Regardless of the BMI, if there are medical complications such as electrolyte disturbances, hypoglycemia, or bradycardia, you should admit the patient. Since this patient has a history of loss of consciousness, low blood glucose, lacks insight, and is refusing voluntary admission, admission under the Mental Health Act would be appropriate.

An official assessment of her mental capacity would need to be performed to look for an impairment or disturbance that leaves the patient unable to make a decision.

ANOREXIA NERVOSA :

Anorexia nervosa is the most common cause of admissions to child and adolescent psychiatric wards.

It is most commonly seen in young women in which there is a marked distortion of body image, pathological desire for thinness, and self-induced weight loss by a variety of methods.

The majority of those with eating disorders are women so in the exam, you should expect a teenage female in the stem.

Features :

• BMI <17.5 or < 85% of that expected

• Self-induced weight loss reduces food intake, vomiting, purging, and excessive exercise

• Intense fear of being obese

• Disturbance of weight perception

• Endocrine disorders that cause amenorrhoea, reduced sexual interest/impotence, raised GH levels, raised cortisol, altered TFTs, abnormal insulin secretion

• Bradycardia

• Hypotension

• Fatigue

• Muscle weakness

• Intolerance to cold.

Bulimia nervosa is an eating disorder characterized by repeated episodes of uncontrolled overeating (binges) followed by compensatory weight loss behaviors.

Features:

• Excessive preoccupation with body weight and shape

• Compensatory weight control mechanisms which can be:

• Self-induced vomiting

• Fasting

• Intensive exercise

• Abuse of medication such as laxatives, diuretics, thyroxine or amphetamines.

Note that a person with bulimia nervosa does not necessarily need to be thin. They sometimes maintained a BMI above 17.5 kg/m2.

Examination:

• Salivary glands (especially the parotid) may be swollen.

• Russell's sign may be present (calluses form on the back of the hand, caused by repeated abrasion against teeth during inducement of vomiting).

• There may be erosion of dental enamel due to repeated vomiting.

The patient is suffering from bipolar disorder. Long-term management requires mood stabilizers and therefore lithium is the best option.

Bipolar affective disorder (commonly known as manic depression) :

Classically, periods of prolonged and profound depression alternate with periods of excessively elevated and irritable mood, known as mania.

Most people who battle with the effects of the disorder would rather live a normal life, free from the unpredictability of mood swings, which most of us take for granted.

The symptoms of mania characteristically include:

• Decreased need for sleep

• Pressured speech

• Increased libido

• Reckless behaviour without regard for consequences

• Grandiosity

• More talkative than usual

These symptoms of mania would alternate with depression.

Treatment Mood stabilizers (Lithium)

 Despite problems with tolerability, lithium still remains the gold standard in the treatment of bipolar affective disorder.

Nihilistic delusion is the delusional belief that the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless. It is a feature of psychotic depressive illness. Patients may believe that he/she is dead and may ask people to bury them.

Delusion of guilt involves feeling guilty or remorseful for no valid reason. An example would be someone who believes they were responsible for a war in another country or hurricane damage in another state. The object of delusion believes that they deserve to be punished for their sins.

Persecutory delusion is a delusional belief that one’s life is being interfered with in a harmful way. It refers to false beliefs or perceptions in which a person believes that they are being treated with malicious intent, hostility, or harassment despite significant evidence to suggest otherwise. This may occur in the context of being tormented, followed, or spied on.

Frégoli delusion is when a person holds a delusional belief that different people are a single person who changes appearance or is in disguise.

Attention deficit hyperactivity disorder (ADHD) is characterized by the three core symptoms of inattention, hyperactivity, and impulsiveness.

Clinical features :

- Inattention, careless with detail, fails to sustain attention, appears not to listen, fails to finish tasks, poor self-organization, loses things, forgetful, easily distracted, and avoids tasks requiring sustained attention.

- Hyperactivity: fidgets with hands or feet, leaves seat in the class, runs/climbs about, cannot play quietly, ‘always on the go’.

- Impulsiveness: Talks excessively, blurts out answers, cannot await turn, interrupts others, intrudes on others.

Frégoli delusion is when a person holds a delusional belief that different people are a single person who changes appearance or is in disguise.

Othello Syndrome is a type of delusional jealousy, marked by suspecting a faithful partner of infidelity like cheating, adultery, or having an affair. The patient may attempt to monitor his spouse or partner.

If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse. When stopping an SSRI the dose should be gradually reduced over 4 weeks (this is not necessary with fluoxetine as it has a long half-life).

This patient has neuroleptic malignant syndrome (NMS). NMS describes a rare and unusual reaction to antipsychotic drugs. The cause of NMS in this case is the patient’s use of clozapine.

Symptoms of NMS usually include high fevers, confusion, agitation, muscle rigidity, sweating, and tachycardia. The onset of these symptoms usually occurs after a few weeks of starting the medication but the symptoms can occur at any time.

Clang association is an abnormality of speech where the connection between words is their sound rather than their meaning. This may occur during the manic flight of ideas.

Clang associations generally sound a bit like rhyming poetry, except that the poems don't seem to make any sense. For example, one may say “Systematic, sympathetic, quite pathetic, apologetic, paramedic, your heart is prosthetic.

Obsessive-compulsive disorder (OCD) is a common, chronic condition, often associated with marked anxiety and depression, characterized by ‘obsessions’. It is characterized by recurrent obsessions or compulsions that are recognized by the individual as unreasonable. Obsessions are anxiety-provoking, intrusive thoughts, commonly concerning contamination, doubt, guilt, aggression, and sex.

Compulsions are peculiar behaviors that reduce anxiety, commonly hand-washing, organizing, checking, counting, and praying.

Management CBT is recommended by guidelines, but essentially takes a behavioral approach, including exposure and response prevention (ERP).

Delusion of control is the false belief that another person, group of people, or external force controls one's general thoughts, feelings, impulses, or behavior.  

Delusion of reference is the false belief that insignificant remarks, events, or objects in one's environment have personal meaning or significance. For example, someone constantly gives him or her a special message through the newspaper.

Persecutory delusion is a delusional belief that one’s life is being interfered with in a harmful way. It refers to false beliefs or perceptions in which a person believes that they are being treated with malicious intent, hostility, or harassment despite significant evidence to suggest otherwise.

Lithium toxicity is a frequently asked topic. Patients would present with symptoms of tremors, nausea, and vomiting followed by drowsiness, confusion, and later a coma. In these cases where lithium toxicity is suspected, urea creatinine, and lithium levels should be obtained.

Note that sodium valproate is also another cause of tremors but it is seen commonly with therapeutic doses rather than an overdose.

One should be very careful when choosing sodium valproate as the cause of tremors over lithium in a situation where an overdose is suspected. With sodium valproate overdose, they may also present with nausea and drowsiness just like in this stem, however, a coarse tremor is rarely seen.

She falls into the category of moderate anorexia. Admission to the hospital is not warranted because her blood pressure and heart rate are fine and her BMI is still above 15.

