SCHIZOPHRENIA1. Predisposing factorsa. Genetic (family history)b. Socialc. Substance abuse (Cannabis)d. Environmente. History of childhood central nervous system infectionf. History of obstetric complication2. Schneiders First rank Symptomsa. Thought Insertionb. Thought withdrawalc. Thought broadcastd. Delusional perceptione. Delusion of controlf. Auditory hallucinationg. Somatic passivity3. DSM IV Criteriaa. Two or more must be present for at least 1 monthi. Delusionsii. Hallucinationsiii. Disorganized speechiv. Disorganized behaviourv. Negative symptomsb. Social / occupational dysfunctionc. At least 6 months (including prodromal or residual periods when above criteria is not met)d. Symptoms not due to medical, neurological or substance induced disorder4. Negative symptomsa. Affect (flat)b. Alogiac. Anhedoniad. Attention (poor)e. Avolition5. Differential diagnosisa. Schizophreniform disorderb. Schizoaffective disorderc. Brief psychotic disorder6. Managementa. Hospitalizationi. Risk of harm to self or othersii. Deterioration in psychosocial functioningiii. Serious / life threatening drug reactionsb. Antipsychoticsi. Dopamine receptor antagonists (Typical psychotics)ii. Serotonin-dopamine antagonists (Atypical antipsychotics)c. Electroconvulsive therapyi. Catatonic schizophreniaii. Cannot tolerate side effect of drugs / not responding to drugsiii. Has previous improvement with ECTd. Psychosocial interventioni. Supportive psychotherapyii. Psychoeducationiii. Social skills trainingiv. Cognitive remediation therapyv. Relaxation therapy / anger management therapyvi. Homecare team if poor complianceSCHIZOPHRENIFORM DISORDER1. DSM IV Criteriaa. When criteria A,D,E of schizophrenia is not metb. An episode of the disorder (including prodromal, active and residual phases) lasts at least 1 month but less than 6 monthsSCHIZOAFFECTIVE DISORDER1. DSM IV Criteriaa. Uninterrupted period of illness which at the same time present with either MDD episode, manic episode or mixed episode concurrent with symptoms that meet criteria A for schizophreniab. Have delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptomsc. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of illnessd. Disturbances not due to direct physiological effects of a substances or general medical condition2. Typea. Schizophrenia with MDD / Manic episode / Mixed episode i. This diagnosis is made if unsureii. Patient may present with 50% schizophrenia symptoms, 50% mood symptomsb. Schizophrenia with depressioni. Know how to differentiate from depression with psychotic symptomsc. Schizophrenia with depression and mood symptomsBRIEF PSYCHOTIC DISORDER1. DSM IV Criteriaa. Presence of one (or more) of the following symptoms:i. Delusionsii. Hallucinationsiii. Disorganized speechiv. Disorganized behaviourb. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioningc. The disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder or schizophreniad. Not due to direct physiological effects of a substance or a general medical condition2. Have presence of stressor(s)MAJOR DEPRESSIVE DISORDER1. Clinical features (SIG E CAPS)a. Sleep changes (Insomnia / hypersomnia)b. Interest (Loss, Anhedonia)c. Guilt (feeling of guilt, worthlessness)d. Energy (lack of energy, fatigueness)e. Cognition / Concentration (reduced cognition or difficulty in concentrating)f. Appetite (loss of appetite)g. Psychomotor (retardation, agitation)h. Suicide (suicide thoughts)

2. DSM IV Criteriaa. 5 or more symptoms present during the same 2 weeks;i. Low mood throughout the dayii. Anhedoniaiii. Loss of appetite with significant weight lossiv. Insomnia or hypersomniav. Psychomotor agitation or retardationvi. Fatiguenessvii. Feeling worthlessness or inappropriate guiltviii. Diminished attention and concentrationix. Recurrent thoughts of death and suicideb. Symptoms do not meet criteria for mixed episodec. Symptoms must cause clinically significant distress or impairment in social, occupational or other important areas of functioningd. Symptoms cannot be due to substance abuse or medical conditionse. Symptoms are not accounted for by bereavement

