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1. Three common features of senile dementia. 2. Delusions-conditions associated. 3. Hallucinations-three drugs causing. 4. Behavior therapy. 5. Electroconvulsive therapy (indications). Korsakoffs peychosis Alasholism-three complications features, treatment Wenicke's encephalopathy clinical Catatonia 12 Antipsychotic drugs. Tricyclic antidepressant drugs. 17. What is panic disorder? Which phobia is often associated with panic disorder? 18 Panic attacks-treatment. 20 Post-traumatic stress disorder. 21. Obsessive compulsive disorder. 22. Anorexia nervosa-management. 23 Munchausen's syndrome. 24. Puerperal psychosis.

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Here is a thorough, structured answer to all your psychiatry topics:

Psychiatry - Comprehensive Notes

1. Senile Dementia - Three Common Features

Senile dementia (most commonly Alzheimer's disease) presents with:

Progressive memory impairment - Recent memory fails first; remote memory is preserved longer. The patient forgets names, appointments, and recent conversations.
Intellectual/cognitive decline - Impaired judgment, disorientation (time > place > person), poor abstract thinking, and difficulty with calculations.
Personality and behavioral changes - Apathy, social withdrawal, wandering, agitation, and loss of social inhibitions. In late stages, language (aphasia), motor skills (apraxia), and recognition (agnosia) deteriorate.

Pathologically: senile plaques (β-amyloid core), neurofibrillary tangles (tau protein), and granulovacuolar degeneration - Kaplan & Sadock's Comprehensive Textbook of Psychiatry

2. Delusions - Conditions Associated

A delusion is a fixed, false belief not in keeping with cultural background, unshakeable by logic.

Condition	Type of Delusion
Schizophrenia	Persecutory, reference, control, grandiose, nihilistic
Mania (Bipolar I)	Grandiose, religious
Severe depression	Nihilistic (Cotard's), guilt, poverty, hypochondriacal
Paranoid personality disorder	Persecutory
Delusional disorder	Erotomania (de Clérambault's), jealousy (Othello), persecutory, somatic
Organic brain disease (dementia, drugs)	Persecutory, misidentification (Capgras)
Puerperal psychosis	Mixed/polymorphic
Folie à deux	Shared persecutory delusion

3. Hallucinations - Three Drugs Causing Them

A hallucination is a perception without an external stimulus.

Three drugs well known to cause hallucinations:

Lysergic acid diethylamide (LSD) - Classic hallucinogen; vivid visual hallucinations, synesthesia (seeing sounds). Mechanism: 5-HT2A agonism.
Cocaine / Amphetamines - Stimulants causing tactile hallucinations ("cocaine bugs" / formication), also visual and auditory.
Phencyclidine (PCP / Angel Dust) - NMDA receptor antagonist causing auditory and visual hallucinations, dissociation.

Other important ones: alcohol withdrawal (delirium tremens - visual/tactile), cannabis (auditory), atropine/anticholinergics (visual - "Lilliputian"), levodopa, corticosteroids.

4. Behavior Therapy

Behavior therapy is based on the principle that maladaptive behaviors are learned and can be unlearned using the same learning principles.

Core principles (Kaplan & Sadock):

Maladaptive behaviors are acquired through learning
No need to identify unconscious cause
Learning principles can modify maladaptive behavior
Focus on current, operationally defined behaviors

Major Techniques:

Technique	Mechanism	Used For
Systematic desensitization (Wolpe)	Graduated exposure + relaxation (reciprocal inhibition)	Phobias, anxiety
Flooding / Implosion	Prolonged exposure to feared stimulus	Phobias
Token economy	Positive reinforcement (operant conditioning)	Schizophrenia, intellectual disability
Aversion therapy	Pairing undesired behavior with unpleasant stimulus	Alcoholism, fetishism
Biofeedback	Learning control of physiological functions	Anxiety, hypertension, headache
Modeling	Learning by observing	Social skills, phobias
Response prevention	Preventing compulsive act after obsessional thought	OCD
Cognitive Behavior Therapy (CBT)	Modifying distorted thoughts + behaviors	Depression, anxiety, OCD

5. Electroconvulsive Therapy (ECT) - Indications

ECT involves passing an electrical current through the brain to induce a generalized seizure.

