Iraqi Board Psychiatry cheat sheet

Dopamine pathways: mesolimbic (reward, positive symptoms), mesocortical (negative/cognitive symptoms; D1 hypofunction in prefrontal cortex), nigrostriatal (extrapyramidal symptoms), tuberoinfundibular (prolactin inhibition; blockade causes hyperprolactinaemia).

Serotonin: 5-HT1A autoreceptors in raphe nuclei regulate firing; 5-HT2A antagonism contributes to atypical antipsychotic action and to reduced extrapyramidal symptoms; 5-HT2C antagonism contributes to weight gain; 5-HT3 antagonism is antiemetic.

Noradrenaline from locus coeruleus; degeneration in Alzheimer's disease and contribution to depression; alpha-2 autoreceptor agonism (clonidine, dexmedetomidine) reduces sympathetic outflow; mirtazapine increases noradrenergic and serotonergic transmission via alpha-2 blockade.

GABA-A receptor is a ligand-gated chloride channel with binding sites for benzodiazepines, barbiturates, neurosteroids and ethanol; benzodiazepine site is distinct from the GABA site, explaining ceiling effect on respiratory depression when used alone.

Glutamate: NMDA receptor hypofunction is a leading model of schizophrenia (ketamine and phencyclidine reproduce positive and negative symptoms); memantine is an uncompetitive NMDA antagonist used in moderate-to-severe Alzheimer's disease.

Neuroanatomy of memory: hippocampus (episodic memory consolidation, Papez circuit), mammillary bodies and anterior thalamic nucleus (Korsakoff), amygdala (emotional/fear conditioning), basal forebrain cholinergic nuclei (nucleus basalis of Meynert, degenerates in Alzheimer's disease).

Frontal lobe syndromes: dorsolateral (executive dysfunction, apathy), orbitofrontal (disinhibition, impulsivity, personality change), medial frontal/anterior cingulate (abulia, akinetic mutism); frontal release signs include grasp, palmomental and glabellar tap.

Heritability estimates: schizophrenia ~80%, bipolar disorder ~60-80%, major depression ~30-40%, autism ~80-90%; no single gene is diagnostic; copy number variants (22q11 deletion, 16p11.2) and polygenic risk scores carry small individual effects.

Pharmacokinetics: hepatic CYP450 - CYP2D6 and CYP2C19 are highly polymorphic; CYP1A2 induced by smoking (reduces clozapine and olanzapine levels), CYP3A4 inhibited by grapefruit and ketoconazole; lithium is renally cleared and follows sodium handling (thiazides, NSAIDs, dehydration raise levels).

Mental state examination domains: appearance and behaviour, speech, mood (subjective) and affect (objective), thought form and content, perception, cognition, insight, judgement, and risk.

Disorders of thought form: flight of ideas (bipolar mania), loosening of associations/derailment (schizophrenia), thought blocking, circumstantiality (eventually reaches the point), tangentiality (never reaches the point), perseveration, neologisms, clang associations.

Schneiderian first-rank symptoms: audible thoughts, voices arguing or discussing, voices commenting on actions, thought insertion, thought withdrawal, thought broadcasting, made feelings/impulses/acts, somatic passivity, delusional perception.

Delusion vs overvalued idea: delusion is a fixed false belief held with unshakeable conviction, not shared by the person's culture, and not amenable to reason; an overvalued idea is an understandable, affect-laden belief held with less than delusional intensity.

Hallucination vs illusion vs pseudohallucination: hallucination is perception without an external stimulus; illusion is misperception of a real stimulus; pseudohallucination is perceived in inner subjective space, not projected outward (e.g., in grief or dissociation).

Capgras syndrome (delusion of doubles, often post-organic or in Lewy body disease) vs Fregoli (persecutor disguises as different people) vs Cotard (nihilistic delusion of being dead or nonexistent, seen in severe depression).

Insight is graded, not binary: complete, partial, or absent; assess recognition of illness, attribution of symptoms, need for treatment, and acceptance of treatment; poor insight predicts non-adherence.

