SCHIZOPHRENIA

1. Predisposing factors
a. Genetic (family history)
b. Social
c. Substance abuse (Cannabis)
d. Environment
e. History of childhood central nervous system infection
f. History of obstetric complication
2. Schneiders First rank Symptoms
a. Thought Insertion
b. Thought withdrawal
c. Thought broadcast
d. Delusional perception
e. Delusion of control
f. Auditory hallucination
g. Somatic passivity
3. DSM IV Criteria
a. Two or more must be present for at least 1 month
i. Delusions
ii. Hallucinations
iii. Disorganized speech
iv. Disorganized behaviour
v. Negative symptoms
b. Social / occupational dysfunction
c. 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 disorder
4. Negative symptoms
a. Affect (flat)
b. Alogia
c. Anhedonia
d. Attention (poor)
e. Avolition
5. Differential diagnosis
a. Schizophreniform disorder
b. Schizoaffective disorder
c. Brief psychotic disorder
6. Management
a. Hospitalization
i. Risk of harm to self or others
ii. Deterioration in psychosocial functioning
iii. Serious / life threatening drug reactions
b. Antipsychotics
i. Dopamine receptor antagonists (Typical psychotics)
ii. Serotonin-dopamine antagonists (Atypical antipsychotics)
c. Electroconvulsive therapy
i. Catatonic schizophrenia
ii. Cannot tolerate side effect of drugs / not responding to drugs
iii. Has previous improvement with ECT
d. Psychosocial intervention
i. Supportive psychotherapy
ii. Psychoeducation
iii. Social skills training

iv. Cognitive remediation therapy

v. Relaxation therapy / anger management therapy
vi. Homecare team if poor compliance
SCHIZOPHRENIFORM DISORDER
1. DSM IV Criteria
a. When criteria A,D,E of schizophrenia is not met
b. An episode of the disorder (including prodromal, active and residual
phases) lasts at least 1 month but less than 6 months
SCHIZOAFFECTIVE DISORDER
1. DSM IV Criteria
a. 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 schizophrenia
b. Have delusions or hallucinations for at least 2 weeks in the absence of
prominent mood symptoms
c. 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 illness
d. Disturbances not due to direct physiological effects of a substances or
general medical condition
2. Type
a. Schizophrenia with MDD / Manic episode / Mixed episode
i. This diagnosis is made if unsure
ii. Patient may present with 50% schizophrenia symptoms, 50% mood
symptoms
b. Schizophrenia with depression
i. Know how to differentiate from depression with psychotic symptoms
c. Schizophrenia with depression and mood symptoms
BRIEF PSYCHOTIC DISORDER
1. DSM IV Criteria
a. Presence of one (or more) of the following symptoms:
i. Delusions
ii. Hallucinations
iii. Disorganized speech
iv. Disorganized behaviour
b. 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 functioning
c. The disturbance is not better accounted for by a mood disorder with
psychotic features, schizoaffective disorder or schizophrenia
d. Not due to direct physiological effects of a substance or a general medical
condition
2. Have presence of stressor(s)
MAJOR DEPRESSIVE DISORDER
1. 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.
f.
g.
h.

Cognition / Concentration (reduced cognition or difficulty in concentrating)

Appetite (loss of appetite)
Psychomotor (retardation, agitation)
Suicide (suicide thoughts)

2. DSM IV Criteria
a. 5 or more symptoms present during the same 2 weeks;
i. Low mood throughout the day
ii. Anhedonia
iii. Loss of appetite with significant weight loss
iv. Insomnia or hypersomnia
v. Psychomotor agitation or retardation
vi. Fatigueness
vii. Feeling worthlessness or inappropriate guilt
viii. Diminished attention and concentration
ix. Recurrent thoughts of death and suicide
b. Symptoms do not meet criteria for mixed episode
c. Symptoms must cause clinically significant distress or impairment in
social, occupational or other important areas of functioning
d. Symptoms cannot be due to substance abuse or medical conditions
e. Symptoms are not accounted for by bereavement
3. Suicide risk assessment
a. Current history
i. Seriousness of attempt
1. Suicidal attempt
2. Suicidal note
3. Doing it alone
ii. Regrets about attempt
iii. Current intent or wish to die
b. Preventers
i. Any loved ones
ii. Support from family or other people
iii. Future prospect or plan
c. Past history
i. Previous self-harm
ii. Previous or current mental illness
iii. Any drugs or alcohol intake
d. Candidates opinion of current risk
e. Candidates immediate plan
f. How candidate react and handle patients reaction during interview
4. Management
a. Hospitalization
i. Risk of suicide or homicide
ii. Unable to care for self
iii. Rapidly progressing symptoms
iv. Diagnostic procedures
b. Antidepressants
i. SSRI
ii. TCA
iii. MAOI
c. Antipsychotics
i. If patient displayed psychotic features
d. Electroconvulsive therapy

