Download MBBS Psychiatry Mnemonic Short Book

Download MBBS (Bachelor of Medicine and Bachelor of Surgery) 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
? Sigmund Freud:
o
Founder of Psychoanalysis
o
Dream interpretation
o
Theory of infantile sexuality
o
Structural and topographical model of mind
o
Theory of instincts
o
Ego defence mechanisms
o
Id, ego and superego
o
Stages of psychosexual development
? Eugen Blueler: Gave 4 A's of schizophrenia. (Autism, Affective flattening, Ambivalence, loosening of
Association)
? Leo Kanner defined autism
? Skinner ? operant conditioning
? Pavlov- classical conditioning
? John F cade - Lithium
? Reserpine ? First drug used in treating psychosis
? Ugo Cerletti and Lucio Bini - ECT
? 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
? 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
Eugen Bleuler
Schizophrenia
James Braid
Hypnosis
Reil Johan Christian
Psychiatry
Eward Hecker
Hebephrenia
Emil Kraeplin
Dementia precox
Sigmund Freud
Free association
Oedipus complex, Electra complex
Penis envy, Psychoanalysis
Ego defence mechanism
Pleasure principle, Reality principle
Alfred Adler
Inferiority complex

---

II.
FUNDAMENTALS IN PSYCHIATRY

Diagnosis and Classification in Psychiatry
The Five Axes of DSM-IV-TR
? AXIS I: Clinical Psychiatric Diagnosis
? AXIS II: Personality Disorder and Mental Retardation
? 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)
? 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
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:
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.
? 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
? 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
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
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
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
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)
? 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"...
? 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)
? 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.
? 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
? 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
Psychosis
Neurosis
Judgment
Lacking or impaired
Present
Insight
Personality
Contact with reality
Delusions/ Hallucinations
Common
Usually not present
Examples
1. Schizophrenia
1. Phobia
2. Delusional disorder
2. Dissociative disorder
3. Mood disorder
3. Conversion / somatoform disorder
Mania
4. OCD (Obsession Compulsive Disorder)
Depression
5. Anxiety: Generalized anxiety & Panic
Bipolar disorder
disorder
DISORDERS OF PERCEPTION
? Hallucination
? Illusion
? Derealization
? Depersonalization

Hallucination
? Perceptions which arise in the absence of any external stimulus.
? Characteristics:
o
Unwilled - not subject to conscious manipulation
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)
? 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
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
? 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)
? Extracampine hallucinations: hallucinations outside the field of sensory perception (eg: outside visual
field).
HALLUCINATIONS
PSEUDOHALLUCINATIONS
Bright vivid perception just like reality
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-
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
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
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
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
? 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)
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
? 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

---

DISORDERS OF CONTENT OF THOUGHT

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

? 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

? Arise de novo
? Cannot be explained on the basis of other experiences or perceptions
? Characteristic of schizophrenia (early stages)
? Types
o
Delusional intuition (autochthonous)
o
Delusional perception
o
Delusional atmosphere
o
Delusional memory.
Secondary delusions

? Commonest type
? Can be seen in other psychoses
? Types:
o
Persecutory (most common type) ? believe that people are conspiring against them.
o
Grandiose ? believe they have a special ability or mission.
o
Poverty ? believe they have been rendered penniless.
o
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.
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.
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
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
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)

? 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
Posturing
o
Stereotypies
o
Waxy flexibility

---

Stupor
? Absence of relational functions, i.e. action and speech
? Usually involves clouding of consciousness
? Occurs in:
o
Schizophrenia (30 %)
o
Depression (25 %)
o
Psychological trauma (psychogenic stupor)
o
Mania
o
Organic brain lesions (20 %):
Diencephalon and upper brain stem
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
Sigmund Freud's psychoanalytic theories
Topographic theory of mind
Mind is divided into
? The unconscious
? The preconscious
? The conscious
Structural theory of mind
The mental apparatus is divided into
? The Id
? The Ego
? The Super-ego
COMMONLY USED EGO DEFENSE MECHANISMS:

Defense Mechanism
Clinical situations
Narcissistic
Denial
Psychoses
Alcohol dependence
Projection
Persecutory delusions
Hallucinations
Distortion
Hallucinations
Delusion of grandiosity
Immature
Acting out
Impulse control disorders
Hypochondriasis
Hypochondriasis
Introjection
Depression
Regression
Neuroses, Psychoses
Severe, prolonged physical illness
Schizoid fantasy
Schizoid personality disorder
Schizotypal personality disorder
Somatization
Somatoform disorders
Neurotic
Displacement
Phobia
OCD
Inhibition
OCD
Phobia
Reaction formation
OCD
Dissociation
Dissociative disorders disorder
Isolation
Obsessional thoughts

---

Repression
Psychogenic amnesia
Conversion
Conversion disorder (Hysteria)
Undoing
Compulsive acts in OCD
Others: Intellectualization, Rationalization, Externalization, Controlling, Sexualization
Mature
Altruism
Anticipation
Asceticism
Suppression
Sublimation
Humour
Theory of Psychosexual development
Oral phase
Birth ? 18 months
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
to
OCD
Phallic phase
3 ? 5 years
Genital area is the site of satisfaction.
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
11 years ?
Capacity for true intimacy
adulthood
Duration criteria of Mental illness (ICD-10)

Adjustment disorder
Onset < 1 month till 6 months
Persistent delusional disorder
3 months
Acute psychosis (brief psychotic disorder in DSM-
2 weeks (less than 1 month in DSM IV)
IV
D )
e mentia
6 months
Schizophrenia
1 month (6 months as per DSM IV)
Schizotypal disorder
2 years
(included under personality disorders in DSM-IV
and under schizophrenia in ICD-10)
Somatisation disorder
2 years
PTSD
Onset within 6 months of trauma, Duration of the
disturbance is more than 1 month.
Acute stress reaction
Onset within minutes of life event resolves within
3
days
Hypomania
4 days
Mania
1 week
Obsessive compulsive disorder
2 weeks
Panic disorder
1 month
Dysthymia
2 years
Depression
2 weeks
Kubler-Ross stages of Death and Dying
? Stage 1: Shock and Denial
? Stage 2: Anger
? Stage 3: Bargaining
? Stage 4: Depression
? Stage 5: Acceptance

