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Dementia

DEMENTIA


DEMENTIA

Introduction:

  • Defined as a progressive impairment of cognitive functions in absence of any disturbances of consciousness.

Prevalence:

  • Increases with age.
  • 5% in population older than 65 years; 20-40% in older than 85 years. 

Symptoms:

1. Cognitive impairment:

  • Characterized by 4 A’s: amnesia, aphasia, apraxia & agnosia.

Amnesia: 

  • Memory impairment.
  • Can be episodic (memory for events) & semantic (memory for facts rules, words and language) & visuospatial deficits.

Aphasia: 

  • Disturbances of language function.

Apraxia: 

  • Inability to perform learned motor functions.
  • Eg: Difficulties in functions like buttoning the shirt or combing the hair.

Agnosia:

  • Inability to interpret sensory stimulus.
  • Most common disturbance -‘prosopagnosia” – Inability identifing face.

Other cognitive impairments:

  • Disturbances in executive functioning (i.e. planning, organizing, sequencing & abstracting).

2. Behavioral & psychological symptoms:

  • Personality changes, hallucinations & delusions, depression, manic & anxiety symptoms, apathy, agitation, aggression, wandering circadian rhythm disturbances, catastrophic reaction.
    • Catastrophic reaction – Subjective awareness of intellectual deficits in stressful situation result in emotional outburst in dementia patient.

3. Focal neurological signs & symptoms:

  • Seen in vascular dementia (multi-infarct dementia) corresponding to site of vascular insults.

Types:

1. Depending on reversibility – Reversible dementia (15% patients) & Irreversible dementia.

Causes of reversible dementia:

  • Neurosurgical conditions (subdural hematoma, normal pressure hydrocephalus, intracranial tumors, intracranial abscess).
  • Infectious causes (meningitis, encephalitis, neurosyphilis, lyme disease).
  • Metabolic causes (vitamin B12 or folate deficiency, niacin deficiency, hypo and hyperthyroidism, hypo & hyperparathyroidism).
  • Others (drugs and toxins, alcohol abuse, autoimmune encephalitis).

2. Depending on involvement of area of brain:

  • Cortical & Sub-cortical (As to area affetced by dementing process first).

Cortical dementias: 

Clinical features: 

  • Characterized by early involvement of cortical structures & hence, early appearance of cortical dysfunction.
  • Amnesia, apraxia, aphasia, agnosia & acalculia (impaired mathematical skills) indicating cortical involvement.

Subcortical dementia: 

Clinical features

  • Early involvement of subcortical structures (basal ganglia, brain stem nuclei & cerebellum).
  • Characterized by early presentation of motor symptoms (abnormal movements like tics, chorea, dysarthria).
  • Significant disturbances of executive functioning.
  • Prominent behavioral & psychological symptoms (apathy, depression, bradyphrenia (slowness of thinking).

Conditions associated: 

  • Parkinson’s disease, Wilson’s disease, Huntington’s disease, multiple sclerosis, progressive supranuclear palsy, normal pressure hydrocephalus.

Other types of dementia:

  • Vascular dementia (multi-infarct dementia), lewy body disease (dementia with lewy body), HIV related Dementia, frontotemporol dementia (FTD) & pseudodementia

1. Vascular dementia (multi-infarct dementia):

  • 2nd most common type of dementia.
  • History of stroke.

Causes:

  • Occurrence of multiple cerebral infarction (due to occlusion of cerebral vessels by arteriosclerotic plaques or thromboemboli) → progressive deterioration of brain functions →  dementia.
  • Acute exacerbations corresponding to new infarcts → Stepwise deterioration of symptoms (step-ladder pattern).

Treatment: 

  • Management of risk factors & cholinesterase inhibitors.

2. Binswanger’s disease:

  • Also referred as “subcortical arteriosclerotic encephalopathy”.
  • Characterized by multiple small white matter infarctions —> Result in subcortical dementia symptoms.

3. Lewy Body Disease (Dementia with Lewy Body):

  • Clinical features similar to Alzheimer’s disease.

Pick’s dlsease: 

  • One pathological variant of FTD. 
  • Characterized by presence of pick’s bodies.
  • Earlier onset (45-65 years).
  • Presents with behavioral symptoms & change in personality with relative memory preservation.

