Psychiatry EMQs from PRN online Flashcards
A. Summarising B. Active listening techniques C. Question funnelling D. Linking E. Reflection F. Platitudes G. Paternalism H. Empathy I. Motivational interviewing J. Bargaining
Student: What happened today to bring you into hospital?
Bob: Well, I got back from visiting my family in Australia, only a few days ago. I was a bit jet-lagged, but pretty good otherwise. Then yesterday, my leg swelled up - really painful! It hurts to walk on it. I kind of thought it would go down, but it didn’t, so I came in here.
Student: What else have you noticed?
Bob: It’s gone really red - and hot. It’s only the right leg, and it makes the left one look tiny by comparison.
Student: I see… Have you had any problems with your breathing?
Bob: No.
C. Question funnelling
Question funnelling is a useful technique, whereby the interviewer starts with an open question(s) and moves to closed or clarifying questions. It allows the patient to freely express what has happened to them whilst enabling you to direct the conversation.
A. Summarising B. Active listening techniques C. Question funnelling D. Linking E. Reflection F. Platitudes G. Paternalism H. Empathy I. Motivational interviewing J. Bargaining
Student: You’ve given me a lot of information. Can I just see if I’ve got this right?
Ahmed: OK
Student: You lost your job about 3 months ago, which led to money problems. Since then you’ve felt increasingly that your life was out of control, and that planning for the future is pointless. You’ve been having a lot of trouble sleeping, which has left you feeling tired.
Ahmed: That’s right. I’m so tired I can’t get out the house anymore. I feel bad for my wife - I must be making her so miserable.
A. Summarising
A. Summarising B. Active listening techniques C. Question funnelling D. Linking E. Reflection F. Platitudes G. Paternalism H. Empathy I. Motivational interviewing J. Bargaining
Anneke: Since the attack, I haven’t been able to let my partner near me. It seems stupid, but I’m just so edgy all the time.
Student: I’m sure he understands.
Anneke: Actually, I don’t think he gets what I’m going through… I can’t see how things will improve until I can sort my head out.
Student: Well, things will get better - they always do.
F. Platitudes
usually unhelpful, since they can come across as dismissive or patronising - no matter how well intended they were.
A. Summarising B. Active listening techniques C. Question funnelling D. Linking E. Reflection F. Platitudes G. Paternalism H. Empathy I. Motivational interviewing J. Bargaining
Dimitrios: I don’t need to be here. I don’t even want to be here. I’m only here because my parents are overreacting. I just don’t want to be spied on by the others anymore.
Student: The others?
Dimitrios: Yeah. Them that follow me. They hear everything I say - and even my thoughts when it’s quiet. I’m tired of it…
E. Reflection
A. Summarising B. Active listening techniques C. Question funnelling D. Linking E. Reflection F. Platitudes G. Paternalism H. Empathy I. Motivational interviewing J. Bargaining
Jean: I need something to help me sleep, Doc. I can’t seem to drop off at night, and then I wake up really early.
Student: I’d imagine that would leave you feeling really tired. Have you noticed that you don’t have as much energy recently?
Jean: Yeah, it’s really hard to get going lately. Everything seems like a battle…
Student: I’m so sorry… How long have you been feeling like this?
D. Linking
A. Akathisia B. Parkinsonism C. Tardive dyskinesia D Mannerisms E. Stereotypies F. Tics G. Compulsions H. Catatonia I. Intention tremor J. Dystonia
You are a junior doctor working in general practice. Mrs Patel is a 78 year old woman who comes to see you complaining that her hands have been shaking for a few weeks, her left worse than the right. She thought it would pass but it hasn’t. She keeps knocking drinks over and is finding it difficult to write.
I. Intention tremor
A. Akathisia B. Parkinsonism C. Tardive dyskinesia D Mannerisms E. Stereotypies F. Tics G. Compulsions H. Catatonia I. Intention tremor J. Dystonia
Gustav Erikson is a 46 year old man who has been treated for paranoid schizophrenia for the last 12 years. His family have noticed that recently he has been grimacing and pulling faces. It seems to be getting worse and they are concerned that he is reacting to hallucinations again.