---

COMMON EMERGENCIES IN PSYCHIATRY
Syndrome
Emergency Manifestations
Treatment Issues
Abuse of child or adult
Signs of physical trauma
Management of medical problems;
Acquired immune deficiency
Changes in behavior secondary to
Management of neurological illness;
syndrome (AIDS)
organic causes; changes in behavior
management of psychological
secondary to fear and anxiety;
concomitants; reinforcement of
suicidal behaviour
social support
Adolescent crises
Suicidal attempts and ideation;
Crisis-oriented family and individual
substance abuse, truancy, trouble
therapy; hospitalization if necessary;
with law, pregnancy, running away;
consultation with appropriate
eating disorders; psychosis
extrafamilial authorities
Agoraphobia
Panic; depression
Alprazolam, propranolol;
antidepressant medication
Agranulocytosis (clozapine-induced)
High fever, pharyngitis, oral and
Discontinue medication immediately;
perianal ulcerations
administer granulocyte colony-
stimulating factor
Akathisia
Agitation, restlessness, muscle
Reduce antipsychotic dosage;
discomfort; dysphoria
propranolol; benzodiazepines;
diphenhydramine orally or IV;
benztropine IM
Alcohol-related emergencies
Alcohol delirium
Confusion, disorientation, fluctuating Chlordiazepoxide; haloperidol
consciousness and perception,
autonomic hyperactivity; may be
fatal
Alcohol intoxication
Disinhibited behavior, sedation at
With time and protective
high doses
environment, symptoms abate
Alcohol persisting amnestic disorder
Confusion, loss of memory even for
Hospitalization; hypnosis;
all personal identification data
amobarbital interview; rule out
organic cause
Alcohol persisting dementia
Confusion, agitation, impulsivity
Rule out other causes for dementia;
no effective treatment;
hospitalization if necessary
Alcohol psychotic disorder with
Vivid auditory (fat times visual)
Haloperidol for psychotic symptoms
hallucinations
hallucinations with affect
appropriate to content (often
fearful); clear sensorium
Alcohol seizures
Grand mal seizures; rarely status
Diazepam, phenytoin; prevent by
epilepticus
using chlordiazepoxide during
detoxification
Alcohol withdrawal
Irritability, nausea, vomiting,
Fluid and electrolytes maintained;
insomnia, malaise, autonomic
sedation with benzodiazepines;
hyperactivity, shakiness
restraints; monitoring of vital signs;
100 mg thiamine IM
Idiosyncratic alcohol intoxication
Marked aggressive or assaultive
Generally no treatment required
behaviour
other than protective environment
Korsakoff's syndrome
Alcohol stigmata, amnesia,
No effective treatment;
confabulation
institutionalization often needed
Wernicke's encephalopathy
Oculomotor disturbances, cerebellar
Thiamine, 100 mg IV or IM, with
ataxia; mental confusion
MgSO4
given before glucose loading
Amphetamine (or related substance)
Delusions, paranoia; violence;
Antipsychotics; restraints;
intoxication
depression (from withdrawal);
hospitalization if necessary; no need
anxiety, delirium
for gradual withdrawal;
antidepressants may be necessary

---

Anorexia nervosa
Loss of 25% of body weight of the
Hospitalization; electrocardiogram
norm for age and sex
(ECG),
fluid and electrolytes;
neuroendocrine
Anticholinergic
Psychotic symptoms, dry skin and
Discontinue drug, IV physostigmine
intoxication
mouth, hyperpyrexia, mydriasis,
0.5 to 2 mg, for severe agitation or
tachycardia, restlessness, visual
fever, benzodiazepines;
hallucinations
antipsychotics contraindicated
Anticonvulsant intoxication
Psychosis; delirium
Dosage of anticonvulsant is reduced
Benzodiazepine intoxication
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
equipment available
Bereavement
Guilt feelings, irritability; insomnia;
Must be differentiated from major
somatic complaints
depressive disorder; antidepressants
not indicated; benzodiazepines for
sleep; encouragement of ventilation
Borderline personality
Suicidal ideation and gestures;
Suicidal and homicidal evaluation (if
disorder
homicidal ideations and gestures;
great, hospitalization); small dosages
substance abuse; micropsychotic
of antipsychotics; clear follow-up
episodes; burns, cut marks on body
plan
Brief psychotic disorder
Emotional turmoil, extreme lability;
Hospitalization often necessary; low
acutely impaired reality testing after
dosage of antipsychotics may be
obvious psychosocial stress
necessary but often resolves
spontaneously
Bromide intoxication
Delirium; mania; depression;
Serum levels obtained (>50 mg a
psychosis
day); bromide intake discontinued;
large quantities of sodium chloride IV
or orally; if agitation, paraldehyde or
antipsychoticis used
Caffeine intoxication
Severe anxiety, resembling panic
Cessation of caffeine-containing
disorder; mania; delirium; agitated
substances; benzodiazepines
depression; sleep disturbance
Cannabis intoxication
Delusions; panic; dysphoria;
Benzodiazepines and antipsychotics
cognitive impairment
as needed; evaluation of suicidal or
homicidal risk; symptoms usually
abate with time and reassurance
Catatonic schizophrenia
Marked psychomotor disturbance
Rapid tranquilization with
(either excitement or stupor);
antipsychotics; monitor vital signs;
exhaustion; can be fatal
amobarbital may release patient
from catatonic mutism or stupor but
can precipitate violent behavior
Cimetidine psychotic disorder
Delirium; delusions
Reduce dosage or discontinue drug
Clonidine withdrawal
Irritability; psychosis; violence;
Symptoms abate with time, but
seizures
antipsychotics may be necessary;
gradual lowering of dosage

---

Cocaine intoxication and withdrawal
Paranoia and violence; severe
Antipsychotics and benzodiazepines;
anxiety; manic state; delirium:
antidepressants or ECT for
schizophreniform psychosis;
withdrawal depression if persistent;
tachycardia, hypertension,
hospitalization
myocardial infarction,
cerebrovascular disease; depression
and suicidal ideation
Delirium
Fluctuating sensorium; suicidal and
Evaluate all potential contributing
homicidal risk; cognitive clouding;
factors and treat each accordingly;
visual, tactile, and auditory
reassurance, structure, clues to
orientation;
hallucinations; paranoia
benzodiazepines and low-dosage,
high- potency antipsychotics must be
used with extreme care because of
their potential to act paradoxically
and increase agitation
Delusional disorder
Most often brought in to emergency
Antipsychotics if patient will comply
room involuntarily; threats directed
(IM if necessary); intensive family
toward others
intervention; hospitalization if
necessary
Dementia
Unable to care for self; violent
Small dosages of high-potency
outbursts; psychosis; depression and
antipsychotics; clues to orientation;
suicidal ideation; confusion
organic evaluation, including
medication use; family intervention
Depressive disorders
Suicidal ideation and attempts; self-
Assessment of danger to self;
neglect; substance abuse
hospitalization if necessary,
nonpsychiatric causes of depression
must be evaluated
L-Dopa intoxication
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
Decrease dosage of antipsychotic;
muscles of neck, tongue, face, jaw,
benztropine or diphenhydramine IM
eyes, or trunk
Group hysteria
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
Hallucinogen-induced psychotic
Symptom picture is result of
Serum and urine screens; rule out
disorder with hallucinations
interaction of type of substance,
underlying medical or mental
dose taken, duration of action, user's
disorder; benzodiazepines (2 to 20
premorbid personality, setting;
mg) orally; reassurance and
panic;
orientation; rapid tranquilization;
agitation; atropine psychosis
often responds spontaneously
Homicidal and assaultive behavior
Marked agitation with verbal threats
Seclusion, restraints, medication

---

Homosexual panic
Not seen with men or women who
Ventilation, environmental
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
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
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
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
or her and defends against them
abdomen or performing a rectal
examination (e.g., on a man who
harbors thinly veiled unintegrated
homosexual impulses)
Hypertensive crisis
Life-threatening hypertensive
Adrenergic blockers (e.g.,
reaction secondary to ingestion of
phentolamine); nifedipine 10 mg
tyramine-containing foods in
orally; chlorpromazine; make sure
combination with MAOls; headache,
symptoms are not secondary to
stiff neck, sweating, nausea,
hypotension (side effect of
vomiting
monoamine oxidase inhibitors
[MAOls] alone)
Hyperthermia
Extreme excitement or catatonic
Hydrate and cool; may be drug
stupor or both; extremely elevated
reaction, so discontinue any drug;
temperature; violent hyperagitation
rule out infection
Hyperventilation
Anxiety, terror, clouded
Shift alkalosis by having patient
consciousness; giddiness, faintness;
breathe into paper bag; patient
blurring vision
education; antianxiety agents
Hypothermia
Confusion; lethargy; combativeness;
IV fluids and rewarming, cardiac
low body temperature and shivering;
status must be carefully monitored;
paradoxical feeling of warmth
avoidance of alcohol
Incest and sexual abuse of child
Suicidal behavior; adolescent crises;
Corroboration of charge, protection
substance abuse
of victim; contact social services;
medical and psychiatric evaluation;
crisis intervention
Insomnia
Depression and irritability; early
Hypnotics only in short term; e.g.,
morning agitation; frightening
triazolam, 0.25 to 0.5 mg, at
dreams; fatigue
bedtime; treat any underlying
mental disorder; rules of sleep
hygiene
Intermittent explosive disorder
Brief outbursts of violence; periodic
Benzodiazepines or antipsychotics
episodes of suicide attempts
for short term; long-term evaluation
with computed tomography (CT)
scan, sleep- deprived
electroencephalogram (EEG),
glucose tolerance curve
Jaundice
Uncommon complication of low-
Change drug to low dosage of a low-
potency phenothiazine use (e.g.,
potency agent in a different class
chlorpromazine)
Leukopenia and agranulocytosis
Side effects within the first 2 months
Patient should call immediately for
of treatment with antipsychotics
sore throat, fever, etc., and obtain
immediate blood count; discontinue
drug; hospitalize if necessary

