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PSYCHIATRY - Complete Study Notes

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1. History of Psychiatry: Principal Stages of Development

• Mental illness attributed to supernatural forces, demonic possession; treatment: exorcism, trepanation, prayer.
• Hippocrates (~400 BCE) was the first to describe melancholia, mania, and phrenitis as brain disorders, not divine punishment.
• Galen (2nd c. CE) elaborated humoral theory: excess black bile = melancholia; excess yellow bile = mania.

• "Madhouses" and asylums emerged across Europe (Bethlem Royal Hospital, London, 1247).
• Patients were chained, exhibited as curiosities.
• Philippe Pinel (France, 1793) and William Tuke (England, 1796): moral treatment - removed chains, treated patients humanely.
• Dorothea Dix (USA, 19th c.): reform movement, state hospital expansion.

• Wilhelm Griesinger (1845): "Mental diseases are brain diseases."
• Emil Kraepelin (1899): divided major mental illness into dementia praecox (schizophrenia) and manic-depressive insanity; founded modern nosology.
• Eugen Bleuler (1911): coined "schizophrenia," described the 4 A's (Affect, Associations, Autism, Ambivalence).
• Alois Alzheimer (1906): described presenile dementia.

• Sigmund Freud: unconscious, psychosexual development, defense mechanisms, psychoanalysis.
• Carl Jung, Alfred Adler, Karen Horney: neo-Freudian schools.

• 1949: John Cade discovers lithium for mania.
• 1952: Chlorpromazine introduced - first antipsychotic (Delay & Deniker, France).
• 1957: First tricyclic antidepressant (imipramine) and first MAOI (iproniazid).
• 1960s: Benzodiazepines (Sternbach).
• 1987: Fluoxetine (Prozac) - SSRI era.
• DSM-I (1952), DSM-III (1980, operationalized criteria), ICD revisions parallel this.

• Deinstitutionalization movement; community mental health centers; shift to outpatient care.

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2. Classifications of Mental Disorders: ICD-10, ICD-11, DSM-5

ICD-10 (WHO, 1992) - Chapter V (F codes)

• F00-F09: Organic mental disorders (including dementia)
• F10-F19: Mental/behavioral disorders due to psychoactive substance use
• F20-F29: Schizophrenia, schizotypal, delusional disorders
• F30-F39: Mood (affective) disorders
• F40-F48: Neurotic, stress-related, somatoform disorders
• F50-F59: Behavioral syndromes (eating disorders, sleep disorders)
• F60-F69: Disorders of adult personality
• F70-F79: Mental retardation
• F80-F89: Developmental disorders
• F90-F98: Childhood behavioral/emotional disorders
• Uses clinical descriptions and diagnostic guidelines (CDDGs), not strict operationalized criteria.

ICD-11 (WHO, 2022 - implementation)

• "Intellectual disability" replaces "mental retardation"
• Catatonia is now a separate entity (not just a schizophrenia subtype)
• Gaming disorder added
• Better dimensional coding options
• Closer alignment with DSM-5 in several areas (e.g., PTSD expanded, complex PTSD added)
• Schizophrenia subtypes removed
• "Prolonged grief disorder" added

DSM-5 / DSM-5-TR (APA, 2013 / 2022)

• Multiaxial system (Axes I-V) abolished; single combined diagnosis
• Dimensional severity ratings added alongside categorical diagnoses
• Key changes: autism spectrum disorder unified; bereavement exclusion removed from MDD; OCD and PTSD given their own chapters; "disorder" replaces "disease" for substance use
• Five key criteria domains for diagnosis: symptoms, duration, functional impairment, exclusion of other disorders, exclusion of substance/medical cause

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3. Structure of Mental Health Service: Hospital and Dispensary; GPs

Levels of Care

1. Primary care (GPs): first contact; screening, treatment of common anxiety/depression, referral
2. Community mental health centers (dispensaries): outpatient follow-up, rehabilitation, social support
3. Day hospitals: structured daytime treatment without overnight stay
4. Inpatient/acute hospital wards: voluntary and involuntary admissions, acute stabilization
5. Forensic units, secure hospitals: mentally disordered offenders
6. Rehabilitation units: long-term, recovery-focused

Dispensary (Outpatient Mental Health Clinic)

• Functions: registration and follow-up of patients with chronic mental illness; medication dispensing; social support and rehabilitation; certification and disability documentation; crisis management; liaison with GPs and social services.

Hospital Psychiatric Department

• Acute wards: involuntary/voluntary inpatients with acute psychosis, severe depression, mania, suicide risk
• Criteria for admission: danger to self or others; inability to care for self; need for close monitoring; treatment that cannot be given safely as outpatient
• Involuntary admission (Mental Health Act/equivalent): requires mental disorder + risk + refusal of treatment

GPs and Mental Disorders

• GPs manage ~90% of mental health problems in primary care
• Common presentations: depression, anxiety, somatization, alcohol misuse
• GP role: initial assessment (history, MSE), prescribing SSRIs/anxiolytics, referral to specialist when needed, monitoring physical health of psychiatric patients
• Screening tools used in GP: PHQ-9 (depression), GAD-7 (anxiety), AUDIT (alcohol), MMSE (cognitive)
• Stepped care model: least intensive effective intervention first

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4. Methods of Psychiatric Investigation

Clinical Interview

• Unstructured, semi-structured (e.g., SCID), or structured interview
• Establish rapport, explore presenting complaint, past psychiatric/medical/family history, personal/developmental/social history

Mental Status Examination (MSE)

1. Appearance and behavior: dress, eye contact, psychomotor activity (agitation/retardation)
2. Speech: rate, volume, fluency, coherence
3. Mood: subjective (what patient reports) and affect (observed emotional expression, range, appropriateness)
4. Thought form: loosening of associations, flight of ideas, tangentiality, circumstantiality, thought blocking, neologisms, perseveration
5. Thought content: delusions, obsessions, suicidal/homicidal ideation
6. Perceptions: hallucinations (type, modality), illusions, depersonalization/derealization
7. Cognition: orientation, attention, memory (immediate, short-term, long-term), abstract thinking, fund of knowledge
8. Insight and judgment: does the patient understand they are ill? Can they make reasonable decisions?

Standardized Assessment Tools

• PANSS (Positive and Negative Syndrome Scale) - schizophrenia
• BPRS (Brief Psychiatric Rating Scale) - general psychopathology
• HDRS / HAM-D - depression severity
• YMRS (Young Mania Rating Scale)
• MMSE / MoCA - cognitive screening
• AUDIT / CAGE - alcohol
• PCL-5 - PTSD screening

Physical Investigation

• Full blood count, LFTs, TFTs, B12/folate, syphilis serology, glucose, electrolytes
• EEG (epilepsy, encephalopathy), brain MRI/CT (organic causes of psychosis, dementia)
• Urine drug screen
• Genetic testing (Huntington's, BRCA if relevant)

Psychological Testing

• IQ: WAIS (Wechsler Adult Intelligence Scale)
• Personality: MMPI, Rorschach
• Neuropsychological batteries (Halstead-Reitan, CANTAB)

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5. Psychosis and Psychotic Symptoms - Hallucinations

Definition of Psychosis

Hallucinations - Definition

Classification by Modality

Auditory Hallucinations in Schizophrenia (Schneider's First-Rank)

• Running commentary: voice describes patient's actions
• Third-person voices: two or more voices discussing the patient
• Thought echo (echo de la pensee): patient hears own thoughts spoken aloud (gedankenlautwerden)

Hypnagogic and Hypnopompic Hallucinations

• Occurring at sleep onset (hypnagogic) or on waking (hypnopompic)
• Can be normal; pathological in narcolepsy

Functional Hallucinations

Differential of Hallucinations

• Schizophrenia (auditory dominant)
• Mood disorders with psychosis (congruent to mood)
• Delirium (visual > auditory)
• Substance intoxication/withdrawal
• Seizure disorder (temporal lobe)
• Parkinson's disease / Lewy body dementia
• Sensory deprivation / bereavement

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6. Psychosis and Psychotic Symptoms - Delusions

Definition

Key Features

• Conviction: the patient holds the belief with absolute certainty
• Incorrigibility: cannot be argued out of it
• Falseness: not consistent with reality or shared belief
• Primacy: arises de novo (true delusion), not derived from another psychopathology

Types of Delusion

• Persecutory (paranoid): belief of being spied on, followed, poisoned, harmed - most common
• Grandiose: inflated sense of self-worth, special power, wealth, mission; common in mania
• Reference: events, objects, or people have special personal significance (ideas of reference escalate to delusions)
• Erotomanic (de Clerambault syndrome): belief that another person (often famous) is in love with the patient
• Nihilistic (Cotard delusion): belief that the patient, others, or the world do not exist
• Somatic/hypochondriacal: belief about bodily function/disease
• Jealous (Othello syndrome): unfounded belief of partner's infidelity
• Thought insertion/withdrawal/broadcasting: thoughts placed in or removed from the mind, or broadcast to others

• Primary (autochthonous) delusion: arises suddenly without a comprehensible prior mental process (delusional perception: normal percept given abnormal significance)
• Secondary delusion: derived from another psychopathological experience (e.g., auditory hallucinations lead to persecutory belief)

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7. Schizophrenia: Definition, Positive and Negative Symptoms

Definition

DSM-5-TR Criteria (A-E)

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized/catatonic behavior
5. Negative symptoms

Positive Symptoms (Abnormal behaviors added to normal repertoire)

• Hallucinations (most commonly auditory)
• Delusions (most commonly persecutory)
• Disorganized thought (loosening of associations, thought disorder)
• Disorganized/bizarre behavior
• Catatonia

Negative Symptoms (Diminution of normal functions)

• Alogia: poverty of speech and speech content
• Avolition: decreased motivation and goal-directed behavior
• Anhedonia: inability to experience pleasure
• Affect (flat/blunted): reduced emotional expression
• Asociality: social withdrawal

Cognitive Symptoms (Third domain)

• Impairment in attention, working memory, executive function, processing speed
• Better predictor of functional status in outpatients than psychotic symptoms

Epidemiology

• Lifetime prevalence: ~1%
• Mean age of onset: males 18-25 years; females 25-35 years (later, bimodal)
• M=F prevalence; females have milder course
• Strong genetic component: concordance in monozygotic twins ~50%

ICD-10 Subtypes (retained in ICD-10, removed in ICD-11/DSM-5)

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8. Catatonia

Definition

Clinical Features

• Stupor: marked psychomotor retardation, no response to environment
• Catalepsy: passive maintenance of postures
• Waxy flexibility (cerea flexibilitas): limbs can be placed in any position and held there
• Mutism: no verbal response
• Negativism: active resistance to instructions

• Purposeless, excessive motor activity
• Agitation not influenced by external stimuli

• Echopraxia: mimicking examiners movements
• Echolalia: repeating examiners words
• Stereotypies: repeated, non-goal-directed movements
• Mannerisms: goal-directed but odd, exaggerated movements
• Posturing: spontaneous, sustained unusual postures

