This document summarizes various topics in psychiatry including sexual disorders, electroconvulsive therapy, psychotherapy, and Jean Piaget's stages of cognitive development. It discusses normal sexual response cycles and disorders that impact desire, arousal, orgasm and resolution. It also outlines techniques for treating premature ejaculation and erectile dysfunction. Gender identity disorder and paraphilias are explained. Details are provided about ECT administration and mechanisms of action. An overview of Freudian psychoanalytic theory and different psychotherapy approaches are presented.

1. SEXUAL DISORDERS
ELECTRO-CONVULSIVE THERAPY
PSYCHOTHERAPY
MISCELLANOUS PSYCHIATRY
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2. Sexual disorders
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3. Normal human sexual response cycle
Female has increased
lag period & have
multiple orgasm
Desire  arousal  orgasm  resolution
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4. Disorders of normal response cycle
Desire Arousal Orgasm resolution
Decreased desire 
decreased libido
(FRIGIDITY)
Increased sexual
desire
• Increased
prolactin by
antipsychotics 
decrease libido
• Flibanserin 
DOC for
decreased libido
in female
• In male
satyriasis
• In female
nymphomania
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5. Premature ejaculation
• Ejaculation occurring earlier before satisfying sexual needs of either sex
• MC cause is anxiety
• NONPHARMACOLOGICAL
• Squeeze technique (masters & Johnson technique)
• Start& stop technique (seamans technique)
• Sex therapy
• Sensate focussing
• PharmacologicAL
• SSRI  delayed ejaculation (DAPOXETINE new drug used in premature
ejaculation)
• Hence used in rx of premacture ejaculationTONY SCARIA 2010
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6. Sensate focusing
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7. Erectile dysfunction
Psychogenic Organic
Early morning erection + -
Penile tumescence + -
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8. Nocturnal penile tumescence recorder
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9. • Rx
• Non Pharmacological
• Sex therpay
• Sensate focussing
• Penile prosthesis /vacuum constrictor devices
• Pharmacological
• Sildenafil (PDE5 inhibitor)
• Phentolamine /Papaverine (PIPE therapy Phentolamine /Papaverine induced penile
erection)
• Alprostadil (PGE1)
• Androgens TONY SCARIA 2010
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10. Gender identity disorder
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11. Gender identity disorder
• Gender dysphoria
• Characterised by
• Persistent discofort with his or her sex
• Strong & persistent cross gender identification
• Wearing clothes of other sex
• Repeatedly stated desire to be or instance that he or she is of other sex
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13. Transsexualism Dual-role transvestism
Most characteristic feature is that there is marked
preoccupation with the wish ro get rid of ones genitals
& secondary secxual characteristic & to adopt the sex
characteristic of othersex
people who wear clothes of the opposite sex to
experience being the opposite sex temporarily, but
don't have a sexual motive or want gender
reassignment surgery.
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14. Disorder of sexual preference  Paraphilia
• Paraphilias-
• Abnormal and unorthodox sex-play by using unusual objects or parts of the
body
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15. paraphilia
Abnormalities
in choice of
sexual object
Inanimate object Fetichism Shoes or garments of other sex for
sexual gratification
Animate object Paedophilia Child
Bestiality Animals
necrophilia Dead body
Abnormalities
in sexual act
Exhibitionism Exposure of ones genital organs to strangers or others
Voyeurism Watching sexual activity of other people or other body parts
Sadism Infliction of pain/ humiliation on the partner
Masochism Sexual excitement achieved by being beaten up by partner
Frotteurism Fondling or rubbing against body of unfamiliar women
Undinism Sexual pleasure by urination
Coprophilia Sexual pleasure from faeces
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16. Fetchism  sexual gratification by shoes or
garments of opposite sex
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17. TONY SCARIA 2010
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18. Rx of paraphilia
• Antidepressnats
• Li & SSRI
• Mood stabilisers
• Antiandrogens
• To decrease sexual drive
• Long acting gonatropin releasing hormone
• Medical castration
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19. ECT
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20. • Von Meduna
• 25 % camphor in oil  seizures
• Cerletti & bini  modern ECT
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21. Indications
• Severe depression
• With suicidal risk 
• First & most important indication for ECT
• With stupor
• With decreased intake of food & fluids
• Severe catatonia (non organic)
• Severe psychosis
• With risk of suicide / homicide or danger of physical assault’
• Severe aggreesion not responding to drugs
• With unsatisfactory response to drug therapy
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22. C/I
• Absolute C/I
• Nil
• Relative
• Severe HTn
• Pheochromocytoma
• Recent MI
• CVA
• Raised ICT
• Retinal detachment
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23. Techniques of ECT
• Direct ECT
• Absence of muscle relaxants & GA
•  # & tooth dislocations
• Modified ECT
• With muscle relaxation & GA
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24. Two types
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25. Bilateral ECT
• Standard form used most
commonly
• Electrode placement on both
sides of skull
