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🧠 MBBS PSYCHIATRY QUIZ PREPARATION

TOPIC 1: HISTORY OF PSYCHIATRY

College → Zone → State → National Level

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QUICK ORIENTATION

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PART 1: FULL CONCEPTUAL COVERAGE

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1. DEFINITION

• The term "psychiatry" was coined by Johann Christian Reil in 1808
• Before psychiatry, mental illness was managed by priests, philosophers, and later, "mad-doctors" (alienists)

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2. ERAS OF PSYCHIATRIC HISTORY

ERA 1 - Ancient/Pre-Scientific Era (Before 1800)

• Black bile = Melancholia (depression)
• Yellow bile = Choleric (irritability)
• Blood = Sanguine (cheerful)
• Phlegm = Phlegmatic (calm/sluggish)

• Black bile → Melancholia
• Blood → Sanguine
• Choleric → Yellow bile
• Phlegm → Phlegmatic

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ERA 2 - Reform Era / Moral Treatment (1790-1850)

Philippe Pinel (France, 1745-1826)

• "Father of Modern Psychiatry"
• In 1793, removed chains from patients at Bicetre Hospital (Paris)
• Later reformed Salpetriere Hospital (for women)
• Introduced "Traitement Moral" (Moral Treatment) - humane, non-restraint approach
• Wrote "Traité médico-philosophique sur l'aliénation mentale" (1801) - first psychiatric textbook
• Classified mental illness into: melancholia, mania, dementia, idiotism
• His student: Jean-Etienne Esquirol - coined the term "hallucination" (1817)

William Tuke (England, 1732-1822)

• Quaker reformer
• Founded York Retreat in 1796 - model humane asylum
• Non-medical approach emphasizing kindness and dignity

Dorothea Dix (USA, 1802-1887)

• American reformer
• Advocated for state mental hospitals across the USA
• Responsible for founding 32 state hospitals

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ERA 3 - Scientific Psychiatry / Nosological Era (1850-1950)

Wilhelm Griesinger (Germany, 1817-1868)

• "Mental diseases are brain diseases" (Geisteskrankheiten sind Gehirnkrankheiten)
• Founded the concept that psychiatry is part of neurology
• Coined the term "Einheitspsychose" (Unitary Psychosis) - all mental disorders are one disorder

Emil Kraepelin (Germany, 1856-1926) - THE MOST IMPORTANT NAME

• "Father of Modern Scientific Psychiatry" / "Father of Biological Psychiatry"
• In 1896/1899, made the most influential classification in psychiatric history:
  • Dementia Praecox (deteriorating course) → later renamed Schizophrenia by Bleuler
  • Manic-Depressive Insanity (episodic course)
• Used prognosis (outcome) as the basis for classification - revolutionary
• Wrote Lehrbuch der Psychiatrie (Textbook of Psychiatry) - 9 editions
• Founded the German Research Center for Psychiatry (Munich)
• Described Kraepelin's dichotomy - the two major psychoses
• Also described paranoia and paraphrenia as separate entities

Eugen Bleuler (Switzerland, 1857-1939)

• In 1911, renamed "Dementia Praecox" to "Schizophrenia" (schizein = split + phren = mind)
• Described 4 A's of Schizophrenia:
  • Affect (flattened)
  • Ambivalence
  • Autism
  • Association (loosening of)
• The above are "Fundamental/Primary symptoms" of schizophrenia
• Also described accessory symptoms: hallucinations, delusions (now considered primary in DSM-5)
• Coined the term "Autism" (1911)

• Affect, Autism, Ambivalence, Associations

Karl Jaspers (Germany, 1883-1969)

• Wrote "General Psychopathology" (1913) - bible of descriptive psychopathology
• Distinguished primary (not understandable, e.g., delusions) from secondary (understandable) symptoms
• Defined "un-understandable" as the hallmark of true psychosis

Kurt Schneider (Germany, 1887-1967)

• Described First-Rank Symptoms (FRS) of Schizophrenia (1959)
• 11 FRS: audible thoughts, voices arguing, voices commenting, somatic passivity, thought insertion, thought withdrawal, thought broadcasting, delusional perception, made affect, made impulse, made volition
• "If a FRS is present and no organic cause = Schizophrenia"

• Auditory hallucinations (3 types)
• Broadcasting of thought
• Commenting voices
• Delusion of perception
• Insertion/withdrawal of thought
• Made experiences (affect, impulse, volition)
• External control

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ERA 4 - Psychoanalytic Era (1890-1940)

Sigmund Freud (Austria, 1856-1939)

• Founded Psychoanalysis
• Key concepts:
  • Topographic model: Conscious, Preconscious, Unconscious
  • Structural model (1923): Id, Ego, Superego
  • Psychosexual stages: Oral → Anal → Phallic → Latency → Genital
  • Defense mechanisms: Repression, Projection, Displacement, etc.
  • Transference and Counter-transference
  • Free association technique
  • Dream analysis (Royal Road to the Unconscious)
• Key works: "The Interpretation of Dreams" (1900), "The Ego and the Id" (1923)
• Anna Freud (his daughter): developed ego psychology and defense mechanisms systematically

Carl Gustav Jung (Switzerland, 1875-1961)

• Broke from Freud
• Founded Analytical Psychology
• Key concepts: Collective Unconscious, Archetypes, Persona, Shadow, Anima/Animus
• Coined "Complex" and "Introvert/Extrovert"
• Word Association Test

Alfred Adler (Austria, 1870-1937)

• Broke from Freud
• Founded Individual Psychology
• Key concepts: Inferiority Complex, Compensation, Birth Order, Social interest
• Coined "Inferiority Complex" and "Superiority Complex"

Otto Rank (1884-1939) - Birth Trauma theory

Melanie Klein (1882-1960) - Object Relations Theory; paranoid-schizoid and depressive positions

Donald Winnicott (1896-1971) - "Good Enough Mother", Transitional Object

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ERA 5 - Biological/Pharmacological Revolution (1950-present)

1952 - Discovery of Chlorpromazine

• Henri Laborit (French surgeon) - noticed anti-anxiety properties during surgical anesthesia
• Jean Delay and Pierre Deniker - first used chlorpromazine to treat psychosis at Sainte-Anne Hospital, Paris
• "Thorazine" = brand name in USA
• This is considered the most important event in 20th century psychiatry
• Laborit described it as producing "artificial hibernation"
• Led to the Dopamine Hypothesis of Schizophrenia

1949 - Lithium

• John Cade (Australia) - discovered lithium's antimanic properties in 1949
• Mogens Schou (Denmark) - conducted first controlled trials, popularized use

1958 - Haloperidol

• Discovered by Paul Janssen (Belgium)

1958 - Imipramine (first TCA)

• Roland Kuhn (Switzerland) discovered imipramine's antidepressant effects
• Originally tested as antipsychotic

1952 - MAOIs

• Nathan Kline and John Crane - discovered iproniazid (first MAOI) had antidepressant effects (1957)
• Iproniazid originally an anti-TB drug

1960 - Chlordiazepoxide (Librium)

• Leo Sternbach (Roche) - first benzodiazepine
• Followed by diazepam (Valium, 1963) - became most prescribed drug in the world

1987 - Fluoxetine (Prozac)

• First SSRI, discovered by Bryan Molloy and David Wong at Eli Lilly
• Transformed treatment of depression globally

1990 - Clozapine revival

• Originally synthesized 1958, withdrawn 1975 due to agranulocytosis
• Reintroduced 1990 as "atypical" antipsychotic for treatment-resistant schizophrenia

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ERA 6 - Deinstitutionalization Era (1960-1980)

• 1963 - Community Mental Health Centers Act (USA, signed by President Kennedy)
• Mass discharge of psychiatric patients from state hospitals
• Led to "transinstitutionalization" - from hospitals to prisons and homeless shelters
• Thomas Szasz (1961) - "The Myth of Mental Illness" - controversial anti-psychiatry movement
• R.D. Laing (UK) - anti-psychiatry; schizophrenia as a "sane response to an insane world"

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3. CLASSIFICATION SYSTEMS - HISTORY

DSM History (USA)

ICD History (WHO)

• Gaming Disorder added (6C51)
• Complex PTSD added
• Prolonged Grief Disorder added
• "Schizophrenia" retained but changed duration criteria
• Personality disorders completely reorganized
• Gender incongruence moved OUT of mental disorders section (to sexual health)
• Removed intellectual disability as "mental retardation"

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4. INDIAN PSYCHIATRY HISTORY

Key Institutions

Key Indian Psychiatrists

• Indian Psychiatric Society (IPS) founded in 1947 (same year as Indian independence)
• Indian Journal of Psychiatry - oldest psychiatry journal in Asia
• Mental Healthcare Act 2017 - replaced Mental Health Act 1987; gives patients rights and autonomy; defines mental illness based on WHO principles

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5. FAMOUS EXPERIMENTS & CASES

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6. NOBEL PRIZES RELATED TO PSYCHIATRY

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7. KEY EPONYMS & SYNDROMES (Historical)

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8. KEY PSYCHOLOGICAL TESTS - HISTORICAL ORIGINS

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9. NEUROTRANSMITTER DISCOVERIES (Historical High-Yield)

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10. MENTAL HEALTH LAWS - HISTORICAL

• Gives every person right to access mental healthcare
• Prohibits electro-convulsive therapy (ECT) without anesthesia
• Decriminalizes suicide attempt (Section 115)
• Defines "mental illness" without using the term "mental disorder"
• Advance Directive allowed
• Nominated Representative concept
• Prohibits chaining of mentally ill persons
• Came into force: July 7, 2018

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11. TOP 20 HIGH-YIELD PEARLS - HISTORY OF PSYCHIATRY

1. "Psychiatry" coined by Johann Christian Reil (1808)
2. Hippocrates first proposed naturalistic theory of mental illness
3. Philippe Pinel unchained patients at Bicetre (1793) - moral treatment
4. Emil Kraepelin classified Dementia Praecox vs. Manic-Depressive Insanity (1896/1899)
5. Bleuler coined "Schizophrenia" (1911) + 4 A's
6. Schneider's FRS - First Rank Symptoms of schizophrenia
7. Freud's structural model - Id, Ego, Superego (1923)
8. Chlorpromazine first antipsychotic - Delay & Deniker (1952)
9. Lithium - John Cade (1949)
10. Imipramine - Roland Kuhn (1958) - first TCA
11. DSM-III (1980) = landmark; introduced criteria-based diagnosis
12. Homosexuality removed from DSM - 1973
13. DSM-5 (2013) - removed multi-axial; DSM-5-TR (2022) current
14. ICD-11 effective January 1, 2022
15. Nobel Prize - only psychiatrist: Wagner-Jauregg (1927) for malaria therapy
16. Rosenhan Experiment (1973) - "On Being Sane in Insane Places"
17. IPS (Indian Psychiatric Society) founded 1947
18. Mental Healthcare Act 2017 - suicide decriminalized, ECT without anesthesia prohibited
19. Ganser Syndrome - approximate answers (in prisoners)
20. Capgras, Cotard, Fregoli - three major delusional misidentification syndromes

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REVISION MNEMONICS

For Era Sequence: "Ancient People Reform Science Psycho Biology"

1. Ancient era
2. Pre-reform (Middle Ages)
3. Reform (Pinel, Tuke, Dix)
4. Scientific (Kraepelin, Bleuler)
5. Psychoanalytic (Freud, Jung, Adler)
6. Biological (Drugs, ECT)

For Chlorpromazine: "LDD - Laborit Discovers Delay Deploys"

• Laborit noticed it → Delay & Deniker deployed it clinically (1952)

For Kraepelin vs. Bleuler:

• Kraepelin = Kategorized (Dementia Praecox vs MDP)
• Bleuler = Baptized it Schizophrenia

For Nobel Prizes:

• Wagner-Jauregg = Worms (malaria parasites treated GPI) = 1927
• Moniz = Mutilated frontal lobe (lobotomy) = 1949

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PART 2: QUESTIONS (150 MCQs + SCENARIOS)

⚠️ DO NOT READ ANSWERS YET. ATTEMPT ALL QUESTIONS, THEN REPLY WITH YOUR ANSWERS.

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SECTION A: EASY MCQs (1-50)

• A) Hippocrates
• B) Johann Christian Reil
• C) Philippe Pinel
• D) Emil Kraepelin

• A) Salpetriere
• B) York Retreat
• C) Bicetre
• D) Bethlem Royal Hospital

• A) Emil Kraepelin
• B) Kurt Schneider
• C) Eugen Bleuler
• D) Karl Jaspers

• A) Kraepelin
• B) Bleuler
• C) Freud
• D) Jung

• A) Bleuler
• B) Kraepelin
• C) Kurt Schneider
• D) Jaspers

• A) Carl Jung
• B) Sigmund Freud
• C) Alfred Adler
• D) Otto Rank

• A) Haloperidol
• B) Lithium
• C) Chlorpromazine
• D) Imipramine

• A) Henri Laborit
• B) Jean Delay and Pierre Deniker
• C) Paul Janssen
• D) Roland Kuhn

• A) Mogens Schou
• B) John Cade
• C) Nathan Kline
• D) Paul Janssen

• A) Roland Kuhn
• B) Nathan Kline
• C) Leo Sternbach
• D) Bryan Molloy

• A) Diazepam
• B) Alprazolam
• C) Chlordiazepoxide
• D) Lorazepam

• A) Paul Janssen
• B) Roland Kuhn
• C) Leo Sternbach
• D) Nathan Kline

• A) Removed homosexuality
• B) Introduced diagnostic criteria
• C) Added multi-axial system
• D) Both B and C

• A) 1952
• B) 1968
• C) 1973
• D) 1980

• A) DSM-IV-TR
• B) DSM-5
• C) DSM-5-TR
• D) DSM-6

• A) January 1, 2019
• B) January 1, 2021
• C) January 1, 2022
• D) January 1, 2023

• A) Wagner-Jauregg
• B) Egas Moniz
• C) Eric Kandel
• D) Arvid Carlsson

• A) Schizophrenia with insulin coma
• B) Depression with ECT
• C) GPI (neurosyphilis) with malaria
• D) Mania with lithium

• A) Obedience to Authority
• B) On Being Sane in Insane Places
• C) The Stanford Prison Experiment
• D) The Milgram Study

• A) 1945
• B) 1947
• C) 1950
• D) 1954

• A) Sigmund Freud
• B) Alfred Adler
• C) Carl Jung
• D) Melanie Klein

• A) Freud
• B) Adler
• C) Jung
• D) Rank

• A) Kraepelin
• B) Pinel
• C) Hippocrates
• D) Bleuler

• A) Dorothea Dix
• B) Philippe Pinel
• C) William Tuke
• D) Benjamin Rush

• A) Freud
• B) Griesinger
• C) Kraepelin
• D) Bleuler

• A) 1905
• B) 1916
• C) 1921
• D) 1935

• A) Herman Rorschach
• B) Henry Murray
• C) David Wechsler
• D) Alfred Binet

• A) 1900
• B) 1905
• C) 1916
• D) 1943

• A) 1896
• B) 1899
• C) 1911
• D) 1923

• A) Belief one is dead
• B) Delusion of parasitosis
• C) Belief a person is replaced by an impostor
• D) Approximate answers to questions

