PSYCHIATRY NOTES

For Medical Students

Mosab Emad Mubayed

AlNeelain University

2022
Hello my colleagues,
Let me to present to you “PSYCHIATRY NOTES For Medical Students”
,which presents the topics of Psychiatry Medicine in a new and practical way.
I would like to note that I have prepared a part of it during my personal study before the final
exam; As for the larger part, I completed it after the exam.
I would like to confirm that I prepared and compiled it from different sources that I mentioned
in the references at the end of the book, and my goal was to help you find one book in which
easy for you to access the information in an easy and interesting way.
In this book you will find the most important topics that may be scattered in other books and
references, I arranged, coordinated and presented them in the way I thought was the best.
I think that the study is completed when you read the topic well and then try to solve questions
on it, so; I allocated a large number of questions, and I put a short test at the end, which I hope
that all of you will succeed in answering it.
I would like to emphasize that this book is not a substitute for doctors' materials, references or
clinical round.
Finally, “Perfection Is For Allah”; you may find errors in this book, please send to me for that.
I wish you success Insha'Allah and that you get the maximum benefit possible from this book.
My sincere love and respect.

Mosab Emad Mubayed

AlNeelain University
2022
According to chapters:
Contents
CHAPTER Page
Chapter One: Psychopathology 3

Chapter Two: Psychopharmacology & Psychotherapy 13

Chapter Three: Anxiety, Mood & Psychotic Disorders 22
Chapter Four: Miscellaneous Disorders 29
Chapter Five: History Taking & Examination 47
Chapter Six: Questions & Short test 53
According to topics:
TOPIC Page
Psychopathology 4
Psychopharmacology 14
Psychotherapy & Defense Mechanisms 19
Anxiety, Mood & Psychotic Disorders 22
Eating Disorders 30
Personality Disorders 31
Sleep Disorders 32
Substance Use Disorders 35
Alcohol abuse 57,58
Child Psychiatry: Autistic Disorder & Enuresis 40
Child Psychiatry: ADHD 55
Somatic disorders 42
Emergency: Suicide 44
Emergency: ECT 68
Emergency: Postpartum Blues, Depression & Psychosis 59
Delirium 60
Dementia 61
Important Notes you must know! 46
History taking & Examination 48
Problems Questions 54
MCQs 62
OSPE Questions 68
Short test 73
References 78
 Chapter One
Psychopathology

PSYCHIATRY NOTES For Medical Students | Mosab Emad Mubayed | AlNeelain University | 2022
3
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

WHAT IS PSYCHIATRY??
An area of medicine involving the study, diagnosis and treatment of mental health disorders.
WHAT IS PSYCHOPATHOLOGY ??
Systematic study of abnormal experience, cognition and behavior.
The study of the products of a disordered mind.
 Note: Psychopathology is the language of Psychiatry; so any term you will find in this
chapter is very important for understanding psychiatric disorders.

 Definitions:
1. Consciousness: a state of awareness of the self and environment.
2. Perception: a process by which individuals organize and interpret their sensory
impressions in order to give meaning to their environment.
3. Hallucinations: a false perception which is not a sensory distortion or a
misinterpretation, but which occurs at the same time as real perceptions, in the absence of
external stimuli.
4. Delusions: a fixed, unshakeable belief that is out of keeping with the patient’s social and
cultural background.
5. Sensory memory: is registered for each of the senses and its purpose is to facilitate the
rapid processing of incoming stimuli so that comparisons can be made with material already
stored in short- and long-term memory.
6. Short-term memory = working memory:
allows for the storage of memories for much longer than the few seconds available to
sensory memory, constant updating of one’s surroundings.
7. Amnesia: partial or total inability to recall past experiences and its origin may be organic
or psychogenic.
8. Hypermnesia “hyperthymesia”: an extreme degree of retentiveness and recall, with
unusual clarity of memory images.
9. Feeling: a positive or negative reaction to some experience or event and is the subjective
experience of emotion.
10. Emotion: stirred-up state caused by physiological changes occurring as a response to
some event and which tends to maintain or abolish the causative event.
11. Mood: a pervasive and sustained emotion that colours the person’s perception of the world.
12. Affect: short-lived emotion, is the patient’s present emotional responsiveness.
13. Intelligence: the ability to think and act rationally and logically.
4
 PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

1. Consciousness
Restriction = loss Dream like changes
awareness is narrowed * some lowering of the
down to a few ideas and level of consciousness
attitudes that dominate
Lowering of consciousness
* rise in the threshold for
the patient’s mind. * psychologically benumbed all incoming stimuli
* general lowering of consciousness * disoriented for time and
* without hallucinations, illusions, place, but not for person
delusions and restlessness

2. Perception
Intensity abnormalities * hyper- or hypo-aesthesia
* Anxious and manic patients perceive
noise as very loud while depressed
patient less intense.
* Mainly visual perceptions that are Quality abnormalities
affected by this, brought about by toxic
substances.
* Schizophrenic patient report that
food tastes unpleasant. Stimuli from a perceived object are
Illusions combined with a mental image to
produce a false perception.
1. Hypnagogic
while falling asleep
2. Hypnopompic Hallucinations of individual senses :
while awaking from sleep
Hallucinations Auditory ,Visual, Smell, Taste, Touch,
Pain and deep sensations
3. Pseudo Hallucinations
as a hallucination, but which is
recognized by the patient it as unreal Depersonalization Person feels unreal

Change in self awareness such Derealization

that the environment feels, unreal.

Micropsia
Dysmegalopsia smaller than they really
change in the shape of an object Macropsia or Megalopsia.

5
PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

3. Thinking
A- Disorders of Stream of thoughts
 Disorders of Continuity:
1. Perseveration: persistent inappropriate repetition of the same thought, the patient
gives the correct answer to the first question but continues to give the same answer
for different questions.
2. Thought blocking: sudden arrest of the train of thought, leaving a blank.
3. Dysphasia: receptive or expressive.
4. Dysarthria: difficulty in articulation.

 Disorders of Tempo:
1. Pressure of thought: rapid, abundant thoughts.
2. Flight of ideas: thoughts follow each other rapidly; no general direction of thinking;
usually understood.
3. Inhibition/retardation of thinking: the train of thought is slowed down and the
number of ideas and mental images that present themselves is decreased.
4. Circumstantiality: thinking proceeds slowly with many unnecessary and trivial
details, but finally the point is reached.

B- Disorders of Form of thoughts

1. Loosening of association: loss of the normal structure, no links between ideas.
2. Neologisms: words created by patient.
3. Echolalia: repetition by the patient of the interviewer’s word.

C- Disorders of Possession
1. Thought insertion: thoughts inserted by an outside agency, recognize them as
being foreign and coming from without.
2. Thought withdrawal: thoughts have been taken out of mind.
3. Thought broadcasting: unspoken thoughts are known to other people through
radio or TV.

6
PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

Continue.. Thinking

D- Disorder of Content
1. Overvalued ideas:
An isolated preoccupying strongly held belief which dominates the person’s life and may
affect his actions, neither delusional nor obsessional in nature.

2. Obsessions:
• Recurrent, persistent & senseless thoughts, images or impulses that appear against
the patients will and unsuccessfully resisted and recognized by the patient as his own
• Seen in Obsessions and compulsions disorder:
 An obsession (also termed a rumination) is a thought that persists and dominates an
individual’s thinking despite the individual’s awareness that the thought is either entirely
without purpose or else has persisted and dominated their thinking beyond the point of
relevance or usefulness.
 Compulsions are, in fact, merely obsessional motor acts. They may result from an
obsessional impulse that leads directly to the action, or they may be mediated by an
obsessional mental image or though

3. Delusions
 Primary delusions “True”:
• Primary delusional experience, not related to another morbid phenomenon.
• Schneider suggested that these experiences can be reduced to three forms of primary
delusional experience:
o Delusional mood: the patient has the knowledge that there is something going on
around him that concerns him, but he does not know what it is.
o Delusional perception: the attribution of a new meaning, usually in the sense of self-
reference, to a normally perceived object.
o Sudden delusional idea: delusion appears fully formed in the patient’s mind. This is
sometimes known as an autochthonous delusion.

 Secondary delusions “delusion like idea”

• Derived from some other morbid psychological phenomenon.
• Types: Delusions of Persecution, Infidelity (morbid jealousy), love (love famous
character), Grandiose, Ill health, Guilt, Poverty and Nihilistic.

7
 PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

4. Memory
Amnesias 1. Anterograde amnesia.
Note: 2. Retrograde amnesia.
The amnesia will be for personal identity such as
name, address and history as well as for personal
3. Psychogenic amnesias.
events, while at the same time the ability to perform 4. Dissociative/hysterical amnesia:
complex behaviors is maintained. sudden amnesia, during periods of extreme
trauma and can last for hours or

Flashbacks Hypermnesia Flashbulb memories

are sudden intrusive memories that memories that are associated with
are associated with the cognitive and intense emotion. They are
emotional experiences of a traumatic unusually vivid, detailed and long-
event such as an accident. lasting.

It manifests itself as the filling-in of

gaps in memory by imagined or Confabulation
untrue experiences that have no
basis in fact.
confabulation that occurs in
those without organic brain
Pseudo logia fantastica pathology such as personality
disorder of antisocial or
hysterical type. Also called: fluent
plausible lying (pathological lying)

Disorder of Recognition

 Déjà vu: Problem with the familiarity of places and events. It comprises the feeling of having
experienced a current event in the past, although it has no basis in fact.
 Jamais vu: The knowledge that an event has been experienced before but is not presently
associated with the appropriate feelings of familiarity.
 Déjà entendu: The feeling of auditory recognition.
 Déjà pense: A new thought recognized as having previously occurred, are related to déjà vu,
being different only in the modality of experience.
8
 PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

5. Mood
A) Abnormalities of nature (quality) of mood
 Depression: pathological feeling of sadness, pervasive lowering of mood and inability to
experience Pleasure “anhedonia”.
 Anxiety: feeling of apprehension which is out of proportion to the actual situation.
 Elation: pervasive rising of the mood accompanied by excessive cheerfulness.
 Euphoria: a state of excessive unreasonable cheerfulness and unconcern.
 Lability: easily provoked to anger with liability to out burst.
 Ambivalence: coexistence of two opposite feelings directed towards the same person at the
same time.
 Dysphoria: unpleasant mood.
 Apathy: loss of affect or absence of feeling often associated with detachment. It is the extreme
form of loss of emotions.

B) Abnormalities of expression of mood

 Incongruity: incongruous inappropriate mood is that which is not keeping with that would
normally be expected.
 Blunting (flatting): insensitivity to emotions of others i.e. sustained emotional indifference,
reduced rather than lost affect.
 La belle indifference: denial of affect “conversion reaction” Hysteria.

C) Abnormalities of constancy (fluctuation) of mood

 Emotional lability: rapid abrupt changes in emotions unrelated to external stimuli.
 Emotional incontinence: extreme form of emotional lability with complete loss of control
over emotion, (brain stem lesion).

9
 PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

6. Motor
A) Disorders of movement

Increased movement Decreased movement

1. Hyperactivity: increased motor activity 1. Immobility or akinesia: no voluntary
usually with talkativeness as in mania, or movement at all as in depressive or
impulsivity as in ADHD. catatonic stupor.
2. Agitation: motor restlessness with 2. Psychomotor retardation: slowness of
increased arousal initiation, execution & completion of
movement

B) Abnormal quality and form of movement

 Mannerism: abnormal repetitive goal-directed movement.
 Stereotypy: abnormal repetitive non-goal-directed movement i.e. purposeless.
 Tics: sudden, irregular, repetitive movement involving a group of muscles as in
encephalitis.
 Compulsion: uncontrollable impulse to perform an act repetitively e.g. checking
or washing.
 Tremors: static tremors of head or hands as in anxiety or drug induced.
 Dystonia: uncontrolled muscle spasm leading to involuntary movements of the
eye lid, face, neck, jaw, shoulders, larynx & hands e.g. tongue protrusion, torticollis
& oculogyric crisis as in drug included.
 Akathisia: inability to sit still with a need to get up & move about.
 Tardive dyskinesia: repetitive purposeless movement of the facial muscles,
mouth and tongue as in drug induced.
 Somnambulism: walking and carrying out complex activities while asleep.
 Perseveration: senseless repetition of a previously requested movement.

10
 PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

Continue.. Motor
B) Abnormal quality and form of movement

Catatonia
Very important topic, see page 71

Catatonia is state of increased muscle tone at rest.

Catatonic symptoms and signs seen in catatonic schizophrenia include:
 Negativism: resistance to command and attempts to be moved.
 Echopraxia: automatic imitation by the patient of the interviewer
 Echolalia: repetition by the patient of the interviewer’s word.
 Ambitendence: patient begins to make a movement but before completing it starts
opposite movement.
 Psychological pillow: Lying in the dorsal position with head elevated as if there
was an invisible pillow under it.
 Automatic obedience: the patient does whatever is asked irrespective of the
consequences.
 Catalepsy or posturing: the patient takes up and uncomfortable posture and
maintains it with immobility for long period.
 Waxy flexibility: the patient limb can be bending and placed in awkward posture
with a feeling of plastic resistance.