Atypical depression is a subtype of major depression or dysthymic disorder that involves several specific symptoms, including increased appetite or weight gain, sleepiness or excessive sleep, and marked fatigue or weakness. Atypical depressive episode regarded as a subtype of depressive disorder, rather than a separate entity.

Clinical features :

• Mood is depressed but remains reactive 

• Hypersomnia (sleeping more than 10 hours/day, at least 3 days / weeks, for at least 3 months)

• Hyperphagia (excessive eating with weight gain of over 3kg in 3 months)

• ‘Leaden paralysis’ (feeling of heaviness in the limbs).

Epidemiology : Onset is usually in the late teens and early twenties.

This woman is suffering from post-traumatic stress disorder.

Fluoxetine is an SSRI.

SSRIs are used second to CBT. As CBT was not an option in this question, fluoxetine would be the next best choice.

Incongruent affect The term “incongruent” means out of place. Incongruent effect is sometimes seen in schizophrenia where their behaviour is out of place.

For example, talking about problems in their family while laughing or laughing when your pet dies. These behaviours are seen as not consistent with the patient’s current mindset. This is also seen in bipolar patients.

It is quite difficult to differentiate generalized anxiety disorder from panic disorder. People with generalized anxiety disorder feel anxious most days and often struggle to remember the last time they felt relaxed. As soon as one anxious thought is resolved, another may appear about a different issue.

Panic disorder, however, is where you have recurring and regular panic attacks, often for no apparent reason similar to thisstem where she had several sudden onset episodes of panic.

Panic disorder is classified as having 2 recurrent panic attacks, which are not secondary to substance misuse, medical conditions, or another psychiatric disorder. The frequency of occurrence may vary from many attacks a day to only a few a year. Usually, patients have a persistent worry about having another attack or the consequences of the attack.

Symptoms/signs :

• Physical symptoms & signs related to autonomic arousal (e.g. tremor, tachycardia, tachypnoea, hypertension, sweating).

• Concerns of death from cardiac or respiratory problems may be a major focus, leading to patients presenting to emergency medical services.

This is a difficult question and many of the choices are potentially correct however the one disorder that stands out is delusion. A delusion is a mistaken belief that is held by a person with a strong conviction despite true evidence against the belief.

The subtype of delusion called “grandiose delusions” is likely what this man is suffering from. This subtype of delusions is seen in manic episodes of bipolar disorder, schizophrenics, and occasionally in substance abuse disorders.

The option of mania and bipolar disorder is not entirely wrong but delusion fits better as the answer.

This is a classic scenario for Tourette’s syndrome in the exam. Other clues that may appear on exam may be the child yelling in class intermittently or shouting expletives. Most Tourette’s syndromes are diagnosed at 6-8 years, maximum to the age of 13.

The other syndromes are less likely to be the answer:

Asperger syndrome : Characterized by severe persistent impairment in reciprocal social interactions, repetitive behaviour patterns, and restricted interests. IQ and language are normal or, in some cases, superior.

Although tics (like the above case) can also be found in Asperger's syndrome, it is more specific for Tourette’s syndrome. Not to mention, the question would include impairment of social skills if the examiners wanted you to have picked Asperger syndrome.

Cotard’s syndrome is a rare mental illness in which an afflicted person holds the delusion that they are dead Rett’s syndrome. 

There is normal development for 2–3 years, followed by a loss of acquired motor, language, and social skills between ages 3 and 4yrs. Stereotypes and compulsions are common.

Ekbom’s syndrome. Also called restless leg syndrome. Unpleasant, often painful sensations in the legs, particularly on sleep onset.

Delusion of control is the false belief that another person, group of people, or external force controls one's general thoughts, feelings, impulses, or behavior.

This patient is refusing any help offered thus voluntary admission to psychiatric wards is not possible. Compulsory admission under the Mental Health Act is the most appropriate answer.

The Mental Health Act allows people with a ‘mental disorder’ to be admitted to a hospital, detained, and treated without their consent – either for their health and safety or for the protection of other people.

This man is suffering from post-traumatic disorder Post-traumatic disorder (PTSD) develops following a traumatic event. In this case, it was a war that stimulated PTSD.

This girl has clinical features of anorexia nervosa. Over exercising, diuretics and laxatives over several weeks could cause a rapid weight loss which has detrimental effects to the cardiovascular system leading to syncope.

Young girls with anorexia nervosa often feel fatigue and intolerance to cold due to their low BMI. Their muscle power is decreased so they may find it more difficult to sit up without using their hands to support them.

There is a fine line between Generalised Anxiety Disorder (GAD) and Panic attacks. They both can present similarly. The major difference is panic attacks are usually short-lived (lasting no longer than 20–30min (rarely over 1 hour). ‘Excessive worry and feelings of apprehension about everyday events like in this case point towards the diagnosis of GAD.

Delusion of reference is the false belief that insignificant remarks, events, or objects in one's environment have personal meaning or significance. For example, someone constantly gives him or her special messages through the newspaper.

Nihilistic delusions are the delusional belief that the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless. It is a feature of psychotic depressive illness.

Patients may believe that he/she is dead and may ask people to bury them.

For the majority of patients with moderate depression, selective serotonin reuptake inhibitors (SSRIs) are considered first-line. If the question gives you options for SSRIs, sertraline would be the best answer to pick as sertraline has a good safety profile with patients with myocardial infarction.

The diagnosis here is obsessive-compulsive disorder (OCD). Exposure and response prevention (ERP) is included in cognitive behavioural therapy (CBT) in the treatment of those who present with OCD. The method is predicated on the idea that therapeutic effect is achieved as subjects confront their fears and discontinue their escape response.

In this case, the patient would be exposed to his feared stimulus and would refuse to respond with any safety behaviors. SSRIs are also a treatment choice for OCD. However as this is only a mild functional impairment, ERP would be a more appropriate answer.

Lithium is still used for bipolar disorder and has been proven to be a very effective treatment. In this stem, we see the blood that shows hypercalcaemia. It is important to remember that lithium toxicity can cause hypercalcemia. Medical professionals who deal with lithium monitoring are trained to look out for side effects of lithium toxicity such as severe or coarse hand shaking or tremors, blurred vision, abdominal pain with diarrhoea, slurred speech, muscle twitching, confusion, and muscle weakness.

We can see some of the symptoms here in this stem. Patients need regular blood tests to monitor lithium levels every 3 months and regular liver function tests and urea and electrolytes every 6 months.

Continuing therapy for at least 6 months is advised to reduce the risk of relapse even when patients are feeling “better”. Patients should be reassured that antidepressants are not addictive.

Depression is an important feature of bereavement. We note a good response with this lady as she feels better and sleeps well, but antidepressive therapy should still be continued for another 3 months (6 months in total) to reduce the risk of relapse.

Borderline Personality Disorder usually characterized by mood swings, marked impulsivity, unstable relationships, and inappropriate anger. They can be very dramatic. They are usually attention-seekers and may have multiple self-inflicted scars. They may threaten to commit suicide.

