disorders diagnosed by time course

3=adjustment disorders

4= enduring personality changes after catastrophic experiencers

Q = Seven medical condition as differential diagnoses of panic disorders=

1=SOB and smothering sensation

2=palpitation and tachycardia

3=chest pain

4=dizziness and faintness

5= numbness and tingling sensation

6= fear of dying

7=fear of going crazy

Q=What are neuropsychiatric and behavouoral symptpoms in multiple

scleroses

1-= chronic neurological disability

2-=seven time risk in suicidal risk

3=depression

Depression is also due to use of beta interferon in multiple scleriposes

4= cognitive impairment in 40%patients

5= intellectual deterioration

Q=PT states that he heared a voice of GOD as her clocked ticked ,shwe
heared voices coming from running tape in a way the voices were audible
simultaneously .she sees someone standing behind her

320
Ans= Reflex hallucination

Q =pt hears voices of GOD giving him direction whenever he sees amber
light at traffic signals,sometimes he seea phantom mirror image of herself

Ans= Autoscopic hallucination

Q= pt hears animal noises at onset of sleep and at awakening from sleep?

ANS=HYPNOPOMPIC AND HYPNOGOGIC HALLUCINATION

Q b=Senarios of pt on antipsychotics inj zuclopentihixol 3days ago

brought to emergency in confusion ,febrile ,bp changes from lying to
standing position

Q=what is most likely diagnose?

Ans=neuroleptic malignant syndrome

Q =in this condition you will see what specific clinical signs on physical
and mental status examination

Ans= 1= muscle stiffness ,cog wheel rigidity

2=hyperthermia

3= autonomic instability

4= delirium

Q = Manage NMS=

1= Immediately discontinue drugs

2= symptomatic treatment

3-=cold sponging

4= intercurrent infections

5= for muscle stiffness give diazepam

6= malignant hypertension is treated by dantroline

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 7= severely ill pt are admitted in icu and intubated and deals with renal;
failure

Complication of NMS=1= secondary pneumonia 2= thromboe mbolism

3= cvs collapse 4= renal failure

Q =PREVENTION OF COMMON MENTAL HEALTH PROBLEMS IN

PAKISTAN
Goal of prevention is to decrease onset and subsequent remaining(residual)
disability of mental disorder
PRIMARY PREVENTION
1-=REMOVE CAUSATIVE AGENTS 2= Increase immunity and
resistance
3= Control mode of disease transmission 4= Education about mental
health
SECONDARY PREVENTION=
1= Search for mental case by door to door services and give support
2= Take mental cases to mental health services
TWO types of centers are 1= Day centre 2= 24h centres
With proper treatment and proper counseling and proper support these pt can be
treated
TERTIARY PREVENTION=
Goal is to decrease residual disability and gives balance personality to
community and to care so that to able those mental disorders and to reach the
highest level of functioning

Fcps and mcps senarios

SOLVED SCENARIOS OF FCPS PART TWO AND MCPS

Q = scenarios of pt of repeated washing of hands

322
Ans=psychological terms such as
A=obsession
B=compulsion
Q =BEHAVIOURAL THEORIES OF OCD
1=behavioral psychotheraphy
A=relaxation techniques
B=guided imagery
C=exposure
D=paradoxical intent
E=response prevention
F=thought stopping techniques
G =modeling
2=pharmacotherapy
A=SSRI INCLUDE 1=FLUXETINE
2=FLOVOXAMINE
3= CLOMIPRAMINNE
Q GIVE 5 SITUATION WHERE YOU MAY FACE PRIOBLEM
REGARDING CONFIDENTIALITY
Although physician are expected to maintain pt confidentiality they are not
required to do so if 1=there pt is a suspected case of child or elder abuse
2=their pt has suspected risk of suicide
4 their pt poses a serious threat to another person
5=there pt poses a risk to another person
Q my complexion is dark and ugly and no boy looks at my long hairs
and green eyes
Ans=Body dismorphic disorder
Q INFERIORITY COMPLEX
323
Is a lack of self worth and uncertainty, it is often subconscious alder was
scientist who introduced inferiority complex. classical Adler psychology
makes a difference between primary and secondary inferiority feeling
Primary inferiority feeling is said to be rooted in young child original
experience of weakness helplessness
Secondry inferiority feelings related tom adult experience of being unable
to reach a subconsiuos goal
Q TRAITS OF EXTRAVERSION
AND INTROVERSION
Is a central dimension of human personality theories .the term introversion
and extroversion were popularized by Carl jung
Extroversion tends to be manifested as outgoing talkative and energetic
behavior
Introversion is manifested as more reserved and solitary behavior
Q PARANOID SHYZOID POSITION
Distrust and suspiciousness and emotionally cold and ood
Detachment and restricted emotionality , social drifting and dysphoria
Q NEUROTRANSMITTER INVOLVED IN ETOLOGY OF
SCYZOPRENIA
A= DOPAMINE HYPOTHESIS OF SCHYZOPRENIA STATES THAT
POSITIVE SYMPTOMMS RESULT FROM EXCESSIVE
DOPAMINERGIC ACTIVITY OR EXAMPLES AN EXCESSIVE NO
OF dopamine receptors ,excessive concentration of dopamine and excessive
hypersensitivity of receptors to dopamine in limbic system .some of
stimulant drugs such as amphetamine and cocaine can cause psychotic
symptoms .

324
Lab test may show elevated level of homovanilic acid a metabolite of
dopamine
Hva in body fluids in pt with scyzophrenia .negative symptoms of
scyzophrenia are believed to result of reduced activity in frontal cortex
B=Serotonin hyperactivity
Is implicated in schizophrenia
Hallucinogens increases serotonin and psychosis
While clozapine decreases serotonin and decrease psychotic symptom
C=Glutamate is implicated in scyzophrenia
NMDA receptor antagonist are used in treating some neurodegenerated
symptoms such as loss of cognitive abilities in pt with schizophrenia
Cocaine and amphetamines increases dopamine activity and leads to
psychosis
Q HALOPERIDOL ARE HIGH POTENCY OLDER
ANTIIPSYCHOTIC
WHILE OLANZAPINE BLOCK D4,D2 ASND SEROTONINE
RECEPTERS
Q POOR COMPLIANCE OCCUR IN 5Opercent of chronic pt
Causes of poor compliance
1=indifference and lack of involvement
2=depress pt
3=lack of response to treatment
4=confusing clinical picture’
5=appearance of unquestioning obedience
Q 5elements in achieving pt adherence
1-=accurate communication between doctor and pt
2=emotional support and understanding of pt

325
3=awareness of pt health belief model
4= focus on overall quality of life of pt
5= recognition of pt depression and hopelessness
Q stages of psychoanalytical theory
It is based on freud concept that behavior is determined by forces derived
by forces derived from unconscious mind process
Psychoanalytical therapy are psych and related therapy are
psychotherapeutic tx based on this concept
Q Freud theory of mind=to explain his idea Freud developed early in his
carrier the topographical theory of mind and later in his carrier structural
theory
Q topographical theory of mind= in this three levels Unconsiouus
Preconscious
Conscious
Unconsiuos mind contain repressed thought and feeling that are not
available to conscious mind and uses primary process of thinking
A=primary process = is a type of thinking associated with primitive
derives, wish fulfilnes and pleasure thinking
Primary thinking process is seen in young children
B= dreams represent gratification of unconscious instinctive Impulses and
wish fulfillment
2=preconscious mind = contains memories that while not immediately
available can be assessed easily
3=conscious mind= contain thought that person is currently aware of it
And it operates in close conjunction with preconscious mind but does not
have acess to unconscious mind

326
The conscious mind uses secondary process thinking(logical and mature)
and can delay gratification
B=Q structural theory of mind
Mind contain three parts
Id ,ego and superego
Id =unconscious
Ego=unconscious
Preconscious
Conscious
Superego=unconsuis
Preconsoius and consiiuos
Q = a 25yr old lady presents with 3week history of psychomotor
overactivity, talking excessively and sexually disinhibited behavior.. this was
preceded by a history of depression started after delivery of her first baby
two month back for which she was treated with setraline
What is most likely diagnoses
Ans =Bipolar current episode mania
Q how you will manage the case in light of recent guideline
Ans= already discussed in back pages
Q benzodiazepine Post-Acute Withdrawal Symptoms

Some of the symptoms of tranquilizer post-acute withdrawal are:

Anxiety
Mood swings
Depersonalization
Poor concentration
Social isolation
327
Low energy
Disturbed sleep

Post-acute withdrawal gradually gets better over two years. Your symptoms
should show gradual improvement. Measure your progress month to month. If you
measure your progress day to day, or week to week, you'll often have one week
that will be worse than the week before. But if you measure your progress month
to month you should see steady improvement. If you take care of yourself, and
you're patient, you can get through this.

Q Recovery and Relapse Prevention Strategies

If you have decided that you are addicted, this is your opportunity to change
your life. Learn more about recovery skills and relapse prevention strategies.
You can recover from addiction and be happier.

Q normal sleep
Sleep stages are REM and nonrem sleep
Numerous differences between these
NREM= a stage OF SLEEP CHARACTERIZED BY SLOWING OF EEG
RHYTHM ,HIGH MUSCLE TONE, absence of eye movements and thought
like mental activity in this brain is inactive and body is active
Rem sleep=characterized by aroused eeg pattern sexual arousal saccadic
eye movement generalize muscle atony except middle ear and eye
movement and dream in this stat brain is active and body inactive
Rem sleep have burst of saw tooth waves and 25% disturbance
Rem stage 2 is longest of all sleep stages
Stage 3 slow wave sleep , hardest to assess

328
Rem easiest to arouse lengthen in time as night progress . increase during
second half of night
REM LATENCY
PERIOD LASTING FROM moment you fall asleep to fo=irst rem period
last aapproximately 90% in most individual .however severall disorder will
shorten rem latency’s disorder include depression and narcolepsy
Sleep latency= time needed before you actually fall asleep ,typically less
than 15min and may be abnormal in insomnia
Q =strategies to treat resistant ocd=

Ans = already discussed

Q = enlist facters to be considered when assessing crime in a pt with

temporal lobe epilepsy

Ans= the association between epilepsy and crime is complex and poorly
understood . while it has been widely believed that risk of epilepsy is greater in
prisoners than in general population, a met analyses of seven studies indicated
that this was not the case

and a later met analyses of nine studies found some evidence of an adverse
relationship between epilepsy and violence

violent behavior is sometimes associated with eeg abnormalities in absence of

clinical epilepsy but it is doubtful whether this u=indicates a causal relationship

epileptic automatism may very rarely be associated with violent behavior and
subsequent criminal proceeding

violence is more common in post ictal state than ictally

329
Q Psycho-oncology is a field of interdisciplinary study and practice at the
intersection of lifestyle, psychology and oncology. It is concerned with aspects of
cancer that go beyond medical treatment and include lifestyle, psychological and
social aspects of cancer. Sometimes it is also referred to as psychosocial
oncology or behavioral oncology because it deals with psychosocial and behavioral
topics. The field is concerned both with the effects of cancer on a person's
psychological health as well as the social and behavioral factors that may affect
the
disease process of cancer and/or the remission of it.

This is where the effects of:

chemobrain or post-chemotherapy cognitive impairment "PCCI" would be

addressed.
Radiation induced cognitive decline issues.
Placebo effect and the nocebo effect will be studied.
Self care issues are studied.
Q Signs and symptoms of mad cow disease or creft jakob diseaee

The first symptom of CJD is rapidly progressive dementia,

leading
to memory loss, personality changes, and hallucinations. Other
frequently
occurring features include anxiety, depression, paranoia,
obsessive-
compulsivesymptoms, and psychosis. This is accompanied by physical problems
such as speech impairment, jerky movements (myoclonus),
balance and
coordination dysfunction (ataxia), changes in gait, rigid posture, and seizures.

330
Q REASEARCH STUDY INVESTIGATING OF EFICACY OF ECT

A meta-analysis done on the effectiveness of ECT in unipolar and bipolar

depression was conducted in 2012. Findings showed that, although patients with
unipolar depression and bipolar depression responded to other medical treatments
very differently, both groups responded equally well to ECT. Overall remission rate
for patients with unipolar depression to a round of ECT treatment was 51.5% and
50.9% in those with bipolar depression. The severity of each patient’s depression
was assessed at the same baseline in each group.

There is little agreement on the most appropriate follow up to ECT for people
with major depressive disorder. When ECT is followed by treatment
with antidepressants, about 50% of people relapsed by 12 months following
successful initial treatment with ECT, with about 37% relapsing within the first 6
months. About twice as many relapsed with no antidepressants. Most of the
evidence for continuation therapy is with tricyclics; evidence for relapse
prevention with newer antidepressants is lacking. In 2008, a meta-analytic review
paper found in terms of efficacy, "a significant superiority of ECT in all
comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus
antidepressants in general, ECT versus TCAs and ECT versus MAOIs."

In 2003, The UK ECT Review group published a systematic review and meta-
analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis
demonstrated a large effect size (high efficacy relative to the mean in terms of
the
standard deviation) for ECT versus placebo, and versus antidepressant drugs.

Compared with transcranial magnetic stimulation for people with treatment-

resistant major depressive disorder, ECT relieves depression about twice as

331
well, reducing the score on the Hamilton Rating Scale for Depression by about
15 points, while TMS reduced it by 9 points.

Q Enuresis , refers to a repeated inability to control urination. Use of the

term is usually limited to describing individuals old enough to be expected to
exercise such control. Involuntary urination is also known as urinary
incontinence.

Classification

Types of enuresis include:

Nocturnal enuresis (bedwetting)

Diurnal enuresis
Mixed enuresis - Includes a combination of nocturnal and diurnal type.
Therefore, urine is passed during both waking and sleeping hours.

Also,

Primary enuresis refers to children who have never been successfully trained
to control urination. This represents a fixation.
Secondary enuresis refers to children who have been successfully trained ( are
for at least 6 months dry ) but revert to wetting in a response to some sort of
stressful situation. This represents a regression.

QNocturnal enuresis

After age 5, wetting at night—often called bedwetting or sleepwetting—is more

common than daytime wetting in boys. Experts do not know what causes
nighttime incontinence. Young people who experience nighttime wetting tend
332
to be physically and emotionally normal. Most cases probably result from a
mix of factors including slower physical development, an overproduction of
urine at night, a lack of ability to recognize bladder filling when asleep, and,
in some cases, anxiety. For many, there is a strong family history of
bedwetting, suggesting an inherited factor.

Slower physical development

Between the ages of 5 and 10, incontinence may be the result of a small
bladder capacity, long sleeping periods, and underdevelopment of the body's
alarms in the brain that signal a full or emptying bladder.

Q Medical uses OF MELATONIN IN AFFECTIVE DISORDERS

Melatonin has been studied for insomnia in the elderly. Prolonged release
melatonin has shown good results in treating insomnia in older adults Short-term
treatment (up to three months) of prolonged-release melatonin was found to be
effective and safe in improving sleep latency, sleep quality and daytime alertness.

Q What are ethical problems in psychiatry

1=dr pt relationship
2=confidentiality
3= consent
4=compulsory treatment
5=research
Dr pt relationship
Include autonomy
Beneficence

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Malevolence and justice
Q ABUSE OF RELATIONSHIP
Impose own values and believes on pt
Put interest of 3rd party before those of pt
Sexually exploit pt
Exploit pt for financial gains
Q DOPAMINERGIC PATHWAYS AND THRE PROJECTION IN
BRAIN
Dopaminergic neuron in substantia nigra in mid brain prolect to striatuim
Effect of dopamine excite direct pathwayuy increase cortical excitation
Dopanmin excite direct pathway thru d1 and inhibit indirect pathway by d2
recepters
STAGES OF ERIK ERIKSON OF LIFE CYCLE
STAGE 1=BASIC TRUST VERSUS MISTRUST (BIRTH TO ONE YEAR
STAGE 2=AUTONOMY VERSUS SHAME AND DOUBT 1-3YR
STAGE 3= INITIATIVE CERSUS GUILT 3-5 YR
STAGE 4= INDUSRY VERSUS INFERIORTY 6-11YR
STAGE 5 IDENTITY VERSUS ROLE DIFFUSION 11-END OF
ADOLESCENCE
STAGE 6= INTIMACY VERSUS ISOLATION 21-40YR
STAGE 7=GENERATIVUITY VERSUS STAGNATION40-65
STAGE 8 INTEGRITY ERSUS DESPAIR OVER 65YR
Q elaborate stages of adolescence crises
Stage 5= identity versus role diffusion 11-end of adolescence
Group identity, preoccupation with apearance.deal with morality and ethics
identity crises and share with others with out fear of losing self

334
Q what are possible hazards of psychiatrist while working with aggressive
pt who have been admitted as emergencies
Ans=1=trauma
2=physical and verbal abuse
3= dangerous harm
Qfollowing measures used to evaluate screening test
sensitivity
A/A+C multiplied by 100
Specificity=
D/ B+D multiplied by 100
Positive predictive value=
a/a+b multiplied by 100
negative predictive value= d/c+d multiplied 100
% of false positive= c/ a +c multiply 100
% of false negative b/ b+d multiply n100
Q PSYCHOMOTOR TOOLS IN ALZEMER DISEASE?
COGNITIVE FUNCTION
Minimental state examination
Six item cognitive impairment test
Seven minute screen
Clock drawing test
Hopkins verbal learning test
Alzheimer disease assessment scale and cognitive sub scale
Cambridge examination for mental disorders of elderly cognitive section
Behavioral and psychological features
Neuropsychological inventory
MOUSE PAD
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BEHAVE AID
COHEN MANS FIELD AGRESSION INVENTORY
ACTIVITIES OF DAILY LEARNING
Bristol scale
Alzheimer disease functional and change scale.
Disability assessment for dementia
DEPRESSION
Cornel scale geriatric depression rating scale
GLOBAL ASSESSMENT
Clinical dementia rating scale
Q imm = SOCIAL DETERMINANTS OF AGRESSION
Factors associated with increase aggression include poverty ,frustration
,physical pain and exposure to aggression in media
Children at risk for aggressive behavior in adulthood have frequently
moved and changed school repeatedly
And have been physically AND SEXUAL ABUSED, Mistreats animals
and younger or weaker children and cannot defer gratification
Threr pt frequently display criminal behavior
And abuse drugs and alcohols
Homicide occurs more often in low socioeconomic population and its
incidence increasing especially from guns use
Q BIOLOGICAL DETERMINENTS OF AGGRESSION= androgens
are closely associated with aggression,
In most animal species and human societies
Male are more aggressive than females
Homicid involving strangers is committed most exclusively by men

336
Androgenic or anabolic steroids often taken by body builders to increase
muscle mass
Can result b in high level of aggression and even psychoses
Severe depression frequently occurs in withdrawal from these hormones
Estrogen , progesterone and anti androgens can be useful in treating male sex
offenders
Q SUBSTANCE ABUSE AND THERE EFFECTS ON AGRESSION
Low doses of alcohol and barbiturates inhibits aggression while high doses
facilitates it
Increase doses of heroin causes little aggression
Increase dose of cocaine , amphetamine and pcp are associated with
increase aggression
Q NEURAL BASES OF AGRESSION
Serotonin and gaba inhibit aggression and dopamine and nor epineprine
facilitates it
Low doses of serotonin metabolites are seen in people who show impulsive
aggression
drugs used to treat inappropriate aggressiveness include antidepressants
,bzd, atypical antipsychotic and mood stabilizers such as lithium
Abnormalities of brain parts such as amygdala , prepyrifoerm area,
psychomotor and temporal lobe epilepsy and hypothalamus assocatecd with
increase aggression
violent people often have history of head injury and abnormal eeg readings
Q =CLUSTER B=ERRATIC AND IMPULSE
INCLUDES
ANTISOOCIAL= DISAGREBLE
BORDERLINE = UNSTABLE
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HISTRIONIC= ATTENTION SEEKING
NARCISTIC= SELF CENTRED
CLUSTER C=
ANXIUOS AND FEARFULL
INCLUDES
AVIODANT =INHIBITED
DEPENDEABLE= SUBMISSIVE
OBSESSIVE= PERFECTIONISM
Q =KEY CLINICAL PROCEDURES IN MENTAL HEALTH ACT

Criteria for detention

Assessment order

Treatment disorder

Transfer from prison and course

Police power and power of entry

Community treatment orders

Q CRETERIA FOR DETENTION

Involuntary or civil commitment is a legal process thru which an individual

with symptoms of severe mental illness is court ordered into treatment in a
hospital(in patient) or in community(out patient)

Criteria for civil commitment are established by laws which vary between nations

Commitment proceeding often follows a period of emergency hospitalization

during which an individual with acute psychiatric symptoms is confined for a
very short duration 72 hr. in a treatment facility for evaluation and stabilization
by
mental health professionals who may then determine whether further civil
commitment is appropriate or necessary

338
If civil commitment proceeding follows then evaluations is presented in formal
court hearing where terrorism and other evidence may also be submitted

PURPOSE

In most jurisdiction involuntary commitment is specially applied to individual

found to be suffering from a mental illness that impairs there reasoning ability to
such an extent that law state or court finds that decision should be made for them
under legal framework

Q = EVIDENCE BASED MEDICINE

Is a systematic way of obtaining clinically important information about etiology

diagnosis prognoses and treatment?

Following steps are applied

Formulation of an answerable clinical question

Identification of best evidence

Appraisal of evidence of validity and utility

Implementations of finding

Evaluation of performance

Principles of EBM CAN BE APPLIED TO A VARIETY OF MEDICAL

PROCEDURESS . FOR PSYCHIATRIST THE MAIN USE OF EBM AT
PRESENT IS TO ASSESS THE VALUE OF THERAPEUTIC INTERVENTION

Q normal sleep

Sleep stages are REM and NONREM sleep

Numerous differences between these

NREM= a stage OF SLEEP CHARACTERIZED BY SLOWING OF EEG

RHYTHM ,HIGH MUSCLE TONE, absence of eye movements and thought like
mental activity in this brain is in active and body is active

339
Rem sleep=characterized by aroused eeg pattern sexual arousal saccadic eye
movement generalize muscle atony except middle ear and eye movement and
dream in this state brain is active and body inactive

Rem sleep have burst of sawtooth waves and 25% disturbance

Rem stage 2 is longest of all sleep stages

Stage 3 slow wave sleep , hardest to assess

REM easiest to arouse lengthen in time as night progress . Increase during second
half of night

Q REM LATENCY

PERIOD LASTING FROM moment you fall asleep to first rem period last
approximately 90% in most individual .however several disorder will shorten
rem latency, disorder include depression and narcolepsy

Sleep latency= time needed before you actually fall asleep ,typically less than
15min and may be abnormal in insomnia

Q =CHARACTERISTICS OF SLEEP FROM INFANCY AND OLD AGE

TOTAL SLLEEP TIME DECREASE

REM % DECREASE

STAGE 3 AND 4 TEND TO VANISH

Q=CONTROLING SIDE EFFECTS OF ANTIPSYCHOTICS

You can help to control possible side effects on their own by getting regular
exercise and eating a low fat ,low sugar , high fiber diet e.g. bran ,fruits,
vegetables to reduce risk of diabetes and help prevent weight gain,
constipation.
Using sugar less candy or gums, drinking water, brushing your tooth
regularly to increase salivation and dry mouth
Getting up slowly from a sitting or lying position to help prevent dizziness

340
Q INDICATION FOR ECT(ROYAL COLLEGE OF PSYCHiATRIST
In severe depressive Illness ECT may be treatment of choice when illness is
associated with life threatening because of refusal of fluids and foods
ECT may be considered for treatment of severe depressive illness
associated with stupor
Marked psychomotor retardation
Depressive delusion and hallucination
ECT may be considered as a second line or third line treatment of
depressive illness that is not responsive to antidepressant drugs
ECT may be considered for treatment of mania
That is associated with life threatening physical exhaustion
That has not responded to appropriate drug therapy
ECT may be considered for treatment of acute scyzophrenia as a fourth
line option for treatment resistant scyzophrenia after treatment with two
antipsychotics and then clozapine proved ineffective
ECT is indicated in pt with catatonia where treatment with a
benzodiazepines usually has proved ineffective.
Q=What dose of current you will give in first ect?
ANS= 400millicoulombs
Q = what will be position of specific electrodes in ect?
Ans=apply bilateral electrodes over 3cm above mid point of mid point of
line drawn between external angle of orbit and external auditory meatus
Q=what are unwanted effects after ect?
Ans=1=anxiety 2=headache 3= retro and anterograde amnesia
4=disorientation 5= git side effects
6= muscle pain
7-= damage to tongue, teeth and lips 8=crush fracture of vertebrae

341
9= cardiac arrhythmias and pulmonary embolism
10= aspiration pneumonia 11= cva and status epilepticus
Q= 30YR male present to you with suspiciousness toward his wife
anger and irritability.
On complete assurance of confidentiality he tell you that he wants to
kill his wife=
How you would resolve the issue of confidentiality in this case?
Answer=confidentiality=physician cannot tell anyone anything about these
pt without permission although pt are expected ethically to maintain pt
confidentiality they are not required to do so 1=there is a suspected case of
child or elder abuse
Q BREAK OF CONFIDENTIALITY=they are not required to do so if
pt poses a threat to another person
They are not required to do so 1= if pt is a suspected case of child or elder
abuse
2=there pt is a significant risk of suicide
3= there pt poses a serious threat
4=there pt poses a risk to public safety e,g impaired driver
Q =old retired professor was brought in ER by his daughter who was in
drowsy state and marked restlessness,walking with unsteady
state.blurred vision ,dry mouth.
Daughter found five blister pack of drug
Answer=sign and symptoms of benzodiazepines or barbiturates
B=Q clinical test and investigation immediately to confirm ur
suspiciousness
Answer=
Eye for pupil constriction show opium if no then phenobarbitone.

342
If euphoric then opium
If depressed bp and decrease respiration then benzodiazepines or barbiturates
3=urine screening test for opoids 4=HBsAg, anti HCV AND HIV ICT
DONE and then by ELISA
Q MANAGEMENT STEPS IN EMERGENCY
1=HISTORY 2=EXAMINATION
3=ADMIT IN HOSPITAL ICU 4=START OXYGEN
5=PASS NG TUBE AND START GASTRIC LAWAGE IF PATIENT
COMES SOON.
STOMACH WASH IS DONE WITH NORMAL SALINE UNTIL IT
BECOMES CLEAR==
6=give activated charcoal it binds with poison in git prevents its
absorption and finally passess out in stool
7=if poison on skin or hairs wash with water and soap 8=pass
iv canulla
9=specific antidotes according to dose 10=psychotheraphy
Q =MANAGEMENT OF DELIBRATE SELF HARM
Organization of services such as primary health team ,social and ambulance
services to enable them to respond appropriately and assess risk and
necessary care can be given
Q ASSESSMENT OF PT AFTER DSH
GENERAL AIMS 1=immediate risk of suicide
2=subsequent risk of further DSH
3=medical and social problems
Q = What are SPECIAL ENQUIRIES into pt with deliberate self harm?
A=what was pt intention to die? B=what was there current problem

343
C=is there any psychotic problem D=what helpful resources are
available.
Q TREATMENT=HOSPITALIZATION
NEEDS TREATMENT for depression and alcoholism and few schyzoprenic
Q MANAGEMENT AFTER ASSESSMENT
Doctor should negotiate with the pt and plan should be discussed with pt .pt
needs fall into 3 groups 1=small minority require admission to psychiatric
unit for treatment
2=1/3 of pt with DSH require treatment in primary care in community
3=reminder need help with psychosocial problem
SOME SPECIAL PROBLEM OF MANAGEMENT
Pt who refuses assessment
They have high risk of repetition of DSH
IT is necessary to gather as much as possible frm other sources before leaving
pt to leave. problem should be discussed with GP and community health team
if they involved
FREQUENT REPEATERS
RISK OF TAKING overdose repeatedly at time of stress .relatives ant
hospital staff often become frustrated by frequent repeaters
REPEATED SELF CUTTING
Sometimes atypical antipsychotics such as resperidone or olanzapine in low
doses may be valuable as short term measure to reduce tension
Q = AGITATED and hostile 23yr old manwith grandiose delusions.how
u would assess risk of voilance in this pt
FACTORS ASSOCIATED WITH DANGEROUSNESS
MALE GENDER
HISTORY

344
One or more episode of voilance
Evidence of difficulty in coping with stress
Lack of social support
History of conduct disorder
OFFENCE
Bizarre violence
Lack of regret
Lack of provocation
Major denial
MENTAL STATE
Morbid jealousy
Paranoid belief
Lack of self control
Poor compliance of treatment given
CIRCUMSTANCES
Alcohol or drug misuse
Social difficuities and lack of social support
Q = HOW MANAGE PT OF VOILANCE USING NICE GUIDELINES
ANSWER
PREVENT VOILANCE DEESCALATION TECHNIQUES
One staff member should take charge of situation
Move pt to suitable room
Make sure that sufficient staff is available
Explain to pt what staff are doing and how they hope to resolve situation
Attempt to establish rapport
Listen attentively
Ask open question
345
If weapon is involved ask for it to be put in neutral location rather than
handed ouer
Q NICE(NATIONAL INSTITUTE OF CLINICAL EXCELLENCE
GUIDELINES)
PREDICTION
RISK ASSESSMENT
SEARCHING
↓
DEESCALATION
↓
INTERVENTION FOR CONTINUE MANAGEMENT1=RAPID
TRANSQUILIZER IF PSYCHOTIC PT 2=SECLUSION 3=PHYSICAL
INTERVENTION
Contraindication as an intervention
1=pt takes previous medication
2=should be terminated if rapid transquilizer if given has taken effect
3=prolong physical intervention
↓
Post incident review
Q= scenarios of suspiiouious and aggressive behavior and personality
change over 2yr and father of pt died from some paranoid delusion
ANSWER
Most likely diagnosis is schizophrenia and differential diagnosis
is1=delusional disorder 2=scyzophrenia 3=organic state
4=affective disorder
Q =explain NEUROPSYCOLOGICAL BASIS OF SCHYZOPRENIA?
ETIOLOGY /RISK FACTORS

346
Men earlier onset Age 20-3oyr
Many theories involved Decrease dopamine and serotonin
Positive family history Double blind theory
If mother gives mixed messages
Families that are intrusive critical and hostile to pt .it has been linked to
higher degree of relapse
Viral in origin
Decreases socioeconomic history
Social causation
DOWNWORD DRIFT
Q how would you use LITHIUM in PREGNANCY?
NEONATAL TOXICITY
Exposure to psychotropic drugs in later stages of pregnasncy can give rise to
neonatal toxicity either the presence of drug or due to withdrawal syndrome.
Perinatal toxicity associated with lithium use include 1=floppy syndrome
2=cyanosis 3=hypotonia
4=long term abnormalities in brain development and behavior
Q how you would use lithium with respect to lactation?
LITHIUM AND BREAST FEEDING
Lithium salt enters milk freely and serum concentration of infant can
approach those of mother .so breast feeding require great caution hoever
amount of carbamazepine and valproate in breast milk are considered to be
too low to be harmful
Q = senarios in which pt on antipsychotics and inj haloperidol and inj
depot 2days ago now pt is febrile and bp changing and rigidity and
increase tone of muscle and altered level of consciousness
.diagnosis is neuroleptic malignant syndrome
347
Q what are RISK FACTORS OF NMS?
1=HIGH DOSE OF ANTIPSYCHOTIC
2=HIGH POTANCY ANTIPSYCHOTIC MEDICATION
Q manage NMS?
MANAGEMENT OF NMS
1=immediate discontinuation of medication
2=psychological supportive measures
3=dantroline 4=bromocriptine
Q u have to plan a trial of an antipsychotics what instrument u will
use to screen population
Answer BPRS
Q senarios of pt on antipsychotics inj of zuclopenthixole 3days ago
brought to emergency in confusion ,febrile bp changes from lying to
standing position and febrile
Answer =NEUROLEPTIC MALIGNANT syndrome
Q in NMS what specific clinical sign you will look for on physical and
mental status examination
1=muscle stiffness(cog wheel rigidity) 2=hyperthermia
3= autonomic instability 4-=delirium
Q investigation in NMS 1=wbc increased
2=CRP gradually increases 3= secondary complication include
pneumonia, thromboembolism .,renal failure ,and cvs collapse
Q WHAT IS Prognosis OF NMS=
10% mortality rate and declining over several years
Dd/ include 1=encephalitis 2= heatstroke
Management =1=immediately discontinue drugs2=symptomatic treatment
3cold sponging
348
3=treat intercurrent infection 4=for muscle stiffness give dyzepam
5=malignant hypertention is treated by dantroline 6=bromocriptine
7=severly ill person are admitted in icu and intubated and deals with renal
failure
Q COMPLICATION OF NMS
1=secondary pneumonia 2=thromboembolism
3=cvs collapse 4=renal failure
Q = 25yr old women with complaint of restlessness apprehension
,palpitation, tremors .these episode last for 15 min
Ans= most likely diagnosis is panic disorders
Q define panic disorder
Recurrent unexpected panic attack are present ,panic attack are attack of
severe anxiety often include marked physical symptoms such as
tachycardia, hyperventilation and sweating
Etiology=1=separation during childhood
2=interpersonal loss in adulthood
3=in response to panic gens like lactate, youhimbin ,and caeffine
4=studies of twins suggest a genetic components
Q DIFFERENTIAL DIAGNOSIS
1=AGORAPOBIA
2=depression
3= generalized anxiety disorders
4=Substance abuse
,Treatment 1=pharmacological intervention
Ssri fluoxetine and alprazolam , Clonazepam, imipramine, and mao
i(phenelzine)
Psychotherapeutic intervention
349
Relaxation techniques for panic attacks and systematic desesnsitiization for
agoraphobic symptoms
Q scenarios of pt of bipolar disorders stabilize on lithium for past 6yr
presenting with hypothyroidism
Diagnosis = lithium toxicity with hypothyroidism
Q=. Management of lithium toxicity
Ans= Keep plasma level above 1.5meq per liter. Dehydration and
hyponatremia predisposes to lithium toxicity by increasing serum lithium
levels .tremors at therapeutic levels may respond to decrease dosage
Divided dosage decrease adverse effects by decreasing peak plasma levels
Q = risk factors of depression
Seen mostly in womens due to hormonal differences
Great stress
No close interpersonal relationship such as divorcé
Abnormalities in serotonin , and dopamine
Family history
Exposure to stress
Hopelessness
Q PROGNOSIS
DEPRESSION ALONG WITH psychotic features has worse prognosis
Depression with atypical features such as increase weight and increase
sleep and has good prognosis
Q TREATMENT OF MAJOR DEPRESSION
Assess for suicidal risk and security
Antidepressents includes Ssri tca and maoi and then ect
Psychotheraphy
COGNITIVE THERAPHY
350
Q =NEUROTRANSMITTER INVIOLVED IN ETOLOGY OF
SCYZOPRENIA
A= DOPAMINE HYPOTHESIS OF SCHYZOPRENIA STATES THAT
POSITIVE SYMPTOMMS RESULT FROM EXCESSIVE
DOPAMINERGIC ACTIVUITY FOREXAMPLES AN EXCESSIVE NO
OF dopamine receptors , excessive concentration of dopamine and
excessive hypersensitivity of receptors to dopamine in limbic system .some
of stimulant drugs such as amphetamine and cocaine can cause psychotic
symptoms .
Lab test may show elevated level of homovanilic acid a metabolite of
dopamine
Hva in body fluids in pt with scyzophrenia .negative symptoms of
scyzophrenia are believed to result of reduced activity in frontal cortex
B=serotonin hyperactivity
Is implicated in schizophrenia
Hallucinogens increases serotonine and psychosis
While clozapine decreases serotonin and decrease psychotic symptom
C=glutamate is implicated in scyzophrenia
NMDA receptor antagonist are used in treating some neuro degenerated
symptoms such as loss of cognitive abilities in pt with schizophrenia
Cocaine and amphetamines increases dopamine activity and leads to
psychosis
Q =senaro as of 5yr hapinaess at some time and depression at other
time for no apparent reason
Ans Cyclothymia
Q TREATMENT OF CYCLOTHYMIA

351
Ant manic drugs like lithium Carbamazepine and valproate are typically
drug of choice
Psychotherapy will focus o helping pt gain insight into there illness and to
cope with their illness
Q scenarios of postpartum psychosis
Treatment is 1=Antidepressant 2= mood stabilizer 3== antipsychotics
Q 109 MCPS= HTN and DIABETES MELLITUS; pt presents with
depression
Ans = sertraline 50mg once daily in morning
Q WHAT IS DOUBLE DEPRESSION ?
ANS=IT IS COMPLICATION OF DYSTHYMIA AND CBT IS
TREATMENT OF CHOICE IN DOUBLE DEPRESSION.
Q ADVERSE EFFECTS OF SSRI
1= SSRI ARE LESS CARDIOTOXIC THAN TCA AND HAVE LESS
ANTICHOLINERGIC SIDE EFFECTS
SAFE IN OVERDOSE AS COMPARED TO TCA
2 GASTRIOINTESTINAL NAUSEA VOMITING DIAREA BLOATING
FLATULANCE AND DYSPEPSIA
3=NEUROPSYCHATRIC EFFECTS INSOMNIA AGITATION TREMOR
RESTLESSNESS SEIZURE
EPSE COMMON WITH SSRI PARKINSONISM AND AKATHESIA THAN
TCA
4=SEXUAL DYSFUNCTON EJACULATRY DELAY AND
ANORGASMIA SWEATNG AND DRY MOUTH
SKIN RASHES SELF HARM BEHAVIOUR AND SUICIDAL
BEHAVIUOR
Q what are causes of stroke?
352
1=CNS=head tumor, trauma and meningitis and radiation to brain

2=metabolic =electrolytes disturbances like hypoxia ,hypoglycemia and

hyper carbia
3= endocrine=thyroid parathyroid, adrenal disease
4=autoimmune disease=SLE
5=parkinsonism Alzheimer disease like neurodegenerative disorders
TREATMENT=CORRECTION OF UNDERLYING CAUSES
Q =CAUSES OF DRUG INDUCED PSYCHOSES
1=ALCOHOL ;2=AMPETAMINE
3=COCAINE
4=HALLUCINOGENS
5=INHALANTS
6=SEDATIVE HYPNOTICS
7=STEROIDS
Q =MANIA=
State of abnormal mood that is predominantly euphoric(pleasurable
feelings) and there may be rapid shift to anger and tearfulness and suicidal
threats
CLINICAL FEATURES=1=OVERSPENDING OF MONEY
2=hyper sexuality 3= increase libido
4= flight of ideas 5= grandiosity
6=insomnia 7=weight loss
Q Hypomania= similar to mania but no social withdrawn
Q =BIPOLAR DISORDER=
Characterized by history of mania or mixed episode of both manic and
depressive episode during course of disorder
353
Treatment=
A= lithium indicated in mania and bipolar disorder
B= antidepressants and lithium
C= antipsychotic if psychotic features
D=ECT is done if no response to above treatment
Q =BIPOLAR DISORDER 2
HYPOMANIA EPISODE AND MAJOR DEPRESSIVE EPISODE
BIPOLAR ONE DISORDER=
1-=MANIA
2=DEPRESSIOJN
BIPOLAR 2 DISORDERS
1-= HYPOMANIC EPISSODE
2= MAJOR DEPRESSIVE EPISODE
Q =bipolar 3 disorder is induced by antidepressants
Q =TREATMENT OF BIPOLAR 2 DISORDER
LITHIUM ANTIDEPRESENT
ANTIPSYCHOTIC IF THERE IS PSYCHOTIC FEATURES
ECT IS AS LAST RESORT
Q ANOREXIA NERVOSA= Is a serious or potentially fatal condition
characterized by self imposed dietry limitation usually resulting in
serious malnutrition
Especially 1% of adolescence girls usually associated with stressful
events
Q =DIAGNOSTIC FEATURES OF ANOREXIA NERVOSA
1= Fear of becoming obese even in weight loss condition
2= disturbed body imaged
3 weight loss of 25% from original weight
354
4=refusal to maintain weight at normal
Q TREATMENT OF ANOREXIA NERVOSA=
HOSPITALIZATION =
Correction of metabolic disturbances Behavioral therapies
Family therapy Antidepresents
Q =BULEMIA NERVOSA
Characterized by frequent bang eating and purging and self image that is
influenced by weight
Usually 40years females
Type= 1=purging 2-= no purging
In bulimia nervosa repeated attempts to lose weight
Weight is increased in bulimia nervosa
Q = Treatment OF BULEMIA NERVOSA=
1= CBT 2= SSRI 3= PSYCHOTHERAPHY
Q =DISSOCIATIVE AMNESIA=
Inability to recall important personal information usually subsequent to
trauma
Q WHAT IS MANIA AND MANIC EPISODES=
Episode of abnormally elevated mood lasting at least one week
Diagnoses require 3 or more of following are present during mood
disturbances
(MANICS DIG FAST)
1=DISTRACTIBILITY=
2=IRESPONSIBILITY( SEEKS PLEASURE WITHOUT REGARD TO
CONSEQUENCES)
3=GRANDIOSITY(INCREASE SELF ESTEEM )
4=FLIGHT OF IDEAS
355
5-=INCREASE IN PSYCHOMOTOR AGITATION
6=Decreased NEED FOR SLEEP
7= TALKATIVENESS OR PRESSURED SPEECH
Q =DELIRIUM TREMENS=
IS one of life threatening alcoholic withdrawal that peaks 2-5 days after last
drink
SYMPTOMS=
1= AUTONOMIC HYPERACTIVITY LIKE TACHYCARDIA,TREMORS,
SEIZURES
2-= PSYCHOTIC SYMPTOMS LIKE HALLUCINATYION AND
DELUSION
3= CONFUSION
Q TREATMENT =BENZODIAZEPINES
Q Drug addiction means repeated consumption of drug which may be
natural or synthetic and which is harmful both for individual and their
family.
Q = visuospatial ability= ability to copy a figure
Q projection = attributes own feeling and attitude to someone else
Q = politician sudden onset of extreme anxiety tremulousness,
diapooreses before his first scheduled appearance on TV
Dx panic disorder and we give inderal 10mg tds
Q =scenario of somatization disorder
Q =recently marred present to ER unable to move his lower limbs
and no abnormality found and bitten by her husband on regular bases
Dx conversion dx
Q =scenario of body dismorpic disorder in which boy is normal but see
himself as ugly

356
Q hx head trauma with basket ball 2month back and player was
unable to play becoz of headach xray show no fracture and does not
relieve with acetaminophen
Dx pain disorder
Q = girl has multiple episode of apnea in night and but in hospital no
sleep apnea ,mother was given apnea moniter to monitor apnea episode
and there were apnea episode in home but not in hospital
Dx factitious disorderd
Q =ADVERSE EFFECTS OF CLOZAPINE
2% pt leucopenia which leads to agranulocytosis
Weekly blood count for first two years AND AFTER 2YR 2weekly blood
count are mandatory
Advice that do nt use Carbamazepine concurrently which also lowers wbc
count
No EPS becoz of weak blockage of D2 receptors like tardive dyskinesias
Hypersalivation, drowsiness, postral hypotension , weight gain and
hyperthermia
Seizure may occur at high stages
Rarely myocarditis and myopathy have been reported
Q =HOW SUICIDE PREVENTED?
ANSWER= better and more accessible services
Restriction of means of suicide
Encouragement of responsible reporting
Educational program
Improved care for high risk group
Crisis centres and telephone hotlines
Q =MANAGE PAROXETINE OVERLOAD
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ANSWER=1=EMESIS
2=GASTRIC LAVAGE
3=UNIVERSAL ANTIDOTE
4=DIALYSES
Q Reasons given for deliberate self harm
Answer=1=to die 2=to escape from unbearable anguish
3=to obtain relief
4=to change the behavior of others
5=to=to escape from situation
6=to show desperation to others
7=to get back at other people /make them feel guilty
8=to get help
Q =PT presents with tremors, chorea form movements’ unusual
clumsiness for his age on physical examination found to be jaundice
Diagnosis with justification
Wilson disease
Becoz above features jaundice , hepatolenticular degeneration ,jaundice and
chorea

Q =pt with abdominal pain but surgeon says that thre is no

intraabdominal pathology and surgeon refers pt to Psychiatrist
Diagnioses is hypochondrias
Q WHAT is psyhiatric response to above patient
Answer=psychotherapy to help relieve stress and help cope with illness .
Frequent regular schedules visits to patient medical doctor
Q =PT presents with tremors, chorea form movements’ unusual
clumsiness for his age on physical examination found to be jaundice
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Diagnosis with justification
Wilson disease
Becoz above features jaundice ,hepatolenticular degeneration ,jaundice and
chorea
Q NEUROLOGICAL MALIGNANT SYNDRROME
Usually due to high potency antipsychotics
Antipsychotics are prescribed for schizophrenia, mania , psychosis or
depressed disorder,
Combined lithium and antipsychotics may be a predisposing factors
Onset during first ten days of antipsychotics
Clinical picture includes rapid onset of severe motor, mental, autonomic
disorders together with hyperpyrexia
The prominent motor symptoms is increase muscle hyper tonicity leading
to dysphagia and dyspnea due to stiffness of muscle of throat
Mental symptoms are mutism and unconsciousness
Autonomic disturbances in form of unstable blood pressure,tachycardia
sweating increase salivation and urinary incontinence
INVESTIGATION=CPK –BB and leukocytosis
SECONDRY COMPLICATIONS
PNEUMONUIA CVS AND TROMBOEMBOLISM
MORTALITY RATE 10%
DIFFERENTIAL DIAGNOSIS
1=ENCEPILITIS
2=HEAT STROKE
3=ACUTE LETHATL CATATONIA
TREATMENT
Stop drug like antipsychotics

359
Cold sponging
Treat infections
Diazepam for muscle stiiffness
Dantroline a drug used to treat malignant hyprethermia
Bromocriptine dopamine agonist is also reconmmended
Q =what medical problem u will rule out before making diagnoses of
GAD
Answer= hyperthyroidism
Treatment of generalize anxiety disorder
1=behavioral psychotherapy
Include relaxation training
And biofeed back
2=pharmacotherapy include
SSRI, VENLAFAXINE, BUSPIERONE AND BENZODIAZEPIONES
Q WHAT ARE PT CHARACTERISTICS THAT MAKE
COMMUNITY CARE DIFFICULT
ANSWER=risk of harm to self and others
Unpredicted behavior and liability to relapse
Substance misuse
Poor motivation and poor capacity for self management
Lack of insight into need for treatment
Low public acceptably
Q Married man with severe depression plus 30pounds weight loss in
last 2months and refuses to eat and does not change clothes and death
wishes
Answer=ECT is indicated in major depressive illness which does not respond
to antidepressants’
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B=HOW would u convince to proceed with your treatment of choice
Answer=discus that ECT is good and rapid long term treatment
Q mcps=what medical problem u will rule out before making diagnoses of
GAD
Answer= hyperthyroidism
Treatment of generalize anxiety disorder
1=behavioral psychotherapy
Include relaxation training
And biofeed back
2=pharmacotherapy include
SSRI, VENLAFAXINE,BUSPIERONE AND BENZODIAZEPIONES
Q Reasons given for deliberate self harm
Answer=1=to die 2=to escape from unbearable anguish
3=to obtain relief
4=to change the behavior of others
5=to=to escape from situation
6=to show desperation to others
7=to get back at other people /make them feel guilty
8=to get help
Q =PT presents with tremors, chorea form movements’ unusual
clumsiness for his age on physical examination found to be jaundice
Diagnosis with justification
Wilson disease
Becoz above features jaundice ,hepatolenticular degeneration ,jaundice and
chorea
Qmcps=PANIC ATTACKS =

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Episode of severe anxiety resulting in physical symptoms like tachycardia
,tachypneas and sweating
PANIC DISORDERS
Recurrent panic attacks are called panic disorders
Etiology=
1=separation during child hood
2=great loss in family
3= genetic causes
Clinical features=
Prevalence about 2% especially among females in adult age
Course of symptoms wax and wane symptoms
Associated symptoms Include agoraphobia and depression
Psychopharmacology=1-=ssri fluoxetine
2=alprazolam
3= clonazepam
4=imipramine
5=maos (phenelzine)
Psychotherapeutic intervention
1=relaxation techniques
2=systematic desensitization for agoraphobia
Q =NON ORGAN FAILURE TO THRIVE AND DEPRIVATION
DWARFISM
If three or less than three yr child fails to thrive when there is no
apparent cause this is called non organ failure to thrive
In older children it is called short statue syndrome or deprivation
dwarfism
Clinical features=
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1= deprivation of food
2=parent child relationship problem
3=hostility toward child
4=physical abuse
5= sexual abuse
The infant which fails to thrive may have recent weight loss, low weight or
short statue, cognitive and developmental delay, unhappy child ,and
lethargic
Q =DEPRIVATION DWARFIISM=
CINICAL FEATURES=
1= short stature
2=developmental delay in speaking
3= speech problems
4= temper tantrums
Treatment= child safety should be first priority
Some pt may be helped to fulfill their child needs and especially if parents
are mentally ill especially post partum depression
Home based intervention may improve cognitive and behavioral domains
PROGNOSES=
Is good for bot syndrome especially sexual abuse
Q =SEXUAL ABUSE=
Involvement of child in sexual abilities which they donot fully comprehend
And to which they cannot give informed consent
And usually there is violation of rules
The abuser is uusually family membr of child and involve child in sexual
activities
EPIDEMIOLOGY=

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Female more sexually abused
Disabled children are victims
CLINICAL FEATURE=
Features depends on types of sexual act and relation of offender to child
If abused child is a bused by stranger then child may report abuse
If child cannot report then physical symptoms in urogenital or anal area or
behavioral disturbances or precousius or other in appropriate sexual
behaviors
In adolescents girls running away from home or suicidal attempt should
raise suspicious of sexual abuse
Q EFFECTS OF SEXUAL ABUSE(COMPLICATIONS OF SEXUAL
ABUSE)
EARLY EMOTIONAL CIRCUMSTANCES
1= anxiety
2= fear and depression
3=reaction to unwanted pregnancy
4= PTSD
LONG TERM CONSEQUENCES
1= depressed mood
2= low self esteem
3= self harm
4= psychiatric disordr later in life like depression and anxiety and
personality disorder
AETIOLOGY=
1-= SOCIALLY deprived families
2= low socioeconomic status

364
3= in abuser sexual motivation may be present which leads to sexual abuse
and impulsivity
ASSESMENT=
It is important to detect sexual abuse and ask and help to describe what have
been done with abuse child
Then ask how dangerous is sexual abuse
Child should be interviewed sympathetically and encouraged to describe
what had happened
Younger children can recall accurately
Multidisciplinary involvement often include police and judicial system is
usually needed to establish wether abuse has been taken place and what
appropriate response should be
We should protect child from sexual abuse
Management similar to physical abuse
GERIATRIC PSYCHIATRY
Q =NEUROPSYCHOLOGY OF AGING
Physically ill health leads to decline in cognitive function
Intellectual and cognitive dysfunction .intellectual function as measured by
standard intelligence tests show a decline in old age
Short term memory as measured by digit span test does not change much
in normal elderly however long term memory with old age
Elderly recall usually remote events of personal significance
However long term memory other than non personal significance show a
decline
PHYSICAL Health
In addition to general decline in functional capacity with aging,
degenerative changes also occur in body
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Q =MOOD DISORDER
Definition= 2week course plus two symptoms 1= anhedonia
2=depressed mood
RISK FACTORS=/ EPIDEMIOLOGY
More common in women due to
1-= hormonal differences
2= stress
3= divorced
4= separated
5= age of onset 40 years
6= neurotransmitter abnormalities
7-=family conflicts
PRESENTING SYMPTOMS
1= depressed mood
2= anhedonia
3= weight loss or gain which is significant
4= insomnia or hypersomnia
5=psychomotor retardation
6= .loss of energy
7= worthlessness
8=suicidal ideas
Physical examination may be normal or may show 1= stooped posture
2= slow speech
3= slow movement
4=cognitive impairment
LAB DIAGNOSES
1= Abnormal dexamethasone suppression test
366
2= thyrotropine releasing hormone test
May also include psychotic features which suggest worse prognoses
May also have atypical features like weight gain and hypersomnias
TREATMENT=
1= safety of patient since suicidal risk is a very high
2=SSRI,TCA,MAO
3=ECT INDICATION= SUICIDAL RISK AND SIDEEFFECTS FROM
MEDICATION
4=PSYCHOTHERAPHY
To help pt deal with conflict
5= cognitive therapy
DIFFERENTIAL DIAGNOSES
MEDICAL DISEASE
1-= HYPOTHYROIDISM
2= Parkinson disease
3= dementia and pseudo dementias
Mental disorders like mood disorders and Greif
Q ANXIETY DISORDERS IN ELDERLY
After age of 50yr increase incidence of new cases of anxiety declined but
consultation with doctor does not fall assumed to be due to chronic cases’
Q =OLD AGE PSYCHIATRIC SERVICES
Aim of old age services is to plan according tom need. Principle is to
respod to medical and surgical problem quickly as they arises,
And to support there relatives and to support these for their son at home
Multidisciplinary approach should be adapted
1=psychiatrist
2=psychologist
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3= community workers 4= social worker
Q =DOMICILIARY SERVICES
In addition ton medical services it includes home help and meal at home and
telephone and emergency call systems
In last decade major changes occurred in providing care to old and elderly
pt especially help from private and ngo .these provision of facilities are
increasing day by day
Q RESIDENTIAL AND NURSING CARE
Old age people usually need accommodation facilities and access to a
warden and to nursing homes where there are staff available at all time
Q VOLUNTRY SERVICES
Voluntary organization has increasing role to provide facilities for older
pt ,there families and there carers
INFORMAL CARERS
Are unpaid relatives and neighbors who ;look after disabled elderly people
at home
About twice as many women as men are informal carers and 50% of all
informal carferes are themselves elderly
FORMAL CARERS
Paid home helps and community nurses, psychiatric nurses
Informal carers contribute significantly to care to old age people at home
Studies show that greater the dementia of old people greater the strain
experienced by carers
Incontinence and behavioral disturbances are most distressing for carers
Q =VASCULAR DEMENTIA=
OR MULTI INFARCT DEMENTIA

368
25% OF Patients ARE having vascular dementia. As compared to
ALZEIMER DISEASE we see vascular dementia more in males causes
are1=aging
2=HTN 3= cardiovascular disorders
It involves mostly small and medium sized vessels
PHYSICAL EXAMINATION
We see carotid brui
Cardiac chambers enlarged
Fundoscopic abnorrmalities
MRI SHOWS
1= HYPERINTENSITIES AND
FOCAL ATROPHY SUGGESTUIVE OF OLD INFARCTION
FOCAL NEUROLOGICAL SYMPTOMS INCLUDES
PSEUDOBULBER PALSY
REFLEXES= abnormal
GAIT=disturbed and abnormal
Propylaxes= control risk factor like htn,smoking,dm, hypercholestrolenmia
and hyperlipidemia are usual
Q =stupor= is a common condition which presents at emergency
services
Stupor is a condition where pt is conscious but there is no
responsiveness to to surrounding
Etiology=
Schizophrenia such as catatonic and depression
Q = management of stupor=assess the nutritional states and hydration
because there is risk of neglect of nutrition
Give immediate iv fluids
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Ryle tube feeding can provided
Administer vitamins to facilitates movement and prevent contractures
because there is total motor inactivity in stupors
Minimal dose of drugs like antipsychotics or antipsychotic are needed to
reliew basic problems
Q =DIAGNOSTIC CRETERIA FOR PANIC DISORDER
In DSM-IV the diagnoses is made when 1=panic attack occur unexpectedly
And 2=more than 4epissode occur in less than one month
3=worry about heart attack
Diagnostic criteria is similar in ICD-10
Q ==EXAMPLES OF CORTICAL, SUBCORTICAL AND MIXED
CAUSES OF DEMENTIA
EXAMPLES of cortical dementia are
Alzheimer disease and
Front temporal dementia
Examples of sub cortical dementia are
Huntington disease
Parkinson disease
And focal thalamic and basal ganglia lesion
Multiple scleroses
MIXED=vascular dementia
Lewy body dementia ,Corticobasal degeneration,
Neurosyphlis
Q = ECHOLALIA =automatic production of words by pt of docter even
when asked not to do so
Q =stupor= is a common condition which presents at emergency
services

370
Stupor is a condition where pt is conscious but there is no responsiveness to
to surrounding
Etiology=\
Schizophrenia such as catatonic and also in depression
Q = management of stupor=assess the nutritional states and hydration
because there is risk of neglect of nutrition Give
immediate iv fluids
Ryle tube feeding can provided
Administer vitamins to facilitates movement and prevent contractures
because there is total motor inactivity in stupors, . Minimal dose of drugs
like antipsychotics or antipsychotic are needed to reliew basic problems
Q = Excitement and voilance
Violence is physical aggression inflicted by one person on another. they
may harm others or harm themselves
Etiology = Psychotic disorders such as mania and schizophrenia and post
partum psychoses
And paranoid schizophrenia
Organic mental disorders such as delirium, drug intoxication and withdrawal
Personality disorders such as antisocial and paranoid personality disorders
Brain disorders=seizure disorders , brain injury ,encephalitis
Management=protect urself ,donot approach alone call for assistance to
manage any situation
Reassure pt ,.Restraint
This should be used as a last resort but when needed it must not be delayed
And must not be attempted in half hearted way

371
Restraint is usually followed by b compulsory hospitalization and parenteral
medication.it is rarely necessary to continue restraint for more than a few
hour’s
Assess nutritional state and if there dehydration iv fluids are wessential
Sedation
The most effective drugs are
Inj chlorpromazine 100mg Inj haloperidol 10-20mg Inj
diazepam 10mg
Q =MENTAL SUBNORMALITY
DEFINITION= condition in which IQ IS less than 70% And Significant
drop I n intellectual functioning
Age of onset is before 18year
There must be associated impairment in school, work society
RISK FACTERS=
1= Metabolic disorders which are since birth like lipid, carbohydrates, and
proteins
2= chromosomal disorders like cri du cat syndrome,, down syndrome, and
fragile x syndrome
3= torch infection like rubella. cytomegalovirus
4=postnatal causes like toxins, drugs, parental neglect, social deprivation
MANIFESTATION
1% prevalence rate
CLASSIFICATION=
1= MILD MR IQ (50-70)
Attain academic skill upto 6th grade level
Often live indepently in community or with minimal supervision
May have associated conduct disorder and ADHD

372
MODERATE RATE= attain academic level upto second grade level
May be able to manage activities’ of daily living and they may have v
problem in social interaction and to conform to social norms
Individual with down syndrome have especially at risk of Alzheimer
disease
SEVERE IQ =(20-30)
PROFOUND IQ LESS THAN 20 SEVERE
Severe and profound retardation required highly supervised settings
Physical examination=
Evidence of underlying metabolic , chromosomal ,intrauterine and post natal
risks may be present
DIAGNOSTIC TESTS=
1=amniocenteses may show chromosomal disorders in especially high risk
pregnancy in age more than 36years
TREATMENT =1=Primary prevention like genetic counselling, good
prenatal care and safe environment
2= treatment of associated medical condition
3=special education techniques
4=behavioral guidance and attention to promote self esteem
DIFFERENTIAL DIAGNOSES
1=Learning and communication disorders 2= autistic disorder
3= borderline intellectual functioning
NORMAL HUMAN SEXUALITY=
SEXUAL AND GENDER IDENTITY
Q SEXUAL IDENTITY TERMINOLOGY
Based on person sexual characteristics like 1== external and internal
genitalia
373
2= hormonal characteristics
3= secondary sexual characteristics
Q GENDER IDENTIITY
Based on person sense of maleness or femaleness established by age of
three
And determined by parents
Q SEXUAL OREANTATION
1-= HETEROSEXUAL 2= HOMOSEXUAL
3= BISEXUAL 4= ASEXUAL
Q SEXUAL DYSFUNCTION
Impaired performance or enjoyment of sex and they are common
SEXUAL DYSFUNCTION INCLUDES
1=SEXUAL DESIRE 2=SEXUAL AROUSAL
3= SEXUAL ORGASM 4 SEXUAL DISORDER
PARAPHILIAS= The abnormalities of sexual preferences are
paraphilias
CAUSES OF SEXUAL DYSFUNCTION
1= ANXIETY
2= LOW sexual drive
3= physical illness like DM leading to autonomic neuropathy and vascular
disease
4=surgical treatment 5=neurological disorders 6= pelvic
surgery in female
Q MEDICAL AND SURGICAL CONDITION COMMONLY
ASSOCIATED WITH SEXUAL DYASFUNCTION
MEDICAL CONDITION
1=ENDOCRINE LIKE DM ,INCREAASE T3 and t4 and Addison disease
374
2=gynecological vaginitis 3= cvs =angina and mi
4=respiratiory asthma and copd
SURGICAL CONDITION=
1= MASTECTOMY 2= OOPHORECTOMY
3= OPERATION FOR PROLAPSE 4= EPISIOTOMY
SEXUAL DYSFUNCTION AND PHYSICAL HANDICAP
1= DIRECT effect of physical handicap on sexual dysfunction and
nonspecific effects like tiredness and pain
Q DRUG THAT MAY IMPAIR SEXUAL DYSFUNCTION
1=THERAPEUTIC AGENTS
2= ANTI HYPERTENSIVE LIKE diuretics
3= antidepressants ssri, tca, mao.
4= mood stabilizer like lithium
5= benzodiazepines and hypnotics
6=antipsychotics anmd steroids like hormonal agents
7=some misuse substances like alcohol, cocaine,. And marijuana
Q ASSESSMENT OF PATIENT WITH SEXUAL DYSFUNCTION
Interview of sexual partner and patient both should be done and history
detailed about medical disorders
Physical examination
Especially in men =special investigation like FBS and testosterone
Q Classification
Psychotic disorder
1= schizophrenia
2=delusional disorder
Mood disorder=
1-= bipolar disorder ( mania and depressed phases
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2=cyclothymiacs
3= major depressive disorder
4= persistent depressive disorder
NON PSYCHOTIC DISORDER Anxiety disorder like GAD
PANIC DISORDER AND PHOBIC DISORDERS
OCD
TRAUMA AND STRESS RELATED DISORDER
FEEDING AND EATING DISORDRR
SOMATOFORM DISORDER
Personality disorders includes
Ood and eccentric
Anxious and fearful
Dramatic and emotional
Q =Promotion of mental health and prevention of mental disorders in
Pakistan
Increase awareness about how to promote mental health and prevent mental
health and suicide wherever possible and reduce stigma
Increase capacities of families and care givers, school, post secondary
institution and commonly organization to promote mental health of infant,
children and youth prevent mental illness and suicide wherever possible and
when problem first emerges creat mental health work places
Increase capacity of older adults, families ,care settings and communication
to promote mental health later in life, prevent mental illness and suicide
wherever possible and intervene early when problem first emerges
Q = neuromalignant disorder
Think
FEVER
376
F= FEVER
E= ENCEPPHALOPATHY
V= VITAL UNSTABLE
E= ELEVATED ENZYMES
R= RIGIDITY OF MIUSCLES
Q MANAGEMENT OF NEUROLEPTIC MALIGNANT SYNDROME
1=DANTROLINE
2= BROMOCRIPTINE
Q= COMPLICATION OF TCA=
1-=CONVULSION
2= COMA
3= CARDIOTOXICITY AND ARRYTHMIAS
Q TREATMENT= NA HCO3 FOR CARDIOVASCULAR TOXCITY
Q =30yr pt not sleeping 5days feel energetic and quarrelsome and has
resigned from work and is planning to start own business
Ddx=insomnia and hypommannia
Q Dependence and withdrawal of bzd
It is now generally agreed that dependence develop after prolong use of bzd
Frequency depend on drug and dosage and he has been estimated up to
50% of t with long term users
Q = psychometric test in parklkinsonism
1=samso n angab test and pans
Q =psychiatric disorder among people with learning disability
1=schizophrenias
2mood disorder3=anxiety disorder4=eating disorder
5=pd 6= delirium and dementia
7Disorder that are first diagnosis in childhood to adolescence
377
8=autism and ADHD
9; abnormal movements
10 sleep disorder
Q HIGHILGHTING MENTAL HEALTH SERVICE
1=IN PT WARD
2=SINGLE SEX ACCOMODATION
3= CONTINUICY OF RESPONSIBILITY
4= LONGRER IN PT CARE
5= DIAGNOSES SPECIFIC WARD
6=DAY CARE 7=SUPORTED ACCOMODATION AD RESIDENTIAL
CARE
8= OUT PT CLI NIC
9=MULTIDISIPLINARY COMMUNITY MENTAL HEALTH TEAM
10= GENERIC SECTRE MHT
11=STAFFING AND MANASGENMENT
12= ASSESSMENT
13= CASE MANAGEMERNT
14= TEAM MEETING
15= CPOMMUNICATUION AND LAISON
16= MENTAL HEALTH SERVICE LAISON
17MENTAL HEAKLTH NATIONAL SERVICE
18 ASSERTIVE OUT REACH TEAM,
19=CRISIS TEAM
20=CRISES RESOLUTION AND HOME TREATMENT TEAMS
21=VARIETTION IN PRACTICE AND SUSTANSIBILITY
22=CRISES HOUSE AND RESPITE CARE
23= EARLY INTERVENTION SERVICES
378
24 CASE MANAGEMENT
25EARLY RECOGNITION AND HIGH RISK INTERVENTION
26FORENSIC AND REHABILITATUIION TEAMS
27= DIAGNOSES SPEWCIFIC TEAMS
Q = name 2 lithium compounds
1=lithium carbonate and lithium citrate
Q indication of lithlum
1= bipolar and schizoaffective disorder
2=adjunctive treatment of major depressive disorder
We do TFTs before starting lithium
Q Adverse effects of lithuium
Dose related tremor and git
Dermatological acne
Weight gain
Cardiac conduction defects
Hypothyroidism
Luecocytoses
Diabetes insipid us
Teratogenecity
Q =amniocenteses may reveal chromosomal abnormalities asocated
with mr In high risk preganancy in mother age more than 35yr
Q =SELECTION CRETERYA OF PT WITH ECT
1= DESCRIPTION OF EACH PROBLEM INCLUDING
BEHAVIUORAL THOUIGHTS
And emotion associated with it
Where it occur most often
Common prior events
379
Pt response to these events
What follows probem
2= factors that alleviate or worsen that problem
3=maintaining factors
Avoidance
Safety behaviors selective attention
Way of thinking
Response of other
Q = SENARIOS OF HALLUCINOGEN TOXOCITY
Brought to ER tremor restless sweating profusely , tachycardia,
mydriase, auditory hallucinations for 10days
Q =BIPOLAR DISORDER IS TO BE TREATED ON LITHIUM
INVESTIGATION NEEDED ARE ECG AND TFTS
Q MONITORING OF SERUM LITHIUM TO PREVENT LITHIUMM
TOXiCITY
Q ETHCAL DELIMAS IN DR LIFE
1=ACCEPTING GIFT
2 SEXUAL BOUNDERIES VOILATION
3 CHARGES AND FEE PT COOLEAGUERS TEACHR AND
MEDICAKL CIOLEAGUES
4=MEDIA AND MEDICINE
5 E CONSULTATIONS AND TELE MEDICINE
6=EUTHANASISA AND PHYSICISAN ASSISSTED SUICIDE
7= RELATUIONSHIPO WITH PHARMACEUTICAKL INDUSTRY
Q CHILDHOOD ENURESES
TREATMENT

380
Appropriate toilet training and avoiding large amount of fluids before bed
are important as are decreasing emotional stressor and rewarding child with
prause for a dry bed or clothes
Bellpade apparatus is sometimes uused
Pharmacotherapy
Imipramine
Decompressin for short term treatment
Q multiaxial approach is applied to scheme of classificatiomn in which
2 or more sets of information are coded
Essen mullar was first to propose such a system for use in psychiatry
using one axis for clinical syndrome and another for aetiology
Multi axial classification is now integral to dsm 4 and available with icd
10
They are attractive for several reason there is a danger that multiaxial
schemes are too compilicated and time consuming to be suitable for
every day use especially if clinical utility of each axis has not been
demonstrated
Q =CHARACRTERISTICS OF SLEEP FROM INFANCY AND OLD
AGE
TOTAL SLLEEP TIME DECREASE
REM % DECREASE
STAGE 3 AND 4 TEND TO VANISH
Q NEROTRANSMITTER OF SLEEP
serotonin is increased during sleep and initiat sleep
Ach also increased in sleep linked to rem sleep
NEP
DECREASED DURING SLEEPP LINKED TO REM
381
DOPAMINE
INCREASE IN SLEEP, linked too arousal and wakefulness
CHEMICAL EFFECTS ON S;LEEP
TRYPTOPAN INCREASE SLEEP TIME
DA AGONIST PRODUCES AROUSAL
DA ANTAGONIST DECREASE AROUSAL INCREASE SLEEP
BZDSUPRESS STAGE 4 WHEN USED CHRONICALLY SLEEP
LATENCY
ALCOHOL INTOXICATION
SUPPRESS REM
BARBITURAE INTOXICATION
SUPPRESSES REM
ALCOHO,LWITHDRAWAL
REM REBOUND
BARBITURATE WITHRDRWAL
REM REBOUND
MAJOR DEPRESSION
Shortened rem latency ,increase rem suppresses of delta mulitiple
awakening and early morning bawzakening
Q =informed consent
With exception to life threartning emergency (when time taken to
obtain consent would further endanger pt)
physicain must obtain consent both verbal and nonvrerbal from
competent pt befor proceeding with any medical or surgical treatment
For minor proceedre no need of consent but for major medical and
surgical need of consent
2=nurses cannot obtain consent
382
3=components of informed consent
1=pt must understand dx a nd other health implication
2=pt should be told risk and benefit
3pt must know likely outcome
4=pt must know that they can withdraw consent any time before procedure
5=pt must also be taken out and given standard treatment for his condition
C=special situation competent pt hav a right to refuse consent to
procedure for religious or other reason if thre health suffer or death
occur from such refusal
2=competent pt has right to refuse to such intervention c section even if
fetus will die be seriously injured without intervention
Q =BIOLOGICAL MARKRERS AND DIAGNOSTIC
INVESTIGATION IN ALZEIMER DISEASE
Diagnosis is based on numerous clinical ,neuroradoilogical , and
neuropsychological evaluation
Definitive diagnosis is based on 1=autopsy
2=brain biopsy
Ct and mri are used to measure length or volume in brain of alzeimer
disease.
SPECT AND PET
Glucose metabolites such as beta amyloidal procurer protein in csf .
Down syndrome pt develops ultimately Alzheimer disease
Q SOCIAL ISSUES IN ALZEIMER PT AND FAMILY
Family caring for a person with Alzheimer disease soon discovered that it is
unlike any other illness. Facing with degenerative brain disease is much
different than dealing with a physical disability. Alzheimer disease has
more disruption to and greater impact on family than other chronic disease

383
Families of Alzheimer disease pt carry a high financial social and economic
price
Families must work together effectively coping with the disease, and
decreasing harmful effects on families and keeping family conflicts to
minimum
Q =what is echopraxia?
Ans= occurs when pt imitates the interviewer movement even when asked
not to do so
Q =apraxia= is inability to perform a volitional act even though motor
system and sensorium are sufficiently intact for person to do so
Q =catalepsy=or waxy flexibility =is term used to describe the tone in
catatonia
It is detected when pt limb can be placed in a position in whioch they
remain for a long period while at same time muscle tone is inc reased
Q =labile mood=emotional mood vary in relation to person circumstances
and preoccupation
In abnormal state this variation witrh circu mstances may continue but
variation may be greater or less than normal
Increased variation are called labiluity of mood
Extreme variation are called emotional incontinence
Q incongruent mood = a delusion that is out of keeping with prevailing
mood is mood incongruent and is suggestive of schyzoprenia
Q = essential elements of hypocratic oath
Ans= already done
Q = how you will respond in following issues of ethically?
Q = a pharmacuetical industry offer you a holiday in dubai if you ensure
100 prescription of their prioduct
384
Ans =no
Q= a medical representative of a drug company offer to fund a double
blind control trial of there newly launched antidepressant in your practice
Ans = yes
Q = a pharmaceutical concern wants to fund a rehabilitation centre for
substance abuse pt in your facility thru a cash deposited in your personal
account
Ans =no
Q = a colleagues report you a that he has decided to see his 25yr old singke
pt of anxiety at end of his clinic for next few weeks
He wants to see her for at least one hour as she is not getting well inspite
of his best efforts and drug treatment.. he thinks that pt feels much better
when he holds her hands and his gestures decreases fear of physical
contact in patient.
Q =q =what ethical issues and psychodynamic isssues are involoved
Ans=malpracticing of medical profession and counter transference
Q = you have been asked to start counseling session with a pt evaluated
from an earth quake affected area
A= what are essential steps that you would put in place in counseling
processes
Ans = counseling session are aimed at
1= establish a relationship of mutual trust in which pt feels secure and able to
express themselves in any way or form necessary
2= giving pt or their families a chance to seek clarification
3-= providing opportunity to pt to freely express his or her feeling and emotion
4= provision of reassurance

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5= achieving a deeper and a clearer understanding of a health related issue
based on scientific and evidence based data
6= dialogue and discussion between counselor and pt to identify bvariuos
choices alongside there pros and cons
7= make suitable decision
8= mobilization of resources to implement solution
9= learning necessary skill to cope with issues
If a doctor opts to take up role of a counselor he needs to develops and exhibit
following attributes
1= unconditioned positive regard and positive feeling for pt
2=empathic understanding ability to accurately perceive other feeling
It differ from sympathy which means feeling sorry for person
3-= warmth and geniuses
4= counseling relationship should remain clear and without mystery to pt
5= here and now=
As a counselor you need to identify present thought and feeling to enhance
problem solving attitude on basis of here and now and focus on present day
issue
Q = 28yr old house wife present with fear of open spaces and crowds
She has found difficult to leave her house for last 2yr
She remain symptom free at home and is able to attend to her routine
comfortably
She refuses to take medication as she is pregnant and seek a
psychological /nonpharmacological methods of treatment
What option would you suggest?
Which psychological modalities will you choose and list steps in volved in
this psychological methiods
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Ans= cognitive behavioral intervention
Combining progressive relaxation and graduated imaginable exposure to feared
stimulus , systematic desensitization has been used
Systematic desensitization works by principle of reciprocal inhibition which
asserts that sympathetic response associated with anxiety is incomparable
with and thus inhibited by parasympathetic response that occur during deep
muscle relaxation\
2= exposure=
Prolong and repeated in vivo exposure to feared stimulus is by far the most
studied and effective form of treatment for a specific phobia
Cognitive restructuring phobia.
Specific irrational thought may contribute to development of phobia. Maintain
avoidance behavior and contribute to physiological symptoms
Cognitive restructuring treatment help pt to monitor irrational thought and
change underlying belief so that they are better able to enter feared situation
Q = 24 yr old married lady presents with you complaining of low mood ,
weeping spell, lack of energy and disturb sleep?
What are essential prerequistes she must fulfill before you choose her to
start a course of antidepresents
Ans= guidelines for management of depression
1=pt with short lived mild depression who may recover quickly without
treatment should be offered an early review(active monitoring)
2= antidepressants are not recommended for treatment of mild depression
3= pt with persistent mild depression should be recommended a guided v self
help program based on cbt
Group CBT is an alternative
An exercise program and sleep hygiene can also be recommended

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4= for pt with mild depression that do not respond to these measures consider
drug treatment with an ssri or a higher intensity psychological treatment (cbt ,
behavioral activation, interpersonal therapy or couple therapy)
5= pt who present with moderate or severe depression should be treated with a
combination of a antidepressants medication and a high intensity psychological
intervention
6= pt who respond to antidepressants medication should continue treatment for
at least 6months
Pt at high risk of relapse should be advised to continue antidepressants
medication for 2yrs
7= consider cbt for pt who have relapsed despite antidepressants treatment or
mind fullness based cognitive therapy for pt who are well but who have
experienced three or more episodes of depression
Q what are investigation in anorexia nervosa
Ans=physical examination= sign of malnutrition includes emaciation,
hypotension, bradycardia , lanugos(fine hair on trunk )and peripheral edema, sign
of purging includes eroded dental enamel caused by emesis and scratched hand
from self gagging to indudce emesis
There may be evidence of general medical condition caused by abnormal diet,
starvation and purging
Diagnostic tests= sign of malnutrition, normochromic normocytic anemia,
elevated liver enzymes, abnormal electrolytes, abnormal electrolytes ,
low
estrogens and testosterone, sinus bradycardia , reduce brain mass and abnormal
eeg
Signs of purging=metabolic alkaloses, hypochlirelemia and hypokalemia caused
by emesis, metabolic acidosis caused by laxative abuse
Q how manage above case
388
Ans= initial treatment should be correction of significant physiologic
consequences of starvation with hospitalization if necessary, behavioral therapy
should be initiated with rewards or punishment based on absolute weight, not on
eating behavior, family therapy designed to reduce conflicts about control by
parents is often helpful. Antidepressants may play a limited role in treatment
when co morbid depression is present
Q= what specific pychosexual and psychtric states is she likely to develop
on account of her illness and its managenment
Ans= pt admitted in cancer ward have high morbidity and mortality
The psychological consequences of cancer are similar to those of any other
physical illness and includes following
Delay in seeking medical help. This may be either due to either fear or denial
Response to diagnose= this may consist of anxiety, anger, disbelief, or depression
Some times the response is severe enough to meet the criteria for a psychiatric
disorder, usually adjustment disorder or some time a depressive disorder
The risk of suicide is increase usually after diagnoses
Major depression in up to 20%pt
The progression and recurrence are associated with increase psychiatric
disturbance which may result from a worsening of physical illness such as pain
nausea, from fear of dying or from development of an organic syndrome
Delirium and dementia may arise from brain metastases and sometime
psychiatric symptoms before primary lesion is disturbed
Neuropsychiatric problems and paraneuplastic syndromes are some times
induced by certain cancer
Treatment for cancer may cause psychological disorder
After mastectomy emotional distress seen
Radiotheraphy causes nausea , fatigue and emotional disturbance

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Chemotherapy= often causes malaise , nauseas and anxiety. Nausea respond to
antiemetic drugs and behavioral treatment
Family and other close relative of cancer pt may experience psychological
problems
Which may persist even if cancer is cured
Treatment for psychological consequences= in past doctor were reluctant to tell pt
that diagnoses was cancer but most pt now prefere to know diagnose and how it
will affect their life
However information must be communicated well otherwise there may be
problems in achieving a psychological adjustment
Depression and anxiety are often missed in this pt and systematic screening has
been recommended
Cognitive behavioural approaches can help these pt to adjust
Q = 24yr old male showing voilant and abusive behaviuor, inappriopirite
behavior, breaking into lauger one minute and then crying for no reason and
gazed meaninglessly at objects and ill for more than 3years continuesly and
treated with haloperidol, olanzapine and rispperidone without any response
to treatment
And rapidly gained weight in last few months and now 110kg weight
And height of 170cm
Q what is most likely diagnose
Ans= cyclothymiacs disorder and management= ant manic drugs like lithium,
Carbamazepine, valproic acid are typically drug of choice
Psychotherapy will focus on helping pt gain insight into there illness and how to
cope with it
Differential diagnoses= medical= seizure, substances, and medication
Mental = other mood disorder, personality disorder, medication again
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Q classification of somatoform disorder according to DSM IV
ANS=1=somatization disorder=history over years of two GIT symptoms(nausea),
four pain symptoms, one sexual symptom(menstrual problems), and one pseudo
neurologic symptoms (paralyses)
Onset before 30yr age
2= hypochondriases= a disorder characterized by pt belief that he or she has
some disease
Despite constant reassurance pt belief remain same
Men and women are equally affected, however some studies indicates that it may
be more common in men
Most common onset is between 20-30yr age
3= conversion disorder=
A disorder in which individual experiences one or more neurologic symptoms
that cannot be explained by any medical or neurologic disorder
Seen most frequently in young women and decrease ses, rural population , low iq
, military personnel
Commonly associated with passive aggressive, dependant, antisocial, and
histrionic personality disorder
4= body dysmorpic disorder
A disorder characterized by belief that some body part is abnormal , defective
and misshapen affect women more often . and are unlikely to be married. Other
disorders that may
be found includes depressive disorder
And psychotic disorder
Family history of depressive illness and ocd
May involves serotenergic systems

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5=pain disorder=
A disorder in which presence of pain is pt main problem
Mostly in women and peak age of onset is in fourth or fifth decade
Secondary gain may be seen in some pt
Q =SCREEENING TESTS FOR DOWN SYNDROME The American College
of Obstetricians and Gynecologists recommends offering the option of screening
tests and diagnostic tests for Down syndrome to all pregnant women, regardless of
age.
Screening tests can indicate the likelihood a mother is carrying a baby with Down
syndrome.
Diagnostic tests can identify whether your baby has Down syndrome.
Your health care provider can discuss the types of tests, advantages and
disadvantages, benefits and risks, and the meaning of your results. If appropriate,
your provider may recommend that you talk to a genetics counselor.
Screening tests during pregnancy
Q Screening for Down syndrome is offered as a routine part of prenatal care.
Screening tests include the first trimester combined test, the integrated screening
test and the cell-free fetal DNA analysis.
The first trimester combined test
Integrated screening test
The integrated screening test is done in two parts during the first and second
trimesters of pregnancy. First trimester. Part one includes a blood test to measure
PAPP-A and an ultrasound to measure nuchal translucency.
Second trimester. The quad screen measures your blood level of four pregnancy-
associated substances: alpha fetoprotein, estriol, HCG and inhibin A.
Cell-free fetal DNA analysis
Q Diagnostic tests during pregnancy
392
If your screening test results are positive or worrisome, or you're at high risk
of having a baby with Down syndrome, you might consider more testing to
confirm the diagnosis. Your health care provider can help you weigh the pros
and cons of these tests.
Diagnostic tests that can identify Down syndrome include:
Amniocentesis.
Chorionic villus sampling (CVS). In CVS, cells are taken from the placenta
and used to analyze the fetal chromosomes.
Cordocentesis. In this test, also known as percutaneous umbilical blood
sampling or PUBS, fetal blood is taken from a vein in the umbilical cord and
examined for chromosomal defects. Doctors can perform this test between 18
and 22 weeks of pregnancy. This test carries a significantly greater risk of
miscarriage than does amniocentesis or CVS, so it's only offered when results
of other tests are unclear and the desired information can't be obtained any
other way.
Q Diagnostic tests for newbornsAfter birth, the initial diagnosis of Down
syndrome is often based on the baby's appearance. But the features associated
with Down syndrome can be found in babies without Down syndrome, so your
health care provider will likely order a test called a chromosomal karyotype.
Using a sample of blood, this test analyzes your child's chromosomes. If
there's an extra chromosome 21 present in all or some cells, the diagnosis is
Down s
Q Down Syndrome - Treatment

is common to experience a wide range of emotions when your baby is born

with Down syndrome. While you have joy from your child's birth, you will
also need to learn about and care for his or her special health care needs. Most

393
families choose to raise their child, while some consider foster care or
adoption. Support groups and organizations can assist you in making the best
decision for your family.

