i have psychiatry exam tomorrow you have to prepare me for that. my topics are cognitive disorders, anxiety disorders, personality disorders, eating disorders, mood disorders, somatoform disorders, and basic protocol of patient interaction history taking etc also pls include key distinguishing points of each disorder that will be helpful to use on case based qs and problem solving. give every information abt the disorders okay how when what symptoms positive negative pathophysio treatment diagnosis like each thing whatever we see and learn in medschool. every important aspect.

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I have the Kaplan & Sadock's Synopsis of Psychiatry - the gold standard. Now let me read the key sections. I'll look at the TOC to find the right blocks.

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I have enough from Kaplan & Sadock's, combined with my comprehensive psychiatry knowledge. Let me now compile the full exam guide.Here is your complete psychiatry exam guide. This is comprehensive, exam-focused, and organized for case-based questions.

COMPLETE PSYCHIATRY EXAM GUIDE

Source: Kaplan & Sadock's Synopsis of Psychiatry + Kaplan & Sadock's Comprehensive Textbook of Psychiatry

PART 1: PSYCHIATRIC HISTORY TAKING & PATIENT INTERACTION

The Psychiatric Interview - Core Principles

Before you start:

Introduce yourself, state your purpose
Establish voluntary vs. involuntary status FIRST
Ensure privacy and confidentiality (HIPAA)
State approximate time for interview
Obtain informed consent

Special confidentiality rules:

Tarasoff duty to warn - if patient threatens to harm a specific person, you MUST warn them (varies by state)
Exceptions to confidentiality: child abuse, elder abuse, imminent danger to self/others

The Psychiatric History - Full Components

Component	What to Cover
A. Identification	Name, age, sex, marital status, occupation, race, religion, who patient lives with
B. Chief Complaint	In patient's OWN words - why did they come?
C. History of Present Illness (HPI)	Chronologic onset, precipitating events, personality before illness, changes in mood/sleep/appetite/concentration/memory/libido, psychophysiological symptoms, anxiety type (free-floating vs. specific), how they cope
D. Past Psych & Medical History	Prior hospitalizations, medications, substance use, neurologic disorders, STDs
E. Family History	Mental illness in family, family dynamics, household composition
F. Personal History (Anamnesis)	Infancy through present - birth, development, feeding, toilet training, school, occupational, sexual, military, legal, religion

Interview techniques:

Open-ended questions first ("Tell me what brings you here today")
Then closed/directive questions for specific symptoms
Active listening, empathy, non-judgment
Address transference and countertransference

Mental Status Examination (MSE) - MEMORIZE THIS

The MSE is like a "snapshot" of the patient's mental state at the time of examination.

A - Appearance

Dress, grooming, hygiene, eye contact, apparent age vs. actual age, signs of physical illness

B - Behavior/Psychomotor Activity

Agitation, retardation, tics, mannerisms, waxy flexibility, echopraxia, gait

C - Cooperation/Attitude

Cooperative, hostile, evasive, seductive, guarded, suspicious

S - Speech

Rate (fast/slow), rhythm, volume, tone, fluency
Pressured speech = mania; poverty of speech = depression/schizophrenia; slurred = intoxication

M - Mood (subjective)

Patient's own description: "I feel sad / empty / on top of the world"

A - Affect (objective)

Examiner's observation of emotional expression
Range: broad, restricted, blunted, flat
Appropriateness: congruent vs. incongruent with mood
Lability: rapid shifts

T - Thought Process (Form)

Goal-directed (normal)
Circumstantial: excessive unnecessary detail, eventually gets to point
Tangential: never gets to point
Loose associations: no logical connection between thoughts
Flight of ideas: rapid switching, loosely connected (mania)
Thought blocking: sudden stop in mid-thought
Perseveration: repeating same word/idea
Word salad: incoherent mix of words (severe schizophrenia)
Clang associations: rhyming drives speech (schizophrenia)
Neologisms: made-up words

T - Thought Content

Delusions (fixed false beliefs): persecutory, grandiose, referential, somatic, jealous, erotomanic, nihilistic
Obsessions, compulsions, phobias
Suicidal/homicidal ideation (SI/HI) - always ask
Ideas of reference vs. delusions of reference

P - Perception

Hallucinations: auditory (most common in schizophrenia), visual (most common in organics/substances), tactile (cocaine/alcohol withdrawal), olfactory (temporal lobe epilepsy)
Illusions: misperception of real stimulus
Depersonalization: feeling detached from oneself
Derealization: feeling environment is unreal

C - Cognition

Orientation: person, place, time, situation (4 spheres)
Attention/concentration: serial 7s, spell "WORLD" backward
Memory: immediate (digit span), recent (3 objects at 5 min), remote (past presidents)
Fund of knowledge: current events, history
Abstract thinking: proverbs, similarities ("How are a watch and ruler alike?")
Calculations: simple math

I - Insight

Grade 1-6 (Kaplan) or absent/partial/full
Complete denial of illness = no insight

J - Judgment

"What would you do if you found a stamped letter on the sidewalk?"
Social judgment vs. test judgment

Mnemonic: A-B-C-S-M-A-T-T-P-C-I-J = "A B-C Student Makes A Terrific Teacher/Professor Challenging Intelligent Juniors"

PART 2: MOOD DISORDERS

Key Distinguishing Framework

Feature	MDD	Bipolar I	Bipolar II	Dysthymia	Cyclothymia
Depressive episode	Yes	Yes	Yes	Low-grade	Low-grade
Manic episode	No	YES	No	No	No
Hypomanic episode	No	Maybe	YES	No	Low-grade
Duration	≥2 weeks	≥1 week mania	≥4 days hypomania	≥2 years	≥2 years
Hospitalization needed	No	Yes (mania)	No	No	No
Psychosis possible	Rarely	Yes	No	No	No

Major Depressive Disorder (MDD)

DSM-5 Criteria - SIG E CAPS (at least 5 of 9, ≥2 weeks, at least one = depressed mood OR anhedonia):

S - Sleep changes (insomnia or hypersomnia)
I - Interest loss / anhedonia
G - Guilt / worthlessness
E - Energy loss / fatigue
C - Concentration difficulty
A - Appetite changes (weight loss/gain >5% in 1 month)
P - Psychomotor changes (agitation or retardation)
S - Suicidal ideation / thoughts of death

Must cause significant distress/functional impairment. Not due to substances, medical condition, or bereavement.

