Download MBBS Psychiatry Mnemonic Short Book

I.
HISTORY OF PSYCHIATRY

PIONEERS IN THE FIELD OF PSYCHIATRY
? Emil Kraepelin: Divided major mental illness into Dementia precox and Manic depressive insanity

--- Content provided by FirstRanker.com ---

? Sigmund Freud:
o
Founder of Psychoanalysis
o
Dream interpretation

--- Content provided by‍ FirstRanker.com ---

o
Theory of infantile sexuality
o
Structural and topographical model of mind
o

--- Content provided by‌ FirstRanker.com ---

Theory of instincts
o
Ego defence mechanisms
o
Id, ego and superego

--- Content provided by⁠ FirstRanker.com ---

o
Stages of psychosexual development
? Eugen Blueler: Gave 4 A's of schizophrenia. (Autism, Affective flattening, Ambivalence, loosening of
Association)
? Leo Kanner defined autism

--- Content provided by FirstRanker.com ---

? Skinner ? operant conditioning
? Pavlov- classical conditioning
? John F cade - Lithium
? Reserpine ? First drug used in treating psychosis
? Ugo Cerletti and Lucio Bini - ECT

--- Content provided by​ FirstRanker.com ---

? Egas Moniz and Almenda Lima ? Psychosurgery (prefrontal leucotomy)
? Emil Durkeim ? Sociology theory of suicide
? Thomas Sydenham ? Hysteria
? Adolf Meyer: founder of psychobiology
? John Broadus Watson: founder of behaviorism

--- Content provided by‍ FirstRanker.com ---

? Philippe Pinel: abandoned forceful restraints, proposed morale & humane Rx of the mentally ill.
? Paolo Zacchia ? first forensic psychiatrist
? Johann Weyer ? Father of modern psychiatry
Personality
Coined the term

--- Content provided by​ FirstRanker.com ---

Eugen Bleuler
Schizophrenia
James Braid
Hypnosis
Reil Johan Christian

--- Content provided by​ FirstRanker.com ---

Psychiatry
Eward Hecker
Hebephrenia
Emil Kraeplin
Dementia precox

--- Content provided by FirstRanker.com ---

Sigmund Freud
Free association
Oedipus complex, Electra complex
Penis envy, Psychoanalysis
Ego defence mechanism

--- Content provided by‍ FirstRanker.com ---

Pleasure principle, Reality principle
Alfred Adler
Inferiority complex

---

II.
FUNDAMENTALS IN PSYCHIATRY

--- Content provided by‌ FirstRanker.com ---

Diagnosis and Classification in Psychiatry
The Five Axes of DSM-IV-TR
? AXIS I: Clinical Psychiatric Diagnosis
? AXIS II: Personality Disorder and Mental Retardation

--- Content provided by FirstRanker.com ---

? AXIS III: General Medical Conditions
? AXIS IV: Psychosocial and Environment Problems
? AXIS V: Global Assessment of functioning: Current and in past one year (Rated on a scale)
Normal experiences
? Hypnagogic hallucinations (Abnormal perception at the time of falling asleep)

--- Content provided by⁠ FirstRanker.com ---

? Hypnopompic hallucinations (Abnormal perception at the time of waking up)
? Near death experiences (complex hallucinatory phenomenon in people who perceive death to be imminent)
? Pseudo hallucinations
? Ideas of reference
? Panoramic memory

--- Content provided by FirstRanker.com ---

THINKING PROCESSES
? Abstract thinking: thinker can conceptualize or generalize, understanding that each concept can have
multiple meanings.
? Concrete thinking: thinking is limited to what's in front of the face, and the here and now.
Freud's Primary and Secondary thinking processes:

--- Content provided by‍ FirstRanker.com ---

Primary Process:
? Drive-dominated, prelogical, preverbal, imaginative thinking
? Consists of those mental processes which are directly related to functions of the primitive life forces
associated with the Id
? The Id has no contact with reality and works on the Pleasure Principle.

--- Content provided by FirstRanker.com ---

? Primary Process is characteristic of unconscious mental activity; marked by unorganized, non-logical
thinking and by the tendency to seek immediate discharge and gratification of instinctual urges.
? When Primary Process plays a significant role in a person's thinking he is incapable of being inner-directed.
Secondary Process:
? Reality oriented, goal-directed, logically ordered, rational, concrete and/or abstract conceptual thinking

--- Content provided by FirstRanker.com ---

? Consists of those mental processes which are directly related to learned and acquired functions of the Ego
? Characteristic of conscious and preconscious mental activity; marked by logical thinking and by the
tendency to delay gratification by regulation of the discharge of instinctual demands.
TERMINOLOGIES IN PSYCHIATRY
? Apraxia: Inability to perform skilled motor movements in the presence of normal comprehension, muscle

--- Content provided by‍ FirstRanker.com ---

strength and coordination
? Aphasia: Loss or impairment of linguistic ability as a result of brain damage
? Agnosia: Deficits in self-experience (anosognosia ? denial of illness)
? Anhedonia: Lack of interest in pleasurable activities (depression)
? Catastrophic reaction: Sudden agitation, anger when demented persons or persons with head injury are

--- Content provided by‌ FirstRanker.com ---

asked to perform tasks beyond their capacity
? Compulsion: An act performed repeatedly to reduce anxiety in response to obsessive thought
? Confabulation: falsification of memory in clear consciousness (Korsakoff's psychosis)
o
Due to hypothalamic-diencephalic lesions

--- Content provided by‌ FirstRanker.com ---

o
Does not occur in bilateral hippocampal lesions (insight also preserved)
o
Two types:
1. Momentary - brief in content and has to be provoked; can be traced to a time-dislocated true

--- Content provided by‍ FirstRanker.com ---

memory

---

2. Fantastic - sustained; spontaneous and elaborate with grandiose, far-fetched content
? Coprolalia: Forced vocalization of obscene words or phrases (Tourette's syndrome)
? Deja vu: Familiarity of unfamiliar situation
? Jamais vu: Unfamiliarity of the familiar situation (temporal lobe epilepsy/schizophrenia)

--- Content provided by‍ FirstRanker.com ---

? Echolalia: Repetition of phrases or sentences (schizophrenia/Mental retardation/learning
disability/dementia/head injury/Tourette's syndrome)
? Echopraxia: Repetition of acts done by examiner
? Perseveration: Persisting with same reply beyond point of relevance (Organic brain lesions) "where do you
live?", "London", "How old are you", "London"...

--- Content provided by‌ FirstRanker.com ---

? Palilalia ? perseverated word is repeated with increasing frequency
? Logoclonia ? perseveration of the last syllable of the last word
? Neologism: New word formation (schizophrenia)
? Palimpsest: Also called as alcoholic black out
? Stereotypy: Repetitive and bizarre movement, non- goal directed (schizophrenia, autism)

--- Content provided by‌ FirstRanker.com ---

? Verbal stereotypy - repetition of a word or phrase (Stock word) which has no immediate relevance to the
context.
? Abreaction: A process by which repressed material, particularly painful experience or a conflict is brought
back to consciousness.
? Alexithymia: Inability to describe or being aware of one's emotions.

--- Content provided by FirstRanker.com ---

? Mood is the pervasive feeling tone which is sustained (lasts for some length of time) and colours the total
experience of the person.
? Affect is the outward objective expression of the immediate, cross-sectional experience of emotion at a
given time.
Neurotransmitters & Associated Disorders

--- Content provided by​ FirstRanker.com ---

? OCD: decrease in serotonin.
? Alzheimer's disease: decrease in Ach & Nor-adrenaline.
? Schizophrenia: increased serotonin, nor adrenaline & dopamine.
? Depression: decreased serotonin, nor adrenaline & dopamine.
Features

--- Content provided by‌ FirstRanker.com ---

Psychosis
Neurosis
Judgment
Lacking or impaired
Present

--- Content provided by​ FirstRanker.com ---

Insight
Personality
Contact with reality
Delusions/ Hallucinations
Common

--- Content provided by FirstRanker.com ---

Usually not present
Examples
1. Schizophrenia
1. Phobia
2. Delusional disorder

--- Content provided by​ FirstRanker.com ---

2. Dissociative disorder
3. Mood disorder
3. Conversion / somatoform disorder
Mania
4. OCD (Obsession Compulsive Disorder)

--- Content provided by‌ FirstRanker.com ---

Depression
5. Anxiety: Generalized anxiety & Panic
Bipolar disorder
disorder
DISORDERS OF PERCEPTION

--- Content provided by‌ FirstRanker.com ---

? Hallucination
? Illusion
? Derealization
? Depersonalization

--- Content provided by FirstRanker.com ---

Hallucination
? Perceptions which arise in the absence of any external stimulus.
? Characteristics:
o
Unwilled - not subject to conscious manipulation

--- Content provided by⁠ FirstRanker.com ---

o
Has the same qualities of a real perception, i.e. Vivid, solid

---

o
Perceived as being located in the external world occurs in five sensory modalities (auditory, visual,
olfactory, gustatory, tactile)

--- Content provided by​ FirstRanker.com ---

? Auditory hallucination -- commonest type in psychiatric disorders
? Visual hallucination - Suspect organic etiology/ withdrawal states)
o
Unformed hallucinations - flashing or steady spots, colored lines and shapes
o

--- Content provided by‍ FirstRanker.com ---

Formed hallucinations - vivid objects, flowers, animals and persons
o
Visual hallucinations of temporal lobe are usually complex, formed hallucinations
o
Unformed hallucinations are common with disorders of the occipital lobe

--- Content provided by⁠ FirstRanker.com ---

? Olfactory hallucination- Temporal lobe epilepsy
? Tactile hallucination - Cocaine/alcohol abusers
? Gustatory hallucination - schizophrenia/temporal lobe epilepsy/ Lithium/disuifiram users
? Hypnagogic hallucinations (Abnormal perception at the time of falling asleep)
? Hypnopompic hallucinations (Abnormal perception at the time of waking up)

--- Content provided by​ FirstRanker.com ---

? Extracampine hallucinations: hallucinations outside the field of sensory perception (eg: outside visual
field).
HALLUCINATIONS
PSEUDOHALLUCINATIONS
Bright vivid perception just like reality

--- Content provided by⁠ FirstRanker.com ---

The lack of vividness (e.g., impossible to distinguish
male and female voices)
Patient gets it with natural way of perception (with
Patient got it with other perception (internal vision
eyes, ears etc.) from the real perpetual space (extra-

--- Content provided by‍ FirstRanker.com ---

or hearing) from out of perpetual space (e.g., intra-
projection)
projection)
Confidence in the fact that other people have the
Ideas of distant influence organized especially for

--- Content provided by‌ FirstRanker.com ---

same perceptions
the patient
Excitement or attempts to act with the false objects.
Indifferent behavior or passive defence (e.g.,
More frequent in the evening and night

--- Content provided by​ FirstRanker.com ---

attempts to shield with metal net or screen)
Typical delirium and other organic disorders
Typical for paranoid schizophrenia
Charles Bonnet Syndrome (CBS)
? A disorder in which patients with normal cognition experience consistent or periodic complex (formed) visual

--- Content provided by​ FirstRanker.com ---

hallucinations
? Have no evidence of dementia, drug abuse, neurological or psychiatric abnormalities
Illusion three types
? A type of false perception in which the perception of a real world object is combined with internal imagery
to produce a false internal perception

--- Content provided by FirstRanker.com ---

? Affect illusion: Misperception + heightened emotion (e.g., while walking across a lonely park at night, briefly
seeing a tree moving in the wind as an attacker)
? Completion illusion: it depends on inattention such as misreading words in newspapers
? Pareidolic illusion: These are meaningful perceptions produced when experiencing a poorly defined stimulus
(seeing faces in fire or clouds)

--- Content provided by⁠ FirstRanker.com ---

Depersonalization-Derealisation syndrome
? Depersonalization - alteration in the perception of self, so that feeling of one's own reality is temporarily
changed or lost
? The person affected is not delusionally convinced about the change, and instead describes it to have
occurred, as-f

--- Content provided by‍ FirstRanker.com ---

? Derealisation ? alteration in the perception of the external world, so that feeling of reality of external world
s temporarily changed or lost
? Both are 'as ? if' phenomenon
? Insight is present
? Episodes occur in the presence of a clear sensorium

--- Content provided by‍ FirstRanker.com ---

---

DISORDERS OF CONTENT OF THOUGHT

? Thought insertion/withdrawal

--- Content provided by​ FirstRanker.com ---

? Thought broadcast
? Delusion
? Passivity phenomenon: Made action/Made impulse/Made affect
DELUSION

--- Content provided by⁠ FirstRanker.com ---

? Disorder of thought
? Fixed, (usually) false or firm unshakeable idea, held in the face of evidence to the contrary, and out of
keeping with the patient's social milieu'

Primary (Autochthonous) delusions

--- Content provided by⁠ FirstRanker.com ---

? Arise de novo
? Cannot be explained on the basis of other experiences or perceptions
? Characteristic of schizophrenia (early stages)
? Types

--- Content provided by‍ FirstRanker.com ---

o
Delusional intuition (autochthonous)
o
Delusional perception
o

--- Content provided by FirstRanker.com ---

Delusional atmosphere
o
Delusional memory.
Secondary delusions

--- Content provided by‍ FirstRanker.com ---

? Commonest type
? Can be seen in other psychoses
? Types:
o
Persecutory (most common type) ? believe that people are conspiring against them.

--- Content provided by​ FirstRanker.com ---

o
Grandiose ? believe they have a special ability or mission.
o
Poverty ? believe they have been rendered penniless.
o

--- Content provided by‌ FirstRanker.com ---

Guilt ? believe they have committed a crime and deserve punishment.
o
Nihilistic ? believe they are worthless or non-existent.
o
Reference ? believe they are being referred to by magazines/television.

--- Content provided by⁠ FirstRanker.com ---

o
Amorous ? believe another person is in love with them.
o
Passivity experiences ? believe they are being made to do something, or to feel emotions, or are being
controlled from the outside; somatic passivity ? feel as though they are being moved from outside.

--- Content provided by FirstRanker.com ---

o
Capgras syndrome (Delusion of doubles) ? thinks that a familiar person is replaced by an identical
looking stranger
o
Fregoli syndrome ? thinks that a stranger is replaced by a familiar person

--- Content provided by⁠ FirstRanker.com ---

o
Othello syndrome or Conjugal paranoia: When the content of delusion is predominantly jealousy or
infidelity involving the spouse
o
Hypochondriacal paranoia or Delusional dysmorphophobia ? delusion of body parts being ugly

--- Content provided by⁠ FirstRanker.com ---

o
Clerambault's syndrome or Erotomania
Mostly in women
She thinks that a person (usually a higher status) is in love with her
Catatonia (Karl Kahlbaum, 1874)

--- Content provided by‌ FirstRanker.com ---

? Predominantly motor disorder thought to be related to affective disorder
? May be found as part of chronic schizophrenia and occasionally in organic cerebral disorders
? Core features are
o

--- Content provided by FirstRanker.com ---

Posturing
o
Stereotypies
o
Waxy flexibility

--- Content provided by‌ FirstRanker.com ---

---

Stupor
? Absence of relational functions, i.e. action and speech
? Usually involves clouding of consciousness
? Occurs in:
o

--- Content provided by⁠ FirstRanker.com ---

Schizophrenia (30 %)
o
Depression (25 %)
o
Psychological trauma (psychogenic stupor)

--- Content provided by FirstRanker.com ---

o
Mania
o
Organic brain lesions (20 %):
Diencephalon and upper brain stem

--- Content provided by FirstRanker.com ---

Frontal lobe
Basal ganglia
? The 'locked in' syndrome is due to lesions in the ventral pons
? Severe stupor seems to have a better prognosis
? Spontaneous resolution occurs in 30 % of cases

--- Content provided by⁠ FirstRanker.com ---

Sigmund Freud's psychoanalytic theories
Topographic theory of mind
Mind is divided into
? The unconscious
? The preconscious

--- Content provided by‍ FirstRanker.com ---

? The conscious
Structural theory of mind
The mental apparatus is divided into
? The Id
? The Ego

--- Content provided by‍ FirstRanker.com ---

? The Super-ego
COMMONLY USED EGO DEFENSE MECHANISMS:

Defense Mechanism
Clinical situations

--- Content provided by‍ FirstRanker.com ---

Narcissistic
Denial
Psychoses
Alcohol dependence
Projection

--- Content provided by​ FirstRanker.com ---

Persecutory delusions
Hallucinations
Distortion
Hallucinations
Delusion of grandiosity

--- Content provided by FirstRanker.com ---

Immature
Acting out
Impulse control disorders
Hypochondriasis
Hypochondriasis

--- Content provided by⁠ FirstRanker.com ---

Introjection
Depression
Regression
Neuroses, Psychoses
Severe, prolonged physical illness

--- Content provided by‌ FirstRanker.com ---

Schizoid fantasy
Schizoid personality disorder
Schizotypal personality disorder
Somatization
Somatoform disorders

--- Content provided by‍ FirstRanker.com ---

Neurotic
Displacement
Phobia
OCD
Inhibition

--- Content provided by​ FirstRanker.com ---

OCD
Phobia
Reaction formation
OCD
Dissociation

--- Content provided by‌ FirstRanker.com ---

Dissociative disorders disorder
Isolation
Obsessional thoughts

---

Repression
Psychogenic amnesia

--- Content provided by⁠ FirstRanker.com ---

Conversion
Conversion disorder (Hysteria)
Undoing
Compulsive acts in OCD
Others: Intellectualization, Rationalization, Externalization, Controlling, Sexualization

--- Content provided by‍ FirstRanker.com ---

Mature
Altruism
Anticipation
Asceticism
Suppression

--- Content provided by⁠ FirstRanker.com ---

Sublimation
Humour
Theory of Psychosexual development
Oral phase
Birth ? 18 months

--- Content provided by‌ FirstRanker.com ---

Mouth is the site of gratification (schizophrenia, mood disorder,
alcohol dependence)
Anal phase
1? 3years
Involved in bladder and bowel control Fixation at this phase leads

--- Content provided by‌ FirstRanker.com ---

to
OCD
Phallic phase
3 ? 5 years
Genital area is the site of satisfaction.

