---

COMPREHENSIVE PSYCHIATRY NOTES

---

1. DEPRESSION (Major Depressive Disorder)

Definition

Etiopathogenesis / Risk Factors

• Monoamine hypothesis: Deficiency of serotonin (5-HT), norepinephrine (NE), and dopamine (DA)
• Neuroendocrine: HPA axis hyperactivity - elevated cortisol; blunted TSH response to TRH
• Neuroimaging: Decreased prefrontal cortex activity; increased amygdala reactivity; hippocampal volume loss
• Genetics: Heritability ~40%; 5-HTTLPR gene polymorphism (serotonin transporter)
• Neuroplasticity: Reduced BDNF; decreased neurogenesis in hippocampus

• Life events (losses, trauma, chronic stress)
• Cognitive triad (Beck): Negative view of self, world, and future
• Learned helplessness (Seligman)
• Psychoanalytic: Loss/grief turned inward (Freud)

• Female sex (2:1 F:M ratio), age (bimodal: 20s and 50s+)
• Family history, prior episodes, medical illness (hypothyroidism, cancer, stroke)
• Substance use, lack of social support, adverse childhood experiences
• Postpartum period, chronic pain

Clinical Features

• S - Sleep disturbance (insomnia/hypersomnia; early morning awakening is classic)
• I - Interest loss (anhedonia)
• G - Guilt (excessive, worthlessness)
• E - Energy loss (fatigue)
• C - Concentration difficulty
• A - Appetite change (decreased or increased) with weight change
• P - Psychomotor agitation or retardation
• S - Suicidal ideation

• Melancholic: Anhedonia, early morning awakening, diurnal variation, psychomotor change, excessive guilt
• Atypical: Mood reactivity + hypersomnia, hyperphagia, leaden paralysis, rejection sensitivity
• Psychotic, Catatonic, Peripartum onset, Seasonal pattern (SAD)
• With anxious distress, mixed features

Diagnosis

1. Depressed mood most of the day
2. Anhedonia
3. Weight/appetite change
4. Insomnia/hypersomnia
5. Psychomotor agitation/retardation (observable)
6. Fatigue/energy loss
7. Worthlessness/guilt
8. Poor concentration/indecisiveness
9. Suicidal ideation/plan/attempt

Management

• SSRIs: Fluoxetine, sertraline, escitalopram (best tolerated, first choice)
• SNRIs: Venlafaxine, duloxetine
• Other: Mirtazapine (sedating, good for weight loss/insomnia), bupropion (good for atypical/sexual dysfunction)
• TCAs: Amitriptyline, imipramine (effective but side effects - anticholinergic, cardiac)
• MAOIs: Phenelzine (atypical depression; dietary tyramine restriction required)
• Duration: 6-9 months after remission for first episode; 2+ years for recurrent; lifelong if ≥3 episodes

• CBT (gold standard for mild-moderate)
• IPT (Interpersonal Therapy)
• Behavioral Activation
• Psychodynamic therapy

• ECT: Best evidence; indications - severe/psychotic/catatonic/melancholic depression, treatment-resistant, pregnancy, rapid response needed, food refusal
• TMS (Transcranial Magnetic Stimulation): Approved for treatment-resistant
• Bright light therapy: Seasonal pattern/SAD

• Options: Augmentation (lithium, atypical antipsychotics - quetiapine, aripiprazole, olanzapine), switch antidepressant class, add T3, MAOIs, ECT, ketamine/esketamine (Spravato - FDA approved)

---

2. BIPOLAR DISORDER

Definition

Etiopathogenesis / Risk Factors

• Highest heritability of all psychiatric disorders (~80%)
• First-degree relative risk: 10x general population
• Genes: CACNA1C, ANK3, CLOCK gene abnormalities
• Monoamine dysregulation: Excess NE/DA in mania; deficit in depression
• Kindling hypothesis: Each episode lowers threshold for future episodes
• Circadian rhythm dysregulation (CLOCK gene)
• Neuroimaging: Enlarged amygdala, reduced prefrontal volume

• Family history (strongest), young onset (late teens-20s)
• Stressful life events, sleep disruption, substance use
• Antidepressant monotherapy (can trigger mania)

Clinical Features

Manic Episode (DSM-5)

• D - Distractibility
• I - Impulsivity/Indiscretion (risky behaviors)
• G - Grandiosity
• F - Flight of ideas / racing thoughts
• A - Activity increase (goal-directed) / Agitation
• S - Sleep decreased (need less, not tired)
• T - Talkativeness (pressured speech)

Hypomanic Episode

• Duration ≥4 days
• Less severe - no marked impairment, no psychosis, no hospitalization
• Observable change in functioning

Bipolar I vs II

Cyclothymia

• ≥2 years of hypomanic + depressive symptoms (not meeting full criteria)
• No symptom-free period >2 months

Mixed Features

Rapid Cycling

Diagnosis

Management

• Mood stabilizers: Lithium, valproate, carbamazepine
• Atypical antipsychotics: Olanzapine, quetiapine, risperidone, aripiprazole (FDA approved)
• Benzodiazepines: Short-term for agitation/sleep
• STOP antidepressants if taken

• Quetiapine (most evidence), lurasidone + lithium/valproate
• Lithium, lamotrigine
• Avoid antidepressant monotherapy (risk of switching to mania/rapid cycling)
• ECT if severe/psychotic

• Lithium: Gold standard; reduces suicide risk; monitor levels (0.6-1.2 mmol/L)
• Valproate: Especially for rapid cycling, mixed features; teratogenic (NTD)
• Lamotrigine: Best for bipolar depression prevention; rash risk (SJS/TEN) - slow titration
• Quetiapine, aripiprazole: Maintenance evidence

Lithium - Important Details

• Therapeutic range: 0.6-1.2 mmol/L (acute: up to 1.5)
• Toxicity (>1.5): Coarse tremor, ataxia, confusion, seizures, renal failure, cardiac arrhythmias
• Side effects: Fine tremor, polyuria/polydipsia (NDI), hypothyroidism, weight gain, acne, teratogenicity (Ebstein's anomaly)
• Monitoring: Renal function, TFTs, plasma levels, ECG, weight
• Interactions: NSAIDs, thiazides, ACEi (increase lithium levels - toxicity risk)
• Contraindications: Renal failure, pregnancy (relative), breastfeeding

• CBT for bipolar, IPSRT (Interpersonal and Social Rhythm Therapy)
• Family-focused therapy, psychoeducation

---

3. EMOTIONAL AND BEHAVIOURAL DISORDERS IN CHILDHOOD

A. ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD)

Definition

Etiopathogenesis

• Genetic: Heritability ~76%; dopamine transporter gene (DAT1), DRD4, DRD5
• Neurobiological: Dysfunction of prefrontal-striatal circuits; dopamine and NE deficiency; delayed cortical maturation
• Neuroimaging: Smaller prefrontal cortex, caudate nucleus, cerebellum
• Environmental: Prematurity, low birth weight, prenatal tobacco/alcohol exposure, lead exposure, psychosocial adversity

Clinical Features

• Fails to pay close attention, makes careless mistakes
• Difficulty sustaining attention in tasks
• Does not listen when spoken to directly
• Does not follow through on instructions
• Difficulty organizing tasks
• Avoids tasks requiring sustained mental effort
• Loses things
• Easily distracted by extraneous stimuli
• Forgetful in daily activities

• Fidgets, squirms
• Leaves seat in classroom
• Runs/climbs excessively
• Cannot play quietly
• "On the go" / "driven by a motor"
• Talks excessively
• Blurts out answers
• Difficulty waiting turn
• Interrupts/intrudes

• Combined (most common)
• Predominantly Inattentive
• Predominantly Hyperactive-Impulsive

Diagnosis

• Clinical - history from parents, teachers, child
• Rating scales: Conners' Rating Scale, SNAP-IV, Vanderbilt
• Onset before age 12; present ≥6 months; in ≥2 settings; not explained by another disorder

Management

• Stimulants (first-line): Methylphenidate (Ritalin), amphetamine salts (Adderall)
  • Mechanism: Block reuptake of DA and NE
  • Side effects: Decreased appetite, insomnia, growth suppression, increased BP/HR, tics, rebound
• Non-stimulants: Atomoxetine (NE reuptake inhibitor - first non-stimulant), guanfacine, clonidine
  • Used when stimulants fail/contraindicated, tics, substance abuse risk, anxiety comorbidity

• Behavioral parent training (most evidence in preschool age)
• School-based interventions, accommodations (extended time, preferential seating)
• CBT (for older children/adolescents)
• Social skills training

---

B. OPPOSITIONAL DEFIANT DISORDER (ODD)

Definition

Clinical Features (DSM-5 - ≥4 symptoms, ≥6 months)

• Often loses temper
• Often touchy or easily annoyed
• Often angry and resentful

• Often argues with authority figures
• Often defies rules/refuses to comply
• Often deliberately annoys others
• Often blames others for his/her mistakes

• Spiteful/vindictive ≥2x in 6 months

Management

• Parent management training (PMT) - first-line
• CBT for child
• Address comorbidities (ADHD, anxiety)
• Family therapy

---

C. CONDUCT DISORDER (CD)

Definition

Clinical Features (DSM-5 - 4 categories)

1. Aggression to people/animals: Bullying, initiates fights, uses weapon, physical cruelty to people, animals, stealing with confrontation, forced sexual activity
2. Destruction of property: Fire-setting, vandalism
3. Deceitfulness/theft: Breaking in, lying, shoplifting
4. Rule violations: Staying out late (before 13), running away, truancy (before 13)

• Childhood-onset (<10 years) - worse prognosis
• Adolescent-onset - better prognosis
• With limited prosocial emotions (callous-unemotional traits) - most severe

Management

• Multisystemic therapy (MST) - most evidence
• PMT, CBT, family therapy, functional family therapy
• Address comorbidities
• Pharmacotherapy for specific symptoms: Stimulants (for comorbid ADHD), mood stabilizers/antipsychotics for aggression

---

4. OTHER SPECIFIC PSYCHIATRIC DISORDERS IN CHILDREN

A. SPECIFIC LEARNING DISORDER (SLD)

Definition

Types (DSM-5 specifiers)

• Dyslexia: Reading difficulties (word recognition, decoding, fluency)
• Dysgraphia: Written expression difficulties (spelling, grammar, written expression)
• Dyscalculia: Mathematics difficulties (number sense, calculation, reasoning)

Etiopathogenesis

• Genetic factors (family clustering)
• Neurobiological: Phonological processing deficits (dyslexia) - left hemisphere posterior temporal/parietal areas
• NOT due to intellectual disability, sensory problems, poor schooling, or psychosocial adversity

Diagnosis

• Standardized tests of academic achievement + cognitive testing
• Present during school years; symptoms must be present ≥6 months despite interventions

Management

• Educational interventions: Individualized Education Program (IEP), special education services, specialized teaching techniques
• Dyslexia: Phonics-based reading instruction (Orton-Gillingham method)
• Accommodations: Extra time, oral exams, assistive technology
• No specific pharmacotherapy; treat comorbidities (ADHD common)

---

B. ENURESIS

Definition

Types

• Nocturnal (most common): Bedwetting at night
• Diurnal: Daytime wetting
• Mixed: Both
• Primary: Never achieved bladder control
• Secondary: Regression after ≥6 months of dryness (more concerning - rule out organic causes, stress)

Etiopathogenesis

• Maturational lag in CNS control
• ADH deficiency/reduced nocturnal vasopressin (nocturnal enuresis)
• Reduced functional bladder capacity
• Deep sleep/arousal disorder
• Genetic factors (AD inheritance)
• Secondary: UTI, DM, DI, seizures, stress, trauma

Management

• Fluid restriction in evenings
• Regular voiding schedule, pre-bedtime toileting
• Enuresis alarm (bell-and-pad) - most effective long-term; 75% success rate
• Star chart (reward system) for motivation

• Desmopressin (DDAVP): Synthetic ADH; rapid effect; not curative; good for short-term (camps, sleepovers); risk of hyponatremia
• Imipramine (TCA): Effective but side effect profile (cardiac) limits use; 2nd/3rd line
• Oxybutynin: For overactive bladder/diurnal enuresis

---

C. SIBLING RIVALRY (SIBLING JEALOUSY)

Definition

Clinical Features

• Regression: Bedwetting, thumbsucking, baby talk, soiling, sleeping difficulties
• Behavior change: Temper tantrums, clinging, aggression toward sibling/parents
• Emotional changes: Jealousy, hostility, sadness, anger
• Social withdrawal

Management

• Parental psychoeducation: Normalize the child's feelings
• Spend dedicated one-on-one time with older child
• Involve the child in care of new baby
• Avoid excessive punishment; do not compare children
• Family therapy if persistent

---

D. OTHER IMPORTANT CHILDHOOD DISORDERS

Separation Anxiety Disorder

• Excessive fear about separation from attachment figures
• Physical complaints (headache, stomachache) when separation expected
• Age-appropriate when <3 years; disorder if causing impairment
• Tx: CBT, parental guidance, SSRI if severe

Selective Mutism

• Consistent failure to speak in specific social situations despite speaking in others
• ≥1 month duration; not due to language disorder or psychosis
• Tx: CBT, behavioral therapy, SSRI

Reactive Attachment Disorder vs Disinhibited Social Engagement Disorder

• Both follow severe neglect/abuse
• RAD: Inhibited, emotionally withdrawn, rarely seeks comfort
• DSED: Disinhibited, overly familiar with strangers, indiscriminate social behavior

---

5. SUBSTANCE USE DISORDERS

Definition

Key Concepts

• Dependence: Physical/psychological reliance
  • Tolerance: Need more for same effect
  • Withdrawal: Physiological symptoms on cessation
• Craving: Intense desire to use
• Addiction: Compulsive use despite consequences
• Intoxication: Reversible syndrome due to recent use
• Harmful use (ICD-11): Use causing physical/mental harm without dependence

DSM-5 Criteria (11 items - 2+ = mild, 4+ = moderate, 6+ = severe)

1. Taking more/longer than intended
2. Unsuccessful efforts to cut down
3. Great deal of time obtaining/using/recovering
4. Craving
5. Failure to fulfill major role obligations
6. Continued use despite social/interpersonal problems
7. Giving up important activities
8. Hazardous use
9. Continued use despite physical/psychological problems
10. Tolerance
11. Withdrawal

Major Substances

Alcohol Use Disorder

• 6-24h: Tremors, anxiety, sweating, tachycardia, hypertension
• 24-48h: Seizures (usually generalized tonic-clonic) - can occur even at 6h
• 48-72h: Delirium Tremens (DTs) - confusion, fever, tachycardia, hypertension, diaphoresis, visual/tactile hallucinations; most severe; 5-15% mortality if untreated

• Acute withdrawal: Benzodiazepines (chlordiazepoxide, diazepam, lorazepam) - GABA agonism
• Thiamine (100mg IV/IM) before glucose - prevent Wernicke's encephalopathy
• Supportive care, fluids, electrolytes

• Naltrexone (opioid antagonist - reduces craving/reward) - First-line
• Acamprosate (GABA/glutamate - reduces craving) - First-line
• Disulfiram (aldehyde dehydrogenase inhibitor - aversive therapy; acetaldehyde buildup causes flushing, nausea, vomiting)
• Psychosocial: AA (Alcoholics Anonymous), 12-step programs, CBT, motivational interviewing

• Thiamine (B1) deficiency
• Wernicke's (acute): Classic triad - Confusion, Ataxia, Ophthalmoplegia (nystagmus, lateral rectus palsy)
• Korsakoff's (chronic): Anterograde > retrograde amnesia, confabulation, intact consciousness; mammillary body damage

• Prenatal alcohol exposure
• FAS: Smooth philtrum, thin vermilion border, small palpebral fissures + growth restriction + CNS abnormalities

Opioid Use Disorder

• Treatment: Naloxone (opioid antagonist) 0.4-2mg IV/IM - repeat every 2-3 min; short half-life - repeat or infusion

• Onset: 8-24h (short-acting); 36-72h (methadone)
• Features: Anxiety, agitation, yawning, lacrimation, rhinorrhea, piloerection ("cold turkey"), myalgia, diarrhea, vomiting, mydriasis, tachycardia, insomnia
• COWS Scale (Clinical Opioid Withdrawal Scale)
• Not life-threatening (unlike alcohol/benzo withdrawal)

• Methadone: Full agonist; daily supervised dosing; reduces craving; QTc risk
• Buprenorphine: Partial agonist; with naloxone (Suboxone) to deter IV use; safer, less overdose risk; can be prescribed in office
• Naltrexone (extended-release): Full antagonist; prevents relapse; good for motivated patients

Stimulant Use Disorders (Cocaine, Amphetamines)

Cannabis Use Disorder

Benzodiazepine Use Disorder

• Similar to alcohol (both GABA-A agonists)
• Withdrawal: Anxiety, tremor, seizures (life-threatening), delirium
• Cross-tolerance with alcohol
• Treatment of withdrawal: Taper with long-acting BZD (diazepam)

Hallucinogens

• LSD, psilocybin, mescaline, PCP (phencyclidine), ketamine
• Intoxication: Hallucinations (visual), perceptual distortions, depersonalization, synesthesia, mydriasis, tachycardia
• PCP: Dissociative, nystagmus (vertical and horizontal), violence, analgesia, anesthesia
• HPPD (Hallucinogen Persisting Perception Disorder): Flashbacks after cessation
• No withdrawal syndrome

Inhalants

• Volatile solvents, aerosols, gases
• CNS depression, euphoria, dizziness; "sudden sniffing death" - VF
• Toxic to multiple organs: Liver, kidney, heart, CNS (leukoencephalopathy)

---

6. BEHAVIOURAL ADDICTIONS

Definition

Gambling Disorder

Diagnostic Criteria (DSM-5 - ≥4 in 12 months)

1. Needs to gamble with increasing amounts (tolerance)
2. Restless/irritable when cutting down (withdrawal-like)
3. Repeated unsuccessful efforts to control
4. Preoccupied with gambling
5. Gambles when distressed
6. Chases losses ("chasing")
7. Lies to conceal
8. Jeopardized significant relationship/job
9. Relies on others for money (bailouts)

Management

• CBT (first-line)
• Gamblers Anonymous (12-step)
• Naltrexone (reduces craving - good evidence)
• SSRIs for comorbid depression/anxiety
• Financial counseling

Gaming Disorder (ICD-11 / WHO)

Criteria (≥12 months)

1. Impaired control over gaming
2. Increasing priority given to gaming over other activities
3. Continuation despite negative consequences

Management

• CBT, family therapy, digital detox
• Address comorbidities (depression, social anxiety)

Other Behavioral Addictions (not formally classified but clinically recognized)

• Compulsive sexual behavior disorder (ICD-11: 6C72)
• Internet addiction, social media addiction
• Shopping addiction (oniomania)
• Exercise addiction
• Food addiction

---

7. PSYCHOTIC DISORDERS

A. SCHIZOPHRENIA

Definition

Etiopathogenesis

• Mesolimbic pathway: Dopamine excess → positive symptoms
• Mesocortical pathway: Dopamine deficiency → negative symptoms + cognitive deficits