7. Intelligence
Dementia is a loss of intelligence resulting from brain disease.
characterized by  disturbances of multiple cortical functions including:
thinking, memory, comprehension and orientation, among others.
“See page 61”

11
 PSYCHIATRY NOTES For Medical Students

Psychopathology
1. Consciousness 2. Perception 3. Thinking 4. Memory 5. Mood 6. Motor 7. intelligence

Practical applications of Psychopathology:

Auditory hallucinations  Schizophrenia
Visual hallucinations  Schizophrenia, alcohol withdrawal and delirium
Touch hallucinations  addiction
Olfactory hallucination  temporal lobe epilepsy
Pressure of thought  Mania
Flight of ideas  Mania
Inhibition or retardation of thinking  Depression
Perseveration  Dementia
Loosening of association  Schizophrenia
Grandiose delusions  Mania
Delusions of guilt  Depression
Nihilistic delusions  Depression
Delusions of poverty  Depression
Obsessions  Obsessive-Compulsive disorder
Confabulation  Alcohol & Dementia
Pseudo logia fantastica  Anti-social personality disorder
Hypermnesia  PTSD
Elation  Mania
Euphoria  Mania
Emotional lability  Mania
Hyperactivity  Mania & ADHD
Agitation Anxiety & Depression
Psychomotor retardation  Depression
Mannerism  Schizophrenia
Stereotypy  Schizophrenia
Tremors  Drug as Lithium
Dystonia  Drug as 1st generation antipsychotics: Haloperidol
Akathisia  Drug as 1st generation antipsychotics
Tardive dyskinesia  Drug as 1st generation antipsychotics
Perseveration  Dementia
Catatonia  Schizophrenia

12
 Chapter Two
Psychopharmacology
& Psychotherapy

PSYCHIATRY NOTES For Medical Students | Mosab Emad Mubayed | AlNeelain University | 2022
13
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Psychopharmacology
Antidepressants - Antipsychotics - Mood stabilizers - Anxiolytics

1. Antidepressants
Types Full Name Examples
TCAs Tricyclic Antidepressants Desipramine, nortriptyline,
Amitriptyline, imipramine,
clomipramine ,doxepin

MAOIs Monoamine oxidase inhibitors Non selective (tranylcypromine,

phenelzine, isocarboxazid)
Selective : selegiline

SSRIs Selective serotonin reuptake Fluoxetine, Sertraline,

inhibitors Citalopram, Paroxetine,
Escitalopram, Fluvoxamine
SNRIs Serotonin Norepinephrine reuptake Venlafaxine, Desvenlafaxine,
inhibitors Duloxetine, Milnacipran,
Levomilnacipran
Atypical Antidepressants Bupropion
Important Notes:
* General SEFs Antihistamine : dry mouth, sedation, NE blockade: hypotension and
Muscarinic blockade: tachycardia, urinary retention.
* Overdose of TCAs result in hypotension and that is the major cause of death here.
* Overdose of TCAs also result in Prolongation of QT interval lead to arrhythmia
treated with NaHCO₃.
* Another uses of TCAs: OCD, Diabetic peripheral neuropathy, Chronic pain, Prevention of
migraine headache, Bed wetting and Insomnia.
* Serotonin Syndrome can develop if take MAOI with drugs that increase serotonin.
* Serotonin syndrome symptoms: abdominal pain, diarrhea, sweats, tachycardia, HTN,
myoclonus, irritability, delirium. Can lead to hyperpyrexia, cardiovascular shock and death.
* SSRI result in : sexual dysfunction, Decrease libido, Anorgasmia, Erectile dysfunction.
So SSRIs can treat premature ejaculation.
* SSRIs result in Discontinuation syndrome :Abrupt discontinuation of antidepressants
Characterized by Dizziness, fatigue, headache and nausea.
* SSRIs used in Bulimia nervosa ttt.
* SSRIs also result in QT prolongation and serotonin syndrome.
* Selegiline used in Parkinson's disease.
* Atypical antidepressant (Bupropion) used in smoking cessation.

14
 PSYCHIATRY NOTES For Medical Students

Psychopharmacology
2. Antipsychotics
antipsychotics First generation Second generation

Examples HIGH Potency: Clozapine , Olanzapine ,

Haloperidol, Fluphenazine, Pimozide Quetiapine, Asenapine,
LOW Potency: Iloperidone, Paliperidone ,
Chlorpromazine, Thioridazine Risperidone, Lurasidone,
Ziprasidone
See
Main * Extrapyramidal symptoms (EPS) below * Metabolic syndrome = weight gain,
problems * Neuroleptic malignant syndrome hyperglycemia, hyperlipidemia
(SEFs) * Prolonged QT interval * Prolonged QT interval
* Retinal & Corneal deposits (low potency)
Important Notes:
* Antipsychotics block dopamine SEFs : Parkinson effects, Hyperprolactinemia,
Gynecomastia, Galactorrhea, Amenorrhea and Antiemetic.
* Other SEFs  Acetylcholine (muscarinic) blockade: Dry mouth, Constipation, Urinary retention
, Tachycardia and Sexual dysfunction, Epinephrine (alpha 1) blockade : Hypotension, Histamine
blockade: Weight gain and sedation
EPS Dystonia Akathisia Bradykinesia Tardive dyskinesia

What is it ? Involuntary muscle restlessness, Slow movement * Choreathetosis: it is

contraction lead to spasm urge to move like Parkinson seen in mouth, tongue,
and stiffness face and limbs
* smacking lips and
grimacing

treatment Antihistamine: benzodiazepine Anticholinergic valbenazine

Diphenhydramine and propranolol : Benztropine

* Neuroleptic malignant syndrome:

rare dangerous reaction to high potency first generation antipsychotics.
Presentation  Fever and rigid muscles, Mental status changes “encephalopathy”, Elevated creatinine
kinase “muscle damage” and Myoglobinuria due to acute renal failure “rhabdomyolysis”.
Treatment Muscle relaxant and Dopamine agonist: bromocriptine
* LOW potency result in : Retinal deposit  retinitis pigmentosa & browning of vision.
Also Corneal deposit  cataract.
* Chlorpromazine specific SEFs; skin pigmentation & Cholestatic jaundice.
* Rapid Notes:
1. Quetiapine has lowest risk of extrapyramidal side effects.
2. Risperidone has highest risk extrapyramidal side effects.
3. Prolonged QT interval has strongest association with IV haloperidol.
4. Ziprasidone is the highest risk of prolonged QT interval.
5. Clozapine associated with Agranulocytosis, Seizures and Myocarditis.
* Long acting antipsychotics (Depot injection): Use in poor compliance and resistance SZP.
Examples Flupenthixsol decanoate, Fluphenazine decanoate, Zuclopenthioxol Decanoate
and Haloperidol Decanoate.
* Antipsychotics are the most common drug induced hyperprolactinemia  as Haloperidol.
15
 PSYCHIATRY NOTES For Medical Students

Psychopharmacology
3. Mood Stabilizers
Mood Lithium Valproic acid Carbamazepine
stabilizer
Main use First medical therapy for as Lithium in 1st line for
bipolar disorders mania acute mania &
prophylaxis mania
prophylaxis

Note Only medication to reduce not as lithium Indicated for

suicide rate effective in rapid cyclers
depression and mixed
prophylaxis patients

SEFs Tremor, Confusion, Seizure , Thrombocytopenia Rash, Nausea,

Nausea, vomiting , diarrhea, Nausea, vomiting, weight vomiting, diarrhea,
Hypothyroidism gain, Transaminitis, transaminitis
Hyperparathyroidism Sedation, tremor, hair ,Sedation, dizziness,
hypercalcemia loss and Increased risk of ataxia, confusion
Polyuria & polydipsia neural tube defect ,AV conduction delays
bradycardia ,Aplastic anemia
Mild leukocytosis ,agranulocytosis
Water retention
Before use it baseline creatinine, TSH, LFTs, CBC and LFTs, CBC and EKG
CBC and pregnancy test pregnancy test
Steady state 5 days 4-5 days 5 days
achieved after

Target blood level between 0.6-1.2 between 50-125 4-12mcg/ml

Important Notes:
* Most common lithium SEFs are GI distress including reduced appetite, nausea/vomiting, diarrhea.
* Lithium contraindicated in patients with renal failure, pregnancy, cardiac arrhythmias, severe
vomiting and diarrhea.
* Lithium can cause Ebestin anomaly because of its teratogenicity.
* Lithium drug interaction: Thiazide diuretic, ACE inhibitor, NSAIDs, Metronidazole, Tetracycline.
* Valproic acid better tolerated than Lithium.
* Tremor is the most common symptoms of lithium toxicity  ttt : propanol.
Lithium toxicity at Symptoms

Mild 1.5 – 2 vomiting, diarrhea, ataxia, dizziness, slurred speech, nystagmus

Moderate 2 – 2.5 nausea, vomiting, anorexia, blurred vision, clonic limb movements,
convulsions, delirium, syncope
Severe > 2.5 generalized convulsions, oliguria and renal failure

16
PSYCHIATRY NOTES For Medical Students

Psychopharmacology
4.Anxiolytics
 Example: Benzodiazepine, Buspirone
 Used to treat:
1. panic disorder
2. generalized Anxiety disorder
3. substance-related disorders and their withdrawal
4. insomnias and parasomnias
5. Brief psychotic event
6. Acute symptoms of acute stress disorder

 In anxiety disorders often use anxiolytics in combination with SSRIS or SNRIs

for treatment.

Prolongation of QT interval  Overdose of TCAs, SSRIs, haloperidol &

Ziprasidone
 SSRIs can treat premature ejaculation and Bulimia nervosa.
 Bupropion used in smoking cessation.
 Selegiline used in Parkinson's disease.
 Serotonin syndrome, Neuroleptic malignant syndrome and
Extrapyramidal symptoms are very important.
Clozapine associated with Agranulocytosis.

17
 PSYCHIATRY NOTES For Medical Students

Psychopharmacology
Rapid MCQs
Choose the One Best answer:

1. Contraindication of lithium therapy includes each of the following EXCEPT:

A. renal impairment
B. liver disease
C. cardiac arrhythmia
D. pregnancy
E. severe vomiting &diarrhea

2. Which of the following is a characteristic feature of neuroleptic malignant

syndrome:
A. hypothermia
B. agranulocytosis
C. increased liver enzymes
D. thrombocytosis
E. increased creatinine phosphokinase

3. Which of the following is a low potency first generation antipsychotics:

A. Clozapine
B. Haloperidol
C. Thioridazine (MCQ 2022)
D. Quetiapine
E. Risperidone

4. Select the best answer from the following:

A. chlorpromazine is more likely to cause EPS than haloperidol
B. haloperidol is less cardio toxic than chlorpromazine
C. haloperidol is a low potency antipsychotic
D. chlorpromazine is less likely to cause hypotension
E. haloperidol should not be given by intramuscular route

18
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Psychotherapy
Psychotherapy: is the use of psychological methods, particularly when based on
regular personal interaction, to help a person change behavior, increase happiness,
and overcome problems, aims to improve an individual's well-being and mental
health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts,
or emotions, and to improve relationships and social skills.

Some of the psychotherapy techniques:

1. Interceptive exposure: Expose patients to feared body sensations. Is the
practice of strategically inducing the somatic symptoms associated with a
threat appraisal and encouraging the patient to maintain contact with the
feared sensations. It is an effective treatment technique for a range of anxiety
conditions including panic attacks and panic disorder.
2. Group therapy: form of psychotherapy in which one or more therapists
treat a small group of clients together as a group, refer to any form of
psychotherapy when delivered in a group format.
3. Cognitive behavior therapy (CBT): a type of behavioral therapy, is a
talking therapy that can help you manage your problems by changing the way
you think and behave. It's most commonly used to treat anxiety and
depression.
4. Exposure and response prevention (ERP): one of the most effective
forms of treatment for OCD, behavioral therapy that gradually exposes
people to situations designed to provoke a person’s obsessions in a safe
environment.
5. Interpersonal therapy (IPT): short-term form of psychotherapy, usually 12
to 16 sessions, that is used to treat depression and other conditions. As its
name suggests, IPT focuses on interpersonal relationships and social
interactions including how much support from others and the impact these
relationships have on mental health.
6. Family therapy: a type of psychological counseling (psychotherapy) that
can help family members improve communication and resolve conflicts.
Usual goals of family therapy are improving the communication, solving
family problems, understanding and handling special family situations, and
creating a better functioning home environment.

19
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Defense Mechanisms
Psychoanalysis and its related therapies are derived from Sigmund Freud’s
psychoanalytic theories of the mind.
Freud proposed that behaviors, or symptoms, result from unconscious
mental processes, including defense mechanisms and conflicts between
one’s ego, id, superego, and external reality.

 Sigmund Freud is now known as the father of psychiatry. (MCQ 2022)

he set the Freud’s Personality Theory of ID, ego and superego
 Topographic theory:
1. Unconscious: Includes repressed thoughts that are out of one’s awareness; involves
primary process thinking. Thoughts and ideas may be repressed into the unconscious
because they are embarrassing, shameful, or otherwise too painful.
2. Preconscious: Contains memories that are easy to bring into awareness,
but not unless consciously retrieved.
3. Conscious: Involves current thoughts and secondary process thinking
(logical, organized, mature, and can delay gratification).

 Structural theory:
1. Id:
Unconscious; involves instinctual sexual/aggressive urges and primary process thinking.
2. Superego:
Moral conscience and ego ideal “inner image of oneself that one wants to become”.
3. Ego: Serves as a mediator between the id, superego, and external environment, and
seeks to develop satisfying interpersonal relationships; uses defense mechanisms to
protect oneself and relieve anxiety by keeping conflicts out of awareness, they are
mostly unconscious processes. often classified into:
Mature, Neurotic and immature defenses.

20
 Defense Mechanisms
PSYCHIATRY NOTES For Medical Students

Defenses What is it?

