The peak incidence of seizures is expected 36 hours following the onset of alcohol withdrawal.

Pathophysiology:
Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors. Alcohol withdrawal is thought to lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission).

Clinical course in alcohol withdrawal:
Symptoms begin 6-12 hours following the onset of alcohol withdrawal
Seizures occur 36 hours following the onset of withdrawal
Delirium tremens (coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia) occurs approximately 72 hours after the onset of alcohol withdrawal.

Management
First-line: benzodiazepines e.g. lorazepam, chlordiazepoxide.
Carbamazepine is also effective in the treatment of alcohol withdrawal.
Phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures.

Seasonal affective disorder (SAD) is a type of depression that’s related to changes in seasons. SAD begins and ends at about the same time every year. For most people with SAD, the symptoms start in the fall and continue into the winter months, sapping the person’s energy and making him feel moody. Less often, SAD causes depression in the spring or early summer.

Treatment for SAD may include light therapy (phototherapy), medications and psychotherapy.

Signs and symptoms of SAD may include:
Feeling depressed most of the day, nearly every day
Losing interest in activities you once enjoyed
Having low energy
Having problems with sleeping
Experiencing changes in your appetite or weight
Feeling sluggish or agitated
Having difficulty concentrating
Feeling hopeless, worthless or guilty
Having frequent thoughts of death or suicide.

Seasonal affective disorder is diagnosed more often in women than in men. And SAD occurs more frequently in younger adults than in older adults.

Factors that may increase your risk of seasonal affective disorder include:
Family history. People with SAD may be more likely to have blood relatives with SAD or another form of depression.
Having major depression or bipolar disorder. Symptoms of depression may worsen seasonally if you have one of these conditions.
Living far from the equator. SAD appears to be more common among people who live far north or south of the equator. This may be due to decreased sunlight during the winter and longer days during the summer months.

The most probable diagnosis in this patient is post-traumatic stress disorder (PTSD). The first-line treatment for this patient would be cognitive behavioural therapy or eye movement desensitization and reprocessing therapy.

Post-traumatic stress disorder (PTSD) can develop in people of any age following a traumatic event, for example, a major disaster or childhood sexual abuse. It encompasses what became known as ‘shell shock’ following the first world war. One of the DSM-IV diagnostic criteria is that symptoms have been present for more than one month.

Clinical features:
Re-experiencing: flashbacks, nightmares, repetitive and distressing intrusive images
Avoidance: avoiding people, situations or circumstances resembling or associated with the event
Hyperarousal: hypervigilance for threat, exaggerated startle response, sleep problems, irritability and difficulty concentrating
Emotional numbing – lack of ability to experience feelings, feeling detached from other people
Depression
Drug or alcohol misuse
Anger

Management:
Following a traumatic event single-session interventions (often referred to as debriefing) are not recommended
Watchful waiting may be used for mild symptoms lasting less than 4 weeks
Trauma-focused cognitive-behavioural therapy (CBT) or eye movement desensitization and reprocessing (EMDR) therapy may be used in more severe cases
Drug treatments for PTSD should not be used as a routine first-line treatment for adults.
If drug treatment is used then paroxetine or mirtazapine are recommended.

Temazepam is a medication that is often prescribed for the treatment of short-term insomnia. It belongs to the benzodiazepine family of drugs and is classed as intermediate-acting, meaning that it can take between six and twenty-four hours for the drug to take effect.

Although it is known that shorter-acting benzodiazepines are more harmful and more likely to cause addiction, temazepam is, nevertheless, a highly addictive drug. It should not be taken for longer than four weeks.

-Adverse effects associated with the use of benzodiazepine hypnotics (to which the elderly are most vulnerable) include confusion, over sedation, increased risks of falls and consequent fractures

-Withdrawal from a benzodiazepine hypnotic must be agreed between the clinician and the patient – patients should never be forced or threatened. The risks of continued benzodiazepine use should be explained. An agreed schedule for reduction of and gradual withdrawal from the benzodiazepine hypnotic should also be agreed. This will involve substitution of the hypnotic with a long-acting benzodiazepine (e.g. diazepam) and a subsequent gradual reduction in dose of the substituted benzodiazepine -the substituted benzodiazepine can then be withdrawn in steps of about one-eighth to one-tenth every fortnight
Example: withdrawal schedule for patient on temazepam 20mg nocte
week 1 – temazepam 10mg, diazepam 5mg
week 2 – stop temazepam, diazepam 10mg
week 4 – diazepam 9mg
week 6 – diazepam 8mg
continue reducing dose of diazepam by 1mg every fortnight – tapering of dose may be slower if necessary

Sleep paralysis is a temporary inability to move or speak that occurs when you’re waking up or falling asleep. Paralysis is often accompanied by hallucinations

REM is a stage of sleep when the brain is very active and dreams often occur. The body is unable to move, apart from the eyes and muscles used in breathing, possibly to stop the person from acting out the dreams and hurting himself.

