PSYCHIATRY

At a glance
Compiled by:
Dr. Md. Naim Uddin
50th MBBS, Chittagong Medical College
Editor of‐
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 Psychiatry @ a glance

PSYCHIATRY AT A GLANCE
Biological functions of human: b. Disinhibition: Without any restrain,
1. Sleep shows sexual behavior
2. Appetite c. Recklessness: Behavior which
3. Sex endangers life of the patient as well as
others, e.g. িবদুয্েতর তার ধের েফলেব
Mind:
Limbic system plus hypothalamus constitute 7. Oddity of behavior
mind. a. Stereotype: Repeatedly do some kind
of behavior that has no social value
e.g. itching
MENTAL STATUS EXAMINATION b. Mannerism: Repeatedly do some kind
of behavior that has some social value
1. Appearance and behavior (kempt or e.g. repeated handshakes. It is found
unkempt) in mania.
a. General appearance
 Hair: Combed/uncombed, 8. Speech
cut/uncut a. Quality: Volume, tone, pitch. Speech is
 Cloths: Torn, dirty, stained high volume in mania.
 Neatness and cleanliness b. Quantity: Normal///mute.
 Nails: Cut/uncut c. Rate: Normal/fast/slow.
b. Facial appearance
 Anxiety 9. Mood and affect
 Eyes a. Euthymia
 Furrows in forehead b. Sadness  depression
 Gloomy face c. Cheerfulness  elation
 Expression Questions asked to the patient:
 Cheerfulness  গত 10 িদন আপনার মন েকমন িছল?
 Irritability  মেন শািn িছল?
 মেন aশািn েকন?
2. Posture: Position of a person within the
space/environment 10. Thought process: It is retrospective
(understood after telling) and known by
3. Gesture: Movement of the body parts speech and gesture.
a. Form of thought: Disorder of form of
4. Rapport: Mental bridge between patient thought is called formal thought
and doctor disorder (FTD). It is of four types—
 Not possible in psychosis যিদ েকান িবষেয় p করা হয় তাহেল utর
 Possible in neurosis েদয়ার সময়-
 Circumstantiality: It is minor form
5. Psychomotor activity of FTD. pাস ীক িবষয় েথেক apাস ীক
a. Agitation e.g. mania, schizophrenia িবষেয় চেল যােব তারপর আবার
b. Retardation e.g. depression, anxiety pাস ীক িবষেয় িফের আসেব।
 Tangentiality: pাস ীক িবষয় েথেক
6. Social behavior
apাস ীক িবষেয় চেল যােব eবং
a. Expansibility: aপিরিচত মানুেষর সােথ
apাস ীক িবষয়i বলেত থাকেব।
েবিশ কথা বলেব।

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 Psychiatry @ a glance

 Loosening of association: সmূণর্  Another process—

apাস ীক িবষয় বলেব। বাকয্ িঠক Conscious
থাকেব িকn বাকয্ েলার মেধয্ েকান Clouding of consciousness
logical associa on থাকেব না। Stupor
 Word salad: It is major form of Coma
FTD. eেলােমেলা শb বলেত থাকেব,
eমনিক সিঠকভােব বাকয্o বলেত পারেব 2. Orientation: Regarding—
না।  Time
b. Content of thought:  Place
 Obsession: Repeated intrusive  Person
thought
 Delusion 3. Memory:
 Retention & recall (working
11. Perceptual disorder: memory is up to 20 seconds and 7
 Illusion: Misperception of digits)
external/true stimuli  Recent memory
 Hallucination  Remote memory

Cognitive Function Test Psychiatric Disorders

1. Consciousness: Psychiatric disorders can be classified into two

 Glasgow coma scale: broad groups—
1. Psychosis: It is major psychiatric illness.
Glasgow Coma Scale Score It is a disorder characterized by altered
Eye opening (E) perception of reality (Davidson’s).
Spontaneous 4  Insight is lost (েস েয মানিসকভােব
To speech 3 aসুs েসটা েস বুঝেত পারেব না। েরাগী
To pain 2 িনেজ কখেনা ডাkােরর কােছ আসেব না,
No response 1 তার আtীয়রা িনেয় আসেব। )
Verbal response (V)  Person cannot differentiate
Oriented 5 between fantasy and reality
Confused: Talks in sentences but 4  Appearance is below normal limit
disoriented 2. Neurosis: It is minor psychiatric illness. It
Verbalizes: Talks words, not sentences 3 is a disorder characterized by excessive
Vocalizes: Sounds (groans/grunts), not 2 worry and distress but has a normal
words perception of reality (Davidson’s).
No vocalization 1  Insight is intact (েস েয মানিসকভােব
Motor response (M) aসুs েসটা েস বুঝেত পারেব। েরাগী
Obeys commands 6 িনেজi ডাkােরর কােছ আসেত পাের। )
Localizes to pain, e.g. brings hand up 5  Person can differentiate between
beyond chin to supraorbital pain fantasy and reality
Flexion withdrawal to pain: No 4  Appearance is within normal limit
localization to supraorbital pain but
flexes elbow to nail bed pressure # Psychosis again can be classified into two
Abnormal flexion to pain 3 groups—
Extension to pain: Extends elbow to nail 2 1. Mood disorders
bed pressure  Depressive disorder
No response 1  Mania & bipolar disorder
Total score (E+V+M) 2. Thought disorders
Maximum 15  Schizophrenia
Minimum 3  Delusional disorders

