Kuwait Board Psychiatry cheat sheet

Mesolimbic dopamine projections (ventral tegmental area to nucleus accumbens and amygdala) are linked to positive psychotic symptoms; mesocortical hypofunction (VTA to prefrontal cortex) is linked to negative and cognitive symptoms.

Nigrostriatal blockade (substantia nigra to striatum) produces extrapyramidal effects; tuberoinfundibular blockade disinhibits prolactin release.

Striatal D2 occupancy of about 65-78% is the usual antipsychotic therapeutic window; above roughly 78% extrapyramidal symptoms emerge and above 80% prolactin rises.

SSRIs raise synaptic serotonin within hours, but clinical response takes 2-4 weeks as somatodendritic 5-HT1A and terminal 5-HT2 autoreceptors desensitise.

Glutamate is the principal excitatory transmitter and GABA the principal inhibitory one; NMDA receptor hypofunction is a leading model of schizophrenia.

HPA axis sequence: hypothalamic CRH -> pituitary ACTH -> adrenal cortisol; dexamethasone non-suppression and blunted TSH response are seen in melancholic depression.

REM sleep shows low-voltage mixed-frequency EEG resembling wakefulness, muscle atonia and dreaming; REM latency is shortened in depression and REM behaviour disorder predicts synucleinopathy.

Amygdala mediates fear conditioning, hippocampus mediates declarative memory and long-term potentiation, and prefrontal cortex mediates working memory and response inhibition.

Kindling describes progressive lowering of seizure or episode threshold with repeated subthreshold stimulation and models episode autonomy in bipolar disorder.

Delusion = fixed false belief held with conviction, not shared by the person's culture and impervious to reason; hallucination = perception without an external stimulus; illusion = misperception of a real stimulus.

Jaspers separated form (the structure of the experience, e.g. delusion, hallucination, passivity) from content (the theme, e.g. persecutory, grandiose, nihilistic).

Schneiderian first-rank symptoms: thought echo, thought insertion, thought withdrawal, thought broadcasting, made feelings/impulses/acts, somatic passivity, delusional perception, and third-person voices commenting or discussing.

Formal thought disorder terms: derailment (loosening of associations), flight of ideas, neologism, clang association, verbigeration, perseveration, thought blocking.

Delusional misidentification: Capgras (impostor), Fregoli (same person in disguise), Cotard (nihilistic/rotten), Othello (morbid jealousy), Ekbom (infestation), reduplicative paramnesia.

An overvalued idea is a comprehensible, affect-laden conviction held with less than delusional fixity and shared by some within the culture; a delusion is idiosyncratic and non-shared.

Mood-congruent psychotic features match the mood polarity (grandeur in mania, guilt/poverty in depression); mood-incongruent features do not and carry a worse prognosis.

Passivity phenomena are experiences that one's thoughts, feelings, impulses or actions are controlled or replaced by an external agency.

Insight is multidimensional: awareness of illness, need for treatment, and attribution of symptoms; intact insight predicts adherence and lower relapse.

DSM-5 schizophrenia: two or more of delusions, hallucinations, disorganised speech, grossly disorganised/catatonic behaviour or negative symptoms, at least one from the first three, continuous signs for 6 months with at least 1 month active symptoms.

ICD-11 schizophrenia requires at least two of delusions, hallucinations, thought disorder, experiences of influence/passivity, negative symptoms or psychomotor disturbance, at least one from the first four, for at least 1 month.

MMSE: score below 24/30 suggests cognitive impairment. MoCA: cut-off 26/30, more sensitive to mild cognitive impairment and executive dysfunction but more education-dependent.

Sensitivity = true positives/(true positives + false negatives); specificity = true negatives/(true negatives + false positives); positive predictive value falls sharply as prevalence falls.

Cohen's kappa: above 0.80 excellent, 0.61-0.80 good, 0.41-0.60 moderate, below 0.40 poor agreement beyond chance.

DSM-5 abandoned the multiaxial system; GAF was replaced by the WHODAS 2.0 for disability, and ICD-11 also uses a single axis with functioning qualifiers.