Cognitive screening in the mental state examination: orientation, attention (digit span, months backward), 3-word recall, language, praxis; formal tools include MMSE (30 points, education-sensitive) and MoCA (30 points, more sensitive to mild cognitive impairment and executive dysfunction).

Risk assessment structure: static factors (male sex, past attempts, family history), dynamic factors (current intent, plan, access to means, hopelessness, substance use, psychosis, recent loss), and protective factors (social support, children, religious belief, engagement); document reasoning, not just a score.

Both ICD-11 and DSM-5-TR are descriptive, atheoretical classifications; ICD-11 is used for WHO reporting and by the Iraqi health system, DSM-5-TR for US clinical and research use; cross-walk between them is imperfect.

DSM-5 abolished the schizophrenia subtypes (paranoid, hebephrenic, catatonic) and the classic five-axis system; ICD-11 similarly uses dimensional specifiers such as positive, negative, depressive, manic, psychomotor and cognitive symptom domains.

Schizophrenia (DSM-5): ≥2 of delusions, hallucinations, disorganised speech, grossly disorganised/catatonic behaviour, negative symptoms; ≥1 must be from the first three; continuous signs ≥6 months with ≥1 month active symptoms; functional decline; not attributable to substance or medical condition.

Major depressive disorder (DSM-5): ≥5 of nine symptoms for ≥2 weeks, including depressed mood or anhedonia; excludes mixed features, mania or hypomania; ICD-11 uses similar symptom counts but allows milder threshold for persistent depressive disorder.

Bipolar I requires ≥1 manic episode (≥1 week or hospitalisation, marked impairment); bipolar II requires hypomania (≥4 days) plus major depression and no lifetime mania; cyclothymia is ≥2 years of subthreshold hypomanic and depressive symptoms.

Generalised anxiety disorder: excessive anxiety and worry on more days than not for ≥6 months, difficult to control, with ≥3 of six symptoms (restlessness, fatigability, poor concentration, irritability, muscle tension, sleep disturbance).

PTSD (DSM-5): exposure to trauma plus ≥1 intrusion, ≥1 avoidance, ≥2 negative alterations in cognition/mood, ≥2 arousal/reactivity symptoms, duration >1 month, functional impairment; ICD-11 requires the core triad of re-experiencing, avoidance and sense of threat, with optional complex PTSD (affective dysregulation, negative self-concept, interpersonal disturbance).

Personality disorder in DSM-5 Section III and ICD-11 is dimensional: ICD-11 uses severity (mild, moderate, severe) plus five trait domain qualifiers (negative affectivity, detachment, dissociality, disinhibition, anankastia) and a borderline pattern qualifier.

Diagnostic caution: delirium must be excluded before diagnosing a primary psychiatric disorder in any acutely confused or behaviourally disturbed patient; a diagnosis of dementia requires cognitive decline sufficient to impair independence, not just memory complaints.

Global burden: depressive disorders and anxiety disorders are the leading contributors to years lived with disability; schizophrenia affects about 0.3-0.7% of the population across cultures, with a similar lifetime risk worldwide.

Lifetime prevalence (approximate, DSM-based community surveys): any mental disorder ~30-50%, major depression ~15-17%, generalised anxiety ~5-6%, bipolar spectrum ~2-4%, PTSD ~7%, obsessive-compulsive disorder ~2-3%.

Treatment gap: in low- and middle-income countries, 75-90% of people with mental disorders receive no treatment; Iraq's treatment gap is compounded by security instability, stigma and limited psychiatric workforce.

Cultural syndromes relevant to the region: jinn possession and evil eye attribution, 'possession' trance states, 'heart distress' (narah), and somatic presentations of depression; ask about traditional healers, religious practice and family explanatory models before labelling symptoms delusional.

Idioms of distress: Middle Eastern patients commonly present with fatigue, headache, chest tightness, back pain and sleep disturbance rather than psychological language; unexplained medically symptoms should prompt screening for depression and anxiety.

