1) Antisocial Personality disorder

Usually a man Characterized by continuous antisocial or criminal acts, inability to conform to social rules, impulsivity,
disregard for the rights of others, aggressiveness, and lack of remorse. They will typically be manipulative, deceitful and
reckless.

• If the patient < 18, it’s called Oppositional defiant disorder (ODD)

2) Borderline Personality Disorder

Usually a Female characterized by mood swings, marked impulsivity, unstable relationships, and inappropriate anger.
They can be very dramatic. They are usually attention seekers and may have multiple self-inflicted scars.
They may threaten to commit suicide.

So By comparison
antisocial - Male + past criminal record + unstable relationships + aggressive
borderline - female + unstable relationship + impulsive + suicidal.
ODD - like anitsocial but less than 18 years old boy

2) Attention deficit hyperactivity disorder (ADHD)

is characterized by the three core symptoms of inattention, hyperactivity, and impulsiveness.

3) Autism spectrum disorder :

It can be characterised by:
1. Severe difficulties in communicating and forming relationships
2. Difficulties in language
3. Repetitive and obsessive behaviour that if interrupted will bring anxiety ( eg : lining up toys or organizing pens )
4. Prefer solitary activities
1) Mini Mental Status Examination (MMSE) is to assess patients with dementia. All patients with cognitive impairment
should be assessed with it
It’s different from normal mental capacity assessment we do before taking consent
 1) Bipolar affective disorder type 2 (commonly known as manic depression)
Classically, periods of prolonged and profound depression alternate with periods of excessively elevated and irritable
mood, known as mania.

Treatment : Mood Stabilizer ( Lithium )

2) Symptoms of depression
• Present for at least 2 weeks and represent a change from normal.
• Depressed mood
• Anhedonia: markedly diminished interest or pleasure
• Weight change: loss or gain associated with decreased or increased appetite
• Disturbed sleep: insomnia or hypersomnia
• Fatigue or loss of energy.
• Reduced libido.
• Feelings of worthlessness or excessive or inappropriate guilt
• Diminished ability to think or concentrate or indecisiveness.
• Recurrent thoughts of death or suicide
3) Postnatal depression
It usually occurs within 6 months peaking at 3 to 4 weeks postnatally.

Clinical features:
• Tearful and anxious
• Worries about her ability to cope adequately with the newborn
• Worries about the newborn
• Struggles to look after herself and the newborn

Management
Treated like any other depressive illness
CBT
SSRI ( If breastfeeding > sertraline)
5) Atypical depressive episode

Clinical features:
• Mood is depressed, but remains reactive (able to enjoy certain experiences but not to ‘normal’ levels)
• Hypersomnia
• Hyperphagia (excessive eating with weight gain of over 3kg in 3 months)
• ‘Leaden paralysis’ (feeling of heaviness in the limbs)
1)
• Erotomania > think that someone loves her secretly

• Pyromania > start fires

• Rejected stalker > Pursues a victim in order to reverse, correct, or avenge rejection (e.g. divorce, separation)

• Trichotillomania > pulls out one’s hair which lead to hair loss and baldness

• Grandiosity > An exaggerated sense of one’s own importance or abilities

2) Obsessive–compulsive disorder (OCD)

Obsessions are anxiety-provoking, intrusive thoughts, commonly concerning contamination, doubt, guilt, aggression,
and sex.
Compulsions are behaviors that reduce anxiety, commonly hand-washing, organizing, checking, counting, and
praying.
If resisted lead to palpitations for example

Management
• CBT including exposure and response prevention (ERP).
• SSRIs (licensed): escitalopram, fluoxetine, sertraline or paroxetine should be considered
• when would electroconvulsive therapy (ECT) be an answer for treatment of OCD:
> If patient is suicidal or severely incapacitated

3) Clang association ( Gang )

Clang association is an abnormality of speech where the connection between words is their sound rather than their
meaning. sound a bit like rhyming poetry, except that the poems don't seem to make any sense.
Example, one may say “systematic, sympathetic, quite pathetic, apologetic, paramedic, your heart is prosthetic.
3)Schizophrenia

first-rank symptom of schizophrenia:

1. Auditory hallucinations:
• third-person auditory hallucinations > voices are heard referring to the patient as ‘he’ or ‘she’, rather than ‘you’
• thought echo > an auditory hallucination in which the content is the individual’s current thoughts
• voices commenting on the patient's behaviour

2. Thought disorder:
• thought insertion > The delusional belief that thoughts are being placed in the patient’s head from outside
• thought withdrawal > The delusional belief that thoughts have been 'taken out' of his/her mind
• thought broadcasting > The delusional belief that one’s thoughts are accessible directly to others
• thought blocking > a sudden break in the chain of thought.

