PSYCHIATRY SHORT NOTES

1. PERSONALITY DISORDERS

• Borderline PD: Unstable mood, identity, and relationships; impulsivity; self-harm; fear of abandonment; splitting (idealization/devaluation); chronic emptiness. Tx: DBT (Dialectical Behavior Therapy) is treatment of choice.
• Antisocial PD: Pervasive disregard for rights of others since age 15; lying, deceit, impulsivity, aggression; no remorse. Must have conduct disorder before age 15. (DSM-5 requires age ≥18 for diagnosis)
• Paranoid PD: Pervasive distrust/suspiciousness; reads hidden malevolent meanings; bears grudges; not delusional.
• Schizoid PD: Detachment from social relationships; restricted affect; prefer solitary activities; no pleasure in social interaction; NOT schizophrenia.
• Schizotypal PD: Magical thinking, odd speech, ideas of reference, eccentric behavior; genetically related to schizophrenia.
• Narcissistic PD: Grandiosity, need for admiration, lack of empathy, sense of entitlement.
• Histrionic PD: Attention-seeking, seductive, dramatic, suggestible, shallow emotions.
• Avoidant PD: Social inhibition, feelings of inadequacy, hypersensitivity to rejection - but DESIRES relationships (unlike schizoid).
• Dependent PD: Excessive need to be taken care of; submissive, clinging behavior; fear of separation.
• OCPD (Obsessive-Compulsive PD): Preoccupation with orderliness, perfectionism, control - NOT the same as OCD; ego-syntonic.

2. HUMAN SEXUALITY AND GENDER DYSPHORIA

• Masters & Johnson: Excitement → Plateau → Orgasm → Resolution
• Helen Singer Kaplan added: Desire (before excitement) → 3-phase model (Desire, Excitement, Orgasm)

• Male: Erectile disorder, Delayed ejaculation, Premature (early) ejaculation, Male hypoactive sexual desire disorder
• Female: Female sexual interest/arousal disorder, Female orgasmic disorder, Genito-pelvic pain/penetration disorder (vaginismus/dyspareunia combined)
• Treatment: Sensate focus (Masters & Johnson), pharmacotherapy (PDE-5 inhibitors for erectile dysfunction), CBT

• Defined as marked incongruence between experienced/expressed gender and assigned gender at birth, lasting ≥6 months, causing significant distress or impairment.
• Previously called "Gender Identity Disorder" - renamed to reduce stigma.
• In children: Strong desire to be the other gender; preference for cross-gender roles/clothing/toys; aversion to own genitalia.
• In adolescents/adults: Incongruence between gender identity and primary/secondary sexual characteristics; strong desire to be treated as the other gender.
• Treatment: Psychotherapy, gender-affirming hormone therapy, gender-affirming surgery (sex reassignment surgery). Involves multidisciplinary team.
• Not classified as a mental illness per se - it is distress arising from incongruence, not the identity itself.
• ICD-11 moved Gender Incongruence out of mental disorders into a new chapter on "Conditions Related to Sexual Health" to reduce stigmatization.

3. SOMATIC SYMPTOM AND RELATED DISORDERS

• Motor: weakness/paralysis, tremor, gait disturbance, non-epileptic seizures (pseudoseizures)
• Sensory: anesthesia, blindness, deafness (tubular vision)
• La belle indifférence - inappropriate lack of concern
• Hoover's sign: weakness of voluntary hip extension but normal reflex hip extension
• Often precipitated by psychological stressor
• Tx: Psychotherapy (CBT), physiotherapy, addressing underlying stress

• Feigning illness in self (Munchausen) or in others - child/dependent (Munchausen by proxy = Factitious disorder imposed on another)
• Primary motivation = to assume sick role; NOT external gain

4. STRESS-RELATED DISORDERS

• Duration: 3 days to 1 month after a traumatic event
• Symptoms: intrusion, negative mood, dissociation, avoidance, hyperarousal
• Predicts development of PTSD if untreated