Etiology

• Medical causes: encephalitis (anti-NMDA receptor especially), metabolic (hypercalcemia, hepatic encephalopathy), neurological (NMS, seizures)
• Psychiatric: schizophrenia, mood disorders (especially bipolar mania/depression), autism
• Neuroleptic malignant syndrome (NMS): a medical emergency related to antipsychotics - fever, rigidity, autonomic instability, elevated CK

Diagnosis

Treatment

• Lorazepam (IV/IM): first-line; rapid improvement in many cases
• ECT (electroconvulsive therapy): first-line for malignant catatonia and NMS; highly effective
• Remove offending antipsychotic if NMS suspected
• Treat underlying cause

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9. Antipsychotics: Mode of Action, Classification, Indications, Side Effects

Mode of Action

Classification

• High potency: Haloperidol, Fluphenazine, Trifluoperazine - high EPS risk, lower sedation, lower anticholinergic
• Low potency: Chlorpromazine, Thioridazine - high sedation, anticholinergic, alpha blockade; lower EPS

• Clozapine (gold standard for treatment-resistant schizophrenia, risk of agranulocytosis)
• Risperidone (most D2-potent atypical; dose-dependent EPS)
• Olanzapine (high metabolic risk; weight gain)
• Quetiapine (sedating; used for insomnia/anxiety off-label)
• Aripiprazole (D2 partial agonist - different mechanism; weight neutral)
• Ziprasidone
• Amisulpride (pure D2/D3; low metabolic risk)
• Paliperidone (active metabolite of risperidone)
• Lurasidone

Indications

• Schizophrenia and schizophrenia-spectrum disorders (primary indication)
• Acute mania (adjunct to mood stabilizer)
• Psychotic depression
• Bipolar maintenance (quetiapine, aripiprazole, olanzapine)
• Tourette's syndrome (haloperidol, aripiprazole)
• Delirium (haloperidol IV is standard)
• Behavioural symptoms of dementia (with caution - increased stroke/mortality risk)
• Augmentation of antidepressants in refractory depression (aripiprazole, quetiapine)

Side Effects

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10. Depressive Episode: Diagnostic Criteria

DSM-5 Major Depressive Episode (MDE) Criteria

1. Depressed mood most of the day, nearly every day (subjective or observed)
2. Diminished interest or pleasure (anhedonia) in all or most activities
3. Weight/appetite change (loss or gain ≥5% body weight in a month, or decreased/increased appetite)
4. Insomnia or hypersomnia (early morning awakening is classic)
5. Psychomotor agitation or retardation (observable by others)
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive/inappropriate guilt
8. Difficulty thinking, concentrating, or making decisions
9. Recurrent thoughts of death, suicidal ideation, or suicide attempt

ICD-10 Depressive Episode (F32)

• Depressed mood
• Anhedonia
• Fatigability

• Disturbed sleep, appetite/weight change, reduced concentration, reduced self-esteem, ideas of guilt/worthlessness, pessimistic views, suicidal ideation, diurnal variation

• Mild (F32.0): 2 core + 2 additional = 4 total
• Moderate (F32.1): 2 core + 3-4 additional
• Severe without psychosis (F32.2): all 3 core + ≥4 additional
• Severe with psychosis (F32.3): mood-congruent delusions/hallucinations (worthlessness, guilt, punishment, nihilistic)

Somatic (Melancholic) Features (ICD-10)

• Marked anhedonia
• Emotional unreactivity
• Early morning awakening (≥2 h before usual)
• Morning worsening of depression (diurnal variation)
• Psychomotor agitation or retardation
• Marked appetite/weight loss
• Loss of libido

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11. Manic Episode: Diagnostic Criteria

DSM-5 Manic Episode Criteria

• Distractibility
• Indiscretion (risky behaviors: shopping sprees, sexual indiscretions, unwise investments)
• Grandiosity (inflated self-esteem)
• Flight of ideas or racing thoughts
• Activity increase (goal-directed) or psychomotor agitation
• Sleep decreased (but does not feel tired)
• Talkative / pressured speech

ICD-10 Mania (F30)

• Elevated or irritable mood + increased energy
• Associated features: reduced sleep, grandiosity, distractibility, reckless behavior
• Duration ≥1 week
• F30.1: Mania without psychosis
• F30.2: Mania with psychosis (mood-congruent: grandiose/religious delusions; or incongruent)

Hypomanic Episode

• Same qualitative symptoms as mania but less severe
• Duration ≥4 days (DSM-5)
• No marked functional impairment; no psychotic features; no hospitalization required
• If present alone (no lifetime mania) + MDEs: Bipolar II disorder

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12. Recurrent (Unipolar) Depression

Definition

Epidemiology

• Lifetime prevalence: ~15-20%; F:M = 2:1
• Leading cause of disability worldwide (WHO)
• Mean age of onset: ~32 years; can occur at any age
• High recurrence rate: after 1st episode ~50% chance of recurrence; after 3 episodes, ~90%

Course Features

• Each episode typically lasts 6-13 months untreated (shorter with treatment)
• Residual symptoms between episodes increase the risk of recurrence
• Kindling hypothesis: each episode lowers the threshold for the next

Risk Factors

• Female sex, family history of depression, adverse childhood events, chronic stress, medical comorbidities (hypothyroidism, chronic pain, cancer), personality traits (neuroticism)
• Social isolation, lack of support

Management

• Acute phase: antidepressant (SSRI first-line) + psychotherapy (CBT, IPT)
• Continuation phase: continue antidepressant ≥6 months after remission to prevent relapse
• Maintenance/prophylaxis: ≥2 years (or lifelong after 3+ episodes); lithium augmentation in recurrent cases

Subtypes

• With melancholic features
• With psychotic features (mood-congruent > incongruent)
• With atypical features (mood reactivity, hypersomnia, hyperphagia, leaden paralysis)
• With seasonal pattern (Seasonal Affective Disorder, SAD)
• With peripartum onset

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13. Bipolar Affective Disorders

Definition

DSM-5 Classification

• Bipolar I: at least one lifetime manic episode (with or without MDEs)
• Bipolar II: at least one hypomanic episode AND at least one MDE; no lifetime mania
• Cyclothymic disorder: chronic (≥2 years) fluctuating hypomanic/depressive symptoms not meeting full episode criteria

ICD-10: F31 - Bipolar affective disorder

• F31.0: current episode hypomanic
• F31.1/31.2: current manic episode (without/with psychosis)
• F31.3/31.4: current episode mild-moderate/severe depression
• F31.5: current episode severe depression with psychosis
• F31.6: current mixed episode
• F31.7: currently in remission

Epidemiology

• Bipolar I: ~1% lifetime prevalence; M=F
• Bipolar II: ~1-2%; more common in women
• Mean age of onset: ~20 years
• High heritability: ~60-80% concordance in monozygotic twins

Clinical Features

• Depressive episodes are more frequent and longer than manic in Bipolar I; predominate in Bipolar II
• Mixed features (concurrent manic + depressive symptoms) common and associated with suicide risk
• Rapid cycling: ≥4 mood episodes per year (associated with hypothyroidism, substance misuse, antidepressant use)

Management

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14. Antidepressants: Mode of Action, Classification, Indications, Side Effects

Monoamine Hypothesis

Classification

• Fluoxetine, Sertraline, Paroxetine, Citalopram, Escitalopram, Fluvoxamine
• MOA: block serotonin transporter (SERT) → increase synaptic 5-HT
• First-line for MDD, anxiety disorders, OCD, panic, PTSD
• Side effects: GI (nausea, diarrhea), sexual dysfunction (anorgasmia, delayed ejaculation), insomnia/activation, headache, SIADH (hyponatremia esp. in elderly), serotonin syndrome, initial anxiety increase

• Venlafaxine, Duloxetine, Desvenlafaxine
• MOA: block SERT + NET (norepinephrine transporter)
• Indications: MDD, GAD, panic, social anxiety, chronic pain (duloxetine), fibromyalgia
• Side effects: SSRIs + increased blood pressure (esp. venlafaxine at high doses), urinary hesitancy

• Amitriptyline, Clomipramine, Imipramine, Nortriptyline
• MOA: block SERT + NET; also antihistaminic, anticholinergic, alpha-1 blocking
• Indications: MDD (second-line), neuropathic pain, migraine prophylaxis, enuresis, OCD (clomipramine)
• Side effects: sedation, anticholinergic (dry mouth, urinary retention, constipation, confusion), weight gain, cardiac arrhythmia (QTc prolongation), dangerous in overdose (cardiotoxic)

• Phenelzine, Tranylcypromine (irreversible); Moclobemide (reversible = RIMA)
• MOA: inhibit MAO-A (breaks down 5-HT, NE) and/or MAO-B (breaks down DA)
• Indications: atypical depression, refractory depression, social anxiety; phenelzine
• Side effects: hypertensive crisis with tyramine-rich foods (aged cheese, wine, cured meats); serotonin syndrome if combined with SSRIs; insomnia, weight gain; moclobemide safer (RIMA)

• Mirtazapine
• MOA: blocks alpha-2 autoreceptors → increases NE and 5-HT release; blocks 5-HT2 and 5-HT3 (reduces side effects); potent H1 block
• Indications: MDD, especially with insomnia/weight loss/anxiety
• Side effects: sedation, weight gain, increased appetite; rare agranulocytosis

• Bupropion (NDRI): inhibits DA + NE reuptake; less sexual dysfunction, no weight gain; used in MDD and smoking cessation; lowers seizure threshold
• Trazodone: SARI (serotonin antagonist/reuptake inhibitor); used for insomnia/depression
• Agomelatine: melatonin MT1/MT2 agonist + 5-HT2C antagonist; no sexual side effects; monitor LFTs

Antidepressant Indications Beyond Depression

• Anxiety disorders (all SSRIs/SNRIs)
• OCD (high-dose SSRI, clomipramine)
• Panic disorder (SSRI, TCA)
• PTSD (sertraline, paroxetine FDA approved)
• Chronic pain / fibromyalgia (duloxetine, amitriptyline)
• Bulimia nervosa (fluoxetine)
• Premenstrual dysphoric disorder (SSRIs)

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15. Mood Stabilizers

Definition

Lithium

• MOA: inhibits inositol monophosphatase and GSK-3 signaling; affects multiple neurotransmitter systems; promotes neuroplasticity (BDNF)
• Therapeutic range: 0.6-1.0 mmol/L (maintenance); 1.0-1.2 mmol/L (acute mania); toxic >1.5 mmol/L
• Indications: Bipolar maintenance (gold standard), acute mania, augmentation in refractory depression, reduces suicidal behavior (best evidence among all psychotropics)
• Side effects: fine tremor, polyuria/polydipsia (nephrogenic diabetes insipidus), weight gain, hypothyroidism, acne/psoriasis, cognitive dulling, leukocytosis, teratogenicity (Ebstein anomaly - relative risk)
• Toxicity signs: coarse tremor, ataxia, confusion, seizure, cardiac arrhythmia, death. Avoid NSAIDs, ACE inhibitors, thiazide diuretics (increase lithium levels)
• Monitoring: serum levels, renal function (eGFR, creatinine), TFTs every 6-12 months; ECG (baseline)

Valproate (Valproic Acid / Sodium Valproate)

