Psychiatry Long Case Discussions

Low Mood and Delusions of Infidelity in Pregnancy

Patient Summary

A 32-year-old woman, 21 weeks into her second pregnancy, presents with her husband due to a severe depressive episode with psychotic symptoms. She complains of having a morbid jealousy of her sister and husband having an affair. She reports seeing and hearing things, which she describes as “everything looks black.” She feels a sense of unreality, and her mood is low with lack of energy, interest, and appetite. She also reports a past history of suicidal thoughts, although she denies them at present. She has a history of two previous depressive episodes, for which she received a total of 7 cycles of ECT and was treated with sertraline and olanzapine. She reports a relapse in her current pregnancy because a doctor in the obs clinic told her to stop her medications.

How would you approach the history and mental state examination to confirm the diagnosis and rule out differentials?

The history and mental state examination (MSE) would be crucial to confirm the diagnosis of a severe depressive episode with psychotic features, while also carefully considering other possibilities, especially given her pregnancy. The “morbid jealousy” is a significant psychotic symptom that needs careful evaluation.

History and MSE Approach

My assessment would be structured to capture key information for diagnosis and management:

History of Present Illness: I would explore the onset, duration, and severity of her current symptoms, including the “everything looks black” imagery and the morbid jealousy. I would clarify the nature of these experiences: are they true hallucinations (seen or heard in external space) or are they more like intrusive thoughts or imagery? I would also ask about core depressive symptoms (low mood, anhedonia, neurovegetative signs) and specifically ask about suicidal ideation and intent, as well as infanticidal thoughts, which are a major risk in postpartum psychosis.
Past Psychiatric History: I would detail the nature of her previous depressive episodes, treatments received (including the 7 cycles of ECT), and her response. The fact that a doctor told her to stop medication is a critical piece of information that points to a common reason for relapse during pregnancy.
Mental State Examination: This would focus on objective signs of severe depression (e.g., psychomotor retardation, tearfulness). I would assess the nature and content of her psychotic symptoms, particularly the morbid jealousy. I’d ask if she believes the jealousy is real, and if it is a fixed, false belief (delusion). The presence of mood-congruent delusions of unworthiness or guilt would support a diagnosis of psychotic depression.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What is the significance of the “morbid jealousy”?

Morbid jealousy, in this context, is a key psychotic symptom. It is a delusional belief in a partner’s infidelity, held on inadequate grounds and unaffected by reason. In psychotic depression, such a delusion is often mood-congruent, meaning she may believe her husband’s infidelity is a justified consequence of her own unworthiness or sinfulness. This differs from jealousy in schizophrenia, where the belief is typically seen as an unwarranted persecution. The delusion of morbid jealousy is a significant risk factor for violence, so a careful risk assessment, including any homicidal ideation, is essential.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What are the specific problems with ECT in pregnancy?

ECT is a highly effective and relatively safe treatment for severe depression, even in pregnancy, though it requires special precautions. My management plan would prioritize the mother’s and baby’s safety by a multidisciplinary approach.

Problems with ECT in Pregnancy

Physical Risks: The main risks are to the mother and fetus from the physical stress of the procedure. These can include an increased risk of miscarriage in the first trimester, premature labor, fetal arrhythmia, or uterine contractions.
Monitoring: Close monitoring of both the mother and fetus is essential during the procedure. This includes fetal heart rate monitoring and obstetric consultation.
Anaesthesia: The choice of anaesthetics and muscle relaxants must be carefully considered to minimize fetal risk.
Misinformation and Stigma: Patients and some medical staff may have misconceptions about the safety of ECT in pregnancy, which can be a barrier to providing this life-saving treatment.

Source: Depression Treatment in Pregnancy: Is It Safe, or Is It Not? – MDPI, Guidelines for the Management of Depression During Pregnancy – PMC, Treatment of depression during pregnancy: a protocol for systematic review and meta-analysis – Frontiers, Management of Women with Mental Health Issues during Pregnancy and the Postnatal Period (Good Practice No.14) | RCOG

What is your management plan, considering her severe symptoms and the potential risks of untreated depression?

Given the severity of her psychotic depression and the history of medication non-compliance leading to relapse, my plan would be as follows:

Multidisciplinary Team (MDT): This case requires close collaboration between a psychiatrist, an obstetrician, and the patient’s family to ensure a holistic approach to care.
ECT as a Primary Option: Given her history of relapse with medication and the severity of her psychotic symptoms, ECT would be the first-line treatment. It has proven efficacy and is considered a safe and effective option for severe depression in pregnancy, often with better outcomes than medication alone.
Pharmacological Management: If she declines ECT or as a continuation therapy, medication would be used. The risks of psychotropic drugs during pregnancy must be carefully weighed against the risks of untreated depression, which include suicide, miscarriage, and poor fetal outcomes.
- Antidepressants: Sertraline is often a first-choice antidepressant in pregnancy due to its safety profile. A typical starting dose is 50mg daily, with a maximum dose of 200mg daily.
- Antipsychotics: An atypical antipsychotic like olanzapine would be added to treat her psychotic symptoms (morbid jealousy). A typical starting dose is 5mg daily, with a maximum dose of 20mg daily. Olanzapine has an established safety record during pregnancy.
Postpartum Management: The risk of postpartum psychosis is high for a patient with a history of severe depression with psychosis. A detailed plan for monitoring and prophylactic treatment would be put in place before delivery. This may involve continuing her medication or initiating a mood stabilizer, if not already started, to prevent a relapse in the high-risk postpartum period.

What are the common side effects of sertraline and how would you manage them?

Sertraline is a selective serotonin reuptake inhibitor (SSRI) and its side effects are typically related to serotonergic activity. They are often dose-dependent and tend to subside over the first few weeks of treatment. Side effects include:

Gastrointestinal Issues: The most common side effects are nausea, vomiting, and diarrhoea.
Sexual Dysfunction: Decreased libido, anorgasmia, or delayed ejaculation are common.
Sleep Disturbances: Insomnia or, less commonly, somnolence can occur.
Activation Syndrome: This can manifest as anxiety, agitation, or restlessness, especially in the initial weeks of treatment.
Suicidal Ideation: An increased risk of suicidal thoughts and behaviors can occur in young people during the initial phase of treatment. This is particularly important to monitor in a patient with a history of suicidal thoughts.

Management: I would warn the patient and her husband about these potential side effects. I would start with a low dose and titrate slowly, advising her that most side effects are transient. If they persist, a dose reduction or a change in medication may be necessary. I would monitor for any worsening of suicidal ideation closely, especially in the first few weeks of treatment.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What specific things would you tell the husband during family therapy to help with the “morbid jealousy”?

Morbid jealousy is a complex and dangerous symptom, and family therapy is a key part of the management plan. During therapy, I would tell the husband the following things:

Illness-Related Symptom: The morbid jealousy is a symptom of her severe illness, not a reflection of a real-life situation. It is caused by her illness and is not her fault.
Avoid Contradiction: Directly arguing with her about the delusion will likely make her more suspicious and distressed. Instead, he should acknowledge her feelings without validating the content of the delusion (e.g., “I know you’re feeling very distressed about this,” rather than “I promise I’m not having an affair”).
Communication: I would help him develop communication skills to respond to her accusations in a calm, consistent, and supportive way. The goal is to reduce the emotional intensity and not to engage in a futile argument about the false belief.
Safety: I would explicitly ask him about his and the children’s safety, and discuss a crisis plan for what to do if her aggression or jealousy escalates. This is crucial as morbid jealousy can be a significant homicidal risk.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

Aggression and Over-expenditure

Patient Summary

A 44-year-old male, known to have an alcohol dependence, presents with a diagnosis of schizoaffective disorder, current episode manic with psychosis. He is irritable, aggressive, and has a history of over-expenditure. He reports a reduced need for sleep and a belief that he has the power of a deity. His family reports that he has periods of low mood, and he has a past history of two depressive episodes. On mental state examination, his mood is labile and his speech is pressured. The panel of examiners have asked questions focusing on his aggression, over-expenditure, alcohol history, and pharmacological management, including rapid tranquilization, mood stabilizers, and clozapine for a difficult-to-treat illness.

What is the definitive management for this patient?

