Clinical Psychology & Psychiatry

Stages: Oral (0-1yr, mouth, weaning conflict), Anal (1-3yr, anus, toilet training), Phallic (3-6yr, genitals, Oedipus/Electra complex), Latency (6-12yr, dormant), Genital (12+, mature sexuality). Defense Mechanisms (Freud/A. Freud): Mature: sublimation, altruism, anticipation, humour, suppression. Neurotic: repression (unconscious forgetting), displacement (redirect to safer target), isolation (separate affect from idea), intellectualization (abstract reasoning to avoid emotion), reaction formation (opposite belief/behavior), rationalization (logical explanation for irrational act). Immature: projection (attributing own feelings to others), denial, acting out, splitting (all-good/all-bad), idealization/devaluation, somatization, dissociation. Psychotic: delusional projection, distortion. Structural Model: Id (pleasure principle, primitive drives), Ego (reality principle, mediates Id/Superego), Superego (morality, conscience).

Eight stages across lifespan, each with a crisis: (1) Trust vs Mistrust (0-1yr, hope). (2) Autonomy vs Shame/Doubt (1-3yr, will). (3) Initiative vs Guilt (3-6yr, purpose). (4) Industry vs Inferiority (6-12yr, competence). (5) Identity vs Role Confusion (12-20yr, fidelity). (6) Intimacy vs Isolation (20-40yr, love). (7) Generativity vs Stagnation (40-65yr, care). (8) Ego Integrity vs Despair (65+, wisdom). Key concepts: Each stage builds on previous; successful resolution yields a virtue. Failure leads to maladaptation. Identity crisis central to adolescence.

Four stages: Sensorimotor (0-2yr): object permanence (8-12mo), stranger anxiety, goal-directed action. Preoperational (2-7yr): egocentrism (three-mountain task), centration (focus on one dimension), animism (inanimate objects have life), magical thinking, no conservation (lacking reversibility). Concrete Operational (7-11yr): conservation (mass, number, volume), reversibility, classification, seriation, logical thought about concrete objects. Formal Operational (12+): abstract reasoning, hypothetical-deductive reasoning, systematic problem-solving. Key terms: Assimilation (new info fits existing schema), Accommodation (schema changes to fit new info), Equilibration (balance between assimilation/accommodation).

Three levels (6 stages): Preconventional (age <10): Stage 1 — obedience/punishment avoidance. Stage 2 — self-interest, reciprocity ("you scratch my back"). Conventional (adolescence-adult): Stage 3 — interpersonal accord, "good boy/good girl". Stage 4 — law and order, social order maintenance. Postconventional (rare): Stage 5 — social contract, individual rights. Stage 6 — universal ethical principles (justice, equality). Influenced by Piaget's formal operations. Critique: Gilligan argued Kohlberg's theory was male-centric; proposed ethics of care (women's moral reasoning based on relationships/care vs justice).

Cognitive development occurs through social interaction. Zone of Proximal Development (ZPD): difference between what a child can do alone vs with guidance. Scaffolding: providing support that is gradually removed as competence increases. Private Speech: self-talk guides thinking/action, becomes inner speech. More Knowledgeable Other (MKO): teacher, peer, or adult who provides guidance within ZPD. Emphasizes cultural tools (language, symbols) in cognitive development. Contrasts Piaget's child-as-scientist with child-as-apprentice.

Bowlby: Attachment is an innate biological system promoting proximity to caregiver for safety. Internal working model (mental representation of self/others formed from early attachment). Phases: pre-attachment (0-6wk), attachment-in-the-making (6wk-8mo), clear-cut attachment (8mo-2yr), goal-corrected partnership (2yr+). Ainsworth — Strange Situation (1978): (1) Secure (B): explores with caregiver present, distressed at separation, easily comforted on reunion (60%). (2) Insecure-Avoidant (A): little distress at separation, ignores caregiver on reunion (15%). (3) Insecure-Anxious/Ambivalent (C): clingy, distressed at separation, difficult to comfort, angry/ambivalent on reunion (10%). (4) Disorganized (D): contradictory behaviors, freezing, approaching but looking away (15%, high-risk populations). Attachment styles influence adult relationships (secure, dismissive-avoidant, preoccupied-anxious, fearful-avoidant).

Classical Conditioning (Pavlov): Unconditioned stimulus (food) → unconditioned response (salivation). Conditioned stimulus (bell) + UCS → CR. Extinction, spontaneous recovery, generalization, discrimination, higher-order conditioning. Watson & Rayner (Little Albert): conditioned fear of white rat. Operant Conditioning (Skinner): Behavior shaped by consequences. Positive reinforcement (add reward → increase behavior). Negative reinforcement (remove aversive → increase behavior). Punishment (positive: add aversive → decrease behavior; negative/response cost: remove reward). Schedules: fixed ratio (high rate), variable ratio (most resistant to extinction), fixed interval, variable interval. Shaping, chaining, extinction burst. Observational Learning (Bandura — Bobo Doll): Learning by watching models. Requires attention, retention, reproduction, motivation. Self-efficacy (belief in one's ability to succeed). Vicarious reinforcement/punishment.

Memory types: Sensory memory (iconic ~250ms, echoic ~2-3s), Short-term/working memory (limited capacity 7±2 chunks, 15-30s without rehearsal), Long-term memory (unlimited). Explicit/declarative (episodic — events, semantic — facts) vs Implicit/non-declarative (procedural — skills, priming, classical conditioning). Encoding (levels-of-processing, elaboration), Storage (consolidation, long-term potentiation), Retrieval (recall, recognition, cued recall). Forgetting: decay, interference (proactive — old interferes with new; retroactive — new interferes with old), retrieval failure (tip-of-tongue). Amnesia: Anterograde (can't form new memories, hippocampus damaged — HM). Retrograde (can't recall past). Sleep stages: N1 (light sleep, theta, hypnic jerks), N2 (sleep spindles, K-complexes, 50% of sleep), N3 (slow wave/deep sleep, delta, parasomnias — sleepwalking, night terrors), REM (rapid eye movements, beta-like EEG, atonia — paralysis, vivid dreaming). Sleep cycle: ~90min per cycle, 4-6 cycles/night. REM increases across the night (early cycles short REM, later cycles longer). Sleep deprivation: impairs attention, memory, executive function, mood. Microsleeps, rebound REM. Dreams: Freud (wish fulfillment, manifest vs latent content). Activation-synthesis (Hobson: random brainstem activation + forebrain synthesis). Neurocognitive (dreams reflect waking concerns).

James-Lange: Physiological arousal → emotion (we feel sorry because we cry). Cannon-Bard: Simultaneous physiological arousal + emotion (thalamus → cortex + hypothalamus). Schachter-Singer Two-Factor: Arousal + cognitive label/attribution → emotion (inject epinephrine, interpret as anger or euphoria depending on context). Lazarus Cognitive Appraisal: Primary appraisal (relevant? positive/threatening?), Secondary appraisal (can I cope?), Reappraisal. Ekman — Basic Emotions: Happiness, sadness, fear, anger, surprise, disgust (universal facial expressions, cross-cultural). Maslow's Hierarchy: Physiological → Safety → Love/Belonging → Esteem → Self-actualization. Drive Reduction (Hull): Homeostasis, drives (hunger, thirst) motivate behavior to reduce tension. Arousal Theory (Yerkes-Dodson): Moderate arousal = optimal performance. Simple tasks need higher arousal; complex tasks need lower arousal.

