Psychiatry

PSYCHIATRY
MATERIAL
By
DR. M NADEEM ZAFAR
RISE WITH ARISE

ARISE MEDICAL ACADEMY
https://instagram.com/arisemedicalacademy
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MEDICAL ACADEMY
Building Better Doctors
BASIC PSYCHIATRY
Sl.No. TOPICS Page No.
1. Basics/General Psychiatry
2. Schizophrenia
3. Mood disorders – Depression/Bipolar
4. Sexual disorders
5. Sleep disorders
6. Neurotic, stress related and somatoform disorders
7. Personality disorders
8. Child psychiatry
9. Psychoanalysis
10. Eating disorders
11. Organic mental disorders
12. Substance related & addictive disorders
13. ECT/Different methods of treatment in psychiatry
ARISE – DELHI ARISE – HYDERABAD ARISE – KERALA (KANNUR) ARISE – CHENNAI

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PSYCHIATRY
andadiological
A reg
Not changes
same changes seen. INTRODUCTION
↑
 Organic and Non-organic diseases
 Psychosis and Neurosis

⑪Acte
Pathophysiology of Psychiatric disorders
condition -> He
⑮ Never acute slow & quensive.
pro
B
ORGANIC MENTAL DISORDERS old NON-ORGANIC (FUNCTIONAL) MENTAL DISORDERS
->
age young
- Damage to brain parenchyma Do not have demonstrable disturbances of brain age
- Demonstrable disturbances of brain parenchyma.
ox
Radiological investigation - ①- Notchange
change san Mania, Schizophrenia seen.
Eg; Dementia, Delirium
Mental
of Confusion ② will oriented
Nonorganic mental disorders are further classified into Psychotic disorders (Psychosis) and Neurotic disorders
(Neurosis) OCO-
PSYCHOSIS NEUROSIS
Insight -> Awayernel of about dis Absent Present
Reality Testing Absent Present
thoughepic
Judgement Disturbed Normal
disorder
Eg;
->
Delusion/Hallucination of e
Present
Bipolar, SCZ
Absent
Depression, anxiety
rientaned.
"
personality distrubed
PSYCHIATRIST (s NE 0) ↑ PSYCHOLOGIST
MBBS Qualified Medical Doctors Not necessarily
I
(NS, N3.0)
Medicines Prescribe ↳
deprasion. Can’t
Illnesses Diagnose No diagnosis
Treatment Psychotherapy + Pharmacotherapy Only Psychotherapy (Talk therapy)
Pathophysiology of Psychiatric disorders

Imbalance in neurotransmitters level
 Eg. Dopamine, serotonin, acetylcholine , Nor-epinephrine, epinephrine, BDNF
Eg;
 Increase dopamine in limbic system – Psychosis
 Decreased dopamine in limbic system – Depression
 Decreased level of serotonin, NE, & Dopamine in limbic system– Depression – Treatment will be TCA (Tricyclic
Antidepressants)
S
serotonin
 BDNF increase- Mania
-> b,4.(Serotmin)
SSRI (slective
 BDNF decrease – Depression Reuptake inhibitor
 BDNF fluctuate – Bipolar ↳
fia oxitive some
↳ Escitalopram)
NEUROTRANSMITTERS SOURCES
reward, Plazar, Addication. hisen
Dopamine -kick for - for Substantia Nigra
mood,sleepMidline Raphe Nucleus Edept
-
SNR2
-
SelectNotein
mappy- Serotonin good food,
->
& ·venlafaxam.
normen Norepinephrine Altertues
Awolan al
-
Locus Ceruleus
Acetylcholine Nucleus Basalis
A Nicotin will stimulati Nucleus of Meynert
Dopamine Ack.
↳
↳ Atancion
enables
it muscle action.

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Date, time.
of place,
[disorientation
I coulding of
consiousness patterled
sensesium
fever
- I salmonelly
High fever Headache & lower obdo. pains Thyphoid.
Thyphi
*
sever
* dich 17
-
-
a neckwigditity ->
Meningitis.
A 2 x
n
11 a neck is a mental
confessions incafalitia.
Rep. Tractinfection.
& thorat -> Upper
↳ 3 Some
* - 2
A n u 2 3 a seven body pain diginous

-> Fangi
& jointpain-chicken gunina.
interval
A n · esenrings
chill at
regular
Malaria
of time -
sporter
a nightsweet
A 2
x 7
2
cough I
wt-loss -> TB.

&
Premonia.
spiptures
a seven reach cough -
pain rasher over

body- Kala ajar.
A sever body N.O
-
O
-
visual
auditory
⑤ mination
a
-> No such couse.

Medical dise.
⑥ dis.I
↳ dis
of mind
-
↳ Brain
walker
ambulisions night
mi observation
A so day for
↳ winm
of
↳ Max fr
10
day
↳electro
30
Therapy.
02D
Lottobrine
stimuliin
magnetic
Anore
xesa Narcose
tree tram cranial
EatingardE bul mic
de
disorde
airmental
↳Olivia ine
↳ Amnesia.
PSYCHIATRY
CHAPTER 1
GENERAL ASPECTS OF PSYCHIATRY
GENERAL PSYCHIATRY
 Psychiatry is derived from Greek word:
 Psyche: means mind or soul s(z)
 Iatros: means physician
 Benjamin Rush – father of American Psychiatry-
(explain
 Emil Kraepelin – Father of modern Psychiatry (Considered by many)
 Philippe Pinel's – Father of modern psychiatry (Considered by few)
 Term psychiatry was coined by – Johann Christian Reil (1808)
 Sigmund Freud – Father of Psychoanalysis
HOW TO ASSESS A PSYCHIATRIC PATIENT?

1. History taking
2. Clinical examination
complication
can had
to
512)
History taking birth (obstrictatic
 Perinatal history -Befor
 Childhood history
 Educational background
 Play history
 Puberty
 Menstrual & obstetric history
 Occupational history
 Sexual & Marital history
 Pre-morbid Personality
 Substance and alcohol history
Q. Which is not the component of psychiatric history taking?

a. Past history
b. Family history
c. Food preferences
d. Marital history
lot
Menia- talking
a
History taking: requires
 Reliability and Adequacy Depression - not talking.
Reliability requires C, D, E
E
1. Consistency
2. Coherence/Logical
3. Continuity - Chronological information (events in the order of their occurrence)
4. Closeness and Concern
-
6. Duration of stay with the patient
3 informants
6. Educated informant will have good observational skills and will be able to verbalize the symptoms
Information should be adequate

Q. Basis of reliability of information of patient provided by informants depend on all except;
a. Educational status
b. Observation skills
c. Duration of stay with patient
- d. Biological relationship

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PSYCHIATRY
cocain -> 1903

2nd step : S. trayd ->
CLINICAL EXAMINATION ↳ father

of SPYScoanalysis.
Q. Clinical examination of a psychiatric patient is done by:
A. Physical examination
B. Palpation and percussion of head
Examnation.
C. MMSE Mine Mental status
-
Mental disorder)
examination (organic
- D. MSE Mental status
MSE (MENTAL STATUS EXAMINATION) –
1. General appearance.
Depression
E
2. Speech ( rate & tone)-> Mania, I
3. Mood & Affect -> describe is emotion e
were
4. Perception - ..
.
.
. Hallusination.
.
.
.
5. Thought -> delection

-
6. Cognition: HIGHER MENTAL FUNCTIONS gasfactor-tast Touch.

↳ Mental Process: the help of Tactatik Hallusinations
7. Insight
which are
8. Judgement learing something he touch
used cogulation Thought
Action, Mathmatatic, speech, sometime
we
like
memory,
Q. Which of the following is not a part of mental status examination in a psychiatric patient?
A. Rate of speech
B. Quality of emotions Aphagia e loss of speech
*
-C. Percussion of spleen Apraxia e loss of Action

*
D. Thought process *Acalculiat loss calculation.

of
Amnesia
*
t loss
Q. Affect is; of memory,
CBT
Cogenative
*
e Behaviour Therapy
A. Memory
B. Abstract thinking
C. Emotion emotion
D. Insight
internal
->
termsatterms external
long
MOOD AND AFFECT
emotion
TO DESCRIBE EMOTIONS
 AFFECT: short lived, external expression of internal emotions, observable

 MOOD: Sustained (long term), internal emotional state
out resion
excessive kapiners
DISTURBANCES OF EMOTIONS:
- oposite ->
1. QUALITY – EUPHORIC AND DEPRESSED
2. FLUCTUATIONS –LABILE AND AFFECTIVE FLATTENING dater Happener
Happy depresente
I
= >
3. APPROPRIATENESS AND CONGRUENCY

meaningborderedinamating.
-
socal situation
emotion
Appropriateness of affect is described in relation to the social situation.
 Eg: Graveyard and party
Congruency of affect is described in relation to the thought content of person.

 Eg: Thought and speech matching
 Normal - CONGRUENT
 Abnormal – INCONGRUENT

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PSYCHIATRY
Q. Depressed mood describes;

A. Congruency of emotions
B. Quality of emotions
C. Fluctuation of emotions
D. Appropriateness of emotions
Q. Congruency of affect is described when the emotional state of patient is synchronized with his:
A. External appearance
B. Thought/speech
C. Intelligence
D. Insight
Some other disturbances depression,

->
of emotions: SCI.
 1. ANHEDONIA: Loss of capacity to experience the pleasure
↳
inability
to in old activites.
exprancance plazer
the
 2. ALEXITHYMIA: Inability to understand and express the emotions.

Lack of words to describe and understand the emotions.
↳System
mammally body
NEUROANATOMICAL SUBSTRATE OF EMOTIONS M
->
LIMBIC SYSTEM – MATCH

A
↳amygdala
Thalamus.
Q. Emotions are getting regulated by: T -
A. Limbic system -> generate. c

ecingulate gyrus
N
B. Frontal lobe ->
C. parietal lobe
regulate n e sippocampus
D. Medulla oblongata
Limbic system generates the emotions* and Frontal lobe regulates the emotions.*
PERCEPTION
ABNORMALITIES:
1. ILLUSION -> false preception of things.
seal
2. HALLUCINATION
 Illusion- false perception of a real object or stimulus.
 Hallucination- false perception in the absence of an object.
Illusion or Hallucination?
HALLUCINATION
 Mc hallucinations in psychiatric disorders- auditory*(overall)
 Mc hallucinations in organic psychiatric disorder- visual*
 Olfactory and gustatory hallucinations are mostly seen in temporal lobe disorder.
 Tactile hallucinations- Cocaine intoxication. /Alcoholism also

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PSYCHIATRY
Q. A patient was saying that he was hearing some sounds, which were originating within his own mind. He is
having:
-> crossing of
senses.
A. Auditory Hallucination
synesthesia
B. Pseudohallucination
↳ seems in substance poising
↳
C. Illusion
D. emotionally unstable ↳LS0& canabill.
I can watch music
Criteria to Diagnose Hallucination: ↳
I can Hear light
1. It occurs in the absence of any stimulus.
2. As vivid as real
3. Experienced in outer objective space.
4. Involuntary
Special types of hallucination:

slee 1. Hypnopompic: Before getting up from the sleep
L
Nar E
so lapsy2. Hypnogogic: Before going to sleep
3. Synesthesia (Reflex hallucination): Stimulus in one modality produces hallucination in another modality.
Lo
modafinil 4. Functional Hallucination: Stimulus in one modality produces hallucination in same modality.
“Other Disturbances of Perception”

 Autoscopy: patient can see an imaginary self from outside
↳ own imagination.
Depersonalization/Derealization: abnormalities in the perception of a person’s reality and are often described as “as-if”
phenomena.
↳ as if I have
changed
inside.
(as itphenomenal
seen in depression, BPD, SCI.
Autoscopy
AUTOSCOPY
e⑧
 Out of body experience: patient can see self from outside
 AUTOSCOPIC HALLUCINATION: patient can see an imaginary self from outside
-
 HEUTOSCOPY: patient can see a real self and imaginary self, not sure about the perspective
 INTERNAL AUTOSCOPY: patient can see internal organs, parts of body etc.
 NEGATIVE AUTOSCOPY: inability to see reflection in the mirror
 POSITIVE AUTOSCOPY: somebody else’s reflection is seen in mirror

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PSYCHIATRY
infant
ideag clangie
d
came
“as-if” phenomena
Depersonalization Derealization
Something inside is changing Something outside is changing
Eg; feeling that the arm is very light or heavy Eg; Feeling under stress or anxiety
Q. Which of the following statement is wrong about hallucination?

A. Occurs in absence of any stimulus
B. Occurs in outer objective space
C. Perceived as not real
D. Appears to be coming from external world
THOUGHT
Disturbances of Thought:
1. Stream of thought -flow of thought
2. Form of thought
3. Content of thought
4. Possession of thought
Disturbances of thought:
1. FLOW OF THOUGHT (Stream): it refers to the speed with which thoughts follow each other. Connection
between thoughts are seen due to rhyming factor.
Eg. Flight of ideas (I live in delhi, my cat has big belly, I like to eat jelly…lilly, lilly, lilly (menia)
2. Inhibition of thinking.
FORM OF THOUGHT:
It refers to the “organization” of thought or “association” between the consecutive thoughts.

a. Derailment – association between two thoughts is disturbed.
b.
Eg. Nehru -1st PM
Sachin scored century - sin in
Loosening of association – connection is lost between components of a single thought. Eg. I thought it will
e n e
rain today, Virat is an awesome player.

c. Incoherence – total lack of organization, so that thought is incomprehensible and does not make any sense. Eg.
India played snooker rice and andhr computer.
d. Cicumstantiality eunnessary details, befor
final Answer.
the
e. Tangentiality -> Ansing in a distantrelation Manner.

f. Neologism- Rin Rin Raga -> coining a new word. -S2
g. Metonyms (Word approximations)- hand socks (Gloves) eye cover
=
(glance), Time vaal (watch)

h. Clanging Rimming butincomprehensible
i. Perseveration ->
unnessary repetation of same things
circumstantial/perseveration of thought
*
-> How
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PSYCHIATRY
Q. Delusion is a disorder of:

A. Illusion
B. Perception
C. Thought
D. Judgement
Q. Delusion is a disorder of:

A. Form of thought
B. Flow of thought
C. Content of thought
D. Possession of thought
3. CONTENT OF THOUGHT: its disturbance is DELUSION.

one kill me
harm me
form false unshakable
Types of Delusion:
~some
belief It
is based on
1. Delusion of persecution (m(2)
everything sense
ters though insational ground.
2. Delusion of reference refling self for
3. Delusion of love-Erotomania, Fantacy Lover Syndrome, de-Clarambault syndrome
4. Delusion of grandiosity negatative.
5. Delusion of negation- – Nihilistic delusion/Cotard’s syndrome. /claming non-existentionse of something
6. Delusion of Infidelity – morbid jealousy/pathological jealousy/Othello syndrome
7. Delusion of Enormity ↳> bobbit syndrom
8. Delusion of guilt -> seven depression
-no
me belife.
 Bizarre delusion: scientifically impossible and culturally implausible. Eg. Patient will say aliens have
stolen my brain.
 Non Bizarre delusion: these are false but possible
-
3. POSSESSION OF THOUGHT:
 Disturbances of possession of thought;
Thought alienation- patient feels that his thoughts are under control of outsiders. Its types are:
 Thought insertion
 Thought withdrawal
 Thought broadcast
Obsessions – i.e. patient is not able to control his thought as thought comes repeatedly into the mind against his will.
LOCD eobsession & complain disorder.

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PSYCHIATRY
HIGHER MENTAL FUNCTIONS:

OST DRI
 A. Attention - Digit span test/digit repetition test
 B. Concentration – Serial Sevens subtraction test(SSST)
C. Memory –
 Immediate memory – Digit repetition test or SSST.
 a/c working memory. Can recall a material after few seconds
-
 Immediate retention & recall are tested by giving the patient six digits to repeat forward and backward.
 Digit Span Forward is a good tets of ATTENTION, CONCENTRATION & IMMEDIATE MEMORY
 Recent memory – can recall after an interval of minutes, hours or days. “24 hour recall test” is used to test it.
 Remote memory – can recall after an interval of years.
D. Intelligence – GK
E. Abstract thinking – ability to form concepts and make generalization.
 Proverb Testing
 Similarities testing
F. Judgement – ability to respond appropriately in a particular situation.

1. Test Judgement Eg. House on Fire,
2. Personal and social judgement
G. Insight – awareness and understanding about diseases. (emotional insight is highest level of insight)
Insight
1. Awareness of illness but no change in behavior on the basis of this awareness ( known as INTELLECTUAL
INSIGHT)
2. Awareness of illness AND change in behavior on the basis of this awareness ( known as EMOTIONAL INSIGHT)
dis(Yan202)
CLASSIFICATORY SYSTEMS IN PSYCHIATRY
1. ICD 10- 5TH CHAPTER AND LETTER “F”. -international
classification of
2. DSM-5 – Dignostic & statishatical Mannual. Addition No.5
3. ICD 11 – 6th Chapter
(USA), any psycrtic.
4. Research domain criteria&
(RDoC) eNeurobiology.
Research Dome criteria.
Q. Psychosis being differentiated from neurosis with the presence of:
A. Insight
B. Reality
C. Delusion
-
D. awareness
Q. A false belief which is unexplained by reality and is shared by number of people is;
A. Delusion
B. Illusion
C. Obsession
D. Superstition
-
Q. Reflex hallucination is a morbid variety of;

A. Kinesthesia
B. Paresthesia
-C. Synesthesia
D. Hyperesthesia

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PSYCHIATRY
Q. If a person is asked, “what will he do if he sees a house on fire”? Then what is being tested in that person?
A. Test Judgment
-
B. Social Judgment
C. Personal Judgment
D. None
Q. A patient believes he is the most important person in the world than anyone, so his neighbours and family is
trying to harm him as they are jealous of him and everyone is talking about him. His wife says otherwise and says
he behaves like this recently only before he was working as a school teacher peacefully and brought to OPD. He is
suffering from:
A. Delusion of persecution
B. Delusion of grandiosity
C. Delusion of persecution and grandiosity
D. Delusion of persecution, grandiosity and reference
Q. Loosening of association is an example of;

A. Formal Thought Disorder
-
B. Perseveration
C. Concrete Thinking
D. Delusion
Q. A patient who laughs at one minute and cries the next minute without any clear stimulus is said to have;
A. Incongruent affect
B. Euphoria
C. Labile Affect
e
D. Split Personality
Q. A 25 year old woman complaints of intense depressed mood for last 6 months. She also reports inability to
enjoy previously pleasurable activities. This symptom is known as;
A. Alexythymia
B. Anhedonia
an
C. Avolition
D. Amotivation
Q. A severely depressed person thinks her intestines are rotten. Is is an example of;
A. Ekbom syndrome
*
B. Nihilistic delusion
C. Illusion
D. Hallucination
Q. Which of the following test is performed to assess immediate memory?

A. Serial (100 – 7) subtraction test upto 5 steps
B. Digit span forward up to 7 digits with 2 skips allowed
C. Serial (20 – 1) subtraction test upto 5 steps
D. Digit span backward test up to 5 steps
Q. A man is brought to psychiatry OPD. He believes that he is the richest person in the world and that his family
members and neighbours are plotting against him and planning to harm him. The family members disagree with
him. Which disorder of content of thought is the patient suffering from?
A. Delusion of grandiosity
B. Delusion of grandiosity and persecution
C. Delusion of grandiosity, persecution and reference
D. Delusion of persecution

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PSYCHIATRY
Q. A person is asked about hos blood sugar level, he answers “Diabetics have sweet urine….urine and faeces are
excreta….even normal person excretes everyday”….before finally telling his blood sugar level. It is an example of;
A. Tangentiality
B. Loosening of association
C. Flight of ideas
a
D. Circumstantiality
CHILD PSYCHIATRY
ADHD
 ADHD-Attention deficit hyperactivity disorder- ↑
 Minimal brain dysfunction – older name

 ICD-10 describes it as hyperkinetic disorder
 ICD-11 – ADHD
 DSM – V -ADHD
 It is a common neuropsychiatric disorder in children. M>>F

 Sign and symptoms:
1. Inattention - usually the first symptom to be noticed – distractibility, restlessness, making more mistakes
2. Hyperactivity –keeps on roaming in class, disturbing others
3. Impulsiveness - inability to wait for his turn
 Neurological examination (detailed examination)

may reveal soft neurological signs- such as difficulty in copying age appropriate figures, right-left
discrimination..(Updated in DSM V)
 Cut off age to diagnose ADHD:
 Symptoms occur <7 years (DSM – IV)
 Symptoms occur <12 years (DSM – V)
Three subtypes of ADHD are:

 class I – Mostly hyperactive/impulsive
 class II – predominantly inattentive
 class III - combined
 Child has distractibility, restlessness, inability to wait for his turn, disturbing to others.
Course:
 50% get remission before puberty/early adulthood.
 Hyperactivity and impulsivity get improved
 Inattention may not be improved.
Those who do not get remission, They are at risk of developing:

 Substance use disorders (particularly alcoholism),
 Antisocial personality disorder and
 Mood disorders (depression)

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PSYCHIATRY
Treatment: ADHD is a serious medical illness*, so must be treated promptly.
Stimulants and Non-stimulants

 Stimulant medications: CNS stimulants are the 1 st line drugs.
 Stimulants are drugs or compounds that stimulate the CNS, which creates increased attention, alertness, and
energy.
 Methyl phenidate is the DOC
Nonstimulant Medications: are used when stimulants are not effective or contraindicated
CNS stimulants are contraindicated:
 If child has ADHD + Seizure
 Or F/H of drug dependence (stimulants could easily be abused)
Drugs for ADHD

STIMULANTS NON-STIMULANTS
Methylphenidate, Dexmethylphenidate Atomoxetin (SNRI)
Modafinil Bupropion
Amphetamine Venlafaxine
Dextro-amphetamine Clonidine, Guanfacine
Other treatment interventions:
 Psychosocial interventions:
 Such as
 Social skill training,
 Psychoeducation for parents,
 Behavioral therapy, CBT.
PERVASIVE DEVELOPMENTAL DISORDERS (AUTISM SPECTRUM DISORDER):

Group of neurobehavioral or neuro-developmental disorders
Include clinically similar conditions which are ch. by 3 symptom clusters;
Impairment of:
 Social interaction. Eg. Lack of social smile
 Communication (language and non-verbal).
 Restricted repetitive and stereotyped behavior, interests and activities. Eg. Stereotypy (hand wringing,
spinning, banging)
Autism
Ch. by all 3 features.
 Impairment of Social Interaction:
- Lack of social smile,
- Poor eye contact,
- Lack of anticipatory posture
- Poor attachment with parents
- Excessive reaction if their routines are getting disturbed
- Difficulty in making friends when they grow up.
Impairment in Communication:
Eg; difficulty in making sentences
Incoordination in using noun and pronouns etc.
Motor milestones are normal, but language milestones are delayed

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PSYCHIATRY
Restricted, Repetitive & stereotyped behaviour:

 - repetitive and boring plays – again & again
 - Stereotyped behaviours – banging, hand wringing etc
 - the restrictive behaviors are usually the result of lack of imagination and creativity
Others are;
 Abnormal fingerprints (dermatoglyphics)
 Extreme interest in some sounds like tickling of clock
 Self destructive acts like scratching, biting, head banging
 Late development of handedness and leteralization
 Mental retardation (30-35%)*
 Hyperkinesis
 Inability to concentrate
 Chromosomal association – 7, 2, 4, 15 & 19.
Other diseases ass. with autism are –

 Fragile x syndrome,
 Tuberous sclerosis,
 Congenital rubella syndrome,
 Phenylketonuria.
 Onset of infantile autism (usual autism) is < 2.5 – 3 years.
 If > 3 years – c/a childhood autism.
 Boys > girls
 Low socioeconomic status
PRECOCIOUS SKILLS OR ISLETS OF PRECOCITY
 Some individuals with autism may have skills in certain areas, which are much higher than their normal peers.
 Eg:
 Hyperlexia (early ability to read well)
 Extremely good
 Rote memory (a technique for learning in which one repeats facts or figures over and over again to instill them
in their memory banks)
 Calculating ability
 Treatment - structured classroom teaching with behavior therapy

 M-CHAT* – Modified Checklist for Autism in toddlers is a questionnaire that evaluates risk for autism spectrum in
toddlers.