Insight In psychology and psychiatry, insight can mean the ability to recognize one's mental illness. This form of insight has multiple dimensions, such as recognizing the need for treatment and recognizing the consequences of one's behavior as stemming from an illness.

For example, people with obsessive-compulsive disorder and various phobias tend to have relatively good insight that they have a problem and that their thoughts and/or actions are unreasonable, yet are compelled to carry out the thoughts and actions regardless.

In general, a patient with insight is a patient who knows that their symptoms represent abnormality and seeks their diagnosis and appropriate treatment.

Somatization disorder is the experience of bodily symptoms with no physical cause for them, with presumed psychological causation. All investigations would be normal.

Hypochondriasis is the persistent belief in the presence of an underlying serious DISEASE, e.g. cancer or HIV. The patient again refuses to accept reassurance or negative test results.

Munchausen's syndrome is also known as factitious disorder. Patients intentionally falsify their symptoms and past history and fabricate signs of physical or mental disorders with the primary aim of obtaining medical attention and treatment.

The diagnostic features are the intentional and conscious production of signs, falsification, or exaggeration of the history, and the lack of gain beyond medical attention and treatment.

Admission should be to a ward where close observation and monitoring are possible, whenever there is a significant risk of harm to self (or others). The patient depicted in this scenario has severe depression. He has obvious depressive symptoms with severe functional impairment (self-neglect).

In addition, he has begun to actively plan a suicide attempt. This is a red flag. If you have reason to believe that he will harm himself or others, you may detain him and admit him.

Mirtazapine is an atypical antidepressant. It is not the correct answer for this scenario. You cannot just give this patient an antidepressant and send him home because he is at high risk of suicide. In addition, antidepressants take weeks to take effect and this patient needs help now.

Electroconvulsive therapy (ECT) is a very controversial mode of treatment. The only people who would be deciding to administer electroconvulsive therapy would be specialists and consultants.

For the majority of patients with moderate depression, selective serotonin reuptake inhibitors (SSRIs) are considered first-line If the question gives you options for SSRIs, sertraline would be the best answer to pick as sertraline has a good safety profile with patients with myocardial infarction.

Abstinence from alcohol in the hospital can cause delirium tremens which is noted here by his sudden confusion, restlessness, and physical aggressiveness.

Delirium tremens :

• Delirium tremens usually begin 24-72 hours after alcohol consumption has been reduced or stopped.

• Seen in chronic alcoholics

• The symptoms/signs differ from usual withdrawal symptoms in that there are signs of altered mental status. These can include hallucinations (auditory, visual, or olfactory), confusion, delusions, and severe agitation. Seizures can also occur.

A common scenario would be a chronic alcoholic who is admitted for an operation where that patient would have to be abstinent from alcohol. A few days after being abstinent, he or she would start having symptoms of an altered mental status which include hallucinations.

Please see Q-3

Abstinence from alcohol in the hospital can cause delirium tremens. The chronic alcoholism is supported by high MCV and GGT here. The GGT result is more useful than the MCV result as a “red flag” to raise the suspicion that the person is drinking too much. Symptoms fit delirium tremens. Seizures can be seen in delirium tremens.

It is unlikely to be Wernicke’s encephalopathy or Korsakoff’s psychosis as in exam they would usually have a triad of confusion, ataxia, and ophthalmoplegia.

This is a high-yield question in the exam. The perforated nasal septum is a huge clue that the route of intake is nasally inhaled. In the majority of cases, the answer when you see that term is cocaine. This along with the signs and symptoms of euphoria and agitation points towards cocaine.

Alcohol hallucinosis can occur during acute intoxication or withdrawal. It usually appears 12-24 hours after alcohol has stopped. It involves auditory and visual hallucinations, most commonly accusatory or threatening voices.

The answer is unlikely to be delirium tremens because of the time frame in which he was drinking alcohol. Delirium tremens usually happens days after alcohol consumption has been stopped and he would need to be a chronic alcoholic.

Please see Q-18

In acute psychosis, the drug of choice is haloperidol. It is still considered a first-line medication for rapid tranquilization. Haloperidol is a drug of choice for the management of psychotic episodes particularly in the elderly.

Diazepam is a long-acting benzodiazepine and so should not be used intramuscularly for rapid tranquilisation as it has a prolonged and erratic absorption. Besides, benzodiazepines generally are not recommended in elderly patients. Clonazepam is a long-acting benzodiazepine and can only be given orally which makes it inappropriate in this situation.

The immediate clue here is that she sees colours when she closes her eyes. These are the effects of LSD.

LSD can cause visual hallucinations, agitation, excitement, tachycardia, and dilated pupils.

You would need to admit this patient to a safe environment and provide symptomatic treatment of the agitation such as benzodiazepines. If the overdose is severe enough, she may go into a coma or have respiratory arrest which needs to be treated supportively. 

This woman requires a psychiatric referral i.e. Neuropsychiatric analysis. She is having a hypochondriacal delusion. Hypochondriasis can be defined as the persistent belief in the presence of an underlying serious disease, e.g. cancer or HIV.

Examples :

• A minor headache is caused by a brain tumour

• A mild rash is the start of skin cancer

• Tiredness is caused by HIV.

Reassurance by a doctor will not help a hypochondriac as a hypochondriac would fear that the doctor has just not found evidence of a serious disease yet.

This question is testing your knowledge of the AUDIT questionnaire. There are many alcohol screening tools and questionnaires but the AUDIT questionnaire remains one of the tops and a must-know for the exam.

Hypnagogic hallucination is a transient false perception experienced while on the verge of falling asleep (e.g. hearing a voice calling one’s name which then startles you back to wakefulness to find no one there).

The same phenomenon experienced while waking up is called hypnopompic hallucination. Frequently experienced by healthy people so not a symptom of mental illness.

There is a fine line between Generalized Anxiety Disorder (GAD) and Panic attacks. They both can present similarly. The major difference is panic attacks are usually short-lived (lasting no longer).

Nihilistic delusions are the delusional belief that the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless.

It is a feature of psychotic depressive illness. Patients may believe that he/she is dead and may ask people to bury them. 

This stem portrays a good history of depression with a background of mania in the past. The symptoms of mania in this stem are very subtle and somewhat within normal limits but the real giveaway is when there is reduced need for sleep. This would be a classic scenario when they would like you to pick Bipolar disorder. 

The abnormal excessive fear of being criticized is seen in social anxiety disorder where sufferers would avoid these social events including business meetings.

SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA) : Social anxiety disorder is the persistent fear and anxiety about one or more social or performance situations. It is characterized by marked fear of one or more social or performance-related situations where the person is exposed to scrutiny and in which embarrassment may occur.

Erotomaniac stalkers have the delusional belief that another person, usually of higher social status, is secretly in love with them. The sufferer may also believe that the subject of their delusion secretly communicates their love through seemingly innocuous acts, or if they are a public figure through clues in the media.