The core of definitive management is to treat the underlying mood disorder, as this is the primary driver of the manic and psychotic symptoms. This is achieved through long-term use of a mood stabilizer, often in combination with an antipsychotic if psychotic symptoms persist. The management would also need to include:

Addressing Alcohol Misuse: His co-morbid alcohol use must be addressed as it can worsen the course of the schizoaffective disorder and interfere with treatment compliance and efficacy. The treatment plan should include motivational interviewing or other psychosocial interventions to encourage him to stop drinking.
Psychosocial Interventions: Family therapy and psychoeducation are essential components of long-term management to help both the patient and his family understand the illness, its triggers (such as alcohol), and how to prevent relapse.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, Assessment and management of bipolar disorder: summary of updated NICE guidance – The BMJ, Schizoaffective disorder – Royal College of Psychiatrists, Schizoaffective Disorder Explained: Signs, Symptoms, Treatment – Rethink Mental Illness

What is the rationale for using a mood stabilizer?

A mood stabilizer is the definitive management for bipolar and schizoaffective disorder because it stabilizes mood and prevents the recurrence of both manic and depressive episodes. Without it, the patient is at a high risk of relapse. Lithium is the most effective long-term treatment for bipolar disorder, with a notable anti-suicidal effect, and is therefore a key choice. Other mood stabilizers like valproate are also effective, particularly for mixed states and rapid cycling.

What investigations would you do before starting Lithium?

Given that lithium is cleared renally and can affect thyroid and cardiac function, a number of baseline investigations are crucial to ensure safety:

Renal Function Tests (RFTs): To establish a baseline kidney function as lithium can cause nephrogenic diabetes insipidus and long-term renal damage.
Thyroid Function Tests (TFTs): To check for pre-existing thyroid abnormalities, as lithium can induce hypothyroidism.
Electrolytes: To ensure that sodium and potassium levels are in the normal range, as lithium toxicity is linked to electrolyte imbalances.
Full Blood Count (FBC): To establish a baseline, as lithium can cause a benign leucocytosis.
Electrocardiogram (ECG): A baseline ECG is necessary to check for pre-existing cardiac conduction abnormalities, as lithium can affect the QT interval.

How would you manage this patient if he becomes aggressive in the ward?

Management of aggression in an inpatient setting follows a stepped approach, prioritizing de-escalation and safety.

De-escalation: The first step is always verbal de-escalation. Staff should use a calm, non-confrontational tone and provide the patient with space in a low-stimulus environment.
Rapid Tranquilization (RT): If de-escalation fails, RT is used to protect the patient and others. Oral medication (e.g., olanzapine or lorazepam) is the first choice. If the patient refuses, intramuscular injection may be necessary. It is crucial to have a team of staff present and to monitor the patient’s vital signs afterward.
Acute Dystonic Reaction: A possible side effect of antipsychotics, which can be distressing. It should be managed with procyclidine or another anticholinergic agent.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What about the management of a relapse if he is non-compliant?

Managing a relapse due to poor compliance requires a non-judgmental approach to understand the reasons and implement a long-term plan for adherence.

Re-establish Trust: The first step is to re-engage with the patient and address the reasons for poor compliance. This could involve side effects, poor insight, or a dislike of the “flat” mood caused by medication.
Long-Acting Injections (Depots): I would discuss the use of a long-acting injectable (depot) antipsychotic to improve adherence and reduce relapse rates.
Community Treatment Order (CTO): In cases of persistent, severe non-compliance leading to dangerous relapses, a Community Treatment Order (CTO) may be necessary to ensure he receives ongoing treatment in the community.

Source: NICE guideline [NG178] – Psychosis and schizophrenia in adults, NICE guideline [CG185] – Bipolar disorder: assessment and management

What are the specific monitoring requirements and side effects of clozapine?

Clozapine is a highly effective antipsychotic but its use is restricted due to potentially serious side effects and mandatory monitoring requirements.

Monitoring Requirements

Agranulocytosis: This is a rare but potentially fatal side effect. It is a mandatory requirement to monitor white cell count (WCC) and absolute neutrophil count (ANC) regularly. International consensus guidelines now recommend weekly monitoring for the first 18 weeks, monthly until 2 years, and then annually if stable.
Other Monitoring: Given the risk of metabolic and cardiac side effects, a shared-care model with the GP is recommended for regular checks of BMI, blood pressure, lipids, and blood glucose.

Side Effects

Constipation: This is the leading cause of mortality in patients on clozapine. It can lead to bowel obstruction and should be screened for regularly. Prophylactic laxatives are recommended.
Myocarditis/Cardiomyopathy: A rare but serious risk. Persistent tachycardia and flu-like symptoms should prompt an urgent ECG and medical evaluation.
Other Common Side Effects: Weight gain, hypersalivation, sedation, and a risk of seizures are also common.

Source: New Consensus Guidelines for Clozapine Drop ANC Monitoring After 2 Years – Medscape, Clinical considerations for patients prescribed clozapine – SPS – Specialist Pharmacy Service – The first stop for professional medicines advice

Grandiose Delusions and Aggression

Patient Summary

A 44-year-old male presents with a diagnosis of a manic episode with psychotic symptoms. He exhibits irritability, aggression, and grandiose delusions, believing he has the power of a deity. His family reports that he has periods of low mood and has a past history of two depressive episodes. On mental state examination, his mood is labile and his speech is pressured. The presenting complaint is centered around his aggression and over-expenditure, prompting a comprehensive discussion on the management and differential diagnosis of his condition.

How would you approach the history and mental state examination to differentiate between Bipolar Affective Disorder (BPAD) and Schizoaffective Disorder (SAD)?

Differentiating between Bipolar Affective Disorder (BPAD) and Schizoaffective Disorder (SAD) is crucial for accurate diagnosis and long-term management. Both conditions can present with mood episodes and psychotic symptoms, but the temporal relationship between them is the key differentiator. My approach would be:

History and MSE Approach

I would specifically ask about the timing of his symptoms:

BPAD with Psychotic Features: In BPAD, psychotic symptoms occur exclusively during a mood episode (manic, hypomanic, or depressive). The delusions and hallucinations are typically mood-congruent (e.g., grandiose delusions during a manic episode or delusions of worthlessness during a depressive episode).
SAD: In SAD, psychotic symptoms are present for at least two weeks in the absence of a major mood episode. The patient must have a major mood episode (depressive or manic) that is present for the majority of the total duration of the illness, but the psychotic symptoms persist when the mood episode resolves.
MSE Findings: I would assess for the presence and nature of his grandiose delusions and irritability. I would also ask about any auditory hallucinations, as these can be a key feature of psychosis. In this case, his labile mood, pressured speech, and grandiose delusions are all classic features of a manic episode with psychotic symptoms, which points towards BPAD.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, Schizoaffective Disorder Explained: Signs, Symptoms, Treatment – Rethink Mental Illness.

How would you approach a problem list and a risk assessment for this patient?

A problem list and risk assessment are essential to formulate a comprehensive management plan that addresses both the immediate crisis and long-term issues.

Problem List

Based on the history, the patient’s problem list would include:

Current manic episode with psychotic features (irritable mood, grandiose delusions).
Aggression and agitation, posing a risk to others.
Poor insight into his illness.
History of two previous depressive episodes.
Co-morbid alcohol misuse.
Poor compliance with past treatment.

Risk Assessment

The risk assessment would be an ongoing process, but my initial assessment would focus on:

Risk to Others: This is a high-priority risk due to his aggression towards his wife and neighbors. The presence of grandiose delusions may also increase this risk.
Risk to Self: While he is currently manic, a history of depressive episodes and suicide attempts must be noted. I would also assess for self-neglect and recklessness.
Vulnerability: His poor insight and alcohol misuse make him vulnerable to exploitation and further health complications.
Risk of Relapse: His poor compliance and alcohol misuse significantly increase the risk of future relapses.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What would be your management plan? What is the role of risperidone, and what are its common side effects?

My management plan would follow a structured approach to ensure the patient’s immediate and long-term safety and recovery.