• Above 2.5cm -4cm above midline
b/w tragus & lateral canthus of
eye
Unilateral ECT
• Placed only on one side usually
on nondominant side
• Safer
• Less S/E
• Less memory disturbances
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26. MOA
• Increase in BDNF (brain derived neurotrophic factor)
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27. • Therapic adequacy is determined by development of generalised
tonic clonic seizure lasting for not less than 25-30 sec
• Total duration & no depends upon diagnosis
• Usually 6-10 are sufficient
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28. S/E
• Memory disturbances
• Most common S/E
• Retrograde amnesia
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29. Cognitive development stage
• Jean piaget
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30. Jean piagets cognitive developmental stage
Sensorimotor stage Preoperational stage Concrete operational stage Formal operational satge
Birth – 2 years 2-7 years 7-11 years Above 11 years
Learns through sensory observation & they
control of their motor functions through activity
development of
object
permanence
• Differentiates self
from objects
• realizes that things
continue to exist
even when no longer
present to the sense
Egocentric thinking Child has difficulty
taking the viewpoint
of others
Volume
Conservation:
Achieves conservation of
nurnber (age 6), mass
(age 7), and weight(age9)
• Can think logically about abstract prepositions
and test hypotheses systemically.
• Becomes concerned with the hypothetical,
the future and idealogical problems.
• Can conceptualize or generalize
understanding that each concept can have
multiple meanings, i.e. Abstract thinking is
ability to form or understand concepts that
are not seen or that can not be touched.
• The ability to systematically solve a problem
in a logical and methodical way emerge.
Animism Belief that
inanimate objects
are capable of
actions and have life
like qualities
Classification Classifies objects according
to several features and
can order them in series
along a single dimension
such as size (seriation)Symbolization: Ability to create visual
image of object
Primitive (intuitive)
thinking
Unable to think
logically
Reversibility Able to realize reversibility
of things that can turn
into another e.g., ice and
water
Magical thinking/
phenomenalistic
causality/fantasy
The events occuring
together are
thought to cause
one another
Transitivity : - The ability to recognize
logical relationship
among elements in
serial orders and perform
transitive inference
Centration act of focusing all
attention on one
characteristic
compared to others
Can only solve problems that apply to actual
(concrete) objects
or events, and not abstract concepts or
hypothetical tasks
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32. • Sensorimotor stage (birth to 2 years)
• Through sensory observations gains control over motor functions
• Out of sight out of mind & here and now type of thinking
• If he cannot see an object he thinks it exists no longer
• Object permanence
• Object exists even if not visible
• He will try to search for missing object
• Indicates transition to next stage
• Symbolisation
• At around 18 months
• Start developing mental symbols
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33. • Stage of preoperational thought
• Egocentric
• Concerned about their own needs cannot think
from others perspective
• Intuitive thought
• Thinking without logic & reasoning
Egocentric
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34. • Stage of concrete
operations (7-11 years)
• Operational thought
• Preoperational thought
(egocentric) replaced by
operational thought
• Thinks from others
perspective also
• Conservation
• Despite change in shape
object remains same
• Reversibility
• One thing csn be turned in
to another & back again
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35. • Stage of formal adolescence (11 –
end adolescence )
• Abstract thinking
• Understand deeper meaning & larger
meaning
• Logical thinking
• Hypothetico deductive thinking
• Make hypothesis & use deductive
thinking
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36. Object constancy Object permanence
Described in objects relations theory Described in cognitive development theory
Remaining calm following separation from separation
form primary care taker
Understanding that an object lost from vision still exist
Develops by 24-36 months Develops by 7-12 months
• Object constancy ill development
 separation anxiety
• Anaclitic depression
depression d/t separation of
peimary care taker in early years
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37. Freuds topographic theory of mind
Conscious preconscious unconscious
that part of the
mind in which
perceptions
coming from the
outside world or
from within the
body or mind are
brought into
awareness
those mental
events, processes,
and contents
capable of being
brought into
conscious
awareness by the
act of focusing
attention
mental contents
and processes kept
from conscious
awareness
through the force
of censorship or
repression
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38. • Conscious
• Part of mind accessible to us
• Everything we know about ourelf is part of conscious mind
• Preconscious
• Normally not accessible
• Repression submerged into unconscious mind
• Can be recalled by focussing attention
• Unconscious
• Not accessible
• Instinct drives
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39. • Failure of repression in unconscious mind  neuroses
• d/t unconscious conflict neurosis
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40. Repressed thoughts can be brought to
consciousness by
• Hypnosis
• Somatic stimulation
• Dream interpretation
• Automatic writing
• Eye movement desensitisation & reprocessing
