How would you distinguish between an organic and functional psychosis? 1348 D01 2. Difference between psychosis and neurosis. 1348 J05 abnormal behavior. 3. Recognize difference between normal and D19(RS3) General Medicine 119 : 64/72 Reactive depression DVOSN BOLLOR Mini-mental state examination Mania-clinical manifestation. Write a note to on lithium carbonate Behavior therapy. Clinical recognition and initial therapy of psychiatric emergencies 10. Dementia (in the elderly). Clinical recognition of early and late dementias 12 Alzheimer's disease etiology and clinical features 13.Delirium tremens 14. Consequences of chronic alcohol misuse. 16. Lewy body dementia. 17. Substance misuse disorder-effects and 18 (Acute) schizophrenia. 18. Paranoid schizophrenia. 21. Psychosis-management. 22. Antipsychotic drugs-side 23. Mood disorders. 24. (Severe) depression-classification, clinical features, treatment.
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. 3. Recognize difference between normal and abnormal behavior Mini-mental state examination Mania-clinical manifestation. Write a note to on lithium carbonate Behavior therapy. Clinical recognition and initial therapy of psychiatric emergencies 10. Dementia (in the elderly). Clinical recognition of early and late dementias 12 Alzheimer's disease etiology and clinical features 13.Delirium tremens 14. Consequences of chronic alcohol misuse. 16. Lewy body dementia. 17. Substance misuse disorder-effects and 18 (Acute) schizophrenia. 18. Paranoid schizophrenia. 21. Psychosis-management. 22. Antipsychotic drugs-side 23. Mood disorders. 24. (Severe) depression-classification, clinical features, treatment. 25. Antidepressants 26. Bipolar affective disorder. 27. Panic disorder (panic attacks) 31. Lithium 32. Obsessive compulsive neurosis. 33. Somalization disorder 35. Chronic fatigue syndrome. 36. Conversion disorder. 37. Dissociative (conversion) disorder. 38. Anorexia nervosa. 40. Bulimia nervosa 41. Postpartum depression.
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Here is a comprehensive structured revision covering every topic on your list, drawing from Kaplan & Sadock's Synopsis and Comprehensive Textbook of Psychiatry, the Essentials of Forensic Medicine, and standard clinical knowledge.
Complete Psychiatry Revision Notes
1. Organic vs Functional Psychosis
| Feature | Organic Psychosis | Functional Psychosis |
|---|---|---|
| Cause | Identifiable brain/systemic disease (tumor, trauma, infection, drugs, metabolic) | No demonstrable structural cause |
| Onset | Often acute or subacute | Usually insidious (schizophrenia) or episodic (bipolar) |
| Consciousness | Impaired (clouding, confusion common) | Clear |
| Memory | Early and prominent impairment | Intact (except severe depression) |
| Orientation | Disoriented (time, place, person) | Oriented |
| Visual hallucinations | Common and prominent | Less common; auditory hallucinations dominate |
| Fluctuation | Symptoms fluctuate with time of day (worse at night) | More stable course |
| Cognitive deficits | Prominent (MMSE reduced) | Less prominent |
| Physical signs | Often present (tremor, jaundice, focal neuro signs) | Absent |
| EEG | Often abnormal | Usually normal |
| Examples | Delirium, dementia, drug-induced psychosis, epileptic psychosis, GPI | Schizophrenia, bipolar disorder |
Key mnemonic for organic features: MIDAS - Memory impaired, Impaired consciousness, Disorientation, Acute onset, Systemic signs.
2. Psychosis vs Neurosis
| Feature | Psychosis | Neurosis |
|---|---|---|
| Insight | Lost - patient does not recognize illness | Retained - patient aware something is wrong |
| Reality testing | Grossly impaired | Intact |
| Personality | Disorganized/disintegrated | Intact |
| Hallucinations | Present | Absent (may have pseudo-hallucinations) |
| Delusions | Present | Absent |
| Social functioning | Severely impaired | Partially maintained |
| Legal responsibility | May be diminished | Retained |
| Examples | Schizophrenia, manic psychosis, organic psychosis | Anxiety, phobia, OCD, hysteria, reactive depression |
3. Normal vs Abnormal Behavior
Criteria for abnormal behavior (the 4 Ds):
- Deviance - statistically or culturally unusual
- Distress - subjective suffering to the individual
- Dysfunction - impairs social, occupational, or personal functioning
- Danger - risk to self or others
Additional criteria: persistence over time, presence of a recognizable clinical syndrome.