Tardive dyskinesia
usually a delayed side effect of antipsychotic use
A. Akathisia B. Parkinsonism C. Tardive dyskinesia D Mannerisms E. Stereotypies F. Tics G. Compulsions H. Catatonia I. Intention tremor J. Dystonia
Esther Smithson is a 24 year old woman who was admitted with an acute psychotic episode and has been taking risperidone for 3 weeks. You are a senior house officer working on her ward, and have been asked to see her by nursing staff, since she “keeps pacing by the door”. Staff are concerned that she is trying to abscond. During the consultation you notice that she seems on edge and unable to settle. On several occasions she rises from her seat to pace up and down.
Akathisia
is an unpleasant subjective sense of restlessness, and is an extrapyramidal side effect of antipsychotic use.
A. Akathisia B. Parkinsonism C. Tardive dyskinesia D Mannerisms E. Stereotypies F. Tics G. Compulsions H. Catatonia I. Intention tremor J. Dystonia
Charles Crawford is a 26 year old man, who has been brought to see you by his wife, Cindy. He was playing football in the garden with their son, Michael, and had to stop because his eyes “got stuck looking up”. He is very frightened, and says his eyes hurt. You note that he is taking quetiapine following a manic episode.
Dystonia
A common extrapyramidal side effect of antipsychotic use. This particular dystonia is an oculogyric crisis.
A. Akathisia B. Parkinsonism C. Tardive dyskinesia D Mannerisms E. Stereotypies F. Tics G. Compulsions H. Catatonia I. Intention tremor J. Dystonia
Sebastian Epstein is a 54 year old who has been treated with haloperidol for 10 years. His wife has noticed that he has become very shaky. When he is watching television is unable to keep his hands still. It seems to be getting worse.
Parkinsonism
A common extrapyramidal side effect of antipsychotic use.
A. Dysarthria B. Dysphasia C. Clang associations D. Punning E. Neologisms F. Pressure of speech G. Poverty of speech H. Flight of ideas I. Perseveration J. Loosening of associations
You are a house officer attached to a general medical firm. You are asked to assess the mental state of Johan Wicklestein. Johan is a 62 year old man with Parkinson’s disease. The nursing staff, who know him from previous admissions, have noticed that he seems to have low mood. During your assessment you notice that although he understands you and answers all questions appropriately, he seems to have problems articulating his words.
Dysarthria
Describes problems with articulation of speech - the brain knows what it wants to say, but problems with the speech apparatus makes this difficult.
A. Dysarthria B. Dysphasia C. Clang associations D. Punning E. Neologisms F. Pressure of speech G. Poverty of speech H. Flight of ideas I. Perseveration J. Loosening of associations
You are a final year medical student on a psychiatry firm. You are asked to assess the mental state of Marjorie Wilson. Marjorie’s speech is coherent and does not seem to jump from topic to topic, but she speaks so quickly that you find her uninterruptible, and struggle to keep up with her.
Pressure of speech
Describes speech that is very fast and full of thoughts. It reflects underlying pressure of thought, and can feel a little like machine gun fire!
A. Dysarthria B. Dysphasia C. Clang associations D. Punning E. Neologisms F. Pressure of speech G. Poverty of speech H. Flight of ideas I. Perseveration J. Loosening of associations
You are a final year medical student on a psychiatry firm. You interview Marcus Steinway, a 32 year old man. He was brought into hospital by his wife, after she became concerned that his mood seemed ‘very black’. Marcus is quiet and withdrawn. He takes a long time to answer your questions and gives mostly monosyllabic answers, struggling to fill out any details.
Poverty of speech
The speech is slow with very few thoughts. It reflects underlying poverty of thought.
A. Dysarthria B. Dysphasia C. Clang associations D. Punning E. Neologisms F. Pressure of speech G. Poverty of speech H. Flight of ideas I. Perseveration J. Loosening of associations
You asked your student, Helen, to clerk Wallace Guilfoye, a 32 year old man with schizophrenia. After an hour, Helen returns, exasperated. She tells you, “I couldn’t follow anything he said - I kept thinking I’d got a hold on what he meant, and then he’d confuse me! He couldn’t get through more than a sentence or two without losing me.”
Loosening of associations
Describes the loss of normal links between thoughts.
A. Dysarthria B. Dysphasia C. Clang associations D. Punning E. Neologisms F. Pressure of speech G. Poverty of speech H. Flight of ideas I. Perseveration J. Loosening of associations
You are a house officer working in accident and emergency. You see Mr McKeen, a 25 year old man who is experiencing psychotic symptoms. He talks in detail about the “interphalancrial business” and the “hemislayer” that have been persecuting him.
Neologisms
“new words” invented by the patient.
