Psychiatry Question And Answers

Classifiatory Systems in Psychiatry

Question 1. Describe and discuss important signs and symptoms of common mental disorders. Mental Status Examination (Systemic Examination in Psychiatry)
Answer:

It involves the following areas:

General Appearance and Behavior

• Grooming: Note whether the patient is well-groomed or has poor hygiene, e.g., overdressed for the occasion/unkempt
  Posture (e.g., drooping of shoulders)
• Facial expressions, e.g., happy, sad, Otto Veraguth sign (increased forehead marking seen in depression), worried, excess perspiration, and tensed voice (signs of anxiety)

Read And Learn More: General Medicine Question And Answers

• Eye-to-eye contact made or not
• Attitude towards examiner (e.g., co-operative/hostile/agitated)
• Psychomotor activity: Motor execution of psychic events (e.g., restlessness/retardation)

Classifiatory Systems in Psychiatry Speech

• Assess fluency, speed, volume, and tone
• Example: Slow and low tone speech in depression, excessive and high tone speech in mania

Classifiatory Systems in Psychiatry Thought Abnormalities

• Thought formation—Is the speech coherent? Or is there a loosening of association? (Suggests schizophrenia)
• Thought possession—Ask the patient if the thoughts are his own or if it is controlled by an external source. It can be:
  • Thought insertion—Someone else’s thoughts are being put in one’s mind.
  • Thought withdrawal—One’s thoughts are being removed from one’s mind.
  • Thought broadcast—Many people are getting to know their thoughts.
• Thought stream—Speed: increased (flight of ideas), decreased (inhibition, slowing of thinking).
• Thought continuity—Perseveration (repetition beyond the point of relevance), thought block.
• Thought content—Determined by asking “What are your main concerns?” Look for the presence of delusions and obsessions.

Question 2. Define delusion. Give examples.
Answer:

Delusion

It is a false belief held with strong conviction despite superior evidence to the contrary (strongly held false beliefs). It is a disorder of thought content.

Types of delusion:

• Persecutory, For Example, the belief that others are out to harm me
• Grandiose, For Example, belief that one has special powers or status (suggests mania)
• Nihilistic, For Example., the conviction that “My head is missing”, “I have nobody”, or “I am dead”.
• Erotomanic delusion (For Example, believing a movie star secretly loves them)
• Somatic delusion (For Example, believing the head is filled with air/worms—parasitosis)
• Delusion of reference (For Example, the belief that the story in a book is referring to them)
• Delusion of control/passivity (For Example, believing one’s thoughts and movements are controlled by aliens).
• Other delusions are delusions of jealousy/ infidelity/ guilt/ misinterpretation/parasitosis, hypochondriacal delusion, and fantastic/bizarre delusion
• In contrast, overvalued ideas are strongly held but not fixed.

Question 3. Define obsession.
Answer:

Obsessions

These are persistent, recurrent, unwanted thoughts/ ideas/impulses/ images that seem to invade a person’s consciousness and hence cause marked anxiety/distress.

The theme of obsessions can be of the following types:

• Cleanliness: Fears of contamination
• Symmetry and numbers: Reading the same line a particular number of times.
• Forbidden or taboo thoughts: Aggressive, sexual, and religious obsessions
• Harm (e.g., thoughts about harm to oneself or others)

Obsessions Mood and Affect

• Mood (subjective long-term emotional state): Ask the patient how he feels, For Example, sad/happy/anxious/tensed/worried
• Affect (objective short-lived emotional state) is assessed by observing facial expression, posture, and movements, For Example, depressed/elated/anhedonic (inability to experience pressure from previously pleasurable activities)
• Elevated mood with excess energy and reduced need for sleep (suggests mania) Feeling guilty or hopeless (suggests depression). Note whether the patient has thoughts of self-harm. If so, enquire about plans.

Feeling excessively worried about many things (suggests anxiety).

Perceptual Abnormalities

Assess for the presence of hallucination or illusion.

Question 4. Define hallucination. Give examples.
Answer:

Hallucination

• It is perception in the absence of corresponding external stimuli, i.e., sensory experiences of stimuli that are not actually present.
• It is a disorder of thought perception.
• It can occur in any sensory modality; most common in psychiatric disorders being auditory (thought echo, command hallucination, running commentary) and most common in organic psychiatric disorders being visual (e.g., seeing “visions”, Lilliputian hallucination).
• Other types include tactile (cocaine bug); superficial/
  kinesthetic/visceral, olfactory, gustatory, and complex hallucinations.
• In narcolepsy, two specific hallucinations are seen. Hypnagogic: They occur when falling asleep. Hypnopompic: They occur on waking.

Pseudohallucination: Phenomenon lying in between true hallucination and mental imagery

• Hare described it as a hallucination with insight
• Jasper described it as a hallucination occurring in inner subjective space
• Kandinsky described it as mental imagery that is clear

In contrast, illusions are misperceptions of real external stimuli (e.g., mistaking a shrub for a person in poor light)

Cognitive Functions

Level of consciousness and alertness: Important in case of delirium.

Normal consciousness: Alert, vigilant, and lucid Orientation to time, place, and person (For Example, ask what time is it? Where are you now? Ability to recognize family members)

• Attention and concentration: It is assessed by serial subtraction test (100 7) in which the patient is asked to subtract 7 from 100 and then 7 from the answer and so on.
• Memory

Question 5. Discuss how is memory tested clinically. Based on the length of storage of memory
Answer:

• Registration/Immediate: It is judged by asking the patient to repeat simple new information (For Example, name and address) immediately after hearing it. It is dependent on attention and concentration.
• Recent: It is judged by asking the patient to repeat msimple new information (as mentioned above) after an interval of 1–2 minutes during which time the patient’s attention should be diverted elsewhere or 24 hours recall.
• Remote: It is judged by asking the patient to recall past events (>24 hours).

Based on the type of information

• Implicit/Procedural memory: It does not require conscious attention to recall (e.g., memory for procedures, skills, and habits).
• Explicit/Declarative Memory: It requires conscious attention to recall. It can be further classified into episodic memory (for specific events and contexts) and semantic memory (for vocabulary and concepts).

Memory  Intellectual Ability

It can be assessed by asking about general knowledge, calculation, and vocabulary.

Memory  Abstract Ability

It can be assessed using similarity tests (For Example, What is the the similarity between chair and table) and proverb test (ability to understand the inner meaning of a proverb).

Memory Judgment

It can be assessed by giving a certain test situation and asking how would the patient respond, For Example, What would you do if you found an addressed letter on road.

Memory Insight

It refers to patients’ understanding of one’s illness, its cause, and the need for treatment.

Lack of insight, i.e., failure to accept that one is ill and/or in need of treatment and is a feature of psychotic disorders.  Grading of insight is described in the color box.

Memory Psychopharmacology

Drugs used in psychiatry:

• Antipsychotics: For psychosis
• Antidepressants: For depression
• Mood stabilizers: For bipolar affective disorders
• Antianxiety drugs: For anxiety disorders

The structure involved in memory Function Cortical:

Grading of Insight

• Grade 1: Complete denial of illness
• Grade 2: Slight awareness of being ill and needing help, but denying it at the same time.
• Grade 3: Aware of being ill, but blaming it on others, external factors or on organic factors.
• Grade 4: Aware of being ill, but attributing it to internal unknown factors
• Grade 5: Intellectual insight—aware of being ill and that the symptoms are due to disturbance in thoughts/feelings/behavior but unable to apply this knowledge to current/future experiences
• Grade 6: True emotional insight—aware of being ill and that the
  symptoms are due to disturbance in thoughts/feelings/behavior and also is able to apply this knowledge to bring about changes in behavior.

Question 6. Write a short note on antipsychotic drugs.
Answer: Classification of Antipsychotics Drugs

Typical antipsychotics/first generation:

• Phenothiazines (chlorpromazine, perphenazine, fluphenazine, and thioridazine)
• Thioxanthenes (flupentixol and zuclopenthixol)
• Butyrophenones (haloperidol and droperidol)

Atypical antipsychotics/second generation:

• Aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, and ziprasidone.

Mechanism of action of most first and second-generation antipsychotics: It appears to be a postsynaptic blockade of brain dopamine D2 receptors Exceptions:

• Aripiprazole and brexpiprazole are D2 receptor partial agonists
  • Cariprazine is a D3-preferring D3/D2 receptor partial agonist
  • Pimavanserin is a serotonin 5HT2A inverse agonist and antagonist with no dopamine D2 affinity

Antipsychotic drugs and their function

Antipsychotic drugs Indications

• Psychomotor agitation: High-potency APMs (haloperidol) parenteral.
• Schizophrenia: Treatment of choice for acute psychotic
  episodes and for prophylaxis.
• Other psychotic disorders: Treatment of psychotic disorders due to general medical conditions and substances, delusional disorder, brief psychotic disorder, schizophreniform disorder, and other rarer psychotic disorders.
• Mood disorders: Treatment of agitation and psychosis during mood episodes.
• Sedation: Useful when benzodiazepines are contraindicated (especially in older patients) or as an adjunct during anesthesia.
• Movement disorders: Treatment of choice for Huntington disease and Tourette’s disorder.

General Adverse Effects

• Sedation: Due to the antihistaminic activity.
• Hypotension: The effect is due to alpha-adrenergic blockade and is most common with low-potency antipsychotic medications.
• Anticholinergic symptoms: Dry mouth, blurred vision, urinary hesitancy, constipation, bradycardia, confusion, and delirium.
• Endocrine effects: Gynecomastia, galactorrhea, and amenorrhea (secondary to hyperprolactinemia).
• Dermal and ocular syndromes: Photosensitivity, abnormal pigmentation, and cataracts. Thioridazine can cause retinitis pigmentosa.
• Cardiac conduction abnormalities: Ziprasidone prolongs QT interval.
• Agranulocytosis: Clozapine
• Movement syndromes: Tardive dyskinesia (TD)
• Extrapyramidal syndromes (EPS): Newer APMs cause minimal or no EPS. Low-potency APMs (For Example, chlorpromazine, thioridazine) cause less EPS than higher-potency APMs but has more sedative effects.
• Metabolic syndrome: Weight gain, diabetes, and dyslipidemia
• Cholestatic jaundice
• Neuroleptic malignant syndrome

Question 7. Write a short note on:

• Antidepressants/newer antidepressants
• Tricyclic antidepressants
• Selective serotonin reuptake inhibitors (SSRIs)

Serotonin Syndrome

• A life-threatening condition associated with increased serotonergic activity in the central nervous system most often due to SSRI overdose.
• Symptoms are diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, diarrhea, tremor, muscle rigidity, myoclonus, hyperreflexia, and bilateral Babinski sign.
• Treatment involves stopping all serotonergic agents, supportive care to normalize vital signs, hyperthermia and autonomic instability, sedation with benzodiazepines, and administration of serotonin antagonists (Cyproheptadine).

Cheese Reaction

• Cheese, beer, wine, meat, fish, and yeast (contain large amounts of tyramine and other indirectly acting amines)→ these escape degradation in the intestinal wall and liver due to an irreversible block of MAO → reach circulation and displace a large amount of noradrenaline from loaded nerves → hypertensive crises (CVA, encephalopathy)
• Treatment: IV phentolamine, prazosin

If antidepressants are given for bipolar depression, they should be combined with a mood-stabilizing drug (mentioned below) to avoid “switching” the patients into (hypo) mania.

Mood-stabilizing Agents

They help in bringing the mood back to normal.

The main drugs consist of lithium, sodium valproate, divalproex, and carbamazepine. Others include lamotrigine, gabapentin, topiramate, olanzapine, quetiapine, and risperidone.

Question 8. Write a short note on lithium and its side effects.
Answer:

Lithium (Lithium Carbonate)

Lithium (Lithium Carbonate) Indications

• It is the first-line medication for the treatment of mania.
• It is used for both treatment and prophylaxis of mood episodes in bipolar affective disorder.
• Adjunctive treatment of resistant depression in combination with tricyclic antidepressants.
• Treatment of schizoaffective disorders.
• It has antisuicidal properties.
• Other uses: Cluster headache, gout, ulcerative colitis, and neutropenia.

