Psychiatry Notes

Psychiatry Books Information

  • For more information on psychiatry books, visit mesfree.com or jaypeebrothers.com.

  • Books are thoroughly updated with all Recent Questions and DSM-5 Guidelines.

  • Offers Free Online Exam Support via www.accesspgmee.com.

  • The book \"Psychiatry\" is based on Kaplan's and Sadock's Comprehensive Textbook of Psychiatry, 9th edition and Short Oxford Textbook of Psychiatry, 6th edition, authored by Praveen Tripathi.

  • It Includes Explained Referenced All Recent Questions (2015-1997) - All India (2012-1997), AIIMS (Nov 2015-1997), DNB (2012-1997), AP, JIPMER, Bihar, UPSC CMS, PGMCET (2015), Other State Exams (2015-1997).

  • It’s a must-buy book for All India, AIIMS, PGI, JIPMER, DNB, FMGE & State entrance exams.

Review of Psychiatry - Praveen Tripathi

  • Authored by Praveen Tripathi, MBBS, MD Consultant, Psychiatry at Kailash Hospital and Research Institute, Noida, Uttar Pradesh, India.

  • Foreword by Kailash Kedia MBBS, MD.

  • Published by Jaypee Brothers Medical Publishers in New Delhi, London, Panama, and Philadelphia.

  • Headquarters: Jaypee Brothers Medical Publishers (P) Ltd, 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India.

  • Overseas Offices:

    • J.P. Medical Ltd, 83 Victoria Street, London SW1H 0HW (UK)

    • Jaypee-Highlights Medical Publishers Inc, City of Knowledge, Bld. 235, 2nd Floor, Clayton Panama City, Panama

    • Jaypee Medical Inc, 325 Chestnut Street Suite 412, Philadelphia, PA 19106, USA

    • Jaypee Brothers Medical Publishers (P) Ltd, 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh

    • Jaypee Brothers Medical Publishers (P) Ltd, Bhotahity, Kathmandu, Nepal

  • Website: www.jaypeebrothers.com, www.jaypeedigital.com

  • First Edition: 2016, ISBN 978-93-85999-52-9

  • Dedication: To My Parents

  • Acknowledgements:

    • Thanks to parents, brother Dr. Anurag Tripathi, and wife Dr Priyanka Goyal.

    • Gratitude to Dr Apurv Mehra and Dr Pritesh Singh.

    • Thanks to Shri Jitendar P Vij, Mr Ankit Vij, Ms Chetna Malhotra Vohra, Ms Payal Bharti, Mr Arun Sharma, Ms Priyanka Shahi, Mr Pankaj K Singh, and the production team of Jaypee Brothers Medical Publishers (P) Ltd.

    • Appreciation to patients and students.

Table Of Content

  • Basics - 1

  • Schizophrenia Spectrum and Other Psychotic Disorders - 10

  • Mood Disorders - 27

  • Neurotic, Stress Related and Somatoform Disorders - 43

  • Substance Related and Addictive Disorders - 63

  • Organic Mental Disorders - 78

  • Personality Disorders - 89

  • Eating Disorders - 95

  • Sleep Disorders - 98

  • Sexual Disorders - 103

  • Child Psychiatry - 107

  • Psychoanalysis - 115

  • Miscellaneous - 122

Basics in Psychiatry

  • Psychiatry:A branch of medicine that deals with morbid psychological processes.

  • Diagnosis: Requires both history and clinical examination.

  • Mental Status Examination (MSE): Records psychiatric signs and symptoms.

Areas Assessed in MSE

  • A. General appearance and behavior:

    • Description of patient's appearance and gross abnormalities.

  • B. Speech:

    • Rate, tone, volume, and spontaneity are described.

  • C. Mood and affect:

    • "Affect": Cross-sectional emotional state.

    • "Mood": Sustained emotional state.

    • Terms used interchangeably sometimes.

    • Quality:

      • Euphoric mood: Excessive happiness (mania, hypomania).

      • Depressed mood: Excessive sadness (depression).

    • Fluctuations:

      • Labile mood: Excessive mood variations (mania).

      • Affective flattening: Absence of mood changes (schizophrenia).

    • Appropriateness and congruency:

      • Appropriateness: Expected emotion in social situation (e.g., sadness at a funeral).