---

Lithium toxicity
Vomiting; abdominal pain; profuse
Lavage with wide-bore tube; osmotic
diarrhea; severe tremor, ataxia;
diuresis; medical consultation; may
coma; seizures; confusion;
require ICU treatment
dysarthria; focal neurological signs
Major depressive episode with
Major depressive episode symptoms
Antipsychotics plus antidepressants;
psychotic features
with delusions; agitation, severe
evaluation of suicide and homicide
guilt; ideas of reference; suicide and
risk; hospitalization and ECT if
homicide risk
necessary
Manic episode
Violent, impulsive behavior;
Hospitalization; restraints if
indiscriminate sexual or spending
necessary; rapid tranquilization with
behavior; psychosis; substance abuse antipsychotics; restoration of lithium
levels
Marital crises
Precipitant may be discovery of an
Each should be questioned alone
extramarital affair, onset of serious
regarding extramarital affairs,
illness, announcement of intent to
consultations with lawyers regarding
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
to resolve the problem; sexual,
psychiatrically ill; one spouse may be
financial, and psychiatric treatment
seeking hospitalization for the other
histories from both, psychiatric
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
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
someone intimately involved in the
social system
Migraine
Throbbing, unilateral headache
Sumatriptan 6 mg IM
Mitral valve prolapse
Associated with panic disorder;
Echocardiogram; alprazolam or
dyspnea and palpitations; fear and
propranolol
anxiety
Neuroleptic malignant syndrome
Hyperthermia; muscle rigidity;
Discontinue antipsychotic; IV
autonomic instability; parkinsonian
dantrolene; bromocriptine orally;
symptoms; catatonic stupor;
hydration and cooling; monitor CPK
neurological signs; 10% to 30%
levels
fatality; elevated creatine
phosphokinase
Nitrous oxide toxicity
Euphoria and light-headedness
Symptoms abate without treatment
within hours of use
Nutmeg intoxication
Agitation; hallucinations; severe
Symptoms abate within hours of use
headaches; numbness in extremities
without treatment
Opioid intoxication and withdrawal
Intoxication can lead to coma and
IV naloxone, narcotic antagonist;
death; withdrawal is not life-
urine and serum screens; psychiatric
threatening
and medical illnesses (e.g., AIDS) may
complicate picture

---

Panic disorder
Panic, terror; acute onset
Must differentiate from other
anxiety- producing disorders, both
medical and psychiatric; ECG to rule
out mitral valve prolapse;
propranolol (10 to 30 mg);
alprazolam (0.25 to 2.0 mg); long-
term management may include an
antidepressant
Paranoid schizophrenia
Command hallucinations; threat to
Rapid tranquilization; hospitalization;
others or themselves
long-acting depot medication;
threatened persons must be notified
and protected
Parkinsonism
Stiffness, tremor, bradykinesia,
Oral antiparkinsonian drug for 4
flattened affect, shuffling gait,
weeks to 3 months; decrease dosage
salivation, secondary to
of the antipsychotic
antipsychotic medication
Perioral (rabbit) tremor .
Perioral tumor (rabbitlike facial
Decrease dosage or change to a
grimacing) usually appearing after
medication in another class
long-term therapy with
antipsychotics
Phencyclidine (or phencyclidine-like
Paranoid psychosis; can lead to
Serum and urine assay;
intoxication)
death; acute danger to self and
benzodiazepines may interfere with
others
excretion; antipsychotics may
worsen symptoms because of
anticholinergic side effects; medical
monitoring and hospitalization
for severe intoxication
Phenelzine-induced psychotic
Psychosis and mania in predisposed
Reduce dosage or discontinue drug
disorder
people
Phenylpropanolamine toxicity
Psychosis; paranoia; insomnia;
Symptoms abate with dosage
restlessness; nervousness; headache
reduction
or discontinuation (found in over-
the-
counter diet aids and oral and nasal
decongestants)
Phobias
Panic, anxiety; fear
Treatment same as for panic
Photosensitivity
Easy sunburning secondary to use of
d
Pis
a o
ti rd
e e
nt r
should avoid strong sunlight
antipsychotic medication
and
use high-level sunscreens
Pigmentary retinopathy
Reported with dosages of
Remain below 800 mg a day of
thioridazine (Mellaril) of 800 mg a
thioridazine
day or above
Postpartum psychosis
Childbirth can precipitate
Danger to self and others (including
schizophrenia, depression, reactive
infant) must be evaluated and
psychoses, mania, and depression;
proper precautions taken; medical
affective symptoms are most
illness presenting with behavioral
common; suicide risk is reduced
aberrations is included in the
during pregnancy but increased in
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

---

Posttraumatic stress disorder
Panic, terror; suicidal ideation;
Reassurance; encouragement of
flashbacks
return to responsibilities; avoid
hospitalization if possible to prevent
chronic invalidism; monitor suicidal
ideation
Priapism (trazodone
Persistent penile erection
Intracorporeal epinephrine;
[Desyrel]-induced)
accompanied by severe pain
mechanical or surgical drainage
Propranolol toxicity
Profound depression; confusional
Reduce dosage or discontinue drug;
states
monitor suicidality
Rape
Not all sexual violations are
Rape is a major psychiatric
reported; silent rape reaction is
emergency; victim may have
characterized by loss of appetite,
enduring patterns of sexual
sleep disturbance, anxiety, and,
dysfunction; crisis-oriented therapy,
sometimes, agoraphobia; long
social support, ventilation,
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
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
diethylstilbestrol orally for 5 days to
disease or being pregnant
prevent pregnancy; if the victim has
contracted a venereal disease,
appropriate antibiotics; witnessed
written permission is required for
the physician to examine,
photograph, collect specimens, and
release information to the
authorities; obtain consent, record
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,
psychic trauma, and pregnancy;
Reserpine intoxication
Major depressive episodes; suicidal
Evaluation of suicidal ideation; lower
ideation; nightmares
dosage or change drug;
antidepressants of ECT may be
indicated
Schizoaffective disorder
Severe depression; manic symptoms; Evaluation of dangerousness to self
paranoia
or others; rapid tranquilization if
necessary; treatment of depression
(antidepressants alone can enhance
schizophrenic symptoms); use of
antimanic agents
Schizophrenia
Extreme self-neglect; severe
Evaluation of suicidal and homicidal
paranoia; suicidal ideation or
potential; identification of any illness
assaultiveness; extreme psychotic
other than schizophrenia; rapid
symptoms
tranquilization
Schizophrenia in exacerbation
Withdrawn; agitation; suicidal and
Suicide and homicide evaluation;
homicidal risk
screen for medical illness; restraints
and rapid tranquilization if
necessary; hospitalization if
necessary; reevaluation of
medication regimen