The object of the delusion usually has little or no contact with the sufferer, who often believes the object initiated the fictional relationship. Erotomaniac delusions are typically found as the primary symptom of a delusional disorder and in schizophrenia or mania.

It is clear that this patient is having periods of depression with other periods of mania. Flight of ideas is thought that jumps from topic to topic. It is the subjective experience of one’s thoughts being more rapid than normal. Meaningful connections between thoughts are maintained. It occurs especially in the manic phase of bipolar disorder. 

She has symptoms of depression. Depressive symptoms One of the most common referrals in liaison psychiatry is of patients with low mood. Patients may present with low mood, tearfulness, hopelessness regarding recovery, biological depressive features (poor sleep, appetite, energy, and concentration).

Some people who have severe clinical depression will also experience hallucinations and delusional thinking, the symptoms of psychosis. Nihilistic delusions are the delusional belief that the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless.

It is a feature of psychotic depressive illness. Patients may believe that he/she is dead and may ask people to bury them.

Hypnagogic hallucination is a transient false perception experienced while on the verge of falling asleep (e.g. hearing a voice calling one’s name which then startles you back to wakefulness to find no one there). The same phenomenon experienced while waking up is called hypnopompic hallucination. Frequently experienced by healthy people and so not a symptom of mental illness.

Withdrawal of alcohol due to hospital admission often leads to delirium tremens. This is noted here by her confusion and picking on her bed sheets. This is seen a couple of days after consumption of alcohol is stopped as seen in this question.

Wernicke's encephalopathy is unlikely as it presents with a triad of confusion, ataxia, and ophthalmoplegia. Korsakoff’s psychosis is characterized by the addition of Antero- and retrograde amnesia and confabulation in addition to the above classic triad of Wernicke's encephalopathy.

Please see Q-11

In order to answer this question appropriately, we need to figure out what is the primary cause of this patient’s symptoms. This patient has bipolar disorder. Bipolar disorder is characterized by episodes of low mood alternating with episodes of high mood.

Mood incongruence is a term used to describe a psychotic feature of bipolar disorder wherein the person’s belief or action does not match his or her mood.

An example would be laughing at the death of a loved one or believing that you have superpowers while going through a depressive episode. Mood congruence also describes a psychotic symptom of bipolar disorder, but, in this case, the belief or action is consistent with that person’s mood.

For example, feeling suicidal when a loved one dies or believing that you have superpowers when going through a manic episode.

Even though mood congruence and incongruence both describe psychotic features of bipolar disorder, psychosis is not correct as the question asks for the best descriptor of the patient’s behavior.

Acamprosate is used in combination with psychological intervention in moderate to severe alcohol dependence. It reduces the risk of relapse by reducing the cravings of alcohol. It is started after a successfully assisted withdrawal. Other alternatives to acamprosate which are not mentioned here are naltrexone or nalmefene. 

Cognitive behavioural therapy (CBT) should be used to treat panic disorders as there is really good evidence to support its use. Benzodiazepines should not be prescribed for the treatment of individuals with panic disorder as they have poor outcomes in the long term. Rebreath into paper bags is useful in acute settings but not as prevention.

Hypochondriasis is the persistent belief in the presence of an underlying serious disease, e.g. cancer or HIV. The patient again refuses to accept reassurance or negative test results. 

This question is not entirely specific. Usually, for a bulimia nervosa question to appear, the stem would give more of a history which includes either fasting or intensive exercise. Self-induced vomiting would be too obvious for the question writers to give. Bilateral parotid swelling and thickened calluses on the knuckles from self-induced vomiting may be found on examination in bulimia nervosa.

He is suffering from panic disorder. An SSRI or cognitive behavioural therapy would be appropriate. Sertraline is an SSRI.

Nihilistic delusions are the delusional belief that the patient has died or no longer exists or that the world has ended or is no longer real. Nothing matters any longer and continued effort is pointless. It is a feature of psychotic depressive illness. Patients may believe that he/she is dead and may ask people to bury them.

Somatization disorder : The experience of bodily symptoms with no physical cause for them, with presumed psychological causation.

This affected individual has lost his job and had a recent divorce. Depression should be something to consider. The auditory hallucinations are signs that this man is having some form of psychosis. The most probable diagnosis here is psychotic depression. Feeling worthless is in line with the delusions of guilt that are seen in psychotic depression.

Disulfiram acts as a deterrant. It reacts with alcohol and causes the patient to feel flushed, nauseous, dizzy, and faint. Because of these effects, patients would stay away from alcohol. Disulfiram works so well that it can even react with alcohol found in perfumes and aerosol sprays causing similar symptoms.

She is suffering from anorexia nervosa. Her BMI is critically low medical admission is warranted to provide her with proper nutrition. A pulse rate lower than 45 beats/minute and hypotension raises great concern and is definitely a criterion for hospital admission. The most common cause of death in patients with anorexia nervosa is due to cardiac complications. 

This is why they are admitted to medical wards and not psychiatry wards when the condition is severe. 

Please see Q-18

This patient is suffering from acute psychosis. No matter the reason, once she is sectioned, sedation would be the next step to calm her down for further investigations such as observations and blood tests.

There are a few drugs used for rapid tranquilization.

Guidelines recommends using lorazepam, olanzapine, or haloperidol. In this context, it is usually appropriate to administer intramuscular lorazepam 2 mg.

If she continues to be agitated, she may require haloperidol intramuscularly.

The reason lorazepam is preferred over the other benzodiazepines is that it is short-acting with a short half-life and respiratory depression is unlikely with the prescribed doses. Diazepam on the other hand should not be used intramuscularly for rapid tranquilisation as it has prolonged and erratic absorption.

Opiate overdose is treated with naloxone. It is given intravenously and repeated every 2 minutes until the patient’s breathing is adequate.

Please see Q-33

The phenomenon where he feels detached from his surroundings as if he is an observer of himself is called depersonalization.

It is a phenomenon where subjects feel that the world has become dreamlike and vague. It is seen in individuals who have experienced severe trauma. It can be one of the symptoms of post-traumatic stress disorder (PTSD).

The patient is suffering from generalized anxiety disorder. If medications were to be prescribed, the first line would be an SSRI.

An adjustment disorder occurs when an individual is unable to adjust to or cope with a particular stress or a major life event. 

Persecutory delusion is a delusional belief that one’s life is being interfered with in a harmful way. It refers to false beliefs or perceptions in which a person believes that they are being treated with malicious intent, hostility, or harassment despite significant evidence to suggest otherwise.

This may occur in the context of being tormented, followed, or spied on.

Medication usually is not used to treat phobias. However, it is sometimes prescribed to help people cope with the effects of anxiety. Beta-blockers are commonly used. It would be appropriate here as it is only for the short term.

Symptoms of depression :

• Present for at least 2 weeks and represent a change from normal.

