PSYCHIATRY QUICK REVISION NOTES

BASICS OF PSYCHIATRY related thalamic and cortical areas)

2. Control/regulation - Frontal lobeQ
COMPONENTS OF MSE (MENTAL
B. Perception -
STATUS EXAMINATION)
Perception involves receiving information and
MSE- The clinical examination in psychiatry is called processing it. Two important disturbances of
as MSE (mental status examination) perception are:
A. Mood and Affect - Both terms 1. Illusions: ‘False perception of a real object’.
reflect ‘emotions’ E.g, A man mistakes a rope for a snake and gets
frightened.Q
• Mood- Sustained (long-term) and internal
emotional state 2. Hallucinations: ‘False perception in the absence of
any object or stimulus’ E.g. A man saw a snake on
• Affect- Short-lived and external expression of the ground when there was nothing there.
internal emotions that can be observedQ
• The terms ‘affect’ and ‘mood’ are used Properties of hallucinations:
interchangeably 1. Occur in the absence of any sensory or perceptual
stimulus.
Abnormalities of affect and mood-
2. Are as vivid (clear or detailed) as true perceptions.
1. Euphoria- Excessive happiness without any reason.
In mania/hypomania 3. Are experienced in the outer objective space. E.g.
A patient with auditory hallucinations reported
2. Dysphoria (dysphoric mood) - Irritability (In that the voices are coming from outside, such as
mania) from the wall or outside the house.
3. Labile mood or emotional lability - Excessive 4. Are not under the wilful control of the patient.
variations in the mood without any apparent reason. The patient can neither start the hallucinations
E.g.- A man starts crying and then starts laughing
nor can he stop them.
the next moment, without any apparent reason. In
mania Pseudohallucinations fulfil the other criteria but are
experienced in the ‘inner and subjective space’. E.g.
4. Affective flattening (flat affect, emotional
A patient with auditory pseudohallucinations reported
blunting, blunt affect): Lack of emotional response.
that the voices are originating from within his mind
In schizophreniaQ
and not from outside.Q
5. Anhedonia-Loss of capacity to experience pleasure
in activities that were previously pleasurable. Can Specific hallucinations:
be seen in depression, and schizophrenia.Q 1. Hypnagogic hallucination- While ‘’going to sleep”. In
Neuroanatomy of emotions narcolepsy.
2. Hypnopompic hallucination - While getting up from
1. Generation- Limbic system ((hippocampus,
sleep. In narcolepsy
amygdala, hypothalamus, cingulate gyrus and
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Cerebellum Quick Revision Notes

3. Reflex hallucinations - Stimulus in one modality b. Loosening of association: Loss of connection

produces hallucinations in another modality. E.g. between components of the same thought.
“Whenever I see a tube light (stimulus- visual
c. Incoherence (Word salad): Complete lack
modality), I start hearing the voice of Deepika
of organization that makes the thought
Padukone” (hallucination- auditory modality). It’s
incomprehensible and impossible to understand.
a morbid variety of synesthesia (syn=combination,
aesthesia=sensations). Seen in cannabis and d. Neologism: Coining of a new word whose
lysergic acid diethyl amide (LSD) intoxication.Q derivation cannot be understood. For example,
a patient used the word “tintintapa” for a pen.
4. Phantob limb hallucinations- Sensations felt after
amputation, in the body part which was removed 3. Disorders of content:Q Delusion is a disorder of
during amputation. the content of thought. Delusion is:
5. Third person auditory hallucination- The patient a. A false belief
hears atleast ‘two voices’ which discuss or argue
b. Firm, fixed, and unshakeable (continues despite
about the patient in the third person. Referring
evidence against it)
the patient as “He/She/Him/Her”
c. Unexplained by social and cultural background
C. Thought
Types of delusions:
The terms “cognition” and “thought” are often used
interchangeably. The disturbances of “thought” can • Delusion of persecution: The most commonQ
be further subdivided into: type of delusion. The patient believes that he is
being harmed. For example, “My family members
1. Disorders of the stream (flow) of thought: The want to kill me and take away my property.”
stream of thought basically refers to the speed
and continuity of thinking. The abnormalities • Delusion of reference: The patient believes
include: that neutral events happening around him are
somehow related to him. For example, “Doctor,
a. Flight of Ideas: Thoughts follow each other the tube light in your room has a camera fitted
rapidly, and the connection between successive which is recording me.”
thoughts appears to be due to chance factors
such as rhyming. For example, a patient said, “I • Delusion of grandeur/grandiosity: The patient
live in Delhi, I like eating jelly, my cat has a big believes that he has some special power/role/
belly.” This is seen in mania. identity. For example, “I am so powerful that I
can push a train with my bare hands.”
b. Perseveration: Repetition of the same response
beyond the point of relevance. For example: • Delusion of love (erotomania, de Clerembault
syndrome, fantasy lover syndrome):Q Patients
Q. What is your name? develop a false belief that someone is in love
Ans: Mahesh Kumar with them. For example, a rickshaw puller who
had never left his town claimed that Katrina
Q. Where do you live?
Kaif is in love with him and was forced to marry
Ans: Mahesh Kumar some other guy by big producers.
Q. How many children do you have? • Delusion of infidelity (morbid jealousy,
pathological jealousy, Othello syndrome): The
Ans: Mahesh Kumar
patient has a false belief that the partner/
2. Disorders of form: The form of thought refers to spouse is having an affair.
the organization of thinking/association between
• Delusion of guilt: The patient develops guilt
thoughts. In disorders of the form of thought or
at a delusional level. The patient may claim
“formal thought disorders,” there is a disturbance
that he is an evil person and has committed
in the organization of thinking. The important
unpardonable sins. Usually seen in patients with
formal thought disorders include:
severe depression.
a. Derailment:Q Loss of connection between
• Nihilistic delusion (delusion of negation, Cotard
successive thoughts.
syndrome): Patients may deny the existence of
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their body, their mind, or the world in general. repeat them back.
For example, a patient with severe depression
– The test begins with a single digit and
claimed that all his internal organs have rotted.
gradually progresses to longer sequences
• Delusion of enormity: The patient believes (e.g. two-digit, three-digit, etc.) until the
that their action will cause a catastrophe. At patient is unable to accurately repeat the
times, patients with the delusion of negation numbers.
also develop delusion of enormity. For example,
– An inability to repeat at least five digits
a patient said, “I cannot urinate because if I
indicates defective attention.
urinate, there will be floods all around the
world. If I sneeze, the world will blow away.” – E.g. If the examiner says 1,4,2,6,9; the
patient should be able to repeat and say
• Delusion of misidentification (misidentification
1,4,2,6,9.
syndrome):Q
– A variation is the digit backward test, where
a. Capgras syndrome (Delusion of doubles):
if the examiner says 1,4,2,6,9; the patient is
The patient believes that a familiar person
supposed to say 9,6,2,4,1, can also be used.
has been replaced by a “similar-looking
stranger.” – Digit repetition test (digit forward test) is
Close Person Got Replaced By A Stranger preferred over digit backward test.

b. Fregoli syndrome:Q The patient believes 2. Concentration - Ability to sustain attention for a
that a familiar person is changing the longer duration.
physical appearance and disguising as a – Tested using Serial Seven Subtraction Test
stranger. And that multiple different in which the patient is asked to serially
appearances can be taken by this person. subtract 7s from 100 (100, 93, 86, 79….)
Familiar person giving goli 3. Memory · Three different types of memory-.
– Immediate memory/Working memory
4. Disorders of Possession:
– For intervals of seconds. Tested using
In disturbances of possession of thought, the patient the digit repetition test or serial seven
may believe that someone is manipulating or interfering subtraction test.
with their thoughts. Alternatively, they may feel that
they have lost control over their thoughts. – Recent memory - For minutes, hours or days.
Tested using 24-hour recall method.
• Thought insertion: “My neighbor is putting
thoughts in my mind.” – Remote memory- For years, tested by asking
for both personal information and historical
• Thought withdrawal: “My neighbor withdrew/ events. E.g.: Which school did you go to?
stole thoughts from my mind.”
When did India win the world cup?
• Thought broadcast: The patient experiences
Clinical relevance- Dementia affects recent memory
that thoughts are escaping his mind, and others
first and remote memory in later stages.
can access them.
4. Judgement- Ability to take the right decision
• Obsessions:Q A thought comes repeatedly into
according to the situation. Three types of
the patient’s mind against his will. judgments are there-
D. Higher mental functions a. Test judgment: Here, a test situation is given,
and the patient is asked to give the appropriate
1. Attention- Ability to attend to a specific stimulus
response in that situation. The commonly asked
without getting distracted.
question is what would the patient do if he sees
– Tested using the Digit Repetition Test (also a “house on fire” and the response is evaluated.
known as the Digit Span Test).
5. Insight: Insight is defined as the ‘awareness of
– During the test, the examiner recites a series the illness’. Insight is rated on a five-point scale:
of numbers, and the patient is required to
– Grade 1: Absent insight (e.g. ‘I don’t have any
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Cerebellum Quick Revision Notes

problem) – Dopamine and serotonin hypothesis

– Grade 2: Some awareness of being sick but ƒ Excessive levels of dopamine & serotonin
denying it at the same time (e.g., At times, cause schizophrenia
I hear some voices, but there is no illness)
• Genetic factors
– Grade 3: Awareness of being sick but
– DiGeorge syndrome (22q11.2 deletion,
attributing the symptoms to external or
velocardiofacial syndrome)
physical factors. (e.g., Yes, I hear voices, and
it is because my neighbours have installed a ƒ 30% develop schizophrenia by the time
hidden speaker to trouble me) they reach adulthood
– Grade 4: Intellectual Insight, awareness of
SYMPTOMS
illness without any accompanying changes in
behaviour. e.g., I know I have schizophrenia, • Positive symptoms (Or psychotic symptoms)
but I don’t want to take any medicines or – Delusions -- M/C is delusion of persecution
treatments.
– Hallucinations -- M/C - auditory hallucinations,
– Grade 5: Emotional Insight, awareness of 2nd M/C - visual hallucinations
illness along with the accompanying changes
in the behaviour. It’s the highest level of – Neurobiology- Dopamine excess in the
insight. e.g. I have schizophrenia, and I want mesolimbic tract (ventral tegmental area
to take regular medications to prevent any to nucleus accumbens) leads to positive
relapses. symptoms.
– Both these positive symptoms respond well to
CLASSIFICATORY SYSTEMS medicationsQ