Mature
1. Altruism Performing acts that benefit others in order to vicariously experience pleasure
 (Cancer survivors help others with same disease)
2. Humor Relief of anxiety with jokes  (Medical student jokes about board studying)

3. Sublimation Using negative emotion in a positive way  (Anxious person becomes a

security guard)
4. Suppression Ignoring an unacceptable impulse or emotion in order to diminish discomfort
and accomplish a task. Is a Conscious defense mechanism.
Neurotic
1. Controlling Regulating situations & events of external environment to relieve anxiety

2. Displacement Shifting emotions from an undesirable situation to one that is personally

tolerable (Student who is angry with his mother talks back to his teacher the
next day and refuses to obey her instructions)
3. Intellectualization Avoiding emotions through reasons  (Spouse going through divorce cites
divorce statistic to friends to avoid admitting sadness)
4. Isolation of affect Unconsciously limiting the experience of feelings or emotions associated with
a stressful life event in order to avoid anxiety  (Woman describes the recent
death of her beloved husband without emotion)
5. Rationalization Explanations of an event to justify outcomes or behaviors and to make them
acceptable  (My boss fired me today because she’s not meeting her quotas,
not because I haven’t done a good job)
6. Reaction formation Doing the opposite of an unacceptable impulse  (Man who is in love with his
married coworker insults her)
7. Repression Preventing a thought or feeling from entering consciousness. Is an unconscious
defense mechanism
Immature
1. Acting out Avoiding emotion by bad behavior. Attention seeking, socially inappropriate
behavior  (Child with sick parents misbehave at school)
2. Denial Refusing to accept unpleasant reality  (Patients think doctor is wrong about diagnosis)

3. Regression Performing behaviors from an earlier stage of development in order to avoid

tension associated with current phase of development  (Stressed adult
watches cartoon from childhood)
4. Projection Attributing feelings/emotions to other  (A cheater accuses a classmate of
cheating him off)
Others
1. Splitting Categorizing others at extremes  (Wonderful or horrible people)

2. Undoing Attempting to reverse a situation by adopting a new behavior (Patient think

about hurting someone acts overly nice to person in response)
21
 Chapter Three

Anxiety Disorders
Panic disorder
Social phobia
Specific phobia
Agoraphobia
Generalized Anxiety Disorder = GAD
Obsessive compulsive disorder = OCD
Acute stress syndrome = ASD
Post traumatic stress disorder = PTSD
Adjustment disorder

Mood Disorders
Major depressive disorders = MDD
Dysthemia
Cyclothymia
Mania
Hypomania
Bipolar 1 disorder
Bipolar 2 disorder

Psychotic Disorders
Schizophrenia = SCP
Schizoaffective disorder
Schizophreniform disorder
Brief psychotic event
Delusional disorders

PSYCHIATRY NOTES For Medical Students | Mosab Emad Mubayed | AlNeelain University | 2022
22
PSYCHIATRY NOTES For Medical Students ‫بسم اهلل الرمحن الرحيم‬

Anxiety, Mood & Psychotic Disorders

Disorder Definition
Panic disorder Recurrent unexpected panic attacks and at least 1month of worrying about
implications of another attack or behavioral adjustment or avoidance.

Social phobia Fear of social situations “socializing-speaking-gym…etc” with embarrassment.

Specific phobia Fear of specific object/situation “animals, heights, flying, medical ttt”

GAD Excessive, irrational and exaggerated anxiety and worry about everyday life
events for no obvious reason. persisting at least six months.

OCD Obsession: Recurrent and persistent thoughts, impulses or images that are
intrusive and unwanted that cause marked anxiety or distress.
Compulsion: Repetitive behaviors or mental acts that the person feels driven to
perform in response to an obsession aimed at reducing distress or preventing
some dreaded situation.
ASD <1 month of severe symptoms of fear particularly flashbacks and nightmares,
anxiety and avoidance following a threatening event.

PTSD As ASD but > 1month

Adjustment d. Maladaptive symptoms of depression, anxiety or behavioral changes. Develop

within one month after stressful life event. Usually resolved within 6 months

MDD At least 2 w. of severe persistent feeling of sad and loss of interest, cause
distress or impairment in social or occupational functioning.
Dysthemia Persistent depressive disorders, Low grade form of depression, Less severe but
more chronic, Depressed mood most of time, Last at least two years
Cyclothymia Fluctuating low-level depressive symptoms along with periods of mild mania
(hypomania).
Mania Abnormal persistent elevated, expansive or irritable mood lasting at least one week.

Hypomania Lesser degree of mania, not accompanied by delusions or hallucinations, with

good function, no need to hospitalization.

Bipolar 1 d. Manic episode+/- depression +/- hypomania

Bipolar 2 d. Hypomania and depression

SCP Group of psychotic disorder characterized by the splitting of normal link

perception, mood , thinking and contact with reality.between

Schizoaffective d. Delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms

Schizophreniform d. SCP but for 1-6 month

Brief psychotic Sudden onset of psychotic symptoms, Full remission within one month
event Commonly follow stressful life events: death in the family and loss of the job

Delusional d. One or more delusional, Last one month or longer, No abnormal behavior
23
PSYCHIATRY NOTES For Medical Students

Disorder Duration NO.

Presentation
Panic 1 m. >4 Psychologic  fear of death, fear loss of control, paranoia, derealization,
disorder depersonalization.
Physiologic  tachycardia, palpitation, SOB, dyspnea, nausea, diaphoresis,
trembling/tangling/numbness, chills, choking, dizzy …etc
Agoraphobia >6m >2 Fear of : public transportation, open spaces, closed spaces, crowd and being
outside of the home alone. Example: fear of empty bus.
Often co occur with panic disorder
GAD >6m >3 Restlessness, fatigue, difficulty concentrating, irritability, muscle tension,
sleep disturbances.
OCD Most common obsessions include: Contamination, Doubt/safety, Sexual and
aggressive impulses, Symmetry and exactness , Somatic and religious preoccupations
Most common compulsions include: Checking, Washing, Repeating, Ordering,
Counting and Hoarding.
Cycle: Obsession Anxiety Compulsion  Relief  Obsession

ASD < 1m. TRAUMA = Traumatic event, Re-experience, Avoidance, Unable to function,
Month , Arousal increase. Note : Recurrent instructive memories
Recurrent distressing dreams

PTSD > 1m. TRAUMA but for more than month. Follow traumatic event: rape, war, physical assault

Adjustment < 6m. Distress in excess of expected, Impairment of daily function

disorder Usually resolved within 6 months
MDD (MCQ) > 2w. 5 Symptoms of depression, Depressed mood + SIG E CAPS
Sleep disturbances, Loss of Interest in activities (anhedonia), Guilty feeling,
Energy loss and fatigue, Concentration problem and inability to make
decision, Appetite and weight changes, Psychomotor agitation and
retardation, Suicidal ideation or attempts
Dysthymia > 2y. Hopelessness, Sleep disturbance, Low appetite, Low energy, Low
concertation and Low self esteem
Cyclothymic > 2y. Mild mania and mild depression
Symptoms comes and go = mood swings + stable mood between periods
Mania > 1w. >3 DIG FAST: Distractibility, Irresponsibility, Grandiosity, Flights of ideas,
(MCQ)
Agitation, Sleep less, Talk too much, + pressure speech
Hypomania 4-7 d. little/no impairment in functioning
More energy but lead to productive activity, No psychotic symptoms
SCP > 6m. >2 Positive symptoms  delusions, auditory hallucinations, disorganized or
catatonic behavior, disorganized speech.
Negative symptoms  Avolition, Anhedonia, Asocialy and Alogia.
Schizoaffective 2 w. Symptoms of Mood disorders and SCP.
Brief psychotic <1m. >1 Sudden onset of psychotic symptoms, Full remission within one
event month.
Delusional d. > 1m. Example: Frequently check someone behind him. Note: No hallucination

Note 1: “>” in 2nd and 3rd column refer to “at least”.

Note 2: “NO.” in 3rd column refer to number of clinical features needed to criteria.
Note 3: “w.” refer to “week” / “m.” refer to “month”/ “y.” refer to “year”. 24
PSYCHIATRY NOTES For Medical Students

Disorder Management
Panic disorder - 1st line: SSRI or SNRI, 2nd line: Benzodiazepine
clinically, a small dose of long acting benzodiazepine is started along with
SSRI/SNRI to provide more immediate relief from distressing symptom.
- Psychological ttt CBT, interceptive exposure, Exposure to avoided situations is important

Social phobia Short term : B blocker “propranolol” Long term : SSRI & group therapy

Specific phobia Exposure therapy “Systemic desensitization”, CBT, may benzodiazepines in

some cases
GAD 1st line: SSRI or SNRI, 2nd line: Benzodiazepine, 3rd line: Adjunctive
olanzapine, risperidone ,Mirtazapine And  CBT

OCD 1st line: SSRI, 2nd line: Clomipramine And Exposure with Response
Prevention (ERP) And combination of CBT + ERP

ASD SSRI & group therapy. Benzodiazepines for acute symptoms

PTSD SSRIs, SNRIs, Prazosin “alpha one blocker” and CBT. Avoid Benzo due to risk of addiction.

Adjustment d. SSRI & psychotherapy

MDD Light to moderate  Psychotherapy, medication

Moderate to severe Medication ± psychotherapy, ECT “see page 68”
Depression with psychotic features  antidepressant + antipsychotic, gold standard is
ECT
Medications: SSRI sertraline, fluoxetine. TACS amitriptyline. SNRI venlafaxine.
Mirtazapine
Psychotherapy: CBT, Interpersonal therapy (grief, transitions, interpersonal conflicts or deficits)

Dysthemia Psychotherapy ± Antidepressants

Cyclothymia CBT, group therapy and Mood stabilizers

Mania 1- Lithium is drug of choice. May “sodium valproate in Sudan”

2- IM Haloperidol : drug of choice clinically
3- Benzodiazepines help in rapidly control restlessness, agitation, or insomnia
4- with antipsychotics start mood stabilizers “Lithium, S. valproate, Carbamazepine” in the
same time and maximize use of it.
5- Switch from Haloperidol to Oral Olanzapine
6- ECT 7- Social ttt

Bipolar 1 d. Always  Lithium, quetiapine.

Acute manic episode  divalproex, olanzapine, risperidone
Acute major depressive episode Lamotrigine. Note: any drug can use for maintenance ttt

SCP Antipsychotics:  typical as Haloperidol & atypical as olanzapine

CBT, Family therapy and social rehabilitation.

Schizoaffective d. Mood stabilizers and Antipsychotics

Schizophreniform d. Antipsychotics.
Brief psychotic event Antipsychotics and may Benzodiazepines. Note: Full remission within one month.

Delusional d. Antipsychotic drugs, antidepressants ,mood-stabilizers and CBT

25
PSYCHIATRY NOTES For Medical Students

Disorder Etiology or Risk factors

Panic disorder Risk factors: Genetic, History of physical abuse and Life stress.
Agoraphobia Often occur with panic disorder.
OCD Occur with Schizophrenia, Bipolar disorder, Eating disorders and
Tourette syndrome “a neurological disorder characterized by sudden, repetitive, rapid,
and unwanted movements or vocal sounds called tics”.

ASD Exposure to threatened death, injury, sexual insult.

PTSD Follow traumatic event: rape, war, physical assault.
Adjustment d. Within one month after stressful life event.
MDD • Genetics “65-75% monozygotic twins”
• Neurotransmitter dysfunction,
• Psychosocial “Low self-esteem, Negative thinking”
• Environmental “acute stressor”
• Co-morbid psychiatric disorders “substance use”
SCP Risk factors:
• Urbans areas
• Obstertic complications “hemorrhage, preterm labour, blood
group mismatch, fetal hypoxia, maternal infection”
• Cannabis use
 Positive symptoms due to increased dopamine in the mesolimbic system.
 Negative symptoms due to decreased dopamine in the mesocortical system.
Brief psychotic event Commonly follow stressful life events: death in the family and loss of the job.

 Risk factors for depression: Female, 20-50 years old, positive family history, childhood
experiences “as loss of parent before age 11 “, personality structure, recent stressors ,
postpartum and lack of support network.
 Subtypes of depression : Atypical (most common), seasonal “in fall and winter; tttphototherapy”,
melancholic, catatonic, psychotic, mixed features and anxious.

26
PSYCHIATRY NOTES For Medical Students

 Involved in Mood abnormalities, it is normal response to loss of loved one

 “Kulber Ross model” Typical acute Greif has five stages : Stage 1”Denial”, Stage 2 “Anger”,
Stage 3 “Bargaining”, Stage 4 “ depression” and Stage 5 “acceptance”.
 Resolve within 6 months; but if last longer considered as Complex Grief and can lead to MDD.

 First rank symptoms of SCP according to Kurt Schneider are “7”:

1. Thought insertion 2. Thought broadcasting 3. Thought withdrawal 4. Thought echo
5. Passivity phenomena: somatic passivity, passivity of affect, passivity of volition
6. Auditory hallucinations: third person, running commentary, echo de la pensée 7.Delusional perception.
 Subgroups of schizophrenia: Paranoid “persecutory, grandiose features or frequent auditory
hallucinations”, Hebephrenic” irresponsible/unpredictable”, Catatonic, Disorganized “odd,
bizarre behavior such as smiling, laughing, or talking to oneself” and Simple “insidious decline
in function”.
 Imaging:
 MRI/CT scan: lateral ventricular enlargement
 PET scan ”positron emission tomography”: Hypoactivity of frontal lobe & Hyperactivity of
basal ganglia
 Monozygotic twin of a schizophrenia patient have 47% risk of be schizophrenic.
 Child of two parents with schizophrenia have 40% risk of be schizophrenic.
 Common age is “18 to 25 years in men” and “25 to 35 years in women”
 Mirror gazing &giggling are found in disorganized schizophrenia.
 Social withdrawal is found in simple schizophrenia.
 Good prognosis include: Old age of onset, female, married, no family history, high IQ,
precipitants, positive symptoms, treatment compliance, acute onset and presence of mood
components. So; Poor prognosis include the opposite of each factor of good prognosis.