      • Congruency: Emotional state in sync with thought content.

    • Other disturbances:

      • Alexithymia: Inability to understand/express emotions.

      • Anhedonia: Loss of capacity to experience pleasure.

    • Neuroanatomical substrate of emotions:

      • Limbic system: Hippocampus, amygdala, hypothalamus, cingulate gyrus.

      • Regulation of emotions: Frontal lobe.

  • D. Perception:

    • Receiving information using sensory modalities.

    • Illusions: False perception of a real object (e.g., rope mistaken for a snake).

    • Hallucinations: False perception without stimulus.

      • Properties:

        • Absence of sensory stimulus.

        • Vivid as true perceptions.

        • Experienced in outer objective space.

        • Not under willful control.

      • Most common: Auditory hallucinations.

      • Organic disorders (delirium): Visual hallucinations.

      • Temporal lobe epilepsy: Various hallucinations.

      • Cocaine intoxication: Tactile hallucinations.

      • Specific hallucinations:

        • Hypnagogic hallucinations: While falling asleep (narcolepsy).

        • Hypnopompic hallucinations: While getting up from sleep.

        • Reflex hallucinations (Synesthesia): Stimulus in one modality produces hallucinations in another sensory modality (cannabis, LSD intoxication).

        • Functional hallucination: Stimulus produces hallucination in same modality.

  • E. Thought (Cognition):

    • Stream:

      • Flight of ideas: Rapid, loosely connected thoughts (mania).

      • Inhibition of thinking: Slow thoughts.

    • Form of thought:

      • Derailment: Disturbed association between successive thoughts

      • Loosening of association: Single thought components are disconnected

      • Incoherence: Lack of organization, incomprehensible thought.

      • Circumstantiality: Unnecessary details, but goal is reached.

      • Tangentiality: Related answer, goal is never reached.

      • Neologism: Coining of new words (schizophrenia).

      • Word approximations (metonyms): Old words used unconventionally.

      • Perseveration: Repetition of same response.

    • Content of thought:

      • Delusion: False, unshakeable belief.

        • Delusion of persecution.

        • Delusion of reference.

        • Delusion of grandeur or grandiosity.

        • Delusion of love (erotomania, fantasy lover syndrome).

        • Nihilistic delusion (delusion of negation,Cotard’s syndrome).

        • Delusion of infidelity (delusion of jealousy).

        • Delusion of guilt.

      • Bizarre Vs Nonbizarre Delusions: Bizarre delusions are scientifically impossible and culturally implausible. Nonbizarre delusions are false but possible.

    • Possession of thought:

      • Obsessions: Repetitive, intrusive thoughts against will.

      • Thought alienation: Thoughts under external control.

        • Thought insertion.

        • Thought withdrawal.

        • Thought broadcast.

  • F. Higher mental functions:

    • Attention, concentration, memory, judgement, abstract thinking, and insight.

Classification in Psychiatry

  • ICD-10: International Classification of Diseases, 10th edition (WHO).

    • Psychiatric disorders are classified in chapter-V (F).

  • DSM-5: Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association).

    • Fifth edition published in 2013.

  • Organic vs. Functional (Nonorganic) Mental Disorders:

    • Organic: Caused by brain disturbances (e.g., delirium, dementia).

    • Functional: No demonstrable brain disturbances (e.g., schizophrenia, mania).

  • Psychoses vs. Neuroses:

    • Psychoses: Lack of awareness of illness and impaired reality testing (e.g., schizophrenia, bipolar disorder).

    • Neuroses: Awareness of illness and intact reality contact (e.g., anxiety disorders, depression).

Mental State Examination Sections

  • General appearance and behavior

  • Speech and language

  • Mood and affect

  • Perception

  • Thought (cognition)

  • Higher mental functions

Important MSE terminology

  • Anhedonia: Inability to enjoy pleasurable activities.

  • Alexithymia: Inability and describe feelings.

  • Labile affect: Rapid changes of affect.

  • Limbic system: Neural Substrate For Generation of Emotions

  • Frontal Lobe: Regulation of emotions.

  • Outer objective space: Where hallucinations occur.

  • Pseudohallucinations: inner subjective space

  • Hypnagogic hallucinations: occur while "going" to sleep.