Epidemiological measures: incidence (new cases per population-time), prevalence (point vs period vs lifetime), relative risk, attributable risk, odds ratio (case-control), standardised mortality ratio; screening test properties are sensitivity, specificity, positive predictive value (depends on prevalence) and likelihood ratios.

Study designs: cross-sectional (prevalence, no temporality), cohort (incidence, relative risk), case-control (rare outcomes, odds ratio), randomised controlled trial (causal inference), meta-analysis (pooled effect sizes, heterogeneity I-squared).

Epidemiological transition and migration: refugees and internally displaced persons show elevated PTSD, depression and psychosis risk; risk rises with exposure to trauma, separation, discrimination and post-migration adversity, not with migration itself.

Cultural formulation: DSM-5 Cultural Formulation Interview covers cultural identity, explanatory models, stressors and supports, and clinician-patient relationship; use interpreters trained in mental health rather than family members where possible.

First-line for moderate-to-severe unipolar depression: SSRI (e.g., sertraline, escitalopram, fluoxetine) or serotonin-noradrenaline reuptake inhibitor; allow 4-6 weeks at therapeutic dose before declaring failure; continue 6-12 months after remission, longer if recurrent.

Treatment-resistant depression: failure of ≥2 adequate antidepressant trials; options include augmentation with lithium, quetiapine, aripiprazole, or T3, switching class, and ECT for severe, psychotic, catatonic or life-threatening depression.

Serotonin syndrome triad: mental status change, autonomic instability and neuromuscular hyperactivity (clonus, hyperreflexia, tremor); risk with MAOIs, multiple serotonergic agents, tramadol, linezolid; stop offending agents, supportive care, cyproheptadine in severe cases.

Bipolar mania first-line: lithium, valproate, or an atypical antipsychotic (olanzapine, risperidone, quetiapine, aripiprazole); add benzodiazepine for agitation; avoid antidepressant monotherapy because of switch risk; check renal and thyroid function before lithium.

Lithium monitoring: target trough 0.6-0.8 mmol/L for maintenance, 0.8-1.0 for acute mania; check level 5 days after initiation or dose change, then every 3-6 months; monitor creatinine, eGFR, TSH and calcium; toxicity signs include coarse tremor, ataxia, vomiting, confusion.

Bipolar depression: quetiapine, lurasidone (with lithium or valproate), or lamotrigine (especially for maintenance and rapid cycling); antidepressant co-administration only with a mood stabiliser and with caution.

Rapid cycling: ≥4 mood episodes in 12 months; more common in women and with hypothyroidism; optimise mood stabiliser, check TSH, avoid antidepressants; lamotrigine and valproate are preferred.

Electroconvulsive therapy indications: severe depression with psychosis, catatonia, refusal of food/fluid, high suicide risk, treatment resistance, and depression in pregnancy; efficacy is high but cognitive side effects (retrograde amnesia) require consent and monitoring.

Peripartum: Edinburgh Postnatal Depression Scale for screening; SSRIs (sertraline preferred in breastfeeding); postpartum psychosis is a psychiatric emergency with high infanticide risk, requiring admission and antipsychotic plus mood stabiliser.

Positive symptoms (delusions, hallucinations, disorganised speech/behaviour) respond to dopamine D2 blockade; negative symptoms (avolition, blunted affect, alogia, anhedonia, social withdrawal) and cognitive symptoms respond poorly and predict functional outcome.

First-episode psychosis: start a low-dose second-generation antipsychotic (e.g., risperidone 2 mg, aripiprazole 10 mg, olanzapine 5-10 mg), titrate slowly, monitor weight, waist, blood pressure, glucose/HbA1c, lipids and prolactin at baseline and periodically.

Clozapine is indicated for treatment-resistant schizophrenia (failure of ≥2 antipsychotics at adequate dose and duration); requires baseline and weekly full blood count for 18 weeks, then fortnightly to 1 year, then monthly; stop if neutrophils <1.0 x 10^9/L.

