Elite

psychiatry
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 Index
Sl.No. Chapter Pg.No.
1. General Psychiatry 09
2. Psychology 25
3. Psychotic disorders 53
4. Neurotic disorders 78
5. Neurocognitive Disorders 99
6. Psychoactive Substance Use Disorders 114
7. Personality disorders 129
8. Psychosexual and gender identity disorders 135
9. Psychiatric disorders in childhood and adolescents 143
10. Psychiatric emergencies 155
11. Community psychiatry 157
12. Psychopharmacology and therapeutics 161
 9
General Psychiatry
History of psychiatry

Reil johann Coined- Psychiatry

Founded the first psychiatric journal

Freud, Sigmund Founder of psychoanalysis

Q .

Coined - Free association, Oedipus, penis envy, Id, ego and superego
- -
Cocaine in Psychiatry Psychosexual Topographical theory
Psychodynamic theory Development of mind
Wrote book - Interpretation of dreams
Alfred Adler Coined - Inferiority complex

Pavlov, Ivan Coined- Classical conditioning

a.

Skinner Coined - Operant Conditioning

Piaget, Jean Stages of cognitive development
Jung, Carl Coined- Introvert/ Extrovert, Electra complex
Q
Emil Kraepelin Dementia praecox
Kubler Ross 5 stages of grief in dealing with death (DABDA)
Q
Erik Erikson Divided personality development in to 8stages - PSYCHOSOCIAL
THEORY
Bleuler, Eugen Coined- Schizophrenia
Q
Described cardinal symptoms (4A’s) of SZ

Dendy Walter Coined- Psychotherapy

Sigmund Freud Erik Erikson

 10

Approach to patient

History Examination Investigations Diagnosis

Most important Least important
in Psychiatry in Psychiatry

Parts of the Initial Psychiatric Interview

I. Identifying data IX. Developmental and social history
II. Source and reliability X. Review of systems
III. Chief complaint XI. Mental status examination
IV. Present illness XII. Physical examination
V. Past psychiatric history XIII. Formulation
VI. Substance use/abuse XIV. DSM-5 diagnoses
VII. Past medical history XV. Treatment plan
VIII. Family history

Reliability of information
Previous Year Questions AIIMS NOV17
• Relation to Patient Q. Basis of reliability of information of patient
• Intimacy with the patient provided by informants depends on all except?
• Interest of the patient’
A. Biological relation
• Does the Informant live with the patient?
B. Educational status

:
• Duration of stay with the patient
C. Observation skill
• Intellectual and observational ability
D. Duration of stay with the patient

COMPONENTS of Personal history

a. Perinatal history Previous Year Questions AIIMS MAY16
b. Childhood history Q. Personal history includes all except?
c. Education history A. Food preferences
d. Play history B. Academic history
e. Emotional problem during adolescence C. Occupational history
f. Puberty D. Marital history
g. Obstetrical history
h. Occupational history
i. Sexual and marital history
j. Premorbid personality
 11
Transference
Transference is redirection of a client's feelings from a significant person to a therapist
There are three stages in dealing and using transference in social casework. these stages are:
1. Understanding the Transference
2. Utilizing the transference.
3. Interpreting the transference.
Understanding of the transference is essential for the worker as it helps to understand the
behaviour of the client and to recognize its significance in his development process.
Explains the present unconscious needs of the client.
Utilization of the transference depends on the understanding of the social case worker of
the phenomena. It explains many cures or treatments of emotional disturbance by life
situations and by fortune relationships with other problems
Interpretation of the transference, that is, confronting the individual with the awareness
that his behaviour is the repetition of a specific unconscious infantile is definitely part of
psychoanalytical therapy and requires preparation of the individual by the careful analysis
of his unconscious defense.
Counter-transference
Counter-transference is defined as redirection of a therapist's feelings toward a client
It’s a therapist's emotional entanglement with a client
It is a two way process.
Social case worker has also unconscious tendency to transfer out the client.
As in the case of transference, these counter transference feelings, both positive an negative,
are unconscious but operate with force.
Therefore, it is the job of case worker to recognize his feelings and must control them.

Previous Year Questions NEET PG 21

Q. While therapy session a
therapist developed unconscious
and conscious feelings towards
the patient . what is it called?

burner transference
 12

Mental status examination

Psychiatric equivalent of the physical examination in the rest of medicine
Components of MSE

Look for Test For

Appearance and Behavior Cognition
Motor Activity Orientation
Speech Attention and concentration
Memory
Mood and affect
Abstract Reasoning
Thought Insight
Perception Judgment

Appearance and Behavior

Does the patient appear to be his or her stated age, younger or older?
Is this related to the patient's style of dress, physical features, or style of interaction?
Motor Activity Normal,
Slowed (bradykinesia), or
To note: Agitated (hyperkinesia).

Gait, freedom of movement, any unusual or sustained postures, pacing, and handwriting
Speech
Elements considered include fluency, amount, rate, tone, and volume.
Mood and affect
Mood Affect

Patient's internal and Expression of mood or what the patient's

sustained emotional state. mood appears to be to the clinician.
What you see
What you feel
Congruent to mood Incongruent to mood
"sad," "angry," "guilty," or "anxious"
Matching Not matching

Bipolar Schizophrenia
 13
Thought → By Schneider
HEALTHY THINKING
CONSTANCY- Persistence of a completed thought whether simple or complex.
Organisation- Contents are related but do not blend with each other but organised
Continuity- Thoughts or ideas are arranged in order

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

Possesion Form

1. Thought block The way thoughts are put in.

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

Possesion
Thought insertion Thought withdrawal Thought broadcasting
The patient believes that The patient believes that The patient believes that his
thoughts that are not his own thoughts have been taken thoughts are broadcast so that he
have been inserted into his mind. away from his mind. himself or others can hear them.

Previous Year Questions INICET NOV 2021

1. A 40 yr old male patient comes to psychiatry OPD with complaints of having repetitive
thoughts that his hands are dirty, though they are not. He knows that these are his thoughts only.
This gives him discomfort and hence he has to wash them again and again. This is a disorder of
thought of?
 14
Formal Thought Disorders

Circumstantiality An inability to answer a question without giving excessive,

unnecessary detail.
Eg: the patient answers the question "how have you been sleeping lately?"
with "Oh, I go to bed early, so I can get plenty of rest. I like to listen to
music or read before bed. Right now I'm reading a good mystery. Maybe I'll
write a mystery someday. But it isn't helping, reading I mean. I have been
getting only 2 or 3 hours of sleep at night."

Clanging A severe form of flight of ideas whereby ideas are related only by
similar or rhyming sounds rather than actual meaning
Commonly seen in bipolar disorder (manic phase)
Eg:"I heard the bell. Well, hell, then I fell."
Q
Derailment The words make sentences, but the sentences do not make sense.
Eg. "The next day when I'd be going out you know, I took control, like uh, I
put bleach on my hair in California."

Flight of ideas A succession of multiple associations so that thoughts seem to move

abruptly from idea to idea
Most characteristic of the manic phase of bipolar illness

Neologism The invention of new words or phrases

Eg: "I got so angry I picked up a dish and threw it at the geshinker."

Perseveration Repetition of out of context words, phrases, or ideas.

Eg: "It's great to be here in Nevada, Nevada, Nevada, Nevada, Nevada."

Tangentiality In response to a question, the patient gives a reply that is appropriate to

the general topic without actually answering the question.
Eg: Doctor: "Have you had any trouble sleeping lately?"
Patient: "I usually sleep in my bed, but now I'm sleeping on the sofa."

Thought blocking A sudden disruption of thought or a break in the flow of ideas.

NEET 2021
Predicted Question
Previous Year Questions

Which is included in form of thought disorder ?

A B C D E A. Derailment
✓

B. Obsession
Loosening of associations- knight's move thinking.
C. Somatic delusion
(Derailment) In schizophrenia
D. Thought insertion
 15

Perception
Perceptual disturbances include hallucinations, illusions, depersonalization, and derealization.

Hallucinations Illusions
False perceptions of internal stimuli Misinterpretation of real stimuli
( no stimuli present)
Considered to be abnormal and associated Considered to be fairly common to be
with a pathological state of the mind experienced by a healthy, normal individual

Visual - flashing lights that Eg: a child experiences an illusion when

no one else can see. she interprets the shadows in the dark
Olfactory - body smells bad when it doesn’t. as monsters or animals.

Gustatory - metallic taste ( in epilepsy)

Auditory - Most common
Someone walking in the attic or
repeated clicking or tapping noises.
Tactile - Feel that bugs are crawling on
your skin or that your internal
organs are moving around.

True Hallucinations Pseudo hallucinations

1.Qualities of real perception. 1. Not clear as real perception.
2.Uncontrollable. 2. Controllable.
3.Perceived as outside subjective space. 3. Within subjective space.
4.Perceived in sensory organs 4. Preceired inside body.
e.g. eye,ear,etc. 5. Intact insight.
5. Lost insight.

Special type of hallucinations

Functional Hallucinations
Hallucinations are triggered by a stimulus in the same modality.
Eg: A patient may report hearing voices criticizing him every time he hears the
sound of a rotating fan, and which stop when the fan is not running.
Reflex hallucinations
Hallucinations in one modality of sensation experienced after experiencing a
normal stimulus in another modality of sensation
Eg: voices that are only heard whenever the lights are switched on.
 16

DSM-5 Diagnostic Criteria for

Depersonalization/ Derealization Disorder

Q
Depersonalisation is more
common after life
threatening trauma

depersonalization derealization

Detached from one’s self Detached from the outside world

Not entirely socially alienated. Socially alienated

Psychological condition Occurs as a result of head injuries

Insight
Degree of personal awareness and understanding of illness
The patient may have no insight, partial insight, or full insight.
The amount of insight is not an indicator of the severity of the illness.
Insight scale
1 . Complete denial of illness
2. Slight awareness of being sick and needing help but denying it at the same time
3. Awareness of being sick but blaming it on others, on external factors, on medical or
unknown organic factors
4. Intellectual insight: Admission of illness and recognition that symptoms or failures in
social adjustment are due to irrational feelings or disturbances, without applying that
knowledge to future experiences
5. True emotional insight: Emotional awareness of the motives and feelings within, of the
underlying meaning of symptoms.
 17

Eg: "I know that there are not really little men talking to me when I am alone, but I
feel like I can see them and hear their voices."

Previous Year Questions AIIMS 2019

A patient is aware that something is wrong with him and it is
because of summer season. What is the score on insight scale?

Questions Used to Test Cognitive Functions in the Sensorium

Section of the Mental Status Examination

1 . Alertness (Observation)

2. Orientation What is your name? Who am I?

What place is this? Where is it located?
What city are we in?
3. Concentration Starting at 1 00, count backward by 7 (or 3).
Say the letters of the alphabet backward starting with Z.
Name the months of the year backward starting with December.
4. Memory:
Immediate Recent Repeat these numbers after me: 1, 4, 9, 2, 5.
What did you have for breakfast?
What were you doing before we started talking this morning?
I want you to remember these three things: a yellow pencil, a cocker
spaniel, and Cincinnati. After a few minutes I'll ask you to repeat them.
Long term What was your address when you were in the third grade?
Who was your teacher?
What did you do during the summer between high school and college?
5. Calculations If you buy something that costs $3.75 and you pay with a $5 bill, how much
change should you get?
What is the cost of three oranges if a dozen oranges cost $4.00?

6. Fund of knowledge What is the distance between New York and Los Angeles? What body of
water lies between South America and Africa?

7. Abstract reasoning Which one does not belong in this group: a pair of scissors, a canary,
and a spider? Why? How are an apple and an orange alike?
 18

Memory

Ability to reproduce or recall what has been learned or retained

through activities or experiences.
Memory ?

encoding retrieving
Necessary
When a person puts information Ability to get information out
into the "filing cabinet drawer." of the "file cabinet drawer"
encoding A
It is usually measured by immediate recall of newly learned information (e.g., narrative
stories or designs) or by demonstrating the ability to learn new material that has been
presented across multiple "learning trials" (e.g., word lists).
a. Remote memory: Childhood data, important events known to have occurred when the patient
was younger or free of illness, personal matters, neutral material
b. Recent past memory: Past few months
c. Recent memory: Past few days, what did patient do yesterday, the day before, have for
breakfast, lunch, dinner
d. Immediate retention and recall: Ability to repeat six figures after examiner dictates them-first
forward, then backward, then after a few minutes' interruption; other test questions; did same
questions, if repeated, call forth different answers
at different times
e. Effect of defect on patient: Mechanisms patient has developed to cope with defect

Amnesia
Loss of new learning ability that extends across all sensory modalities and stimulus domains.
Anterograde amnesia: Decreased ability to retain new information
Retrograde Amnesia: Loss of information that was acquired before the onset of amnesia.
 19

Neuropsychological tests
The Mini–Mental State Examination (MMSE) or Folstein test is a 30-point questionnaire that is
used extensively in clinical and research settings to measure cognitive impairment.

Any score of 24 or more (out of 30) indicates a normal cognition.

Below this, scores can indicate
Severe (≤9 points),
Moderate (10–18 points) or
Mild (19–23 points) cognitive impairment.
 20

Classification in Psychiatry
The two most widely established systems of psychiatric classification are:
Diagnostic and Statistical Manuel of Mental Disorders (DSM)
International Classification for Diseases (ICD)

ICD 10 DSM 5
WHO APA
Used more in Europe and other Official diagnostic system for
parts of the world mental disorders in the US
Different criteria for One version for both
clinical and research use
All languages English

Does not include social Includes social factors (national)

factors(international)

Multi axial organisation Non axial (has 3 sections)

General classification for Only mental disorders

ALL diseases

Alpha-numeric organisation Numeric organisation

(F 19, E 10. 65, etc) (313. 13, 256. 21, etc)
 21
The main categories of ICD- 10 Chapter V (F)
F0 Organic, including symptomatic, mental disorders
F1 Mental and behavioural disorders due to psychoactive substance use
F2 Schizophrenia, schizotypal, and delusional disorders
F3 Mood (affective) disorders
F4 Neurotic, stress-related, and somatoform disorders
F5 Behavioural syndromes associated with physiological disturbances and
physical factors
F6 Disorders of adult personality and behaviour
F7 Mental retardation
F8 Disorders of psychological development
F9 Behavioural and emotional disorders with onset usually occurring in
childhood or adolescence
The Five Axes of DSM-IV-TR
AXIS I: Clinical Psychiatric Diagnosis
AXIS II: Personality Disorders and Mental Retardation
AXIS III: General Medical Conditions
AXIS IV: Psychosocial and Environmental Problems
AXIS V: Global Assessment of Functioning: Current and in past one year
(Rated on a scale)
ICD -11
The ICD 11 is the eleventh revision of the International Classification of Diseases. It replaces
the ICD-10 starting 1 January 2022 as the global standard for coding health information and
causes of death.
Somewhat similar to the DSM-5 OCRD section,
The proposed OCRD section includes
obsessive-compulsive disorder (OCD),
body dysmorphic disorder,
olfactory reference disorder,
hypochondriasis,
hoarding disorder,
trichotillomania
skin-picking disorder.
Tourette syndrome is also cross-referenced in OCRD.
 22

Body-focused repetitive behavior

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

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

Previous Year Questions INICET JULY 2021

Q. Body focused repetitive behaviour comes under which OCD in ICD 11?
a. Hypochondriacal disorders Predicted Question

b. Body dystrophic disorders

c. Olfactory reference disorders
✓d. Trichotilomania
23
 24
Burnout
Burnout is now categorized as a “syndrome” that results from “chronic workplace stress
that has not been successfully managed,” according to the World Health Organization’s
International Disease Classification (ICD-11)
Burnout appears in the ICD-11 section on problems related to employment or unemployment.
According to this handbook, burnout is described as:
• Feelings of energy depletion or exhaustion.
• Increased mental distance, or feelings of negativism or cynicism related to one's job.
• Reduced professional efficacy.

mental health status

Burn-out Exhaustion resulting from chronic workplace stress.

Depression is a mental health disorder characterised by persistently

depressed mood or loss of interest in activities, causing significant
impairment in daily life.
Suicide is non-fatal, potentially injurious behavior that is self-directed, with the
original intent to bring about death
Overworking can be described as working beyond your capacity and more than
your regular working hours.

Previous Year Questions INICET JULY 2021

Q. A 35 year old Physician works in the emergency department and is frequently on
night duties. Which among the following is the correct match regarding his mental
health status. Predicted Question

a. Burn-out- Exhausted and reduced professional efficacy

✓

b. Depression- frequent fluctuations in mood.

c. Suicide- self harm without an intention of causing death.
d. Overworking- excess work but according to ones capacity.
 25
Psychology
Cognitive development stages
Q
Proposed by Jean Piaget

Four major stages that lead to the

capacity for adult thought:
(1) Sensorimotor,
(2) Pre operational thought,
(3) Concrete operations,
(4) Formal operations.

