Psychiatry Revision 1 PDF

Psychiatry Revision 1 01 1 PSYCHIATRY REVISION 1 ----- Active space ----- Psychosis 00:00:28 Neurotic vs Psychotic Illn...

Psychiatry Revision 1 01 1 PSYCHIATRY REVISION 1 ----- Active space ----- Psychosis 00:00:28 Neurotic vs Psychotic Illness : Neurotic illness JIPR Psychotic illness Judgement Insight + Personality -/↓ Reality contact Psychotic symptoms : Delusions. Aimless wandering. Hallucinations. Talking/smiling/muttering to self. Disorganized speech/behavior/ Catatonia. thoughts. Delusions : False fixed beliefs. Note : Ideas are false Persecutory delusions (M/C). fluctuating beliefs Grandiose delusions. Referential delusions. Othello syndrome : Delusion of infidelity, aka delusional jealousy, commonly seen in chronic alcoholics. Magnan syndrome : Delusion of persecution + tactile hallucinations. Aka cocaine bugs/cocaine psychosis/formication. De Clerambault syndrome : Delusion of love/erotomania. Cotard syndrome : Severe depression + nihilistic delusions. Delusion of misidentification : Negative Positive Capras syndrome Fregoli syndrome (Delusion of doubles) E.g: Misidentifying one’s E.g: Misidentifying a stranger spouse as a stranger. as one’s persecutor. Psychiatry Revision v1.0 Marrow 6.5 2023  2 01 Psychiatry ----- Active space ----- Hallucinations : Perceptions without stimuli. Visual : Organic conditions. Auditory : Schizophrenia. Tactile : Cocaine abuse. True v/s Pseudo-hallucinations : True hallucinations : Arise from outer objective space. Pseudo hallucinations : Arise from inner subjective space. Special hallucinations : Extracampine Functional Reflex hallucinations hallucinations hallucinations Require stimulus Stimulus and Stimulus and hallucinations hallucinations are in Hallucinations are in the same modality. different modalities occur beyond the (Synesthesia). sensory field. E.g. Auditory stimulus E.g. Visual stimulus producing auditory producing auditory hallucinations. hallucinations. Timeline of psychotic disorders : Time period DSM ICD < 1 month Bipolar disorder Acute transient psychosis 1-6 months Schizophreniform illness Schizophrenia > 6 months Schizophrenia First rank symptoms : Eleven symptoms described by Kurt Schneider : 3 auditory hallucinations : 1st, 2nd, 3rd person hallucinations. 3 made phenomena : Made impulse, volition, affect. 3 thought phenomena : Thought insertion, broadcast, withdrawal. Somatic passivity (Delusion of control). Primary delusional experience (Delusional idea/memory/mood/perception). Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 1 01 3 Negative symptoms : 6 A’s ----- Active space ----- Apathy. Avolition. Affective flattening. Attention deficit. Anhedonia : Loss of pleasure from previously pleasurable activities. Alogia : Poverty of thinking/speech. Prognostic factors of Schizophrenia : Good prognostic factors Poor prognostic factors Acute onset. Insidious onset. Late onset. Early onset. Female sex. Male sex. Positive symptoms. Negative symptoms. Presence of a stressor. History of perinatal trauma/ Affective/mood symptoms. personality issues. Family support. History of aggression/hospital Compliance with medication. admission. Family history of mood disorder. Substance abuse. Family history of schizophrenia. Delusional disorder vs Schizophrenia : Delusional disorder Schizophrenia DSM 1 month. 1 month. Duration ICD 3 months. 