7. Pseudodementia:

  • Depression in elderly patients mimicing dementia symptoms.

Management for dementia:

  • mini mental status examination (MMSE):
    • Screening test.
    • Evaluation of cognitive functions.
    • Score of less than 24 (out of a maximum 30) – Suggestive of dementia.

Medications:

  • Cholinesterase inhibitors  – Donepezil, rivastigmine, galantamine & tacrine.
  • NMDA receptor antagonist – Memantine.
  • Symptomatic treatment – For behavioral & psychological symptoms of dementia.
    • Includes antidepressants, antipsychotics & benzodiazepines.

Exam Important

  • Cognitive impairment in dementia is characterized by 4 A’s: amnesia, aphasia, apraxia & agnosia.
  • Catastrophic reaction is subjective awareness of intellectual deficits in stressful situation result in emotional outburst in dementia patient.
  • Reverslble causes of dementia includes subdural hematoma, normal pressure hydrocephalus, intracranial tumors, intracranial abscess.
  • Alzheimer’s disease is the prototype of cortical dementia.
  • Binswanger’s disease is also known as subcortical arteriosclerotic encephalopathy.
  • Pick’s dlsease is one pathological variant of FTD characterized by earlier onset & presence of pick’s bodies.
  • Depression in elderly patients may mimic symptoms of dementia and hence is known as pseudodementia.
  • The evaluation of cognitive tunctions in dementia is done using screening test of mini mental status examination (MMSE).
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Amnestic Disorders

AMNESTIC DISORDERS


AMNESTIC DISORDERS

  • Broad category including variety of conditions presenting amnestic syndrome.

Features:

  • Characterized by inability to form new memories (anterograde amnesia) & inability to recall previously remembered knowledge (retrograde amnesia).
  • Short-term & recent memory – Impaired with preservation of remote & immediate memory.

Causes:

Major causes:

  • Thiamine deficiency (Korsakoff syndrome).
  • Hypoglycemia.
  • Primary brain conditions (head trauma, seizures, cerebral tumors, cerebrovascular disease, hypoxia, electroconvulsive therapy, multiple sclerosis).
  • Substance related disorders (alcohol, benzodiazepines).

Exam Important

  • Major causes of amnestic disorders are thiamine deficiency (Korsakoff syndrome), hypoglycemia, primary brain conditions (head trauma, seizures, cerebral tumors, cerebrovascular disease, hypoxia, electroconvulsive therapy, multiple sclerosis).
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Dyssomnia & Parasomnia

DYSSOMNIA & PARASOMNIA


DYSSOMNIA & PARASOMNIA

I) Dysomnia

Introduction:

  • Characterized by abnormality in duration or quality of sleep.

Subtypes:

  • Insomnia.
  • Hypersomnia.

1. Insomnia:

Features:

  • Decreased sleep.
  • Difficulty in initiation of sleep.
  • Difficulty in maintenance of sleep.
  • Frequent awakening during night.
  • Early morning awakening.
  • Nonrestorative sleep.
  • Not feeling refreshed in morning due to poor quality of sleep.

Syndromes associated:

Periodic limb movement disorder: 

  • Non-restorative sleep and day time sleepiness.

Restless leg syndrome (Ekbom syndrome):

  • Difficulty in initiation of sleep due to moving legs. Treated with ropinirole (dopamine agonist).

Treatment:

  • Benzodiazepines, zolpidem & hypnotics.

2. Hypersomnia:

Features: 

  • Excessive sleepiness.
  • Prolonged sleep episodes.
  • Excessive day time sleep episodes.

Syndromes associated:

Narcolepsy:

  • Reduced latency of REM sleep (reaching REM sleep earlier).
  • Sleep attacks (irresistible urge for sleep at anytime of day) & sleep paralysis (Occurs in morning. patient awake but unable to move body).

Kleine-Levin syndrome:

  • Characterized by episodes of hypersomnia, hyperphagia & hypersexuality (increased sexual activity).

II). PARASOMNIA:

Introduction:

  • Disorders characterized by dysfunctional events associated with sleep.