Lithium (Lithium Carbonate) Mechanism of action

• Lithium partly replaces sodium and is nearly equally distributed in and outside the cell: This affects ionic fluxes across the brain cells.
• It decreases the release of NA and DA without affecting 5 HT releases.
• It inhibits the hydrolysis of inositol monophosphate.
• It has a narrow therapeutic range. Hence, regular blood monitoring is needed to maintain a plasma level of 0.6–1.2 mmol/L.

Lithium (Lithium Carbonate) Side effects

• Dose-related: Tremor, convulsions, gastrointestinal distress (nausea, vomiting), and headache.
• Acne and weight gain: Long-term use may result in weight gain, interfere with patient compliance and exacerbate psoriasis.
• Cardiac conduction: Prolonged QRS, heart blocks, T wave inversions, and ECG changes are usually benign.
• Hypothyroidism, nephrogenic diabetes insipidus, increased calcium and parathormone, and renal failure.
• Teratogenicity: Associated with Ebstein’s anomaly, and should not be given during the first trimester of pregnancy.
• Leukocytosis: Usually occurs and seems to be benign.

Lithium (Lithium Carbonate) Divalproex

• Treatment of choice for rapid-cycling bipolar disorder, or when lithium cannot be used.
• The time course of treatment response is similar to lithium.
• Side effects: Sedation, cognitive impairment, tremor, GI distress, and hepatotoxicity.
• Teratogenicity: Associated with spina bifida.

Lithium (Lithium Carbonate) Carbamazepine

The second-line choice for treatment of bipolar disorder is when Lithium and Divalproex are ineffective or contraindicated.

Lithium (Lithium Carbonate) Side effects: Agranulocytosis hematologic toxicity, hyponatremia, and hepatotoxicity.

Gabapentin

Question 10. Write a short note on gabapentin.
Answer: This lipophilic GABA derivative crosses the blood-brain barrier and enhances GABA release but does not act as an agonist at the GABA receptor.

It is used primarily to treat focal seizures and neuropathic pain, and can also be used for bipolar disorders.

Gabapentin Sodium Valproate and Olanzapine

They can be used both as prophylaxis in bipolar disorder and as a second-line alternative to lithium.

Gabapentin Side effects: Valproate can cause birth defects and, hence, should not be given to women of childbearing age. Olanzapine can produce weight gain.

Anxiolytic (Antianxiety) Medications

Question. Write short notes on anxiolytic (antianxiety) medications
Answer:

Indications for anxiolytic (antianxiety) medications:

• Panic disorder: Alprazolam, SSRIs, imipramine, and clonazepam
  decrease frequency and intensity
• Generalized anxiety disorder: Venlafaxine, other SSRIs, and buspirone decrease overall anxiety
• Social phobia: SSRIs and buspirone decrease fear associated with social situations
• Adjustment disorder with anxious mood: Benzodiazepines with supportive psychotherapy
• Obsessive-compulsive disorder: SSRIs and clomipramine decrease obsession thinking

Features of Benzodiazepines:

• Mechanism: Bind to specific CNS receptors that modulate GABA transmission
• Commonly used for the treatment of anxiety, insomnia, and for alcohol withdrawal symptoms
• First choice for emergency treatment of acute anxiety and severe mania
• Alprazolam is the first choice for panic attack
• Chlordiazepoxide is used for the prevention of alcohol withdrawal
• Benzodiazepines that do not interact with P450: lorazepam, oxazepam, and temazepam
• Zolpidem: Used in initial insomnia ½ 2–3 hours. Side effects include headache, nausea, dry mouth, etc.
• Zopiclone: Also acts on GABA receptors, and has a short duration of action.
• Suredone, bretazenil, imidazenil, alpidem, and abecarnil: Anxiolytic as well as anticonvulsant

Anxiolytic (Antianxiety) Medications Adverse effects:

• Sedation, disinhibition, tolerance, withdrawal, abuse potential, and possible teratogenicity
• Impairment of cognitive and motor performance

Anxiolytic (Antianxiety) Medications Features of Buspirone:

• It is used for the treatment of generalized anxiety disorder and social phobia
• Lag time of about 1 week before the clinical response
• No additive effect with alcohol or sedative-hypnotics
• No withdrawal syndrome
• No sedation or cognitive impairment
• Headache may occur

Electroconvulsive Therapy

Question 11. Write a short note on electroconvulsive therapy.
Answer:

Electroconvulsive therapy (ECT) is a procedure in which electrical stimuli is used to induce seizures.

Procedure for Modern ECT

• Obtain written informed consent
• Preanesthetic work-up
• Withholding drugs that can raise seizure threshold, NPO for 12 hours prior to the procedure
• Premedication with anticholinergics to decrease secretions Administration of muscle relaxant (to prevent trauma to muscles and bones) and short-acting anesthetic agent
• Electrode placement: Electrodes are placed at the temporal fossa, 2.5–4 cm (1–1.5 inches) above the line joining the tragus of the ear and the lateral canthus of the eye.
• A brief electrical stimulus is delivered and seizure activity is noted mechanically via isolated limb and electrically via EEG.

Electroconvulsive Therapy Mechanism of Action

• Alteration in levels of neurotransmitters, neuromodulators, e.g., increase in brain-derived natriuretic factor (BDNF).

Indications

Question 12. Write a short note on indications for ECT.
Answer:

Severe depression: When a rapid antidepressant response is needed (For Example, due to failure to eat or drink in a depressive stupor; high suicide risk), previous history of good response to ECT, patient preference, and suicidal ideas.

Failure to respond to drug treatments or patient is not able to tolerate side effects of drugs (For Example, puerperal depressive disorder or postpartum psychosis.

Catatonic schizophrenia

• Resistant OCD
• Neuroleptic malignant syndrome
• Intractable seizure
• Parkinson’s diseases rigidity, bradykinesia)

Indications Contraindications

• Absolute: None
• Relative:
  • Increased intracranial pressure (ICP)
  • Cardiovascular diseases: Recent MI, coronary artery disease, hypertension, aneurysms, and arrhythmias.
  • Cerebrovascular disease: Recent strokes, space-occupying lesions, and aneurysms.
  • Severe pulmonary diseases: Tuberculosis, pneumonia, and asthma
    Deep vein thrombosis (DVT).
  • High-risk pregnancy

Types of electroconvulsive therapy (ECT):

• Direct: ECT without general anesthesia which has been prohibited and hence not practiced
• Modified: Use general anesthesia and muscle relaxants
• Unilateral ECT: Right unilateral (RUL) has a less cognitive effect, and may be less clinically effective
• Bilateral ECT: Most common, most effective, most [cognitive dysfunction
• Risks and side effects: ECT is safe with few side effects.
• Impairment of cognition: Period of confusion immediately after ECT and generally lasts for a few minutes to several hours.
• Memory loss: May forget weeks/months before treatment, during treatment, or after treatment has stopped.
• Usually improves within a couple of months. Permanent loss of memory is rare.
• Myalgia, dislocation, and fractures

Medical complications: Nausea, vomiting, headache, aspiration, and jaw pain.

Question 13. Write short notes on types of psychotherapy.
Answer:

Psychotherapy

It mainly can be classified into three types:

Psychotherapy Supportive

• It focuses on enhancing stress coping mechanisms and strengthening defenses to bring about emotional equilibrium.
• There is no cause finding or intent to change the personality.
• It is used in the management of adjustment disorder.

Psychotherapy Reconstructive

• It focuses on finding out the root cause of a problem in personality and attempts at personality reconstruction.
• Based on Sigmund Freud’s principles of psychoanalysis: Making the patient aware of repressed unconscious conflicts, teaching them skills for better personality development
• Classical psych analysis and brief psychodynamic therapy are the two types
• It is less commonly used in the current day.

Psychotherapy Re-educative

• It focuses on modifying patients’ thinking (cognitive), behavior, or both (combined)
• It aims at restructuring cognitive distortions with not much emphasis on cause finding and has been given specific names based on methods used, such as:

Systematic desensitization in phobia and OCD where systematic exposure to phobic stimuli is followed by the use of relaxation techniques to desensitize the patient.

It is based on the principle of exposure decreases fear and avoidance increases fear.

Graded exposure and response prevention in phobia and OCD: It is similar to systematic desensitization; however, no relaxation techniques are used.

Cognitive behavior therapy for depression wherein negative schemas, cognitive distortions 7 automatic thoughts are addressed.

Eye-movement desensitization reprocessing is used for PTSD.

Aversive therapy is used in paraphilias, wherein aversive stimuli are applied to decrease the undesired behavior.

Clinical Psychiatry: Approach To Diagnosis In Psychiatry

Question 14. Write a short essay on the differences between psychosis and neurosis.
Answer:

Psychosis

• Psychosis is a symptom or feature of mental illness characterized by radical changes in personality, impaired functioning, and thoughts that are distorted or nonexistent.
• It is an abnormal condition of the mind described as involving a ‘loss of contact with reality’.
• Psychosis is not pathognomonic of a psychiatric disorder.
• It is a nonspecific cluster of signs and symptoms that may occur in medical, neurologic, and surgical disorders or as a consequence of pharmacologic treatment, substance abuse, or the withdrawal of drugs and alcohol.

Classification of psychoses: Organic or functional:

• • Organic psychotic disorders are caused by structural defects or physiologic dysfunction of the brain, e.g., brain tumors.
  • Functional disorders have no identifiable cause, e.g., schizophrenia or bipolar disorder.
• Lack of insight refers to failure to accept that one is ill and/or in need of treatment and is characteristic of acute psychosis.

Specific psychotic symptoms include delusions, hallucinations, ideas of reference, and disorders of thought.

Question 15. Write a short essay on the distinction between organic and functional psychosis.
Answer:

Functional psychosis can be affective or nonaffective the differences between schizophrenia and delusional disorders.

Based on the duration of symptoms schizophrenia-like disorders can be further differentiated as:

• <1 month: Acute and transient psychotic disorder/brief psychotic disorder
• 1–6 months: Schizophreniform disorder
• >6 months: Schizophrenia

Affective psychosis can be further differentiated:

Psychotic Disorders

Psychotic disorders were also called:

• Demence Precoce: Benedict Morel
• Dementia Praecox, Manic depressive illness: Emil Kraeplin
• Eugene Bleuler coined the term schizophrenia

Schizophrenia

Question 16. Write a short essay/note on schizophrenia.
Answer:

Schizophrenia is a disorder characterized by perturbations of language, perception, thinking, social activity, affect, and volition.

Schizophrenia occurs with regular frequency nearly everywhere in the world in 1% of the population and begins mainly at a young age (mostly around 16–25 years).

Schizophrenia has a 10% suicide rate (approximately one-third attempt suicide).

Question 17. Write a short note on the etiology of schizophrenia.
Answer:

Genetic: Schizophrenia has a high genetic predisposition, involving many susceptibility genes, e.g., disrupted in schizophrenia (DISC-1), neuregulin (NRG-1), and 22q deletion.

Schizophrenia Biochemical:

Dopamine: ↑ in mesolimbic (+ve symptoms), ↓ in mesocortical (–ve symptoms)

Serotonin increase: Responsible for +ve and –ve symptoms

Norepinephrine decrease: Responsible for –ve symptoms

Neuropathological: ↑ the size of ventricles, ↓ size of the limbic system, basal ganglia

Environmental: Maternal exposure to infection (influenza, rubella), advanced paternal age, winter birth, urban birth and upbringing, stressful life events, cannabis use, obstetric complications, and developmental abnormalities.

Abnormal family dynamics: Negative expressed emotions in the family lead to early relapse.

Psychological stresses: Episodes of acute schizophrenia may be precipitated by social stress, adverse life events, and cannabis (which increases dopamine turnover and sensitivity).

