Psychiatry Revision Edition 8 (1)

Contents
Psychiatry Revision - 1 1
PSYCHIATRY REVISION - 1 ----- Active space -----
Psychosis 00:02:45
Neurotic vs. Psychotic Symptoms :

• Judgement (Prefrontal cortex)
+
• Insight/Epiphany ↓/ -
Neurotic Illness • Personality changes Psychotic Illness
• Reality contact
PSYCHOTIC SYMPTOMS
Delusion :
False fixed belief. Note : Idea False fluctuating belief.
Types of delusions :
Delusions of
Persecution/ Grandiosity : Poverty : Reference

Paranoid (M/c) Seen in mania. Seen in depression.
Named delusions :
Delusion of infidelity/jealousy
Othello Syndrome
(Commonly seen in chronic alcoholism)
• AKA Cocaine bugs/psychosis/formication.
Magnan Syndrome
• Delusion of persecution + tactile hallucination.
Erotomania/Delusion of love/
-
De Clerambault syndrome
Severe depression + Nihilistic delusion
Cotard Syndrome
(Delusion of negation)
• AKA Delusional parasitosis.
Ekbom Syndrome • Type of restless leg syndrome.
• Match box sign + .
• Negative : Capgras Syndrome/Delusion of doubles
- Known person is believed to be a stranger.
Delusion of misidentification
• Positive : Fregoli Syndrome
- Stranger is believed to be a persecutor.
Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

2 Psychiatry
----- Active space ----- Hallucination :

• Perception without stimuli.
• Auditory hallucination : M/c in schizophrenia.
• Visual hallucination : M/c in organic mental illness/neurocognitive disorders.
Note : Illusion Misinterpretation of stimuli
Types :
True hallucinations : Originates from outer objective space.
Pseudohallucinations : Originates from inner subjective space.
Special Hallucinations :
• Extracampine hallucination : Hallucinatory experience from beyond sensory
field.
• Hallucinations that originate from a stimulus :
Functional hallucination : Reflex hallucination :

• Stimulus & hallucination are of • Stimulus & hallucination are of
same modality. different modality : Synesthesia.
• Eg : Another voice heard when • Eg : Voice heard on turning on light.
someone speaks.
Schizophrenia 00:29:54
IMPORTANT CONTRIBUTIONS
Eugene Bleuler :
Coined the term ‘Schizophrenia’ & the diagnostic 4 A’s.
Autism Ambivalence Affective Blunting/ Association : Lost

Flattening
Note : Auditory hallucination is not a part of 4 A’s of Bleuler.
Emil Kraepelin :
Psychosis
Good prognosis : Manic depressive psychosis Bad prognosis : Dementia Praecox

(AKA BPD) (AKA schizophrenia)
• Episodic • Chronic & continuous
• Mood Symptoms • Cognitive decline
Kurt Schneider : ----- Active space -----

1. First rank symptoms :
3 auditory hallucinations 3 made phenomena 3 thought phenomena
• 1 person
st
• Made impulse • Thought insertion
• 2nd person :
• Made volition • Thought broadcast
Commanding & commentary
• Made affect • Thought withdrawal
• 3rd person
2. Somatic passivity/Delusion of control : Believes being controlled by an external
agency.
3. Primary delusional experience.
DIAGNOSTIC CRITERIA
Following symptoms are seen for >1 month (ICD)/>6 months (DSM) :
Positive psychotic symptoms Negative psychotic symptoms
(Mesolimbic pathway) (Mesocortical pathway)
• Apathy
• Delusions. 1 out of 3 must • Avolition
• Hallucinations. be present • Attention deficit
• Disorganized thinking. for diagnosis. • Anhedonia
• Disorganized/Catatonic behavior. • Alogia
• Affective blunting/flattening
Note : Mesocortical pathway Cognitive symptoms of psychosis.
TIMELINE FOR DIAGNOSIS

Duration of symptoms Disorder
<1 month Acute Transient Psychotic (ATP) disorder
ICD 11
>1 month Schizophrenia
<1 month Brief psychotic disorder
DSM V 1-6 months Schizophreniform illness
>6 months Schizophrenia
D/D
Delusional Disorder :
Delusional disorder Schizophrenia
Delusions
Delusions + other
Symptoms • >1 month (DSM V)
psychopathology (FRS+)
• >3 months (ICD)
Type of delusions Simple Complex/bizarre
Vegetative symptoms
(Sleep/Appetite) & Normal Abnormal
Daily functioning

4 Psychiatry
----- Active space ----- PROGNOSTIC FACTORS

Better prognosis Worse prognosis
Onset Acute Gradual
Age of onset Late Early
Presence of preceding
+ -
stressor
Gender Female Male
Symptoms More positive symptoms More negative symptoms
Family history - +
Mood symptoms + -
Compliance to medication Compliant Non compliant
Family support + -
Substance abuse - +
Premorbid personality
- +
disorder
Neurodevelopmental delay
H/o perinatal asphyxia/ - +
obstetric complications
Multiple hospital admissions - +
Antipsychotics 00:51:13
Duration of treatment : For 1st episode of psychosis 1-2 years (Minimum : To

avoid relapse).
TYPES
Typical antipsychotics Atypical antipsychotics
Generation First (Older) Second (Newer)
Antipsychotic effect by Blockade of all D2 receptors Blockade of 80% of D2 receptors
Receptor interaction - Fast dissociation
Extrapyramidal side
Prominent Less prominent
effects (EPS)
Metabolic side effects :
• Sedation.
Other side effects Neurotoxicity • Weight gain.
• Dyslipidemia.
• Hyperglycemia

Third Generation : ----- Active space -----

MOA : 2nd generation + 5HT1a partial agonist.
Drugs :
• Aripiprazole. • Cariprazine.
• Brexpiprazole.
CLOZAPINE
• Most effective antipsychotic.
• DOC : Treatment resistant schizophrenia
(Refractory to 2 different antipsychotics).
Side effects :
• Agranulocytosis. • ↑Salivation.
• Myocarditis. • ↓Seizure threshold (Dose-dependent).
• Metabolic side effects (Sedation, weight gain, dyslipidemia, hyperglycemia).
EXTRAPYRAMIDAL SIDE EFFECTS

Acute :
Akathisia Acute dystonia
• Oculogyric crisis
• Inner restlessness ↑Risk of suicide
• Orolingual dystonia
C/f • Motor movements
• Laryngeal dystonia
(↑Lower limb movements)
• Limb dystonia
• b-blockers (M/c : Propranolol)
Antihistamines/
Rx • Benzodiazepines
Anticholinergics
• Trihexyphenidyl
Chronic :
• Tardive dyskinesia :
- Rabbit syndrome (Perioral tremors).
- Rx : VMAT 2 inhibitors (Tetrabenazine/Deutetrabenazine/Valbenazine).
• Tardive dystonia.
Lethal :
• Laryngeal dystonia.
• Neuroleptic malignant syndrome :
C/f Ix TOC
• ↑CPK Mnemonic : BADE
• Fever/hyperthermia • ↑WBC • Bromocriptine
• Lead pipe rigidity • Myoglobinuria • Amantadine
• Delirium (M/c cause of death in • Dantrolene
NMS d/t renal failure) • ECT

6 Psychiatry
----- Active space ----- Catatonia 01:05:00
Etiology : Frontal lobe dysfunction d/t

• Mood disorders.
• Schizophrenia.
• Organic mental illness.
Clinical features :
• Posturing :
- Catalepsy.
- Waxy flexibility.
- Psychological pillow : Neck remains elevated even upon removal of pillow.
• Automatic obedience.
• Mutism.
• Withdrawn.
Management :
Lorazepam trial test :
No response
Improvement in 48-72 hours Electroconvulsive therapy.

