DAMS

26 August 2017 09:48

10 Q in NEET PG
~2 Q from general psychiatry
6-8 Q from clinical psychiatry
1-2 Q from psychology

Dr Sachin Arora [8411888304]

Read DAMS notes

Practice MCQs

Time is limited; Work is unlimited

One who knows how to prioritise → wins
Priority
1. Medicine, surgery, Ob Gyn, Paeds, Ortho
2. Skin, Anesthesia, Radio, Psychiatry
3. PSM, ENT, Ophtha

Priority
1. Class notes
2. Class test/Grand test/Subject wise tests
3. CRS MCQs
4. DAMS club/cloud
5. CRS theory

Psychiatry Page 1
General Psychiatry
26 August 2017 10:06

≡┬─{aka approach to a patient

├─{History Taking
├─{Mental Status Examination [MSE]─┬─{Thought
│ ├─{Perception
│ ├─{Mood
│ ├─{Behaviour
│ └─{Cognition
├─{Disorders of Thought─┬─{Disorders of form─┬─{Loosening of association
│ │ ├─{Neologism
│ │ └─{Derailment
│ ├─{Disorders of content─┬─{Delusions
│ │ ├─{Obsessions
│ │ └─{Preoccupations
│ ├─{Disorders of possession of thought─┬─{Thought
Insertion
│ │ ├─{Thought
Withdrawal
│ │ └─{Thought
Broadcast
│ ├─{Disorders of stream of thought─┬─{Flight of
Ideas
│ │ ├─{Slowing
│ │ ├─{Thought
Block
│ │
└─{Perseveration
│ ├─{Form of thought─┬─{Normal thought
│ │ ├─{Loosening of association
│ │ └─{Neologism
│ ├─{Content of thought─┬─{Delusion
│ │ └─{Obsession
│ ├─{Possession of thought
│ ├─{Stream of thought─┬─{Thought tempo
│ │ └─{Thought continuity
│ └─{Other thought disturbances───{Clang
associations
├─{Disorders of Perception───{Hallucination─┬─{Types
│ └─{Special Types
├─{Disorders of Mood───{Emotions
├─{Behaviour
├─{Cognition─┬─{Orientation
│ ├─{Attention & Concentration
│ ├─{Memory───{Remote memory
│ ├─{Abstract Ability─┬─{Concretisation of thinking
│ │ └─{Testing abstract ability
│ └─{Judgement & Reasoning
└─{Investigation─┬─{Neuropsychological tests─┬─{MMSE
│ └─{BGT
├─{Intelligence Tests
└─{Personality Tests─┬─{Rorschach's Ink blot test

Psychiatry Page 2
 └─{Personality Tests─┬─{Rorschach's Ink blot test
└─{Thematic Apperception Test
aka approach to a patient

History + Examination + Investigation → Diagnosis

History is most imp in psychiatry diagnosis

History Taking
1. Identifying data
2. Chief Complaints
3. HOPI
4. Past History
5. Family History
6. Personal History
a. Most imp
b. Includes
i. Marital history [Good prognosis]
ii. Occupational history [Doctors have highest incidence]
iii. Academic history
1) MC cause of poor scholastic performance is mental retardation
2) Other causes → Autism, ADHD, anxiety
c. Does not include food preferences

Mental Status Examination [MSE]

Thought
Perception
Mood
Behaviour
Cognition

Disorders of Thought
Disorders of form
Loosening of association [Derailment]
Neologism
Disorders of content
Delusions
Obsessions
Preoccupations
Disorders of possession of thought
Thought Insertion
Thought Withdrawal
Thought Broadcast
Disorders of stream of thought
Flight of Ideas
Slowing
Thought Block
Perseveration

Form of thought

Psychiatry Page 3
Form of thought
Form = formation [genesis of thought process]

Normal thought
Logical sequence of events
A → B → C → D and so on

Loosening of association
Disorganised speech
Derailment
It's like train ka track change hota rehta he. The next topic has no
relationship with the previous one

Loss of association seen in → schizophrenia

In LOA, individual parts of the thought process are not connected to each other by
logic/meaning such that the overall speech output is not understandable

Agar patient ki baat samajh nhi aa rhi → Diagnosis is schizophrenia

Neologism
Coining new words which have meaning to the patient but not to the examiner

Ex What did you have for dinner last night

Patient → I had aloo sabji + dal + abru dabru [patient wants to say roti
but this word doesn't mean anything to you]
Jargon speech Neologism
Fluent but Incoherent/Incomprehensible Irrelevant words present in
[There's no meaning but it will sound ok to a otherwise normal speach
speaker of a foreign language]
Organic disorder Functional disorder

Neologism is MC specific speech sign of psychosis/schizophrenia

If word "Not understood" given in stem of Q → Schizophrenia

Content of thought
Delusion
False, firm and fixed belief that persists even after evidence against it is provided

Types of delusion
1. Delusion of persecution/paranoid delusion
a) Person feels that people are planning & plotting against me to cause
destruction/harm to myself, my family members or my property
b) Conspiracy
c) Suspicious
d) Seen in schizophrenia
2. Delusion of reference
a) Person feels things, acts, places, talks, events make a direct reference
to me
b) Seen in schizophrenia
3. Delusion of grandiosity
a) Supremacy
i) Wealth
ii) Power

Psychiatry Page 4
 ii) Power
iii) Position
b) Seen in mania
4. Delusion of guilt/sin
a) Blaming himself/herself
b) Seen in depression
5. Delusion of Nihilism
a) Person denies existence of
i) Himself
ii) World
b) Clinical clues
i) Internal organs have rotten
ii) Bad smell coming out of my body
c) MC cause → Severe depression
d) 2nd MC cause → Cotard's syndrome [Total 7 syndromes in psychiatry

Delusion of grandiosity & Guilt → Mood congruent delusions

Mania + Grandiosity
Depression + Guilt

Other classification
Bizarre delusions Non-bizarre delusions
Implausible Possible

Q A person thinks that his thoughts are taken away by his neighbour who
has inserted a device inside his head. Diagnosis?
1. Bizarre delusions
2. Non-bizarre delusions

Obsession

Obsession Compulsion
Thought Act
Dirt contamination → Hand washing
[MC obsession]
Pathological doubt → Checking
[MC compulsion]
Overall MC OCD → Thought > Action [So, Dirt contamination > Checking]

Patient is aware that hands are NOT dirty but this unwanted thought comes in

Properties of an obsession
DOIRS
D Distressing [= Ego-dystonic or inconsistent with self image]
O Own but unwelcome[= Ego-alien]
I Intrusive/Irresistible
R Recurrent
S Senseless [Irrational]

Persists despite resistance

Causes Anxiety
Long term complication Depression

Psychiatry Page 5
 Long term complication Depression

Signs in OCD
Ambivalency Ambitendency
Indecisiveness between 2 opposite Indecisiveness between 2 opposite
1. thoughts actions
MC seen in OCD
2. Magical thinking
1. My thinking makes it happen
2. Excessively correlating thoughts with events
3. Very common in OCD

Possession of thought
Thought alienation
All of these are bizarre delusions
Thought Insertion Thought Withdrawal Thought Broadcast
Outside thoughts Your thoughts few others get Your thoughts many others get
come in your mind to know without speaking to know without speaking

Stream of thought

Thought tempo
Flight of Ideas
By chance association
Subtle/small/one word connection [Partially understandable]

Flight of Ideas Loosening of association

Connection present No connection
Partially understandable Not understandable
D/o flow/stream D/o form
Mania Schizophrenia

Ex
I love my home, home sweet home, sugar is sweet, sweet gives
diabetes, diabetics have sweet urine
1. Flight of ideas [As words matching with each other]
2. Derailment
3. Circumstantiality
4. Tangentiality
Inhibition or slowing of thinking
Seen in depression

Thought continuity
Perseveration
Persistence of the same response beyond the point of relevance

Ex
What's your name? Rahul
Father's name? Rahul
Where are you from? Rahul
And so on

Psychiatry Page 6
 Seen in
Organic Mental Disorders
Also, schizophrenia

Thought Block
Sudden break in the train of thoughts

Seen in
Schizophrenia
Anxiety [Seen in normal person]

Other thought disturbances

Circumstantiality Tangentiality
Overinclusion of unnecessary details Going off track & NEVER reaching the
but ultimately reaching the answer answer
Ex Ex
Patient asked, "When did you reach the Patient asked, "How are you feeling
hospital?" today?"
Patient replied with details of his morning Patient replies, "The sofa is feeling
like when he woke up and ends with the time soft today"
[the required answer] [Didn't give the required answer]

Clang associations
Words are linked to each other by rhyme

Disorders of Perception

Hallucination Illusion
Perception without stimulus Perceptual misinterpretation
Ex Mirage
Pareidolia

Psychiatry Page 7
 Pareidolia
[mind perceives a familiar pattern where none exists]
Hallucination
Types
1. Auditory
1. Overall MC hallucination
2. Types
1st person Own thoughts as voices Thought echo/Audible thoughts
1. 2nd person 1 persons voice in ears Command hallucination
3rd person > 2 voices in ears Running commentary
2. Visual
1. MC in organic disorders
3. Olfactory
1. Temporal lobe epilepsy
4. Gustatory
1. Temporal lobe epilepsy
5. Tactile
1. Cocaine