• MOA: enhances GABA, blocks voltage-gated sodium channels, reduces NMDA activity
• Indications: acute mania, bipolar maintenance (especially mixed states, rapid cycling), epilepsy, migraine prophylaxis
• Side effects: weight gain, sedation, tremor, alopecia, GI upset, teratogenicity (neural tube defects - avoid in women of childbearing age), polycystic ovary syndrome, hepatotoxicity (rare), thrombocytopenia
• Monitoring: LFTs, FBC, weight; serum valproate levels (50-100 µg/mL)

Lamotrigine

• MOA: blocks voltage-gated sodium channels; reduces glutamate release
• Indications: bipolar maintenance (especially for depressive predominance / bipolar II); epilepsy; no role in acute mania
• Side effects: rash (2-3%, potentially Stevens-Johnson syndrome - slow titration essential), dizziness, headache, diplopia; minimal weight effects; relatively safe in pregnancy
• Drug interactions: valproate doubles lamotrigine levels; carbamazepine halves lamotrigine levels

Carbamazepine

• MOA: sodium channel blockade
• Indications: acute mania, bipolar maintenance (second-line), epilepsy, trigeminal neuralgia
• Side effects: diplopia, dizziness, ataxia, rash (Stevens-Johnson in HLA-B*1502 carriers), hyponatremia, agranulocytosis (rare), hepatotoxicity; potent enzyme inducer (CYP3A4)
• Monitoring: FBC, LFTs, sodium, levels

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16. Neurocognitive Disorders: MCI, Dementia, Amnestic Syndrome; Prevention

Mild Cognitive Impairment (MCI)

• Definition: cognitive decline greater than expected for age and education, but not interfering significantly with daily function (does not meet dementia criteria)
• Types: amnestic (memory prominent) vs. non-amnestic; single vs. multi-domain
• Significance: ~15% per year progress to dementia (especially amnestic MCI → Alzheimer's)
• Diagnosis: patient/informant complaint + objective cognitive test impairment + preserved ADLs
• Prevention/management: treat vascular risk factors, cognitive stimulation, exercise, no approved pharmacotherapy yet

Dementia

• Significant cognitive decline from baseline in ≥1 domain (memory, language, executive function, visuospatial, social cognition) causing functional impairment in daily activities. Consciousness is preserved (distinguishes from delirium).
• Major subtypes: Alzheimer's, vascular, Lewy body, frontotemporal (see Topics 18-20)

Amnestic Syndrome

• Isolated severe memory impairment (anterograde > retrograde), with intact intelligence and other cognition
• See Topic 21

Prevention of Cognitive Disorders

• Early life: low education
• Midlife: hypertension, obesity, hearing loss, TBI, excessive alcohol, air pollution
• Late life: smoking, depression, social isolation, physical inactivity, diabetes
• Interventions: blood pressure control (<130 systolic), Mediterranean/MIND diet, aerobic exercise (30 min/day), cognitive engagement, social interaction, hearing aids, alcohol reduction, smoking cessation, treating depression

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17. Delirium: Definition and Clinical Features

Definition

• Disturbance of attention and awareness (reduced ability to focus, sustain, or shift attention)
• Disturbance in cognition (disorientation, memory, language, visuospatial, perception)
• Acute onset (hours to days) and fluctuating course - symptoms worse at night ("sundowning")
• Not better explained by pre-existing neurocognitive disorder, coma, or other altered consciousness
• Usually caused by underlying medical condition, substance, or withdrawal

Clinical Features

Subtypes

• Hyperactive: agitation, autonomic hyperactivity, hallucinations (recognized more easily)
• Hypoactive: lethargy, reduced responsiveness (most common, often missed, higher mortality)
• Mixed: fluctuating between both

Common Causes - "I WATCH DEATH"

Management

• Identify and treat underlying cause (urgent)
• Non-pharmacological: reorientation, consistent lighting, clock and calendar visible, familiar faces, hearing aids/glasses, avoid unnecessary catheterization/restraints
• Pharmacological: low-dose haloperidol for severe agitation/dangerous behavior; avoid in Lewy body dementia (severe sensitivity)
• Do not use benzodiazepines unless for alcohol/benzodiazepine withdrawal delirium specifically

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18. Dementia: Definition, Classification, Clinical Features, Anti-dementia Therapy

Definition (ICD-10/DSM-5)

Classification by Etiology

Clinical Features (General)

• Early: forgetting appointments, word-finding difficulties, getting lost, personality changes
• Middle: unable to manage finances/medications, wandering, behavioral disturbances (agitation, aggression, disinhibition), psychosis (delusions of theft, Capgras syndrome)
• Late: loss of basic ADLs (dressing, bathing), incontinence, dysphagia, immobility, death from aspiration pneumonia

Anti-dementia Therapy

• Donepezil (5-10 mg/day), Rivastigmine (oral + patch), Galantamine
• MOA: inhibit acetylcholinesterase → increase synaptic ACh
• Effect: modest improvement in cognition, ADLs, behavior; slow progression
• Side effects: GI (nausea, diarrhea, vomiting - take with food), bradycardia, vivid dreams, muscle cramps
• Rivastigmine also inhibits butyrylcholinesterase; patch form better tolerated

• Memantine (5-20 mg/day)
• MOA: blocks pathological NMDA receptor activation (reduces excitotoxic glutamate effects)
• Indications: moderate-severe Alzheimer's; can be combined with ChEI
• Side effects: dizziness, confusion, headache

• Non-pharmacological first (structured activities, music therapy, caregiver support)
• Antipsychotics (risperidone, quetiapine - lowest dose, shortest duration; avoid in Lewy body dementia)
• Antidepressants (SSRIs for depression/agitation)
• Benzodiazepines (short-term for severe anxiety/agitation only)

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19. Dementia in Alzheimer's Disease: Clinical Features and Therapy

Pathophysiology

• Amyloid plaques (extracellular beta-amyloid 42 deposits) and neurofibrillary tangles (intracellular hyperphosphorylated tau)
• Loss of cholinergic neurons (nucleus basalis of Meynert) - basis for ChEI treatment
• Spread follows Braak stages (entorhinal cortex → hippocampus → neocortex)
• Genetic factors: APOE ε4 allele (strongest sporadic risk factor); APP, PSEN1, PSEN2 mutations in familial early-onset form

Clinical Stages

• Episodic memory loss (anterograde - forgetting recent events, appointments)
• Visuospatial difficulties (getting lost in familiar places)
• Word-finding difficulties (anomia)
• Personality changes (apathy, withdrawal)
• Insight may be preserved

• Clear functional impairment; needs help with ADLs
• Disorientation (to time and place)
• Delusions (theft, infidelity, abandonment - Capgras syndrome common)
• Depression, agitation, wandering
• Executive function severely impaired

• Complete dependence for all ADLs
• Loss of meaningful language; mutism
• Incontinence
• Motor deterioration, dysphagia, falls
• Death typically from aspiration pneumonia or infection

Investigations

• MRI brain: hippocampal and entorhinal atrophy (disproportionate to diffuse atrophy)
• Biomarkers: CSF amyloid-42 (decreased), tau and phospho-tau (increased); amyloid PET scan
• Clinical diagnosis; biomarkers confirm

Therapy

• Mild-moderate: donepezil or rivastigmine or galantamine
• Moderate-severe: memantine (add-on to ChEI)
• New disease-modifying therapies: Anti-amyloid monoclonal antibodies - Lecanemab (FDA approved 2023) and Donanemab - slow decline in early AD by clearing amyloid plaques; risk of ARIA (amyloid-related imaging abnormalities - cerebral edema/microhemorrhage); highly selected patients only currently
• Manage BPSD, vascular risk factors, caregiver support, advance care planning

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20. Mental Disorders in Cerebrovascular Disease: Vascular Dementia

Vascular Dementia (VaD)

Subtypes

• Multi-infarct dementia: multiple large cortical infarcts; stepwise decline
• Small vessel disease / subcortical vascular dementia (most common): lacunar infarcts, periventricular white matter changes (leukoaraiosis); Binswanger's disease is an extreme form
• Strategic infarct dementia: single infarct in critical area (thalamus, basal ganglia, hippocampus, angular gyrus)
• CADASIL: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (NOTCH3 mutation)

Clinical Features

• Stepwise progression (with each new infarct) vs. smooth decline in Alzheimer's
• Executive dysfunction and psychomotor slowing prominent early (frontal-subcortical circuits)
• Focal neurological signs (UMN, dysarthria, dysphagia, gait disorder)
• Relatively preserved memory until later
• Emotional incontinence (pathological laughing/crying)
• Depression very common (~40%)
• Vascular risk factors present (hypertension, diabetes, atrial fibrillation, smoking, hyperlipidemia)

Diagnosis (ICD-10 F01; NINDS-AIREN criteria)

• Dementia + cerebrovascular disease (clinical or neuroimaging evidence) + temporal relationship between stroke and onset of cognitive decline

Neuroimaging

• MRI: multiple cortical/subcortical infarcts OR extensive white matter hyperintensities (WMH) = Fazekas grade III

Treatment

• Vascular risk factor control is the most important intervention (antihypertensives, statins, antiplatelet/anticoagulant therapy, diabetes control, smoking cessation)
• Cholinesterase inhibitors (modest evidence)
• Memantine (some evidence)
• Depression treatment (SSRIs for post-stroke depression)

Other Mental Disorders in Cerebrovascular Disease

• Post-stroke depression: ~30%; treat with SSRIs (sertraline, citalopram); affects rehabilitation
• Post-stroke anxiety: GAD, PTSD-like; treat with SSRIs
• Post-stroke psychosis: rare; secondary to right hemisphere lesions typically
• Post-stroke mania: rare; associated with right-hemisphere lesions
• Pathological laughing and crying (pseudobulbar affect): treat with SSRIs, low-dose TCA

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21. Amnestic Syndrome: Causes, Diagnostic Criteria, Treatment

Definition

• Intact immediate recall (digit span)
• Relatively preserved other cognitive functions (intelligence, language, visuospatial)
• Preserved consciousness (distinguishes from delirium)
• Significant functional impairment

Key Features

• Anterograde amnesia: inability to form new memories after the insult
• Retrograde amnesia: loss of memories from before the insult (usually less severe)
• Confabulation: fabrication of plausible but false memories (not intentional lying) - classic in Korsakoff's
• Intact procedural memory (motor skills, conditioning) - spares cerebellum/basal ganglia circuits

Causes

Korsakoff's Syndrome Specifically

• Caused by chronic thiamine deficiency (usually alcoholism; also post-bariatric surgery, prolonged vomiting, malnutrition)
• Follows or coexists with Wernicke's encephalopathy (acute phase: confusion, ophthalmoplegia, ataxia)
• Lesions: mammillary bodies, dorsomedial thalamus, periaqueductal gray
• Confabulation (especially in acute/subacute stage)
• Only ~20% recover fully with thiamine treatment; most have permanent amnestic syndrome

DSM-5 Diagnostic Criteria (Amnestic Disorder due to another medical condition)