Assessment of Mood :
Mood vs. Affect :
Mood Over a period of time
• Current state of emotion (Cross-sectional).
Affect
• Incongruent affect : Disconnect b/w thoughts & mood (seen in psychosis).
Reactivity :↓ in schizophrenia & depression.
Range : Restricted/flattened/blunted affect seen in schizophrenia.
Depression 00:06:28
Presentation :
Core Others
Mnemonic : DIGESCAPS
• Depressed affect
• Interest ↓
• Guilty (Pathological)
Mnemonic : EMI
• Energy ↓
• Energy ↓
• Sleep problems (Terminal insomnia/
• Mood ↓
Symptoms early morning awakening)
• Interest ↓/Anhedonia
• Concentration issues
• Appetite changes (↓Weight)
• Psychomotor changes
• Suicidal behavior
+/- Psychotic symptoms
Severity : Mild Moderate/severe.
(Mood congruent/secondary symptoms)
Criteria for
2 out of 3 symptoms for ≥2 weeks 5 out of 9 symptoms for ≥2 weeks
diagnosis
Types :
Based on number of episodes :
• Single episode.
• Recurrent depressive disorder (ICD) : ≥2 episodes.
- AKA major depressive disorder (DSM-5)/Unipolar depression (Earlier term).

8 Psychiatry
----- Active space ----- Chronic major depression : Presence of symptoms for >2 years.
Double depression : Patient with dysthymia developing depression.
Premenstrual Dysphoric Disorder (PMDD)/Premenstrual syndrome (Earlier term) :

Depressive symptoms before If recurrent
↑Risk of depression.
onset of menstrual cycle
Seasonal affective disorder:
• Depressive episodes especially during winters with no other triggers.
• Rx : Phototherapy (Light therapy).
Note :
• Duration of depressive episodes : 6-9 months (M/c).
• Dysthymia : Chronic low mood (For >2 years).
Atypical depression :
• Features :
- Hypersomnia. - Leaden paralysis.
- Hyperphagia (↑Carbohydrate - Preserved reactivity.
cravings ↑Risk of obesity). - Interpersonal sensitivity.
• Rx : MAOIs > SSRIs.
Note : Avoid TCA in atypical depression.
Objective Signs of Depression :

Omega sign Veraguth fold
Described by Charles Darwin Otto Veraguth
Appearance Omega shaped fold at the root of nose Triangular folds in upper eyelid
D/t contraction of Corrugator muscles Palpebral muscles
Pharmacologic Management of Depression 00:26:44
Typical Antidepressants :
SSRIs SNRIs TCAs
• Most lethal
Onset of action : 2-3 weeks
Dual-acting : antidepressant
Features (D/t downregulation of post-synaptic
↑5HT & ↑NE • Rx for TCA toxicity :
5HT receptors)
Sodium bicarbonate

----- Active space -----
SSRIs SNRIs TCAs

• Sedation
• Weight gain
• Cardiac toxicity
(D/t initial ↑serotonin)
Hypertension (D/t long- • ↓Seizure threshold
Side • GI distress
term Venlafaxine usage) • Anticholinergic :
effects • Sexual dysfunction
- Blurred vision
• Sleep issues : Vivid dreams
- Confusion
- Constipation
- Dryness of mouth
• Venlafaxine
• Paroxetine : Maximum
• Duloxetine, Milnacipran
withdrawal symptoms
C/I in
Drugs • Fluoxetine : Least -
pregnancy Note : Pain Mx
withdrawal symptoms
in fibromyalgia
• Sertraline : DOC in pregnancy
(FDA approved).
Atypical Antidepressants :
Mirtazapine :
α2 blocker.
• MOA : NaSSA
Selective Serotonin antagonist Blocks 5HT2A, 5HT3, & 5HT2C.
• Side effects :
- Weight gain
D/t 5HT2c blockade.
- Sedation
- Agranulocytosis.
Trazodone :
Side effects : Priapism.
Newer Antidepressants :
Vilazodone : 5HT1A partial agonist.
Vortioxetine : Multimodal serotonergic agent.
• Blocks SERT (Serotonin receptor). • 5HT1D & 5HT3 antagonist.
• 5HT1A : Full agonist. • 5HT7 antagonist : Procognitive effect.
• 5HT1B : Partial agonist.

10 Psychiatry
----- Active space ----- Resistant Depression :

• Incidence : 10-20 %.
• Esketamine (FDA approved).
Augmentation strategies Combine antidepressant with :

• Another antidepressant. • Low dose Antipsychotics.
• Somatic Rx (ECT/rTMS). Lithium.
Thyroxine.
Folic acid.
Antidepressant Associated Conditions :
1. Serotonin Syndrome :
• Etiology : Antidepressant + drug that ↑ serotonin levels.
(Example : Tramadol/another antidepressant).
• Features :
- Acute altered sensorium
Delirium.
- Autonomic dysfunction
- Brisk deep tendon reflexes.
- ↑Plantar response.
- Myoclonus/clonus.
• Rx : Cyproheptadine (DOC).
2. Neuroleptic Malignant Syndrome (NMS) : Lead pipe rigidity.
Non-Pharmacologic Mx of Depression 00:45:20
Modified Electroconvulsive Therapy (ECT) :

• Only acceptable form of ECT.
• Short-acting Anaesthetic agent : Methohexital (DOC).
Muscle relaxant : Succinylcholine-like drugs.
• Monitoring
Advantages
• ↓Orthopaedic complications
Electrode Bifrontotemporal (M/c) : 2-4 cm above midpoint of line joining tragus
placement & eye’s lateral canthus
• Severe mood disorders • Catatonia
Indications • ↑Suicide risk • Resistant Seizures
Rarely
• NMS • Parkinsonism
• Body ache/headache (M/c)
Side effects
• Amnesia (Reversible in 48-72 hours) : Retrograde > Anterograde
• Minors
C/I
• ↑ICT (Relative)

Repetitive Transmagnetic Stimulation (rTMS) : ----- Active space -----
MOA : 8 or H-shaped coil Current is Electromagnetic Stimulate Brain tissue.

passed waves produced
Advantages : Indication :
• Anesthesia not required. • Depression.
• No loss of consciousness. • OCD.
• Resistant auditory hallucinations.
Disadvantage : ↓Effectiveness than ECT.