  • Hypnopompic hallucinations: occur while waking up.

  • Synesthesia: stimulus in one sensory modality produces hallucinations in another sensory modality

  • Vorbeireden: Skirting around end point but never reaching it

Schizophrenia Spectrum and Other Psychotic Disorders

History of Schizophrenia

  • Emil Kraepelin:

    • Classified psychiatric illnesses into Dementia Praecox and Manic Depressive Illness.

    • Dementia Praecox: Chronic, deteriorating course with cognitive decline.

    • Manic Depressive Illness: Distinct episodes alternating with normal functioning, no cognitive decline.

  • Eugen Bleuler:

    • Coined the term "Schizophrenia".

    • Fundamental symptoms (4 A’s of Bleuler):

      • Autistic thinking and behavior (Autism).

      • Ambivalence.

      • Affect disturbances.

      • Association disturbances.

  • Kurt Schneider:

    • Described Schneiderian First Rank Symptoms (SFRS), frequently seen in schizophrenia.

Schneiderian First Rank Symptoms (SFRS)

A. Tree thought phenomenon:

  • Thought insertion.

  • Thought withdrawal.

  • Thought broadcast.
    B. Tree made phenomenon:

  • Made volition.

  • Made affect.

  • Made impulses.
    C. Tree auditory hallucinations:

  • Voices arguing or discussing (third person).

  • Voices commenting on patient’s action.

  • Audible thoughts.
    D. Somatic passivity:

  • Tactile or visceral hallucinations imposed by external agent.
    E. Delusional perception:

  • A delusion attached to a normal perception (primary delusion).
    Examples for Voice in 3rd person, thought insertion, etc, can be added.

Epidemiology of Schizophrenia

  • Lifetime prevalence: 1%.

  • Point prevalence: 0.5–1%.

  • Incidence rate: 0.15–0.25 per thousand.

  • High heritability.

  • Usual age of onset: Adolescence and young adulthood.

  • Onset after 45 years: Late-onset schizophrenia.

  • Equally prevalent in men and women, but earlier onset in men.

  • More prevalent in lower socioeconomic status.

  • Body types: Asthenic and athletic types believed to be predisposed.

Etiology and Pathogenesis of Schizophrenia

A. Genetic factors:
* Higher monozygotic concordance rate than dizygotic.
* Linkage sites: 1q, 5q, 6p, 6q, 8p, 10p, 13q, 15q and 22q.
* Candidate genes: a-7 nicotinic receptor, DISC 1, COM, NRG 1, GRM-3, RGS-4 and DAOA.
B. Biochemical factors:
* Dopamine hypothesis: Excess dopaminergic activity.
* Serotonin: Excess.
* Other neurotransmitters: GABA, glutamate, norepinephrine, acetylcholine, nicotine implicated.
C. Neuropathological factors:
* Cerebral ventricles: Enlargement of lateral and third ventricles.
* Limbic system: Abnormalities in hippocampus, amygdala, and parahippocampal gyrus.
* Prefrontal cortex : Anatomical abnormalities.
* Talamus: Neuronal loss especially in medial dorsal nucleus
* Basal ganglia and cerebellum: Abnormalities have been reported without any conclusive proof.

Symptoms of Schizophrenia

A. Positive symptoms (or psychotic symptoms):
*Delusions and hallucinations (respond well to medications)

  • Delusions: Most common is delusion of persecution.
    Bizarre delusions are considered scientifically impossible and culturally implausible.

  • Hallucinations: Most common are auditory hallucinations. Raises suspision if visual hallucination are present.
    B. Negative symptoms:

  • Loss of normal functions (respond poorly to medications)

  • Avolition: Loss of will or drive.

  • Apathy: Loss of concern.

  • Anhedonia: Loss of ability to derive pleasure.

  • Asociality: Indifference to social relationships.

  • Affective flattening (or blunting): Inability to understand and express emotions.

  • Alogia: Decrease in verbal communication.
    C. Disorganization symptoms:

  • Formal thought disorder. These are the disturbances in the form of thought characterized by loss of organization of thought.

  • Disorganized behavior: Inappropriate behavior.