• A) Morbid jealousy
• B) Nihilistic delusions (belief one is dead)
• C) Shared delusions
• D) Visual agnosia

• A) Visual hallucinations
• B) Approximate answers (Vorbeireden)
• C) Morbid jealousy
• D) Nihilistic delusions

• A) 1975
• B) 1980
• C) 1987
• D) 1992

• A) Jean Delay
• B) Roland Kuhn
• C) Paul Janssen
• D) Leo Sternbach

• A) Aaron Beck
• B) Martin Seligman
• C) B.F. Skinner
• D) Ivan Pavlov

• A) 1912
• B) 1987
• C) 2017
• D) 2018

• A) Allowed in emergencies
• B) Prohibited
• C) Allowed for children
• D) Allowed with patient consent

• A) Two doctors diagnosing the same patient differently
• B) A shared delusional disorder between two people
• C) A patient with two personalities
• D) Double-blind study in psychiatry

• A) Food in attachment
• B) Contact comfort in attachment
• C) Peer relationships
• D) Operant conditioning

• A) Stanley Milgram
• B) Philip Zimbardo
• C) Solomon Asch
• D) Leon Festinger

• A) Calcutta (1817)
• B) Madras (1787)
• C) Bombay (1745)
• D) Ranchi (1918)

• A) N.S. Vahia
• B) L.P. Varma
• C) Vidya Sagar
• D) M.V. Govindaswamy

• A) ICD-4
• B) ICD-6
• C) ICD-8
• D) ICD-9

• A) DSM-5
• B) DSM-5-TR
• C) ICD-10
• D) ICD-11

• A) Etiology
• B) Pathology
• C) Prognosis/course
• D) Symptoms at onset

• A) "Mind doctor"
• B) "Soul healer"
• C) "Brain physician"
• D) "Nerve specialist"

• A) Freud
• B) Jung
• C) Melanie Klein
• D) Erik Erikson

• A) Melanie Klein
• B) Donald Winnicott
• C) Anna Freud
• D) John Bowlby

• A) Malaria
• B) Tuberculosis
• C) Hypertension
• D) Epilepsy

• A) The role of contact comfort
• B) Obedience to authority
• C) Social conformity
• D) Learned helplessness

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SECTION B: MODERATE MCQs (51-100)

• A) Age of onset
• B) Symptom profile
• C) Long-term prognosis and course
• D) Response to treatment

• A) Hallucinations, delusions, thought disorder, catatonia
• B) Affective flattening, ambivalence, autism, association disturbance
• C) Auditory hallucinations, passivity phenomena, thought alienation
• D) Negative symptoms, positive symptoms, cognitive symptoms

• A) Thought insertion
• B) Audible thoughts
• C) Visual hallucinations
• D) Somatic passivity

• A) Classification of psychoses
• B) General Psychopathology and descriptive phenomenology
• C) Psychoanalytic theory
• D) Introduction of rating scales

• A) Kraepelin
• B) Griesinger
• C) Bleuler
• D) Morel

• A) Bleuler
• B) Griesinger
• C) Morel (as "démence précoce")
• D) Pinel

• A) Freud and Jung
• B) Thomas Szasz and R.D. Laing
• C) Kraepelin and Bleuler
• D) Delay and Deniker

• A) Franklin Roosevelt
• B) Harry Truman
• C) John F. Kennedy
• D) Lyndon Johnson

• A) His results could not be replicated
• B) Deliberate infection with malaria is now considered unethical
• C) He shared it with another psychiatrist
• D) It was based on animal experiments

• A) Tardive dyskinesia
• B) Agranulocytosis
• C) Seizures
• D) Prolonged QT interval

• A) Repression
• B) Displacement
• C) Projection
• D) Reaction formation

• A) Oral
• B) Anal
• C) Phallic
• D) Genital

• A) Hoarding Disorder
• B) Prolonged Grief Disorder
• C) Gaming Disorder
• D) Binge Eating Disorder

• A) Mental and behavioral disorders
• B) Conditions related to sexual health
• C) Neurological conditions
• D) Endocrine disorders

• A) Indian Lunacy Act 1912
• B) Mental Health Act 1987
• C) Mental Healthcare Act 2017
• D) IPC Section 309

• A) Schizophrenia is caused by low socioeconomic status
• B) People with schizophrenia drift down the social ladder due to illness
• C) Social factors cause schizophrenia more than genetic factors
• D) Urban migration causes schizophrenia

• A) Frontal lobe
• B) Parietal lobe
• C) Temporal lobe (bilateral)
• D) Occipital lobe

• A) In Fregoli, different people are same person; in Capgras, same person is replaced
• B) Fregoli is a mood disorder; Capgras is a psychosis
• C) Fregoli involves visual hallucinations; Capgras does not
• D) Capgras is culture-bound; Fregoli is not

• A) Kanner (for childhood autism)
• B) Asperger (for high-functioning autism)
• C) Bleuler (as a symptom of schizophrenia)
• D) Freud

• A) Discovery of serotonin
• B) Discovery of dopamine and its role in Parkinson's disease
• C) Development of SSRI drugs
• D) Discovery of endorphins

• A) Ethical guidelines for psychiatrists
• B) Treatment based on religion and morality
• C) Humane, non-restraint treatment emphasizing dignity
• D) Legal/court-ordered treatment

• A) 1921
• B) 1935
• C) 1943
• D) 1955

• A) Monkeys with surrogate mothers
• B) Dogs unable to escape unavoidable shocks
• C) Rats in maze tests
• D) Humans in prison simulations

• A) First hospital to use chlorpromazine
• B) It was one of the earliest hospitals for mental illness and became synonymous with chaotic conditions
• C) Pinel unchained patients here
• D) First hospital to offer psychoanalysis

• A) Indian Penal Code Section 309 (2018 amendment)
• B) Mental Healthcare Act 2017, Section 115
• C) Criminal Procedure Code amendment 2016
• D) NDPS Act

• A) Bleuler
• B) Kraepelin
• C) Schneider
• D) Jaspers

• A) Drosophila
• B) Aplysia (sea slug)
• C) Rhesus monkeys
• D) Mice

• A) Ivan Pavlov
• B) John Watson
• C) B.F. Skinner
• D) Albert Bandura

• A) Alfred Binet
• B) William Stern
• C) Lewis Terman
• D) David Wechsler

• A) 2
• B) 3
• C) 4
• D) 5

• A) Freud
• B) Jung
• C) Otto Rank
• D) Adler

• A) John Bowlby
• B) Mary Ainsworth
• C) Melanie Klein
• D) Donald Winnicott

• A) Aaron Beck
• B) Albert Ellis
• C) B.F. Skinner
• D) Joseph Wolpe

• A) Skinner
• B) Bandura
• C) Joseph Wolpe
• D) Beck

• A) Aaron Beck
• B) Albert Ellis
• C) Albert Bandura
• D) Martin Seligman

• A) Mumbai
• B) Chennai
• C) Hyderabad
• D) Bangalore

• A) EEG findings
• B) Effects of chlorpromazine and amphetamine
• C) MRI brain studies
• D) Genetic linkage studies

• A) 25%
• B) 40%
• C) 65%
• D) 80%

• A) Life instinct (Eros)
• B) Death instinct/drive
• C) Sexual energy (libido)
• D) Anxiety

• A) Contains only repressed memories
• B) Is unique to each individual
• C) Is shared across humanity and contains archetypes
• D) Is accessible through free association

• A) Adolescence
• B) First 3 months of life
• C) Ages 2-3 years
• D) School age

• A) 1938
• B) 1948
• C) 1955
• D) 1960

• A) Conversion Disorder
• B) Somatic Symptom Disorder
• C) Illness Anxiety Disorder
• D) Functional Neurological Symptom Disorder

• A) 6C51
• B) F63.0
• C) 6A20
• D) F91.0

• A) Founding first psychiatric institution in USA
• B) Advocating for humane treatment, leading to establishment of 32 state hospitals
• C) Developing first psychometric test
• D) Discovering chlorpromazine

• A) Freud
• B) William Cullen (1769)
• C) Kraepelin
• D) Bleuler

• A) Ugo Cerletti and Lucio Bini (1938)
• B) Ladislas Meduna (1934, using camphor)
• C) Manfred Sakel (1927, insulin coma)
• D) Egas Moniz (1936)

• A) Ugo Cerletti
• B) Manfred Sakel (1927)
• C) Ladislas Meduna
• D) Freeman and Watts

• A) Egas Moniz
• B) Walter Freeman and James Watts (1936)
• C) Ugo Cerletti
• D) John Fulton

• A) Walter Freeman (USA)
• B) Egas Moniz (Portugal, 1935)
• C) John Fulton (UK)
• D) Manfred Sakel (Austria)

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SECTION C: DIFFICULT MCQs (101-150)

• A) 3rd edition (1889)
• B) 5th edition (1896) - first introduction of dementia praecox
• C) 6th edition (1899) - manic-depressive vs dementia praecox
• D) Both B and C are correct for different aspects

• A) It established community mental health centers
• B) It established criteria for involuntary commitment to psychiatric facilities
• C) It legalized ECT
• D) It decriminalized drug use for psychiatric patients

• A) Personality disorders (development) vs. Schizophrenia (process)
• B) Neurosis vs. Psychosis
• C) Depression vs. Mania
• D) Organic vs. Functional psychosis

• A) Freud
• B) Kraepelin
• C) Hubert Boirac (coined the term, 1876)
• D) Bleuler

• A) Pavlov
• B) Watson
• C) Skinner
• D) Bandura

• A) L.P. Varma
• B) M.V. Govindaswamy
• C) N.S. Vahia
• D) Vidya Sagar

• A) Freud
• B) Pierre Janet
• C) Kraepelin
• D) Bleuler

• A) To explain Kraepelin's dichotomy
• B) To reconcile genetic vulnerability with environmental triggers
• C) To explain the dopamine hypothesis
• D) To describe the effects of early trauma

• A) Bleuler (1911) → Kraepelin (1896) → Schneider (1959)
• B) Kraepelin (1896) → Bleuler (1911) → Schneider (1959)
• C) Schneider (1959) → Kraepelin (1896) → Bleuler (1911)
• D) Bleuler (1911) → Schneider (1959) → Kraepelin (1896)

• A) Sleep apnea in psychiatric patients
• B) Cyclical nature of bipolar disorder (Kraepelin's analogy)
• C) Anxiety-induced hyperventilation
• D) Terminal event in catatonia

• A) Founding the first American asylum
• B) Writing the first American textbook on psychiatry ("Medical Inquiries on Diseases of the Mind," 1812)
• C) Discovering lithium
• D) Founding the American Psychiatric Association

• A) National Institute of Mental Health (NIMH)
• B) American Psychological Association (APA)
• C) American Psychiatric Association (APA)
• D) American Academy of Child Psychiatry

• A) F00-F99
• B) 6A00-6E8Z
• C) 300-309
• D) Z00-Z99

• A) France
• B) USA
• C) Scotland (Sir Arthur Mitchell, 1864)
• D) Germany

• A) 10
• B) 38
• C) 100
• D) 450

• A) Transfer of patients between different psychiatric hospitals
• B) Movement of mentally ill from asylums to prisons and homeless shelters after deinstitutionalization
• C) International transfer of psychiatric patients
• D) Cross-cultural differences in psychiatric diagnosis

• A) Paul Broca
• B) Jean-Martin Charcot
• C) John Hughlings Jackson
• D) Pierre Janet

• A) Ida Bauer (Dora)
• B) Bertha Pappenheim
• C) Emma Eckstein
• D) Sabina Spielrein

• A) Freud
• B) George Miller Beard (1869)
• C) Janet
• D) Kraepelin

• A) Sublimation: directing unacceptable impulses to acceptable activities (CORRECT)
• B) Reaction Formation: unconsciously forgetting traumatic events
• C) Projection: expressing opposite of true feelings
• D) Displacement: attributing own feelings to others

• A) Aaron Beck
• B) Jerome Frank
• C) George Engel
• D) Thomas Szasz

• A) Freud
• B) George Engel (1977)
• C) Thomas Szasz
• D) Adolf Meyer

• A) Adolf Meyer
• B) Freud
• C) Kraepelin
• D) Griesinger

• A) 1947
• B) 1950
• C) 1961
• D) 1971

• A) During pregnancy only
• B) During pregnancy or within 4 weeks of delivery
• C) During the last trimester or within 4 weeks of delivery (previously; now: "during pregnancy or in the 4 weeks following delivery")
• D) Within 6 weeks of delivery only

• A) The patient's neurosis being transferred to the analyst
• B) Intensification of transference into a new artificial neurosis during analysis
• C) The analyst's emotional reaction to the patient
• D) A neurosis caused by transference

• A) ECT vs. pharmacotherapy
• B) Imipramine, CBT, IPT, and placebo
• C) Lithium vs. valproate
• D) SSRIs vs. TCAs

• A) Freud
• B) Kraepelin
• C) Bleuler
• D) Schneider

• A) Id, Ego, Superego
• B) Conscious, Preconscious, Unconscious
• C) Eros, Thanatos, Libido
• D) Primary process, Secondary process, Tertiary process

• A) Prosopagnosia
• B) Visual agnosia
• C) Alexithymia
• D) Anosognosia

• A) 5
• B) 12
• C) 20
• D) 30

• A) Indian Lunacy Act 1912
• B) Mental Health Act 1987
• C) Mental Healthcare Act 2017
• D) Both B and C

• A) Literal stone operations depicted by Hieronymus Bosch
• B) Ancient Greek surgical texts
• C) Medieval Islamic medicine
• D) Egyptian papyri

• A) Secure
• B) Anxious-avoidant
• C) Anxious-ambivalent
• D) Disorganized (Main & Solomon, 1986)

• A) Thomas Szasz
• B) Loren Mosher
• C) R.D. Laing
• D) David Rosenhan

• A) Kraepelin
• B) Benedict Morel (1857)
• C) Griesinger
• D) Bleuler

• A) Bleuler
• B) Kraepelin
• C) Kretschmer
• D) Schneider

• A) Explaining vs. Understanding (Erklären vs. Verstehen)
• B) Primary vs. Secondary symptoms
• C) Positive vs. Negative symptoms
• D) Axis I vs. Axis II disorders

• A) NIMH founding (1949)
• B) Kennedy's Community Mental Health Centers Act (1963)
• C) Dix's asylum reform (1840s)
• D) Mental Healthcare Act 2017