• Glutamate (NMDA receptor hypofunction) - explains psychosis, negative, cognitive symptoms
• Serotonin (atypical antipsychotics target 5-HT2A)
• GABA interneuron dysfunction (parvalbumin neurons)

• Monozygotic twins: ~50% concordance
• First-degree relatives: ~10% risk
• Genes: DISC1, COMT, NRG1, DTNBP1

• Prenatal insults (viral infection in 2nd trimester, malnutrition, obstetric complications)
• Enlarged ventricles, cortical volume loss (frontal, temporal), hippocampal abnormalities
• No gliosis - suggests early developmental disturbance, not progressive neurodegeneration

• Cannabis use (high-potency THC, early use)
• Urban upbringing, migration, social defeat
• Stress (social adversity)
• Expressed emotion (family's hostility/criticism) → relapse

Clinical Features

• Hallucinations: Most commonly auditory (voices commenting, giving commands, 3rd person); visual, olfactory, tactile less common
• Delusions: Fixed false beliefs
  • Persecutory (most common): Being followed, plotted against
  • Reference: Events/media have special personal meaning
  • Grandiose: Special powers, identity
  • Thought insertion, thought withdrawal, thought broadcasting
  • Passivity/made experiences: Alien control of thoughts, actions, feelings
• Disorganized thinking: Thought disorder (loosening of associations, derailment, word salad, tangentiality, circumstantiality, neologisms, clang associations)
• Disorganized behavior: Unpredictable agitation, inappropriate affect, catatonia

• Affective flattening: Reduced emotional expression
• Alogia: Poverty of speech (brief, empty replies)
• Avolition: Lack of motivation
• Anhedonia: Inability to experience pleasure
• Asociality: Social withdrawal

• Impaired working memory, attention, executive function, processing speed
• Most important predictor of functional outcome

• Auditory hallucinations: Thought echo, voices arguing, voices commenting
• Thought alienation: Insertion, withdrawal, broadcasting
• Made/passivity experiences
• Somatic passivity
• Delusional perception

Diagnosis (DSM-5 Criteria)

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

Course

• Prodrome: Subthreshold symptoms, social withdrawal, odd beliefs, decline in function
• First Episode Psychosis (FEP) → Acute phase → Recovery/Residual
• ~20% single episode, ~35% multiple episodes with recovery, ~35-40% chronic

Management

• Chlorpromazine (low potency), haloperidol (high potency), fluphenazine
• EPS (extrapyramidal side effects): Akathisia, parkinsonism, dystonia, tardive dyskinesia
• Effective for positive symptoms mainly

• Olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, clozapine, amisulpride
• Better for negative symptoms, fewer EPS (except risperidone at high doses)
• Metabolic side effects: Weight gain, dyslipidemia, diabetes (olanzapine, clozapine > risperidone > ziprasidone, aripiprazole)

• Risk: Agranulocytosis (1-2%), neutropenia, seizures, myocarditis, metabolic syndrome, hypersalivation, constipation
• Requires mandatory CBC monitoring (weekly for 18 weeks, then monthly)
• No EPS or tardive dyskinesia

• Life-threatening emergency
• Features: Fever, severe rigidity ("lead pipe"), autonomic instability (BP fluctuations, tachycardia, diaphoresis), altered consciousness
• Labs: Elevated CK, leukocytosis, elevated LFTs, myoglobinuria
• Treatment: STOP antipsychotic, supportive care (cooling, hydration), dantrolene (muscle relaxant), bromocriptine/amantadine (dopamine agonist), ECT for refractory catatonia

• CBTp (CBT for psychosis)
• Family therapy / family education
• Social skills training
• Supported employment (IPS model)
• Early Intervention in Psychosis (EIP) services
• Case management

B. OTHER PSYCHOTIC DISORDERS

Schizoaffective Disorder

• Concurrent psychotic and mood episodes
• Psychotic symptoms for ≥2 weeks in absence of prominent mood episode
• Bipolar type: Manic episodes
• Depressive type: Major depressive episodes
• Treatment: Antipsychotic (essential) + mood stabilizer/antidepressant

Brief Psychotic Disorder

• Psychosis lasting 1 day to 1 month, with full recovery
• Often precipitated by stress
• No prodrome
• DSM-5: With/without marked stressor, postpartum onset

Schizophreniform Disorder

• Same as schizophrenia criteria but duration 1-6 months
• With/without good prognostic features
• ~1/3 recover; ~2/3 progress to schizophrenia or schizoaffective

Delusional Disorder

• Non-bizarre delusions ≥1 month
• Functioning not markedly impaired apart from delusion
• No hallucinations prominent, no disorganized speech
• Types: Persecutory, grandiose, erotomanic (de Clerambault's), jealous (Othello syndrome), somatic, mixed
• Folie a deux (Shared Delusional Disorder/Induced Delusional Disorder): Two people share a delusion; primary and secondary case

---

8. PSYCHIATRIC DISORDERS IN THE ELDERLY

Unique Features in Elderly Psychiatry

• Increased prevalence of comorbid medical illness
• Multiple medications (polypharmacy)
• Atypical presentations
• Cognitive changes can mask or mimic other disorders
• Social isolation, bereavement, role transitions

A. DEPRESSION IN ELDERLY

Distinguishing from Dementia ("Pseudodementia")

Features specific to elderly depression:

• Somatic symptoms prominent (masked/somatized depression)
• Psychotic features more common
• Cognitive symptoms more prominent (executive dysfunction)
• Suicide risk: Elderly men have highest completed suicide rate
• Often underdiagnosed/undertreated

Treatment:

• SSRIs (first-line): Sertraline, escitalopram (fewest interactions)
• Avoid: TCAs (anticholinergic, cardiac risk), MAOIs
• Mirtazapine: Good if anorexia, insomnia; stimulates appetite
• ECT: Often very effective in elderly, even safer than medications
• Psychotherapy: CBT, problem-solving, IPT (adapt for elderly)

B. LATE-ONSET PSYCHOSIS (LATE-ONSET SCHIZOPHRENIA / "PARAPHRENIA")

• Onset ≥45 years (late-onset schizophrenia) or >60 years (very late-onset)
• More common in women
• Prominent persecutory and partition delusions (neighbors spying through walls/floors)
• Auditory and visual hallucinations common
• Negative symptoms less prominent
• Better premorbid function
• Treatment: Low-dose atypical antipsychotics

C. DEMENTIA AND BEHAVIORAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA (BPSD)

BPSD:

• Agitation, aggression, wandering, disinhibition
• Psychosis (delusions of theft, Capgras syndrome), hallucinations
• Depression, anxiety, apathy
• Sleep disturbance

Management of BPSD:

• Non-pharmacological first: Environmental modification, caregiver education, activity programs
• Pharmacological: Low-dose antipsychotics (risperidone - limited use due to increased stroke risk in dementia), SSRIs for depression/agitation

D. DELIRIUM

Definition

Features:

• Disturbance in attention and awareness
• Acute onset, fluctuating course
• Additional cognitive disturbance (disorientation, memory, language, visuospatial)
• Not explained by existing neurocognitive disorder
• Evidence of medical causation (3M: Medical, Metabolic, Medication)

Types:

• Hyperactive: Agitation, picking at IV lines, combativeness (most recognized)
• Hypoactive: Withdrawal, somnolence (most common, most missed; worst prognosis)
• Mixed: Both

Common Causes (AEIOU TIPS):

Management:

• Treat underlying cause
• Non-pharmacological: Reorientation, familiar objects, family presence, lighting, early mobilization, avoid restraints
• Pharmacological: Low-dose haloperidol (most evidence), atypical antipsychotics; BZDs only for alcohol/BZD withdrawal delirium

---

9. PSYCHIATRIC EMERGENCIES

A. SUICIDE AND SUICIDAL BEHAVIOR

Definitions

• Suicidal ideation: Thoughts about killing oneself (passive: wishing to die; active: with plan)
• Suicidal intent: Degree of expectation/hope to die
• Suicide plan: Specific method, means, time, place
• Suicide attempt: Self-injurious behavior with intent to die
• Completed suicide: Death resulting from the act
• Parasuicide: Self-harm with suicidal intent but survival (includes suicide attempts)

Epidemiology

• ~800,000 deaths globally per year
• Leading cause of death in 15-29 age group
• Sex paradox: Women attempt more; men complete more (more lethal means)
• M:F ratio for completions ~3:1

Risk Factors (Mnemonic: SAD PERSONS)

• S - Sex (male)
• A - Age (elderly men, adolescents)
• D - Depression
• P - Previous attempt (strongest predictor)
• E - Ethanol/substance use
• R - Rational thinking loss (psychosis)
• S - Social support lacking
• O - Organized plan
• N - No spouse/recently bereaved/divorced
• S - Sickness (chronic illness, pain, terminal)

• Previous attempt (single strongest predictor)
• Psychiatric illness (depression, bipolar, schizophrenia, BPD, substance use)
• Access to means (firearms especially)
• Male sex, older age
• Social isolation, recent loss
• Hopelessness (strongest psychological predictor - Beck)
• Impulsivity
• Family history of suicide

Protective Factors

• Social support (family, friends)
• Religious beliefs, cultural sanctions against suicide
• Reasons for living, children at home
• Therapeutic alliance
• Access to mental health care
• Problem-solving ability

Assessment

• C-SSRS (Columbia Suicide Severity Rating Scale) - gold standard
• SAD PERSONS scale
• Determine: Ideation type, plan, intent, means, previous attempts, reasons for living

Management

• Safety planning (Stanley-Brown Safety Planning Intervention)
• Hospitalization if high risk (involuntary if needed)
• Means restriction counseling (remove firearms, medications)
• Treat underlying psychiatric disorder
• Psychotherapy: DBT (best evidence for suicidal behavior/BPD), CBT-SP
• Medications: Lithium (reduces suicide in bipolar), clozapine (reduces suicide in schizophrenia), ketamine (acute antisuicidal effect)
• Follow-up: Crisis plans, regular contact, telehealth

B. DELIBERATE SELF-HARM (DSH) / NON-SUICIDAL SELF-INJURY (NSSI)

Definition

Epidemiology

• Peak in adolescents (10-15%)
• Female > Male (but males underreport)
• Associated with: BPD, depression, eating disorders, PTSD, trauma

Functions

• Emotion regulation (most common - relieve overwhelming emotions)
• Self-punishment
• Anti-dissociation
• Feeling "real"

Management

• DBT (Dialectical Behavior Therapy) - most evidence
• Individual psychotherapy, emotion regulation skills
• Safety planning
• Treatment of underlying disorder

C. VIOLENCE AND AGGRESSION

Risk Assessment

• History of violence (strongest predictor)
• Substance use disorder
• Diagnosis: Antisocial PD, psychopathy; (schizophrenia - modestly increased with no treatment)
• Psychotic symptoms (command hallucinations, persecutory delusions with identified victim)
• Impulsivity
• Anger dysregulation
• Social instability, victim of abuse

Duty to Warn (Tarasoff Case)

• Tarasoff v. Regents of University of California (1976)
• Therapist duty to protect identified third party from patient's serious threat
• Requires warning potential victim, law enforcement, hospitalization

Management of Acute Violence/Agitation:

1. De-escalation (verbal first): Calm voice, personal space, empathy, non-threatening posture
2. Voluntary medication: Offer oral medication
3. Rapid Tranquilization if de-escalation fails:
   • IM haloperidol + lorazepam (most common combination)
   • IM olanzapine (do NOT combine with benzodiazepines - respiratory depression risk)
   • IM droperidol, IM ziprasidone
4. Physical restraint as last resort; close monitoring

D. MEDICATION-RELATED COMPLICATIONS

Serotonin Syndrome

1. Neuromuscular abnormalities: Clonus (spontaneous, inducible, ocular), hyperreflexia, tremor, myoclonus
2. Autonomic instability: Hyperthermia, tachycardia, diaphoresis, diarrhea, BP fluctuations
3. Altered mental status: Agitation, confusion

Neuroleptic Malignant Syndrome (NMS) - see above under antipsychotics

Anticholinergic Toxidrome

• Hyperthermia, tachycardia, mydriasis (dilated pupils), dry/flushed skin, urinary retention, constipation, confusion/delirium, seizures
• Causes: TCAs, antihistamines, antipsychotics (low-potency), atropine, scopolamine
• Treatment: Physostigmine (cholinesterase inhibitor) for severe cases; supportive

Lithium Toxicity

• Narrow therapeutic window (therapeutic 0.6-1.2, toxic >1.5-2.0 mmol/L)
• Features: Tremor → ataxia, dysarthria, nystagmus, confusion → seizures, cardiac arrhythmias, renal failure, death
• Management: STOP lithium; saline hydration (enhances excretion); hemodialysis if severe (>4 mmol/L, severe symptoms, renal failure)

SSRI Discontinuation Syndrome

• Mnemonic: FINISH (Flu-like, Insomnia, Nausea, Imbalance/Sensory disturbance "electric shocks", Hyperarousal, Sadness)
• Short half-life SSRIs most at risk (paroxetine > sertraline > fluoxetine least risk due to long half-life)
• Management: Restart at lower dose, taper slowly; switch to fluoxetine if troublesome

QTc Prolongation

• Antipsychotics, TCAs risk QTc prolongation → torsades de pointes → VF
• Highest risk: Haloperidol IV, droperidol, ziprasidone, thioridazine, chlorpromazine
• Monitor ECG; correct electrolytes (K+, Mg2+)

---

10. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

A. OBSESSIVE-COMPULSIVE DISORDER (OCD)

Definition

Etiopathogenesis

• Neurobiological: Orbitofrontal cortex - striatum - thalamus circuit hyperactivity (OFC-caudate loop)
• Serotonin hypothesis: Strong evidence - clomipramine and SSRIs (serotonergic) most effective
• Genetic: ~40-65% heritability; COMT, SLC1A1 genes
• PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections): Group A Strep triggers OCD/tics in children via molecular mimicry

Clinical Features

• Contamination (most common) - dirt, germs, illness
• Harm/Aggressive - fear of harming self/others
• Symmetry/order
• Sexual/religious (taboo) thoughts
• Doubt/checking

• Washing/cleaning
• Checking (gas, locks, switches)
• Ordering/arranging
• Counting, repeating
• Mental rituals (praying, counting mentally)
• Hoarding

Diagnosis (DSM-5)

• Obsessions and/or compulsions
• Time-consuming (>1hr/day) or distress/impairment
• Not due to substance or medical condition
• Specify: With good/fair/poor/absent insight; with tic-related disorder

Related Disorders (OC Spectrum)

• Body Dysmorphic Disorder (BDD): Preoccupation with perceived appearance defect; mirror checking/avoidance; "Muscle dysmorphia" in males; high suicide risk
• Hoarding Disorder: Difficulty discarding possessions regardless of value; clutter
• Trichotillomania (Hair-Pulling Disorder): Recurrent hair-pulling causing hair loss
• Excoriation (Skin-Picking Disorder): Recurrent skin picking causing lesions
• Tourette's/Tic Disorders: Often comorbid with OCD

Management

• Gold standard psychological treatment
• Exposure to feared stimulus + prevention of compulsion
• Habituation and inhibitory learning

• Fluvoxamine, fluoxetine, sertraline, paroxetine (all FDA-approved for OCD)
• Higher doses required than for depression (e.g., fluoxetine 40-80mg)
• Slower response (8-12 weeks); longer trial needed
• ~40-60% response rate

• Most potent anti-OCD drug historically
• Second-line due to side effects (anticholinergic, cardiac, seizures)
• Use if SSRIs fail

• Add antipsychotic (risperidone, aripiprazole, haloperidol) to SSRI for partial responders
• Especially if comorbid tics

• Deep Brain Stimulation (DBS) - for severe, refractory cases
• Anterior capsulotomy/cingulotomy (psychosurgery - last resort)
• IV clomipramine, IV ketamine

---

11. SLEEP DISORDERS

Classification

Sleep Architecture

• NREM Sleep: Stage N1 (drowsy, theta waves), N2 (sleep spindles, K-complexes), N3 (slow-wave/deep sleep - delta waves)
• REM Sleep: Rapid eye movements, vivid dreams, muscle atonia, REM rebound with abstinence from alcohol/BZDs
• Sleep cycle ~90 minutes; 4-6 cycles/night
• REM increases in later cycles; N3 predominates early

A. INSOMNIA DISORDER

Definition

Types

• Sleep onset insomnia (anxiety, circadian)
• Sleep maintenance insomnia (depression, aging, pain)
• Early morning awakening (depression, elderly)

Etiopathogenesis

• 3P model (Spielman): Predisposing (genetics, anxiety) + Precipitating (stressor) + Perpetuating (poor sleep hygiene, cognitive arousal)
• Hyperarousal theory: Increased HPA activation, increased metabolic rate, high-frequency EEG activity

Management

• Sleep restriction therapy (limit time in bed)
• Stimulus control (bed only for sleep/sex)
• Sleep hygiene education
• Relaxation techniques
• Cognitive restructuring (catastrophic thoughts about sleep)
• Most effective and durable; preferred over medications

• Consistent sleep/wake times, limit caffeine/alcohol, dark/cool/quiet room, no screens before bed

• Benzodiazepines (temazepam, triazolam): GABA-A agonists; effective but dependence risk; avoid long-term
• Z-drugs (zolpidem, zaleplon, eszopiclone): GABA-A (BZD site) - selective; short-term; sleepwalking, amnesia risk
• Melatonin receptor agonists: Ramelteon (MT1/MT2); good for sleep onset; minimal dependence; good for elderly; circadian disorders
• Orexin receptor antagonists: Suvorexant, lemborexant (newest class) - block wake-promoting orexin; good evidence; low dependence risk
• Sedating antidepressants: Mirtazapine, doxepin (low dose), trazodone (off-label, widely used)
• Antihistamines: Diphenhydramine, doxylamine (OTC); tolerance develops rapidly; not recommended long-term

B. NARCOLEPSY

Definition

Types

• Type 1 (with cataplexy): Low/absent orexin (hypocretin) in CSF; HLA-DQB1*06:02; autoimmune destruction of lateral hypothalamic orexin neurons
• Type 2 (without cataplexy): Normal orexin; less severe

Clinical Features (CHESS)

• C - Cataplexy (pathognomonic of Type 1): Sudden bilateral muscle weakness triggered by strong emotions (laughter, anger); consciousness maintained; seconds to minutes
• H - Hypnagogic/Hypnopompic hallucinations: Vivid, often frightening; on falling asleep (hypnagogic) or waking (hypnopompic)
• E - EDS: Irresistible sleep attacks; automatic behaviors; "sleep attacks"
• S - Sleep paralysis: Unable to move when falling asleep/waking; frightening; seconds to minutes
• S - Sleep disrupted (nocturnal)

Diagnosis

• MSLT (Multiple Sleep Latency Test): Mean sleep latency ≤8 min + ≥2 sleep-onset REM periods (SOREMPs)
• PSG: Short REM latency
• CSF hypocretin ≤110 pg/mL (for Type 1)