Treatment for Down syndrome focuses on making sure that your child has
regular medical checkups, helping your child develop, watching for early signs
of health problems, and finding support. With treatment and support, you can
help your child live a happy, healthy life.

Q Help your child to develop

Although it may take extra time for your child to learn and master skills, you
may be surprised at how much he or she will be able to do. With
encouragement, your child can learn important skills. You can help your baby
learn to walk, talk, or eat by himself. You can help your child make friends
and do well in school. Later you can help him or her learn job skills and
maybe live independently.

Q Serotonin Syndrome Treatments

People with serotonin syndrome are typically hospitalized for observation and
treatment of symptoms. For example, benzodiazepines are given to treat
agitation and/or seizures. Intravenous fluids are given to maintain hydration.
Removing the drug responsible for the serotonin syndrome is
critical. Hydration by intravenous (IV) fluids) is also common. In severe cases,
a medication called Periactin (cyproheptadine) that blocks serotonin production
is used.

Types of Psychosocial Treatments

394
Psychotherapy
Often called talk therapy, psychotherapy is when a person, family, couple or
group sits down and talks with a therapist or other mental health provider.
Psychotherapy helps people learn about their moods, thoughts, behaviors and
how they influence their lives. They also provide ways to help restructure
thinking and respond to stress and other conditions.
Psychoeducation

Psychoeducation teaches people about their illness and how they’ll receive
treatment. Psychoeducation also includes education for family and friends
where they learn things like coping strategies, problem-solving skills and how
to recognize the signs of relapse. Family psychoeducation can often help ease
tensions at home, which can help the person experiencing the mental illness to
recover. Many of NAMI's education programs are examples of
psychoeducation.
Self-help and Support Groups
Self-help and support groups can help address feelings of isolation and help
people gain insight into their mental health condition. Members of support
groups may share frustrations, successes, referrals for specialists, where to
find the best community resources and tips on what works best when trying to
recover. They also form friendships with other members of the group and help
each other on the road to recovery. As with psychoeducation, families and
friends may also benefit from support groups of their own.
Q Psychosocial Rehabilitation
Psychosocial rehabilitation helps people develop the social, emotional and
intellectual skills they need in order to live happily with the smallest amount
of professional assistance they can manage. Psychosocial rehabilitation uses
two strategies for intervention: learning coping skills so that they are more
395
successful handling a stressful environment and developing resources that
reduce future stressors.
Treatments and resources vary from case to case but can include medication
management, psychological support, family counseling, vocational and
independent living training, housing, job coaching, educational aide and social
support.
Assertive Community Treatment (ACT)
Assertive community treatment (ACT) is a team-based treatment model that
provides multidisciplinary, flexible treatment and support to people
with mental illness 24/7. ACT is based around the idea that people receive
better care when their mental health care providers work together. ACT team
members help the person address every aspect of their life, whether it be
medication, therapy, social support, employment or housing.
ACT is mostly used for people who have transferred out of an inpatient setting
but would benefit from a similar level of care and having the comfort of living
a more independent life than would be possible with inpatient care.
Studies have shown that ACT is more effective than traditional treatment for
people experiencing mental illnesses such as schizophrenia and schizoaffective
disorder and can reduce hospitalizations by 20%.
behavioral techniques used in rehabilitation

Speech therapy, occupational therapy, and other methods that "exercise"

specific brain functions are used. For example, eye–hand coordination exercises
may rehabilitate certain motor deficits, or well structured planning and
organizing exercises might help rehabilitate executive functions, following a
traumatic blow to the head.

396
Brain functions that are impaired because of traumatic brain injuries are often
the most challenging and difficult to rehabilitate. Much work is being done in
nerve regeneration for the most severely damaged neural pathways.

Neurocognitive techniques, such as cognitive rehabilitation therapy, provide

assessment and treatment of cognitive impairments from a variety of brain
diseases and insults that cause persistent disability for many individuals. Such
disabilities result in a loss of independence, a disruption in normal childhood
activities and social relationships, loss in school attendance, and educational
and employment opportunities. Injuries or insults that may benefit from
neurocognitive rehabilitation include traumatic and acquired brain
injuries (such as stroke, concussion, neurosurgery, etc.), cranial radiation,
intrathecal chemotherapy and neurological disorders, such as ADHD. The
rehabilitation targets cognitive functions such as attention, memory, and
executive function (organization, planning, time management, etc.). Programs
are developed to address an individual's challenges after a baseline assessment
of abilities and challenges

Q ELECTROENCEPHALOGRAPHY
EEG may help may help establish and characterize type of epilepsy
Determination of type is important for determining the most appropriate
anticonvulsant drug with which to start treatment
EEG may confirm the presence of seizure by demonstrating spikes even in
interictal period
.

Q What is Sensate Focus?

397
Sensate focus or sensate focusing is a term usually associated with a
set of specific sexual exercises for couples or for individuals. The term
was introduced by Masters and Johnson,[1] and was aimed at increasing
personal and interpersonal awareness of self and the other's needs.
Each participant is encouraged to focus on their own
varied sense experience, rather than to see orgasm as the sole goal
of sex.[2][3]

Method

A sex therapist will usually guide the timing and technique of the
sensate focusing. In the first stage, the couple may touch each
other's bodies excluding breasts and genitals. They are encouraged to
enjoy and become increasingly aware of the texture and other
qualities of their partner's skin. Participants concentrate on what they
themselves find interesting in the skin of the other rather than what
they think the other may enjoy.

The second stage increases the touch options to include breasts.

Sensation and gathering information about the partner's body is still
encouraged and intercourse and touching of the genitals is still
forbidden. The participants then use a technique of placing their hand
over their partner's hand in order to show what they find pleasurable
in terms of pace and pressure. Learning about the partner's body is
still the goal rather than pleasure.

Further stages include the gradual introduction of genitals and then

full intercourse. Orgasm is never the focus.

This is also used as a treatment for impotence in males, and arousal

difficulties especially where anxiety is involved. Because of
performance anxiety in men, the obsessional focus on the penis can
result in impotence. The therapist will encourage the man to forget
about his penis, and forget about his partner's genitals, and instead
concentrate on the sensual possibilities available in the feel of his
own and his partner's skin, hair, mouth, body, (breasts), etc.
Contact with the penis is 'forbidden' and the only sexual contact that

398
is 'allowed' is sessions of interaction with the partner during which
only the non-penis aspects of sex are
explored: touching, talking, hugging, kissing, and so on. This includes
not only touch but taste, sound and hearing, as partners are
encouraged to talk to each other, to express emotion and to encourage
each other.

The aim here is to have an appreciation of a whole new set of sensual

possibilities, leading to a reduced concentration on the penis and its
tendency to be the male's dominant concern. Patients often report an
improvement in their sex life generally with less anxiety. As the man
reports increasing awareness and attention paid to these holistic
sense aspects of sex, potency often returns. This works well for
women too. Women report more sensation in their vagina, and
lubrication.

Q FIVE PSYCHIATRIC DISORDERS THAT CAN LEAD TO

SHOPLIFTING

KLEPTO MANIA OR SHOPLIFTING is associated with mood

swings,eating disorders such as bulimia nervosa,alcoholism , substance
abuse,pathological gambling,pyromania,nail biting and trichotolomania

Q =echolalia refer to automatic production of words and sentences by pt of

docter even when asked not to do so
Q Capropraxia= exhibition of obscene behaviuor
Q Causes 5 causes of frontal lobe syndrome
Q Head trauma

Closed head injuries, for example from motor vehicle accidents, can cause damage
to the orbitofrontal cortex. Pre-frontal lobotomies and antipsychotics, severing
connections between the pre-frontal cortex and the rest of the brain, are
effectively
a form of iatrogenic trauma resulting in a frontal lobe syndrome.

399
Cerebrovascular disease may cause a stroke in the frontal lobe. Tumours such
as meningiomas may present with a frontal lobe syndrome. Frontal lobe
impairment is also a feature of Alzheimer's disease,
frontotemporal
dementia and Pick's disease.[9

Q Diagnosis
Q Clinical history

Frontal lobe disorders may be recognized through a sudden and dramatic

change in a person's personality, for example with loss of social awareness,
disinhibition, emotional instability, aggression, irritability or impulsiveness
(for example sexually inappropriate behaviour or spending money
impulsively). Alternatively the disorder may become apparent because of
mood changes such as depression, anxiety or apathy.

Examination

On mental state examination a person with frontal lobe damage may show
reduced speech, with reduced verbal fluency and impaired expressive
language. The person might have flattened or blunted affect. Typically the
person is lacking in insight and judgment, but does not have marked cognitive
abnormalities or memory impairment (as measured for example by the mini-
mental state examination). With more severe impairment there may
beecholalia or mutism. Neurological examination may show
primitive
reflexes (also known as frontal release signs) such as the grasp reflex or
the rooting reflex. These are reflexes normally found in babies, but normally
suppressed and absent in adults. Akinesia (lack of spontaneous movement)
and urinary incontinence will be present in more severe and advanced

400
cases. The frontal assessment battery (FAB), which includes simple tests of
sequencing, behavioural inhibition, planning and frontal release signs, can be
used as a screening test to elicit typical neurological and cognitive features.

Further investigation

A range of neuropsychological tests are available for clarifying the nature and
extent of frontal lobe dysfunction. For example, concept formation and ability
to shift mental sets can be measured with the Wisconsin Card Sorting Test,
planning can be assessed with the Mazes subtest of the WISC, switching
between plans is assessed with the Trail-making test, and screening out
distracting stimuli is assessed with the Stroop test.
Individuals
with frontotemporal dementia and Pick's disease will show
frontal
cortical atrophy on CT scans or MRIs. Frontal impairment due to head
injuries, tumours or cerebrovascular disease will also be apparent on brain
imaging.

Q = you are counseling 20yr old medical studnt for adjustment disorder for
last one month and show conduct problem at home and aggravated by
conflict of parent in which father deals harshly with his mother His mother
accompanies him in asession .she aacts out and and shout out at you saying
that her son is not improving due to your faul Q what two
defence
mechanism sheis usingAns-= 1=projection 2=acting out

Q mcps=30yr old house wife comers to you with ten year history of feeling
restless symptoms of irrirttable bowel syndriomer, muscle tension dry mouth
and finer tremor of hands she has been taking diazepam orally for five years
and now inspit of taking adose more than prescribed by her family physician

401
she cannot get relief from anxiet What is most likely diagnosesAns= generalize
anxiety disorder

Q =what medical problem you would like to rule out

Ans= thyroid function test

Q=what treatment you would recommend=

Ans=behavoural psychotheraphy

Relaxation techniqueas

Biofeeed back

Ssri, venlafaxine, buspironne

Benzodiazepine

Q Ceruloplasmin

Levels of ceruloplasmin are abnormally low (<0.2 g/L) in 80–95% of cases

Serum and urine copper

Serum copper is paradoxically low but urine copper is elevated in Wilson's disease.
Urine is collected for 24 hours in a bottle with a copper-free liner. Levels above
100 μg/24h (1.6 μmol/24h) confirm Wilson's disease, and levels above 40 μg/24h
(0.6 μmol/24h) are strongly indicative.

402
Liver biopsy
Genetic testing
Q Treatment
Dietary

In general, a diet low in copper-containing foods is recommended with the

avoidance of mushrooms, nuts, chocolate, dried fruit, liver, and shellfish.[1]

Medication

Medical treatments are available for Wilson's disease. Some increase the removal
of copper from the body, while others prevent the absorption of copper from the
diet.

Generally, penicillamine is the first treatment used. This binds copper (chelation)
and leads to excretion of copper in the urine.

Transplantation

Liver transplantation is an effective cure for Wilson's disease

Q = you are asked to train some volunteers for counseling of flood

victimsTaking ooppertunity you obtained data about these volunteers
Knowledge at start of training and at end All data is in measurable . Name
any test of statistical significance that can be applicable for data

Ans= chi square test

Q = main components of limbic system = 1=hypocampus 2=amygdale 3=

hypothalamus

403
Function of limbic system includes

1=emotion 2=sexual 3= autonomic nervous system and endocrine system

Q mcps=clinical features of kluver bucky syndrome

Ans hypersorality and hypersexuuality

Q = pt presents with episode of alteration in consioyusness and feeling of
unfamilirty to her usual environment
Theses episodes last for 1-2 min and are not related to any stressful
situation
Name perceptual disturbasnce he is experiencing
Ans dearealization
Q what other perceptual disturbance can occur in this pt
Ans=depersonalization
Q psychiatric manifestation of brain tumors=
Dysfunction: depending on the tumor location and the damage it may have caused
to surrounding brain structures, either through compression or infiltration, any
type
of focal neurologic symptoms may occur,
such
ascognitive and behavioral impairment (including impaired judgment, memory
loss, lack of recognition, spatial orientation disorders), personality or emotional
changes, hemiparesis, hypoesthesia, aphasia, ataxia, visual
fieldimpairment,
impaired sense of smell, impaired hearing, facial paralysis,
double
vision, dizziness, but more severe symptoms might occur too, such as paralysis on
one side of the body hemiplegia or impairment in swallowing. These symptoms are
not specific for brain tumors – they may be caused by a large variety of neurologic
conditions (e.g. stroke, traumatic brain injury). What counts, however, is the
location of the lesion and the functional systems (e.g. motor, sensory, visual,
etc.) it

404
affects. A bilateral temporal visual field defect (bitemporal hemianopia—due to
compression of the optic chiasm), often associated with endocrine dysfunction—
either hypopituitarism or hyperproduction of
pituitary hormones and hyperprolactinemia is suggestive of a pituitary tumor.
Irritation: abnormal fatigue, weariness, absences and tremors, but also epileptic
seizures.

A benign brain tumor may be present for some years and be asymptomatic. Others
might present ambiguous and intermittent symptoms like headaches and vomiting
or weariness and so be mistaken for gastrointestinal disorders. In these cases
secondary symptoms need to be looked into.

Q =what is most common psychiatric manifestation of brain tumors

Ans= cognitive and behavioral impairments
Q= what are most important facters which predict psychiatric presentation
of brain tumors
Ans= stated above
Q =opoid withdrawal investigation and treatment
Exams and Tests
Your doctor can often diagnose opiate withdrawal after performing a physical
exam and asking questions about your medical history and drug use.
Urine or blood tests to screen for drugs can confirm opiate use.
Other testing will depend on the physician's concern for additional medical
problems. These test may include:
Blood chemistries and liver function tests such as CHEM-20
CBC (complete blood count, measures red and white blood cells, and platelets,
which help blood to clot)

405
Treatment
Treatment involves supportive care and medications. The most commonly used
medication, clonidine, primarily reduces anxiety, agitation, muscle aches,
sweating, runny nose, and cramping.
Other medications can treat vomiting and diarrhea.
Buprenorphine (Subutex) has been shown to work better than other medications for
treating withdrawal from opiates, and it can shorten the length of detoxification
(detox). It may also be used for long-term maintenance, like methadone.
Persons withdrawing from methadone may be placed on long-term maintenance.
This involves slowly decreasing the dosage of methadone over time. This helps
reduce the intensity of withdrawal symptoms.
Some drug treatment programs have widely advertised treatments for opiate
withdrawal called detox under anesthesia or rapid opiate detox. Such programs
involve placing you under anesthesia and injecting large doses of opiate-blocking
drugs, with hopes that this will speed up the return the body to normal opioid
system function.
There is no evidence that these programs actually reduce the time spent in
withdrawal. In some cases, they may reduce the intensity of symptoms. However,
there have been several deaths associated with the procedures, particularly when it
is done outside a hospital.
Because opiate withdrawal produces vomiting, and vomiting during anesthesia
significantly increases death risk, many specialists think the risks of this
procedure
significantly outweigh the potential (and unproven) benefits.
Q Neuropsychiatric complications of epilepsy.Psychiatric complications of
epilepsy are multiple and result from the complex interaction between endogenous,
genetic, therapeutic, and environmental factors. The relationship between epilepsy
and psychiatric disorders may be much closer than previously appreciated. Recent

406
studies have suggested the existence of a bi-directional relationship between
depression and epilepsy, whereby patients with epilepsy have a higher risk than the
general population of suffering from depression, not only after, but also before
the
onset of epilepsy. Furthermore, similar neurotransmitter changes have been
identified in depression and epilepsy, suggesting the possibility that these two
disorders share common pathogenic mechanisms. Although the clinical
manifestations of psychiatric disorders in epilepsy are often indistinguishable
from
those of nonepileptic patients, certain types of depression and psychotic disorders
may present with clinical characteristics that are particular to epilepsy patients.
These include the psychosis of epilepsy, postictal psychotic disorders, alternative
psychosis (or forced normalization), and certain forms of interictal depressive
disorders.

Q how diifentiate between geniun fits and histerical fits thru history

Answer discussed

Q =5symptoms of depression in a learning disabled persons

Ans=1=low mood 2=loss of interest

3=lowered energy

4=anxiety and repetitive behaviuor

5=obssessional thoughts

6= decrease appetite

7= weight loss

407
8= loss of sexual interest

Q manage depression in learning disabled pts

Ans=1=medication

2=psychological treatment

3=behaviors modification

Q =32 old pt becoming physically unwell over last 24hrs

He is not your pt but you know that recently antidepresent has been changed

His medicine chart show that he is on ssri

His symptoms are confusion and delirius

Restless and agitation

Sweating

Shivering

Tachycardia

Q What is most likely diagnoses

Ans= benzodiazepine withdrwal

Q =name 9 principles for planning metal health services

Already in previus pages and senarios

408
Q enlist various modelas of counsellings

Ans=1=debriefing

2=counseling for relationship problems

3=grief counseling

4= counseling about risks

5=counseling in primary care

Q senarios of person saying that I am suffering from cancer but no evidence

of disesea in body diagnoses is hypochondriase

Q = 33 yr male brought to ER with tremor ,restless and agitated and

swaei=ting profusely and have tachycardia and mydrses and hearing voices
since 10 day

Ans=diagnoses is hallucinogen toxicity

Q manage case in above question

Ans= supportive measures for toxicity

Antipsychotics

And bzd

Q handy point=neurotransmitters

Dopamine play role in schizophrenia and dementia

409
While norepineprine in mood disorder

Q Drug addiction means repeated connsumption of drug which may be

natural or synthetic and which is harmful both for individual and their family.

q mcps= some consequwences of intravenous drug abuse=

local=vein thromboses

infection of injection site

damage to arteries

systemic= bacterial endocarditic

hepatitis B and C

hiv infection and accidental overdose

Q = 18yr old single school fallout who has beenm apprehended following a
failed attempt by him to blow out himself with a suicidal jacket in a busy
bstreeety

duiriong his summery trial in a military court the individual has openly
expreesed his desire to repeat action and has stated that he is on holy
mission , the police reports that individual tends to lie extensively the court
approechhres you for an option on his mental health

ans =pt is manic

Q =8yr child with two year history of trelling lies, kinlling animals and
settting fire to objects but gradually it came into notice that child acts

410
were more than simple mischief,stealing household items, fighting witrh
other kids angery outburst, killing animals and settong fire

what is most likely disgnoses

ans= conduct disorder

Q what are causes=genetic influences play a role by affecting

temperament ,stressful family and school enviroment have also been reported

Q = facters that predict poor outcome inm children with conduct sdisorder
In young person
Early onset severe frequent and varied antisocial behavior
Hyperactivity and attention problems
Pervasiveness at home, school and elasewhere
In family=
Parental criminality and alcoholism
High hostility
Low income
In wider environment
Economically deprived areas
Ineffective school
Q = =what is psychosurgery
Ans= use of neurosurgical procedures to modify symptomas of psychiatric
uillness by operating in either the nuclei of brain and white matter
Q what are stereotactic procedures involved in psychosurgery
Ans= subcaudate tracheotomy

411
Anterior cingulectomy
Limbic leucotomy
Anterior capsulotomy
Q = effects of emotional arousal
Emotional responses are natural and normal part of life
Even unpleasant emotion serve as a important purposes
Like physical pain, painful emotion can serve as warnings that one needs to take
action
However strong emotion can also interfere with efforts to cope with stress
e.g there is evidence that high emotional arousal can interfere with attention and
memory retrieval and can impair judgment and decision making
although emotional arousal may hurt coping efforts inverted u hypotheses
predicts that task performance should improve with increased emotional arousal
upto a point after which further increases in arousal becomes disruptive and
performance deteriorates
this idea is referred as inverted u hypotheses because when performance is
plotted as a function of arousal the resulting graph approximate an upside down
in these graphs the level of arousal at which performance peaks is characterized
as optimal level of arousal for a task
this optimal level appears to depend in part on complexity of task at hand
the conventional wisdom is that as task becomes more complex
the optimal level of arousal for peak performance tends to decrease
Q elements of family intervention in schyzoprenia
Ans= already discussed previously
Q=Bariatric surgery e,g. gastric bypass , gastric banding is initially
effective but of limited value for maintaing a long term weight loss

412
Pharmacological agents for weight loss Include orlistate a pancreatic lipase
inhibiter that limits breakdown of dietry fat and phentermine.
Sympathomimetic agents that decrease appetite
A combination of sensible dieting and exercise is most effective way to
maintain long term weight loss

Q Risk factors OF ANOREXIA NERVOSA

Certain risk factors increase the risk of anorexia nervosa, including:

Being female. Anorexia is more common in girls and women. However, boys
and men have been increasingly developing eating disorders, perhaps because
of growing social pressures.
Young age. Anorexia is more common among teenagers. Still, people of any
age can develop this eating disorder, though it's rare in those over 40. Teens
may be more susceptible because of all the changes their bodies go through
during puberty. They also may face increased peer pressure and be more
sensitive to criticism or even casual comments about weight or body shape.
Genetics. Changes in certain genes may make people more susceptible to
anorexia.
Family history. Those with a first-degree relative — a parent, sibling or child
— who had the disease have a much higher risk of anorexia.
Weight changes. When people lose or gain weight — on purpose or
unintentionally — those changes may be reinforced by positive comments
from others if weight was lost or by negative comments if there was a weight
gain. Such changes and comments may trigger someone to start dieting to an
extreme. In addition, starvation and weight loss may change the way the brain

413
works in vulnerable individuals, which may perpetuate restrictive eating
behaviors and make it difficult to return to normal eating habits.
Transitions. Whether it's a new school, home or job; a relationship breakup;
or the death or illness of a loved one, change can bring emotional stress and
increase the risk of anorexia.
Sports, work and artistic activities. Athletes, actors, dancers and models are at
higher risk of anorexia. Coaches and parents may inadvertently raise the risk
by suggesting that young athletes lose weight.
Media and society. The media, such as TV and fashion magazines, frequently
feature a parade of skinny models and actors. These images may seem to
equate thinness with success and popularity. But whether the media merely
reflect social values or actually drive them isn't clear-cut.
Q tests and diagnosis

If your doctor suspects that you have anorexia nervosa, he or she will typically
run
several tests and exams to help pinpoint a diagnosis, rule out medical causes for
the
weight loss, and check for any related complications.

These exams and tests generally include:

Physical exam. This may include measuring your height and weight; checking
your vital signs, such as heart rate, blood pressure and temperature; checking your
skin and nails for problems; listening to your heart and lungs; and examining your
abdomen.
Lab tests. These may include a complete blood count (CBC) and more specialized
blood tests to check electrolytes and protein as well as functioning of your liver,
kidney and thyroid. A urinalysis also may be done.

414
Psychological evaluation. A doctor or mental health provider will likely ask about
your thoughts, feelings and eating habits. You may also be asked to complete
psychological self-assessment questionnaires.
Other studies. X-rays may be taken to check your bone density, check for stress
fractures or broken bones, or check for pneumonia or heart problems.
Electrocardiograms may be done to look for heart irregularities. Testing may also
be done to determine how much energy your body uses, which can help in
planning nutritional requirements.
Diagnostic criteria for anorexia

To be diagnosed with anorexia nervosa, you generally must meet criteria in the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the
American Psychiatric Association. This manual is used by mental health providers
to diagnose mental conditions and by insurance companies to reimburse for
treatment.

Q DSM-5 diagnostic criteria for anorexia include:

Restricting food intake — eating less than needed to maintain a body weight
that's at or above the minimum normal weight for your age and height
Fear of gaining weight — intense fear of gaining weight or becoming fat, or
persistent behavior that interferes with weight gain, such as vomiting or using
laxatives, even though you're underweight
Problems with body image — denying the seriousness of having a low body
weight, connecting your weight to your self-worth, or having a distorted image of
your appearance or shape

415
Q Epilepsy and pregnancy: What you need to know

The combination of epilepsy and pregnancy might seem risky, but the odds are in
your favor. Find out how to promote a healthy pregnancy.

Epilepsy during pregnancy can pose some unique concerns. However, most women
who have epilepsy deliver healthy babies. If you have epilepsy and are considering
pregnancy, here's what you need to know.

Q Does epilepsy make it more difficult to conceive?

Some drugs used to treat seizures might contribute to infertility. However, certain
anti-seizure medications can also reduce the effectiveness of hormonal birth
control methods.

Q How does epilepsy affect pregnancy?

Seizures during pregnancy can cause:

Fetal heart rate deceleration

Fetal injury, premature separation of the placenta from the uterus (placental
abruption) or miscarriage due to trauma experienced during a seizure
Preterm labor
Premature birth
Q Does epilepsy change during pregnancy?

Every woman reacts to pregnancy differently. For most pregnant women who have
epilepsy, seizures remain the same. For a few, seizures become less frequent. For
others, particularly women who are sleep deprived or don't take medication as
prescribed, pregnancy increases the number of seizures.

416
Q = 48 yr old man is suffering from bipolar affective disorder for last 18yr is
on propylaxtic lithium theraphy for last 4years
For ;last few months he feels that he has become slowwv and has developed
intolerance to cold
What is possible wrong with this individual
And= lithium induced hypothyroidism
Q =How manage him
Ans = replacement theraphy with tab thyroxin available in 25, 50 and 100ug
Start with 50ug for first three weeks
100ug per day for next three weeks
150ug per day for whole life
Correct dose of thyroxin is that which restoresd serum tsh to normal
In pt with ischemic heart disease and elderly the initial dose should be 25ug per
day along with beta blockers and vasodilators
Thyroxin should always be taken as single daily dose of as its half ;life is
approximately 7days
Pt feels better ithin 3weeks
Reduction in weight and peri orbital puffiness occurs quickly but restoration of
skin texture takes 3-6months
Q = indication of antidepresent drugs?
Ans= depressive episode
Endogenous depression
Depressive episode with melancholia
Dysthymia
Reactive depression
Secondary depression
In hypothyroidism and Cushing disease
417
Child hood psychiatric disorder such as enuresis, adhd, school phobia,
somnambulism
Other psychiatric disorder=panic attack, ocd with or without depression, eating
disorder, borderline personality disorder
PTSD
Medical disorder such as chronic pain, migraine and peptic ulcer
Q =enumerate various substance related disorder in ICD 10
Ans=1=intoxication
2=harmful use
3=dependence syndromes
4=withdrawal state
5=withdrawal state with delirium
6=psychotic disorder
7=amnestic syndrome
8= residual and late onset psychotic disorder
9=other mental and behaviuoral disorders
Q = features of withdrawal disorder
Ans= anxiety, agitation, and insomnia
Tachycardia and sweating
Tremor of limbs, tongue and eye lids
Nausea and vomiting
Seizures
Confusion and hallucinations
Q =features of schizoid personality disorders
Ans=features includes
Emotionally cold
Detached’
418
Aloof(detached)
Lacking enjoyment
Introspective(thoughtful)
Q Signs and symptoms of borderline personality disorders

Borderline personality disorder may be characterized by one or more of the

following signs and symptoms:

Splitting
Chaos in relationships
Markedly disturbed sense of identity
Intense or uncontrollable emotional triggers
Unstable interpersonal relationships and self-esteem
Concerns about abandonment
Self-damaging behavior
Impulsivity
Frequently accompanied by depression, anxiety, anger, substance abuse or rage
Q = DDx and investigation in transient loss of consiuosness
Ans dd=systemic causes=
Metabolic such as renal and hepatic failure hypo/hypernatremia ,
hypo/hyperkalemia and metabolic acidize
Endocrine such as dka,myxedema
Drug overdose such as batrbiturates and organophosporus poisoning
Physical agents= hypothermia and heat stroke
Decrease cardiac output in arrhythmias
Intracranial disorder
Head injury

419
Infection dsuch as meningitis ,encephalitis and brain abscesses
Vascular such as subarachnoid hemorrhage
Epilepsy
Brainstem lesions
Psychiatric disorder
Hysteria and fugue states
Fever with unconsciousness such as cerebral malaria and meningitis and
encephalitis
Investigation=
1=Urine for sugar , albumin and ketone bodies
2= blood tests= RBS,urea electrolytes calcium, LFTs
Endocrine such as serum t3 t4 tsh and serum cortisol
blood culture]
Blood smear of malaria parasite
3= Ct scan of head= to indicate intracranial haemorage or mass ;lesions
4=Csf examination= if meningitis or encephalitios
Csf r/e it is contraindicated in raised intracranial pressure
5=ect may indicate epilepsy, herpes simlesx encephalitis and metabolic
encephalopathy
Q =55yr old business men presents with more than six year history of
inability to face the world disinterest in sex, suicidal thought and weight loss .
he relates his current plight to loosing a ;large sum of money and a part of
his fortune in gambling
Ans= dd includes
Mediical =none
Psychiatric =depression, pathological gambling
Q = what is treatment of pathologic gambling
420
Ans= gambler anonymous is most effective treatment
It involves public confession, peer pressure and sponsors
Although pharmacotherapy is usually not indicated some studies have shown
efficacy with ssri
Q = a case of bipolar disorder with implanted pacemaker and carrieng a
hisitry of severe alcohol abuse has suddenly become markedly siucuddal
explain
Wether ect can be administresd in this pt or not
Ans= yes
Q Diagnosis In those patients with clinical indicators of delirium, diagnosis
should be confirmed using the Confusion Assessment Method (CAM). CAM
should be used by a person competent in identifying delirium.
Causes of excessive daytime sleepeness
Insufficient night time sleep
Unsatisfactory sleep routines of circumstances
Circadian-rhythm sleep disorder
Frequent parasomnias
Chronic physical illness
Psychiatric disorders
Pathological seep
Narcolepsy
Obstructive sleep apnea
Others central nervous system deases
Drugs effects
Kleine-levin syndrome
Depressive illness
Assessment and investigation for excessive day time sleepiness
421
Narcolepsy usually presents to neurologist. The differential diagnosis is from
other
causes of excessive day time sleepiness and occasionally epilepsy, shizoophrenia
or chronic fatigue syndrome. Psychatrics referral may occur it the latter are
suspected. A full history , especially a sleep history. Is the main assessment
tool.
The Epworth sleepiness scale is often used. Sleep laboratory studies. If available
are valuable. Measurement of HLA status or hppocretin levels in CSF is some time
under taken but is not rountine.

Q Psychiatric disorders differ depending on gender. Women who have

alcohol-use disorders often have a co-occurring psychiatric diagnosis such as
major depression, anxiety, panic disorder, bulimia, post-traumatic
stress
disorder (PTSD), or borderline personality disorder. Men with alcohol-use
disorders more often have a co-occurring diagnosis of narcissistic or antisocial
personality disorder, bipolar disorder, schizophrenia, impulse disorders
orattention
deficit/hyperactivity disorder. Women with alcoholism are more likely to have a
history of physical or sexual assault, abuse and domestic violence than those in
the
general population, which can lead to higher instances of psychiatric disorders and
greater dependence on alcohol.

Q What Is Alcohol-Related Neurologic Disease?

Alcohol-related neurologic disease includes the following conditions:

Wernicke-Korsakoff syndrome (Wernicke’s encephalopathy and Korsakoff

psychosis)
alcoholic neuropathy
alcoholic cerebellar degeneration
alcoholic myopathy

422
fetal alcohol syndrome
alcohol withdrawal syndrome
dementia and other cognitive deficits

Women are more susceptible to many of the negative consequences of alcohol use,
like nerve damage, when compared to men.

Moderate drinking is probably safe for most people. The best way to prevent these
diseases is to avoid alcohol.

Q = facters that predict poor outcome of schyzoprennia

Ans=early outcome

Insidiuos outcome

Long duration of untreated psychoses

Previous psychiatric history

Hebephrenic subtypes

Negative symptoms

Enlarged left ventricles

Male gender

Single ,separated ,widowed and divorse

Poor psychosexiual adjustment

Abnormal previous personality

423
Poor work record

Social isolation

Poor compliance

Substance misuse

Q Big Five personality traits

A summary of the factors of the Big Five and their constituent traits, such that
they
form the acronym OCEAN:

Openness to experience:.
Conscientiousness: (efficient/organized vs. easy-going/careless).
Extraversion: (outgoing/energetic vs. solitary/reserved).
Agreeableness: (friendly/compassionate vs. analytical/detached).
Neuroticism: (sensitive/nervous vs. secure/confident). ".
Q Complications of child abuse
Some children overcome the physical and psychological effects of child abuse,
particularly those with strong social support who can adapt and cope with bad
experiences. For many others, however, child abuse has lifelong consequences. For
example, child abuse may result in physical, behavioral, emotional and mental
issues. Examples include:
QC Physical issues
Death
Physical disabilities and health problems
Learning disabilities
Attention-deficit/hyperactivity disorder (ADHD)

424
Substance abuse
Behavioral issues
Delinquent or violent behavior
Abuse of others
Withdrawal
Suicide attempts
Frequent, casual sex with many different partners (sexual promiscuity) or teen
pregnancy
Emotional issues
Low self-esteem
Difficulty establishing or maintaining relationships
Challenges with intimacy and trust
An unhealthy view of parenthood that may perpetuate the cycle of abuse
Inability to cope with stress and frustrations
Mental disorders
Eating disorders
Personality disorders
Depression
Anxiety
Post-traumatic stress disorder (PTSD)
Q Case Definition/note on chronic fatigue syndrome

There are several case definitions for CFS and all require fatigue as one of the
symptoms. CDC uses the 1994 CFS case definition, which requires meeting three
criteria:

The individual has had severe chronic fatigue for 6 or more consecutive months
and the fatigue is not due to ongoing exertion or other medical conditions
425
associated with fatigue (these other conditions need to be ruled out by a doctor
after diagnostic tests have been conducted)
The fatigue significantly interferes with daily activities and work
The individual concurrently has 4 or more of the following 8 symptoms:
post-exertion malaise lasting more than 24 hours
unrefreshing sleep
significant impairment of short-term memory or concentration
muscle pain
pain in the joints without swelling or redness
headaches of a new type, pattern, or severity
tender lymph nodes in the neck or armpit
a sore throat that is frequent or recurring

These symptoms should have persisted or recurred during 6 or more consecutive

months of illness, and they cannot have first appeared before the fatigue.

Q Causes of CFS

Some of the possible causes of CFS might be:

infections
immune dysfunction
abnormally low blood pressure that can cause fainting (neurally mediated
hypotension)
nutritional deficiency
stress that activates the axis where the hypothalamus, pituitary, and adrenal
glands
interact (the HPA axis)

426
Q Symptoms of CFS

. These symptoms include:

post-exertion malaise lasting more than 24 hours

unrefreshing sleep
significant impairment of short-term memory or concentration
muscle pain
pain in the joints without swelling or redness
headaches of a new type, pattern, or severity
tender lymph nodes in the neck or armpit
a sore throat that is frequent or recurring

The symptoms listed above are the symptoms used to diagnose this illness.
However, many CFS patients may experience other symptoms, including irritable
bowel, depression or other psychological problems, chills and night sweats, visual
disturbances, brain fog, difficulty maintaining upright position, dizziness,
balance
problems, fainting, and allergies or sensitivities to foods, odors, chemicals,
medications, or noise.

Q =age related sleep changes from infancy to old age

Ans=total sleep time decreases

Rem percentage decreases

Stage 3 and 4 trend to vanish

Neurotransmitter in sleep

427
Serotononiner increased during sleep

And iniates sleep

Acetyl choline =Increased during sleep,linked to rem sleep

Norepineprine deecresed during sleep, linked to rem sleep

Dopamine increased during sleep linked to arousal and walkfulness

Q = a 40 yr old man receaving tricyclic antidepresents brought to

emergency roonm with a history of ingestionof 40tab of imipraamine

Give an outline of steps in management of this case

Treatment of TCA overdose depends on severity of symptoms:

Initially, gastric decontamination of the patient is achieved by administering,
either
orally or via a nasogastric tube, activated charcoal pre-mixed with water,
which adsorbs the drug in the gastrointestinal tract(most useful if given within 2
hours of drug ingestion). Other decontamination methods such as stomach pumps,
gastric lavage, whole bowel irrigation, or (ipecac induced) emesis, are not
recommended in TCA
poisoning.
If there is metabolic acidosis, intravenous infusion of sodium bicarbonate is
recommended by Toxbase.org, the UK and Ireland poisons advice database (TCAs
are protein bound and become less bound in more acidic conditions, so by
reversing the acidosis, protein binding increases and bioavailability thus
decreases
– the sodium load may also help to reverse the Na+ channel blocking effects of the
TCA). Intralipid therapy has also been successfully used with a mechanism of
action thought to be similar to that of treatment for local anesthetic systemic
toxicity.

428
Treatment is otherwise supportive.

Q = care of potentially suicidal pt in community

Ans= full assessment of pt and proposed carers

Organizationof adequate social support

Regular review of suicide risk and arrangemenmts

Safe psychiatric treatment given in adequate dosage using less toxioc drugs

Small prescriptions

Invilovement of relatives in safe storage of tablt\ets

Arrangement for immediate access to extra help for pt and carers\

Suicide prevention=

Better and more accessable psychitruic services

Encouragement of responsible reporting

Educational programs

Improved care for high risk groups

Crises centres and telephone hotlines

Q = 30yr old female presents to er

She was recently prescribed sulfonamides for fever

429
She reports abdominal pain is restless and agitatyed

She claims that she is being followed by police

What are DDx

Ans=1=paranoid schyzoprenia

2=delusional disorder 3=organic disorder

Q what investigation you would request

Ans= abdominal ultrasounds and basse line investigation

Q what are treatment=ans treat underlying cause and already discussed in

previous pages

Q steps in assessment of and management of child sexual abuse

Ans=1=suspicion and recognition=refereal to child protection services

2=establish wether immediate protection is needed

3= plan investigation,interagency discussion,interview child, medical

exanmmination,family assessment

4= initial multiagency child protection meeting

5= draw up protection plan

6=plan implementation and review

7= prosecution

430
8 theraphy

Q =dissociative amnesia=def= significant episode in whch individual is

unable to recall important and often emotionally charged memories

Risk facters and etiology=psychological stress and mostly in women and

younger adults

Onset is usually detected retrospectively by discovery of memory gaps of

extremely variable duration

Symptoms-= amnesia may be general or sele tive for certain events

Course= amnesia may suddenly or gradual remit particularly when traumatic

circumstances resolves or may become chronic

Associated problems= mood disorder, conversion disorders, and personality

disorder

Treatment= diagnostic evaluation for general medical condition e.g head

trauma, seiziures and cerebrovascular disease or substanmces e.g anxiolytic
and hypnotic medication ,alcohol that may cause amnesia

Hypnoses,suggestion and relaxation techniques are useful

The pt should be removed from stressful situation when possible, psychotheraphy

should be directed at resolving underlying emotional stress

DDx= major rule out are amnestic diosorder due to general medical condition.,
substance induced amnestic disorder

431
And other dissociative disorder

Q Dissociative fugue=def= sudden unexpected trival accpompanied by inability

to remember ones past and by confusion about personal identity, or byu
assumption of a new identity

Risk facters=

Psychosocial stresses

Incidence= o.2%

Onset= usually sudden and often foloewing a stressful event

Course= most episodes are isolated and last from hour to months

Outcome= mood disorder

Ptsd and substance abuse disorder

Treatment = same as for dissociative amnesia

Differential diagnoses

Major rule out are complex partial seizures, other dissociative disorders and
factitious disordrers and malingering

Q Demographic factors
Gender and suicide

In the United States, males are four times more likely to die by suicide
than females, although more women than men report suicide attempts. Male

432
suicide rates are higher than females in all age groups (the ratio varies from 3:1
to
10:1). In other western countries, males are also much more likely to die by
suicide
than females (usually by a factor of 3–4:1). It was the 8th leading cause of death
for males, and 19th leading cause of death for females. Excess male mortality from
suicide is also evident from data from non-Western countries.

Attention Deficit Hyperactivity Disorder (ADHD)

Post-traumatic stress disorder (PTSD)
Personality disorders
Psychosis (anxiety or detachment from reality)
Paranoia
Schizophrenia
Q =do pt have right to kil themselves

Ans =no

Q prevention psychiatry

It is defined as preventing mental illness , promoting mental health, proper

disgnoses and treat ment oof mental illness and rehabilitate of pt to avoid disable
And recurrebnce of illness

Q list five causes of overactivity in child

Ans=1= ADHD 2= bipolar disorder

3=adrenoleukodystrophy

4= carbon monooxide poisoning

433
5= fragile x syndrome

6= central sleep apneas

7= phenylketonuria’

8= fetal alcohol syndrome

Q -=what is meant by daly and qaly

Quality-adjusted life year

The quality-adjusted life year or quality-adjusted life-year (QALY) is a generic

measure of disease burden, including both the quality and the quantity of life
lived.
It is used in assessing the value for money of a medical intervention. One QALY
equates to one year in perfect health. If an individual's health is below this
maximum, QALYs are accrued at a rate of less than 1 per year. To be dead is
associated with 0 QALYs, and in some circumstances it is possible to accrue
negative QALYs to reflect health states deemed 'worse than dead'.

Use

The QALY is often used in cost-utility analysis to calculate the ratio of cost to
QALYs saved for a particular health care intervention. This is then used to
allocate healthcare resources, with an intervention with a lower cost to QALY
saved (incremental cost effectiveness) ratio ("ICER") being preferred over an
intervention with a higher ratio.

434
In the United Kingdom, the National Institute for Health and Care Excellence,
which advises on the use of health technologies within the National Health Service,
has since at least 2013 used "£ per QALY" to evaluate their utility.

Q Diagnostic criteria for Encopresis

Repeated passage of feces into inappropriate places (e.g., clothing or floor)
whether involuntary or intentional.
At least one such event a month for at least 3 months.
Chronological age is at least 4 years (or equivalent developmental level).
D. The behavior is not due exclusively to the direct physiological effects of a
substance (e.g., laxatives) or a general medical condition except through a
mechanism involving constipation. Episodic dyscontrol syndrome

Q Episodic dyscontrol syndrome (EDS, or sometimes just dyscontrol), is a pattern

of abnormal, episodic, and frequently violent and uncontrollable social behavior in
the absence of significant provocation; it can result fromlimbic system diseases,
disorders of the temporal lobe, or abuse of alcohol
or
other psychoactive substances. EDS may affect children or adults.

Treatment

Treatment for EDS usually involves treating the underlying causative factor(s).
This may involve psychotherapy, substance abuse treatment, or medical treatment
for diseases.

EDS has been successfully controlled in clinical trials using prescribed

medications, including Carbamazepine, Ethosuximide, and Propranolol.

435
Q = summary of major differences between dsm iv and icd 10 in schzoprenia
ans= icd 10 places greater weight on shneder first rank symptoms .dsm iv
emphasizes course and functional impairment
icd 10 requires a duration of illness of one month whereas dsm iv requires
duration of 6month
schyzotypal disorder is included in icd 10 but is categorized vas personality
disorder in dsm iv
Icd 10 includes some additional types namely simple schyzoprenia and post
schyzoprenic depression
Disorganized schyzoprenia in dsm iv is called hebephrenic schyzoprenia in icd
Q =diagnostic criteria for schyzoprenia in icd 10 and dsm iv
The ICD-10 criteria are typically used in European countries, while the DSM-IV-
TR criteria are used in the United States and the rest of the world, and are
prevailing in research studies. The ICD-10 criteria put more emphasis on
Schneiderian first-rank symptoms. In practice, agreement between the two systems
is high. According to the revised fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR), to be diagnosed with schizophrenia,
three diagnostic criteria must be met: Characteristic symptoms: Two or more of the
following, each present for much of the time during a one-month period (or less, if
symptoms remitted with treatment).
Delusions
Hallucinations
Disorganized speech, which is a manifestation of formal thought disorder
Grossly disorganized behavior (e.g. dressing inappropriately, crying frequently)
or catatonic behavior

436
Negative symptoms: Blunted affect (lack or decline in emotional
response), alogia (lack or decline in speech), or avolition (lack or decline in
motivation)
If the delusions are judged to be bizarre, or hallucinations consist of hearing one
voice participating in a running commentary of the patient's actions or of hearing
two or more voices conversing with each other, only that symptom is required
above. The speech disorganization criterion is only met if it is severe enough to
substantially impair communication.
Social or occupational dysfunction: For a significant portion of the time since the
onset of the disturbance, one or more major areas of functioning such as work,
interpersonal relations, or self-care, are markedly below the level achieved prior
to
the onset.
Significant duration: Continuous signs of the disturbance persist for at least six
months. This six-month period must include at least one month of symptoms (or
less, if symptoms remitted with treatment).
If signs of disturbance are present for more than a month but less than six months,
the diagnosis of schizophreniform disorder is applied. Psychotic symptoms lasting
less than a month may be diagnosed as brief psychotic disorder, and various
conditions may be classed as psychotic disorder not otherwise specified.
Schizophrenia cannot be diagnosed if symptoms of mood disorder are substantially
present (although schizoaffective disorder could be diagnosed), or if symptoms
of pervasive developmental disorder are present unless prominent delusions or
hallucinations are also present, or if the symptoms are the direct physiological
result of a general medical condition or a substance, such as abuse of a drug or
medication.
Q = anorexia nervosa physical changes
Ans= already discussed

437
Q = a 38 yr old lady presents with history of palpitation, sweating , loss of
weight , fine tremors and heat into;lerance low mood ansd b nervousness , her
serum t3 t4 and incdecreased tsh level
Ans = DDx = hyperthyroidism
Atriial fibrillation and cardiac asthma
Most probable diagnoses is hyperthyroidism
Discussed management in this pt
Ans=1=beta blocker, propranonlol ,
2=radioactive iodine
3= mehemazolle
4= carbimazole
Q = enlist ten therapeutic facters ingroup theraphy
Ans = already discussed

Neuroimaging includes the use of various techniques to either directly or

indirectly image the structure, function/pharmacology of the nervous system. It is
a
relatively new discipline withinmedicine and neuroscience/psychology. Physicians
who specialize in the performance and interpretation of neuroimaging in the
clinical setting are neuroradiologists.

Neuroimaging falls into two broad categories:

Structural imaging, which deals with the structure of the nervous system and the
diagnosis of gross (large scale) intracranial disease (such as tumor), and injury,
and
Functional imaging, which is used to diagnose metabolic diseases and lesions on a
finer scale (such as Alzheimer's disease) and also for neurological and cognitive
psychology research and building brain-computer interfaces.

438
Functional imaging enables, for example, the processing of information by centers
in the brain to be visualized directly. Such processing causes the involved area of
the brain to increase metabolism and "light up" on the scan. One of the more
controversial uses of neuroimaging has been research into "thought identification"
or mind-reading.

Q Benefits and Disadvantages of MRI

Benefits of MRI:

MRI is non-invasive and does not use radiation

MRI does not involve radiation
MRI contrasting agent is less likely to produce an allergic reaction that may occur
when iodine-based substances are used for x-rays and CT scans
MRI gives extremely clear, detailed images of soft-tissue structures that other
imaging techniques cannot achieve
MRI can easily create hundreds of images from almost any direction and in any
orientation
Unlike techniques that examine small parts of the body (i.e. ultrasound or
mammography) MRI exams can cover large portions of the body
MRI can determine if a cancer has spread, and help determine the best treatment

Disadvantages of MRI:

MRI is expensive ($1000-$1500)

MRI will not be able to find all cancers (i.e. breast cancers indicated by
microcalcifications)
MRI cannot always distinguish between malignant tumors or benign disease (such
as breast fibroadenomas), which could lead to a false positive results

439
MRI is not painful, but the patient must remain still in an enclosed machine, which
may be a problem for claustrophobic patients
An undetected metal implant in a patient’s body may be affected by the strong
magnet of the MRI unit
There is a small chance that a patient could develop an allergic reaction to the
contrasting agent, or that a skin infection could develop at the site of injection
If a patient chooses to be sedated for the scanning, there is a slight risk
associated
with using the sedation medication
Q Autosomal recessive

Autosomal recessive is one of several ways that a trait, disorder, or disease can
be
passed down through families.

An autosomal recessive disorder means two copies of an abnormal gene must be

present in order for the disease or trait to develop.

Information

Inheriting a specific disease, condition, or trait depends on the type of

chromosome
that is affected (autosomal or sex chromosome). It also depends on whether the
trait is dominant or recessive.

A mutation in a gene on one of the first 22 nonsex chromosomes can lead to an

autosomal disorder.

Genes come in pairs. One gene in each pair comes from the mother, and the other
gene comes from the father. Recessive inheritance means both genes in a pair must
be abnormal to cause disease. People with only one defective gene in the pair are
called carriers. However, they can pass the abnormal gene to their children.

440
Q CHANCES OF INHERITING A TRAIT

If you are born to parents who carry the same autosomal recessive change
(mutation), you have a 1 in 4 chance of inheriting the abnormal gene from both
parents and developing the disease. You have a 50% (1 in 2) chance of inheriting
one abnormal gene. This would make you a carrier.

In other words, for a child born to a couple who both carry the gene (but do not
have signs of disease), the expected outcome for each pregnancy is:

A 25% chance that the child is born with two normal genes (normal)
A 50% chance that the child is born with one normal and one abnormal gene
(carrier, without disease)
A 25% chance that the child is born with two abnormal genes (at risk for the
disease)

Note: These outcomes do not mean that the children will definitely be carriers or
be severely affected.

Q =Enumerate common clinical conditions caused by autosomal rececive

transmission.

Ans: cystic fibroses, sickle cell anemia, tay sachk diseases

Q = write 3 conditions in which informed consent is not required

1emergency
2waiwer by patient
3pt is incompetent
4= therapeutic previlagerest of health( unconscious confused physician
deprives pt of autonomy in st of health
441
Consent can be oral. A signed
A signed paper the pt has not read or does not understand does not
constitute informed consent can be revoked at any ttime
Q u have to plan a trial of an antipsychotics what instrument u will
use to screen population
Answer
BPRS
Q senarios of pt on antipsychotics inj of zuclopenthixole 3days ago
brought to emergency in confusion ,febrile bp changes from ling to
standing position and febrile
Answer
NEUROLEPTIC MALIGNANT syndrome
Q in NMS what specific clinical sign you will look for on physical and
mental status examination
1=muscle stiffness(cog wheel rigidity)
2=hyperthermia
3= autonnom,instability
4-=delirium
Q Prognosis=
10% mortality rate and declining over several years
Dd/ include 1=encephalitis 2= heatstroke
Management =1=immediately discontinue drugs 2=symptomatic treatment
3=cold sponging
3=treat intercurrent infection
4=for muscle stiffness give dyzepam
5=malignant hypertention is treated by dantroline
6=bromocriptine
442
7=severly ill person are admitted in icu and intubated and deals with renal
failure
Q COMPLICATION OF NMS
1=secondory pneumonia
2=thromboembolism
3=cvs collapse
4=renal failure
Q =there is serious concern about long term use of benzodiazepines in older
person owing to adverse outcomes
However estimates of prevalence of benziodiazepines use in older people
remain high.
In light of recent advances\
Q =in above case enumerate adverse effects of benzodiazepines in elderly
and giove reasons
Q =what are evidence based intervention for bzd withdrawal in elderly
population according to recent advances
Ans= the withdrawal associatyed with bzd is chassracterized by several different
kind of symptoms
Apptrehension, anxiety and insomnia
Tremor, nauseas, increase sebnsirtivity to perceptual stimuli and perceptual
sdisturbances
Depression and suiociodal thinking
Epileptic seizures
These above symptoms resemble anxiety disorder , it some times can be difficult
wether pt is experiencing a bzd withdrawal or anxiety .
Perceptual disturbances are more likely to indicate bzd withdrwal.withdrwal
symptoms 3day and seven days afters after long acting bzd
443
Symptoms last from 3-10days
Withdrawal symptoms seem to be more frequenmt after taking those with long
acting ones
If bzd are taken for long time withdrawl should be done . it is better to withdraw
them gradually over a period of several weeks
If this is done withdrawal can be avoided oer minimized; bzd is quikly
effective
Q =there has been substantial uncertainity regarding incidence of ptsd in
children and adolescents exposed to trauma
A recent metaanalyses has evaluated this issue in detail
A=with reference to recent advances what is overall rate of ptsd in children and
adolescents exposed to trauma
Q prevention of relapse and recurrence= relapse refer to worsening of
symptoms after an initial improvement during treatment of a single episode of
mood disorder whereas recurrence refers to a new episode after a period of
complete recovery. Treatment to prevent relapse should be called continuation
treatment while treatment to prevent recurrence should be called prophylactic.
Q =22yr old female pt presented to psychtric opd with complain of weight
loss more than 20% And body mass index of 16.5. on her mental
examination it was revealed that she has fear of fatness therefore she avoids
food and show a behavior aimed to losing weight by purging,vomiting
,excessive exercise and use of apetite suppresents and diuretics , she also
complain of absence of menstruation for last few months
A =enlist ten specific question that you would ask for this pt for assessment of
eating disorder
Ans =assessment of eating disorder=
1=what is typical day eating?

444
To what degree pt attempting restraints?
2=is there a pattern ? does it vary?
Is easting ritualized?
3=does pt avoids typical foods?and if so why?
4=does she restricts fluids?
5=what is pt experience of hunger or if any urge to eat?
6=does she binges?
Are theses objectively large binge?
Does she feels out of control
7= are bing planned ?how do the begin?
How do they end?
How often do they occur?
8=does she makes herself vomit?
If so how ?
Does she vomit blood ?
Does she washes out with copius fluids afterwards
9= does she takes laxatives,diuretics ,emetics or appetite supppresents?if so with
what effect?
10=can she eat in front of others?
Does she exercise?is this to burn off calories? B b =considderi g above scenarios
what is your provisional diagnoses?
Ans=anorexia nervosa
Q =how you will manage this case?(eating disorder)
Ans=treatment=
Short term management-=to ensure weight gain and correct nutritional deficiencies
Long term treatment aimed at maintaining a normal weight achieved thru short
term management
445
Treatment modalities=
Includes behavioral therapies based on positive reinforcement sometimes
negative reinforcement
Individual psychotherapy
Hospitalization with adequate nursing care
Pharmacotheraphy with cpz,amt,clomipramnine ,and ceproheptadine(8-32yr)
Group therapy
Family therapy
Prognoses=
Is better in young age of onset
Less no of hospitalization
No bulimic episodes
Q =30 yr old man brought to psychiatric emergency, his pulse is 100per
min,bp =170/95mmhg
And he is profusely sweating, he is shaky And Has difficulty in giving his
history . he has had difficulty falling asleep two nights and see spiders
ewalking on wall, he has been a drinker for last 10yr but has hard no drink
for last three days
Q =what is most likely diagnoses ?in above senarios
Ans =delirium tremens
Q =name three psychometric scale that are used for alcohol dependence or
withdrawal?
Ans= lab test for alcohol dependence
1=gamma glutamyl transpeptidase
70% sensitivity and useful screening test
2=mcv raised in alcohol mostly women

446
3= carbohydratye deficient transferin =this is a variant of serum protein which
transport iron and is more specific than GGT.
4= blood alcohol concentration’
C = mention ten social hazards that can result from chronic alcohol abuse
Ans=1=accidents
2= criminality
3=marital disharmony
4=finantial difficulties
5=divorse
6= occupational problems
7= wernick encepahalopathy
8= korsakoff psychoses
9= alcoholic dementia
10= gastrointestinal side effects
Q = what possible strategy you could employ to treat sexual side effect in a
30yr old male receaving treatment with ssris?
Treatment=
Biological treatment=
A=pharmacotheraphy
Sildenafill , oral pentolamine , alprostadill transurethral n alprostadil
Anti anxiety agents
Bromiocriptine may improve sexiual function
Sexual function impauired by hyper prolactinemia
B hormonal theraphy
Androgens and antiestriogens
C= mechanical treatment apprioaches vaccum pump
D= surgical treatment like maale prostheses and dual sex theraphy
447
Aspecific techniques of exercise
A= squeeze techniques
B= stop and start techniques
C= hypnotheraphy
D= behavioural theraphy
E=group theraphy
F= analytical oriented sex theraphy
Q = a 34 yr old women who had been married for some time became
pregenant for first time. 4week after delivery she became seriously
aagitated .
In this state she drowned the child in bath tube and then slashed her wrist
A -=what is most likely differential diagnoses
Ans =1 -= post partum psychoses
2-=post partum depression
Q = how would you manage this case (post partum psychoses)
Ans =1= antidepressents
2=antipsychotics
3= mood stabilizerse
4= ect
C =what medicolegal issues are likely to be involved over here
Ans= suicide and homicides
Q = 30 yr old house wife being managed for bipolar disorder has been
stabled on lithium using lithium for past 3yrs,
She Hs presented to your clinic along with her husband to seek information
regarding risk of of continuing lithium use during pregnancy as she wishes
to conceave again

448
A=what informational care would you like to give to this pt keeping in view
the adverse effects of lithium use during pregenancy
Ans =lithium causes ebsten anomaly which is atrialization of ventricles right
sideof heart
We should explain pregnant women of risk and benefits of continuing lithium use
during pregnancy and effects of use of lithium include floppy baby syndrome,
with cyanoses and hypotonocity
Lithium salts enter milk freely and serum concentration can approach those of
mother so breast feeding require great caution
Q = what investigation you would like to carry out if pt decides to continue
use of lithium during pregnancy
Ans= we will do ultrasound during pregenancy Ans will fgive folic acid during
or before pregnancyand we will see if baby suffering then we will see both risk
and benefits and if baby suffer then then will have to stop lithium
We will discuss above risk and benefit and will asked from mother what we do and
will leave decision to parents
Some times baby is aborted if there is risk of abortion
Q = what alternative management plan would you suggest in light of above
current international guidelines
An= we will provide information abiout risk and benefits of continuing lithium
during lithium during pregnancy and pt should then decide what to do
Q = 23 yr bold female master in psycho;logy comes to your office with
history of repeated washing of hands and thought of contamination for past
3MONTHS
She had similar episode 2yr back which got better with ndeep breathing
and progressive relaxattiion for past 3monthas . she has been trying these
methods but condition has worsened . she is in distress and has stopped
449
pursuing her phd in clinical psychology for fear of contamination of her
clothesc and if she sits asome where else other that her own chair which
she washed 13 times daily
A= how would you respond to her queries regarding most likely diagnoses?
Ans= ocd
Q =nerobiological basess of her illness
Ans= etiology of illness
1= behaviuoral theory
Obsession=conditioned strimuli to anxiety
Compulsion=learned behaviuor
Which decrease anxiety associated with obsession , thisd decrease in anxiety
positively reinforces compulsive act and they become stable learned behavior
Biological theory=
Secondary to basal ganglia lesion
Altered serotonin level and noradrenaline level
Genetics = it can be transmitted genetically
Eeg= temporal lobe spikes and increased theta waves have been reported in
sleep EEG of OCD patients
Q =draw a algorism for treatment of her illness keeping in view the recent
guidelines
Ans= 1=psychotheraphy
Supportive psychotheraphy
2=behaviour theraphy
Thechniques used are thought stopping , response prevention, systematic
desensitization, modeling and time out
3=drugs= bzd to control anxiety
Antidepresents like ssri and flouxetine
450
TCA= clomipramine75-300mg
Antipsychotics like halorperiodol
4=ECT= in presence of severe depression with ocd ect may be needed, ect is
particularly indicated when there is a risk of suicide and when there is poor
response to other modes of treatment,. However ect is not treatment of first choice
in ocd
5=psychosurgery
Stereotactic limbic leucotomy
Stereotactic sub caudate leucotomy
Q =25 yr old convict on terrorism charges is brought to you for
assessment ,,. His lawyer has taken a plea that he is a psychiatric pt and
therefore should be pardoned . he has produced an eeg of pt when he was
12yr old showing abnormal slow wave in temporal leads
The convict is known to have skinned his victim , tortured them before
killing them and would cut their nose and store it in a bag as a souvenirs of
his victim . there is a history of his fall while one wheeling ion huis bike , five
year ago, when approached the convict has no remorse or feeling of guilt
about his action
Q =What is differential diagnoses and most likely diagnoses and most likely
diagnoses
Cvauses= of crimes
Criminal behaviour needs to be distinguished from rule breaking behavior
Q = 21yr old college student came to psychtry with her mother with
complain that she had awakened from sleep 2days earlier with total
numbness and paralyses in both legs
She said she was feeling ok but is incapable of caring for herself and had
summoned her mother from another city to come and take care of her
451
For past 2yr she had shared an appartement with her friend who moved
out on day preceding the onset of her symptom after a fight.On examination
pt was tense and in distyress
No neurological deficit was found
What is most likely diagnoses
And differentisal diagnoses
Ans =dd=1=cataplexy
2= hypnogogic hallucination
3= sleep paralyses
Q = A 25 yr old male is brought to hospital in account of 10 month history
of irrelevant talk , aggressive out bursts , suspecting his family members of
joining hands with teroruists to kidnap him , disturb sleep and decrease a
petitrev
For past 4 month he has confined himself to his room . he has been often
observed to be talking to himself and has lost his job as a technician in a
construction firm
A = give a list of differential diagnoses and most probable diagnoses
Ans= paranoid schizophrenia
Dd = 1= organic syndrome delirium , psychotic disorder
Organic delusional disorder
Are simply as delusional disorder
2= substance misuse
3= mood disorder with psychotic features
4--=delusional disorder
5=personality disorders

452
Management -PHARMACIOLOGICAL MANAGEMENT= of schyzoprenia
includes traditional antipsychotics and atypical antipsychotics because of there
better side effects profile the atypical agents are now first line of treatment
Long acting antipsychotics injectables
Depot form haloperidol decanuate of antipsychotics are useful option in pt
whose symptoms leads to non compliance with medication
Bzd may be added such as lorazepam in those with agitation
Psychological treatment= although medication are cornerstone of schyzoprenia
treatment once psychoses recedes psychosocial treatment are important
These may includes=
Social skill training=
This focuses on improving communication and social interaction
Family therapy=
Provides support and education to families dealing with schizophrenia
Vocational rehabilitation =and supported employment =
This focuses on helping pt with schyzoprenia find And keeps job
Individual theraphy=
Leading to cope with stress and identify early warning signs of relapse can help
people manage with there illness
Prognoses-=
Usually involves repeated psychotic episodes and a chronic downhill course over
years the illness often stabilizes in mid ;life
Suicide is common in pt with schyzoprenia . .More than 50% attempt suicide
ioften during post psychotic depression or when having
hallucination
commanding thwem to harm themselves and 10% of those die in attempt

453
Prognoses is better and suicide rate is lower iff pt is older at onset of illness
and
is married , has social relationship, is female, has a good emplotyment history and
has mood symptoms and has few negativ symptoms and has few relapses
Q = disorder associated with pathologic jealousy
1=Schyzoprenia
2-= Mood disorder
3= ORGANIC DISORDER
4= Alcohol misuse
5= Paranioid personality disorder
Q = 14 yr old boy is evaluatyed for excessive nioght time eating. Since early
child hood he awakenes every night around mid night and consumes large
quantity of food , even those he dislikes otherwise alarm .lock
and
punishment have not stopped this habit . he remembers his eating in
morning but has not regret during day he eats a small breakfast and a lunch
and dinner.
He had gained 40 ib in last year
Physical examination reveals an interactive boy who answer question
appropriately
His vital signs are normal. He has mild hypotoonia and weakness of legs
other than obesity all other physical signs are normal
A= what is differential dia gnoses and most likely diagnoses?
Ans=dd are major rule out are anorexia nervosa
. binge eating/purging, major depressive disorder with atypical features and
borderline personality disorder
Most likely diagnosesis Bulimia Nerviosa
B =what pertinent investigation would you request for
Ans= physical examination =Eviodence of purging

454
Diagnostic test=Evidence of laxative or diuretic abuse
Q =what are management steps in above case?(bulemia nervosa)
1= behavior theraphy
2= based on positive and negative reinforcements
3= individual psychotheraphy
4= drugs as adhjuntive theraphy=imipramine and FXD.
5=group theraphy
6= family theraphy
Q = 7yr old boy brought by his mother with complains by his class teacher
that he is very restless
He cannot sit at one place for long period and keep on roamuing in class and
disturbing other children and teacher, he doesnot seems to listen to teacher
and fails to folloew in struction or finish his school work . he wants to play
with others childrens but if they refuses as he cannot wait for his turn and
leaves play abruptly
He is not bothered about his safety and gets injured frequently
He talks excessively , interefere when elders are speaking And is frequently
beaten by his father because he does not learn and keeps on making same
mistakes repeatedlty
His mother gives history of normal birth and developmental milestones
with normal developments, she says THAT HE IS AN INTELLIGENT BOY ,
solcially interacts normally with sibs and show no stereotyped pattern of
interest or behavior
A= what is your diagnose according to icd 10
Ans= ADHD
Attention deficite hyperactivity disorder
B= name common comorbid condition known to exist with this disorder
455
Ans =DD= major rule outs are age appropriate behavior , responase to
environmental problems , mental retardation, autistic disorder, mood disorders
Treatment = target symptoms are defined before initiating treatment ,
psychological social , educational intervention, includes adding stru cture and
stability to home and school environment.specialized educational twechniques
includes use of multiple sensory modalities for teaching instruction that are
short and frequently repeated, immediate reinforcement for learning and
minimization of class room distraction
Pharmacotheraophy of choice is stimulant medication, especially methyl
phenydate (Ritalin) and other amphetamines
They are usually effective in decreasing hyperactivity , inattention, and
impulsivity , they should generally be given only on school days and not
automatically restarted following summer vacation
. other medication includes antidepresents and clonidine
Q =67 yr old male is brought to psychiatric opd with complaints of
insidioous onset of forgetfulness , visual hallucination, frequent falls and
variation in attention and alertness, on physical examination pt is found to
have fine tremors , rigidity and difficulty in initiating movements
A= what is your provisional diagnoses
And differential diagnoses
Ans = provisional diagnoses is parkinsonism
B = what specific data would you collect to substantiate your provisional
diagnoses?
Ans =1= tremor
2= rigidity
3= difficulty in initiating movements
C= name 5 investigation you would like to request in this case

