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 Index
Sl.No. Chapter Pg.No.
1. Classification in Psychiatry 09
2. Psychiatric History and Examination 11
3. Organic Mental Disorders 17
4. Psychoactive Substance Use Disorders 28
5. Schizophrenia 37
6. Mood Disorders 40
7. Neurotic, Stress-related and Somatoform Disorders 47
8. Disorders of Adult Personality and Behaviour 58
9. Sexual Disorders 61
10. Sleep Disorders 69
11. Behavioural Syndromes 75
12. Mental Retardation and Child Psychiatry 83
13. Psychosocial Skin Disease 104
14. Psychopharmacology 105
15. Emergency Psychiatry 114
 9

Classification in Psychiatry
NORMAL MENTAL HEALTH
Health is a state of complete physical, mental and social well-being, and not
merely absence of disease or infirmity.
traits in normal individuals
1. Reality orientation.
2. Self-awareness and self-knowledge.
3. Self-esteem and self-acceptance.
4. Ability to exercise voluntary control over their behaviour.
5. Ability to form affectionate relationships.
6. Pursuance of productive and goal-directive activities.

CLASSIFICATION IN PSYCHIATRY
1. To enable communication regarding the diagnosis of disorders,
2. To facilitate comprehension of the underlying causes of these disorders,
3. To aid prediction of the prognosis of psychiatric disorders.

The Five Axes of DSM-IV-TR

AXIS I: Clinical Psychiatric Diagnosis
AXIS II: Personality Disorders and Mental Retardation
AXIS III: General Medical Conditions
AXIS IV: Psychosocial and Environmental Problems
AXIS V: Global Assessment of Functioning: Current and in past one year
(Rated on a scale)

Some Versions of ICD-10

A. Clinical Descriptions and Diagnostic Guidelines (CDDG)
B. Diagnostic Criteria for Research (DCR)
C. Multi-axial Classification Version
D. Primary Care Version

Reference: Shorter Oxford Textbook of Psychiatry (pg 21)

Short Textbook of Psychiatry, Niraj Ahuja (pg 1 )
 10

ICD-10 (International Classification of Diseases, 10th Revision, 1992) is World

Health Organisation’s classification for all diseases and related health problems
(and not only psychiatric disorders).

DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, IV Edition, Text

Revision, 2000) is the American Psychiatric Association (APA)’s classification of
mental disorders.

The main categories of ICD- 10 Chapter V (F)

F0 Organic, including symptomatic, mental disorders
F1 Mental and behavioural disorders due to psychoactive substance use
F2 Schizophrenia, schizotypal, and delusional disorders
F3 Mood (affective) disorders
F4 Neurotic, stress-related, and somatoform disorders
F5 Behavioural syndromes associated with physiological disturbances and
physical factors
F6 Disorders of adult personality and behaviour
F7 Mental retardation
F8 Disorders of psychological development
F9 Behavioural and emotional disorders with onset usually occurring in
childhood or adolescence
 11

Psychiatric History and Examination

life chart

A life chart provides a valuable display of the course of illness, episodic

sequence, polarity (if any), severity, frequency, relationship to stressors, and
response to treatment, if any.

Outline of the personal history

Mother’s pregnancy and the birth
Early development
Childhood: separations, emotional problems, illnesses, education
Occupations
Relationships and sex
Children
Social circumstances
Substance use
Forensic history

Assessment of personality
Relationships
Leisure activities
Prevailing mood and emotional tone
Character
Attitudes and standards
‘Ultimate concern’
Reference: Shorter Oxford Textbook of Psychiatry (pg 35 )
Short Textbook of Psychiatry, Niraj Ahuja (pg 5 )
 12

FAMILY HISTORY
Drawing of a ‘family tree’ (pedigree chart) can help in recording all the relevant
information in very little space which is easily readable.
The communication patterns in the family, range of affectivity, cultural and religious
values, and social support system, should be enquired about, where relevant
 13

Risk factors for harm to others

Mental Status Examination

 14

Obsessions – Unwanted thoughts, images or impulses that cause a lot of stress and anxiety.
Compulsions – Behaviours or acts that are carried out to reduce the anxiety
HEALTHY THINKING
CONSTANCY- Persistence of a completed thought whether simple or complex.
Organisation- Contents are related but do not blend with each other but organised
Continuity- Thoughts or ideas are arranged in order
Disorders of thought

Stream Content
Flow of ideas
1. Disorders of tempo- 1. Overvalued idea
i. Flight of ideas 2. Magical thinking
ii. Inhibition of thinking 3. Superstition
2. Disorders of Continuing- 4. Delusion - Fixed, firm belief in
i. Perseveration something that is not a fact
ii. Thought blocking
Possesion Form

1. Thought block The way thoughts are put in.

2. Obsession— Repeated intrusive Characteristic of Schizophrenia
thoughts eg:- OCD i. Loosening of association
3. Thought alienation- Controlled by ii. Verbigeration- no connection b/w words
someone eg:- Schizophrenia iii. Neologism - coining new word
i. Thought insertion iv. Tangentiality- loss of connection
ii. Thought withdrawal v. Circumstantiality- unnecessary details
iii. Thought broadcasting vi. Derailment- jumping to new topic

The diagnostic formulation

focuses on aetiological
factors based on the
biopsychosocial model

Q. Which is included in form of thought disorder ?

NEETU
 15

Countertransference and Transference

Transference
Transference is redirection of a client's feelings from a significant person to a therapist
There are three stages in dealing and using transference in social casework. these stages are:
1. Understanding the Transference
2. Utilizing the transference.
3. Interpreting the transference.
Understanding of the transference is essential for the worker as it helps to understand the
behaviour of the client and to recognize its significance in his development process. It also
explains the present unconscious needs of the client.
Utilization of the transference depends on the understanding of the social case worker of
the phenomena. It explains many cures or treatments of emotional disturbance by life
situations and by fortune relationships with other problems
Interpretation of the transference, that is, confronting the individual with the awareness
that his behaviour is the repetition of a specific unconscious infantile is definitely part of
psychoanalytical therapy and requires preparation of the individual by the careful analysis
of his unconscious defense.
Counter-transference
Counter-transference is defined as redirection of a therapist's feelings toward a client
It’s a therapist's emotional entanglement with a client
It is a two way process.
Social case worker has also unconscious tendency to transfer out the client.
As in the case of transference, these counter transference feelings, both positive an negative,
are unconscious but operate with force.
Therefore, it is the job of case worker to recognize his feelings and must control them.

Q. While therapy session a therapist developed unconscious and

conscious feelings towards the patient . what is it called?

MEET 21
 16

Learning
Learning is not an event. It is a process.
It is the continual growth and change in the brain's architecture that results from the many ways
we take in information, process it, connect it, catalogue it, and use it (and sometimes get rid of it).
Learning can generally be categorized into three domains: cognitive, affective, and psychomotor.
Within each domain are multiple levels of learning that progress from more basic, surface-level
learning to more complex, deeper-level learning.

NEET 21

Q. A teacher taught steps of hand washing. Students learned and

repeated at home. What domain of learning does it fall under?
 17

Organic Mental Disorders

DELIRIUM
1. A relatively acute onset,
2. Clouding of consciousness, characterised by a decreased awareness of
surroundings and a decreased ability to respond to environmental stimuli, and
3. Disorientation (most commonly in time, then in place and usually later in
person), associated with a decreased attention span and distractibility.

sun downing
Disturbance of sleep-wake cycle; most commonly, insomnia at night with
daytime drowsiness.
Diurnal variation is marked, usually with worsening of symptoms in the evening
and night

motor symptoms in delirium

1. Asterixis (flapping tremor),
2. Multifocal myoclonus,
3. Carphologia or floccillation (picking movements at cover-sheets and clothes),
4. Occupational delirium (elaborate pantomimes as if continuing their usual
occupation in the hospital bed), and
5. Tone and reflex abnormalities.

Asterixis

Reference: Shorter Oxford Textbook of Psychiatry (pg 345)

Short Textbook of Psychiatry, Niraj Ahuja (pg 19)
 18

Predisposing Factors in Delirium

1. Pre-existing brain damage or dementia
2. Extremes of age (very old or very young)
3. Previous history of delirium
4. Alcohol or drug dependence
5. Generalised or focal cerebral lesion
6. Chronic medical illness
7. Surgical procedure and postoperative period
8. Severe psychological symptoms (such as fear)
9. Treatment with psychotropic medicines
10. Present or past history of head injury Q. Identify the
predisposing factors of
11. Individual susceptibility to delirium delirium?

Delirium: Some Important Causes

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DEMENTIA
1. Impairment of intellectual functions,
2. Impairment of memory (predominantly of recent memory, especially in
early stages),
3. Deterioration of personality with lack of personal care

Additional features
Emotional lability (marked variation in emotional expression).
Catastrophic reaction (when confronted with an assignment which is beyond the
residual intellectual capacity, patient may go into a sudden rage).
Thought abnormalities, e.g. perseveration, delusions.
Urinary and faecal incontinence may develop in later stages.
Disorientation in time; disorientation in place and person may also develop in
later stages.
Neurological signs may or may not be present, depending on the underlying
cause.

Depressive pseudodementia:
Depression in the elderly patients may mimic dementia clinically.

Causes of Dementia
 20

Dementia

Cortical Subcortical Mixed

1. HUNTINGTON’S DISEASE
1. ALZHEIMER’S DISEASE 1. LEWY BODY
2. PARKINSON’S DISEASE
DEMENTIA
2. MOTOR NEURONE
DISEASE 3. PROGRESSIVE
SUPRSNUCLEAR PALSY 2. VASCULAR
DEMENTIA
3. PICK’S DISEASE 4. AIDS DEMENTIA

4. PROGRESSIVE APHASIA 5. CREUTZFELDT-JAKOB 3. BINSWANGER’S

DISEASE DISEASE
6. WILSON’S DISEASE

FEATURES CORTICAL SUBCORTICAL

FUNCTIONAL Apraxia, Agnosia, Aphasia Impaired processing &
DEFICIT executive
Memory Learning deficit Retrieval deficit
impairment
Neuropsychiatric Uncommon Depression, apathy
symptoms
Motor Extrapyramidal
symptoms Uncommon symptoms, dystopia
Slow, hypophonic,
Speech Normal dysarthric
Language Aphasic Normal

Reference: Kaplan & Sadock's Synopsis of Psychiatry

 21

Delirium -Presence of altered level of consciousness with cognitive impairment.