Area stimulated in depression : DLPFC (Dorsolateral Prefrontal Cortex).
Vagus Nerve Stimulation :

Indications : Drawbacks : Mechanism :
• Resistant seizure disorders. • Hoarseness of voice. Stimulation of left
• Resistant depression. • Neck pain. vagus nerve.
Phototherapy :
Indications : Seasonal affective disorder.
Mechanism :
UV filtered white light 15-45 minutes Modulation of Improves mood.
(5000-10,000 lux units) Serotonergic pathway
Psychological Rx :
• Cognitive Behavioral Therapy (CBT). • Solution Focused Therapy (SFT).
• Interpersonal Psychotherapy (IPT). • Psychodynamic therapy.
Post-partum Mental Disorders 00:57:40
Postpartum period : Following delivery 4 weeks (DSM-5).

6 weeks (ICD-1I).
Postpartum/baby blues Postpartum psychosis Post partum depression
Timing (After • Occurs & resolves in <2 weeks • Abrupt onset
Onset : 2-4 weeks
delivery) • Lasts for 2-3 days • Within 2 weeks
Incidence M/c (50-80%) 1 in 1000 (Rare) -
Self-limiting, irritable, tearful, • Psychotic symptoms + • Mnemonic : DIGESCAPS
Features
sleep disturbances • Poses danger to baby & self • ≥2 weeks duration
Antidepressants :
• Sertraline (Preferred)
Treatment Reassurance Antipsychotics
• Brexanolone (FDA
• Zuranolone approved)
12 Psychiatry
----- Active space ----- Bipolar Disorder 01:02:42
Types : ≥v1 episode of mania +/- depression/hypoma-

Bipolar type I
nia
Bipolar type II Depression + hypomania only
Mania vs Hypomania :
Hypomania Mania
Severity Mild Moderate to severe
Psychotic symptoms - +/-
Admission - May require
• Flight of ideas
Ideas Prolixity of speech • Clang associations
• Pressurized speech
Rapid Cycling Disorder
Criteria : ≥4 mood episodes in 1 year.
Risk factors :
• Female bipolar patients. • Bipolar type II.
• Hypothyroidism. • Cyclothymia.
• Substance Use disorder. • Hyperthymic personality.
• Antidepressants without mood stabilizer.
Rx : Divalproate (DOC).
Cyclothymia :
Persistent mood disorder (Low mood + hypomania) that lasts >2 years.
Management :
Mania Depression
• Lithium (Caution in pregnancy d/t risk of Ebstein anomaly)
• ECT
• Lamotrigene (Safest in pregnancy)
• Antidepressants + mood stabilizers.
• Carbamazepine C/I in
• Antipsychotics for bipolar depression (FDA approved) :
• Valproate pregnancy
- Quetiapine - Lumateperone
• Antipsychotics (DOC : Acute mania)
- Lurasidone - Olanzapine + Fluoxetine
- Cariprazine
: Mood stabilizers Prophylactic Rx
Lithium :
Therapeutic range :
<0.5 : Ineffective 0.5 - 1.5 mEq/L >1.5 : Toxicity.
Best response : 0.8 - 1.2 mEq/L (Around 1.0 mEq/L).
Side effects : ----- Active space -----

• Hypothyroidism.
Long term.
• Diabetes insipidus nephropathy
• Benign/fine tremors Rx : β-blockers (Propranolol/Trihexyphenidyl).
Lithium toxicity :
• Coarse tremors. • Ataxia.
• Myoclonic jerks. • Nystagmus.
Suicidal Behaviour 01:20:07
Suicide rate : 12.4 (12.4 deaths/1 lakh population).

Attempted suicide rate : 10-25 times more/suicide.
Risk factors :
• M > F (2 : 1). • Undiagnosed/untreated mental illness :
• Alone/aloof/single/unemployed. - Mood disordrs : 15%.
• Access to means & methods : - Schizophrenia : 10-12%.
Doctors ↑Risk. - Anorexia nervosa/Substance use disorder/
• Feeling of hopelessness. Borderline personality disorder : 10%.
Note : ↓Access Best suicide prevention strategy.
M/c method (India) : Hanging.
Management :
• Ketamine therapy (Temporary) : ↑Relapse rate.
• ECT.
Paradoxical Suicide :
↑Risk of suicide in patients on antidepressants.
High Risk groups : Children, adolescent & young adults.
Cause : Rx initiation/Dosage change ↑Energy, ↑agitation & suicidal ideations.
Non-Suicidal Self-Injurious Behaviour (NSSI)

• AKA Deliberate Self-Harm (DSH)/Parasuicide (Earlier Term).
• Self-harm without an intention to die.
M/c mode : Wrist slashing.
Seen in :
• Personality disorders : Borderline/Histrionic/Antisocial.
• Depression.

14
----- Active space ----- PSYCHIATRY REVISION - 3
Psychiatric conditions requiring a causative factor (Life event) :
Grief Acute stress Reaction. Adjustment PTSD

Disorder disorder
Grief 00:03:49
Response to loss of loved one/an object of value.
Stages :
Described by Kubler Ross.
• Denial : Ostrich phenomena.
• Anger.
• Bargaining. Can occur in any sequence.
• Depression.
• Acceptance.
Pathological Grief :
Types Features
1. Absent grief Absence of emotions
2. Hypertrophic grief ↑Reaction (Eg : Suicidal thoughts)
ICD : >6 months
3. Chronic grief Prolonged period of grief
DsM : >12 months
4. Delayed grief Onset of grief ≥2 weeks after triggering event
5. Anniversary grief Annual occurrence of grief
6. Traumatic grief Hypertrophic grief present chronically
Trauma Related Disorders 00:09:50
Acute stress reaction Acute stress disorder Adjustment disorder/Situational depression

Resolution
<2 days ≤ 1 month <6 months
(Post stressor)
Confused/dazed/ • Stressed/anxious • Mild anxiety & depression symptoms
Symptoms
shocked • Hyperaroused • Conduct/behavioural problems

Post Traumatic Stress Disorder (PTSD) : ----- Active space -----

Symptoms : Present ≥4 weeks.
• Hyperarousal/startle response.
• Nightmares.
• Flashbacks.
• Avoidance behaviour.
Risk factors :
• Females.
• H/o childhood/past trauma.
• An external locus of control (Example : Flood).
• Mental illness : Personality/anxiety/substance use disorders.
Mx :
Pharmacologic Behavioural
• SSRI/SNRI • CBT (Best)
• Prazosin (a-1 blocker) : • Eye Movement Desensitisation & Reprocessing
Rx for nightmares (EMDR) : Most specific for PTSD
Anxiety Disorders 00:18:13
Abnormal anxiety :
• Causes significant distress (Self/others) & dysfunctionality.
• ↑Duration.
Normal situations Stressors +
Trait anxiety :
Anxiety + Anxiety ↑
Prone to recurrence
State anxiety :
Relaxed Anxiety +
Quicker recovery
GENERALIZED ANXIETY DISORDER (GAD) :

• M/c anxiety disorder.
• Females > Males.
Symptoms : Present >6 months.