Indications:

Severe/treatment-resistant depression (most common indication)
Suicidal risk requiring rapid response
Severe depression in pregnancy (when drugs are contraindicated)
Mania (treatment-resistant)
Catatonia (especially stuporous type - highly effective)
Schizophrenia with severe agitation or acute exacerbation (adjunct)
Neuroleptic malignant syndrome (NMS)

Contraindications: Recent MI, raised intracranial pressure, recent stroke, space-occupying brain lesion (relative).

Side effects: Anterograde and retrograde amnesia (usually transient), headache, muscle aches, confusion.

6. Korsakoff's Psychosis

Also called: Korsakoff amnesic syndrome / Korsakoff psychosis

Cause: Thiamine (Vitamin B1) deficiency, most often due to chronic alcoholism

Features (the classic triad):

Anterograde amnesia - Cannot form new memories (profound, the hallmark)
Retrograde amnesia - Cannot recall recent past
Confabulation - Filling memory gaps with fabricated, unintentionally false stories (not deliberate lying)

Disorientation
Peripheral neuropathy (often co-existing)
Relatively intact immediate recall and general intelligence
Alert, cooperative patient (unlike Wernicke's acute confusion)

Pathology: Hemorrhagic lesions in mammillary bodies and medial thalamus

Treatment:

High-dose thiamine IV (100-500 mg IV/IM daily) - must be given BEFORE glucose
Balanced diet with all B vitamins
Abstinence from alcohol
Prognosis: <20% recover fully; most have permanent memory deficits

Alcoholism - Three Complications

Three major complications:

Wernicke-Korsakoff syndrome (thiamine deficiency)
Alcoholic liver disease (fatty liver → hepatitis → cirrhosis)
Alcoholic withdrawal syndrome - ranging from tremors, seizures to delirium tremens (DT)

Other complications: peripheral neuropathy, cardiomyopathy, pancreatitis, Marchiafava-Bignami disease, cerebellar degeneration, fetal alcohol syndrome.

Wernicke's Encephalopathy - Clinical Features

A medical emergency caused by acute thiamine deficiency.

Classic triad:

Ophthalmoplegia - Nystagmus (most common), bilateral abducens (6th nerve) palsy, conjugate gaze palsy
Ataxia - Cerebellar gait ataxia (wide-based gait)
Confusion / Encephalopathy - Apathy, disorientation, global confusion (not usually profound amnesia at this stage)

Pathology: Punctate hemorrhages and necrosis in:

Mammillary bodies (most characteristic)
Periaqueductal gray matter
Medial thalamic nuclei
Floor of the 4th ventricle

Treatment: IV thiamine 200-500 mg TDS before any glucose infusion. Magnesium supplementation. If untreated, progresses to Korsakoff psychosis.

(Note: All three features of the triad are present together in only ~10% of cases - treat on suspicion) - Adams and Victor's Principles of Neurology

Catatonia

A syndrome of abnormal motor behavior, most classically associated with schizophrenia but also seen in mood disorders, medical/neurological conditions, and drugs.

Features:

Type	Features
Stuporous (retarded) catatonia	Mutism, immobility, negativism, waxy flexibility
Excited catatonia	Purposeless agitation, violence

Specific signs:

Waxy flexibility (cerea flexibilitas) - Limbs can be placed in any position and held there
Catalepsy - Maintaining postures against gravity
Mutism - No verbal response
Negativism - Resistance to all instructions (active) or doing opposite (Gegenhalten)
Stereotypies / Mannerisms
Echolalia (repeating examiner's words)
Echopraxia (copying examiner's movements)
Posturing

Associations: Schizophrenia (most common), bipolar disorder, severe depression, encephalitis, NMS, toxic states

Treatment: Benzodiazepines (lorazepam IV - first line), ECT (highly effective), treat underlying cause

12. Antipsychotic Drugs

Also called neuroleptics or major tranquilizers. Primary mechanism: D2 receptor blockade.