Schizophrenia syndrome: It is characterized by temporal lobe epilepsy, Huntington’s chorea, cerebral tumors, and demyelinating diseases. This is known as symptomatic schizophrenia.

Question 18. Write a short essay/note on the clinical features of schizophrenia.
Answer: DSM-5 diagnostic criteria for schizophrenia: Patient must have at least two of five symptoms for 6 months, with at least 1-month of active symptoms.

Question 19. Write a short note on Eugen Bleuler’s criteria for the diagnosis of schizophrenia.
Answer:

Eugene Bleuler’s 4A’s/primary symptoms of schizophrenia:

Autism: Self-absorbed, totally engrossed in own thoughts, not concerned of external stimuli.

Association loosening: Loss of logical sequence of thought, disconnected thoughts.

Ambivalence: Inability to choose between 2 opposite thoughts (Ambitendency: Inability to choose between 2 opposite actions, do/do not)

Affective blunting/(Snap prop): Decreased expression of feelings

Question 20. Write a short note on Schneider’s first-rank symptoms of schizophrenia.
Answer:

Question 21. Write a short note on subtypes of schizophrenia.
Answer:

Major Subtypes of Schizophrenia

1. Paranoid schizophrenia:

• The most common type of schizophrenia has a good prognosis
• Predominant features include Delusions and hallucinations that are persecutory/ grandiose or of reference/control

2. Disorganized (Hebephrenic) schizophrenia:

• Predominant features of disorganization of behavior, speech, affect, and volition.
• Marked thought disorder, incoherence, loosening of associations
• Emotional disturbances—blunted affect, and senseless giggling

3. Catatonic schizophrenia has marked disturbance of motor behaviors:

Clinical forms:

• Excited catatonia: Increase in psychomotor activity (restlessness, agitation, excitement aggressiveness) and increase in speech production
• Stuporous (retarded) catatonia: Extreme retardation of psychomotor function
• Catatonia alternating between excitement and stupor: Features of both the above forms

4. Simple schizophrenia: Has predominant negative symptoms

5. Schizophrenia undifferentiated type: Meets criteria for schizophrenia. Do not meet the criteria for other schizophrenia types. Note: Subtyping of schizophrenia has been removed in DSM-5/ICD-11 versions

ICD-11 Course Specifirs for Schizophrenia

• 1st episode: No past episodes
• Multiple episodes: At least 1 past episode with significant remission of symptoms between current and last episode Continuous: No remission of symptoms, illness present for >1 year
• Typical stages of schizophrenia: Prodromal phase, active phase, and residual phase.

Investigation of schizophrenia

• Full neurological examination: Gait and motor
• Cognitive examination: MMSE
• Blood: Complete blood count, liver function tests, renal function tests, thyroid functions tests, and glucose Urine drug screen
• EEG if suspicion of temporal lobe epilepsy
• Brain imaging findings:
  • CT: Lateral and third ventricular enlargement, reduction in
    cortical volume
  • MRI: Increased cerebral ventricles
  • PET: Hypoactivity of the frontal lobes

Question 22. Write a short essay on the management/treatment of schizophrenia/
psychosis.
Answer:

Management of schizophrenia

Hospital admission is necessary for a first episode to permit a full physical and psychiatric assessment.

Indications for hospital admission

Indications include suicidal tendencies, violent behavior, severe psychosis, severe depression, catatonic schizophrenia, noncompliance, and failure of outpatient treatment.

Management of schizophrenia Drug treatment

Antipsychotics (atypicals preferred) + Benzodiazepines are the mainstay in the acute phase of treatment.

Management of schizophrenia Psychological treatment

It is an essential component of management in the maintenance phase of treatment.

• Psychoeducation can prevent relapse by enhancing insight.
• Cognitive remediation to challenge delusions.
• Social skill training: Improve relationships.
• Behavioral: Positive reinforcement of desirable behavior.
• Family therapy: To reduce expressed emotion (EE). (High EE includes hostility, over-involvement, and critical comments from family; hence reducing relapse rate).

Management of schizophrenia Social treatment

• After the control of an acute episode of schizophrenia, social rehabilitation may be needed.
• Patients with chronic schizophrenia may need long-term, supervised accommodation.

Management of schizophrenia Other treatments

• Rehabilitation to enhance self-care, compliance, and insight.
• ECT (electroconvulsive therapy) is for catatonic schizophrenia.

Management of schizophrenia Prognosis

• Rules of quarters: Complete remission (25%), good recovery (25%), partial recovery (25%), and downhill course (25%).
• Good prognostic factors: Late-onset, female gender, married, and presence of the precipitating event.

Other Psychotic Disorders

Schizophreniform Disorder (>1 Month but <6 Months)

Presenting symptoms: Same as in schizophrenia (hallucinations, delusions, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms, social and/or occupational dysfunction).

Difference from schizophrenia: Symptoms are present > 1 month but < 6 months and most of the patients return to their baseline level of functioning.

Management of schizophrenia Treatment

• Must assess whether the patient needs hospitalization, to assure the safety of the patient and/or others.
• Antipsychotic medication is indicated for a 3–6-month course.
• Individual psychotherapy

Schizoaffective Disorder

• Presenting symptoms: Mood disorders (major depressive episode, manic episode, or mixed episode) + psychosis (schizophrenia).
• Delusions or hallucinations for at least 2 weeks in the absence of mood symptoms.
• Prognosis: Better prognosis than patients with schizophrenia. Worse prognosis than patients with affective (mood) disorders.

Management of schizophrenia Treatment

Antidepressant medications and/or anticonvulsants to control mood/symptoms.

If these are not effective, consider the use of antipsychotic medications to help control the ongoing symptoms.

Mood Disorders

Question 23. Write a short essay on:

• Mood/affective disorders and their classification.
• Bipolar affective disorders.

Answer:

• Mood or affective disorders are among the most common diagnoses in psychiatry.
• Mood refers to a pervasive and sustained emotional state (as differentiated from affect, which is immediately expressed and observed emotion).
• Mood disorders are characterized by a disturbance of mood and behavior.
• It can either be unipolar (depression/mania) or bipolar.

Categories/Classification of Mood Disorder.

 

Unipolar depression: Only one end of the emotion spectrum and characterized by one or more episodes of low mood and associated symptoms (depression form).

Dysthymic disorder: Characterized by chronic low-grade depressed mood without sufficient other symptoms to count as “clinically significant” or “major” depression.

Bipolar disorder: Cycling between both ends of the emotion spectrum and characterized by episodes of elevated mood interspersed with episodes of depression (both manic and
depression).

Mood (affective) disorders can be classified into primary and secondary.

In primary affective disorder, the affective episodes (mania or depression) are not secondary to any other psychiatric or physical illness.

In secondary affective disorder, the affective episodes are secondary to another psychiatric or physical illness.

Unipolar Depression/Major Depressive Disorder

Question 24. Write a short essay/note on depression, its clinical features, and management.
Answer:

Depressive disorders are characterized by persistent low mood, loss of interest, and reduced energy that usually impairs day-to-day functioning.

It is more common in middle-aged females.

A number of episodes:

A single episode of major depression.

Recurrent: Two or more episodes of major depression.

Persistent depressive disorder (dysthymia): Low mood persisting for more than 2 years

The risk of suicide in an individual with a depressive disorder is 10 times more than that in the general population.

Etiology

• Trimonoaminergic depletion: Reduced levels of serotonin, epinephrine, and dopamine are seen in depression.
• HPA axis dysfunction: Evident through blunted response to dexamethasone suppression test.
• Hypothyroidism
• Pathology of the left side of the brain: Predominantly involving the prefrontal cortex, amygdala, hippocampus, and anterior cingulate cortex
• Aaron T Beck’s cognitive triad of depression: Negative thoughts about self (worthlessness), environment (helplessness), and future (hopelessness)

Question 25. Write a short note on reactive depression.
Answer: Reactive depression is a type of clinical depression that is precipitated by events in the individual’s life (to be differentiated from normal grief) arising as a consequence of severe traumatic events in life (e.g., the loss of a home in a fire).

Reactive depression becomes a clinical concern if the depression lasts too long without signs of recovery or if the depression becomes too deep (e.g., leading to suicidal feelings).

Most of the time, reactive depression resolves itself.

Melancholic/endogenous depression:

• Depression that occurs in the absence of external life stressors
• Mostly seen in elderly
• Characterized by severe anhedonia, severe vegetative symptoms (early morning awakening, decreased appetite), profound guilt, and suicidal thoughts

Treatment of depression

Both drug and psychotherapy (e.g., cognitive behavioral therapy, interpersonal therapy) are effective in the treatment of depression either alone or in combination.

Medication alone also can relieve symptoms. However, the combined approach generally provides the patient with the quickest and most sustained response.

Drug treatment (pharmacotherapy)

All antidepressants are potentially effective in patients whose depression is secondary to medical illness, as well as those in whom it is the primary problem.

They are effective in moderate and severe depression. Usually, 2–6 weeks at a therapeutic dose level are needed to observe a clinical response. Commonly used antidepressants.

Psychological treatments

• Mild-to-moderate depression: Both cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are as effective.
• Severe depression: Antidepressant drugs are preferred.

Nonpharmacologic treatments

• Electroconvulsive therapy (ECT): Highly effective for depression and may have a more rapid onset of action than drug treatments.
• ECT may be indicated if the patient is suicidal or worried about side effects from medications.
• Other magnetic and electrical stimulatory methods like r-TMS

Acute Mania

Question 26. Write a short essay/note on the clinical features of mania.
Answer: Mania is an abnormally elevated mood state.

Treatment of Mania

• Hospitalization: To avoid injury to self/ others, to control agitation and to ensure medication compliance
• Mood stabilizing agents (discussed earlier)
• Antipsychotics
• Electroconvulsive therapy (ECT) (discussed earlier)

Bipolar Disorder

Question 27. Write a short essay on bipolar affective disorders.
Answer: Bipolar disorder is characterized by episodes of elevated mood interspersed with episodes of depression (both manic and depressive).

• Elevated mood when mild or short-lived (4 days) is known as hypomania, or when severe or chronic (at least 1 week), is called mania.
• The lifetime risk of developing bipolar disorder is about 1–2%. The lifetime risk of suicide is about 5–10%.
• Types: As per DSM-5, bipolar disorders are divided into bipolar I disorder, bipolar II disorder, cyclothymic disorder, substance/medication-induced bipolar disorder, and bipolar disorder due to another medical condition.
  • Bipolar I disorder: It is characterized by the occurrence of one or more manic or mixed episodes (usually), and usually one or more major depressive episodes.
  • Bipolar II disorder: It is characterized by the occurrence of one or more major depressive episodes, at least one hypomanic episode, and without any manic or mixed episodes.

Management and Prognosis of Bipolar Disorders

• Mood stabilizing agents (discussed earlier) + Antipsychotics/Antidepressants
• Electroconvulsive therapy (ECT) (discussed earlier)

Cyclothymic Disorder

Question 28. Write a short note on the features of cyclothymia.
Answer:

It is characterized by:

• Chronically fluctuating mood states; periods of hypomania and depression
• Duration of at least 2 years in adults and 1 year in adolescents and children.
• The individual is not without symptoms for more than 2 months at a time.
• There are no major depressive, manic, or mixed episodes during the initial 2 years.
• After the initial 2 years, there may be superimposed manic, mixed, or depressive episodes.

Cyclothymic Disorder Neurotic Disorders

Neurotic disorders can be:

• Anxiety symptom predominant
• Somatic symptom predominant
• After stress/trauma
• Dissociative disorders
• Anxiety Predominant Disorders

Types of Phobia

• Specific phobia: Fear of a specific situation/object
• Social phobia: Fear of socially demanding situations
• Agoraphobia: Fear of places from where escape is difficult

Disorders Occurring After Trauma/Stress

Dissociative Disorders

• Dissociative amnesia: Patchy loss of autobiographical memory
• Dissociative fugue: Amnesia + travel, attains a new identity
• Dissociative identity disorder: ≥2 identities in a person at a time
• Depersonalization and derealization disorder: “As if” change in person/environment respectively.