3. Suicide risk assessmenta. Current historyi. Seriousness of attempt1. Suicidal attempt2. Suicidal note3. Doing it aloneii. Regrets about attemptiii. Current intent or wish to dieb. Preventersi. Any loved onesii. Support from family or other peopleiii. Future prospect or planc. Past historyi. Previous self-harmii. Previous or current mental illnessiii. Any drugs or alcohol intaked. Candidates opinion of current riske. Candidates immediate planf. How candidate react and handle patients reaction during interview4. Managementa. Hospitalizationi. Risk of suicide or homicideii. Unable to care for selfiii. Rapidly progressing symptomsiv. Diagnostic proceduresb. Antidepressantsi. SSRIii. TCAiii. MAOIc. Antipsychoticsi. If patient displayed psychotic featuresd. Electroconvulsive therapyi. Unresponsive to pharmacotherapyii. Cannot tolerate with drugs adverse effectsiii. Desire rapid reduction of symptoms (in suicidal patients)e. Psychotherapyi. Cognitive therapyii. Interpersonal therapyiii. Supportive therapyiv. Family therapy

5. Differential diagnosisa. Adjustment disorder with depressed moodb. Hypothyroidism

BIPOLAR DISORDERBipolar Type 11. DSM IV Criteria for Manic Episodea. Distinct period of abnormally and persistently elevated, expansive or irritable mood lasting at least 1 weekb. During the period, three (or more) of the following symptoms have persisted (four if the mood is only irritable);i. Inflated self-esteem or grandiosityii. Decreased need for sleepiii. Pressure of speechiv. Flight of ideasv. Distractibilityvi. Increase in goal directed activityvii. Excessive involvement in pleasurable activities that have a high potential for painful consequences (shopping sprees, etc)c. Symptoms do not meet criteria for a mixed episoded. The disturbance sufficiently severe to cause marked impairment in occupational and social functioninge. Symptoms are not due to direct physiological effects of a substance or a general medical condition

2. DSM IV Criteria for Mixed episodea. Criteria are met both for Manic Episode and Major Depressive Disorder nearly every day during at least one week periodb. The disturbance sufficiently severe to cause marked impairment in occupational and social functioningc. Symptoms are not due to direct physiological effects of a substance or a general medical condition

3. Pneumonic for symptoms (DIGFAST)a. Distractibilityb. Impulsive behaviour (shopping spree, sexual promiscuity)c. Grandiosityd. Flight of idease. Agitation (psychomotor)f. Sleep changesg. Talkativeness (pressured speech)

Bipolar Type 21. DSM V Criteria for hypomanic episodea. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day.b. During the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behaviour, and have been present to a significant degree:i. Inflated self-esteem or grandiosity.ii. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).iii. More talkative than usual or pressure to keep talking. iv. Flight of ideas or subjective experience that thoughts are racing.v. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.c. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation.d. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).e. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.f. The disturbance in mood and the change in functioning are observable by others.g. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.h. Symptoms are not due to direct physiological effects of a substance or a general medical condition

2. DSM V criteria for Bipolar type 2a. Criteria have been met for at least one hypomanic episode and at least one major depressive episode b. There has never been a manic episode.c. The occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.d. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

3. Managementa. Hospitalizationi. Risk of bringing harm to self or othersii. Marked psychotic symptomsiii. Deliriumiv. Total inability to functionv. Medical conditions that warrant medication monitoring (eg, substance withdrawal / intoxication)b. Pharmacotherapyi. Mood stabilizers1. Lithium2. Carbamazepine3. Valproate4. Lamotrigineii. Anti-psychoticsc. Psychotherapyi. Cognitive behavioural therapyii. Interpersonal and social rhythm therapyiii. Behavioural family therapyiv. Group Psychoeducation