• Depressed mood: present most of the day, nearly every day, with little variation

• Anhedonia: markedly diminished interest or pleasure in all, or almost all, activities most of the day

• Weight change: loss of weight when not dieting or weight gain associated with decreased or increased appetite

• Disturbed sleep: Insomnia 

• Fatigue or loss of energy.

• Reduced libido.

• Feelings of worthlessness or excessive or inappropriate guilt

• Diminished ability to think or concentrate or indecisiveness.

• Recurrent thoughts of death or suicide.

The patient is suffering from schizophrenia. This can be shown by the fact that he thinks that ideas are being stolen from his mind (thought withdrawal) and that the nurses are plotting to harm him (persecutory delusion). The feeling of nurses controlling his body is consistent with schizophrenia. It is called a passive phenomena.

Given in the previous questions

Despite problems with tolerability, lithium still remains the gold standard in the treatment of bipolar affective disorder.

Lithium is a teratogen. If a woman taking lithium is planning a pregnancy and is well and not at high risk of relapse, she should be advised to stop taking the drug because of the risk of cardiac malformations in the fetus. This should be done by gradual discontinuation before conception.

This boy displays traits of autism. He has difficulties in communication and forming relationships alongside having repetitive and obsessive behaviour that brings anxiety when disturbed. Patients with autism usually present at particular times of change. The change in this stem is represented by moving to a new school.

He describes his movements as being controlled by the radio. This is known as a passive phenomena. He also describes voices describing what he is doing. This is called third-person auditory hallucinations. Sometimes these voices can be heard like a running commentary. For example, the patient hears one or more voices providing a narrative of their current actions, ‘he’s getting up…now he’s going towards the window’. All these features are features of schizophrenia.

Her obsession and persistent belief that there is an underlying serious disease is evidence of hypochondriasis. As there is a lump and she is not falsifying the symptoms, it is not Munchausen's syndrome or malingering. Hypochondriasis is the persistent belief in the presence of an underlying serious DISEASE, e.g. cancer or HIV. The patient again refuses to accept reassurance or negative test results. 

Munchausen's syndrome is known as a factitious disorder. 

This is thought withdrawal. Which is the delusional belief that thoughts have been 'taken out' of his/her mind. It is commonly associated with thought block. But the difference is that in the thought block, there is a sudden break of a chain of thought and no one is stealing the ideas.

Capgras syndrome : A type of delusional misidentification in which the patient believes that a person known to them has been replaced by a ‘double’ who is to all external appearances identical, but is not the ‘real person’.

Explanation given in the previous questions

The answer here is agoraphobia as she has a fear of going out into the open.

Agoraphobia : Fear of open spaces

An adjustment disorder occurs when an individual is unable to adjust to or cope with a particular stress or a major life event. 

Thought insertion is the delusional belief that thoughts are being placed in the patient’s head from outside. It is a first-rank symptom of schizophrenia.

Please see the previous questions

Munchausen's syndrome would fit best. Likely she is adding blood into her stools at home for medical attention. This can easily be done with a pin prick on the finger.

Munchausen's syndrome is also known as factitious disorder. Patients intentionally falsify their symptoms and past history and fabricate signs of physical or mental disorders with the primary aim of obtaining medical attention and treatment.

The diagnostic features are the intentional and conscious production of signs, falsification, or exaggeration of the history, and the lack of gain beyond medical attention and treatment.

Delusion of guilt  involves feeling guilty or remorseful for no valid reason. An example would be someone who believes they were responsible for a war in another country or hurricane damage in another state. The object of delusion believes that they deserve to be punished for their sins.

The thickened calluses on the knuckles are from self-induced vomiting which is called “Russell’s sign. It may be found on examination in patients with bulimia nervosa or anorexia nervosa. She falls into the category of moderate anorexia. Admission to the hospital is not warranted because her blood pressure and heart rate are fine and her BMI is still above 15. Referral to an eating disorder unit or service would be the most appropriate.

Explanation discussed in previous questions.

This affected individual has lost her husband. Depression should be something to consider. The auditory hallucinations are signs that this woman is having some form of psychosis. The most probable diagnosis here is psychotic depression. Very commonly in exam, they would give a scenario of a person having symptoms of an atypical or typical depression plus having some form of hallucinations.

In the majority of the cases, the answer to that scenario would be psychotic depression.

Folie à deux is the best term to describe this. It is a symptom of a delusional belief and hallucinations that are transmitted from one individual to another usually by two people in a close relationship like in this case, husband and wife. Folie à deux is French for “madness of two”.

It is a situation where two people with a close relationship share a delusional belief.

This arises as a result of a psychotic illness in one individual with the development of a delusional belief, which comes to be shared by the second. The delusion resolves in the second person on separation, the first should be assessed and treated in the usual way.

Given above

Assessment of his mental capacity to refuse treatment would be the most appropriate next course of action. If his state of mind is fine, we can follow his instructions and leave the lesion there. But obviously, his mental state is not fine as he believes that this growth helps him think clearly. Mini Mental Status Examination (MMSE) is to assess patients with dementia.

All patients with cognitive impairment should be assessed with a Mini-Mental Status Examination (MMSE) to identify the areas of cognitive impairment.

Acamprosate, in combination with counseling, may be helpful for maintaining abstinence in alcohol-dependent patients. It is useful for patients who are concerned that strong cravings will result in relapse. Clinical psychologists and mental health support groups are the wrong places to refer a chronic alcoholic.

If a patient with diagnosed depression has been taking first-line antidepressant therapy (SSRIs) at a therapeutic dose for at least two to four weeks and presents with no improvement in symptoms after that period, there are steps that the clinician must take to manage the patient.

Lithium is a mood stabilising drug used in bipolar disorder. Its features include a coarse tremor (a fine tremor is seen in therapeutic doses), acute confusion and coma if severe.

Sufferers of social phobias (social anxiety disorders) can have anxiety when going out of the house and when seen in public. When doing so, they fear of doing something embarrassing like looking incompetent, stupid, or unentertaining.

The distractor here is agoraphobia. Agoraphobia is the fear of open spaces which can also be seen when sufferers go to the shopping mall. However, the trigger for this fear is more of the inability to escape the open space rather than the fear of being criticized.

Postnatal depression is seen commonly among women affecting up to 10% of women giving birth. Crying, not bonding, worrying, and feeling as if she cannot cope a typical presentations of postnatal depression.

Referral to a psychiatric team would be the most accurate option here. Acute alcohol consumption is an inhibitor of the P-450 enzyme system. Since she has consumed alcohol acutely, the risk of fatal effects of paracetamol poisoning would be reduced.

Not to mention that 10 tablets of paracetamol in a 17-year-old is not life-threatening. She does however need a psychiatric evaluation before she leaves the hospital as she was clearly trying to harm herself.

Thought broadcasting is the delusional belief that one’s thoughts are accessible directly to others. It is found in schizophrenia

The diagnosis here is baby-blues which is seen in around 3/4 of women after delivering. Whilst poor sleep could potentially be a sign of depression, poor sleep is expected with a new baby. 