Treatment

• Thiamine replacement: immediate IV thiamine in Wernicke's (before any glucose administration) - 200-500 mg IV TDS for 3-5 days
• Alcohol abstinence for Korsakoff's
• Cognitive rehabilitation strategies (external memory aids, errorless learning)
• Treat underlying cause (antiviral for HSV encephalitis, hyperbaric oxygen for CO)
• No pharmacotherapy proven effective for amnestic syndrome per se

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22. Mental Disorders in Epilepsy

Classification of Psychiatric Comorbidities by Timing

• Automatisms, fear, panic, depersonalization, brief hallucinations, déjà vu, jamais vu, fugue states
• Complex partial (focal onset impaired awareness) seizures of temporal lobe most commonly present with psychiatric symptoms

• Confusion, agitation, depression, psychosis (postictal psychosis - persecutory delusions, hallucinations lasting days; not associated with ongoing seizures)
• Postictal psychosis may occur after a cluster of generalized tonic-clonic seizures

• Depression: most common psychiatric comorbidity (~30-35%); bidirectional risk; underdiagnosed; SSRIs effective (note some antidepressants can lower seizure threshold - bupropion, clomipramine highest risk)
• Anxiety: GAD, panic disorder, social anxiety common (~20-25%)
• Psychosis: ~5-10% of epilepsy patients; "schizophrenia-like psychosis of epilepsy" (SLPE) - especially temporal lobe epilepsy; relatively preserved affect, less formal thought disorder
• Cognitive impairment: related to seizure frequency, anticonvulsant side effects, underlying etiology
• Personality changes (controversial "interictal personality syndrome"/Geschwind syndrome in TLE - viscosity, religiosity, hypergraphia, hyposexuality, hypermoralism)
• ADHD: especially in children

Treatment Principles

• Achieve best possible seizure control
• Treat depression/anxiety with SSRIs (sertraline, citalopram preferred)
• Antipsychotics with lowest seizure-threshold lowering potential (quetiapine, olanzapine preferred over chlorpromazine)
• Assess psychosocial burden, employment, driving regulations, stigma
• Clozaril is relatively contraindicated (lowers seizure threshold significantly)

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23. Definition of Anxiety: Clinical Features and Classification

Definition

• Normal anxiety: adaptive; appropriate response to real threat; resolves with threat removal
• Pathological anxiety: disproportionate, prolonged, interferes with functioning, occurs without clear threat

Clinical Features

Neurobiological Basis

• Amygdala: fear conditioning and threat detection
• HPA axis: cortisol release in chronic anxiety
• Noradrenergic system: locus coeruleus hyperactivity
• GABA deficiency, serotonin dysregulation

DSM-5 / ICD-10 Classification of Anxiety Disorders

• Separation Anxiety Disorder
• Selective Mutism
• Specific Phobia (animal, natural environment, blood-injection-injury, situational, other)
• Social Anxiety Disorder (Social Phobia)
• Panic Disorder + Agoraphobia (in DSM-5, these are now separate; ICD-10 keeps them linked)
• Generalized Anxiety Disorder (GAD)
• Substance/Medication-Induced Anxiety Disorder
• Anxiety Disorder Due to Another Medical Condition

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24. Panic Disorder: Diagnostic Criteria and Treatment

Definition

Panic Attack - Features (DSM-5: ≥4 of 13 symptoms, peaking within minutes)

DSM-5 Panic Disorder Criteria

1. Persistent concern about future attacks or their consequences, OR
2. Significant maladaptive behavior change (avoidance of exercise, unfamiliar situations) C. Not attributable to substance/medication or medical condition D. Not better explained by another mental disorder

ICD-10: F41.0 Panic disorder

Comorbidities

Treatment

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25. Generalized Anxiety Disorder: Diagnostic Criteria and Treatment

DSM-5 GAD Criteria

1. Restlessness or feeling keyed up/on edge
2. Easily fatigued
3. Difficulty concentrating / mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (trouble falling/staying asleep) D. Causes clinically significant distress or functional impairment E. Not attributable to substance or medical condition F. Not better explained by another mental disorder

ICD-10: F41.1 Generalized Anxiety Disorder

Treatment

• SSRIs: sertraline, escitalopram, paroxetine
• SNRIs: duloxetine, venlafaxine (FDA-approved for GAD)
• Buspirone: 5-HT1A partial agonist; non-sedating, non-addictive; onset 2-4 weeks; good for chronic GAD
• Pregabalin: alpha-2-delta calcium channel ligand; effective; used in Europe; some addiction potential

• Benzodiazepines (short-term only - dependence risk)
• Mirtazapine

• CBT: most evidence; targets cognitive distortions (catastrophizing) and behavioral avoidance
• Relaxation training, mindfulness-based interventions
• Combined CBT + pharmacotherapy often superior

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26. Obsessive-Compulsive Disorder: Diagnostic Criteria and Treatment

DSM-5 OCD Criteria

• Obsessions: recurrent, persistent thoughts/urges/images experienced as intrusive and unwanted; patient attempts to ignore, suppress, or neutralize them (with compulsions)
• Compulsions: repetitive behaviors or mental acts that the person feels driven to perform in response to obsessions or rigid rules; aimed at reducing distress; not connected realistically or clearly excessive B. Obsessions/compulsions are time-consuming (>1 hour/day) or cause clinically significant distress/impairment C. Not attributable to substance or medical condition D. Not better explained by another disorder

ICD-10: F42 OCD

Common OCD Themes

• Contamination (cleaning rituals)
• Symmetry/ordering (arranging, counting)
• Forbidden thoughts (aggressive, sexual, religious)
• Harm (checking - gas, locks, appliances)

OCD Spectrum Disorders (DSM-5 Chapter)

Treatment

• Fluoxetine 40-80 mg, sertraline 100-200 mg, fluvoxamine (especially), paroxetine, citalopram
• Adequate trial = 12 weeks at maximum tolerated dose Second-line: Clomipramine (TCA; potent SERT inhibitor; effective but side effect burden) Augmentation (partial responders): antipsychotic augmentation (aripiprazole, risperidone, haloperidol)

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27. Phobic Anxiety Disorders: Agoraphobia

Phobia Definition

Specific Phobia (DSM-5, F40.2 ICD-10)

• Types: Animal, Natural environment (heights, storms), Blood-injection-injury (fainting response - unique vasovagal mechanism), Situational (flying, elevators), Other
• Treatment: Exposure therapy (systematic desensitization or flooding); single-session therapy effective for specific phobias; SSRIs/benzodiazepines as adjuncts

Social Anxiety Disorder (Social Phobia) (F40.1)

• Fear of social situations where scrutiny/embarrassment may occur
• Leads to avoidance of social/performance situations
• Most common anxiety disorder
• Treatment: SSRIs/SNRIs (first-line); CBT (exposure + cognitive restructuring); beta-blockers (propranolol) for performance anxiety

Agoraphobia (DSM-5 F40.00; ICD-10 F40.0)

1. Using public transportation
2. Being in open spaces (parking lots, marketplaces)
3. Being in enclosed places (shops, cinemas)
4. Standing in line or being in a crowd
5. Being outside the home alone

• CBT with graduated exposure (in vivo): most effective
• SSRIs (especially if comorbid panic disorder)
• Benzodiazepines (short-term only)
• For severe housebound patients: home-based therapy, virtual reality exposure

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28. Anxiolytics: Indications and Side Effects

Benzodiazepines

• Short-acting: Oxazepam, Lorazepam, Alprazolam - useful when no active metabolites desired (hepatic impairment, elderly)
• Long-acting: Diazepam, Chlordiazepoxide, Clonazepam, Nitrazepam (accumulate)

• Acute anxiety (short-term only, ≤2-4 weeks)
• Panic disorder (adjunct, acute)
• Alcohol withdrawal (first-line: chlordiazepoxide or diazepam)
• Status epilepticus (lorazepam IV)
• Catatonia (lorazepam)
• Pre-procedural sedation
• Acute mania (adjunct)
• Insomnia (short-term)

• Sedation, psychomotor impairment, cognitive impairment (anterograde amnesia)
• Tolerance (within 2-4 weeks)
• Physical dependence and withdrawal syndrome (anxiety, insomnia, tremor, seizures)
• Abuse potential (especially short-acting, high-potency)
• Respiratory depression (caution with alcohol/opioids; severe in overdose)
• Paradoxical disinhibition (especially in elderly, children)
• Falls/fractures in elderly

Buspirone

• MOA: 5-HT1A partial agonist; no GABAergic effect; no sedation, no dependence, no abuse
• Indications: GAD (first-line for chronic treatment); not effective for panic/phobia; not for acute anxiety
• Onset: 2-4 weeks
• Side effects: dizziness, nausea, headache; no cognitive impairment; no withdrawal

Pregabalin / Gabapentin

• MOA: alpha-2-delta subunit of voltage-gated calcium channels → reduces neurotransmitter release
• Indications: GAD (pregabalin is approved in Europe), social anxiety, neuropathic pain
• Side effects: dizziness, sedation, weight gain, peripheral edema; some abuse potential

Beta-Blockers (Propranolol)

• Block peripheral autonomic symptoms of anxiety (palpitations, tremor, sweating)
• Used for situational/performance anxiety
• No effect on psychological anxiety symptoms
• Not a primary anxiolytic

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29. Dissociative (Conversion) Disorders

Definition

ICD-10 Classification (F44)

• F44.0 Dissociative amnesia: inability to recall important personal information, usually traumatic (not due to organic brain disorder)
• F44.1 Dissociative fugue: purposeful travel/confused wandering with amnesia for past
• F44.2 Dissociative stupor: marked reduction in voluntary movement/response
• F44.3 Trance and possession disorders: temporary loss of sense of personal identity
• F44.4-F44.7 Conversion disorder (motor/sensory): motor symptoms (weakness, paralysis, gait disorder, tremor), sensory symptoms (anesthesia, blindness, deafness), convulsions/fits without EEG changes
• F44.8 Ganser's syndrome: approximate answers (Vorbeigehen), pseudohallucinations, clouding

DSM-5

• Dissociative disorders: dissociative identity disorder (DID), dissociative amnesia (+/- fugue specifier), depersonalization/derealization disorder
• Conversion disorder (Functional Neurological Symptom Disorder): separate chapter; characterized by incompatibility with known neurological disease; positive clinical signs (Hoover sign, inconsistency)

Key Features

• La belle indifférence: apparent emotional indifference to significant disability (classic but not pathognomonic)
• Symptoms are not feigned (distinguish from factitious disorder and malingering)
• Often precipitated by psychosocial stressor
• Previous trauma/abuse a significant risk factor
• Comorbid depression, anxiety, PTSD common

Treatment

• Psychotherapy (CBT, trauma-focused therapy, psychodynamic) - first-line
• Physiotherapy for motor conversion symptoms
• Treat comorbid depression/anxiety
• Avoid repeated negative investigations (reinforces sick role)
• Multidisciplinary rehabilitation approach
• Prognosis better when onset is acute and linked to identifiable stressor

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30. Alcohol Use Disorders: Alcohol Dependence

Alcohol Dependence Syndrome (Edwards & Gross, 1976; ICD-10 F10.2)