Management

• EDS: Modafinil/armodafinil (first-line wake-promoting agents); methylphenidate, amphetamines; solriamfetol, pitolisant
• Cataplexy: Sodium oxybate (GHB - gold standard); venlafaxine, fluoxetine, clomipramine (suppress REM)
• Sodium oxybate: Also helps EDS, sleep paralysis, and hallucinations; Schedule I/II controlled substance; hepatitis risk; GHB mechanism
• Scheduled naps (prophylactic short naps)
• Sleep hygiene

C. OBSTRUCTIVE SLEEP APNEA (OSA)

• Repetitive upper airway obstruction during sleep
• Apnea-Hypopnea Index (AHI): ≥5 with symptoms, or ≥15 (mild: 5-14, moderate: 15-29, severe: ≥30)
• Features: Loud snoring, witnessed apneas, choking, EDS, morning headaches, nocturia
• Risk: Obesity, male, older age, large neck, retrognathia, Down syndrome
• Diagnosis: PSG (gold standard) or Home Sleep Testing
• Treatment: CPAP (continuous positive airway pressure) - gold standard; weight loss, positional therapy, mandibular advancement device, surgery (UPPP) for resistant cases

D. PARASOMNIAS

NREM Parasomnias (Disorders of Arousal)

REM Parasomnias

• Loss of normal REM atonia → physically acting out vivid/violent dreams
• Patient may injure self or bed partner
• Recall of dreams
• Strong association with alpha-synucleinopathies (Parkinson's, DLB, MSA) - can precede by years
• PSG: REM without atonia
• Treatment: Clonazepam (most used); melatonin; safety (bed rails, padding)

E. RESTLESS LEGS SYNDROME (RLS)

• Urge to move legs with uncomfortable sensations; worse at rest, at night, relieved by movement
• "Pins and needles," "creeping," "crawling" in legs
• Associated: Iron deficiency (most treatable secondary cause), pregnancy, renal failure, peripheral neuropathy, dopaminergic deficiency
• Treatment: First correct iron if ferritin <75; dopamine agonists (pramipexole, ropinirole - first-line); α2δ ligands (pregabalin, gabapentin); opioids

---

12. EATING DISORDERS

A. ANOREXIA NERVOSA (AN)

Definition

1. Restriction of energy intake leading to significantly low body weight
2. Intense fear of gaining weight or behavior interfering with weight gain
3. Disturbance in body weight/shape perception OR denial of seriousness of low weight

Types

• Restricting type: Diet, fasting, excessive exercise
• Binge-Purge type: Purging behaviors (vomiting, laxatives) in context of restriction

Severity (BMI)

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

Epidemiology

• F:M = 10:1; peak onset: 14-18 years; lifetime prevalence ~0.5-1% in females
• Highest mortality of any psychiatric disorder (~5-10% per decade; death from cardiac complications and suicide)

Etiopathogenesis

• Genetic: Strong family history; serotonin abnormalities
• Psychological: Perfectionism, low self-esteem, need for control, OCD traits, fear of maturity
• Sociocultural: Thin ideal, media influence, dance/modeling profession
• Family: Enmeshed family dynamics (Minuchin)

Physical/Lab Complications

• Cardiac: Bradycardia, hypotension, arrhythmias (QTc prolongation), sudden death
• Electrolytes: Hypokalemia, hyponatremia, hypomagnesemia, hypophosphatemia
• Endocrine: Amenorrhea, low estrogen, osteoporosis, hypothyroidism (euthyroid sick), elevated cortisol, low IGF-1, low LH/FSH
• Hematological: Leukopenia, anemia, thrombocytopenia
• Dermatological: Lanugo hair (fine body hair), hair loss, dry skin, acrocyanosis
• Neurological: Cerebral atrophy, peripheral neuropathy
• Russell's sign: Calluses/scars on knuckles from self-induced vomiting (also in BN)
• Refeeding syndrome: Hypophosphatemia + cardiac failure when nutrition restarted after prolonged starvation → supplement phosphate

Management

• Medical stabilization first (cardiac monitoring, electrolyte correction, weight restoration)
• Hospitalization criteria: BMI <15, rapid weight loss, cardiac arrhythmias, severe electrolyte disturbance, suicide risk, failure of outpatient
• Nutritional rehabilitation: Gradual refeeding (start 1000-1200 kcal, increase slowly); nasogastric tube if refuses
• Psychotherapy:
  • Adolescents: Family-Based Treatment (Maudsley approach) - MOST EVIDENCE
  • Adults: CBT-E (enhanced CBT for eating disorders), MANTRA, SSCM
• Pharmacotherapy: Limited evidence; olanzapine may help weight gain/anxiety; SSRIs not effective for AN in underweight state; treat comorbidities

B. BULIMIA NERVOSA (BN)

Definition

DSM-5 Criteria:

1. Recurrent binge eating episodes (discrete period, large amount, loss of control)
2. Recurrent compensatory behaviors (vomiting, laxatives, diuretics, fasting, excessive exercise)
3. ≥1x/week for 3 months
4. Self-evaluation unduly influenced by shape/weight
5. Not exclusively during anorexia episodes

Types

• Purging type: Vomiting, laxatives, diuretics
• Non-purging type: Fasting/excessive exercise

Physical Signs

• Parotid gland enlargement (sialadenosis)
• Russell's sign (dorsal hand calluses)
• Dental enamel erosion (perimylolysis) from acid vomiting
• Hypokalemia, hyponatremia, metabolic alkalosis (from vomiting), metabolic acidosis (laxatives)
• Mallory-Weiss tears, aspiration, esophageal rupture (Boerhaave) in severe cases
• Menstrual irregularities

Management

• CBT-E (best evidence - gold standard)
• IPT (Interpersonal Therapy)
• Fluoxetine 60mg/day: Only FDA-approved drug for bulimia; reduces binge-purge frequency
• Guided self-help (CBT-based) - effective and accessible

C. BINGE EATING DISORDER (BED)

DSM-5 Criteria (New in DSM-5)

1. Recurrent binge eating (≥1x/week for 3 months)
2. Associated with ≥3: Eating faster, eating until uncomfortably full, eating large amounts without hunger, eating alone due to embarrassment, feeling disgusted/guilty after
3. Marked distress
4. No compensatory behaviors (differentiates from BN)

Management

• CBT-E, DBT, IPT
• Lisdexamfetamine (Vyvanse) - only FDA-approved medication for BED
• Topiramate (reduces binge frequency)
• SSRIs

D. AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER (ARFID)

• Not about weight/shape concerns (unlike AN/BN)
• Restriction based on sensory features, fear of choking/vomiting, lack of interest in food
• More common in children; associated with ASD, anxiety
• Management: CBT, FBT

---

13. STRESS-RELATED DISORDERS

A. ACUTE STRESS REACTION / ACUTE STRESS DISORDER (ASD)

Definition

Symptom Clusters (DSM-5)

• Intrusion: Flashbacks, recurrent distressing memories, dreams, intense distress to cues
• Negative mood
• Dissociative: Altered sense of reality, depersonalization, derealization, amnesia
• Avoidance: Avoid trauma-related thoughts, feelings, external reminders
• Arousal: Sleep disturbance, irritability, hypervigilance, startle response, concentration

Management

• Psychological First Aid
• Watchful waiting (most resolve spontaneously)
• Brief trauma-focused CBT (TF-CBT) if persistent
• Debriefing (CISD) - NOT recommended (may increase PTSD risk)

B. POST-TRAUMATIC STRESS DISORDER (PTSD)

Definition

Diagnostic Criteria (DSM-5 - ≥1 month, impairment)

1. Intrusion (≥1): Flashbacks, nightmares, intrusive memories, psychological/physiological distress to cues
2. Avoidance (≥1): Avoid trauma-related thoughts/feelings; avoid external reminders
3. Negative cognitions/mood (≥2): Amnesia, negative beliefs, blame, persistent negative emotions, diminished interest, detachment, anhedonia
4. Hyperarousal/Reactivity (≥2): Irritability, reckless behavior, hypervigilance, exaggerated startle, concentration difficulty, sleep disturbance

ICD-11 Additions

• Complex PTSD (CPTSD): PTSD + disturbances in self-organization (affect dysregulation, negative self-concept, interpersonal disturbances) - after prolonged, repeated trauma (childhood abuse, war, torture)

Management

• Trauma-focused CBT (TF-CBT): Including prolonged exposure (PE) and cognitive processing therapy (CPT)
• EMDR (Eye Movement Desensitization and Reprocessing): Highly effective; bilateral stimulation during trauma recall
• Both recommended as first-line by WHO, NICE, ISTSS

• SSRIs (sertraline, paroxetine): First-line; FDA-approved; ~60% response
• SNRIs (venlafaxine): Second-line
• Prazosin: Alpha-1 blocker; good for PTSD nightmares
• Avoid: Benzodiazepines (no evidence, risk of dependence, may worsen PTSD)

C. ADJUSTMENT DISORDERS

Definition

Subtypes

• With depressed mood
• With anxiety
• With mixed anxiety and depressed mood
• With disturbance of conduct
• With mixed disturbance of emotions and conduct
• Unspecified

Management

• Psychotherapy: Brief therapy, CBT, supportive therapy, problem-solving
• Treat comorbidities
• Pharmacotherapy if needed (SSRIs for anxiety/depression component)

---

14. ANXIETY DISORDERS

A. GENERALIZED ANXIETY DISORDER (GAD)

Definition

Clinical Features (Mnemonic: WATCHERS)

• Worry
• Anxiety
• Tension (muscle)
• Can't concentrate (concentration difficulty, mind going blank)
• Hyperarousal / Hypervigilance
• Energy low (fatigue)
• Restlessness
• Sleep disturbance

Management

• Psychotherapy: CBT (gold standard; worry postponement, relaxation, cognitive restructuring)
• Pharmacotherapy:
  • SSRIs/SNRIs: First-line (escitalopram, sertraline, venlafaxine, duloxetine)
  • Buspirone: Non-benzodiazepine anxiolytic (5-HT1A partial agonist); no dependence; works slowly (2-4 weeks)
  • Benzodiazepines: Short-term only; dependence risk
  • Pregabalin: Good evidence; especially in Europe
  • Hydroxyzine: Antihistamine; useful short-term

B. PANIC DISORDER

Definition

Panic Attack (DSM-5 - ≥4 symptoms, peaks within minutes)

• Sweating
• Trembling/shaking
• Unsteady (dizziness, lightheadedness)
• Dyspnea (shortness of breath/smothering)
• Elevated HR (palpitations, pounding heart)
• Nausea/abdominal distress
• Tingling (paresthesias)
• Shivering/chills
• Fear of dying
• Excessive heartbeat
• Angina-like chest pain/discomfort
• Rushes of heat

Management

• CBT (best evidence): Interoceptive exposure, cognitive restructuring, breathing retraining
• SSRIs/SNRIs: First-line medications; start low (can initially worsen anxiety)
• Benzodiazepines: Short-term; alprazolam (high abuse potential); clonazepam (longer acting)
• Agoraphobia often comorbid: Fear of situations where escape might be difficult (open spaces, public transport, crowds); treat with CBT exposure

C. SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)

Definition

Features

• Blushing, sweating, shaking (common physical symptoms in social situations)
• Anticipatory anxiety, post-event rumination
• Performance only (public speaking) vs generalized (most social situations)

Management

• CBT (social skills training, exposure)
• SSRIs/SNRIs: First-line
• Beta-blockers (propranolol): For performance anxiety (situational) - physical symptoms
• MAOIs: Historically most effective but side effects

D. SPECIFIC PHOBIA

• Marked fear/anxiety about specific object/situation (animal, natural environment, blood-injection-injury, situational, other)
• Immediate fear response; avoidance/endurance with distress; ≥6 months
• Blood-injection-injury type: Unique vasovagal response - tachycardia → bradycardia → fainting (diphasic response)
• Treatment: Specific phobia responds best to in vivo exposure; single-session therapy effective

E. AGORAPHOBIA

• Fear/anxiety of ≥2: Public transport, open spaces, enclosed places, standing in a crowd, being outside home alone
• Fear of inability to escape/get help in case of incapacitation
• Persistent ≥6 months
• CBT with exposure; SSRIs

---

15. PERSONALITY DISORDERS

Definition

Clusters

Cluster A - "Odd/Eccentric" (psychosis spectrum)

• Pervasive distrust/suspiciousness without sufficient basis
• Suspects exploitation, bears grudges, questions loyalty of friends/spouse (pathological jealousy)
• NOT a psychotic disorder

• Detachment from social relationships, restricted emotional expression
• Solitary activities, indifference to praise/criticism, flat affect, no close friends (except first-degree relatives)
• Not distressed by lack of relationships (vs. social anxiety)

• Social/interpersonal deficits + cognitive/perceptual distortions + eccentricities
• Ideas of reference, magical thinking, odd speech (vague, circumstantial), suspiciousness
• Transient psychotic episodes; on genetic spectrum of schizophrenia

Cluster B - "Dramatic/Emotional/Erratic"

• Pervasive pattern of disregard/violation of rights of others, since age 15
• Must be ≥18 AND have conduct disorder before 15
• Features: Deceitfulness, impulsivity, irritability/aggression, reckless disregard for safety, irresponsibility, lack of remorse
• Psychopathy/Sociopathy: More severe subtype (Hare Psychopathy Checklist-Revised PCL-R)
• Difficult to treat; limited evidence for CBT, therapeutic communities

• Most clinically important; highest treatment engagement and evidence

• Identity disturbance (unstable sense of self)
• Impulsivity (≥2 self-damaging areas: spending, sex, drugs, reckless driving, binge eating)
• Abandonment (frantic efforts to avoid real/imagined abandonment)
• Relationships (unstable, intense: idealization/devaluation - "splitting")
• Affective instability (mood rapidly shifting)
• Emptiness (chronic feelings of emptiness)
• Self-harm/suicidal behavior (recurrent)
• Anger (intense, inappropriate, difficulty controlling)
• Paranoid ideation/dissociation (transient, stress-related)

• Excessive emotionality and attention-seeking
• Uncomfortable when not center of attention, seductive behavior, shallow emotional expression, theatrical, suggestible

• Grandiosity, need for admiration, lack of empathy
• Fragile self-esteem; rage when criticized; entitlement; envies others; exploitative

Cluster C - "Anxious/Fearful"

• Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
• Avoids interpersonal contact due to fear of rejection (wants relationships - unlike schizoid)
• Pervasive across ALL social situations (vs social anxiety - situational)
• CBT, SSRIs

• Excessive need to be taken care of → submissive, clinging, separation anxiety
• Difficulty making decisions, needs reassurance, difficulty initiating projects alone
• Urgently seeks new relationship when one ends
• More common in women; cultural considerations

• Pervasive preoccupation with orderliness, perfectionism, control (at expense of efficiency and relationships)
• Ego-syntonic (unlike OCD which is ego-dystonic)
• Miserly, workaholism, rigidity, stubbornness, perfectionism that interferes with task completion
• CBT

ICD-11 Dimensional Approach

---

16. PSYCHOSOMATIC DISORDERS / SOMATIC SYMPTOM AND RELATED DISORDERS

DSM-5 Classification (replaced DSM-IV "somatoform disorders")

• Somatic Symptom Disorder (SSD)
• Illness Anxiety Disorder (formerly Hypochondriasis)
• Conversion Disorder (Functional Neurological Symptom Disorder)
• Psychological Factors Affecting Other Medical Conditions
• Factitious Disorder

A. SOMATIC SYMPTOM DISORDER (SSD)

Definition

Etiopathogenesis

• Biopsychosocial: Genetic predisposition, adverse childhood experiences (abuse, neglect), alexithymia (inability to identify/describe emotions), somatosensory amplification
• Psychological: Unconscious conversion of psychological distress to physical
• Medical: Actual physical symptoms can be present (unlike DSM-IV)
• Abnormal central sensitization, altered pain processing

Management

• Psychoeducation: Explain biopsychosocial model, validate symptoms
• Regular scheduled appointments (not as-needed - reduces doctor shopping)
• CBT (most evidence): Target maladaptive beliefs, behaviors
• Limit unnecessary investigations
• Antidepressants for comorbid depression/anxiety
• Avoid: Dismissing patient, multiple specialists, unnecessary surgery

B. ILLNESS ANXIETY DISORDER (Hypochondriasis)

Definition

Types

• Care-seeking type: Frequent medical visits
• Care-avoidant type: Avoids medical care (fear of bad news)

Management

• CBT (health anxiety program)
• SSRIs
• Scheduled appointments with single GP, limit investigations

C. CONVERSION DISORDER (Functional Neurological Symptom Disorder)

Definition

Features

• Motor: Weakness/paralysis, tremor, gait disturbance, non-epileptic attacks (PNEA - psychogenic non-epileptic attacks)
• Sensory: Numbness, blindness (tubular/tunnel vision - seeing normally in everyday function), deafness, anosmia
• Cognitive: Memory loss, dissociation
• Hoover's sign: Hip extension returns when asked to flex other hip (positive in functional weakness)
• La belle indifférence: Apparent lack of concern about disability (not pathognomonic; also in anosognosia)

Management

• Psychoeducation (explain positive diagnosis, not "all in head")
• Physical/occupational therapy (focus on rehabilitation)
• CBT
• Treat comorbid PTSD, depression, anxiety

D. FACTITIOUS DISORDER / MUNCHAUSEN SYNDROME

Factitious Disorder Imposed on Self

• Falsification of physical or psychological signs/symptoms; deceptive behavior; no obvious external incentive
• Munchausen's: Severe, chronic form; dramatic presentations; hospital hopping; pseudologia fantastica
• Treatment: Confrontational yet supportive; treat psychiatric comorbidities; protect therapeutic relationship

Factitious Disorder Imposed on Another (Munchausen by Proxy / Medical Child Abuse)

• Caregiver fabricates symptoms in another person (child); form of child abuse
• Management: Safeguard child, report to child protective services, forensic involvement

Malingering (not a mental disorder)

• Intentional production of false/exaggerated symptoms for external incentive (compensation, avoiding military duty, avoid criminal prosecution)
• Distinguished from factitious (internal motivation/sick role vs external gain)

---

17. WOMEN AND MENTAL HEALTH

A. PREMENSTRUAL DYSPHORIC DISORDER (PMDD)

Definition

• ≥5 symptoms in final week before menses onset
• Improving within a few days after menses begins
• Minimal/absent in week post-menses
• Must include ≥1 of: Marked affective lability, irritability/anger, depressed mood, anxiety/tension
• Additional: Decreased interest, concentration, fatigue, appetite change, hypersomnia/insomnia, sense of being overwhelmed, physical symptoms (breast tenderness, bloating, joint/muscle pain)
• Present in most menstrual cycles over the past year
• Causes clinically significant distress/impairment
• Confirmed by prospective daily ratings (≥2 symptom cycles)

Etiopathogenesis

• Abnormal response to normal fluctuations of ovarian hormones (progesterone/allopregnanolone interactions with GABA-A)
• Serotonin sensitivity to hormonal fluctuations
• Not a hormonal deficiency per se