  • Inappropriate affect: Affect not in sync with social situation. D. Motor symptoms (catatonic symptoms):

    • Stupor : Extreme hypoactivity or immobility and minimal responsiveness to stimuli.
      *Excitement : Extreme hyperactivity which is usually non goal directed
      *Posturing/catalepsy : Spontaneous maintenance of posture for long periods of time.
      *Waxy flexibility : When examiner makes a passive movement on patient, there is a feeling of plastic resistance which resembles bending of a soft wax candle
      *Automatic obedience : Excessive cooperation with examiner’s commands despite unpleasant consequences
      *Echolalia and Echopraxia
      *Negativism: Patient refuses to accept examiner’s instructions or any attempts to move him.
      *Grimacing and Stereotypy
      *Gegenhalten: Resistance to passive movement which is directly proportional to the strength of force applied.
      *Mannerisms: Spontaneous repetition of odd, purposeful movements.
      *Perseveration: Senselessly repeated induced movement.
      *Ambitendency: Inability to decide desired motor movement

Diagnosis of Schizophrenia

*DSM-5 Criteria: Two or more of the following symptoms should be present for 1 month with long term symtpoms for 6months:
Delusions, Hallucinations, Disorganized speech, Disorganized Behavior and Negative Symptoms
*ICD-10 criteria is similar but symptom should be seen for >1 month.

Types of Schizophrenia According to ICD-10

A. Paranoid schizophrenia:
* Hallucinations and delusions.
* Late onset and good prognosis.
* Personality preserved.
B. Catatonic schizophrenia:

  • Dominated by motor symptoms.

  • Best prognosis.

  • First line treatment intravenous lorazepam and electroconvulsive therapy.
    C. Hebephrenic (disorganized) schizophrenia:

  • Disorganization and negative symptoms.

  • Early onset and bad prognosis. D. Undifferentiated schizophrenia:

    • Features of multiple subtypes.
      E. Residual schizophrenia:

    • Progresses from positive to mostly negative symptoms.
      F. Simple schizophrenia:

  • Bad prognosis (prominent negative symptoms without history of positive symptoms).
    G. Post schizophrenic depression: increased risk of suicide
    *A depressive episode which develops after the resolution of schizophrenic

Other Classifications of Schizophrenia

A. TJ Crow:
*Type I & Type II schizoprenia:
*Increased positive symptoms is type I = normal ventricles, medications work, better progonsis
*Increased negative symptoms is type II = dilated ventricles, medications dont work, decreased prognosis
B. Pfropf schizophrenia:
Schizophrenia in a patient with mental retardation
C. Van Gogh syndrome:
Self mutilation (injuring self) in schizophrenia

Treatment for Schizophrenia

*Antipsychotics (neuroleptics):
*Typical Antipsychotics (First Generation Antipsychotics):
Primarily act on dopamin D2 receptor antagonists, minimal effects on negative symptoms. Improvement from the action of D2 receptors.
*movement/neurological disorders due to D2 blockade in Nigrostriatal Tract Pathway like:
acute dystonia, acute akathisia, Drug-induced parkinsonism, Tardive dyskinesia,
and Neuroleptic Malignant Syndrome.
*Endocrine side effects:
Tuberoinfundibular tract blockade resulting in hyperprolactinemia.
*Sedation, orthostatic hypotension and anticholinergic side effects
*Atypical Antipsychotics (Second Generation Antipsychotics):
Act through antagonism of 5 H 2 receptors. Lesser D2 blockade than typical antipsychotics. Used to treat positive and negative symptoms and have lesser risk of causing extrapyramidal side effects as well as hyper- prolactinemia.
weight gain, increased risk of dyslipidemia, diabetes and cardiovascular disease, QTc prolongation and Seizures.

  • Clozapine:Drug of choice in treatment resistance schizophrenia (higher weight gain amongst all antipsychotics is sialorrhea). Can cause agranulocytosis, seizures and myocarditis.
    *Tioridazine can cause irreversible retinal pigmentation & cardiac arrhythmias
    *Chlorpromazine can cause corneal and lenticular deposits.
    *Penfluridol is the longest acting antipsychotic.
    *Ziprasidone is known to cause cardiac arrhythmias (prolongation of Q interval)
    *Aripiprazole is a partial agonist at D2 receptors

Prognosis of Schizophrenia

  • Good prognostic factors:

    • Acute or abrupt onset.