- Sudden and acute
Dementia - Loss of cognitive functions in clear consciousness.
- Chronic condition

Features Delirium Dementia

Onset Sudden & Insicious

Acute
Course Fluctuating- Progressive
Sundowning
Reversible Irreversible
Duration Days to weeks Months to years
Altered Often normal
Consciousness sensorium
Lack of Often normal
Attention concentration
Immediate recall & Immediate recall
Memory New learning impaired often normal

Psychomotor Hyperactive or Not usually present

changes hypoactive

Sleep-Wake Often Often normal

cycle reversed

Mnemonic
OCD CAMPS

Alzheimer’s Dementia
Commonest cause of dementia
Neurochemically, there is a marked decrease in brain choline acetyltransferase
(CAT) with a similar decrease in brain acetylcholinesterase (AchE).
The condition progresses gradually for the first 2–4 years, with increasing
memory disturbance and lack of spontaneity.
 22

Core features
Memory impairment (amnesia), with gradual onset and continuing decline
Aphasia
Apraxia
Agnosia
Anosmia
Disturbance in executive functioning (e.g. planning, reasoning)
Other features
Depression
Psychosis
Behavioural symptoms (e.g. agitation, wandering)
Personality change
Risk factors for non- familial Alzheimer’s disease
 23

Lewy Body Dementia

i. Fluctuating cognitive impairment over weeks or months, with involvement of
memory and higher cortical functions (such as language, visuo-spatial ability,
praxis and reasoning). Lucid intervals can be present in between fluctuations.
ii. Recurrent and detailed visual hallucinations.
iii. Spontaneous extrapyramidal or parkinsonian symptoms such as rigidity and
tremors.
iv. Neuroleptic sensitivity syndrome, characterised by a marked sensitivity to
the effects of typical doses of antipsychotic drugs (resulting in severe
extrapyramidal side-effects with use of antipsychotics).

A PET (Positron Emission Tomography) or SPECT (Single Photon Emission

Computerised Tomography) scan of brain may show low dopamine transporter
uptake in basal ganglia.

Lewy body
Progressive disease involving
abnormal deposits of a protein
called alpha-synuclein in the brain

The swallow tail sign describes the normal axial imaging appearance of nigrosome-1
within the substantia nigra on high-resolution T2*/SWI weighted MRI.
Absence of the sign (absent swallow tail sign) is reported to have a diagnostic
accuracy of greater than 90% for Parkinson disease and dementia with Lewy bodies
 24

ORGANIC CATATONIC DISORDER

1. Stupor (diminution or complete absence of sponta- neous movement with
partial or complete mutism, negativism, and rigid posturing);
2. Excitement (gross hypermotility with or without a tendency to
assaultiveness);
3. Mixed (shifting rapidly and unpredictably from hypo- to hyperactivity)

Catatonia
A state of psycho-motor immobility and behavioural abnormality.
Often associated with Schizophrenia
Types- i. Catatonia with other medical disorders
ii. Catatonia due to other medical disorders
iii. Unspecific Catatonia
Clinical features

Symptoms

Stupor Excitment

STUPOR- no psycho-motor activity IMPULSEIVENESS

catalepsy- passive induction of a
agitation
posture held against gravity stereotypy- repetitive, abnormally
waxy flexibility- allowing positioning frequent, non-goal-directed movements
by examiner and maintaining that
echolalia- mimicking another's speech
position
mutism- no, or very little, verbal response echopraxia: mimicking another's
negativism- opposition or no response to movements.
instructions or external stimuli
posturing- spontaneous and active
maintenance of a posture against
gravity
grimacing- keeping a fixed facial
expression

Benzodiazepine is the drug of choice preferable

Intramuscular Lorazepam.
Electro convulsive therapy (ECT) is effective in Catatonia
 25

Parkinson’s disease
The cardinal triad of idiopathic Parkinson’s disease is a rest tremor,
cog-wheel rigidity, and bradykinesia.
Psychiatric manifestations in Parkinson’s disease
Delirium, stupor (especially due to drugs, or intercur- rent infection)
Cognitive decline (subcortical dementia, dysexecutive syndrome)
Depression, apathy, mania
Hallucinations (chiefly visual)
Delusions
Sleep attacks, REM sleep behaviour disorder
Sexual disorders
Impulse control disorders, e.g. gambling (largely medication-related)
 26

ORGANIC HALLUCINOSIS
1. Drugs: Hallucinogens (LSD, psilocybin, mesca- line), cocaine, cannabis, phencyclidine
(PCP), levodopa, bromocriptine, amantadine, ephedrine, propranolol, pentazocine,
methylphenidate, imi- pramine, anticholinergics, bromide.
2. Alcohol: In alcoholic hallucinosis, auditory hallucinations are usually more common.
3. Sensory deprivation.
4. ‘Release’ hallucinations due to sensory pathway disease, e.g. bilateral cataracts,
otosclerosis, optic neuritis.
5. Migraine.
6. Epilepsy: Complex partial seizures.
7. Intracranial space occupying lesions.
8. Temporal arteritis.
9. Brain stem lesions (peduncular hallucinosis).

ORGANIC AMNESTIC SYNDROME

1. Impairment of memory due to an underlying organic cause,
2. No severe disturbance of consciousness and attention (unlike delirium),
3. No global disturbance of intellectual function, abstract thinking and
personality (unlike dementia).

Wernicke-Korsakoff syndrome.
Thiamine deficiency
Most common cause of organic amnestic
syndrome is chronic alcohol dependence.
Wernicke’s encephalopathy is the acute phase of
delirium preceding the organic amnestic
syndrome, while Korsakoff’s syndrome is the
chronic phase of amnestic syndrome.
 27

Confabulation
To fill in the memory gaps, the patient uses imaginary events in the early
phase of illness.

Organic Personality Disorders

Significant alteration of the premorbid personality caused by an underlying
organic cause without major disturbance of consciousness, orientation,
memory or perception.
causes of symptomatic or secondary psychiatric syndromes
 28

Psychoactive Substance Use Disorders

A psychoactive drug is one that is capable of altering the mental functioning
patterns of substance use disorders
Acute Intoxication
Transient condition following the administration of alcohol or other
psychoactive substance, resulting in disturbances in level of consciousness,
cognition, perception, affect or behaviour, or other psychophysiological
functions and responses.
Withdrawal State
Characterised by a cluster of symptoms, often specific to the drug used,
which develop on total or partial withdrawal of a drug, usually after
repeated and/or high-dose use
Dependence Syndrome

Cluster of physiological, behavioural, and cognitive phenomena in which

the use of a substance or a class of substances takes on a much higher
priority for a given individual than other behaviours that once had
greater value.
Harmful Use
1. Continued drug use, despite the awareness of
harmful medical and/or social effect of the drug being used, and/or
2. A pattern of physically hazardous use of drug (e.g. driving during intoxication).

major dependence producing drugs

1. Alcohol 7. Sedatives and hypnotics, e.g. barbiturates
2. Opioids, e.g. opium, heroin 8. Inhalants, e.g. volatile solvents
3. Cannabinoids, e.g. cannabis 9. Nicotine, and
4. Cocaine 10. Other stimulants (e.g. caffeine).
5. Amphetamine and other sympathomimetics
6. Hallucinogens, e.g. LSD, phencyclidine (PCP)

Reference: Shorter Oxford Textbook of Psychiatry (pg 563)

Short Textbook of Psychiatry, Niraj Ahuja (pg 33)
 29

mechanism of drug addiction

 30

Scar in intravenous drug

addict (antecubital region)
Scars of cocaine shots on
dorsum of the right hand
in cocaine addict

ALCOHOL USE DISORDERS

A. Alpha (α) B. Beta (β)

i. Excessive and inappropriate drinking to i. Excessive and inappropriate drinking.
relieve physical and/or emotional pain. ii. Physical complications (e.g. cirrhosis,
ii. No loss of control. gastritis and neuritis) due to cultural
iii. Ability to abstain present. drinking patterns and poor nutrition.
iii. No dependence.

C. Gamma (γ); also called as D. Delta (δ)

malignant alcoholism i. Inability to abstain.
i. Progressivecourse. ii. Tolerance.
ii. Physical dependence with tolerance iii. Withdrawal symptoms.
and with-drawal symptoms. iv. The amount of alcohol consumed can be
iii. Psychological dependence, with controlled.
inability to control drinking. v. Social disruption is minimal.

E. Epsilon (ε)
i. Dipsomania (compulsive-drinking).
ii. Spree-drinking.
 31

Classification of Alcoholism

CAGE questionnaire
 32

Symptoms and signs of acute

alcohol withdrawal

Anxiety, agitation, and insomnia

Tachycardia and sweating
Tremor of limbs, tongue, and eyelids
Nausea and vomiting
Seizures
Confusion and hallucinations
 33

Approach to treatment of alcohol misuse

● Raise awareness of problem
● Increase motivation to change
● Support and advice
● Withdraw alcohol (or controlled drinking)
● High-intensity psychological treatments
● Alcoholics Anonymous
● Medication (disulfiram, acamprosate, naltrexone)

Disulfiram: Mode of Action

Alcoholics Anonymous

Voluntary self-help group with

branches all over the world and a
membership in hundreds of thousands.