Age (yr) Period Cognitive Developmental Characteristics

Divided into six stages, characterized by:

1 . Inborn motor and sensory reflexes
Q
0-1 .5 (to 2) Sensorimotor 2. Primary circular reaction
3 . Secondary circular reaction
Out of sight - out 4. Use of familiar means to obtain ends
of mind thinking 5. Tertiary circular reaction and discovery
through active experimentation
6. Insight and object permanence

Preoperations Deferred imitation, symbolic play, graphic

2-7 subperiod
Egocentric thinking imagery (drawing), mental imagery, and language

Concrete Conservation of quantity, weight, volume, length, and

7-1 1 operations
time based on reversibility by inversion or reciprocity;
Concrete &
Literal thinking operations; class inclusion and seriation

Formal
11 - end of operations Combinatorial system, whereby variables are
adolescence isolated and all possible combinations are
Abstract thinking
examined; hypotheticodeductive thinking
 26

stages of psychosexual development

:
Proposed by Sigmund Freud
If the child experienced frustration at any of the psychosexual developmental stages, they would
experience anxiety that would persist into adulthood as a neurosis, a functional mental disorder.

Stage Age Range

Oral Birth–1 year

Anal 1–3 years

Phallic 3–6 years

Latency 6–puberty

Genital Puberty–death

Latency

Stage Erogenous zone Consequences of psychologic fixation

Orally aggressive: chewing gum and the ends of pencils, etc.

Oral Mouth
Orally passive: smoking, eating, kissing, oral sexual practices
Oral stage fixation might result in a passive, gullible,
immature, manipulative personality,QAlcohol dependence.
" Q

Anal Bowel and bladder Anal retentive: Obsessively organized, or excessively neat
elimination Anal expulsive: reckless, careless, defiant, disorganized,
coprophiliac
Q

Phallic Genitalia Oedipus complex (in boys and girls); according to Sigmund Freud.
Electra complex (in girls); according to Carl Jung.
Promiscuity and low self-esteem in both sexes.

Latency Dormant sexual Immaturity and an inability to form fulfilling non-sexual

feelings relationships as an adult if fixation occurs in this stage.

Sexual interests Frigidity, impotence, sexual perversion, great difficulty in

Genital
mature forming a healthy sexual relationship with another person
 27

Structural Theory of the Mind

According to Sigmund Freud, human personality is complex and has more than a single component.
In his famous psychoanalytic theory, Freud states that personality is composed of three elements.
These elements work together to create complex human behaviors.
id, Innate desires, Pleasure seeking, Aggression, Sexual impulse
the ego Mature adaptive behaviour
the superego Moral ethical values, parentral

ID
Pleasure principle
Present at birth
Primitive features that are driven by an
unconscious need for pleasure
Ego
Reality principle
Develops around the age of 2
Reduces the conflict between Id and Superego
by implementing defence mechanism
Superego
Morality principle
Develops around the age of 5
Internal morals that we learn from
same sex parent, that punishes our
ego for any wrong through guilt
 28

TOPOGRAPHICAL model of mind

Repression
Conscious mind Currently thinking

=
Pre- conscious Were thinking , Easily recollected

Unconscious mind Apparently forgotten

Consciousness
Subjective phenomenon whose content can be communicated only by means of
language or behavior.
Perceptions coming from the outside world or from within the body or mind are brought
into awareness.
preconscious
Serves to maintain the repressive barrier and to censor unacceptable wishes and desires.
unconscious
Characterized byprimaryprocess thinking, which is principally aimed at facilitating wish fulfill
ment and instinctual discharge.
 29

Defense Mechanisms

George Valliant's classification

Narcissistic Immature Neurotic Mature

Acting out Displacement Altruism

Denial

Regression Dissociation Humour

Projection

Distortion Passive-aggressive Reaction Sublimation

Behaviour Formation
Splitting Schizioid Fanatasy Anticipation
Repression
Somatization Isolation Suppression

Introjection Rationalization Ascetiscism

Hypochondriosis Sexualization

Blocking Intellectualization

Narcissistic defenses:
Q
Most primitive and appear in children and persons Predicted Question
who are psychotically disturbed.
Q. Which one of these is a Mature
Immature defenses:
defence mechanism ?
Seen in adolescents and some nonpsychotic patients
a. Somatization
Neurotic defenses:
Q b. Rationalization
Encountered in obsessive-compulsive and
c. Anticipation
hysterical patients, adults under stress.
d.Projection
Mature defences:
Commonly found among emotionally healthy adults

Narcissistic defenses

Denial Refusal to accept external reality because it is too threatening

Eg:- When some very near and dear one die in the family. Some people say
no, he is still alive.

Projection Attribute feelings/ thoughts onto someone else

Eg: I don’t like a boy, and I say “ I know he hates me, I know it.
 30

Distortion A gross reshaping of external reality to meet internal needs

Eg: A person may believe that they failed a test because of difficult
questions, not because they did not prepare fully.

Splitting All good or all bad. Black or white , no grays

Eg: The nurses from the day shift are terrific. The ones from the night shift suck.”

Immature defenses
Acting out Direct expression of an unconscious wish or impulse in action, without
conscious awareness of the emotion that drives the expressive behavior
Eg: Instead of saying, “I'm angry with you,” a person who acts out may instead
throw a book at the person, or punch a hole through a wall.
Temper tantrum, Self harm
Regression Reversion to an earlier stage of development
Eg: A person who is depressed may withdraw to his or her room, curl up in a
fetal position on the bed.
Passive- Indirect expression of hostility
aggressive
Eg: “She agreed to share her notes with me, but after class she went
Behaviour
straight home.”
Schizioid Tendency to retreat into fantasy in order to resolve inner and outer conflicts
Fanatasy Eg: A young boy who could not help his sick father due to shortage of money, day
dreams that he has got lot of money from lottery ticket and his father, mother
and family members has best of the facilities for everything.
Somatization Psych problems becomes physical
Eg: “ I had a terrible headache during the exam.”

Introjection The values and characteristics of significant persons are incorporated in

one’s personality. Unconscious imitation.
Eg: A person acts and dresses like the person he admires the most
Hypochondriosis An excessive preoccupation or worry about having a serious illness
Eg: A simple sneeze is the sign they have a horrible disease.
Blocking Temporary inability to remember
Eg: “I don’t remember his name! It’s on the tip of my tongue.”
 31

Neurotic defenses
Displacement Emotion or drive shifted to another person or object
Eg: A husband who is angry at his boss shouts at his wife on reaching home.

Dissociation Separates from ones experience, like outer body experience

Eg: Victims of sexual abuse sometimes describe the moment as if
experiencing as an outsider.

Reaction Transformation of the feeling to its exact opposite.

Formation Eg: Two people who fight with each other all the time although they like
each other very much.

Repression An unpleasant or unacceptable feeling or thought is completely pushed out

from consciousness.
Eg: A man is jealous of his good friend’s success but is unaware of his
feeling of jealousy.

Isolation Separation of feelings from ideas and events,

Eg:describing a murder with graphic details with no emotional response.

Rationalization Convincing oneself that no wrong has been done and that all is or was all
right through faulty and false reasoning.
Eg: A husband does not enjoy the company of wife outside the the home and
usually leave his wife at home. He gives logic that his wife is social shy.

Sexualization Attributing the erotic component to negative events in order to make

them positive

Intellectualism Attempt to avoid expressing actual emotions associated with a stressful

situation by using the intellectual processes of logic, reasoning and analysis.
Eg: a young professor receives a letter from his fiancee breaking off their
engagement. He shows no emotion when discussing this with his best
friend. Instead he analyzes his fiancee’s behavior and tries to reason why
the relationship failed
 32

Mature defenses
Altruism Constructive service to others that brings pleasure and personal satisfaction
Eg: A cruel CEO regularly donates to charity and takes part in the
charity organization activities.

Humour Expressing uncomfortable feelings (in the form of jokes, for

example) without causing oneself discomfort.
Eg: An expert makes a mistake in front of the trainees and then laughs about it
saying that the trainees are already smarter than she is.

Sublimation Expressing a personally unacceptable or unattainable feeling in a socially

acceptable or useful way.
Eg: A teenager who often gets into fights starts playing sports heavily,
including boxing.

Anticipation Realistic planning for future discomfort

Suppression Voluntary blocking of unpleasant feelings and experiences from one’s

awareness to avoid discomfort and anxiety.
Eg: Student consciously decides not to think about her insult in examinations
hall so that he can study effectively.
Ascetiscism Eliminates pleasurable effects of experiences.
Uses morals to assign values to specific pleasures.

Mnemonics Predicted Question

S Sublimation Q. Which one of these is a Mature

A Altruism defence mechanism ?
H Humour a. Somatization
A Anticipation b. Rationalization
S Suppression c. Anticipation
A Ascetiscism d.Projection
 33

Psychiatric Disorders Defence mechanism

Anxiety Repression

Phobia Displacement
Regression

OCD Isolation of affect

Undoing
Reaction formation

Depression Regression
Turning of aggression against self

Denial
Mania
Projection
Regression

Projection
Paranoid Regression
Rationalisation

Regression
Schizophrenia
Projection
Isolation of affect
 34

Dreams
Conscious expression of unconscious fantasies or wishes not readily acceptable to conscious waking
experience.
The analysis of dreams elicits material that has been repressed (hidden).
These unconscious thoughts and wishes include
Nocturnal sensory stimuli
(sensory impressions such as pain, hunger, thirst, urinary urgency),
Day residue
(thoughts and ideas that are connected with the activities and
preoccupations of the dreamer's current waking life),
Repressed unacceptable impulses
Not understood by
Understood by layers of dream content clients, needs help for
client themselves decoding
The manifest content refers to The latent content involves the
what is recalled by the dreamer unconscious thoughts and wishes that
v
threaten to awaken the dreamer
v

“What Happens ?” “Hidden Meaning”

Eg: The Person recalls a dragon Eg: The hidden meaning for his dream he
chasing him recalled might be some work life stress which is
an unconscious thought
INTERPRETATION OF DREAMS
~ By Sigmund Freud Predicted Question

primary process Q. Which one of these is not included in

Condensation /Diffusion , Interpretation Of Dreams ?
Displacement, a. Displacement
Symbolic representation b. Condensation
Projection c. Primary Revision
secondary process d. Dream Affects
Secondary Revision
Affects in Dreams

Dream Work
Conscious process that transforms latent content into manifest content.
E

Similar to censoring of movies.

E

Described as the “essence of dreaming” by Freud.

E
 35
Dream Work

Condensation
All our internal
conflicts, ideas,
Displacement
desires Manifest
- Dream
Latent layer of Projection
(What we can see
dream content
Symbolic as our dream)
Representation

A psychiatrist after listening to the manifest dream of the client helps them to
trace it back to understand the latent dream.

primary process
Condensation
Mechanism by which several unconscious wishes, impulses, or attitudes can be combined
into a single image in the manifest dream content.

• Bk •
} Unconscious wishes / impulses

✓ V L

} Manifested Dream content

Eg: In a child’s nightmare an attacking monster may be a representation of not only his father but
also some aspects of his mother and even the child’s own hostile conditions in an abusive family.
Diffusion
The converse of condensation
An irradiation or of a single latent wish or impulse that is distributed through multiple repre-
sentations in the manifest dream content.

•
} Unconscious wishes / impulses

~
L ✓

} Manifested Dream content

 36

Displacement
The mechanism of displacement refers to the transfer of amounts of energy (cathexis)
from an original object to a substitute or symbolic representation of the object.
Eg: In a dream mother may be represented visually by an unknown female figure
Projection
Allows dreamers to rid themselves of their own unacceptable wishes or impulses and experience
them as coming from another person or independent sources.
Eg: A person who wants to be unfaithful to his wife may dream that his wife has been unfaithful to
him.
Symbolic Representation
An abstract concept or a complex set of feelings toward a person could be symbolized by a
simple, concrete, or sensory image.
secondary process
Secondary Revision
Dreams become somewhat more rational.
A more mature and reasonable aspect of ego works during dreams to organise primitive aspects
of dream into a more logical form.
Affects in Dreams
Secondary emotions may not appear in the dream at all, or they may be
experienced in somewhat altered form.
Eg: Repressed rage toward a person's father may take the form of mild annoyance.

Punishment Dreams
Dreams in which dreamers experience punishment
Reflects a compromise between the repressed wish and the repressing agency or conscience.
The wish for punishment on the part of the patient's conscience is satisfied by giving
expression to punishment fantasies.

Psychoanalysis techniques
free association
Requires patients to tell the analyst everything that comes into their heads-however
disagreeable, unimportant, or nonsensical
To let themselves go
Patient's thoughts into words
Eg: "cabbages to kings."
 37

Hypnosis
State in which the person is relaxed and drowsy, and more suggestible than usual.
Abreaction
Reliving an experience to purge it of its emotional excesses
In this process the person not only recalls but also relives the repressed
material causing an emotional release
Eg: A rape victim forgets the incident happened by recalling the repressed memories
with emotional outburst
Type of catharsis
Catharsis
Emotional release
Primary through art
Purification and purgation of emotions—particularly pity and fear—through art

4 components of Psychoanalysis
 38

Erikson's Psychosocial Stages

Q
Erik Erikson divided personality development in to 8 stages

Predicted Question

Q. Which stage of personality development

does teachers have an important role and what
is the basic virtue of that stage?

Q
 39

Stage 1
Infancy

Stage 2
Early
childhood

Stage 3
Preschool
 40

Stage 4
School age

Stage 5
Adolescent

Stage 6
Young adult
 41

Stage 7
Middle
adulthood

Stage 8
Maturity
 42
Projective Tests
*

Helps to understand the hidden emotions and internal conflicts of patients.

*

Rorschach’s ink blot test

*

Thematic appreciation test

*

Sentence completion test

*

Draw a person test

Sleep
Naturally recurring state of mind and body, characterized by altered consciousness, relatively
inhibited sensory activity, reduced muscle activity and inhibition of nearly all voluntary muscles
during rapid eye movement (REM) sleep,and reduced interactions with surroundings.

NREM REM
Non-rapid eye Rrapid eye
movement sleep movement sleep.

Paradoxical sleep
N1 N2 N3 N4 Main occasion for dreams and nightmares

:
Largest Delta sleep or Saw tooth waves
percentage slow-wave sleep
of sleep time Deepest sleep N1 N2 N3 N2 REM.

Distribution of sleep stages

NREM (75 percent)
Stage 1 : 5 percent
Stage 2: 45 percent
Stage 3 : 12 percent
Stage 4: 13 percent
REM (25 percent)

Amplitude increases as frequency decreases

Previous Year Questions NEET 2020

Identify REM waves from the given EEG?
43
 44

SLEEP DISORDER CLASSIFICATION

The sleep-wake disorders' current classifications in accordance with the
DSM-5 include the following:
Insomnia Disorder
Hypersomnolence Disorder
Narcolepsy
Breathing-Related Sleep Disorders
Circadian Rhythm Sleep-Wake Disorders
Non-Rapid Eye Movement Sleep Arousal Disorders
Parasomnias
Nightmare Disorder
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome Substance/Medication-Induced Sleep Disorder

Insomnia Disorder
Difficulty falling asleep or staying asleep is characteristic of insomnia disorder.
Non organic insomnia
A. The individual complains of difficulty falling asleep, difficulty maintaining sleep, or
nonrefreshing sleep.
B. The sleep disturbance occurs at least 3 times a week for at least 1 month.
C. The sleep disturbance results in marked personal distress or interference with
personal functioning in daily living.
D. There is no known causative organic factor, such as a neurological or other medical
condition, psychoactive substance use disorder, or a medication.
Primary insomnia is characterized both by difficulty falling asleep and by repeated awakening.
Primary insomniais commonly treated with benzodiazepines, zolpidem, eszopiclone
(Lunesta), zaleplon (Sonata), and other hypnotics.

melancholia
"Endogenous depression"
Severe form of major depression
Q
Characterized by severe anhedonia, early morning awakening, weight loss,
and profound feelings of guilt (often over trivial events).
Also carries with it a high risk of suicide
Previous Year Questions AIIMS 2019
What are the features of Melancholia?
 45

Narcolepsy
Disorder characterised by excessive day- time sleepiness, often disturbed night-
time sleep and disturbances in the REM-sleep.
The hallmark of this disorder is decreased REM latency,
i.e. decreased latent period before the first REM period occurs

The classical tetrad of symptoms is:

i. Sleep attacks (most common):

The person is unable to resist a sleep attack or ‘nap’, from which he
or she awakens refreshed.
These ‘attacks’ can occur during any time of the day, even whilst
driving. Usually, there is a gap of 2-3 hours between the two attacks.
ii. Cataplexy:
Characterised by a loss of muscle tone in the various parts of body, e.g. jaw
drop, or paresis of all skeletal muscles of body resulting in a fall.
This may be precipitated by sudden emotion.
The consciousness is usually clear and memory is normal, unless sleep
attacks supervene.
iii. Hypnagogic hallucinations:

These are vivid perceptions, usually dream-like, which occur at the onset of
sleep and are associated with fearfulness.
When these occur at awakening, they are called hypno pompic hallucinations.
iv. Sleep paralysis (least common):
This occurs either at awakening in the morning (usually) or at sleep onset.
The person is conscious but unable to move his body.
The episode may last from 30 seconds to a few minutes and may cause
significant distress.