• A) "Madness and Civilization"
• B) "The Myth of Mental Illness"
• C) "Asylums" - described total institutions
• D) "Sanity, Madness and the Family"

• A) Complete symptomatic remission
• B) Medication adherence
• C) Living a meaningful life despite symptoms
• D) Returning to pre-morbid functioning

• A) 5HT2A antagonism
• B) Dopamine D2 receptor blockade
• C) Inhibition of dopamine synthesis
• D) Norepinephrine reuptake inhibition

• A) Kraepelin
• B) Zubin and Spring (1977)
• C) Bleuler
• D) Gottesman and Shields

• A) Insulin coma (1927) → ECT (1938) → Lobotomy (1935) → Chlorpromazine (1952)
• B) Lobotomy (1935) → Insulin coma (1927) → ECT (1938) → Chlorpromazine (1952)
• C) Insulin coma (1927) → Lobotomy (1935) → ECT (1938) → Chlorpromazine (1952)
• D) ECT (1938) → Insulin coma (1927) → Lobotomy (1935) → Chlorpromazine (1952)

• A) Who first discovered antimanic properties (Cade, 1949) vs. who proved efficacy in trials (Schou)
• B) Toxicity of lithium in different preparations
• C) The naming of lithium treatment
• D) Priority dispute over Nobel Prize

• A) Vaughn and Leff
• B) George Brown (1958) - original study; Vaughn & Leff (1976) - replicated
• C) Zubin and Spring
• D) Leff and Wing

• A) Schizophrenia is more common in developing countries
• B) Schizophrenia has a better prognosis in developing countries
• C) Schizophrenia is a culture-bound syndrome
• D) Schizophrenia is more severe in developed countries

• A) Strauss and Carpenter (1974)
• B) Timothy Crow (1980)
• C) John Hughlings Jackson (original concept)
• D) Both A and B, with Crow's Type I/II being the most quoted

• A) 1980s
• B) 1990-1999
• C) 2000s
• D) 2010-2019

• A) Only a family member
• B) A person appointed by the patient or a family member if patient cannot
• C) Only a doctor
• D) Only a lawyer

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SECTION D: CLINICAL SCENARIO QUESTIONS (151-200)

• A) Cotard syndrome - Jules Cotard (1880)
• B) Capgras syndrome - Joseph Capgras (1923)
• C) Fregoli syndrome - Courbon and Fail (1927)
• D) Ekbom syndrome - Karl-Axel Ekbom (1938)

• A) Mental Healthcare Act 2017, Section 115 - rebuttable presumption of mental illness in suicide attempt
• B) Mental Health Act 1987, Section 30
• C) IPC Section 84
• D) CrPC Section 328

• A) Bicetre, Paris
• B) Salpetriere, Paris
• C) Bethlem Royal Hospital (Bedlam), London
• D) York Retreat, England

• A) Allowed in life-threatening emergencies
• B) Absolutely prohibited in all circumstances
• C) Allowed if two psychiatrists agree
• D) Allowed if nominated representative consents

• A) Capgras syndrome
• B) Intermetamorphosis
• C) Fregoli syndrome
• D) Subjective doubles syndrome

• A) Malingering
• B) Pseudodementia
• C) Ganser syndrome (Vorbeireden)
• D) Factitious disorder

• A) Milgram Experiment (1963)
• B) Stanford Prison Experiment (1971) by Philip Zimbardo
• C) Rosenhan Experiment (1973)
• D) Harlow's Monkey Experiment (1950s)

• A) Wernicke-Korsakoff; mammillary bodies and thalamus
• B) Kluver-Bucy syndrome; bilateral temporal lobes (amygdala)
• C) Balint syndrome; bilateral parieto-occipital cortex
• D) Frontal lobe syndrome; bilateral prefrontal cortex

• A) Validity of psychiatric diagnoses
• B) Safety of psychiatric hospitals
• C) Ethics of ECT
• D) Effectiveness of antipsychotics

• A) Capgras syndrome
• B) Othello syndrome
• C) Cotard syndrome (le délire de négation)
• D) Folie à deux

• A) Paranoid schizophrenia in both
• B) Shared delusional disorder (Folie à deux)
• C) Paranoid personality disorder
• D) Delusional disorder, persecutory type, in both

• A) Dorothea Dix
• B) Benjamin Rush - "Medical Inquiries and Observations upon the Diseases of the Mind" (1812)
• C) Adolf Meyer
• D) William Tuke

• A) 1965
• B) 1970
• C) 1975
• D) 1980

• A) Freud won for psychoanalysis
• B) Kandel won for discovery of dopamine
• C) Wagner-Jauregg (1927) is the only psychiatrist to have won the Nobel Prize in Medicine
• D) Moniz won for ECT

• A) Second-rank symptom
• B) First-rank symptom - audible thoughts (Gedankenlautwerden)
• C) Fundamental symptom (Bleuler)
• D) Accessory symptom (Bleuler)

• A) iv, iii, ii, i
• B) iii, iv, ii, i
• C) iv, i, iii, ii
• D) ii, iii, iv, i

• A) From husband alone
• B) From woman herself (she has decisional capacity)
• C) From nominated representative
• D) From mental health review board

• A) Conditioning anxiety
• B) Learned helplessness (Martin Seligman) - model for depression
• C) Operant conditioning failure
• D) Anhedonia

• A) Vaughn and Leff (1976), originally proposed by George Brown (1958)
• B) Wing and Cooper
• C) Zubin and Spring
• D) Leff and Vaughn

• A) Epidemiological Catchment Area (ECA) Study
• B) International Pilot Study of Schizophrenia (IPSS, WHO, 1973)
• C) CATIE Trial
• D) National Comorbidity Survey

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SECTION E: IMAGE-BASED QUESTIONS (171-195)

• A) Introduced chlorpromazine
• B) Described dementia praecox and manic-depressive insanity
• C) Unchained psychiatric patients
• D) Coined the term psychiatry (Answer relates to Kraepelin)

• A) York Retreat, England
• B) Bethlem Hospital, London
• C) Bicetre Hospital, Paris
• D) Charenton Hospital, Paris

• A) Kraepelin's Munich clinic
• B) Sigmund Freud's consulting room (psychoanalysis setting)
• C) A behavior therapy room
• D) A CBT session room

• A) Thematic Apperception Test
• B) Bender Gestalt Test
• C) Rorschach Inkblot Test
• D) MMPI

• A) Freud's topographic model only
• B) Freud's structural model combined with topographic model
• C) Jung's model of the psyche
• D) Adler's Individual Psychology model

• A) Haloperidol
• B) Clozapine
• C) Chlorpromazine
• D) Imipramine

• A) Frontal lobe syndrome
• B) Kluver-Bucy Syndrome
• C) Balint Syndrome
• D) Korsakoff Syndrome

• A) Anna Freud
• B) Melanie Klein
• C) Dorothea Dix
• D) Mary Ainsworth

• A) Classical conditioning
• B) Operant conditioning
• C) Systematic desensitization
• D) Social learning

• A) M00-M99
• B) 6A00-6E8Z
• C) G00-G99
• D) Z00-Z99

• A) Imprinting theory
• B) Operant conditioning (food = reinforcer)
• C) Contact comfort > food in attachment (Harlow's study)
• D) Social learning theory

• A) Classical fear conditioning
• B) Learned helplessness (Seligman)
• C) Punishment in operant conditioning
• D) Extinction of conditioned response

• A) 100,000 copies, sold immediately
• B) 600 copies, took 8 years to sell
• C) 5,000 copies
• D) 2,500 copies

• A) Schizophrenia with insulin
• B) General Paralysis of the Insane (GPI - neurosyphilis) with malaria fever
• C) Depression with ECT
• D) Catatonia with barbiturates

• A) National Institute of Mental Hygiene and Neurological Sciences
• B) National Institute of Mental Health and Neuro Sciences
• C) National Institute of Mood, Health And Neuro Sciences
• D) National Institute of Medical Health and Neuropsychiatric Studies

• A) Prohibited
• B) Allowed in emergencies
• C) Allowed in children with parental consent
• D) Allowed when patient is unconscious

• A) Insulin coma therapy
• B) Malaria fever therapy for GPI (Wagner-Jauregg)
• C) Hyperthermia for depression
• D) Typhoid fever therapy for schizophrenia

• A) First DSM to list mental disorders
• B) Introduced the multiaxial system and operationalized diagnostic criteria
• C) Removed the multiaxial system
• D) Added biological tests for diagnosis

• A) Introduction of ECT
• B) Moral treatment - removal of chains from mental patients (Bicetre, 1793)
• C) Discovery of chlorpromazine
• D) Deinstitutionalization movement

• A) MCI (Medical Council of India)
• B) IPS (Indian Psychiatric Society)
• C) ICMR
• D) Ministry of Health

• A) ICD-10
• B) ICD-11
• C) DSM-5-TR
• D) WHO Mental Health Action Plan

• A) It is faster than hypnosis
• B) Freud abandoned hypnosis after seeing its limitations, and used free association instead
• C) Patients refused hypnosis
• D) It is more ethical than hypnosis

• A) Carl Jung
• B) Alfred Adler
• C) Sigmund Freud
• D) Josef Breuer

• A) Delay and Deniker (1952)
• B) Carlsson and Lindquist (1963)
• C) Paul Janssen (1958)
• D) Seeman and Lee (1975)

• A) NIMHANS
• B) Indian Psychiatric Society
• C) Indian Journal of Psychiatry
• D) Indian Council of Medical Research

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PREVIOUS-YEAR / NEET-PG / INI-CET STYLE QUESTIONS (196-225)

• A) Delusion of reference
• B) Capgras delusion (delusional misidentification)
• C) Persecutory delusion
• D) Cotard delusion

• A) Believing one is dead
• B) Giving approximate/near-miss answers (Vorbeireden)
• C) Morbid jealousy
• D) Parasitosis delusion

• A) Auditory hallucinations are fundamental
• B) The 4 A's are Affect, Ambivalence, Autism, Associations
• C) Delusions are fundamental
• D) First-rank symptoms are Bleuler's contribution

• A) Haloperidol
• B) Reserpine
• C) Chlorpromazine
• D) Thioridazine

• A) Benjamin Rush
• B) Emil Kraepelin
• C) Philippe Pinel
• D) William Tuke

• A) IPC amendment 2014
• B) Mental Healthcare Act 2017, Section 115
• C) CrPC amendment 2016
• D) NDPS Act 2001

• A) Kraepelin
• B) Bleuler
• C) Morel (as démence précoce)
• D) Griesinger

• A) F63.0
• B) 6C51
• C) F91.8
• D) 6A20

• A) Lobotomy
• B) Malaria fever therapy for GPI
• C) Insulin coma therapy
• D) ECT

• A) 1975
• B) 1980
• C) 1987
• D) 1992

• A) Social conformity
• B) Obedience to authority
• C) Aggression under stress
• D) Bystander effect

• A) Appointed by court
• B) A registered psychiatric nurse
• C) A person appointed by patient to act on their behalf
• D) Always the next of kin

• A) It validated psychiatric diagnostic criteria
• B) It showed that psychiatric staff cannot distinguish sane from insane
• C) It proved ECT is effective
• D) It demonstrated high sensitivity of DSM-II

• A) Thought broadcasting
• B) Somatic passivity
• C) Visual hallucinations
• D) Made volition

1. Philippe Pinel → ?
2. Eugen Bleuler → ?
3. Emil Kraepelin → ?
4. Kurt Schneider → ?

• A) 1-Moral Treatment; 2-Schizophrenia & 4A's; 3-Dementia Praecox/MDP; 4-FRS
• B) 1-First antipsychotic; 2-Dementia Praecox; 3-Schizophrenia; 4-4A's
• C) 1-Psychoanalysis; 2-Moral Treatment; 3-FRS; 4-Schizophrenia
• D) 1-IQ testing; 2-Neurotransmitters; 3-EEG; 4-MRI

• A) Psychoanalysis → ECT → DSM-I → Chlorpromazine
• B) Psychoanalysis → DSM-I → ECT → Chlorpromazine
• C) ECT → Psychoanalysis → Chlorpromazine → DSM-I
• D) DSM-I → Psychoanalysis → ECT → Chlorpromazine

• A) Lobotomy (Moniz, 1949) - Moniz was a neurologist
• B) Malaria fever therapy - Wagner-Jauregg (1927) - psychiatrist
• C) Memory research - Eric Kandel (2000) - psychiatrist/neuroscientist
• D) MRI development - Lauterbur (2003)

• A) Grandiose delusion
• B) Capgras syndrome
• C) Cotard syndrome
• D) Nihilistic personality

• A) New York
• B) Geneva
• C) London
• D) Paris

• A) Mental and behavioral disorders (Chapter 6)
• B) Conditions related to sexual health (Chapter 17)
• C) Endocrine disorders (Chapter 5)
• D) Neurological conditions (Chapter 8)

• A) Ivan Pavlov
• B) John Watson
• C) B.F. Skinner
• D) Albert Bandura

• A) L.P. Varma
• B) Vidya Sagar (family involvement, Amritsar)
• C) N.S. Vahia
• D) M.V. Govindaswamy

• A) Placing mental patients in hotels
• B) Community placement of patients with families outside asylums
• C) Boarding schools for mentally ill children
• D) Treatment in general hospitals

• A) DSM-5 only
• B) ICD-11 (as a new category)
• C) DSM-5-TR
• D) ICD-10 revision

• A) Emil Kraepelin
• B) Karl Jaspers
• C) Eugen Bleuler
• D) Wilhelm Griesinger

• A) WHO
• B) American Psychological Association
• C) American Psychiatric Association
• D) National Institute of Mental Health

• A) Repressed childhood memories
• B) Sexual drives
• C) Universal inherited archetypes (Jung)
• D) Ego defense mechanisms

• A) Adolf Meyer (1917)
• B) George Engel (1977)
• C) Freud (1923)
• D) Thomas Szasz (1960)

• A) 1990
• B) 2000
• C) 2010
• D) 2020

• A) Always false beliefs
• B) "Un-understandable" from the patient's personality and circumstances (not derivable by empathy)
• C) Always accompanied by hallucinations
• D) Always mood-congruent

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ONE-PAGE RAPID REVISION SHEET - HISTORY OF PSYCHIATRY

ERAS: Ancient (humoral) → Reform (Pinel 1793) → Scientific (Kraepelin 1896) → 
      Psychoanalytic (Freud 1900) → Biological (Chlorpromazine 1952) → 
      Community (Kennedy 1963) → Modern (DSM-5 2013, ICD-11 2022)

KEY PEOPLE:
• Pinel (1793) = Unchained patients, Bicetre, Moral Treatment
• Kraepelin (1896/99) = Dementia Praecox vs MDP, prognosis-based
• Bleuler (1911) = Coined Schizophrenia, 4 A's, coined Autism
• Schneider = FRS (11 symptoms)
• Freud = Psychoanalysis, Id/Ego/Superego, Unconscious
• Jung = Collective Unconscious, Archetypes, Introvert/Extrovert
• Adler = Inferiority Complex
• Delay/Deniker (1952) = First use of Chlorpromazine
• John Cade (1949) = Lithium
• Roland Kuhn (1958) = Imipramine (first TCA)
• Paul Janssen (1958) = Haloperidol
• Leo Sternbach = Chlordiazepoxide (first BZD)

DRUGS (chronology):
Insulin coma (Sakel, 1927) → Lobotomy (Moniz, 1935) → ECT (Cerletti+Bini, 1938) → 
Lithium (Cade, 1949) → Chlorpromazine (1952) → Haloperidol (1958) → 
Imipramine (1958) → BZD (1960) → Fluoxetine (1987) → Clozapine re-intro (1990)

DSM: I(1952) → II(1968) → III(1980)★ → IIIR → IV(1994) → IVR → 5(2013) → 5-TR(2022)
ICD: ICD-6(1948, first mental) → ICD-10(1992) → ICD-11(2022★)

EPONYMS: Capgras=impostor, Cotard=dead, Fregoli=same person, Ganser=approx answers, 
         Ekbom=parasitosis, Othello=jealousy, Kluver-Bucy=bilateral temporal

LAWS: India: Lunacy(1858) → Indian Lunacy(1912) → MHA(1987) → MHCA(2017★)
      MHCA 2017: Suicide decriminalized(S.115), ECT without anesthesia BANNED

NOBEL: Wagner-Jauregg (1927) = ONLY psychiatrist = malaria for GPI
       Moniz (1949) = lobotomy (neurologist)
       Kandel (2000) = Aplysia/memory

IPS = 1947 | NIMHANS = Bangalore

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🎯 REPLY WITH YOUR ANSWERS NOW!