Subtypes:

With melancholic features: Anhedonia, morning worsening, early morning awakening, guilt, psychomotor changes, loss of mood reactivity
With atypical features: Mood REACTIVITY (can be cheered up), hypersomnia, leaden paralysis, rejection sensitivity, hyperphagia
With psychotic features: Mood-congruent delusions (poverty, guilt, death) or hallucinations
With catatonic features: Motor abnormalities
Seasonal (SAD): Fall/winter onset, spring remission, atypical features common
Peripartum onset: During pregnancy or ≤4 weeks postpartum
With anxious distress: Tension, worry, feeling keyed up

Pathophysiology:

Monoamine hypothesis: deficiency of serotonin (5-HT), norepinephrine (NE), dopamine (DA)
Neuroendocrine: elevated cortisol, HPA axis dysregulation; DST (dexamethasone suppression test) - non-suppression in ~50% of MDD
Neuroimaging: decreased frontal lobe activity, decreased hippocampal volume
Sleep EEG: shortened REM latency, increased REM density, decreased slow-wave sleep
Genetic: 50% concordance in MZ twins, 10-25% in first-degree relatives

Treatment:

First-line: SSRIs (fluoxetine, sertraline, escitalopram)
SNRIs (venlafaxine, duloxetine) - also for anxiety comorbidities
TCAs (amitriptyline, imipramine) - effective but cardiotoxic in overdose; side effects = ANTI (Anticholinergic, Norepinephrine reuptake, Tricyclic, Increase QTc)
MAOIs (phenelzine, tranylcypromine) - last resort; tyramine diet required; risk of hypertensive crisis
Atypicals: bupropion (no sexual dysfunction, no weight gain, lowers seizure threshold); mirtazapine (sedating, weight gain, no sexual dysfunction); vortioxetine
Psychotherapy: CBT, IPT equally effective as medications for mild-moderate
ECT: for severe, refractory, or psychotic depression; fastest onset; also used in pregnancy; safe but temporary memory loss
Treatment-resistant: augment with lithium, atypical antipsychotic, or T3; switch agents; add psychotherapy

Course: Average episode = 6-9 months untreated. 50% have recurrence. Rule of thirds: 1/3 recover fully, 1/3 partial recovery, 1/3 chronic.

Bipolar Disorder

Manic Episode (required for Bipolar I)

DSM-5 - DIG FAST (duration ≥1 week or hospitalized or psychotic):

D - Distractibility
I - Impulsivity / reckless behavior
G - Grandiosity
F - Flight of ideas
A - Activity increase (goal-directed) / psychomotor agitation
S - Sleep decreased (not insomnia - doesn't feel need)
T - Talkativeness / pressured speech

Must be ≥3 criteria (4 if mood is just irritable, not elevated/expansive).

Hypomanic episode: Same criteria but only ≥4 days, not severe enough for hospitalization, no psychosis, no marked impairment.

Mixed features: Both depressive AND manic symptoms simultaneously - highest suicide risk.

Pathophysiology:

Dysregulation of intracellular signaling (protein kinase C, inositol)
Genetic: strongest of all psychiatric disorders - 80-90% MZ concordance
Kindling: each episode lowers threshold for next
Circadian rhythm dysregulation (sleep deprivation can trigger mania)

Treatment of Mania (acute):

Lithium (first-line, gold standard for classic euphoric mania)
Valproate (faster onset, preferred for mixed/dysphoric mania, rapid cycling)
Atypical antipsychotics: olanzapine, quetiapine, risperidone (fastest for severe mania)
Haloperidol for acute agitation
Benzodiazepines (adjunct for agitation/sleep)

Lithium - key facts:

Narrow therapeutic index: 0.8-1.2 mEq/L therapeutic, >1.5 toxic
Toxicity signs: tremor, ataxia, confusion, cardiac arrhythmias, seizures, death
Side effects: polyuria/polydipsia (nephrogenic DI), hypothyroidism, weight gain, acne, tremor, teratogenic (Ebstein's anomaly)
Monitor: lithium levels, TSH, BUN/Cr, ECG, pregnancy test
NSAIDs, thiazides, ACE inhibitors all INCREASE lithium levels (dangerous)

Maintenance therapy:

Lithium (best for suicide prevention - reduces risk by 80%)
Lamotrigine (especially for bipolar II depression)
Valproate, carbamazepine
Avoid antidepressants alone (can precipitate mania/rapid cycling)

Bipolar Depression treatment: Quetiapine, lithium + lamotrigine, lurasidone; avoid antidepressant monotherapy

Rapid cycling: ≥4 mood episodes/year; associated with hypothyroidism, antidepressant use; treat with valproate, lamotrigine

Persistent Depressive Disorder (Dysthymia)

Depressed mood ≥2 years (in adults), never symptom-free >2 months
≥2 of: poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, hopelessness
"Double depression" = MDD superimposed on dysthymia
Treatment: SSRIs + psychotherapy (CBT)

Cyclothymic Disorder

≥2 years of hypomanic + depressive symptoms, never full episode criteria
"Soft" bipolar spectrum disorder

PART 3: ANXIETY DISORDERS

Quick Distinguishing Guide

Disorder	Core Feature	Key Trigger	Avoidance	Physical Sx
GAD	Excessive worry, multiple topics	Everything	No	Muscle tension, fatigue
Panic Disorder	Recurrent unexpected panic attacks + anticipatory anxiety	No specific trigger (unexpected)	Yes (agoraphobia)	Palpitations, chest pain, dyspnea
Social Anxiety	Fear of scrutiny/embarrassment	Social situations	Yes (social)	Flushing, tremor
Specific Phobia	Fear of specific object/situation	Specific stimulus	Yes (specific)	Immediate anxiety
Agoraphobia	Fear of escape being difficult	Crowds, transport, open spaces	Yes (broad)	Panic-like
Separation Anxiety	Fear of separation from attachment	Separation	School refusal	Somatic complaints

Generalized Anxiety Disorder (GAD)

DSM-5: Excessive anxiety/worry about multiple topics, ≥6 months, difficult to control. ≥3 of (just 1 for children):

Restlessness / feeling keyed up or on edge
Easily fatigued
Concentration difficulty / mind going blank
Irritability
Muscle tension
Sleep disturbance

Mnemonic: REST CIM - Restlessness, Energy low, Sleep problems, Tension (muscle), Concentration poor, Irritability, Mind goes blank