True hallucinations Pseudo hallucinations

Outer objective space [In ears]
Clear & Substantial
[As clear as normal perception]
Sensory organs are involved
NOT under voluntary control
Ex
Person feels that everyone is
hearing something even if no
auditory stimulus
Inner subjective space [In mind]
Not clear
Not substantial
Sensory organs NOT involved
Somewhat under control
Ex
Patient says he hears voices of lord krishna
coming from his own mind as he feels lord krishna
is sitting inside him

Phantom limb is a TRUE hallucination

Special Types
Reflex hallucination Functional hallucination
Synaesthesia BOTH misnomers as stimulus
present
Stimulus in 1 modality → Perception in Stimulus & perception in same
other modality modality
1.
Ex Ex
Sound of a clap → feeling of itching on Person waves hand → Patient sees
hand dog
[Stimulus is auditory while perception is [Stimulus & perception both visual]
tactile]

Autoscopy Negative autoscopy

2. Seeing yourself as hallucination without Unable to see yourself in the
mirror mirror
3. Extracompine hallucination
1. Hallucination from outside limits of sensory field
2. Ex Hearing voices from Pluto

Psychiatry Page 8
 Functional hallucination Illusion
On hearing sound of fan I see a rope as a snake
↓
I hear voices scolding me + Sound of fan
Original stimulus + hallucination TOGETHER Original stimulus
DISAPPEARS

Disorders of Mood
Emotions
Mood Affect
Pervasive & sustained emotional state Outward emotional facial expression
Inner subjective Outer objective

Behaviour
Observed By family members

Cognition
Higher mental functions & abilities

Orientation
Time → Place → Person
Attention & Concentration
Serial subtraction test [100-7]
Memory
Immediate Recent Remote
Seconds to minutes Minutes to hours to days Days to months to years
Tested by attention test 24 hour recall test Past events of life
Working memory = Immediate + Recent

Remote memory
Implicit [procedural]
Does not require
conscious attention to
recall
Ex Skills, habits,
procedures
Explicit [declarative]
Requires conscious attention to recall
2 Types
1. Semantic [Facts; ex Rules, words, language]
2. Episodic [Events; ex Autobiographical memory]

Remembering that school closes every year before summer holidays is an example
of what kind of memory?
1. Semantic
2. Episodic
Remembering that India gained independence on 15th August 1947 is what kind?
1. Semantic
2. Episodic
Remembering that independence day is celebrated on 15th August is what kind?
1. Semantic
2. Episodic

Psychiatry Page 9
 2. Episodic
Abstract Ability
Understanding in depth the hidden meaning or concept

Concretisation of thinking
Loss of abstract ability

Testing abstract ability

1. Proverb test
1. Literal meaning → Concrete
2. In depth meaning → Abstract
3. Ex
All that glitters is not gold
1. Concrete → Yes sir, even my teeth glitter but they are not made of
gold
2. Abstract → Don't go by external appearances. Inner soul matters more
than beauty
2. Similarity test
1. Similarity between table & chair
1. Concrete → Structural similarity [4 legs]
2. Abstract → Functional similarity [Furniture]
3. Asking the person to interpret a story
1. Ex Moral science → finding moral of a story

Judgement & Reasoning

If you find an addressed letter on road side

Schizophreni Will never open letter because it may contain bomb & sent by
a enemies
Depression Will never open letter because no use as everyone will die
Mania Will always read letter as it may be a love or lottery letter

Investigation
Least important
Psychological testing [3 types]

Neuropsychological tests → Cognition

Intelligence tests → IQ
Personality tests → Personality

Neuropsychological tests
MMSE
BGT

MMSE
Mini Mental Status Examination
11 Items
Total domains tested: 5
Total Score = 30
Screening test for dementia < 24

Psychiatry Page 10
 Orientation 10
Language 9
Attention & Calculation 5
Registration 3
Recall 3

BGT
Bender Gestalt Test
Give patient target figures and ask him to copy them as well as possible
MC used screening test for organic brain dysfunction

Intelligence Tests
MC used test is Wechsler's Adult Intelligence Scale [WAIS]
For IQ assessment
Grading of severity of mental retardation [DSM IV]

In DSM V, Intellectual disability replaces mental retardation

Grading based on adaptive functioning

Personality Tests

Rorschach's Ink blot test

Bilaterally symmetrical pictures of ink blots
Thematic Apperception Test
Pictures of people & things
Patient told to construct a story around the card

Psychiatry Page 11
Classification in Psychiatry
26 August 2017 15:07

ICD-10
DSM-5

ICD-10
International Classification of Diseases
22 chapters
Chapter 5 [Mental Illnesses]
3 axes
I → All psychiatric disorders
II → Disabilities
III → Contextual factors
Coding system = F [Functional]
F00-F09 → Organic Mental Disorders
F10-F19 → Substance Use Disorders
F20-F29 → Schizophrenia & related
Disorders
F30-F39 → Mood disorders [MC]
F40-F48 → Neurotic disorders
DSM-5
Diagnosis & Statistical Manual of Mental Disorders
DSM IV TR → 5 axis
TR → Text Revision
I → All psychiatric disorders except MR & PD
II → MR & PD [Mental Retardation + Personality
Disorders]
III → General medical/surgical conditions
IV → Psychosocial [stress] factors
V → Global Assessment of Function [GAF] [Disability]
The multiaxial system of DSM IV abolished in DSM V

Psychiatry Page 12
Psychotic Disorders
26 August 2017 15:20

≡┬─{Psychotic Disorders
└─{Schizophrenia─┬─{Bleuler's 4 A's of schizophrenia
├─{Kurt Schneider's 11 schizophrenic first rank symptoms─┬─{3 Thought
│ ├─{3 Perception
│ ├─{3 Made
│ ├─{2 Special
│ └─{Passivity
├─{Diagnostic Criteria───{Duration needed to diagnose Schizophrenia
├─{Neurotransmitters in Schizophrenia
├─{Subtypes
├─{Catatonia─┬─{Signs of catatonia
│ ├─{Neurotransmitter decreased?
│ └─{Treatment
├─{Prognostic Factors
├─{Types of persistent delusional disorders─┬─{Delusion of infidelity
│ ├─{Paranoid disorder [MC]
│ ├─{Delusion of love
│ ├─{Delusional parasitosis
│ └─{Delusional misidentification
└─{Treatment of schizophrenia───{How long to continue antipsychotics?

Psychosis Neurosis
Old concept Insight/Awareness ABSENT Insight/Awareness PRESENT
Recent Loss of reality contact No loss of reality contact
[Delusions & Hallucinations]

Psychotic Disorders
First classified by Emil Kraepelin
Based on course
Episodic Continuous
Manic Depressive Psychosis Dementia praecox
Later named, Later named
Bipolar affective disorder Schizophrenia

Schizophrenia
Spirit mind
Term by Eugene Bleuler

Schisms amongst mental processes [original]

↓
Splitting of psychic functions [→ Spirit mind]

Bleuler's 4 A's of schizophrenia

A1 Autism [↓ Social interaction]

A2 Affective Flattening [↓ Expressions]
A3 Association loss [Formal thought disorder]
A4 Ambivalency [Indecisiveness]

Psychiatry Page 13
 A4 Ambivalency [Indecisiveness]

Kurt Schneider's 11 schizophrenic first rank symptoms

3 Thought
Insertion
Withdrawal
Broadcast
3 Perception
1st person
2nd person
3rd person
3 Made
Feeling/affect
Impulse
Action/Volition
2 Special
Somatic passivity
Delusional perception

Passivity
I am under control/influence
Motor functions under control Made phenomenon
[Made me to do]
Sensations under control Somatic passivity
[Pain as neighbour inserted a device in me]

Diagnostic Criteria
2/5 should be present x 6 months [DSM-5]

1. Delusions
i. Bizarre
2. Hallucinations
i. Running commentary
3. Disorganised speech
i. Loosening of Association
4. Disorganised behaviour
i. Animal like
5. Negative symptoms

Positive Negative Symptoms

Symptoms
Added to your Subtracted from your life
life
Delusions & Anhedonia [Pleasure]
Hallucinations Affective flattening [Expressions]
Avolition [Drive]
Apathy [Emotions]
Alexithymia [Inability to express emotions]
Alogia [↓ use of Language]
Abulia [Speaks less]

Duration needed to diagnose Schizophrenia

. ICD-10 DSM-5
< 1 month Acute psychosis Brief Psychotic disorder
Onset within 2 weeks

Psychiatry Page 14
 Onset within 2 weeks
1 - 6 months Schizophrenia Schizophreniform disorder
> 6 months Schizophrenia Schizophrenia

Incidence Prevalence
0.5-5.0/10,000 0.6-1.9% [DSM IV]
population 0.3-0.7% [DSM V]
[Ref- DSM IV]
1% → General population
8% → Non twin sibling
12% → One parent schizophrenic
12% → Dizygotic twins
40% → Both parents schizophrenic
47% → Monozygotic twins

