DAMS COMPREHENSIVE

REVIEW SERIES

Short Subjects
Psychiatry
For PG Medical Entrance
–Especially made for
NIMHANS—
 CONTENTS
Chapter - 01: GENERAL PSYCHIATRY
Chapter - 02: PSYCHOLOGY
Chapter - 03: SCHIZOPHRENIA AND
OTHER PSYCHOTIC DISORDERS
Chapter - 04: MOOD DISORDERS
Chapter - 05: NEUROTIC DISORDERS
Chapter - 06: ORGANIC MENTAL
DISORDERS
Chapter - 07: SUBSTANCE USE
DISORDERS
Chapter - 08: MISCELLANEOUS
QUESTIONS BANK
Important Topics
1. Classification in Psychiatry
2. Epidemiology of psychiatric
disorders
3. Examination in psychiatry
4. Basic Terminologies

CLASSIFICATION IN PSYCHIATRY

ICD-10 DSM IV
(International (Diagnostic
Classification and statistica
of Diseases) manual)
Disorders Mental
All
covered disorders
Limited to few
Acceptability Universal
nations
APA
(American
Published by WHO
Psychological
 Association)
Multi-axial
approach
AXIS I: Clinica
Psychiatric
Diagnosis
AXIS II:
Personality
Disorders and
Mental
Retardation
AXIS III:
Commonly Single axis General
used as diagnosis Medical
Conditions
AXIS IV:
Psychosocial
and
Environmenta
Problems
AXIS V: Globa
Assessment o
Functioning:
Current and in
past one year
Points to remember:
1) DSM 5 is latest DSM, which does
not recommend multi-axial
approach to diagnosis
2) In India, both ICD and as well as
DSM are followed in routine
practice.
3) There is no GAF score (Axis 5) in
DSM 5.

MENTAL HEALTH CENSUS

Census (Kaplan Textbook)

Mental Health Census
Lifetime Li
Disorder Prevalence Disorder P
(%) (%
Any anxiety Mood
28.8 2
disorder disorder
Major
Panic disorder 4.7 1
depression
Agoraphobia
1.4 Dysthymia 2
without panic
Specific Bipolar 1 or
12.5 3
phobia 11
Impulse-
Social phobia 12.1 control 2
disorder
Generalized Oppositional-
anxiety 5.7 defiant 8
disorder disorder
Posttraumatic
Conduct
stress 6.8 9
disorder
disorder
Attention-
Obsessive-
1.6 deficit 8
compulsive
hyperactivity
Separation Intermittent
5.2 5
anxiety explosive
Substance
1
disorder
Alcohol
1
abuse
Alcohol
5
 dependence
Drug abuse 7

Points to remember (Psychiatric

Epidemiology)
1) All answers to questions asked
related to prevalence of
psychiatric disorders, should be
as per above stated mental
health census data (most
reliable, 2003 data, published in
Kaplan)
2) As a group Any Anxiety Disorder
(28.8) > Mood Disorders (20.8),
but if individually asked than
major depressive disorder (16.6)
carries highest prevalence.
3) Most DALY lost is due to
depression.

EXAMINATION IN PSYCHIATRY AND

BASIC TERMINOLOGIES TO
REMEMBER
A complete psychiatric work up of
the patient needs to have following:
(History + Examination)
I. Psychiatric History:
A. Identification Data
B. Chief complaints
C. History of present illness
D. Past psychiatric and medical
history
E. Family history
F. Personal history
II. Mental Status Examination:
A. Appearance and Behaviour
B. Speech: Rapid, slow,
pressured, hesitant,
emotional, monotonous, loud,
whispered, slurred, mumbled,
stuttering, echolalia (repetition
of examiner’s commands),
intensity, pitch, ease,
spontaneity, productivity,
manner, reaction time,
vocabulary, prosody(flow)
 C. Mood and affect
1. Mood (a pervasive and sustained
emotion that colours the person's
perception of the world): How does
patient say he or she feels; depth,
intensity, duration, and
fluctuations of mood ; depressed,
despairing, irritable, anxious,
terrified, angry, expansive,
euphoric (normal mood), empty,
guilty, awed, futile, self-
contemptuous, anhedonic (lack of
interest in previously pleasurable
activities), alexithymic (inability to
express emotions)
2. Affect (the outward expression of
the patient's inner experiences) :
Objective assessment
D. Thinking and perception
1. Form of thinking : neologisms
(coining new words), loose
associations (the ideas expressed
seem unrelated and
 idiosyncratically connected)
2. Flow of thinking
a. Productivity: Overabundance
of ideas, paucity of ideas, flight
of ideas(A succession of
multiple associations so that
thoughts seem to move
abruptly from idea to idea;
often (but not invariably)
expressed through rapid,
pressured speech), rapid
thinking, slow thinking,
hesitant thinking; does patient
speak spontaneously or only
when questions are asked,
stream of thought, quotations
from patient
b. Continuity of thought:
Whether patient's replies
really answer questions and
are goal directed, tangential,
circumstantial,
perseverative(persistence of
 same response beyond point
of relevance), clang
associations (linked by
rhyming)
Circumstantiality indicates the loss
of capacity for goal-directed
thinking; in the process of
explaining an idea, the patient
brings in many irrelevant details
and parenthetical comments but
eventually does get back to the
original point. Tangentiality is a
disturbance in which the patient
loses the thread of the
conversation, pursues divergent
thoughts stimulated by various
external or internal irrelevant
stimuli, and never returns to the
original point.
3. Content of thinking
a. Preoccupations
b. Delusions
c. Obsessions
4. Perceptual disturbances
a. Hallucinations and illusions:
Whether patient hears voices
or sees visions; content,
sensory system involvement,
circumstances of the
occurrence; hypnagogic or
hypnopompic
hallucinations(sleep related)
b. Depersonalization and
derealization: Extreme feelings
of detachment from self or
from the environment.
E. Sensorium
1. Alertness: Awareness of
environment, attention span,
clouding of consciousness,
fluctuations in levels of
awareness, somnolence, stupor,
lethargy, fugue state, coma
2. Orientation
a. Time: Whether patient
identifies the day correctly; or
 approximate date, time of day;
if in a hospital, knows how
long he or she has been there;
behaves as though oriented to
the present
b. Place: Whether patient knows
where he or she is
c. Person: Whether patient
knows who the examiner is
and the roles or names of the
persons with whom in contact
3. Concentration and calculation:
Subtracting 7 from 100 and keep
subtracting 7s (Serial 100-7
subtraction test)
4. Memory:
a. Remote memory: Childhood
data, important events known
to have occurred when the
patient was younger or free of
illness, personal matters,
neutral material
b. Recent past memory: Past few
 months
c. Recent memory: Past few days,
what did patient do yesterday,
the day before, have for
breakfast, lunch, dinner
d. Immediate retention and
recall: Ability to repeat six
figures after examiner dictates
them first forward, then
backward, then after a few
minutes' interruption
5. Abstract thinking: Disturbances
in concept formation; manner in
which the patient conceptualizes
or handles his or her ideas;
similarities (e.g., between apples
and pears), differences,
absurdities; meanings of simple
proverbs (e.g., A rolling stone
gathers no moss) answers may
be concrete (giving specific
examples to illustrate the
meaning) or overly abstract
 (giving generalized explanation);
appropriateness of answers
F. Insight: Degree of personal
awareness and understanding of
illness
G. Judgment and Reasoning
Important topics:
1) Piaget’s Theory
2) Freudian Theory
3) Freudian Stages
4) Erikson’s Stages
5) Learning theories
6) Defence mechanisms

TOPIC 1: PIAGET’S THEORY OF

COGNITIVE DEVELOPMENT (MAY
AIIMS)
TOPIC 2: FREUD’S PSYCHOSEXUAL
STAGES OF DEVELOPMENT

Psych
syndro
Normal to resu
Age
No. Stage Development from f
Range
(gratification) (and
regres
to this
 1. Dep
person
traits a
Major site of disord
gratification is 2.
the oral Schizo
region. 3. Seve
1. Oral 0-1.5y
i. Oral erotic mood
phase (sucking) disord
ii. Oral sadistic 4. Alco
phase (biting) depen
syndro
and dr
depen
Major site of
gratification is
the anal area;
1. Obs
It consists of 2
compu
phases:
person
i. Anal erotic
traits a
2. Anal 1.5-3y phase
disord
(excretion)
2. OCD
ii. Anal sadistic
sadisti
phase
phase)
(’holding’ and
’letting go’ at
will)

Major site of
gratification is
the genital
area;
According to
Freud, this
development is
different
in both sexes.
Male
development
The boy
develops
castration
anxiety (fear
of castration
at the hand of
his father in
retaliation
for the boy’s
desire to
replace his
father in his
mother’s
 affections).
This leads to
formation of
the Oedipus
complex
(aggressive
impulses
directed
towards the
father; named
after the Greek
tragedy
Oedipus rex in
which Oedipus
unknowingly 1. Sexu
kills his father deviat
3. Phallic 3-5y and marries his 2. Sexu
mother, dysfun
unaware of 3. Hys
their true
identities).
Oedipus
complex is
usually
resolves by
identification
with father,
attempting to
adopt his
characteristics.
Female
development
The girl
develops penis
envy
(discontent
with female
genitalia
following a
fantasy that
they result
from loss of
penis). This is
theorised by
Freud to
lead to a wish
to ’receive’ the
penis and to
bear a child.
Resolution
occurs by
identification
 with the
mother. This
phase has
been called as
Electra
complex.
Oedipus (and
Electra)
complex is
usually
resolved at the
beginning of
this stage. This
is a
stage of
relative sexual
quiescence.
Super-ego is
Neuro
4. Latency 5-12y formed at this
disord
stage. Sexual
drive is
channelized
into socially
appropriate
goals such as
development
 of
interpersonal
relationships,
sports, school,
work, etc.
Adult sexuality
develops.
Neuro
5. Genital >12y True self-
disord
identity
develops.

TOPIC 3 : FREUD’S STRUCTURAL AND

TOPOGRAPHICAL THEORY
2 model’s of freud:
1. Topographical model
(Preconscious, Unconscious and
Conscious)
2. Structural model (Id, Ego And
Superego)

CONTRIBUTIONS OF FREUD:
1. Father of classical psychoanalysis
2. Gave models of mind
3. Dream analysis (He said “dream is
a royal road to unconsciousness”)
4. Coined the terms transference,
countertransference, neurosis
5. Gave concept of hysteria
6. First description of defence
mechanisms (Later the classification
of defence mechanisms was given by
George Valliant)

TOPIC 4: ERIK ERIKSON’S STAGES OF

PSYCHOSOCIAL DEVELOPMENT
Erikson’s Theory of Psychosocial
Development has eight distinct
stages, each with two possible
outcomes. According to the theory,
successful completion of each stage
results in a healthy personality and
successful interactions with others.
Failure to successfully complete a
stage can result in a reduced ability
to complete further stages and
therefore a more unhealthy
personality and sense of self.
1) Stage 1: Trust Versus Mistrust.
(From birth to one and half year)
children begin to learn the ability to
trust others based upon the
consistency of their caregiver(s). If
trust develops successfully, the child
gains confidence and security in the
world around him and is able to feel
secure even when threatened.
Unsuccessful completion of this
stage can result in an inability to
trust, and therefore an sense of fear
about the inconsistent world. It may
result in anxiety, heightened
insecurities, and an over feeling of
mistrust in the world around them.
2) Stage 2 : Autonomy vs. Shame and
Doubt. (Between the ages of one
and half years and three), children
begin to assert their independence,
by walking away from their mother,
picking which toy to play with, and
making choices about what they like
to wear, to eat, etc. If children in this
stage are encouraged and supported
in their increased independence,
they become more confident and
secure in their own ability to survive
in the world. If children are
criticized, overly controlled, or not
given the opportunity to assert
themselves, they begin to feel
inadequate in their ability to
survive, and may then become
overly dependent upon others, lack
self-esteem, and feel a sense of
shame or doubt in their own
abilities.
3) Stage 3: Initiative vs. Guilt.
(Around age three and continuing to
age five), children assert themselves
more frequently. They begin to plan
activities, make up games, and
initiate activities with others. If given
this opportunity, children develop a
sense of initiative, and feel secure in
their ability to lead others and make
decisions. Conversely, if this
tendency is squelched, either
through criticism or control, children
develop a sense of guilt. They may
feel like a nuisance to others and
will therefore remain followers,
lacking in self-initiative.
4) Stage 4: Industry vs. Inferiority.
(From age 5-13y), children begin to
develop a sense of pride in their
accomplishments. They initiate
projects, see them through to
completion, and feel good about
what they have achieved. During this
time, teachers play an increased role
in the child’s development. If
children are encouraged and
reinforced for their initiative, they
begin to feel industrious and feel
confident in their ability to achieve
goals. If this initiative is not
encouraged, if it is restricted by
parents or teacher, then the child
begins to feel inferior, doubting his
own abilities and therefore may not
reach his potential.
5) Stage 5: Identity vs. Role
Confusion. (13-21y) During
adolescence, the transition from
childhood to adulthood is most
important. Children are becoming
more independent, and begin to
look at the future in terms of career,
relationships, families, housing, etc.
During this period, they explore
possibilities and begin to form their
own identity based upon the
outcome of their explorations. This
sense of who they are can be
hindered, which results in a sense of
confusion ("I don’t know what I want
to be when I grow up") about
themselves and their role in the
world.
6) Stage 6: Intimacy vs. Isolation. (21-
40y) Occurring in Young adulthood,
we begin to share ourselves more
intimately with others. We explore
relationships leading toward longer
term commitments with someone
other than a family member.
Successful completion can lead to
comfortable relationships and a
sense of commitment, safety, and
care within a relationship. Avoiding
intimacy, fearing commitment and
relationships can lead to isolation,
loneliness, and sometimes
depression.
7) Stage 7: Generativity vs.
Stagnation.(41-60y) During middle
adulthood, we establish our careers,
settle down within a relationship,
begin our own families and develop
a sense of being a part of the bigger
picture. We give back to society
through raising our children, being
productive at work, and becoming
involved in community activities and
organizations. By failing to achieve
these objectives, we become
stagnant and feel unproductive.
8) Stage 8: Ego Integrity vs. Despair.
(61-beyond) As we grow older and
become senior citizens, we tend to
slow down our productivity, and
explore life as a retired person. It is
during this time that we
contemplate our accomplishments
and are able to develop integrity if
we see ourselves as leading a
successful life. If we see our lives as
unproductive, feel guilt about our
pasts, or feel that we did not
accomplish our life goals, we
become dissatisfied with life and
develop despair, often leading to
depression and hopelessness.

(This topic is given here in details for

proper understanding, individual
stage identification questions can be
expected in future exams)

Topic 5 : Defence mechanisms

The ego deals with the demands of
reality, the id, and the superego as
best as it can. But when the anxiety
becomes overwhelming, the ego
must defend itself. It does so by
unconsciously blocking the impulses
or distorting them into a more
acceptable, less threatening form.
The techniques are called the ego
defense mechanisms

Narcssistic defenses:
1) Denial involves blocking external
events from awareness. If some
situation is just too much to handle,
the person just refuses to
experience it.
2) Projection, involves the tendency
to see your own unacceptable
desires in other people

Immature defense:
1) Regression is a movement back in
psychological time when one is faced
with stress. When we are troubled
or frightened, our behaviors often
become more childish or primitive
2) Introjection, sometimes called
identification, involves taking into
your own personality characteristics
of someone else, because doing so
solves some emotional difficulty.
3) Acting Out: Conflicts are
translated into action with little or
no intervening reflection. The
unconscious fantasy is lived out
impulsively in behavior, thereby
gratifying the impulse, rather than
the prohibition against it.

Neurotic defenses:
1) Repression, is just that: not being
able to recall a threatening
situation, person, or event. Most
basic defence mechanism and is
mother of all other defence
mechanisms.
2) Reaction formation, is changing
an unacceptable impulse into its
opposite.
3) Displacement is the redirection of
an impulse onto a substitute target.
If the impulse, the desire, is okay
with you, but the person you direct
that desire towards is too
threatening, you can displace to
someone or something that can
serve as a symbolic substitute.
4) Rationalization is the cognitive
distortion of "the facts" to make an
event or an impulse less
threatening. We do it often enough
on a fairly conscious level when we
provide ourselves with excuses. But
for many people, with sensitive
egos, making excuses comes so easy
that they never are truly aware of it.
In other words, many of us are quite
prepared to believe our lies.
5) Undoing involves "magical"
gestures or rituals that are meant to
cancel out unpleasant thoughts or
feelings after they've already
occurred.

