Mission NEET PG / INI CET 1.

5: Psychiatry
“Your Course Completion, Our Responsibility"

Psychiatry

(By Dr. Praveen Tripathi)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

BASICS
• Psychiatry

• History taking

• Informant

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Reliability of informant (5Cs)

• C

• C

• C

• C

• C

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• MSE (Mental Status Examination

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

A. Mood & Affect

1. Quality

a. Elevation of mood

• Euphoria

• Elation (↑PMA)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

b. Dysphoria

c. Depressed mood

2. Fluctuations

a. Labile mood

b. Affective flattening

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• MSE (Mental Status Examination)

B. Perception

1. Illusion

2. Hallucination

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Properties of hallucinations-

a. Occur in the absence of any object/stimulus

b. Are as vivid (detailed/clear) as a real perception

c. Occur in outer and objective space

d. Are not under wilful control

Pseudohallucinations

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

One-liners (m/c)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Specific hallucinations
a.Hypnagogic hallucinations

b. Hypnopompic hallucinations

c. Reflex hallucinations (synesthesia)

d. Phantom limb (somatic hallucination)

e. Third-person auditory hallucinations

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

C. Thought (cognition)

1. Disorders of stream (flow)

a. Flight of Ideas
Thoughts follow each other rapidly,
connection between successive
thoughts appears to be due to chance
factors such as rhyming
I live in Delhi, I like eating jelly,
my cat has a big belly
Mania

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

b. Circumstantiality

c. Perseveration: Repetition of the same

response beyond the point of relevance.

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

2. Disorders of form

What is form?
Thought 1: My name is Praveen & I am a Psychiatrist

Thought 2: I practice in Delhi & Noida

Formal thought disorders

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Types of formal thought disorders

a.Derailment- Loss of connection between
successive thoughts.

b. Incoherence (Word salad)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

c. Tangentiality- Thought is related to goal in

a distant way, but the goal is never reached

d. Neologism

e. Metonyms (word approximation)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
f. Clanging (clang association)- Words are
associated with each other, as they sound
similar, and there may be a lack of any
meaningful connection.

E.g- I make sense

out of nonsense and nonsense is the
essence of turbulence of life

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

3. Disorders of content
a. Delusion

False belief

Firm, fixed and unshakeable

(continues despite evidence against it)
Unexplained by social, and cultural background

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Types of delusions
a. Delusion of persecution

b. Delusion of reference

c. Delusion of grandeur/grandiosity

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

d. Delusion of love (erotomania,

de Clerembault syndrome, fantasy lover syndrome)

e.Delusion of infidelity (morbid jealousy,

pathological jealousy, othello syndrome)

f. Delusion of guilt

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

g. Nihilistic delusion (delusion of negation,

cotard syndrome)

h. Delusion of enormity- Patient believes that

their action will cause a catastrophe

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

i. Delusion of misidentification
(misidentification syndrome)

Capgras syndrome (Delusion of doubles): Patient

believes that a familiar person has been replaced
by a ‘similar looking stranger ’
Close Person Got Replaced by A Stranger

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Fregoli syndrome- Patient believes that a familiar

person is changing the physical appearance and
disguising as a stranger. And that multiple
different appearances can be taken
Familiar person giving goli

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

4. Disorders of possession

a. Thought insertion

b. Thought withdrawal

c. Thought broadcast

d. Obsessions

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• MSE (Mental Status Examination)

F. Higher mental functions

1.Attention- Ability to attend to a specific
stimulus without getting distracted.

Test: Digit span test (digit repetition test)

2.Concentration- Sustained attention

Test: Serial 7 subtraction

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
3. Memory

a. Immediate memory- For seconds

Test: Digit repetition test/Serial 7 subtraction

b.Recent memory- For min, hours or days

Test: 24-hour recall

c. Remote memory- For years

Test- Personal/historical information

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
4. Insight

a. Grade 1- Complete denial

b.Grade 2- Awareness of being sick

but denying it at the same time

c.Grade 3- Aware of being sick but

attributing symptoms to external or
physical factors

d. Grade 4- Intellectual insight

e. Grade 5- Emotional insight

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

PYQs (Previous year questions)

Q 1. A 40-year-old male patient presented to psychiatry OPD with the complaints of
having repetitive thoughts that, he feels are his own thoughts only. The thoughts
make him uncomfortable, and he has to wash his hands again and again. This is a
disorder of thought .? (INICET-20)

A. Form

B. Flow

C. Content

D. Possession
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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
Q 2. Make the diagnosis based on the following
image? (NEET PG 16)

A. Capgras syndrome

B. Fregoli syndrome

C. Othello syndrome

D. Cotard syndrome

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

SCHIZOPHRENIA & OTHER PRIMARY PSYCHOTIC

DISORDERS

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Epidemiology

A. Lifetime prevalence: 1%

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

B. Age of onset

C. Late age of onset

D. Sex ratio

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Etiology & Pathogenesis

A. Neurotransmitter hypothesis

1. Dopamine hypothesis

2. Dopamine & serotonin hypothesis

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
B. Genetic factors
DiGeorge syndrome (22q11.2 deletion,
velocardiofacial syndrome)- 30% develop
schizophrenia.