---

Sedative, hypnotic, or anxiolytic
Alterations in mood, behavior,
Naloxone to differentiate from
intoxication and withdrawal
thought-delirium; derealization and
opioid intoxication; slow withdrawal
depersonalization; untreated, can be
with phenobarbital or sodium
fatal; seizures
thiopental or benzodiazepine;
hospitalization
Seizure disorder
Confusion; anxiety; derealization and
Immediate EEG; admission and
depersonalization; feelings of
sleep- deprived and 24-hour EEG;
impending doom; gustatory or
rule out pseudoseizures;
olfactory hallucinations; fuguelike
anticonvulsants
state
Substance withdrawal
Abdominal pain; insomnia,
Symptoms of psychotropic drug
drowsiness; delirium; seizures;
withdrawal disappear with time or
symptoms of tardive dyskinesia may
disappear with reinstitution of the
emerge; eruption of manic or
substance; symptoms of
schizophrenic symptoms
antidepressant withdrawal can be
successfully treated with
anticholinergic agents, such as
atropine; gradual withdrawal of
psychotropic substances over two to
four weeks generally obviates
development of symptoms
Sudden death associated with
Seizures; asphyxiation;
Specific medical treatments
Antipsychotic medication
cardiovascular causes; postural
hypotension; laryngeal-pharyngeal
dystonia; suppression of gag reflex
Sudden death of psychogenic origin
Myocardial infarction after sudden
Specific medical treatments; folk
psychic stress; voodoo and hexes;
healers
hopelessness, especially associated
with serious physical illness
Suicide
Suicidal ideation; hopelessness
Hospitalization, antidepressants
Sympathomimetic withdrawal
Paranoia; confusional states;
Most symptoms abate without
depression
treatment; antipsychotics;
antidepressants if necessary
Tardive dyskinesia
Dyskinesia of mouth, tongue, face,
No effective treatment reported;
neck, and trunk; choreoathetoid
may be prevented by prescribing the
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,
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
elderly and brain-damaged;
first sign of dyskinetic movements
symptoms are intensified by
antiparkinsonian drugs and
masked but not cured by increased
dosages of antipsychotic
Thyrotoxicosis
Tachycardia; gastrointestinal
Thyroid function test (T3, T4, thyroid-
dysfunction; hyperthermia; panic,
stimulating hormone [TSH]); medical
anxiety, agitation; mania; dementia;
consultation
psychosis
Toluene abuse
Anxiety; confusion; cognitive
Neurological damage is
impairment
nonprogressive and reversible if
toluene use in discontinued early

---

Vitamin B12 deficiency
Confusion; mood and behavior
Treatment with vitamin B12
changes; ataxia
Volatile nitrates
Alternations of mood and behavior;
Symptoms abate with cessation of
light-headedness; pulsating
use
headache


PSYCHOLOGICAL TESTING
? Reliability assesses the reproducibility of results.
? Validity assesses whether the test measures what it purports to measure.
? The two types of tests are:
? Objective tests:
o
Typically pencil-and-paper tests based on specific items and questions.
o
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
Projective Measures of Personality
Minnesota-Multiphasic Personality Inventory (MMPI)
Rorschach test
Minnesota Multiphasic Personality Inventory-2
Thematic Apperception Test (TAT)
(MMPI-2)
Million Clinical Multiaxial Inventory (MCMI)
Sentence Completion Test
Million Clinical Multiaxial Inventory-II (MCMI-11)
Holtzman Inkblot Technique (HIT)
16 Personality Factor Questionnaire (16 PF)
Figure drawing
Personality Assessment Inventory (PAI)
Make-a-Picture Story (MAPS)
California Personality Inventory (CPI)
The Draw-a-Person test
Jackson Personality Inventory (JPI)
Edwards Personal Preference Schedule (EPPS)
Psychological Screening Inventory (PSI)
Eysenck Personality Questionnaire (EPQ)
Adjective Checklist (ACL)
Comrey Personality Scales (CPS)
Tennessee Self-Concept Scale (TSCS)

---

III.
DELIRIUM AND DEMENTIA

DELIRIUM
? Most common organic mental disorder seen in clinical practice
Etiology:
? Seen in approximately 10 to 30 % of medically ill patients who are hospitalized
? 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
Generalized or focal cerebral lesion
Chronic medical illness
Surgical procedure and postoperative period
Treatment with psychotropic medicines
Present or past history of head injury
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
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:
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:
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.
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
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
o
Delirium, superimposed on dementia
o
Other delirium
o
Delirium, unspecified
Clinical Features:
? Sudden onset with fluctuating course
? Cognitive impairment

---

? Clouding of consciousness -- decreased awareness of surroundings and decreased ability to respond to
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
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.
? 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.
? Impairment of judgment and impulse control
? Impairment of abstract thinking.
? No impairment of consciousness
Additional features:
? Emotional lability (marked variation in emotional expression)
? 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.
? 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
impairment
impairment
Patient often emphasizes achievements
Patient often emphasizes disability
Patients often appears unconcerned
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
Impairment of recent memory
Rarely impaired
Confabulation may be present
Confabulation very rare
Consistently poor performance on similar tests
Marked variability in performance on similar tests
History of depression less common
Past history of manic and/ or depression episodes
Features
Cortical Dementia
Subcortical Dementia
Site of lesion
Cortex (frontal and temporo parieto-
Subcortical grey matter (thalamus, basal
occipital association areas, hippocampus) ganglia, and rostral brain stem)
Examples
Alzheimer's disease, Pick's disease
Huntington' chorea, Parkinson's disease,
Progressive supranuclear palsy, Wilson's
disease
Severity
Severe
Mild to moderate
Motor system
Usually normal
Dysarthria, flexed/extended posture, tremors,
dystonic, chorea, ataxia, rigidity

---

Other features
Simple delusions; depression uncommon; Complex delusions; depression common;
severe aphasia, amnesia, agnosia,
rarely mania
apraxia, acalculia, slowed cognitive speed
(bradyphrenia)
Memory deficit
Recall helped very little by cues
Recall partially helped by cues and recognition
(Short-term)
tasks
Reversible causes of dementia:
? Hypothyroidism
? Infections
? B1 B12 deficiency
? Wilsons disease
? NPH
Feature
Dementia
Delirium
Onset
Slow
Rapid
Duration
Months to years
Hours to weeks
Consciousness
Normal
Clouded
Orientation
Normal until late stages
Disturbed
Memory
Immediate retention and recall
Impaired recent and immediate memory
normal
Recent memory disturbed
Impaired remote memory in late
stages
Attention and
Usually normal
Disturbed
concentration
Comprehension
Impaired only in late stages
Impaired
Speech
Word-finding difficulty
Incoherent (slow or rapid)
Sleep-wake cycle
Normal
Frequent disruption (e.g., day & night
reversal)
Thoughts
Impoverished
Disorganized
Awareness
Unchanged
Reduced
ALZHEIMER'S DISEASE
? Most common cause of dementia (> 50%)
NINCDS-ARDRA CRITERIA used for diagnosis
? Presence of dementia
? Deficits in at least two areas of cognition
? Progressive deterioration
? No clouding of consciousness
? Age between 40 and 90
? Absence of systemic disorders
? Neurofibrillary tangles
? Beta amyloid plaques
? Apolipoprotein E4
Clinical features:
? Delayed recall is the best overall discriminator for early Alzheimer's disease
? 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%)
? 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
o
Acute exacerbations (due to repeated infarctions),
o
Stepwise clinical deterioration (step-ladder pattern),
o
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).
? 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
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
? Second most common cause of the degenerative dementias
? Typically, the clinical features include:
o
Fluctuating cognitive impairment over weeks or months
o
Lucid intervals can be present in between fluctuations.
o
Recurrent and detailed visual hallucinations.
o
Spontaneous extrapyramidal symptoms such as rigidity and tremors.
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
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
? 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).