Subtypes:

Stage 4, NREM sleep disorders:

  • Occur during stage 4, NREM.

Events:

  • Night terror or sleep terror (pavor nocturnus).
  • Sleepwalking (somnambulism).

Sleep-related enuresis – 

  • Most common cause of bed wetting – Due to psychosocial (sibling rivalry).
  • Treated by bed alarms, imipramine & intranasal desmopressin.
    • Bruxism (teeth grinding).
    • Sleep talking (somniloquy).

Other sleep disorders:

Nightmare:

  • Occurs during REM sleep.
  • Patient able to recall dream (contrast to night terror).

Exam Important

  • Restless leg syndrome (Ekbom syndrome) is associated with sleep disturbances treated with ropinirole.
  • Narcolepsy exhibits reduced latency of REM sleep.
  • Kleine-Levin syndrome is characterized by episodes of hypersomnia, hyperphagia & hypersexuality.
  • Night terror or sleep terror (pavor nocturnus), Sleepwalking (somnambulism), Sleep-related enuresis & Bruxism (teeth grinding) are all features of Stage 4, NREM sleep disorders.
  • Sleep-related enuresis is most common cause of bed wetting.
  • Nightmare occurs during REM sleep.
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Compilation Of Psychiatric Disorders In Pediatric Patients

COMPILATION OF PSYCHIATRIC DISORDERS IN PEDIATRIC PATIENTS


COMPILATION OF PSYCHIATRIC DISORDERS IN PEDIATRIC PATIENTS

  • Important psychiatric disorders in pediatric patients include,
    • Conduct disorder.
    • Oppositional defiant disorder.
    • Specific disorders of scholastic skills – Learning disorders.

Conduct disorder:

  • Associated with unsatisfactory family relationships & failure at school.
  • Later stages lead to antisocial personality disorder (dissocial personality disorder).

Features:

Characterized by –

  • Repetitive & persistent pattern of disregard for rights of others.
  • Aggressiveness & dissocial behavior (excessive fighting or bullying).
  • Cruelty to animals/people.
  • Severe destruction of property (fire setting).
  • Stealing.
  • Truancy from school.
  • Repeated lying.
  • Frequent running from school & home.
  • Defiance of authority figures.
  • Disobedience pattern.

Oppositional defiant disorder:

  • Less severe than conduct disorder.

Features: 

  • Characterized by persistently negativistic & defiant behavior (frequent arguing with adults, refusal to comply with adults).
  • Frequent loss of temper (deliberately annoying adults).
  • Note: No serious violations (theft, fire setting, destruction, etc.) – Unlike conduct disorder.

Management:

  • Conduct & oppositional defiant disorder –
    • Family intervention & behavioral therapy.
    • Low dose antipsychotics effective in some.

Learning disorders:

  • Also referred as Specific developmental disorders of cholastic skills”.

Features: 

  • Characterized by significant impairment in one or more of scholastic skills which are out of proportion to intellectual functioning of child.
  • Eg: Significant difficulty in reading while having normal writing & arithmetic skills with normal IQ.

Subtypes: 

  • Specific reading disorder (Dyslexia).
  • Disorder of written expression (specific spelling disorder).
  • Specific disorder of arithmetic skills.
  • Mixed disorders of scholastic skills (reading, writing & arithmetics).

Other features:

  • Inattention.
  • Hyperactivity.
  • Emotional disturbances.

Exam Important

  • Repetitive & persistent pattern of disregard for rights of others is seen in conduct disorder.
  • Aggressiveness & dissocial behavior (excessive fighting or bullying) and repeated lying is feature of conduct disorder.
  • Dyslexia is specific reading disorder.
  • Learning disorders are developmental disorders are characterized by significant impairment in one or more of the scholastic skills which are out of proportion to intellectual functioning of child.
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Mental Retardation

MENTAL RETARDATION


MENTAL RETARDATION

Introduction:

  • Condition characterized by incomplete development of intellectual functions & adaptive skills (skills for successful Iife).
  • Intelligence is measured by Intelligence Quotient (IQ).