4. Differential diagnosisa. Hyperthyroidb. Major depressive disorderc. Cyclothymic disorderd. Panic disorder or other anxiety disordere. Substance use disorderf. Attention-deficit / hyperactivity disorderg. Personality disorder

ANXIETY DISORDERPanic Attack1. DSM IV Criteria for panic attacka. A discrete period of intense fear or discomfort, in which 4 (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:i. Palpitationsii. Sweatingiii. Trembling or shakingiv. Sensations of shortness of breathv. Feeling of chokingvi. Chest pain or discomfortvii. Nausea or abdominal distressviii. Feeling dizzy, unsteady, lightheaded or faintix. Derealization (feeling of unreality)x. Fear of losing control or going crazyxi. Fear of dyingxii. Parasthesiasxiii. Chills or hot flushes

2. DSM IV Criteria for panic disorder without agoraphobiaa. Both (1) and (2)i. Recurrent unexpected panic attacksii. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following1. Persistent concern about having additional attacks2. Worry about the implications of the attack or its consequences (e.g. losing control, having heart attack, going crazy)3. A significant change in behaviour related to the attacksb. Absence of agoraphobiac. The panic attack are not due to the direct physiological effects of a substance (e.g. drug of abuse, a medication) or a general medical condition (e.g. hyperthyroidism).d. The panic attacks are not better accounted for by another mental disorder, such as social phobia (e.g. occurring on exposure to feared social situations, specific phobia (e.g. exposure to a specific phobic situation, obsessive-compulsive disorder (e.g. on exposure to dirt in someone with obsession about contamination), posttraumatic stress disorder (e.g. in response to stimuli associated with severe stressor) or separation anxiety disorder (e.g. in response to being away from home or close relatives)

3. DSM IV Criteria for Agoraphobiaa. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms.b. The situations are avoided (e.g. travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms or require the presence of a companion.c. The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder or separation anxiety disorder.

4. DSM IV Criteria for Agoraphobia without history of panic disordera. The presence of agoraphobia related to fear of developing panic-like symptoms (e.g. dizziness or diarrhea)b. Criteria have never been met for panic disorder. c. The disturbance is not due to the direct physiological effects of a substance or a general medical condition.d. If an associated general medical condition is present, the fear described in Criterion A is clearly in excess of that usually associated with the condition.

5. Treatmenta. Pharmacotherapyi. Selective serotonin reuptake inhibitorsii. Benzodiazepinesb. Psychotherapyi. Applied relaxationii. Cognitive therapyiii. Respiratory trainingiv. Insight-oriented psychotherapy

Generalized Anxiety Disorder1. DSM IV criteria for GADa. Excessive anxiety and worry occuring more days than not for at least 6 months, about a number of events or activities.b. The person finds it difficult to control the worry.c. The anxiety and worry are associated with 3 (or more) of the following 6 symptoms:i. Restlessness or feeling keyed up or on edgeii. Being easily fatiguediii. Difficulty concentrating or mid going blankiv. Irritabilityv. Muscle tensionvi. Sleep disturbanced. The focus of anxiety and worry is not confined to features of Axis 1 disorder.h. The anxiety, worry or physical sufficiently severe to cause marked impairment in occupational and social functioningi. Symptoms are not due to direct physiological effects of a substance or a general medical condition2. Treatmenta. Pharmacotherapyi. Antidepressant1. SSRI2. Buspironeii. Benzodiazepines

Obsessive Compulsive Disorder1. DSM IV criteria for OCD (Obsessions a to d, Compulsions e to f) a. Recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate, causing marked anxiety or distress.b. The thoughts, impulses, or images are not simply excessive worries about real-life problems.c. The person attempts to ignore or suppress them with some other thought or action.d. The person recognizes that those are product of his or her own mind.e. Repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.f. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