Typical (First Generation) Antipsychotics:

Drug	Class	Features
Chlorpromazine	Phenothiazine	Prototype; sedating; causes postural hypotension
Haloperidol	Butyrophenone	High potency; strong EPS; drug of choice for acute psychosis
Trifluoperazine	Phenothiazine	High potency; less sedation
Thioridazine	Phenothiazine	Low potency; retinal pigmentation; QT prolongation
Fluphenazine	Phenothiazine	Available as depot injection
Zuclopenthixol	Thioxanthene	Available as depot (acuphase for acute agitation)

Side effects of typical antipsychotics:

EPS (extrapyramidal side effects):
- Acute dystonia (oculogyric crisis, torticollis) - within hours/days
- Akathisia (motor restlessness) - within days/weeks
- Parkinsonism (drug-induced) - within weeks
- Tardive dyskinesia (late) - after months/years; oro-facial movements; often irreversible
Hyperprolactinemia (amenorrhea, galactorrhea, gynecomastia)
Anticholinergic effects (dry mouth, retention, blurred vision, constipation)
Sedation, postural hypotension
Neuroleptic Malignant Syndrome (NMS) - fever, rigidity, altered consciousness, autonomic instability (treat: stop drug, dantrolene, bromocriptine, ICU)

Atypical (Second Generation) Antipsychotics:

Drug	Key Features
Clozapine	Most effective (treatment-resistant); agranulocytosis (monitor WBC weekly); seizures; weight gain; no tardive dyskinesia
Olanzapine	Weight gain, metabolic syndrome; sedating
Risperidone	Hyperprolactinemia; at high doses EPS
Quetiapine	Sedating; low EPS; used in Parkinson's psychosis
Aripiprazole	Partial D2 agonist; weight neutral; akathisia
Ziprasidone	QT prolongation; weight neutral
Amisulpride	Hyperprolactinemia; low EPS otherwise

13. Tricyclic Antidepressant (TCA) Drugs

Mechanism: Block reuptake of noradrenaline and serotonin (5-HT). Also block muscarinic, histamine H1, and α1-adrenergic receptors (causing side effects).

Common TCAs:

Drug	Notes
Imipramine	Prototype; also used in enuresis, panic disorder
Amitriptyline	Most sedating; also used for neuropathic pain, migraine prophylaxis
Clomipramine	Most serotonergic TCA; drug of choice for OCD
Nortriptyline	Less anticholinergic; therapeutic window effect
Desipramine	Most noradrenergic; least sedating
Doxepin	Sedating; useful in anxiety + depression
Trimipramine	Sedating
Lofepramine	Safer in overdose

Side effects (3 major groups):

Anticholinergic: Dry mouth, blurred vision, urinary retention, constipation, confusion (especially elderly)
Cardiovascular: QRS widening, QT prolongation, heart block, arrhythmias; most dangerous in overdose (major cause of death)
CNS: Sedation, lowered seizure threshold, tremor

Overdose (TCA poisoning): Cardiac arrhythmias (major cause of death), hypotension, seizures, anticholinergic delirium. Treatment: Sodium bicarbonate (for cardiac effects), supportive care.

Contraindications: Recent MI, glaucoma, prostatic hypertrophy, severe cardiac disease.

17. Panic Disorder and Associated Phobia

Panic disorder is characterized by recurrent, unexpected panic attacks - sudden surges of intense fear reaching a peak within minutes, with:

Palpitations, tachycardia
Chest pain/tightness
Shortness of breath, choking sensation
Dizziness, depersonalization
Fear of dying or losing control
Sweating, trembling
Paresthesias

Plus persistent concern about future attacks and/or behavioral change (avoidance).

Onset: Young adults; more common in women; strong genetic component.

Phobia most commonly associated with panic disorder:

Agoraphobia - Fear of open spaces, crowds, public transport, or situations from which escape might be difficult. It develops secondary to panic attacks - the person avoids situations where a panic attack occurred or where escape would be embarrassing. Up to 50-75% of agoraphobia cases have panic disorder. They often become housebound.