Management Plan

Treatment Setting: Given the severe aggression and poor insight, inpatient admission is mandatory to ensure safety and provide a low-stimulus environment. This would likely be an involuntary admission under mental health legislation.
Risk Management: This would involve frequent monitoring by nursing staff and a clear plan for rapid tranquilization if his aggression escalates. The priority is to de-escalate and ensure a safe environment for everyone.
Investigations: I would perform baseline investigations including a physical health screen (Full Blood Count, Renal and Liver Function, Blood Glucose, Lipids) and an ECG to rule out any physical causes of his symptoms and to prepare for pharmacological treatment.
Pharmacological Treatment: I would initiate pharmacological treatment to stabilize his mood and manage his psychotic symptoms.
- Risperidone: Risperidone is an atypical antipsychotic and is a first-line agent for acute mania with psychotic features. It would be started to target the grandiose delusions, aggression, and agitation. The dose would be titrated carefully, and I would aim for the lowest effective dose.
- Mood Stabilizer: Once his acute symptoms are under control, a mood stabilizer (e.g., lithium, valproate, or carbamazepine) would be introduced for long-term maintenance to prevent future relapses.

Risperidone Side Effects and Monitoring

Risperidone is generally well-tolerated but has a number of important side effects that require monitoring:

Extrapyramidal Side Effects (EPS): Including dystonia, akathisia, and tardive dyskinesia. The risk of these is dose-dependent, and careful monitoring is required.
Weight Gain and Metabolic Syndrome: Risperidone can cause significant weight gain, leading to an increased risk of diabetes and cardiovascular disease. Regular monitoring of BMI, blood pressure, lipids, and blood glucose is essential.
Hyperprolactinemia: This can lead to galactorrhoea, amenorrhoea, and sexual dysfunction.
Tachycardia and Orthostatic Hypotension: Especially during initial dose titration.

Source: NICE guideline [CG185] – Bipolar disorder: assessment and management; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf.

Social Phobia and Anxiety

Patient Summary

A 28-year-old woman is being managed for Social Anxiety Disorder (Social Phobia). She has been prescribed medication and is engaged in psychological therapy. She has a number of questions for her care team regarding her social support, the adequacy of her family’s support, and how to apply therapeutic techniques like activity rescheduling and graded exposure. She is also concerned about a lack of connection with her husband, which she believes is a result of her condition. Her questions reflect a desire to take an active role in her recovery and to understand the psychosocial aspects of her illness.

How would you systematically approach the history and examination to confirm a diagnosis of Social Anxiety Disorder (Social Phobia) and rule out differential diagnoses?

A systematic approach is essential to confirm the diagnosis of Social Anxiety Disorder (SAD) while carefully excluding other conditions that may present similarly. The diagnosis relies heavily on a detailed history, with the mental state examination (MSE) providing supporting evidence.

Systematic History Taking

I would follow a structured approach, focusing on the following key diagnostic criteria:

Fear of Scrutiny: I would ask about a marked and persistent fear of one or more social or performance situations in which she is exposed to unfamiliar people or possible scrutiny by others. I would ask for specific examples (e.g., public speaking, eating in front of others, starting a conversation, using public restrooms).
Fear of Negative Evaluation: A key feature of SAD is the fear that she will act in a way that will be humiliating or embarrassing. I would ask her to describe the specific feared consequence, such as blushing, stammering, sweating, or trembling.
Anxiety Response: I would ask her to describe her anxiety response when she is in these situations. Is it an immediate, excessive anxiety that may escalate to a panic attack?
Avoidance: I would ask about her behavioral response. Does she avoid the feared situations or endure them with intense anxiety and distress? I would also explore how this avoidance has impacted her daily life, work, and relationships.
Duration and Impairment: I would confirm that the symptoms have been present for at least 6 months and cause significant distress or impairment in social, occupational, or other important areas of functioning.

Differential Diagnosis – Ruling Out Other Conditions

Panic Disorder: I would ask about unexpected panic attacks and a persistent worry about having more attacks. In SAD, panic attacks are expected and triggered by social situations, whereas in panic disorder, they are often cued or uncued.
Agoraphobia: I would check if her anxiety is also present in non-social situations, such as open spaces, public transport, or being outside the home alone.
Generalized Anxiety Disorder (GAD): I would inquire about a chronic, pervasive anxiety and worry that is not limited to social situations but encompasses multiple life domains (e.g., finances, health, family).
Specific Phobia: The fear is limited to a single, specific trigger (e.g., flying, heights), not a broad range of social situations.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

What is the recommended first-line pharmacological treatment for Social Anxiety Disorder, and what are the key considerations regarding dosage and side effects?

Pharmacological treatment for Social Anxiety Disorder is a key part of management, especially for moderate to severe cases. The most effective options are typically antidepressants, particularly SSRIs and SNRIs.

First-Line Pharmacological Treatment

According to NICE guidelines and international consensus, Selective Serotonin Reuptake Inhibitors (SSRIs) such as Sertraline, Escitalopram, or Paroxetine are considered the first-line treatment for SAD.
Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs), particularly Venlafaxine, are also highly effective and often considered a second-line option. The choice between an SSRI and an SNRI often depends on side effect profiles and patient preference.

Dosage and Side Effects

Starting Dose: It is important to start with a low dose and titrate slowly to minimize initial side effects. For example, Sertraline might be started at 25-50mg and gradually increased.
Therapeutic Dose: The therapeutic dose for SAD is often higher than for depression. For Sertraline, this can be up to 200mg/day. It can take several weeks for the full therapeutic effect to be seen.
Common Side Effects:
- Gastrointestinal Issues: Nausea, vomiting, and diarrhoea are common, especially at the start of treatment. These usually subside within a week or two.
- Sexual Dysfunction: Decreased libido, delayed ejaculation, and anorgasmia are common and may lead to non-compliance.
- Sleep Disturbances: Insomnia or somnolence can occur. It may be necessary to adjust the timing of the dose.
- Activation Syndrome: Increased anxiety or restlessness can occur in the first few weeks, which may be mistaken for worsening anxiety.
Management of Side Effects: Patient education about side effects and their transient nature is vital. For persistent side effects like sexual dysfunction, a dose reduction, or a switch to another medication (e.g., Bupropion) may be considered.

Source: NICE guideline [CG178] – Psychosis and schizophrenia in adults, NICE guideline [CG113] – Social anxiety disorder: recognition, assessment and management.

What are the key components of psychological management for Social Anxiety Disorder?

Psychological therapy, particularly Cognitive Behavioral Therapy (CBT), is a cornerstone of management for Social Anxiety Disorder. The goal is to address the cognitive, emotional, and behavioral aspects of the illness.

The primary psychological intervention is Cognitive Behavioral Therapy (CBT), which typically includes the following components:

Psychoeducation: Providing the patient with a clear understanding of SAD, including the cognitive, behavioral, and physiological components of anxiety. This helps to demystify the illness and normalize her experiences.
Cognitive Restructuring: This involves identifying and challenging negative, distorted thoughts about social situations (e.g., “everyone is judging me,” “I will make a fool of myself”). The goal is to replace these thoughts with more realistic and balanced ones.
Exposure Therapy: This is a core behavioral component where the patient is systematically and gradually exposed to feared social situations. The process is guided and starts with low-anxiety situations before progressing to higher-anxiety situations. The goal is to allow the patient to experience the feared situation without engaging in avoidance, thus learning that the anxiety subsides naturally and that the feared outcome does not occur.
Graded Exposure: I would guide her to create a hierarchy of feared situations, from least to most anxiety-provoking. We would then work together, starting with the least feared situation, and gradually move up the hierarchy. For example, starting with a brief phone call, then a short conversation with a shopkeeper, then a larger social gathering.
Activity Scheduling: This involves encouraging the patient to plan and engage in pleasant and social activities, even if she doesn’t feel motivated to do so. It helps to break the cycle of avoidance and low mood.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, NICE guideline [CG113] – Social anxiety disorder: recognition, assessment and management.

How would you address her concerns regarding her relationship with her husband?