Drug Induced
Psychotic Features
 Drugs: Anesthetics, antimicrobials, corticosteroids, antiparkinsonian agents, anticonvulsants,
antihistamines, anticholinergics, antihypertensive, NSAIDs, digitalis, methylphenidate, and
chemotherapeutic agents
 Substances: alcohol, cocaine, cannabis, benzodiazepines and barbiturates

27
 PSYCHIATRY NOTES For Medical Students

Anxiety, Mood & Psychotic Disorders

Rapid MCQs
Choose the One Best answer:

1. Systemic desensitization is effective for the treatment of:

A. adjustment disorder
B. specific phobia
C. generalized anxiety disorder
D. agoraphobia
E. panic disorder

2. Recurrent intrusive thoughts that lead to resistance and worry occur in:
A. obsessive compulsive disorder
B. delusion
C. agoraphobia
D. panic disorder
E. generalized anxiety disorder

3. Mania tends to be characterized by all of the following EXCEPT:

A. increased sociability
B. irritability
C. decreased libido
D. over spending
E. goal-directed hyperactivity

4. For a diagnosis of bipolar 1 disorder, which one of the following criteria is

a must:
A. At least one hypomanic episode
B. At least one MDD episode
C. Depressed mood for more than 2 years
D. Numerous periods of hypomania
E. At least one manic episode

28
 Chapter Four
Miscellaneous Disorders
Eating Disorders
Personality Disorders
Sleep Disorders
Substance Use Disorders
Child Psychiatry: Autistic Disorder, ADHD & Enuresis
Somatic disorders
Suicide

PSYCHIATRY NOTES For Medical Students | Mosab Emad Mubayed | AlNeelain University | 2022
29
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

Eating Disorders
Eating Disorders are Mental disorder defined by abnormal eating behaviors that
negatively affect a person's physical or mental health, more common in woman.
Q1. What are an examples of eating disorders?
Examples  Binge eating disorder, anorexia nervosa, bulimia nervosa, pica, rumination disorder,
avoidant/restrictive food intake disorder and night eating syndrome.
Note: Coexist with Depression, Anxiety, OCD, PTSD and Substance abuse.
Q2. What is the difference between Anorexia nervosa & Bulimia nervosa?
Anorexia Nervosa Bulimia Nervosa
Weight Significantly underweight Normal or overweight

Eating habit Eat little food, few calories Eat large amount of food,
then purges by vomiting and may
using laxatives

Presentation - BMI < 18 Kg/m2 (characteristic) 1.Russel sign: classic sign for
- Intense fear of gaining weight bulimia nervosa which is scar or
- Bradycardia krunckles from induced vomiting.
- Hypotension 2. Presented by purging
- Decrease bowel sound complications :
- Xerosis = dry scaly skin - Increase bicarbonate
- Hair loss: soft fine hair - Vomiting
- Hyponatremia - Hypokalemia
- Low creatinine - Hypochloremia
- Hypokalemia - Metabolic alkalosis
- Decrease bone density - Parotid swelling
 osteoporosis and osteopenia - Erosion of dental enamel
- pancytopenia

Treatment 1) Nutritional rehabilitation, 1) Nutritional rehabilitation

2) Psychotherapy and 2) Psychotherapy
3) Olanzapine 3) SSRIs
Hospitalization indicated in very low
BMI, hemodynamically unstable,
volume depletion or refuse to eat.

 Note: Subtypes of Anorexia:

1. Restricting low calorie intake and exercise.
2. Binge-purging involves eating much larger amounts than normal (bingeing), then attempting
to compensate by removing the food consumed from the body (purging).
Q3. What is Binge eating disorder and how to treat it?
Compulsive overeating excessively large amount of food,
occurs at least once a week for three months, treated by CBT as first line & SSRI.
30
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

Personality Disorders
Personality Presentation
disorders
Cluster “A”  Weird : Odd and eccentric behavior
1. Paranoid Distrust of others even friend and family, Guarded, Suspicious, Struggles
to build close relationship. Note: ego defense mechanism

2. Schizoid More comfortable alone, Choose social isolation, Doesn't enjoy close
relationship, Little or no interest in sexual experiences, Few or no
pleasure activity and Lacks close friends.

3. Schizotypal Paranoia, Social anxiety, Fear of social interaction, Few closed friends,
Odd beliefs or magical thinking, Superstitious, Believes in telepathy.

Cluster “B”  Wild : Dramatic and erratic behavior

1. Antisocial More common in Men at least age of 18 year, Disregard for rights of
others, break the law, Impulsive and lack of remorse.

2. Borderline More common in Women, Unstable person relationships, “All people are
very good or very bad”, Fear of abandonment, Display impulsivity, Self
mutilation and Suicide gestures or attempt. Note: Splitting defense mechanism

3. Histrionic Want to be the center of attention: talks loudly, tells wild story, use hand
gesture, Inappropriate sexually provocative behavior and very concern
with physical appearance.

4. Narcissistic Inflated sense of self “think everything they do is great” , Lacks empathy
for others “other people are competitor” , Wants to hear they are great
and Overact to criticism with anger/rage.

Cluster “C”  Wacky : Anxious and fearful behavior

1. Avoidance Social inhibition, Feels inadequate, Afraid of people wont like them,
Afraid of embarrassment and Struggles with intimate relationships.

2. Obsessive Preoccupied with order and control, Loves to do list, Always need a plan,
Inflexible at work or in a relationship. Note: Behaviors help to achieve
compulsive goals (contrast with OCD)

3. dependent Clingy, Low self confidence, Struggles to care for them self, Depend on
other excessively, Rarely alone and always in relationship, Hard to make
decision on their own, Want someone to tell them what to do, Difficulty
in expression and opinion and May involve in abusive relationship.
Notes:
1. If child < 18 year have presentation of antisocial personality disorder we called it conduct disorder.
2. Avoidant disorder patient want to socialized but cannot, which differ from Schizoid patient who
prefer to be alone.
31
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Sleep Disorders
What is sleep?
naturally recurring state of mind and body, characterized by altered consciousness,
relatively inhibited sensory activity, reduced muscle activity and inhibition of nearly
all voluntary muscles during rapid eye movement stage and reduced interactions with
surroundings.

 Stages of sleep:
1. Non-rapid eye movement (NREM) sleep transition from the waking sleep to deep sleep.
Stages of NREM: Awake, Drowsy, Stage I theta waves, Stage II (k complex-sleep spindles), Stage III
delta waves, Stage IV 50% delta waves.
2. Rapid eye movement (REM) sleep characterized by small, variable-speed brain waves,
rapid eye movements, dreaming, increased heart rate, and muscle paralysis.
Note About every 90 minutes, NREM sleep alternates with REM sleep.

 ECG patterns of different stages of sleep:

32
 PSYCHIATRY NOTES For Medical Students

Sleep disorders classified as either:

1. Dyssomnias: Insufficient, excessive, or altered timing of sleep.
2. Parasomnias: Unusual sleep-related behaviors.

Dyssomnias Etiology Characteristics treatment

Insomnia 1. Idiopathic - Difficulty initiating sleep - CBT
2. Mood/anxiety disorders  initial insomnia - Chronotherapy:
3. Preoccupation with a - Frequent nocturnal (bright light therapy)
perceived inability to sleep awakenings entraining the circadian
4. poor sleep hygiene middle insomnia rhythm
- Early morning - Benzodiazepines
awakenings - Antidepressants
late insomnia - others: melatonin,
- Waking up feeling zolpidem, eszopiclone
fatigued & unrefreshed Zaleplon, Suvorexant
1. Viral infections : Excessive sleepiness - 1st line: modafinil or
Hypersomnia despite at least 7 hours of stimulants as
HIV pneumonia, infectious
mononucleosis, sleep, with symptoms of methylphenidate;
Guillain–Barré excessive quantity of sleep, - 2nd line: amphetamine-
reduced quality of like antidepressants as
2. Head trauma.
wakefulness, and sleep. atomoxetine.
3. Genetic: autosomal Occurs at least three times
dominant mode - Pitolisant and sodium
per week for at least 3 oxalate
months
- Scheduled napping.
Risk Factors Repetitive upper airway - Positive airway pressure:
Obstructive collapse during sleep  continuous (CPAP) and in
1. Obesity
sleep apnea 2. Increased neck multiple episodes of apnea some cases bilevel (BiPAP)
circumference or hypopnea per hour of - Behavioral strategies:
sleep. such as weight loss and
3. Airway narrowing
Excessive daytime exercise.
sleepiness, Snoring, - Surgery: tonsillectomy
Frequent awakenings due and selective upper
to gasping or choking,
airway stimulation
Sleep fragmentation.
implants
Nonrefreshing sleep or
fatigue, Morning
headaches and HTN

Central sleep 1. idiopathic - Cessation of air flow - Treat the cause.

2. Opioid use secondary to lack of - CPAP/BiPAP.
apnea 3. Cheyne-Stokes breathing respiratory effort - Supplemental O2
4. High-altitude periodic - Abrupt awakenings - Drugs: acetazolamide,
breathing accompanied by theophylline, sedative-
shortness of breath hypnotics
Pathophysiology: - by excessive daytime - Sleep hygiene
Narcolepsy sleepiness and falling - scheduled daytime naps.
1. Linked to a loss of
hypothalamic neurons that asleep at inappropriate - Avoid shift work.
produce hypocretin. times - Amphetamines
- At least three times per Others: methylphenidate,
2. May have autoimmune
week for at least 3 months, modafinil, sodium oxybate,
component with: and pitolisant
Cataplexy, Reduced REM - Cataplexy Sodium
sleep latency, Sleep oxybate (drug of choice)
paralysisand Hypnagogic & Tricyclic antidepressants
hypnopompic hallucination SSRIs and SNRIs

33
 PSYCHIATRY NOTES For Medical Students

Sleep disorders classified as either:

1. Dyssomnias: Insufficient, excessive, or altered timing of sleep.
2. Parasomnias: Unusual sleep-related behaviors.

Parasomnias Occur in Characteristics treatment

Nightmare REM - Recurrent frightening dreams that - Not always needed. -
occur during the second half of the Desensitization or
disorder sleep episode. Imagery rehearsal
- Terminate in awakening with vivid therapy (IRT)  modify
the outcome of a
recall
recurrent nightmare
- No confusion or disorientation
- drugs(rarely): Prazosin
upon awakening. and antidepressants if
- Causes clinically significant distress related to PTSD
or impairment in functioning

Sleep terror NREM - Sudden awakening with intense - benign and self-limited
anxiety, common in children “boys” - Low dose of
disorder - Patient does not remember events benzodiazepine
- episodes of sudden terror arousals - Supportive psycho ttt
associated with: tachycardia,
tachypnea, diaphoresis, and mydriasis

Sleep Walk NREM 3&4 - sitting up in bed, walking around, - do not need to be
eating, and in some cases escaping treated.
Disorder outdoors. - education, reassurance,
- Eyes are usually open with a blank ensuring a safe
stare and “glassy look.” environment, and
- Difficulty arousing the sleepwalker proper sleep hygiene.
during an episode. - low-dose of
- Dreams aren’t remembered and benzodiazepine
there is amnesia for the episode.

Note: When taking a sleep history, ask about:

1. Activities prior to bedtime that may interfere with restful sleep.
2. Bed partner history.
3. Consequence on waking function; quality of life.
3. Drug regimen, medications.
4. Exacerbating or relieving factors.
5. Frequency and duration.
6. Genetic factors or family history.
7. Habits “alcohol consumption, use of caffeine, nicotine, illicit substances, and hypnotics”.

34
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Substance Use Disorders

NOTE  See Alcohol use disorder in page 57 & 58
1. Cocaine
Blocks the reuptake of dopamine, epinephrine, and norepinephrine from
the synaptic cleft, causing a stimulant effect. Is also local anesthesia
(Na channel blocker). Cocaine activate sympathetic nervous system.

 Cocaine intoxication:
 Effects:
• General effects: Euphoria, Heightened self-esteem, Increase or decrease in blood pressure,
Tachycardia or bradycardia, Nausea, dilated pupils, weight loss, Psychomotor agitation or
depression, chills, and sweating.
• Dangerous effects:
Seizures, Cardiac arrhythmias, Hyperthermia, Paranoia and Tactile Hallucinations.
• Deadly effects:
Cocaine’s vasoconstrictive effect may result in myocardial infarction,
intracranial hemorrhage or stroke.

 Signs:  Dilated pupils, Tachycardia and Hypertension

“due to sympathetic nervous system activation and stimulate alpha and beta”

 Management:
1. For mild-to-moderate agitation and anxiety:
Reassurance of the patient and benzodiazepines.
2. For severe agitation or psychosis:
- Antipsychotics as haloperidol.
- Symptomatic support: control hypertension, arrhythmias.
- Temperature: ice bath, cooling blanket, and other supportive measures.

 Cocaine withdrawal:
With stopping after chronic heavy use, usually not life threating. Presented with:
Depression and Anhedonia, Anxiety, Craving and Increase sleep.

35
 PSYCHIATRY NOTES For Medical Students

Substance Use Disorders

2. Amphetamine
Modified phenethylamines, Stimulant, has indirect sympathomimetic
Increase synaptic dopamine/NE levels.

 Amphetamine intoxication:
• Similar to cocaine
• Effects: fever, euphoria, sympathetic stimulation, tachycardia, hypertension
pupillary dilation, rhabdomyolysis, seizures and ischemia.
• Treatment: benzodiazepines.

 Amphetamine withdrawal as cocaine.

Depression and Anhedonia, Anxiety, Craving and Increase sleep.

3. Opioids
Activates opioids receptors: Mu, kappa and delta
• Types: Morphine, hydromorphone, meperidine, codeine, heroin (diamorphine)
• Highly addictive and Tolerance develops:
Less effects of drug overtime and higher doses required to achieve effects
• Clinical uses: Pain control, acute pulmonary edema (iv morphine),
cough suppression (codeine), diarrhea (lipoamide), shivering (meperidine)
• CNS effects of opioid: Pain relive, euphoria, sedation, slurred speech, respiratory depression,
cough suppression, miosis = small pupil.
• Peripheral nervous system effects:
Nausea, vomiting, constipation, skin warmth and flushing.