A. ICD-11 (International Classification of Diseases, – Good prognostic factor

11th edition): Published by WHO • Negative symptoms
B. DSM-5-TR (Diagnostic and statistical manual of – Avolition - Loss of drive for goal-directed
mental disorders, text revision) - Published by activities
American Psychiatric Association
– Anhedonia -Lack of pleasure in previously
pleasurable activities
SCHIZOPHRENIA AND OTHER
– Asociality -Lack of social interaction
PRIMARY PSYCHOTIC DISORDERS
– Affective flattening (Or emotional blunting)
HISTORY - Lack of emotional response
– Neurobiology- Decreased dopamine in the
Epidemiology
mesocortical tract (Ventral tegmental area
• Lifetime prevalence: 1% to the prefrontal cortex) results in negative
• Equally prevalent in men and women; however, symptoms.
the onset of illness is earlier in males and later – Respond poorly to medications
in females
– Poor prognostic factors
• Age of onset- adolescence and young adulthood
(15-24 years) • Disorganization symptoms
– Disorganized behaviour (odd & socially
ETIOLOGY & PATHOGENESIS inappropriate behaviour)

• Neurotransmitter hypothesis – Disorganized speech and thinking (Formal

Thought Disorders)
– Dopamine hypothesis
– Inappropriate affect
ƒ Excessive levels of dopamine cause
schizophrenia • Motor symptoms (Catatonic symptoms/
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symptoms of conation) attempt suicide

Motor symptoms include – M/C cause of premature & unnatural death in
– Stupor- A state of extreme inactivity schizophrenia.
or immobility (akinesis) & minimal Risk factors for suicide in a patient with
responsiveness. schizophrenia-
– Waxy flexibility Q - It is the feeling of plastic
– Presence of a major depressive episode
resistance that the examiner experiences
(similar to what is experienced while – Increased symptoms (esp. command
bending a wax candle) while making a passive hallucinations, delusion of persecution)
movement on the patient. – Early in course of illness, immediately after
– Posturing- Maintenance of a posture for a admission or discharge
long period of time – Young males, comorbid substance abuse,
– Echolalia - Repetition of speech unemployed
– Echopraxia- Repetition of behaviour – At times paradoxical (Fewer negative
symptoms, less affect disturbances)
– Grimacing - Maintenance of odd facial
expressions Duration Criteria
– Ambitendency- Inability to decide the motor • According to DSM-5, for the diagnosis of
movements schizophrenia, the total duration of illness
– Stereotypy - Spontaneous, repetition of odd should be at least six months.
purposeless movements • According to ICD-11, the duration criterion of
– Mannerisms- Spontaneous repetition of ICD-11 is one month and not six months.
semi-purposeful movements, done in an
exaggerated manner.
TREATMENT
– PerseverationQ - Induced movement,
• Antipsychotics are the mainstay of treatment
repeated beyond the point of relevance.
in schizophrenia
It is suggestive of organic brain disorder.
Two special types of perseveration • Duration of treatment. For first episode, at
least one year of treatment needs to be given.
• Suicide and violence For more than one episodes, atleast 5 years of
– 10% of patients with schizophrenia die by treatment is recommended.Q
suicide (DSM-5 figure: 5-6%) • Typical antipsychotics and atypical
– 20%-50% of patients with schizophrenia antipsychotics

Typical (FGA) Atypical (SGA)

Mechanism D2 antagonism D2 and 5HT2 antagonism

Effective against Positive symptoms Positive and Negative symptoms

Extrapyramidal symptoms & More Less

hyperprolactinemia
Metabolic side effects Less More
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Cerebellum Quick Revision Notes

Typical antipsychotics (First generation • Acute akathisia

antipsychotics)- – Commonest side effect of antipsychotics
Classification according to chemical groups- – Characterised by an inner sense of
• Phenothiazines-Chlorpromazine, restlessness along with objective signs of
trifluoperazine, thioridazine, prochlorperazine, restlessness such as fidgeting of legs, pacing
triflupromazine, fluphenazine, perphenazine around, and inability to sit or stand in one
place for a long time
• Thioxanthenes- Thiothixene, flupenthixol
– DOC - PropranololQ
• Butyrophenones- Haloperidol, droperidol,
– Anticholinergics, benzodiazepines can also be
penfluridol
used.
• Miscellaneous- Pimozide, loxapine, molindone
• Tardive dyskinesia
Side effects – The term ‘tardive’ means long-term and
A. Movement disorders (or extrapyramidal side dyskinesia means abnormal movements
effects or EPS)Q – Develops after long-term treatment with
– Caused by the blockade of dopamine antipsychotics
receptors in the nigrostriatal tract (neural – Can present with involuntary movement of
pathway from substantia nigra to striatum) jaw (chewing movements), lips (pouting,
– More common with typical antipsychotics puckering, smacking) or extremities
than atypical antipsychotics – Choreiform (rapid, jerky, nonrepetitive) or
– More common with parenteral administration athetoid movement (slow, sinusoid)
than oral administration – Rabbit syndrome - Rhythmic motions of the
• Drug-induced parkinsonism mouth along a vertical planeQ

– Symptoms: Tremors (3-6 Hz), Rigidity, – Cause- Long term use of antipsychotics and
Bradykinesia accompanying blockade of D2 receptors
results in D2 receptors up-regulation
– Prophylaxis - Anticholinergics (E.g. along with postsynaptic dopamine receptor
trihexyphenidyl, diphenhydramine etc) supersensitivity.Q
– Treatment - Anticholinergics (E.g. – Treatment- Shift to second generation
trihexyphenidyl, diphenhydramine etc), shift antipsychotics, Use of Valbenazine,
to second generation antipsychotics. Tetrabenazine, and Deutetrabenazine.
• Acute dystonia • Neuroleptic malignant syndrome
– Symptoms - Sudden contraction of a muscle – Symptoms - Muscle rigidity, elevated
group resulting in symptoms like torticollis, temperature (greater than 38°C), and
trismus (contraction of jaw muscles), increased CPK (creatine phosphokinase) levels.
deviation of eyeballs (oculogyric crisis due
– Other symptoms- diaphoresis, tremors,
to contraction of extraocular muscles),
confusion, autonomic disturbances, liver
laryngospasm, etc
enzyme elevation and leukocytosis.
– Earliest side effect of antipsychoticsQ
– Pathophysiology- D2 blockade in-
– More common in young males
ƒ Corpus striatum causes muscle rigidity
– Treatment - Parenteral anticholinergics (e.g. that generates heat.
i.m. promethazine)
ƒ Hypothalamus interferes with heat
– Prophylaxis - Anticholinergics (E.g. regulation
trihexyphenidyl, diphenhydramine etc)
ƒ Spinal neurons causes autonomic
disturbances
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ƒ Muscle injury causes an increase in CPK Clozapine

levels
• Treatment-resistant schizophrenia (TRS)-
ƒ Continuing muscle damage can cause
Lack of response to at least two different
myoglobinuria and renal failure. antipsychotics, including at least one second-
– Treatment- Withdraw antipsychotic, generation antipsychotic, given in adequate
adequate hydration, dantrolene is the drug of dosage and for an adequate duration (at least
choice, dopamine agonists like bromocriptine 4-6 weeks)
and amantadine can be used too. • Clozapine is the drug of choice (DOC) in TRS.
– How to restart the antipsychotics? - Keep the • Unique mechanism of action- More affinity for
patient antipsychotic-free for 2 weeks, then D4 than D2, hence causes minimal EPS.
start with second-generation antipsychotics.
• Antipsychotic that causes max weight gain
B. Endocrine side effects
• Clozapine is the only antipsychotic with
• Blockade of dopamine receptors in antisuicide property
the tuberoinfundibular tract causes
hyperprolactinemia (remember dopamine Side effects of clozapine
inhibits prolactin secretion)
• Life-threatening: Agranulocytosis
• Symptoms- Galactorrhoea, menstrual (idiosyncratic), myocarditis (idiosyncratic),
disturbances in females, Sexual dysfunction, seizures (dose-dependent)
low libido in males
• Sedation (most common), sialorrhea
Atypical antipsychotics (Second • Syncope, hypotension, tachycardia, nausea,
generation antipsychotics) vomiting

• Clozapine, olanzapine • Weight gain, anticholinergic side effects

• Risperidone, paliperidone, iloperidone Due to the possibility of agranulocytosis, when a
patient is on clozapine, ANC and TLC monitoring is
• Quetiapine, ziprasidone, aripiprazole
required. The regime of monitoring-
• Sertindole, zotepine, lurasidone
– First 6 months- Once a week
• Asenapine, amisulpride
– Next 6 months- Once in two weeks
• Newer ones - Brexpiprazole, cariprazine,
– After 1 year- Once in four weeks, till
pimavanserin
clozapine is continued
Side effects of atypical antipsychotics • Stop clozapine, if WBC<3000/dl or ANC
• Movement disorders (Extrapyramidal symptoms): <1500/dl
Less likely than typical antipsychotics
Long-acting injectable antipsychotics (Depot
• Endocrine side effects: Less likely than antipsychotics)
typical antipsychotics (except risperidone and
amisulpride, which have a comparatively higher • Used in cases of poor compliance with
incidence)Q antipsychotics

• Metabolic side effects- More common than • Intramuscular injections of antipsychotics are
typical antipsychotics. Amongst atypicals, typically given once a month or once a fortnight
clozapine and olanzapine have the highest • Z track technique is used to give the
incidence of metabolic side effects.Q intramuscular injectionQ
• Depot preparations are available for the
following antipsychotics-
– Flupenthixol, fluphenazine, haloperidol
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Cerebellum Quick Revision Notes

– Pipotiazine, zuclopenthixol Treatment of catatoniaQ

– Risperidone, paliperidone, olanzapine, • In catatonia, the first line treatment is i.v
aripiprazole lorazepam and electroconvulsive therapy

Prognosis
Good prognostic factors Bad prognostic factors

Acute or abrupt onset Insidious onset

Advanced age (>35 yrs) Early onset (<20 yrs)

Female sex Male sex

Prominent positive symptoms Prominent negative symptoms
Presence of affective symptoms Absence of affective symptoms
Family history of mood disorders Family history of schizophrenia

