UKOM Sp.KJ cheat sheet

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

Serotonin: 5-HT2A blockade contributes to atypical antipsychotic efficacy and to weight gain; 5-HT1A partial agonism (buspirone, aripiprazole) reduces anxiety and akathisia.

Clozapine risk factors for agranulocytosis: weekly FBC for 18 weeks then fortnightly to 1 year, then monthly; stop if neutrophils <1.0 x10^9/L or platelets <50.

NMS: dopamine D2 blockade, rigidity, hyperthermia >38C, CK rise, leukocytosis; treat with dantrolene or bromocriptine plus supportive cooling.

Serotonin syndrome: clonus, hyperreflexia, agitation, autonomic instability; Hunter criteria; caused by SSRI+MAOI, tramadol, linezolid, triptans.

Lithium: narrow therapeutic index 0.6-0.8 mmol/L maintenance; toxicity risk rises with dehydration, NSAIDs, ACE inhibitors, thiazides; check renal and thyroid function 6-monthly.

Tricyclic overdose: sodium-channel blockade, QRS >100 ms predicts arrhythmia; give sodium bicarbonate; avoid flumazenil if co-ingestion of TCA.

Heritability estimates: schizophrenia ~80%, bipolar disorder ~80%, major depression ~35-40%; no single gene is diagnostic; copy-number variants (22q11) raise psychosis risk.

Formal thought disorder signs: derailment, neologism, word salad, clang association, thought blocking; flight of ideas suggests mania, not schizophrenia alone.

Schneiderian first-rank symptoms: audible thoughts, voices arguing/discussing, thought insertion/withdrawal/broadcast, made feelings/impulses/acts, delusional perception.

Delusion vs overvalued idea: delusion is fixed and held with extraordinary conviction despite contrary evidence; overvalued idea is understandable and less rigid.

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

DSM-5-TR vs ICD-11: ICD-11 drops schizophrenia subtypes and uses symptom dimensions; DSM-5-TR retains course specifiers and requires 6 months total for schizophrenia.

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

Capacity (four abilities): understand, retain, weigh, and communicate a decision; capacity is decision-specific, not global.

Cultural formulation: distinguish culture-bound idioms of distress (e.g., susto, koro) from psychopathology; use interpreters, not family members, for consent discussions.

Schizophrenia DSM-5-TR: >=2 of delusions, hallucinations, disorganized speech, grossly disorganized/catatonic behaviour, negative symptoms, with >=1 from first three, continuous signs >=6 months, functional decline.

Duration thresholds: brief psychotic disorder 1 day-1 month; schizophreniform 1-6 months; schizophrenia >=6 months; schizoaffective requires delusions/hallucinations >=2 weeks without mood symptoms.

First-episode psychosis: baseline metabolic and prolactin panel, ECG if QT risk, MRI only if neurological signs; minimize duration of untreated psychosis.

Treatment-resistant schizophrenia: failure of >=2 adequate antipsychotic trials; clozapine is indicated; monitor for myocarditis in first 8 weeks.

EPS timeline: acute dystonia hours-days, parkinsonism days-weeks, akathisia days-weeks, tardive dyskinesia months-years; treat TD with VMAT2 inhibitors (valbenazine, deutetrabenazine).

Hyperprolactinemia: risperidone and paliperidone highest risk; aripiprazole is prolactin-sparing; screen for galactorrhea, amenorrhea, osteoporosis.

Catatonia: >=3 of stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, echopraxia; treat with benzodiazepines then ECT.

Postpartum psychosis is a psychiatric emergency: onset within 2 weeks of delivery, bipolar diathesis, risk of infanticide; admit and consider ECT.

Major depressive episode: >=5 of 9 symptoms for >=2 weeks, including depressed mood or anhedonia; exclude mania/hypomania.

Bipolar I requires >=1 manic episode (>=1 week or hospitalization); bipolar II requires hypomania (>=4 days) plus major depression, no mania.

Mixed features specifier: >=3 manic symptoms during depression or >=3 depressive symptoms during mania; raises suicide and switch risk; avoid antidepressant monotherapy.

Rapid cycling: >=4 mood episodes in 12 months; first-line is lithium or valproate plus atypical antipsychotic; antidepressants may worsen cycling.

Treatment-resistant depression: failure of >=2 antidepressants at adequate dose/duration; options include lithium augmentation, aripiprazole, T3, ECT, ketamine/esketamine.

Serotonin syndrome vs anticholinergic toxicity vs NMS: clonus points to serotonin; dry skin and mydriasis to anticholinergic; lead-pipe rigidity and bradyreflexia to NMS.

Suicide risk in depression: prior attempt, male sex, older age, living alone, hopelessness, comorbid substance use; ask directly, screening does not increase risk.