 Opioids intoxication:
Most common cause of drug overdose death.
• Effects:
 Euphoria to depressed mental status.
 Decrease respiratory rate.
 Decrease bowel sounds.
 Miotic “constricted” pupil.
 Seizure: most common with tramadol and meperidine.
• Treatment:
Naloxone “Short acting opioid antagonist” note: may cause withdrawal if high dose!

36
 PSYCHIATRY NOTES For Medical Students

Substance Use Disorders

 Opioids withdrawal:
Naturally start 6-12 hours after last dose.
OR may caused by opioid antagonists  Naloxone.
• Presentation:
Restlessness, yawing, rhinorrhea and lacrimation, piloerection, nausea, vomiting, diarrhea,
and abdominal cramps.
• Treatment:
1. Clonidine “Central alpha agonist”
2. Opioid agonist as: Methadone or Buprenorphine
 Note: Buprenorphine Sublingual tablets, Partial agonist = agonist and antagonist.

Notes:
• Heroin is Drug of abuse injected into vein: if contaminated needle or drugs lead
to: Bacteremia “tricuspid endocarditis”, HIV, HBV or HCV.
• Meperidine don’t affect CNS.
• Abuse potential:
 Heroin  very high potential and there is no medical indication for it.
 Cocaine  high abuse potential.
 Benzodiazepines  low abuse potential.
 Codeine  very low potential and used as cough suppressant.

4. Benzodiazepines
Increase GABA activity : Diazepam, lorazepam, oxazepam.
 Overdose lead to:
CNS depressant, altered mental illness, slurred speech and ataxia.
Overdose treated by Flumazenil “benzodiazepines antagonist”.
 Benzodiazepine withdrawal
can be life threating, presented as: Tremor, anxiety, depressed mood, hypersensitivity to sensation
(noise, touch), psychosis and seizures. Treated by benzodiazepine.

5. Barbiturates
Anti seizure drugs , GABA activators, CNS depressant as alcohol.
: Phenobarbital, pentobarbital
Note Now replaced by benzodiazepines.
 Overdose lead to: respiratory depression, there is no antidote.
 withdrawal lead to: Delirium, Hallucination, Seizures, CVS collapse.

37
 PSYCHIATRY NOTES For Medical Students

Substance Use Disorders

6. Marijuana
Derived form cannabis and stimulate cannabinoid receptors in CNS.
• Presentation: Euphoria, anxiety, impaired coordination, conjunctival injection, dry mouth,
increase appetite, tachycardia and may hallucination.
 Synesthetic cannabinoid
 What is it? Pharmacological forms of dronabinol, available with capsule form.
 Uses: Cannabis withdrawal, in chemotherapy induced nausea and vomiting
& appetite stimulation as in HIV patient.

7. Ecstasy
Methylenediooxymethamphatamine “MDMA”
Increase release of serotonin and inhibit serotonin reuptake
• Presentation: Euphoria, alertness, increase sexual desire and bruxism “grinding teeth”
• Effects: Tachycardia, hypertension, hyperthermia, hypernatremia, hepatotoxicity and serotonin
syndrome.
 Ecstasy withdrawal lead to: Depression and anxiety, fatigue and lethargy, difficulty in
concentration and loss of appetite.

8. Caffeine
Methylxanthine “Adenosine receptors antagonist”
Lead to release of dopamine and NE, Renal adenosine blockade  diuresis.

 CNS depressant  Alcohol, Barbiturates and Benzodiazepines

 CNS stimulant  Cocaine and Amphetamine
 Pupil dilation  Cocaine and Amphetamine
 Pupil constriction  Cannabis and Opioid

 Tolerance  Amphetamines, Ecstasy, Heroin and benzodiazepines

 Most common cause of drug overdose death is heroin

38
 PSYCHIATRY NOTES For Medical Students

Substance Use Disorders

Rapid MCQs

Choose the One Best answer:

1. Which of the following drugs is a CNS stimulant:

A. Alcohol
B. Cannabis
C. Heroin
D. Amphetamine
E. ketamine hydrochloride

2. Which of the following not seen in heroin withdrawal:

A. Rhinorrhea
B. Muscle cramps
C. Miosis
D. Diarrhea
E. Mydriasis

3. Which of the following substances causes a higher number of deaths:

A. Alcohol
B. Nicotine
C. Cocaine
D. Heroin
E. Marijuana

4. Wernicke’s encephalopathy is best treated by: “see alcohol abuse”

A. IV glucose infusion
B. IV saline infusion
C. IV thiamine
D. IV diazepam
E. IV fluphenazine

39
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Child Psychiatry
NOTE  See Attention-deficit/Hyperactivity Disorder (ADHD) in page 55

1. Pervasive Developmental Disorders

A group of disorders in understanding, expressing language and the production of
speech, affect multiple areas of development, are manifested early in life, and cause
persistent dysfunction. Include:
1- Autistic Disorder (most common)
2- Rett’s Disorder
3- Childhood Disintegrative Disorder
4- Asperger’s Disorder
5- Pervasive Disorder not otherwise specified

 Autistic Disorder
 What is it ?
Qualitative deficits in reciprocal social interaction and communication skills and
restricted patterns of behaviors.
 deficits in language development and difficulty using language to communicate
Occurs in 0.05% of children, more common in males, onset before age 3 years

 Etiology:
1. Genetic factors: Higher concordance rate in monozygotic than dizygotic twins
2. Biologic factors: high rates of seizure disorder and mental retardation.
3. Immunologic factors: Incompatibility and prenatal and perinatal insults

 Course and prognosis:

- Generally a lifelong disorder with a guarded prognosis.
- Two thirds remain severely handicapped and dependent.
- Improved prognosis if child has:
IQ >70 and Communication skills are seen by age 5 to 7 years

 Common behavior problems included in autistic disorder:

 Hyper kinesis, hypo kinesis, aggressive, head banging, biting, scratching,
hair pulling, and resistance to routine.
 Note: Prodigious cognitive or visuomotor capabilities may occur in a
small subgroup, “be special in a certain thing, such as memorizing”.
40
 PSYCHIATRY NOTES For Medical Students

Child Psychiatry
 Case of autistic patient:
Child don't demonstrate special attention to important people in their lives and have
impaired eye contact and attachment behaviors to family members and notable
deficits in interacting with peers.
Note: Activities and play are often rigid, repetitive, and monotonous.

 Treatment of autistic disorder:

 Goals of treatment target core behaviors, improve social interactions and
communication, broaden strategies to integrate into schools, develop meaningful
peer relations and finally increase long-term skills in independent living.
 There is no cure for autism, but various treatments are used to help manage
symptoms and improve basic social, communicative and cognitive skills:
1. Early intervention.
2. Remediation (most effective treatment method) : Structured classroom training in a
combination with behavioral methods..
3. Behavioral therapy.
4. Psychoeducation.
5. Low-dose atypical antipsychotic medications as risperidone, aripiprazole
: may help reduce disruptive behavior, aggression, and irritability
6. Parents are often struggle and need support and counseling.

2. Enuresis
 Definition and Criteria: Repeated voiding of urine into clothes or bed,
whether the voiding is involuntary or intentional, must occur twice weekly for at
least 3 months or cause clinically significant distress or impairment socially or
academically child’s chronological or developmental age must be at least 5 years.
 Prevalence: “The prevalence of enuresis decreases with increasing age”
5-10 % in 5 year olds, 1.5-5 % in 9-10 year olds and 1% in 15 years and older.

 Treatment:
Often self-limited, and a child with enuresis may have a spontaneous remission.
1. Star chart.
2. Restricting fluids before bed and night lifting to toilet trains the child.
3. Alarm therapy “mainstay of treatment for enuresis” which is triggered by wet
underwear.
4. Behavioral Therapy: Classic conditioning with the bell (or buzzer) and pad (alarm)
apparatus, Bladder training—encouragement or reward for delaying micturition for
increasing times during waking hours.
5. Drugs if above fails and social or school impairment occur: Small dose Imipramine.

41
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Somatic disorders
1. Somatization
Physical symptoms due to stress or emotions, there is no medical illness
and not consciously created for gain “factitious”.
 Risk factors:
1. Depression and anxiety.
2. Female gender.
3. Less education.
4. Low socioeconomic status.
 Symptoms:
1. Pain symptoms: headache, back pain, joint pain.
2. GI symptoms: nausea, vomiting, diarrhea, bloating, gas.
3. Cardiopulmonary symptoms: chest pain, palpitation, dizziness.
4. CNS symptoms: muscle weakness, fainting, blurred vision.
 Diagnosis:
- Somatic symptoms that cause distress.
- Persistent though about seriousness of symptoms.
- Anxiety about symptoms.
- Excessive time and energy devoted to symptoms.
- Persistent more than 6 months.
 Management:
- Avoid debating if symptoms are psychiatric or medical.
- Regular visits with same physician.
- Limits tests and referral.
- Reassure patient that serious diseases are ruled out.
- Set goals of functional improvement.
- Address psychiatric issue gently.
- Psychotherapy
- May need antidepressant

 Hypochondriasis “illness anxiety disorder or somatic symptom disorder ”: is an

excessively morbid fear or belief that one has serious illness present for at least six
months and cause functional impairment. “Preoccupation with having undiagnosed illness”.
 Hypochondriasis is often accompanied: Bipolar disorder, clinical depression, OCD,
phobias, and somatization disorder. as well as a generalized anxiety disorder diagnosis at
some point in their life.
 CBT is an effective treatment for hypochondriasis, about two-thirds of patients respond
to treatment. Associated disorders treated accordingly.

42
 PSYCHIATRY NOTES For Medical Students

Somatic disorders
2. Conversion disorder
Functional neurological symptom disorder characterized by sudden onset of Voluntary motor or
sensory neurological symptoms following stressor.
 Symptoms:
“Loss of vision, double vision, sensitivity to light”, Limb weakness or paralysis, “Loss of voice, slurred
or stuttered speech”, Memory issues, thinking problems, Headaches, migraines, Loss of sense of smell
Chronic pain, Loss of sense of touch, Loss of hearing, Numbness, tingling, Seizures, Tremors, spasms,
Sleep problems, Overactive bladder and Hallucinations.
 Note:
• Associated with La Bella indifference “Patient shown lack of concern about symptoms”.
• Neurological examination is normal and positive finding is incompatible with disease.
• Co-exist with histrionic and avoidance personality disorders, and is more common in female.
• Diagnosis is accordingly “CT or MRI, EEG & history and examination to rule out other illnesses”.
 Management:
• CBT involves learning about the disorder, recognizing triggers and symptoms, and learning new
ways to respond and control them.
• Hypnosis!
• Stress management training to make symptoms more manageable.
• Physical therapy for weak limbs, walking problems, other movement problems.
• Occupational therapy.
• Speech therapy.
• Medications to treat the medical conditions that may co-exist in.

3. Factitious disorder
A- Factitious disorder on self:
- Called Munchausen syndrome: Falsified medical or psychiatric disorder, done consciously out of
desire for attention.
- Patient may feign illness or may aggravate genuine illness.
- Patient often willing to go for tests or surgery.
- Example: patient afraid of work or afraid to be alone.
- Risk factors: Female gender, Unmarried or Prior or current healthcare worker.
B- Factitious disorder on another:
Falsified medical symptoms by caregiver , Often parent of child or caretaker of elderly.

4. Malingering
Consciously falsified medical symptoms done for secondary external gain.
End when secondary gain is achieved.
Example: 60 years old homeless present to hospital complain of headache and feel. better when
doctor tell he will admit him in hospital.

43
 PSYCHIATRY NOTES For Medical Students
‫بسم اهلل الرمحن الرحيم‬

Suicide
Suicide is fatal act that fulfill the persons wish to die
 Terms used to describe suicide:
o Suicide attempt: self injurious behavior with non fatal outcome accompanies by evidence
that the person intend to die.
o Aborted suicide attempt: potentially self injurious behavior with evidence that the patient
intend to die but stopped the attempt before physical damage occur.
o Para suicidal patient: who injury him self by self mutilation but usually do not wish to die.
o Suicidal ideation: thought of wanting to die it’s varies with in serious ness depend on suicidal
plan intent.
o Suicidal intent: subjective expectation and desire to end life.
o Lethality of suicidal behavior: objective danger to life associated with suicide method.

 Risk Factors: “important”

1. Male.
2. Method: males have high rate of suicidal using highly lethal method.
3. Age: 45 year for male 65 year female, after 75 year in both.
4. Older attempt suicide less but more successful!
5. Marital status: more common in window divorce or single.
6. Mental illness: positive psychiatric illness more risky.
7. Substance use.
8. Personality disorder: Borderline personality disorder higher rate of Para suicide
and Antisocial disorder for homicide.
9. Lack of family support.
10. Un employee.
11. Previous suicidal attempt.
12. Family history of suicidal attempt.

 Management:
- Admission
- 24 close monitoring  patient alone and remove the dangerous objects in room.
- Assessment: Whether attempt planned or impulsive, lethality of method,
assess chance of discovery, reaction of being safe, guilt feeling, if he write note and
coping of stress.
- ECT: Suicidal and Homicidal are indication for ECT.
- Use medication according to diagnosis.

44
PSYCHIATRY NOTES For Medical Students

Suicide

SAD PERSONS scale for suicide

Score: 0-10
1. Sex (male)
2. Age (adult and elderly)
3. Depression 0-4  low risk
4. Prior attempts 5-6  medium risk
5. Ethanol or drug 7-10  high risk
6. Rational thinking loss (psychosis)
7. Sickness (medical illness)
8. Organized plan
9. No spouse (lack of social support)
10. Stated intent to harm themselves

 Note: Violence is Intentional act of doing bodily harm to another person.