OTHER PSYCHOTIC DISORDERS of delusions, the functioning is not markedly

impaired
Acute Psychotic Disorders – Depending on the content of delusion,
Characteristics different types, including persecutory,
infidelity, grandiosity, and delusional
• Symptoms similar to schizophrenia (Delusions, parasitosis (matchbox sign), have been
hallucinations, disorganization) described.
• Acute onset – Treatment- Antipsychotics
• Often preceded by stressor - Fever is a common
stressor MOOD DISORDERS (DEPRESSIVE
• Often, symptoms resolve completely DISORDERS)
• Do not meet the duration criterion of • DSM-5 uses the term ‘Major Depressive
schizophrenia Disorder’

Different terms have been used in ICD-11 and DSM-5 • ICD-11 used the term ‘Depressive Disorders’
for acute psychotic disorders. • Also often referred to as ‘depression’ or
ICD-11: Acute & transient psychotic disorders (if ‘unipolar depression’.
symptom duration is less than 1 month)

DSM-5
EPIDEMIOLOGY
• According to WHMS (world mental health
• < 1 month - Brief psychotic disorder survey), depression is the second most common
• Between 1-6 months - Schizophreniform psychiatric disorder in the world (most common
disorder is specific phobias)
• According to National Mental Health Study
Treatment - Antipsychotics/benzodiazepines
(NMHS-2016), carried out by NIMHANS,
depression is the most common mental illness in
Delusional disorder
India (excluding tobacco use disorders)
– Delusions- Single or set of related delusions
• Most common age of onset is middle-age, and
– Hallucinations - Usually absent, If the mean age of onset is 40 years, prevalence is
hallucinations are present, they have the increasing in young people too.
same content as the delusion
• Female: Male prevalence = 2:1
– Functioning- Apart from the direct impact
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• Depression is the most common cause of suicide. – Treatment implications- SSRIs and MAOIs
are better than TCAs, in atypical depression
• Suicide rate in depression - 10-15%
• Melancholic features (melancholic depression)
SYMPTOMS (MNEMONIC- – Significant biological features (significant
SIGECAPSS) anorexia, weight loss, early morning insomnia)

S-Sadness of mood/ depressed mood (persistent & – Significant mood symptoms

pervasive sadness) ƒ Feeling of misery
I-Loss of Interest/ loss of pleasure (anhedonia) ƒ Mood worse in the morning
G-Guilt/ Feeling of worthlessness ƒ Lack of mood reactivity/anhedonia
E-Energy (Loss)/ Fatigue – Excessive guilt, psychomotor agitation/
C-Concentration loss, cognition negative (negative psychomotor retardation
thoughts) • Catatonic features- Patients may develop
A-Appetite (Loss/ gain). Significant weight change is catatonic symptoms (the list of catatonic
defined as >5% weight change in 1 month symptoms was discussed in the last chapter)

P-Psychomotor Agitation/ Retardation

ETIOLOGY
S-Suicidal thoughts
• Monoamine hypothesis- Depression is caused by
S-Sleep disturbances. Characteristic sleep
a deficiency of monamines.
disturbances in depression-
– Serotonin deficiency
• Early morning insomnia (getting up >2 hrs
earlier than the usual waking time) – Serotonin, norepinephrine and dopamine
• Reduced latency of REM sleep deficiency

• Sleep is usually decreased but may be

increased too PSYCHOLOGICAL THEORIES OF
DEPRESSION
Duration Criterion Of Depression- 2 WeeksQ • Cognitive theory of depression- Given by Aaron
Specifiers Beck
– Negative thoughts have a central role in the
In addition to the above-mentioned symptoms, the
development of depression.
patient may have other special features which are
called ‘specifiers’. These include- – Three negative thoughts are particularly
important ( Beck’s cognitive triad)Q
• Psychotic symptoms/features (psychotic
depression) ƒ Negative view of self (ideas of
worthlessness)
– Presence of delusions/hallucinations
ƒ Negative view of environment (ideas of
• Atypical features (atypical depression)Q
helplessness)
– Reversed biological features (Increased
ƒ Negative view of the future (ideas of
appetite, weight and sleep)
hopelessness)
– Mood reactivity present (mood improves with
positive events) Treatment
– Leaden paralysis (subjective feeling of • Pharmacotherapy
heaviness of limbs and difficulty in moving • Psychotherapy
them)
• Other somatic treatments
– Extreme sensitivity to interpersonal
rejection
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Pharmacotherapy – Hyperprolactinemia (mostly with amoxapine)

• Antidepressants are chosen on the basis of TCA toxicity

their side effect profile • TCAs have a narrow therapeutic index
• First line- SSRIs are the first line due to better • The following are the signs & symptoms of
side effect profile TCA toxicity
• Onset of action- In 1-2 weeksQ – CVS - hypotension, tachycardia, chest pain
• Maximum therapeutic effect- In 4-6 weeks – CNS - altered sensorium, respiratory
depression, convulsions
Antidepressants
– ANS - dry mouth, blurred vision, urinary
1. Tricyclic and tetracyclic antidepressants (TCAs) retention
• Mechanism of action- Block serotonin & – Metabolic acidosis (due to tissue hypoxia)
norepinephrine reuptake transporters and
hence increase the levels of serotonin and – ECG changes- prolonged PR, QRS and QT
norepinephrine. interval, AV block, right axis deviation

• Following drugs are TCAs • Management of TCA toxicity

– Imipramine, desipramine, trimipramine – If QRS > 100 ms, serum alkalinization using
i.v. sodium bicarbonate is the mainstay of
– Amitriptyline, nortriptyline, protriptyline treatment
– Amoxapine, doxepin, maprotiline, – Gastric lavage and activated charcoal can
clomipramine be administered immediately after the
• Clomipramine- most serotonin-selective TCA overdosage.

• Desipramine- most norepinephrine selective

TCA 2. Selective serotonin reuptake inhibitors (SSRIs)
• Mechanism of action- Act by blocking the
Side effects of TCAs reuptake of serotonin. SSRIs do not have
• Due to muscarinic receptors blockade problematic side effects seen with TCAs.
(anticholinergic side effects)Q • SSRIs include fluoxetine, fluvoxamine,
– Constipation, urinary retention, dry mouth, citalopram, escitalopram, sertraline, paroxetine
blurred vision, decreased sweating, delirium & vilazodone

– Can cause acute angle closure glaucoma • Side effects of SSRIs

– Benign prostatic hyperplasia – Gastrointestinal- nausea (most common),Q

diarrhoea, constipation (more common with
• Due to alpha-adrenergic receptors blockade, paroxetine), anorexia
cardiac sodium channel blockade
– Sexual side- Most common long-term side
– Postural hypotension effects, include low libido, delayed orgasm,
– QT prolongation and poor erection. The side effect of delayed
orgasm is useful in patients with premature
– Tachycardia, rarely hypertension
ejaculation (PME), hence SSRIs are often
• Other side effects used for the management of PME.Q
– Sedation (due to H1 blockade) – CNS- anxiety, insomnia, sedation, vivid
– Weight gain dreams, sweating, seizures, emotional
blunting, extrapyramidal side effects.
– Tremors
– QTc prolongation
– Seizures (due to excessive serotonin &
norepinephrine receptors blockade) – Anticholinergic side effects
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– Haematological - Platelet aggregation, – NSSA (noradrenergic & specific serotonergic

hyponatremia antidepressant)

– Weight gain – Central a2 antagonism (increases

norepinephrine and serotonin)
• Vortioxetine- A novel antidepressant with a
unique mechanism of action that includes- – Antagonism of 5HT2 and 5HT3 receptors

– Blockade of the reuptake of serotonin – Side effects- sedation, wt gain and vivid
dreams
– Agonism at 5HT1A, partial agonism at 5HT1B,
antagonism at 5HT3, 5HT1D and 5HT7 – Minimal sexual side effect Q
receptors. • Bupropion Q

3. Serotonin-norepinephrine reuptake inhibitors – NDRI (norepinephrine dopamine reuptake

(SNRIs) inhibitor)
• Mechanism of action- Blockade of the reuptake – Side effects- insomnia, restlessness,
of both serotonin and norepinephrine seizures
• SNRIs include venlafaxine, desvenlafaxine, – Minimal risk of sexual side effects, weight
duloxetine, milnacipran, levomilnacipran gain or sedationQ
• Some studies have found that SNRIs are more • Antipsychotics
effective than SSRIs in the management of
severe depression. – Use in the presence of psychotic features

• Side effect profile is similar to SSRIs. In – Also for augmentation of antidepressants

addition, SNRIs can cause anticholinergic side Psychotherapy
effects and hypertension.Q
• Cognitive behavioural therapy (CBT)- Most
Discontinuation syndrome commonly used psychotherapy in depression.Q
Most effective and with the best evidence in
• Due to the sudden discontinuation of
patients with depression
antidepressants
– Focussed on fixing automatic negative
• Most commonly associated with venlafaxine,
thoughts and cognitive distortions
paroxetine and fluvoxamine
– As effective as antidepressants in mild
• The patient presents with the following
depression
symptoms (Mnemonic- FINISH)
– In pregnant and lactating women with
– F - Flu-like symptoms (fatigue, aches etc)
mild depression, CBT is preferred over
– I - Insomnia antidepressants
– N - Nausea
Other somatic therapies
– I - Imbalance (vertigo)
1. Electroconvulsive therapy (ECT)- First-line
– S - Sensory disturbances (paraesthesia) treatment in cases of -
– H - Hyperarousal (anxiety, irritability) • Depression with suicide risk
4. Atypical antidepressants • Depression with stupor
• Trazodone & nefazodone In patients with depression with psychotic symptoms
or who are intolerant to antidepressants, ECT can be
– Mechanism of action- SARI (5HT2A and
5HT2C antagonism and reuptake inhibition) considered.