Alcoholics Anonymous is based on a

number of fundamental principles,
known as the ‘Twelve Steps’, to which
members adhere.
 34

CANNABIS USE DISORDER

Cannabis plant: (A) Plant; (B)

Female plant with flowering buds
with white hairs; (C) Male plant;
(D) Dried Weed ready to smoke;
(E) Seeds

Mild cannabis intoxication is characterised by mild impairment of consciousness and

orientation, light- headedness, tachycardia, a sense of floating in the air, a euphoric
dream-like state, alternation (either an increase or decrease) in psychomotor
activity and tremors, in addition to photophobia, lacrimation, tachycardia, reddening
of conjunctiva, dry mouth and increased appetite.
‘Flashback phenomenon’ recurrence of
cannabis use experience in the absence
of current cannabis use.

consequences of intravenous drug misuse

Local
Vein thrombosis
Infection of injection site
Damage to arteries
Systemic
Bacterial endocarditis
Hepatitis B and C
HIV infection
Accidental overdose
 35

Cocaine Preparations

Cocaine is a central stimulant which inhibits the reuptake of dopamine, along with
the reuptake of norepinephrine and serotonin
Cocaine use produces a very mild physical, but a very strong psychological,
dependence. A triphasic withdrawal syndrome usually follows an abrupt
discontinuation of chronic cocaine use
The complications of chronic cocaine use include acute anxiety reaction, uncontrolled
compulsive behaviour, psychotic episodes (with persecutory delsions, and tactile and
other hallucinations), delirium and delusional disorder.

Phases in Cocaine Withdrawal Syndrome

 36

Delirium tremens
Delirium tremens (DTs) is a rapid onset of confusion usually caused by withdrawal from
alcohol.
When it occurs, it is often three days into the withdrawal symptoms and lasts for two to
three days.
Physical effects may include shaking, shivering, irregular heart rate, and sweating.
People may also hallucinate.
Occasionally, a very high body temperature or seizures may result in death.
Symptoms
nightmares,
fever,
agitation,
high blood pressure,
global confusion,
heavy sweating,
disorientation,
other signs of autonomic hyperactivity
visual and auditory hallucinations,
(fast heart rate and high blood pressure).
tactile hallucinations,
These symptoms may appear suddenly but typically develop two to three days
after the stopping of heavy drinking, being worst on the fourth or fifth day.
These symptoms are characteristically worse at night

Treatment
• Benzodiazepines, such as lorazepam (Ativan), diazepam (Valium), or
chlordiazepoxide (Librium), which can effectively manage the majority of alcohol
withdrawal symptoms, including delirium tremens, and reduce the risk of seizures.
These are the most commonly used medications, and large doses may be required.
• Barbiturates, like phenobarbital, although these tend to be added on when
benzodiazepines alone haven’t been sufficient in managing symptoms.
• Antipsychotics, such as haloperidol (Haldol), may be used in low doses to help reduce
problematic behaviors such as agitation, manage psychotic symptoms like
hallucinations, and help you think more clearly, although this type of medication has
been associated with negative side effects.

Q. A 53 year male, who is a chronic alcoholic, tried to stop using alcohol after several
requests by his family members. He started feeling uneasy and on day 3, he was
brought to the hospital with disorientation, irritability, paranoid delusions , visual
hallucinations and altered sensorium. Which is your probable diagnosis?

NEETU
 37

Schizophrenia
Psychosis characterised by delusions, hallucinations and lack of insight.
Genetic association. - Disrupted in schizophrenia-1 (DISC1)
- Neuregulin-1 (NRG1)

Positive symptoms (ABCD) Negative symptoms (A’s)

1. Auditory hallucinations 1. Flattened affect

2. Broadcasting, insertion/ 2. Avolition - Apathy &
withdrawal of thoughts loss of drive
3. Bizarre behaviour 3. Autism - Social isolation
4. Controlled feelings, & withdrawal
impulses or acts 4 Alogia - Poverty of
5. Delusions esp persecutory speech
6. Disorganised thought 5. Poor self care

Good prognosis Poor prognosis

1. Late onset 1. Young onset

2. Precipitating factors+ 2. No precipitating factors
3. Acute onset 3. Insidious onset
4. Mood disorder esp 4. Withdrawal , autistic
depression behaviour
5. Married 5. Single
6. Female 6. Male
7. Family history of mood 7. Family history of
disorder schizophrenia
8. Good support system 8. Poor support system
9. Positive symptoms 9. Negative symptoms

Reference: Shorter Oxford Textbook of Psychiatry (pg 253 )

Short Textbook of Psychiatry, Niraj Ahuja (pg 54)
 38

First-rank symptoms
Hearing thoughts spoken aloud
Third-person hallucinations
Auditory hallucinations in the form of a ‘running commentary’
Somatic (bodily, tactile) hallucinations
Thought withdrawal or insertion
Thought broadcasting
Delusional perception
Feelings or actions experienced as made or influenced by external agents
(passivity)

Eugen Bleuler’s Fundamental Symptoms of Schizophrenia

1. Ambivalence: Marked inability to decide for or against
2. Autism: Withdrawal into self
3. Affect disturbances: Disturbances of affect such as inappropriate affect
4. Association disturbances: Loosening of associations, thought disorder

Cerebral and psychological correlates of three

subsyndromes of chronic schizophrenia
 39

Psychosocial interventions for schizophrenia

Family therapy (psychoeducation)
Cognitive behaviour therapy
Cognitive remediation
Art therapy
Social skills training
Illness management skills
Supported employment
Integrated treatment for comorbid substance misuse

Acute episode
● Initiate antipsychotic medication at lower end of the licensed dose range.
● Do not use loading doses (‘rapid neuroleptization’). If sedation is needed, use adjunctive
benzodiazepines.
● The choice of drug should be based on patient preference, effects of previous treatments,
and relative liability of the drug to cause serious side effects (especially extrapyramidal and
metabolic syndromes).
● Titrate dose within licensed range, monitoring for effects and side effects.
● Aim to achieve optimum dose with good adherence for 2 weeks. If no response at that
time, consider changing drug.
● Record the indications for medication, the antici- pated benefits and time course, and
discussions with patient and carers.
● Consider psychological interventions whenever medication is being introduced or changed.
Maintenance and relapse prevention
● Continue medication for a year, or longer, using the same principles as for the acute
episode.
● Ensure that dose, duration, and adherence are ade- quate before switching drug.
● Drug withdrawal should be gradual, and the mental state should be monitored.
● Continuous treatment is more effective than intermittent treatment.
● Monitor adherence regularly.
● Monitor for side effects, including metabolic syndrome, regularly.
● Consider depot formulations, especially if adherence is a problem.
● Always consider psychological interventions together with pharmacological options
 40

Mood Disorders
Manic Episode
a. Euphoria (mild elevation of mood): An increased
sense of psychological well-being and happiness, not in keeping with ongoing
events. This is usually seen in hypomania (Stage I).
b. Elation (moderate elevation of mood): A feeling of confidence and
enjoyment, along with an increased psychomotor activity. Elation is classically
seen in mania (Stage II).
c. Exaltation (severe elevation of mood): Intense elation with delusions of
grandeur; seen in severe mania (Stage III).
d. Ecstasy (very severe elevation of mood): Intense sense of rapture or
blissfulness; typically seen in delirious or stuporous mania (Stage IV).

Depressive Episode
Sadness of mood is usually associated with pessimism, which can result in
three common types of depressive ideas. These are:
a. Hopelessness (there is no hope in the future).
b. Helplessness (no help is possible now).
c. Worthlessness (feeling of inadequacy and inferiority).
Somatic Syndrome in Depression (ICD-10)
a. Significant decrease in appetite or weight
b. Early morning awakening, at least 2 (or more)Bhours before the usual
time of awakening
c. Diurnal variation, with depression being worst in the morning
d. Pervasive loss of interest and loss of reactivity to pleasurable stimuli
e. Psychomotor agitation or retardation
Suicidal risk is much more in the presence of following factors:
a. Presence of marked hopelessness
b. Males; age>40; unmarried, divorced/widowed
c. Written/verbal communication of suicidal intent and/or plan
d. Early stages of depression
e. Recovering from depression (At the peak of depression, the patient is usually
either too depressed or too retarded to commit suicide)
f. Period of 3 months from recovery.

Reference: Shorter Oxford Textbook of Psychiatry (pg 299)

Short Textbook of Psychiatry, Niraj Ahuja (pg 69 )
 41

Cognitive model of how latent dysfunctional assumptions (laid down by early

experience ) are activated by critical incidents, leading to a vicious cycle of
negative thinking and depressed mood.

Treatment
● Increase antidepressant to the maximum dose, if tolerance permits; if the patient
has depressive psychosis, add an antipsychotic drug; try a different class of
antidepressant drug, including venlafaxine and tricyclic antidepressants
● Try an antidepressant combination (e.g. an SSRI or venlafaxine with mirtazapine)
● Add an atypical antipsychotic drug to an SSRI or venlafaxine
● Add lithium to antidepressant drug treatment
● MAOIs (can be usefully combined with lithium)
● ECT
 42

Adjustment disorder
Occurs when an individual has significant difficulty coping with significant
psychosocial stressors
Symptoms usually occur 2 weeks to 3 months after the event and resolve
within 6 months

Depression
Characterised by persistently depressed mood or loss of interest in activities,
Cause significant impairment in daily life.

Timeline
Timeline of events that occur after a stressful event Dysthmia
(chronic depression)
Acute stress Depression Adjustment Cyclothymia
reaction disorder (mood swings)
Stress
Event <2days 2days- 1month >2wks >1month <6months >6months >2yrs

Chronic
Acute stress
disorder PTSD grief

A Stressful event is necessary for

i. Acute stress reaction
ii. Acute stress disorder
iii. Post traumatic stress disorder
iv. Adjustment disorder

Q. A male patient who lost his job recently (1 week back) following which he
became irritable and had sad mood, the thoughts of job and future made his
mood even worse. He was more irritated towards the people in his home, but
occasionally went for a movie with his friends and was able to enjoy with them
but after returning back to his home, he again had similar symptoms.
What is the probable diagnosis?
A. Adjustment disorder
 43

Bipolar Mood (or Affective) Disorder

Recurrent episodes of mania and depression in the same patient at different times

These episodes can occur in

any sequence.