2. Treatmenta. Pharmacotherapyi. SSRIii. TCAb. Psychotherapyi. Behaviour therapy

Acute Stress Disorder1. DSM IV Criteriaa. Exposure to actual or threatened death, srious injury or sexual violation in one or more of following ways:i. Direct exposure to the eventii. Witnessing, in person.iii. Indirectly, close relative or close friend was exposed to trauma.iv. Repeated or extreme exposure to aversive details of the event(s).b. Presence of 9 or more of following symptoms from any 5 categories of intrusion, negative mood, dissociation, avoidance and arousali. Intrusion1. Recurrent, involuntary & intrusive distressing memories2. Traumatic nightmares, traumatic distressing dreams3. Dissociative reactions (eg: flashback)4. Intense or prolonged distress after exposure to internal or external cues that symbolize or resemble the traumatic event.5. Marked physiologic reactivity after exposure to trauma-related stimuli.

ii. Negative mood1. Persistent inability to experience positive emotioniii. Dissociative symptoms1. Altered sense of reality of ones surrounding 2. Inability to remember an important aspect of traumatic eventiv. Avoidance symptom1. Effort to avoid distressing memories, thoughts or feelings2. Effort to avoid external remindersv. Arousal symptoms1. Sleep disturbance2. Irritable behavior and angry outburst3. Hypervigilance4. Problem with concentration5. Exaggerated startle responsec. Duration of disturbance is 3 days to 1 month after trauma exposured. Clinically significant distress or impairment in important areas of functioning as a result of the evente. Disturbance cannot be attributed to a substance or another medical condition and cannot be better explained as brief psychotic disorder

2. Treatmenta. Pharmacologicali. Antidepressantsii. Anticonvulsantsb. Psychotherapyi. Cognitive behavioral therapyii. Family therapyiii. Group therapy

Post-traumatic Stress Disorder1. Diagnostic criteria and treatment for PTSD is same as acute stress disorder

2. Difference between ASD & PTSDa. PTSDi. Event occur at any time in pastii. Symptoms last more than 1 monthb. ASDi. Event occur less than one month agoii. Symptoms last less than one month

3. Treatmenta. Pharmacotherapyi. SSRI1. Sertraline, paroxetine2. First line of treatmentii. TCA1. Imipramine, amitriptylineiii. MAOI1. Phenelzine, trazodone2. Effective in reducing re-experiencing symptoms and insomnia but cause hypertensive crisisiv. Benzodiazepines1. clonazepam, diazepamv. Anticonvulsants1. Carbamazepine, valproateb. Psychotherapyi. Supportive psychotherapyii. Insight oriented psychotherapyiii. Behaviour therapyiv. Cognitive therapyv. Group therapy

ANTIPSYCHOTICSTypical1. Examplesa. Haloperidolb. Fluphenazine (IM)c. Flupenthixol (IM)d. Zuclopenthixol (IM)2. Indicationsa. Psychotic symptoms3. Adverse effectsa. Extrapyrimidal side effectsi. Parkinsonismii. Akathisiaiii. Dystonia b. Hyperprolactinemiac. Anti-HAM effecti. Anti-histaminic = causes sedationii. Anti-adrenergic = orthostatic hypotension, cardiac abnormalities, sexual dysfunctioniii. Anti-muscarinic = tachycardia, dry mouth, urinary retention, constipation, blurry visiond. Weight gaine. Neuroleptic malignant syndromef. Tardive dyskinesiaAtypical1. Examplesa. Clozapine, Risperidone, Quetiapine, Olanzapine2. Indicationsa. Psychosis in schizophrenia and schizoaffective disordersb. Acute treatment of manic or mixed episodes in bipolar disorderc. Psychoses of all types; secondary to head trauma, dementia or drug induced psychosis3. Adverse effectsa. Agranulocytosis in Clozapineb. Prolactinemia in Risperidonec. Weight gain in Olanzapined. Postural hypotension in Quetiapine