• Symptoms persist >1 month after exposure to traumatic event (actual/threatened death, sexual violence, serious injury)
• 4 symptom clusters (DSM-5):
  1. Intrusion - flashbacks, nightmares, intrusive memories
  2. Avoidance - avoiding trauma-related thoughts/stimuli
  3. Negative cognitions and mood - persistent negative beliefs, guilt, diminished interest, emotional numbing
  4. Hyperarousal/Reactivity - hypervigilance, exaggerated startle, sleep disturbance, irritability, reckless behavior
• Specifiers: With dissociative symptoms (depersonalization/derealization); delayed expression (full criteria not met until ≥6 months)
• Treatment:
  • First-line: Trauma-focused CBT (TF-CBT), EMDR (Eye Movement Desensitization and Reprocessing)
  • Pharmacotherapy: SSRIs (sertraline, paroxetine - FDA approved), SNRIs (venlafaxine)
  • Prazosin for PTSD-related nightmares
  • Avoid benzodiazepines (worsen outcomes long-term)

• Emotional/behavioral symptoms in response to identifiable stressor
• Onset within 3 months; does not persist >6 months after stressor ends
• Subtypes: with depressed mood, with anxiety, with mixed emotional features, with disturbance of conduct, mixed disturbance
• Treatment: Psychotherapy (supportive, CBT)

5. ANXIETY DISORDERS

• Excessive, uncontrollable worry about multiple domains (work, health, family) for ≥6 months
• Associated with ≥3 of: restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance (only 1 in children)
• Treatment: CBT (most effective), SSRIs/SNRIs, buspirone, TCAs; avoid benzodiazepines long-term

• Recurrent unexpected panic attacks + persistent concern about future attacks or maladaptive behavioral change ≥1 month
• Panic attack: abrupt surge of intense fear/discomfort, peaks within minutes; ≥4 of: palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, chills/heat, paresthesias, derealization, fear of losing control/dying
• With or without agoraphobia
• Treatment: CBT (exposure), SSRIs, TCAs (imipramine); acute attack - benzodiazepines

• Marked fear/anxiety about specific object/situation (animals, heights, blood-injection-injury, natural environment)
• Exposure therapy (systematic desensitization) is treatment of choice

• Fear of social/performance situations; fear of negative evaluation
• Treatment: CBT, SSRIs, beta-blockers (for performance anxiety)

• Fear/avoidance of ≥2 situations (public transport, open spaces, enclosed spaces, crowds, being outside home alone)
• Can occur with or without panic disorder (DSM-5 separates them)

• Consistent failure to speak in specific social situations (school) despite speaking in others (home)
• Seen in children; treated with CBT, SSRIs

• Developmentally inappropriate fear of separation from attachment figures
• Most common anxiety disorder in children under 12

6. OCD AND CHILDHOOD DISORDERS

• Obsessions: Recurrent, intrusive, unwanted thoughts/images/urges causing distress (ego-dystonic); person tries to suppress/neutralize them
• Compulsions: Repetitive behaviors or mental acts aimed at reducing obsession-related distress; NOT realistically connected to the feared event
• DSM-5 specifiers: With good/fair/poor/absent insight; with tic-related disorder
• Prevalence: 1-2%; equal sex ratio in adults; male predominance in childhood
• Yale-Brown Obsessive Compulsive Scale (Y-BOCS) used to assess severity

• Contamination + washing
• Symmetry + ordering/arranging
• Forbidden thoughts + mental rituals/checking
• Harm + checking

• First-line: CBT with Exposure and Response Prevention (ERP) - most effective
• Pharmacotherapy: SSRIs (fluoxetine, fluvoxamine, sertraline, paroxetine); clomipramine (TCA - most effective but more side effects)
• Resistant OCD: Augment with antipsychotics (risperidone, aripiprazole)
• Severe, refractory: Deep Brain Stimulation (DBS), Transcranial Magnetic Stimulation (TMS)