456
Ans =1=EEG may show focal abnormalities
2= neuroimaging
3= neuropsychological testing
With specific abnormal findings
4= folstein mmse is used to detect amnesia
5=b12 and folate
6=cbc with sma
7=TFTs
Differential diagnoses=
There is no lab test for this disese, the diagnoses is made on clinical grounds
alone
Other condition that may cause slowing , rigidity and tremors should be rul out
before diagnoses of parkinsonism such as 1-== hypothyroidism
2= depression
3= drug induced parkinsonism
4-= multiinfarct dementia
5= alzeimer disease
6=shy dragger syndrome
7= essential benign familiar tremor
8=Wilson disease
9= Huntington diseasr
10= corticobasal degeneration
Q = how will you proceed with non pharmacological management
according to recent international guidelines?
Ans = management= treatmwent is directed toward restoring dopaminergic and
choluinergic balance in striatum by blocking effect of acetyl choline with
anticholinergic drug or by enhancing dopaminergic transmission
457
1= anticholinergic transmission for useful effect on tremor and rigidity but do not
help in hypokinesia
Benzexazol kemadrin(procyclidine)
2=amantadine potentiate release of endogenous dopamine
3= levodopa release dopamine in body
4=bromocriptine(dopamine agonist )
5=selegline
6=surgical treatment thalamotomy and pallidotomy
Q = 65yr old married retired dentist presents with complasining of feeling
low ,. He has experienced a series of professional difficulties over years
including a prosecution for fraud ulent billing. The mental state examination
shows depressed mood, however the pt has no vegetative signs and no
history of mental illness. He had difficulty finding physician office and
instead wander away
He had problem in recent memory and calculation and could not
rememberbv where his daudgter lived . he walks with an unsteady gait and
his families v noticed that he passed feces in clothes twice,
Ans = parkinsonism
Depressive illness?
Encoperesis?
Alzeimer disease?
B = what specific investigation would you request for to confirm your
diagnose and changes in these investigation?
Ans=1=EEG may show focal abnormalities
2= neuroimaging testing show ct and mri
3= neuropsychIatric testing show specific abnormal findings
4= basic lab test for dementia includes
458
B12 and folate
CBC WITH SMA AND THYROID FUNCTION TESTS\
Q = what is specific treatment for parkinsonism ?
Already discissesd
Q = 40 yr old man comes to emergency room with symptoms of
tachycardia ,diaphoreses, mydriases and hyperthermia
He also muscle twitching and clonus, his medication includes a protease
inhibiters and flouxetine 20mg daily which was started one week ago
Q =what is most likely diagnoses in above case
Ans= panic disorder
Q = what is most likely pathophysiology of this case?
ans =pathophysiology of panic disorder=
Already discussed previously
Q = essay on treatment adherence and compliance
Failure to follow health related advice some time termed as noncompliance I and
is wide spread and occur in upto 50%of chronic pt and involves pt taking
medication correctly or not at all , forgetting or refuses to make
essessntial
behaviuoral changes for there care and persisting in there behaviuor such as
smoking that jeopardize there health ,. Failure to adhere to advice is related to
pt
age , illness,illness chronicity, communication and various cognitive facters such
as ignorance of sideeefects of treatment and a failure to understand advice . non
compliance is frustrating for health workers,. It should not be underestimated
As a result of there failure to adhere to recommwended treatment pt might
become seriously ill and treatment resistant pathogens may develop.
Failing to recognize pt ,non adherence may prompt physician to adjust medication
dosages

459
Practitioner and pt becomes frustrated by nonadherence and time and mioney
spent on medical visits as wasted
Some of clues which should alert a physician that a pt might not be adhering to
treatment plan as following
1=indifference and lack of involvement
2=appearance of unquestioning obediance
3= deperessed pt
4-= lack of response to treatment
5= confusing clinical picture
Treatment adherence or lack of it is often on account of social reason
The view point is advice of neigbhour,a wise man or sometimes another pt is
often bases of path that a pt or family may take .
Essential elements required to improvwe a pt compluiance are summarized
below
1= accurate communication of information between pt and doctor
2= emotional support and understasnding of pt
3= awarenss of pt health belief model
4= help in choosing an acceptable course of action to which a commitment can
be ,made
5= focus on overall quality of life of pt
6= development of a specific plan to implement regimn
7= recognition of pt depression or hopelessness
Q = 19 yr old female brought to opd on account of persistent refusal to eat
adequetly for pasty one year she is on a diet plan as she think she is fat,
Her mother is worried because she looks very thin , has history of frequent
headache and episode of fainting,. Recently there has three proposals for
her marriage but were declined on account of her poor health.
460
On examination she is 5 feet and 7 inches tall and has a weight of 40 kg .
She has a low mood, occasional episode of weeping and feeling of
inadequacy , about herself.
Q what is most likely diagnoses
Ans = Anorexia nervosa
B=Q what metabolic and endoctriniological and heamatological abnormalities
would be present in this case
Ans= metabolic problem,s
1= hypercholesterolemia
2= raised serum carotene
3= hypophospatemia
4=dehydration
5= electrolyte disturbances
6= hypokalemia
Endocrinological abnormalities
1= low fsh ,lh and low estradiol
2=lowt3, low t4 and low tsh
3=increase plasma cortisol and dexamethasone non suppression
4=increase growth hormone
5=severe hypoglycemia
Hemamatological abnormalities
Moderate normocytic normochromic aneamia
Mild leucopenia with relative lympocytoses
thrombocytopenia
Q = what is management of anorexia nervosa in light of recent guidelines
Ans= mosty pt with anorexia nervosa should be managed on out pt bases with
psychological treatment and maintaining there physical condition
461
Psychological therapiers includes cogniotive analytical theraphy,
,CBT, ,
interpersonal theraphy and focal psychodynamixc theraphy and family
intervention focused explicitly on eating disorders
Out pt psychological treatment for anorexia nervosa should normally be of at
least 6 month duration . Failure to improve or deterioration should lead to more
intensive form of treatment e.g a move from individual theraphy to combine
individual and family work or day care or pt care
Dietry counseling should not be provided as sole treatment for anorexia nervosa
For in pt with anorexia nervosa it is important to monitor pt physical status
during refeeding. Psychological treatment should be provided which has focus
both on eating behavior and attitudes to body weuight and wider psychposocial
issues with expectation of weight gain
Treatment= short term management to ensure weight gain and correct nutritional
deficiencies
Long term treatment aimed at maintaining a normal weight achieved thru short
term management
Treatment modalities includes behavioural theraphy based on positive and
negatrive reinforcement
Individual psychiotheraphy
Hospitaluization with adequate nursing care
Pharmacotheraphy with CPZ, FXT, AMT, CLOMIPRAMNE AND
CIPROHEPTADINE(8-32 MG )
Group theraphy and family theraphy
Prognoses =is better in younger age of onset, less no of hoaspitalization, no
bulimic episodes
Q = 33yr olsd truck driver reported to hospital with history of fever, body
aches and weakness
462
Detailed history reveals that he had been using alcohol and canabios for
past 12yrs
He further discloases that he had been having frequent sexual contacts with
female commercial sex workers. He never used condoms while having sexual
intercourse and has been treated 4 times in past for yellowish discharge
from urethra
On investigation he is found to be hiv positive
A =what are psychological reaction that pt is likely to expperence after he
learnt about diagnoses?
Ans=psychological reaction includes=
1=anger 2=denial 3=dependence
4=depression
B =enumerate neuropsychological asequelae that you will warn him
against
Ans = neuropsyuchological sequelae of hiv
Both secondry to complication of immune supreession and as direct effect of
hiv on brain
Mild cognitive disorder are common
Hiv dementia COMPLEX
Hiv encephalopathy
In one third of pt subacute encephalitis
Progression to profound dementia from insidious onset of dementia
Neurological symptoms
Delusion may occur when there is an opportunistic infection or
cerebral
malignancy
C= Q what treatment option you would suggest to him
Ans= control of aids=

463
Four basic approaches=
1=prevention a=education=until a vaccine is found thwe only mean is health
education e.g avoiding indiscriminate sex and using condoms
B=blood and blood produxct safety= for screening of all blood born infection
C= inj safety
Create a consumer denmand for safe injection thru social marketing
ALSO IMPLEMENT A NATIONAL HEALTH CARE WASTE
MANAGEMENT SYSTEM .
D=youth= improve acess of youth to effective hiv aids control program
2= antiretroviral treatment= the antiviral chemotheraphy while not a cure
has proved to be useful in prolonging life
Drug used are
A= nucleioside analogues
Zidovudine
Stavudine
Lamivudine
B=protease Inhibiters
Saquinavir and ritonavir
C= non nucleoside reverese transcriptase inhibiters
Nevirapoine
Delavirdine
3= specific propyhylaxis
Propylaxes against pneumocystic carineee pneumonia with trimethoprim and
sulfamethoxazole
Propylaxes against myco tuberculoi is isoniazid 300mg daily for 9 month to 1yr
Kapose sarcoma may be treated with interferon, chemmotheraphy and radiation
Crryptococal meningitis may be controlled with fluconozole
464
Esophahgial candidiases or recurrent vaginal candidiasers can be treated with
fluconozol or keteoconazole
4=primary control program are not developed in isolatuion, integration into
country phc is therefore essential

Q = a couple in there early fouties married for past 15yr present to you in
clinic , the husband has recently developed inability to reach an errection
Q what diagnose come in to your mind
Ans =impotency or erectile dysfunction
B =enlist 4 test you would recommend for condition
Ans=1= physical examnination shold be performed directed especially to evidence
of diabtes mellitus , thyroid and adrenal disorder
Hair distributrion
Gynaecomastia
Bp and perioperal pulse
Reflexes and peripheral sensation
Genital examination for penis , testicle, and prostrate
Investigation
1=fbc and HBA1C
2=serum testosterone
3=serum prolactine level
4=androgens
Q enlist five treatment option for it
Ans=1=give advice, information and reassurance
2=treatment of underlying cause
3=psychological methods
Behavioral techniques and sex theraphy
465
4=drug treatment=PDE-5 inhibiters
Other physical treatment vacuum devises
5=sildenafil (vigra)
Intracorporeal injection
Q = mr x is a 28yr old male admitted in psychtry ward , he presents with
complain of eatring insects, wearing bangales, having stitched ski n of his
forarm , believing that this could strenrthen him . he occasionally wears
female dress , these complaints began 8yr back after he had a severe
accident while driving in which he remained unconsiuos for half day
There is no previous history of any psychiatric illness
Ans -=diagnioses is transvestism
Q how would you manage this case
Ans=1= individual psychotheraphy
2= behaviuoral techniques
3= aversive conditioning
4=ssri
5= anti androgens
Q = 27yr old female presented to you with features suggestive of ocd
A=what specific queries would you make in history as regards onset and
course of her illness
Ans =some key cognitive process in ocd
1=thought action fusion
Magical thinking for example the belief that if one thinks of harming other one
is likely to act on thoughts or might have done so in past
2=resposnsbility for prevailing harm to others
3= compulsion and safety seeking behaviuor
4= overestinmation of likelihiood that harm will occur
466
5= intolerance of uncertainty and ambiquity
6=need for control
Q = 35yr old mother of 3 female offspring presents with ghistory of feeling
of suffocation especially while in closed spaces, she gets an impending
feeling of death. During these episodes that last for upto 30min
She became an orphan at age of 4 and was raised as an adopted child by a
distant relatives
A= what is most likely diagnoses
Ans= Agoraphobia
B= identify risk facters in this pt that are likely to predispose her tom
develop psychiatric disorder
Ans= risk facters
1= classical conditioning theories=phobias are learnt thru association of negative
experience with situation
2=psychodynamic theoroies-=
Role of three specific defence mevchanism in phobia
A=displacement
B =projection
C=neutral object choosen
Unconsiuos is one which can be easily avoided
3=biological theories
Role of amygdale
Role of dopaminergic, gabergic and serotonergic dysfunction may cause phobia
Q =what is freud explanation of such a presentation
Ans = Freud case of little han is model for psychoanalytical understanding of
phobias

467
Freud conceptualise little han fear of horse as resulting from unconscious oepidal
fear. little hans denied these fears and projected them into horses
Symptoms of phobia are thought to be related to unresolved unconsiuos conflicts
Q = 35 yr old man rought by his 30yr old wife following difficultues in
relationship in there marriage presents to psychiatric
On persuation of there parents the wife narrates that she finds her husband
stubborn and insensitive with a fragile ego. He always tries to find out some
hidden meaning in a routine conservation.
She says that she is now seriously thinking about diverse As her husband is
a very difficult person . present mental status examination of husband does
not revea;led any hallucination and delusion
Q what is most likely diagnoses and list dd in this case
Ans= pathological jealousy
Previously describes
Q = give neurodevelopmental hypotheses of schyzoprenia and what are
findings in support of this hypothyese
Ans = neural pathology
Anatomy=
A=abnormality of frontal lobe as evidenced by decrease use of glucoise in
frontal lobe on pet scan seen in pt of schyzoprenia
b-= lateral and third ventricle enlargement
abnormal cerebral symmetry and changes in brain density
c= decrease volume of limbic system like amygdale and hypocampous
2= neuriotransmitter abnormalities
A= dopamine hypothese=
Increase dopamine →positive symptoms
Amphetamine produces increase dopamine and leads to psychotic symptoms
468
Also increase dopamine leads to increase homovanaLIC ACID
Decrease dopamine in frontal lobe produices negative symptoms
B = serotonine hyperactivity
Hallucinogens produces increase serotomiine and leads to psychotic symptoms
Clozapine is antiserotonergic and decrease both posirtive and negative symptoms
C= glutamate
NMDA antagonist memantine treats neuro degenerative symptoms in
schyzoprenia
Q FINDINGS that support neurodevelopmental hypotheses of schyzoprenia
1=structural brain differences present at or before illness onset
2= limited progression of structural brain changes after onset
3= cognitive and social impairment in chioldhood
4= neuropathological changes without glioses
5= soft neurological signs at presentation
6= minor physical anomalies and aberrant dermatoglypics
7= pre and perinatal risk facters
8= increase frequency of large cavum septum pellucidem
9=schyzoprenia risk genes affect neurodevelopment
10=animal models show delayed effects of early brain lesion
Q provide data to mother of pt wearing opposite sex dress and wants to live
like opposite sex
Ans=diagnoses is transvestic fetchism
It ranges from occasionally wearing of a few articles of opposite sex to complete
cross dressing
It is rare among women and description below applies to men
Prevalence is one percent
And onset occurs usually around time of puberty
469
Pt generally experiences sexual arousal when cross dressing and behavuior often
termintes woith masturbation.
With aging sexual arousal may diminish so that person dresses mainly in order
to feel femin. Sometimes clothes are worn in public either underneath male outer
garments
Their gender conform with their external sexual characteristics
Most are heterosexual and may have sexual partner who may or may not know
about behavior
There have been no reliable follow up studies evaluasted treatments
Q = a mother of 15yr old boy bring her son to you with complains are 1=lack
of siocial skills
2=dislikes for changes in routine
3= speaks in a monotonous tone and excessively
4=few interests
A= what is most likely diagnoses and differential diagnoses
Ans= Autistic disorder
Dd=1= Mental retardartion
2= Hearing impairment
3=Environmental deprivation
4=Selective mutism
5=Ret syndrome 6= Asperger syndrome
Q =what are psychological and social intervention and drugs that have
role in treatment of this disorder(autism )
Ans= management has three main aspects
1-=management of abnormal behavior
2=education
3= social services
470
4 help for family
Management of abnormal behavior=
Contingency management may control abnormal behavior of autistic child
Education and social services=
Most autistic children require special schooling
It is generally thought better for them to live at home and to attend special day
schools
Help for family=other suggested treatment
Individual theraphy has been used in hopes of effecting more bb fundamental
changes
Antipsychotic drugs respiridone
There is currently no cure for autism
However research shows that early intervention treatment
Treatment can greatly improve a child development,. early intervention services
help children from birth to 3yr old learn important skills. Services can include
theraphy to help child talk ,walk and interact with others.
Therefore it is important to talk to your child doctor as soon as possible, if you
think your child has an autism or other developmental problem
Even if your child has not been diagnosed with autism he or she may be eligible
for early intervention treatment services, the individual with disabilities
education act(IDEA) say that children under 3yr age who are at risk of having
developmental delay may be eligible for services
These services are provided thru early in tervention system in your state.
Thru this system you can ask for an evaluation
In addition treatment for particular symptom such as speech theraphy for language
delay often does not need to wait for a formal autism diagnoses

471
Q = 70yr old female brought to opd by her relatives with complain of
forgetfulness which is more for a recent events
She has difficulty in finding words and naming objects
On her mri brain there is hypocampaL atrophy and ventricular enlargement
A= what is most likely diagnoses
Ans= Alzeimer dementia
Q = what Are enviromental isssues that can lead to this disease
Ans = Enviriomental issues=
1=low education attainment
2-=previous headinjury
3=Cerebro vascular diseas
4= history of depression
5--= high homocystein level
6= diabetes mellitus
7= obesity 8= herpes simplex virus
Q = what is natural course of dioseae in alzeimer dementia
Ans= stages of dementia=
Early stage(2-4yr)
Forgetfulllness
Decrease interest in enviroment
Poor performanceat work
Middle stage(2-12yr)
Progressive memory loss
Hesitancy in response to question
Has difficulty in following simple instruxction
Irritable , anxious wandering , neglect personal hygieine ansd social isolation
Final stage(upto 12 yr)

472
Marked loss of weight, unable to communicate does not recogniose family
Loss the ability to stand and walk
Death is usually caused by aspiratuion pneumonia
Q = 25yr old male had a road traffic accident 2 week ago, he had a direct
blow on his head in frontal region, he is now reffered to psychiatry out pt
clinic for a ssessment
A = list specific question that should be asked from rescue team member
who had brought the pt to hospital ?
B =what clinical sign would you elicit
C=what are long term psychiatric sequelae that you expect in this pt with
head injury.
Ans= psychiatric usually see 2 main group of pt suffered from head injury
1= smaller group with serious cognitive and behavioural sequelae
2=larger group with emotional and personality changes
Severety of closed head injury is assessed by duration of post traumatic amnesia
= interval between injury and return to nornmal day to day memory
A period of less of post traumatic amnesia(pta) of less than week is associated
with a good outcome and return to work
A PTA of more than one month results in failure to return to work
Retrograde amnesia which is loss of memory of events prior to injury
Retrograde amnesia is much less predictive of outcme
Mri is useful for defining extent of injury to brain,CT for intracranial bleeding
,and plain xray skull for fractures.
Vast majority of closed head in jury Are due to acceleration and deceleration
forces
Loss of consiuosness for few seconds may be due to disruption of cholinergic
transnmission in brain stem
473
With severe injury damage may occur to white matter a nd axonal injury
Both of above leads to coma duration
Other complication includes 1= 1=extradural 2=subdural haemorage and anoxia
Deposition of b amyloid show link between head injury and later development
of alzeimer dementia
Also apolipoprotein E4 in brain increases risk of death or cognitive effects after
head injury
ACUTE PSYCHOLOGICAL EFFECTS=
Severe head injury leads to delirium and delirium may follow awakening from
coma plus transient confabbulatry state
Plus delusional misidentification and agitation and sexual disinhibition
CHRONIC PSYCHOLOGICAL EFEECTS=
Primary and secondary damage in head injury leads to head injury then pt
condition deteriorates → brain swelling and increase Intracranial pressure damage
determine the neurological and cognitive decline
Long term outcome is also affected by premorbid personality traits
In severe cases post traumatic epilepsy plus seizure chances also increased
POST CONCUSSION SYNDROME= head injury →post concessional
syndriome
Symptomas are anxity , depression , headache , dizziness , poor concenmtrastion
and insomnia
LASTING COGNITIVE IMPAIRMENT
Injury to frontal and temporal lobe leads to →neurological defecits , memory
loss, executive function affected
PERSONALITY CHANGES= especial;lly after frontal lobe damage →
irritability , apathy, disinhibition and impulse discrimination
DEPRESSION AND EMOTIONAL DISORDERS=
474
And anxiety in 25%pt
PSYCHOSES-=
Transient psychiatic symptomas are common In delusion after head injury
Q BOXING AND HEAD INJURY=Robert in 1970 drew attention to
tendency for professional boxers to develop a chronic traumatic
encephalopathy called punch drunk syndrome
The principle early features are executive function
Bradyphrenia
Dysarthria
Incoordination
Followed by parkinsonism , spasticity and ataxia
LATER motor , cognitive and behaviuoral manifestation may be seen
Neuropathology= loss of neurion in cortex , substantia nigra and cerebellum
together with Neurofibrilory tangles And amyloid plaques
TREATMENT= early assessment of extent of neurological signs
→ provides a usefull guides to long term physical disability
Neuropsychiatric symptoms should be assessed psychologist contribute to
behavioral and cognitive techniques
Support for family and carers needed medication is often used to treat aggression,
depression, apathy, psychoses, and start with a low dose drugs and choose a
drug with low potential for seizure generation and less anticholenergic
or
extrapyramidal side effects
Most impriovement seen in first year after head injury . late deterioration shall
raise suspicion of subdural haemorahge, hydrocephalus and epilepsy and
depression
Q B = 52 yr old man reffered to you by casuality medical officer because of
fits associated with impaired consciousness

475
He is already a diagnosed case of schyzoprenia. Detail of current treatment
not imediately available
(A). Enumerate possible differential diagnoses to explain cauase of fits in
this case
Ans=1= TIA
2 =pseudioseizures
3=syncope
4= cardiac arrytrhmias
(B). What specific information will you look for in this case
Ans= Diagnosing epilepsy= take a detail history from pt
Interview an eye witness who has observed an attack
Specific questions=
Events leading upto attack includes sleep deprivation, drugs and alcohol
Time of day or night= symptoms of aura and duration. Abnormal movements limb
stiffening, jerking and automatism salivation, cyanoses, tongue biting, urinary
incontinence
Post ictal symptoms
Limb pain
Headache and drowsiness
Q MANAGEMENT OF EPILEPSY=
IMMEDIATE CARE OF SEIZURE=
Move pt away from fire, water and machinery
After convulsion ceases turn pt into semiprone position, ensure that airway is
clear
If convulsion continue for more than five minutres call for medical help to try to
prevent tongue bite is unnecessary because tongue bite cannot be prevented
because it starts at initial stage of epilepsy and cannot be prevented
476
To offset cerebral hypoxia give oxygen at high concentration and pass airway if
possible
GENERAL MEASURES = 1=restriction a=cycling and sswimming should not be
allowed for at least six months freedom from seizure has been achieved
B= drug should be restricted until pt is free from seizure for 2yrs
2= anticonvulsant drug theraphy
Single seizure is an indication for investigation while two seizure is an
indication for starting treatment
For partial seizure we give carbamazepine. Valproic acid and phenytoin bzd and
barbiturates
Q = what is drug abuser= the term abuse in DSM IV and harmfull use in icd
10 refered to maladaptive pattern of substance use that impair health in a
broad sense
Substance abuse= characterized by substance abuse that leads to loss of
control of substance use monopolization of time by substance use
The individual spends majority of his time in obtaining and using drugs ,
recovering from drug use and discssing drugs
Presence of adverse medical, social , emotional consequences from
substance use invvcluding tolerance and withdrawal
Q = 5 prescription of drugs that have a high potential for physical
deperndance
Ans=1-= amphetamines 2= cocain
3=bzd
4;’barbiturates
5=methadone
Q - =what is emotional interviewing?
Ans=1= express empathy
477
2=avoid arguing and donot be judgemental
3=detect and role with resistance
4point out discrepancies in pt history
5=raise awarenerss about contrast between substance user aim and behaviuor\
Q =how will you assess a recently married 40yr iold pt who has presented with
history of erectile dysfunction
Ans= assessment of sexual dysfunction
Define the problem (ask both parteners)
Origin and course
Prior baseline sexual function
Sexual drives
Knowledge And fears
Sociaal relationship generally
Relationship between partners
Any psychiatric disorder
Substance misuse
Medical illness, medical or surgical treatment
Why seek help now
Physical exanmination
Lab tests
B Q what psychological facters play a role in causing sexual dysfunction?
ANS = SOME PSYCHOLOGICAL DRUGS THAT MAY IMPAIR SEXUAL
DYSFUNCTION
Therapeutic agents such as anti hypertensive such as diuretics , spironolactens,
alpha and beta blockers
ANTI DEPRESENTS= TCA, MAO AND SSRI
Mood stabilizers=lithium
478
Anxiolytics and hypnotics=bzd
Antipsychotic agents
Hormonal agents=
Anabolic disorder and corticosteroids and oestrogens
Misused substance =
Alcohol , marijuana, and cocaine
SPECIFIC PSYCHOLOGICAL CAUSES INCLUDES
1= CURRENT RELATIONSHIP PROBLEMS
2=STRESS
3= DEPRESSION
4= ANXIETY GUILT AND PERFORMANCE PRESSURE
In men with erectile disorder he presence of morning errection , errection during
masturbation or errection during REM sleep suggest a psychological rather than
physical causes
C= what psychological intervention would you offer to him?
Q Enlist steps involved in this treatment?
Ans= behavioural management techniques= in sensate focus exercises used to
manage sexual desire , arousal and orgasmic disorder
The individual awwreness of touch , sight , smell and sound stimuli are increased
during sexual activity and psychological pressure to achieve an errection
b-= in squeeze techniques which is used to manage premature ejaculation
the man is taught to identify sensation that occur before emission of semen
at this moment the man asked his partner to exert pressure on coronal ridge of
glans rigde of glans on both sides of penis until errectioon subsides thereby
delaying errection
c=relaxation techniques
hypnoses
479
systematic desensitization are used to treat anxiety associated with sexual
performance
d= masturbaton=
may be recommended to help the person unlearn . what stimli are most effective
for achiving arousal and orgasm
Q = assessment of sleep disturbance
ans = screening question
do you sleep well enough and long enough ? are you sleepy during during
day ? is your sleep disturbed at night?
Sleep history= detailed history of sleep complains patern of occurrence ,
facters that improve or worsen sleep. Consequently for mood every day life
and family
Past and present treatment
Typical 24hr sleep walk schedule
Sleep diary =
Systematic 2weeks or longer record
History from bed partner
Investigation= videao recording
Wrist scintigraphy
(maintaining body movements)
Polysomnography (eeg and emg)
Hla typing
Csf hypocretin (orexin level)
Q PRINCIPLES OF SLEEP EDUCATION
SLEEP HYGIENE
SLEEP ENVIROMENT
Familiar and comfortable
480
Dark
Quiet
Encourage
Bed time routines
Consistent time for going bed and walking up. Going to bed only when tired
Thinking about problems before going bed
Regular exercise
AVOID=overexitment before going bed
Late event exercise
Caffeine containing drinks late in day
Excessive alcohol and smoking
Excessive day time sleep
Large late meals
Too much time in bed lying awake
Q == how would assess pt for alcoholism
Ans=DIAGNOSTIC TESTS FOR ALCOHOLISM
CAGE= affirmative answer to any two of following question or to last
question alone
Are suggestive of alcoholl abuse
C=have you ever felt that you should cut down on your dressiong?
A= have you ever felt annoyed by other by other who have criticized
drinking?
G= have you ever felt guilty about your drinking?e
E= have you ever had a morning drink (eye opener ) to steady your nerves
or alleviate a hang over)
Q = michuigan alcohol screening test=
Common question are used to detect alcohol abuse.
481
In addition to a general physical examination the clinician should look for sign of
poor hygiene
Poor nutrition
Cough
Physical signs of drug use including burn , needle marks or skin infection
Evidence of self inflicted injuries or accident
Substance intoxication
Substance withdrwal
Laboratory toxicology= breath , blood , and urine drug screen
Laboratory detection of alcohol abuse
SGPT, SGOT, SGPT,SGGT , LDH
Intravenous drug abuse workshop= hiv , hepatitris b and hepatitis c and
tuberculoases
Q = how manage alcohol abuse?
Ans=1= prevention programs= teach adolescence
How to resist social pressure to use drugs a nd to enhance other social and
personal skill
2=detoxification= substance specific but generally involves calming support ,
reassurance, occasional adjunctive pharmacological and diasgnoses and
treatment of medical complication
3-=drug rehabilitation=
Cessation of drug use and development of new coping skill that makes relapse
less likely
4=self help group
e.g = 12 step program of alcoholic aanonymous have been most effective
treatment available for many adults substance abuser both for rehabilitation and
relapse prevention.
482
5= disulfram = an aldehyde dehydrogenase inhibiter that causes an unplaeasant
reactiionwhen alcohol is ingested
6= nalterexone= an opoid antagoniast that blocks the pleasurable effects of opids
and alcohol
7= methadione and long acting l alpha acetyl methadol= opoids agonist that
decreases chances of recurrence of severe heroin dependence
Q = 21 yr old lady with diagnoses of schyzoprenia inform you that she will
kill her neibour tomorrow as she has ruined her life
She tell you not discloser this thing to any one
A=Q what are ethical issues in this case
Ans= ETHICAL AND LEGAAL ISSUES=
DOMESTIC VOILANCE=
Confidentiality is especially important
Carefull records are essential including documentation of injuries]
Written consent should be oobtained for photographs
Specialist advice should be sought about providing practical and other help to
those who wish to end relations
Where risk of serious voilance is believed to be very high and disclosure to
police and other authorties and other individual in order to provide protection
needs to be carefully planned maximum collaboration with victim
Q =what will be your response in above case?
Ans=inform police and confidentioality should be broken plus collaboration with
victims
Q= what are key recommendation in pharmacological treatment of
schyzoprenia=
Acute episode=initite antipsychotics medication at lower end of lisences dose
range
483
Donot use loading doses
If sedation needed use benzodiazepine
The choice of drug should be based on pt prefence, effects of previous treatment,
relative liability of drug to cause serious side effects especially extrapyramidal
and metabolic syndrome and relevant medical history
Titrate dose within licensed range , monitoring for side effects and effects
Aim to achieve optimum dose with good adherence for 4weeks
Record the indication for medication, anticipated benefits and time course and
discussion with pt and carers
MAINTENANCE AND RELAPSE PREVENTION-=
Continue medication using principles as for acute episodes
Ensure the dose duration and adherence are adequate before switchuing drugs
Drug withdrawal should be gradual and,mental state should be monitored
Continue treatment is more effectivwe than intermittent treatment
Monitor adherence regularly
Consider depot formulation especially if adherence is a problem
Q = a 14 yr old girl was refered to you by physician because of physical
and mental exhaustion following relentless pursuits to lose 15kg weight
over a month period
A= eniumerate expected hormonal, cardiovascular aand biochenmical
abnormalities in this case
Ans= Hormonal abniormalities=decrease LH, decreseFSH, decrease oestradiol,
decrease t3 And t4 and normal tsh
Increase cortisol, dexamethasone nonsuprression
Increase growth hormone concentratiin
Severe hypoglycemia
CARDIVASCULAR ABNORMALITIES=
484
Eeg abnormalitieres, conduction defects such as prolongation of QT interval
BIOCHEMICAL ABNORMALITIES=
Hyper cholestrolemnia, raised serum carotene
And hypophosphatemia, dehydration
Electrolyte disturbance and possible hypokalemia
B= what specific question will you ask in mental state exanmination
Ans== assessment of psychological issues
= what does pt feel about her body and weight?
If she is restraing her eating what is her motivatyion?
Does she feel fat?
Does she dislike her body?
What does she feel would happen if she dis not control her weight or her
eating?
Does she fear loss of control?
Is she able to say what she means by this?
Does she feel guilt or self disguised?
If so what leads her to feel this?
Does anything about this disorder lead her to feel goot ?
If she binges what are her feeling before, during and after binging?
What has she told other about her eating disorder if any thing?
How does she think a bout her disorder?
What does she make it ?
Q= what are DD?
ANS= medical illness such as 1=hypopituitrism
2=TB
3= depressive episodes

485
Q = enumerate six clinical condition that you would consider in differential
diagnoses
Ans=1-= generalize anxeity disorder
2=panic disorder
3=phobic disorder
4 deprssive illness
5= schyzoprenia’6= organic disorder
Chronic cases of encephalitis lethargic
Treatment==1=psychotheraphy
Supportive psychotheraphy
2= behaviour theraphy
Techniques used are thought stopping techniques, response prevention,
systematiuc desensitization, modeling, time out
3= drugs= bzd to control anxiety
Antidepresent such as ssri and flouxetine
TCA= clomipramine 75-300mg
Antipsychotics like haloperiodol
4-=ECT in presence of severe depression with OCD , ect may be needed
Ect is particularly indicated in when there is risk of suicide or when therr is
poor
response to other modes of treatment,
However ect is not treatment of first choice in ocd
5= psychosurgery stereolimbic leucotomy
Stereotactic subcaudate leucotomy
Q anxiety disorder= syndrome with psychologic and physiologic
components
Psychologic components include worry that is difficult to
control,restlessness, And Sleep disturbances

486
Physiologic components include autonomic hyperactivity and motor tension
Risk factors= behavioural theraphy states that anxiety is a conditioned
response to environmental stimuli originally pared with fear situation
Biological theories suggest role of neurotransmitter llike gaba,NE. AND
serotonin
And also role of limbic and reticular activating system
Q panic disorder=
Recurrent panic attacks are present ‘.panic attack are attack of severe anxiety
that often includes physical symptoms like tachycardia ,hyperventilation
and sweating
Etiogy=1 separation during childhood 2= interpersonal loss in adult
3= genetic components
4= in response to panicogens like youhombin and caffreine
Presenting symptom =
Prevalence= 2% of population
Onset= 3rd decade
Course= waxing and wanning of anxiety symptom
Associated symptoms
Agoraphobia and depression
Tx ssri like v flouxetine alprazolam
Clonazepam
Imipramine
Maoi
Relaxation training
Systematic desensitization for agoraphobia
Q MOOD DISORDER

487
IN this emotion that individual cannot control causes serious distress and
occupational and social trouble or both.
Major categories
1=major depressive disorder = recurrent episode of depressed mood each
episode lasting at least 2weeks
2=bipolar disorder
Bipolar 1= episode of both mania and depression
Bipolar 2= episode of both hypomania and depression
Q Epidemiology of mood disorders
Life time prevalence
2time more common in women thhan men
Biological factorss
Neurotransmitter activity is altered
Abnornmalities of both limbic hypothalmic pituitary adrenal axis
Abnormal dexamethasonme suppression test
Immne system function abnormaly
Sleep patern are abnormal
Psychosocial factors=
Loss of parent
Loss of sspouse
Learned helplessness
Psychosocial factors are not involved in etiology of mania and hypomania
Q clinical sign and symptoms of depression
SAGS
S=SADNES
A=ANHEDONIA
D= guilt=feeling of fault
488
S= suicidality serious thought of killing himself
Q masked depression= some pt denies depression even symptioms are
present.some time along with depression psychotic features may be present
Q leaden paralyses
Atypical depression feels that one arm, and legs are as heavy as lead
Q ATYPICAL DEPRESSION
=OVERSLEEPING
OVEREATING
LEADEN PARALYSES
SEASONAL AFFECTIVE DISORDER=SUBTYPE OF MDD associated
with short day light in winter
Tx increase of light exposure using artificial lighting
Q personality disorder
Longstanding rigid unsuitable pattern of relating to other and thus causes
social and occupational problems
Q CLASIFICATION =OF TO DSM PD
ACCORDING TO DSM 4 INTO A ,b and c
Each with specific characters and familial association
Tx=pt with PD ARE USUALLY ARE not aware of their problem and do not
seek psychiatric help ‘those who seek help individual group
psychotheraphy

Q obesity= is defined as being more than 20% over ideal weight or

having a body mass index of 30 or higher
Obesity is not an eating disorder
Tx= commerciall diet
Weight loss program
489
Surgical techniques
Q CLASSIFICATION OF CHILDHOOD NEURO PSYCHTRIC
DISORDER
1=PERVASIVER DEVELOPMENTAL DISORDER
2= ADHD
3=TOURETT
4=SEPARATION NXIETY
Q acute stress disorder= and post traumatic stress disoreder
Characterized by severe anxiety symptoms and feeling fear and helplessness
.when anxiety last for less than one month and greater than 2 days ,sign and
symptom occur within 1month of stresser
Acute stress disorder
When anxety last for more than one month it is post traumatic stress disorder
Etiology=Traumatic event precipitates ASD and PTSD
Presenting symptoms= may occur at any age
About 50% pt resolve within 3months
Symptoms= three key symptoms group
1-= re-experience of traumatic event
2=avoidsance of stimuli associated with trauma
3= increase arousal
Anxety sleep disorder and impulsivity is cmmon
Surviover group= feeling of guilt about an event sometimes occur
Tx
Counselling after stressful event may prevent ptsd from developing
Group psychotheraphy with other surviver
Ssri antagonist
Bzd
490
Q generalized anxety disorder=extremely poorly controlled about life
circumstances that contine for more than 6months
.both psychological and physiological symptioms present
Etioology=genetic predisposition
Presenting symptoms 5% of population
Onset = childhood
Course= chronic symptoms worsen with stress
Assiociated symptoms
Depression and somatic symptoms
Tx=behavioural psychotheraphy
Relaxation techniques
Biofeed bback
Ssri
Venlafaxine
Buspirone
Bzd
Q somatoform disorder
Group of disorder characterized by presence of physical symptoms with no
medical explanation
There are several factors to interfere with pt ability to function in social or
occupational activities
Q somatization disorder Multiple system affecting multiple organs
Q primary gain in cv=Keep internal conflicts outside pt awareness
Q Secondry gain=benefits received from being sick
Q Labella indifference= pt seems unconcerned about impairment
Q Identification =py usually model there behavior on some one who is
important to them

491
Psychotheraphy to establish caring relationship in threat and
amobarbital interview may be helpful to obtain more information
DDx nerologic= dementia and tumer
Psychiatric=schyzoprenia, depression and malignancies
Q hypochondrises
Pt belief thaty he has some specific disease despite constant resassurance
pt belief remaine same
Tx psychotharaphy and numerous visits to doctor
Q body dismorpic disorder
Pt belief that some body part is abnormal and defective
Etiology=women more than man
Unmarruied women
Assossiated disorder include depression and anxiety
Family history
Serotonergic system involves
Physical and psychiatric symptoms present
Most common concern about facial flaws
Constant miror checking
Attempt to hide alleged deformity
House bound
Avoid social situation
Causes impairment in level of functioning
Tx=individual psycotheraphy
Ssri tca and maoi
ddx of body dismorpic syndrome
Medical-= brain damage
Psychiatric=anorexia nervisa
492
Pd, OCD
Schyzioprenia and deluisional disorder
Q pain disorder= presence of pt pain is main complaints
Women more than men
Secondory gain may be seen in many pt
Physical and psychiatric presenting
Pain in one or more anatomic site and causes distress to pt
Psychological features are usually present
Symptom not faked
Must hav long medical and surgery
.more than half pt have depression and dysthymia
Tx =Should discuss probably psychologic origin of pain with pt early
treatment
Ssri biofeed back
Hyppnoses
Nerve block
Individual psychpotheraphy
Ddx
Medical=muscle contractile headache
Psychiatric = other somatoform disorder
Q SEIZURE AND EPILEPSY
Seizure is an abnormal excessive electrical activity in cerebral neurons which
may manifest as sensory, motor or psychomotor experiences.
Epilepsy is a tendency to have recurrent seizure due to chronic underlying
process Single seizure is an indication for investigation to identify cause
while second seizure is an indication for treatment

493
Etiology =several causes and usually related to age of patient. 70%pt have
their first seizure before age of 20.
Epilepsy may be primary due to genetic predisposition and secondary due to
known metabolic or structural disease of brain
Primary epilepsy is usually idiopathic primary epilepsy usually begin
between age of 5-20yr and no cause can be found,
Q Secondary epilepsy:
Causes are following
GENETICS=congenital abnormalities and perinatal abnormalities
METABOLIC DISORDERS=
Hypoglycemia, hyperglycemia, hepatic failure and renal failure
HEAD INJURY AND BIRTH INJURY
Tumors and other space occupying lesions
VASCULAR LESIONS
Stroke and A V malformation
INFECTIUOS DISEASES LIKE MENINGITIS AND ENCEPHALITIS
INFLAMATORY DISEASES LIKE SLE
DRUGS LIKE penicillin, Antidepressants and antipsychotics, lithium and
metronidazole and quinolones
WITHDRAWAL OF ALCOHOL, BENZODIAZEPINES and
BARBITURATES
Q CLASSIFICATION OF SEIZURES=
SEIZURES are broadly classified into two groups.
Partial or focal seizures=
There is focus of abnormal activity in one cerebral hemisphere
Q GENERALIZED SEIZURE=

494
THOSE involving diffuse regions of both cerebral hemisphere both
simultaneously and synchronously
As a rule partial seizure are typically associated with structural abnormalities
of brain such as tumours, av malformation
In contrast generalized seizure result from cellular, biochemical or structural
lesion that have more diffuse distribution
1=partial seizures=simple partial seizure in which no impairment of
consciousness like jacks onion seizures
Complex partial seizures with impairment of consciousness like psychomotor
epilepsy
Partial seizure evolving to generalize seizures
2= GENERALIZE SEIZURES=
Q ABSENCE SEIZURES ALSO CALLED PETIT MAL
SEIZURE.INCLUDE TYPICAL ABSENCE AND ATYPICAL ABSENCE
MYOCLONIC SEIZURES
TONIC CLONIC SEIZURES
ATONIC SEIZURES
PARTIAL SEIZURES= they start by activation of group of neurons in one
part of one hemisphere, they are also called as focal seizures
SIMPLE PARTIAL SEIZURES
Consciousness is preserved in this .it may present with motor, sensory
,autonomic or psychic symptoms as following
PARTIAL MOTOR SEIZURES=
There may be three pattern in partial motor seizures
Q JAKSONIAN MARCH= jerky movement typically begins in a very
restricted region such as thumb and Index fingers spreading to whole limb
in within seconds and minutes

495
The clinical evidence of this spread of activity is called march of seizures
Representing the spread of seizure activity over a progressively larger part of
motor cortex
Q TODDS PARALYSES=
Is local paresis after jacksonian march
Epilepsies partials continua= rarely jacksonian march may continuefor hour
or days
PARTIAL SENSORY SEIZURES=

PARASTHESIA or tingling or electric sensations in contralateral face and

limbs
And arises from sensory cortex
PARTIAL PSYCHIC SEIZUERES= sensation of falling or vertigo,
abnormal odors or sounds
PARTIAL VISUAL SEIZURES=
Light flashes, and visual hallucinations of faces, there may be illusion that
objects are growing smaller (micropsias) or bigger(macropsia)
COMPLEX PARTIAL SEIZURES=from temporal or frontal lobe
PSYCHOMOTOR OR TEMPORAL SEIZURES=
Altered consiuousness without pt collapses to ground
Pt stops when he or she doing and stares blankly and then gain
consiuosness and may be drowsy
Imediately before such an attack pt may report alteration of mood memory
or perception such as undue familiarity in déjà vu or unreality(jami vu).there
may be hallucination of sound smell , vision fear ,sexual arousal
GENERALIZED SEIZURES=

496
They start by activation of group of neurons in large areas of both hemisphere
simultaneously
Typical absence seizure=
In this child during episode stops activity, stares, blinks, or roll up eyes and
fails to response to commands and last few seconds
ATYPICAL ABSENCE SEIZURES=
More gradual onset and termination as compared to typical absence seizures
MYOCLONIC SEIZURES=

Single jerk Involving one part of body

ATONIC SEIZURES= sudden loss of postural muscle tone lasting 1-2
seconds
Q PHASES OF TONIC CLONIC SEIZURES=

PRODROMAL PHASE=
Hour or days before attack, unease, irritability
AURA=
Due to partial ONSET OF SEIZURES e.g. olfactory hallucination,
epigastric discomfort AND déjà vu
TONIC PHASE=
Rapid discharge of motor cortex cells, arm flexed and adducted, leg
extended, respiratory muscle spasm causes cry as air expelled, cyanoses and
loss of consciousness
Last 10-30 seconds
CLONIC PHASE=
GRADUAL SLOWING DISCHARGE OF CORTICAL cells, violent
jerking of face and limbs tongue biting, incontinence, last 5min

497
Post ictal phase = deep unconsciousness, flaccid limb and jaw, loss of
corneal reflexes, extensor plantar responses. Last a few minutes to hours.
Headache, confusion, aching muscles and occasional violence.
Q 539 FACTERS WHICH MAY TRIGGER SEIZURE
Sleep deprivation
Emotional stress
Physical and mental exhaustion
Pyrexia
Drugs or alcohol
Q 540 DIFFERENTIAL DIAGNOSIS
D/D OF PARTIAL SEIZURES
1=transient ischemic attack
Are distinguished from seizures by longer duration.
2=panic attacks=
D/D OF GENERALIZE SEIZURES=
1=syncope usually in relation to postural change
2=cardiac dysrhythmias=
3= Psuedoseizures is used to denote hysterical conversion reaction and
attack due to Malingering when these stimulate epileptic seizures. EEG is
normal.
Q 541 DIAGNOSES= HISTORY=
The most important tool in diagnoses is to determine wether the event was a
truly a seizure
In order to discriminate seizure from other similar condition by asking
question before ,during and after seizures
History from witness is very important as pt may be unaware of ictal and
post ictal phases
498
Ask about tongue bite and urinary incontinence
Ask about predisposing facters liker febrile seizure, family history of
seizures,head trauma,stroke and tumors
Identify precipitating facters like sleep deprivation,metabolic derangement
EXAMINATION=examination for predisposing or precipitating factors,
injuries getting during seizures.
Assessment for mental status, language, and abstract thinking
EXAMINTION IN EPILEPSY
Auscultation of neck and eyes for bruits
Pulse , blood pressure, heart auscultation
Head for evidence of trauma, visual field, optic fundi
Limbs for evidence of hemi paresis or hyperrelexia
INVESTIGATIONS= are done to rule out metabolic or infectious causes of
seizures
Blood cp to look for luecocytoses
Serum urea , creatinine and electrolytes
Random blood sugar
Serum calcium and magnesium
Liver function tests
Screen for toxins in blood and urea if toxicity is suspected
Lumber puncture if meningitis or encephalitis is suspected
Q ELECTROENCEPHALOGRAPHY
EEG may help may help establish and characterize type of epilepsy
Determination of type is important for determining the most appropriate
anticonvulsant drug with which to start treatment
EEG may confirm the presence of seizure by demonstrating spikes even in
interictal period
499
CT SCAN OR MRI SCAN =
Does not help establish a diagnoses of epilepsy but is useful in in excluding
structural cause of seizures such as tumors or infections
CHEST X RAY=
Epilepsy start after age of 20years because of possibility of underlying
neoplasms,a chest x ray should be obtained in such patients because lungs
are common site for primary or secondary neoplasms
PET AND SPECT=
Used to evaluate certain type of seizure which does not respond to medical
therapy
Q Management of epilepsy=
IMMEDIATE CARE OF SEIZURES=
Move pt from danger such as fire, machinery or water
After convulsion cease turn pt into semiprone position, ensure their air way
was clear.
If convulsion continue for more than 5min call for medical help
Do not insert anything in mouth because tongue bite occur at seizure start and
cannot be prevented by observers
Person may be drowsy and confused for 30-60min and should not be left
alone until fully recovered
IMMEDIATE MEDICAL CARE
Ensure airway is clear
Give oxygen to offset cerebral hypoxia
Give intravenous anticonvulsant like diazepam 10mg only, if convulsion are
continue then treat as status epilepticus
TREATMENT OF UNDERLYING CONDITIONS

500
If underlying cause is correctable promptly antiepileptic drug theraphy is
unnecessary
If underlying cause is not found then anticonvulsant theraphy is unnecessary
AVOIDANCE OF PRECIPITATING FACTER
Such as sleep deprivation should be avoided
ANTICONVULSANT DRUG THERAPHY
WHEN TO INITIATE ANTIEPILEPTIC DRUG THERAPHY
A single seizure is an indication for investigation while second attack of
seizure is an indication for treatment
SELECTION OF ANTIEPILEPTIC DRUGS
Drug should be selected depends on type of seizures
Dose is increased till seizures are controlled or side effects prevent further
increase
If seizure still continue despite treatment at maximal tolerable dose a second
drug is added
If still seizures then third drug is added while first two are maintained
Monitoring for side effects like bone marrow suppression or hepatotoxicity
therefore baseline blood count or lfts should be done
MEASURING PLASMA DRUG LEVELS
Especially measurement of plasma level of carbamazepins
WITHDRAWAL OF ANTICONVULSANT THERAPHY
2 to 3yr seizure free period is required before considering with drawal dose
reduction over 2 to 3 months
Recurrence may occur
EPILEPSY OUTCOME AFTER 20YEARS
50% seizure free without drugs for last 5years
20%seizure free for last 5year but continue to take medication

501
30%seizure continue inspit of antiepileptic theraphy
Q GUIDELINES FOR CHOICE OF ANTIEPILEPTIC DRUGS
SECONDARY GTCS=
FIRST LINE = Carbamazepine or Valproate or phenytoin
Second line=lamotrigine or topiramate
Third line=gabapentine or clobazem or phenobarbitone
PRIMARY GCTS=
First line= Valproate
Second line= Carbamazepine OR Lamotrigine or topiramate
Third line= Gabapentine , primidone or phenobarbitone
ABSENCE SEIZURE=
First line= Etthosuximide
Second line = Valproate
Third line= Lamotrigine or Clonazepam
MYOCLONIC =
First line= Valproate
Second line= Clonazepam
Third line= phenobarbitone
Q ANTIEPILEPTIC SHOULD BE AVOIDED IN
PHENYTOIN SHOULD BE AVOIDED IN YOUNG PT BECAUSE IT
CAUSES HIRSUTISM AND GINGIVAL HYPERTROPHY
CARBAMAZEPINE AVOIDED IN WOMEN TAKING
CONTRACEPTIVE PILLS BECAUSE IT CAUSES HEPATIC
ENZYME INDUCTION AND LEADS TO FAILURE OF
CONTRACEEPTION AND PREGNANCY RESULTS
VALPROATE=avoided in infants and childrens becasse it causes
idiosyncratic hepatic failure
502
NEW ANTICONVULSANT DRUGS=
THE patient who don’t respond to carbamazepine and valproate .we can add
to theraphy in partial and generalize tonic clonic seizures
Include=
Lamotrigine
Gabapentin
Febamate
Topiramate
Primidone
Vigabatrin
Q EPILEPSY ,PREGNANCY AND CONTRACEPTION
Hepatic enzyme induction is caused by carbanmazepine, phenytoin and
phenobarbitone accelerates metabolism of oral contraception causing
contraceptive failure therefore alternate methods of contraception should be
used
Epilepsy worsen during pregnancy hence plasma levels of antiepileptics
should be performed regularly
All antiepileptic causes teratogenicity and congenital defects hence
minimum effective dose should be used
Folic acid 5mg daily taken to month before conception may reduce risk of
some fetal anomalies
Q STATUS EPILEPTICUS
Life threatening and medical emergency and is condition in which seizure is
prolonged than 15-30minutes without recovery in between
Prolong seizure leads to cardio respiratory dysfunction, hyperthermia and
metabolic derangement and these leads to irreversible neuronal injury after
approximately 2hours
503
PRECIPIATING FACTERS=
1=abrupt withdrawal of anti epileptics
2=cerebral hemorrhage
3=most common with epileptic focus in frontal lobe
4=metabolic derangement
5=drug toxicity
6= CNS infection
7=cns tumors
8=head trauma and refractory epilepsy
Q STRATEGY OF MANAGEMENT OF STATUS EPILEPTICUS
DIAZEPAM 10MG IV
↓
DIAZEPAM 10MG IV AFTER 15 MIN
↓
PHENYTOUIN 20MG PER KG IV AT RATE OF 50MG /MIN
↓
PHENYTOIN 10MG /KG IV AT RATE OF 50MG /MIN
↓
PHENOBARBITAL 20MG /KG AT RATE OF 50-100MG /MIN
↓
PHENOBARBITAL 10MG /KG AT RATE OF 50-100MG /MIN
↓
BARBITURATE OR BENZODIAZEPINE ANAESTHESIA
COMMON DOSES OF COMMON DRUGS
IN MG /DAY
Carbamazepine=200-2ooomg /day
Clobazem 20-30mg /day
504
Clonazepam 1-8mg
Etthosuximide=500-1500
Gabapentine=300-2400
Lamotrigine=25-500
Phenobarbital 60-180
Phenytoin =150-350
Sodium valproate=400-2500. Primidone is converted in liver to
phenobarbitone
Q =SENARIOS OF ALZEMERS DISEASE pt of 77yr old with history
of gradual loss of recent memory for a few months.
What are biological investigation in alzemer disease?
Answer=biological investigations
IN PRIMARY CARE
Full blood count
ESR
Urea and electyroytes
LFTS
Calcium and phosphate
TFt
Vitamin b12 and folate
IN SECONDERY CARE
MRI
CT BRAIN
URINALYSIS
SYPILIS SEROLOGY
HIV STATUS
CXR RADIOGRAPH

505
NEUROPSYCHOLOGICAL ASSESSMENT
GENETIC TESTING AND EEG

Q STUPOR
Is a common condition which presents at emergency services
Word stupor derived from latin word stupure meaning insensible
Stupor is condition where pt is consiuios but there is non responsiveness to
surrounding
Q ETIOLOGY
SHYZOPRENIA CATATONIC TYPE AND DEPRESSION
Clinical features=
Total motor Inactivity
Total absence of self cone
Neglecting physiological needs like like food and fluid intake
Management=
Assess nutritional status and hydrationm because there is risk of neglect of
nutirition
Give iv fluids
Ryled tube feeding can be
Provided
Administer vitamins to facilitates movement and prevent contracture
Minmal dose of drugs like antipsychotics and antidepresents are helpful to
relieve basic problems
Q CRIMINAL RESPONSIBILTY AND MC NAUGHTEN RULE=
= nouthing is an offense which is done by pt who at time of doing it by
reason of unsoundness of mind ,was in capable of knowing the nature of
act or that what he was doing either wrong or contrary to law
506
Q CRISES INTERVENTION= is a techniques used to help individual or
family to understand and cope with intense feeling of crises
Resolution ends in positive or negative outcomes
Crises intervention aims at positive outcome
Resolusion is influienced by three facters1= perception of event
2=availability of emotional support
And availability of adequate coping mechanism
When a person seeks assistance these three fators represent a guide for
effective intervention
Intervention includes assisting person to use existing supports or helping
individual to find new sourses of support and to learn new ways of coping
Early intervention is associated with better outcome
Person experiencing a crises usually are distressed and likely to seek help
for their distress
They are ready to learn and will try new coping skills to resolve the distress
This is ideal time for intervention and resolution will be successful in termof
positive outcomes
Types of intervention
2 categories includes
1= AUTHORTIVE intervention are designed to asseass personal health
status, and promote problem solving duch as offering a person new
information,knowledge raising the person self awareness by positive feed
back about behavior and directing person behavior by offering suggestions
2 FACILITATIVE INTERVENTION
Dealing with person need for empathic understanding such as encouraging
the person ,to identify and discussing feelings and thus facilitates person
self worth

507
GOLD FRIED states seven steps in crises intervention
1-= identify problems
2-= propose person alternative solution
3= reahearse each alternative
4= choose one situation
5= define needed steps
6= take up the steps
7= cech result
Q CRISES INTERVENTION MODES
Telephone counselling
Home crises visit,crises counselling b
Common crises situation= insomnia,night mare, amnesia, social isolation,
spiritual distress, anxiety, anger,guilt, hallucination,illusion, potential for
voilance, rape truma syndrome
Q =TREATMENT RESISTANT DEPRESSION
Is commonly regarded as a failure of depression to respond to two adequate
courses of depression
Cases of treatment resistant depression may also be referred to by which
medication they are resistant to that is SSRI resistant.
PREVALENCE=
Treatment resistance is relatively common in cases of major depression.
Rates of total remission following antidepressants are only 50%.
In cases of depression treated by primary care physician 32% of patients
particularly responded to treatment and 45% did not responded at all.
Q RECENT UPDATES OF NATIONAL INSTITUTE OF MENTAL
HEALTH
One in three people were symptoms free with the first medicine they used

508
One in threepeople becamesymptom free with help of an additional
medicine
One in four people became symptom free after switching toa different
medicine
For those people who tried switching to a second medicine and still had
symptoms, one in five of them then became symptom free when they
switched to medicine again
CAUSES=A=COMORBID PSYCHATRIC DISORDER
Comorbid psychatric disorder commonly go undetected in treatment of
depression ,if left untreated,symptoms of these disorders can interfere with
both evaluation and treatment
Anxiety disorders are one of most common.some studies have shown that pt
with both MDD AND PANIC DISORDER are likely to be nonresponsive to
treatment
Depressed patient with substance abuse may be noncompliant intheir
treatment and effects of certain substances can worsen the effects of
depression .other psychotic disorders that may predict treatment resistant
depression include personality disorders, obsessive compulsive disorders and
eating disorders
B=COMORBID MEDICAL DISORDERS
Some patient are diagnosedwith treatmentresistantdepression may have an
underlying undiagnosed healthcondition that are causing or contributing
totheir depression
Endocrine disorders like hypothyroidism, Cushing disease, Addison disease
are among most commonly identified as contributing to depression
Other include diabetes, coronary artery disease, cancer, hiv,and Parkinson
disease
509
Another factor is that medication used to treat comorbid medical disorders
may lessen the effectiveness of antidepressents or causes depressive
symptoms
C=FEATURES OF DEPRESSION=cases of depression in which pt also
display psychotic symptoms such delusion or hallucination are more likely
to be treatment resistant
Another depressive feature that has been associated with poor response to
treatment is longer duration of depressive episode.
Finally patient with more severe depression andthose who are suicidal are
more likely to be nonresponsive to antidepressant treatment
D= IDIOPATHIIC
Q DRUG TREATMENT OF RESISTANT DEPRESSION
SWITCHING THERAPHY
COMBINATION THERAPHY
AUGMENTATION THERAPHY
SSRI
↓
SSRI or SNRI
FIRST TREATMENT CHOICE SHOULD BE
MIRTAZAPINE +ATYPICAL ANTI PSYCHOTIC AGENTS
OR
MIRTAZEPINE +LITHIUM
OR
MIRTAZEPINE + T3 THYROXIN
OR
MIRTAZEPINE +BUSPIRON
OR
510
MIRTAZEPINE +BUPROPIONE
ELECTROCONVULSIVE THERAPHY
ECT is also first choice in treatment resistant depression
Ideally in treatment resistant depression after ECT,the pt should be switched
on to antidepressant of another class or lithium instead to maintain the same
antidepressents
Second choice of treatment resistant depression
SSRI +TCA
OR
TCA +MAOI
OR
LAMOTRIGINE
OR
TCA +LITHIUM
OR
PINDOLOL
OTHER CHOICES
DEXAMETHASONE
KETOCONAZOLE
ESTROGEN OR TESTOSTERONE GEL
OMEGA 3 TRIGLYCERIDES
EPA(EICOSAPENTANIOC ACID)ETC
DOSE RESPONSE CURVE
There seems to be a significant relationship between response rate and TCA
plasma level while SSRI does not have clear dose response curve
Further improvement in response to higher doses should be expected more in
cases where there is partial response to current therap[eutic doses
511
HOW TO SWITCH FROM ONE TO ANOTHER
If both have same pharmacological properties then first compound should
be fully with drawen if at all possible and second one should be started at
half dose or less
When switching between agents with different pharmacological properties
e.g Escitalopram to mirtazapine and cross tapering can be employed
Your first opinion should be SSRI and when it fails to respond then switch
to SSRI or SNRI or TCA
PSYCHOLOGICAL COUNSELLING IN DRUG RESISTANT
DEPRESSION
Psychotheraphy combined with medication works best and psychotheraphy
include
1=CBT
2=ACCEPTANCE AND COMMITMENT THERAPHY
A form of CBT acceptance and commitment theraphy helps you to engage in
positive behabviour even when u have negative thought and emotion
It is designed for treatment resistant condition
3=INTERPERSONAL PSYCHOTHERAPHY
Focuses on resolving relationship issue that may contribute to ur depression
4=family theraphy=
Involving family member or your spouse or patner in counselling
5=GROUP PSYCHOTHERAPHY
This involve counselling of a group of people who struggle with
depression working together with psychotherapist
6=PSYCHODYNAMIC TREATMENT=
Aim of this counselling is to help resolve underlying problem linked to ur
depression by exploring your felling and belief in depths
512
7=DIALECTICAL BEHAVIUORAL THERAPHY=
This type of therapy helps u built acceptance strategies and problem solving
skill and is usefull for chronic suicidal thoughts or deliberate self harm
which sometimes accompanies treatment resistant depression
In long standing resistant depression with severe symptoms other treatment
option of deep brain stimulation or neurosurgery can be considered
Q =TREATMENT RESISTANT SCHYZOPRENIA
About 30% of patient donot respond to antipsychotic or are intolerant to them
.the only proven drug intervention for this group is clozapine which is
effective in about one third of such patients
There is no evidence that any other atypical antipsychotic share this greater
efficacy
Clozapine may also have benefit with regard to suicidal
risk,aggression,substance misuse
But one drawback of clozapine is that it needs regular blood monitoring and
risk of agranulocytosis as well as by other side effects
Notably weight gain, sedation,hyper salivation
Clozapine should be recommended to all patient who do not respond to or
cannot tolerate at least two other ANTIPSYCHOTICS.
In practice only a minority of suitable patient have a trial of drug and often it
does not occur until many years to illness
There is little evidence based guidance on appropriate drugs treatment of
patient who are un responsive to clozapine
There are two common augmentation strategies for which there is some
evidence the first is to add antipsychotic that has a high affinity for dopamine
d2 such as amisulpride
There is also emerging evidence for aripiprazole

513
This is only situation in which antipsychoticspoly pharmacy is currently well
justified
A trial of at least 3months may be necessary
THE OTHER STRATEGY IS TO ADD MOOD STABILIZER with the
strongest evidence being for lamotrigine
OccasionallyECT is used
Q =Vascular dementia mostly involves small and medium sized vessels
Physical examination=1=carotid bruit
2= cardiac chambers enlarged
3=fundoscopic abnormalities
MRI=1=SHOWS
1= hyperintensities
2=focal atrophy suggestive of old infarction
FOCAL NEUROLOGICAL =
Symptoms like pseudobulbar palsy
REFLEXES=abnormal
GAIT = disturbed and abnormal
PROPYLAXES= control risk factors like htn
,smoking,DM,HYPERCHOLESTROLEMIA,hyperlipidemias
Some pt respond to embolic sourse correction.2= endeartrectomy
3= anticoagulants
4= tpa thrombolytic agents
Pick disease=
Neuroanatomic finding
1=atrophy of frontal and temporal lobe
2=histopathology will show pick cells

514
Like swollen neurons and pick bodies (intraneuronal argentopilic inclusion
)
No cause known but family history will cause pick disease
We don’t clearly distinguish alzeimer from pick disesase
Sometimes kluver bucky syndrome v like features may bew present in
picks disease
Q CREEUTZ JAKOB DISEASE
Slow prion virus →spongiform encephalopathy result in
1=myoclonus2=dementia3=EEG abnormal discharge
Ultimately leads to death
Plus gait and vision abnoermalities .kuru disease may occur
Q HUNTINGTON DISEASE
Neurodegenerative disease with loss of GABA ergic neurons In basal
ganglia
MANIFESTATION
1=Choreaoatetoses
2=dementia
Onset around 40years suicidal and psychotic features
Q PARKINSON DISEASE
Neurodegenerative disease wit loss of dopaminergic neurons in substantia
nigra
Onset around 60years
Manifestation
1=resting tremors
2= cogwheel rigidity
3 bradykinesia
4= dementia in 40% parkinsonian disease
515
Los of dopaminergic neurons is caused by envioromental toxin and
infection and genetic and aging facters
Q TREATMENT OF PARKINSONISM
1= dopaminergic precursers like levodopa and carbidopa
2= dopamine agonists like bromocriptines
3= anticholinergic medication like benztropines,trihexypohenadyles,
amantadine and selegilines
Side effects of antiparkinsonism drugs are 1=personality and cognitive
change
2=psychoses
Q HIV RELATED DEMENTIA
30% of hiv pt suffers from deme ntia because hiv damages brain
pharenchyma
MOTOR FINDINGS
Hyperreflexia , hypertonia and gait
MOOD DISTURBANCES
Cognitive impairments
Q WILSON DISEASE
OR HAPATOLENTICULAR DEGENERATION
Caused by ceruloplasmine deficiency
Eye changes like Kaiser flesher rings and astrexis in hand
Q NORMAL PRESSURE HYDROCEPHALUS
Pressure is normal but ventricles appears enlarged
Manifestation
1= gait disturbences2=urinary incontinence
3= dementia
Treatment =shunt placement

516
Q VOILANCE
IS PHYSICAL AGGRESSION INFLICTED BY ONE PERSON ON
ANOTHER.
They may harm other or themselves
ETIOLOGY=
PSYCHOTIC DIOSORDER SUCH AS SCHYZOPRENIA, mania ,
paranoid and post partum psychoses
ORGANIC MENTAL DISORDER=delirium ,drug intoxication and
withdrawal
PERSONALITY DISORDER=
Antisocial and paranoid personality disorder
BRAIN DISORDER=
Seizure disorder, brain injury, encephalitis and MR with behavior problem
MANAGEMENT=protect your self and donot approach alone, call for
assistance to manage any situation
Reassure patient
Restraint
This should not be used as last resort, but when needed it must not be
delayed and must not be attempted in halfheartedway. Restraint is usually
followed by compulsory hospitalization And parenteral medication.
It is rarely necessary to continue restraint for more than few hours
Assess nutritional state and if there is dehydration ivfluidsare necessary
Sedation.
The most effective drugs are
Inj chlorpromazine 100mg
Inj haloperidol10-20mg ‘
Inj diazepam 10mg

517
Q REFUSAL OF FOOD
ETIOLOGY=
They are not bothered by nutrition(schizophrenia)
Suspect that food is poisonous (paranoid disorders)
Lack of appetite and lack of interest (depression)
Too busy And active that they do not have time to eat(mania)
Protest against hospitalization or treatment
MANAGEMENT=
Regular diet supervision
Maintain weight chart
Encourage and support to eat
Iv fluid or Ryle’s tube feeding if necessary
Q= what are culture bound syndrome?
Ans=already discussed
Q =what is amoke?
Ans= amoke has been described among men in Indonesia and Malaysia
It begins with a period of brooding which is followed by voilant behavior and
some time dangerous use of weapons
Amnesia is usually reported afterwards
Some suffer from dissociative , shyzoprenia plus mania or post epileptioc state.
Q =what is latach?
Ans= is found among women in Malaysia characterized by echopraxia and other
kinds of abnormally compliant behavior
The condition usually follows a frighetening experience
Q =kuru= is included in prion disease transmitted by ritual canabiolismn .
the disease has virtuially disappeared as this practice was abolished in
518
1950. The transmission of kuru to monkeys was first experimental proof of
infectivity of prion disease
Q= 25 yrold has been diagnosed as a case of schizophrenia and has been
on haloperidol 20mg per day
In follow up after two weeks pt has difficulty to rest at on place,
psychiatrist noticed restlessness and constant crossing and uncrossing of
legs
What is most likely diagnoses?
Ans =extrapyramidal syndrome
Q= which psychometric test you will apply in this case
Answer=ask
Q= manage this condition
Answer=anticholinergic such as benztropine,dimenhydramine,trihexyphedyl
Lowering dose of haloperidol,adding benzodiazepine or beta blockers,
switching to other antipsychotic drugs
Start new antipsychotics and stop older antipsychotics
Q = 35 yr lady presented with generalize anxiety disorders and she has
used several treatment including tricyclic,ssri,trifluperazine but with no
sustained effect
For last six month she is not taking any treatment and is doing yoga
and meditation but anxiety is not under control
And has started to interfere with her social and occupational life
Q==pharmacotherapy with no addiction potential that she can be
offered
Ans=1-escitalopram like ssri
2-=venlafaxine
3-= buspirone
519
Benzodiazepine used but have sedation effects
Q= SIDE EFFECTS OF SSRI=
Ans=side effects=low sedation
Hypotension
Anticholinergic effects
Cardiac
Seizures
Sexual dysfunction
Doses
Tab Escitalopram 10mg od at morning
Tab fluoxetine 20mg in morning
Tab paroxetine 20mg od at morning
Tab setraline 50mg od at morning
Buspirione= side effects= no additive effects with sedative and hypnotics
No withdrawal syndrome
No sedation or cognitive imparment
Headache may occur
Another drug is venlafaxine profile similar to ssri And
Dose of venlafaxine
Dose=37.5 mg at morning and increase upto 70mg
Q=What is mechanism of action of antidepressants especially SSRI?
Answer= true mechanism is unknown
Many antidepressants inhibit reuptake of serotonin, norepinephrine or both
Some also block muscarinic , alpha adrenergic and histamine recepters
Q = some month back school children became victim of a brutal
terrorist attack
You have to approach to organize mental health support for school
520
Q=what will be yr. key principles of your program in a short run?
Ans==specialist services for acute psychiatric disorders=
Pt who are referred to specialist care
Provision of acute specialist care
Generic versus specialized services
Day hospitals includes
Acute day hospital care
Transitional day care
Day treatment programs
Day care centers
Inpatient units= depends on level of morbidity
Willingness and abilities of families too care for acutely ill relatives
Extent and availability of crises services
Facilities for treatment of acute psychtric disorders outside hospital
Collaboration with community teams
Q=Aims of mental health service=
1=prevention and treatment of mental and neurological disorders and there
associated disabilities
2= us of mental health technology to improve general health services
3= application of mental health principles to total national development
OBJECTIVES=
1 =to ensure availability and accessibility
Of minimal mental health care to most vulnerable section of population
2= to encourage application of mental health knowledge in general health
care and in social development
3=to provide community participation in mental health services
Q PSYCHIATRIC REHABILITATION=
521
Providing facilities to disables
In patient care need to be given
Day hospital
Out patent cares
Psychiatric day hospital
Psychiatric day training centers
Sheltered work shops
Social clubs
Half way house
Compassionate rehousing
Long stay care home
Correctional homes
Psychosocial rehabilitation institution
Q= truck driver with history of fever, body aches, and weakness ,
Detailed history show that he is alcohol and cannabis addict for 12
years.
He has frequent sexual contacts with commercial female sex workers
with no use of condoms ad has been treated for 4times for yellowish
discharge from urethra
On investigation he is found to be hiv positive
Q=what are psychological reaction that you expect in pt following
diagnoses?
Answer=1= denial 2= anger 3= depression
4-= dependence
Q=Write neuropsychiatric sequelae in newly diagnosed hiv positive pt?
Ans= neuropsychiatric sequelae are common in this pt and both secondary to
complication of immune suppression and as direct effect of hiv on brain
522
Cognitive disorders
Hiv related dementia
Hiv related encephalopathy
Subacute encephalitis in one third of pt .
Insidious onset of dementia and leads to profound dementia
Delirium can occur thru opportunistic infection and also due to cerebral
malignancy
Q= List key areas that you cover in your interaction with family of
pt ?
Answer=we should deliver bad news as
1= advance preparation
2= built a good environment and relationship
3=communicate well
4= deal with family reaction and deal with pt
5= encourage and validate emotion
6=final comment
Q=28yr old male pt with complaints of eating insects. Wearing
bangels, having stitched skin of forearm believing that it could
strengthen him
He occasionally wears female dress .
These complaints began 8year back after he had a severe accident
while driving in which he remained unconsiuos for half a day
There is no previous history of any psychiatric illness
Make DD for this pt?
Answer=1= head injury
2=transvestism
3=eating disorder
523
4=sexual disorder
Q= what are point in favour of first differential diagnose?
Ans=Head injury has occurred at onset of scenario event and pt was
unconscious after that and started sexual symptom and eating disorders
Treatment according to underlying cause.e.g. TREATMENT of eating
disorder is
Treatment=1-=CBT
2=psychodynamic psychotherapies for accompanying borderline personality
traits
Antidepresents are usually employed
Q=What dose of current you will give in first ect?
Ans=400milicoulomb
Q =what will be specific position of electrodes in pt?
Answer=in bitemporal place electrode on midpoint at junction of mid point
of external auditory meatus and external angle of orbit
Q=What are stages of trans-theoretical change model ?
Ans=precontemplation= misuser does not believe that there is a problem
although other recognize it
Contemplation= individual weigh up the prons and cons and consider that
change may be necessary
Decision =
The point is reached where decision is made to act on issue of substance
abuse
Action= individual chooses a strategy for change and persuses it
Maintenance= gains are maintained and consolidated
Failure may lead to relapse
Relapse= return to previous pattern of behavior
524
Q = a 50 yr old catholic unmarried mother of two school age children lady
presents with poor apetite difficulty in falling a sleep, early morning
awakening and irritable mood
Initial evaluation suggest depressive episode and tremors . of late she has
also started neglect her personal hygiene
What psychiatric and medical disorder would you consider in differential
diagnoses
Ans= Medical disorder= pain, cns lesions, endocrine disease, aging, brainstem
lesion,
Alcohol, diet , mediccatioon
Psychiatric=anxiety, tension, depression, and environmental changes, other sleep
disorder
Q = list evaluate and manage in this case(insomnia)
Ans=def= a disorder characterized by difficulty in Initiating and maiontaing sleep
Risk facters= typically associaed with anxiety or depression
If due to psychiatric causes seen mostly in women
Other condition includes ptsd, ocd. And eating disorder
Physical and psychiatric presenting symptoms
Predominant complaint is difficulty in iniating and maintainbng sleep
Affects pt level of function
Frequent yawning and tiredness during day
Treatment= consider good sleep hygiene techniques such as arising at same time
of day, avoiding daytime naps, avoiding evening stimulation, discontinuing cns,
acting drugs, taking hot bath near bed time, eating meals at regular time, using
relaxation techniqyues and maintaingg comfortable sleeping condition
If these donot work consider behaviuiral modification are to be used ,
consider benzodiazepines for a short period of time
525
Q = senarios of alcohol abuse already discussed about alcohol investigation
and comprehensive management =
Q =senarios of child presenting with speech difficulty and restlessness and
disorganized and disobedient and has a poor academic records
Diagnoses is ADHD
Q = 10yr old boy studying in boarding school has been brought to you by his
mother complaing that he liers, steals, and damages house hold items and
repeated complains from school in last 4yrs about his poor academic
perfotrmance and refusal to follow rules
The child was copperative during interview
He expressed his unhappiness with school authiorties and his parents who
quarrel all time and pay little attention to him
Psychological testing showed no evidence of any abnormality of inteelect or
cognitive function
What is your proivisional diagnoses
Ans= conduct disorder
Q =what are complication, outcome and DD and treatment for this
disorder(conduct disorder)
Ans-= complication of ocd= substance related disorder and school failure
Out come of conduct disorder-= antisocial personality disorder, somatoform
disorder,.depressive disorder
And substance related disorder
DDx-= major rule out are environmental problems
Adhd,and opposite defiant disorder
Treatment = healthy group identity and role model are provided by structured
sports programs and other programs like big brother programs

526
Structured living setting that place value on group identitfication and cooperation
are useful
Punishment and incarceration are not offen effective
Child training
School based program
Family intervention
Q =Senarios of alzeimer disease have been discussed in previois pages
Q = handy point = ziprasidone causes QT interval and is dangerous
Q = the psychosocial etiology of depression and dysthymia=1= loss of parent
in childhood
2= loss of spouse or child in adulthood
3= loss of health
4= low self esteem and negative interpretationof life events
5= learned helplessness
Psychosocial factors are not directly involved in etiology of ,mania or
hypomania
Management of depression=
Depression is successfully managed in in most patents
Only about 25% pt with depression seek and receave treatment
Pt who do not seek treatment in part because american often beliew that mental
illness indicates personal failure or weakness
As in other illness women are more likely than man to seek treatment
Untreated episodes of depression and mania are usually self limiting and last
approximately 2- 3 months
The most effective management of mood disorder is pharmacologic
Differential diagnoses of depression are
Medical condition= cancer particularly pancreatic and git tumors
527
Viral infection like pneumonia , aids
Endocrinological abnormality includes diabetes , hypothyroidism and cushing
syndriome
Meurological such as parki nson ,Huntington , denmentia and stroke
Nutritional deficiency such as folate and b 12
Renal or cardiopulmonaruy disease
Psychiatric and related condition
Schyzoprenia
Adjustment disorder
Anxeity disorder
Somatoform disorder eating disorder
Pharmacological management of depression=
1=Treatment includes ssri, mao and tca and stimulants
2= mood stabilizers= lithium , and anticonvulsant such as carabamazepinr]] and
valproate ate used to manage bipolar disorders
Mood stabilizers in dose similar to those used to manage bipolar are primarily
treatment for cyclothymic disorder
Atypical antipsychotics such as olanzapine and risperidone
Sedative management such as lorazepam are used to manage acute
manic
episodes because they resolve symptoms gradually
3=Psychological managements== psychoanalytic , interpersonal,
family,
brehavuiural and cognitive theraphy
Psychological management in conjunction with medication is more effective than
either type of management alone
4=electroconvulsive theraphy
The primary indication iof ect is major depressive disorder
The symptoms which donot respond to antidepressant medication

528
Antidepressants are too dangerous or have intolerable side effects
Thus ect may be used for elderly pt
Rapid resolution of symptoms is necessary e.g the pt is acutely suicidal or
psychotic
Q =Pharmacological management of opoid withdrawal=
If short term , non opoid treatment is desired, use an alpha 2 adrenocepter
such as lofexidine
Bupronorphene can be uised for short term opoid withdrewwal
Methadone treatment for withdrwal can bwe successful but needs to be carried
out slowly with a gradual tapering of dose
Q 35 yr old gentle man brought to emergency in a confused state and
agitated state ,ataxic gait and slurred speech
He complains of insects over his body and tries to remove them
On investigation the family reveals that a long standing history of substance
abuse
Ans= diagnose is cocain abuse
As cocain bug is feature of ccocain poisoning
DDx=1=caeffine, nicotine and amphetamine and cocaine abuse
Ans= initial managenment=bzd to decrease agitation
Antipsychotics to treat psychotic symptoms
Medical and psychological support
Extended management= education for initition and maintenance of abstinence
Q = a 25 yr old male with family history of major depressive diagnoses
reports to you with symptoms of low self esteem low confidence and poor
functiona;lity
All these symptoms are at sub threshold level and ongoing for over a period
of 3-4 yrs
529
What is your main diagnoses
Ans=dysthymia
Q what are risk facter=the disorder is more common in women who are
younger than 64 yr age as well as in those that are married and young
individuals from low income families
Pt typically have other psychiatric disorder such as anxiety, drug abuse and
borderline personality disorder
Q = what is treatment of dysthymia=
Ans= hospitalization is usually not indicated in these pt
The benefit from long term individual insight oriented psychotheraphy to help
overcome their long term sense of despair and remove conflicts from childhood
If medication are indicated ssri , tcs or maoi are usually the choice
Q = a depressed female reports in medical opd with backache which had
been fully investigated and no organic pathology is founded
What can be most propable diagnose
Ans=pain disorder
What are other comorbid associated with condition=somatoform disorder
Q = DDx=medical =muscle contraction headache
Psychiatric= other somatoform disorder
Q = how to assess and treat this pt
Ans=physical and psychiatric presenting symptoms
Pain is present in one or more anatomic sites
Pain causes distress to pt
Psychologic facters are usually found
Symptoms are not faked
Must have long history of surgeries or medical care

530
More than half of pt may have depression whereas most of them have
dysthymia
Treatment=
Should discuss the probable psychogenic origin of pain with pt early in
treatment
May offer antidepresents such as ssri
Biofeed back
Hypnoses
Nerve blockng have also been helpful in some case
Individual psychotheraphy is necessary to explore emotional content
Of pain .
Q = a cardiologist reffered to you a case of young men , labeling him with
diagnoses nof anxiety neuroses
Based on standardized diagnostic classification what pertinent question
would you ask and order investigation accordingly
Ans=diagnostic convention= there is no clear dividing line between generalize
anxiety disorder and normal anxity
They differ both in extent of symptom
And in there duration
The diagnostic criteria for both extent and duration are arbitrary and they differ
in several ways between dsm iv and icd 10 with regard to extent both dsm iv and
research of icd 10 require the presence of mi ni mum no of symptoms from a
list
Icd 10 list contain 22symptoms of banxiety whereseas there are only six such
symptoms in dsm iv list
Dsm iv require that symptonm causes clinically significant distress or problem
in functioning in daily life
531
With regard to duration in dsm iv And research version of icd 10 symptoms must
have been present for 6 month
However icd 10 criteria for clinical practive4 are more flexible-symptoms should
have been present on most days for at least several weeks at a time and usually
several months
DD OF Generalize anxiety disorder=1-= depressive disporder
2= schzoprenia 3=dementia
4=substance misuse
5=physical ilnes
6= ANXIETY SECONDRY TO SYMPTOMS OF PHYSICAL ILLNESS
7=GAD that is mistaken for physical illness
Q CLASSIFICATION OF PERSONALITY DISORDER=
CLUSTER A=OOD/ECCENTRIC = INCLUDES
PARANOID
SHYZOID
SHIZOTYPAL
CLUTER B = DRAMATIC / EMOTIONAL
ANTISOCIAL
BORDERLINE
HISTRIONIC
NARCISSTIC
CLUSTER C =ANXIOUS /FEARFULL
AVOIDANT
DEPENDANT
AND OBSESI

VE COMPULSIVE
532
Q= mother bring her bright child on recommendation of school teacher as
he is recently showing poor academic performance=
There are bruises and fearfull on examination of this case
What is most likely diagnoses=
Ans= adhd
Q =what sign and symptoms you would check to confirm your diagnoses
Ans = a child with adhd might
Have a hard time paying attention
Day dream, a lot
Not seem to listen
Be easily distract from school work or play
Forget things
Be in constant motion
Or unable to stay seated
Fidgeting
Talk too much
Not be able to play quitly
Act and speak without thinking
Have trouble taking turns
Interrupt other
Q = a boy of 13yr age brought to you by his fatherb with over a year
history of argumentiveness , deliberately annoying people, irritability and
vindictiveness
What is most probable diagnoses
Ans= Conduct disorder which is persitant violation in four areas,aggression,
property destruction, decetfullness and rules
Q = What are essential features of this disorder
533
Ans =essential features=
Onset= in childhood or early adulthood
Course=in most individual symptoms gradually remit
Key symptoms= bullying, fighting, creul to people or animals and
rape,
vandalism ,fire setting, theft, robbery, running away and school truancy
Q -= what do you know about epidemiology of eating disorder
Ans =epidemiology of anorexia nervosa=prevalence is between .5 -1%women .
and 90%pt are women,.prevalence in men is not clear
Average age of onset is 17 and sometime before puberty or after 40yr
Anorexia nervosa is common in industralized societies and high socioeconomic
status
Q Epidemiology of bulimia nervosa=
The estimated point prevalence is 1-3% of women
The male ;female ratio is 1;10
This illness occurs disproportionally among whites in united states
Q a 40 yr old man attends your out pt clinic carrieng his ct brain which is
suggestive of space occupying lesion in parietal lobe what clinical sign
would you look for while examine ng this pt?how would yoyu elicit those
signs?
Ans=paarital lobe
1=superior parietal lobule= contralateral astereognosses and apraxia
2=inferior parietal lobule = gerstmamnn syndrome=confusion, alexia, dyscalculia
and dysphagia
3= primary somatosensory contralateral hemi hypesthesia
Q = psychiatric aspects of pregnancy=
Ans= psychiatric disorders are common In first and third trimester of pregenancy
than in second trimester
534
Unwanted pregnancy is associated with a anxiety and depression. Psychiatric
symptoms are in pregnancy are more common in women with history of previous
psychtric disorder and also those with seroious medical problems affecting
course of illness
Minor affective disorder are common.
Some women who had chronic psyuchological problems before being pregnant
report improvement In these problems in pregnancy,.misuse of aalcohol, opiates
should be strongly discouraged during pregnancy especially during first trimestr
when risk to fetus is greatest
Eating disorder do not appear to be precipitated by pregnancy and bulimic
symptoms may improve
Great care must be taken in use of psychotroic drugs during pregnancy and
while breast feeding
Q Practical Guidelines for Transgender Hormone Treatment
KEY POINTS
In order to improve transgender individuals’ access to health care, the approach to
transgender medicine needs to be generalized and accessible to physicians in
multiple specialties.
A practical target for hormone therapy for transgender men (FTM) is to increase
testosterone levels to the normal male physiological range (300–1000 ng/dl) by
administering testosterone.
A practical target for hormone therapy for transgender women (MTF) is to
decrease testosterone levels to the normal female range (30–100 ng/dl) without
supra- physiological levels of estradiol (<200 pg/ml) by administering an
antiandrogen and estrogen.