• Free floating anxiety.
• Motor tension/restlessness : Inability to relax.
• Sleep disturbances.
• Irritability.
16 Psychiatry
----- Active space ----- Mx :

Pharmacologic Rx Psychologic Rx
• SSRI/SNRI
• Jacobson’s Progressive Muscle
• Pregabalin
Relaxation (JPMR) technique
• Buspirone (5HT1A partial agonist)
• Deep breathing technique
Anxiolytic
• Guided imagery (visualization) technique
- Advantage : No sedation/addiction
• Mindfulness based stress reduction
(No action on GABA receptor)
technique
- Disadvantage : Late onset of action
PANIC DISORDER : Panic attack triggers

Characteristics : • Caffeine.
• De novo recurrent panic attacks. • Cannabis, cocaine.
• Panic attack : Brief intense anxiety episode • Cholecystokinin.
of 5 - 15 minutes. • CO2/lactate accumulation.
• Anticipatory anxiety (In b/w attacks). • Nicotine.
• +/- Agoraphobia : Fear of open spaces. • Theophylline.
Mx : SSRIs, SNRIs. • Flumazenil.
• Yohimbine.
PHOBIA :
Irrational fear.
Types :
Generalized phobia : AKA social phobia/social anxiety disorder.
Specific phobia :
Types : BANSO (Mnemonic)
• Blood injection. • Situational.
• Animal. • Others.
• Natural environment.
Management :
Pharmacologic Rx Behavioural Rx
• Flooding :
- Sudden exposure to aversive stimuli
• Generalized phobia : SSRI - Useful if indication is immediate
• Specific phobia : b-blockers • Systematic desensitization : Graded
exposure to aversive stimuli + relaxation
Propranolol (M/c) techniques + regulation of emotions

Obsessive Compulsive & Related Disorders 00:35:48 ----- Active space -----
Disorders
Mnemonic : O2 B2 H2
• Olfactory reference
• Body dysmorphic disorder :
syndrome : Belief that a bad
Preoccupation with aspects
smell emanates from their • Hoarding disorder
of their body
body Feels judged • Hypochondriasis
• Bodily focused repetitive
• Obsessive Compulsive
behavioral disorders
Disorder (OCD)
Bodily Focused Repetitive Behaviour Disorder :
Trichotillomania : Dermatotillomania :
• Compulsive hair pulling (M/c of scalp). • Compulsive skin picking.
• Females > males. • Seen in cocaine &
• A/w trichophagia (Biting or chewing of methamphetamine abuse.
hair) Trichobezoar.
Mx : Habit reversal technique ↑Awareness.
Education or relaxation techniques.
Competitive response training
(To keep hands busy).
Hoarding Disorder :
• An independent disorder (Earlier : Part of OCD).
• Collecting items of no emotional/financial value Cluttering
A/w
Severe distress/anxiety.
Hypochondriasis (ICD)/Illness Anxiety Disorder (DSM-5) :
• Earlier term : Medical student syndrome.
• Constant preoccupation of becoming ill >6 months.
• Illness either absent/present in a mild form.
Obsessive Compulsive Disorder (OCD) :

Thought possession/Thought content disorder.
Obsessions : Mysophobia (M/c).
Compulsions : • Repetitive.
• Mental : Counting numbers/chanting prayers. • Distressing.
• Physical : Handwashing (M/c). • Egodystonic.

18 Psychiatry
----- Active space ----- Mx :

• Pharmacological :
SSRI Failure of 2 SSRIs Clomipramine (TCA) : Maximum serotonergic activity.
• Exposure Response Prevention (ERP) :
Repeated graded exposure to aversive stimuli (Making patient touch unclean surfaces)
Prevent patient response (Handwashing)
Habituation & desensitization.
Tic Disorder :
Types : Symptoms :
• Motor tics. • < 1 year : Provisional tic disorder.
• Vocal tics. • 1 year : Persistent tic disorder.
Tourette’s syndrome :
• Motor & vocal tics.
• Coprolalia : Involuntary utterance of bad words.
• Copropraxia : Involuntary obscene gestures.
PANDAS :
Pediatric Autoimmune Neuropsychiatric Disorders Associated with group A
b-hemolytic Streptococci.
Features :
• Abrupt episodic illness preceded by sore throat.
• Neuropsychiatric : Tics, ADHD or OCD symptoms.
Investigations : Rx :
• ↑ASO titre, ↑Anti DNase B. • Plasmapheresis.
• Throat swab : Culture + . • IV immunoglobulins.
Somatic Symptom & Factitious Disorder 00:56:27
Somatic Symptom Disorder (DSM)/Bodily Distress Disorder (ICD) :

• Earlier term : Briquet syndrome/Somatoform disorder.
• Stressors Somatic symptoms Multiple investigations
Somatization (Normal).
(Defense mechanism) (Multisystem
involvement)
Multiple consultations.
Duration : >6 months.
Rx : ----- Active space -----

• SSRI.
• Antidepressants.
• Reattribution therapy : ↑Awareness of psychological connection b/w symptoms
& stressors.
Factitious Disorder :
AKA Munchausen Syndrome/Doctor shoppers.
• Deliberately creating symptoms for medical attention.
• Not seeking for secondary gain.
Pseudologia fantastica : Excessive pathological lying.

Peregrination : Travel long distances for medical attention.
Munchausen/factitious disorder by proxy : An adult brings a person dependent on
them (Child/elderly).
Grid abdomen : Multiple surgical scars on abdomen.
Note :
Malingering : Conscious creation of symptoms for secondary gain.
Dissociation & Related Disorders 01:04:10
Dissociative amnesia :
Unconscious circumscribed loss of traumatic memory.
Dissociative fugue : Dissociative identity disorder :

• Purposeful wandering. • Earlier term : Multiple personality
• Primary identity is forgotten. disorder.
• New identity retained for weeks/ • >2 alters (Alternate ego).
months. • Frequent shifts b/w alters.
Dissociative Neurological Symptom Disorder (ICD) :

• AKA functional neurological symptom disorder (DSM).
• Earlier terms : Conversion disorder/hysteria.
• Presentation :
- Bizarre unexplainable motor, sensory or gait disturbances (Astasia abasia).
- La belle indifference : Mood is indifferent to level of presentation.
Depersonalization : Detachment from self.

Derealization : Detachment from surroundings.