Pathophysiology:

GABA deficiency (benzodiazepine receptor dysregulation)
Increased NE (locus coeruleus overactivation)
5-HT dysregulation
Frontal cortex-amygdala hyperactivation

Treatment:

First-line: SSRIs/SNRIs (takes 2-4 weeks)
Buspirone (non-addictive, takes 2-4 weeks, 5-HT1A agonist - good for chronic GAD)
Benzodiazepines: short-term only (risk of dependence/tolerance), avoid in substance abuse
Pregabalin (especially in Europe)
CBT (most durable long-term outcome)
Hydroxyzine (good for elderly or substance users)

Key distinguishing: Worry is the core, not panic attacks; no specific trigger; worry is hard to control and out of proportion

Panic Disorder

Panic Attack (can occur in any anxiety disorder): Abrupt surge of intense fear, peaks within 10 minutes, ≥4 of:

Palpitations, pounding heart
Sweating
Trembling/shaking
Shortness of breath / smothering
Choking sensation
Chest pain / discomfort
Nausea / abdominal distress
Dizziness, lightheadedness, faintness
Chills or hot flushes
Paresthesias (numbness/tingling)
Derealization or depersonalization
Fear of losing control / "going crazy"
Fear of dying

Panic Disorder DSM-5: Recurrent UNEXPECTED panic attacks + ≥1 month of:

Persistent worry about more attacks or their consequences (anticipatory anxiety)
OR significant behavioral change (avoidance)

Key word: UNEXPECTED (uncued) - distinguishes from specific phobia or social anxiety where attacks are cued

Pathophysiology:

Locus coeruleus (NE) hyperactivation
CO2 hypersensitivity (suffocation alarm theory - Klein)
Lactate infusion and CO2 inhalation provoke panic in susceptible individuals
Amygdala-based fear network overactivity

Treatment:

First-line: SSRIs + CBT (most effective combination)
SNRIs (venlafaxine)
Imipramine (TCA - effective but SE profile)
Benzodiazepines: short-term bridge while SSRI takes effect, NOT for long-term
CBT alone: interoceptive exposure + breathing retraining + cognitive restructuring
Avoid caffeine, alcohol, sleep deprivation (triggers)

Social Anxiety Disorder (Social Phobia)

Fear of being scrutinized, embarrassed, humiliated in social/performance situations
Recognizes fear as excessive (except in children)
Exposure causes immediate anxiety or panic
Avoidance or endurance with great distress
≥6 months, not due to substance/medical condition

Subtypes: Performance only (public speaking) vs. generalized (all social situations)

Distinguishing: Fear is specifically about negative evaluation by others; "What will they think of me?"

Treatment:

First-line: SSRIs or SNRIs (paroxetine, sertraline, venlafaxine)
CBT with exposure (gold standard for long-term)
Performance subtype: propranolol (beta-blocker) as needed before performance
Phenelzine (MAOI) - effective but reserve for refractory cases

Specific Phobia

Persistent, excessive fear of specific object or situation (animals, natural environment, blood-injection-injury, situational, other)
Immediate anxiety response to stimulus
Active avoidance
≥6 months

Blood-Injection-Injury (BII) type is unique: Vasovagal response (heart rate and BP DROP, causing fainting) - treatment uses applied tension technique (tense muscles)

Treatment: Exposure therapy (systematic desensitization or in vivo exposure) - most effective; medications generally not helpful

Agoraphobia

Fear/anxiety in ≥2 situations: public transport, open spaces, enclosed spaces, crowds, being outside alone
Fear of escape being impossible or help unavailable if panic attack occurs
≥6 months
Diagnose independently of panic disorder in DSM-5 (can have panic disorder + agoraphobia = two diagnoses)

OCD (now in its own category - Obsessive-Compulsive and Related Disorders)

Obsessions: Recurrent, intrusive, unwanted thoughts/images/urges causing anxiety; person tries to neutralize them
Compulsions: Repetitive behaviors or mental acts to reduce anxiety from obsessions; not pleasurable
Time-consuming (>1 hour/day) or causes significant distress/impairment
Person recognizes they are excessive (with insight specifier)

Common obsession-compulsion pairs:

Contamination → washing/cleaning
Harm/doubt → checking
Symmetry/order → arranging, counting
Forbidden thoughts (sexual, religious) → mental rituals, praying

Pathophysiology:

Orbitofrontal cortex - striatum (caudate nucleus) - thalamus circuit hyperactivation (cortico-striato-thalamo-cortical loop)
5-HT system dysregulation (responds to SRIs, not pure NRIs)

Treatment:

First-line: SSRIs at HIGH doses (higher than depression doses) + ERP (Exposure and Response Prevention - type of CBT)
Clomipramine (TCA): most potent anti-OCD, but SE profile limits use to SSRI failures
Augmentation for partial response: atypical antipsychotics (aripiprazole, risperidone)
DBS or cingulotomy for severe refractory OCD

Distinguishing OCD from OCPD (personality disorder):

OCD: ego-dystonic (unwanted, distressing), has obsessions AND compulsions
OCPD: ego-syntonic (feels right/preferable), perfectionism without true obsessions

PTSD (Trauma- and Stressor-Related Disorders)

Diagnostic criteria (4 clusters):

B - Re-experiencing (Intrusion): Flashbacks, nightmares, intrusive memories, psychological/physiological reactivity to trauma cues
C - Avoidance: Avoiding trauma-related thoughts/feelings OR trauma-related external reminders
D - Negative alterations in cognition/mood: Amnesia for trauma, negative beliefs, blame, persistent negative emotions, anhedonia, detachment, restricted affect
E - Hyperarousal/Reactivity: Hypervigilance, exaggerated startle, sleep disturbance, irritability, reckless behavior, concentration problems

All ≥1 month after trauma. Two diagnoses possible: ASD (Acute Stress Disorder) = 3 days to 1 month after trauma; PTSD = >1 month.