Bipolar Disorder: Rapid Cycling

Some patients with bipolar mood disorder have more than 4 episodes per year;
they are known as rapid cyclers . About 70-80% of all rapid cyclers are women.
When phases of mania and depression alternate very rapidly (e.g. in matter of
hours or days), the condition is known as ultra-rapid cycling.
 44

NICE guidance on the pharmacological

treatment of bipolar depression

1. If a person develops moderate or severe bipolar depression and is not taking a

drug to treat their bipolar disorder, offer fluoxetine combined with olanzapine,
or quetiapine on its own, depending on the person’s preference and previous
response to treatment.
2. If the person prefers, consider either olanzapine (without fluoxetine) or
lamotrigine on its own.
3. If there is no response to fluoxetine combined with olanzapine, or quetiapine,
consider lamotrigine on its own.
4. If a person develops moderate or severe bipolar depression and is taking
either lithium or val- proate, first (if tolerance permits) increase the mood
stabiliser to within the maximum permitted by the therapeutic range. If this is
unsuccessful add one of the options above.1
 45

Other Psychotic Disorders

Psychosis
1. Gross impairment in reality-testing (‘not in contact’ with reality).
2. Marked disturbance in personality, with impairment in social, interpersonal and
occupational functioning.
3. Marked impairment in judgement and absent understanding of the current
symptoms and behaviour (loss of insight).
4. Presence of the characteristic symptoms, like delusions and hallucinations.

Delusion Disorder
Persistent delusions must be present for at least 3 months and these can include
delusions of persecution (being persecuted against), delusions of grandeur (inflated
self-esteem and self image), delusions of jealousy (infidelity), somatic
(hypochondriacal) delusions, erotomanic delusions (delusions of love), and/or other
non-bizarre delusions.

Differential Diagnosis of Delusional Disorders

 46

CAPGRAS’ SYNDROME
(THE DELUSION OF DOUBLES)
1. Typical Capgras’ syndrome (Illusion des sosies):
Here the patient sees a familiar person as a complete stranger who is imposing on him
as a familiar person.
2. Illusion de Fregoli: The patient falsely identifies stranger(s) as familiar person(s).
3. Syndrome of subjective doubles: The patient’s own self is perceived as being replaced
by a double.
4. Intermetamorphosis: Here the patient’s misidentification is complete and the patient
misidentifies not only the ‘external appearance’ (as in the previous three types) but
also the complete personality.

REACTIVE PSYCHOSIS
1. A sudden onset of symptoms.
2. Presence of a major stress before the onset (the quantum of stress
should be severe enough to be stressful to a majority of people).
3. A clear temporal relation between stress and the onset of psychotic symptoms.
4. No organic cause underlying the psychosis.

Descriptions of delusions
 47

Neurotic, Stress-related and Somatoform Disorders

Neurosis
1. The presence of a symptom or group of symptoms which cause subjective
distress to the patient.
2. The symptom is recognised as undesirable (i.e. insight is present).
3. The personality and behaviour are relatively preserved and not usually
grossly disturbed.
4. The contact with reality is preserved.
5. There is an absence of organic causative factors.
6. Reaction to severe stress, and adjustment disorders,
7. Dissociative (conversion) disorders,
8. Somatoform disorders, and
9. Other neurotic disorders.

ANXIETY DISORDER
State of apprehension or unease arising out of anticipation of danger.

1. Trait anxiety: This is a habitual tendency to be anxious in general (a trait) and is

exemplified by ‘I often feel anxious’.
2. State anxiety: This is the anxiety felt at the present, cross-sectional moment
(state) and is exemplified by ‘I feel anxious now’.

In generalized anxiety disorders, anxiety is continuous, although it

may fluctuate in intensity.
In phobic anxiety disorders, anxiety is intermittent, arising in
particular circumstances.

In panic disorder, anxiety is intermittent, but its occurrence is

unrelated to any particular circumstances.

Reference: Shorter Oxford Textbook of Psychiatry (pg 161)

Short Textbook of Psychiatry, Niraj Ahuja (pg 89)
 48

Stepped-care approach for generalized

anxiety disorder
1. Identification and assessment: education about GAD and treatment options;
active monitoring.
2. Low-intensity psychological interventions: pure self help and guided self-
help, group psychoeducation.
3. Choice of a high-intensity psychological intervention (cognitive behaviour
therapy or applied relaxation) or a drug treatment.
4. Specialist treatment (complex drug and psychological regimens): input
from multiagency teams, crisis services, or day hospitals.
 49

PHOBIC DISORDER
1. Presence of the fear of an object, situation or activity.
2. The fear is out of proportion to the dangerousness perceived.
3. Patient recognises the fear as irrational and unjustified (Insight is present).
4. Patient is unable to control the fear and is very distressed by it.
5. This leads to persistent avoidance of the particular object, situation or activity.
6. Gradually, the phobia and the phobic object become a preoccupation with the patient,
resulting in marked distress and restriction of the freedom of mobility (afraid to
encounter the phobic object; phobic avoidance).

Agoraphobia
Example of irrational fear of situations.
It is the commonest type of phobia encountered in clinical practice.
Characterised by an irrational fear of being in places away from the familiar
setting of home.
It includes fear of open spaces, public places, crowded places, and any other place
from where there is no easy escape to a safe place.
 50

Social Phobia
Irrational fear of activities or social interaction, characterised by an irrational
fear of performing activities in the presence of other people or interacting
with others.
The patient is afraid of his own actions being viewed by others critically,
resulting in embarrassment or humiliation.
There is marked distress and disturbance in routine daily functioning.

Fear of blushing (erythrophobia),

Eating in company of others, public speaking, public performance (e.g. on
stage), participating in groups, writing in public (e.g. signing a check),
speaking to strangers (e.g. for asking for directions), dating, speaking to
authority figures, and
Urinating in a public lavatory (shy bladder).

Specific (Simple) Phobia

Characterised by an irrational fear of a specified object or situation.
Anticipatory anxiety leads to persistent avoidant behaviour, while
confrontation with the avoided object or situation leads to panic attacks.
Gradually, the phobia usually spreads to other objects and situations.
 51

OBSESSIVE-COMPULSIVE DISORDER
obsession
1. An idea, impulse or image which intrudes into the conscious awareness
repeatedly.
2. It is recognised as one’s own idea, impulse or image but is perceived as
ego-alien (foreign to one’s personality).
3. It is recognised as irrational and absurd (insight is present).
4. Patient tries to resist against it but is unable to.
5. Failure to resist, leads to marked distress. Compulsions may diminish
the anxiety associated
compulsion with obsessions.
1. A form of behaviour which usually follows obsessions.
2. It is aimed at either preventing or neutralising the distress or fear arising
out of obsession.
3. The behaviour is not realistic and is either irrational or excessive.
4. Insight is present, so the patient realises the irrationality of compulsion.
5. The behaviour is performed with a sense of subjective compulsion (urge or
impulse to act).

Psychodynamic Theory of Obsessive Compulsive Disorder

 52

Conversion Disorder
1. Presence of symptoms or deficits affecting motor or sensory function,
suggesting a medical or neurological disorder.
2. Sudden onset.
3. Development of symptoms usually in the presence of a significant
psychosocial stressor(s).
4. A clear temporal relationship between stressor and development or
exacerbation of symptoms.
5. Patient does not intentionally produce the symptoms.
6. There is usually a ‘secondary gain’ (though not required by ICD-10 for
diagnosis).
7. Detailed physical examination and investigations do not reveal any
abnormality that can explain the symptoms adequately.
8. The symptom may have a ‘symbolic’ relationship with the stressor/
conflict.

Dissociative Disorder

1. Disturbance in the normally integrated functions of consciousness, identity

and/or memory.
2. Onset is usually sudden and the disturbance is usually temporary. Recovery
is often abrupt.
3. Often, there is a precipitating stress before the onset. There is a clear
temporal relationship between the stressor and the onset of the illness.
A frequent stressful situation is an ongoing war.
4. A ‘secondary gain’ resulting from the development of symptoms may be
found.
5. Detailed physical examination and investigations do not reveal any
abnormality that can explain the symptoms adequately.
 53

Types of Dissociative Amnesia

1. Circumscribed amnesia (commonest type):
There is an inability to recall all the personal events during a circumscribed period
of time, usually corresponding with the presence of the stressor.
2. Selective amnesia (less common):
This is similar to circumscribed amnesia but there is an inability to recall only
some selective personal events during that period while some other events during
the same period may be recalled.
3. Continuous amnesia (rare):
In this type, there is an inability to recall all personal events following the
stressful event, till the present time.
4. Generalised amnesia (very rare):
In this type, there is an inability to recall the personal events of the whole life, in
the face of a stressful life event.
 54

Psychodynamic Theory of Dissociative (Conversion) Disorder

SOMATOFORM DISORDER
Characterised by repeated presentation with physical symptoms which do not have
any adequate physical basis
1. Multiple somatic symptoms in the absence of any physical disorder.
2. The symptoms are recurrent and chronic (of many years duration, usually); at least 2
year duration is needed for diagnosis.
3. The symptoms are vague, presented in a dramatic manner, and involve multiple organ
systems. The common symptoms include gastrointestinal (abdominal pain, beltching,
nausea, vomiting, regurgitation), abnormal skin sensations (numbness, soreness,
itching, tingling, burning), and sexual and menstrual complaints (menorrhagia,
dysmenorrhoea, dyspareunia).
4. There is frequent change of treating physicians.
5. Persistent refusal to accept the advice or reassurance of several doctors that there is
no physical explanation for the symptoms.
6. Some degree of impairment of social and family functioning attributable to the nature
of the symptoms and resulting behaviour.
7. Presence of conversion symptoms is common.
 55

Hyperventilation Syndrome (HVS)

Characterised by a ‘habit’ of hyperventilation which becomes particularly marked in
the presence of psychosocial stress, or any emotional upheaval.
In its mild form, it is characterised by excessive fatigue, chest pain, headache,
palpitations, sweating and a feeling of ‘lightheadedness’.
In severe hyperventilation syndrome, carpopaedal spasm (tetany),
paraesthesias and loss of consciousness may occur.