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 Psychiatry @ a glance

# Neurosis can be classified into three groups— It has two components—

1. Anxiety disorders 1. Psychic component
2. Somatoform disorders 2. Somatic component
3. Stress related disorders
Thought:
There are other psychiatric disorders besides Thought may be defined as goal directed flow of
these two major groups‐ idea from brain initiated by tasks culmination
1. Substance misuse disorder towards the reality oriented conclusion.
2. Organic disorder
3. Personality disorder Thought process has two components—
4. Eating disorder etc. 1. Form of thought: How the person is
associating his/her thoughts.
Classification of psychiatric disorders: 2. Content of thought: Actually what the
(Davidson’s) person is thinking.
1. Stress‐related disorders
• Acute stress disorder Affect:
• Adjustment disorder Current emotional responsiveness is called affect.
• Post‐traumatic stress disorder It is understood by facial expression, speech and
2. Anxiety disorders gesture.
• Generalised anxiety
• Phobic anxiety Stages of affect—
• Panic disorder Normal
• Obsessive‐compulsive disorder Constricted
3. Affective (mood) disorders Blunted
• Depressive disorder
Flattened
• Mania and bipolar disorder
4. Schizophrenia and delusional disorders
5. Substance misuse disorders # Affect is flattened, when there is—
• Alcohol  Face is expressionless
• Drugs  Speech is mute
6. Organic disorders  No gestural movement
• Acute, e.g. delirium
• Chronic, e.g. dementia # Affect is blunted, when there is—
7. Disorders of adult personality and  Little facial expression
behaviour  Scanty speech
• Personality disorder  Little gestural movement
• Factitious disorder
8. Eating disorders # Affect is constricted, when it is more than
• Anorexia nervosa blunted but less than normal.
• Bulimia nervosa
9. Somatoform disorders Mood:
• Somatisation disorder Sustained emotional state of individual
• Dissociative (conversion) disorder subjectively felt by him/her and objectively seen
• Pain disorder by others is called mood.
• Hypochondriasis
• Body dysmorphic disorder It has two components:
• Somatoform autonomic dysfunction 1. Subjectivity
10. Neurasthenia 2. Objectivity
11. Puerperal mental disorders Mood
Depression Elation
Emotion:
Inner complex feeling of individual is called
emotion.
Sadness Euthymic mood Cheerfulness

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 Psychiatry @ a glance
Delusion:
It may be defined as abnormal belief, based on
inadequate ground, cannot be erased by rational
argument and the belief is such that, it is not
shared by the same socioeconomic and religious
groups.
Delusion may be of several types—
1. Persecutory delusion: আমার kিত করেব e
ধরেণর িব াস।
e.g. belief of being harmed, being killed,
being poisoned, being harassed, being
followed by others.
In case of delusion of persecution,
delusion related reactionary behavior has
to be detected from the care giver.
It is common in schizophrenia.
2. Delusion of reference: Patient believes
that, people are talking about him (দূের
aনয্ েকu িকছু বলেল (যা েস নেছ না) বা
েকান ভ ী করেল মেন করেব তার িব েd িকছু
বলেছ।) It is common in schizophrenia.
3. Delusion of grandeur: Grandeur
regarding identity, wealth, power etc.
(িনেজেক aেনক বড়, kমতাবান মেন করেব।
েযমন-আিম েনেপািলয়ন, আিম পুেরা িবে র
শাসক।) It is common in mania.
Opposite— delusion of poverty
4. Delusion of guilt & worthlessness: িনেজর
aতীেতর েকান েছাট ভু েলর জনয্ িনেজেক aেনক
বড় aপরাধী মেন করেব। িনেজেক মূলয্হীন মেন
করেব।
It is common in MDD and schizophrenia.
5. Delusion of jealousy/infidelity: Patient
has a false believe that his/her spouse has
an extra‐marital affair. It sometimes leads
to extreme violence. It is more common in
male.
Reactionary behavior— checking mobile
phone, physical assault etc.
6. Delusion of hypochondriasis/ delusion
of disease conviction: িনেজেক বড় েকান
েরােগর েরাগী মেন করেব যিদo েস সmূণর্ সুs,
েযমন- eiডস, কয্াnার।
7. Nihilistic delusion: Patient believes that,
some of his/her internal organ is absent
or dead. e.g. I have no heart. It is common
in MDD.
8. Erotic delusion: Abnormal belief that
some person of higher socioeconomic
class is in love with the patient. It is more
common in female and seen in
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schizophrenia. েযমন- িবল েগটস eর েছেল
আমার েpেম পেড়েছ।
9. Delusion regarding possession of
thought: False belief about thought
insertion, withdrawal or broadcasting. It
is common in schizophrenia. েযমন- oরা
(বাiেরর েকান শিk) আমার মেধয্ িচnা ঢু িকেয়
িদেc, আমার িচnা েলা চু ির কের িনেয় যােc;
মানুষ আমার সব িচnা েজেন যােc।
10. Delusion of control: Belief about being
controlled by some outer power. It is
common in schizophrenia. েযমন- আিম েতা
করেত চাi না, oরা আমােক িদেয় করােc।
11. Bizarre delusion: Absurd thinking that is
not possible. (সমােজর েকান িকছু র সােথi িমেল
না eরকম িচnা।) েযমন- আমার মাথায় eকটা
antena ঢু িকেয় েদয়া হেয়েছ েযখােন ম ল gহ
েথেক signal আসেছ।
Perception:
It is the process of becoming aware what is
entering through the sense organs.
Major perceptual disorders are—
1. Hallucination
2. Illusion
Hallucination:
Misperception of presence of external stimuli that
is exact quality to the real stimuli is called
hallucination.
Or, Misperception without the presence of
external stimulus with the same intensity and
quality to that of the true stimuli is called
hallucination.
Or, Hallucinations are sensory perception, which
occur in the absence of external stimuli.
(Davidson)
It is of several types—
1. Auditory hallucination
 First person: Hearing own thought,
spoken out loud
 Second person: Hearing someone else
is telling something (bad) about
him/her
 Third person: Hearing two or more
persons are discussing among
themselves about him/her
 Running commentary: The patient
hears running commentary regarding
his/her activities
5
 Psychiatry @ a glance