Mature defenses:
1) Asceticism, or the renunciation of
social needs; Eliminating the
pleasurable effects of experience.
2) Altruistic surrender is a form of
projection that at first glance looks
like its opposite: Here, the person
attempts to fulfill his or her own
needs vicariously, through other
people.
3) Sublimation is the transforming of
an unacceptable impulse, whether it
be sex, anger, fear, or whatever, into
a socially acceptable, even
productive form.
4) Anticipation: Realistically
anticipating or planning for future
inner discomfort
5) Humour: Emphasizing the
amusing or ironic aspects of the
conflict or stressors.
6) Suppression: The conscious
process of pushing unacceptable
thoughts into the preconscious.
Discomfort is acknowledged but
minimized.
TOPIC 6 : LEARNING THEORIES
There are three types of learning:
(1) In classic conditioning, learning is
thought to take place as a result of
the contiguity of environmental
events; when events occur closely
together in time, persons will
probably come to associate the two.
Classic (also called respondent)
conditioning results from the
repeated pairing of a neutral
(conditioned) stimulus with one that
evokes a response (unconditioned
stimulus), such that the neutral
stimulus eventually comes to evoke
the response. (CLASSICAL PAVLOV
EXPERIMENT)
(2) In operant conditioning, learning
is thought to result from the
consequences of a person's actions.
It is a form of learning in which
behavioural frequency is altered
through the application of positive
and negative consequences
(3) Social learning theory
incorporates both classic and
operant models of learning, but also
considers a reciprocal interaction
between the person and the
environment.

There are also questions asked on

different forms of operant
conditioning, and students gets
confused between reinforcements
and punishments.
Premack's Principle (TYPE OF
OPERANT CONDITIONING ONLY)
(NOV AIIMS)
• It states that a behavior engaged
in with high frequency can be used
to reinforce a low-frequency
behavior.
• “In one experiment, Premack
observed that children spent more
time playing with a pinball machine
than eating candy when both were
freely available. When he made
playing with the pinball machine
contingent on eating a certain
amount of candy, the children
increased the amount of candy they
ate.”
• This principle is also known as
Grandma's rule (If you eat your
spinach, you can have dessert).
Epidemiology of Schizophrenia:
1) In the United States, the lifetime
prevalence of schizophrenia is about
1 percent, which means that about 1
person in 100 will develop
schizophrenia during their lifetime.
The Epidemiologic Catchment Area
study sponsored by the National
Institute of Mental Health reported
a lifetime prevalence of 0.6 to 1.9
percent.
2) According to DSM-IV-TR, the
annual incidence of schizophrenia
ranges from 0.5 to 5.0 per 10,000
3) Schizophrenia is equally prevalent
in men and women. In general, the
outcome for female schizophrenia
patients is better than that for male
schizophrenia patients. When onset
occurs after age 45, the disorder is
characterized as late-onset
schizophrenia.

Prevalence of Schizophrenia in
Specific Populations
Prevalence
Population
{%)
General population 1
Non-twin sibling of a
8
schizophrenia patient
Child with one parent with
12
schizophrenia
Dizygotic twin of a
12
schizophrenia patient
Child of two parents with
40
schizophrenia
Monozygotic twin of a
47
schizophrenia patient
Neurotransmitters in schizophrenia:
1) Dopamine Hypothesis:
Schizophrenia results from too much
dopaminergic activity.
2) Serotonin: Current hypotheses
posit serotonin excess as a cause of
both positive and negative
symptoms in schizophrenia.
3) Norepinephrine: A selective
neuronal degeneration within the
norepinephrine reward neural
system could account for anhedonia
in schizophrenia.
4) GABA: patients with
schizophrenia have a loss of
GABAergic neurons in the
hippocampus.
5) Neuropeptide: substance P and
neurotensin
6) Glutamate: Glutamate has been
implicated because ingestion of
phencyclidine, a glutamate
antagonist, produces an acute
syndrome similar to schizophrenia.
7) Acetylcholine and Nicotine:
Postmortem studies in schizophrenia
have demonstrated decreased
muscarinic and nicotinic receptors

DIAGNOSTIC CRITERIA OF
SCHIZOPHRENIA (DSM- IV TR)
A. Characteristic symptoms: Two (or
more) of the following, each present
for a significant portion of time
during a 1-month period (or less if
successfully treated):
1. delusions
2. hallucinations
3. disorganized speech (e.g.,
frequent derailment or incoherence)
4. grossly disorganized or catatonic
behavior
5. negative symptoms, i.e., affective
flattening, alogia, or avolition
Note: Only one Criterion A 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.
B. Social/occupational dysfunction:
For a significant portion of the time
since the onset of the disturbance,
one or more major areas of
functioning such as work,
interpersonal relations, or self-care
are markedly below the level
achieved prior to the onset (or when
the onset is in childhood or
adolescence, failure to achieve
expected level of interpersonal,
academic, or occupational
achievement).
C. Duration: Continuous signs of the
disturbance persist for at least 6
months. This 6-month period must
include at least 1 month of
symptoms (or less if successfully
treated) that meet Criterion A (i.e.,
active-phase symptoms) and may
include periods of prodromal or
residual symptoms. During these
prodromal or residual periods, the
signs of the disturbance may be
manifested by only negative
symptoms or two or more symptoms
listed in Criterion A present in an
attenuated form (e.g., odd beliefs,
unusual perceptual experiences).
D. Schizoaffective and mood disorder
exclusion: Schizoaffective disorder
and mood disorder with psychotic
features have been ruled out
because either (1) no major
depressive, manic, or mixed
episodes have occurred concurrently
with the active-phase symptoms; or
(2) if mood episodes have occurred
during active-phase symptoms, their
total duration has been brief
relative to the duration of the active
and residual periods.
E. Substance/general medical
condition exclusion: The disturbance
is not due to the direct physiological
effects of a substance (e.g., a drug of
abuse, a medication) or a general
medical condition.
F. Relationship to a pervasive
developmental disorder: If there is a
history of autistic disorder or
another pervasive developmental
disorder, the additional diagnosis of
schizophrenia is made only if
prominent delusions or
hallucinations are also present for at
least a month (or less if successfully
treated).
NOTE :
1) IN DSM 5, THERE ARE NO
SUBTYPES OF SCHIZOPHRENIA
2) DSM-5 raises the symptom
threshold, requiring that an
individual exhibit at least two of the
specified symptoms. (In DSM-IV, that
threshold was one.)
3) ICD-10 CRITERIA SPECIFIES
MINIMUM SURATION TO DIAGNOSE
SCHIZOPHRENIA AS 1 MONTH

SUBTYPES OF SCHIZOPHRENIA

DSM-IV KEY FEATURES

Persecutory, systematized
delusions; Most common
Paranoid form of schizophrenia
type Hallucinations, usually
auditory; Personality
relatively preserved
Early onset; Odd behavior;
Labile or inappropriate
mood ; Poor prognosis
Disorganized Mirror gazing, giggling, silly
type smiles; Disorganized
speech and behavior(often
silly/shallow) and flat or
inappropriate affect
Psychomotor disturbance
viz stupor, mutism,
excitement, negativism,
Catatonic waxy flexibility, automatic
type obedience, echopraxia.
 best response to ECT but
best response to BZD esp:
lorazepam.
Social withdrawal, more
Simple Type negative symptoms, worst
prognosis

Features Weighting Toward Good to

Poor Prognosis in Schizophrenia

Good Prognosis Poor Prognosis

Late onset Young onset
Obvious precipitating No precipitating
factors factors
Acute onset Insidious onset
Good premorbid Poor premorbid
social, sexual, and social, sexual, and
work histories work histories
Mood disorder Withdrawn,
symptoms (especially autistic behavior
depressive disorders)

Single, divorced,
Married
 or widowed
Family history of Family history of
mood disorders schizophrenia
Good support Poor support
systems systems
Negative
symptoms
Neurological signs
and symptoms
Positive symptoms History of
perinatal trauma
No remissions in 3
years
Many relapses

Treatment Of Schizophrenia:
Antipsychotics (1st generation and
2nd generation)

Extrapyramidal SIDE EFFECTS of

AntiPsychotic medications:
AKATHISIA –
• Greek word means inability to sit
still or inner restless or urges to
move.
• Subjective and objective
restlessness.
• Propranolol is effective

ACUTE DYSTONIA:
• Slow, sustained painful muscular
contraction one group of muscle.
• Spasm of muscles of trunk, head
and neck.
• Risk Factor--- young male, high
potency dopamine receptor
antagonist.
• Treatment: Anti – Parkinsonism
drugs.

PARKINSONISM
• Symptoms like rigidity,
bradykinesia, shuffling gait and
tremor,
• Treatment: Anti – Parkinsonism
drugs.
NEUROLEPTIC MALIGNANT
SYNDROME –
• Life threatening
• Main features,
Hyperthermia
Muscular rigidity
Autonomic instability including
hyperthermia, tachycardia, increased
blood pressure,’ tachypnea and
dipahoresis,
Changing leves of sensorium;
• Often CPK Creatinine
phosphokinase increased
• Treatment:
1. Dantrolene iv.
2. orally Bromocriptine and
Amantadine

TARDIVE DYSKINESIA
• Delayed painless peri-oral
movements
• Movement disorders that may
occur following long – term
treatment with anti – psychotic
medication. Mainly mouth and
tongue movements. Rabbit
Syndrome
• Risk Factors : Increasing age,
mainly elderly female; Mood
disorder patients, Dosage and
duration of medication.
• Perioral tremor is uncommon S/E
which is called as rabbit syndrome
• Treatment- Clozapine may be
started. It carries minimal risk of TD.

DELUSIONAL DISORDERS
Delusion A false belief based on
incorrect inference about external
reality that is firmly sustained
despite what almost everyone else
believes and despite what
constitutes incontrovertible and
obvious proof of evidence to the
contrary. The belief is not one
ordinarily accepted by other
members of the person's culture or
subculture (e.g., it is not an article of
religious faith).
TYPES :
• Erotomanic type: delusions that
another person, usually of higher
status, is in love with the individual.
• Grandiose type: delusions of
inflated worth, power, knowledge,
identity, or special relationship to a
deity or famous person
• Jealous type: delusions that the
individual's sexual partner is
unfaithful
Persecutory type: delusions that the
person (or someone to whom the
person is close) is being
malevolently treated in some way
• Somatic type: delusions that the
person has some physical defect or
general medical condition
Schizoaffective disorder :
Schizoaffective disorder has features
of both schizophrenia and affective
disorders (now called mood
disorders).

Acute Psychosis : < 1 month of

symptoms (ICD-10)
Brief Psychotic Disorder : < 1 month
of symptoms (DSM)
Schizophreniform Disorder : 1-6
months of symptom (DSM)
EPIDEMOLOGY OF MOOD DISORDERS
1) In the most recent surveys, major
depressive disorder has the highest
lifetime prevalence (almost 17
percent) of any psychiatric disorder.
2) There is twofold greater
prevalence of major depressive
disorder in women than in men.
Bipolar I disorder has an equal
prevalence among men and women.
Manic episodes are more common in
men, and depressive episodes are
more common in women.
3) No correlation has been found
between socioeconomic status and
major depressive disorder.
4) Depression is more common in
rural areas than in urban areas.

Neurotransmitters in mood
disorders:
Of the biogenic amines,
norepinephrine and serotonin are
the two neurotransmitters most
implicated in the pathophysiology of
mood disorders.
1) Norepinephrine: Clinical
antidepressant responses is
probably the single most compelling
piece of data indicating a direct role
for the noradrenergic system in
depression.
2) Serotonin: Depletion of serotonin
may precipitate depression, and
some patients with suicidal impulses
have low cerebrospinal fluid (CSF)
concentrations of serotonin
metabolites and low concentrations
of serotonin uptake sites on
platelets.
3) Dopamine: The data suggest that
dopamine activity may be reduced in
depression and increased in mania.
4) Other Neurotransmitter
Disturbances: Cholinergic agonist
and antagonist drugs have
differential clinical effects on
depression and mania. Agonists can
produce lethargy, anergia, and
psychomotor retardation in healthy
subjects, can exacerbate symptoms
in depression, and can reduce
symptoms in mania.
5) Reductions of GABA have been
observed in plasma, CSF, and brain
GABA levels in depression.

DEPRESSIVE EPISODE
DSM-IV-TR Criteria for Major
Depressive Episode
A. Five (or more) of the following
symptoms have been present during
the same 2-week period and
represent a change from previous
functioning; at least one of the
symptoms is either (1) depressed
mood or (2) loss of interest or
pleasure.
Note: Do not include symptoms that
are clearly due to a general medical
condition, or mood-incongruent
delusions or hallucinations.
1. depressed mood most of the day,
nearly every day, as indicated by
either subjective report (e.g., feels
sad or empty) or observation made
by others (e.g., appears tearful).
Note: In children and adolescents,
can be irritable mood
2. markedly diminished interest or
pleasure in all, or almost all,
activities most of the day, nearly
every day (as indicated by either
subjective account or observation
made by others)
3. significant weight loss when not
dieting or weight gain (e.g., a change
of more than 5% of body weight in a
month), or decrease or increase in
appetite nearly every day. Note: In
children, consider failure to make
expected weight gains.
4. insomnia or hypersomnia nearly
every day
5. psychomotor agitation or
retardation nearly every day
(observable by others, not merely
subjective feelings of restlessness or
being slowed down)
6. fatigue or loss of energy nearly
every day
7. feelings of worthlessness or
excessive or inappropriate guilt
(which may be delusional) nearly
every day (not merely self-reproach
or guilt about being sick)
8. diminished ability to think or
concentrate, or indecisiveness,
nearly every day (either by
subjective account or as observed by
others)
9. recurrent thoughts of death (not
just fear of dying), recurrent suicidal
ideation without a specific plan, or a
suicide attempt or a specific plan for
committing suicide
B. The symptoms do not meet
criteria for a mixed episode.
C. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other
important areas of functioning.
D. The symptoms are not due to the
direct physiological effects of a
substance (e.g., a drug of abuse, a
medication) or a general medical
condition (e.g., hypothyroidism).
E. The symptoms are not better
accounted for by bereavement, i.e.,
after the loss of a loved one, the
symptoms persist for longer than 2
months or are characterized by
marked functional impairment,
morbid preoccupation with
worthlessness, suicidal ideation,
psychotic symptoms, or
psychomotor retardation.
Cognitive Distortions
Drawing a specific
Arbitrary inference conclusion without
sufficient evidence
Focus on a single
detail while ignoring
Specific
other, more
abstraction
important aspects of
an experience
Forming conclusions
based on too little
Overgeneralization
and too narrow
experience
Over- or
Magnification and undervaluing the
minimization significance of a
particular event
Tendency to self-
Personalization reference external
events without basis

Absolutist, Tendency to place

dichotomous experience into all-
thinking or-none categories

Aaron Beck postulated a “cognitive

triad of depression” that consists of
(1) views about the self with a
negative self-precept;
(2) about the environment with a
tendency to experience the world as
hostile and demanding, and
(3) about the future with the
expectation of suffering and failure.

ATYPICAL FEATURES
Patients with atypical features have
specific, predictable characteristics:
overeating and oversleeping. These
symptoms have sometimes been
referred to as reversed vegetative
symptoms, and the symptom
pattern has sometimes been called
hysteroid dysphoria.
The patients with atypical features
are found to have a younger age of
onset, more severe psychomotor
slowing, and more frequent
coexisting diagnoses of panic
disorder, substance abuse or
dependence, and somatization
disorder. The high incidence and
severity of anxiety symptoms in
patients with atypical features have
sometimes been correlated with the
likelihood of their being
misclassified as having an anxiety
disorder rather than a mood
disorder. Patients with atypical
features may also have a long-term
course, a diagnosis of bipolar I
disorder, or a seasonal pattern to
their disorder.