Clozapine adverse effects: agranulocytosis (~1%), myocarditis (first 8 weeks), seizures at high dose, constipation and ileus, sialorrhoea, sedation, weight gain and metabolic syndrome; smoking cessation raises clozapine levels.

Extrapyramidal syndromes: acute dystonia (hours-days; treat with procyclidine or benztropine), parkinsonism (weeks), akathisia (days-weeks; treat with propranolol or reduce dose), tardive dyskinesia (months-years; higher risk with typical antipsychotics; treat with VMAT2 inhibitors or clozapine switch).

Neuroleptic malignant syndrome: lead-pipe rigidity, hyperthermia >38°C, autonomic instability, altered consciousness, raised creatine kinase; stop antipsychotic, aggressive cooling, hydration, dantrolene or bromocriptine; mortality ~10%.

Catatonia: immobility, stupor, mutism, negativism, posturing, waxy flexibility, echolalia/echopraxia; use lorazepam challenge and ECT if refractory; can occur in schizophrenia, mood disorders and medical illness.

Brief psychotic disorder (<1 month), schizophreniform disorder (1-6 months), delusional disorder (≥1 month, non-bizarre delusions, functioning otherwise preserved) and schizoaffective disorder (mood episode concurrent with psychosis plus ≥2 weeks of psychosis alone) are distinguished mainly by duration and mood overlap.

Relapse prevention: continue antipsychotic for at least 1-2 years after first episode and longer for multiple episodes; psychoeducation with family, adherence support and monitoring for metabolic effects reduce relapse.

First-line pharmacotherapy for generalised anxiety, panic disorder and social anxiety: SSRI or SNRI; benzodiazepines only short-term for severe agitation because of dependence, tolerance and cognitive effects.

Panic attack vs panic disorder: a panic attack is an abrupt surge peaking within minutes with ≥4 of 13 symptoms; panic disorder requires recurrent unexpected attacks plus ≥1 month of anticipatory anxiety or maladaptive behaviour.

OCD: obsessions (intrusive, unwanted, ego-dystonic thoughts) and compulsions (repetitive behaviours or mental acts to reduce distress) taking >1 hour/day or causing impairment; first-line treatment is CBT with exposure and response prevention plus an SSRI at higher dose (e.g., fluoxetine 40-60 mg) for 10-12 weeks.

PTSD first-line: trauma-focused CBT and EMDR; SSRIs (sertraline, paroxetine) are first-line pharmacotherapy; avoid benzodiazepines because they may impair emotional processing and carry dependence risk; prazosin is used for trauma-related nightmares.

Acute stress disorder: symptoms lasting 3 days to 1 month after trauma; PTSD requires symptoms >1 month; both share intrusion, avoidance, negative cognition/mood and arousal clusters.

Adjustment disorder: emotional or behavioural symptoms within 3 months of an identifiable stressor, resolving within 6 months of stressor removal, not meeting criteria for another disorder and not normal bereavement.

Dissociative disorders: dissociative amnesia (inability to recall autobiographical information, often following trauma), dissociative fugue (purposeful travel with amnesia for identity), depersonalisation/derealisation disorder, and dissociative identity disorder (two or more distinct personality states with gaps in recall).

Somatic symptom and related disorders: somatic symptom disorder (distressing symptoms plus excessive thoughts, anxiety or time devoted), illness anxiety disorder (preoccupation without significant somatic symptoms), conversion disorder (functional neurological symptoms incompatible with recognised disease), factitious disorder (intentional production for the sick role) and malingering (external gain).

Treatment of dissociative and trauma-related conditions: phase-oriented approach (stabilisation and safety, trauma processing, integration); avoid aggressive uncovering in unstable patients; treat comorbid depression, PTSD and substance use.