2. Visual hallucination  Alogia: Poverty of speech (কথা বেল না,

3. Olfactory hallucination বলেলo খুব কম)
4. Gustatory hallucination  Catatonia: Patient is mute, immobile
5. Tactile hallucination and unresponsive but appears to be
 Superficial fully conscious. It is special type of
 Deep (sexual) negative symptom, presenting as—
 Stupor
Question asked to the patient:  Rigidity
 আপিন যখন সmূণর্ eকা থােকন, তখন িক েকান  Negativism
কnsর নেত পান?  Waxy flexibility
Circumstantial evidences:  Odd posture
 Self smile  Echolalia: Repeats what is said
 Self uttering  Echoprexia: Repeats what is done
 Catatonic excitement: Outburst of
SCHIZOPHRENIA excitement followed by
depression and stupor
3. Cognitive symptoms
Schizophrenia is a psychosis characterized by
 Lack of attention
delusions, hallucinations and lack of insight.
 Forgetfulness
(Davidson’s)
 Poor executive functions
Causes:
DSM‐IV diagnostic criteria of schizophrenia:
1. Genetic
DSM = Diagnostic and Statistical Manual
2. Dopamine hypothesis: Due to ↑ dopamine.
1. Grossly disorganized behavior
3. Developmental abnormality: During
2. Disorganized speech
neurodevelopment, any virus/birth
3. Delusion
injury> enlargement of ventricles and
4. Hallucination
reduction of neurons> cortical shrinkage.
5. Negative symptoms or catatonia
4. Environmental: Precipitating cause
Diagnosis:
Symptoms:
 Any 2 of above symptoms for ≥6 months
1. Positive symptoms
is diagnostic for schizophrenia.
 Grossly disorganized behavior
 But if anyone has bizarre delusion or
 Combativeness hallucination in the form of running
 Assaultiveness commentary or third person auditory
 Destructiveness hallucination for ≥6 months, one symptom
 Verbally abusiveness is enough for diagnosis.
 Nakedness in public
 Outgoing Some conditions for schizophrenia:
 Biting  The symptoms should persist for ≥6
 Talkativeness months.
 Delusions  There should be hampering of familial,
 Hallucinations social and professional life of the patient.
 Disorganized speech  The symptoms should not be due to
2. Negative symptoms (6‘a’) substance abuse or general medical
 Apathy (েকান িকছু র pিত আgহ েনi) conditions, e.g. thyrotoxicosis, heart
 Amotivation: Lack of drive and failure.
initiative (িনজ েথেক েকান কাজ কের না)
 Aloofness: Social withdrawal/ If symptoms persists for <6 months—
isolation (eকা eকা থাকেত পছn কের)  Acute psychotic syndrome: Short period
 Anhedonia: Loss of feeling of pleasure  Schizophreniform disorder: >1 month but
(েকান িকছু েতi আনn পায় না) <6 months
 Flattening of affect (aিভবয্িkহীন)  Brief psychotic disorder: 1‐7 days

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 Psychiatry @ a glance

 Brief reactive psychosis (there is an  Schizophrenia with suicidal thoughts/

underlying cause like failure in intension/ attempt
examination or love, spontaneous reversal  Psychological and social therapy:
within 7 days)  Behavioral modification
 Occupational therapy
Schneider’s first‐rank symptoms of acute  Rehabilitation
schizophrenia:
 A = Auditory hallucinations‐second or Prognosis:
third person Rule of third/Turray—
 B = Broadcasting, insertion/withdrawal of  One third: Full remission
thoughts  One third: No change of baseline
 C = Controlled feelings, impulses or acts symptoms
('passivity' experiences/phenomena)  One third: Gradual deterioration despite
 D = Delusional perception (a particular treatment
experience is bizarrely interpreted)
Classification of antipsychotic drugs:
Subtypes of schizophrenia:
1. Paranoid (35‐40%) Group Example
2. Disorganized (10%) Phenothiazines Chlorpromazine
3. Catatonic (10%) Fluphenazine
4. Undifferentiated (20%) Trifluoperazine
5. Residual (20%) Butyrophenones Haloperidol
Thioxanthenes Flupentixol
Differential diagnoses of schizophrenia: Diphenylbutylpiperidines Pimozide
1. Schizoaffective disorder: Patient has Substituted benzamides Sulpiride
symptoms of both schizophrenia and Dibenzodiazepines Clozapine
bipolar mood disorder. Symptoms persist Benzisoxazole Risperidone
for > 1 month but < 6 months. Thienobenzodiazepines Olanzepine
2. Schizophreniform disorder Dibenzothiazepines Quetiapine
3. Delusional disorder
4. Organic psychosis (dementia) Side effects of typical antipsychotic drugs:
5. Psychosis due to general medical 1. Weight gain due to increased appetite
conditions (GMC) 2. Effects due to dopamine blockade:
6. Substance induced psychosis  Parkinsonism
 Akathisia (motor restlessness)
Treatment:  Acute dystonia
 Pharmacotherapy: By Antipsychotics  Tardive dyskinesia
1. Conventional/ typical antipsychotics:  Gynaecomastia
 Haloperidol  Galactorrhoea
 Chlorpromazine 3. Effects due to cholinergic blockade:
 Fluphenazine  Dry mouth
 Flupentixol  Blurred vision
 Trifluoperazine  Constipation
2. Atypical antipsychotics:  Urinary retention
 Risperidone  Impotence
 Olanzapine 4. Effects due to ⍺‐receptor blockade:
 Clozapine  Postural hypotension
 Quetiapine  Ejaculatory failure
 Physical therapy: Electro‐convulsive therapy 5. Hypersensitivity reactions
(ECT): Indicated for—  Cholestatic jaundice
 Catatonic schizophrenia  Photosensitive dermatitis
 Medication resistant schizophrenia  Blood dyscrasias
 Severe disorganized schizophrenia