20
Eating Disorders 00:02:34
SCOFF Questionnaire :
• Screening tool for eating disorders.
- S : Feeling sick after eating.
- C : Loss of control.
- O : Loss of one stone weight (6.35 kg/14 pounds) in 3 months.
- F : Erroneous self-perception of being fat.
- F : Dominance of food in life.
• Positive : ≥2 + Requires further detailed assessment.
Types :
Binge-eating disorder (M/c) Bulimia nervosa Anorexia nervosa

BMI ↑(Overweight/obese) Normal <18.5/↓15% of ideal body weight
Onset Young adults Late adolescence Early adolescence
Compensatory
None Laxatives, induced vomiting -
mechanisms
• Clinical features :
- Fear of weight gain
- Distorted body image
- ↑Exercising
• Binge-eating & purging - ↑Morbidity/mortality
• Clinical features : - Suicidal risk (10%)
B : Eating beyond fullness - Retching - Amenorrhea (D/t
I : Eating in isolation - Russell’s Sign : Calluses/ hyperprolactinemia)
Features N : Eating when not hungry pigmentation on the Restrictive
G : Guilty after eating dorsum of the hand (D/t • Types
Binge-purge
E : Eating rapidly repeated purging)
- Mallory-Weiss syndrome • Complications : Refeeding
: Lower esophageal tear syndrome
- Electrolyte imbalance :
↓PO43-, ↓Mg2+, ↓K+
- ↑Risk of cardiac
arrhythmias

Sleep & Related Disorders 00:17:40 ----- Active space -----
Stages of Sleep N1
N2
NREM (Orthodox sleep)
N3
REM (Paradoxical sleep)
Latency :
Sleep latency REM latency
Time between Going to bed & onset of sleep Onset of sleep & onset of first REM phase
Duration 20 - 30 minutes 90 mins
Characteristics :
Stage % of sleep EEG waves & Frequency
• β (>14 Hz) : A ll areas except occipital lobe
Awake -
• α (7 - 14 Hz) : In occipital lobe
Meditative
- • α : All areas except occipital lobe
(↓Visual stimuli)
REM 25% • β (With sawtoothing)
N1/microsleep :
Myoclonic/hypnic jerks
5% • θ (Theta) : 4 - 7 Hz
• Sleep spindle : Burst of α wave
(↑Frequency, ↓amplitude).
N2 45%
• K-complex : Biphasic wave
(↓Frequency, ↑amplitude).
N3
25% • δ (Delta) : <4 Hz
Delta/restorative sleep
Saw toothing of β waves

Associated Agents :
Wakefulness promoting : Sleep promoting :
• Serotonin. • Melatonin.
• Norepinephrine. • Adenosine.
• Dopamine. • Galanin.
• Histamine. • GABA.
• Acetylcholine.
• Glutamate.
• Orexin/hypocretin.

22 Psychiatry
----- Active space ----- SLEEP DISORDERS

Types :
Parasomnia Dysomnias
(Disorders associated with sleep) (Disorders of sleep)
• Nightmares. • Narcolepsy (↓Orexin).

• Night terrors. • Insomnia.
• Nocturnal enuresis (Bed wetting). • Hypersomnia.
• Somnambulism (Sleep walking). • Jet lag syndrome.
• Somniloquy (Sleep talking).
Nightmares vs night terrors :

Nightmares Night terrors (Pavor nocturnus)
Stage/phase of Sleep REM N3
Age groups All ages Children
Amnesia - +
Autonomic arousal - +
Post-arousal confusion - +
Narcolepsy :
↓Orexin (Source : Lateral hypothalamus).
Features :
• Sleep attacks (REM sleep) during daytime.
Hypnagogic : While going to sleep.
• Hallucinations
Hypnopompic : While waking up from sleep.
Cataplexy : Extreme emotional stimuli Hypotonia.
SOREM (Sleep-onset REM) : Saw tooth appearance in routine EEG.
Treatment :
• Modafinil. • Methylphenidate.
• Armodafinil. • Pitolisant (H3 antagonist) Newer
• Amphetamines. • Solriamfetol agents.
Note : Cataplexy seen in catatonia.
Treatment Strategies in Insomnia :

Melatonin (M1/M2) agonists : Ramelteon, tasimelteon.
GABAA agents :
• Benzodiazepines : ↑Potential for abuse.

• Z-class of drugs : Acts on α1 subunit ↓Potential for abuse. ----- Active space -----
Zaleplon Zolpidem Zopiclone

DORA (Dual acting Orexin Receptor Antagonist) : Suvorexant, lemborexant.
TCA : Doxepin.
Antipsychotic : Quetiapine.
Sleep Hygiene Measures :

Sleep efficiency : Hours of sleeping x 100 = ≥85% for adequate sleep.
Hours of lying on bed
Stimulus control : Use bed for sleep/sexual intimacy only.
Sexual Disorders & Paraphilias 00:45:28
Phase of Normal Sexual Response Cycle :

Desire Excitement Plateau Orgasm Resolution/refractory.
Disorders : Erectile dysfunction. Disorders : Premature ejaculation.
Resolution phase :
Males Females
Refractory phase is long Refractory phase is short
Single orgasm : Cannot immediately attain another orgasm Can have multiple orgasms
SEXUAL DISORDERS
Erectile Dysfunction (ED) :
Psychogenic ED Organic ED
Early morning erection + -
Penile tumescence/doppler
Normal Abnormal
studies/plethysmography
Treatment :
Tadalafil.
• PDE5 - I • PGE analogue : Alprostadil - Short
Vardenafil. acting (Used in investigations).
Sildenafil.
Premature Ejaculation :
Ejaculation within a minute of vaginal intercourse.

24 Psychiatry
----- Active space ----- Management :

• SSRI (Delay ejaculation) :
- Dapoxetine. - Paroxetine.
• Non-Pharmacological :
- Squeeze technique (Master & Johnson) :
Squeezing of glans penis Delays ejaculation & ↓arousal.
- Start-stop technique.
- Sensate focusing : Advised focus on non-consummatory aspects of sexual
activity.
SEXUAL PARAPHILIAS
Paraphilia Condition for sexual arousal
Fetishism Touching inanimate objects
Frotteurism Touching non consenting individuals
Exhibitionism Exhibiting/displaying genitalia, masturbating in public
Voyeurism/peeping tom Diagnosed in >18 yrs only
Pedophilia Sexual activity with prepubescent children
Sadism Inflicting pain on others
Masochism Self inflicting or allowing others to inflict pain
Transvestic fetishism Wearing the opposite gender’s clothes
Note :
Cross-dressing : Not a sexual paraphilia.
Nymphomania : ↑Sexual desire in females.
Satyriasis : ↑Sexual desire in males.
Gender Identity 01:00:10
Assigned gender : At birth based on external genitalia.

Perceived gender : Gender identity develops at 3-6 years.
Gender Dysphoria (DSM)/Gender Incongruence (ICD) :
Disconnect b/w perceived & assigned gender.
Methods of transitioning :
Non Clinical : Clinical :

• Gender roles/responsibilities. • Hormone Replacement Therapy (HRT).
• Adopting required appearance • Sex Affirmation surgery
& behaviours. (Earlier : Sex reassignment surgery).
Personality Disorders 01:04:42 ----- Active space -----
Criteria :
Pervasive persistent patterns leading to maladaptive relationships (Distress/
dysfunctionality to self/others).
Onset :
Late adolescence.
Big 5 personality traits :
• Mnemonic : OCEAN
- Openness.
- Conscientiousness.
- Extraversion.
- Agreeableness.
- Neuroticism.
Older Classification :
Cluster A : Cluster B : Cluster C :

(Odd & eccentric) (Emotional, dramatic, erratic) (Anxious & fearful)
• Paranoid PD. • Borderline PD/Emotionally • Obsessive compulsive/
• Schizoid PD. Unstable PD (EUPD) : anankastic PD : Prone to
• Schizotypal PD : Prone - Prone for bipolar disorder. depression.
for schizophrenia. - Rx : Dialectical behavioral • Dependent PD.
therapy. • Anxious avoidant PD.
• Histrionic PD.
• Narcissistic PD.
• Antisocial PD : Prone to
addiction.
ICD 11 updates :
No more named personality disorders.
Five domains : Types : (Based on 5 domains).
• Negative affectivity. • Mild.
• Detachment. • Moderate.
• Disinhibition. • Severe.
• Dissocial.
• Anankastia.