Her concern about the lack of connection with her husband is a direct consequence of her anxiety and avoidance. My approach would be:

Normalize the Experience: I would explain that social anxiety can strain relationships, as it often leads to social withdrawal and a lack of emotional intimacy. This helps her understand that the problem is a symptom of her illness, not a fundamental flaw in her or the relationship.
Involve the Husband: I would suggest involving her husband in psychoeducation sessions to help him understand her illness and her symptoms. He needs to know that her avoidance is not a personal rejection of him, but a manifestation of her fear.
Couples Therapy: If the “lack of connection” is a significant issue, I would recommend couples therapy. This provides a safe space for them to communicate their feelings and to work together on strategies to rebuild their connection. For example, they can work on shared, low-anxiety activities to do together, which can be part of her activity scheduling.

Post-Traumatic Stress Disorder

Patient Summary

A 35-year-old female presents with a diagnosis of Post-Traumatic Stress Disorder (PTSD) following a recent road traffic accident where her friend died. She has been experiencing recurrent, intrusive memories of the accident, nightmares, and flashbacks. She avoids driving, and avoids conversations about the event. Her sleep is disturbed, and she is easily startled. She feels detached from her family and friends. Her questions to the care team center on the diagnostic criteria for PTSD, the differential diagnoses, and the recommended pharmacological and psychological treatments.

What are the key diagnostic criteria for Post-Traumatic Stress Disorder?

The diagnosis of Post-Traumatic Stress Disorder (PTSD) is based on a specific set of criteria outlined in diagnostic manuals like the DSM-5. The symptoms must be present for more than one month and cause significant distress or functional impairment.

Key Diagnostic Criteria (DSM-5)

Exposure to a Traumatic Event: The person was exposed to actual or threatened death, serious injury, or sexual violence.
Intrusion Symptoms: One or more of the following must be present:
- Recurrent, involuntary, and intrusive distressing memories of the event.
- Recurrent distressing dreams or nightmares related to the event.
- Dissociative reactions (e.g., flashbacks) where the individual feels or acts as if the traumatic event is recurring.
- Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
Avoidance: Persistent avoidance of stimuli associated with the traumatic event, as evidenced by one or both of the following:
- Avoidance of distressing memories, thoughts, or feelings about or closely associated with the traumatic event.
- Avoidance of external reminders (e.g., people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event.
Negative Alterations in Cognition and Mood: Two or more of the following must be present:
- Inability to remember an important aspect of the traumatic event.
- Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world.
- Persistent distorted cognitions about the cause or consequences of the traumatic event that lead to self-blame or blaming of others.
- Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
- Markedly diminished interest or participation in significant activities.
- Feelings of detachment or estrangement from others.
- Persistent inability to experience positive emotions (e.g., happiness, satisfaction, loving feelings).
Alterations in Arousal and Reactivity: Two or more of the following must be present:
- Irritable behavior and angry outbursts.
- Reckless or self-destructive behavior.
- Hypervigilance.
- Exaggerated startle response.
- Problems with concentration.
- Sleep disturbance.

Source: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

What are the key pharmacological and psychological treatments recommended for PTSD?

Management of PTSD involves a combination of trauma-focused psychological therapies and, in some cases, pharmacological interventions, as per NICE guidelines.

Psychological Treatments

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): This is the most widely recommended and evidence-based psychological treatment. It helps the patient process traumatic memories and change unhelpful thoughts and beliefs about the trauma. Key components include:
- Exposure Therapy: The patient gradually confronts their fear in a safe, controlled environment, helping to reduce the anxiety response.
- Cognitive Restructuring: Patients learn to identify and challenge negative thoughts related to the trauma, such as self-blame or a sense of permanent danger.
Eye Movement Desensitization and Reprocessing (EMDR): This therapy uses bilateral stimulation (e.g., eye movements) to help the brain process and integrate traumatic memories, reducing their emotional impact.
General supportive therapy alone is not recommended.

Pharmacological Treatments

Pharmacological treatment is typically reserved for patients who do not respond to or cannot engage in psychological therapy, or for those with severe co-morbid depression.

SSRIs: Selective Serotonin Reuptake Inhibitors like Sertraline and Paroxetine are the first-line medication options. They have been shown to be effective in reducing core symptoms of PTSD, particularly hyperarousal and avoidance.
SNRIs: Serotonin–Norepinephrine Reuptake Inhibitors like Venlafaxine are also effective.
Mirtazapine: May be considered if there is a co-morbid depressive episode and insomnia is a significant issue.
Prazosin: An alpha-1 adrenergic antagonist, is often used off-label to treat nightmares associated with PTSD.

Source: NICE guideline [CG26] – Post-traumatic stress disorder; American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

What specific things would you look for in the history and examination to differentiate PTSD from other conditions like Adjustment Disorder or Acute Stress Disorder?

The distinction between PTSD and other stress-related conditions is primarily based on the duration and type of symptoms following a traumatic event. A systematic history and examination are crucial for a precise diagnosis.

Differentiating PTSD from Other Conditions

Acute Stress Disorder (ASD): This is the most common differential. The diagnostic criteria are very similar to PTSD, but the symptoms last for a shorter period, typically from 3 days to 1 month after the trauma. If the symptoms persist beyond one month, the diagnosis is changed to PTSD. I would ask specifically about the timeline of her symptoms.
Adjustment Disorder: In this condition, the symptoms (e.g., low mood, anxiety) are a response to a stressor, but they are not as severe as those seen in PTSD and do not meet the full diagnostic criteria for an intrusive, avoidance, and hyperarousal cluster. I would specifically ask if she has the characteristic intrusive memories or flashbacks. The symptoms also typically resolve within six months after the stressor or its consequences have terminated.
Major Depressive Disorder: While depression is a common comorbidity, I would ask if her symptoms meet the full criteria for PTSD. If she only has symptoms of low mood, anhedonia, and sleep disturbance without the intrusive memories and hyperarousal specific to the trauma, then a diagnosis of a depressive episode would be more appropriate.

Specific Examination Findings

On examination, a patient with PTSD would likely exhibit:

Hypervigilance: An exaggerated state of awareness and scanning the environment for threats.
Exaggerated Startle Response: A strong, physical reaction to a sudden noise or movement.
Labile Mood: Sudden shifts between emotional states, for example, from appearing calm to suddenly tearful when discussing the event.
Dissociative Symptoms: The patient might describe feelings of unreality or detachment from their body (depersonalization) or from their surroundings (derealization).

Source: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Obsessive Doubts and Contamination Fears

Patient Summary

A 21-year-old male university student presents with a history of persistent, intrusive thoughts about contamination, doubts about his work (such as submitting an application twice), and a need for order. These thoughts cause him significant anxiety and distress. To neutralize his distress, he engages in repetitive compulsions, including excessive reassurance-seeking from his family and a constant need for checking and ordering objects. He reports that these symptoms have severely impacted his studies and social life. He also reports a history of mild depressive symptoms in the past and has a family history of a suicide attempt by his mother. He acknowledges that these thoughts are his own and recognizes them as excessive and irrational, but he is unable to stop them.

How would you approach the history and mental state examination to confirm a diagnosis of Obsessive-Compulsive Disorder (OCD) and differentiate it from normal worries?

Differentiating OCD from normal worries or other anxiety disorders is crucial. The history and mental state examination (MSE) would focus on the specific nature of obsessions and compulsions.

History and MSE Approach

Obsessions: I would ask about the nature of his intrusive thoughts. I would confirm if they are:
- Recurrent and Persistent: Do they come back repeatedly?
- Intrusive and Unwanted: Do they feel like they are entering his mind against his will?
- Distressing: Do they cause him marked anxiety or distress?
- Ego-dystonic: Does he recognize them as products of his own mind but also as irrational and excessive?
Compulsions: I would ask about the repetitive behaviors he feels driven to perform. I would confirm if they are:
- Repetitive Behaviors or Mental Acts: For example, hand washing, checking, arranging, or praying.
- Aim to Neutralize Distress: Are they performed in response to an obsession to prevent a feared event or reduce anxiety?
Insight: A key feature of OCD is that the patient recognizes the obsessions and compulsions as unreasonable or excessive. I would assess this by asking him directly about his belief in his thoughts and actions.
Time and Impairment: I would confirm that the obsessions and compulsions are time-consuming (e.g., take more than one hour a day) and cause significant distress or impairment in his functioning.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, Psychiatry Long Cases.B30 (2).pdf

What are the key cognitive errors or psychopathological features seen in Obsessive-Compulsive Disorder?