Common screens: PHQ-9 for depression, GAD-7 for anxiety, CAGE and AUDIT for alcohol, MDQ for bipolarity, Y-BOCS for OCD severity.

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

Diagnostic hierarchy principle: exclude substance/medication-induced and medical causes before attributing symptoms to a primary psychiatric disorder.

Lifetime prevalence of schizophrenia is 0.3-0.7%, equal across sexes, with earlier onset in males (early 20s vs late 20s); heritability is about 80%.

Duration rules: DSM-5 requires 6 months of disturbance with at least 1 month of active symptoms; ICD-11 and brief psychotic disorder require shorter durations (brief psychotic disorder: 1 day to 1 month).

Clozapine is indicated after failure of at least two antipsychotics, one second-generation, each at adequate dose for at least 6 weeks; full blood count weekly for 18 weeks then at least 2-weekly.

Extrapyramidal timeline: acute dystonia within hours to days, akathisia within days to weeks, parkinsonism within weeks, tardive dyskinesia after months to years.

Neuroleptic malignant syndrome: rigidity, hyperthermia, autonomic instability, altered consciousness, raised CK; stop the drug, supportive care, dantrolene or bromocriptine, ECT if refractory.

Catatonia: stupor, catalepsy, waxy flexibility, negativism, mutism, posturing, stereotypy; lorazepam challenge first, ECT for malignant or refractory cases.

People with schizophrenia lose 15-20 years of life expectancy, and 5-10% die by suicide, mostly early in the illness.

First-episode psychosis: start at a low antipsychotic dose, avoid polypharmacy, and offer a long-acting injectable if adherence is poor or patient preference favours it.

Schizoaffective disorder requires a major mood episode concurrent with active psychotic symptoms plus at least 2 weeks of delusions or hallucinations without mood symptoms.

Major depressive episode: at least 5 of 9 symptoms for at least 2 weeks, with depressed mood or anhedonia required; the 9 are mood, anhedonia, appetite/weight change, sleep change, psychomotor change, fatigue, worthlessness/guilt, concentration loss, death/suicidal thoughts.

Mania: elevated, expansive or irritable mood with increased energy for at least 1 week (any duration if hospitalised) plus 3 of 7 symptoms (4 if mood is only irritable); hypomania: at least 4 days without marked impairment.

Twelve-month prevalence: major depression about 7%, bipolar I about 0.6-1%, bipolar II about 0.5%; bipolar disorder affects sexes equally and has a mean onset in the early 20s.

Rapid cycling = at least 4 mood episodes in 12 months; more common in women, linked to antidepressants, hypothyroidism and poor outcome.

Lithium: target 0.6-1.0 mmol/L (0.4-0.8 in older adults), level drawn 12 hours post-dose, with renal, thyroid and calcium checks every 6 months.

ECT is indicated for severe or psychotic depression, catatonia, high suicide risk, refusal of food/fluid, and treatment resistance; a course is typically 6-12 sessions.

Pregnancy: paroxetine is avoided (cardiac defects); lithium carries Ebstein anomaly risk; sertraline is often preferred; valproate is contraindicated in women of childbearing potential.

Postpartum psychosis begins usually within 2 weeks of delivery, is a psychiatric emergency with high suicide and infanticide risk, and needs admission plus antipsychotic and mood stabiliser treatment.

Seasonal affective disorder: light therapy 10,000 lux for about 30 minutes in the morning; melancholic features predict better ECT and biological treatment response, atypical features (leaden paralysis, hyperphagia, hypersomnia) do not.

A panic attack peaks within minutes (classically under 10) and needs at least 4 of 13 symptoms; panic disorder requires 1 month of worry about further attacks or maladaptive change in behaviour.

Duration thresholds: generalised anxiety disorder 6 months, social anxiety disorder 6 months, specific phobia 6 months, agoraphobia fear in at least 2 situations.

OCD: obsessions and/or compulsions that are time-consuming (often over 1 hour daily) or cause clinically significant distress; DSM-5 adds insight and tic-related specifiers.