26
Neurodevelopmental Disorders 00:02:25
HEADSSS Assessment :
Psychosocial assessment for adolescents.
Home : Home structure/environment.
Education : Regularity to school/absenteeism.
Activities : Extracurricular activities.
Drugs : H/o drug abuse/social media usage.
Sexuality : Sexual/gender concerns.
Suicidal risk
Safety : Environmental safety.
Autism Spectrum Disorder :

Males > Females (Except Rett syndrome).
Age at presentation : 3-4 years.
Diagnostic criteria :
• Stereotypic behavior : Repetitive behaviour.
• Socialization deficits : Poor eye to eye contact.
• Speech problems : No longer considered specific.
Asperger syndrome :
• Speech preserved.
• Special skills + .
Rett syndrome :
• Normal development up to 6m-3yrs Regression of milestones (Motor skills &
hand lost).
• A/w MeCP2 gene on X chromosome.
• Rx : Trofinetide (Acts on IGF-1 ↑Neuroplasticity, ↓symptoms).
• Poor prognosis.
Intellectual Development Disorder (DSM) :

• AKA disorder of intellectual development (ICD).
• Mental retardation (No longer used).

Grading : IQ score : ----- Active space -----

Mental age
Grade IQ Disability % x 100.
Chronological age
Mild 50-69 50%
Moderate 35-49 75%
Severe 20-34 90%
Profound <20 100%
Assessment tools :
• Worldwide :
- Weschler’s Adult Intelligence Scale (WAIS).
- Weschler’s Intelligence Scale for Children (WISC).
• India :
- Binet Kamat test.
- Bhatia’s test : Performance based test, used in illiterate subjects.
• Siguine form board test : In children <10 yrs.
• Raven’s progressive matrices : Both individual & group assessments.
Attention Deficit Hyperactivity Disorder (ADHD) :
40-50% children with ADHD Adults with ADHD.
Core symptoms : Diagnostic criteria :
1. Poor attention. • Onset after <12 yrs age.
2. Hyperactivity. • + in >2 settings.
3. Impulsivity. • ≥6 attention symptoms (≥5 in adults).
• ≥6 hyperactivity & impulsivity symptoms.
Treatment : Stimulants > Non-stimulants.
• Stimulants :
- Methylphenidate.
- Lisdexamfetamine.
More effective
- Amphetamine. Unavailable
- Dextroamphetamine. in India
• Non-stimulants :
- SNRI : Atomoxetine, Viloxazine.
- α2 agonists : Clonidine, Guanfacine.
Oppositional Defiant Disorder (ODD) :
Children <10 yrs with symptoms >6 months.
Symptoms :
• Oppositional & defiant behavior. • Tantrums + .
• ↑Anger & stubbornness. • Vindictiveness.
28 Psychiatry
----- Active space ----- Adolescent onset ODD : Symptoms only present in adolescence.
Treatment : Individual & family counseling.
Conduct Disorder : Antisocial Personality Disorder :
Children <18 yrs, symptoms >6 months. Adults ≥18 yrs.
Symptoms : Symptoms :
• Defiant. • ↓Empathy.
• Deceitful (Lying, manipulation, • Manipulative.
stealing). • Often get into trouble with the law.
• Destructive to property, people, • Prone to addictions.
animals.
• Often get into trouble with the law.
Nocturnal Enuresis :
Diagnostic criteria : Children >5 yrs + Symptoms >3 months + Bedwetting ≥2 times/
week.
Treatment :
• Symptoms ↓ with age Remission.
• Bladder training.
• Hygiene practices (Using the bathroom before bed).
• Star charting & reward system.
• Alarm method : Underwear sensitive to moisture Rings alarm to wake up.
• Drugs (Side effects + , used with caution) :
- Desmopressin. - Anticholinergic
- Imipramine. drugs.
Delirium 00:32:08
Clinical Features & Management :

Symptoms : Mnemonic (AS)3.
• Acute emergency. • Sleep reversal.
• Altered Sensation/disorientation/ • Sun downing (Symptoms ↑ at night).
confusion. • Slowing of EEG waves (Generalized).
• Autonomic dysfunction.
Assessment :
• Mini Mental State Examination • Confusion Assessment Method (CAM).
(MMSE)
Also used to assess : Dementia, general brain function.

Treatment : ----- Active space -----

• Delirium tremens (D/t alcohol withdrawal) : Benzodiazepines (DOC).
• Antipsychotics.
Assessment of Higher Mental Functions :
Memory :
• Immediate/working memory : Digit repetition (Backwards or forwards).
• Recent memory : 24 hr recall.
• Remote memory : Questions about family/schooling.
Attention/Concentration :
• Spell WORLD backwards.
• Serial subtraction (100-7-7-...)
Orientation : Time, place, person (In that order).
Changes in Consciousness :
Features
Break in consciousness (Confusion, amnesia,
Twilight state
aggression) seen in epilepsy
Oneiroid state Dream-like state (Hallucinations + )
Stupor/Akinetic mutism Absent movements, mute, minimal response
Dementia 00:43:25
• Major neurocognitive disorder.

• Chronic, progressive neurodegenerative condition.
Reversible dementia :
• Vit. B12 dementia. • Neuroinfections.
• Hypothyroidism dementia. • Head injury. Early stages.
• Normal pressure hydrocephalus.
Cortical vs. subcortical dementia :
Cortical dementia Subcortical dementia
A symptoms : M symptoms :
• Apraxia • Motor problems
Symptoms
• Agnosia • Movement problems
• Aphasia • Memory problems
• Alzheimer's disease (M/c) • Huntington's chorea
Examples • Creutzfeldt-Jakob disease • Supranuclear palsy
• Pick's disease (Frontotemporal dementia) • Parkinson's disease related dementia
30 Psychiatry
----- Active space ----- Alzheimer's Disease (AD) :

Pathology :
• Extracellular accumulation of b amyloids (Amyloid plaques).
• Intracellular accumulation of phosphorylated Tau proteins (Neurofibrillary
tangles)
Risk factors :
• Advancing age. • Down's syndrome.
• DM, hypertension, dyslipidemia. • Apolipoprotein E4 (E2 ↓risk).
• Presenilin 1 > 2 gene (Familial • Lower education status.
autosomal dominant).
Clinical features :
• Visuospatial memory problems (D/t temporoparietal region involvement).
• Anosmia (D/t entorhinal complex involvement).
• Focal neurological deficits (Less common).
Treatment :
1. AChE inhibitors : Donepezil, Galantamine, Rivastigmine (Patch).
2. NMDA antagonists : Memantine (For severe dementia).
3. Monoclonal antibodies /mAb (Newer drugs) : Aducanumab, Lecanemab,
Donanemab.
Frontotemporal Dementia/Pick's disease :
Pick cells : Swollen neuronal cells.
Pick bodies : Argentophyllic bodies.
Clinical features :
Frontal lobe symptoms :
• Echolalia/echopraxia. • Urinary incontinence.
• Personality change : • Disinhibitory behavior.
Jocularity (↑Jokes). • Apathy.
Lewy Body Dementia :

