Arab Board Psychiatry Part 1 cheat sheet

Dopamine pathways: mesolimbic (reward/positive symptoms), mesocortical (negative/cognitive symptoms), nigrostriatal (EPS), tuberoinfundibular (prolactin inhibition).

Serotonin: 5-HT1A autoreceptor agonism reduces firing; 5-HT2A blockade underlies atypical antipsychotic action and reduced EPS; 5-HT3 antagonism is antiemetic.

Norepinephrine: locus coeruleus is the principal source; alpha-2 autoreceptor agonism (clonidine, dexmedetomidine) reduces central noradrenergic outflow.

GABA-A receptor is a ligand-gated chloride channel; benzodiazepines increase frequency of channel opening, barbiturates increase duration; flumazenil antagonises the benzodiazepine site.

NMDA receptor hypofunction (ketamine model) reproduces positive, negative and cognitive symptoms; glycine/D-serine are co-agonists at the glycine site.

Huntington disease: CAG trinucleotide repeat expansion in HTT on chromosome 4; anticipation occurs with paternal transmission.

Cytochrome P450: CYP2D6 and CYP3A4 metabolise most psychotropics; CYP2D6 poor metabolisers have higher antipsychotic and TCA levels; smoking induces CYP1A2 (reduces clozapine/olanzapine levels).

Lithium is eliminated renally and is not protein bound; NSAIDs, thiazides and ACE inhibitors raise lithium levels by reducing renal clearance.

Thought disorder signs: flight of ideas (mood-linked, pressured), loosening of associations (schizophrenia), circumstantiality (goal retained), tangentiality (goal lost).

First-rank (Schneiderian) symptoms: audible thoughts, voices arguing/discussing, voices commenting on actions, thought insertion, thought withdrawal, thought broadcasting, made feelings/impulses/acts, delusional perception.

Delusion vs overvalued idea: delusion is fixed and held with extraordinary conviction despite contrary evidence; overvalued idea is understandably linked to personality and less rigidly held.

Insight domains: awareness of illness, need for treatment, and attribution of symptoms; poor insight predicts non-adherence and involuntary admission.

ICD-11 replaced the ICD-10 schizophrenia subtypes with a dimensional symptom specifier (positive, negative, depressive, manic, psychomotor, cognitive).

DSM-5-TR requires symptoms for 6 months for schizophrenia (1 month active) and 2 years for schizoaffective disorder, with mood present for the majority of the illness.

Mini-Mental State Examination maximum 30; scores are education- and culture-sensitive, so the Rowland Universal Dementia Assessment Scale is preferred in low-literacy populations.

Mental state examination sequence: appearance/behaviour, speech, mood and affect, thought form and content, perception, cognition, insight, risk.

Delirium: acute onset, fluctuating course, impaired attention; hyperactive, hypoactive and mixed subtypes; hypoactive is most often missed.

Anticholinergic burden, urinary retention, constipation and infection are common reversible precipitants of delirium in older adults.

Delirium tremens occurs 48-96 hours after alcohol cessation; treat with benzodiazepines (chlordiazepoxide or lorazepam), thiamine and fluid/electrolyte correction.

Wernicke encephalopathy triad: ophthalmoplegia/nystagmus, ataxia, confusion; give parenteral thiamine before glucose to prevent precipitation.

Alzheimer disease: medial temporal/hippocampal atrophy, amyloid plaques and tau tangles; donepezil, galantamine and rivastigmine are acetylcholinesterase inhibitors; memantine is an NMDA antagonist.

Frontotemporal dementia presents with early personality change, disinhibition or language impairment with relatively preserved memory and visuospatial function.

Post-ictal psychosis typically follows a lucid interval of hours to days after seizure clustering; interictal psychosis is more chronic and often temporal lobe related.

Chronic subdural haematoma and normal-pressure hydrocephalus (gait apraxia, urinary incontinence, dementia) are reversible causes of cognitive decline.

Schizophrenia lifetime prevalence approximately 0.3-0.7%; incidence higher in males, with earlier onset in males (early 20s) than females (late 20s).

Duration criteria: DSM-5-TR continuous signs for 6 months; ICD-11 requires at least 1 month of core symptoms.

Poor prognostic factors: insidious onset, male sex, early onset, negative symptoms, long untreated psychosis, family history, substance use.

Clozapine is indicated for treatment-resistant schizophrenia (failure of two adequate antipsychotic trials); monitor white cell count weekly for 18 weeks then monthly.