i. Unresponsive to pharmacotherapy
ii. Cannot tolerate with drugs adverse effects
iii. Desire rapid reduction of symptoms (in suicidal patients)
e. Psychotherapy
i. Cognitive therapy
ii. Interpersonal therapy
iii. Supportive therapy
iv. Family therapy
5. Differential diagnosis
a. Adjustment disorder with depressed mood
b. Hypothyroidism

BIPOLAR DISORDER
Bipolar Type 1
1. DSM IV Criteria for Manic Episode
a. Distinct period of abnormally and persistently elevated, expansive or
irritable mood lasting at least 1 week
b. During the period, three (or more) of the following symptoms have
persisted (four if the mood is only irritable);
i. Inflated self-esteem or grandiosity
ii. Decreased need for sleep
iii. Pressure of speech
iv. Flight of ideas
v. Distractibility
vi. Increase in goal directed activity
vii. 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 episode

d. The disturbance sufficiently severe to cause marked impairment in

occupational and social functioning
e. Symptoms are not due to direct physiological effects of a substance or a
general medical condition
2. DSM IV Criteria for Mixed episode
a. Criteria are met both for Manic Episode and Major Depressive Disorder
nearly every day during at least one week period
b. The disturbance sufficiently severe to cause marked impairment in
occupational and social functioning
c. Symptoms are not due to direct physiological effects of a substance or a
general medical condition
3. Pneumonic for symptoms (DIGFAST)
a. Distractibility
b. Impulsive behaviour (shopping spree, sexual promiscuity)
c. Grandiosity
d. Flight of ideas
e. Agitation (psychomotor)
f. Sleep changes
g. Talkativeness (pressured speech)

Bipolar Type 2
1. DSM V Criteria for hypomanic episode
a. 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 2
a. 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. Management
a. Hospitalization
i. Risk of bringing harm to self or others
ii. Marked psychotic symptoms
iii. Delirium
iv. Total inability to function
v. Medical conditions that warrant medication monitoring (eg,
substance withdrawal / intoxication)
b. Pharmacotherapy
i. Mood stabilizers
1. Lithium
2. Carbamazepine
3. Valproate
4. Lamotrigine
ii. Anti-psychotics
c. Psychotherapy
i. Cognitive behavioural therapy
ii. Interpersonal and social rhythm therapy
iii. Behavioural family therapy

iv. Group Psychoeducation

4. Differential diagnosis
a. Hyperthyroid
b. Major depressive disorder
c. Cyclothymic disorder
d. Panic disorder or other anxiety disorder
e. Substance use disorder
f. Attention-deficit / hyperactivity disorder
g. Personality disorder

ANXIETY DISORDER
Panic Attack
1. DSM IV Criteria for panic attack
a. 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. Palpitations
ii. Sweating
iii. Trembling or shaking
iv. Sensations of shortness of breath
v. Feeling of choking
vi. Chest pain or discomfort
vii. Nausea or abdominal distress
viii. Feeling dizzy, unsteady, lightheaded or faint
ix. Derealization (feeling of unreality)
x. Fear of losing control or going crazy
xi. Fear of dying
xii. Parasthesias
xiii. Chills or hot flushes
2. DSM IV Criteria for panic disorder without agoraphobia
a. Both (1) and (2)

i. Recurrent unexpected panic attacks

ii. At least one of the attacks has been followed by 1 month (or more)
of one (or more) of the following
1. Persistent concern about having additional attacks
2. 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 attacks
b. Absence of agoraphobia
c. 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 Agoraphobia