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PSYCHIATRY
RETT’S SYNDROME:
 Age of onset is 5 years.
 Development may proceed normally upto 5 -12 months of age, when regression of language & motor
milestones become apparent.
 Ch. feature – they begin to lose their acquired skills.
 Acquired microcephaly.
 Breath holding spells.

 Autistic behavior is a typical finding in all patients.
 GTCS: Generalized tonic-clonic convulsions occur in majority.* - 75% of children.
 Feeding disorder, poor weight gain.
 Death occurs mostly in 3rd decade.
 Cardiac arrhythmias may result in sudden death.*
ASPERGER SYNDROME:
 Qualitative impairment in the development of reciprocal social interaction after the age of 3 years.
 More common in males.
 Normal intelligence. *
 No language impairment that characterize autism.*
 They are at high risk of getting other psychiatric disorders.
HELLER’S SYNDROME:
 Childhood disintegrative disorder.
 Ch. by normal development till the age of 2 years.
 Loss of acquired skills, social skills, bowel or bladder control between 2-10 years.
 Symptomatic treatment requirement.
LEARNING DISABILITY:
 Specific developmental disorders of scholastic skills with normal IQ.*
 DSM-IV defines three academic skill specific learning disorders.
 Reading disorder
 Mathematic disorder
 Disorder in writing expression
 Other subtype is dyslexia. Dyslexia is the mc type of learning disability. They have problem in reading,
spelling and written expression. Reading is slow, inaccurate and labored.

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PSYCHIATRY
CONDUCT DISORDER AND OPPOSITIONAL DEFIANT DISORDER:
CONDUCT DISORDER:
 Aggressive and dissocial behavior.
 Repetitive disregard for rights of others.
 Cruelty to animals, repeated lying, stealing, severe destruction to properties.
 It is frequently related to unsatisfactory family relationships and failure at school.
 Later they may develop dissocial/antisocial personality disorder.
OPPOSITIONAL DEFIANT DISORDER:

 It is less severe than conduct disorder. It is ch. by;
 Persistently negativistic and defiant behavior such as frequent arguing with adults.
 Refusal to comply with adults.
 Deliberately annoying behaviors to adults.
 No serious violations like conduct disorder.
 Treatment- family intervention and behavior therapy.
MENTAL RETARDATION:
 Updates:
 In DSM V: diagnosis of MR is replaced with “ INTELLECTUAL DISABILITY”
 ICD-11: diagnosis of MR is replaced with “DISORDERS OF INTELLECTUAL DEVELOPMENT”
Ch. by incomplete development of intellectual functions and adaptive skills.

 IQ = mental age/chronological age x 100.
In this formula max Chronological age is 15.
 MR is diagnosed when IQ < 70*
 Case A: A 14 year old boy has mental age of 7 year child. What will be his IQ?
Ans:
 IQ = MA/CA x 100 = 7/14 x 100 = 50
 Case B: A 17 year old boy has mental age of 7.5 year child. What will be his IQ?
Ans:
 IQ = MA/CA x 100 = 7.5/15 x 100 = 50
 Note: Maximum Chronological age will be 15 only
Category IQ
Normal 90-109
Borderline 70-89
Mild MR 50-69 (Educable – upto 6th class)
Moderate MR 35-49 (Trainable – educable upto 2nd class)

Severe MR 20-34 (Dependent )
Profound MR <20 (Needs Life Support)
Wechsler intelligence scale:
 WISC – Wechsler intelligence scale for children- for 6 1/2 to 16 years of age
 WAIS – Wechsler adult intelligence scale

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PSYCHIATRY
IQ classification IQ range
 Very superior (extremely bright) 130 and above
 Superior high (very bright) 120-129
 Superior (bright) 110-119
 Average 90-109
 Low average 80-89
 Borderline 70-79
 Extremely low 69 and below
 Behavioral problems in MR are being treated by behavioral therapy techniques like contingency
management,* in which desired behaviors are rewarded and undesired behaviors are punished.
HABIT DISORDER
 To describe a class of disorder that is characterized by repititive and unwanted behaviours.

Two types:
1. Tic disorder
2. Body focussed repetitive behaviours such as hair pulling, skin picking, nail biting, thumb sucking and cheek
chewing
Tic disorders:
 Tics are brief, rapid, recurrent motor movements (motor tics ) or vocalizations (vocal tics), that are performed in
response to internal urges.
Motor tics can be:

 Simple motor tics like eye blinking, head jerking, shoulder shrugging, face grimacing.
 Complex motor tics - like jumping, echopraxia ( repetition of observed behavior), corpropraxia (
displaying obscene gestures).
 Simple vocal tics like coughing, grunting and throat clearing.
 Complex vocal tics like – echolalia – repetition of words or coprolalia – use of obscene words.
Tourette’s syndrome
 It is a form of tic disorder in which there are multiple motor tics and one or more vocal tics.
 Mc comorbidity with tourette’s is ADHD f/b OCD*. Another is depression.
 Onset is usually in between 4 and 6 years. Symptoms peak in between 10-12 years.
Treatment:
 Behavioral therapy > pharmacotherapy
 First line behavioral therapy is “Habit Reversal”*. In this patient learns to identify urge that happens
before tics. And when he senses the urge, he follows it with a voluntary behavior (such as slow rhythmic
breathing) instead of the tic.
 Other BT is exposure and response prevention.
Pharmacotherapy – Noradrenergic agents such as clonidine and guanfacine.

 Atypical antipsychotics like resperidone.
 Haloperidol and pimozide are used but ass. wit many S/Es.
Q1. Minimal brain dysfunction syndrome is the older name of;

A. Dyslexia
B. ADHD
C. MR
D. Down’s

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PSYCHIATRY
Q. A girl with normal milestones spend her time seeing her own hand and does not interact with others. What is
the likely diagnosis?
A. ADHD
B. Autism
C. Rett’s disorder
D. Asperger’s syndrome
Q. Rett’s syndrome is characterized by all except;

A. Autistic behaviour
B. breath holding spells
C. regression of acquired skills
D. Macrocephaly
Q. ADHD in childhood can lead to what in future?

A. Alcoholism
B. schizophrenia
C. OCD Personality disorder
D. None
Q. A 10 year old child presents with impaired social interaction, impaired communication and stereotyped
behaviour. He has normal IQ and language skills. What is the most probable diagnosis?
A. Autism
B. Asperger’s syndrome
C. Rett’s syndrome
D. Childhood depression
Q. M-CHAT is used for screening of;

A. Autism
B. ADHD
C. Schizophrenia
D. Separation anxiety disorder
Q. A child finds difficulty to spell and read, otherwise his IQ is normal, interacts well with parents and friends.
Vision is normal. What is the most probable diagnosis?
A. Autism
B. ADHD
C. Dyslexia
D. Asperger syndrome
Q. What will be the preferred drug to treat ADHD in a 5 year old boy, whose father has a history of substance
abuse?
a. Methylphenydate
b. Clonidine
c. Modafinil
d. Atomoxitine
-Female)
EATING DISORDERS
CLINICAL PRESENTATION
Binging: Once a week duration > 3 months
- Eating very rapidly
- Eating beyond fullness
- Guilty feel following eating

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PSYCHIATRY
Restriction:
- Avoid eating in order to prevent weight gain.
- Seen in anorexia nervosa
Compensatory behaviour: A
- Purging B)
- Laxative uses L
- Induce vomiting
more
commen
ANOREXIA NERVOSA: ↓, secondary sexual growth.
 It’s a misnomer, appetite of patients is normal. Usually seen in adolescent females.
Sign & Symptoms:

 Disturbance of body image
 Excessive fear of fatness and emphasis on thinness.
 Significant weight loss due to restriction of energy intake.
 Medical symptoms secondary to starvation such as amenorrhea*, lanugo, hypothermia, bradycardia and
dependent edema seen.
 Adolescent patients have poor sexual development whereas adult patients get less interest in sexual activities.
 Patients exhibit some peculiar behavior about food;
 Hiding food, rearranging food repeatedly, cooking many dishes.
2 SUBTYPES:
Restricting type – seen in 50% and is ch. by highly restrictive food intake.
 Decreased BMI
Binge eating/purging subtype – seen in 25-50% cases.
BMI:
<18.5 (ICD)
<17.5 (DSM)
 Patient do rigorous dieting with intermittent binge eating & purging episodes.
 Dental caries, parotitis and metabolic alkalosis are seen due to repeated episodes of vomiting.
Treatment
 Hospitalization for nutritional, electrolyte (Na and K) and dehydration maintenance.

 Psychotherapy.
 Medicines like TCAs, SSRIs
UPDATES: DSM-5 & ICD 11

 In DSM-4 and ICD 10, amenorrhea was a necessary symptom for diagnosis of anorexia nervosa.
 However in DSM-5 AND ICD-11, this criteria has removed and it anorexia nervosa can be diagnosed in the absence
of amenorrhoea now.

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PSYCHIATRY
Bulimia Nervosa
 Its ch. by episodes of binge eating combined with inappropriate ways of preventing weight gain.
 It is more common than anorexia nervosa.
 More common in late adolescent females.
Features:
 Binge eating in small time
 Compensatory behavior like self induced vomiting, gymming, dieting etc.
 Fear of gaining weight.
 Weight is usually normal. This is differentiating feature from anorexia nervosa
 They have some features secondary to purging like dental caries, callus on knucles, salivary gland inflammation,
hypochloremic alkalosis.
 They don’t have peculiar patterns of food handling like hiding and being secretive.*
 They have normal sexual functioning.*
 Treatment: usually CBT and SSRI occasionally
SYMPTOMS ANOREXIA NERVOSA BULEMIA NERVOSA

Image conscious/Fear of fatness Yes yes
Purging Episodes Yes Yes
Restricting Type More common Less common
Weight Loss Yes No

Menstruation Problem Amenorrhoea No
Sexual problems Yes No
Dental caries Yes Yes
Salivary gland inflammation Yes Yes
Russel’s sign Yes Yes
-> Alcohalis
* SCOFF QUESTIONNAIRE- screening test for eating disorder cage
-> Autism
 S – Sick – Do you feel sick that you have eaten a lot? M-chat
 C – Control – Do you think you have lost control over amount of food you eat?
 O – One stone – have you lost more than 6Kg in last 4-6 months?
 F – Fat - Do you believe that your are Fat when others are saying, you are thin?
 F – Food – do you think food dominates your life?
 If yes for > 2 questions – Detailed examination needed
BINGE EATING DISORDER: ->

 Most common eating disorder.
 Ch. By episodes of binge eating, but there are no compensatory behaviours like bulemia nervosa.
 It is associated with overweight and obesity.
 Treatment is similar to bulemia nervosa

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PSYCHIATRY
UPDATES: DSM-5 & ICD-11

 A new diagnosis of eating disorder has been added.
AVOIDANT RESTRICTIVE FOOD INTAKE DISORDER:

 Insufficient intake of quantity/variety of food, that results in weight loss & nutritional deficiencies.
 The patient may report lack of interest in eating or avoid food due to sensory characteristics (eg. Not liking the
smell or taste of food).
 But there are no disturbance of body image.( this helps is differentiating from anorexia , restrictive type).
PICA
 Psychological disorder characterized by an appetite for substances that are largely non-nutritive, such as
 Ice - PAGOPHAGIA
 Soil, Dirt, Clay- GEOPHAGIA
 Hair - TRICHOPHAGIA
 Paper - XYLOPHAGIA
 Drywall or paint
 Sharp objects – ACUPHAGIA (acuphagia)
 Metal - METALLOPHAGIA
 Stones -LITHOPHAGIA
 Glass - HYALOPHAGIA
 Feces – COPROPHAGIA
 Vomit - EMETOPHAGIA
 Chalk, Brick
DSM -5 : Duration >1 month

 Pica is most commonly seen in pregnant women, small children, and persons with developmental disabilities such
as autism.
 Rule out psychosis/mental condition
COMPLICATIONS:
 Lead poisoning may result from the ingestion of paint or paint-soaked plaster. (Brain damage in children due to
lead)
 Hairballs may cause intestinal obstruction
 Toxoplasma or Toxocara infections may follow ingestion of feces or dirt.
Q. Anorexia nervosa can be differentiated from bulimia nervosa by;

A. Fear of weight gain
B. Disturbance of body image
C. Adolescent age
D. Peculiar patterns of food handling.
Q. False regarding bulimia nervosa is:

A. Onset is in adolescent
B. Dental carries seen
C. Amenorrhea is a common finding
D. Normal weight
Q. Which of the psychiatric illnesses is more common in females?

A. Autism
B. Conduct disorder
C. ADHD
D. Eating disorder

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PSYCHIATRY
Q. Which of the following is not a common feature of Anorexia nervosa?

A. Amenorrhea
B. Binge eating
C. Under weight
D. Self perception of being fat
Q. Differentiating feature of avoidant restrictive food intake disorder and restrictive type of anorexia nervosa is;
A. Weight loss is seen
B. Nutritional deficiencies
C. Absence of body image consciousness
D. Insufficient intake of food
MOOD DISRODERS
BDNF hypothesis:
 Brain Derived Neurotropic Factor. BDNF increases neuroplasticity and neuroprotection of the CNS
neurons.
 Trimming of extra neural pathways
 Increase in BDNF causes mania and decrease in BDNF causes depression.
QUALITY OF MOOD:
 Abnormalities: A-Euphoric state.
 Euphoria: excess happiness without any reason. Seen in mania and hypomania
 Elation: euphoria with increased in psychomotor activity(running and jumping)
 Exaltation: euphoria + increased psychomotor activity + delusion of grandiosity
 Ecstasy: highest level of happiness. a/c sense/state of bliss.
 B. Depressed mood- state of pervasive (in all domain of life) and persistent sadness.
MOOD DISORDERS/AFFECT DISORDERS

1. Major depressive disorder ( or unipolar depression or depression)
2. Bipolar disorder
3. Hypomania
4. Cyclothymia (less severe form of bipolar disorder)
5. Dysthymia (less severe and chronic form of major depression)
DEPRESSION

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PSYCHIATRY
Etiology
 Neurotransmitter disturbances: decreased level of monoamines i.e. serotonin, NE and dopamine in limbic
system.
 Hormonal disturbances- dysfunction of HPA axis has been seen in 50% of patients, which manifest as cortisol
hyper secretion.
 Hypothyroidism is a common cause.
 Neuroanatomical- decreased activity in dorsolateral prefrontal cortex and increased activity in amygdala have
been found in depression.
Features:
 Lifetime prevalence = 12% (around 5%-17%)
 M:F=1:2
 Mean age of onset – 40 years( i.e. middle aged females mostly)
 More commonly seen in divorced and separated persons.
 Depression is responsible for max. DALYs (disability adjusted life years)
 It is the mcc of suicide.
SYMPTOMS OF DEPRESSION:
These symptoms must last for >2 weeks for the diagnosis.
1. Sadness/depressed mood
2. Anhedonia
3. Guilt feelings
4. Lack of energy
5. Loss of appetite, hence the weight loss.
6. Cognition/concentration- negative thoughts and poor concentration
7. Suicidal thoughts
8. Psychomotor agitation or retardation (increased or decreased)
9. Sleep disturbances- insomnia> hypersomnia. Early morning awakening and reduced latency of REM sleep are
characteristic.
Symptoms: must last for >2 weeks for the diagnosis.

SWAG – suggestive of depression
 Suicide
 Weight loss
 Anhedonia
 Guilt
PHYSICAL SIGNS OF DEPRESSION

 OMEGA SIGN-
Above Root of Nose
VERAGUTH FOLD-
 Triangular fold near
in nasal corner

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PSYCHIATRY
PSYCHOTIC DEPRESSION
 With psychotic features- delusion and hallucination.
Psychotic symptoms can be mood congruent and mood incongruent.
Mood congruent: i.e. content of delusion/hallucination is consistent with the depressed mood. Eg; Nihilisric delusion –
in a severe depressed case.
 Mood Incongruent: Content of delusion is inconsistent with depressed mood. Eg: delusion of grandiosity in a
severe depressed patient.
Psychotic depression: DEPRESSION + PSYCHOTIC FEATURES

 ICD-11 UPDATE: Psychotic features can be seen in severe and moderate depression.
With atypical features (ATYPICAL DEPRESSION)

These patients present with reverse biological symptoms such as
 Hypersomnia, Overeating/hyperphagia
 Weight gain/Obesity
 Interpersonal sensitivity (feeling of being rejected and disliked by others)
 Leaden paralysis (feeling that limbs have become heavy and difficulty in moving the limbs).
 Presence of mood reactivity: patient mood improves if some positive events occurs
MELANCHOLIC DEPRESSION
 Also called as involutional melancholia,
 usually seen in old ages.
 Severe anhedonia,
 Profound guilt feelings
 Feels miserable with intensely depressed mood
 Prominent biological symptoms:
- Early morning awakening (waking up 2 hours before usual time)
- Significant anorexia and weight loss
 Depression is worse in morning
 They have higher suicidal risk
With catatonic features-

 Patient with depression may develop catatonic symptoms such as stupor and negativism, etc.
PSYCHOLOGICAL THEORY
Cognitive triad of depression.*- proposed by Aoron Beck.
 Hopelessness- negative thought about future
 Helplessness- negative views about environment
 Worthlessness- negative view of self.
TREATMENT
Pharmacotherapy;
 TCAs –(2nd line drugs) Imipramine, Amitryptyline, amoxapine etc.
 SSRI - DOC
 SNRI
 MAO
 Atypical antidepressants
Psychotherapy;
 Cognitive behavioral therapy
 Interpersonal therapy
 Family therapy
 Antidepressant treatment should be maintained for at least 6 months.
Prophylactic treatment with antidepressant is effective in reducing the number and severity of episodes. It
should be given to patients who had;
 1. 3 or more prior depressive episodes
 2. have chronic major depressive disorder (>2 years duration is chronic depression)
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PSYCHIATRY
TCAs (Tricyclic and tetracyclic antidepressants)

 Blocking Serotonin and Norepinephrine, hence increasing the levels of these two.
 Secondary effects of TCAs: antagonising M, H1, α1 & α2 receptors and blockage of cardiac sodium channels.
 These secondary effects are responsible for the unfavourable side effect profile of these drugs.
 Anticholinergic S/Es: constipation, urinary retention, blurred vision, dry mouth, decreased sweating & delirium.
(so TCAs should be avoided in GLAUCOMA & BPH)
 Due to α blockade – postural hypotension (rarely hypertension can also be seen)
 Cardiac S/Es: tachycardia, flattened T waves, QT prolongation & ST depression. Severe S/E like arrhythmia &
hypotension due to blocking of cardiac sodium channels.
 Neurological S/Es: Fine & rapid tremors.