Calculation method:

  • IQ = Mental age/Chronological age x 100 
    • Maximum denominator – 15 (even for elderly assessment).
  • IQ less than 70 – Considered as “mental retardation”.

Category & their IQ:

  • Normal – 90-109
  • Borderline – 70-89
  • Mild mental retardation – 50-69
  • Moderate mental retardation – 35-49
  • Severe mental retardation – 20-34
  • Profound mental retardation – <20.
  • Level of functioning varies with severity of mental retardation.

Causes: 

  • Down syndrome & fragile-X syndrome – Most common chromosomal cause.

Features:

  • Behavioral problems in mental retardation – Have maladaptive behavior (aggression, self injurious behaviors, hyperactivity, etc).

Management:

  • Modified by behavioral therapy techniques – Contingency management.
    • Desired behaviors rewarded & undesired behaviors punished.

Exam Important

  • Calculation for IQ = Mental age/Chronological age x 100.
  • IQ less than 70 is considered as “mental retardation”.
  • Down syndrome & fragile-X syndrome are the most common chromosomal cause of mental retardation.
  • Behavioral problems in mental retardation are managed by behavioral therapy techniques like contingency management.
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Electroconvulsive Therapy (Ect)

ELECTROCONVULSIVE THERAPY (ECT)


ELECTROCONVULSIVE THERAPY (ECT)

Introduction:

  • A type of convulsive therapies used for psychiatric disorders treatment.
  • Usage of electricity as an agent inducing convulsions – Referred as “electroconvulsive therapy.”

Types:

A. Direct ECT:

  • Anesthetic agents & muscle relaxants not used.
  • Generalized convulsions produced result in fractures or teeth dislocations.
  • Higher incidence of side effects – Rarely used now.

B. Modified ECT (Indirect ECT):

  • Anesthetic agents & muscle relaxants are administered before ECT.
  • Muscles relaxed → risk of bone fractures &other injures from motor activity during seizures minimized.

Technique:

  • Based on electrode placement – Bilateral ECT & Unilteral ECT.

Bilateral ECT: 

  • Most commonly used.
  • Involves electrodes placed on both sides of skull (bifronto-temporal electrode placement).

MOA:

  • Induction of bilateral generalized seizure via ECTs.
  • By down regulation of postslnaptic beta-adrenergic receptors.
  • Changes in growth factors & molecular mechanisms (increased brain derived neurotrophic factor, BDNF)
  • Neurogenesis (hippocampus).

Indications:

Depression (Major depressiue disorder): 

  • Both major depressive disorder & bipolar disorder.
  • Mainly for depression with suicide risk (Acute suicidal patients).
  • Depression with stupor.
  • Depression with psychotic symptoms (psychotic depression or delusional depression).

Manic episode:

  • Acute mania – Not 1st line treatment.
  • Only for intolerant/unresponsive to pharmacotherapy.
  • Severe maniac patients with suicide risk.

Schizophrenia:

  • Catatonic schizophrenia – 1st line treatment.
  • Note: Not effective in chronic schizophrenia.

Other indications:

  • Intractable seizures.
  • Neuroleptic malignant syndrome.
  • Delirium.
  • On-off phenomenon of Parkinson’s disease

Adverse effects:

Memory disturbances:

  • Most common side effect.
  • Retrograde amnesia more common.
  • Mild & recovery within 1-6 months after treatment.

Other side effects:

  • Delirium
  • Headache
  • Muscle aches
  • Fractures (very rare with modified ECT)
  • Nausea
  • Vomiting.

Contraindications:

  • No absolute contraindications.

Relative contraindication:

  • Raised intracranial tension (space occupying lesion in CNS).
  • Recent myocardial infarction
  • Severe hypertension
  • Cerebrovascular disease
  • Severe pulmonary disease
  • Retinal detachment

Note: Pregnancy not a contraindication.

Exam Important

  • Generalized convulsions produced during direct ECT result in fractures or teeth dislocations.
  • ECT is used for major depressiue disorder, catatonic schizophrenia, intractable seizures, neuroleptic malignant syndrome, delirium & on-off phenomenon of Parkinson’s disease.
  • ECT not effective in chronic schizophrenia.
  • Memory disturbances most commonly retrograde amnesia occur as side effect to ECT.
  • There are no absolute contraindications to ECT.
  • Raised intracranial tension (space occupying lesion in CNS) is a relative contraindication to ECT.
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Psychotherapy

PSYCHOTHERAPY


PSYCHOTHERAPY

  • Treatment of psychiatric disorders by using psychological methods.
  • Most important method – Behavior therapy.

