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Mental health vvi question

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I now have comprehensive material to compile a thorough VVI (Very Very Important) topic list for mental health exams. Here is the full organized list:

Mental Health - VVI Exam Topics

(Source: Kaplan & Sadock's Synopsis of Psychiatry + Comprehensive Textbook of Psychiatry)

1. SCHIZOPHRENIA

DSM-5 Diagnostic Criteria (need ≥2 of the following, at least 1 from first 3):
  1. Delusions
  2. Hallucinations
  3. Disorganized speech
  4. Grossly disorganized behavior or catatonia
  5. Negative symptoms (flat affect, alogia, avolition)
  • Duration: Symptoms continuously present for ≥6 months (DSM-5); ICD-10 requires only 1 month
  • Subtypes (ICD-10): Paranoid, Hebephrenic (disorganized), Catatonic, Undifferentiated, Residual
  • Catatonic features: Stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, stereotypies
Key points for exams:
  • Hallucinations/delusions are NOT mandatory if ≥2 criteria are met
  • Functional impairment is required (DSM-5 only)
  • Must exclude: substances, medical conditions, schizoaffective disorder
Treatment:
  • First-line: Atypical (second-generation) antipsychotics - risperidone, olanzapine
  • Clozapine: reserved for treatment-resistant cases; risk of agranulocytosis (requires CBC monitoring)
  • Negative symptoms respond poorly to typical antipsychotics; aripiprazole, sulpiride, low-dose clozapine helpful

2. DEPRESSION (Major Depressive Disorder)

DSM-5: ≥5 symptoms for ≥2 weeks, at least one must be depressed mood OR anhedonia:
  • Depressed mood, Anhedonia, Sleep change (insomnia/hypersomnia), Appetite/weight change, Psychomotor agitation or retardation, Fatigue, Worthlessness/guilt, Concentration difficulties, Suicidal ideation
Depression vs. Dementia (Pseudodementia) - VVI Table:
FeatureDepressionDementia
OnsetDatable with precisionOnly within broad limits
Symptom durationShort before seeking helpLong before seeking help
Patient complaintsEmphasizes disabilities, "don't know" answersConceals disability, near-miss answers
Social skillsLost earlyOften retained
InsightGoodPoor
Nocturnal worseningUncommonCommon (sundowning)
Response to antidepressantsYesNo
Treatment of Depression:
  • First-line: SSRIs (fluoxetine, sertraline, escitalopram)
  • Second-line: SNRIs (venlafaxine, duloxetine), MAOIs, TCAs
  • Augmentation: Aripiprazole, quetiapine, lurasidone, lithium, lamotrigine
  • Atypical depression: MAOIs preferred
  • Emotional lability/rapid cycling: Lithium, Lamotrigine, Valproate
  • Avoid TCAs in rapid cycling (risk of switching to mania)

3. BIPOLAR DISORDER

Manic episode criteria (DSM-5): Elevated/expansive/irritable mood + increased goal-directed activity/energy for ≥1 week (or any duration if hospitalization needed), PLUS ≥3 of:
  • Grandiosity, decreased sleep need, pressured speech, flight of ideas, distractibility, increased goal-directed activity, reckless behavior (DIGFAST mnemonic)
Types:
  • Bipolar I: Full manic episode (may or may not have depression)
  • Bipolar II: Hypomania + major depression (NO full mania)
  • Cyclothymia: ≥2 years of hypomanic + depressive symptoms not meeting full criteria
Treatment of Acute Bipolar Depression:
  • First-line: Lithium, Lamotrigine, Quetiapine, Lurasidone
  • Avoid standard antidepressants as monotherapy (risk of switching to mania)
  • Emotional lability/rapid cycling: Lithium, Valproate, Lamotrigine
Lithium key facts:
  • Monitoring: Serum levels, thyroid, renal function
  • Teratogenic: Ebstein's anomaly (cardiac)
  • Toxicity signs: Tremor, ataxia, confusion, arrhythmias

4. ANXIETY DISORDERS

Drug Treatment Summary:
Symptom TypeFirst-lineAlternatives
Chronic cognitive anxietySSRIs, SNRIsMAOIs, buspirone, valproate
Chronic somatic/physicalSNRIs (duloxetine), MAOIsPregabalin, beta-blockers, TCAs
Obsessions (OCD)SSRIsClomipramine (TCA), quetiapine
Acute severe anxietyMirtazapine, quetiapineClonazepam, valproate
  • GAD: SSRIs, SNRIs, buspirone, pregabalin (NOT benzodiazepines as first-line)
  • Panic disorder: SSRIs, imipramine; avoid abrupt benzodiazepine withdrawal
  • Social anxiety (SAD): SSRIs, MAOIs (phenelzine), beta-blockers (situational)
  • PTSD: SSRIs (sertraline, paroxetine - FDA approved)

5. SUICIDE RISK ASSESSMENT

High-risk factors (VVI):
  • Male sex, age >45 years
  • Previous suicide attempt (single strongest predictor)
  • No social support / social isolation
  • Alcohol or substance dependence
  • Severe/incapacitating medical illness with pain
  • Hopelessness (Beck's Hopelessness Scale - better predictor than depression severity alone)
  • Family history of suicide
  • Access to means (firearms, medications)
SAD PERSONS Scale (mnemonic for risk factors): S - Sex (male), A - Age, D - Depression, P - Previous attempt, E - Ethanol use, R - Rational thinking loss, S - Social support lacking, O - Organized plan, N - No spouse, S - Sickness
Clinical rule: Psychiatric admission is indicated if a patient is actively suicidal. Nearly 75% of suicide completers had seen a physician in the preceding weeks.