1. Check every answer
2. Explain WHY each correct answer is right
3. Explain WHY each wrong option is wrong
4. Give memory tricks for every answer

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🧠 MBBS PSYCHIATRY QUIZ PREPARATION

COMPLETE DISEASES & DISORDERS GUIDE

Topics 2 through 12 — Full Teaching + MCQ Practice

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⚠️ HOW TO USE THIS GUIDE: Read the full explanation for each disorder first. Then attempt the MCQs WITHOUT looking at answers. Write your answers, then check against the answer key provided at the end of each section. This mirrors real quiz conditions.

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TOPIC 2: SCHIZOPHRENIA & PSYCHOTIC DISORDERS

═══════════════════════════════════════

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PART A — FULL CONCEPTUAL TEACHING

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1. WHAT IS SCHIZOPHRENIA? (Definition)

• Thought (delusions, disorganization)
• Perception (hallucinations)
• Affect (blunted, flat)
• Behavior (bizarre, catatonic)
• Cognition (memory, attention, executive function)

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2. EPIDEMIOLOGY (Numbers to memorize)

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3. ETIOLOGY — THE BIG FOUR

A. Genetic Factors

• Heritability: ~80% (high genetic component)
• Polygenic — no single gene; copy number variants (CNVs) like 22q11 deletion important
• 22q11.2 microdeletion syndrome (DiGeorge Syndrome) = high risk for schizophrenia (20-30%)
• DISC1 (Disrupted in Schizophrenia 1) gene on chromosome 1q42

B. Neurodevelopmental Theory

• "Two-hit model": Genetic predisposition (hit 1) + environmental insult (hit 2)
• Prenatal insults: influenza in 2nd trimester, malnutrition, obstetric complications
• Perinatal hypoxia is a major risk factor
• Evidence: winter birth effect - maternal influenza exposure during gestation

C. Neurotransmitter Hypotheses (MOST QUIZ-TESTED)

• Positive symptoms = Excess dopamine in mesolimbic pathway (D2 hyperactivity)
• Negative/cognitive symptoms = Reduced dopamine in mesocortical pathway (D1 hypoactivity in prefrontal cortex)
• Evidence: Amphetamine (increases DA) → causes psychosis; Antipsychotics (block D2) → treat psychosis
• Carlsson and Lindquist (1963) proved D2 blockade mechanism

• Atypical antipsychotics block 5HT2A + D2
• 5HT2A blockade in frontal cortex increases DA release → helps negative symptoms
• LSD (5HT agonist) causes hallucinations

• PCP (Phencyclidine) blocks NMDA glutamate receptors → causes BOTH positive AND negative symptoms (better model than dopamine alone)
• NMDA hypofunction = schizophrenia-like state

• Reduced GABAergic interneurons (parvalbumin-positive) in prefrontal cortex

• Mesolimbic → positive symptoms (excess DA)
• Mesocortical → negative/cognitive (deficit DA)
• Infundibular/tuberoinfundibular → prolactin (D2 block → hyperprolactinemia)
• Nigrostriatal → EPS (extrapyramidal side effects)
• Tuberoinfundibular → (same as infundibular)
• Striatum involved in all motor effects

D. Structural Brain Changes

• Enlarged lateral ventricles (most consistent finding on CT/MRI)
• Reduced gray matter (especially prefrontal cortex, temporal lobe, hippocampus)
• Reduced hippocampal volume - most replicated finding
• No gliosis (unlike degenerative diseases) - suggests neurodevelopmental, not neurodegenerative

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4. CLINICAL FEATURES — SYMPTOMS IN DETAIL

POSITIVE SYMPTOMS (added to normal experience)

• Auditory hallucinations = most common type in schizophrenia
• Types: Elementary (noises) → Simple (words) → Complex (sentences, commands, conversations)
• Most characteristic: Third-person auditory hallucinations (voices talking about the patient)
• Also: voices commenting on actions, two or more voices conversing
• Visual, olfactory, tactile hallucinations = think of organic/medical causes first

• Fixed, false, unshakeable beliefs not in keeping with culture
• Most common: Persecutory delusions (being followed, poisoned, spied upon)
• Delusion of reference: neutral events have special personal significance
• Delusion of control/passivity: external forces controlling thoughts/feelings/actions
• Grandiose delusions: inflated self-importance
• Nihilistic: body/world is dying/non-existent (Cotard)
• Bizarre delusions: completely impossible (e.g., aliens replaced my brain)

• Loosening of associations (derailment): thoughts slip off track
• Tangentiality: never answers the question, goes off on tangents
• Circumstantiality: eventually gets to the point but very indirectly
• Word salad (incoherence): meaningless string of words
• Neologisms: invented new words
• Clang associations: rhyming speech ("I went to the store, shore, bore, more")
• Thought blocking: sudden stop in speech, patient reports mind going blank
• Echolalia: repetition of examiner's words
• Perseveration: repeating same words/ideas

• Bizarre, purposeless behavior
• Catatonia (see below)
• Poor self-care, neglect

NEGATIVE SYMPTOMS (subtracted from normal experience)

• Affect - flat/blunted
• Alogia - poverty of speech
• Avolition - inability to initiate/sustain goal-directed activity
• Anhedonia - inability to experience pleasure
• Attention - impaired

• Primary negative symptoms = core of schizophrenia (deficit syndrome)
• Secondary negative symptoms = due to depression, EPS, institutionalization, medication

COGNITIVE SYMPTOMS

• Impaired working memory (most prominent)
• Impaired attention, processing speed, verbal memory, executive function
• Cognitive deficits present even before psychosis onset and persist with treatment
• Best predicted by working memory deficits

CATATONIA SYMPTOMS

• Catatonic stupor: motionless, mute
• Waxy flexibility (Cerea Flexibilitas): body maintains positions placed in
• Negativism: resistance to all instructions/movement
• Echopraxia: imitating examiner's movements
• Stereotypy: repetitive non-goal-directed movements
• Mannerisms: odd, stilted goal-directed movements
• Posturing: maintaining bizarre postures voluntarily

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5. DSM-5-TR DIAGNOSTIC CRITERIA (Must memorize)

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

• A = Active symptoms (≥2 of 5)
• B = Bad functioning
• C = Continuous 6 months
• D = Differential (rule out mood/schizoaffective)
• E = Exclude substances/medical
• F = Foundational ASD history check

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6. DSM-5 vs ICD-11 COMPARISON (High-yield quiz differences)

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7. SCHIZOPHRENIA SPECTRUM IN DSM-5-TR

1. Schizotypal Personality Disorder (listed in both Chapter 2 and personality)
2. Delusional Disorder - fixed delusions, no hallucinations, functioning preserved
3. Brief Psychotic Disorder - ≥1 symptom, duration >1 day but <1 month, then full recovery
4. Schizophreniform Disorder - criteria met except duration 1-6 months
5. Schizophrenia - full criteria, ≥6 months
6. Schizoaffective Disorder - schizophrenia + major mood episode concurrently

• Delusional → Brief Psychotic → Brief-but-longer (Schizophreniform) → Schizophrenia → Schizoaffective

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8. SPECIAL TOPICS

Delusional Disorder

• Delusions only (non-bizarre in DSM-5; any type in ICD-11)
• No hallucinations, functioning preserved
• Types: Persecutory (most common), Grandiose, Erotomanic (de Clerambault's), Somatic, Jealous (Othello), Mixed
• Erotomanic subtype = belief that a person of higher status is in love with you

Brief Psychotic Disorder

• Duration: >1 day but <1 month
• Acute onset (often triggered by stressor = Brief Psychotic Disorder with marked stressor = Bouffée Délirante in French literature)
• Full remission expected
• Can occur postpartum (postpartum psychosis - within 2 weeks of delivery)

Schizophreniform Disorder

• Same criteria as schizophrenia but duration 1-6 months
• 2/3 progress to schizophrenia or schizoaffective disorder

Schizoaffective Disorder

• Two requirements:
  1. Meets criteria for schizophrenia AND major mood episode (manic or depressive) concurrently
  2. Delusions/hallucinations for ≥2 weeks WITHOUT mood symptoms

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9. TREATMENT OF SCHIZOPHRENIA

Antipsychotics - Two Generations

• Primarily D2 receptor antagonists
• Effective for positive symptoms; poor for negative/cognitive
• Examples: Chlorpromazine, Haloperidol, Fluphenazine, Trifluoperazine
• Side effects:
  • EPS (Extrapyramidal Symptoms): Parkinsonism, Akathisia, Acute dystonia, Tardive Dyskinesia
  • Hyperprolactinemia (galactorrhea, amenorrhea, gynecomastia)
  • Neuroleptic Malignant Syndrome (NMS)
  • Sedation, anticholinergic effects

• Block 5HT2A + D2 (dual action)
• Better for negative symptoms and cognition; lower EPS risk
• Examples: Clozapine, Risperidone, Olanzapine, Quetiapine, Aripiprazole, Ziprasidone

• Indication: Treatment-Resistant Schizophrenia (TRS) - fails ≥2 adequate antipsychotic trials
• Mechanism: Weak D2 + strong D4, 5HT2A, alpha, muscarinic, histamine blockade
• Life-threatening side effect: AGRANULOCYTOSIS (1-2%)
• Also causes: Seizures (dose-dependent), hypersalivation, weight gain, myocarditis, metabolic syndrome
• Monitoring: Weekly CBC for first 6 months, then fortnightly, then monthly
• The ONLY antipsychotic proven to reduce suicide (FDA-approved for suicidality)
• No tardive dyskinesia risk (but can cause tardive seizures)

EPS Side Effects in Detail

• Life-threatening emergency
• Triad: Hyperthermia + Rigidity + Altered consciousness
• Also: Autonomic instability (BP fluctuations, tachycardia, diaphoresis), elevated CK
• Treatment: Stop antipsychotic immediately, supportive care, Dantrolene (muscle relaxant) + Bromocriptine (DA agonist)
• NMS vs Serotonin Syndrome: NMS = lead-pipe rigidity, slower onset; SS = hyperreflexia, myoclonus, rapid onset

• Fever (hyperthermia)
• Encephalopathy (altered consciousness)
• Vitals unstable (autonomic)
• Elevated CK
• Rigidity (lead-pipe)

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10. PROGNOSIS - GOOD vs BAD

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11. RATING SCALES FOR SCHIZOPHRENIA

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SCHIZOPHRENIA MCQ PRACTICE

⚠️ ATTEMPT ALL QUESTIONS BEFORE CHECKING ANSWERS

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• A) 1 week
• B) 1 month
• C) 3 months
• D) 6 months

• A) 1 week
• B) 1 month
• C) 3 months
• D) 6 months

• A) Visual
• B) Olfactory
• C) Auditory
• D) Tactile

• A) Paranoid, Catatonic, Disorganized, Undifferentiated, Residual
• B) Paranoid and Catatonic only
• C) All subtypes eliminated
• D) Paranoid, Disorganized only

• A) Mesocortical pathway
• B) Mesolimbic pathway
• C) Nigrostriatal pathway
• D) Tuberoinfundibular pathway

• A) Mesolimbic
• B) Mesocortical
• C) Nigrostriatal
• D) Tuberoinfundibular

• A) Mesolimbic pathway
• B) Mesocortical pathway
• C) Nigrostriatal pathway
• D) Tuberoinfundibular pathway

• A) Tardive Dyskinesia
• B) Akathisia
• C) Acute Dystonia
• D) Neuroleptic Malignant Syndrome

• A) Give dantrolene immediately
• B) Give bromocriptine immediately
• C) STOP the antipsychotic drug immediately
• D) Reduce the dose of antipsychotic

• A) Haloperidol high dose
• B) Clozapine
• C) Olanzapine + Risperidone combination
• D) ECT

• A) Thrombocytopenia
• B) Hemolytic anemia
• C) Agranulocytosis
• D) Aplastic anemia

• A) Haloperidol
• B) Risperidone
• C) Clozapine
• D) Aripiprazole

• A) Pure D2 antagonist
• B) Pure 5HT2A antagonist
• C) Partial D2 agonist
• D) Full D2 agonist

• A) Cortical thickening
• B) Enlarged lateral ventricles
• C) Cerebellar atrophy
• D) Basal ganglia enlargement

• A) Benztropine
• B) Diphenhydramine
• C) Propranolol
• D) Diazepam

• A) Negativism
• B) Echopraxia
• C) Catalepsy (Cerea Flexibilitas)
• D) Posturing

• A) Brief Psychotic Disorder
• B) Schizophreniform Disorder
• C) Schizophrenia
• D) Delusional Disorder

• A) Schizophrenia
• B) Delusional Disorder
• C) Brief Psychotic Disorder
• D) Schizoaffective Disorder

• A) 1 week
• B) 2 weeks
• C) 1 month
• D) 2 months

• A) Blocking dopamine reuptake
• B) Blocking NMDA glutamate receptors
• C) Stimulating serotonin 2A receptors
• D) Blocking GABA-A receptors

• A) Auditory hallucinations
• B) Persecutory delusions
• C) Avolition
• D) Disorganized speech