--- Content provided by‍ FirstRanker.com ---

Oedipus complex ? fear that the wish to get rid of the rival father
will result in retaliatory castration
Latency phase 5 to 11 years
Formation of superego
Genital phase

--- Content provided by​ FirstRanker.com ---

11 years ?
Capacity for true intimacy
adulthood
Duration criteria of Mental illness (ICD-10)

--- Content provided by‍ FirstRanker.com ---

Adjustment disorder
Onset < 1 month till 6 months
Persistent delusional disorder
3 months
Acute psychosis (brief psychotic disorder in DSM-

--- Content provided by FirstRanker.com ---

2 weeks (less than 1 month in DSM IV)
IV
D )
e mentia
6 months

--- Content provided by⁠ FirstRanker.com ---

Schizophrenia
1 month (6 months as per DSM IV)
Schizotypal disorder
2 years
(included under personality disorders in DSM-IV

--- Content provided by FirstRanker.com ---

and under schizophrenia in ICD-10)
Somatisation disorder
2 years
PTSD
Onset within 6 months of trauma, Duration of the

--- Content provided by‌ FirstRanker.com ---

disturbance is more than 1 month.
Acute stress reaction
Onset within minutes of life event resolves within
3
days

--- Content provided by FirstRanker.com ---

Hypomania
4 days
Mania
1 week
Obsessive compulsive disorder

--- Content provided by​ FirstRanker.com ---

2 weeks
Panic disorder
1 month
Dysthymia
2 years

--- Content provided by⁠ FirstRanker.com ---

Depression
2 weeks
Kubler-Ross stages of Death and Dying
? Stage 1: Shock and Denial
? Stage 2: Anger

--- Content provided by‍ FirstRanker.com ---

? Stage 3: Bargaining
? Stage 4: Depression
? Stage 5: Acceptance

---

COMMON EMERGENCIES IN PSYCHIATRY
Syndrome

--- Content provided by⁠ FirstRanker.com ---

Emergency Manifestations
Treatment Issues
Abuse of child or adult
Signs of physical trauma
Management of medical problems;

--- Content provided by⁠ FirstRanker.com ---

Acquired immune deficiency
Changes in behavior secondary to
Management of neurological illness;
syndrome (AIDS)
organic causes; changes in behavior

--- Content provided by‍ FirstRanker.com ---

management of psychological
secondary to fear and anxiety;
concomitants; reinforcement of
suicidal behaviour
social support

--- Content provided by​ FirstRanker.com ---

Adolescent crises
Suicidal attempts and ideation;
Crisis-oriented family and individual
substance abuse, truancy, trouble
therapy; hospitalization if necessary;

--- Content provided by FirstRanker.com ---

with law, pregnancy, running away;
consultation with appropriate
eating disorders; psychosis
extrafamilial authorities
Agoraphobia

--- Content provided by⁠ FirstRanker.com ---

Panic; depression
Alprazolam, propranolol;
antidepressant medication
Agranulocytosis (clozapine-induced)
High fever, pharyngitis, oral and

--- Content provided by⁠ FirstRanker.com ---

Discontinue medication immediately;
perianal ulcerations
administer granulocyte colony-
stimulating factor
Akathisia

--- Content provided by‍ FirstRanker.com ---

Agitation, restlessness, muscle
Reduce antipsychotic dosage;
discomfort; dysphoria
propranolol; benzodiazepines;
diphenhydramine orally or IV;

--- Content provided by‌ FirstRanker.com ---

benztropine IM
Alcohol-related emergencies
Alcohol delirium
Confusion, disorientation, fluctuating Chlordiazepoxide; haloperidol
consciousness and perception,

--- Content provided by⁠ FirstRanker.com ---

autonomic hyperactivity; may be
fatal
Alcohol intoxication
Disinhibited behavior, sedation at
With time and protective

--- Content provided by‍ FirstRanker.com ---

high doses
environment, symptoms abate
Alcohol persisting amnestic disorder
Confusion, loss of memory even for
Hospitalization; hypnosis;

--- Content provided by‌ FirstRanker.com ---

all personal identification data
amobarbital interview; rule out
organic cause
Alcohol persisting dementia
Confusion, agitation, impulsivity

--- Content provided by FirstRanker.com ---

Rule out other causes for dementia;
no effective treatment;
hospitalization if necessary
Alcohol psychotic disorder with
Vivid auditory (fat times visual)

--- Content provided by‍ FirstRanker.com ---

Haloperidol for psychotic symptoms
hallucinations
hallucinations with affect
appropriate to content (often
fearful); clear sensorium

--- Content provided by FirstRanker.com ---

Alcohol seizures
Grand mal seizures; rarely status
Diazepam, phenytoin; prevent by
epilepticus
using chlordiazepoxide during

--- Content provided by‍ FirstRanker.com ---

detoxification
Alcohol withdrawal
Irritability, nausea, vomiting,
Fluid and electrolytes maintained;
insomnia, malaise, autonomic

--- Content provided by‍ FirstRanker.com ---

sedation with benzodiazepines;
hyperactivity, shakiness
restraints; monitoring of vital signs;
100 mg thiamine IM
Idiosyncratic alcohol intoxication

--- Content provided by‍ FirstRanker.com ---

Marked aggressive or assaultive
Generally no treatment required
behaviour
other than protective environment
Korsakoff's syndrome

--- Content provided by⁠ FirstRanker.com ---

Alcohol stigmata, amnesia,
No effective treatment;
confabulation
institutionalization often needed
Wernicke's encephalopathy

--- Content provided by⁠ FirstRanker.com ---

Oculomotor disturbances, cerebellar
Thiamine, 100 mg IV or IM, with
ataxia; mental confusion
MgSO4
given before glucose loading

--- Content provided by⁠ FirstRanker.com ---

Amphetamine (or related substance)
Delusions, paranoia; violence;
Antipsychotics; restraints;
intoxication
depression (from withdrawal);

--- Content provided by FirstRanker.com ---

hospitalization if necessary; no need
anxiety, delirium
for gradual withdrawal;
antidepressants may be necessary

---

Anorexia nervosa

--- Content provided by⁠ FirstRanker.com ---

Loss of 25% of body weight of the
Hospitalization; electrocardiogram
norm for age and sex
(ECG),
fluid and electrolytes;

--- Content provided by​ FirstRanker.com ---

neuroendocrine
Anticholinergic
Psychotic symptoms, dry skin and
Discontinue drug, IV physostigmine
intoxication

--- Content provided by⁠ FirstRanker.com ---

mouth, hyperpyrexia, mydriasis,
0.5 to 2 mg, for severe agitation or
tachycardia, restlessness, visual
fever, benzodiazepines;
hallucinations

--- Content provided by⁠ FirstRanker.com ---

antipsychotics contraindicated
Anticonvulsant intoxication
Psychosis; delirium
Dosage of anticonvulsant is reduced
Benzodiazepine intoxication

--- Content provided by⁠ FirstRanker.com ---

Sedation, somnolence, and ataxia
Supportive measures; flumazenil, 7.5
to 45 mg a day, titrated as needed,
should be used only by skilled
personnel with resuscitative

--- Content provided by‍ FirstRanker.com ---

equipment available
Bereavement
Guilt feelings, irritability; insomnia;
Must be differentiated from major
somatic complaints

--- Content provided by​ FirstRanker.com ---

depressive disorder; antidepressants
not indicated; benzodiazepines for
sleep; encouragement of ventilation
Borderline personality
Suicidal ideation and gestures;

--- Content provided by FirstRanker.com ---

Suicidal and homicidal evaluation (if
disorder
homicidal ideations and gestures;
great, hospitalization); small dosages
substance abuse; micropsychotic

--- Content provided by‌ FirstRanker.com ---

of antipsychotics; clear follow-up
episodes; burns, cut marks on body
plan
Brief psychotic disorder
Emotional turmoil, extreme lability;

--- Content provided by⁠ FirstRanker.com ---

Hospitalization often necessary; low
acutely impaired reality testing after
dosage of antipsychotics may be
obvious psychosocial stress
necessary but often resolves

--- Content provided by FirstRanker.com ---

spontaneously
Bromide intoxication
Delirium; mania; depression;
Serum levels obtained (>50 mg a
psychosis

--- Content provided by‍ FirstRanker.com ---

day); bromide intake discontinued;
large quantities of sodium chloride IV
or orally; if agitation, paraldehyde or
antipsychoticis used
Caffeine intoxication

--- Content provided by‍ FirstRanker.com ---

Severe anxiety, resembling panic
Cessation of caffeine-containing
disorder; mania; delirium; agitated
substances; benzodiazepines
depression; sleep disturbance

--- Content provided by​ FirstRanker.com ---

Cannabis intoxication
Delusions; panic; dysphoria;
Benzodiazepines and antipsychotics
cognitive impairment
as needed; evaluation of suicidal or

--- Content provided by​ FirstRanker.com ---

homicidal risk; symptoms usually
abate with time and reassurance
Catatonic schizophrenia
Marked psychomotor disturbance
Rapid tranquilization with

--- Content provided by​ FirstRanker.com ---

(either excitement or stupor);
antipsychotics; monitor vital signs;
exhaustion; can be fatal
amobarbital may release patient
from catatonic mutism or stupor but

--- Content provided by‍ FirstRanker.com ---

can precipitate violent behavior
Cimetidine psychotic disorder
Delirium; delusions
Reduce dosage or discontinue drug
Clonidine withdrawal

--- Content provided by⁠ FirstRanker.com ---

Irritability; psychosis; violence;
Symptoms abate with time, but
seizures
antipsychotics may be necessary;
gradual lowering of dosage

--- Content provided by⁠ FirstRanker.com ---

---

Cocaine intoxication and withdrawal
Paranoia and violence; severe
Antipsychotics and benzodiazepines;
anxiety; manic state; delirium:
antidepressants or ECT for

--- Content provided by FirstRanker.com ---

schizophreniform psychosis;
withdrawal depression if persistent;
tachycardia, hypertension,
hospitalization
myocardial infarction,

--- Content provided by FirstRanker.com ---

cerebrovascular disease; depression
and suicidal ideation
Delirium
Fluctuating sensorium; suicidal and
Evaluate all potential contributing

--- Content provided by‌ FirstRanker.com ---

homicidal risk; cognitive clouding;
factors and treat each accordingly;
visual, tactile, and auditory
reassurance, structure, clues to
orientation;

--- Content provided by⁠ FirstRanker.com ---

hallucinations; paranoia
benzodiazepines and low-dosage,
high- potency antipsychotics must be
used with extreme care because of
their potential to act paradoxically

--- Content provided by‌ FirstRanker.com ---

and increase agitation
Delusional disorder
Most often brought in to emergency
Antipsychotics if patient will comply
room involuntarily; threats directed

--- Content provided by​ FirstRanker.com ---

(IM if necessary); intensive family
toward others
intervention; hospitalization if
necessary
Dementia

--- Content provided by​ FirstRanker.com ---

Unable to care for self; violent
Small dosages of high-potency
outbursts; psychosis; depression and
antipsychotics; clues to orientation;
suicidal ideation; confusion

--- Content provided by​ FirstRanker.com ---

organic evaluation, including
medication use; family intervention
Depressive disorders
Suicidal ideation and attempts; self-
Assessment of danger to self;

--- Content provided by⁠ FirstRanker.com ---

neglect; substance abuse
hospitalization if necessary,
nonpsychiatric causes of depression
must be evaluated
L-Dopa intoxication

--- Content provided by⁠ FirstRanker.com ---

Mania; depression; schizophreniform Lower dosage or discontinue drug
disorder, may induce rapid cycling in
patients with bipolar I disorder
Dystonia, acute
Intense involuntary spasm of

--- Content provided by FirstRanker.com ---

Decrease dosage of antipsychotic;
muscles of neck, tongue, face, jaw,
benztropine or diphenhydramine IM
eyes, or trunk
Group hysteria

--- Content provided by⁠ FirstRanker.com ---

Groups of people exhibit extremes of Group is dispersed with help of other
grief or other disruptive behavior
health care workers; ventilation,
crisis- oriented therapy; if necessary,
small dosages of benzodiazepines

--- Content provided by‌ FirstRanker.com ---

Hallucinogen-induced psychotic
Symptom picture is result of
Serum and urine screens; rule out
disorder with hallucinations
interaction of type of substance,

--- Content provided by‌ FirstRanker.com ---

underlying medical or mental
dose taken, duration of action, user's
disorder; benzodiazepines (2 to 20
premorbid personality, setting;
mg) orally; reassurance and

--- Content provided by⁠ FirstRanker.com ---

panic;
orientation; rapid tranquilization;
agitation; atropine psychosis
often responds spontaneously
Homicidal and assaultive behavior

--- Content provided by​ FirstRanker.com ---

Marked agitation with verbal threats
Seclusion, restraints, medication

---

Homosexual panic
Not seen with men or women who
Ventilation, environmental

--- Content provided by​ FirstRanker.com ---

are comfortable with their sexual
structuring, and, in some instances,
orientation; occurs in those who
medication for acute panic (e.g.,
adamantly deny having any

--- Content provided by‌ FirstRanker.com ---

alprazolam, 0.25 to 2 mg) or
homoerotic impulses; impulses are
antipsychotics may be required;
aroused by talk, a physical overture,
opposite-sex clinician should

--- Content provided by‌ FirstRanker.com ---

or play among same-sex friends,
evaluate the patient whenever
such as wrestling, sleeping together,
possible, and the patient should not
or touching each other in a shower

--- Content provided by​ FirstRanker.com ---

be touched save for the routine
or hot tub; panicked person sees
examination; patients have attached
others as sexually interested in him
physicians who were examining an

--- Content provided by‍ FirstRanker.com ---

or her and defends against them
abdomen or performing a rectal
examination (e.g., on a man who
harbors thinly veiled unintegrated
homosexual impulses)

--- Content provided by​ FirstRanker.com ---

Hypertensive crisis
Life-threatening hypertensive
Adrenergic blockers (e.g.,
reaction secondary to ingestion of
phentolamine); nifedipine 10 mg

--- Content provided by⁠ FirstRanker.com ---

tyramine-containing foods in
orally; chlorpromazine; make sure
combination with MAOls; headache,
symptoms are not secondary to
stiff neck, sweating, nausea,

--- Content provided by FirstRanker.com ---

hypotension (side effect of
vomiting
monoamine oxidase inhibitors
[MAOls] alone)
Hyperthermia

--- Content provided by‍ FirstRanker.com ---

Extreme excitement or catatonic
Hydrate and cool; may be drug
stupor or both; extremely elevated
reaction, so discontinue any drug;
temperature; violent hyperagitation

--- Content provided by FirstRanker.com ---

rule out infection
Hyperventilation
Anxiety, terror, clouded
Shift alkalosis by having patient
consciousness; giddiness, faintness;

--- Content provided by‌ FirstRanker.com ---

breathe into paper bag; patient
blurring vision
education; antianxiety agents
Hypothermia
Confusion; lethargy; combativeness;

--- Content provided by‌ FirstRanker.com ---

IV fluids and rewarming, cardiac
low body temperature and shivering;
status must be carefully monitored;
paradoxical feeling of warmth
avoidance of alcohol

--- Content provided by⁠ FirstRanker.com ---

Incest and sexual abuse of child
Suicidal behavior; adolescent crises;
Corroboration of charge, protection
substance abuse
of victim; contact social services;

--- Content provided by‍ FirstRanker.com ---

medical and psychiatric evaluation;
crisis intervention
Insomnia
Depression and irritability; early
Hypnotics only in short term; e.g.,

--- Content provided by‍ FirstRanker.com ---

morning agitation; frightening
triazolam, 0.25 to 0.5 mg, at
dreams; fatigue
bedtime; treat any underlying
mental disorder; rules of sleep

--- Content provided by‍ FirstRanker.com ---

hygiene
Intermittent explosive disorder
Brief outbursts of violence; periodic
Benzodiazepines or antipsychotics
episodes of suicide attempts

--- Content provided by‍ FirstRanker.com ---

for short term; long-term evaluation
with computed tomography (CT)
scan, sleep- deprived
electroencephalogram (EEG),
glucose tolerance curve

--- Content provided by FirstRanker.com ---

Jaundice
Uncommon complication of low-
Change drug to low dosage of a low-
potency phenothiazine use (e.g.,
potency agent in a different class

--- Content provided by‍ FirstRanker.com ---

chlorpromazine)
Leukopenia and agranulocytosis
Side effects within the first 2 months
Patient should call immediately for
of treatment with antipsychotics

--- Content provided by FirstRanker.com ---

sore throat, fever, etc., and obtain
immediate blood count; discontinue
drug; hospitalize if necessary

---

Lithium toxicity
Vomiting; abdominal pain; profuse

--- Content provided by‌ FirstRanker.com ---

Lavage with wide-bore tube; osmotic
diarrhea; severe tremor, ataxia;
diuresis; medical consultation; may
coma; seizures; confusion;
require ICU treatment

--- Content provided by​ FirstRanker.com ---

dysarthria; focal neurological signs
Major depressive episode with
Major depressive episode symptoms
Antipsychotics plus antidepressants;
psychotic features