535
Transgender adolescents usually have stable gender identities and can be given
GnRH analogs to suppress puberty until they can proceed with hormone therapy as
early as age 16.
Q Hormone regimes for transgender men (female to men, FTM)
Oral
Testosterone undecanoate* 160–240mg/day
Parenterally (i.m. or subcutaneous)
Testosterone enanthate or cypionate 50–200mg/week or 100–200mg/2 weeks
Testosterone undecanoate 1000 mg/12 weeks
Transdermal
Testosterone 1% gel 2.5 – 10 g/day
Testosterone patch 2.5 – 7.5 mg/day
i.m., intramuscular.
*Not available in the USA.
Monitoring for transgender men (FTM) on hormone therapy:
Monitor for virilizing and adverse effects every 3 months for first year and
then every 6 – 12 months.
Monitor serum testosterone at follow-up visits with a practical target in the
male range (300 – 1000 ng/dl). Peak levels for patients taking parenteral
testosterone can be measured 24 – 48 h after injection. Trough levels can be
measured immediately before injection.
Monitor hematocrit and lipid profile before starting hormones and at follow-
up visits.
Bone mineral density (BMD) screening before starting hormones for patients
at risk for osteo- porosis. Otherwise, screening can start at age 60 or earlier if
sex hormone levels are consistently low.
FTM patients with cervixes or breasts should be screened appropriately.
536
Hormone regimes for transgender women (male to women, MTF)
Anti-androgen
Spironolactone 100 – 200 mg/day (up to 400 mg)
Cyproterone acetatea 50–100mg/day
GnRH agonists 3.75 mg subcutaneous monthly
Oral estrogen
Oral conjugated estrogens 2.5–7.5mg/day
Oral 17-beta estradiol 2–6mg/day
Parenteral estrogen
Estradiol valerate 5–20mg i.m./2 weeks or cypionate 2–10mg i.m./week
Transdermal estrogen
Estradiol patch 0.1–0.4mg/2X week
i.m., Intramuscular; MTF, male to female. aNot available in the USA.
Monitoring for transgender women (MTF) on hormone therapy:
Monitor for feminizing and adverse effects every 3 months for first year and then
every 6– 12 months.
Monitor serum testosterone and estradiol at follow-up visits with a practical
target
in the female range (testosterone 30 – 100 ng/dl; E2 <200 pg/ml).
Monitor prolactin and triglycerides before start- ing hormones and at follow-up
visits.
Monitor potassium levels if the patient is taking spironolactone.
BMD screening before starting hormones for patients at risk for osteoporosis.
Otherwise, start screening at age 60 or earlier if sex hormone levels are
consistently low.
MTF patients should be screened for breast and prostate cancer appropriately.
Q =a 45yr old widow with one day history of stupor. Family gives hx of
distuirb sleep , low mood and restlessness for last two weeks And there is
537
past hx of hospitalization three yr ago on account of some psychtric illness
after which she had made a suicidal attempt
What Are various possibility you will consider in yr DDx
And how you will manage this case
Ans=stupor is a common condition which presents at emergency services , the
word stupor derives from latin word meaning insensible
Stupor is a condition when pt is consiuos but there is no responsiveness to
surrounding
Etiology= 1=schyzoprenia (catatonic )
2=depression
Clinical features= total absence of self cone
Neglecting physiological needs like food and fluid intake
Total motor inactivity
Management of stupor-= assess nutritionsal states and hydration because there
is risk of neglect of nutrition
Give iv fluid
Ryles tube feeding can be provided
Administer vitamin to facilitate movements and to prevent contractures
Minimal dose of drugs (antipsychotiocs 0r antidepresents ) are helpful to relieve
basic problems
Q Signs and symptoms of ssri discontinuation

People with discontinuation syndrome have been on an antidepressant for at

least four weeks and have recently stopped taking the medication, whether
abruptly, after a fast taper, or each time the medication is reduced on a slow
taper. Commonly reported symptoms include flu-like symptoms (nausea, vomiting,
diarrhea, headaches, sweating), sleep disturbances (insomnia, nightmares, constant

538
sleepiness). Sensory and movement disturbances have also been reported,
including imbalance, tremors, vertigo, dizziness, and electric-
shock-like
experiences in the brain, often described by sufferers as "brain zaps". Mood
disturbances such as dysphoria, anxiety, or agitation are also reported, as are
cognitive disturbances such as confusion and hyperarousal.

In cases associated with sudden discontinuation of MAO

inhibitors,
acute psychosis has been observed. Over fifty symptoms have been reported.

Most cases of discontinuation syndrome last between one and four weeks, are
relatively mild, and resolve on their own; in rare cases symptoms can be severe or
extended. Paroxetine (Paxil) and venlafaxine (Effexor) seem to be particularly
difficult to discontinue and prolonged withdrawal syndrome lasting over 18 months
have been reported with paroxetine.

Q Sex reassignment surgery (initialized as SRS; also known as gender

reassignment surgery (GRS), genital reconstruction surgery, sex affirmation
surgery, gender confirmation surgery, sex realignment surgery, or, colloquially, a
sex change) is the surgical procedure (or procedures) by
which
a transgender person's physical appearance and function of their existing sexual
characteristics are altered to resemble that of their identified sex. It is part of
a
treatment for gender dysphoria in transgender people. It may also be performed
on intersex people, often in infancy and without their consent. A 2013 statement by
the United Nations condemns the nonconsensual treatment of normalization
surgery to treat intersexuality.

Another term for SRS includes sex reconstruction surgery, and more clinical terms,
such as feminizing genitoplasty or penectomy , orchiectomy, and vaginoplasty, are

539
used medically for trans women, with masculinizing
genitoplasty, metoidioplasty or phalloplasty often similarly used for trans men.

People who pursue sex reassignment surgery are usually referred to as transsexual;
"trans" – across, through, change; "sexual" – pertaining to
the
sexual characteristics (not sexual actions) of a person. More recently, people
pursuing SRS may identify as transgender as well as transsexual.

While individuals who have undergone and completed SRS are sometimes referred
to as transsexed individuals, the term transsexed is not to be confused with the
termtranssexual, which may also refer to individuals who have not undergone SRS,
yet whose anatomical sex may not match their psychological sense of personal
gender identity.

Q Recommendations on how to prevent possible complications after Sex

reassignment surgery (SRS)

Avoid medications that cause bleeding

Bleeding after Sex reassignment Surgery is possible; however the chance of major
bleeding should be considered very low when this operation is performed by a
competent and highly experienced surgeon.

At Chettawut Plastic Surgery Center, we have never experienced serious bleeding

complications from the surgery and there is no case where blood transfusion is
needed due to bleeding from surgery.

During Sex Reassignment Surgery (SRS), Dr.Chettawut will control and stop
bleeding carefully by meticulous cauterization with an electrosurgical unit and
also
utilize hemostatic agents.

There are some medications or underlying diseases which might increase the risk
of bleeding during SRS operation and it is important that you never conceal any
known condition(s) or underlying disease(s) which might cause post-operative
bleeding or complications during or after surgery.

540
Recommendation:

The following medications must be completely stopped at least 2 weeks prior to

surgery.

-Aspirin (ASA) or Baby aspirin or any medications which contain aspirin, for
example oxycodone plus aspirin (Percodan, Endodan, etc).

-Blood thinner medication, for example Coumadin (Warfarin), Pradaxa, Brilinta,

Clopidogrel, Dipyridamole, Persantine, Plavix, Pletal, Ticagrelor, Ticlopidine,
Ticlid, Trental, etc.
-NSAID (Non-steroidal-anti-inflammation drug), for example Advil, Celebrex,
Diclofenac, Dolabid, Feldene, Ibuprofen, Indocin, Indomethacin, Mefenamic,
Meloxicam, Norgesic, Piroxicam.
-Vitamin E
-Some antidepressants also known as selective serotonin reuptake inhibitors
(SSRIs), such as Prozac (fluoxetine) and Paxil (paroxetine).

Empty your bowel completely before sex reassignment surgery to avoid wound
contamination

Since Gender Reassignment Surgery is classified as clean surgery, the risk of

infection is significantly low.

However the risk of infection can be increased if your bowel is not clean during
operation.

Bowel movement during operation or early stages of recovery should be a good

example of a situation which causes the risk of genital wound infection.

Another good example is the risk of intra-abdominal infection in colon

vaginoplasty surgery, this happens when unclean bowel is cut and re-positioned
during the colon graft vaginoplasty.

Dr.Chettawut implements a thorough program of bowel cleaning before sex

reassignment surgery (SRS) and also colon vaginoplasty which can help reduce the
chance of wound contamination and/or infection to be almost impossible.

541
Dr.Chettawut’s SRS patients require arriving in Bangkok at least 3 full days prior
to SRS or colon vaginoplasty to complete the bowel cleaning program. The
following is a brief of what patients can expect:

1. Patients must change the type of food from normal food to be clear liquid diet 3
days prior to SRS or colon vaginoplasty.

Laxative pills and Fleet enema are required on the second day prior to SRS or
colon vaginoplasty.

Swiff (Sodium phosphate oral solution) needs to be consumed on the first day prior
to SRS or colon vaginoplasty.

Note:

Swiff solution is a hyper osmotic strong laxative drug which causes urgent and
recurrent movement of the bowels occurring in one to two hours’ time.

Swiff solution is so distasteful to drink; so patients should mix it with a soda

drink
(for example, Coca Cola or Sprite) or fruit juice into the required amount of Swiff
and drink it quickly.

Vaginal shortening or narrowing or collapse after sex change surgery

Dr.Chettawut will always strive to create the maximum depth of your vagina.

Even though there is minor variation of depth due to individual anatomy; the
average vaginal depth of standard Sex Reassignment Surgery (SRS with skin graft
technique) is 6.5 inches, while the average depth of sigmoid colon vaginoplasty
(SRS with colon graft technique) is 8.5 inches.

Either skin graft or colon graft technique will provide healthy tissue lining for
vagina in order to accommodate dilation and successful sexual intercourse.

Vaginal shortening or collapse can happen from the shrinking of skin graft inside
the vagina if the patient does not perform dilation adequately or incorrectly.

It is the patients’ full responsibility to routinely perform dilation as instructed

to
maintain the original depth of vagina.

542
Q fcps=what will be duration of treatment of first time
depression and relapse of depression

Ans= ist time =6month

Relapse and second time = 2yr
C=q what will be your first choice of drug justify your choice
Ans= ssri are first choice because high efficacy and few side effects
Q = what phenomenologival term used for this sentence=
When I try to think my head fill up with noises that is heard by every body
in room
Ans= thought broadcasting
Q = my thought were taken from me years ago by pesh imam of my village
mosque
Ans-=thought withdrawal
Q = An alleoin agent has inserted a chip in my head by making a hole in my
skull to control my brain
Ans -= bizarre delusion is phenomenological term
Q = people acts if they know what I am thinking
Ans= telepathy
Q -= list five most relevant question that yoyu will ask to assess his current
voilance risk
Ans= during history
1= one or more previous episode of voilasnce
2= repeative impulsive behavior
3= evidence of difficulty in coping with streasss
4= antisocial traits and lack of support
5= history of conduct disorder
Q = list four condition that you will consider in DD justify each

543
Ans=DD=1= PSYCHOTIC DISORDER
Schyzoprenia, mania, paranoid and post partum psychoses
2= personality disorder
Antisocial and paranoid personality disorder
3= organic mental disorder
Like delirium, drug Intoxxiocation,
And with drawl
4-= brain disorder , brain injury , encephalitis and MR with behavuior problem
Q = 28 Yr old recently married female brought to psyciatric opd and she
is mute and does not make any eye contact
According to her mother pt Hs been liked this for last few weeks
And has already eaten anything , she has told her mother that she is died
and therdfore should not be fed, earlier on same day she wasd found
digging a grave in garden as if she wanted to burry her dead body
Her past psychtric history is unremarkable
List five differential diagnosdes that yoyu would consider in this case and
justify your first choice
Ans DD= Medical disorder
Like hypothyroidism , parkinsonism , dementia, pseudiodementia, tumor and cva
Mental disordrr
Mood disorder
Substance diosorder
And grief’
First choice is antidepresent because pt is having nihilistic delusion and want to
be dead and have decrease sleep and decrease apetite
Q = Manage depression=
Ans= must first secure safety of pt given that suicide is a a high risk
544
Pharmacotheraphy includes antideptresents such as ssri , tca and maoi
Ect may be indicated if pt is suicidal or worried about side effects from
medication individual psychotheraphy indicated to help pt deal with conflict,
sence of loss and another form of theraphy is cognitive theraphy which wil
change pt distorted thought about self , future and world etc
Q = 25 yr old lady presented with 3month history of sleep disturbance ,
decrease energy, multiple aches and ;pain . she was previously good home
worker but currently she find it difficult to do her routine house chores. Her
mood remain low and iorritable , she drinks excessively quantity of water
but feels thirst
She had gained 6kg weight I n last 4 weeks
Her pulse 58 per minute
Bp=90/50mmhg and oedema feet is evident and she has koilonhychia
q what is most likely diagnoses in above case
ans = bulimia nervosa
Q = What is defense mechanism that are being used in this scenarios
Ans= Projection is defense mechanism in above scenarios
Q = what is most likely psychosocial explanation of her state in above
senarios
Ans=GRIEF, denial, bargaining
Q = what are possible psychiatric disorder that you would consider in this
case and why
Ans= Depressive illness and grief
Q =what are different steps and option for pharmacological treatment of
major And resistant depression
Ans= treatment=already discussed in back pages

545
Q – = what are international treatment guidelines that you would consider in
depressive illness
Ans= already discussed
Q = a 26 yr old film artist was reffered to to you by plastic surgeon because
is insisting for nasal surgery with surgeon consider unnecessary?
During initial interview the artist appeared low and weepy, he informs you
that his nose was ugly and a reason for this failure in film industry, he was
upset on being reffered to you for a physical problem
How you would assess this pt
Ans= def=a group of disorder characterized by presentation of physical
symptoms with no medical explaination
These are severe enough to interfere with pt ability to cope function in social and
or occupational activities
Assessment= somatization disorder affects women more often than men and
usually inversely related to SES.usually begin by age of 30, data suggest that
there may be a genetic linkage to disorder, within families male relative tend to
have antisocial personality disorder while female tend to have histrionic
personality disorder
Q what are differential diagnoses in above case
Ans=medical = MS, myasthenia GRAVIS
Sle ,AIDS, THYROID, AND CHRONIC SYSSTEMATIC INFECTION
PSYCHIATRIC= MAJOR DEPRESSION, GENERALIZE ANXIETY
DISORDER
AND SCHYZOPRENIA
Q = what is management of somatform disorder=
Must have a single identified physician as a primary care taker

546
Pt should be seen during regularly shedulews= brief monthly visits. Should
increase the pt awareness of possibility that symptom are psychological in
nature. Individual psychotheraphy is needed to help pt cope with their
symptoms and develop other ways of expressing feelings .
Q = a 35 yr old teacher was reffered to you because of low mood , weeping
spells, difficulty in teaching for 6month duration .
During interview he exhibits psychomotor retardation, examination revealed
rigidity which was more marked on right side,he already received some
psychotropic medication from local GP. No significant medical or psychtric
illness
Q= WHAT is DDx
Ans=medical disorder=hypothyroidism , Parkinson disease, dementia and
,medication, pseudodementia, CVA
MENTAL DISORDER= other mood disorder
Substance disorder
And grief
Q =how you will investigate this case
Ans= physical investigation= usually within normal limits, may find evidence of
psychomotor retardation such as stooped posture, slowing of movements, slow
speech etc,
May also find evidence of cognitive impairment such as decrease concentration
and forgetfulness
Laboratory test are not diagnostic but may find a bnormal dexamethasone
suppression tesy or throtropine releasing hormone test
Q how manage major depression?
Ans = already described in back pages
Q = a 45 yr old man is hospitalized for treatment of low back ache
547
During his hospitalization for 3weeks he receaves lorazepam at dose of 2mg
daily for insomnia related to discomfort, he has never used sedative and
hypnotics agents in past and on discharge dose not wish to continue his
medication, twelve day after discontinuing lorazepam he telephones his
doctor to complain of repeated grue some night mares, many of which
involve his time in hospital
Q what is most likely explaination for this case
Ans= bernzodiazepine withdrawal
Q= what is prodrome phase of schyzoprenia
Ans= sign and symptoms occur prior to first psychotic episode and include
avoidance of social; activities, physical complaints and new interest in religion ,
the occult or philosophy
Q =genetic counseling =is about reproductive risk of hereditory disease is
mainly given to couples who are contemplating marriage or planning or
expecting a child
Psychiatrist used to be involved in this but it is now responsibility of
medical genetiicits , not least because of rapid development inm range and
methods of testing available counseling includes
Providing information about risks
Helping individual cope with concern a bout diagnoses
Enabling pt to make informed dedcision about family planning
Occasionally medical geneticts may request the collaboration or advice of
psychtrist particularly when potential pt appears to be significantly
distressed by advice and unable to concentrate on making decision
Q = a 19 yr old girl brought by her mother with lack of interest and
avoidance of food , weight loss of 18yr during last three month, fear of
gaining weight , disturbed sleep. Menstrual irregularities and irritability . on
548
examination bp is 90/60mmhg, pulse is 56/min, with physical examination,
neuropsychtric evaluation reveals mild cognitive impairment
What is diagnoses
Ans=Anorexia nervosa
Q =what are DDx
Ans= Major rule out are bulimia nervosa, general medication that cause weight
loss, depressive disorder, schyzoprenia, ocd, body dismorpic disorder
Q =senarios in which treatment for oc d presented in ER for a
sustauined conjugate deviation of eyes upward to one side .conditon is
painful and un comfortable
Answer dd include 1 =acute dystonia
2=bradykkinesua
3=akathesia
4 tardive dyskinesia p
5=NMS 6bleprospasm
7=torticollis
8=writer cramp
Managment of acute dystonia
1=anticholinergic such as benztropine
Trihexyphenoidyl
Q senaro as of 5yr hapinaess at some time and depression at othr time
for no apparent reason
Ans
Cyclothymias
TREATMENT OF CYCLOTHYMIA
Antimanic drugs like lithium carbamazepine and valproate are typically drug
of choice
549
Psychotheraphy will focus on helping pt gain insight into there illness and to
cope with there illness
Q senarois of postpartum psychosis
Treatment is
1=antidepressant 2= mood stabilizer
3== antipsychotics
Q what could be reson for poor response to treatment
Ans= already described in back pages
Q = a 36 yr old taxy driver brought to you by his father. The man has not
been sleeping well since one week , purchased ten pairs of shoes, a dozen
shirts in;last two days, sold his taxi for two hundrend thousand rupees ans
donated at quake relief fund a day earlier. He claimed himself to be greatest
social worker who had a mission to helpo mankind and believed that he
never felt soo well ever in his life
Ans=diagnoses is mania
Q =a 38 yr old lady presented with restlessness , overactivity and interfering
behavior for last two weeks , the psychtrist found her overconfident,
distractible for last two weeks, had pressured speech and seemingly
extremely happy without any obvious reason and previously she was
hospitalized thrice in past five years for treatment of depression that she
left a year ago
Ans= bipolar disorder
Q =in above scenario what is commonality between them
Ans= manic psychoses
Q = identify treatment for each(mania and bipolar both)
Ans=treatment for bipolar disorder=
Must assess pt safety to determine needs for hospitalization.

550
Pharmacotheraphy will includes mood stabilizers, bzd, and antipsychotics,
individual psychotheraphy is also indicated
Treatment of mania =usually same treatment given as like bipolar disorder
Q= a 50yr old married bank officer presents for first time with features of
acute anxiety including palpitation , excessive sweating giddiness and
fearfulness
Q what medical causes would you consider in differential diagnoses?
Ans=organic bases of anxiety= 1= neurotransmittersd inviolved in anxiety
includes increase norepineprine, decrease serotonine, decrease GABA
2= locus serolus is site of site of noradrenergic neurons, raphe nuclus iss site of
serotonergic neurons and caudate nucleus for ocd, temporal cortex and frontal
cortex are brain areas likely to be involved in aanxiety disorder
3= organic causes of anxiety includes excessive caeffine intake, substance abuse,
hyperthyroidism, vit b12 deficiency, hypoglescemia , cardiac artythmias, anemia,
pulmonary diseses and pheochromocytomas
If etiology is primarily organic the diagnioses substance abuse anxiety disorder
or banxiety diosorder caused by a general medical condition may be appropriate
Q =how you will manage panic disorder?
Ans=treatment= pharmacological intervention includes ssri,
alprazolam
,Clonazepam , imipramine and maoi e.g phenelzene
Psychotherapeutic intervention includes relaxation training for panic attack and
systemic desensitization for agoraphobic symptoms
Q = fifteen yr old girl living in an orphanage, she find it exceedingly
difficult to sleep on account of night mares and complains of a persistent
dull lower abdominal pain that does not respond to any painkiller. all lab and
radiological and ultrasonograpic investigation have been found normal

551
She has been a victim of regular physical and sexual abuses suince age of
eight
What is most likely diagnoses?
Ans=somatoform disorder
Q = in above case what are likely psychosocial difficulties and psychtric
morbidities that she may develop in years to come
Ans=many physical symptoms affecting many organs
No medical explanation can be found
Long complicated medical histories
Interpersonal and psychological problems are usually present
Musty have complained of at least four pain symptoms , two gastrointestinal
symptoms, one sexual symptom and one pseudo neurologic symptom in order to
make diagnoses
Pt usually seek out treatment and have significant impairment in level of
functioning
Commonly associated with major depressive disorder, personality disorder,
substance related disorder , generalize anxiety disorder and phobia
Q what are pharmacological and non pharmacological intervention whuich
can be offered to this pt
Ans=management of somatoform disorder=
Effective strategies for management pt with somatoform disorder I nclude
A= forming a good doctor pt relationshiop(e,g . scheduling regularmonthly
appointments , providing re assurance)
B -=providing a multidisciplinary approach incliuding other medical
professionalas(pain management, mental health services)
C=identifying and decreasing social difficulties in pt life that may intensify
symptoms
552
2= anxiety and antideppresents, hypnoses, and behavioural relaxation theraphy
may also be useful
Q -= what is psychophysiology of antisocial personality disorder?
What psychophysiological measures can be used in assessment of antisocial
personality diasorders
Ans=Antisocial personsality disorder-=
Individual with antisocioal personality disorder repeatedly disregard rules and
laws of society and rarely experience remorse for there actions
Epidemiology=ASP is present in 3% of men and 1% of women
About half have been arrested and about half of thoses are in prison
Etiology-= ASP is more common among first degree relatives of
those
diagnosed with asp. In families of asp men show a higher brates of asp and
substance abuser wheraese women have high rate of somatoization disorder,
A harsh , voilant, and criminal environment also prediaspose to this disorder
Clinical manifestation=callous
Transient relationship
Irresponsible
Impulsive and irritable
Lacking guilt and remorse
Failure to accept responsibility
DDx==bipolar and substance abuse disorder can prompt antisocial behavuir
which remit when disorder is controlled
The antisocial behaviuor of individual with asp conversely is not state
dependant
Q = 35 yr old house wife is having resistant depression no responding to
escitalopram and venlafaxine

553
Assess and what are different sytteps and options for pharmacological
treatment in this case
Ans =physical examination = and treatment of major depression already discussed
in previous pages
Q = 5yr old child presents with behaviuoral problems at home thatincludes
refusal to follow parental instruction and poor table manners, his teachrr
reports that he has difficulty in getting along with friends and day dream
excessively
Ans=, DDx are
1=ADHD 2=major rule out are age appropriate behaviuor, response to
environmental problems, mental retardation , autistic disiorder
Opposite defiant disorderr And mood disorder, and conduct disorder
Treatment of ADHD= target symptoms are defined before iniiting treatment
Psychological, social and educational intervention including adding structutre
and stability to home and school environment,
Following are treatment option for adhd
Medication
Behaviuoral intervention strategies
Parent training
Adhd and school
Medication includes
Stimulants and nonstimulants
80%pt respond to stimulants
Nonstimulants are apoproved for treating adhd in 2003 and they have fewer side
effects than stimulants and and can last upto 24hr
Behaviuoral techniques includes positive reinforcement, firm limit setting and
techniques for reducing stimulation
554
Parent training
Stimulants includes methyl phenydate , dextrioampetamine and
Atomoxetine is a norepineprine reuptake inhibiters for adhd
For adhd cns stimulus decreases hyperactivity and increases attention span
Faily theraphy is most effective management for conduct and opposite defliant
disordrr
Q =60 yr old banker is brought by his colleagues for making repeated
mathematical errors in calculation, ingoring the entities of important
documents , coming late to office and frequently spiling teas on his clothes
Ans= alzeimer disease
Q = 52 yrr old lady Is refered by a general physician with complaints of
abnormal movement around mouth and some abnormal hand movement\
The pt was treated by a psychtrist 2yr back but never revisited psychiatrist
and continued treatment on own
Q what is differential diagnioses would you consisder
Ans= tardive dyaskinesia
DDx are bradykinesia
Acute dystonia
And akathesia
And neuroleptic malignant syndrome
Q Treatment options= use newer antipsycjotic medication if TD develops
stop older antipsychotic drugs
Q = a young lady comes to psychtric opd with unresistable urge to overeat
followed by feeling of guilt and self Induced vomiting
She also uses laxatives to compensate for overeating
And she wants to know if this is normal pattern of behaviuor or an illness
Q=how will you respond to her
555
ANS= we wil explain that symptoms resembling to bulimia netrvosa and she needs
counseling
Q what is most likely diagnose in above case
Ans= bulimia nervosa
Q management of bulemias nervosa=
According to NICE guidelines
There are four steps of management
Steps 1= identify the small minority of individual who need specialist
care
because of severe depression,, physical complication or substance abuse that
require treatment in its own right
Step 2-= offer guided
Cognitive behavioural self help as appropriate using a self help book aand with
guidasnce of non specialist nfacilitater treatment usually takers upto 4 moths and
require ten meeting with facilitater
Such treatment is appropriate for primary care and appears to leads to good
prognoses in about one third of pts
Step3= pt who donnot show benefit within around 6weeks of commencing
step2require full cbt
In a minority of case where xconcomitant depressive symptoms are severe add an
antidepresents such as bflouxetine in doses upto 60mg daily aned psychotheraphy
will also needed
Step 4= pt who donot improve with cbt require comprehensive
specialist
reassessment.
In some cases measure to provide more intensive cognitive therapohy
or
antidepresent drugg may be useful
Q = what are psychophysiological effects of nicotine
Ans=psychological effects of nicotine=
556
Increase alertness and mild improvement of mood
Agitation and insomnia
Physical effects= decrease apetite, increase nbp and tachyxccardia
And increase gastrointestinal actiuvity
Effects of withdrwal
Lethargy
Depress mood
Increase apetite and weight gain
Fatigue and headaches
Q = 38 yr old operating room assistant has been reffered to you by physician
to whom he reported 9th time in last three month with a fear that he has
developed aids requesting to examine him and retesting him for aids
He reveals that his room mate in mess recently revealed himself to have
homosexual relationship with multiple partners, the client himself never had
a homosexual contact nor carries a risk facter for aids.
He has anan castric traits
He remained worried about his health however has no depression or
disturbed biological function
What is most likely diiagnises’
Ans=hypochondiases
Q what are DDx
Ans=1=unidentified organic disease
2-=factitious disorder
3=malingering
4= masked depression
Q = manage hypochondriaese
Ans=treatment = psychotheraphy to help relieve stress and help cope with stress
557
Frequent regularly scheduled visits to pt medical doctors
Q 25yr old women with complaint of restlessness apprehension
,palpitation,tremors .these episode last for 15 min
Ans= most likely diagnosis is panic disorders
Q define panic disorder
Recurrent unexpected panic attack are present ,panic attack are attack of
severe anxiety often include marked physical symptoms such as
tachycardia, hyperventilation and sweating
Etiology=1=separation during childhood
2=interpaersonal loss in adulthood
3=in response to panicogens like lactate,youhiombin ,and caeffine
4=studies of twins suggest a genetic components
DIFFERENTAIL DIAGNOSIS
1=AGORAPOBIA
2=depression
3= generalized anxiety disorders
4=Substance abuse
,Treatment 1=pharmaclologiical intervention
Ssri fluoxetine and alprazolam ,clonazepam, imipramine, and mao
i(phenelzine)
Psychotherapeutic intervention
Relaxation techniaques for panic attacks and systematic desesnsitiization for
agoraphobic symptoms
Q senarios of pt of bipolar disorders stabilize on lithium for past 6yr
presenting with hypothyroidism
Diagnosis = lithium toxicity with hypothyroidism
Q Management of lithium toxicity
558
Ans= Keep plasma level above 1.5meq per liter. Dehydration and
hyponatremia predisposes to lithium toxicity by increasing serum lithium
levels .tremors at therapeutic levels may respond to decrease dosage
Divided dosage decrease adverse effects by decresig peak plasma levels
Q SENARIOS of death of female teacher and mother and father death
3yr before and husband death 2yr before now feel sad and decrease
sleep and fatigue easily and increase weight loss
Answer
Diagnosis is major depressive disorders
DD includes1=medical diseases such as hypothyroidism 2= Parkinsonism
3= dementia and pseudo dementia
MENTAL DISORDER
Mood disorders and grief
Q risk factors of depression
Seen mostely in womens due to hormonal differences
Great stress
No close interpersonal relationship such as divorse
Abnormalities in serotonin n ,dopamine and dopamine
Family history
Exposure to stress
Hopelessness
PROGNOSIS
DEPRESSION ALONG WITH psychotic features has worse prognosis
Depression with atypical features such as increase weigt and increase sleep
and has good prognosis
Q TREATMENT OF MAJOR DEPRESSION
Assess for suicidal risk and security
559
Antidepressents includes
SSRI,TCA and MAOI and then ECT .
Psychotheraphy
COGNITIVE THERAPHY
Q SENarios of 58yr old man with cva with rt hemiplegia and speech
problems ,crying spells ,anhedonia and suicidal ideations
HISTORY OF HTN
Ans=VASCULAR DEMENTIA
TREATMENT OF VASCULAR DEMENTIA
TREAT UNDRELYING CAUSE
CONTROL OF RISK FACTORS SUCH AS HTN ,DM ,SMOKING,
HYPERCHOLESTROLEMUIA,
HYPPERLIPIDEMIA
ENDARTERECTOMY for cerebrovascular pathology ,correction of sourcers
of emboli
Anticoagulent theraphy
Thrombolytic agent TPA
Q scenario of 70 yr man with forgetfulness
Diagnosis is alzeimer disease
Q MRI changes in brain in alzeimer disease
Answer=on neuroanatomic findings 1=cortical atrophy
2=widebning of sulci 3-=enlarged ventricles
HISTOPATHOLOGY
Senile plaques
Neuro fibrilleary tangles
Neuronal loss
Synaptic loss
560
Granulovascuolar degeneration
Associated with chromosomes 21
Decrease ach and NE
Death after 8yr of diagniosis
5 REVELAnt test in alzeimer disease
1=b12
2=folate
3=RPR
4=CBC WITH SMA
5=LFT T3 AND T4 and tsh
Q senarios of depression of diabetic patient
Diabetes mellitus
Chronic condition
Require prolong medical supervision
Diabetes melitis is having a lot of long tterm compliance so psychological
factors are needed for good compliance so that pt take drugs and prevent
long term compliocation and thus
Psychological and social problems are mainly caused by restriction of diet
and activity
Control of diabetic problem is more difficult when diabetic pt has an eating
disorder
Sexual problems are especially impotence caused in diabetic men
Two kinds
First psychogenic and 2nd due too autonomic neuropathy
Pregna ncy is a difficult time for diabetic and miscarriages and fetal
malformation occurs

561
Organic psychtry syndrome in diabetic pt are delirium diabetic coma and
chronic cognitive impairment
Q PSYCHIATRIC ASPECTS OF MANAGEMENT
Diabetic has been cause of considerable psychotic research involving a
range of psychological treatment particularly in adolescence diabetic
Q PSYCHATRIC ASPECTS OF ENDOCRINE DISORDERS AND
STERIOD THERAPHY
1=HYPERTHYRIODISM
INCLIUDE anxiety,decrease concentration ,irritability,
And emiotional lability
Treatmernt of T3 and T4 improves anxiety
2=hypothyroidism = cognitive impairment and mood disorders
3=cushing syndrome = depressive symptoms and psychological distress
4=steroid theraphy
Mania symptoms and paranoid symptoms
5=anabolic steroids
Used widely by atheletes .mood disturbances and aggression reported
Q STEPS IN ELECTROCONVULSIVE THERAPHY
ECT involves induction of a generalize seizure lasting 25-65seconds by
passing an electric cureent across brain .prior to seizure induction pt is
premedicated with atropine .general anaesthetic is given either with
propofol and muscle relaxant such as succinyl choline ,.after few ECT
improvement is seen .
Q INDICATION=1=MAJOR DEPRESSIVE DISORDER THAT HAVE
NOT responded to antidepressents and mood disorders
2=MDD with high risk for immediate suicide
3=MDD with contraindication to antidepresents
562
4=MDD who responded well to ECT in past
elderly with depression
Q RISK AND PROBLEM IN ECT1= ante and retrograde amnesia
2= increease intracranial pressure or MI is relative contraindicated to ECT
3=LOW mortality rate with ECT AND MAINLY DUE TO GA
Q SUICIDE RISK
A=PT WITH MOOD DISORDER ARISK FOR SUICIDE ARE AT HIGH
risk for suicide
B=certain demographic psychoxsocial and physical factors affects the risk
top5 risk factres for suicide from highest to lower risk rate
1=serious previous suicide attempt
2=age of older than 45yr
3=alcohol dependence
4-=history of violant behavior
5=male sex
Suicide is very complex multicausal human behaviuor with many causes and
several biological as well as psychosocial and cultural componrents.90% of
pt who do suicide have underlying psychiatric disorder in them .by provision
of psyh services suicide can be erasdicated from community.
Major depressive disorder are stated to be associated with 60percent suicide
Mental disorder
Past suicidal attempt
Un employment
Low income
Single and divorced merital status
Painful physical illness
Alcohol and drug problems
563
Family history of suicide
CHRONIC RISK
Borderline personality disorder
Emotional stress
Psych symptoms such as depression psychosis hopelessness AND
impulsiveness
Alcohol and drug dependence
Physical illness such as cancer and aids
Diviorced and widowed
Single and unmarried
Live alone and elderly age
Q CONVERSION DISORDER= AN INDUIVIDUAL EXPERIENCE
ONE or more neurologic symptom that cannot be explained by any
medical or neurological disorded
Q etiology=young female
Decrease Socioeconomic stress
Rural population
Low IQ
Military personell
C ommonly associated with histrionic and antisocial pd
Q psychiatric and physical symptoms
One or two neurioologc symptiomms
Psychological factres
Mutism blindness. Paralyses
Sensory symptoms anaesthesia and paresthesia
Motor symptoms = abnormal movement and gait disorder
Seizure =pseudoseizure
564
Primary and secondery gain
Lasbela indifference
Pt seems unconcerned about his impairment
Q somatic disorder= physical symptoms without sufficient organic
cause
Imp ddx is unidentified organic disease
Q EPIDEMIOLOGY=STUDY OF facters that determin the occurrence
and distribution of disease in human population
Q incidence rate= total no of individual who newly developed illness in
a specified peroiood of time and divided by total no of individual at
risk
Q prevalence rate= no of new and old cases
Rate of prevalence is greater than incidence if disease is long lasting
Q neurotransmiter transfer of eletricasal impulsez from one neuron
to next neuron
Q neuro transmiters in schyzopreniaa =increase dopamine
Mood disorder= decrease gaba and decrease serotonin
Dementia = decrease acetyl choline
Q CLASSIFICATIONOF POBIA ACCORDING TO ICD TEN
1=SOCIAL PHOBIA
2-=SOCIAL PHOBIA 3=AGORAPHOBIA
Q CLINICAL FEATURES OF SOCIAL PHOBIA
FEAR OF HUMILATION
Emberrasment in general or specific social situation such as public
speaking stage fright ,urinating in public latereen
Tx
Cbt

565
Systematic desensitization
Assertive training
Pharmakiotheraphy
Ssri
Buspoirone beta blockr
In stage fright
Q pt with one day h of severe loss of vision iborn left eye and optic disc
swelling on ophthalmoscopy b and pt is anxious asnd worried and past h
show that 6moonth back she was admitted for lower limb weakness
Dd 1=amorous fugax
2clouding oof normality
3=transparent eye structuee
4=CRVO
5=CRAO
6= ABNORMALITIES OF RETINA AND NERVE RY
INVESTIGATION
1=MRI OR CT OR USG FOR CAROTID ARTERYFOR TIA OR FOR
AMAPOUS FUGAX
2=EEG =continues monitoring of heart brythm
3=ESR measurement
4=CRP and platelets
5examination by doctor
Treatment option
Disorder causing loss of vision is treated as early as possible althought
treatment may not be able to save vision
However prompt treatment may decrease risk of same process in other
eye .sudden loss of vision is emergency so shold g pto to hospital
566
.presence or absence of pain help indicate whaty causes are most likely
If visuion returns early on its owmn TIA or ocular migraine are among
likely causes
Q htn and dm pt presents with depression
Ans = sertraline 50mg once daily in morning
Q Six month hx of generalize anxiety disorder difficult to give
presentation in meeting due to tremor blushing loss of confidence
preoccupied with negative thought
Manage it
Behavioralpsychotherapy include relaxaytion techniques, biofeed back ,
Pharmacotherapy include ssri venlafaxine
Buspirone and bzd
Q female student with depressive illness in opd consultant wants to
admit him but he is reluctant to admit
She is stating multiple stresses due to illness ans hospitalizatuion
Enlist four stresses due to illness
Women more than man
Great stress
Bais in dx
40 yr age
No interpersonal relatuionship
Divorse and separation
Abnormalities in serotinine norepinephrine and DA
LEArned helplessness
Family hx
Exposure to stresses

567
Q=old retired professor was brought in ER by his daughter who was in
drowsy state and marked restlessness,walking with unsteady
state.bluurred vision ,dry mouth.
Daughter found five blister pack of drug
Answer=sign and symptoms of benzodiazepines or barbiturates
B=Q clinical test and investigation immediately to confirm ur
suspiciousness
Answer=
Eye for pupil constriction show opium if no then phenobarbitone.
If euphoric then opium
If depressed bp and decrease respiration then benzodiazepines or barbiturates
3=urine screening test for opoids
4=HBsAg,anti HCV AND HIV ICT DONE
Q MANAGEMENT STEPS IN EMERGENCY
1=HISTORY
2=EXAMINATION
3=ADMIT IN HOSPITAL ICU
4=START OXYGEN
5=PASS NG TUBE AND START GASTRIC LAWAGE IF PATIENT
COMES SOON.
STOMACH WASH IS DONE WITH NORMAL SALINE UNTIL IT
BECOMES CLEAR==
6=give activated charcoal it binds with poison in git prevents its absorption
and finaslly passess out in stool
7=if poison on skin or hairs wash with water and soap
8=pass iv canulla
9=specific antidotes according to dose
568
10=psychotheraphy
Q senarios of 20yr old girl with history of repeated self harm having
cut marks on both arms ,she has histry of frequent anger outbirsts.
Diagnosis is depressive illness follo
Ed by alcohol or drug abuse n males and anxiety disorder in women
Q MANAGEMENT OF DELIBRATE SELF HARM
Organization of services such as primary health team,social and
ambulance services to enable them to respond appropriately and asess
risk and necessary care can be ginen
ASSESSMENT OF PT AFTER DSH
GENERAL AIMS
1=immediate risk of suicide
2=subsequent risk of further DSH
3=medical and social problems
SPECIAL ENQUIRIES
A=what was pt intention to die?
B=what was there current problem
C=is there any psychotic problem
D=what helpful resources are available.
Q 756 TREATMENT=HOSPITALIZATION
NEEDS TREATMENT for depression and alcoholism and few schyzoprenic
MANAGEMENT AFTER ASSESSMENT
Doctor should negotiate with the pt and plan should be discussed with pt .pt
needs fall into 3 groups 1=small minority require admission to psychiatric
unit for treatment
2=1/3 of pt with DSH require treatment in primary care in community
3=reminder need help with psychosocial problem
569
SOME SPECIAL PROBLEM OF MANAGEMENT
Pt who refuses assessment
They have high risk of repetition of DSH
IT is necessary to gather as much as possible frm other sources before leaving
pt to leave.problem should be discussed with GP AND community health
team if they involved
FREQUENT REPEATERS
RISK OF TAKING overdose repeatedly at time of stress.relatives ant
hospital staff often become frustaterd by frequent repeaters
REPEATED SELF CUTTING
Sometimes atypical antipsychotics such as resperidone or olanzapine in low
doses may be valuable as short term measure to reduce tention
Q HOW MANAGE PT OF VOILANCE USING NICE GUIDELINES
ANSWER
DEESCALATION TECHNIQUES USED TO PREVENT VOILANCE
One staff member should take charge of situation
Move pt to suitable room
Make sure that sufficient staff is available
Explain to pt what staff are doing and how they hope to resolve situation
Attempt to establish rapport
Listen attentively
Ask open question
If weapon is involved ask for it to be put in neutral location rather than
handed ouer
Q NICE(NATIONAL INSTITUTE OF CLINICAL EXCELLENCE
GUIDELINES)
PREDICTION

570
RISK ASSESSMENT
SEARC HING
↓
DEESCALATION
↓
INTERVENTION FOR CONTINUE MANAGEMENT1=RAPID
TRANSQUILIZER IF PSYCHOTIC PT 2=SECLUSION 3=PHYSICAL
INTERVENTION
Contraindication as an intervention
1=pt takes previous medication
2=should be terminated if rapid transquilizer if given has taken effect
3=prolong physical intervention
↓
Post incident review
Q senarios of suspiocious and aggressive behavior and persoveronality
change over 2yr and father of pt died from some paranoid delusion
ANSWER
Most likely diagnosis is schyzoprenia and differential diagnosis
is1=delusional disorder2=scyzophrenia 3=organic state
4=affective disorder
Q MODE OF INHERITANCE OF SHYZOPRENIA
GENERAL POPULATION=1-2%
Monozygotic twins 47%
Dizygotic twins12%
One schyzoprenic parent 12%
Two schyzoprenic parent 40%
First degree relative is 12%

571
Second degree relative is6%
Q NEUROPSYCOLOGICAL BASIS OF SCHYZOPRENIA
ETIOLOGY /RISK FACTORS
Men earlier onset
Age 20-3oyr
Many theories involved
Decrease dopamine and serotonin
Positive family history
Double blind theory
If mother gives mixed messages
Families that are intrusive critical and hostile to pt .it bhas been linked to
higher degree of relapse
Viral in origin
Decressase socioeconomic history
Social causation
DOWNWORD DRIFT
Q =PSYCHATRIC SEQUELAE OF MULTIPLE SCLEROSIS
1=MOST COMMON CAUSE OF NNEUROLOGICAL DISABILITY
2=depression
3=euphoric
4=emotional lability
5=cognitive impairment in 40% of cases
6=dementia
Q PRIMARY SLEEP DISORDERS
Pt may come to psychiatrist either problem in speech or excessive
sleep.sleep problems are imp in for several reasons
They may represent primary sleep disorders

572
1=they may be causes of psychological problems
2=they may be symptoms of psychological disorders
3=sleep disorders may occur in a medical disorders
Q CLASSIFICATION OF PRIMARY SLEEP DISORDERS
DYSOMNIAS
Primary insomnia
Primary hypersomnias
Narcolepsy
Breathing related sleep disorder
Circardian rhythm related sleep disorder
Dyssomnia not otherwise specified
PARASOMNIAS
Night mare disorder
Sleep terror disorder
Sleep walking disorder
Parasomnias not otherwise specified
SLEEP DISORDER RELATED TO ANOTHER MENTAL DISORDER
Insomnia and hypersomnia
OTHER SLEEP DISORDERi
OTHER SLEEP DISORDER
Secondary sleep disorder due to medical conditions
Substance abuse sleep disorder
Qsenarios of multiple headache episode on same side around same eye
Diagniosis =classical migraine
Arteries ,venous sinuses,and duramater at base of brain all are sensitive to
pain.sudden displacement of these structures leads to headache
AETIOLOGY
573
LOCAL INTRACRANIAL CAUSES
1=INFLAMATION =MENINGITIS AND ENCEPALITIS
2=migraine and hypertension
3=raised intracranial pressure
4=reduced intracranial pressure e.g. due to lumber puncture or dehydration
LOCAL EXTRACRANIAL CAUSES
1=boil or cellulitis of scalp
2=refeered pain from
Eye,ear, nose and sinuses
SYSTEMIC CAUSES
1=NEUROLGIA Such as temporomandibular neuralgia
2=metabolic facters such as acidosis alkalosis and hypoglycemia
3=toxic facters such as uremia
4=tension anxiety and depression
SPECIAL CONSIDERATION
HEADACHE OF RAISED INTRACRANIAL PRESSURE
Intracranial mass lesion displaces meninges and basal vessels leading to
headache
CEREBRAL EDEMA Causes displacement of structures especially on lying
down for some hour
SINGLE EPISODE OF SEVERE HEADACHE
1=subaracnoid haemorage
2=migrane
3=meningitis
RECURRENT HEADCHES ARE CAUSED BY
1=TENSION
2=MIGRAIN
574
3=SINUSITIS 4 GLAUCOMA 5=MALIGNANT HTN
CHRONIC HEADACHES
1=tension 2=migrane
Q MANAGEMENT OF MIGRAINE
GENERAL MEASURESS
1=RESSURANCE AND RELIEF OF ANXIETY
2=AVOIDANCE OF PRECIPITATING FACYTORS
3=stop oral contraceptives if attack are frequent
DURING ATTACK
1=paracetamol or aspirin 2tablets
2=metachloperamide an antiemetic with aspirin and paracetamol
3=ergotamine .5 to 1mg(migril)
In classical migraine relieves headache if taken as soon as visual or sensory
symptoms are felt
SIDE EFFECTS
Nausea and vomiting
Vasospasm leads to paradoxical headache
CONTRAINDICATION
1=ISCHEMIC HEART disease
2=PREGNANCY
3=PERIPHERAL VASCULAR DISEASE
Q PROPHYLAXIS
1=pizotifine is serotonin antagonist (mosigar).5mg at night
2=propranolol(Inderal) 10mg tds and increase upto 40-80mg tds
3=amitryptaline 25- 100mg at night
4=methyl sergide 1-2mg tds
Methylsergide is used in resistant ccases
575
Side effects are retroperitoneal fibrosis with prolong use
Q LITHIUM AND PREGNANCY
NEONATAL TOXICITY
Exposure to psychotropic drugs in later stages of pregnasncy can give rise to
neonatal toxicity either the presence of drug or due to withdrawal syndrome.
Pperinatal toxicity associated with lithium use include 1=floppy syndrome
2=cyanosis
3=hypotonia
4=long term abnormalities in brain development and behavior
Q LITHIUM AND BREAST FEEDING
Lithium salt enters milk freely a nd serum concentration of infant can
approach those of mother .so breast feeding require great caution hoever
amount of carbamazepine and valproate in breast milk are considered to be
too low to be harmful
Q senarios in which pt on antipsychotics and inj haloperidol and inj
depot 2days ago now ppt is febrile and bp changing and rigidity and
increase tone of muscle and altered level of consciousness
.diagnosis is neuroleptic malignant syndrome
RISK FACTORS OF NMS
1=HIGH DOSE OF ANTIPSYCHOTIC
2=HIGH POTANCY ANTIPSYCHOTIC MEDICATION
Q MANAGEMENT OF NMS
1=immediate discontinuation of medication
2=psychological supportive measures
3=dantroline
4=bromocroptine
PSYCHOPHARMACOLOGY BY DR ZUHAIB GULL
576
Q OVERVIEW OF PSYCHOPHARMACOLOGY
Neurotransmitter abnormalities are invoved in etiology of many psychtric
illnesses such as psychotic disorders,mood disorders , and anxiety disorders
Although normalization of neurotransmitters levels can reliew multiple
symptoms but these agents do not cure psychtric disorders
Psychopharmacological agents may also be useful in treatment of symptoms
of gastrointestinal problems,pain ,seizures
Q WHAT ARE GENERAL PRINCIPLES OF ANTIPSYCHOTIC
MEDICATION
Used to treat psychoses and other psychiatric disorders
Precise mechanism of antipsychotic action is unknown however
antipsychotic medication blocks several population of D2,D4 recepters in
brain .
Some newer antipsychotic medication e.g.clozapine,risperidone ,olanzapine
and quiitepine also block some serotonine recepters a property that may be
associated with increase efficacy
Antipsychotic also invariably blocks central and peripheral cholinergic
,histaminic, And alp[ha adrenergic recepters
Q THREE MAIN GROUPS
PURE D2 ANTAGONISTS= typical antipsychotic medication include low
potency older mediicastion e.g chloropromazine and high potency older
medication such as haloperidol
D2-SEROTONINE ANTAGONISTS = risperidone
MULTIRECEPTER ANTAGONIST=
Clozapine=D4,D2 AND SEROTONIN
Olanzapine=D2,D4,-SEROTONINE ANTAGONIST
QUETIAPINE=D2,D4,-SEROTONINE
577
ZIPRASIDONE=D2,D4-SEROTONONE
ARIPIPRAZOLE=D2,D4, SEROTONINE
Q WHAT ARE INDICATION FOR ANTIPSYCHOTIC
MEDICATIONS
PSYCHOMOTOR RETARDATION
SCHYZOPRENIA= for acute episodes and for propylaaxes of further
episodes
Other psychotic disorders= effecti ve in treating psychosezs and cognitive
disorders due to general medical condition and substances,delusional
disorders,brief psychotic disorders,shyzophreniform disorders
MOOD DISORDERS= for agitation and psychoses during manic episodes
SEDATION=USEFUL WHEN BENZODIAZENES ARE
CONTRAINDICATED
MOVEMENT DISORDERS== for huntington and Tourette disorders
NAUSEAS AND HICCUPS
PT with poor compliance c an be treated with long acting depot form such as
haloperidole deconuate or fluphenazine deconuate adminuisterd in every 2-
4weeks
Q=GENERAL ADVERSE EFFECTS OF ANTIPSYCHOTIC
MEDICATIONS =
Sedation due to antipsychotic medication
Hypotension due to alpha adrenergic blockers and is most common e=with
low potency antipsychotic medication
Anticholinergic symptoms =dry mouth ,blurred vision urinary
hesitancy,constipation ,bradycardia , confusion and delirium
Endocrine effects =gynecomastia,galactorea and amenorea

578
Dermal and ocular syndromes=photosensitivity,abnormal pigmentation and
cataract
Other effects= cardiac conduction abnormalities especially with thioridazine,
agranulocytosis with clozapine
Q ADVERSE EFFECTS =MOVEMENT DISORDERS=
Older antipsychotic medicare associated with a high incidence of
extraramidal symptoms
Newer antipsychotics causes minimal or no EPS
Low potency antipsychotic medication such as chloroperazine than high
potency older antipsychotic medications
ion but has more sedative effects
Q TYPES OF ACUTE MOVEMENT DISORDERS
ACUTE DYSTONIA
Presentation =spasm of various muscle group.can be dramatic and
frightening to pt.can be a major contributing factor to subsequent non
compliance with treatment
Young men may be at high risk
Treatment=anticholinergics such as benztropine, diphenhydramine or
trihexyphenadyl
Q BRADYKINESIA(PARKINSONISM)
Presenting symptoms =slowed volitional movement,increase muscle tone
and resting tremer
Key signs=decreased facial expression,festinating gait,cogwheel rigidity
And pill rolling
The elderly may be more predisposed
Differential diagnoses=catatonic rigidity or apathy and withdrawal
Q AKATHESIA=
579
Presenting =symptoms =motor restlessness
Ddx= often mistaken for anxiety and agitation
Treatment=lowering dose,addig benzodiazepines or betablockers,swithing
to other antipsychotics medication
Q TARDIVE DYSKINESIA=
Characterized by choreoathetoid and other involuntary movements
Movements often involve tongue or fingers
and later involve trunk
etiology may be a form of chemical denervation hypersensitivity which is
caused by chronic dopamine blockage in basal ganglia
pt who take high doses of older antipsychotic medication for long period
of time are at high risk and movement gradually worsen with continue use
treatment= use newer antipsychotic medication.if TD develops stop older
antipsychotic medication
Q ADVERSE EFFECTS OF ATYPICAL ANTIPSYCHOTICS
=WEIGHT HGAIN, DIABETES MELLITUS ,EPS,PROLACTIN
ELEVATION,SEDATION , INCREASE QT INTERVAL
NEUROLEPTIC MALIGNANT SYNDROME
Presentation= fairly rare and potentially life threatning condition
characterized by muscular rigidity,hyperthermia ,autonomic instability and
delirium
Usually associated with high dosages of high potency antipsychotic
medication
Treatment = immediate discontinuation of medication of medication and
physiologic supportive measures , dantriolinee or bromocriptine may be used
Q CLASSIFICATIO N OF CLINICAL PSYCHOTROPIC DRUGS

580
ANTIPSYCHOTICS =INCLUDES pheniothiazin,butyropenones,
substituted benzamide
Indication= acute treatment of schyzoprenia , and mania
Propylaxes of schyzoprenia
Antidepressents =TCA,MAOI,SSRI
INDICATION=MAJOR DEPRESSION (ACUTE TREATMENT AND
PROPYLAXES
,ANXIETY DISORDERS AND OBXSSESSIVE COMPULSIVE
DISORDERS
MOOD STABILIZERS=include lithium and carbamazepines
Indication= acute treatment of mania and propylaxes of reccurent mood
disorders
Anxiolytics=includes benzodiazepines and buspirone
Indicated in generalize anxiety disorders
HYPNOTICS=benzodiazepines and z drugs
Indicated in insomnioa
Q PSYCHOSTIMULANTS=INCLUDES METHYL PHENIDATE AND
MODAFINIL
INDICATED IN HYPERKINETIC DISORDER OF CHILDHOOD
AND NARCOLEPSY
SPECIFIC ANTIPSYCHOTIC MEDICATION
OLDER LOW POTENCY D2
Highly sedating
More hypotension
More anticolinergic effects
Low frequency of acute movement syndrome
Few remainng indication for primary selection
581
OLDER HLIGH POTENCY D2
Less sedating ,less hypotensipon and less anticholinergic
High frequency bof acute movement syndromes
Remains useful for treatment of acute agitation especially via intramuscular
rate
Remain useful as depot medication e.g haloperidol decanuate
Q Clozapine =most effective treatment for acute shyzoprenia but
significant adverse effects make it a second line medication
Serious side effects including 5% seizures and 1% agranulocytosis ne
cessitate close monitoring
No evidence of movement disorsders
Drooling,sedation ,anticholinergic effects and weight gain are a;lso common
Q RISPERIDONE= a first choice medication for treatment of shyzoprenia
especially when sedation is not tolerable
Minimal sedation
Smaller incidence of acute movement disorders in doses below 6mg
QOLANZAPINE,QUITIAPINE,ZIPRASIDONE,ARIPIPRAZOLE,PAL
IPREDONE,=
FIRST Choice medication for schyzoprenia especially when insomnia is
prominent
No incidence of mood disorders
Significant sedation and weight gain
Q ANTIDEPRESSENT MEDICATION=
OVERVIEW=use to treat mood adjustment and psychotic disorder
,anxsiety disorders,bulemiz nervosa ,dosorders of impulse control.nurssess
and chronic pain .some antidepressents are extremely dangerous when an
overdose is ingested.when used to treat individualall with depressive

582
symptom ,clinicuian should generally prescribe in small quantities
genrssive sympt with deprand only after determining the absence of suicidal
symptoms
Thyroid hormones can also used in management of mood disorders
Levothyroxine is a synthetic form of thyroxin which has mood stabilizing
effects in pt with bipolar disorders
Leithyronin is a synthetic form of t4 metabolically active form t3 which can
augment the effects of antidepresents
Q MECHANISM OF ACTION= CORRECT MECHANISM IS
UNKNOWN
After monoamine neurotranstransmission ion cns thru reuptake inhibion
and modulation of receptor function
Many antidepressents inhibit reuptake of serotonine ,norepinephrine or both
Some ads block cholinergic ,alphgic anda adrener histamine recepters
Indication=major depressiove disorders,(SSRI)
Depressive disorders of bipolar disorders(SSRI)
anxiety disorders=panic disorders,ocd, social phobia,GAD(SSRI)
BULEMIA NERVOSA(SSRI)
ENURESSES(IMIPRAMINE)
CHRONIC PAIN (AMITRIPTALINE)
CLINICAL GUIDELINES
OVERALL EFFICACY FOR TREATMENNT of major depressive
dissorders is around 70%
Newer ads should be considered first becoz of better safety profile
Difficult to predict which pt will respond to which Ads so trial of several
antidepreents may be necessary before an effective one is found

583
Individual antidepressents differ greatly in their side effects profile and must
be nmatched to pt ptreference and ability to tolerate
Older ads are especially dangerous especially when an overdose is ingested
When used to treat individual with deo=pressive symptoms clinician sould
generally prescribe in small quantities and only and only after determining
the absence of suicidal intent
If no response to treatment after 4-6week,switch to another
Treatment response may be augmented with lithium or thyroxine
Treatment should continues for 6months after favourable response
Q UNTOWARD EFFECTS =SEDATION
HYPOTENSION ESP WITNH TCA
ANTICHHOLINERGIC EFFECTS WITH AMITRYPTALINE
CARDIAC CONDUCTION ABNORMALITIES
SEIZURS
SEXUAL DYSFUNCTIONS
DRUG INTERACYTION
SSRI=FLUXETINE ,PAROXETINE. SETRALINE , FLOVOXAMINE B
CITALOPRAM AND ESITALOPRAM
REDUCED NUMBERS OF SERIOUS SIDE EFFECTS
SIMPLE DOSING SHEDULE
SPECIFIC EFFICACY IN OCD ,PANIC DISORDERS, BULEMIA
NERVOSA
FEW CARDIAC,ANTICHOLINERGIC AND HYPOTENSIVE EFFECTS
Q SIDE EFFECTS =GASTROINTESTINAL ,CNS EFFECTS AND
OTHERS

584
SIGNIFICANT INCIDENCE OF AGITATION, APPETITE
LOSS,NAUSEAS VOMITING,HEADACHE DIAREA AND SEXUAL
DYSFUNCTION
OTHER NEW ADS=TRAZODONE MARKEDLY SEDATIVE AND
MINIMAL ANTICHOLINERGIC SIDE EFFECTS USED TO TREAT
DEOPRESSION WITH INSOMNIA
DYSVENLAFAXINE, DULOXETINE, BUPROPIONE,(MORE
SEIZURES) AND VENLAFAXENE HAVE PROFOILE SIMIAR TO
SSRI
MIRTAZAPINE = SIMILAR TO TCA
Q TCA=EARLIEST ADS TO BE WIDELY USED
TERTIRY TCA are imipramine amitriptaline AND
CLOMMIPRAMINE
SECONDRY TCA=DESIPRAMINE ,NORTRIPTALINE
EFFICACY= IN adition to use of tca for mood disoerdes ,imipramine is use
to panic disorders,clomipopramin is used to treat in ocd and amiytriptaline
is used to treat chronic pain
Adverse effects =anticholinergic effects ,such as sedation and hypotension
and .they are more dangrerous antiidepresents in overdose
Antihistaminic symptomds such as wweight gain ,,membrane stabilizing
properties
Cardiac conduction defects and cardiac arrhythmias
Q MAOI=inhibit mao-a and mao-b in cns and have ads efficacy
Diffedr by type of inhibition that is reversible or irreversible ,severity of
adverse effects and specificity of inhibition
Pennalzine and isocarboxid are more sedating
Tranylcypromine is more activating
585
Selegline is used in parkinsonism and is selective inhibiter of mao-b
Indication==second line tx for MDD,DEPRESSIVE DISORDERS WITH
ATYPICAL FEATURES AND ANXIETY DX LIKE PANIC DX,SOCIAL
PHOBIA AND PTSD
Hypertensive crises= may occur with tyramine rich food or if certain other
medication are taken including nasal decongesents, antiasthmatic and
amphetamines
Advserse effects=sedation weight gain ,orthostaic hypotension ,livr toxicity
and sexual dysfunction
Q Serotonion syndrome=MAOI AND SSRI USED TOGETHER VAS
WELL AS MAOI USED ALONG WITH SEROTONERGIC
ANALGESICAS SUCH AS MEPRIDINE OR TRAMADOL CAN
CAUSE A POTENTIALLY DANGEROUS DRUG DRUG
INTERACTION WHICH IS SEROTONERGIC SYNDROME
CHARACTERIZED BY HIGH FEVER,AAUTONOMIC
INSTABILITYS AND MUSCULAR RIGIDITY,HEADACHE AND
DELIRIUM
TO AVOID THIS REACTION RECOMMENDED WASH OUT
PERIOD FOR AN SSRI OR HCA BEFORE STARTING AN MAOI IS
5WEEK AND 2WEEK RESPECTIVELY
Q MOOD STABILIZER MEDICATIONS=
Q LITHIUM CARBONATE AND CITRATE=
Indications=bipolar and shyzoaffective disorders=first line medication for
treatment and propylaxes of mood disorders
Adjunctive treatment of major depressive disorders with asntidepressents
Side effects=
Dose related=tremor ,git distress and headache
586
Dermatological problems such as acne ,interfere with pt compliance
Weight gain
Cardiac conduction defects
Hypothyrioidoism in 5%
Leukocytosis
Polyuria and diabetes insipidus
Teratogenicity and associated with cardiac problems
Q TOXICITY MANAGEMENT=keep plasma level below 1.5meq/litre
Dehydration and hyponatremia predisposes to lihium toxicity by increase
serum lithium levls
Tremor at therapeutic levels may respond to decrease dosage
Divided doses minimizes dose related untoward effects by decreasing peak
plasma level
Q 798 Valproic acid=ttx of choice for rapid cycling bipolar disorder or when
lithium is ineffective or contraindicated
Increasingly poular in emergency setting
Time course of treatment response is similar to lithium
Efficacy for propylaxes is unclear
Side effects=sedation ,cognitive impairment ,tremor , gi stress, hepatotoxicity
and teratogenecty like spina bifida
Q CARBAMAZEPINE= second line choice for treatment of bipolar
disorder when lithium and valproic acid are ineffective or
contraindoicated
Rare but serious hematological and he apatic side effect and significant
sedation make carbamazepine less usefull
Q some drug interaction of lithium =
Pharmacokinetic=

587
Increase lithium levels
Diuretics ,nsaids, ace inhibiters,arbs,and metronidazole
Decrease serum lithium levels =
Theopyline
Sodum bicarbonate

Q Antianxiety agents=
Bzd= bzd activates binding site on GABA receptor there by neuronal and
muscle foiring
These agents have a short,intermediate or long onset and duration of
action and may be used to treat disorders other than anxiety disorders
There characteristics of action are related to there clinicall indication and
there potential of use e.g short acting agent are good hypnotics but have
greater potential for abuse than long acting agents
Bzd causes sedation but have few other adverse effects in adults
Tolerance and dependence may occur due to chronic use of theses agents
Flumazenil is a bzd receptor antagonist that can reverse effects of bzd in
case of overdosage or when bzd such as midazolam are used for sedation
during medical and surgical procedures
Non benzodiazepines=
Buspirone= is not related to bzd
In contrast to bzd buspirone is not sedating and is not associated with
dependence,abuse or withdrawal problems
It is used primarily treat condition causing chronic anxiety in whioch bzd
dependence can become a problem that is in chronic anxiety disorders
Buspirone takes upto to 2weeks of work and may not be acceptable to pt
wsho are accustomed to taking the fast acting bzd for there symptoms
588
Zolpidem ,zoliplane and remilton are short acting agents used primarily to
treat insomnia
Like bzd
Like bzd first two of agents are used act on gaba recepters , in contrast
remelton is a selective melatonin agonist
Antihypertensive such as beta blockers such as propranolol and alpha-
blockers antagonist such as clonidine decrease autonomic hypperarousal
and is used to treat symptoms of anxiety e.g, tachycardia particularly in pt
with social phobias such as fear of public speaking ng
Q AUTISTIC DISORDER-=DEFINITION=
QUALITATIVE IMPAIRMENT IN social interaction,
communication,imagination and interests
Risk factors=
1= damage to brain due to known and unknown stimuli
2-=encephalitis
3= maternal rubella
4= pku
5= tuberous scleroses
6= fragile x syndrome
7= perinatal hypoxia
PRESENTING SYMPTOMS
ESPECIIALLY before three years of age
1= social symptoms like loss of peer relationship
2=cmmunication symptioms = unusuall speech or absent speech
3=behavioural symptoms
4=MR PRESENT IN 75% OF CASES
PHYSICAL SYMPTOMS
589
1= ABNORMAL EEG
2= SEIZURES
3=ABNORMAL BRAIN MORPHOLOGY
PHYSICAL EXAMINATION== self injuries by banging and biting
Treatment= family counselling
Special education
Antipsychotics medication to control episode of agitation and self
destructiove beha viuor
DD=
MR, HEARING IMPAIRMENT
ENVIROMENTAL DEPRIVATION
Selective mutism
Rett syndrome
Asperger syndrome
Q ATTENTION DEFECT HYPERACTIVITY DISORDER=
characterized by inattention ,increase motor activity,that interfere with
academic and social function
Duration 6month
Onset before 7year age
Subtypes
Based on presence of either inattention ,hyperactivity and impulsiovity
Prevalence= 5% of children
Male to female =9 to 1 ratio
Onset usually first recognized when child enters school and symptom
usually persist thru out childhood
ADHD= PERSIST INTO ADULTHOOD
IN approximately 30% octed individuals
590
Symptoms= 1= short attention span
2= constant moving hand feet and body
3= failure to sit in class or wait in ;line
4= disobedance
5= shunning by pears
7= poor academic performance

Physical examination = perceptual motor roblems ( mental image of object

seen tru senses)
Diagniostic test=IQ
DD= MR
ENVIROMENTAL PROBLEMS
AUTISTIC DISORDER
Q = pt is fearful of lizard and spiders and now his family moved to a
house of lot of spider
How u will proceed with desensitization
In desensitization pt is helped to
1= construct a herarchy by making a list of situation that provoke
increasing degree of anxiety
Abt 10items are choosen with an equal increment of aanxiety between
them
2= imagine entering situation on herarchy until this can be ddone without
hetrarchy
3= use relation while imaging situation so as to reduce anxiety response4=
repeat the procediure with each items when exposure to actuall situation is
impractical i.e phone ,desensitization in imagination is used

591
Q = Female pt with depression comes to Psychiatric opd and also have
lump on breast exam you are best doctor I have ever seen and I only
trust you
Will u examine
No but if do then do breast exam in presence of female attendant
We are not competent to examine
Q what are ethical issues in this pt
Transference and counter transference
Q IN EPILEPSY THERE SHOLD BE NO DRIVING
Q 50 YR FEMALE PRESENTS TO EMERGENCY AFTER
COMING TO WORK CONFUSED .SHE HAS
DIFFICULTY IN ANSWERING FOLOWING AUESTIONS AND HER
COWORKER SAW HER STUMBLING
SHE has many such episodes in past and heavy alciohol use for many yers
and disoriented with disconjugated gaze
Dx delirium
Cause is alciohol pt
Q anatomical structure having lesion in this condition
Cerebellum
Q BENZODIIAZEPINES
PHARMACOLOGY
ACTIONS
ANXIOLYTICS SEDATIVE AND HYPNOTICS
MUSCLE RELAXANTS
ANTICONVULSANTS
EFFECTS ARE MEDIATED THRU GABA RECEPTRES PLUS other
neurotransmitters such as noreadrenalie and serotonoine
592
SHORT ACTING BZD
LESS THAN 12HR HALF LIFE
LORAZEPAN
TEMAZEPAM LORMETTAZEPAM
LONG ACTING BZD
DIAZWPAM
ALPRAZOLAM
CLONAZZEPAM
Q FLUMAZENIL IS ITS BZD ANTAGONIST
Q UNWANTED EFFECTS
SEDATION
ATAXIA
DROWESINESS
AMNESIA AND AFFECTS DRIVING SKILL
DEPENDANCE AND WITHDRWAL
Dependence after prolong use of bzd
Withdrawal is associated with
Apprehension anxiety insomnia tremors nauseas perceptual disturbances
Depression and suicidfal thought and epileptic seizures
Since many of those symptons resemble those of anxiety it can some time be
difficult to differentiate between bzd withdrawal or anxiety
Perceptual disturbances are likely to indicate bzd withderawal
Q ASK question fm suicidal pt 1ideas=do you have any thought about
suicide?
2intent=are you serious about suicide?
3plan= have u made any plan for suicide?
Q what percentage of brain tumor causes psychiatric symptoms
593
Substantial amount of brain tumor causes psychiatric
symptoms.CORRECT PERCENTAGE NOT KNOWN .
Q = SHOP LIFTING AND PSYCHIATRIC ILLNESS
Vast amount of short lifting like other theift iss carried out by people without
any mmental disorder
Many adolescence admiot to occaational shoplifting
A minority of shopliftiong suffer from psychtric disorder
Depression is common and other mental disorder are common
Pt with any type of mental illness especially substanceabuse problem may
steal becoz of economic necessity
Pt with depressing condioiotion may be more likely to stael impulsicvity
and pt with early disorder may steal food
Shoplifting may result from distractibility
Forexample in organic disorder when pt is confuse or forgetfulness and
during panic attack when person may run out of shop without pay
Assessment of person chargedwith shoplifting is similar to forensic problem
If accused has depression ast time of examination psychtrist should try to
establish b wether disorder was presemmnt at time of offence or developed
after charge was brought
Q adverse effects of lithum
Congenital abnormalituioes such as ebstein anomally
2=hypothyroidism
3=tremor
4= diabetes insipidus
5=cardiac conduction problem
6=gastric distress
7=mild cognitive impairment

594
It takes two week to work
Antipsychotic or BZD rather than lithium are therefore initial treatment for
psychotic symptoms in an acute manic episode
Becoz of potential toxicity blood lituhim must be maintained at .8 -1.2
meq/litre
TFT AND RFT should be treated with carbamazepine and valproate .pt
taking lithium can cause hypo or hyperthyroidism
Q BREIF PSYCHOTIC DISORDER
Is characterized by sudden onset of brief psychotioc episode
Causes= 1=stress
2-=postpartium period
3= idiopathic and no cause can be found
Episdode may resolve within o new month
Treatment - =antipsychotic meduicxation
Q PSYCHOSES MAY BE DUE TO GENERAL MEDICAL
CONDITION
PSYCHOSES may be one of feature of medical condition therefore always
rule outr possible medical disorders before labelling pt as psychiatrist
patent
CAUSES= CVS= STROKE

Q =MOOD STABILIZERS
Are psychotropic medication that produces euthymic that is a normal non
depressed reasonably positive mood in bipolardisorders. They generally treat
andprevent the recurrence of manicor depressive mood in bipolar disorder.
The term mood stabilizers refer to lithium, valproate, carbamazepine and

595
lamotrigine and recently some antipsychotic medication have been added to
have membrane stabilizing properties.
Mood stabilizers are indicated acutely in acute mania in conjunction with
antipsychotics. They are also indicated for long term maintenance
prophylaxes against mania and depression in bipolar disorder
Anticonvulsant medication such as valproate, lamotrigine, and
carbamazepine may also be useful in individual experiencing seizure related
mood instability
In impulse dyscontrol in individual without bipolar disorder
Mechanism of action of moodstabilizers in bipolar illness is unclear
Since mood stabilizer are helpful in mania by altering function of different
neurotransmitter
Q WRITE NOTE ON LITHIUM
MECHANISM IOF ACTION=not well determined
Lithium alters at least two intracellular secondmessenger system
Both NEP And serotonins in CNS uses g protein coupled receptors their
function is altered by lithium and also alters GABA metabolism
INDICATION=1=acute mania
2=bipolar disorder
3=long term maintenance in bipolar disorder
4=augmentation of antidepressants medications
5= impulse dyscontrol
In regular cycling bipolar disorder lithium has been shown to reduce
incidence of completed suicide
Lithium is also indicated as a first line oftreatment for regular cycling bipolar
disorder in normal renal function.in unipolar depression it is also used to
augment other antidepressants.