OCD treatment: SSRI at higher doses for 8-12 weeks plus exposure and response prevention; clomipramine or augmenting with a low-dose antipsychotic for refractory cases.

PTSD (DSM-5) after trauma exposure requires at least 1 intrusion symptom, 1 avoidance, 2 negative alterations in cognition/mood and 2 arousal/reactivity changes, lasting over 1 month.

Acute stress disorder lasts 3 days to 1 month after trauma; symptoms beyond 1 month indicate PTSD.

First-line PTSD treatment is trauma-focused CBT (prolonged exposure, cognitive processing) or EMDR; sertraline and paroxetine are first-line drugs; benzodiazepines are avoided.

Obsessive-compulsive and related disorders include body dysmorphic disorder, hoarding disorder, trichotillomania and excoriation disorder.

PANDAS/PANS describes abrupt OCD or tics with other neuropsychiatric symptoms following streptococcal infection or other triggers in children.

DSM-5 substance use disorder uses 11 criteria over 12 months: 2-3 mild, 4-5 moderate, 6 or more severe; tolerance and withdrawal each count as criteria.

Alcohol withdrawal timeline: tremor and autonomic hyperactivity at 6-24 hours, seizures at 12-48 hours, delirium tremens at 48-96 hours.

Give parenteral thiamine before or with glucose in at-risk patients to prevent Wernicke encephalopathy; untreated Wernicke can progress to Korsakoff amnestic syndrome.

Delirium tremens carries untreated mortality of up to 5-15%; treat with benzodiazepines (lorazepam or oxazepam if hepatic impairment), using symptom-triggered CIWA-Ar scoring.

Alcohol pharmacotherapy: naltrexone (opioid antagonist, reduces craving and heavy drinking), acamprosate (maintenance of abstinence), disulfiram (aversive, requires supervision and abstinence).

Opioid use disorder: methadone full agonist or buprenorphine partial agonist (with naloxone combination) for maintenance; naltrexone for relapse prevention after detoxification; naloxone reverses overdose.

Benzodiazepine withdrawal can be life-threatening (seizures, delirium); taper gradually by about 10-25% every 1-2 weeks and never stop abruptly.

Cannabis: no approved pharmacotherapy for cannabis use disorder; heavy use causes cannabinoid hyperemesis syndrome and increases psychosis risk in vulnerable individuals.

Smoking cessation: varenicline is the most effective single agent, followed by combination nicotine replacement and bupropion; assess dependence with the Fagerstrom test.

Cluster A (odd/eccentric): paranoid, schizoid, schizotypal. Cluster B (dramatic/emotional): antisocial, borderline, histrionic, narcissistic. Cluster C (anxious/fearful): avoidant, dependent, obsessive-compulsive.

Borderline pattern: fear of abandonment, unstable intense relationships, identity disturbance, impulsivity, recurrent self-harm, affective instability, emptiness, anger, transient stress-related paranoia.

Dialectical behaviour therapy modules: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness; targets are parasuicidal behaviour, therapy-interfering behaviour, quality of life and post-traumatic stress.

ICD-11 replaced categorical types with a severity dimension (personality difficulty, mild/moderate/severe disorder) plus five trait domains: negative affectivity, detachment, dissociality, disinhibition, anankastia; a borderline pattern qualifier is retained.

Antisocial personality disorder: pervasive disregard for others' rights since age 15, age at least 18, with conduct disorder before age 15.

OCPD is ego-syntonic and features perfectionism, orderliness and control; OCD is ego-dystonic with true obsessions and compulsions.

Psychopathy is measured by the PCL-R (score of 30 or more), with interpersonal/affective and lifestyle/antisocial facets distinct from antisocial personality disorder.

Personality disorders affect about 10% of the general population and are common comorbidities of mood, anxiety and substance use disorders, worsening their prognosis.

Psychological treatments with evidence: DBT, mentalization-based therapy, schema-focused therapy, transference-focused psychotherapy, STEPPS and general psychiatric management for borderline disorder.