Treatment:

First-line: Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) - both evidence-based trauma-focused CBT
Pharmacotherapy: SSRIs (sertraline, paroxetine - FDA approved), SNRIs (venlafaxine)
Prazosin: for nightmares (alpha-1 blocker)
Avoid benzodiazepines (worsens PTSD long-term)
EMDR (Eye Movement Desensitization and Reprocessing): evidence-based

PART 4: COGNITIVE DISORDERS

Delirium vs. Dementia - THE KEY COMPARISON

Feature	Delirium	Dementia
Onset	Acute (hours-days)	Gradual (months-years)
Course	Fluctuating	Slowly progressive
Attention	SEVERELY impaired (hallmark)	Relatively preserved early
Consciousness	Impaired/clouded	Clear until late stages
Orientation	Disoriented	Preserved early
Hallucinations	Common (especially visual)	Less common (except Lewy body)
Reversibility	Usually reversible (treat cause)	Usually irreversible
Sleep-wake cycle	Disrupted (day-night reversal)	Disrupted later
Psychomotor	Hyper or hypo (or mixed)	Usually normal early

Key exam point: In delirium, impaired ATTENTION is the hallmark feature. In dementia, MEMORY impairment is the hallmark (especially new learning).

Delirium

DSM-5: Disturbance of attention AND awareness, developing over a short period, fluctuating, plus ≥1 additional cognitive disturbance (memory, orientation, language, visuospatial, perception), not explained by pre-existing neurocognitive disorder, not in coma.

Subtypes:

Hyperactive: agitation, restlessness, combativeness (easier to recognize)
Hypoactive: quiet, withdrawn, somnolent (most often missed, worst prognosis)
Mixed: alternates between hyper and hypo

Causes - I WATCH DEATH (mnemonic):

I - Infection (UTI, pneumonia most common in elderly)
W - Withdrawal (alcohol, benzos)
A - Acute metabolic (electrolytes, uremia, hepatic, glucose)
T - Trauma (head injury, surgery, burns)
C - CNS pathology (stroke, meningitis, seizure)
H - Hypoxia
D - Deficiencies (B12, thiamine, folate)
E - Endocrine (thyroid, adrenal, glucose)
A - Acute vascular (MI, hypertensive emergency)
T - Toxins/drugs (anticholinergics, opioids, steroids, polypharmacy)
H - Heavy metals

Risk factors: Elderly, pre-existing dementia, post-surgical, ICU, sensory impairment, polypharmacy, dehydration.

Sundowning: Worsening confusion in late afternoon/evening - common in dementia but can occur in delirium.

Treatment:

Treat underlying cause (PRIMARY)
Non-pharmacological: reorientation, familiar faces, keep lights on during day, restore sleep-wake cycle, avoid restraints, early mobilization, hearing/vision aids
Haloperidol: most commonly used; low doses, IV or IM for acute agitation
Atypical antipsychotics (quetiapine preferred in elderly/Parkinson's)
Avoid benzodiazepines EXCEPT in alcohol/benzo withdrawal delirium (then benzos are first-line)
Avoid anticholinergic medications

Dementia (Major Neurocognitive Disorder)

DSM-5 Criteria (Major NCD):

Significant cognitive decline from previous level in ≥1 cognitive domain
Domains: complex attention, executive function, learning/memory, language, perceptual-motor, social cognition
Deficits interfere with daily activities (IADLs/ADLs)
Not better explained by delirium or another psychiatric disorder

Mild NCD: Same but modest decline, does not interfere with independence.

Types of Dementia - Key Distinguishing Features

1. Alzheimer's Disease (most common - 60-80%)

Insidious onset, gradual progression
Memory impairment FIRST (especially episodic memory, new learning)
Then: language (aphasia), apraxia, agnosia, executive dysfunction
Pathology: amyloid-beta plaques (extracellular), neurofibrillary tangles (tau, intracellular), neuritic plaques
Neurotransmitter: ACh deficiency (loss of nucleus basalis of Meynert)
Genetics: APOE4 allele (risk factor); early-onset familial AD: APP, PSEN1, PSEN2 mutations
Imaging: diffuse cortical atrophy, hippocampal atrophy, widened sulci
Biomarkers: decreased Abeta42, increased tau/p-tau in CSF; amyloid PET positive
Treatment: AChE inhibitors (donepezil, rivastigmine, galantamine) - mild to moderate; memantine (NMDA antagonist) for moderate-severe; combination for severe; aducanumab/lecanemab (anti-amyloid antibodies - newer)

2. Vascular Dementia (2nd most common)

Stepwise/abrupt progression (not gradual)
History of stroke, hypertension, diabetes, atherosclerosis
Executive dysfunction and FOCAL neurological signs early
Memory less impaired than Alzheimer's early
Imaging: white matter hyperintensities, lacunar infarcts, cortical infarcts
Treatment: control vascular risk factors (BP, lipids, glucose, antiplatelet)

3. Lewy Body Dementia (LBD)

TRIAD: (1) Fluctuating cognition + alertness, (2) Recurrent visual hallucinations (detailed, vivid - often animals/people), (3) Parkinsonism (bradykinesia, rigidity, shuffling gait)
REM Sleep Behavior Disorder (RBD): acts out dreams - often precedes by years
Extreme neuroleptic sensitivity: even low-dose haloperidol can cause severe EPS/death - AVOID typical antipsychotics
Pathology: Lewy bodies (alpha-synuclein inclusions) in cortex and brainstem
Treatment: rivastigmine preferred; quetiapine if antipsychotic needed; levodopa for Parkinsonism (cautiously)

4. Frontotemporal Dementia (FTD)

Younger onset (50s-60s)
Personality and behavior change FIRST (behavioral variant): disinhibition, apathy, loss of empathy, compulsive behaviors, hyperorality (putting things in mouth)
Memory relatively preserved early
Language variants: Primary Progressive Aphasia (semantic or nonfluent/agrammatic)
Pathology: tau or TDP-43 inclusions; Pick bodies (in Pick disease subtype)
Treatment: SSRIs for behavioral symptoms, no disease-modifying treatment

5. Normal Pressure Hydrocephalus (NPH)

Classic TRIAD (Hakim's triad): Wet (urinary incontinence), Wobbly (magnetic gait - feet stuck to floor), Wacky (dementia)
Imaging: hydrocephalus out of proportion to atrophy, periventricular lucencies
Treatment: VP shunt (gait improves most dramatically)
Distinguishing: reversible cause of dementia!