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41. Structural theory of mind by freud
Id Ego Super ego
Present from birth 5-6 months Last to develop (4-5 yrs)
Entirely unconscious Functions in conscious
unconscious preconscious
mind
Occur largely unconscious
Pleasure principle Reality principle Idealism principle
Instinctive & primitive
reflex behaviour
Strives to to satisfy ids
desires in realistic &
socially appropriate way
Tries to prove or disprove
urge of id
Component of personality
responsible for dealing
with reality
Internalised moral ideals &
standard obtained from
parents & society
Responsible for defence
mechanism
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42. Structural theory of mind
• Id
• Instinctual drive
• Hunger anger sex
• Immediate gratification
• Pleasure principal
• Ego
• Reality principle
• Ego has both conscious & unconscious
components
• Defence mechanism  in unconscious part
• Maintains balance b/w id & superego
• Superego
• Has mostly unconscious & less conscous partTONY SCARIA 2010
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43. Freuds primary & secondary process of
thinking
Primary process Secondary process
Associated with id Directly related to learned & acquired functions of ego
Unorganised non logical thinking Logical thinking
Unconscious mental activity Conscious & preconscious mental activity
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44. Primary process thinking
• Immediate wish fulfilment &
instinctual discharge with out
thinking of consequences
• Illogical & contradictory
• Normally in dream
• abnormally in psychosis
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45. PSYCHOTHERAPY
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46. TONY SCARIA 2010
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47. Psychotherapy
• Rx of psychiatric disorders by psychological methods
• Behaviour therapy
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48. Psychoanalysis
Psychoanalysis depends on dream interpretation, transference manifestation, and
recovery of repressed memories
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49. Sigmeud freud
• Father of psychoanalysis
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50. Doctor patient relationship
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51. Parapraxis
• Slips of tongue
• Important information
about unconscious mind
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52. Transference means feeling pt develops toward
doctor and emotion of therapist towards client
is called as counter transference.
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53. transference & countertransference
• In doctor patient relationship
Transference Counter transference
Patient towards therapist Therapist towards client
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54. TONY SCARIA 2010
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55. Transference
• Feeling the patient develops for the
doctor
• Past feelings + real feelings for clinician
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56. Contertransference
• Feeling therapist develops
toward patient during
psychotherapy
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58. TONY SCARIA 2010
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59. Catharsis /abreation
• Client getting in touch with inner emotions or distress in a therapeutic
setting
• Emotional release after recall of painful experience
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60. Shaping in psychotherpay
• Approximation
• Breaking down in to small
steps to reach target
• Reinforced at each step
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61. Modelling
• Observational learning
• Follows steps of chosen model
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62. Types of psychotherapy
Psychodynamic Deals with subconscious motives or conflicts
Cognitive behaviour therapy Thoughts feelings behaviours are interlinked
Logotherapy Understaning the underlying meaning
Behavioural therapy Learning & conditioning principles
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63. Behaviour therapy
• Maladaptive behaviors are learnt by classical conditioning or operant
conditioning
• Behaviour therapy is a psychological Rx in which maladaptive
behaviours are changed to improve quality of life
• Systematic desensitisation
• Therapeutic graded exposure
• Flooding
• Modelling
• Aversive conditioning
• Social skill training
• Assertive training TONY SCARIA 2010
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64. Systematic desensitisation
• Joseph wolpe
• Used in phobias & OCD
• Based on principle of reciprocal inhibition
• If an anxiety provoking stimulus is provided while a person is In a relaxed
state
Anxiety gets inhibited
• Relaxation initially taught by progressive muscle relaxation technique
• Followed by hierarchy of feared situation
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67. Therapeutic graded exposure /in vivo
exposure
• Used in phobias & OCD
• Similar to systemic desensitisation
• Hierarchy of feared stimulus+
• Except for NO MUSCLE RELAXATION TECHNIQUES ARE USED
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68. Flooding or implosion
• No hierarchy of feared stimulus
• No relaxation technique
• Used in phobia
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69. Modelling (participant modelling)
• Therapist himself makes contact with phobic stimulus
• Demonstrates this to the patient
• Patient learns by imitation & observation
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70. Exposure response prevention
• In OCD
• Prevent routine response & allow individual to habituate to higher
levels of anxiety
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71. Aversive conditioning