Dopamine (DA): 4 pathways — mesolimbic (reward, positive symptoms — excess), mesocortical (negative/cognitive symptoms — deficit in schizophrenia), nigrostriatal (motor, extrapyramidal — degeneration in Parkinson’s), tuberoinfundibular (prolactin inhibition). D1-like (D1, D5, stimulatory), D2-like (D2, D3, D4, inhibitory). D2 blockade = antipsychotic effect + EPS + prolactin elevation. Serotonin (5-HT): Mood, anxiety, appetite, sleep, aggression, libido. 7 families (5-HT1-7). 5-HT1A (anxiolytic, antidepressant — buspirone, partial agonist). 5-HT2A (psychosis — LSD/psilocybin agonist; atypical antipsychotics antagonist). 5-HT3 (emesis — ondansetron antagonist). 5-HT reuptake inhibition = SSRI/SNRI mechanism. Norepinephrine (NE): Arousal, attention, fight-or-flight, mood. α1 (vasoconstriction, mydriasis), α2 (autoreceptor — presynaptic inhibition, clonidine/guarfacine agonist), β1 (heart rate/contractility), β2 (bronchodilation, peripheral vasodilation). GABA: Primary inhibitory neurotransmitter. GABA-A (ionotropic, Cl− channel, BZD binding site — enhance GABA effect), GABA-B (metabotropic). Reduced in anxiety, epilepsy. Glutamate: Primary excitatory neurotransmitter. NMDA, AMPA, kainate receptors. NMDA hypofunction → cognitive deficits + psychosis in schizophrenia (glutamate hypothesis). Ketamine (NMDA antagonist) — rapid antidepressant. Acetylcholine (ACh): Muscarinic (M1-M5, cognition, memory — anticholinergic = cognitive impairment, delirium). Nicotinic (nAChR, attention, reward). Reduced in Alzheimer’s (ACh depletion). Histamine: H1 (arousal, appetite — antihistamines = sedation). H2 (gastric acid). Antipsychotics with high H1 blockade = weight gain, sedation.

Major psychotropic-metabolizing enzymes: CYP2D6 (many antidepressants, antipsychotics — 10% poor metabolizers), CYP3A4 (most common, bupropion, aripiprazole, quetiapine, BZDs), CYP2C19 (escitalopram, citalopram, sertraline, diazepam), CYP1A2 (clozapine, olanzapine, caffeine, theophylline). Inhibitors (↑ drug levels): Fluoxetine/paroxetine (2D6), fluvoxamine (1A2, 2C19, 3A4), bupropion (2D6), ketoconazole (3A4), cimetidine (multiple). Inducers (↓ drug levels): Carbamazepine (3A4, 2C19, 1A2 — reduces levels of most psychotropics), phenytoin, phenobarbital, St. John’s Wort (3A4), smoking (1A2 — smokers need higher clozapine/olanzapine doses). Clinical implications: Fluoxetine → ↑ TCAs, antipsychotics (2D6). Paroxetine + tamoxifen → ↓ endoxifen (active metabolite) → ↑ breast cancer recurrence. Carbamazepine + OCP → OCP failure. Smoking cessation → ↑ clozapine/olanzapine levels (must reduce dose). Check Drug-Drug Interactions (DDIs) for all combinations.

SSRIs (first-line): Citalopram, escitalopram, fluoxetine, paroxetine, sertraline, fluvoxamine. SE: GI upset, sexual dysfunction, insomnia, activation, SIADH, bleeding risk. Withdrawal (dizziness, nausea, paresthesias — especially paroxetine). SNRIs: Venlafaxine, desvenlafaxine, duloxetine, levomilnacipran. SE: similar + ↑ BP (dose-dependent venlafaxine). TCAs: Amitriptyline, nortriptyline, imipramine, desipramine, clomipramine. SE: sedation, dry mouth, constipation, blurred vision, urinary retention, orthostasis, QTc prolongation. Lethal in overdose. MAOIs (last-line): Phenelzine, tranylcypromine, selegiline. Tyramine-free diet → hypertensive crisis. Atypicals: Bupropion (NDRI, no sexual SE). Mirtazapine (NaSSA, sedation + weight gain). Trazodone (SARI, sedation, priapism rare). Vortioxetine (pro-cognitive). Vilazodone. Ketamine/Esketamine: Rapid antidepressant for TRD. Esketamine intranasal + oral AD. SE: dissociation, ↑ BP, abuse potential. Washout: SSRI/SNRI → MAOI: 2wk (5wk fluoxetine). MAOI → SSRI: 2wk. Serotonin syndrome risk with combinations.

Lithium: First-line for bipolar I maintenance + acute mania. Target: acute 0.8-1.2, maintenance 0.6-1.0. Toxicity >1.5. SE: polyuria/polydipsia (nephrogenic DI), tremor, weight gain, hypothyroidism, acne, psoriasis, GI upset, renal impairment, leukocytosis, Ebstein anomaly. Monitoring: Li level q3-6mo, Cr/eGFR, TSH, BMP, EKG. Valproate: Acute mania, mixed, rapid cycling. Target 50-125 μg/mL. SE: weight gain, sedation, tremor, hair loss, thrombocytopenia, hepatotoxicity, pancreatitis, PCOS, neural tube defects. Monitoring: LFTs, CBC, valproate level. Lamotrigine: Bipolar I maintenance (depression > mania). Titrate slowly to ↓ SJS risk (25mg ×2wk, 50mg ×2wk, 100mg ×1wk, target 200mg). Valproate doubles level. Carbamazepine: Acute mania, especially rapid cycling/mixed. Auto-inducer. SE: dizziness, ataxia, hyponatremia, leukopenia, SJS (HLA-B*1502). Monitoring: CBC, CMP, carbamazepine level. Drug interactions: ↓ OCP, warfarin, antipsychotics, BZDs. Other SGAs: Olanzapine, quetiapine (300-800mg for bipolar depression), aripiprazole, risperidone — all FDA-approved for acute mania or maintenance.

First-Generation (FGA): High potency (haloperidol, fluphenazine) — D2 antagonist, high EPS. Low potency (chlorpromazine) — low D2, high anticholinergic/sedation. EPS: Acute dystonia (hours-days, benztropine/diphenhydramine), Parkinsonism (weeks, anticholinergic), Akathisia (days-weeks, propranolol/BZD/mirtazapine), Tardive Dyskinesia (months-years, irreversible, VMAT2i: valbenazine, deutetrabenazine). Second-Generation (SGA): D2 + 5-HT2A antagonism. Lower EPS risk (except risperidone high dose). Clozapine (refractory): Superior for TRS, ↓ suicide risk, ↓ aggression. SE: agranulocytosis (1-2%, weekly CBC ×6mo → biweekly ×6mo → monthly), myocarditis (first 2mo), seizures, sedation, hypersalivation, weight gain, metabolic syndrome, constipation. LAIs: Haloperidol decanoate, fluphenazine decanoate, risperidone microspheres, paliperidone palmitate, aripiprazole monohydrate/lauroxil, olanzapine pamoate. Metabolic syndrome monitoring: Weight/BMI q3mo, fasting glucose/HbA1c, lipids. Switch to ziprasidone/lurasidone/aripiprazole if severe. NMS: Rigidity + fever + autonomic instability + altered MS + ↑ CK. Stop AP, supportive care, dantrolene, bromocriptine. QTc: Haloperidol IV, ziprasidone, thioridazine highest risk.

BZDs: GABA-A positive allosteric modulators. Short (triazolam, midazolam), Intermediate (lorazepam, alprazolam, oxazepam), Long (diazepam, clonazepam, chlordiazepoxide). SE: sedation, ataxia, dependence, tolerance, withdrawal (seizures, delirium — potentially fatal), cognitive impairment, falls, anterograde amnesia, respiratory depression. Withdrawal: Taper slowly over weeks-months. Flumazenil: Reverses OD — SE: seizures in chronic users. Non-BZD: Buspirone (5-HT1A partial agonist, delayed onset 2-4wk, for GAD). Hydroxyzine (H1 antagonist). Propranolol (β-blocker for performance anxiety). Pregabalin/gabapentin (α2δ ligand, GAD off-label). Z-drugs: Zolpidem, zaleplon, eszopiclone. SE: sleepwalking/sleep-eating, tolerance, dependence. Short-term only (<4wk). Ramelteon: Melatonin agonist, no abuse potential. Doxepin (low dose): H1 antagonist for sleep maintenance. Suvorexant (orexin antagonist).

