Psychiatry

Delusions

de Clerambault- Kadinsky Delusion that someone from higher socio-economic status

complex is in love with the patient
Othello syndrome Delusion of infidelity
Capgrass syndrome Delusion of doubles
Delusion that one has lost everything, including
Cotard’s syndrome/ Nihilism possessions, status, strength and body organs.
Delusion that a persecutor is able to assume the
Fregoli’s delusions appearance of others
Delusion that persons in the environment take on the
Intermetamorphosis appearance of tormentors
Parasitosis Delusion that one is infested with parasites
Lycanthropy / Werewolfism Delusion that one turns periodically into an animal
Heutoscopy/ doppelganger Delusion that patient has a twin or second half
Incubus Delusion that patient has a phantom or demon lover
Delusion that unwelcome guests are living in patient’s
Phantom boarder house
Delusion that others are aging, while the patient remains
Dorian Gray young
Illusion de Sorias Delusion that one’s family has been replaced
Primary, de novo, can’t be explained on the basis of past
Autochthonous delusions experiences.
Amphitryon’s delusion Delusion that one’s spouse has been replaced
HALLUCINATIONS

Hypnopompic
hallucinations Hallucination while awakening
Hypnagogic Hallucination while sleeping
External stimulus is necessary to produce hallucinations.
Normal perception and hallucination are in the same modality
and experienced simultaneously.
Functional
Stimulus in one sensory modality produces hallucination in
Reflex / Synaesthesia another sensory modality
Hallucinations are experienced outside the limits of the sensory
Extracampine field.
*Visual hallucinations are characteristically seen in organic psychosis, whereas auditory hallucinations are more

common in functional psychosis.

QUOTE CORNER
The greatest mistake in the treatment of diseases is that there are physicians
for the body and physicians for the soul, although the two cannot be
 separated.- Plato
ELEVENTH HOUR PSYCHIATRY 174

EUGEN BLEULER’S CARDINAL SYMPTOMS OF SCHIZOPHRENIA( FOUR A’S )

Blunted Affect
Loosening of Association
Ambivalence
Autism
KURT SCHNEODER’S FIRST RANK SYMPTOMS OF SCHIZOPHRENIA
Hearing one’s thoughts aloud.
Auditory hallucinations commenting on one’s behaviour.

Thought withdrawal, insertion and broadcasting.

Somatic hallucinations or the experience of one’s thoughts as being controlled or

influenced from outside.

TYPES OF SCHIZOPHRENIA

Delusions of persecution
Paranoid Late onset and progressive course.
schizophrenia
Marked thought disorder, severe loosening of association.
Emotional disturbances.
Hebephrenic Progressively worse course.
schizophrenia
Acute onset in 2nd to 3rd decade.
Episodic and complete recovery.

Clinical features include-

Mutism, rigidity, negativism, posturing, stupor, echolalia,

echopraxia, waxy flexibility, ambitendency, automatic obedience,
Catatonic verbigeration.
schizophrenia
Pseudo neurotic Initially there are predominant neurotic symptoms. Three classical
schizophrenia features are pan anxiety, pan neurosis, and pan sexuality
Subtype of schizophrenia with acute onset, clouding of
Oneiroid consciousness, disorientation, dream like state and perceptual
schizophrenia disturbances with rapid shifting.
Van Gogh
syndrome Schizophrenia with self mutilation.
Propf syndrome Schizophrenia with mental retardation.
Psychotic diseases Neurotic diseases
Impaired reality testing Reality testing is intact
Marked disturbance in personality Personality and behaviour are preserved
Loss of insight Insight present
Delusions and halluciantions are presentDelusions and halluciantions absent

TRIVIAL TRUTH
Men commit suicide three times more frequently than women do. But women
attempt suicide two to three times more often than men.
ELEVENTH HOUR PSYCHIATRY 175

DRUGS OF CHOICE OF PSYCHIATRIC DISORDERS

DISEASE DRUGS OF CHOICE

Generalized anxiety Benzodiazepines
Panic attack Fluoxetine
Nocturnal enuresis Imipramine
Opioid withdrawal Methadone → 2nd DOC → Clonidine
Opioid intoxication Naloxone / Naltrexone
Alcohol withdrawal Chlordiazepoxide → 2nd DOC→ Diazepam
Alcohol abstinence Disulfiram
Benzodiazepines intoxication Flumazenil
Obsessive compulsive disorder Clomipramine→ 2nd DOC→ Fluoxetine.
Attention deficit hyperactivity disorder Amphetamine→ 2nd DOC→ Methylphenidate
Tic disorder Haloperidol
Bulimia nervosa Fluoxetine
Alcoholic hallucinations Diazepam
Neuroleptic induced urinary retention Bethanecol
Neuroleptic induced hyperprolactinomaAmantadine
Akathisia Propranolol
*No withdrawal syndrome is seen with LSD