A. Grandiose B. Thought withdrawal C. Nihilistic D. Erotomanic E. Thought broadcasting F. Jealousy G. Reference H. Guilt I. Hypochondrial J. Persecutory
Steve is a 22 year old physics student. His flat mate, Hussein, brings him to your GP surgery. Hussein tells you how Steve has become increasingly withdrawn, refusing to leave his room for days at a time. Steve insists on wearing a thick hat in all weathers, which he says is “for protection”. On close questioning, Steve explains that his lecturers have been “spraying” his thoughts across the lecture hall with mobile phone technology. He hates knowing that all the other students know what he is thinking.
E. Thought broadcasting
A. Grandiose B. Thought withdrawal C. Nihilistic D. Erotomanic E. Thought broadcasting F. Jealousy G. Reference H. Guilt I. Hypochondrial J. Persecutory
Mary Hamilton is a 36 year old woman who has been referred by her GP to your psychiatry outpatient clinic. She has received a verbal warning from the police after allegedly stalking the chief executive at the firm where she works as a cleaner. She has been sending him love letters and presents. Mary is convinced that he loves her, and says that the police warning is “just for show”, to hide their love from her colleagues. Her manager is openly gay, and now off work due to the stress associated with Mary’s behaviour.
D. Erotomanic
Erotomanic delusions are those in which there is a false belief that someone (often of higher status) is in love with the patient. They are more common in women and sometimes called “amorous delusions”.
A. Grandiose B. Thought withdrawal C. Nihilistic D. Erotomanic E. Thought broadcasting F. Jealousy G. Reference H. Guilt I. Hypochondrial J. Persecutory
Nigel Pieterson is a 54 year old man, referred to you by the police after he walked into his local police station and confessed to the murder of his mother. There were concerns that he was mentally ill, and he was brought to hospital. You contact his younger sister, who explains that their mother died 52 years before, in childbirth.
H. Guilt
This is a delusion of guilt. Mr Pieterson clearly had nothing to do with his mother’s death while she gave birth to his younger sibling
A. Grandiose B. Thought withdrawal C. Nihilistic D. Erotomanic E. Thought broadcasting F. Jealousy G. Reference H. Guilt I. Hypochondrial J. Persecutory
Stephano Romero is a 25 year old man who has been brought to Accident and Emergency by his mother. She noted that he has been acting strangely for some weeks, laughing to himself and spending a lot of time at the local church. This evening, he pointed out eight people crossing the road ahead, and nodded sagely, telling her that this meant that The End Was Nigh.
G. Reference
Delusions of reference are those in which special meaning, signs or signals are found in everyday events.
A. Grandiose B. Thought withdrawal C. Nihilistic D. Erotomanic E. Thought broadcasting F. Jealousy G. Reference H. Guilt I. Hypochondrial J. Persecutory
Gloria Bunford is a 57 year old woman, who attends your GP surgery to make you aware that she died last Thursday.
C. Nihilistic
The belief that you are dead is classed as a nihilistic delusion. Nihilism is to do with the absence of things - in this case, the absence of life.
A. Manic episode B. Cyclothymia C. Schizoaffective disorder D. Delirium E. Bipolar affective disorder F. Schizophrenia G. Depressive episode H. Pseudodementia
Persecutory delusions and auditory hallucinations without a strong mood component.
F. Schizophrenia
A. Manic episode B. Cyclothymia C. Schizoaffective disorder D. Delirium E. Bipolar affective disorder F. Schizophrenia G. Depressive episode H. Pseudodementia
Labile mood, boundless energy, reduced sleep and past history of depression.
E. Bipolar affective disorder
A. Manic episode B. Cyclothymia C. Schizoaffective disorder D. Delirium E. Bipolar affective disorder F. Schizophrenia G. Depressive episode H. Pseudodementia
Anergia, anhedonia, low mood.
G. Depressive episode
A. Manic episode B. Cyclothymia C. Schizoaffective disorder D. Delirium E. Bipolar affective disorder F. Schizophrenia G. Depressive episode H. Pseudodementia
Persistent instability of mood with mild episodes of elation and low mood.
B. Cyclothymia
A. Manic episode B. Cyclothymia C. Schizoaffective disorder D. Delirium E. Bipolar affective disorder F. Schizophrenia G. Depressive episode H. Pseudodementia
Labile mood, boundless energy, reduced sleep. No previous history of mood disorder.