--- Content provided by‌ FirstRanker.com ---

with delusions; agitation, severe
evaluation of suicide and homicide
guilt; ideas of reference; suicide and
risk; hospitalization and ECT if
homicide risk

--- Content provided by FirstRanker.com ---

necessary
Manic episode
Violent, impulsive behavior;
Hospitalization; restraints if
indiscriminate sexual or spending

--- Content provided by FirstRanker.com ---

necessary; rapid tranquilization with
behavior; psychosis; substance abuse antipsychotics; restoration of lithium
levels
Marital crises
Precipitant may be discovery of an

--- Content provided by⁠ FirstRanker.com ---

Each should be questioned alone
extramarital affair, onset of serious
regarding extramarital affairs,
illness, announcement of intent to
consultations with lawyers regarding

--- Content provided by‌ FirstRanker.com ---

divorce, or problems with children or
divorce, and willingness to work in
work; one or both members of the
crisis- oriented or long-term therapy
couple may be in therapy or may be

--- Content provided by‍ FirstRanker.com ---

to resolve the problem; sexual,
psychiatrically ill; one spouse may be
financial, and psychiatric treatment
seeking hospitalization for the other
histories from both, psychiatric

--- Content provided by​ FirstRanker.com ---

evaluation at the time of
presentation; may be precipitated by
onset of untreated mood disorder or
affective symptoms caused by
medical illness or insidious-onset

--- Content provided by​ FirstRanker.com ---

dementia; referral for management
of the illness reduces immediate
stress and enhances the healthier
spouse's coping capacity; children
may give insights available only to

--- Content provided by⁠ FirstRanker.com ---

someone intimately involved in the
social system
Migraine
Throbbing, unilateral headache
Sumatriptan 6 mg IM

--- Content provided by FirstRanker.com ---

Mitral valve prolapse
Associated with panic disorder;
Echocardiogram; alprazolam or
dyspnea and palpitations; fear and
propranolol

--- Content provided by⁠ FirstRanker.com ---

anxiety
Neuroleptic malignant syndrome
Hyperthermia; muscle rigidity;
Discontinue antipsychotic; IV
autonomic instability; parkinsonian

--- Content provided by‍ FirstRanker.com ---

dantrolene; bromocriptine orally;
symptoms; catatonic stupor;
hydration and cooling; monitor CPK
neurological signs; 10% to 30%
levels

--- Content provided by‍ FirstRanker.com ---

fatality; elevated creatine
phosphokinase
Nitrous oxide toxicity
Euphoria and light-headedness
Symptoms abate without treatment

--- Content provided by​ FirstRanker.com ---

within hours of use
Nutmeg intoxication
Agitation; hallucinations; severe
Symptoms abate within hours of use
headaches; numbness in extremities

--- Content provided by⁠ FirstRanker.com ---

without treatment
Opioid intoxication and withdrawal
Intoxication can lead to coma and
IV naloxone, narcotic antagonist;
death; withdrawal is not life-

--- Content provided by⁠ FirstRanker.com ---

urine and serum screens; psychiatric
threatening
and medical illnesses (e.g., AIDS) may
complicate picture

---

Panic disorder

--- Content provided by FirstRanker.com ---

Panic, terror; acute onset
Must differentiate from other
anxiety- producing disorders, both
medical and psychiatric; ECG to rule
out mitral valve prolapse;

--- Content provided by⁠ FirstRanker.com ---

propranolol (10 to 30 mg);
alprazolam (0.25 to 2.0 mg); long-
term management may include an
antidepressant
Paranoid schizophrenia

--- Content provided by‌ FirstRanker.com ---

Command hallucinations; threat to
Rapid tranquilization; hospitalization;
others or themselves
long-acting depot medication;
threatened persons must be notified

--- Content provided by‌ FirstRanker.com ---

and protected
Parkinsonism
Stiffness, tremor, bradykinesia,
Oral antiparkinsonian drug for 4
flattened affect, shuffling gait,

--- Content provided by‌ FirstRanker.com ---

weeks to 3 months; decrease dosage
salivation, secondary to
of the antipsychotic
antipsychotic medication
Perioral (rabbit) tremor .

--- Content provided by FirstRanker.com ---

Perioral tumor (rabbitlike facial
Decrease dosage or change to a
grimacing) usually appearing after
medication in another class
long-term therapy with

--- Content provided by⁠ FirstRanker.com ---

antipsychotics
Phencyclidine (or phencyclidine-like
Paranoid psychosis; can lead to
Serum and urine assay;
intoxication)

--- Content provided by‍ FirstRanker.com ---

death; acute danger to self and
benzodiazepines may interfere with
others
excretion; antipsychotics may
worsen symptoms because of

--- Content provided by‍ FirstRanker.com ---

anticholinergic side effects; medical
monitoring and hospitalization
for severe intoxication
Phenelzine-induced psychotic
Psychosis and mania in predisposed

--- Content provided by​ FirstRanker.com ---

Reduce dosage or discontinue drug
disorder
people
Phenylpropanolamine toxicity
Psychosis; paranoia; insomnia;

--- Content provided by⁠ FirstRanker.com ---

Symptoms abate with dosage
restlessness; nervousness; headache
reduction
or discontinuation (found in over-
the-

--- Content provided by‌ FirstRanker.com ---

counter diet aids and oral and nasal
decongestants)
Phobias
Panic, anxiety; fear
Treatment same as for panic

--- Content provided by‍ FirstRanker.com ---

Photosensitivity
Easy sunburning secondary to use of
d
Pis
a o

--- Content provided by​ FirstRanker.com ---

ti rd
e e
nt r
should avoid strong sunlight
antipsychotic medication

--- Content provided by⁠ FirstRanker.com ---

and
use high-level sunscreens
Pigmentary retinopathy
Reported with dosages of
Remain below 800 mg a day of

--- Content provided by‍ FirstRanker.com ---

thioridazine (Mellaril) of 800 mg a
thioridazine
day or above
Postpartum psychosis
Childbirth can precipitate

--- Content provided by‌ FirstRanker.com ---

Danger to self and others (including
schizophrenia, depression, reactive
infant) must be evaluated and
psychoses, mania, and depression;
proper precautions taken; medical

--- Content provided by​ FirstRanker.com ---

affective symptoms are most
illness presenting with behavioral
common; suicide risk is reduced
aberrations is included in the
during pregnancy but increased in

--- Content provided by⁠ FirstRanker.com ---

differential diagnosis and must be
the postpartum period
sought and treated; care must be
paid to the effects on father, infant,
grandparents, and other children

--- Content provided by FirstRanker.com ---

---

Posttraumatic stress disorder
Panic, terror; suicidal ideation;
Reassurance; encouragement of
flashbacks
return to responsibilities; avoid

--- Content provided by⁠ FirstRanker.com ---

hospitalization if possible to prevent
chronic invalidism; monitor suicidal
ideation
Priapism (trazodone
Persistent penile erection

--- Content provided by​ FirstRanker.com ---

Intracorporeal epinephrine;
[Desyrel]-induced)
accompanied by severe pain
mechanical or surgical drainage
Propranolol toxicity

--- Content provided by​ FirstRanker.com ---

Profound depression; confusional
Reduce dosage or discontinue drug;
states
monitor suicidality
Rape

--- Content provided by⁠ FirstRanker.com ---

Not all sexual violations are
Rape is a major psychiatric
reported; silent rape reaction is
emergency; victim may have
characterized by loss of appetite,

--- Content provided by​ FirstRanker.com ---

enduring patterns of sexual
sleep disturbance, anxiety, and,
dysfunction; crisis-oriented therapy,
sometimes, agoraphobia; long
social support, ventilation,

--- Content provided by⁠ FirstRanker.com ---

periods of silence, mounting anxiety,
reinforcement of healthy traits, and
stuttering, blocking, and physical
encouragement to return to the
symptoms during the interview when previous level of functioning as

--- Content provided by​ FirstRanker.com ---

the sexual history is taken; fear of
rapidly as possible; legal counsel; if a
violence and death and of
woman, methoxyprogesterone or
contracting a sexually transmitted

--- Content provided by​ FirstRanker.com ---

diethylstilbestrol orally for 5 days to
disease or being pregnant
prevent pregnancy; if the victim has
contracted a venereal disease,
appropriate antibiotics; witnessed

--- Content provided by FirstRanker.com ---

written permission is required for
the physician to examine,
photograph, collect specimens, and
release information to the
authorities; obtain consent, record

--- Content provided by⁠ FirstRanker.com ---

the history in the patient's own
words, obtain required tests, record
the results of the examination, save
all clothing, defer diagnosis, and
provide protection against disease,

--- Content provided by FirstRanker.com ---

psychic trauma, and pregnancy;
Reserpine intoxication
Major depressive episodes; suicidal
Evaluation of suicidal ideation; lower
ideation; nightmares

--- Content provided by‍ FirstRanker.com ---

dosage or change drug;
antidepressants of ECT may be
indicated
Schizoaffective disorder
Severe depression; manic symptoms; Evaluation of dangerousness to self

--- Content provided by⁠ FirstRanker.com ---

paranoia
or others; rapid tranquilization if
necessary; treatment of depression
(antidepressants alone can enhance
schizophrenic symptoms); use of

--- Content provided by⁠ FirstRanker.com ---

antimanic agents
Schizophrenia
Extreme self-neglect; severe
Evaluation of suicidal and homicidal
paranoia; suicidal ideation or

--- Content provided by‍ FirstRanker.com ---

potential; identification of any illness
assaultiveness; extreme psychotic
other than schizophrenia; rapid
symptoms
tranquilization

--- Content provided by‍ FirstRanker.com ---

Schizophrenia in exacerbation
Withdrawn; agitation; suicidal and
Suicide and homicide evaluation;
homicidal risk
screen for medical illness; restraints

--- Content provided by⁠ FirstRanker.com ---

and rapid tranquilization if
necessary; hospitalization if
necessary; reevaluation of
medication regimen

---

Sedative, hypnotic, or anxiolytic

--- Content provided by⁠ FirstRanker.com ---

Alterations in mood, behavior,
Naloxone to differentiate from
intoxication and withdrawal
thought-delirium; derealization and
opioid intoxication; slow withdrawal

--- Content provided by​ FirstRanker.com ---

depersonalization; untreated, can be
with phenobarbital or sodium
fatal; seizures
thiopental or benzodiazepine;
hospitalization

--- Content provided by FirstRanker.com ---

Seizure disorder
Confusion; anxiety; derealization and
Immediate EEG; admission and
depersonalization; feelings of
sleep- deprived and 24-hour EEG;

--- Content provided by FirstRanker.com ---

impending doom; gustatory or
rule out pseudoseizures;
olfactory hallucinations; fuguelike
anticonvulsants
state

--- Content provided by FirstRanker.com ---

Substance withdrawal
Abdominal pain; insomnia,
Symptoms of psychotropic drug
drowsiness; delirium; seizures;
withdrawal disappear with time or

--- Content provided by​ FirstRanker.com ---

symptoms of tardive dyskinesia may
disappear with reinstitution of the
emerge; eruption of manic or
substance; symptoms of
schizophrenic symptoms

--- Content provided by⁠ FirstRanker.com ---

antidepressant withdrawal can be
successfully treated with
anticholinergic agents, such as
atropine; gradual withdrawal of
psychotropic substances over two to

--- Content provided by​ FirstRanker.com ---

four weeks generally obviates
development of symptoms
Sudden death associated with
Seizures; asphyxiation;
Specific medical treatments

--- Content provided by FirstRanker.com ---

Antipsychotic medication
cardiovascular causes; postural
hypotension; laryngeal-pharyngeal
dystonia; suppression of gag reflex
Sudden death of psychogenic origin

--- Content provided by FirstRanker.com ---

Myocardial infarction after sudden
Specific medical treatments; folk
psychic stress; voodoo and hexes;
healers
hopelessness, especially associated

--- Content provided by​ FirstRanker.com ---

with serious physical illness
Suicide
Suicidal ideation; hopelessness
Hospitalization, antidepressants
Sympathomimetic withdrawal

--- Content provided by‌ FirstRanker.com ---

Paranoia; confusional states;
Most symptoms abate without
depression
treatment; antipsychotics;
antidepressants if necessary

--- Content provided by​ FirstRanker.com ---

Tardive dyskinesia
Dyskinesia of mouth, tongue, face,
No effective treatment reported;
neck, and trunk; choreoathetoid
may be prevented by prescribing the

--- Content provided by‍ FirstRanker.com ---

movements of extremities; usually
least amount of drug possible for as
but not always appearing after long-
little time as is clinically feasible and
term treatment with antipsychotics,

--- Content provided by‍ FirstRanker.com ---

using drug-free holidays for patients
especially after a reduction in
who need to continue taking the
dosage; incidence highest in the
drug; decrease or discontinue drug at

--- Content provided by⁠ FirstRanker.com ---

elderly and brain-damaged;
first sign of dyskinetic movements
symptoms are intensified by
antiparkinsonian drugs and
masked but not cured by increased

--- Content provided by⁠ FirstRanker.com ---

dosages of antipsychotic
Thyrotoxicosis
Tachycardia; gastrointestinal
Thyroid function test (T3, T4, thyroid-
dysfunction; hyperthermia; panic,

--- Content provided by‌ FirstRanker.com ---

stimulating hormone [TSH]); medical
anxiety, agitation; mania; dementia;
consultation
psychosis
Toluene abuse

--- Content provided by FirstRanker.com ---

Anxiety; confusion; cognitive
Neurological damage is
impairment
nonprogressive and reversible if
toluene use in discontinued early

--- Content provided by⁠ FirstRanker.com ---

---

Vitamin B12 deficiency
Confusion; mood and behavior
Treatment with vitamin B12
changes; ataxia
Volatile nitrates

--- Content provided by⁠ FirstRanker.com ---

Alternations of mood and behavior;
Symptoms abate with cessation of
light-headedness; pulsating
use
headache

--- Content provided by​ FirstRanker.com ---

PSYCHOLOGICAL TESTING
? Reliability assesses the reproducibility of results.
? Validity assesses whether the test measures what it purports to measure.

--- Content provided by​ FirstRanker.com ---

? The two types of tests are:
? Objective tests:
o
Typically pencil-and-paper tests based on specific items and questions.
o

--- Content provided by‍ FirstRanker.com ---

Yield numerical scores and profiles easily subjected to mathematical or statistical analysis.
? Projective tests:
o
Have no right or wrong answers.
Objective Measures of Personality in Adults

--- Content provided by​ FirstRanker.com ---

Projective Measures of Personality
Minnesota-Multiphasic Personality Inventory (MMPI)
Rorschach test
Minnesota Multiphasic Personality Inventory-2
Thematic Apperception Test (TAT)

--- Content provided by​ FirstRanker.com ---

(MMPI-2)
Million Clinical Multiaxial Inventory (MCMI)
Sentence Completion Test
Million Clinical Multiaxial Inventory-II (MCMI-11)
Holtzman Inkblot Technique (HIT)

--- Content provided by​ FirstRanker.com ---

16 Personality Factor Questionnaire (16 PF)
Figure drawing
Personality Assessment Inventory (PAI)
Make-a-Picture Story (MAPS)
California Personality Inventory (CPI)

--- Content provided by⁠ FirstRanker.com ---

The Draw-a-Person test
Jackson Personality Inventory (JPI)
Edwards Personal Preference Schedule (EPPS)
Psychological Screening Inventory (PSI)
Eysenck Personality Questionnaire (EPQ)

--- Content provided by⁠ FirstRanker.com ---

Adjective Checklist (ACL)
Comrey Personality Scales (CPS)
Tennessee Self-Concept Scale (TSCS)

---

III.
DELIRIUM AND DEMENTIA

--- Content provided by FirstRanker.com ---

DELIRIUM
? Most common organic mental disorder seen in clinical practice
Etiology:
? Seen in approximately 10 to 30 % of medically ill patients who are hospitalized

--- Content provided by​ FirstRanker.com ---

? The incidence is higher in postoperative patients
? Predisposing factors
Preexisting brain damage (e.g., dementia, cerebrovascular disease, tumor)
History of delirium
Alcohol or drug dependence & withdrawal

--- Content provided by​ FirstRanker.com ---

Generalized or focal cerebral lesion
Chronic medical illness
Surgical procedure and postoperative period
Treatment with psychotropic medicines
Present or past history of head injury

--- Content provided by FirstRanker.com ---

Diabetes, Cancer
Sensory impairment (e.g., blindness)
Male gender
Diagnostic Criteria for Delirium, Not Induced by Alcohol and Other Psychoactive Substances
A. There is clouding of consciousness, i.e., reduced clarity of awareness of the environment, with reduced

--- Content provided by‌ FirstRanker.com ---

ability to focus, sustain, or shift attention.
B. Disturbance of cognition is manifest by both:
1. impairment of immediate recall and recent memory, with relatively intact remote memory;
2. disorientation in time, place, or person.
C. At least one of the following psychomotor disturbances is present:

--- Content provided by FirstRanker.com ---

1. rapid, unpredictable shifts from hypoactivity to hyperactivity;
2. increased reaction time;
3. increased or decreased flow of speech;
4. enhanced startle reaction.
D. There is disturbance of sleep or of the sleep-wake cycle, manifest by at least one of the following:

--- Content provided by​ FirstRanker.com ---

1. insomnia, which in severe cases may involve total sleep loss, with or without daytime drowsiness, or
reversal of the sleep-wake cycle;
2. nocturnal worsening of symptoms;
3. disturbing dreams and nightmares, which may continue as hallucinations or illusions after awakening.
E. Symptoms have rapid onset and show fluctuations over the course of the day.