Management

• SSRIs (first-line): Can be given continuously or only in luteal phase (days 14-28); fluoxetine/sertraline/escitalopram
• OCP (combined): Drospirenone-containing pills (Yaz); suppresses ovulation
• GnRH agonists: For refractory cases; medical menopause; add-back HRT
• Calcium supplementation, aerobic exercise, dietary changes (reduce caffeine, salt, sugar)
• Cognitive-behavioral coping strategies

---

B. PERINATAL MENTAL HEALTH

1. POSTPARTUM BLUES (BABY BLUES)

• Tearfulness, emotional lability, anxiety, irritability, mood swings
• Not severe; no functional impairment; transient self-limiting

• Reassurance and psychoeducation
• Practical support, sleep
• Monitor for progression to postpartum depression
• No pharmacotherapy needed

---

2. POSTPARTUM DEPRESSION (PPD)

• History of depression/PPD (strongest)
• Depression/anxiety during pregnancy
• Stressful life events, poor social support
• Unplanned/unwanted pregnancy
• Neonatal complications
• Thyroid dysfunction (postpartum thyroiditis)
• Domestic violence, low socioeconomic status

• Same as MDD: Low mood, anhedonia, energy loss, guilt, sleep/appetite disturbance, cognitive impairment
• Specific to postpartum: Anxiety about baby's health, feelings of being a bad mother, inability to bond with baby, intrusive thoughts of harming baby (ego-dystonic, distinguish from infanticide intent)
• Negative impact on infant's emotional, cognitive, and behavioral development

• EPDS (Edinburgh Postnatal Depression Scale) - most widely used; ≥13 = positive screen; question 10 asks about self-harm
• PHQ-9

• Mild-moderate: Psychotherapy (CBT, IPT - first-line)
• Moderate-severe: Antidepressants (SSRIs preferred - sertraline, paroxetine lowest in breast milk; fluoxetine active metabolite in breast milk)
• Brexanolone (Zulresso): IV synthetic allopregnanolone (GABA modulator); FDA-approved specifically for PPD; rapid effect (60hr infusion); expensive
• Zuranolone (oral, 2023 FDA approved): Oral GABA modulator for PPD
• Maintain breastfeeding if possible (not a contraindication to treatment)
• Social support, peer support groups
• Infant mental health intervention if bonding impaired

---

3. POSTPARTUM PSYCHOSIS (PPP)

• Bipolar disorder (strongest - risk ~20-30%)
• First episode of postpartum psychosis
• Personal or family history of bipolar or PPP
• Primiparous, sleep deprivation

• Rapidly changing mental state (confusion, perplexity, disorientation)
• Manic features: Elation, grandiosity, decreased sleep, pressured speech
• Psychotic features: Delusions (often about baby - baby is special, possessed, harmed, or that patient must harm baby to save it), hallucinations (command type)
• Severe depression with suicidal ideation
• Disrupted reality testing, confusion
• HIGH RISK OF INFANTICIDE AND SUICIDE

• Full psychiatric history, MSE
• Medical investigations (to rule out organic causes: Thyroid, infection, delirium)

• Hospitalization (ideally mother-baby unit to preserve bonding and breastfeeding)
• Antipsychotics: Haloperidol, olanzapine, quetiapine
• Mood stabilizers: Lithium (most evidence for bipolar-related PPP and prevention)
• ECT: Very effective, especially for rapid stabilization and depressive PPP
• Stop breastfeeding if lithium used (excreted in breast milk; risk of toxicity in infant)
• Ensure baby safety - may need safeguarding review
• Close monitoring for suicide/infanticide risk
• After recovery: Counsel about future pregnancy risk; lithium prophylaxis if bipolar

---

C. PSYCHIATRIC ISSUES IN PREGNANCY

• Many psychotropic drugs are teratogenic
• Valproate: High risk NTD (spina bifida), PCOS, cognitive effects in child - avoid in women of childbearing age
• Lithium: Ebstein's anomaly (cardiac) - relative CI especially in 1st trimester
• Carbamazepine: NTD
• Benzodiazepines: Neonatal withdrawal; cleft palate (controversial)
• SSRIs: Relatively safe; paroxetine associated with cardiac defects (caution); persistent pulmonary hypertension of newborn with late pregnancy use
• Antipsychotics: Most relatively safe; gestational diabetes risk; neonatal withdrawal/extrapyramidal effects if used near term

---

QUICK REFERENCE TABLES

DSM-5 Duration Criteria Summary

First-Line Treatments Summary

---

What's Covered

• Highest mortality: Anorexia Nervosa
• Most effective antipsychotic: Clozapine (requires CBC monitoring)
• Gold standard for insomnia: CBT-I
• Gold standard for BPD: DBT
• PPP = Psychiatric Emergency: admit, antipsychotics + lithium/ECT
• Lithium reduces suicide in bipolar; clozapine reduces suicide in schizophrenia
• Serotonin syndrome: Clonus + hyperreflexia (vs NMS: lead-pipe rigidity + hyperthermia)

---

PSYCHIATRY RAPID REVISION

---

1. DEPRESSION (MDD)

• Dx: ≥5 symptoms ≥2 weeks; must have depressed mood ±anhedonia → SIGECAPS
• Subtypes: Melancholic (early AM awakening, diurnal variation), Atypical (mood reactivity + hypersomnia + hyperphagia), Seasonal (SAD), Psychotic
• Bio: ↓ 5-HT, NE, DA | ↑ Cortisol | ↓ REM latency on PSG
• Tx: Mild = CBT | Mod-Severe = SSRI + CBT | ECT = severe/psychotic/catatonic/pregnant/food refusal
• TRD: Fail ≥2 antidepressants → augment (lithium, atypical AP) or ketamine/ECT
• Duration: 6-9 months post-remission; lifelong if ≥3 episodes

---

2. BIPOLAR DISORDER

• Mania ≥1 week + impairment: DIG FAST (Distractibility, Impulsivity, Grandiosity, Flight of ideas, Activity↑, Sleep↓, Talkativeness)
• Hypomania: Same but ≥4 days, no impairment/psychosis
• Bipolar I: ≥1 manic episode | Bipolar II: Hypomania + depression (NO mania)
• Rapid cycling: ≥4 episodes/year → hypothyroidism? antidepressant?
• Acute mania Tx: Lithium / Valproate / Atypical AP (olanzapine, quetiapine, risperidone)
• Bipolar depression Tx: Quetiapine, lurasidone, lamotrigine - AVOID antidepressant monotherapy
• Maintenance: Lithium (gold standard; reduces suicide) | Lamotrigine (prevents depression)
• Lithium levels: Therapeutic 0.6-1.2 | Toxic >1.5 → coarse tremor, ataxia, confusion, seizures
• Lithium SE: Fine tremor, polyuria (NDI), hypothyroidism, weight gain, Ebstein's anomaly
• Lithium ↑ by: NSAIDs, thiazides, ACEi

---

3. ADHD

• Onset <12 years; ≥2 settings; ≥6 inattentive or hyperactive-impulsive symptoms (≥5 if ≥17y)
• Presentations: Combined (most common), Inattentive, Hyperactive-Impulsive
• Tx: Stimulants (methylphenidate/amphetamine) = first-line | Atomoxetine = non-stimulant (tics, anxiety, substance abuse risk)
• Behavioral parent training in preschool; CBT in older children

4. ODD

• ≥4 symptoms ≥6 months: Angry/irritable mood + Argumentative/defiant + Vindictive
• Tx: Parent Management Training (PMT) first-line

5. CONDUCT DISORDER

• ≥3 of 15 criteria in 12 months: Aggression / Destruction / Deceit / Rule violations
• Childhood onset (<10y) = worse prognosis | ~40% → ASPD
• Tx: Multisystemic Therapy (MST)

---

6. CHILDHOOD - OTHER

---

7. SUBSTANCE USE DISORDERS

Alcohol

• Withdrawal timeline: Tremors 6-24h → Seizures 24-48h → Delirium Tremens 48-72h (fever, confusion, visual/tactile hallucinations; 5-15% mortality)
• Tx withdrawal: Benzodiazepines + Thiamine IV/IM before glucose (prevent Wernicke's)
• Relapse prevention: Naltrexone (reduces reward) | Acamprosate (reduces craving) | Disulfiram (aversive)
• Wernicke's: Confusion + Ataxia + Ophthalmoplegia | Korsakoff's: Anterograde amnesia + Confabulation (mammillary body)

Opioids

• OD triad: Miosis + Respiratory depression + Coma → Naloxone
• Withdrawal: Opposite signs - mydriasis, rhinorrhea, piloerection, diarrhea; not life-threatening
• OAT: Buprenorphine (partial agonist) + Methadone (full agonist)

Cocaine/Stimulants

• Intoxication: Euphoria, mydriasis, tachycardia, hypertension; severe → psychosis, MI, stroke
• Withdrawal: Crash - dysphoria, fatigue, hypersomnia; no medical emergency
• Tx: CBT + Contingency Management (no approved pharmacotherapy)

Cannabis

• Intoxication: Euphoria, tachycardia, conjunctival injection, ↑ appetite
• Cannabis psychosis: High-potency THC; risk factor for schizophrenia
• Cannabis Hyperemesis: Cyclical vomiting; relieved by hot showers

---

8. BEHAVIOURAL ADDICTIONS

• ICD-11 recognized: Gambling Disorder, Gaming Disorder
• DSM-5 recognized: Gambling Disorder only
• Gambling Dx: ≥4 of 9 criteria in 12 months (tolerance-like, withdrawal-like, chasing losses, lies, bailouts)
• Tx: CBT + Gamblers Anonymous + Naltrexone (best pharmacotherapy)

---

9. SCHIZOPHRENIA

• Dopamine: Mesolimbic ↑ DA = positive sx | Mesocortical ↓ DA = negative sx + cognitive
• Genetics: MZ twins ~50%; 1st degree ~10%
• Schneider's First Rank Symptoms: Thought echo/insertion/withdrawal/broadcasting, passivity, delusional perception, 3rd person hallucinations
• Negative sx (5 A's): Affective flattening, Alogia, Avolition, Anhedonia, Asociality
• Dx DSM-5: ≥2 symptoms ≥1 month (must include ≥1 of delusions/hallucinations/disorganized speech) + 6 months total

Antipsychotics

EPS

NMS (Emergency)

• Fever + Lead-pipe rigidity + Autonomic instability + Altered consciousness
• ↑ CK, leukocytosis
• Tx: Stop AP, dantrolene, bromocriptine, ECT

---

10. PSYCHOTIC DISORDERS - COMPARISON

---

11. ELDERLY PSYCHIATRY

Depression vs Pseudodementia

• Elderly men = highest completed suicide rate
• Tx: Sertraline/escitalopram (fewest interactions); avoid TCAs; ECT very effective

Delirium

• Acute onset, fluctuating, inattention + cognitive disturbance
• Hypoactive = most common, most missed, worst prognosis
• Tx: Treat underlying cause; haloperidol low dose; non-pharm measures first

---

12. PSYCHIATRIC EMERGENCIES

Suicide Risk - SAD PERSONS

• Hopelessness = strongest psychological predictor (Beck)
• Lithium reduces suicide in bipolar | Clozapine reduces suicide in schizophrenia
• DBT = best evidence for suicidal behavior/BPD

Serotonin Syndrome vs NMS

Rapid Tranquilization

1. De-escalation → Oral medication → IM medication
2. IM haloperidol + lorazepam (standard)
3. DO NOT combine IM olanzapine + benzodiazepine (respiratory depression)

Lithium Toxicity

• Levels >1.5 → coarse tremor, ataxia, confusion

• 2.0 → seizures, arrhythmias, renal failure

• Tx: Stop, saline hydration, hemodialysis if >4 mmol/L or severe

---

13. OCD

• Circuit: OFC - Caudate - Thalamus (hyperactive loop)
• Obsessions = ego-dystonic | Compulsions to reduce anxiety
• Y-BOCS: >16 = moderate; >24 = severe
• Tx: ERP (gold standard psychotherapy) + SSRI (high dose, 8-12 weeks for response)
• SSRI hierarchy: Fluvoxamine, fluoxetine, sertraline, paroxetine (all FDA-approved)
• Clomipramine: Most potent; 2nd line (SE: cardiac, seizures, anticholinergic)
• Augmentation: Add risperidone/aripiprazole for partial response

OC Spectrum

• BDD: Perceived appearance defect; mirror checking; high suicide risk
• Hoarding Disorder, Trichotillomania, Excoriation

---

14. SLEEP DISORDERS

• Sleep cycle: N1 → N2 (spindles, K-complexes) → N3 (delta, deep) → REM | ~90 min
• Depression → ↓ REM latency, ↑ REM density

---

15. EATING DISORDERS

• Refeeding syndrome: Hypophosphatemia → cardiac failure → supplement phosphate
• AN hospitalization: BMI <15, rapid weight loss, cardiac arrhythmia, electrolyte crisis

---

16. STRESS DISORDERS

• PTSD 4 clusters: Intrusion + Avoidance + Negative cognitions + Hyperarousal
• Prazosin: PTSD nightmares | SSRIs: Sertraline, paroxetine (FDA-approved)
• Avoid BZDs in PTSD | Avoid debriefing (CISD) (may worsen)
• Complex PTSD (ICD-11): PTSD + affect dysregulation + negative self-concept + interpersonal difficulties

---

17. ANXIETY DISORDERS

• GAD mnemonic WATCHERS: Worry, Anxiety, Tension, Can't concentrate, Hypervigilance, Energy↓, Restlessness, Sleep↓

---

18. PERSONALITY DISORDERS

Clusters

High-Yield Distinctions

---

19. PSYCHOSOMATIC / SOMATIC DISORDERS

• La belle indifférence: Apparent lack of concern in conversion disorder (not pathognomonic)

---

20. WOMEN'S MENTAL HEALTH

The 3 Postpartum Conditions - KEY DISTINCTIONS

• Biggest risk for PPP: Bipolar disorder (risk 20-30%)
• Brexanolone (IV) + Zuranolone (oral) = FDA-approved specifically for PPD (GABA modulators)
• EPDS ≥13 = positive screen for PPD

PMDD

• Luteal phase (days 14-28) symptoms; resolve after menses
• Tx: Luteal-phase SSRIs (first-line) | Drospirenone OCP | GnRH agonist (refractory)

Teratogenic Drugs

---

QUICK MNEMONICS BANK

---

Exam day reminders:

• Always ask about suicidal ideation in any mood/psychotic disorder question
• Previous attempt = strongest predictor of future suicide
• ECT works faster than medications - use for emergencies
• Clozapine = most effective antipsychotic, but CBC monitoring mandatory
• Lithium requires: Levels + TFTs + RFTs + ECG
• Valproate = avoid in women of childbearing potential
• DBT = BPD + suicidal behavior | ERP = OCD | CBT-I = Insomnia | TF-CBT/EMDR = PTSD | FBT = Adolescent AN

---

PSYCHIATRY STRUCTURED NOTES

Based on DSM-5, ICD-11 & Kaplan & Sadock's Synopsis

---

1. DEPRESSION (Major Depressive Disorder)

Definition

Etiopathogenesis / Risk Factors

• Monoamine hypothesis: ↓ serotonin (5-HT), norepinephrine (NE), dopamine (DA)
• Neuroendocrine: HPA axis hyperactivity → ↑ cortisol; non-suppression on DST
• Neuroimaging: ↓ prefrontal cortex activity; hippocampal volume loss
• Neuroplasticity: ↓ BDNF; ↓ hippocampal neurogenesis
• Genetics: Heritability ~40%; 5-HTTLPR polymorphism
• Cognitive (Beck): Cognitive triad - negative view of self, world, future
• Risk factors: Female sex (2:1), prior episodes, FH, hypothyroidism, chronic illness, bereavement, substance use, adverse childhood experiences

Clinical Features

• S - Sleep: Insomnia or hypersomnia; early morning awakening (classic)
• I - Interest loss (anhedonia)
• G - Guilt / worthlessness (excessive)
• E - Energy loss / fatigue
• C - Concentration difficulty / indecisiveness
• A - Appetite/weight change (↓ or ↑)
• P - Psychomotor agitation or retardation (observable by others)
• S - Suicidal ideation / thoughts of death

• Melancholic: Anhedonia, early AM awakening, diurnal variation, psychomotor change, excessive guilt
• Atypical: Mood reactivity + hypersomnia + hyperphagia + leaden paralysis + rejection sensitivity
• Psychotic: Mood-congruent delusions (guilt, poverty, nihilism) or hallucinations
• Seasonal (SAD): Recurrent winter pattern; atypical features
• Catatonic: Stupor, posturing, waxy flexibility, mutism, echolalia

Diagnosis

• DSM-5: ≥5/9 symptoms, ≥2 weeks, must include depressed mood ±anhedonia; significant impairment
• Severity: Mild (5-6 sx), Moderate, Severe (≥7 ± psychosis)
• Rating scales: HAM-D, PHQ-9, MADRS, BDI
• Investigations: TFTs, CBC, glucose, B12/folate (rule out secondary causes)
• PSG findings: ↓ REM latency, ↑ REM density, ↓ slow-wave sleep
• DST: Cortisol non-suppression in ~50%

Management

• Mild: CBT, Behavioural Activation, watchful waiting
• Moderate-Severe: SSRI + psychotherapy
• Pharmacotherapy:
  • First-line: SSRIs (fluoxetine, sertraline, escitalopram)
  • SNRIs: Venlafaxine, duloxetine
  • Mirtazapine: Insomnia, weight loss (sedating, ↑ appetite)
  • Bupropion: Atypical, sexual dysfunction (no sexual SE)
  • TCAs: Amitriptyline (effective; anticholinergic, cardiac SE)
  • MAOIs: Phenelzine (atypical; tyramine restriction)
• Psychotherapy: CBT (gold standard), IPT, psychodynamic
• Somatic: ECT (severe/psychotic/catatonic/pregnant/food refusal/rapid response needed), TMS (treatment-resistant), Light therapy (SAD)
• Duration: 6-9 months post-remission; 2 years if recurrent; lifelong if ≥3 episodes

Important Information

• TRD (Treatment-Resistant Depression): Fail ≥2 adequate trials → augment (lithium, atypical AP - quetiapine, aripiprazole), switch class, ECT, ketamine/esketamine (Spravato) - FDA approved
• Antidepressants take 2-4 weeks for effect; full response 6-8 weeks
• Suicide risk: Highest early in treatment (energy returns before mood lifts)

---

2. BIPOLAR DISORDER

Definition

Etiopathogenesis / Risk Factors

• Highest heritability of all psychiatric disorders (~80%)
• FDR risk: ~10x general population; MZ twins: 60-70%
• Kindling hypothesis: Each episode lowers threshold for future episodes
• Circadian dysregulation: CLOCK gene; sleep disruption triggers episodes
• Neurochemical: ↑ NE/DA in mania; ↓ in depression
• Risk factors: FH (strongest), young onset (late teens-20s), substance use, antidepressant monotherapy, sleep disruption, stressors