This individual is suffering from schizophrenia. The speeches that are interrupted with silence followed by an unrelated topic are called thought blocking. The feature that he is no longer in control of his own body and thoughts is called the passivity phenomenon.

Both of these are features of schizophrenia. First-line treatment in newly diagnosed schizophrenia involves the use of newer atypical antipsychotics like olanzapine or risperidone.

Benzodiazepines are only used if rapid tranquillization is needed. This may be the choice if the scenario involves a violent, aggressive patient.

The diagnosis here is obsessive-compulsive disorder (OCD). Exposure and response prevention (ERP) is included in cognitive behavioural therapy (CBT) in treatment for those who present with OCD.

Pressure of speech The pressure of speech is a tendency to speak rapidly and frenziedly as if motivated by an urgency not apparent to the listener. The speech is rapid and difficult to interrupt, and, with the increasing severity of illness, the connection between sequential ideas may become increasingly hard to follow. Pressure of speech is a hallmark of mania and is often seen during manic periods in patients with bipolar disorder.

Please see Q -3

Please see Q-3

For the majority of patients with moderate depression, selective serotonin reuptake inhibitors (SSRIs) are considered first-line If this question gave you options for SSRIs, Sertraline would be the best answer to pick as sertraline has a good safety profile with patients with myocardial infarction.

The other antidepressants have not been studied enough in the context of myocardial infarction however citalopram has gained popularity and is also considered safe for use in patients with depression with a history of myocardial infarction. Citalopram and fluoxetine are the preferred SSRIs if there is no relevant past medical history.

Third-person auditory hallucinations Auditory hallucinations are characteristic of schizophrenia where voices are heard referring to the patient as ‘he’ or ‘she’, rather than ‘you’. For example "She is an evil person". Sometimes the voices are of a running commentary.

For example, the patient hears one or more voices providing a narrative of their current actions, ‘he’s getting up…now he’s going towards the window’.

Conversion (dissociative) disorders typically involve loss or disturbance of normal motor or sensory function which initially appears to have a neurological or other physical cause but is later attributed to a psychological cause.

The patient does not consciously feign the symptoms or seek material gain. Memory loss, seizures, loss of speech, and paralysis can occur.

The diagnosis here is obsessive-compulsive disorder (OCD).

Exposure and response prevention (ERP) is included in cognitive behavioural therapy (CBT) in treatment for those who present with OCD. The method is predicated on the idea that a therapeutic effect is achieved as subjects confront their fears and discontinue their escape response.

The patient has tardive dyskinesia likely caused by his treatment with antipsychotic drugs. A common side effect of long-term use of antipsychotic drugs is tardive dyskinesia which is a movement disorder characterised by continuous involuntary movement of the tongue and lower face. Patients are often unaware of these movements and they are reported by family members like in this case, his mother.

The phrase to pick up in this question stems is the fear of “being criticized”. This is a good example of social phobia (social anxiety disorder). Sufferers avoid situations like meetings, group events, and public speaking as they may bring about the possibility of embarrassment.

She has features of depression: feels sad, not eating well, has difficulty sleeping, feeling weak. On top of that she has delusional ideas: no interest to feed the baby, she thinks the baby has evil eyes and not taking the baby out of the house. These points to postpartum psychosis.

A key feature to look out for in EXAM is the words “evil eyes”. If a mother has recently delivered and thinks that her baby has evil eyes, pick the answer that has postpartum psychosis. You are most likely to be correct.

Postpartum psychosis usually starts with postpartum depression. Classically, they would have thoughts of harming their newborn baby. She would have delusional ideas that the baby is deformed, evil, or otherwise affected in some way and she has intent to kill or harm the baby. Onset usually within the first 2-3 weeks following birth.

Management :

• Admission to the hospital (specialist mother-baby unit if possible) is usually required

• For major affective disorder there is good evidence for ECT.

His delusions describe a type of delusion called grandiose delusions which are usually found in patients with mania.

The key here is to understand what medication can cause both hypokalaemia and lithium levels to rise. Thiazides (e.g. bendroflumethiazide) can cause hypokalaemia. Thiazide and related diuretics can cause a rapid rise in serum lithium levels leading to toxicity. Guidelines recommend avoiding concurrent use unless lithium levels can be closely monitored and the lithium dose adjusted as necessary.

Conversion (dissociative) disorders typically involve loss or disturbance of normal motor or sensory function which initially appears to have a neurological or other physical cause but is later attributed to a psychological cause. The patient does not consciously feign the symptoms or seek material gain. Memory loss, seizures, loss of speech, and paralysis can occur. In this case, she lost her vision.

Remember that patients with conversion disorder are not feigning the signs and symptoms. Despite the lack of an organic diagnosis. The person’s distress is very real and the physical symptoms the person is experiencing cannot be controlled at will. Fortunately, a good prognosis can be expected and she will likely recover from her visual symptoms.

There is a history of depression and symptoms of mania. This would be a classic scenario where they would like you to pick Bipolar disorder.

Antisocial Personality disorder : Characterized by continuous antisocial or criminal acts, inability to conform to social rules, impulsivity, disregard for the rights of others, aggressiveness, and lack of remorse. They will typically be manipulative, deceitful, and reckless.

Like other types of personality disorder, antisocial personality disorder is on a spectrum, which means it can range in severity from occasional bad behavior to repeatedly breaking the law and committing serious crimes. Psychopaths are considered to have a severe form of antisocial personality disorder.

Please see Q-124

The symptoms here are representative of hypomania which can be thought of as a milder form of mania. With hypomania, there are higher than normal energy levels but they do not generally lead to hospitalization whereas manic episodes usually last for a week or more and may result in hospitalization.

Usually, if the stem includes grandiose ideas, hallucinations, or delusions PLUS elevated moods, then pick mania, otherwise pick hypomania. It is especially important to remember that hypomania does NOT present with hallucinations or delusions.

This would often be the difference between picking mania and picking hypomania as the answer.

We are all very automated into picking LSD as the answer as soon as we see some form colour vision distortion in the stem but what happens when LSD is not part of the options. This patient has likely taken Ecstasy. She has no past medical problems so diphenhydramine (an antihistamine) and amiodarone are incorrect.

Thought broadcasting is the delusional belief that one’s thoughts are accessible directly to others. It is found in schizophrenia.

Please see Q - 114

Please see Q-32

Hallucinations like this are common with patients on Lysergic acid diethylamide (LSD). Whenever you see a stem with odd sensations such as smelling colours or seeing sound, think LSD.

The above described is anorexia nervosa. A low BMI and the refusal to maintain a normal body weight for her age are key towards the diagnosis. Fatigue and loss of interest in social events are also features of anorexia nervosa.

The most important thing to glean from this question is that this patient has conceded that he has a problem and that he needs help. This single fact would be grounds for a voluntary hospital admission. He needs a general hospital admission, voluntary or otherwise, for the very fact that he has ingested a large quantity of medications.