DSM-5 substance use disorder combines abuse and dependence into one disorder with 11 criteria across four groups (impaired control, social impairment, risky use, pharmacological); ≥2 criteria in 12 months; severity mild (2-3), moderate (4-5), severe (≥6).

Tolerance and withdrawal define physiological dependence; withdrawal syndromes: alcohol (tremor, sweating, seizures, delirium tremens at 48-96 hours), opioids (rhinorrhoea, lacrimation, piloerection, diarrhoea, mydriasis), benzodiazepines (anxiety, insomnia, seizures), nicotine (irritability, craving, weight gain).

Alcohol withdrawal: use a benzodiazepine (chlordiazepoxide or diazepam) symptom-triggered with CIWA-Ar; give thiamine before glucose to prevent Wernicke encephalopathy; delirium tremens is a medical emergency with 5-15% mortality if untreated.

Wernicke encephalopathy triad: ophthalmoplegia/nystagmus, ataxia and confusion; treat with high-dose parenteral thiamine; if untreated, Korsakoff syndrome with anterograde amnesia and confabulation follows.

Opioid use disorder: methadone (full agonist, supervised daily dosing, QT monitoring) or buprenorphine (partial agonist, safer in overdose, office-based) as maintenance; naloxone reverses overdose; naltrexone is an antagonist for relapse prevention after detoxification.

Alcohol relapse prevention: naltrexone (reduces craving and heavy drinking), acamprosate (maintains abstinence, requires normal renal function), disulfiram (aversive, requires supervision and abstinence), plus psychosocial treatment (motivational interviewing, CBT, 12-step facilitation).

Benzodiazepine dependence: taper slowly (e.g., 10-25% dose reduction every 2-4 weeks); abrupt withdrawal risks seizures and delirium; substitute a long-acting agent (diazepam) before tapering.

Stimulant and cannabis use: no approved pharmacotherapy for stimulant use disorder; contingency management is the best-supported psychosocial intervention; cannabis withdrawal includes irritability, insomnia, anorexia and craving.

Screening tools: AUDIT or AUDIT-C for alcohol, CAGE (cut down, annoyed, guilty, eye-opener), DAST for drugs; urine drug screening has limited sensitivity and specificity and requires confirmatory testing.

Autism spectrum disorder (DSM-5): persistent deficits in social communication and interaction across contexts plus restricted, repetitive patterns of behaviour, interests or activities, present in early development and causing impairment; severity graded by support needs; no language delay criterion in DSM-5.

Attention-deficit/hyperactivity disorder: ≥6 inattentive or hyperactive-impulsive symptoms (≥5 for age ≥17) for ≥6 months, in ≥2 settings, onset before age 12, impairing; first-line treatment is behavioural parent/teacher training for preschool children and stimulant medication (methylphenidate) for school-age children.

Stimulant monitoring: height, weight, blood pressure, heart rate and sleep/appetite at each visit; atomoxetine (non-stimulant) is an alternative with slower onset and boxed warning for suicidal ideation in children.

Intellectual disability (DSM-5): deficits in intellectual functions (reasoning, problem-solving, planning, abstract thinking, academic learning, experiential learning) and adaptive functioning, onset during the developmental period; severity is based on adaptive functioning, not IQ score alone.

Global developmental delay: failure to meet expected developmental milestones in several areas of intellectual functioning in children under 5; reassess with standardised testing later.

Specific learning disorder: persistent difficulty in reading, written expression or mathematics despite intervention, below age expectation and interfering with academic or occupational performance; requires a discrepancy from expected achievement, not from IQ.

Tic disorders: Tourette disorder requires multiple motor and ≥1 vocal tic for >1 year; transient tic disorder <1 year; first-line behavioural treatment is comprehensive behavioural intervention for tics (CBIT); medication options are alpha-2 agonists (clonidine, guanfacine) and aripiprazole or risperidone.

Childhood trauma and attachment: reactive attachment disorder (inhibited, withdrawn) and disinhibited social engagement disorder (indiscriminate friendliness) follow severe early neglect; separation anxiety disorder is common and treatable with CBT and family work.