Clinical Features

• D - Distractibility
• I - Impulsivity / Indiscretion (risky behavior: spending, sex, driving)
• G - Grandiosity (inflated self-esteem)
• F - Flight of ideas / racing thoughts
• A - Activity ↑ (goal-directed) / Agitation
• S - Sleep ↓ (decreased need; not tired)
• T - Talkativeness (pressured speech)
• Mood: Elevated, expansive, or irritable (must be present)
• Psychotic features (mood-congruent), hypersexuality, poor insight

Diagnosis

• Clinical diagnosis; exclude thyroid, neurological, substance causes
• YMRS (Young Mania Rating Scale) for severity
• MDQ (Mood Disorder Questionnaire) for screening

Management

• Acute mania: Lithium / Valproate / Carbamazepine + Atypical AP (olanzapine, quetiapine, risperidone, aripiprazole); BZDs for agitation; STOP antidepressants
• Acute bipolar depression: Quetiapine, lurasidone + lithium/valproate, lamotrigine; AVOID antidepressant monotherapy (risk of switching/rapid cycling); ECT if severe/psychotic
• Maintenance: Lithium (gold standard; reduces suicide), Valproate (rapid cycling, mixed), Lamotrigine (depression prevention), Quetiapine
• Psychotherapy: IPSRT, CBT, psychoeducation, family-focused therapy

Important Information

• Lithium monitoring: Levels (0.6-1.2 mmol/L), TFTs (hypothyroidism), RFTs (NDI), ECG, weight
• Lithium toxicity >1.5: Coarse tremor → ataxia, dysarthria, confusion → seizures, arrhythmias, death
• Lithium levels ↑ (toxicity risk): NSAIDs, thiazides, ACEi
• Lithium SE: Fine tremor, polyuria (NDI), weight gain, hypothyroidism, Ebstein's anomaly (fetal)
• Valproate: Neural tube defects → avoid in women of childbearing age

---

3. EMOTIONAL AND BEHAVIOURAL DISORDERS IN CHILDHOOD

A. ADHD

Definition

Etiopathogenesis / Risk Factors

• Heritability ~76%; dopamine transporter gene (DAT1), DRD4, DRD5
• ↓ dopamine and NE in prefrontal-striatal circuits
• Delayed cortical maturation (frontal lobe)
• Smaller prefrontal cortex, caudate, cerebellum on neuroimaging
• Environmental: Prematurity, low birth weight, prenatal tobacco/alcohol, lead exposure

Clinical Features

• Fails to give close attention / careless mistakes
• Difficulty sustaining attention in tasks/play
• Doesn't listen when spoken to directly
• Doesn't follow through on instructions
• Difficulty organizing tasks
• Avoids tasks requiring sustained mental effort
• Loses necessary things
• Easily distracted by extraneous stimuli
• Forgetful in daily activities

• Fidgets/squirms in seat
• Leaves seat when expected to remain seated
• Runs/climbs excessively (or restlessness in adults)
• Cannot play/engage quietly
• "On the go," acts as if "driven by a motor"
• Talks excessively
• Blurts out answers before question completed
• Difficulty waiting turn
• Interrupts or intrudes on others

Diagnosis

• Clinical; history from parents, teachers, child
• Conners' Rating Scale, SNAP-IV, Vanderbilt scales
• Onset <12 years; ≥2 settings; ≥6 months; not explained by another disorder
• Rule out: Anxiety, mood disorder, learning disability, ASD, thyroid disease

Management

• Multimodal approach (most effective)
• Stimulants (first-line): Methylphenidate, amphetamine salts → block DA/NE reuptake
  • SE: ↓ appetite, insomnia, ↑ BP/HR, growth suppression, rebound, tics
• Non-stimulants: Atomoxetine (NE reuptake inhibitor; use if tics, anxiety, substance abuse risk), guanfacine, clonidine
• Behavioral parent training (preschool), school accommodations, CBT (adolescents), social skills training

Important Information

• ADHD persists into adulthood in ~50%
• Most common comorbidities: ODD, anxiety, learning disorders, mood disorders
• Stimulants do NOT increase substance abuse risk; untreated ADHD does

---

B. OPPOSITIONAL DEFIANT DISORDER (ODD)

Definition

Etiopathogenesis / Risk Factors

• Genetic contribution; temperament (difficult, reactive)
• Harsh/inconsistent parenting, neglect, abuse
• Family conflict, parental psychopathology (esp. depression, ASPD)
• Comorbid ADHD (strongest risk factor)

Clinical Features

• Often loses temper
• Often touchy or easily annoyed
• Often angry and resentful

• Often argues with authority figures
• Often defies or refuses to comply with rules/requests
• Often deliberately annoys others
• Often blames others for mistakes/misbehavior

• Spiteful or vindictive ≥2 times within past 6 months

Diagnosis

• Clinical; structured interviews with child, parent, teacher
• Rating scales (Eyberg Child Behavior Inventory)
• Rule out: CD (more severe), ADHD, mood/anxiety disorders

Management

• Parent Management Training (PMT) - first-line (Barkley, Webster-Stratton programs)
• CBT for child (problem-solving, anger management)
• Family therapy
• Treat comorbid ADHD (often improves ODD)
• No specific pharmacotherapy for ODD

Important Information

• ODD precedes CD in many cases but most children with ODD do NOT develop CD
• Strongest predictor of persistence: comorbid ADHD + callous-unemotional traits

---

C. CONDUCT DISORDER (CD)

Definition

Etiopathogenesis / Risk Factors

• Genetic: ~50% heritability; serotonin dysregulation
• Neurobiological: ↓ amygdala reactivity (callous-unemotional); ↓ cortical arousal
• Family: Harsh/abusive parenting, inconsistent discipline, parental criminality/substance use
• Social: Peer deviance, poverty, neighborhood violence, school failure
• Comorbid ADHD (most common)

Clinical Features

• Bullies, threatens, or intimidates others
• Initiates physical fights
• Used a weapon (bat, knife, gun)
• Physical cruelty to people
• Physical cruelty to animals
• Stolen while confronting victim (mugging)
• Forced someone into sexual activity

• Deliberately set fires with intent to cause serious damage
• Deliberately destroyed others' property

• Broken into house, building, or car
• Often lies or "cons" others
• Stolen items of nontrivial value without confrontation (shoplifting)

• Stays out at night despite parental prohibitions (before age 13)
• Has run away from home overnight ≥2 times
• Often truant from school (before age 13)

• Childhood onset (<10y): Worse prognosis; more physical aggression; predominantly male
• Adolescent onset: Better prognosis; more peer influence
• With limited prosocial emotions (callous-unemotional traits): Most severe; ↓ guilt, ↓ empathy, shallow affect

Diagnosis

• Clinical; structured interviews; teacher/parent rating scales
• Rule out: ODD (less severe), ADHD, mood disorder, substance use
• ~40% develop Antisocial Personality Disorder in adulthood (requires CD before 15)

Management

• Multisystemic Therapy (MST) - most evidence (community-based, family systems)
• Parent Management Training, Functional Family Therapy
• CBT (problem-solving skills, anger management)
• Stimulants for comorbid ADHD (reduces aggression significantly)
• Mood stabilizers / atypical APs for severe aggression
• School interventions

Important Information

• CD = most common reason for psychiatric referral in children
• Prognosis better: Female sex, adolescent onset, higher IQ, social support
• Psychopathy spectrum: Callous-unemotional traits + childhood onset = most severe form

---

4. OTHER SPECIFIC PSYCHIATRIC DISORDERS IN CHILDREN

A. SPECIFIC LEARNING DISORDER (SLD)

Definition

Etiopathogenesis / Risk Factors

• Genetic: Strong family clustering; DYX1C1 gene (dyslexia)
• Dyslexia: Phonological processing deficit; left hemisphere posterior temporal-parietal dysfunction
• NOT due to ID, sensory impairment, inadequate schooling, psychosocial adversity
• Risk: Male sex, FH, prematurity, low SES

Clinical Features

• With impairment in reading (Dyslexia): Inaccurate/slow word recognition, poor decoding, poor spelling; reads slowly, effortfully; avoids reading
• With impairment in written expression (Dysgraphia): Poor spelling, grammar/punctuation errors, unclear written expression; messy handwriting
• With impairment in mathematics (Dyscalculia): Poor number sense, difficulty memorizing arithmetic facts, inaccurate calculation, poor math reasoning

Diagnosis

• Standardized tests of academic achievement (e.g., WIAT, WJ-IV) + cognitive testing (IQ)
• Persistent despite targeted remediation ≥6 months
• Symbols present during school-age years even if not formally identified until later

Management

• Individualized Education Program (IEP) - cornerstone
• Dyslexia: Orton-Gillingham method (structured, multisensory phonics)
• Accommodations: Extended time, oral exams, assistive technology, reduced written work
• Treat comorbidities (ADHD very common)
• No specific pharmacotherapy for SLD

Important Information

• Most common: Dyslexia (~80% of all SLD)
• Comorbidities: ADHD (~50%), anxiety, depression, low self-esteem
• Early identification and intervention = best prognosis

---

B. ENURESIS

Definition

Etiopathogenesis / Risk Factors

• Maturational lag in CNS bladder control
• Reduced nocturnal ADH secretion (vasopressin) → nocturnal enuresis
• Reduced functional bladder capacity
• Deep sleep / arousal disorder (difficulty waking to bladder cues)
• Genetic: Autosomal dominant pattern; strong FH
• Secondary enuresis causes: UTI, DM, DI, seizures, stress/trauma, constipation, sexual abuse

Clinical Features

• Nocturnal (most common): Bedwetting at night (monosymptomatic nocturnal enuresis)
• Diurnal: Daytime wetting (more often organic/overactive bladder)
• Mixed: Both day and night
• Primary: Never achieved ≥6 months of dryness
• Secondary: Regression after ≥6 months of established dryness (more often psychological, UTI, DM)
• May have associated constipation, urgency, frequency, small-capacity bladder

Diagnosis

• Clinical; voiding diary, history
• Urinalysis + urine culture (rule out UTI, DM, DI)
• Renal ultrasound if structural abnormality suspected
• Secondary enuresis → rule out organic causes first

Management

• Enuresis alarm (bell-and-pad): Best long-term outcome; 75% success; conditioning method; needs ≥8-12 weeks
• Fluid restriction in evenings; regular voiding schedule; pre-bed toileting
• Star chart (reward system): Motivational for young children

• Desmopressin (DDAVP): Synthetic ADH; rapid onset; not curative; ideal for short-term (holidays, sleepovers); risk of hyponatremia → restrict fluids
• Imipramine (TCA): Effective but limited use (cardiac arrhythmia risk); 2nd/3rd line; monitor ECG
• Oxybutynin: Anticholinergic; for overactive bladder/diurnal enuresis

Important Information

• Spontaneous resolution rate: ~15% per year
• Reassurance to child and family essential (avoid shame/punishment)
• Enuresis alarm + motivational therapy = most effective combination

---

C. SIBLING RIVALRY (SIBLING JEALOUSY DISORDER)

Definition

Etiopathogenesis / Risk Factors

• Loss of exclusive parental attention
• Child's stage of development (toddlers/preschoolers most vulnerable)
• Inadequate parental preparation of the older child
• Large family, close birth spacing

Clinical Features

• Regression: Bedwetting (secondary enuresis), thumbsucking, baby talk, soiling, demand for bottle/breast
• Behavioral changes: Temper tantrums, clinging, disobedience, aggression toward sibling or parents, sleep difficulties
• Emotional changes: Jealousy, hostility, anger, sadness, tearfulness
• Social: Withdrawal, school refusal, decline in school performance

Diagnosis

• Clinical; history from parents; temporal relationship to birth of sibling
• Assess severity: Duration, degree of functional impairment

Management

• Parental psychoeducation: Normalize the child's feelings; explain it's common
• Dedicated one-on-one time with older child
• Involve older child in caregiving of new baby (age-appropriate)
• Praise positive behaviors toward sibling; avoid excessive comparison
• Avoid shaming or punishment for regressive behaviors (usually self-limiting)
• Family therapy if persistent or severe

Important Information

• Usually self-limiting (weeks to few months)
• Regression should be treated with patience, not punishment
• Persistent sibling rivalry → consider family therapy, parenting support

---

D. OTHER IMPORTANT CHILDHOOD DISORDERS

---

5. SUBSTANCE USE DISORDERS

Definition

Etiopathogenesis / Risk Factors

• Mesolimbic dopamine pathway ("reward pathway"): Nucleus accumbens; all addictive substances ↑ DA in this pathway
• Genetic: ~40-60% heritability; ALDH2 (alcohol), opioid receptor gene variants
• Neuroadaptation: Tolerance (receptor downregulation), sensitization, withdrawal
• Risk factors: FH, early initiation, trauma/ACEs, comorbid psychiatric disorders, peer use, impulsivity, low SES, availability, male sex

Clinical Features

1. Taking more/longer than intended
2. Persistent desire/unsuccessful efforts to cut down
3. Great deal of time spent obtaining/using/recovering
4. Craving
5. Failure to fulfill major role obligations
6. Continued use despite social/interpersonal problems
7. Giving up important activities
8. Recurrent use in hazardous situations
9. Continued use despite knowing physical/psychological harm
10. Tolerance
11. Withdrawal

• Intoxication: Disinhibition, slurred speech, ataxia, nystagmus, blackouts, respiratory depression
• Withdrawal: 6-24h tremor/anxiety/sweating/tachycardia → 24-48h seizures → 48-72h Delirium Tremens (fever, confusion, visual/tactile hallucinations, autonomic instability; mortality 5-15% untreated)
• Wernicke's (acute B1 deficiency): Confusion + Ataxia + Ophthalmoplegia
• Korsakoff's (chronic): Anterograde amnesia + confabulation (mammillary body damage)

• Intoxication: Euphoria, miosis, respiratory depression, constipation, bradycardia
• Overdose triad: Miosis + Respiratory depression + Coma → Naloxone
• Withdrawal (not life-threatening): Anxiety, yawning, lacrimation, rhinorrhea, piloerection ("cold turkey"), diarrhea, vomiting, mydriasis, tachycardia, myalgia, insomnia

• Intoxication: Euphoria, mydriasis, tachycardia, hypertension, hyperthermia, paranoia; severe → MI, stroke, seizures
• Withdrawal: Crash - dysphoria, fatigue, hypersomnia, hyperphagia, craving (not life-threatening)

• Intoxication: Euphoria, perceptual distortions, ↑ appetite, tachycardia, conjunctival injection
• Cannabis Hyperemesis Syndrome: Cyclical vomiting relieved by hot showers
• Withdrawal: Irritability, anxiety, sleep disturbance (mild)

Diagnosis

• DSM-5/ICD-11 criteria; structured clinical interview
• Urine drug screen, blood alcohol level
• LFTs (γ-GT, MCV ↑ in alcohol use), hepatitis screen
• CAGE questionnaire (alcohol), AUDIT, DAST

Management

• Withdrawal: BZDs (chlordiazepoxide/diazepam) + Thiamine IV/IM before glucose; CIWA-Ar guided
• Relapse prevention: Naltrexone (↓ reward), Acamprosate (↓ craving), Disulfiram (aversive - aldehyde buildup)
• Psychosocial: AA (12-step), CBT, Motivational Interviewing

• Buprenorphine (partial agonist ± naloxone = Suboxone): First-line; safer, office-prescribable
• Methadone (full agonist): Daily supervised; QTc risk
• Naltrexone (antagonist): For motivated patients; prevents relapse
• Withdrawal management: Clonidine, loperamide, NSAIDs

Important Information

• CAGE (≥2 = positive screen): Cut down, Annoyed, Guilty, Eye-opener
• Motivational Interviewing: Non-confrontational approach to build motivation to change
• Harm reduction approach: Needle exchange, supervised injection, naloxone distribution
• FASD: Prenatal alcohol → smooth philtrum, thin vermillion, small palpebral fissures + growth/CNS effects

---

6. BEHAVIOURAL ADDICTIONS

Definition

Etiopathogenesis / Risk Factors

• Same reward pathway: ↑ DA in nucleus accumbens during behavior
• Near-miss phenomenon (gambling), variable reward schedules (intermittent reinforcement)
• Genetic overlap with substance use disorders
• Risk factors: Male sex (gambling), adolescent gaming, social isolation, depression, anxiety, ADHD, impulsivity, access/availability

Clinical Features

1. Needs to gamble with increasing amounts (tolerance)
2. Restless/irritable when cutting down (withdrawal-like)
3. Repeated unsuccessful efforts to control
4. Preoccupied with gambling
5. Gambles when distressed ("escape gambling")
6. Chasing losses (returns after losing to "get even")
7. Lies to conceal gambling
8. Jeopardized significant relationship or career
9. Relies on others for money to relieve desperate gambling situation ("bailout") Severity: Mild (4-5), Moderate (6-7), Severe (8-9)

1. Impaired control over gaming (frequency, intensity, duration)
2. Increasing priority given to gaming over other activities
3. Continuation/escalation despite negative consequences

• Affects daily functioning: School, work, relationships, sleep, physical health
• Preoccupation with gaming when not playing; mood changes with gaming

• Persistent failure to control intense, repetitive sexual impulses
• Significant distress or impairment
• Not due to substance, paraphilia, or another condition

Diagnosis

• Clinical interview; DSM-5/ICD-11 criteria
• South Oaks Gambling Screen (SOGS), PGSI for gambling
• Rule out: Bipolar disorder (risky behavior during mania), substance use

Management

• CBT (first-line for all behavioral addictions; address distorted cognitions, triggers)
• Gamblers Anonymous (GA) - 12-step model
• Naltrexone: Best pharmacotherapy evidence for gambling disorder (↓ craving)
• SSRIs for comorbid depression/anxiety/OCD
• Financial counseling, family therapy
• Gaming: Digital detox, screen time limits, address comorbidities (depression, social anxiety)

Important Information

• Behavioral addictions ≠ substance addictions but share same reward circuitry
• High comorbidity with depression, anxiety, ADHD, substance use
• Gambling has highest suicide risk among behavioral addictions
• ICD-11 recognition of Gaming Disorder remains controversial but clinically useful

---

7. PSYCHOTIC DISORDERS

A. SCHIZOPHRENIA

Definition

Etiopathogenesis / Risk Factors

• Dopamine hypothesis: Mesolimbic ↑ DA → positive sx; Mesocortical ↓ DA → negative/cognitive sx
• Glutamate hypothesis: NMDA receptor hypofunction (explains all symptom domains; PCP/ketamine model)
• Genetic: MZ twin concordance ~50%; FDR ~10%; DISC1, COMT, NRG1 genes
• Neurodevelopmental: Prenatal 2nd trimester viral infections, malnutrition, obstetric complications → aberrant neuronal migration
• Neuroimaging: Enlarged lateral ventricles, ↓ frontal/temporal volume, ↓ hippocampal volume; no gliosis (neurodevelopmental, not neurodegenerative)
• Cannabis: High-potency THC, early use → ↑ risk 2-7x
• Expressed Emotion (EE): High family criticism/hostility/overinvolvement → ↑ relapse
• Social: Urban upbringing, migration, social defeat