 Include:
1. Assault
2. Rape
3. Robbery
4. Homicide
5. Physically and sexually abuse.

45
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

Important Notes you must know!

 ADHD is more common in boys than in girls.
 Rett’s Disorder common in girls than in boys.
 Drug of choice in the ADHD is methylphenidate.
 Depression associated with highest risk of suicide.
 Epilepsy associated with 50% risk of major depression.
 Characteristic feature of delirium is clouding of consciousness.
 Confabulation is a characteristic feature of dementia and Alcoholic Korsakoff syndrome.
 The earliest sign of dementia is disturbance in memory.
 CNS depressant  Alcohol, Barbiturates and Benzodiazepines.
 CNS stimulant  Cocaine and Amphetamine.
 Cocaine and Amphetamine pupil dilation.
 Cannabis and opioid cause  pupil constriction.
 Most common cause of dementia is Alzheimer disease.
 Tolerance can develop rapidly with: Amphetamines, Ecstasy, Heroin and
benzodiazepines.
 DSM  Diagnostic and Statistical Manual of Mental Disorders.
 ICD  International classification of diseases.
 Serial sevens test is clinical test used to test mental function by counting down from
one hundred by sevens.
 Personality disorder cannot be diagnosed before age 18.
 Most common cause of drug overdose death is heroin.
 Awaking much earlier than normal is terminal insomnia, and associated with severe
depression.
 The most characteristic feature of mania is hyperactivity.
 Most common obsessions is contamination.
 Scientists:
• Sigmund Freud set the Freud’s Personality Theory of ID, ego and superego.
• Emil Kraepelin distinguished the catatonic, hebephrenic and paranoid clinical varieties.
• Eugene Bleuler coined the term schizophrenias. Also defined “4A”; Ambivalence,
Autistic behavior, Abnormal associations and Abnormal (blunting of) affect.
• Kurt Schneider set the First rank symptoms of schizophrenia.
 Hypomanic episode is more energy than mania but lead to productive activity “mania
is unproductive”
 Treatment of choice of nocturnal enuresis is alarm therapy.
 Most common obsessions is contamination.
 SIG E CAPS presentation of MDD and DIG FAST of Mania are very important for MCQs.
 La Bella indifference seen in conversion disorder.
 Clinical Schizophrenia appear when biological factors interact with environmental
factors.
 Symptoms of ADHD are often present by age 3 years. “see page 55”
 Wernicke’s encephalopathy is an important long-term complications of alcohol intake,
caused by thiamine (vitamin b1 ) deficiency. If not treated progress to Korsakoff
syndrome. “see page 58”
46
 Chapter Five
History taking &
Examination

PSYCHIATRY NOTES For Medical Students | Mosab Emad Mubayed | AlNeelain University | 2022
47
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

History taking & Examination

Before you start; you must go back to the Psychopathology chapter page 3
and presentation of Anxiety, Mood & Psychotic Disorders page 24

1. Personal (Identifying) Data:

Name, Sex, Marital Status, Age, Residence, Occupation, Educational Level,
Patient brought by, Reasonable Referred
Informer: Is he or she reliable? Date of admission.
2. Presenting Complaint:
the main problems in the patient’s own words,
in one or two sentences + duration.
3. History of Presenting Illness:
- The patient’s psychosocial and environmental conditions “predisposing
to, precipitating, perpetuating, and protecting against the current episode”.
- The patient’s support system “whom the patient lives with, distance
and level of contact with friends and relatives”.
- Neurovegetative symptoms (quality of sleep, appetite, energy,
psychomotor retardation/activation, concentration).
- Suicidal ideation/homicidal ideation.
- How work and relationship have been affected
(for most diagnoses in the DSM-5 there is a criterion that specifies that
symptoms must cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning).
- Psychotic symptoms (e.g., auditory and visual hallucinations, delusions).
- Establish a baseline of mental health.
- Patient’s level of functioning when well.
- Goals “outpatient setting”.
Examples of questions can help you:
Sleep: lack of sleep? disturbance of sleep? increase sleep? times of wakeup and sleep?
Appetite: poor appetite? increase appetite? normal appetite?
Weight: loss of weight? gain of weight?
Mood: What are you feeling? Happiness? Sadness? Normal?
Hygiene: washing? take care of himself? neglect himself?
Social withdrawal? Lack of concentration? Guilt feeling?
Activity: increase? Decrease? Lack of interest?
Hearing voices? Seeing images?
48
 PSYCHIATRY NOTES For Medical Students

History taking & Examination

4. Past psychiatric History:
- history of suicide attempts.
- history of self-harm “cutting, burning oneself”.
- information about previous episodes.
Note: for episode ask about 
time, duration, complains, medication used, ECT intervention, functioning, compliance
- other psychiatric disorders in remission.
- medication trials.
- past psychiatric hospitalizations.
- current psychiatrist.

5. Past medical History:

- Ask specifically about head trauma, seizures and convulsion.
- if women pregnancy status.
- Serious medical illness.
- Loss of consciousness.
6. Family History:
- Mother, Father, Sibling and number ordering of patient.
- Relationship.
- Financial support.
- Family history of psychiatric illness “include substance use, suicides.
and response to specific psychotropic agents as patient may respond similarly”
7. Personal History:
Is important as it helps you to understand what has led to your patient
becoming the person they are.
Ask about:
family of origin, early experiences, schooling, friendships, qualifications,
further or higher education.
You can then move on to ask about the following areas:
- Employment history.
- Interests and current friendships.
- Significant relationships, marriage and children.
- Psychosexual history.
- Forensic History.
- Use of alcohol and illicit drugs.
49
 PSYCHIATRY NOTES For Medical Students

History taking & Examination

8. Social History:
- Sexual history:
Men arch, Puberty, Fantasies and Experience “homosexual or heterosexual”
- Marital History; How long relationship? Kids? If divorced why?

9. Drug History:
Sensitivity, Side effects, Current medication and allergy.

10. Substance History:

Name? Route of admission? “IV, Oral or Inhaled” When? Whom?
Where? Effect? How many? Tried to stop? Withdrawal symptom? Craving?
Possible dependence?

11. Personal History:

indication of the patient’s personality and character before the onset of
mental illness. It can be difficult to ascertain retrospectively.
Indirect evidence of it can be provided from the personal history.
Ask about:
- Coping styles, interests, hobbies and activities and
how the person usually relates to other people?
- Patient is Sociable, Calm, Criminal or Obsessive?

50
PSYCHIATRY NOTES For Medical Students

Mental State Examination

1. General Appearance:
Weight, height, hygiene, disinhibition, over familiar, dress,
psychomotor “agitated, retarted, normal”
up normal movement “tremor , up normal gate, catatonic, sign of extra pyramidal
symptom”, facial expression, eye to eye contact “poor, avoid, maintain” and
rapport, consciousness, cooperation and hallucinatory attitude.

2. Speech:
- Rate “pressured, slowed, regular”
- dysprosody “unusual speech rhythm, melody, intonation or pitch”
- Articulation “dysarthria, stuttering”
- Accent/dialect
- Volume/modulation “loudness or softness”
- Tone
- Long or short latency of speech
- Coherent or incoherent

3. Mood:
Mood is the emotion that the patient tells you he/she feels, often in quotations.
- Elevated or depressed mood.
- Other mood states such as anxiety and panic.
- Ask the patient to describe their mood subjectively.
- you also need to assess their mood and affect objectively.
- Associated symptoms.

4. Thinking :
Stream, Form, Content and Poisson.
Examples: Pressure of thought, flight of ideas, circumstantiality, thought blocking,
dysphasia, thought withdrawal, thought insertion & delusions.
Note  see page 6 & 7

51
PSYCHIATRY NOTES For Medical Students

Mental State Examination

5. Perception:
 Illusion:
Inaccurate perception of existing sensory stimuli, “wall appears as if it’s moving!”
 Hallucination:
- Describe the sensory modality: Auditory (most common), visual, olfactory, or
tactile.
- Describe the details “auditory hallucinations may be ringing, humming, whispers, or
voices speaking clear words”.
- Ask if the hallucination is experienced only while falling asleep “hypnagogic
hallucination” or upon awakening “hypnopompic Hallucination”.
 Also pseudo hallucination, derealization or depersonalization.

6. Cognitive Function:
- Consciousness: alert, drowsy, lethargic, stuporous or comatose.
- Orientation: To person, place, and time.
- Calculation: Ability to add/subtract.
- Memory:
1. Immediate “registration” can be tested by asking a patient to repeat several digits
or words.
2. Recent “short-term memory” events within the past few minutes, hours or days.
3. Remote memory “long-term memory”.
- Fund of knowledge: Who is the president? Who was Maradona?
- Attention/Concentration: Ability to subtract serial 7s from 100 “Serial sevens test”
or to spell “world” backward.
- Reading/Writing: Simple sentences “must make sure the patient is literate first”.
- Abstract concepts: Ability to explain similarities between objects and understand
the meaning of simple proverbs.

7. Insight:
Insight is not an ‘all or nothing’ attribute, often described as “good, partial or poor”
- Does the patient believe they are unwell in any way?
- Do they believe they are mentally unwell?
- Do they think they need treatment (pharmacological, psychological or both)?
- Do they think they need to be admitted to hospital?

8. Judgment!
Judgment is the patient’s ability to understand the outcome of his or her actions and
use this awareness in decision making; it is best determined from information from
the HPI and recent behavior.
52
 Chapter Six
Questions & Short test
Problems Questions
MCQs
OSPE Questions
Short test

PSYCHIATRY NOTES For Medical Students | Mosab Emad Mubayed | AlNeelain University | 2022
53
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

Problems Questions
1. Previous exams questions:

1) A 29 year old man is brought to the hospital because he was found running around on the streets
with no shoes on in the middle of winter, screaming to everyone that he was going to be elected
president. He was found to be irritable and excited, he doesn’t seen to be able to concentrate as well
as he had previously. Six weeks prior to this he had been to the emergency room for an acute asthma
attack.
1. What is the most likely diagnosis? Mania
2. Outline the management?
Lithium, Haloperidol, IV Benzodiazepines, ECT and CBT

2) While driving his car recklessly, a university student had a fatal car accident causing severe head
injury and subsequent death of his classmate in the passenger seat. Luckily, he was unhanned.
However, few weeks later he started to experience dreams about the event, insomnia and increased
arousal. Ultimately he started to drop class.
1. What is the most likely diagnosis? PTSD
2. Mention two clinical features of this disorder?
Avoidance of reminders, Hypervigilance, social dysfunction …etc
3. Mention one differential diagnosis? Adjustment disorder
4. What groups of drug are used in treatment of this disorder?
SSRI, SNRI, alpha1 blockers “Prazosin”

3) A 25 year old man with fear of having run over someone when he is driving, he has to stop his car
and get out to make sure if there is a body in the road every time he drives. He also said that he
checks his doors and windows many time to ensure they are locked. Also he spends much time in
dressing. He tries to resist doing these things which he feels they don’t make sense but feels anxious
if he doesn’t go and check.

1. What is the most likely diagnosis? OCD

2. Mention one effective non-pharmacological treatment?
Behavioral therapy  ERP “Exposure with Response Prevention“ & CBT

4) A 18 year old male patient was brought by his father to psychiatrist. His father stated that over
the past 6 months his son started to behave abnormally with periods of excitement, self-talking and
laughing followed by periods of immobility and described odd posturing for several hours.
Psychotropic medications were used for 3 months without response.
1. What is the most likely diagnosis? Schizophrenia
2. What is the treatment of choice? ECT, others CBT, Family therapy and social rehabilitation
3. Mention the main presentation found in your diagnosis?
Auditory hallucinations

54
 PSYCHIATRY NOTES For Medical Students

Problems Questions
5) A 30 years old woman has 2 years history of repeated episodes of hypomania and depression.
1. What is the most likely diagnosis? Bipolar disorder
2. Mention one important medication useful in controlling these episodes? Lithium
3. Mention two important tests before starting this drug?
Thyroid function test, CBC and Creatinine
4. Mention one important test after starting this drug? Serum lithium level

6) A 5 years old child is brought to the psychiatrist because of difficulty in his ability to focus
attention at school. He fidgets and is not able to stay seated in class. At home he talks excessively
and cannot be put off for even a minute.
1. What is the most likely diagnosis? ADHD
2. What is first choice drug used in treatment? CNS stimulants: methylphenidate
2. Outline the management?
* Pharmacologic treatment is considered the first line of treatment for ADHD:
1. CNS stimulants: methylphenidate
2. Norepinephrine uptake inhibitor: Atomoxetine (Strattera)
* Psychosocial Interventions:
Psychoeducation, Academic organization skills remediation, Parent training, Behavior
modification in the classroom and at home, CBT and Social skills training.

 ADHD have significant impairment in academic functioning as well as in social and

interpersonal situations.
 Frequently associated with comorbid disorders including learning disorders,
anxiety disorders, mood disorders, and disruptive behavior disorders.
 ADHD is common in male than female.
 Presentation of ADHD patient  Symptoms of ADHD are often present by age 3
years and characterized by: impulsiveness and an inability to delay gratification,
hyperactivity, attention deficit “short attention span, distractibility, perseveration,
failure to finish tasks, inattention, poor concentration”
 ADHD affects up to 5-8 % of school-aged children, with 60-85% of those
diagnosed as children continuing to meet criteria for the disorder in adolescence,
and up to 60% continuing to be symptomatic into adulthood.
 Causes and Risk factors include: Genetic “75% heritability”, Prenatal toxic
exposures, Prematurity, Prenatal mechanical insult to the fetal nervous system,
Food additives, colorings and sugar

55
 PSYCHIATRY NOTES For Medical Students

Problems Questions
7) A 23 year old lady delivered her first child normally, but in the first week of her delivery she
suddenly started to be agitated and restless, confused with labile mood and refused to breast feed
her baby saying that it is not her baby it is the devil and she said she is hearing voices talking about
her.