Neurotransmitters in Schizophrenia

DA ↑ Most Imp for +ve symptoms

BUT ↓ in catatonia
5 HT ↑ +ve & -ve symptoms
NE ↓ Only -ve symptoms
GABA ↓ NOT linked to symptoms
ACh ↓ Cognitive symptoms
Glutamate ↓ NMDA receptor hypofunction

Subtypes

Paranoid Catatonic Hebephrenic Simple

Most Common - - Least Common
F>M - M>F -
20 - 30 years - Adolescents & Early -
& Late onset [> 45 years] Onset
[Bimodal distribution] [< 18 years]
Personality intact STRIKINGLY abnormal Disorganised personality Socially withdrawn personality
behaviour [Hallmark]
Delusion of persecution Motor signs & symptoms Mirror gazing Only NEGATIVE symptoms for 1
Delusion of reference of catatonia Giggling year
Auditory hallucinations [STUPOR] Silly smiles
First rank symptoms Grimacing NO positive symptoms
Socially inappropriate
behaviour
Good prognosis BEST prognosis Worse prognosis WORST prognosis

Catatonia
↑ in muscle tone
Catalepsy
BUT cataplexy → ↓ muscle tone
1
Stuporous catatonia Excitatory catatonia
Stupor Agitation
Akinesia + Mutism in awake, alert person
MC Cause → Depression Mania
2nd → Schizophrenia

Psychiatry Page 15
 2nd → Schizophrenia

Signs of catatonia
1. Posturing [Patient maintains posture]
2. Waxy flexibility
3. Ambivalency & Ambitendency
4. Negativism
5. Rigidity
6. Gegenhalten [Negativity + Rigidity]
7. Stereotypy [Non goal directed]
& Mannerisms [Goal directed]
1) Repetitive voluntary motor activities
8. Echolalia [Imitation of words]
& Echopraxia [Imitation of actions]

Neurotransmitter decreased?
Dopamine
Treatment
1st line → IV lorazepam
Best → Electroconvulsive Therapy

Anti-psychotics are USELESS

Prognostic Factors
Good Bad
Sex Females Males
Age Late onset Early onset
Onset Acute Slow & insidious
Marriage + -
Precipitating factors + -
Symptoms + -
[Affective Flattening/Autism]
Affective symptoms + -
[Presence of depression]
CT scan Normal Abnormal
[Type 1] [Type 2]
Family History of schizophrenia - +
Family History of mania + -

D/D Schizophrenia Delusional disorders

Delusions Only delusions
+ hallucinations No hallucinations
+ abnormal behaviour Normal behaviour
Socio-occupational impairment No socio-occupational impairment

Types of persistent delusional disorders

1. Delusion of infidelity/morbid jealousy/OTHELLO syndrome
1. Partner is not loyal/faithful
2. Seen in use of alcohol
2. Paranoid disorder [MC]
Pseudo community Foli a deux
Secondary elaboration of a delusion Shared delusional disorder
Ex Goes from a dominant to a dependent family member
Person thinks 2 colleagues are

Psychiatry Page 16
 1. Person thinks 2 colleagues are
against him; Ex
those 2 talk to 2 more Elder brother thinks neighbours are trying to harm; After some time
→ so now thinks that all 4 are younger brother shares same delusion but NOT father [as father NOT
against him dependent but younger brother dependent]
3. Delusion of love/EROTOMANIA/De Clerambaut's syndrome
1. In this a lower SES female believes that a higher SES male is SECRETLY in love with her
4. Delusional parasitosis/Ekbom's syndrome
1. Body is infested with worms
→ Keeps moving leg at night
→ Restless Legs syndrome
5. Delusional misidentification syndrome
CAPGRAS syndrome FREGOLI syndrome
Delusion of doubles .
1. Family member has been replaced by an impostor or Family member can change to the disguise of a
intruder [Double] stranger
C/C → Stranger looking like family member C/C → Family member looking like a stranger
Treatment of schizophrenia
3 step algorithm
ATC
1st step/DOC Atypical antipsychotics other than clozapine
2nd step Typical antipsychotics
3rd step Clozapine

Clozapine is DOC for treatment resistant schizophrenia

[Failure to respond to 2 different antipsychotics of different MOA]

Step 4 Clozapine augmentation [Clozapine + Other]

Step 5 ECT

How long to continue antipsychotics?

IPS guidelines

1st episode 1 - 2 years

Multiple episodes 5 years - Lifelong

Psychiatry Page 17
Mood Disorders
26 August 2017 17:50

≡┬─{Bipolar Disorder───{Cyclothymia───{Rapid cyclers

├─{Mania───{Symptoms
├─{Depression─┬─{Epidemiology
│ ├─{Clinical Features─┬─{Suicide one liners
│ │ ├─{Suicide predictors
│ │ └─{Physical Signs of depression
│ ├─{Neurotransmitters
│ ├─{Treatment─┬─{Electroconvulsive therapy
│ │ ├─{rTMS
│ │ ├─{Vagal Nerve Stimulation
│ │ └─{Deep Brain Stimulation
│ ├─{Other forms of depression─┬─{Atypical Depression
│ │ ├─{Premenstrual Dysphoric
Disorder [PMDD]
│ │ └─{Post-partum psychiatric
disorder
│ └─{Special Q on depression─┬─{Sleep changes in depression
│ ├─{Learned Helplessness Model
│ └─{Empty Nest Syndrome
└─{Bipolar Management Principles

Mania Depression
1 week 2 weeks required for Dx
required for
Dx
Hypomania Sub syndromal Depression
4 days required No duration
for Dx
Dysthymia
Chronic Low mood > 2 years
in ICD-9 → Neurotic depression
in DSM-5 → Persistent depressive disorder

Depression on top of dysthymia → DOUBLE depression

Seasonal Depressive Disorder
Seen in winters
Rx → Light therapy

Bipolar Disorder

Type 1 Mania + Depression

Type 2 Hypomania + Depression
Type 3 Cyclothymia

Cyclothymia
Psychiatry Page 18
 Cyclothymia
Persistent mood disorder
Bipolar type 3
Hypomania + Sub syndromal depression
> 2 years

Rapid cyclers
> 4 episodes in 1 year → Rapid cyclers
DOC: Valproate

Q All are included under bipolar EXCEPT

1. Mania alone
2. Depression alone
3. Hypomania + sub syndromal depression
4. Hypomania + depression

1 episode of mania by rule → Bipolar

Mania

Euphoric Mania Dysphoric Mania

Happy Irritable
[Both types can convert into each other]
Rx Rx
Li > Valproate Valproate > Li
Overall, DOC for acute mania → Valproate

Symptoms
D Distractibility [Poor attention span]
I Irritability
G Grandiosity
F Flight of Ideas
A Activity ↑ [Goal directed]
Social welfare
Donation
Religiosity
Political
S Sleep ↓ [Need for sleep ↓]
T Talkativeness
E Energy increased
R Reckless/Risk taking behaviour
R Rarely suicidal attempt

All atypical antipsychotics are FDA approved as monotherapy for Tx of Acute mania, except
Clozapine

So, atypical antipsychotics are drugs for acute mania BUT valproate, Li > antipsychotics
So used when valproate, Li are C/I → DOC is antipsychotics
Pregnancy
Lactation

Psychiatry Page 19
Depression
Depression: Let's talk

Epidemiology
Maximum DALY loss

Prevalence → 12-17% [By 2030]

1 in 8 Males
1 in 6 Females
F >> M

MC affects which age group of females

1) Adolescent
2) Young
3) Middle aged
4) Elderly

Mean age of onset of depression → 40 years

Clinical Features
1. Low mood [Sadness]
2. Anhedonia [↓ interest in previously pleasurable activities]
3. ↓ psychomotor activity [Lethargy, easy fatigability, lack of energy, lack of concentration]
i. MC presenting symptom

These 3 are cardinal symptoms of depression

2/3 for 2 weeks → depression

4. Somatic complaints [Multiple aches & pains]

5. Vegetative symptoms [↓ sleep, ↓ appetite, ↓ oral intake]
i. Significant weight loss
6. Cognitive symptoms [Thinking related]
Cognitive distortion Cognitive triad
Maladaptive assumptions Aaron T Beck
Automatic thoughts
Ex Negative views
Selective abstraction about
i. [Child with pimple feels that she's no longer beautiful Self [Worth]
as focuses only on negative aspects] Future [Hope]
Arbitrary inference Environment
[Newlywed wife spills milk so she thinks that [Help]
she will be unable to do other things required of a wife]
Overgeneralisation or Magnification
[Student feels that failing in class 12 → failure in life]
• Depression → Poor attention + Registration → “Pseudodementia”
7. Mood congruent delusions & hallucinations [Psychotic symptoms]
8. Death wish [Intent to die]
9. Suicidal ideation [Plan to die]
i. Suicide in 10-15% of cases
ii. Maximum suicide is seen in early recovery stage of depression
iii. Paradoxical suicide [Depression in involution]