The type of medication was not given in the stem but it would be dangerous to send him elsewhere.

One of the hallmarks of social anxiety disorder is the intense fear of public speaking. They have a fear of being criticized. Sufferers fear that they may look stupid or appear boring.

He thinks that the changing of traffic lights is giving him a message. These are called delusional perceptions and are a feature of schizophrenia.

Ganser syndrome is a type of factitious disorder, a mental illness in which a person deliberately and consciously acts as if he or she has a physical or mental illness. They mimic behavior that is typical of a mental illness, such as schizophrenia. It is also sometimes called prison psychosis because the syndrome occurs most frequently in prison inmates, where it may represent an attempt to gain leniency from prison or court officials.

Capgras syndrome - A type of delusional misidentification in which the patient believes that a person known to them has been replaced by a ‘double’ who is to all external appearances identical, but is not the ‘real person’.

The first question to ask yourself is, is this a suitable environment for a person with a depressive illness. Obviously not, and thus he should be admitted to the psychiatry ward. Admission should be to a ward where close observation and monitoring are possible, whenever there is a significant risk of harm to self (or others) The ward environment is often not the quiet sanctuary patients hope for and this may lead to difficult decisions in balancing the risk of self-harm against the use of compulsory admission.

Please see Q-16

Tardive dyskinesia occurs especially in patients with long-term treatments with antipsychotic agents. The word “tardive” means delayed, and “dyskinesia” means abnormal movement. Put together “tardive dyskinesia” refers to the delay between the first use of offending medication and the onset of abnormal movements.

It takes several months to years to develop the symptoms of tardive dyskinesia from the use of antipsychotics. It is characterized by continuous involuntary movement of the tongue and lower face. The disorder can also affect the fingers, arms, and legs causing either rapid, jerking movements or slow, writhing movements.

Huntington’s disease usually presents at an earlier age with tremors and choreiform movements.

Parkinsonism can also be caused by antipsychotic medications however it is characterized by resting tremors, rigidity, and bradykinesia. The onset of parkinsonism as an extrapyramidal side effect of antipsychotics usually occurs after 1 week of administration of the offending antipsychotic drug.

Akathesia like tardive dyskinesia and Parkinson’s can be caused by the use of antipsychotic medications but the symptoms involve motor restlessness. These are restlessness of the lower limbs where the patient would have the urge to move. The word “akathisia” is derived from Greek and it means “not to sit still”. 

The single best test to do for this patient would be to confirm his suspicion of lithium toxicity with a serum lithium level. Lithium is mostly excreted by the kidneys, and drugs such as NSAIDs increase renal reabsorption of lithium thus increasing serum lithium levels. Chronic accumulation of lithium such as in this case would usually result in mild to moderate symptoms.

Although a full battery of tests such as a full blood count, typically blood glucose and renal function tests would be done in real life, if asked for “the most APPROPRIATE test” the examiners would like you to consider lithium toxicity as a diagnosis, and request a serum lithium concentration.

Before treatment with lithium is commenced, tests are needed to assess both kidney function and thyroid function. The kidneys mostly excrete lithium with minimal metabolism by the liver. In addition, it can also cause long-term kidney damage, so kidney monitoring is done at regular intervals.

A thyroid function test is done initially because abnormal levels of thyroid hormones can mimic or precipitate mania and depression. It is also good practice to have a baseline prior to starting lithium.

Thyroid monitoring is done at regular intervals because lithium can induce hypothyroidism. Following the initial test, anyone on lithium should have their lithium levels checked 3 monthly, and TSH and renal function checked at least 6 monthly if not more frequently.

Obsessive-Compulsive Disorder (OCD) is a disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviors (compulsions) that he or she feels the urge to repeat over and over. Here patient’s thoughts are obsession and though no compulsive act is described (like repeated cleansing of dirt) but his nature of thought like inability to resist thinking or getting palpitations on trying to avoid thinking can be regarded as compulsion of thought.

CBT is 1st line treatment and antidepressants (SSRIs) are tried if no response to CBT.

More severe OCD may require a longer course of therapy and/or medication.

Erotomania is a type of delusion in which the affected person believes that another person, usually a stranger, high-status or famous person, is in love with them]. Pyromania is an impulse control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires, in order to relieve tension or for instant gratification.

Kleptomania is the inability to refrain from the urge to steal items. Trichotillomania is an impulse disorder characterized by the compulsive urge to pull out one's hair, leading to noticeable hair loss and balding. Grandiosity refers to an unrealistic sense of superiority.

Usually occurs after prolonged treatment. [Neuroleptic malignant syndrome is a life-threatening reaction that can occur in response to neuroleptic or antipsychotic medication.

Symptoms include high fever, confusion, rigid muscles, variable blood pressure, sweating, and fast heart rate. Neuroleptic malignant syndrome usually occurs SOON after the start or in increasing doses of antipsychotic drugs.

All other conditions mentioned are seen in this syndrome like renal failure, pyrexia, elevated creatinine kinase, tachycardia, etc.

Thought insertion is feeling as if one's thoughts are not one's own, but rather belong to someone else and have been inserted into one's mind. It is a common feature of schizophrenia.

This is mild depression. In mild depressive illness CBT is the preferred treatment.

The diagnosis is Post Traumatic Stress Disorder. Guidelines suggest that trauma-focused psychological therapies (CBT or EMDR) should be offered before medication, wherever possible.

As these are not in option the best answer here is Fluoxetine (SSRI).

At present, there is evidence that EMDR, psychotherapy, behaviour therapy, and antidepressants are all effective.

There is not enough information for us to say that one of these treatments is better than another.

The diagnosis is obsessive-compulsive disorder. For obsessive-compulsive disorder CBT is the 1st treatment of choice and if fails next comes drugs.

Voluntary admission to the psychiatry ward.

CBT is the treatment of choice in PTSD. Guidelines recommends that you are offered 8–12 regular sessions of around 60–90 minutes, seeing the same therapist at least once a week.

Hyperventilation causes CO2 washout and respiratory alkalosis. An increase in pH, alkalosis, promotes increased protein binding, which decreases free calcium levels and this low calcium causes perioral paresthesia and carpopedal spasm.

If you continue breathing and rebreathing in the paper bag it will allow CO2 concentration to rise in the paper bag and as you rebreath this again and again you will regain some washed-out CO2 and thus relief to this alkalosis.

Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen.

Attention deficit hyperactivity disorder (ADHD) is a condition that affects people's behaviour. People with ADHD can seem restless, may have trouble concentrating, and may act on impulse.

Symptoms of ADHD tends to be noticed at an early age and may become more noticeable when a child's circumstances change, such as when they start school. Most cases are diagnosed when children are 6 to 12 years old.

The symptoms improve with age, but many adults continue to experience problems.

Repeated flashbacks and tendency to avoid the thoughts of stressors is diagnostic of PTSD.

PTSD is diagnosed after a person experiences symptoms for at least one month following a traumatic event. However, symptoms may not appear until several months or even years later. The disorder is characterized by three main types of symptoms: Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.