– Important side effect of trazodone - 2. Repetitive Transcranial magnetic stimulation

priapism Q (rTMS)

• Mirtazapine • Uses rapidly changing magnetic fields to

produce small electric currents (known as eddy
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Cerebellum Quick Revision Notes

currents) in superficial cortical neurons. A - Activity levels increased

• Approved as a treatment modality in major F - Flight of ideas
depressive disorder.
A - Abnormally increased levels of activity/energy
• Non-convulsive, no anaesthesia required
S - Sleep decreased (decreased need for sleep) (e.g.
Other important diagnoses patient feels refreshed after 2 hours of sleep)
T - Talkativeness (Overtalkativeness)
1. Recurrent depressive disorder- History of more
than one depressive episode. G - Grandiose ideas and increased self-esteem
(Increased self-confidence, maybe boastful, and may
2. Dysthymia (Dysthymic disorder)- Depressive
make big claims)
symptoms for more than 2 years; symptoms are
not severe enough to make a diagnosis of even D - Distractibility
mild depressive episode (subsyndromal depressive
P - Painful consequences (involvement in activities with
symptoms > 2yrs)
potentially painful consequences like making foolish
3. Double depression- Depressive episode investments)
superimposed over dysthymia.
• Duration criterion: At least 7 daysQ

MOOD DISORDERS (BIPOLAR SPECIFIERS

DISORDERS)
• Bipolar type I - Mania/Mixed + Depression Psychotic symptoms
– Even a single manic/mixed episode is enough • Presence of delusions/hallucinations
to make the diagnosis of Bipolar type I
Hypomania
disorder, however, most of these patients
experience depressive episodes too. • Symptoms- Similar to manic symptoms
• Bipolar type II - Hypomania + Depression • Severity- Symptoms are the same but not as
severe as in mania
– It is characterised by atleast one episode of
hypomania and depression each • Impairment- Less impairment in comparison to
mania
EPIDEMIOLOGY • Duration- Atleast 4 daysQ
• Lifetime prevalence of Bipolar I- 1% Rapid cycling in bipolar disorders
• Sex ratio • Four or more episodes in one year
– Bipolar I - Roughly equal (1.1:1)
– Bipolar II- More common in women
TREATMENT OF BIPOLAR
• Mean age of onset
DISORDER
– Bipolar I - 18 yrs
1. Acute manic episode or mixed episode
• For less severe symptoms, monotherapy with
– Bipolar II - Mid 20s
mood stabilisers or atypical antipsychotics can
• Suicide rate in bipolar disorder- 4-19% be usedQ
– Mood stabiliser monotherapy (Lithium,
SYMPTOMS OF MANIA Valproate/Divalproex, Carbamazepine)
(MNEMONIC- MY ASIA FAST – Atypical antipsychotic monotherapy
GDP) • For severe symptoms, a combination of mood
M - Mood elevation (undue excessive happiness) or stabilisers and antipsychotics are preferred.
irritable mood
• If in the exam, you are asked the DOC for
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Psychiatry

acute mania or severe mania, and you have to Therapeutic drug monitoring for lithium
pick one class of drug, antipsychotics is the
Lithium has a narrow therapeutic index. Following
better answer. However, for the same question,
are the effective serum concentration of lithium-
if a combination of mood stabilisers and
antipsychotics is one of the options, go for it. • For acute mania- 1.0-1.2 mEq/L
• In presence of psychotic symptoms, • For maintenance treatment- 0.4-0.8 mEq/L
antipsychotics should be added to the treatment • Lithium toxicity is usually seen when levels
regime. are > 1.5 mEq/L; however, toxicity should be
• For mixed episodes - Valproate > Lithium suspected in the presence of relevant signs
and symptoms irrespective of serum lithium
2. Acute depression (bipolar depression) levels.
• The following are first line treatments for acute • Monitoring of serum lithium levels should be
depression in a patient with bipolar disorder- done after 12 hours of the last dose. So if the
– Mood stabilisers (Lithium, lamotrigine). patient took the lithium at 9 pm at night, the
According to American Psychiatric blood sample should be taken at 9 am in the
Association (APA) guidelines, the first-line morning to measure the serum lithium levels.
pharmacological treatment is the initiation
of either lithium or lamotrigine. Side effects of lithium
– Olanzapine + Fluoxetine A. Neurological side effects
– Quetiapine • Postural tremors (DOC- beta blockers)Q
• A combination of mood stabilisers + • Lack of spontaneity (memory disturbances,
antidepressants, can also be used, but in slowness of thinking)
general antidepressants are avoided in a patient
• Raised ICT and peripheral neuropathy
with bipolar disorder to avoid the risk of ‘manic
switch’ B. Endocrine side effects

• Electroconvulsive therapy becomes the • Hypothyroidism

preferred modality in cases of high suicide risk. • Rarely hyperthyroidism, hyperparathyroidism
• Concept of a manic switch- A patient with C. Renal side effects
depressive symptoms, when prescribed an
antidepressant, may switch from depression • Most common is polyuria with secondary
to mania. This is more likely to happen, if an polydipsia. Lithium interferes with the action
underlying diagnosis of bipolar disorder was of ADH (antidiuretic hormone), resulting in
missed, and the patient was treated with polyuria.Q
antidepressants without adding the cover of • May progress to Diabetes insipidus
mood stabilisers. In case of a ‘manic switch’,
stop the antidepressant, and start a mood • Management of lithium-induced polyuria-
Potassium-sparing diuretics like Amiloride, and
stabiliser/antipsychotic.
triamterene. Amiloride blocks the entry of
Lithium lithium into the principal cell of collecting ducts
by blocking the Na+ epithelial channels. Lithium
• Is a monovalent cation like Na+, and the body uses these Na+ epithelial channels to enter the
handles lithium the way it handles Na+ collecting ducts.
• Lithium is rapid and completely absorbed after • Thiazides can also be used for the management
oral intake. of lithium-induced polyuria. Thiazides work
• Doesn’t bind to plasma proteins, not metabolised, by inducing hypovolemia, which in turn results
and is excreted unchanged through the kidney. in increased proximal sodium and water
reabsorption and decreasing water delivery to
ADH sensitive collecting ducts & reducing urine
output.
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Cerebellum Quick Revision Notes

• Rare side effects- Nephrotic syndrome, renal – Muscle fasciculations, increased DTR,
tubular acidosis, interstitial fibrosis. convulsions, impaired consciousness, death
D. Dermatological side effects Management of lithium toxicity
• Acne, psoriasis (worsening), hair loss, rashes • Stop lithium
E. Nausea, vomiting, wt gain, leukocytosis • Correct dehydration
F. Teratogenic side effect- Ebstein’s anomaly • Use of sodium polystyrene sulphonate or
Mnemonic of side effects of lithium (LITHIUM Q polyethylene glycol (to remove unabsorbed
WASHER) lithium from GI). Activated charcoal is not
useful
L- Leukocytosis
• Hemodialysis, in severe cases.Q Usually, when
I- Increased urination, polydipsia s.lithium levels are more than 3.5mEq/dl, but
T- Tremors, clinical symptoms are given more importance
than serum lithium levels.
H- Hypothyroidism, hyperthyroidism,
Hyperparathyroidism
PREGNANCY AND MOOD
I - Interstitial fibrosis STABILISERS
U- Upset stomach (nausea, vomiting) • Lithium
M- Mother (ebstein’s anomaly) – Can cause ebstein’s anomaly, ASD and VSD
W- Weight gain – Hence, high resolution ultrasound and
A - Acne echocardiography is recommended in 6th
and 18th week of pregnancy
S - Psoriasis, Spontaneity (lack)
– Chances of lithium toxicity increase with
H- Hairfall
hypovolemia, chances may increase during
E- ECG changes (T wave flattening or inversion) delivery/in postpartum period if there is
excessive bleeding,
R- Rash, Rental tubular acidosis
• Valproate
Lithium toxicity
– Most teratogenic, use of valproate in
Remember the body deals with lithium, the way it pregnancy must be avoided
deals with sodium.
– High risk of NTD (neural tube defect in the
Hence anything which causes hypovolemia or baby) if valproate is used
hyponatremia would lead to increased sodium
– Child may have low IQ if mother using
reabsorption in the kidney, and it would also result in
valproate during the pregnancy
increased lithium reabsorption, increasing the chances
of lithium toxicity. • Carbamazepine

• Low dietary intake, use of diuretics and – Teratogenic, but not as much as valproate
diarrhoea, increase the risk of lithium toxicity. – Can cause NTD in the child
• Lithium has a low therapeutic index, and serum – Can cause hemorrhagic disease in both
lithium levels > 1.5mEq/dl increase the risk of mother as well as the child
toxicity.
– In case carbamazepine is used in pregnancy,
Symptoms of lithium toxicity- prophylactic vitamin K injections should be
given to mother to prevent hemorrhagic
• GI symptoms- Abdominal pain, vomiting
disease
• CNS symptoms
• Lamotrigine
– Coarse tremors, ataxia, dysarthria
– Considered safer than lithium, valproate and
 165
Psychiatry

carbamazepine 3. Postpartum psychosis

• AntipsychoticsQ • Onset is within 2-3 weeks of delivery
– Much more safer than mood stabilisers, also • Symptoms- Initial symptoms include tearfulness,
effective. If a pregnant female develops a insomnia, and lability
manic episode, chose antipsychotics over
• Later delusions (e.g baby is dead, didn’t give
mood stabilisers. birth to child) and hallucinations develop.
Psychiatric aspects of pregnancy • There is a risk of harm to self or the baby. In
some cases, the baby has to be separated from
1. Postpartum blues (baby blues)Q
the mother to prevent harm to the baby.
• Seen in 30-75% of females after childbirth
• Postpartum psychosis is basically an episode
• Transient symptoms like tearfulness, sadness, of bipolar disorder, triggered by the stress of
mood lability and sleep disturbances (basically child birth
mild depressive symptoms)
• Mostly recovery is complete
• Onset is in 3-5 days of delivery
• In 50% of cases, the episode happens after
• Symptoms last for days to weeks delivery of the first child; in 50% cases, another
perinatal complication is there, in 50% cases
• Support to mother is enough for resolution of
there is a family history of mood disorders.
symptoms
• 2/3rd of patients have another episode in the
• Diagnosis should be made on the basis of
next 1 year
symptoms, do not give too much importance to
the onset of symptoms while solving the MCQs • Treatment - Antipsychotics with lithium;
antidepressants may be added if required.
2. Postpartum depression
• More severe depressive symptoms are present SUICIDE
in comparison to postpartum blues.
• Suicide rate in India- 12 per lakh of the
• DSM-5 uses the diagnosis of “Depressive population (2021 data)
episode with peripartum onset” for this clinical
• Method- Most common method of dying by
condition.
suicide is hanging, followed by the use of poisons
• Seen in 10-15% of females post delivery,
• CSF levels of 5 HIAA (5 hydroxyindoleacetic
• Symptom onset is within 3 months of acid) are inversely related with the suicide risk.
delivery Remember, 5 HIAA is a metabolite of serotonin.
• Symptoms- Sadness, tearfulness, lability, sleep
disturbances, anhedonia, suicidal thoughts/
Causes
thoughts of harming baby, guilt • Depression (most common cause of suicide)
• As is clear, the symptoms are more severe, and • Schizophrenia
that should be the basis of making the diagnosis.
• Alcohol dependence
• Often patients have a history of mood disorder,
• Borderline personality and antisocial personality
and family h/o mood disorders is also often
disorder
present
• There is an increased risk of future depressive Risk factors of suicideQ
episodes if a patient has a post partum • Previous suicide attempt (most important risk
depression episode. factor)
• Treatment - Pharmacotherapy and • Signs of suicidal intent (e.g. writing a suicide
psychotherapy. Treated along the lines of note, transferring money into the accounts of
depression. relatives)
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Cerebellum Quick Revision Notes

• Hopelessness • All anxiety disorders are more common in

• Male sex females than males.