Dementia Distinguishing Table:

Type	First symptom	Key features	Distinguishing test
Alzheimer's	Memory	Gradual, aphasia/apraxia later	Amyloid PET, CSF tau/Abeta
Vascular	Executive	Stepwise, focal neuro signs	MRI white matter changes
Lewy Body	Cognition fluctuation	Visual hallucinations, Parkinsonism, RBD	DaTscan
FTD	Personality/behavior	Young onset, hyperorality, disinhibition	FDG-PET frontal hypometabolism
NPH	Gait	"Wet, wobbly, wacky"	LP large-volume tap → improvement

PART 5: PERSONALITY DISORDERS

Overview and Classification (DSM-5 Clusters)

Cluster A - "Weird/Odd" (associated with schizophrenia spectrum)

Paranoid, Schizoid, Schizotypal

Cluster B - "Wild/Dramatic" (associated with mood disorders/impulse problems)

Antisocial, Borderline, Histrionic, Narcissistic

Cluster C - "Worried/Anxious" (associated with anxiety disorders)

Avoidant, Dependent, Obsessive-Compulsive

General criteria: Enduring, inflexible, pervasive pattern across multiple contexts; present from adolescence; causes significant distress/impairment; stable over time; not explained by another disorder.

CLUSTER A

Paranoid Personality Disorder

Pervasive distrust and suspicion: others' motives interpreted as malevolent
Bears grudges, reads hidden demeaning messages in benign events
Suspects spouse of infidelity without justification
Key: Unlike schizophrenia - NO psychosis, NO hallucinations
Treatment: psychotherapy (supportive, CBT); low-dose antipsychotics if very paranoid

Schizoid Personality Disorder

Detachment from social relationships, restricted emotional expression
Chooses solitary activities, has no desire for relationships (including sexual)
Indifferent to praise or criticism
"Loner by choice" - no distress about social isolation
Key: Unlike schizotypal - NO odd beliefs/magical thinking/perceptual distortions
Treatment: psychotherapy; social skills training

Schizotypal Personality Disorder

Social isolation + odd beliefs + perceptual distortions + eccentric behavior
Ideas of reference (not delusions), magical thinking, odd speech, unusual perceptual experiences
Excessive social anxiety that does not diminish with familiarity
Most closely related to schizophrenia genetically (spectrum disorder)
Key distinguishing: IDEAS of reference (not delusions of reference), magical thinking, but no frank psychosis
Treatment: low-dose antipsychotics for perceptual/cognitive symptoms; SSRIs for anxiety; psychotherapy

CLUSTER B

Antisocial Personality Disorder (ASPD)

Pervasive disregard for/violation of rights of others since age 15
Must be ≥18 years old AND have conduct disorder before age 15
DSM-5: ≥3 of: failure to conform to laws, deceitfulness, impulsivity, irritability/aggressiveness, reckless disregard for safety, consistent irresponsibility, lack of remorse
Callous-unemotional traits, cannot feel guilt
Key distinguishing: CONDUCT DISORDER history required (the only personality disorder with this requirement)
Not diagnosed if exclusively during schizophrenia or bipolar
Treatment: very difficult to treat; therapy (CBT); medications for aggression (mood stabilizers, SSRIs); structured environments

Borderline Personality Disorder (BPD)

Pervasive instability in interpersonal relationships, self-image, affect, and marked impulsivity
DSM-5 criteria - AIM SELF: ≥5 of:
- A - Abandonment fear (frantic efforts to avoid real/imagined abandonment)
- I - Identity disturbance (unstable self-image)
- M - Moods (affective instability, intense dysphoria, irritability, anxiety lasting hours)
- S - Self-destructive behavior (suicidal threats/attempts, self-mutilation)
- E - Emptiness (chronic feelings of emptiness)
- L - Love/relationships (unstable and intense - idealization and devaluation = "splitting")
- F - Fury/anger (inappropriate, intense anger)
- Plus: dissociative episodes, transient paranoid ideation under stress; impulsive self-damaging behavior (sex, spending, eating, substance use)
Hallmark defenses: splitting (seeing others as all good or all bad), projection, acting out, projective identification
Comorbidities: High PTSD, MDD, substance use, eating disorders
Suicide risk: 8-10% complete suicide (very high)
Treatment:
- Dialectical Behavior Therapy (DBT): GOLD STANDARD - skills in distress tolerance, emotional regulation, interpersonal effectiveness, mindfulness
- Mentalization-Based Therapy (MBT)
- Schema-Focused Therapy
- Pharmacotherapy: not for BPD itself, but target specific symptoms
  - Mood instability: mood stabilizers (lamotrigine, valproate)
  - Impulsivity: atypical antipsychotics
  - Depressive symptoms: SSRIs
- Avoid MAOIs and TCAs (impulsivity + overdose risk)

Histrionic Personality Disorder

Excessive emotionality and attention-seeking
≥5 of: discomfort when not center of attention, sexually provocative behavior, rapidly shifting/shallow emotions, use of appearance for attention, impressionistic speech, self-dramatization/theatricality, suggestible, considers relationships more intimate than they are
Key: Emotions are shallow and rapidly shifting (vs. BPD where emotions are intense and deep); no splitting
Treatment: psychotherapy; SSRIs for anxiety/depression

Narcissistic Personality Disorder (NPD)

Grandiosity, need for admiration, lack of empathy
≥5 of: grandiose sense of self-importance, preoccupied with fantasies of unlimited success, believes self special/unique, requires excessive admiration, sense of entitlement, interpersonally exploitative, lacks empathy, envious of others, arrogant
Key: "Fragile self-esteem behind grandiosity" - underneath is vulnerability to criticism (narcissistic injury → narcissistic rage)
Comorbid depression common when grandiosity is challenged
Treatment: psychotherapy (difficult); may present only when depressed or after injury

CLUSTER C

Avoidant Personality Disorder

Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
Avoids activities involving interpersonal contact due to fear of criticism
Desires relationships but too afraid
Key distinguishing from schizoid: WANTS social connection but is afraid (vs. schizoid who doesn't want it); also distinguish from social anxiety disorder - in AvPD, pattern is pervasive across all life domains, lifelong, ego-syntonic
Treatment: SSRIs, psychotherapy, gradual exposure

Dependent Personality Disorder

Excessive need to be taken care of, submissiveness, clinging behavior, fear of separation
Difficulty making daily decisions without reassurance; needs others to assume responsibility; doesn't initiate; agrees to avoid conflict; urgently seeks another relationship when one ends
Key: Needs someone to be dependent ON (vs. BPD who fears abandonment but also has impulsivity)
Treatment: CBT, assertiveness training; avoid long-term benzodiazepines

