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SECTION A

Q1a. Paranoid Schizophrenia - Clinical Features and Management

Definition

Clinical Features

• Persecutory delusions - the patient believes they are being watched, followed, harassed, poisoned, or conspired against (e.g., "My neighbors are planning to kill me")
• Delusions of reference - believing unrelated events specifically refer to them (e.g., news broadcasts contain personal messages)
• Delusions of grandeur - belief in special powers or identity
• Auditory hallucinations - typically running commentary, voices discussing the patient in 3rd person, or command hallucinations
• Delusions of control/influence - belief that thoughts or actions are controlled by an external force

• Mild emotional blunting
• Social withdrawal
• Reduced motivation

• Suspiciousness, hostility, aggressiveness
• Argumentativeness
• Social isolation
• Potential violence if commanding hallucinations are present
• Relatively preserved daily functioning compared to disorganized schizophrenia

• Affect and emotional responses are relatively intact
• Cognitive function less impaired
• Speech relatively coherent

Diagnosis (DSM-5 / ICD-10 Criteria)

Management

1. Antipsychotics are the mainstay
   • First-line: Second-generation (atypical) antipsychotics: Risperidone (2-8 mg/day), Olanzapine (10-20 mg/day), Quetiapine, Aripiprazole
   • Paranoid subtype: Responds particularly well due to prominent positive symptoms
   • Typical antipsychotics: Haloperidol (5-20 mg/day), Chlorpromazine - still used, especially for acute agitation
   • Long-acting injectables (LAIs): For non-compliant patients - Risperidone depot, Paliperidone palmitate, Haloperidol decanoate
2. Clozapine - for treatment-resistant cases (requires blood monitoring for agranulocytosis)

1. Cognitive Behavioral Therapy (CBT) - challenges delusional beliefs, improves coping
2. Family therapy / psychoeducation - reduces expressed emotion, improves adherence
3. Social skills training - improves interpersonal functioning
4. Assertive Community Treatment (ACT) - intensive community-based support

• Hospitalization if risk to self or others
• Oral or IM antipsychotics for acute agitation
• Benzodiazepines (lorazepam) for adjunctive sedation

• Maintenance antipsychotic therapy (minimum 1-2 years after first episode, often lifelong)
• Regular monitoring for metabolic side effects
• Relapse prevention planning

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Q1b. Neurobiology of Addiction - Emphasis on Alcohol Use Disorder (AUD)

Overview of the Neurobiology of Addiction

1. Binge/Intoxication (reward)
2. Withdrawal/Negative affect
3. Preoccupation/Anticipation (craving)

Key Brain Systems Involved

• Ventral Tegmental Area (VTA) → Nucleus Accumbens (NAc) → Prefrontal Cortex
• Alcohol increases dopamine release in the NAc → euphoria and reward
• Repeated exposure causes neuroadaptation: fewer D2 receptors → tolerance → need more alcohol for same effect
• "Hijacking" of natural reward circuitry - food, sex, social reward become less motivating

• Alcohol is a positive allosteric modulator of GABA-A receptors → anxiolysis, sedation, ataxia
• Chronic alcohol causes downregulation of GABA-A receptors → tolerance
• On withdrawal: GABA inhibition reduced → CNS hyperexcitability → seizures, delirium tremens

• Alcohol inhibits NMDA glutamate receptors (excitatory)
• Chronic use leads to upregulation/supersensitivity of NMDA receptors
• Withdrawal: excess glutamate activity → hyperexcitability, seizures, excitotoxicity

• Alcohol stimulates endogenous opioid release (beta-endorphins) → euphoria
• This reinforces drinking behavior
• Naltrexone (opioid antagonist) blocks this effect - used in treatment

• Alcohol acutely increases serotonin
• Chronic use depletes serotonin → depression, anxiety, dysphoria during abstinence

• Chronic alcohol elevates Corticotropin-Releasing Factor (CRF)
• This drives negative emotional states during withdrawal → drinking to relieve distress (negative reinforcement)
• Allostatic model: stress system becomes dysregulated

• Impaired executive function, decision-making, impulse control
• Reduced "top-down" control over craving and compulsive use

Neuroadaptations

Clinical Correlation - AUD

• Tolerance: Need more to get same effect (neuroadaptation)
• Withdrawal syndrome: Tremors, anxiety, seizures, delirium tremens (due to NMDA/GABA imbalance)
• Wernicke-Korsakoff: Thiamine (B1) deficiency → damage to mammillary bodies and thalamus → memory impairment
• Craving: Conditioned cue-induced reinstatement via dopamine and glutamate