A. Manic episode
A. Antidepressant and antipsychotic B. Cognitive behavioural therapy and antidepressant C. Supportive counselling D. Antidepressant E. Mood stabiliser or antipsychotic F. Mood stabiliser and antidepressant G. Electroconvulsive therapy (ECT) H. Mood stabiliser and antipsychotic
Severe depression with life-threatening anorexia and dehydration.
G. Electroconvulsive therapy (ECT)
ECT can be life-saving in severe depression, since it is a very fast and effective treatment.
A. Antidepressant and antipsychotic B. Cognitive behavioural therapy and antidepressant C. Supportive counselling D. Antidepressant E. Mood stabiliser or antipsychotic F. Mood stabiliser and antidepressant G. Electroconvulsive therapy (ECT) H. Mood stabiliser and antipsychotic
Mild depression.
C. Supportive counselling
Supportive counselling is often sufficient, though mildly depressed patients should still be reviewed to ensure that they are not deteriorating, despite the counselling.
A. Antidepressant and antipsychotic B. Cognitive behavioural therapy and antidepressant C. Supportive counselling D. Antidepressant E. Mood stabiliser or antipsychotic F. Mood stabiliser and antidepressant G. Electroconvulsive therapy (ECT) H. Mood stabiliser and antipsychotic
Moderate depression.
B. Cognitive behavioural therapy and antidepressant
This combination is the ideal, though be aware that CBT waiting lists can be long (e.g. 6 months), so this is not always achievable.
A. Antidepressant and antipsychotic B. Cognitive behavioural therapy and antidepressant C. Supportive counselling D. Antidepressant E. Mood stabiliser or antipsychotic F. Mood stabiliser and antidepressant G. Electroconvulsive therapy (ECT) H. Mood stabiliser and antipsychotic
Psychotic depression.
A. Antidepressant and antipsychotic
Both are required to effectively treat the two aspects of this diagnosis: psychosis and depression.
A. Antidepressant and antipsychotic B. Cognitive behavioural therapy and antidepressant C. Supportive counselling D. Antidepressant E. Mood stabiliser or antipsychotic F. Mood stabiliser and antidepressant G. Electroconvulsive therapy (ECT) H. Mood stabiliser and antipsychotic
Initial treatment of acute mania.
E. Mood stabiliser or antipsychotic
Addictionally, antidepressants and other exacerbating medications should be stopped. A short course of benzodiazepines may be additionally needed for sedation. Is symptoms are severe or don’t respond to a mood stabiliser or antipsychotic alone, they may need to be combined.
A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.
Electroconvulsive therapy (ECT).
C. Amnesia
Most other side effects from ECT relate to use of the general anaesthetic (e.g. risk of death).
A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.
Monoamine oxidase inhibitors (MAOIs).
B. Hypertensive crisis following ingestion of yeast extracts
Other side effects of MAOIs include hypotension, dizziness, drowsiness, insomnia, headache, blurred vision, constipation, nausea and vomiting.
A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.
St John’s wort.
A. Unreliable oral contraceptive pill cover
St John’s Wort is an enzyme inducer, causing some drugs (like the OCP) to be metabolised more quickly, making them ineffective.
A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.
Lithium.
G. Foetal Ebstein’s anomaly
This is a risk when lihium is used during pregnancy.
Ebstein anomaly is a congenital malformation of the heart that is characterized by apical displacement of the septal and posterior tricuspid valve leaflets, leading to atrialization of the right ventricle with a variable degree of malformation and displacement of the anterior leaflet.
A. Unreliable oral contraceptive pill cover
B. Hypertensive crisis following ingestion of yeast extracts
C. Amnesia
D. Anaemia
E. Foetal spina bifida
F. Malnutrition
G. Foetal Ebstein’s anomaly
H. Depression
Instructions: For each treatment below, choose the single most likely side-effect from the above list of options. Each option may be used once, more than once, or not at all.
Sodium valproate.
E. Foetal spina bifida
This is a risk when sodium valproate (or carbamazapine) is used during pregnancy.
A. 1 hour B. 2 hours C. 6 hours D. 12 hours E. 1 week F. 2 weeks G. 4-6 weeks H. 6 months I. 8-9 months J. 1 year
Appropriate post-dose timing of blood samples for lithium levels.
E. 1 week
A. 1 hour B. 2 hours C. 6 hours D. 12 hours E. 1 week F. 2 weeks G. 4-6 weeks H. 6 months I. 8-9 months J. 1 year
Delay in antidepressant effect.