Cultural context matters - what is abnormal in one culture may be normal in another (e.g., spirit possession rituals).
4. Mini-Mental State Examination (MMSE)
Folstein's MMSE - tests cognitive function, maximum score = 30.
| Domain | Max Score |
|---|---|
| Orientation (time) | 5 |
| Orientation (place) | 5 |
| Registration (repeat 3 words) | 3 |
| Attention & calculation (Serial 7s or WORLD backwards) | 5 |
| Recall (3 words after delay) | 3 |
| Language (naming 2 objects) | 2 |
| Repetition ("No ifs, ands, or buts") | 1 |
| 3-stage command | 3 |
| Reading ("Close your eyes") | 1 |
| Writing (write a sentence) | 1 |
| Visuospatial (copy intersecting pentagons) | 1 |
Scoring interpretation:
- 24-30: Normal
- 18-23: Mild cognitive impairment
- 12-17: Moderate dementia
- <12: Severe dementia
5. Mania - Clinical Manifestations
ICD-10/DSM-5: Elevated, expansive, or irritable mood lasting ≥1 week, with ≥3 of the following (DIGFAST):
- Distractibility
- Impulsivity / Indiscretion (risk-taking behavior)
- Grandiosity
- Flight of ideas / racing thoughts
- Activity increased (goal-directed) / Agitation
- Sleep decreased (need for sleep reduced, not insomnia)
- Talkativeness (pressure of speech)
Other features: Elevated libido, spending sprees, hypergraphia, psychotic features (mood-congruent grandiose delusions, auditory hallucinations) in severe cases.
Stages of mania: Hypomania → Acute mania → Delirious mania.
6. Lithium Carbonate
Indications: Acute mania, prophylaxis of bipolar disorder, augmentation of antidepressants, schizoaffective disorder.
Mechanism: Inhibits inositol monophosphatase, modulates second messenger systems (IP3/DAG), stabilizes neuronal membranes.
Therapeutic range: 0.6 - 1.2 mmol/L (prophylaxis: 0.4-0.8; acute mania: 0.8-1.2).
Side effects:
- Early/dose-related: Fine tremor, polyuria, polydipsia, nausea, diarrhea, weight gain, acne, psoriasis
- Toxic (>1.5 mmol/L): Coarse tremor, ataxia, dysarthria, confusion, seizures, coma, cardiac arrhythmias
Monitoring: U&E, TFTs, renal function, serum levels every 3-6 months; ECG baseline.
Contraindications: Renal failure, pregnancy (Ebstein's anomaly risk), severe cardiac disease, sodium-depleted states.
Drug interactions: NSAIDs, thiazides, ACE inhibitors all increase lithium levels (reduce renal clearance).
7. Behavior Therapy
A group of psychological treatments based on learning theory (classical and operant conditioning).