Obsessive-Compulsive Disorder is characterized by specific cognitive errors and psychopathological features that drive the cycle of obsessions and compulsions. Identifying these is a key part of therapy.

Key Cognitive Errors and Features

Inflated Responsibility: The patient has an exaggerated sense of responsibility for preventing harm. This leads to compulsive behaviors as a way of attempting to control negative outcomes.
Overestimation of Threat: The patient overestimates the likelihood and severity of a feared outcome (e.g., believing that if they don’t check a door lock, a burglar will definitely break in).
Thought-Action Fusion: This is the belief that having a thought is as bad as performing the action, or that having a thought increases the likelihood of the event happening.
Intolerance of Uncertainty: The patient has a strong need for certainty and is unable to tolerate the normal ambiguities of life. Compulsions are often an attempt to achieve this impossible certainty.
Arbitrary Thinking: This is a form of cognitive distortion where the patient draws a specific conclusion without any supporting evidence, often linking an obsession to an unrelated feared event.

Source: Psychiatry Long Cases.B30 (2).pdf, Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What are the key components of psychological management for this patient, and how do they work?

The mainstay of management for OCD is psychological therapy, particularly Cognitive Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP). The goal is to break the link between obsessions and compulsions. The key components include:

Psychoeducation: To help the patient understand the nature of OCD and the rationale behind the therapy.
Exposure Therapy: The patient is deliberately and gradually exposed to the feared situation or obsessive thought in a controlled environment. The patient learns that the anxiety will subside naturally without engaging in the compulsive act.
Response Prevention: This is the crucial step where the patient is prevented from performing the compulsive ritual that would normally relieve their anxiety.
Thought Habituation: For patients with obsessions but no overt compulsions, thought habituation is used. This involves deliberately and repeatedly thinking the feared thought until the anxiety naturally diminishes.

Source: NICE guideline [CG31] – Obsessive-compulsive disorder and body dysmorphic disorder: treatment; Psychiatry Long Cases.B30 (2).pdf; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf.

What is the role of pharmacological management in this case?

Pharmacological treatment is typically started alongside or after an unsuccessful trial of CBT. The recommended first-line drugs are SSRIs, usually at higher doses than for depression.

First-Line: SSRIs such as Fluoxetine, Sertraline, or Escitalopram. The therapeutic dose for OCD is often higher than for depression (e.g., Fluoxetine 20-80mg, Sertraline 50-200mg). It can take up to 10-12 weeks to see a full response.
Second-Line: If there is no response, a switch to a different SSRI or the TCA Clomipramine may be considered.

How would you manage the common side effects of SSRIs?

Common side effects of SSRIs include:

Gastrointestinal Issues: Nausea, vomiting, and diarrhoea are common, especially at the start. These usually subside within a few weeks. Starting with a low dose and titrating slowly can help.
Sexual Dysfunction: Decreased libido, anorgasmia, or delayed ejaculation are common and may be a reason for non-compliance. I would discuss this openly with the patient and consider a dose reduction or a switch to another medication if necessary.
Activation Syndrome: Initial anxiety, agitation, or restlessness may be mistaken for a worsening of symptoms. I would reassure the patient that this is a transient effect.
Serotonin Syndrome: This is a rare but life-threatening side effect. Features include hyperthermia, muscle rigidity, tachycardia, and altered mental state. It is managed by stopping the drug and providing supportive care.

Source: Psychiatry Long Cases.B30 (2).pdf; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf; NICE guideline [CG31] – Obsessive-compulsive disorder and body dysmorphic disorder: treatment.

How would you educate the family to help with management?

The family plays a crucial role in supporting the patient’s recovery. I would involve them in psychoeducation and advise them on specific behaviors:

Do Not Reassure: The family should be advised not to provide excessive reassurance, as this can reinforce the compulsion and dependency on others.
Do Not Participate in Rituals: Family members should not participate in the patient’s compulsive rituals (e.g., re-checking locks with him or repeatedly answering his questions). This is a key part of response prevention.
Provide a Supportive Environment: The family should be taught to be patient, supportive, and non-judgmental. They need to understand that the patient’s behaviors are symptoms of an illness, not personal choices.
Encourage Therapy: The family should be encouraged to support the patient’s engagement in both pharmacological and psychological therapy.

Postpartum Depression and Suicidal Ideation

Patient Summary

A 37-year-old mother of a 2-year-old baby girl is admitted following a suicide attempt by hanging two days prior. She is reportedly unsupportive and denies a history of morbid jealousy, instead attributing her distress to property issues. She has a history of a sister with Bipolar Affective Disorder. The patient did not talk about her feelings or reasons for her suicide attempt, but expressed concern about her decision after the fact. She is diagnosed with a severe depressive episode without psychotic symptoms. The discussion revolves around her risk assessment, management of her severe depression, and family education.

How would you perform a comprehensive risk assessment for this patient?

A comprehensive risk assessment is crucial, especially following a suicide attempt. It is a dynamic process and must be revisited throughout her treatment. My assessment would cover the following domains:

Risk to Self (Suicidal Risk)

Intent and Planning: I would evaluate the lethality of her attempt (hanging) and the degree of planning. A hanging attempt is a highly lethal method, indicating high intent. However, she has expressed regret about her decision, which may lower the immediate risk, but this needs careful monitoring.
Past History: She has a past history of suicide attempts, which is the strongest predictor of a future attempt.
Current State: I would assess her current level of suicidal ideation, hopelessness, and impulsivity. I would ask her directly about passive death wishes or any future planning.
Protective Factors: I would identify her protective factors, such as her child, her family, and her regret about the attempt, and work to strengthen these.

Risk to Others (Homicidal or Filicidal Risk)

While the patient has denied morbid jealousy, I would still explore this discreetly, especially given the history of her sister’s BPAD and the original case discussion. I would screen for any thoughts of harming her child (filicide), which is a rare but serious risk in postpartum depression, especially if it progresses to psychosis.

Vulnerability and Other Risks

Neglect: I would assess for signs of self-neglect or neglect of her child due to her severe depression.
Social Support: Her family and relationship with her husband are crucial. I would assess the quality of her social support system.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What is your management plan for this patient, starting from her admission to the ward?

My management would be a multi-faceted approach, addressing her immediate safety, her depressive episode, and her long-term psychosocial needs.

Immediate Management (Inpatient)

Treatment Setting: Given her recent suicide attempt and diagnosis of severe depression, an inpatient admission is necessary to ensure her safety.
Risk Mitigation: I would place her under close observation (e.g., one-to-one special nursing) and remove any potential means of self-harm.
Psychological Support: I would provide a supportive and empathetic environment, encouraging her to talk about her feelings without pressure.

Pharmacological Management

Antidepressants: As she has severe depression without psychotic symptoms, I would start a Selective Serotonin Reuptake Inhibitor (SSRI) such as Sertraline or Fluoxetine.
- Sertraline Dose: The typical starting dose is 50mg daily, which can be titrated up to a maximum of 200mg daily.
- Anticipated Side Effects: I would warn her about common side effects such as nausea, headaches, and sexual dysfunction.
Augmentation: If she does not respond to the SSRI alone, I would consider augmenting with another antidepressant, such as Venlafaxine (an SNRI) or Mirtazapine. In a severe, non-responsive case, augmentation with an atypical antipsychotic like Risperidone could also be considered, even in the absence of psychotic symptoms.

Psychosocial Management

Family Meeting: I would arrange a meeting with her husband and family members to provide psychoeducation about her illness and discuss the importance of their support. I would also ask them to be alert for signs of relapse, especially given her sister’s history of BPAD.
Psychotherapy: Once her acute symptoms have stabilized, I would introduce psychotherapy. Options would include Cognitive Behavioral Therapy (CBT) to address her negative thought patterns and problem-solving therapy for her reported “property issues.”

Source: NICE guideline [CG90] – Depression in adults: recognition and management; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf.

If the patient’s depression is not responding to pharmacological management, what is the next step? What are the key considerations for this treatment?

If the patient’s severe depression is not responding to medication (treatment-resistant depression), the next step would be to consider Electroconvulsive Therapy (ECT).

Indications for ECT

ECT is a highly effective treatment for severe, treatment-resistant depression. It is particularly indicated in this case because of her:

High Suicidal Risk: Her recent attempt by a lethal method and her current severe depression make her a high-risk patient.
Treatment-Resistant Features: If she has not responded to multiple trials of antidepressants.

