2. Core clinical problem 1
A 37-year-old woman comes to the outpatient
department saying that for the past month she has
felt as if she ''just can't cope". She states that her
husband left her and her two children without
warning a month ago.
Since that time, she has been unable to sleep
more than 3 or 4 hours a night. She has lost 5 kg
without trying to, and her appetite has decreased.
She says nothing interests her & easily irritated
and she cannot concentrate. She admits to hearing
a voice telling her that she is "no good".
3. • Q1.What are the likely differential diagnoses?
• Q2. What information in the history supports the
diagnosis, and what other information would help to
confirm it?
– Note: Ask about mood, psychomotor agitation/retardation,
suicidal ideation, social and occupation dysfunction, manic
features, other psychotic features, substance use,
• Q3. How would you assess her for the risk of suicide?
• Q4. What treatment options are available?
4. Question 1
DDx:
• MDD with psychotic features (provisional diagnosis)
• Schizoaffective disorder
• Brief psychotic episode
• Bipolar disorder, depressive episode
• Organic diseases that can cause psychosis, e.g., brain
tumor in frontal lobe.
Why isn’t this PTSD? This isn’t PTSD, as there needs to be a
certain kind of trauma preceding it, clinical features aside, e.g.,
car accidents, witnessing murder or being threatened, natural
disaster, sexual violence, etc.
5. Question 3 – suicide risk
assessment
Ask:
• Intention:
– How do you feel about life?
– Do you ever think you’d rather die than live?
• Idea of self harm?
• Any plans?
• Any attempts
Afterwards, assess for the presence of risk factors from the history and MSE:
• Demographic data:
– occupation (e.g., someone with access to weapons such as a Peshmerga; jobless),
– male gender (male gender is a risk factor for successfully committing suicide, and female gender is a
risk factor for attempting suicide)
– Elderly
– No spouse
• Diagnosed psychiatric disorder, e.g., mood disorders
• Substance abuse
6. Question 3 – suicide risk
assessment (cont)
• History of childhood abuse
• Previous suicide attempts
• Family history of psychiatric disorders and suicide.
• Presence of psychotic features (due to commanding hallucinations or
annoyed by commentary hallucinations; psychotic features may also be a
feature of a more severe mood disorder)
7. Question 4 – treatment
• Pharmacotherapy first, since there is severe
depression and psychotic features:
Combination of antidepressant (e.g., SSRI) and
antipsychotic (e.g., risperidone, since it’s
sedative and the patient has insomnia).
• Psychotherapy after the psychotic features
have settled (psychotherapy is not beneficial
in psychosis as there is loss of insight)
• ECT may also be an option as there is
psychotic depression
8. Core clinical problem 2
An 18 –years –old young woman presents to
Emergency room in a distressed state seeking
medical help for a reported overdose of 30
tablets of paracetamol two hours ago
9. • How would you respond to this case?
• How would you assess the case?
• If this case & her family insisting that they
want to go home, What would you do next?
10. Answer
• Admit the patient and make a file, ABC, insert
cannulas, take a sample of blood for investigations
(e.g., LFT, RFT)
• Decontamination with gastric lavage or activated
charcoal if less than 2 hours
• Antidote (N-acetyl cysteine)
• Police paper
• Stabilize the patient, and make sure to have
appropriate charting of what you did for the patent
and follow up chart.
11. Answer (cont)
• It’s important to not write this off as parasuicide, as the line
between parasuicide and suicide may be blurry.
• Assess the suicidal attempt to see what the intentions were:
– What were the means?
• If drugs, what was the amount taken?
– When it was attempted? If done at night, it means the patient was
intending not to be found and hence was intending on dying
– Was it a planned or impulsive attempt? A planned attempt is more
serious
– Have they communicated about suicide to anyone before? A patient
talking about suicide is not an indicator they wont do it, but is rather is
an indicator of high intention
– Ask the patient directly if they regret it or not?
12. Answer (cont)
• Refer to a psychiatrist.
• It’s important to educate the patient and family regarding
suicide and the fact that the patient is a psychiatric
emergency; they should be seen by a psychiatrist and
potentially admitted.
• If the family are insisting to go home and refuse admission
(note: Reasons for refusing admission may be stigma): you
make the family sign a weaver taking full responsibility if they
cant be convinced otherwise; closely observe the patient and
avoid potential means for suicide inside the house, such as
medications, knives, guns [be direct in giving this advice], and
recommend outpatient follow up.
13. Core clinical problem no.3
• A 20-year-old man presents to the hospital
accompanied by his parents, owing to a change in
mental status and behavior, eruptions of laughter,
excessive talking, and unusual thoughts.
• He is being treated for depression and insomnia
• For the past 2 weeks he has missed college classes,
while staying up most nights until 4 or 5 a.m.,
• Efforts by his family to understand his recent
change in thinking and behavior
14. Questions
• Q1.What are the likely differential diagnoses?