6 months. Predominately Delusions + multiple Symptoms delusions. psychopathologies. Delusions Simple. Complex/bizzare. Vegetative Mostly normal. Mostly affected. symptoms Functionality Mostly normal. Mostly affected. Psychiatry Revision v1.0 Marrow 6.5 2023  4 01 Psychiatry ----- Active space ----- Clozapine : Most effective anti-psychotic drug. Least extra-pyramidal side effects. Used in treatment resistant schizophrenia (Persistence of symptoms despite 2 trials of anti-psychotic drugs). Side effects : Sedation. Weight gain. Maximum among antipsychotics Dyslipidemia. Hyperglycemia. Sialorrhoea. Reduced seizure threshold. Myocarditis. Life-threatening Agranulocytosis. Monitoring for agranulocytosis : Blood tests are conducted as follows : 1st 6 months : Weekly. Next 6 months : Fortnightly. After 1 year : Monthly. Extra pyramidal side effects 00:20:55 Dopaminergic pathways : Mesocortical : Negative symptoms. Mesolimbic : Positive symptoms. Tuberoinfundibular : Regulates prolactin levels. Nigrostriatal : Extrapyramidal symptoms. Acute EPS : Akathesia : M/C EPS. Occurs within 1-2 weeks of anti-psychotic exposure. Inner restlessness. Lower limb movements. DOC : Propranolol. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 1 01 5 Acute dystonia : ----- Active space ----- Occulogyric crisis can occur. Rx : Injectable anticholinergics or antihistaminics. Chronic EPS : Tardive dyskinesia and dystonia Rx : VMAT2 inhibitors like valbenazine, tetrabenazine and deutetrabenazine. Lethal EPS : Acute laryngeal dystonia. Neuroleptic malignant syndrome : Triad : Fever, delirium and lead pipe rigidity. Tests : ↑TWBC, ↑CPK, and ↑myoglobinuria (Suggests renal failure). DOC : Dantrolene sodium. Other Rx options : Bromocriptine, amantidine and ECT. Mood disorders 00:26:18 Typical Depression : Diagnosis of depression : ≥ 2 weeks of 5/9 symptoms. Core symptoms : 2/3 should be present (EMI). 1. Reduced energy. 2. Reduced mood. 3. Reduced interest (Anhedonia). Other symptoms : 4. Pathological guilt. 5. Sleep problems (Insomnia). 6. Concentration issues. 7. Reduced appetite. 8. Pyschomotor changes. 9. Suicidal ideas. Beck’s cognitive triad of depression : Hopelessness. Helplessness. Worthlessness. Psychiatry Revision v1.0 Marrow 6.5 2023  6 01 Psychiatry ----- Active space ----- Atypical depression : Increased sleep. Interpersonal sensitivity. Increased carbohydrate craving. Preserved reactivity. Increased weight. Poor response to TCAs. Leaden paralysis. Respond to MAO inhibitors/SSRIs. Resistant depression : Seen in 10-20% of patients with depression. Rx : Combination of antidepressants (Monitor for serotonin syndrome). Low dose of anti-psychotics/lithium/thyroxine/folic acid (Augment the effect of anti-depressants). Electroconvulsive therapy (ECT). Repetitive transmagnetic stimulation (rTMS). Vagus nerve stimulation. Light therapy : TOC in seasonal affective disorder. Esketamine nasal spray. Antidepressants for depression : Selective serotonin reuptake inhibitors (SSRIs) : S/E : GI disturbances : Nausea, vomiting, and diarrhoea. Sleep disturbances : Insomnia, sedation, and vivid dreams. Sexual dysfunction : Decreased libido, erectile dysfunction, delayed ejaculation, and anorgasmia (in women). Drugs : Buproprion (NDRI : NE + dopamine reuptake inhibitor) : Least sexual S/E (D/t no 5-HT action). Trazadone : Priapism. Paroxetine : Maximum withdrawal symptoms. Fluoxetine : Least withdrawal symptoms. Selective norepinephrine reuptake inhibitors (SNRIs) : Dual acting antidepressants (↑5-HT and NE). S/E : Hypertension d/t ↑NE. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 1 01 7 Suicide : ----- Active space ----- M/C mode : Hanging. Suicide rate : 11.3/1 lakh population. Suicides/year in India: 1,60,000. Risk factors : Male >> females. Unemployment. Mental illness : a. Mood disorders → 15%. b. Schizophrenia → 10-12%. c. Substance use disorder. d. Anorexia nervosa. 