Key Considerations for ECT

Patient and Family Education: I would sit down with the patient and her family to explain the procedure, its high efficacy for severe depression, and its side effects. I would address the stigma associated with ECT and emphasize that it is a safe procedure performed under general anesthesia.
Preparation: I would ensure she is fit for the procedure by ordering a full medical workup, including an ECG and blood tests.
Side Effects: The most common side effect is short-term post-ECT amnesia, which she must be warned about. Other side effects include headaches, confusion, and muscle aches, which are usually transient.

Source: NICE guideline [CG90] – Depression in adults: recognition and management; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf.

Persistent Low Mood and Somatic Symptoms

Patient Summary

A 53-year-old female patient presents with persistent low mood for three years, interspersed with relapses of severe depression lasting for two to three weeks. In the intervals, she has mild depressive symptoms. Her diagnosis is Recurrent Depressive Disorder, current episode of severe depression without psychotic symptoms. The discussion focuses on her diagnosis, management strategies, and the reasons for her recurrent relapses.

How would you justify your diagnosis of Recurrent Depressive Disorder, current episode severe depression, based on the patient’s history?

The diagnosis is based on a careful assessment of the patient’s history and symptoms according to ICD-10 or DSM-5 criteria. My justification would be as follows:

Recurrent Depressive Disorder: The patient has a history of at least two depressive episodes, with a significant period of improvement in between. The three-year history of persistent low mood with interspersed relapses strongly points to this diagnosis.
Current Severe Depressive Episode: I would have elicited symptoms that meet the criteria for a severe episode. These typically include three or more core symptoms (e.g., depressed mood, anhedonia, fatigue) and at least four of the associated symptoms (e.g., sleep disturbance, appetite changes, suicidal ideation), and the symptoms cause marked distress and functional impairment.
Without Psychotic Symptoms: I would have confirmed the absence of delusions or hallucinations. This is crucial as it guides pharmacological management.

Source: Psychiatry Long Cases.B30 (2).pdf

What is your management plan for this patient, addressing both the acute severe episode and the long-term recurrence?

Management must be comprehensive, addressing the immediate severe episode, preventing future relapses, and providing psychosocial support.

Acute Management

Treatment Setting: Inpatient admission would be considered, especially if there is a high risk of suicide or if the patient is unable to function at home.
Pharmacological Treatment:
- First-Line: I would start a Selective Serotonin Reuptake Inhibitor (SSRI) like Sertraline or Fluoxetine at a therapeutic dose.
- Augmentation: If there is no or partial response, I would consider augmenting with another antidepressant from a different class, such as an SNRI (e.g., Venlafaxine) or a mood stabilizer.
Psychological Treatment: While in the acute phase, I would provide supportive therapy and introduce the concepts of CBT, which would be the mainstay of long-term psychological management.

Long-Term Management (Relapse Prevention)

Mood Stabilizer: Given the recurrent nature of her illness, I would consider adding a mood stabilizer (e.g., Lithium) to her treatment plan. This is particularly important in recurrent depression to prevent future episodes.
Psychotherapy: Once the acute symptoms have remitted, I would begin regular psychotherapy sessions, focusing on CBT to address cognitive errors and develop coping strategies. Interpersonal Therapy (IPT) could also be a good option to address any relationship or social issues that may be contributing to her depression.

Source: NICE guideline [CG90] – Depression in adults: recognition and management; Psychiatry Long Cases.B30 (2).pdf; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf

What are the key side effects of SSRIs and how would you monitor for them?

Patient education and careful monitoring are key to managing the side effects of SSRIs, which are often a reason for non-compliance.

SSRI Side Effects and Management

Gastrointestinal Issues: Nausea and diarrhea are common, especially in the first few weeks. I would advise the patient to take the medication with food and reassure her that these side effects are usually transient.
Sexual Dysfunction: This is a common and often persistent side effect, including decreased libido and anorgasmia. I would discuss this openly with the patient and, if she finds it unacceptable, consider a dose reduction or a switch to another medication.
Activation Syndrome: This can include restlessness, anxiety, and insomnia, particularly at the beginning of treatment. This needs to be differentiated from worsening anxiety and managed with reassurance and dose titration.
Serotonin Syndrome: This is a rare but life-threatening emergency. The symptoms include hyperthermia, muscle rigidity, and altered mental state. I would educate the patient and family on these symptoms and advise them to seek immediate medical attention if they occur.

Monitoring

I would monitor her clinical response using a validated scale (e.g., PHQ-9) and assess for side effects at every follow-up visit. This is a crucial part of long-term management and compliance.

Why would you consider a mood stabilizer for a patient with recurrent depression, and what are the key side effects of lithium?

The use of a mood stabilizer in recurrent unipolar depression is an important strategy for long-term relapse prevention, especially in treatment-resistant cases.

Rationale for a Mood Stabilizer

Relapse Prevention: In cases of recurrent depressive disorder, mood stabilizers like lithium can be highly effective in preventing future episodes. This is especially true for patients who have not responded to multiple antidepressants.
Augmentation: Lithium can also be used as an augmenting agent alongside an antidepressant to enhance its effect and accelerate a response.

Key Side Effects of Lithium

Lithium Toxicity: This is the most dangerous side effect. It is a narrow therapeutic index drug, and toxicity can occur with dehydration, over-dosing, or drug interactions (e.g., with NSAIDs). Symptoms include coarse tremor, ataxia, confusion, and vomiting.
Renal Impairment: Long-term use can lead to chronic kidney disease and nephrogenic diabetes insipidus. Regular monitoring of renal function is essential.
Hypothyroidism: Lithium can interfere with thyroid function, leading to hypothyroidism. This also requires regular monitoring.
Other Side Effects: Fine tremor, weight gain, and gastrointestinal upset are common.

Alcohol Dependence and Delirium Tremens

Patient Summary

A 45-year-old male with a long-standing history of alcohol dependence presents to the casualty department with reduced responsiveness after a period of heavy drinking followed by a sudden cessation. His wife reports that he frequently experiences withdrawal symptoms. He denies any issues with his wife but expresses a belief that her infidelity is the reason he drinks. He has a history of a suicide attempt and a previous diagnosis of comorbid depression. The case discussion centers on the management of his acute presentation, detoxification, and long-term pharmacological and psychosocial interventions.

How would you systematically approach the history and examination to confirm a diagnosis of alcohol dependence syndrome and rule out differential diagnoses?

A systematic history and examination are critical for confirming the diagnosis of alcohol dependence syndrome, assessing for complications, and ruling out other conditions. My approach would be as follows:

Systematic History Taking

I would use the ICD-10 criteria to guide my questioning, looking for at least three of the following six features in the last year:

Strong Craving: A powerful desire or sense of compulsion to consume alcohol.
Impaired Control: Difficulty in controlling the onset, termination, or level of alcohol use.
Withdrawal State: Physiological withdrawal symptoms when alcohol use is reduced or stopped (e.g., tremors, sweating, anxiety), or using alcohol to relieve or avoid these symptoms.
Tolerance: Evidence of increased tolerance to the effects of alcohol, so that larger doses are required to achieve the same effect.
Salience: Progressive neglect of other pleasures or interests due to alcohol use, with an increased amount of time spent on obtaining or recovering from its effects.
Persistence despite Harm: Continued alcohol use despite clear evidence of harmful consequences (physical or psychological).

Differential Diagnosis – Ruling Out Other Conditions

Harmful Use of Alcohol: The patient does not meet the criteria for dependence, but their alcohol use is causing physical or psychological harm.
Acute Intoxication: The patient’s symptoms are caused by the direct effects of alcohol, not withdrawal. I would confirm this by collateral history, timeline of last drink, and blood alcohol levels if necessary.
Organic Conditions: I would consider organic causes for his reduced responsiveness, such as head trauma, hypoglycemia, or infection.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, Psychiatry Long Cases.B30 (2).pdf, Psychiatry Viva 29th_240923_203823 (1).pdf

What are the key features and complications of alcohol withdrawal and Delirium Tremens (DT)?