 Excessive blockade of serotonin & NE can cause seizures.
 H1 Blockade: sedation
Other S/Es:
 Weight gain
 TCAs (especially amoxapine) – hyperprolactinemia, amenorrhea, gynaecomastia, impotence, galactorhhea etc.)
TCA Toxicity
Manifestations:
CVS: Hypotension, chest pain, palpitations
CNS: altered sensorium, respiratory depression, seizures
Peripheral autonomic: dry mouth, blurred vision, urinary retention etc.
Metabolic acidosis
ECG: Prolonged PR, QRS & QT interval, AV block & right axis deviation.
TREATMENT: A QRS interval of >100 millisecond is the basis of treatment with I/V sodium bicarbonate (serum
alkalization) – mainstay treatment in TCA toxicity.
Gastric lavage and use of activated charcoal is only beneficial if administered after the overdosage.
SSRI
 Most commonly antidepressants
 No S/Es like TCAs
 Side effects:
- GI S/Es – short lasting
- Sexual dysfunction – mc S/E on long term use
- CNS – anxiety, insomnia, sedation, vivid dreams , nightmares, seizures, EPSs, sweating.
- Anticholinergic S/Es- Mostly associated with paroxetine
- Blood: functional impairment in platelet aggregation
- Others: weight gain
SSRIs are the DOC for treatment of;

 Depression
 Premenstrual syndrome
Neurotic disorders like
 Phobia,
 OCD,
 PTSD,
 Anorexia Nervosa
 Bulemia Nervosa
 Gneralized anxiety disorder

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PSYCHIATRY
SEROTONIN SYNDROME
 Concurrent administration of serotonin with MAO inhibitor, L-tryptophan or Lithium can raise plasma serotonin
concentration.
 It is potentially a fatal syndrome.
FEAUTRES:
1. Diarhhea, restlessness
2. Hyperreflexia, agitation & autonomic instability
3. Myoclonus, hyperthermia, rigidity, seizures
4. Delirium, coma and death
Treatment: Cyproheptadine and supportive care
DISCONTINUATION SYNDROME
 Sudden discontinuation or rapid reduction of dosage of antidepressants can cause this.
Features: FINISH
 Flu like symptoms
 Insomnia
 Nausea
 Imbalance (vertigo, dizziness)
 Sensory disturbances (paraesthesia)
 Hyperarousal (anxiety, irritability)
 All antidepressants can cause this.
 VENLAFAXINE – most comonly associated
 Short acting SSRIs ( paroxetine & fluvoxamine) – commonly ass.
ESKETAMINE
 S enantiomer of ketamine
 FDA approved (in 2019) use of nasal spray of esketamine – for treatment of TREATMENT RESISTANT
DEPRESSION
 Used as nasal spray along with an oral antidepressant.
 Bcoz of risk of misuse, it would be administered in the office of a certified medical doctor.
OTHER SOMATIC TREATMENTS;

ECT (electroconvulsive therapy)- its indications in depression;*
 Severe depression with suicidal risk.
 Severe depression with stupor.
 Depression with psychotic symptoms.
 Refractoriness to other treatment modalities.
2. Transcranial magnetic stimulation – uses magnetic energy to stimulate nerve cells. It is non-convulsive and requires
no anesthesia.
3. Vagal nerve stimulation
4. Deep brain stimulation- not approved by FDA*
5. Sleep deprivation
6. Phototherapy (primarily used for seasonal affective disorders (Winter). It involves exposure to bright light in range
of 1500-10,000 lux or more.

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PSYCHIATRY
TMS
Vagal Nerve Stimulation
BIPOLAR DISORDERS
Etiology:
 Neurotransmitters: increased levels of dopamine
 Genetic factors: chromosome 18q and 22q have strong ass.
 Both mania and depression.

 Lifetime prevalence- 1%
 Lifetime prevalence of bipolar I in M:F=1.1:1.
 Mean age of onset of bipolar I is 18years and for bipolar II is in mid 20s.
 More common in divorced and singles.
Types of bipolar disorders:

 Bipolar ½ - schizobipolar disorder (schizoaffective disorder)
 Bipolar I – mania with depression (or mania alone)
 Bipolar I ½ - depression with protracted hypomania
 Bipolar II – depression with discrete hypomanic episodes
 Bipolar II ½ - depression superimposed on cyclothymia

 Bipolar III – depression + induced hypomania ( eg. Hypomania occurring solely in association with
antidepressants or other somatic treatment)
 Bipolar IV – depression superimposed on hyperthymic(hyper-energetic) treatment

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PSYCHIATRY
Symptoms: should last at least for 7 days and must cause marked impairment in social and occupational functioning.
 Elevated or irritable mood
 Over talkativeness
 Increased self-esteem or grandiosity
 Distractibility
 Flight of ideas
 Decreased need for sleep
 Increased in goal directed activities (hyper sexuality, over activity )
 Excessive involvement in activities that high potential for painful consequences ( too much shopping,
foolish business investment )
 Psychotic symptoms: delusion and hallucinations may present in mania.

 Hypomania – less severe than mania. Duration criterion for hypomania is 4 days.
 Mixed episodes – both manic and depressive symptoms lasting for at least 7 days.
Treatment
 Required during acute illness and for prophylaxis
 Mood stabilizers: Lithium + valproate+lamotrigine
 Valproate - better than lithium in acute mania
 Lamotrigine – bipolar depression
 Antipsychotics – atypical
 Benzodiazipines – Lorazepam and clonazepam, used in acute mania due to their calming effect.
 Antidepressants – always used along with mood stabilizers and never alone* in bipolar.
Treatment guidelines
Acute manic or mixed episode:
 For severe mania or mixed episode: initiate with Atypical antipsychotic + Lithium +/- BZD for 2-4 months and
continue with Lithium
or Valproate + antipsychotic
 For less ill patient – monotherapy with lithium/valproate/antiphychotic
 If patient has psychotic symptoms: antipsychotics must be added to the regimen.
Acute depression(bipolar depression):

 Initiate with lithium or lamotrigine.
 In severely ill patient – lithium + antidepressant.
 Patients with suicidal risk – ECT.*
 Antidepressant monotherapy should never be given.*
Maintenance :
 Usually given after 2 or more acute episodes.
 Lithium and valproate
 Treatment should be continued for at least 2 years.*
Other mood disorders:

 Recurrent depressive disorder; more than one episodes
 Premenstrual dysphoric disorder – onset 1 week before menses.
 Dysthymia – presence of mild depressive symptoms(not enough to diagnose a major depression) for more than 2
years
 Chronic depression – depression more than 2 years
Note: in DSM-V, dysthymia has been removed and a new category of diagnosis has been added, “Persistent depressive
disorder” for both chronic and dysthymia.
 Double depression* – superimposed development of depressive episode in a patient already suffering from
dysthymia.
 Cyclothymia – milder form of bipolar disorder for 2 years.

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PSYCHIATRY
 Rapid cycling – if a patient of bipolar has 4 or more episodes of mania/hypomania/depression in one calendar
year.
Psychiatric aspects of pregnancy

POSTPARTUM BLUES POSTPARTUM DEPRESSION
INCIDENCE 30 – 75% 10 – 15%
TIME OF ONSET 3-5 days postpartum Within 3 months of postpartum
TEARFULNESS Yes Yes

ANHEDONIA No Yes (common)
TEARFULNESS Yes Yes
SLEEP DISTURBANCES Occasional Common
THOUGHT OF HARMIN BABY No Sometimes
SUICIDAL THOUGHTS No Sometimes

HISTORY OF MOOD Not associated Usually present
DISORDER
FAMILY HISTORY OF MOOD Not associated Usually present
DISORDER
GUILT Rare Common
INCREASED RISK OF No Yes
DEVELOPMENT OF FUTURE
EPISODES OF DEPRESSION
TREATMENT Support to mother Pharmacotherapy +
Psychotherapy
Post Partum Psychosis – a/c puerperal psychosis.

 Seen within 2-3 weeks of delivery
 Insomnia, tearfulness and emotional lability followed by developments of delusions and hallucinations.
 Associated with mood disorders/bipolar
 Incidence – 1-2/1000 pregnancies
 Duration – 2 – 4 weeks
 Effect – patient can harm themselves/new born
 Recurrence in future pregnancies - >50% chance
Note:
 B- Baby blues - <2weeks
 P- Psychosis – 2-4 weeks
 D- Depression – 4-6 weeks
BREXANOLONE
 FDA approved 2019, I/V infusion (60 hours continuous I/V infusion)
 First ever drug to be approved specifically for treatment of POSTPARTUM DEPRESSION.
SUICIDE:
Highest risks are associated with;
 Depression
 Schizophrenia
 Alcohol dependency
 Personality disorders (esp. borderline and antisocial personality disorders)

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PSYCHIATRY
 Substance related.
 Low CSF level of 5 HIAA (5- hydroxyindoleacetic acid), a metabolite of serotonin is ass. with higher risk of
suicide.*
 PARASUICIDE: when a person indulges in self injurious behavior (eg; making superficial cuts on skin), however,
doesn’t have the intention to kill self
 COPYCAT SUICIDE: adolescents belonging to same group have committed suicide one after another. Suicide after
the suicide of any popular figure.
 PHYSICIAN SUICIDE: doctors have higher risk
Psychiatrist > Opthalmologist > anaesthesist
LITHIUM: It is an effective antisuicidal agent and decreases the risk by 80%*.

T ½ : 24 hours
 Effective serum concentration for treatment should be 1.0-1.5mEq/dL.*
 Serum concentration for maintenance should be 0.6-1.2mEq/dL.*
 Signs of toxicity starts at the levels above 1.5mEq/dL.*
 Lithium toxicity and therapeutic drug monitoring (TDM):
 ACUTE LITHIUM TOXICITY: presents with nausea, voimiting, ataxia, dysarthria and tremors, which can progress
to cardiac arrhythmias, hypotension and coma. To prevent toxicity, TDM is done.
Plasma conc. of lithium (mEq/L) Relevance

1 – 1.5 acute attack of mania
0.6 – 1 prophylaxis of mania, BPD
>2 indicator of toxicity
>3 Permanent neurological damage.
Absolute indication for dialysis.
>4 Death
Q. Double depression is;

A. Depression with dysthymia
B. 2 episodes of depression
C. Dysthymia
D. None
Q. Neurotransmitters involved in depression are;

A. GABA and dopamine
B. Serotonin and Norepinephrine
C. Serotonin and Dopamine
D. Norepinephrine and GABA
Q. Stimulation of which nerve cause elevation of mood?

A. Optic nerve
B. Olfactory nerve
C. Trigeminal nerve
D. Vagus nerve
Q. A patient comes in stuporous condition. Patient’s parents give history of patient being continually sad and
suicidal attempts and not eating and sleeping most of the time. The best treatment for this patient is;
A. Antidepressant
B. Antipsychotic
C. ECT
D. Sedative
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PSYCHIATRY
Q. Sleep pattern in mania is;

A. Hypersomnia
B. Insomnia
C. Decreased need for sleep
D. Somnambulism
Q. Best use of Lithium is in:

A. Treatment of schizophrenia
B. Treatment of recurrent depression
C. Treatment of first depressive episode
D. Prevention of recurrence in bipolar mood disorder
Q. A young female on antidepressants presents to the emergency with altered sensorium and hypotension. ECG
reveals wide QRS complexes and right axis deviation. What is the next best step in management?
A. Fomepizole
B. Flumazenil
C. Sodium bicarbonate
D. hemodialysis
Q. Incidence of suicide in India is;

A. 8-10/100 population
B. 8-10/100o population
C. 8-10/10000 population
D. 8-10/100000 population
Q. Not a symptoms of mania;

A. Distractibility
B. Delusion of grandiosity
C. Increased sleep
D. Elation
Q. Higher cortisol level is seen in;

A. Phobia
B. Schizophrenia
C. Depression
D. Parkinson’s
Q. A postnatal mother who delivered 2 days back presents with increased tearfulness and sleeplessness. No
features of anhedonia, suicidal or lack of interest present. Most probable diagnosis?
A. Postpartum psychosis
B. Postpartum depression
C. Postpartum blues
D. Mania
Q. A 60 year old man whose wife died 3 months back now starts to believe that his intestines have rotten away and
that he is responsible for the death of his wife and should be sent to prison. Most likely diagnosis;
A. Grief psychosis
B. Schizophrenia
C. Psychotic depression
D. Delusional disorder
Note: Nihilistic delusion ass.

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PSYCHIATRY
Q. A 44 year old male with a past history of a manic episode presents with an illness of 1 month duration
characterized by depressed mood, anhedonia and profound psychomotor retardation. The most appropriate
management strategy is prescribing a combination of;
A. Antipsychotics + Mood stabilizers
B. Antidepressants + benzodiazepines
C. Antipsychotics + Antidepressants
D. Antidepressants + Mood stabilizers
Q. A 23 year old man has presented with increased alcohol consumption & sexual indulgence, irritability, lack of
sleep & not feeling fatigued even on prolonged periods of activity. All these changes have been seen for last 3
weeks. What is the most likely diagnosis?
A. Alcohol dependence
B. Mania
C. Schizophrenia
D. Impulsive control disorder
Q. A 25 year old female, living as a paying guest, consumed multiple number of sleeping pills. Which of the
following is not a risk factor of suicide?
A. Social isolation
B. Hopelessness
C. Substance abuse
D. Insomnia
PERSONALITY DISORDERS
-Tower of adjectment.
PERSONALITY DISORDERS
 Defined as the dynamic organization within the individual that determines his unique adjustment to the
environment.
WHAT ARE THE PERSONALITY TRAITS?
These are normal and prominent aspects of personality. And these are broadly described by the big five:
1. Openness to experience
2. Conscientiousness
3. Extraversion
SAN (Menamic)
4. Agreeableness
5. Neuroticism
1. Openness to experience:
High: enjoy adventure, Sensation seeking. They appreciate art, imagination and new things. Eg: bungee jumping,
sky diving etc.
Low: Avoid new experiences and they are not adventurous.

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PSYCHIATRY
2. Conscientiousness :
High: organized and have a strong sense of duty.

- >
-> Butiful.
 Disciplined, achievement focused and good planners.
Low: More spontaneous and freewheeling and careless.
3. Extraversion: on the basis of this distinguished personality trait, we easily differentiate the people into extrovert and
andits
us did on
introvert.
e
EXTROVERT: are very talkative, sociable and mostly they prefer group activities.
mt and onstant sitti
->
INTROVERT: they speak less. They need their alone time and They prefer solitary activities. It doesn’t mean they are shy.
-
They can perfectly be fine and charming at parties.
4. Agreeableness: It measures the extent of a person’s warmth and kindness.

 Agreeable people are very trusting, helpful and compassionate.
 Disagreeable people are very suspicious of others and they are less likely to be cooperative.
5. Neuroticism: Degree of emotional stability.

 High: worry frequently and easily slip into anxiety and depression. Difficulty in handling any criticism
 Low: tend to be emotionally stable.

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PSYCHIATRY normal
santonic) fell
the
normal.
ago does't satified he is
PERSONALITY DISORDER: dystonics

↳- 0 ch
-
- -
 is defined as presence of abnormal behavior and subjective experiences which causes significant
impairment.
 Prevalence – 10-20%
 Onset – adolescence or early adulthood
 Maturing occurs by 40 years. (maturing means the resolution of abnormal patterns of behavior)
 Ego Syntonic* - agreeable to self

⑧
Individual with personality disorder dose not find anything wrong with himself, hence unwilling to take
any treatment.
Classification of personality disorder into three clusters(as per DSM-V):
Cluster A personality disorders: ODD & ECCENTRIC

1. Paranoid personality disorder -> sak Karna Hemesa.
2. Schizoid personality disorder

3. Schizotypal personality disorder
Paranoid personality disorder; (More Common in Mah)

 Paranoia - relentless mistrust and suspicion of others without adequate reason to be suspicious.
 Excessive sensitive and quick to react angrily.
 Excessive self-importance and believe in conspiracy theories.
 Treatment- psychotherapy
 BZD and antipsychotics for paranoia( excessive suspiciousness)
mimic likehe ↳
Alpes, dizipam,oxizipam
Q. History of a great man: he used to enjoy mostly solitary life, with least interest in social life and very less
attracted towards opposite sex. His personality will be considered as:
A. Schizotypal
B. Schizoid
C. Narcissistic
D. Paranoid
ditacted.
SCHIZOID PERSONALITY DISORDER: (socaly
Isolated) motionaly cold & socaly
 Emotionally cold (Indifferent to appreciation and criticism)
-
- Socially detached
-Self absorbed & lost in day dreams & they may have their own fantasy world

 Solitary & sheltered lifestyle
 Secretive
They may have lack of sexual interest as they are uncomfortable with human interaction.
 Treatment – psychotherapy and occasionally BZD, antipsychotics.
SCHIZOTYPAL PERSONALITY DISORDER: lodde impropriate

behaviour)
↳ In 6/w SC2.
 Patients have disturbances of thinking and communication.
 Exhibit odd beliefs and magical thinking ( superstitions etc.)
 Their inner world is childish, full of fear and fantasies.
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PSYCHIATRY
 Socially withdrawn with odd, eccentric and inappropriate behavior, so they do not have any close
relationship.
 ometimes short term PSYCHOSIS like illusion, hallucinations and delusion like ideas.
UPDATES: ICD-11
 Schizotypal disorder is not considered as personality disorder.
 Instead it is classified as a psychotic disorder along with schizophrenia
-
 Cluster A personality disorder (esp. schizotypal*) are considered to be on a “schizophrenia continuum”,

which means they lie somewhere in between the normal & schizophrenia.
Cluster B -> full drama

of
Personality Disorders:
“ EMOTIONAL, ERRATIC & DRAMATIC”
Cluster B personality disorders: “ EMOTIONAL, ERRATIC & DRAMATIC”

attitude)
1. Histrionic personality disorder full of drama. (Attance siling
-
2. Narcissistic personality disorder

3. Antisocial personality disorder (dissocial personality disorder)
4. Borderline personality disorder
HISTRIONIC PERSONALITY DISORDER:
 Full of drama
 Patients behave in extroverted way.
 They exaggerate the expression of emotions, shallow and labile affectivity.
 They have attention seeking attitude
 Sometimes they behave in a seductive manner and use physical appearances to draw the attention.
 There is an attempt to look beautiful and gorgeous.
 Anticipating appreciation, Easy to get hurt, manipulative behaviours to achieve own needs.
 Anger outburst or tantrums are common.
 Suicidal gestures may be made at times.
 Interpersonal relationships are often stormy.
Most successful method of management: Psychoanalysis and psychoanalytical psychotherapy.

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PSYCHIATRY
NARCISSISTIC PERSONALITY DISORDER self
 People who have this disorder will have ideas of grandiosity and inflated sense of SELF IMPORTANCE.
 They believe that they are special and very talented.
 They are preoccupied with fantasies of unlimited success.
 They have lack of empathy with others and exploitative behavior.
They always want admiration. They should always be praised by everyone.
 At the same time, they are unable to face any criticism

 They have fragile self esteem and underlying sense of inferiority, easily get depressed by minor events.
 They are susceptible to have development of depression, when faced with rejection.
 Treatment: Psychotherapy
 Medicines – antidepressants
ANTISOCIAL PERSONALITY DISORDER: -> Alcoholism

commonaly seen.
This disorder is synonymous with old terms like PSYCHOPATHY & SOCIOPATHY…but does not always mean
criminal behavior .
 Unlawful behavior such as theft, lying, conning etc. dre



They do not have regards for others and don’t feel guilty for their actions.
They easily get Aggressive and Violent.
performancemold
 Substance abuse are frequently present in these patients. pro

 And there are no psychotic features in this PD enxity.
History of conduct disorder in young age may support the diagnosis.
 Treatment – psychotherapy and carbamazepine & beta blockers occasionally.
BORDERLINE PERSONALITY DISORDER (BPD): excessive Ryn coatany resion.

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PSYCHIATRY
CBT
eagretive form of
-
BPD
 Also known as EMOTIONALLY UNSTABLE PERSONLAITY DISORDER
 They are always in the state of crisis
 Significant mood swings.
 They may start feeling angry, anxious or frustrated without any reason.
 Unstable and intense interpersonal relationship pattern
 They are indulged into self destructive acts like over dosage of medicines, slashing of wrists.
 These patients are also very impulsive in certain areas like spending, sex and substance use.
 And they excessively use a defense mechanism of SPLITTING, wherein they consider each person to be
either “all good” or “all bad”.
Treatment – psychotherapy
 “Dialectical behavior therapy” is used for BPD.***
 Medications- anti depressants, anti-psychotics and mood stabilizers.
Note: in ICD-10, BPD has been described as a subtype of “emotionally unstable personality disorder”
CLUSTER C PERSONALITY DISORDERS- “ANXIOUS & FEARFUL” ->

alway dare he
log.
AVOIDANT PERSONALITY DISORDER:
 They are excessively sensitive to rejection. They are scared of criticism, hence they tend to remain socially
withdrawn.
 Fear of rejection
 Inferiority complexed
 Treatment – psychotherapy & SSRI occasionally
DEPENDENT PERSONALITY DISORDER:
 These patients are dependent on others for everyday decisions.

 All major decisions in their lives are taken by someone else.
 Seek excessive amount of advices and reassurance from others.
 They feel uncomfortable or helpless when they are alone.
 They have difficulty in SAYING NO to others, because of fear of loss of support.
Treatment: Psychotherapy
 BZD & beta blockers for symptomatic relief
 Treatment – psychotherapy, BZD & SSRIs occasionally

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PSYCHIATRY
OBSESSIVE COMPULSIVE PERSONALITY DISORDER:
 They are preoccupied with rules and regulations.

 They get into details and show perfectionism which often result into the delay of tasks.
 Inflexible, formal, workaholic, having no time for leisure activities and often lack a sense of humor.
ICD-10 uses the diagnosis of “anakastic personality disorder”* for these patients.
UPDATES: ICD-11
 The older classification of PDs (eg. Schizoid, paranoid, narcissistic etc.) has been removed.
 Acc. To ICD-11, PDs have been divided according to severity of symptoms into:
1. Mild PD
2. Moderate PD
3. Severe PD A competitiveness we
repressed.
↳ AD in
feature
Other classification of personality:
B* Ralaxed
Type A: ch. by: H-Hardiness.
 Competitiveness
 Time urgency hostility and anger to illness
ceProne
 Ambitious, impatient, workaholic
 Risk factor of CAD
Type B:
 Easy going and relaxed.
 They are not excessively competitive and focus more on enjoyment & less on winning or losing.
Type C:
 Prone to illness
 Stressed
Type D:
 Ch. by negative affectivity and social inhibition( tendency to inhibit expression of emotions). Dysthymic and
depressed.
 Predisposed to CAD.
Type H:
 Also known as hardiness personality
 Always looking for control, commitment and challenges.

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37 | P a g e
PSYCHIATRY
IMPULSE CONTROL DISORDERS Lurget

 These disorders are ch. by irresistible impulses or temptations to perform a particular act which is
harmful to others. These acts give a sense of relief and gratification to the patient.
 Pyromania – recurrent and purposeful setting of fire
 Kleptomania – recurrent stealing of objects (choni Karna]
 Pathological gambling

-
type
Trichotillomania – hair pulling
 Oniomania – compulsive buying
 Intermittent explosive disorder – ch. by episodes of aggression, resulting in destruction of properties etc.
Dipsomenia
y
Urge for Alcohol.
Q. Which of the following is a type C PD?
A. Narcissistic PD
B. BPD
C. Schizotypal PD
D. Dependent PD
Q. Which one is not a compulsive disorder?