• Q2. What information in the history supports the
diagnosis, and what other information would help
to confirm it?
– Ask about other features of manic episode: distractibility,
inflated self esteem or grandiosity, excessive involvement
in pleasurable activities that have a high potential for
painful consequences, flight of ideas, reckless spending of
money, etc.
• Q3. What treatment options are available?
15. Question 1 – DDx
• Bipolar-I manic episode
– Use of antidepressants alone without mood
stabilizers may precipitate mania, e.g., when the
patient presents first with depression and is
diagnosed with a unipolar mood disorder and
administered antidepressants
– Supportive of bipolar I: decreased sleep, previous
history of depression, more talkative than usual
• Schizomanic disorder
• Substance abuse, e.g., stimulants
17. Core clinical problem 4
• A 35-year-old man presents with feelings of
helplessness& easy fatigability. He says that
he cries for no reason, and has difficulty
sleeping. He noticed that the problems began
about 5 weeks before, and he didn’t feel able
to shrug them off. He has been drinking more
alcohol than usual, and has stopped going to
work. When on his own he admitted that he
had thought of driving his car into the local
lake.
18. • Q1. What is the most probable
diagnosis?
• Q2.How would you discuss
antidepressant treatment with him?
• Q3.If this patient attempted suicide,
how would you take care of him in the
psychiatric ward?
21. To know patient’s intention
Begin with questions
that address the
patient's feeling
about living
Have you ever felt life
was not worth
living?
Did you ever wish you
could go to sleep
and just not wake
up?
22. 1-To know patient’s intention
Follow on with specific
questions that ask
about thoughts of
death, self harm, or
suicide
Is death something you
have thought about
recently?
Have things reached the
point that you have
thought of harming
yourself?
23. To know patient’s intention
For individuals who have
thoughts of self harm or
suicide
When did you first notice such
thoughts?
What led up to the thoughts
How close have you come to
acting on those thoughts?
Have you ever started to harm
yourself but stopped before
doing something?
Have you made a specific plan to
harm or kill yourself?
If so what does the plan
include?
24. 2-History &Mental state examination
You should take detail history &do mental state
examination to search for risk factors for suicide like:
*Age, gender, race (elderly or young adult, unmarried, white,
male, living alone)
*Recent discharge from an inpatient psychiatric unit
*Family history of suicide
*History of abuse (physical, sexual or emotional)
25. History &Mental state
examination
*Current ideation, intent, plan, access to means
*Previous suicide attempt or attempts
*History of Alcohol / Substance abuse
*Current psychiatric diagnosis or previous history of
psychiatric diagnosis.
*Recent losses – physical, financial, personal
*Recent discharge from an inpatient psychiatric unit.
26. History &Mental state examination
*Family history of suicide
*History of abuse (physical, sexual or emotional)
*Co-morbid health problems, especially a newly
diagnosed problem or worsening symptoms.
*Impulsivity and poor self control
*Hopelessness – presence, duration, severity.
*Co-morbid health problems, especially a newly diagnosed
problem or worsening symptoms
Editor's Notes
Ask about mood, psychomotor agitation/retardation, suicidal ideation, social and occupation dysfunction, manic features, other psychotic features, substance use,
This isn’t PTSD, as there needs to be a certain kind of trauma preceding it, clinical features aside, e.g., car accidents, witnessing murder or being threatened, natural disaster, sexual violence, etc.
Risk of suicide:
It’s important to not write this off as parasuicide, as the line between parasuicide and suicide may be blurry.
Assess the suicidal attempt to see what the intentions were:
What were the means?
If drugs, what the amount taken was
When it was attempted? If done at night, it means the patient was intending not to be found and hence was intending on dying
Was it a planned or impulsive attempt? A planned attempt is more serious
Have they communicated about suicide to anyone before? A patient talking about suicide is not an indicator they wont do it, but is rather is an indicator of high intention
Ask the patient directly if they regret it or not?
It’s important to not write this off as parasuicide, as the line between parasuicide and suicide may be blurry.
Assess the suicidal attempt to see what the intentions were:
What were the means?
If drugs, what the amount taken was
When it was attempted? If done at night, it means the patient was intending not to be found and hence was intending on dying
Was it a planned or impulsive attempt? A planned attempt is more serious
Have they communicated about suicide to anyone before? A patient talking about suicide is not an indicator they wont do it, but is rather is an indicator of high intention
Ask the patient directly if they regret it or not?
Add dig fast mnemonic
Bipolar disorder can also have a mixed phase.
Disinhibited behavior: behavior that is not socially acceptable, e.g., taking clothes off, talking about inappropriate things, lack of shame
Why is lithium not used commonly here? It has a narrow TI, and hence laboratory monitoring of blood levels is required, and that’s not available here. The weather here predisposes to dehydration, which increases lithium toxicity; patients given lithium are advised to stay hydrated.
It’s the only drug that is excreted in the kidneys.