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 Psychiatry @ a glance

MOOD DISORDERS 8. High intention to engage in pleasurable

activities, the ultimate fate of which is
grave—
Classification:  Levish expenditure
Mood disorders can be classified as—  Sexual indiscretion
1. Unipolar mood disorder: Depressive (exhibitionism)
disorders— Diagnosis:
 Major depressive disorder (MDD) Criterion no. 1 + any 3 or more of the rest of the
 Dysthymic disorder: Depression >2 criteria is diagnostic for mania.
years
 Depressive disorder NOS (not D/D of mania:
otherwise specified)  Schizoaffective disorder
2. Bipolar mood disorder:  Attention deficit hyperactivity
 Bipolar I: One or more manic disorder (ADHD)
episodes, usually accompanied by  Substance misuse
MDD episodes  Hyperthyroidism
 Bipolar II: One or more MDD episodes  Head injury/brain tumor
with at least one hypomanic episode.  Epilepsy
 Cyclothymic: At least 2 years of
numerous episodes of hypomanic & Treatment:
depressive symptoms.
 Pharmacotherapy:
 Bipolar disorder NOS: Features that
1. Mood stabilizer: to prevent recurrence
do not meet criteria of other bipolar
 Lithium carbonate (Li2CO3)
mood disorders.
 Valproic acid/ Sodium valproate
3. Other mood disorders:
 Carbamazepine
 Mood disorder due to GMC, e.g.
 Lamotrizine
hypothyroidism, post‐MI depression,
2. Antipsychotics
post‐stroke depression
 Haloperidol
 Substance induced mood disorder
 Quetiapine
 Mood disorder NOS
 Risperidone
3. Hypnotics
Mania (Bipolar I):  Flurazepam
Mania is the severe form of elevated mood.  Nitrazepam
(Davidson’s)  Clonazepam
 It is a bipolar mood disorder  Physiotherapy:
 It is episodic  Electro‐convulsive therapy (ECT)
 It is self limiting
Major Depressive Disorder (MDD):
Diagnostic criteria of mania:
1. Mood: Elated mood for most of the time of
Cause:
day (>12 hours/day) and most of the days
1. Endogenous:
of week (>4 days/week) for at least 2
 Chemical imbalance:  serotonin
weeks.
and norepinephrine
2. Delusion of grandeur/ inflated self esteem
2. Reactive:
3. Decreased need for sleep (not insomnia/
 Loss of love object
sleep disorder)
 Helplessness
4. More talkative than normal, pressure of
speech
The negative cognitive triad of depression:
5. Flight of ideas (but there has some logical
 Negative view of self, e.g. ‘I am no good’
connections between sentences)
 Negative view of current life experiences,
6. Distractibility: Attention to irrelevant
e.g. ‘The world is an awful place’
external stimuli
 Negative view of the future, e.g. ‘The
7. Increased goal directed activity
future is hopeless’