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Symptoms

A. Positive symptoms
Delusion

Hallucinations

Neurobiology

Prognosis

Antipsychotic response

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 Mission NEET PG / INI CET 1.5: Psychiatry
B. Negative symptoms “Your Course Completion, Our Responsibility"

A
A

Neurobiology

Prognosis
Antipsychotic response

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
C. Disorganisation symptoms
Disorganised behaviour

Disorganised speech & thought

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
D. Motor symptoms

Stupor

Waxy flexibility

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Posturing

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Echolalia

Echopraxia

Grimacing

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
Ster eotypy

Mannerism

Perseveration

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
E. Suicide & violence

10% (5%-6%, 20%)

Risk factors
Major depressive episode

Symptomatology

Early, immediately after admission & discharge

Young male, unemployed, comorbid substance use

Paradoxical (less negative & affective symptoms)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Types (changes in ICD-11 & DSM-5)

• ICD-11, Catatonia, a separate diagnosis

Catatonia associated with a mental
disorder

Catatonia induced by use of psychoactive

substances and medications

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Treatment

• Antipsychotics (neuroleptics)

• Duration

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Antipsychotics

Typical (FGA) Atypical (SGA)

Mechanism

Effective against

Extrapyramidal
symptoms &
hyperprolactinemia

Metabolic side effects

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Typical antipsychotics
Phenothiazines- Chlorpromazine,
trifluoperazine, thioridazine, prochlorperazine,
triflupromazine, fluphenazine, perphenazine

Thioxanthenes- Thiothixene, flupenthixol

Butyrophenones- Haloperidol, droperidol,

penfluridol

Miscellaneous- Pimozide, loxapine, molindone

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Side effects

A. Movement disorders (Extrapyramidal

symptoms)

Cause

More common?

1. Drug-induced par kinsonism

Tremors (3-6 Hz), Rigidity, Bradykinesia

Prophylaxis
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Treatment
 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
2. Acute dystonia
Earliest side effect

Young males

Torticollis, trismus,
oculogyric crisis

Pr ophylaxis

Treatment

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
3. Acute akathisia

Commonest side effect

Subjective feeling & objective signs

Treatment

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
4. Tardive dyskinesia

Involuntary movement of jaw (chewing

movements), lips (pouting, puckering,
smacking) or extremities

Choreiform (rapid, jerky, nonrepetitive) or

athetoid movement (slow, sinusoid)

Rabbit syndrome

Cause

Treatment- Change the antipsychotic,

valbenazine, tetrabenazine
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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
5. Neuroleptic malignant syndrome
Fever
Rigidity

Increased CPK
Autonomic disturbances
Diaphoresis
Altered consciousness
Tremors

Leukocytosis
Liver enzyme elevation
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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
5. Neuroleptic malignant syndrome
Pathophysiology

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
5. Neuroleptic malignant syndrome
Corpus striatum
Hypothalamus
Spinal neurons
Raised CPK

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
5. Neuroleptic malignant syndrome
Treatment

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
B. Endocrine side effects

Mechanism
Galactorrhea, menstrual disturbances
(females)

Sexual dysfunction, lower libido (males)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Atypical antipsychotics
Serotonin dopamine antagonists
Clozapine, olanzapine
Risperidone, paliperidone, iloperidone
Quetiapine, ziprasidone, aripiprazole
Sertindole, zotepine, lurasidone
Asenapine, amisulpride
Brexpiprazole, cariprazine, pimavanserin

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Side effects

A. Movement disorders (Extrapyramidal

symptoms)

B. Endocrine side effects

C. Metabolic side effects

D. Sedation, QTc prolongation & seizures

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Clozapine

Important points

DOC

Unique mechanism of action- More affinity for

D4 than D2

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Side effects
Agranulocytosis, myocarditis, seizures

Sedation (most common), sialorrhea

Syncope, hypotension, tachycardia, nausea,

vomiting

Weight gain, anticholinergic side effects

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• ANC and TLC monitoring
First six months
Next six months

Till clozapine is continued

• Stop, if WBC<3000/dl or ANC <1500/dl

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Long-acting injectable antipsychotic (depot
antipsychotic)

Indication

Technique

Risperidone, paliperidone, olanzapine,

aripiprazole

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Treatment of catatonia

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Prognosis

Good prognostic factors Bad prognostic factors

Acute or abrupt onset Insidious onset

Advanced age (>35 yrs) Early onset (<20 yrs)

Female sex Male sex

Prominent positive symptoms Prominent negative symptoms

Presence of affective symptoms Absence of affective symptoms

Family history of mood disorders Family history of schizophrenia

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Other psychotic disorders
A. Acute psychotic disorders
Acute onset

Symptoms
Stressors

Often resolve completely

Do not meet the duration criterion of
schizophrenia

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
A. Acute psychotic disorders
ICD-11 : Acute & transient psychotic
disorders

Duration of symptoms

DSM-5

a. Brief psychotic disorder (< 1month)

b. Schizophreniform disorder (1-6 months)

Treatment
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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
B. Delusional disorder
Delusion
Hallucination
Functioning

Types

Persecutory, infidelity, grandiosity, delusional

parasitosis (matchbox sign) etc.

Treatment

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

PYQs (Previous year questions)

Q 1. Which of the following is not a correct statement about the mechanism of
action of antipsychotics? (INICET-22)

A. D2 receptor blockade improves positive symptoms

B. 5HT1A receptor blockade improved positive symptoms

C. 5HT2A blockade helps improve negative symptoms

D. M1 blockade helps in reducing extrapyramidal side effects

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

Q 2. A psychotic patient presented with purposeless movements &

was once observed to stand still in the ward for long periods of time.
On examination he had negativism and waxy flexibility. What is the
appropriate medical management for this patient? (INICET-20)

A. Haloperidol

B. Clonidine

C. Propranolol

D. Lorazepam

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

MOOD DISORDERS (DEPRESSIVE DISORDERS)

• Major depressive disorder (depressive disorder)

• More common

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Suicide rate

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Symptoms (SIGECAPSS)