Somatic Symptom Predominant Disorders

• Preoccupation with symptoms: Somatization/somatic symptom disorder
• Preoccupation with pain: Somatoform pain disorder
• Preoccupation with diagnosis: Hypochondriasis/illness anxiety disorder
• Preoccupation with an imagined defect: Body dysmorphic disorder

Based on Symptom Production

Anxiety Disorders

Anxiety disorders are characterized by unrealistic, irrational fear or anxiety of disabling intensity, worrisome thoughts, avoidance behavior, and the somatic symptoms of autonomic arousal.

Anxiety is a syndrome with psychological (insecurity, worry, apprehension) and physiologic (sympathetic activation) components.

Patients with anxiety may also have depression.

Question 29. Write short notes on types of anxiety disorder.
Answer:

Generalized Anxiety Disorder (GAD)

• It is a chronic state associated with uncontrollable excessive and free-floating anxiety and worry persisting for a minimum of 6 months.
• Symptoms: It is associated with somatic symptoms of muscle tension and bowel disturbance, sleep disturbance, and difficulty concentrating or the mind going blank.

Panic (Paroxysmal) Disorder

Panic disorder is defined as the occurrence of recurrent unexpected attacks of intense anxiety that include marked physical symptoms, such as tachycardia, chest pain, hyperventilation, dizziness, trembling, numbness, and sweating.

Panic disorder may occur with or without agoraphobia (avoidance of situations where a person may feel trapped and unable to escape).

A discrete period of intense fear or discomfort develops abruptly and reaches a peak within 10 minutes. In between the attacks, the patient is free from anxiety.

The age of onset for panic disorder varies but lies between late adolescence and mid-30s.

Patients have a persistent concern about having an attack and they worry about the implications of the attack.

Phobic Anxiety Disorder

• A phobia is an abnormal or excessive, persistent and disproportionate fear of an object or situation that presents little or no actual danger to the person. It causes avoidance of it (e.g., excessive fear of dying in an air crash leading to avoidance of flying). Phobic responses can develop to general medical procedures, such as venipuncture.
• Specific phobias: It is characterized by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance.
• Social phobia: It is characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations, in which people are exposed to unfamiliar people or to scrutiny by others.
• Agoraphobia: It is a generalized phobia (marked fear) of going out alone or being in crowded places. Thus, avoid being alone or being in a public place (e.g., bridges, tunnels, crowds, etc.).

List of phobias:

• Claustrophobia: Fear of being in constricted, confined spaces
• Aerophobia: Fear of flying
• Arachnophobia: Fear of spiders
• Zoophobia: Fear of animals
• Aquaphobia: Fear of water
• Acrophobia: Fear of heights

Question 30. Mention the differential diagnosis of anxiety disorders.
Answer:

Physical illness which mimics anxiety disorder:

Hyperthyroidism, pheochromocytoma, hypoglycemia, paroxysmal atrial arrhythmias, alcohol withdrawal, and temporal lobe epilepsy.

Question 31. Write short notes on the management of anxiety disorders.
Answer:

Psychological treatment:

• Explanation and reassurance
• Specific treatment may be necessary. Treatments include relaxation training, graded exposure (desensitization) to feared situations for phobic disorders, flooding and implosive therapy, and CBT (cognitive behavioral therapy).

Drug treatment:

Drugs of choice are antidepressants (SSRIs). Benzodiazepines are useful in the short-term but long-term use can result in dependence.

When somatic symptoms are prominent, a β-blocker (e.g., propranolol) may be used.

Post-traumatic Stress Disorder

Question 32. Write short notes on post-traumatic stress disorder (PTSD).
Answer:

It is characterized by the re-experiencing (recurrent bouts) of an extremely traumatic event accompanied by the symptoms of increased arousal and by avoidance of stimuli associated with trauma.

The traumatic event (e.g., a military experience, a physical or sexual assault, a motor vehicle accident, a natural disaster) involved may have caused death or near-death experience or serious injury to self or others.

Typically, patients re-experience the traumatic event (e.g., nightmares, flashbacks intrusive recollections), engage in avoidance of trauma or talk of trauma, or recollections of stimuli associated with the sentinel trauma.

Patients experience increased autonomic reactivity, such as hypervigilance, irritability, insomnia startle responses, etc.

Classification of PTSD

• Acute PTSD: Symptoms begin within 3 months of trauma or the duration of symptoms is less than 3 months.
• Chronic (or delayed) PTSD: Symptoms start more than 3 months after trauma (delayed) or persist for 3 months or longer.
• With delayed onset: 6 months have passed between the traumatic event and the onset of symptoms.

Dissociative Disorder

Question 33. Write short notes on dissociative disorder.
Answer: It was formerly called hysteria (dissociative disorder) and this old term was replaced in DSM-IV and ICD-10 by the new term dissociative disorder. More common in women and children.

Definition: Dissociative disorder is a syndrome characterized by a loss or distortion of neurological function which cannot be fully explained by organic disease.

Psychological functions commonly affected include conscious awareness and memory.

Physical functions affected (conversion) include changes in sensory or motor function.

These changes may resemble lesions in the motor or sensory nervous system.

Dissociative Disorder Etiology

• Unconscious psychological process: The patient lacks insight into the nature of symptoms. It is a maladaptive way of coping with an unresolved psychological conflict by becoming ill.
• An association of this disorder with adverse childhood experiences, including physical and sexual abuse, is being observed.

Dissociative Disorder Clinical Features

• Primary gain: Keeps internal conflicts outside patient’s awareness.
• Secondary gain: Benefits received from being “sick”.
• La belle indifference: The patient seems unconcerned about impairment.
• Gait disturbance
• Loss of function in limbs
• Aphonia
• Pseudoseizures (nonepileptic seizures)
• Sensory loss
• Blindness

Management/Treatment of Dissociative Disorder

• Physical and psychiatric examination to exclude organic disease.
• Explanation and reassurance.
• Resistant cases: Abreaction under hypnosis or small IV dose of panthenol.

Conversion Disorder

• It is called functional neurological symptom disorder in DSM-5.
• Etiology: Unresolved psychological conflict is converted acutely and unconsciously into sensorimotor neurological symptoms → maladaptive coping mechanisms.
• Treatment: Psychodynamic therapy—resolution of psychological conflict.

Somatoform Disorders

These disorders have somatic symptoms which are not explained by a medical condition (medically unexplained symptoms), nor are better diagnosed as part of a depressive or anxiety disorder.

Symptom Production

• If unconscious—comes under somatoform disorders
• If conscious with a motive to obtain benefit is called malingering.
• If conscious but done without motive—factitious disorder/Munchausen syndrome.

Factitious Disorder

It is an uncommon disorder characterized by the repeated and deliberate production of the signs or symptoms of disease to gain medical care, e.g., dipping of thermometers into hot drinks to fake a fever.

Munchausen’s Syndrome

Question 34. Write short notes on Munchausen’s syndrome.
Answer:

• It is a rare, severe, chronic form of a factitious disorder named after the German Baron von Munchausen, who was legendary for his inventive lying.
• He traveled widely, sometimes visiting several hospitals in one day.
• The patient frequently changes his name, with a history of doctor shopping.
• These patients are memorable because they present so dramatically.
• They usually seek medical attention at night when junior doctors or residents are on duty.
• They fabricate a convincing history and present to the doctor with dramatic symptoms of a medical emergency.
• They persuade an inexperienced doctor to undertake investigations or initiate treatment including exploratory surgery.
• The abdomen may show several scar marks (“surgical battlefield”) due to previous operations.

Munchausen’s Syndrome Management

• Gentle and firm confrontation with clear evidence of the fabrication of illness.
• Psychological support.
• Recognition of the condition to avoid further iatrogenic harm.
• Obsessive-Compulsive Disorder

Question 35. Write short notes on obsessive-compulsive disorder.
Answer:

Obsessive-compulsive disorder (OCD) is characterized by obsessive, recurrent, unwanted thoughts (which cause marked anxiety) and compulsions (which serve to neutralize or relieve anxiety).

Obsessions: These are persistent thoughts, ideas, impulses, or images that seem to invade a person’s consciousness.

Compulsions: Repetitive behaviors (e.g., handwashing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession.

Munchausen’s Syndrome Etiology

Cortico-striatal-thalamo-cortical circuit dysfunction.

Types People have symptoms like:

• Cleaning: Fears of contamination
• Symmetry: Arranging items symmetrically and repeating, ordering, and counting compulsions.
• Forbidden or taboo thoughts: Aggressive, sexual, and religious
  obsessions.
• Harm (e.g., thoughts about harm to oneself or others).
• Other OCD-related Disorders
• Trichotillomania
• Skin picking/excoriation disorder
• Hoarding disorder: Difficulty in disposing of items regardless of their value
• Body dysmorphic disorder
• Impulse Control Disorders

Question 36. Write a short essay/note on impulse disorders.
Answer:

Impulsive disorder is defined as a sudden and irresistible force that compels a person to do some action without motive or forethought. A normal person always tries to analyze his actions whether they are consistent with the law or not.

Once he realizes that his action may be contrary to law he stops it.

But in impulsive disorder, a person is not able to control himself.

impulse disorders Examples:

• Kleptomania: An irresistible desire to steal things usually of low value.
• Pyromania: An irresistible desire to set things on fire.
• Mutilomania: An irresistible impulse to maim animals.
• Dipsomania: An irresistible impulse to drink at periodic intervals.
• Sexual impulses: All sexual perversions.
• Homicidal impulses: To kill some persons.
• Suicidal impulses: To commit suicide. Impulses are quite commonly seen in various mental disorders like depression, schizophrenia, mania, etc.
• Trichotillomania: It is an irresistible desire to pull out one’s own hair.
• Oniomania: Compulsive desire to shop (shopping addiction).

Organic Mental Disorders

Delirium

Question 37. Write short essay/notes on the definition, causes, clinical features (clinical recognition), and initial management of delirium.
Answer:

Definition of Delirium

It is an acute organic mental disorder characterized by confusion, restlessness, incoherence, inattention, anxiety, or hallucinations which may be reversible with treatment.

Delirium Clinical Features

• Acute course: Sudden onset, short episode.
• Global impairment of cognitive functions (memory, attention, orientation, thinking, etc.).
• Fluctuating course.
• Cardinal features:
  • Clouding of consciousness, impaired alertness, awareness, and attention.
  • Variability in state of arousal.
  • Reduced responsiveness is interspersed with periods of excited outbursts.
  • Sleep/wake cycle disrupted.
• Impaired perception: Misperceives surrounding and attendants, hallucinations.
• Disturbance of emotion: Agitation, fear, depression, and anxiety.
• Psychomotor changes: Hyperactivity, restlessness, and repetition (plucking, tossing).

Predisposing and precipitating factors of delirium are shown in and causes of delirium.

Delirium Investigations

If the cause is not obvious: Complete blood count, urine analysis, blood glucose, blood urea, serum electrolytes, liver and renal function tests, arterial blood gases, thyroid function test, X-ray chest, ECG, CSF, VDRL, HIV-testing, EEG, and cranial CT scan or MRI scan.

Delirium Management: Identify the cause and treat it accordingly

• Chlorpromazine (50–100 mg 8th hourly) or haloperidol (5–10 mg 8th hourly) are the drugs of choice except in delirium tremens, where benzodiazepines (BZDs) or diazepam 10–20 mg 6th hourly is preferred.
• Also, give supportive medical and nursing care

Question 38. Write short notes on the differences between delirium, dementia, and psychosis.
Answer: Differences between delirium, dementia, and psychosis.

Substance Use Disorders

Question 39. Write short notes on substance use, its effects, and treatment.
Answer:

Substance use includes harmful use, dependence, effects of intoxication, and withdrawal.