• A) Better in developed countries
• B) Better in developing countries like India
• C) Equal in all countries
• D) Better with higher medication use

• A) 18
• B) 24
• C) 30
• D) 42

• A) 10-15%
• B) 20-25%
• C) 40-50%
• D) 70-80%

• A) The patient reads others' thoughts
• B) The patient believes others can hear/know their thoughts
• C) The patient hears their thoughts spoken aloud
• D) External thoughts are inserted into the patient's mind

• A) NMS - Haloperidol
• B) NMS - Dantrolene + Bromocriptine
• C) NMS - Lithium
• D) NMS - Clonazepam

• A) Bipolar disorder
• B) Autism only
• C) Schizophrenia (20-30% lifetime risk)
• D) OCD

• A) Kay et al.
• B) Nancy Andreasen
• C) Overall and Gorham
• D) Hamilton

• A) Auditory hallucinations
• B) Bizarre delusions
• C) Both A and B
• D) Negative symptoms

• A) 5HT2A blockade in striatum reduces EPS
• B) 5HT2A blockade in frontal cortex increases DA release → improves negative symptoms
• C) Both A and B
• D) It increases prolactin less

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SCHIZOPHRENIA ANSWER KEY

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═══════════════════════════════════════

TOPIC 3: MOOD DISORDERS

(Major Depressive Disorder + Bipolar Disorder)

═══════════════════════════════════════

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PART A — MAJOR DEPRESSIVE DISORDER (MDD)

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1. DEFINITION

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2. EPIDEMIOLOGY

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3. ETIOLOGY & NEUROBIOLOGY

Monoamine Hypothesis (Most tested)

• Serotonin deficiency (5-HT) - most important
• Norepinephrine deficiency (NE)
• Dopamine deficiency (especially for anhedonia)
• Evidence: Reserpine (depletes monoamines) causes depression; SSRIs (increase 5-HT) treat depression

HPA Axis (Neuroendocrine)

• Hypercortisolemia in depression
• Dexamethasone Suppression Test (DST): Cortisol not suppressed in ~50% of depressed patients (non-suppression = positive DST = abnormal)
• Normal: cortisol suppressed after 1mg dexamethasone
• Positive DST (non-suppression) suggests melancholic/endogenous depression

Neuroimaging

• Reduced blood flow and activity in prefrontal cortex (PFC) - especially left PFC
• Increased amygdala activity (excessive fear/emotional response)
• Reduced hippocampal volume (stress-cortisol mediated neuronal damage)

Sleep Changes (High-yield)

• Reduced REM latency (REM sleep comes early) - biological marker of depression
• Increased total REM sleep
• Decreased slow-wave (deep) sleep
• Early morning awakening (diurnal variation - worst in morning)
• 90% of depressed patients have insomnia

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4. DSM-5-TR CRITERIA FOR MAJOR DEPRESSIVE EPISODE

1. Depressed mood most of the day (or irritable in children/adolescents)
2. Anhedonia - markedly diminished interest/pleasure in activities
3. Weight/appetite change (significant loss or gain; failure to gain expected weight in children)
4. Sleep disturbance (insomnia or hypersomnia)
5. Psychomotor changes (agitation or retardation observable by others)
6. Fatigue or loss of energy
7. Worthlessness or excessive/inappropriate guilt
8. Concentration difficulty / indecisiveness
9. Suicidal ideation (recurrent thoughts of death, suicidal ideation, attempt)

• Sleep (insomnia/hypersomnia)
• Interest (anhedonia)
• Guilt (worthlessness)
• Energy (fatigue)
• Concentration
• Appetite (weight change)
• Psychomotor (agitation/retardation)
• Suicidal ideation

• Depressed mood (the core)

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5. SPECIFIERS (VERY HIGH-YIELD FOR QUIZZES)

Melancholic Features

• Loss of pleasure in ALL activities (complete anhedonia)
• Mood doesn't react to positive events
• Distinct quality of depressed mood (different from grief)
• Early morning awakening (≥2 hours before usual)
• Diurnal variation (worse in morning)
• Psychomotor changes (marked agitation or retardation)
• Anorexia/weight loss
• Excessive guilt
• More biological, responds well to TCAs and ECT

Atypical Features

• Mood reactivity (brightens when something good happens = OPPOSITE of melancholic)
• Weight GAIN / increased appetite (craving carbohydrates)
• Hypersomnia (sleeping too much)
• Leaden paralysis (heavy limbs)
• Rejection sensitivity (lasting feature, not just during depression)
• Responds better to MAOIs than TCAs

• Melancholic: worse AM, weight LOSS, insomnia, NO reactivity
• Atypical: better AM, weight GAIN, hypersomnia, mood REACTIVE

Psychotic Features

• Mood-congruent: delusions/hallucinations consistent with depressive themes (guilt, worthlessness, nihilism)
• Mood-incongruent: not consistent with depressive themes (poor prognosis)
• Treatment: Antidepressant + Antipsychotic (or ECT)

Seasonal Pattern (SAD - Seasonal Affective Depression)

• Episodes regularly occur at a particular time of year (usually winter)
• Full remission in spring/summer
• Atypical features common (hypersomnia, hyperphagia, carb craving)
• Treatment: Light therapy (Bright light therapy) - 10,000 lux for 30 min every morning; also SSRIs (Fluoxetine or Sertraline preferred)

Peripartum Onset

• Onset during pregnancy or within 4 weeks postpartum
• Postpartum Blues: Days 1-5, brief, self-limiting (50-80% of mothers)
• Postpartum Depression: After 2 weeks, persistent, requires treatment (10-15%)
• Postpartum Psychosis: First 2 weeks, severe, emergency (1-2/1000)
• New FDA-approved drug for postpartum depression: Brexanolone (IV, 2019) and Zuranolone (oral, 2023)

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6. TREATMENT OF DEPRESSION

Severity-Based Approach

Antidepressants — Complete Classification

• Fluoxetine, Sertraline, Paroxetine, Fluvoxamine, Citalopram, Escitalopram
• "FLuSSy ParCiE" = Fluoxetine, Fluvoxamine, Sertraline, Paroxetine, Citalopram, Escitalopram
• Side effects: GI upset, sexual dysfunction, serotonin syndrome, activation/agitation, insomnia
• Fluoxetine: Longest half-life (1-4 days; active metabolite: 1-2 weeks) → safest in OD, least discontinuation syndrome
• Paroxetine: Shortest half-life, most anticholinergic, worst discontinuation syndrome, safest in cardiac disease (paradox)
• Sertraline: Safest in pregnancy and post-MI
• Fluvoxamine: Used for OCD

• Venlafaxine, Duloxetine, Desvenlafaxine, Levomilnacipran
• Venlafaxine: Higher doses = more NE effect; can cause hypertension
• Duloxetine: Also approved for chronic pain, diabetic neuropathy

• Imipramine (first), Amitriptyline, Clomipramine, Nortriptyline, Doxepin
• Block NE + 5HT reuptake
• Clomipramine: Best for OCD (most serotoninergic TCA)
• Side effects: Anticholinergic (dry mouth, constipation, urinary retention, blurred vision), Cardiotoxic (dangerous in OD - widened QRS), orthostatic hypotension, sedation, weight gain
• Nortriptyline: Best tolerated TCA (least anticholinergic, has a therapeutic window 50-150 ng/mL)

• Phenelzine, Tranylcypromine, Isocarboxazid, Moclobemide (reversible)
• Irreversible (except Moclobemide = RIMA = Reversible Inhibitor of MAO-A)
• Best for: Atypical depression, treatment-resistant depression, phobias
• DANGEROUS interaction: Tyramine-containing foods → Hypertensive crisis (Aged cheese, red wine, cured meats, liver, soy sauce, yeast extract)
• Drug interaction: SSRIs + MAOIs = SEROTONIN SYNDROME (avoid combination; washout period needed)

• Bupropion: NE + DA reuptake inhibitor (NDRI); NO sexual dysfunction; weight LOSS; used for smoking cessation; AVOID in seizure disorders and eating disorders (lowers seizure threshold); no serotonin syndrome risk
• Mirtazapine: NaSSA (Noradrenergic and Specific Serotonergic Antidepressant); alpha-2 antagonist; causes SEDATION and WEIGHT GAIN; good for insomnia and underweight depressed patients; NO sexual dysfunction
• Trazodone: SARI (Serotonin Antagonist and Reuptake Inhibitor); used for insomnia; can cause priapism (sustained painful erection)
• Vortioxetine: Newest; multimodal; improves cognition; 5HT3 and 5HT7 antagonist

Time to Effect

• All antidepressants: 2-4 weeks to therapeutic effect
• However: Sleep and appetite improve first (1-2 weeks)
• Full effect: 4-6 weeks
• Trial period: Adequate trial = full dose for at least 4-6 weeks
• Treatment duration after first episode: 6-12 months
• After second episode: 2 years
• After third or more: Lifelong

Electroconvulsive Therapy (ECT)

• Fastest acting treatment in psychiatry
• Best for: Severe depression with suicidality, psychotic depression, melancholic depression, treatment-resistant depression, catatonia, postpartum psychosis (safest in pregnancy)
• Absolute contraindication: Raised intracranial pressure (ICP)
• Relative contraindications: Recent MI, aortic aneurysm, brain tumor, hemorrhagic stroke
• Side effects: Anterograde amnesia (most common), headache, confusion
• Course: 6-12 sessions (typically 3 per week)
• Mechanism: unclear; likely increases monoamines, GABA, neuropeptides
• Bilateral ECT: More effective; more memory side effects
• Unilateral (non-dominant) ECT: Less effective; fewer memory side effects

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PART B — BIPOLAR DISORDER

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1. DEFINITION

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2. EPIDEMIOLOGY

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3. DSM-5-TR CRITERIA

Manic Episode (for Bipolar I):

• Distractibility
• Impulsivity / reckless behavior
• Grandiosity (inflated self-esteem)
• Flight of ideas (racing thoughts)
• Activity increase (goal-directed) / Agitation
• Sleep decreased (feels rested with less sleep)
• Talkativeness (pressured speech)

Hypomanic Episode:

• Same symptoms as mania but duration at least 4 consecutive days
• NOT severe enough to cause marked impairment or require hospitalization
• No psychotic features (if present → it's mania, not hypomania)

Bipolar I vs II:

Mixed Features Specifier

• Manic/hypomanic episode WITH ≥3 depressive symptoms simultaneously
• OR Major depressive episode WITH ≥3 manic symptoms simultaneously
• Highest suicide risk in bipolar disorder

Rapid Cycling

• ≥4 mood episodes within 12 months
• More common in women and with hypothyroidism
• Antidepressants can precipitate or worsen rapid cycling

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4. TREATMENT OF BIPOLAR DISORDER

Acute Mania Treatment:

1. Lithium - first choice for classic euphoric mania
2. Valproate (Sodium Valproate) - rapid onset, good for mixed, dysphoric, rapid cycling
3. Antipsychotics - haloperidol, olanzapine, risperidone (quick control)
4. Benzodiazepines - lorazepam (for acute behavioral control)

LITHIUM — Most Important Drug in Psychiatry

• Mechanism: Not fully known; inhibits inositol monophosphatase → reduces inositol → affects phosphoinositide pathway; also modulates GSK-3β
• Therapeutic range: 0.6-1.2 mEq/L (narrow range!)
• Toxic level: >1.5 mEq/L (mild toxicity); >2.0 (severe)
• Half-life: ~24 hours
• Excretion: 100% renal (no hepatic metabolism)
• Lithium is reabsorbed at proximal tubule along with sodium → sodium depletion causes lithium retention → TOXICITY

• Low sodium diet (proximal tubule reabsorbs more Li)
• Dehydration / diarrhea / vomiting
• NSAIDs (reduce renal Li excretion) - important drug interaction
• Thiazide diuretics (increase renal Li reabsorption)
• ACE inhibitors

• Early (therapeutic levels): Fine tremor (postural), polyuria, polydipsia, nausea, diarrhea, weight gain, acne
• Long-term: Hypothyroidism (30-40%), Nephrogenic Diabetes Insipidus, hyperparathyroidism
• Toxic (>1.5 mEq/L): Coarse tremor, ataxia, confusion, dysarthria
• Severely Toxic (>2.0 mEq/L): Seizures, arrhythmias, coma, death
• Teratogenicity: Ebstein's anomaly (cardiac malformation - apical displacement of tricuspid valve) - small but real risk
• Memory trick for lithium toxicity: "DAMN CAN" - Dehydration, Antihypertensives (ACE-I), Mine (NSAIDs), No salt (sodium depletion), Constipation (vomiting/diarrhea), Adding Thiazides, Nausea

• Before starting: TFT, RFT, ECG, calcium, pregnancy test
• Steady state: 5 days after starting
• Level checked: 12 hours after last dose (trough level)

• Acute mania (first-line)
• Bipolar maintenance (gold standard - reduces relapse)
• Augmentation in treatment-resistant depression
• Reduces suicide (strongest evidence in bipolar)

Valproate (VPA)

• Mechanism: Blocks Na+ channels + increases GABA
• Better than lithium for: Mixed states, rapid cycling, dysphoric mania
• Side effects: Weight gain, alopecia (hair loss), tremor, sedation, teratogenic (neural tube defects - spina bifida), hepatotoxicity, polycystic ovarian syndrome (PCOS in women)
• Teratogenicity: Neural tube defects (spina bifida) - highest risk of any mood stabilizer
• Contraindicated in women of childbearing age if possible

Lamotrigine

• Mechanism: Blocks Na+ and Ca2+ channels; reduces glutamate release
• Best for: Bipolar DEPRESSION (better than lithium/valproate for depressive episodes)
• Maintenance in Bipolar II
• Side effect: RASH - can progress to Stevens-Johnson Syndrome (SJS) - life-threatening
• Must titrate slowly to avoid rash
• Only mood stabilizer with minimal weight gain and NO cognitive impairment

Carbamazepine

• Mechanism: Blocks Na+ channels
• Good for: Rapid cycling, mixed states, secondary mania
• Side effects: Agranulocytosis, hyponatremia (SIADH), teratogenic (neural tube defects, craniofacial abnormalities)
• Induces P450 enzymes (reduces levels of many drugs including itself - autoinduction)
• Contraindicated with MAOIs

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5. SEROTONIN SYNDROME vs NMS (High-yield comparison)

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MOOD DISORDERS MCQ PRACTICE

• A) 5%
• B) 10%
• C) 15-20%
• D) 30%

• A) 1:2 (more common in men)
• B) 2:1 (more common in women)
• C) 1:1 (equal)
• D) 3:1 (much more in women)

• A) Increased REM latency
• B) Decreased REM latency
• C) Increased slow wave sleep
• D) Normal sleep architecture

• A) Mania
• B) PTSD
• C) Major Depressive Episode
• D) Generalized Anxiety Disorder