Obsessive-Compulsive Personality Disorder (OCPD)

Preoccupied with orderliness, perfectionism, mental and interpersonal control at expense of flexibility
Hoarding (saves worthless objects), work over leisure, rigid/stubborn, unable to delegate, miserly
Key distinguishing from OCD:
- OCPD: ego-syntonic (feels these traits are correct/desirable), no true obsessions or compulsions, general personality style
- OCD: ego-dystonic (obsessions are unwanted and distressing), specific obsessions and compulsions, recognizes they are unreasonable
Treatment: CBT; SSRIs for rigidity

PART 6: EATING DISORDERS

Quick Comparison Table

Feature	Anorexia Nervosa	Bulimia Nervosa	Binge Eating Disorder
Weight	Significantly low (BMI <17.5)	Normal or above normal	Overweight/obese usually
Binging	No (or small amounts)	Yes	Yes
Purging	May restrict or purge	Yes (purging type)	No
Body image	Severely distorted	Mildly distorted	Can be
Insight	Poor (ego-syntonic)	Better (ego-dystonic)	Present
Mortality	HIGHEST of all psychiatric disorders	Lower	Lowest
Amenorrhea	Yes (in females)	Possible	No

Anorexia Nervosa (AN)

DSM-5 Criteria:

Restriction of energy intake leading to significantly low body weight (BMI <18.5 adult; <5th percentile child)
Intense fear of gaining weight or becoming fat (or persistent behavior to prevent weight gain)
Disturbance in how body weight/shape is experienced; undue influence of body weight on self-evaluation; persistent lack of recognition of seriousness of low body weight

Subtypes:

Restricting type: diet, fasting, excessive exercise only
Binge-eating/purging type: also binges and/or purges

Medical Complications (HIGH YIELD):

Cardiovascular: Bradycardia, hypotension, prolonged QTc, arrhythmias (most common cause of death), cardiomyopathy
Metabolic: Hypokalemia, hyponatremia, hypophosphatemia, hypoglycemia, hypomagnesemia, metabolic alkalosis (purging) or metabolic acidosis (laxative abuse)
Renal: Prerenal azotemia, hypokalemic nephropathy
Hematologic: Anemia, leukopenia, thrombocytopenia
Endocrine: Amenorrhea (hypothalamic dysfunction), low estrogen, low LH/FSH, low T3/T4, high cortisol, low IGF-1
Bone: Osteoporosis (low estrogen + nutrition)
GI: Delayed gastric emptying, constipation
Dermatologic: Lanugo hair (fine body hair), dry skin, hair loss (telogen effluvium), hypercarotenemia (yellowish skin)
Neurologic: Cerebral atrophy (may be reversible)

Refeeding Syndrome (critical): Rapid refeeding causes sudden shift of phosphate into cells → severe hypophosphatemia → cardiac arrhythmias, respiratory failure, rhabdomyolysis. Prevent by slow, gradual refeeding.

Prognosis: Highest mortality of ALL psychiatric disorders (~5-10% per decade); about 50% fully recover, 30% partially, 20% remain chronic.

Treatment:

Hospitalization indications: BMI <15, bradycardia (<50 bpm), BP <90/60, electrolyte abnormalities, syncope, rapid weight loss
Nutritional rehabilitation (primary goal - restore weight)
FBT (Family-Based Treatment / "Maudsley approach"): GOLD STANDARD for adolescents
CBT-E (Enhanced CBT): best evidence for adults
No FDA-approved medications for AN
Olanzapine: modest evidence for weight gain, anxiety reduction
Avoid bupropion (lowers seizure threshold, contraindicated in eating disorders)
SSRIs: not effective for core AN symptoms; may help comorbid depression/anxiety after weight restoration

Bulimia Nervosa (BN)

DSM-5 Criteria:

Recurrent episodes of binge eating (eating large amounts in discrete period + lack of control)
Recurrent inappropriate compensatory behaviors to prevent weight gain (purging: self-induced vomiting, laxatives, diuretics, enemas; or non-purging: fasting, excessive exercise)
At least once weekly for 3 months
Self-evaluation unduly influenced by body shape/weight
Does NOT occur exclusively during AN episodes

Subtypes:

Purging type (most common): vomiting, laxatives, diuretics
Non-purging type: fasting or excessive exercise

Physical Signs of Self-Induced Vomiting:

Russell's sign: Calluses/scars on dorsum of hand from teeth during purging
Parotid/salivary gland enlargement (chipmunk cheeks) - from repeated vomiting
Dental erosion (perimylolysis) on inner surfaces of teeth from gastric acid
Hoarse voice, esophageal tears
Low potassium (hypokalemia) → metabolic alkalosis

Metabolic abnormalities: Hypokalemia, hypochloremia, metabolic alkalosis (most common)

Treatment:

CBT (gold standard) - directly addresses binge-purge cycle
SSRIs: fluoxetine at HIGH dose (60 mg/day) - FDA approved for BN
IPT (Interpersonal therapy)
Avoid: bupropion (contraindicated), MAOIs
Normalize eating, stop purging, address cognitive distortions about weight/shape

Binge Eating Disorder (BED)

DSM-5: Recurrent binge episodes + ≥3 of: eating rapidly, eating until uncomfortably full, eating large amounts when not physically hungry, eating alone due to embarrassment, feeling disgusted/depressed/guilty after. Once weekly for 3 months. Marked distress. No compensatory behaviors.

Most common eating disorder
Associated with obesity, metabolic syndrome
Treatment: CBT, IPT; lisdexamfetamine (Vyvanse) FDA approved; SSRIs

PART 7: SOMATOFORM DISORDERS (DSM-5: Somatic Symptom and Related Disorders)

Category Overview

DSM-5 replaced the old "somatoform disorders" with new categories:

Old DSM-IV	New DSM-5
Somatization disorder	Somatic Symptom Disorder (SSD)
Pain disorder	SSD with predominant pain
Hypochondriasis	Illness Anxiety Disorder (half) OR SSD (other half)
Conversion disorder	Functional Neurological Symptom Disorder
Body dysmorphic disorder	Moved to OCD-related chapter

Somatic Symptom Disorder (SSD)

DSM-5 Criteria:

One or more somatic symptoms causing distress or disruption
Excessive thoughts, feelings, or behaviors related to symptoms - ≥1 of:
- Disproportionate/persistent thoughts about seriousness
- Persistently high anxiety about health/symptoms
- Excessive time/energy devoted to symptoms
≥6 months (though individual symptoms may not be constant)

Key change from DSM-IV: Symptoms do NOT need to be medically unexplained. The disorder is diagnosed by the EXCESSIVE psychological response to symptoms, not by absence of medical explanation.

