Arab Board Psychiatry Final Written cheat sheet

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

Serotonin cell bodies in raphe nuclei; SSRIs block SERT, increasing synaptic 5-HT; downregulation of 5-HT2A receptors is linked to antidepressant latency.

Clozapine and olanzapine carry the highest metabolic risk (weight gain, diabetes); risperidone and haloperidol carry higher EPS/prolactin risk.

Lithium is renally excreted; NSAIDs, thiazides, and ACE inhibitors reduce clearance and raise lithium levels.

Cytochrome P450: CYP2D6 and CYP3A4 metabolize most psychotropics; smoking induces CYP1A2 (reduces clozapine and olanzapine levels).

Heritability estimates: schizophrenia ~80%, bipolar disorder ~80-90%, major depression ~30-40%.

Norepinephrine locus coeruleus; cholinergic deficit is associated with Alzheimer disease; GABA is the principal inhibitory transmitter.

Antipsychotic D2 blockade above ~65% occupancy produces EPS; above ~78% raises prolactin.

Delusion = fixed false belief not shared by the patient's culture and held despite contrary evidence.

Hallucination = perception without an external stimulus; illusion = distorted perception of a real stimulus.

Thought insertion, withdrawal, broadcasting, and made feelings/acts are passivity (first-rank) phenomena.

Flight of ideas, pressure of speech, and distractibility suggest mania; loosening of associations suggests schizophrenia.

DSM-5-TR and ICD-11 are the two major systems; ICD-11 replaces ICD-10 with a dimensional approach to personality disorder.

Schneiderian first-rank symptoms are not diagnostic of schizophrenia alone; duration criterion is >=6 months (DSM-5-TR).

Insight is rated on a continuum: complete, partial, absent; poor insight predicts poor adherence.

Depersonalization = feeling detached from self; derealization = feeling the external world is unreal.

MSE components: appearance, behavior, speech, mood/affect, thought process/content, perception, cognition, insight, judgment.

Cognition screening: MMSE or MoCA; MoCA is more sensitive for mild cognitive impairment and executive dysfunction.

Suicide risk assessment covers ideation, intent, plan, means, prior attempts, and protective factors.

Collateral history from family or records is essential when insight or reliability is impaired.

Delirium screen: CAM or 4AT; look for acute onset, fluctuating course, inattention, and altered consciousness.

Capacity (four abilities): communicate a choice, understand information, appreciate consequences, reason.

Substance history should be quantified (AUDIT-C, CAGE) and include withdrawal history and last use.

Mental state exam is cross-sectional; history is longitudinal; both are needed before diagnosis.

Schizophrenia: >=2 core symptoms, >=1 from delusions/hallucinations/disorganized speech, continuous signs >=6 months.

Brief psychotic disorder lasts >1 day and <1 month; schizophreniform is 1-6 months; schizophrenia >=6 months.

Delusional disorder: delusions >=1 month with functioning preserved apart from delusion impact.

Schizoaffective disorder: mood episode concurrent with psychotic symptoms plus >=2 weeks of delusions/hallucinations without mood symptoms.

Clozapine is indicated after >=2 failed antipsychotic trials; monitor FBC weekly for 18 weeks then fortnightly (varies by protocol).

Neuroleptic malignant syndrome: rigidity, hyperthermia, autonomic instability, raised CK; stop antipsychotic and give dantrolene/bromocriptine.

Acute dystonia responds to anticholinergics (procyclidine, benztropine); tardive dyskinesia is treated by reducing or switching the antipsychotic.

First-episode psychosis: start low-dose antipsychotic, monitor metabolic parameters and prolactin.

Major depressive episode: >=5 symptoms for >=2 weeks, including depressed mood or anhedonia.

Manic episode: elevated/irritable mood plus increased energy for >=1 week (or any duration if hospitalized), with marked impairment.

Hypomania: >=4 days, observable change, no marked impairment or psychosis.

Bipolar I requires a manic episode; bipolar II requires hypomania plus major depression and no mania.

Lithium is first-line for maintenance; therapeutic range 0.6-0.8 mmol/L; toxicity signs include tremor, ataxia, vomiting, confusion.

ECT is indicated for severe depression with psychosis, catatonia, refusal of food/fluid, or high suicide risk.

Serotonin syndrome: clonus, hyperreflexia, agitation, hyperthermia; stop serotonergic drugs and use cyproheptadine if severe.

Rapid cycling = >=4 mood episodes in 12 months; more common in women and with antidepressant monotherapy.

Panic attack peaks within minutes; panic disorder requires recurrent unexpected attacks plus >=1 month of worry or behavior change.

Agoraphobia is fear of situations where escape is difficult or help unavailable.

Social anxiety disorder: fear of negative evaluation in social situations, persistent >=6 months.

OCD = obsessions and/or compulsions that are time-consuming (>1 hour/day) or cause distress/impairment.

PTSD requires exposure to trauma plus intrusion, avoidance, negative cognitions/mood, and arousal for >1 month.

Acute stress disorder occurs 3 days to 1 month after trauma; PTSD is diagnosed >1 month after trauma.