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 Psychiatry @ a glance

Diagnostic criteria of MDD:  Fluoxetine

 Major:  Sertraline
1. Mood: Depressed mood for most of the  Mirtazepine etc.
time of day (>12 hours/day) and most of  Psychotherapy:
the days of week (>4 days/week) for at  Cognitive behavior therapy (CBT)
least 1 week.  Insight oriented psychotherapy
2. Markedly decreased or absence of interest  Interpersonal therapy
or pleasure in all or almost all activities  Marital therapy
(মেন শািn নাi)  Physiotherapy:
 Others:  Electro‐convulsive therapy (ECT)
1. Significant weight loss/gain: >5% within 1
month Classification of antidepressant drugs:
2. Insomnia/hypersomnia; insomnia 1. Tricyclic antidepressants (TCA)
characterized by‐  Imipramine
 Delay in initiating sleep  Desipramine
 Early morning awakening  Clomipramine
3. Psychomotor retardation/agitation  Amitriptyline
4. Reduced energy/fatigue (িকছু করেত iেc  Nortriptyline
কের না) 2. Tetracyclic antidepressants
5. Delusion of guilt and worthlessness  Maprotiline
6. Decreased attention and concentration 3. Selective serotonin reuptake inhibitors
7. Repeated suicidal thoughts/ plans/ (SSRI)
attempts  Fluoxetine
8. Recurrent thought about death (e জীবন  Paroxetine
আর বেয় েবড়ােনা যােc না)  Sertraline
 Citalopram
Diagnosis:  Fluvoxamine
Any 1 or both of major criteria + any 4 or more of  Escitalopram
other criteria is diagnostic for major depressive 4. Nonselective serotonin‐noradrenaline
disorder. reuptake inhibitors
 Venlafaxine
D/D of MDD: 5. Selective noradrenaline reuptake
 Dysthymia inhibitors (SNRI)
 Bipolar mood disorder  Duloxetine
 Catatonic schizophrenia 6. Atypical antedepressants
 Dementia  Mirtazepine
 Hypothyroidism  Bupropion
 Trazodone
Dangers/complications of MDD:  Nefazodone
 Interruption in family & social life 7. MAO inhibitors
 Loss of job & economic problem  Phenalzine
 Sexual dysfunction  Pergylline
 Marital break‐up  Chlorgylline
 Increased incidence of general medical  Selegiline
conditions
 Drug addiction Side effects of TCAs:
 Suicide 1. Anticholinergic effects:
 Dry mouth
Treatment:  Paradoxical excessive sweating
 Pharmacotherapy: By Antidepressants  Constipation
 Imipramine  Urinary retention
 Clomipramine  Mydriasis
 Amitriptylne  Blurred vision

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 Psychiatry @ a glance

2. Postural hypotension  Abdominal distress (called, butterfly

3. Drowsiness, sedation distress)
4. Weight gain  Frequent desire to pass urine
5. Cardiotoxicity (palpitation)  Chest pain
6. Sexual dysfunction:  Breathlessness
 Loss of libido  Headache
 Erectile dysfunction  Dry mouth
 Ejaculatory failure  Parasthesia in lips & fingers
 Anorgasmia  Physical signs
 Face is strained
Side effects of SSRIs:  Brow is furrowed
1. Jitteriness  Tense posture
2. Sexual dysfunction  Pale skin
3. GIT upset: Nausea, vomiting, diarrhea,  Readiness to tears
anorexia, flatulence, dyspepsia
4. CNS toxicity: Anxiety, somnolence, Phobic Panic Generalised
nightmares, yawning, seizures, akathisia, anxiety disorder anxiety
dystonia, tremor, cogwheel rigidity disorder disorder
Occurrence Situational Paroxysmal Persistent
of anxiety
ANXIETY DISORDERS Associated Avoidance Escape Agitation
behaviour
Associated Fear of Fear of Worry
Anxiety Disorders: cognitions situation symptoms
Anxiety disorders can be classified into 4 Somatic On Episodic Persistent
groups— symptoms exposure
1. Generalized anxiety disorder (GAD)
2. Panic disorder Management:
3. Phobic disorder  Pharmacotherapy:
4. Obsessive‐compulsive disorder (OCD) 1. Anxiolytics (BDZs):
Others:  Diazepam
5. Agoraphobia
 Alprazolam
6. Specific phobia
 Lorazepam
7. Social phobia
 Flurazepam
8. Post traumatic stress disorder
 Temazepam
9. Anxiety disorder due to GMC
10. Acute stress disorder
 Oxazepam
11. Anxiety disorder NOS
 Nitrazepam etc.
2. Antidepressants:
Clinical features:  Amitryptyline
 Psychological  Fluoxetine
 Apprehension
 Imipramne etc.
3. β‐Blockers
 Irritability, restlessness
 Worry
 Propranolol
 Fear of impending disaster  Atenolol
 Poor concentration 4. ⍺‐ Receptor blockers
 Depersonalisation  Clonidine
5. Anticonvulsant
 Somatic
 Palpitations
 Tiagabine
6. Antihistamine
 Fatigue
 Tremor  Hydroxyzine
 Dizziness, insomnia  Phychological management:
 Sweating 1. Counseling: Explanation & reassurance
 Diarrhea, nausea 2. Cognitive behavior therapy (CBT)

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 Psychiatry @ a glance

D/D of anxiety disorder: Compulsion:

1. Normal response to threat Repeated senseless act in reaction to the
2. Adjustment disorder obsessive thoughts is called compulsion.
3. Organic (medical) cause Or, Repeated behaviors or mental acts that
 Hyperthyroidism people feel they must perform to prevent or
 Paroxysmal arrhythmias reduce anxiety.
 Phaeochromocytoma
 Alcohol and benzodiazepine Etiology of OCD:
withdrawal 1. Biological
 Hypoglycaemia  Imbalance of serotonin within the
 Temporal lobe epilepsy nervous system
2. Genetic
Post‐traumatic Stress Disorder 3. Obsessive personality
(PTSD): Treatment:
This is a protracted response to a stressful event
 Pharmacotherapy:
of an exceptionally threatening or catastrophic
1. Antidepressants
nature.
 Clomipramine
Examples include natural disasters, terrorist
 Escitalopram
activity, serious accidents and witnessing violent
2. Anxiolytics (benzodiazepines)
deaths. PTSD may also occur after distressing
medical treatments.
 Diazepam
There is usually a delay ranging from a few days  Flurazepam
to several months between the traumatic event  Nitrazepam
and the onset of symptoms.  Alprazolam
 Midazolam
Symptoms:  Lorazepam
Typical symptoms are‐ 3. β‐Blockers (if there is palpitation)
 Recurrent intrusive memories  Propranolol
(flashbacks) of the trauma  Timolol
 Sleep disturbance, especially nightmares  Psychotherapy:
(usually of the traumatic event) from  Cognitive behavior therapy (CBT)
which the patient awakes in a state of  Marital counseling
anxiety  Sex counseling
 Symptoms of autonomic arousal  Family counseling
 Emotional blunting
 Avoidance of situations which evoke Prognosis:
memories of the trauma Relapse is common
Remission  Relapse
Management:
 Pharmacotherapy: antidepressants MEDICALLY UNEXPLAINED
 Amitriptyline
 Imipramine SYMPTOMS (MUS)
 Phenalzine etc.
 Psychotherapy: Patients commonly present to doctors with
 Cognitive behavior therapy (CBT) somatic symptoms. These may be clearly
associated with a medical condition. When they
Obsessive Compulsive Disorder: are disproportionate to, or occur in the absence of
বাংলা- িচবায়ু/ িচবাi
a physical disease, they are termed medically
unexplained symptoms (MUS).
Obsession: These occur in a quarter to a half of patients
Repeated intrusive (against own will) thought, attending general medical clinics. Almost any
image or impulse that enter the mind in spite of symptom can be medically unexplained. Common
active resistance with anxiety. examples include:

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 Psychiatry @ a glance

 Pain (including back, chest, abdominal General management principles for MUS:
and headache)  Take a full, sympathetic history
 Fatigue  Exclude disease but avoid unnecessary
 Dizziness investigation or referral
 Fits, 'funny turns' and feelings of  Seek specific treatable psychiatric
weakness syndromes
 Demonstrate to patients that you believe
Differential diagnoses: their complaints
 Anxiety disorders  Establish a collaborative relationship
 Depressive disorders  Give the patient a positive explanation
 Somatoform disorders including but not over‐emphasising
 According to the presentation psychological factors
 Encourage a return to normal functioning
Functional somatic syndromes:
SOMATOFORM DISORDERS (SFD)
Gastroenterology Irritable bowel syndrome,
non‐ulcer dyspepsia
These are a broad group of illness which have
Gynaecology Premenstrual syndrome,
bodily signs & symptoms as a major component
chronic pelvic pain
without any identifiable medical condition
Rheumatology Fibromyalgia
causing physical complaints.
Cardiology Atypical or non‐cardiac These causes clinically significant distress or
chest pain impairment in social, occupational or other
Respiratory Hyperventilation syndrome important areas of functioning.
medicine Psychosocial stress or conflicts are judged to be
Infectious Chronic (post‐viral) fatigue responsible for the initiation, exacerbation &
diseases syndrome maintenance of the disturbance.
Neurology Tension headache,
non‐epileptic attacks Classification of SFD:
Dentistry Temporomandibular joint 1. Conversion/dissociative disorder
dysfunction, atypical facial (Hysteria)
pain 2. Somatization disorder
ENT Globus syndrome 3. Body dysmorphic disorder
Allergy Multiple chemical 4. Hypochondriasis
sensitivity 5. Somatoform pain disorder
6. Somatoform autonomic dysfunction
Psychiatric diagnoses for MUS: 7. Chronic fatigue syndrome
1. Hypochondriasis: predominant worry 8. Undifferentiated SFD
about disease 9. Somatoform disorder NOS
2. Somatisation: predominant concern
about symptoms Conversion Disorder:
a. Somatic presentation of It is characterized by a loss or distortion of
depression and anxiety neurological function not fully explained by
b. Simple somatoform disorders: organic disease. [Davidson’s]
small number of symptoms
c. Somatisation disorder Synonyms:
(Briquet's syndrome): chronic  Hysteria
multiple symptoms  Hysteric conversion disorder
3. Conversion disorder: Loss of function  Hysteric conversion reaction (HCR)
4. Body dysmorphic disorder: Dislike of
 Dissociative disorder
body parts
 Pseudoseizure/ hysteric convulsion

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 Psychiatry @ a glance

Characteristics of conversion disorder: Froath in Yes No

1. Present with multiple somatic/ mouth
neurological symptoms that cannot be Timing At any time Suitable time,
evaluated by any physical or laboratory even during never during
test deep sleep sleep
Post‐seizure Yes No
2. Some sorts of psychosocial stress and
amnesia
conflict should be present
3. These symptoms should not be produced
Management of conversion disorder:
intentionally (if produced intentionally, it
1. Explanation and reassurance
is called malingering)
2. Psychological:
Diagnostic criteria of conversion disorder:
 Emotional abreaction or catharsis
One or more symptoms or deficits affecting  Rapport/transference
voluntary motor or sensory function that suggest  Cognitive
a neurological or other general medical condition 3. Reduction of reinforce (which  any kind
of desired behavior)
 With motor symptoms or deficits
4. Counseling of caregivers
 With sensory symptoms or deficits
5. Usually no role of drug, but coexisting
 With seizure or convulsions
depression should be treated with
 With mixed presentation
antidepressants
Etiology:
 Psychosocial stress Somatization disorder:
 Conflict: Desirable/not desirable Patient presents with a history of many physical
complaints beginning before age 30 that occur
Clinical features: over a period of several years and result in
1. Motor: treatment being sought or significant impairment
 Hemiplegia/hemiparesis in social, occupational, or other important areas
 Gait disturbance of functioning.
 Aphonia Patients may undergo a multitude of negative
 Pseudoseizure investigations and unhelpful operations,
2. Sensory: particularly hysterectomy and cholecystectomy.
 Parasthesia
Diagnostic criteria:
 Blindness
 Pain related to at least 4 different sites or
 Deafness
functions, e.g. head, abdomen, back, joints,
 Autonomic hyperventilation
extremities, chest, rectum, during
 Cardiac pain
menstruation, during coitus, during
micturition etc.
Difference between true seizure &
 At least gastrointestinal symptoms other
pseudoseizure:
than pain, e.g. nausea, vomiting, bloating,
dyspepsia etc.
Trait True seizure Pseudoseizure
 At least one sexual or reproductive
Clinical pattern Generalized No specific
symptom other than pain, e.g. erectile or
tonic clonic pattern
seizure (GTCS) body rolling ejaculatory dysfunction, irregular menses
pelvic thrusting etc.
Duration 5‐10 min Hours  At least one neurological symptom not
Sex Both sexes More in female limited to pain, e.g. localized weakness,
Pervasiveness Yes (anywhere No (in home & in loss of sensation, deafness, seizure etc.
& in any front of care‐
situation) giver) Management:
Tongue bite Yes No  Explanation & reassurance
Incontinence Yes No  Psychotherapy
Trauma Yes No  Anxiolytic: Midazolam
Eyeball Fixed Rolling  Antidepressant: Amitriptyline etc.