• Age> 45 years
A. PANIC DISORDER
• Substance abuse
• Panic attack- It’s an acute attack of intense
• Delusions/Hallucinations anxiety, with a ‘feeling of impending doom’.
• Divorced, separated Patient may feel that ‘he is having a heart
attack’, ‘he is about to die’, or that ‘he is about
• Unemployed to go crazy’.Q
• Chronic illness • Usually panic attacks resolve in 20-30 minutes
• Family history of suicide • Symptoms of a panic attack- Palpitations,
• Poor social support choking sensations, chest pain, dizziness,
depersonalisation, derealisation
• H/o sexual abuse
• Panic disorder is characterised by recurrent
Some related terms and unexpected panic attacks
• Copycat suicide- Instances have been reported
Treatment
where adolescents from the same social group
die by suicide in succession. This phenomenon, • A combination of pharmacotherapy and
known as copycat suicide, occurs when one psychotherapy is preferred.
person’s suicide influences the actions of • PharmacotherapyQ
others.
– Benzodiazepines (short term, tapered and
• Paradoxical suicideQ- Paradoxical suicide: In stopped) & SSRIs (long term)
certain cases, a person with depression might
die by suicide while their symptoms show signs • Psychotherapy
of improvement after beginning antidepressant – Cognitive behavioural therapy (CBT)
treatment. This is referred to as paradoxical
suicide, as it occurs when symptoms have already
started to improve. The hypothesis is that a B. SPECIFIC PHOBIAS
depressed individual may not have the energy • Phobia is defined as a strong, persistent &
to act on suicidal thoughts initially; however, as irrational fear of an object or a situation.
their condition begins to improve, their energy
• Common types of phobias
levels increase before their suicidal thoughts
subside. This creates a window of time during Nyctophobia Dark
which the person has regained energy but still Acrophobia Heights
experiences suicidal thoughts, and it is within
Claustrophobia Closed spaces
this window that they may die by suicide.
Ailurophobia Cats

ANXIETY OR FEAR RELATED Cynophobia Dogs

DISORDERS Mysophobia Germs or dirt

Pyrophobia Fire
SYMPTOMS OF ANXIETY Xenophobia Strangers
• Sweating, tremors, restlessness, tachycardia, Thanatophobia Death
mydriasis Hydrophobia Water
– Increased urinary frequency, diarrhoea
– Hyperreflexia, cold clammy skin Treatment
– Feeling of nervousness Pharmacotherapy
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Psychiatry

– Benzodiazepines (short term, tapered and E. SELECTIVE MUTISM

stopped) & SSRIs (long term)
• More common in children and is comparatively
– Beta blockers can be used less common in adolescents/adults.
– Psychotherapy- Behavioural therapy is the • Characterised by a consistent failure to speak
preferred psychotherapy for patients with in one or more specific social situations (usually
specific phobias. the school setting) while speaking fluently in
other more familiar situations, such as at home.
C. GENERALISED ANXIETY • Treatment- SSRIs and CBT (cognitive
DISORDER behavioural therapy).

• Characterised by excessive worries and anxiety

about minor and everyday issues; hence the OBSESSIVE-COMPULSIVE &
patient is almost always anxious (the term RELATED DISORDERS
‘free-floating anxiety is used to describe this
persistent anxiety)Q
A. OBSESSIVE COMPULSIVE
In addition, there are somatic symptoms of
•
DISORDER
anxiety such as
• Obsessive compulsive disorder (OCD) is
– Restlessness, easy fatigue, muscle tension
characterised by obsessions and compulsions
– Poor concentration, insomnia, irritability • Obsessions are-
Treatment- – Recurrent, intrusive thoughts, images
or impulses, which cause anxiety (e.g. a
– Pharmacotherapy- Benzodiazepines (short
repetitive thought that ‘my hands are
term, tapered and stopped) & SSRIs (long
unclean’)Q
term).
– Patient considers them as a product of their
– Psychotherapy- CBT own mind (D/d thought insertion)- Patient
considers ‘obsessions’ as his own thoughts,
D. SEPARATION ANXIETY whereas a patient with thought insertion
DISORDER says that ‘someone is inserting thoughts in
the mind’
• More common in children and is comparatively
less common in adolescents/adults. – Patient finds them excessive, irrational and
senseless, at some time during the illness
• Characterised by a persistent and excessive (D/d delusions) - Patient with obsessions
fear of separation from prominent attachment usually doesnt believe in the obsessive
figures (such as parents), which manifests in thoughts that he gets, whereas a patient
the form of reluctance to go to school, work, with delusion believes in the content of
or away from home, or sleep in a separate room delusion.
• If separation happens, the child may experience – Patient tries to resist or neutralize them
physical symptoms such as abdominal pain or
headache. • Compulsions are

• Fear that something bad will happen to the – Repetitive behaviours / mental acts
attachment figures or to self, in case of performed in response to obsessions
separation – They reduce anxiety temporarily
• Treatment- SSRIs and CBT (cognitive – E.g. The patient who repeatedly gets the
behavioural therapy). thought that ‘my hands are unclean’ washes
his hands despite knowing that they are
not unclean. This washing of hands is a
‘compulsion’.
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Cerebellum Quick Revision Notes

• Both obsessions and compulsions are ego- • Magical thinking- Just because they thought
dystonic (thoughts/behaviours which are not about an event, it will occur in reality. E.g. A
agreeable to self, i.e., unwanted thoughts/ patient would repeatedly have a thought, “If
behaviours) Q I do not knock on the door three times, the
mother will die”
• Duration criterion for making the diagnosis - 2
weeks • Most common obsession- Obsession with
contamination.
• Lifetime prevalence: 2-3%, more common in
females • Most common compulsion- Compulsion of
washing.
• Most common comorbidity with OCD is
depression Treatment
Etiology • A combination of pharmacotherapy and
psychotherapy gives better results
• Neurotransmitter- Primarily caused by
serotonergic dysfunction • Pharmacotherapy

• Circuit involved- Dysfunction in the cortico- – SSRIs and clomipramine (first-line

striato-thalamico-cortical tract (a neural treatment)
circuit that starts in the orbitofrontal cortex – Antipsychotics (used for augmentation)
and anterior cingulate cortex, and projects to
the striatum, from the striatum to the thalamus – Li, Valproate, carbamazepine, venlafaxine
and back to the cortex) has been hypothesized (can be used)
to be responsible for the development of OCD. • Psychotherapy

Symptom patterns – Exposure and response prevention (kind of

CBT/BT)- Therapy of choiceQ
•
Q
Obsession of contamination with compulsion of
washing and avoidance- This is the most common
presentation of OCD wherein patients have an B. HOARDING DISORDER
obsession of contamination (e.g., the thought • Characterised by an inability to discard things,
that hands are contaminated with dirt) followed that are of little or no value & fear of losing
by compulsion of washing something important
• Pathological doubt with compulsions of checking- • In DSM-5 and ICD-11, hoarding disorder has
This is the second most common pattern where been made a separate diagnosis, earlier it was
patients have obsessions of doubt followed considered as a type of OCD
by compulsions of checking. For example, a
housewife would have repeated doubts about • Treatment- SSRIs and CBT
whether she locked the door properly and would • Exposure and response prevention is not so
repeatedly check it. effective in the management of hoarding
• Intrusive thoughts (usually with mental disorder.
compulsions)- The third most common pattern
is characterized by repetitive, intrusive C. BODY DYSMORPHIC DISORDER
thoughts without any apparent compulsions.
These obsessive thoughts often revolve around • Characterised by a preoccupation with an
themes of religion, aggression, or sexuality and imagined defect in the physical appearance.
often cause significant guilt and distress in the • If a slight physical anomaly is present, the
patient. concern regarding it is clearly excessive.
• Symmetry or precision with compulsion of • There are repetitive behaviours such as mirror
slowness- In this fourth most common pattern, checking or repeatedly asking others about the
patients have an extreme need for symmetry or ‘physical anomaly’
precision along with the compulsion of slowness.
• Usually, the preoccupation is about hair, nose
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Psychiatry

or skin repetitive events that involve exposure to

actual/threatened death, serious injury or
• Treatment- SSRIs and CBT
sexual violence to self or others
• E.g.-Trauma such as earthquake/ floods, wars,
D. BODY FOCUSSED REPETITIVE murder, rape, serious accidents etc.
BEHAVIOUR DISORDER- • Clinical symptoms of PTSD
• It is characterised by repetitive actions
– Intrusion symptoms such as
directed at the integument (skin, hair) and the
inability to stop them. It includes- ƒ Flashbacks (patient may feel as if the
traumatic event is happening again and
– Trichotillomania- It is characterised by-
may also act as if he is in the middle of
ƒ Repetitive hair pulling, resulting in hair the traumatic event
loss.
ƒ Vivid memories of the trauma, nightmares
ƒ Patients have an impulse to pull out their about the trauma
hair and try to resist it
– Avoidance of situations that remind of the
ƒ But the feeling of tension increases, trauma
driving them to engage in hair-pulling
– Arousal symptoms such as hypervigilance
ƒ The act brings a sense of relief and, at (a state of excessive alertness) and
times, pleasure exaggerated startle response
ƒ A subset of patients chew or swallow the – Other symptoms such as emotional numbing,
hair they pull (trichophagy) emotional detachment and anhedonia
ƒ Trichophagy may lead to complications such – To make the diagnosis of PTSD, the
as trichobezoars (hairball accumulation in symptoms should be present for more than
the intestine), intestinal blockages, and one month.
malnutrition.
– Excoriation disorderQ - It is characterised Treatment of PTSD
by- • SSRIs (drug of choice)Q
ƒ Repetitive picking of the skin resulting in • CBT (treatment of choice)
skin lesions
• Eye movements desensitisation and reprocessing
ƒ The impulse, increasing tension and the (EMDR)- A technique that has been developed
feeling of relief/pleasure is similar to for the management of PTSD.
what happens in trichotillomania.