Kleine-Levin Syndrome

1. Hypersomnia (always present), occurring recurrently for long periods of time.

2. Hyperphagia (usually present), with a voracious appetite.
3. Hypersexuality (associated at times), consisting of sexual disinhibition,
masturbatory activity, exhibitionism, and/or inappropriate sexual advances.
 46

•
Narcolepsy is due to the decrease in orexin/hypocretin from lateral hypothalamus which is
responsible for promoting wakefulness.
Treatment - Modafinil (DOC), Armodafinil {dopamine reuptake inhibitors}
Almorexant, Suvorexant, Lemborexant {orexin receptor antagonist}
•
Restless Leg Syndrome - always rule out Fe deficiency, uremia & pregnancy
•
Somnambulism
- Max seen between 4-8yrs of age
- They don’t harm themselves or others during such episodes
- Treatment: Benzodiazepines, TCA {reduce NREM 3 sleep}
•
Somniloquy
- Sleep talking seen during NREM 3 sleep

Night Terrors Night mares

NREM - 3 REM
Amnesia (+) (-)
Autonomic features (+) (-)
(HR , RR , flushing of
skin, mydriasis)
Post arousal confusion (+) (-)
Adolescents/ young children Any age group
Restless legs syndrome (RLS)
Ekbom syndrome
Uncomfortable, subjective sensation ofthe limbs, usually
the legs, sometimes described as a "creepy crawly" feeling,
and the irresistible urge to move the legs when at rest or
while trying to fall asleep.
It tends to be worse at night and moving the legs or
walking helps to alleviate the discomfort
Results in profound insomnia
•
The dopaminergic agonists pramipexole (Mirapex) and
ropini role (Requip) are FDA approved and represent the
treatments of choice.
Nonpharmacological treatments include avoiding alcohol
use close to bedtime, massaging the affected parts of the
legs, taking hot baths, applying hot or cold to the affected
areas, and engaging in moderate exercise.
 47

Sleep-Related Bruxism
Teeth grinding occurs in any sleep stage but appears to be most com mon at
transition to sleep, in stage 2 sleep, and during REM sleep.
It worsens during periods of stress. Predicted Question

Bruxism most commonly occurs in which stage of

Sleep?

Sleepwalking
The predominant symptom is repeated (two or more) episodes of rising from bed, usually during
the first third of nocturnal sleep, and walking about for between several minutes and half an hour.
During an episode, the individual has a blank, staring face, is relatively unresponsive to the efforts
of others to influence the event or to communicate with him or her, and can be awakened only with
considerable difficulty.
Upon awakening (either from an episode or the next morning), the individual has amnesia for the
episode.
Within several minutes of awakening from the episode, there is no impairment of mental activity
or behavior, although there may initially be a short period of some confusion and disorientation.
There is no evidence of an organic mental disorder, such as dementia, or a physical disorder, such
as epilepsy.

Polysomnography
Continuous, attended, comprehensive recording of the biophysiological
changes that occur during sleep.
Each 30-second segment of the recording is considered an "epoch."
Typically recorded at night and lasts between 6 and 8 hours.
Gold Standard diagnosis of sleep disorder.

ooh
The following are measured
Brain wave activity (EEG from occipital and parietal leads) respiratory effort
eye movements (EOG) oxyhemoglobin saturation
submental electromyography activity (EMG) heart rhythm (ECG)
nasal-oral airflow leg movements during sleep
Indications
(1) diagnosis of sleep-related breathing disorders,
(2) positive airway pressure titration and assessment oftreatment efficacy,
(3) evaluation of sleep-related behaviors that are violent or may potentially harm
the patient or bed partner.
 48

hypnogram
A form of polysomnography; it is a graph that represents the stages of sleep as a
function of time.
It was developed as an easy way to present the recordings of the brain wave activity
from an electroencephalogram during a period of sleep.
Q

Previous Year Questions AIIMS 2018 Previous Year Questions NEET 2019
Identify the investigation from the graph ? What are the features of Somnambulism?

Hierarchy of needs
 49

:
Abraham Maslow’s hierarchy of needs is a theory of psychology explaining human motivation based
on the pursuit of different levels of needs.
The theory states that humans are motivated to fulfill their needs in a hierarchical order. This order
begins with the most basic needs before moving on to more advanced needs.
The ultimate goal, according to this theory, is to reach the fifth level of the hierarchy:
self-actualization.

Learning theories
 50

Operant conditioning

Positive Negative
Applies Stimulus Applies Stimulus

Reinforcement
Increases the frequency Positive Negative
of desirable behaviour Reinforcement Reinforcement

Punishment Negative
Positive
Decreases the frequency Punishment Punishment
of desirable behaviour

Premack principle
Operant conditioning First Then
Theory of reinforcement that states that a less desired behavior can be
reinforced by the opportunity to engage in a more desired behavior.
"Grandma's rule" First you eat spinach then you can have candy.
 51
Classical conditioning
(also known as Pavlovian or respondent conditioning)

Developed by Ivan Petrovich Pavlov

Process in which a formerly neutral stimulus when paired with an unconditional
stimulus becomes a conditioned stimulus that illicit a conditioned response
Stage 1: Before Conditioning:
The unconditioned stimulus (UCS) produces an unconditioned response (UCR) in an organism.
Also involves another stimulus which has no effect on a person and is called the neutral
stimulus (NS)
Stage 2: During Conditioning:
During this stage, a stimulus which produces no response (i.e., neutral) is associated
with the unconditioned stimulus at which point it now becomes known as the conditioned
stimulus (CS).
Stage 3: After Conditioning:
Now the conditioned stimulus (CS) has been associated with the unconditioned stimulus
(UCS) to create a new conditioned response (CR).
 52

Previous Year Questions NEET 2021

A teacher taught steps of hand
washing. Students learned and
repeated at home. What
domain of learning does it fall
under?
 53

Psychotic Disorders

Psychosis Neurosis

Insight is absent Insight is present

Judgement and reasoning is impaired Judgement and reasoning is intact
Reality contact is lost Reality contact is present
Delusions usually present Delusions are absent
True hallucinations usually presents True hallucinations usually absent
Change in personality may be there Change in personality is usually absent

Delusions
A fixed belief that is not amenable to change in light of conflicting evidence.
Bizarre delusion Non-bizarre delusion
Clearly implausible and not understandable A delusion that, though false, is at least
to same-culture peers and do not derive technically possible
from ordinary life experiences
v

Eg., the affected person mistakenly

v

Eg: Belief that someone replaced all of one's

believes that they are under constant
internal organs with someone else's without
police surveillance.
leaving a scar, depending on the organ in question.

Mood-congruent delusion Mood-neutral delusion

Any delusion with content consistent A delusion that does not relate to the
with either a depressive or manic state. sufferer's emotional state;
v r

Eg: a depressed person believes that news Eg: a belief that an extra limb is growing
anchors on television highly disapprove of out of the back of one's head is neutral to
them, or a person in a manic state might either depression or mania.
believe they are a powerful deity.
 54
Types of Delusions

Erotomanic type: This subtype applies when the central theme of the delusion is that another
(De Clarembault) person is in love with the individual.

:
Grandiose type: This subtype applies when the central theme of the delusion is the conviction
of having some great (but unrecognized) talent or insight or having some
important discovery.
Jealous type: This subtype applies when the central theme of the individual's delusion
(Othello) is that his or her spouse or lover is unfaithfuI.

Prosecutory type: This subtype applies when the central theme of delusion involves the
(Nihilistic) individual's belief that he or she is being conspired against, cheated, spied
on, followed, poisoned or drugged, maliciously maligned, harassed, or
obstructed in the pursuit of long-term goals.
Somatic type: This subtype applies when the central theme ofthe delusion involved bodily
functions or sensations.
Mixed type: This subtype applies when no one delusional theme predominates.

Unspecified type: This subtype applies when the dominant delusional belief cannot
be clearly determined or is not described in the specific types
(e.g., referential delusions without a prominent persecutory or
grandiose component).
 55

Previous Year Questions

Predicted Question AIIMS 2017
Q. A person believes that he is the most important person and is very powerful. He also
believes that his colleagues and relatives are trying to harm him because of his powers. What
type of delusion is he suffering from?
A. Delusion of Grandiose and Prosecutory

Risk Factors Associated with

Delusional Disorder Previous Year Questions
Predicted Question NEET 2019

:
Advanced age Q. Which of the following is not a risk
Sensory impairment or isolation factor for Delusional Disorders?
Family history A. Young age
Social isolation B. Family history
Personality features C. Isolation
Recent immigration D. Recent immigration

Othello syndrome Morbid jealousy, or delusional jealousy, is a psychological disorder in which a

person is preoccupied with the thought that their spouse or sexual partner is
being unfaithful without having any real proof.
Capgras delusion A person holds a delusion that a friend, spouse, parent, or other close family
member (or pet) has been replaced by an identical impostor.

Fregoli delusion A person holds a delusional belief that different people are in fact a single
person who changes appearance or is in disguise.

Nihilistic delusions Delusional belief of being dead or even not existing entirely as a human being.

Cotard delusion A false belief that you or your body parts are dead, dying, or don't exist.

REACTIVE PSYCHOSIS
1. A sudden onset of symptoms.
2. Presence of a major stress before the onset (the quantum of stress
should be severe enough to be stressful to a majority of people).
3. A clear temporal relation between stress and the onset of psychotic symptoms.
4. No organic cause underlying the psychosis.
 56

CAPGRAS’ SYNDROME
(THE DELUSION OF DOUBLES)
1. Typical Capgras’ syndrome (Illusion des sosies):
Here the patient sees a familiar person as a complete stranger who is imposing on him
as a familiar person.
2. Illusion de Fregoli: The patient falsely identifies stranger(s) as familiar person(s).
3. Syndrome of subjective doubles: The patient’s own self is perceived as being replaced
by a double.
4. Intermetamorphosis: Here the patient’s misidentification is complete and the patient
misidentifies not only the ‘external appearance’ (as in the previous three types) but
also the complete personality.
Predicted Question
Previous Year Questions AIIMS 2017
A young patient is admitted with acute psychosis. He wakes up and asks for his
Wife. Upon pointing her out He denies that it is his wife and claims that she is
an imposter. What is the diagnosis?

Differential Diagnosis of Delusional Disorders

 57

Schizophrenia

Psychosis characterised by delusions, hallucinations and lack of insight.

Genetic association. - Disrupted in schizophrenia-1 (DISC1)
- Neuregulin-1 (NRG1)
Q
Schizophrenia ~ Coined by Eugene Bleuler

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

1. Auditory hallucinations
2. Broadcasting, insertion/ 1. Flattened affect
withdrawal of thoughts 2. Avolition - Apathy &
3. Bizarre behaviour loss of drive
4. Controlled feelings, 3. Autism - Social isolation
impulses or acts & withdrawal
Q
5. Delusions esp persecutory 4 Alogia - Poverty of speech
6. Disorganised thought 5. Poor self care

Good prognosis Poor prognosis

1. Late onset 1. Young onset

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

Eugen Bleuler’s Fundamental Symptoms of Schizophrenia

1. Ambivalence: Marked inability to decide for or against
2. Autism: Withdrawal into self
3. Affect disturbances: Disturbances of affect such as inappropriate affect
4. Association disturbances: Loosening of associations, thought disorder
 58

:
ICD -11 criteria of diagnosis
Episode lasting for at least 1 month

1 of the following 2 of the following

Thought alienation A) Persistent hallucinations in

Delusions of control ,influence or any modality
passivity ,actions or sensations, B) Neologisms ,breaks in the
delusional perceptions train of thoughts , resulting in
Hallucinatory voices incoherent or irrelevant
(running commentary Discussing speech (FTD)
the patients between them) C) Catatonic behaviour
Persistent delusions D) Negative symptoms
(culturally inappropriate or
completely impossible)

Previous Year Questions

Predicted Question
INICET 2020
Q. All of the following are good prognostic factors in Schizophrenia except?
a. Positive symptoms
b. Late age of onset
c. Insidious onset of symptoms
d. Associated with depression
 59

First rank symptoms of schizophrenia

Q
 60
Neurotransmitters in Schizophrenia

Dopamine in schizophrenia ②

Positive symptoms of schizophrenia

Result of increased subcortical

release of dopamine

D2 receptor activation

Negative symptoms of schizophrenia

Reduced D1 receptor activation

in the prefrontal cortex

Decreased activity of
the nucleus caudatus

•
Endophenotypic markers of genetically transmitted schizophrenia
• Smooth pursuit eye movements
• Anti saccadic eye movement
• P50 auditory evoked potential
• Pre pulse inhibition
 61
Catatonic Schizophrenia
✓
⑧
excited catatonia stuporous catatonia Catatonia alternating between
excitement and stupor

1. Increase in psychomotor activity, ranging from restlessness, agitation,

excitement, aggressiveness to, at times, violent behaviour (furore).
2. Increase in speech production, with increased spontaneity, pressure of
speech, loosening of associations and frank incoherence.
Stuporous (or Retarded) Catatonia
1. Mutism: Complete absence of speech
2. Rigidity: Maintenance of a rigid posture against efforts to be moved
3. Negativism: An apparently motiveless resistance to all commands and attempts to be
moved, or doing just the opposite
4. Posturing: Voluntary assumption of an inappropriate and often bizarre posture for long
periods of time
5. Stupor: Akinesis (no movement) with mutism but with evidence of relative preservation
of conscious awareness
6. Echolalia: Repetition, echo or mimicking of phrases or words heard
7. Echopraxia: Repetition,echo or mimicking of actions observed
8. Waxy flexibility: Parts of body can be placed in positions that will be maintained for long
periods of time, even if very uncomfortable; flexible like wax
9. Ambitendency: Due to ambivalence, conflicting impulses and tentative actions are made,
but no goal directed action occurs,
e.g. on asking to take out tongue, tongue is slightly protruded but taken back again
10. Other signs such as mannerisms, stereotypies (verbal and behavioural), automatic
obedience (commands are followed automatically, irrespective of their nature) and
verbigeration (incomprehensible speech).
 62

Psychosocial interventions for schizophrenia

Family therapy (psychoeducation)
Cognitive behaviour therapy
Cognitive remediation
Art therapy
Social skills training
Illness management skills
Supported employment
Integrated treatment for comorbid substance misuse
CQ
Schizotypal personality disorder Odd thoughts, odd behaviour, odd appearance

Schizophrenia Psychotic symptoms + Social/

occupational dysfunction ( > 6 months)

Schizoaffective Psychotic symptoms + Mood disorder

( on and off for 2 or more weeks)

Schizoid personality disorder Voluntary social isolation

Schizophreniform Schizophrenia ( < 6months )

Brief psychotic disorder Psychosis ( < 1 month)

Q
Van Gogh syndrome —> Schizophrenia + Self-mutilations.

Management
1. Somatic treatment
a. Pharmacological treatment:
Atypical (or the second generation) antipsychotic drugs, such as risperidone,
olanzapine, quetiapine, aripiprazole, and ziprasidone, are more commonly used.
b. Electro-convulsive therapy (ECT) - Schizophrenia is not a primary indication
c. Miscellaneous treatments- Limbic leucotomy (not routinely indicated)
2. Psychosocial treatment and rehabilitation.
Psychoeducation
Group psychotherapy
Family therapy
Milieu therapy (or therapeutic community)
Individual psychotherapy
Psychosocial rehabilitation
 63

Example for Schizoaffective disorder

25 year old girl presented to OPD with features suggestive of mania for the past 2 months. Her
parents also reported she was normal for a period of 2 weeks last month during which she
complained of hearing voices. What is the patient’s condition?

Mood Disorders

Major depressive Disorder

Characterized by a persistently depressed mood and long-term loss of pleasure or
interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or
inadequacy, and suicidal thoughts.
Must last at least 2 weeks.
Mania
State of abnormally elevated arousal, affect, and energy level for at least 1 week.

Hypomania
Similar to a maniac episode and last at least 4 days
Not sufficiently severe to cause impairment in social or occupational functioning
Dysthymia
Low mood occurring for at least two years, along with at least two other symptoms
of depression.
 64

Cyclothymia
Characterized by marked swings of mood between depression and elation for at least two years
Bipolar I disorder
A clinical course of one or more manic episodes and sometimes major depressive episodes.
Bipolar II disorder Q

Characterised by episodes of major depression and hypomania rather than mania.

Mania

Manic syndrome:- State of abnormally elevated arousal, affect, and energy level
During a manic episode, an individual will experience rapidly changing emotions and moods,
highly influenced by surrounding stimuli.
Although mania is often conceived as a "mirror image" to depression, the heightened mood can
be either euphoric or dysphoric.
symptoms Previous Year Questions
Predicted Question NEET 2021
elevated mood (either euphoric or irritable),
flight of ideas Q. 16 year old female patient
pressure of speech, presented with overfamiliarity, flight of
increased energy, ideas, elevated mood, increased sexual
decreased need and desire for sleep, desires, pseudo hallucinations. What is
hyperactivity. the diagnosis?