Lewy body :
• Eosinophilic dense core + Radiating halo.
• Accumulate in cortical & subcortical areas.
Clinical features :
• Episodes of confusion. • Antipsychotic sensitivity :
• Visual hallucinations. - ↑Extrapyramidal symptoms (EPS)
• Capgras syndrome. - Clozapine can be considered (Least EPS).
Huntington's Chorea : ----- Active space -----

Pathology : Defect in GABAergic neurons (Caudate nucleus degeneration).
Genetics :
• Autosomal dominant.
• Defect in Chr. 4.
• CAG - CAG - CAG trinucleotide repeats.
Clinical features :
• Presents in 4th decade.
• Chorea.
Normal Pressure Hydrocephalus (NPH) :
Triad :
• Dementia.
• Urinary disturbance.
• Gait disturbance (Magnetic/apraxic gait).
Substance Use Disorders (SUD) 01:01:08
Spectrum of use : Dependence :

• Tolerance.
Description Physiological
• Withdrawal symptoms.
Teetotaler Do not use
• Craving.
Experimental use Experimenting/trying Psychological
• Loss of control.
Recreational use Use for + effects • Harmful use.
Behavioural
Abuse Use to feel well/normal • Salience : ↑Importance.
Hazardous use Potential harm
Harmful use Actual harm occurs
Cannabis :
New gateway drug (Earlier : Nicotine).
Forms : Bhang > Ganja > Charas > Hash oil
Low concentration High concentration
Components :
• Δ-9 Tetrahydrocannabinol (THC) : Psychoactive.
• Cannabidiol (CBD) : Therapeutic.

32 Psychiatry
----- Active space ----- Therapeutic indications of CBD :

• Resistant seizures.
• Cachexia (D/t HIV, cancer, chemotherapy) : To ↑ appetite.
• Chronic pain syndromes.
• Movement disorders/muscle spasms.
• Glaucoma.
Synthetic forms : Nabilone, Dronabinol.
Alcohol Use Disorder :

Withdrawal symptoms :
Time since last drink Type of symptoms Symptoms
Tachycardia, autonomic arousal,
<12 hrs Simple
↑sweating, tremors
12-24 hrs Perceptual Auditory hallucinations
<48 hrs - Alcohol withdrawal related seizures
Delirium tremens Delirium + Tremors
<72 hrs
(Emergency) Lilliputian hallucinations
Wernicke's encephalopathy :
• Acute emergency presentation
• C/f : Mnemonic GOA
- Global confusion
- Ophthalmoplegia
- Ataxia.
• Investigations :
- ↓Thiamine.
- Petechial hemorrhages in mammillary bodies & periaqueductal grey matter.
Korsakoff's psychosis :
• Chronic condition.
• Confabulation (D/t gaps in memory).
• Anterograde amnesia.
• ↓Thiamine.
Delirium tremens vs. Alcoholic psychosis :
Delirium tremens Alcoholic psychosis
Clear sensorium,
Altered sensorium
Auditory hallucinations +
Treatment : ----- Active space -----
Drugs
Benzodiazepines
Withdrawal • Lorazepam (M/c)
symptoms • Oxazepam Safe in liver diseases
• Temazepam
• Acamprosate
• Naltrexone
• Topiramate
Craving
• SSRI
• Ondansetron
• Baclofen
Disulfiram (Irreversible aldehyde dehydrogenase inhibitor)
• ↑Aldehydes, histamine, serotonin, dopamine Disulfiram ethanol
reaction.
• Benign : Nausea, vomiting, bad breath, vasodilation, flushing,
Aversive
↓BP, headache, seizure, coma, death
drug
Rare
• Started 12-24 hrs after last drink
• Avoid alcohol 10-14 days after stopping drug
• C/I : Psychosis, peripheral neuropathy
Assessment of motivation to change :

Stages of motivation (By Prochaska & Diclemente) :
Precontemplation Contemplation Decision Action Maintenance

(Denial) (Acceptance) (Planning) (overt change) (overt change
>6 months)
Recovery
(0% temptation, 100% self-efficacy/control)
OR
Relapse (Drinks again)
Psychological Therapies for SUD :

• Motivational interviewing. • Craving management
• Assertiveness training. • Self-help groups : Alcoholics
• Relapse prevention. Anonymous, Narcotics Anonymous
34 Psychiatry
----- Active space ----- Nicotine Cessation Management :

Drugs to reduce craving :
• Varenicline (Most preferred) : a4b2 partial agonist.
- C/I : Neuropsychiatric symptoms.
• Bupropion : ↑Norepinephrine & dopamine.
- Advantages : Least sedation & weight gain.
- Disadvantage : ↓Seizure threshold.
Nicotine supplements :
Form Dose available
Patch 7 mg, 14 mg, 21 mg
Gums, Lozenges 2 mg, 4 mg
Precautions for using gums :
• Avoid hot food & drinks for 20-30 mins to prevent denaturation.
• Chew & park method (For gums) :
Gastric irritation
Juice released by Parked, not swallowed To avoid
↓Bioavailability (D/t
chewing gum
gastric denaturation)
Opioids :
Signs of poisoning : Management of poisoning :
• Comatose/unconscious Naloxone injection (DOC) : μ antagonist.
• Respiratory depression
• Pin point pupils.
Management of abuse :
1. Naltrexone : μ antagonist.
• Oral & depot form (Given every 3 months).
• ↓Craving.
2. Methadone : Long acting μ agonist.
• Harm reduction.
• Habit forming.
3. Buprenorphine : Partial μ agonist.
• ↑Harm reduction.
• ↓Habit forming.
4. Buprenorphine + μ antagonist : Currently used.

Models of Mind & Related Defense Mechanisms 00:02:00
Models of Mind :
Proposed by Sigmund Freud.
Structural theory :
Id Ego Superego
Develops at Birth 4-6 months 2-3 years
Principle Pleasure Reality Morality
Impulsive/instinctive, seeks Uses defense mechanisms Higher concepts of
Features
immediate gratification to balance Id & Superego being
Topographical theory :
3 parts :
Conscious
Preconscious : Accessible
Unconscious (Majority) :
Inaccessible
Superego
Ego
Iceberg model Id (Completely unconscious)
Defense Mechanisms :
Mature Psychotic/Narcissistic : Immature : Neurotic :
(Helps in growth) : • Denial (Ostrich phenomenon). • Regression. • Intellectualization.
• Humor. • Splitting (Black & white thinking). • Passive aggression. • Displacement.
• Anticipation. • Psychotic projection.
• Altruism.
• Asceticism.
• Suppression : Conscious.
• Sublimation.