• Based on classical conditioning
• Rx of unwanted behaviours PARAPHILIAS
• Pairing of unwanted behaviour (SMOKING)
& painful stimuli (ELECTRIC SHOCK)
• Rarely used d/t ethical considerations
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72. Assertiveness trainining
• A person is taught to be assertive
while asking for his rights & while
refusing unjust demands of others
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73. Social skills training
• Usually used in patients with schizophrenia
• It involves imparting skills required for dealing with others & living a
social life
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74. Learning principles of behaviour
therapy
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75. Learning theory
• Classical conditioning
• Pavlov
• Operant conditioning
• Skinner
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76. Elements of Classical conditioning
• Unconditioned stimulus
• Stimulus which naturally produces a response without any learning
• Smell of food  salivation
• Unconditioned response
• Natural response to unconditioned stimulus
• Salivation  unconditioned response
• conditioned stimulus
• Stimulus when paired with unconditioned stimulus response
• conditioned response
• Response to conditioned stimulusTONY SCARIA 2010
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77. Pavlov dog conditioning
conditioned response
Unconditioned
stimulus
Unconditione
d response
conditioned stimulus
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78. Extinction
• If conditioned stimulus is presented repeatedly with unconditioned
stimulus
• Response will decrease & eventually disappear
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79. Stimulus generalisation
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80. Operant conditioning
• Any behaviour can be learned or unlearned & its frequency can be
changed by modifying consequences of that behaviour
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81. Operant conditioning
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82. • Positive reinforcement (reward)
• Behaviour is increased by a positive consequence
• Negative reinforcement
• Behaviour is increased to avoid a negative consequence
• Punishment
• Behaviour is decreased by negative consequence
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83. Reinforcement
• To increase desirable behaviour
+ve reinforecemnt -ve reinforcement
Rewards /praize/money Aversive environment till completion of
job
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86. Biofeedback
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87. Biofeedback
• Operant conditioning
• Bases on a feedback instrument
• Autonomic nervous system which
is involuntary can be brought
under voluntary control with the
help of operant conditioning
• Used in Rx of ANS
• BA
• Tension headache
• Arrhythmia
• Control muscle tone  Rx bruxism
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88. Cognitive behaviour therapy
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89. TONY SCARIA 2010
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90. Cognitive therapy
• Used by AARON BECK
• Used in cognitive distortions
• Maladaptive assumptions
• 3 components of cognitive behaviour therapy
• Didactic aspects
• Cognitive technique
• Behavioural technique
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91. Cognitive therapy
• Cognitive therapy is based on the concept that psychopathology is a
consequence of distorted beliefs and faulty assumptions.
• Used in
• depression
• Anxiety
• Panic disorder
• OCD
• Personality disorders
• Somatoform disorders
• Eating disorder
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92. 3 components of CBT
• Didactic aspects
• Cognitive technique
• Behavioural technique
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93. Behavioural therapy
Thoughts Behaviours Emotions
Automatic thoughts
Cognitive errors
Schemas
Behavioural activation in
depression
Emotional regulation
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94. Stages of CBT
Stages of CBT
• Precontemplation
• Contemplation
• Preparation/planning
• Action
• Maintenance
• Recovery/ relapse
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95. TONY SCARIA 2010
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96. In substance abuse disorder
Motivational interviewing
• Motivating the patient to quit ambivalence in
case of substance abuse disorder
• Motivate the patient to quit smoking
Assertiveness training
• To say NO
• To decrease peer pressure
Relapse prevention
• To prevent relapse
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97. Psychosocial Rx in substance abuse disorders
• Patients with substance
use go through a seies
of changes before
quitting substance abuse
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98. Not aware of the problem
• Aware of problem
• Pros & cons of stopping
substance
• No plan how to quit
• Makes a plan to quit
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99. TONY SCARIA 2010
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100. • Most commonly used in substance use
• Motivation enhancement therapy /motivational interviewming
• Increases the motivation of the patient
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101. EMDR
• Eye movement desensitisation & reprocessing
• In post traumatic stress disorder
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102. EMDR in PTSD
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103. Cognitive distortions
• Common thinking errors described in the cognitive model are
• arbitrary inference (drawing a conclusion in the absence of sup porting
evidence),
• selective abstraction (focusing on only one small part of a situation or