Clinical Features

• Hallucinations: Most often auditory - voices commenting on behavior, 3rd person voices arguing/discussing, command hallucinations; also visual (rare), tactile, olfactory
• Delusions (fixed false beliefs, culturally inconsistent):
  • Persecutory (most common): Being followed, poisoned, plotted against
  • Reference: TV/radio/events have special personal meaning
  • Grandiose: Special identity, powers, mission
  • Thought alienation: Insertion, withdrawal, broadcasting (Schneider FRS)
  • Passivity/Made experiences: Actions/feelings/impulses controlled by external force
  • Somatic: Body being transformed/controlled
  • Nihilistic, jealous
• Disorganized thought: Loosening of associations (derailment), tangentiality, circumstantiality, word salad, neologisms, clang associations, thought blocking
• Disorganized behavior: Unpredictable agitation, neglect of hygiene, catatonia (stupor, posturing, waxy flexibility, negativism, echolalia, echopraxia)

• Affective flattening: Reduced/absent emotional expression
• Alogia: Poverty of speech; brief, empty replies
• Avolition: ↓ motivation; unable to initiate/persist in goal-directed activity
• Anhedonia: ↓ ability to experience pleasure (especially social)
• Asociality: Social withdrawal, lack of interest in social interactions

• ↓ Working memory, attention, executive function, processing speed, verbal memory

• Thought echo, voices arguing/commenting
• Thought insertion/withdrawal/broadcasting
• Passivity of affect/impulse/action
• Somatic passivity
• Delusional perception

Diagnosis

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized/catatonic behavior
5. Negative symptoms Plus: ≥6 months total (incl. prodrome/residual); significant functional decline; rule out schizoaffective, mood disorder, substances, medical condition

Management

• First-generation (FGA/typical): Haloperidol, chlorpromazine, fluphenazine; effective for positive sx; ↑ EPS risk
• Second-generation (SGA/atypical): Olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone; ↓ EPS; ↑ metabolic SE; also ↓ negative sx
• Clozapine: Treatment-resistant schizophrenia (≥2 APs failed, incl. ≥1 SGA); most effective; agranulocytosis → mandatory weekly CBC x18 weeks then monthly; no EPS/TD; ↓ suicide risk
• LAI (Long-Acting Injectables): Risperidone, paliperidone, aripiprazole every 2-4 weeks; for adherence issues

• CBT for psychosis (CBTp), Family therapy (↓ high EE), Social skills training, Supported employment (IPS), Case management, Early Intervention in Psychosis (EIP)

Important Information

• NMS features: Fever + Lead-pipe rigidity + Autonomic instability + Altered consciousness + ↑ CK
• Prognosis better: Female, acute onset, late onset, good premorbid function, + mood symptoms, FH absent, good social support
• "Rule of thirds": ~1/3 good outcome, ~1/3 episodic, ~1/3 chronic deterioration

---

B. OTHER PSYCHOTIC DISORDERS

---

8. PSYCHIATRIC DISORDERS IN THE ELDERLY

Definition

Etiopathogenesis / Risk Factors

• Neurobiological aging: ↓ neurotransmitters (DA, NE, ACh), ↓ neuroplasticity
• Medical comorbidities (thyroid, cardiac, neurological, pain)
• Polypharmacy; social isolation; bereavement; loss of role
• Cognitive vulnerability; sensory impairment (hearing, vision)

Clinical Features

• Prominent somatic symptoms (masked/somatized depression)
• Cognitive symptoms (executive dysfunction) - can mimic dementia
• Psychotic features more common (delusions of poverty, guilt, nihilism - "Cotard's")
• Hypochondriasis, anxiety prominent
• Often underdiagnosed and undertreated

• Onset >45-60 years; more common in women
• Partition delusions (neighbors spying through walls/floors/ceilings)
• Auditory + visual hallucinations
• Relatively preserved personality/function

• Acute onset, fluctuating course, ↓ attention + cognitive disturbance
• Hypoactive type: Most common, most missed; somnolent, withdrawn; worst prognosis
• Precipitants: Infection, drugs, metabolic, surgical, pain, urinary retention, constipation

• Agitation, aggression, wandering, psychosis (Capgras, delusions of theft), depression, apathy, sleep disturbance, sexual disinhibition

Diagnosis

• GDS (Geriatric Depression Scale), PHQ-9 for depression
• MMSE, MoCA for cognition
• Delirium: CAM (Confusion Assessment Method)
• Full medical workup (TFTs, B12, glucose, infection screen, CT brain)

Management

• Depression: SSRIs (sertraline, escitalopram - fewest interactions); avoid TCAs (anticholinergic, cardiac); mirtazapine (↑ appetite, sleep); ECT very effective and often safer than medications
• Late-onset psychosis: Low-dose atypical antipsychotics
• Delirium: Treat cause; non-pharmacological first (reorientation, familiar objects, lighting, family); haloperidol low dose if needed
• BPSD: Non-pharmacological first; risperidone (limited - ↑ stroke risk in dementia); SSRIs for agitation/depression in dementia; avoid BZDs

Important Information

• Elderly men have highest completed suicide rate
• Use START/STOPP criteria to optimize medications in elderly
• Prescribe "start low, go slow" due to pharmacokinetic changes (↓ renal/hepatic clearance, ↑ fat/water ratio, ↑ blood-brain barrier permeability)
• Anticholinergic drugs: Worsen cognition, constipation, urinary retention in elderly - avoid

---

9. PSYCHIATRIC EMERGENCIES

A. SUICIDE AND SUICIDAL BEHAVIOR

Definition

• Suicidal ideation: Thoughts of death/suicide (passive: wish to die; active: with plan)
• Suicidal intent: Expectation/hope of dying
• Suicide attempt: Self-injurious behavior with intent to die
• Completed suicide: Death from self-inflicted injury
• Parasuicide: Act resembling suicide but without full intent (includes attempts)

Etiopathogenesis / Risk Factors

• S - Sex (male; men complete; women attempt more)
• A - Age (elderly men highest; adolescents ↑)
• D - Depression (and other psychiatric illness)
• P - Previous attempt (STRONGEST predictor)
• E - Ethanol/substance use
• R - Rational thinking loss (psychosis, intoxication)
• S - Social support lacking
• O - Organized plan
• N - No spouse/widowed/divorced/bereaved
• S - Sickness (chronic illness, terminal, pain)

Clinical Features

• Expressed suicidal thoughts (always take seriously)
• Active ideation: Specific plan (method, time, place), access to means, intent, rehearsal
• Passive ideation: Wishing to be dead, not wanting to wake up
• Behavioral: Giving away possessions, saying goodbyes, sudden calmness after agitation (decision made)
• Psychomotor agitation, insomnia, hopelessness, social withdrawal
• Psychiatric sx: Severe depression, command hallucinations, severe anxiety/panic

Diagnosis

• C-SSRS (Columbia Suicide Severity Rating Scale): Gold standard
• SAD PERSONS scale
• Direct, non-judgmental inquiry (asking does NOT plant the idea)
• Assess: Ideation type, plan, intent, means, previous attempts, reasons for living, protective factors

Management

• Safety planning (Stanley-Brown Safety Planning Intervention)
• Hospitalization (voluntary or involuntary) if high acute risk
• Means restriction counseling: Remove firearms, stockpiled medications
• Treat underlying disorder
• Psychotherapy: DBT (best evidence for suicidal behavior and BPD), CBT-SP, IPT
• Pharmacotherapy: Lithium (↓ suicide in bipolar), Clozapine (↓ suicide in schizophrenia), Ketamine (acute antisuicidal effect), SSRIs (for depression)
• Close follow-up; crisis plans; crisis line numbers

Important Information

• 90% of suicide completers have a diagnosable psychiatric disorder
• Access to firearms is the single most modifiable environmental risk factor
• Protective factors: Social support, religious beliefs, children at home, therapeutic alliance, reasons for living

---

B. DELIBERATE SELF-HARM (DSH) / NON-SUICIDAL SELF-INJURY (NSSI)

Definition

Etiopathogenesis / Risk Factors

• Biosocial theory (Linehan): Emotional vulnerability + invalidating environment
• Emotion dysregulation; dissociation; trauma (especially sexual abuse)
• Risk: Adolescent females (most common), BPD, depression, eating disorders, PTSD, substance use, history of trauma

Clinical Features

• Cutting (most common): Arms, thighs; superficial wounds; often concealed
• Burning, hitting, scratching, hair-pulling, branding
• Functions of NSSI:
  • Emotion regulation (most common): Relieve overwhelming negative emotions; "feels better after"
  • Self-punishment (guilt, shame)
  • Anti-dissociation: To "feel real"
  • Communication of distress
  • Social reinforcement
• May describe relief/calm immediately after
• Often secretive, shame, guilt after

Diagnosis

• Clinical interview; non-judgmental approach
• Assess intent (NSSI vs. suicide attempt - distinguish carefully)
• Assess underlying psychiatric diagnosis (BPD, depression, PTSD)
• Physical examination for extent of wounds

Management

• DBT (Dialectical Behavior Therapy): Most evidence; targets emotion regulation, distress tolerance, mindfulness, interpersonal effectiveness
• Individual therapy (trauma-focused if applicable)
• Safety planning; crisis management skills
• Treat underlying disorder
• Hospitalization only if suicide risk present or wounds require medical attention

Important Information

• NSSI is NOT the same as a suicide attempt but is a risk factor for suicide
• Avoid reinforcing NSSI; focus on building alternative coping skills
• Family involvement (psychoeducation, communication skills) is important
• Therapeutic relationship is key; avoid punitive or dismissive responses

---

C. VIOLENCE AND AGGRESSION

Definition

Etiopathogenesis / Risk Factors

• History of violence (strongest predictor)
• Substance intoxication (especially alcohol, stimulants, PCP)
• Psychiatric illness: ASPD, psychopathy, acute psychosis (command hallucinations, persecutory delusions with identified victim), bipolar mania, delirium
• Organic causes: Brain injury, temporal lobe epilepsy, dementia, encephalitis, hypoglycemia
• Impulsivity, anger dysregulation, victim of past violence, social instability

Clinical Features

• Agitation, pacing, threatening speech/gestures
• Clenched fists, raised voice, invasion of personal space
• Inability to be redirected, hypervigilance
• Command hallucinations directing to harm
• Paranoid delusions about specific individuals
• Disinhibited/intoxicated state

Diagnosis

• Clinical assessment; risk assessment tools (HCR-20, VRAG)
• Tarasoff ruling (1976): If patient makes credible threat against identifiable victim → duty to protect (warn victim, law enforcement, hospitalize)

Management

1. Verbal de-escalation: Calm voice, non-threatening posture, acknowledge feelings, offer choices, ensure space
2. Offer voluntary oral medication: Olanzapine ODT, diazepam oral
3. Rapid Tranquilization (RT) if fails:
   • IM Haloperidol + IM Lorazepam (most used combination)
   • IM Olanzapine: Effective BUT do NOT combine with IM benzodiazepine (fatal respiratory depression risk)
   • IM Droperidol, IM Ziprasidone
4. Physical restraint: Last resort; constant monitoring; risk of positional asphyxia

Important Information

• Always ensure staff safety; remove potential weapons from environment
• Document risk assessment and interventions
• Debrief patient after agitation resolves; develop care plan
• Organic causes must be ruled out (especially hypoglycemia, encephalitis, head injury)

---

D. MEDICATION-RELATED COMPLICATIONS

Serotonin Syndrome vs NMS

• Neuromuscular: Clonus (inducible/spontaneous/ocular), hyperreflexia, tremor, myoclonus
• Autonomic: Hyperthermia, tachycardia, diaphoresis, diarrhea, BP fluctuations
• Mental: Agitation, confusion

• "FEVER": Fever, Encephalopathy, Vitals unstable, Elevated CK, Rigidity (lead-pipe)

• "Mad as a hatter (confusion), hot as a hare (hyperthermia), blind as a bat (mydriasis), red as a beet (flushing), dry as a bone (dry skin/mouth)"
• • Urinary retention, tachycardia, ileus, seizures
• Causes: TCAs, antihistamines, antipsychotics (low-potency), atropine, scopolamine
• Treatment: Physostigmine (if severe); supportive care

• Levels >1.5: Coarse tremor, ataxia, dysarthria, nystagmus, confusion
• Levels >2.0: Seizures, arrhythmias, renal failure
• Levels >4.0: Dialysis
• Tx: Stop lithium, IV saline, hemodialysis if severe/levels >4

• Flu-like, Insomnia, Nausea, Imbalance/"electric shock" sensations, Superimposed hyperarousal, Headache
• Worst with paroxetine (shortest half-life); least with fluoxetine
• Tx: Restart → slow taper; switch to fluoxetine then taper

---

10. OBSESSIVE-COMPULSIVE DISORDER

Definition

Etiopathogenesis / Risk Factors

• Neurobiological: OFC → Caudate → Globus Pallidus → Thalamus → OFC loop (hyperactive)
• Serotonin: Strong evidence (clomipramine + SSRIs effective)
• Genetic: Heritability 40-65%; COMT, SLC1A1 genes
• PANDAS: Group A Strep infection → autoimmune attack on basal ganglia → OCD/tics in children
• Risk: FH of OCD/Tourette's, perfectionism, anxiety disorders, trauma

Clinical Features

• Contamination (most common): Fear of germs, dirt, disease, bodily fluids
• Harm/aggressive: Fear of harming self or others (stabbing, hitting); intrusive violent images
• Symmetry/exactness: Need for things to be "just right"
• Sexual/religious (taboo): Intrusive blasphemous or sexual thoughts
• Doubt: "Did I leave the gas on?", "Did I hit someone while driving?"
• Somatic: Fear of having a disease
• Hoarding: Fear of discarding items

• Washing/cleaning: Handwashing (raw, cracked skin), showering rituals
• Checking: Locks, gas, switches, appliances; reassurance-seeking
• Ordering/arranging: Items in specific pattern, symmetrical placement
• Counting: Specific numbers, "magical" numbers, repetitions
• Mental rituals: Counting mentally, praying, replacing bad thoughts with "safe" thoughts
• Hoarding: Difficulty discarding, piles of worthless objects

• Contamination/washing
• Checking
• Symmetry/ordering
• Intrusive thoughts (pure O)
• Hoarding

Diagnosis

• DSM-5: Obsessions + compulsions; time-consuming (>1hr/day) or distress/impairment; not due to substances or medical condition
• Y-BOCS (Yale-Brown OC Scale): Obsessions (0-20) + Compulsions (0-20) = total 0-40; >16 moderate; >24 severe
• Specifiers: With good/fair/poor/absent insight; tic-related
• Rule out: GAD (worry ≠ obsession), psychosis (ego-syntonic), OCD spectrum

Management

• First-line: ERP + SSRI (combination most effective)
• ERP (Exposure and Response Prevention): Gold standard psychotherapy
  • Graduated exposure to feared stimulus + prevention of compulsive response
  • Habituation; challenging the feared consequences
• SSRIs (higher doses than depression; response at 8-12 weeks):
  • Fluvoxamine, fluoxetine, sertraline, paroxetine (all FDA-approved)
  • Need higher doses: e.g., fluoxetine up to 80mg, sertraline up to 200mg
• Clomipramine (TCA): Most potent anti-OCD drug; 2nd line due to SE (anticholinergic, cardiac, seizures)
• Augmentation (partial SSRI response): Add risperidone or aripiprazole (especially if comorbid tics)
• Treatment-resistant OCD: DBS, anterior capsulotomy (last resort)

Important Information

• OCD is ego-dystonic (distressing, unwanted) - unlike OCPD (ego-syntonic)
• OC Spectrum Disorders:
  • BDD: Perceived appearance defect; mirror checking; ↑↑ suicide risk
  • Hoarding Disorder: Difficulty discarding; clutter; functional impairment
  • Trichotillomania: Hair-pulling causing hair loss
  • Excoriation: Skin-picking causing lesions
• Tourette's syndrome: Comorbid in ~20% OCD; tics + coprolalia/echolalia
• OCD in children: More common in boys; contamination/symmetry most common; involve parents in ERP

---

11. SLEEP DISORDERS

Definition

Etiopathogenesis / Risk Factors

• Disruption of circadian rhythm (SCN - suprachiasmatic nucleus)
• Imbalance of sleep-promoting (GABA, adenosine, melatonin) vs wake-promoting (orexin/hypocretin, histamine, NE, DA, ACh) systems
• Genetic factors (narcolepsy: HLA-DQB1*06:02; RLS: familial), autoimmune (narcolepsy)
• Medical comorbidities (pain, cardiac, respiratory, neurological)
• Psychiatric comorbidities (depression, anxiety, PTSD, substance use)

Clinical Features

• NREM: N1 (theta waves, hypnic jerks) → N2 (sleep spindles, K-complexes) → N3 (delta/slow-wave sleep)
• REM: Rapid eye movements, vivid dreams, muscle atonia; REM increases in later cycles
• Cycle: ~90 minutes; 4-6 cycles/night
• Depression → ↓ REM latency, ↑ REM density

• Difficulty initiating sleep (sleep onset insomnia - anxiety, circadian)
• Difficulty maintaining sleep (sleep maintenance - depression, pain, aging)
• Early morning awakening (depression, elderly)
• ≥3 nights/week, ≥3 months, despite adequate opportunity
• Daytime: Fatigue, irritability, cognitive impairment, mood disturbance
• Hyperarousal: Racing thoughts, tension, monitoring clock, concern about sleep

• C - Cataplexy (Type 1 only): Sudden bilateral muscle weakness/paralysis triggered by strong emotions (laughter, surprise, anger); consciousness maintained; seconds to minutes; pathognomonic
• H - Hypnagogic/Hypnopompic hallucinations: Vivid, frightening; on falling asleep/waking
• E - Excessive daytime sleepiness: Irresistible sleep attacks; "automatic behaviors"; refreshing brief naps
• S - Sleep paralysis: Can't move when falling asleep/waking; terrifying; seconds to minutes
• S - Sleep disrupted at night (fragmented nocturnal sleep)

• Loud snoring, witnessed apneas, choking/gasping, EDS, morning headache, nocturia
• ↑ BP, personality change, cognitive impairment, sexual dysfunction

• Sleepwalking: Ambulation; glazed expression; automatic behaviors; can injure self; do not forcibly wake
• Sleep Terrors: Abrupt arousal with piercing scream, intense fear, tachycardia, sweating; inconsolable; amnesia; peaks 5-7 years
• Confusional Arousals: Confusion/disorientation on awakening; slow speech; common in toddlers

• RBD (REM Sleep Behavior Disorder): Acts out vivid/violent dreams; injures self/partner; strongly associated with Parkinson's disease, DLB, MSA (may precede by 5-15 years); men >50 most common
• Nightmare Disorder: Vivid frightening dreams; full awakening; distress; recall; second half of night
• Sleep Paralysis: Isolated or with narcolepsy

• Urge to move legs with uncomfortable sensations ("creeping," "crawling," "pins and needles")
• Worse at rest and in evenings/night
• Relieved by movement
• Associated: Iron deficiency, pregnancy, renal failure, peripheral neuropathy

Diagnosis

• PSG (Polysomnography): Gold standard for narcolepsy, OSA, RBD
• MSLT: Narcolepsy (mean latency ≤8 min; ≥2 SOREMPs)
• ISRS/PSQI: Insomnia scales
• AHI ≥5 with sx or ≥15: OSA diagnosis
• Iron studies (RLS), CSF hypocretin ≤110 (narcolepsy Type 1), HLA typing