--- Content provided by‌ FirstRanker.com ---

F. There is objective evidence from history, physical and neurological examination, or laboratory tests of an
underlying cerebral or systemic disease (other than psychoactive substance-related) that can be presumed
to be responsible for the clinical manifestations in Criteria A to D.
Comments
? Emotional disturbances such as depression, anxiety or fear, irritability, euphoria, apathy, or wondering

--- Content provided by‌ FirstRanker.com ---

perplexity, disturbances of perception (illusions or hallucinations, often visual), and transient delusions are
typical but are not specific indications for the diagnosis. A fourth character may be used to indicate whether
or not the delirium is superimposed on dementia
o
Delirium, not superimposed on dementia

--- Content provided by​ FirstRanker.com ---

o
Delirium, superimposed on dementia
o
Other delirium
o

--- Content provided by‌ FirstRanker.com ---

Delirium, unspecified
Clinical Features:
? Sudden onset with fluctuating course
? Cognitive impairment

---

? Clouding of consciousness -- decreased awareness of surroundings and decreased ability to respond to

--- Content provided by​ FirstRanker.com ---

environmental stimuli
? Disorientation (mostly in time)
? Perceptual disturbances - Illusions, hallucinations
? Delirium may first present with daytime drowsiness and night time insomnia (sun downing)
? Motor symptoms: asterixis, incoordination, carphologia or floccillation (picking movements at cover-sheets

--- Content provided by⁠ FirstRanker.com ---

and clothes), Multifocal myoclonus
? When a psychiatric illness causes symptoms of delirium, patients are said to have a pseudodelirium
? Delirium can occur in older patients wearing eye patches after cataract surgery (black-patch delirium)
Treatment
? Primary goal: treat the underlying cause.

--- Content provided by FirstRanker.com ---

? Commonly used drug: haloperidol.
DEMENTIA
? Impairment of intellectual functions
? Impairment of memory (predominantly of recent memory, especially in early stages),
? Deterioration of personality with lack of personal care.

--- Content provided by FirstRanker.com ---

? Impairment of judgment and impulse control
? Impairment of abstract thinking.
? No impairment of consciousness
Additional features:
? Emotional lability (marked variation in emotional expression)

--- Content provided by‌ FirstRanker.com ---

? Catastrophic reaction (when confronted with an assignment which is beyond the residual intellectual
capacity, patient may go into a sudden rage).
? Thought abnormalities, e.g. perseveration, delusions.
? Urinary and faecal incontinence may develop in later stages.
? Disorientation in time; disorientation in place and person may also develop in later stages.

--- Content provided by FirstRanker.com ---

? Neurological signs may or may not be present, depending on the underlying cause.
Dementia
Pseudodementia (Depression)
Patient rarely complains of cognitive
Patient usually always complains about memory

--- Content provided by FirstRanker.com ---

impairment
impairment
Patient often emphasizes achievements
Patient often emphasizes disability
Patients often appears unconcerned

--- Content provided by​ FirstRanker.com ---

Patient very often communicates distress
Usually labile affect
Severe depression on examination
Patient makes errors on cognitive examination
Do not know' answers are more frequent

--- Content provided by​ FirstRanker.com ---

Impairment of recent memory
Rarely impaired
Confabulation may be present
Confabulation very rare
Consistently poor performance on similar tests

--- Content provided by‍ FirstRanker.com ---

Marked variability in performance on similar tests
History of depression less common
Past history of manic and/ or depression episodes
Features
Cortical Dementia

--- Content provided by FirstRanker.com ---

Subcortical Dementia
Site of lesion
Cortex (frontal and temporo parieto-
Subcortical grey matter (thalamus, basal
occipital association areas, hippocampus) ganglia, and rostral brain stem)

--- Content provided by​ FirstRanker.com ---

Examples
Alzheimer's disease, Pick's disease
Huntington' chorea, Parkinson's disease,
Progressive supranuclear palsy, Wilson's
disease

--- Content provided by​ FirstRanker.com ---

Severity
Severe
Mild to moderate
Motor system
Usually normal

--- Content provided by‍ FirstRanker.com ---

Dysarthria, flexed/extended posture, tremors,
dystonic, chorea, ataxia, rigidity

---

Other features
Simple delusions; depression uncommon; Complex delusions; depression common;
severe aphasia, amnesia, agnosia,

--- Content provided by⁠ FirstRanker.com ---

rarely mania
apraxia, acalculia, slowed cognitive speed
(bradyphrenia)
Memory deficit
Recall helped very little by cues

--- Content provided by‍ FirstRanker.com ---

Recall partially helped by cues and recognition
(Short-term)
tasks
Reversible causes of dementia:
? Hypothyroidism

--- Content provided by FirstRanker.com ---

? Infections
? B1 B12 deficiency
? Wilsons disease
? NPH
Feature

--- Content provided by⁠ FirstRanker.com ---

Dementia
Delirium
Onset
Slow
Rapid

--- Content provided by​ FirstRanker.com ---

Duration
Months to years
Hours to weeks
Consciousness
Normal

--- Content provided by⁠ FirstRanker.com ---

Clouded
Orientation
Normal until late stages
Disturbed
Memory

--- Content provided by‍ FirstRanker.com ---

Immediate retention and recall
Impaired recent and immediate memory
normal
Recent memory disturbed
Impaired remote memory in late

--- Content provided by​ FirstRanker.com ---

stages
Attention and
Usually normal
Disturbed
concentration

--- Content provided by​ FirstRanker.com ---

Comprehension
Impaired only in late stages
Impaired
Speech
Word-finding difficulty

--- Content provided by⁠ FirstRanker.com ---

Incoherent (slow or rapid)
Sleep-wake cycle
Normal
Frequent disruption (e.g., day & night
reversal)

--- Content provided by‍ FirstRanker.com ---

Thoughts
Impoverished
Disorganized
Awareness
Unchanged

--- Content provided by⁠ FirstRanker.com ---

Reduced
ALZHEIMER'S DISEASE
? Most common cause of dementia (> 50%)
NINCDS-ARDRA CRITERIA used for diagnosis
? Presence of dementia

--- Content provided by‍ FirstRanker.com ---

? Deficits in at least two areas of cognition
? Progressive deterioration
? No clouding of consciousness
? Age between 40 and 90
? Absence of systemic disorders

--- Content provided by‍ FirstRanker.com ---

? Neurofibrillary tangles
? Beta amyloid plaques
? Apolipoprotein E4
Clinical features:
? Delayed recall is the best overall discriminator for early Alzheimer's disease

--- Content provided by‌ FirstRanker.com ---

? Early dementia is probable with a MMSE score of 24-27
? CT- cortical atrophy over parietal and temporal lobes

---

? MRI- atrophy of grey matter (hippocampus, amygdala, medial temporal lobe)
Multi -- infarct Dementia
? Second most common cause of dementia (10-15%)

--- Content provided by​ FirstRanker.com ---

? Some studies indicate that multi-infarct dementia is probably far more common in India.
? It is also one of the important treatable causes of dementia.
? Characterized by :
o
An abrupt onset

--- Content provided by FirstRanker.com ---

o
Acute exacerbations (due to repeated infarctions),
o
Stepwise clinical deterioration (step-ladder pattern),
o

--- Content provided by FirstRanker.com ---

Fluctuating course,
o
Presence of hypertension (most commonly) or any other significant cardiovascular disease, and
o
History of previous stroke or transient ischemic attacks (TIAs).

--- Content provided by‌ FirstRanker.com ---

? Focal neurological signs are frequently present.
? Insight into the illness is usually present in the early part of the course.
? Emotional lability is common.
? EEG - focal area of slowing
? CT scan or MRI - multiple infarcts

--- Content provided by‌ FirstRanker.com ---

AIDS Dementia Complex
? Seen in about 50-70% of patients suffering from AIDS
? Triad of cognitive, behavioral and motoric deficits of subcortical dementia type.
? Cranial CT scan can show cortical atrophy 1-4 months before the onset of clinical dementia
Lewy Body Dementia

--- Content provided by‍ FirstRanker.com ---

? Second most common cause of the degenerative dementias
? Typically, the clinical features include:
o
Fluctuating cognitive impairment over weeks or months
o

--- Content provided by​ FirstRanker.com ---

Lucid intervals can be present in between fluctuations.
o
Recurrent and detailed visual hallucinations.
o
Spontaneous extrapyramidal symptoms such as rigidity and tremors.

--- Content provided by⁠ FirstRanker.com ---

o
Neuroleptic sensitivity syndrome - marked sensitivity typical doses of antipsychotic drugs (resulting in
severe extrapyramidal side-effects with use of antipsychotics).
Antipsychotics (Haloperidol and Risperidone) use to treat disruptive behavior in dementia has decreased
markedly due to possible association with increased mortality

--- Content provided by‍ FirstRanker.com ---

Antipsychotics should be avoided if Lewy body dementia is suspected
ORGANIC HALLUCINOSIS
? Presence of persistent or recurrent hallucinations due to an underlying organic cause.
? Usually visual (most common) or auditory in nature.
Etiology

--- Content provided by FirstRanker.com ---

? Drugs: Hallucinogens (LSD, psilocybin, mescaline), cocaine, cannabis, phencyclidine etc.
? Alcohol: In alcoholic hallucinosis, auditory hallucinations are usually more common.
? Sensory deprivation.
? 'Release' hallucinations due to sensory pathway disease, e.g. bilateral cataracts, otosclerosis, optic neuritis.
? Brain stem lesions (peduncular hallucinosis).

--- Content provided by‍ FirstRanker.com ---

---

Neurofibrillary tangles
Seen in
Not in

--- Content provided by‌ FirstRanker.com ---

? Alzheimer's disease
? Lewy body dementia
? Punch-drunk' syndrome
? Pick's disease
? Postencephalitic Parkinsonism

--- Content provided by‍ FirstRanker.com ---

? Amyotrophic lateral sclerosis
? Progressive supranuclear palsy
Amyloid plaques
Seen in
Not in

--- Content provided by‌ FirstRanker.com ---

? Alzheimer's disease
? Pick's disease
? Lewy body dementia
? `Punch-drunk' syndrome
Lewy bodies

--- Content provided by⁠ FirstRanker.com ---

Seen in
? Alzheimer's disease
? Ataxia-telengectasia
? Progressive supranuclear palsy
? Lewy body dementia

--- Content provided by⁠ FirstRanker.com ---

Clinical Tests of Attention and Concentration:
? Subtract sevens or threes, serially, from 100
? Reverse the days of the week or months of the year
? Spell simple words backwards (eg, world ).

--- Content provided by⁠ FirstRanker.com ---

? Repeat digits (two, three, four, or more) forward and backward
? Perform mental arithmetic (Number of nickels in $1.35? Interest on $200 at 4% for 18 months?

---

IV.
PSYCHOACTIVE SUBSTANCE ABUSE

--- Content provided by‌ FirstRanker.com ---

Complications of alcoholism
DELIRIUM TREMENS
? Most severe alcohol withdrawal syndrome
? It occurs usually within 2-4 days of complete or significant abstinence from heavy alcohol drinking
? The course is short, with recovery occurring within 3-7 days.

--- Content provided by⁠ FirstRanker.com ---

? This is an acute organic brain syndrome (delirium) with characteristic features of:
o
Clouding of consciousness
o
Disorientation in time and place.

--- Content provided by‌ FirstRanker.com ---

o
Poor attention span and distractibility.
o
Visual (also auditory) hallucinations and illusions, which are often vivid and very frightening.
o

--- Content provided by FirstRanker.com ---

Marked autonomic disturbance - tachycardia, fever, hypertension, sweating, mydriasis
o
Psychomotor agitation and ataxia.
o
Insomnia, with a reversal of sleep-wake pattern.

--- Content provided by FirstRanker.com ---

o
Dehydration with electrolyte imbalance.
? It is extremely important not to administer 5% dextrose in delirium tremens without thiamine
Alcoholic seizures ('rum fits')
? Generalized tonic clonic seizures

--- Content provided by‍ FirstRanker.com ---

? Usually occurs 12-48 hours after a heavy bout of drinking
? Often these patients have been drinking alcohol in large amounts on a regular basis for many years.
? Multiple seizures (2-6 at one time) are more common than single seizures.
? In 30% of the cases, delirium tremens follows.
Alcoholic hallucinosis

--- Content provided by FirstRanker.com ---

? Presence of hallucinations (usually auditory) during partial or complete abstinence
? They occur during clear consciousness
WERNICKE'S ENCEPHALOPATHY
? An acute reaction to a severe deficiency of thiamine
? Commonest cause - chronic alcohol use.

--- Content provided by⁠ FirstRanker.com ---

? Ophthalmoplegia with bilateral external rectus paralysis
? Higher mental function disturbance: disorientation, confusion, recent memory disturbances, poor attention
span and distractibility
? Apathy and ataxia.
? Neuronal degeneration and haemorrhage are seen in thalamus, hypothalamus, mammillary bodies and

--- Content provided by‌ FirstRanker.com ---

midbrain.
? Completely reversible with treatment

Korsakoff's psychosis
? Often follows Wernicke's encephalopathy; and referred to as Wernicke-Korsakoff syndrome.

--- Content provided by‍ FirstRanker.com ---

? Gross memory disturbances, with confabulation
? 20 percent of patients with Korsakoff's syndrome recover
? Insight is often impaired.
? Neuropathological lesions are symmetrical and paraventricular, involving the mammillary bodies, the
thalamus, the hypothalamus, the midbrain, the pons, the medulla, the fornix, and the cerebellum.

--- Content provided by‍ FirstRanker.com ---

Marchiafava -- Bignami disease
? Disorientation, epilepsy, ataxia, dysarthria, hallucinations, spastic limb paralysis, and deterioration of
personality and intellectual functioning
? There is a widespread demyelination of corpus callosum, optic tracts and cerebellar peduncles.
Legal limit for driving in India: 30 mg/100 ml (Section 185 of the Motor Vehicle Act, 1988)

--- Content provided by​ FirstRanker.com ---

---

Screening test for alcoholism:
? MAST (Michigan Alcoholism Screening Test)
? CAGE questionnaire test
CAGE Questionnaire
? Ever had to Cut down the amount of alcohol

--- Content provided by‍ FirstRanker.com ---

? Been Annoyed by people's criticism of alcoholism
? Felt Guilty of drinking.
? Need of an Eye opener.
Withdrawal syndrome: Drugs of 1st choice -- Chlordiazepoxide (diazepam 2nd)
Treatment of Alcohol Dependence

--- Content provided by‌ FirstRanker.com ---

? Behaviour therapy
? Psychotherapy
? Group therapy
? Deterrent agents
The deterrent agents are also known as alcohol sensitizing drugs.

--- Content provided by⁠ FirstRanker.com ---

Disulfiram (tetraethyl thiuram disulfide) -- most commonly used
Other deterrent agents: Citrated calcium carbimide (CCC), Metronidazole. animal charcoal, a fungus
(coprinus atramentarius), sulfonylureas and certain cephalsoporins
? Anti -- craving agents
Acamprosate - interacts with NMDA receptor -- mediated glutamatergic neurotransmission in the

--- Content provided by FirstRanker.com ---

various brain regions and reduces Ca++ fluxes through voltage -- operated channels.
Naltrexone - probably interferes with alcohol -- induced reinforcement by blocking opioid receptors
SSRIs (such as fluoxetine)
OPIUM ABUSE
? Opium use has increased markedly all over the world in the past few decades

--- Content provided by‌ FirstRanker.com ---

? India is surrounded both sides by the infamous routes of illicit transport ? Golden triangle (BurmaThailand-
Laos) and Golden Crescent (Iran-Afghanistan-Pakistan)
? Heroin (Di-acetyl-morphine) can be smoked or chased (chasing the dragon)
? Tolerance to heroin occurs very rapidly
Withdrawal syndrome

--- Content provided by FirstRanker.com ---

? Occurs typically within 12-24 hours
? Lacrimation, rhinorrhea, pupillary dilation. sweating, diarrhea, yawning, tachycardia, insomnia, raised
body temperature, muscle cramps, piloerection
Treatment
? Overdose: Naloxone

--- Content provided by FirstRanker.com ---

? Withdrawal: Methadone (1st choice), Clonidine (2' choice); others: LAAM, buprenorphine
? Maintenance: Methadone
Nicotine withdrawal
? Anxiety, restlessness, poor concentration, decreased sleep, increased appetite, exacerbation of psychiatric
symptoms

--- Content provided by FirstRanker.com ---

? Drugs used in smoking cessation: Bupropion (amfebutamone), Varenicline

Substance
Characteristic feature
Cocaine

--- Content provided by⁠ FirstRanker.com ---

Magnus symptom (cocaine bugs/tactile hallucinations)
Cannabis
Run amok, Amotivation syndrome, Flash backs, Hemp insanity,
Alcohol
Mc-Evan's sign, Morbid jealousy

--- Content provided by FirstRanker.com ---

LSD
Bad trips, Flash backs
Amphetamine
Paranoid hallucinatory syndrome (like paranoid schizophrenia)

---

Phencyclidine (angel dust)

--- Content provided by‌ FirstRanker.com ---

Dissociative anesthesia

LSD: No withdrawal syndrome
Cannabis: No physical dependence; mild to marked psychological dependence
Cocaine: Mild physical dependence; severe psychological dependence

--- Content provided by​ FirstRanker.com ---

Amok is an episode of acute violent behavior for which the person claims amnesia. Seen in cannabis abuse.