Mild depression First 3

Moderate depression First 6

Psychiatry Page 20
 Moderate depression First 6
Severe depression + CF #7-9

Suicide one liners

Rate 10.4/1 lakh
MC method Hanging
Neurotransmitter Serotonin
related
Biochemical marker ↓ CSF
5 HIAA [Hydroxy indole acetic acid]
Theory of suicide Emile Durkheim
Egoistic
[No integration with society; Doesn't give a fuck]
Altruistic
[Excessive integration with society; suicide for benefit of
mankind]
Anomic
[Life has no meaning]

Suicide predictors
1. Sex
Suicide → M>F
1)
Suicidal attempt → F > M
2. Age
Suicide Elderly > Young
1)
Suicidal attempt Young > Elderly
3. Depression
1) HOPELESS
4. Previous suicidal attempt
1) Strongest predictor
5. Alcohol use
6. Long standing physical illness
7. Relationship
1) Single, unmarried, divorced > Married

Physical Signs of depression

1. Otto-Veraguth fold
1) Triangle shaped fold on nasal corner of eyelid
2. Inverted omega sign
1) Seen on forehead

Neurotransmitters

5 HT ↓
NE ↓
DA ↓
ACh ↑
GABA ↓

Psychiatry Page 21
 Glutamate ↑

1st 3 neurotransmitters → Trimonoaminergic depletion theory

Glutamate → Excitotoxic theory

Treatment
Drugs Psychotherapy Somatic modalities
DOC: SSRI Of choice: Cognitive Electroconvulsive
Behavioural Therapy
Therapy
Most effective drug: TCA Principle: Cognitive rTMS
reconstruction [Repetitive transcranial
magnetic stimulation]
Depression + Psychotic symptoms: Target cognitive VNS [Vagal Nerve
Antidepressant + Antipsychotics distortions to Stimulation]
modify behaviour DBS [Deep Brain
Stimulation]

Electroconvulsive therapy

MOA
1. ↑ Seizures → ↓ Psychosis
a) Minimum 25 s seizures for effective ECT
2. Neurotransmitter booster via ↑ BDNF
a) Brain Derived Neurotropic factor

Indications
1. Depression with suicidal tendencies
2. Depression with stupor [Catatonia]
3. Non responders for schizophrenia & mania
4. Neuroleptic Malignant Syndrome & Parkinson's Disease [New]

Types
Direct ECT [w/o GA]
Modified ECT [under GA]
Methohexitol [Anaesthetic agent]

Maybe unilateral or bilateral [only TEMPORAL electrodes counted]

Side Effects
Amnesia [MC] > Headache
Both Anterograde & Retrograde
Completely reversible
Anterograde reverses in 5 hours
Retrograde reverses in 6 - 9 months
Contraindications
Absolute NONE
[Recent; Older → ↑ ICP]
Relative 1. ↑ ICP
2. Recent MI
3. Cardiac compromise
4. High risk pregnancy

Psychiatry Page 22
 4. High risk pregnancy
Pregnancy is NOT C/I to ECT
rTMS
Indications
1. Depression
2. OCD
3. PTSD
4. Schizophrenia
5. Migraine
6. Parkinson's
Vagal Nerve Stimulation
Invasive
Always left vagus [As right vagus supplies SA node]
Only cranial nerve whose stimulation → ↑ mood
Pulse generator implanted inside left vagus
Deep Brain Stimulation
Indications
1. Parkinson's
a) Subthalamic Nucleus stimulated
2. Depression

Other forms of depression

1. Atypical Depression
1. Younger
2. Reversal of vegetative symptoms
1. ↑ sleep; ↑ appetite; weight gain
2. Hallmark
3. Carbohydrate craving
4. Profound psychomotor retardation
1. Leyden paralysis: Body is like a log of wood
5. Impulsivity, mood, anger swings, outbursts
6. Interpersonal rejection sensitivity
7. DOC: SSRI
2. Premenstrual Dysphoric Disorder [PMDD]
1. It is a somato psychic syndrome with certain body & psychological changes
2. Onset: 5-7 days prior to menses
3. Symptoms ↓ with menses
4. Disappear AFTER menses
5. Body changes
1. Heaviness/Edematous
2. Multiple pains
3. Lethargy
4. Easy fatigability
5. Breast tenderness
6. Psychological changes
1. Mood swing
2. Irritability
3. Anger outburst
4. Anxiety
5. Depression
7. Milder forms are self-limiting [Premenstrual syndrome]
1. No Rx required
8. Severe [socio-occupational dysfunction]
& for > 2 cycles → PMDD
9. Rx: SSRI
3. Post-partum psychiatric disorder

Psychiatry Page 23
 Condition Onset Symptoms Treatment
PP Blues Days of MC → labile mood No Treatment
Baby blues delivery Tearfulness [self-limiting]
[MC] Low mood [< 2 weeks]
1. PP Depression < 4 weeks of Low mood [> 2 weeks] Anti-depressants
delivery + Guilt, Anhedonia, Rarely, ECT may be
Suicide [GAS] needed
PP Psychosis < 4 weeks of Depression with psychotic Anti-depressants +
delivery symptoms [infanticide] Anti-psychotics
2. Max recurrence in next pregnancy → PP psychosis
3. MC risk factors for PP psychosis
1. Previous h/o PP psychosis
2. Previous h/o mood disorder
3. Family h/o mood disorder
Special Q on depression
1. Sleep changes in depression
1. ↓ REM latency [Most imp]
2. ↓ Total sleep
3. ↓ NREM sleep
4. ↑ REM sleep
5. ↑ Core body temperature
6. Early morning awakening
7. Nocturnal awakening
2. Learned Helplessness Model
3. Empty Nest Syndrome
1. Depression in elderly when youngest child leaves home

Bipolar Management Principles

Bipolar in mania Antimanic + Mood stabiliser

Bipolar in depression Antidepressants + Mood stabiliser
Bipolar in normal Mood stabiliser

DOC: Mood stabiliser

DOC bipolar prophylaxis: Lithium

Psychiatry Page 24
Child Psychiatry
26 August 2017 20:11

≡┬─{Childhood Depression─┬─{Warning Signs

│ └─{Treatment
├─{Tic Disorders───{Chronic motor or vocal tic disorder
├─{ADHD───{Treatment─┬─{Stimulants [↑ DA]
│ └─{Non stimulants
└─{Autism Spectrum Disorder [DSM-5]─┬─{Triad of─┬─{Impairment in social
communication & interaction
│ ├─{Language developmental
delay [Milestones delayed]
│ └─{Restrictive,
Repetitive & Stereotyped behaviour [Movement]
├─{Other Features
└─{Savants

Childhood Depression
Warning Signs
1. School Refusal [↓ interest in studies]
2. Anger outbursts [Quarrelsome]
3. Somatic symptoms [Headache]

Treatment
SSRIs [Fluoxetine]
Black box warning [↑ suicidal tendencies]

Tic Disorders
Chronic motor or vocal tic disorder

Motor & vocal tics

[Gilles De La Tourette's syndrome]
Tetrad of
1. Motor Tics [Neck; Eye blinking]
2. Vocal Tics [Throat clearing; Grunting]
3. Coprolalia [Obscene words]
4. Palilalia [Repeating words]
↑ DA
DOC: Anti D2 [Haloperidol, Risperidone] [Kaplan]
New DOC: Clonidine [↓ SE; Pharma books]

ADHD
Attention Deficit Hyperactivity Disorder

M>F

Triad of HIA
H Hyperactivity [Motor]
I Impulsivity
A Attention Deficit

Psychiatry Page 25
 A Attention Deficit

Poor Concentration
Poor Retention [↓ Memory]
Poor scholastic performance
Despite normal IQ

Adult ADHD → ONLY attention deficit

Onset ALWAYS < 12 years

Sequence of symptom response

H→I→A

Symptom MUST be present in at least 2 situations [Home, playground, school]

DSM-5 onset < 12 years

DSM-4 onset < 7 years of age

Hypodopaminergic state in mesocortical tract

Serious illness → Medical treatment

Treatment
Stimulants [↑ DA]
Methylphenidate [DOC → ADHD]
But ↑ tics so C/I in ADHD + tics
Amphetamines
Non stimulants
Atomoxetine [DOC → ADHD + tics]
Bupropion
Clonidine
Guanfacine

Autism Spectrum Disorder [DSM-5]

Pervasive Developmental Disorder [DSM-4]

Triad of
1. Impairment in social communication & interaction
i. ↓ attachment to parents
ii. Never maintains eye contact
iii. Delayed social milestones
iv. Stranger anxiety
2. Language developmental delay [Milestones delayed]
i. Pronomial reversal
1) Replacing pronouns with nouns
2) Ex Varun will eat; Varun will cook etc
3. Restrictive, Repetitive & Stereotyped behaviour [Movement]
i. Ex Hand wringing in Rett's syndrome

Other Features
Mental Retardation in 30% cases
Abnormal dermatoglyphic [fingerprints]

Savants
Psychiatry Page 26
Savants
Autistic children with special abilities

Autism Rett's Heller's Asperger's

M>F Only F M>F M>F
[X linked dominant]
< 1 year of age Childhood Disintegrative Do not follow
→ Kanner's disorder triad features
infantile autism
Language delay Language delay Language delay Language
normal
NO delay
IQ ↓; MR IQ ↓; MR IQ ↓; MR IQ Normal
No MR
No regression of Regression of milestones Regression of milestones No regression
milestones AFTER 5 months - 1 year of AFTER 2 - 3 years of of milestones
normal development normal development
Hand wringing + Hand wringing -
Microcephaly + Microcephaly -