Adolescent suicide risk: suicide is a leading cause of death in 15-29 year olds; screen for self-harm, bullying, substance use, family conflict and access to means; confidentiality limits should be explained at the start of the assessment.

Delirium: acute onset, fluctuating course, inattention and disorganised thinking; common causes are infection, medication, pain, constipation, dehydration, hypoxia and metabolic derangement; non-pharmacological measures first, antipsychotics (low-dose haloperidol or quetiapine) only for severe distress or danger.

Dementia (major neurocognitive disorder): significant cognitive decline from previous level in ≥1 domain, interfering with independence, not explained by delirium or another disorder; mild neurocognitive disorder requires preserved independence with compensatory strategies.

Alzheimer's disease: insidious progressive episodic memory loss, medial temporal and parietal atrophy, amyloid plaques and tau tangles; treatment with cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild-to-moderate disease and memantine for moderate-to-severe; benefits are modest and symptomatic.

Vascular dementia: stepwise decline, focal neurological signs, executive dysfunction prominent; risk factor control (hypertension, diabetes, smoking, lipids, anticoagulation for atrial fibrillation) is the main preventive strategy.

Dementia with Lewy bodies: fluctuating cognition, visual hallucinations, parkinsonism, REM sleep behaviour disorder and neuroleptic sensitivity; avoid typical antipsychotics; cholinesterase inhibitors are preferred.

Frontotemporal dementia: behavioural variant (disinhibition, apathy, loss of empathy, hyperorality) or language variants (primary progressive aphasia); often presents before age 65 and can be misdiagnosed as a psychiatric disorder.

Depression vs dementia: depression causes prominent low mood, anhedonia, early morning wakening and variable effortful memory complaints ('pseudodementia'); dementia shows poor effort, confabulation and preserved mood; screen with geriatric depression scale and treat depression to reassess cognition.

Elderly psychopharmacology: start low and go slow; reduced hepatic and renal clearance; anticholinergic burden worsens cognition and falls; benzodiazepines increase falls, fractures and confusion; antipsychotics in dementia carry increased mortality and stroke risk (use only for severe agitation or psychosis, short term).

Capacity and safeguarding in older adults: assess understanding, retention, communication of decision and reasoning; screen for elder abuse, neglect, self-neglect and financial exploitation; consider driving safety and home safety assessments.

Cognitive behavioural therapy: identifies and modifies maladaptive automatic thoughts, cognitive distortions and behaviours; effective for depression, anxiety disorders, OCD, PTSD and insomnia; typically 12-20 sessions.

Behavioural therapy: exposure and response prevention for OCD, graded exposure for phobias, behavioural activation for depression, and contingency management for substance use; grounded in classical and operant conditioning.

Psychodynamic psychotherapy: explores unconscious conflict, transference, defence mechanisms and early relationships; longer-term and less symptom-focused; supportive psychotherapy emphasises alliance, coping and reality testing.

Dialectical behaviour therapy: for borderline personality disorder and chronic suicidality; combines individual therapy, skills group (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness), phone coaching and consultation team.

Interpersonal psychotherapy: time-limited (12-16 sessions) for depression; focuses on role transitions, grief, role disputes and interpersonal deficits; strong evidence for perinatal depression.

Motivational interviewing: collaborative, person-centred approach to ambivalence; uses open questions, affirmations, reflections and summaries; avoid confrontation and the righting reflex; effective in substance use and adherence.

Family and group therapy: family interventions reduce relapse in schizophrenia (psychoeducation, communication and problem-solving); group therapy offers universality, universality of experience, altruism and interpersonal learning.

Eye movement desensitisation and reprocessing: trauma-focused therapy with bilateral stimulation and memory processing; recommended for PTSD alongside trauma-focused CBT; mechanism remains debated.

Therapeutic alliance and common factors: alliance, empathy, positive regard and expectation account for a substantial share of outcome variance; monitor outcome and rupture-repair; match modality to diagnosis, preference and availability.