event while ignoring other, usually more positive, aspects),
• over- generalization (drawing a general conclusion on the basis of a single
incident),
• magnification (of problems) and
• minimization (of positive factors),
• personalization (tendency to relate external events to oneself without
reason for doing so), and
• dichotomous thinking (extreme, black-or-white thinking).
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104. Jumping to conclusion
• Making an interpretation with
minimal evidence
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105. Personalisation
• Blaming yourself for an event
which you are not responsible
for
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106. Transcranial magnetic stimulation
• Noninvasive method to cause depolarisation in the neurons of brain
• Using electromagnetic induction using a rapidly changing magnetic field
• OCD
• PTSD
• Resistant major depression
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107. Psychosurgery
• In c/c severe OCD
• c./c depression
• Severe uncontrolled aggressive behaviour
• Stereotactic subcaudate tractotomy
• Severe depression & OCD
• Stereotactic limbic leucotomy
• Limbic system is responsible for emotions
• Amydalotomy
• In uncontrolled aggression
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108. Deep brain stimulation
• Small electrical stimulator implsnted in to a defined brain location
which typically provides c/c brain stimulation
• b/l DBS of subthalamus or globus pallidus
• Rx of parkinsons ds
•
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109. Phototherapy
• In seasonal depression
• Sleep disorder
• Jet lag
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110. Sleep deprivation
• To Rx depression
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111. Neuropsychological test
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113. Projection test
• Using ambiguous stimuli
• while responding patent projects his own ideas
Rorsachs inkblot
test
Thematic
apperception test
Sentence
completion
Draw a person test
Using inkblots Using pictures 
make story
Series of sentences
are used
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114. Rorschach ink blot test  shown to the
patient and asks what he sees in the card
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117. Bender gestalt test
• Screening tool for organic brain disorders
• Involves copying of figures
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118. Halsted reitan battery organic brain ds
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120. Memory
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121. • Memory consolidation in REM sleep
• Steps in memory
• Encoding /registration
• Storage
• Recall/retrieval
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122. Interference theory
Proactive interference Retroactive interference
Earlier acquired information interferes with
retrieval of new information
Newly acquired information interferes with
early acquired information
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137. Stockholm syndrome
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138. Stockholm syndrome
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139. stockholm syndromeTONY SCARIA 2010
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140. Miscellaneous
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141. IDEAS
• Indian disability evaluation and assessment scale (IDEAS)
• In patients with schizophrenia
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142. Right of person with disability act 2016
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143. RPwD
• Benchmark disability  40 %
• No conditions increased from 7 to 21
• MR +mental illness + learning disability+cerebral palsy
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146. Grief reaction by kubler
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147. Pathological grief
• Absent grief
• Delayed grief
• Hypertrophic grief
• Chronic grief
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148. GERSTMANN SYNDROME
• Lesion in dominant parietal lobe
• Agraphia
• Acalculia
• R/L confusion
• Finger agnosia
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149. Huntington chorea
• 4th decade
• AD
• 4th chromosome
• Caudate N + putamen involved
• Dementia
• Chorea
• CAG trinucleotide repeats
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150. NT in psychiatric disorders
Depression NE serotonin and dopamine are decreased
Schizophrenia NE Dopamine serotonin are increased
Mania NE Increased
Panic disorder NE (increased)
serotonin GABA (decreased)
CCK –pentagastrin /tetrapeptide
OCD Serotonin decreased
Alzheimers ds Acetycholine NE (decreased)
Glutamate (increased)
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151. Duration in psychiatric ds
Postpartum blues Starting after 2-3 days & resolves with in 10 days
Post partum mood disturbances with in 4 weeks of delivery
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152. Duration of psychiatric ds
hypoania Symptoms for 4 days
Mania Symptoms for 7 days (1 week)
Depression Symptoms for 2 weeks
Effect of antidepressant In 3 weeks
Acute stress disorder Symptoms last <4 weeks (from 3 days to 4 weeks)
Post traumatic stress disorder Symptoms last > 4 weeks & onset with in 6 months of stressor
Adjustment disorder Onset With in 3 months of stressor & lasts < 6moths (>6 months
in presence of c/c stressor)
Generalised anxiety disorder >6 months
Rapid cycling 4 or more episodes of depression and or mania or hypomania
occur per year
With either less than 2 weeks of normal mood b/w episodes or
switch directly from one pole to another with out intervening
normal period
Pathological grief > 1 year
Persistent mood disorder (dysthymia /cyclothymia) More than 2 years
TONY SCARIA 2010
KMC