Techniques:
| Technique | Basis | Used for |
|---|---|---|
| Systematic desensitization | Classical conditioning - graded exposure + relaxation | Phobias, anxiety |
| Flooding/Implosion | Maximal exposure to fear stimulus | Phobias |
| Aversion therapy | Pair undesired behavior with aversive stimulus | Alcohol dependence, paraphilias |
| Token economy | Operant conditioning - rewards for desired behavior | Schizophrenia inpatients |
| Biofeedback | Awareness + control of physiological responses | Anxiety, tension headache |
| Cognitive Behavioral Therapy (CBT) | Alter maladaptive thoughts and behaviors | Depression, anxiety, OCD, PTSD |
| Exposure and Response Prevention (ERP) | Exposure + prevention of compulsive response | OCD |
| Social skills training | Modeling, role-play | Schizophrenia, autism |
8. Psychiatric Emergencies - Clinical Recognition & Initial Therapy
| Emergency | Recognition | Initial Management |
|---|---|---|
| Acute psychosis | Agitation, hallucinations, delusions, disorganized behavior | Haloperidol 5mg IM or oral olanzapine; lorazepam if needed; safe environment |
| Acute suicidal crisis | Expressed intent, plan, means, hopelessness | Remove means; inpatient admission; supportive crisis intervention |
| Delirium | Acute confusion, disorientation, altered consciousness, fluctuating course | Treat underlying cause; haloperidol low dose; reorientation; avoid restraints |
| Neuroleptic malignant syndrome | Hyperthermia, rigidity, altered consciousness, autonomic instability (after antipsychotic) | Stop antipsychotic; IV fluids; cooling; dantrolene/bromocriptine; ITU |
| Serotonin syndrome | Triad: altered mental status + autonomic instability + neuromuscular abnormalities | Stop offending drug; cyproheptadine; benzodiazepines; ITU if severe |
| Alcohol withdrawal/DTs | Tremor, agitation, seizures, hallucinations, autonomic hyperactivity | Chlordiazepoxide (reducing regime); thiamine (Pabrinex) IV; fluids |
| Acute panic attack | Palpitations, dyspnea, chest pain, derealization, fear of dying | Reassurance; breathing control; lorazepam if severe |
9. Dementia in the Elderly
Definition: Acquired, progressive, global impairment of memory, personality, cognition, and function without impaired consciousness, in a previously normal person.
Early dementia signs: Forgetting recent events, repetitive questioning, getting lost in familiar places, word-finding difficulties, personality change (irritability, withdrawal), impaired ADLs.
Late dementia signs: Severe memory loss (may not recognize family), complete disorientation, incontinence, loss of speech (aphasia), dysphagia, immobility, seizures, pressure sores, cachexia.
Reversible causes (DEMENTIA mnemonic): Drugs, Emotional (depression/pseudodementia), Metabolic (thyroid, B12, folate, electrolytes), Eyes/Ears (sensory deprivation), Normal pressure hydrocephalus, Toxins (alcohol), Infection (syphilis, HIV, CJD), Anatomic (SDH, tumor, abscess).
10. Alzheimer's Disease
Etiology:
- Amyloid cascade hypothesis - abnormal processing of amyloid precursor protein (APP) → Aβ42 deposition → senile plaques
- Neurofibrillary tangles (hyperphosphorylated tau protein)
- Loss of cholinergic neurons (basal nucleus of Meynert)
- Genetics: APP gene (chr 21), Presenilin 1 (chr 14), Presenilin 2 (chr 1); APOE ε4 allele = risk factor; Down syndrome patients universally develop AD pathology by 40s
Clinical features:
- Insidious onset, progressive decline
- Memory loss (episodic first, semantic later)
- Language: anomia → aphasia
- Visuospatial: getting lost, apraxia
- Executive dysfunction
- Behavioral: apathy, depression, wandering, aggression
- Late: incontinence, immobility, death from aspiration/infection
Neuropathology: Neuritic (senile) plaques, neurofibrillary tangles, granulovacuolar degeneration, amyloid angiopathy, cortical atrophy (hippocampus, parietal, frontal).
Management: Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild-moderate; memantine (NMDA antagonist) for moderate-severe; non-pharmacological: reality orientation, structured activities.
11. Lewy Body Dementia (DLB)
Core features (all 3 needed for probable DLB):
- Fluctuating cognition with pronounced variations in attention and alertness
- Recurrent visual hallucinations (well-formed, detailed - e.g., people or animals)
- Spontaneous parkinsonism (rigidity, bradykinesia, tremor)
Supportive features: REM sleep behavior disorder (acting out dreams), severe neuroleptic sensitivity (use of conventional antipsychotics can be fatal), repeated falls, syncope, delusions.
Pathology: Alpha-synuclein aggregates (Lewy bodies) in cortex and brainstem.
Treatment: Cholinesterase inhibitors (rivastigmine most evidence); avoid conventional antipsychotics (haloperidol - risk of severe/fatal reaction); memantine; levodopa for parkinsonism (low dose).