EEG WAVES AND SLEEP CYCLES

 SLEEP /
FREQUENCYAWAKE
BRAIN E.E.G.CONDITION
STAGE
REGIONFEATURES
Hz Awake
WAVES β waves
and alert /
Parietal Tension, excitation,
β 14-80 Awake ,
Frontal hypnotic over dosage
restful,
Occipital Awake, at rest with eyes
α 8-13 eyes
αclosed.
closed
Parietal Disappointment, frustration,
4-7
Temporal θorganic, functional
NREM- 1
Hippocampus.
θdegenerative, brain
NREM-2
θ disorders
δ
NREM-3
Parietal, Very deep sleep, organic,
3-5
δ Temporal, δfunctional degenerative,
NREM-4
Hippocampus, brain disorders
β
REM
REM
stage
of
sleep Nightmares.
Somnambulis
NRE m, Night-
M- 4 terror,
stage bedwetting,
of Bruxism,
sleep sleep talking.

QUOTE CORNER
Cured yesterday
of my disease, I
died last night of
my physician. -
Matthew Prior
ELEVENTH HOUR PSYCHIATRY 176

TYPES OF PHOBIAS

Acrophobia Fear of high places

Zoophobia Fear of animals
Xenophobia Fear of strangers
Algophobia Fear of pain
ClaustrophobiaFear of closed spaces
Thanatophobia Fear of death
Sitophobia Fear of eating
PERSONALITY TYPES

Personality type Characteristics

Schizoid
personality type Introverted, withdrawn, solitary and distant.
Interprets the action of others as deliberately threatening. Untrusting,
Paranoid unforgiving, guarded, and prone to aggression. Perceive others as
personality jealous, deceitful and condescending.
Schizotypal Odd and eccentric manners of dressing and speaking. Strange,
personality paranoid beliefs. Have difficulties forming relations and extreme anxiety
disorder in social situations. Display sign of magical thinking.
Antisocial
personality Impulsive, irresponsible, callous and aggressive. No respect for others
disorder and no remorse. High risk for alcohol and substance abuse
Abrupt and extreme mood changes. Unstable and fluctuating self
Borderline image. Unpredictable and self destructive. Fears of abandonment.
personality Excessive dependency, self mutilation or recurrent suicidal gestures.
disorder Impulsive, chronic feeling of boredom, bouts of intense anger.
Exaggerated senses of self importance, fantasies of unlimited success,
seek constant attention, oversensitive to failure, and complains of
Narcissistic multiple somatic symptoms, extreme mood swings, between self
personality admiration and insecurity.
Avoidant
personality Hypersensitive to rejection, excessive social discomfort, timidity, fear of
disorder criticism, avoidance of social work
Dependant
personality Dependant and submissive behavior, feel fear of rejection, lack self
disorder confidence.
Compulsive Compulsive personalities, high levels of aspirations, strive for
personality perfection, never satisfied with achievements .Reliable, dependable,
disorder orderly, methodical and highly cautious.
Histrionic Self dramatization, exaggerated expressions, suggestibility, attention
personality seeking attitude. Seductiveness, concerned with physical appearance.

TRIVIAL TRUTH
Hippopotomonstrosesquippedaliophobia is the fear of long words.
ELEVENTH HOUR PSYCHIATRY 177

Selfish, primitive, childish and pleasure oriented part of the personality with
Id no ability to delay gratification.
Internalised societal and parental standards of good, bad, right and wrong
Superego behaviour.
Ego Moderator between the Id and Superego which compromises to pasify both.
Anna Freud’s types of ego defense mechanisms

Compensation Takes up one behaviour because one cannot accomplish another

 behaviour.
Denial Refuses to perceive the more unpleasant aspects of external reality.
Redirects emotions from a dangerous object to a safe object. Shifts
sexual or aggressive impulses to a more acceptable or less
Displacement threatening target.
Concentrating on the intellectual components of the situations as to
Intellectualization/ distance oneself from the anxiety provoking emotions associated
isolation with these situations.
Attributing to others, one’s own unacceptable or unwanted thoughts
and/or emotions. Projection reduces anxiety in the way that it allows
the expression of the impulse or desire without letting the ego
Projection recognise it.
The process of constructing a logical justification for a decision that
Rationalization was originally arrived at through a different mental process.
The conversion of unconscious wishes or impulses that are
Reaction formation perceived to be dangerous into their opposites.
The reversion to an earlier stage of development in the face of
Regression unacceptable impulses.
The process of pulling thoughts into the unconscious and preventing
Repression painful or dangerous thoughts from entering consciousness.
Rechanneling of psychic energy away from negative outlets to more
positive outlets. It is the process of transforming libido into ‘socially
useful’ achievements, mainly art. Psychoanalysts often refer to
Sublimation sublimation as the only truly successful defence mechanism.
A person tries to ‘undo’ a negative or threatening thought by their
Undoing actions.
Suppression The conscious process of pushing thoughts into the preconscious.
Separation or postponement of a feeling that normally would
Dissociation accompany a situation or thought.