Treatment B. ADJUSTMENT DISORDERS

SSRIs and Behavioural therapy (e.g. habit reversal • May develop after traumatic events which are
technique, in which the patient learns to identify and critical but not uncommon in the course of life
be aware of the urge that precedes hair pulling and • E.g. Relationship issues, change of job, migration,
then replaces the act of hair-pulling with some other death of a loved one
voluntary acts such as making a fist)
• Symptoms- Presents with anxiety and depressive
symptoms, but the symptoms are not severe
TRAUMA AND STRESSOR enough to make the diagnosis of depression or
RELATED DISORDERS an anxiety disorder.
• Adjustment disorder and depression: If after
A. POST TRAUMATIC STRESS a traumatic event, the symptoms are severe
enough to make the diagnosis of depression,
DISORDER (PTSD)
the diagnosis of depression should be given
• Follows a significant traumatic event or preference over the diagnosis of adjustment
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Cerebellum Quick Revision Notes

disorder/ C. Conversion disorder (ICD-11

• Treatment-Psychotherapy is the treatment of uses the term ‘Dissociative neurological
choice for adjustment disorder. Supportive symptom disorder’)
psychotherapy is often used. Pharmacological
• Patients present with symptoms suggestive of
treatment is symptomatic, i.e. depends on the
motor, sensory or cognitive deficits; however,
type of symptoms.
no neurological cause can be found.
Also, the symptoms do not conform to the
SOMATIC SYMPTOMS & RELATED •
anatomical and physiological principles
DISORDERS (SOMATOFORM
• Patients may have ‘la belle indifference’, which
DISORDERS) is a lack of concern for the symptoms. E.g. A
patient with sudden onset loss of vision in an
A. SOMATIC SYMPTOM eye may appear unconcerned with her symptom.
DISORDER (ICD-11 USES THE • An important d/d of conversion disorder is
TERM ‘BODILY DISTRESS acute intermittent porphyria.
DISORDER’) • More common in females
• Characterised by the presence of one or
more somatic symptoms, in the past the term, DISSOCIATIVE DISORDERS
medically unexplained symptoms (MUS), was
• Characterised by dissociation. Dissociation is a
used as the cause of the symptom could not be
disruption in normally integrated functions of
found.
memory, identity, perception, consciousness
• Patients present with excessive thoughts (too and motor behaviour.
much worried about the symptom),Q excessive
• The symptoms are unconscious, which means,
feelings (too high anxiety about the symptoms)
the patient doesnt deliberately produce the
and excessive behaviours (excessive time,
symptoms (unlike factitious disorders and
and energy spent visiting multiple doctors and
malingering)
getting unnecessary tests done) in relation to
the somatic symptoms. • Onset is usually associated with a stressor.

B. ILLNESS ANXIETY TYPES OF DISSOCIATIVE

DISORDER (HYPOCHONDRIASIS) DISORDERS
• Characterised by a preoccupation with having or Dissociative amnesiaQ
acquiring a serious physical illness
– Sudden loss of autobiographical memory or
• The preoccupation persists despite normal personal memory (usually for a traumatic
investigations and medical reassurances event)
• Excessive thoughts, feelings and behaviours are
associated with the preoccupation. Dissociative identity disorder (Multiple
personality disorder)
• A patient with somatic symptom disorder
is preoccupied with the symptoms, whereas • It is characterised by the presence of two or
a patient with an illness anxiety disorder is more personalities (or “personality states” or
preoccupied with the idea of having a serious ‘alters’) in an individual, out of which, only one is
illness. E.g. A patient with somatic symptoms evident at a time.
disorder may be preoccupied with the symptom • Usually, the different personalities are
of ‘abdominal bloating’ whereas a patient with
completely unaware of each other’s existence.
illness anxiety disorder/hypochondriasis would
be preoccupied with the idea of having ‘stomach
cancer’.
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Psychiatry

Depersonalization/derealization – Disturbances of consciousness,

disorder – Disorientation to time, place and person,
• Depersonalisation is characterised by feelings – Hallucinations (most commonly visual)
of unreality or detachment from oneself or
one’s body – Surgery or infections may trigger delirium
tremens
• The patients feel “as if”Q they have changed,
although find it difficult to describe what
exactly has changed Alcohol induced neurocognitive
disorders
• The patients frequently report that they feel
as if they were detached from their bodies and These are amnestic disorders characterised by
were watching themselves as if a movie is going disturbances in short term memory. They include-
on. A. Wernicke’s encephalopathy- Acute complication
• Depersonalisation is often accompanied by of thiamine deficiency.
derealisation, in which the patient experiences • Symptoms- Mnemonic GOAQ
“as if” the world is unreal.
– G: Global confusion
• Reality testing is intact; in other words, the
patient during the episode realises that, in – O: Ophthalmoplegia (6th nerve palsy > 3rd
reality, nothing has changed; they are just nerve palsy)
feeling like that. – A: Ataxia
SUBSTANCE-RELATED AND • Cause- Thiamine deficiency
ADDICTIVE DISORDERS • Treatment- High dose of parenteral thiamine.
Ophthalmoplegia responds first to the
TERMINOLOGY treatment, ataxia doesnt improve completely in
• Tolerance- Increasing amounts of a substance almost 50% of cases.
are required to get the desired effect
B. Korsakoff syndrome- Chronic complication of
• Withdrawal symptoms: Typical symptoms that
thiamine deficiency.
develop when the substance intake is reduced
or stopped. • Symptoms
– Anterograde amnesia (inability to form new
ALCOHOL memories) > retrograde amnesia (inability to
recall old memories)
Alcohol withdrawal
– Confabulations (making of false stories to fill
• Symptoms that develop after cessation of memory gaps, which is unintentional)
alcohol intake
• Cause- Thiamine deficiency
• After 6-8 hours: Tremors (most common,
coarse tremors),Q nausea, vomiting, anxiety, • Treatment - Oral thiamine for around 3–12
hypertension, mydriasis months

• After 12-24 hours: Alcoholic hallucinosis • Prognosis is guarded

(hallucinations without any disturbances of In Wernicke’s korsakoff syndrome, the
consciousness) neuropathological lesions are usually symmetrical
• After 24-48 hours: Alcohol withdrawal and involve mammillary bodies. Other sites involved
seizures. Usually generalised and tonic-clonic. include the thalamus, hypothalamus, midbrain, pons,
Patients have more than one seizure in a short medulla, fornix and cerebellum.
span, hence often called, cluster seizures.
Treatment
• After 48-72 hours: Delirium tremens.
Characterised byQ A. Detoxification- Focuses primarily on managing the
withdrawal symptoms
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Cerebellum Quick Revision Notes

• Benzodiazepines are considered the drug of Opioid intoxication

choice for the management of alcohol withdrawal
• Symptoms of opioid intoxication
• In presence of liver damage- short-acting
benzodiazepines, such as oxazepam or – Euphoria, initial euphoria followed by a period
lorazepam, are preferred of sedation (nodding off)

• Role of carbamazepine- Can be used to – Slow respiration, hypothermia, hypotension,

manage alcohol withdrawal. bradycardia, pinpoint pupil, cyanosis

• Thiamine administration- Alcohol-dependent • Overdosage

patients are often deficient in thiamine – Can be lethal by causing respiratory
due to poor intake and absorption. Thiamine depression
must be administered before giving glucose,
to prevent the precipitation of Wernicke’s – DOC- i.v. naloxone (opioid antagonist)Q
encephalopathy.
Opioid withdrawalQ
• For delirium tremens- Intravenous
• Opioid withdrawal presents with a flu-like
benzodiazepines are the drugs of choice,
syndrome, with the following symptoms
parenteral thiamine (and other B vitamins)
must be administered, and antipsychotics can – Lacrimation, rhinorrhea, sweating, diarrhoea
be used to manage hallucinations and agitation.
– Yawning and piloerection
B. Maintenance of abstinence (relapse prevention)- – Mydriasis
Follows detoxification; the goal is to prevent the
– Body ache and insomnia
patient from relapsing to alcohol use
– Hypertension, anxiety, tachycardia
• Pharmacological agent
– Anticraving agents- Help decrease the Treatment
craving for alcohol. The preferred are • Detoxification- Focuses primarily on managing
naltrexone and acamprosate. Others include the withdrawal symptoms.
topiramate, baclofen, and serotonergic
agents like fluoxetine – Long-acting opioids like methadone
(preferred) or dextropropoxyphene are used
– Deterrent agents (aversive agents)-
Disulfiram, acts by inhibiting the enzyme • Maintenance of abstinence
aldehyde dehydrogenase leading to the – Opioid substitution therapyQ- methadone,
accumulation of acetaldehyde after alcohol buprenorphine. Harm reduction approach as
consumption. This results in an unpleasant the patient is shifted from more harmful
reaction called as ‘disulfiram ethanol and often parenterally administered and
reaction’ short-acting opioids (like heroin) to less
harmful. orally taken and long-acting opioids
• Non-pharmacological management
like methadone (preferred).
– Alcoholic Anonymous (12 steps self-help
– Naltrexone- Can be given to the patient
group)
after detoxification is complete

OPIOIDS – Narcotic anonymous (12 step self-help group)

• Heroin (diacetylmorphine)
CANNABIS
– m/c abused opioid
• Derived from the hemp plant, Cannabis Sativa
– street name- smack, brown sugar
• m/c used illegal drug in India and the world
• Other commonly abused opioids include
morphine, codeine etc. • δ-9 tetrahydrocannabinol (THC) is the active
ingredient
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Psychiatry