To be classified as a manic episode, while the disturbed mood and an increase in goal-
directed activity or energy is present, at least three (or four, if only irritability is
present) of the following must have been consistently present:
1 Inflated self-esteem or grandiosity.
2 Decreased need for sleep (e.g., feels rested after 3 hours of sleep).
3 More talkative than usual, or acts pressured to keep talking.
4 Flights of ideas or subjective experience that thoughts are racing.
5 Increase in goal-directed activity, or psychomotor acceleration.
6 Distractibility (too easily drawn to unimportant or irrelevant external stimuli).
7 Excessive involvement in activities with a high likelihood of painful consequences.
(e.g., extravagant shopping, improbable commercial schemes, hypersexuality).[18]
 65
Treatment
The acute treatment of a manic episode of bipolar disorder involves the utilization of either
Mood stabilizer
Carbamazepine, lithium,
valproate, lamotrigine
Atypical antipsychotic
olanzapine, risperidone,
quetiapine, aripiprazole
When the manic behaviours have gone, long-term treatment then focuses on prophylactic
treatment to try to stabilize the patient's mood, typically through a combination of
pharmacotherapy and psychotherapy.

Mnemonics for Depression Mnemonics for Mania

S Sleep disturbance D Distractibility and easy frustration
I Interest impaired I Irresponsibility & erratic uninhibited behavior
G Guilt G Grandiosity
E Energy impaired F Flight of ideas
C Concentration impaired A Activity increased with weight loss & increased libido
A Appetite decreased (more common) or increased S Sleep is decreased
P Psychomotor impairment T Thoughtfulness & Talkativeness
S Suicide (thoughts, ideation, attempt)
 66
Depression
Most common psychiatric disorder

Two facial features classically considered diagnostic of melancholic depression.

Veraguth's Sign Omega sign

“omega melancholicum”
Triangular palpebral folds running diagonally from Resembles Greek alphabet ‘Ω’
the lateral corners of the eyes, medially upward to Vertical wrinkling between the eyebrows joined
the medial end of the eyebrows at the top by a horizontal crease (white arrow)

2 major forms of Depression

Endogenous depression Exogenous depression

Biological depression Psychological depression

Without stress factor With stress factor
Melancholic depression Reactive depression
 67

Atypical depression
According to the DSM-IV, symptoms of depression with atypical features include the following
A Mood reactivity (i.e., mood brightens in response to positive events)
B Two or more of the following features, present for most of the time, for at least two weeks:
1 Increased appetite
2 Increased sleep
3 Leaden paralysis (i.e., heavy, leaden feelings in arms or legs)
4 Interpersonal rejection sensitivity (not limited to episodes of mood disturbance)
resulting in significant social or occupational impairment
C Criteria are not met for melancholic or catatonic features of depression.

Symptom Atypical Melancholic (nonatypical)

Mood reactivity present Lack of mood reactivity even

Mood reactivity (brightens in response to temporarily, when something
positive events) good happens
Significant weight gain or Significant anorexia or weight
Weight/appetite
increase in appetite loss
Excessive sleep all through Decreased sleep with early
Sleep
the day morning awakening
Psychomotor Leaden paralysis (heavy Psychomotor retardation or
activity feeling in arms, legs) agitation
Interpersonal rejection
Excessive or inappropriate guilt
Personality/thinking sensitivity not limited to
during mood episodes
mood episodes
Depression likely worse in
Depression regularly worse in
Diurnal variation evening (not part of
mornin
diagnostic criteria)
 68
Melancholic depression
Requiring at least one of the following symptoms:
• Anhedonia (the inability to find pleasure in positive things)
• Lack of mood reactivity (i.e. mood does not improve in response to positive events)
And at least three of the following:
• Depression that is subjectively different from grief or loss
• Severe weight loss or loss of appetite
• Psychomotor agitation or retardation
• Early morning awakening
• Guilt that is excessive
• Worse mood in the morning

Cognitive distortions
Beck proposes that those with depression develop cognitive distortions
Faulty or unhelpful thinking patterns.

• Arbitrary inference - drawing conclusions from insufficient or no evidence.

• Selective abstraction - drawing conclusions on the basis of just one of many
elements of a situation.
• Overgeneralisation - making sweeping conclusions based on a single event.
• Magnification - exaggerating the importance of an undesirable event.
• Minimisation - underplaying the significance of a positive event.
• Personalisation - attributing negative feelings of others to oneself.
 69
Beck's cognitive triad
~ Aaron beck
Negative triad
Cognitive-therapeutic view

• The self – "I'm worthless and ugly" or "I

wish I was different" (Helplessness)
• The world – "No one values me" or "people
ignore me all the time" (Worthlessness)
• The future – "I'm hopeless because things
will never change" or "things can only get
worse!" (Hopelessness)

Phases of treatment for depression

The primary goal in the acute phase is to achieve a response using psychotherapy,
medications, or a combination of the two forms of therapy, eventually resulting in
remission. (Paradoxical suicide in Acute phase)
Response: A significant improvement in depressive symptoms, although residual
symptoms are usually present.
Remission is achieved when the patient has achieved a full restoration of normal
capacity for social and occupational function.
The goal in the continuation phase of treatment is to prevent relapse, and this phase
lasts for up to 9 months.
The maintenance phase of treatment typically lasts for a year after a patient's first
episode of depression, but may continue indefinitely, depending on the patient's likelihood
risk for recurrence.
 70

Major depression is highly recurrent.

single episode▪
of depression ~40% recurrence within 2 years

2 episodes of depression ~75% recurrence

•
A combination of psychotherapy and pharmacotherapy is the most effective treatment for
major depressive disorder.
psychotherapy
Cognitive Behavioral Therapy (CBT) is one of the most common types of talk therapy
used in the treatment for depression
Education (pinpointing the life problems that contribute to a patient's depression
& which aspects of those problems they may be able to solve or improve)
Improving self-esteem (a patient's sense of self-regard, confidence & hope)
Psychological (ego) functioning (cognitive abilities, affect regulation, morals &
ability to relate to others)
Adaptive skills (behaviors associated with effective function with friends, family &
coworkers)
Interpersonal Therapy
Consists of 12 to 1 6 weekly sessions and is characterized by an active therapeutic approach.
Behavior Therapy
By addressing maladaptive behaviors in therapy, patients learn to function in the
world in such a way that they receive positive reinforcement.

pharmacotherapy

AIIMS 2018
Patients with atypical depression respond
effectively to treatment with MAOIs and
SSRIs than TCAs
 71

Somatic modalities
 72

BEREAVEMENT, GRIEF, AND MOURNING

••
Grief: Subjective feeling precipitated by the death of a loved one.
•
Mourning: Process by which grief is resolved;
It is the societal expression of post bereavement behavior and practices.
•
Bereavement: The state of being deprived of someone by death and refers to being in the state
of mourning.

Bereavement Major Depressive Disorder

Symptoms may meet syndromal criteria for Any symptoms as defined by DSM-5
major depressive episode, but the survivor
rarely has morbid feelings of guilt and
worthlessness, suicidal ideation, or
psychomotor retardation
Considers self bereaved May consider self weak, defective, or bad

Dysphoria often triggered by thoughts or Dysphoria is often autonomous and

reminders of the deceased independent of thoughts or reminders of the
deceased
Onset is within the first 2 months of Onset at any time
bereavement
Duration of depressive symptoms is less than Depression often becomes chronic,
2 months intermittent, or episodic
Functional impairment is transient and mild Clinically significant distress or
impairment
No family or personal history of major Family or personal history of major
depression depression

Previous Year Questions NEET 2020

Q. A 25 yearPredicted
old female
Question patient presented with

loss of interest in daily activities, insomnia,

weight loss for past 6 months . She hears voices
instructing her to kill herself.
What is the diagnosis?
A. Major Depressive Disorder with psychotic features
 73

Stages of grief
Q
Proposed by Kubler-Ross

Refuse to believe the diagnosis

Stage 1 :
Shock and Appear dazed at first
Denial "I feel fine."; "This can't be happening, not to me."

Persons become frustrated, irritable, and angry at being ill.

They commonly ask, "Why me?" "Who is to blame?"
Stage 2:
Anger Patients in the stage of anger are difficult to treat.
Become angry at God, their fate, a friend, or a family member they
may even blame themselves.

Attempt to negotiate with physicians, friends, or even God

Stage 3:
Bargaining Involves the hope that the individual can somehow postpone or delay death.
"I'll do anything for a few more years."; "I will give my life savings if..."

Begins to understand the certainty of death

Clinical signs of depression:-
Withdrawal,
Stage 4: Hopelessness,
Psychomotor retardation,
Depression Suicidal ideation.
Sleep disturbances,
"I'm going to die... What's the point?"

Patients realize that death is inevitable

Stage 5 :
Acceptance Feelings can range from a neutral to a euphoric mood.
"I can't fight it, I may as well prepare for it."

Mnemonics
D Denial
A Anger
B Bargaining
D Depression
A Acceptance
 74

Previous Year Questions

Most common Suicidal tendency High recurrence in
NEET 2020
Predicted Question

Q.Treatment for No treatment Common after next pregnancy

postpartum blues? 2nd birth Mother child separation

Bipolar disorder

Recurrent episodes of mania and depression in the same patient at different times
 75

Hypomania
Mania
Normal mood Mixed episode

Depression
Subsyndromal
depression

Subtypes of Bipolar Disorder

1. Bipolar I
Characterised by episodes of severe mania and severe depression
2. Bipolar II
Characterised by episodes of hypomania (not requiring
hospitalisation) and severe depression

Depression
Mania

Unipolar in depression Bipolar in depression

Bipolar in mania

Once a Maniac, always a bipolar

Bipolar mood disorder has an earlier age of onset (third decade) than recurrent depressive
(unipolar) disorder.
Unipolar depression is common in two age groups: late third decade and fifth to sixth decades.
An average manic episode lasts for 3-4 months
A depressive episode lasts from 4-6 months.
Unipolar depression usually lasts longer than bipolar depression.
 76

rapid cyclers
Patients with bipolar mood disorder have more than 4 episodes per year.
About 70-80% of all rapid cyclers are women.
ultra-rapid cycling
When phases of mania and depression alternate very rapidly (e.g. in matter of
hours or days)
Factors associated with rapid cycling
Use of antidepressants (especially tricyclic antidepres- sants),
low thyroxin levels,
female gender,
bipolar II pattern of illness,
Presence of neurological disease.
Rapid cycling

Normal mood

Depression
l 12 months

Prognostic Factors
Good Prognostic Factors
1. Acute or abrupt onset
2. Typical clinical features
3. Severedepression
4. Well-adjusted premorbid personality
5. Good response to treatment.

Poor Prognostic Factors

1. Co-morbid medical disorder, personality disorder or alcohol dependence
2. Double depression (acute depressive episode superimposed on chronic depression
or dysthymia)
3. Catastrophic stress or chronic ongoing stress
4. Unfavourable early environment
5. Marked hypochondriacal features, or mood-incongruent psychotic features
6. Poor drug compliance.
 77
Treatment of Bipolar disorder

Bipolar management principle

Antimaniac
A
2014 Bipolar in depression
Bipolar in normal
Bipolar in Mania B Mood stabilisers
2015 2016
C
Antidepressants

A —> Antimaniac or Mood stabilisers

B —> Antidepressants + Mood stabilisers
C —> Mood stabilisers

indications for ECT in depression

i. Severe depression with suicidal risk.
Predicted Question

ii. Severe depression with stupor, severe psycho-

Q. All are included in Bipolar except?
motor retardation, or somatic syndrome.
A. Mania alone
iii. Severe treatment refractory depression.
yB. Depression alone
iv. Delusional depression (psychotic features).
C. Hypomania and subsyndromal depression
v. Presence of significant antidepressant side-
D. Hypomania and depression
effects or intolerance to drugs.
 78

Neurotic disorders
Anxiety disorder
Generalised Anxiety Disorder
Phobic disorders
Panic disorders
Obsessive- Compulsive and related disorders (OCD)
OCD
Hoarding disorder
Trichotillomania
Skin picking disorder
Body Dysmorphic Disorder
Trauma and Stress - related disorders
Acute stress reaction
Adjustment disorders
Post- traumatic stress disorder
Dissociative disorders
Dissociative Fugue
Dissociative identity disorder
Depersonalisation and Derealization
Dissociative Amnesia
Somatic Symptom and Related disorders
Somatic Symptom Disorder
Illness anxiety disorder
Pain disorder
Functional neurological symptom disorder

Anxiety disorder
Generalized anxiety disorders
Anxiety is continous, although it may fluctuate in intensity.
Phobic anxiety disorders
Anxiety is intermittent, arising in particular circumstances.
Panic disorder
Anxiety is intermittent, but its occurrence is unrelated to any particular circumstances.
Previous Year Questions NEET 2020
Q.A Medical student presented to opd with intermittent episodes of
Predicted Question

a feeling of impending doomed by intense perspiration usually

prior to exams. What is the diagnosis ?
 79
Symptoms of anxiety
Psychological arousal
Fearful anticipation Restlessness
Irritability Poor concentration
Sensitivity to noise Worrying thoughts
Autonomic arousal
Gastrointestinal Respiratory
● Dry mouth ● Constriction in the chest
● Difficulty in swallowing ● Difficulty inhaling
● Epigastric discomfort Cardiovascular
● Excessive wind ● Palpitations
● Frequent or loose motions ● Discomfort in the chest
Genitourinary ● Awareness of missed beats
● Frequent or urgent micturition
● Failure of erection
● Menstrual discomfort
Muscle tension Hyperventilation
Tremor Dizziness
Headache Tingling in the extremities
Aching muscles Feeling of breathlessness

Sleep disturbance
Insomnia
Night terror

Phobic anxiety Panic disorder Generalised anxiety

Occurrence
Situational Paroxysmal Persistent
of anxiety

Associated
Avoidance Escape Agitation
behaviour

Associated Fear of situation Fear of symptoms Worry

cognitions

Somatic
With exposure Episodic Persistent
Symptoms
 80

Phobia Panic disorder Generalised

ni
Feeling of impending doom anxiety disorder
Episodic Episodic
Panic attack Always worried
Continuous
-

N For 6 months

Stimulus + Sudden in onset, lasts for a few

Free floating anxiety
Irrational fear of a specific minutes and is characterised
object, situation or activity by very severe anxiety.
Q
D/d -> Medical emergencies
81
 82

PHOBIC DISORDER
Irrational fear of a specific object, situation or activity, often leading to persistent
avoidance of the feared object, situation or activity.

Agoraphobia Social phobia Specific (Simple) phobia.

Irrational fear of situations Irrational fear of Irrational fear of a specified
Most common performing activities in object or situation.
Fear of the presence of other Leads to persistent avoidant
Open spaces, people or interacting behaviour
public places, with others.
Crowded places, Eg. Fear of
Eg. Fear of
Any place from which Acrophobia (high places),
Blushing (erythrophobia), Zoophobia (animals),
there is no easy escape
Public speaking/ performance Xenophobia (strangers)
Q

Speaking to strangers Claustrophobia (closed places).

(Most common)

Syncope and bradycardia

All other phobias cause tachycardia
 83

Treatment of Phobia
Drug Treatment

:
Behaviour Therapy
1. Flooding. Benzodiazepines
2. Systematic desensitisation. Alprazolam (DOC) is stated to have anti-
3. Exposure and response prevention. phobic, anti-panic and anti-anxiety properties.
4. Relaxation techniques. Antidepressants
SSRIs( DOC)
- paroxetine (most widely used drug)

Exposure therapy ( Type of Behavioral therapy)

Graded exposure
Sudden exposure
+
Relaxation

Better Flooding
Systemic desensitisation
 84

Obsessive Compulsive Disorder

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

Psychodynamic Theory of Obsessive Compulsive Disorder

a
 85
DSM-5 – characteristics of OCD
OCD: Characterised by either obsessions (recurring thoughts, images etc.) and/or
compulsions (repetitive behaviours such as hand washing). Most people with a diagnosis of
OCD have both obsessions and compulsions .
Q
Trichotillomania: Compulsive hair pulling
Hoarding disorder: the compulsive gathering of possessions and the inability to part with
anything regardless of its value.
Excoriation disorder: Compulsive skin picking.