---

Neurofibrillary tangles
Seen in
Not in
? Alzheimer's disease
? Lewy body dementia
? Punch-drunk' syndrome
? Pick's disease
? Postencephalitic Parkinsonism
? Amyotrophic lateral sclerosis
? Progressive supranuclear palsy
Amyloid plaques
Seen in
Not in
? Alzheimer's disease
? Pick's disease
? Lewy body dementia
? `Punch-drunk' syndrome
Lewy bodies
Seen in
? Alzheimer's disease
? Ataxia-telengectasia
? Progressive supranuclear palsy
? Lewy body dementia

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 ).
? 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

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.
? This is an acute organic brain syndrome (delirium) with characteristic features of:
o
Clouding of consciousness
o
Disorientation in time and place.
o
Poor attention span and distractibility.
o
Visual (also auditory) hallucinations and illusions, which are often vivid and very frightening.
o
Marked autonomic disturbance - tachycardia, fever, hypertension, sweating, mydriasis
o
Psychomotor agitation and ataxia.
o
Insomnia, with a reversal of sleep-wake pattern.
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
? 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
? 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.
? 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
midbrain.
? Completely reversible with treatment

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

---

Screening test for alcoholism:
? MAST (Michigan Alcoholism Screening Test)
? CAGE questionnaire test
CAGE Questionnaire
? Ever had to Cut down the amount of alcohol
? 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
? Behaviour therapy
? Psychotherapy
? Group therapy
? Deterrent agents
The deterrent agents are also known as alcohol sensitizing drugs.
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
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
? 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
? Occurs typically within 12-24 hours
? Lacrimation, rhinorrhea, pupillary dilation. sweating, diarrhea, yawning, tachycardia, insomnia, raised
body temperature, muscle cramps, piloerection
Treatment
? Overdose: Naloxone
? 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
? Drugs used in smoking cessation: Bupropion (amfebutamone), Varenicline

Substance
Characteristic feature
Cocaine
Magnus symptom (cocaine bugs/tactile hallucinations)
Cannabis
Run amok, Amotivation syndrome, Flash backs, Hemp insanity,
Alcohol
Mc-Evan's sign, Morbid jealousy
LSD
Bad trips, Flash backs
Amphetamine
Paranoid hallucinatory syndrome (like paranoid schizophrenia)

---

Phencyclidine (angel dust)
Dissociative anesthesia

LSD: No withdrawal syndrome
Cannabis: No physical dependence; mild to marked psychological dependence
Cocaine: Mild physical dependence; severe psychological dependence
Amok is an episode of acute violent behavior for which the person claims amnesia. Seen in cannabis abuse.

---

V.
SCHIZOPHRENIA

? 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
? 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
Schneider's second rank symptoms
? Hallucination
?
Other disorders of perception
o Audible thoughts (thought echo)
?
Sudden delusional ideas
o Voices heard arguing
?
Perplexity
o Voices commenting on one's action
?
Depressive and euphoric mood changes
? Delusional perception
?
Feelings of emotional impoverishment
? Thoughts Alienation phenomena
?
Several others as well
o Thoughts withdrawal
o Thoughts insertion
o Thought diffusion / broadcasting
? Passivity phenomena
o Made feeling (affect)
o Made impulses
o Made volition or act
o Somatic passivity

Bleuler's '4-A'
? Ambivalence (inability to decide for or against)
? Autism (withdrawal into self)
? Affect disturbance
? Association disturbance

DSM-IV CRITERIA FOR DIAGNOSIS OF SCHIZOPHRENIA:
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)
? 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.
? 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
? Commonest type ? Paranoid
? Amphetamine induced - Paranoid
? Early onset & bad prognosis ? Hebephrenic
? Late onset & best prognosis ? Catatonic

---

? Very late (3rd 4th decade) ? Paranoid
? Worst prognosis & most difficult to diagnosis ? Simple
? Associated with mental retardation ? Ptropf

DSM-IV-TR Diagnostic Criteria for Schizophrenia Subtypes
Paranoid type (Paraphrenia)
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:
1.
Catalepsy (including waxy flexibility) or stupor
2.
Excessive motor activity (purposeless and not influenced by external stimuli)
3.
Negativism or mutism
4.
peculiarities of posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped
5.
movements, prominent mannerisms, or prominent grimacing
6.
echolalia or echopraxia
Undifferentiated type
Residual type: Absence of prominent delusions, hallucinations, disorganized speech, and grossly
disorganized or catatonic behavior.

? 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:

? Bouff Dlirante (Acute Delusional
? Pseudoneurotic schizophrenia
? Psychosis)
? Deficit schizophrenia
? Latent schizophrenia
? Early onset schizophrenia
? Oneiroid state
? Late onset schizophrenia

CATATONIC SCHIZOPHRENIA
Excited catatonic:
? Known as Acute lethal catatonic or pernicious catatonia
? Increased psychomotor activity
? Death may occur.
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
uncomfortable
? Stupor: no movement with mutism but preservation of consciousness.
? Negativism
? Echolalia, Echopraxia
? Mannerism & Grimacing
? 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).

---

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
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
Positive symptoms
Negative symptoms
Disorganized symptoms
? Delusions
? Affective flattening
? Inappropriate affect
? Hallucinations
? Attentional impairment
? Disorganized behavior
? Avolition-apathy (lack of initiative
? Thought disorder
associated with psychomotor
? Loosening of association
slowing)
? Asociality (social withdrawal)
? Alogia (lack of speech output)
? Anhedonia

? The delusions included in 1st rank symptoms are primary or autoconthous delusions - characteristic of
schizophrenia.
? 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
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
Prognosis
Good Prognosis
Poor Prognosis
Late onset > 35 years
Early onset < 20 years
Obvious precipitating factors
No precipitating factors
Acute onset
Insidious onset
Good premorbid social, sexual &work histories
Poor premorbid social, sexual & work histories
Short duration < 6 months
Chronic course > 2 years
Fat physique
Thin physique
Female sex
Male sex
Good social support
Poor social support
Married
Single, divorced, or widowed
Family history of mood disorders
Family history of schizophrenia
Presence of depression
Absence of depression
Confusion, perplexity, disorientation
Flat or blunt affect
Positive symptoms
Negative symptoms
Neurological signs and symptoms
History of perinatal trauma /assaultiveness
Many relapses/No remissions in 3 years

---

Catatonic subtype
Disorganized, simple, undifferentiated, chronic
Paranoid ? intermediate prognosis
catatonic subtypes
Outpatient treatment
Long term hospitalization
Normal cranial CT scan
Evidence of ventricular enlargement

Indications for ECT in schizophrenia
? Catatonic stupor
? Uncontrolled catatonic excitement
? Acute exacerbation not controlled with drugs
? Severe side effect with drugs, in presence of untreated schizophrenia

Psychosurgery
? Very rarely performed
? Limbic leucotomy -- is the procedure of choice
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
Delusions
o
Hallucinations
o
Bizarre behavior and posture
o
Disorganized speech

---

VI.
ANXIETY & STRESS RELATED DISORDERS

TYPES OF ANXIETY DISORDERS (DSM-IV-TR)
? Panic disorder with or without agoraphobia
? Agoraphobia with or without panic disorder
? Specific phobia
? Social phobia
? Obsessive-compulsive disorder (OCD)
? Posttraumatic stress disorder (PTSD)
? Acute stress disorder
? Generalized anxiety disorder