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 Psychiatry @ a glance

ORGANIC DISORDERS  Calcium, magnesium

 Liver function tests
 Thyroid function tests
Classification: 2. CNS investigations:
 Acute: Delirium (acute confusional state)  Head imaging (CT and/or MRI)
 Chronic: Dementia  Lumbar puncture
 EEG
Delirium: 3. Others:
This term is now replaced by acute confusional  Arterial blood gases
state.  ECG
It is a disturbance of arousal that accompanies  Blood cultures
the global impairment of mental function in the  Chest X‐ray
form of drowsiness with disorientation,  Urine culture
perceptual disturbances and muddled thinking.
Management:
Causes:  Identify the cause and correcting it if
1. Infective: possible
 Chest infection  Confused patients should be nursed in a
 Urinary infection well‐lit room
 Septicaemia  During the period of confusion, sedatives
 Viral illness are best avoided
 Meningitis  Occasionally drugs such as haloperidol (1‐
 Encephalitis 10 mg 8 hourly) may be required
2. Metabolic/endocrine:
 Hypoxia (respiratory failure)
Dementia
 Cardiac failure
It is defined as a progressive impairment of
 Acute (internal) haemorrhage
cognitive function occurring in clear
 Hyper‐/hypoglycaemia
consciousness, i.e. in absence of delirium.
 Hyper‐/hypocalcaemia
It is one of the cognitive disorders where
 Hyponatraemia
impairment of memory occurs without
 Liver failure, renal failure
impairment of consciousness.
3. Vascular:
 Acute cerebral haemorrhage/
Causes:
infarction
1. Degenerative diseases (Irreversible):
 Subarachnoid haemorrhage
 Alzheimer’s disease
4. Toxic:
 Parkisons’s disease
 Alcohol intoxication/withdrawal
 Huntington’s disease
 Drugs (therapeutic/illicit)
 Mad cow disease
5. Neoplastic:
 Lewy body disease
 Secondary deposits
 Wilson’s disease
6. Trauma:
 Pick’s disease
 Head injury (cerebral contusions)
2. Metabolic disorders:
Subdural haematoma
 Hypothyroidism
7. Others:
 Electrolyte imbalance
 Post‐ictal state
 Uremia
 Perioperative
3. Neoplastic:
 Acute decompensation of
 Primary cerebral tumor
dementia
 Secondary deposits
 Paraneoplastic syndrome
Investigations:
4. Traumatic:
1. Blood tests:
 Chronic subdural hematoma
 Full blood count, ESR
5. Demyelinating disease:
 Urea and electrolytes
 Multiple sclerosis
 Glucose