A. S

B. I

C. G

D. E

E. C

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Symptoms (SIGECAPSS)

F. A

G. P

H. S

I. S

• 5 out of 9, 1 out 2

• Duration criterion
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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Specifiers

A. Psychotic symptoms/features (psychotic

depression)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Specifiers

B. Atypical features (atypical depression)

1. Reversed biological features

2. Mood reactivity present

3. Leaden paralysis

4. Extreme sensitivity to interpersonal

rejection

5. Treatment implications

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Specifiers

C. Melancholic features (melancholic

depression)

1. Significant biological features

2. Significant mood symptoms

a. Feeling of misery

b. Worse in morning

c. Lack of reactivity/anhedonia

3. Excessive guilt, PMA/PMR

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Specifiers

D. Catatonic features

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Etiology

A. Monoamine hypothesis

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
B. Psychological theories
1. Cognitive theory
ANT

Beck’s cognitive triad

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Treatment

A. Pharmacotherapy

B. Psychotherapy

C. Other somatic treatments

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

A. Pharmacotherapy

Chosen on the basis of?

First line

Onset of action

Maximum therapeutic effect

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
1. Tricyclic and tetracyclic antidepressants (TCAs)
Blocks serotonin & norepinephrine reuptake
transporters

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Side effects - Due to alpha-adrenergic receptors

blockade, cardiac sodium channel blockade

Postural hypotension

QT prolongation

Tachycardia, rarely hypertension

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Other side effects

a. Sedation (H1 blockade)

b. Weight gain

c. Tremors
d.Seizures (excessive serotonin &
norepinephrine receptors blockade)

e. Hyperprolactinemia (mostly with amoxapine)

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• TCA toxicity

Narrow therapeutic index

CVS - hypotension, tachycardia, chest pain

CNS - altered sensorium, respiratory

depression, convulsions

ANS - dry mouth, blurred vision, urinary

retention

Tissue hypoxia - Metabolic acidosis

ECG- prolonged PR, QRS and QT interval, AV
block, right axis deviation
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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

• Management of TCA toxicity

If QRS > 100 ms, serum alkalinization using i.v.

sodium bicarbonate is the mainstay of treatment

If immediately administered - Gastric lavage and

activated charcoal

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
2. Selective serotonin reuptake inhibitors (SSRIs)

Mechanism
Fluoxetine, fluvoxamine, citalopram,
escitalopram, sertraline, paroxetine & vilazodone

Side effects
a. GI - nausea (most common), diarrhoea,
constipation (more common with
paroxetine), anorexia
b. Sexual - Most common long term, low libido,
delayed orgasm

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
Side effects
c. CNS- anxiety, insomnia, sedation, vivid
dreams, sweating, seizures, emotional blunting,
EPS

d. Weight gain

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"

3. Serotonin norepinephrine reuptake inhibitors

(SNRIs)

Mechanism

Venlafaxine, desvenlafaxine, duloxetine,

milnacipran, levomilnacipran

Severe depression?
Side effect profile

Hypertension

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
• Discontinuation syndrome (FINISH)
F - Flu like symptoms (fatigue, aches etc)

I - Insomnia

N - Nausea

I - Imbalance (vertigo)

S - Sensory disturbances (paraesthesia)

H - Hyperarousal (anxiety, irritability)

• Venlafaxine, paroxetine, fluvoxamine

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 Mission NEET PG / INI CET 1.5: Psychiatry
“Your Course Completion, Our Responsibility"
4. Atypical antidepressants
• Trazodone & nefazodone

Trazodone - priapism

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• Mirtazapine

NSSA (noradrenergic & specific serotonergic

antidepressant)

Side effects- sedation, wt gain and vivid

dreams

Minimal sexual side effect

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• Bupropion

NDRI

Side effects- insomnia, restlessness, seizures

Minimal risk- sexual side effects, weight gain

or sedation

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 Mission NEET PG / INI CET 1.5: Psychiatry
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• Ketamine

• i.v. infusion at sub anaesthetic dosages

• rapid onset of action (particularly useful in
case of suicidal ideation)

• FDA-approved nasal spray of esketamine (s

enantiomer of ketamine) for TRD, along with
oral

• Administered?

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B. Psychotherapy

1. Cognitive behavioural therapy

• ANT & Cognitive distortions

• Mild depression

• Pregnancy & breast feeding

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C. Other somatic therapy

1. Electroconvulsive therapy

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2.Transcranial magnetic stimulation
Non convulsive, no anaesthesia required

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• Recurrent depressive disorder

• Dysthymia

• Double depression

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 Mission NEET PG / INI CET 1.5: Psychiatry
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MOOD DISORDERS (BIPOLAR DISORDERS)

• Bipolar type I - Mania/Mixed + Depression

• Bipolar type II - Hypomania + Depression

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Epidemiology

• Lifetime prevalence of Bipolar I - 1%

• Sex ratio

Bipolar I - Roughly equal (1.1:1)

Bipolar II

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• Mean age of onset

Bipolar I - 18 yrs

Bipolar II - Mid 20s

• Suicide rate

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Symptoms of Mania (My Asia FAST GDP)

• M

• A

• F

• A

• S

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• T

• G

• D

• P

• 5 out of 9, both 1 and 2

• Duration-

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 Mission NEET PG / INI CET 1.5: Psychiatry
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• Specifiers

Psychotic symptoms

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• Hypomania

Symptoms

Severity

Impair ment

Duration

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 Mission NEET PG / INI CET 1.5: Psychiatry
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• Rapid cycling in bipolar disorders

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Treatment of bipolar disorder

• Acute manic episode or mixed episode

Mood stabiliser monotherapy (Lithium ,

Valproate/Divalproex, Carbamazepine)