Anxiety
? It is the most common psychiatric symptom
? Physical symptoms
o
Motor: tremors, muscle twitching
o
Autonomic and visceral: sweating, palpitation, tachycardia, flushes, hyperventilation, dry mouth,
dizziness, diarrhea, mydriasis
? Psychological symptoms
o
Cognitive: poor concentration, hyperarousal, vigilance or scanning, negative automatic thoughts
o
Perceptual: derealisation, depersonalization
o
Affective: fearfulness, irritability, inability to relax, fear of impending
o
Others: insomnia, increased sensitivity to noise, exaggerated startle response

DIFFERENTIAL DIAGNOSIS OF ANXIETY:
Medical Illnesses
Substance Use/Abuse
Psychiatric Disorders
Cardiac
Endocrinologic
Prescription or over-the-
? Adjustment
counter drug use
disorders
? Angina
? Hyperthyroidism
? Antidepressants
? Affective disorder
? Arrhythmias
? Cushing's disease
? Fenfluramine/phentermine
? Dissociative
disorders
? Congestive failure
? Hyperparathyroidism
? Psychostimulants (eg,
? Infarction
? Hypoglycemia
methylphenidate,
? Personality
amphetamine)
disorders
? Mitral valve
? Premenstrual
prolapse
? syndrome
? Steroids
? Somatoform
disorders
? Paroxysmal atrial
? Sympathomimetics
tachycardia
? Schizophrenia
(and other
psychotic
disorders)
Neoplastic
Neurologic
Substance abuse
? Carcinoid
? Huntington's disease
? Alcohol/sedative
? Insulinoma
? Meniere's disease
withdrawal
? Pheocromocytoma
? Migraine
? Caffeine
? Multiple sclerosis
? Hallucinogen
? Seizure disorder
? Stimulant abuse (eg,
? Transient ischemic
cocaine)
attack
? Vertigo
? Wilson's disease
Pulmonary
Other

---

? Asthma
? Porphyria
? Embolism
? Uremia
? Obstruction
? Obstructive
? pulmonary
disease

PANIC DISORDER
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.
o
Palpitations, pounding heart, or accelerated heart rate
o
Sweating
o
Trembling or shaking
o
Sensations of shortness of breath or smothering
o
Feeling of choking
o
Chest pain or discomfort
o
Nausea or abdominal distress-
o
Feeling dizzy, unsteady, lightheaded, or faint
o
Derealization or depersonalization
o
Fear of losing control or going crazy
o
Fear of dying
o
Paresthesias (numbness or tingling)
o
Chills or hot flashes

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

PHOBIA
? Insight is present.
? Agoraphobia
o
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
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
o
Erythro phobia: Fear of blushing.
? Simple (specific) phobia ? irrational fear of objects or situations
o
Claustro phobia- Fear of closed spaces
o
Acrophobia ? fear of high places.
o
Algophobia ? fear of pain
o
Arachnophobia- fear of spiders
o
Xeno phobia ?fear of strangers
o
Zoophobia ? fear of animals
o
Sito phobia - fear of eating
o
Thanatophobia ? fear of death

---

o
Cynophobia: fear of dogs
o
Mysophobia: fear of dirt & germs
o
Pyrophobia: fear of fire
o
Ailurophobia: fear of cats
Behavior therapy for phobia
? Flooding
? Systematic desensitization
? Exposure and response prevention
? Relaxation techniques
OBSESSIVE COMPULSIVE DISORDER
? Prevalence in the world 2-3%

Obsessions
Compulsions
? An idea, impulse or image which intrudes into
? A form of behaviour which usually follows
the conscious awareness repeatedly
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
? 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
? 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)

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

Clinical Manifestations
? Washers
o
Most common type
o
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
? 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
? New defences are needed as reaction formation is not enough
? Isolation of affect
Obsessive thoughts
? Undoing
Compulsive acts
? Displacement
Phobias

Treatment of choice:
? First: Behavior therapy - Exposure & response prevention
? 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)

---

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
? 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
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
Treatment
? SSRIs
? MAO inhibitors
? Benzodiazepines
? Behavior therapy, cognitive therapy

---

VII.
MOOD DISORDERS

MOOD DISORDERS
? Manic episode
? Depressive episode
? Bipolar mood disorder
? Recurrent depressive disorder
? Persistent mood disorder

MANIC EPISODE Symptoms should last for atleast 1 week for diagnosis
? Elevated, Expansive or Irritable mood:
o
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]
o
Ecstasy: very severe elevation of mood, seen in delirious/ stuporous mania [STAGE-4]
? Psychomotor activity
o
Increased
o
Rarely - manic stupor
? Speech and though
o
Flight of ideas
o
Prolixity
o
Mood congruent psychotic features
o
hallucinations
? Goal directed activity
? Reduced sleep

Treatment:
? Atypical antipsychotics (Risperidone, olanzapine, quetiapine, haloperidol)
? Mood stabilizers (Sodium valproate, Carbamazepine, Benzodiazepines, Lithium, Lamotrigine)

DEPRESSION Diagnostic Criteria
A. At least 2 weeks of duration
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
? Decrease / increase psychomotor activity (psychomotor retardation or agitation)
? Decrease / increase sleep (Insomnia/ hypersomnia)
? Fatigue
? Feeling of worthlessness or guilt
? Decreased concentration
? Recurrent thoughts of death.

Depressive ideation/Cognition:
? Sadness of mood (depression) is usually associated with pessimism, which can result in
o
Hopelessness
o
Helplessness
o
Worthlessness
? Difficulty in thinking, concentration, indecisiveness
? Nihilistic delusions (e.g: world is coming to an end)

---

Somatic syndrome (Melancholia) in depression
? 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
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
Theories
? Cognitive theory: Postulated by Aaron Beck consists of the following triad
o
About self - Negative self-precept
o
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
? 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.
? 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%)
? 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
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.
o
Psychological Factors: Freud's Theory/ Menninger's Theory

Evaluation of Suicide Risk

Variable
High Risk
Low Risk
Demographic and Social Profile
Age
Over 45 years
Below 45 years
Sex
Male
Female
Marital status
Divorced or widowed
Married
Employment
Unemployed
Employed
Interpersonal relationship Conflictual
Stable
Family background
Chaotic or conflictual
Stable
Health

---

Physical
Chronic illness
Good health
Hypochondriac
Feels healthy
Excessive substance intake
Low substance use
Mental
Severe depression
Mild depression
Psychosis
Neurosis
Severe personality disorder
Normal personality
Substance abuse
Social drinker
Hopelessness
Optimism
Suicidal activity
Suicidal ideation
Frequent, intense, prolonged
Infrequent, low intensity, transient
Suicide attempt
Multiple attempts
First attempt
Planned
Impulsive
Rescue unlikely
Rescue inevitable
Unambiguous wish to die
Primary wish for change
Communication internalized (self-
Communication externalized (anger)
blame)
Method lethal and available
Method of low lethality or not readily
Resources
available
Personal
Poor achievement
Good achievement
Poor insight
Insightful
Affect unavailable/ poorly
Affect available and appropriately controlled
Social
co
P n
o t
o r
r o
r ll
a e
p d
p ort
Good rapport
Socially isolated
Socially integrated
Unresponsive family
Concerned family

Risk Factors
? Age> 40 years
? Male sex
? Staying single
? Previous suicidal attempts
? Suicidal pre occupation (e.g. a written suicidal note)
? Depression
? Alcohol/ drug dependence
? Severe/ painful physical illness
? Recent serious loss or major stressful event
? Social isolation
? High degree of impulsivity
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
? 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
? SNRIs: venlafaxine, duloxetine

---

Neurotransmitters
? Mania: increased norepinephrine at the synaptic cleft
? 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
? 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
? 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
? Acute or abrupt onset
? Comorbid medical disorder, personality disorder or
? Typical clinical features
alcohol dependence
? Severe depression
? Double depression (acute depressive episode
? Well-adjusted premorbid
superimposed on chronic depression or dysthymia)
personality
? Catastrophic stress or chronic ongoing stress
? Good response to treatment
? Unfavorable early environment
? Marked Hypochondriacal features
? Mood incongruent psychotic features
? Poor drug compliance

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.
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.
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
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.
Note:
Dysthymia ? if the symptoms consist of persistent mild depression
Cyclothymia ?frequent mood swings of mild depression and mild elation.