OBJECTIVE RATING SCALES FOR

DEPRESSION
Zung Self-Rating Depression Scale is a
20-item report scale. A normal score
is 34 or less; a depressed score is 50
or more
Raskin Depression Scale : five-point
scale of three dimensions: verbal
report, displayed behavior, and
secondary symptoms. The scale has
a range of 3 to 13; a normal score is
3, and a depressed score is 7 or
more
Hamilton Rating Scale for Depression
(HAM-D) is a widely used depression
scale with up to 24 items, each of
which is rated 0 to 4 or 0 to 2, with a
total score of 0 to 76

MANIC EPISODE
DSM-IV-TR Criteria for Manic
Episode
A. A distinct period of abnormally
and persistently elevated, expansive,
or irritable mood, lasting at least 1
week (or any duration if
hospitalization is necessary).
B. During the period of mood
disturbance, three (or more) of the
following symptoms have persisted
(four if the mood is only irritable)
and have been present to a
significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g.,
feels rested after only 3 hours of
sleep)
3. more talkative than usual or
pressure to keep talking
4. flight of ideas or subjective
experience that thoughts are racing
5. distractibility (i.e., attention too
easily drawn to unimportant or
irrelevant external stimuli)
6. increase in goal-directed activity
(either socially, at work or school, or
sexually) or psychomotor agitation
7. excessive involvement in
pleasurable activities that have a
high potential for painful
consequences (e.g., engaging in
unrestrained buying sprees, sexual
indiscretions, or foolish business
investments)
C. The symptoms do not meet
criteria for a mixed episode.
D. The mood disturbance is
sufficiently severe to cause marked
impairment in occupational
functioning or in usual social
activities or relationships with
others, or to necessitate
hospitalization to prevent harm to
self or others, or there are psychotic
features.
E. The symptoms are not due to the
direct physiological effects of a
substance (e.g., a drug of abuse, a
medication, or other treatment) or a
general medical condition (e.g.,
hyperthyroidism).
Note: Manic-like episodes that are
clearly caused by somatic
antidepressant treatment (e.g.,
medication, electroconvulsive
therapy, light therapy) should not
count toward a diagnosis of bipolar I
disorder.

Features of
Features of mania
hypomania
Present for at least Present for at least
4 days 7 days
Core features mild Core features
or moderate marked
Mild or moderate Substantial
dysfunction dysfunction
Partial insight Minimal or absent
preserved insight
Psychotic
No psychotic
symptoms may
features
occur

BPAD-1 : Mania and Depression

BPAD-2: Hypomania and depression
TREATMENT OF MOOD DISORDERS

DEPRESSION:
The range of initial treatment
modalities includes psychotherapy,
pharmacotherapy, or a combination
of the two.

Choosing ECT as initial treatment

• ECT should be considered as a
first-line therapy for severe major
depressive disorder when there are
debilitating neuro-vegetative
symptoms (e.g., significant weight
loss and nutritional compromise
from reduced appetite, profound
psychomotor retardation, catatonic
stupor, etc).
• Also should be considered when
the patient has high potential
lethality issues (e.g., intense
suicidality, clear evidence of
repeated suicide attempts,
significantly aggressive behavior) or
prominent psychotic features.
• ECT should also be considered a
treatment choice for severely
depressed patients who are
pregnant, who have responded well
to prior ECT course(s), who have
responded poorly to adequate trials
of antidepressants, or in situations
where a particularly rapid response
is needed.
Pharmacotherapy: Antidepressants,
Tricyclic, SSRI’s, SNRI’s, other atypical
antidepressants etc
Psychotherapy: Most evidence
based support in depression
psychotherapy is for “COGNITIVE
BEHAVIOURAL THERAPY” (CBT).
Other approach is interpersonal
therapy or psychodynamic
psychotherapy.

OTHER THERAPIES
• Vagal Nerve Stimulation
The use of left vagal nerve
stimulation (VNS) using an electronic
device implanted in the skin, similar
to a cardiac pacemaker. Preliminary
studies have shown that a number
of patients with chronic, recurrent
major depressive disorder went into
remission when treated with VNS.

• Sleep Deprivation
Mood disorders are characterized by
sleep disturbance. Mania tends to
be characterized by a decreased
need for sleep, whereas depression
can be associated with either
hypersomnia or insomnia. Sleep
deprivation may precipitate mania
in patients who are bipolar I and
temporarily relieve depression in
those who are unipolar.
Approximately 60 percent of
depressive disorder patients exhibit
significant but transient benefit from
total sleep deprivation
• Phototherapy (light therapy)
Used as treatment for SAD (mood
disorder with seasonal pattern).
Phototherapy typically involves
exposing the afflicted patient to
bright light in the range of 1,500 to
10,000 lux or more, typically with a
light box that sits on a table or desk.
Patients sit in front of the box for
approximately 1 to 2 hours before
dawn each day, although some
patients may also benefit from
exposure after dusk.

Treatment of Acute Mania

1) Lithium Carbonate
Lithium carbonate is considered the
prototypical mood stabilizer. Yet,
because the onset of antimanic
action with lithium can be slow, it
usually is supplemented in the early
phases of treatment by atypical
antipsychotics, mood-stabilizing
anticonvulsants, or high-potency
benzodiazepines. Therapeutic
lithium levels are between 0.6 and
1.2 mEq/L. The acute use of lithium
has been limited in recent years by
its unpredictable efficacy,
problematic side effects, and the
need for frequent laboratory tests.
The introduction of newer drugs
with more favorable side effects,
lower toxicity, and less need for
frequent laboratory testing has
resulted in a decline in lithium use.
For many patients, however, its
clinical benefits can be remarkable.
2) Valproate
Valproate has surpassed lithium in
use for acute mania. Unlike lithium,
Valproate is only indicated for acute
mania, although most experts agree
it also has prophylactic effects.
Typical dose levels of valproic acid
are 750 to 2,500 mg per day,
achieving blood levels between 50
and 120 μg/mL. Rapid oral loading
with 15 to 20 mg/kg of divalproex
sodium from day 1 of treatment has
been well tolerated and associated
with a rapid onset of response.
3) Carbamazepine and
Oxcarbazepine
Carbamazepine has been used
worldwide for decades as a first-line
treatment for acute mania, but has
only gained approval in the United
States in 2004. Typical doses of
carbamazepine to treat acute mania
range between 600 and 1,800 mg per
day associated with blood levels of
between 4 and 12 μg/mL. The keto
congener of carbamazepine,
oxcarbazepine, may possess similar
antimanic properties. Higher doses
than those of carbamazepine are
required, because 1,500 mg of
oxcarbazepine approximates 1,000
mg of carbamazepine.
4) Clonazepam and Lorazepam
The high-potency benzodiazepine
anticonvulsants used in acute mania
include clonazepam and lorazepam.
Both may be effective and are widely
used for adjunctive treatment of
acute manic agitation, insomnia,
aggression, and dysphoria, as well as
panic. The safety and the benign
side effect profile of these agents
render them ideal adjuncts to
lithium, carbamazepine, or
valproate.
5) Atypical and Typical
Antipsychotics
All of the atypical antipsychotics
olanzapine, risperidone, quetiapine,
ziprasidone, and aripiprazole have
demonstrated antimanic efficacy
and are FDA approved for this
indication. Compared with older
agents, such as haloperidol and
chlorpromazine, atypical
antipsychotics have a lesser liability
for excitatory postsynaptic potential
and tardive dyskinesia; many do not
increase prolactin. However, they
have a wide range of substantial to
no risk for weight gain with its
associated problems of insulin
resistance, diabetes, hyperlipidemia,
hypercholesteremia, and
cardiovascular impairment. Some
patients, however, require
maintenance treatment with an
antipsychotic medication.

Treatment of Acute Bipolar

Depression
1) The relative usefulness of
standard antidepressants in bipolar
illness, in general, and in rapid
cycling and mixed states, in
particular, remains controversial
because of their propensity to
induce cycling, mania, or hypomania.
2) Accordingly, antidepressant drugs
are often enhanced by a mood
stabilizer in the first-line treatment
for a first or isolated episode of
bipolar depression.
3) A fixed combination of olanzapine
and fluoxetine has been shown to
be effective in treating acute bipolar
depression for an 8-week period
without inducing a switch to mania
or hypomania.
4) Paradoxically, many patients who
are bipolar in the depressed phase
do not respond to treatment with
standard antidepressants. In these
instances, lamotrigine or low dose
ziprasidone (20 to 80 mg per day)
may prove effective.

Electroconvulsive therapy may also

be useful for bipolar depressed
patients who do not respond to
lithium or other mood stabilizers
and their adjuncts, particularly in
cases in which intense suicidal
tendency presents as a medical
emergency.
 Neurotic Disorders (Neurosis)
Include
Generalised Anxiety disorders
Phobic disordrs
Panic disorder
Obsessive – compulsive disorder
(OCD)
Dissociative disorders

Stress - related disorders

Acute stress reaction
Adjustment disorders
Post - traumatic stress disorder

Somatoform disorders
Hypochondriasis
Body Dysmorphophobia
Somatization disorder
Somatoform Pain disorder
Conversion disorder
Other somatoform disorders
Points to remember:
1) There are certain common
symptoms of anxiety seen in many
of these neurotic disorders.

Common Symptoms of anxiety

Component Prominent features
Emotion/mood Anxiety, irritability
Exaggerated worries and
Cognitions
fears
Avoidance of feared
Behaviour
situations
Checking
Seeking reassurance
Somatic
Tight chest
symptoms
Short of breath
Palpitations
'Butterflies'
Tremor
 Tingling of fingers (due
to hyperventilation)
Aches and pains
Poor sleep
Frequent desire to pass
urine and defecate

2) Neurotransmitters
The three major neurotransmitters
associated with anxiety on the bases
of animal studies and responses to
drug treatment are norepinephrine
(NE), serotonin, and GABA.
(From Kaplan Textbook, important
chart to remember basic clinical
manifestations of some important
neurotic disorders) : will help in
clinical questions

Key Phenomenological Features of

Major Anxiety Disorders As Defined
by DSM-IV-TR
1) Panic disorder
Recurrent unexpected panic attacks
characterized by four or more of
the following:
Palpitations
Sweating
Trembling or shaking
Shortness of breath
Feeling of choking (also known as
air hunger)
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, lightheaded, or faint
Derealization or depersonalization
Fear of losing control or going
crazy
Fear of dying
Numbness or tingling
Chills or hot flashes
Persistent concern of future
attacks
Worry about the meaning of or
consequences of the attacks (e.g.,
 heart attack or stroke)
Significant change in behavior
related to the attacks (e.g.,
avoiding places at which panic
attacks have occurred)
± Presence of agoraphobia
2) Agoraphobia
Fear of being in places or situations
from which escape might be difficult,
embarrassing, or in which help may
be unavailable in the event of
having a panic attack
Often results in avoidance of the
feared places or situations, for
example:
Crowds
Stores
Bridges
Tunnels
Traveling on a bus, train, or
airplane
Theaters
Standing in a line
 Small enclosed rooms
3) Social phobia
Marked and persistent fear of one or
more social or performance
situations in which the person is
concerned about negative
evaluation or scrutiny by others, for
example:
Public speaking
Writing, eating, or drinking in
public
Initiating or maintaining
conversations
Fears humiliation or embarrassment,
perhaps by manifesting anxiety
symptoms (e.g., blushing or
sweating)
Feared social or performance
situations are avoided or endured
with intense anxiety or distress

4) Specific phobia (Most common)

[Ref : Census in chapter 1]
Marked and persistent fear that is
excessive, unreasonable, cued by the
presence or anticipation of a specific
object or situation, for example:
Flying
Enclosed spaces
Heights
Storms
Animals (e.g., snakes or spiders)
Receiving an injection
Blood
Provokes an immediate anxiety
response
Recognition that the fear is excessive
or unreasonable
Avoidance, anticipatory anxiety, or
distress is significantly impairing
5) Obsessive-compulsive disorder
Has obsessions or compulsions
Obsessions are defined as
recurrent and persistent thoughts,
impulses, or images that are
experienced as intrusive and
inappropriate, for example:
Contamination (most common)
Repeated doubts
Order
Impulses
Sexual images
Compulsions are defined as
repetitive behaviors or mental
acts whose goal is to prevent or
to reduce anxiety or distress, for
example:
Hand washing
Ordering
Checking (most common)
Praying
Counting
Repeating words
Recognition that the fear is
excessive or unreasonable
Obsessions cause marked
distress, are time-consuming
(more than 1 hour per day), or
cause significant impairment in
 social, occupational or other
daily functioning

6) Generalized anxiety disorder or

overanxious disorder
Excessive anxiety and worry about
a number of events or activities
(future oriented), occurring more
days than not for at least 6
months
Worry is difficult to control
Worry is associated with at least
three of the following symptoms:
Restlessness or feeling keyed up
or on edge
Easily fatigued
Difficulty concentrating
Irritability
Muscle tension
Sleep disturbance
Anxiety and worry cause significant
distress and impairment in social,
occupational, or other daily
functioning

7) Separation anxiety disorder

Developmentally inappropriate
and excessive anxiety concerning
separation from home or to an
attachment figure. Characterized
by three or more of the following:
Recurrent and excessive distress
when separation from home or
major attachment figure occurs or
is anticipated
Persistent and excessive worry
that major attachment figure will
be lost or harmed
Persistent and excessive worry
that an event will lead to
separation from major attachment
figure (e.g., getting kidnapped)
Persistent and recurring fear of
being alone or without
attachment figure at home
Reluctance or refusal to sleep
 away from home or without being
near major attachment figure
Duration of at least 4 weeks
Age of onset before 18 years of
age
Causes distress or impairment in
functioning
Physical symptoms (e.g.,
headaches, stomachaches, nausea,
and vomiting) when separation
occurs or is anticipated

Features distinguishing the three

types of anxiety disorder.

Phobic Panic Genera

anxiety disorder anxiety
Occurrence
Situational Paroxysmal Persist
of anxiety
Associated
Avoidance Escape Agitatio
behaviour
Associated Fear of Fear of
Worry
cognitions situation symptoms
Somatic With
Episodic Persist
symptoms exposure

TREATMENT ANXIETY DISORDERS:

1) Psychotherapy is very effective
(behavioral therapy used)
2) Pharmacotherapy : SSRI most
preferred
3) For Panic Attack : Benzodiazepines
and for panic disorder : SSRI

TREATMENT PHOBIAS:
Behavior therapy:- Systemic de-
sensitization ( treatment of choice) ;
Flooding also used
Pharmacological: - SSRIs,
benzodiazepines (alprazolam &
clonazepam) and buspirone

TREATMENT OCD:
Behavior Therapy :
• Exposure and response prevention
• Thought stopping
• Modeling
Drug of choice—SSRI (fluoxetine,
fluvoxamine preferred)
Treatment resistant—ECT and
psychosurgery (cingulotomy) may be
considered

STRESS RELATED DISORDERS:

DSM-IV-TR Diagnostic Criteria for

Acute Stress Disorder
A. The person has been exposed to a
traumatic event in which both of the
following were present:
1. the person experienced,
witnessed, or was confronted with
an event or events that involved
actual or threatened death or
serious injury, or a threat to the
physical integrity of self or others
2. the person's response involved
intense fear, helplessness, or horror
B. Either while experiencing or after
experiencing the distressing event,
the individual has three (or more) of
the following dissociative symptoms:
1. a subjective sense of numbing,
detachment, or absence of
emotional responsiveness
2. a reduction in awareness of his or
her surroundings
3. derealization
4. depersonalization
5. dissociative amnesia (i.e., inability
to recall an important aspect of the
trauma)
C. The traumatic event is
persistently reexperienced in at least
one of the following ways: recurrent
images, thoughts, dreams, illusions,
flashback episodes, or a sense of
reliving the experience; or distress
on exposure to reminders of the
traumatic event.
D. Marked avoidance of stimuli that
arouse recollections of the trauma
(e.g., thoughts, feelings,
conversations, activities, places,
people).
E. Marked symptoms of anxiety or
increased arousal (e.g., difficulty
sleeping, irritability, poor
concentration, hypervigilance,
exaggerated startle response, motor
restlessness).
F. The disturbance causes clinically
significant distress or impairment in
social, occupational, or other
important areas of functioning or
impairs the individual's ability to
pursue some necessary task, such as
obtaining necessary assistance or
mobilizing personal resources by
telling family members about the
traumatic experience.
G. The disturbance lasts for a
minimum of 2 days and a maximum
of 4 weeks and occurs within 4
weeks of the traumatic event.
H. The disturbance is not due to the
direct physiological effects of a
substance (e.g., a drug of abuse, a
medication) or a general medical
condition, is not better accounted
for by brief psychotic disorder, and
is not merely an exacerbation of a
preexisting Axis I or Axis II disorder.