596
Lithium is renally cleared and can reach toxic level in people with altered
renal function in elderly and dehydration
Therapeutic monitoring
Therapeutic effect occur after 4week of consistent use and monitoring is
required in a pt with variable compliance or altered renal function
Pt should be warned of toxicity
5% develop hypothyroidism because of interference with thyroid hormone
production
TSH and creatinine level should be checked at regular interval
Lithium has a narrow therapeutic window and will develop toxicity at
prescribed doses if they undergo abrupt change in renal function
Side effects=1=tremor 2=nephrogenic diabetes insipidus 3=gastrointestinal
distress4=minor memory problem5=acne exacerbation6=weight gain
At toxic levels 1= ataxia
2= coarse tremor
3= diarrhea
4=confusion
5=coma
6=sinus arrest and death
Q BREIFLY DESCRIBE=VALPRAOTE
MECHANISM OF ACTION = In CNS augmentation of GABA
dysfunction
Valproate also increase synthesis of GABA and decreases its breakdown and
enhances its post synaptic efficacy
Its capacity to raise threshold level allow it to beused totreat seizure disorder
as well
Choice of medication =1=acute mania

597
2=long term maintenance in bipolar disorder
3=may be more effective in rapid cycling bipolar disorder
4=impulse dyscontrol
Therapeutic monitoring
It is initiated at larger than usual doses that is 20-25mg /kg body weight for
acute treatment of manic episode known as Depakote dosing
In acute hospital setting this allows for rapid achievement of a therapeutic
blood level
A lower average daily dose is then is started the day after loading
Rapid (less than seven days) decreases in manic symptoms is achieved in
this method
Full effect needs 4weeks consistent daily dosing at a therapeutic levels
Serumlevel should be monitored regularly. Until a stable bloodlevel
anddosing regimen has been obtained
LFT should be checked at baseline and frequently during first six months esp.
because of idiosyncratic reaction of fatal hepatotoxicity is most frequent at
this time frameside effects at therapeutic blood levels
1=sedation
2= ataxia and tremors
3=git distress
4=thrombocytopenia
At toxic blood levels
Confusion coma and cardiac arrest and death
3 idiosyncratic drug reaction includes
1=fatal hepatotoxicity
2= fulminant pancreatitis
3= agranulocytosis

598
Q WRITE A DETAIL NOTE ON Lamotrigine
Mechanism of action
Unknown mechanism, and is approved by fda for use in maintenance and
depressed phases ofbipolar 1 diasorder.it is not approved for acute treatment
of mania and less effective inn this
Lamotrigine in vitro has been shown to inhibit voltagesensitive sodium
channels
This effect is used to stabilize neuronal membranes and modulate presynaptic
excitatory neurotransmitter release
Choice of action=although studies are still undergoing regarding the use of
lamotrigine in bipo.ar disorder and it appears to be more effective in in
treating or preventing depressed phase of bipolar disorder..Also good in
rapid cycling bipolar disorder. Dosages are started low at 25mg daily and
increased gradually 200mg daily
Dosages are lowered in elderly and renal or other organ impairment or when
combined with interacting agents such as valproate
Therapeutic monitoring
Gradually needed to increase dosage. Benefit seen after 4week of use of dose
daily150mg.
Development of serious allergic reaction like StevenJohnson syndrome
Clinically usefulassay forserum level of lamotrigine is not available
Generally this medication should only be prescribed by a
qualifiedpsychiatrist or neurologist or other provider who is aware of
complex drug inter action between valproate and lamotrigine
Side effects
1=ataxia
2=blurred vision

599
3=diplopia
4=dizziness
5=nausea and vomiting
Q Serious potentially life threatening allergic reaction have been
reported. This begins as simple rash and progresses to StevenJonson like
syndrome and this is more in pediatric group
Q CARBAMAZEPINE
Mechanism of action=
Unknown mechanism
It blocks sodium channels in neurons that have just produced as an action
potential,blocking neuron from repetitive firing .also crabamaze pine
decreases amount of neurotransmitter release at presynaptic terminals and
also appear to alter indirectly central gaba receptors
Choice of medication=it is not fda approved and is second line drug after
lithium and valproate for treatment of mania
It is also used in mania and propylaxes against mania in bipolar disorder and
may be more effective than lithium in rapid cycling bipolar disorder and
mixed mania
It is unclear that in prophylaxisand treatment of depression and it is also
important in treating impulse dyscontrol
Therapeutic monitoring
4week of consistent use should be monitored regularly until a stable dosing
regimen has been obtained.pt should be carefully monitored for rash ,sign of
toxicity ,evidence of severe bone marrow suppression
Side effects= at therapeutic levels similar side effects to valproate and lithium
1=nauseas
2=rash

600
3= leukopenia
At toxic levels =1= autonomic instability
2= av block
3=respiratory depression
4 coma
Idiosyncratic drug interaction=
1=agranulocytosis
2=pancytopenia
3= aplastic anemia
Q Oxcarbazepine=
Is an anticonvulsant that is structurally similar to carbamazepine but fewer
side effects and drug interaction.
The efficacy in various stages of bipolar disorder not proven well
But few small controlled studies suggest that oxcabazepine is effective in
acute mania and also effective in maintenance phase of bipolar disorder
Q ANTIPSYCHOTIC MEDICATION
ARE also approved for mood component of bipolar disorder
Includes1=olanzapine
2=quetiapine
3= risperido ne
4= ziprasidone
5= aripiprazole
Q fcps= what are HPERKINEETIC DISORDER=usually parents and
in some cases teacher inform psychiatrist about over activity of child
Some of the over activity of movements are associated with
inattention for which specific words is used like a ADHD.
Cardinal features of HKD
601
1=extreme restlessness
2=extreme movements
3= lack of attention and cognition
Children do not take care and sometimes suffer accidental injury
These pt have usually learning and attention abnormalities.
Many pt develop antisocial behavior and temper tantrum and also
agressions
Diagnoses=1=ICD -10 requires that symptoms appears before 6yr while in
DSM-IV it occurs before 7yrs
2=ICD-10 requires both a= hyperactivity
B= inattention
While DSM-IV require one either hyperactivitry and impulsivity
3=ICD-10 require that symptoms should be present both at home and
school while in DSM-IV symptoms should be present only either in home
or in school
4=ICD-10 criteria if met with show more severely diseased than DSM-
IV criteria
In ICD-10 disorder can be furture classified as
1= disturbed activity and attention
2-=hyperkinetic disorder includes both hyperkinetic disorder and conduct
disorders are met
COMORBIDITY=
Assiociated with hyperkinetic disorder are autism ,conduct disorder and
deptression in about 50% of cases
EPIDEMIOLOGY=
DSM-IV show 5% prevalence
ICD-10= show 2%prevalence
602
Rates are 3times more in boys than girls
AETIOLOGY=
1=ABNORMALITIES in neurotransmitters in prefrontal cortex
2= neurological findings
Delay in neuro development in hyperkinetic disorders
3=genetic studies are important and heretibalies estimate about 80% of
cases especially genes invol ed in dopaminergic transmitter symptoms are
primarily involved
4-= social factors influence and increase activity increased
5=lead intoxication
6=zink deficiency
PROGNOSES=
Hyperactivity decreases as pt grows and at puberty it usually stops,
But inattention may persists
Prognoses of learning disorder is good and is worse for antisocial
behaviuor
Q what is TREATMENT OF HKD
1=SUPPORT AND PSYCHOLOGICAL TREATMENT.hyperactivity
needs support from start
2=medication=
For in attention especially stimulant drug may be tried .these drugs increase
activity of dopamine and norepinephrine
Drug name is1= methyl phenidate
2=dextroampetamine these drugs decrease restlessness and inattention
Q SIDE EFFECTS OF STIMULANTS=
1=DEPRESSION
2=INSOMNIAS
603
3=IRRITABILITY
4=stereotyped behavior
5=tics
3=Q =ATOMOXETINE IS NOREPINEPRINE REUPTAKE
INHIBITERS is good for treatment of hyperkinetic disorder
Q SIDE EFFECTS=1=git side effects nauseas,vomiting
diadrhea2=hepatotoxicity

Decrease doses improves side effectas

Q =CONDUCT DISORDERS
IN THIS WE SEE SEVERE ANTISOCIAL BEHAVIUOR
Clinical features=
1=in preschooler aggressive behavior at home
2=disobedience
3=temper tantrum
4=in later childhood disorders may be present both at home and at school
and may include delinquency and vandalism
5= stealing
6= in younger children mustarbation and sexual curiosity may be present
Q =CLASSIFICATION OF CONDUCT DISORDER
Both DSM-IV AND ICD-10 REQUIRE that symptom should be present
for at least 6month and should have three symptoms out of 15
symptoms .this disorder occur before 10yr of age
ICD-10 has four divition of conduct disorder
1=socialize conduct disorder
2=unsocialize conduct disorder
3=conduct disorders confined to family
604
4=opposite defliant disorder
PREVALENCE=3 times more common in boys and girls
Aetiology=
Environmental disorder= conduct disorder is found in unstable families and
poor families living in deprived areas
GENETIC FACTERS=
Variant of monoamine oxidase A gene predisposed to conduct disorder
ORGANIC FACTORS
Children with brain damage causes conduct disorder
OTHER ASSOCIATION=
ADHD and specific reading disorder
PROGNOSES=
POOR outcome due to following facters
IN YOUNG CHILDREN
Early onset
Severe antisocial behaviuor
Hyperactivity and attention problems
Low IQ
At multiple settings
IN FAMILY
Criminality of parents
Hostility
Low income
ENVIROMENTAL
Poor region
TREATMENT=
1=mild CD subsides itself
605
2=social support of family
3=associated disease should be treated
4=Parent training program and support
5=based on behaviuoral symptoms
6=anger management
Q GENERALIZED ANXIETY DISORDER
Anxiety is continues and arises in particular condition while in phobic
anxiety is intermittent but it effect is unrelated to any particular
circumstances
Q fcps=describe DEVELOPMENT OF IDEAS ABOUT ANXEITY
DISPORDER
Anxiety is prominent symptom in many psychtric problems often
depression and anxiety occur in association
Sigmeud freud classify anxity as a separate group called anxity neuroses
Anxiety include anxiety neuroses with psychological symptoms
Anxiety hysteria with physical symptoms e.g phobia now also called as
agoraphobia
Common cause of both anxiety is sexual conflicts
Q role of psyhchiatrst in care of mentally handicap child
Physical examination
Evidence of under disorder such as inborn error of metabolism
Chromosomal abnormalities like down syndrome
Intrauterine infection such as torch infection
Error of metabolism such as lipidosiss aminaciduria and glycogen storage
disease
And chromosomal abnormalities like cri du cat syndrome and down and
fragile x syndrome

606
Rubella cmv intrauterine exposure to toxin and other insults such as
alcohol,hypoxia malnutrition
Post natal causes include expooxin and infection poor parental care
exposure to ,postnattals physical trauma exposure to heavy metal and social
deprivatuion
Q Diagnostic tests
Amniocentessess
Treatment
Primary prevention
Genetic counseling good prenatal care
environment
Treatment of associated medical condition may improve cognitive and
adaptive function
Behavioural guidance Increase self esteem and incresse long term emotion
Q NEURODEVELOPMENTAL HYPOTHESES OF SCHYZOPRENIA
THE LEADING HYPOTHETESIS IS THAT iz a disorder of
neurodevelopment
Structural brain differences present at or before illness onset
Limited progression of structural brain changes after onset
Cognitive and social impairment in childhood
Neuropathological changes without gliosis
Soft neiurologica signs at presentation
Minor physical anomalies and abberant dermatoglypoics
Pre and perinatal risk factres
Increase frequency of large cavum septum polucidum
Schzoprenias risk gene affect neuro development
Animal modelds show delayed effects of early brain lesion
607
Q EXAMPLES OF CORTICAL, SUBCORTICAL AND MIXED
CAUSES OF DEMENTIA
EXAMPLES of cortical dementia are
Alzheimer disease and
Frontotemporal dementia
Examples of subcortical dementia are
Huntington disease
Parkinson disease
And focal thalamic and basal ganglia lesion
Multiple scleroses
MIXED=vascular demetia
Lewy body dementia
Corticobasal degeneration
Neurosyphlis
Q=NEUROPSYCHTRIC AND BEHAVIUORAL SYMPTOMS
ASSOCIATED WITH MULTIPLE SCLEROSES
1=Multiple scleroses is most common cause of neurological disability in
developed countries
2=depression and also as result of side effect of beta interferon which is used
to treat multiple scleroses
3= euphoria
4=emotional liability
5=seven fold increase in risk of suicide
6=cognitive impairment in 40% pt
Q Etiologies and theories about schyzoprenia?
Ans= biological theories= focus on genetic factor, neuroanatomic,
neurochemical, immunovirology

608
Genetic contribution= genetic studies have concentratred on immediate
families, parents, sibling, offsprings
Twin studies,
Adoption studies
May be polygenic
Neurochemical and neuro anatomical system of brain with sc hyzoprenia
involve=
Dopamine and sefrotonine
Dopamine hypotheses=
Too much dopamine linked to schyzoprenic symptoms .
Substances that decrease dopamine improves symptoms of schyzoprenia
Reserpine reduces schyzoprenia
Apomorpine is agonist of dopamine
Levodopas increase dopamines formation
Ampetamines increase dopamine release
All worsen schyzoprenics
Q Characteristic features of adictionalogy=
1=craving=actual need of a drug to take it and obtain it by any means.
2=tendency to increase the dose
3=psychological and
4=physiological dependence.
5=withdrawal symptoms when drug is withdrawn

Q Drug habit
A condition which results from continuous use of a drug which does not cause
much harm to individual and their family and their society.
Drug habit is commonly caused by caeffine.drug habit is characterized by
609
1=tendency [but not craving ]to take drug and repeat it
2=harmful effects mainly to individual
3=psychological but not physical dependence
Q Drug dependence
Who has used the term drug dependence to replace drug addiction and drug
habiDefinition= a state of physical and psychological condition in which pt is
compelled to take a drug either to produce pleasurable effects or to avoid
withdrawal symptoms in its absence.
Number of drugs are increasing day by day and include
*volatile anaesthetics solvents such as toluene also known as glue sniffing.
Alcohol
Hypnotics and transquilizers and psychostimulants
Drug abuse
Persistant and excessive use of drug which is not normal according to medical
practice
Q Phases of addiction
1=tolerance
Need to increase dose of drug to get an effect similar to earliest one
2=habituation
Psychological need felt for drug
3=dependence
Body need to get the drug .
Different people use different drugs for different purposes.
Some are sedative .
Some are hypnotics and some are stimulants
Q Aetiology for drug addiction
1=economic factors
610
Preparation ,sale ,transport of drug is either compleletly banned or is licensed to
restrict their use.greater the restriction on drug , more the profit to person who
is
involved in their illegal trade
2=social factors
Knowledge and awareness about drug is given to people thru novels and books
.pleasurable effects of alcohol attracts the muind of youth.
3=cultural factors
In some communities people drink alcohol in meal and refreshments
Q Patterns of drug use
1=initial and experimental use
Drug are taken initially to relieve anxiety and forget worrys
And enhance sexual activity
2=causal and recreasional use
For releife and relaxation and as pain killer and hypnotics
3=addiction and dependence use
Ultimatelly pt becomes addicted and he is dependant on drug
Q Haramful effects of drug addiction
1=pt becomes weak physically
2=sexual power weakens
3=economically ruins
4=mothers who are addicted their sons are born handicapped and disables
5=loss of confidence
6=drug addict drivers are cause of accidents
7=addicts male indulge in crimes to obtain money for drugs.
Q Treatment of drug addiction
1 =hospital treatment

611
Any treatment is effective only if pt agree to treatment and his family cooperates
with doctor
And further drug should not be supplied and there should be foolproof system.
2 psychatric treatment
A=remove cause of addiction
B=religious education
C=social support in treating addiction
D=pt should be informed about haramful effects of drug addiction
Substance use disorders include substance abuse and substance dependence
Substance abuse is maladaptive patterns of substance use that leads to
impairments of occupational ,physical or social functioniong.
It is not diagnosed if meets creterya of substance dependence
Substance dependence is substance use and withdrawal symptoms,tolerance or a
pattern of compulsive use
A=withdrawal is development of physical or psychological symptoms
after
cessation of intake of substance.
B=tolerance =is need for increase amount of substance to achieve same
psychological effects
C=cross tolerance=is development of tolerance to one substance as a result of
another substance use.
Stimulants
Are cns activaters that include caffeine, nicotine , amphetamine and cocaine
Caeffine is founed in coffee ,and tea.
Nicotine is toxic substance present in tobacco.cigrettee smoking is reducing life
expectancy more than any other substance .smoking is increasingly most in
teenager girls.
Amphetamine is used clinically and also a drug of abuse.
612
Amphetamines are used in management of attention deficit hyperactivity disorder
And narcoleppsy and depression in elderly and obesity when it does not respond
to other TREATMENTS.
Q MOST COMMON CLINICALLY USED COMPOUNDS ARE
DEXTROAMPETAMINE , STREEMETHAMPHETAMINE AND METHYL
PHENIDATE.
Q SPEED ,ICE AND ECSTACY ARE STREET NAMES FOR
AMPHETAMINE COMPOUNDS.
COCAINE
WOMENS WHO USE COCAINE THEIR SONS ARE BORN WITH THEIR
GROWTH RETARDATION AND HYPERACTIVITY’.
Q TACTILE HALLUUCINATION OF BUGS CRAWLING ON SKIN
[FORMICATION] ARE SEEN WITH THE USE OF COCAINE.
COCAINE AND NIICOTINE PSYCHOLOGICAL EFFECTS ON USE ARE
INCREASE ALLERTNESS AND ATTENTION SPAN .EUPHORIA
AGITATION AND INSOMNIA.ON WITHDRAWAL WEE SEE LETHARGY
DEPRESSED MOOD.
AMPHETAMINE AND COCAINE
PSYCHOLOGICAL SYMPTOMS INCLUDE EUPHORIA INCREASED
ALLERTYNESS AND ATTENTION SPAN PSYCHOTIC SYMPTOMS AND
AGITATION AND INSOMNIA.
ON WITHDRAWAL WE SEE DEPRESSION AND IRRITABILITY.
PHYSICAL SYMPTOMS ON USE ARE LOSS OF APPETITE AND
MYDRIASIS AND TACHYCARDIA AND SEIZURE AND
HYPERSEXUALITY.
PHYSICAL SYMPTOMS ON WITHDRAWAL INCLUDE HUNGER FATIGUE
AND MIOSIS
613
AMPHETAMINNES WORK PRIMERILY BY INCREASING AVAILABILITY
OF DOPAMINE.
AND RELEASE OF DOPAMINE.
COCAINE BLOCKS THE REUPTAKE OF DOPAMINE.AND THUS LEADS
TO EUPHORIA AND PSYCHOTIC SYMPTOMS LIKE SHYZOPHRENIA
Q Creutzfeldt-Jakob disease

Creutzfeldt-Jakob disease (CJD) is a form of brain damage that leads to a rapid

decrease of movement and mental function.

Q Causes

CJD is caused by a protein called a prion. A prion causes normal proteins to fold
abnormally. This affects other proteins' ability to function.

CJD is very rare. It occurs in about 1 out of every 1 million people.

Q There are several types of CJD. It can be grouped into sporadic, familial, or
acquired types.

CJD may be related to several other diseases caused by prions, including:

Chronic wasting disease (found in deer)

Kuru (seen in New Guinea women who ate the brains of dead relatives as part of a
funeral ritual)
Scrapie (found in sheep)
Other very rare inherited human diseases, such as Gerstmann-Straussler-Scheinker
disease and fatal familial insomnia
Q Symptoms
Dementia that gets worse quickly over a few weeks or months
614
Blurred vision (sometimes)
Changes in gait (walking)
Confusion, disorientation
Hallucinations (seeing things that aren't there)
Lack of coordination (for example, stumbling and falling)
Muscle stiffness
Muscle twitching
Nervous, jumpy feelings
Personality changes
Sleepiness
Sudden jerky movements or seizures
Trouble speaking

CJD is rarely confused with other types of dementia (such as Alzheimer's disease)
because the symptoms get worse much more quickly in CJD.

Q Exams and Tests

Early in the disease, a nervous system and mental examination will show memory
problems and changes in other intellectual functions. Later in the disease, a motor
system examination (an exam to test muscle reflexes, strength, coordination, and
other physical functions) may show:

Abnormal reflexes or increased normal reflex responses

Increase in muscle tone
Muscle twitching and spasms
Strong startle response
Weakness and loss of muscle tissue (muscle wasting)

615
There is a loss of coordination and changes in the cerebellum, the area of the
brain
that controls coordination. An eye examination shows areas of blindness that the
person may not notice.

Tests used to diagnose this condition may include:

Blood tests to rule out other forms of dementia and to look for markers that
sometimes occur with the disease
CT scan of the brain
Electroencephalogram (EEG)
MRI of the brain
Spinal tap to test for a protein called 14-3-3

The disease can only be confirmed with a brain biopsy or autopsy. Today, it is very
rare for a brain biopsy to be done to look for this disease.

Q Treatment

There is no known cure for this condition. Interleukins and other medications may
help slow the disease. The person may need care early in the disease. Medications
may be needed to control aggressive behaviors.

Providing a safe environment, controlling aggressive or agitated behavior, and

meeting the person's needs may require monitoring and assistance in the home or
in a care facility. Family counseling may help the family cope with the changes
needed for home care.

Visiting nurses or aides, volunteer services, homemakers, adult protective

services,
and other community resources may help care for the person with CJD.

616
People with this condition may need help controlling unacceptable or dangerous
behaviors. This involves rewarding positive behaviors and ignoring negative
behaviors (when it is safe). They may also need help getting oriented to their
surroundings.

Getting legal help with advance directives, powers of attorney, and other legal
actions early in the disorder can make it easier to make ethical decisions about
the
CJD patient's care.

Q Outlook (Prognosis)

The outcome of CJD is very poor. People with sporadic CJD are unable to care for
themselves within 6 months or less after symptoms begin.

The disorder is fatal in a short time, usually within 8 months. People who have
variant CJD get worse more slowly, but the condition is still fatal. A few people
survive for as long as 1 or 2 years. The cause of death is usually infection, heart
failure, or respiratory failure.

The course of CJD is:

Infection with the disease

Loss of ability to interact with others
Loss of ability to function or care for oneself
Death
When to Contact a Medical Professional

CJD is not a medical emergency. However, getting diagnosed and treated early
may make the symptoms easier to control, give patients time to make advance

617
directives and prepare for the end of life, and give families extra time to come to
terms with the condition.

Q encephalopathy =disturbed cerebral function usually due to some metabolic

disorder sauch as renal failure(uremia ) and liver failure such as hepatitis.

Q Encephalitis

acuteinflammation of the brain. Encephalitis with meningitis is

known
as meningoencephalitis.
Symptoms
include headache, fever, confusion, drowsiness, and fatigue. Further symptoms
include seizures or convulsions, tremors, hallucinations, stroke, and
memory
problems.

Q list symptoms of dependence with receptors and brain areas iinvolved

ans =receptors are mue , kappa and delta

and brain area s involved are limbic system

neurobilogical mechanism involved in addiction=

animportant neurological substrate that mediates such effects is mid

brain
dopamine system , the cell boodiers of which originate in ventral tegmental area
and innervate forebrain particularly ventral striatum

it has been proposed that dolpamine pathways form part of a

physiologiczal
reward system which has property of increasing frequency of behaviuor that
activeates it rtherefore it is of interest that administration of different kindsof
drugs of misuse includes alcohol, nicotine and opoids to aninmals increases

618
dopamine release in nucleus accumbans . this suggget that activation of midbrain
dopamine pathway may be a common property of drugs that have a propensity to
ber used and misuse

neurobillogy of tolerance and dependdance= these are believed to be result of

neuroadaptive changesd in brain

these are part of homeostatic process which countractas the acute

pharmacological effects that occurs when a drug is administered e.g many drugs
that are misused for their anxiolytics and hypnotic properties such as bzd ,
barbituratres and alcohol have among there acute phatrmacologgical effects the
ability to enhance brain gabas functioin

Q = 25yr female presented at emergency department with sudden

inability to move her right arm
Family is not forthcoming to tell history ion detail and gives vague
account of pt distress over a marriage proposal
Neurological examination revealas no abnormality they look as little
suspicious
Q =what is most propable diagnose
Ans= conversion disorders
Q =what are differential diagnoses?
Ans=neurological= dementia, tumors, basal ganglia disease and optic neuritis
Psychiatric-=scyzophrenia,, depressive disorders, anxiety , factitious and
malingering
Q =what is likely etiology=seen most commonly in women
Low socioeconomic status, rural population
Low IQ, military personnel

619
Commonly associated with passive aggressive, dependent, antisocial,
histrionic personality disorders
Q=what will be your management plan ?
Ans=psychotheraphy to establish a caring relationship wit treater and focus
on stress and coping skill
Amobarbital interview may be helpful in obtaining more information
Q=seven essentials In informational care to pt and family?
Physician must set aside certain time within consultation to giver
reasonable level of in formzation to pt and his family about disease and
treatment
1= IC SESSION MUST take place In language that pt can understand
2= it must start with pt knowledge,understanding and expectation
3= disease must remove any myths and misconception that pt mention in his
description
These misconception must be immediately replaced with scientific and
evidence basis
4= the task of giving information must be professionalized meaning thereby
that evidence based facts are provided without fear of causing negative
reaction in pt or relatives
It must however be done with , compassion, empathy and sensitivity
Vague statements and building false hopes should be avoided
5=both aspects of diagnoses and treatment ,negative and positive should be
communicated to pt but informational overload should be avoided
6= use of simple figures, diagrams and sketches are often helpful to
understand pt understanding(most pt or relatives may like to keep sketches at
end of session which consolidates interest and utility of informational care
in therapeutic process

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7= IC session ends with pt briefly summarizing his new understanding of
3D.
Q= 9yr old boy brought to you by his mother with history of
irritability and overactive behavior, restless in class and fail to focus on
lessons
He frequently forgets things in school does not sit quietly to watch tv
unlike his younger brother
During interview child is unable to stand still and refuses to answer any
question
Q=what is most likely diagnoses?
Answer=attention deficit hyperactivity disorders
Q=enlist areas of assessment in this case?
Answer= is characterized by inattention , hyperactivity, impulsivity that
interfere with social or academic function
The symptoms last for 6month and onset occurs before 7yr age
Symptoms are present in multiple setting
Subtypes are based on predominance of symptoms of b inattention or of
hyperactivity and impulsivity
Q =what are common comorbid psychiatric condition in this disorders
Ans==1=mental retardation
2=autistic disorders
3= mood disorders
Q=what are various pharmacological condition in this case?
Ans=pharmacotherapy of choice is stimulant medication especially methyl
phenydate and other amphetamines
They are usually effective in decreasing hyperactivity, in attention, and
impulsivity,
621
They should generally be given only In school days and not automatically
restarted following summer vacation
Other medication includes various antidepressants and clonidine
Q= 67yr old male brought to psychiatric OPD with forgetfulness, visual
hallucination, variation in attention and alertness
On physical Examination pt have tremor rigidity and difficulty in
initiating movement
Ans=parkinsonism –
Q=what are points in this favour?
Ans=the hallmark of Parkinsonism are tremor rigidity and akinesia
Other symptoms are forgetfulness ,variation in alertness and delirium ,
frequent fall may occur in this disease
Q= what are DD?
ANS=destruction of dopaminergic neurons is a key pathogenic components
and may be caused by 1= environmental toxins
2-=infection
3= genetic predisposition
4= aging
There is no laboratory test for disease
Diagnoses is based on clinical grounds alone
Many condition will be ruled out before diagnoses od Parkinson disease is
ruled out
Such as
1= hypothyroidism
2= depression
3=drug induced parkinsonism
4= multi infarct dementia
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5= Alzheimer disease
6= shy dagger syndrome
7= corticobasal degeneration
8=Wilson disease
9= huntingtin disease
Q = investigate this case?
Answer=no laboratory test available and diagnoses is based on clinical
grounds
Q= what are pharmacological treatments?
Ans=1=dopamine precursor like levodopa
And carbidopa
2= dopamine agonist like bromocriptine
3-= anticholinergic medication like benztropine ,truihexyphrnidyl
4= amantadine
5= selegline
Q = a chronic schizophrenic pt started biting other pt and staff .
several option were tried but staff were unavailable to control his
behavior
A board of three doctors decided that because pt is dangerous to
other, all his teeeths should be removed .the dental surgeon removed his
teeths and provided a dentuire which could be used at time of taking
food.when relatives visited they got angry and went in a court of law
where after proper hearing 3 doctor of board and dental surgeon was
declared guilty
What are principles of medical ethics and in this case what principles
are violated?
Answer-=three ethical principles are widely adopted in medical ethics
623
1= respect for autonomy= involving pt in health care decision, informing
them so that they can make decision and respecting their views
2= beneficence and nonmalevolence= doing what is best for pt and not doing
harm ,
In practice this usually means doing what body of professional opinion
judges to be best
3= justice=acting fairly and balancing interest of different peoples
Ethical principles can and do regular conflict with each other
In above principles nonmalevolence was principles but this was violated and
thus malevolence was observed
Q : How you will take interview in emergency from psychiatric Patient?
INTERVIEW IN AN EMERGENCY
Has to be brief ,focused on key issues and effective in leading to a
provisional diagnosis and plan of Immediate action
.these assessment generally allows acutly distressed and often takes place in
different bsetting such as police station or medical ward.the diagnosis which
are usually inn questions are psychosis (schyzoprenia ,manias,drug induced)
and delirium and others organic brain disorders .through out interviewer
should consider which questions need to be anawer at time and which can be
delayed
An emergency assessment should wherever possible Include following care
information
1=presenting complaints in term of symptoms or behavior,together with oset
course and present severirity
2=history of psyciahtric or medical disorder
3=current medical illness
4=use of alcohol and drugs
624
5=stressful circumstances around time of onset and at present time
6=family and personal history
7=social circumstances
8=risk assessment .iimmediatly risk of harm to self AND others
Q: Best Screening questions for psychotic disorders
BEST SCREENING QUESTIONS FOR PSYCHOTIC DISORDERS
DURING PAST MONTHS AND FOR SCREENING
1=HAVE U FELY LOW IN SPIRIT?(DEPRESSION)
2=DO YOU ENJOY THINGS LEESS THAN YOU USUALLY DO?
(DEPRESSION)
3=HAVE U BEING FEELING GENERALLY ANXIUOS( NEUROSIS
,ANXIETY)
4=ARE YOU WORRIED ABOUT YOUR HEALTH OR OTHER SPECIFIC
THINGS(NEUROSIS ,ANXIETY)
5=HAS YOUR EATING FELT OUT OF CONTROL?(EATING
DISORDER)
6 DO U DRINK ALCOHOL?IF SO ASK FAST OR CAGE
QUESTIONS(ALCOHOL PROBLEMS)
7=PRESENT THREE ITEMS ASK PATIENT TO RECALL THEM AFTER
2MINUTES?(DEMENTIA/DELIRIUM)
TOPICS TO BE EVALUATED DURING PSYCHIATRIC ASSESSMENT
PATIENT PROBLEMS AND ITS CONSEQUENCES
Diagnosis
Impact on self and others
Risk to self and others
Effect on others
PATEINT AND THEIR CIRCUMSTANCES
625
PERSONAL HISTORY
Current circumstances
Personality
AETIOLOGY
RESPONSE TO PATIENT PROBLEMS
Treatment and prognosis
PATIENT UNDERSTANDING OF ABOVE

COMMUNICATING WITH PATIENTAND RELATIVES

Relevant questions from following list can be helpful when deciding what
information should be given to pt and their relatives
DIAGNOSIS
What is psychiatric illness?
If it is certain what are possibilities?
IS THERE A GENERAL MEDICAL COONDITION?
WHAT further investigation are required?
What are implication for diagnosis in this patient?what may have caused this
condition?
CARE PLAN
What is your plan and how it will help patient and your family?
What needs to be communicated about medical and psychological
treatments?
WHO DOES WHAT?
Who is key worker and what they will do?
What is role of psychiatrist?
What is role of other members of psychiatric team ?
What is role of general practiotioner?
626
What can family do to patient ?
EMERGENCY
What are risks and how to avoid that?
Are there possible early warning signs of a crisis?
Who should be approached in emergency and how they can be found quic
kly?
FORMULATION
Statement of problem
Differential diagnosis
Aetiology
Plan of treatment and
Prognosis
Q What is Purposes of Classifications?
NOSOLOGY=CLASSIFICATION OF DRUGS AND ITS STUDY
PURPOSE OF CLASSIFICATION
1=to enable clinician to communicate with each other
2=to understand implication of these diagniosis in treatment and prognosis
3=to relate finding of clinical research to pt seen in every day practice
Q : Define Mental illness in your own words?
5 types of definition of mentall illness
1=WHO definition=
A state of complete physical mental and sociakll wellbeing and not merely
absence of disease or infirmity
2=disease is what the doctor treats
3=biological disadvantage is mental illness
4=pathological process is brain is mental illness
5=presence of suffering
627
Q: Define Impairment and Handicap ?
IMPAIRMENTS
Refers to pathological defect forexam,ple hemiparesis after stroke
DISABILITY
Is limitation of physical or psychological function that arises from
impairment for example difficiulties in self care that are caused by
hemiparesis
HANDICAP=
Refedrs to resulting social dysfunction that are result of hemiparesis
Q= senarios of 20yr old girl with history of repeated self harm having
cut marks on both arms ,she has histry of frequent anger outbursts.
Diagnosis is depressive illness followed by alcohol or drug abuse n
males and anxiety disorder in women
Q =describe PSYCHATRIC SEQUELI OF MULTIPLE SCLEROSIS?
1=MOST COMMON CAUSE OF NEUROLOGICAL DISABILITY
2=depression
3=euphoric
4=emotional lability
5=cognitive impairment in 40% of cases
6=dementia
Q = senarios of 77y old retired person with history of gradual loss of
recent memory for a few months
Diagnosis is alzeuimrer disease
Biological investigations
1=EEG shows focal abnormalities
2=neuroimaging and neuropsychhartric testing show abnormal findings
3=folstein MMSE show dementia

628
4=b12 and folate levels
5=RPR
6=CBC WITH SMA
7=THYROID FUNCTION TESTS
PSYCHOMEETRIC TEST have already been discussed in back pages
Q BIOLOGICAL MARKRERS AND DIAGNOSTIC
INVESTIGATION IN ALZEIMER DISEASE
Diagnosis is based on numerous clinical ,neuroradoilogical
,neuroradiological and neuropsychological evaluation
Definitive diagnosis is based on 1=autopsy
2=brain biopsy
Ct and mri are used to measure length or volume in brain of alzeimer
disease.
SPECT AND PET
Glucose metabolites such as beta amyloid precurser protein in csf .
Down syndrome pt develops ultimately alzeimer disease
Q WHAT ARE SOCIAL ISSUES IN ALZEIMER PT AND FAMILY?
Family caring for a person with alzeimer disease soon discovered that it is
unlike any other illness
Facing with degenerative brain disease is much different than dealing with a
physical disability
Alzeimer disease has more disruption to and greater impact on family than
other chronic disease
Families of alzeimer disease pt carries a high financial social and economic
price

629
Families must work togather effectively coping with the disease,and
decreaseing harmful effects on families and keeping family conflicts to
minimum
Q neuro psychiatric symptoms in parkinsonism
1= delirium stuper
2 cognitive
3= depsressive apathy
4 hallucination
5=delusion
6=sleep attack rem sleep behavviour disorder sexual disorder
Impulse comtrol disorder e.g gambling which is largely medication related
Q =you are asked to see old man who has been becoming more
physically un well over lastg 24hrs he is not your pt but you know that
antidepressant has recently changed
His symptoms are1=confusion and delirium
2= restless and agitation
3= sweating and shivering
4=tachycardia
Dx is ssri withdrawal leading to serotonin syndrome
Q =SEROTONIN SYNDROME
MAOI AND SSRI OR TCA used together as wll as maoi along with
serotnergic analgesics such as tramadol or mepiridine can cause potentially
fatal drug drug Interacytion serotonrgic syndromerer featuresv are high fever
autionomic in stability headach seizure delirium diarea and muscle rigidity
To avoid this reaction recommended washout period for an ssri or an hca
before starting on mao is 5wk and 2wk respectively

630
Q senaarios of 58yr old man with cva with right hemiplegia and
speech problems ,crying spells ,anhedonia and suicidal ideations
HISTRY OF HTN
Ans=VASCULAR DENEMTIA
TREATMENT OF VASCULAR DEMENTIA
TREAT UNDRELYING CAUSE
CONTROL OF RISK FACTORS SUCH AS HTN ,DM ,SMOKING,
HYPERCHOLESTROLEMUIA,
HYPPERLIPIDEMIA
ENDARTERECTOMY for cerebrovascular pathology ,correction of
sourcers of emboli
Anticoaguleent theraphy
Thrombolytic agent TPA
Q scenario of 70 yr man with forgetfulness
Diagnosis is alzeimer disease
Q MRI changes in brain in alzeimer disease
Answer=on neuroanatomic findings 1=cortical atrophy
2=widening of sulci 3-=enlarged ventricles
HISTOPATHOLOGY
Senile plaques
Neuro fibrillory tangles
Neuronal loss
Synaptic loss
Granulovascuolar degeneration
Associated with chromosomes 21
Decrease ach and NE
Death after 8yr of diagniosis
631
Q 5 REVELANT test in alzeimer disease
1=b12
2=folate
3=RPR
4=CBC WITH SMA
5=LFT T3 AND T4 and tsh
Q senarios of depression of diabetic patient
Diabetes mellitus
Chronic condition
Require prolong medical supervision
Diabetes melitis is having a lot of long tterm compliance so psychological
factors are needed for good compliance so that pt take drugs and prevent
long term compliocation and thus
Psychological and social problems are mainly caused by restriction of diet
and activity
Control of diabetic problem is more difficult when diabetic pt has an eating
disorder
Sexual problems are especially impotence caused in diabetic men
Two kinds
First psychogenic and 2nd due too autonomic neuropathy
Pregna ncy is a difficult time for diabetic and miscarriages and fetal
malformation occurs
Organic psychiatry syndrome in diabetic pt are delirium diabetic coma and
chronic cognitive impairment
Q PSYCHIATRIC ASPECTS OF MASNAGEMENT

632
Diabetic has been cause of considerable psychotic research involving a
range of psychological treatment particularly in adolescence diabetic
Q PSYCHATRIC ASPECTS OF ENDOCRINE DISORDERS AND
STERIOD THERAPHY
1=HYPERTHYRIODISM
INCLIUDE anxiety,decrease concentration ,irritability,
And emotional lability
Treatmernt of T3 and T4 improves anxiety
2=hypothyroidism = cognitive impairment and mood disorders
3=cushing syndrome = depressive symptoms and psychological distress
4=steroid theraphy
Mania symptoms and paranoid symptoms
5=anabolic steroids
Used widely by atheletes .mood disturbances and aggression reported
Q STEPS IN ELECTROCONVULSIVE THERAPHY
ECT involves induction of a generalize seizure lasting 25-65seconds by
passing an electric cureent across brain .prior to seizure induction pt is
premedicated with atropine .general anaesthetic is given either with
propofol and muscle relaxant such as succinyl choline ,.after few ECT
improvement is seen .
Q INDICATION=
1=MAJOR DEPRESSIVE DISORDER THAT HAVE NOT responded to
antidepressents and mood disorders
2=MDD with high risk for immediate suicide
3=MDD with contraindication to antidepresents
4=MDD who responded well to ECT in past
elderly with depression
633
RISK AND PROBLEM IN ECT1= ante and retrograde amnesia
2= increease intracranial pressure or MI is relative contraindicated to ECT
3=LOW mortality rate with ECT AND MAINLY DUE TO GA
Q E XPLAIN SUICIDE RISK IN MOOD DISORDER
A=PT WITH MOOD DISORDER At RISK FOR SUICIDE ARE AT HIGH
risk for suicide
B= certain demographic psychoxsocial and physical factors affects the
risk top5 risk factres for suicide from highest to lower risk rate
1=serious previous suicide attempt
2=age of older than 45yr
3=alcohol dependence
4-=history of violant behavior
5=male sex\
Suicide is very complex multicausal human behaviuor with many causes and
several biological as well as psychosocial and cultural componrents.90% of
pt who do suicide have underlying psychiatric disorder in them .by provision
of psyh services suicide can be erasdicated from community.
Major depressive disorder are stated to be associated with 60percent suicide
Mental disorder
Past suicidal attempt
Un employment
Low income
Single and divorced merital status
Painful physical illness
Alcohol and drug problems
Family history of suicide
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CHRONIC RISK
Borderline personality disorder
Emotional stress
Psych symptoms such as depression psychosis hopelessness AND
impulsiveness
Alcohol and drug dependence
Physical illness such as cancer and aids
devorced and widowed
Single and unmarried
Live alone and elderly age
Q INFERIORITY COMPLEX
Is a lack of self worth and uncertainty,it is often subconsious adler was
sceintist who introduced inferiority complex. Classical adler psycology
makes a difference between primary and seciondory inferiority feeling
Primary inferiority feeling is said to be rooted in young child original
experience of weakness helplessness
Secondry inferiority feelings related to adult experience of being unable to
reach a subconsiuos goal
PARANOID SHYZOID POSITION
Distrust and suspisuiuons and emotionally cold and ood
Detachment and restricted emotionality , social drifting and dysphoria
Q PSYCHOTIC DEPRESSION that type of depression in which there
are feature of delusion and hallucinatuion
Type of delusion seen are
1=delusion of guilt
2= hypochondrial delusion
3=persecutory dell
635
4= dellusion=impoversment
5=nihilistic dell and costard syndrome
Q =AGITATED DEPREESSION
DEPRESSIVE DISORDER IN WHICH AGITATION IS PROMINENT
RETARDED DEPRESSION
DEPRESSIVE DISORDER IN WHICH PSYCHOMOTRO
RETARDATION IS PROMINANCE
DEPRESSIVE STUPOR
In severe depressive disorder slowing off movement and poverty of
speech may become so extreme that pt is motionless and mute
Q Atypical depression
Characterized by
1= variable depressed mood with mood reaction to positive events
2 overeating and oversleeping
3=extreme fatigue and heaviness in limbs that is leaden paralyses
4=pronounced anxiety
Treatment
Poor response to tca
Better response to ssri and maoi
Q =Major depression
Mood disorder that presents with aat least 2wk course of symptoms that is
change from previous level of functioning
Must have depressed mood and anhedonia
Risk factor and epidemilology
MDD seen most frequently in women due to several factres such ass
hormonal differences,great stress or simply bias in diagnoses
Typical age of onset is 40yr
636
There is higher incidence in divorced or separated many studies reporte
abnormalities in serotonin .NE,and DOPAMINE
FAMILY HISTORY
EXPOSURE TO STRESSOR AND behaviuoral reason such as learned
helplessness
Presenting symptoms
Depressed nood
Anhedonia
Wt loss or gain
Insomnia or hypersomniasa
Psychomotor retardation or excitation
Loss of energy
Worthlessness
Recurrent thouhts about death
Physical examination
May find evidence of psychomotor retardation such as stooped postre
Slowing of movement slow speech and cognitive impairment
Q Laboratory test
Abnormal dexamethasone suppression test
Thyriotropin relerasing test
May also include psychotic features =worse progniooses
Atypical feature increase wt gain increase appetite and increase sleep
Treatyment
Must first secure safety of pt given that suicide is a such high risk ssri tca
and maoi
Ect if pt is suicidal or worried about sideeffects from medication
Individual psychotheraphy cognitive theraphy

637
Dd =mental disorders
Hypothyroidism
Parkinsonism
Dementia
Pseudodementia
MENTAL DISORDERS
MOOD DISORDER
SLEEP DISORDER
GRIEF
Q =TREATMENT OF DEPRESSION
1= MEDICATION
2=PSYCHOTHERAPHY
3=ECT
THESE MAY BE USED AS SINGLY OR IN COMBINATION
Q ANTIDEPRRESSANT MEDICATION
First antidepressent was introduced in 1950
Researches have shown that imbalance in neurotransmitters like
serotonin,dopamine, and norepineprinr can be corrected with antidepressents
Four groups of antidepresents are commonly prescribed uusually
1= TCA= for severe depression in which there mechanism is to elevate
mood and to restore there normal sleep,appetite
And energy
And response to antidepresesnts is witin 4weeks
MEDICATION=
1= AMITRYPTALINE
2=IMIPRAMINE
3=CLOMIPRAMINE
638
4-==NORTRYPTALINE
5= DOTHEPIN (PROTHEDIN )
TETRACYCLIC ANTIDEPRESSENTS=
1-= MAPROPTYLINE
Q fcps=SIDE EFFECTS= 1-DRY MOUTH
2-=CONSTIIPATION
3-= BLADDER PROBLEM
4= SEXUAL PROBLEM
5-=WEIGHT GAIN
6= BLURRED VISION
Q SELECTIVE SEROTONINE REUPTAKE INHIBITER
They act specifically on serotonin as compared to TCA and MAOI.
SSRI HAVE LESS SIDE EFFECT
Q CLASIFICATION
1=FLUOXETINE
2=SETRALINE
3= PARAXETINE
4=CITALOPRAM
5=ESCITALOPRAM
Q SEROTONINE AND NOREPINEPRINE REUPTAKE INHIBITERS
EXAMPLE IS VENLA FAXINE
They are given to depress pt in early course of disease
They are also used when there is no response to other medication
Q = SIDE EFFECTS OF SSRI AND SNRI
1= NAUSEA AND DIASREA
2= NERVOUSNESS
3=INSOMNIA
639
4-=SKIN RASHES
5=SEXUAL SIDE EFFECTS
Q =MONOAMINE OXIDASE INHIBITERS
In atypical depression these are drugs of choice
Also used in anxiety, irritation., phobia, excessive sleeping
Hypochondria and other related symptoms
Example is meclobamide
Q SIDE EEFECTS OF MAO
1= pt should not take smoked fermented and pickled food along with MAO
Also beaverages are not allowed to take
Becoz such combination of food and MAO causes high blood pressure
Other side effects are
Dry mouth
Constipation
Insomnia
Weight gain
Sexual side effects
PSYCHOTHERAPHY in depression
Several types of psychotheraphy available for depression
Types include
1= cognitive behavioural therapies
2=interpersonal theraphy
For severe depression we use both IPT AND CBT
For mild to moderate depression we use only IPT OR CBT
COGNITIVE BEHAVIUORAL THERAPHY

640
Used to correct negative thinking and negative behaviour associated with
depression and to control behaviuoral disturbances that leads to there
illnesses
INTERPERSONAL THERAPHY
In this type of psychotheraphy we improve troubled personal relations and
other factors that have been associated with depression
Q =COGNITIVE DISORDERS=
Are due to organic causes
Three types
1= delirium , dementia
And amnestic disorders
2= mental disorders due to general medical condition
3= substance related disorder

Disturbances in cognition may be

1-= memory loss
2=aphasia
3= apraxia (loss of learned skills )
4= agnosia=failure to recognize objects and peoples
5=disturbance in thinking and planning

Q delirium=
Changes in sensorium is literal meaning of delirium
It is reversible mental disorder characterized by confusion,impairment
of consiuosness, hallucination. delusions , inappropriate voilant
behavior
Q CAUSES=
641
CERTAIN MEDICAL CONDITION
Infection
Metabolic disorder’
Hepatitis or renal failure
Seizures
SUBSTANCE RELATED DISORDER
Drug intoxication
Drug withdrawal
TREATMENT= treat underlying medical and substance related disorder
Protectyion of pt
Antipsychotics
Q AMNESIA=Impaired short term and long term memory especially
due to specific organic condition, drug and medical condition
Pt is normal in other areas of cognition
Causes= systemic medical condition
Thiamine deficiency
(korsakof syndrome)
Hypogylycemia
PRIMARY BRAIN CONDITION
Seizures
Head trauma
Cvs
Encephalitis
Hypoxia
Ect
Multiple scleroses
SUBSTANCE USE
642
Alcohol and benzodiazepines
Q DELUSION =
False but firm belief which is held by pt tightly and belief persists even if
proved to be false and not corrected by arguiment and reasoning
Q =PANIC DISORDER=
Episode of intense fear, peaking in 10min, and have at least 4 of following
P=palpitation and paresthesia
A=abdominal discomfort
N=nausea=
I=intense fear and light headedness
C=chest pain,chills and chocking
S =sweating and shortness of breath
Strongly genetically inherited
Treatment = CBT
Also=SSRI,TCA, BENZODIAZEPINESQ
Q =ASSESSMENT OF COMPETENCE OF ADULT PATIENT
STEP1=identify decision required and information relevant to it
Decision to be made
Alternative reasoning decision
Pros and cons of each reasonable decision
STEP 2=assess cognitive abilities .ass ability to understand information
,retain information evauate informationon and recall information
STEP3=consider possible cause of impaired cognitive ability
Delirim dementia and other neuronological disordes that may impair
cognition such as learning disabilities
STEP 4
Assess other factors that may interfere capacities with
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deliusions
Mental illness
Hallucination
Mood disorders
Lack of maturity
Assess emotional and cognitive impairment

Q = SERVICES FOR PSYCHIATRIC DISOREDRS IN PRIMARY

CARE
CLASSIFICATION OF PSYCHIATRIC DISORDER IN PRIMAY
CARE
IDENTIFICATRIC DISORDER IN OF PSYCHIATRY ILLNES IN
PRIMARY CARE
DISORDERS THAT ARE TREATED IN PRIMARY CARE
PERSON SEEKING HELP
Leads to
Primary care
Leads to
Specialist care
Q =DISORDERS THAT ARE REFFERED FROM PRIMERY CARE
TO PSYCHTRIC SERVICES
TREATTMENT PROVIDED BY PRIMARY CARE S FOR ACUTE
DISORDERS
IMPROVING ACESS TO PSYCHOLOGICAL THERAPIES(IAPT)
TREATMENT PROVIDED BY PRIMARY CARE TO CHRIONIC
DISORDERS
WORK IN PRIMARY CARE BY PSYCHTRIC TEAM
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Advicing and training general practitioner and there staff
Assessing and refering
Assessing and treating
Shared care and lason meeting
Q FRONTAL LOBE SYNDROME is impairment of frontal lobe that
occurs due to disease or head trauma. The frontal lobe of brain plays a
key role in higher mental function such as motivation, planning and
social behavior and speech production
Q CAUSES=
1= head trauma
2= tumors
3=degenerative disease
4=neurosurgery
5= cerebrovascular disease
Diagnosis= on recognition of typical signs ,use of simple screening tests
and specialist neurological testing
Q PATHOLOGY=
1=foster kenedy syndrome
2=foster disinhibition syndrome,rett syndrome and ADHD
3=frontal abulic syndrome
Q Clinical features oof frontal lobe syndrome
1=cognitive
Short attention span
Poor working and short term memory
Difficulty in planning and reasoning
2=emotionall-=depression
Anger, frusturation and sadness
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3=behavioural
Perseverable behaviuor
Sexual behaviuor
4=frontal release signs
Grasp reflex ,palmomental reflex and rooting reflex
Q = HEADinjury in accident pt was modest hard working in hospital pt
is rude to nurses and loses his temper and refuse to wear gown
Answer=injury to prefrontal cortex
And investigation include CT,MRI, and EEG.
Q =BRIEFLY DISCUSS REPETETION OF SELF HARM
A systematic review of 90 studies concluded that among people who have
engage in DSH
A=about one sixth repeates DSH within one year
B=about one fourth repeats DSH within 4yrs
Q Reasons given for deliberate self harm
Answer=1=to die 2=to escape from unbearable anguish
3=to obtain relief
4=to change the behaviuor of others
5=to=to escape from situation
6=to show disperation to others
7=to get back at other people /make them feel guilty
8=to get help
Q Married man with severe depression plus 30pounds weight loss in
last 2months and refuses to eat and does not change clothes and death
wishes
Answer=ect is indicated in major depressive illness which does not respond
to antidepressents
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B=HOW would u convince to proceed with your treatment of choice
Answer=discus that ect is good and rapid long term treatment
Q =THREE INVESTIGGATION FOR WILSON DISEASE
1=SERUM COPPER REDUCED BECOZ IT IS DEPPOSITED IN
TISSUES
2=24HR URINARY COPPER IS INCCREASED
3= LIVER BIOPSY BECOZ HIGH LEVEL OF COPPER IN LIVER
TREATMERNT
RESTRICTION OF DIETRY COPER SUCH AS IN SHELLFISH AND
LEGUMES
1=PENICILLAMINES 1GM PER DAY IS a drug of choice that chelates and
excretes coper thru kidney in urine
Pyridoxine 50mg per week should be asddedd since pencillamine is an
antimetabolites of this viitamins and causes deficiency
2=trientine dihydrochloride
3=zinc acetate
Q =CARE OF POTENTIALLY SUICIDAL PATIENT IN A
COMMUNITY
Answer= FULL ASSESSMENT OF PATENT AND PROPOSED CARERS
ORGANIZATION OF ADEQUATE SOCIAL SUPPORT
REGULAR VREVIEW OF SIUCIDAL RISK AND ARRANGEMENT
SAFE PSYCHTRIC TREATMENT GIVEN IN ADEQUETE DOSES
USING LESS TOXIC DRUGS
SMALL PRESCRIPTYION
INVIOLVEMENT OF RELATIVE IN SAFE STORAGE OF TABLETS
ARRANGEMENTS FOR IMMEDIATE ACESS TO EXTRA HELP FOR
PT AND CARERS
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Q = CARE OF SUICIIDAL PATEINT IN HOSPITAL?
ANSWER=GENERAL REQUIREMENTS
Safe ward requirmentrs
An adequate no of well trained staff
Good working relationship among stasff and betweedn staff and pt
Agreed polices for observation assessment and review of patients
ON ADMISSION
Assess risk
Remove any object which may be used for suicide
Disicuss agree plan with pt
Agree a policy for visitors (no and duration of vsit and what they need to
know)
DURING ADMISSION
Regular review of risk and plan
Agreed plan for level of supervision clear communities of assessment and
plan between staff especially when shift changes
Agreed action to be taken if pt leaves the ward without notice or permission
AT DICHARGE
Agree date and plan for after care in advance of discharge
Discuss and agree the plan with the pt and those involved in thre care
Prescribe in adequate but not dangerous amounts
Arrange follow up and agree action to be taken if pt not attended
Q = CLINICAL FEATURES OF ADHD
ANS=
Short attention span , constant fidgeting and inability to sit thru cartoons
inability to wait in lines and failure to stay quiet or sit still in class,

648
disobedience, shunning by peers, fighting, poor academic performance,
carelessness, poor relationship with siblings
Dd MR ,AUTISTIC DISORDER AND MOOD DISORDER
TREATMENT
1=METHYL PHENYDATE
2= AMLPHETYAMINE
3=ANTIDEPRESSENTS
4= CLONIODINE
Q CAPACITY TO STAND TRIAL OR TESTAMENTRY CAPACITY
THIS TERM REFFERS TO CAPACITY TO MAKE A VALID WILL ,IF
SOMEONE IS SUFFERING FROM MENTAL DISORDERS AT TIME
OF MAKING A WILL,ITS VALIDITY MAY BE IN DOUBT AND OTHER
PEOPLES MAY CHALLENGE IT .THE WILL MAY STILL BE LEGALLY
VALID OF TESTETER WAS OF SOUND DISPOSING MIND AT TIME
OF MAKING IT
PSYCHIATRIST MAY BE ASKED TO REPORT IN RELATION TO
2 ISSUES
1=TESTAMENTRY Capacity
2=the possibility that testater was subjected to undue influence,in order to
decide wether or not a testeror is of sound disposing mind the doctor should
decide wether the person making will
Understand that a will and its consequences
Knows the nature and extent of his property
Knows name of close relatives and can assess there claim to his property
Is free from abnormal state of mind that might distort judgments relevant to
making will .

649
To decide these matters dr should intrerview testater alone and then
interview relatives to check accuracy of factual statements
Assessment of undue influence is more complex and require an assessment
of relationship between testater, beneficiary , mental state of tester and what
is known of person earlier intensions
Q 3MONTH history of voilance against wife And daughter
Pt suspect sexual involment with neibour
He also plan to remove daughter name from his name becoz he thinks that
features resemble that of neibiour. pt denies any illness
DD 1=delusional disoreder
2=schyzopreniac 3= anxiety
4= depressive illness5= mood disorder
Q = MANAGEMENT OF VOILANCE IN HEALTH CATRE
SETTINGS
ANSWER==voilance incident is increasing .the reason for this increase
appears to include the following
Morbid jealousy or delusional jealousy is a psychological disorder in which
pt strongly believes that their sexual partner is being unfaithful wiyhout
having real proof to back up there clam
Q WHAT ARE PT CHARACTERISTICS THAT MAKE
COMMUNITY CARE DIFFICULT
ANSWER=risk of harm to self and others
Unpredicted behavior and liability to relapse
Substance misuse
Poor motivation and poor capacity for self management
Lack of insight into need for treatment
Low public acceptably

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Q YOU ARE BEING ASKED TO TRAIN SOME VOLUNTEERS FOR
COUNSELLING OF FLOOD VICTIMS TAKING THE
OPPURTUNITY YOU OBTAIN DATA ABOUT THESE
VOLUNTEERS AT START OF TREATMENT AND AT END ALL
DATA IS IN MEASURABLE FORM
A=NAME ANY TEST OF STATISTICAL SIGNIFICANCE THAT CAN
BE APPLIED FOR DATA?
Answer=chi square test
Q =CRETIRIA FOR DETENTION UNDER MENTAL HEALTH ACT
Condition for detention are 4=
1=you consider that pt is likely to be suffering from a MENTAL
DISORDER(detention may sometime be necessary to establish that)
2=detention is necessary for health and safety of pt. and others
3=pt refuses voluntary admission
4=appropriate treatment is available for treatment order
Until 2007 revision there were four classes of mental disorder subject to
detention
A=mental illness b= mental impairment c=severe mental impairment
D=psychopathic disorder
But these were replaced by a single category of mental disorder this was to
remove individual requirement for specific disorders.
Pt must be given an opportunity to accept voluntary treatment before
compulsion can be used
Q =PSYCHOSOCIAL FACTORS FOR OFFENDING
INDIVIDUAL FACTORS
Hyperactivity and impulsivity
Low intelligence
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Child rearing poor supervision
Harsh discipline and rejection
Teenage mother
Parent conflict and separation
Criminal parents
Large family size
SOCIAL FACTORS
Socioeconomic deprivation
Peer influences
School influence
Criminal infliuences
PSYCHIATRIC CAUSES
Psychiatric disorder and offending
People with psychotic disorder are more likely than member of general club
to acquire conviction for voilance and other crimes by factor of 4 and 10
respectively
This increase likelihood is alteredin strength by local factors such as criminal
rate and sociodemograpic variables
Antisocial disorder of personality and substance misuse disorder have strong
association with offending than does psychotic illness
A combination of psychtric disorder particularly when one of these is
substance misuse disorder may be more releva nt than any single category of
psychotic disorder
SCHYZOPRENIA AND RELATED DISORDER
Psychotic illnesses may be associated with voilance especially paranoid
symptomatology is prent or pt has substance misuse problem .voilance may

652
occur becoz offender is frightened and self control may be reduced by
presence of psychotic illness
Paranoid psychotic symptoms increases risk of violent behaviors
EPIDEMIOLOGY
Studies have shown that strongly suggested that schizophrenia is associated
with an increase risk of both voilant and non voilant offending
This risk is substantially increase by substance misuse but proportion of
violent crimes attributable to schyzoprenia are less
Violence in schizophrenia has been proposed including the following
Fear and loss of self control associated with delusion
Irresistible urges
Paranoid delusions including conviction that enemies must be defendant
against
Instruction for hallucination voices (command hallucination)
Dual diagnosis particularly substance misuse
A strong negative effect such as depression anger and agitation
Voillant threats made by pt with psychosis should be taken very
seriously(especially in those with a history of previous violence
Q = enumerate section of mental health ordinance 2001 that deals with
detension of a pt in a psychIatric fac ility and duration of detension
allowed by law according to section 9
MENAL HEALTH ACT
COMPULSORY TREATMENT OF MENTAL DISIORDER
Specific legislation to ensure that people with severe mental illness can be
treated involuntary and that such treatment is subjected tocareful scrutiny is
a feature of all developed societies

653
In most cases where people are treared in hospital or another health facility
they have agreed to be there or volumnteered to be there this pt is called as
voluntary patient
However there are cases when person can be detained(also known as
sectioned) under mental health ordinance(1983) and treated without their
agreement
Mental health act is the main piece of legislation that covers
assessment,treatment and rights of people with mental health disorder
People detained under mental health ordinance needs urgent treatment for a
mental health disorder and are at risk of harm to self and others
ADVICE FOR CARERS AND FAMILIES
If your lover has been detained she will have to stay in hospital until doctor
decide otherwise however you still have right to visit
Visiting arrangement depends on hospital so check visiting hours with staff
or on hospital website
In some cases pt may refuse visitors and hospital staff will respect pt wishes
If u are unable to see relative hospital staff will explain reason with
permission from an un relative doctor may discuss treatment plan with u
Hospital accommodation should be age and gender appropriate
Not all hospital will be able to offer a WORD dedicated to each gender but
all should atleast ofer same sex toilets and wash facilities

Q =CAPROPRAXIA=exhibition of obsene behaviuor

Q suicide=suicidology is is progression of thought of suicide to
attempted suicide
Suicide is intensional act of killing ones self.suicidal ideation= it means
thinking about killing ones self

654
Active suicidal ideation =when person think about and seeks ways to
commit suicide
It ends with fatal outcome
Passive suicidal ideation =when person thinks about wanting to die but
no plans gto commit suicide and it ends with non fatal outcome
Epidemiology= majority of suicide occur in young age group.women try
more often and men succed more often
ETIOLOGY=pt with psychtric disorder such as depression,shyzoprenia
,ptsd, substance abuse
Chronic mental illness such as hiv and cancer
Enviriomental factors=isolation,any recent loss,lack of any social
support,unemploymeral facters,divorse behaviuorall facters=impulsivity and
unexplained changes from usual behaviuor.
Unstable life style
Risk facters=risk of completed suicide increases in sad person
It means
S=sex
A=age adolescent and age more than 40years
D=depression=about 25 % more common in depressed person than normal
person
P=previous history of suicidal attempt
E=ethanol
R=rational thinking loss due to mental illness
S= ill severe illness
O=organized plan =
N= no spouse, divirsed .or separated
S=social isolation
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Q 975 Methods used are poisoning,hanging,drowning,jumping , and burning

Q=48YR old retired wapda employee was brought by wife with 10days
history reveales depressive episode 5yr back plus distractible plus
overtalkative. Expressed business plan about making a lot of money out
of pastries .he was not hallucination, impaired concentration and lacked
insight?
Answer=diagnosis is mania
Differential diagnosis are
1=BAD
2=mania
3=depression
4=mood disorder
5 personality disorder
IMPORTANT TREATMENT
=1=LITHIUM
2=CARBAMAZEPINE 3=valproic acid

Q CHOOSE at least two antidepressents for following special group

A=pregnancy=1=fluoxetine 2nortriptaline
B=lactation1=paroxetine and 2 = sensival
C=hepatic impairment = 1 = paroxetine and Escitalopram
D=renal impairment1=paroxetine
2=escitalopram
E=Parkinson 1=citalopram and escitalopram
F=children (5-14yr)
fluexetinee and amitryptaline
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G=epilepsy
Escitalopram and Setralin
H= ischemic heart disease
I=geritrics(age above 65)citalopram and Escitalopram
Q =CHILD NEGLECT=
Failure to provide necessary care to child
It can have following forms
1=emotional neglect
2=physical neglect
3=educational neglect
4=neglect of medical and surgical conditions
Child neglect is more common than child abuse and it can be detected by
various peoples including relatives and neibours and teachers
Q =CARE OF POTENTIALLY SUICIDAL PATIENT IN A
COMMUNITY
Answer= FULL ASSESSMENT OF PATENT AND PROPOSED
CARERS
ORGANIZATION OF ADEQUATE SOCIAL SUPPORT
REGULAR VREVIEW OF SIUCIDAL RISK AND ARRANGEMENT
SAFE PSYCHTRIC TREATMENT GIVEN IN ADEQUETE DOSES
USING LESS TOXIC DRUGS
SMALL PRESCRIPTYION
INVIOLVEMENT OF RELATIVE IN SAFE STORAGE OF TABLETS
ARRANGEMENTS FOR IMMEDIATE ACESS TO EXTRA HELP FOR
PT AND CARERS
Q =KEY CLINICAL FEATURES IN MENTAL HEALTH ACT
1= CRETERIA FOR DETENTION
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2= ASSESSMENT DISORDER
3=TREATMENT ORDER
4= TRANSFER FROM PRISON AND COURT
5= POLICE POWER AND POWER OF ENTRY
6= COMMUNITY TREATMENT ORDERS
Q=NEUROPSYCHIATRIC AND BEHAVIUORAL SYMPTOMS
ASSOCIATED WITH MULTIPLE SCLEROSES
1=Multiple scleroses is most common cause of neurological disability in
developed countries
2=depression and also as result of side effect of beta interferon which is used
to treat multiple scleroses
3= euphoria
4=emotional lability
5=seven fold increase in risk of suicide
6=cognitive impairment in 40% pt
Q fcps=PHOBIC DISORDERS
Fear without any reason and pt avoids certain objects and situation
Clinical features=
1=agoraphobia=
Fear of open places from which escape would be difficult and common in
womens
2=specific phobia
Fear of object or situation other than specific pobia and agoraphobia
For example = fear from spiders,darkness,injection and storm like causes
SOCIAL PHOBIA=
Pt feels ashamed of social situation like pt cannot urinates in a public
latereens and fear of doing demonstration in like stage fright

658
TREATMENT=
1= relaxation techniques
2=systematic desensitization
3= psychopharmacological
A= SSRI
B=BUSPIRON
C= BETABLOCKER INDERAL FOR STAGE FRIGHT
Q =DIAGNOSTIC CRETERIA BETWEEN ANXIETY AND
GENERALIZE ANXIETY DISORDER
No clear dividing line between these two disease
They differ both in symptoms and there duration . According to ICD -10
there are 22 symptom while in DSM includes 6 symptoms
Also according to ICD -10
Symptoms must be present for more than six month duration
COMORBIDITY
1=anxiety and depression
2=generalize anxiety disorder
DIFFERENTIAL DIAGNOSES
1= DEPRESSIVE ILLNESS
2=SCHYZOPRENIA
3=DEMMENTIA
4=SUBSTANCE MISUSE
5=PHYSICAL ILLNESSES INCLUDES
THYROTOXICOSES (TREMOR, TACHYCARDIA ,ENLATRGED
THYROID ,ARIAL FIBRILATATION AND EXOPTHALMOS)
PHEOCHROMOCYTOSES= hypoglecemia
Laboratory test will confirm these disease
659
6=anxiety secondary to these illnesesse
7= generalize anxiety disorder that is mistaken for physical ilnessess
AETIOLOGY=
1= STRESSFUL EVENT
2=GENETIC CAUSES=risk of GAD in first degree relatives is five
times than in control
3= EARLY ADVERSE EXPERIENCES=
Some relationship exist between adverse experiences in child hood and
anxiety disorder in adults
4=PSYCHOANALYTICAL THEORIES
From intrapsychic conflicts in which ego is potentiated by excitation from
A= outside world
B=id like love
c= superego
5= COGNITIVE BEHAVIOURAl theories
These theories suggest that when there is inherent predisposition to
excessive responsiveness of autonomic nervous system
6=PERSONALITY
7=NEUROBIOLOGICAL MECHANISM
8=BEHAVIUORAL THEORIES
States that anxiety is a response to some environmental situation like fear
like situation
9= NEUROBIOLOGICAL MECHANISM = states that various
neurotransmitters especially GABA,NEP,SEROTONINE) AND various cns
structures like reticular activation system and limbic system
PROGNOSES=
GAD which last more than 6 months have poor prognoses