---

VIII.
SOMATOFORM, DISSOCIATIVE & PERSONALITY DISORDERS

Type of Somatoform Disorder
Features
Hypochondriasis
? Persistent preoccupation with fear or belief of having serious
disease based on own interpretation
? Detailed physical examination and investigations do not reveal
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
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
? Refusal to accept reassurance
? More common in females
Conversion disorder
Features common to Conversion and Dissociative disorders
? Symptoms/sign affecting motor or
? Sudden onset
sensory function or convulsions
? Presence of precipitating stress
suggesting a neurological disorder
? Clear temporal relationship between stressor and development
? No ANS involvement
of symptoms
? Not intentionally produced
? There is usually a secondary gain
? Detailed physical examination and investigations do not reveal
any abnormality that can explain the symptoms adequately
Dissociative disorder
? More common in women
? Disturbance in normally integrated
functions of consciousness,
? Onset usually in 2nd or 3rd decade
identity and/or memory
Body dysmorphic disorder
Preoccupation with an imagined defect in appearance.
Somatoform pain disorder
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
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
? 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.

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
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

---

Clinical features
Epileptic seizures
Dissociative convulsions (Hysterical fits )
Attack pattern
Stereotyped, known clinical patterns
Absence of any established clinical pattern
Purposive body movements occur
Place of occurrence
Any where
Usually indoor or at safe places
Sleep
Can occur during sleep
Never occur during sleep
Tongue bite
Present
Absent
Incontinence of
Present
Absent
urine and faeces
Neurological signs
Present
Absent
Post ictal confusion
Present
Absent
Injury
Can occur
Very rare
Speech
No verbalization during seizure
Verbalization can occur during seizure
Duration
Short (30 ? 70 secs)
Prolonged
Head turning
Unilateral
Side to side
Eye gaze
Staring, if eyes are open
Avoidant gaze
Amnesia
Complete
Partial
EEG
Abnormal
Normal
Serum prolactin
Increased in post ictal period (15-20
Normal
minutes after seizure, returns to
normal in one hour)

GANSER SYNDROME (HYSTERICAL PSEUDODEMENTIA)
? Commonly found in prison inmates
? 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
? 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
PERSONALITY
? The four components in the concept of personality are:
? Adjustment
? Agreeableness
? Sociability
? 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.
? 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

DSM-IV-TR
ICD-10
Description
Paranoid
Paranoid
Excessive sensitiveness, tendency to bear grudges persistently,
suspiciousness, preoccupied with conspiratorial explanations, self-
referential, distrust of others.
Schizoid
Schizoid
Emotional coldness, lack of pleasure from activities, little interest
in sex, excessive preoccupation with introspection and fantasy.
Schizotypal
(classified with
Inappropriate affect, odd, eccentric or peculiar behavior, social
schizophrenia and
withdrawal, magical thinking, obsessive ruminations, transient
related disorders)
quasi-psychotic episodes
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.
Borderline
Emotionally unstable--
Disturbance of identity, unstable relationships, unpredictable
borderline type
affect, acts of self-harm, suicidal gestures, impulsivity, unstable
emotions
Histrionic
Histrionic
Self-dramatization, exaggerated emotions, shallow affect, attention
seeking, easily influenced by others, over-concern for physical
attractiveness
Narcissistic
Grandiosity, lack of empathy, need for admiration, preoccupation
with fantasies of unlimited success
Avoidant
Anxious (avoidant)
Tension, self-consciousness, fear of negative evaluation by others,
timid, insecure.
Obsessive-
Anankastic
Doubt, indecisiveness, caution, pedantry, rigidity, perfectionism,
compulsive
preoccupation with orderliness and control.
Dependent
Dependent
Clinging, submissive, excess need for care, feels helpless when not
in relationship.

---

IX.
MISCELLANEOUS

EATING DISORDERS

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
? 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
? 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
? 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)
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)
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.
? There are attempts to 'counteract' the effects of overeating by one or more of the following
o
Self-induced vomiting
o
Purgative abuse
o
Periods of starvation
o
Use of drugs such as appetite suppressants.

FEATURES
ANOREXIA NERVOSA
BULIMIA NERVOSA
Feature
Refusal to maintain body
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
eating
Weight
Markedly decreased
Usually normal
Binge eating
25-50%
Required for diagnosis
Amenorrhea
100%
50%
Ritualized exercise,
Common
Rare
decreased vitals (BP, PR),
hypothermia, skin changes
(hirsutism)

---

Patient believes that their
-Dental caries are frequent
body as a whole, or some part
-Antisocial behavior &drug abuse is common
of their body, is too fat.
-Prognosis is worse

CULTURE BOUND SYNDROMES
? Dhat syndrome
fear of losing semen
? Amok
sudden, unprovoked episode of rage
? Koro
strong belief that his penis is shrinking
? Wihtigo (windigo)
belief that he has been transformed to a cannibal.
? Pibloktoq
Arctic Hysteria
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.
? 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
? 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
? 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
? 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
Two phases:
1.
D-Sleep (desynchronized or dreaming sleep) OR REM-sleep (rapid eye movement sleep), active sleep or
paradoxical sleep.
2.
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.
? NREM ?sleep
o
Stage 1: first and the lightest stage of sleep, absence of alpha-waves, and low voltage, predominantly
theta activity.
o
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
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.
? 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.
? 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
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
? 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
? Common in preschool (3-6years) children

Characteristic
Sleep walking
Sleep terrors
Night mares
Nocturnal seizures
Timing during sleep
First third
First third
Last third
Variable, often during
sleep-wake transition
Stage of sleep
Slow wave
Slow wave
REM
Non REM > SWS
Arousal threshold
High
High
Low
High
Day time sleepiness
None
None
Yes
Probable
'
Recall of event
None
None
Frequent, vivid
None
Incidence
Common
Rare
Very common
Rare
Family history
Common
Common
None
Variable

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
transsexualism.
? Cross-dressing is commonly known as transvestism, and the cross-dresser as a transvestite.