Previous Year Questions AIIMS 2018

Predicted Question
Q. Frequency of presenting patterns in OCD?
Obsession of contamination > Pathological doubt > Need for symmetry > Sexual
 86

The OCD cycle

Treatment
Psychotherapy
Psychoanalytic psychotherapy
Supportive psychotherapy
Behaviour Therapy and Cognitive Behaviour Therapy
i. Thought-stopping (and its modifications).
ii. Response prevention.
iii. Systematic desensitisation.
iv. Modelling.
Drug Treatment
Benzodiazepines (e.g. alprazolam, clonazepam)
Antidepressants ( e.g. Clomipramine, Fluoxetine)
Antipsychotics (e.g. haloperidol, risperidone, olanzapine, aripiprazole, pimozide)
Buspirone
Electroconvulsive Therapy
Psychosurgery
i. Stereotactic limbic leucotomy.
ii. Stereotactic subcaudate tractotomy.
 87
Treatment of OCD
DOC : SSRI
Therapy : ERP
• fluoxetine Exposure and Response prevention
• fluvoxamine
Do not respond Make the Don’t make
Be hands dirty him wash
Clomipramine
(The 1st FDA approved drug for OCD)
Most effective

Predicted Question
•
Resperidone
Q. Treatment of choice in OCD?
(augmentation strategies
in resistant OCD)
A. SSRI
B. ECT
C. CBT
-
ECT
( for comorbid depression ) D. Psychoanalytic psychotherapy

Psychosurgery
Q
“ Cingulotomy”

Intrinsic risk factors for poor response to

conventional treatment of OCD
Early onset
Content of obsessive- compulsion symptoms
Hoarding Previous Year Questions NEET 2019
Sexual Predicted Question
A. Which of the following is a poor
Religious prognostic factor with exposure and
Somatic response prevention in OCD?
Overvalued ideas and poor insight
A. Pathological doubt
Sensorial phenomena
B. Magical thinking
Higher symptom severity at onset C. Hoarding
Presence of tics D. Contamination obsession
Comorbidities
Schizotypal, borderline and paranoid personality disorder,
Anankastic personality disorder

Previous Year Questions AIIMS 2018

Predicted Question
Q. Frequency of presenting patterns in OCD?
Obsession of contamination > Pathological doubt > Need for symmetry > Sexual
 88

Hoarding Disorder
Characterized by acquiring and not discard ing things that are deemed to be of
little or no value, resulting in excessive clutter of living spaces.
Challenges posed by hoarding patients to typical CBT treatment include poor insight
to the behavior and low motivation and resistance to treatment.
The most effective treatment for the disorder is a cognitive behavioral model that
includes training in decision making and categorizing; exposure and habituation to
discarding; and cognitive restructuring.

trichotillomania
Hair-pulling disorder
Chronic disorder characterized by repetitive hair pulling, leading to variable
hair loss that may be visible to others.
There is an intense urge to pull out hair with mounting tension before the act
and a sense of relief afterwards.
The management of impulse control disorders consists of behaviour therapy (e.g. aversion
therapy), cognitive behaviour therapy (CBT), individual psychotherapy, and occasionally
Q
pharmacotherapy (e.g. carbamazepine for intermittent explosive disorder; fluoxetine for
trichotillomania).
 89
Diogenes syndrome
•
Diogenes Syndrome is a behavioral disorder that affects older adults.
•
It occurs in both men and women.
•
The main symptoms are excessive hoarding, dirty homes, and poor personal hygiene.
•
People with Diogenes syndrome also withdraw from life and society.
They often live alone and are unaware that anything is wrong with the condition of their

:home and lack of self-care.

These conditions often lead to illnesses like pneumonia, or accidents like falls or fires.
It is often through these situations that the person’s condition first becomes known.
•
Extremely difficult to treat.
Body dysmorphic disorder
Characterized by a preoccupation with an imagined defect in appearance

Firm conviction Doubt checking

Delusional dysmorphophobia OCD

The DSM–5 list the following criteria for diagnosing BDD:

• Preoccupation with one or more imperfections in a person’s appearance that others
cannot see or that are very slight.
• Carrying out repetitive behaviors, such as mirror checking, touching, rubbing or
picking at the perceived flaw, or drawing comparisons with others.
• Preoccupation that causes significant distress, leaving the person unable to function
effectively in social, occupational, and other areas of life.
• The concern does not relate to weight or body fat in people who have an eating
disorder, such as anorexia nervosa.

STRESS RELATED DISORDERS

Exceptionally stressful life event Significant life change

(death of a loved one, natural
(Financial loss, exam failure, breakup,
catastrophe, accident, rape)
major illness in family member)

acute stress post traumatic stress

disorder ADJUSTMENT DISORDERS
disorder (PTSD)
Begins after 1-2 days Onset in 1 month of stress Begins within 1 month of stressor
and is usually minimal If > 1 month : Duration is usually less than 6 months
after about three days. Delayed onset PTSD
 90

Timeline
Timeline of events that occur after a stressful event Dysthmia
(chronic depression)
Acute stress Adjustment Cyclothymia
Depression
reaction disorder (mood swings)

Stress
Event <2days 2days- 1month >2wks >1month <6months >6months >2yrs

Chronic
Acute stress
disorder PTSD grief

Timeline in Psychiatry
Mania 1 week
Hypomania 4 consecutive days
Major Depressive Disorder >= 2 weeks for 6 - 12 months
Cyclothymia >= 2 years
Dysthymia >= 2 years
Maternal Blues 2 weeks
Post Partum Mood disturbances Within 4 weeks of delivery
Brief Psychotic Disorder < 1 month Tourette
Schizophreniform disorder 1 - 6 months < 18 years age onset
••

Schizophrenia > 6 months ticks for > 1 year

••

Schizoaffective > 2 weeks duration.

Delusional Disorder > 1 month
Panic Disorder One episode followed by 1 month of
concern of additional attacks.
Specific Phobia > 6 months
General Anxiety Disorder > 6 months
Acute Stress Disorder 3 days to 1 month
PTSD > 1 month
Adjustment Disorder 3 months - 6 months of stress
( > 6 months in chronic stress)
Bulimia Nervosa >= 3 months
ADHD > 6 months
Somatic Symptom Disorder >= 6 months
 91
acute stress disorder
Commonly seen in female gender and people with poor coping skills.
The symptoms range from a ‘dazed’ condition, anxiety, depression, anger, despair,
overactivity or withdrawal, and constriction of the field of conscious- ness.
Treatment is removal of the patient from the stressful environment .
IV or oral benzodiazepines (such as diazepam) in cases with marked agitation.
92
 93
Symptoms of PTSD
Reliving Avoiding
Relive the ordeal through thoughts and The person may avoid people, places,
memories of the trauma. thoughts, or situations that may remind
These may include flashbacks, hallucinations, them of the trauma.
and nightmares. (flash bulb memory) This can lead to feelings of detachment
They also may feel great distress when and isolation from family and friends, as
certain things remind them of the trauma, well as a loss of interest in activities that
eg: anniversary date of the event. the person once enjoyed.

Negative cognitions and mood Increased arousal

Excessive emotions; problems relating to
others, including feeling or showing affection;
This refers to thoughts and feelings
difficulty falling or staying asleep; irritability;
related to blame, estrangement, and
outbursts of anger; difficulty concentrating;
memories of the traumatic event.
and being "jumpy" or easily startled.
The person may also suffer physical
symptoms, such as increased blood
pressure and heart rate, rapid breathing,
muscle tension, nausea, and diarrhea.

Treatment of PTSD
1. Prevention: Anticipation of disasters in the high risk areas, with the training of personnel
in disaster management.
2. Disaster management: Here the speed of providing practical help is of paramount
importance. This is also a preventive measure.
3. Supportive psychotherapy.
4. Cognitive behaviour therapy (CBT).
5. Drug treatment: Antidepressants and benzodiazepines (in low doses for short periods) are
useful in treatment, if anxiety and/or depression are present.

Previous Year Questions INICET 2020

Q. A male patient who lost his job recently (1 week back) following which he
became irritablePredicted
and had sad mood, the thoughts of job and future made his
Question

mood even worse. He was more irritated towards the people in his home, but
occasionally went for a movie with his friends and was able to enjoy with them
but after returning back to his home, he again had similar symptoms.
What is the probable diagnosis?
A. Adjustment disorder
 94
Adjustment disorder
Mental symptoms include:
• rebellious or impulsive actions
• withdrawn attitude
• anxiousness
• lack of concentration
• feelings of sadness, hopelessness, or being trapped
• loss of self-esteem
• crying • suicidal thoughts
Clinical Subtypes
1. Adjustment disorder with depressed mood
2. Adjustment disorder with anxiety
3. Adjustment disorder with disturbance of conduct
4. Adjustment disorder with disturbance of emotion and conduct
Treatment
1. Supportive psychotherapy remains the treatment of choice.
2. Crisis intervention
3. Stress management training and Coping skills training.
4. Drug treatment anxiety (benzodiazepines) and/or depressive symptoms (antidepressants)
DSM-5 Diagnosis
Symptoms
Cause
Treatment
 95
Dissociative Disorders

Derealization: Loss of sense of the reality of the external world

Depersonalization: Loss of sense of your own reality
Dissociative amnesia: A condition that involves the inability to remember
important information about your life
Dissociative fugue: A form of reversible amnesia that involves personality,
memories, and personal identity
Dissociative identity disorder (DID): A condition marked by the presence of two or
more distinct personalities within one individual

Depersonalization
Alexithymia, or an inability to recognize or describe emotions
Feeling physically numb to sensations
Feeling robotic or unable to control speech or movement
Feeling unconnected to your body, mind, feelings, or sensations
Inability to attach emotions to memories
The sense that your body and limbs are distorted (swollen or shrunken)
The sense that your head is wrapped in cotton
Derealization
Distance and the size or shape of objects may be distorted.
You may have a heightened awareness of your surroundings.
Recent events may seem to have happened in the distant past.
Surroundings may seem blurry, colorless, two-dimensional, unreal, or larger-than-
life or cartoonish.

Types of Dissociative Amnesia

1. Localized amnesia: Inability to recall events related to a circumscribed period of time.
2. Selective amnesia: Ability to remember some, but not all, of the events occurring
during a circumscribed period of time.
3. Generalized amnesia: Failure to recall one's entire life.
4. Continuous amnesia: Failure to recall successive events as they occur.
5. Systematized amnesia: Amnesia for certain categories of memory , such as all
memories relating to one's family or to a particular person.
 96

Somatic Symptom and Related disorders

ik

Conversion disorder
Loss of functioning in some part of the body for psychological rather than physical reasons
Patient is not bothered by/ is comfortable in spite of symptoms.
La belle indifference.
ik

Somatization disorder
History of complaints about physical symptoms, affecting many different areas of the
body, for which medical attention has been sought but no physical cause found
ik

Pain disorder
History of complaints about pain, for which medical attention has been sought
but that appears to have no physical cause
ik

Hypchondriasis
Chronic worry that one has a physical disease in the absence of evidence that one does;
frequently seek medical attention
ik
Body dysmorphic disorder
Excessive preoccupation with some part of the body the person believes is defective
 97

Factitious Disorder
Also called Munchausen syndrome,
Deliberate feigning of physical or psychological symptoms to assume the sick role.
Factitious disorder is distinguished from malingering in which symptoms are also falsely
reported; however, the motivation in malingering is external incentives, such as
avoidance of responsibility, obtaining financial compensation, or obtaining substances.
Pseudologia fantastica
The patients distort their clinical histories, laboratory tests’ reports,
and even facts about other aspects of their lives
Factitious disorder by proxy
Factitius disorder imposed on another is when one person presents the other
person as ill, most often mother and child.
Grid-iron abdomen
Evidence of earlier treatment, usually surgical procedures, is often available
in the form of multiple scars
 98
Ganser Syndrome
Seen in prisoners under trial
: Conversion symptoms, hallucinations, confusion, approximate answers.
 99

Neurocognitive Disorders
Organic mental disorders
Reduced brain function due to illnesses that are not psychiatric in nature.
F00 Dementia in Alzheimer’s disease
F01 Vascular dementia
F02 Dementia in other diseases classified elsewhere
F03 Unspecified dementia
F04 Organic amnesic syndrome, not induced by alcohol and other psychoactive substances
F05 Delirium, not induced by alcohol and other psychoactive substances
F06 Other mental disorders due to brain damage and dysfunction and to physical disease
F07 Personality and behavioural disorders due to brain disease, damage and dysfunction
F09 Unspecified organic or symptomatic mental disorder

Dementia
Progressive cognitive impairment in clear consciousness.
1. Impairment of intellectual functions,
2. Impairment of memory (predominantly of recent memory, especially in early stages),
3. Deterioration of personality with lack of personal care
Additional features
Emotional lability - marked variation in emotional expression.
Catastrophic reaction- when confronted with an assignment which is beyond the residual
intellectual capacity, patient may go into a sudden rage.
Thought abnormalities, e.g. perseveration, delusions.
Urinary and faecal incontinence may develop in later stages.
Disorientation in time; disorientation in place and person may also develop in later stages.
Neurological signs may or may not be present, depending on the underlying cause.
 100

Causes of Dementia

Causes of Delirium
 101

Dementia

Cortical Subcortical Mixed

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

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

DISEASE DISEASE
6. WILSON’S DISEASE

FEATURES CORTICAL SUBCORTICAL

FUNCTIONAL Apraxia, Agnosia, Aphasia Impaired processing &
DEFICIT executive
Memory Learning deficit Retrieval deficit
impairment
Neuropsychiatric Uncommon Depression, apathy
symptoms
Motor Extrapyramidal
symptoms Uncommon symptoms, dystopia
Slow, hypophonic,
Speech Normal dysarthric
Language Aphasic Normal
 102
Alzheimer’s Dementia
Commonest cause of dementia
Neurochemically, there is a marked decrease in brain choline acetyltransferase (CAT)
with a similar decrease in brain acetylcholinesterase (AchE).
The condition progresses gradually for the first 2–4 years, with increasing memory
disturbance and lack of spontaneity.

Core features
Memory impairment (amnesia), with
Risk factors for non- familial Alzheimer’s disease

gradual onset and continuing decline

Aphasia
Apraxia
Agnosia
Anosmia
Disturbance in executive functioning
(e.g. planning, reasoning)

Other features
Depression
Psychosis
Behavioural symptoms
(e.g. agitation, wandering)
Personality change
 103

Lewy Body Dementia

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

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

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

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

The swallow tail sign describes the normal axial imaging appearance of nigrosome-1
within the substantia nigra on high-resolution T2*/SWI weighted MRI.
Absence of the sign (absent swallow tail sign) is reported to have a diagnostic
accuracy of greater than 90% for Parkinson disease and dementia with Lewy bodies
 104

Parkinson’s Disease
Parkinsonism is a clinical syndrome involving bradykinesia, plus at least one of
the following three features: tremor, rigidity and postural instability.
All patients with Parkinson's disease have parkinsonism, but not all patients with
parkinsonism have Parkinson's disease.

Clinical features
The presentation is usually asymmetrical, e.g. a resting tremor in an upper limb.
Typical features of an established case include:
Bradykinesia: Slowness in initiating or repeating movements, impaired fine
movements (causing small handwriting) and expressionless face. The patient is slow to
start walking, with reduced arm swing, rapid small steps and a tendency to run
(festination).
Tremor: Present at rest (4–6 Hz), diminished on action; it starts in the fingers/thumb
and may affect arms, legs, feet, jaw and tongue.
Rigidity: Cogwheel type mostly affects upper limbs; plastic (lead-pipe) type mostly
affects legs.
Non-motor symptoms may precede typical motor symptoms and include:
● Depression
● Anxiety
● Cognitive impairment

Investigations
Diagnosis is clinical.
CT may be needed if any features suggest pyramidal, cerebellar or autonomic
involvement, or if the diagnosis is in doubt, but is usually normal for age.
Patients <50 yrs should be tested for Wilson’s disease and Huntington’s disease.

Mnemonics
The cardinal triad of idiopathic
Parkinson’s disease is T Tremor at rest,
a rest tremor, R Rigidity,
cog-wheel rigidity, A Akinesia (or bradykinesia)
bradykinesia. P Postural instability.
 105

Psychiatric manifestations in Parkinson’s disease

Delirium, stupor (especially due to

drugs, or intercur- rent infection)
Cognitive decline (subcortical
dementia, dysexecutive syndrome)
Depression, apathy, mania
Hallucinations (chiefly visual)
Delusions
Sleep attacks, REM sleep behaviour
disorder
Sexual disorders
Impulse control disorders, e.g.
gambling (largely medication-
related)
 106
Extrapyramidal symptoms

Mnemonics
Extrapyramidal side effects of anti- psychotic drugs

P - Parkinsonian syndrome
A - Akathisia PAARTy Night
A - Acute dystonia
R - Rabbit syndrome
T - Tardive dyskinesia
N - Neuroleptic malignant syndrome
 107

Delirium
Delirium is characterised by
1. A relatively acute onset,
2. Clouding of consciousness, characterised by a decreased awareness of surroundings
and a decreased ability to respond to environmental stimuli,
3. Disorientation (time > place > person), associated with a decreased attention span and
distractibility.
Disturbance of sleep-wake cycle;( insomnia at night with daytime drowsiness)
sun downing
Diurnal variation is marked, usually with worsening of symptoms in the evening and night.

motor symptoms in delirium

1. Asterixis (flapping tremor),
2. Multifocal myoclonus,
3. Carphologia or floccillation (picking movements at cover-sheets and clothes),
4. Occupational delirium (elaborate pantomimes as if continuing their usual
occupation in the hospital bed), and
5. Tone and reflex abnormalities.
 108

Predisposing Factors
1. Pre-existing brain damage or dementia Previous Year Questions NEET 2018
2. Extremes of age (very old or very young) Predicted Question
A. Which of the following is in
3. Previous history of delirium
favour of delirium ?
4. Alcohol or drug dependence
A. Occurs gradually
5. Generalised or focal cerebral lesion

:
B. Fluctuating
6. Chronic medical illness
C. Preserved consciousness
7. Surgical procedure and postoperative period
D. Auditory hallucinations
8. Severe psychological symptoms (such as fear)
9. Treatment with psychotropic medicines
10. Present or past history of head injury Mnemonic
11. Individual susceptibility to delirium OCD CAMPS

Features Delirium Dementia

Onset Sudden & Insicious

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

Psychomotor Hyperactive or Not usually present

changes hypoactive

Sleep-Wake Often Often normal

cycle reversed

Delirium -Presence of altered level of

Previous Year Questions INICET 20
consciousness with cognitive Q. . Which of the following features differentiate
Predicted Question

impairment. delirium from dementia in Alzheimer’s Disease?