Psychiatry Page 27
Neurotic Disorders
27 August 2017 09:10

≡┬─{MC psychiatric disorder─┬─{MC group of disorders → Anxiety [GAD +

Panic + Phobia]
│ └─{MC single psychiatric disorder → Major
depression
├─{Neurobiology of Anxiety─┬─{Serotonin dysregulation
│ └─{For all neurotic disorders
├─{Anxiety Disorders───{Exposure therapy
├─{OCD & related disorders─┬─{OCD───{Treatment
│ ├─{Body Dysmorphic Disorder
│ ├─{Trichotillomania───{Rx
│ ├─{Hoarding disorder
│ ├─{Skin pricking/Excoriation disorder
│ └─{Trauma & stress related disorder───{Stages
after death of loved one
├─{Somatoform Disorders─┬─{Common Features
│ ├─{Symptom production───{Munchausen Syndrome
│ └─{Conversion disorder─┬─{Mechanism
│ ├─{Forms of conversion
│ └─{Treatment
└─{Dissociative Disorders─┬─{Dissociative Amnesia [MC]───{Dissociative
Pseudo amnesia [Ganser's syndrome]
├─{Dissociative fugue
├─{Amnesia [Loss of identity memory]
├─{↓
├─{Travels & reaches a new place
├─{↓
├─{Assumes a new identity
├─{Dissociative Identity
Disorder───{Dissociative trance & possession disorder
├─{Dissociative Depersonalisation [self] &
Derealisation [environment]───{As If phenomenon
└─{Disruptive behaviours of childhood [ODD +
CD]
1. Anxiety Disorders
2. OCD & related disorders
3. Trauma & stress related disorders
4. Somatic symptoms & related disorders
5. Disruptive, impulse control & conduct disorders
6. Dissociative disorders

MC psychiatric disorder
Anxiety disorder [30%] > Major depression [17%] > Phobia [15%] > Substance use
[12%] > GAD/Panic disorder/OCD [3-4%]

MC group of disorders → Anxiety [GAD + Panic + Phobia]

MC single psychiatric disorder → Major depression

Neurobiology of Anxiety
Psychiatry Page 28
Neurobiology of Anxiety
Serotonin dysregulation
Most Imp

GABA ↓ NE ↑
Psychic anxiety Physical anxiety
Apprehension Palpitation
Insecurity Tachycardia
Insomnia Tremors
Worry ↑ Urinary frequency
Restless
Dryness of throat
Performance anxiety
DOC for acute anxiety: BZD DOC: Propranolol
DOC for chronic anxiety overall: SSRI
[prevents acute anxiety attack]

For all neurotic disorders

Rx: SSRI [1 OD] + BZD [SOS previous night]

SSRI takes 2-3 weeks to act

Propranolol → can be taken on exam morning

Hyper person → Sedative → Normal → Hypnotic → Sleeping

Hyper person ko sedative de ke normal karte he
Normal ko hypnotic de ke sulate he

All sedatives in high doses are hypnotics

Anxiety Disorders

Generalised Panic disorder [Episodic] Phobia [Episodic]

Anxiety Disorder
Free floating Sudden acute paroxysmal Stimulus present
continuous anxiety anxiety with feeling of Morbid & irrational fear out of
x 6 months impending doom [Catastrophe] proportion with ACUTE anxiety
symptoms

Panic is d/d of medical emergencies so diagnosis of a panic disorder is made after ruling out
other causes of feeling of impending doom

Q A patient presents with intense ghabrahat & feeling of impending doom. All of the following
investigations would you like to do in an emergency EXCEPT
1. ECG [for MI]
2. RBS [for hypoglycemia]
3. TSH [for thyroid storm]
4. Hb

Agoraphobia Social phobia Specific phobia

Psychiatry Page 29
 Least common Most common
Fear of crowd Fear of socially demanding Fear of one specific situation
+ market situations Ex Only closed [Claustrophobia]
+ open
+ closed spaces ex stage phobia;
unable to urinate in public
when others are around
Fear of places from which
escape is difficult
[new definition]

All phobias cause tachycardia EXCEPT Blood phobia which causes Bradycardia & syncope

Exposure therapy
Psychotherapy of choice for phobia
Type of behavioural therapy

Sudden Exposure Graded exposure + relaxation

Flooding Systemic desensitisation
[of choice]

DOC for panic disorder SSRI

DOC for panic attack BZD

OCD & related disorders

OCD
Obsessive Compulsive Disorder

Treatment
Drugs + Psychotherapy

Exposure & Response prevention

Psychotherapy of choice

FCR
1st drug Fluoxetine or Fluvoxamine
2nd Clomipramine
[Most effective drug]
3rd Risperidone
[Augmenting agent → Resistant OCD]
↓
Electroconvulsive Therapy [for comorbid depression]
↓
Psychosurgery
Cingulotomy

Body Dysmorphic Disorder

In this the person feels that a part of my body [hair, nose, skin] is disfigured/not proper

Go to plastic surgeons who refer them to psychiatrists

Psychiatry Page 30
 Go to plastic surgeons who refer them to psychiatrists

It can present as a
Firm conviction Doubt
Delusional disorder OCD

Trichotillomania
Hair pulling disorder

Rx
SSRI
+
Habit reversal
Psychotherapy of choice
Ex Making a fist while studying if person pulls hair while studying

Hoarding disorder
DSM-5 new
Person hoards/collects relatively useless & less useful things considering them of
emotional value

Skin pricking/Excoriation disorder

DSM-5 new

Trauma & stress related disorder

After major life After a mild to moderate routine life stressful event
threatening precipitating [GRADUAL]
trauma [SUDDEN]
Ex Murder, suicide, rape, Ex Financial loss, break up, exam failure, knowing about
robbery, war veterans, major illness in a family member
earthquake etc
Acute stress disorder Adjustment disorder
[ < 1 month]
Post-Traumatic Stress Within 1 month of stress → ICD
Disorder Within 3 months of stress → DSM
[ > 1 month]
Symptoms [Triad; DSM-IV] Symptoms are mild-moderate depression
1. Hyperarousal
a. Vigilance After stress
b. Startle Differentiate between depression & adjustment disorder
c. ↓ sleep in Q
2. Intrusiveness [MC] Depression → Severe depression
a. Re- [Lethal suicidal attempt mentioned in Q]
experiencing
the trauma Adjustment disorder→ Mild - moderate depression
b. Flashbacks & [Wants to die given in Q; NO attempt]
nightmares
3. Avoidance
4. Emotional numbing
a. Negative
alteration in
cognition &
mood

Psychiatry Page 31
 mood
b. DSM-5 new
Rx of PTSD: CBT Rx: SUPPORTIVE psychotherapy [Teach coping skills]

Stages after death of loved one

Given by Kubler Ross

D Denial & shock

A Anger
B Bargain
D Depression
[Grief Reaction]
A Acceptance

Grief Reaction
Normal Grief Pathological
Grief
Maximum up to 6-12 months > 1 years
Any symptoms within 2 months of death
Bereavement reaction

Symptoms
Mild - Moderate depression
+ Preoccupation with thoughts of dead one
[hearing him, seeing him, discussing with him]
This is not a hallucination/ghost

Rx
Drugs + Supportive psychotherapy
SSRI/TCA

Eye movement desensitisation & reprocessing

New psychotherapy for PTSD

1st treatment to start in PTSD

Pharmacotherapy [SSRI]

Somatoform Disorders

Somatoform disorders [DSM-4] Somatic symptoms & related disorders [DSM-5]

Somatisation disorder
Somatoform pain disorder
Hypochondriasis
Body dysmorphic disorder
Conversion disorder
Somatic symptom disorder
Pain disorder
Illness anxiety disorder
Moved to OCD
Functional Neurological symptom disorder

DSM-5 has 4 types of somatoform disorders

Psychiatry Page 32
Somatisation Somatoform pain Hypochondriasis
disorder disorder
Multiple somatic Only pain symptom of 1 Perception of having a serious life
complaints x 6 months location of long threatening medical illness
Ex standing duration Ex
4 pains Cough → Ca lung
2 GI symptoms Headache → Brain tumour
1 sexual/GU symptom
1 pseudo neurological
Preoccupied with Preoccupied with pain Preoccupied with diagnosis/illness
symptoms
Ask for symptom relief Ask for pain relief Ask for confirmation of diagnosis

Common Features
Multiple investigations normal
Doctor shopping behaviour

Symptom production
Unconscious Conscious & Intentional
Somatoform disorder With goal/Motive → Legal, court, prisoner's Malingering
Without goal/motive → Factitious disorder
Factitious disorder → Munchausen syndrome

Munchausen Syndrome
1. Consciously produce symptoms to enjoy the hospital stay [Professional patients]
2. Fabricate/feign symptoms & request for procedures [Pseudologia fantastica]
1) Multiple scars over abdomen [Grid Iron abdomen]