IMPULSE CONTROL DISORDERS
Kleptomania (pathological stealing)
? 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
gain)
Pyromania (pathological fire-setting)
? Deliberate and purposeful fire setting on two or more occasions

---

? No apparent motive
? 90% are male.
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
?
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
?
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:

---

X.
TREATMENT MODALITIES

ANTIPSYCHOTIC DRUGS

TYPICAL (Neuroleptics, D2 blockers)
ATYPICAL
Phenothiazines
Thioxanthines
Butyrophenones
Miscellaneous
Clozapine , Olanzapine
Quetiapine,
Chlorpromazine
Flupenthixol
Haloperidol
Pimozide
Risperidone
Thioridazine
Thiothixene
Droperidol
Loxapine
Ziprasidone,
Trifluoperazine
Penfluridol
Iloperidone,
Fluphenazine
Lurasidone,
Aripiprazole,
Asenapine
? Longest acting: Fluphenazine (2-4 weeks), Penfluridol (1 week).
? Longest half- life: Aripiprazole (75 hours)
? Shortest half-life: Quetiapine (6 hours)
? Least potent: Chlorpromazine
? With antidepressant action: Flupenthixol.
? More emetic potential: Clozapine/ Olanzapine/ Risperidone/ Molindone
Actions
Extra pyramidal symptoms
Sedation
Hypotension
Anti emetic
Maximum: Haloperidol
Maximum: Chlorpromazine,
Maximum:
Triflupromazine,
Least: Thioridazine
Triflupromazine,
Thioridazine,
Trifluoperazine
Almost nil: Clozapine,
Thioridazine, Clozapine &
Clozapine &
Fluphenazine,
Risperidone
Quetiapine
Risperidone
Haloperidol
? All anti psychotics are potent antiemetics except Thioridazine & atypical drugs.
? 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 &
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.
? 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.
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.
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
-- 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.
? 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
? 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
Time of
Mechanism
Treatment
maximal risk
Acute dystonia
Spasm of muscles of
1-5 days
Unknown
Anti parkinsonian agents
tongue, face, neck,
are diagnostic
back, may mimic
and curative
seizures, not hysteria
Akathisia
Motor restlessness,
5-60 days
Unknown
Reduce dose or change
not anxiety or agitation
drug; anti parkinsonian
drugs, BDZ / propranolol
may help
Parkinsonism
Bradykinesia, rigidity,
5-30 days; can
Antagonism of
Anti parkinsonian
variable tremor, mask
recur even after dopamine
agents helpful
facies, shuffling gait
a single
dose
Neuroleptic
Catatonia, stupor,
Weeks; can
Antagonism of
Stop neuroleptic;
malignant
fever, unstable BP,
persist for days
dopamine
Dantrolene /
syndrome
myoglobinemia, can be
after stopping
bromocriptine may
fatal
neuroleptic
help. Anti parkinsonian
agents not useful
Perioral tremor "
Perioral tremor (may
After months
Unknown
Anti parkinsonian
rabbit syndrome"
be a late variant of
or years of
agents often help
parkinsonism)
treatment
Tardive dyskinesia
Oral- facial dyskinesia;
After months
Excess function
Prevention crucial;
Widespread
or years of
of dopamine
Treatment
choreoathetosis or
treatment
hypothesized
unsatisfactory
dystonia
(worse on
withdrawal)
Adverse effect
Maximum with
Minimum with
Dry mouth, constipation, cycloplegia
Chlorpromazine
Haloperidol, Risperidone
Impotence, orthostatic hypotension
Chlorpromazine
Aripiprazole
Impaired ejaculation
Thioridazine
Haloperidol
Parkinsonian features [tremor]
Haloperidol
Clozapine, quetiapine, aripiprazole
Akathisia, acute dystonia, rabbit
Haloperidol
Clozapine, quetiapine
syndrome

---

Tardive dyskinesia
-
Clozapine
Neuroleptic malignant syndrome
Probably haloperidol
-
Seizures
Clozapine, chlorpromazine
Trifluperazine
Sedation
Clozapine, chlorpromazine
Haloperidol , aripiprazole
Weight gain
Clozapine , olanzapine
Haloperidol , aripiprazole
Diabetes
Clozapine , olanzapine
Ziprasidone, aripiprazole
Agranulocytosis
Clozapine
-
ECG changes
Thioridazine, pimozide
Aripiprazole
Ocular granular deposits
Chlorpromazine
Haloperidol
Pigmentary retinopathy
Thioridazine
-
Contact dermatitis, photosensitive
Chlorpromazine
-
reactions, Blue- gray metallic
discoloration
ANTI ANXIETY DRUGS
? Reduction in the GABAergic activity or increase in serotonergic activity
anxiety.

BENZODIAZEPINES
? Chlordiazepoxide is used for chronic anxiety states
? Oxazepam, lorazepam, alprazolam and diazepam for short lasting anxiety.

AZAPIRONES
? Buspirone, gepirone and ipsapirone (partial agonists of presynaptic 5-HT1A)
decrease the release of
serotonin.
? 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
? 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:

Cyclic anti-
Tricyclic tertiary amines
Imipramine, amitriptyline, doxepine,
depressants
Clomipramine, Dothiepine [Dosulepin]
Tricyclic secondary amines
Nortriptyline, protriptyline, desipramine
Tetracyclic
Mianserin, maprotiline, amoxapine
Bicyclic
Viloxazine
Selective serotonin reuptake inhibitor [SSRIs]
Fluoxetine, paroxetine, fluvoxamine,
sertraline, citalopram, escitalopram
Serotonin norepinephrine reuptake inhibitors [SNRIs]
Venlafaxine, duloxetine
Norepinephrine serotonin reuptake enhancers [NSRE's]
Tianeptin
Noradrenergic and specific serotonergic antidepressant [NaSSA]
Mirtazepine
Norepinephrine dopamine reuptake inhibitors [NDRIs]
Bupropion
Serotonin antagonists and reuptake inhibitors [SARIS]
Trazadone, nefazodone

---

Noradrenergic reuptake inhibitors [NARIs]
Reboxetine
Mono amine
Irreversible
oxidase
Reversible
MAGI-B
Selegiline
inhibitors
MAGI-A
Moclobemide
? 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,
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
? 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
? 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
? 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.
? 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
New
? Lithium
? Lamotrigine
? Carbamazepine
? Levo thyroxine (T3)
? Valproate
? Calcium channel blockers
? Clorgyline
? Clonazepam
? Gabapentin
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:
? 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:
? 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.
? Reduce thyroxine synthesis & leads to goiter & hypothyroidism.
Indications
? Acute mania
? Bipolar mood disorders
? Schizo-affective disorder
? Prophylaxis of unipolar mood disorder
? Cyclothymia
? Acute depression
? Chronic alcoholism (in the presence of significant depressive symptoms)
? Impulsive aggression
? 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.
Indications
? Major severe depression with
? Suicidal risk - first, most important and most common indication
o
Stupor
o
Poor intake of food and fluids
o
Melancholia
o
Psychotic features
o
Unsatisfactory response to drug therapy
o
Contraindication to drugs
? Severe psychosis (Schizophrenia or mania) with
? Risk of suicide, homicide or physical assault
o
Unsatisfactory response to drug therapy
o
Contraindication to drugs
o
Prominent depressive features (e.g: schizo-affective disorder)
? Severe catatonia (non-organic) with
? Stupor
? Poor intake of food and fluids
? Unsatisfactory response to drug therapy
? Contraindication to drugs
Contraindications:
? ABSOLUTE: Raised intra cranial tension (fear of brain herniation)
? Relative
o
Cerebro vascular accident (CVA)
o
Recent MI
o
Severe hypertension
o
Pheochromocytoma
o
Severe pulmonary disease
o
Retinal detachment

---

Types:
? Direct ECT (unmodified): ECT is given without muscle relaxants and anesthesia. Direct ECT causes decreased
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)
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
? 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
Based on
Used in
Systemic
Reciprocal inhibition
Phobias (treatment of choice)
desensitization
OCD (treatment of choice)
Psycho-sexual dysfunctions
Aversion therapy
Pairing of pleasant stimulus with an
Drug abuse
unpleasant responses e.g. Pairing alcohol with
Sexual deviations
electric shock
Flooding
Direct exposure to phobia but escape not
Phobias
possible
Operant conditioning
Positive reinforcement
For augmenting an adaptive
for increasing a
Negative reinforcement
behavior
behavior
Modeling
Operant conditioning
Time out
For demoting maladaptive
for decreasing a
Punishment
behavior
behavior
Satiation(negative practice procedure)
Other physical treatments for Depression

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).
? 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
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.

---

? 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
ECT and restarted immediately post-ECT.
*****END*****

---