---

V.
SCHIZOPHRENIA

--- Content provided by FirstRanker.com ---

? Emil Kraeplin- In 1896, described dementia precox
? Eugen Bleuler- renamed dementia precox as schizophrenia (fundamental symptom), developed 4 A's of
schizophrenia
? Kurt Schneider- First rank symptoms

--- Content provided by‍ FirstRanker.com ---

? Point prevalence: 0.5-1%
? Incidence: 0.5 per 1000
? 8-10% of first degree relatives of patients can present with schizophrenia

Schneider's first rank symptoms

--- Content provided by‌ FirstRanker.com ---

Schneider's second rank symptoms
? Hallucination
?
Other disorders of perception
o Audible thoughts (thought echo)

--- Content provided by‍ FirstRanker.com ---

?
Sudden delusional ideas
o Voices heard arguing
?
Perplexity

--- Content provided by⁠ FirstRanker.com ---

o Voices commenting on one's action
?
Depressive and euphoric mood changes
? Delusional perception
?

--- Content provided by FirstRanker.com ---

Feelings of emotional impoverishment
? Thoughts Alienation phenomena
?
Several others as well
o Thoughts withdrawal

--- Content provided by​ FirstRanker.com ---

o Thoughts insertion
o Thought diffusion / broadcasting
? Passivity phenomena
o Made feeling (affect)
o Made impulses

--- Content provided by FirstRanker.com ---

o Made volition or act
o Somatic passivity

Bleuler's '4-A'
? Ambivalence (inability to decide for or against)

--- Content provided by⁠ FirstRanker.com ---

? Autism (withdrawal into self)
? Affect disturbance
? Association disturbance

DSM-IV CRITERIA FOR DIAGNOSIS OF SCHIZOPHRENIA:

--- Content provided by⁠ FirstRanker.com ---

Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if
successfully treated):
? Delusions
? Hallucinations
? Disorganized speech (e.g., frequent derailment or incoherence)

--- Content provided by⁠ FirstRanker.com ---

? Grossly disorganized or catatonic behavior
? Negative symptoms, i.e., affective flattening, alogia, or avolition

Only one Criterion symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a
running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

--- Content provided by⁠ FirstRanker.com ---

? All patients with schizophrenia have psychotic symptoms (reality distortion or disorganization) at some
point in the course of their illness, but there is no single pattern of psychotic symptoms.
? Continuous signs of the disturbance persist for at least 6 months.
? This 6-month period must include at least 1 month of symptoms.
Types

--- Content provided by FirstRanker.com ---

? Commonest type ? Paranoid
? Amphetamine induced - Paranoid
? Early onset & bad prognosis ? Hebephrenic
? Late onset & best prognosis ? Catatonic

---

? Very late (3rd 4th decade) ? Paranoid

--- Content provided by‍ FirstRanker.com ---

? Worst prognosis & most difficult to diagnosis ? Simple
? Associated with mental retardation ? Ptropf

DSM-IV-TR Diagnostic Criteria for Schizophrenia Subtypes
Paranoid type (Paraphrenia)

--- Content provided by‍ FirstRanker.com ---

A. Preoccupation with one or more delusions or frequent auditory hallucinations.
B. Absence of disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
Disorganized type (Hebephrenic)
Prominence of disorganized speech, disorganized behavior & flat or inappropriate affect
Catatonic type: Presence of at least two of:

--- Content provided by‌ FirstRanker.com ---

1.
Catalepsy (including waxy flexibility) or stupor
2.
Excessive motor activity (purposeless and not influenced by external stimuli)
3.

--- Content provided by⁠ FirstRanker.com ---

Negativism or mutism
4.
peculiarities of posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped
5.
movements, prominent mannerisms, or prominent grimacing

--- Content provided by FirstRanker.com ---

6.
echolalia or echopraxia
Undifferentiated type
Residual type: Absence of prominent delusions, hallucinations, disorganized speech, and grossly
disorganized or catatonic behavior.

--- Content provided by‌ FirstRanker.com ---

? Schizophreniform disorder -patients who meet the symptom requirements but not the duration
? Schizoaffective disorder -manifest symptoms of schizophrenia and independent periods of mood
disturbance.
? Other subtypes:

--- Content provided by FirstRanker.com ---

? Bouff Dlirante (Acute Delusional
? Pseudoneurotic schizophrenia
? Psychosis)
? Deficit schizophrenia

--- Content provided by FirstRanker.com ---

? Latent schizophrenia
? Early onset schizophrenia
? Oneiroid state
? Late onset schizophrenia

--- Content provided by⁠ FirstRanker.com ---

CATATONIC SCHIZOPHRENIA
Excited catatonic:
? Known as Acute lethal catatonic or pernicious catatonia
? Increased psychomotor activity
? Death may occur.

--- Content provided by​ FirstRanker.com ---

Retorted (stupor) catatonic:
? Decreased psychomotor activity
? Mutism: absence of speech
? Rigidity 2
? Waxy flexibility: parts of body placed in position that will be maintained for long period even if very

--- Content provided by‍ FirstRanker.com ---

uncomfortable
? Stupor: no movement with mutism but preservation of consciousness.
? Negativism
? Echolalia, Echopraxia
? Mannerism & Grimacing

--- Content provided by⁠ FirstRanker.com ---

? Automatic obedience
? Ambitendancy: due to ambivalence, tentative actions occurs
? Verbigeration: Incomprehensible speech
All specific terminologies like Echolalia, Echopraxia, waxy flexibility, grimacing etc... are seen in catatonic
schizophrenia except senseless giggling and mirror gazing (hebephrenic schizophrenia).

--- Content provided by‍ FirstRanker.com ---

---

Characteristic Hallucinations
? Most common - Auditory Hallucinations.
? 3rd person hallucinations - consist of voice keeping up a running commentary on the person's behavior or
thoughts or two or more voices conversing with each other
? The oneiroid state - a dream-like state in which patients may be deeply perplexed and not fully oriented in

--- Content provided by​ FirstRanker.com ---

time and place.
? Cenesthetic hallucinations are unfounded sensations of altered states in bodily organs. Examples: a burning
sensation in the brain, a pushing sensation in the blood vessels.
? Hallucination - 1st symptom to go with treatment & the 1st symptom to reappear after resistance
Symptom clusters in Schizophrenia

--- Content provided by‍ FirstRanker.com ---

Positive symptoms
Negative symptoms
Disorganized symptoms
? Delusions
? Affective flattening

--- Content provided by⁠ FirstRanker.com ---

? Inappropriate affect
? Hallucinations
? Attentional impairment
? Disorganized behavior
? Avolition-apathy (lack of initiative

--- Content provided by‍ FirstRanker.com ---

? Thought disorder
associated with psychomotor
? Loosening of association
slowing)
? Asociality (social withdrawal)

--- Content provided by FirstRanker.com ---

? Alogia (lack of speech output)
? Anhedonia

? The delusions included in 1st rank symptoms are primary or autoconthous delusions - characteristic of
schizophrenia.

--- Content provided by FirstRanker.com ---

? Von-Gogh syndrome- is dramatic self-mutilation in schizophrenia (named after famous painter Von Gogh
who had cut his ear during active schizophrenia)
? Schizophrenia is thought to be due to a functional increase of dopamine at the postsynaptic receptor
? Other neurotransmitters ? serotonin, GABA, acetylcholine may also be involved
? PET scan: hypofrontality and decreased glucose utilization in the dominant temporal lobe

--- Content provided by FirstRanker.com ---

Pharmacological treatment
? First drug used with beneficial effect: Reserpine (not used now)
? Atypical or second generation antipsychotics - are more commonly used
? Atypical antipsychotics are more useful when negative symptoms are prominent
? Clozapine ? effective in patients who had no response to commonly used drugs

--- Content provided by FirstRanker.com ---

Prognosis
Good Prognosis
Poor Prognosis
Late onset > 35 years
Early onset < 20 years

--- Content provided by‍ FirstRanker.com ---

Obvious precipitating factors
No precipitating factors
Acute onset
Insidious onset
Good premorbid social, sexual &work histories

--- Content provided by‍ FirstRanker.com ---

Poor premorbid social, sexual & work histories
Short duration < 6 months
Chronic course > 2 years
Fat physique
Thin physique

--- Content provided by​ FirstRanker.com ---

Female sex
Male sex
Good social support
Poor social support
Married

--- Content provided by‌ FirstRanker.com ---

Single, divorced, or widowed
Family history of mood disorders
Family history of schizophrenia
Presence of depression
Absence of depression

--- Content provided by FirstRanker.com ---

Confusion, perplexity, disorientation
Flat or blunt affect
Positive symptoms
Negative symptoms
Neurological signs and symptoms

--- Content provided by FirstRanker.com ---

History of perinatal trauma /assaultiveness
Many relapses/No remissions in 3 years

---

Catatonic subtype
Disorganized, simple, undifferentiated, chronic
Paranoid ? intermediate prognosis

--- Content provided by⁠ FirstRanker.com ---

catatonic subtypes
Outpatient treatment
Long term hospitalization
Normal cranial CT scan
Evidence of ventricular enlargement

--- Content provided by‍ FirstRanker.com ---

Indications for ECT in schizophrenia
? Catatonic stupor
? Uncontrolled catatonic excitement
? Acute exacerbation not controlled with drugs

--- Content provided by‍ FirstRanker.com ---

? Severe side effect with drugs, in presence of untreated schizophrenia

Psychosurgery
? Very rarely performed
? Limbic leucotomy -- is the procedure of choice

--- Content provided by⁠ FirstRanker.com ---

Acute (brief) psychotic disorder
? Differentiated from other related disorders by its sudden onset, relatively short duration (< 1 month), and
the full return of functioning
? Abrupt onset of one or more of the following symptoms
o

--- Content provided by​ FirstRanker.com ---

Delusions
o
Hallucinations
o
Bizarre behavior and posture

--- Content provided by⁠ FirstRanker.com ---

o
Disorganized speech

---

VI.

--- Content provided by FirstRanker.com ---

ANXIETY & STRESS RELATED DISORDERS

TYPES OF ANXIETY DISORDERS (DSM-IV-TR)
? Panic disorder with or without agoraphobia
? Agoraphobia with or without panic disorder

--- Content provided by​ FirstRanker.com ---

? Specific phobia
? Social phobia
? Obsessive-compulsive disorder (OCD)
? Posttraumatic stress disorder (PTSD)
? Acute stress disorder

--- Content provided by⁠ FirstRanker.com ---

? Generalized anxiety disorder

Anxiety
? It is the most common psychiatric symptom
? Physical symptoms

--- Content provided by‌ FirstRanker.com ---

o
Motor: tremors, muscle twitching
o
Autonomic and visceral: sweating, palpitation, tachycardia, flushes, hyperventilation, dry mouth,
dizziness, diarrhea, mydriasis

--- Content provided by​ FirstRanker.com ---

? Psychological symptoms
o
Cognitive: poor concentration, hyperarousal, vigilance or scanning, negative automatic thoughts
o
Perceptual: derealisation, depersonalization

--- Content provided by FirstRanker.com ---

o
Affective: fearfulness, irritability, inability to relax, fear of impending
o
Others: insomnia, increased sensitivity to noise, exaggerated startle response

--- Content provided by⁠ FirstRanker.com ---

DIFFERENTIAL DIAGNOSIS OF ANXIETY:
Medical Illnesses
Substance Use/Abuse
Psychiatric Disorders
Cardiac

--- Content provided by‌ FirstRanker.com ---

Endocrinologic
Prescription or over-the-
? Adjustment
counter drug use
disorders

--- Content provided by​ FirstRanker.com ---

? Angina
? Hyperthyroidism
? Antidepressants
? Affective disorder
? Arrhythmias

--- Content provided by​ FirstRanker.com ---

? Cushing's disease
? Fenfluramine/phentermine
? Dissociative
disorders
? Congestive failure

--- Content provided by FirstRanker.com ---

? Hyperparathyroidism
? Psychostimulants (eg,
? Infarction
? Hypoglycemia
methylphenidate,

--- Content provided by FirstRanker.com ---

? Personality
amphetamine)
disorders
? Mitral valve
? Premenstrual

--- Content provided by​ FirstRanker.com ---

prolapse
? syndrome
? Steroids
? Somatoform
disorders

--- Content provided by‌ FirstRanker.com ---

? Paroxysmal atrial
? Sympathomimetics
tachycardia
? Schizophrenia
(and other

--- Content provided by FirstRanker.com ---

psychotic
disorders)
Neoplastic
Neurologic
Substance abuse

--- Content provided by‍ FirstRanker.com ---

? Carcinoid
? Huntington's disease
? Alcohol/sedative
? Insulinoma
? Meniere's disease

--- Content provided by FirstRanker.com ---

withdrawal
? Pheocromocytoma
? Migraine
? Caffeine
? Multiple sclerosis

--- Content provided by‍ FirstRanker.com ---

? Hallucinogen
? Seizure disorder
? Stimulant abuse (eg,
? Transient ischemic
cocaine)

--- Content provided by‍ FirstRanker.com ---

attack
? Vertigo
? Wilson's disease
Pulmonary
Other

--- Content provided by​ FirstRanker.com ---

---

? Asthma
? Porphyria
? Embolism
? Uremia
? Obstruction

--- Content provided by⁠ FirstRanker.com ---

? Obstructive
? pulmonary
disease

PANIC DISORDER

--- Content provided by​ FirstRanker.com ---

Panic attacks
? Occur in panic disorder, specific phobia, social phobia and PTSD
? Unexpected panic attacks occur at any time and are not associated with identifiable situational stimulus
? A discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop
abruptly and reached a peak within 10 minutes.

--- Content provided by‍ FirstRanker.com ---

o
Palpitations, pounding heart, or accelerated heart rate
o
Sweating
o

--- Content provided by‌ FirstRanker.com ---

Trembling or shaking
o
Sensations of shortness of breath or smothering
o
Feeling of choking

--- Content provided by‍ FirstRanker.com ---

o
Chest pain or discomfort
o
Nausea or abdominal distress-
o

--- Content provided by‌ FirstRanker.com ---

Feeling dizzy, unsteady, lightheaded, or faint
o
Derealization or depersonalization
o
Fear of losing control or going crazy

--- Content provided by⁠ FirstRanker.com ---

o
Fear of dying
o
Paresthesias (numbness or tingling)
o

--- Content provided by⁠ FirstRanker.com ---

Chills or hot flashes

Panic disorder
? Recurrent panic attacks
? Extreme fear and sense of impending death and doom

--- Content provided by‌ FirstRanker.com ---

? Patients usually cannot name the source of their fear
? Generally lasts 20-30 minutes
? Depression and depersonalization may be seen
? Mental status examination: rumination, difficulty speaking, impaired memory
? Between attacks they have anticipatory anxiety about another attack

--- Content provided by‌ FirstRanker.com ---

PHOBIA
? Insight is present.
? Agoraphobia
o

--- Content provided by‌ FirstRanker.com ---

Fear of open places, crowded places or any place from where there is no escape to safe place
o
Most common & most disabling type
o
More common in women

--- Content provided by⁠ FirstRanker.com ---

o
Only one or two persons are relied upon - phobia companions.
? Social phobia ? irrational fear of activities or social interaction
o
Shy-Bladder: fear of urinating in public lavatory

--- Content provided by​ FirstRanker.com ---

o
Erythro phobia: Fear of blushing.
? Simple (specific) phobia ? irrational fear of objects or situations
o
Claustro phobia- Fear of closed spaces

--- Content provided by⁠ FirstRanker.com ---

o
Acrophobia ? fear of high places.
o
Algophobia ? fear of pain
o

--- Content provided by‍ FirstRanker.com ---

Arachnophobia- fear of spiders
o
Xeno phobia ?fear of strangers
o
Zoophobia ? fear of animals

--- Content provided by‍ FirstRanker.com ---

o
Sito phobia - fear of eating
o
Thanatophobia ? fear of death

---

o

--- Content provided by⁠ FirstRanker.com ---

Cynophobia: fear of dogs
o
Mysophobia: fear of dirt & germs
o
Pyrophobia: fear of fire

--- Content provided by FirstRanker.com ---

o
Ailurophobia: fear of cats
Behavior therapy for phobia
? Flooding
? Systematic desensitization

--- Content provided by⁠ FirstRanker.com ---

? Exposure and response prevention
? Relaxation techniques
OBSESSIVE COMPULSIVE DISORDER
? Prevalence in the world 2-3%

--- Content provided by⁠ FirstRanker.com ---

Obsessions
Compulsions
? An idea, impulse or image which intrudes into
? A form of behaviour which usually follows
the conscious awareness repeatedly

--- Content provided by FirstRanker.com ---

obsessions
? It is recognized as one's own idea, but perceived
? It is aimed at preventing or neutralizing the distress
as ego-alien (foreign to one's personality)
or fear arising out of obsession

--- Content provided by​ FirstRanker.com ---

? It is recognized as irrational and absurd (insight
? The behaviour is not realistic and is either irrational
present)
or excessive
? Patient tries to resist but is unable to

--- Content provided by‌ FirstRanker.com ---

? Insight is present
? Failure to resist leads to marked distress
? The behaviour is performed with a sense of
subjective compulsion (urge or impulse to act)

--- Content provided by FirstRanker.com ---

Delusion is differentiated from obsession by
? The thought is not recognized as ego-alien
? The thought is not recognized as irrational
? The thought is never resisted

--- Content provided by FirstRanker.com ---

Clinical Manifestations
? Washers
o
Most common type
o

--- Content provided by‍ FirstRanker.com ---

Obsession is of contamination with dirt, germs
o
Compulsion -- washing hands or body repeatedly, many times a day
o
Spreads on to washing clothes, bathroom, bedroom, personal articles etc

--- Content provided by‌ FirstRanker.com ---

? In all cases obsessive-compulsive activities take up >1 hour per day
? Depression is very commonly associated with OCD
? The disorder usually has a waxing and waning course
Psychodynamic theory of Freud
? Explains OCD by a defensive regression to anal-sadistic phase of development

--- Content provided by⁠ FirstRanker.com ---

? New defences are needed as reaction formation is not enough
? Isolation of affect
Obsessive thoughts
? Undoing
Compulsive acts