DSM-IV-TR Diagnostic Criteria for

Posttraumatic Stress Disorder
A. The person has been exposed to a
traumatic event in which both of the
following were present:
1. the person experienced,
witnessed, or was confronted with
an event or events that involved
actual or threatened death or
serious injury, or a threat to the
physical integrity of self or others
2. the person's response involved
intense fear, helplessness, or horror.
Note: In children, this may be
expressed instead by disorganized or
agitated behavior.
B. The traumatic event is
persistently reexperienced in one (or
more) of the following ways:
1. recurrent and intrusive distressing
recollections of the event, including
images, thoughts, or perceptions.
Note: In young children, repetitive
play may occur in which themes or
aspects of the trauma are expressed.
2. recurrent distressing dreams of
the event. Note: In children, there
may be frightening dreams without
recognizable content.
3. acting or feeling as if the
traumatic event were recurring
(includes a sense of reliving the
experience, illusions, hallucinations,
and dissociative flashback episodes,
including those that occur on
awakening or when intoxicated).
Note: In young children, trauma-
specific reenactment may occur.
4. intense psychological distress at
exposure to internal or external cues
that symbolize or resemble an
aspect of the traumatic event
5. physiological reactivity on
exposure to internal or external cues
that symbolize or resemble an
aspect of the traumatic event
C. Persistent avoidance of stimuli
associated with the trauma and
numbing of general responsiveness
(not present before the trauma), as
indicated by three (or more) of the
following:
1. efforts to avoid thoughts, feelings,
or conversations associated with the
trauma
2. efforts to avoid activities, places,
or people that arouse recollections
of the trauma
3. inability to recall an important
aspect of the trauma
4. markedly diminished interest or
participation in significant activities
5. feeling of detachment or
estrangement from others
6. restricted range of affect (e.g.,
unable to have loving feelings)
7. sense of a foreshortened future
(e.g., does not expect to have a
career, marriage, children, or a
normal life span)
D. Persistent symptoms of increased
arousal (not present before the
trauma), as indicated by two (or
more) of the following:
1. difficulty falling or staying asleep
2. irritability or outbursts of anger
3. difficulty concentrating
4. hypervigilance
5. exaggerated startle response
E. Duration of the disturbance
(symptoms in Criteria B, C, and D) is
more than 1 month.
F. The disturbance causes clinically
significant distress or impairment in
social, occupational, or other
important areas of functioning.
Specify if:
Acute: if duration of symptoms is
less than 3 months
Chronic: if duration of symptoms is 3
months or more
Specify if:
With delayed onset: if onset of
symptoms is at least 6 months after
the stressor

Treatment of stress related

disorders:
1) Pharmacotherapy
Selective serotonin reuptake
inhibitors (SSRIs) are considered
first-line treatments for PTSD.
2) Psychotherapy
• Psychodynamic psychotherapy may
be useful in the treatment of many
patients with PTSD.
• Psychotherapeutic interventions
for PTSD include behavior therapy,
cognitive therapy, and hypnosis. CBT
IS MOST PREFERRED
• Another psychotherapeutic
technique that is relatively novel
and somewhat controversial is eye
movement desensitization and
reprocessing (EMDR), in which the
patient focuses on the lateral
movement of the clinician's finger
while maintaining a mental image of
the trauma experience.
• In addition to individual therapy
techniques, group therapy and
family therapy have been reported
to be effective in cases of PTSD.

DSM-IV-TR Diagnostic Criteria for

Adjustment Disorders
A. The development of emotional or
behavioral symptoms in response to
an identifiable stressor(s) occurring
within 3 months of the onset of the
stressor(s).
B. These symptoms or behaviors are
clinically significant as evidenced by
either of the following:
1. marked distress that is in excess
of what would be expected from
exposure to the stressor
2. significant impairment in social or
occupational (academic) functioning
C. The stress-related disturbance
does not meet the criteria for
another specific Axis I disorder and
is not merely an exacerbation of a
preexisting Axis I or Axis II disorder.
D. The symptoms do not represent
bereavement.
E. Once the stressor (or its
consequences) has terminated, the
symptoms do not persist for more
than an additional 6 months.
Specify if:
Acute: if the disturbance lasts less
than 6 months
Chronic: if the disturbance lasts for 6
months or longer
Adjustment disorders are coded
based on the subtype, which is
selected according to the
predominant symptoms. The specific
stressor(s) can be specified on Axis
IV.
With depressed mood
With anxiety
With mixed anxiety and depressed
mood
With disturbance of conduct
With mixed disturbance of emotions
and conduct
Unspecified

Treatment : Psychotherapy is
treatment of choice
SOMATOFORM DISORDERS
Repeated physical symptoms,
together with persistent request for
medical investigation, in spite of
repeated negative findings and
reassurances by the doctor that the
symptoms have no physical basis.
Seven somatoform disorders are
listed in the revised fourth edition of
the Diagnostic and Statistical
Manual of Mental Disorders (DSM-
IV-TR):
(1) somatization disorder,
characterized by many physical
complaints affecting many organ
systems
(2) conversion disorder,
characterized by one or two
neurological complaints
(3) hypochondriasis, characterized
less by a focus on symptoms than by
patients' beliefs that they have a
specific disease
(4) body dysmorphic disorder,
characterized by a false belief or
exaggerated perception that a body
part is defective
(5) pain disorder, characterized by
symptoms of pain that are either
solely related to, or significantly
exacerbated by, psychological
factors
(6) undifferentiated somatoform
disorder, which includes
somatoform disorders not otherwise
described that have been present
for 6 months or longer
(7) somatoform disorder not
otherwise specified, which is the
category for somatoform symptoms
that do not meet any of the
somatoform disorder diagnoses
mentioned above
Clinical clues for TYPES
1) Somatization disorder: -
• Usually female of age less than 30
yrs, duration should be more than 2
yrs
• Multiple somatic symptoms
involving multiple organ system
Symptoms are recurrent and chronic
changing symptoms
• Refusal to accept the advice or
reassurance of doctors not
explained by another mental illness
e.g. Depression.

2) Hypochondriacal disorder
• Persistent pre occupation with fear
or belief of having serious disease,
based on their misinterpretation of
physical signs and sensations.
• The belief must last 6 months
• Fear or belief is not a delusion
• Belief persists even after showing
normal reports

3) Body Dysmorphic Disorder

• Precoccupation with an imagined
defect in appearance
• If a slight anomaly is present, the
person’s concern is markedly
excessive
• The preoccupation causes clinically
significant distress or impairment in
functioning

4) Persistent somatoform pain

disorder

5) CONVERSION DISORDER
It is a disturbance of bodily
functioning that does not conform
to current concepts of anatomy and
physiology of the central nervous
system.

DSM-IV-TR Diagnostic Criteria for

Conversion Disorder
A. One or more symptoms or deficits
affecting voluntary motor or sensory
function that suggest a neurological
or other general medical condition.
B. Psychological factors are judged to
be associated with the symptom or
deficit because the initiation or
exacerbation of the symptom or
deficit is preceded by conflicts or
other stressors.
C. The symptom or deficit is not
intentionally produced or feigned
(as in factitious disorder or
malingering).
D. The symptom or deficit cannot,
after appropriate investigation, be
fully explained by a general medical
condition, or by the direct effects of
a substance, or as a culturally
sanctioned behavior or experience.
E. The symptom or deficit causes
clinically significant distress or
impairment in social, occupational,
or other important areas of
functioning or warrants medical
evaluation.
F. The symptom or deficit is not
limited to pain or sexual
dysfunction, does not occur
exclusively during the course of
somatization disorder, and is not
better accounted for by another
mental disorder

Common Symptoms of Conversion

Disorder
Motor Symptoms
Involuntary movements
Tics
Blepharospasm
Torticollis
Opisthotonos
Seizures
Abnormal gait
Falling
Astasia-abasia
Paralysis
Weakness
Aphonia
Sensory Deficits
Anesthesia, especially of extremities
Midline anesthesia
Blindness
Tunnel vision
Deafness

Visceral Symptoms
Psychogenic vomiting
Pseudocyesis
Globus hystericus
Swooning or syncope
Urinary retention
Diarrhea

• In setting of stress & Considerable

dysfunction
• Usually occur in safe places and in
front of people
• Never during sleep
• Injury, incontinence, tongue bite
usually absent
Distinctive Physical Examination
Findings in Conversion Disorder
Conversion
Condition Test
Findings
Sensory los
does not
Map conform to
Anesthesia
dermatomes recognized
pattern of
distribution
Strict half-
Hemianesthesia Check midline
body split
With
suggestion,
those who
cannot wal
may still be
Walking,
Astasia-abasia able to dan
dancing
alteration o
sensory and
motor findi
with
suggestion
 Drop
Hand falls n
paralyzed
to face, not
hand onto
it
face
Pressure no
in examiner
Paralysis, hand under
paresis paralyzed le
Hoover test
when
attempting
straight leg
raising
Check motor Give-away
strength weakness
Resists
Examiner opening; ga
attempts to preference
open eyes away from
doctor
Coma
Eyes stare
Ocular straight ahe
cephalic do not mov
maneuver from side to
side
Essentially
 normal
Request a coughing
Aphonia
cough sound
indicates co
are closing
Short nasal
grunts with
little or no
sneezing on
inspiratory
phase; little
no
Intractable
Observe aerosolizat
sneezing
of secretion
minimal fac
expression;
eyes open;
stops when
asleep; aba
when alone
Magnitude
changes in
vital signs a
Head-up tilt venous
Syncope
test pooling do
explain
 continuing
symptoms
Changing
pattern on
Tunnel vision Visual fields
multiple
examinatio
Absence of
relative
afferent
pupillary
Swinging
defect
flashlight sign
Profound Sufficient
(Marcus
monocular vision in ba
Gunn)
blindness eye preclud
Binocular
plotting
visual fields
normal
physiologic
blind spot in
good eye
Patient may
Wiggle your begin to mi
fingers, I'm new
just testing movements
before
coordination• realizing the
Severe bilateral slip
blindness Sudden flash Patient
of bright light flinches
Look at your Patient doe
hand• not look the
Even blind
Touch your patients can
•
index fingers do this by
propriocept

TREATMENT :
Psychiatric interviewing
Drug assisted interviewing or
narcoanalysis
Hypnosis
Strong suggestion
Aversion therapy

Factitious Disorder:

DSM-IV-TR Diagnostic Criteria for

Factitious Disorder
A. Intentional production or feigning
of physical or psychological signs or
symptoms.
B. The motivation for the behavior is
to assume the sick role.
C. External incentives for the
behavior (such as economic gain,
avoiding legal responsibility, or
improving physical well-being, as in
malingering) are absent.
Code based on type:
With predominantly psychological
signs and symptoms: if psychological
signs and symptoms predominate in
the clinical presentation
With predominantly physical signs
and symptoms: if physical signs and
symptoms predominate in the
clinical presentation
With combined psychological and
physical signs and symptoms: if both
psychological and physical signs and
symptoms are present but neither
predominates in the clinical
presentation

Dissociative Disorders

According to the text revision of the

fourth edition of the Diagnostic and
Statistical Manual of Mental
Disorders (DSM-IV-TR), the essential
feature of the dissociative disorders
is a disruption in the usually
integrated functions of
consciousness, memory, identity, or
perception of the environment. The
disturbance may be sudden or
gradual, transient or chronic.

The DSM-IV-TR dissociative disorders

are dissociative identity disorder,
depersonalization disorder,
dissociative amnesia, dissociative
fugue, and dissociative disorder not
otherwise specified (NOS).
DSM-IV-TR Diagnostic Criteria for
Dissociative Amnesia
A. The predominant disturbance is
one or more episodes of inability to
recall important personal
information, usually of a traumatic
or stressful nature, that is too
extensive to be explained by
ordinary forgetfulness.
B. The disturbance does not occur
exclusively during the course of
dissociative identity disorder,
dissociative fugue, posttraumatic
stress disorder, acute stress
disorder, or somatization disorder
and is not due to the direct
physiological effects of a substance
(e.g., a drug of abuse, a medication)
or a neurological or other general
medical condition (e.g., amnestic
disorder due to head trauma).
C. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other
important areas of functioning.

DSM-IV-TR Diagnostic Criteria for

Depersonalization Disorder
A. Persistent or recurrent
experiences of feeling detached
from, and as if one is an outside
observer of, one's mental processes
or body (e.g., feeling like one is in a
dream).
B. During the depersonalization
experience, reality testing remains
intact.
C. The depersonalization causes
clinically significant distress or
impairment in social, occupational,
or other important areas of
functioning.
D. The depersonalization experience
does not occur exclusively during the
course of another mental disorder,
such as schizophrenia, panic
disorder, acute stress disorder, or
another dissociative disorder, and is
not due to the direct physiological
effects of a substance (e.g., a drug of
abuse, a medication) or a general
medical condition (e.g., temporal
lobe epilepsy).

DSM-IV-TR Diagnostic Criteria for

Dissociative Fugue
A. The predominant disturbance is
sudden, unexpected travel away
from home or one's customary place
of work, with inability to recall one's
past.
B. Confusion about personal identity
or assumption of a new identity
(partial or complete).
C. The disturbance does not occur
exclusively during the course of
dissociative identity disorder and is
not due to the direct physiological
effects of a substance (e.g., a drug of
abuse, a medication) or a general
medical condition (e.g., temporal
lobe epilepsy).
D. The symptoms cause clinically
significant distress or impairment in
social, occupational, or other
important areas of functioning.