Neurologic malignant syndrome: hyperthermia, rigidity, autonomic instability, raised creatine kinase; stop antipsychotic, cool, dantrolene or bromocriptine.

Delusional disorder: delusions for at least 1 month with functioning otherwise preserved and no prominent hallucinations; subtypes include erotomanic, grandiose, jealous, persecutory, somatic.

Schizoaffective disorder requires delusions or hallucinations for 2 weeks in the absence of mood symptoms, with mood symptoms present for most of the illness.

Brief psychotic disorder lasts 1 day to 1 month with full return to premorbid functioning; postpartum psychosis usually emerges within 2 weeks of delivery.

Major depressive episode: at least 5 of 9 symptoms for 2 weeks, including depressed mood or anhedonia; DSM-5-TR recognises mixed features.

Bipolar I requires at least one manic episode (7 days or hospitalisation); bipolar II requires hypomania (4 days) plus major depression, no mania.

First-line acute mania: lithium, valproate, or an atypical antipsychotic (aripiprazole, risperidone, quetiapine, olanzapine); avoid antidepressants as monotherapy.

Serotonin syndrome: clonus, hyperreflexia, agitation, hyperthermia; caused by serotonergic combinations; treat with cyproheptadine and supportive care.

Panic attack peaks within minutes; agoraphobia is fear of situations where escape is difficult; both respond to CBT and SSRIs.

Obsessive-compulsive disorder: obsessions are intrusive and ego-dystonic, compulsions are repetitive acts to reduce distress; first-line treatment is CBT with exposure and response prevention plus an SSRI.

Post-traumatic stress disorder: re-experiencing, avoidance, negative cognitions/mood, hyperarousal for more than 1 month; first-line psychotherapy is trauma-focused CBT or EMDR.

Generalised anxiety disorder requires excessive worry for 6 months; buspirone and SSRIs/SNRIs are first-line pharmacotherapy; benzodiazepines are short-term only.

Alcohol withdrawal timeline: tremor and anxiety 6-12 hours, seizures 12-48 hours, delirium tremens 48-96 hours.

Alcohol dependence: disulfiram (aversive), acamprosate (anti-craving, needs normal renal function), naltrexone (opioid antagonist, hepatotoxicity risk).

Opioid substitution: methadone (full agonist, QT prolongation) and buprenorphine (partial agonist, ceiling effect, precipitated withdrawal risk).

Opioid overdose: pinpoint pupils, respiratory depression, coma; naloxone is the antidote and may need repeat dosing due to short half-life.

Cannabis-induced psychosis typically resolves within days to weeks; heavy adolescent use increases risk of later schizophrenia.

Stimulant intoxication: tachycardia, hypertension, hyperthermia, agitation, paranoia; treat with benzodiazepines and cooling.

Tobacco cessation first-line: varenicline, bupropion, or nicotine replacement; varenicline is most effective but requires monitoring for neuropsychiatric effects.

DSM-5-TR substance use disorder severity: mild 2-3 criteria, moderate 4-5, severe 6 or more of 11 criteria in 12 months.

Autism spectrum disorder: deficits in social communication plus restricted/repetitive behaviours, onset in early developmental period; male-to-female ratio approximately 4:1.

Attention-deficit/hyperactivity disorder: symptoms before age 12, present in 2 or more settings, for at least 6 months; first-line is behavioural therapy in preschool children and stimulants in older children.

Conduct disorder vs oppositional defiant disorder: ODD is a pattern of angry/irritable mood and defiance for 6 months; conduct disorder involves violation of rights or major rules.

Separation anxiety disorder is the most common childhood anxiety disorder; school refusal may be its presenting feature.

Tourette syndrome: multiple motor plus at least one vocal tic for more than 1 year; commonly comorbid with OCD and ADHD.

Eating disorders: anorexia nervosa has low BMI, fear of weight gain and body image disturbance; bulimia has binge-purge cycles with relatively normal weight.

Selective mutism: consistent failure to speak in specific social situations despite speaking elsewhere, lasting at least 1 month; treat with behavioural therapy and SSRIs.

Childhood depression: SSRIs (fluoxetine first-line) plus CBT; monitor for activation and suicidality in the first weeks.

CBT model: thoughts, feelings and behaviours interact; treatment targets cognitive distortions and behavioural avoidance through Socratic questioning and behavioural experiments.

Psychodynamic therapy focuses on transference, countertransference, defence mechanisms and repetition of early relational patterns.

Dialectical behaviour therapy (Linehan) for borderline personality disorder: individual therapy, skills group, phone coaching and consultation team.