First-line pharmacotherapy for most anxiety disorders and OCD is an SSRI; OCD often needs higher doses and 8-12 weeks.

CBT with exposure and response prevention is first-line psychological treatment for OCD.

Tolerance and withdrawal are physiological; DSM-5-TR substance use disorder uses 11 criteria, >=2 = disorder, severity by count.

Alcohol withdrawal: tremor, anxiety, seizures at 6-48 hours, delirium tremens at 48-96 hours.

Treat alcohol withdrawal with benzodiazepines (chlordiazepoxide or diazepam); give thiamine before glucose to prevent Wernicke encephalopathy.

Wernicke triad: ophthalmoplegia, ataxia, confusion; Korsakoff syndrome: anterograde amnesia and confabulation.

Opioid substitution: methadone or buprenorphine; buprenorphine is partial agonist with ceiling effect.

Naltrexone (opioid and alcohol) and acamprosate (alcohol) reduce relapse; disulfiram causes acetaldehyde accumulation.

Cannabis withdrawal: irritability, insomnia, reduced appetite, cravings; not life-threatening.

Stimulant intoxication: tachycardia, hypertension, agitation, psychosis; treat with benzodiazepines and supportive care.

Autism spectrum disorder: deficits in social communication plus restricted/repetitive behaviors, onset in early developmental period.

ADHD: inattention and/or hyperactivity-impulsivity, >=6 months, several symptoms before age 12, present in >=2 settings.

First-line for ADHD: methylphenidate or amphetamine; monitor growth, blood pressure, and sleep.

Separation anxiety disorder is normal in early childhood; disorder when developmentally inappropriate and impairing.

Conduct disorder: persistent violation of rights of others or major age-appropriate norms; callous-unemotional traits predict worse outcome.

Tourette disorder: multiple motor plus >=1 vocal tic for >1 year; comorbidity with OCD and ADHD is common.

Eating disorders: anorexia nervosa (low weight, fear of weight gain, body image disturbance); bulimia (bingeing and purging).

Child abuse/neglect must be reported under mandatory reporting laws; document objectively.

Delirium is the most common psychiatric syndrome in hospitalized elderly; it is a medical emergency.

Dementia: progressive cognitive decline affecting function; Alzheimer disease is the commonest cause.

Depression in older adults may present with pseudodementia (cognitive impairment resolving with treatment of depression).

Anticholinergic burden worsens cognition; avoid tricyclics and strongly anticholinergic drugs in dementia.

Start psychotropics at half adult dose in elderly (start low, go slow).

Elderly patients are at higher risk of hyponatremia with SSRIs (especially within the first weeks).

Benzodiazepines increase fall, fracture, and delirium risk in older adults.

Capacity and advance care planning should be documented; assess for elder abuse and neglect.

CBT targets maladaptive cognitions and behaviors; effective for depression, anxiety, OCD, and PTSD.

Behavioral activation increases engagement in rewarding activities; used in depression.

Psychodynamic therapy explores unconscious conflict and transference; typically longer-term.

DBT (Linehan) combines individual therapy, skills group, phone coaching, and consultation; indicated for borderline personality disorder.

Exposure therapy involves graded, repeated exposure to feared stimuli without avoidance (habituation).

Motivational interviewing uses open questions, affirmation, reflection, and summarization to resolve ambivalence.

Family therapy and psychoeducation reduce relapse in schizophrenia (expressed emotion).

Common factors: therapeutic alliance, empathy, and expectancy predict outcome across modalities.

Delirium causes: infection, withdrawal, metabolic derangement, trauma, hypoxia, drugs, and pain (mnemonic approach).

Organic psychosis should be suspected with fluctuating course, visual hallucinations, or cognitive impairment.

Steroid-induced psychosis is typically mood-congruent and resolves on dose reduction.

Hypothyroidism causes depression and cognitive slowing; hyperthyroidism causes anxiety and tremor.

Post-stroke depression is common; screen and treat with SSRIs (watch for hyponatremia and bleeding risk).

Serotonin syndrome vs NMS: serotonin syndrome has rapid onset, clonus, hyperreflexia; NMS has rigidity, raised CK, and slow onset.

Catatonia: mutism, stupor, posturing, waxy flexibility; treat with benzodiazepines or ECT.

Consultation-liaison assessment includes capacity, risk, medication interactions, and psychiatric impact of medical illness.

Fitness to stand trial: ability to understand proceedings and instruct counsel; not the same as criminal responsibility.

M'Naghten rule: not guilty by reason of insanity if unable to know the nature/wrongfulness of the act due to mental disease.

Confidentiality may be broken with patient consent, legal obligation (mandatory reporting), or imminent risk to others.

Informed consent requires capacity, adequate information, and voluntariness.

Duty to warn/protect third parties from serious threats (e.g., Tarasoff principle) varies by jurisdiction.

Involuntary admission criteria generally require mental disorder plus risk to self/others or serious deterioration.

Psychiatric reports must distinguish fact from opinion and state limitations of assessment.

Restraint and seclusion are last-resort measures requiring documentation and monitoring.