• Body Dysmorphic Disorder (BDD) - preoccupation with imagined/slight defect in appearance
• Trichotillomania (hair-pulling disorder)
• Excoriation (skin-picking disorder)
• Hoarding disorder - persistent difficulty discarding possessions

7. ASD, INTELLECTUAL DISABILITY, AND SPECIFIC LEARNING DISORDER

• Neurodevelopmental disorder with onset in early childhood
• Two core domains (DSM-5):
  1. Persistent deficits in social communication and interaction: Poor social-emotional reciprocity, deficits in nonverbal communication (eye contact, gestures, facial expressions), difficulty developing/maintaining relationships
  2. Restricted, repetitive patterns of behavior/interests/activities: Stereotyped movements/speech/use of objects; insistence on sameness/routines; highly restricted/fixated interests; hyper/hypo-reactivity to sensory input
• Symptoms present in early developmental period, though may not manifest fully until social demands exceed capacity
• With/without intellectual impairment; with/without language impairment
• Severity levels 1 (requiring support), 2 (requiring substantial support), 3 (requiring very substantial support)
• Previously: Asperger syndrome (no language/cognitive delay), PDD-NOS, Childhood Disintegrative Disorder - all now subsumed under ASD
• Investigations: No specific biomarker; M-CHAT (Modified Checklist for Autism in Toddlers); ADOS (Autism Diagnostic Observation Schedule)
• Treatment: Applied Behavior Analysis (ABA), speech therapy, occupational therapy, social skills training; no curative pharmacotherapy; risperidone and aripiprazole for irritability/aggression (FDA-approved)

• Significant limitations in intellectual functioning (IQ ≤70) AND adaptive behavior, onset before age 18
• Severity based on adaptive functioning (not just IQ alone - DSM-5):
  • Mild (IQ 50-70): Can learn academic skills to ~6th grade level; can work with support
  • Moderate (IQ 35-50): Academic skills ~2nd grade; needs supervision
  • Severe (IQ 20-35): Limited speech; needs support for basic activities
  • Profound (IQ <20): Very limited; requires constant care
• Common Causes:
  • Chromosomal: Down syndrome (Trisomy 21 - most common identifiable cause), Fragile X (most common inherited cause - trinucleotide repeat CGG expansion), Turner's, Klinefelter's
  • Prenatal: Fetal alcohol syndrome, TORCH infections, PKU (treatable with diet)
  • Perinatal: Birth asphyxia
  • Postnatal: Infections (meningitis), severe malnutrition, hypothyroidism

• Persistent difficulties in learning academic skills for ≥6 months despite intervention
• Subtypes: With impairment in reading (Dyslexia - most common), with impairment in written expression (Dysgraphia), with impairment in mathematics (Dyscalculia)
• Diagnosis requires age-appropriate educational history + standardized testing
• Treatment: Specialized educational interventions, accommodations

8. PSYCHIATRIC EMERGENCY

• Risk assessment (SAD PERSONS scale): Sex (male), Age (<19 or >45), Depression, Previous attempts, Ethanol/substance use, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness
• High-risk features: Definite plan, lethal method, hopelessness (strongest predictor), previous attempt (strongest predictor of future attempt), command hallucinations, social isolation
• Immediate management: Safe environment, remove means, continuous observation, inpatient admission if high risk

• De-escalation first (verbal, calm environment, offer choices)
• Pharmacological sedation if needed: Haloperidol + lorazepam (IM); olanzapine IM; droperidol
• Restraints as last resort; document thoroughly

• Acute, fluctuating disturbance in attention and cognition
• Identify and treat underlying cause (infection, metabolic, drugs, withdrawal)
• Pharmacological: Haloperidol (standard), quetiapine; avoid benzodiazepines (except in alcohol/benzo withdrawal delirium)