36 Psychiatry
----- Active space ----- Transference vs. Countertransference :

Transference Countertransference
Patient’s feelings towards doctor Doctor’s feelings towards patient
Can be
Negative Positive
Catharsis vs. Abreaction :
Catharsis Abreaction
Meaning Ventilation/expression/sharing Abnormal/exaggerated reaction
+
Benefits ±
(Important aspect of therapy)
Projective tests :
Ambiguous stimuli used to tap into the unconscious.
• Rorschach ink blot test.
• Thematic Apperception Test (TAT).
• Sentence completion test.
• Draw a person test.
Supportive Psychotherapy 00:27:24
Indications :
• Chronic medical problems. • Low motivation.
• Crisis events. • Low IQ.
Cognitive Behavioral Therapy :

Developed by Aaron Beck.
Cognitive/Beck’s triad : CBT Triangle :

Common in patients with depression. Bidirectional (Each factor
influences the other)
Negative feelings towards
Hopelessness The world & future Cognition Emotion
Helplessness Others people
Worthlessness The self Behaviour

Automatic Negative Thoughts (ANT) : ----- Active space -----

• Series of spontaneous negative thoughts.
• Present even in N individuals.
• Dealt with using CBT.
Schemas : Deep-rooted beliefs about self, others & the world.
Thought errors/Cognitive distortion :

• Baseless negative thoughts.
• Eg : Overgeneralization.
Mental Health Acts 00:37:30
Mental Health Care Act (MHCA 2017) :

Prohibitions :
• Chaining mentally ill patients.
• All forms of ECT except modified ECT.
• ECT in minors without permission from Mental Health Review Board (MHRB).
• Sterilization procedures without medical indications.
Decriminalization of suicide (Section 115) :

Referred to Mental Health Professional (MHP) for severe stress.
Advanced directive :
Document containing details of :
• Desired Rx.
• Undesirable Rx.
• Nominated Representative (NR) : Adult responsible for taking decisions if one
loses capacity of thinking.
Admissions :
Old terms New terms
Voluntary admission Independent admission.
Supported admission.
MHRB needs to be notified within :
Involuntary admissions
• Female/Minor : <72 hrs.
• Male : <7 days
Emergency treatment :
Only at licensed Mental Health Establishment (MHE) or upto 72 hrs in a regular Rx
facility Refer to MHE.
38 Psychiatry
----- Active space ----- Rights of Persons with Disabilities Act (RPwD) :
Previously called National Disability Act.
Inclusions :
• Intellectual developmental disorder/Disorder of intellectual development
(Previously mental retardation).
• Mental illness (Disability assessed using IDEAS :
Indian Disability Evaluation & Assessment Scale).
• Autism spectrum disorder.
New additions
• Developmental/scholastic learning disorder.
Benchmark disability : >40%.
Mental Health Gap Action Programme (mhGAP) :
WHO programme.
Aim :
To ↓Rx gap (Currently at 75%) for the following disorders :
• Mental illnesses : Childhood developmental problems, depression, psychosis,
anxiety.
• Neurological problems : Epilepsy.
• Substance abuse disorders : Alcohol, nicotine.

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Contents

PSYCHIATRY REVISION - 1 ----- Active space -----

Neurotic vs. Psychotic Symptoms :

Persecution/ Grandiosity : Poverty : Reference

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

----- Active space ----- Hallucination :

Note : Illusion Misinterpretation of stimuli

Functional hallucination : Reflex hallucination :

Autism Ambivalence Affective Blunting/ Association : Lost

Good prognosis : Manic depressive psychosis Bad prognosis : Dementia Praecox

Kurt Schneider : ----- Active space -----

TIMELINE FOR DIAGNOSIS

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

----- Active space ----- PROGNOSTIC FACTORS

Duration of treatment : For 1st episode of psychosis 1-2 years (Minimum : To

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

Third Generation : ----- Active space -----

EXTRAPYRAMIDAL SIDE EFFECTS

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

----- Active space ----- Catatonia 01:05:00

Etiology : Frontal lobe dysfunction d/t

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

PSYCHIATRY REVISION - 2 ----- Active space -----

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

Premenstrual Dysphoric Disorder (PMDD)/Premenstrual syndrome (Earlier term) :

Note : Avoid TCA in atypical depression.

Objective Signs of Depression :

Pharmacologic Management of Depression 00:26:44

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

----- Active space -----

SSRIs SNRIs TCAs

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

----- Active space ----- Resistant Depression :

Augmentation strategies Combine antidepressant with :

2. Neuroleptic Malignant Syndrome (NMS) : Lead pipe rigidity.

Non-Pharmacologic Mx of Depression 00:45:20

Modified Electroconvulsive Therapy (ECT) :

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

Repetitive Transmagnetic Stimulation (rTMS) : ----- Active space -----

MOA : 8 or H-shaped coil Current is Electromagnetic Stimulate Brain tissue.

Disadvantage : ↓Effectiveness than ECT.

Vagus Nerve Stimulation :

Post-partum Mental Disorders 00:57:40

Postpartum period : Following delivery 4 weeks (DSM-5).

----- Active space ----- Bipolar Disorder 01:02:42

Types : ≥v1 episode of mania +/- depression/hypoma-

Side effects : ----- Active space -----

Suicidal Behaviour 01:20:07

Suicide rate : 12.4 (12.4 deaths/1 lakh population).

Note : ↓Access Best suicide prevention strategy.

M/c method (India) : Hanging.

Non-Suicidal Self-Injurious Behaviour (NSSI)

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

----- Active space ----- PSYCHIATRY REVISION - 3

Psychiatric conditions requiring a causative factor (Life event) :

Grief Acute stress Reaction. Adjustment PTSD

Response to loss of loved one/an object of value.

Trauma Related Disorders 00:09:50

Acute stress reaction Acute stress disorder Adjustment disorder/Situational depression

Psychiatry Revision • v4.0 • Marrow 8.0 • 2024

Good prognosis : Manic depressive psychosis Bad prognosis : Dementia Praecox

Duration of treatment : For 1st episode of psychosis 1-2 years (Minimum : To

----- Active space ----- Catatonia 01:05:00

Pharmacologic Management of Depression 00:26:44

Non-Pharmacologic Mx of Depression 00:45:20

Post-partum Mental Disorders 00:57:40

----- Active space ----- Bipolar Disorder 01:02:42

Suicidal Behaviour 01:20:07

Trauma Related Disorders 00:09:50

Anxiety Disorders 00:18:13

Somatic Symptom & Factitious Disorder 00:56:27

Dissociation & Related Disorders 01:04:10

Eating Disorders 00:02:34

Sleep & Related Disorders 00:17:40 ----- Active space -----

Sexual Disorders & Paraphilias 00:45:28

Gender Identity 01:00:10

Personality Disorders 01:04:42 ----- Active space -----

Neurodevelopmental Disorders 00:02:25

Substance Use Disorders (SUD) 01:01:08