Behavior therapy:

  • Psychological treatment where patient’s maladaptive behaviors changed to improve quality of life.
  • “Behavior therapy” is generic term – Used to describe a variety of specific techniques intended to remove maladaptive behaviors. 

Techniques of behavior therapy: 

  • Systematic desensitization.
  • Therapeutic graded exposure or in vivo exposure (or exposure & response prevention)
  • Flooding (Implosion).
  • Modeling (Participant modeling).
  • Assertiveness training.
  • Social skills training.
  • Aversive conditioning (Aversion therapy).

Systemic desensitization:

  • Based on “reciprocal inhibition” principle.
  • According to this principle, f anxiety-provoking stimulus provided while a person is in relaxed state, the anxiety gets inhibited.
  • Used in treatment of phobias, obsessive-compulsive disorders & certain sexual disorders.

Therapeutic graded exposure or in vivo exposure (or exposure & response prevention):

  • Similar to systematic desensitization except that no relaxation techniques used & real-life situations used.
  • Used in phobias & obsessive-compulsive disorder.

Flooding (Implosion):

  • Patient made to confront feared situation directly, without any hierarchy (as in systematic desensitisation or graded exposure & no relaxation exercises used).

Modeling (Participant modeling):

  • Therapist himself makes contact with phobic stimulus & demonstrates patient.
  • Patient learns by imitation & observation.

Assertiveness training:

  • Person is taught to be assertive (asking for his rights & refusing unjust demands of others).

Social skills training:

  • Involves imparting skills required for dealing with others & living a social life.
  • Used in schizophrenia.

Aversive conditioning (Aversion therapy):

  • Clinical use of classical conditioning principle.
    • An association created between unwanted behavior & painful stimuli —> unwanted behavior ceases.
  • Now rarely used due to ethical considerations.
  • Used for unwanted behaviors treatment (paraphilias).

Indications for behavior therapy:

  • Primarily in anxiety disorders treatment (like phobia, panic disorders).
  • Also used in depression, dissociative disorders, eating disorders, sexual disorders, personality disorders, substance used disorders & schizophrenia.

Exam Important

  • Most important method in psychotherapy is behavior therapy.
  • Techniques used in behavious therapy includes Systematic desensitization, therapeutic graded exposure or in vivo exposure (or exposure & response prevention), flooding (Implosion), modeling (participant modeling), assertiveness training, social skills training & aversive conditioning (aversion therapy).
  • Systemic desensitization is based on “reciprocal inhibition” principle.
  • Systemic desensitization used in treatment of phobias, obsessive-compulsive disorders & certain sexual disorders.
  • Therapeutic graded exposure is also referred as in-vivo exposure/exposure & response prevention.
  • Exposure & response prevention is used in phobia treatment.
  • Aversive conditioning is used for unwanted behaviors treatment (paraphilias).
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Death & Dying

DEATH & DYING


DEATH & DYING

  • Is a series of responses in an iindividual after informing about his impending death.
  • 3 stages of death and dying were proposed by Elizabeth Kubler-Ross.

Stage 1 – Denial and shock:

  • Characterized by refusal to accept diagnosis & reaction of shock.
  • Stage 2: Anger.
  • Stage 3: Bargaining.
  • Stage 4: Depression.
  • Stage 5: Acceptance.

Grief, bereavement & mourning:

Bereavement:

  • State of being deprived of someone due to death.

Grief:

  • Is psychological feeling precipitated by death of a loved one.

Mourning:

  • Process by which grief is resolved.
  • Involves societal practices like funerals, burial & memorial services.

Exam Important

  • 3 stages of death and dying were proposed by Elizabeth Kubler-Ross.
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Adjustment Disorder

ADJUSTMENT DISORDER


ADJUSTMENT DISORDER

  • Disorders characterized by emotional responses to stressful events like financial problems, medical illness, relationship problems or death of a loved one.