DSM-IV-TR Diagnostic Criteria for

Dissociative Identity Disorder
A. The presence of two or more
distinct identities or personality
states (each with its own relatively
enduring pattern of perceiving,
relating to, and thinking about the
environment and self).
B. At least two of these identities or
personality states recurrently take
control of the person's behavior.
C. Inability to recall important
personal information that is too
extensive to be explained by
ordinary forgetfulness.
D. The disturbance is not due to the
direct physiological effects of a
substance (e.g., blackouts or chaotic
behavior during alcohol intoxication)
or a general medical condition (e.g.,
complex partial seizures). Note: In
children, the symptoms are not
attributable to imaginary playmates
or other fantasy play.
 DELIRIUM
DELIRIUM
A. 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, 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:
(1) Rapid, unpredictable shifts
from hypo-activity to hyper-
activity;
 (2) Increased reaction time;
(3) Increased or decreased flow of
speech;
(4) enhanced startle reaction.
D. Disturbance of sleep or 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. Rapid onset and fluctuations of
the symptoms over the course of the
day.
F. 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 A-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
• Delirium is marked by short term
clouding of consciousness and
changes in cognition.
• Commonest organic disorder seen
in clinical practice.
• 5-15% of all medical and surgical
inpatients
• Acute onset, fluctuating course,
 rapid improvement and generally
considered to be reversible
disorder
• New memory registration &
retention impaired
• Clouding of consciousness is or
impaired consciousness or altered
sensorium is main feature
• Attention reduced ability to direct,
focus, sustain, and shift attention
• Disorientation (time > place >
person)
• Illusions & Hallucinations (most
commonly visual)
• Psychomotor disturbance (hypo or
hyperactive)
• carphologia /floccillation (picking
movement at bed sheets/clothes)
• Disturbed sleep wake cycle,
insomnia, daytime drowsiness,
nightmares
• Diurnal variations – worsening of
symptoms in evening & night (sun
 downing)
• Emotional disturbance, e.g.
Depression, anxiety or fear,
irritability, euphoria, apathy, or
wondering perplexity
• It may occur at any age but is most
common at age of 60 years, most
cases recover within 4 weeks or
less. However can last up to 6
months
• Treatment : benzodiazepines
(lorazepam) or antipsychotic
(haloperidol)
 DEMENTIA
DEMENTIA
1. Evidence of each of the following:
(1) A decline in memory, which is
most evident in the learning of new
information, although in more
severe cases, the recall of previously
learned information may be also
affected. The impairment applies to
both verbal and non-verbal material.
The decline should be objectively
verified by obtaining a reliable
history from an informant,
supplemented, if possible, by
neuropsychological tests or
quantified cognitive assessments.
The severity of the decline, with mild
impairment as the threshold for
diagnosis, should be assessed as
follows:
Mild: a degree of memory loss
sufficient to interfere with everyday
activities, though not so severe as to
be incompatible with independent
living. The main function affected is
the learning of new material. For
example, the individual has difficulty
in registering, storing and recalling
elements in daily living, such as
where belongings have been put,
social arrangements, or information
recently imparted by family
members.
Moderate: A degree of memory loss
which represents a serious handicap
to independent living. Only highly
learned or very familiar material is
retained. New information is
retained only occasionally and very
briefly. The individual is unable to
recall basic information about where
he lives, what he has recently been
doing, or the names of familiar
persons.
Severe: a degree of memory loss
characterized by the complete
inability to retain new information.
Only fragments of previously learned
information remain. The subject fails
to recognize even close relatives.
(2) A decline in other cognitive
abilities characterized by
deterioration in judgement and
thinking, such as planning and
organizing, and in the general
processing of information. Evidence
for this should be obtained when
possible from interviewing an
informant, supplemented, if
possible, by neuropsychological tests
or quantified objective assessments.
Deterioration from a previously
higher level of performance should
be established. The severity of the
decline, with mild impairment as the
threshold for diagnosis, should be
assessed as follows:
Mild : The decline in cognitive
abilities causes impaired
performance in daily living, but not
to a degree making theindividual
dependent on others. More
complicated daily tasks or
recreational activities cannot be
undertaken.
Moderate : The decline in cognitive
abilities makes the individual unable
to function without the assistance of
anotherin daily living, including
shopping and handling money.
Within the home, only simple chores
are preserved. Activities are
increasingly restricted and poorly
sustained.
Severe : The decline is characterized
by an absence, or virtual absence, of
intelligible ideation.
The overall severity of the dementia
is best expressed as the level of
decline in memory or other cognitive
abilities, whichever is the more
severe (e.g. Mild decline in memory
and moderate decline in cognitive
abilities indicate a dementia of
moderate severity).
2. Preserved awareness of the
environment (i.e. Absence of
clouding of consciousness (as
defined in F05, criterion A)) during a
period of time long enough to
enable the unequivocal
demonstration of

3. When there are superimposed

episodes of delirium the diagnosis of
dementia should be deferred.

4. A decline in emotional control or

motivation, or a change in social
behaviour, manifest as at least one
of the Following:
(1) Emotional
(2) Irritability;
liability;
(4) Coarsening of social
(3) Apathy;
behaviour.
4. For a confident clinical diagnosis,
G1 should have been present for at
least six months; if the period since
the manifest onset is shorter, the
diagnosis can only be tentative.

Comments: The diagnosis is further

supported by evidence of damage to
other higher cortical functions, such
as aphasia, agnosia, apraxia.
Judgment about independent living
or the development of dependence
(upon others) needs to take account
of the cultural expectation and
context. Dementia is specified here
as having a minimum duration of six
months to avoid confusion with
reversible states with identical
behavioural syndromes, such as
traumatic subdural haemorrhage,
normal pressure hydrocephalus and
diffuse or focal brain injury

Syndrome due to disease of brain,

usually of chronic or progressive
nature

There is impairment of higher

cortical functions evident for at least
6 months
• Stable level of consciousness

Memory & personality deterioration

with lack of personal care

Abstract thinking & Intellectual

function
• Impulse control& Judgment

* The most common cause of

Dementia is Alzheimer’s
dementia (50 to60%) followed by
Multi infarct
Dementia (10 to15%) The risk
factor for Alzheimer’s is female,
family history, head injury and
Down
Syndrome. It has gradual and
 downward progression.

Reversible dementia ---15% Toxic,

Hypothyroid & Multi infarct
• 20 to 30% hallucinations
• 30 to 40% delusions
• 40 to 50% depression
• Catastrophic reaction
• Perseveration
• Urinary and fecal incontinence
• Aphasia, apraxia, agnosia and
executive functions

Treatment : donepezil, rivastigmine,

galantamine and tacrine are
cholinesterase inhibiters
Memantine, esterogen replacement
therapy

TYPES OF DEMENTIA
CORTICAL SUBCORTICAL
Sub cortical
Site Cortex grey matter

Mild to
moderate,
Severe, recall recall helped
Memory
helped very partially by
loss
little by clues clues and
recognizable
tasks
Dysarthria
dystonia,
chorea,
Motor Usually normal rigidity,
System tremors’,
ataxia, flexed
or extended
posture
Aphasia,
apraxia,
Executive
Complex
functionally,
delusions,
Others agnosia,
depression,
acalculia,
mania
bradyphrenia,
dyslexia simple
 delusions

DIFFERENCES IN DELIRIUM AND

DEMENTIA
DELIRIUM DEMENTIA
insidious &
Onset acute chronic
course
immediate
immediate
and recent
Memory memory
memory
normal
Disturbed
very
Hallucination common
may occur
Comprehension impaired in
impaired late stage

ORGANIC AMNESTIC SYNDROME

A. Memory impairment, manifest in
both:
(1) a defect of recent memory
(impaired learning of new
 material), to a degree sufficient
to interfere with daily living; and
(2) a reduced ability to recall past
experiences.
B. Absence of:
(1) a defect in immediate recall
(as tested, for example, by the
digit span);
(2) clouding of consciousness and
disturbance of attention, as
defined in FO5, criterion A;
(3) global intellectual decline
(dementia).
C. Objective evidence (physical &
neurological examination,
laboratory tests) and/or history of
an insult to or a disease of the brain
(especially involving bilaterally the
diencephalic and medial temporal
structures but other than alcoholic
encephalopathy) that can
reasonably be presumed to be
responsible for the clinical
manifestations described under A.
Comments: Associated features,
including confabulations, emotional
changes (apathy, lack of initiative),
and lack of insight, are useful
additional pointers to the diagnosis
but are not invariably present.
In this syndrome the immediate
memory is normal, recent memory is
disturbed & remote memory is
disturbed.
Causes are-
• Thiamine deficiency (most
commonly due to alcoholism
Wernickes Encephalopathy/
Korsakoff syndrome)
• Hypoglycemia
• Herpes simplex
• Electroconvulsive therapy
• Lesions involving B/L limbic system
(head injury, B/L posterior cerebral
stroke)
 TYPE OF MEMORY LOSS IN
DIFFERENT ORGANIC MENTAL
DISORDERS
ORGANIC
DELIRIUM DEMENTA AMNEST
SYNDRO
Immediate
Disturbed Normal Normal
memory
Recent
Disturbed Disturbed Disturbed
memory
Remote
Normal Disturbed Disturbed
memory

Clinical features distirguishirg

between the dementias.
Proiminent
Other clini
symptoms
features
and signs
Memory loss,
especially
short term
Dysphasia and
dyspraxia
Relentlessl
Alzheimer's Sense of smell progressive
disease impaired early Survival 5-3
Behavioural years
changes, e.g.
wandering
Psychotic
symptoms at
some stage
Stepwise
progression
Signs of
Personality
cerebrovas
change
Vascular disease
Labile mood
dementia History of
Preserved
hypertensio
insight
More comm
in men,
smokers
Fluctuating
dementia
Delirium-like Antipsycho
Dementia with
phases worsen
Lewy bodies
Parkinsonism condition
Visual
hallucinations
 Stereotyped
behaviours
Personality Slowly
change progressive
Early loss of Family hist
Frontotemporal insight common
dementia Expressive More comm
dysphasia in women
Memory Onset usua
relatively before age
preserved
Early primitive
reflexes
Schizophrenia-
like psychosis
Presents in
Choreiform
20s-Ws
Huntington's movements
Afiected pa
disease Depression
and other
and irritability
relatives
Dementia
occurs later
Mental
slowing,
Most comm
apathy,
in 5i>-70 ye
Normal inattention
olds
pressure Urinary Most comm
hydrocephalus incontinence reversible
Problems dementia
walking (gait
apraxia)
Myoclonic Often pres
jerks Rapid onse
Prion disease Seizures progression
Cerebellar Death with
ataxia year
DATA FROM MANUAL FOR
PHYSICIANS- SUBSTANCE USE
DISORDER
Published by National Drug
Dependence Treatment Centre
(NDDTC), AIIMS, New Delhi.

Major Drugs of Abuse in India

NHS DAMS (%
Drug (current among
Type prevalence, treatment
%) seekers)
Alcohol 21.4% 43.9%
Cannabis 3.0% 1 1.6%
Heroin 0.2% 11.1%
Opium 0.4% 8.6%
Ojrher
0.1% 6.3%
Opiates
Source : National Survey, 2004
ALCOHOL IS THE MOST FREQUENTLY
ABUSED SUBSTANCE AS SEEN IN THE
NHS AND THE DAMS.

Estimates of Number of Users of

Select Drug Type (approximate, in
millions Based on 1991 census male
population stratified for age (15-60
years) adjusted for ten-year growth
in males)
Ever Current
Drug Type
Use Use
Tobacco 168.99 162.86
Alcohol 75.59 62.46
Cannabis 11.96 8.75
Opiates 2.92 2.04
Sedative/
0.58 0.29
[Hypnotics
Source : NHS
COMMENT : At the time of this
survey, tobacco was not considered
as a drug of abuse. If AIIMS declares
tobacco as drug of abuse in further
studies, answer may change as mc
substance abuse : tobacco.
ALCOHOL

SCREENING TESTS
CAGE: an acronym for 4 questions
used to assess those with alcohol
problem (FASTEST AND EASIEST)
MAST: Michigan Alcohol Screening
Test
DAST: Drug Abuse Screening Test
AUDIT: Alcohol Use Disorder
Identification Test

ALCOHOL WITHDRAWAL (imp topic)

Any three of the following:

(1) tremor of the outstretched
hands, tongue or eyelids;
(2) sweating;
(3) nausea, retching or vomiting;
(4) tachycardia or hypertension;
(5) psychomotor agitation;
(6) headache;
(7) insomnia;
(8) malaise or weakness;
(9) transient visual, tactile or
auditory hallucinations or illusions;
(10) grand mal convulsions.

Comment: If delirium is present, the

diagnosis of alcohol withdrawal
state with delirium ("delirium
tremens") should be made
• Onset 24 – 48 hours after stopping
heavy, prolonged drinking
• Delirium
• Visual hallucinations
• Delusions, usually persecutory and
transient
• Fear and agitation, sometimes
aggression
• Coarse tremor
• Seizures
• Autonomic disturbance (sweating,
fever, tachycardia, hypertension)
• Insomnia
• Dehydration and electrolyte
disturbance
• Lasts 3 – 4 days, followed by
exhaustion and patchy amnesia for
the episode

TREATMENT OF WITHDRAWAL:
Benzodiazepines can be given either
orally or parenterally;
Drug Therapy for Alcohol Intoxicatio
Clinical
Drug Route
Problem
Tremulousness
and mild to
Chlordiazepoxide Oral
moderate
agitation

Diazepam Oral

Hallucinosis Lorazepam Oral

Extreme
Chlordiazepoxide Intraveno
agitation

Withdrawal
Diazepam Intraveno
seizures

Delirium
Lorazepam Intraveno
tremens

Advise the patient to drink plenty of

non-alcoholic liquids. Prescribe
vitamins (thiamine 300 mg per day
— deficiencies are common and
withdrawal may precipitate
Wernicke’s syndrome. Consider
parenteral thiamine if risk of
Wernicke’s syndrome is judged to be
high.

Special notes:
In alcoholic hallucinosis, a heavy
drinker experiences recurrent
auditory hallucinations, usually of a
threatening or derogatory nature.
The hallucinations occur in clear
consciousness (cf. withdrawal
hallucinations). The syndrome is an
example of a drug - induced
psychosis

Medications for Treating Alcoho

Oisulfiram Naltrex
(Anatabuse) (Re Via
Inhibits
intermediate
Blocks
metabolism of
opioid
alcohol, causing
recepto
a build-up of
resultin
acetaldehyde
reduce
Action and a reaction
craving
of flushing,
reduce
sweating,
reward
nausea, and
respon
tachycardia if a
drinkin
patient drinks
alcohol
Curren
Concomitant using o
use of alcohol or in ac
 or alcohol- opioid
containing withdra
Contraindications
preparations or anticip
metronidazole; need fo
coronary artery opioid
disease; severe analges
myocardial acute
disease hepatit
liver fa
Other
hepatic
High
disease
impulsivity–
renal
likely to drink
impairm
while using it;
history
psychoses
suicide
(current or
attemp
history);
opioid
diabetes
analges
Precautions mellitus;
require
epilepsy;
larger d
hepatic
may be
dysfunction;
require
hypothyroidism;
respira
renal
depres
impairment;
may be
rubber contact
 dermatitis deeper
more
prolong

Will
precipi
severe
Hepatitis; optic
withdra
neuritis;
patient
peripheral
depend
Serious Adverse neuropathy;
on opio
Reactions psychotic
hepato
reactions.
(uncom
Pregnancy
at usua
Category C.
doses).
Pregna
Catego

Nausea
abdom
pain;
Metallic after-
Common Side constip
taste;
Effects dizzine
dermatitis
headac
 anxiety
fatigue

Amitryptyline;
anticoagulants
Opioid
such as
analges
warfarin;
(blocks
diazepam;
action)
isoniazid;
Examples of drug yohimb
metronidazole;
Interactions (use wi
phenytoin;
naltrex
theophylline;
increas
warfarin; any
negativ
nonprescription
drug ef
drug containing
alcohol

Blackouts (May aiims)

• Alcohol-related Blackouts are
similar to episodes of transient
global amnesia in that they are
discrete episodes of anterograde
amnesia that occur in association
with alcohol intoxication.
• During a blackout, persons have
relatively intact remote memory but
experience a specific short-term
memory deficit in which they are
unable to recall events that
happened in the previous 5 or 10
minutes.
• Because their other intellectual
faculties are well preserved, they can
perform complicated tasks and
appear normal to casual observers.

OPIOIDS
DSM-IV-TR Diagnostic Criteria for
Opioid Intoxication
A. Recent use of an opioid.
B. Clinically significant maladaptive
behavioral or psychological changes
(e.g., initial euphoria followed by
apathy, dysphoria, psychomotor
agitation or retardation, impaired
judgment, or impaired social or
occupational functioning) that
developed during, or shortly after,
opioid use.
C. Pupillary constriction (or pupillary
dilation due to anoxia from severe
overdose) and one (or more) of the
following signs, developing during,
or shortly after, opioid use:
1. drowsiness or coma
2. slurred speech
3. impairment in attention or
memory
D. The symptoms are not due to a
general medical condition and are
not better accounted for by another
mental disorder.

DSM-IV-TR Diagnostic Criteria for

Opioid Withdrawal
A. Either of the following:
1. cessation of (or reduction in)
opioid use that has been heavy
and prolonged (several weeks or
longer)
 2. administration of an opioid
antagonist after a period of
opioid use
B. Three (or more) of the following,
developing within minutes to several
days after Criterion A:
1. dysphoric mood
2. nausea or vomiting
3. muscle aches
4. lacrimation or rhinorrhea
5. pupillary dilation, piloerection,
or sweating
6. diarrhea
7. yawning
8. fever
9. insomnia
C. The symptoms in Criterion B
cause clinically significant distress or
impairment in social, occupational,
or other important areas of
functioning.
D. The symptoms are not due to a
general medical condition and are
not better accounted for by another
mental disorder.