Management

• Insomnia: CBT-I = gold standard (sleep restriction, stimulus control, relaxation, cognitive restructuring); pharmacotherapy short-term (zolpidem, ramelteon, suvorexant, mirtazapine/trazodone)
• Narcolepsy: Modafinil (EDS first-line); sodium oxybate (cataplexy + EDS); venlafaxine/fluoxetine (cataplexy); scheduled naps
• OSA: CPAP = gold standard; weight loss, positional therapy, MAD, surgery
• Sleepwalking/Terrors: Reassurance + safety measures; clonazepam if frequent/dangerous
• RBD: Clonazepam (most used); melatonin; safety (bed rails, padding, mattress on floor)
• RLS: Correct iron if ferritin <75 μg/L; dopamine agonists (pramipexole, ropinirole) first-line; pregabalin/gabapentin; opioids (severe)

Important Information

• RBD = early marker of synucleinopathy (Parkinson's, DLB, MSA) - counsel patient about monitoring
• Augmentation (dopamine agonist treatment paradoxically worsens RLS over time) - monitor and switch
• Z-drugs (zolpidem): Risk of complex sleep behaviors (sleepwalking, sleep-driving) - FDA black box warning
• Melatonin: Safe in elderly and children; minimal dependence; good for circadian rhythm disorders

---

12. EATING DISORDERS

A. ANOREXIA NERVOSA

Definition

Etiopathogenesis / Risk Factors

• Genetic: ~60-80% heritability; serotonin system abnormalities
• Psychological: Perfectionism, obsessionality, need for control, fear of maturity, low self-esteem, rigid thinking
• Sociocultural: Thin ideal, social media, dance/gymnastics/modeling/wrestling
• Developmental: Adolescent identity issues, difficult family dynamics (enmeshment, Minuchin)
• Neurobiological: Altered reward processing to food (↑ striatal DA with food avoidance), altered interoception

Clinical Features

• Severe food restriction, calorie counting, fat avoidance
• Intense fear of weight gain
• Distorted body image (perceives self as fat despite being underweight)
• Denial of seriousness of low weight
• Food rituals (cutting food into tiny pieces, rearranging)
• Excessive exercise, secrecy around eating, avoiding eating with others
• Preoccupation with food, recipes, cooking (without eating)
• Social withdrawal, mood changes

• Emaciation, prominent bones
• Lanugo hair (fine downy body hair)
• Hair loss (alopecia), dry skin, acrocyanosis
• Bradycardia, hypotension, hypothermia (cardiovascular compromise)
• Amenorrhea (secondary; low LH/FSH/estrogen)
• Russell's sign: Calluses on dorsal hand (if purging subtype)
• Parotid enlargement (if purging)
• Dental erosion (if purging)
• Edema on refeeding

• Hypokalemia, hyponatremia, hypophosphatemia
• ↑ LFTs, ↓ glucose, ↓ estrogen/testosterone
• ↑ Cortisol, ↓ T3 (euthyroid sick syndrome)
• Leukopenia, anemia, thrombocytopenia (bone marrow suppression)
• ECG: Bradycardia, ↑ QTc, T wave inversions, ST changes

Diagnosis

1. Restriction of energy intake → significantly low body weight
2. Intense fear of gaining weight OR behavior that interferes with weight gain
3. Disturbance in body weight/shape perception, undue influence on self-evaluation, OR denial of seriousness

Management

• Medical stabilization: Cardiac monitoring, electrolyte correction, slow refeeding
• Nutritional rehabilitation: Start 1000-1200 kcal/day, increase gradually; NG tube if refuses
• Refeeding syndrome prevention: Monitor phosphate, supplement prophylactically (Thiamine + Phosphate)
• Psychotherapy:
  • Adolescents: Family-Based Treatment (FBT/Maudsley approach) = most evidence
  • Adults: CBT-E (enhanced CBT), MANTRA, SSCM
• Pharmacotherapy: Limited evidence; olanzapine (↑ weight, ↓ anxiety); SSRIs not effective in underweight state; treat comorbid depression/OCD after weight restoration

Important Information

• Highest mortality of any psychiatric disorder (~5-10% per decade); death from cardiac complications and suicide
• Refeeding syndrome: Hypophosphatemia + cardiac failure + Wernicke's → supplement phosphate and thiamine before refeeding
• FBT (Maudsley): Phase 1 - parents take full control of eating; Phase 2 - return control to adolescent; Phase 3 - establish healthy identity

---

B. BULIMIA NERVOSA

Definition

Etiopathogenesis / Risk Factors

• Overlap with AN; binge-purge as emotion regulation strategy
• Impulsivity, mood instability, low self-esteem, dietary restraint
• Serotonin dysregulation (binge → temporary ↑ tryptophan)
• Risk: FH of eating/mood/substance use disorders, sexual abuse, perfectionism, dieting

Clinical Features

• Binge episodes: Eating large amount in discrete period (often 2hrs); sense of loss of control; secretive; disgusted/ashamed after
• Compensatory behaviors:
  • Purging type: Self-induced vomiting (most common), laxative abuse, diuretic abuse, enemas
  • Non-purging type: Fasting, excessive exercise
• Overconcern with body weight/shape
• Normal weight or slightly above/below
• Fluctuating mood, depression, anxiety, self-criticism

• Russell's sign: Calluses/scars on dorsal surface of hand (from self-induced vomiting)
• Dental enamel erosion (perimylolysis): From gastric acid; especially upper front teeth
• Parotid gland enlargement (sialadenosis): Bilateral, painless; "chipmunk cheeks"
• Hoarse voice; esophagitis; Mallory-Weiss tears; esophageal rupture (Boerhaave syndrome - rare, life-threatening)
• Peripheral edema (from laxative abuse)
• Calluses on fingers

• Vomiting → hypokalemia, hyponatremia, metabolic alkalosis (↓ Cl-, ↑ HCO3-)
• Laxative abuse → hypokalemia, metabolic acidosis, hypomagnesemia

Diagnosis

1. Recurrent binge eating (discrete period + large amount + loss of control)
2. Recurrent compensatory behaviors
3. ≥1x/week for ≥3 months
4. Self-evaluation unduly influenced by shape/weight
5. NOT exclusively during anorexia episodes (if both present → diagnose AN binge-purge type)

Management

• CBT-E: Gold standard; addresses maintaining factors (dietary restraint, weight/shape concerns)
• IPT (Interpersonal Therapy): Second-line psychotherapy
• Guided self-help (CBT-based): Effective and accessible
• Fluoxetine 60mg/day: Only FDA-approved medication for BN; reduces binge-purge frequency; higher than antidepressant dose
• Nutritional counseling; avoid strict dieting (triggers binging)

Important Information

• Weight usually normal → easily missed clinically
• Physical signs guide clinical suspicion
• Medical complications from purging can be life-threatening (arrhythmias from hypokalemia, esophageal rupture)

---

C. BINGE EATING DISORDER (BED)

Definition

Clinical Features

• Eating faster than normal
• Eating until uncomfortably full
• Eating large amounts without physical hunger
• Eating alone due to embarrassment
• Feeling disgusted/depressed/guilty after overeating
• Marked distress
• No compensatory behaviors (distinguishes from BN)
• Often overweight/obese

Diagnosis

Management

• CBT-E, DBT, IPT
• Lisdexamfetamine (Vyvanse): Only FDA-approved for BED; stimulant; reduces binge frequency
• Topiramate (reduces binge frequency; weight loss)
• SSRIs for comorbid depression/anxiety

---

13. STRESS-RELATED DISORDERS

A. ACUTE STRESS DISORDER (ASD)

Definition

Etiopathogenesis / Risk Factors

• Traumatic event exposure (actual/threatened death, serious injury, sexual violence)
• Prior trauma, psychiatric history, peritraumatic dissociation, poor social support
• Severity and nature of trauma (interpersonal trauma > impersonal)

Clinical Features

• Intrusive memories of trauma
• Recurrent distressing dreams
• Flashbacks (dissociative reactions where trauma feels like it's reoccurring)
• Intense psychological distress to trauma cues
• Physiological reactions to cues

• Persistent inability to experience positive emotions

• Altered sense of reality
• Depersonalization (detached from self)
• Derealization (dreamlike quality to surroundings)
• Dissociative amnesia (inability to recall important aspect of trauma)

• Avoid trauma-related thoughts/feelings
• Avoid external reminders (people, places, conversations, objects)

• Sleep disturbance
• Irritability/angry outbursts
• Hypervigilance
• Exaggerated startle response
• Concentration difficulty

Diagnosis

• ≥9/14 symptoms, ≥3 days, <1 month; not due to substances/medical; significant impairment
• If persists >1 month → evaluate for PTSD

Management

• Psychological First Aid (immediate); safety, comfort, connection, practical assistance
• Watchful waiting (most resolve)
• Brief TF-CBT if sx persist
• Debriefing (CISD) NOT recommended (can increase PTSD risk)
• Short-term anxiolytics/hypnotics if severe distress (with caution)

---

B. POST-TRAUMATIC STRESS DISORDER (PTSD)

Definition

Etiopathogenesis / Risk Factors

• Overactivation of amygdala (fear processing); impaired hippocampal memory consolidation; ↓ prefrontal inhibition of amygdala
• ↓ cortisol (unlike depression); enhanced GC sensitivity; ↑ NE
• Prior trauma, prior psychiatric illness, female sex, poor social support, peritraumatic dissociation

Clinical Features

• Intrusive, involuntary, distressing memories
• Recurrent nightmares about trauma
• Dissociative flashbacks (re-experiencing trauma as if happening now - most specific)
• Intense psychological distress to trauma-related cues
• Physiological reactions to cues

• Avoid trauma-related thoughts/feelings/memories
• Avoid external reminders (people, places, activities, objects, situations)

• Inability to recall important trauma details (dissociative amnesia)
• Persistent exaggerated negative beliefs ("World is dangerous," "I am permanently damaged")
• Distorted blame of self/others
• Persistent negative emotional states (fear, horror, anger, guilt, shame)
• Markedly diminished interest in activities
• Feeling detached/estranged from others
• Persistent inability to experience positive emotions (emotional numbing)

• Irritable behavior and angry outbursts
• Reckless or self-destructive behavior
• Hypervigilance (always on guard)
• Exaggerated startle response
• Concentration difficulties
• Sleep disturbance (difficulty falling/staying asleep)

• Affect dysregulation (emotional storms, chronic emptiness)
• Negative self-concept (shame, guilt, worthlessness, failure)
• Interpersonal disturbances (inability to trust, difficulty with intimacy)

Diagnosis

• DSM-5 criteria: Criterion A + B (≥1) + C (≥1) + D (≥2) + E (≥2) + >1 month + impairment
• PCL-5: PTSD Checklist (DSM-5 version); screen + severity
• Specifiers: With dissociative sx (depersonalization/derealization), delayed expression
• Rule out: ASD, adjustment disorder, depression, substance use

Management

• Trauma-Focused CBT (TF-CBT): Prolonged Exposure (PE) + Cognitive Processing Therapy (CPT)
• EMDR (Eye Movement Desensitization and Reprocessing): Bilateral stimulation during trauma recall; highly effective; WHO and NICE recommended
• Both equally effective; recommended over pharmacotherapy

• SSRIs: Sertraline, paroxetine (FDA-approved); first-line pharmacotherapy
• SNRIs: Venlafaxine (second-line)
• Prazosin (alpha-1 blocker): Specifically for PTSD nightmares
• Avoid benzodiazepines: No evidence; may worsen PTSD long-term; dependence risk

Important Information

• Avoid re-traumatization; trauma processing requires safety first
• Complex PTSD seen after prolonged, repeated, interpersonal trauma (childhood abuse, domestic violence, torture, trafficking)
• MDMA-assisted psychotherapy: Promising emerging evidence for treatment-resistant PTSD

---

C. ADJUSTMENT DISORDER

Definition

Clinical Features

• Depressed mood (crying, hopelessness)
• Anxiety (worry, nervousness)
• Disturbance of conduct (reckless behavior, fighting)
• Mixed symptoms
• Disproportionate reaction to stressor
• Common stressors: Job loss, divorce, medical diagnosis, academic failure, financial crisis

Diagnosis

• Clinical; identify stressor and temporal relationship
• Rule out bereavement, PTSD, MDD (if MDD criteria met → diagnose MDD)
• DSM-5: Does not qualify for another mental disorder; not a normal bereavement; cause impairment

Management

• Psychotherapy: Brief CBT, problem-solving therapy, supportive therapy, IPT
• Address the stressor (practical support)
• Short-term pharmacotherapy for specific symptoms (sleep, anxiety) if needed

---

14. ANXIETY DISORDERS

A. GENERALIZED ANXIETY DISORDER (GAD)

Definition

Etiopathogenesis / Risk Factors

• Overactivation of amygdala; dysregulation of GABA, NE, serotonin
• Genetic contribution (~30% heritability)
• Childhood anxiety, adverse experiences, chronic stress
• Comorbid depression (>50%)

Clinical Features

• W - Worry (excessive, about multiple domains: work, health, family, finances, world events)
• A - Apprehensiveness/Anxiety (muscle tension)
• T - Tension (muscle tension, headaches, backaches)
• C - Concentration impaired (mind going blank)
• H - Hypervigilance / Irritability
• E - Energy ↓ (fatigue, easily tired)
• R - Restlessness (keyed up, on edge, can't relax)
• S - Sleep disturbance (difficulty initiating/maintaining)

Diagnosis

• DSM-5: Excessive worry + ≥3 symptoms + ≥6 months + impairment + not substance/medical/another disorder
• GAD-7 screening tool
• Rule out: Hyperthyroidism, pheochromocytoma, substance use, other anxiety disorders

Management

• CBT (gold standard): Worry postponement, relaxation training, cognitive restructuring, problem-solving, worry exposure
• SSRIs/SNRIs (first-line): Escitalopram, sertraline, venlafaxine, duloxetine
• Buspirone: Non-BZD anxiolytic (5-HT1A partial agonist); no sedation/dependence; 2-4 weeks onset
• Pregabalin: Good evidence; first-line in Europe
• BZDs: Short-term only; dependence risk; avoid long-term
• Exercise, mindfulness, relaxation techniques

---

B. PANIC DISORDER

Definition

Etiopathogenesis / Risk Factors

• Hyperactivation of amygdala-locus coeruleus circuit; ↑ NE, ↑ CO2 sensitivity
• "False alarm" theory: Normal physiological sensation misinterpreted as catastrophic
• Genetic; FH of panic; anxiety sensitivity (trait)
• Triggers: Caffeine, cannabis, cocaine, hyperventilation, sodium lactate infusion (research)

Clinical Features

• Palpitations, pounding heart, tachycardia
• Chest pain or discomfort
• Shortness of breath or smothering sensation
• Choking feeling

• Dizziness, unsteadiness, lightheadedness, faintness
• Paresthesias (numbness or tingling)
• Chills or hot flushes
• Sweating
• Trembling or shaking
• Nausea or abdominal distress

• Derealization (unreality of surroundings)
• Depersonalization (detachment from self)
• Fear of losing control or "going crazy"
• Fear of dying

Diagnosis

• Rule out cardiac (ECG, Holter), respiratory (PFTs), endocrine (TFTs, glucose, pheochromocytoma catecholamines), vestibular
• DSM-5: Recurrent unexpected attacks + ≥1 month of concern/behavioral change + not substance/medical

Management

• CBT: Most effective long-term; interoceptive exposure (induce feared sensations → habituation), cognitive restructuring, breathing retraining
• SSRIs/SNRIs: First-line; start at low dose (may worsen anxiety initially); full effect 4-6 weeks
• BZDs (alprazolam, clonazepam): Rapid relief; short-term only; dependence risk; clonazepam preferred (longer half-life)
• Combined CBT + SSRI for severe cases

---

C. SOCIAL ANXIETY DISORDER

Definition

Clinical Features

• Fear of: Being embarrassed, humiliated, rejected, offending others
• Physical symptoms in social situations: Blushing (most characteristic), sweating, trembling, tachycardia, nausea
• Anticipatory anxiety (hours/days before the event)
• Post-event rumination (going over what was said, dwelling on perceived mistakes)
• Avoidance of social situations OR endurance with intense distress
• Performance only subtype (just public speaking) vs Generalized (most social situations)

Diagnosis

• DSM-5: Marked fear in social situations + fear of acting in a way that is humiliating + avoidance + ≥6 months + impairment; specify "performance only"

Management

• CBT (social skills training, cognitive restructuring, exposure)
• SSRIs/SNRIs: First-line; sertraline, escitalopram, venlafaxine
• Beta-blockers (propranolol): For situational/performance anxiety only (physical symptoms); not for generalized SAD
• MAOIs: Phenelzine historically most effective but SE profile limits use
• Not BZDs as maintenance

---

D. SPECIFIC PHOBIA

Definition

Types (DSM-5)

• Animal, Natural environment (heights, storms, water), Blood-Injection-Injury, Situational, Other

Clinical Features

• Immediate fear/anxiety on exposure to phobic stimulus
• Avoidance or endurance with intense distress
• Blood-Injection-Injury type unique: Diphasic vasovagal response - initial ↑ HR/BP → sudden ↓ HR/BP → fainting (vasovagal syncope); applied tension technique (tensing muscle groups to ↑ BP) used in treatment

Management

• In vivo exposure therapy (most effective; single-session for some phobias)
• Applied tension: BII type (to prevent fainting)

---

15. PERSONALITY DISORDERS

Definition

Etiopathogenesis / Risk Factors

• Gene-environment interaction; early temperament
• Adverse childhood experiences (abuse, neglect, invalidation) - especially BPD
• Attachment disruptions; chaotic family environments
• Neurobiological: ↓ prefrontal inhibition (impulsive types), ↓ serotonin (ASPD, BPD), altered amygdala reactivity

Clinical Features

• Pervasive distrust/suspiciousness without sufficient basis
• Suspects exploitation/harm, doubts loyalty of friends
• Reads hidden meanings into benign events; bears grudges; pathological jealousy (infidelity doubts)
• Angry/hostile reactions; reluctant to confide

• Neither desires nor enjoys close relationships; chooses solitary activities
• Little interest in sexual experiences; indifferent to praise/criticism
• Flat affect; solitary lifestyle; no close friends
• Not distressed by social isolation (vs avoidant PD)

• Ideas of reference (not delusions)
• Magical thinking (telepathy, sixth sense influencing behavior)
• Unusual perceptual experiences (body illusions)
• Odd/eccentric speech (vague, circumstantial, metaphorical)
• Suspiciousness/paranoid ideation
• Inappropriate/constricted affect
• Odd/eccentric behavior
• No close friends except FDR
• Transient, stress-related psychosis
• Genetically related to schizophrenia

• Must be ≥18 AND have conduct disorder before age 15
• Failure to conform to lawful behaviors; deceitfulness; impulsivity; irritability/aggression
• Reckless disregard for safety of self/others
• Consistent irresponsibility (work/finances)
• Lack of remorse; indifferent to or rationalizing having hurt others
• Psychopathy: More severe; grandiosity, shallow affect, callousness (PCL-R)