Physiology of Hyperventilation Syndrome

Depersonalisation Disorder
(or Depersonalisation-Derealisation Syndrome)
Depersonalisation is characterised by an alteration in the perception or experience
of self, so that the feeling of one’s own reality is temporarily changed or lost.
This is often accompanied by derealisation, which is an alteration in the perception
or experience of the external world, so that the feeling of reality of external
world is temporarily changed or lost.
As they both often occur together the syndrome is also called as
depersonalisation-derealisation syndrome.
 56

Depersonalisation: Causes

Post-traumatic Stress Disorder (PTSD)

Characterised by recurrent and intrusive recollections of the stressful event,
either in flashbacks (images, thoughts, or perceptions) and/or in dreams.
There is an associated sense of re-experiencing of the stressful event.
There is marked avoidance of the events or situations that arouse recollections
of the stressful event, along with marked symptoms of anxiety and increased
arousal.
1. Prevention: Anticipation of disasters in the high risk areas, with the training of
personnel in disaster management.
2. Disaster management: Here the speed of providing practical help is of
paramount importance. This is also a preventive measure.
3. Supportive psychotherapy.
4. Cognitive behaviour therapy (CBT).
5. Drug treatment: Antidepressants and benzodiazepines
 57

Neuromyelitis optica spectrum disorders (NMOSD)

Inflammatory disorders of the central nervous system characterized by severe,
immune-mediated demyelination and axonal damage predominantly targeting
the optic nerves and spinal cord, but also the brain and brainstem.

The characteristic symptoms of NMOSD are either optic neuritis or

myelitis; either may occur as the first symptom.
Optic neuritis is inflammation, of the optic nerve (optic neuritis) leading
to pain inside the eye which rapidly is followed by loss of clear vision
(acuity).
Usually, only one eye is affected (unilateral) although both eyes may be
involved simultaneously (bilateral).
NMOSD may or may not be preceded by a prodromal upper respiratory
infection.

Q. Diagnosis of neuromyelitic spectrum

disorders does not include.
1h11 CETZI
 58

Disorders of Adult Personality and Behaviour

Paranoid Personality Disorder antisocial personality disorder

Suspicious Callous
Mistrustful Transient relationships
Jealous Irresponsible
Sensitive Impulsive and irritable
Resentful Lacking guilt and remorse
Bears grudges Failure to accept responsibility
Self-important

Schizoid Personality Disorder histrionic personality disorder

Emotionally cold Self-dramatization

Detached Suggestibility
Aloof Shallow labile affect
Lacking enjoyment Seeks attention and excitement
Introspective Inappropriately seductive
Over-concern with physical attractiveness

Narcissistic Personality Disorder

Anxious (Avoidant)
Grandiose sense of self-importance Personality Disorder
Fantasizes about unlimited success, power, etc. Feels socially inferior
Believes himself or herself to be special Preoccupied with rejection
Requires excessive admiration Avoids involvement
Sense of entitlement to favours and Avoids risk
compliance Exploits others Avoids social activity
Lacks empathy
Envious of others, and believes that others
envy him or her
Arrogant and haughty

Reference: Shorter Oxford Textbook of Psychiatry (pg 299)

Short Textbook of Psychiatry, Niraj Ahuja (pg113 )
 59

Dependent Personality Disorder

Allows others to take responsibility
Unduly compliant
Unwilling to make reasonable demands
Feels unable to care for himself or herself
Fear of being left to care for himself or herself
Needs excessive help to make decisions

Obsessive-Compulsive (Anankastic) Personality Disorder

Preoccupied with details, rules, etc.
Inhibited by perfectionism
Over-conscientious and scrupulous
Excessively concerned with work and productivity
Over-conscientious, scrupulous, and inflexible in ethics and morals
Unable to discard worthless objects
Reluctant to delegate tasks or work with others
Miserly
Rigidity and stubbornness

borderline personality disorder

1. Significant and persistent disturbance of identity of self, e.g. ‘who am I’. There
is marked uncertainty about major issues in life.
2. Unstable and intense interpersonal relationship patterns.
3. Impulsivity.
4. Unstable emotional responses, with rapid shifts. Anger outbursts may occur.
5. Chronic feelings of boredom or emptiness with. inability to stay alone.
6. Deliberate self-harm is common in the form of self-mutilation, suicidal
gestures, or accident- proneness.
 60
Mania

Also known as manic syndrome, is a mental and behavioral disorder defined as a state of
abnormally elevated arousal, affect, and energy level, or "a state of heightened overall activation
with enhanced affective expression together with lability of affect.
During a manic episode, an individual will experience rapidly changing emotions and moods,
highly influenced by surrounding stimuli.
Although mania is often conceived as a "mirror image" to depression, the heightened mood can
be either euphoric or dysphoric.
As the mania intensifies, irritability can be more pronounced and result in anxiety or anger.
The symptoms of mania include :
elevated mood (either euphoric or irritable), MEET21
flight of ideas
Q. 16 year old female patient presented with
pressure of speech, overfamiliarity, flight of ideas, elevated mood,
increased energy, increased sexual desires, pseudo hallucinations.
decreased need and desire for sleep, What is the diagnosis?
hyperactivity.
To be classified as a manic episode, while the disturbed mood and an increase in goal-
directed activity or energy is present, at least three (or four, if only irritability is
present) of the following must have been consistently present:
1 Inflated self-esteem or grandiosity.
2 Decreased need for sleep (e.g., feels rested after 3 hours of sleep).
3 More talkative than usual, or acts pressured to keep talking.
4 Flights of ideas or subjective experience that thoughts are racing.
5 Increase in goal-directed activity, or psychomotor acceleration.
6 Distractibility (too easily drawn to unimportant or irrelevant external stimuli).
7 Excessive involvement in activities with a high likelihood of painful consequences.
(e.g., extravagant shopping, improbable commercial schemes, hypersexuality).[18]
Treatment
The acute treatment of a manic episode of bipolar disorder involves the utilization of either
Mood stabilizer
Carbamazepine, lithium,
valproate, lamotrigine
Atypical antipsychotic
olanzapine, risperidone,
quetiapine, aripiprazole
When the manic behaviours have gone, long-term treatment then focuses on prophylactic
treatment to try to stabilize the patient's mood, typically through a combination of
pharmacotherapy and psychotherapy.
 61

Sexual Disorders
GENDER IDENTITY DISORDERS

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

Dual-role Transvestism
Characterised by wearing of clothes of the opposite sex in order to enjoy the
temporary experience of membership of the opposite sex, but without any desire
for a more permanent sex change (unlike transexualism).
No sexual excitement accompanies the cross-dressing (unlike in fetishistic
transvestism).
Gender-identity Disorder of Childhood
1. Persistent and significant desire to be of the other gender, or insistence on
being of the other gender.
2. Marked distress regarding the anatomic sex, with strong denial of anatomic sex
(in contrast, there is no denial of anatomic sex in transexualism).
3. Involvement in traditional activities, games and clothing pattern of the
perceived gender.
4. Onset before puberty.

Inter-sexuality
1. External genitals, e.g. pseudo-hermaphroditism.
2. Gonads, e.g. ovotestes.
3. Internal sex organs, e.g. true hermaphrodite.
4. Hormonal disturbances, e.g. testicular feminisation syndrome, congenital adrenal
hypoplasia.
5. Chromosomes, e.g. Turner’s syndrome, Klinefelter’s syndrome.

Reference: Shorter Oxford Textbook of Psychiatry (pg )

Short Textbook of Psychiatry, Niraj Ahuja (pg )
 62

[11-111^952018]
Webbing of neck is
associated with higher risk
of cardiac anomalies
 63

PSYCHOLOGICAL AND BEHAVIOURAL DISORDERS ASSOCIATED

WITH SEXUAL DEVELOPMENT AND MATURATION

Homosexuality
Sexual relationship between persons of the same sex

1. Obligatory homosexuality
• Only homosexuality
• No heterosexuality.
2. Preferred homosexuality
• Predominant homosexuality
• Occasional heterosexuality.
3. Bisexuality
• Almost equal homosexuality and heterosexuality.
4. Situational homosexuality
• Predominant heterosexuality
• Occasional homosexuality.
5. Latent homosexuality
• Only heterosexuality
• Fantasies of homosexuality.

homosexuality

Ego-syntonic homosexuality Ego-dystonic homosexuality

(no distress about homosexual (associated with marked distress)
behaviour).

Treatment for seeking a Change in Sexual Orientation

i. Psychoanalytic psychotherapy (especially when associated with
personality issues).
ii. Behaviour therapy: Aversion therapy (rarely used), covert sensitisation,
systematic desensitisation (especially if there is a phobia of
heterosexual relationship).
iii. Supportive psychotherapy.
iv. Androgen therapy (occasionally).
 64

Gender dysphoria

PARAPHILIAS
(DISORDERS OF SEXUAL PREFERENCE)
Fetishism
The sexual arousal occurs either solely or predominantly with a nonliving
object, which is usually intimately associated with the human body.

Fetishistic Transvestism
The person actually or in fantasy wears clothes of the opposite sex (cross-
dressing) for sexual arousal. This disorder should be differentiated from
dual-role transvestism and transexualism.
 65

Sexual Sadism
The person (the ‘sadist’) is sexually aroused by physical and/or psychological
humiliation, suffering or injury of the sexual partner (the ‘victim’).

Sexual Masochism

Reverse of sexual sadism. Here the person (the ‘masochist’) is sexually

aroused by physical and/or psychological humiliation, suffering or injury
inflicted on self by others (usually ‘sadists’).

Exhibitionism
Persistent (or recurrent) and significant method of sexual arousal by
the exposure of one’s genitalia to an unsuspecting stranger.

Voyeurism
Persistent or recurrent tendency to observe unsuspecting persons (usually
of the other sex) naked, disrobing or engaged in sexual activity.

Frotteurism
Persistent or recurrent involvement in the act of touching and rubbing against
an unsuspecting, nonconsenting person (usually of the other sex).

Paedophilia

Persistent or recurrent involvement of an adult (age >16 years and at least 5

years older than the child) in sexual activity with prepubertal children, either
heterosexual or homosexual.

Zoophilia (Bestiality)
Persistent and significant involvement in sexual activity with animals is
rare.