1. Compulsion to drink (craving)
2. Difficulties in controlling drinking onset, termination, or levels
3. Physiological withdrawal when drinking stops
4. Tolerance: need more alcohol to achieve the same effect
5. Neglect of other interests/pleasures
6. Persistent use despite knowledge of harmful consequences
7. Primacy: alcohol takes priority over other activities

DSM-5 Alcohol Use Disorder

Brief CAGE Questionnaire

• Cut down attempts
• Annoyed by criticism
• Guilty about drinking
• Eye-opener (morning drink) 2+ positive = probable dependence

Neurobiology

• Acute alcohol: GABA-A agonist (sedation) + NMDA glutamate antagonist
• Chronic use: NMDA receptors upregulate, GABA-A receptors downregulate
• Withdrawal: excess glutamate activity (excitotoxicity) = seizures/delirium

Complications

• Neurological: Wernicke-Korsakoff, peripheral neuropathy, cerebellar degeneration, dementia
• Hepatic: fatty liver → alcoholic hepatitis → cirrhosis
• GI: gastritis, peptic ulcer, pancreatitis, esophageal varices
• Cardiovascular: cardiomyopathy, atrial fibrillation, hypertension
• Psychiatric: depression, anxiety, suicide (15x increased risk), psychosis (alcoholic hallucinosis)

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31. Alcohol Withdrawal Syndrome

Timeline

• 6-12 hours after last drink: tremor, sweating, tachycardia, hypertension, anxiety, insomnia, nausea
• 12-24 hours: alcoholic hallucinosis (visual > auditory, usually brief, in clear consciousness)
• 24-48 hours: withdrawal seizures (generalized tonic-clonic; ~5-10% of dependent patients)
• 48-72+ hours: delirium tremens (see Topic 32)

Clinical Assessment: CIWA-Ar Scale

Treatment

• Chlordiazepoxide (long-acting, preferred - self-tapering due to long half-life; standard fixed reducing regimen over 7-10 days)
• Diazepam (alternative; also long-acting)
• Lorazepam (preferred in liver failure - no active metabolites; smaller doses)
• Oxazepam (also no active metabolites; second-line)
• Symptom-triggered regimens using CIWA-Ar superior to fixed-dose in medically stable patients

• Thiamine (mandatory, IV first): 200-300 mg IV TDS before glucose to prevent Wernicke's
• Hydration and electrolyte correction (K+, Mg²+)
• Beta-blockers (symptom control, not prevent seizures)
• Anticonvulsants (valproate, carbamazepine) as alternatives in mild withdrawal or adjuncts

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32. Alcohol Withdrawal State with Delirium (Delirium Tremens)

Definition

• Global confusion/delirium (disorientation, impaired cognition)
• Autonomic hyperactivity (fever, tachycardia, hypertension, diaphoresis)
• Vivid hallucinations (predominantly visual - "seeing animals"/zoopsia, insects)
• Severe tremor

Timing

Risk Factors for DTs

Management (ICU setting often required)

1. High-dose benzodiazepines: IV diazepam or lorazepam - titrated to calm without over-sedation; large doses may be needed
2. IV thiamine (before glucose): 500 mg TDS
3. Fluid and electrolyte replacement: IV fluids, correct K+ and Mg²+
4. Monitoring: vital signs, blood glucose, blood cultures
5. Antipsychotics (haloperidol): for residual hallucinations/agitation after benzodiazepines; do not prevent seizures
6. Phenobarbital: some evidence as adjunct in severe/refractory DTs
7. Treat precipitants: infections, GI bleed, head injury (common in alcoholic patients)

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33. Opioid Use Disorders

Definition

Common Opioids

• Illicit: heroin (diacetylmorphine) - most commonly involved in opioid dependence
• Prescription: oxycodone, hydrocodone, codeine, tramadol, fentanyl, morphine
• Synthetic: fentanyl analogues (illicit; extremely potent - overdose risk)

Mechanism

• Mu receptors: analgesia, euphoria, respiratory depression, constipation, physical dependence
• Mesolimbic dopamine activation: reinforcement/addiction

Acute Opioid Intoxication

Complications

• Overdose/respiratory arrest (especially with fentanyl, combined with benzodiazepines/alcohol)
• IV use complications: HIV, hepatitis B/C, bacterial endocarditis, abscess
• Constipation, urinary retention, hypogonadism (chronic use)
• Neonatal opioid withdrawal syndrome (NOWS) if use in pregnancy

Treatment

• Opioid Substitution Therapy (OST): gold standard for opioid dependence
  • Methadone: full agonist, long-acting oral; most evidence for retention and harm reduction; COWS monitored; risk of QTc prolongation; dispensed in controlled setting
  • Buprenorphine (or buprenorphine/naloxone = Suboxone): partial agonist + ceiling effect on respiratory depression = safer overdose profile; sublingual; can be office-based
• Naltrexone (oral or monthly injectable - Vivitrol): full opioid antagonist; requires opioid-free for 7-10 days before starting; good for highly motivated patients; no diversion risk
• Psychosocial interventions: contingency management, CBT, 12-step programs (NA)

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34. Opioid Withdrawal Syndrome

Timeline

• Short-acting opioids (heroin, morphine): onset 6-12 hours, peak 24-72 hours, subsides 5-7 days
• Long-acting (methadone): onset 36-72 hours, peak 5-7 days, subsides 2-3 weeks

Clinical Features

• Drug craving, anxiety, yawning, lacrimation, rhinorrhea, diaphoresis

• Mydriasis (dilated pupils), piloerection ("goose flesh" = "cold turkey"), severe restlessness, insomnia
• Nausea, vomiting, diarrhea, abdominal cramps
• Muscle aches and pains, bone pain, myoclonus
• Tachycardia, hypertension, fever
• Intense craving

Key Point

Treatment

• Substitution (buprenorphine or methadone): most effective; reduces withdrawal severity and prevents relapse
• Symptomatic:
  • Lofexidine (alpha-2 agonist): reduces autonomic symptoms (BP, pulse, sweating); approved alternative to methadone for detoxification
  • Clonidine (alpha-2 agonist): similar mechanism to lofexidine; used off-label
  • NSAIDs/paracetamol: musculoskeletal pain
  • Loperamide: diarrhea
  • Antiemetics: nausea/vomiting
  • Benzodiazepines: insomnia, severe anxiety (short-term)
• Rapid/ultra-rapid detoxification under anesthesia: high risk, no long-term benefit - not recommended

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35. Somatic Consequences of Drug Use (Substance-Related Disorders)

Alcohol (also see Topics 30-32)

• Liver: fatty liver (reversible), alcoholic hepatitis, cirrhosis, hepatocellular carcinoma
• GI: gastritis, peptic ulcer, pancreatitis (acute/chronic), oesophageal varices, Mallory-Weiss tears
• CNS: Wernicke-Korsakoff, peripheral neuropathy, cerebellar degeneration, alcoholic dementia, subdural haematoma
• Cardiovascular: cardiomyopathy, holiday heart (AF), hypertension
• Cancer: oral, oesophageal, laryngeal, breast, colorectal
• Endocrine: pseudo-Cushing's, hypogonadism, hypoglycemia
• Haematological: macrocytosis, thrombocytopenia, anaemia

Opioids

• IV use: HIV, Hepatitis B/C, bacterial endocarditis (tricuspid most common), deep vein thrombosis, skin abscesses, septic emboli
• Systemic: constipation, urinary retention, impotence, menstrual irregularity, immunosuppression
• Overdose: respiratory failure, hypoxic brain injury

Stimulants (Cocaine, Amphetamines)

• Cardiovascular: acute MI (vasospasm, thrombosis), hypertensive crisis, aortic dissection, cardiomyopathy, arrhythmias, stroke (hemorrhagic or ischemic)
• CNS: seizures, stroke, psychosis (cocaine/amphetamine-induced), anxiety, Parkinson's (methamphetamine, chronic)
• Nasal: septal perforation (cocaine insufflation)
• Pulmonary: crack lung (cocaine free-base inhalation), pneumothorax, pneumomediastinum

Cannabis

• Respiratory: chronic bronchitis, chronic cough (smoked); no clear link to lung cancer
• CNS: cannabis-induced psychosis, exacerbation of schizophrenia, cannabinoid hyperemesis syndrome
• Cardiovascular: increased MI risk in young users (vasoconstriction, tachycardia)

Benzodiazepines

• Anterograde amnesia, psychomotor impairment, falls, respiratory depression (with alcohol), dependence, withdrawal seizures

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36. Personality Disorders: Diagnostic Criteria and Classification

Definition

DSM-5 General Criteria (must meet ALL)

ICD-10 General Criteria (F60)

DSM-5 Classification (Cluster System)

• Paranoid PD
• Schizoid PD
• Schizotypal PD

• Antisocial PD (= ICD-10 Dissocial PD)
• Borderline PD (= ICD-10 Emotionally Unstable, Borderline type)
• Histrionic PD
• Narcissistic PD

• Avoidant PD
• Dependent PD
• Obsessive-Compulsive PD (not OCD)

ICD-11 Changes

• Single diagnosis: "Personality Disorder" with severity qualifier (mild, moderate, severe)
• Five domain traits: Negative Affectivity, Detachment, Dissociality, Disinhibition, Anankastia
• Borderline Pattern Specifier retained as an exception

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37. Specific Personality Disorders: Paranoid, Schizoid, Schizotypal

Paranoid Personality Disorder (F60.0)

1. Suspects others are exploiting, harming, or deceiving them
2. Preoccupied with unjustified doubts about loyalty of friends/associates
3. Reluctant to confide in others (fears information used against them)
4. Reads hidden demeaning/threatening meanings into benign remarks
5. Bears grudges (does not forgive insults)
6. Perceives attacks on character not apparent to others; quick to react with anger
7. Recurrent unjustified suspicions about fidelity of spouse/partner

Schizoid Personality Disorder (F60.1)

1. Neither desires nor enjoys close relationships
2. Almost always chooses solitary activities
3. Little/no interest in sexual experiences
4. Takes pleasure in few activities (if any)
5. Lacks close friends/confidants other than first-degree relatives
6. Appears indifferent to praise or criticism
7. Shows emotional coldness, detachment, or flattened affect

Schizotypal Personality Disorder (F21 in ICD-10 - placed with schizophrenia spectrum; F60.1 in DSM)

1. Magical thinking (belief in clairvoyance, telepathy, "sixth sense")
2. Experiences of reference (ideas of reference, not full delusions)
3. Perceptual aberrations (illusions, bodily illusions, sensing a presence)
4. Eccentric behavior and appearance
5. Constricted affect
6. Unusual speech (vague, circumstantial, metaphorical, overelaborate, stereotyped)
7. Lack of close friends
8. Ideas of reference
9. Anxiety in social situations (paranoid fear rather than negative self-judgment)
10. Rule-out: not during schizophrenia or psychotic mood disorder

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38. Specific Personality Disorders: Dissocial, Emotionally Unstable, Histrionic

Dissocial Personality Disorder (ICD-10 F60.2) = Antisocial PD (DSM-5)

1. Callous unconcern for the feelings of others
2. Gross and persistent attitude of irresponsibility, disregard for social norms/rules/obligations
3. Incapacity to maintain enduring relationships (though able to establish them)
4. Very low tolerance to frustration and a low threshold for discharge of aggression
5. Incapacity to experience guilt or to profit from experience/punishment
6. Marked proneness to blame others or offer plausible rationalizations for behavior