QUOTE CORNER
A hypochondriac is one who has a pill for everything except what ails him.
Mignon McLaughlin, The Second Neurotic’s Notebook, 1966
ELEVENTH HOUR PSYCHIATRY 178

Anna Freud’s types of ego defense mechanisms CONTINUED…

Refocuses attention on the somewhat comical side of the situation as to

Humor relieve negative tension.
Form of denial in which the object of attention is presented as “all good”
Idealization masking true negative feelings towards the other.
Identification The unconscious modeling of one’s self upon another person’s behavior.
Identifying with some idea or object so deeply that it becomes a part of that
Introjection person.
Refocusing of aggression or emotions evoked from an external force onto
Inversion one’s self.
SomatisationManifestation of emotional anxiety into physical symptoms.
Splitting A person sees external objects or people as either “all good” or “all bad.”
Substitution When a person replaces one feeling or emotion for another.

0.8-1.2 mEq / L
Therapeutic level of blood lithium
0.6-1.2 mEq / L
Prophylactic blood lithium
>2 mEq / L
Side effects
>3.5 mEq / L
Life threatening toxicity
Alcoholism

Alpha Milieu limited

Beta Male limited
GammaMalignant alcoholism
Epsilon Spree drinking
*Alcoholics anonymous-Self-help society of recovered and recovering alcoholics.

Alanon / Alateen- For relatives and friends of alcoholics.

Similarly there are Narcotics anonymous and Naranon for substance abusers.

*Traditional neuroleptics are most effective in treating positive symptoms of schizophrenia

Most common side effect of neuroleptic drugs (haloperidol) is drowsiness.

Tardive dyskinesia is the most common delayed complication of antipsychotic medication, characterized by

purposeless, involuntary facial and lip movement.

Most common extrapyramidal side effect is Akathisia, which is treated with Propranolol and Clonazepam.

TRIVIAL TRUTH
A heavy cigar smoker, Freud endured more than 30 operations during his life
due to mouth cancer. In September 1939 he prevailed on his doctor and
friend Max Schur to assist him in suicide. After reading Balzac’s La Peau de
chagrin in a single sitting he said, “My dear Schur, you certainly remember
our first talk. You promised me then not to forsake me when my time comes.
Now it is nothing but torture and makes no sense any more.” Schur
administered three doses of morphine over many hours that resulted in
Freud’s death on September 23, 1939.
ELEVENTH HOUR PSYCHIATRY 179
*Neuroleptic malignant syndrome

Muscle rigidity, autonomic dysregulation and hyperthermia.

Idiosyncratic reaction to inhibition of central dopamine receptors that results in increased heat production and failure

of heat dissipation.

Management-

Rapid physical cooling.

Administration of an antipyretic or actainophenbromocriptine and Dantrolene.

*Major depression with suicidal risk is the first and the most important indication of electroconvulsive therapy

In unilateral ECT, the electrodes are placed on the non-dominant side.

Much safer

*Klein-Levin syndrome

Recurrent episode of hypersomnia and hyperphagia, each lasting 1-3 weeks.

*Mythomania (Pseudologia fantastica or Pathological lying) is a condition involving compulsive lying by a person with

no obvious motivation. The affected person might believe their lies to be truth, and may have to create elaborate

myths to reconcile them with other facts.

*Munchausen’s syndrome is a disorder in which those affected feign disease, illness, or psychological trauma in order

to draw attention or sympathy to themselves. It is also sometimes known as Hospital addiction syndrome.

*Diogenes syndrome is a behavioral disorder characterized by extreme self-neglect. It usually affects the elderly who

live alone. Its symptoms include body odor and other signs of severe hygienic neglect. Physical diseases relating to

bodily neglect usually accompany the syndrome.

*Heutoscopy is a term used in psychiatry for the reduplicative hallucination of “seeing one’s own body at a distance”

* Media Induced Post-traumatic Stress Disorder (MIPTSD). is a manifestation of Post-traumatic stress disorder type;

symptoms specifically due to exposure to entertainment media that focuses excessively on violence.

*Retired husband syndrome is a psychosomatic, stress related illness It is a condition where a woman begins to

exhibit signs of physical illness and depression as their husband reaches, or approaches retirement.