12. Delirium Tremens (DTs)
Definition: A severe, life-threatening form of alcohol withdrawal, typically occurring 48-72 hours after the last drink (up to 7 days).
Clinical features:
- Autonomic hyperactivity: tachycardia, hypertension, diaphoresis, fever
- Tremor (coarse, generalized)
- Agitation, confusion, disorientation
- Vivid hallucinations (visual most common - Lilliputian - also tactile, auditory)
- Seizures (typically within 24-48h of last drink, before DTs peak)
- Mortality: 5-15% if untreated, <1% with treatment
Management:
- Benzodiazepines (chlordiazepoxide fixed schedule or lorazepam IV in severe cases) - first line
- IV Thiamine (Pabrinex) BEFORE glucose - to prevent Wernicke's encephalopathy
- IV fluids, electrolyte replacement (esp. K+, Mg2+)
- Antipsychotics (haloperidol) only for persistent hallucinations not responding to BZDs
- ICU for severe cases
13. Consequences of Chronic Alcohol Misuse
CNS/Psychiatric:
- Wernicke's encephalopathy (confusion, ophthalmoplegia, ataxia - thiamine deficiency)
- Korsakoff's psychosis (anterograde amnesia, confabulation - irreversible)
- Peripheral neuropathy
- Cerebellar degeneration
- Alcohol-related dementia
- Alcoholic hallucinosis (auditory hallucinations in clear consciousness)
- Depression, anxiety, suicide risk
Systemic:
- Liver: Fatty liver → alcoholic hepatitis → cirrhosis → hepatocellular carcinoma
- GI: Gastritis, peptic ulcers, pancreatitis (acute/chronic), oesophageal varices
- CVS: Cardiomyopathy, hypertension, arrhythmias (Holiday Heart)
- Haematological: Macrocytosis, thrombocytopenia, anaemia
- Metabolic: Hypoglycemia, hypomagnesemia, hypokalemia, gout
- Endocrine: Pseudo-Cushing's, sexual dysfunction, testicular atrophy
- Social: Domestic violence, accidents, occupational dysfunction, crime
14. Schizophrenia
Acute Schizophrenia (DSM-5: 2+ symptoms for ≥1 month, total duration ≥6 months)
Positive symptoms: Hallucinations (auditory - third-person, running commentary, thought echo), delusions (persecutory, reference, control, grandiose), thought disorder (loosening of associations, tangentiality), disorganized behavior.
Schneider's First Rank Symptoms (diagnostic importance):
- Thought insertion/withdrawal/broadcasting
- Delusions of control/passivity
- Third-person auditory hallucinations (voices arguing, commenting)
- Delusional perception
Negative symptoms: Alogia (poverty of speech), affective flattening, avolition, anhedonia, asociality.
Cognitive symptoms: Impaired working memory, executive function, processing speed.
Paranoid Schizophrenia
The most common subtype:
- Prominent persecutory or grandiose delusions
- Auditory hallucinations consistent with the delusions
- Relatively preserved affect and cognition (better prognosis)
- Systematic, organized delusional system
- May be associated with hostility and aggression
15. Psychosis - Management
Acute phase:
- Safety: hospitalize if risk to self/others
- Antipsychotic: oral (risperidone, olanzapine) preferred; IM (haloperidol, lorazepam) if agitated
- De-escalation, low-stimulation environment
Maintenance:
- Continue antipsychotic for ≥2 years after first episode, longer for recurrent
- Clozapine for treatment-resistant schizophrenia (2 failed antipsychotic trials)
- Psychosocial: CBT for psychosis, family therapy, supported employment
Physical health monitoring: Weight, glucose, lipids, BP, ECG (QTc with antipsychotics)
16. Antipsychotic Drugs - Side Effects
Typical (1st generation - e.g., haloperidol, chlorpromazine)
| Category | Side Effects |
|---|---|
| Extrapyramidal (EPS) | Acute dystonia, akathisia, Parkinsonism, tardive dyskinesia |
| Endocrine | Hyperprolactinaemia → galactorrhea, amenorrhea, sexual dysfunction |
| Anticholinergic | Dry mouth, urinary retention, blurred vision, constipation |
| Sedation | Particularly chlorpromazine |
| Cardiovascular | Postural hypotension, QTc prolongation |
| Metabolic | Weight gain (mainly atypicals) |
| Serious rare | Neuroleptic Malignant Syndrome (NMS), agranulocytosis (clozapine) |
Atypical (2nd generation - e.g., olanzapine, risperidone, clozapine, quetiapine)
- Less EPS, less tardive dyskinesia
- More metabolic: weight gain, diabetes, dyslipidemia (especially olanzapine, clozapine)
- Clozapine: agranulocytosis (1%), mandatory regular FBC monitoring; also seizures, myocarditis, hypersalivation
Tardive dyskinesia: Irreversible involuntary movements (oro-facial, limb) from chronic D2 blockade. Managed by stopping drug if possible or switching to clozapine.