A. Kleptomania
B. Pyromania
C. Nymphomania
D. Pathological gambling
Q. Characteristic disorder that appears in late childhood and continues in adulthood is;
A. Anxiety disorder
B. Personality disorder
C. Somatoform disorder
D. Mood disorder
Q. A lady has changed multiple boyfriends in last 5 months. She keeps on breaking her relationships and she also
has attempted suicide many times. What is the likely diagnosis?
A. Acute depression
B. Borderline personality disorder
C. Acute panic attack
D. Post traumatic stress disorder
Q. Odd beliefs, oddities of speech, fantasie mannerisms, odd clothing with magical thinking is seen in;
A. Schizoid PD
B. Schizotypal PD
C. Paranoid PD
D. Borderline PD
Q. Individuals with type D personality are recently found to be at risk of developing;

A. Depression
B. Mania
C. Schizophrenia
D. Coronary artery disease
Q. A person is very impatient, competitive and works like a perfectionist. He/she can be described as;
A. Type A Personality
B. Type B Personality
C. Type C Personality
D. Type D Personality

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PSYCHIATRY
Q. Pervasive pattern of instability of interpersonal relationships, self image and affect, with marked impulsivity
that begins at early adulthood and present in varieties of context is characteristics of;
A. Schizotypal Personality disorder
B. Schizoaffective disorder
C. Borderline Personality Disorder
-
D. Bipolar disorder
Q. A 17 year old girl was brought to psychiatric emergency after she slashed her wrist in an attempt to commit
suicide. On enquiry her father revealed that she has made several such attempts of wrist slashing in past, mostly
in response to trivial fights in her house. Further she has marked fluctuations in her mood with a pervasive
pattern of unstable interpersonal relationships. What is the most probable diagnosis?
A. Major depression
B. Histrionic personality disorder
C. Adjustment disorder
D. Borderline personality disorder
-
SCHIZOPHRENIA
Professor John Nash - Noble prize in economic science, 1994
HISTORY
Emil kraepelin- classified psychiatric illnesses into 2 clinical types:

 Dementia praecox
 Manic depressive illness
 Eugen bleuler – coined the term schizophrenia, which replaced dementia praecox in scientific literature.
 Kurt Schneider: First Rank Symptoms
 Karl Kahlbaum- coined the Term Catatonia
4 A’s of Bleuler:
1. Autism
2. Ambivalence
3. Affect disturbances
4. Association disturbances
Schneiderian First Rank Symptoms: 11
A. Three thought Phenomenon:

 Thought insertion
 Thought withdrawal
 Thought broadcast
B. Three made phenomenon:
 Made volition
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39 | P a g e
PSYCHIATRY
 Made affect
 Made impulse
C. Three auditory hallucinations:
 Voices arguing
 Voices commenting on patient’s actions
 Audible thoughts
D. Somatic Passivity- visceral hallucination, which he believes are being imposed by some external agents.
E. Delusional Perception
EPIDEMIOLOGY
 1. Lifetime prevalance – 1%(general population)
 2. Incidence rate – 0.15-0.25/1000
 Usual age of onset- adolescence*
 Onset after 45years is c/a Late onset schizophrenia.*
3. Prevalence in specific population:

 Non twin sibling of a schizophrenic patient-8%
 Dizygotic twin of a schizophrenic patient-12%
 Monozygotic twin of a schizophrenic patient-47%
 Child with one parent with schizophrenia-12%
 Child with both parents with schizophrenia-40%
Etiology and pathogenesis:

 A. Genetic factors: monozygotic > dizygotic
 Deletions at chromosome 22- velocardial syndrome/DiGeorge syndrome – 30% ass.
 B. Biochemical factors: excess of Dopamine and Serotonin.
 C. Environmental factors;
 Risk of SCZ increases with-
 obstetric complications and abnormalities in development.
 Season of birth – Winter* and early spring
 Prenatal exposure to Influenza virus* and malnutrition.
 Advanced paternal age.
 Immigration,
 Drug abuse- cannabis*
Q. Delusion in schizophrenia is due to:

a. Decreased dopamine in mesolimbic tract
b. Increased dopamine in mesolimbic tract
c. Increased dopamine in mesocortical pathway
d. Decreased dopamine in mesocortical pathway
DOPAMINERGIC PATHWAYS

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PSYCHIATRY
SYMPTOMS IN SCZ:
A. Positive symptoms (psychotic symptoms)- delusions and hallucinations – due to excess of dopamine in
mesolimbic tract (neural pathway from ventral segmental area to nucleus accumbens.)
 Most common delusion in SCZ is Delusion of persecution.
 Most common hallucination in scz is auditory.
 Good prognosis
 Respond well to medications.
B. Negative symptoms: due to decreased dopamine activity in mesocortical pathway (ventral segmental area to
prefrontal cortex)
 Represent loss of normal functions.

 Bad prognosis
 Respond poorly to medications
 Avolition- Loss of drive to do goal directed activities( grooming, hygiene, education etc.)
 Apathy- unconcerned with results
 Asociality
 Anhedonia
 Alogia- decrease verbal communication
 Affective flattening
C. Disorganization symptoms:
A. Formal thought disorder
B. Disorganized behavior
C. Inappropriate affect
D. Catatonic Symptoms (motor symptoms)- karl kahlbaum
1. Stupor- immobility or extreme hypoactivity (akinesis)

2. Waxy flexibility
3. Catalepsy
4. Posturing
5. Hyperactivity/Excitement – non-goal directed activities
6. Automatic obedience
7. Negativism
8. Echolalia – mimicking examiner’s speech
9. Echopraxia – mimicking examiner’s movements.
10. Grimacing – odd facial expression
11. Stereotypy – spontaneous repetition of odd, purposeless movements. Eg strange movements of fingers
repeatedly.
12. Mannerisms – odd, purposeful movements. Eg repeatedly saluting passerby.
13. Ambitendency
14. Gegenhalten- Resistence to passive movement.
15. Perseveration – senselessly repeated movements. Tongue in and out

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PSYCHIATRY
CATATONIA
CATATONIC Schizophrenia
 E. Violence , homicide and suicide.

 Suicide is the mcc of premature death in Scz.
 Suicide rate in scz is 5-6%
UPDATES: ICD-11 (CATATONIA)

 In ICD-11, catatonia has been made a separate diagnostic category.
 It has been further divided into following groups:
 A. Catatonia associated with another mental disorder (eg; associated with SCZ, mood disorders or autism
spectrum disorder)
 B. Catatonia induced by use of psychoactive substances (drugs of abuse) and medications.
Q. All are the features of catatonia except:

A. Stupor
B. Negativism
C. Cataplexy
D. Echolalia
DIAGNOSIS
 According to DSM-V, two or more of the following symptoms should be present for 1 month* and at least
one of these must be 1,2,3.
1. Delusions
2. Hallucinations
3. Disorganized speech(or formal thought disorder)
4. Disorganized or catatonic behavior
5. Negative symptoms
 Total duration of illness should be at least 6 months* and 6 months period must include at least one
month of above mentioned symptoms.
TYPES OF SCZ- acc. To ICD-10

PARANOID SCZ;
 Mc type
 Late onset and good prognosis.
 Personality is preserved.(social interaction and daily activities are normal)
 Dominated by delusions and hallucinations.

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PSYCHIATRY
CATATONIC SCZ;
 Dominated by catatonic(motor)symptoms.
 Best prognosis.
 1st line treatment – I/V lorazepam and ECT
HEBEPHRENIC/DISORGANIZED SCZ;
 Dominated by prominent disorganization symptoms and negative symptoms.
 It has an early onset and bad prognosis.
 Severe deterioration of personality is seen.
UNDIFFERENTIATED SCZ: the scz not conforming to any of the above subtypes or exhibiting features of
more than one of them.
SIMPLE SCZ: there are prominent negative symptoms without any history of positive symptoms.
 It has worst prognosis.*
RESIDUAL SCZ: ch. By progression from an early stage of delusion and hallucinations to later stage with
more negative symptoms. Positive symptoms are minimal.
UPDATES: DSM-5 & ICD-11

 Scz was divided into types on the basis of their symptoms. (Acc. To both ICD 10 & DSM-IV)
 DSM-5 & ICD-11 have removed these symptoms based subtypes.
The types of SCZ that have been described in ICD-11 are according to course of illness and include:
1. Schizophrenia, first episode: Diagnostic criterion of scz + No past episode

2. Schizophrenia, multiple episodes: Diagnostic criterion of scz + at least one episode in past.
And between the last & current episode, there was significant remission of symptoms.
3. Schizophrenia, continuous: Diagnostic criterion of scz for almost the entire duration of illness ( duration should be
more than 1 year)
 Post-schizophrenic depression: a depressive episode which develops after the resolution of schizophrenic
symptoms. It is ass. with increased risk of suicide.
Other types of SCZ:

 Pfropf-schizophrenia- scz in a patient with mental retardation.*
 Von Gogh syndrome: self-mutilation in scz patient.
 Oneiroid Schizophrenia: subtype of scz with an acute onset, cloudiness of consciousness, disorientation, dream
like states (Oneiroid means ‘dream’) and perceptual disturbances with rapid shifting. Brief episode is seen.
Diagnosis ?
A. Von Gogh Syndrome

B. Pfropf schizophrenia
C. Oneiroid
D. None
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PSYCHIATRY
TREATMENT PROTOCOL
ATYPICAL ANTIPSYCHOTICS or 2nd Gen drugs: Serotonin Dopamine Antagonists
COZ-RAQ
 CLOZAPINE
 OLANZAPINE –
 ZIPRASIDONE – S/E cardiac arrythmia (QTc prolongation) & seizure
 RESPERIDONE
 ARIPIPRAZOLE- partial agonis at D2 receptor (all other antipsycotics are D2 antagonists)
 QUETIAPINE
Clozapine:
 1st atypical antipsychotic to be synthesized. Least EPS seen overall.

 It is DOC for treatment resistant schizophrenia.
 Preferred agent in patients with intolerant to other antipsychotics because of EPS.
 It is the only drug which decreases the suicidal tendency in scz.
 It causes maximum weight gain.
 Other S/Es are constipation, anticholinergic side effects, sialorrhea or hypersalivation.*
It causes life threatening S/E like agranulocytosis, seizures and myocarditis. Hence blood counts should be checked
weekly. If WBC falls below 3500/dl or neutrophil falls below 1500/mm3, clozapine therapy should be stopped.
Blood test to be done;
 Weekly – for 1st 6 months
 Fortnightly (2 weeks) – 6 months – 1 year
 Monthly >1 year
Q. The blood test which should be done before a clinician starts a patient on Clozapaine?
A. CBC – Leucocyte counts
B. Hemoglobin
C. ABG
D. Erythrocytes count
Q. A patient is on clozapine therapy for last 6 months. Which of the following suggests to stop the clazapine in that
patient after the blood test?
1. Neutrophils < 3000/mm3
2. WBC < 1500/dL
3. Myocarditis
4. Seizures
A. 1 & 2
B. 1 & 3
C. 3 & 4
D. 1,2,3 & 4

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PSYCHIATRY
TYPICAL ANTIPSYCHOTICS: D2 Antagonists

Low potency drugs: High potency drugs:
Dihydroindolone Butyrophenon”
- Molindone - Haloperidol
- Droperidol
- penfluridol
Phenothiazines: Phenothiazines:
- Thioridazone - Fluphenazine
- Chlorpromazine
Thioxanthenes
- Thiothixene
EPS: Extra Pyramidal Symptoms

Acute:
 Dystonia
 Akathisia
 Neuroleptic Malignant syndrome
Chronic:
 Tardive dystonia
 Tardive dyskinesia
 Chronic Akathisia
EPS:
 1. Acute dystonia- Earliest S/E
 can be seen within minutes of receiving an injectable antipsychotics (also seen with oral).
 It is ch. by sudden contraction of a muscle group and can result in symptoms like torticollis, trismus, deviation
of eye balls, laryngospasm etc.
 Management: includes immediate administration of parentral anticholinergics like benztropine, promethazine or
diphenhydramine.
 So prophylactically anti-cholinergic is given.
 2. Acute akathisia – Most common S/E

 ch. by inner sense of restlessness along with objective, observable movements, such as fidgeting of legs, inability
to sit, pacing around.
 Increase risk of suicidal behaviour
Treatment- beta blockers like propranolol (DOC), anticholinergics and BZD.
3. Drug induced parkinsonism

 Ch. by rigidity, bradykinesia and resting tremor.
 Treatment – anticholinergics or shift to 2nd generation drugs.
 Prophylactically anticholinergics
4. Tardive dyskinesia
 develops after long term exposure to anti-psychotics.
 It involves movements of tongue, jaw, lips and trunks. Treatment – shift to 2nd generation.
5. Neuroleptic malignant syndrome: it is fatal S/E.

 ch. by muscle rigidity, elevated temperature and increased CPK (creatine phosphokinase – causes muscle injury)
levels.
 Other symptoms are tremors, diaphoresis, autonomic disturbances (because of dopamine blockade of
spinal neurons), confusion, leukocytosis.
 Treatment: dantrolene-DOC (muscle relaxant), dopamine agonists like amantadine and bromocriptine (most
specific drug).

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PSYCHIATRY
NEW ANTIPSYCHOTICS:
1. BREXPIPRAZOLE:
 Atypical antipsychotic
 MOA: Partial agonist at D2 & 5HT1 receptors & antagonist at 5HT2A receptor.
 It is described as Serotonin dopamine activity modulator (SDAM)
 Used in the treatment of SCZ and major depressive disorder.
2. CARIPRAZINE:
 Atypical antipsychotic
 MOA: partial agonist at D2, D3, & 5HT1A receptors & antagonist at 5HT2A receptor.
 Used for SCZ, bipolar mania & bipolar depression
3. PIMAVANSERIN:
 MOA: inverse agonist and antagonist activity at 5HT2a receptors.
 1st FDA approved drug for treatment of delusion & hallucinations in parkinson’s disease associated with
psychosis.
 It can increase QT interval.
Treatment of schizophrenia- Antipsychotics are the mainstay of treatment for psychotic disorders like scz,
shizoaffective disorders, delusional disorders
 Start with an atypical antipsychotic except olanzapine and clozapine.

If not reactive after 6 weeks-
 Change to another atypical antipsychotic except olanzapine and clozapine.
 Change to typical antipsychotics like haloperidol or fluphenazine
 Resistant schizophrenia: DOC Clozapine.
 ECT
Q. A 25 year old boy with schizophrenia is well maintained on schizophrenia for the last 2 months. He has no
family history of this disease. For how long will you continue treatment in this patient?
A. 6 months
B. 1 year
C. 2 years
D. 5 years
 First episode and when patient is maintaining well and there is no family history – Continue treatment minimum
for 2 years.
 >1 episodes = 5 years
 Multiple relapses: Indefinite Treatment
Psychosocial treatment:
 Family interventions
 Supported employment
 Assertive community treatment
 Skills training
 Cognitive behavioral therapy-for management of residual symptoms
 Cognitive remediation therapy*-to improve the congnitive functions like memory etc.
 Token economy
Medical treatment:.
 Typical Antipsychotics (1st gen. D2 antagonists) are effective against positive symptoms and have minimal
effect on negative symptoms.
 Clozapine is the DOC in treatment resistant SCZ (TRS).

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PSYCHIATRY
PROGNOSTIC FACTORS
Good prognostic factors;*

 Acute or abrupt onset
 Female sex*
 Late onset(>35 years)
 Catatonic subtype and paranoid subtype
 Prominent positive symptoms
 Presence of affective symptoms(eg. Depression)
 Family history of mood disorder
Bad Prognostic Factors:*

 Insidious onset
 Male sex*
 Early onset(<20years)*
 Simple, disorganized, undifferentiated subtype
 Prominent negative symptoms
 Absence of affective symptoms
 F/h of scz
Other psychotic disorders:
1. Acute Psychotic Disorders:

 They have symptoms similar to SCZ but duration criterion do not meet.
 Symptoms are present <1 month & resolve completely. These are frequently preceded by a stressor (stressful
events), fever.*
2. Schizoaffective Disorder:
 They have features of both scz and mood disorders concurrently.

Two types;
 Schizoaffective disorder (bipolar or manic type): with manic symptoms.
 Schizoaffective disorder (depressive type): with depressive symptoms.
Treatment- antipsychotics combined with mood stabilizers or anti-depressants, depending on the presentation.
3. Delusional disorders:
 Persecutory type
 Jealous type- delusion of infidelity
 Erotomanic type- delusion of love
 Somatic type- delusion of having infested by parasites(delusional parasitosis),
 That he has misshaped body parts(delusion of dysmorphophobia), or his body has foul smell(delusion of
halitosis)
PRIMARY DELUSION SECONDARY DELUSION

Not in correlation with other In accordance with some other psychopatholigical
conditions
Begins without any predating problems Develops as an after effect in a person who is already
going through an emotional problem
Also called as Autochthonous delusions Also called as Mood Congruent Delusions
Seen in schizophrenia Perceptual disturbances, intense emotions & personality

disorder

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PSYCHIATRY
4. Unspecified type:
CAPGRASS SYNDROME: patient believes that a familiar person has been replaced by an imposter. It is also known
as “DELUSION OF DOUBLE”.
FREGOLI SYNDROME: patient believes that a familiar person can change his appearances and disguise as a
stranger.
 A delusional belief that a familiar acquires diff. Physical identities, while the psychological identity
remains the same.
FREGOLI SYNDROME CAPGRASS SYNDROME

Positive misidentification Negative misidentification
- Delusion of double
A stranger appears to be a known person Known person is believed to a stranger
 SYNDROME OF INTER METAMORPHOSIS: patient believes that people can undergo changes in physical and
psychological identity and become a different person together.
 SYNDROME OF SUBJECTIVE DOUBLES: patient believes that he has many doubles who are living life of
their own.
 Patients of delusional disorders usually work normally in unaffected domains.

 Treatment – antipsychotics are DOC
Shared psychotic disorders/induced Delusional Disorders:

 Ch. by spread of delusions from one person to another person.
 When 2 people are involved-“Folie a Deux” term is used and when more than 2 people, it is c/a Folie a Trois,
Folie a Quatre etc.
Substances which can cause scz like symptoms are:*

 Cannabis
 Amphetamines
 Cocaine
 Alcohol
 Phencyclidine and other hallucinogens
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PSYCHIATRY
Q. Which of the following is a purposeless movement in scz?

A. Mannerism
B. Stereotypy
C. Both
D. None
Q. A 23 year university student had a fight with the neighboring boy. On the next day while out, he started feeling
that two men in police uniform were observing his movements. When he reached home in the evening, he was
frightened and told his family members that police was after him and would arrest him. Despite reassurances by
family members, he remained afraid that he is about to be arrested. History is suggestive of;
A. Delusion of reference
B. delusion of persecution
C. somatic passivity
D. Thought insertion
Q. True about scz is all except;

A. Hyperdopaminergic state
B. Ambivalence
C. Autism
D. Hypodopaminergic
Q. Schizophrenia with early onset and bad prognosis:

A. Catatonic
B. Undifferentiated
C. Paranoid
D. Hebephrenic
Q. The American mathematician who got a noble prize for game theory and also was a known case of paranoid
schizophrenia;
A. John Harsanyi
B. Sylvia Nasar
C. John Nash
D. Reinhard Selten
Q. A 32 year old female is diagnosed with paranoid schizophrenia. Her father wants to know about the bad
prognostic factors. Which of the following is a poor prognostic factor?
A. Female gender
B. Insidious onset
C. Married
D. Concomitant mood disorder
Q. Blood sample of a 45 years old male shows increased homovanillic acid (HVA). This patient is most likely to
suffer from;
A. Depression
B. Parkinson’s disease
C. Schizophrenia
D. Dementia
Q. Cognitive Remediation is used for;
A. Cognitive Restructuring
B. Memory Improvement
C. Correcting Cognitive distortion
D. None

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PSYCHIATRY
Q. Bleuler’s symptoms of schizophrenia include all except;

A. Autism
B. Ambivalence
C. Automatism
D. Affect disturbances
Q. In which phase, a patient with schizophrenia is most likely to commit suicide?