Emotional numbness and avoidance of places, people, and activities that are reminders of the trauma. Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.

Initial depressive episode (may be befor a long) followed by mania is bipolar affective disorder.

Borderline personality disorder: Act impulsively and develop an intense but short-lived emotional attachment to others. They are usually attention seekers but not suicidal.

Now she is depressed but before hypomanic which makes the likely diagnosis of bipolar disorder.

Assess his mental capacity to refuse treatment.

Antisocial personality disorder is a particularly challenging type of personality disorder, characterized by impulsive, irresponsible, and often criminal behavior.

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder, is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of self, and unstable emotions. There is often an extreme fear of abandonment, frequent dangerous behavior, a feeling of emptiness, and self-harm.

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder is a long-term pattern of abnormal behavior characterized by unstable relationships with other people, unstable sense of self, and unstable emotions.

There is often an extreme fear of abandonment, frequent dangerous behavior, a feeling of emptiness, and self-harm.

The deliusion metioned is a delusion of perception - he thinks that the changing traffic lights are giving a message to him and this is often seen in schizophrenic patients (one of the 1st rank symptoms).

The likely diagnosis is obsessive-compulsive disorder. Most effective treatment for obsessive-compulsive disorder is cognitive behavioral therapy.

Hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness.

Features like i) elevated mood ii) more energy than before iii) getting more work done at the office (loss of inhibition) is common for both mania and hypomania. This is not mania as in mania we shall get psychotic symptoms like :

i) delusion of grandeur and

ii) auditory hallucinations, which are absent here.

The patient is not psychotic and with normal neurology! So she may be having some problem in family life, finance, job, social life or somewhere like this which she is not able to cope with and that is leading to her suicidal thoughts.

Diagnosis is postpartum depression. Intrusive thought of harming the baby is a feature of postpartum depression. CBT should be tried first.

Antidepressants if CBT does not work or the patient does not want CBT. If severe depression and all other fail ECT is considered.

A delusion of grandeur is the false belief in one's own superiority, greatness, or intelligence. People experiencing delusions of grandeur do not just have high self-esteem; instead, they believe in their own greatness and importance even in the face of overwhelming evidence to the contrary.

Nihilistic delusion: parts of the body do not exist or are dead.  

Guilt: an emotion that occurs when a person feels that they have violated a moral standard.  

Hypochondriasis: worry about having a serious illness.  

Munchausen’s: a psychiatric factitious disorder wherein those affected feign disease, illness, or psychological trauma to draw attention, sympathy, or reassurance to themselves.

Capgras syndrome: a delusion that a friend, spouse, parent, or other close family member (or pet) has been replaced by an identical-looking impostor.

This is multiple, recurrent, medically unexplained symptoms usually starting early in life. Usually patient presents with one symptom at a time. Investigations are normal.

Features of depression: feels sad, poor eating, difficulty sleeping, feeling weak ii) delusional ideas: thinks baby has evil eyes and not taking the baby out of the house. These features point to the diagnosis of postpartum psychosis.

Postpartum psychosis starts within 2 weeks (occasionally later) of delivery and it can take 6 -12 months or more to recover from postpartum psychosis.

This patient is refusing any help offered! And his son cannot deal with him anymore! In this situation voluntary admission to the psychiatry ward is not possible and the option of choice is “compulsory admission under MHA”.

The point here is the man has felt himself in danger by self-neglect.

Autistic spectrum disorder. Autism spectrum disorders affect three different areas of a child's life:

1. Social interaction

2. Communication - both verbal and nonverbal

3. Behaviors and interests In some children, a loss of language is a major impairment.

In others, unusual behaviors (like spending hours lining up toys) seem to be the dominant factors.

Recommended treatment for panic disorder is i) CBT ii) Medication (SSRIs or TCA). NICE recommends a total of seven to 14 hours of CBT to be completed within a four month period. Treatment will usually involve having a weekly one to two-hour session.

When the drug is prescribed usually an SSRI is preferred. Antidepressants can take two to four weeks before becoming effective.

Depression is an important feature of bereavement. Patients may pass sleepless nights.

As this patient's sleep has improved it indicates she has a good response to antidepressants and as she still speaks about her husband there is a chance of deterioration of her depression if an antidepressant is stopped. For depressive episodes antidepressants should be continued for at least 6-9 months.

Hypnagogic or hypnopompic hallucinations are visual, tactile, auditory, or other sensory events, usually brief but occasionally prolonged, that occur at the transition from wakefulness to sleep (hypnagogic) or from sleep to wakefulness (hypnopompic).

CBT

Psychotic depression, also known as depressive psychosis, is a major depressive episode that is accompanied by psychotic symptoms (hallucinations, delusions).

In this patient, nihilistic delusion favours the diagnosis of psychotic depression. It can occur in the context of bipolar disorder or major depressive disorder.

Collateral information

Low mood

In psychiatry, the patient's awareness and understanding of the origins and meaning of his attitudes, feelings, and behavior and his disturbing symptoms (self-understanding) is known as insight.

Presently patient has depression and previous features of mania make the likely diagnosis of bipolar affective disorder.

Atypical depression is a subtype of major depression or dysthymic disorder that involves several specific symptoms, including increased appetite or weight gain, sleepiness or excessive sleep, marked fatigue or weakness, moods that are strongly reactive to environmental circumstances, and feeling extremely sensitive to rejection.

Reduce lithium gradually and stop when pregnancy is confirmed.

Patient has an anxiety disorder (panic) which causes hyperventilation and CO2 washout leading to respiratory alkalosis.

Symptoms will improve by rebreathing into a paper bag as it will cause a gradual increase of CO2 in the paper bag and decrease the severity of respiratory alkalosis.

Here closest d/d to panic disorder is pheochromocytoma. But in pheochromocytoma, the most important feature is resistant hypertension and other important features are headache and abdominal pain which all are absent here. Moreover overwhelming fear is more suggestive of panic disorder. Hence here the diagnosis is Panic disorder.

18 year thin girl, bilateral parotid swelling and thickened calluses on the knuckles from self induced vomiting are suggestive of Bulimia nervosa. Bulimia often is associated with bilateral parotid swelling (parotid hypertrophy).

Third-person hallucinations are auditory hallucinations in which patients hear voices talking about themselves, referring to them in the third person, for example "he is an evil person".

Thought broadcasting

Mild depression: i)Low mood ii) Anhedonia iii) Guilt iv) Hopelessness v) Worthlessness vi) Inability to concentrate.

Delusions of persecution refer to false beliefs or perceptions in which a person believes that they are being treated with malicious intent, hostility, or harassment – despite significant evidence to suggest otherwise.

The diagnosis is anorexia nervosa. At this critical low BMI medical admission is indicated to improve her deficiency states and proper nutrition. BMI <15kg/m2, rapid weight loss + evidence of system failure requires urgent referral to eating disorder unit (EDU), medical unit (MU) or paediatric medical wards.