17. Mood Disorders
Classification (DSM-5):
- Depressive disorders: Major depressive disorder (MDD), persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, seasonal affective disorder
- Bipolar and related disorders: Bipolar I (full mania), Bipolar II (hypomania + depression), cyclothymia
18. Severe Depression - Classification, Clinical Features, Treatment
ICD-10 Classification:
- Core symptoms (at least 2): Low mood, anhedonia, fatigue/loss of energy
- Other symptoms: Poor concentration, low self-esteem, guilt, hopelessness, disturbed sleep, reduced appetite, suicidal thoughts, psychomotor changes
- Mild = 4 symptoms; Moderate = 5-6; Severe = 7+ including all 3 core
Biological (somatic/melancholic) features: Early morning wakening, diurnal variation (worse in AM), psychomotor retardation, anorexia with weight loss, loss of libido, anhedonia.
Psychotic depression: Mood-congruent delusions (guilt, poverty, nihilism - Cotard's syndrome), hallucinations.
Treatment:
- Mild: Psychological therapy (CBT, counseling), watchful waiting
- Moderate-severe: Antidepressant + CBT
- Severe/psychotic: Antidepressant + antipsychotic; ECT for severe, treatment-resistant, or life-threatening
- SSRIs first line; SNRIs if inadequate response; TCAs/MAOIs reserved for refractory cases
19. Antidepressants
| Class | Examples | Mechanism | Key Side Effects |
|---|---|---|---|
| SSRI | Fluoxetine, sertraline, citalopram, escitalopram | Serotonin reuptake inhibition | GI upset, sexual dysfunction, insomnia, serotonin syndrome (rare) |
| SNRI | Venlafaxine, duloxetine | 5-HT + NE reuptake inhibition | Hypertension, sweating, discontinuation syndrome |
| TCA | Amitriptyline, imipramine, clomipramine | 5-HT + NE reuptake + anticholinergic | Cardiotoxic in OD, sedation, dry mouth, urinary retention |
| MAOI | Phenelzine, tranylcypromine | MAO inhibition → ↑amines | Hypertensive crisis with tyramine (cheese reaction), drug interactions |
| NaSSA | Mirtazapine | α2 blockade + 5-HT2/3 blockade | Sedation, weight gain, rarely agranulocytosis |
| NDRI | Bupropion | DA + NE reuptake | Seizures, insomnia, no sexual side effects |
All antidepressants: Take 2-6 weeks to work; continue 6 months after remission; discontinuation syndrome if stopped abruptly.
20. Bipolar Affective Disorder
Bipolar I: ≥1 manic episode (may include depressive episodes)
Bipolar II: Recurrent depressive episodes + hypomanic episodes (no full mania)
Cyclothymia: Chronic, fluctuating mood with hypomanic and depressive symptoms not meeting full criteria
Management:
- Acute mania: Lithium, valproate, or atypical antipsychotic (olanzapine, quetiapine); if psychotic add antipsychotic
- Acute depression: Quetiapine, lamotrigine; antidepressants with caution (risk of switching to mania)
- Prophylaxis: Lithium (gold standard), valproate, lamotrigine (esp. for depressive phase), olanzapine
- Psychoeducation, regular sleep, avoid alcohol/drugs
21. Panic Disorder (Panic Attacks)
Panic attack: Abrupt surge of intense fear with ≥4 of: palpitations, sweating, trembling, dyspnea, choking, chest pain, nausea, dizziness, derealization/depersonalization, fear of dying, fear of losing control, paresthesias, chills/hot flushes - peaks within 10 minutes.