A. With delusion of negation
B. Immediately after getting discharged from hospital
C. Both
D. None
Q. Antipsychotic drug with least incidence of extrapyramidal side effects and maximum incidence of weight gain
is;
A. Thioridazine
B. Chlorpromazine
C. Clozapine
D. Pimozide
Q. A 55 year old female suffering from schizophrenia is on antipsychotic medication. She developed purposeless
involuntary facial and limb movements, constant chewing and puffing of cheeks. Which of the following drugs is
least likely to be involved in this side effect?
A. Haloperidol
B. Fluphenazine
C. Clozapine
D. Loxapine
Ans: C
 Diagnosis is TARDIVE DYSKINESIA.
 Clozapine has least incidence of EPS like tardive dyskinesia
Q. A psychotic patient on antipsychotic drugs develops torticollis within 4 days of starting therapy. What is the
appropriate medication that should be added in the treatment regimen?
A. Beta blockers
B. Dantrolene
C. Central anticholinergics
D. Cholinergic medicines
Q. A man had a fight with his neighbour. The next day he started feeling that police is following him and his brain
is controlled by radio waves by his neighbors. The history is suggestive of which psychiatric symptom?
A. Thought insertion
B. Passivity
C. Obsession
D. Delusion of persecution
Q. A psychotic disorder which is of acute onset and precipitated by fever;

A. Schizophrenia
B. Shizoaffective disorder
C. Acute psychotic disorder
D. Delusional disorder

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PSYCHIATRY
Q. 35 year old man with violent behaviour and agitation was diagnosed to have schizophrenia and was started on
haloperidol. Following this he developed rigidity and inability to move his eyes. Which of the following drugs
should be added to his treatment intravenously for his condition?
A. Resperidone
B. Promethazine
C. Diazepam
D. Haloperidol
Ans: B
 Symptoms are suggestive of ACUTE DYSTONIA (inability to move eyes is most likely due to oculogyric crisis) and
dug induced parkinsonism (development of rigidity).
 For both cases, an anticholinergic needs to be added.
Q. A patient with schizophrenia was admitted in psychiatry ward. When the nurse entered the room, he started
beating the nurse and accused that actually this nurse is his real wife & accuses her of giving him wrong
medication. What is the likely diagnosis?
a. Capgrass syndrome
b. Fregoli syndrome
c. Syndrome of subjective double
d. Othello syndrome
Q. A 45 year old woman working as an executive in a company is convinced that the management has denied her
promotion by preparing false reports about her competence & have forged her signature on sensitive documents
so as to convict her. She files a complaint in the police station and requests for security. Despite all this she
attends to her work and manages the household. What is the most likely diagnosis?
a. Late onset psychosis b. Obsessive Compulsive Disorder
c. Persistent delusional disorder d. Paranoid schizophrenia
Q. A 32 year old unmarried woman from a low socioeconomic status family believes that a rich boy from her
neighbourhood is in deep love with her. The boy clearly denies his love towards this lady. Still the lady insists that
his denial is a secret affirmation of his love towards her. She makes desperate attempts to meet the boy despite
resistance from her family. She also develops sadness at times when her effort to meet the boy does not
materialize . She is able to maintain her daily routine. She however, remains preoccupied with the thoughts of this
boy. She is likely to be suffering from;
A. Depression B. Mania
C. Personality disorder D. Delusion
Q. A 32 year old unmarried woman from a low socioeconomic status family believes that a rich boy from her
neighbourhood is in deep love with her. The boy clearly denies his love towards this lady. Still the lady insists that
his denial is a secret affirmation of his love towards her. She makes desperate attempts to meet the boy despite
resistance from her family. She also develops sadness at times when her effort to meet the boy does not
materialize . She is able to maintain her daily routine. She however, remains preoccupied with the thoughts of this
boy. She is likely to be suffering from;
A. Disorder of mood
B. Disorder of personality
C. Disorder of Perception
D. Disorder of thought

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PSYCHIATRY
Q. This type of delusion is seen in;

A. Schizoaffective disorder
B. Paranoid schizophrenia
C. Capgrass syndrome
D. None
Q. These pictures describe what sign of schizophrenia?

A. Cataplexy
B. Negativism
C. Posturing
D. Waxy flexibility
Q. Identify the type of unspecified type of delusion

A. Capgras Syndrome
B. Fregoli Syndrome
C. Persecutory type
D. Delusion of self love
MISCELLANEOUS
TREATMENTS AND THERAPIES IN PSYCHIATRY
ECT (ELECTROCONVULSIVE THERAPY)

Types
 Direct ECT - anesthetic agents and muscle relaxants are not used.
 The generalized convulsions can result into fractures and teeth dislocations. So rarely used.
 Indirect (modified) ECT – anesthetic and muscle relaxants are used. So better response.

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PSYCHIATRY
Mechanism of action
Hypotheses:
 Changes in neurotransmitters (esp. down regulation of postsynaptic beta-adrenergic receptors),
 Changes in growth factors and molecular mechanisms (BDNF)*.
 Neurogenesis in areas like hippocampus.
Electrode placement: mc is bilateral placement
Indications:
 Major depressive disorders;

 Depression with suicidal risk, stupor, psychotic symptoms and failed medical treatment.
 Acute mania - ECT is used in failed medical treatment.
 Schizophrenia – 1st line treatment in catatonic scz.
 It is not effective in chronic scz.
Other indications:
 Intractable seizures
 Neuroleptic malignant syndrome
 Delirium
 On-off phenomenon of Parkinson’s
Adverse effects
 Memory disturbances - mc S/E
 Retrograde amnesia > anterograde
 Other S/Es - delirium, headache, muscle aches, fractures, nausea and vomiting.

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PSYCHIATRY
Contraindications:
There is no any absolute C/I of ECT.

Relative C/Is:
 Raised intracranial tension (space occupying lesion in CNS)
 Recent MI
 Severe HTN
 Cerebrovascular disease
 Severe pulmonary disease
 Retinal detachment
Note: Pregnancy is not a C/I of ECT*
Cognitive development stages:
 Jean piaget described four stages of development of thinking processes, a/k/a cognitive development stages.
1. Sensorimotor stage
 Birth to 2 years
 During this stage, child learns through sensory observations and gradually gains control of his motor functions.
 “OUT OF SIGHT, OUT OF MIND” & “HERE AND NOW”
 In the end of sensorimotor stage, child develops “object permanence.
 At the age of 18 months, child develops “symbolization”.
 Infants start developing mental symbols and using words for objects.
 The development of “object permanence” indicates the transition to the next stage of development i.e. stage of
preoperational thought.
2. Stage of preoperational thought
 From 2-7 years

 In this stage, use of symbols and language becomes more extensive.
 Thinking process is ch. by “intuitive thought” which refers to thinking without reasoning and an inability to use
logicality.
 Children are “egocentric” i.e. they are concerned about their own needs only. They can’t see the things from other
perspectives.
3. Stage of concrete operations
 From 7-11 years

 Egocentric thought is replaced by “operational thought” and start to see from others perspective also.
 Thinking is concrete. Eg. On being asked the meaning of proverb “people who live in glasshouses, should not
throw stones”. Child won’t understand the deeper meaning.
 Two important development in this stage are attainment of:

 Conservation: ability to understand that despite changes in shape, the object remains the same. Eg water from
cup to glass.
 Reversibility: the capacity to understand that one thing can turn into another and back again. Eg water & ice.
Stage of formal operations

 (11 to end of adolescence):
 Ch. by stage of development of abstract thinking, which is ability to understand the deeper meaning.
 There is development of “hypothetico deductive thinking”- ability to make hypothesis and use deductive
reasoning.

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PSYCHIATRY
Learning theory:
 It is acquiring of new behavioral patterns. Two types:
1. Classical conditioning
2. Operant conditioning
Classical conditioning:
 a/c respondent conditioning
 Results from the repeated pairing of a neutral stimulus with one that naturally produces a response. E.g.
Experiment of Ivan Pavlov- dog-bell-food experiment.
 Following are the elements of classical conditioning;
Operant conditioning
 Also called as instrumental conditioning.
 This principle was given by “BF Skinner.”*
 Acc. to this theory, a behavior is determined by its consequences for the individual.
 Hence, as per this theory, any behavior can be learned or unlearned and its frequency can be changed by
modifying the consequences of that behavior.
 If a behavior is f/b pleasant consequence called “reward”, its frequency will increased, i.e. that behavior will get
reinforced.
 Similarly if the consequence is negative frequency of behavior will decreased.
 Frequency of a behavior is:

 Increased by positive or negative reinforcement
And
 Decreased by punishment or extinction.
OPERANT CONDITIONING

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PSYCHIATRY
Psychotherapy:
 Treatment by using psychological methods. Important kinds are:
Behavior therapy: Eg;

• Systemic Desensitization & Therapeutic Graded exposure
 Assertiveness training: here a person is taught to be assertive while asking for his rights and while refusing
unjust demands of others.
 (assertive: having or showing a confident or forceful personality)
 Social skills training: usually used in patients with scz.
AVERSIVE CONDITIONING (aversion therapy):
 it is the clinical use of principles of classical conditioning. It is used for treatment of unwanted behaviors, like
paraphilias.
 Here, the patient is asked to imagine about an unwanted behavior, and then suddenly a painful stimulus is given.
In this way, an associations between unwanted behavior and painful stimulus is created and the unwanted
behavior ceases. It’s rarely used nowadays due to ethical considerations.
BIOFEEDBACK: Mirror to the mind
 A process whereby electronic monitoring of a normally automatic bodily function is used to train someone to
acquire voluntary control of that function.
Biofeedback is built on the concept of “mind over matter.” The idea is that, with proper techniques, you can
change your health by being mindful of how your body responds to stressors and other stimuli.
 It uses the principles of operant conditioning. It is based on the idea that ANS (which is involuntary), can be
brought under voluntary control with the help of operant conditioning.
 Use for asthma, tension headaches, arrhythmias etc.
 EMG may be used to give patient feedback about muscle tension in a particular muscle group.
COGNITIVE THERAPY:
 It is based on the thought process (cognitions) of the individual.
 An individual may develop wrong patterns of thinking, c/a cognitive distortions (or maladaptive assumptions).
 Eg. A child was praised for 1st rank and got scolded for the 2nd rank. Now this child may develop a cognitive
distortion that to be successful, we shall always be the 1st rank holder.
 These cognitive distortions give rise to “negative automatic thoughts”, which are thoughts with negative
connotation and appear automatically. Eg. That child will think now- I can never be successful, I cannot pass any
exams etc. for this cognitive therapy is used.
 Cognitive therapy and CBT are used in: depression, panic disorder, OCD, personality disorder and somatoform
disorder.
COGNITIVE DISTORTIONS
1. Approval seeking – a belief that I shall always be praised and loved by others, or else life will be terrible.
2. All or nothing thinking – seeing things in black and white. Eg. If I failed here, I can’t pass anywhere else.
 3. Emotional reasoning – belief that your emotions reflect the reality. Eg. If I feel he is bad, then it means he is
really bad.
 4. Disqualifying positive – it is a tendency of refusal to acknowledge the positive events in life and insisting that
they “don’t count’. Eg. A child was praised by his mother, but thinks that mother is just praising me to feel better,
actually I don’t deserve it.
 Fallacy of fairness: tendency to judge a random negative event as an issue of justice. Eg. You missed a train
because of heavy traffic and u believe that life is always unfair to you.
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PSYCHIATRY
 Labelling mislabeling: giving labels to self or others.
 Jumping to conclusions: making an interpretation with minimal evidence. Eg. A friend missed ur call, and you
made a conclusion that he hates you.
 Magnification (catastrophizing):eg. On losing 10 rupees, u r saying this was the biggest loss of your life.
 Minimization – a chronic alcoholic says, I don’t drink much, just a peg here n there.
 Mental filtering/selective perception: picking a single negative detail while ignoring the rest. Eg. A lady got
praised by everyone in a function except one friend, who asked her did you get some weight? And she picked that
negative remark.
 Overgeneralization: considering a single negative event and making a general rule out of it.
Eg. He made a mistake in any work and after that he starts thinking that he always do mistakes. Labelling is an
extreme form of overgeneralization.
 Personalization; blaming self for which he/she is not responsible for.

 Should statements: making many rules as how you and other should behave. Eg. I should not be lazy etc.
Personality assessment:
By 2 tests:
1. Objective test: these are standardized tests which give numerical scores and can be analyzed using standard
results. Eg. MMPI-* Minnesota Multiphasic Personality Inventory.
2. Projective tests: In these tests, patients are provided with ambiguous stimuli (unclear stimuli), and the patients
response reflects their internal thought process and emotions.
PROJECTIVE TESTS
They include;
 Rorschach test:* patient is shown 10 cards which have inkblots and is asked what he sees in the card.
 Thematic apperception test (TAT): patients are shown some pictures and are asked to make some stories.
 Sentence completion test:
 Word association technique;
 Draw a person test (DAPT):
Rorschach test
Patients are shown a picture & asked to make stories

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PSYCHIATRY
Maslow Hierarchy of needs (Humanistic theory of personality)
 For the highest motive of self actualization all other needs have to be fulfilled.
 So though the motive is self actualization, the physiological is the most important as one cannot proceed up in the
pyramid without the base.
 In order of increasing priority:
 Self actualization < esteem < love < safety < physiological.
Q. Anesthetic agent used in ECT;

A. Methohexital
B. Propofol
C. Ketamine
D. Thiopentone
Q. Cocaine was introduced in psychiatry by;

A. Miller
B. Freud
C. Kraeplin
D. Morel
Q. Ability to form a concept and generalize is c/a;

A. Concrete thinking
B. Abstract thinking
C. Intellectual thinking
D. Delusional thinking
Q. Psychiatrists are not posted at:

A. PHC
B. District hospital
C. medical college
D. military hospital
Q. ECT is indicated in;

A. Neurotic depression
B. Auditory hallucination
C. Chronic schizophrenia
D. Delusional Depression
Q. Rorschach test measures;

A. Intelligence
B. Creativity
C. Personality
D. Neuroticism

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PSYCHIATRY
Q. Operant conditioning in which pain stimulus are given to a child for decreasing a certain undesired behavior
can be classified as;
A. Operant conditioning
B. Negative reinforcement
C. Negotiation
D. Punishment
Q. A person laughs to a joke, and then suddenly he loses tone of all his muscles. Most probable diagnosis of this
condition is;
A. Catalepsy
B. Cachexia
C. Cathexis
D. cataplexy
Q. Along a pleasant stimulus, a noxius stimuli is given in treatment of alcohol dependence and paraphilias. This is
an example for which kind of behavior therapy?
A. Flooding
B. Aversive therapy
C. Punishment
D. Negative Reinforcement
SLEEP DISORDERS
STAGES OF SLEEP:
1. NREM or slow wave sleep
2. REM or paradoxical sleep
NREM:
STAGE 1: light sleep

 EEG: loss of alpha waves & predominance of theta waves.
STAGE 2: Maximum Duration

 EEG findings: Sleep spindles and K-complexes
STAGE 3: sleep deepens and appearance of delta waves
STAGE 4: deep sleep , predominance of delta waves
REM
 It follows NREM sleep.

 EEG: shows similar to awake state (beta activity) with return of alpha wave.
 There is generalized loss of muscle tone.
 Increased rate of metabolism in brain.
 Penile erection , autonomic hyperactivity( increase in PR, BP, RR)
 Dreams, which can be recalled.
 It is called as paradoxical sleep, because though the EEG is similar to awake state, its very difficult to awaken the
patient.
IN 8 HOUR SLEEP:
 Maximum time (6.5 hours) – NREM sleep
 1.5 hours – REM sleep
 Most of the stage 4, NREM occurs in first 1/3rd of night, whereas most of REM sleep occurs in last 1/3 rd of night.
 The REM sleep occurs regularly after every 90-100 minutes with a total of around 4-5 REM in whole night.

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PSYCHIATRY
Sleep Disorders:
 Dyssomnias – insomnia & hypersomnia
 Parasomnias – dysfunctional events associated with the sleep.
Dyssomnias: abnormality in the duration or quality of sleep. They include:
 Insomnia: primary insomnia is diagnosed when no cause can be found for decreased sleep.
 Difficulty in initiation of sleep
 Difficulty in maintenance of sleep (frequent awakening in night or early morning awakening)
 Non restorative sleep (not feeling refreshed in the morning due to poor quality of sleep)
Treatment: Benzodiazepines, Z compound
 Treatment: BZD
 Triazolam is the best BZD for insomnia
Z compounds
 Zaleplon: Shortest acting and hence DOC for sleep induction in insomina and jet lag
 Zolpidem: intermediate acting
 Eszopiclone: longest acting and hence DOC for sleep maintenance in insomnia and is also preferred for long
treatment of insomnia.
Few disorders which can present with insomnia:
 Periodic limb movement disorder:

- it is ch. by sudden contraction of muscle groups (usually leg) while sleeping, results into partial or complete awakening,
repeatedly in night.
 Patient may report non restorative sleep and day time sleepiness.
Ekbom syndrome (restless leg syndrome):
 it is ch. by uncomfortable sensation in legs (such as insect crawling) which get relieved by moving the leg or
walking around. This cause difficulty in initiation of sleep as patient keeps on moving the leg.
 Treatment: only one drug is approved for this. Ropinirole *(dopamine agonist).
 Note: Ekbom syndrome is also synonymous with Delusional Parasitosis
Hypersomnia:
 Primary hypersomnia is excessive sleepiness without any known cause.

 Either prolonged sleep or excessive day time sleep episodes.
Other disorders which include hyperinsomnia are:
Narcolepsy:
 it is ch. by following symptoms;
1. Cataplexy: it is sudden loss of muscle tone, due to which patient can even fall.
2. Sleep attacks: patient has irresistible urge for sleep which can occur at any time during the day.
3. Hypnogogic hallucinations: patient gets hallucinations while going to sleep.
Hypnopompic hallucinations: patient gets hallucination before getting up from the sleep.
4. Sleep paralysis: it usually occurs when patient gets up in the morning. Though he has woken up but he won’t be able to
move.
 Hallmark of narcolepsy is reduced latency of REM sleep.

Normaly it takes 90 minutes to reach REM sleep (after crossing all the NREM stages), but here it will reach much earlier.

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PSYCHIATRY
 Narcolepsy is caused by the deficiency of hypocretin, a neurotransmitter which promotes appetite and
alertness.
 Hypocretin neurons project from hypothalamus to other parts of brain.
 Treatment:
Modafinil and forced naps at regular time.
 Kleine-Levin Syndrome: ch. by triad of

 Hypersomnia
 Hyperphagia
 Hypersexuality
 Patient is completely asymptomatic in between the symptoms.
PARASOMNIAS
Parasomnias:
 Ch. by the dysfunctional events associated with the sleep.

 Stage 4, NREM( deep sleep disorders): occurs at stage 4 and last phase of stage 3 also.
 These disorders are seen in 1st third of sleep and patient is not able to recall the events in the morning.
Usually seen in children and they include;

 Night terror or sleep terror (Pavor Nocturnus)*: patient suddenly gets up screaming and has symptoms of
intense anxiety such as tachycardia and sweating. Patient is not able to recall any dream.
 Somnambulism (sleep walking): Usually seen in children and mostly prevalent in age group of 4-8 years.
Sleep related enuresis: enuresis is defined as voiding of urine at inappropriate places, is nocturnal in around 80% of
cases.
 Mcc of bed wetting are psychosocial such as sibling rivalry.
 TOC is bed alarm, which starts ringing, as soon as child passes urine.
 Medicines used are Imipramine ( a TCA- tricyclyic antidepressant), and intra-nasal desmopressin.
 Bruxism (teeth grinding)

 Somniloquy (sleep talking) – during NREM 3&4. Patient won’t remember anything.
 In most cases, treatment is reassurance. Sometime BZD is used.
REM SLEEP DISORDERS

 1. Nocturnal penile tumescence – erection. It’s a normal phenomenon.
 2. Night mares (dream anxiety disorder)
 Person wakes up frightened and remembers the dream( in contrast to night terror).
 3. Narcolepsy

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PSYCHIATRY
TECHNIQUES TO STUDY SLEEP PATTERNS:
ACTIGRAPHY: it is the procedure which is sued for studying sleep patterns.

 It usually involves wearing a small sensor on the wrist, which detects the movements
Gold standard technique for studying sleep disorder is POLYSOMNOGRAPHY.
ACTIGRAPHY
POLYSOMNOGRAPHY
 Polysomnography, also called a sleep study, is a comprehensive test used to diagnose sleep disorders by
recording biophysiological changes.
 Polysomnography records :brain waves, the oxygen level in blood, heart rate and breathing, as well as eye and leg
movements during the study.
 Note: Arterial pCO2 is not measured
 Nasal airflow, respiratory effort and oxyhemoglobin saturation are instrumental in diagnosing sleep apnea &
other sleep related disorders.
Indications of Polysomnography:
1. Diagnosis of sleep related breathing disorders
2. Positive airway pressure titration and assessment of treatment efficacy
3. Evaluation of sleep related behaviours that are violent or may potentially harm the patient or bed partners.
Q. Which of the following are seen during NREM sleep?

A. Nightmare
B. sleep paralysis
C. teeth grinding
D. narcolepsy

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PSYCHIATRY
Q. Not seen in narcolepsy:

A. Sleep paralysis
B. Ataxia
C. Catalepsy
D. Abnormal REM sleep
Q. Maximum duration of time spent is in which of the following NREM stage?

A. I
B. II
C. III
D. IV
Q. Pavor Nocturnus is;

A. Sleep Terror
B. Sleep Bruxism
C. Night Mare
D. Somnambulism
Q. Not true about narcolepsy;

A. Sudden sleep
B. Cataplexy
C. Long duration (>3 hours) of sleep
D. Present in 2nd decade
Q. Polysomnography contains all of the following tests except;

A. Pulse oximetry
B. Electroencephalography
C. Electrooculography
D. Arterial pCO2 measurement
ORGANIC MENTAL DISORDERS
 These are caused by demonstrable cerebral disease, brain injury or other factors which cause cerebral
dysfunction.
 Common symptoms which are seen in organic mental disorders are:
Cognitive impairment
 Term cognition is used to describe all the mental processes which are utilized to gain knowledge.
 Cognition: include memory, judgment, language, orientation, praxis (performing actions) and problem solving.
 Term cognition is also being used inter-changeably with thought.
 Cognitive impairment means disorientation to (time, place, person), impaired attention and concentration,
memory disturbances (esp. anterograde amnesia).
 Hence organic mental disorders are also called as cognitive disorders.
DISTURBANCES OF CONSCIOUSNESS:
 Confusional state, clouding of consciousness and altered sensorium are the other terms used for this.
 severity in patient ranges from alertness to coma.
 Different levels are:
 Somnolence or lethargy: when patient tends to drift off to sleep when not actively stimulated.
 Obtundation: patient is difficult to arouse & when aroused appears confused.
 Stupor or semicoma: mute and immobile.
 Coma: unarousable and remain with eyes closed.
 Delusions: usually transient
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PSYCHIATRY
 Hallucinations: mostly visual but others can too happen.
Organic mental disorders are classified as:

 Delirium
 Dementia
 Amnestic disorders
Delirium:
 Mc OMD
 Ch. by acute onset of symptoms and a fluctuating course.
 Mostly seen in elderly and hospitalized patients.
 Post surgical and severely ill patients such as, open heart surgeries, hip fractures, severe burns are more
prevalent.
 Other causes are multiple medications (esp. anticholinergic), withdrawal from psychoactive substances like
alcohol and sedatives/hypnotics.
 It can develop in older patients wearing eye patches after cataract surgery (due to sesnsory deprivation), a/c
“black patch delirium”.
Symptoms are:
Characteristic symptoms of OMDs with some peculiar features:

 Recent memory impairment with relatively intact remote memory.
 Visual hallucination and transient delusion.
 Agitation, hyper or hypoactive
 Insomnia
 Sundowning: diurnal variation of symptoms with worsening of symptoms in the evening (i.e. with downing of
sun).
 Carphologia (Floccilations): aimless picking behavior, where patient appears to be picking at his bed/clothes.
 Occupational delirium: although patient is in hospital, he ll behave as if he is still on his job.