Stimulants for ADHD: Methylphenidate (MPH, block DA/NE reuptake), Mixed Amphetamine Salts (MAS, ↑ release + block reuptake, Vyvanse = lisdexamfetamine prodrug). SE: insomnia, ↓ appetite/weight, ↑ HR/BP, growth delay, tic exacerbation, dysphoria/irritability, abuse potential. Non-stimulant ADHD: Atomoxetine (SNRI, SE: GI upset, sedation, hepatotoxicity rare, suicidal thinking boxed warning). Guanfacine XR (α2A agonist, SE: sedation, ↓ BP/HR). Clonidine ER. Wake-promoting: Modafinil/armodafinil (narcolepsy/shift work). Cognitive Enhancers (Alzheimer’s): Donepezil, rivastigmine, galantamine (cholinesterase inhibitors). Memantine (NMDA antagonist). Modest benefit. SE: GI upset, bradycardia.

Alcohol: Naltrexone (first-line, ↓ craving, 50mg PO/380mg IM q4wk). Acamprosate (666mg TID, ↓ abstinence-induced craving). Disulfiram (deterrent, 250-500mg). Opioid: Methadone (full μ-agonist, daily at OTP). Buprenorphine/naloxone (partial μ-agonist, office-based). Naltrexone XR (after detox). Naloxone (overdose reversal). Tobacco: Varenicline (best quit rate). NRT (patch + short-acting). Bupropion. BZD withdrawal: Phenobarbital taper (severe). Carbamazepine/valproate for seizure prophylaxis. Symptom-triggered BZD.

DSM-5 Criteria (≥5 of 9 in 2wk, at least 1 = depressed mood or anhedonia): SIGECAPS — S: Sleep disturbance, I: Interest loss, G: Guilt/worthlessness, E: Energy loss, C: Concentration difficulty, A: Appetite/weight change, P: Psychomotor agitation/retardation, S: Suicidal ideation. Specifiers: Anxious distress, Mixed features, Melancholic (worse AM, early awakening, marked anhedonia), Atypical (mood reactivity, leaden paralysis, hypersomnia, hyperphagia, rejection sensitivity), Psychotic, Catatonia, Peripartum onset, Seasonal pattern. PHQ-9: 9-item self-report, score 0-27. ≥10 = moderate. Etiology: Monoamine hypothesis (↓ 5-HT, NE, DA), HPA axis hyperactivity (↑ cortisol), inflammation (↑ CRP, IL-6), ↓ BDNF, genetic (heritability ~37%). Treatment: Mild-moderate: CBT/IPT (first-line) or SSRI. Moderate-severe: SSRI/SNRI + psychotherapy. STAR*D trial: Step 1 — citalopram (~30% remission). Step 2 — switch or augment (bupropion, buspirone, CBT). Step 3 — switch (mirtazapine, nortriptyline) or augment (lithium, T3). Step 4 — tranylcypromine or venlafaxine + mirtazapine. Cumulative remission ~67%. Treatment-resistant depression (TRD): Esketamine intranasal, ECT (most effective), rTMS, VNS, MAOI, augmentation (lithium, T3, SGA). ECT: Indications: severe MDD with psychosis, catatonia, TRD, suicidal, food refusal, pregnancy. SE: short-term retrograde amnesia. rTMS: Left DLPFC high-frequency, for mild-moderate TRD, no seizure risk. Light therapy: Seasonal affective disorder, 10,000 lux 30min AM. CBT: Addresses negative cognitive triad (self, world, future) + cognitive distortions (all-or-nothing, catastrophizing, overgeneralization). Behavioral activation. IPT: Focus on interpersonal disputes, role transitions, grief, interpersonal deficits.

Depressed mood for ≥2yr (≥1yr in children/adolescents). During this period, ≥2 of: poor appetite/overeating, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, hopelessness. Symptoms never absent for >2mo. Double depression = MDD superimposed on dysthymia. Treatment: SSRI/SNRI + psychotherapy. Chronic course, earlier onset than MDD.

DSM-5: ≥5 symptoms in luteal phase, resolve menses. Core: affective lability, irritability/anger, depressed mood/anxiety, anhedonia. Plus: fatigue, sleep/appetite change, physical symptoms. Confirmed with ≥2mo prospective daily ratings. Treatment: SSRIs (intermittent luteal phase or continuous), combined OCP (drospirenone + ethinyl estradiol), CBT. Response within days.

Manic Episode (DSM-5): ≥1wk (or any duration if hospitalized), elevated/expansive/irritable mood + ≥3 of DIGFAST (or ≥4 if irritable only): Distractibility, Insomnia/decreased need for sleep, Grandiosity, Flight of ideas, Activity increase, Speech pressured, Thoughtless risky behavior. Causes marked impairment ± psychosis. Bipolar I: ≥1 manic episode. Bipolar II: ≥1 hypomanic episode (≥4d, no marked impairment) + ≥1 MDE. Rapid cycling: ≥4 mood episodes in 12mo. Mixed features: Manic/hypomanic episode + ≥3 depressive symptoms OR depressive episode + ≥3 manic/hypomanic symptoms. Treatment — Acute Mania: First-line: Lithium, Valproate, or SGA (olanzapine, quetiapine, risperidone, aripiprazole, asenapine, cariprazine). Combination (Li/Valproate + SGA) for severe/psychotic. Bipolar Depression: Quetiapine, Lamotrigine (maintenance), Lithium, Olanzapine + fluoxetine, Lurasidone, Cariprazine. No antidepressant monotherapy. Maintenance: Lithium (↓ suicide risk), Valproate, Lamotrigine (depression prevention), Olanzapine (manic prevention).

≥2yr (≥1yr in children/adolescents) with numerous hypomanic symptoms (not meeting full criteria) and depressive symptoms (not meeting full MDD criteria). Never without symptoms for >2mo. High risk of progressing to bipolar I/II (~15-50%). Treatment: Psychotherapy, mood stabilizer (lithium, lamotrigine, valproate). Avoid antidepressant monotherapy.

DSM-5: Excessive anxiety/worry ≥6mo about multiple domains (work, school, health, finances). Difficulty controlling worry + ≥3 of: restlessness, easy fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance. Prevalence ~3-5%. Comorbid with MDD (60%). Treatment: SSRI/SNRI (escitalopram, paroxetine, sertraline, duloxetine, venlafaxine). CBT (cognitive restructuring, relaxation training, worry time, exposure to uncertainty). Second-line: Buspirone, pregabalin, hydroxyzine. BZDs short-term only. Response ~60-70%.

DSM-5: Recurrent unexpected panic attacks + ≥1mo of persistent concern about additional attacks or consequences + maladaptive behavioral change. Panic attack: abrupt fear peaking within minutes with ≥4 of: palpitations, sweating, trembling, SOB, choking, chest pain, nausea, dizziness, paresthesias, derealization, fear of dying/losing control. Agoraphobia: Fear/avoidance of ≥2: public transport, open/enclosed spaces, crowds, being alone/outside. Treatment: SSRI (first-line — paroxetine, sertraline, escitalopram). CBT (interoceptive exposure, cognitive restructuring, breathing retraining). BZD short-term. Agoraphobia: gradual exposure.

DSM-5: Marked fear/anxiety about social situations where exposed to possible scrutiny. Fear of negative evaluation. Avoidance or endured with distress. Duration ≥6mo. Performance-only specifier. Prevalence ~7-13% lifetime. Treatment: CBT (cognitive restructuring, exposure, social skills training). SSRI/SNRI (paroxetine, sertraline, escitalopram, venlafaxine). Performance-only: propranolol 20-40mg 1h before. BZD PRN with caution. Phenelzine effective but dietary restrictions.

DSM-5: Marked fear/anxiety about a specific object/situation (flying, heights, animals, injections, blood). Subtypes: animal, natural environment, blood-injection-injury (vasovagal fainting), situational. Treatment: Exposure therapy (systematic desensitization). Blood-injection-injury: applied tension technique. BZD PRN if needed.