153. Duration
Panic attack One attack followed by 1 month of persistent concern
of future attack /worry about consequence of attack /
Bulimia nervosa Atleast twice a week for 3 months
ADHD Symptoms for > 6 months in a child <12 yrs of age
Tourette syndrome Onset in age <18 yrs
Tics that persist for > 1 year
TONY SCARIA 2010
KMC

154. Duration
Schizoaffective disorder >2 weeks
brief psychotic disorder Lasts <1month
Usually stress related
Delusional disorder Last > 1month
Schizophreniform disorder lasts 1-6 months
Schizophrenia > 6 months
TONY SCARIA 2010
KMC

155. Phileppel pinel • Father of modern psychiatry
• Moral & humane treatment of mentally ill
Jones Maxwell propagated therapeutic community concept
Sigmund freud Father of psychoanalysis
TONY SCARIA 2010
KMC

156. Sigmeund freud
• Psychoanalysis
• Topographic theory of mind
• Id superego ego
• Cocaine in psychiatry
• Psychodynamic theory
• Psychosexual development
• Free association
TONY SCARIA 2010
KMC

157. Topographic theory of mind
TONY SCARIA 2010
KMC

158. Free association by sigmond freud
TONY SCARIA 2010
KMC

159. Syndromes
TONY SCARIA 2010
KMC

160. Othello syndrome • Alcoholic
• Delusional jealousy (infedility)
Magnan syndrome • Tactile hallucination (formication)+ delusion of
presecution
• Cocaine bugs
DeChemerlaut • Erotomania
• Delusion of love
Ekbom syndrome • Delusional parasitosis  restless leg syndrome
TONY SCARIA 2010
KMC

161. Delusional misidentification syndrome
Capgras syndrome (delusion of double) Patient falsely sees a familiar person as a complete
stranger who is imposing them as a familiar person
Fregoli syndrome Patient falsely identifies stranger as a familiar person
syndrome of subjective double Patient own itself is perceived as being replaced by
double
Syndrome intermetamorphosis A aflse belef that a person can transform in toa nother
person
Most commonly appear in schizophrenia
TONY SCARIA 2010
KMC

162. Ganser syndrome • Syndrome of approximate answers
• Approximate answers + clouding of consciousness
+ hallucination
TONY SCARIA 2010
KMC