Atypical antipsychotic monotherapy

Combination

Severe symptoms/ Less severe

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Treatment of bipolar disorder

• Acute manic episode or mixed episode

DOC for acute mania

DOC for severe mania

Combination in options

For mixed episode - Valproate > Lithium

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Treatment of bipolar disorder

• Acute depression (bipolar depression)

Mood stabilisers (Lithium, lamotrigine)

Olanzapine + Fluoxetine

Quetiapine

Mood stabilisers + antidepressants

ECT
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Treatment of bipolar disorder

• Acute depression (bipolar depression)

Concept of manic switch Treatment

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Treatment of bipolar disorder

• Maintenance treatment

Lithium or valproate

Atleast 2 years

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Lithium

• First effective use

• Monovalent cation (like Na+)

• Rapid and complete absorption after oral intake

• T1/2 - Initially 1.3 days, later 2.4 days (> 1 yr)

• Doesn't bind to plasma proteins, not metabolised,

excreted unchanged through kidney

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Therapeutic drug monitoring

• Acute mania- 1.0-1.2 mEq/L

• Maintenance treatment- 0.4-0.8 mEq/L

• Usually toxicity > 1.5 mEq/L

• Monitoring : After 12 hours of the last dose

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Side effects

A. Neurological side effects

• Postural tremors (beta blockers)

• Lack of spontaneity

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B. Endocrine

• Hypothyroidism

• Rarely hyperthyroidism, hyperparathyroidism

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 Mission NEET PG / INI CET 1.5: Psychiatry
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C. Renal
• Most common is polyuria (mechanism?),
secondary polydipsia
• May progress to Diabetes insipidus

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 Mission NEET PG / INI CET 1.5: Psychiatry
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D. Dermatological side effects

• Acne, psoriasis (worsening), hair loss, rashes

E. Nausea, vomiting, wt gain, leukocytosis

F. Teratogenic side effect

• Ebstein’s anomaly

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 Mission NEET PG / INI CET 1.5: Psychiatry
Lithium toxicity “Your Course Completion, Our Responsibility"

• Diet, diuretics , Diarrhea (hypovolemia,

hyponatremia)

• Narrow TI (>1.5 mEq/dL)

• GI symptoms- Abdominal pain, vomiting

• CNS symptoms

• coarse tremors, ataxia, dysarthria

• muscle fasciculations, increased DTR,

convulsions, impaired consciousness, death
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 Mission NEET PG / INI CET 1.5: Psychiatry
Management “Your Course Completion, Our Responsibility"

• Stop lithium

• Correct dehydration

• Use of sodium polystyrene sulphonate or

polyethylene glycol (to remove unabsorbed
lithium from GI)

• Hemodialysis, in severe cases

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Pregnancy and mood stabilisers

• Risk of relapse?

• Lithium

• High resolution ultrasound and

echocardiography- 6th and 18th week

• Chances of toxicity

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 Mission NEET PG / INI CET 1.5: Psychiatry
• Valproate “Your Course Completion, Our Responsibility"

• Carbamazepine

• Lamotrigine

• Antipsychotics

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 Mission NEET PG / INI CET 1.5: Psychiatry
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Psychiatric aspects of pregnancy

• Postpartum blues (baby blues)- 30-75% of

females

• Transient symptoms like tearfulness,

sadness, mood lability and sleep
disturbances.

• Onset in 3-5 days

• Lasts for days to weeks, support to mother is

enough
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 Mission NEET PG / INI CET 1.5: Psychiatry
• Postpartum depression “Your Course Completion, Our Responsibility"

• More severe

• DSM-5: Depressive episode with peripartum

onset

• 10-15%, In 3 months of delivery

• Sadness, tearfulness, lability, sleep

disturbances

• Anhedonia, suicidal thoughts/thoughts of

harming baby, guilt
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 Mission NEET PG / INI CET 1.5: Psychiatry
Postpartum psychosis “Your Course Completion, Our Responsibility"

• Within 2-3 weeks

• Initial- tearfulness, insomnia, lability

• Delusions and hallucinations (baby is dead,

didn’t give birth)

• Risk of harm to self or baby

• Episode of bipolar disorder

• Mostly recovery is complete

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 Mission NEET PG / INI CET 1.5: Psychiatry
• SUICIDE “Your Course Completion, Our Responsibility"

• 12 per lakh of population (NCRB 2021)

• Method

• CSF levels of 5 HIAA (5 hydroxyindoleacetic

acid)

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 Mission NEET PG / INI CET 1.5: Psychiatry
Causes “Your Course Completion, Our Responsibility"

• Depression

• Schizophrenia

• Alcohol dependence

• Borderline personality and antisocial

personality disorder

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 Mission NEET PG / INI CET 1.5: Psychiatry
Risk factors “Your Course Completion, Our Responsibility"

• Previous suicide attempt

• Signs of suicidal intent (writing a suicide note)

• Hopelessness

• Male sex

• Age> 45 years

• Substance abuse
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• Delusions/Hallucinations

• Divorced, separated

• Unemployed

• Chronic illness

• Family history of suicide

• Poor social support

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 Mission NEET PG / INI CET 1.5: Psychiatry
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• Paradoxical suicide

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Anxiety or Fear related disorders
A. Panic disorder

• Panic attack

• An acute attack of intense anxiety, with a ‘feeling

of impending doom’

• Palpitations, choking sensations, chest pain,

dizziness, depersonalisation, derealisation
• Panic disorder
Differential Diagnosis