DSM-5: Obsessions (recurrent intrusive thoughts/urges/images) + Compulsions (repetitive behaviors/mental acts in response to obsessions). Time-consuming (>1h/day) or cause distress. Insight specifier (good/fair, poor, absent/delusional). Tic-related specifier. Common themes: Contamination/washing, Checking, Symmetry/ordering, Forbidden/taboo thoughts. Treatment: ERP (Exposure and Response Prevention) — gold-standard. High-dose SSRIs (fluoxetine 60-80mg, fluvoxamine 200-300mg, sertraline 200mg). Clomipramine (TCA, effective but SE-prone). Augmentation: atypical antipsychotic (risperidone, aripiprazole). DBS for severe refractory. Body Dysmorphic Disorder: Preoccupation with perceived defect/flaw. Repetitive behaviors (mirror checking, comparing, skin picking). High suicide risk. Treatment: SSRI (high dose), CBT. No cosmetic procedures. Hoarding Disorder: Difficulty discarding possessions, clutter compromises living space. CBT (cognitive restructuring, graded exposure to discarding). SSRI for comorbid conditions.

PTSD (DSM-5): Exposure to trauma (death/injury/sexual violence). Criterion B (Intrusion): memories, nightmares, flashbacks, reactivity. Criterion C (Avoidance): reminders. Criterion D (Negative cognition/mood): negative beliefs, blame, detachment, ↓ positive emotions. Criterion E (Arousal): irritability, recklessness, hypervigilance, startle, sleep/concentration. Duration >1mo. Specify with dissociative symptoms (depersonalization, derealization) or delayed expression. Acute Stress Disorder: Same clusters but 3d-1mo, emphasis on dissociation. Treatment — Pharmacotherapy: SSRIs/SNRIs (sertraline, paroxetine, fluoxetine, venlafaxine). Prazosin (α1 antagonist) for nightmares. Atypical antipsychotics for refractory. BZDs NOT recommended (may worsen recovery). Psychotherapy: Trauma-focused CBT, EMDR, Prolonged Exposure, Cognitive Processing Therapy. Prevention: CISD (critical incident stress debriefing) is NOT effective. Prognosis: Chronic in ~30-40%. Spontaneous recovery ~50%.

≥2 of 5 symptoms for ≥1mo (at least 1 must be 1, 2, or 3): (1) Delusions (persecutory, grandiose, referential, somatic, erotomanic, bizarre). (2) Hallucinations (auditory most common). (3) Disorganized speech (derailment, tangentiality, word salad). (4) Grossly disorganized/catatonic behavior (agitation, bizarre dress, posturing, waxy flexibility, echolalia). (5) Negative symptoms (affective flattening, alogia, avolition, anhedonia, asociality). Continuous signs for ≥6mo. Rule out schizoaffective, mood disorder with psychosis, substance/medical condition. Subtypes (historic): Paranoid, Disorganized/Hebephrenic, Catatonic, Undifferentiated, Residual. Etiology: DA hypothesis (mesolimbic ↑ = positive, mesocortical ↓ = negative/cognitive). Glutamate hypothesis (NMDA hypofunction). Genetic (heritability ~80%). Environmental: urbanicity, migration, cannabis (high-THC in adolescence), childhood adversity. Course: Prodromal → First episode (late teens-20s) → Progressive. Poor prognosis: insidious onset, family history, negative symptoms, longer DUP.

DSM-5: ≥3 of: stupor, catalepsy (waxy flexibility), mutism, negativism, posturing, mannerisms, stereotypies, agitation, grimacing, echolalia, echopraxia. Occurs in schizophrenia, mood disorders, medical/neurological conditions, NMS. Treatment: BZD challenge (lorazepam 1-2mg IV/IM/PO — often dramatic). ECT (definitive, especially if BZD fails). Malignant catatonia (autonomic + fever + ↑ CK) → urgent ECT. Rule out NMS.

DSM-5: Uninterrupted illness with psychotic symptoms + major mood episode (depressive or manic). Delusions/hallucinations present for ≥2wk WITHOUT mood episode. Mood symptoms present for majority of total illness. Depressive vs Bipolar type. Treatment: Antipsychotic + mood stabilizer ± antidepressant. SGA (paliperidone FDA-approved). Prognosis intermediate between schizophrenia and bipolar.

DSM-5: ≥1mo of ≥1 non-bizarre delusion (plausible situations: followed, poisoned, loved, deceived). No prominent hallucinations/disorganized behavior/negative symptoms. Functioning not markedly impaired. Subtypes: Erotomanic, Grandiose, Jealous, Persecutory (most common), Somatic. Treatment: Antipsychotics (LAI may help). Non-confrontational approach. Prognosis: ~50% full recovery.

Choice: SGA first-line for first-episode. Olanzapine = most effective but worst metabolic. Aripiprazole = partial agonist, low metabolic, akathisia. Risperidone = dose-related EPS (>/=6mg). Quetiapine = sedating, lower efficacy. Ziprasidone = low metabolic, QTc. Lurasidone = low metabolic/EPS, take with food. Cariprazine = good for negative symptoms. Treatment-resistant: Clozapine (after ≥2 failed adequate trials). LAIs: For non-adherence (most common cause of relapse). Monitoring: Weight/BMI, glucose/HbA1c, lipids, prolactin, QTc, EPS (AIMS for TD). Metabolic syndrome: Olanzapine/clozapine > quetiapine/risperidone > aripiprazole/ziprasidone/lurasidone. Metformin ± lifestyle. Tardive Dyskinesia: Clozapine or VMAT2 inhibitors (valbenazine, deutetrabenazine). Hyperprolactinemia: Risperidone/paliperidone highest. Switch to aripiprazole or add aripiprazole.

DSM-5: Enduring pattern deviating markedly from cultural expectations, pervasive and inflexible, onset in adolescence/early adulthood, stable over time, leading to distress/impairment. Manifested in ≥2: cognition, affectivity, interpersonal functioning, impulse control. AMPD (Section III): Criterion A — impairment in self-functioning (identity, self-direction) and interpersonal functioning (empathy, intimacy). Criterion B — pathological traits (negative affectivity, detachment, antagonism, disinhibition, psychoticism).

Paranoid PD: Pervasive distrust/suspiciousness of others’ motives. Bears grudges, reads hidden meanings, reluctant to confide, perceives attacks. Schizoid PD: Pervasive detachment from social relationships + restricted emotional expression. Neither desires nor enjoys relationships, solitary activities, emotional coldness, apathy. Schizotypal PD: Social/interpersonal deficits + cognitive/perceptual distortions + eccentric behavior. Ideas of reference, odd beliefs/magical thinking, unusual perceptions, odd speech, inappropriate affect, eccentric appearance. Related to schizophrenia spectrum. Treatment: antipsychotics (low dose) for cognitive/perceptual symptoms. Social skills training. Prognosis: stable, low functioning.

Antisocial PD (ASPD): Pervasive disregard for others’ rights since age 15. ≥3: criminal acts, deceitfulness, impulsivity, irritability/aggressiveness, reckless disregard, irresponsibility, lack of remorse. Must be ≥18 + conduct disorder before 15. Psychopathy (PCL-R): Callous-unemotional traits, lack of empathy, grandiosity, manipulation. Borderline PD (BPD): Pervasive instability of relationships, self-image, affect + impulsivity. ≥5: abandonment fears, splitting, identity disturbance, impulsivity, suicidal/self-harm behavior, affective instability, emptiness, anger, paranoid/dissociative. DBT (Dialectical Behavior Therapy): Developed by Linehan for BPD. Skills: mindfulness, distress tolerance (STOP, TIPP), emotion regulation, interpersonal effectiveness (DEAR MAN). Pharmacotherapy: No FDA-approved. SSRIs for comorbid depression, mood stabilizers (lamotrigine, valproate), SGAs (aripiprazole, olanzapine). Avoid BZD. Histrionic PD: Excessive emotionality + attention seeking. Inappropriate seductive behavior, rapidly shifting shallow emotions, self-dramatization, suggestible. Narcissistic PD: Grandiosity, need for admiration, lack of empathy. Sense of entitlement, exploitative, envious, arrogant. Subtypes: Grandiose/overt, Vulnerable/covert. Treatment: Psychodynamic therapy.