10% e. Borderline personality disorder. Access to means + methods. Past attempt. Hopelessness. Rx : ECT. Ketamine : Temporary relief. Lithium. Reduce suicide risk on long-term use Clozapine. Note : Drugs to be avoided in suicidal patients : TCAs. Rx for TCA overdose : Sodium bicarbonate. Bipolar disorder : 00:40:20 Type I : Mania ± Depression ± Hypomania episodes. Type II : Hypomania + Depression. Management of bipolar disorder : Mania/depression : Lithium. ECT in severe disorder. Mania : Valproate. Carbamazepine. Anti-psychotics : DOC in acute mania. Psychiatry Revision v1.0 Marrow 6.5 2023  8 01 Psychiatry ----- Active space ----- Depression : Lamotrigine. Antidepressants under cover of mood-stabilizers. Antipsychotics : a. Quetiapine (M/C used). b. Lurasidone. c. Lumateperone. d. Cariprazine. e. Olanzapine + Fluoxetine. Mood-stabilizers : given as Maintenance drugs. Lithium. Lamotrigine : Safest mood-stabilizer in pregnancy. Valproate. Carbamazepine. Persistent mood disorders : Duration of symptoms > 2 years. Disorder Pattern Dysthymia : Continuous low mood Cyclothymia : Hypomania + Low mood Double depression : Depressive episodes on top of dysthymia. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 1 01 9 Rapid cycling disorders : ----- Active space ----- Bipolar disorder with ≥ 4 episodes/year. Risk factors : Female gender. Bipolar disorder type II. Hypothyroidism. Cylothymia. Substance use disorder. Hyperthymic personality. Use of antidepressants without cover of mood-stabilizers. DOC : Valproate/divalproate. Post partum mental illnesses 00:48:00 Post-partum period : Duration following delivery : ICD : 6 weeks. DSM : 4 weeks. Types : Post partum Post partum Post partum blues psychosis depression Within 2-3 days Around 2 weeks Around 2-4 weeks Onset and resolves within after delivery. after delivery. 2 weeks. Incidence 50 % 0.1 % 5-15 % Abrupt. Acting out (+). Symptoms of Remarks Benign/self-limiting Thoughts of depression (+). harming baby (+). Rx : SSRI of choice : Sertraline. SSRIs to be avoided : Fluoxetine, paroxetine. Brexenalone : Specific for post-partum depression. Route of administration : I/v infusion over 60 hours. Psychiatry Revision v1.0 Marrow 6.5 2023  10 02 Psychiatry ----- Active space ----- PSYCHIATRY REVISION 2 Stress, trauma & anxiety disorders 00:00:18 Stress Burnout Life event Test of resources/skill D : Detachment. Changes the course of sets (E.g. : Exams). I : Ineffective- life. Forces a reaction/re- ness. Needs a causative sponse. E : Exhaustion. factor : Based on the intensity, 1. Grief reaction. duration & nature : Nor- 2. Adjustment disorder. mal or abnormal. 3. Acute stress disorder. 4. PTSD (Post-traumatic stress disorder). Grief reaction : Different stages of grief reaction given by Kubler Ross : DABDA. Can occur in any order. D : Denial. A : Anger. B : Bargaining. D : Depression. A : Acceptance. Pathological grief reaction : Types Features Absent grief No reaction. Hypertrophic grief Too much emotion. Persistence of grief for > 6 months (ICD) or Chronic grief > 1 year (DSM) Traumatic grief Hypertrophic grief + Chronic grief. Delayed grief Reaction after 2 weeks. Remember the person on every anniversary Anniversary grief of an event. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 2 02 11 Other life events : ----- Active space ----- Acute stress disorder. Adjustment disorder. PTSD (Post traumatic stress disorder) Duration. < 1 month. Starts within 3 ≥ 4 weeks. months of the life Late onset PTSD : Starts event & lasts a after 6 months of life maximum of up to 6 event. months. Symptoms Stress reaction : Mild depression Hyperarousal. a. Hyperarousal. & anxiety. Nightmares. b. ↑ autonomic Conduct behav- Flashbacks. activity. iors (Stealing, Avoidance behavior. c. ↑ vigilance. telling lies). Aka situational depression. Acute stress disorder Complex PTSD : Seen in continuous/repetitive trauma. Adjustment disorder Features : PTSD 1. Negative self-concept. 2. Interpersonal issues. 3. Emotional dysregulation. 1 month 6 month Life event Rx of PTSD : Specific : EMDR (Eye movement desensitization & reprocessing therapy). Best : CBT (Cognitive behavioral therapy). Anxiety disorders : GAD (Generalized Panic disorder Phobia anxiety disorder) Free floating anxiety. Recurrent denovo 2 types : Constant worrying. panic attacks. Generalized : Social anxiety, Impending doom social phobia. : Present in an Specific : Blood injection/ emergency room Animal/Natural environmen- (Extreme fear of tal/Situational/Others. dying, collapsing). Psychiatry Revision v1.0 Marrow 6.5 2023  12 02 Psychiatry ----- Active space ----- Rx : Pharmacotherapy : a. Low dose SSRIs. b. Benzodiazepines (Cautious use). c. Buspirone : 5-HT1A partial agonist. Anxiolytic. No sedation & addictive effect. Behavioral therapy : a. JPMR (Jacobson progressive muscle relaxation technique). b. MBSRT (Mindfulness based stress reduction technique). c. Deep breathing (Diaphragmatic breathing). d. Specific for phobia : 1. Flooding : One shot exposure of the stimuli for hours. 2. Systematic desensitization : Graded exposure to the avulsive stimuli. Somatic symptoms, OCD & dissociation disorders 00:16:04 Alexithymia : Inability to label one’s own emotions. Defense mechanisms in stress : 1. Somatization. 2. Dissociation. 3. Conversion. Somatic symptom disorder (DSM)/bodily distress disorder (ICD) : Aka somatoform/somatization disorder/briquet syndrome. Duration : > 6 months. Predisposing factor : Many stressors. Presentation : Multiple complaints (Eg : Body pains). Multi-system involvement (CVS, GIT, neurological complaints, etc). Multiple investigations (Usually normal). Multiple consultations. Rx : Reattribution therapy, Antidepressants + anxiolytics. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 2 02 13 Factitious disorder (Munchausen syndrome/doctor shoppers) : ----- Active space ----- Deliberately create symptoms for no apparent reason (No secondary gain). Pseudologica fantastica : Excessive lies. Peregrination : Travel long distances for medical attention. Grid abdomen : Multiple scars on the abdomen d/t multiple Surgeries. Munchausen syndrome/factitious disorder by proxy : An adult brings a child or a dependant person. Note : Malingering is conscious production of symptoms for secondary gain (like leave compensation etc). Illness anxiety disorder/hypochondriasis : Previously called medical student syndrome. Duration : > 6 months. C/F : Preoccupation about having a serious illness like cancer, TB, etc. Exaggerated fear. Body dysmorphic disorder/dysmorphophobia : Preoccupied with body shape, size, & color. Obsessive-compulsive & related disorders : These include : O2B2H2 (mnemonic). O : OCD. O : Olfactory reference syndrome. B : Body dysmorphic disorder. B : Bodily focused repetitive behavior disorder. H : Hoarding disorder. H : Hypochondriasis. OCD (Obsessive-compulsive disorder) : Egodystonic obsessions & compulsions : Repeated unwanted thoughts & actions. M/C obsession : Mysophobia (Fear of