a. 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 paniclike 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, obsessivecompulsive disorder, posttraumatic stress disorder or separation anxiety
disorder.
4. DSM IV Criteria for Agoraphobia without history of panic disorder
a. 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. Treatment
a. Pharmacotherapy
i. Selective serotonin reuptake inhibitors
ii. Benzodiazepines
b. Psychotherapy
i. Applied relaxation
ii. Cognitive therapy
iii. Respiratory training
iv. Insight-oriented psychotherapy
Generalized Anxiety Disorder
1. DSM IV criteria for GAD
a. 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 edge
ii. Being easily fatigued
iii. Difficulty concentrating or mid going blank
iv. Irritability
v. Muscle tension
vi. Sleep disturbance
d. 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 functioning
i. Symptoms are not due to direct physiological effects of a substance or a
general medical condition
2. Treatment
a. Pharmacotherapy
i. Antidepressant
1. SSRI
2. Buspirone
ii. Benzodiazepines
Obsessive Compulsive Disorder
1. 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. Treatment
a. Pharmacotherapy
i. SSRI
ii. TCA
b. Psychotherapy
i. Behaviour therapy
Acute Stress Disorder
1. DSM IV Criteria
a. Exposure to actual or threatened death, srious injury or sexual violation in
one or more of following ways:
i. Direct exposure to the event
ii. 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 arousal
i. Intrusion
1. Recurrent, involuntary & intrusive distressing memories
2. Traumatic nightmares, traumatic distressing dreams
3. 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 traumarelated stimuli.
ii. Negative mood
1. Persistent inability to experience positive emotion
iii. Dissociative symptoms
1. Altered sense of reality of ones surrounding
2. Inability to remember an important aspect of traumatic event
iv. Avoidance symptom
1. Effort to avoid distressing memories, thoughts or feelings
2. Effort to avoid external reminders
v. Arousal symptoms
1. Sleep disturbance
2. Irritable behavior and angry outburst
3. Hypervigilance
4. Problem with concentration
5. Exaggerated startle response
c. Duration of disturbance is 3 days to 1 month after trauma exposure
d. Clinically significant distress or impairment in important areas of
functioning as a result of the event
e. Disturbance cannot be attributed to a substance or another medical
condition and cannot be better explained as brief psychotic disorder
2. Treatment
a. Pharmacological

i. Antidepressants
ii. Anticonvulsants
b. Psychotherapy
i. Cognitive behavioral therapy
ii. Family therapy
iii. Group therapy

Post-traumatic Stress Disorder

1. Diagnostic criteria and treatment for PTSD is same as acute stress disorder
2. Difference between ASD & PTSD
a. PTSD
i. Event occur at any time in past
ii. Symptoms last more than 1 month
b. ASD
i. Event occur less than one month ago
ii. Symptoms last less than one month
3. Treatment
a. Pharmacotherapy
i. SSRI
1. Sertraline, paroxetine
2. First line of treatment
ii. TCA
1. Imipramine, amitriptyline
iii. MAOI
1. Phenelzine, trazodone
2. Effective in reducing re-experiencing symptoms and insomnia
but cause hypertensive crisis
iv. Benzodiazepines
1. clonazepam, diazepam
v. Anticonvulsants

1. Carbamazepine, valproate
b. Psychotherapy
i. Supportive psychotherapy
ii. Insight oriented psychotherapy
iii. Behaviour therapy
iv. Cognitive therapy
v. Group therapy

ANTIPSYCHOTICS
Typical
1. Examples
a. Haloperidol
b. Fluphenazine (IM)
c. Flupenthixol (IM)
d. Zuclopenthixol (IM)
2. Indications
a. Psychotic symptoms
3. Adverse effects
a. Extrapyrimidal side effects
i. Parkinsonism
ii. Akathisia
iii. Dystonia
b. Hyperprolactinemia
c. Anti-HAM effect
i. Anti-histaminic = causes sedation
ii. Anti-adrenergic = orthostatic hypotension, cardiac abnormalities,
sexual dysfunction
iii. Anti-muscarinic = tachycardia, dry mouth, urinary retention,
constipation, blurry vision
d. Weight gain
e. Neuroleptic malignant syndrome
f. Tardive dyskinesia
Atypical
1. Examples
a. Clozapine, Risperidone, Quetiapine, Olanzapine

2. Indications
a. Psychosis in schizophrenia and schizoaffective disorders
b. Acute treatment of manic or mixed episodes in bipolar disorder
c. Psychoses of all types; secondary to head trauma, dementia or drug
induced psychosis
3. Adverse effects
a. Agranulocytosis in Clozapine
b. Prolactinemia in Risperidone
c. Weight gain in Olanzapine
d. Postural hypotension in Quetiapine