 Neurotransmitters involved: acetylcholine*
 Neuroanatomical area: reticular formation (note: reticular ascending system is responsible for arousal in
person).
Diagnosis:
 is made by symptoms. Sudden onset & fluctuations in symptoms are important pointers.
 MMSE & MSE are used to provide a measure of cognitive impairment.
 Generalized slowing on EEG is a common finding in delirium.
 Delirium caused by alcohol or sedative hypnotic withdrawal has low voltage fast activity on EEG.

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PSYCHIATRY
MMSE –to assess cognitive functions

 MMSE assesses the following five cognitive functions and gives them different weightage.
1. Orientation – 10 points
2. Registration – 3 points
3. Attention and concentration – 5 points
4. Recall – 3 points
5. Language – 9 points
Max score = 30
<24/30 = indicative of cognitive impairment
MMSE:
Treatment:
 Treat the underlying cause.
 Antipsychotics for delusions, agitations and hallucinations.
 Benzodiazepines for insomnia and are the DOC in delirium tremens ( alcohol withdrawal delirium).
DELIRIUM & Schizophrenia

 In delirium, hallucinations are not constant
 and delusions are TRANSIENT
 Patient of delirium has disturbances of attention and disturbed consciousness which is not see in patient with scz
DEMENTIA
Dementia:
 It is a progressive impairment of cognitive functions without any disturbances of consciousness.*
 Prevalence: 5% in >65 years old and 20-40% in >85 years old population.*
Symptoms:
 Cognitive impairment: 4A’s
 Amnesia, aphasia, apraxia & agnosia. (prosopagnosia and autoprosopagnosia)
Behavioral and psychological symptoms:
 Personality changes: patient may become introvert, hostile and unconcerned about others. Mostly seen in frontal
and temporal lobes damages.
 Hallucinations and delusions: mostly delusion of persecution and delusion of theft seen.
 Depression & mania
 Catastrophic reaction: emotional outburst in a patient of dementia.
 Focal neurological signs and symptoms: usually seen in vascular dementia (multyi-infarct dementia).
 Aphasia: disturbances of language function.

 Apraxia: inability to perform learned motor functions, like buttoning of shirt etc.
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PSYCHIATRY
 Agnosia: inability to interpret a sensory stimulus.

 Prosopagnosia: inability to identify the face
 Autoprosopagnosia: inability to identify own face
 Other disturbances are: disturbances in executing functioning ( like planning, abstracting and sequencing)
Types of dementia:
 Reversible and irreversible.
15% are reversible.
Reversible causes of dementia are:
 Neurosurgical conditions: subdural hematoma, normal pressure hydrocephalus, intracranial tumors and
abscesses.
 Metabolic causes: hyper or hypo thyroidism, Vit B12 deficiency etc
 Infectious causes: encephalitis, meningitis, lymes’ disease, neuro-syphilis.
 Drugs and toxins, alcohol abuse.
Dementia can be classified as

cortical and subcortical types:
CORTICAL DEMENTIA:
 ch. by early involvement of cortical structures and hence early appearance of cortical dysfunction. Like A’s;
amnesia, apraxia, aphasia, agnosia and acalculia.
 Alzheimer’s disease, Creutzfeldt-jakob disease, pick’s disease and frontotemporal dementias are cortical
dementia.
SUBCORTICAL DEMENTIA: ch. by early involvement of subcortical structures like basal ganglia, brain stem nuclei and
cerebellum.
 These disorders are ch. by early presentation of motor symptoms (like tics, chorea and dysarthria etc.),
significant disturbances of executive functioning and prominent behavioral and psychologicalsymptoms like
apathy, depression, bradyphrenia (slowness of thinking).
 Eg. Parkinson’s, Wilson disease, Huntington’s disease, Multiple sclerosis, Progressive supra nuclear palsy, normal
pressure hydrocephalus.
 Some dementia with mixed presentation- vascular dementia, dementia with lewy body.
Delirium and Dementia

 Acute presentation and fluctuation of symptoms – Delirium
 Cloudiness of concsiouness – Delerium
Note:
 BECLOUDED DEMENTIA: sometimes patient of dementia may develop superimposed delirium.
AMNESIA:
 Refers to memory impairment

 Loss of recent memory f/b immediate memory f/b remote memory.
 Other way of describing memory impairment is in terms of;
 - Episodic memory –memory for events. Recent events lost > remote memory
 - Semantic memory – memory for facts like rules, words & language. It is preserved in early course and gradually
lost as the disease progresses.
 - Visospatial deficits. Disorientation with the environment.

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PSYCHIATRY
Amnestic disorders:
 Ch. by inability to form new memories (anterograde amnesia) and inability to recall previously remembered
knowledge (retrograde amnesia).
Major causes are:
 Thiamine deficiency (korsakoff syndrome)
 Hypoglycemia
 Primary brain conditions ( head trauma, seizures, cerebral tumors, hypoxia, CVS disease, MS)
 Substance related disorders.
Q. MMSE is used for diagnosis of;

A. Alzheimers
B. Schizophrenia
C. Depression
D. Anxiety
Q. Delirium and schizophrenia differ from each other by;

A. Change in mood
B. Cloudiness of consciousness
C. Tangential thinking
D. All
Q. Disorientation occurs in;

A. Schizophrenia
B. Depression
C. mania
D. Organic mental disorder
Q. Catastrophic reaction is seen in;

A. Delirium
B. Dementia
C. Anxiety
D. Amnesia
Q. Delirium and dementia can be differentiated on the basis of;

A. Loss of memory
B. Apraxia
C. Delusion
D. Altered sensorium
Q. A 75 year old man flown to america from Siberia (war zone), to stay with his son. He is having nightmares and
flashback. He was brought to hospital by his son. It was informed that he is getting irritated, insomnia and easily
forgetting incidences. What is the most probable diagnosis?
A. PTSD
B. Mania
C. Dementia
D. Phobia
SEXUAL DISORDERS
Sexual disorders can be classified into four main types:
1. Gender identity disorders

2. Psychological & behavioral disorders associated with sexual development and maturation
3. Paraphilias (disorders of sexual preferences)
4. Sexual dysfunctions

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PSYCHIATRY
Gender identity disorder

 Gender is a sense of being male or female.
 Mostly anatomical sex corresponds to the gender ( i.e. a man with male body organs, considers himself a man
psychologically too). However mismatch resulting in gender identity disorder.
Gender identity disorder of childhood:

 Usually manifests in preschool years.
 The child shows preoccupation with the dress and activities of the opposite sex.
 Child expresses the desire to be of opposite anatomical sex.
 Some of them may find penis and testicles disgusting.
TRANS-SEXUALISM:
 In adolescents and adults, the symptoms are quite similar to gender identity disorder of childhood.
 Patients manifest a desire to live and be treated as the other sex.
 They are discomfort with their anatomical sex and insist for surgery.
 Homosexual orientation is frequently present.
 Patient frequently uses the phrases like “I am a man trapped in body of a woman”.
 Treatment: sex reassignment surgery if patient insist for this.
DUAL-ROLE TRANSVESTISM:
 Patient wears the dress of opposite sex to enjoy the temporary feeling of belonging to other sex.
 Unlike trans sexualism, there is no desire of permanent sex change.
 There is no sexual arousal associated with cross dressing.
Note: in fetishistic transvestism, which is a type of paraphilia, the cross dressing is associated with sexual
arousal.*
 In DSM-5 , the diagnosis of “Gender Dysphoria” is used in place of DSM-4 diagnosis of “gender identity
disorder”.
DISORDERS OF SEXUAL ORIENTATION:
 Homosexuality is considered as a normal variant, if it is ego-syntonic(if individual accepts his sexual orientation)
and a disorder if ego-dystonic( if he doesn’t accept his sexual orientation and wants to change it)
Phases of sexual response cycle;
 1. Desire – to have sex

 2. Excitement (arousal) – penile erection and vaginal lubrication, Increased heart rate, BP & respiratory rate.
 Associated sense of pleasure.
 Plateu phase is seen, which is intensified sexual tensions before orgasm.
 3. Orgasm – peak of sexual pleasure, followed by release of sexual tension and ejaculation of semen (in male),
involuntary contractions of lower vagina (in female).
 4. Resolution – body goes to the resting stage.
Disorders of sexual desire:
 1. Hypoactive sexual desire disorder: lack of desire

Note: Only one drug has been approved for this in females is “flibanserin”, approved in august 2015.
Flibanserin should not be taken concomitantly with alcohol due to risk of severe hypotension.
2. Sexual aversion disorder: active aversion and avoidance of sexual activity.

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PSYCHIATRY
Disorder of excitement phase;
 Male erectile dysfunction*- usually caused by psychogenic and poor marital relation.
 Presence of early morning erections and erections during REM sleep(nocturnal erection) are suggestive of
psychogenic erectile dysfunction.
Investigations to record nocturnal erections are;

 Nocturnal penile intumescence(NPT)
 Penile plethysmography
Physical causes are – arteriosclerosis and autonomic neuropathy.

Treatment – PDE-5 inhibitors like Sildenafil, Tadalafil and Verdenafil- they facilitate the blood flow into penis and
enhance erection.
 Oral phentolamine –decreases sympathetic tone and relaxes smooth muscles of corpora cavernosa.
 Injectable Alprostadil-* vasodilator. Injected into corpora cavernosa or administered intraurethrally.
 Female sexual arousal disorder- due to lack of adequate vaginal lubrication required for intercourse.
Treatment- Lubricants
DUAL-SEX THERAPY
 Psychotherapy –*
 (simply sex therapy).
 It was developed by Masters and Johnson. This therapy treats couple and not the individual.
 Couple is taught the exercises and the way of improving sex quality.
 Couple is taught the exercises which increases sensory awareness, c/a sensate focus exercises.
 Non genital and genital sensate focus.
Disorders of orgasm phase:
 Premature ejaculation – pattern of ejaculation within approximately one minute after the penetration into
vagina.
 Cause is usually psychogenic.
TREATMENT FOR PREMATURE EJACULATION
1. Squeeze technique:*
2. Stop-start technique (semans technique)
 SSRIs can delay the ejaculation too
PARAPHILIAS
PARAPHILIAS:
 SADISM: sexual gratification is obtained by infliction of pain on one’s partner

 LUST MURDER/EROTOPHONOPHILIA: in extremes of sadism, murder serves as a stimulus for the sexual act
and becomes the equivalent of coitus, the act being accompanied by erection, ejaculation and orgasm.
 NECROPHAGIA: this is extreme degree of sadism in which the person after mutilating the body, sucks or licks the
wounds, bites the skin, drinks blood and eats the flesh of his victim to derive sexual pleasure.
 MASOCHISM: sexual gratification is obtained or increased by the suffering of pain.
 BONDAGE/ALGOLANIA: sadism + Masochism
 NECROPHILIA: desire of sexual intercourse with dead bodies

 FETISHISM: Perversion associated with the compulsive usage of an inanimate objects in order to attain the sexual
gratification.
 Common fetish objects are: hand kerchief, undergarments like panties, bras, stockings.
 TRANSVESTISM/EONISM: sexual gratification is obtained by wearing the dress of opposite sex.
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PSYCHIATRY
 MASTURBATION/ONANISM/IPSATION: deliberate self stimulation that affects sexual arousal

 EXHIBITIONISM: the act of exposing one’s genital to unsuspecting persons for sexual arousal.
 VOYEURISM/SCOTOPHILIA/PEEPING TOM: sexual gratification by watching the act of sexual intercourse or
witnessing undressing by a women or any person.
 FROTTEURISM: Sexual satisfaction is obtained by rubbing against persons in crowd.

 URANISM: sexual pleasure is obtained by witnessing the act of urination by someone of the same or opposite sex.
 COPROPHILIA: sexual excitement provoked by the sight or odour of stool of the partner.
 SODOMY: sexual intercourse through anus

 If passive agent is adult, the act is called as GERONTOPHILIA
 If passive agent is a child, the act is called as PAEDERASTY (Passive agent is labeled as CATAMITE and the active
agent is PAEDOPHILE.
 BESTIALITY: sex with animal
 TRIBADISM/LESBIANISM: sexual gratification of a female by a female. Ative partner is called as DYKE or BUTCH
and passive agent is FEMME.
 FELLATIO: oral stimulation of penis by male or female

 CUNNILINGUS: oral stimulation of female genitals.
 BOBBIT SYNDROME: female amputates the genitalia of male partner with a knife due to sexual jealousy of
infidelity.
 TROILISM: inducing his wife to have sexual intercourse with another man and by observing the same.
 TELEPHONE SCATOLOGIA: Sexual arousal by using Obscene language over phone.
OTHER DISORDERS
 Dyspareunia – genital pain in men or women during or after sexual intercourse.

 Vaginismus – it is involuntary muscle contraction of outer third of vagina which makes penile insertion difficult.
Viginismus and dyspareunia frequently coexist
 Nymphomania* –excessive sexual desire in females
 Satyriasis* – excessive sexual desire in males.
Q. A homosexual person feels that “he is a woman trapped in man’s body and has persistent discomfort with his
sex. Most likely diagnosis is:
A. Voyeurism
B. Transvestism
C. Trans-sexualism
D. Paraphilias
Q. True about dual sex therapy is:

A. Uses sildenafil
B. Patient alone is not treated
C. It treats sexual perversion
D. It is used for people with dual gender identities.
Q. Squeeze technique is used for;

A. Impotence
B. Premature Ejaculation
C. Priapism
D. Infertility

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PSYCHIATRY
Q. Premature ejaculation is a disorder of which phase of sexual cycle?

A. Excitement
B. Desire
C. Orgasm
D. None
Q. The drug which is FDA approved for hypoactive sexual desire disorder in female is;
A. Sildenafil
B. Modafinil
C. Flibanserin
D. Fluoxetine
Q. Sexual gratification by contact with articles of opposite sex like hanky, sandals and clothes, is called as;
A. Sadism
B. Voyeurism
C. Fetishism
D. Transvestism
PSYCHOANALYSIS
Sigmund Freud
 Coined the term Psychoanalysis
 Known as Father of Psychoanalysis
 Gave technique of Free Association
 Proposed Topographical Theory of Mind – In his book “The Interpretation of Dreams”
 Later he replaced it with - Structural theory of mind
 Psychosexual stages of development
 Pshychoanalysis Theory- childhood experiences and memories and unconscious mental activity plays an
important role in determining human behavior and emotions and also in the development of psychiatric
disorders.
 Role of psychoanalysis: to bring unconscious memories into conscious.

To bring out the childhood memories into conscious mind.
ABREACTION: A process by which forgotten/repressed material is remembered back
ABREACTION
 It is a process by which repressed/forgotten material is remembered back, relived again along with expression of
associated emotions.
 Abreaction helps in improvement of symptoms.
 Later, Freud developed a technique called free association.

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PSYCHIATRY
HYSTERIA – DISSOCIATIVE DISORDER

“TECHNIQUE OF FREE ASSOCIATION”
Slips of tongue- Parapraxis
Psychoanalytical treatment - the principles of transference and counter-transference
TRANSFERENCE -feeling that the patient develops for the doctor.

-COUNTERTRANSFERENCE– the feeling that the clinician develops for the patient
DREAMS
The Interpretation of dreams
Topographical theory of mind:

 In his book “the interpretation of dreams”. (1900)
 Acc. To this theory, Mind can be divided into three regions.
1. The Conscious- accessible to an individual
2. The Preconscious – Can be accessible with some focus. Repression is found here.
3. The Unconscious- not accessible to an individual
The Unconscious-
 it contains the instinctual drives (with which a person is born), such as sexual instinct & aggressive
instinct.
 It is ch. By primary process thinking-immediate wish fulfillment.
Rorschach inkblot test
 What do you see in these picture?
What is the first word comes

to your mind if i say these words?
Horse.. God.... Hero ... Father...etc

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PSYCHIATRY
STRUCTURAL THEORY OF MIND

3 components of mind are:
1. Id
2. Ego
3. Superego
Id
 The most primitive part of mind with which an infant is born.
 It consists of the instinctual drives (i.e. the desires and drives with which an individual is born with) like
sexual instincts and aggressive instincts.
 It works on “pleasurable principle”
 Id uses the primary process of thinking.
 It is completely in the unconscious domain of mind.
EGO
 It’s the part of mind which deals with the external world. Its function is to deal with the “id” and “super ego” and
maintain a balance between the two and the external world.
 It works on “reality principle”.
 Ego is said to be the executive organ of the mind.
 It has both conscious and unconscious components.
 The defense mechanisms reside in the unconscious component of ego.
SUPEREGO
 part of the mind, which wants to follow the moral principles and do the right thing.
 It is mostly unconscious, but also has a conscious component.
DEFENSE MECHANISMS:
 An imp. function of ego is to prevent a buildup of excessive and unbearable anxiety.
 Defense mechanisms are the tools used by the “ego” to prevent the development of excessive anxiety.
Defense mechanisms
 Narcissistic
 Immature
 Neurotic
 Mature
Narcissistic defenses:
 Denial – refusal to acknowledge the reality. Person continues to behave as nothing has happened. Eg. Mother
refused to accept the death of her son.
 Projection – projecting own unacceptable feeling about others, on to others.
 Eg. An accused of infidelity, Husband started accusing his wife.
 This defense mechanism is responsible for development of delusions and hallucinations.
IMMATURE DEFENSES:
1. Acting out: acting on unconscious desires without becoming aware of them.
 It is involved in development of impulsive control disorders.
2. Passive aggressive behavior: indirectly expressing the anger towards others. Eg. A son accidentally drop a glass of
water for his father.
3. Regression: attempt to return to an earlier phase of development ( i.e. childhood) to avoid the tensions and conflicts of
present phase of adulthood.
 It is involved in development of neurosis.*
4. Projective identification: intolerable aspects of self are projected on to another person, that person is induced to play
the projected part and the two persons than act in unison.

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PSYCHIATRY
Eg. A wife who has lots of aggression on to her husband and make him behave in aggressive manner and finally a system
develops where the husband indulges in aggression and wife is the recipient of aggression. Seen in BPD.
NEUROTIC DEFENCES:
1. Displacement: shifting emotions about one object/individual onto another object/individual.

2. Eg. After getting scolded from consultant, an SR came to ward & scolded an intern.
 It is involved in the development of phobias.
2. Intellectualization: excessive use of intellectual process to avoid the painful emotions.Eg. Excessive discussion about
pancreatic Cancer with a patient.
3. Isolation of affect: removing the feelings associated with a stressful life event.
Eg. Without showing any emotions, a lady tells her family that she has been diagnosed with a cancer.
4. Repression: it is one of the most important defense mechanism, c/a the primary defense mechanism. It is
unconsciously forgetting something, which cannot be retrieved later. Eg . a young girl who was sexually abused by
her father, forgets it.
5. Rationalization: Offering rational explanations to justify own unacceptable behavior. Eg. I drink because of my wife
only. It is commonly used defense in substance use disorders.
6. Dissociation: splitting of a single or group of mental functions from the remaining mental functions.
It is seen in disorders like dissociative identity disorder.
7. Reaction formation: Transformation of feelings into exact opposite.eg. a man who is actually infatuated by a colleague
will tell his friends that he hates her.
8. Undoing: an act which is done to nullify a previous act. Eg. Presenting a gift to ur wife after a last night fight. It is used in
OCD.
9. Aim inhibition: placing a limitation upon instinctual demands, accepting partial or modified fulfillment of desires. Eg.
An mbbs aspirant, later takes admission in BHMS.
MATURE DEFENSES:
1. Altruism: Satisfying internal need by helping others. Eg. A drunk man, who lost his son while driving started a campaign
against drunk driving and educate people about alcohol.
2. Anticipation: planning in advance to deal with an uncomfortable event. Eg. A student plans all the arguments before
going to his home after a bad exam result.
3. Humor: using comedy to deal with unpleasant feeling and situations. Eg. Two medicos joked and laughed at themselves
after getting humiliated by the examiner in viva.
4. Sublimation: expression of unacceptable feelings in a socially acceptable manner. Eg. A middle aged woman with
unacceptable sexual desire becomes a painter & starts making nude paintings.
5. Suppression: it is the only voluntary or conscious defense mechanism. It involves a voluntary decision to not think
about an event for some time and hence avoid the accompanying emotions.
Eg, An FMG, who is extremely stressed bcoz of exam, takes one day break for 100% rest without thinking of exam.
 NOTE: all the defence mechanisms operate at an unconscious level (except, suppression which is a conscious and
voluntary defence mechanism).

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PSYCHIATRY
Defense mechanisms in psychiatric disorder:

 Excessive use of defense mechanism can result into psychiatric disorder.
 Defensive mechanisms and associated disorders:
 OCD; reaction formation, displacement, undoing, isolation of affect & inhibition.
 Phobia: displacement and inhibition.
 Dissociative disorder and inhibition.
 Neurosis: regression.
PSYCHOSEXUAL STAGES OF DEVELOPMENT

 Proposed by Sigmund Freud.
 He used the term Sexuality in broader term.
- He included some other forms of pleasure other than genital sexuality.
- He proposed 5 stages of development, and he proposed that development may get arrested at a particular stage c/a
“fixation” which may result into psychiatric disorders.
 Oral stage – zero to 1.5 years. Child derives pleasure in cutting, biting and chewing.
 Anal stage – 1.5-3 years. Child gets a sense of achievement by getting toilet trained. Fixation at this stage can
result into OCD.
 Phallic stage – 3-5 years: the site of pleasure is genital area.
 Penis becomes the organ of principle interest for both sexes.
 Male child develops “Oedipus Complex” – gets sexual feelings for mother. And also get scared that if his father
comes to know, he will castrate (castration anxiety).
 Female child develops “Electra Complex” – sexual desire for father.
 At the same time, she becomes aware that she does not have a penis and desires to get one.(penis envy). She
believes that she was castrated and hold her mother responsible for this.
 Failure to resolve Oedipus and electra complexes can result into the development of neurotic illness like
hysteria.
 Hence neurotic illness develops due to fixation at phallic stage.*
 Latent stage: 5-12 years –relative quiescent and inactive sexual drive and child focuses on learning and gaining
skills.
 Genital stage: 12 years onward till young adulthood –maturation of genital functioning.
Q. Defense mechanism in phobia is;

A. Inhibition
B. Distortion
C. Dissociation
D. Conversion
Q. Fixation of hysteria is at which stage?

A. Oral stage
B. Anal stage
C. Genital stage
D. Phallic stage

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PSYCHIATRY
Q. Which is not a defense mechanism?