    • Late onset (age > 35 years).

    • Catatonic subtype and paranoid subtype.

    • Female sex.

    • Prominent positive symptoms.

    • Presence of affective symptoms.

    • Family history of mood disorder.

  • Bad prognostic factor:

    • Insidious onset.

    • Early onset (age <20 years).

    • Simple, disorganized, undifferentiated subtype.

    • Male sex.

    • Prominent negative symptoms.

    • Absence of affective symptoms.

    • Family history of schizophrenia.

Other Psychotic Disorders

A. Acute psychotic disorders:
* Symptoms similar to schizophrenia, but do not meet duration criterion.
* Frequently preceded by a stressor, acute onset, and often resolve completely.
* Duration<1 month = Brief psychotic disorder, and 1-6 months makes the person a schizophreniform disorder patient
B. Schizoaffective disorder:
* Features of both schizophrenia and mood disorders concurrently.
* Schizoaffective disorder (Bipolar type or manic type): With manic symptoms
* Schizoaffective disorder (Depressive type): With depressive symptoms.
* Treatment : It involves combination of mood stabilis- ers, antipsychotics and antidepressants depending on the presentation.
C. Delusional disorder:
* Single delusion or related delusions, usually persistent and sometimes life long.
*Types: Persecutory, Jealous, Erotomanic, Somatic, Grandiose, & Unspecified.
*Delusion of misidentification ( Capgras syndrome Fregoli syndrome,
Syndrome of inter metamorphosis & Syndrome of subjective doubles) are example of unspecified type

D. Shared psychotic disorders (or induced delusional disorder):
* Spread of delusions from one person to another.
* Treatment : Antipsychotics are the drug of choice.

Mood Disorders

Types of Mood Disorders

  • Major depressive disorder (Unipolar depression): Depressive episodes only.

  • Bipolar disorder: Manic and depressive episodes.

  • Hypomania: Less severe form of mania.

  • Cyclothymia: Less severe form of bipolar disorder.

  • Dysthymia: Less severe and chronic form of major depression.

Depression (Major Depressive Disorder)

  • Characterized by major depressive episodes in the absence of manic, mixed, or hypomanic episodes.

  • Twice as prevalent in women as in men.

  • Mean age of onset: Around 40 years.

  • Responsible for maximum DALYs amongst psychiatric disorders.

  • Most common cause of suicide.

Symptoms (SIGECAPS)

  • Sleep disturbances.

  • Interest (loss).

  • Guilt.

  • Energy (lack).

  • Cognition/Concentration.

  • Appetite.

  • Psychomotor agitation or retardation.

  • Suicidal thoughts and sadness of mood.

Physical Signs

  • Veraguth fold: Triangular shape fold in the nasal corner of upper eyelid.

  • Omega sign: Omega-shaped fold in the forehead above the root of nose.

  • Psychotic features, atypical features, melancholic features and catatonic features have been described

Endogenous vs Exogenous (Reactive) Depression

The symptoms of endogenous depression were quite similar to today’s psychotic and melancholic depression. he exogenous depression (reactive depression) was believed to occur in response to a negative life event

Etiology

A. Biological factors:

  • Neurotransmitters : Serotonin and norepinephrine reduction.

  • Hormonal disturbances: Hypothyroidism.

  • Neuroanatomical considerations: Decreased prefrontal cortex activity & increased Amygdala activity.
    B. Genetic factors: link to cAMP response element binding protein (CREB 1) on
    Chromosome 2, Serotonin transporter gene
    C. Psychological theories:

  • Cognitive theory (Aaron Beck): Negative view of self, environment, and future

  • Learned helplessness: No control over events leads to depression

Treatment of Depression

A. Pharmacotherapy:
* Most antidepressants take 3–4 weeks for therapeutic effects.
* Choice determined by side-effect profile.
* Antidepressant treatment should be maintained for at least 6 months or equal to the duration of a previous episode, whichever is greater.