Panic disorder: Recurrent unexpected attacks + persistent worry about further attacks or maladaptive behavior changes.
Treatment:
- Psychological: CBT (first line) - teaches interoceptive exposure, breathing control
- Pharmacological: SSRIs/SNRIs (first line long-term); benzodiazepines for acute relief only (risk of dependence)
- Avoid caffeine, alcohol
22. Obsessive-Compulsive Disorder (OCD)
Obsessions: Intrusive, recurrent, ego-dystonic thoughts, images, or urges (recognized as products of one's own mind) → cause anxiety.
Compulsions: Repetitive behaviors or mental acts performed to neutralize the anxiety from obsessions.
Common themes: Contamination, symmetry/order, harm, forbidden thoughts, religion.
Treatment:
- CBT with Exposure and Response Prevention (ERP) - first line
- SSRIs (higher doses than depression: fluoxetine up to 80mg) - first line pharmacotherapy
- Clomipramine (TCA with anti-OCD properties) - second line
- Refractory: augmentation with antipsychotics; deep brain stimulation
23. Somatization Disorder
Definition: Multiple, recurrent, and frequently changing physical symptoms of ≥2 years duration, not explained by physical disease, for which medical help has been sought.
Features: Multiple system involvement (GI, neurological, pain, sexual), illness behavior, frequent doctor consultations, repeated investigations, medical treatments, disability out of proportion to objective findings, often comorbid anxiety/depression.
DSM-5 term: Somatic symptom disorder.
Management: Establish therapeutic alliance; regular scheduled appointments (not symptom-driven); avoid invasive investigations; CBT; antidepressants (for comorbid depression/anxiety); graded exercise.
24. Chronic Fatigue Syndrome (CFS / Myalgic Encephalomyelitis)
Diagnosis (requires all):
- Profound fatigue ≥6 months, new onset, not lifelong, not improved by rest
- Post-exertional malaise (key feature - worsening after exertion)
- Unrefreshing sleep
- Cognitive impairment ("brain fog") and/or orthostatic intolerance
Exclusion: Rule out treatable causes (hypothyroidism, anaemia, sleep apnea, depression).
Management:
- Pacing (activity management) - avoid "boom and bust"
- Specialist MDT input
- CBT for associated psychological distress
- Sleep hygiene; low-dose antidepressant for pain/sleep
- Note: Graded exercise therapy (GET) is now NOT recommended (NICE 2021 guideline change)
25. Conversion Disorder / Dissociative (Conversion) Disorder
Definition (ICD-10: Dissociative disorders; DSM-5: Functional Neurological Symptom Disorder):
Loss of or alteration in motor, sensory, or consciousness function, temporally related to psychosocial stress, without demonstrable neurological disease.
Positive diagnostic features:
- Hoover's sign (hip extension weakness resolves when contralateral hip flexed)
- Variable weakness (changes with distraction)
- Non-anatomical sensory loss (splitting at midline)
- Inconsistency on examination
- La belle indifférence (lack of concern about symptoms - not reliable/pathognomonic)
- Symptoms may be reinforced by attention/secondary gain
Types: Motor (paralysis, abnormal movements), sensory (anesthesia, blindness, deafness), seizures (pseudo-seizures/NEAD), fugue, stupor, amnesia.
Management: Explain diagnosis honestly but non-blaming; physiotherapy for motor symptoms; psychotherapy (psychodynamic or CBT); address underlying stress/trauma; avoid iatrogenic harm.