- Sudden and acute a. Acuity of onset and agitation
b. Acuity of onset and level of consciousness
Dementia - Loss of cognitive functions c. Visual hallucinations and impaired memory
in clear consciousness. d. Agitation and irritation
- Chronic condition
 109

Previous Year Questions NEET 2018

Predicted Question
Q. The confusion assessment
test is used in?
 110

ORGANIC AMNESTIC SYNDROME

1. Impairment of memory due to an underlying organic cause,
2. No severe disturbance of consciousness and attention (unlike delirium),
3. No global disturbance of intellectual function, abstract thinking and personality
(unlike dementia).
Wernicke-Korsakoff syndrome.
Thiamine deficiency
Most common cause of organic amnestic syndrome is chronic
alcohol dependence.
Wernicke’s encephalopathy-> acute phase of delirium
preceding the organic amnestic syndrome,
Korsakoff’s syndrome-> chronic phase of amnestic syndrome.

Wernicke's encephalopathy.
Acute neuropsychiatric condition due to an initially reversible biochemical brain
lesion caused by depletion of vitamin B1 (thiamine).
Causes
• Chronic alcohol use
• Protein-calorie malnutrition from malabsorption or forced/self-imposed inadequate diet
• Patients with protracted vomiting
• Carbohydrate loading (intravenous or oral) when thiamine stores are minimal
• Chronic renal failure
• Hyperalimentation, AIDS, and drug misuse
• Genetic abnormality of transketolase enzyme
Clinical Features
• Mental disturbances:
• Progressive depression of the state of consciousness.
• Global confusional apathetic state, profound listlessness,
inattentiveness and disorientation.
• Paralysis of eye movements:
• Vlth nerve palsy and diplopia.
• Nystagmus.
• Internuclear ophthalmoplegia.
• Ataxia of gait-this affects stance and gait predominantly.
 111

Management
• Immediate administration of thiamine.
• Magnesium is often required as it is a cofactor required for normal functioning of
thiamine-dependent enzymes.
• Intravenous glucose solutions should not be given particularly in malnourished
patients, as they may exhaust the patient's reserve of B vitamins and either
precipitates Wernicke's disease in a previously unaffected patient or cause a rapid
worsening of an early form of the disease.

Korsakoff psychosis
A late complication of persistent Wernicke encephalopathy and results in memory
deficits, confusion, and behavioral changes.
Korsakoff psychosis occurs in 80% of untreated patients with Wernicke encephalopathy.
Korsakoff syndrome is often accompanied by Wernicke encephalopathy; this
combination is called Wernicke–Korsakoff syndrome.
Symptoms
1 anterograde amnesia, memory loss for events after the onset of the syndrome
2 retrograde amnesia, memory loss extends back for some time before the onset
of the syndrome
3 amnesia of fixation, also known as fixation amnesia (loss of immediate memory, a
person being unable to remember events of the past few minutes)
4 confabulation, that is, invented memories which are then taken as true, due to
gaps in memory, with such gaps sometimes associated with blackouts
5 minimal content in conversation
6 lack of insight
7 apathy – interest in things is quickly lost, and there is an indifference to change

Mnemonics Mnemonics
Wernicke's encephalopathy. Korsakoff psychosis
C Confusion R Retrograde amnesia
O Ophthalmoplegia A Anterograde amnesia
A Ataxia C Confabulation
T Thiamine deficiency K Korsakoff’s psychosis

Confabulation
To fill in the memory gaps, the patient uses imaginary events in the early
phase of illness.
 112

ORGANIC CATATONIC DISORDER

1. Stupor (diminution or complete absence of sponta- neous movement with partial

or complete mutism, negativism, and rigid posturing);
2. Excitement (gross hypermotility with or without a tendency to assaultiveness);
3. Mixed (shifting rapidly and unpredictably from hypo- to hyperactivity)

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

Stupor Excitment

STUPOR- no psycho-motor activity IMPULSEIVENESS

catalepsy- passive induction of a
agitation
posture held against gravity stereotypy- repetitive, abnormally
waxy flexibility- allowing positioning frequent, non-goal-directed movements
by examiner and maintaining that
echolalia- mimicking another's speech
position
mutism- no, or very little, verbal response echopraxia: mimicking another's
negativism- opposition or no response to movements.
instructions or external stimuli
Previous Year Questions INICET 20
posturing- spontaneous and active
Q. A psychotic patient developed voluntary
maintenance of a posture against
purposeless movements and was once observed
gravity
grimacing- keeping a fixed facial
to be standing still forPredicted
hoursQuestion
with waxy flexibility,
expression What is the appropriate medical management?
a. Haloperidol
b. Lorazepam
✓
Stupor Akinesis and Mutism c. Clonidine
d. Propranolol

Benzodiazepine is the drug of choice preferable

Intramuscular Lorazepam.
Electro convulsive therapy (ECT) is effective in Catatonia
 113

Organic Personality Disorders

Significant alteration of the premorbid personality caused by an underlying
organic cause without major disturbance of consciousness, orientation,
memory or perception.

1. Frontal lobe syndrome (Types)

a. Orbito-frontal syndrome Disinhibition, jocularity, impulsivity, impaired
(Pseudo-psychopathic) insight and judgement
b. Frontal convexity type Apathy, lack of initiative, retardation, perseveration
(Pseudo-depressive)
c. Medial frontal syndrome (Akinetic) Akinesis, incontinence, poor verbal output

2. Temporal lobe syndrome Egocentricity, explosive affect, perseveration, excessive

religiosity, obsessional traits

3. Bilateral temporal lobe or Emotional placcidity, hyper-orality, altered sexual behaviour,

limbic system lesions excessive exploration of environment (hyper-metamorphosis)
 114

Psychoactive Substance Use Disorders

mechanism of drug addiction

Substances of dependence and abuse

• Alcohol • Cannabis
• Opium and its derivatives • Cocaine
• Barbiturates • Caffeine
• Chloral hydrate • Nicotine
 115

w
Addiction Mechanism

Dopamine Dynorphin Disinhibition of

Increase Increase Prefrontal areas

From ventral From Can’t think properly

segmental area nucleus accumbens

Gives a feeling It’s an opioid that

oh high satisfaction numbs the area
which increases tolerance.

A psychoactive drug is one that is capable of altering the mental functioning

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

Cluster of physiological, behavioural, and cognitive phenomena in which

the use of a substance or a class of substances takes on a much higher
priority for a given individual than other behaviours that once had
greater value.
Harmful Use
1. Continued drug use, despite the awareness of
harmful medical and/or social effect of the drug being used, and/or
2. A pattern of physically hazardous use of drug (e.g. driving during intoxication).
 116

major dependence producing drugs

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

ALCOHOL USE DISORDERS

Signs of Alcohol Intoxication

1 . Slurred speech
2. Dizziness
3. lncoordination
4. Unsteady gait
5. Nystagmus
6. Impairment in attention or memory
7. Stupor or coma
8. Double vision

Level Likely Impairment

20-30 mg/dL Slowed motor performance and decreased thinking ability
30-80 mg/dL Increases in motor and cognitive problems
80-200 mg/dL Increases in incoordination and judgment errors
Mood lability
Deterioration in cognition
200-300 mg/dL Nystagmus, marked slurring of speech, and alcoholic blackouts
>300 mg/dL Impaired vital signs and possible death
 117
Classification of Alcoholism

Factors Type I Type II

Synonym Milieu-limited Male-limited
Gender Both sexes Mostly in males
Age of onset > 25 years < 25 years
Aetiological factors Genetic factors important; Heritable; environmental influences
strong environmental are limited
influences are contributory
Family history May be positive Parental alcoholism and antisocial
behaviour usually present
Loss of control Present No loss of control
Other features Psychological dependence; Drinking followed by aggressive
and guilt present behaviour; spontaneous alcohol seeking
Pre-morbid Harm avoidance; Novelty-seeking
personality traits High reward dependence

A. Alpha (α)
B. Beta (β)
i. Excessive and inappropriate drinking to relieve
i. Excessive and inappropriate drinking.
physical and/or emotional pain.
ii. Physical complications (e.g. cirrhosis,
ii. No loss of control.
gastritis and neuritis) due to cultural
iii. Ability to abstain present.
drinking patterns and poor nutrition.
iii. No dependence.
C. Gamma (γ); malignant alcoholism
i. Progressivecourse. D. Delta (δ)
ii. Physical dependence with tolerance and i. Inability to abstain.
with- drawal symptoms. ii. Tolerance.
iii. Psychological dependence, with iii. Withdrawal symptoms.
inability to control drinking. iv. The amount of alcohol consumed can
be controled.
E. Epsilon (ε) v. Social disruption is minimal.
i. Dipsomania (compulsive-drinking).
ii. Spree-drinking.
 118

Mnemonics
Alcohol intoxication
S -SPEECH SLURRED
A -ATTENTION IMPAIRMENT
M -MEMORY IMPAIRMENT
S -STUPOR OR COMA
G -GAIT UNSTEADY
I -INCOORDINATION
N -NYSTAGMUS
119
 120

Withdrawal Syndrome

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

Treatment
• Benzodiazepines- lorazepam (Ativan), diazepam (Valium), or chlordiazepoxide
(Librium), which can effectively
• Barbiturates, like phenobarbital
• Antipsychotics, such as haloperidol (Haldol), may be used in low doses to help reduce
problematic behaviors

2. Alcoholic seizures (‘rum fits’) Multiple Generalised tonic clonic seizures

3. Alcoholic hallucinosis Presence of hallucinations (usually auditory) during

partial or complete abstinence

Previous Year Questions NEET 21

Previous Year Questions AIIMS 2019
Q. What is the cause of delirium Q. A 53 year male, who is a chronic alcoholic, tried to stop
tremens in an alcoholic? using alcohol after severalPredicted
requests by his family
Question

A. Acute Infection members. He started feeling uneasy and on day 3, he was

brought to the hospital with disorientation, irritability,
paranoid delusions , visual hallucinations and altered
sensorium. Which is your probable diagnosis
 121
Screening
AUDIT
The Alcohol Use Disorders Identification Test (AUDIT) is considered the most accurate
alcohol screening tool for identifying potential alcohol misuse, including dependence.
It was developed by the World Health Organisation, designed initially for use in primary
healthcare settings with supporting guidance.
CAGE
The CAGE questionnaire, the name of which is an acronym of its four questions, is a widely
used method of screening for alcoholism.
SADQ (more specific)
The Severity of Alcohol Dependence Questionnaire (SADQ or SAD-Q) is a 20 item clinical
screening tool designed to measure the presence and level of alcohol dependence

CAGE questionnaire

Alcoholics Anonymous

Voluntary self-help group with

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

Alcoholics Anonymous is based on a

number of fundamental principles,
known as the ‘Twelve Steps’, to which
members adhere.
 122
Approach to treatment of alcohol misuse
● Raise awareness of problem
● Increase motivation to change
● Support and advice
● Withdraw alcohol (or controlled drinking)
● High-intensity psychological treatments
● Alcoholics Anonymous
● Medication (disulfiram, acamprosate, naltrexone)

Disulfiram: Mode of Action

Motivation cycle
Cycle of change
Prochaska & DiClemente

Revolving door syndrome refers to

the tendency of clients to get
better for a while, and then end up
relapsing.
 123
Treatment of alcohol withdrawal
Detoxification is the treatment of alcohol withdrawal symptoms, i.e. symptoms
produced by the removal of the ‘toxin’ (alcohol).
The drugs of choice for detoxification are usually benzodiazepines. Chlordiazepoxide
(80-200 mg/day in divided doses) and diazepam (40-80 mg/day in divided doses) are the
most frequently used benzodiazepines.

Treatment of Alcohol Dependence

i. Behaviour therapy
Aversion therapy Eg: sub- threshold electric shock
emetic such as apomorphine.

ii. Psychotherapy - group and individual psychotherapy

iii. Deterrent agents - alcohol sensitising drugs.

Eg: Disulfiram
iv. Anti-craving agents - Acamprosate, naltrexone and SSRIs (such as fluoxetine)

v. Psychosocial rehabilitation

CANNABIS USE DISORDER

Mild cannabis intoxication
Mild impairment of consciousness and orientation, Tremors,
Light- headedness, Photophobia,
Tachycardia, Lacrimation,
A sense of floating in the air, Reddening of conjunctiva,
A euphoric dream-like state, Dry mouth
Alternation (either an increase or decrease) in Increased appetite.
psychomotor activity,

Perceptual disturbances RUN AMOK

Depersonalisation, Caused by the continued use or
even first time use of cannabis
Derealisation, Characterized by a frenzied desire
Synaesthesias (sensation in one sensory modality caused by a of the person to commit murders.
He first kills a person against
sensation in another sensory modality, e.g. ‘seeing’ the music), whom he may have real or
Increased sensitivity to sound. imaginary enmity and then kills
anyone who comes in his way until
‘Flashback phenomenon’ recurrence of
the homicidal tendency lasts.
cannabis use experience in the absence
of current cannabis use. Then he may commit suicide or
surrender himself.
 124
Q
complications of cannabis use
Hemp insanity or cannabis psychosis Cannabis :
(Good prognosis) Most common illegal
• Acute schizophreniform disorder substance
• Disorientation Nicotine :
Most common substance
• Confusion use/abuse
Amotivational syndrome
Lethargy, Anergia, Mnemonics
Apathy, Reduced drive Cannabis intoxication
Loss of interest, Lack of ambition.
M MOUTH DRY
E ERYTHEMATOUS CONJUNCTIVA
A APPETITE INCREASED
T TACHYCARDIA

Q
Magnan's sign

Clinical sign in which people

with cocaine addiction
experience paraesthesia which
feels like a constantly moving
foreign body, such as fine sand
or powder, under the skin.

COCAINE USE DISORDER

Can be administered by:

orally intranasally smoking (free basing) parenterally

 125

Followed by
cocaine ‘runs’ (binges) cocaine ‘crashes’ (interruption of use).

speed ball Heroin (an opioid depressant) + Cocaine (a stimulant)

Acute cocaine intoxication

Pupillary dilatation,
Sniffing Snorting
Tachycardia,
Hypertension, Anterior nasal Posterior nasal
Sweating, septum perforation septum perforation
Nausea or vomiting.
A hypomanic picture with increased psychomotor activity, grandiosity,
elation of mood, hypervigilance and increased speech output.
Later, judgement is impaired and there is impairment of social or
occupational functioning.
Phases in Cocaine Withdrawal Syndrome
Sub-stage & Clinical Features
Phase Duration
i. 9 hours to Agitation, depression, anorexia, craving +++
I (Crash phase)
ii. 4 days Fatigue, depression, sleepiness, craving +
iii. after discontinuation Exhaustion, hypersomnia with intermittent
awakening, hyperphagia, craving ±

II i. 4 to 7 days after Normal sleep, improved mood, craving ±

discontinuation
ii Anxiety, anergia, anhedonia, craving ++

III (Extinction phase) After 7-10 days No withdrawal symptoms, increased

of discontinuation vulnerability to relapse

treatment of overdose
Oxygenation, Triphasic withdrawel
Muscle relaxants,
IV thiopentone and/or IV diazepam
(for seizures and severe anxiety).
Treatment of Chronic Cocaine Use
Bromocriptine (a dopaminergic agonist)

I
Reduce cocaine craving
Amantadine (an antiparkinsonian)
Supportive psychotherapy and
Prevention of relapse
Contingent behaviour therapy
 126

OPIOID USE DISORDERS

Opioid Derivatives

A. Natural Alkaloids of Opium B. Synthetic Compounds

1. Morphine 1. Heroin
2. Codeine 6. Meperidine (Pethidine)
2. Nalorphine 7. Cyclazocine
3. Thebaine 3. Hydromorphone
4. Noscapine 8. Levallorphan
4. Methadone 9. Diphenoxylate
5. Papaverine 5. Dextropropoxyphene

Parenteral mode
heroin
Smoked or ‘Chased’ (chasing the dragon)

:
Impure form ‘smack’ or ‘brown sugar’ in India
More addicting than morphine and can cause
dependence even after a short period of exposure.

Acute Intoxication
Apathy, Respiratory depression,
Bradycardia, Subnormal core body temperature,
Hypotension, Pin-point pupils.
Later, delayed reflexes, thready pulse and coma may occur in case of a large overdose.
In severe intoxication, mydriasis may occur due to hypoxia.

Withdrawal Syndrome
Peaks
within 24-72 hours

Onset of symptoms
within 12-24 hours
^ Subside
within 7-10 days

Lacrimation, Insomnia,
Rhinorrhoea, Raised body temperature,
Pupillary dilation, Muscle cramps,
Sweating, Generalised bodyache,
Diarrhoea, Severe anxiety,
Yawning, Piloerection,
Tachycardia, Nausea and vomiting
Mild hypertension, Anorexia.
 127

laboratory tests
1. Naloxone challenge test (to precipitate withdrawal symptoms).
2. Urinary opioids testing:
Radioimmunoassay (RIA), Gas-liquid chromatography (GLC),
Free radical assay technique (FRAT), High pressure liquid chromatography (HPLC) or
Thin layer chromatography (TLC), Enzyme-multiplied immunoassay technique (EMIT).