Delirium workup: full blood count, urea and electrolytes, glucose, calcium, liver and thyroid function, arterial blood gases, urinalysis, ECG, chest radiograph, blood cultures and medication review; consider neuroimaging if focal signs, head injury or anticoagulation.

Psychiatric symptoms of medical illness: hypothyroidism (depression, cognitive slowing), hyperthyroidism (anxiety, agitation), hypercalcaemia (depression, confusion), hyponatraemia (confusion, seizures), uraemia (apathy, asterixis), porphyria (psychosis, neuropathy), SLE (psychosis, mood change).

Steroid-induced psychiatric symptoms: euphoria, insomnia, irritability, mania or psychosis; usually dose-related and occur early; treat with dose reduction and antipsychotic or mood stabiliser; avoid abrupt withdrawal.

Serotonin syndrome vs neuroleptic malignant syndrome vs anticholinergic toxicity: serotonin syndrome has clonus and hyperreflexia; NMS has rigidity and raised creatine kinase with bradyreflexia; anticholinergic toxicity has dry skin, mydriasis, urinary retention and flushing.

Post-stroke depression: common within the first year, associated with left frontal lesions; treat with SSRI; post-stroke anxiety and emotionalism (pathological laughing/crying) may respond to SSRIs.

Epilepsy and psychiatry: temporal lobe epilepsy can produce ictal fear, automatisms and post-ictal psychosis; interictal depression and anxiety are common; some antiepileptics (levetiracetam) cause irritability, and carbamazepine is enzyme-inducing.

Capacity assessment for treatment refusal: patient must understand, retain, weigh and communicate the decision; if capacity is absent, act in best interests under local mental health or guardianship law; document the reasoning.

Somatoform and functional presentations in liaison settings: medically unexplained symptoms are common; avoid unnecessary investigations; use a biopsychosocial explanation, scheduled follow-up and CBT; conversion disorder symptoms are involuntary and not feigned.

Psychotropic use in medically ill patients: SSRIs are preferred in cardiac disease (sertraline, escitalopram with QT monitoring); avoid tricyclics in conduction disease; haloperidol is relatively safe in delirium but monitor QT; adjust doses for renal and hepatic impairment.

Four ethical principles: autonomy (respect for informed choice), beneficence (act in the patient's interest), non-maleficence (avoid harm) and justice (fair distribution of resources); confidentiality may be breached only where there is a legal duty, serious risk to others or patient consent.

Informed consent requires capacity, adequate information and voluntariness; for research and treatment of incapable patients, follow local law and ethics committee approval; document the discussion.

Fitness to stand trial: ability to understand the charges, instruct counsel, follow proceedings and understand the consequences; unfitness leads to treatment and review rather than trial; insanity defence concerns mental state at the time of the offence.

Malingering vs factitious disorder: malingering is intentional production for external gain (avoidance of work, drugs, money); factitious disorder is intentional production for the sick role with no external gain.

Risk assessment instruments: HCR-20 (historical, clinical, risk management), Violence Risk Appraisal Guide, Static-99 for sexual offending; tools support but do not replace structured clinical judgement.

Duty to protect: where a patient poses a serious threat to an identifiable person, clinicians may need to warn the potential victim or notify authorities, depending on local law; document risk and actions.

Mental health law principles: involuntary admission requires mental disorder plus risk to self or others or need for treatment, least restrictive option, independent review and appeal; in Iraq, the Mental Health Act of 1987 (amended 2001) governs admission, guardianship and patient rights.

Community psychiatry: assertive community treatment (multidisciplinary, low caseload, 24-hour), case management, early intervention in psychosis services, supported housing and vocational rehabilitation reduce hospitalisation and improve function.

Stigma and service delivery: anti-stigma campaigns, integration of mental health into primary care (WHO mhGAP), task-shifting to trained primary care staff, and reliable supply of essential psychotropics are priorities in low-resource settings such as Iraq.