ADHD: at least 6 inattentive and/or hyperactive-impulsive symptoms (5 for age 17 and over), present before age 12, for at least 6 months, in 2 or more settings with impairment; prevalence about 5% in children.

ADHD treatment: behavioural parent training and school support first for preschool children; methylphenidate or lisdexamfetamine first line for school-age children; atomoxetine or guanfacine as alternatives.

Autism spectrum disorder: deficits in social communication/interaction plus restricted repetitive behaviours, early onset, about 1-2% prevalence, male:female roughly 3-4:1.

Disruptive mood dysregulation disorder: severe persistent irritability with temper outbursts at least 3 times weekly for 12 months, onset before age 10, diagnosed only between ages 6 and 18.

Tourette disorder: multiple motor tics and at least one vocal tic for over 1 year; first-line treatment is behavioural (CBIT), with antipsychotics or clonidine/guanfacine for impairing tics.

Intellectual disability: IQ about 70 or below with deficits in adaptive functioning, onset in the developmental period; severity is graded by adaptive, not IQ, level.

Childhood depression: fluoxetine is the only agent licensed for under-12s and is combined with psychological therapy; SSRIs carry a small increased risk of suicidal ideation in under-18s requiring close monitoring.

Attachment patterns in the strange situation: secure, insecure-avoidant, insecure-ambivalent/resistant, disorganised (associated with maltreatment).

Eating disorders: anorexia nervosa has significantly low BMI with fear of weight gain; bulimia nervosa has recurrent binges with compensatory behaviours; refeeding syndrome is a key medical risk in malnutrition.

Delirium: acute onset, fluctuating course, inattention and either disorganised thinking or altered consciousness; screen with 4AT or CAM; hypoactive delirium is easily missed.

Delirium management: identify and treat the cause (infection, drugs, pain, constipation, retention, hypoxia), non-pharmacological measures first, and low-dose haloperidol or quetiapine only for severe distress; avoid benzodiazepines except in alcohol or benzodiazepine withdrawal.

Dementia prevalence rises steeply with age; Alzheimer disease accounts for 60-70% of cases, followed by vascular dementia, Lewy body dementia and frontotemporal dementia.

Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) for mild to moderate Alzheimer disease; memantine for moderate to severe disease, alone or added to a cholinesterase inhibitor.

Lewy body dementia: fluctuating cognition, recurrent formed visual hallucinations, parkinsonism and REM sleep behaviour disorder; severe neuroleptic sensitivity means antipsychotics should be avoided.

Frontotemporal dementia presents at 45-65 years with behavioural variant (disinhibition, apathy, loss of empathy) or language variants, and often with motor neuron disease.

Depression in older adults more often presents with somatic complaints, agitation and cognitive impairment (pseudodementia) rather than stated sadness; ECT is safe and effective in this group.

Capacity for a specific decision requires understanding, appreciation, reasoning and expression of choice; the presence of a mental disorder does not by itself negate capacity.

Beers criteria: avoid long-acting benzodiazepines, strong anticholinergics and tricyclics in older adults because of falls, confusion and fracture risk; antipsychotics carry a boxed warning for increased mortality in dementia.

Somatic symptom disorder: distressing or disruptive physical symptoms with excessive thoughts, feelings or behaviours about them, persisting usually over 6 months; illness anxiety disorder involves preoccupation with having or acquiring illness without prominent somatic symptoms.

Conversion (functional neurological symptom) disorder: altered voluntary motor or sensory function with clinical findings of internal inconsistency, not intentionally produced; diagnose positively rather than by exclusion.

Factitious disorder is intentional symptom production for the sick role; malingering is intentional symptom production for external gain (money, avoiding duty) and is not a psychiatric diagnosis.

Epilepsy-related psychoses: postictal psychosis (after a seizure cluster, with a lucid interval), interictal psychosis of temporal lobe epilepsy, and forced normalisation when seizures are suppressed.

Huntington disease is autosomal dominant (CAG repeat expansion), with chorea, cognitive decline and prominent depression and suicide risk often preceding motor signs.

