PSCHIATRY.pdf

s t 1|Page 1 June 2024 NEET special PSYCHIATRY REVISION (PDF 1) Chapter 1 : GENERAL PSYCHIAT...

s t 1|Page 1 June 2024 NEET special PSYCHIATRY REVISION (PDF 1) Chapter 1 : GENERAL PSYCHIATRY HIGH YIELD CHART 1 (Asked in NEET) DISORDERS OF PERCEPTION Illusions Hallucinations (PAREIDOLIA) MC : Auditory, 3rd person, running commentary Reflex hallucinations: Synaesthesia (LSD) FUNCTIONAL DISORDER ORGANIC DISORDERQ Auditory hallucination Visual hallucinations Acute onset, Younger age Gradual onset, Older age Terminologies to remember: Affective flattening: No expressions (Schizophrenia) Apathy: No emotions Anhedonia: No pleasure Alexithymia: Can’t describe feelings in words Labile affect : Fluctuating expressions (Bipolar) Cognitive function testing: Screening test for DEMENTIA: MMSE (6 m duration), Schizophreniform disorder (1-6 months), Brief psychotic disorder/acute psychosis ( chlorpromazine : Dryness of mouth, Blurring of vision, Constipation, Urinary retention, Delirium (Especially frequent in the elderly) 3. Cardiac side effects : Postural hypotension (autonomic) : Maximum with chlorpromazine 4. Sexual side effects : Inhibition of ejaculation (alpha) and decreased libido (dopamine) 5. Prolactin elevation : Causes amenorrhoea, galactorrhoea (due to D2 blockage) infertility 6. Metabolic side effects : More with atypical (pines > dones) The next 2 charts about drugs are extremely important….  n d 2|Page 2 June 2024 NEET special PSYCHIATRY REVISION (PDF 2) Typical antipsychotics Atypical antipsychotics Primary action D2 receptor blockade D2 AND 5HT2A AND 5HT2C Relieve Only positive symptoms of Positive symptoms, schizophrenia negative symptoms Extrapyramidal reactions More prominent Less prominent and hyperprolactinemia Metabolic complication Less prominent More prominent (5HT2C) EXTRA PYRAMIDAL SIDE EFFECTS OF ANTIPSYCHOTICS Diagnosis Clinical Features Treatment Acute Muscular Torticollis Inj: Promethazine dystonia Oculogyric crisis Diphenhydramine Sudden abnormal posture Parkinson disease Resting tremors Centrally acting anticholinergics Rigidity Benzhexol, Biperidine Bradykinesia Benztropine, Procyclidine Akathisia Anxiety like, urge to move Propranolol (DOC) Most common Subjective Restlessness Aggravated by smoking Tardive dyskinesia Several months to years Valbenazine (DOC) Last to develop Orofacial Tetrabenazine Permanent symptom Abnormal facial movements Clozapine Neurolept malignant Hyperthermia, Severe rigidity, raised Dantrolene (DOC) syndrome (LETHAL) CPK, altered sensorium, autonomic Bromocriptine (specific drug) instability NEW antipsychotics: 1. CARIPRAZINE 2. Brexpiprazole 3. Lurasidone 4. Iloperidone 5. Luamteperone 6. Blonanserin @dr.sachin_damspsy (Instagram)  r d 1|Page 3 June 2024 NEET special PSYCHIATRY REVISION (PDF 3) DEPRESSION/Major Depressive disorder Neurotransmitters : Serotonin (Most imp) , norepi, dopamine decreased Minimum duration : 2 weeks (SIGECAPSS criteria for diagnosis) More than 2 year duration is DYSTHYMIA (Neurotic depression) Usually depression has decreased sleep, decreased appetite and weight loss but atypical depression has reversal of these vegetative symptoms. COTARD’s syndrome: Severe depression with psychotic symptoms (mood congruent delusion of nihilism) and suicide provoking auditory hallucinations (NEET PG) Maximum chances of suicide: Depression in early recovery (involution) Disorder Onset Symptoms Treatment Postpartum blues or Immediately after birth Sadness < 2 weeks, Supportive, usually self- “baby blues” (MC) up to 2 weeks mood lability (MC) limited Postpartum depression Within 1-3 months after Low mood > 2 weeks, Antidepressant birth (usually within 4 GUILT, Anhedonia, Rarely ECT may be weeks of delivery) Suicide attempt needed Postpartum psychosis Within 2-3 weeks after Depression, delusions Antipsychotic and (HIGH RECURRENCE) birth against newborn and antidepressants, thoughts of harm Mother to child (INFANTICIDE) separation Cognitive triad: Negative views of self (worthlessness), environment (helplessness) and future (hopelessness) Treatment: Antidepressants (SSRI, SNRI, NDRI, TCA) and CBT(psychotherapy of choice), ECT(depression with suicidal tendencies) SSRI MC side effect: Upper GI dysfunction SSRI MC long term side effect: Sexual dysfunction (anorgasmia) TCA side effects: Anticholinergic syndrome, toxic in overdose(ECG changes), antidote : Sodium bicarbonate NDRI: Bupropion, used in smoking cessation, side effect : seizure Newer treatment in depression: rTMS, VNS, DBS