Emotionally Unstable Personality Disorder (ICD-10 F60.3) = Borderline PD (DSM-5)

• F60.30 Impulsive type: emotional instability + explosive outbursts of threatening behavior
• F60.31 Borderline type (main): additionally - disturbed self-image, chronic emptiness, unstable relationships, self-harm

1. Identity disturbance (unstable self-image)
2. Difficulty controlling anger (intense, inappropriate anger)
3. Efforts to avoid abandonment (frantic; real or imagined)
4. Self-damaging impulsivity (≥2: spending, sex, substance, reckless driving, binge eating)
5. Paranoid ideation or severe dissociation (transient, stress-related)
6. Affective instability (intense episodic dysphoria, irritability, anxiety lasting hours-days)
7. Instability of relationships (intense, alternating idealization and devaluation = "splitting")
8. Recurrent suicidal behavior, gestures, threats, or self-mutilation (deliberate self-harm)
9. Chronic feelings of emptiness

• Dialectical Behavior Therapy (DBT): gold standard; combines CBT with acceptance/mindfulness; targets emotional dysregulation, self-harm, impulsivity
• Mentalization-Based Therapy (MBT): psychodynamic approach
• Schema Therapy
• Pharmacotherapy: no specific agent; SSRIs for depression/impulsivity; mood stabilizers (valproate, lamotrigine) for affective instability; low-dose antipsychotics for transient psychotic features/dissociation
• Crisis management; DBT skills training; avoid iatrogenic polypharmacy

Histrionic Personality Disorder (ICD-10 F60.4; DSM-5)

1. Uncomfortable when not the center of attention
2. Interactions characterized by sexually seductive or provocative behavior
3. Rapidly shifting and shallow expression of emotions
4. Consistently uses physical appearance to draw attention
5. Style of speech excessively impressionistic (lacks detail)
6. Shows self-dramatization, theatricality, exaggerated expression
7. Suggestible (easily influenced by others or circumstances)
8. Considers relationships more intimate than they actually are

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How to Use These Notes

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PSYCHIATRY - Study Notes (Topics 39-48)

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39. Specific Personality Disorders: Anankastic, Anxious, Dependent

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Anankastic (Obsessive-Compulsive) Personality Disorder

1. Feelings of excessive doubt and caution
2. Preoccupation with details, rules, lists, order, organization, schedules
3. Perfectionism that interferes with task completion
4. Excessive conscientiousness, scrupulousness, undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships
5. Excessive pedantry and adherence to social conventions
6. Rigidity and stubbornness
7. Unreasonable insistence that others submit to one's own way of doing things, or reluctance to allow others to do things
8. Intrusion of insistent and unwelcome thoughts or impulses

1. Preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost
2. Perfectionism that interferes with task completion (cannot finish project because own standards are not met)
3. Excessively devoted to work and productivity to the exclusion of leisure and friendships
4. Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
5. Unable to discard worn-out or worthless objects even when they have no sentimental value
6. Reluctant to delegate tasks or to work with others unless they submit to exactly their way of doing things
7. Adopts a miserly spending style toward self and others; money is viewed as something to be hoarded for future catastrophes
8. Shows rigidity and stubbornness

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Anxious (Avoidant) Personality Disorder

1. Persistent and pervasive feelings of tension and apprehension
2. Belief that one is socially inept, personally unappealing, or inferior to others
3. Excessive preoccupation with being criticized or rejected in social situations
4. Unwillingness to become involved with people unless certain of being liked
5. Restrictions in lifestyle because of need to have physical security
6. Avoidance of social or occupational activities that involve significant interpersonal contact, because of fear of criticism, disapproval, or rejection

1. Avoids occupational activities involving significant interpersonal contact (fears criticism, disapproval, or rejection)
2. Unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
4. Preoccupied with being criticized or rejected in social situations
5. Inhibited in new interpersonal situations because of feelings of inadequacy
6. Views self as socially inept, personally unappealing, or inferior to others
7. Unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

• CBT targeting core beliefs of inadequacy and anticipated rejection
• Graduated social exposure
• SSRIs/SNRIs (especially if comorbid social anxiety)
• Group therapy (allows safe social practice)
• Long-term therapy needed; prognosis better than Cluster A/B

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Dependent Personality Disorder

1. Encouraging or allowing others to make most of one's important life decisions
2. Subordination of one's own needs to those of others on whom one is dependent, and undue compliance with their wishes
3. Unwillingness to make even reasonable demands on the people one depends on
4. Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself
5. Preoccupation with fears of being abandoned by a person one has a close relationship with, and of being left to care for oneself
6. Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others

1. Difficulty making everyday decisions without excessive advice/reassurance
2. Needs others to assume responsibility for most major areas of their life
3. Difficulty expressing disagreement with others (fear of loss of support or approval)
4. Difficulty initiating projects or doing things on their own (lack of self-confidence, not lack of motivation/energy)
5. Goes to excessive lengths to obtain nurturance and support, to the point of volunteering to do things that are unpleasant
6. Feels uncomfortable or helpless when alone (because of exaggerated fears of being unable to care for themselves)
7. Urgently seeks another relationship as a source of care and support when a close relationship ends
8. Unrealistically preoccupied with fears of being left to take care of themselves

• Psychotherapy: CBT (building autonomy, assertiveness training), psychodynamic
• Avoid reinforcing dependency in the therapeutic relationship itself
• SSRIs for comorbid depression/anxiety
• Risk: vulnerability to abusive relationships; may remain in harmful situations rather than risk separation

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40. Neurodevelopmental Disorders: Mental Retardation (Intellectual Disability)

Definition

1. Significant limitations in intellectual functioning (reasoning, learning, problem-solving) - typically IQ ≤70 (approximately 2 standard deviations below mean)
2. Significant limitations in adaptive behavior (conceptual, social, and practical skills needed for daily life)
3. Onset during the developmental period (before age 18)

ICD-10 Classification by Severity

Prevalence and Epidemiology

• Prevalence: ~1-3% of the general population
• M:F = approximately 1.5:1
• Most common cause overall: Down syndrome (trisomy 21) in moderate-severe range; Fragile X syndrome is the leading inherited cause

Etiology

• Chromosomal: Down syndrome (T21), Edward syndrome (T18), Patau (T13), Turner, Klinefelter, Fragile X (FMR1 gene mutation)
• Teratogenic: alcohol (Fetal Alcohol Spectrum Disorder - most preventable), infections (TORCH), radiation
• Metabolic: PKU (phenylketonuria - treatable by diet), hypothyroidism, galactosaemia
• Structural CNS malformations

• Birth asphyxia, prematurity, intraventricular hemorrhage, neonatal hypoglycemia

• CNS infections (meningitis, encephalitis)
• Severe TBI, near-drowning
• Toxins (lead, mercury)

Psychiatric Comorbidities ("Dual Diagnosis")

• ADHD (~15-25% in mild ID)
• Stereotyped movement disorders
• Autism Spectrum Disorder (~30% in moderate-severe ID)
• Mood disorders, anxiety
• Psychosis (schizophrenia prevalence ~3x general population)
• Behavioral phenotypes specific to genetic syndromes: Prader-Willi (hyperphagia, OCD traits), Angelman (happy affect, minimal speech), Lesch-Nyhan (self-injurious behavior)

Assessment

• Standardized IQ tests: WAIS (adults), WISC (children), Leiter (non-verbal)
• Adaptive behavior scales: Vineland Adaptive Behavior Scales, AAMR Adaptive Behavior Scale
• Full medical/genetic workup, chromosomal analysis, metabolic screening

Management

• No cure for most forms; management is habilitative (developing skills) rather than rehabilitative
• Early intervention: speech/language therapy, occupational therapy, physiotherapy, special education
• Supported employment and community living programs
• Pharmacotherapy: for psychiatric comorbidities (same agents as general population but with increased sensitivity; start low, go slow); treat pain/epilepsy
• Genetic counseling for families
• Legal advocacy: guardianship, rights protection, education rights

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41. Attention Deficit Hyperactivity Disorder (ADHD)

Definition and Epidemiology

• Most common childhood behavioral disorder: prevalence ~5-7% in children worldwide; ~2.5% in adults
• M:F = 2-3:1 in children (male predominance in hyperactive/combined; more equal in inattentive)
• Persists into adulthood in ~60-70% of cases

DSM-5 Diagnostic Criteria

1. Fails to give close attention to details/makes careless mistakes
2. Difficulty sustaining attention in tasks or play
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions; fails to finish tasks
5. Difficulty organizing tasks and activities
6. Avoids/dislikes tasks requiring sustained mental effort
7. Loses things necessary for tasks
8. Easily distracted by extraneous stimuli
9. Forgetful in daily activities

1. Fidgets with or taps hands/feet; squirms in seat
2. Leaves seat when remaining seated expected
3. Runs about or climbs in situations where it is inappropriate (in adults: subjective feeling of restlessness)
4. Unable to play or engage in leisure activities quietly
5. "On the go" / acts as if "driven by a motor"
6. Talks excessively
7. Blurts out answers before question is completed
8. Difficulty waiting their turn
9. Interrupts or intrudes on others

• Combined (ADHD-C): both inattention and hyperactivity-impulsivity criteria met
• Predominantly Inattentive (ADHD-PI): "daydreamer"; often missed, especially in girls
• Predominantly Hyperactive-Impulsive (ADHD-HI): more visible; rare in isolation

ICD-10: Hyperkinetic Disorder (F90)

Neurobiology

• Dopaminergic and noradrenergic dysregulation in prefrontal cortex
• Structural MRI: reduced volume in prefrontal cortex, caudate nucleus, cerebellum
• Genetic: highly heritable (~76%); DAT1, DRD4, DRD5 gene variants implicated

Comorbidities

• Oppositional defiant disorder (~40-50%)
• Conduct disorder (~25%)
• Learning disabilities (~25-30%)
• Anxiety disorders (~25%)
• Mood disorders, especially in adults
• Substance use disorders (untreated ADHD increases risk 2-3x)
• Sleep disorders
• ASD (can now be co-diagnosed in DSM-5)

Treatment

• Parent training in behavior management (especially in young children)
• Classroom accommodations (extra time, preferential seating, structured environment)
• CBT (for older adolescents and adults)
• Psychoeducation for child, family, teachers

• Methylphenidate (Ritalin, Concerta - extended release): dopamine/norepinephrine reuptake inhibitor; onset within 30 min; immediate or extended release; most widely used and studied; response rate ~70-80%
• Amphetamine salts (Adderall, Dexamfetamine): dopamine/norepinephrine releasing agent + reuptake inhibitor; equally effective; also first-line
• Side effects (stimulants): decreased appetite, weight loss, insomnia, headaches, abdominal pain, elevated BP/HR, rebound effect, tics (controversial); potential for misuse/diversion; Schedule II substances