Avoidant PD: Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation. Avoids occupational/social activities fearing rejection. Views self as socially inept/inferior. Key distinction from social anxiety: more pervasive, more severe, includes low self-esteem beyond fear of evaluation. Treatment: CBT (social skills training, exposure, cognitive restructuring). SSRIs. Dependent PD: Excessive need to be taken care of + submissive/clinging behavior + fear of separation. Difficulty making decisions, needs others to assume responsibility, difficulty expressing disagreement, uncomfortable when alone. Treatment: psychotherapy (assertiveness training, independence). Obsessive-Compulsive PD (OCPD): Preoccupation with orderliness, perfectionism, control. ≥4: details/rules/lists, perfectionism interfering with task completion, excessive devotion to work, overconscientiousness, hoarding, reluctance to delegate, miserly spending, rigidity. Key distinction from OCD: OCPD is ego-syntonic, no true obsessions/compulsions, not distressing. Treatment: psychodynamic psychotherapy.

≥2 of 11 in 12mo. Severity: Mild (2-3), Moderate (4-5), Severe (≥6). Criteria: (1) Larger amounts/longer periods. (2) Unsuccessful efforts to cut down. (3) Great deal of time spent. (4) Craving. (5) Failure at work/school/home. (6) Social/interpersonal problems. (7) Giving up activities. (8) Hazardous situations. (9) Physical/psychological problem despite use. (10) Tolerance. (11) Withdrawal. Intoxication: Reversible substance-specific syndrome from recent use. Withdrawal: Substance-specific syndrome after cessation of prolonged heavy use.

Screening: AUDIT (≥8 = hazardous). CAGE (≥2 = positive). Single question: “How many times in past year have you had >4 (M) or >3 (F) drinks in a day?” Intoxication: Slurred speech, incoordination, nystagmus, impaired memory, stupor/coma. Blood alcohol >300 = severe risk. Withdrawal: Onset 6-12h (minor: tremor, anxiety, insomnia). 12-24h: hallucinosis. 24-48h: withdrawal seizures (generalized). 48-96h: delirium tremens (DTs) — hallucinations, disorientation, autonomic storm, potentially fatal (mortality 5-15%). CIWA-Ar: 10-item scale. ≥8 = moderate → symptom-triggered BZD. Treatment: BZD (diazepam, chlordiazepoxide, lorazepam). Thiamine 100-500mg IV/IM daily (Wernicke prophylaxis). Wernicke-Korsakoff: Wernicke (confusion, ataxia, ophthalmoplegia) → thiamine 500mg IV TID BEFORE glucose. Korsakoff (irreversible anterograde amnesia, confabulation). Abstinence pharmacotherapy: Naltrexone (first-line, 50mg PO/380mg IM q4wk). Acamprosate (666mg TID). Disulfiram (250-500mg, deterrent). Psychosocial: AA/12-step, CBT (relapse prevention), MET, Community Reinforcement.

Intoxication: Euphoria, sedation, respiratory depression, miosis, constipation. Overdose triad: respiratory depression + miosis + unconsciousness. Naloxone: 0.4-2mg IV/IM/IN, may repeat q2-3min. Duration 30-90min (may need infusion). Withdrawal: Onset 6-12h (short-acting) to 24-48h (long-acting). Anxiety, yawning, diaphoresis, piloerection, rhinorrhea, mydriasis, GI cramps, diarrhea, myalgias, fever. Not life-threatening. COWS: 11 items. ≥13 guides buprenorphine initiation. Maintenance: Methadone (full μ-agonist, daily OTP). Buprenorphine/naloxone (partial μ-agonist, office-based). Naltrexone XR (after detox). All reduce mortality >50%. Overdose prevention: Naloxone distribution, fentanyl test strips.

Stimulants (cocaine, amphetamines): Intoxication: euphoria, grandiosity, agitation, tachycardia, HTN, chest pain (MI), seizure, stroke. Withdrawal: “crash” (dysphoria, depression, fatigue, hypersomnia, craving). No FDA-approved pharmacotherapy. CBT + contingency management. Cannabis: Intoxication: euphoria, relaxation, impaired coordination, conjunctival injection, ↑ appetite. Withdrawal: irritability, anxiety, insomnia, ↓ appetite, craving. Cannabis hyperemesis syndrome (cyclic vomiting + hot baths). Treatment: CBT, MI. No FDA-approved meds. Dronabinol off-label for withdrawal. Sedative/BZD: Withdrawal can be fatal (seizures, delirium). Taper with long-acting BZD over weeks-months. Adjunctive anticonvulsants (carbamazepine, valproate, gabapentin). Avoid flumazenil. Tobacco: Varenicline (best quit rate). NRT (patch + short-acting combination > single). Bupropion. Combination pharmacotherapy + counseling most effective.

DSM-5: Persistent recurrent problematic gambling. ≥4 of: needs to gamble with ↑ money, withdrawal-like irritability, unsuccessful control, preoccupation, gambles when distressed, chases losses, lies, jeopardized relationship/employment, relies on bailout. Treatment: CBT, MI, Gamblers Anonymous. Naltrexone/nalmefene (↓ craving). SSRI for comorbid anxiety/depression.

DSM-5: Persistent inattention and/or hyperactivity-impulsivity interfering with functioning/development. Onset <12yr. ≥6 symptoms (≥5 if ≥17yr) in one domain. Inattentive: fails attention, difficulty sustaining, does not listen, does not follow through, disorganized, avoids sustained mental effort, loses things, easily distracted, forgetful. Hyperactive-Impulsive: fidgets, leaves seat, runs/climbs, unable to play quietly, “on the go”, talks excessively, blurts, difficulty waiting, interrupts. Presentations: Combined, Inattentive, Hyperactive-Impulsive. Etiology: Genetic (heritability ~75%), ↓ DA/NE in PFC, delayed cortical maturation. Comorbidities: ODD (50%), conduct disorder (25%), anxiety, depression, learning disorders, ASD, tics. Treatment: Stimulants first-line (MPH, amphetamine derivatives). Non-stimulants: Atomoxetine (SNRI), Guanfacine XR (α2A), Clonidine ER. Psychosocial: Parent training, school accommodations (504/IEP), behavioral therapy. Adult ADHD: Same criteria ≥5 symptoms. Stimulants effective. ~30-50% persist.

DSM-5: Persistent social communication/interaction deficits + restricted/repetitive patterns/behaviors/interests. Onset early developmental. Severity: Level 1 (support), Level 2 (substantial), Level 3 (very substantial). Social deficits: Social-emotional reciprocity, nonverbal communication, relationships. Restricted/repetitive: Stereotypies, insistence on sameness, restricted interests, sensory hyper/hyporeactivity. Etiology: Genetic (heritability ~80%, CHD8, SHANK3, CNVs). Screening: M-CHAT 18-24mo. Treatment: ABA (Applied Behavior Analysis). Speech/OT. Social skills training. Pharmacotherapy: Risperidone and aripiprazole FDA-approved for irritability/agitation. SSRIs for comorbid anxiety/OCD. Stimulants for ADHD (less effective/more SE). Melatonin for sleep. Prognosis: variable; early intensive intervention improves outcomes.

Intellectual Disability: Deficits in intellectual functions (IQ ≈ ≤70) + adaptive functioning deficits. Onset developmental. Severity: Mild (IQ 50-70, ~85%), Moderate (35-49), Severe (20-34), Profound (<20). Specific Learning Disorder: Dyslexia (reading, phonological processing), Dyscalculia (math), Dysgraphia (writing). Academic skills substantially below age/IQ. Tourette’s Disorder: Multiple motor + ≥1 vocal tic for >1yr. Onset <18. Premonitory urge. Comorbid ADHD, OCD. Treatment: CBIT (Comprehensive Behavioral Intervention for Tics). Pharmacotherapy: α2 agonists (guanfacine, clonidine) first-line. Antipsychotics (haloperidol, pimozide, aripiprazole) for severe. Persistent (Chronic) Motor/Vocal Tic Disorder: Single type (motor or vocal) for >1yr.