• A) Melancholic features
• B) Atypical features
• C) Psychotic features
• D) Seasonal pattern

• A) Paroxetine
• B) Sertraline
• C) Fluoxetine
• D) Venlafaxine

• A) Citalopram
• B) Fluvoxamine
• C) Escitalopram
• D) Paroxetine

• A) SSRI + TCA
• B) SSRI + MAOI
• C) TCA + Mirtazapine
• D) SNRI + Bupropion

• A) Fluoxetine
• B) Mirtazapine
• C) Trazodone
• D) Bupropion

• A) Smoking cessation
• B) Atypical depression
• C) Eating disorders (anorexia/bulimia) and seizure disorders
• D) Sexual dysfunction

• A) SSRI (starts in 2-4 weeks)
• B) SNRI
• C) ECT
• D) Ketamine (IV)

• A) Hypothalamic disorder
• B) Melancholic/endogenous depression (HPA axis dysregulation)
• C) Psychotic depression only
• D) Bipolar depression

• A) 1 day
• B) 4 days
• C) 7 days
• D) 2 weeks

• A) Schizophrenia
• B) Mania
• C) PTSD
• D) Anxiety

• A) Full mania + depression
• B) Hypomania + depression (no full mania)
• C) Mania only
• D) Psychotic depression only

• A) 0.2-0.5 mEq/L
• B) 0.6-1.2 mEq/L
• C) 1.5-2.0 mEq/L
• D) 2.0-3.0 mEq/L

• A) Lithium + Benzodiazepines
• B) Lithium + NSAIDs
• C) Lithium + Antipsychotics
• D) Lithium + Antidepressants

• A) Ventricular septal defect
• B) Tetralogy of Fallot
• C) Ebstein's anomaly
• D) Transposition of great vessels

• A) Classic euphoric mania
• B) Mixed states and rapid cycling
• C) Bipolar depression
• D) Bipolar with psychotic features

• A) Agranulocytosis
• B) Stevens-Johnson Syndrome (SJS)
• C) Hypothyroidism
• D) Hepatic failure

• A) Lithium
• B) Valproate
• C) Lamotrigine
• D) Carbamazepine

• A) ≥2 episodes per year
• B) ≥4 episodes per 12 months
• C) ≥6 episodes per year
• D) ≥2 episodes per month

• A) Dantrolene
• B) Bromocriptine
• C) Cyproheptadine
• D) Propranolol

• A) SSRI alone
• B) Antipsychotic (+ lithium or valproate for mood stabilization); ECT may be needed
• C) Benzodiazepine alone
• D) Psychotherapy only

• A) Blocking serotonin reuptake
• B) Blocking alpha-2 receptors (increases NE + 5HT release) + blocking 5HT2 and 5HT3
• C) Blocking dopamine D2 receptors
• D) Inhibiting MAO enzymes

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MOOD DISORDERS ANSWER KEY

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═══════════════════════════════════════

TOPIC 4: ANXIETY DISORDERS

═══════════════════════════════════════

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FULL TEACHING — ANXIETY DISORDERS

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OVERVIEW & DSM-5 CLASSIFICATION

1. Separation Anxiety Disorder
2. Selective Mutism
3. Specific Phobia
4. Social Anxiety Disorder (Social Phobia)
5. Panic Disorder
6. Agoraphobia
7. Generalized Anxiety Disorder (GAD)
8. Substance/Medication-induced Anxiety
9. Anxiety Disorder due to another medical condition

• OCD-related disorders (OCD, BDD, Hoarding, etc.)
• Trauma/Stressor-related disorders (PTSD, Acute Stress, Adjustment)

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A. GENERALIZED ANXIETY DISORDER (GAD)

• Excessive anxiety/worry about ≥2 areas, difficult to control, for ≥6 months
• ≥3 of: (1) Restlessness, (2) Fatigue, (3) Concentration difficulty, (4) Irritability, (5) Muscle tension, (6) Sleep disturbance
• In children, only 1 criterion B symptom required

• 1st line: SSRIs (sertraline, escitalopram) or SNRIs (venlafaxine, duloxetine)
• Also: Buspirone (partial 5HT1A agonist; non-addictive; no sedation; takes 2-4 weeks)
• Benzodiazepines: Effective but addictive; avoid long-term use
• Psychotherapy: CBT (Cognitive Behavioral Therapy) - gold standard
• 1st line psychotherapy: CBT with worry exposure and relaxation

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B. PANIC DISORDER

1. Palpitations/pounding heart
2. Sweating
3. Trembling/shaking
4. Shortness of breath/smothering
5. Choking feeling
6. Chest pain
7. Nausea/abdominal distress
8. Dizziness/lightheadedness/faintness
9. Chills or hot flushes
10. Paresthesias (numbness/tingling)
11. Derealization/depersonalization
12. Fear of losing control/going crazy
13. Fear of dying

• Sweating, Trembling, Unexpected (episodic), Dizziness, EN-chest pain, Nausea, Tachycardia, Shortness of breath - Fear of dying, Estrangement (derealization), All about Rapid onset + 3C's: Choking, Chills, Cramps

• Persistent worry about future attacks OR
• Maladaptive behavioral change (avoidance)

• 1st line: SSRIs/SNRIs (long-term)
• 2nd line: TCAs (Imipramine), MAOIs
• Acute: Benzodiazepines (Lorazepam, Clonazepam - short-term)
• Psychotherapy: CBT + Interoceptive exposure
• Best long-term: CBT = Medications (evidence equal)

• CO2 inhalation / Sodium lactate infusion → provokes panic in susceptible patients but NOT in healthy controls

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C. SPECIFIC PHOBIA

• Animal type (most common in children)
• Natural environment (heights, storms, water)
• Blood-injection-injury (BII) - unique: causes vasovagal syncope (FAINTING - opposite of usual anxiety response where HR increases; in BII = HR DROPS first = bradycardia and hypotension → faint)
• Situational (planes, elevators, enclosed spaces)
• Other (clowns, vomiting, sounds)

• Systematic desensitization (Wolpe) - relaxation + gradual exposure
• In vivo exposure = most powerful
• For BII phobia: Applied muscle tension (to prevent fainting)

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D. SOCIAL ANXIETY DISORDER (Social Phobia)

1. Performance only (e.g., public speaking)
2. Generalized (all or most social situations)

• Blushing (erythrophobia) is the most typical symptom
• Taijin Kyofusho = Japanese culture-bound variant; fear of offending others (not embarrassing oneself)

• 1st line: SSRIs (paroxetine, sertraline, escitalopram), SNRIs (venlafaxine)
• Performance anxiety only: Propranolol (beta-blocker) - taken before performance
• Psychotherapy: CBT with social skills training

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E. AGORAPHOBIA

• Public transport, Open spaces, Enclosed places, Being in a crowd, Being outside home alone

• Can occur with OR without Panic Disorder (separate diagnoses in DSM-5)
• Often most disabling anxiety disorder (can become housebound)

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F. SEPARATION ANXIETY DISORDER

• Previously "childhood disorder" but DSM-5 includes adults
• Must last ≥4 weeks in children; ≥6 months in adults
• School refusal most common presentation in children

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ANXIETY DISORDERS MCQ PRACTICE

• A) 2 weeks
• B) 1 month
• C) 3 months
• D) 6 months

• A) Social phobia
• B) GAD
• C) Blood-Injection-Injury (BII) phobia
• D) Panic disorder

• A) GAD patients only
• B) Normal volunteers
• C) Panic disorder patients but NOT normal volunteers
• D) Any anxious patient

• A) Benzodiazepines (long-term)
• B) SSRIs or SNRIs
• C) Beta-blockers
• D) MAOIs

• A) GABA-A potentiation
• B) Partial 5HT1A agonist
• C) D2 dopamine antagonist
• D) Alpha-2 adrenergic antagonist

• A) SSRI daily
• B) Propranolol before performance
• C) Clonazepam before performance
• D) CBT only

• A) An Indian culture-bound syndrome of anxiety
• B) A Japanese culture-bound social anxiety variant - fear of offending others
• C) A Chinese anxiety syndrome involving ghost fears
• D) A Korean variant of OCD

• A) Separation Anxiety Disorder
• B) Social Anxiety Disorder
• C) PTSD and OCD
• D) Panic Disorder

• A) Psychodynamic therapy
• B) CBT with in vivo exposure
• C) Mindfulness-based therapy
• D) Supportive therapy

• A) 1
• B) 2
• C) 3
• D) 4

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ANXIETY MCQ ANSWER KEY

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═══════════════════════════════════════

TOPIC 5: OCD & RELATED DISORDERS

═══════════════════════════════════════

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FULL TEACHING — OCD

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1. DEFINITION

• Obsessions: Recurrent, intrusive, unwanted thoughts/images/urges causing anxiety
• Compulsions: Repetitive behaviors or mental acts performed to reduce anxiety caused by obsessions

• Ego-dystonic vs Ego-syntonic: Obsessions feel wrong (dystonic); in OCD personality = ego-syntonic

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2. EPIDEMIOLOGY

• Lifetime prevalence: 2-3%
• M:F = Equal in adults; more common in boys during childhood
• Mean onset: 19-20 years (earlier in males)
• 4th most common psychiatric disorder (after depression, phobia, alcohol use)
• Most patients have both obsessions AND compulsions (75-80%)

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3. CONTENT OF OBSESSIONS AND COMPULSIONS

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4. NEUROBIOLOGY

• Serotonin dysregulation (most important: responds to serotonergic drugs)
• Cortico-Striato-Thalamo-Cortical (CSTC) circuit dysfunction - overactive
  • Orbital frontal cortex → Caudate nucleus → Thalamus → back to OFC (hyperactive loop)
• Neuroimaging: Increased metabolism in orbitofrontal cortex (OFC), caudate nucleus, and thalamus on PET scan
• After successful treatment (SSRI or CBT): metabolic activity NORMALIZES

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5. DIAGNOSTIC CRITERIA (DSM-5-TR)

• Obsessions: recurrent/persistent, intrusive, unwanted thoughts; person attempts to suppress or neutralize them
• Compulsions: repetitive behaviors or mental acts; aimed at reducing distress; not realistically connected

• Good/fair insight (most common)
• Poor insight
• Absent insight/delusional beliefs (even if delusional = still OCD if OCD symptoms present)

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6. TREATMENT OF OCD

• 1st line: SSRIs (any; higher doses needed than for depression)
  • Fluvoxamine (most commonly cited for OCD)
  • Sertraline, Paroxetine, Fluoxetine, Escitalopram
• 2nd line (most effective TCA): Clomipramine (most serotoninergic TCA - Gold standard among TCAs)
  • Better than other TCAs; comparable to SSRIs; more side effects (cardiac, anticholinergic)
• Note: OCD requires higher doses and longer trial (10-12 weeks) than depression
• Augmentation (partial response): Antipsychotics (risperidone, aripiprazole)

• ERP = Exposure and Response Prevention
  • Expose patient to feared stimulus (obsession trigger)
  • Prevent the compulsive response
  • Most effective psychotherapy for OCD
• Combined (SSRI + ERP) = best outcomes

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7. OCD-RELATED DISORDERS (DSM-5 chapter)

• Preoccupation ≥1 hour/day
• Rhinoplasty most commonly sought (nose most common concern)
• Muscle dysmorphia (Reverse Anorexia) = preoccupation with being not muscular enough (more common in males)
• High suicide risk
• Treatment: SSRIs + CBT

• Emotional attachment to possessions
• Difficulty parting (not same as collecting)
• Living space becomes non-functional
• Often ego-syntonic (patient doesn't see problem)
• Harder to treat than OCD

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OCD MCQ PRACTICE

• A) Sexual thoughts
• B) Contamination thoughts
• C) Harm thoughts
• D) Religious thoughts

• A) Limbic-thalamic circuit
• B) Cortico-Striato-Thalamo-Cortical (CSTC) circuit
• C) Hippocampo-amygdala circuit
• D) Frontoparietal network

• A) Imipramine
• B) Amitriptyline
• C) Clomipramine
• D) Nortriptyline

• A) Free association
• B) Systematic desensitization
• C) Exposure and Response Prevention (ERP)
• D) Eye Movement Desensitization and Reprocessing (EMDR)

• A) DSM-IV
• B) DSM-5 (2013)
• C) ICD-10
• D) ICD-11

• A) Ears
• B) Skin
• C) Nose
• D) Hair

• A) Decreased orbitofrontal cortex metabolism
• B) Increased orbitofrontal cortex and caudate metabolism
• C) Decreased basal ganglia activity
• D) Increased prefrontal cortex activity only

• A) Patient enjoys the thoughts
• B) Patient finds the thoughts unwanted and foreign to their self
• C) Patient has no insight
• D) Patient believes the obsessions are completely rational

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OCD ANSWER KEY

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TOPIC 6: TRAUMA-RELATED DISORDERS

(PTSD, Acute Stress Disorder, Adjustment Disorder)

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FULL TEACHING — PTSD

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1. DSM-5-TR CRITERIA FOR PTSD

• Direct experience
• Witnessing (in person)
• Learning it happened to close person
• Repeated/extreme exposure to aversive details (e.g., first responders)

1. Recurrent involuntary distressing memories
2. Flashbacks (dissociative reactions - reliving the event)
3. Recurrent distressing dreams
4. Intense psychological distress at trauma cues
5. Physiological reactions to trauma cues

1. Avoidance of distressing memories/thoughts
2. Avoidance of external reminders (places, people, activities)

1. Inability to remember aspects of trauma (dissociative amnesia)
2. Persistent negative beliefs about self/world ("I am bad")
3. Distorted blame of self/others
4. Persistent negative emotional state (fear, horror, anger, guilt, shame)
5. Diminished interest in activities
6. Feelings of detachment/estrangement
7. Inability to experience positive emotions (emotional numbing)

1. Irritable behavior/angry outbursts
2. Reckless/self-destructive behavior (new in DSM-5)
3. Hypervigilance
4. Exaggerated startle response
5. Concentration problems
6. Sleep disturbance

• Broken intrusions (flashbacks, nightmares)
• Inability to avoid
• Ruminations (negative thoughts)
• Dys-regulation/arousal
• Symptomatic >1 month

• Added specifier: Depersonalization (feeling detached from self) OR Derealization (surroundings seem unreal)

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2. ACUTE STRESS DISORDER vs PTSD

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3. ADJUSTMENT DISORDER

• Onset within 3 months of stressor
• Symptoms don't meet criteria for another specific disorder
• Symptoms resolve within 6 months after stressor (or its consequences) terminates
• Subtypes: With depressed mood; with anxiety; with mixed; with disturbance of conduct; with mixed disturbance of emotions and conduct; unspecified

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4. TREATMENT OF PTSD

• SSRIs: Sertraline and Paroxetine (FDA-approved for PTSD)
• SNRIs: Venlafaxine (widely used)
• Avoid Benzodiazepines (may worsen PTSD long-term; impair fear extinction)