A. Sublimation
B. Undoing
C. Repression
D. Derailment
Q. Which of the following is a mature defense mechanism?

A. Denial
B. Acting out
C. Anticipation
D. Projection
Q. The part of mind which works on reality principle?

A. Super Ego
B. Ego
C. Id
D. All
Q. Psychodynamic theory of mental illness is based on;

A. Maladjustment reinforcement
B. Unconscious internal conflict
C. Organic neurological problem
D. Focuses on teaching patients to restrain absurd thoughts
Q. Wrong statement about psychoanalysis is:

A. Parapraxis has meaning
B. Transference is patient’s feeling for therapist
C. Counter transference is clinician’s feelings for patient
D. Unguided communication has no meaning
Q. Term Super Ego and Id were coined by;
A. Elik Erikson
B. Bleuler
C. Freud
D. Skinner
Q. Castration anxiety is seen with;

A. Electra complex
B. Anal stage
C. Oedipus complex
D. Genital stage
Q. Instinctual drives exist in which part of mind?

A. Id
B. Ego
C. Super Ego
D. Conscious

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PSYCHIATRY
NEUROTIC, STRESS RELATED AND SOMATOFORM DISORDERS

ANXIETY
ANXIETY AND FEAR

 Anxiety - is the response to an unknown, internal and vague threat.
 Fear – is response to a known, external and definite threat.
Ansityattack
Symptoms of Anxiety:
Gart
-
 Nervousness
- all
sym.
of
v Sweating, tachycardia, restlessness, mydriasis, tremors.
W Urinary frequency, diarrhea Attack sym
 Cold clammy skin, hyper reflexia
~ Panic
Q. One of the followings is not an anxiety disorder:
A. Panic disorder
B. Agoraphobia
C. Social phobia
D. Depression
Anxiety disorders
 Panic disorder din
 Agoraphobia ka
 Specific phobia amat
 Social anxiety disorder (social phobia) kaY
 Generalized anxiety disorder in chest
Panic disorder -> sever

rustlessners, Breathlenner, Trachycardia,
Choking
pain
sensation
 Acute attack of intense anxiety accompanied by “feeling of impending doom” . sear of dying,
 Symptoms – chest pain, sudden onset of palpitations, choking sensation, dizziness and feeling of
unreality(depersonalization). drom
 Fear of dying and losing control are also there. feeling of impending
 Mean age presentation is 25 years. M:F-1:2-3.
Differential diagnosis of panic disorder:

 MI, angina, MVP, Asthma, pulmonary embolism, anemia, hyperthyroidism, hypoglycemia, carcinoid syndrome,
pheochromocytoma.
 Neurotransmitters involved are; NE, serotonin, GABA and Cholecystokinin.*
Treatment:
 Pharmacotherapy- SSRIs and benzodiazepine
 Psychotherapy- CBT
 Relaxation techniques and psychodynamic psychotherapy
PHOBIA: It is a strong, persistent and irrational fear of an object or a situation.

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PSYCHIATRY
SPECIFIC PHOBIAS
 Arachnophobia – fear of spiders

 Ophidiophobia – fear of snakes
 Aerophobia – fear of flying
 Glossophobia – fear of public speaking
 Ornithophobia - fear of birds
 Trypanophobia – fear of needles.
 Hoemophobia – fear of blood.
 Vehophobia – fear of driving

 Iatrophobia – fear of doctors
 Nosocomophobia – fear of hospitals
 Phasmophobia/spectrophobia – fear of ghosts
 Astraphobia – fear of thunders/lightening. a/k/a brontophobia, tonitrophobia.
 Cynophobia – fear of dogs
 Claustrophobia – fear of closed spaces( elevators, small rooms)
 Agoraphobia – fear of places from where escape might be difficult.

 Open, crowded, enclosed spaces, travelling alone. Patient won’t leave home.
 Xenophobia – fear of strangers
 Zoophobia – fear of animals
 Thanatophobia – fear of death
 Acrophobia- fear of heights
 Ailurophobia – fear of cats
 Hydrophobia – fear of water
 Mysophobia – fear of dirt and germs
 Pyrophobia – fear of fire
 Treatment:
 Pharmacotherapy – BZD, beta blockers and SSRIs
 Psychotherapy – Behavior therapy is the most effective treatment of phobias.*
 Systemic desensitization (SD) – exposure to anxiety provoking stimuli f/b relaxation techniques(muscle
relaxants). This has best evidence in treatment.
 Therapeutic graded exposure or in vivo exposure – patient learns to get habituated to anxiety. It is same as SD
except that no relaxation technique is used.
 Flooding(implosion) – exposure to most severe form of anxiety stimuli.

 Modeling (participant modeling) – therapist himself makes the demonstration. Patient learns by imitation
Other techniques;
 Psychodynamic therapy (insight oriented psychotherapy)
 Supportive therapy
 Family therapy
 Hypnosis
Agoraphobia:
 Fear of places from where escape might be difficult. It can manifest as;
 Fear of being in enclosed places like elevators,*
 crowded places,
 open spaces*,
 travelling alone*.
 It usually coexist with panic disorder.
 Treatment: BZD, SSRI and CBT like SD

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PSYCHIATRY
Generalized anxiety disorder:

 Symptoms > 6 months
 3 symptoms:
 Free floating anxiety
 Restlessness/motor symptoms
 Inability to relax
 Ch. By excessive anxiety which is generalized and persistent and is not restricted to a particular situation. It is a/c
free floating anxiety.
 Treatment: BZD, SSRIs and CBT (relaxation technique)
OCD- OBSESSIVE AND COMPULSIVE DISORDER AND RELATED DISORDERS
1. OCD- obsessive and compulsive disorder
Obsessions
 Recurrent and intrusive thoughts, images or impulses which cause marked anxiety.
 Person recognizes that the thoughts, images and impulses are the product of their own mind, which are
irrational, senseless and ego dystonic i.e. unwanted and unacceptable.
 Person attempts to resist such thoughts and impulses.
Compulsions
 Repetitive behaviors (hand washing) or mental acts (e.g. Counting, praying) which a person performs in response
to an obsession.
 They perform to reduce the distress caused by obsessions.
 Symptoms of OCD should persist for 2 weeks for diagnosis.
 Life time prevalence of OCD- 2-3%
 Mc comorbidity associated with OCD is depression* and both should be treated together.
Serotonin deregulations*- Etiopathogenesis

 Neuroanatomical model of OCD –dysfunction in the circuit CSTC*- cortico-striatal-thalamic-cortical circuitry. i.e.
starts in prefrontal cortex.
Note:
Most common obsession is obsession of contamination.
Most common compulsion is compulsion of checking
Symptoms of OCD: 4 major symptoms

1. Contamination – mc, f/b hand washing*
2. Pathological doubt – 2nd mc, i.e. obsession of doubt which is f/b compulsion of checking.
3. Intrusive thoughts – patient gets intrusive obsessional thoughts. Eg. Patient gets the thought of having sex with
god, which causes extreme anxiety.
4. Symmetry – patient always feels the need of symmetry
UPDATES: ICD-11 & DSM-5

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2. HOARDING DISORDER:
 Earlier it was considered as a subtype of OCD, but now it has been made a separate diagnostic entity.
 Patients keep on accumulating useless item & the house gets cluttered, to the point, that it becomes unsafe to live.
 This disorder id characterized by acquiring & not being able to discard the things that are considered to have little
or no use.
 This disorder is driven by fear of losing something important.
 Treatment: CBT + SSRI + Exposure &
3. Body dysmorphic disorder:

ch. by the preoccupation with an imagined defect in body appearance, usually hair, nose and skin.
Note: As per DSM-V, it is being considered as a type of OCD.
4. OLFACTORY REFERENCE SYNDROME

Its a new diagnostic entity added in ICD-11.
Characterized by preoccupation with the belief that one is emitting a foul breath or body odour that in
reality is unnoticeable or only slightly noticeable to others.
Person feels conscious about this that other may notice it.
So he repeatedly check the odour or try to mask it or may start avoiding the social situations.
Treatment:
 Pharmacotherapy – SSRI
 Other drugs are – lithium, valproate, carbamazepine*
 Psychotherapy – CBT-exposure and response prevention is the best modality.
 Other behavioral therapy – desensitization, thought stopping. Flooding and aversive conditioning.
 Other treatment modalities;
 In resistant case, ECT and psychosurgery can be considered. Psychosurgery includes cingulectomy and
capsulotomy (a/c caudate tractomy).*
TRAUMA AND STRESS-RELATED DISORDERS:
PTSD (post-traumatic stress disorder);
 Traumatic events like earthquake, rape, war, accidents can cause PTSD (duration >1 month) or acute stress
disorder (duration <1 month).

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SYMPTOMS :
 INTRUSIVE SYMPTOMS- FLASHBACK AND NIGHTMARES

Avoidance – patient will avoid all the stimuli which can remind him of trauma
 Arousal symptoms – insomnia, poor concentration, hypervigilence, exaggerated startle response.
 Emotional numbing, emotional detachment, anhedonia.
 If symptoms occur after 6 months of trauma, it is c/a PTSD with delayed onset.
 Mostly prevalent in young adult.
 F>>>M
 Area of brain involved in the pathogenesis of PTSD are hippocampus and amygdala.
TREATMENT
 SSRIs – 1st line treatment*

 CBT- Treatment of choice*
 Others – psychodynamic psychotherapy
 EMDR- eye movement desensitization and reprocessing
ASD: acute stress disorder

 Its acute stress reaction: daze, depression, anxiety, anger, despair.
 Usually short lasting and resolves within days.
 Treatment: CBT and debriefing*(which helps in promoting adaptation to traumatic event).
 Others – SSRI
Adjustment Disorders:
 Ch. by emotional responses to stressful events like financial problems, death of loved one, relationship problems
or medical illness. It usually involve anxiety and depressive episodes.
 Psychotherapy is the TOC.
DISSOCIATIVE DISORDERS (CONVERSION DISORDERS): HYSTERIA
Old name – Hysteria

 Disruptions or breakdowns of memory, awareness, identity, or perception
 People with dissociative disorders use dissociation as a defense mechanism, pathologically and involuntarily.
 These symptoms are produced by the “psyche”(mind) to deal with the unconscious conflicts that are
producing anxiety.
 These symptoms are produced unconsciously and help the patient to get attention.
 Symptoms occur suddenly and are caused by psychological trauma (such as stressful events or
relationship turbulence).
Types of dissociative disorders:

 Dissociative amnesia: amnesia is usually for traumatic events of personal significance.* such as a rape victim is
not able to recall anything about rape.

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Q. A person missing from home is found wandering purposefully. He is well groomed and denies remembering
how he reached there. Diagnosis is;
A. Dementia
B. Dissociative amnesia
C. Dissociative fugue
D. Mania
 Dissociative fugue: it is ch. by a sudden, unexpected travel away from home with inability to recall some or all of
one’s past. The basic self-care and normal behavior is maintained during the travel.
 Dissociative stupor: patient is in stupor due to psychological factors.

 Dissociative trance and possession disorder:
 It is ch. by loss of sense of identity and loss of awareness of the surroundings. Patient behaves as if she has been
over taken or possessed by some spirit or goddess.
 Dissociative disorders of movement and sensation: without any physical disorder, patient presents with
deficits in motor and sensory functions. Eg. Paralysis, visual disturbances.
 La belle indifference- is a phrase used to describe the feeling of indifference which patients of conversion
disorders have towards their symptoms. Eg. Patient will complete unconcerned /indifferent if he gets sudden
visual loss.
 Dissociative identity disorder (multiple personality disorder). 2 or more distinct personalities exist within an
individual. One personality will be evident at one time.
 Diff. personalities are c/a “alters” and they are unaware of each other’s existence.
Other dissociative disorders:

 GANSER’S SYNDROME:* ch. symptom is approximate answers (vorbeighen). Answers are not correct but bear
an obvious relation to the question. Eg. Ask the patient, what is the taste of sweets? He may answer as sour.
 Other symptoms are: auditory and visual hallucinations, clouding of consciousness.
 Frequently seen in prisoners.
Treatment:
 CBT- patient is motivated to be the normal people only.
 Psychoanalysis
 Abreaction*- attempt is made to bring unconscious memories and emotions to conscious awareness using
hypnosis and medications.
 Drugs- BZD

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SOMATOFORM DISORDERS:
UNEXPLAINED DISORDERS
 Patient typically presents with physical symptoms which cannot be explained by any known medical
condition.
 He will persistently request for many tests despite of negative results and reassurance of doctors.
Types of somatoform disorders:

 Somatization disorder (briquet’s syndrome) – presence of multiple physical symptoms for which no any
medical cause can be ascertained.
 These symptoms should be present to diagnose it;
 4 pain symptoms(pain at 4 different sites).
 2 GIT symptoms
 1 sexual symptom
 1 pseudoneurological symptom
 Treatment – psychotherapy
Hypochondriasis
 –ch. by a preoccupation with the fear of having or the idea that one has one or more serious physical
illnesses. Preoccupation persists despite the normal investigations and doctors’ reassurance.
 Note: emphasis in hypochondriasis is on the diagnosis and in somatization disorder is on the symptoms.
 In DSM-V, the diagnosis of hypochondriasis has been replaced by “illness anxiety disorder”.
UPDATES: ICD-11
 The corresponding diagnosis for somatic symptom disorder is BODILY DISTRESS DISORDER.
FACTITIOUS DISORDER: HOSPITAL ADDICTION

 a/c Munchausen syndrome- Patient produces fake symptoms with the sole intention of seeking medical
attention (hence c/a professional patients).
 Patients distort the history and make stories (pseudologia fantastica) to convince the doctors.
 Mostly patients are from the medical background.
 When a caregiver produces fake symptoms in those who are in their care(usually children) to gain the attention, it
is c/a “Munchausen syndrome by proxy”*.
STAGES OF DEATH AND DYING

 When a person is informed about his impending death, he usually goes through a series of responses.
 Proposed by: “Elizabeth Kubler-Ross”***
 Stage 1: denial and shock
 Stage 2: anger
 Stage 3: bargaining
 Stage 4: depression
 Stage 5: acceptance

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 BEREAVEMENT: means the state of being deprived of someone due to death.

 GRIEF: it is the psychological feeling precipitated by the death of someone.
Patient experiences intense sadness.
 Patient may have longing to join the deceased person and may experience the transient hallucination.*
 Mourning: is the process through which grief is resolved. It involves the social practices like funerals and
burials.
Malingering:
 Intentional production of false physical or psychological symptoms with a motivation of getting some external
benefits.
 It should be suspected when there would be;
 Medico-legal cases
 Marked discrepancy in complaints and findings
 Lack of co-operation by the patients in diagnosing the case.
Q. Mc psychiatric disorder is;

A. Depression
B. Anxiety
C. Mania
D. schizophrenia
Q. Which of the following is not a part of kubler-Ross’s stages of impending death?

A. Depression
B. Anxiety
C. Anger
D. Bargain
Q. False about Ganser syndrome;

A. Dissociative disorder
B. Mostly seen in prisoners
C. Repeated lying
D. Vorbeigehen(word approximations)
Q. A 35 year old lady presents with sudden onset breathlessness, anxiety, palpitation and feeling of impending
doom. Physical examination does not reveal any abnormality. What is the probable diagnosis in this case?
A. Panic attack
B. Conversion disorder
C. Acute psychosis
D. Anxiety disorder
Q. Drug of choice for OCD is;

A. Clomipramine
B. Carbamzapine
C. Fluoxetine
D. Chlorpromazine
Q. True about OCDs are all except:

A. Patient tries to resist against obsessions and compulsions
B. Obsessions are ego syntonic
C. Insight is present
D. Exposure and response prevention has the best outcome

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Q. Which of the following is not a somatic symptom?

A. Constipation
B. Impotence
C. Numbness
D. Anhedonia
Q. Maintaining sick role by any means is a characteristic feature of;

A. Conversion disorder
B. Hypochondriasis
C. Factitious disorder
D. Somatization disorder
Q. La bella indifference is seen in;

A. Mania
B. Depression
C. Schizophrenia
D. Conversion disorder
Q. A 55 year old man feels uncomfortable in using lift, being in crowded places and travelling alone. What will be
the most appropriate line of treatment?
A. Relaxation therapy
B. Counselling
C. Exposure and response prevention
D. Pharmacotherapy
Q. A 40 year old lady presented to physician with complaints of hematuria. On evaluation, RBCs were found in
urine but no cause was found. On further enquiry it was found that she has gone to many doctors with the same
complaints and would demand inpatient care. She would prick her finger and mix blood in her urine sample. What
is the diagnosis?
A. Dissociative disorder
B. Hypochondriasis
C. Factitious illness
D. Malingering
Substance Related and Addictive Disorders
Acc. to De-addiction centre, India, Jan 2019

 MC substance abuse in India – ALCOHOL
 MC illicit (illegal) use substance – CANNABIS
Reason for the controversy:

 2003 – CANNABIS (WHO-AIIMS)
 2006 – Tobacco (UN)
 2010 – ALCOHOL (AIIMS)
 2015 – TOBACCO/NICOTINE (AIIMS)
It includes 10 separate classes of drugs;

 Alcohol
 Caffeine
 Cannabis
 Hallucinogens
 Inhalants
 Opioids
 Sedatives
 Hypnotics
 Stimulants
 Tobacco and other substances.
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TERMINOLOGIES
A. Dependence:
 use of a substance is being prioritized much over other behaviors.
 Behavioral dependence – substance seeking behavior
 Physical dependence – physiological effects of multiple episodes of substance use
 Psychological dependence – continuous or intermittent craving
Acc. To ICD-11, the presence of the following in past 1 year is required for diagnosis of dependence on a substance.
Craving – strong desire
 Difficulty in controlling substance taking behavior
Withdrawal symptoms
Tolerance – increased doses of substance is required to achieve the effects originally produced by lower dosage.
 Progressive neglect of alternative pleasures or interests.
 Using the substance despite the harm
B. Harmful use: acc. to ICD-11, it is defined as a pattern of substance use causing damage to physical and mental
health, or behavior leading to harm of the health of others.
C. Single episode of harmful use: A single episode of substance use that has caused damage to physical or mental
health to a person.
 DSM-5 doesn’t use the categories of ‘dependence’ and ‘harmful use’ and instead uses a single diagnostic category
of ‘substance use disorders’
 E. Intoxication: altered consciousness, thinking, perception or behavior due to substance taking.
 F. Withdrawal: specific symptoms that occur after stopping the amount of substance.
Q. A person was using 6 pegs of alcohol everyday for last 15 years. Now he is getting kick only after 1 peg. This
phenomenon is called as;
A. Dependence
B. Tolerance
C. Reverse Tolerance
D. Abuse
 REVERSE TOLERANCE: decrease in quantity of substance because of end organ damage or supersensitivity of
receptors.
 Note: In cocaine abuse: psychosis occurs because of Reverse Tolerance, due to supersensitivity of receptors
 It is best explained by bio-psycho-social model.
 The drugs act on particular receptors and brain pathways - Dopaminergic neurons in the ventral tegmental area
which project to cortical and limbic regions, esp. nucleus accumbens. - “brain reward pathway”.
 Major neurotransmitters involved are: opiods, catecholamines (esp. dopamine) and GABA.
Other factors which contribute to the development of substance use disorders are:
 Social acceptance
 Peer pressure
 Easy availability
 Personality type
ALCOHOL
 Active ingredient – ethyl alcohol or ethanol.

 The standard drink or a unit of alcohol corresponds to 10 ml of absolute alcohol or 7.8 gram of of absolute
alcohol (specific gravity of alcohol = 0.78)
 Arrack – country made liquor
 Fortified wine – made by adding brandy to wine
 Absorption: 20% from stomach, 80% from intestine. Empty stomach > full stomach.
 Peak blood alcohol concentration is reached in 30-90 minutes.
MELLANBY EFFECT: Rising level of BAC will have more behavioral consequences compared to same falling level
of BAC.

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 Reverse tolerance: the phenomenon where the intoxicating effects of alcohol are seen progressively with lower
dosages.*
 Metabolism: 90% through oxidation by liver. 10% excreted unchanged through kidney and the lungs.
Q. Shown apparatus helps in measuring;

a. Halitosis
b. Oxygen pressure
c. Blood alcohol concentration
d. Carbohydrate deficit transferrin
 Alcohol in alveolar air = alcohol in blood passing through pulmonary capillaries → Alcohol level in breath by
breath analyzer gives a good estimate of blood alcohol level
 Alcohol → Acetaldehyde (by alcohol dehydrogenase) → Acetate (by aldehyde dehydrogenase) → CO2 +
H2O.
Symptoms are dependent upon the blood alcohol concentration.
 Blood levels Symptoms

 20-30 mg/dl decreasing thinking ability and slowness
of motor performances.
30mg/dl is the legal limit for driving
india.
 30-80-mg/dl Further decrease in thinking ability and. worsening of motor performance.
 80-200mg/dl incoordination, judgment errors, mood lability.
 200-300 mg/dl Nystagmus, slurring of speech, alcoholic blackouts
 >300 mg/dl impaired vital signs and possible death.
 Alcoholic blackout: anterograde amnesia seen during acute intoxication.