G. 4-6 weeks
A. 1 hour B. 2 hours C. 6 hours D. 12 hours E. 1 week F. 2 weeks G. 4-6 weeks H. 6 months I. 8-9 months J. 1 year
Early morning wakening is defined as waking at least this much earlier than usual.
B. 2 hours
A. 1 hour B. 2 hours C. 6 hours D. 12 hours E. 1 week F. 2 weeks G. 4-6 weeks H. 6 months I. 8-9 months J. 1 year
Average duration of an untreated depressive episode.
I. 8-9 months
A. 1 hour B. 2 hours C. 6 hours D. 12 hours E. 1 week F. 2 weeks G. 4-6 weeks H. 6 months I. 8-9 months J. 1 year
Duration of antidepressant treatment of a first depressive episode once symptoms have resolved.
H. 6 months
A. Hypnotherapy B. Social intervention C. Interpersonal therapy (IPT) D. Problem-solving approach E. Automatic recognition therapy F. Relationship focus therapy G. Cognitive behavioural therapy (CBT) H. Psychodynamic psychotherapy
Helps the patient to recognise negative automatic thoughts.
G. Cognitive behavioural therapy (CBT)
Negative Automatic Thoughts (NATs) are the unhelpful, negative thoughts, typical of depression, that pop into a person’s mind as a knee-jerk reaction to everyday situations. They are often overly pessimistic or critical, and contribute to low mood and further depressive thoughts, which trap the person in their depression. E.g. in response to someone not greeting them at work, a depressed person may think, “He hates me” or “No-one likes me.” These are identified in CBT and the patient works with the therapist to consider how true they really are. Logic and practical testing of NATs can usually show that they are at some level erroneous. The patient is helped to recognise these NATs, recognise underlying thinking errors and think more positively and realistically, in order to combat depression.
A. Hypnotherapy B. Social intervention C. Interpersonal therapy (IPT) D. Problem-solving approach E. Automatic recognition therapy F. Relationship focus therapy G. Cognitive behavioural therapy (CBT) H. Psychodynamic psychotherapy
Makes use of transference to understand the patient’s problems.
H. Psychodynamic psychotherapy
Transference describes the emotions that a patient feels towards the therapist. It can be used to interpret the patient’s problems, and help the patient to think about relationships outside the therapy session - since it usually sheds light on the way they view other people and interact with them.
A. Hypnotherapy B. Social intervention C. Interpersonal therapy (IPT) D. Problem-solving approach E. Automatic recognition therapy F. Relationship focus therapy G. Cognitive behavioural therapy (CBT) H. Psychodynamic psychotherapy
Makes use of behavioural experiments to help the patient re-evaluate their beliefs.
G. Cognitive behavioural therapy (CBT)
Behavioural experiments are practical and logical tests, which help patients do as “homework” in their own time, to test out their beliefs.
A. Hypnotherapy B. Social intervention C. Interpersonal therapy (IPT) D. Problem-solving approach E. Automatic recognition therapy F. Relationship focus therapy G. Cognitive behavioural therapy (CBT) H. Psychodynamic psychotherapy
The relationship between the therapist and the patient is the key issue in this therapy.
H. Psychodynamic psychotherapy
The relationship that is built in the session gives insight into the relationships and relationship difficulties outside the therapy.
A. Hypnotherapy B. Social intervention C. Interpersonal therapy (IPT) D. Problem-solving approach E. Automatic recognition therapy F. Relationship focus therapy G. Cognitive behavioural therapy (CBT) H. Psychodynamic psychotherapy
Focuses on themes of unresolved loss, psychosocial transitions, relationship conflicts and social skills deficit.
C. Interpersonal therapy (IPT)
A. Acute and transient psychotic episode B. Schizophrenia C. Drug induced psychosis D. Mania E. Personality disorder F. Bipolar affective disorder G. Drug induced psychosis H. Alcohol dependence I. Depression J. Delirium tremens
A 24 year old woman, treated for a drug induced psychosis last year, presents complaining of voices commanding her to kill herself. She denies drug use since the last episode, but explains that the voices never fully resolved, and she is “sick of them taking her thoughts for their own purposes.” She is now seriously considering suicide, “To shut them up for good”.
B. Schizophrenia
Schizophrenia is the most likely diagnosis, in view of ongoing (>1 month) symptoms, in the absence of ongoing drug misuse. The symptom of thought withdrawal is not diagnostic in its own right (first rank symptoms can occur in other disorders, e.g. organic), but again supports the diagnosis of schizophrenia.