Others
Sexual arousal with urine (urophilia); faeces (coprophilia); enemas
(klismaphilia); corpses (necrophilia),
 66

SEXUAL DYSFUNCTIONS
normal human sexual response cycle
1. Appetitive Phase: The phase before the actual sexual response cycle. This
consists of sexual fantasies and a desire to have sexual activity.
2. Excitement Phase: The first true phase of the cycle, which starts with physical
stimulation and/or by appetitive phase.
3. Plateau Phase: The intermediate phase just before actual orgasm, at the height of
excitement.
4. Orgasmic Phase: The phase with peak of sexual excitement followed by release of
sexual tension, and rhythmic contractions of pelvic reproductive organs.
5. Resolution Phase: A general sense of relaxation and well-being, after the slight
clouding of consciousness during the orgasmic phase

Physical Causes of Male Erectile Disorder/Impotence

 67

Sexual Dysfunctions Caused by Drugs

 68

Components of ANTIDEPRESSANT WITH LEAST

sexual response SEXUAL DYSFUNCTION
Desire BUPROPTION
Arousal AGOMELATINE
Orgasm MITRAZAPINE
TRAZADONE

DRUGS ANTIDEPRESSANT CLASS SIDE EFFECT

Atypical
Mirtazapine antidepressant DESIRE
Serotonin & Norepinephrine DESIRE, AROUSAL,
Venlafaxime ORGASM
reuptake inhibitors (SNRI)
TRICYCLIC DESIRE, AROUSAL,
Imipraine ANTIDEPRESSANT ORGASM
Selective serotonin DESIRE, AROUSAL,
Fluoxetine reuptake Inhibitor (SSRI) ORGASM

Treatments for sexual dysfunction

 69

Sleep Disorders
Stages of Sleep

EEG recordings

D-sleep (desynchronised or S-sleep (synchronised sleep),

dreaming sleep), NREM-sleep (non-REM sleep),
REM-sleep (rapid eye quiet sleep, or
movement sleep), orthodox sleep.
active sleep, or Divided into four stages, ranging from
paradoxical sleep. stages 1 to 4. As the person falls asleep,
the person first passes through these
stages of NREM-sleep.

Reference: Shorter Oxford Textbook of Psychiatry (pg 313)

Short Textbook of Psychiatry, Niraj Ahuja (pg133 )
 70

Stage 1,
NREM-sleep is the first and the lightest stage of sleep characterised by an absence
of alpha- waves, and low voltage, predominantly theta activity
Stage 2,
NREM-sleep follows the stage 1 within a few minutes and is
characterised by two typical EEG changes:

i. Sleep spindles: Regular spindle shaped waves of 13-15

cycles/sec. frequency, lasting 0.5-2.0 seconds, with a
characteristic waxing and wan- ing amplitude.
ii. K-complexes: High voltage spikes present in- termittently.

Stage 3,
NREM-sleep shows appearance of high voltage, 75 µV, δ-waves of 0.5-3.0
cycles/sec.

Stage 4,
NREM-sleep shows predominant δ-activity in EEG.

Depending on the duration of total sleep, two extremes of ‘normal’ sleeping

patterns have been described.

Long-sleepers:
These persons regularly and habitually sleep for more than 9 hours/
night, and this pattern of sleep does not cause any symptoms or
dysfunction.

Short-sleepers:
These persons regularly and habitually sleep for less than 6 hours/night, and
this pattern of sleep does not cause any symptoms or dysfunction.
 71

Classification of sleep disorders in ICD-10

Common Causes of Insomnia

 72

Treatments for insomnia

Sleep Hygiene
1. Regular, daily physical exercises (preferably not in the evening).
2. Minimise daytime napping.
3. Avoid fluid intake and heavy meals just before bed- time.
4. Avoid caffeine intake (e.g. tea, coffee, cola drinks) before sleeping hours.
5. Avoid regular use of alcohol (especially avoid use of alcohol as a hypnotic for
promoting sleep).
6. Avoid reading or watching television while in bed.
7. Sleep in a dark, quiet, and comfortable environment.
8. Regular times for going to sleep and waking-up
9. Try relaxation techniques

Causes of excessive daytime sleepiness

Insufficient sleep
Narcolepsy
Depression
Other medical disorders (e.g. hypothyroidism, Prader– Willi syndrome)
Shift-work sleep disorder Use of sedative medications
Obstructive sleep apnoea
 73

Hypersomnia
Disorder of excessive somnolence (DOES). Hypersomnia means one or more of
the following:

1. Excessive day time sleepiness.

2. ‘Sleep attacks’ during day time (falling asleep unintentionally).
3. ‘Sleep drunkenness’ (person needs much more time to awaken; and during
this period is confused or disoriented).

Causes of Hypersomnia
 74

Kleine-Levin Syndrome
1. Hypersomnia (always present), occurring recurrently for long periods of time.
2. Hyperphagia (usually present), with a voracious appetite.
3. Hypersexuality (associated at times), consisting of sexual disinhibition,
masturbatory activity, exhi- bitionism, and/or inappropriate sexual advances.
Parasomnias
Dysfunctions or episodic nocturnal events occurring with sleep, sleep stages or
partial arousals.
Stage 4 Sleep Disorders

1. Sleep-walking (somnambulism): The patient carries out automatic

motor activities that range from simple to complex. He may leave the
bed, walk about or leave the house. Arousal is difficult and accidents may
occur during sleep-walking.

2. Sleep-terrors or night terrors (pavor nocturnus): The patient suddenly

gets up screaming with autonomic arousal (tachycardia, sweating and
hyperventilation). He may be difficult to arouse and rarely recalls the
episode on awakening. In contrast, nightmares (which occur during REM-
sleep) are clearly remembered in the morning

3. Sleep-related enuresis (bedwetting)

4. Bruxism (teeth-grinding): The patient has an involuntary and forceful

grinding of teeth during sleep. Though the bed partner reports loud sounds
produced by grinding of teeth and destruction of the tooth enamel is
obvious, the patient remains completely unaware of the episode(s).

5. Sleep-talking (somniloquy): The patient talks during stages 3 and

4 of sleep but does not remember anything about it in the morning
on awakening.

Benzodiazepines suppress
stage 4 of NREM- sleep
 75

Behavioural Syndromes
EATING DISORDERS

Schematic representation of
temporal movement between
the eating disorders. The size
of the arrow indicates the
likelihood of movement in the
direction shown.
Arrows that point outside of
the circle indicate recovery.

Anorexia Nervosa
1. It occurs much more often in females as compared
to the males. The common age of onset is adolescence (13-19 years of age).
2. There is an intense fear of becoming obese. This fear does not decrease even
if body becomes very thin and underweight.
3. There is often a body-image disturbance. The person is unable to perceive own
body size accurately. However, body image disturbance may sometimes not be
seen in patients from non-Western cultural settings and several such cases
have been described from India.
4. There is a refusal to maintain the body weight above a minimum normal
weight for that age, sex and height.
5. Significant weight loss occurs, usually more than 25% of the original weight.
The final weight is usually 15% less than the minimum limit of normal weight
(for that age, sex and height) or a Quetelet’s body-mass index (BMI) of 17.5 or
less (Quetelet’s body-mass index = weight in kg divided by square of height in
meters).
6. No known medical illness, which can account for the weight loss, is present.
7. Absence of any other primary psychiatric disorder.
8. Amenorrhoea, primary or secondary, is often present in females.

Reference: Shorter Oxford Textbook of Psychiatry (pg 313)

Short Textbook of Psychiatry, Niraj Ahuja (pg142 )
 76

Bulimia Nervosa
1. Bulimia nervosa usually has an onset in early teens or adolescence.
2. There is an intense fear of becoming obese. There may be an earlier history of
anorexia nervosa.
3. There is usually body-image disturbance and the person is unable to perceive own
body size accurately.
4. There is a persistent preoccupation with eating, and an irresistible craving for food.
There are episodes of overeating in which large amounts of food are consumed within
short periods of time (eating binges).
5. There are attempts to ‘counteract’ the effects of overeating by one or more of the
following: self- induced vomiting, purgative abuse, periods of starvation, and/or use of
drugs such as appetite suppressants.
Physical complications of bulimia nervosa
 77

Psychosomatic Disorders

The 7 classical psychosomatic disorders are:

1. Bronchial asthma
2. Ulcerative colitis
3. Peptic ulcer
4. Neurodermatitis
5. Thyrotoxicosis
6. Rheumatoid arthritis
7. Essential hypertension.

Franz Alexander, the Father of Psychosomatic Medicine, initially described the seven
classical psychosomatic illnesses . His specificity hypothesis stated that if a specific
environmental stressor or emotional conflict occurs, it results in a specific illness in a
genetically predetermined organ.

A Biopsychosocial Model for Psychosomatic Illness

George Engel in 1977, described a biopsychosocial model to explain the

complex interaction between biological, psychological and social spheres
resulting in a psychosomatic illness.
 78

Examples of Psychosomatic Disorders

 79

GRIEF
Normal response of an individual to the loss of a loved object. An “object”
(psychological speaking) can include a close relative or a friend, material values or
non-material things such as reputation and self-esteem.

Three phases of the behaviour response to loss of a loved object:

i. protest,
ii. despair,and
iii. detachment.

Pathological Grief Reaction

When there is an exaggeration of one or more symptoms of normal grief, or the
duration becomes prolonged beyond 6 months without spontaneous recovery, grief
becomes morbid.
i. chronic grief (duration more than 6 months);
ii. delayed grief (onset after 2 weeks of loss);
iii. inhibited grief (denial of loss);
iv. excessive anxiety, guilt, anger or religiosity grief;
v. identification with the deceased;
vi. over-idealisation of the deceased; and
vii. anniversary reactions (grief reaction on death anniversary).
80
 81

Body-focused repetitive behavior

Body-focused repetitive behavior (BFRB) is an umbrella name for impulse
control behaviors involving compulsively damaging one's physical appearance or
causing physical injury.
Body-focused repetitive behavior disorders (BFRBDs) in ICD-11 is in
development.
BFRB disorders are currently estimated to be under the obsessive-compulsive
spectrum.