Conversion disorder
Called hysteria by Hippocrates

Mechanism
After an acute precipitating psychosocial stress factor [TRIGGER]
↓
Psychic conflict in unconscious mind
↓
Converted to
[Acutely & unconsciously]
↓
Bodily symptoms
[Sensory, motor, neurological]

Production of → Reduces anxiety → Primary gain

symptoms [Unconscious]
Attendant's attention → Propagation of → Secondary gain
symptoms [Conscious]

Forms of conversion
1. Pseudo aphonia [Cough test]
2. Pseudo blindness [Optokinetic nystagmus; Visual Evoked Potential]

Psychiatry Page 33
 2. Pseudo blindness [Optokinetic nystagmus; Visual Evoked Potential]
3. Pseudo paralysis [Astacia abasia → gait seen in conversion]
4. La Belle Indifference [Lack of emotional reactivity to suffering]
Pseudo seizure True seizure
Out of phase movement In phase movement
No injury May be seen
No tongue bite ""
No incontinence ""
5. No amnesia ""
No post ictal confusion ""
Never in night Nocturnal +nt
Never when alone Can occur
Normal Serum Prolactin ↑ Serum Prolactin
[As Seizure → ↓ DA]

Treatment
Symptomatic
1) Cut the secondary gain [remove attendants]
2) SSRI/BZD
3) Supportive psychotherapy

Best → Psychoanalytical psychotherapy

Based on principles of classical psychoanalysis by Sigmund Freud
Resolution of unconscious conflict & overall personality reconstruction
techniques

Personality reconstruction technique

Free Association Catharsis Abreaction

Patient is allowed to Venting your Carrying out catharsis
speak uninterrupted emotions & therapeutically by drugs
[Parapraxes] conflict [Thiopentone]
Slip tongue

Dissociative Disorders
Happen after a physical or psychological trauma/stress

Dissociative Amnesia [MC]

Patchy loss of autobiographical memory
Completely reversible
Retrograde psychogenic amnesia

Dissociative Pseudo amnesia [Ganser's syndrome]

Vorbereiden/Past pointing/approximate answers

Ex Q Colour of grass? Pink

Dissociative fugue
Amnesia [Loss of identity memory]
↓

Psychiatry Page 34
 ↓
Travels & reaches a new place
↓
Assumes a new identity

Dissociative Identity Disorder

Multiple personality disorder
SPLIT personality

≥ 2 identities in the same person

Identities are not aware of each other

Dissociative trance & possession disorder

Ex Mata coming into women

Dissociative Depersonalisation [self] & Derealisation [environment]

As If phenomenon
Jaise ki

Transient feelings of detachment from sense of self/environment as if the person is

changed or detached from self/environment

He is an external observer of his own body

Habit & Impulse Control Disruptive, Impulse control & conduct

Disorder [DSM-4] disorder [DSM-5]
Kleptomania Kleptomania
Irresistible impulse to steal
Pyromania Pyromania
Irresistible impulse to set things on fire
Intermittent Explosive Disorder Intermittent Explosive Disorder
Anger
Trichotillomania Moved to OCD
Pathological gambling Gambling disorder
Under Substance use & related disorder

Disruptive, Impulse control & conduct disorder [DSM-5]

So 2 removed in DSM 5 and +2 NEW [ODD & CD]

1. Kleptomania
2. Pyromania
3. Intermittent Explosive Disorder
4. Oppositional Defiant Disorder [ODD]
5. Conduct Disorder [CD]

Disruptive behaviours of childhood [ODD + CD]

Do not follow rules

Oppositional Defiant Conduct Disorder

Disorder
Do not violate rights of Violates rights of others

Psychiatry Page 35
Do not violate rights of Violates rights of others
others
Ex Stealing, setting fire, torturing animals
Verbally abusive to Physically + Verbally abusive to parents
parents

Psychiatry Page 36
Eating Disorders
27 August 2017 13:42

Anorexia Nervosa Bulimia Nervosa Binge Eating

Disorder [MC]
No anorexia [↑ appetite] .
[↓ Leptin]
F:M::10-20:1 . .
Body image preoccupation . .
Morbid fear of gaining weight . .
Underweight weight <85% of normal Normal weight .
2 types No avoidance Only binge & no
Avoidant type compensation
Peculiar pattern of food Binge → Post binge anguish →
handling/avoiding behaviour Compensation [Vomit or purge]
[Hallmark of Anorexia nervosa] [Characteristic]
Binge type
Sometimes binge → Post binge anguish
→ compensation [Vomiting or purging]
Medical Complications Excessive vomiting → Bulimia .
1. Dental caries; Parotid abscess stigmata
2. Amenorrhoea [3 months] → ↓LH; ↓ FSH Russel's sign [Calluses over
[Removed from diagnostic criteria] knuckle]
3. Osteoporosis [↓ BMD] & Chipmunk facies
4. SMA syndrome [Abdominal angina]
5. Pre renal azotemia
6. CNS atrophy & seizure prone
7. Lanugo hair & signs of starvation
8. ↑ S Prolactin, ↑ S Cortisol, ↑ S CRH
9. ↓ T3, T4
Rx Rx
SSRI + BT/CBT SSRI + BT/CBT

Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder

Avoidance Binge Binge
Binge Compensation
Compensation
ABC BC B

Psychiatry Page 37
Organic Mental Disorders
27 August 2017 14:56

≡┬─{Delirium─┬─{Precipitating cause
│ └─{Treatment
├─{Dementia─┬─{Behavioural & Psychological symptoms of
dementia─┬─{Catastrophic reaction
│ │
├─{Neurotransmitters
│ │
└─{Causes
│ ├─{One liners
│ └─{Treatment
└─{Korsakoff Amnestic Syndrome─┬─{Severe anterograde + Mild retrograde
amnesia
├─{Confabulation
├─{Cause
└─{Treatment

Delirium Dementia Amnestic

Acute Chronic Chronic
Fluctuating Progressive Progressive
Altered Sensorium Clear sensorium Clear sensorium
Disoriented Oriented Oriented
Global cognition Global cognition affected Only memory affected
affected
Psychotic + + -
symptoms
Fleeting delusions Fixed delusions & Audio-visual No delusion
& Visual hallucinations No hallucination
hallucinations
Ability to - - +
learn
Remote Normal ↓↓↓ Mild ↓
memory

Delirium
Hallmark: Altered sensorium
Acute confusional state/Acute brain failure/Organic psychosis/ICU psychosis
Acute & fluctuating in nature
Precipitating cause
Medical Drugs Surgical
Fever Datura Head injury
Encephalitis Anticholinergic Post Op
Pneumonia Atropine ICU
Endocrine Alcohol withdrawal

Poor attention & concentration

Alteration in sleep wake cycle
Evening worsening of symptoms [Sun down phenomenon]
Flocillation → Plucking behaviour on bed sheets

Psychiatry Page 38
 Flocillation → Plucking behaviour on bed sheets
Emotional lability
↑ psychomotor activity [restless]
Neurotransmitter: ACh ↓

Treatment
Treat underlying cause
DOC for agitation → Haloperidol

Dementia
Globally progressive cognitive decline x > 6 months
Characterised by
Amnesia + 2 out of 4
1. Apraxia [Motor]
2. Agnosia [Sensory recognition]
3. Aphasia [Speech & language]
4. Loss of executive function [Planning, organising, sequencing,
multitasking]

4 A's → amnesia + apraxia + agnosia + aphasia

Apraxia → Inability to perform any given motor task despite tone & power being
normal
Ex Constructional apraxia; Dressing apraxia

Agnosia → Inability to perform sensory recognition tasks despite intact peripheral

sensation
Ex Astereognosia [Shapes]; Prosapagnosia [Familiar faces]

Behavioural & Psychological symptoms of dementia

1. Personality decline, poor self-care, apathy, lack of drive, ↓ Interaction
2. 25% dementia patients → Psychotic symptoms → Delusions & Hallucinations
3. Catastrophic reaction
i. Sudden agitation in dementia
4. Neurotransmitters
ACh ↓
i.
Glutamate ↑
5. Causes
i. Irreversible [85%]
1. Alzheimer's disease [MC]
2. Vascular dementia [Post stroke] [Multi-infarct dementia]
3. Frontotemporal dementia [Pick's disease]
4. Lewy Body dementia
5. Parkinson's dementia
6. Huntington's dementia
7. Creutzfeldt Jacob Disease [Prions]
ii. Reversible [15%]
1. Depression [MC]
2. Surgical
a) Normal pressure hydrocephalus
b) Subdural hematoma
3. Metabolic
a) Hypothyroidism
4. Vitamin B12 deficiency dementia
5. Post encephalitis

Psychiatry Page 39
 5. Post encephalitis
One liners
MC psychiatric disease in elderly Depression
MC psychiatric disease after stroke in elderly Depression > Dementia
Predominant visual hallucination & movement Lewy Body Dementia
problems
Rapidly progressive dementia + Myoclonus Creutzfeldt Jacob Disease
Step Ladder progression Post stroke dementia
Dementia + Urinary incontinence + Ataxia Normal pressure
hydrocephalus

Treatment
↑ ACh ↓ Glutamate
Acetylcholine esterase inhibitors NMDA antagonist
Donepezil, Galantamine, Rivastigmine, Tacrine Memantine