--- Content provided by FirstRanker.com ---

? Displacement
Phobias

Treatment of choice:
? First: Behavior therapy - Exposure & response prevention

--- Content provided by⁠ FirstRanker.com ---

? Second: Systematic desensitization
Medical treatment:
? Fluoxetine (Drug of choice) & other SSRI
? Fluvoxamine: Specific anti-obsession actions.
? Clomipramine (this TCA is most selective for serotonin reuptake) (Drug of IInd choice)

--- Content provided by⁠ FirstRanker.com ---

---

POST --TRAUMATIC STRESS DISORDER (PTSD)
? Arises as a delayed/protracted response to an exceptionally stressful or catastrophic life event or situation
(e.g. war, rape, torture, serious accident)
? Recurrent and intrusive recollections of the stressful event either in flashbacks (image, thoughts or
perceptions) and/or in dreams

--- Content provided by FirstRanker.com ---

? Avoidance of the events or situations that arouse recollections of the stressful event
? Numbing of general responsiveness
? Amnesia for some aspects of the event
? Anhedonia (inability to experience pleasure)
? Hyperarousal

--- Content provided by‌ FirstRanker.com ---

DSM-IV-TR definitions
? Acute stress disorder: symptoms appear within 4 weeks of the event and remits within 2 days to 4 weeks
? PTSD: occurs after 4 weeks of a stressful event and duration of symptoms > 1 month
? Delayed onset PTSD: occurs after 6 months
? Acute PTSD - duration of symptoms < 3 months; chronic PTSD: duration - > 3 months

--- Content provided by‍ FirstRanker.com ---

Treatment
? SSRIs
? MAO inhibitors
? Benzodiazepines
? Behavior therapy, cognitive therapy

--- Content provided by⁠ FirstRanker.com ---

---

VII.
MOOD DISORDERS

--- Content provided by FirstRanker.com ---

MOOD DISORDERS
? Manic episode
? Depressive episode
? Bipolar mood disorder
? Recurrent depressive disorder

--- Content provided by​ FirstRanker.com ---

? Persistent mood disorder

MANIC EPISODE Symptoms should last for atleast 1 week for diagnosis
? Elevated, Expansive or Irritable mood:
o

--- Content provided by‍ FirstRanker.com ---

Euphoria: mild elevation of mood, seen in hypomania [STAGE-1]
o
Elation: moderate elevation of mood, seen in mania (STAGE-2]
o
Exaltation: severe elevation of mood, seen in severe mania [STAGE-3]

--- Content provided by⁠ FirstRanker.com ---

o
Ecstasy: very severe elevation of mood, seen in delirious/ stuporous mania [STAGE-4]
? Psychomotor activity
o
Increased

--- Content provided by‌ FirstRanker.com ---

o
Rarely - manic stupor
? Speech and though
o
Flight of ideas

--- Content provided by‌ FirstRanker.com ---

o
Prolixity
o
Mood congruent psychotic features
o

--- Content provided by‌ FirstRanker.com ---

hallucinations
? Goal directed activity
? Reduced sleep

Treatment:

--- Content provided by⁠ FirstRanker.com ---

? Atypical antipsychotics (Risperidone, olanzapine, quetiapine, haloperidol)
? Mood stabilizers (Sodium valproate, Carbamazepine, Benzodiazepines, Lithium, Lamotrigine)

DEPRESSION Diagnostic Criteria
A. At least 2 weeks of duration

--- Content provided by‌ FirstRanker.com ---

B. > 5 features should be present most of the day
? Depressant mood
? Loss of interest/pleasure (Absence of pleasure in normally pleasurable environment: Anhedonia) (Among
these two, one is essential for the diagnosis), plus
? Decrease or increase in appetite or significant weight loss/ gain

--- Content provided by​ FirstRanker.com ---

? Decrease / increase psychomotor activity (psychomotor retardation or agitation)
? Decrease / increase sleep (Insomnia/ hypersomnia)
? Fatigue
? Feeling of worthlessness or guilt
? Decreased concentration

--- Content provided by‍ FirstRanker.com ---

? Recurrent thoughts of death.

Depressive ideation/Cognition:
? Sadness of mood (depression) is usually associated with pessimism, which can result in
o

--- Content provided by​ FirstRanker.com ---

Hopelessness
o
Helplessness
o
Worthlessness

--- Content provided by⁠ FirstRanker.com ---

? Difficulty in thinking, concentration, indecisiveness
? Nihilistic delusions (e.g: world is coming to an end)

---

Somatic syndrome (Melancholia) in depression

--- Content provided by​ FirstRanker.com ---

? Significant decrease in appetite or weight
? Early morning awakening (atleast 2 hours early than the usual time)
? Diurnal variation (depression worst in the morning)
? Pervasive loss of interest and loss of reactivity to pleasurable stimuli
? Psychomotor agitation or retardation

--- Content provided by‍ FirstRanker.com ---

Other features
? Pseudo-dementia
? Otto veraguth fold
? Depression is seen in - Myxedema, AIDS, Cancer, post MI, surgery & post-partum
? Depression is most common in middle age females

--- Content provided by⁠ FirstRanker.com ---

Theories
? Cognitive theory: Postulated by Aaron Beck consists of the following triad
o
About self - Negative self-precept
o

--- Content provided by FirstRanker.com ---

About the environment - Tendency to experience the world as hostile and demanding
o
About the future -- the expectation of suffering and failure
? Learned helplessness theory
Sleep studies

--- Content provided by⁠ FirstRanker.com ---

? Decreased REM latency (the time between falling asleep and the first REM period is decreased)
? Increased duration of the first REM period
? Delayed sleep onset
SUICIDE
? Suicide is intentional self-destruction.

--- Content provided by FirstRanker.com ---

? The term parasuicide refers to suicidal attempts or gestures.
? Patients suffering from severe depression with suicidal intent or attempt have a marked decrease in the
serotonergic function
? Official suicide rate in India in 2008 -- 10.8 per 100000 population per year
? Most common mode of committing suicide -- ingestion of poison (35%) hanging (32%)

--- Content provided by‍ FirstRanker.com ---

? The psychiatric disorder with greatest risk of suicide in both sexes -- Mood disorder
? Widely accepted theory for suicide:
o
Sociological factors: Durkheim's Theory:
Egoistic suicide applies to those who are not strongly integrated into any social group

--- Content provided by‍ FirstRanker.com ---

Altruistic suicide applies to those susceptible to suicide stemming from their excessive integration
into a group, with suicide being the outgrowth of the integration., for example, a soldier who
sacrifices his life in battle.
Anomic suicide applies to persons whose integration into society is disturbed so that they cannot
follow customary norms of behavior.

--- Content provided by​ FirstRanker.com ---

o
Psychological Factors: Freud's Theory/ Menninger's Theory

Evaluation of Suicide Risk

--- Content provided by‌ FirstRanker.com ---

Variable
High Risk
Low Risk
Demographic and Social Profile
Age

--- Content provided by‍ FirstRanker.com ---

Over 45 years
Below 45 years
Sex
Male
Female

--- Content provided by‍ FirstRanker.com ---

Marital status
Divorced or widowed
Married
Employment
Unemployed

--- Content provided by FirstRanker.com ---

Employed
Interpersonal relationship Conflictual
Stable
Family background
Chaotic or conflictual

--- Content provided by⁠ FirstRanker.com ---

Stable
Health

---

Physical
Chronic illness
Good health

--- Content provided by FirstRanker.com ---

Hypochondriac
Feels healthy
Excessive substance intake
Low substance use
Mental

--- Content provided by​ FirstRanker.com ---

Severe depression
Mild depression
Psychosis
Neurosis
Severe personality disorder

--- Content provided by FirstRanker.com ---

Normal personality
Substance abuse
Social drinker
Hopelessness
Optimism

--- Content provided by‍ FirstRanker.com ---

Suicidal activity
Suicidal ideation
Frequent, intense, prolonged
Infrequent, low intensity, transient
Suicide attempt

--- Content provided by FirstRanker.com ---

Multiple attempts
First attempt
Planned
Impulsive
Rescue unlikely

--- Content provided by‍ FirstRanker.com ---

Rescue inevitable
Unambiguous wish to die
Primary wish for change
Communication internalized (self-
Communication externalized (anger)

--- Content provided by​ FirstRanker.com ---

blame)
Method lethal and available
Method of low lethality or not readily
Resources
available

--- Content provided by‌ FirstRanker.com ---

Personal
Poor achievement
Good achievement
Poor insight
Insightful

--- Content provided by‍ FirstRanker.com ---

Affect unavailable/ poorly
Affect available and appropriately controlled
Social
co
P n

--- Content provided by FirstRanker.com ---

o t
o r
r o
r ll
a e

--- Content provided by​ FirstRanker.com ---

p d
p ort
Good rapport
Socially isolated
Socially integrated

--- Content provided by​ FirstRanker.com ---

Unresponsive family
Concerned family

Risk Factors
? Age> 40 years

--- Content provided by‍ FirstRanker.com ---

? Male sex
? Staying single
? Previous suicidal attempts
? Suicidal pre occupation (e.g. a written suicidal note)
? Depression

--- Content provided by‌ FirstRanker.com ---

? Alcohol/ drug dependence
? Severe/ painful physical illness
? Recent serious loss or major stressful event
? Social isolation
? High degree of impulsivity

--- Content provided by‍ FirstRanker.com ---

Risk factors for suicide in depression
? Early stages of depression
? Recovering from depression
? With mood disorder, personality disorder, psychosis, hypochondriac
? Child with conduct disorder or substance abuse

--- Content provided by⁠ FirstRanker.com ---

? 45 years male, unemployed, single, separated, divorced, widowed, recently bereaved, chronically ill
? Positive family history
Treatment
? Tricyclic anti-depressants: imipramine, amitriptyline
? SSRIs: fluoxetine, sertraline, citaprolam

--- Content provided by‍ FirstRanker.com ---

? SNRIs: venlafaxine, duloxetine

---

Neurotransmitters
? Mania: increased norepinephrine at the synaptic cleft

--- Content provided by‌ FirstRanker.com ---

? Depression: decreased norepinephrine and/or 5-HT

BIPOLAR MOOD DISORDER
? Previous called as Manic depressive psychosis (MDP)
? Unpredictable swings in mood from mania to depression at different times

--- Content provided by FirstRanker.com ---

? In the intervening period, patient may be normal
o
Bipolar-1: episodes of severe mania and depression.
o
Bipolar-2: episodes of hypomania and severe depression

--- Content provided by​ FirstRanker.com ---

? Rapid cyclers: > 4 episodes per year; mostly women
? Ultra-rapid cycling: episodes of mania and depression alternate very rapidly (in hours or days)

Good prognostic factors
Poor prognostic factors

--- Content provided by⁠ FirstRanker.com ---

? Acute or abrupt onset
? Comorbid medical disorder, personality disorder or
? Typical clinical features
alcohol dependence
? Severe depression

--- Content provided by FirstRanker.com ---

? Double depression (acute depressive episode
? Well-adjusted premorbid
superimposed on chronic depression or dysthymia)
personality
? Catastrophic stress or chronic ongoing stress

--- Content provided by​ FirstRanker.com ---

? Good response to treatment
? Unfavorable early environment
? Marked Hypochondriacal features
? Mood incongruent psychotic features
? Poor drug compliance

--- Content provided by FirstRanker.com ---

Other forms of depression
Atypical depression ? a term that has been applied to a variety of presentations, but particularly to patients
who present with mild to moderate depression, some mood reactivity, reverse diurnal variation in mood (i.e.
worse in the evening), overeating, hypersomnia and fatigue.

--- Content provided by​ FirstRanker.com ---

Dysthymia ? depressive symptoms which are insufficient to meet the criteria for a clinical depression. The
patient's symptoms are present for 2 or more years. Can be associated with other psychiatric conditions
such as borderline personality disorder. Sufferers often go on to develop more serious mood disorder.
Cyclothymic disorder ? chronic mood fluctuations over at least 2 years with episodes of elation and of
depression insufficient to meet the criteria for a hypomanic depressive episode.

--- Content provided by FirstRanker.com ---

Masked depression ? a state in which depressed mood is not particularly prominent, but other features of
depressive disorder are present, e.g. sleep disturbance, diurnal mood variation, depressive cognitions.
Mild depressive disorders ? milder forms of the symptoms of depression, with less disruption to social
functioning. These are likely to be accompanied by prominent anxiety, phobic or obsessional symptoms.
Recurrent brief depressive disorder ? lasts for <2 weeks, usually around 2-3 days. Occurs around once per

--- Content provided by‍ FirstRanker.com ---

month, with complete recovery between episodes. The actual symptoms collectively may fulfil the criteria
for mild, moderate or severe depression, but the difference is in the duration of the episode.
SAD ? a temporal relationship between the season of the year and the onset of depression. The depression
starts in autumn/winter and resolves in spring/ summer. There may be symptoms of depression and
additional atypical biological features such as carbohydrate craving, fatigue and hypersomnia.

--- Content provided by​ FirstRanker.com ---

Note:
Dysthymia ? if the symptoms consist of persistent mild depression
Cyclothymia ?frequent mood swings of mild depression and mild elation.

--- Content provided by‌ FirstRanker.com ---

---

VIII.
SOMATOFORM, DISSOCIATIVE & PERSONALITY DISORDERS

Type of Somatoform Disorder

--- Content provided by​ FirstRanker.com ---

Features
Hypochondriasis
? Persistent preoccupation with fear or belief of having serious
disease based on own interpretation
? Detailed physical examination and investigations do not reveal

--- Content provided by⁠ FirstRanker.com ---

any abnormality
? Belief persists even after seeing his normal lab reports
? The fear or belief is not a delusion
Somatization disorder or
? Multiple somatic symptoms

--- Content provided by​ FirstRanker.com ---

Briquet Disorder or
? 4 pain symptoms (2 in GIT, 1 sexual, 1 pseudo neurological)
Brissaud Marie Syndrome
? Atleast 2 years duration needed for diagnosis
? Frequent change of treating physicians

--- Content provided by‌ FirstRanker.com ---

? Refusal to accept reassurance
? More common in females
Conversion disorder
Features common to Conversion and Dissociative disorders
? Symptoms/sign affecting motor or

--- Content provided by​ FirstRanker.com ---

? Sudden onset
sensory function or convulsions
? Presence of precipitating stress
suggesting a neurological disorder
? Clear temporal relationship between stressor and development

--- Content provided by‌ FirstRanker.com ---

? No ANS involvement
of symptoms
? Not intentionally produced
? There is usually a secondary gain
? Detailed physical examination and investigations do not reveal

--- Content provided by​ FirstRanker.com ---

any abnormality that can explain the symptoms adequately
Dissociative disorder
? More common in women
? Disturbance in normally integrated
functions of consciousness,

--- Content provided by FirstRanker.com ---

? Onset usually in 2nd or 3rd decade
identity and/or memory
Body dysmorphic disorder
Preoccupation with an imagined defect in appearance.
Somatoform pain disorder

--- Content provided by‌ FirstRanker.com ---

Pain does not vary in intensity & insensitive to emotional, cognitive
attentional & situational influence.

? The word Hysteria is removed from ICD-10 and replaced by 'Conversion and Dissociative disorders'
Dissociative disorders

--- Content provided by‌ FirstRanker.com ---

DISSOCIATIVE AMNESIA
? Circumscribed amnesia (M/C form) - failure to recall all events occurring during a circumscribed period of
time.
? Selective amnesia - failure to recall some but not all of the events during a circumscribed period of time.
? Continuous amnesia -- failure to recall all personal events following a stressful event, till the present time

--- Content provided by‌ FirstRanker.com ---

? Generalized amnesia - failure of recall all personal events of the whole life, in the face of a stressful life
event
? Systematized amnesia is a loss of memory for specific categories of information, such as all memory relating
to one's family or a particular person.

--- Content provided by‍ FirstRanker.com ---

DISSOCIATIVE FUGUE
? Episodes of wandering away (usually away from home)
? During the episode, the person usually adopts a new identity with complete amnesia for the earlier life
? Sudden onset, often in the presence of severe stress
? Abrupt termination of the episode and followed by amnesia for the episode with recovery of memories of

--- Content provided by FirstRanker.com ---

earlier life
? The characteristic feature ? assumption of a purposeful new identity, with absence of awareness of
amnesia
? Complex partial seizures ? no assumption of new identity, confusion present during the episode, no
precipitating stress

--- Content provided by​ FirstRanker.com ---

---

Clinical features
Epileptic seizures
Dissociative convulsions (Hysterical fits )
Attack pattern
Stereotyped, known clinical patterns

--- Content provided by⁠ FirstRanker.com ---

Absence of any established clinical pattern
Purposive body movements occur
Place of occurrence
Any where
Usually indoor or at safe places

--- Content provided by‍ FirstRanker.com ---

Sleep
Can occur during sleep
Never occur during sleep
Tongue bite
Present

--- Content provided by​ FirstRanker.com ---

Absent
Incontinence of
Present
Absent
urine and faeces

--- Content provided by‍ FirstRanker.com ---

Neurological signs
Present
Absent
Post ictal confusion
Present

--- Content provided by‌ FirstRanker.com ---

Absent
Injury
Can occur
Very rare
Speech

--- Content provided by⁠ FirstRanker.com ---

No verbalization during seizure
Verbalization can occur during seizure
Duration
Short (30 ? 70 secs)
Prolonged

--- Content provided by⁠ FirstRanker.com ---

Head turning
Unilateral
Side to side
Eye gaze
Staring, if eyes are open

--- Content provided by⁠ FirstRanker.com ---

Avoidant gaze
Amnesia
Complete
Partial
EEG

--- Content provided by​ FirstRanker.com ---

Abnormal
Normal
Serum prolactin
Increased in post ictal period (15-20
Normal

--- Content provided by‌ FirstRanker.com ---

minutes after seizure, returns to
normal in one hour)

GANSER SYNDROME (HYSTERICAL PSEUDODEMENTIA)
? Commonly found in prison inmates

--- Content provided by‌ FirstRanker.com ---

? Characteristic feature ? vorbeireden (approximate answers)
? The answers are wrong, but show that the person understands the nature of question asked

La Belle Indifference
? Patient's lack of concern towards serious symptoms, despite the apparent severity of the disability produced

--- Content provided by⁠ FirstRanker.com ---

? Previously thought as hallmark of dissociative (conversion) disorders, it is now known to be present even in
physical illness
Treatment of conversion and dissociative disorders
? Aversion therapy (liquor ammonia, electrical stimulus, pressure just above eyeballs or tragus of ear etc)
? Psychotherapy with abreaction

--- Content provided by FirstRanker.com ---

PERSONALITY
? The four components in the concept of personality are:
? Adjustment
? Agreeableness
? Sociability

--- Content provided by FirstRanker.com ---

? Openness
PERSONALITY DISORDERS
? Cluster A (paranoid, schizoid, schizotypal), which includes individuals who are odd or eccentric.
? Cluster B (antisocial, borderline, histrionic, narcissistic), which includes individuals with dramatic, acting-out
behaviors and who have problems with empathy.