Types of BFRB
• Skin
◦ Dermatillomania (excoriation disorder), skin picking
◦ Dermatophagia, skin nibbling
• Mouth
◦ Morsicatio buccarum, cheek biting
◦ Morsicatio labiorum, inner lip biting
◦ Morsicatio linguarum, tongue biting
• Hands
◦ Onychophagia, nail biting
◦ Onychotillomania, nail picking
• Nose
◦ Rhinotillexomania, compulsive nose picking[2]
• Hair
◦ Trichophagia, hair nibbling
◦ Trichotemnomania, hair cutting
◦ Trichotillomania, hair pulling
• Eyes
◦ Mucus fishing syndrome - compulsion to remove or "fish"
strands of mucus from the eye

Q. Body focused repetitive behaviour comes

under which OCD in ICD 11?

INICETZI
82
 83

Mental Retardation and Child Psychiatry

INTELLECTUAL DEVELOPMENT
Sensori-Motor Stage
Birth to 2 years of age
i. Actions related to sucking, orality and assimilation of objects.
ii. Ability to think of only one thought at a time.
iii. Inanimate objects are given human qualities.
iv. ‘Out of sight’ means ceasing to exist.
Concrete Thinking Stage

2 years to 7 years of life

i. Egocentric thought with a unique logic of its own, involving a limited
point of view and lacking introspection.
ii. Inability to generalise from specific events and to specify from
general events.
Abstract or Conceptual Thinking Stage
7 years of age and lasts till 11 years of age
i. Ability to focus on several dimensions of a problem at one time,
mentally.
ii. The thought process is flexible and reversible.
iii. Ability of abstraction, i.e. ability to generalise from specific and ability
to find similarities and differences among specific objects.
Adolescent Thinking or Formal Operational Stage
Begins at 11 years of age and continues life-long.
i. Ability to imagine the possibilities inherent in a situation, thus making the
thought comprehensive.
ii. Ability to develop complete abstract hypotheses and to test them.

Reference: Shorter Oxford Textbook of Psychiatry (pg 415)

Short Textbook of Psychiatry, Niraj Ahuja (pg 153 )
 84
MENTAL RETARDATION
Significantly sub-average general intellectual functioning, associated with
significant deficit or impairment in adaptive functioning, which manifests during
the developmental period (before 18 years of age).

mental age
Intelligence Quotient × 100
chronological age

Developmental delay
Developmental quotient (DQ)=
developmental age/ chronological age x 100

DQ<70% -> Developmental delay

If it involves two or more field -> global developmental delay
Eg. cerebral palsy

Causes of Mental Retardation

 85
Features of mild, moderate, and severe/profound
intellectual disability

Windows of achievement of six major motor milestones

 86

Developmental milestones

Key gross motor developmental milestones

Age Milestone

3 Months Neck holding

5 Months Rolls over

Sits in tripod fashion

6 Months (sitting with own support)

8 Months Sitting without support

9 Months Stands holding on (with support)

Creeps well; walks but falls;

12 Months stands without support

15 Months Walks alone; creeps upstairs

18 Months Runs; explores drawers

Walks up and downstairs (2 feet/step);

2 years jumps
Rides tricycle; alternate feet
3 years going upstairs

4 years Hops on foot; alternate

feet going downstairs
 87

Gross Motor Development

Infant lifts head from the supine position

Pull to sit; complete head lag in a newborn
when about to be pulled at 5 months

Pull to sit; no head lag at 4 months

Ventral suspension; unable to hold neck in
the line with trunk at 4 weeks

Pull to sit; flexes the head on to chest at Ventral suspension; head in line with the
5 months trunk at 8 - 10 weeks
 88

In prone: face lifted to about 45° at 8 weeks

Ventral suspension; head in line with the
trunk at 12 weeks

In prone: face, head and chest off the couch

at 3 months
The infant lies on the bed with high pelvis and
knees drawn up at 2 weeks

In prone: weight on hands with extended

The infant lies with flat pelvis and extended arms at 6 months
hips at 6 weeks
 89

Creep position at 10 months of age

(abdomen off ground and weight on
hands and knees
Sitting with support of hands at 6
months

Sitting; back rounded but able to Sitting without support at 8

hold head at 8 weeks months

Pivoting; turns around to pick up an

Sitting; back much
object at 11 months
straighter at 4 months
 90

Child walking with one hand-

Bears almost entire weight at 6 months held at 12-13 months

Stands well at 12 months

The child is able to walk upstairs
and downstairs one foot per step
at 4 yr
 91

Key fine motor developmental milestones

Age Milestone

4 Months
Bidextrous reach
(reaching out for objects with both hands)

Unidextrous reach (reaching out for objects

6 Months with one hand); transfer objects

9 Months Immature pincer grasp;

probes with forefinger

12 Months Pincer grasp mature

15 Months Imitates scribbling; tower of 2 blocks

18 Months Scribbles; tower of 3 blocks

2 years Tower of 6 blocks;

vertical and circular stroke

3 years Tower of 9 blocks; copies circle

4 years Copies cross; bridge with blocks

5 years Copies triangle; gate with blocks

Tower of cubes

3 yrs = (3x 3) = 9 cubes E 3yxs 33 3 yrs- Circle

2 yrs = (2x 3) = 6 cubes 4 yrs - X/+
4 4yrs
8 months = 3 cubes 4 1/2 yrs- Square
15 months= 2 cubes 5 yrs- Triangle
442yes
6 yrs - Diamond
5
yes

6
yes
 92
Fine Motor Development

Hand regard (between 12 and 20

weeks)

The child brings hands in midline as

he plays at 3 to 4 months of age

Bidextrous grasp approach to a

dangling ring at 4 months

[NEET 19 ]

Bidextrous grip is seen at

what age?
 93

Immature grasp at 6
months (palmar
grasp)

Intermediate grasp at 8
months, beginning to use
radial aspect of the hand

Mature grasp at 1 yr of age,

note the use of thumb and
index finger

Pincer grasp approach to

small objects (index finger
and thumb)
 94

A child mouthing an object at 6

months of age

Scribbles spontaneously at 15
months

A child makes tower of 5-6

cubes at 2 yr of age
 95

Key social and adaptive milestones

Age Milestone

2 Months Social smile (smile after being talked to)

3 Months Recognizes mother; anticipates feeds

6 Months Recognizes strangers, stranger anxiety

9 Months Waves “bye bye”

12 Months Comes when called; plays simple ball game

15 Months Jargon

18 Months Copies parents in task (e.g. sweeping)

2 years Asks for food, drink, toilet, pulls

people to show toys

3 years Shares toys; knows full name and gender

4 years Plays cooperatively in a group;

goes to toilet alone

5 years Helps in household tasks.

Dresses and undresses
 96

Personal and Social Development and General Understanding

At 1 month, the baby

showing intent regard
of his mother's face as
she talks to him

Social smile

A child smiles at himself in the

mirror at 6 months of age
 97

Key language milestones

Age Milestones

1 Months Alerts to sound

3 Months Coos (musical vowel sound)

4 Months Laugh loud

6 Months Monosyllables (ba, da, pa). ah-goo sould

9 Months Bisyllables (mama, dada, baba)

12 Months 1-2 words with meaning

18 Months 8-10 words vocabulary

2 years 2-3 word sentences, used pronouns, “I”,“me”, “you”

3 years Asks questions; knows full name and gender

4 years Says song or poem; tells stories

5 years Asks meaning of words

 98

Vision and Hearing

Infant fixates on her mother as

she talks to her at 1 month

Grasping 'with the eye' at 3

months

Diagonal localization of the

source of sound at 10 months
 99

CHROMOSOMAL DISORDERS

[NEET 19] Alzheimer’s

disease is
commonly
associated with
Down’s
syndrome.

Robbin & Cotran Pathological basis of diseases (pg 168); Text book of Pathology , Harsh Mohan (pg253)
 100
Infantile autism
Childhood onset autism or childhood onset pervasive developmental disorder.
The onset occurs before the age of 2 1⁄2 years

1. Autism (marked impairment in reciprocal social and interpersonal

interaction):
i. Absent social smile.
ii. Lack of eye-to-eye-contact.
iii. Lack of awareness of others’ existence or feelings; treats people as furniture.
iv. Lack of attachment to parents and absence of separation anxiety.
v. No or abnormal social play; prefers solitary games.
vi. Marked impairment in making friends.
vii. Lack of imitative behaviour.
viii. Absence of fear in presence of danger.
2. Marked impairment in language and non-verbal communication
i. Lack of verbal or facial response to sounds or voices;
ii. In infancy, absence of communicative sounds like babbling.
iii. Absent or delayed speech
iv. Abnormal speech patterns and content. Presence of echolalia,
perseveration, poor articulation and pronominal reversal (I-You) is common.
v. Rote memory is usually good.
vi. Abstract thinking is impaired.
3. Abnormal behavioural characteristics
i. Mannerisms.
ii. Stereotyped behaviours such as head-banging, body-spinning, hand-flicking,
lining-up objects, rocking, clapping, twirling, etc.
iii. Ritualistic and compulsive behaviour.
iv. Resistance to even the slightest change in the environment.
v. Attachment may develop to inanimate objects.
vi. Hyperkinesis is commonly associated. Idiot savant syndrome
In spite of the pervasive impairment of
4. Mental retardation functions, certain islets of precocity or
splinter functions may remain.
Eg : prodigious rote memory or
calculating ability, and musical abilities.
 101

ATTENTION DEFICIT DISORDER

(HYPERKINETIC DISORDER)
1. Attention deficit disorder with hyperactivity
(Hyperkinetic disorder)
Commonest type.
Poor attention span with distractibility
i. Fails to finish the things started.
ii. Shifts from one uncompleted activity to another.
iii. Doesn’t seem to listen.
iv. Easily distracted by external stimuli.
v. Often loses things.
Hyperactivity
i. Fidgety.
ii. Difficulty in sitting still at one place for long.
iii. Moving about here and there.
iv. Talks excessively.
v. Interference in other people’s activities.
Impulsivity
i. Acts before thinking, on the spur of the moment.
ii. Difficulty in waiting for turn at work or play.