Child/Adolescent MDD: Similar DSM-5 criteria. Irritability may be prominent (especially in children). Psychotherapy (CBT, IPT-A) first-line for mild-moderate. Fluoxetine and escitalopram FDA-approved for adolescents. Black box warning: increased suicidal ideation (monitor closely first 4-8wk). Separation Anxiety Disorder: Developmentally inappropriate excessive fear/anxiety about separation. ≥3: distress when anticipating/experiencing separation, worry about losing attachment figures, worry about calamity, reluctance to go to school/elsewhere, fear of being alone, reluctance to sleep away, nightmares, physical symptoms. School Refusal: Differentiate from truancy (child stays home with parent knowledge, anxiety-driven). Assessment: triggers (academic, social, family), comorbid anxiety/depression. Treatment: CBT (gradual exposure, cognitive restructuring, parent training), SSRI if comorbid anxiety/depression. Multidisciplinary approach (school, family, therapist). Oppositional Defiant Disorder (ODD): Pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness for ≥6mo. ≥4 from any category. Conduct Disorder (CD): Repetitive persistent pattern violating rights of others or social norms. ≥3 in 12mo from: aggression to people/animals, destruction of property, deceitfulness/theft, serious rule violations. Childhood-onset vs adolescent-onset. Precursor to ASPD.

DSM-5: Disturbance in attention and awareness, acute onset (hours-days), fluctuation over course, additional cognitive disturbance (memory, orientation, language, perception). Not better explained by dementia or preexisting neurocognitive disorder. Evidence from history/physical that it is direct physiological consequence of medical condition, substance intoxication/withdrawal, toxin, or multiple etiologies. Hyperactive: agitated, hypervigilant, hallucinating. Hypoactive: lethargic, withdrawn, decreased motor activity (often missed). CAM (Confusion Assessment Method): (1) Acute onset + fluctuating course, (2) Inattention, AND (3) Disorganized thinking OR (4) Altered level of consciousness. I WATCH DEATH mnemonic: Infectious, Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia, Deficiencies (B12, thiamine), Endocrinopathies, Acute vascular, Toxins/drugs, Heavy metals. Treatment: Identify and treat underlying cause. Environmental measures (reorientation, family presence, minimize room changes, sleep hygiene, glasses/hearing aids). Pharmacotherapy: High-potency antipsychotic (haloperidol 0.5-10mg PO/IM/IV) for agitation/psychosis. Atypical (olanzapine, quetiapine, risperidone) as alternatives. Avoid BZDs (except for alcohol/BZD withdrawal delirium). Avoid anticholinergics. Prevention: HELP (Hospital Elder Life Program) — multicomponent non-pharmacologic. Antipsychotics not recommended for prevention. Prognosis: often reversible; associated with increased mortality, LOS, cognitive decline.

DSM-5 Major NCD: Significant cognitive decline from previous level in ≥1 domain (complex attention, executive function, learning/memory, language, perceptual-motor, social cognition). Interferes with independence. Not exclusively during delirium. Alzheimer’s Disease: Most common (~60-80%). Insidious onset, gradual progression. Memory impairment (especially recent). Aphasia, apraxia, agnosia, executive dysfunction. Brain: amyloid plaques, neurofibrillary tangles (tau), cortical atrophy (hippocampus early). Treatment: Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) — modest benefit. Memantine for moderate-severe. Frontotemporal Dementia (FTD): Behavioral variant (personality change, disinhibition, apathy, loss of empathy, hyperorality, perseverative behaviors) — Pick’s bodies (tau). Primary progressive aphasia. Onset earlier (50-60s). No approved pharmacotherapy. Lewy Body Dementia: Fluctuating cognition, visual hallucinations, Parkinsonism, REM sleep behavior disorder, neuroleptic sensitivity (avoid antipsychotics; severe reactions). Treatment: Cholinesterase inhibitors. Vascular Dementia: Stepwise progression, focal neurological signs, CV risk factors. Treatment: BP control, antiplatelets, risk factor management. Normal Pressure Hydrocephalus (NPH): Triad: gait apraxia (magnetic gait), urinary incontinence, dementia. Communicating hydrocephalus. Treatment: VP shunt. Pseudodementia (depression): Cognitive deficits due to depression in elderly. Differentiate: depressed mood, rapid onset, patient complains of deficits (vs Alzheimer’s patient minimizes), inconsistent performance. Treat depression → cognition improves.

Malingering: Intentional fabrication of physical/psychological symptoms for external incentive (avoid work, financial compensation, obtain drugs, avoid legal consequences). No psychiatric diagnosis. High suspicion if: medicolegal context, discrepancy between claimed disability and objective findings, lack of cooperation, antisocial PD, “worst-case” presentation, demands for specific meds. Factitious Disorder (Munchausen): Intentional feigning of symptoms to assume sick role (internal incentive). No external incentive. Factitious disorder imposed on self (patient fakes illness) vs imposed on another (caregiver fakes in dependant — Munchausen by proxy). Treatment: avoid confrontation, therapeutic alliance, coordinate across providers. Factitious disorder imposed on another: Child protective services mandatory report. Somatic Symptom Disorder: One or more distressing/disruptive somatic symptoms + excessive thoughts/feelings/behaviors about health (disproportionate and persistent). ≥6mo. Specifier: with predominant pain. Treatment: CBT (reduce catastrophizing, improve function, reduce healthcare utilization), regular follow-up with PCP, avoid unnecessary tests/procedures, SSRI for comorbid depression/anxiety. Conversion Disorder (Functional Neurological Symptom Disorder): One or more symptoms of altered voluntary motor/sensory function (weakness/paralysis, gait disorder, pseudoseizures, tremor, dystonia, sensory loss, blindness, aphonia, globus). Incompatibility between symptom and recognized neurological/medical condition (positive sign: Hoover sign, give-way weakness, non-anatomic sensory loss, la belle indifférence). Not feigned. Treatment: PT/OT, CBT, explain diagnosis positively (“real symptoms, no structural damage, brain-misfiring, treatable”). Illness Anxiety Disorder (Hypochondriasis): Preoccupation with having/acquiring serious illness despite no/only mild somatic symptoms. High health anxiety, frequent checking/reassurance seeking, or maladaptive avoidance. Psychological factors affecting medical conditions: Psychological/behavioral factors adversely affect medical condition (e.g., anxiety triggering asthma, depression ↓ adherence, stress → IBS).

Capacity vs Competence: Capacity = clinical assessment by physician (decision-specific, can fluctuate). Competence = legal determination by judge. MacKay Criteria (4 elements of capacity): (1) Communicate a choice (consistent, stable). (2) Understand relevant information (diagnosis, risks/benefits of treatment/alternatives/no treatment). (3) Appreciate situation and consequences (apply info to own condition). (4) Reason about treatment options (logical process, weigh risks/benefits). Capacity is decision-specific — a patient may have capacity for low-risk high-benefit decisions but not for high-risk decisions. Informed Consent: Must include: nature of procedure, risks, benefits, alternatives (including no treatment). Exceptions: emergency (implied consent), patient waiver, therapeutic privilege (withholding info if harmful to patient — rarely used, controversial). HIPAA: Privacy of protected health information. Involuntary Hospitalization (Civil Commitment): Criteria (state-dependent, generally): (1) Mental illness, (2) Danger to self (suicidal, grave disability — unable to provide for basic needs), or (3) Danger to others (violent/threats). Emergency hold typically 48-72h for evaluation. Court order for extended commitment. Duty to Protect (Tarasoff): Duty to protect identifiable third party from serious threat of harm by patient. Steps: assess threat, warn potential victim, notify police, hospitalize. Applies when therapist determines or reasonably should determine patient presents serious danger of violence to identifiable victim. Mandated reporting: Child abuse/neglect (all states), elder abuse (most states), duty to protect (Tarasoff), impaired physician reporting (varies). Not privileged (report suspected abuse even if patient disclosed in confidence). Right to Refuse Treatment: Competent patients have right to refuse treatment (including psychotropics, ECT). Exceptions: emergency (imminent danger), court-ordered treatment (involuntary meds after hearing), incompetence (surrogate decision-maker). Advanced Directives: Living will, durable power of attorney for healthcare. Psychiatric advance directives (PAD) in some states.