contamination by dirt/germs). M/C compulsions : Hand washing. Rx : Pharmacotherapy : a. Two trials of SSRIs. b. When SSRIs fail → Clomipramine (Tricyclic antidepressant/TCA). S/E of Clomipramine : TCA toxicity. Psychiatry Revision v1.0 Marrow 6.5 2023  14 02 Psychiatry ----- Active space ----- Rx of TCA toxicity : NaHCO3. Behavior strategy : Exposure & response prevention → Desensitization & habituation to high levels of stress & anxiety. Bodily focused repetitive behavior disorder : Trichotillomania Dermatotillomania Compulsive hair pulling (M/C : Scalp hair). Compulsive skin picking. M/C in females. Trichophagia → trichobezoar. Rx : Habit reversal technique (HRT). Dissociative disorders : Defense mechanism : Disassociation/dissociation. Types : 1. Dissociative Amnesia : Circumscribed loss of traumatic memory (Forgets a particular component of memory). 2. Dissociative Fugue : a. Primary identity lost. b. Purposeful wandering. 3. Dissociative Identity disorder : Previously called as multiple personality disorder. 4. Dissociative neurological symptom disorder : a. Known as conversion disorder (ICD). b. known as functional neurological symptom disorder (DSM5 : type of somatic symptom disorder). c. Present with bizarre unexplainable neurological symptoms : Can be motor, sensory or gait disturbances (Astasia abasia). Labelle indifference : Mood is indifferent to the level of presentation. Seen in dissociative disorders. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 2 02 15 Eating disorders 00:30:41 ----- Active space ----- Anorexia nervosa Bulimia nervosa Binge eating disorder Age group. Early adolescence. Late adolescence. Young adults. Presentation. Fear of weight gain. Binge eating & purg- M/C eating disorder. Distorted body image. ing. Binge eating : < 15% of ideal body weight. No fear of eating Beyond fullness. 2 types : food. Isolation. 1. Restrictive. Not hungry. 2. Binge purge. Guilty. Eating rapidly. BMI Low (< 18.5). Normal. High. Complications of Anorexia nervosa : Complications of Bulimia 1. Medical comorbidities (CVS/ nervosa : endocrinological). 1. Mallory weiss syndrome 2. Lanugo hair. (Lower esophageal tear). 3. Hyperprolactinemia → Amenorrhea. 2. Retching. 4. 10% risk of suicide. 3. Russell’s sign : Calluses 5. Refeeding syndrome → ↑sed calorie & pigmentation on the intake during Rx → ↓PO43-, ↓K+, ↓Mg2+. dorsum of the hand d/t purging. Sleep & sleep related disorders 00:35:56 Stages of sleep : Stages Duration Features N1 5% (Least duration) Theta waves in EEG. Microsleep. Hypnic (Myoclonic) jerks seen. N2 45% (Maximum) K-complexes : a. Biphasic b. Low frequency & high voltage waves. Sleep spindles : a. Burst of alpha rhythm (7 to 14 Hz). b. High frequency & low voltage. N3 25% Delta waves. Maximum threshold to awake. Delta/restorative sleep. REM sleep 25% Saw-tooth appearance in EEG. Paradoxical sleep. Psychiatry Revision v1.0 Marrow 6.5 2023  16 02 Psychiatry ----- Active space ----- Beta waves in EEG : When eyes are open. Alpha waves in EEG : Closed eyes & focussed. Night terrors Vs nightmares : Both are examples of parasomnia. Night terrors/pavor nocturnus. Nightmares. Adolescents & young children Any age. N3 stage of sleep REM sleep. Amnesia Remembered. Autonomic arousal (tachycardia, tremors) Not seen. Post-arousal confusion Narcolepsy : Day time Type of dyssomnia. Pathology : ↓sed orexin/hypocretin. Hypnagogic C/F : Daytime sleep attacks. Hypnopompic ↓sed sleep latency & REM latency. REM REM SOREM can also occur (Sleep onset REM). Hypnogogic & hypnopompic hallucinations. Cataplexy : Loss of muscle tone in emotional situations & collapse on the floor. Note : Catalepsy is seen in catatonia. Rx : Modafinil (Dopamine reuptake inhibitor) Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 2 02 17 Rx of insomnia : ----- Active space ----- 1. Benzodiazepines. Smallest doses & the shortest duration Clonazepam >> alprazolam (Short acting → rebound anxiety & insomnia). 