Opioid Agents for Treating Opioid

Withdrawal
1) Methadone
• Methadone is a synthetic
narcotic (an opioid) that
substitutes for heroin and can be
taken orally. When given to
addicts to replace their usual
substance of abuse, the drug
suppresses withdrawal
symptoms.
• A daily dosage of 20 to 80 mg
suffices to stabilize a patient,
although daily doses of up to 120
mg have been used. The
duration of action for
methadone exceeds 24 hours;
thus, once-daily dosing is
adequate.
• Methadone maintenance is
 continued until the patient can
be withdrawn from methadone,
which itself causes dependence.
An abstinence syndrome occurs
with methadone withdrawal, but
patients are detoxified from
methadone more easily than
from heroin. Clonidine (0.1 to 0.3
mg three to four times a day) is
usually given during the
detoxification period.
• Methadone maintenance has
several advantages. First, it frees
persons with opioid dependence
from using injectable heroin and,
thus, reduces the chance of
spreading HIV through
contaminated needles.
• Second, methadone produces
minimal euphoria and rarely
causes drowsiness or depression
when taken for a long time.
Third, methadone allows
 patients to engage in gainful
employment instead of criminal
activity. The major disadvantage
of methadone use is that
patients remain dependent on a
narcotic.

Other Opioid Substitutes

2) Levomethadyl (LAAM)
• LAAM is an opioid agonist that
suppresses opioid withdrawal. It
is no longer used, however,
because some patients
developed prolonged QT
intervals associated with
potentially fatal arrhythmias
(torsades de pointes).

3) Buprenorphine
• As with methadone and LAAM,
buprenorphine is an opioid
agonist approved for opioid
dependence in 2002. It can be
 dispensed on an outpatient basis
but prescribing physicians must
demonstrate that they have
revived special training in its use.
Buprenorphine in a daily dose of
8 to 10 mg appears to reduce
heroin use.
• Buprenorphine also is effective
in thrice-weekly dosing because
of its slow dissociation from
opioid receptors. After repeated
administration, it attenuates or
blocks the subjective effects of
parenterally administered
opioids such as heroin or
morphine. A mild opioid
withdrawal syndrome occurs if
the drug is abruptly discontinued
after chronic administrations.
4) Opioid Antagonists
Opioid antagonists block or
antagonize the effects of opioids.
Unlike methadone, they do not
 exert narcotic effects and do not
cause dependence. Opioid
antagonists include naloxone,
which is used in the treatment of
opioid overdose because it
reverses the effects of narcotics,
and naltrexone, the longest-acting
(72 hours) antagonist. The theory
for using an antagonist for opioid-
related disorders is that blocking
opioid agonist effects, particularly
euphoria, discourages persons
with opioid dependence from
substance-seeking behavior and,
thus, deconditions this behavior.
The major weakness of the
antagonist treatment model is the
lack of any mechanism that
compels a person to continue to
take the antagonist.

CANNABIS
ACUTE INTOXICATION:
Dysfunctional behaviour or
perceptual disturbances which
include at least one of the following:
(1) euphoria and disinhibition;
(2) anxiety or agitation;
(3) suspiciousness or paranoid
ideation;
(4) temporal slowing (a sense that
time is passing very slowly, and/or
the person is experiencing a rapid
flow of ideas);
(5) impaired judgement;
(6) impaired attention;
(7) impaired reaction time;
(8) auditory, visual or tactile
illusions;
(9) hallucinations with preserved
orientation;
(10) depersonalisation;
(11) derealization;
(12) interference with personal
functioning.
At least one of the following signs:
(1) increased appetite;
(2) dry mouth;
(3) conjunctival injection;
(4) tachycardia.

WITHDRAWAL
This is an ill-defined syndrome for
which definitive diagnostic criteria
cannot be established at the present
time. It occurs following cessation of
prolonged high-dose use of
cannabis. It has been reported
variously as lasting from several
hours to up to seven days.
Symptoms and signs include anxiety,
irritability, and tremor of the
outstretched hands, sweating, and
muscle aches.

The active compounds in cannabis

products are called Cannabinoids.
Most potent among them is
tetrahydrocannabinol (THC). The
concentration of THC varies in
different forms of cannabis products

THC concentration of Cannabis

Products
THC content (extremely
Forms
variable)
Marijuana
1 – 3 % THC
Ganja
6 – 20 % THC
(cultivated)
10 – 20 % THC
Hashish
15 – 30% THC
(charas)
(may be more)
Hashish oil

AMOTIVATIONAL SYNDROME
A controversial cannabis-related
syndrome is amotivational
syndrome. Whether the syndrome is
related to cannabis use or reflects
characterological traits in a
subgroup of persons regardless of
cannabis use is under debate.
Traditionally, the amotivational
syndrome has been associated with
long-term heavy use and has been
characterized by a person's
unwillingness to persist in a tasks be
it at school, at work, or in any
setting that requires prolonged
attention or tenacity. Persons are
described as becoming apathetic
and anergic , usually gaining weight,
and appearing slothful

Summary of acute effects of

cannabis
Mental &
Physical Effects
Behavioural Effects
Drowsiness Red eyes
(at high closes) Dry mouth
Euphoria Thirst
Anxjiety Increased appetite

Suspiciousness Tachycardia
Expectations of (or Bradycardia at
harm high doses)
Sensation of slowed
Light headedness
time
(Postural
Social withdrawal
hypotension)
Impaired judgement
Illusions & halluc
inations with insight
COCAINE
ADVERSE EFFECTS
• A common adverse effect
associated with cocaine use is
nasal congestion; serious
inflammation, swelling, bleeding,
and ulceration of the nasal
mucosa can also occur. Long-
term use of cocaine can also lead
to perforation of the nasal septa.
• Freebasing and smoking crack
can damage the bronchial
passages and the lungs.
• The IV use of cocaine can result
in infection, embolisms, and the
transmission of HIV.
• The major complications of
cocaine use are cerebrovascular,
epileptic, and cardiac.
• About two thirds of these acute
toxic effects occur within 1 hour
of intoxication, about one fifth
occur in 1 to 3 hours, and the
remainder occurs up to several
days later.
The most common
cerebrovascular diseases
associated with cocaine use are
non-hemorrhagic cerebral
infarctions due to
vasoconstriction.
• Cocaine is the substance of abuse
most commonly associated with
seizures; the second most
common substance is
amphetamine. Cocaine-induced
 seizures are usually single
events, although multiple
seizures and status epilepticus
are also possible
• Myocardial infarctions and
arrhythmias are perhaps the
most common cocaine-induced
cardiac abnormalities.
Cardiomyopathies can also
occur.

WITHDRAWAL:
Dysphoric mood (for instance
sadness or anhedonia)
Any two of the following symptoms
and signs:
(1) lethargy and fatigue;
(2) psychomotor retardation or
agitation;
(3) craving for cocaine;
(4) increased appetite;
(5) insomnia or hypersomnia;
(6) bizarre or unpleasant dreams
 STAGES OF CHANGE
(Motivation Cycle)

State Instructional strategi

• Engage the individu
with information
Precontemplation about need for
No intention of change
taking action in • Provide personaliz
the next 6 months information about
risks if no change a
 benefits of change
• Motivate and
Contemplation
encourage the
Intends to take
individual to set go
action in the next
and make specific
6 months
plans
Preparation
Intends to take
• Help the individual
action in the next
create and implem
month and has
specific action plan
taken some steps
and set realistic go
to change
behavior
• Provide problem-
Action based (action-
Has changed oriented) learning
behavior for <6 experiences
months • Provide social
support, feedback
• Continue to provid
social support, assi
with problem-solvi
Maintenance
positively address
Has changed
slips and relapses i
behavior for >6
necessary
months • Employ reminder
systems/performa
support tools

CHARACTERISTIC
SUBSTANCE
FEATURES
Magnus Symptoms
Cocaine (cocaine bugs or
tactile hallucination)
Cannabis Run Amok
Alcohol Morbid jealousy
LSD Bad Trips
flash backs;
Paranoid
hallucinatory
Amphetamine Syndrome (like
paranoid
schizophrenia)

Phencyclidine(Angel Dissociative
dust) anesthesia
 ANOREXIA NERVOSA
A. Weight loss, or in children a
lack of weight gain, leading to a
body weight of at least 15%
below the normal or expected
weight for age and height.
B. The weight loss is self-induced
by avoidance of "fattening
foods".
C. A self-perception of being too
fat, with an intrusive dread of
fatness, which leads to a self-
imposed low weight threshold.
D. A widespread endocrine
disorder involving the
hypothalamic-pituitary-gonadal
axis, manifest in the female as
amenorrhoea, and in the male as
a loss of sexual interest and
potency
 E. Does not meet criteria A and B
of Bulimia nervosa

Comments: The following features

support the diagnosis, but are not
necessary elements: self-induced
vomiting; self-induced purging;
excessive exercise; use of appetite
suppressants and/or diuretics. If
onset is pre-pubertal, the sequence
of pubertal events is delayed or
even arrested (growth ceases; in girls
the breasts do not develop and
there is a primary amenorrhoea; in
boys the genitals remain juvenile).
With recovery, puberty is often
completed normally, but the
menarche is late.

Physical symptoms
Sensitivity to cold
Gastrointestinal symptoms —
constipation, bloating
Dizziness
Amenorrhea
Poor sleep

Physical signs
Emaciation
Cold extremities
Dry skin, sometimes orange
(hypercarotenaemia)
Downy hair (’lanugo ’) on back,
forearms and cheeks
Poorly developed or atrophic
secondary sexual characteristics
Bradycardia, postural hypotension,
arrythmias
Peripheral oedema
Proximal myopathy

Abnormalities on investigation
Low LH, FSH, estradiol, T3,
somatomedin C
Increased cortisol and CRH, growth
hormone
Hypoglycaemia
Hypokalaemia, hyponatraemia,
metabolic alkalosis
ECG: prolonged QT interval (serious)
Hypercholesterolaemia
Osteopenia and osteoporosis
Delayed gastric emptying
Acute gastric dilatation (due to over
- rapid refeeding)

EPIDEMIOLOGY AND ETIOLOGY

Anorexia mainly affects females (sex
ratio 10-20: 1).
The average age of onset is 15 – 16
years.
The prevalence is estimated to be
around 0.5-1%

In -patient care is indicated if weight

loss is intractable and severe (e.g.
BMI < 14), or if there is a serious risk
of death from suicide or medical
complications. Admission is
preferably to a specialist unit. It
usually lasts 8 – 12 weeks

GENERAL PRINCIPLES OF
TREATMENT:
• Weight restoration is the
cornerstone of treatment for low
weight patients.
• Most patients are treated as
outpatients at varying levels of
intensity (e.g., partial hospital,
intensive outpatient, individual
treatment).
• Consider specialized eating
disorder hospitalization in patients
with markedly low weight or with
medical or psychiatric instability (see
criteria below).
• A multidisciplinary team approach
is the standard of care and includes
a psychiatrist, psychotherapist,
dietitian, and primary care
physician.
• Psychotherapy—There is no strong
evidence for any psychotherapeutic
approach. Family therapy is
recommended for children and
adolescents. CBT may be helpful for
adults.
• Pharmacology—No evidence of
efficacy for any medication to
ameliorate core symptoms of AN.
SSRIs may be useful for managing co-
morbid anxiety and/or depression in
weight-restored patients only, but
the evidence is weak. Some evidence
that second-generation
antipsychotics may decrease
obsessional thinking and anxiety in
low- weight patients.

CRITERIA FOR ADMISSION TO

HOSPITAL:
• Extremely low body weight: less
than 85% of ideal body weight or a
BMI < 17.5.
• Acute medical instability.
• Rapid, excessive weight loss (~10%
weight loss within 3 months).
• Psychosis or significant risk of
suicide.
• Other serious psychiatric co-
morbidities.
• Failure of outpatient treatment.
• Involuntary admission is
considered when compulsory
refeeding is needed to medically
stabilize patient and/or decision
making capacity is impaired.

REFEEDING SYNDROME:
• A potentially lethal consequence
of refeeding characterized by
cardiovascular decompensation
(myocardium weakened in
starvation) and serious electrolyte
disturbances (including
hypophosphatemia, which produces
abnormalities in cardiac
contractility) that can lead to heart
failure, severe fluid retention, and
multiorgan system collapse. Risk is
highest in early refeeding and when
using TPN.
• General inpatient refeeding
guidelines
• Controlled weight gain of 1-
1.5kg/week in hospitalized patients
and 0.25-0.5kg/week in outpatients.
• Intake levels begin around
35kcal/kg/day and increase by 200-
300kcal every 3-5 days (working with
a nutritionist).
• Medical monitoring with daily
attention to vital signs,
cardiovascular status (including
edema), and gastrointestional
symptoms.
• Electrolyte and mineral level
monitoring frequently during early
refeeding.
Anorexia nervosa has one of the
highest mortality rates (~5.6% per
decade of illness) of any psychiatric
disorder. Women with anorexia
nervosa are 12 times more likely to
die and have a suicide rate 57 times
higher than women of a similar age
group in the general population.
Poor prognostic factors include:
• Late age of onset.
• Chronicity of illness.
• Lower initial minimum weights.
• Bulimic features (vomiting,
purgative abuse).
• Obsessive-compulsive personality
features.

BULIMIA NERVOSA

A. Recurrent episodes of
overeating (at least two times
per week over a period of three
 months) in which large amounts
of food are consumed in short
periods of time.
B. Persistent preoccupation with
eating and a strong desire or a
sense of compulsion to eat
(craving).
C. The patient attempts to
counteract the fattening effects
of food by one or more of the
following:
(1) self-induced vomiting;
(2) self-induced purging;
(3) alternating periods of
starvation;
(4) use of drugs such as appetite
suppressants, thyroid
preparations or diuretics. When
bulimia occurs in diabetic
patients they may choose to
neglect their insulin treatment.
D. A self-perception of being too
fat, with an intrusive dread of
 fatness (usually leading to
underweight).
Patients with eating disorders have
in common the core
psychopathology of extreme
concerns about body shape and
weight.

● Recurrent binge eating (more

than twice a week); 1000 – 4000
kcal (4 – 8 MJ) are typically
consumed in a binge.
● ’Loss of control ’ during binges.
● Attempts to counteract the
binges by vomiting, or by using
other means such as laxatives,
enemas, diuretics or excessive
exercise.
● Does not meet diagnostic
criteria for anorexia nervosa.
● The combination of dieting and
bingeing means body weight is
usually unremarkable — the
 most obvious difference from
anorexia nervosa.
● A small proportion of bulimia
nervosa occurs in women with
borderline personality disorder
who self - harm (often by cutting)
and misuse alcohol or drugs.(15%
of bulimic patients)
If body weight is decreased, some
of the physical features and
complications of anorexia nervosa
may be present
● Repeated vomiting may produce
pitted teeth (eroded by gastric
acid), calluses on the knuckles (
Russell’s sign from putting
fingers down throat), hoarse
voice, salivary gland
enlargement, metabolic
disturbances
● Diuretic use: electrolyte
disturbances and renal
dysfunction.
 ● Laxatives: electrolyte
disturbances and colonic motility
problems.
Menstrual disturbances can occur in
small proportion of bulimia patients
too.

EPIDEMIOLOGY
Estimates of bulimia nervosa range
from 2 to 4 percent of young women
bulimia nervosa is significantly more
common in women than in men
(10:1),history of obesity maybe
present
but its onset is often later in
adolescence than that of anorexia
nervosa.

TREATMENT:
General Principles
• Assessment: Full psychiatric and
medical evaluation
• Management: Outpatient
management is typical. Hospital
admission may be indicated for
acute medical instability, extremely
refractory symptoms, suicidality, or
severe co-morbid psychiatric illness.
• Nutrition counseling: Includes the
development of a structured,
balanced meal plan to reduce
dietary restriction and urges to
binge and purge.
• Psychotherapy (the cornerstone of
treatment):
o CBT has a strong evidence base
and is effective in addressing the
core symptoms of bulimia
nervosa.
o Interpersonal Therapy (IPT)
appears to be effective long-
term, but acts less quickly
“Guided self-help” may be a
useful first step (e.g.,
bibliotherapy, on-line programs)
in the absence of available CBT.
PHARMACOTHERAPY
Antidepressants are effective in
reducing binge eating and purging
behaviors, with SSRIs considered to
be the safest. Fluoxetine (at doses of
60mg) is the best studied and
currently is the only FDA approved
medication for bulimia nervosa.
There is some initial evidence
supporting topiramate.1

Prognosis
Short term reduction of binge eating
and purging behaviors for patients
treated with psychosocial or
pharmacological interventions is
approximately 50-70%. There are
high rates of relapse (30-85%),
reflecting a frequently waxing and
waning course of the illness.
Long-term prognostic data are
limited, but in clinical studies more
than 50% of patients do not meet
criteria for bulimia nervosa at the
end of study. Onset of illness in
adolescence is associated with a
better outcome, while co-morbid
depression is associated with a
poorer outcome. Bulimia nervosa
does not appear to be associated
with increased relative mortality.