Read genetics & pathology for all dementias

From DAMS CRS

Korsakoff Amnestic Syndrome

Recent memory loss [in ALL cases]
+
Remote memory loss [in 1/3 cases]

Severe anterograde + Mild retrograde amnesia

Confabulation
Filling of gaps in the recent memory

Apathy
Lack of drive
Impairment in executive functions
↓ social interaction & day to day activities affected

Cause
Thiamine deficiency [Chronic alcoholic]
Treatment
Thiamine [200-300 mg/day]

Psychiatry Page 40
Substance Use Disorders
27 August 2017 15:55

≡┬─{Substance Dependence─┬─{Caffeine withdrawal

│ ├─{Cannabis withdrawal
│ ├─{Cocaine & Amphetamine withdrawal
│ ├─{Nicotine withdrawal
│ ├─{Opium/Heroin withdrawal
│ ├─{Alcohol withdrawal
│ ├─{Rave party drugs [ Club drugs]─┬─{Date rape drugs
│ │ └─{Amphetamines including
MDMA
│ └─{Gateway substances
├─{Clinical Features of Substance Use─┬─{Cannabis
│ ├─{LSD
│ ├─{Cocaine───{Long term use
│ ├─{Amphetamines
│ ├─{Dissociative Anaesthetics
│ └─{Opium Intoxication─┬─{Respiratory depression
│ └─{DOC: IV Naloxone
├─{Drugs for deaddiction─┬─{Opium deaddiction───{Opium withdrawal
│ └─{Tobacco deaddiction
├─{Alcohol Intoxication─┬─{Mellanby phenomenon
│ ├─{Drugs for alcohol withdrawal─┬─{DOC: Benzodiazepine
│ │ ├─{BZD of choice
│ │ ├─{If patient is in delirium
or having seizures & oral can't be administered
│ │ └─{Thiamine
│ └─{Drugs for alcohol deaddiction
└─{Stages of motivation/change in behaviour───{Revolving door phenomenon
MC substance used/abused in India/World Tobacco
MC illicit substance used in India/World Cannabis
MC substance used among treatment seekers Alcohol
MC used stimulant substance in world Caffeine

Substance Dependence

Psychological dependence Physical dependence

Mind needs drug Body needs drug
Craving Withdrawal
[Intense desire to procure a substance] [Body reaction in absence of substance]

Substance with ONLY psychological dependence LSD

[NO physical dependence/NO Withdrawal]

The 3 withdrawal given below are new in DSM 5

Caffeine withdrawal
Headache [MC]
Lethargy
Drowsiness
Cannabis withdrawal

Psychiatry Page 41
 Cannabis withdrawal
[Minimal]
Anxiety
Nervousness
Cocaine & Amphetamine withdrawal
Depression

Nicotine withdrawal
1. ↓ attention & concentration
2. Irritability
3. Drowsiness
4. Bradycardia [NOT tachycardia]
5. Constipation

Opium/Heroin withdrawal
Mydriasis
Lacrimation
Rhinorrhoea
Yawning
Diarrhoea
Sweating
Piloerection
Goose bumps
Cold turkey [Hypothermia + piloerection]
Muscle cramps
Autonomic hyperactivity

Alcohol withdrawal
Dependent on time since last drink
BOTH visual & auditory hallucinations seen
6 - 8 hours 1. Tremors [1st, MC]
[↑ NE] 2. Tachycardia & autonomic hyperactivity
8 - 12 hours 1. Alcoholic paranoia [Fixed delusions]
[↑ DA] 2. Alcoholic hallucinosis [Auditory hallucinations]
12 - 24 hours GTCS [Rum fits]
24 - 72 hours 1. Delirium Tremens
1. Altered sensorium
2. Visual hallucinations
a. Microscopic VH [Lilliputian hallucinations]
b. Macroscopic VH
3. Autonomic hyperactivity

Concept of substance
Substance action → x
If you take 1/x → Withdrawal
If you take 2x → Intoxication
So, symptoms of intoxication & withdrawal will be opposite

Smack Impure form of heroin

Crack Cocaine
Designer drug MDMA [Amphetamine]

Rave party drugs [ Club drugs]

Date rape drugs
Gamma hexene butyrate
Flunitrazepam

Psychiatry Page 42
 Flunitrazepam
Ketamine
LSD
Amphetamines including MDMA
MC used rave party drug
MDMA → Methylene dioxy methamphetamine

MC used date rape drug → alcohol

Gateway substances
Tobacco
Alcohol
Volatile solvents [Glue sniffing]

Clinical Features of Substance Use

Cannabis
Active ingredient → Δ-9 THC
Single use Intoxication Long term use
Flashbacks Run amok Amotivational syndrome
↓ appreciation of time Run aimlessly ↓ drive & motivation
Violent, aggressive, homicidal

LSD
MC side effect → Bad trip [Panic like reaction]
Reflex hallucination [Synaesthesia]

Cocaine
Nasal septal perforation
Long term use
Paranoid psychosis [Delusion of persecution]
Reverse tolerance seen [Less amount of substance → psychosis]
Tactile hallucination

Amphetamines
Acute intoxication Long term use
Paranoid schizophrenia like symptoms Tactile hallucinations

Dissociative Anaesthetics
Ketamine Phencyclidine [PCP/Angel dust]
Paranoid psychosis [Anti NMDA] Paranoid psychosis [Anti NMDA]
Vertical nystagmus

Opium Intoxication
1. Pin point pupils
2. Paralytic ileus
3. GTCS
4. Respiratory depression
i. Cause of death

DOC: IV Naloxone

Drugs for deaddiction

Psychiatry Page 43
Drugs for deaddiction
Opium deaddiction
Relapse prevention Long term maintenance
Naltrexone Buprenorphine & Methadone
[Anti-craving] [Opium substitution therapy]

Opium withdrawal
No specific DOC for opium withdrawal
Symptomatic therapy OR Substitution therapy can be used
For pain Tramadol
For autonomic hyperactivity Clonidine

Tobacco deaddiction
Nicotine replacement Anti-craving
therapy
Gums, patches, lozenges Varenicline [α4β2 nicotine partial agonist]
Bupropion [Norepinephrine Dopamine Reuptake Inhibitor]

Alcohol Intoxication
Dependent on Blood Alcohol Concentration [BAC]

Mellanby phenomenon
Person appears more intoxicated when BAC is rising than when it is falling at same level of BAC

Concentration Clinical Features

> 30 mg % Signs of intoxication appear
> 50-80 mg % Incoordination
> 80-200 mg % -- [No MCQ asked]
200 - 300 mg % Alcoholic Blackouts
1. Discrete Anterograde Amnesia
2. Remote memory normal
3. Person appears normal to onlookers
> 300 mg % Nystagmus, coma, death

Drugs for alcohol withdrawal

DOC: Benzodiazepine

BZD of choice
Chlordiazepoxide

If patient is in delirium or having seizures & oral can't be administered

Parenteral BZD [Diazepam or Lorazepam]

Thiamine
2nd most imp drug
To prevent Wernicke's encephalopathy

Wernicke's Encephalopathy
1. Global confusion
2. Ophthalmoplegia [Responds 1st to Rx]

Psychiatry Page 44
 2. Ophthalmoplegia [Responds 1st to Rx]
3. Ataxia

Treatment
Thiamine 200-300 mg/day

Ophthalmoplegia responds first

Drugs for alcohol deaddiction

Deterrent agents [Aversive therapy] Anti-craving agents
Disulfiram Acamprosate
[Last 12 hours abstinence] Naltrexone
Topiramate
Fluoxetine
Baclofen

Most important in deaddiction → MOTIVATION

Stages of motivation/change in behaviour

Revolving door phenomenon

In pre-contemplation stage
Self-Exemption → It won't harm me
Contemplation & cost analysis
Commitment = Preparation

Psychiatry Page 45
Sexual Disorders
27 August 2017 17:53

≡┬─{Sexual Cycle───{Disorders─┬─{Desire
│ ├─{Arousal
│ └─{Orgasm
├─{Paraphilias───{Rx───{Aversive therapy
└─{Gender Identity Disorders
Sexual Dysfunction [Related to phases of sexual cycle]
Paraphilias
Gender Identity disorders

Sexual Cycle
Desire → Arousal/Excitement → Orgasm → Resolution → Plateau

Shortest phase → Orgasm [3-15 s]

Longest → Arousal

Disorders
1. Desire
i. ↑
1) Male → Satyriasis
2) Female → Nymphomaniac
ii. ↓
1) Frigidity
2. Arousal
i. Male arousal disorder → Erectile dysfunction
Psychogenic Organic
MC
ii.
Early morning erections + -
[Tumescence]

Psychiatry Page 46
 [Tumescence]
iii. DOC : PDE-5 inhibitors [Sildenafil, Tadalafil, Vardenafil]
iv. α blocker → Phentolamine
3. Orgasm
i. Premature Ejaculation
1) DOC: SSRI
2) Therapy [Dual sex therapy by Masters & Johnson]
a) Squeeze therapy [Start & stop technique]
b) Sensate focus technique
Paraphilias
Abnormalities in sexual preferences
Deviation in
Sexual act Sexual object
Sadism Animate Inanimate
Masochism Bestiality Fetishism
Voyeurism Paedophilia [MC] ex transvestitism
Exhibitionism