26. Anorexia Nervosa
Diagnostic criteria (DSM-5):
- Restriction of energy intake → significantly low body weight
- Intense fear of gaining weight or persistent behavior preventing weight gain
- Disturbance in self-perception of body weight/shape
Types: Restricting type vs Binge-purge type.
Physical complications: Amenorrhea, lanugo, bradycardia, hypotension, peripheral edema, hypothermia, electrolyte disturbances (hypokalemia, hypophosphatemia), osteoporosis, Russells sign (calluses on knuckle in purging type), parotid enlargement, QTc prolongation.
Refeeding syndrome: Hypophosphatemia when nutrition restarted - monitor and supplement.
Management: Weight restoration (inpatient if BMI <15 or rapid weight loss or medical instability); psychological therapy (family-based therapy in adolescents; CBT-E in adults); nutritional counseling; treat complications; olanzapine (modest evidence for weight gain).
27. Bulimia Nervosa
Criteria: Recurrent binge eating (large amounts in discrete time period with loss of control) + recurrent compensatory behaviors (purging, laxatives, fasting, exercise), ≥1 per week for ≥3 months; self-evaluation unduly influenced by body shape/weight.
Physical complications: Electrolyte imbalance (hypokalemia - risk of arrhythmia), dental erosion (acid), parotid enlargement, Mallory-Weiss tears, constipation (laxative abuse), Russells sign.
Management: CBT-BN (first line); high-dose fluoxetine 60mg (only SSRI licensed for bulimia); self-help programmes.
28. Postpartum (Postnatal) Depression
Distinguish from:
- Baby blues (50-80%): Days 3-5, transient tearfulness, mood lability - reassurance only
- Postnatal depression (10-15%): Weeks to months after birth, meets criteria for MDD
- Puerperal psychosis (0.1-0.2%): Within first 2 weeks, severe - manic/psychotic features, risk to infant - psychiatric emergency
PND clinical features: Low mood, anhedonia, anxiety (often prominent), intrusive thoughts about harming baby (ego-dystonic), guilt, exhaustion, impaired bonding.
Management:
- Mild: Self-help, counseling, peer support
- Moderate-severe: SSRIs (sertraline preferred - safest in breastfeeding); CBT
- Severe/psychotic: Inpatient (mother-baby unit if possible); antipsychotics; ECT in life-threatening cases
29. Reactive Depression
A depressive episode that is clearly precipitated by an identifiable psychosocial stressor (bereavement, relationship breakdown, job loss). Features are similar to MDD but:
- More obvious precipitant
- Mood may still be reactive (can be lifted by positive events - unlike endogenous/melancholic depression)
- Less biological features
Note: ICD-11 now uses "Prolonged Grief Disorder" for grief-specific presentations.
Management: Counseling, supportive therapy, brief psychodynamic therapy; SSRIs if meets MDD criteria.
30. Substance Misuse Disorder
DSM-5 Substance Use Disorder criteria (≥2 in 12 months):
Impaired control (taking more than intended, failed attempts to cut down, craving, time spent obtaining/using), social impairment (failure to fulfill roles, withdrawal from activities), risky use, pharmacological (tolerance, withdrawal).
Effects by substance:
| Substance | Intoxication | Withdrawal |
|---|---|---|
| Alcohol | Disinhibition, sedation, ataxia | Tremor, seizures, DTs |
| Opioids | Euphoria, miosis, respiratory depression | Rhinorrhea, myalgia, diarrhea, craving |
| Stimulants (cocaine, amphetamine) | Euphoria, tachycardia, paranoia | Crash, hypersomnia, depression |
| Cannabis | Relaxation, paranoia, amotivation | Mild withdrawal (irritability, insomnia) |
| Benzodiazepines | Sedation, amnesia | Seizures, anxiety (similar to alcohol) |
| Hallucinogens (LSD) | Perceptual distortions, HPPD | Minimal physical withdrawal |
Sources: Kaplan & Sadock's Synopsis of Psychiatry; Stahl's Essential Psychopharmacology; The Maudsley Prescribing Guidelines in Psychiatry 15th ed.; Essentials of Forensic Medicine & Toxicology 36th ed.; DSM-5/ICD-10; NICE guidelines.
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