--- Content provided by FirstRanker.com ---

? Cluster C (avoidant, dependent, obsessive-compulsive), which includes personality styles marked by
prominent anxiety and novelty avoidance.

---

DSM-IV-TR and ICD-10 classifications of personality disorder

--- Content provided by‌ FirstRanker.com ---

DSM-IV-TR
ICD-10
Description
Paranoid

--- Content provided by‌ FirstRanker.com ---

Paranoid
Excessive sensitiveness, tendency to bear grudges persistently,
suspiciousness, preoccupied with conspiratorial explanations, self-
referential, distrust of others.
Schizoid

--- Content provided by​ FirstRanker.com ---

Schizoid
Emotional coldness, lack of pleasure from activities, little interest
in sex, excessive preoccupation with introspection and fantasy.
Schizotypal
(classified with

--- Content provided by​ FirstRanker.com ---

Inappropriate affect, odd, eccentric or peculiar behavior, social
schizophrenia and
withdrawal, magical thinking, obsessive ruminations, transient
related disorders)
quasi-psychotic episodes

--- Content provided by‍ FirstRanker.com ---

Antisocial
Dissocial
Callous lack of concern for others, irresponsibility, aggression,
inability to maintain enduring relationships, disregard and
violation social norms, evidence of childhood conduct disorder.

--- Content provided by⁠ FirstRanker.com ---

Borderline
Emotionally unstable--
Disturbance of identity, unstable relationships, unpredictable
borderline type
affect, acts of self-harm, suicidal gestures, impulsivity, unstable

--- Content provided by FirstRanker.com ---

emotions
Histrionic
Histrionic
Self-dramatization, exaggerated emotions, shallow affect, attention
seeking, easily influenced by others, over-concern for physical

--- Content provided by FirstRanker.com ---

attractiveness
Narcissistic
Grandiosity, lack of empathy, need for admiration, preoccupation
with fantasies of unlimited success
Avoidant

--- Content provided by⁠ FirstRanker.com ---

Anxious (avoidant)
Tension, self-consciousness, fear of negative evaluation by others,
timid, insecure.
Obsessive-
Anankastic

--- Content provided by​ FirstRanker.com ---

Doubt, indecisiveness, caution, pedantry, rigidity, perfectionism,
compulsive
preoccupation with orderliness and control.
Dependent
Dependent

--- Content provided by‍ FirstRanker.com ---

Clinging, submissive, excess need for care, feels helpless when not
in relationship.

--- Content provided by FirstRanker.com ---

---

IX.
MISCELLANEOUS

EATING DISORDERS

--- Content provided by FirstRanker.com ---

ANOREXIA NERVOSA
? More often in females, Common age of onset is adolescence (13-19 years)
? It is seen with greatest frequency among young women in professions that require thinness (modeling and
ballet)
? Intense fear of becoming obese

--- Content provided by‌ FirstRanker.com ---

? There is often a body-image disturbance (inability to perceive size of body image correctly)
? Significant weight loss occurs, usually > 25% of the original weight.
? The final weight is usually 15% less than the minimum limit of normal weight (for that age, sex and height) or
a BMI of 17.5 or less
? No known medical illness, which can account for the weight loss, is present

--- Content provided by‌ FirstRanker.com ---

? Amenorrhea, primary or secondary, is often present
? Absence of primary psychiatric disorder
? Depressive symptoms are common and so are obsessive-compulsive personality traits.
? Anorexia (a misnomer) -- no decrease in appetite
? Poor sexual adjustment

--- Content provided by‍ FirstRanker.com ---

? In severe cases, fine lanugo hair may develop all over the body.
? Bulimic episodes
o
Rapid consumption of large amount of food in a relatively short period of time, usually occurring when
alone (binges or binge-eating)

--- Content provided by‌ FirstRanker.com ---

o
These binges are followed by intense guilt and attempts to remove eaten food, for example, by self-
induced vomiting, laxative abuse, and/or diuretic abuse
? Death may occur due to hypokalemia (caused by self-induced vomiting), dehydration, malnutrition or
congestive cardiac failure (caused by anemia)

--- Content provided by⁠ FirstRanker.com ---

BULIMIA NERVOSA
? Onset in early teens or adolescence
? Intense fear of becoming obese and h/o anorexia nervosa present sometimes
? There is often a body-image disturbance.
? There is a persistent preoccupation with eating and an irresistible craving for food.

--- Content provided by​ FirstRanker.com ---

? There are attempts to 'counteract' the effects of overeating by one or more of the following
o
Self-induced vomiting
o
Purgative abuse

--- Content provided by‍ FirstRanker.com ---

o
Periods of starvation
o
Use of drugs such as appetite suppressants.

--- Content provided by FirstRanker.com ---

FEATURES
ANOREXIA NERVOSA
BULIMIA NERVOSA
Feature
Refusal to maintain body

--- Content provided by‌ FirstRanker.com ---

Irresistible craving for food with episodes of
weight above a minimal normal over eating in less time (being eating)
Method of weight control
Very less eating
Attempts to counter act the effects of over

--- Content provided by‌ FirstRanker.com ---

eating
Weight
Markedly decreased
Usually normal
Binge eating

--- Content provided by‍ FirstRanker.com ---

25-50%
Required for diagnosis
Amenorrhea
100%
50%

--- Content provided by‌ FirstRanker.com ---

Ritualized exercise,
Common
Rare
decreased vitals (BP, PR),
hypothermia, skin changes

--- Content provided by‌ FirstRanker.com ---

(hirsutism)

---

Patient believes that their
-Dental caries are frequent
body as a whole, or some part

--- Content provided by⁠ FirstRanker.com ---

-Antisocial behavior &drug abuse is common
of their body, is too fat.
-Prognosis is worse

CULTURE BOUND SYNDROMES

--- Content provided by​ FirstRanker.com ---

? Dhat syndrome
fear of losing semen
? Amok
sudden, unprovoked episode of rage
? Koro

--- Content provided by‍ FirstRanker.com ---

strong belief that his penis is shrinking
? Wihtigo (windigo)
belief that he has been transformed to a cannibal.
? Pibloktoq
Arctic Hysteria

--- Content provided by‍ FirstRanker.com ---

Eskimos, extreme excitement of as long as 30 minutes' duration and
frequently followed by convulsive seizures and coma lasting as long as 12 hours
? Suchi-bai purity mania
? Hwa-Byung / Wool-Hwa-Byung: Korean folk syndrome [anger syndrome] and is attributed to the
suppression of anger.

--- Content provided by‍ FirstRanker.com ---

? Latah: hypersensitivity to sudden fright, often with echopraxia, echolalia, command obedience, and
dissociative or trance-like behavior.
? Locura: severe form of chronic psychosis [inherited vulnerability, the effect of multiple life difficulties, or a
combination of both factors]
? Mal de ojo: evil eye

--- Content provided by​ FirstRanker.com ---

? Ideas of nerves/Nervios: general state of vulnerability to stressful life experiences and to a syndrome
brought on by difficult life circumstances.

FACTITIOUS DISORDER (MUNCHAUSEN SYNDROME)
? Also known as hospital addiction, hospital hoboes, professional patients

--- Content provided by‌ FirstRanker.com ---

? Simulate or fake diseases for the sole purpose of obtaining medical attention.
? No other recognized motive.
? Pseudologia fantastica - distort their clinical histories, lab reports and even facts about their lives
? Drug abuse is common
? They have superficial knowledge of medical terms

--- Content provided by FirstRanker.com ---

? Evidence of earlier treatment, usually surgical procedures, is often found in the form of multiple scars (e.g:
grid iron abdomen)
? They often tell lies and leave the hospital against medical advise

SLEEP

--- Content provided by‍ FirstRanker.com ---

Two phases:
1.
D-Sleep (desynchronized or dreaming sleep) OR REM-sleep (rapid eye movement sleep), active sleep or
paradoxical sleep.
2.

--- Content provided by‌ FirstRanker.com ---

S-Sleep (synchronized sleep), or NREM ? sleep (non-REM sleep), quiet sleep, or orthodox sleep. S-sleep or
NREM-sleep is further divided into four stages, 1 to 4.
The EEG recording
? During the awake state shows alpha waves of 8-12 cycles/sec. frequency
? The onset of sleep is characterized by a disappearance of the alpha ? activity.

--- Content provided by‌ FirstRanker.com ---

? NREM ?sleep
o
Stage 1: first and the lightest stage of sleep, absence of alpha-waves, and low voltage, predominantly
theta activity.
o

--- Content provided by‍ FirstRanker.com ---

Stage 2: characterized by two typical EEG changes:
Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0
seconds, with a characteristic waxing and waning amplitude.
K-complexes: High voltage spikes present intermittently.
o

--- Content provided by‍ FirstRanker.com ---

Stage 3: appearance of high voltage, 751.1V, 6-waves of 0.5-3.0 cycles/sec.
o
Stage 4: predominant -activity

---

The important time periods of the various sleep stages
? In an 8 hour sleep, usually 6-61/2 hours are spent in NREM ?sleep & 11/2 ? 2 hours in REM-sleep.

--- Content provided by FirstRanker.com ---

? Out of 6-6112 hours NREM-sleep period, only about 70-80 minutes are spent in Stage 4 sleep.
? The maximum Stage 4 sleep occurs in the first one-third of the night
? In the later part, the REM-sleep follows the Stage 3 NREM ?sleep directly.
? REM-sleep occurs maximally in the last one-third of the night.
? REM-sleep occurs regularly after every 90-100 mins, with progressive lengthening of each REM period.

--- Content provided by‍ FirstRanker.com ---

? The first REM period typically lasts for less than 10 minutes.
? Usually, there are 4-5 REM periods in the whole night of sleep.
? The usual sleep duration in newborn children is 16-18 hours/day, with nearly 8-10 hours spent in the REM-
sleep.
DISORDERS OF SLEEP

--- Content provided by​ FirstRanker.com ---

Nightmares
? Almost always occur during REM sleep and usually after a long REM period late in the night.
? The awakening may occur during any part of the sleep period, but typically during the second half.
Sleep terror: Arousal in the first third of the night during deep NREM (stages III and IV) sleep.
Kleine Levin syndrome

--- Content provided by⁠ FirstRanker.com ---

? Recurrent periods of prolonged sleep (from which patients may be aroused) with intervening periods of
normal sleep and alert waking

PARASOMNIAS
? Sleep walking and sleep terrors

--- Content provided by​ FirstRanker.com ---

? Common in preschool (3-6years) children

Characteristic
Sleep walking
Sleep terrors

--- Content provided by⁠ FirstRanker.com ---

Night mares
Nocturnal seizures
Timing during sleep
First third
First third

--- Content provided by‍ FirstRanker.com ---

Last third
Variable, often during
sleep-wake transition
Stage of sleep
Slow wave

--- Content provided by​ FirstRanker.com ---

Slow wave
REM
Non REM > SWS
Arousal threshold
High

--- Content provided by‍ FirstRanker.com ---

High
Low
High
Day time sleepiness
None

--- Content provided by‌ FirstRanker.com ---

None
Yes
Probable
'
Recall of event

--- Content provided by‌ FirstRanker.com ---

None
None
Frequent, vivid
None
Incidence

--- Content provided by​ FirstRanker.com ---

Common
Rare
Very common
Rare
Family history

--- Content provided by FirstRanker.com ---

Common
Common
None
Variable

--- Content provided by⁠ FirstRanker.com ---

GENDER IDENTITY DISORDERS
? Common feature is a strong, persistent preference for living as a person of the other sex.
? Discontent with one's designated birth sex and a desire to have the body of the other sex, and to be
regarded socially as a person of the other sex.
? Gender identity disorder in adults

--- Content provided by⁠ FirstRanker.com ---

transsexualism.
? Cross-dressing is commonly known as transvestism, and the cross-dresser as a transvestite.

IMPULSE CONTROL DISORDERS
Kleptomania (pathological stealing)

--- Content provided by‍ FirstRanker.com ---

? Failure to resist the impulse to steal useless objects that have little monetary value.
? Usually women
? No apparent motive
? Usually there is a feeling of tension before the act and sense of relief afterwards
? Differential diagnosis: Shoplifting (actions are usually well-planned and motivated by need or monetary

--- Content provided by FirstRanker.com ---

gain)
Pyromania (pathological fire-setting)
? Deliberate and purposeful fire setting on two or more occasions

---

? No apparent motive
? 90% are male.

--- Content provided by‌ FirstRanker.com ---

Pathological Gambling : Two or more gambling episodes per year which have not profitable outcome
Trichotillomania: Recurrent pulling out of one's hair resulting in noticeable hair loss
Dipsomania ? irresistible urge to drink alcohol at regular intervals
Mutilomania ? irresistible urge to mutilate animals
?

--- Content provided by FirstRanker.com ---

De Clerambult's syndrome: Erotic delusions
?
Alice in Wonderland syndrome: Disturbance of one's view of self.
?
Couvade syndrome: experiencing the symptoms of pregnancy in males

--- Content provided by‌ FirstRanker.com ---

?
Kanner's syndrome is autism with a normal ICI.

Asperger's syndrome, or schizoid personality of childhood, may be a mild form of autism and comprises eccentric
isolated behavior with circumscribed interests and stilted speech:

--- Content provided by‌ FirstRanker.com ---

---

X.
TREATMENT MODALITIES

--- Content provided by​ FirstRanker.com ---

ANTIPSYCHOTIC DRUGS

TYPICAL (Neuroleptics, D2 blockers)
ATYPICAL
Phenothiazines

--- Content provided by‍ FirstRanker.com ---

Thioxanthines
Butyrophenones
Miscellaneous
Clozapine , Olanzapine
Quetiapine,

--- Content provided by⁠ FirstRanker.com ---

Chlorpromazine
Flupenthixol
Haloperidol
Pimozide
Risperidone

--- Content provided by FirstRanker.com ---

Thioridazine
Thiothixene
Droperidol
Loxapine
Ziprasidone,

--- Content provided by‍ FirstRanker.com ---

Trifluoperazine
Penfluridol
Iloperidone,
Fluphenazine
Lurasidone,

--- Content provided by⁠ FirstRanker.com ---

Aripiprazole,
Asenapine
? Longest acting: Fluphenazine (2-4 weeks), Penfluridol (1 week).
? Longest half- life: Aripiprazole (75 hours)
? Shortest half-life: Quetiapine (6 hours)

--- Content provided by FirstRanker.com ---

? Least potent: Chlorpromazine
? With antidepressant action: Flupenthixol.
? More emetic potential: Clozapine/ Olanzapine/ Risperidone/ Molindone
Actions
Extra pyramidal symptoms

--- Content provided by‌ FirstRanker.com ---

Sedation
Hypotension
Anti emetic
Maximum: Haloperidol
Maximum: Chlorpromazine,

--- Content provided by‌ FirstRanker.com ---

Maximum:
Triflupromazine,
Least: Thioridazine
Triflupromazine,
Thioridazine,

--- Content provided by⁠ FirstRanker.com ---

Trifluoperazine
Almost nil: Clozapine,
Thioridazine, Clozapine &
Clozapine &
Fluphenazine,

--- Content provided by‌ FirstRanker.com ---

Risperidone
Quetiapine
Risperidone
Haloperidol
? All anti psychotics are potent antiemetics except Thioridazine & atypical drugs.

--- Content provided by‍ FirstRanker.com ---

? Low potency drugs possess significant blocking (maximum with chlorpromazine) and anticholinergic
(maximum with thioridazine) properties.
? D2 receptors blockage in hypothalamus & pituitary
increase prolactin release
galactorrhoea &

--- Content provided by FirstRanker.com ---

amenorrhea.
? Aripiprazole: acts as a partial agonist at 5-HT1A and D2 receptors and antagonist at 5-HT2A receptors. It is
also known as dopamine- serotonin stabilizer.
? Ziprasidone: D2 +5-FIT2A/2c + H1- 1 blocker
? Thioridazine: interferes with ejaculation, can cause cardiac arrhythmias and retinal damage.

--- Content provided by​ FirstRanker.com ---

? Asenapine: used sublingually for schizophrenia & acute mania.
? Amisulpiride: congener of sulpiride (typical antipsychotic) is categorized with the atypical antipsychotics
because it produces few extrapyramidal side effects and improves many negative symptoms of
schizophrenia as well. However, it retains high affinity for D2 (and D3) receptors and has low-affinity for 5-
HT2 receptors.