660
Associated disease with other depression cause poor out come and
prognoses
TREATMENT=
1= SELF HELP
2=PSYCHOEDUCATION
3= relaxation technioques
4=cognitive behaviuioral theraphy
5=medication like Escitalopram and paroxetine
SHORT TERM TREATMENT MEDICATION
1= diazepam 5mg up to 10mg tds from mild to severe cases
2= buspiron also for short term management
3= for performance anxiety we give beta blockers
LONG TERM TREATMENT=
First choice is SSRI OR SNRI SUCH AS duloxetine and venlafaxine and
pregabaline also
MEDICATION
1= first make diagnoses and see assoc iated comorbidity like thyrotixicoses
and treat them appropriately
2= see and assess persistant social problems and social conflicts
3= propose treatment=
4= CBT
5=RELAXATION TECHNIQUES
6=short course of benzodiazepines may be prescribed
7=discuss treatment plan with general practitioner and community teams
Q =CONDUCT DISORDER
Violation in four areas
1= aggression
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2=property destruction 3= theft and 4=rules
Etiology=
1=genetic causes 2-= environmental causes
3= stressful life experiences
Prevalence more in males .10% of school age childrens
FAMILY HISTORY=
1=ANTISOCIAL
2= CONDUCT
3= ADHD
CLINICAL FEATURES=
1= BULLYING 2= FIGHT
3=ABSENCY FROM SCHOOL WITHOUT ANY REASON
4=THEIFT 5=RAPE
COMPLICATION=SCHOOL FAILURE AND SUBSTANCE RELATED
DISORDER
CHILD ABUSE
1= PHYSICAL ABUSE
2=FACTITTIOUS DISORDER
3= EMOTIONAL ABUSE
4=FETAL abuse
5=SEXUAL ABUSE
Factitious disorder is an apparent illness in child abuse is concealed by
parents
Q PHYSICAL ABUSE=
(NONACCIDENTAL ABUSE)

662
Parent usually bring the abuse child and parent say that this has been
accidental injury but history from relatives,neighours and other may report
this problem to police
Q COMMON FORM OF INJURIES INCLLUDE=
1=BRUISES
2= BURNS,ABRASION
3= BITES
4= FRACTURES
5= SUBDURAL HAEMORAGE
Q Etiology
1=ENVIROMENTAL FACTERS=
Child abuse is common in neibghourhood of families in which there is
voilance common
2=PARENTS=
Child parent usually are1=young
2=abnormal personality disorder like schyzoprenia
3=psychiatric disorder
4=marital conflict
5= criminal record
CHILDREN = early separation, premature birth , congenital
malformation and chronic diseases
Q ASSESSMENT AND MANAGEMENT=
Doctor should be alert about abuse of child.
Point that may raise suspicious includes
1=delay in seeking help
2=concealment of ways in which injuries occurred
3=concealment of nature and extent of injury
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4=lack of concern for child
Doctor should refer child to paediatricuian and doctor should inform
paediatrician of child abuse case.
Paeditrician will do physic al examination to see for physical consequences
Docter should inform magistrate if parents are not coopereating in child
abuse case
Doctor should do photography of injuries and xray for skeletal fractures
Radiological examination may show evidence of previuos injuries or bone
abnormalities like osteo geneses imperfect
A CT SCAN may be done for subdural haenmorage suspicion
Doctor first duty is safety of child
Doctor should put name of child in register
Q PROGNOSES=
1= high risk of problem in child abusefor children risk percentage is 30%
2= delayed development
3=physical injurioes
4= mental learning difficulties
Q fcps=REQUIRMENT OF COMMUNITY SERVICES PROVIDING
LONG TERM CARE
The following seven provision are required to replace long term care in
hospital
1=suitable and self supported care
2=appropriate accommodation
3=suitable occupation
4= arrangement that enlist the pt collaboration with treatment
5=regular reassessment including assessment of physical health
6=effective collaboration among health carers

664
7=continuity of care and rapid response to crisis
Q =SCHYZOPRENIA LIKE DISORDERS
Psychotic dosorders like schyzoprenia and paranoid disorder is a common
cause of debate among psychiatrists
Q =describe ORGANIZATION OF SERVICES
An international consensus statement defined essential elements of mental
health
services of elderly as follows
1= primary health care team
2=geriatric psychiatrist
3= inpatient unit
4= rehabilitation
5= day care centre
6 residential care faciilities
7=family support
8= education OF HEALTH CARE PROVIDERS with psychtric patients
Q =NATIONAL DEMENTIA STARTEGY
Has been launched for uk and has three steps
1= better knowledge about dementia
2= early diagnoses and treatment
3= develop services to meet with changing demands
HEALTH SERVICES
PRIMARY CARE
General practitioner have a prominent role in assessment and management
of old age psychtric patients
In uk old age pateints are given health check which is provided for
screening of psychtric disorders
665
In many cases GP and other health team assess and manage pt without
refering to a specialist
Even if disorder like dementia if pt refered to specialist still early
duiagnioses and mmanagement is done by GP and health team
Q =48YR old retired waoda employee was brought by wife with 10days
history reveales depressive episode 5yr back plus distractible plus
overtaklative. Expressed business plan about making a lot of money out
of pastries .he was not hallucination, impaired concentration and lacked
insight?
Answer=diagnosis is mania
Differential diagnosis are
1=BAD
2=mania
3=depression
4=mood disorder
5 personality disorder
IMPORTANT TREATMENT
=1=LITHIUM
2=CARBAMaazzepine
3=valproic acid
Q =DOMICILIARY PSYCHIATRIC CARE
Care of old age pt at home is called domiciliary care
Which is good both for carers at home and old age pt
Community psychtrist acts as a brigde between primary care and specialist
services
OUT PATIENT CLINICS

666
Small role in old age but they play greatb role in providing care for young
and mobile pts because assessment for eldetrly are best done at home
MEMORY CLINICS
Especially developed for old age pt who have dementia and suspected
alzeimer disease
DAY HOSPITALS AND DAY CENTRES
We know that treatment of old age pt are given at home but old age pt may
require to attend day hospital and day centres
Geriatric hospital develop day care to take care of elderly pt and to
mprovide diagnoses and to mprovide short term and long term care for
psychiatric pt and to provide support to relatives
In patient units
Multidisciplinary assessment provides severe psychtric disorder in elderly
LONG TERM CARE=
In some countries elders are treated in psychtric hospital and they need
some requirments like opportunities for privacy and use of personal
possession
If these requirments are nmet then long term treatment can be best for
disable patients
SOCIAL SERVICES
Q = SERVICES FOR PSYCHTRIC DISOREDRS IN PRIMARY CARE
CLASSIFICATION OF PSYCHTRIC DISORDER IN PRIMAY CARE
IDENTIFICATRIC DISORDER IN OF PSYCHTY ILLNES IN PRIMARY
CARE DISORDERS THAT ARE TREATED IN PRIMARY CARE
PERSON SEEKING HELP
Leads to
Primary care
667
Leads to
Specialist care
Q =DISORDERS THAT ARE REFFERED FROM PRIMERY CARE
TO PSYCHIATRIC SERVICES
TREATTMENT PROVIDED BY PRIMARY CARE S FOR ACUTE
DISORDERS
IMPROVING ACESS TO PSYCHOLOGICAL THERAPIES(IAPT)
TREATMENT PROVIDED BY PRIMARY CARE TO CHRIONIC
DISORDERS
WORK IN PRIMARY CARE BY PSYCHTRIC TEAM
Advicing and trainimng general practitioner and there staff
Assessing and refering
Assessing and treating
Shared care and lason meeting
Q =48YR old retired wapda employee was brought by wife with 10days
history reveales depressive episode 5yr back plus distractible plus
overtaklative. Expressed business plan about making a lot of money out
of pastries .he was not hallucination, impaired concentration and lacked
insight?
Answer=diagnosis is mania
Differential diagnosis are
1=Bipolar affective disorder
2=mania
3=depression
4=mood disorder
5 personality disorder
IMPORTANT TREATMENT
668
=1=LITHIUM
2=CARBAMaazzepine
3=valproic acid
Q =PSYCHIATRIC TREATMENT IN ELDERLY AND THERE
REHABILITATION
Principle of psychiatric treatment in elderly resembles those in adults. there
are three issues to be kept in mind which may have effect on treatment
Elderly may have multiple problems like psychtric ,physical and social
difficulties may usually coexist to some extent
Treatment may include wide range of intervention beyond these normally
associated with psychiatry
Boundaries between normality and disease are rare this provides challenge
for treatment threshold and services provision
Lack of competetivenerss is common due to cognitrive impairment
Physical treatments= dangerous side effects of physic al treatment included .
Most grugs used to treat cardiovascular disorders like htn and used to treat
cns depression,antipsychotics and thses are anti parkinsonian drugs these
problems
Compliance with treatment may be compromised in those who live alone or
who are forgetfull or confused
Start with low dose increase slowely to final dose.exception is ssri
Drug regimn should be as simple as possible and medicine bottle should be
labeklled clearly
ECT
Most effective for psychiatric disorder of elderly .attention should be paid to
physical health of all elderly pt undergoing treatment
PSYCHOLOGICAL TREATMENT

669
Supportive theraphy for elderly pt and pt carers
PSYCHO SOCIAL TREATMENTS
Q ABUSE AND NEGLECT OF ELDERLY
Elderly pt are abusef and neglected by family membres as is an issue of
increasing concern for all health professional working with elderly
Five forms
1=physical2=psychological 3=sexual 4=finanxcial 5=neglect
Prevalence is conmon and and have a high risk of
Abused pt have dementia
Elderly and carers live together
Socially isolated elderly
Carers have a psychiatric disorders
Carers is finantially depending on person who is being abused
Elder abuse have three fold mortality rate compared with that of normal
elders
Treatment bof dementia
Behavioural and psychiological symptom of dementia
Behavioural symptoms
1= agitation
2=shouting
3= wanderiong
4 apathy
5 inapproprate sexual behavviour
Symptoms=1-= delusion 2-= hallucination
3= depression 4= sensory deficits
C
CONTRIBUTING FACTERS
670
1= constipation
2= pain
3= delirium
4= sensory defecits
PREVALENCE=5% PREVALENCE in elderly n with age 50yr
20% prevalence in elderly with age above 80yr
Heretibilities in dementia is impoertant in neurodegenretive disease likev
huntington disease
ABNORMAL FINDINGS=
FROM neuroimaging and neuropsychiatric testing
Physical examination shows cns motor pathology
DIAGNOSTIC TESTS
1= EEG
MMSI
B12 AND FOLATE LEVELS
CBC WITH SMA
TFT,S
DIFFERENTIA;L DIAGNOSES
1-= DELIRIUM
2=AGE RELATED COGNITIVE DECLINE
Q =NON PHARMACOLOGICAL TREATMNT OF BEHAVIOURAL
AND PSYCHOLOGICAL TREATMENTS
1-=SENSORY STIMULATION INCLUDES MUSIC THERAPHY AND
MASSAGE THERAPHY
2=BEHAVIOURAL MANAGEMENT
3= MEDICATION WHICH IMPAIR COGNITION SHOULD BE STOPPED
4=SOCIAL AND V EMOTIONAL SUPPORT
671
5=EXERCISE
6=ENVIROMENTAL MODIFICATION
7=CARER VEDUCATION AND SUPPORT
8 MULTIPLE OTHER THERAPIES LIKE COMBINATION THERAPIES
Q=SIDE EFFECTS of anticholenergics include git effects and insomnia
and depressdion and bradycardia and most dangerous is syncope which
is transient loss of consiuosness
Start with low dose and slow increase dose if pt does not improve drug
can be changed
Q MEMANTINE=
NMDA glutamate antagonist .it is used becoz NMDA causes damage to
nervioous system thus leads to damage to brain especially alzeimer disease
hence NMDA receptor antagonist is developed to coontriol and manage
alzeimer disease process
Q GINKO BILOBA = tree from which extract from leaves is being long
term in china used for lot of disease like alzeimer disease
Q NOVEL TREATMENT APPROACHES=
Beta amyloid protein is having a CENTRAL ROLE IN ALZEIMER
DISEASE PROCESS.
so drugs which decreses syntheses and decrease agraggregatio and
immunological targeted beta amyloid protein are widely used to control this
disease
Q 3MONTH history of voilanc against wife And daughter
Pt suspect sexual involment with neibour
He also plan to remove daughter name from his name becoz he thinks
that features resemble that of neibiour. pt denies any illness
DD 1=delusional disoreder
672
2=schyzopreniac 3= anxiety 4= depressive illness5= mood disorder
Q =REQUIRMENT OF COMMUNITY SERVICES PROVIDING
LONG TERM CARE
The following seven provision are required to replace long term care in
hospital
1=suitable and self supported care
2=appropriate accommodation
3=suitable occupation
4= arrangement that enlist the pt collaboration with treatment
5=regular reassessment including assessment of physical health
6=effective collaboration among health carers
7=continuity of care and rapid response to crisis
Q Married man with severe depression plus 30pounds weight loss in last
2months and refuses to eat and does not change clothes and death wishes
Answer=ect is indicated in major depressive illness which does not respond
to antidepressents
B=HOW would u convince to proceed with your treatment of choice
Answer=discus that ect is good and rapid long term treatment
Q =CARE OF POTENTIALLY SUICIDAL PATIENT IN A
COMMUNITY
Answer= FULL ASSESSMENT OF PATENT AND PROPOSED CARERS
ORGANIZATION OF ADEQUATE SOCIAL SUPPORT
REGULAR VREVIEW OF SIUCIDAL RISK AND ARRANGEMENT
SAFE PSYCHIATRIC TREATMENT GIVEN IN ADEQUETE DOSES
USING LESS TOXIC DRUGS
SMALL PRESCRIPTYION
INVIOLVEMENT OF RELATIVE IN SAFE STORAGE OF TABLETS
673
ARRANGEMENTS FOR IMMEDIATE ACESS TO EXTRA HELP FOR
PT AND CARERS
Q = CARE OF SUICIIDAL PATEINT IN HOSPITAL?
ANSWER=GENERAL REQUIREMENTS
Safe ward requirments
An adequate no of well trained staff
Good working relationship among stasff and betweedn staff and pt
Agreed polices for observation assessment and review of patients
ON ADMISSION
Assess risk
Remove any object which may be used for suicide
Disicuss agree plan with pt
Agree a policy for visitors (no and duration of vsit and what they need to
know)
DURING ADMISSION
Regular review of risk and plan
Agreed vplan for level of supervision clear communities of assessment and
plan between staff especially when shift changes
Agreed action to be taken if pt leaves the ward without notice or permission
AT DICHARGE
Agree date and plan for after care in advance of discharge
Discuss and agree the plan with the pt and those involved in thre care
Prescribe in adequate but not dangerous amounts
Arrange follow up and agree action to be taken if pt not attended
Q = MANAGEMENT OF VOILANCE IN HEALTH CATRE
SETTINGS

674
ANSWER==voilance incidernt is increasing .the reason for this increase
apearsto include the following
Morbid jealousy or delusional jealousy is a psychological disorder in which
pt strongly believes that their sexual partner is being unfaithful wihout
having real proof to back up there clam
=CARE OF POTENTIUALLY SUICIDAL PATIENT IN A
COMMUNITY
Answer= FULL ASSESSMENT OF PATENT AND PROPOSED CARERS
ORGANIZATION OF ADEQUATE SOCIAL SUPPORT
REGULAR VREVIEW OF SIUCIDAL RISK AND ARRANGEMENT
SAFE PSYCHTRIC TREATMENT GIVEN IN ADEQUETE DOSES
USING LESS TOXIC DRUGS
SMALL PRESCRIPTYION
INVIOLVEMENT OF RELATIVE IN SAFE STORAGE OF TABLETS
ARRANGEMENTS FOR IMMEDIATE ACESS TO EXTRA HELP FOR
PT AND CARERS
Q =THREE INVESTIGATION FOR WILSON DISEASE
1=SERUM COPPER REDUCED BECOZ IT IS DEPPOSITED IN
TISSUES
2=24HR URINARY COPPER IS INCCREASED
3= LIVER BIOPSY BECOZ HIGH LEVEL OF COPPER IN LIVER
TREATMENT
RESTRICTION OF DIETRY COPER SUCH AS IN SHELLFISH AND
LEGUMES
1=PENICILLAMINES 1GM PER DAY IS a drug of choice that chelates and
excretes coper thru kidney in urine

675
Pyridoxine 50mg per week should be asddedd since pencillamine is an
antimetabolites of this viitamins and causes deficiency
2=trientine dihydrochloride
3=zinc acetate

Q=CAPROPRAXIA=exhibition of obsene behaviuor

Q suicide=suicidology is is progression of thought of suicide to
attempted suicide
Suicide is intensional act of killing ones self.suicidal ideation= it means
thinking about killing ones self
Active suicidal ideation =when person think about and seeks ways to
commit suicide
It ends with fatal outcome
Passive suicidal ideation =when person thinks about wanting to die but
no plans gto commit suicide and it ends with non fatal outcome
Epidemiology= majority of suicide occur in young age group.women try
more often and men succed more often
Q ETIOLOGY=pt with psychiatric disorder such as
depression,shyzoprenia ,ptsd, substance abuse
Chronic mental illness such as hiv and cancer
Enviriomental factors=isolation,any recent loss,lack of any social
support,unemploymeral facters
t,divorse
behaviuorall facters=impulsivity and unexplained changes from usual
behaviuor.
Unstable life style
Risk facters=risk of completed suicide increases in sad person
676
It means
S=sex
A=age adolescent and age more than 40years
D=depression=about 25 % more common in depressed person than normal
person
P=previous history of suicidal attempt
E=ethanol
R=rational thinking loss due to mental illness
S= ill severe illness
O=organized plan =
N= no spouse, divirsed .or separated
S=social isolation
Methods used are poisoning,hanging,drowning,jumping , and burning
Q WHAT ARE PT CHARACTERISTICS THAT MAKE
COMMUNITY CARE DIFFICULT
ANSWER=risk of harm to self and others
Unpredicted behavior and liability to relapse
Substance misuse
Poor motivation and poor capacity for self management
Lack of insight into need for treatment
Low public acceptably
Q =48YR old retired waoda employee was brought by wife with 10days
history reveales depressive episode 5yr back plus distractible plus
overtaklative. Expressed business plan about making a lot of money out
of pastries .he was not hallucination, impaired concentration and lacked
insight?
Answer=diagnosis is mania
677
Differential diagnosis are
1=BAD
2=mania
3=depression
4=mood disorder
5 personality disorder
IMPORTANT TREATMENT
=1=LITHIUM
2=CARBAMaazzepine
3=valproic acid

Q = MANAGEMENT OF VOILANCE IN HEALTH CATRE SETTINGS

ANSWER==voilance incidernt is increasing .the reason for this increase
apearsto include the following
Morbid jealousy or delusional jealousy is a psychological disorder in which
pt strongly believes that their sexual partner is being unfaithful wiyhout
having real proof to back up there clam
Q=48YR old retired waoda employee was brought by wife with 10days
history reveales depressive episode 5yr back plus distractible plus
overtaklative. Expressed business plan about making a lot of money out
of pastries .he was not hallucination, impaired concentration and lacked
insight?
Answer=diagnosis is mania
Differential diagnosis are
1=BAD
2=mania
3=depression
678
4=mood disorder
5 personality disorder
IMPORTANT TREATMENT
=1=LITHIUM
2=CARBAMaazzepine
3=valproic acid
Q =REQUIRMENT OF COMMUNITY SERVICES PROVIDING
LONG TERM CARE
The following seven provision are required to replace long term care in
hospital
1=suitable and self supported care
2=appropriate accommodation
3=suitable occupation
4= arrangement that enlist the pt collaboration with treatment
5=regular reassessment including assessment of physical health
6=effective collaboration among health carers
7=continuity of care and rapid response to crisis
Q Married man with severe depression plus 30pounds weight loss in last
2months and refuses to eat and does not change clothes and death wishes
Answer=ect is indicated in major depressive illness which does not respond
to antidepressents
B=HOW would u convince to proceed with your treatment of choice
Answer=discus that ect is good and rapid long term treatment
CONTRINDICATION OFF ECT
1=respiratory illness2= cardiac
3=pyrexial illness

679
Q =48YR old retired waoda employee was brought by wife with 10days
history reveales depressive episode 5yr back plus distractible plus
overtaklative. Expressed business plan about making a lot of money out
of pastries .he was not hallucination, impaired concentration and lacked
insight?
Answer=diagnosis is mania
Differential diagnosis are
1=Bipolar affective disorders
2=mania
3=depression
4=mood disorder
5 personality disorder
IMPORTANT TREATMENT
=1=LITHIUM
2=CARBAMaazzepine
3=valproic acid
Q=HYPNOGOGIC HALLYUCINATION=
Vivid dream like hallucination at on set of sleep
Q HYPNOPOMPIOC HALLUCINATION =
Vivid dream like hallucination on awakening from sleep
Q KINESTHETIC HALLUCINATION=
Hallucination involving sense of bobily movements
QLILIPUTIAN HALUCINATION=
WHEN thing and peoples looks smaller
Than they are in reality
Q CAUSE OF VISUAL HALUCINATION=
1-= MIGRAIN
680
2-=EPILEPSY
3=PARKINSON DISESEA
4=ALZEIMMER DISESAE
5=ALCOHOL
6=DRUGS
7= NARCOLEPSY
8=PSYCHOSES
Q=DELUSIONAL DISORDER=
IS characterized by condtion in which primary manifestatiom is delusion
that is fixed and cannot be removed
Unlike schyzoprenia delusional disorder are not bizzar but there thoughts
are organized
Treatment of deluisional dizsorder=
1= antipsychotic medication
2= anxiolytic medication
3= supportived and cognitiver psychotheraphy
Q = Long-term effects OF BENZODIAZEPINES

The long-term effects of benzodiazepine use can include cognitive impairment as

well as affective and behavioural problems. Feelings of turmoil, difficulty in
thinking constructively, loss of sex-drive, agoraphobia and social phobia,
increasing anxiety and depression, loss of interest in leisure pursuits and
interests,
and an inability to experience or express feelings can also occur. Not everyone,
however, experiences problems with long-term use. Additionally an altered
perception of self, environment and relationships may occur.

Diazepam 2 mg and 5 mg diazepam tablets, which are commonly used in the

treatment of benzodiazepine withdrawal.

681
The main problem of the chronic use of benzodiazepines is the development
of tolerance and dependence. Tolerance manifests itself as diminished
pharmacological effect and develops relatively quickly to the sedative, hypnotic,
anticonvulsant, and muscle relaxant actions of benzodiazepines. Tolerance to anti-
anxiety effects develops more slowly with little evidence of continued
effectiveness beyond four to six months of continued use. In general, tolerance to
the amnesic effects does not occur. However, controversy exists as to tolerance to
the anxiolytic effects with some evidence that benzodiazepines retain efficacy and
opposing evidence from a systematic review of the literature that tolerance
frequently occursand some evidence that anxiety may worsen with long-term
use. The question of tolerance to the amnesic effects of benzodiazepines is,
likewise, unclear. Some evidence suggests that partial tolerance does develop, and
that, "memory impairment is limited to a narrow window within 90 minutes after
each dose".

Discontinuation of benzodiazepines or abrupt reduction of the dose, even after a

relatively short course of treatment (three to four weeks), may result in two
groups
of symptoms —rebound and withdrawal. Rebound symptoms are the return of the
symptoms for which the patient was treated but worse than before. Withdrawal
symptoms are the new symptoms that occur when the benzodiazepine is stopped.
They are the main sign of physical dependence.

Q =CAUSES OF CRIMINOLOGY AND TERRORISM

Criminal behaviuor is different from rule breaking behasviour.not all rule
breaking behavior is criminal.Violence is agereessive behaviuor that crosses
social norm as in street fight
GENETICS AND PHYSIOLOGICAL BEHAVIOUR

682
Studies of twins suggests that CONCORDANCE RATE IS FOR CRIME
are more in monozygotic twins than in dizygotic twins .genetic factores are
well established for conduct disorder in children and the continuity in
aggressive antisocial behavioour. Genetic differences in offending has raised
the questions of influence
Of either 4chromosome or testosterone level on offending
Q= Young trainee enters psychiatry ward pt repeatedly saluting.
Trainee want to shack hand with him but he pulls his hand back then
stretch it again and then pul him back
Ans=psychopathology=mannerism and ambetidence
Q=pt is in a corner of room and staring at ceiling ,trainee requested him
to sit down he refuses to sit down ‘
He also refuses to drink juice
Answer=psychopathology is negativism
Q=pt was wandering in ward and shouting some slogans and say that
he is minister of health and is on special mission
he is not a patient but when nurse asked him why he shouts he told it is
a n intelligence agency which made him shout,he also told that there are
secret cameras by which agency peoples by which observe his behavior
he request traine that he wants to be discharged from hospital
answer=psychopathology is grandiose delusion,persecutory delusion and lack
of insight
Q=30 yr schyzoprenic pt was admitted with positive symptoms
There was history of smoking fourty cigrates per day and amphetamine
and cocaine abuse
Haloperidol was started which improved positive symptoms but
negative symptoms became more prominent
683
He also developed extrapyramidal symptoms and gynecomastia so
olanzapine was started in place of haloperidol
Answer=high level of dopamine and abnormalities in serotonin
Positive symptom result from excessive dopaminergic activity in limbic
system and negative symptoms result from reduced dopaminerguic activity
in frontal lobe
Increase serotonergic activity in schyzoprenia
Glutamate is implicated in schyzoprenia
Q =what is body mass index=it is calculated by dividing weight inkg
divided by height in meter square
Bmi-=kg/m2

Q =1 Classification of organic mentaldisorders [cognitive disorders]

according to diagnostic statistical manual ivand international classification of
diseases ICD 10.

Cognitive disorders can be broadly classified into 1=delirium 2=dementia

3=amnesia

1=delirium can be further classified according to causes into general

medical,substance related and multifactorial.

2=Dementia into Alzheimer dementia,vascular origin, head trauma related,levy

body related,Huntington related,

Fronttemporal degeneration,creutz Jacob disease, general medical origin,substance

related, multifactorial related.

3=Amnesia into general medical and substance related

Symptoms associated with regional brain pathology

Q Frontal lobe regions and their deficits after lesions.

684
1=primary motor area and premotor cortex=lesion leads to contralateral spastic
paresis

2=frontal eye field. Lesion leads to deviation of eyes toward ipsilateral side

3=brocas speech area .lesion lead to expressive or nonfluent aphasia.

4=prefrontal cortex=lesion leads to frontal lobe syndrome symptoms are poor

judgment,difficulty in concentrating and problem solving ability and inappropriate
social behavior.

Q Parietal lobe lesions and their efeects

1=superior parietal lobule=contralateral astreiognosis and apraxia

2=inferior parietal lobule=Gerstmamnn syndrome=confusion,

alexia,
dyscalculia and dysgraphia

3=primary somatosensory =contralateral hemihyphesthesia

Q Temporal lobe lesions and their effects

1=primary auditory cortex=bilaterally leads to deafness and unilaterally leads to

slight hearing loss

2=wernick area =receptive and fluent aphasia

3=hippocampus=bilaterally leads to inability to convert short term into long term

memory loss

4=amygdala=kluver bucky syndrome= hyperphagia.hyper sexuality and visual

agnosia

5=olfactory bulb=ipsilateral anosmia

6=Meyer loop=contralateral upper quaderativenopia

Q Occipital lobe

Cortical blindness if bilateral and macular sparing hemianopia

Q Limbic system components and functions

685
Is involved in emotion .behaviour and recent memory.it
includes1=hypocampus2=amygdala3=septal nuclei4=subiculm and dentate gyrus

Q =CAUSES OF DRUG INDUCED PSYCHOSES

1=ALCOHOL;2=AMPETAMINE

3=COCAINE

4=HALLUCINOGENS

5=INHALANTS

6=SEDATIVE HYPNOTICS

7=STEROIDS

Q =TREATMENT OF DEPRESSION

1= MEDICATION

2=PSYCHOTHERAPHY

3=ECT

THESE MAY BE USED AS SINGLY OR IN COMBINATION

Q ANTIDEPRESSANT MEDICATION

First antideptressent was introduced in 1950

Researches have shown that imbalance in neurotransmitters like

serotonin,dopamine, and norepineprinr can be corrected with antidepressents

Four groups of antidepresents are commonly prescribed uusually

1= TCA= for severe depression in which there mechasnism is to elevate mood

and to restore there normal sleep,appetite

And energy

And response tom antidepresesnts is witin 4weeks

MEDICATION=

686
1= AMITRYPTALINE

2=IMIPRAMINE

3=CLOMIPRAMINE

4-==NORTRYPTALINE

5= DOTHEPIN (PROTHEDIN )

TETRACYCLIC ANTIDEPRESSENTS=

1-= MAPROPTYLINE

Q==SIDE EFFECTS= 1-DRY MOUTH

2-=CONSTIIPATION

3-= BLADER PROBLEM

4= SEXUAL PROBLEM

5-=WEIGHT GAIN

6= BLURRED VISION

Q SELECTIVE SEROTONINE REUPTAKE INHIBITER

They act specifically on serotonin as compared to TCA and MAOI.

SSRI HAVE LESS SIDE EFFECT

Q CLASIFICATION

1=FLUOXETINE

2=SETRALINE

3= PARAXETINE

4=CITALOPRAM

5=ESCITALOPRAM

Q SEROTONINE AND NOREPINEPRINE REUPTAKE INHIBITERS

687
EXAMPLE IS VENLAFAXINE

They are given to depreses pt in early course of disease

They are also used when there is no response to other medication

Q = SIDE EFFECTS OF SSRI AND SNRI

1= NAUSEA AND DIASREA

2= NERVOUSNESS

3=INSOMNIA

4-=SKIN RASHES

5=SEXUAL SIDE EFFECTS

Q =MONOAMINE OXIDASE INHIBITERS

In atypical depression are these drugs of choice

Also used in anxiety, irritation., phobia, excessive sleeping

Hypochondria and other related symptoms

Example is meclobamide

Q SIDE EEFECTS OF MAO

1= pt should not taker smoked fermented and pickled food along with MAO

Also beaverages are not allowed to take

Becoz such combinatgion of food and MAO causes high blood pressure

Other side effects are

Dry mouth

Constipation

Insomnia

Weight gain

688
Sexual side effects

Q PSYCHOTHERAPHY

Several types of psychotheraphy available for dep;ression

Types include

1= cognitive behavioural therapies

2=interpersonal theraphy

For severe depression we use both IPT AND CBT

For mild to moderate depression we use only IPT OR CBT

COGNITIVE BEHAVIUORAL THERAPHY

Used to correct negative thinking and negative behaviuor associated with

depression and to control behaviuoral disturbances that leads to there illnesses

INTERPERSONAL THERAPHY

In this type of psychotheraphy we improve troubled personal relations and oter

factors that have been assocuited with depression

Q =MANIA=

State of abnormal mood that is predominantly euphoric(pleasurable feelings) and

there may be rapit shift to anger and tearfulness and suicide threats

CLINICAL FEATURES=1=OVERSPENDING OF MONEY

2=hyper sexuality

3= increase libido

4= flight of ideas

5= grandiosity

6=insomnia

7=weight loss

689
Q Hypomania= similar to mania but no social WITHDRAWN

Q =BIPOLAR DISORDER=

Characterized by history of mania or mixed episode of both manic and

depressive episode during course of disorder

Treatment=

A= lithium indicated in mania and bipolar disorder

B= antideptreesents and lithium

C= antipsychotic if psychotic features

D=ECT is done if no response to above tx

Q =BIPOLAR DISORDER 2

HYPOMANIA EPISODE AND MAJOR DEPRESSIVE EPISODE

BIPOLAR ONE DISORDER=

1-=MANIA

2=DEPRESSIOJN

BIPOLAR 2 DISORDER

1-= HYPOMANIC EPISSODE

2= MAJOR DEPRESSIVE EPISODE

Q =TREATMENT OF BIPOLAR 2 DISORDER

LITHIUM

ANTIDEPRESENT

ANTIPSYCHOTIC IF THERE IS PSYCHOTIC FEATURES

ECT IS AS LAST RESORT

Q =COGNITIVE DISORDERS=

690
Are due to organic causes

Three types

1= delirium , dementia

And amnesic disorders

2= mental disorders due to general medical condition

3= substance related disorder

Disturbances in cognition may be

1-= memory loss

2=aphasia

3= apraxia (loss of learned skills )

4= agnosia=failure to recognize objects and peoples

5=disturbance in thinking and planning

Q delirium=

Changes in sensorium is litera;l meaning of delirium

It is reversible mental disorder characterized by confusion,impairment of

consiuosness,hallucination.delusions ,inaoppropriate voilant behavior

CAUSES=

CERTAIN MEDICAL CONDITION

Infection

Metabolic disorder’

Hepatitis or renal failure

691
Seiozures

SUBSTANCE RELATED DISORDER

Drug intoxication

Drug withdrawal

TREATMENT= treat underlying medical and substance related disorder

Protectyion of pt

Antipsychotics

QAMNESIA=Impaired short term and long term memory especially due to

specific organic condition,drug and medical condition

Pt is normal in other areas of cognition

Causes= systemic medical co ndition

Thiamine defiociency’

(korsakof syndrome)

Hypogylycemia

PRIMARY BRAIN CONDITION

Seizures

Head trauma

Cvs

Encephalitis

Hypoxia

Ect

Multiple scleroses

SUBSTANCE USE

692
Alcohol and benzodiazepines

Q = EATING DISORDER

ANOREXIA NERVOSA= Is a serious or potentially fatal condition

characteruized by self imposed dietry limitation usually resulting in serious
malnutrition

Especially 1% of adolescence girls usually associated with stressful events

Q =DIAGNOSTIC FEATURES OF ANOREXIA NERVOSA

1= Fear of becoming obese even in weight loss condition

2= disturbed body imasged

3 weight loss of 25% from original weight

4=refusal to maintain weight at normal

Q TREATMENT OF ANOREXIA NERVOSA=

HOSPITALIZATION =

Correction of metabolic disturbances

Behavioral therapies

Family therapy

Antidepresents

Q =BULEMIA NERVOSA

Characteruized by frequent being eating and purging and self image that is
influenced by weight

Usually 40years females

Type=

1=purging

2-= nonpurging

693
In bulenmia nervosa repeatyed attempts to lose weight

Weight is increased in bulimia nervosa

Q = Treatment OF BULEMIA NERVOSA=

1= CBT

2= SSRI

3= PSYCHOTHERAPHY

Q= HIGH LIGHT BIOLOGICAL , PSYCHOLOGICAL AND SOCIAL

,PRECIPITATIONG FACTORS FOR SUICIDE?

ANS=ETIOLOGY =

Pt with psychiatric disorders like depression , schyzoprenia ,PTSD, substance

abuse

Chronic mental illness such as hiv and cancer

Environmental factors=isolation,any recent loss, lack of any social

support,unemployment facters, and divorse

Behaviural factors= impulsivity and unexplained changes from usual behaviuore,

Unstable life style,

Risk facters= risk of completed suicide increases in sad person

Mnemonic SAD PERSONS

S= sex male

A= age adolescence and age more than 40years

D= Depression( about 25% more in depressed person)

P=previous history of suicidal attempt

E=ethanol use

694
R= rational thinking loss due to mental illness

S= severely ill

O=organized plan for suicide

N= no spouse, divorced or separated

S= social isolation

Q=ENUMERATE THE SECTION OF MENTAL HEALTTH ACT OF

DETENTION OF PT IN PSYCHTRIC HOSPITAL?

ANS= creteria for detention are

1 detention is necessary to establishe that pt is suffering from psychtric illness

2= detention is necessary for health and safety of pt

3=pt refuses voluntary admission

4= appropriate treatment is available for treatment order

Q=how u can determine the competence to stand trial ?

Ans=step 1= identify decision required and information relevant to it ,decision to

be made and alternative decision

Step 2= assess cognitive ability to understand information and decision

Step3=consider possible causes of impaired cognitive ability such as delirium

Step 4= assess other factors ;like cognitive immaturity that can interfere with
decision capacity

Q= organize a psychIAtric medical camp in a town of .5 miilion population

with a town medical centre having no psychiatric facility

Write down four priority objectives that u will address during this camp

Ans=1= advising and training GPs and their staff

2= assessing and reffering

695
3= shared care

5= laison meeting

Q whate are steps involved to achieve these objectives?

Ans=

1=classification of psychtric disorders in primary care

2= identification of psychtric disorders in primary care

3= disorders that are treated in primary care

Person seeking help first to primary care and if not managed or is complicated
then is reffered to specialist care

4= disorders that are reffered from primary care to psychtric specialist

5-= treatment provided by primary team for acute disorders

6= improving access to psychological therapies

7=treatment provided by primary care for chronic cases

8= work in primary care by psychtric team

Q EXAMPLES OF CORTICAL DEMENTIA ARE

Are 1= alzeimer and frontgotemporal dementias

Examples of subcortical dementia are

1=huntington disease

2= Parkinson disease

3= focal thalamic and basal ganglia lesion

4 multiple scleroses

MIXED DEMENTIA

1=vascular dementia

696
2= lewy body dementia

3= corticobasal degeneration

4= neurosypilis

Q=What are neuropsychiatric and behavouoral symptpoms in multiple

scleroses

1-= chronic neurological disability

2-=seven time risk in suicidal risk

3=depression

Depression is also due to use of beta interferon in multiple scleriposes

4= cognitive impairment in 40%patients

5= intellectual deterioration

Q=YOUNG FEMALE DEVELOPS depression after divorse

,psychotheraphy was adviced it was noted that during theraphy she started
calling her therapist about mionor thing , send jokes on sms wearing more
and more provocative dresses and calling her therapist by his name

Q= what pt is showing this behaviuior?

Ans= positive transfersance

Q = how this behavior can affect her treatment?

Ans= treatment should not be given and refered to another psychtrist

Q =how you can manage this behaviuor?

Ans =doctor should not show counter trasnsferance ansd it is against medical
ethics

Q =40YEAR lady is offered antidepressants treatment for moderate

depressive episode

Please respond to following queries

697
A what is chance of my 17 year old daughter developing this disease

Ans =if one parent is ill chance will be 20%

Ai both then chance is 40%

So chances in this case is 20%

Q =Can I become dependant on this prescribe drugs

Ans= no dependence

Q=pt say can I safely quit them ?

Ans =yes

Q= what will be course of my illness if I don’t take the prescribed

treatment?

Ans=symptoms will exacerbate and duration increase and pt becomes major

depressive disorders

Q81=for how long I should take medication?

Ans= six months from date of improvement

Q= what are chances of re;lapse if I complete entire duration of treatment?

ANS= Ask pt to refrain from stress and be relax

If again stress comes then again there wil be relapse

Q=20YR old boy with self inflicted cuts on fore arms ,thighs and bruises on
hands

History of mood swings ,,episode of self harm followed by feeling of regret

There is history of substance abuse and child hood sexual abuse , he

frequently asks who am I

Q=what is your provisional diagnioses=

Ans =substance induced bipolar affective disorders

698
Q=enlist three differential diagnoses

Ans=1- =mania 2= scyzophrenia 3= drug induced BAD

Q=what are pharmacological option you wil consider

Ans =1= antipsychotics

2= mood stabilizers

3=cbt psychotherapy

Q =28 year old u nmarried diagnosed as case of chronic schyzoprenia has

been treated with haloperidol olla nzapine and quetiapine without any
responder for last 6years he has recently gain weight in last few months

What could be reason for poor response

Ans=1=noncompliance

2=resistant scyzophrenia

3=unmarried

Q what is likely pathophysiological bases for rapid gain in this patient?

ANSWER=olanzapine

Q = in light of current evidence what option you would suggest to pt to reduce

weight?

Answer=1=exercise

2=antihyperlipidemics

3=lemon juices like lemo pani

4=metformin for antipsychotics weight reduction

Q=40 YEAR lady is offered antidepresents for moderate depressive

episodes please respond to following querfies

A= what is chance in my daughter developi g this disease?

699
Ans=20% chances compared to that in mother

Q B=WILL I BECOME DEPENDENT ON PRESCRIBESD DRUGS

ANS= NO DEPENDANCE

Q c= Can I safely quit them?

Ans=yes

Q =what will be my course of symptoms if I I do not take prescribe drugs?

Ans = disease will get out of control ans sympotoms will exerbate and and resist
ant depression will develop

Q =for how long I should take medication

Ans= 6 month from date of initiation of treatment

Q=what Are chances of relapse if I completed duration of treatment?

Ans= with stresser there is increase chances of relapse and disease will exacerbate

Q=pt is a known case of psychiatric illness for 15 years

There is history of episode of fatigue increase sleep and apetite Interspersed

With episode of ooveractivity, talkatgiveniss overdressing and singing

She has been on medication for last one year and complaining of weight
gain,tiredness and lethargy

Her bp is 140/90mmhg and pulse=56per min also has tremors and mood is
euthymic on mse

What is most likely diagnoses=lilthium induced hypothyroidism

And symptoms of hypothyroidism such as weight gain lethargy and tiredness

And symptoms of bipolar affective disorders are present such as overacytivity,

talkativeness and singing and lithium is drug of choice in this case

Q What specific clinical queries will you raise in history ?

700
Ans= her mood is euthymic

Q WHAT specific lab test would you request for and why?

Answer= serum lithium level and it needs close monitoring and we need to keep it
below 1.5meq /liter

Q=write a prescription for this pt

Prescription

Tab risp 2mg 1+1

Tab kempro 5mg bd

Tab neeurolith sr 400 mg od for 3day

Then 400mg bd continues

But also given tegral instead of lithium

Tab tegral 200mg bd

Nowadays quetiapine instead of risperidone because it has more mood stabilizing

effects

Q=40 yr male married for last 8years father of 5children shopkeeper by

occupation and says during interview that my wife who is is not loyal to me
and has illegal teenagweer boy who comes in his absence and say that he has
seen semen stains on underagermwent of my wife whenever io comes home
she is well groomed with All sortg of cosmetics applied on face

Q=what specific question you would ask from pt

Ans = 1= both partners should be interviewed separately

2= partner will give more detail of pt morbid belief and action that can be
elicited from pt

3=doctor should try to find out how firmly pt believes in partner infidelity

And how much resentment he feels

701
4=what factors provoke outbursts of accusation and questioning?

5=doctor should see how does partner respond to such outbursts?

6= how does pt respond in turn to partner behavior?

7=has there any violence so far?

8=has there been any serious injury?

9=doctor should take detailed history of relationship and sexual history from both
partners and assess for underlying psychiatric disorders and this will need
treatment

Q=what is provisional diagnoses=

Ans=pathological jealousy

Q=what are disorders associsated with pathological jealousy?

Ans=1=schizophrenia 2=mood disorder

3=organic disorders

4= substance misuse such as alcohol\

5=paranoid personality disorders

Q =what is management plan for this pt?

Ans-= mainstay treatment is antipsychotics

Adequate treatment of underlying disorders or mood disorder is first requirement

If intake of alcohol or substance abuse present then specific treatment will be

needed

In other cases pathological jealousy may be symptom of delusional disorders or

an overvalued ideas in a pt with low esteem or personality disorders

In delusional disorders antipsychotics need to be given

If depression is cause treat it with antidepressants and also overvalued ideas will
respond to antidepressants

702
In case of personality disorders psychotherapy needs to be given

Behavioral methods such as encouraging partner to produce behavior to reduce

jealousy

CBT also needs to be done, multiple session needs to be done

If there is risk of violence doctor should warn partner even if this involves a
breach of confidentiality.

Q=what is mechanism of action of therapeutic and its abuse?

Answer= ecstasy is a synthetic drug that is classified in DSM-IV substance use as

a hallucinogen .

However it has stimulant as well as mild hallucinogenic properties

It is usually taken in tablet or capsule form in a dose of about 50-150mg

Given in this way its effects lasts about 4-6 hours

Like amphetamine ecstasy increases release of dopamine but it also releases

serotonin which may account for its hallucinogenic properties

Q =list potential therapeutic uses of this drug in medicine with references

Answer=

1=ADHD 2= NARCOLAPSY

3= DEPRESSION IN ELDERLY AND TERMINALLY ILL

4=depression and obesity pt who does not response to treatment

Q = married male presents with sexual inadequacy and was married one
year ago but unable to consummate marriage on account of inability to
sustain errection.

What areas will you cover in history and examination

Answer=assessment of sexual dysfunction

Define problem (ask both partners)

703
Origin whether primary or secondary

Prior sexual function

With other partners

Sexual drive

Knowledge and fears

Social relationship generally

Relationship between partners

Psychiatric disorders

Substance misuse

Medical Illness, medical or surgical treatment

Why seek help now?

Physical examination of male patient presenting with sexual dysfunction

general examination directed especially to evoidence of diabetes mellitus,thyroid

disorders and adrenal disorders

hair distribution

gynsacomastia

blood pressure and peripheral pulses

reflexes, ocular fundi

peripheral sensation

GENITAL EXAMINATION

Penis testes and prostate

Penis includes

704
 Congenital abnormalities, foreskin , pluses tenderness infection and urethral
discharge

Testicle, size .symmetry , texture and sensation

Q=WHAT psychometric test will you do?

answer=fasting blood sugar, testosterone, other hormones in male in erectile

dysfunction

Q=what psychological intervention in this patient?

Answer-=1-= provide advice and reassurance

2= underlying cause should be treated

3=specific intervention includes psychological and behavioral therapy including

sex therapy

QSEX THERAPHY=

Many pt receive benefit by simple advice and reassurance

Sex therapy is result of master and john and has four characteristic features

1= partner are treated together

2=they are helped to consummate better about there relationship problem

3=they receive education about anatomy and physiology of sexual intercourse

4-=they complete a series of graded tasks which focus as much not yet to be
attempted as what is to be done,

This prohibition reduces performance anxiety resulting in increased confidence

and subsequent success

Sex therapy is effective in orgasmic disorders in women and erectile disorders in

men

Q=what is treatment for sexual dysfunction

Answer=advice ,information and reassurance

705
Treatment of underlying causes

Psychological methods

Includes behavioral techniques and sex therapy

Q Drug treatment

PG&E -5 inhibiters

Other physical treatments

Vacuum devices and dilators

Q WHAT ARE PHARMACOTHERAPY=

Answer= sildenafils,oral pentolamines, alprostadil transurethral

alprostadyl,intravenous methohexytal sodium hasd been used in desensitization
therapy.

Antianxiety agents,bromocriptine, a dopamine agonist may improve sexual

dysfunction impaired by hyperprolactinemia

Dopamine agonist have been reported to increase libido and improve sex function

Q HORMONE THERAPHY

Androgen increase sex drive

Ant androgens have been used to treat compulsive sexual behavior in men

Ant estrogen increases libido

Q =40YR old pt presents with clouding of

consciousness,disoreantation,marked tremors, vivid hallucinastion, on
examination congested eyes, changing and unstable bp and enlarged liver

Q=what is diagnoses= delirium

Q= enlist psyuchometric tools to assess his condition

Answer=1=confusion assessments model

706
2=eeg shows generalize slowing of activity,fast wave activity,or focal
abnormalities, abnormal neuroimaguing and neuro psychtric testing may be
present. 3=neurotransmitters such as acetylcholine and dopamine are implicated in
a common final pathway

Q=manage the case?

Answer= correction of physiologic problem is essential

Frequent orientation and reassurance, protective use of physical restraints and

high
potency antipsychotic medication for dangerous agitation should be considered

Q=female pt with amenorrhea, excessive weight loss and episode of severe

vomiting .on examination low bp,brady cardia and scar marks on back of
fingers

Bmi of 15

What is dioagnises=anorexia nerviosa

DD INCLUDES=1=BULEMIA NERVOSA

2= major depreesive diasorders, 3=schyzoprenioas,4=ocd, 5=body dismorpic

disorders

Q=what will be Prognoses=

Ans= long term mortality rate of individual hospitalized for anorexia nervosa is
10%

Resulting from effects of starvation,and purging or suicide

Q Investigation in alzeimmer disease

1=COMPUTER TOMOGRAPHY=USED TO MEASURE STRUCTURAL

CHANGES IN BRAIN E.G ENLARGED VENTRICLES IN ALZEIMER
DISEASE.

2=NUCLEIR MAGNETIC RESONANCE IMAGING=SHOW BIOCHEMICAL

CONDITION OF NEURAL TISSUE E.G DEMYLLINATING DISEASES
SUUCH AS MULTIPLE SCLETROSIS.

707
3=POSITRON EMISSION TOMOGRAPHY OR FUNCTIONAL
MRI=LOCALIZES AREAS OF BRAIN THAT ARE PHYSIOLOGICALLY
ACTIVE BY MEASURING METABOLISM OF GLUCOSE IN NEURAL
TISSUES.REQUIRE USE OF CYCLOTRON

4=SINGLE POSITRON EMISSION TOMOGRAPHY

SIMILAR TO PET AND NMRI BUT IS MORE USEFUL FOR PRACTICAL

USE BECOZ IT USES GAMMA CAMERA INSTEAD OF CYCLOTRON

5=ELECTROENCEPHALOGRAM=MEASURE ELECTRICAL ACTIVITY IN

CORTEX SO USEFUL IN DIAGNOSING EPILEPSY AND IN
DIFFERENTIAING DELIRIUM[ABNORMAL EEG ] FROM
DEMENTIA[NORMAL EEG].SHOW IN PATIENT WITH SCYZOPHRENIA
DECREASE ALPHA waves and increase theta and delta waves.

6=evoked potentials=measure electrical activity in cortex in in response to

tactile,auditory or visual stimulation used to determine vision and hearing loss in
infants.

7=CSF examination

8=genetic testing

9=brain biopsy

10=neuropsychological testing

Include mainly folstein minimental state and Glasgow comma scale

Q ELECTROCONVULSIVE THERAPHY

HISTORY

ECT WAS INTRODUCED IN 1930 ON BASIS OF MISTAKEN IDEA THAT

EPILEPSY AND SCYZOPRENIA CANNOT OCCUR TOGETHER.IT WAS
FACT THAT INDUCED FITS LEADS TO IMPROVEMENT IN
SHYZOPHRENIA.AT FIRST FITS WERE PRODUCED BY DRUGS OR BY
PASSING ELECTRIC CURRENT THRU BRAIN.AFTER THAT ELECTRIC
CURRENT STIMULATION BECAME RULE

708
SUBSEQUENT ADDITION OF BRIEF ANAESTHESIA AND MUSCLE
RELAXATION MADE TREATMENT SAFER AND MORE ACCEPTABLE

INDICATION FOR ECT

IT IS RECOMMENDED THAT ECT USED ONLY TO ACHEVE RAPID AND

SHORT TERM IMPROVEMENT OF SEVERE SYMPTOMS AFTER ASN
ADEQUATE TRIAL OF OTHER TREATMENT OPTIONS HAS PROVED
INEFFECTIVE AND WHEN CONDITION IS CONSIDERED TO BE
POTENTIALLY LIFE THREATNUING IN AN INDIVIDUAL WITH

1=SEVERE DEPRESSIVE ILLNESSES

2=CATATONIA

3=SEVERE MANIC EPISODE

.INDICATION FOR ECT ACCORDING TO ROYAL COLLEGE OF

PSYCHATRIST 2005

1= WHEN DEPRESSION ARE ASSOCIATED WITH LIFE THREATNING

ILNESSES SUCH AS REFUSAL OF FOOD AND FLUIDS AND A HIGH
SUICIDAL RISK

2=FOR DEPRESSIVE ILLNESS ASSOIATED WITH STUPOR OR MARKED

PSYCHOMOTOR RETARDATION OR DELUSIONS AND HALLUCINATIONS

3=ECT IS USED AS 2ND AND 3RD LINE OF TREATMENT THAT IS NOT

RESPONSIVE TO ANTIDEPRESSENTS

4=ECT MAY BE USED IN MANIA IF IT IS ASSOCIATED WITH LIFE

TREATNING PHYSICAL EXAUSTIONS OR NO RESPONE TO DRUGS.

5=ECT MAY BE USED FOR TREATMENT OF SCYZOPRENIA AS A FORTH

LINE OPTION FOR TREATMENT RESSISTANT SCYZOPRENIA AFTER
TREATMENT WITH 2 ANTIPSYCHOTICS HAS PROVEN INECTIVE.AND
THEN CLOZAPINE PROVEN INEFFECTIOVE

6=ECT MAY BE GIVEN IN CATATONIA WHEN BENZODIAZEPINS HAS

PROVED INEFFECTIVE

709
MECHANISM OF ACTION

ROLE OF A SEIZURE

IN THIS ANAESTHESIA IS GIVEN THEN MUSCLE RELAXANTS ARE

GIVEN AFTER THAT ELLECTRIC CURRENT IS PASSED THRU BRAIN
FOR THERAPEUTIC PURPOSES BY PRODUCING GENERALIZED
SIZURES .

WITH THIS MODE OF ADMINISTRATION BOTH ELECTRIC NODE

PLACEMENT AND ELECTRIC DOSAGE CAN HAVE PROFOUND
EFFECTS ON THERAPEUTIC EFFICACY OF ECT.

AMOUNT BY WHICH ELECTRICAL DOSE APPLIED EXCEEDS SEIZURES

IS THRESOLD OF INDIVIDUAL PT..IT IS AN IMP DETERMINANT OF
BOTH EFFICACY AND COGNITIVE SIDE EFFECTS OF ECT.SEIZURE
THRESOLD VARY GREATLY BETWEEN INDIVIDUALS.

PHYSIOLOGICAL CHANGES DURING ECT

IF ECT GIVEN WITHOUT ATROPINE FIRST BRADY CARDIA THEN

TACHYCARDIA OCCURS.ALSO BP RISES TO 2OOMMHG

.CEREBRAL BLOOD FLOW INCREASES BY 2OO%

UNILATERAL OR BILATERAL ECT

BILATERAL IS SUPERIOR TO UNILATERAL. UNILATERAL IS

ASSOCIATED WITH MORE COGNITIVE IMPAIRMENTS .

BUT WHEN RIGHT UNILATERAL IS DOSED TO 6TIMES THE SEIZURE

THRESOLD ITS EFFICACY APPROACHES THAT OF BILATERAL ECT.

Q UNWANTED EFFECTS AFTER ECT

1=ANXIETY

2=HEADACHE

3=RETROGRADE AND ANTR=EROGRADE AMNESIA

4=DISORIENTION
710
5=GIT SIDE EFFECCT

6=MUSCLE PAIN

7=DAMAGE TO TONGUE TEETH AND LIPS

8=CRUSH FRACTURE OF VERTEBRAE

9=CARDIAC ARRYTHMIAS AND PULMONAR EMBOLISMS.

10=ASPIRATION PNEMONIA

11=CVA AND STATUS EPILEPTIUS

Q =MORTALITY AFTER ECT

3 PER LACKS AND MAINLY DUE TO VENTRICULAR FIBRILATION AND

MI

Q CONTRAINDICATION

1=respiratory illness

2= heart disease

3=pyrexia

4=sickle cell trait

Techniques of administration

Ect is a procedure and must be learn by reading and practically

Ect clinic shold be in pleasant and safe surrounding.pt should not to have wait and
see or hear treatment being given to others

Arrival of patient

Electrode placement.if unilateral it is imp to apply electrode to non dominant

hemisphere

Anaeasthesia and nothing by mouth for atleast5hr and for anaesthesia remove
denture

711
Propofol are given for brief anaesthesia and then muscle relaxant such as succinyl
choline given thru separate syringe.

Also ensure that lung are well oxygenated before a mouth gag is inserted. Initial
dose shold be in unilateral ect400milicoulombs.electrode in bilateral ect are
placed
at opposite side of head and one electrode is placed at at junction of external
auditory meatus and external angle of orbit.

Q Frequency and no of ect

Ect is given twice atweek.some ect given three time a week and Has little
advantage over twice weekly regimen.acource of ect is usually between 6 to 12.

Consent and ethical aspects of ect

A full explanation of procedure,itsbenefits,risks especially its effect on

memory.full
informed consent,in general ect is widely regarded as safe and effective treatment

Q Obssessions

Are recurrent persistent thought that enter mind despite efforts to

exclude
them.These are un reasonable.

Q Obsession are anxiety provoking thought commonly

concerning
1=contamination

2=aggression

3=illness

4=sex

5=illness

6=doubt

Q Compulsion are peculiar behavior that reduce anxiety. Commonly hand

washing,organizing ,checking ,counting and praying.pt with obsession usually have
intact insight.usually start in adulthood but may begin in childhood .genetic

712
factors are involved. Increase in first degree relative of pt with toureete
disorder.
May be associated with serotonin metabolic abnormalities.

Q Various form of obssessions

Obsessional thoughts are repeated words which are upsetting to pt.e.g repeated
phrases coming into awareness of a religious person.

Obsessional ruminations are repeated worrying thought of a more complex kind

forexample about ending of world.

Obsessional doubts are repeating themes expressing uncertainty about previous

actions e.g wethere or not the person turned off electrical appliance that MAY
CAUSES FIRE .

OBSSESSIONAL Impulses ARE REPEATED URGES TO CARRY OUT

ACTIONS USUALLY Aggression ,dangerousnesse.g urge to pick up a knife and
stab another person

Obsessional phobia

Repeated thought associated WITH AVOIDANCE AS WELL AS ANXIETY.

ILLNESS PHOBIAS SOME TIME OBSSESSIONAL FEAR OF ILLNESS IS

CALLED ILLNESS PHOBIAS

OBSSESSIONAL SLOWENESS

MANY OBSSESSIONAL PATIENTS PERFORM ACTIONS THAT ARE

SLOW.

COMPULSIONS MAY CAUSE FOR SEVERAL REASONS

1= MAY CAUSE DERMATITIS FOR SEVERAL REASONS

2= INTERFERE WITH NORMAL LIFE

3=COMPULSION REDUCES ANXIETY .INFACT COMPULSION HELPS TO

MAINTAION CONDITION

FOUR TYPES1= CHECKING RITUALS SAFETY CHECKING OVER AGAIN

AND AGAIN THAT FIRE HAVE BEEN TURNED OFF

713
2=CLEANING RITUALS

3=COUNTING RITUALS

4= DRESSING RITUAL PT PUTS CLOTHES IN ORDERS.

Q Psychopathology is study of abnormal state of mind

2types

1 descriptive psychopathology as

2 explanatory psychopathology

1 descriptive psychopathology is description of abnormal state of mind

limited to description of conscious experiences and observable behavior.some
time also called phenomenological psychopathology.

2experimental

This explain mental phenomenon as well as describe them. One of first

attempt was psychodynamic events in term of mental processes of which pt is
unaware .experimental psychopathology has focused and functional brain imaging.
Forexample there are cognitive theories of origin of delusion and panic attack and
depression..

Objective means something observed directly by doctor such as meningsm and

jaundice.

Subjective for example in evaluation of depression complaints of low mood and

tearfulness are objective and but content is different. 1=if patient say that he
hear voices is homosexual .form is auditory hallucination and content is
homosexual.

2=second pt might hearing voices that he is to be killed.form is auditory

hallucination but content is different

3=third person might experience repeated intrusive thought that he is

homosexual but he realize that these are u calling untrue.cotntent is same as
first pt but form is different. form is often critical when making
diagnoss.presence of hallucination indicate psychosis of one kind or another
714
whereas third example suggest ocd ‘.content is less diagnostically useful but
can help in management forexample content of delusion may suggest that pt
could attack persecutor.

Primary and secondary symptoms refering to which ocured first

2nd meaning is causal that arise directly from pathological processes .

Secondary means arising as a reaction to primary symptoms.

Snificance of individual symptoms.

Psychiatrist disorders are diagnosed when a group of symptoms are

present[syndrome]

Psychiatric assessment

It has three goals

1=to make a diagnosis

2=to understand the context of diagnosis

3=to establish the therapeutic relationship

1 –to make a diagnosis

Diagnosis is central to practice of psychiatry

. since it provide evidence basis for treatment and prognosis and to allow a
differential diagnosis to be made.

2=to understand context to be made

Psychiatrist needs to have sufficient information about a pt life history in turn

has
a major impact on management and prognosis.

3=to establish a therapeutic relationship

If pt is to engage fully in discussion about management

715
Q 3stages of psychiatric assessment

1=preparation

To achieve above three goals .this includes having interviewing skills necessary.

2=collection of information

Is by means of a series of headings covering psychiatric history mental status

examination and other components

3=evaluation of information

In order to arrive at differential diagnosis. This is the hardest part of process

to
describe to readers new to psychiatry as it require knowledge of diagnosis
significance of particular symptoms and symptoms combination

4= using information to make a treatment decision and prognosis.

5=recording and communicating the assessment and its conclusion .

The information must be shared with other health professionals involved with the
care of patient both now and in future and with pt . various modes of
communication are necessary with regard to its nature depending on
circumstances of assessment.

Q Psychiatric interviewing

Preparring for interview

Psychiatric assessment have to be conducted in many settings. only small no of

pt are potentially dangerous but needs for precaution should be considered before
every interview .the interviewer should always 1=make sure that another person
know where and when and how long it is expected .this is especially relevant to
interview in community

2= ensure that help can be called if needed .in hospital check for an emergency
call button

3=no obstruction between him or herself and exit,

4=remove from sight any object

716
That can be used as weapon. if above requirements cannot be met it may be
necessary to differ interview

Starting interview

Interviewer should welcome pt by name an status and explain in few words

purpose of assessment.if pt is being seen at request of another doctor interviewer
should indicate this

Interviewer should explain how long they expect to wait and wether companion
will be intervived

It is betrsholdbeter to see pt alone first and pt should be able to provide

adequate
history.

,interviewershold be confidential with pt

.if interview is for purpose of report to an outside agency that is legal report
this
should be made clear.pt should be comfortable and pt should sit in chair at an
angle.following techniques have been shown to improve result of an interview

.the interviewer should 1=ADOPT A RELAXED POSTURE EVEN WHEN TIME

IS SHORT

2=MAINTAIN A N APPRORIATE EYE CONTACT WITH PT

3=BE ALERT TO VERBAL AND AND NONVERBAL CUES OF PT IF

DISTRESS AS WELL AS TO FACTUAL CONTENT OF INTERVIEW

CONTINUING AND

COMPLETING INTERVIEW

OPEN ENDED QUESTIONS ALLOW PT TO SPEAK IN OWN WORDS AS

MUCH AS POSSIBLE

E.G CAN U TELL ME ABOOUT VOICES?

CLOSE ENDED QUESTIONS .

ASK FOR SPECIFIC INFORMATION WITHOUT ALLOWING PT IN

ANSWERING E.G ARE U HEARING VOICES?

717
FACILITATION

PHYSICIAN HELP PT CONTINUE BY PROVIDING VERBAL AND

NONVERBAL CUES E,G YES CONTINUE?

CONFRONTATION

PT POINTS SOMETHING OUT TO PATIENT E.G U ARE VERY UPSET

TODAY?

REASSURANCE

IF TRUTHFUL CAN LEAD TO INCREASE COMPLIANCE.IF FALSE CAN

LEAD TO DECREASE COMPLIANCE

WE BOTH KNOW WHAT U HAVE IS SERIUOS[TRUTHFUL]

OF EVERY THING WILL BE ALL RIGHT[FALSE]

LEADING QUESTIONS

ANSWER IS SUGGESTED IN QUESTION

ARE VOICES TELLING U TO HURT URSELF? INTERVIEWING

INFORMANTS

PT NEWS SHOULD BE SUPPLEMENTED BY INFORMATION BY CLOSE

RELATIVE

IS VERY IMP IN PSYCHATRY TO TAKE INFORMATION FROM

RELATIVES AND NEIBOURS

BECOZ SOME PT ARE UN AWARE ABOUT SOME OF INFORMATION

ABOUT RELATIVES AND OTHER ARE AWARE BUT DOES NOT WANT TO
DISCLOSE THE INFORMATION SO ALCOHOLOIC DRINKER CONCEAL
THE EXTENT OF THERE DRINKING

NOT ONLY RELATIVE PROVIDE INFORMATION ADISIONLY ABT PT

CONDITION BUT ALSO TO ASSESS THEIR ATTITUDE TO PT AND OFTEN
TO INVOLVE THEM IN SUBSEQUENT MANAGEMENMNT PLAN AND TO
ASSESS HOW MUCH BURDON ILLNESS HAS PLACED ON RELATIVES

718
 AND TO PROVIDE INFORMATION PT CHILDHOOD INFORMATION.
INFORMATION CAN BE SEEN SEPARATELY FROM PT OR INVITED TO
JOIN INTERVIEW

BUT PT MUST GIVE THEIR CNSENT

FEW SITUATION IN WHICH PT PERMISION NOT REQUIRED BEFORE

INTERVIEWING RELATIVES

E,G IF PT IS A CHILD OR ADULT WITH MUTISM OR CONFUSIONS

Q define =Schizophrenia is a chronic debilitating mental disorder characterized

by period of loss of touch with reality that is psychosis .symptoms must be present
for at least 6months for making diagnosis.in schizophrenia we see persistent
disturbances of thought, behavior, appearance, speech,abnormal affect and social
withdrawal.

Age of onset

15-25 in men

25-35 in women

Schizophrenia occur equally in men and women,all cultures all ethnic groups
studied.

Q =Symptom of scyzophrenia

Can be classified as positive and negative symptoms.

Positive symptoms are things additional to expected behavior include delusion

,hallucination, agitation and talkativeness.

Negative symptoms are things missing from expected behavior e.g social
withdrarawal, flattened affect, cognitive disturbances and poor speech.

Classification of symptoms into positive and negative symptoms can be useful in

predicting effects of antipsychotic medication.

Positive symptoms respond well to most traditional and atypical antipsychotics

medication.

719
Negative symptooms respond well to atypical antipsychotics than traditional
antipsychotics. Pt with predominantly negative symptoms have more
neuroanatomic and metabolic abnormalities such as decreased metabolism of
glucose than those with predominantly positive symptoms.

Q Course

Scyzophrenia has three phases

1=prodromal

2=active

3=residual

Prodromal phase sign and symptoms occur prior to first psychotic episode and
include avoidance of social activities and new interest in religion and physical
complainants .

ability Thought processes include impaired abstraction and magical thinking .

Form of thought includes circumstantialities ,loose association, neologism

perseveration and

Q Genetics

General population1%

Monozygotic twin47%

Dizygotic twins12%

One scyzophrenic parent 12%

Two relative schizophrenic parents 40%

First degree relative 12%

2nd degree 6%

720
Q Etiology

Exact cause not kown but certain factors have been implicated in its
development .=genetic factors include ,1%population is suffering from
scyzophrenia.first degree relative have more shyzophrenia than 2%degree relative.

Markers on chromosomes 1,6,7,8.21.22, have been associated with scyzophrenia.

2=seasons of birth is associated is related to scyzophrenia.more people with

scyzophrenia are born during winters and early spring. one explanation for this
finding is viral infection of mother during pregnancy since such infection occur
seasonally.

3=no social or environmental factor cause scyzophrenia.scyzophrenia is more

prevalent in low socioeconomic status groups either as a result of downward drift
or social causation.

Q Brain imaging finding

Computed tomography show n lateral and third degree enlargement and reduction
in cortical volume associated with presence of negative
symptoms
,neuropsychiatric symptoms and increase neurologic signs.

Magnetic resonance imaging show increase cerebral ventricles ,

Positron emission tomography show hypo activity of frontal lobes and

hyperactivity of basal ganglia related to cerebral cortex.

Brain imaging finding show decrease volume of limbic structres such as amygdala
and hippocampus.

Neurotransmitters abnormalities

721
1=dopamine hypotheses states that positive symptoms of scyzophrenia result from
excessive dopaminergic activity e.g excessive number of dopamine recepters,
excessive concentration and hypersensitivity of receptors to dopamins in limbic
system. As evidence of this hypothesis stimulant drugs that increase dopamine
activity such as amphetamine and cocaine can cause psychotic symptoms.also lab
test reveal that elevated levels of homovanilic acid a metabolite of dopamine in
body fluids of patients of scyzophrenia .negative symptoms of scyzophrenia result
from reduced dopaminergic activity in frontal lobe.

scyzophrenia because hallucinogens that increase 2=serotonin hyperactivity is

implicated in serotonergic activity causes psychotic symptoms and important
efeect of antipsychotics such as clozapine have antiserotonergic activity.

3=glutamate is implicated in scyzophrenia. nmda receptor antagonist memantine is

usefull in cognitive abilities in scyzophrenia.

Psychologic tests

Iq test reveal score lower in all iq tests may be due to score lower at onset or as
a
result of deterioration as a result of disease

Neuropsychological test are consistent with bilateral frontal and temporal lobe
dysfunction including deficits in attention and problem solving ability

Differential diagnoses

1=medical illness that can cause psychotic symptoms such as and thus mimic
scyzophrenia include neurological infections ,neoplasm’s . trauma , diseases such
as huntington disease and multiple sclerosis .

722
Temporal lobe epilepsy endocrine disorders such as Cushing syndrome and acute
intermittent porphyries.

2=medications can cause psychotic symptoms such as analgesics antibiotics anti

histamines antineoplastics and steroids hormones.

3=other psychiatric illness may be associated with psychotic symptoms such as

other psychotic disorders

Mood disorders e.g manic phase of bipolar disorder .and major depression

Cognitive disorders such as delirium dementia and amnesia

4=shzotypal paranoid and borderline personality disorders

Q Management

Hospitalization is usualy recommended for stabilization or safety of patient.

Pharmacological management include traditional antipsychotics and atypical

antipsychotics .because of there better side effects profiles atypical
antipsychotics
are used as first life treatment.

Use traditional drugs if no response then clozapine is given for treatment

resistant
scyzophrenia.

Long acting inject able may be used if pt show noncompliance,.

Psychological managements includes individual ,family and group psychotherapy

is useful to provide long term support and compliance

Q Schneider symptoms of first rank

Hearing thoughts spoken aloud

723
Third person spoken aloud

Hallucination in form of commentary

Somatic hallucination

Thought withdrawal or insertion

Thought broadcasting

Delusional perception

Delusions of reference

Q Types of shyzophrenia

1=Scyzophrenia paranoid type

Presenting symptoms include preoccupation with delusion or halucinaition of

grander or persecution these tend to be older

Type2=scyzophrenia disorganized

Poor grooming and disheveled personal appearance

Inappropriate emotional responses

3=scyzophrenic catatonic type Psychomotor retardation ranging from severe

retardation to excitement Extremely negativism Peculiarity of body movements
and mutism is very common. complication is that medical care may be necessary
because of exhaustion ,malnutrition and self-neglected injury and hyperpyrexia

4=undifferentiated type Characteristics of more than one sub type

5=residual type

724
Atleast one previous psychotic episode subsequent residual symptoms but no
current frank psychotic symptoms

Q mcps what are causes of stroke? 1=CNS=head tumor ,trauma and meningitis
and radiation to brain

2=metabolic =electrolytes disturbances like hypoxia ,hypoglycemia and hyper

carbia

3= endocrine=thyroid parathyroid, adrenal disease

4=autoimmune disease=

SLE

5=parkinsonism Alzheimer disease like neurodegenerative disorders

TREATMENT=CORRECTION OF UNDERLYING CAUSES

TREATMENT =BENZODIAZEPINES

Q =ENUMERATE THE SECTION OF MENTAL HEALTH ACT OF

DETENTION OF PT IN PSYCHTRIC HOSPITAL?

ANS= creteria for detention are

1 detention is necessary to established that pt is suffering from psychiatric

illness

2= detention is necessary for health and safety of pt

3=pt refuses voluntary admission

4= appropriate treatment is available for treatment order

Q =how u can determine the competence to stand trial ?

Ans=step 1= identify decision required and information relevant to it ,decision to

be made and alternative decision

Step 2= assess cognitive ability to understand information and decision

Step3=consider possible causes of impaired cognitive ability such as delirium

725
Step 4= assess other factors ;like cognitive immaturity that can interfere with
decision capacity

Q= organize a psychiatric medical camp in a town of .5 miilion population

with a town medical centre having no psychtric facility

Write down four priority objectives that u will address during this camp

Ans=1= advising and training GPs and their staff

2= assessing and referring

3= shared care

5= liaisons meeting

Q what are steps involved to achieve these objectives?

Ans=

1=classification of psychtric disorders in primary care

2= identification of psychtric disorders in primary care

3= disorders that are treated in primary care

Person seeking help first to primary care and if not managed or is complicated
then is reffered to specialist care

4= disorders that are reffered from primary care to psychtric specialist

5-= treatment provided by primary team for acute disorders

6= improving access to psychological therapies

7=treatment provided by primary care for chronic cases

8= work in primary care by psychiatric team

Q =write note on biopsychosocial model?

George angel In 1970 emphasize the importance of integrating traditional

biological with behavioral sciences and put forward the concept of bps model

726
Bps model provides a comprehensive clinical approach toward practice of
holistioc medicine

And lays great emphases on doctor pt relationship, psychosocial assessment,

communication skills and informational care , crises intervention, and expansion
of care to family

Q Social determinants of aggression=

Poverty ,frustration, low socioeconomic stress

Biological determinants of aggression=

Hormones and anabolic steroids and estrogens and progesterone

Substance abuse

Amphetamine and phencyclidine

Q NUEURAL BASIS OF AGRESSION=

SEROTONINE AND GABA decrease aggression and dopamine and

norepinephrine facilitates it

Abnormal activity of brain especially amygdala ,prepyriform cortex,frontal lobe

and hypothalamus

Q =What is diagnostic creteria for post traumatic stress disoreder?