1. What is the most likely diagnosis? Postpartum psychosis

2. What other types of psychiatric disorders associated with delivery?
Postpartum depression and postpartum blues
3 how you manage this case?
Separate baby, admission mother, give Antipsychotics, may need
ECT and psychotherapy

8) A 27 year old woman has been feeling sad for the past 2 weeks. She has little energy & has
trouble concentrating. She states that 6 weeks ago she had been feeling very good with lots of
energy & no need for sleep. She said that this pattern has been occurring for at least the past 3
years; though the episodes have never been so severe that she couldn’t work.

1. What is the most likely diagnosis? Cyclothymia

2. What is the best treatment of this patient? Mood Stabilizer

9) An 11 years boy frequently leaves his bed & goes to living room late at night. On several occasions
his parents have talked to the child at that time & found him as if he were in a dream & staring into
space with his eyes opened. The next day the child denies having left his room.
1. What disorder most likely is this child exhibiting? Sleep walking
2. What is the best treatment for this patient ?
Reassurance and safety measures

10) A 23 years old woman visits a physician because of multiple physical complaints, then after a
thorough examination, she found to have no physical problem, she presented her complaint in a
dramatically & aggravated ways & her history reveals numerous medical visits to various physicians.

1. What is the most likely diagnosis? Somatization disorder

2. What are the principles of management of this patient?
Regular visits with same physician, limits tests and referral, set goals of
functional improvement and psychotherapy
3. If a medication was to be prescribed for this patient, what is the best option?
Antidepressants

56
 PSYCHIATRY NOTES For Medical Students

Problems Questions
2. Other important topics for problems questions:
1) Generalized anxiety disorder
 What is GAD? Excessive, irrational and exaggerated anxiety and worry
about everyday life events for no obvious reason. persisting at least six months.
 What is the presentation of GAD?
Restlessness, fatigue, difficulty concentrating, irritability, muscle tension
and sleep disturbances. More common in women. Last of more than 6 months
 Outline the management of GAD?
- 1st line SSRI or SNRI
- 2nd line Benzodiazepines only for short term use
- 3rd line Adjunctive olanzapine or risperidone
- CBT also 1st line, include  Psychoeducation, Cognitive interventions, Exposure,
Relaxation strategies, Problem Solving, Assertiveness training and Relapse Prevention

2) Alcohol Intoxication
 What is alcohol and what it’s action??
 Alcohol (ethyl alcohol/ethanol), found in alcoholic beverages, metabolized by
liver, activates GABA, dopamine, and serotonin receptors in CNS, inhibits
glutamate receptor activity and voltage-gated calcium channels.
 NOTE: GABA receptors are inhibitory, glutamate receptors are excitatory
So Alcohol is a potent CNS depressant
 What are alcohol biomarkers?
AST, GGT, High MCV and Hypertension
 What is alcohol intoxication?
When drinking too much alcohol in a short amount of time,
blood alcohol concentration (BAC) of greater than 25–80 mg/dL or 0.025–0.080%
 What are the clinical features of alcohol intoxication?
CNS depressant, slurred speech, incoordination, steady state, stupor, coma and
respiratory depression. Death may occur.
 How to treat alcohol intoxication?
o Monitor  Airway, breathing, circulation, glucose, electrolytes, acid–base status.
o Give parenteral thiamine (for Wernicke’s encephalopathy) and folate.
o Naloxone may be necessary to reverse effects of co-ingested opioid.
 Note: thiamine before glucose, as it’s a necessary cofactor for glucose
metabolism
 What is ALCOHOL POISONING?
Very high BAC “> 400mg/dl” which lead to respiratory depression.
57
 PSYCHIATRY NOTES For Medical Students

Problems Questions
3) Alcohol Withdrawal
 What is Alcohol withdrawal?
Symptoms occur following a reduction in alcohol use after a period of excessive use. Cessation of
use causes a compensatory hyperactivity with glutamate excitotoxicity.
 What are the clinical features of alcohol withdrawal?
Tremor, Anxiety, GI upset, Headache, Sweating, Palpitation
 Outline the management of Alcohol withdrawal?
- Benzodiazepines (lorazepam, diazepam, or chlordiazepoxide) given in sufficient doses to keep the
patient calm and lightly sedated, then tapered down slowly.
- Carbamazepine or valproic acid can be used in mild withdrawal.
- Banana bag: Thiamine, folic acid, and a multivitamin treat nutritional deficiencies
- Electrolyte and fluid abnormalities must be corrected.
- CIWA scale  Monitor withdrawal signs and symptoms with the Clinical Institute Withdrawal
Assessment scale.
 What are severe symptoms of Alcohol withdrawal and when to occur?
- Generalized tonic clonic seizure  Occur 24-48 hours after last drink
- Visual hallucination  Occur 24-48 hours after last drink : Seeing insect or animal, Hearing voice,
Tactile sensation: feel a bug on the skin.
- Delirium tremens  Occur between 48-96 hours after last drink,
symptoms: delirium, visual hallucination, agitation, gross tremor, autonomic instability, and
fluctuating levels of psychomotor activity.
Note: alcohol withdrawal has 20% mortality rate, Death occur from hyperthermia, arrhythmia,
cardiac collapse and electrolytes imbalance, treat with benzodiazepines.
 What is the most severe withdrawal manifestation? Delirium tremens
Alcohol Abuse
Complications
 Wernicke’s encephalopathy is an important long-term complications of alcohol intake, caused by
thiamine (vitamin b1 ) deficiency. If not treated progress to Korsakoff syndrome.
 Features of Werincke’s encephalopathy: Visual disturbance/nystagmus, Gait ataxia & Confusion.
 Features of Korsakoff syndrome: anterograde amnesia, apathy, compensatory confabulation.
 Both associated with: Thiamine B1 deficiency, alcohol use, atrophy of mammillary bodies and damage
to thalamic nuclei.
 Note : Korsakoff syndrome is permanent and affect recent memory more than remote.
 Treatment for both: Banana bag contained: (Thiamine “VB1”, Folate “VB9” and Magnesium),
Pyridoxine “VB6”, Calcium and Phosphorus.

4) Neuroleptic malignant syndrome

 What is NMS?
Rare dangerous reaction to high potency first generation drugs Usually 7-10 days after treatment
started.
 What is presentation of NMS?
Fever and rigid muscles, Mental status changes “encephalopathy”, Elevated creatinine kinase “muscle
damage”, Myoglobinuria due to acute renal failure “rhabdomyolysis”.
 How to treat NMS?
Muscle relaxant and Dopamine agonist: bromocriptine.
58
 PSYCHIATRY NOTES For Medical Students

Problems Questions
5) Postpartum Blues, Depression & Psychosis
 What is postpartum psychosis?
Severe mental illness characterized by extreme difficulty in responding emotionally to
a newborn baby, it can even include thoughts of harming the child
 What are the symptoms of postpartum psychosis?
Delusions or strange beliefs, hallucinations, very irritated, hyperactivity, decreased
need for or inability to sleep, paranoia and suspiciousness, rapid mood swings and
difficulty communicating at times.
 What is the difference between Postpartum psychosis, depression and blues?

Post Partum Post Partum Post Partum

Blues Depression Psychosis
Onset 3-5 days after delivery 3-6 months Almost Always
within 8 weeks

Incidence 50 - 85% 10 - 15% 0.1 - 0.2%

Duration 1 day to 2 weeks 2 weeks to 12 Always within 8
months weeks

Symptoms Mild insomnia, Irritability, nihilistic Delusion, confusion,

tearfulness, fatigue, delusions, labile attention deficits,
irritability, poor mood, anxiety, Hallucination,
concentration phobias, difficulty Affective mood and
falling sleep with Infanticide attempt
ideation of death
and suicidal and
infanticide attempt
Management - Self limited - Emergency - Emergency
- Supportive ttt - Admission - Admission
- Psychotherapy - Separate baby - Separate baby
- Observe  20% will
- Antidepressant - Antipsychotic
develop post partum
depression in the 1st - ECT - ECT
year - Psychotherapy - Psychotherapy-

59
 PSYCHIATRY NOTES For Medical Students

Problems Questions
6) Delirium
 What is Delirium?
State of mental confusion that starts suddenly and is caused by a physical condition of some sort.
You don’t know where you are, what time it is, or what’s happening to you.
It is also called an 'acute confusional state
 What are the types of Delirium?
Mixed type (most common), Hypoactive (quiet) and Hyperactive (ICU psychosis)
 What is the Etiology of Delirium according to DSM-5?
Substance intoxication, Substance withdrawal, Medication, Medical condition and Multiple etiology
 What are the Risk factors of Delirium?
Age, preexisting cognitive impairment or depression , history of delirium, alcohol use or withdrawal,
infection, pain, dehydration, malnutrition, sleep deprivation, organ failure and hearing/vision impairment.
 What is the clinical manifestation of delirium?
Disorder of attention and awareness (orientation), Cognitive deficits develop acutely over hours to
days, Symptoms fluctuate throughout the course of a day , worsening at night, Deficits in recent
memory, Language abnormalities, Perceptual disturbance, Circadian rhythm and emotional
symptom.
 Outline the management of delirium?
1. Calm the patient and avoid use of restraints.
2. Treatment the cause.
3. Haloperidol is the treatment of choice.
4. D2 an antagonist can be given in case of agitation, but should be avoided in parkinsonism patients.
5. Use Benzodiazepine only if delirium cause by Alcohol or Benzodiazepine withdrawal.

What is the difference

between
Delirium & Dementia? See the next page

60
PSYCHIATRY NOTES For Medical Students

Dementia is a chronic progressive state of global cortical dysfunction

 characterized by:
1. Mood and Memory disturbance
2. Behavioral changes
3. Multiple cognitive defect
 But without consciousness disturbance

 Pathogenesis: Brain neuronal loss due to normal degeneration or cell death secondary due to
organic disease of the brain.

 Cause: Alzheimer's disease “most common cause and very important”

 Other causes: Cerebrovascular as stroke “second most common cause”, Parkinson's disease,
Wilson's disease, multiple sclerosis ,Huntington's disease, head trauma, alcohol, toxin, AIDS
and metabolic endocrine &nutritional disorders.

 Features:
 Global disturbance of cognitive functions:
- Disturbed attention, perception and orientation
- Memory loss
Other:
1. Emotional disturbance.
2. Psychosis symptoms.
3. CNS manifestation.
4. Disturbance of executive function.
5. Impairment of judgment

 Management:
 Treatment of the cause in reversible types as Vitamins deficiency.
 No specific treatment for Irreversible types: Anticholinesterase inhibitors
“may help delay memory and cognitive decline”
 Supportive measurement:
 Physical and psychological rehabilitation.
 Emotional support for the patient and his family.
 Safe, calm and orienting environment.
 Diet
 Maintain physical health and treat the medical illnesses.
 Symptomatic treatment for anxiety or psychotic symptoms “Haloperidol, Risperidone or
benzodiazepines”

61
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

MCQs
Previous exams questions

1) The treatment of choice in neuroleptic malignant syndrome is:

A- Haloperidol
B- Promethazine
C- Bromocriptine
D- Flupenthixol
E- Lorazepam
2) Functional inability of speech:
A- Alogia
B- Stuttering
C- Mutism
D- Aphonia
E- Stammering

3) Regarding to Postpartum psychosis, what is true:

A- occurs most commonly in multigravida women
B- is rarely correlated with perinatal complications
C- usually occurs abruptly, with no prodromal psychotic symptoms
D- is essentially an episode of a psychotic disorder
E- almost always begin within 8 weeks of delivery
4) A 32 years old lady presents with refusal to eat, hopelessness, guilt
feelings and severe sadness for the past 4 weeks. During this period she had
difficulty to sleep, and fatigability in addition to loss of desire in previously
enjoyable activates she has death wishes. What is the most appropriate
treatment at this point:
A- tricyclic antidepressants
B- SSRI
C- mono amine oxidase inhibitors
D- electroconvulsive therapy
E- mirtazapine

62
 PSYCHIATRY NOTES For Medical Students

MCQs
Previous exams questions
5) Diagnostic criteria for borderline personality disorder include all the
following except:
A- excessive efforts to avoid abandonment
B- disturbance in and uncertainty about self-image, aims and internal
preferences
C- liability to become involved in intense and unstable relationships
D- recurrent threats or acts of self-harm
E- chronic feeling of low mood and depression
6) According to DSM-IV, for a mixed manic episode, criteria for both major
depressive disorder and mania should be present for :
A- one day
B- one week
C- one month
D- three days
E- two months
7) A 55 year old lady who lives on her own, wears odd cloths and pokes
around in her neighbor’s garbage. She claims to have psychic powers but
doesn't repeat hearing voices. What is the most likely diagnosis:
A- schizoid personality disorder
B- schizotypal personality disorder
C- avoidant personality disorder
D- paranoid personality disorder
E- Asperger syndrome
8) All the following statements regarding cyclothymic disorder are true
except:
A- symptoms must be present for at least 2 years
B- occurs at the same rate among men and women
C- symptoms satisfy major depressive disorder
D- patient don’t return to baseline for more than 2 months
E- mood swings appears to the individual as not related to life events

63
 PSYCHIATRY NOTES For Medical Students

MCQs
Previous exams questions
9) All the following personality disorders are cluster B except:
A- narcissistic
B- antisocial
C- borderline
D- obsessive compulsive
E- histrionic
10) Which of the following is true:
A- withdrawal symptoms are needed for a diagnosis of dependence
B- withdrawal is seen only when the substance used is stopped
C- the signs and symptoms of withdrawal are same for all drugs
D- the severity of withdrawal is not related to the amount of substance used
E- the severity of withdrawal is related to the duration and pattern of use
11) Which one of the following is not complication of amphetamine use:
A- hypotension
B- weight loss
C- depression
D- paranoid psychosis
E- mania