Pharmacological Treatments Targeting Neurobiology

• Naltrexone - blocks opioid-mediated reward
• Acamprosate - modulates NMDA/GABA system, reduces withdrawal distress
• Disulfiram - inhibits aldehyde dehydrogenase → accumulation of acetaldehyde → aversive reaction
• Benzodiazepines - for acute withdrawal (GABA agonism)

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Q1c. Delirium - Causes and Management

Definition

Causes (Mnemonic: I WATCH DEATH)

• Urinary retention, constipation, pain
• Sleep deprivation, unfamiliar environment (ICU delirium)
• Dehydration

Types of Delirium

• Hyperactive - agitation, restlessness, hallucinations (most recognized)
• Hypoactive - withdrawn, lethargic, reduced responsiveness (most common, often missed)
• Mixed - fluctuates between both

Management

• Full workup: CBC, metabolic panel, LFTs, TFTs, blood cultures, urinalysis, arterial blood gas, ECG, CT brain
• Discontinue offending drugs
• Treat infection, correct metabolic abnormalities

• Frequent reorientation (tell patient date, place, time)
• Maintain day/night cycle - adequate lighting during day, dim at night
• Ensure hearing aids and glasses are worn
• Avoid physical restraints (worsen agitation)
• Involve familiar family members
• Early mobilization
• Adequate hydration and nutrition
• Minimize catheterization

• For hyperactive delirium with agitation/psychosis:
  • Haloperidol (0.5-1 mg IV/IM/oral) - most widely used, first-line
  • Atypical antipsychotics: quetiapine (25-50 mg), olanzapine
  • Avoid benzodiazepines (worsen delirium) EXCEPT in alcohol/benzo withdrawal delirium
• For alcohol withdrawal delirium (DTs): IV/oral benzodiazepines (lorazepam, diazepam) + thiamine
• Dexmedetomidine - used in ICU delirium, especially ventilated patients
• Avoid: anticholinergics, antihistamines (worsen delirium)

• HELP program (Hospital Elder Life Program)
• Early mobilization, sleep protocols, sensory aids
• Avoid polypharmacy

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Q1d. Delusions - Definition and Types

Definition

• Firmly held despite evidence to the contrary
• Not consistent with the person's cultural or religious background
• Not explainable by normal reasoning
• Unshakeable by logical argument

Types of Delusions

• Belief that one is being harassed, followed, poisoned, cheated, or conspired against
• Example: "My neighbors are putting poison in my food"
• Seen in: Paranoid schizophrenia, delusional disorder

• Belief of exceptional status, power, wealth, or special identity
• Example: "I am the Prime Minister chosen by God to rule the world"
• Seen in: Mania, schizophrenia

• Belief that random events have personal, specific meaning directed at them
• Example: "The TV presenter is sending me secret messages"; "That newspaper article is about me"
• Seen in: Schizophrenia, paranoid states

• Belief that thoughts, feelings, impulses, or actions are being controlled by an outside force
• Example: "Radio waves are making me move my arm"; "My thoughts are being inserted by aliens"
• Subtypes: Thought insertion, thought withdrawal, thought broadcasting
• Highly specific to schizophrenia

• Belief that one's partner is being unfaithful without evidence
• Example: "I know my wife is cheating even though there is no proof"
• Seen in: Alcohol use disorder, paranoid states

• Belief that oneself, others, or the world does not exist or has been destroyed
• Example: "I have no brain, I am already dead"; "The world has ended"
• Seen in: Severe depression, schizophrenia

• Fixed false belief about having a physical illness or body abnormality
• Example: "My intestines are rotting away" (despite normal investigation)
• Seen in: Delusional disorder (somatic type), psychotic depression

• Unwarranted belief of having committed terrible sins or being responsible for disasters
• Example: "I caused the earthquake by my sins"
• Seen in: Severe/psychotic depression

• Belief that a person (usually of higher status) is in love with them
• Example: "That celebrity is secretly in love with me and sends messages through the TV"

• Belief of being impoverished or ruined despite normal financial status
• Seen in: Severe depression

Classification by Structure

• Primary delusions - arise "out of the blue," without preceding mood or thought - most characteristic of schizophrenia
• Secondary delusions - arise from another psychopathological phenomenon (e.g., from mood, hallucination) - seen in mood disorders

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Q1e. ADHD - Clinical Features and Management

Definition

Epidemiology

• Affects 6-9% of children and adolescents worldwide
• Persists into adulthood in ~50% of patients
• Male:female ratio approximately 3:1 in children

DSM-5 Types

1. Predominantly Inattentive (ADD - old terminology)
2. Predominantly Hyperactive-Impulsive
3. Combined Presentation (most common)