Peripartum depression: Edinburgh Postnatal Depression Scale; SSRIs (sertraline) are preferred in breastfeeding; untreated illness carries greater fetal risk than most SSRIs.

Panic attack vs panic disorder: attacks are abrupt, peak within minutes; disorder requires recurrent attacks plus >=1 month of worry or behavioural change.

Agoraphobia: fear in >=2 of public transport, open spaces, enclosed places, crowds, being outside home alone; treat with CBT plus SSRI.

OCD: obsessions and/or compulsions causing >=1 hour/day or impairment; first-line SSRI at higher dose plus ERP; clomipramine if refractory.

PTSD DSM-5-TR: exposure to trauma plus intrusion, avoidance, negative cognitions/mood, and arousal >=1 month; specify dissociative or delayed expression.

Acute stress disorder: 3 days to 1 month after trauma; PTSD requires >1 month; both can follow the same event in sequence.

Adjustment disorder: symptoms within 3 months of a stressor, resolve within 6 months of stressor termination; not better explained by another disorder.

GAD: excessive worry >=6 months plus >=3 of restlessness, fatigue, concentration difficulty, irritability, muscle tension, sleep disturbance.

Trauma-focused psychotherapy (prolonged exposure, EMDR, TF-CBT) is first-line for PTSD; benzodiazepines are not recommended and may worsen outcomes.

DSM-5-TR substance use disorder: >=2 of 11 criteria in 12 months; severity mild 2-3, moderate 4-5, severe >=6; tolerance and withdrawal are not counted for prescribed medications taken appropriately.

Alcohol withdrawal timeline: tremor/anxiety 6-24 h, seizures 12-48 h, delirium tremens 48-96 h; treat with benzodiazepines using a symptom-triggered CIWA protocol.

Wernicke encephalopathy triad: ophthalmoplegia, ataxia, confusion; give parenteral thiamine before glucose to prevent Korsakoff syndrome.

Opioid overdose: pinpoint pupils, respiratory depression, reduced consciousness; naloxone reverses but has short half-life, so observe for renarcotization.

Alcohol biomarkers: GGT, MCV, AST:ALT ratio >2; ethyl glucuronide and phosphatidylethanol detect recent or chronic use.

Stimulant intoxication: tachycardia, hypertension, hyperthermia, agitation, paranoia; treat with benzodiazepines and cooling; avoid antipsychotics if possible in severe hyperthermia.

Nicotine withdrawal: irritability, craving, insomnia, increased appetite; varenicline, bupropion, or NRT double quit rates with counselling.

Gambling disorder is the only non-substance behavioural addiction in DSM-5-TR; it shares reward-circuitry dysfunction with substance use disorders.

Delirium: acute onset, fluctuating course, inattention plus disorganized thinking or altered consciousness; use 4AT or CAM; treat the cause, avoid restraints, use low-dose antipsychotics only if needed.

Dementia DSM-5-TR: major neurocognitive disorder with significant functional decline; mild NCD requires preserved independence.

Alzheimer disease: hippocampal atrophy, amyloid plaques and tau tangles; first-line are cholinesterase inhibitors (donepezil, rivastigmine, galantamine); memantine for moderate-severe.

Frontotemporal dementia: behavioural variant with disinhibition, apathy, hyperorality; language variants; cholinesterase inhibitors may worsen symptoms.

Lewy body dementia: fluctuating cognition, visual hallucinations, parkinsonism, REM sleep behaviour disorder; severe neuroleptic sensitivity, avoid typical antipsychotics.

Vascular dementia: stepwise decline, focal signs, executive dysfunction; control vascular risk factors; no approved disease-modifying drug.

Epilepsy and psychiatry: temporal lobe epilepsy may cause ictal fear and interictal depression; psychosis of epilepsy often follows seizure freedom (forced normalization).

TBI: post-concussion symptoms persist >3 months in some; screen for depression, PTSD, and substance use; avoid benzodiazepines long-term.

ADHD DSM-5-TR: >=6 inattentive or hyperactive-impulsive symptoms (>=5 for age >=17), onset before 12, present in >=2 settings; stimulants are first-line, monitor growth and blood pressure.

Autism spectrum disorder: deficits in social communication plus restricted/repetitive behaviours, early onset; screen with M-CHAT; avoid chelation and other unproven treatments.

Intellectual disability: IQ ~70 or below plus adaptive deficits; severity by adaptive functioning, not IQ alone; assess for coexisting psychiatric and medical causes.

Tourette disorder: multiple motor plus >=1 vocal tic for >1 year; comorbid ADHD and OCD common; treat with behavioural therapy or alpha-2 agonists, antipsychotics if severe.