Exposure and response prevention is the psychotherapy of choice for OCD; exposure without response prevention is less effective.

Motivational interviewing: collaborative, evocative, supports autonomy; uses open questions, affirmations, reflections and summaries (OARS).

Systemic/family therapy views symptoms as serving a function within the family system; useful in adolescent anorexia and conduct problems.

Group therapy therapeutic factors (Yalom): universality, instillation of hope, altruism, catharsis, interpersonal learning, cohesiveness.

Psychotherapy efficacy: CBT has the strongest evidence base for anxiety and depression; combined medication plus psychotherapy is superior to either alone in moderate-severe depression.

Suicide risk assessment: ideation, intent, plan, means, previous attempts, protective factors; previous attempt is the strongest single predictor.

Violence risk: static (history, male sex, substance use, personality disorder) plus dynamic (intoxication, agitation, acute psychosis) factors; use least restrictive intervention first.

Neuroleptic malignant syndrome vs serotonin syndrome: NMS has rigidity and bradyreflexia, serotonin syndrome has clonus and hyperreflexia.

Acute dystonia: treat with anticholinergics (benztropine, procyclidine) or diphenhydramine; oculogyric crisis is a variant.

Delirium in the medically ill is the most common reason for psychiatric consultation in general hospitals; assess for hypoxia, sepsis, metabolic and drug causes.

Capacity assessment (four abilities): understand, retain, weigh and communicate a decision; capacity is decision-specific.

Serotonin syndrome and NMS both require stopping the offending agent; NMS additionally needs cooling, hydration, dantrolene or bromocriptine.

Postpartum psychosis is a psychiatric emergency with high suicide and infanticide risk; requires inpatient care, often with the infant, and antipsychotics or lithium.

Fitness to stand trial: ability to understand the charges, instruct counsel and follow proceedings; distinct from criminal responsibility.

M'Naghten rule: not guilty by reason of insanity if a defect of reason from disease of mind meant the defendant did not know the nature/quality of the act or that it was wrong.

Confidentiality limits: risk of serious harm to self or others, court order, statutory reporting (child abuse, communicable disease), and public safety.

Informed consent requires capacity, adequate information and voluntariness; refusal by a capacitous patient must be respected even if life-threatening.

Duty to warn/protect third parties (Tarasoff principle) applies where a patient makes a serious threat to an identifiable person.

Ethical principles: autonomy, beneficence, non-maleficence, justice; in psychiatry autonomy is balanced against paternalism when capacity is impaired.

Fitness to plead and insanity are legal tests, not clinical diagnoses; the psychiatrist provides evidence, the court decides.

Restraint and seclusion must be proportionate, time-limited, documented and used only to prevent imminent harm.

Assertive community treatment: multidisciplinary team, low caseload, 24-hour availability, reduces hospitalisation in severe mental illness.

Case management models: broker, clinical and assertive; assertive is most effective for high-utilisation patients.

Stigma reduction: education, contact with people with lived experience and protest; contact is the most effective strategy.

Cultural formulation (DSM-5-TR Cultural Formulation Interview) explores cultural identity, explanations of illness, stressors and supports, and clinician-patient relationship.

Deinstitutionalisation shifted care to community settings; consequences include transinstitutionalisation into prisons and homelessness.

Social determinants of mental health: poverty, unemployment, housing instability, social isolation, discrimination and armed conflict.

Involuntary admission criteria typically require mental disorder, risk to self/others or deterioration, and least restrictive alternative; duration is time-limited and reviewable.

Epidemiological measures: incidence is new cases per population per time; prevalence is all cases at a point (point) or over a period.

Sensitivity = true positives / (true positives + false negatives); specificity = true negatives / (true negatives + false positives).

Positive predictive value depends on prevalence; a test with fixed sensitivity and specificity has lower PPV when prevalence is low.

Number needed to treat = 1 / absolute risk reduction; NNT is the reciprocal of the difference in event rates.

Type I error is a false positive (alpha, usually 0.05); type II error is a false negative (beta); power = 1 - beta.

Randomised controlled trials minimise selection bias; blinding reduces performance and detection bias; intention-to-treat analysis preserves randomisation.

Levels of evidence: systematic reviews/meta-analyses of RCTs at the top, then RCTs, cohort, case-control, case series, expert opinion.

Mean is affected by outliers, median is resistant; standard deviation describes spread of normally distributed data; 95% of values lie within 2 SD of the mean.

Odds ratio approximates relative risk when the outcome is rare; for common outcomes the odds ratio overstates the risk ratio.