THE SCOFF QUESTIONS

These questions are useful as a
screening tool for eating disorders
(highly sensitive for both anorexia
nervosa and bulimia nervosa) in
primary care. A score of 2+ “yes”
answers indicates that a more
detailed history is indicated (before
considering treatment or referral).
• Do you make yourself sick (vomit)
because you feel uncomfortably full?
• Do you worry you have lost control
over how much you eat?
• Have you recently lost more than
14 pounds in a 3-month period?
• Do you believe yourself to be fat
when others say you are too thin?
• Would you say that food
dominates your life?

DSM-5 CHANGES
DSM-5 criteria reduce the frequency
of binge eating and compensatory
behaviors that people with bulimia
nervosa must exhibit, to once a
week from twice weekly as specified
in DSM-IV.

BINGE EATING DISORDER

Recurrent episodes of binge eating.
An episode of binge eating is
characterized by both of the
following:
• eating, in a discrete period of time
(e.g., within any 2-hour period), an
amount of food that is definitely
larger than what most people would
eat in a similar period of time under
similar circumstances
• a sense of lack of control over
eating during the episode (e.g., a
feeling that one cannot stop eating
or control what or how much one is
eating)
The binge-eating episodes are
associated with three (or more) of
the following:
• eating much more rapidly than
normal
• eating until feeling uncomfortably
full
• eating large amounts of food when
not feeling physically hungry
• eating alone because of being
embarrassed by how much one is
eating
• feeling disgusted with oneself,
depressed, or very guilty after
overeating
Binge eating disorder was approved
for inclusion in DSM-5 as its own
category of eating disorder. In DSM-
IV, binge-eating disorder was not
recognized as a disorder but rather
described in Appendix B: Criteria
Sets and Axes Provided for Further
Study and was diagnosable using
only the catch-all category of “eating
disorder not otherwise specified.”
Binge eating disorder is defined as
recurring episodes of eating
significantly more food in a short
period of time than most people
would eat under similar
circumstances, with episodes
marked by feelings of lack of control.
Someone with binge eating disorder
may eat too quickly, even when he
or she is not hungry. The person
may have feelings of guilt,
embarrassment, or disgust and may
binge eat alone to hide the
behavior. This disorder is associated
with marked distress and occurs, on
average, at least once a week over
three months.

SLEEP DISORDERS
NARCOLEPSY
• There are repeated attacks of
daytime somnolence usually leading
irresistibly to sleep.
• It usually begins in the second
decade and is associated with
cataplexy (abrupt loss of muscle
tone), hypnagogic hallucinations and
sleep paralysis (the patient wakes
but is unable to move).
• An autoimmune origin is
suspected as 98% have the DR15
variant of HLA - DR2.
• Pathologically, there is a loss of
hypothalamic hypocretin -producing
neurons. Stimulants (amphetamines
or modafinil) are the main
treatment. (Modafinil is DOC)

NREM parasomnias :
Somnambulism, somniloquy, night
terrors, bruxism and enuresis
REM Parasomnias : Narcolepsy and
Nightmares

SEXUAL DISORDERS
The sexual disorders can be
classified into four main types:
1. Gender identity disorders
(Transexualism and Dual Role
Transvestism)
2. Psychological and behavioural
disorders associated with sexual
development and maturation.
3. Paraphilias (disorders of sexual
preference).
4. Sexual dysfunctions

Transexualism
Transexualism, the severest form of
gender identity disorders, is
characterised by the following
clinical features:
1. Normal anatomic sex.
2. Persistent and significant sense of
discomfort regarding one’s anatomic
sex and a feeling that it is
inappropriate to one’s perceived-
gender.
3. Marked preoccupation with the
wish to get rid of one’s genitals and
secondary sex characteristics, and to
adopt sex characteristics of the other
sex (perceived-gender).
4. Diagnosis is made after puberty.

Dual-role Transvestism
Dual-role transvestism is
characterised by wearing of clothes
of the opposite sex in order to enjoy
the temporary experience of
member ship of the opposite sex,
but without any desire for a more
permanent sex change (unlike
transexualism).
PARAPHILIAS
• Paraphilias (sexual deviations;
perversions) are disorders of sexual
preference in which sexual arousal
occurs persistently and significantly
in response to objects which are not
a part of normal sexual arousal (e.g.
nonhuman objects; suffering or
humiliation of self and/or sexual
partner; children or nonconsenting
person).
• These disorders include: Fetishism;
fetishistic transvestism; sexual
sadism; sexual masochism;
exhibitionism; voyeurism;
frotteurism; pedophilia; zoophilia (
bestiality); and others.

SEXUAL DYSFUNCTIONS:
PHASES DYSFUNCTION
1. Desire
Hypoactive sexual desire
Or
disorder; sexual aversion
Appetitive
disorder
Phase
Female sexual arousal
disorder; male erectile
2.
disorder (may also occur in
Excitement
stages 3 and 4); male erectile
and
disorder due to a general
Plateau
medical condition;
Phase
Female orgasmic disorder;
3.
male orgasmic disorder;
Orgasmic
premature ejaculation;
phase
Postcoital dysphoria;
postcoital headache
4.
Resolution
Phase

CHILDHOOD ONSET PSYCHIATRIC

DISORDERS
Autistic Asperger's
Feature
Disorder Syndrome
 Age at
recognition 0-36 Usually >36
(months)
Male > Male >>
Sex ratio
Female Female
Loss of skills Variable Usually not

Social skills Very poor Poor

Communication
Usually poor Fair
skills
Circumscribed Variable Marked
interests (mechanical) (facts)
Family history-
similar Sometimes Frequent
problems
Seizure disorder Common Uncommon
Head growth
No No
decelerates
Severe MR Mild MR to
IQ range
to normal normal
Fair to
Outcome Poor to fair
good
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER
Attention-deficit/hyperactivity
disorder (ADHD) is characterized by a
pattern of diminished sustained
attention and higher levels of
impulsivity in a child or adolescent
than expected for someone of that
age and developmental level.

CORE FEATURES
• Hyperactivity
• Poor attention and concentration
• Impulsivity
• Present for at least 6 months
• Evidence for impaired functioning
in two or more settings
• Onset by age 7, usually by 3

OTHER FEATURES
• Distractibility
• Poor at planning and organizing
tasks
• Learning difficulties
• Clumsiness
• Low self - esteem
• Socially disinhibited
• Unpopular with other children
• Non - localizing neurological signs
• Conduct disorder coexists in 50%,

TREATMENT
• Pharmacologic treatment is
considered to be the first line of
treatment for ADHD. Central nervous
system stimulants are the first
choice of agents in that they have
been shown to have the greatest
efficacy with generally mild tolerable
side effects.
• The US Food and Drug
Administration (FDA) approved the
use of dextroamphetamine in
children 3 years of age and older
and methylphenidate in children 6
years of age and older. These are the
two most commonly used
pharmacologic agents for the
treatment of children with ADHD

Other drugs include :

• Atomoxetine , a norepinephrine
uptake inhibitor, shown to be
effective in the treatment of children
with ADHD;
• Antidepressants, such as
bupropion , venlafaxine; and the α
adrenergic receptor agonists
clonidine and guanfacine.
• In children with a history of motor
tics, some caution must be used; in
some cases, methylphenidate can
exacerbate the tic disorder
• Dextroamphetamine and
dextroamphetamine/amphetamine
salt combinations are usually the
second drugs of choice when
methylphenidate is not effective
• Atomoxetine is considered DOC
for adult-ADD

PERSONALITY DISORDERS

CLUSTER A- ODD, ECCENTRIC

• Suspicion and distrust of

others
• Sensitivity to criticism
• Bears grudges
• Self – importance
Paranoid • Excessive sense of all
above
• Underlying defense-
mechanism is projection
• Differential diagnosis is
paranoid schizophrenia &
paranoid delusional disorders
• Emotionally cold and
detached
• Introspective and prefers
solitary activities
 • Social isolation and few
close friends
Schizoid • Little interest in sex
• Lack of joie de
vivre(pleasure in activities)
• Psychotic features are
typically absent
• Defense mechanisms:
Fantasy
• Emotional coldness
• Social isolation
• Suspiciousness
• Magical thinking
• Metaphorical or
Schizotypal stereotypical thinking
• Occasional transient quasi-
psychotic episodes
• Maybe seen in individuals
related to schizophrenics
• Defense mechanisms:
Distortion, fantasy

CLUSTER B (DRAMATIC)
EMOTIONALLY LABILE AND INTENSE
 • Callous
• Unstable, transient
relationships but forms
relationships easily
• Low frustration
threshold
• Irritable and impulsive
• Failure to learn from
experience
Dissocial (= • Failure to accept
psychopathic, responsibility
antisocial) • Lack of guilt/remorse
• Tend to be young men
• History of conduct
disorder in childhood
• Extremely manipulative
& gives plausible
rationalization for
irrational behaviors
• Defense mechanisms:
Conversion
• Multiple, turbulent
relationships
• Impulsivity
• Recurrent emotional
 crises
• Variable, intense mood
• Stress - related psychotic
- like symptoms
• Tend to be young
Borderline (= women
emotionally • Chronic feeling of
unstable) emptiness
• Anxiety and unstable
mood
• “confused personality”
• Defense mechanisms:
Splitting, acting out,
projective identification,
dissociation
• Dialectical behavior
therapy (DBT) is the
treatment of choice
• Exaggerated, theatrical
displays of emotion
• Attention seeking
• Vain
Histrionic • Suggestible
• Shallow, labile mood
• Crushes and fads
 • Defense mechanisms:
Dissociation, repression
• Grandiose self –
importance
• Exaggerates
achievements and
abilities
• Exploits others
• Arrogant
Narcissistic • Expects special praise
and respect
• Defense mechanisms:
Acting out, idealization,
symbolization
• Psychotherapy is therapy
of choice though lithium
maybe added

CLUSTER C (ANXIOUS) TIMID,

DEPENDENT, LOW SELF-ESTEEM

• Excessive orderliness
• Preoccupation with detail
• Perfectionist
 • Excessively adherent to
Anankastic social customs
(= • Inflexible and dogmatic
obsessional) • Humourless
• Miserly spending style
toward both self and
others
• Defense mechanisms:
Isolation
• Persistent tense and
apprehensive feelings
• Avoid personal contact
• Hypersensitivity to
rejection by others
• Afraid to speak up in
public or to make requests
of others
• Desire to make social
Anxious (=
interactions
avoidant)
• Views self as inept and
inferior
• Defense mechanisms:
Introjection
• Individual or group
psychotherapy are both
effective
 • Anti-depressants or
anxiolytics may be added
• Encourage others to make
decisions.
• Excessive need to be
taken care of
unrealistically preoccupied
with fears of caring for
Dependent
self.
• More likely to have “foli a
deux” i.e. shared
delusional disorder.
• Defense mechanisms:
Identification

HABIT AND IMPULSE DISORDERS

1) Pathological Gambling
2) Intermittent Explosive Disorder
3) Pathological Fire-Setting
[Pyromania]
4) Pathological Stealing
[Kleptomania]
5) Trichotillomania
Habit reversal is the treatment of
choice in trichotillomania and other
impulse control disorders. (There is
nothing called as habit and response
prevention)

ELECTROCONVULSIVE THERAPY

• Discovered by Cerletti and Bini

1938
• Modified ECT means during
anesthesia
• Two types: Unilateral electrode
over the nondominant
hemisphere and B/L Electrode
• Most Common side effect of ECT
is Amnesia. Mainly retrograde
though some anterograde also
although amnesia is reversible in
most cases.
• Pregnancy and old age ECT can
be given
INDICATIONS:-
1. Catatonic Schizophrenia
2. Depression with suicidal tendency
3. Pts who are intolerant to S/E of
medication non – responder (mania,
schizophrenia)

NON PSYCHIATRIC INDICATIONS FOR

ECT:
1. Parkinson’s Disease, particularly
rigidity and bradykinesia
2. Intractable seizure
3. Neuroleptic malignant syndrome

CONTRAINDICATION:
No absolute contraindications

HIGH RISK PATIENTS ARE

1. CNS lesions with increased
intracranial pressure
2. Neurosurgical procedures.
3. Recent myocardial infarction or
stroke within 4 to 6 weeks of events
4. Uncompensated congestive heart
failure
5. High Risk Pregnancy

SIDE EFFECTS:-
• Headache
• Delirium &confusion 10%
• Memory loss 75%
• Mortality 0.01 each patient
Practice Questions

1. 22 years old young person shows

aggressive behavior for the last 2
weeks, also has auditory
hallucination not heard by anybody
else & suspicious behavior.
Diagnosis is:
a. Schizophrenia b. Depression
c. Mania d. Acute psychosis

2. Which of the following drug

causes akathisia most often:
a. Haloperidol b. Thioridazine
c. Chlorpromazine d. Thiothixene

3. A reluctant child forced to bring

sugar from a shop, spills half of it on
the way. This is an example of:
a. Hysteria b. Passive aggression
c. Disobedience d. Active aggressive

4. Which of the following is not

classical of schizophrenia:
a. Autism b. Automatism
c. Association defect d. Ambivalence

5. Drug of choice for panic disorders

is :
a. Nitrazepam b. Imipramine
c. Diazepam d. Clonidine

6. Which is not a feature of

Hyperkinetic Child?
a. Low IQ
b. Low attention span
c. Right to left dissociation
d. Amphetamine is drug of choice

7. Cognitive Therapy is used for :

a. Mania b. Paranoia
c. Schizophrenia d. Depression

8. Which of the following is a mature

defense mechanism?
a. Projection b. Reaction formation
c. Anticipation d. Denial

9. Most common cause of mood

congruent delusion is:
a. Schizophrenia b. Mania
c. OCN d. Dementia

10. An antidepressant found to be

associated with Tardive dyskinesia
and neuroleptic malignant syndrome
is :
a. b. c. d.
Fluxoetine Amineptine Amoxapine Trazodon

11. Not a proper match:

a. Auditory hallucination-
Alcoholism
b. Thought broadcasting-
schizophrenia
c. Delusion of infidelity-obsessive
compulsive neurosis
d. Delusion of grandeur-mania

12. Suicidal tendencies are least

common with :
a. Alone b. Depression
c. Old age d. Married person

13. Psycho analysis was introduced

by :
a. Freud b. Schielder
c. Dale & Denicker d. Eugen Bluer

14. ’Reinforcement’ is used in:

a. Psychoanalysis
b. Hypnoanalysis
c. Abreaction
d. Conditioned learning
15. Dissociation is seen in all except:
a. Somnambulism
b. Fugue
c. Multiple personality
d. depersonalization

16. Thematic perception test is

named after:
a. Freud
b. Simon paul
c. Henry Murray & Christiana
Morgan
d. Wechsler’s

17. That part of mind which is

working on reality principle is :
a. Id b. Ego
c. Super ego d. Ego-ideal

18. All are features of type A

behavior, proposed by Friedman and
Rosenman except:
a. Time urgency and impatience
b. hard driving career orientation
c. Ambitiousness
d. Poor job involvement

19. Vasanthi 45 years was brought

to casually with abnormal
movement which included
persistent deviation of neck to right
side one day before she was
prescribed Haloperidol 5 mgs three
times daily from the psychiatry OPD.
She also had an altercation with her
husband recently, which of the
following is the most likely cause for
her symptoms:
a. Acute drug dystonia
b. Conversion reaction
c. Acute psychosis
d. Cerebrovascular accident

20. The commonest cause of mental

retardation is:
a. Alkaptonuria
b. Kluver-Bucy syndrome
c. Korsakoffs syndrome
d. Birth asphyxia