Treatment of Opioid Overdose

Narcotic antagonists (such as naloxone, naltrexone).
Detoxification
‘taken off’ opioids. Withdrawal symptoms are managed by:
Use of substitution drugs such as methadone
Clonidine- α2 agonist that acts by inhibiting norepinephrine release at
presynaptic α2 receptors.
Naltrexone with Clonidine
Maintenance Therapy
1. Methadone maintenance (Agonist substitution therapy)
2. Opioid antagonists
3. Psychotherapy, behaviour therapy, interpersonal therapy, CBT.

LSD USE DISORDER

Trip Occasional use followed by a long period of abstinence.

flashback A spontaneous recurrence of the LSD use experience in a drug free state.
Usually occurs weeks to months after the last experience
bad trip Acute panic reaction
Substance with no physical dependence
Substance with no withdrawal symptoms
LSD
Substance with only psychological dependence
Substance with only craving
 128
Cannabis Types
Bhang - Uncultivated plant Increase in concentration
: Ganja - Dried leaves, inflorescence
do drug (Tetrahydrocannabinol)
Hashish/Charas - Resin, exudates
: Hash Oil - Oil extract
(Most potent)

Nicotine - craving management

Buproprion
:
Varenicline
 129

Personality Disorders
and Miscellaneous Disorders

Personality disorders Previous Year Questions INICET 20

Traits start in childhood Q. A 24 yr old male who is shy and prefers social
Matures by 18 x 25 yrs isolation appears to be emotionally cold and
Difficult to change or treat resides alone. There is no hallucinations or
delusions. What is the probable diagnosis ?
 130

Personality types

Type A and D are more prone to Coronary artery disease

 131

Paranoid Personality Disorder antisocial personality disorder

Suspicious Callous
Mistrustful Transient relationships
Jealous Irresponsible
Sensitive Impulsive and irritable
Resentful Lacking guilt and remorse
Bears grudges Failure to accept responsibility
Self-important
histrionic personality disorder
Schizoid Personality Disorder
Self-dramatization
Emotionally cold Suggestibility
Detached Shallow labile affect
Aloof Seeks attention and excitement
Lacking enjoyment Inappropriately seductive
Introspective Over-concern with physical attractiveness

Narcissistic Personality Disorder Anxious (Avoidant)

Personality Disorder
Grandiose sense of self-importance
Fantasizes about unlimited success, power, etc. Feels socially inferior
Believes himself or herself to be special Preoccupied with rejection
Requires excessive admiration Avoids involvement
Sense of entitlement to favours and Avoids risk
compliance Exploits others Avoids social activity
Lacks empathy Obsessive-Compulsive (Anankastic)
Envious of others, and believes that others Personality Disorder
envy him or her Preoccupied with details, rules, etc.
Arrogant and haughty Inhibited by perfectionism
Over-conscientious and scrupulous
Dependent Personality Disorder Excessively concerned with work and
productivity
Allows others to take responsibility
Over-conscientious, scrupulous, and inflexible
Unduly compliant
in ethics and morals
Unwilling to make reasonable demands
Unable to discard worthless objects
Feels unable to care for himself or herself Reluctant to delegate tasks or work with
Fear of being left to care for himself or herself others
Needs excessive help to make decisions Miserly
Rigidity and stubbornness
 132
Feeding and Eating Disorders
anorexia nervosa
Syndrome characterized by three essential criteria.
A behavior self-induced starvation to a significant degree

*o
A psychopathology a relentless drive for thinness or a
morbid fear of fatness
A physiological
symptomatology Presence of medical signs and
symptoms resulting from starvation

Restricting type: During the last 3 months, the individual

has not engaged in recurrent episodes of binge eating or
purging behavior. Weight loss is accomplished primarily
through dieting, fasting, and/or excessive exercise.

Binge-eating/ purging type: During the last 3 months, the individual is engaging in
recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the
misuse of laxatives, diuretics, or enemas).
DSM-5 Diagnostic Criteria for Anorexia Nervosa
A. Restriction of energy intake relative to requirements, leading to a significantly low body
weight in the context of age, sex, developmental trajectory, and physical health.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes
with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one's body weight or shape is experienced, undue
influence of body weight or shape on self-evaluation, or persistent lack of
recognition of the seriousness of the current low body weight.

Body mass index (BMI) is used by the DSM-5 as an

indicator of the level of severity of anorexia nervosa.
• Mild: BMI of greater than 17
• Moderate: BMI of 16–16.99
• Severe: BMI of 15–15.99
• Extreme: BMI of less than 15

Anorexia Nervosa is associated with amenorrhea,

A patient with anorexia nervosa hypothyroidism, hypoglycemia,
leukopenia,hypercholesterolemia, hypersecretion of CRH,
Hypotension, Hypokalemic alkalosis.
Previous Year Questions AIIMS 2019
A patient with anorexia is following the diet prescribed but is still not gaining
weight. What is the next step in management ?
A. Observe the patient for 2 hrs after food to rule out any history of vomiting.
 133
Scoff Questionnaire for Anorexia Nervosa and Bulimia
The SCOFF Questionnaire is a valid and reliable screening tool for detecting the existence
of an eating disorder.
The questions focus on some key characteristics of anorexia and bulimia.
S -Do you make yourself SICK (vomit) because you feel uncomfortably full?
C - Do you worry that you have lost CONTROL over how much you eat?
O - Have you recently lost more than ONE stone in a 3 month period?
F - Do you believe yourself to be FAT when others say you are too thin?
F - Would you say that FOOD dominates your life?
if NO to every question, the test indicates the unlikelihood of an eating disorder.
If YES to one question, it may be useful to further examine eating patterns and the
presence of body image issues.
If YES to two or more questions, there may be an eating disorder that may need further
investigation, support or treatment.
Adapted from Morgan J.F., Reid F., and Lacey, J.H (1999)
Rumination Disorder
Repeated involuntary regurgitation of food over a period of > 1 month
Night Eating Disorder
Recurrent episodes of hyperphagia at night.
:
Insomnia.
Lack of desire for food in morning.
Bulimia nervosa
Episodes of binge eating combined with inappropriate ways of stopping weight gain.
DSM-5 Diagnostic Criteria for Bulimia Nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterised by:
1 . Eating, in a discrete period of time (e.g., within any 2-hour time period), an
amount of food that is definitely larger than what most individuals would eat in a
similar period of time under similar circumstances.
2. A sense of lack of control over eating during episode (e.g., a feeling that one
cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-
induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive
exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least
once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
 134

Predicted Question

What are the DSM-5 Diagnostic Criteria

for Bulimia Nervosa?
 135

Psychosexual and
gender identity disorders
Sexual disorders

Psychological and Behavioural Sexual Paraphilias

Gender identity
Disorders Associated With Sexual dysfunctions
disorders
Development and Maturation

1. Transexualism 1. Sexual maturation disorder 1. Delayed ejaculation

2. Gender identity 2. Egodystonic sexual orientation 2. Erectile disorder
disorder of childhood. 3. Sexual relationship disorder 3. Female orgasmic disorder
3. Dual-role transvestism. 4. Female arousal disorder
4. Intersexuality. 5. Penetration disorder

Gender identity disorders

Transexualism
A person who strongly desires to assume
the physical characteristics and gender
role of the opposite sex

1. Normal anatomic sex.

2. Persistent and significant sense of discomfort
regarding one’s anatomic sex and a feeling that it
is inappropriate to one’s perceived-gender.
3. Marked preoccupation with the wish to get rid of one’s genitals and secondary sex
characteristics, and to adopt sex characteristics of the other sex (perceived-gender).
4. Diagnosis is made after puberty.
Primary secondary
Onset in early childhood and has Onset later in life, less severe
a stable course over time.
i. Male (or, male-to-female) primary transexualism.
ii. Female (or, female-to-male) primary transexualism.
Dual-role Transvestism
People who wear clothes of the opposite sex to experience being the opposite sex
temporarily, but don't have a sexual motive or want gender reassignment surgery.
No sexual excitement accompanies the cross-dressing (unlike in fetishistic transvestism).
 136

Gender-identity Disorder of Childhood

Very early age of onset (2-4 years of age)
1. Persistent and significant desire to be of the other gender, or insistence on being of the
other gender.
2. Marked distress regarding the anatomic sex, with strong denial of anatomic sex
(in contrast, there is no denial of anatomic sex in transexualism).
3. Involvement in traditional activities, games and clothing pattern of the perceived gender.
4. Onset before puberty.

PSYCHOLOGICAL AND BEHAVIOURAL DISORDERS ASSOCIATED

WITH SEXUAL DEVELOPMENT AND MATURATION
1. Sexual maturation disorder
Uncertainty regarding the gender identity or sexual orientation.
2. Egodystonic sexual orientation
Sexual orientation is clear. Most common is homosexuality

Homosexuality

Sexual relationship between persons of the same sex

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

Ego-syntonic homosexuality Ego-dystonic homosexuality

(no distress about homosexual (associated with marked distress)
behaviour).
 137

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

Physical Causes of Male Erectile Disorder/Impotence

I. Local Genital Pathology
1. Priapism
2. Congenital malformations
3. Surgical procedures on pelvic region,
4. Mumps
5. Elephantiasis
6. Hydrocele or varicocele.
II. Endocrine Disorders
1. Diabetes mellitus
2. Dysfunction of pituitary-adrenal-testis axis
3. Testicular atrophy,
4. Thyroid dysfunction.
III. Neurological Disorders
1. Autonomic neuropathy,
2. Spinal cord lesions
3. 3rd ventricle tumours
4. Brain damage, especially in temporal lobe
5. Multiple sclerosis.
IV. Cardiovascular Disorders
Sildenafil citrate has
1. Leriche syndrome. been used for
V. Any Severe or Debilitating Systemic Illness treatment of erectile
VI. Alcohol and Drugs. dysfunction.
 138

Sexual Dysfunctions Caused by Drugs

•
 139

Components of ANTIDEPRESSANT WITH Previous Year Questions INICET 2020

LEAST SEXUAL DYSFUNCTION
sexual response Q. Which of the following
Desire BUPROPION
antidepressants is associated with
Arousal AGOMELATINE
least sexual dysfunction?
MITRAZAPINE
Orgasmic a. Mirtazapine
•
TRAZADONE
Resolution b. Venlafaxine
c. Imipraine
d. Fluoxetine

Phases Dysfunction
Desire or Appetitive Hypoactive sexual desire disorder
phase Sexual aversion disorder

Excitement and Female sexual arousal disorder

plateau phase Male erectile disorder

Female orgasmic disorder

Orgasmic
phase
Male orgasmic disorder
Premature ejaculation
Resolution Postcoital dysphoria
phase
Postcoital headache

Erectile dysfunction (MC)

Satyriasis
sed: 1 2
Nymphomaniac Had erection once
Arousal/ Excitement Never had erection
•
Longest stage Mostly
Always organic
psychogenic
Desire Resolution Sexual cycle Plateau Early morning
erection. + in 2

sed: Frigidity
Orgasm Q
Shortest stage

Premature ejaculation Previous Year Questions NEET 19

( <1 min) Q. What is the order of
phases of sexual response?
 140

Premature ejaculation

Ejaculation before the completion of satisfactory sexual activity for both partners.
In severe cases, it is characterised by ejaculation either before penile entry into
vagina or soon after penetration.

biological psychological
(relatively uncommon) (e.g. performance anxiety).
Doc: SSRI
Squeeze technique (Seman’s technique)
Dual Sex therapy : Patient + Partner

PARAPHILIAS
(DISORDERS OF SEXUAL PREFERENCE)

Fetishism
The sexual arousal occurs either solely or predominantly with a nonliving
object, which is usually intimately associated with the human body.

Fetishistic Transvestism
The person actually or in fantasy wears clothes of the opposite sex (cross-
dressing) for sexual arousal. This disorder should be differentiated from
dual-role transvestism and transexualism.
 141

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

Sexual Masochism

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

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

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

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

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

Paedophilia

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

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

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

Others
Sexual arousal with urine (urophilia); faeces (coprophilia); enemas
(klismaphilia); corpses (necrophilia),
 142

Dhat Syndrome
Seen in sexually illiterate people.
Belief that seminal discharge causes loss of energy, fatigue, somatic symptoms.

Koro Syndrome
Fear of shrinking of male sex organs into the abdomen causing fear, depression.

Male Hypoactive Sexual Desire Disorder

Symptoms for min 6 months.
Deficient thoughts, desires for sexual activity.
 143

Psychiatric disorders in childhood and adolescents

•Mental Retardation •Conduct disorders
Specific developmental disorders •Tic disorders
•Pervasive Developmental Disorders •Elimination Disorders
•Attention Deficit Hyperactive Disorders •Other Disorders

Mental Retardation

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

2 years to 7 years of life

i. Egocentric thought with a unique logic of its own, involving a limited
point of view and lacking introspection.
ii. Inability to generalise from specific events and to specify from
general events.
Abstract or Conceptual Thinking Stage
7 years of age and lasts till 11 years of age
i. Ability to focus on several dimensions of a problem at one time,
mentally.
ii. The thought process is flexible and reversible.
iii. Ability of abstraction, i.e. ability to generalise from specific and ability
to find similarities and differences among specific objects.
Adolescent Thinking or Formal Operational Stage
Begins at 11 years of age and continues life-long.
i. Ability to imagine the possibilities inherent in a situation, thus making the
thought comprehensive.
ii. Ability to develop complete abstract hypotheses and to test them.
 144

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

mental age
Intelligence Quotient × 100
chronological age

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

DQ<70% -> Developmental delay

If it involves two or more field -> global developmental delay
Eg. cerebral palsy
 145

Causes of Mental Retardation

Previous Year Questions NEET 18

Q. What is the new term for Mental

retardation According to American
psychiatric association in its
revision of DSM-5?
A. Intellectual disability
 146

Classification of Mental Retardation

(Based on Standard Deviation and Percentile difference)
Mild Moderate Severe Profound
2 to 3 SD 3 to 4 SD 4 or more SD 4 or more SD
below mean below mean below mean below mean

0.1 - 2.3 0.003 - 0.1 < 0.003 < 0.003

percentile percentile percentile percentile

Check adaptive functioning to differentiate

Levels of disability
Benefits from Level of
Levels IQ disability act Prevalence functioning
Mild 50 - 69 50% 85% Educate 9 - 12 years
Moderate 35 - 49 75% Trained 6 - 9 years
Severe 20 - 34 90% Dependence 3- 6 years
Profound < 20 100% 1% Life Support < 3 years
 147

Specific developmental disorders

Developmental reading disorder dyslexia

Developmental arithmetic disorder dyscalculia

Developmental language disorder

dyslalia Phonological disorder: articulation errors
(e.g. wabbit for rabbit, ca for car, bu for blue).
Expressive language disorder:
Restricted vocabulary, difficulty in selecting appropriate words, and
immature grammatical usage, Cluttering of speech
Receptive language disorder:
Receptive-expressive language disorder
Problems include failure to respond to simple instructions.
Developmental coordination disorder
clumsy child syndrome or motor dyspraxia
poor coordination in daily activities of life,
 148

Pervasive Developmental Disorders

Infantile autism
Childhood onset autism or childhood onset pervasive developmental disorder.
The onset occurs before the age of 2 1⁄2 years

1. Autism (marked impairment in reciprocal social and interpersonal

interaction):
i. Absent social smile.
ii. Lack of eye-to-eye-contact.
iii. Lack of awareness of others’ existence or feelings; treats people as furniture.
iv. Lack of attachment to parents and absence of separation anxiety.
v. No or abnormal social play; prefers solitary games.
vi. Marked impairment in making friends.
vii. Lack of imitative behaviour.
viii. Absence of fear in presence of danger.
2. Marked impairment in language and non-verbal communication
i. Lack of verbal or facial response to sounds or voices;
ii. In infancy, absence of communicative sounds like babbling.
iii. Absent or delayed speech
iv. Abnormal speech patterns and content. Presence of echolalia,
perseveration, poor articulation and pronominal reversal (I-You) is common.
v. Rote memory is usually good.
vi. Abstract thinking is impaired.
3. Abnormal behavioural characteristics
i. Mannerisms.
ii. Stereotyped behaviours such as head-banging, body-spinning, hand-flicking,
lining-up objects, rocking, clapping, twirling, etc.
iii. Ritualistic and compulsive behaviour.
iv. Resistance to even the slightest change in the environment.
v. Attachment may develop to inanimate objects.
vi. Hyperkinesis is commonly associated. Idiot savant syndrome
In spite of the pervasive impairment of
4. Mental retardation functions, certain islets of precocity or
splinter functions may remain.
Eg : prodigious rote memory or
calculating ability, and musical abilities.
 149

Types of autism spectrum disorder

Feature Childhood disintegrative

Autistic disorder Asperger’s syndrome Rett’s syndrome
disorder/ Heller Syndrome

Age at 0-36 Usually >36 5-30 > 24

recognition (Months) (Months) (Months) (Months)

Sex ratio Male > Female Male >> Female Females only Male > Female

Loss of skills Variable Usually not Marked Marked

Social skills Very poor Poor Varies with age Very poor
Communication
Usually poor Fair Very poor Very poor
skills
Circumscribed Variable Marked NA NA
interest (Mechanical) (Facts)

Family history Sometimes Frequent Not usually No

Seizure disorder Common Uncommon Frequent Common

Head growth No No Yes Q No

decelerates

Severe MR Mild MR
IQ range Severe MR Severe MR
to normal to normal

Outcome Poor to fair Fair to good Very poor Very poor

 150

Rhett Syndrome
- Associated with MECP2 gene in Chromosome X (so affects female more).
Childhood Disintegrative Psychosis (Heller Syndrome)
- Bowel and Bladder disturbances present.