Separation anxiety disorder vs school refusal: school refusal is a symptom not a diagnosis; assess for anxiety, depression, bullying, and family factors.

Childhood depression: irritability may predominate; fluoxetine is the best-evidenced SSRI; combine with CBT and monitor for activation and suicidality.

Eating disorders: anorexia nervosa has highest mortality of psychiatric disorders; refeeding syndrome risk requires electrolyte monitoring; family-based therapy is first-line for adolescents.

Transition to adult services: plan from mid-adolescence; unmanaged transition is associated with treatment dropout and relapse.

Depression vs dementia: pseudodementia shows prominent complaints, variable effort, and improvement with treatment; dementia shows concealment and consistent deficits.

Late-life depression: higher risk of psychosis, cognitive impairment, and suicide; ECT is effective and safe with cardiac assessment.

Anticholinergic burden (ACB score) increases delirium and falls in older adults; review medications such as oxybutynin, amitriptyline, and diphenhydramine.

Benzodiazepines in older adults: Beers criteria list them as potentially inappropriate; risk of falls, fractures, and delirium.

Dementia behavioural symptoms: first rule out pain, constipation, infection, and sensory deficits; non-pharmacological approaches before antipsychotics.

Elder abuse: screen for unexplained bruising, dehydration, financial exploitation; in Indonesia report to local social services or police under Law No. 13/1998 on older persons' welfare.

Driving and dementia: assess attention, visuospatial function, and insight; legal reporting duties vary, and disclosure should be discussed with the patient.

Polypharmacy: older adults on >=5 medications; deprescribe antipsychotics used for behavioural symptoms when risks outweigh benefits.

CBT: identifies and modifies cognitive distortions and behavioural patterns; effective for depression, anxiety, OCD, and insomnia; typically 12-20 sessions.

Psychodynamic therapy: explores unconscious conflict, transference, and defence mechanisms; brief forms are evidence-based for depression.

DBT: skills of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness; first-line for borderline personality disorder and self-harm.

Motivational interviewing: collaborative, evocative, supports autonomy; use OARS (open questions, affirmations, reflections, summaries) to build change talk.

Family interventions in schizophrenia: psychoeducation, communication training, and problem solving reduce relapse; high expressed emotion predicts relapse.

Group therapy: universality, altruism, and interpersonal learning are therapeutic factors (Yalom); avoid in acute psychosis or severe paranoia.

Psychoeducation: improves adherence and relapse rates in bipolar disorder and schizophrenia; include patients and caregivers.

Therapeutic alliance predicts outcome across modalities; rupture repair is a core clinical skill.

Suicide risk assessment: ask directly about ideation, plan, intent, access to means, and prior attempts; document risk formulation and management plan.

High-risk features: prior attempt, access to firearms or pesticides, agitation, hopelessness, recent discharge, and living alone.

Agitated or violent patient: ensure safety, use verbal de-escalation first, offer oral medication; rapid tranquillity with IM antipsychotic plus benzodiazepine if needed, monitoring vitals.

Delirium in the medically ill: treat the underlying cause; use haloperidol low dose if needed; avoid benzodiazepines except in alcohol or benzodiazepine withdrawal.

Serotonin syndrome, NMS, and malignant catatonia are emergencies requiring ICU-level monitoring; distinguish by clonus, rigidity, and CK.

Consultation-liaison: assess capacity for treatment decisions, distinguish delirium from depression, and screen for alcohol withdrawal in surgical patients.

Postpartum psychiatric emergency: risk of infanticide and suicide; inpatient admission with mother-baby unit when available.

Suicide postvention: contact bereaved family, offer support, and review care; do not blame clinicians; document incident review.

Indonesian mental health law: Law No. 18/2014 on Mental Health covers rights, voluntary and involuntary care, and prohibition of shackling (pasung); implementation regulated by government regulations.

Informed consent: requires capacity, adequate information, and voluntariness; for minors, parental consent plus assent from the child.

Confidentiality exceptions: risk of serious harm to self or others, court order, and mandatory reporting; disclose minimum necessary information.

Involuntary admission: requires serious mental disorder with risk to self or others or inability to care for self; periodic review and legal representation are required.

Forensic assessment: evaluate fitness to stand trial and criminal responsibility; a mental disorder alone does not determine responsibility; document objectively.

Fitness to stand trial elements: understand charges, understand proceedings, assist counsel, and make reasoned decisions.

Boundary violations: sexual contact with patients is always unethical; non-sexual boundary crossings should be documented and discussed in supervision.

Health systems: Indonesia's JKN national insurance covers mental health services at primary care and referral hospitals; integrate mental health into primary care (puskesmas).