6. PERSONALITY DISORDERS

Cluster A (Odd/Eccentric): Paranoid, Schizoid, Schizotypal Cluster B (Dramatic/Emotional): Antisocial, Borderline, Histrionic, Narcissistic Cluster C (Anxious/Fearful): Avoidant, Dependent, Obsessive-Compulsive
Borderline PD treatment (VVI):
  • Psychotherapy (especially DBT - Dialectical Behavior Therapy) is first-line
  • Pharmacotherapy by target symptom:
    • Affective instability: Lithium, SSRIs, valproate
    • Impulsivity/aggression: Lithium, SSRIs, anticonvulsants
    • Psychotic symptoms: Low-dose atypical antipsychotics
    • Avoid benzodiazepines (disinhibition risk)

7. PSYCHOPHARMACOLOGY QUICK REFERENCE

Antipsychotics:
  • Typical (1st gen): Haloperidol, chlorpromazine - high risk EPS (extrapyramidal side effects), tardive dyskinesia
  • Atypical (2nd gen): Risperidone, olanzapine, quetiapine, aripiprazole, clozapine
  • Neuroleptic Malignant Syndrome (NMS): Hyperthermia, rigidity, altered consciousness, autonomic instability - treat with bromocriptine, dantrolene
Antidepressants:
  • SSRIs: Fluoxetine (longest half-life), sertraline, paroxetine (most anticholinergic), citalopram, escitalopram
  • SNRI: Venlafaxine (dose-dependent BP increase), duloxetine
  • TCA: Amitriptyline, imipramine - lethal in overdose (cardiac arrhythmia)
  • MAOI: Phenelzine, tranylcypromine - tyramine-free diet required (hypertensive crisis)
  • Mirtazapine: Weight gain, sedation; useful in depression with insomnia/poor appetite
  • Bupropion: No sexual side effects, lowers seizure threshold, used in smoking cessation
Mood stabilizers:
  • Lithium, valproate, carbamazepine, lamotrigine
  • Carbamazepine: P450 inducer, autoinduction; Stevens-Johnson syndrome risk
  • Lamotrigine: Best for bipolar depression; rash risk (titrate slowly)

8. ELECTROCONVULSIVE THERAPY (ECT)

Indications:
  • Severe/psychotic depression not responding to medications
  • Catatonia
  • Acute mania unresponsive to pharmacotherapy
  • Depression in pregnancy (when drugs are unsafe)
Absolute contraindications: None (relative: raised ICP, recent MI, severe cardiopulmonary disease) Side effects: Short-term memory loss (anterograde > retrograde), confusion, headache

9. SLEEP DISORDERS

Key Disorders:
  • Insomnia: CBT-I is first-line (not benzodiazepines long-term)
  • Narcolepsy: Cataplexy + excessive daytime sleepiness + sleep paralysis + hypnagogic hallucinations; treat with modafinil, sodium oxybate
  • REM sleep behavior disorder: Acting out dreams, associated with Parkinson's, Lewy body dementia
  • Obstructive Sleep Apnea: First-line treatment is CPAP

10. SPECIAL TOPICS (Frequently Tested)

Delirium vs. Dementia vs. Schizophrenia:
  • Delirium: Acute onset, fluctuating, impaired attention, reversible
  • Dementia: Chronic, insidious, memory-dominant, progressive
  • Schizophrenia: No global cognitive deficit in early stages; thought disorder prominent
Eating Disorders:
  • Anorexia Nervosa: BMI <17.5; lanugo hair, amenorrhea, osteoporosis; highest mortality of all psychiatric disorders
  • Bulimia Nervosa: Binge-purge cycles; electrolyte disturbances (hypokalemia), dental erosion, Russell's sign (calluses on knuckles); treat with SSRIs + CBT
ADHD:
  • First-line pharmacotherapy: Methylphenidate (stimulant), amphetamines
  • Non-stimulant alternatives: Atomoxetine (SNRI), clonidine, guanfacine
Autism Spectrum Disorder:
  • No FDA-approved medication for core symptoms
  • Aripiprazole and risperidone: FDA-approved for irritability in ASD
Sources: Kaplan & Sadock's Synopsis of Psychiatry; Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Stahl's Essential Psychopharmacology - all available in the medical textbook library.
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