Clinical Features

• Difficulty sustaining attention in tasks or play
• Easily distracted by external stimuli
• Fails to follow through on instructions, doesn't complete schoolwork
• Loses things necessary for tasks (pencils, books)
• Forgetful in daily activities
• Avoids tasks requiring sustained mental effort
• Difficulty organizing tasks
• Does not seem to listen when spoken to directly

• Fidgets with hands/feet, squirms in seat
• Leaves seat when expected to remain seated
• Runs or climbs excessively (in children); restlessness in adults
• Unable to play quietly
• Talks excessively
• Blurts out answers before question completed
• Cannot wait turn
• Interrupts or intrudes on others

Diagnosis

• Symptoms present before age 12
• Present in 2+ settings (home and school)
• Symptoms >6 months duration
• Rating scales: Conners Rating Scale, Vanderbilt Assessment Scale

Management

• Methylphenidate (Ritalin): immediate release or extended release (Concerta, Ritalin LA)
• Amphetamines: Mixed amphetamine salts (Adderall), Lisdexamfetamine (Vyvanse)
• Mechanism: Increase synaptic dopamine and norepinephrine
• Start low, titrate; adequate trial = >0.8 mg/kg/day for methylphenidate

• Atomoxetine (Strattera) - selective norepinephrine reuptake inhibitor; used when stimulants are contraindicated or abused
• Clonidine/Guanfacine (alpha-2 agonists) - for hyperactivity/impulsivity, especially with tics or sleep problems

• Behavior therapy for children < 6 years: parent-management training (PMT) is first-line
• Parent training - positive reinforcement, consistent routines, clear rules
• Teacher support - individualized education plan (IEP), preferential seating, extended test time
• Cognitive-behavioral therapy - for older children/adults; organizational skills training
• Social skills training

• Structured classroom environment
• Short, clear instructions
• Break tasks into smaller steps
• Reward systems

• MTA Study: combined medication + behavioral therapy superior to either alone for most outcomes

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SECTION B

Q2a. Suicide - Causes and Management of Suicidal Attempt

Definition

Epidemiology

• ~800,000 deaths/year worldwide (WHO)
• For every completed suicide, 20+ attempts occur
• Leading cause of death in young adults (15-29 years)

Causes / Risk Factors

• Depression (most common - 60% of suicides)
• Schizophrenia (command hallucinations)
• Bipolar disorder (especially depressive phase)
• Borderline personality disorder
• Alcohol and substance use disorders (2-3x increased risk)
• Anxiety disorders
• Eating disorders

• Recent significant loss (bereavement, divorce, job loss)
• Financial problems, homelessness
• Interpersonal conflicts, domestic violence
• Social isolation, loneliness
• History of sexual/physical abuse
• Recent humiliation or shame (especially cultural)

• Chronic pain conditions
• Terminal illness (cancer, AIDS)
• Neurological disorders (epilepsy, TBI, Huntington's)
• Chronic disability

• Low serotonin (5-HT) levels - linked to impulsivity and suicide
• Family history of suicide (genetic component)
• HPA axis dysregulation

• Previous suicide attempt (strongest predictor)
• Access to lethal means (firearms, medications)
• Male sex (higher completion rate; females attempt more)
• Younger age and elderly (bimodal peaks)
• LGBTQ+ individuals (2-6x higher risk)

Assessment of Suicidal Patient (SADPERSONS Scale)

• Low: ideation only, no plan, no intent, good support
• Moderate: plan, some intent, partial support
• High: detailed plan, access to means, severe illness, no support

Management

1. Safety - remove access to lethal means (medications, sharp objects, firearms)
2. Medical stabilization - treat injuries from the attempt (wounds, overdose - gastric lavage, activated charcoal, antidotes)
3. Hospitalization - for high-risk patients (involuntary if needed)
4. 1:1 nursing observation - constant supervision

• Full mental state examination
• Assess intent, lethality of method, precipitating factors
• Collateral history from family

• Treat underlying psychiatric disorder
• Antidepressants for depression (SSRIs - fluoxetine, escitalopram)
  • Note: Monitor closely in first 2 weeks (initial activation can increase suicide risk in under-25s)
• Lithium - shown to reduce suicide in bipolar disorder
• Clozapine - reduces suicidality in schizophrenia
• Avoid tricyclics/large quantities in potentially suicidal patients (high lethality in overdose)

• CBT - reduces hopelessness and cognitive distortions
• Dialectical Behavior Therapy (DBT) - specifically designed for borderline PD with suicidality; most evidence-based
• Problem-solving therapy
• Crisis intervention