• Atomoxetine (Strattera): selective norepinephrine reuptake inhibitor (SNRI); first non-stimulant approved; once/twice daily; no abuse potential; onset 4-6 weeks; good when tics or substance abuse concern; SE: GI upset, initial sedation, black-box warning for suicidality in children
• Guanfacine ER / Clonidine ER: alpha-2 agonists; useful for ADHD + tics or aggression; also second-line
• Bupropion: NDRI; evidence in adults; not first-line

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42. Autistic Spectrum Disorders (ASD)

Definition

1. Persistent deficits in social communication and social interaction across multiple contexts
2. Restricted, repetitive patterns of behavior, interests, or activities

• Symptoms present in the early developmental period (though may not fully manifest until social demands exceed capacity)
• Symptoms cause clinically significant impairment

DSM-5 Diagnostic Criteria

1. Deficits in social-emotional reciprocity (abnormal social approach, failure of back-and-forth conversation, reduced sharing of interests/emotions/affect, failure to initiate/respond to social interactions)
2. Deficits in nonverbal communicative behaviors used for social interaction (poor eye contact, abnormal body language, deficits in understanding/using gestures, absent facial expressions)
3. Deficits in developing, maintaining, and understanding relationships (difficulties adjusting behavior to social contexts, difficulty making friends, absence of interest in peers)

1. Stereotyped or repetitive motor movements, use of objects, or speech (simple motor stereotypies, lining up toys, echolalia, idiosyncratic phrases)
2. Insistence on sameness, inflexible adherence to routines, ritualized patterns (extreme distress at small changes, rigid thinking, greeting rituals, same route)
3. Highly restricted, fixated interests that are abnormal in intensity or focus
4. Hyper- or hyporeactivity to sensory input (apparent indifference to pain/temperature, adverse response to specific sounds/textures, excessive smelling/touching of objects, visual fascination with lights/movement)

• Level 1: Requiring support
• Level 2: Requiring substantial support
• Level 3: Requiring very substantial support

ICD-10 Classification (more fragmented, replaced by ASD in ICD-11)

• F84.0 Childhood autism (Kanner's autism): classic; onset before 3 years; language delay + social/behavioral features
• F84.1 Atypical autism
• F84.2 Rett syndrome (now recognized as genetic - MECP2 mutation; predominantly girls)
• F84.5 Asperger's syndrome: normal language/cognitive development; social deficits + restricted interests; NO intellectual disability; merged into ASD spectrum in DSM-5

Epidemiology

• Prevalence: ~1 in 36 children (CDC 2023); rates have risen substantially (increased awareness + diagnostic criteria changes)
• M:F = ~4:1 (females often underdiagnosed; present differently - "camouflaging")
• Highly heritable: ~80% concordance in monozygotic twins

Neurobiology

• Multiple genetic factors; de novo mutations (CHD8, SHANK3, NRXN1); copy number variants
• Synaptic protein abnormalities, altered connectivity between brain regions
• Brain overgrowth in early childhood then relative plateau
• NOT caused by vaccines (Wakefield 1998 paper retracted, fraudulent)

Assessment

• Gold standard diagnostic tools: ADOS-2 (Autism Diagnostic Observation Schedule) + ADI-R (Autism Diagnostic Interview - Revised)
• Developmental history from parents/caregivers; cognitive/language assessment
• Medical workup: EEG (~30% of ASD have epilepsy), genetic testing (chromosomal microarray, Fragile X), audiological assessment

Comorbidities

• Intellectual disability (~30-40%)
• Epilepsy (~30%)
• ADHD (~50-70%)
• Anxiety disorders (~40-50%)
• Depression (especially in higher-functioning adults)
• Sleep disorders (insomnia, ~50-80%)
• GI problems (constipation, GI pain)
• Sensory processing differences

Treatment

• Applied Behavior Analysis (ABA): most evidence for improving communication, social, and adaptive skills; intensive early intervention (20-40 hrs/week) in young children
• Speech and language therapy: communication skills, augmentative/alternative communication (AAC) for non-verbal children
• Occupational therapy: sensory integration, daily living skills
• Social skills groups
• Special education: individualized education plans
• Pharmacotherapy (for comorbidities only, not core ASD features):
  • Risperidone / Aripiprazole: FDA-approved for irritability/aggression/self-injurious behavior in ASD
  • SSRIs: for anxiety or repetitive behaviors (modest evidence)
  • Methylphenidate/Atomoxetine: for comorbid ADHD
  • Melatonin: for sleep disorders
• Family support and psychoeducation: essential

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43. Anorexia Nervosa

Definition

DSM-5 Diagnostic Criteria

• Restricting type: weight loss achieved by dieting, fasting, and/or excessive exercise; no binge/purge episodes
• Binge-eating/purging type: recurring binge eating or purging behavior (self-induced vomiting, laxatives, diuretics) in the context of low weight

• Mild: BMI ≥17
• Moderate: 16-16.99
• Severe: 15-15.99
• Extreme: <15

ICD-10: F50.0 Anorexia Nervosa

• Body weight ≥15% below expected (or BMI ≤17.5)
• Self-induced weight loss (avoidance of fattening foods + one of: self-induced vomiting/purging, excessive exercise, use of appetite suppressants/diuretics)
• Body image distortion (dread of fatness as intrusive, overvalued idea)
• Endocrine disorder: amenorrhea in females (or loss of libido in males)

Epidemiology

• Lifetime prevalence: ~1% women; ~0.1-0.3% men
• Peak onset: adolescence (15-19 years); bimodal peak at 14 and 18
• Highest mortality of any psychiatric disorder (~5-10% per decade); causes: starvation, electrolyte imbalance, cardiac arrhythmia, and suicide

Medical Complications

Treatment

• Criteria for hospitalization: BMI <15, rapid weight loss (>1 kg/week), electrolyte disturbance, cardiac instability, syncope, suicide risk, failure of outpatient treatment
• Nasogastric feeding if oral intake insufficient; in extremis: parenteral nutrition

• Structured meal plan; gradual caloric increase (starting ~1200-1500 kcal/day, increasing slowly)
• Monitor phosphate, potassium, magnesium, glucose (refeeding risk)

• In adolescents: Family-Based Treatment (FBT / Maudsley Approach): most evidence; parents take control of eating; best outcomes in adolescent AN
• In adults: CBT-E (Enhanced CBT for eating disorders); Adolescent-focused psychotherapy; SSCM (specialist supportive clinical management); psychodynamic therapy
• Anorexia-specific CBT: addresses core beliefs about weight/shape, perfectionism, and emotional avoidance

• No drug approved specifically for AN
• Olanzapine: modest evidence for weight gain and reducing anxiety around eating (low-dose, 2.5-5 mg/day)
• SSRIs: not effective during starvation state (serotonin synthesis requires adequate tryptophan/nutrition); may help once weight restored for comorbid depression/OCD
• Treat osteoporosis: calcium + vitamin D; consider bisphosphonates if severe

• ~50% full recovery, ~30% partial recovery, ~20% chronic/fatal course
• Worse prognosis: older age at onset, longer duration, binge-purge subtype, medical severity, comorbid personality disorder

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44. Psychomotor Excitation in Mental Disorders: Causes and Emergency Interventions

Definition

Causes (Differential Diagnosis)

• Acute psychosis (schizophrenia, brief psychotic episode) - most common
• Manic episode (acute mania/mixed state)
• Severe agitated depression
• Borderline/antisocial personality disorder (impulsive aggression)
• Delirium (hyperactive type - see below)
• Dissociative episodes
• Catatonic excitement

• Delirium from any cause (infection, metabolic, drug intoxication/withdrawal)
• Substance intoxication: alcohol, stimulants (cocaine, amphetamine), PCP, bath salts (synthetic cathinones)
• Substance withdrawal: alcohol (DTs), benzodiazepine withdrawal
• Neurological: post-ictal state, encephalitis (anti-NMDA receptor), TBI, stroke
• Metabolic: hypoglycemia, thyrotoxicosis, hyponatremia, hypoxia
• Pain (especially in non-verbal patients with dementia)
• Akathisia (antipsychotic-induced inner restlessness - must distinguish from agitation requiring more antipsychotic)

Risk Assessment

• STAMP/OAS (Overt Agitation Severity Scale) or PANSS Excited Component
• Assess for: immediate danger, weapons, triggers, history of violence, intoxication
• Key risk factors for violence: male sex, youth, substance misuse, history of violence, command hallucinations, persecutory delusions, antisocial PD, akathisia

Emergency Interventions (Stepped/De-escalation Approach)

• Calm, non-threatening tone; maintain safe distance
• Reduce stimulation (quiet environment, remove bystanders)
• Empathic listening; validate emotions ("I can see you're frightened")
• Offer choice, negotiate; avoid confrontation or commands
• Offer oral medication voluntarily

• Lorazepam 1-2 mg PO/sublingual
• Olanzapine 10 mg PO/wafer (Zydis)
• Haloperidol 5 mg PO
• Promethazine 25-50 mg PO (antihistamine/antipsychotic combination; useful when etiology unclear)

• Lorazepam 1-2 mg IM (first-line for most causes, including unknown etiology)
• Haloperidol 5 mg IM (for psychotic agitation; avoid in DTs and Lewy body dementia)
• Olanzapine 10 mg IM (avoid combining IM olanzapine with IM benzodiazepine - respiratory depression risk)
• Promethazine 50 mg IM (can be combined with haloperidol; reduces EPS)
• Droperidol IM/IV: rapid onset; effective; QTc monitoring required
• For alcohol/benzo withdrawal agitation: high-dose IV diazepam or lorazepam; NOT haloperidol alone (does not prevent seizures)

• Last resort only; legal and ethical requirements (documentation, appropriate staffing, monitoring)
• Prone restraint (face-down) is particularly dangerous - positional asphyxia risk
• Continuous monitoring of airway, breathing, circulation, oxygen saturation, ECG
• Remove restraint as soon as safely possible

• Vital signs every 5-15 minutes
• Pulse oximetry
• Resuscitation equipment available (flumazenil for benzodiazepine reversal, naloxone for opioids)

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45. Suicidal Behaviour in Mental Disorders: Causes and Emergency Interventions

Definitions

• Suicidal ideation: thoughts about suicide (passive = wish to be dead; active = plan to kill oneself)
• Suicidal attempt: non-fatal self-injurious behavior with some intent to die
• Deliberate self-harm (DSH): self-injurious behavior that may or may not have suicidal intent (includes self-cutting, burning, overdose)
• Suicide: completed self-killing

Epidemiology

• ~800,000 suicides per year worldwide (WHO)
• Suicide is the leading cause of death in 15-29 year-olds in many countries
• For every completed suicide: ~20 attempts
• M:F = 3-4:1 for completed suicide (men use more lethal methods); F>M for attempts

Causes and Risk Factors

• Depression (50-60% of suicides): highest absolute number; most important risk
• Bipolar disorder (risk 20-30x general population; mixed states and depressive phases particularly high risk)
• Schizophrenia (lifetime risk ~5-10%; often during periods of insight, post-discharge)
• Borderline personality disorder (lifetime risk ~8-10%)
• Alcohol/substance use disorders (10-15% of alcoholics die by suicide; disinhibition, impulsivity, hopelessness)
• Anorexia nervosa (highest suicide risk of eating disorders)
• PTSD, panic disorder