Insta: dr.sachin_damspsy  t h 1|Page 4 June 2024 NEET special PSYCHIATRY REVISION (PDF 4) Mania Minimum duration needed to diagnose: 7 days (DIGFAST criteria) + euphoria/dysphoria. Hypomania doesn’t have delusion of grandiosity, no admission is needed and duration for diagnosis is 4 days. Endoxifen is protein kinase C inhibitor, new drug in MANIA Bipolar disorders: Bipolar 1: Mania and Depression Bipolar 2: Hypomania and Depression Cyclothymia: Hypomania and subsyndromal depression for 2 years Rapid cyclers: 4 episodes in 1 year Treatment Disorder Treatment Bipolar in mania Antimanics Bipolar in depression Antidepressant + Mood stablizers Bipolar in normal Mood stablizers (make sure to see the DOC table shared today on whatsapp group and telegram group) Lithium: Blood levels therapeutic: 0.6-1.2 Meq/L, Adverse effects: Polyuria, polydipsia, diabetes insipidus, T-wave changes (ecg), hypothyroidism, acne, rash, fine tremors(MC) Toxicity: (>1.5 meq/l) CNS toxicity (Coarse tremors, seizures, increased DTR, confusion), Nephrotoxic(Kidney failure) Valproate: Blood levels therapeutic: 50-150 microgram/ml Adverse effects: weight gain, alopecia, tremors, PCOD, raised hepatic transaminases Rare side effects: Agranulocytosis, pancreatitis, thrombocytopenia, hyperammonemia Insta: dr.sachin_damspsy  t h 1|Page 5 June 2024 NEET special PSYCHIATRY REVISION (PDF 5) Anxiety disorders 1. GAD: Free floating anxiety, continuous 2. Panic disorder: Episodic attacks, feeling of impending doom 3. Phobia: Episodic, panic like acute anxiety with a stimulus ▪ Agoraphobia: Fear of open, crowded, closed ▪ Social phobia: Fear of socially demanding situations eg: stage ▪ Specific phobia: fear of 1 specific situation eg: claustrophobia (closed) Treatment of phobia: Systemic desensitization(graded exposure + relaxation) DOC Panic attack: BZD and DOC Panic disorder: SSRI OCD and related disorders 1. OCD DOC is SSRI, but most effective is clomipramine, and augmenting agent in resistant OCD is Risperidone, therapy of choice is ERP (exposure and response prevention) 2. Body dysmorphic disorder Preoccupied with imagined defect in a part of body(shape or appearance) 3. Trichotillomania (hair pulling disorder): Treatment- Habit reversal Trauma and stress related disorders 1. After a major life threatening trauma(sudden), if symptom triad of HIA(hyperarousal, intrusiveness and avoidance) comes its PTSD(if duration more than 1 month) or acute stress disorder(if duration is less than 1 month). Therapy of choice in PTSD: CBT, New therapy is EMDR 2. After a mild-moderate routine life stressful event(Gradual), if mild moderate depressive or anxiety symptoms present, its adjustment disorder, provided that the onset of symptoms is with in 1 month(ICD) or 3 months(DSM) of stress and symptoms must improve in 6 months of removal of stress. Therapy of choice: Supportive psychotherapy(teach coping skills) Insta: dr.sachin_damspsy  t h 1|Page 6 June 2024 NEET special PSYCHIATRY REVISION (PDF 6) 1. Disruptive, impulse control and conduct disorders a. Kleptomania (irrestible impulse to steel) b. Pyromania (to set fire) c. Intermittent explosive disorder (anger outbursts) d. ODD (oppositional defiant disorder) e. CD (Conduct disorder) 2. Somatoform disorders Somatization disorder Somatoform pain disorder Hypochondriasis Multiple symptoms eg: pains, GI Only pain symptom of 1 location Preoccupied with having a symptoms, Sexual, of long duration severe life threatening medical Pseudoneurological etc diagnosis 3. CONVERSION DISORDER/HYSTERIA: Stressful event (quarrel etc) > Psychic conflict in unconscious mind > Bodily symptoms (sensorimotor neurological) eg: aphonia, blindness, pseudo-seizure, pseudo-paralysis etc PRIMARY GAIN (unconscious) SECONDARY GAIN (conscious) Production of symptoms leads to reduce in anxiety Attendant’s attention enjoyed by patient LA BELLE INDIFFERENCE : Lack of concern (emotional reactivity) about symptoms TRUE SEIZURE (EPILEPSY) PSEUDOSEIZURE (HYSTERIA) In phase movements, injury, incontinence, tongue Out of phase movements, No injury, bite, can occur in sleep incontinence , tongue bite, no attacks in sleep 4. Dissociative disorders Dissociative Amnesia Dissociative Fugue Dissociative Dissociative Depersonalisation (self) & Identity Derealisation (environment) disorder Patchy loss of Memory loss + Travel “As if” phenomenon Change of autobiographical Feelings of detached from self identity memory Reaches a new place or environment, as if external (retrograde amnesia) observer