• Myocardial Infarction, angina, cardiac arrhythmias, mitral valve

prolapse

• Acute asthma, COPD, Pulmonary embolism

• Pheochromocytoma, carcinoid syndrome, hyperthyroidism,

hypoglycemia

• Anaemia, seizure disorder

Treatment

• Combination

• Pharmacotherapy

• Benzodiazepine & SSRIs

Psychotherapy

• Cognitive behavioural therapy

B. Agoraphobia

• Fear of places from which escape might be difficult

❖ Fear of open spaces

❖ Fear of crowded places

❖ Fear of enclosed places

❖ Fear of travelling alone

❖ Fear of public transport

• Home bound

• Agoraphobia and panic disorder are usually comorbid

Treatment

• Combination

• Pharmacotherapy

• Benzodiazepines & SSRIs

• Psychotherapy

• Cognitive behavioural therapy

• Behavioural therapy
C. Specific Phobias

• Strong, persistent & irrational fear of an object or a situation

Common Phobias

Nyctophobia Dark
Acrophobia Heights
Claustrophobia Closed spaces
Ailurophobia Cats
Cynophobia Dogs
Mysophobia Germs or dirt
Pyrophobia Fire
Xenophobia Strangers
Thanatophobia Death
Hydrophobia Water
Treatment

• SSRIs, benzodiazepines, Behavioural therapy

❖ Systematic desensitisation

❖ Therapeutic graded exposure (or exposure and response

prevention or in vivo exposure)

❖ Flooding (implosion technique)

Social Anxiety Disorder (Social Phobia)

• Fear of social situations (fear of embarassment)

• Treatment same as other phobias

Generalised Anxiety Disorder

• Free-floating anxiety
• Excessive worries
• Somatic symptoms of anxiety
• Restlessness, easy fatigue, muscle tension
• Poor concentration, insomnia, irritability
• Treatment
• SSRIs, BZDs
• CBT
• Separation anxiety disorder

• Selective mutism
Obsessive compulsive & related disorders

A. Obsessive-compulsive disorder
• Obsessions are-
• Recurrent, intrusive thoughts, images or
impulses, which cause anxiety
• Patient considers them as a product of their own
mind (D/d thought insertion)
• Patient finds them excessive, irrational and
senseless, at some time during the illness (D/d
delusions)
• Patient try to resist or neutralize them
• Compulsions are
• Repetitive behaviours / mental acts performed in
response to obsessions
• They reduce anxiety temporarily

• Ego dystonic (not acceptable to self)

• Duration criterion

• Lifetime prevalence: 2-3%

• M/c comorbidity
 Etiology

• Neurotransmitter

• Circuit involved

• Cortico-striato-thalamico-cortical tract
• Symptom patterns

❖ Obsession of contamination with compulsion of

washing and avoidance (m/c)
❖ Pathological doubt with compulsions of checking
(second m/c)
❖ Intrusive thoughts (usually with mental compulsions)-
sexual, aggressive and religious content
❖ Symmetry or precision with compulsion of slowness
❖ Magical thinking- Just because they thought about an
event, it will occur in reality
Treatment

• Combination of pharmacotherapy and

psychotherapy

• Pharmacotherapy

❖ SSRIs and clomipramine

❖ Antipsychotics (augmentation)

❖ Li, Valproate, carbamazepine, venlafaxine

• Psychotherapy

❖ Exposure and response prevention (kind

of CBT/BT)
B. Hoarding Disorder

• Inability to discard things, that are of little or

no value

• Fear of losing something important

• DSM-5 and ICD-11 changes

• SSRIs and CBT

• Exposure and response prevention is not so

effective
C. Body dysmorphic disorder
• Preoccupation with an imagined
defect/slight anomaly in physical
appearance

• Repetitive behaviours

• Usually hair, nose or skin

D. Body focussed repetitive behaviour
• Repetitive actions directed at integument (skin,
hair) and inability to stop them
• Trichotillomania
➢ Repetitive pulling of hair
➢ Trichophagy
➢ Trichobezoar

• Excoriation disorder
➢ Repetitive picking of skin
Trauma and stressor related disorders

A. Post traumatic stress disorder

• Follows a significant traumatic event or
repetitive events that involve exposure to
actual/threatened death, serious injury or
sexual violence to self or others
• E.g.
Clinical symptoms
• Intrusion symptoms: Flashbacks, vivid
memories, nightmares

• Avoidance

• Arousal symptoms

• Other symptoms
Treatment
• SSRIs
• CBT (treatment of choice)
• Eye movements desensitisation and reprocessing (EMDR)
B. Acute stress disorder

• DSM diagnosis

• Symptoms similar

• More than 3 days and less than 1 month

C. Adjustment disorders

• Events which are critical but not uncommon in the course

of life

• Relationship issues, change of job, migration, death of a

loved one

• Symptoms

• Adjustment disorder and depression

• Treatment
Somatic symptoms & related disorders
(somatoform disorder)

A. Somatic symptom disorder (Bodily distress disorder)

• One or more somatic symptoms (MUS)

• Excessive thoughts, excessive feelings, excessive
behaviours
B. Illness anxiety disorder (Hypochondriasis)

• Preoccupation with having or acquiring a serious

physical illness

• Despite investigations and medical reassurances

• Excessive thoughts, feelings and behaviours

• Difference ?