Diagniostic creteria is similar in ICD 0-10 AND DSM –IV

DSM –IV ASSIGNS MORE IMPORTANCE TO NUMBERING

DSM –I V require two creteria that are not present in icd 10

According to icd -10 symptoms must be present for at least 1month and may
cause v social impairment

As a result of these differences the concordance between the diagnoses of these

two sets of cretyeria is 35%

727
 By convention n PTSD can be diagnosed in people having a history of psychtric
disorders before the stressful events

Differential diagnoses includes following

1=stress induced exacerbation of anxiety or mood disorders

2= acute stress disorders diagnosed by time course

3=adjustment disorders

4= enduring personality changes after catastrophic experiencers

Q EXAMPLES OF CORTICAL DEMENTIA ARE

Are 1= alzeimer and frontgotemporal dementias

Examples of subcortical dementia are

1=huntington disease

2= Parkinson disease

3= focal thalamic and basal ganglia lesion

4 multiple scleroses

MIXED DEMENTIA

1=vascular dementia

2= lewy body dementia

3= corticobasal degeneration

4= neurosypilis

Q=YOUNG FEMALE DEVELOPS depression after divorse

,psychotheraphy was adviced it was noted that during theraphy she started
calling her therapist about mionor thing , send jokes on sms wearing more
and more provocative dresses and calling her therapist by his name

Q= what pt is showing this behaviuior?

728
Ans= positive transfersance

Q= how this behavior can affect her treatment?

Ans= treatment should not be given and refered to another psychtrist

Q=how you can manage this behaviuor?

Ans =doctor should not show counter trasnsferance ansd it is against medical
ethics

Q=40YEAR lady is offered antidepressants treatment for moderate

depressive episode

Please respond to following queries

A what is chance of my 17 year old daughter developing this disease

Ans =if one parent is ill chance will be 20%

Ai both then chance is 40%

So chances in this case is 20%

Q =Can I become dependant on this prescribe drugs

Ans= no dependence

Q =pt say can I safely quit them ?

Ans =yes

Q= what will be course of my illness if I don’t take the prescribed

treatment?

Ans=symptoms will exacerbate and duration increase and pt becomes major

depressive disorders

Q=for how long I should take medication?

Ans= six months from date of improvement

Q= what are chances of re;lapse if I complete entire duration of treatment?

729
ANS= Ask pt to refrain from stress and be relax

If again stress comes then again there wil be relapse

Q =20YR old boy with self inflicted cuts on fore arms ,thighs and bruises on
hands

History of mood swings ,,episode of self harm followed by feeling of regret

There is history of substance abuse and child hood sexual abuse , he

frequently asks who am I

Q=what is your provisional diagnioses=

Ans =substance induced bipolar affective disorders

Q=enlist three differential diagnoses

Ans=1- =mania 2= scyzophrenia 3= drug induced BAD

Q =what are pharmacological option you wil consider

Ans =1= antipsychotics

2= mood stabilizers

3=cbt psychotherapy

Q=28 year old u nmarried diagnosed as case of chronic schyzoprenia has

been treated with haloperidol olla nzapine and quetiapine without any
responder for last 6years he has recently gain weight in last few months

What could be reason for poor response

Ans=1=noncompliance

2=resistant scyzophrenia

3=unmarried

Q what is likely pathophysiological bases for rapid gain in this patient?

ANSWER=olanzapine

730
Q= in light of current evidence what option you would suggest to pt to reduce
weight?

Answer=1=exercise

2=antihyperlipidemics

3=lemon juices like lemo pani

4=metformin for antipsychotics weight reduction

Q =40 YEAR lady is offered antidepresents for moderate depressive

episodes please respond to following querfies

A= what is chance in my daughter developi g this disease?

Ans=20% chances compared to that in mother

Q B =WILL I BECOME DEPENDENT ON PRESCRIBESD DRUGS

ANS= NO DEPENDANCE

Q c= Can I safely quit them?

Ans=yes

Q=what will be my course of symptoms if I I do not take prescribe drugs?

Ans = disease will get out of control and symptoms will exerbate and and resist ant
depression will develop

Q =for how long I should take medication

Ans= 6 month from date of initiation of treatment

Q=what Are chances of relapse if I completed duration of treatment?

Ans= with stressor there is increase chances of relapse and disease will exacerbate

Q =pt is a known case of psychtric illness for 15 years

There is history of episode of fatigue increase sleep and apetite Interspersed

With episode of over activity, talkativeness overdressing and singing

731
She has been on medication for last one year and complaining of weight
gain,tiredness and lethargy

Her bp is 140/90mmhg and pulse=56per min also has tremors and mood is
euthymic on mse

What is most likely diagnoses=lilthium induced hypothyroidism

And symptoms of hypothyroidism such as weight gain lethargy and tiredness

And symptoms of bipolar affective disorders are present such as overactivity,

talkativeness and singing and lithium is drug of choice in this case

Q What specific clinical queries would you raise in history ?

Ans= her mood is euthymic

Q WHAT specific lab test would you request for and why?

Answer= serum lithium level and it needs close monitoring and we need to keep it
below 1.5meq /liter

Q =write a prescription for this pt

Prescription

Tab risp 2mg 1+1

Tab kempro 5mg bd

Tab neurolith sr 400 mg od for 3day

Then 400mg bd continues

But also given tegral instead of lithium

Tab tegral 200mg bd

Nowadays quetiapine instead of risp[eridone because it has more mood stabilizing

effects

Q=40 yr male married for last 8years father of 5children shopkeeper by

occupation and says during interview that my wife who is is not loyal to me

732
and has illegal teenagweer boy who comes in his absence and say that he has
seen semen stains on underagermwent of my wife whenever io comes home
she is well groomed with All sortg of cosmetics applied on face

Q=what specific question you would ask from pt

Ans = 1= both partners should be interviewed separately

2= partner will give more detail of pt morbid belief and action that can be
elicited from pt

3=doctor should try to find out how firmly pt believes in partner infidelity

And how much resentment he feels

4=what factors provoke outbursts of accusation and questioning?

5=doctor should see how does partner respond to such outbursts?

6= how does pt respond in turn to partner behavior?

7=has there any violence so far?

8=has there been any serious injury?

9=doctor should take detailed history of relationship and sexual history from both
partners and assess for underlying psychtric disorders and this will need treatment

Q=what is provisional diagnoses=

Ans=pathological jealousy

Q =what are disorders associsated with pathological jealousy?

Ans=1=schizophrenia 2=mood disorder

3=organic disorders

4= substance misuse such as alcohol

5=paranoid personality disorders

Q=what is management plan for this pt?

733
Ans-= mainstay treatment is antipsychotics

Adequate treatment of underlying disorders or mood disorder is first requirement

If intake of alcohol or substance abuse present then specific treatment will be

needed

In other cases pathological jealousy may be symptom of delusional disorders or

an overvalued ideas in a pt with low esteem or personality disorders

In delusional disorders antipsychotics need to be given

If depression is cause treat it with antidepressants and also overvalued ideas will
respond to antidepressants

In case of personality disorders psychotherapy needs to be given

Behavioral methods such as encouraging partner to produce behavior to reduce

jealousy

CBT also needs to be done, multiple session needs to be done

If there is risk of violence doctor should warn partner even if this involves a
breach of confidentiality.

Q =what is mechanism of action of therapeutic and its abuse?

Answer= ecstasy is a synthetic drug that is classified in DSM-IV substance use as

a hallucinogen .

However it has stimulant as well as mild hallucinogenic properties

It is usually taken in tablet or capsule form in a dose of about 50-150mg

Given in this way its effects lasts about 4-6 hours

Like amphetamine ecstasy increases release of dopamine but it also releases

serotonin which may account for its hallucinogenic properties

Q =list potential therapeutic uses of this drug in medicine with references

Answer=

734
1=ADHD 2= NARCOLAPSY

3= DEPRESSION IN ELDERLY AND TERMINALLY ILL

4=depression and obesity pt who does not response to treatment

Q = married male presents with sexual inadequacy and was married one
year ago but unable to consummate marriage on account of inability to
sustain erecting.

What areas will you cover in history and examination

Answer=assessment of sexual dysfunction

Define problem (ask both partners)

Origin whether primary or secondary

Prior sexual function

With other partners

Sexual drive

Knowledge and fears

Social relationshipgenerally

Relationship between partners

Psychiatric disorders

Substance misuse

Medical Illness, medical or surgical treatment

Why seek help now?

Physical examination of male patient presenting with sexual dysfunction

general examination directed especially to evidence of diabetes mellitus, thyroid

disorders and adrenal disorders

hair distribution

735
gynsacomastia

blood pressure and peripheral pulses

reflexes, ocular fundi

peripheral sensation

GENITAL EXAMINATION

Penis testes and prostate

Penis includes

Congenital abnormalities, foreskin , pulses tenderness infection and urethral

discharge

Testicle, size. symmetry ,texture and sensation

Q=WHAT psychometric test will you do?

answer=fasting blood sugar, testosterone, other hormones in male in erectile

dysfunction

Q =what psychological intervention in this patient?

Answer-=1-= provide advice and reassurance

2= underlying cause should be treated

3=specific intervention includes psychological and behavioral therapy including

sex therapy

SEX THERAPHY=

Many pt receive benefit by simple advice and reassurance

Sex therapy is result of master and john and has four characteristic features

1= partner are treated together

2=they are helped to consummate better about there relationship problem

3=they receive education about anatomy and physiology of sexual intercourse

736
4-=they complete a series of graded tasks which focus as much not yet to be
attempted as what is to be done,

This prohibition reduces performance anxiety resulting in increased confidence

and subsequent success

Sex therapy is effective in orgasmic disorders in women and erectile disorders in

men

Q=what is treatment for sexual dysfunction

Answer=advice ,information and reassurance

Treatment of underlying causes

Psychological methods

Includes behavioral techniques and sex therapy

Drug treatment

PG&E -5 inhibiters

Other physical treatments

Vacuum devices and dilators

Q= WHAT ARE PHARMACOTHERAPY=

Answer= sildenafils,oral pentolamines, alprostadil transurethral

alprostadyl,intravenous methohexytal sodium hasd been used in desensitization
therapy.

Ant anxiety agents,bromocriptine, a dopamine agonist may improve sexual

dysfunction impaired by hyperprolactinemia

Dopamine agonist have been reported to increase libido and improve sex function

HORMONE THERAPHY

Androgen increase sex drive

Ant androgens have been used to treat compulsive sexual behavior in men

737
Ant estrogen increases libid

Q=40YR old pt presents with clouding of consciousness,disoreantation,

marked tremors, vivid hallucinastion, on examination congested eyes,
changing and unstable bp and enlarged liver

Q=what is diagnoses= delirium

Q =enlist psychometric tools to assess his condition

Answer=1=confusion assessment model

2=eeg shows generalize slowing of activity, fast wave activity,or focal

abnormalities, abnormal neuroimaging and neuro psychiatric testing may be
present. 3=neurotransmitters such as acetylcholine and dopamine are implicated in
a common final pathway

Q =manage the case?

Answer= correction of physiologic problem is essential

Frequent orientation and reassurance, protective use of physical restraints and

high
potency antipsychotic medication for dangerous agitation should be considered

Q=female pt with amenorrhea, excessive weight loss and episode of severe

vomiting .on examination low bp,brady cardia and scar marks on back of
fingers

Bmi of 15

What is diagnoses=anorexia nervosa

DD INCLUDES=1=BULEMIA NERVOSA

2= major depressive disorders, 3=schyzoprenioas,4=ocd, 5=body dismorpic

disorders

Q=what will be Prognoses=

Ans= long term mortality rate of individual hospitalized for anorexia nervosa is
10%

738
Resulting from effects of starvation,and purging or suicide

Q= organize a psychiatric medical camp in a town of .5 miilion population

with a town medical centre having no psychtric facility

Write down four priority objectives that u will address during this camp

Ans=1= advising and training GPs and their staff

2= assessing and referring

3= shared care

5= liaison meeting

Q what are steps involved to achieve these objectives?

Ans=

1=classification of psychiatric disorders in primary care

2= identification of psychiatric disorders in primary care

3= disorders that are treated in primary care

Person seeking help first to primary care and if not managed or is complicated
then is reffered to specialist care

4= disorders that are referred from primary care to psychiaiatric specialist

5-= treatment provided by primary team for acute disorders

6= improving access to psychological therapies

7=treatment provided by primary care for chronic cases

8= work in primary care by psychiatric team

Q =write hypocrate oath?

Ans= whatever in my connection with professionals practice or not in connection

with it,I see or hear in life of men which ought not be spoken abroad, I will not
divulge, as reckoning that all such should be kept secret

739
It was restated in 1948 in declaration of Geneva.

Q =write note on biopsychosocial model?

George angel In 1970 empasisize the importance of integrating traditional

biological with behavioral sciences and put forward the concept of bps model

Bps model provides a comprehensive clinical approach toward practice of holistic

medicine

And lays great emphaseson doctor pt relationship, psychosocial assessment,

communication skills and informational care , crises intervention, and expansion
of care to family

Social determinants of aggression=

Poverty ,frustration,low socioeconomic stress

Biological determinents of aggression=

Hormones and anabolic steroids and estrogens and progesterone

Substance abuse

Amphetamine and phencyclidine

NUEURAL BASIS OF AGRESSION=

SEROTONINE AND GABA decrease aggression and dopamine and

norepinephrine facilitates it

Abnormal activity of brain especially amygdala ,prepyriform cortex,frontal lobe

and hypothalamus

Q=YOUNG FEMALE DEVELOPS depression after divorse

,psychotheraphy was adviced it was noted that during theraphy she started
calling her therapist about mionor thing , send jokes on sms wearing more
and more provocative dresses and calling her therapist by his name

Q= what pt is showing this behaviuior?

Ans= positive transfersance

740
Q= how this behavior can affect her treatment?

Ans= treatment should not be given and refered to another psychtrist

Q=how you can manage this behaviuor?

Ans =doctor should not show counter trasnsferance ansd it is against medical
ethics

Q =40YEAR lady is offered antidepressants treatment for moderate

depressive episode

Please respond to following queries

A what is chance of my 17 year old daughter developing this disease

Ans =if one parent is ill chance will be 20%

Ai both then chance is 40%

So chances in this case is 20%

Q =Can I become dependant on this prescribe drugs

Ans= no dependence

Q=pt say can I safely quit them ?

Ans =yes

Q = what will be course of my illness if I don’t take the prescribed

treatment?

Ans=symptoms will exacerbate and duration increase and pt becomes major

depressive disorders

Q=for how long I should take medication?

Ans= six months from date of improvement

Q= what are chances of relapse if I complete entire duration of treatment?

ANS= Ask pt to refrain from stress and be relax

741
If again stress comes then again there wil be relapse

Q=20YR old boy with self inflicted cuts on fore arms ,thighs and bruises on
hands

History of mood swings ,,episode of self harm followed by feeling of regret

There is history of substance abuse and child hood sexual abuse , he

frequently asks who am I

Q=what is your provisional diagnioses=

Ans =substance induced bipolar affective disorders

Q=enlist three differential diagnoses

Ans=1- =mania 2= scyzophrenia 3= drug induced BAD

Q=what are pharmacological option you wil consider

Ans =1= Antipsychotics

2= Mood stabilizers

3=CBT psychotherapy

Q=28 year old u nmarried diagnosed as case of chronic schyzoprenia has

been treated with haloperidol olla nzapine and quetiapine without any
responder for last 6years he has recently gain weight in last few months

What could be reason for poor response

Ans=1=noncompliance

2=resistant scyzophrenia

3=unmarried

Q what is likely pathophysiological bases for rapid gain in this patient?

ANSWER=olanzapine

742
Q = in light of current evidence what option you would suggest to pt to reduce
weight?

Answer=1=exercise

2=antihyperlipidemics

3=lemon juices like lemo pani

4=metformin for antipsychotics weight reduction

Q =40 YEAR lady is offered antidepresents for moderate depressive

episodes please respond to following querfies

A= what is chance in my daughter developing this disease?

Ans=20% chances compared to that in mother

Q B=WILL I BECOME DEPENDENT ON PRESCRIBESD DRUGS

ANS= NO DEPENDANCE

Q c= Can I safely quit them?

Ans=yes

Q=what will be my course of symptoms if I do not take prescribe drugs?

Ans = disease will get out of control ans symptoms will exerbate and and resist ant
depression will develop

Q=for how long I should take medication

Ans= 6 month from date of improvement of treatment started.

Q=what Are chances of relapse if I completed duration of treatment?

Ans= with stressor there is increase chances of relapse and disease will exacerbate

Q=pt is a known case of psychiatric illness for 15 years

There is history of episode of fatigue increase sleep and apetite Interspersed

With episode of ooveractivity, talkativeness overdressing and singing

743
She has been on medication for last one year and complaining of weight gain,
tiredness and lethargy

Her bp is 140/90mmhg and pulse=56per min also has tremors and mood is
euthymic on mse

What is most likely diagnoses=lilthium induced hypothyroidism

And symptoms of hypothyroidism such as weight gain lethargy and tiredness

And symptoms of bipolar affective disorders are present such as overactivity,

talkativeness and singing and lithium is drug of choice in this case

What specific clinical queries wilud you raise in history ?

Ans= her mood is euthymic

WHAT specific lab test would you request for and why?

Answer= serum lithium level and it needs close monitoring and we need to keep it
below 1.5meq /liter

Q =write a prescription for this pt

Prescription

Tab risp 2mg 1+1

Tab kempro 5mg bd

Tab neeurolith sr 400 mg od for 3day

Then 400mg bd continues

But also given tegral instead of lithium

Tab tegral 200mg bd

Nowadays quetiapine instead of risperidone because it has more mood stabilizing

effects

Q=40 yr male married for last 8years father of 5children shopkeeper by

occupation and says during interview that my wife who is is not loyal to me

744
and has illegal teenagweer boy who comes in his absence and say that he has
seen semen stains on underagermwent of my wife whenever io comes home
she is well groomed with All sortg of cosmetics applied on face

Q=what specific question you would ask from pt

Ans = 1= both partners should be interviewed separately

2= partner will give more detail of pt morbid belief and action that can be
elicited from pt

3=doctor should try to find out how firmly pt believes in partner infidelity

And how much resentment he feels

4=what factors provoke outbursts of accusation and questioning?

5=doctor should see how does partner respond to such outbursts?

6= how does pt respond in turn to partner behavior?

7=has there any violence so far?

8=has there been any serious injury?

9=doctor should take detailed history of relationship and sexual history from both
partners and assess for underlying psychiatric disorders and this will need
treatment

Q=what is provisional diagnoses=?

Ans=pathological jealousy

Q=what are disorders associated with pathological jealousy?

Ans=1=schizophrenia 2=mood disorder

3=organic disorders

4= substance misuse such as alcohol

5=paranoid personality disorders

Q=what is management plan for this pt?

745
Ans-= mainstay treatment is antipsychotics

Adequate treatment of underlying disorders or mood disorder is first requirement

If intake of alcohol or substance abuse present then specific treatment will be

needed

In other cases pathological jealousy may be symptom of delusional disorders or

an overvalued ideas in a pt with low esteem or personality disorders

In delusional disorders antipsychotics need to be given

If depression is cause treat it with antidepressants and also overvalued ideas will
respond to antidepressants

In case of personality disorders psychotherapy needs to be given

Behavioral methods such as encouraging partner to produce behavior to reduce

jealousy

CBT also needs to be done, multiple session needs to be done

If there is risk of violence doctor should warn partner even if this involves a
breach of confidentiality.

Q=what is mechanism of action of therapeutic and its abuse?

Answer= ecstasy is a synthetic drug that is classoified in DSM-IV substance use

as a hallucinogen .

However it has stimulant as well as mild hallucinogenic properties

It is usually taken in tablet or capsule form in a dose of about 50-150mg

Given in this way its effects lasts about 4-6 hours

Like amphetamine ecstasy increases release of dopamine but it also releases

serotonin which may account for its hallucinogenic properties

Q=list potential therapeutic uses of this drug in medicine with references

Answer=

746
1=ADHD 2= NARCOLAPSY

3= DEPRESSION IN ELDERLY AND TERMINALLY ILL

4=depression and obesity pt who does not response to treatment

Q= married male presents with sexual inadequacy and was married one
year ago but unable to consummate marriage on account of inability to
sustain errection.

What areas will you cover in history and examination

Answer=assessment of sexual dysfunction

Define problem (ask both partners)

Origin wether primary or sec ondery

Prior sexual function

With other partners

Sexual drive

Knowledge and fears

Social relationshipgenerally

Relationship between partners

Psychtric disorders

Substance misuse

Medical Illness, medical or surgical treatment

Why seek help now?

Physical examination of male patient presenting with sexual dysfunction

general examination directed especially to evoidence of diabetes mellitus,thyroid

disorders and adrenal disorders

hair distribution

747
gynsacomastia

blood pressure and peripheral pulses

reflexes, ocular fundi

peripheral sensation

GENITAL EXAMINATION

Penis testes and prostate

Penis includes

Congenital abnormalities,foreskin , pulases tenderness infection and urethral

discharge

Testicle,size.symmetry ,texture and sensation

Q=WHAT psychometric test will you do?answer=fasting blood sugar,

testosterone, other hormones in male in erectile dysfunction

Q=what psychological intervention in this patient?

Answer-=1-= provide advice and reassurance

2= underlying cause should be treated

3=specific intervention includes psychological and behavioral therapy including

sex therapy

SEX THERAPHY=

Many pt receive benefit by simple advice and reassurance

Sex therapy is result of master and john and has four characteristic features

1= partner are treated together

2=they are helped to consummate better about there relationship problem

3=they receave education about anatomy and physiology of sexual intercourse

748
4-=they complete a series of graded tasks which focus as much not yet to be
attempted as what is to be done,

This prohibition reduces performance anxiety resulting in increased confidence

and subsequent success

Sex therapy is effective in orgasmic disorders in women and erectile disorders in

men

Q=what is treatment for sexual dysfunction

Answer=advice ,information and reassurance

Treatment of underlying causes

Psychological methods

Includes behavioural techniques and sex therapy

Drug treatment

Pge -5 inhibiters

Other physical treatments

Vacuum devices and dilaters

Q=female pt with amenorrhea, excessive weight loss and episode of severe

vomiting .on examination low bp,brady cardia and scar marks on back of
fingers

Bmi of 15

What is dioagnises=anorexia nerviosa

DD INCLUDES=1=BULEMIA NERVOSA

2= major depreesive disorders, 3=schyzoprenioas,4=ocd, 5=body dismorpic

disorders

Q=what will be Prognoses=

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Ans= long term mortality rate of individual hospitalized for anorexia nervosa is
10%

Resulting from effects of starvation,and purging or suicide

Q: How you will assess risk to general public

RISK FACTORS OF HARM TO OTHERS
PERSONAL FACTORS
Previuos voilance to others
Antisocial personality trait
Impulsive personality trait
Male and young
Recent life crises
Poor social network
Divorced or sepatrated
Unemployed or social instability
ILLNESS RELATED FACTORS
Psychotic symptoms
Substance misuse
Treatment resistance
Poor compliance with resistance
Stopped medication recently
FACTORS IN MENTAL STATE
Irritability, hostility, anger, suspiciousness , thought of voilance toward others
Threats to people to whom pt have acess
Planning of violence toward others
Delusion of paranoia
Delusion of jealousy
Delusion of influence

750
Hallucination commanding violence to others
Suicidal ideas with severe depression
Clouding of consciousness
Lack of insight about illness
SITUATIONAL FACTIORS
Situation associated with previous violence
Ready availability of weapons
Q = a 4 yr old boy has just reunited with his biological mother after
spending six months with in law and difficult divorse. The boy is noted to
play in destructive and disorganize manner,throwing and breaking his toys .
he also hits and bites mother when asked.
What is most likely diagnoses and how you will manage this case
Ans =Dx=conduct disorder
Treatment =
Healthy group identity and role models are provided by structured
support
program and other programs e.g. big brothers
Structured living setting that place value on group identification and cooperation
are useful. Punishment and incarceration are not often effective.
Q = 50 yr old presents with a gradual deterioration of low mood, decrease
sleep and inability to cope , he has been treated with paroxetine upto 40mg
for six weeks and later with imipramine upto 2oomg for eight weeks . his
blood glucose is 7.8mg /dl and he has a sustained reading of bp 145/95mmhg
What is diagnoses of this case on multiaxial system of ocd 10?
Ans=Resistant depression
Q = a 25 yr old housewife presents with 15dayshisory of
insomnia ,
irritability . hypervigilance, night mare , flash backs and aavoidance of
avctivities

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This started just after a decoity at her home in which she and her husband
was physically abuse?
Ans= a= what is most likely diagnoses according to DSM IV diagnostic
criteria?
Ans= ans-= Dx = acute stress reaction
Q =what neuroendocrine changes may occur in case state persists beyond
six months
Ans= PTSD
Q = in above case what evidence based psychological intervention would you
offer if the symptom persists after six months?
List steps in treatment in interventional study you choice
Ans= COGNITIVE BEHAVIOURAL THERAPHY
Steps already discussed in back pages
Q WHAT IS CONTINGENCY MANAGEMENT AND ITS STAGES
Contingency management or systematic use of reinforcement is a type of
treatment used in the mental health or substance abuse fields. Patients'
behaviors are rewarded (or, less often, punished); generally, adherence to
or failure to adhere to program rules and regulations or their treatment plan.
As an approach to treatment, contingency management emerged from
the behavior therapy and applied behavior analysis traditions in mental
health. By most evaluations, contingency management procedures produce
one of the largest effect sizes out of all mental health and educational
interventions

Token economies

One form of contingency management is the token economy systemToken

systems can be used in an individual or group format. Token systems have
been shown to be successful with a diverse array of populations including
752
those suffering from addiction, those with retardation, and delinquents.
However, recent research questions the use of token systems with very
young children. The exception to the last would be the treatment of
stuttering The goal of such systems is to gradually thin out and to help the
person begin to access the natural community of reinforcement (the
reinforcement typically received in the world for performing the behavior).

Walker (1990) presents an overview of token systems and combining such

procedures with other interventions in the classroom. He relates the
comprehensiveness of token systems to the child's level of difficulty.

Q what are stages of contingency MANAGEMENT=

1= Define the behaviuior to be changed and record that behavior

thru nurse

2=identify the stimuli and reinforcements

3=change the reinforcement

4= moniter progress

Contingency management is used alone and also a part of a

wider programe forexample in treatment of a substance abuse

MOVEMENTS DISORDERS

Q name various subcortical nuclei included in basal

ganglia

Ans =1=caudate and putamen

2= external and internal segmentas of globus pallidus

3=substanntia nigra

4= subthalamic nucleus

Q what are function of basal ganglia

753
Ans=the basal ganglia play important motor function in starting
and stoping voluntary motor function and inhibiting unwanted
movements

There are direct and indirect pathway thru basal ganglia

The direct pathway increases level of cortical excitation and

promotes movement

The indirect pathway decreases the level of cortical excitation

and supreses unwanted movement.

Q what are various disease of basal ganglia

Ans=1=Parkinson disease

2= Huntington disease

3= Wilson disease

4= hemi ballism

5= tourete syndrome

Movement disorder

Q what mechanism is involved in voluntary movements?

Ans=The voluntary movement is controlled by interaction of

pyramidal, extrapyramidal systems, cerebellar system with each
other as well as cranial nerve nuclei.

The extrapyramidal consists of nuclei of basal ganglia.

Q how many types of dystonia are present?

There are two types of dyskinesias

HYPOKINETIC MOVEMENT DISORDERS=

Characterized by reduction or absent purposeful motor activity

such as in Parkinsonism

754
HYPERKINETIC MOVEMENT DISORDERS= characterized by
excessive amount of involuntary movements

Involuntary movements may be regular such as tremors or

irregular such as tremor ,chorea, athetoses, dystonia,ballismus,
and rigidity

Q what are types of tremors?

TREMORS=three types of tremors

Rest tremors=present at rest and become less prominent with

activity

Examples are parkinsonism and drug induced caused by

phenothiazine’s

Postural tremors=

Are maximal while limb posture is actively maintained against

gravity and lessened by rest

Examples are hyperthyroidism ,stress, toxicity, and familial

essential tremors

INTENSION TREMORS=these movements are more prominent

during voluntary movement toward target and not present
during postyural maintenance or at rest.

Examples are cerebellar lesions

Q what are choreas?

CHOREA= consist of involuntary ,irregular , jerky movements

affecting limbs and axial muscle groups ,they have
semipurposeful appearance such as crossing and uncrossing of
legs

Q what are Causes of chorea?

1= Huntington’s chorea’s

755
2= syandhamen choreas

3= benign hereditary chorea’s

4= abetalipoprotenemia with choreas

5= drug induced due to phenytoin, levodopa, alcohol

6=SLE , thyrotoxiocoses, polycythemias , encephaitis lethargica

and stroke of basal ganglia

Rarities includes tumor, trauma

Q what is Huntington choreas?

HUNTINGTON CHOREAS=

Autosomal dominant disorders with onset in middle life death

within ten years

There is cerebral atrophy and caudate nucleus lesion, loss of

GABA and acetylcholine

No management is possible but some drugs can reduce chorea’s

to some extent with phenothiazine’s.

PROGNOSES=bad prognoses

Q what is SYNDEHAMIN CHOREAS?

Occur in children as a complication of rheumatic fever .

Good prognoses

Recovery occurs within weeks and ,months

Benzyl penicillin is given up to age of 20 to prevent carditis

which can leads to death

ATHETHOSES=

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 Presents in childhood and appears as a slow twisting
movements that occurs continuously in distal muscles involving
digits, hands and face

Causes are mainly

1= hypoxic neonatal brain injury

2=kernicterus

3=lipid storage disease

Q what is HEMIBALLISMIS=characterized by movement

disorders which is unilateral swinging of limbs

Lesion is in contralateral subthalamic lesions

Q what is MYOCLONUS=

Sudden involuntary jerking of single muscle

Q what are Tics =repetitive jerky movement of face, neck

and trunk or irregular repeated movements of group of muscles
such as sideway movements of head or raising of one shoulder

And can be voluntarily suppressed examples are grimacing

,shoulder shrugging ,sniffing, and throat clearing

Q what are DYSTONIAS= is a sustained abnormal posture

produced buy contraction of large trunk and limb muscles such
as sustained head retraction

Types=IDIOPATHIC TORSION DYSTONIA=

Occurs in child hood , initially flexion deformity of legs develops

then movements become generalized with abnormal posturing
of head trunk and limbs

Cause is known

Cause is known

757
Treatment is levodopa ,carbamazepine or anticholinergics

SPASMOTIOC TORFTICOLLIS

BODY DYSTIONIC SPASM DEVELPOS AROUND NECK IN 3 RD TO

5TH Decade causing head to turn or to draw backward or forward

Cause unknown

Treatment is haloperidol, or anticholinergics such as benzhexol.

Inj of botulinum toxins may v=be helpful

Q what are TOURETTE DISORDERS?

TOURETTE DISORDERS

DEF= childhood onset of multiple motor and vocal ticks

Autosomal dominant transmission

Association between ADHD (50%) and obsessive compulsive

disorders(40%) prevalence =7 per 10000

Twice as frequent in females

Age=7years

COURSE=

MOTOR TICS==twitching of face trunk and extremities

Vocals TICS= GRUNTS AND COPROLALIA

Course is lifelong with remission and exacerbation

Treatment=high potency antipsychotics such as pimozide

haloperidol and risperidone are treatment of choce.clonazepam
and clonidine sometimes are helpful

Q what are Mannerisms = repeated movements that have

functional significance such as saluting

758
Q what are Stereotyped=repeated movements which are
regular (unlike tics) and have no functional significance(unlike
mannerism )

Q what are CATATONIAS= state of increase muscle tone that

affect flexion and extension

Catalepsy=(waxy flexibility)

Term used to describe tone in catatonia and detected when

limb can be placed in a position in which they remain for long
period of time

Posturing= adoption of unusual body posture for long period of

time and liker standing on one leg and have no functional
significance

Negativism =

Pt do opposite of what is asked

apraxi

Ambitendence=

Is state when they alternate between two movements?

PHANTOM LIMB =pain in limbs even amputation of limb have

been done

UNILATERAL LACK OF AWARENESS=

IN stroke

HEMISOMATOGNOSIAS= feels incorrectly that limb is missing

Q what is REDUPLICATION PHENOMENON=

PT suspects that he has two limbs and ioccur in

MIGRAIN,temporal LOBE EPI,LEPSY AND SCHYZOPRENIA

759
Q MCPS=BEHAVIOURAL THEORIES OF OCD
1=behavioral psychotheraphy
A=relaxation techniques
B=guided imagery
C=exposure
D=paradoxical intent
E=response prevention
F=thought stopping techniques
G =modeling
Q general characterterics of CBT
For depressive illness essential aim of ect is to change way of thinking
There are many studies of cbt in acute depression that have been reveaved
recently by nice
Conclusion currently are following
CBT=is superior to other waiting list control in depressive illness
Cbt is not generally superior to IPT
CBT is effective as pharmacological treatment
Combined cbt and pharmacologically is better than pharmacological tx
alone
Q stages of psychoanalytical theory
It is based on freud concept that behavior is determined by forces derived
by forces derived from unconscious mind process
Psychoanalytical therapy are psych and related therapy are
psychotherapeutic tx based on this concept
Q DIIFFERENT TECHNIQUES OF BEHAVIOURAL THERAPHY
1=Systematic desensitization in management of phobia

760
2=aversive conditioning in mx of parapilias , pedophilia and addiction such
as smoking
3=flooding and implosion in mx of phobias
4;Token economy to increase positive behavior in a person who is severely
disorganized or autistic or MR
5=biofeedback to manage HTN , RAYNAUD DISEASE MIGRAIN
TENSION HEADACHE,CHRONIC PAIN , FECAL INCONTINENCE
TEMOPOROMANDIBULAR JOINT PAIN
6= CBT to manage mild to moderate depression somatoform disorder and
eating disorder
Mcps Q= you are working in a detoxification and rehabilitation unit
for drug dependence .you have been told to conduct group theraphy
session
Name therapeutic factors that you consider important=
Answer=1-=universality (shared experiences)
2= altruism 3= group cohesion 4=socialization
5-=imitation 6=interpersonal learning
7=recapitulation of family group
Q= Enlist five issues that you are likely to face in course of group
theraphy session and how you will address them ?
Answer=1-=formation of subgroup=some member may form subgroup
based on age, social status, therapist should discourage such grouping by
asking the group to discuss reasons for their formation
2=members who talk too much =therapist should draw attention to this
problem at early stage before group rejects talkative member
3=members who talk too little= therapist should assist silent members to
speak and should therefore understand the reason for silence
761
4=conflict between members
=therapist should not take sides in conflicts but should encourage the whole
group to discuss issue in a way that leads them to understand why conflict
has arisen for example because a hostile transference has developed
5=potentially embarrassing revelation==
Common sense and judgment has to be used to protect vulnerable pt from
burning out potentially devastating information before they are well
established in a group
Q= you are working in a detoxification and rehabilitation unit for
drug dependence .you have been told to conduct group theraphy session
Name therapeutic factors that you consider important=
Answer=1-=universality (shared experiences)
2= altruism 3= group cohesion 4=socialization
5-=imitation 6=interpersonal learning
7=recapitulation of family group
Q= Enlist five issues that you are likely to face in course of group
theraphy session and how you will address them ?
Answer=1-=formation of subgroup=some member may form subgroup
based on age, social status, therapist should discourage such grouping by
asking the group to discuss reasons for their formation
2=members who talk too much =therapist should draw attention to this
problem at early stage before group rejects talkative member
3=members who talk too little= therapist should assist silent members to
speak and should therefore understand the reason for silence
4=conflict between members

762
=therapist should not take sides in conflicts but should encourage the whole
group to discuss issue in a way that leads them to understand why conflict
has arisen for example because a hostile transference has developed
5=potentially embarrassing revelation==
Common sense and judgment has to be used to protect vulnerable pt from
burning out potentially devastating information before they are well
established in a group
Q =pt with abdominal pain but surgeon says that thre is no
intraabdominal pathology and surgeon refers pt to Psychiatrist
Diagnioses is hypochondrias
Q WHAT is psyhiatric response to above patient
Answer=psychotherapy to help relieve stress and help cope with illness .
Frequent regular schedules visits to patient medical doctor
Q = you have been asked to start counseling session with a pt evaluated
from an earth quake affected area
A= what are essential steps that you would put in place in counseling
processes
Ans = counseling session are aimed at
1= establish a relationship of mutual trust in which pt feels secure and able to
express themselves in any way or form necessary
2= giving pt or their families a chance to seek clarification
3-= providing opportunity to pt to freely express his or her feeling and emotion
4= provision of reassurance
5= achieving a deeper and a clearer understanding of a health related issue
based on scientific and evidence based data
6= dialogue and discussion between counselor and pt to identify bvariuos
choices alongside there pros and cons

763
7= make suitable decision
8= mobilization of resources to implement solution
9= learning necessary skill to cope with issues
If a doctor opts to take up role of a counselor he needs to develops and exhibit
following attributes
1= unconditioned positive regard and positive feeling for pt
2=empathic understanding ability to accurately perceive other feeling
It differ from sympathy which means feeling sorry for person
3-= warmth and geniuses
4= counseling relationship should remain clear and without mystery to pt
5= here and now=
As a counselor you need to identify present thought and feeling to enhance
problem solving attitude on basis of here and now and focus on present day
issue
Q = 28yr old house wife present with fear of open spaces and crowds
She has found difficult to leave her house for last 2yr
She remain symptom free at home and is able to attend to her routine
comfortably
She refuses to take medication as she is pregnant and seek a
psychological /nonpharmacological methods of treatment
What option would you suggest?
Which psychological modalities will you choose and list steps in volved in
this psychological methiods
Ans= cognitive behavioral intervention
Combining progressive relaxation and graduated imaginable exposure to feared
stimulus , systematic desensitization has been used

764
Systematic desensitization works by principle of reciprocal inhibition which
asserts that sympathetic response associated with anxiety is incomparable
with and thus inhibited by parasympathetic response that occur during deep
muscle relaxation\
2= exposure=
Prolong and repeated in vivo exposure to feared stimulus is by far the
most
studied and effective form of treatment for a specific phobia
Cognitive restructuring phobia.
Specific irrational thought may contribute to development of phobia. Maintain
avoidance behavior and contribute to physiological symptoms
Cognitive restructuring treatment help pt to monitor irrational thought
and
change underlying belief so that they are better able to enter feared situation
Types of Psychosocial Treatments
Psychotherapy
Often called talk therapy, psychotherapy is when a person, family, couple or
group sits down and talks with a therapist or other mental health provider.
Psychotherapy helps people learn about their moods, thoughts, behaviors and
how they influence their lives. They also provide ways to help restructure
thinking and respond to stress and other conditions.
Psychoeducation

Psychoeducation teaches people about their illness and how they’ll receive
treatment. Psychoeducation also includes education for family and friends
where they learn things like coping strategies, problem-solving skills and how
to recognize the signs of relapse. Family psychoeducation can often help ease
tensions at home, which can help the person experiencing the mental illness to
recover. Many of NAMI's education programs are examples
of
psychoeducation.

765
Self-help and Support Groups
Self-help and support groups can help address feelings of isolation and help
people gain insight into their mental health condition. Members of support
groups may share frustrations, successes, referrals for specialists, where to
find the best community resources and tips on what works best when trying to
recover. They also form friendships with other members of the group and help
each other on the road to recovery. As with psychoeducation, families and
friends may also benefit from support groups of their own.
Q = what point you will keep in mind while delivering a lecture on following
areas
ans=indication of family theraphy=
1=marital problems
2=child mental health problem
3=adjustment disorder
4=alcoholiosm and drug dependence
5= attempted suicide
Q =non specific facters in psychotheraphy
1--=therapeutic relationship
2=listening
3=release of emotion thru abreaction
4=restoratopn of moral
5=providing information
6=providing a ratational
7= advice and guidance
Q =complication (unwanted effects of psychotheraly)
Ans= pt may become dependant on theraphy or therapist excessively
Intensive psychotheraphy may be distressing to pt
766
Ineffective psychotheraphy wast time and money and damage pt morale
Q =how you will manage this case?(eating disorder)
Ans=treatment=
Short term management-=to ensure weight gain and correct nutritional deficiencies
Long term treatment aimed at maintaining a normal weight achieved thru short
term management
Treatment modalities=
Includes behavioral therapies based on positive reinforcement sometimes
negative reinforcement
Individual psychotherapy
Hospitalization with adequate nursing care
Pharmacotheraphy with cpz,amt,clomipramnine ,and ceproheptadine(8-32yr)
Group therapy
Family therapy
Prognoses=
Is better in young age of onset
Less no of hospitalization
No bulimic episodes
Q= 23 yr bold female master in psychology comes to your office with history
of repeated washing of hands and thought of contamination for past
3MONTHS
She had similar episode 2yr back which got better with ndeep breathing
and progressive relaxattiion for past 3monthas . she has been trying these
methods but condition has worsened . she is in distress and has stopped
pursuing her phd in clinical psychology for fear of contamination of her
clothesc and if she sits asome where else other that her own chair which
she washed 13 times daily
767
A= how would you respond to her queries regarding most likely diagnoses?
Ans= ocd
Q =Nerobiological basess of her illness
Ans= etiology of illness
1= behaviuoral theory
Obsession=conditioned stimuli to anxiety
Compulsion=learned behaviuor
Which decrease anxiety associated with obsession , this decrease in anxiety
positively reinforces compulsive act and they become stable learned behavior
Biological theory=
Secondary to basal ganglia lesion
Altered serotonin level and noradrenaline level
Genetics = it can be transmitted genetically
Eeg= temporal lobe spikes and increased theta waves have been reported in
sleep EEG of OCD patients
Q =Draw a algorism for treatment of her illness keeping in view the recent
guidelines
Ans= 1=psychotheraphy
Supportive psychotheraphy
2=behaviour theraphy
Thechniques used are thought stopping , response prevention, systematic
desensitization, modeling and time out
3=drugs= bzd to control anxiety
Antidepresents like ssri and flouxetine
TCA= clomipramine75-300mg
Antipsychotics like halorperiodol

768
4=ECT= in presence of severe depression with ocd ect may be needed, ect is
particularly indicated when there is a risk of suicide and when there is poor
response to other modes of treatment,. However ect is not treatment of first choice
in ocd
5=psychosurgery
Stereotactic limbic leucotomy
Stereotactic sub caudate leucotomy
Q = CBT has established ITS ROLE IN treatment of depressive disorders
In light of current evidence on use of cbt in general and schyzoprenia in
particular respond to following queries
Cbt for depressive disorder=
Beck developed the first effective form of cognitive theraphy.
It is complex behavior intended to alter 3 aspects of thinking of depressed
pts .1=negative intrusive thoughts
2=belief
3= assumption that render ordinary situation stressful
Monitoring is of 3kinds
1= pt identify intrusive thought( e.g I am a failure)
By writing their thought when there mood is low
2= therapiat uncover dysfunctional belief and assumption by asking question
3= pt record there activities and mark each one p if it was pleasurable and m if it
was accompanied by a sence of mastery and improvement
Q Cbt for schyzoprenia=
Two approaches are used
The first aim to help to nreduce and cope better with stressor that may be
exacerbating the distress

769
And to cope better with hallucination. Pt are helped to cope with ha.llucination by
distressioing themselves and repeating statyements that neutralizing their effects
The aim of second approach is challenge delusion. This approach is directed for
secondry delusion.
Q = mr x is a 28yr old male admitted in psychtry ward , he presents with
complain of eating insects, wearing bangales, having stitched ski n of his
forarm , believing that this could strenrthen him . he occasionally wears
female dress , these complaints began 8yr back after he had a severe
accident while driving in which he remained unconsiuos for half day
There is no previous history of any psychiatric illness
Ans -=diagnoses is transvestism
Q how would you manage this case
Ans=1= individual psychotheraphy
2= behaviuoral techniques
3= aversive conditioning
4=ssri
5= anti androgens
Q = 27yr old female presented to you with features suggestive of ocd
A=what specific queries would you make in history as regards onset and
course of her illness
Ans =some key cognitive process in ocd
1=thought action fusion
Magical thinking for example the belief that if one thinks of harming other one
is likely to act on thoughts or might have done so in past
2=responsibility for prevailing harm to others
3= compulsion and safety seeking behaviuor
4= overestimation of likelihood that harm will occur
770
5= intolerance of uncertainty and ambiquity
6=need for control
Q =what are psychological and social intervention and drugs that have role
in treatment of this disorder(autism )
Ans= management has three main aspects
1-=management of abnormal behavior
2=education
3= social services
4 help for family
Management of abnormal behavior=
Contingency(emergency) management may control an abnormal behavior of
autistic child
Education and social services=
Most autistic children require special schooling
It is generally thought better for them to live at home and to attend special day
schools
Help for family=other suggested treatment
Individual theraphy has been used in hopes of effecting more bb fundamental
changes
Antipsychotic drugs respiridone
There is currently no cure for autism
However research shows that early intervention treatment
Treatment can greatly improve a child development,. early intervention services
help children from birth to 3yr old learn important skills. Services can include
theraphy to help child talk ,walk and interact with others.
Therefore it is important to talk to your child doctor as soon as possible, if you
think your child has an autism or other developmental problem
771
Even if your child has not been diagnosed with autism he or she may be eligible
for early intervention treatment services, the individual with disabilities
education act(IDEA) say that children under 3yr age who are at risk of having
developmental delay may be eligible for services
These services are provided thru early in tervention system in your state.
Thru this system you can ask for an evaluation
In addition treatment for particular symptom such as speech theraphy for language
delay often does not need to wait for a formal autism diagnoses
Q =what are various behavioural techniques used to treat phobic disorder
And ocd
Ans=for phobic disorder we use cbt(systematic desensitization and assertaive
training)
For ocd behavioural psychotherapies includes 1=relaxatioin training
2=guided imagery
3= exposure 4=paradoxical intent
5= thought stopping techniques
6=response prevention
7= modeling
Q PSYCHOLOGICAL COUNSELLING IN DRUG RESISTANT
DEPRESSION
Psychotheraphy combined with medication works best and psychotheraphy
include
1=CBT
2=ACCEPTANCE AND COMMITMENT THERAPHY
A form of CBT acceptance and commitment theraphy helps you to engage in
positive behaviour even when u have negative thought and emotion
It is designed for treatment resistant condition
772
3=INTERPERSONAL PSYCHOTHERAPHY
Focuses on resolving relationship issue that may contribute to ur depression
4=family theraphy=
Involving family member or your spouse or patner in counselling
5=GROUP PSYCHOTHERAPHY
This involve counselling of a group of people who struggle with
depression working together with psychotherapist
6=PSYCHODYNAMIC TREATMENT=
Aim of this counselling is to help resolve underlying problem linked to ur
depression by exploring your felling and belief in depths
7=DIALECTICAL BEHAVIUORAL THERAPHY=
This type of therapy helps u built acceptance strategies and problem solving
skill and is usefull for chronic suicidal thoughts or deliberate self harm
which sometimes accompanies treatment resistant depression
In long standing resistant depression with severe symptoms other treatment
option of deep brain stimulation or neurosurgery can be considered

Q= prima gravida referred to you by gynae with complaints of insomnia,

over activity, undressing in public, raising slogan and singing at top of
his voice for past ten days
Also having lower abdominal pain but no risk of pregnancy was found
on obstretric work up
She is 32week pregnant and there is no previous psychtric history
Q=what is most likely diagnoses?
Ans=acute mania
Q= manage in this case In term of acute treatment
Answer=acute treatment of mania
773
Anti manic drugs are also called mood stabilizers
1=antipsychotic like typical antipsychotics includes haloperidol and
chlorpromazine
2=atypical antipsychotics such as aripiprazole, olanzapine,quetiapine and
risperidone
3=mood stabilizers=
LITHIUM CARBONATE
Carbamazepine
Valproic acid
Q Mechanism of mood stabilizers=
It enhances reuptake of biogenic amines in brain and lower the level of
amines in body resulting in decrease hyperactivity
Benzodiazepines such as lorazepam and clonazepam
Ect is used as last resort
Q=How you will modify treatment plan in perperual period?
Answer=Withhold mood stabilizer
Q =SPECIFIC DEMENTIA
ALZERIMER DISEASE IS Cause of more than 50% of all dementia
RISK FACTERS
1= DOWN SYNDROME
2= HEAD INJURY
3=FAMILY HISTORY
4= FEMALE
FINDING IN CT WILL BE CORTIICAL ATROPHY, FLATTENED SULCI
AND ENLARGED VENTRICLES
Histopathological finding
1= amyloid senile plaques
774
2= neurofibrillrry tangles
3=Loss of neuron and synapse
4= associated with chromosome 21
8 yr course of death
TREATMENT =for cognitive dysfunction and behavioral dysfunction
cholinestrrase inhibiters such as tacruine and donepozel and memantin
For mild agitation we use trazodone 50-100mg
Plus bzd(lorazepam) and carbamazepine and valproic acid
For sever agitation and psychoses we use quitiepine or risperidone or
olanzapine
For depression ssri
For behavioural symptoms we use haloperioidol .5 -4mg for limited time
CHOLINESTRASE INHIBITERS
Loss of ach was first neurotransmitter in Alzheimer disease so cholinestras
inhibiters developed for this disease
For example tacrine
But side effects is hepatotoxicity
Q =BRIEFLY DISCUSS REPETETION OF SELF HARM
A systematic review of 90 studies concluded that among people who have
engage in DSH
A=about one sixth repeates DSH within one year
B=about one fourth repeats DSH within 4yrs
ow after a lot of research further drugs available are donepozel.
Rivastigmine and gallant amine
Q =pt with abdominal pain but surgeon says that thre is no
intraabdominal pathology and surgeon refers pt to psychiatrist
Diagnioses is hypochondrioase
775
Q WHAT is psyhiatric response to above patient
Answer=psychotherapy to help relieve stress and help cope with illness .
Frequent regular schedules visits to patient medical doctor
Q OVERVEIW ON MENTAL HEALTH
ALL over world 500 millions suffer from neuroses
200milians suffers from mood disorder
In Pakistan 4 millions suffers from drug addicts and those especially live
in city areas
Q CLASIFICATION MENTAL ILLNESESS
There are two types of mental illnesses
.1: MAJOR ILLNESS (PSYCHOSES)
2: MINOR ILLNESSES
1: MAJOR ILLNESS(PSYCHOSES)
Definition=

Severe mental disorder in which there is loss of contact with reality

There are;3 types

1=schizophrenia means split personality
In this person lives in a dream world of his own
2= manic depressive psychoses some times severe excitement and and at
other time severe depression
3= Paranoia= extreme suspiciousness
MINOR ILLNESSES
1: Neuroses or psychoneuroses
NO loss of contact with reality and person is unable to react normally to
life situation symptoms like morbid fear and obsessive compulsive disorder

776
MINOR ILLNESS ALSO INCLUDE PERSONALITY CHARACTER
DISORDER
These disorder result from unfortunate childhood experiences
Q define rape?
Ans:
Unlawful sexual intercourse or any other sexual penetration of the vagina,
anus, or mouth of another person, with or without force, by a sex organ, other body
part, or foreign object, without the consent of the victim.
Q =Sodomy

Ans:

Anal or oral intercourse between human beings, or any sexual relations betw
een a human being and an animal, the act of which may be punishable as a criminal
offense.

Q describe ETIOLOGY OF MENTALL ILLNESS

1= GENETIC ILLNESSES
A number of mental illness are genetically determined
If mother is mentally ill sibling will, have 20%chances of mental illness
If father is only ill then chances are 20% if both parent ill then chances are
40% in children of mental illness
Genetic factors determine mental illness in psychiatric pt
2= Stresses and pressures of life
With pressure of life subnormal personality becomes totally abnormal
especially in schizophrenias and depression
3= PERSONALITY= SUM TOTAL OF PHYSICAL MENTAL AND
PHYSIOLOGICAL CHARACTERS
TYPE A: PERSIONALITY
Will have power and determination and they are hard workers
They can cross the border line

777
 from sub normal to normal
4=EXTRINSIC CAUSES
(1) Infection (2) Trauma to brain (3) Alcoholic intoxication
(4) Lack of vitamin b12 (5) Biochemical changes
Certain Infection ,brain trauma and anoxia can cause permanent brain
damage and dementia
5=PSYCHOSOCIAL SERVICES
CAUSE = Loss of loved person or financial losses and loss of friends can
also cause mental illness
Q describe MENTAL HEALTH SERVICES
1= Early diagnoses and treatment
2= Rehabilitation, 3= Group and individual psychiatric
help(psychotheraphy)
4= Mental health education 5= Use of modern psychoactive drugs
6= After care services

Q PSYCHATRIC HISTORY
Main part of psychiatric assessment are psychiatric history and MSE. MSE
covers symptoms and signs present during interview and psych history deals
with everything else. Assessment is then completed by physical examination
and sometimes further by investigation. Psychiatric history is followed by
MSE and then by other aspects of assessment
OUTLINE OF PSYCHATRIC HISTORY
Name age sex and address
Name of informants and their relationship with pt
History of present condition.
Family history

778
Personal history
Past illness
Personality
HISTORY OF PRESENT CONDITION
This section is core of interview providing one of most important
information.
List symptoms with onset and duration fluctuation of each
Ask about symptoms and record symptoms which might have been expected
but which are not present no suicidal ideas in low mood and no first rank
symptoms in scyzophrenia in a pt with delusions .the temporal relationship
between symptoms and physical psychological or social problem .nature
and duration of any functional impairment caused by symptoms’
Any treatment received and its effects and side effects
FAMILY HISTORY
Parents and siblings. Age, current state of health or date and cause of death,
occupation, personality, quality of relationship with pt and psychiatric
medical history. Social position of family .when family history is complex
and relevant, summarize it as a family tree
PERSONAL HISTORY
Mother pregnancy and birth
Early development
Childhood separation, emotional problems illnesses education
Occupation
Relationship and sex
Children’s
Social circumstances
Substance use and forensic history

779
PAST PSYCHATRIC AND MEDICAL HISTIORY
PERSONALITY ASSESSMENT
Relationship
Leisure activities
Prevailing mood and emotional tone
Character
Attitudes and standards
Ultimate concerns
Assessment of personality
It helps the interviewer to understand patient as a person and to put their
current difficulties into their context. Personality trait can be a risk factor for
psychiatric disorder e.g. obssessionality increases risk of depressive disorders
Personality trait can affect presentation of psychiatric disorder.

Q =PSYCHIATRIC ASSESSMENT OF CHILD

AIM of psychiatric assessment are to see presenting complaints and to treat
accordingly
Psychiatric assessment of child is not as simple as in adults and needs to
take information thru
1= a most flexible approach of interviewing is needed
2= interviewing and obtaining information from parents of child and
relatives
3= information from school teacher to see how is there intellectual progress
and behavior during school.
Different psychiatrists have different techniques of psychiatric assessment
One important point in assessment is that psychiatric doctor should observe
how parents and child interacts in family

780
As we know that in child assessment parent should be interviewed but in
child abuse child should be given right to tell what it is original condition
INTERVIEWING PARENTS
Some pt are anxious and fear that they may be blamed for their child
problem
Psychtrist should make pt at ease and allow parent to talk and encourage the
parent to talk freely about child problems.
After taking into confident the parents then psychiatrist should ask
question relevant to child problem
INTERVIEWING AND OBSERVING CHILD
Young children may not be able to express their feeling and ideas in
words but older children can express their ideas and feeling in words and
thus there interview is like adults since we know that younger children are
not able v to express their problem in words so their behavior is seen by
psychiatrist
Some standard procedures for interviewing child are
1= start the interview by making friendly atmosphere is winning child
confidence and ask which game they like before starting interview
2= TECHNIQUES OF INTERVIEWING
In interviewing ask about like and dislikes of pt and their hopes about
future. therefore it is important not to give leading question and child can
accurately b recall important events related to their problems
BEHAVIOR AND MENTAL STATE
Children who are brought usually silent should not be taken as depressed pt.
DEVELOPMENTAL ASSESSMENT
By end of interview we should see that compare the child with problem
with another child and compare their developmental stages.
781
INTERVIEWING FAMILY
To obtain good information about problem of child parents and family
should be interviewed
Disorganization is the most important phenomenon which is observed
during taking interview about interaction between family members and
communication of family members are observed
Interviews could begin by asking which person will be good for giving
information about child problem and another important question is how u
think that if your daughter or sister if see the problem?
And ask about spokesman of family and who seems most worried about
child problem and how is interaction and communication and how they
deal with conflict in family?
PSYCHOLOGICAL ASSESSMENT=
Measurment of intelligence and educational achievement are usually done.
If less than against specific age then it may indicate a disorder
OTHER INFORMATION
From child teachers
Teacher can tell about child behavior ,educational achievement .
Some psychiatrist may visit child home to see interaction in family
CHILDREN AS WITNESSESS
Especially in child abuse psychiatric should ask from child and especially
In condition in which there is assault or beating of mother by father,
Psychiatric should see about memory of child in such assessment.
Memory varies with age .child below 3yrs have less memory while child
above 3yr have good memory and subsequent good cognitive function ,.

782
Child above 3yr of age can do mathematical calculation and grammer since
child have less memory below three years so this can be used as or
presented in court of law.

important tables

Qsign AND SYMPTOMS OF OPOID DEPENDANCCE

Narcotics or opoids include agents used medically as

analgesics(morpine) as well as drug of abuse (heroin )

PSYCHOLOGICAL SYMPTIOMS OF OPOIDS

EFFECTS OF USE EFFECTS OF WITHDRAWAL

EUPORIA DEPREISSONS
RELAXATION ANXIETY
SOMNOLENCE INSOMNIA
PHYSICAL SYMPTOMS

SEDATION SWEATING
ANAGESICS RHINORIA
CONSTIPATION DIAREA
MIOSIS MYDRIASIS

Q Q=FEATURES OF CORTICAL AND SUBCORTICAL DEMENTIA

SUBCORTICAL CORTICAL
DEMENTIA DEMENTIA
MEMORY IMPAIRMENT MODERATE SEVERE AND
EARLY

LANGUAGE NORMAL DYASPHASIA

,EARLY

783
MATHEMATICAL PRESERVED IMPAIRED
SKILLS
PERSONALITYY APATHETIC INDIFFEREN
MOOD DEPRESSED NORMAL

COORDINATION IMPAIRED NORMAL

COGNITIVE AND SLOWED NORMAL
MOTOR SPEED
ABNORMAL COMMON LIKE RARE
MOVEMENTS CHOREA

Q 255Papez circuit=

Abnormal activity in amygdale and prepiriform area and

psychomotor and temporal lobe epilepsy and are associated
with increase aggression

Poor new learning implicated specifically in Alzheimer disease

Kluver buchy syndrome (decrease aggression increase hyper

sexuality and hyper orality )

Q =describe at least 5 pharmacologically properties of atypical

antipsychotics which distinguish them from typical antipsychotics

Ans=

Typical antipsychotics Atypical antipsychotics

784
1=dopamine blockers Serotonin plus dopamine
blocker
2=cause eps Minimal or no eps
3=cover positive symptoms Cover positive and negative
symptoms
4=no weight gain Weight gain
5=less expensive Expensive
6=minimal or no sedation Sedation

Q =you have seen a person who is complaining of feeling low

after death of his mother.

How you will differentiate normal grief from abnormal grief and
depression

Grief Depression
Sadness, tearful ,decrease Same
sleep and apetite and
decrease interest in world
Symptoms wax and wane Symptoms pervasive
Shame and guilt less Common
common
Threaten suicide less often Threaten suicide more
often
Symptoms can last upto one More than one year
year
Usually return to baseline of Pt donot return to baseline
function within 2 months of function
Treatment includes Treatment includes anti
supportive psychotheraphy depresents

Q =classification of anxiety disorders=

Answers

ICD -10 DSM -IV

F4 Anxiety disorders Anxiety disorders

785
F40 Phobic anxiety
disorders
Agoraphobioa agoraphobia
Without Panic disorder
panicdisorder without
agoraphobia
Social phobia Social phobia
F41 Other anxiety
disorder
Panic disorder Panic disorder
without
agoraphobia
Generalioze anxiety Generalize anxiety
disorder disorder
Mixed anxiety and
depressive disorder

Q =what is genetic epidemillogy of bipolar and unipolar

disorders=

Answer=

Bipolar disorder Unipolar disorder

Life time risk About one percent 10-20%
Sex ratio(m;f) 1;1 1;2
First degree
reklatives
Life time risk for 10% 2%
bipolar disorder
Life time risk for 20-30% 20-30%
unipolar
Average age of 21year 27year
onset

Q = CLASSIFICATION OF PERSONALITY

CLUSTER A SUB TYPE DISCRIMINATING

786
 FEATURES
OOD AND PARANOID  SUSPICIUOS
EECENTRIC  SHIZOID  SOCIALLY IN DIFFERENT
 ECCENTRIC
 SHIZOTYPAL
ERATIC AND
IMPULSE

CLUSTER B=ERRATIC AND IMPULSE

INCLUDES

ANTISOOCIAL= DISAGREBLE

BORDERLINE = UNSTABLE

HISTRIONIC= ATTENTION SEEKING

NARCYSTIC= SELF CENTRED

CLUSTER C=

ANXIUOS AND FEARFULL

INCLUDES

AVIODANT =INHIBITED

DEPENDEABLE= SUBMISSIVE

OBSESSIVE= PERFECTIONISM

Q=PERVASIVE DEVELOPMENTAL DISORDER

It is term used for a group of disorder in which child or pt cannot

talk and communicate and don’t have social interaction with
other peoples so these abnormalities can occur in a wide range of
situation

787
DSM –IV ICD-10
AUTISTIC DISORDER CHILDHOOD AUTISM
RET SYNDROME RET SYNDROME
CHILDHOOD OTHER CHILDHOOD
DESINTEGRATIVE DISORDER DESINTEGRATED
DISORDER,OVER ACTIVE
DISORDER WITH MR
ASPERGER DISORDER ASPERGER DISORDER
PERVASIVE DEVELOPMENTAL PDDNOS WITH MR
DISORDER NOT OTHERWISE
SPECIFIED INCLUDING
ATYPICAL AUTISM

Q =CURRENT PSYCHIATRIC CLASSIFCATION

CHARACTERISTICS ICD 10 DSM 4

1. ORIGIN WHO AMERICAN
PSYCHTRIC
2. PRESENTATION DIFFERENT VERSES ASSOCIATION
FOR CLINICAL
WORK ,RESEARCH A SINGLE
AND PRIMRY CARE DOCUMENT
3,LANGUAGES
AVAILABLE IN ALL
LANGUAGES
4STRUCTURE ENGLISH VERSUS
PART OF OVERALLL ONLY
5CONTENT ICD FRAMEWORK
AND SINGLE AXIS IN
CHAPTER 5 MULTIAXIAL
DIAGNOSTIC
CRETERYA DONOT
INCCLUDE SOCIAL
CONSEQUENCES OF DIAGNOSTIC
DISEASE CRETERYA INCLUDE

788
 SIGNIFICANT
IMPIARMENT IN
SOCIAL FUNCTION

Q Mini mental state examination

Is a brief 30 point questionnaire test used to screen for cognitive

impairment and dementia

Category Points Description

possible
Orientation 5 What is the (years)(season)(date)(day)
to time (month)?
Orientation 5 Where are we(state)(country(city)
to place (hospital)(floor)
Registratio 3 Name 3 objects one second to say each,
n then ask the patient all three after you
have said them, give one points for each
correct answer, repeat them until he
learns all three(note number of trails)
Attention 5 Begin w0ith 100 and count backwards by
and 7 (stop after five answer
calculation
Recall 3 Ask for 3 objects repeated above, give
one point for each correct answer

Language 2 Show pencil and a watch and ask subject

to name them
Repetition 1 Speaking back of phrase
Complex 3 Take a paper in your right hand, fold it in
commands half and put it on the floor
1 Read the obey the following (shows
subject the written items)
1 Close your eyes. Write a sentence,
1 Copy a design
789
INTERPRETATION

A greater the or equal to 25 points----Normal

21-24 points--- mild cognitive impairment

10-20 points--- moderate cognitive impairment

Below 9---- severe cognitive impairment

Q=KEY CLINICAL PROCEDURES IN MENTAL HEALTH ACT

Criteria for detention

Assessment order

Treatment disorder

Transfer from prison and course

Police power and power of entry

Community treatment orders

CRETERIA FOR DERENTION

Involuntary or civil commitment is a legal process thru which an

individual with symptoms of severe mental illness is court
ordered into treatment in a hospital(in patient) or in
community(out patient)

Criteria for civil commitment are established by laws which vary

between nations

Commitment proceeding often follows a period of emergency

hospitalization during which an individual with acute psychiatric
symptoms is confined for a very short duration 72 hr. in a
treatment facility for evaluation and stabilization by mental health

790
professionals who may then determine whether further civil
commitment is appropriate or necessary

If civil commitment proceeding follows then evaluation is

presented in formal court hearing where terrorism and other
evidence may also be submitted

PURPOSE

In most jurisdiction involuntary commitment is specially applied

to individual found to be suffering from a mental illness that
ipairs there reasoning ability to such an extent that law state or
court finds that decision should be made for them under legal
framework

First aid and

Section of England and wales mental health act commonly

used by clinician

Section number Purpose Duration

Section 2 Assessment 28days

Section 3 Treatment 6months and
repeatable
Section 4 Emergency 72 hours
assessment
Section 5 Detention of 72 hr
patient
Section 17 Leave while on Section 3 still in
section 3 force

Section 17a Treatment in 6mionth

community renewable

Q =MENTAL STATUS EXAMINATION

791
Is a standardized format in which clinician records the psychiatric
sign and symptoms present at time of interview

Objectives=

1=to confirm sign and symptoms narrated by patient and his

relatives in interview

2=it provides an opportunity to observe patient and elicit and

clarify symptoms.

Mental status examination is covered systematically under the

following readings

1=general appearance and behavior

2=speech

3=mood and affect

4=thoughts

5=perception

6=cognition

7=insight

8=judgement

GENERAL APEARANCE AND BEHAVIOUR

GENERAL APPEARANCE

Physical characteristics

Apparent age

Cleanliness (peculiarities) of dressing

Grooming

LEVEL OF CONSIOUSNESS

792
Alert /lethargic

MOTOR

Status=posture(erect ,stooped)gait (shuffling,awkward)

Activity=active or underactive, stereotype ,gracefull

Facial expression=verbal and nonverbal expressions

Worried ,sad, happy,

frightened,laughing,smiling,suspiciuosness(facial expression
control)

Alert, angry, afraid tense

BEHAVIUOR=indifferent
frank,embarrassed,irritable,angry,friendly,assaultive,dramatic,exi
bitioniastic

RELATIONSHIP TO EXAMINER

Cooperative /noncooperative

Comfortable /uncomfortable

Guardedness/insecuredness

Attentive/neglected

Reindliness/believeness

SPEECH=

DISCRIPTION

Soft, loud, stuttering, hesitant,mutism

Speed and quantity

Fast /delay in answering

Relationship with motor activity

793
Volume and tone(increased /decreased)

EMOTION=

MOOD=subjective statement of feeling state

Affect=observing appearance and behavior (including verbal and

nonverbal) emotional display in association with situation

Exhibition cheerfulness, satrcastic,hostile,depression,tensed ,dull,

Apathetic

PERCEPTION=

ILLUSION=misperception of external symptoms

HALLUCINATION=

Auditory

Visual

Olfactory

Gustatery

Tactied

THOUGHTS=

CONTENT=spontinous trends of thought toward particular topics

and preoccupation with these topic can be noted

Delusion of perception,delusion of grandeur and somatic

hallucination due to severe illness e,g cancer

PROGRESSION=association,circumstantiality,blocking and flight of

ideas

COGNITION=

794
CONSIOUSNESS=

Wheather conscious, confusion, clouding, delirium, stupor, comma

to be assessed

Orientation

Time

Place

Person
self

Attention

Digit span test, digit forward and backword test to be done.

Concentration

In the patient easily distractible or able to concentrate to be

tested by giving simple mathematical problem

Memory

Immediate

Recent

Remote

Intelligient

General information

Calculation

Reasoning and judgement

Proverb interpretation

Similatrities
795
Insight

Realization of (patients) symptoms, current

situation,understanding of need of help

Judgement

Social judgment

It is observed during hospital stay and duing the interview

session. It is includes the evaluation of personal judgment

Test judgment

It is assessed by asking the patient what he should do in certain

test situation like a house on fire or a man lying on road

Judgement is rated as good/intact/normal

Q =MENTAL STATUS EXAMINATION

Is used to describe the clinician observation and impression of pt during
interview,in conjunction with history it is best way to make an accurate
diagnosis
GENERAL DESCRIPTION
APEARANCE
GROOMING[CLEAN APEARANCE]
POISE [NOT IN ORDER]clothes
Body type[disheveled →not clean]→
Clean and child like
BEHAVIOR→QUANTITATIVE AND QUALITATIVE ASPECT OF PT
MOTOR BEHAVIOUR
e.g restless and tics
ATTITUDE TOWARD EXAMINER
Cooperative, frank and seductive

796
MOOD AND AFFECT
Mood emotion perceived by pt [depressed, anxious or angry]
AFFECT patient present emotional responsiveness
May be blunted, flat and labile
APPROPRIATENESS
In reference to context of subject appropriate or inappropriate
SPEECH=
PHYSICAL characters of speech may be fluent,coherent [clear talk]and
relevant[closely related to subject]
PERCEPTUAL DISTUIRBANCES
Experienced in reference to self or environment[hallucination and
illusion]
THOUGHT
FORM OF THOUGHT
The way in which person thinks1=flight of ideas
2=loose associations 3= tangentially
4=circumstantialities
TANGENTIALITY
Means irrelevant reply to question and response never approach to point
of question
CIRCUMSTANTIALITY
Response eventually approach to point of question
CONTENT OF THOUGHT
What pt is actually thinking about delusion ,paranoia and suicidal ideas
SENSORIUM AND COGNITION
Alertness, clouding of consciousness, awake and decrease consciousness
ORIENTATION time place and person
797
MEMORY
Recent, remote, recent past and immediate retention and recall
CONCE NTRATION AND ATTENTION
Serial sevens and ability to spell backwards
CAPACITY TO READ AND WRITE
VISUOSPATIAL ABILITY
Copy a figure
ABSTRACT THINKING
SIMILARITIES AND PROVERB INTERPRETATION
Q =medical complications of eating disorder
Behaviuor Medical complications
Binge eating Obesity and gastric rupture
Vomiting Esophageal rupture ,hypokaslemic, hu=ypochloremic
metabiloc aklkaoses.ipicac toxicity
Laxative USE CONSTIPATION,METABOLIC
ACIDOSES,dehydration

Diuretic use Electrolyte disturbance and dehydration

Starvation Leucopenia, anemia ,potension,hypothernmia

hypercholesterolemia edema dry skin and lanugo hairs

Cranial nerves

There are twelve pair of cranial nerves

Nuclei of Cranial nerves=

1st and 2nd goes directly to cerebral cortex.

3rd and 4rth to mid brain

798
5th ,6th ,7th and 8th goes to pons

9th 10th, 11th and 12th to medulla oblongata

Examination of cranial nerves

Olfactory nerve -=it is first cranial nerve and carries sensation

of smell from nasal mucosa thru cerebriform plate to olfactory
bulb and then to temporal lobe

Testing smell = exclude local nasal pathology. Test each nostril

separately .Ask pt wether hecan appreciate common smelks ?
ask pt to close one eye And one nostril and present common
smells like peper mintr , kerosene oil, soap and fruits

Anosmia = is loss of smell usually due to head injury

Perosmia = is perversion of smell and is psychogenic in origin

Intemporal lobe epilepsy we see usually see hallucination of

smell

Optic nerve examination= 2nd cranial nerve

Fibers from retina converge at optic disk and to optic nerve ,

fibers of nasal half decussate at optic chiasma and to optic
tract to orbital cortex

In second cranial nerve examine 1= visual acuity

2= colour vision

3= field of lesion

4 = fundus

Visual acuity= test each eye sepatrately both for near and far
vision

Near vision= is tested by asking pt to read standard charts

799
 On bed side ask pt to read a book or newspaper keeping it at
a distance of ten inches from eyes

Far vision is tested by snellen chart which consists of letters of

various sizes arranged b in line normal readabvles from a
distance indicated from each line

Colour vision=

Ishara chart are used for this purpose ,. On bed side ask pt to
recognize each colour

Field of vision = proper method of testing of visual field is by

perimetry

Om bed side a rough assessment can be made by confrontation

methods in which examiner compare his own visual field with
that of patent

Hemianopia is loss of vision affected on one half of visual field

Two types

Heteronymous hemianopia and homonymous hemianopia

Heteronymous hemianopia = loss of nasal or temporal half of

visual field of both sides

It is also called as binasal or bitemporal hemianpopia

Homonymous hemianopia = loss of vision affecting

corresponding half of (left or right) of both visual fields

Quadratonopia = loss of vision of one quadrent of visual field

Papiledema = following changes are seen

Physiologic cup is obliterated

Margins of disk are blurred. Colour of disk is blurred

Vein are congested

800
Haemorages may be present

Causes=

1= raised intracranial pressure

2 = malignant hypertension

Optic atrophy = optic disk becomes pale in this

OCULOMOTOR NERVE , TROCHLEAR, AND ABDUCENT

NERVE

OCULAR MUSCLES= are divided into extraocular and intraocular

muscles

Extraocular muscles are seven in number.