A. Acute and transient psychotic episode B. Schizophrenia C. Drug induced psychosis D. Mania E. Personality disorder F. Bipolar affective disorder G. Drug induced psychosis H. Alcohol dependence I. Depression J. Delirium tremens
A 48 year old man took an overdose of 38 paracetamol tablets with a bottle of gin. He is intoxicated and smells strongly of alcohol. His wife states that he has been very low in mood for the past 3 months, doesn’t seem to enjoy spending time with their children anymore, and “drags himself around the house like an old man”. He has not been eating well and wakes very early in the morning. She says that he doesn’t normally drink heavily. His LFTs and MCV are normal.
I. Depression
Depression is the most likely diagnosis, since this man has core and biological features sufficient to make the diagnosis, and symptoms have been ongoing for greater than two weeks. The recent alcohol misuse does not amount to alcohol dependence, and this is supported by the normal blood results.
A. Acute and transient psychotic episode B. Schizophrenia C. Drug induced psychosis D. Mania E. Personality disorder F. Bipolar affective disorder G. Drug induced psychosis H. Alcohol dependence I. Depression J. Delirium tremens
A 29 year old man with a history of childhood abuse presents with lacerations to his shins. He states he is depressed and cut himself with a razor following his girlfriend’s decision to break up with him; he hoped that would show her how much he loved her, and make her change her mind. He reports that he has had a “very short fuse” since he was a teenager, losing his temper easily, which has caused break ups with all his previous girlfriends, and the loss of a number of jobs. He describes his mood as “always being very up and down,” and was feeling “great” until she “dumped him” earlier today. He says he cuts himself or smokes cannabis to calm down when his anger gets too much.
Personality disorder is the most likely diagnosis, though note that, even with a clear history of personality difficulties, this diagnosis is not always reliable after a single interview, and the diagnostic label can be stigmatising rather than helpful. That stated, there is evidence from the history that this man’s personality has caused him chronic difficulties (e.g. impulsivity and outbursts of anger; ongoing affective instability). With closer questioning, it should be possible to elicit elements such as ongoing fears of abandonment or intense and unstable relationships, etc - sufficient to decide whether he fulfils criteria for emotionally unstable personality disorder.
A. Acute and transient psychotic episode B. Schizophrenia C. Drug induced psychosis D. Mania E. Personality disorder F. Bipolar affective disorder G. Drug induced psychosis H. Alcohol dependence I. Depression J. Delirium tremens
A 32 year old woman presents to A&E with two deep lacerations to her wrists. She has no past psychiatric history. Having snorted cocaine at a friend’s house, she reported feeling cockroaches crawling under her skin, which she then tried to remove with a knife. Nothing like this has ever happened before. She uses cocaine intermittently, and drinks around 4-6 units of alcohol each Friday and Saturday night.
C. Drug induced psychosis
A drug induced psychosis is the most likely diagnosis, due to the temporal relationship between the use of cocaine and onset of psychotic symptoms, as well as the fact that this symptom (formication) being well-recognised in cocaine use. Symptoms should resolve with cessation of coke use. Although her pattern of alcohol use does not suggest dependency, and the clinical picture is more suggestive of coke intoxication than alcohol withdrawal/ delirium tremens. She should be given advice on her harmful levels of alcohol use, as well as the dangers of cocaine - but this is best done once she is medically fit, and once the cockroaches have stopped running about under her skin…
A. Acute and transient psychotic episode B. Schizophrenia C. Drug induced psychosis D. Mania E. Personality disorder F. Bipolar affective disorder G. Drug induced psychosis H. Alcohol dependence I. Depression J. Delirium tremens
A 42 year old plumber is brought to hospital by the police, after walking along railway lines. He explains that God started talking to him two weeks ago, and an angel announced that he had been chosen to “fulfil the prophecy”. He was going to “sacrifice himself for the sake of mankind” by “allowing” a train to hit him. He says he hasn’t been sleeping, since he stays up all night painting and writing prophecies. His mood is very labile: he is tearful at times, but also jokes with the police; at one point he becomes aggressive and hits one of the officers. He suffered an episode of depression in the past, but now says he has “never felt better.” He denies substance misuse.
F. Bipolar affective disorder
Bipolar affective disorder is the preferred diagnosis, in view of a previous affective episode (depression) - this can no longer be viewed as a single manic episode.