• Management
C. Conversion disorder (Dissociative neurological
symptom disorder)
• Symptoms suggestive of motor, sensory or
cognitive deficit,
• Do not confirm to anatomical and physiological
principles

• La belle indifference.
• D/d Acute intermittent porphyria
D. Factitious disorder (Munchausen syndrome)

• Wilful production of symptoms to get medical attention

• Relation to medical field

• Pseudologica fantastica

• Sick role

• Munchausen syndrome by proxy

Dissociative disorders

• Dissociation is disruption in normally integrated

functions of memory, identity, perception,
consciousness and motor behaviour

• Produced by ‘psyche’, unconscious symptoms

• Onset?
Types
1. Dissociative amnesia
• Sudden loss of autobiographical memory (usually for
a traumatic event)
2. Dissociative fugue
• Sudden, unexpected travel (unexpected but a place
with emotional significance)
• May involve confusion about identity
3. Depersonalization/derealization disorder

• Depersonalization

➢Feeling of unreality of self

➢Feeling of being detached from body and watching

self, like in a movie

➢ás if’ they have changed

• Derealization

➢feeling of unreality of the world, world appears fuzzy,

dream like

• Reality testing is intact.

SUBSTANCE RELATED
&
ADDICTIVE DISORDERS
Terminology
A. Dependence
• Inability to regulate the use of a substance after
repetitive or continuous use. Characterised by a
strong drive to use the substance.
Alcohol
Acute intoxication
• CNS depressant
• 20-30 mg/dl- Slow motor performance and
decreased thinking ability (legal limit: 30 mg/dl)
• 30-80 mg/dl: Further worsening
• 80-200 mg/dl: Incoordination, emotional lability and
judgement errors
• 200-300 mg/dl: Slurred speech, nystagmus, alcoholic
blackout
• >300 mg/dl: Impaired vital signs & possible death
• Alcoholic blackout- anterograde
amnesia, at that time behaviour
appears to be goal directed, no
confusion observed
Alcohol withdrawal
• After 6-8 hours: Tremors (m/c), nausea,
vomiting, anxiety, hypertension, mydriasis
• After 12-24 hours:
• After 24-48 hours:
• After 48-72 hours:
Alcohol induced neurocognitive disorders

• Amnestic disorders characterised by disturbances in

short term memory

A. Wernicke’s encephalopathy- Acute complication

• Symptoms

• Cause

• Treatment
B. Korsakoff syndrome- Chronic complication

• Symptoms
• Cause
• Treatment
• Prognosis is guarded
Treatment

A. Detoxification

• Benzodiazepines

• In presence of liver damage

• Thiamine administration

• For delirium tremens

B. Maintenance of abstinence (relapse prevention)

• Pharmacological agents

• Anticraving agents
o Naltrexone, acamprosate
o Topiramate, baclofen, serotonergic agents like
fluoxetine
• Deterrent agents (aversive agents)
o Disulfiram (disulfiram ethanol reaction)
OPIOIDS
• Heroin, Morphine, codeine etc.
Intoxication

• Euphoria, initial euphoria followed by period of

sedation (nodding off)

• Slow respiration, hypothermia, hypotension,

bradycardia, pin point pupil, cyanosis

• Overdosage

• Lethal

• DOC
Withdrawal symptoms
• Flu like syndrome

o Lacrimation, rhinnorhea, sweating, diarrhoea

o Yawning and piloerection
o Mydriasis
o Body ache and insomnia
o Hypertension, anxiety, tachycardia
Treatment

• Detoxification

o Methadone, buprenorphine,
dextropropoxyphene
• Maintenance of abstinence

o Opioid substitution therapy- methadone, buprenorphine

o Naltrexone

• Narcotic anonymous
 Cannabis

• δ-9 tetrahydrocannabinol (THC)

• Street name- Joints, marijuana, grass, pot, weed etc

• Intoxication
o Euphoria, sense of slowing of time, sense of floating in air, reddening of
conjunctiva, increased appetite, dryness of mouth

o Depersonalization, Derealization, synaesthesia

• Withdrawal symptoms
o Irritability
Cannabis related disorders

• Flashback phenomenon

• Amotivational syndrome

• Running amok
Hallucinogens

• LSD (lysergic acid diethylamide), mescaline,

psilocybin, methylenedioxyamphetamines (MDMA,
ecstasy), phencyclidine (angel dust), ketamine
• No withdrawal symptoms

• Flashback phenomenon

• Treatment
Cocaine

• Erythroxylum coca

• Was prepared as a LA
o Blocks fast sodium channel
o ENT surgery
• Blocks dopamine and norepinephrine receptors
o Vasoconstriction : HTN, MI
o Nasal septal perforation

o Seizures
o Jet black pigmentation of tongue
• Intoxication

• Euphoria

• Sympathetic symptoms (tachycardia,

palpitations, hypertension, sweating, mydriasis)

• Tactile hallucinations or cocaine bugs or magnan

phenomenon or formication
Tobacco

• Most common substance used in India

Withdrawal symptoms
• Within 2 hours, peak in 24-48 hours
o Irritability
o Poor concentration
o Anxiety, restlessness
o Bradycardia
o Drowsiness but paradoxical insomnia
o Increased appetite, wt gain
o Depression
o Constipation
Treatment
• Nicotine replacement therapy
• Medications
o Varenicline
o Mechanism of action
o Partial agonist- Prevents high and reinforcement and also craving
and withdrawal
o Nausea, insomnia, ?? suicidal thoughts
• Bupropion
Personality Disorders
 Cluster A PD
1. Paranoid PD

o Suspiciousness
o Keep grudges

o Conspiracy theories
2. Schizoid PD
o Prefer solitary activities
o Emotionally cold and detached
o Indifferent to praise or criticism
3. Schizotypal PD

o Odd and eccentric thinking & behaviour

o Magical thinking
o Illusions and momentary hallucinations
Cluster B PD

1. Histrionic PD

o Dramatic & exaggerated emotions

o Need to be the centre of attention
o Behave in sexually seductive way & use physical
appearance
2. Narcissistic PD