Symptoms:

  • Symptom complex includes anxiety & depressive symptoms.
  • Depressed mood
  • Worry
  • Feeling of inability to cope.
  • Disturbance in individuals daily functioning.

Differential diagnosis:

Depression – 

  • Depression follows negative life event.
  • Differentiated by delineating uncomplicated bereavement/grief reactions.

In uncomplicated bereavement:

  • Symptoms & dysfunctions developing are within expected limits.

In adjustment disorder:

  • Symptoms & dysfunction are beyond expectable reaction to stressor.

Other differential diagnosis:

  • PTSD
  • Brief psychotic disorders.
  • Diagnoses should be given precedence if their diagnostic criterion are met, irrespective of stressors presence.

Treatment:

  • Psychotherapy – Treatment of choice.
    • Supportive psychotherapy commonly used.

Medications

  • Adjuvant to psychotherapy.
  • Antidepressants & antianxiety drugs.

Exam Important

  • Disorders characterized by emotional responses to stressful events like financial problems, medical illness, relationship problems or death of a loved one.
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Bipolar Disorders

BIPOLAR DISORDERS


BIPOLAR DISORDERS

  • Characterized by episodes of both mania & depression.
  • Equally prevalent in men & women.
    • Manic episodes – More common in men; depressive episodes – More common in women.
    • More commonly seen in divorced and single persons.
  • Onset age – 30 yrs (average). 
Causes:

Neurotransmitters:

  • Increased dopamine levels for manic episode.

Genetic factors:

  • Chromosomes 18q & 22q – Strongest evidence linked to bipolar disorder.
  • Chromosome 21q involved.

Subtypes:

  • Bipolar 1/2 = Schizobipolar disorder (schizoaffective disorder)
  • Bipolar I = Mania with depression (or mania alone).
    • Bipolar I 1/2 = Depression with protracted hypomania.
  • Bipolar ll = Depression with discrete hypomanic episodes.
    • Bipolar ll 1/2 = Depression superimposed on cyclothymia.
  • Bipolar lll = Depression plus induced hypomania 
    • (e.g. hypomania occurring solely in association with antidepressants or other somatic treatment.
    • Bipolar lll 1/2 = Bipolar disorder associated with substance use
  • Bipolar lV = Depression superimposed on hyperthymic temperament.

Symptoms:

Symptoms of manic episode:

  • Elevated mood – Undue happiness or irritable mood.
  • Increased self-esteem or grandiosity.
  • Decreased need for sleep (e.g. patient feels rested after 2 hours of sleep)
  • Over-talkativeness.
  • Flight of ideas.
  • Distractibility (not able to concentrate on task in hand).
  • Increased goal-directed activities (overactivity, hypersexuality overfamiliarity).
  • Psychomotor agitation.

Diagnostic criteria:

  • Symptoms should last for at least 7 days.
  • Must cause marked impairment in social & occupational functioning.

Psychotic symptoms:

  • Delusions & hallucination.
  • Maybe mood congruent (delusion of grandiosity)/incongruent (delusion of persecution).

Diagnostic criteria:

  • Must exhibit manic episode with psychotic symptoms.

Hypomania:

  • Symptoms similar to mania with lesser severity & reduced social & occupational functioning impairment.
  • Duration criterion = 4 days.

Mixed episodes:

  • Presents with both manic & depressive symptoms.
  • Duration = Min. 7 days.

TREATMENT:

  • Mood stabilizer: Lithium (prototyplcal mood stabilizer), valproate, carbamazepine, oxcarbazepine & lamotrigine (For bipolar depression).
  • Antipsychotics.
  • Benzodiazepines (lorazepam & clonazepam) – Used in acute mania due to their calming effect.
  • Antidepressants – Only as combination drug.

Exam Important

  • Chromosomes 18q & 22q have strongest evidence linked to bipolar disorder.
  • Symptoms of manic episode includes distractibility, flight of ideas & decreased need for sleep.
  • Diagnostic criteria for manic episode is that symptoms should last for at least 7 days.
  • Lithium is considered “prototypical mood stabilizer”.
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