• Harmful use: Substance use pattern that causes harm to an individual’s physical/mental health or has caused harm to others through behavioral changes.
• Dependence: Due to continuous use of substances, an individual has become dependent on the substance and is unable to regulate the pattern of his use.
• Manifestation can be either psychological or physiological.
• Psychological manifestations can be seen as craving (strong desire to use the substance), loss of control in using the substance, continuing use despite harmful consequences, and prioritizing substance use while neglecting alternate activities for pleasure.
• Physiological manifestations can be seen in symptoms of tolerance and withdrawal.
• Tolerance: It is defined by either of the following:
  • A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
  • A markedly diminished effect with continued use of the same amount of the substance.
• Substance intoxication: Reversible, substance-specific syndrome caused by the recent ingestion of or exposure to a substance.
• Substance withdrawal: Characteristic substance-specific, maladaptive behavioral change, with physiologic and cognitive concomitants, caused by the cessation of or reduction in heavy and prolonged substance use.

Risk Factors/Etiology

• Family history: Parental drug use, marital conflict, and disturbed family environment.
• Physiology: Individuals who are innately more tolerant to substance.
• Developmental history: Poor parenting, childhood physical and sexual abuse.
• Environmental: Peer pressure, economic disadvantage, and social isolation. Availability and access to drugs.
• Psychiatric illness: Conduct disorder, depression, and bipolar disorder.
• Age group: Highest prevalence of substance abuse is between 18 and 22 years of age.
• Experimentation with gateway drugs may start as early as pre-adolescence.

Investigations and Diagnosis

Diagnosis may be apparent from the history or may be made when the patient presents with a complication.

Laboratory Toxicology

• Breath, blood, and urine examination: Screen for types of substances of abuse and their concentrations.
• Intravenous drug abuse workup:
  • HIV, hepatitis B, hepatitis C, and tuberculosis.
  • Drug screening of samples of urine or blood will help in confirming the diagnosis.
• Other laboratory studies for evidence of systemic damage from substance use.

Treatment of Substance-related Disorders

Biological treatment: Pharmacologic intervention to ameliorate psychological or physical symptoms.

• Agonist substitution: Safe drug with similar chemical composition as the abused drug, e.g., methadone for heroin addiction.
• Antagonistic treatment: Drugs that blo Treatment of Substance-related Disorders ck or counteract the positive effects of
  substances, e.g., naltrexone for opiate and alcohol problems.
• Aversive treatment: Drugs that make the injection of abused substances extremely unpleasant, e.g., disulfiram for alcoholism and silver nitrate for nicotine addiction.

Psychosocial treatment

• Community support programs: These are strongly encouraged.
• Emotional reassurance and providing a structured and secure environment.
• Components of comprehensive treatment and prevention programs:

Individual and group therapy, aversion therapy and convert sensitization, contingency management, community reinforcement, relapse prevention, and preventative efforts
via education.

Main Categories of Substances

• Depressants: Result in behavioral sedation (e.g., alcohol, sedatives, anxiolytic, and hypnotic drugs).
• Stimulants: Increase alertness and elevate mood (e.g., cocaine, nicotine, caffeine, and amphetamines).
• Opiates: Primarily produce analgesia and euphoria (e.g., heroin, morphine, codeine, and brown sugar).
• Hallucinogens: Alter sensory perception [e.g., marijuana (cannabis), lysergic acid diethylamide, phencyclidine]
• Club/rave party drugs: Cause anterograde amnesia (e.g., gamma hexane butyrate, flunitrazepam, and ketamine)
• Other drugs of abuse: Includes volatile solvents, anabolic steroids, and medications.

Nicotine

Nicotine withdrawal: Symptoms in chronic users appear about 30 minutes after every dose.

These include confusion, anxiety, restlessness, insomnia, depression, frustration and anger, nightmares, and headache.

Treatment of Tobacco Use Disorder

• Smoking cessation
• Cognitive behavioral therapy (CBT)
• Nicotine gum or lozenge, transdermal patch, and nasal spray inhalers
• Medication:
  • Bupropion: It is an antidepressant that is chemically unrelated to tricyclic antidepressants or SSRIs. Dose 150 mg PO twice a day.
  • Varenicline and cytisine: It is an alpha-4 beta-2 nicotinic receptor partial agonist more effective than nicotine and bupropion. Dose 1 mg PO bid.

Alcohol

Consumption of alcohol when associated with social, psychological, and physical problems constitutes alcohol use disorder.

Alcohol Etiology

Alcohol is a central nervous system depressant. It influences several neurotransmitter systems, mainly GABA (inhibition of behavior) but also the glutamate system and serotonin system.

Alcohol Dependence

It is characterized by a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by multiple psychosocial, behavioral, or physiologic features.

Features of alcohol dependence.

• Loss of control: Engaging in risky behaviors while under the influence.
• Compulsive preoccupation: Worrying compulsively about getting a “fix” and spending a lot of their time thinking about the drug.
• Continued use of alcohol despite negative consequences: Losing control of the ability to monitor how much and how often the user takes their drug.
• Loss of motivation: Losing interest in activities that the user enjoyed prior to addiction.
• Desire to stop drinking, but inability to do so.
• Excessive time spent getting or using alcohol or recovering from its effects.
• Craving, or preoccupation with drinking.
• Problems stemming from alcohol use; ignoring those problems; drinking despite obvious hazards, including physical danger.
• Retreating from important work, family, or social activities and roles.
• Tolerance: The need to drink more and more alcohol to feel the same effects, or the ability to drink more than other people without getting drunk.
• Withdrawal symptoms: After stopping or cutting back on drinking, symptoms are anxiety, sweating, trembling, trouble sleeping, nausea or vomiting, and, in severe cases, physical seizures and hallucinations.
• The person may drink to relieve or avoid such symptoms.

Question 40. Write short notes on the consequences/complications of alcohol harmful use/dependence.
Answer:

Consequences of alcohol harmful use/dependence

Neuropsychiatric

• Depression, suicide
• Alcohol relieves anxiety in the short term, dependence can develop in long-term use
• Alcoholic hallucinosis: auditory hallucinations
• Alcoholic “blackouts”: Amnesia for events that occurred during bouts of intoxication in very heavy alcoholic drinkers.
• Alcohol withdrawal (discussed below): Maximum symptoms usually develop 2–3 days after the last drink and can produce seizures (“rum fits”).
• Delirium tremens: It is a form of delirium found with severe alcohol withdrawal.
• Neurological: Peripheral neuropathy, dementia, cerebral hemorrhage, cerebellar degeneration, Marchiafava-Bignami syndrome, subacute combined degeneration of the cord myopathy, ventricular enlargement, and cognitive impairment.
• Wernicke’s encephalopathy: Global confusion, nystagmus, ophthalmoplegia, and ataxia.
• Korsakoff’s syndrome: Short-term memory deficits, confabulation
• Alcoholic dementia: It is a global cognitive impairment that may resemble Alzheimer’s disease.
• It does not progress and may improve if the patient abstains from alcohol.
• Indirect effects on the brain: It may be due to head injury subdural hematoma, hypoglycemia, and encephalopathy.

Medical

• Hepatic: Fatty change and cirrhosis, hepatocellular carcinoma
• Gastrointestinal: Esophagitis, esophageal varices, Mallory-Weiss syndrome, esophageal carcinoma, gastritis, malabsorption, pancreatitis, and parotid enlargement.
• Skin: Palmar erythema, spider naevi, Dupuytren’s contractures, and telangiectasias.
• Cardiac: Cardiomyopathy and hypertension.
• Respiratory: Pneumonia and tuberculosis
• Musculoskeletal: Myopathy and fractures
• Endocrine and metabolic: Pseudo-Cushing’s syndrome, hypoglycemia, and gout.
• Reproductive: Hypogonadism, infertility, and fetal alcohol syndrome
• Social: Absenteeism from work, unemployment, marital discord, child abuse, financial difficulties, violence, and traffic offenses.

Investigations and Diagnosis

Laboratory detection of alcohol abuse:

• Breath, blood, and urine examination: Screen for alcohol.
• Gamma-glutamyl transpeptidase (GGT): It is most sensitive to alcohol abuse and is raised in patients with alcohol abuse.
• MCV (mean corpuscular volume): Raised, but is less sensitive than GGT.
• Carbohydrate-deficient transferrin level: Elevated and highly specific in the absence of liver disease.
• Phosphatidylethanol (PEth)—concentration greater than 20 ng/dL is evidence of intoxication; it can detect excessive alcohol intake within a 2-week period.
• Others: Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH).

CAGE questionnaire: Affirmative answers to any two of the following questions (or to the last question alone) are suggestive of alcohol abuse.

• Have you ever felt that you should Cut down on your drinking?
• Have you ever felt Annoyed by others criticizing your drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had a morning drink (Eye-opener) after a hangover?

Investigations and Diagnosis Treatment

It involves the management of the intoxication phase, withdrawal phase, and rehabilitation.

Alcohol Intoxication

Features of Acute Alcoholic Intoxication

• Ataxia, slurred speech, emotional incontinence, and aggression
• Hypotension, gastritis, hypoglycemia, collapse, respiratory depression, coma, and death
• Disturbances in emotional and behavioral state
• Medical symptoms: Due to hypoglycemia, aspiration of vomit, respiratory depression
• Complications of other medical problems
• Accidents, injuries developed in fights

Question 41. Write a short note on the treatment of acute alcoholic intoxication.
Answer:

Treatment of acute alcoholic intoxication

• Maintain a patent airway and prevent aspiration of vomitus. Tracheal intubation and positive pressure respiration may be needed.
• Do not use analeptics because they may precipitate convulsions.
• Maintain fluid and electrolyte balance.
• Hypoglycemia is corrected by glucose infusion.
• Thiamine 100 mg in 500 mL glucose solution infused intravenously.

Note: Gastric lavage is helpful only when the patient is brought immediately after alcohol ingestion.

Alcohol Withdrawal

Question 42. Write a short note on the clinical features of alcohol withdrawal syndrome.
Answer:

Alcohol withdrawal is characterized by the sudden exhibition of central nervous system excitation.

Clinical Features

They occur 6–8 hours after the reduction of ethanol intake and may last for 2–7 days.

• Minor withdrawal symptoms:
• Psychological: Restlessness, anxiety, panic attacks, insomnia, and tremors (the shakes)
• Autonomic: Tachycardia, palpitations, sweating/diaphoresis, hypertension, pupil dilatation, nausea, vomiting, and hyperreflexia
• Others: Gastrointestinal upset, anorexia, and headache
• They resolve within 24–28 hours.

Alcoholic hallucinosis:

• These hallucinations appear within 8–12 hours of abstinence and disappear within 48–72 hours.
• Usually, these hallucinations are visual. In contrast to delirium tremens, it is not associated with clouding of the sensorium.
• Withdrawal seizures

Question 43. Write short notes on the causes and management of convulsions in alcoholics.
Answer: These seizures (“rum fits”) are generalized tonic-clonic convulsions.

• These develop usually 12–24 hours after the last drink but may develop after only 2 hours of abstinence.
• About 3% of chronic alcoholics develop withdrawal-associated seizures and, about 3% of them may develop status epilepticus.
• About 30% of patients, who develop delirium tremors, give a history of preceding alcohol withdrawal seizures.
• Delirium tremens

Question 44. Write a short note on delirium tremens.
Answer:

It usually develops between 24 and 72 hours after the last drink and lasts for about 1–5 days.

If early alcohol withdrawal is not treated, about 5% will progress to delirium tremens.

Delirium tremens Clinical features:

These include agitation, visual hallucinations (Lilliputian/macroscopic), illusions, delusions, tachycardia, hypertension, diaphoresis, and dilated pupils.

Dehydration may occur as a result of diaphoresis, hyperthermia, vomiting, and tachypnea.

Other features: Hypokalemia, hypomagnesemia, and hypophosphatemia.
Death occurs in about 5% of patients, usually due to arrhythmias, pneumonia, or electrolyte imbalance.