• Trauma-Focused CBT (TF-CBT) - first line
• EMDR (Eye Movement Desensitization and Reprocessing) - validated, especially for single-incident trauma
• Prolonged Exposure (PE) therapy
• Cognitive Processing Therapy (CPT)

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TRAUMA MCQ PRACTICE

• A) 2 weeks
• B) 3 weeks
• C) 1 month
• D) 3 months

• A) Type of trauma required
• B) Absence of re-experiencing symptoms
• C) Shorter duration (3 days to 1 month) and prominent dissociation
• D) Not requiring exposure to actual trauma

• A) Enhanced Memory Desensitization Reorganization
• B) Eye Movement Desensitization and Reprocessing
• C) Empathic Modeling and Directed Reflection
• D) Extended Memory Desensitization Reprogramming

• A) Sertraline
• B) Prazosin
• C) Propranolol
• D) Quetiapine

• A) 1 month
• B) 3 months
• C) 6 months
• D) 12 months

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TRAUMA MCQ ANSWER KEY

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TOPIC 7: PERSONALITY DISORDERS

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FULL TEACHING — PERSONALITY DISORDERS

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1. DEFINITION

• Deviates markedly from cultural expectations
• Is stable and of long duration (onset ≥ adolescence/early adulthood)
• Leads to significant distress or impairment
• Is NOT explained by another mental disorder or substance

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2. DSM-5 THREE CLUSTERS

CLUSTER A — "Odd and Eccentric" (Think: Psychotic-like)

CLUSTER B — "Dramatic, Emotional, Erratic"

CLUSTER C — "Anxious and Fearful"

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3. KEY DISTINCTIONS (Commonly confused)

• Antisocial PD = DSM diagnosis based on behaviors
• Psychopathy = includes callousness, lack of remorse, manipulativeness (Hare PCL-R measures this)
• Psychopathy is more severe; subset of ASPD

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4. BORDERLINE PD — DETAILED (Most asked)

1. Frantic efforts to avoid real/imagined abandonment
2. Unstable, intense relationships (idealization and devaluation = splitting)
3. Unstable self-image/sense of identity
4. Impulsivity (in ≥2 self-damaging areas: sex, spending, substance, binge eating, reckless driving)
5. Recurrent suicidal or self-mutilating behavior (parasuicide)
6. Affective instability (intense, reactive mood; dysphoria lasting hours)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

• Identity disturbance
• Difficulty controlling anger
• Emptiness (chronic)
• Self-harm/suicidal
• Paranoid under stress
• Abandonment fears
• Impulsivity
• Relationship instability

• Dialectical Behavior Therapy (DBT) = Marsha Linehan; gold standard treatment for BPD
  • 4 modules: Mindfulness, Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness
• Mentalization-Based Therapy (MBT) - also effective
• Pharmacotherapy: Adjunctive; SSRIs for mood; atypical antipsychotics for cognitive-perceptual symptoms; mood stabilizers for impulsivity
• No drug is FDA-approved specifically for BPD

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5. TREATMENT APPROACHES BY CLUSTER

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PERSONALITY DISORDERS MCQ PRACTICE

• A) Cluster B
• B) Cluster C
• C) Cluster A
• D) None

• A) Projection
• B) Repression
• C) Splitting
• D) Reaction formation

• A) Cognitive Behavioral Therapy (CBT)
• B) Dialectical Behavior Therapy (DBT)
• C) Psychodynamic Therapy
• D) EMDR

• A) Age ≥18 years at diagnosis
• B) Evidence of Conduct Disorder before age 15
• C) Disregard for rights of others
• D) No diagnosis of schizophrenia

• A) Schizoid has psychotic symptoms; Avoidant does not
• B) Schizoid wants relationships but cannot maintain them; Avoidant doesn't want any
• C) Schizoid doesn't WANT relationships; Avoidant WANTS relationships but fears rejection
• D) They are essentially the same disorder

• A) The symptoms cause severe distress
• B) The symptoms feel alien and unwanted to the patient
• C) The symptoms feel natural, consistent with self-image, and acceptable to the patient
• D) The symptoms are easily treated

• A) Aaron Beck
• B) Albert Ellis
• C) Marsha Linehan
• D) Joseph Wolpe

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PERSONALITY DISORDERS ANSWER KEY

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TOPIC 8: SUBSTANCE USE DISORDERS

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FULL TEACHING — SUBSTANCE USE

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1. KEY CONCEPTS

• 11 criteria in 4 domains: Impaired control, Social impairment, Risky use, Pharmacological
• Mild: 2-3 criteria; Moderate: 4-5; Severe: ≥6 criteria

• Tolerance: Need more substance for same effect
• Withdrawal: Syndrome when substance discontinued

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2. ALCOHOL — MOST IMPORTANT

Alcohol Metabolism:

Alcohol Withdrawal Syndrome (TIME LINE - critical to memorize):

• Altered consciousness, confusion, disorientation
• Visual hallucinations (classically: insects, small animals = Lilliputian hallucinations)
• Severe autonomic instability
• Mortality: 5-15% if untreated; <1% with treatment
• Treatment: Benzodiazepines (first-line; diazepam or lorazepam) + supportive care + Thiamine (BEFORE glucose)

Wernicke-Korsakoff Syndrome:

• Cause: Thiamine (Vitamin B1) deficiency in alcoholics
• Wernicke's Encephalopathy (ACUTE): Triad:
  • Ataxia (gait)
  • Confusion (altered consciousness)
  • Ophthalmoplegia (eye movement abnormalities)
  • Memory trick: "ACO" or "AOP" - Ataxia, Confusion/Oculomotor
• Korsakoff's Psychosis (CHRONIC): Amnesia
  • Anterograde amnesia (can't form new memories) - PRIMARY
  • Retrograde amnesia
  • Confabulation (filling memory gaps with fabricated information; not deliberate lying)
  • Relatively preserved intelligence
  • Structural: Damage to mammillary bodies and mediodorsal thalamus
• Treatment: IV Thiamine (give BEFORE glucose - glucose without thiamine worsens Wernicke's)
• Important rule: ALWAYS give thiamine before glucose in alcoholic patients

Alcohol Treatment:

• Detoxification: Benzodiazepines (lorazepam, diazepam) - prevent DTs and seizures
• Maintenance/Relapse Prevention:
  • Disulfiram (Antabuse): Aversive therapy; blocks ALDH
  • Naltrexone (Revia): Opioid antagonist; reduces craving and reward from alcohol (FDA-approved)
  • Acamprosate (Campral): NMDA antagonist; reduces withdrawal-related dysphoria (FDA-approved; better for maintaining abstinence)
  • Naltrexone + Acamprosate = most evidence together

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3. OPIOIDS

• Triad: Miosis (pinpoint pupils) + Respiratory depression + CNS depression
• Treatment: Naloxone (opioid antagonist; IV; short-acting)

• Symptoms: Mydriasis (dilated pupils), yawning, piloerection ("goosebumps"), lacrimation, diarrhea, anxiety, restlessness, muscle cramps
• Memory trick: "DUMBLESS" = Diarrhea, yawning (Unable to stop), Mydriasis, Bone/muscle pain, Lacrimation, Elevated BP, Sneezing/rhinorrhea, Sleeplessness

• Methadone: Long-acting opioid agonist; reduces craving; oral; monitored dispensing
• Buprenorphine: Partial opioid agonist; safer (ceiling effect on respiratory depression); used with naloxone as Suboxone (buprenorphine + naloxone)
• Naltrexone: Opioid antagonist; for maintaining abstinence; requires detox first
• Clonidine (alpha-2 agonist): For acute withdrawal symptoms (not maintenance); reduces autonomic symptoms

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4. BENZODIAZEPINES

• Withdrawal: Can be life-threatening (like alcohol) → seizures, delirium
• Treatment: Gradual tapering (not abrupt discontinuation); substitute with long-acting BZD (diazepam)

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5. STIMULANTS (Cocaine, Amphetamine)

• Euphoria, tachycardia, hypertension, dilated pupils, sweating, weight loss
• Cocaine: Chest pain, myocardial infarction (coronary vasospasm)
• Formication ("coke bugs") = tactile hallucination of insects crawling on skin

• "Crash": Depression, fatigue, hypersomnia, increased appetite, dysphoria
• NOT medically dangerous (no seizures/delirium)

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6. CANNABIS

• Active compound: THC (delta-9-tetrahydrocannabinol)
• Mechanism: CB1 receptors (brain), CB2 receptors (immune)
• Intoxication: Euphoria, time distortion, increased appetite ("munchies"), conjunctival injection (red eyes), tachycardia
• Cannabis Use Disorder: Withdrawal - irritability, insomnia, decreased appetite
• Cannabis-induced psychosis: Can precipitate psychosis in vulnerable individuals
• High-potency cannabis (skunk) = highest risk for psychosis

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7. HALLUCINOGENS (LSD, Psilocybin)

• LSD (Lysergic Acid Diethylamide): 5HT2A agonist; visual hallucinations, synesthesia (mixing senses)
• HPPD (Hallucinogen Persisting Perception Disorder): Flashbacks of perceptual disturbances after stopping; visual trails
• No true withdrawal syndrome

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SUBSTANCE USE MCQ PRACTICE

• A) 6-12 hours after last drink
• B) 12-24 hours
• C) 48-72 hours
• D) 1 week

• A) IV dextrose (glucose)
• B) IV thiamine (before glucose)
• C) Benzodiazepine infusion
• D) CT scan of brain

• A) Wernicke's Encephalopathy
• B) Korsakoff's Psychosis
• C) Alcohol Intoxication
• D) DTs

• A) Stimulating opioid receptors
• B) Blocking opioid receptors (antagonist)
• C) Inhibiting opioid metabolism
• D) Reducing respiratory rate directly

• A) Methadone
• B) Naltrexone
• C) Buprenorphine
• D) Clonidine

• A) Blocks alcohol dehydrogenase
• B) Blocks aldehyde dehydrogenase → acetaldehyde accumulation
• C) Opioid antagonism reducing alcohol reward
• D) NMDA antagonism

• A) Auditory hallucinations
• B) Tactile hallucination of insects crawling on skin
• C) Visual hallucination of bright lights
• D) Olfactory hallucination

• A) Benzodiazepines
• B) Nitrates
• C) Beta-blockers
• D) Calcium channel blockers

• A) Cannabidiol (CBD)
• B) Delta-9-THC
• C) Cannabigerol
• D) Delta-8-THC

• A) Replacing the opioid
• B) Alpha-2 agonism - reducing autonomic withdrawal symptoms
• C) Blocking opioid withdrawal at receptor level
• D) Preventing seizures

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SUBSTANCE USE ANSWER KEY

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TOPIC 9: NEUROCOGNITIVE DISORDERS

(Dementia / Delirium)

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A. DELIRIUM

• A: Disturbance in attention (reduced ability to focus, sustain, shift attention) AND awareness
• B: Develops ACUTELY, tends to FLUCTUATE
• C: Additional cognitive disturbance (memory, orientation, language, perception)
• D: Not explained by established neurocognitive disorder
• E: Due to medical condition, substance, or multiple causes

• ACUTE onset (hours to days) - distinguishes from dementia
• Fluctuating course (worse at night = "sundowning")
• Disturbed sleep-wake cycle
• Psychomotor changes: Hyperactive (agitated, restless) or Hypoactive (quiet, withdrawn) or Mixed
• Hypoactive delirium = most common subtype; most UNDERDIAGNOSED

• Treat UNDERLYING CAUSE first
• Behavioral: Reorientation, calm environment, familiar faces, avoid restraints, maintain normal sleep-wake cycle
• Pharmacological: Haloperidol (low dose) = most used; NOT benzodiazepines (worsen delirium except in alcohol/BZD withdrawal)
• Exception: BZDs ARE first-line for alcohol withdrawal delirium (DTs)

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B. ALZHEIMER'S DISEASE

• Most common cause of dementia (60-70%)
• Insidious onset, gradual progression

• Amyloid plaques (beta-amyloid/Aβ42 deposition) - extracellular
• Neurofibrillary tangles (hyperphosphorylated tau protein) - intracellular
• Loss of acetylcholine (cholinergic deficit in nucleus basalis of Meynert → hippocampus and cortex)
• Gross atrophy: hippocampus and entorhinal cortex first, then parietal/temporal lobes

• APOE ε4 allele: most common genetic RISK factor (not deterministic)
• APP (chromosome 21), Presenilin 1 (chromosome 14), Presenilin 2 (chromosome 1) mutations → early-onset familial AD
• Down Syndrome (Trisomy 21): Almost all develop AD by age 40 (APP gene on chromosome 21)

• Mild-Moderate AD: Cholinesterase Inhibitors (Donepezil, Rivastigmine, Galantamine)
  • Mechanism: Block acetylcholinesterase → increase ACh availability
  • Donepezil: Approved for all stages; once daily; most commonly used
• Moderate-Severe AD: Memantine (NMDA receptor antagonist; reduces glutamate excitotoxicity) - can combine with cholinesterase inhibitor
• Disease-modifying (NEW): Lecanemab (2023) and Donanemab (2024) - anti-amyloid monoclonal antibodies; FDA-approved; slow progression in early AD

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C. OTHER DEMENTIAS

• Fluctuating attention/alertness (minutes to hours)
• Spontaneous Parkinsonism
• Recurrent vivid visual hallucinations (formed, detailed)
• REM sleep behavior disorder (acts out dreams)
• AVOID antipsychotics (severe sensitivity reaction - worsens parkinsonism drastically)
• Rivastigmine is treatment of choice

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MINI-MENTAL STATE EXAM (MMSE)

• Developed by: Folstein (1975)
• Maximum score: 30 points
• Tests: Orientation (10), Registration (3), Attention/Calculation (5), Recall (3), Language (8), Construction (1)
• Cutoff for dementia: <24 (mild cognitive impairment may score 24-27)
• Limitations: Education-biased; poor for frontal functions

• MoCA (Montreal Cognitive Assessment): Better for MCI detection; max 30; cutoff <26
• MMSE: Quick screening; max 30; cutoff <24
• CDR (Clinical Dementia Rating): Staging dementia (0=normal, 0.5=MCI, 1=mild, 2=moderate, 3=severe)

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NEUROCOGNITIVE MCQ PRACTICE

• A) Vascular dementia
• B) Lewy Body Dementia
• C) Alzheimer's Disease
• D) Frontotemporal Dementia

• A) Type of hallucinations
• B) Acute fluctuating onset vs insidious gradual onset
• C) Age of patients affected
• D) Response to treatment

• A) Lewy bodies and alpha-synuclein
• B) Amyloid plaques and neurofibrillary tangles (tau)
• C) TDP-43 inclusions and tau
• D) Prion proteins and amyloid

• A) Presenilin 1 (PS1) mutation
• B) APP mutation
• C) APOE ε4 allele
• D) MAPT mutation