18. Panic Attacks - Treatment

Acute Panic Attack:

Reassurance, controlled breathing, paper bag rebreathing
Benzodiazepines (lorazepam 1-2 mg sublingual/oral) - for acute relief

Long-term Treatment:

Pharmacological:

SSRIs (first line) - Fluoxetine, paroxetine, sertraline, escitalopram; start low (risk of initial jitteriness); full effect in 4-6 weeks
SNRIs - Venlafaxine (second choice)
TCAs - Imipramine, clomipramine (effective but poorly tolerated)
Benzodiazepines (clonazepam, alprazolam) - short-term adjunct; risk of dependence; avoid long-term
MAOIs (phenelzine) - used in refractory cases

Psychological:

Cognitive Behavior Therapy (CBT) - treatment of choice for long-term; includes psychoeducation, interoceptive exposure, cognitive restructuring
Combined SSRIs + CBT is most effective

20. Post-Traumatic Stress Disorder (PTSD)

A disorder arising after exposure to a traumatic event (actual/threatened death, serious injury, sexual violence).

Diagnostic Criteria (DSM-5) - 4 Clusters:

Re-experiencing (Intrusion):
- Flashbacks (re-living the event as if happening now)
- Nightmares
- Intrusive distressing memories
- Psychological and physiological distress to trauma cues
Avoidance:
- Avoiding internal reminders (thoughts, feelings)
- Avoiding external reminders (places, people, conversations)
Negative cognitions and mood:
- Persistent negative beliefs ("I am bad")
- Guilt, shame
- Emotional numbing, anhedonia
- Estrangement from others
Hyperarousal:
- Hypervigilance
- Exaggerated startle response
- Sleep disturbance
- Irritability, anger outbursts
- Concentration difficulties

Duration: >1 month (if <1 month = Acute Stress Disorder)

Treatment:

Trauma-focused CBT (TF-CBT) - first line psychological treatment
EMDR (Eye Movement Desensitization and Reprocessing)
SSRIs (paroxetine, sertraline - FDA approved for PTSD)
Prazosin (for nightmares)
Avoid benzodiazepines (may worsen long-term)

21. Obsessive Compulsive Disorder (OCD)

Obsessions: Recurrent, intrusive, ego-dystonic thoughts/images/impulses the patient recognizes as their own but cannot control (e.g., contamination, harm, symmetry, blasphemous thoughts).

Compulsions: Repetitive behaviors or mental acts performed to neutralize anxiety from obsessions, temporarily (e.g., washing, checking, counting, praying).

Key feature: Patient has insight (recognizes obsessions are irrational) - ego-dystonic.

Common themes:

Contamination (washing hands repeatedly)
Harm (checking if gas is off)
Symmetry/order (arranging objects)
Taboo thoughts (sexual, religious)

Course: Chronic, waxing and waning; onset typically in adolescence/young adulthood.

Treatment:

Pharmacological:
- Clomipramine (TCA, serotonergic) - first proven drug; still used
- SSRIs (first line today): fluoxetine, fluvoxamine, paroxetine, sertraline, escitalopram - at higher doses than for depression; treatment trial 8-12 weeks
- Augmentation: antipsychotics (haloperidol, risperidone) for partial responders
Psychological:
- Exposure and Response Prevention (ERP) - gold standard; patient faces the obsessional trigger without performing the compulsion
- CBT
- Combination ERP + SSRI is most effective
Refractory OCD: Deep Brain Stimulation (DBS), anterior cingulotomy

22. Anorexia Nervosa - Management

Anorexia nervosa is characterized by:

Restriction of energy intake
Intense fear of gaining weight
Disturbed body image
BMI <17.5 kg/m² (or failure to achieve expected weight in adolescents)

Two subtypes: Restricting type; Binge-purging type

Management:

Medical Stabilization (first priority if severe):

Refeeding - carefully (risk of refeeding syndrome: hypophosphatemia, hypokalemia, cardiac failure)
Correct electrolyte imbalances (especially K+, PO4, Mg²+)
Nasogastric feeding if patient refuses and BMI <13.5 or medically compromised
Monitor cardiac status (bradycardia, QT prolongation)

Nutritional Rehabilitation:

Gradual caloric increase (start 1000-1500 kcal/day, increase weekly)
Target weight restoration (0.5-1 kg/week)