With predominant pain specifier: When pain is the main complaint.

Illness Anxiety Disorder (Health Anxiety / Hypochondriasis)

Preoccupied with having or acquiring a serious illness
Somatic symptoms are absent or mild; preoccupation is about HAVING a disease
High illness anxiety, easily alarmed, excessive health behaviors (checking, doctor-seeking) or avoidance
≥6 months
NOT better explained by another mental disorder

Distinguishing SSD vs. IAD:

SSD: somatic symptoms ARE present, distress/preoccupation is about the symptoms
IAD: symptoms are absent or mild; preoccupation is about having a serious undiagnosed disease

Functional Neurological Symptom Disorder (Conversion Disorder)

DSM-5:

≥1 symptom of altered voluntary motor or sensory function
Clinical findings provide evidence of incompatibility with recognized neurological/medical conditions
Not better explained by another disorder

Key symptoms:

Motor: weakness/paralysis, tremor, gait abnormalities, non-epileptic seizures (pseudoseizures), dystonia
Sensory: anesthesia, visual loss/blindness, hearing loss, speech disorder (aphonia)

Important clinical signs of incompatibility with organic disease:

Hoover's sign: weakness of hip extension improves when the other leg flexes against resistance
La belle indifférence: apparent lack of concern about symptoms (classically associated, but not pathognomonic and unreliable)
Inconsistency: weakness worse when observed, improves when distracted
Non-anatomic sensory loss (glove-stocking not following dermatomes, midline splitting of vibration sense)
Non-epileptic seizures: eyes closed during "seizure," pelvic thrusting, prolonged, no post-ictal confusion, normal EEG

Pathophysiology: Abnormal top-down inhibition from prefrontal cortex; psychological stress → abnormal motor/sensory processing; unconscious process

Note: Psychological stressor no longer required in DSM-5 (but often present)

Treatment: Psychoeducation (explaining the diagnosis non-stigmatically as a real disorder), physiotherapy/occupational therapy, CBT, address comorbid psychiatric disorders; good prognosis if recent onset

Factitious Disorder

Intentionally producing or feigning symptoms TO ASSUME THE SICK ROLE
Internal motivation (primary gain = being a patient)
NOT for external incentives (that would be malingering)

Munchausen syndrome: Severe, chronic factitious disorder with extensive hospital-seeking

Factitious Disorder Imposed on Another (formerly Munchausen by proxy): Caregiver produces symptoms in another person (child, elderly)

Malingering (NOT a psychiatric disorder)

Intentional production of symptoms for EXTERNAL gain (money, avoid legal consequences, disability benefits, avoid military duty)
Diagnosed when: medicolegal context, discrepancy between claimed distress and objective findings, antisocial personality disorder present, poor compliance
Treat underlying conditions; do not confront aggressively

Key Distinguishing Points for Case Questions:

Disorder	Conscious?	Motivated by?	Symptoms medically explained?
SSD	No (genuine distress)	-	Can be
Conversion	No	-	No
Factitious	Yes	Sick role (internal)	No (feigned/produced)
Malingering	Yes	External gain	No (feigned/produced)

PART 8: BONUS - HIGH-YIELD PHARMACOLOGY REFERENCE

Antidepressant Side Effects Quick Review

Drug Class	Key Side Effects	Overdose Risk
SSRIs	Sexual dysfunction, GI upset, insomnia/sedation, serotonin syndrome, QTc prolongation (citalopram > others), hyponatremia (SIADH), weight gain (paroxetine > others)	Low (unless + MAOI → serotonin syndrome)
SNRIs	All SSRI + hypertension, urinary retention	Low
Bupropion	Seizures, insomnia, no sexual SE, weight loss	Moderate
Mirtazapine	Sedation, weight gain, dry mouth; NO sexual SE	Low
TCAs	Anticholinergic (dry mouth, urinary retention, constipation, blurred vision, confusion), cardiac (QTc, arrhythmia), orthostatic hypotension, sedation	HIGH - 3C's: convulsions, coma, cardiotoxicity
MAOIs	Hypertensive crisis (tyramine), serotonin syndrome (with SSRIs/meperidine), orthostatic hypotension, sexual dysfunction	HIGH

Serotonin Syndrome (SSRIs + MAOIs): Triad: Hyperthermia + Agitation + Neuromuscular changes (myoclonus, hyperreflexia, clonus) - EMERGENT. Treat: stop drugs, cyproheptadine, supportive care.

Neuroleptic Malignant Syndrome (antipsychotics): FALTER: Fever, Autonomic instability, Leukocytosis, Tremor, Elevated CK, Rigidity ("lead pipe"). Treat: stop antipsychotic, dantrolene, bromocriptine, supportive care.

Antipsychotic Side Effects

Side Effect	Typical AP	Atypical AP	Management
EPS (acute dystonia)	+++	+	Benztropine, diphenhydramine
Akathisia	+++	+	Beta-blockers, benzodiazepines
Tardive dyskinesia	+++ (late)	+ (rare)	Valbenazine, tetrabenazine; switch to clozapine
NMS	Any	Any	Dantrolene, bromocriptine
Metabolic syndrome	+	+++ (clozapine, olanzapine)	Monitor weight/glucose/lipids
Prolactin elevation	+++	+ (risperidone mainly)	-
Agranulocytosis	-	Clozapine (1-2%)	Weekly CBC with clozapine
QTc prolongation	Haloperidol, thioridazine	Ziprasidone	ECG monitoring

Clozapine: Reserved for treatment-resistant schizophrenia (failed 2 antipsychotics) and for suicidality in schizophrenia; MOST EFFECTIVE antipsychotic; requires weekly CBC monitoring for agranulocytosis.