• Safety planning (written plan with patient: warning signs, coping strategies, contacts)
• Restrict lethal means (counsel family)
• Follow-up appointment within 1 week of discharge
• Family education and support
• Community mental health team involvement
• Crisis helpline numbers provided

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Q2b. Mental Retardation (Intellectual Disability) - Etiology, Classification, and Role of Physiotherapist

Definition

• Significantly below-average intellectual functioning (IQ < 70)
• Deficits in adaptive behavior (conceptual, social, practical domains)
• Onset during the developmental period (before age 18)

Classification (based on IQ)

Etiology

• Genetic/Chromosomal:
  • Down syndrome (Trisomy 21) - most common identifiable cause
  • Fragile X syndrome - most common inherited cause
  • Turner syndrome, Klinefelter's
  • Phenylketonuria (PKU) - metabolic
  • Tuberous sclerosis, Neurofibromatosis
• Teratogenic:
  • Fetal Alcohol Syndrome
  • TORCH infections (Toxoplasmosis, Rubella, CMV, Herpes)
  • Maternal diabetes, hypothyroidism
  • Medications (thalidomide, valproate, retinoids)
• Neural tube defects: Spina bifida, hydrocephalus

• Birth asphyxia / hypoxic-ischemic encephalopathy
• Prematurity / low birth weight
• Kernicterus (bilirubin toxicity)
• Intracranial birth injury
• Infections (herpes, group B streptococcus)

• Infections: meningitis, encephalitis
• Head injury / trauma
• Environmental toxins: lead poisoning
• Severe malnutrition (kwashiorkor, protein-calorie malnutrition)
• Hypothyroidism (cretinism - iodine deficiency)
• Psychosocial deprivation (extreme neglect)

Role of the Physiotherapist in ID

• Assess muscle tone (hypotonia in Down syndrome), reflexes, and developmental milestones
• Gait and posture analysis
• Range of motion and strength assessment

• Neurodevelopmental treatment (NDT/Bobath) - for children with associated cerebral palsy
• Stimulate motor milestones (head control, sitting, standing, walking)
• Sensorimotor integration activities

• Strengthening programs for hypotonic muscles
• Balance and coordination training
• Gross motor skill development

• Cerebral palsy: Spasticity management, stretching, positioning, splinting
• Scoliosis: Postural exercises, bracing guidance
• Atlantoaxial instability (in Down syndrome): Cervical precautions, strengthen neck muscles
• Epilepsy: Safety education, positioning during seizures
• Obesity: Physical activity programs

• Reduces weight-bearing, improves mobility, enjoyable for the child

• Wheelchairs, walkers, orthoses, adaptive seating
• Environmental modifications for mobility

• Home exercise programs
• Handling and positioning techniques
• Activity promotion

• Work-related physical conditioning
• Ergonomic training

• Promoting participation in sports and recreation
• Special Olympics preparation

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Q2c. Cognitive Behavioral Therapy (CBT)

Definition

Theoretical Basis

• Aaron Beck developed CBT for depression (1960s-70s)
• Albert Ellis developed Rational Emotive Behavior Therapy (REBT), a precursor
• Based on the cognitive model: Situations → Automatic thoughts → Emotions → Behaviors → Physical reactions

Core Concepts

• All-or-nothing thinking: "If I'm not perfect, I'm a failure"
• Catastrophizing: "This headache means I have a brain tumor"
• Mind reading: "They must think I'm stupid"
• Overgeneralization: "I always fail"
• Selective abstraction: Focusing on negatives, ignoring positives
• Personalization: Blaming self for external events

Techniques Used in CBT

Indications (Evidence-based)

• Depression - first-line, equivalent to antidepressants
• Anxiety disorders - GAD, social anxiety, panic disorder, specific phobias
• OCD - with ERP (Exposure and Response Prevention)
• PTSD - Trauma-focused CBT is gold standard
• Eating disorders - especially bulimia nervosa
• Schizophrenia - reduces positive symptoms, improves coping
• Bipolar disorder - relapse prevention
• Chronic pain
• Insomnia (CBT-I)
• Substance use disorders

Structure

• Typically 12-20 sessions (short-term)
• Weekly 45-60 minute sessions
• Collaborative, structured, goal-oriented
• Active patient participation and homework expected

Comparison with Other Therapies

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Q2d. Post-Traumatic Stress Disorder (PTSD)

Definition

Diagnostic Criteria (DSM-5) - 4 Symptom Clusters

• Directly experienced
• Witnessed in person
• Learned it occurred to close person
• Repeated exposure to traumatic details (e.g., first responders)