  • Types:
    *Tricyclic and tetracyclic antidepressants (TCAs like:
    Imipramine, desipramine, trimipramine,
    amitriptyline, nortriptyline, protriptyline, amoxapine, doxepin, maprotiline and clomipramine.
    side effects: Cardiotixicity, anticholinergic effects

  • Secondary effects of CAs include antagonism of muscarinic, histaminic H1, a 1 and a2 adrenergic receptors and blockage of cardiac sodium channels
    Amoxapine has D2 blocking action. and Clomipramine is first line therapy for OCDs
    Tricyclic antidepressants are used to treat enuresis/bed-wetting
    * Selective serotonin reuptake inhibitors (SSRIs) like: fluoxetine, fluvoxamine, citalopram, escitalopram,
    sertraline, paroxetine and vilazodone
    Serotonin syndrom occurs when mixed when another MAOI . Give cyproheptadine and for suppotive care

  • SNRIs (Serotonin Norepinephrine Reuptake Inhibitors) like: venlafaxine, desvenlafaxine, duloxetine,
    milnacipran, levomilnacipran.

  • Monoamine oxidase inhibitors

  • Atypical antidepressants like trazodone, nefazodone, mirtazapine, bupropion (used for smoking cessation), tianeptine and amineptine and Antipsychotics B. Psychotherapy:

    • Cognitive behavioral therapy: Correcting cognitive distortions.

    • Interpersonal therapy: Managing interpersonal problems.
      C. Other somatic treatments:

    • Electroconvulsive therapy: severe depression with suicide risk, Depression with stupor and psychotic symptoms, refractoriness to other treatment modalities

  • Transcranial magnetic stimulation, Vagal nerve stimulation, Deep brain stimulation, Sleep deprivation & Phototherapy.

  • A combination of pharmacotherapy and psychotherapy is usually used in management of depressed patients, in cases of suicide risk, EC is the preferred treatment.

Bipolar Disorder

*Episodes:
Manias and depressive
*Manic episodes are more comon in men and depressive are more common in women

Mainic and Depressive episodes

*Symptoms of Mainic episode are *Elevated mood, increased self esteem,decreased sleep, etc.*
*Symptoms of depressive espisodes are Sleep disturbancesWeight changesLow energy/fatigueFeelings of worthlessness Diminished interest (Anhedonia)
*Symptoms of Hypomania are similar to mania, but not sever enough to cause *marked impairment.
*Symptoms of mixed episodes have Manic and depressive mixed but lasts >7 days.

Etiology

Neurotransmitters: Increased levels of dopamine has been implicated
*Chromosomes 18q,22q and 21q are strongly linked.

Treatment Guidelines For Bipolar Disorder

A.)Acute Treatment (Treat mania and depressive episodes)
B.) Prophylaxis to prevent further episodes
Drugs used:
*Mood stabilizers - Lithium, valproate, carbamazepine, oxcarbazepine and lamotrigine
*Lithium is considered a prototypic mood stabilizer. Best for mania & suicide risk
Atypical Antipsychotics- For severe mania or mixed episode initiate with Lithium +Antipsych
*For mixed episodes, valproate is preferred over lithium. Antidepressant mono therapy should never be given.
Lamotrigine: Best for Bipolar Depression
Maintenance:
Continue drug admin for at least 2 years. Lithium and Valproate have the best evidence.
Lithium needs drug monitoring as effective serum concentration for acute mania is 1.0–1.5 mEq/dL.The serum concentration required for maintenance treatment is 0.6–1.2 mEq/dL

Lithium Toxicity

*Includes renal impairment, dehydration, and low sodium diet
*GI distress symptoms like Vomiting & Neurological- Coarse tremors, ataxia, dysarthia. Late signs and symptoms includes Circulatory Failure that might lead to death
*Mangement includes: correct dehydration using Hemodialysis - give Pglycol not activated charcoal

Other Mood Disorders

If there are more than one depressive episodes, diagnosis of recurrent depressive disorder is made, The symptoms continue for more that 2 years.
Chronic Depresion: If the depression continues for more than 2 years, it is known as chronic depression.
Cylothymia: mider form for bipolar dosorder, in which manic symptoms and depressive symptoms occur for >2 years at a time. Rapid cycling occurs when person has >4 episode episodes/yr

Suicide

Psychiatric illnesses has high rate for suicide, some risks includes but are not linimitted:
Being male, >45yrs in age, Drug dependence and personality disorder,
Other Risk factors includes: family history AND poor social support