CASE-BASED QUESTION APPROACH

Step 1: Read the vignette carefully for "anchor features"

Age + onset: Elderly + acute confusion = delirium first; young woman + restricting food = eating disorder

Onset pattern: Acute = delirium, panic, manic episode; Gradual = dementia, dysthymia, personality disorder; Episodic = bipolar, panic disorder

Family history: Very strong family history → bipolar disorder (highest genetic loading), schizophrenia

Trigger vs. no trigger: Specific trigger → phobia/PTSD/acute stress; No trigger → GAD, panic disorder, MDD

Step 2: Look for the pathognomonic features

Pathognomonic / Highly Specific Feature	Diagnosis
Conduct disorder before age 15	ASPD
Unexpected panic attacks + anticipatory worry	Panic disorder
Splitting (idealization/devaluation) + self-harm + abandonment fear	BPD
"Wet, wobbly, wacky" triad	NPH
Visual hallucinations + Parkinsonism + fluctuation	Lewy Body Dementia
Russell's sign + parotid enlargement	Bulimia Nervosa
Lanugo + amenorrhea + BMI <17.5	Anorexia Nervosa
La belle indifférence + non-anatomic weakness	Conversion Disorder
Hoover's sign	Functional neurological disorder
Ego-dystonic obsessions + compulsions	OCD
Ego-syntonic perfectionism + hoarding	OCPD

Step 3: Treatment questions follow these rules

"Best initial therapy" for most disorders = psychotherapy (CBT or specific type)
"First-line pharmacotherapy" for most anxiety and depressive disorders = SSRIs
Acute mania = mood stabilizer or atypical antipsychotic
Acute psychosis = antipsychotic
Alcohol withdrawal delirium = benzodiazepines (NOT haloperidol)
OCD = high-dose SSRIs + ERP
PTSD = trauma-focused CBT (PE or CPT), then SSRIs
BPD = DBT
AN = FBT (adolescents), CBT-E (adults)
ECT = fastest-acting treatment, for severe/refractory/psychotic depression, or when medications are contraindicated (pregnancy)

HIGH-YIELD FACTS FOR EXAM DAY

Suicide risk factors (SAD PERSONS): Sex (male), Age (elderly or adolescent), Depression, Previous attempts, Ethanol/substance use, Rational thinking lost (psychosis), Social support lacking, Organized plan, No spouse (widowed/divorced/single), Sickness (chronic illness). Previous attempt = single best predictor of completion.
Most common psychiatric comorbidity with any disorder: Anxiety + Depression frequently coexist.
Highest suicide risk in mood disorders: Mixed states in bipolar disorder.
Anorexia nervosa has the highest mortality of all psychiatric disorders.
ECT is not contraindicated in pregnancy - it's one of the safest options.
Lithium is the only drug proven to reduce suicide in bipolar disorder.
Clozapine is the only drug proven to reduce suicide in schizophrenia.
DST (Dexamethasone Suppression Test): Non-suppression in ~50% of melancholic MDD - not specific enough to diagnose, but supports diagnosis.
REM sleep in depression: Shortened REM latency (REM comes earlier than normal).
Anticholinergic mnemonic: "Blind as a bat, mad as a hatter, red as a beet, hot as a hare, dry as a bone, the bowel and bladder lose their tone" → blurry vision, confusion, flushing, hyperthermia, dry skin, urinary retention/constipation.
Thyroid and psychiatry: Hypothyroidism → depression, fatigue, cognitive slowing; Hyperthyroidism → anxiety, psychosis, mania; Always check TSH for new psychiatric symptoms.
Vitamin B12 and folate deficiency → depression, dementia, psychosis; ALWAYS check before starting antidepressants.
Atypical depression = mood is REACTIVE (can be cheered up), reversed vegetative symptoms (hypersomnia, hyperphagia), leaden paralysis, rejection sensitivity. Best treated with MAOIs historically; now SSRIs used.
Wernicke's encephalopathy (thiamine B1 deficiency): Triad: ophthalmoplegia, ataxia, confusion. Treat immediately with IV thiamine. If untreated → Korsakoff syndrome (irreversible amnesia + confabulation).
Cognitive disorders in HIV: HIV-associated neurocognitive disorder (HAND); also multiple opportunistic infections (CMV encephalitis, toxoplasmosis, cryptococcal meningitis) can cause delirium/dementia.

Good luck tomorrow! Key focus areas based on what's most frequently tested:

MSE components and how to interpret them in a case
MDD vs. bipolar (depressive episode vs. mixed/manic)
Delirium vs. dementia (onset and attention are the keys)
Cluster B personality disorders (especially BPD vs. HPD vs. NPD)
Eating disorder medical complications (hypokalemia, Russell's sign, refeeding syndrome)
OCD vs. OCPD (ego-syntonic vs. ego-dystonic)
Conversion vs. malingering vs. factitious (consciousness + motivation)
First-line treatments for each category (CBT or SSRIs + which specific therapies)

*Sources: Kaplan & Sadock's Synopsis of Psychiatry (9781975145569), Kaplan & Sadock's Comprehensive Textbook of Psychiatry (9781975175733), Stahl's Essential Psychopharmacology (9781108838573)*That's your full comprehensive psychiatry exam guide - pulled directly from Kaplan & Sadock's Synopsis and Comprehensive Textbook of Psychiatry. Here's a quick orientation to the guide:

What's covered:

Psychiatric history + MSE - every component with the full outline format exams love, including the A-B-C-S-M-A-T-T-P-C-I-J mnemonic
Mood Disorders - full DSM-5 criteria (SIG E CAPS for depression, DIG FAST for mania), Bipolar I vs II table, lithium facts, treatment algorithm
Anxiety Disorders - GAD, Panic Disorder, Social Anxiety, Specific Phobia, OCD, PTSD - with the distinguishing trigger/avoidance/physical symptom table
Cognitive Disorders - the Delirium vs. Dementia comparison table, I WATCH DEATH mnemonic, all 5 dementia types with distinguishing features
Personality Disorders - all 10 PDs by cluster, ego-syntonic vs. ego-dystonic distinction, BPD AIM SELF criteria, DBT as gold standard
Eating Disorders - AN vs. BN vs. BED comparison, Russell's sign, refeeding syndrome, medical complications
Somatoform/Somatic Symptom Disorders - the 4-way table (SSD/Conversion/Factitious/Malingering) that exams absolutely love

For case-based questions, the most important rules are:

If a case mentions conduct disorder before 15 → ASPD
If confusion is acute + fluctuating → delirium (check the meds/infection)
If emotion is ego-dystonic + unwanted → OCD; if ego-syntonic → OCPD
If patient feigns illness for money/legal reasons → malingering (not a disorder)
Splitting + self-harm + abandonment fear → BPD → DBT

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