Alcohol withdrawal is a spectrum of symptoms that can range from mild to life-threatening. Delirium tremens represents the most severe form of withdrawal.

Alcohol Withdrawal Symptoms (typically start 6-24 hours after last drink)

Tremors, sweating, nausea, and vomiting.
Tachycardia and hypertension.
Anxiety, restlessness, and insomnia.
Perceptual disturbances (e.g., visual or tactile hallucinations).

Delirium Tremens (DT) (typically starts 48-72 hours after last drink)

Global Confusion: A state of altered consciousness and disorientation.
Autonomic Hyperactivity: Severe tremors, profuse sweating, and marked tachycardia.
Hallucinations: Often vivid, frightening visual hallucinations (e.g., seeing insects or small animals).
Complications: The most feared complications are seizures and Wernicke-Korsakoff syndrome.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, Psychiatry Long Cases.B30 (2).pdf, Psychiatry Viva 29th_240923_203823 (1).pdf

How would you manage this patient’s acute presentation in the ward, including medication and monitoring? What is the role of thiamine?

Management of the acute withdrawal state is a medical emergency that requires a safe environment and a clear detoxification protocol.

Acute Management and Detoxification

Treatment Setting: Inpatient admission is essential for monitoring and managing the withdrawal state, especially given his reduced responsiveness and history of complications.
Risk Mitigation: I would ensure a calm, low-stimulus environment and provide close observation to prevent self-harm or aggression.
Pharmacological Management: The mainstay of treatment is a benzodiazepine.
- Chlordiazepoxide: This is the drug of choice. A tapering regimen would be used, with the dose gradually reduced over several days. The dose should be high enough to control symptoms but not so high as to cause over-sedation.
- Lorazepam: Can be used for short-term control of severe agitation or seizures.
Thiamine: The role of thiamine is crucial. I would administer intramuscular (IM) thiamine immediately to prevent Wernicke-Korsakoff syndrome, which is a medical emergency. I would give it IM over oral as oral absorption is poor in these patients. It must be given before any glucose-containing fluid to prevent precipitating Wernicke’s encephalopathy.

Monitoring

I would monitor his vital signs (heart rate, blood pressure, temperature) and mental state frequently to detect any signs of worsening withdrawal or delirium tremens.
I would also monitor his fluid balance, blood sugar, and electrolytes.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, Psychiatry Long Cases.B30 (2).pdf, Psychiatry Viva 29th_240923_203823 (1).pdf

How would you manage him long-term after the acute phase, including pharmacological, psychological, and social interventions?

Long-term management of alcohol dependence is aimed at preventing relapse and improving the patient’s quality of life. It requires a sustained, multidisciplinary approach.

Pharmacological Management (Relapse Prevention)

Disulfiram: This medication works by causing an unpleasant physical reaction (e.g., flushing, nausea) if alcohol is consumed. It requires a highly motivated and compliant patient. I would provide a detailed explanation of the drug’s mechanism and side effects.
Naltrexone: This reduces cravings for alcohol and the rewarding effects of drinking. It is an opioid antagonist.
Acamprosate: This helps to maintain abstinence in patients who have already stopped drinking.

Psychological Management

Motivational Interviewing: This technique helps to enhance the patient’s internal motivation for behavior change. It is particularly useful for patients who are ambivalent about quitting.
Cognitive Behavioral Therapy (CBT): This helps the patient identify triggers for drinking and develop coping strategies to manage cravings and high-risk situations.

Social Interventions

Psychosocial Support: I would refer him to a social worker for assistance with housing, employment, and social support.
Family Education: I would hold a family meeting to educate his wife and family on alcohol dependence and the importance of creating a supportive home environment. I would also provide guidance on how to avoid enabling behaviors.
Support Groups: I would recommend he attend self-help groups like Alcoholics Anonymous (AA) for ongoing peer support.

Source: Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf, Psychiatry Long Cases.B30 (2).pdf, Psychiatry Viva 29th_240923_203823 (1).pdf

Suspiciousness and Hearing Voices

Patient Summary

A 50-year-old male presents with a long history of schizophrenia, characterized by persistent delusions and auditory hallucinations. His current symptoms include thought broadcasting, persecutory delusions, and third-person auditory hallucinations (voices discussing him). He has a history of poor treatment compliance and lives alone, with limited family support. He is noted to have comorbid hypertension and diabetes. The discussion focuses on confirming the diagnosis, managing acute aggression, and long-term pharmacological and psychosocial management, including for treatment-resistant illness.

How would you approach the history and mental state examination to justify a diagnosis of Schizophrenia, particularly focusing on first-rank symptoms?

The diagnosis of Schizophrenia relies on a careful history and mental state examination (MSE) to elicit characteristic symptoms, particularly Schneider’s first-rank symptoms (FRS), which are highly suggestive of the disorder.

History and MSE Approach

I would approach the assessment systematically, paying close attention to the nature of the patient’s psychotic experiences:

First-Rank Symptoms: I would specifically inquire about a number of FRS, which are key to the diagnosis. These include:
- Third-Person Auditory Hallucinations: Voices that talk about the patient in the third person (e.g., “he is going to the hospital”).
- Thought Broadcasting: The belief that one’s thoughts are being transmitted out loud for others to hear.
- Thought Insertion/Withdrawal: The belief that thoughts are being put into or removed from one’s mind by an external force.
- Delusions of Control: The belief that one’s feelings, impulses, or actions are being controlled by an external force.
Nature of Delusions: I would explore the content of his delusions. Persecutory delusions are a common feature of schizophrenia, but I would also assess for bizarre delusions, which are often characteristic.
Negative Symptoms: I would also ask about symptoms that are often missed, such as a loss of motivation (avolition), lack of pleasure (anhedonia), and social withdrawal, as these contribute significantly to the functional impairment and prognosis.
Functional Impairment: I would confirm that his symptoms have led to a decline in his social, occupational, and personal functioning.

Source: Psychiatry Viva 29th_240923_203823 (1).pdf; Psychiatry Long Cases.B30 (2).pdf

How would you manage this patient if he presents with acute aggression in the ward? What is Rapid Tranquilization and how is it done?

Aggression in a psychotic patient requires immediate and systematic management to ensure the safety of the patient and others. My management would follow a clear protocol.

Acute Management of Aggression

De-escalation: The first step is always verbal de-escalation, creating a safe, calm environment, and giving the patient space. Nurses and other staff should be trained in these techniques.
Rapid Tranquilization (RT): If de-escalation fails, RT is used to manage acute aggression and psychosis.
- Oral Medication: The first choice is a fast-acting oral medication like **olanzapine** (5-10mg) or a benzodiazepine like **lorazepam** (1-2mg).
- Intramuscular (IM) Medication: If the patient refuses oral medication or the aggression is severe, an IM injection is used. **Haloperidol** (5-10mg) with a benzodiazepine like **promethazine** (25-50mg) is a common combination to manage psychosis and agitation while mitigating the risk of extrapyramidal side effects from the haloperidol.
Post-RT Monitoring: After administering RT, it is crucial to monitor the patient’s vital signs and level of sedation to ensure they do not become over-sedated. This is a continuous process until they are stable.

Source: Psychiatry Viva 29th_240923_203823 (1).pdf; Psychiatry Long Cases.B30 (2).pdf

What are the key non-pharmacological management strategies, and how would you educate the family to provide support?

Non-pharmacological interventions are vital for long-term recovery, improving social functioning, and preventing relapse. Family involvement is a key part of this process.

Non-Pharmacological Strategies

Psychoeducation: This involves teaching the patient and their family about schizophrenia, its symptoms, triggers for relapse, and the importance of medication adherence.
Cognitive Behavioral Therapy (CBT) for Psychosis: This helps the patient to understand their psychotic symptoms, challenge their beliefs, and develop coping strategies.
Social Skills Training: This helps the patient to improve their social interactions and re-engage with their community.
Occupational Therapy and Rehabilitation: These services help the patient find meaningful activities, vocational training, and re-enter the workforce, which can significantly improve their quality of life.

Family Education

Warning Signs: I would educate the family on the early warning signs of a relapse, such as increased social withdrawal, sleep disturbance, or changes in behavior.
Communication: I would teach them to be calm, non-judgmental, and supportive. It is important to avoid arguing with the patient about their delusions but to express concern for their feelings.
Support: I would connect them with support groups and social workers who can provide practical and emotional support.