Psychological Treatments:

Family-based therapy (FBT/Maudsley approach) - first line in adolescents (parents control refeeding)
CBT-E (enhanced CBT) - first line in adults
Cognitive Analytic Therapy (CAT)
Individual psychodynamic therapy
Motivational enhancement therapy

Pharmacological:

No drug is specifically effective for core symptoms
Olanzapine - for weight gain and anxiety (modest evidence)
SSRIs - treat co-morbid depression/anxiety (not effective for weight alone)
Osteoporosis prevention: calcium, vitamin D

Indications for inpatient admission:

BMI <13.5 (or rapidly falling)
Medical complications (cardiac arrhythmia, electrolyte disturbance)
Failed outpatient treatment
Severe psychiatric comorbidity

Prognosis: ~50% full recovery, ~30% partial, ~20% chronic course; highest mortality of any psychiatric disorder (~5-10% per decade from cardiac complications and suicide).

23. Munchausen's Syndrome

Also called Factitious Disorder Imposed on Self (DSM-5).

Definition: The deliberate simulation, induction, or fabrication of physical or psychological symptoms in oneself, motivated by the desire to assume the sick role, with no obvious external incentive (unlike malingering).

Key features:

Self-inflicted or fabricated symptoms/signs
Patient presents repeatedly to hospitals (hospital hopping - "peregrination")
Willingness to undergo investigations, surgery, and painful procedures
Pseudologia fantastica (elaborate, dramatic, false accounts of symptoms)
Extensive medical knowledge
Absconding before discharge
Multiple scars from previous procedures ("grid-iron abdomen")
No obvious secondary gain (financial, legal)

Named after: Baron von Munchausen - famous teller of exaggerated tales

Related:

Munchausen's by proxy (Factitious Disorder Imposed on Another) - caregiver (usually mother) fabricates illness in a child; a form of child abuse
Malingering - simulating illness for external gain (compensation, avoiding military duty) - NOT a psychiatric disorder

Management:

Confrontation in a supportive, non-punitive way
Multidisciplinary liaison psychiatry involvement
Avoid unnecessary investigations/procedures
Long-term psychotherapy (often difficult as patients reject psychiatric labels)
Safeguarding if by proxy

24. Puerperal Psychosis

Definition: Severe psychiatric illness with onset within 2-4 weeks postpartum (most within first 2 weeks after delivery).

Incidence: ~1-2 per 1000 deliveries

Features:

Abrupt onset (can deteriorate within hours)
Confusion and disorientation (often the first sign - unlike typical mania/depression)
Rapidly changing mood - elation, depression, irritability (polymorphic presentation)
Delusions - often about the baby (the baby is dead, the baby is not hers, the baby is evil)
Hallucinations (auditory, visual)
Thought disorder
Insomnia, restlessness, agitation
Infanticide risk and suicidal risk

Risk factors: Prior puerperal psychosis (40-50% recurrence), bipolar disorder (most important), first pregnancy, family history, abrupt discontinuation of prophylactic mood stabilizers.

Most cases are bipolar in nature (manic episode triggered by delivery).

Treatment:

Psychiatric emergency - urgent inpatient admission (ideally mother-baby unit)
Antipsychotics (haloperidol, olanzapine) - for psychosis
Mood stabilizers (if bipolar): Lithium preferred (monitor levels; limit breastfeeding); avoid valproate (teratogenic)
Benzodiazepines (short-term sedation)
ECT - highly effective and rapid; preferred if severe, suicidal, not eating/drinking, or drug not tolerated; also safe in breastfeeding
Mother-baby unit admission (preserves mother-infant bonding)
Breastfeeding: generally supported with appropriate drug monitoring

Prognosis: Most recover fully within weeks to months with treatment.

vs. Postpartum blues (days 3-5, transient tearfulness, self-limiting) and Postnatal depression (weeks 2-6+, gradual, no psychosis; treat with SSRIs + psychotherapy).

Sources: Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Adams and Victor's Principles of Neurology 12th Ed; Kaplan and Sadock's Synopsis of Psychiatry; The Maudsley Prescribing Guidelines in Psychiatry 15th Ed.

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