Management of alcohol withdrawal syndrome

• Maintains patent airway and breathing.
• Thiamine 100 mg in 500 mL glucose solution infused intravenously after withdrawing appropriate blood samples since in alcoholics, the thiamine will be depleted and the TPP would not be present as a result, in patients with altered sensorium for prevention of progress to Wernicke Korsakoff psychosis.
• Maintain fluid and electrolyte balance.
• Mild cases of withdrawal: Provide supportive care, such as reassurance and nursing care (monitoring of vital signs).
• Benzodiazepines (nitrazepam, diazepam, and lorazepam): For patients with moderate to severe withdrawal. They also control seizures.
• β-blockers: They may reduce anxiety and tremors.
• Anticonvulsants: Such as phenytoin, valproic acid, carbamazepine, and levetiracetam are of little value in treating or preventing alcohol withdrawal seizures.
• Management of associated conditions: Such as pneumonia, electrolyte imbalances, GI bleeding, liver failure, pancreatitis, neurological injury, and trauma.

Delirium tremens Rehabilitation

Aims at relapse prevention by using pharmacotherapy and psychotherapy.

• Disulfiram
• Disulfiram is an inhibitor of the enzyme aldehyde dehydrogenase (ALDH) and blocks the conversion of acetaldehyde (derived from alcohol) to acetic acid, thus increasing the levels of the toxic substance, acetaldehyde in the body.
• When alcohol is consumed while on disulfiram, acetaldehyde accumulates in tissues and blood and produces distressing symptoms (aldehyde syndrome).
• These unpleasant symptoms include flushing, burning sensation, throbbing headache, perspiration, uneasiness, palpitations, nausea, postural faintness, and, in some cases, circulatory collapse.
• Duration of symptoms (1–4 hours) depends on the amount of alcohol consumed.
• Side effects: Infrequent and include rashes, metallic taste, nervousness, and malaise.
• Very rarely myocardial infarction, congestive heart failure, respiratory depression, convulsions, and death may develop.
• Dosage: Oral 250–500 mg/daily.
• Naltrexone:
• It is an opioid-receptor antagonist. It reduces alcohol cravings, the number of drinking days, and the chances of resuming heavy drinking.
• Dose: Oral 50 mg/day in a single dose.
• Side effects: Nausea decreased appetite, fatigue, and headache.
• Acamprosate:
• It is a weak N-methyl-D-aspartate (NMDA) receptor antagonist with a modest GABA A receptor antagonist.
• It normalizes the dysregulated NMDA-mediated glutamatergic excitation that occurs in alcohol withdrawal and early abstinence.
• It reduces relapse of the drinking behavior.
• Dose: Oral 666 mg given thrice a day. It is available in 333 mg enteric-coated tablets.
• Side effects: Diarrhea, dizziness, and headache.

Drugs used for relapse prevention in alcohol dependence:

• First-line medications: Naltrexone and acamprosate
• Second-line medications: Disulfiram, topiramate, gabapentin, baclofen, and nalmefene

Eating Disorders

Anorexia Nervosa

Question 45. Write a short note on anorexia nervosa (AN) and its management.
Answer:

Etiology: Unknown but probably includes genetic, environmental, psychological, and cultural factors.

Onset: Average age is 17 years, often associated with emotional stressors, particularly conflicts with parents about independence and sexual conflicts.

Very late-onset anorexia nervosa has a poorer prognosis.

Anorexia Nervosa Clinical Features

• Avoidance of high-calorie food and restricted food intake because of intense fear of gaining weight or becoming fat.
• Compensatory behaviors: Excessive exercise routine, self-induced vomiting, or use of laxatives/diuretics/enemas
• Marked weight loss: Refusal to maintain body weight at or above minimally normal weight for age and height.
• Distortion of body image so that patients regard themselves as fat even when they appear grossly underweight, significant amount of time spent examining and denigrating self for perceived signs of excess weight, great concern with appearance, and denial of emaciated condition.
• In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles.
• Excessive interest in food-related activities (other than eating).
• Obsessive-compulsive symptoms and depressive symptoms.

Anorexia Nervosa Major Subtypes

• Restricting type: Fasting, introverted, decreased risk of substance abuse, family conflict is covert.
• Bulimic type: Binge eating or purging, more volatile, family frequently disengaged, prone to substance abuse.

Anorexia Nervosa Physical Examination

• Signs of malnutrition: Emaciation, hypotension, bradycardia, lanugo (i.e., fine hair on the trunk), and peripheral edema.
• Signs of purging: Eroded dental enamel caused by emesis and scarred or scratched hands from self-gagging to induce emesis. Parotid abscess and dental caries—because of keeping food in the mouth for a long time.
• Evidence of medical conditions due to abnormal diets, starvation, and purging.

Diagnostic Tests

• Signs of malnutrition: Normochromic normocytic anemia, abnormal electrolytes, and elevated liver enzymes
• Signs of purging: Metabolic alkalosis, hypochloremia, and hypokalemia due to emesis. Metabolic acidosis caused by laxative abuse.

Hormonal abnormalities:

• Elevated growth hormone and plasma cortisol levels and reduced gonadotropin levels (along with low FSH, LH, estrogen, and testosterone).
• T3 may be reduced, but T4 and TSH are often normal.
• Increased corticotrophin CSF levels.

Course and Outcome

• About 20–30% of restricting anorexics eventually develop binge eating within the first 5 years of onset.
• These illnesses have a chronicity of 5–10%.
• Generally favorable outcome is achieved in 60–70% of patients at 5–7-year outcome.
• The long-term mortality rate of individuals hospitalized for anorexia nervosa is 10%, due to the effects of starvation and purging or suicide.

Anorexia Nervosa Treatment

• Initial treatment should be the correction of significant physiologic consequences of starvation with hospitalization if necessary.
• Behavioral therapy should be initiated, with rewards or punishments based on absolute weight, not on eating behaviors.
• Family therapy is designed to reduce conflicts about control by parents.
• Antidepressants when comorbid depression is present.

Bulimia Nervosa

Question 46. Write short note on bulimia nervosa.
Answer:

Occurs at a 1:9 male-to-female ratio.

• Etiology: Psychologic conflict regarding guilt, helplessness, self-control, and body image may be predisposing factors.
• Onset: During late adolescence or early adulthood and often follows a period of dieting.

Bulimia Nervosa Clinical Features

• Recurrent episodes of binge eating
• Obsession with dieting followed by binge eating of high-calorie foods.
• Absence of self-control over eating during binges.
• Binges are associated with emotional stress and followed by feelings of guilt, self-recrimination, and compensatory behaviors.
• Recurrent, inappropriate compensatory behavior: Self-induced vomiting, purgation or dieting after binges.
• Self-castigation for mild weight gain or binges. Attempts to conceal binge-eating or purging, or lies about behaviors.
• Weight maintained within normal range.

Bulimia Nervosa Major Subtypes

• Purging type: Self-induced vomiting or use of laxatives, diuretics, or enemas.
• Nonpurging type: Use of other compensatory mechanisms, such as fasting or excessive exercise.

Physical Examination

• Calluses on the dorsal surface of their hands (self-induced vomiting), dental erosion and caries, esophageal erosion, lanugo hair, enlarged parotid glands (chipmunk face secondary to increased amylase), bradycardia, hypotension, and arrhythmias (secondary to hypokalemia).
• Associated problems: Depression, substance abuse, and impulsivity (kleptomania).
• Comorbid disorders: Borderline personality disorder is present in 50% of patients.

Diagnostic Tests: Evidence of Laxative or Diuretic Abuse

Course: It may be chronic or intermittent.

Outcome: The prognosis of bulimia is better than anorexia.

• Favorable prognostic indicators: Younger age at onset, higher social class, and family history of alcohol abuse.
• Differences between anorexia and bulimia

Bulimia Nervosa Treatment

• Antidepressants (SSRI).
• Cognitive and behavioral therapy.
• Psychodynamic psychotherapies are useful for borderline personality traits

Sleep Disorders

Disturbed sleep is one of the most frequent health complaints.

Sleep disorders can be of various types:

• Dyssomnias: Insomnia and hypersomnia
• Parasomnias:
  • NREM parasomnias: Somnambulism, somniloquy, sleep terrors, and bruxism (teeth grinding)
  • REM parasomnias: Nightmares, REM behavioral disorder Narcolepsy, Kleine Levin syndrome
• Circadian rhythm disorders
• Sleep-related movement disorders: RLS and PLMD
• Obstructive sleep apnea, upper airway resistance syndrome

Major categories of sleep disorders as per DSM IV:

• Dyssomnias: A sleeping disorder that makes it difficult to get to sleep, or to stay sleeping.
• Parasomnias
• Neurological/psychiatric disorders

Question 47. Write short notes on insomnia.
Answer:

Insomnia is the complaint of inability to sleep long enough or maintain sleep despite the patient having an adequate amount of time to devote to sleep.

It is associated with impairment of daytime functioning or mood symptoms.

Insomnia can be classified according to the nature of sleep disruption and the duration of the complaint.

Most insomnia patients present with two or more of these symptoms.

• Sleep onset insomnia: Difficulty falling asleep.
• Sleep maintenance insomnia: Frequent or sustained awakenings.
• Sleep offset insomnia: Early morning awakenings or frequent nocturnal awakenings.

Common causes of insomnia

Primary sleep disorders:

• Idiopathic insomnia
• Periodic leg movements
• Restless legs syndrome

Secondary sleep disorders:

• Psychiatric or psychological problems: Mood disorders (e.g., mania, depressive, and anxiety disorders); delirium and dementia
• Use or misuse of drug/substance abuse: Consumption or discontinuation of drugs/substances. Withdrawal of addictive drugs (e.g., alcohol and benzodiazepines); stimulant drugs (e.g., caffeine, nicotine, and amphetamines); prescribed drugs (corticosteroids and dopamine agonists).
• Physical/medical disorders: Chronic pain (e.g., carpal tunnel syndrome); nocturia (e.g., prostatism); malnutrition, chronic obstructive pulmonary disease, asthma, menopause, and neurologic disorders.

insomnia Consequences

• Depression may cause insomnia, and insomnia may cause depression.
• Can heighten the perception of pain.
• May be associated with:
  • Development of endocrine disturbances.
  • Increased risk for hypertension or cardiovascular disease.
  • Increased risk for motor vehicle accidents and occupational errors.

insomnia Treatment

• Behavioral therapy is effective but may be time-consuming. These include Relaxation techniques and cognitive behavior therapy.
• Other measures include: Decreasing alcohol intake, having an early supper, daily exercise, and hot bath prior to going to bed, and routine of going to bed at the same time.
• Pharmacologic treatment:
  • Benzodiazepines (e.g., temazepam, triazolam, estazolam, and eszopiclone) for sleep-maintenance insomnia.
  • Nonbenzodiazepines (e.g., zolpidem, zolpidem-controlled release zaleplon, zopiclone, or eszopiclone) for both sleep-onset and sleep-maintenance insomnia.
  • Melatonin agonist (e.g., ramelteon) for sleep onset insomnia.
  • Antihistamines (e.g., diphenhydramine and promethazine) and antidepressants (e.g., amitriptyline, trimipramine, trazodone, and mirtazapine).

Question 48. Write short notes on parasomnias.
Answer: It consists of various uncommon disruptive sleep-related disorders with abnormal unpleasant or undesirable behaviors or experiences that occur during sleep, entry to sleep, or arousal from sleep.

Parasomnias Treatment

• Avoid Caffeine or alcohol and drugs, such as serotonin reuptake inhibitors and MAO inhibitors.
• Remove dangerous objects from the environment of sleep.
• Pharmacologic therapy: These include clonazepam, tricyclic antidepressants, dopamine agonists or levodopa, melatonin, and carbamazepine.

Parasomnias Narcolepsy

Question 49. Write short notes on narcolepsy.
Answer:

Parasomnias Etiology

• Loss of orexin (hypocretin) signaling
• Strong genetic/HLA association: HLADQB1*0602 haplotype is present in 95% of patients with cataplexy and in 96% of those with orexin deficiency.