• Previous suicide attempt (strongest single predictor; risk 30-40x higher)
• Male sex
• Older age (men), young adult (women)
• Access to lethal means (firearms, medications)
• Social isolation, recent loss (bereavement, divorce, unemployment)
• Chronic physical illness (pain, terminal diagnosis)
• Family history of suicide
• Recent discharge from psychiatric hospital (peak risk in first 2 weeks)
• Impulsivity, hopelessness (the most potent psychological predictor), worthlessness

• Strong social/family support
• Religious belief (inhibits suicidal behavior in some cultures)
• Children at home (especially for women)
• Help-seeking behavior, good therapeutic alliance
• Restricted access to means
• Reason for living

Risk Assessment Tools

• SAD PERSONS scale (historical but still used in teaching)
• Columbia Suicide Severity Rating Scale (C-SSRS): gold standard; rates ideation and behavior
• Beck Scale for Suicide Ideation (BSS)
• PHQ-9 item 9 (screening in primary care)

• Specific plan (method, time, place)
• Access to lethal means
• Strong intent; hopelessness
• Previous serious attempt
• Psychotic command hallucinations ordering suicide
• Recent discharge from hospital

Emergency Interventions

• Establish safety; do not leave alone
• Ask directly about suicidal ideation (asking does NOT increase risk - evidence shows it may reduce it)
• Assess severity: ideation frequency, plan, intent, means, deterrents
• Assess mental state (psychosis, intoxication, severe depression)

• Safety planning (collaborative; list coping strategies, contacts, crisis line numbers, reasons for living)
• Remove/restrict access to means (medications locked away, firearms removed from home)
• Increase outpatient follow-up frequency
• Involve family/carer with patient consent
• Crisis card / crisis team contact

• Admit to psychiatric inpatient unit (voluntary if possible)
• If patient refuses, consider involuntary admission under Mental Health Act if criteria met
• One-to-one nursing observation (constant or intermittent)
• Treat underlying psychiatric disorder aggressively (antidepressant, antipsychotic, mood stabilizer)
• Lithium: only psychotropic with robust evidence for anti-suicidal effect (reduces completed suicide ~80% in mood disorders)
• Clozapine: reduces suicidal behavior in schizophrenia (only antipsychotic FDA-approved for this)
• ECT: for severe suicidal depression, especially with psychosis or refusal to eat

• Medical treatment (GCS, vital signs, antidote: N-acetylcysteine for paracetamol overdose; naloxone for opioids; flumazenil for benzodiazepines; activated charcoal if within 1 hour and airway protected)
• Psychiatric assessment before discharge
• Safety planning
• Brief contact interventions (postcards, follow-up calls) shown to reduce re-attempt

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46. Food Refusal in Mental Disorders: Causes and Emergency Interventions

Definition

Causes by Diagnosis

• Anorexia nervosa: most classic cause; motivated by fear of weight gain and body image distortion
• ARFID (Avoidant/Restrictive Food Intake Disorder): limited food intake based on sensory characteristics, fear of choking/vomiting, or lack of interest in eating; NOT motivated by weight/shape concerns; often in autism and anxiety disorders
• Orthorexia (not a formal diagnosis): obsessive restriction of "unhealthy" foods

• Persecutory delusions about food being poisoned
• Olfactory/gustatory hallucinations (food tastes bad/contaminated)
• Command hallucinations ordering not to eat
• Nihilistic delusions (belief that stomach/bowel does not exist)

• Severe depression: loss of appetite, anhedonia, inability to initiate eating, psychomotor retardation
• Depressive stupor: complete withdrawal from food and fluids
• Manic episode: too distractible/excited to eat

• Confusion, altered consciousness; unable to recognize/initiate eating; paranoid misidentification of food

• Dysphagia, apraxia of eating, loss of recognition of food, behavioral agitation at mealtimes, loss of satiety regulation (frontotemporal dementia may cause hyperphagia instead)

• Complete immobility and mutism; refuses or cannot eat

• Contamination obsessions about food; ritual-bound eating that makes adequate nutrition impossible

• Dysphagia (neurological, structural), severe nausea/vomiting, mucositis, oral pain

Assessment

• Medical: weight, BMI, vital signs, electrolytes (K+, Na+, Mg²+, PO₄), LFTs, FBC, glucose, BUN/Creatinine
• Swallowing assessment (SLT) if dysphagia suspected
• Psychiatric assessment: identify driving psychopathology

Emergency Interventions

• Treat psychotic food refusal with antipsychotics (rapid tranquilization if needed)
• Treat severe depressive stupor or catatonic food refusal with lorazepam +/- ECT
• Treat anorexia with multidisciplinary eating disorder team (see Topic 43)

• Oral supplementation: high-calorie oral nutritional supplements (Fortisip, Ensure); encourage +/- assist with eating
• Nasogastric (NG) tube feeding:
  • Indicated if oral intake inadequate and patient refuses voluntary feeding
  • May be given under mental health legislation/incapacity law if patient lacks capacity
  • For anorexia: used in life-threatening situations; can be voluntary or compulsory
  • For psychotic food refusal: may be bypassed once antipsychotic takes effect
• Parenteral nutrition (TPN): only if GI tract non-functional or NG tube cannot be placed

• In most jurisdictions, a patient who lacks capacity due to a mental disorder can be fed against their will under mental health or mental capacity legislation
• In anorexia, the mental illness (cognitive distortion about weight) impairs capacity, and compulsory nasogastric feeding may be lawful
• Always document decision-making capacity assessment, best-interest decision, multi-disciplinary involvement, and patient/family discussion

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47. Legal Regulation of Ordinary Psychiatric Practice

Core Legal Principles in Psychiatry

• The default for all psychiatric treatment is voluntary consent
• Patient must give informed consent: capacity to understand information, weigh it, and communicate a decision; must be given information about diagnosis, treatment, benefits, risks, alternatives
• Capacity is decision-specific and fluctuating (not all-or-nothing)

• Assume capacity unless proven otherwise
• Incapacity must be caused by an impairment or disturbance of mind
• Four-part capacity test: can the patient (1) understand the information, (2) retain it long enough to decide, (3) weigh/use it, (4) communicate their decision?
• If lacking capacity: best interest decision; least restrictive option; involve family/proxy

• All clinical information is confidential; cannot be shared without patient consent
• Exceptions to confidentiality (duty to breach):
  • Risk of serious harm to the patient (if not competent to decide)
  • Risk of serious harm to an identifiable third party (Tarasoff duty to warn/protect - US; similar in many jurisdictions)
  • Public health notifications (notifiable diseases)
  • Court orders
  • Child protection concerns (mandatory reporting)
• Document rationale for any breach

• Contemporaneous, accurate, factual records
• Patient has right of access (subject to some exceptions)
• Risk assessments, capacity assessments, and treatment decisions must be documented

• Only permissible to prevent harm; least restrictive principle applies
• Must follow local policy/law; documented, time-limited, regularly reviewed
• Not to be used as punishment

• Requires informed consent from a capable patient
• If patient lacks capacity: second opinion required (in many jurisdictions, independent psychiatrist approval mandatory - e.g., SOAD in UK)

• Psychotropics can only be prescribed in accordance with licensed indications, or off-label with appropriate documentation
• Clozapine: requires registration in national monitoring systems (CPMS/REMS), mandatory FBC monitoring
• Controlled drugs (stimulants, benzodiazepines): require special prescription and dispensing rules

• Psychiatrists owe a duty of care to patients; must meet the standard of a reasonable psychiatrist (Bolam test)
• Breaches: failure to assess suicide risk properly; failure to act on it; wrongful detention

• Right to appeal detention (Tribunal/Hospital Managers)
• Right to an independent mental health advocate (IMHA)
• Right to a named nurse/responsible clinician
• Right to aftercare on discharge (Section 117 aftercare in England & Wales)

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48. Forensic Psychiatry: Non-Responsibility (Non Compos Mentis), Compulsory Treatment

Definition of Forensic Psychiatry

• Psychiatric assessment of individuals involved with the criminal or civil justice system
• Fitness to stand trial / fitness to plead
• Criminal responsibility
• Risk assessment for violence/recidivism
• Treatment of mentally disordered offenders
• Expert witness testimony

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Criminal Responsibility and Mental Disorder

• Actus reus: the guilty act
• Mens rea: the guilty mind (intention, knowledge, recklessness)

Legal Tests for Non-Responsibility

1. The nature and quality of the act being done, OR
2. That what they were doing was wrong (legally or morally)

1. To appreciate the criminality (wrongfulness) of his conduct, or
2. To conform his conduct to the requirements of law."

• Personality disorders (especially antisocial PD) do NOT qualify as grounds for non-responsibility
• Substance intoxication voluntarily induced does NOT generally qualify
• Psychopathy is NOT a recognized defense

Diminished Responsibility

• Abnormality of mental functioning from a recognized medical condition that substantially impaired ability to understand the nature of conduct, form a rational judgment, or exercise self-control
• Reduces murder to manslaughter (does not result in acquittal)

Fitness to Plead (Competency to Stand Trial)

1. Understand the charges against them
2. Understand the nature and purpose of the proceedings
3. Understand the possible consequences (conviction)
4. Instruct a solicitor/counsel
5. Follow the evidence and court proceedings
6. Give evidence in their own defense

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Compulsory (Involuntary) Treatment

Criteria for Involuntary Admission (Mental Health Act - principles common across most jurisdictions)

1. Mental disorder of a nature or degree warranting detention
2. Necessity: the treatment cannot be given unless the patient is detained (patient refuses or lacks capacity)
3. Risk: detention necessary for the health or safety of the patient, OR for the protection of others

Mental Health Act (England & Wales 1983, amended 2007) Key Sections

Treatment Under the Mental Health Act

• Once detained on Section 3: consent to treatment provisions apply
  • First 3 months: RC can treat without consent
  • After 3 months: either patient consents or a Second Opinion Appointed Doctor (SOAD) must certify treatment appropriate
• ECT: always requires either valid consent or SOAD approval, even in first 3 months
• Medication for physical disorders is governed by capacity law (Mental Capacity Act), NOT the Mental Health Act

Community Treatment Orders (CTOs)

• Allow treatment of detained patients (previously on Section 3) in the community
• Conditions may include: residence at specified address; accepting medication (community); attending appointments
• If conditions breached: patient can be recalled to hospital
• Controversial: evidence of effectiveness mixed; risks of coercion

Compulsory Treatment Controversy

• Ethical tension: patient autonomy vs. duty to protect (patient and public)
• International human rights: UN CRPD (Convention on Rights of Persons with Disabilities) argues against compulsory treatment on grounds of disability alone
• Debate about least restrictive alternative; importance of advance directives

Disposal Options for Mentally Disordered Offenders

Risk Assessment in Forensic Psychiatry

• HCR-20 V3: Historical-Clinical-Risk Management scale (20 items; most widely used for violence risk)
• PCL-R (Hare Psychopathy Checklist Revised): measures psychopathic traits; predictor of recidivism
• OASys (UK prison/probation)
• VRAG (Violence Risk Appraisal Guide): actuarial tool
• Static-99: sexual offending recidivism

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Quick Revision Summary for Topics 39-48