21. A Tibetan living in high altitude

is now at sea level. His wife dies 2
weeks back. He says he has seen his
wife twice during this period and
she asked him to join her at heaven.
The diagnosis is:
a. Normal grief reaction
b. Brief reactive psychosis
c. Motor behavior
d. Bereavement Reaction

22. The following drugs are likely to

show anti-anxiety effect except:
a. Chlorpromazine
b. Tricyclic antidepressants
c. Benzodiazepines
d. Lithium
23. Ego’s defense mechanism
“Undoing” is typically seen in:
a. Depression
b. Schizophrenia
c. Obsessive – Compulsive
d. Hysteria

24. Kalloo a 24 years old occasional

alcoholic has got a change in his
behavior. He has become suspicious
that people are trying to conspire
against him though his father states
that there is no reason for his fears.
He is getting hallucinations of voices
commenting on his actions. What is
the most probable diagnosis?
a. Delirium tremens
b. Alcohol induced psychosis
c. Schizophrenia
d. Delusional disorder

25. The eight – stage classification of

human life is proposed by:
a. Sigmund Freud b. Pavlov
c. Strauss d. Erikson

26. An alcoholic woman was brought

to the casually following a suicide
attempt by taking several tables of
diazepam. There is history of
previous attempts of suicide by wrist
slashing etc. The type of personality
disorder in this woman is:
a. Histrionic personality
b. Dependent personality
c. Narcissistic personality
d. Borderline personality

27. Patient presents with altered

behavior, delusions & hallucination
suggest :
a. Psychotic disorder
b. Confirms schizophrenia
c. Korsakoff’s psychosis
d. Obsessive – compulsive neurosis
28. All are psychiatric disorder
except :
a. Depression
b. Obsessive compulsive neurosis
c. Reaction formation
d. Adjustment reaction

29. Pigment retinopathy is a side

effect of:
a. Chlorpromazine b. Thioridazine
c. Trifluoperazine d. Fluphenazine

30. One of the most important

defense mechanisms
a. Alienation b. Confabulation
c. Repression d. Suppression

31. A middle- aged patient was

brought to the hospital in stuporous
conditions with loss of power in all
four limbs. Waxy flexibility of muscle
tone in the limbs was detected. The
most likely diagnosis is :
a. Hysterical stupor b. Organic stupor
c. Catatonic stupor d. Depressive stupor

32. Oedipus complex (given by

Sigmund Freud ) is seen in :
a. Boys of 1-3 years of age
b. Girls of 1-3 years of age
c. Boys of 3-5 years of age
d. Girls of 3-5 years of age

33. The tern “Ambivalence” was

coined by:
a. Hippocrates b. Eugene Bleuler
c. Kraeplein d. Sigmund freud

34. Least addictive is:

a. Alprazolam
b. Fluoxetine
c. Dihydroxypropoxyphene
d. Buprenorphine
35. Which is most specific of
psychosis :
a. Pressure of speech
b. Neologism
c. Incoherence
d. Preservation

36. Appropriate management of

phobias include:
a. Systematic desensitization
b. Chlorpromazine
c. Bio feedback
d. Electro convulsive therapy

37. Basanti age 27 years, female

thinks her nose is ugly, her idea is
fixed not shared by anyone else.
Whenever she goes out of home,
she hides her face with a cloth. She
visits to surgeon. Next step would
be :
a. Investigate and then operate
b. Refer to psychiatrist
c. Reassure the patient
d. Immediate operation

38. Irresistible urge to move about

and increased motor activity is :
a. Rabbits syndrome
b. Malignant neuroleptic syndrome
c. Akathasia
d. Tardive dyskinesia

39. Which is in first rank syndrome

described by Scheidner ?
a. Echolalia b. Thought insertion
c. Autism d. Suicidal tendency

40. The characteristic symptom of

Hyperkinetic syndrome is :
a. Reduced attention span
b. Mental retardation
c. Extreme shyness
d. Truancy
41. Disturbances of affect include:
a. Panic b. Obsession
c. Phobia d. Apathy

42. 30 years old man has decreased

sleep, hyper sexually, sexually
promiscuous, had spent a lot of
money in last 2 weeks. Diagnosis is :
a. Psychosexual development
b. Mania
c. Schizophrenia
d. Hysteria

43. A false belief unexplained by

reality shared by a number of
people is :
a. Superstition b. Illusion
c. Delusion d. Obsession

44. Which of the following is a

center for recent memory :
a. Parietal cortex
b. Temporal lobe
c. Hippocampus
d. Thalamus and sub thalamus

45. Sleep deprivation leads to :

a. Psychotic behavior
b. Decreased mental alertness
c. Emotional disturbances
d. Anxiety neurosis

46. A person who is a chronic

alcoholic is brought to the casualty.
When asked he says that he is
drinking because of the quarrels
with his wife. The defense
mechanism is :
a. Dental b. Rationalization
c. Sublimation d. Projection

47. Drug of choice for delirium

tremens:
a. Diazepam b. Chlorpromazine
c. Haloperidol d. Reserpine

48. Mature defense mechanism is

seen in :
a. Altruism b. Repression
c. Regression d. None

49. The following are psychotic

disorder except :
a. Schizophrenia
b. Mania
c. Psychotic depression
d. Hysteria

50. Picasso syndrome (painter’s

obsession developed into artistic
painting) Ego defense mechanism is :
a. Substitution b. Sublimation
c. Acting out d. Undoing

51. Schizophrenia is associated

personalities:
a. Athletic b. Pyknic
c. Asthenic d. both a & c

52. Drug of therapeutic benefit in

schizophrenia is:
a. Lithium b. Imipramine
c. Doxepin d. Fluphenazine

53. Following are true of Obsessive

compulsive neurosis except:
a. Persistence b. Irrational thought
c. Ego syntonic d. resisting

54. a person missing from home,

fraud wandering purposefully, well
groomed, has some degree of
amnesia:
a. Dissociative fugue
b. Dissociative amnesia
c. Schizophrenia
d. Dementia
55. Ambivalence is most commonly
seen in:
a. Schizophrenia
b. Hysteria
c. Mania
d. Obsessive compulsive neurosis

56. Major depression is most

commonly associated with:
a. Poverty
b. Death of loved person
c. Major accident
d. Prolonged physical illness

57. The following are psychosomatic

disorder except:
a. Hypertension b. Peptic ulcer
c. Cirrhosis of liver d. Asthma

58. Confabulation means:

a. Conversation with imaginary
person
b. Misinterpretation stimulus
c. Perception in the absence of
stimuli
d. filling up gaps in memory

59. Which category is most prone for

suicide:
a. Adolescent girl
b. Old man
c. Unemployed youth
d. Married woman

60. One of the following is used to

test I.Q
a. Eyesenck personality
b. Ink blot test
c. Sentence completion
d. Binet test

61. ’Fugue’ state occurs in:

a. Head injury b. Depression
c. Hysteria d. Mania

62. All of following are defense

mechanisms of ego except:
a. Projection b. Conversion
c. Reaction formation d. Transference

63. A 30 year old man represent

with symptoms of palpitations and
sweating on meeting seniors and on
making public presentation. This
made him try to avoid such
situation. This diagnosis possibly:
a. Panic reaction
b. Social phobia
c. Avoidance personality
d. Adjustment disorder

64. Atypical depression may be

characterized by all except:
a. Ravenous appetite b. insomnia
c. Increased libido d. Weight gain
65. In psychoanalytic terms,
obsessive compulsive disorder is
fixed at :
a. Oedipal stage b. Genital stage
c. Oral stage d. Anal stage

66. Preoccupation with body

diseases is seen in:
a. Obsession
b. Somatisation
c. Hypochondriasis
d. Conversion disorder

67. Fixation of Hysteria is :-

a. Genital b. Anal
c. Oral d. Phallic

68. “Pseudocommunity” is seen in :-

a. Hysteria
b. Schizoid personality
c. Paranoid disorder
d. Depreciation

69. Waxy flexibility is characteristic

of :-
a. Excitatory catatonia
b. Stuporous catatonia
c. OCD
d. All

70. In catatonic schizophrenia, all

are seen except :-
a. Mannerism b. Negativism
c. Echolalia d. Flight of ideas

71. The basic disturbance seen in

Mania is:
a. Coining new jokes
b. Elation
c. Ideas of reference
d. Delusions of grandiosity

72. Mania is usually associated with

the following except:-
a. Euphoria
b. Good humor
c. Physical over activity
d. Thought disorder

73. Dementia is produced by

deficiency of vitamin:
a. a b. d
c. Pyridoxine d. B 12

74. Suicidal tendency is most

common with:
a. Mania b. Depression
c. Obsessive disorder d. Schizophrenia

75. All are features of Dementia

except:
a. Impaired memory
b. Loss of judgment
c. Impaired consciousness
d. Loss of learned function
76. Biochemical etiology of
Alzheimer’s disease related it to:
a. Acetylcholine b. GABA
c. Serotonin d. Dopamine

77. Dementia is seen in all except:

a. Head injury
b. Alzheimer’s
c. Schizophrenia
d. Huntington’s chorea

78. In a patient presenting with

Nihilistic delusions and early
morning insomnia most probable
diagnosis is:
a. Major depression
b. Schizophrenia
c. Dementia
d. Obsessive compulsive neurosis

79. Which of the following

behavioral problems would suggest
an organic brain lesion?
a. Formal thought disorder
b. auditory hallucinations
c. Visual hallucinations
d. Depression

80. For severe intractable

obsessional neurosis the
psychosurgery of the choice:
a. Bifrontal tracototomy
b. Cingulotomy
c. Amygdalotomy
d. Temporal lobe lesion

81. A 68 years old man complaining

of hearing voices from the upper
floor using abusive language
believes that somebody is trying to
take away his property. He also does
unusual things as wearing his vest
over his shirt. He could be suffering
from:
a. Schizophrenia b. Dementia
c. Delusion d. Hysteria

82. One of these symptoms does not

occur in schizophrenia:
a. Thought alienation
b. Paranoid delusion
c. Disorientation
d. Hallucination

83. Reversible cause of dementia :

a. Post encephalitis b. Multi infarct
c. Hydrocephalus d. Senile dementia

84. Following are predisposition to

Alzheimer’s disease except:
a. Down’s syndrome
b. Head trauma
c. Smoking
d. Low education group

85. In schizophrenia, good prognosis

is indicated by:
a. Early onset
b. flat affect
c. Visual hallucinations
d. anhedonia

86. Most common hallucination in

schizophrenia is:
a. Auditory b. Visual
c. Olfactory d. Tactile

87. Neurotransmitter which is found

in increased quantities in
schizophrenia is :
a. Nor adrenaline b. Serotonin
c. Dopamine d. GABA

88. In schizophrenia, good prognosis

is indicated by:
a. Family history
b. Affective symptoms
c. Hebephrenic type
d. Gradual onset

89. Auditory hallucinations not seen

in :
a. Schizophrenia
b. Mania
c. Hysteria
d. Amphetamine toxicity

90. Schizophrenia is more common

in the ----------- class :
a. Middle
b. Low socio economic
c. Upper
d. Upper middle

91. All are features of catatonia

except :
a. Automatic obedience
b. Cataplexy
c. Catalepsy
d. Negativism
92. Most common comorbidity of
obsessive compulsive neurosis is :-
a. Mania
b. Depression
c. Dissociation of symptom
d. Persecutory delusions

93. A 8 year old child after a

tonsillectomy sees a bear in her
room. She screams in fright. A nurse
who rushes in switches on the light,
finds a rug wrapped on a armchair.
She pacificies the child. What the
child experienced was a
a. Delusion b. Illusion
c. Hallucination d. None of the above

94. Pseudo dementia is commonly

seen in:
a. Depression b. Hysteria
c. Mania d. Anxiety neurosis
95. An example of a form of thought
disorder is :
a. Obsessive compulsive neurosis
b. Delusion
c. Schizophrenia
d. Loosening of association

96. A pt with pneumonia for 5 days

admitted to hospital. He suddenly
ceases to recognize doctor and staff
and think that he is in jail. He
complains of scorpions attaching
him, is in altered sensorium,
condition is:
a. Acute delirium
b. Acute dementia
c. Acute schizophrenia
d. Acute paranoid

97. Delusion is not seen in:

a. Depression b. Anxiety
c. Schizophrenia d. Mania
98. Delusion of infidelity on part of
the sexual partner is known as :
a. De Clerambault’s syndrome
b. Couvade syndrome
c. Othello syndrome
d. Ekbim’s syndrome

99. Subcortical dementia is seen in

all except
a. Parkinsonism
b. Alzheimer’s disease
c. Wilson’s disease
d. Huntington’s chorea

100. Commonest symptoms hysteria

is :-
a. Motor or sensory phenomena
b. Hypchondriasis
c. Dissociation of symptoms
d. Persecutory delusions
101. In which type of schizophrenia
is grimacing a feature of:
a. simple b. Hebephrenic
c. Paranoid d. Catatonic

102. Obsessive compulsive neurosis

is characterized by all except:
a. Elaborate checking
b. repeated hand washing
c. Enjoyable Sexual thoughts
d. Excessive slowness

103. Ramesh, 30 years says that

whenever he goes to the temple, he
has to abuse God. He feels guilty
about this though he cannot control
his thoughts. What is he suffering
from?
a. Obsessive compulsive disorder
b. Schizophrenia
c. Anxiety
d. Depression
104. First symptom to disappear
with treatment of schizophrenia is:
a. Apathy
b. Poverty of thoughts
c. auditory hallucination
d. Anhedonia

105. Schizophrenia mostly occurs in :

a. Adolescents b. Children
c. Middle age d. Old age

106. Female patient with acute

restlessness and fear of impending
doom, the diagnosis is
a. Schizophrenia b. Delirium
c. Anxiety neurosis d. MDP

107. The neurotransmitters most

implicated in depression are:
a. GABA and dopamine
b. Serotonin and nor epinephrine
c. Dopamine and serotonin
d. GABA and nor epinephrine

108. All are features of Mania

except:
a. Insomnia b. Pressure on speech
c. Disorientation d. Grandeur delusion

109. All of the following

neurotransmitters are suspected of
being involved in the
pathophysiology of schizophrenia
except:
a. Prostaglandin E1 b. Nor epinephrine
c. ascorbic acid d. 5-HT

110. Babu, age 40 years suffers

sudden palpitations and
apprehension. He is sweating lasting
10 minutes, with dooming of death
diagnosis is:
a. Hysteria
b. Cystic fibrosis
c. Panic attack
d. Generalized anxiety disorder

111. Psychosis resulting due to

chronic amphetamine intake most
commonly resembles :
a. Delirium
b. Mania
c. Paranoid schizophrenia
d. Dissociative disorder

112. Anxiety neurosis is manifested

by all except :
a. Difficulty in breathing
b. Complete consciousness
c. Tangential thinking
d. All

113. Grossly disorganized, severe

personally deterioration and worst
prognosis is seen in
a. Hebephrenic b. Catatonic
c. Simple d. Paranoid

114. One of the following is not a

compulsive & habit forming disorder
:
a. Kleptomania
b. Pyromania
c. Nymphomania
d. Pathological gambling

Answer Key

1 D 61 C
2 A 62 D
3 B 63 B
4 B 64 B
5 B 65 D
6 A 66 C
7 D 67 D
8 C 68 C
9 B 69 B
10 C 70 D
11 C 71 B
12 D 72 D
13 A 73 D
14 D 74 B
15 A 75 C
16 C 76 A
17 B 77 C
18 D 78 A
19 A 79 C
20 D 80 B
21 D 81 B
22 D 82 C
23 C 83 A
24 C 84 C
25 D 85 C
26 D 86 A
27 A 87 C
28 C 88 B
29 B 89 C
30 C 90 B
31 C 91 B
32 C 92 B
33 B 93 B
34 B 94 A
35 B 95 D
36 A 96 A
37 B 97 B
38 C 98 C
39 B 99 B
40 A 100 A
41 D 101 B
42 B 102 C
43 A 103 A
44 C 104 C
45 B 105 A
46 B 106 C
47 A 107 B
48 A 108 C
49 D 109 C
50 B 110 C
51 D 111 C
52 D 112 C
53 C 113 A
54 A 114 C
55 D
56 D
57 C
58 D
59 B
60 D