o Excessive self importance (grandiose)

o Belief about being special and talented

o Fantasies of unlimited success and power

3. Antisocial PD (Dissocial PD)

o Unlawful behaviour

o No regards for rights of others & violations

o Lack feelings of guilt and remorse

o Substance use disorders

4. Borderline PD (emotionally unstable PD)

o Emotional instability

o Impulsivity

o Intense but unstable relationships

o Self injurious behaviour

o Psychotherapy (dialectical behaviour therapy),
Cluster C PD
1. Avoidant (anxious) PD

o Excessive sensitivity to rejection

o Fear of being criticised or not accepted by others
o Avoid social activities
2. Dependent PD

o Let others take decisions of their lives

o Need reassurance for mundane decisions too
3. Obsessive compulsive PD (anankastic PD)

o Preoccupied with rules and regulations

o Excessively organised
o Perfectionism that slows them down

o Stubborn & inflexible

o No time for leisure, no sense of humour
Impulse control disorder

• Failure to resist an impulse or drive

• For an act harmful to self/others
• Feeling of increasing tension, and
arousal
• After performing behaviour, sense of
relief or gratification, later guilt
 Types
• Pyromania

• Kleptomania
• Intermittent explosive disorder
• Compulsive sexual behaviour disorder (Satyriasis,
nymphomania)
• Others- Oniomania, mutilomania
EATING DISORDERS
Anorexia Nervosa
 Symptoms
• Restriction of energy intake resulting in significantly less weight than normal

• BMI <18.5 kg/m² (ICD-11)

• Severity

• Disturbance of body image

• Excessive fear of wt gain

• Medical signs and symptoms of starvation such as

• amenorrhea, lanugo (neonatal hairs)

• hypothermia, dependent edema

• bradycardia.
• Poor sexual development (adolescents), low interest
in sexual activities (adults)

• Secretive and deny any symptoms

Adolescent females

Misnomer

Subtypes

• Restricting type- 50%

• Binge eating/purging type

Treatment
Treatment
• Hospitalisation (dehydration/electrolyte
imbalance/significant weight loss?)
• Behavioural therapy
• SSRIs, TCAs, cyproheptadine
• In case of failure to gain weight (??)
 BULIMIA NERVOSA

• Females, late adolescence

• Episodes of binge eating

• Followed by inappropriate ways of stopping wt gain

o Purging (??)
o Hypergymnasia
• Fear of gaining weight

• Purging:
o Dental caries (enamel erosions)
o Callous on knuckles,
o Parotitis (salivary gland inflammations),
o Hypokalemic and hypochloremic alkalosis
o Rarely oesophageal or gastric tear during forceful vomiting
• Weight is usually normal

• Normal sexual functioning

• Not secretive

• T/t- Cognitive behavioural therapy, SSRI

Binge eating disorder

• Most common eating disorder

• Only binges , no compensatory behaviour

• Overweight
SLEEP DISORDERS
Dyssomnias- Abnormality in duration or quality of sleep

1. Hypersomnia

A. Narcolepsy: Reduced latency of REM sleep

Symptoms
• Hypnagogic and hypnopompic hall
• Cataplexy: Sudden loss of muscle tone

• Sleep attacks: Irresistible urge to sleep

• Sleep paralysis
Etiology

• Deficiency of hypocretin

• Hypocretin neurons project from hypothalamus

• Immune-mediated disorder

• Strong association with human leucocyte

antigen class II (HLA-DR2 and HLA-DQB1*0602)
Management

• Forced naps, modafinil

2. Insomnia

A. Periodic limb movement disorder

• Sudden contractions of muscle groups (usually legs) while
sleeping
• Partial or complete awakening during night
• Bed partner is aware (patient is usually not)

• Non restorative sleep, day time sleepiness

• Benzodiazepines
B. Restless leg syndrome (Ekbom syndrome)

• Uncomfortable sensation in legs (such as insect

crawling), which gets relieved by moving the leg or
walking around
• Difficulty in initiation of sleep
• Ropinirole
Parasomnias

• Characterised by dysfunctional events

A. NREM disorder (usually in NREM 4, NREM 3)

• Night terror or sleep terror or pavor nocturnus

• Somnambulism
o Sleepwalking

o More complex activities like dressing, move around or driving

• Sleep related enuresis

o Usually psychogenic (in children ‘sibling rivalry’)

o Rule out organic causes (e.g DM, DI, UTIs, obstructions)
o TOC- Bed alarms (behavioural therapy)
o Desmopressin, TCAs (like imipramine)
o Bruxism (teeth grinding)- NREM II

o Sleep talking
B. Nightmare
SEXUAL DISORDERS
• Gender

• Gender dysphoria (gender incongruence)

A. Gender dysphoria of childhood

o Dress & activities (play) of opposite gender
o Desire to be of opposite gender, but usually no rejection of
anatomical structures
B. Gender dysphoria in adolescents & adults

o Desire to live and be treated as the other gender.

o Discomfort with one’s anatomical sex organs

o Desire to change the sex organs & convert into opposite

gender

o ‘I am a man trapped in a women’s body’ or vice versa

Erectile dysfunction (male erectile disorder)

• Most common cause: Psychogenic

• Most common organic cause: Diabetes
 Psychogenic ED Organic ED
History of early
morning
erections and + -
nocturnal
erections
Penile
+ -
plethysmography
Nocturnal penile
+ -
intumescence
• Treatment of ED

o PDE-5 inhibitors like sildenafil, tadalafil

o Oral phentolamine
o Injectable & transurethral alprostadil
• Dual sex therapy (or sex therapy)

o Masters & Johnsons technique

o Couple is treated
o Improve communication
o Sensate focus exercise
3. Disorders of orgasm phase