--- Content provided by​ FirstRanker.com ---

Clozapine:
? Most potent with least extrapyramidal S.E. & least antiemetic property
? Has weak D2 blocking action
? Reserve drug for resistant schizophrenia
? Most important side effect is agranulocytosis.

--- Content provided by⁠ FirstRanker.com ---

SIDE EFFECTS
? Extra pyramidal symptoms are due to D2 blockade in limbic system.
? Perioral movements [Rabbit syndrome]
Within 7 days of starting or rapidly raising the dose of drugs -- Neuroleptic induced dystonia

---

Drugs is taken for less than 3 months (or 1 month if > 60 years), within 4 weeks of withdrawal from drug

--- Content provided by​ FirstRanker.com ---

-- Neurolept induced -- tardive dyskinesia.
? Neuroleptic induced akathisia
Inner restlessness (feeling of discomfort & agitation)
External restlessness (compulsion to move extremities, pacing, rocking, fidgety movements)
-Blocker (Propanolol) is the drug of choice.

--- Content provided by‌ FirstRanker.com ---

? NEUROLEPTIC MALIGNANT SYNDROME
More common with high potency D2 antagonists
Severe muscle rigidity & elevated temperature with diaphoresis (sweating), tachycardia, elevated or
labile BP, leucocytosis & lab
Evidence of muscle injury e.g. elevated CPK

--- Content provided by‍ FirstRanker.com ---

? Hyperprolactinemia is associated with blockade of D2 receptors in the tuberoinfundibular dopamine system
hypogonadism, infertility, amenorrhea, galactorrhoea and gynecomastia.
? Hyperprolactinemia is more common with typical antipsychotics and risperidone
Reaction
Features

--- Content provided by‍ FirstRanker.com ---

Time of
Mechanism
Treatment
maximal risk
Acute dystonia

--- Content provided by⁠ FirstRanker.com ---

Spasm of muscles of
1-5 days
Unknown
Anti parkinsonian agents
tongue, face, neck,

--- Content provided by‌ FirstRanker.com ---

are diagnostic
back, may mimic
and curative
seizures, not hysteria
Akathisia

--- Content provided by‌ FirstRanker.com ---

Motor restlessness,
5-60 days
Unknown
Reduce dose or change
not anxiety or agitation

--- Content provided by​ FirstRanker.com ---

drug; anti parkinsonian
drugs, BDZ / propranolol
may help
Parkinsonism
Bradykinesia, rigidity,

--- Content provided by‌ FirstRanker.com ---

5-30 days; can
Antagonism of
Anti parkinsonian
variable tremor, mask
recur even after dopamine

--- Content provided by‍ FirstRanker.com ---

agents helpful
facies, shuffling gait
a single
dose
Neuroleptic

--- Content provided by⁠ FirstRanker.com ---

Catatonia, stupor,
Weeks; can
Antagonism of
Stop neuroleptic;
malignant

--- Content provided by‍ FirstRanker.com ---

fever, unstable BP,
persist for days
dopamine
Dantrolene /
syndrome

--- Content provided by FirstRanker.com ---

myoglobinemia, can be
after stopping
bromocriptine may
fatal
neuroleptic

--- Content provided by FirstRanker.com ---

help. Anti parkinsonian
agents not useful
Perioral tremor "
Perioral tremor (may
After months

--- Content provided by⁠ FirstRanker.com ---

Unknown
Anti parkinsonian
rabbit syndrome"
be a late variant of
or years of

--- Content provided by FirstRanker.com ---

agents often help
parkinsonism)
treatment
Tardive dyskinesia
Oral- facial dyskinesia;

--- Content provided by‌ FirstRanker.com ---

After months
Excess function
Prevention crucial;
Widespread
or years of

--- Content provided by​ FirstRanker.com ---

of dopamine
Treatment
choreoathetosis or
treatment
hypothesized

--- Content provided by FirstRanker.com ---

unsatisfactory
dystonia
(worse on
withdrawal)
Adverse effect

--- Content provided by​ FirstRanker.com ---

Maximum with
Minimum with
Dry mouth, constipation, cycloplegia
Chlorpromazine
Haloperidol, Risperidone

--- Content provided by⁠ FirstRanker.com ---

Impotence, orthostatic hypotension
Chlorpromazine
Aripiprazole
Impaired ejaculation
Thioridazine

--- Content provided by‌ FirstRanker.com ---

Haloperidol
Parkinsonian features [tremor]
Haloperidol
Clozapine, quetiapine, aripiprazole
Akathisia, acute dystonia, rabbit

--- Content provided by‍ FirstRanker.com ---

Haloperidol
Clozapine, quetiapine
syndrome

---

Tardive dyskinesia
-

--- Content provided by FirstRanker.com ---

Clozapine
Neuroleptic malignant syndrome
Probably haloperidol
-
Seizures

--- Content provided by‌ FirstRanker.com ---

Clozapine, chlorpromazine
Trifluperazine
Sedation
Clozapine, chlorpromazine
Haloperidol , aripiprazole

--- Content provided by⁠ FirstRanker.com ---

Weight gain
Clozapine , olanzapine
Haloperidol , aripiprazole
Diabetes
Clozapine , olanzapine

--- Content provided by⁠ FirstRanker.com ---

Ziprasidone, aripiprazole
Agranulocytosis
Clozapine
-
ECG changes

--- Content provided by​ FirstRanker.com ---

Thioridazine, pimozide
Aripiprazole
Ocular granular deposits
Chlorpromazine
Haloperidol

--- Content provided by‍ FirstRanker.com ---

Pigmentary retinopathy
Thioridazine
-
Contact dermatitis, photosensitive
Chlorpromazine

--- Content provided by‌ FirstRanker.com ---

-
reactions, Blue- gray metallic
discoloration
ANTI ANXIETY DRUGS
? Reduction in the GABAergic activity or increase in serotonergic activity

--- Content provided by‌ FirstRanker.com ---

anxiety.

BENZODIAZEPINES
? Chlordiazepoxide is used for chronic anxiety states
? Oxazepam, lorazepam, alprazolam and diazepam for short lasting anxiety.

--- Content provided by​ FirstRanker.com ---

AZAPIRONES
? Buspirone, gepirone and ipsapirone (partial agonists of presynaptic 5-HT1A)
decrease the release of
serotonin.

--- Content provided by‌ FirstRanker.com ---

? Sedation, cognitive impairment, abuse potential, muscle relaxant, anticonvulsant activity are not seen
? Ineffective in acute anxiety states like panic attacks.
? These are indicated for mild to moderate generalized anxiety states.
BETA BLOCKERS - Propranolol is indicated for performance anxiety.
Other drugs

--- Content provided by‌ FirstRanker.com ---

? Hydroxyzine is H1 antihistaminic having anti-anxiety activity but profound sedation limits its usefulness.
? SSRIs like Fluoxetine - agent of choice for acute conditions like panic attacks.
ANTI-DEPRESSANTS
ANTIDEPRESSANTS/ MOOD ELEVATORS/ THYMOLEPTICS:

--- Content provided by​ FirstRanker.com ---

Cyclic anti-
Tricyclic tertiary amines
Imipramine, amitriptyline, doxepine,
depressants
Clomipramine, Dothiepine [Dosulepin]

--- Content provided by‍ FirstRanker.com ---

Tricyclic secondary amines
Nortriptyline, protriptyline, desipramine
Tetracyclic
Mianserin, maprotiline, amoxapine
Bicyclic

--- Content provided by⁠ FirstRanker.com ---

Viloxazine
Selective serotonin reuptake inhibitor [SSRIs]
Fluoxetine, paroxetine, fluvoxamine,
sertraline, citalopram, escitalopram
Serotonin norepinephrine reuptake inhibitors [SNRIs]

--- Content provided by⁠ FirstRanker.com ---

Venlafaxine, duloxetine
Norepinephrine serotonin reuptake enhancers [NSRE's]
Tianeptin
Noradrenergic and specific serotonergic antidepressant [NaSSA]
Mirtazepine

--- Content provided by⁠ FirstRanker.com ---

Norepinephrine dopamine reuptake inhibitors [NDRIs]
Bupropion
Serotonin antagonists and reuptake inhibitors [SARIS]
Trazadone, nefazodone

---

Noradrenergic reuptake inhibitors [NARIs]

--- Content provided by FirstRanker.com ---

Reboxetine
Mono amine
Irreversible
oxidase
Reversible

--- Content provided by‍ FirstRanker.com ---

MAGI-B
Selegiline
inhibitors
MAGI-A
Moclobemide

--- Content provided by⁠ FirstRanker.com ---

? Bupropion's most potent blocker of DA reuptake, indicated for cessation of smoking.
? Venlafaxine is a potent inhibitor of NE reuptake and a weak inhibitor of DA reuptake.
? Mirtazapine enhances central noradrenergic and serotonergic activity through the antagonism of central
presynaptic 2-adrenergic autoreceptors and heteroreceptors.
? St John's Wart, an herbal over-the-counter medication, may be effective for mild to moderate depression,

--- Content provided by‌ FirstRanker.com ---

but it is associated with several drug interactions.
? Maprotiline and Amoxapine are inhibitors of NE reuptake, with less effect on 5-HT reuptake.
NOTE:
? Other noradrenaline reuptake inhibitors: atomoxetine
? Most potent blocker of 5-HT reuptake ? Paroxetine

--- Content provided by‍ FirstRanker.com ---

? Least potent blocker of 5-HT reuptake ? Bupropion
? Most potent blocker of NA reuptake ? Desipramine
? Least potent blocker of NA reuptake ? Mirtazapine
? Most selective inhibitor of 5-HT reuptake ? Escitalopram
? Most selective inhibitor of DA reuptake ? Bupropion

--- Content provided by FirstRanker.com ---

? Most selective inhibitor of NA reuptake ? Oxaprotiline
? Maximum antimuscarinic activity ? Amitriptyline
? Maximum antihistaminic activity ? Nefazodone
? Maximum 1 blocking activity ? Doxepin
? Minimum antimuscarinic, 1 blocking and antihistaminic activity ? Venlafaxine

--- Content provided by​ FirstRanker.com ---

? Doxepin contains high antimuscarinic, antihistaminic and ? blocking (maximum) activities.
? Fluoxetine is longest acting and nefazodone is shortest acting antidepressant.
? Amoxapine: chemically related to the antipsychotic drug loxapine, has mixed antidepressant +neuroleptic
properties-offers advantage for patients with psychotic depression.
? Atomoxetine is the first drug for ADHD that is not a stimulant under the Controlled Substances Act.

--- Content provided by​ FirstRanker.com ---

? Many other drugs like Protriptyline, Maprotiline, Nafazodone, etc. are marketed in other countries.
MOOD STABILIZERS

Drugs used in prophylaxis of bipolar disorder (Mood Stabilizers)
Established

--- Content provided by⁠ FirstRanker.com ---

New
? Lithium
? Lamotrigine
? Carbamazepine
? Levo thyroxine (T3)

--- Content provided by‍ FirstRanker.com ---

? Valproate
? Calcium channel blockers
? Clorgyline
? Clonazepam
? Gabapentin

--- Content provided by‍ FirstRanker.com ---

LITHIUM
? Discovered in 1817 by Arfeudson
? First used in the treatment of gout & salt replacement in cardiac disease
? Starting dose for acute mania: 900-2100 mg/day lithium carbonate.
Blood lithium levels:

--- Content provided by⁠ FirstRanker.com ---

? Therapeutic levels [for treatment of acute mania]: 0.6 -1.2 mEq /1;
? Prophylactic levels [for relapse prevention in bipolar disorder]: 0.6 ?1.0 mEq/L
? Toxic levels: > 1.5 mEq/L

---

Effects:

--- Content provided by‌ FirstRanker.com ---

? Most affected organ is kidney > thyroid, Least affected organ is liver.
? Most common side effect is tremor
? Lithium can induce a fine postural tremor of the hands (8 to 12 Hz)
? Most common ECG finding: T wave depression
? Secreted in breast milk & hence contra indicated in pregnancy and lactation.

--- Content provided by‍ FirstRanker.com ---

? Reduce thyroxine synthesis & leads to goiter & hypothyroidism.
Indications
? Acute mania
? Bipolar mood disorders
? Schizo-affective disorder

--- Content provided by‌ FirstRanker.com ---

? Prophylaxis of unipolar mood disorder
? Cyclothymia
? Acute depression
? Chronic alcoholism (in the presence of significant depressive symptoms)
? Impulsive aggression

--- Content provided by​ FirstRanker.com ---

? Kleine-Levin syndrome
? Chemotherapy induced leucopenia & agranulocytosis (Leucocyte count is increased)
? SIADH (Inhibits ADH action on distal tube)
ELECTRO CONVULSIVE THERAPY
? Developed by Cerletti & Beni in 1938 as electro shock therapy.

--- Content provided by​ FirstRanker.com ---

Indications
? Major severe depression with
? Suicidal risk - first, most important and most common indication
o
Stupor

--- Content provided by​ FirstRanker.com ---

o
Poor intake of food and fluids
o
Melancholia
o

--- Content provided by⁠ FirstRanker.com ---

Psychotic features
o
Unsatisfactory response to drug therapy
o
Contraindication to drugs

--- Content provided by‌ FirstRanker.com ---

? Severe psychosis (Schizophrenia or mania) with
? Risk of suicide, homicide or physical assault
o
Unsatisfactory response to drug therapy
o

--- Content provided by​ FirstRanker.com ---

Contraindication to drugs
o
Prominent depressive features (e.g: schizo-affective disorder)
? Severe catatonia (non-organic) with
? Stupor

--- Content provided by​ FirstRanker.com ---

? Poor intake of food and fluids
? Unsatisfactory response to drug therapy
? Contraindication to drugs
Contraindications:
? ABSOLUTE: Raised intra cranial tension (fear of brain herniation)

--- Content provided by⁠ FirstRanker.com ---

? Relative
o
Cerebro vascular accident (CVA)
o
Recent MI

--- Content provided by FirstRanker.com ---

o
Severe hypertension
o
Pheochromocytoma
o

--- Content provided by‌ FirstRanker.com ---

Severe pulmonary disease
o
Retinal detachment

---

Types:
? Direct ECT (unmodified): ECT is given without muscle relaxants and anesthesia. Direct ECT causes decreased

--- Content provided by‍ FirstRanker.com ---

intra ocular tension.
? Modified ECT: given with drug induced muscle relaxation and anesthesia.
Complications:
? ECT- Direct: Most common side effect is fracture T4T8 spine
? Modified --ECT: Most common is retrograde amnesia (ante grade amnesia is also found)

--- Content provided by⁠ FirstRanker.com ---

Light & melatonin therapy
? Based on the concept that humans are subject to circadian rhythms that affect physiological processes in
predictable ways
? By varying light exposure, circadian rhythms can be altered
? The concentration of melatonin in blood is highest at night and lowest or absent during the daylight

--- Content provided by⁠ FirstRanker.com ---

? Artificial bright light therapy is a proved method to treat depressive disorder with seasonal pattern which is
seen in winter months when daylight hours are reduced
BEHAVIOR THERAPY

Type

--- Content provided by FirstRanker.com ---

Based on
Used in
Systemic
Reciprocal inhibition
Phobias (treatment of choice)

--- Content provided by FirstRanker.com ---

desensitization
OCD (treatment of choice)
Psycho-sexual dysfunctions
Aversion therapy
Pairing of pleasant stimulus with an

--- Content provided by‍ FirstRanker.com ---

Drug abuse
unpleasant responses e.g. Pairing alcohol with
Sexual deviations
electric shock
Flooding

--- Content provided by‌ FirstRanker.com ---

Direct exposure to phobia but escape not
Phobias
possible
Operant conditioning
Positive reinforcement

--- Content provided by‌ FirstRanker.com ---

For augmenting an adaptive
for increasing a
Negative reinforcement
behavior
behavior

--- Content provided by‌ FirstRanker.com ---

Modeling
Operant conditioning
Time out
For demoting maladaptive
for decreasing a

--- Content provided by‌ FirstRanker.com ---

Punishment
behavior
behavior
Satiation(negative practice procedure)
Other physical treatments for Depression

--- Content provided by​ FirstRanker.com ---

Light therapy (phototherapy):
? For the treatment of "seasonal affective disorder" (SAD) by Rosenthal
? Effects of phototherapy may be independent of melatonin and produce a "phase advance" in circadian
rhythms (hence treatment may be best given first thing in the morning).

--- Content provided by FirstRanker.com ---

? Usually administered by use of a light box.
? Optimal intensity of light appears to be 10,000 lux.
? Ideal treatment duration is for 30 minutes (at 10,000 lux) a day.
? Although treatment response is generally noticeable within five days.
? For patients with seasonal depressive symptoms, maintenance therapy is recommended throughout the

--- Content provided by‌ FirstRanker.com ---

winter months
Vagus nerve stimulation (VNS) therapy:
? Approved for severe, recurrent unipolar and bipolar depression in July 2005.
? Left cervical vagus nerve stimulation is accomplished through leads attached to a pulse generator implanted
in the left chest area.

--- Content provided by‍ FirstRanker.com ---

---

? Response rates of 40-46% have been shown for treatment-resistant depressive disorder after 10 weeks to 9
months, with a remission rate of 29% at one year, suggesting that the effectiveness of VNS may have a slow
trajectory.
? VNS may be combined with essentially all existing treatments for depressive disorders.
? It has been safely used with antidepressants (including MAOIs) and can be temporarily shut off to allow for

--- Content provided by FirstRanker.com ---

ECT and restarted immediately post-ECT.
*****END*****

---