Lateral , medial , superior and infereior recti , and superior and

inferior oblique and levater palpebrae superioris

Lateral and medial recti move eye ball laterally and medially
respectively

In mid position superior rectus and inferior oblique move eyeball

upwards and infereior rectus and superior oblique move eye ball
down wards

If eye ball is moved laterally upward And downward movements

are are carried out by superior and inferior recti. If eye ball is
moved medially upward and downward movement are carried
by Inferior and superior oblique respectively

Oblique muscle move eye ball in direction opposite to their

names

Leveter palpebra superioris elevate upper eye lids

All extraocular muscle are supplied by 3 rd cranial nerve except

superior oblique which is supplied by 4rth cra nial nerve and
lateral rectus supplied by 6th cranial nerves

801
Intraocular muscle are ciliary muscles , spincter pupilae and
dilater pupilae \

Examination of eye= ask pt to look straight and compare two

sides for drooping of eyelids called ptoses and palpebral
fissures

Observe ocular movements =

Pupils -=note size , shape , test light and accommodation

reflexes

Size of pupil = compare two sides, see pupil are dilated or

conmstricted

Light reflex= check both direct and consensual light reflex

Its afferent pathway is thru 2ndnerve and effent is thru 3rd nerve

Shine bright light into eye from side while pt looks straight
focusing at a distant object to avoid accommodation response

A hand should be placed over nose to prevent light from

entering thru opposite eye

Normal respionse is brisk contraction of pupil followed by slight

relaxation

This resonse occur from same side (direct light reflex ) as well as
in opposite side (consensual light reflex)

Accommodation reflex= ask pt to look at a distant object and

then look at his nose there is convergence of eyes and
constriction of pupil

Trochlear nerve =

Superior oblique move eye downwards and medially at his

nose

802
 Abducent nerves-= as name indicates it causes abduction of
eye ball

3rdnerve paralyses=1 = ptoses due to paralyses of levater

paklpebrae superioris

Except superior oblique ,and lateral rectus all extraocular musles

are paralysed and eye deviates laterally , and slight downwards
and pupil dilates causes of pupil dilation are diabetes mellitus
and mid brain lesion

Cavernous sinus syndrome causes involvement of 4rth and 6 th

cranial nerves

Fourthcranial nerve paralyses= superior oblique is paralysed

Sixth cranial nerve paralyses

Lateral rectus paralyses

Internuclear opthalmoplegia = when pt is asked to nmove eye

laterally there is nystagmus of that eye is called ataxic
nystagmus

Lesion in medial longitudinal muscle on side of weakness of

adduction

Bilateral internuclear opythalmoplegia is characteristeristics of

multiple scleroses

Ptoses= is due to three cause

1= 3rd nerve palsy

2= myasthenia gravis

3 =horner syndrome

Pupil sizes= normal size of pupil is from 3mm to 5mm

803
It may be dilated or constricted less than 3mm and dilated if
more than 5mm

Causes of dilated pupil

Bilaterally = anxiety

On affected side = due to atropine or homatropine mydriatric

drops

Causes of constricted pupils =bilaterally =1= pontine lesion

And opium overdoses

On affected side = miotic drugs like pilocarpine

And horner syndrome

Hornerr syndrome =1 = ptoses

2= mioses

3= exopthalmos

4-= loss of sweating on face

Nystagmus = are involuntary oscillation of eye balls and

should be looked for when testing ocular movements

Ask pt to follow your fingers laterally and keep it there for

some time and note oscilation

Repeate process by taking your finger toward opposite side

and upward and downwards

Nystagmus may be vertical, horizontal and rotator

Types =

Pendular nystagmius = oscilation are equal in rate , amplitude ,

on oth sides of a centr al point

804
 Jerky nystagmus = oscillation are quick in one direction and
slower in other direction

Direction of nystagmus is named after direction of quick

components

Trigeminal nerve= examine both motor and sensory

function=

Motor function= place both hands on both sides of pt cheek ,

finger being on temple

Ask him to clench the teeth and your hand will feel contracting
masseter and temporal muscles

In unilateral paralyses= muscle of affected side will not contract

In bilateral paralyses jaw will hang loosly

Ask pt to open jaw against resistance to test pterigoid of both

sides

Jaw will deviate toward weak side

Ask pt to move jaw laterally Against resistance

In uni lateral paralyses jaw will move toward normal side

Jaw jerk = ask pt to open mouth and hang jaw loosely

Place your thumb over chin and strike it with your ha mer

There is closure of jaw if reflex is present

Norm ally it is not elicitable and brisk in supranuclear paralyses

of 5th nerve

Sensory function==touch pain and tempera ture should be

tested on both sides of midline in teretery of three sensory
divisions

805
Test corneal and conjuctival reflex by asking pt to look medially
with a wisp of cotton from lateral side or it can also be elicitable
by blowing into pt eye

Afferent part of reflex arc is ophthalmic division of 5 th nerve3

and efferent component of this is 7th nerve

If there is 7tth nerve paralyses there will be no closure of that

side and loss of corneal reflex may be in lesion of 5 th cranial
nerve

Facial nerve= examination= on paralyse there will be failure

of closure of eye lids and collection of food in mouth and
dripling of saliva on affected side and deviation of angle of
mouth toward opposite side, .

On inspection palpebral fissure may be wide and nasolabial fold

may be flattened on paralyzed side

When asked to wrinkle forehead no wrinkling on affected side

Ask pt to close eye affected side will remain open and there will
be brisk upward rolling of eye ball called as bells phenomenon

To test power of orbicularis oculi ask pt to close eye as strongly

as possible while you try to open upper eye lid affected side will
be weak

Inflat cheek and tap ion cheek weak side will be deflated easily

Ask pt to show teeth angle of mouth will be deviated toward

affected side

Pt cannot wistle as air escapes from Affected side

Taste= test anterior two third of tongue by following techniques

Get solution of four common tastes ,sweat, salt, sour and bitter

806
 Ask pt to protrude tongue,hold it with a gauze, dry it , and test
each aside separately

Put drops of each side one by one and ask for response,. Test
bitter at end

We see upper and lower motor neuron lesion

Vesrtibulochochlear nerve=

Cochlear division= exclude local nasal pathology of ear by

auriscopic excamination= formal test of hearing are performed by
audiometry. On bed side following simple test are used for gross
assessment . test each ear separately

Whisper test=ask patient to close eye . whisper pt name or

someother word and go on decreasing the distance from his ear
tuill he can hear

Tuning fork test = these are used to differentiate between

sensorineural and conductive deafness

Normally air conduction is more than bone conduction.

In conductive deafness bone conduction is more than air

conduction

A 256 or 512 frequency tuning fork is usually used for this

purpose

Rinne test-= it compare air and bone concuction of same ear

Place a base of vibrating tuning fork on mastoid process

If pt cannot hear there is severe sensorineural; deafness

If pt cannot hear ask him to indicate when he stops hearing

then bring this tuning fork close to his external auditory meatus,
if he can hear it means air conduction is better than bone
comduction And rinne test is positive

807
If cannot hear then repeate test in reverse order.

Keep tuning fork close to external auditory meatus and when

stops hearing place it on mastoid process if he can still hear bone
conduction is better than air conduction and rinne test is
negative

Weber test= it compare bone conduction of both ears

Place a vibrating tuning fork on middle of forehead and ask pt

in which ear hearing is better if it is equal on both sides test is
central it indicates normal hearing. In sensorineural deafness it
lateralizes to normal ear and in conductive deafness it is
lateralized to diseasesd ear

Vestibular division= caloric stimulation test are not possible on

bedside but presence of positional nystagmus can be looked
for .

Project pt head beyond couch

Ectend head fully and rotate it on one side if nystagmus

appears transiently and then dispear this is called positional
nysta gmus and is due to lesion of otolith organ of ear.

GLOSSSOPHARYNGEAL NERVE=

Most of function of 9 th nnerve are intermingled with tenth

nerve

Taste on posterior one third of tiongue is difficult to test on bed

side

Sensory function =

GAG REFLEX=

Ask pt to open mouth and depress tongue with spatula . touch

posterior pha ryngeal wall with a stick having cotton raped on

808
that end first on one side of middle and then other . there will
be contraction and elevation of pharyngeal wall on that side

The sensory component of this reflex arch is 9 th nerve and

motor component is tenth nerve

Palatal REFLEX= when soft palate is touched it moves upward

Each side is tested separately pathway is same as that of gag

reflex

Vagus nerve=

Examination=

Only its motor function is tested

Speech= if larynx is paralysed there is hoarseness , if soft palate

is paralysed voice has nasal quality

Ask pt to cough , in tenth nerve is paralysed cough becomes

nasal

Soft palate= ask pt to open mouth and depress the tongue

with tongue depresser to visualize UVULA

Ask him to say ah

In bilateral paralyses soft palate will not move, in unilateral

paralyses affected side will remain immobile and uvula will
deviate toeward normal side

Ask pt to puff out cheek . normally palate elevates and

occludes nasopharynxe

In tenth nerve paralyses air will audibly escapes from nose

Pt also has history of dysphagia and nasal regurgitation this can

be confirmed by asking pt to take a drink

809
Posterior pharyngeal wall =observe movement of posterior
pharyngeal wall when pt say ah

Vocal cords=

Observe movements of vocal cords on laryngoscopy . paralysed

side will not move

Accessory nerve= is eleventh cranial nerve

Ask pt to bend head down ewards against resistance. Ask pt to

turn head toeward left against resistance to test right
sternomastoid muscle and vice versa, contracted muscle will also
be seen and palpated

Ask pt to shruge shoulder against resistance to testy power of

trapezius

Hypoglossal nerve=

Ask pt to open mouth and inspect tongue as it lies on floor of

mouth for size , shape , wasting and fasciculation

Ask pt to protrude tongue it wil deviate toward paralysed side

as normal genioglossius will push it toward opposite side

Ask pt to press tongue against bcheek while you resist with

finger pressure on outside of cheek

In unilateral paralyses movement toward normal side will be

weak

Motor system = examine the following and compare twio sides.

Notes any abnormalities and its location

1-=bulk of muscle

2=tone of muscle

3= power of muscle

810
4= reflexes

PSYCHATRY PRESCRIPTIONS AND DRUG DOSES OF IMPORTANT

MEDICINES BY DR ZUHAIB GUL

INSOMNIA AND SLEEP DISTURBANCES

Tab Xanax .5mg OD at night

Or

Tab ALP.5mg OD at night

Or

Tab noctamid 1mg OD at night

Or tab frisium 10mg od or bd or

Tab arivan 1mg OD at night or

Tab Ativan 1mg od at night

Or tab RIVOTRIL 2mg od at night(.5-8mg)

EPILEPSY IN CHILDHOOD

Syp Revalp(valproic acid)

1+1+1 for 3months

Or syp epival 1+1+1

OBSSESIVE COMPULSIOVE DISORDERS

Tab faxetine 20mg OD at morning

Or tab zauxite 20mg OD at morning or tab clomifranil 25mg od at night

Conversion disorders

811
Tab frisium 10mg 1+1 or rivotril drops 5drops SOS

TOURETTE SYNDROME

Tab buzon 2mg 1+1

Or tab recept 2mg 1+1 or tan oridone 2mg bd

MANIA AND HYPOMANIA and BIPOLAR DISORDER

FIRST LINE OF TREATMENT IS valproic acid if no improvement then lithium

salts are given

First line of treatment is as

Tab epival 250mg bd

If no improvement then tab epival 5oomg bd

2nd line of treatment is as

Tab neurolith sr 400mg

1 at night for 3days then

2 at night continue

While giving ect for rapid improvement , stop lithium and put on vailproic acid or
carbamazepine

PARKI NSONISM =

Tab sinemet 2.5mg 1/2 +1/2+1/2+1/2

And tab inderal 40mg bd

SUICIDAL ATTACK

We put on inj serenace and inj zyclidine mixed together and inj given im .if ect
available then give ect for rapid improvement

TREATMENT RESISTANT SCHYZOPRENIA

Day first 25mg

812
Day 2 =50mg

Day 3=75mg

Day 4=100mg

Day5=125mg

Day 6=150mg

Day6=175mg

Day7=200mg

Day8=225mg

Day 9 =250mg

Day 10=275mg and continue as maintenance theraphy and if side effects

emerge then decrease dose and if reponse seen then maintain this dose

Tab amlepo or tab clozaril 100mg and can be increase upto 800mg

PSYCHOSES WITH NO COMPLIANCE

Inj psychate im or inj clopexol 20mg IM

For every 2-4 weeks

Or inj fluphenazine 20mg given im or inj flucate

DEPREESION WITH OBSESSIVE COMPULSIVE DISORDERS

Tab galaxy 20mg od at morning(fluxaetine)

Or tab faxetine 20mg od at night or

Tab zauxite 20 mg at morning or tab clomifranil 25mg od at night

MAJOR DEPRESSIVE DISORDERS

Or treatment resistant depression

Ta venlafaxine (velax)37.5 mg at morning and increase upto 70mg od at morning

813
Or

TAB CO DEPRICAP 6/25mg 1od at morning

Codepricar contain both fluoxetine and olanzapine

ACUTE PSYCHOSES=irrelevant talk for less than 1month and mmore than
2days

If not control at this stage pt pprogressess to schyzopreniform disorder and

shyzoprenia

Tab buzon 2mg 1+1

Or

TAB RISP 2mg bd

Or

Tab oridone 2mg bd

Or tab regrace 2mg bd

If no compliance shown in acute psychoses we should give risperidone

Tab risp2mg 1+0+2

Or

Tab buzon 2mg 1+0+2

In pregnancy we give tab aripiprazole 5mg in morning and can be increased

upto 15mg

2nd line drugs in especially schyzoprenia we give tab dequit(quetiapine)25mg

od in morning and also 2tab dequit 25mg in night time or tab evokalm100mg
(quetipine)in night time

Myasthenia gravis

Tab neostigmine .5-2.5mg every 2hr and maximum upto 10mg /24hr

814
HICCOUPS

Inj largiectel

Or Inj decadron

Or Inj metoclopramide

Or inj stemetil or Breathing in close bag

Or Sips of milk every 5minutes

SCHOOL PHOBIA

Teachere cooperation and wean the child

SOMNAMBULISM(SLEE[ WALKING)

In valium 2-5mg

NOSTURNAL ENURESES

Tab tofranil 25mg for 2months

IMPOTENCE OR ERECTYLE DISTURBANCE

Tab vigra (sildenafil)25-100mg usually 25mg given before 30min

Tab evion 1bd

ALZEMER DEMENTIA

Tab stirrup 10mg bd

Or

Tab donecept 10mg bd or

Syp zexa 1tsf bd or syp ginko biloba

Or inj neuroplus iv inj gliatin 1gm od in adults and cap gliatin 400mg tds

EPILEPSY IN ADULTS

Tab epitaB –XR 200mg bd

815
Or

Tab tegral 200mg bd

Or tab epicar 2oomg bd

TRIOIGEMINAL NEURALGIA

Tab tegral 200mg bd

Or tab epitab –xr 200mg bd

If no response then

Tab epival 500mg continue

DIABETIC NEUROPATHY

TAB ZEEGAP 75MG BD

Tab neogab 300mg initially in

Day first 300mg od

Day 2=300mg bd

Day 3=3oomg tds

Furthur 800mg in three divided doses

Or tab vaniqa

Same dose as above

SCIATICA , BACK ACHE AND PHANTOM LIMB ( IT IS condition in

which pain is felt in limb which have been removed)

Same dose of neoggab and gabika as shown in above example

PSYCHOTIC DISIORDERS IN CHILDRENS we usually give syp risp half

teaspoonful daily bd and tab kempro half tab bd

EXTRAPYRAMIDAL SYNDROME AND DYSTONIA AND

PARKINSONISM

816
Tab kemadrin 5mg tds after meal or

Inj zyclidine im and tab valium 5mg bd

TAB AMANTIN 100MG OD FOR 1ST WEEK INCREASE TO DAILY

100MG BD FOR NEXT WEEK AND MAINTAIN THIS

OR

TAB PARLODIL(BROMOCRIPTINE)

2.5MG IST WEEK 1.25 MG AT BED TIME

SECOOND WEEK = 2.5MG AT BED TIME

WEEK 3RD=2.5MG TWICE DAILY

WEEK 4=2.5MG TDS

DOSE SHOULD BE TAKEN DURING MEAL

OR TAB SINEMET 2.5MG 1/2QID

AND

TAB INDERAL 40MG BD

OR TAB KEMPRO 5MG TDS

OR INJ ZYCLIDINE(PROCYCLIDINE) OR TAB ROPINOL OR RONIROL

2.5MG

WEEK IST 2.5MG TDS AFTER MEAL

WEEK 2=.5MG TDS

WEEK 3=.75 TDS

WEEK 4= 1MG TDS

WEEK 5-7 3MG TDS

MAXIMIUM 30MG DAILY

817
GENERALIZED ANXIETY DISORDER AND PANIC DISORDER AND
SOCIAL PHOBIA

Tab es-pramcit10mg od at morning or tab preloft 50-100mg

ACUTE PSYCHOSES

Tab olaNZIA 5-10MG or

Tab lepinza 5-10mg

No need of giving kempro along with olanzapine

Or

Tab risp 2 mg bd

Or tab kempro5mg bd

NOCTURNAL ENURESES

Tab imipramine 25mg

In child below 10yr give 10mg

In child above 11yr 20-30mg od at bed time

ATTENTION DEFICITE HYPERACTIVITY DISORDER(in this child can

play well but memory and attention to study is not present )

Cap attentra 400mg per day

Increase upto 800mg and further increase upto 1000 mg per day

VERTIGO,TINNITUS ,DEAFNESS, MENIER DISEASE TB STUGERON

FORT BD OR

TAB SERC 8MG TDS MAXIMIUM 6TAB DAILY

Tab stemetil 5mg tds

DRUG ABUSE TREATMENT CENTRE FOR CANNABES ,HEROIN

,SMOKING AND FURTHUR DRUGS

818
Tab rimargon 15mg od at night

Tab zylex sr 75mg od at day time

Tab avil retard od at NIGHT TIME

Tab brufen 400mg tds or tab nuberol fort bd sos and tab flagyl 400mg tds

DYSMENOREA(pain during menses) AND DYSPEURENIA(pain during

sexual intercourse)

Tab brexin 50mg or

Inj toradol (ketorolac)iv stat

Q
Premature ejaculation: treatment 2 S's:Typically consist of behaviuoral techniqes
aimed at prolonging time before ejaculation occurs
SSRIs [eg: fluoxitime]
Squeezing technique [glans pressure before climax]
More detail with 2 more S's:
Sensate-focus exercises [relieves anxiety]
Stop and start method [5-6 rehearsals of stopping stimulation before climax]

AZOOSPERMIA=(NO SPERM PRODUCTION)

Tab GONADIL F 2 BD FOR THREE WEEKS and

Tab vioviptal 1 od and

Tab polybion z 1 od and

Tab ciproxin 500mg bd for 7days

INFERTILITY AND WEEKNESS AND IMPOTENCY=

Tab sidenafil 25mg one tab 30min before sex

819
Tab clomiphene 50mg 1+1 for 10days

Tab Ginbex 1+1 for 30 days

Tab surbex z 30mg one od

IRREGUULARITIES OF MENSTRUAL CYCLE

Tab cecon 1+1 for 40days

Tab pioglitone one od for 40days

MOTION SICKNESS PLUS VERTIGO

tab serc 8mg tds

Or tab stugron 25mg bd

Or tab novertigo 25mg or

Tab cerebrin 25mg 3omin before bed time

ADHD AND NARCOLEPSY

Tab Ritalin 10-60mg per day

In child 5mg bd if no response maximum 60mg per day

Narcolepsy and obstructive sleep apnea

Tab evigil 200mg bd (modafanil)

Or Tab v-zac 200mg bd

HYPERSALVATION=

Inj pyrolate iv or im 4-10mcg every 4hour maximum .8mg /day

MIGRAIN syp mosegar 1tsf bd

Tab migril 1od if no response another tab may be used

OR TAB CAFERGOT 2TAB STAT if no response within half hour another tablet
can be given for episode of migraine or

820
Tab amyline 25mg at night and can be increased upto 150mg

Or tab Elle 40mg

During headache episode 40mg taken if no response repeat dose within 24hr butt
within 2hr of first dose and tab inderal 10mg tds upto 40mg bd

And tab nuberol forte 1bd for pain if pain not controlled then give inj toradol

Tab cafergot 2mg should be given if no response repeat 2mg again

Or

Tab zomig 2.5mg if no response repeat the dose again

MONOTHERAPHY OF SEIZURE

Tab lamital25mg od

Increase 50mg od for next 14 days

Maximum dose is 100mg od in two divided doses

ADJUVANT THERAPHY OF SEIZURE WITH VALPROATE

ABOVE LAMITAL PLUS

TaB LERACE (LEVETRACETAM)500MG BD

INCREASE IN 500MG BD FOR 1MONTH MAXIMUM 1500MG TWICE

DAILY

OR TAB LEVEFILL(LEVETRACETAM)

500MG BD

increase in 500mg bd for one month

or

tab trioptal (oxcarbazepine)300mg bd

as monotheraphy then increase of 30omg per day every three days

821
maintenance 1200mg per day

GENERALIZE ANXIETY DISORDERS

PREGABALIN

150MG TDS

INCREASE UPTO 300MG TDS AND FURTHUR UPTO 6OOMG TDS

OR

TAB XAAR(PREGABALIN) SAME DOSE AS ABOVE

OR

TAB TOPIROMA(TOPIRAMATE)

INITIALLY 50MG OD DOSE FOR 1WEEK THEEN INCRESAE DOSE BY

50MG AT WEEKLY INTERVAL MAINTENANCE IS 200-400MG IN TWO
DIVDED DOSESE

TOPIRAMATE ALSO GIVEN IN MIGRAIN PROPYLAXES

RESTLESS LEG SYNDROME= DOSE OF ROPINIROL GIVEN IN

PARKINSONISM

OR TAB JUMEX (SELEGLINE)5mg or tab selgin 5mg

10mg or two tab given as single dose at morning with breakfast

Or tab trihexyphenadyl(pacitone )2mg

Or Tab pacitone

Ist day = 1mg daily

2nd day 2mg

And increase in 1week upto 5-15mg daily

Generalize anxiety disorders

Tab benzodep(buspirone)7.5mg bd

822
Or

Tab busron

7.5mg bd and maximum 60mg per day

Dose of valium

1-5mg daily in anxiety , insomnia and night terror and somnambulism

In status epilepticus=

Tab relax (diazepam) 1-5mg daily

DOSE OF DOSIK THAT IS HALOPERIDOL=

INITIALLY 1.5-20MG DAILY

MAINTENANCE 3-10MG

DOSE IS REDUCED IN MAINTENANCE

PANIC ATTAKS= tab preloft(sertraline)50-100mg or tab

recept(rsperidiione)

1,2,3,4 mg or tab helixa(Escitalopram 10mg

Od at morning

AGGRESSION=

TAB EVOKALM(quetiapine) 100MG AT NIGHT

ANTIPSYCHOTICS TAB DEQUIT (QUITIAPINE) OR TAB QUETAPINE

First day 50mg /day in two divided doses

2nd day=100mg in two divided dosers

3rd day =200mg

4rth day 400mg

Or tab buzon 1,2,3,4mg

823
IN PREGANCY WITH PSYCHOSES WE GIVE ARIPPIRAZOLE 5MG OD
AT MORNING AND INCREASE UPTO 15MG PER DAY

Deression in pregnant give fluoxetine

In lactation give peroxaetine

In htn and dm give sertraline

DEPRESSION

TAB DEPRICAPE 20MG OD AT NIGHT(fluoxetine)

Or tab hapicit-e 10mg od or

Tab deprell 5o-1oomg or tab zolp 10mg or

Tab tryptanol 25mg tds (amitryptaline)

Maintenance dose is 100mg at bed time

Or Tab amitryp 25mg

Or citard 20mg 1od (citalopram)

Or tab cheer (citalopram)20mg od at bed time

Increase and should not be given more than 60mg

Or tab hapicit 20mg od

Or tab ilario2o,3o,6omg(duloxetine) or

Tab cheer up 10mg dose and not more than 20mg

Or tab prothedine(dotherpin)75-150mg as single dose in evening for depression

Or tab citanew 1omg

Half od for five days then itab od continue

Tab es pramcit 10mg

Or tab escam 10mg

824
Or Tab advance 20mg (fluoxetine) opr tab faxetine 20mg

Or Tab peroxa 20mg 1tab daily

Or cap depricap 20mg safe in pregnancy

Or Tab sensival 25mg 2noct or tab zauxite 20mg od at morning

Or tab clofranil 25mg one tab (3days )

2tab next three days and then 3tab 75MG continue
Child psychiatry=
For depression syp depricap 1tsf od upto one tsf bd
For epilepsy syp epival 1tsf tds or syp tegral one tsf od
Irrelevant talk(acute psychoses) syp vepridone half tsf bd
No alternative syp available for kempro so half tablet bd
For migraine syp mosegar one tsf bd
Some IMPORTANT DOSES
Atypical antipsychotics
Clozapine 25-900mg
Risreridone2-16
Olanzia 5-20mg
Quitapine 1oo-800mg
COMMON DOSES OF COMMON DRUGS
IN MG /DAY
Carbamazepine=200-2ooomg /day
Clobazem 20-30mg /day
Clonazepam 1-8mg
Etthosuximide=500-1500
Gabapentine=300-2400
Lamotrigine=25-500

825
 Phenobarbital 60-180
Phenytoin =150-350
Sodium valproate=400-2500. Primidone is converted in liver to
phenobarbitone

REFERAL TO OTHER WARDS=

If pt is febrile , hypertensive or diabetic or cardiac pt or in shock or

comatose or
drowsy then refere to neurology or medicine but if pt is suicide then it is our
emergency and admit them in psychtry ward, if pt have history of short duration
then rule out organic cause by reffering to medicine or neurology and by doing
ct
brain

Scales of psychology

Global Assessment of Functioning (GAF) Scale (DSM - IV Axis V)

Note: This version of the GAF scale is intended for academic use
only. Although it is based on the clinical scale presented in the DSM -
IV, this summary lacks the detail and specificity of the original
document. The complete GAF scale on page 32 of the DSM - IV should
be consulted for clinical use.

Code Description of Functioning

91 - 100 Person has no problems OR has superior functioning in several

areas OR is admired and sought after by others due to positive
qualities

81 – 90 Person has few or no symptoms. Good functioning in several areas.

826
 No more than "everyday" problems or concerns.

71 – 80 Person has symptoms/problems, but they are temporary, expectable

reactions to stressors. There is no more than slight impairment in
any area of psychological functioning.

61 – 70 Mild symptoms in one area OR difficulty in one of the following:

social, occupational, or school functioning. BUT, the person is
generally functioning pretty well and has some meaningful
interpersonal relationships.

51 – 60 Moderate symptoms OR moderate difficulty in one of the following:

social, occupational, or school functioning.

41 – 50 Serious symptoms OR serious impairment in one of the following:

social, occupational, or school functioning.

31 – 40 Some impairment in reality testing OR impairment in speech and

communication OR serious impairment in several of the following:
occupational or school functioning, interpersonal relationships,
judgment, thinking, or mood.

21 – 30 Presence of hallucinations or delusions which influence behavior

OR serious impairment in ability to communicate with others OR
serious impairment in judgment OR inability to function in almost all
areas.

11 – 20 There is some danger of harm to self or others OR occasional

failure to maintain personal hygiene OR the person is virtually unable
to communicate with others due to being incoherent or mute.

827
1 – 10 Persistent danger of harming self or others OR persistent inability
to maintain personal hygiene OR person has made a serious attempt
at suicide.

HAMILTON DEPRESSION RATING SCALE (HAM-D) Instructions for

the Clinician: the Hamilton Depression Rating Scale (HAM-D) has
proven useful for many years as a way of determining a patient’s
level of depression before, during, and after treatment. It should
be administered by a clinician experienced in working with
psychiatric patients . Although the HAM-D form lists 21 items, the
scoring is based on the first 17. It generally takes 15-20 minutes
to complete the interview and score the results. Eight items are
scored on a 5-point scale, ranging from 0 = not present to 4 =
severe. Nine are scored from 0-2. Since its development in 1960
by Dr. Max.Hamilton of the University of Leeds, England, the scale
has been widely used in clinical practice and become a standard
in pharmaceutical trials.

HAM-D Scoring Instructions:

Sum the scores from the first 17 items. 0-7 = Normal 8-13 = Mild
Depression

14-18 = Moderate Depression 19-22 =

Severe Depression ≥ 23 =

Very Severe Depression Hamilton, M: A rating scale for

depression,

Hamilton rating scale for depression

1. DEPRESSED MOOD

828
(Sadness, hopeless, helpless, worthless)

Absent

These feelings are indicated only on questioning

These feelings are spontaneously reported verbally

Communicates feelings non-verbally i.e., through facial

expression, posture, voice, and tendency to weep

Patient reports VIRTUALLY ONLY these feelings in his

spontaneous verbal and non-verbal communication

2. FEELINGS OF GUILT

Absent

Self reproach, feels he has let people down

Ideas of guilt or rumination over past errors or sinful deed

Present illness is a punishmnent. Delusions of guilt

Hears accusatory or denunciatory voices and/or experiences

threatening visual hallucinations

3. SUICIDE

Absent

Feels life is not worth living

Wishes he were dead or any thoughts of possible death to self

829
 Suicide ideas or gesture

Attempts at suicide (any serious attempt rates)

4. INSOMNIA EARLY

No difficulty falling asleep

Complains of occasional difficulty falling asleep - more than 1/2

hour
Complains of nightly difficulty falling asleep

5. INSOMNIA MIDDLE

No difficulty

Patient complains of being restless and disturbed during the

night
Waking during the night - any getting out of bed (except for

purposes of voiding)

6. INSOMNIA LATE

No difficulty

Waking in early hours of the morning but goes back to sleep

Unable to fall asleep again if he gets out of bed

7. WORK AND ACTIVITIES

No difficulty

830
 Thoughts and feelings of incapacity, fatigue or weakness related

to activities (work or hobbies)

Loss of interest in activities (hobbies or work) - either directly

reported by patient, or indirectly in listlessness, indecision and

vacillation (feels he has to push himself to work or do activities)
Decrease in actual time spent in activities or decrease in

productivity. In hospital, if patient does not spend at least three hours

a day in activities (hospital job or hobbies) exclusive of ward chores
Stopped working because of present illness. In hospital, if patient

engages in no activities except ward chores, or if patient fails to

perform ward chores unassisted

8. RETARDATION: PSYCHOMOTOR
(Slowness of thought and speech; impaired ability to concentrate;
decreased motor activity)

Normal speech and thought

Slight retardation at interview

Obvious retardation at interview

Interview difficult

Complete stupor

9. AGITATION

None

Fidgetiness

831
 Playing with hands, hair,etc

Moving about, can't sit still

Hand wringing, nail biting, hair-pulling, biting of lips

10. ANXIETY: PSYCHIC

No difficulty

Subjective tension and irritability

Worrying about minor matters

Apprehensive attitude apparent in face or speech

Fears expressed without questioning

11. ANXIETY: SOMATIC

(Physiological concomitants of anxiety, such as - Gastro-intestinal:
dry mouth, wind, indigestion, diarrhea, cramps, belching. - Cardio-
vascular : palpitations, headaches. - Respiratory: hyperventilation,
sighing. - Urinary frequency - Sweating)

Absent

Mild

Moderate

Severe

Incapacitating

12. SOMATIC SYMPTOMS: GASTROINTESTINAL

832
 None

Loss of appetite but eating without staff encouragement. Heavy

feelings in abdomen
Difficulty eating without staff urging. Requests or requires

laxatives or medication for bowels or medication for gastro-intestinal

symptoms

13. SOMATIC SYMPTOMS: GENERAL

None

Heaviness in limbs, back or head. Backaches, headache, muscle

aches. Loss of energy and fatigability

Any clear-cut symptom

14. GENITAL SYMPTOMS

(loss of libido, menstrual disturbances)

Absent

Mild

Severe

15. HYPOCHONDRIASIS

Not present

Self-absorption (bodily)

Preoccupation with health

833
 Frequent complaints, requests for help, etc. ...

Hypochondriacal delusions

16. LOSS OF WEIGHT

No weight loss

Probable weight loss associated with present illness

(>500g/week)
Definite weight loss(>1kg/week)

17. INSIGHT

Not depressed (based on above items) OR Acknowledges being

depressed and ill

Acknowledges illness but attributes cause to bad food, climate,

overwork, virus, need for rest, etc.

Denies being ill at all

The Holmes and Rahe Stress Scale

In 1967, psychiatrists Thomas Holmes and Richard Rahe decided to study

whether or not stress contributes to illness. They surveyed more than 5,000
medical patients and asked them to say whether they had experience any of
a series of 43 life events in the previous two years.

834
Each event, called a Life Change Unit (LCU), had a different "weight" for
stress. The more events the patient added up, the higher the score. The
higher the score, and the larger the weight of each event, the more likely the
patient was to become ill.

The Stress Scale

To score your stress levels, simply select Yes or No for each of the events in
the Statements column that have happened to you in the last year. Then
click Calculate My Total.

This scale must not be used in any way to cause harm to an

individual's professional career.

43 Statements to Answer Yes No

1Death of spouse (100)

2Divorce (73)

3Marital separation (65)

4Jail term (63)

5Death of close family member (63)

6Personal injury or illness (53)

7Marriage (50)

8Fired at work (47)

9Marital reconciliation (45)

10Retirement (45)

11Change in health of family

835
43 Statements to Answer Yes No

member (44)

12Pregnancy (40)

13Sex difficulties (39)

14Gain of new family member (39)

15Business readjustment (39)

16Change in financial state (38)

17Death of close friend (37)

18Change to a different line of work

(36)

19Change in number of arguments

with spouse (35)

20A large mortgage or loan (31)

21Foreclosure of mortgage or loan

(30)

22Change in responsibilities at work

(29)

23Son or daughter leaving home

(29)

24Trouble with in-laws (29)

25Outstanding personal
achievement (28)

836
43 Statements to Answer Yes No

26Spouse begins or stops work (26)

27Begin or end school/college (26)

28Change in living conditions (25)

29Revision of personal habits (24)

30Trouble with boss (23)

31Change in work hours or

conditions (20)

32Change in residence (20)

33Change in school/college (20)

34Change in recreation (19)

35Change in church activities (19)

36Change in social activities (18)

37A moderate loan or mortgage (37)

38Change in sleeping habits (16)

39Change in number of family get-

togethers (15)

40Change in eating habits (15)

41Vacation (13)

42Christmas (12)

837
 43 Statements to Answer Yes No

43Minor violations of the law (11)

Calculate My Total

Total = 0
Note: If you experienced the same event more than once, then to
gain a more accurate total, add the score again for each extra
occurrence of the event.

Score Interpretation

Scor
Comment
e

You have only a low to moderate chance of becoming

11- ill in the near future.
150

You have a moderate to high chance of becoming ill

150- in the near future.
299

You have a high or very high risk of becoming ill in

300- the near future.
600

POSITIVE AND NEGATIVE SYNDROME SCALE (PANSS)

RATING CRITERIA
GENERAL RATING INSTRUCTIONS
Data gathered from this assessment procedure are applied to the

838
PANSS
ratings. Each of the 30 items is accompanied by a specific
definition as well
as detailed anchoring criteria for all seven rating points. These
seven points
represent increasing levels of psychopathology, as follows:
1- absent
2- minimal
3- mild
4- moderate
5- moderate severe
6- severe
7- extreme
In assigning ratings, one first considers whether an item is at all
present, as
judging by its definition. If the item is absent, it is scored 1,
whereas if it is
present one must determine its severity by reference to the
particular criteria
from the anchoring points. The highest applicable rating point is
always
assigned, even if the patient meets criteria for lower points as
well. In
judging the level of severity, the rater must utilise a holistic
perspective in
deciding which anchoring point best characterises the patient’s
functioning
and rate accordingly, whether or not all elements of the
description are
observed.
The rating points of 2 to 7 correspond to incremental levels of
symptom
severity:
• A rating of 2 (minimal) denotes questionable or subtle or

839
suspected
pathology, or it also may allude to the extreme end of the normal
range.
• A rating of 3 (mild) is indicative of a symptom whose presence is
clearly established but not pronounced and interferes little in day-
today functioning.
• A rating of 4 (moderate) characterises a symptom which,
though
representing a serious problem, either occurs only occasionally or
intrudes on daily life only to a moderate extent.
• A rating of 5 (moderate severe) indicates marked
manifestations that
distinctly impact on one’s functioning but are not all-consuming
and
usually can be contained at will.
• A rating of 6 (severe) represents gross pathology that is present
very
frequently, proves highly disruptive to one’s life, and often calls
for
direct supervision.
• A rating of 7 (extreme) refers to the most serious level of
psychopathology, whereby the manifestations drastically interfere
in
most or all major life functions, typically necessitating close
supervision and assistance in many areas.
Each item is rated in consultation with the definitions and criteria
provided in
this manual. The ratings are rendered on the PANSS rating form
overleaf by
encircling the appropriate number following each dimension.
PANSSRATINGFORM
absent minimal mild moderate moderate
severe
severe extreme

840
P1 Delusions 1 2 3 4 5 6 7
P2 Conceptual disorganisation 1 2 3 4 5 6 7
P3 Hallucinatory behaviour 1 2 3 4 5 6 7
P4 Excitement 1 2 3 4 5 6 7
P5 Grandiosity 1 2 3 4 5 6 7
P6 Suspiciousness/persecution 1 2 3 4 5 6 7
P7 Hostility 1 2 3 4 5 6 7
N1 Blunted affect 1 2 3 4 5 6 7
N2 Emotional withdrawal 1 2 3 4 5 6 7
N3 Poor rapport 1 2 3 4 5 6 7
N4 Passive/apathetic social
withdrawal 1 2 3 4 5 6 7
N5 Difficulty in abstract thinking 1 2 3 4 5 6 7
N6 Lack of spontaneity &
flow of conversation 1 2 3 4 5 6 7
N7 Stereotyped thinking 1 2 3 4 5 6 7
G1 Somatic concern 1 2 3 4 5 6 7
G2 Anxiety 1 2 3 4 5 6 7
G3 Guilt feelings 1 2 3 4 5 6 7
G4 Tension 1 2 3 4 5 6 7
G5 Mannerisms & posturing 1 2 3 4 5 6 7
G6 Depression 1 2 3 4 5 6 7
G7 Motor retardation 1 2 3 4 5 6 7
G8 Uncooperativeness 1 2 3 4 5 6 7
G9 Unusual thought content 1 2 3 4 5 6 7
G10 Disorientation 1 2 3 4 5 6 7
G11 Poor attention 1 2 3 4 5 6 7
G12 Lack of judgement & insight 1 2 3 4 5 6 7
G13 Disturbance of volition 1 2 3 4 5 6 7
G14 Poor impulse control 1 2 3 4 5 6 7
G15 Preoccupation 1 2 3 4 5 6 7
G16 Active social avoidance 1 2 3 4 5 6 7
SCORING INSTRUCTIONS
Of the 30 items included in the PANSS, 7 constitute a Positive

841
Scale, 7 a
Negative Scale, and the remaining 16 a General
Psychopathology Scale.
The scores for these scales are arrived at by summation of ratings
across
component items. Therefore, the potential ranges are 7 to 49 for
the Positive
and Negative Scales, and 16 to 112 for the General
Psychopathology Scale.
In addition to these measures, a Composite Scale is scored by
subtracting
the negative score from the positive score. This yields a bipolar
index that
ranges from –42 to +42, which is essentially a difference score
reflecting the
degree of predominance of one syndrome in relation to the other.
POSITIVE SCALE (P)
P1. DELUSIONS - Beliefs which are unfounded, unrealistic and
idiosyncratic.
Basis for rating - Thought content expressed in the interview
and its influence on social relations and behaviour.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Presence of one or two delusions which are vague,
uncrystallised and not
tenaciously held. Delusions do not interfere with thinking, social
relations or behaviour.
4 Moderate - Presence of either a kaleidoscopic array of poorly
formed, unstable delusions or a
few well-formed delusions that occasionally interfere with
thinking, social relations or behaviour.
5 Moderate Severe - Presence of numerous well-formed
delusions that are tenaciously held

842
and occasionally interfere with thinking, social relations and
behaviour.
6 Severe - Presence of a stable set of delusions which are
crystallised, possibly systematised,
tenaciously held and clearly interfere with thinking, social
relations and behaviour.
7 Extreme - Presence of a stable set of delusions which are
either highly systematised or very
numerous, and which dominate major facets of the patient’s life.
This frequently results in
inappropriate and irresponsible action, which may even
jeopardise the safety of the patient or others.
P2. CONCEPTUAL DISORGANISATION - Disorganised process
of thinking characterised by
disruption of goal-directed sequencing, e.g. circumstantiality,
loose associations,
tangentiality, gross illogicality or thought block.
Basis for rating - Cognitive-verbal processes observed during
the course of interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Thinking is circumstantial, tangential or paralogical.
There is some difficulty in directing
thoughts towards a goal, and some loosening of associations may
be evidenced under pressure.
4 Moderate - Able to focus thoughts when communications are
brief and structured, but becomes
loose or irrelevant when dealing with more complex
communications or when under minimal pressure.
5 Moderate Severe - Generally has difficulty in organising
thoughts, as evidenced by frequent
irrelevancies, disconnectedness or loosening of associations even
when not under pressure.

843
6 Severe - Thinking is seriously derailed and internally
inconsistent, resulting in gross
irrelevancies and disruption of thought processes, which occur
almost constantly.
7 Extreme - Thoughts are disrupted to the point where the
patient is incoherent. There is marked
loosening of associations, which result in total failure of
communication, e.g. “word salad” or mutism.
P3. HALLUCINATORY BEHAVIOUR - Verbal report or
behaviour indicating perceptions which are
not generated by external stimuli. These may occur in the
auditory, visual, olfactory or somatic realms.
Basis for rating - Verbal report and physical manifestations
during the course of interview as well as reports of behaviour by
primary care workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - One or two clearly formed but infrequent hallucinations,
or else a number of vague
abnormal perceptions which do not result in distortions of
thinking or behaviour.
4 Moderate - Hallucinations occur frequently but not
continuously, and the patient’s
thinking and behaviour are only affected to a minor extent.
5 Moderate Severe - Hallucinations occur frequently, may
involve more than one sensory modality,
and tend to distort thinking and/or disrupt behaviour. Patient
may have a delusional interpretation of
these experiences and respond to them emotionally and, on
occasion, verbally as well.
6 Severe - Hallucinations are present almost continuously,
causing major disruption of
thinking and behaviour. Patient treats these as real perceptions,

844
and functioning is impeded
by frequent emotional and verbal responses to them.
7 Extreme - Patient is almost totally preoccupied with
hallucinations, which virtually dominate
thinking and behaviour. Hallucinations are provided a rigid
delusional interpretation and
provoke verbal and behavioural responses, including obedience
to command hallucinations.
P4. EXCITEMENT - Hyperactivity as reflected in accelerated
motor behaviour, heightened
responsivity to stimuli, hypervigilance or excessive mood lability.
Basis for rating - Behavioural manifestations during the course
of interview as well as reports of behaviour by primary care
workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Tends to be slightly agitated, hypervigilant or mildly
overaroused throughout the interview, but
without distinct episodes of excitement or marked mood lability.
Speech may be slightly pressured.
4 Moderate - Agitation or overarousal is clearly evident
throughout the interview, affecting
speech and general mobility, or episodic outbursts occur
sporadically.
5 Moderate Severe - Significant hyperactivity or frequent
outbursts of motor activity are observed,
making it difficult for the patient to sit still for longer than
several minutes at any given time.
6 Severe - Marked excitement dominates the interview, delimits
attention, and to some
extent affects personal functions such as eating or sleeping.
7 Extreme - marked excitement seriously interferes in eating
and sleeping and makes

845
interpersonal interactions virtually impossible. Acceleration of
speech and motor activity
may result in incoherence and exhaustion.
P5. GRANDIOSITY - Exaggerated self-opinion and unrealistic
convictions of superiority, including
delusions of extraordinary abilities, wealth, knowledge, fame,
power and moral righteousness.
Basis for rating - Thought content expressed in the interview
and its influence on behaviour.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Some expansiveness or boastfulness is evident, but
without clear-cut grandiose
delusions.
4 Moderate - Feels distinctly and unrealistically superior to
others. Some poorly formed
delusions about special status or abilities may be present but are
not acted upon.
5 Moderate Severe - Clear-cut delusions concerning
remarkable abilities, status or power are
expressed and influence attitude but not behaviour.
6 Severe - Clear-cut delusions of remarkable superiority
involving more than one parameter (wealth,
knowledge, fame, etc) are expressed, notably influence
interactions and may be acted upon.
7 Extreme - Thinking, interactions and behaviour are dominated
by multiple delusions of amazing
ability, wealth, knowledge, fame, power and/or moral stature,
which may take on a bizarre quality.
P6. SUSPICIOUSNESS/PERSECUTION - Unrealistic or
exaggerated ideas of persecution, as
reflected in guardedness, ad distrustful attitude, suspicious
hypervigilance or frank

846
delusions that others mean harm.
Basis for rating – Thought content expressed in the interview
and its influence on behaviour.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Presents a guarded or even openly distrustful attitude,
but thoughts, interactions and
behaviour are minimally affected.
4 Moderate - Distrustfulness is clearly evident and intrudes on
the interview and/or behaviour, but
there is no evidence of persecutory delusions. Alternatively, there
may be indication of loosely formed
persecutory delusions, but these do not seem to affect the
patient’s attitude or interpersonal relations.
5 Moderate Severe - Patient shows marked distrustfulness,
leading to major disruption of
interpersonal relations, or else there are clear-cut persecutory
delusions that have limited
impact on interpersonal relations and behaviour.
6 Severe - Clear-cut pervasive delusions of persecution which
may be systematised and
significantly interfere in interpersonal relations.
7 Extreme - A network of systematised persecutory delusions
dominates the patient’s
thinking, social relations and behaviour.
P7. HOSTILITY - Verbal and nonverbal expressions of anger and
resentment, including
sarcasm, passive-aggressive behaviour, verbal abuse and
assualtiveness.
Basis for rating – Interpersonal behaviour observed during the
interview and reports by primary care workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper

847
extreme of normal limits
3 Mild - Indirect or restrained communication of anger, such as
sarcasm, disrespect, hostile
expressions and occasional irritability.
4 Moderate - Presents an overtly hostile attitude, showing
frequent irritability and direct
expression of anger or resentment.
5 Moderate Severe - Patient is highly irritable and occasionally
verbally abusive or threatening.
6 Severe - Uncooperativeness and verbal abuse or threats
notably influence the interview and
seriously impact upon social relations. Patient may be violent and
destructive but is not
physically assualtive towards others.
7 Extreme - Marked anger results in extreme
uncooperativeness, precluding other
interactions, or in episode(s) of physical assault towards others.
NEGATIVE SCALE (N)
N1. BLUNTED AFFECT - Diminished emotional responsiveness
as characterised by a
reduction in facial expression, modulation of feelings and
communicative gestures.
Basis for rating - Observation of physical manifestations of
affective tone and emotional responsiveness during the course of
the interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Changes in facial expression and communicative
gestures seem to be stilted, forced,
artificial or lacking in modulation.
4 Moderate - Reduced range of facial expression and few
expressive gestures result in a dull
appearance

848
5 Moderate Severe - Affect is generally ‘flat’ with only
occasional changes in facial
expression and a paucity of communicative gestures.
6 Severe - Marked flatness and deficiency of emotions exhibited
most of the time. There may
be unmodulated extreme affective discharges, such as
excitement, rage or inappropriate
uncontrolled laughter.
7 Extreme – Changes in facial expression and evidence of
communicative gestures are
virtually absent. Patient seems constantly to show a barren or
‘wooden’ expression.
N2. EMOTIONAL WITHDRAWAL - Lack of interest in,
involvement with, and affective
commitment to life’s events.
Basis for rating - Reports of functioning from primary care
workers or family and observation of interpersonal behaviour
during the course of the interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Usually lack initiative and occasionally may show
deficient interest in surrounding events.
4 Moderate - Patient is generally distanced emotionally from the
milieu and its challenges
but, with encouragement, can be engaged.
5 Moderate Severe - Patient is clearly detached emotionally
from persons and events in the milieu,
resisting all efforts at engagement. Patient appears distant,
docile and purposeless but can be
involved in communication at least briefly and tends to personal
needs, sometimes with assistance.
6 Severe - Marked deficiency of interest and emotional
commitment results in limited conversation

849
with others and frequent neglect of personal functions, for which
the patient requires supervision.
7 Extreme – Patient is almost totally withdrawn,
uncommunicative and neglectful of
personal needs as a result of profound lack of interest and
emotional commitment.
N3. POOR RAPPORT - Lack of interpersonal empathy, openness
in conversation and sense of
closeness, interest or involvement with the interviewer. This is
evidenced by interpersonal
distancing and reduced verbal and nonverbal communication.
Basis for rating - Interpersonal behaviour during the course of
the interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Conversation is characterised by a stilted, strained or
artificial tone. It may lack
emotional depth or tend to remain on an impersonal, intellectual
plane.
4 Moderate - Patient typically is aloof, with interpersonal
distance quite evident. Patient may
answer questions mechanically, act bored, or express disinterest.
5 Moderate Severe - Disinvolvement is obvious and clearly
impedes the productivity of the
interview. Patient may tend to avoid eye or face contact.
6 Severe - Patient is highly indifferent, with marked
interpersonal distance. Answers are perfunctory,
and there is little nonverbal evidence of involvement. Eye and
face contact are frequently avoided.
7 Extreme - Patient is totally uninvolved with the interviewer.
Patient appears to be completely
indifferent and consistently avoids verbal and nonverbal
interactions during the interview.

850
N4. PASSIVE/APATHETIC SOCIAL WITHDRAWAL - Diminished
interest and initiative in
social interactions due to passivity, apathy, anergy or avolition.
This leads to reduced
interpersonal involvements and neglect of activities of daily
living.
Basis for rating – Reports on social behaviour from primary
care workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Shows occasional interest in social activities but poor
initiative. Usually engages with
others only when approached first by them.
4 Moderate – Passively goes along with most social activities
but in a disinterested or
mechanical way. Tends to recede into the background.
5 Moderate Severe - Passively participates in only a minority of
activities and shows virtually
no interest or initiative. Generally spends little time with others.
6 Severe - Tends to be apathetic and isolated, participating very
rarely in social activities and
occasionally neglecting personal needs. Has very few
spontaneous social contacts.
7 Extreme – Profoundly apathetic, socially isolated and
personally neglectful.
N5. DIFFICULTY IN ABSTRACT THINKING - Impairment in the
use of the abstract-symbolic
mode of thinking, as evidenced by difficulty in classification,
forming generalisations and
proceeding beyond concrete or egocentric thinking in problem-
solving tasks.
Basis for rating - Responses to questions on similarities and
proverb interpretation, and use of concrete vs. abstract mode

851
during the course of the interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Tends to give literal or personalised interpretations to
the more difficult proverbs
and may have some problems with concepts that are fairly
abstract or remotely related.
4 Moderate - Often utilises a concrete mode. Has difficulty with
most proverbs and some
categories. Tends to be distracted by functional aspects and
salient features.
5 Moderate Severe - Deals primarily in a concrete mode,
exhibiting difficulty with most
proverbs and many categories.
6 Severe - Unable to grasp the abstract meaning of any
proverbs or figurative expressions
and can formulate classifications for only the most simple of
similarities. Thinking is either
vacuous or locked into functional aspects, salient features and
idiosyncratic interpretations.
7 Extreme - Can use only concrete modes of thinking. Shows no
comprehension of proverbs,
common metaphors or similes, and simple categories. Even
salient and functional attributes
do not serve as a basis for classification. This rating may apply to
those who cannot interact
even minimally with the examiner due to marked cognitive
impairment.
N6. LACK OF SPONTANEITY AND FLOW OF CONVERSATION -
Reduction in the normal flow
of communication associated with apathy, avolition,
defensiveness or cognitive deficit. This
is manifested by diminished fluidity and productivity of the

852
verbal interactional process.
Basis for rating - Cognitive-verbal processes observed during
the course of interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild – Conversation shows little initiative. Patient’s answers
tend to be brief and
unembellished, requiring direct and leading questions by the
interviewer.
4 Moderate – Conversation lacks free flow and appears uneven
or halting. Leading questions
are frequently needed to elicit adequate responses and proceed
with conversation.
5 Moderate Severe - Patient shows a marked lack of
spontaneity and openness, replying to
the interviewer’s questions with only one or two brief sentences.
6 Severe - Patient’s responses are limited mainly to a few words
or short phrases intended to
avoid or curtail communication. (e.g. “I don’t know”, “I’m not at
liberty to say”).
Conversation is seriously impaired as a result and the interview
is highly unproductive.
7 Extreme - Verbal output is restricted to, at most, an occasional
utterance, making
conversation not possible.
N7. STEREOTYPED THINKING - Decreased fluidity, spontaneity
and flexibility of thinking, as
evidenced in rigid, repetitious or barren thought content.
Basis for rating - Cognitive-verbal processes observed during
the interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits

853
3 Mild - Some rigidity shown in attitude or beliefs. Patient may
refuse to consider alternative
positions or have difficulty in shifting from one idea to another.
4 Moderate - Conversation revolves around a recurrent theme,
resulting in difficulty in
shifting to a new topic.
5 Moderate Severe - Thinking is rigid and repetitious to the
point that, despite the
interviewer’s efforts, conversation is limited to only two or three
dominating topics.
6 Severe – Uncontrolled repetition of demands, statements,
ideas or questions which severely
impairs conversation.
7 Extreme - Thinking, behaviour and conversation are
dominated by constant repetition of
fixed ideas or limited phrases, leading to gross rigidity,
inappropriateness and restrictiveness
of patient’s communication.
GENERAL PSYCHOPATHOLOGY SCALE (G)
G1. SOMATIC CONCERN - Physical complaints or beliefs about
bodily illness or malfunctions. This
may range from a vague sense of ill being to clear-cut delusions
of catastrophic physical disease.
Basis for rating - Thought content expressed in the interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Distinctly concerned about health or bodily malfunction,
but there is no delusional
conviction and overconcern can be allayed by reassurance.
4 Moderate - Complains about poor health or bodily
malfunction, but there is no delusional
conviction, and overconcern can be allayed by reassurance.
5 Moderate Severe - Patient expresses numerous or frequent

854
complaints about physical
illness or bodily malfunction, or else patient reveals one or two
clear-cut delusions
involving these themes but is not preoccupied by them.
6 Severe - Patient is preoccupied by one or a few clear-cut
delusions about physical disease
or organic malfunction, but affect is not fully immersed in these
themes, and thoughts can
be diverted by the interviewer with some effort.
7 Extreme – Numerous and frequently reported somatic
delusions, or only a few somatic
delusions of a catastrophic nature, which totally dominate the
patient’s affect or thinking.
G2. ANXIETY - Subjective experience of nervousness, worry,
apprehension or restlessness,
ranging from excessive concern about the present or future to
feelings of panic.
Basis for rating - Verbal report during the course of interview
and corresponding physical manifestations.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Expresses some worry, overconcern or subjective
restlessness, but no somatic and
behavioural consequences are reported or evidenced.
4 Moderate - Patient reports distinct symptoms of nervousness,
which are reflected in mild
physical manifestations such as fine hand tremor and excessive
perspiration.
5 Moderate Severe - Patient reports serious problems of
anxiety which have significant
physical and behavioural consequences, such as marked tension,
poor concentration,
palpitations or impaired sleep.

855
6 Severe - Subjective state of almost constant fear associated
with phobias, marked
restlessness or numerous somatic manifestations.
7 Extreme - Patient’s life is seriously disrupted by anxiety, which
is present almost constantly
and at times reaches panic proportion or is manifested in actual
panic attacks.
G3. GUILT FEELINGS - Sense of remorse or self-blame for real
or imagined misdeeds in the past.
Basis for rating - Verbal report of guilt feelings during the
course of interview and the influence on attitudes and thoughts.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild – Questioning elicits a vague sense of guilt or self-blame
for a minor incident, but the
patient clearly is not overly concerned.
4 Moderate - Patient expresses distinct concern over his
responsibility for a real incident in
his life but is not pre-occupied with it and attitude and behaviour
are essentially unaffected.
5 Moderate Severe - Patient expresses a strong sense of guilt
associated with selfdeprecation or the belief that he deserves
punishment. The guilt feelings may have a
delusional basis, may be volunteered spontaneously, may be a
source of preoccupation
and/or depressed mood, and cannot be allayed readily by the
interviewer.
6 Severe - Strong ideas of guilt take on a delusional quality and
lead to an attitude of hopelessness
or worthlessness. The patient believes he should receive harsh
sanctions as such punishment.
7 Extreme - Patient’s life is dominated by unshakable delusions
of guilt, for which he feels

856
deserving of drastic punishment, such as life imprisonment,
torture, or death. There may be
associated suicidal thoughts or attribution of others’ problems to
one’s own past misdeeds.
G4. TENSION -Overt physical manifestations of fear, anxiety, and
agitation, such as stiffness,
tremor, profuse sweating and restlessness.
Basis for rating - Verbal report attesting to anxiety and
thereupon the severity of physical manifestations of tension
observed during the interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Posture and movements indicate slight
apprehensiveness, such as minor rigidity,
occasional restlessness, shifting of position, or fine rapid hand
tremor.
4 Moderate - A clearly nervous appearance emerges from
various manifestations, such as
fidgety behaviour, obvious hand tremor, excessive perspiration,
or nervous mannerisms.
5 Moderate Severe - Pronounced tension is evidenced by
numerous manifestations, such as nervous
shaking, profuse sweating and restlessness, but can conduct in
the interview is not significantly affected.
6 Severe - Pronounced tension to the point that interpersonal
interactions are disrupted. The patient,
for example, may be constantly fidgeting, unable to sit still for
long, or show hyperventilation.
7 Extreme - Marked tension is manifested by signs of panic or
gross motor acceleration,
such as rapid restless pacing and inability to remain seated for
longer than a minute, which
makes sustained conversation not possible.

857
G5. MANNERISMS AND POSTURING – Unnatural movements
or posture as characterised be an
awkward, stilted, disorganised, or bizarre appearance.
Basis for rating - Observation of physical manifestations during
the course of interview as well as reports from primary care
workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Slight awkwardness in movements or minor rigidity of
posture
4 Moderate – Movements are notably awkward or disjointed, or
an unnatural posture is
maintained for brief periods.
5 Moderate Severe - Occasional bizarre rituals or contorted
posture are observed, or an
abnormal position is sustained for extended periods.
6 Severe - Frequent repetition of bizarre rituals, mannerisms or
stereotyped movements, or a
contorted posture is sustained for extended periods.
7 Extreme - Functioning is seriously impaired by virtually
constant involvement in ritualistic, manneristic,
or stereotyped movements or by an unnatural fixed posture
which is sustained most of the time.
G6. DEPRESSION - Feelings of sadness, discouragement,
helplessness and pessimism.
Basis for rating - Verbal report of depressed mood during the
course of interview and its observed influence on attitude and
behaviour.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Expresses some sadness of discouragement only on
questioning, but there is no

858
evidence of depression in general attitude or demeanor.
4 Moderate - Distinct feelings of sadness or hopelessness, which
may be spontaneously
divulged, but depressed mood has no major impact on behaviour
or social functioning and
the patient usually can be cheered up.
5 Moderate Severe - Distinctly depressed mood is associated
with obvious sadness,
pessimism, loss of social interest, psychomotor retardation and
some interference in
appetite and sleep. The patient cannot be easily cheered up.
6 Severe - Markedly depressed mood is associated with
sustained feelings of misery, occasional
crying, hopelessness and worthlessness. In addition, there is
major interference in appetite and
or sleep as well as in normal motor and social functions, with
possible signs of self-neglect.
7 Extreme - Depressive feelings seriously interfere in most
major functions. The
manifestations include frequent crying, pronounced somatic
symptoms, impaired
concentration, psychomotor retardation, social disinterest, self
neglect, possible depressive
or nihilistic delusions and/or possible suicidal thoughts or action.
G7. MOTOR RETARDATION – Reduction in motor activity as
reflected in slowing or lessening
or movements and speech, diminished responsiveness of stimuli,
and reduced body tone.
Basis for rating - Manifestations during the course of interview
as well as reports by primary care workers as well as family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Slight but noticeable diminution in rate of movements

859
and speech. Patient may be
somewhat underproductive in conversation and gestures.
4 Moderate - Patient is clearly slow in movements, and speech
may be characterised by poor
productivity including long response latency, extended pauses or
slow pace.
5 Moderate Severe – A marked reduction in motor activity
renders communication highly
unproductive or delimits functioning in social and occupational
situations. Patient can
usually be found sitting or lying down.
6 Severe - Movements are extremely slow, resulting in a
minimum of activity and speech.
Essentially the day is spent sitting idly or lying down.
7 Extreme - Patient is almost completely immobile and virtually
unresponsive to external stimuli.
G8. UNCOOPERATIVENESS - Active refusal to comply with the
will of significant others,
including the interviewer, hospital staff or family, which may be
associated with distrust,
defensiveness, stubbornness, negativism, rejection of authority,
hostility or belligerence.
Basis for rating - Interpersonal behaviour observed during the
course of the interview as well as reports by primary care
workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Complies with an attitude of resentment, impatience, or
sarcasm. May inoffensively
object to sensitive probing during the interview.
4 Moderate - Occasional outright refusal to comply with normal
social demands, such as making own bed, attending
scheduled programmes, etc. The patient may project a hostile,

860
defensive or negative attitude but usually can be worked with.
5 Moderate Severe - Patient frequently is incompliant with the
demands of his milieu and may be
characterised by other as an “outcast” or having “a serious
attitude problem”. Uncooperativeness is reflected in
obvious defensiveness or irritability with the interviewer and
possible unwillingness to address many questions.
6 Severe - Patient is highly uncooperative, negativistic and
possibly also belligerent. Refuses to comply
with the most social demands and may be unwilling to initiate or
conclude the full interview.
7 Extreme - Active resistance seriously impact on virtually all
major areas of functioning. Patient may refuse to join in
any social activities, tend to personal hygiene, converse with
family or staff and participate even briefly in an interview.
G9. UNUSUAL THOUGHT CONTENT - Thinking characterised
by strange, fantastic or bizarre ideas,
ranging from those which are remote or atypical to those which
are distorted, illogical and patently absurd.
Basis for rating - Thought content expressed during the course
of interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Thought content is somewhat peculiar, or idiosyncratic,
or familiar ideas are framed in an odd context.
4 Moderate - Ideas are frequently distorted and occasionally
seem quite bizarre.
5 Moderate Severe - Patient expresses many strange and
fantastic thoughts, (e.g. Being the
adopted son of a king, being an escapee from death row), or
some which are patently absurd (e.g.
Having hundreds of children, receiving radio messages from
outer space from a tooth filling).

861
6 Severe - Patient expresses many illogical or absurd ideas or
some which have a distinctly
bizarre quality (e.g. having three heads, being a visitor from
another planet).
7 Extreme - Thinking is replete with absurd, bizarre and
grotesque ideas.
G10. DISORIENTATION - Lack of awareness of one’s
relationship to the milieu, including
persons, place and time, which may be due to confusion or
withdrawal.
Basis for rating - Responses to interview questions on
orientation.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - General orientation is adequate but there is some
difficulty with specifics. For example, patient
knows his location but not the street address, knows hospital
staff names but not their functions, knows
the month but confuses the day of the week with an adjacent day,
or errs in the date by more than two
days. There may be narrowing of interest evidenced by
familiarity with the immediate but not extended
milieu, such as ability to identify staff but not the mayor,
governor, or president.
4 Moderate - Only partial success in recognising persons,
placesand time. For example, patient knows he is in a
hospital but not its name, knows the name of the city but not the
borough or district, knows the name of his
primary therapist but not many other direct care workers, knows
the year or season but not sure of the month.
5 Moderate Severe - Considerable failure in recognising
persons, place and time. Patient has only a
vague notion of where he is and seems unfamiliar with most

862
people in his milieu. He may identify
the year correctly or nearly but not know the current month, day
of week or even the season.
6 Severe - Marked failure in recognising persons, place and
time. For example, patient has no knowledge of his
whereabouts, confuses the date by more than one year, canname
only one or two individuals in his current life.
7 Extreme - Patient appears completely disorientated with
regard to persons, place and time.
There is gross confusion or total ignorance about one’s location,
the current year and even
the most familiar people, such as parents, spouse, friends and
primary therapist.
G11. POOR ATTENTION - Failure in focused alertness
manifested by poor concentration, distractibility
from internal and external stimuli, and difficulty in harnessing,
sustaining or shifting focus to new stimuli.
Basis for rating – Manifestations during the course of interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Limited concentration evidenced by occasional
vulnerability to distraction and
faltering attention toward the end of the interview.
4 Moderate - Conversation is affected by the tendency to be
easily distracted, difficulty in long
sustaining concentration on a given topic, or problems in shifting
attention to new topics.
5 Moderate Severe - Conversation is seriously hampered by
poor concentration,
distractibility, and difficulty in shifting focus appropriately..
6 Severe - Patient’s attention can be harnessed for only brief
moments or with great effort,
due to marked distraction by internal or external stimuli.

863
7 Extreme - Attention is so disrupted that even brief
conversation is not possible.
G12. LACK OF JUDGEMENT AND INSIGHT - Impaired
awareness or understanding of one’s own
psychiatric condition and life situation. This is evidenced by
failure to recognise past or present
psychiatric illness or symptoms, denial of need for psychiatric
hospitalisation or treatment, decisions
characterised by poor anticipation or consequences, and
unrealistic short-term and long-range planning.
Basis for rating – Thought content expressed during the
interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Recognises having a psychiatric disorder but clearly
underestimates its seriousness, the implications for
treatment, or the importance of taking measures to avoid
relapse. Future planning may be poorly conceived.
4 Moderate - Patient shows only a vague or shallow recognition
of illness. There may be fluctuations in
acknowledgement of being ill or little awareness of major
symptoms which are present, such as
delusions, disorganised thinking, suspiciousness and social
withdrawal. The patient may rationalise the
need for treatment in terms of its relieving lesser symptoms,
such as anxiety, tension and sleep difficulty.
5 Moderate Severe - Acknowledges past but not present
psychiatric disorder. If challenged, the patient
may concede the presence of some unrelated or insignificant
symptoms, which tend to be explained away by
gross misinterpretation or delusional thinking. The need for
psychiatric treatment similarly goes unrecognised.
6 Severe - Patient denies ever having had a psychiatric disorder.

864
He disavows the presence of any psychiatric
symptoms in the past or present and, though compliant, denies
the need for treatment and hospitalisation.
7 Extreme - Emphatic denial of past and present psychiatric
illness. Current hospitalisation and treatment
are given a delusional interpretation (e.g. as punishment fro
misdeeds, as persecution by tormentors, etc),
and the patient thus refuse to cooperate with therapists,
medication or other aspects of treatment.
G13. DISTURBANCE OF VOLITION – Disturbance in the wilful
initiation, sustenance and
control of one’s thoughts, behaviour, movements and speech.
Basis for rating - Thought content and behaviour manifested in
the course of interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - There is evidence of some indecisiveness in conversation
and thinking, which may
impede verbal and cognitive processes to a minor extent.
4 Moderate - Patient is often ambivalent and shows clear
difficulty in reaching decisions.
Conversation may be marred by alteration in thinking, and in
consequence, verbal and
cognitive functioning are clearly impaired.
5 Moderate Severe - Disturbance of volition interferes in
thinking as well as behaviour.
Patient shows pronounced indecision that impedes the initiation
and continuation of social
and motor activities, and which also may be evidence in halting
speech.
6 Severe - Disturbance of volition interferes in the execution of
simple automatic motor
functions, such as dressing or grooming, and markedly affects

865
speech.
7 Extreme – Almost complete failure of volition is manifested by
gross inhibition of movement
and speech resulting in immobility and/or mutism.
G14. POOR IMPULSE CONTROL - Disordered regulation and
control of action on inner urges, resulting in sudden,
unmodulated, arbitrary ormisdirected discharge of tension and
emotions withoutconcern about consequences.
Basis for rating – Behaviour during the course of interview and
reported by primary care workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Patient tends to be easily angered and frustrated when
facing stress or denied
gratification but rarely acts on impulse.
4 Moderate - Patient gets angered and verbally abusive with
minimal provocation. May be occasionally
threatening, destructive, or have one or two episodes involving
physical confrontation or a minor brawl.
5 Moderate Severe - Patient exhibits repeated impulsive
episodes involving verbal abuse,
destruction of property, or physical threats. There may be one or
two episodes involving
serious assault, for which the patient requires isolation, physical
restraint, or p.r.n. sedation.
6 Severe - Patient frequently is impulsive aggressive,
threatening, demanding, and destructive,
without any apparent consideration of consequences. Shows
assualtive behaviour and may
also be sexually offensive and possibly respond behaviourally to
hallucinatory commands.
7 Extreme - Patient exhibits homicidal, sexual assaults, repeated
brutality,or self-destructive behaviour. Requires

866
constant direct supervision or external constraints because of
inability to control dangerous impulses.
G15. PREOCCUPATION - Absorption with internally generated
thoughts and feelings and with
autistic experiences to the detriment of reality orientation and
adaptive behaviour.
Basis for rating - Interpersonal behaviour observed during the
course of interview.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Excessive involvement with personal needs or problems,
such that conversation
veers back to egocentric themes and there is diminished
concerned exhibited toward others.
4 Moderate - Patient occasionally appears self-absorbed, as if
daydreaming or involved with
internal experiences, which interferes with communication to a
minor extent.
5 Moderate Severe - Patient often appears to be engaged in
autistic experiences, as evidenced by
behaviours that significantly intrude on social and
communicational functions, such as the presence
of a vacant stare, muttering or talking to oneself, or involvement
with stereotyped motor patterns.
6 Severe - Marked preoccupation with autistic experiences,
which seriously delimits
concentration, ability to converse, and orientation to the milieu.
The patient frequently may
be observed smiling, laughing, muttering, talking, or shouting to
himself.
7 Extreme - Gross absorption with autistic experiences, which
profoundly affects all major
realms of behaviour. The patient constantly may be responding

867
verbally or behaviourally to
hallucinations and show little awareness of other people or the
external milieu.
G16. ACTIVE SOCIAL AVOIDANCE - Diminished social
involvement associated with
unwarranted fear, hostility, or distrust.
Basis for rating - Reports of social functioning primary care
workers or family.
1 Absent - Definition does not apply
2 Minimal - Questionable pathology; may be at the upper
extreme of normal limits
3 Mild - Patient seems ill at ease in the presence of others of
others and prefers to spend
time alone, although he participates in social functions when
required.
4 Moderate - Patient begrudgingly attends all or most social
activities but may needs to be
persuaded or may terminate prematurely on account of anxiety,
suspiciousness, or hostility.
5 Moderate Severe - Patient fearfully or angrily keeps away
from many social interactions
despite others’ efforts to engage him. Tends to spend
unstructured time alone.
6 Severe - Patient participates in very few social activities
because of fear, hostility, or distrust. When approached, the
patient shows a strong tendency to break off interactions, and
generally he tends to isolate himself from others.
7 Extreme - Patient cannot be engaged in social activities
because of pronounced fears, hostility, or
persecutory delusions. To the extent possible, he avoids all
interactions and remains isolated from others.

YOUNG MANIA RATING SCALE

868
 The YMRS is typically administered by a third-party clinician, but it is
provided here, in a slightly reworded form, as a self-assessment. This may
not be as accurate when self-administered, as people suffering from
mania are often unable to properly assess relevant outward symptoms.
There are 11 groups of statements in this questionnaire, read each group
of statements carefully. Specify one of the choices that best describes the
way you have been feeling for the past week by clicking the dot next to
the appropriate statement.
1 Elevated Mood

o Absent

o Mildly or possibly increased

o Definite subjective elevation; optimistic, self-confident; cheerful;

appropriate to content
o Elevated, inappropriate to content; humorous

o Euphoric, inappropriate laughter, singing

2 Increased Motor Activity or Energy

o Absent

o Subjectively increased

o Animated; gestures increased

o Excessive energy; hyperactive at times; restless (can be calmed)

o Motor excitement; continuous hyperactivity (cannot be calmed)

3 Sexual Interest

o Normal; not increased

o Mildly or possibly increased

o Definite subjective increase

869
o Spontaneous sexual content; elaborates on sexual matters;

hypersexual
o Overt sexual acts

4 Sleep

o No decrease in sleep

o Sleeping less than normal amount by up to one hour

o Sleeping less than normal by more than one hour

o Decreased need for sleep

o No need for sleep at all

5 Irritability

o Absent

o Subjectively increased

o Irritable at times; recent episodes of anger or annoyance

o Frequently irritable; short, curt

o Hostile, uncooperative

6 Speech: Rate & Amount

o No increase

o Feel talkative

o Increased rate or amount at times, verbose at times

o Push; consistently increased rate and amount;

o Pressured; uninterruptedly, continuous speech

7 Language: Thought Disorder

870
o Absent

o Circumstantial; mild distractibility; quick thoughts

o Distractible; loses goal of thought; change topics frequently; racing

thoughts
o Flight of ideas; tangentially; difficult to follow; rhyming, echolalia

o Incoherent; communication impossible

8 Content

o Normal

o Questionable plans, new interests

o Special project(s); hyper religious

o Grandiose or paranoid ideas; ideas of reference

o Delusions; hallucinations

9 Disruptive or Aggressive Behavior

o Absent

o Sarcastic; loud at times, guarded

o Demanding; threats

o Threats, shouting

o Assaultive; destructive

10 Appearance

o Appropriate dress and grooming

o Minimally unkempt

o Poorly groomed; moderately disheveled; overdressed

871
o Disheveled; partly clothed; garish make-up

o Completely unkempt; decorated; bizarre garb

11 Insight

o Present; admits illness; agrees with need for treatment

o Possibly ill

o Admits behavior change, but denies illness

o Admits possible change in behavior, but denies illness

o Denies any behavior change

12
Score my Answers

POSITIVE AND NEGATIVE SYNDROME SCALE (PANSS)

RATING CRITERIA
GENERAL RATING INSTRUCTIONS
Data gathered from this assessment procedure are applied to the
PANSS ratings. Each of the 30 items is accompanied by a specific
definition as well as detailed anchoring criteria for all seven rating
points. These seven points represent increasing levels of
psychopathology, as follows:
1- absent
2- minimal
3- mild
4- moderate
5- moderate severe
6- severe
7- extreme

872
In assigning ratings, one first considers whether an item is at all
present, as judging by its definition. If the item is absent, it is
scored 1, whereas if it is present one must determine its severity
by reference to the particular criteria from the anchoring points.
The highest applicable rating point is always assigned, even if the
patient meets criteria for lower points as well. In judging the level
of severity, the rater must utilise a holistic perspective in
deciding which anchoring point best characterises the patient’s
functioning and rate accordingly, whether or not all elements of
the description are
observed.
The rating points of 2 to 7 correspond to incremental levels of
symptom
severity:
• A rating of 2 (minimal) denotes questionable or subtle or
suspected
pathology, or it also may allude to the extreme end of the normal
range.
• A rating of 3 (mild) is indicative of a symptom whose presence is
clearly established but not pronounced and interferes little in day-
today functioning.
• A rating of 4 (moderate) characterises a symptom which,
though representing a serious problem, either occurs only
occasionally or intrudes on daily life only to a moderate extent.
• A rating of 5 (moderate severe) indicates marked
manifestations that distinctly impact on one’s functioning but are
not all-consuming and
usually can be contained at will.
• A rating of 6 (severe) represents gross pathology that is present
very
frequently, proves highly disruptive to one’s life, and often calls
for
direct supervision.
• A rating of 7 (extreme) refers to the most serious level of
psychopathology, whereby the manifestations drastically interfere
in
most or all major life functions, typically necessitating close
supervision and assistance in many areas.
Each item is rated in consultation with the definitions and criteria

873
provided in
this manual. The ratings are rendered on the PANSS rating form
overleaf by
encircling the appropriate number following each dimension.

874
SCORING INSTRUCTIONS

Of the 30 items included in the PANSS, 7 constitute a Positive

Scale, 7 a Negative Scale, and the remaining 16 a General
Psychopathology Scale. The scores for these scales are arrived
at by summation of ratings across component items. Therefore,
the potential ranges are 7 to 49 for the Positive and Negative
Scales, and 16 to 112 for the General Psychopathology Scale. In
addition to these measures, a Composite Scale is scored by
875
subtracting the negative score from the positive score. This yields
a bipolar index that ranges from –42 to +42, which is essentially a
difference score reflecting the degree of predominance of one
syndrome in relation to the other.

876