Roots in Freudian theory. Focus on unconscious conflicts, defense mechanisms, transference (patient projects feelings onto therapist), countertransference (therapist’s emotional response to patient), resistance (unconscious avoidance of painful material), and interpretation (of dreams, free associations, parapraxes/Freudian slips). Brief psychodynamic therapy (IPT-adapted or supportive-expressive): Time-limited (12-24 sessions), focus on core conflictual relationship theme (CCRT). Key concepts: Unconscious processes shape behavior. Early attachment patterns replay in current relationships (including with therapist). Therapeutic relationship is vehicle for change. Making unconscious conscious → insight → symptom relief. Techniques: Free association, dream analysis, confrontation, clarification, interpretation, working through. Contrast CBT: Psychodynamic focuses on past + unconscious + insight; CBT focuses on present + conscious thoughts + behavior change. Evidence: Effective for depression, personality disorders (especially BPD, Cluster C), anxiety, chronic medical illness.

Developed by Beck (1960s). Based on cognitive model: thoughts → emotions → behaviors. Negative Cognitive Triad (Depression): Negative view of self, world, future. Cognitive Distortions: All-or-nothing thinking, catastrophizing (assuming worst), overgeneralization (single negative → universal), mental filtering (focus on negatives only), disqualifying positives, jumping to conclusions (mind reading, fortune telling), magnification/minimization, emotional reasoning, personalization, should statements, labeling. ABC Model (Ellis REBT): Activating event → Belief (rational or irrational) → Consequence (emotional/behavioral). Replace irrational beliefs with rational ones. Techniques: Cognitive restructuring (identify, challenge, replace distorted thoughts), behavioral activation (schedule pleasant activities), exposure therapy (gradual confrontation of feared stimuli), Socratic questioning (guided discovery), thought records, behavioral experiments, homework assignments, activity scheduling, graded task assignments. Indications: MDD (first-line), GAD, panic disorder, social anxiety, OCD, PTSD, bulimia, insomnia (CBT-I), chronic pain. Structure of session: Brief check-in, agenda setting, bridge from last session, homework review, session topic, new homework, summary/feedback. Evidence: Gold-standard psychotherapy. Equivalent or superior to medication for mild-moderate MDD. Durable effects (relapse prevention).

Developed by Linehan (1993) for BPD. Dialectic: balance between acceptance (validation) and change (problem-solving). Core dialectic: patient is doing the best they can AND need to change. Components: (1) Individual therapy — one session/week, prioritize target hierarchy (life-threatening → therapy-interfering → quality-of-life interfering). (2) Group skills training — 4 modules: Mindfulness (core, observe/describe/participate non-judgmentally), Interpersonal Effectiveness (DEAR MAN, GIVE, FAST), Emotion Regulation (identify/change emotions), Distress Tolerance (STOP, TIPP, self-soothe, pros/cons, radical acceptance). (3) Phone coaching — between-session skill generalization. (4) Therapist consultation team — therapist support. Indications: BPD (multiple RCTs), suicidal behavior, self-harm, substance use + BPD, binge eating. Evidence: ↓ suicide attempts, ↓ self-harm, ↓ hospitalizations, ↓ dropout vs treatment-as-usual.

Developed by Klerman & Weissman. Time-limited (12-16 sessions). Focus on current interpersonal problems → depressive symptoms. Four problem areas: (1) Grief (uncomplicated vs complicated — restore interest after loss). (2) Role disputes (conflicts with significant other — renegotiate expectations). (3) Role transitions (life changes — manage loss of old role, develop new skills). (4) Interpersonal deficits (social isolation, chronic loneliness — improve communication skills). Techniques: Communication analysis, clarification, role-playing, decision analysis. Indications: MDD (equivalent to CBT + medication), bulimia, binge eating, peripartum depression, adolescent depression (IPT-A). Structure: Initial phase (interpersonal inventory), middle phase (focus on problem area), termination phase (consolidate gains, prevent relapse).

Developed by Hayes. Third-wave CBT. Goal: psychological flexibility — accept internal experiences (thoughts, feelings) while committing to value-driven behavior. Six core processes (Hexaflex): (1) Acceptance (embrace unwanted private experiences without avoidance). (2) Cognitive defusion (observe thoughts without buying into them — “I am having the thought that I am worthless” vs “I am worthless”). (3) Present moment awareness (mindfulness). (4) Self-as-context (observe experience without identifying). (5) Values (clarify what matters). (6) Committed action (set goals aligned with values). Indications: Chronic pain, anxiety disorders, depression, psychosis, substance use disorders. Contrast CBT: ACT does not challenge content of thoughts (CBT does); instead changes relationship to thoughts.

Developed by Miller & Rollnick. Client-centered, directive style for resolving ambivalence about behavior change (substance use, medication adherence, health behaviors). Spirit of MI: Collaboration, Evocation, Autonomy. OARS skills: Open-ended questions, Affirmations, Reflective listening, Summarizing. Four processes: Engaging, Focusing, Evoking, Planning. Change Talk (DARN-CAT): Desire, Ability, Reasons, Need (preparatory) → Commitment, Activation, Taking steps (mobilizing). Sustain talk / Resistance: Roll with resistance, do not argue. Stages of Change (Prochaska & DiClemente): Precontemplation (no intention), Contemplation (ambivalent, thinking about change), Preparation (intending to act soon), Action (modifying behavior), Maintenance (sustaining change), Relapse (resumption of old behavior — not failure, part of process). Match intervention to stage. Indications: Substance use disorders, medication adherence, weight loss, smoking cessation, HIV risk reduction.

Exposure Therapy: Core CBT technique for anxiety disorders. Systematic confrontation with feared stimuli (in vivo, imaginal, interoceptive) without avoidance. Extinction learning: new safety learning competes with fear memory. Habituation → fear reduction. Types: Graded exposure (hierarchy from least to most feared), flooding (intense exposure), systematic desensitization (exposure + relaxation), prolonged exposure (for PTSD: imaginal + in vivo), exposure and response prevention (ERP for OCD). Mechanism: Inhibitory learning theory — new learning of safety (not erasure of fear). EMDR (Eye Movement Desensitization and Reprocessing): Developed by Shapiro for PTSD. Bilateral stimulation (eye movements, tapping, tones) while recalling traumatic memory. Components: history taking, preparation, assessment (target memory, negative/positive cognition, SUD, VOC), desensitization, installation, body scan, closure, re-evaluation. Evidence: EMDR equally effective to trauma-focused CBT for PTSD. Mechanism debated (bilateral stimulation may enhance working memory capacity, reduce vividness of trauma memories). Indications: PTSD (Level A / strong evidence).

Group Therapy: Yalom’s therapeutic factors: universality, altruism, group cohesiveness, interpersonal learning, catharsis, imparting information, corrective recapitulation, imitative behavior, instillation of hope, existential factors. Types: psychoeducational, process-oriented, CBT groups, DBT skills groups, support groups (AA/NA). Family Therapy: Focus on family system dynamics, communication patterns, boundaries, roles. Structural (Minuchin): enmeshment vs disengagement, family mapping, boundary-making. Strategic (Haley): paradoxical interventions, reframing. Systemic (Bowen): differentiation, triangles, multigenerational transmission. Indications: child/adolescent behavioral problems, eating disorders, schizophrenia (psychoeducation reduces relapse), substance use. Couples Therapy: Improve communication, resolve conflict, rebuild intimacy. Gottman method: Sound Relationship House (trust, commitment, conflict management, shared meaning). Emotionally Focused Therapy (EFT, Johnson): attachment-based, repair attachment injuries. Behavioral Couples Therapy: communication/ problem-solving skills training, behavioral exchange. Indications: relationship distress, extramarital affairs, substance use (behavioral couples therapy for alcohol). Supportive Therapy: Non-specific, common-factors approach. Strengthens coping, self-esteem, adaptive defenses. Techniques: active listening, validation, reassurance, advice, environmental interventions. Indications: broad (any patient, especially those too fragile for insight-oriented therapy, acute crisis, chronic severe mental illness). No specific theory of change (relies on common factors: therapeutic alliance, empathy, positive regard).