2. Attention deficit disorder without hyperactivity:

It is a rare disorder with similar clinical features, except hyperactivity.

3. Residual type:
It is usually diagnosed in a patient in adulthood, with a past history of ADD
and presence of a few residual features in adult life.
4. Hyperkinetic disorder with conduct disorder (Hyperkinetic
conduct disorder).
 102

CONDUCT DISORDERS
Characterised by a persistent and significant pattern of conduct, in which the
basic rights of others are violated or rules of society are not followed.

According to ICD-10, there are four subtypes of conduct disorder:

1. Conduct disorder confined to the family context.
2. Unsocialised conduct disorder.
3. Socialised conduct disorder.
4. Oppositional defiant disorder.
The characteristic clinical features include:
1. Frequent lying.
2. Stealing or robbery.
3. Running away from home and school.
4. Physical violence such as rape, fire-setting, assault
or breaking-in, use of weapons.
5. Cruelty towards other people and animals.

Childhood anxiety disorder

Most common type of psychiatric problem in children.
Cause severe impairment and excessive distress.
1. Separation anxiety disorder
Excessive anxiety concerning separation from home or major attachment figures
2. selective mutism
The persistent failureto speak in specific social situations despite
speaking in other favourable situations
selective mutism
Children refuse to speak in situations where talking is expected or necessary
It interferes with school and making friends
They stand motionless and expressionless, turn their heads, chew or twirl
hair, or withdraw into a corner to avoid talking
Avoid eye contact,
They can be very talkative and display normal behaviors at home or in
comfortable places
Diagnosed at around 5 years of age
 103
TIC DISORDERS
Tic is an abnormal involuntary movement (AIM) which occurs suddenly,
repetitively, rapidly and is purposeless in nature.
1. Motor tic, characterised by repetitive motor movements.
2. Vocal tic, characterised by repetitive vocalisations.
Tourette’s disorder is typically characterised by:
1. Multiple motor tics.
2. Multiple vocal tics.
3. Duration of more than 1 year.
4. Onset usually before 11 years of age and almost always before 21 years of age.

Nocturnal enuresis
Involuntary voiding at night after 5 yrs of age for more than 3 months
Primary- Child has not yet had a prolonged period of dry
Secondary- Child begins wetting after having stayed dry
Epidemiology
- 60% are boys
- 50% have family history

Treatment
Rule out any organic causes
1. Reassure parents. - Self limiting
- Restrict fluid intake after 6pm
- Child to void at bedtime
2. Motivational therapy(initial measure)
- Star chart with reward for delaying
3. Conditioning therapy- Bell and pad alarm method.
- 30%-60% success
- Lower relapse rate than drugs
4. Pharmacotherapy- with Oral Desmopressin at bedtime
5. Combination of alarm & desmopressin- more effective
 104

Psychosocial Skin Disease

Purpura and erosions on the soft,

padded areas of the buttock and thighs,
Trichotillomania. This extensive alopecia
representing very obvious abuse.
resulted from pulling and plucking hairs by
the 17-yearold patient. Hairs are broken at
different lengths throughout the scalp.

Bite marks

Trichophagia is the compulsive eating of

hair associated with trichotillomania
(hair pulling). In trichophagia, people
with trichotillomania also ingest the hair
that they pull; in extreme cases this can
lead to a hair ball (trichobezoar)

Track marks from intravenous drug use on

the upper extremity.
 105

Psychopharmacology
Ideal Psychotropic Drug
1. It should cure the underlying pathology causing the disorder or symptom(s)
under focus, so that the drug can be stopped after sometime.
2. It should benefit all the patients suffering from that disorder.
3. It should have no side-effects or toxicity in the therapeutic range.
4. It should have rapid onset of action.
5. There should be no dependence on the drug and no withdrawal symptoms on
stopping the drug.
6. There should be no tolerance to the drug so that same dose is effective for
long duration of time.
7. It should not be lethal in overdoses.
8. It can be given in both inpatient and outpatient settings.

Factors in Poor Drug Concordance

Reference: Short Textbook of Psychiatry, Niraj Ahuja (pg 172 )

 106

Antidepressants
107
 108

'

[ MEET 18]

Drug of choice for resistant rheumatic chorea: Valproate

 109

Probable Mechanism of Action of Benzodiazepines (BDZ)

Disulfiram
i. Aversive agent in chronic alcoholics
ii. Given only in a very highly motivated person committed to maintaining abstinence
with a care taker
iii. Inhibits aldehyde dehydrogenase
iv. It’s action persists for 24~48 hours after stopping the drug
v. Initially daily dosage of 500 mg for 1~2 weeks, maintenance dosage 125~500 mg.

Medications for FDA

treatment of approval Dosage
alcohol use

1. ACAMPROSTAT YES 2 x 333 mg three times/ day

Initially 250 mg, to 500 Increase acetaldehyde (metabolite)
2. DISULFIRAM YES mg once/ day
CausesT
3. FLUOXETINE NO 20 mg once/ day
(a) Drowsiness
4. GABAPENTIN NO 300 mg twice/ day (b) Chest discomfort
(c) Respiratory depression
5.NALTEXONE YES 50~100 mg/ day

6. ONDANSETRON NO 4 mcg twice/ day

7. SERTRALINE NO 50 mg/ day

8. TOPIRAMATE NO 25 mg/ day

 110

Tca
i. 15% risk of suicidal attempt in major depressive disorder
ii. Most lethal antidepressants are TCAs
iii. In depressed patients: sedative effect, After 2–3 weeks of continuous treatment, the
mood is gradually elevated.
iv. Lower seizure threshold and produce convulsions in overdose.
v. Are potent anticholinergics.
vi. CVS effects: (a) Tachycardia
(b) Postural hypotension
(c) T wave suppression or inversion- most consistent change
(d) Arrhythmias (seen in case of toxicity)
vii. TDM is done within 4 weeks of starting the medication

Paradoxical suicide
Patients recovering from suicidal depression are at high risk
As the depression lifts, patient become energised and put their suicidal plan
to action.

Toxic effects of TCA

Due to
i. Inhibition of norepinephrine and serotonin reuptake
ii. Anticholinergic action
iii. Direct alphaadrenergic blockade
iv. Membrane stabilising effect on the myocardium by blocking the
cardiac myocyte sodium channels

ECG changes
PR, QRS & QT prolongation
Brugada syndrome- drug induced
Useful measure of toxicity than plasma level monitoring
 111

Antidepressants
SSRI’s
causes side effects
A
Serotonin

T Brain
Stimulate 5-HT2 receptor D
Spinal cord
to
Sexual dysfunction
i. Erectile dysfunction
ii. Anorgasmia
iii. Delayed ejaculation

5-HT2 Receptor i. Nefazodone (Priapism)

•
blockers ☒
ii. Trazodone • Causes less sexual
(serotonin receptor) iii. Mirtazapine dysfunction

mirtazapine
i. Antidepressant
ii. Enhances both NA and 5-HT release.
5-HT1 receptor selective enhancement • Blocking 5-HT2 & 5-HT3 receptors
By

Less serotonin side effects (sexual dysfunction)

i. Any drug increasing serotonin causes sexual dysfunction.

ii. Antidepressants increase serotonin.
iii. Maximum sexual dysfunction is seen with SSRI’s (Maximum in Paroxetine)
iv. Least sexual dysfunction is seen with Bupropion (no effect on serotonin)

Inhibitor of DA and NA uptake

 112

psychosurgery

Papez circuit
The aim of psychosurgery is to produce surgical lesions in carefully selected
parts of limbic system and/or its connecting fibres.
One major part of limbic system, believed to be important in emotional
experiences, is Papez circuit.
This important circuit, which lies within the limbic system, connects cingulate
bundle, hippocampus, anterior thalamus, mammillary bodies, fornix and septum
Indications
1. Chronic, severe, incapacitating depression, which has not responded to all
available treatments.
2. Chronic, severe, incapacitating obsessive-compulsive disorder (OCD), which
has not responded to all available treatments.
3. Chronic, severe, incapacitating anxiety disorder, which has not responded to
all available treatments.
4. Schizophrenia with severe depressive component, which has not responded to
all available treatments.
5. Severe, pathological and uncontrolled aggressive behaviour associated with a
psychiatric or neurological illness (e.g. temporal lobe epilepsy).
 113

Risperidone

Risperidone is a second-generation antipsychotic (SGA) medication used in the

treatment of a number of mood and mental health conditions including schizophrenia
and bipolar disorder.

“Off label” refers to using a drug for conditions not listed on the Food and Drug
Administration (FDA) label of approved uses. Drugs are commonly prescribed off
label when approved drugs cannot be used or do not work. Off-label uses may be
supported by clinical evidence.
• Dementia-related behavioral problems
• Depression
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Personality disorders
• Tourette’s syndrome in children and adolescents

The primary action of risperidone is to decrease dopaminergic and serotonergic

pathway activity in the brain, therefore decreasing symptoms of schizophrenia
and mood disorders.
Risperidone has a high binding affinity for serotonergic 5-HT2A receptors when
compared to dopaminergic D2 receptors in the brain.
Risperidone binds to D2 receptors with a lower affinity than first-generation
antipsychotic drugs, which bind with very high affinity.

Q. Off label use of Resperidone except.

INICETZI
 114

Emergency Psychiatry
Unforeseen combination of circumstances which calls for an immediate action.
Suicide
Commonest cause of death among the psychiatric patients.
Deliberate self-harm (DSH) and is defined as a human act of self-intentioned
and self-inflicted cessation (death)

1. A crisis that causes intense suffering with feelings of hopelessness and helplessness
2. Conflict between unbearable stress and survival
3. Narrowing of the person’s perceived options
4. Wish to escape (it can often be an escape, rather than a going-towards)
5. Often a wish to punish self and/or punish significant others with guilt

Risk Factors for Suicide

Reference: Short Textbook of Psychiatry, Niraj Ahuja (pg 221 )

 115

Care of the suicidal patient in hospital

116