 Blood alcohol level - 200-300 mg/dL
Acute intoxication:
 Alcohol is CNS depressant.* Excitement is due to decrease in conscious self-control.
SYMPTOMS OF ALCOHOL WITHDRAWAL:

 Anxiety
 Depression
 Irritability
 Fatigue
 Tremors ( 1st and the most common)
 Palpitations
 Clammy skin
 Dilated pupils
 Sweating
 Headaches
 Difficulty sleeping
 Vomiting
 Seizures
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SERIOUS COMPLICATIONS:
 Delirium tremens (20% mortality rate)
 High fever
 Intense agitation
 Visual hallucinations
 Tactile hallucinations
Q. All of the following symptoms will occur in alcohol withdrawal, except;

A. Tremors
B. Insomnia
C. Hypersomnia
D. Anxiety
 Symptoms which develop after cessation of alcohol intake.

 After 6-8 hours: tremulousness (coarse tremors)- mc & classic symptom.
 Others – GIT like N &V, sympathetic ANS hyperactivity like anxiety, sweating, mydriasis, tachycardia HTN.
 After 12-24 hours: alcoholic hallucinosis (hallucination in the absence of any disturbances of consciousness).
Usually auditory.
 After 24-48 hours: seizures, usually GTCS. Alcoholic withdrawal seizure is often c/a cluster seizres.*
 After 48-72 hours: delirium tremens. It’s a medical emergency and if untreated, the mortality rate is around
20%.
 Symptoms are – disorientation to time, place and person, hallucination (visual > auditory and tactile), coarse
tremors and autonomic hyperactivity.
SERIOUS LONG TERM HEALTH CONSEQUENCES:

 Heart: Dilated cardiomyopathy, Arrhythmias, Stroke
 Liver: Steotosis, steatohepatitis, fibrosis, cirrhosis
 Pancreatitis
 Vitamin deficiencies: Korsakoff’s syndrome, wernickes
 Cancers: Mouth, esophagus, throat, liver, breast
Alcohol induced disorders:

 Alcohol induced psychotic disorder
 Bipolar disorders
 Depressive disorders
 Anxiety disorders
 Sleep disorder
 Sexual dysfunction
 Neurocognitive disorders (amnestic syndrome)
Q. Which of the following deficiency is found in alcoholic patients?

A. Ascorbic acid
B. Cyanocobalamine
C. Thiamine
D. Retinol
The classic names for alcohol induced amnestic disorders are: WERNIKES’S AND KORSAKOFF’S
Wernicke’s encephalopathy: it is the acute neurological complication characterized by the following symptoms;
( GOA)
 Global confusion
 Ophthalmoplegia-6th nerve palsy > 3rd n. palsy causing horizontal nystagmus and gaze palsy. It responds rapidly to
thiamine treatment and may reversed within hours.
 Ataxia

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 Although Wernicke’s may reversed completely with treatment , residual ataxia and horizontal nystagmus
remains there.
 Opthalmoplegia responds rapidly to thiamine treatment and may get reversed within hours.
 Wernicke’s encephalopathy may clear spontaneously in days to weeks or progress to Korsakoff’s syndrome.
Q. After the complete management for wernickes encephalopathy, which of the following conditions can remain
despite the treatment?
A. Global confusion
B. Horizontal nystagmus
C. Residual Ataxia
D. B and C
Q. Which of the following symptoms will get reversed in hours after the thiamine infusion in wernickes
encephalopathy?
A. Ataxia
B. Ophthalmoplegia
C. Complete wernickes
D. None
KORSAKOFF’S SYNDROME: it is the chronic neurological complication of long term alcohol use.
 Ch. by impaired recent memory, anterograde amnesia (inability to form new memory) > retrograde amnesia
(inability to recall old memories) and confabulations (making of false stories to fill memory gaps which is
unintentional.)
 Pathophysiology of both is thiamine deficiency.
 Neuropathological lesions are usually symmetrical and involve mammillary bodies.
 Treatment of WE – high dose of parenteral thiamine.

 Korsakoff’s – oral thiamine for 3-12 months. Only 20 % of korsakoff’s patients recover.
MARCHIAFAVABIGNAMI DISEASE:
 it is a rare neurological complication of long term alcohol use.
 Ch. by epilepsy,ataxia, dysarthria, hallucinations and intellectual deterioration.
 Pathophysiology is demyelination of corpus callosum, optic tracts and cerebellar peduncles.
Evaluation:
Screening test: CAGE questionnaire
 Have you ever felt that you should Cut down on your drinking?
 Have people Annoyed you by criticizing your drinking?
 Have you ever felt bad or Guilty about it?
 Have you ever had a drink first think in the morning as Eye opener?
 A positive response on 2 or more than 2 of the above questions is suggestive of alcohol use disorder.
Other tests:
 AUDIT- alcohol use disorders identification test.
 SADQ – severity of alcohol dependence questionnaire.
 1. Blood alcohol concentration – measured by breath analyzers. It can also be measured by “Widmark
formula”, if the amount of alcohol consumed and body weight is known.
 2. Carbohydrate deficit transferrin (CDT): most sensitive and specific laboratory test for the identification of
heavy drinking is elevated level of CDT.
 3. Gamma-glutamyltransferase (GGT): poor sensitivity and specificity (50-60%).

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Diagnostic markers:
 4. Alaline aminotransferase (ALT)& Aspartate aminotransferase (AST):these are less sensitive than GGT but has
higher specificity.
 ALT is more specific than AST*, as it is mostly found in liver. A ratio of AST: ALT is a good marker for heavy
alcohol consumption.
 5. Mean corpuscular volume: frequently elevated.
 6. Alkaline phosphatase: elevated levels indicate liver injury secondary to heavy drinking.
Treatment:
It is done in following phases;
 Detoxification
 Maintenance of abstinence
 Deterrent agent
Detoxification: it’s the 1st phase, which involves withdrawal symptoms. Duration is 7-14 days.
 Benzodiazepines ( esp. chlordiazepoxide – T1/2 – 12-24 hours)* - DOC + Thiamine to be added.
 Carbamazepine can be used in place of BZD.
 Patients who are undergoing detoxification, parental thiamine 250mg/day should be given for 5 days
followed by oral thiamine.
 As delirium tremens is complicated alcohol withdrawal that is always treated inpatient, the same dosage should
be used.
Maintenance of abstinence: its long term treatment for maintenance.

 Pharmacological – 2 types of drugs are used;
1. Deterrent agents
2. Anticraving drugs
 Deterrent agents: Disulfiram (mc). It is an irreversible inhibitor of aldehyde dehydrogenase, the enzyme which
metabolites acetaldehyde.
 Acetaldehyde is the first product of alcohol.
 If a patient who is on disulfiram, consumes alcohol, will result into accumulation of toxic levels of acetaldehyde
and causes many unpleasant signs and symptoms, c/a “disulfiram ethanol reaction”.
Drugs which cause disulfiram like reaction are:

 Citrated calcium carbimide
 Hydrogen cyanamide
 Abacavir
 Cephalosporins like ceftriaxone, cefuroxime etc.
 Chloral hydrate
 Chloramphenicol
 Cotrimoxazole
 Ethacrynic acid
 Griseofulvin
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 Isoniazid
 Ketoconazole
 Metronidazole
 Sulfonamides etc
Q. If a high profile person wants to leave the alcohol but he is asking that he can’t use disulfiram drug. He has to
attend high profile meetings with his clients and he has to take alcohol professionally. What should be prescribed
next?
A. Stay on disulfiram
B. Anticraving drugs
C. Suggest him to leave the job
D. Thiamine intake
Anticraving agents:
 Naltrexone
 Acamprosate
 Topiramate
 Gabapentine
 Serotonergic agents like fluoxetine, and baclofen.
 Baclofen can be given even in liver cirrhosis and it can be used as a detoxifying drug also.
Non-pharmacological treatment:
psychosocial treatment.
 CBT: motivational enhancement therapy
 Relapse prevention model and cognitive therapy
 Alcoholic anonymous: it is a self help group, which follows 12 steps to quite alcohol use. Members include
recovered patients, current alcohol users, and volunteers.
 Family therapy
 Group therapy
OPIOIDS
 Opiates: psychoactive alkaloids like Morphine and Codeine which are present in opium (derived from
papaversomniferum, the poppy plant).
 Opioids: it’s a broader term which includes synthetic compounds like Heroin and Methadone.
 Heroine (diacetyl morphine) is the most abused opioids.*
 Initially heroine was used as a treatment for de-addiction of morphine, but later it was found that its dependency
was more than morphine.
 Street names of heroine – “Smack” and “Brown sugar”.
How it is abused?
 Orally,
 Snorted intranasally( also c/a chasing the dragon), and
 Injected I/V or S/C.
 The I/V route tend to gradually shift from peripheral to larger veins ( a phenomenon called “mainlining”).
 Once the user is not able to find any vein, he starts using s/c. S/c route is c/a “skin popping”.
Intoxication:
 Begin with euphoria and then feeling of warmth, heaviness of extremities and facial flushing.
 This initial euphoria f/b sedation is c/a “Nodding Off”.
 Overdose can be lethal due to respiratory depression.* symptoms are – slow respiration, hypothermia,
hypotension, bradycardia, pin point pupils, cyanosis and coma.
Withdrawal symptoms:
 Short term use of opioids decrease the activity of noradrenergic neurons and the long term use results in
compensatory hyperactivity.
 When opioids are suddenly stopped, there are symptoms of rebound noradrenergic hyperactivity.
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PSYCHIATRY
 This hypothesis explains the mechanism of action of clonidine (alpha-2 adrenergic agonist) in
management of opioid withdrawal.
 The withdrawal symptoms usually appear 6-8 hours* after the last dose, peak during 2-3rd day and subside
during 7-10th days.*
Symptoms produces a Flu Like Syndrome with the symptoms like;

 Rhinorrhea, lacrimation, sweating and diarrhea.*
 Yawning and piloerection.
 Pupillary dilatation
 Muscle cramps and generalized bodyache
 Insomnia, anxiety, HTN & tachycardia
 Nausea, vomiting and anorexia.
 Detoxification: for 2-3 weeks treatment, managing withdrawal symptoms by long acting opioids like methadone
or buprenorphine. Clonidine is also used.*
 Accelerated detoxification; initially low doses of naltrexone (opioid antagonist) is given which produces severe
withdrawal symptoms. After that, clonidine is used to control the symptoms. This method reduces the
detoxification period to 4-5 days.
 Maintenance treatment: its aim is to prevent relapse.
It is done by 2 methods.
 Opioid substitution therapy – short acting opioid like heroine is substituited by long acting methadone and
buprenorphine.
 Opioid antagonist treatment – naltrexone after the detoxification is completed.
 Overdose treatment – by Naloxone i/v – DOC. Naloxone is short acting opioid antagonist.
 Nonpharmacological approaches like- CBT, family therapy.
CANNABIS
 Derived from the hemp plant, cannabis sativa.

 Cannabis sativa indica in India and cannabis sativa Americana in USA.
 It is the mc illegally used drug in the world and india.
 Street names are – joints, marijuana, grass, pot, weed, etc. *
 The active ingredient is delta-9 tetrahydrocannabinol (THC).
 THC can be found in patient’s blood, urine, sweat and saliva.
Q. All of the following are the products of cannabis except;

A. Hashish
B. Bhang
C. Heroine
D. Ganja
Q. Which of the following should be assessed in cannabis poisoning?

A. VMA
B. 5HIAA
C. THC
D. 5HT
Cannabis preparation THC content(%)

 Bhang (derived from dried leaves) 1
 Ganja (derived from inflorescence) 1-2
 Hashis/Charas (derived from resinous exudates) 8-14
 Hash oil (lipid soluble plant extract) 15-40
 Cannabis is more commonly smoked and taken orally. Unsuitable for i/v.

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PSYCHIATRY
Intoxication:
 It is ch. by euphoria, reddening of conjunctiva, sense of slowing of time, sense of floating in air, increased appetite
and dryness of mouth.
 Other symptoms are: depersonalization, derealization and synesthesia* (crossing over of sensory perception,
i.e. patient will say he is hearing light and seeing the music)*
 The unpleasant experience (like fear, extreme anxiety etc.) is c/a “bad trip”*
 Mild symptoms within 1-2 weeks of cessation & include insomnia, anxiety, irritability and decreased appetite etc.
Cannabis Related Disorders:

 Cannabis induced psychotic disorder: it is a/c “hemp insanity”. Symptoms like delusion and hallucinations.
 Flashback phenomenon: (due to high fat solubility)* recurrence of cannabis use experience in the absence of
current cannabis use.
 Running amok:* developing rage following cannabis use. Patient may hurt or kill someone.
 Amotivational syndrome:*unwillingness to persist in any task.
Treatment:
 BZD for short term only.
 Long term treatment involves psychotherapy.
Note: CANNABIS & LSD

 - ?No physical dependence
 - Flashback phenomena
 - High fat solubility
HALLUCINOGENS
It includes;
 LSD (lysergic acid diethylamide)
 Mescaline
 Psilocybin
 MDMA (methylenedioxyamphetamine) – a/c Ecstasy*
 Phencyclidine (Angel Dust)*
 Ketamine
 Typical symptoms are – depersonalization, derealization, synesthesia, illusion & hallucinations, autonomic
hyperactivity like pupillary dilatation, tachycardia, sweating, palpitations, tremors etc.
 Patient may get “bad trip” like experience similar to cannabis i.e. patient may become restless, fearful and may
develop panic reaction.
 Phencyclidine and ketamine are termed as dissociative anesthetics.*i.e. patients feel dissociative or cut off
from the environment. Both of them act by blocking NMDA receptors.
 Symptoms in phencyclidine and ketamine intoxication are closely similar to schizophrenia.*
 Phencyclidine intoxication produces some specific symptoms like;
 Vertical or horizontal nystagmus, ataxia, dysarthria and extreme agitation and assaultiveness.
 Hallucinogens do not cause physical dependence, so no dependency and withdrawal symptoms are seen.
 LSD cause flashback phenomenon.
Treatment:
 Mostly psychotherapy

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PSYCHIATRY
STIMULANTS
Cocaine , Amphetamine
Cocaine
 Derived from plant erythroxylum coca. Its pharmacological effect was studied by “Sigmund Freud”. He was
believed to be addicted with this.
 Coca cola –used to contain cocaine till 1903.
 It was used as LA and still used in eye, nose & throat surgery. The LA effect is being mediated by blockade of fast
sodium channels.
Mechanism of action:
 Cocaine acts primarily by blocking D1 & D2 (dopaminergic receptors) and increasing dopamine concentration in
synaptic cleft.
Basically it blocks all amines:

 Increase choline – Attention hormone
 Increase dopamine – Kick hormone
 Increase serotonin – happy hormone
 Increase noradrenalin – happy hormone
Q. Psychosis and formication occur in cocaine use, because of ;

a. Increase choline
b. Increase dopamine
c. Increase serotonin
d. Increase noradrenalin
 Note: psychosis in cocaine abuse is because of REVERSE TOLERANCE
Q. Flashback and psychosis occur in which substance use?

A. Coacaine
B. Alcohol
C. Cannabis
D. Tobacco
 Note:
 Formication + Psychosis = seen in Cocaine abuse
 Flashback + psychosis = seen in Cannabis abuse
 It causes marked vasoconstriction of peripheral arteries, which causes HTN, and that of epicardial coronary
arteries can lead to ischemic myocardial injury.
 It can cause seizures.*
 COCAINE > AMPHETAMINES *- CAUSING SEIZURES.*
Methods of abusing:
 It is usually inhaled (snorting)*. Can cause nasal congestion and even nasal septal perforation. Long tem can
cause “jet black pigmentation of tongue”.
 other methods are smoking (c/a free basing) and i/v &s/c.
 Freebasing involves mixing of street cocaine ( which has procaine or sugar as adultrants) with freebase (pure
cocaine).
 Speed ball – cocaine + heroine *
 Crack –is a freebase form of cocaine which is smoked. It is extremely potent and even a single dose can cause
intense craving.
 Ch. by euphoria, tachycardia, HTN, pupillary dilatation & sweating.
 Moderate to high dose can cause paranoid ideations,* auditory hallucinations and visual illusons.
 Tactile hallucination seen – a/c formication and magnan
phenomenon.*

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PSYCHIATRY
 Cases strong psychological dependence.
 Symptoms include – exhaustion, feeling low, fatigue, lethargy, insatiable hunger.
 Most severe withdrawal symptom is depression, which can be ass. with suicidal tendency.
COCAINE INDUCED PSYCHOTIC DISORDER:

 mc seen with i/v use and crack users. The hallmark is paranoid delusions *(delusion of persecution)&
auditory hallucinations.*
 The disorder is similar to paranoid schizophrenia in its presentation.
Treatment:
 Mostly psychotherapy
AMPHETAMINES:
 Include dextroamphetamine, metamphetamine, methylphenidate.

 Used to increase performance and induce a euphoric feeling.
 Long term use can result in amphetamine psychotic disorder, whose hallmark is presence of paranoid delusion*
(delusion of persecution)* and auditory hallucination.*
TOBACCO
 Use as smoking, chewing, applying, sucking and gargling.
 Beedi> cigarette smoking is mc form.
 Nicotine is the active ingredient which is responsible for addiction.
 Nicotine gives kick by increasing Choline (attention hormone) and dopamine (kick hormone)
 Constituents responsible for CVS disorders are nicotine and CO.
 Nicotine has a stimulant action and improves the attention, learning, reaction time and problem solving
ability.
 Withdrawal symptoms: dullness, poor attention, lack of motivation.
which can develop within 2 hours of last smoking and peak in 24 hours.
 Symptoms include – craving for nicotine, irritability, anxiety, difficulty in concentrating, bradycardia, drowsiness,
paradoxical trouble sleeping, inceased appetite and weight gain.
Pharmacotherapy:
 Nicotine replacement therapy*: gums, patches, inhalers, spray.
Medications;
 Bupropion( 1st line) – antidepressant – NDRI (noradrenergic dopamine reuptake inhibitor) – so increase
dopamine and hence improves the symptom.
 Varenicilline - α2β4 agonist (it won’t let the kick and craving to happen)
 clonidine, nortriptyline (2nd line)
Other drugs
 Inhalants or volatile solvents: include gasoline (petrol), glues, thinners, industrial solvents. These solvents are
soaked in a cloth and are sniffed (vapors are inhaled).
 More commonly seen in children and adolescents.
 Long term use can cause irreversible liver and kidney damage, peripheral neuropathy and brain damage.
 Benzodiazepines & other sedative hypnotics: BZD produces physical and psychological dependence.
Withdrwal symptoms are – anxiety, irritability & insomnia.
CAFFEINE
 It is the most widely used psychoactive substance worldwide. It is ass. with feeling of improved efficiency,
increased energy levels and concentration.
 Excessive use can produce anxiety, restlessness, irritability.
 Can produce dependency and withdrawal symptoms like anxiety, restlessness, nausea and vomiting.

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PSYCHIATRY
Q. Flu like symptoms are seen in withdrawal symptoms of which substance?

A. Heroine
B. Ganja
C. Cannabis
D. Alcohol
Q. Irresistible urge to drink alcohol is known as;

A. Pyromania
B. Trichitolomania
C. Dypsomania
D. None
Q. A patient was brought with symptoms of tremulousness, arousal, sweating, irritability and tachycardia. History
of daily alcohol intake is present. The diagnosis is;
A. Korsakoff’s psychosis
B. Alcohol withdrawal
C. Delirium tremens
D. Wernicke’s encephalopathy
Q. A patient was brought with symptoms of tremulousness, arousal, sweating, irritability and tachycardia. History
of daily alcohol intake is present. The diagnosis is;
A. Korsakoff’s psychosis
B. Alcohol withdrawal
C. Delirium tremens
D. Wernicke’s encephalopathy
Q. After use of some drug, a person develops episodes of rage in which he runs about and indiscriminately injures
a person who is encountered in way. He is probably addict of;
A. Opium
B. Cannabis
C. Cocaine
D. Alcohol
Q. A chronic alcoholic patient stopped alcohol intake for 2 days due to religious reasons, developed symptoms of
withdrawal on first day. On second day he had GTCS followed by another episode of GTCS after few hours. Which
drug should be given to control the symptoms?
A. Sodium valproate
B. Phenytoin
C. Diazepam
D. Clonidine

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PSYCHIATRY

RISE WITH ARISE

Sl.No. TOPICS Page No.

3. Mood disorders – Depression/Bipolar

6. Neurotic, stress related and somatoform disorders

10. Eating disorders

11. Organic mental disorders

12. Substance related & addictive disorders

13. ECT/Different methods of treatment in psychiatry

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Reality Testing Absent Present

Pathophysiology of Psychiatric disorders

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A n u 2 3 a seven body pain diginous

wt-loss -> TB.

pain rasher over

-> No such couse.

HOW TO ASSESS A PSYCHIATRIC PATIENT?

Q. Which is not the component of psychiatric history taking?

Information should be adequate

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cocain -> 1903

CLINICAL EXAMINATION ↳ father

MSE (MENTAL STATUS EXAMINATION) –

5. Thought -> delection

6. Cognition: HIGHER MENTAL FUNCTIONS gasfactor-tast Touch.

-C. Percussion of spleen Apraxia e loss of Action

D. Thought process *Acalculiat loss calculation.

 AFFECT: short lived, external expression of internal emotions, observable

3. APPROPRIATENESS AND CONGRUENCY

Congruency of affect is described in relation to the thought content of person.

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Q. Depressed mood describes;

Some other disturbances depression,

 2. ALEXITHYMIA: Inability to understand and express the emotions.

LIMBIC SYSTEM – MATCH

A. Limbic system -> generate. c

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Special types of hallucination:

“Other Disturbances of Perception”

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Q. Which of the following statement is wrong about hallucination?

It refers to the “organization” of thought or “association” between the consecutive thoughts.

rain today, Virat is an awesome player.

e. Tangentiality -> Ansing in a distantrelation Manner.

(glance), Time vaal (watch)

Q. Delusion is a disorder of:

Q. Delusion is a disorder of:

3. CONTENT OF THOUGHT: its disturbance is DELUSION.

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HIGHER MENTAL FUNCTIONS:

F. Judgement – ability to respond appropriately in a particular situation.

Q. Reflex hallucination is a morbid variety of;

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Q. Loosening of association is an example of;

Q. Which of the following test is performed to assess immediate memory?

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 Minimal brain dysfunction – older name

 It is a common neuropsychiatric disorder in children. M>>F

 Neurological examination (detailed examination)

Three subtypes of ADHD are:

Those who do not get remission, They are at risk of developing:

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