MC paraphilia → Paedophilia
Paraphilia seen only in males → Exhibitionism

Rx
Aversive therapy
Type of behavioural therapy

Gender Identity Disorders

Gender dysphoria

Person has dissatisfaction with the allotted sex

Male trapped in female sex

Female trapped in male sex

Want themselves to be identified as members of opposite sex

↓
CROSS DRESS
↓
Sex change surgery
Yes Transsexualism
No Dual role transvestitism

If cross dressing for identification → Dual role transvestitism

If cross dressing for sexual gratification → Fetish transvestitism

Psychiatry Page 47
Personality Disorders
27 August 2017 18:19

≡┬─{Cluster A───{Odd & Eccentric

├─{Cluster B─┬─{Dramatic & Emotional
│ ├─{Histrionic PD
│ ├─{Narcissistic PD
│ ├─{Antisocial PD
│ └─{Borderline PD───{Rx
└─{Cluster C───{Anxious & Fearful

Clusters Types
A A
B B
C Later Type D [Coronary artery disease prone]
For personality disorders

Type A Type B
CAD prone CAD not prone
Hostile Relaxed
Competitive Easy Going
Time bound
Aggressive
Career oriented
Impatient
Anxious
Ambitious
Good Job involvement

Cluster A
Odd & Eccentric

Schizoid Schizotypal Paranoid

Social Isolation Schizophrenia like Generalised mistrust
Schizoid fantasy Relatives of schizophrenia patient Lack close friends
Emotional Magical thinking Friends have an ulterior
coldness [My thinking makes it happen] motive
Speech oddities
[Extragalactic forces]

Cluster B
Dramatic & Emotional

1. Histrionic PD
a. Love to be the centre of attraction
b. Emotionally labile
c. Try to act in a seductive way
2. Narcissistic PD
Psychiatry Page 48
 2. Narcissistic PD
a. Self-love
b. Constant admiration from others
c. Leadership
d. Arrogant & Adamant
3. Antisocial PD
a. Rebels
b. Love to break rules
c. Criminals, legal, eve teasing
d. Drug addiction, Violent
e. ODD [6-12 y] → CD [12-18 y] → ASPD [> 18 y]
i. Tom riddle → Voldemort
4. Borderline PD
a. Emotionally unstable PD
b. Pervasive & intense pattern of unstable interpersonal relationships [Emotional
dysregulation]
c. Frequent relationship breakups
d. Need to get into a close relationship again as chronic feeling of emptiness inside
e. Mood swings, Impulsivity, Anger outbursts
f. Recurrent suicidal attempts, gestures, threatening & para suicides [wrist cutting]
g. Manipulative behaviour
i. Parents
ii. Partners
iii. Doctor
h. Comorbid alcohol use & depression
i. Rx
i. SSRI [to control impulsivity]
ii. Dialectical Behavioural Therapy [DBT]
1) Issues with this therapy
Transference Countertransference
Emotional reaction of patient Emotional reaction of therapist
a) towards therapist towards patient
Ex patient likes/hates psychiatrist Ex Psychiatrist likes/hates patient

Cluster C
Anxious & Fearful

Avoidant Dependent Anankastic [Obsessive Compulsive PD]

Avoid socially Lack Preoccupied with rules, regulations, perfection,
demanding situations assertiveness Symmetry, Orderliness & Cleanliness
Shy & Introvert Lack decision Rigid & Inflexible
making skills
Perfectionist but slow

OCD OCPD
Ego dystonic Ego syntonic
[No distress]
Compulsions Compulsions -
+

Psychiatry Page 49
Sleep Disorders
27 August 2017 19:13

Normal Sleep

NREM [75%] REM [25%]

Non Rapid Eye Movement
NOT remembered
Somnambulism [Sleep walking]
Somniloquy [Talking]
Bruxism [Teeth grinding]
Night Terrors [Pavor nocturnus]
Nocturnal Enuresis
Bed wetting > 5 years
Best Rx: Bed alarms
DOC: Desmopressin > Imipramine
Rapid Eye Movement
Remembered
Nightmares [M for Memory]
REM sleep behavioural disorders
REM w/o muscle atonia
[Partner kicked; Pt remembers]
Narcolepsy
Hypersomnolesence
Cause: Hypocretin/Orexin deficiency
Tetrad
1. Day time sleep attacks [MC]
2. Hypnagogic & hypnopompic hallucinations
gogic → going to sleep
pompic → getting up from sleep
3. Cataplexy [Loss of tone on emotional events]
4. Sleep paralysis

DOC: Modafinil

Sleep Cycle
Sleep latency → Time taken from going to bed to finally falling asleep
NREM I comes only once

1 sleep cycle = 90-120 minutes

1 NREM + 1 REM
[2 → 3 → 4 → 3 → 2 → REM]

Brain likes to sleep in multiples of sleep cycles

Normal sleep → 8 hours [6 h NREM + 2 h REM]

If sleep for 6 hours; REM → 1.5 hours
REM effects memory so don't cut down on sleep

1st effect of sleep deprivation is on memory

MINIMUM 6 hours of sleep for adequate REM

Psychiatry Page 50
Psychology
27 August 2017 19:25

≡┬─{Sigmund Freud Psychosexual stages of development

├─{Learning theories───{Types of operant conditioning
└─{Sigmund Freud Models of the mind─┬─{Ego defence mechanisms─┬─{Denial
│
└─{Displacement
├─{Defence mechanisms in
OCD─┬─{Repression
│
├─{Regression
│
└─{Isolation of affect
└─{One liners on defences

Sigmund Freud Psychosexual stages of development

Stage & Organ of Gratification Disease linked to

Age fixation
Oral Mouth Schizophrenia
[0 - 1.5 y] Breast sucking & biting Alcoholism
Dependent PD
Anal Faeces holding OCD
[1.5 - 3 y] Faeces giving OCPD
Phallic Males [Mother] Hysteria
[3 - 5 y] Oedipal complex Perversion
Castration anxiety

Female [Father]
Electra complex
Penis envy
Latency NONE Neurosis
[5 - 12 y]
Genital Genitalia Neurosis
[> 12 y]

Learning theories
Classical Conditioning Operant Conditioning
Bell + food → Dog → Saliva .
Bell → Dog → Saliva
Learner Passive Active
Behaviour Involuntary Voluntary

Types of operant conditioning

1. Positive reinforcement
i. ↑ desired behaviour
ii. Child studies to get car in class 12th
iii. Child studies to be allowed to watch TV

Psychiatry Page 51
 iii. Child studies to be allowed to watch TV
2. Negative reinforcement
i. ↑ desired behaviour
ii. Child studies to avoid losing bike he got in class 10th
iii. Child told, "If you don't study for 3 hours; No food for you"
3. Punishment
i. ↓ undesired behaviour
ii. Child doesn't talk to avoid being sent out of class
iii. Child told, "If you play for > 2 hours; No food for you"

Sigmund Freud Models of the mind

Topographical model Structural model

Conscious Id
Pre conscious Ego
Unconscious Super ego

Id Ego Superego
Innate & inborn Maintains balance between Id & Moralistic values & principles
Superego
Hunger, anger & sex Mature thinking It tells us what one must NOT
do
Immediate Delayed gratification .
gratification
Pleasure principle Reality principle

Ego defence mechanisms

Largely unconscious
Defend you from anxiety, guilt & shame

1. Denial
i. Denying the reality when it is too painful to be acceptable
ii. Examples
1) Stages of grief
2) All is well
3) Substance using people
2. Rationalisation 3. Projection
Neurotic Psychotic
Blaming others or giving excuses & explanations Attributing your own inner
2. for your unacceptable behaviour unacceptable feelings on to others
Ex Ex
Alcoholic blaming boss, family I hate Varun so I tell everyone that
Grapes are sour Varun hates me
3. Displacement
i. Defence mechanism in Phobia
ii. Venting your emotions onto someone inferior than you
iii. Ex
1) Boss has argument with partner so scolds junior employees

Defence mechanisms in OCD

1. Repression

Psychiatry Page 52
 1. Repression
2. Regression
3. Isolation of affect
4. Undoing 5. Reaction Formation
Making your unwanted thoughts go Doing reverse of your inner unacceptable
4. away by performing actions impulses
Ex Ex
Compulsions, apology Over caring for mother
Porn addict lecturing about harms of porn

Case Defence Mechanism

I don't hate my brother Denial
My brother hates me Projection
It's ok to be jealous of my brother because he is so rich Rationalisation
I presented flowers to my brother Reaction formation

One liners on defences

Most primitive defence Repression

mechanism
Primary neurotic defence
mechanism
Unconscious forgetting
Mature Defence SAHASA
Mechanism Suppression [Conscious forgetting]
Anticipation
Humour
Asceticism
Sublimation [Most mature DM]
[utilising inner unacceptable impulses constructively
ex painter with libidinal content Picasso's syndrome
ex Cutting [homicidal] → Surgeon/Butcher]
Altruism

Psychiatry Page 53