MOOD STABILIZERSLithium1. Brand name = LLiconate2. Indicationa. Bipolar disorderb. Explosive outburst in mental retardation & conduct disorder3. Adverse effectsa. Nauseab. Vomitingc. Headached. Hypothyroid e. Weight gainCarbamazepine1. Brand name = Tegretol2. Indicationsa. Bipolar disorder (effective in those do not respond to lithium)b. Explosive outburst in mental retardation & conduct disorder3. Adverse effectsa. Nauseab. Drowsinessc. VertigoValproate1. Brand name = Epilim / Epilim Chrono2. Indicationsa. Bipolar disorderb. Explosive outburst in mental retardation & conduct disorder3. Adverse effectsa. Nauseab. Vomitingc. Sedationsd. Weight gaine. Hair lossLamotrigine1. Brand name = Lamictal2. Indicationsa. Bipolar disorderb. Anticonvulsant3. Adverse effectsa. Skin rashb. Stevens Johnson syndromec. Toxic epidermal necrolysis

ANTIDEPRESSANTSSelective Serotonin Reuptake Inhibitor1. Examplesa. Citalopramb. Fluoxetinec. Sertralined. Paroxetine2. Indicationsa. Depressionb. OCDc. Panic disorderd. GADe. PTSDf. Social anxiety disorder3. Adverse effectsa. Headacheb. Nauseac. Vomitingd. Weight gaine. Insomniaf. Loss of libidog. Anorgasmia4. Serotonin syndromea. Symptoms = restlessness, excessive sweating, insomnia, hyperthermia symptomsb. Causesi. SSRI overdoseii. SSRI + MAOIiii. MAOI + synthetic narcotics

Tricyclic Antidepressants1. Examplesa. Amitriptyllineb. Clomipramine2. Indicationsa. MDDb. Panic disorder with agoraphobiac. GADd. OCDe. Neuropathic painf. Childhood enuresis3. Adverse effectsa. Muscarinic receptor blockagei. Dry mouth, tachycardia, blurred vision, constipation, urinary retention, sexual dysfunctionb. Adrenoreceptor blockadei. Drowsiness, postural hypertension, sexual dysfunctionc. H1 receptor blockadei. Drowsiness, weight gaind. Membrane stabilizing propertiesi. Rash, oedema, leukopenia, elevated liver enzymes

Monoamine oxidase inhibitors1. Examplesa. Irreversible non-selective inhibitorsi. Tranylcypromine, Phenelzineb. Reversible inhibitors of MAO-A (RIMA)i. Moclobemidec. Reversible inhibitors of MAO-Bi. Selegiline2. Indicationsa. Depressionb. Bipolar depressionc. Panic disorder & social phobiad. Bulimia nervosae. PTSDf. ADHD3. Adverse effectsa. Serotonin syndromei. Initial = lethargy, restlessness, tremorii. Later = hyperthermia, renal failure, convulsion, coma, deathb. Hypertensive crisisi. When MAOI taken with tyramine rich foods (red wine, cheese, chicken liver, fava bean)ii. Chest pain, headache, mydriasisc. Othersi. Orthostatic hypotension, blurred vision

Atypical antidepressants1. Bupropion2. Mitazapine3. Nefazodone

ANTI ANXIETY DRUGSBenzodiazepines1. Examplesa. Short acting = Triazolam, Midazolamb. Intermediate acting = Alprazolam, Lorazepam, Oxazepamc. Long acting = Diazepam, Clonazepam2. Indicationsa. Panic disorderb. GADc. Social anxiety3. Adverse effectsa. Drowsinessb. Teratogenic4. Withdrawal symptomsa. Anxietyb. Irritabilityc. Insomniad. Tremore. DeliriumBuspirone1. Indicationsa. GADb. Not effective but less weight gain and sexual dysfunction compared to SSRI in treating panic disorder, OCD or social phobia2. Adverse effectsa. Nauseab. Dizzinessc. HeadacheBeta Adrenergic Receptor Antagonist (Beta Blockers)1. Examplesa. Propranolol2. Indicationsa. Panic disorderb. PTSDc. GADSSRITCA