• Premature ejaculation
o DSM-5 , < 1 min
o Psychogenic
o SSRIs
o Squeeze technique (coronal ridge of glans)
o Stop start technique (semans technique)
o Sex therapy
CHILD PSYCHIATRY
Attention Deficit Hyperactivity Disorder
• Symptoms

A. Inattention
B. Hyperactivity
C. Impulsivity
Pharmacotherapy

Stimulants Non stimulants

Methylphenidate,
Atomoxetine
dexmethylphenidate
Amphetamines Bupropion
Modafinil Clonidine, guanfacine
Venlafaxine
Pervasive developmental disorders

➢ Group of neurodevelopmental disorder

A. Autism

• Impairment in social interaction

o Poor eye contact, lack of social smile and anticipatory
posture
o Poor attachment to parents and others
o Difficulty in making friends
• Restricted, repetitive behaviours

o Repetitive plays
o Stereotyped movements like hand wringing, spinning and head
banging

• Impairment of communication and language

o Delayed language milestones

B. Rett’s disorder (Rett’s syndrome)

• Females

• Normal development till 5 months, between 5-48 months

o Deceleration of head circumference (microcephaly)
o Loss of acquired hand skills and speech
o Poor gait
o Three symptoms of autism
o 75% have seizures
ICD-11 & DSM-5 update

• Autism spectrum disorder

• Language dysfunction has been removed as a criterion

Mental Retardation (Intellectual disability)

• Incomplete development of intellectual functions and

adaptive skills

• IQ = Mental age/chronological age X 100

Normal 90-109
Borderline 70-89
Mild MR 50-69
Mod MR 35-49
Severe MR 20-34
Profound MR <20
• Down’s syndrome, followed by Fragile-X syndrome

• Behavioural problems: Contingency management

Learning disorders
• Significant impairment in one or more scholastic
skills, out of proportion to intellectual functioning
(usually IQ is normal)

• Specific reading disorder (dyslexia)

• Disorders of written expression (specific spelling

disorder)

• Specific disorders of arithmetic skills

• Mixed disorders
Disruptive behaviour disorders
A. Conduct disorder- Pattern of ‘disregard for
rights of others’ and aggressive and dissocial
behaviour

• Stealing , repeated lying, aggression,

bullying, cruelty towards animals,
disobedience, running away from school

• Later development of antisocial personality

disorder
B. Oppositional defiant disorder- Negativistic and defiant
behaviour towards adults and authority figures

Management
• Behavioural therapy, Family therapy
• Low dose antipsychotics
PSYCHOANALYSIS
• Father of psychoanalysis

• What does it say?

• In 1900, Freud published ‘Interpretation of dreams’

• Topographical theory of mind

o Conscious
o Preconscious- "Repression"
o Unconscious - Distressing memories and
instinctual drives
• Free association

o Unguided communication

• Abreaction: Recall of memory with release of emotions

• Transference- Feeling that patient develops
for the doctor.

• Counter transference
• Structural theory of mind

o Id- Pleasure principle

o Ego- Reality principle
o Superego- Moral principle
DEFENSE MECHANISMS
• Mechanisms used by ego to prevent buildup
of excessive anxiety.

• Unconscious
• Denial : Refusal to accept the reality
• Projection: Transfer of feelings about a person, on to, that
person. Involved in development of hallucinations and
delusions
• Displacement: Transfer of emotions from one individual to
another. Involved in phobias.

• Repression: Loss of memory and loss of access to it

• Rationalisation: Giving a logical reason for an unacceptable

behaviour. Involved in substance use disorder.

• Reaction formation: Transforming an impulse into its exact

opposite
Mature defences (SAHAS)

• Sublimation: Transformation of a socially unacceptable

impulse into socially acceptable behaviour

• Anticipation: Preparing in advance for an unpleasant situation

• Humour: Use of comedy to deal with unpleasant situation

• Altruism: Use of social cause to deal with own emotions

• Suppression: Loss of a memory which can be easily brought

back
MISCELLANEOUS
Electroconvulsive therapy

Types

• Direct ECT

• Indirect ECT (Modified ECT)

• Methohexital is the anaesthetic agent of choice

• Thiopental and propofol

• Succinylcholine

• Atropine
Side effects
1. Memory disturbances - Retrograde amnesia is more common (mild,
recovery in 1-6 months)

2. Headache, muscle aches, fractures, tooth dislocations, rarely

delirium
 Substance use disorder (Psychosocial treatment)

• Transtheoretical model of change

A. Precontemplation
B. Contemplation- Starts realising that he has a
problem, ‘pros and cons’ evaluated
C. Preparation- Takes a decision and starts planning
D. Action- Quits and make changes in behaviour

E. Maintenance
Mental Healthcare Act, 2017 (MHCA 2017)
B. Advance directive- Every person (not a minor) can
make an advance directive

1. How they wish to be treated/not treated for a mental

illness
C. Nominated representative

• Every person can appoint a nominated representative

• In case of loss of capacity, NR would help in taking

decisions about treatment
E. Ban on direct ECT

F. Ban on ECT for minors

G. Ban on psychosurgery

H. Decriminalisation of suicide attempt

 DELIRIUM DEMENTIA

Onset Sudden onset Insidious onset

Consciousness Dist. of consciousness Not present

Course Fluctuating course Progressive

course
 DELIRIUM DEMENTIA

Onset Sudden onset Insidious onset

Consciousness Dist. of consciousness Not present

Course Fluctuating course Progressive

course