3. Passivity phenomena:
• bodily sensations being controlled by external influence

4. Delusional perceptions
• a two stage process where first a normal object is perceived then secondly there is a sudden intense delusional
insight into the object's meaning for the patient e.g. 'The traffic light is green therefore I am the King'.
4)
• (H)ypochondriasis : serious diseases like (H)IV.
• (S)omatization : in the presence of (S)ymptoms
• (M)unchausen : fake symptoms and signs with primary aim of (M)edical attention.
By proxy = to others
• (Mal)ingering: fake symptoms and signs with secondary aim of ( Compensation, avoid military service ...etc )

• Conversion (dissociative) disorders > usually following a stressful event ( like post stress disorder ) but typically
involves loss or disturbance of normal motor or sensory function which initially appears to have a neurological or other
physical cause but is later attributed to a psychological cause. The patient does not consciously feign the symptoms

• Nihilistic delusions is the delusional belief that the patient has died or part of him dead and rotten or no longer exists
or that the world has ended or is no longer real, he may ask people to bury him or cut his dead part

• Cotrad syndrome : the same as nihilistic delusions + Depression

• Capgras syndrome > A type of delusional in which the patient believes that a person known to him has been
replaced by a ‘double’ who is to all external appearances identical, but is not the ‘real person .

• Todd's syndrome > Also known as “Alice in Wonderland Syndrome”. Patients may feel as their body is expanding or
getting smaller.

• Frégoli delusion (Delusion of doubles) > is when a person belief that different people are in fact a single person who
changes appearance or is in disguise.

• Ganser Syndrome : is like Malingering but usually mimic psychotic symptoms and usually in prisoners

• Folie à deux > is French for “madness of two”. It is a situation where two people with a close relationship share a
delusional belief.

• Hypnagogic hallucination > Hallucination while falling asleep like hearing voices

• hypnopompic hallucination > The same phenomenon experienced while waking up

• Othello > delusional jealousy think that her partner cheat on her and may follow him or hire a detective

• Ebkom > think that his body is infested with parasites

TCA

Clinical features:
Dilated pupils
Dry mouth
Dry flushed skin
Urinary retention
Drowsiness and altered mental state leading to coma
Hypotension

ECG monitoring for TCA overdose is essential. The important ECG finding suggestive of TCA poisoning is QRS widening
(>100 ms) and tall peaked T wave indicate Hyperkalemia . Broad complex tachycardias may occur which are life
threatening.

Two popular stems in the exam where the answer is likely to be TCA overdose is the young child that takes his/her
grandparents medication who later becomes drowsy and lethargic. Another is an elderly person who has a terminal
illness and wants to take his/her own life who comes in the ED having dry and flushed and pupils are dilated. TCA's are a
prescription only medication and so you should think about how the person in the stem obtained the medication before
you choose an answer.
4)
• Agoraphobia > Fear of open spaces , shopping center , traveling on public transport , leaving home
• Social phobia (Social Anxiety Disorder) > Persistent fear and anxiety about one or more social or performance
situations
• Claustrophobia > Irrational fear of confined spaces
• Arachnophobia > Fear of spiders
• Acrophobia > Fear of heights
 Alternative episodes of excessive eating and trials of weight
loss
They sometimes maintained a BMI above 17.5 kg/m2.

Examination:
• Salivary glands (especially the parotid) may be swollen.
• Russell's sign may be present (calluses form on the back
of the hand, caused by repeated abrasion against teeth
during inducement of vomiting).
• There may be erosion of dental enamel due to repeated
vomiting.

7) For Anxiety Disorders like social anxiety:

• Acute episode : rebreathing in a paper bag

• For prevention of anxiety in anticipation of a single event only : propranolol
• Long term theraypy : CBT & SSRIs
1) Common reasons for hospital admission
• Serious risk of suicide
• Serious risk of harm to others
• Significant self-neglect
• Severe depressive symptoms
• Severe psychotic symptoms
• Lack or breakdown of social supports
• Initiation of electroconvulsive therapy Treatment-resistant depression (where inpatient monitoring may be helpful)

3)
• Alcohol hallucinosis can occur during acute intoxication or withdrawal. It usually appears 12-24 hours after drinking
alcohol . It involves auditory and visual hallucinations, most commonly accusatory or threatening voices.

Investigations: chronic alcoholism will lead to increase GGT and MCV

Management: Diazepam and chlorodiazepoxide

• If it continues to be severe with confusion, disorientation, restlessness, aggressive, hallucinations and tremors , it’s
called delirium tremens ( especially when it is cut in hospital admission)

Management: Lorazepam

4)
• Wernicke's encephalopathy presents with a triad of confusion, ataxia and ophthalmoplegia. ( only ataxia and
confusion will be needed to diagnose ) ,, ( not only in alcoholics but also for Pregnancy with hyperemisis gravidarum )

• Korsakoff’s psychosis is characterised by the addition of the triad of Wernicke, antero- and retrograde amnesia and
confabulation