• Timeline: Tremors (6-8h) → Hallucinations (12-24h) → Seizures (24-48h) → Delirium Tremens (48-72h - most severe; autonomic instability, confusion, can be fatal)
• Treatment: Benzodiazepines (diazepam, lorazepam - lorazepam preferred in liver disease), thiamine BEFORE glucose (to prevent Wernicke's encephalopathy), CIWA-Ar monitoring

• Triad: Hyperthermia + Muscle rigidity (lead-pipe) + Autonomic instability + altered consciousness (HALT mnemonic variant)
• Caused by dopamine blockade (antipsychotics)
• Labs: Elevated CK, leukocytosis, myoglobinuria
• Treatment: STOP antipsychotic immediately; ICU care; dantrolene (muscle relaxant), bromocriptine/amantadine (dopaminergic), benzodiazepines; ECT in refractory cases

• Triad: Altered mental status + Autonomic instability + Neuromuscular abnormalities (clonus, hyperreflexia, tremor)
• Hunter's Criteria for diagnosis
• Caused by serotonergic agents (SSRIs + MAOIs most dangerous combination)
• Treatment: Stop offending agent, cyproheptadine (5-HT2 antagonist), supportive care

9. LEGAL, ETHICAL, AND DISASTER PSYCHIATRY

• Competency is a legal determination (by court); Capacity is a clinical determination (by physician)
• Elements: Understanding information, appreciating its significance, reasoning about options, communicating a choice
• Incompetent patients: Court-appointed guardian, or substitute decision-maker

• Elements: Disclosure, Comprehension, Voluntariness, Competence, Decision
• Exceptions: Emergency, waiver, therapeutic privilege (rare), incompetence

• Patient is dangerous to self or others OR so severely mentally ill they cannot care for themselves
• Criteria vary by jurisdiction; typically requires two physician certificates
• India: Mental Healthcare Act, 2017 (MHCA 2017) - Rights-based approach; patient has right to make advance directive (Ullas - advance directive = document expressing treatment preferences)

• Psychiatrist must maintain confidentiality; exceptions:
  • Tarasoff duty to warn (third-party danger) - "Duty to protect" identifiable third parties
  • Child/elder abuse reporting
  • Court orders

• M'Naghten Rules (India uses modified version): Not guilty by reason of insanity if: (1) had a mental disease, and (2) due to disease, did not know the nature of the act OR did not know it was wrong
• Indian Penal Code: Section 84 (act of a person of unsound mind)

• Psychological First Aid (PFA): First-line response; not formal therapy; contact, safety, stabilization, information, connections
• Phases of disaster: Impact, Heroic, Honeymoon, Disillusionment, Reconstruction
• Critical Incident Stress Debriefing (CISD): Single session, group; controversial evidence
• Common disorders post-disaster: Acute Stress Disorder, PTSD, Depression, Substance use, Complicated grief
• Vulnerable groups: children, elderly, pre-existing mental illness, first responders
• Psychological triage: START (Simple Triage and Rapid Treatment); integrate mental health into medical teams

• Every person has right to mental healthcare and to live in community
• Advance directive allowed
• Decriminalizes suicide attempt (Section 309 IPC effectively no longer applies to mentally ill)
• Prohibits ECT without anesthesia, chaining, seclusion

10. INTERSEX, PARAPHILIAS, AND PARAPHILIC DISORDERS

• Congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical
• Examples:
  • Congenital Adrenal Hyperplasia (CAH) - most common cause of female pseudohermaphroditism (46XX, virilized genitalia)
  • Androgen Insensitivity Syndrome (AIS) - 46XY, female external phenotype, no uterus/ovaries; testes intraabdominal
  • Klinefelter's (47XXY) - male, small testes, infertile, gynecomastia
  • Turner's (45X0) - female, short stature, streak gonads, primary amenorrhea
• Management: Multidisciplinary team; sex assignment surgery increasingly deferred; counseling

• Intense, persistent sexual interest in atypical objects, situations, or individuals
• Not inherently a disorder unless causes distress or involves non-consenting persons