• Fear of abandonment: Frantic efforts to avoid real or imagined abandonment
• Unstable intense relationships: Alternating extremes of idealization and devaluation ("splitting")
• Identity disturbance: Unstable self-image/sense of self
• Impulsivity in ≥2 self-damaging areas (spending, sex, substances, reckless driving, binge eating)
• Recurrent suicidal behavior/gestures/threats or self-mutilating behavior
• Affective instability: Intense episodic dysphoria, irritability, anxiety (hours, rarely days)
• Chronic feelings of emptiness
• Inappropriate, intense anger: Difficulty controlling anger; temper tantrums
• Transient paranoid ideation or severe dissociation under stress

• Uncomfortable when not center of attention
• Inappropriate sexually seductive/provocative behavior
• Shallow/rapidly shifting emotional expression
• Uses physical appearance to draw attention
• Impressionistic speech (vague, lacking detail)
• Self-dramatization, theatricality, exaggerated emotion
• Suggestible; easily influenced
• Considers relationships more intimate than they are

• Grandiose sense of self-importance
• Preoccupied with fantasies of success/power/beauty
• Believes self is special/unique
• Requires excessive admiration
• Sense of entitlement
• Interpersonally exploitative
• Lacks empathy
• Envious of others or believes others envious of self
• Arrogant, haughty behaviors
• Narcissistic rage when criticized; fragile self-esteem underneath

• Avoids occupational activities involving significant interpersonal contact
• Unwilling to get involved unless certain of being liked
• Shows restraint in intimate relationships (fear of shame/ridicule)
• Preoccupied with criticism/rejection in social situations
• Inhibited in new interpersonal situations
• Views self as socially inept, unappealing
• Reluctant to take risks due to fear of embarrassment
• Wants relationships but fears rejection (vs schizoid - doesn't want relationships)

• Difficulty making everyday decisions without reassurance
• Needs others to assume responsibility for major life areas
• Difficulty expressing disagreement (fear of losing support)
• Difficulty initiating projects independently
• Goes to excessive lengths to obtain nurturing
• Feels uncomfortable/helpless when alone
• Urgently seeks new relationship when one ends
• Preoccupied with fears of being left to care for themselves

• Preoccupied with orderliness, perfectionism, control
• Perfectionism that interferes with task completion
• Excessively devoted to work/productivity
• Overly conscientious, inflexible about ethics/values
• Unable to discard worn-out/worthless objects
• Reluctant to delegate unless tasks done exactly right
• Miserly spending style (hoards money)
• Shows rigidity and stubbornness
• Ego-syntonic (unlike OCD which is ego-dystonic)

Diagnosis

• Clinical interview, longitudinal history (pattern since adolescence/early adulthood)
• Structured interviews: SCID-II, IPDE
• Rule out: Acute psychiatric illness (e.g., bipolar, psychosis), medical conditions, substance use
• ICD-11 severity: Mild (personal/social impairment), Moderate (marked impairment), Severe (all areas)

Management

• BPD: DBT (gold standard) → Emotion regulation, Distress tolerance, Mindfulness, Interpersonal effectiveness; also MBT, Schema Therapy, TFP; SSRIs/mood stabilizers for specific symptoms
• ASPD: Limited evidence; CBT, therapeutic communities; treat comorbidities; manage risk
• Cluster A: Social skills training, low-dose antipsychotics (schizotypal)
• Cluster C: CBT (avoidant: social exposure), SSRIs (avoidant, dependent)
• All: Long-term therapeutic relationship, consistent boundaries, structured approaches

Important Information

• Personality disorders ≠ untreatable; BPD has good evidence base for change
• Comorbidity is the rule not the exception (depression, anxiety, substance use)
• Self-harm in BPD ≠ always suicidal; assess intent every time
• DBT targets 4 skills: Mindfulness, Distress tolerance, Emotion regulation, Interpersonal effectiveness

---

16. PSYCHOSOMATIC / SOMATIC SYMPTOM AND RELATED DISORDERS

Definition

Etiopathogenesis / Risk Factors

• Biopsychosocial: Genetic predisposition, adverse childhood experiences (abuse, neglect, medical trauma), alexithymia, somatosensory amplification
• Central sensitization, altered pain processing, abnormal interoception
• Illness behavior learned from family; cultural factors (somatization more common in some cultures)
• Psychodynamic: Unconscious expression of psychological distress through physical channel
• High comorbidity with depression, anxiety, PTSD, personality disorders

Clinical Features

• ≥1 somatic symptom causing distress/disruption
• PLUS ≥1 of:
  • Disproportionate, persistent thoughts about seriousness of symptoms
  • Persistently high anxiety about health/symptoms
  • Excessive time/energy devoted to symptoms
• Persistent (>6 months)
• Specifier: With predominant pain (previously "pain disorder")

• Preoccupation with having or acquiring serious illness
• Somatic symptoms absent or mild
• High anxiety about health; easily alarmed by health information
• Excessive health behaviors (checking, seeking repeated reassurance) OR maladaptive avoidance (avoiding medical care)
• ≥6 months
• Types: Care-seeking vs Care-avoidant

• ≥1 symptom of altered voluntary motor or sensory function
• Clinical findings INCOMPATIBLE with recognized neurological disease
• Not better explained by another disorder
• Motor symptoms: Weakness/paralysis, tremor (entrainable, variable), gait disturbance (astasia-abasia), non-epileptic attacks (PNEA - pseudoseizures)
• Sensory symptoms: Numbness/anesthesia (non-dermatomal), blindness (tubular vision), deafness
• Cognitive: Dissociative amnesia, "functional memory disorder"
• Hoover's sign: Hip extension returns when asked to flex contralateral hip (positive = functional)
• La belle indifférence: Apparent lack of concern about disability (not pathognomonic)
• Usually precipitated by psychological stressor; high comorbidity with trauma/PTSD

• Falsification of physical/psychological signs OR induction of injury/disease
• Deceptive behavior; WITHOUT obvious external incentive (sick role motivation)
• Munchausen syndrome: Severe, chronic; pseudologia fantastica, hospital hopping, dramatic presentations
• Factitious Disorder Imposed on Another (Munchausen by Proxy/Medical Child Abuse): Caregiver fabricates symptoms in child → child abuse; mandatory reporting

• Intentional production of false/exaggerated symptoms for external incentive (compensation, avoiding work/jail, obtaining drugs)
• Suspected when: Medicolegal context, large discrepancy between claimed disability and objective findings, uncooperative with evaluation, antisocial traits

Diagnosis

• Positive diagnosis (not just exclusion of medical illness)
• Establish what IS present (functional signs) not just what is absent
• Neurological exam (Hoover's sign, Dravet test, Entrainment for tremor)
• Validated scales: PHQ-15 (somatic symptom severity), Health Anxiety Inventory (HAI)
• Liaison with other specialties (neurology, gastroenterology, etc.)

Management

• Psychoeducation: Explain biopsychosocial model; validate symptoms as real; frame neurologically ("software not hardware problem" for conversion)
• Regular scheduled appointments (not as-needed): Prevents doctor shopping; reduces healthcare utilization
• CBT: Most evidence (challenging catastrophic beliefs, activity scheduling, symptom exposure, health anxiety)
• Graded exercise/activity: Functional rehabilitation
• Liaison psychiatry model: Coordination between medical and psychiatric care
• Treat comorbidities: Antidepressants for depression/anxiety; appropriate analgesia
• Avoid: Dismissing patient, unnecessary investigations (reinforces illness behavior), multiple specialist referrals

Important Information

• Factitious disorder vs Malingering: Internal motivation (sick role) vs External motivation (tangible gain)
• Conversion disorder has positive findings on examination (not just absence of neurological findings)
• BDD: Special mention - preoccupation with slight/imagined appearance defect; mirror checking or avoidance; "muscle dysmorphia" in men (preoccupation with muscularity); very high suicide risk; treat with SSRIs + CBT (ERP)

---

17. WOMEN AND MENTAL HEALTH

A. PREMENSTRUAL DYSPHORIC DISORDER (PMDD)

Definition

Etiopathogenesis / Risk Factors

• NOT a hormonal deficiency; abnormal sensitivity to normal fluctuations of ovarian hormones
• Allopregnanolone (progesterone metabolite) has paradoxical excitatory effect on GABA-A in PMDD
• Serotonin system sensitivity to estrogen/progesterone fluctuations
• Risk: FH, prior PMS/PMDD, depression/anxiety, stress, trauma, age 25-35 most commonly presenting

Clinical Features

• Marked affective lability (mood swings, sudden tearfulness)
• Marked irritability, anger, or interpersonal conflicts
• Markedly depressed mood, hopelessness, self-deprecating thoughts
• Marked anxiety, tension, feeling "keyed up" or "on edge"

• Decreased interest in usual activities
• Subjective difficulty concentrating
• Lethargy, easy fatigability, marked lack of energy
• Marked change in appetite; overeating; specific food cravings
• Hypersomnia OR insomnia
• Sense of being overwhelmed or out of control
• Physical symptoms: Breast tenderness/swelling, joint/muscle pain, "bloating," weight gain

• Daily Record of Severity of Problems (DRSP)
• Premenstrual Symptoms Screening Tool (PSST)

Diagnosis

• Prospective symptom diary (at least 2 cycles): Timing must correlate with luteal phase
• Rule out: PMDD exacerbation of another disorder (pre-existing anxiety/depression worsens premenstrually - premenstrual magnification) vs PMDD

Management

• SSRIs (first-line): Continuously OR luteal phase only (days 14-28) - both equally effective
  • Sertraline, fluoxetine (Sarafem), escitalopram, paroxetine
• OCP (combined): Drospirenone + ethinyl estradiol (Yaz/Yasmin) - suppresses ovulation; FDA-approved for PMDD
• GnRH agonists (leuprolide): Refractory cases; medical menopause; add-back HRT to prevent osteoporosis/vasomotor sx
• Calcium (1200mg/day): Evidence for reducing mood and physical symptoms
• Aerobic exercise, dietary modifications (↓ caffeine, salt, sugar, alcohol)
• CBT for cognitive coping

Important Information

• Responds rapidly to SSRIs (unlike depression; effect within first luteal phase - possibly due to allopregnanolone/GABA effect rather than serotonin)
• Distinguish PMDD from PMS: PMDD requires 5 symptoms including core affective symptom + functional impairment; confirmed prospectively
• Discontinuation of SSRIs after remission: PMDD often recurs

---

B. POSTPARTUM BLUES (BABY BLUES)

Definition

Etiopathogenesis / Risk Factors

• Rapid ↓ in estrogen and progesterone after placental delivery
• Sleep deprivation, psychosocial adjustment to new role
• Prevalence: 30-80% of all deliveries (most common postpartum response)

Clinical Features

• Onset: Days 3-5 (correlates with hormonal nadir)
• Tearfulness (disproportionate, unprovoked)
• Emotional lability (mood swings)
• Anxiety, irritability
• Difficulty sleeping even when baby sleeps
• Feeling overwhelmed; mild confusion
• NOT: Severe depression, psychosis, functional impairment, inability to care for self/baby
• Duration: Peaks by day 5; resolves by 10-14 days

Diagnosis

• Clinical; exclude PPD if symptoms persist >2 weeks or worsen
• EPDS screening at 2-4 weeks and 3-4 months postpartum

Management

• Reassurance and psychoeducation (very common, self-limiting, not a sign of failure)
• Practical support (family, partner involvement)
• Adequate sleep/rest
• No pharmacotherapy needed
• Monitor for progression to PPD (if symptoms persist >2 weeks, intensify, or functional impairment develops)

---

C. POSTPARTUM DEPRESSION (PPD)

Definition

Etiopathogenesis / Risk Factors

• Strongest RF: History of depression/PPD or depression during pregnancy
• Anxiety during pregnancy, recent stressful life events
• Poor social support, domestic violence, relationship difficulties
• Unplanned/unwanted pregnancy; neonatal complications (NICU)
• Thyroid dysfunction (postpartum thyroiditis)
• Low socioeconomic status; history of trauma/abuse
• Breastfeeding difficulties, sleep deprivation

Clinical Features

• Persistent low mood most of the day
• Anhedonia - inability to enjoy baby or other activities
• Energy loss, fatigue
• Sleep disturbance (beyond normal infant care disruption)
• Appetite/weight change
• Guilt (excessive, often about being a "bad mother")
• Concentration difficulty; difficulty making decisions
• Suicidal ideation

• Anxiety about baby's health/wellbeing (often excessive)
• Feelings of being a bad/inadequate mother
• Inability to bond with baby (important: different from indifference in psychosis)
• Intrusive ego-dystonic thoughts of harming baby (e.g., "What if I dropped the baby?") - patient is distressed by these thoughts, does not intend to act
• Anger/irritability (common; often more prominent than sadness)
• Social withdrawal, isolation
• Impact on infant: Poor attunement, development delays in child

Diagnosis

• EPDS (Edinburgh Postnatal Depression Scale): Most widely used; ≥10-13 = positive screen; question 10 asks about self-harm directly
• PHQ-9 can also be used
• TFTs (rule out postpartum thyroiditis)
• Screen at: Prenatal visits, 1-2 weeks postpartum, 1-month and 6-month checkups

Management

• Mild-Moderate: Psychotherapy first-line
  • CBT, IPT (Interpersonal Therapy) - both effective for PPD
  • Mother-infant therapy if bonding impaired
  • Peer support groups (other mothers with PPD)
• Moderate-Severe: Antidepressants + psychotherapy
  • SSRIs: Sertraline (lowest breast milk transfer, best studied), paroxetine (low breast milk); prefer over fluoxetine (active metabolite in breast milk)
  • Breastfeeding: Generally compatible with SSRI; benefits usually outweigh risks
• Novel pharmacotherapy:
  • Brexanolone (Zulresso): IV synthetic allopregnanolone (GABA-A modulator); FDA-approved 2019 specifically for PPD; rapid effect (within 60hr infusion); requires hospital monitoring
  • Zuranolone: Oral neuroactive steroid; FDA-approved 2023 for PPD; 14-day course; faster onset than SSRIs
• Social support mobilization; partner/family education
• Address practical barriers (sleep, childcare support)
• Do not advise stopping breastfeeding to take medication without careful discussion

Important Information

• Impacts not just mother but infant development (cognitive, emotional, behavioral)
• ~50% of PPD begins antenatally → screen during pregnancy too
• Recurrence risk: ~50% with subsequent pregnancy if prior PPD

---

D. POSTPARTUM PSYCHOSIS (PPP)

Definition

Etiopathogenesis / Risk Factors

• STRONGEST RF: Bipolar disorder (risk 20-30% developing PPP postpartum)
• Prior episode of PPP (~50% recurrence risk with future pregnancy)
• FH of bipolar disorder or PPP
• Primiparity (first birth)
• Sleep deprivation (acute trigger)
• Abrupt hormonal shift → destabilizes circadian/sleep-wake systems → precipitates mania in vulnerable

Clinical Features

• Confusion, perplexity, disorientation (often prominent; distinguishes from typical mania)
• Rapidly fluctuating, labile mood
• Manic features: Elation, grandiosity, decreased need for sleep, pressured speech, racing thoughts, disinhibition
• Psychotic features:
  • Delusions about baby (baby is specially gifted/divine, baby is not hers, baby is defective/damaged, baby must be harmed "to save them")
  • Command hallucinations
  • Paranoid delusions
• Depressive features: Severe depression, hopelessness, nihilism
• Agitation, restlessness, bizarre behavior
• Refusal to eat/drink
• HIGH RISK OF INFANTICIDE AND SUICIDE

• Sleep deprivation prominent
• May neglect self-care and infant

Diagnosis

• CLINICAL EMERGENCY: Requires immediate psychiatric assessment
• Exclude organic causes: Postpartum thyroiditis, autoimmune encephalitis (anti-NMDAR), infections, metabolic
• Bloods: TFTs, glucose, LFTs, renal, CBC, Ca, ammonia
• CT brain/LP if encephalitis suspected

Management

• Ideally Mother-Baby Unit (MBU): Allows treatment while maintaining mother-infant bond and breastfeeding support
• Safeguarding assessment: Baby must be safe; involve neonatology/pediatrics if needed
• Pharmacotherapy:
  • Antipsychotics: Haloperidol, olanzapine, quetiapine (control psychosis/agitation)
  • Mood stabilizers: Lithium (most evidence; reduces recurrence; stop breastfeeding if lithium used)
  • BZDs: Short-term for agitation/sleep
  • Antidepressants: If prominent depression (with antipsychotic cover)
• ECT: Highly effective and often preferred; rapid stabilization; safe in postpartum; especially for depressive PPP or treatment resistance
• Breastfeeding: Continue if possible (on quetiapine/antipsychotics); STOP if lithium used (infant toxicity risk)
• Close 1:1 nursing supervision; no unsupervised access to baby until risk decreases
• Family education and involvement

Important Information

• PPP vs PPD vs Blues (MOST TESTED COMPARISON):

• After recovery: Genetic counseling, discuss recurrence risk (~50% with next pregnancy if bipolar), lithium prophylaxis from delivery in high-risk women
• PPP is NOT just severe PPD - it is phenomenologically closer to bipolar disorder

---

IMPORTANT DRUG SAFETY IN PREGNANCY

1. Definition
2. Etiopathogenesis / Risk Factors
3. Clinical Features (detailed, with sub-points)
4. Diagnosis
5. Management
6. Important Information

• Depression, Bipolar Disorder
• ADHD, ODD, Conduct Disorder
• SLD, Enuresis, Sibling Rivalry + others
• Substance Use Disorders (alcohol, opioids, stimulants, cannabis)
• Behavioural Addictions (Gambling, Gaming)
• Schizophrenia + other psychotic disorders
• Elderly Psychiatry (depression, late-onset psychosis, delirium, BPSD)
• Psychiatric Emergencies (Suicide, DSH/NSSI, Violence, Serotonin syndrome, NMS, Anticholinergic toxidrome, Lithium toxicity)
• OCD + OC spectrum
• Sleep disorders (Insomnia, Narcolepsy, OSA, Parasomnias, RLS)
• Eating disorders (AN, BN, BED)
• Stress disorders (ASD, PTSD, Adjustment disorder)
• Anxiety disorders (GAD, Panic, Social anxiety, Specific phobia)
• Personality disorders (all 10 with features)
• Psychosomatic disorders (SSD, Illness anxiety, Conversion, Factitious, Malingering)
• Women's MH (PMDD, Baby Blues, PPD, PPP - detailed comparison table included)

• Focus on the comparison tables - examiners love asking Blues vs PPD vs PPP, NMS vs Serotonin Syndrome, Depression vs Dementia
• Know your mnemonics cold - SIGECAPS, DIG FAST, SAD PERSONS, CHESS, WATCHERS
• First-line treatments are high yield - CBT-I for insomnia, DBT for BPD, FBT for adolescent AN, ERP for OCD, TF-CBT/EMDR for PTSD
• Duration criteria trip many students up - keep that table handy