• Recurrent intrusive memories of the trauma
• Nightmares related to the trauma
• Dissociative flashbacks (reliving the event)
• Psychological distress to trauma cues
• Physiological reactions to trauma cues

• Avoiding internal reminders (thoughts, feelings)
• Avoiding external reminders (places, people, activities)

• Inability to remember key aspects of trauma
• Persistent negative beliefs ("I am bad"; "No one can be trusted")
• Distorted blame of self or others
• Persistent negative emotional states (fear, horror, guilt, shame)
• Diminished interest in activities
• Feeling detached or estranged from others
• Inability to experience positive emotions (emotional numbing)

• Hypervigilance
• Exaggerated startle response
• Irritability/anger outbursts
• Reckless or self-destructive behavior
• Sleep disturbance
• Difficulty concentrating

Risk Factors

• Previous trauma history
• Female sex
• Young age at trauma
• Low social support
• Comorbid mental health conditions
• Severity and duration of trauma

Biological Basis

• Amygdala hyperactivity - exaggerated fear response
• Hippocampal atrophy - impaired contextual processing of fear memories
• Prefrontal hypoactivity - reduced inhibitory control over fear
• HPA axis dysregulation - low cortisol levels
• Noradrenergic hyperactivity - heightened arousal, startle

Management

1. Trauma-Focused CBT (TF-CBT) - most evidence-based
2. EMDR (Eye Movement Desensitization and Reprocessing) - equally effective for adults; uses bilateral stimulation while processing trauma memories
3. Prolonged Exposure (PE) - systematic exposure to trauma memories
4. Cognitive Processing Therapy (CPT) - challenges maladaptive cognitions about trauma

1. SSRIs - first-line pharmacotherapy
   • Sertraline and Paroxetine - FDA-approved for PTSD
   • Fluoxetine also used
2. SNRIs - Venlafaxine - also effective
3. Prazosin - alpha-1 blocker, specifically for nightmares
4. Benzodiazepines - generally NOT recommended (worsen avoidance, no evidence)

• Group therapy, peer support
• Mindfulness-based interventions
• Treat comorbid depression and substance use

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Q2e. Electroconvulsive Therapy (ECT)

Definition

Mechanism of Action (not fully understood)

• Increases synaptic dopamine, serotonin, norepinephrine
• Enhances neuroplasticity (increased BDNF - Brain-Derived Neurotrophic Factor)
• Modulates HPA axis (normalizes CRF)
• Anticonvulsant effects (raises seizure threshold over course)
• Promotes neurogenesis in hippocampus

Indications

• Severe depression - especially with psychotic features, suicidal risk, refusal to eat/drink
• Treatment-resistant depression (failed ≥2 antidepressants)
• Acute mania - severe, not responding to medications
• Catatonia (any etiology) - very effective
• Schizophrenia - treatment-resistant, when antipsychotics have failed
• Postpartum psychosis - safe alternative when medications risky

• When rapid response is needed (imminent suicide risk)
• Pregnancy (safer than many psychotropics in first trimester)
• Medical fragility (patients who cannot tolerate medications)
• Patient preference

Absolute Contraindications

• None (ECT has no absolute contraindications)

Relative Contraindications

• Raised intracranial pressure (space-occupying lesion)
• Recent MI or stroke (<3 months)
• Severe osteoporosis
• Pheochromocytoma
• High anesthetic risk (ASA Class 4-5)

Procedure

• Full history and examination
• ECG, CBC, metabolic panel, CXR
• Anesthesia consultation
• Informed consent

1. Patient is fasted (≥6-8 hours)
2. IV access established
3. Short-acting anesthesia (propofol or methohexital) for unconsciousness
4. Succinylcholine (muscle relaxant) to prevent physical convulsion injury
5. Atropine (to prevent bradycardia/asystole)
6. Oxygenation with 100% O2
7. Bilateral or unilateral electrode placement (unilateral non-dominant - right side - has fewer cognitive side effects)
8. Brief electrical pulse (0.5-2 ms) delivered
9. Seizure duration monitored by EEG: adequate seizure = 25-50 seconds
10. Patient awakens in ~15-30 minutes

• Typically 6-12 sessions (3x/week for 2-4 weeks)
• Maintenance ECT: monthly after acute course for relapse prevention

Side Effects

Efficacy

• >80% response rate in severe depression
• Faster onset than antidepressants (critical in life-threatening cases)
• Highly effective for catatonia (>90% response)
• Considered the most effective treatment for severe depression

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Summary Guide

Section A (Pick any 4)

Section B (Pick any 4)