• A) Memantine
• B) Donepezil (cholinesterase inhibitor)
• C) Lecanemab
• D) Haloperidol

• A) Antipsychotics are first-line treatment
• B) Parkinsonism always precedes dementia by >1 year
• C) Visual hallucinations and fluctuating cognition are characteristic; antipsychotics can cause severe worsening
• D) APOE ε4 is the main genetic risk

• A) 20
• B) 25
• C) 30
• D) 40

• A) They have trisomy 21 - APP gene on chromosome 21 leads to excess amyloid
• B) They have lower intelligence making them more susceptible
• C) They have APOE ε4 more commonly
• D) They have Presenilin mutations

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NEUROCOGNITIVE ANSWER KEY

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TOPIC 10: EATING DISORDERS

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FULL TEACHING — EATING DISORDERS

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A. ANOREXIA NERVOSA (AN)

1. Restriction of energy intake → significantly low body weight
2. Intense fear of gaining weight or persistent behavior preventing weight gain
3. Disturbance in body image OR lack of recognition of seriousness of low weight

• Restricting type: No binge-purge
• Binge-Eating/Purging type: Regular binge-eating or purging

• Lanugo hair (fine downy body hair - thermoregulation)
• Amenorrhea (hypothalamic, not in DSM-5 criteria anymore)
• Bradycardia, hypotension, hypothermia
• Osteoporosis (estrogen deficiency + low calcium)
• Refeeding syndrome: Dangerous hypophosphatemia when feeding resumes (phosphate enters cells)
• Russell's sign: Calluses on dorsum of hand from self-induced vomiting (in purging subtype)
• Parotid gland enlargement (purging)
• Electrolyte imbalances: Hypokalemia (can cause arrhythmias and death)
• Highest mortality of any psychiatric disorder (~10%; due to cardiac arrhythmias and suicide)

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

• Inpatient if medically unstable; Outpatient for stable patients
• Weight restoration = primary goal
• Family-Based Treatment (Maudsley Approach) = best evidence in adolescents
• CBT = for adults
• No medication clearly effective for weight restoration; Olanzapine may have small benefit for weight gain
• Avoid fluoxetine in underweight AN (not effective below healthy weight)

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B. BULIMIA NERVOSA (BN)

1. Recurrent binge eating (eating large amount + loss of control)
2. Recurrent compensatory behavior (purging, fasting, excessive exercise, laxatives)
3. Both ≥1x/week for ≥3 months
4. Self-evaluation unduly influenced by shape/weight
5. Not occurring exclusively during AN episodes

• Dental erosion (acid from vomit)
• Parotid hypertrophy (sialadenosis)
• Russell's sign (hand calluses from purging)
• Hypokalemia (from vomiting and laxatives → cardiac arrhythmias)
• Metabolic alkalosis (from vomiting = loss of HCl)
• Mallory-Weiss tears (esophageal tears)

• Vomiting: Hypokalemia, hypochloremia, metabolic alkalosis
• Laxative abuse: Hypokalemia, metabolic acidosis

• Fluoxetine (60mg/day) = ONLY FDA-approved drug for Bulimia (higher dose than depression)
• CBT = gold standard psychotherapy
• Combined CBT + Fluoxetine = best outcomes

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C. BINGE EATING DISORDER (BED)

• New in DSM-5 (was in appendix before)
• Binge eating without compensatory behaviors
• Associated with obesity
• Treatment: CBT + SSRIs; Lisdexamfetamine (Vyvanse) = FDA-approved for BED (first drug)

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EATING DISORDERS MCQ PRACTICE

• A) Bulimia Nervosa
• B) Binge Eating Disorder
• C) Anorexia Nervosa
• D) ARFID

• A) Parotid swelling
• B) Calluses on dorsum of the hand from self-induced vomiting
• C) Lanugo hair on the body
• D) Dental erosion from acid reflux

• A) Sertraline 50mg
• B) Fluoxetine 60mg/day
• C) Olanzapine
• D) Naltrexone

• A) Hyponatremia
• B) Hyperkalemia
• C) Hypophosphatemia
• D) Hypercalcemia

• A) DSM-III
• B) DSM-IV
• C) DSM-5 (2013)
• D) DSM-5-TR (2022)

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EATING DISORDERS ANSWER KEY

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TOPIC 11: CHILD PSYCHIATRY

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HIGH-YIELD CHILD PSYCHIATRY TOPICS

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A. AUTISM SPECTRUM DISORDER (ASD)

1. Deficits in social-emotional reciprocity
2. Deficits in nonverbal communication
3. Deficits in developing/maintaining relationships

1. Stereotyped/repetitive motor movements, speech, use of objects
2. Insistence on sameness, inflexible routines
3. Highly restricted, fixated interests
4. Hyper/hyporeactivity to sensory input

• Asperger's Disorder, Autistic Disorder, PDD-NOS all merged into "Autism Spectrum Disorder"
• Two domains (social + RRB) instead of three (social, communication, RRB)
• Language delay is NOT a criterion

• Fragile X Syndrome (most common genetic cause of intellectual disability; also ASD)
• Tuberous Sclerosis
• Rett Syndrome (MECP2 mutation; X-linked dominant; affects girls)
• 22q11 deletion
• Heritability: ~80-90%

• Increased head circumference (macrocephaly) in first 2 years
• Mirror neuron dysfunction theory
• Elevated serotonin in blood platelets (one of most replicated findings)

• NO evidence linking MMR vaccine to ASD (Wakefield 1998 paper was fraudulent - retracted; Wakefield lost medical license)

• Applied Behavior Analysis (ABA) = gold standard behavioral intervention
• Social skills training, speech therapy, occupational therapy
• Risperidone and Aripiprazole = FDA-approved for irritability/aggression in ASD
• No drug treats core ASD symptoms

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B. ADHD

• ≥6 inattentive AND/OR ≥6 hyperactive-impulsive symptoms (≥5 if ≥17 years)
• Several symptoms before age 12 (changed from 7 in DSM-IV)
• ≥2 settings
• Functional impairment
• Not explained by another disorder

1. Combined (most common)
2. Predominantly Inattentive
3. Predominantly Hyperactive-Impulsive

• Prevalence: ~5% in children, ~2.5% in adults
• M:F in children: 2-3:1; in adults: more equal

• First-line: Stimulants (Methylphenidate/Ritalin; Amphetamine/Adderall)
• Non-stimulant first-line: Atomoxetine (NE reuptake inhibitor; good for comorbid anxiety or substance use risk)
• Non-stimulant 2nd line: Clonidine, Guanfacine (alpha-2 agonists)
• Bupropion: Useful but not first-line

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C. CONDUCT DISORDER vs OPPOSITIONAL DEFIANT DISORDER (ODD)

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D. INTELLECTUAL DISABILITY (ID)

• Replaces "Mental Retardation" in DSM-5
• 3 criteria: Deficits in intellectual functions + Deficits in adaptive functioning + Onset during developmental period

• Most common genetic cause worldwide: Down Syndrome (Trisomy 21)
• Most common inherited cause: Fragile X Syndrome
• Most common preventable cause: Iodine deficiency (globally) / Fetal Alcohol Syndrome (in developed countries)
• Most common in India: Iodine deficiency

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E. SPECIFIC LEARNING DISORDER (SLD)

• Includes dyslexia (reading), dysgraphia (writing), dyscalculia (math)
• Dyslexia: Phonological processing deficit; most common SLD
• Requires neuropsychological testing for diagnosis

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CHILD PSYCHIATRY MCQ PRACTICE

• A) Given its own chapter
• B) Removed from DSM entirely
• C) Merged into Autism Spectrum Disorder
• D) Renamed Pervasive Developmental Disorder

• A) Play therapy
• B) Applied Behavior Analysis (ABA)
• C) Psychodynamic therapy
• D) Cognitive processing therapy

• A) Lithium and Valproate
• B) Risperidone and Aripiprazole
• C) Methylphenidate and Atomoxetine
• D) Fluoxetine and Sertraline

• A) Before age 5
• B) Before age 7 (DSM-IV was 7; now:)
• C) Before age 12
• D) Before age 16

• A) Fetal Alcohol Syndrome
• B) Down Syndrome
• C) Iodine deficiency
• D) Fragile X Syndrome

• A) Chromosomal cause of ID
• B) Inherited/single-gene cause of intellectual disability
• C) Cause of Down syndrome
• D) X-linked dominant disorder

• A) Atomoxetine
• B) Methylphenidate (stimulant)
• C) Bupropion
• D) Clonidine

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CHILD PSYCHIATRY ANSWER KEY

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TOPIC 12: SOMATIC SYMPTOM & RELATED DISORDERS

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FULL TEACHING

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DSM-5 CLASSIFICATION

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A. SOMATIC SYMPTOM DISORDER (SSD)

• NEW in DSM-5: Does NOT require symptoms to be "medically unexplained" (can have real physical disease but excessive concern)
• Core = disproportionate thoughts/feelings/behaviors about symptoms

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B. ILLNESS ANXIETY DISORDER (IAD)

• Somatic symptoms absent or mild
• High anxiety about health
• Excessive health behaviors (checking, googling) OR avoidance
• ≥6 months duration
• Two subtypes: Care-seeking and Care-avoiding

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C. CONVERSION DISORDER (Functional Neurological Symptom Disorder)

• La belle indifférence - remarkable lack of concern about serious symptoms (not diagnostic but classic)
• Glove and stocking anesthesia (does not follow dermatomal pattern → functional)
• Paralysis, blindness, seizures, tremor (all functional - no organic cause)
• Hoover's Sign: Patient can't consciously raise a "paralyzed" leg but reflexively extends it when the other leg is lifted against resistance → confirms functional paralysis

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D. FACTITIOUS DISORDER

• Deliberately producing/faking symptoms for psychological gain (to assume sick role)
• NOT malingering (which is for external gain - money, avoiding work)

• Caregiver (usually mother) induces illness in child for secondary gain (attention, sympathy)
• Form of child abuse

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SOMATIC MCQ PRACTICE

• A) Illness Anxiety Disorder
• B) Somatic Symptom Disorder
• C) Conversion Disorder
• D) Functional Neurological Disorder

• A) Illness Anxiety Disorder
• B) Conversion Disorder (Functional Neurological Symptom Disorder)
• C) Somatic Symptom Disorder
• D) Malingering

• A) In malingering, the patient is not aware they are faking
• B) In factitious disorder, faking is for external gain; in malingering it is for psychological gain (sick role)
• C) Factitious disorder = faking for psychological gain (sick role); Malingering = faking for external gain
• D) They are the same condition

• A) Somatic Symptom Disorder with Proxy
• B) Factitious Disorder Imposed on Another (FDIA)
• C) Illness Anxiety Disorder Proxy Type
• D) Conversion Disorder, Proxy Type

• A) Malingering
• B) Functional (conversion) leg weakness
• C) Organic hemiplegia
• D) Lower motor neuron disease

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SOMATIC MCQ ANSWER KEY

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📋 MASTER RAPID REVISION SHEET — ALL DISORDERS

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SCHIZOPHRENIA
• DSM-5: 6mo total / 1mo active; ICD-11: 1mo only
• Pos symp = Mesolimbic excess DA
• Neg symp = Mesocortical deficit DA
• TRS → Clozapine; Monitor CBC weekly
• NMS: Stop drug + Dantrolene + Bromocriptine
• EPS: Akathisia → Propranolol | Dystonia → Benztropine
• Best prognosis: Female, late onset, acute, good premorbid

MOOD DISORDERS
• MDD: SIG E CAPS; F:M=2:1; 15-20% prevalence
• Atypical: mood reactive, hypersomnia, weight gain, MAOIs best
• Melancholic: diurnal variation, weight loss, no reactivity
• ECT = fastest treatment
• Fluoxetine = longest half-life; Paroxetine = worst discontinuation
• Mania: DIG FAST; ≥7 days; Bipolar II = hypomania only
• Lithium range: 0.6-1.2; Ebstein anomaly teratogenicity
• Valproate = mixed/rapid cycling; neural tube teratogenicity
• Lamotrigine = bipolar depression; SJS rash; titrate slowly
• NMS vs SS: NMS=rigid/slow; SS=hyperreflexia/rapid

OCD & ANXIETY
• OCD: ERP+SSRI; Clomipramine TCA; OFC-caudate circuit
• GAD: ≥6mo; buspirone; 3 of 6 symptoms; SSRIs
• Panic: SSRIs long-term; BZDs acute
• BII phobia: FAINTING (vasovagal not fight-flight)
• PTSD: >1mo; B+C+D+E clusters; EMDR, TF-CBT, SSRIs
• Prazosin for nightmares

PERSONALITY DISORDERS
• Cluster A (odd): Paranoid, Schizoid, Schizotypal
• Cluster B (dramatic): ASPD, BPD, Histrionic, Narcissistic
• Cluster C (anxious): Avoidant, Dependent, OCPD
• BPD: Splitting, DBT (Marsha Linehan), parasuicide
• Schizoid WANTS no relationships; Avoidant WANTS but fears

SUBSTANCE USE
• Alcohol DTs: 48-72hr; Benzodiazepines treatment
• Thiamine BEFORE glucose in alcoholics
• Wernicke: Ataxia+Confusion+Ophthalmoplegia (ACO)
• Korsakoff: Confabulation+anterograde amnesia
• Opioid OD: Naloxone; Maintenance: Buprenorphine/Methadone
• Cocaine: avoid beta-blockers; formication

NEUROCOGNITIVE
• Alzheimer: Amyloid plaques + tau tangles; AChE inhibitors
• APOE ε4 = most common risk factor
• DLB: fluctuating, visual hallucinations, parkinsonism; AVOID antipsychotics
• MMSE max=30; cutoff<24

EATING DISORDERS
• Anorexia: highest mortality; lanugo; Russell's sign; refeeding→hypophosphatemia
• Bulimia: Fluoxetine 60mg FDA approved; CBT gold standard
• BED: Lisdexamfetamine FDA approved

CHILD PSYCHIATRY
• ASD: DSM-5 merged all into one; ABA therapy; Risperidone/Aripiprazole FDA approved
• ADHD: before age 12 (was 7); Methylphenidate 1st line
• ID: Down=chromosomal; Fragile X=inherited; Iodine=India

SOMATIC
• Conversion: La belle indifférence; Hoover's sign
• Factitious=sick role; Malingering=external gain
• FDIA=Munchausen by Proxy
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⚠️ YOUR NEXT STEP

Q1:__ Q2:__ Q3:__ Q4:__ Q5:__
Q6:__ Q7:__ Q8:__ Q9:__ Q10:__
... and so on up to Q120

1. Mark each answer ✅ or ❌
2. Give a score with percentage
3. Explain why each answer is correct
4. Explain why each wrong option is wrong
5. Give memory tricks for every mistake you made
6. Tell you which topics need revision

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