2. Z-class drugs. Site of action : α1 subunit of GABAA recep- tors (Preferred over BZDs). Drugs : Zolpidem. Zaleplon (Shortest acting). Zopiclone (Longest acting). 3. Melatonin (M1/M2) agonists : Melatonin released by pineal gland Maintains circadian rhythm. Drugs : Ramelteon (Shorter). Tasimelteon. 4. DORAs (Dual acting orexin re- Drugs : ceptor antagonists). Suvorexant. Doridorexant. Sexual cycle & related disorders. 00:46:07 Sexual response cycle : DEOR. Desire → Excitement → Plateau → Orgasm → Resolution. Erectile dysfunction & premature ejaculation : Erectile dysfunction. Premature ejaculation. Phase Excitement phase. Orgasm phase. Rx PDE 5 inhibitors : SSRIs (Delays ejaculation) : a. Tadalafil Paroxetine & dapoxetine. b. Vardenafil 3S : c. Sildenafil. Squeeze technique (Master’s & PGE analogue : Alprostadil. Johnson’s). Start stop technique. Sensate focusing. Psychiatry Revision v1.0 Marrow 6.5 2023  18 02 Psychiatry ----- Active space ----- Sexual paraphilias : Disorder Feature Fetishism Sexual arousal by touching inanimate objects. Touching/rubbing one’s genitalia to nonconsenting Frotteurism individuals. Exhibitionism Expose oneself/undress. Voyeurism Peeping tom (Diagnosed only after 18 years of age). Pedophilia Sexual activity with prepubescent children. Transvestic fetishism Cross dressing for sexual arousal. Nymphomaniac ↑sed sexual desire in females Satyriasis ↑sed sexual desire in males Note : Cross dressing In gender dysphoria/gender incongruence : a. To align with the gender they identify with. b. Not for sexual arousal purposes. Culture bound syndromes : Dhat syndrome : Preoccupation with semen discharge. Koro syndrome : Preoccupation with shrinking/disappearing penis. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 3 03 19 PSYCHIATRY REVISION 3 ----- Active space ----- Neurocognitive disorders 00:00:15 Old name : Organic mental illness. M/c type of hallucinations in neurocognitive disorders : Visual. Delirium : M/c type of neurocognitive disorder. Features (Mnemonic : AAASSS) Acute (Emergency). Altered sensorium. Autonomic dysfunction. Sleep reversal. Sundowning. Slowing of waves in EEG (Generalized slowing). MMSE : Mini Mental State Examination (For delirium & dementia). ≤24/30 : Significant brain dysfunction. Dementia : Major neurocognitive disorder (Activities of daily living impaired). Chronic, progressive and degenerative condition. For diagnosis : Symptoms ≥6 months. Alzheimer’s disease : Cortical type of dementia. Temporoparietal areas are affected. Visuospatial deficits are common. Sex : Females > Males. Risk factors for Alzheimer’s disease : Age ≥65 years. Lower education status. Diabetes. Down’s syndrome. Hypertension. Apolipoprotein E4. Dyslipidemia. Presenilin 1 and 2 (Familial autosomal dominant alzheimers, ≥50 yrs). Psychiatry Revision v1.0 Marrow 6.5 2023  20 03 Psychiatry ----- Active space ----- Low acetylcholine levels in the nucleus of Meynert and nucleus basalis. Extracellular accumulation : Beta-amyloids. Intracellular accumulation : Phosphorylated tau proteins. Management : Acetylcholine esterase inhibitors : Galantamine. Rivastigmine. Donepezil. NMDA antagonist : Memantine. Monoclonal antibodies : Aducanumab, Lecanemab (Remove amyloid deposits). Frontotemporal dementia/Pick’s disease : Frontal and temporal lobes affected. Frontal lobe symptoms : Echolalia. Echopraxia. Perseveration. Personality changes. Social incontinence. Lewy body dementia : Caused due to intracellular accumulation of alpha-synuclein. Fluctuating course of symptoms. Prominent visual hallucinations. Extreme sensitivity to anti psychotics. Huntington’s chorea : Autosomal dominant. CAG trinucleotide repeats. Chromosome 4 is affected. GABAergic neurons are affected in the caudate nucleus. Seen in the 4th decade. Dementia is seen. Normal pressure hydrocephalus : Triad of dementia + urinary incontinence + magnetic/apraxic gait. Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 3 03 21 Dependence and alcohol withdrawal 00:11:00 ----- Active space ----- Craving. Withdrawal. Control is lost. Salience. Tolerance. Knowledge of harmful use. Reverse tolerance : Also known as sensitization/hypersensitization. Genetic vulnerability : Even a small dose of substance induce psychosis. E.g : Cocaine. Alcohol withdrawal : Simple withdrawal Complex withdrawal Seen within 12-24 hours. Within 48 hours : Seizures (GTCS, Features : clusters of seizures). Tremors. Tachycardia. Within 72 hours : Delirium tremens. Increased sweating. Prominent visual hallucinations. Insomnia. Lilliputian hallucinations (seeing all Night tremors. things small). Rebound REM phenomenon : Altered sensorium. Alcohol : REM suppressant. Tremors. On stopping alcohol → Rebound REM. Treatment : DOC : Benzodiazepines. Safe in liver dysfunction (Mnemonic → LOT) : Lorazepam, Oxazepam, Temazepam. Alcohol related psychosis : 1. Delirium tremens. 2. Alcoholic hallucinosis : Occurs in clear sensorium. Auditory hallucinations (common). 3. Korsakoff’s psychosis (Mnemonic → CCA) : Chronic. Confabulation (filling of gaps in memory). Anterograde amnesia. Areas affected in Korsakoff’s psychosis : Mammillary nuclei, anterior thalamic nuclei. Psychiatry Revision v1.0 Marrow 6.5 2023  22 03 Psychiatry ----- Active space ----- Wernicke’s encephalopathy (Mnemonic → GOA) : Acute (Emergency) condition. Petechial hemorrhages in the mammillary bodies and periaquedectal grey matter areas. Global confusion. Ophthalmoplegia. Ataxia. Aversive drugs : Disulfiram : Irreversible aldehyde dehydrogenase inhibitor. Increases the levels of aldehydes, serotonin, dopamine and histamine. If taken with alcohol, it causes disulfiram ethanol reaction. It should be given 12-24 hours after stopping alcohol. Indicated only for patients who are willing to quit and have good motivation. It is avoided in peripheral neuropathy and psychosis. Anti craving drugs for alcohol cessation : Acamprosate. SSRIs. Naltrexone. Ondansetron. Topiramate. Baclofen. Anti craving drugs for nicotine cessation : Varenicline (α 4 β 2 partial agonist) : Best drug. Avoided in neuropsychiatric symptoms (suicidal ideas, severe depression, etc). Bupropion. Opioid poisoning and dependence 00:20:35 C/F : Unconsciousness + respiratory depression + pinpoint pupils. DOC of opioid poisoning : Naloxone (i.v/nasal spray). Management of opioid dependence : Methadone : Long acting agonist, has abuse potential. Buprenorphine : Partial agonist, has less abuse potential. Naltrexone : Opioid antagonist, can be used for long term maintenance (oral form & depot preparation). Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 3 03 23 Personality disorders 00:23:10 ----- Active space ----- Big 5 personality factors : OCEAN. Openness. Conscientiousness. Extraversion. Agreeableness. Neuroticism. Clusters of personality disorders (PD) : Cluster A Cluster B Cluster C Odd & eccentric. Emotional, dramatic & erratic. Anxious and fearful. Paranoid PD. Borderline PD. OCPD (obsessive compulsive PD) Schizoid PD. Histrionic PD. /Anankastic PD. Schizotypal PD. Narcissistic PD. Dependant PD. Antisocial PD. Anxious avoidant PD. Borderline personality disorder : Also known as emotionally unstable personality disorder. Thoughts : See things as extreme → Splitting/Black & white thinking/ All or none thinking/Dichotomous thinking. Parasuicide/deliberate self harm/non suicidal self injurious behavior (NSSI) +. M/c type of NSSI : Slashing the wrist. More prone to develop bipolar disorder. Rx : Dialectical Behavioral Therapy (DBT). Mind and Defense Mechanisms 00:28:00 Defense mechanisms are produced by ego. Mature defense mechanisms : (Mnemonic → HAAASS) Humor. Anticipation. Altruism. Ascetism. Suppression (Conscious defense mechanism). Sublimation. Psychiatry Revision v1.0 Marrow 6.5 2023  24 03 Psychiatry ----- Active space ----- Topographical theory Structural theory Mind is divided into : Mind is divided into : Conscious. Id : completely in unconscious part of mind. Preconscious. Ego. In all 3 aspects of mind Unconscious. Super ego. Defense mechanisms in some disorders : Disorder Defense mechanisms Undoing. 1. Obsessive compulsive disorder Reaction formation. Isolation. Projection. 2. Phobia Avoidance. Displacement. Projection. 3. Psychotic defenses Denial. Distortion. List of therapies and their uses 00:33:08 Disorder Therapies CBT (Cognitive behavioral therapy). Depression IBT (Interpersonal psychotherapy). SFT (Solution focussed therapy). Bipolar disorder IPSRT (Interpersonal social rhythm therapy). Relaxation techniques : JPMR (Jacobson progressive muscle relaxation technique). Stress/ Anxiety MBSRT (Mindfulness based stress reduction technique). Deep breathing/diaphragmatic breathing. Guided imagery. Systematic desensitization. Phobia Flooding. OCD ERP (Exposure response prevention). Trichotillomania/ HRT (Habit reversal technique). dermatotillomania PTSD EMDR (Eye movement desensitization therapy). Psychiatry Revision v1.0 Marrow 6.5 2023  Psychiatry Revision 3 03 25 Important concepts in doctor-patient relationship 00:35:10 ----- Active space ----- Transference : Feelings of patient towards the professional. It can be positive or negative. Counter transference : Feelings of professional towards the patient. It can be positive or negative. Catharsis : Patient ventilates/share/process when talking in therapy sessions. Patient feels comfortable and safer when sharing. Abreaction : Unexpected emotional outburst. Mental Health Care Act, 2017 00:37:15 1. Decriminalization of suicide by section 115 of mental health care act. 2. Advanced directive : Registered document with the Mental Health Review Board (MHRB) which contains three components : a. How you want to be treated? b. How you don’t want to be treated? c. Who is your nominated representative ? (An adult who is nominated on behalf of the patient to take decisions for him/her when capacity of thinking is lost). The directive is activated only when the thinking capacity of patient is lost. 3. All admissions in mental health establishment (MHE) should be informed to the MHRB within 72 hours if the patient is a minor or female and within 7 days if patient is a male. 4. Emergency Rx : Any hospital, which is not a mental health establishment can admit and treat a psychiatric patient maximum upto 72 hours. Psychiatry Revision v1.0 Marrow 6.5 2023