Psychiatry basics

Depression

• Core symptoms for at least 2 weeks: low mood, anhedonia and low energy. Others: poor concentration, guilt, low self-worth, hopelessness, suicidal thoughts, sleep and appetite change, psychomotor change, low libido.
• Biological (somatic) features: early morning waking, diurnal variation (worse in mornings), weight loss, psychomotor retardation. Severe depression may have mood-congruent delusions of guilt, poverty or nihilism (Cotard).
• Biology: monoamine deficiency, overactive HPA axis (high cortisol, failure of dexamethasone suppression), shortened REM latency.
• Organic causes: hypothyroidism, Cushing syndrome, Addison disease (depression with pigmentation, postural hypotension, low sodium and high potassium, eosinophilia, high ACTH), Parkinson disease, stroke, MS, pancreatic cancer; drugs (steroids, isotretinoin, interferon, levetiracetam).
• Treatment: stepped care with guided self-help, CBT, behavioural activation and exercise; SSRIs first line for moderate to severe depression (sertraline after MI). SSRIs are also preferred in epilepsy because tricyclics and bupropion lower the seizure threshold more. ECT for severe, psychotic, life-threatening (refusing food and fluids) or resistant depression; main side effects are headache and memory loss.
• Perinatal: baby blues (days 3–5, resolve within 2 weeks); postnatal depression (Edinburgh scale); puerperal psychosis (first 2 weeks, linked to bipolar disorder, an emergency).

Mania and bipolar disorder

• Manic episode (at least one week, or any duration if admitted): elevated or irritable mood, reduced need for sleep without tiredness, grandiosity (may be delusional), pressure of speech, flight of ideas, overspending, disinhibition, distractibility. Hypomania is milder, lasts at least 4 days and has no psychosis.
• Treat with antipsychotics or valproate acutely and lithium for prophylaxis.

Suicide risk

• Strongest predictor: previous attempt. Others: male sex, older age and young men, depression, schizophrenia, substance misuse, chronic painful illness, isolation, unemployment, recent loss, hopelessness, a definite plan, final acts (note, will), precautions against discovery, access to means (pesticides in rural Pakistan).
• Asking directly about suicidal thoughts does not increase risk. Manage with a safety plan, removal of means, family involvement and urgent psychiatric referral or admission when risk is high. Attempted suicide was decriminalised in Pakistan in 2022.

Anxiety and related disorders

• Benzodiazepines reduce anxiety by enhancing GABA-A receptor chloride currents.
• Exclude hyperthyroidism, phaeochromocytoma, hypoglycaemia, arrhythmia, caffeine, stimulants and alcohol or benzodiazepine withdrawal. Hyperventilation lowers ionised calcium, causing tingling and carpopedal spasm.
• Alexithymia is difficulty identifying and describing one's own emotions; it is common in somatisation.

Psychosis, delusions and catatonia

• Schizophrenia: positive symptoms (delusions, third-person auditory hallucinations, thought insertion, withdrawal and broadcasting, passivity: first-rank symptoms), negative symptoms (apathy, poverty of speech, blunted affect, withdrawal) and cognitive decline. Antipsychotics plus psychosocial care; anticholinergic side effects (dry mouth, constipation, blurred vision, urinary retention) are marked with chlorpromazine (phenothiazines) and clozapine.
• A delusion is a fixed, false belief held with conviction, out of keeping with the person's culture.

• Catatonia: mutism, stupor, immobility with fixed postures, negativism and refusal of food and fluids; it can follow abrupt clozapine withdrawal. First treatment is intravenous (or oral) lorazepam; ECT if this fails. Antipsychotics first can precipitate neuroleptic malignant syndrome.
• Organic psychosis clues: visual hallucinations, late first onset, clouded consciousness, drugs (steroids, levodopa, stimulants, cannabis).

Personality and abnormal illness behaviour

• Emotionally unstable (borderline): unstable intense relationships, fear of abandonment, impulsivity, self-harm, chronic emptiness, splitting (others all good or all bad). Psychotherapy (dialectical behaviour therapy).
• Antisocial (dissocial): lying, theft, forging, aggression, no remorse, with conduct disorder in adolescence.
• Factitious disorder: deliberately produces illness (for example a nurse injecting herself with insulin) with no external gain, only the patient role. Malingering seeks external gain.

Sleep

• Cycles last about 90 minutes; N3 dominates the first half of the night and REM the second. Infants spend about half of sleep in REM; the elderly have less slow-wave sleep.
• Insomnia: sleep hygiene and CBT for insomnia first; hypnotics only short term.
• Obstructive sleep apnoea: obesity, snoring, witnessed apnoeas, daytime sleepiness (Epworth score), hypertension; CPAP.
• Narcolepsy: daytime sleepiness, cataplexy, sleep paralysis, hypnagogic hallucinations, low orexin, sleep-onset REM.
• REM sleep behaviour disorder (acting out dreams) often precedes Parkinson disease or Lewy body dementia. Alcohol and antidepressants suppress REM.

Delirium

• Acute onset, fluctuating course, inattention, disorganised thinking and altered consciousness; visual hallucinations, disturbed sleep–wake cycle, worse at night. Hypoactive delirium (quiet, drowsy) is often missed and has a worse prognosis.
• Screening: 4AT or CAM (acute onset and fluctuation, plus inattention, plus disorganised thinking or altered consciousness).
• Causes: infection, drugs (opioids, anticholinergics, benzodiazepines, steroids), dehydration, electrolyte disturbance, hypoxia, hypoglycaemia, urinary retention, constipation, pain, alcohol withdrawal, surgery (hip fracture), stroke. Dementia is the strongest risk factor.
• Treat the cause, review drugs, and use non-drug measures first (reorientation, glasses and hearing aids, familiar faces, light in the day, mobility, hydration). Low-dose haloperidol only for dangerous distress; avoid it in Parkinson disease and Lewy body dementia.

• Dementias: Alzheimer (commonest; plaques and tangles; memory first; cholinesterase inhibitors), vascular (stepwise), Lewy body (fluctuation, visual hallucinations, parkinsonism, severe antipsychotic sensitivity), frontotemporal (early personality change). Exclude hypothyroidism, B12 deficiency, normal pressure hydrocephalus, depression, syphilis and subdural haematoma.

Mental state examination and law

• Appearance and behaviour, speech, mood and affect, thought form and content, perception, cognition, insight, risk.
• Pakistan: Mental Health Ordinance 2001 and provincial Mental Health Acts allow assessment and treatment of people with mental disorder who pose risk.

Remember Delirium is acute, fluctuating and inattentive; dementia is slow with attention preserved early.

Exam trap Catatonia needs lorazepam first, not an antipsychotic, even in a patient with schizophrenia.

Exam trap A previous suicide attempt is the strongest predictor of suicide.

How FCPS asks about this

• Woman believes a neighbour or famous man secretly loves her: erotomania (de Clérambault syndrome).
• Sleeps two hours without tiredness, overspends, rapid speech, grandiose: manic episode.
• Mute, motionless, fixed postures after stopping clozapine: catatonia; intravenous lorazepam.
• Repeated door checking with intrusive doubts: OCD; CBT with exposure and response prevention plus SSRI.
• Nurse injecting herself with insulin to be cared for: factitious disorder.
• Unstable relationships, fear of abandonment, splitting: emotionally unstable (borderline) personality disorder.
• Night terrors and sleepwalking: slow-wave (N3) sleep.