QUOTE CORNER
The only difference between psychiatrists and their patients is that the
 patients have a chance of getting better.-Anonymous.
ELEVENTH HOUR PSYCHIATRY 180

*Medical student syndrome is a type of literary self-imposed hypochondria. It typically starts as a person reads or

learns about an illness or disorder and begins to believe they have it.

*Cryptomnesia, or “concealed recollection,” is a phenomenon involving suppressed or ‘forgotten’ memories. It refers

to cases where a person believes that he is creating or inventing something new, such as a story, poem, artwork, or

joke, but is actually recalling a similar or identical work which he or she has previously encountered.

*Ringxiety / Phantom ring effect / Fauxcellarm.

the sensation and the false belief that one can hear his or her mobile phone ringing or feel it vibrating, when in fact

the telephone is not doing so.

PSYCHIATRY

1. Axis Determination I = clinical psych disorders II personality disorders, III Coexisting medical conditions IV

psychosocial stressors, V global assessment of functioning

2. Schizophrenia Positive Sx: delusions, hallucinations, bizarre behavior; Negative Sx: alteration of affect,

ambivalence, apathy, loosening of associations; males=females; industrial nations have incr. prevalence;

Misalignment of cells in cortex; incr. ventricle size; decr. activity in frontal cortex on PET scan.

3. Disorganized: insidious, incoherent, inappropriate affect, social impaired

4. Catatonic: rigidity, posturing or excitement, negativism

5. Paranoid: highest functioning type, grandiose, jealous, persecution

6. Undifferentiated: not defined by other subtypes

7. Melerill = Retrograde ejaculation, Tx: Respiradol (Best side effect profile), Clozaril (agranulocytosis w/ weekly

CBC) prescribed weekly,

8. Neurolyptic Malignant Syndrome = incr. temp, incr. CPK, rigidity

9. Schizophrenifrom same sx as schizophrenia but have lasted for less than 6 months

10. Schizoaffective mood disorder and separate psychotic sx. Must experience 2 weeks of psychotic sx w/o mood

impairment for dx to be made; Antidepressants are 1st line tx

11. Major Depression loss of interest in activities, sleep, wt, concentration, hopelessness, suicidal ideation, nihilism;

Seasonal affective, Vegetative (non functioning can be terminal) Dysthymia(chronic low level); Reactive related to

environment w/o severity id sx; Masked 1o depression denied or hidden by other sx

12. Depression & anxiety can occur together & can be treated w/ an antidepressent; Left anterior or rt posterior

stroke => incr. possibility of depression; Tx: 1st Tricyclic (Imiprimine); SSRI = side effects; Trazadone=priapism

Asendin (Amoxipine) = Extrapyramidal Symptoms

13. BiPolar Bimodal peak 20’s & 30’sCycling mood= highs w/ euphoria, hyperactive, pressured speech, flight of

ideas, decr need for sleep, delusions, inflated self esteem, risks, poor judgement; Lows are major depressive

episodes tx: lithium

14. Panic Attacks Sudden, unprovoked onset of fear, impending doom, palpitations, SOB, chest pain, smothering,

dizziness. May be associated w/ agoraphobia Tx: with SSRI’s

15. Phobias Persistent and irrational fear of a specific object or activity or situation. Tx like a phobia

16. Obsessive Compulsive Persistent, unwanted thoughts, impulses or images

17. repetitive, purposeful intentional behaviors meant to decrease tension caused by the obsessive thoughts; genetic

Tx: Anafranil (Tricyclic) Prozac & Luvox (SSRI)

18. PTSD intrusive recollections, daydreams, nightmares, poor concentration, psychic numbing; Tx: don’t treat w/

meds unless compulsion component

19. Studies: Buffalo Creek Disaster, Beverly Hills Nightclub

20. Dissociative Disorder Amnesia = loss of memory, Fugue = assoc w/ physical flight, Identity Disorder = multiple

ego states; Depersonalization = feelings of self estrangement or unreality

21. Whirndingo Fear of becoming a cannibal

22. Amok sudden unprovoked outburst of wild rage usually ending in homicide

23. Coprolalia Feces & filth

24. Koro penis is shrinking and may disappear

25. Latah imitate words or actions to which they are exposed

26. Piblotko Run around in snow naked

27. White Out Syndrome lack of diverse stimuli in snow clad environment
28. Narcolepsy REM sleep, sudden onset of daytime sleep and cataplexy; REM sleep is inappropriately present at

beginning

29. Personality Disorders Cluster A = Bizarre = Paranoid, Schizoid (no close relationships, restricted emotions)

Schizotypical (schizoid + odd or distorted behavior or cognition)

30. Cluster B = Over emotional = Antisocial (Disregard for social norms) Borderline, Histrionic, Narcissistic (self

centered)

31. Cluster C = Anxiety & Fear = avoidant, dependent, Obsessive compulsive