• Psychotherapy: CBT, relapse prevention
• Pharmacotherapy: SSRIs (reduce sexual drive/obsessional quality), anti-androgens (medroxyprogesterone acetate = chemical castration for severe/dangerous cases), GnRH agonists (leuprolide)

11. PSYCHIATRIC DISORDERS IN THE ELDERLY

• Progressive decline in ≥1 cognitive domain (memory, executive function, language, attention, perceptual-motor, social cognition) interfering with independence
• Alzheimer's Disease (AD): Most common (60-70%); insidious onset, progressive; episodic memory loss first; later aphasia, apraxia, agnosia; neuritic plaques (amyloid beta) + neurofibrillary tangles (tau); risk: ApoE4 gene
  • Treatment: AChE inhibitors (donepezil, rivastigmine, galantamine), memantine (for moderate-severe)
• Vascular Dementia: Stepwise/abrupt onset; focal neurological signs; associated with hypertension, stroke; CT/MRI shows infarcts
• Lewy Body Dementia (LBD): Fluctuating cognition, visual hallucinations, parkinsonism; REM sleep behavior disorder; extremely sensitive to antipsychotics (avoid)
• Frontotemporal Dementia (FTD): Behavioral/personality change, disinhibition, apathy; language variants; younger onset; Pick bodies histologically

• May present as pseudodementia (cognitive impairment reversible with treatment)
• "Masked depression" with somatic complaints
• Higher suicide completion rates
• Treatment: SSRIs (sertraline, escitalopram preferred); avoid TCAs in elderly (anticholinergic, cardiotoxic); ECT safe and effective

• Schizophrenia-like illness with onset >40 years (late-onset) or >60 years (very late-onset)
• Often persecutory delusions + hallucinations
• More common in women; associated with sensory impairment, social isolation
• Treatment: Low-dose atypical antipsychotics

• Very common in hospitalized elderly; often superimposed on dementia
• Hypoactive subtype commonly missed
• Remove precipitants; haloperidol for agitation

• Reduced slow-wave and REM sleep; advanced sleep phase; REM Behavior Disorder (acts out dreams) - associated with LBD, Parkinson's

• Alcohol use often underdetected; benzodiazepine dependence common
• Pharmacokinetic changes (reduced renal/hepatic clearance) = higher drug sensitivity

12. ECT AND PSYCHOTHERAPY

• Passage of electric current through brain to induce generalized seizure under general anesthesia + muscle relaxant (succinylcholine)
• Indications:
  • Major depression: Severe, psychotic features, suicidal risk, food refusal, failed drug treatment, pregnancy (preferred over medications)
  • Mania: Rapid cycling, severe/unresponsive
  • Schizophrenia: Catatonia (most responsive), acute psychosis unresponsive to medications
  • Catatonia regardless of etiology
  • NMS (refractory cases)
• Contraindications: No absolute contraindications; relative: space-occupying brain lesion (raised ICP), recent MI, recent intracerebral hemorrhage, pheochromocytoma
• Pre-ECT workup: ECG, CBC, electrolytes, LFT, KFT, Chest X-ray, Spine X-ray (cervical), anesthesia fitness, informed consent
• Electrode placement: Bilateral (bitemporal) - most effective; Unilateral (right) - less cognitive side effects; Bifrontal
• Parameters: Typically 6-12 sessions, 3x/week (MWF)
• Side Effects:
  • Cognitive: Anterograde and retrograde amnesia (usually transient; most common complaint)
  • Confusion, headache, muscle aches, nausea
  • Cardiovascular: Initial bradycardia, then tachycardia
• Mechanism: Not fully understood; enhances GABA, normalizes HPA axis, neurogenesis in hippocampus
• Under Mental Healthcare Act 2017 (India): ECT only with consent + under general anesthesia; ECT without anesthesia banned; ECT in minors only with guardian consent + board approval