12) Which of the following substances causes the highest number of death:
A- alcohol
B- nicotine
C- cocaine
D- marijuana
E- heroin
13) Who is the Father of psychiatry: (MCQ 2022)
A- Emil Kraepelin
B- Eugen Bleuler
C- Sigmund Freud
D- Kurt Schneider
E- Erik Erikson

64
 PSYCHIATRY NOTES For Medical Students

MCQs
Previous exams questions
14) Characteristic feature of delirium include:
A- grandiose delusions
B- clouding of consciousness
C- thought insertion
D- compulsive behavior
E- thought withdrawal
15) Flight of ideas:
A- characteristic of a depressive disorder
B- due to rapid fluctuation of mood
C- diagnostic feature of manic episode
D- an early sign of dementia
E- non of above
16) Delirium Tremens is a complication of:
A- Amphetamine abuse
B- Alcohol withdrawal
C- Cannabis abuse
D- Opiate Abuse
E- Alcohol intoxication

17) Incidence refers to:

A- number of all cases in a population
B- number of new cases in a population over a period of time
C- Prevalence of cases
D- admission rate of new cases
E- non of above
18) Akathisia is:
A- a positive psychotic symptom
B- a side effect of alprazolam
C- a subjective feeling of restlessness
D- a negative psychotic symptom
E- a jerky movement

65
 PSYCHIATRY NOTES For Medical Students

MCQs
Previous exams questions
19) A medical student finds it hard to follow a patient’s train of thought
because he gives very long, complicated explanations and many
unnecessary details before finally answering the original questions. In his
report, the medical student writes that the patient displayed:
A- Loosening of association
B- circumstantialities
C- echolalia
D- neologisms
E- flight of ideas

20) Features of childhood autism include all of the following EXCEPT:

A- distractibility
B- occurrence before age 3 years
C- poor eye contact
D- poor communications
E- speech difficulty
21) All of the following are indications for antipsychotic medications except:
A- acute schizophrenia
B- mania
C- obsessive compulsive disorder
D- violent patient
E- psychotic depression

22) Which of the following is under conscious control:

A- conversion disorder
B- somatization disorder
C- body dysmorphic disorder
D- factitious disorder
E- hypochondriasis

66
 PSYCHIATRY NOTES For Medical Students

MCQs
Previous exams questions
23) 34-year-old woman presented with low mood, insomnia, weight loss
and loss of interest for the last 4 months. She was diagnosed as depression
and given antidepressant drugs for a reasonable period and optimum dose
without achieving remission.
The most appropriate laboratory test for this patient is:
A- CT brain
B- serum folate
C- TFT “thyroid function test”
D- HCG “human chorionic gonadotropin” level
E- serum prolactin
24) 24-year-old man is admitted to the inpatient psychiatry unit after his
mother observed him standing in place for hours at a time in abnormal
postures. During his exam, the patient stands with one arm raised directly
above his head and the other straight out in front of him. He is mute, does
not appear aware of his surroundings, and actively resists any attempts to
change his position.
Which of the following best describes the patient’s behavior:
A- apraxia
B- dystonia
C- tardive dyskinesia
D- catatonia
E- dissociation

25) Features of bulimia nervosa include all of the following except:

A- enlarged parotid gland
B- purging
C- dental caries
D- severe weight loss
E- induced vomiting

67
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

OSPE Questions
AlNeelain Exam 2022 OSPE questions:
1) Look for this picture and answer:

1. What is this device? ECT = Electro convulsive therapy

2. Give one preparation before use it? General anesthesia
Other preparation include: Medical history, Physical Examination,
Investigation , CXR, ECG, Consent and use unilateral bilateral electrode.
3. What are indications to use it?
 Severe depression
 Depression with psychosis
 Catatonia
 Pregnancy, Post partum depression or psychosis
 Refuse to eat, Resistant of ttt
 Highly suicidal risk or suicidal attempt
 Neuroleptic malignant syndrome.
4. Give one complication for it? Anterograde or retrograde amnesia
5. What are absolute contraindications of it? NO absolute contraindications
6. What are contraindications of it?
Cerebral aneurysm, increase Intracranial pressure, Recent MI, Arrhythmia,
Impending retinal detachment and Highly anesthetics risk.
68
 PSYCHIATRY NOTES For Medical Students

OSPE Questions
AlNeelain Exam 2022 OSPE questions:

2) This collection of screenshots take from a video in which a strangely dressed

woman speaks a lot at a fast pace, showing increased movement and activity.

1. What you see?

Agitated woman, talk too much
2. What is your diagnosis? Mania
3. What is the clinical presentation of your diagnosis?
DIG FAST  Distractibility, Irresponsibility, Grandiosity, Flights of ideas,
Agitation, Sleep less, Talk too much, pressure speech
4. What is the treatment of this case?
Lithium, Haloperidol, IV Benzodiazepines for acute phase, ECT and CBT

69
 PSYCHIATRY NOTES For Medical Students

OSPE Questions
AlNeelain Exam 2022 OSPE questions:

3) This collection of screenshots take from a video in which A man in shabby clothes,
walking alone in the street, suddenly appears to pick up a stone from the ground, hit
a man on his bicycle and knock him to the ground, then proceeds as if nothing had
happened.

1. Describe what you see?

A shabby man suddenly exhibits aggressive behavior
2. What is the appropriate diagnosis? Schizophrenia
3. Give differential diagnosis. Schizoid personality disorder!
4. What is the clinical presentation of your diagnosis?
delusions, auditory hallucinations, disorganized or catatonic behavior,
disorganized speech, Avolition, Anhedonia, Asocialy, Alogia
5. Outline the management.
Antipsychotics as haloperidol, CBT,
Family therapy and social rehabilitation

70
 PSYCHIATRY NOTES For Medical Students

OSPE Questions
AlNeelain Exam 2022 OSPE questions:

4) Look for this picture and answer:

1. What does this picture represent (diagnosis!)?

Catatonia
2. What are the diseases accompanied whit this case?
Depression, Bipolar & Schizophrenia
3. What is the clinical presentation of your diagnosis?
Immobility, Stupor or mutism, Negativism, Catalepsy, Posturing,
Echolalia and Echopraxia
4. How to treat this patient?
Benzodiazepine & ECT
Note: avoid antipsychotics

71
 PSYCHIATRY NOTES For Medical Students

OSPE Questions
AlNeelain Exam 2022 OSPE questions:

5) This collection of screenshots take from a video shows a man entering the room
and sitting in front of a bottle of alcohol, while listening to two people talking badly
about him.

1. How to describe this case?

3rd person auditory hallucination
2. Which psychiatric condition related to this case?
Schizophrenia & alcohol use disorder

6) Look for this picture and answer:

1. What is this drug?
Citalopram
2. What is the group of this drug?
SSRI = Selective serotonin reuptake inhibitors
3. What are indications to use it?
GAD, Panic disorder, MDD …etc
4. What are side effects?
Sexual dysfunction, headache, insomnia, GIT upset …etc
72
 ‫بسم اهلل الرمحن الرحيم‬
PSYCHIATRY NOTES For Medical Students

Short
You have only 30 minuets
Test
, Try to answer by yourself
, then compare your performance with the answers below
One Mark for
First Question: Select the one best answer:- each question

1) Which of the following personality disorder is social phobia most likely confused with:
A. avoidant
B. dependent
C. schizoid
D. Paranoid
E. histrionic

2) A psychiatric patient who, although coherent, never gets to the point has a
disturbance in the form of thoughts, called:
A. word salad
B. circumstantially
C. verbigeration
D. blocking
E. tangentiality

3) Feeling unfamiliarity with a familiar situation is known as :

A. Jamis vu
B. Deja pense
C. confabulation
D. Deja vu
E. Deja entendu

4) A 23-year-old woman arrives at the emergency room complaining that, out of the
blue, she had been seized by an overwhelming fear, associated with shortness of
breath and a pounding heart. These symptoms lasted for approximately 20 minutes,
and while she was experiencing them, she feared that she was dying or going crazy.
The patient has had four similar episodes during the past month, and she has been
worrying that they will continue to recur. Which of the following is the most likely
diagnosis:
A. acute psychotic episode
B. Hypochondriasis
C. Panic disorder
D. Generalized anxiety disorder
E. Posttraumatic stress disorder

73
 PSYCHIATRY NOTES For Medical Students

Short Test
5) Which of the following statements concerning ADHD is correct?
A. it is more common in boys
B. stereotypy is common
C. social isolation is common
D. onset is at age of 10
E. there is an increased incidence in social high class
6) The following drug is used in the treatment of nocturnal enuresis:
A. citalopram
B. imipramine
C. carbamazepine
D. promethazine
E. propranolol
7) Which of the following is a negative symptom of schizophrenia?
A. though reading
B. avolition
C. visual illusion
D. hostility
E. delusions
8) Contraindications of ECT include:
A. pregnancy
B. epilepsy
C. elderly
D. cerebral tumour
E. diabetic patients

9) the most common cause of amnestic syndrome is:

A. Alzheimer disease
B. concussion
C. hypoxia
D. intracranial infarction
E. vitamin deficiency

10) Among persons who commit suicide; the most frequent diagnosis are major
depression &:
A. borderline personality
B. alcoholism
C. dementia
D. Schizophrenia
E. Somatization disorder

74
 PSYCHIATRY NOTES For Medical Students

Short Test
Second Question: Read the following and answer:-
1) A 20-year-old man presented with the chief complaint of persistent desire to count
things and numbers wherever he goes , in spite that he knows it is senseless and it is
his own thinking so he used to resist and this resistance led to an intense anxiety.
1. What psychopathology is this man having?
……………………………………………………………………… 8 Marks
2. What is the most likely diagnosis?
………………………………………………………………………
3. What is the 1st line of treatment you can describe for this man?
………………………………………………………………………
4. Which psychotherapy can be useful for this case?
………………………………………………………………………

2) A 30- year old married male Sudanese has 2 years history of gradual
onset of social withdrawal and decreased emotional responsiveness.
Recently he started to believe that his food is being poisoned and he will
chock and also his food is pureed. He has lost weight and he started to
neglect his personal hygiene. He has no history of substances abuse.
1. What is the most likely diagnosis?.
……………………………………………………………………… 4 Marks
2. Choose the correct one: This man displays:
A. persecutory delusion
B. ideas of reference
C. an overvalued ideas
D. 2nd person hallucination
E. Depersonalization

3) A 17 year Sudanese girl is brought to emergency room by her parents because of

sudden blindness. The patient is from an intensely religious background. She states
that she cannot see anything, and she believe her condition is divine punishment for
her sinful behavior. She also states that she gracefully accepts “Gods will”.
Physical examination shows intact visual reflex.
1. What is the most likely diagnosis? 4 Marks
………………………………………………………………………
2. Outline the management.
………………………………………………………………………

75
 PSYCHIATRY NOTES For Medical Students

Short Test
Third Question: look for the pictures and answer:-
Picture 1: 8 Marks
1. What is the name of this abnormality?
………………………………………………………………………
2. What is the most likely diagnosis?
………………………………………………………………………
3. What are other signs is your diagnosis may
be presented with?
………………………………………………………………………
………………………………………………………………………
4. What is appropriate treatment?
………………………………………………………………………

Picture 2: 6 Marks

1. What is the most severe withdrawal manifestation of this substance?

………………………………………………………………………
2. Give 3 clinical features result of intoxication of this substance?
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………
3. Give one long-term complications result of this substance abuse?
………………………………………………………………………

76
 PSYCHIATRY NOTES For Medical Students

Short Test
ANSWERS
WHAT IS YOUR FINAL SCORE? 40
How many questions did you get correctly? How long did it take you for that?

First Question: Select the one best answer:-

Question 1 2 3 4 5 6 7 8 9 10
Answer A E A C A B B D A B
Full correct answers = 10 Marks
Second Question: Read the following and answer:-
1) 1 : Compulsion
2 : OCD
3 : SSRI as citalopram
4 : CBT and/or ERP
2) 1 : Schizophrenia
2 : A = persecutory delusion
3) 1 : Conversion disorder
2 : CBT, Hypnosis, Stress management, Physical therapy, Occupational therapy, Speech
therapy, Medications to treat the medical conditions.
Full correct answers = 16 Marks
Third Question: look for the pictures and answer:-
Picture 1: 1 : Catatonia
2 : Catatonic Schizophrenia
3 : Immobility, negativism, catalepsy, posturing, echolalia and echopraxia
4 : ECT and Benzodiazepine
Picture 2: 1 : Delirium tremens
2 : Slurred speech, incoordination & steady state.
3 : Wernicke’s encephalopathy
Full correct answers = 14 Marks
77
References
• First aid for the psychiatry, 5th edition
• Lecture notes of Dr. Safa AlSarrag, Psychiatrist, AlNeelain university
• Lecture notes of Dr. Nada Mohammed Ahmed Kheiry, Psychiatrist, Taha Bashar Teaching Hospital
• Psych Central.com
• History Taking & Risk Assessment and Mental State Examination, Dr. Sian Hughes, University of Bristol
• Cleveland Clinic
• Nurseslabs.com
• Osama Jamal notes, Medical student, AlNeelain university
• Rhesus Medicine channel on YouTube
• Some previous psychiatric Exams of AlNeelain university and another Sudanese universities.
• The American Psychiatric Association (APA)
• Royal College of Psychiatrists
• Ashford and St. Peter’s Hospitals NHS Foundation Trust
• Science photo library

.. ‫مت حبمد اهلل وتوفيقه‬

ّ‫دعواتكم يل ولوالدَي‬
‫مصعب عماد املبيض‬
‫م‬2022

78
PSYCHIATRY NOTES For Medical Students | Mosab Emad Mubayed | AlNeelain University | 2022