Source: Psychiatry Long Cases.B30 (2).pdf; NICE guideline [CG178] – Psychosis and schizophrenia in adults.

What is resistant schizophrenia, and how would you manage it with a drug like Clozapine, including monitoring requirements?

A significant number of patients with schizophrenia do not respond to initial treatment. This is known as treatment-resistant schizophrenia, which has a specific management protocol.

Resistant Schizophrenia

Schizophrenia is considered **treatment-resistant** if a patient has not had an adequate response to at least two different antipsychotic medications (one of which should be a second-generation antipsychotic) for an adequate duration and at a therapeutic dose.

Management with Clozapine

Clozapine is the only antipsychotic proven to be more effective than other drugs in treatment-resistant schizophrenia. It is a second-generation antipsychotic with a unique mechanism of action. However, its use is restricted due to serious side effects and mandatory monitoring requirements.

Agranulocytosis: This is a rare but potentially fatal side effect. It is a mandatory requirement to monitor white cell count (WCC) and absolute neutrophil count (ANC) regularly. The monitoring protocol involves weekly checks for the first 18 weeks, then monthly for the next two years, and then annually if the patient is stable.
Side Effects: Common side effects include **constipation** (the leading cause of mortality in patients on clozapine), weight gain, hypersalivation, and sedation. Other serious side effects include myocarditis and cardiomyopathy, which require vigilant monitoring for symptoms like persistent tachycardia or fever.

Source: Psychiatry Viva 29th_240923_203823 (1).pdf; NICE guideline [CG178] – Psychosis and schizophrenia in adults.

Belief of Being Targeted and Threats of Violence

Patient Summary

A 64-year-old Buddhist priest presents with symptoms of a severe depressive episode, including low mood and anhedonia, following the death of his son six months ago. He has developed persecutory delusions towards his daughter-in-law’s family, believing they are responsible for his son’s death. This has led to homicidal ideas towards them. He also has a past history of a suicidal attempt. The discussion focuses on a comprehensive risk assessment, management strategies, including the role of ECT, and prognosis.

What is your approach to a comprehensive risk assessment for this patient?

A comprehensive risk assessment is paramount, given the patient’s presentation. It would be a dynamic process focusing on the immediate risks to himself and others.

Risk to Self (Suicidal Risk)

Past History: A history of a previous suicide attempt is the single strongest predictor of a future attempt. This patient’s history significantly elevates his risk.
Current Symptoms: His severe depression, feelings of hopelessness, and anhedonia contribute to a high baseline risk.
Impulsive Acts: I would assess for current impulsive suicidal ideas or plans.

Risk to Others (Homicidal Risk)

Delusional Content: The presence of persecutory delusions with homicidal ideas towards a specific family is a major risk factor for violence. The risk is heightened by the specific target (the daughter-in-law’s family) and the strong emotional link to his son’s death.
Access to Means: I would assess whether he has access to any weapons or other means to carry out his homicidal ideas.
Behavioral History: I would inquire about any history of aggression or violence towards others, as this would further increase the risk.

Vulnerability and Other Risks

Self-Neglect: Severe depression can lead to self-neglect, such as poor hygiene, malnutrition, and not taking care of his physical health.
Isolation: His delusions and low mood could lead to social withdrawal, making him more vulnerable.

Source: Psychiatry Viva 29th_240923_203823 (1).pdf; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf.

How would you manage this patient? What is the role of antidepressants and ECT in this case?

Management must be a multi-faceted approach, prioritizing immediate safety while treating the underlying severe depressive and psychotic symptoms. A multidisciplinary team approach is essential.

Management Plan

Treatment Setting: Immediate inpatient admission is essential, given the high risk of homicidal and suicidal behavior. This would likely be an involuntary admission under mental health legislation. He would be placed under close observation with a clear plan to ensure the safety of staff and other patients.
Pharmacological Treatment:
- Antidepressants: I would start with an antidepressant, such as a Selective Serotonin Reuptake Inhibitor (SSRI) like Sertraline (starting dose 50mg, max 200mg) or an SNRI like Venlafaxine (starting dose 75mg, max 375mg).
- Antipsychotics: Given the presence of psychotic symptoms (persecutory delusions and homicidal ideas), a co-prescription of an atypical antipsychotic is necessary. Olanzapine (starting dose 5mg, max 20mg) or Risperidone (starting dose 1mg, max 6mg) would be good options. The antipsychotic is crucial to address the psychotic and homicidal symptoms.
Role of ECT: Electroconvulsive Therapy (ECT) is a highly effective treatment for severe depression, especially with psychotic features. It would be a first-line consideration in this case due to the severity of the symptoms and the high risk of suicidal and homicidal behavior. ECT provides a rapid and robust response, which is critical in a high-risk situation.

Source: Psychiatry Viva 29th_240923_203823 (1).pdf; NICE guideline [CG90] – Depression in adults: recognition and management.

How would you prepare the patient for ECT, what side effects would you monitor for, and what is his likely prognosis?

ECT requires careful preparation and monitoring. The patient’s prognosis is a key part of the discussion with both the patient and their family.

Preparation for ECT

Informed Consent: I would explain the procedure, its benefits, risks, and alternatives. This would be a crucial step as the patient must provide consent.
Medical Workup: A full medical examination, including a physical examination, an ECG, and basic blood tests (FBC, U&E), is required to ensure the patient is fit for general anesthesia.
Pre-Procedure Instructions: The patient would be asked to fast and all dentures or loose items would be removed.

Side Effects and Monitoring

Post-ECT Amnesia: The most common side effect is short-term retrograde and anterograde amnesia, which is usually transient.
Physical Symptoms: Muscle aches, headaches, and confusion are also common in the immediate post-ECT period.
Monitoring: I would monitor for his cognitive status and vital signs in the recovery room. I would also monitor his mood and psychotic symptoms to assess the effectiveness of the treatment.

Prognosis

The prognosis for an older patient with a first episode of severe depression with psychotic features is generally good with treatment. However, the patient’s homicidal ideas and past suicidal attempt are significant risk factors for a poorer outcome.
The delusional content related to the death of his son suggests a pathological grief reaction, which, if not treated, can lead to a more chronic and difficult-to-treat course.
With appropriate and timely management, including ECT, his immediate symptoms and risk can be reduced, and his quality of life can be significantly improved. However, long-term monitoring and psychosocial support would be essential to prevent relapse.

Source: Psychiatry Viva 29th_240923_203823 (1).pdf; Shorter Oxford Textbook of Psychiatry by Paul Harrison, Philip Cowen, Tom Burns, Mina Fazel (z-lib.org).pdf.

Psychiatry Long Case Discussions

Low Mood and Delusions of Infidelity in Pregnancy

Patient Summary

Aggression and Over-expenditure

Patient Summary

Grandiose Delusions and Aggression

Patient Summary

Social Phobia and Anxiety

Patient Summary

Post-Traumatic Stress Disorder

Patient Summary

Obsessive Doubts and Contamination Fears

Patient Summary

Postpartum Depression and Suicidal Ideation

Patient Summary

Persistent Low Mood and Somatic Symptoms

Patient Summary

Alcohol Dependence and Delirium Tremens

Patient Summary

Suspiciousness and Hearing Voices

Patient Summary

Belief of Being Targeted and Threats of Violence

Patient Summary

Leave a ReplyCancel reply

Latest Posts

Psychiatry Long Case Discussions

Low Mood and Delusions of Infidelity in Pregnancy

Patient Summary

Aggression and Over-expenditure

Patient Summary

Grandiose Delusions and Aggression

Patient Summary

Social Phobia and Anxiety

Patient Summary

Post-Traumatic Stress Disorder

Patient Summary

Obsessive Doubts and Contamination Fears

Patient Summary

Postpartum Depression and Suicidal Ideation

Patient Summary

Persistent Low Mood and Somatic Symptoms

Patient Summary

Alcohol Dependence and Delirium Tremens

Patient Summary

Suspiciousness and Hearing Voices

Patient Summary

Belief of Being Targeted and Threats of Violence

Patient Summary

Share this:

Leave a ReplyCancel reply

Latest Posts