• Systematic Desensitization: Gradual exposure + relaxation (Wolpe) - for specific phobia
• Flooding/Implosion: Intense exposure without escape
• Aversion therapy: Unpleasant stimulus paired with undesired behavior
• Token economy: Operant conditioning; rewards for desired behavior
• Biofeedback: Feedback on physiological signals to achieve control

13. PSYCHOLOGICAL DISORDERS IN CHILDREN AND ADOLESCENTS

• Most common neurodevelopmental disorder in children
• Symptoms (present before age 12, in ≥2 settings, impairing):
  • Inattention: Cannot sustain attention, easily distracted, forgetful, loses things, doesn't follow through
  • Hyperactivity-Impulsivity: Fidgets, leaves seat, runs/climbs inappropriately, talks excessively, blurts out, cannot wait turn
• Subtypes: Predominantly inattentive, Predominantly hyperactive-impulsive, Combined
• Males > Females (3:1); males more hyperactive, females more inattentive
• Neurobiological: Dopamine and norepinephrine deficiency; reduced prefrontal cortex activity
• Treatment:
  • Stimulants: Methylphenidate (Ritalin) - first-line; amphetamine salts
  • Non-stimulants: Atomoxetine (NE reuptake inhibitor - preferred if tics/anxiety/substance abuse), clonidine, guanfacine
  • Behavioral interventions: Parent training, school-based interventions

• Persistent pattern of aggression toward people/animals, destruction of property, deceitfulness/theft, serious rule violations
• Before age 10 = childhood-onset (worse prognosis); after 10 = adolescent-onset
• Precursor to Antisocial PD in adulthood
• Treatment: Behavioral/family therapy; limited pharmacotherapy

• Pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness toward authority figures
• Less severe than conduct disorder; no violation of others' rights
• Treatment: Parent management training, CBT

• Excessive anxiety about separation from home or attachment figures
• Can manifest as school refusal
• Treatment: CBT, family therapy; SSRIs if severe

• Tourette's Disorder: Multiple motor tics + ≥1 vocal tic, present for >1 year, onset <18 years
• Coprolalia (involuntary obscene speech) - seen in only ~10%
• Often comorbid with OCD and ADHD
• Treatment: Behavioral (CBIT - Comprehensive Behavioral Intervention for Tics), haloperidol, pimozide, clonidine, aripiprazole

• Repeated voiding of urine into bed/clothes in child ≥5 years
• Primary (never dry) vs secondary (regression after dry period)
• Nocturnal most common; diurnal or mixed also occur
• Treatment: Behavioral (bell-and-pad = urine alarm most effective); desmopressin; imipramine (TCA - last resort due to cardiac side effects)

• Repeated passage of feces into inappropriate places, age ≥4 years
• Usually associated with constipation and overflow soiling
• Treatment: Medical (bowel cleanout, stool softeners) + behavioral therapy

• Pica: Eating non-nutritive, non-food substances (clay, dirt, paint) for ≥1 month; seen in intellectual disability, pregnancy, iron deficiency
• Rumination disorder: Repeated regurgitation and re-chewing of food
• Avoidant/Restrictive Food Intake Disorder (ARFID): Restricted eating not due to body image concerns

• Not a DSM diagnosis; associated with separation anxiety, social anxiety, depression, bullying
• "Emotional school refusal" vs truancy (conduct disorder, no anxiety)
• Treatment: Graduated return to school + CBT

• Pattern of inhibited, emotionally withdrawn behavior toward adult caregivers following insufficient care
• Disinhibited Social Engagement Disorder (DSED): Inappropriately familiar with strangers
• Both associated with neglect/abuse/institutional care

Sources: Kaplan & Sadock's Comprehensive Textbook of Psychiatry (10th ed.), Kaplan & Sadock's Synopsis of Psychiatry, Stahl's Essential Psychopharmacology, Maudsley Prescribing Guidelines in Psychiatry (15th ed.)