Autonomy: Respect patient’s right to make their own decisions. Informed consent, right to refuse treatment, confidentiality. Beneficence: Act in patient’s best interest. Provide benefit. Non-maleficence: Do no harm. Minimize risks. Justice: Fair distribution of healthcare resources. Treat similar cases similarly. Informed consent: Disclosure (of diagnosis, treatment, risks/benefits, alternatives), Capacity (to understand and decide), Voluntariness (free from coercion). Confidentiality: Protect patient information (HIPAA). Exceptions: Tarasoff (duty to protect), mandated reporting (child/elder abuse), danger to self, court order. Boundary issues: Dual relationships (should avoid). Sexual relationships with current or former patients strictly prohibited (ethical + legal + licensing violation). Gifts, self-disclosure, touch (clinical context).

MMSE (Mini-Mental State Examination): 30 points. Orientation (10), Registration (3), Attention/Calculation (5), Recall (3), Language (9). Score ≤24 suggestive of dementia. Advantages: standardized, widely used. Disadvantages: education/age/language bias, not sensitive for FTD, ceiling effect for MCI. MoCA (Montreal Cognitive Assessment): 30 points. More sensitive for MCI and vascular/executive dysfunction. Executive/visuospatial (5), Animal naming (3), Attention (6), Language (3), Abstraction (2), Delayed recall (5), Orientation (6). Cutoff <26. Adds: trail-making, clock-drawing, cube copy, phonemic fluency, abstraction. Mini-Cog: Clock-drawing + 3-item recall. Quick (3-5min). Score: recall 0/3 = dementia likely; 1-2/3 + abnormal clock = dementia likely. Other: SLUMS (St. Louis University Mental Status). Neuropsychological testing (comprehensive: IQ, attention, executive, memory, language, visuospatial). Indications: dementia diagnosis, capacity evaluation, pre-surgical, TBI.

HAM-D (Hamilton Depression Rating Scale): 17-21 item, clinician-rated. ≥24 = severe. Historical gold standard for depression trials. MADRS (Montgomery-Asberg Depression Rating Scale): 10-item, clinician-rated, more sensitive to change. PHQ-9: 9-item patient self-report (DSM-5 matched). HAM-A (Hamilton Anxiety Rating Scale): 14-item, clinician-rated. Somatic + psychic anxiety. Y-BOCS (Yale-Brown Obsessive Compulsive Scale): 10-item severity scale (obsessions + compulsions subscales). Clinician-rated. Gold standard for OCD trials. PANSS (Positive and Negative Syndrome Scale): 30-item, clinician-rated for schizophrenia (positive + negative + general psychopathology). Gold standard for psychosis trials. YMRS (Young Mania Rating Scale): 11-item, clinician-rated for mania. CGI (Clinical Global Impression): Severity + Improvement scales. AIMS (Abnormal Involuntary Movement Scale): 12-item for TD assessment. CIWA-Ar: 10-item alcohol withdrawal. COWS: 11-item opioid withdrawal. C-SSRS (Columbia-Suicide Severity Rating Scale): Structured assessment of suicidal ideation + behavior (wish to die, non-specific thoughts, method/intent/plan, preparatory behavior, aborted/interrupted attempt, actual attempt). Gold standard for suicide assessment. SAD PERSONS: Sex (M), Age (<20 or >45), Depression, Previous attempt, Ethanol abuse, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness. Score ≥6 = high risk → hospitalize. ≥2 = consider admission. Less validated than C-SSRS.

High Adaptive (Mature): Altruism (constructive service to others), Sublimation (redirect unacceptable impulses into socially acceptable), Suppression (voluntary postponement), Humour, Anticipation, Self-assertion, Self-observation. Mental Inhibitions (Neurotic): Repression (unconscious forgetting), Displacement (transfer feelings to safer target), Isolation (separate affect from idea), Intellectualization (abstract reasoning to avoid emotion), Reaction formation (opposite behavior/attitude), Rationalization (logical explanation for irrational), Dissociation (temporary altered identity/awareness to avoid distress), Undoing (ritual to counteract). Major Image Distorting (Narcissistic): Omnipotence (grandiose self-image), Idealization/devaluation (attributing exaggerated positive/negative qualities), Splitting (all-good/all-bad, no integration). Disavowal (Immature): Denial (refusal to acknowledge reality), Projection (attributing own feelings to others), Rationalization, Fantasy. Action Level (Immature): Acting out (direct behavior expressing unconscious impulse), Apathetic withdrawal, Passive aggression, Help-rejecting complaining. Level of Defensive Dysregulation (Psychotic): Delusional projection, Psychotic denial, Distortion. Key associations: Projection = paranoia / paranoid PD. Splitting = BPD. Intellectualization = OCD/OCPD. Sublimation = mature adaptive. Denial = substance use. Acting out = conduct disorder / antisocial.

Prevalence: Total cases in population at a given time (point = at one point; period = over period; lifetime = ever). Incidence: New cases in a time period. Prevalence = Incidence × Duration. Relative Risk (RR): Incidence in exposed / incidence in unexposed. Odds Ratio (OR): Odds of exposure in cases / odds in controls. Approximates RR for rare diseases. Number Needed to Treat (NNT): 1 / Absolute Risk Reduction. Number Needed to Harm (NNH): 1 / Attributable Risk. Absolute Risk Reduction (ARR): Control event rate − treatment event rate. Sensitivity: Probability test positive if disease present (TP / [TP + FN]). Specificity: Probability test negative if disease absent (TN / [TN + FP]). SnOUT (high sensitivity → negative test rules out). SpIN (high specificity → positive test rules in). Positive Predictive Value (PPV): Probability disease if test positive (depends on prevalence). Negative Predictive Value (NPV): Probability no disease if test negative. Likelihood Ratio (LR+): sens/(1-spec). Large LR+ → strong rule-in. Intention-to-Treat (ITT): Analyze all randomized patients regardless of adherence (preserves randomization, real-world effect). Per Protocol: Analyze only those who completed treatment (potential bias). Confidence Interval (CI): 95% CI = range that includes true value with 95% confidence. CI including 1.0 for RR/OR = not statistically significant. P-value: Probability of observing result (or more extreme) if null hypothesis true. P < 0.05 = conventionally significant. Effect size: Cohen’s d (standardized mean difference). 0.2 = small, 0.5 = medium, 0.8 = large. Reliability: Test-retest, inter-rater, internal consistency (Cronbach’s α). Validity: Content, criterion (concurrent, predictive), construct. Confounders: Variable associated with both exposure and outcome (masks true association). Bias: Selection bias, information bias, recall bias, observer bias, publication bias, lead-time bias, length-time bias (screening studies). RCT: Gold standard for treatment efficacy. Systematic review/Meta-analysis: Highest level of evidence.

Psychiatry is one of the highest-yield subjects for USMLE, MBBS, and psychiatry board exams. Master these core topics in order: (1) DSM-5 criteria — know the diagnostic criteria for every major disorder (MDD, mania, schizophrenia, GAD, panic, PTSD, OCD, BPD, substance use). (2) Psychopharmacology — know mechanisms, side effects, dosing, interactions for every major drug class. (3) Psychotherapy modalities — which therapy for which disorder is a must-know. (4) Child & adolescent — ADHD, autism, and developmental milestones. (5) C-L/forensic — capacity, delirium vs dementia, Tarasoff. Use the cheat cards above for rapid recall before exams.

Depressed mood: Rule out medical (thyroid, B12, anemia, sleep apnea, substances). Screen for bipolar. Assess suicide risk (C-SSRS). Mania: Rule out substances, medical (hyperthyroid, Cushing’s, CNS lesion). Check thyroid, Utox. Psychosis: Rule out delirium, dementia, medical (autoimmune encephalitis, Wilson’s, metachromatic leukodystrophy, TB, HIV, syphilis, B12), substances (PCP, stimulants, cannabis), mood disorder with psychosis. Anxiety: Rule out medical (hyperthyroid, pheochromocytoma, caffeine, OSA, arrhythmia, asthma, COPD). Child with learning difficulty: Screen vision/hearing, ADHD, learning disorder, ID, ASD, anxiety/depression, sleep, lead, seizures. Memory loss in elderly: Pseudodementia vs dementia (Alzheimer’s, FTD, LBD, vascular) vs delirium vs NPH. Check B12, TSH, RPR, neuroimaging. MoCA > MMSE for MCI.