Parasomnias Clinical Features

The classic “narcolepsy tetrad” consists of four main clinical features.

1. Excessive daytime sleepiness (EDS): occurring almost daily for at least 3 months that interferes with functioning plus
three specific symptoms related to an intrusion of REM sleep characteristics.

Sleep attack is the most common symptom.

2. Cataplexy (pathognomonic sign): Sudden weakness or loss of muscle tone without loss of consciousness, usually precipitated by loud noise, laughter, or other intense emotions.

3. Hypnagogic/hypnopompic hallucinations: Hypnagogic hallucinations (hallucinations occur as the patient is going to sleep) or hypnopompic hallucinations (hallucinations upon awakening).

4. Sleep paralysis: Muscle paralysis upon awakening. It consists of episodes up to several minutes in duration of inability to move and occasionally feeling unable to breathe despite being awake. Fragmented sleep is classically seen in patients.

Parasomnias Diagnosis

• Electrographic evidence/multiple sleep latency test: Demonstration of rapid transition from wakefulness to sleep and shortened REM sleep onset is confirmatory for the diagnosis.
• A mean sleep latency of ≤8 minutes and two or more sleep onset REM periods (SOREMPs) on a multiple sleep latency test (MSLT) is performed using standard techniques.
• HLA testing may also be useful.
• Cerebrospinal fluid (CSF) hypocretin-1 concentration is low.

Parasomnias Treatment

Mainly symptomatic: Forced naps at a regular time of day are usually the treatment of choice.

Parasomnias Psychostimulants:

Wake-promoting therapeutics: Modafinil is the drug of choice, principally because it has few side effects and has low addiction potential.

Older drugs such as methylphenidate or methamphetamine or dextroamphetamine are used as alternatives, particularly in refractory patients.

Tricyclic antidepressants (TCAs) help to suppress REM sleep (e.g., protriptyline, imipramine, and clomipramine) or the selective serotonin reuptake inhibitors (SSRIs) [e.g., fluoxetine (10–20 mg/d)] or selective norepinephrine reuptake inhibitors (e.g., venlafaxine) can improve cataplexy.

Gamma hydroxybutyrate (GHB) is effective in reducing daytime cataplectic episodes.

Sodium oxybate, a sodium salt of GHB alone or combined with modafinil, can reduce sleep disruption significantly.

It is administered at night to help consolidate REM sleep and increase slow-wave sleep.

It significantly reduces daytime sleepiness and also improves cataplexy.

Pitolisant, a histamine H3 receptor inverse agonist, is an effective treatment for cataplexy and daytime sleepiness.

Others: Selegiline, clomipramine, fluoxetine, and venlafaxine.

Question 50. Write short notes on circadian rhythm sleep disorders.
Answer: Circadian rhythm sleep disorders (CRSDs) are mainly due to alterations of the circadian time-keeping system or asynchrony between the endogenous circadian rhythm and external factors that affect the timing or duration of sleep.

Wake-sleep schedule disorders fall into two categories:

• 1. Primary malfunction of the biologic clock per se
• 2. Secondary malfunction due to environmental effects on the underlying clock. Example: Shift work type: Night shift or shift changes Jet Lag Disorder is associated with excessive daytime sleepiness, sleep onset insomnia, and frequent arousals from sleep, especially in the latter half of the night.

Transient symptoms of difficulty falling asleep at the appropriate time and daytime sleepiness following rapid changes in time zones alter the timing of exogenous light stimuli.

Diagnosis

• Made by history and sleep diaries.
• Actigraphy: Based on a wrist-mounted motion detector worn as an outpatient for at least 7 days. It can help in quantifying time spent asleep.

Treatment of the Primary Circadian Rhythm Disorders

• Chronotherapy:
  • Useful in delayed sleep phase type of circadian rhythm disorders.
  • Patient delays the onset of sleep by a few hours every day and sleeps only the predetermined number of hours until the onset of
    sleep occurs at the desired time.
• Phototherapy: Bright light therapy:
  • The patient sits at a prescribed distance from a bright light with an illuminance of greater than 2,500 lux at that distance for 2–3 hours in the morning.

Pharmacologic therapy:

Melatonin 3 mg is given 4–5 hours before the desired time of sleep onset. Useful in patients with delayed sleep phase.

For jet lag:

• Behavioral strategies (good sleep hygiene), shifting sleep, and wake times gradually before travel to conform to the destination’s time
  zone, and avoiding bright light exposure before bedtime.
• Melatonin is administered before bedtime in the new time zone.

Question 51. Write short notes on sleep-related movement disorders.
Answer:

These include restless leg syndrome and periodic limb movement disorder.

Restless Leg Syndrome (Willis-Ekbom Disease)

It is characterized by an urge to move the legs and the patient usually complains of a variety of uncomfortable sensations in the legs (e.g., pins and needles, creeping or crawling sensations, aching, itching, stabbing, heaviness, tension, burning, or coldness).

• Symptoms are usually experienced during periods of prolonged rest or inactivity.
• Symptoms are typically relieved only by movement or stimulation of the legs.
• The discomfort appears more prominent during the evening and between midnight and 4 AM.
• May disrupt sleep initiation.

Restless Leg Syndrome Types

• Primary or idiopathic: Inherited as an autosomal dominant disorder.
• Secondary: To other causes, including iron deficiency, pregnancy, varicose vein or venous reflux, uremia, or folate deficiency, peripheral neuropathy, radiculopathy rheumatoid arthritis, etc. It often develops suddenly and may be daily from the very beginning.

Restless Leg Syndrome Treatment

• Treatment of the underlying condition.
• First-line drugs: Dopamine agonists (e.g., pramipexole, carbidopa/levodopa or pergolide, and ropinirole) are the treatments of choice.
• Other drugs include quinine levodopa preparations, gabapentin, opiate agonists (e.g., oxycodone, codeine, propoxyphene oxycodone, or methadone), benzodiazepines (e.g., clonazepam which often assists in staying asleep and reducing awakenings from the movements) may also be effective.
• Anticonvulsants, such as gabapentin, are often helpful in patients with painful sensations.

Periodic Limb Movement Disorder

• It is a repetitive, stereotyped limb movement and consists of 0.5- to 5.0-s extensions of the great toe and dorsiflexion of
  the foot.
• It occurs/recurs every 20–40 seconds during NREM sleep and each episode lasts from minutes to hours.
• Movements often disrupt sleep and lead to daytime sleepiness.

Sexual Disorders

It includes sexual dysfunction, paraphilia, and gender identity disorder.

Question 52. Write short notes on sexual dysfunctions: based on phases of the sexual cycle.
Answer:

• Desire disorders:
  • Decreased—frigidity/hypoactive sexual desire disorder
  • Increased—satyriasis (male), nymphomaniac (female)
• Arousal disorders: Erectile dysfunction (organic/psychological), female sexual arousal disorder
• Orgasm disorders: Premature ejaculation, female orgasm disorder
• Resolution disorders: Post-coital dysphoria

Question 53. Write short notes on paraphilias.
Answer:

Question 54. Write short notes on gender identity disorders (DSM-IV).
Answer:

• It has been renamed as gender dysphoria in DSM-5 and as gender incongruence in ICD-11.
• ICD-11 considers gender identity disorder as a sexual health disorder and not a psychiatric disorder.
• It refers to the presence of incongruence/dissatisfaction with the allotted/biological sex + persistent desire to be identified as a member of the opposite sex.

It can be further classified as:

• Transsexualism is the severe form and they can be offered sex reassignment surgery along with hormonal therapy.
• Removal of the male external genitalia and reconstruction of the female external genitalia and vice-versa is the procedure followed in sex reassignment surgery.

Personality Disorders

Personality: Enduring pattern of behavior, cognition, and emotions that makes every individual unique.

Personality disorder: Problems with understanding self and others, thus causing interpersonal dysfunction.

Question 55. Write short notes on clinical features of personality disorders.
Answer:

Management of personality disorders includes both pharmacological methods (like antidepressants, antipsychotics, and mood stabilizers) as well as psychotherapy.

Dialectic behavior therapy is used for borderline personality disorder.

Personality Disorders Child Psychiatry

It includes the following disorders:

• Neurodevelopmental disorders: Intellectual disability, specific learning disability
• Disruptive behavioral disorders of childhood: Oppositional defiant disorder, conduct disorder
• ADHD, Tourette’s syndrome
• Autism spectrum disorders
• Disruptive mood dysregulation disorder
• Intellectual Disability

Question 56. Write short notes on intellectual disability (ID).
Answer: It was called mental retardation in ICD-10. It has been renamed as intellectual disability in DSM-5 and ICD-11 calls it disorders of intellectual development.

• Normal intelligence is defined as IQ 90–110
• Dull normal intelligence: IQ 80–89
• Borderline intelligence: IQ 70–79

Personality Disorders Etiology

Genetic disorders like Down syndrome and Fragile X syndrome are the most common causes of intellectual disability.

Other causes include metabolic and chromosomal disorders, obstetric complications, and nutritional and infectious causes.

Personality Disorders Clinical Features

These include physical stigmata of respective chromosomal anomalies like wide-spaced eyes, microcephaly, short stature, etc., slow learning, and below-average intelligence.

Personality Disorders Investigations

• Blood and urine workup to look for inborn errors in metabolism
• Neuroimaging and karyotyping to establish the cause of ID
• Intelligence assessment

Personality Disorders Management

It includes behavior therapies like contingency management, life skills training, use of antipsychotics to control aggression, etc.

Specific learning disability includes:

• Dyslexia: Difficulty in reading
• Dysgraphia: Difficulty in writing
• Dyscalculia: Difficulty in arithmetics

Management: Training with the help of a special educator

Question 57. Write short notes on disruptive behavioral disorders of childhood.
Answer:

Attention Deficit Hyperactivity Disorder

Question 58. Write short notes on attention deficit hyperactivity disorder.
Answer:

It is a disorder characterized by a triad of hyperactivity, impulsivity, and attention deficit manifesting at ≥2 contexts and having its onset before 12 years of age.

It is more common in boys.

Etiology: Abnormality in information processing due to involvement of cortico-striato-thalamo-cortical loop.

Clinical features include—the inability to wait for their turn or to sit in one place, poor concentration, losing things easily, poor scholastic performance despite normal IQ, etc.

Management includes pharmacotherapy stimulants like methylphenidate and dextroamphetamine and non-stimulants like atomoxetine, clonidine, and behavioral techniques like attention-enhancing tasks, social skills training, and behavior therapy.

Tic/Tourette Disorder

• Tourette syndrome (TS) is a neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics.
• It can be of four types:
  1. Vocal tics: Throat clearing, grunting
  2. Motor tics: Eye blinking, head nodding
  3. Coprolalia: Blurting obscene words
  4. Palilalia: Repeating words
• It can be managed by using antipsychotics like risperidone and haloperidol. Clonidine can also be used.
• Behavioral techniques include habit reversal and others.

Autistic Spectrum Disorder

Question 59. Write short notes on autism spectrum disorders.
Answer: It was previously called pervasive developmental disorders to describe a group of disorders that shared similar clinical features, i.e., abnormalities in reciprocal communication and repetitive stereotyped behaviors as core features.

Clinical features include a self-absorbed child with poor eye-to-eye contact, lack of social smile, delayed milestones, problems in attachment with parents and others, repetitive hand wringing, banging, etc.

Management is mainly with psychotherapy (social skills training, speech, and communication, behavioral) and antipsychotics like risperidone and aripiprazole.

Question 60. Write short notes on mood disorders seen in children.
Answer:

Autistic Spectrum Disorder Childhood Depression

• It can also be called anaclitic depression.
• Clinical features differ from that in adults in that they can present with school refusal, frequent anger outbursts, and recurrent somatic complaints.
• Fluoxetine is an antidepressant approved for use.