• Street name- Joints, marijuana, grass, pot, • Paranoid ideations (persecutory ideations) +
weed etc auditory hallucinations
• Tactile hallucinations or cocaine bugs or magnan
Intoxication
phenomenon or formication (sensation of insects
• Euphoria, sense of slowing of time, sense of crawling under the skin)Q
floating in the air, reddening of the conjunctiva,
increased appetite, dryness of mouth
TOBACCO
• Depersonalization, Derealization, synaesthesia,
• Most common substance used in India
illusions
• Nicotine, the active ingredient, is a stimulant
Withdrawal symptoms
Withdrawal symptoms
• Irritability
• Develop within 2 hours and peak in 24-48 hours.
• Depressed mood, sleep disturbances, headaches
Include
etc.
– Irritability

HALLUCINOGENS – Poor concentration

• Includes drugs like LSD (lysergic acid – Anxiety, restlessness

diethylamide), mescaline, psilocybin, – Bradycardia
methylenedioxyamphetamines (MDMA,
ecstasy), phencyclidine (angel dust), ketamine – Drowsiness but paradoxical insomnia

• Intoxication symptoms – Increased appetite, wt gain

– Depersonalization, Derealization, – Depression

synaesthesia, illusions – Constipation
TreatmentQ
COCAINE
• Nicotine replacement therapy- Various
• Derived from the plant, Erythroxylum coca preparations include nicotine gums, nicotine
• Was initially used as a local anaesthetic (as it lozenges, nicotine patches, nicotine inhalers
blocks fast sodium channels), especially for and nicotine spray.
ENT surgeries. • Medications
• Blocks dopamine and norepinephrine receptors – Varenicline (most effective)
(dopamine & NE reuptake is inhibited) resulting
in- – Mechanism of action- Partial agonism at
α4β2 & α7 nicotinic acetylcholine receptors.
– Vasoconstriction: HTN, MIQ As a partial agonist prevents high and
– Nasal septal perforation (nasal inhalation of reinforcement and also controls craving and
cocaine results in nasal congestion and long- withdrawal.
term use can cause nasal septal perforation) – Side effects- nausea, insomnia, ??suicidal
– Seizures thoughts (initially warning was given that
varenicline can cause suicidal ideations,
– Jet black pigmentation of tongue later the warning was withdrawn)

Intoxication – Bupropion, clonidine and nortriptyline too

can be used but are not as effective.
• Euphoria
• Sympathetic symptoms (tachycardia,
palpitations, hypertension, sweating, mydriasis)
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Cerebellum Quick Revision Notes

NEUROCOGNITIVE DISORDERS – Hip fractures, open heart surgery,

severe burns, infections like pneumonia,
postoperative patients, critically ill patients
A. DELIRIUM
– Alcohol and sedatives withdrawal
• Most common neurocognitive disorders with an
acute onset – On multiple medications (especially with
anticholinergic actions)
• More common in old age
– Sensory deprivation (e.g. Black patch delirium
• Sudden onset & fluctuating course
after cataract surgery)
• Symptoms-
• Neurotransmitter involved- Acetylcholine
– Disturbances of consciousness (hallmark
• Neuroanatomy- ARAS (ascending reticular
symptom)Q
activating system) dysfunction.
– Disorientation to time, place and person
• Diagnosis- Clinical (i.e. made if characteristic
– Perceptual disturbances like illusions and symptoms are present). Certain tools can be
hallucinations used to identify the cognitive impairment-
– Transient delusions – MMSE (mini mental status examination)
and MSE are used to measure cognitive
– Impairment of attention
impairment
– Memory disturbances (recent and immediate,
– Confusional assessment method to identify
remote is intact)
patients with delirium
– Agitation (or hypoactivity), autonomic
• Common finding- Generalised slowing on EEG
disturbances
(alcohol and sedative withdrawal delirium- low
– Sleep-wake cycle disturbancesQ voltage fast activity)
– Sundowning- Symptoms of delirium tend to • Treatment- Treat the cause; benzodiazepinesQ
worsen during the night; this phenomenon is & antipsychotics can be used in some case
called ‘sundowning’
• Causes
MMSE (mini mental status examination)
• Assesses five cognitive functions
– Medical and surgical disorders/in hospitalised
patients. • Maximum score on MSE- 30
• Score less than 24 indicates cognitive
impairment
Delirium Vs Dementia
DELIRIUM DEMENTIA
Onset Sudden onset Insidious onset

Consciousness Dist. of consciousness Not present

Course Fluctuating course Progressive course

PERSONALITY DISORDERS • Impulsivity

• Intense but unstable relationships
BORDERLINE PD (EMOTIONALLY • Indulge ins self-injurious behaviour (e.g. cutting
UNSTABLE PD) the wrist, overdosage of medications)
These individuals have the following characteristics- • Identity disturbances, unstable self-image
(suddenly change life goals, values, career plans,
• Emotional instability
sexual identity)
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Psychiatry

• Splitting (seeing things in black and white)Q ANOREXIA NERVOSA

• Management - Psychotherapy (dialectical
behaviour therapy),Q antidepressants,
antipsychotics, carbamazepine

IMPULSE CONTROL DISORDERS

• They are characterised by repeated failures to
resist an impulse/drive to perform an act that
is clearly harmful to the self or others.
• In these disorders-
– There is an impulse to do a particular act
– Followed by a feeling of increasing tension
– Action is taken, and after performing the
behaviour, there is a sense of relief or even
gratification Anorexia nervosa is characterised by the following
– After some time, the individual feels guilt features-
• Restriction of energy intake resulting in
TYPES significantly less weight than normal (BMI (body
mass index) less than 18.5 kg/m2 ). The severity
– Pyromania- Repetitive episodes of deliberate of anorexia nervosa is defined on the basis of
fire setting BMI in adults and BMI for age percentiles in
– Kleptomania- Repetitive episodes of stealing, children and adolescents
the stolen items are usually of no value to • Disturbance of body imageQ ( the way one’s
the individual. body weight or shape is experienced)
– Intermittent explosive disorder- Repeated • Excessive fear of gaining weight (despite having
episodes of significant aggression in which significant weight loss)
the individual may assault others or destroy
property. • Medical signs and symptoms of starvation such
as
– Compulsive sexual behaviour disorder
(Satyriasis, nymphomania)- Persistent – Amenorrhea, lanugo (neonatal hairs)
pattern of inability to control sexual – Hypothermia, dependent edema
impulses, resulting in repetitive and often
– Bradycardia.
dangerous sexual behaviour. The terms
‘satyriasis’ and ‘nymphomania’ are used to • Poor sexual development (adolescents), low
describe excessive sexual desire in males interest in sexual activities (adults)
and females, respectively.
• Endocrine abnormalities (Decreased FSH, LH,
– Oniomania- Repetitive shopping CRH, increased Cortisol)
– Mutilomania- Mutilation of animals • Patients with anorexia nervosa are secretive
and deny having any symptoms
EATING DISORDERS • More common in females, most common age of
onset is in the mid-teens
All eating disorders are more common in females
• Anorexia nervosa is a misnomer since there is no
‘anorexia or ‘loss of appetite’ in these patients.
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Cerebellum Quick Revision Notes

Subtypes of Anorexia Nervosa- forceful vomiting

• Restricting type- 50% (characterised by highly • Weight is usually normal (helps in differentiation
restricted food intake ) from anorexia nervosa)

• Binge eating/purging type (alternating with • Sexual functioning is normal

restricted food intake, are episodes of binging • Usually, patients are not secretive
and purging)
• Treatment- Cognitive behavioural therapy,
Treatment SSRI
• Hospitalisation is indicated in cases of
dehydration, electrolyte imbalance and SLEEP DISORDERS
significant weight loss (if patient’s weight is 20
per cent below the expected)Q a. Narcolepsy:
• Calorie intake is gradually increased • There is reduced latency of REM sleepQ

• Behavioural therapy Symptoms

• SSRIs, TCAs, cyproheptadine – Hypnagogic and hypnopompic hallucinationsQ
• In case of failure to gain weight, suspect – Cataplexy: Sudden loss of muscle tone
purging (self-induced vomiting) after the meals,
and supervision for 2 hours after the meals is – Sleep attacks: Irresistible urge to sleep
recommended. – Sleep paralysis

Etiology
BULIMIA NERVOSA
– Deficiency of hypocretinQ
• More common than anorexia nervosa
– Hypocretin-secreting neurons project from
• Usual age of onset- late adolescence, more
the hypothalamus
common in females than males.
– Immune - mediated disorder, causes
• It is characterised by-
destruction of these neurons
– Episodes of binge eating (Eating a large
– Strong association with human leucocyte
amount of food in a short duration, along
antigen class II (HLA-DR2 and HLA-
with a feeling of ‘loss of control’ during the
DQB1*0602)
episode)
– Followed by inappropriate ways of stopping Management
wt gain, such as – Modafinil (stimulant)
ƒ Purging (most commonly by self-induced – Forced naps
vomiting, other ways include the use of
laxatives, diuretics, emetics, and use of – Patients should not do any potentially
enemas) dangerous activity alone (e.g. driving,
swimming)
ƒ Hypergymnasia (excessive exercising)

– Fear of gaining weight SLEEP RELATED ENURESIS

• Purging behaviour can lead to the following- Q
• Usually psychogenic (e.g. due to ‘sibling rivalry’)
– Dental caries (enamel erosions) – Rule out organic causes before making
– Callouses on knuckles, a diagnosis of psychogenic nocturnal
enuresis(e.g DM, DI, UTIs, obstructions)
– Parotitis (salivary gland inflammations),
– TOC- Bed alarms (behavioural therapy)
– Hypokalemic and hypochloremic alkalosis
– DOC-DesmopressinQ
– Rarely, oesophageal or gastric tear during
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Psychiatry

– TCAs (like imipramine) can be used too Treatment

• Hormonal treatment- Individuals who identify
SEXUAL DISORDERS with the male gender are offered testosterone
treatment. Individuals who identify with
GENDER DYSPHORIA (GENDER the female gender are offered estrogen,
progesterone, and testosterone blockers.
INCONGRUENCE)
• Sex reassignment surgery
• Characterised by incongruence between the
experienced gender (the gender with which an
individual identifies with) and the one they were SEXUAL RESPONSE CYCLEQ-
born with (referred to as assigned gender) • Divided into four phases-
A. Gender dysphoria in adolescents & – Desire
adults – Excitement (arousal) - Final part of the
• Desire to live and be treated as the other excitement phase is called as plateau phase
gender. – Orgsam (shortest phase),
• Discomfort with one’s anatomical sex organs – Resolution
• Desire to change the sex organs & convert into
the opposite gender ERECTILE DYSFUNCTION (MALE
• ‘I am a man trapped in a women’s body’ or vice ERECTILE DISORDER)
versa (key phrase for exams)
• Most common cause: Psychogenic
• Most common organic cause: Diabetes