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 Psychiatry @ a glance
6. Infective:
 Prion disease
 AIDS
 Neurosyphilis
7. Toxic/nutritional:
 Thiamine deficiency
 Vitamin B12 & folate deficiency
 Alcohol
 Heavy metal poisoning
 Radiation
 Carbon monoxide poisoning
Clinical features:
1. Cognitive disturbances:
 Gradual impairment of memory:
Impaired ability to learn new
information or to recall previously
learned information. Defects in
short term memories are usually
obvious.
 Aphasia
 Apraxia: Inability to perform
certain motor skills despite intact
motor system
 Agnosia: Inability to recognize
faces, objects, sounds despite
intact sensory system
 Disturbance in executive
functions, e.g. planning,
organizing, sequencing
 Disorientation
2. Behavioral disturbances:
 Change in personality
 Apathy
 Irritability
 Emotional lability
 Disinhibition
 Wandering
 Agitation
 Excessive orderliness
 Sudden outburst of anger
 Vacant facial expression
3. Persecutory delusion
4. Visual & auditory hallucination
5. Mood: Anxious, depressed
6. Impaired judgement
Initial investigation of dementia:
1. Imaging of head: CT, MRI
2. Blood tests:
 CBC, ESR
 Blood urea & glucose
 Serum electrolytes & calcium
 Vitamin B12 & folate assay
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 VDRL
 ANA & anti‐dsDNA
 Liver function tests
 Thyroid function tests
3. Chest X‐ray
4. EEG
5. Lumbar puncture
6. HIV serology
Management of dementia:
 No specific treatment exists
 Identify & treat correctable causes
 Preventive measures
 Supportive medical care, nursing care
 For disruptive behavior/ delusion,
antipsychotics, preferably risperidone
 Anticholinesterases, e.g. donepezil,
rivastigmine, galantamine may improve
cognitive function
SUBSTANCE RELATED DISORDER
DSM‐IV criteria of substance abuse:
1. Recurrent substance use resulting in a
failure to fulfill major role obligations at work
2. Recurrent substance use in situations in
which it is physically hazardous
3. Recurrent substance related legal
problems
4. Continued substance use despite having
persistent or recurrent social or interpersonal
problems caused by the effects of the substance
Common drugs of misuse:
 Alcohol
 Opioids: Heroin, morphine, methadone,
codeine phosphate (phensidil), pathedine
 Psychostimulants: Amphitamine (yaba),
ephedrine, cocaine, pseudoephedrine,
caffeine
 Hallucinogens: Cannabis, marijuana, LSD,
ecstasy
 Sedative‐hypnotics
 Nicotine
 Anabolic steroids
 Inhalants
Alcohol Abuse:
Criteria of alcohol dependence:
 Narrowing of the drinking repertoire
 Priority of drinking over other activities
(salience)
15
 Psychiatry @ a glance
 Tolerance of effects of alcohol
 Repeated withdrawal symptoms
 Relief of withdrawal symptoms by further
drinking
 Subjective compulsion to drink
 Reinstatement of drinking behaviour
after abstinence
Delirium tremens:
It is an acute confusional state secondary to
alcohol withdrawal. It is a medical emergency.
Clinical features include—
 Clouding of consciousness
 Disorientation
 Amnesia for recent events
 Marked psychomotor agitation
 Visual, auditory & tactile hallucination
(characteristically diminution of people
or animals— “Lilliputian hallucination”)
 Marked fluctuation in severity hour by
hour, usually worse at night
 In severe cases, heavy sweating, fear
paranoid delusion, agitation, raised
temperature, cardiovascular collapse etc.
Treatment of delirium tremens:
1. Benzodiazepines:
 Start with 30 mg diazepam qds by
mouth or I/V
 Taper the dose to 10 mg bd within
5 day
2. Others: Phenytoin, carbamazepine (oral)
3. Antipsychotics: Haloperidol
 5‐10 mg tds orally or parenterally
4. Supplementary vitamins:
 Parenteral vitamin B complex, if
evidence of malnutrition
 Others: Thiamine 100 mg tds for 4
weeks
Opioid Withdrawal:
Clinical features:
 Lacrimation  Rhinorrhea
 Mydriasis  Nausea
 Vomiting  Diarrhea
 Abdominal cramp  Piloerection
 Sweating  Muscle ache
 Yawning  Fever
 Shivering  Insomnia
 Tachycardia  Hypertension
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Complications of I/V opioid use:
 Hepatitis B & C
 Abscess & other bacterial infections
 Endocarditis & other infections of heart
 Embolism & block of blood vessels of vital
organs by emboli
 Tuberculosis
Opioid withdrawal detoxification:
1. ⍺‐Blockers:
 Clonidine 0.1 mg orally 4‐6 hourly
2. Hypnotics:
 Midazolam 15 mg I/V slowly bd,
or
 Flurazepam 30‐60 mg at bed time
3. Antipsychotics:
 Inj. Clopentixol 50‐100 mg stat
4. Analgesics:
 Tramadol HCl 50 mg I/V tds
5. Anti‐histamine:
 Hydroxyzine 25 mg by mouth
every 4 hourly for anxiety &
restlessness
6. Vitamins:
 Inj. Multivitamins
7. Antibiotics
8. Maintain fluid and electrolyte balance
Follow up (maintenance):
1. Clonidine: 1 month
2. Naltrexone: 50 mg once daily for 6
months
ELECTRO‐CONVULSIVE THERAPY
Electro‐convulsive therapy (ECT) is the physical
method for treatment of psychological disorders.
During therapy, there is tonic convulsion followed
by clonic convulsion.
 Tonic convulsion: Sudden tautness of
muscles of the body
 Clonic convulsion: All four kinds of
movements of muscle are present at time
viz. flexion, extension, abduction and
adduction.
ECT causes chemical balance of neurotransmitter
but its effect is transient. So, pharmacotherapy
has also to be given.
16
 Psychiatry @ a glance

Indications:
1. Primary (absolute):
 Major depressive disorder
2. Secondary (relative):
 Catatonic schizophrenia
 Suicidal thought
 Postpartum psychosis
 Mania with restless behavior
 Any severe psychotic illness with
poor response to drugs

Contraindications:
1. Absolute:
 Raised intracranial pressure
2. Relative:
 Recent myocardial infarction
 High fever
 Fracture and dislocation
 Loose motion

Procedure:
 Give general anesthesia by Thiopental
sodium
 Muscle relaxation by Suxamethonium
 Then, a bipolar “lead” is placed on head
(unipolar lead is ideal, but in our country
bipolar lead is used)
 ECT is given by >150 millicoulomb
current for very short period (normal
seizure threshold of brain is 150
millicoulomb)

Side effects:
 Anterograde amnesia
 Injury to mouth, tongue
 Post ECT headache
 Fracture of bone
 Apnea (rare)

References:
1. Lectures of Dr. Mohiuddin Sikder
2. Davidson’s Principles & Practice of Medicine
3. Harrison’s Principles of Internal Medicine

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