of my own body Presence of 2 Completely Assumes a new identity (Out of self experience) or >2 identities reversible in 1 person Insta: dr.sachin_damspsy  t h 1|Page 7 June 2024 NEET special PSYCHIATRY REVISION (PDF 7) Organic mental disorders DELIRIUM DEMENTIA ACUTE, FLUCTUATING CHRONIC, PROGRESSIVE ALTERED SENSORIUM CLEAR Disoriented to T/P/P Oriented Remote memory Normal Impaired DELIRIUM OTHER FEATURES:- 1. Alteration in sleep wake cycle 2. Sundowning phenomenon: evening worsening of symptoms 3. Flocillation/caprhologia : plucking bed sheets 4. Increased psychomotor activity (restlessness) 5. Autonomic hyperactivity 6. Psychotic symptoms : Fleeting paranoid delusions and transient visual hallucinations 7. Emotional lability 8. Confusional assesment method : scale used (NEET) 9. Neurotransmitter: Ach decreased and dopamine increased Dementia other features: Amnesia + 2 out of 4 (apraxia, agnosia, aphasia, loss of executive functions) BEHAVIOURAL SYMPTOMS: Psychosis, Personality decline, decreased self care, lack of drive, apathy, Catastrophic reaction (sudden agitation) Neurotransmitters : Ach decreased and glutamate increase Anti-Dementia Drugs Acetylcholinesterase inhibitors: donepezil and NMDA antagonists: Memantine Korsakoff amnestic syndrome: Thiamine deficiency Recent memory loss (AG amnesia) + Confabulation (filling gaps in recent memory). Treatment is thiamine parenteral. Insta: dr.sachin_damspsy  t h 1|Page 8 June 2024 NEET special PSYCHIATRY REVISION (PDF 8) SUBSTANCE USE DISORDERS SUBSTANCE WITHDRAWAL Treatment ALCOHOL 1. TREMORS (1st symptom, key BZD is DOC. symptom, most common symptom) Chlordiazepoxide is 2. Autonomic hyperactivity preferred. (Tachycardia, Inc BP) Thiamine to be added to 3. Alcoholic Paranoia (Fixed Delusions) prevent wernicke’s 4. Alcoholic Hallucinosis (Auditory encephalopathy Hallucinations in clear sensorium) In case of seizures, we 5. GTCS (Alcohol Withdrawal Seizures) give diazepam IV + 6. Delirium Tremens (Visual thiamine Hallucinations in altered sensorium) In case of delirium we give IV lorazepam + thiamine OPIUM NO SPECIFIC DOC FOR WITHDRAWL Morphine Mydriasis, rhinorrhea, lachrymation, Codeine YAWNING, sweating, piloerection (goose We can start Smack bumps), COLD TURKEY, diarrhea, muscle OST (Opium substitution therapy) Brown sugar cramps, autonomic hyperactivity. for IV users > 3 months Heroin (IV) BUPRENORPHINE METHADONE NICOTINE Decreased attention and concentration, No specific DOC increased appetite and weight gain, drowsiness with paradoxical trouble sleeping, constipation, irritability, bradycardia. CANNABIS NO SPECIFIC DOC (AMOTIVATIONAL SYNDROME: single use: Decreased appetite and weight loss, low LONG TERM USE CAUSES perception of mood, stomach pain (minimal withdrawal). decrease in drive) slowed time (FLASHBACK) paranoid psychosis (HEMP INSANITY), DRUGS USED IN DEADDICTION: ❖ Alcohol: Disulfiram (aversive therapy), naltrexone and acamprosate (anti-craving) ❖ Opium: Naltrexone ❖ Nicotine: Varenicline and Bupropion Insta: dr.sachin_damspsy  t h 1|Page 9 June 2024 NEET special PSYCHIATRY REVISION (PDF 9) CHILD PSYCHIATRY Attention deficit hyperactivity disorder Hyperactivity, Impulsivity, Attention deficit (HIA triad) Onset 12y Neurosis EGO DEFENSE MECHANISMS: Defense mechanism Definition 1. Denial Denying the reality when it is too painful to be acceptable 2. Projection Attributing one’s own thoughts & feelings to others. 3. Regression Acting childish (going to a previous developmental stage) 4. Acting Out Ventilating your frustrations by actions 5. Introjection Introjection may be of the loved one (to develop ideals and values) or may be of the aggressor (to obliterate or make the object disappear) 6. Rationalization Making excuses and giving explanations for one's mistakes (shortcomings) 7. Repression Unconscious forgetting (Automatic forgetting) 8. Reaction Doing reverse of your unacceptable emotions formation 9. Displacement Ventilating your anger to someone weaker or inferior than you 10. Undoing Making your unwanted thoughts go away by performing actions Mature defense mechanisms: (SAHASA) 1. Suppression (conscious forgetting) 2. Anticipation (all good to happen) 3. Humor (Making fun of all conflicts) 4. Asceticism (rejecting societal comforts) 5. Sublimation: It is the utilisation of inner conflicts in a constructive way. 6. Altruism (self surrender) : Constructive service to others (in order to remove guilt) that brings pleasure and personal satisfaction. Insta: dr.sachin_damspsy