Psychogenic ED Organic ED

History of early morning erections and nocturnal erections + -

Penile plethysmography + -

Nocturnal penile intumescence + -

Treatment of ED Treatment

• PDE-5 inhibitors like sildenafil, tadalafil • SSRIsQ

• Oral phentolamine • Squeeze technique (coronal ridge of glans)

• Injectable & transurethral alprostadil • Stop-start technique (semans technique)

• Dual sex therapy (or sex therapy) • Sex therapy

– Masters & Johnsons technique
– Couple is treated
PARAPHILIAS
• Sexual arousal and orgasm achieved by sexual
– Focuses on Improving communication
stimuli/acts that are deviations from normal
– Sensate focus exercises- Include nongenital sexual behaviour
sensate focus & genital sensate focus
Types
PREMATURE EJACULATION • Voyeurism- Watching an unsuspected person
during undressing/naked state/ engaged in
• DSM-5 definition, < 1 min sexual activity.
• Cause- Usually psychogenic
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Cerebellum Quick Revision Notes

• Exhibitionism- Exposing one’s genitalia to an ƒ Methylphenidate is considered the drug of

unsuspected person choice for the treatment of ADHD
• Frotteurism- Touching/rubbing against a
nonconsenting person, usually in public places PERVASIVE DEVELOPMENTAL
such as a bus or in the metro. DISORDERS
• Sadism- Inflicting physical or psychological • A group of neurodevelopmental disorders that
suffering on another person.
include-
• Masochism- Sexual arousal and gratification
are achieved from acts of being tortured or A. Autism-
otherwise made to suffer. Autism is characterised by the following symptoms-
• Pedophilic disorder- Sexual arousal and • Impairment in social interaction, as manifested
gratification are achieved through sexual by
activity with a prepubescent child
– Poor eye contact, lack of social smile and
• Fetishism: Use of non-living objects or non- anticipatory posture
genital parts
– Poor attachment to parents and others
• Transvestism: Cross-dressing
– Difficulty in making friends

CHILD PSYCHIATRY • Restricted, repetitive behaviours, as manifested

by

ATTENTION DEFICIT – Repetitive plays

HYPERACTIVITY DISORDER – Stereotyped movements like hand wringing,

spinning and head banging
• More common in boys
– Lack of imaginative & interactive play
• Symptoms of ADHDQ
– If routines are disturbed, may have an
– Inattention - Difficulty in giving close
excessive reaction
attention to details, makes frequent mistakes
in school work, distractible, frequently • Impairment of communication and language, as
shifts from one activity to another without manifested by
finishing the task – Delayed language milestonesQ
– Hyperactivity - Keeps on roaming in the – Abnormal sentences formation, pronoun
class, disturbs other students too reversals
– Impulsivity- Can’t wait for his turn, answer
even before the question is complete B. Rett’s disorder (Rett’s syndrome)
– Other symptoms- Destructive behaviour, • Much more common in females than males
irritability • Normal development till 5 months, between
• Children with ADHD may have soft neurological 5-48 months, there isQ
signs (difficulties in copying age-appropriate – Deceleration of head circumference
figures, and difficulty in right-left (resulting in microcephaly)
discrimination). Soft neurological signs are fine
– Loss of acquired hand skills and speech
abnormalities that can be elicited only during a
detailed neurological examination. – Poor gait

• Treatment – Impairment in social interaction; restricted,

repetitive behaviours & impairment of
– Pharmacotherapy
communication and language
ƒ Pharmacotherapy with stimulants is
• 75% of the patients have seizures
considered the first-line treatment.
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Psychiatry

In both ICD-11 & DSM-5, the diagnosis of ‘pervasive Management

developmental disorders’ has been replaced by a
new diagnosis of ‘autism spectrum disorder’. All • Behavioural therapy, Family therapy
the subtypes have been removed too, and language • Low dose antipsychotics
dysfunction has been removed as a core criterion
PSYCHOANALYSIS
MENTAL RETARDATION • Father of psychoanalysis- Sigmund Freud
(INTELLECTUAL DISABILITY) • According to psychoanalysis, childhood
• Characterised by Incomplete development of experiences and memories, and unconscious
intellectual functions and adaptive skills mental activity (activity of mind which we are not
aware of) plays an important role in determining
• Intellectual functioning is measured by human behaviour and in the development of
calculating the IQ (intelligence quotient) psychiatric disorders.
• IQ = Mental age/chronological age X 100 • Term “psychoanalysis” is used to refer to both
this theory & the treatment method based on
Normal 90-109
it.
Borderline Intelligence 70-89 • Freud proposed a theory of mind, called the
Mild Mental Retardation 50-69 topographical theory of mind, according to
which the mind has three parts-
Moderate Mental Retardation 35-49
ƒ Conscious - Part of the mind, accessible
Severe Mental Retardation 20-34 to us
ProfoundMental Retardation <20 ƒ Preconscious- Content of the preconscious
mind is not accessible to us; however, by
• Most common chromosomal cause of mental concentrating our attention on it, we can
retardation is Down syndrome followed by bring it into our conscious awareness. The
fragile X syndrome preconscious mind has a barrier called
‘repression’, which normally does not allow
the contents of the unconscious mind to
DISRUPTIVE BEHAVIOUR reach the conscious mind
DISORDERS
ƒ Unconscious - Not accessible to the
Oppositional defiant disorder and conduct disorder individual, contains distressing memories
are the two major disruptive behaviour disorders. and instinctual drives (i.e. the drives and
A. Conduct disorder- Characterised by a persistent desires one is born with)
pattern of ‘disregard for rights of others’ and • Freud used different techniques to gain access
aggressive and dissocial behaviour, and manifests with to the unconscious mind, including-
the following-
– Free association- Technique developed by
• Stealing , repeated lying, aggression, bullying, Freud, which involves
cruelty towards animals, disobedience, running ƒ Unguided communication (patients are
away from school asked to say whatever comes into her
• High risk of later development of antisocial mind without censoring)
personality disorder ƒ Slips of tongue ‘parapraxis’ are analysed
B. Oppositional defiant disorder- Characterised by – Abreaction:Q Recall of forgotten material
negativistic and defiant behaviour towards adults with the expression of associated emotions.
and authority figures. Can be considered a milder
• Transference-Q Feeling that the patient
form of conduct disorder, unlike conduct disorder,
develops for the doctor; it’s a combination of
there are no serious violations. the feelings patient had for important figures
from the past and the real feeling for the
clinician
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Cerebellum Quick Revision Notes

• Countertransference- Feeling the clinician accompanying emotions. E.g. A highly stressed

develops for the patient. medical student, facing an upcoming entrance
exam, chooses to take a one-day break and
STRUCTURAL THEORY OF MIND doesnt think about the exam at all. It is the only
voluntary/conscious defense mechanism
• Given by Sigmund Freud
• According to this theory, components of the MISCELLANEOUS
mind include-
ƒ Id- Consists of instinctual drives, and ELECTROCONVULSIVE THERAPY
works on pleasure principle
ƒ Ego- Part of the mind that deals with the Types-
external world, works on reality principle 1. Direct ECT - Anesthetic agents and muscle
ƒ Superego- Part of the mind that works on relaxants are not used
moral principle
2. Indirect ECT (Modified ECT)- Anesthetic agents
and muscle relaxants are used
DEFENSE MECHANISMS • Methohexital is the anaesthetic agent of choice
• Mechanisms used by ego to prevent buildup of
• Thiopental and propofol, can also be used
excessive anxiety
• Are unconscious • Succinylcholine, used as a muscle relaxant

• Displacement: Transfer of emotions from one • Atropine, used to decrease secretions

individual to another. Involved in phobias. E.g. • Indications
After being scolded by the consultant, a senior
resident entered the ward and started shouting – Depression with suicide risk (First line)
at the intern – Depression with stupor (First line)
• Reaction formation: Transforming an impulse – Depression with psychotic symptoms
into its exact opposite behaviour. E.g. A man
who is infatuated with an office colleague tells • Side effects
his friend that he ‘really hates’ her. – Memory disturbances - Retrograde amnesia
• Sublimation: Transformation of a socially is more common (mild, recovery in 1-6
unacceptable impulse into socially acceptable months)
behaviour. E.g. A middle-aged man with – Headache, muscle aches, fractures, tooth
unacceptable sexual desire becomes a painter dislocations, rarely delirium
and starts making nude paintings
– Prolonged seizures- If seizure continues for
• Anticipation: Preparing in advance for an
more than 180 seconds
unpleasant situation. E.g. A student plans all his
arguments comprehensively before telling his – Absolute contraindication for ECTQ- None.
father about a bad exam result Earlier raised intracranial tension was
considered an absolute contraindication.
• Humour: Use of comedy to deal with an
unpleasant situation. E.g Two medical students
joked and laughed at themselves after getting MENTAL HEALTHCARE ACT, 2017
humiliated by the examiner during the viva (MHCA 2017)
• Altruism: Use of a social cause to deal with own
• Deals with rights of patients with mental illness
emotions. E.g. After losing his son in an accident
and treatment delivery. Important clauses-
while driving drunk, a man launched an anti-
drunk driving campaign, educating others about A. Advance directiveQ- Every person (not a minor)
the dangers of driving under the influence. can make an advance directive n which he can
mention-
• Suppression: A voluntary decision not to think
about an event for some time and avoid the • How they wish to be treated/not treated for a
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Psychiatry

mental illness
• Applicable only if a person loses the capacity to
take mental healthcare or treatment decisions
• Duty of psychiatrist (or medical officer) to give
treatment according to the advance directive
B. Nominated representative (NR)
• Every person can appoint a nominated
representative
• In case of loss of capacity to make mental
healthcare and treatment decision, NR would
help in taking decisions about treatment
C. Ban on direct ECT
D. Ban on ECT for minors
E. Ban on psychosurgery
F. Decriminalisation of suicide attemptQ- Any
person who attempts suicide shall be presumed to
be under severe stress and should not be tried or
punished.