ATTENTION DEFICIT DISORDER (HYPERKINETIC DISORDER)

1. Attention deficit disorder with hyperactivity

(Hyperkinetic disorder)
Q Previous Year Questions NEET 18
Commonest type.
Q. Which disorder is known as
Poor attention span with distractibility Minimal brain dysfunction ?
i. Fails to finish the things started.
ii. Shifts from one uncompleted activity to another.
iii. Doesn’t seem to listen.
iv. Easily distracted by external stimuli.
v. Often loses things. 60% of cases with Tourette
Hyperactivity syndrome develop ADHD.
i. Fidgety.
ii. Difficulty in sitting still at one place for long.
iii. Moving about here and there.
iv. Talks excessively.
v. Interference in other people’s activities.
Impulsivity
i. Acts before thinking, on the spur of the moment.
ii. Difficulty in waiting for turn at work or play.

2. Attention deficit disorder without hyperactivity:

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

3. Residual type:
It is usually diagnosed in a patient in adulthood, with a past history of ADD
and presence of a few residual features in adult life.
4. Hyperkinetic disorder with conduct disorder (Hyperkinetic
conduct disorder).
 151
Treatment
Pharmacotherapy
Stimulant medication:
Stimulation of the Decreasing
Dextroamphetamine
methylphenidate } Act on the reticular
activating system
inhibitory influences on
the cerebral cortex
hyperactivity and/or
distractibility.

In pre - school children, 4 methyl phenidate can cause sympathomimetic side effects like a raise
in BP, tachycardia, insomnia and has abuse potential.
Drugs like Atomocetine (SNRI) is preferred in such cases.
Behaviour Modification
Counselling and Supportive Psychotherapy

ATTENTION DEFICIT DISORDER

CONDUCT DISORDERS
Characterised by a persistent and significant pattern of conduct, in which the
basic rights of others are violated or rules of society are not followed.
According to ICD-10, there are four subtypes of conduct disorder:
1. Conduct disorder confined to the family context.
2. Unsocialised conduct disorder.
3. Socialised conduct disorder.
4. Oppositional defiant disorder.
 152

The characteristic clinical features include:

1. Frequent lying.
2. Stealing or robbery.
3. Running away from home and school.
4. Physical violence such as rape, fire-setting, assault
or breaking-in, use of weapons.
5. Cruelty towards other people and animals.

socialised (group) type unsocialised (solitary) type

More common More serious disorder with usually a
The person claims loyalty severe underlying psychopathology.
to his or her group.

€0
For conduct disorder, >= 6 months of symptoms is required.
€0
Symptoms must start at < 18 years ( after 18 years, it is anti social personality disorder)
€0
Destructive, deceitful gang activities.
Oppositional Defiant Disorder
Age < 10 years
•

Opposition and defiance (+), no destructive features

•

Reactive Attachment Disorder

•
Child doesn’t seek comfort when distressed, minimally responds to comfort.
•< 5 years of age.

Adoptive Trial
•
Birth parents, adoptive parents, adopted child.
Encopresis
•
Soiling of clothes with feces (diagnosis at > 4 years of age).
Enuresis
•
> 5 years of age.
 153

TIC DISORDERS
Tic is an abnormal involuntary movement (AIM) which occurs suddenly,
repetitively, rapidly and is purposeless in nature.

1. Motor tic, characterised by repetitive motor movements.

2. Vocal tic, characterised by repetitive vocalisations.
Tourette’s disorder is typically characterised by:
1. Multiple motor tics.
2. Multiple vocal tics.
3. Duration of more than 1 year.
4. Onset usually before 11 years of age and
almost always before 21 years of age.

Motor tics Earliest to appear, beginning in the head

region and then progressing downwards.

i. Simple motor tics: ii. Complex motor tics:

Eye- blinking, Facial gestures, Twirling,

Grimacing, Stamping, Echokinesis (repetition of
Shrugging of shoulders, Jumping, observed acts),
Tongue protrusion. Hitting self, Copropraxia (obscene acts).
Squatting,
Vocal tics
i. Simple vocal tics: ii. Complex vocal tics:
Coughing, Symptoms of Tourette syndrome;
Barking, Eg: , Echolalia (repetition of heard phrases),
Throat-clearing, Palilalia (repetition of heard words),
Sniffing, and Coprolalia (use of obscene words),
Clicking. Mental coprolalia (thinking of obscene words).

Previous Year
Previous Year Questions INICET 20 Questions
INICET 20
Q A 7 year old child presented with history of bed wetting for last 1 year, at a
Q. Selective Mutism in
frequency being twice a week. With thorough investigations, organic cause
children is indication of:
is ruled out. What should be the initial treatment plan:
a. Childhood depression
a. Pharmacotherapy with imipramine
b. Childhood anxiety
•
b. Psychodynamic psychotherapy
c. Hyperkinetic disorder
c. Bladder training with reward for delaying micturition in daytime
d. Childhood Psychosis
d. Bell and pad based classical conditioning
✓
 154
Elimination Disorders
Nocturnal enuresis
Involuntary voiding at night after 5 yrs of age for more than 3 months
Primary- Child has not yet had a prolonged period of dry
Secondary- Child begins wetting after having stayed dry
Epidemiology
- 60% are boys
- 50% have family history

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

Childhood anxiety disorder

Most common type of psychiatric problem in children.

Cause severe impairment and excessive distress.
1. Separation anxiety disorder
Excessive anxiety concerning separation from home or major attachment figures
2. selective mutism
The persistent failureto speak in specific social situations despite
speaking in other favourable situations
selective mutism
Children refuse to speak in situations where talking is expected or necessary
It interferes with school and making friends
They stand motionless and expressionless, turn their heads, chew or twirl
hair, or withdraw into a corner to avoid talking
Avoid eye contact,
They can be very talkative and display normal behaviors at home or in
comfortable places
Diagnosed at around 5 years of age
 155

Psychiatric emergencies
Suicide
Commonest cause of death among the psychiatric patients.
Deliberate self-harm (DSH) and is defined as a human act of self-intentioned
and self-inflicted cessation (death)

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

Drugs that reduce the risk of suicide

- Lithium
- Clozapine
ECT also reduces the risk of suicide.

Paradoxical suicide
Patients recovering from suicidal depression are at high risk
As the depression lifts, patient become energised and put their suicidal plan to action.
 156

Care of the suicidal patient in hospital

Previous Year Questions INICET 20

Q. A patient was treated with TCA for a major depressive episode in the hospital for 4
weeks. Which of the following are main concerns while considering his discharge?
t
a. Suicidal risk
b. ECG monitoring for arrhythmias
c. Drug monitoring
d. Sedation being the side effect
 157

Community psychiatry
MENTAL HEALTH ACTS IN INDIA
Developed to protect the basic fundamental right of people “Right to live ” that
comes under article 21 of constitution.
MENTAL HEALTH ACTS IN INDIA

PRE-INDEPENDENCE POST-INDEPENDENCE
1947:Indian Psychiatric
1858:Indian Lunatic
association established.
assylum act of 1858
1987:Mental Health act of
1912:Indian Lunancy
1987(indian psychiatric society)
act of 1912
Mental Health Care Bill
proposed in 2013

Mental Health Care Bill , 2013

Comes under Ministry Of Health and Family Welfare.

Introduced in the Rajya Sabha on August 19, 2013.
The Bill repeals the Mental Health Act, 1987.
The union cabinet has approved the amendments on Jan 30, 2014.
The new Bill is much longer than the existing MHA having 16 Chapters and 137 clauses.

Mental Health Care Bill , 2016

Comes under Ministry Of Health and Family Welfare

Passed in the Rajya Sabha on August 8th , 2016.
If passed in Lok Sabha, then it repeals the Mental Health Act, 1987.
The premeable clearly depicts protect, promote and fulfill rights of persons with mental
illnesses.
Consists of 16 chapters and 126 clauses

Mental health bill,2017

Right of mentally ill

Advanced directive
Mental health authorities
Decriminalizing suicide, prohibiting ECT
 158
Chapters
CHAPTER I: PRELIMINARY:CLAUSES
CHAPTER II: MENTAL ILLNESS AND CAPACITY TO MAKE MENTAL HEALTH CARE AND TREATMENT DECISIONS
CHAPTER III: ADVANCE DIRECTIVE
CHAPTER IV: NOMINATED REPRESENTATIVE
CHAPTER V: RIGHTS OF PERSON WITH MENTAL ILLNESS
CHAPTER VI:DUTIES OF APPROPRIATE GOVERNMENT
CHAPTER VII: CENTRAL MENTAL HEALTH
CHAPTER VIII: STATE MENTAL HEALTH
CHAPTER IX :FINANCE,ACCOUNTS AND AUDIT
CHAPTER X :MENTAL HEALTH ESTABLISHMENTS
CHAPTER XI: MENTAL HEALTH REVIEW COMMISSION
CHAPTER XII: ADMISSION, TREATMENT AND DISCHARGE
CHAPTER XIII :RESPONSIBILITIES OF OTHER AGENCIES
CHAPTER XIV: RESTRICTION TO DISCHARGE FUNCTIONS BY PROFESSIONALS NOT COVERED BY PROFESSION
CHAPTER XV: OFFENCES AND PENALTIES
CHAPTER XVI: MISCELLANEOUS
 159
⑥
Advance Directives
(1) Every person, who is not a minor, shall have a right to make an advance
directive in writing, specifying any or all of the following, namely:—

(a) the way the person wishes to be cared for and treated for a mental illness;

(b) the way the person wishes not to be cared for and treated for a mental illness;

(c) the individual or individuals, in order of precedence, he wants to appoint as his

nominated representative as provided under section 14.

(2) An advance directive may be made by a person irrespective of his past mental
illness or treatment for the same.

(3) An advance directive made shall be invoked only when such person ceases to
have capacity to make mental healthcare or treatment decisions and shall remain
effective until such person regains capacity to make mental healthcare or
treatment decisions.

(4) Any decision made by a person while he has the capacity to make mental
healthcare and treatment decisions shall over-ride any previously written advance
directive by such person.

(5) Any advance directive made contrary to any law for the time being in force
shall be ab initio void.

Independent Admission:
Any person who considers himself to have mental illness and desires admission, who is not a
minor
Admitted if the Medical officer or Psychiatrist is satisfied that
Mental illness of severity requiring admission
Patient should benefit from admission and treatment
Request made is under free will
Has capacity to make mental health care decisions
Informed consent
Bound to rules and regulations of the establishment
Limited to a period of 30 days •
To be informed to MHRB within 7 days of admission
 160

Mental Health Act

During court trial, for the diagnosis of mental illness, an individual can be kept in

:a psychiatric hospital for 10 days.

If a minor/women is admitted, mental health review board should be informed in 72 hours.
Other cases are usually reported within a week.
 161

Psychopharmacology and therapeutics

Psychopharmacology

Ideal Psychotropic Drug

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

Factors in Poor Drug Concordance

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Antidepressants
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•
Drug of choice for resistant rheumatic chorea: Valproate
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Previous Year Questions AIIMS 2017

Q. 25 yr old male patient is given Haloperidol
for 1 month. Recently he is having
restlessness and irresistible desire to move
around. The probable diagnosis is ?
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Risperidone

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

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

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

The primary action of risperidone is to decrease dopaminergic and serotonergic

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

Previous Year Questions INICET 21

Mnemonics
Side effects of SSRIs Q. Off label use of Resperidone.

S Stomach upset
S Sexual dysfunction
S Serotonin syndrome
S Suicidal thoughts
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Serotonin syndrome

A toxic state caused by an increase in brain serotonin activity

Causes
Most often with combined or consecutive treatment with SSRIs, Tricyclics, MAOIs, Tryptophan.

Manifestations
Neuromuscular abnormalities Autonomic hyperactivity
Hyperreflexia, Tachycardia on admission,
Inducible clonus, Mydriasis, diaphoresis, and the
Myoclonus, Presence of bowel sounds and Diarrhea
Ocular clonus,
Spontaneous clonus, Mental status changes
Peripheral hypertonicity, Agitation and delirium
Shivering
The onset of symptoms is usually rapid, with clinical findings often occurring within
minutes after a change in medication or self-poisoning.

Treatment
Stop drugs - usually resolves in no more than 24hrs
Symptomatic measures- Cooling BDZS
Prevention
Caution when combining or switching seratonergic antidepressants

Mnemonics
Serotonin syndrome
S Shivering
H Hyperreflexia, myoclonus
I Increased temperature
(>41C)
S
V Vital signs instability
S
S (HR ,Rr ,BP )
S E Encephalopathy
(Altered LOC)
R Restlessness
S Sweating(Diaphoresis)
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psychosurgery

Papez circuit
The aim of psychosurgery is to produce surgical lesions in carefully selected
parts of limbic system and/or its connecting fibres.
One major part of limbic system, believed to be important in emotional
experiences, is Papez circuit.
This important circuit, which lies within the limbic system, connects cingulate
bundle, hippocampus, anterior thalamus, mammillary bodies, fornix and septum
Indications
1. Chronic, severe, incapacitating depression, which has not responded to all
available treatments.
2. Chronic, severe, incapacitating obsessive-compulsive disorder (OCD), which
has not responded to all available treatments.
3. Chronic, severe, incapacitating anxiety disorder, which has not responded to
all available treatments.
4. Schizophrenia with severe depressive component, which has not responded to
all available treatments.
5. Severe, pathological and uncontrolled aggressive behaviour associated with a
psychiatric or neurological illness (e.g. temporal lobe epilepsy).
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ELECTROCONVULSIVE THERAPY
Electroconvulsive therapy (ECT) is a psychiatric treatment where a generalized
seizure (without muscular convulsions) is electrically induced to manage refractory
mental disorders.
• A) According to technique: • B) According to placement of electrodes
Direct ECT Modified ECT Bilateral Unilateral Bifrontol

Indications
1. Major severe depression
i. With suicidal risk (This is the first and mostimportant indication for ECT)
ii. With stupor
iii. With poor intake of food and fluids
iv. With melancholia
v. With psychotic features
vi. With unsatisfactory response to drug therapy
vii. Where drugs are contraindicated, or have
serious side effects
viii. Where speedier recovery is needed.
2. Severe catatonia (non-organic)
i. With stupor
ii. With poor intake of food and fluids
iii. With unsatisfactory response to drug therapy
iv. Where drugs are contraindicated, or have serious side-effects.
v. Where speedier recovery is needed.
3. Severe psychoses (schizophrenia or mania)
i. With risk of suicide, homicide or danger of physical assault
ii. With unsatisfactory response to drug therapy
iii. Where drugs are contraindicated, or have serious side effects
iv. With very prominent depressive features (e.g. schizo-affective disorder).

Modified ECT
• Electroconvulsive therapy is modified with the use of Anesthesia, muscle relaxation and oxygenation.
• The use of anesthesia is necessary to allay anxiety and achieve the maximum effect.
• It is used to modify the force of convulsion and to avoid complications like bone fractures.
• Modified ECT is also used for the patients who are recovering from heart conditions.
Q
A short acting Barbiturate, methohexial sodium (Brevital sodium) or Theopental (pentothal)
and ultra short acting depolarizing agent succinylcholine are given intravenously.
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Cognitive Behaviour Therapy

Type of psychotherapy which aims at correcting the maladaptive methods of
thinking, thus providing relief from con sequent symptoms.
The therapist plays an active role, unlike in psychoanalysis.
A typical cognitive therapy schedule consists of about 15 visits over a three-month period.
Developed separately by Beck and Meichenbaum, it is used for treatment of depression,
anxiety disorder, panic disorder, phobias, eating disorders, anticipatory anxiety, and also for
teaching problem-solving methods.

Techniques in CBT are:

Cognitive techniques such as recognising and correcting negative automatic thoughts,
teaching reattribution techniques, increasing objectivity in perspectives, identifying and
testing maladaptive assumptions, and decentering.
Behavioural techniques such as activity scheduling, homework assignments, graded task
assignment, behavioural rehearsal, role playing, and diversion techniques, and
Teaching problem-solving skills.
Mindfulness, originally a Buddhist technique, can also be combined with CBT.
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Other therapies
✗
Eye movement desensitisation and reprocessing - Treatment of PTSD
Dialectical behavioural therapy - Treatment of Borderline Personality Disorder
: Light Therapy - Treatments of seasonal affective disorder
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