Medical mimics of psychosis and mood disorder to exclude: B12/folate and thiamine deficiency, thyroid disease, hypercalcaemia, neurosyphilis, HIV, systemic lupus erythematosus, Wilson disease and anti-NMDA receptor encephalitis.

Corticosteroid-induced psychosis is typically affective or manic in polarity, dose-related, and managed by dose reduction plus short-term antipsychotic or mood stabiliser.

Post-stroke depression affects up to a third of survivors, is commoner with left frontal lesions, and responds to SSRIs; emotionalism (pathological laughing/crying) responds to SSRIs.

Serotonin syndrome (clonus, hyperreflexia, agitation, hyperthermia, hours) and neuroleptic malignant syndrome (rigidity, bradyreflexia, hyperthermia, days) must be differentiated because management differs.

Common SSRI adverse effects: nausea, insomnia, sexual dysfunction, hyponatraemia/SIADH (especially in older adults), increased bleeding risk with NSAIDs/anticoagulants, and a discontinuation syndrome on abrupt stopping.

Tricyclic overdose is lethal: anticholinergic effects, coma, seizures and cardiotoxicity with QRS widening over 100 ms; give intravenous sodium bicarbonate, avoid class IA antiarrhythmics.

MAOIs cause the tyramine pressor reaction; allow a 2-week washout (5 weeks after fluoxetine) when switching to or from an MAOI, and avoid combining with SSRIs, tramadol or linezolid.

Lithium toxicity features tremor, ataxia, confusion, vomiting and seizures; risk rises with dehydration, NSAIDs, ACE inhibitors, thiazides and renal impairment.

Valproate carries about 10% risk of major congenital malformation and 30-40% risk of neurodevelopmental disorder after prenatal exposure; it must not be used in women of childbearing potential without a pregnancy prevention programme.

Lamotrigine must be titrated slowly (rash, Stevens-Johnson syndrome); the dose is halved with valproate and increased with enzyme inducers such as carbamazepine.

Antipsychotic monitoring: weight/BMI, waist, blood pressure, fasting glucose or HbA1c and lipids at baseline, 12 weeks and then annually (more often for clozapine and olanzapine).

QTc prolongation: highest risk with thioridazine, pimozide, haloperidol (intravenous), ziprasidone and quetiapine; keep QTc under 500 ms and correct potassium and magnesium.

CYP interactions: smoking induces CYP1A2 (lower clozapine/olanzapine levels), fluoxetine and paroxetine inhibit CYP2D6, and grapefruit inhibits CYP3A4.

ECT technique: brief general anaesthesia and muscle relaxation, unilateral or bilateral electrode placement, typically 2-3 sessions weekly for 6-12 treatments; commonest adverse effects are transient memory problems.

Cognitive therapy (Beck) targets negative automatic thoughts and cognitive distortions through behavioural experiments and thought records; the cognitive triad is negative views of self, world and future.

Behavioural activation is as effective as full CBT for depression and focuses on increasing activity and reducing avoidance.

Exposure and response prevention is the psychological treatment of choice for OCD: graded exposure to obsessional triggers with prevention of the ritual that reduces anxiety.

Dialectical behaviour therapy (Linehan) combines individual therapy, skills group, telephone coaching and consultation team, and reduces self-harm and hospitalisation in borderline personality disorder.

Prochaska and DiClemente stages of change: precontemplation, contemplation, preparation, action, maintenance, relapse; motivational interviewing (OARS: open questions, affirmations, reflections, summaries) matches the stage.

Expressed emotion (criticism, hostility, emotional overinvolvement) predicts relapse in schizophrenia; family interventions of at least 10 sessions reduce relapse rates.

Yalom's therapeutic factors in group therapy include universality, altruism, instillation of hope, corrective recapitulation, imitative behaviour, catharsis and existential factors.

Mentalization-based therapy (Bateman and Fonagy) improves reflective function in borderline personality disorder and reduces suicide attempts and hospital admissions.

Stepped care: low-intensity guided self-help and psychoeducation first, then high-intensity CBT or interpersonal therapy, then specialist or combined pharmacological treatment for complex or refractory presentations.