MOOD STABILIZERS
Lithium
1. Brand name = LLiconate
2. Indication
a. Bipolar disorder
b. Explosive outburst in mental retardation & conduct disorder
3. Adverse effects
a. Nausea
b. Vomiting
c. Headache
d. Hypothyroid
e. Weight gain
Carbamazepine
1. Brand name = Tegretol
2. Indications
a. Bipolar disorder (effective in those do not respond to lithium)
b. Explosive outburst in mental retardation & conduct disorder
3. Adverse effects
a. Nausea
b. Drowsiness
c. Vertigo
Valproate
1. Brand name = Epilim / Epilim Chrono
2. Indications
a. Bipolar disorder
b. Explosive outburst in mental retardation & conduct disorder
3. Adverse effects
a. Nausea

b.
c.
d.
e.

Vomiting
Sedations
Weight gain
Hair loss

Lamotrigine
1. Brand name = Lamictal
2. Indications
a. Bipolar disorder
b. Anticonvulsant
3. Adverse effects
a. Skin rash
b. Stevens Johnson syndrome
c. Toxic epidermal necrolysis

ANTIDEPRESSANTS
Selective Serotonin Reuptake Inhibitor
1. Examples
a. Citalopram
b. Fluoxetine
c. Sertraline
d. Paroxetine
2. Indications
a. Depression
b. OCD
c. Panic disorder
d. GAD
e. PTSD
f. Social anxiety disorder
3. Adverse effects
a. Headache
b. Nausea
c. Vomiting
d. Weight gain
e. Insomnia
f. Loss of libido
g. Anorgasmia
4. Serotonin syndrome
a. Symptoms = restlessness, excessive sweating, insomnia, hyperthermia
symptoms
b. Causes
i. SSRI overdose
ii. SSRI + MAOI
iii. MAOI + synthetic narcotics
Tricyclic Antidepressants
1. Examples
a. Amitriptylline
b. Clomipramine

2. Indications
a. MDD
b. Panic disorder with agoraphobia
c. GAD
d. OCD
e. Neuropathic pain
f. Childhood enuresis
3. Adverse effects
a. Muscarinic receptor blockage
i. Dry mouth, tachycardia, blurred vision, constipation, urinary
retention, sexual dysfunction
b. Adrenoreceptor blockade
i. Drowsiness, postural hypertension, sexual dysfunction
c. H1 receptor blockade
i. Drowsiness, weight gain
d. Membrane stabilizing properties
i. Rash, oedema, leukopenia, elevated liver enzymes
Monoamine oxidase inhibitors
1. Examples
a. Irreversible non-selective inhibitors
i. Tranylcypromine, Phenelzine
b. Reversible inhibitors of MAO-A (RIMA)
i. Moclobemide
c. Reversible inhibitors of MAO-B
i. Selegiline
2. Indications
a. Depression
b. Bipolar depression
c. Panic disorder & social phobia
d. Bulimia nervosa
e. PTSD
f. ADHD
3. Adverse effects
a. Serotonin syndrome
i. Initial = lethargy, restlessness, tremor
ii. Later = hyperthermia, renal failure, convulsion, coma, death
b. Hypertensive crisis
i. When MAOI taken with tyramine rich foods (red wine, cheese,
chicken liver, fava bean)
ii. Chest pain, headache, mydriasis
c. Others
i. Orthostatic hypotension, blurred vision
Atypical antidepressants
1. Bupropion
2. Mitazapine
3. Nefazodone

ANTI ANXIETY DRUGS

Benzodiazepines
1. Examples
a. Short acting = Triazolam, Midazolam
b. Intermediate acting = Alprazolam, Lorazepam, Oxazepam
c. Long acting = Diazepam, Clonazepam
2. Indications
a. Panic disorder
b. GAD
c. Social anxiety
3. Adverse effects
a. Drowsiness
b. Teratogenic
4. Withdrawal symptoms
a. Anxiety
b. Irritability
c. Insomnia
d. Tremor
e. Delirium
Buspirone
1. Indications
a. GAD
b. Not effective but less weight gain and sexual dysfunction compared to
SSRI in treating panic disorder, OCD or social phobia
2. Adverse effects
a. Nausea
b. Dizziness
c. Headache
Beta Adrenergic Receptor Antagonist (Beta Blockers)
1. Examples
a. Propranolol
2. Indications
a. Panic disorder
b. PTSD
c. GAD
SSRI
TCA