Disruptive Mood Dysregulation Syndrome

• Characterized by the presence of temper outbursts which can be expressed verbally/ physically, are out of keeping with the situation and in excess than that expected for a child’s developmental age.
• Seen in children of age 6–18 years
• Temper outbursts occur ≥3 times/week for at least 12 months, in at least two different settings (school, home, etc.)
• Management is with pharmacotherapy (SSRI, stimulants, etc.) and psychotherapy (CBT).

Geriatric Psychiatry

• All psychiatric disorders can occur in the elderly too.
• They might vary in their presentation due to significant overlap of symptoms of dementia and other medical comorbidities.
• Due to the altered bodily response to the drug, management of the illness varies from adult psychiatry.

Common psychiatric disorders in the elderly are:

• • Geriatric depression/melancholic depression (described under depression): Sertraline may be beneficial, especially in those with cardiac comorbidities.
  • Old age psychosis: Features of late-onset schizophrenia may be seen including paranoid ideations.
• Management depends on the management of comorbidities, avoiding polypharmacy, adequate palliative care, slower titration of drug dosage, active watch for side effects, and supportive psychotherapy.

Puerperal Disorders

Three common psychiatric disorders occur after childbirth.

1. Postpartum blues: These are characterized by irritability, labile mood, and tearfulness.

Symptoms start soon after childbirth, and peak by about the fourth day and then resolve.

2. Postpartum depression: It develops in 10–15% of women within a month of delivery and is characterized by guilt, anhedonia, and suicidal thoughts.

It is managed with antidepressants, ECT.

3. Puerperal psychosis

Question 61. Write a short note on puerperal psychosis.
Answer:

• It is a rare disorder occurring in perhaps less than 1 or 2 per 1,000 deliveries.
• It is more common in primiparous than multiparous women.
• Symptoms generally appear abruptly within about 3 days to several weeks after delivery.
• Rarely serious complications, such as manic or depressive psychosis may develop.
• It may be associated with a personal or familial history of bipolar disorder.
• Management is with antidepressants, antipsychotics, and ECT.
• Hospitalization is generally indicated.
• Most women recover but have an increased (25%) risk of developing puerperal psychosis in the next pregnancy, and a 50% lifetime risk.

Emergencies In Psychiatry

Question 62. Enumerate and describe the recognition and clinical presentation of psychiatric emergencies. Describe the initial stabilization and management of psychiatric emergencies.
Answer: It can be broadly classified as behaviors manifesting with harm to self/others, acute effects of substance use, and acute psychosis/mania.

• Suicide, Deliberate Self Harm
• It is an act leading to intentional death.
• September 10 is observed as World Suicide Prevention Day by WHO and the International Association for suicide prevention as an awareness-creating tool regarding the preventability of suicide.
• Suicide has become one of the leading causes of preventable deaths.
• Mental Health Care Act, 2017 has decriminalized suicide by stating that any individual committing suicide shall be presumed to be under severe stress unless proven otherwise.

Emil Durkheim described three types of suicide:

1. Egoistic: Due to lack of integration into society, e.g., a person with poor support committing suicide
2. Altruistic: Due to excessive integration into society, e.g., committing suicide for the sake of a celebrity
3. Anomic: Due to rejection of integration into society, e.g., committing suicide due to debts

Emergencies In Psychiatry Risk Factors

• Middle-aged men
• Poor family and social support
• Single/unmarried/divorced
• Recent loss in relationship, occupation, and finance
• Medical comorbidities: Long-standing illness, end-stage diseases
• Psychiatric comorbidities: Depression, substance use, and schizophrenia
• Previous suicide attempt
• Family history of suicide
• Postmortem studies have found low levels of 5-hydroxy indole acetic acid in those who completed suicide

Early warning signs of suicidal intent:

• Writing a suicide note
• Making a will
• Transferring money to the account of a family member
• Transferring one’s responsibility
• Indicating that this is my last visit and after this, all the problems will be solved
• Procuring/collecting harmful substances (guns, knives, and insecticides)
• Visiting the site to inspect and find out the timings when human traffic will be lower
• Expressing feelings of hopelessness, worthlessness
• Indulging in harmful behavior: Driving at high speeds, excessive substance intake

Emergencies In Psychiatry Management

• Suicidal risk assessment: Assess for risk factors and early warning signs.
• Hopelessness carries a high risk
• IP care is advisable for an individual with high suicidal risk.
• 24-hour supervision while ensuring a safe environment (keep away any objects that can be used to harm oneself).
• Complete diagnostic evaluation for medical and psychiatric comorbidities and their management.
• Clozapine and lithium are the two drugs with antisuicidal properties.
  Antidepressants and mood stabilizers can be used in comorbid depressive disorders.
• Intranasal/IV Esketamine/ECT also has been used for rapid control of symptoms
• Provision of psychological and emotional support through supportive, cognitive behavioral psychotherapy, and family therapy

Emergencies In Psychiatry Acute Agitation

Agitation refers to a state of sudden behavioral activation.

It can occur as a symptom of psychiatric disorders (mania, substance intoxication/ withdrawal), depression, schizophrenia, dissociative disorders, or due to organic causes (delirium, catastrophic reaction in dementia, and head injury).

Management includes:

Evaluation of organic causes

Ensure the safety of the patient and the examiner: Examination in the open room which is free of objects that can be used to harm.

Oral/IV drugs: Benzodiazepines (lorazepam and diazepam) and antipsychotics (haloperidol)

Use of physical restraints if required

Monitoring vitals and detailed evaluation once the patient is calm.

Psychosomatic Disorder

Question 63. Write a short note on the psychosomatic disorder.
Answer: Psychosomatic disorder is characterized by the presence of organic pathology, but is altered by psychological influence.

It includes those disorders which are either initiated or exacerbated by the presence of meaningful psychosocial environmental stressors.

Community Psychiatry

Question 64. Write a short note on National Mental Health Programme (NMHP), 1982.
Answer:

Community Psychiatry Objectives

• To ensure availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged section of the population.
• Encourage the application of mental health knowledge in general health care and social development.
• Promote community participation in mental health service development and stimulate efforts toward self-help in the community.

Community Psychiatry Strategies

• Integration of mental health care with primary health care (training PHC doctors in diagnosis and treatment of common psychiatric disorders like depression and insomnia).
• Strengthening tertiary care institutions for treatment of mental health disorders.
• Eradicating stigmatization of mentally ill patients (through awareness campaigns) and protecting their rights through regulatory institutions like central and state mental health authorities.
• NMHP is implemented through District Mental Health Program (DMHP) and School Mental Health Program (SMHP).

Activities in District Mental Health Program:

• Training of medical, paramedical personnel, and community leaders
• Community mental health care through the existing infrastructure of health services.
• Information, education, and communication activities

Activities in School Mental Health Program: Training school teachers by providing:

• Knowledge and skills to identify emotional, conduct in students
• System to refer students with psychological problems to the DMHP team for evaluation and treatment
• Skills to promote life skills among students

Forensic Psychiatry

Confidentiality in Psychiatry

• The mental healthcare professional has the duty to maintain confidentiality with respect to the information provided during the diagnosis and treatment of mental illness.
• However, maintaining confidentiality is exempted when the information is required for treatment, in legal issues, to prevent harm to others, or for public safety.

Question 65. Write a short note on the criminal responsibility of the mentally ill.
Answer:

• If the act occurred as a product of mental illness, the individual with mental illness is not criminally responsible, if at the time of committing the act, he was unable to understand the nature and consequences of the act or that the act is wrong or contrary to law.
• This is also called the insanity defense.
• McNaghten’s rule states that unless proven otherwise, every person shall be considered to be of sane mind which shall be decided by the jury.
• Insanity is punishable if he was of sound mind at the time of committing the act (i.e., during a lucid interval, remission of the phase of episodic illness)
• Acts committed under the intoxication of substance/hypnotization cannot stand for legal defense as the person was aware of the consequences while initiating the act.

Question 66. Write a short note on the civil responsibility of the mentally ill.
Answer:

During lucid intervals of psychiatric disorder when he is able to understand the consequences of the act, one can exercise his civil rights of making a will to dispose of one’s assets, to give witness, and also can make a contract.

However, these arẹ subject to the court’s discretion.

Classical psychosomatic illnesses:

• Ulcerative colitis
• Peptic ulcer
• Neurodermatitis
• Thyrotoxicosis
• Rheumatic arthritis

Essential hypertension

Individuals with profound intellectual disability/dementia cannot hold a driving license.

A marriage shall be void and eligible for divorce if, at the time of marriage, either of the party was incapable of giving valid consent or has been suffering from such severity of illness that interferes with the usual course of marriage and procreation.

Question 67. Write a short note on the Mental Health Care Act, of 2017.
Answer: It has replaced the Mental Health Care (MHC) bill of 2013, wherein the previous assurance-based approach has been changed to the right-based approach. Its main features include:

• It recognizes the rights of the mentally ill by recognizing the capacity of individuals to make mental healthcare decisions, making regulations for hospitalization (independent and supported), and use of restraints.
• Advanced directive: An individual has the right to choose how he wants to be treated for mental illness.
• Nominated representative: Every individual can appoint his representative who would take decisions on his behalf in case he loses his capacity to make mental health decisions.
• Central and state mental health authorities to protect the rights of the mentally ill.
• Decriminalizing suicide: Any person attempting suicide shall be presumed to be under severe stress and hence should not be punished.
• Prohibition of ECT in minors and prohibition of direct ECT Rules for establishing Mental Health Establishments

Child Abuse

• Abuse is defined by tissue damage, neglect, sexual exploitation, and mental cruelty.
• It is a mandatorily reportable offense.
• The treating physician will be charged with a criminal offense if not reported.
• Duties of the treating physician include: To report the offense and to protect the child
• Clinical features that should raise the index of suspicion: Broken bones in 1st year of life, STD in young children, soft tissue injuries, and nonaccidental burns.

POCSO: Prevention of Children from Sexual Offences Act, 2012 has been framed to protect the child from such offenses.

Penetrative and aggravated penetrative sexual assault have a punishment of a minimum of 10 and 20 years life imprisonment + fine, respectively, whereas sexual assault and aggravated sexual assault have a punishment of fine + imprisonment for 3–5
years and 5–7 years, respectively.

Miscellaneous Topics

Important Names in Psychiatry

• Johann Christian Reil: Coined the term “Psychiatry”, Father of Psychiatry
• Philippe Pinel: Unchaining and humane treatment of mentally ill
• Sigmund Freud: Father of Psychoanalysis, interpretation of dreams, structure of mind
• Ugo Cerlitti and Bini: ECT
• John Cade: Lithium

Terminologies

• Rapport: Meaningful and therapeutic relation between patient and healthcare provider
• Empathy: Ability to understand what and how others feel
• Stigma: A sign of disgrace that sets a person apart from others
• Stereotype: Generalized belief about a particular group/class of people
• Prejudice: Affective feeling toward an individual solely based on his group membership

Breaking Bad News

Question 68. Discuss SPIKES protocol for breaking bad news.
Answer:

SPIKES protocol is followed for breaking bad news.

S: Setting up and starting the conversation

P: Elicit patient/family members’ perception

I: Invite them to ask what they would want to know

K: Provide knowledge in small pieces

E: Recognize and empathize with their emotions

S: Set out the strategy of the plan of action and summarize the gist of the conversation

Doctor-Patient Relationship

Question 69. Write short notes on four models of the doctor-patient relationship
Answer:

Learning

Question 70. Explain the theories and process of learning.
Answer:

Learning: Process by which behavioral changes occur.

• Ivan Pavlov’s classical conditioning using dog experiment:
  • Neutral stimulus (bell) + Unconditioned stimulus (food) = Unconditioned response (drool)
  • After conditioning, a neutral stimulus becomes a conditioned stimulus to produce a conditioned response (drool).

Skinner’s: Operant conditioning using rats and pigeons:

• Operant chamber in which food was delivered when the animal pressed the lever. This was used to describe the effect of reinforcement and punishment on behavioral change.