It’s not clear why REM sleep can sometimes occur while one is awake, but it has been associated with:
-not getting enough sleep (sleep deprivation or insomnia)
-irregular sleeping patterns – for example, because of shift work or jet lag
-narcolepsy – a long-term condition that causes a person to suddenly fall asleep at inappropriate times
-a family history of sleep paralysis
-sleeping on one’s back

Among the given options, an addiction to opiates is considered the strongest risk factor for committing suicide.

Other options:
Being a female – Being male is one of the most significant risk factors for suicide.
Being married – Having family support is an important protective factor for suicide.
Having five children – Having children at home is thought to be a protective factor.
Having never seen a general practitioner – Having a chronic mental or physical condition is however a risk factor for suicide.

Risk factors of suicide:
There are several factors shown to be associated with an increased risk of suicide:
Male sex
History of deliberate self-harm
Alcohol or drug misuse
History of mental illness (depression, schizophrenia)
History of chronic disease
Advancing age
Unemployment or social isolation/living alone
Being unmarried, divorced or widowed
Previous attempt to commit suicide.

Signs pointing towards suicidal intension:
Efforts to avoid discovery
Planning
Leaving a written note
Final acts such as sorting out finances
Violent method

Protective factors against suicide:
Family support
Having children at home
Religious belief

The most probable diagnosis of this patient is Cotard syndrome.

Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders.

Other delusional syndromes:
– Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
– De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
– Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
– Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
– Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.

Physiological abnormalities in anorexia include:
– Hypokalaemia – from diuretic or laxative use
– Low FSH, LH, oestrogens and testosterone – most consistent endocrine abnormality was low serum luteinizing and follicle stimulating hormone (LH and FSH) levels associated with depressed serum oestradiol levels.
– Raised cortisol and growth hormone
– Impaired glucose tolerance – lack of glucose precursors in the diet or low glycogen stores. Low blood glucose may also be due to impaired insulin clearance
– Hypercholesterolemia
– Hypercarotenaemia
– Low T3

Weight gain is an extremely common (5-40%) adverse effect of atypical antipsychotics such as olanzapine (dose dependent). Olanzapine causes orthostatic hypotension ≥20% of reported cases. Parkinsonism reactions occurs in 4% of people.

The most probable diagnosis of this patient is Cotard syndrome.

Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders.

Other options:
– Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
– De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
– Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.
– Capgras delusion is the belief that friends or family members have been replaced by an identical-looking imposter.

Most new moms experience postpartum baby blues after childbirth, which commonly include mood swings, crying spells, anxiety and difficulty sleeping. Baby blues typically begin within the first two to three days after delivery, and may last for up to two weeks.

Postpartum depression may be mistaken for baby blues at first — but the signs and symptoms are more intense and last longer, and may eventually interfere with your ability to care for your baby and handle other daily tasks. Symptoms usually develop within the first few weeks after giving birth, but may begin earlier, during pregnancy or later, up to a year after birth.

The period prevalence of postpartum depression among women is a striking 21.9% the first year after birth, which makes it one of the most common medical complications of childbearing. Sertraline has been identified as an antidepressant of choice for breastfeeding women because infants are unlikely to develop quantifiable serum sertraline levels and very few adverse events associated with sertraline have been reported.

Women with a prior episode of postpartum psychosis have about a 30% risk of having another episode in the next pregnancy.

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by stressful, frightening or distressing events.

PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster. Families of victims can also develop PTSD, as can emergency personnel and rescue workers.

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.

The goal of PTSD treatment is to reduce the emotional and physical symptoms, to improve daily functioning, and to help the person better cope with the event that triggered the disorder. Treatment for PTSD may involve psychotherapy (a type of counselling), medication, or both.

Certain antidepressant medications are used to treat PTSD and to control the feelings of anxiety and its associated symptoms including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. Mood stabilizers such are sometimes used.

Charles Bonnet syndrome (CBS) involves visual hallucinations due to eye disease, usually associated with a sharp decline in vision. The phenomenon is seen in patients with moderate or severe visual impairment. It can occur spontaneously as the vision declines or it may be precipitated, in predisposed individuals, by concurrent illness such as infections elsewhere in the body.

It is not clear why CBS develops or why some individuals appear to be predisposed to it. It is particularly noted in patients with advanced macular degeneration. It has been suggested that reduced or absent stimulation of the visual system leads to increased excitability of the visual cortex (deafferentation hypothesis). This release phenomenon is compared to phantom limb symptoms after amputation.

CBS is much more common in older patients because conditions causing marked visual loss are more common in older people. However, it can occur at any age and has been described in children.
The prevalence is hard to assess due to considerable under-reporting, perhaps because patients frequently fear that it is a sign of mental illness or dementia. However, it is thought to occur in:
About 10-15% of patients with moderate visual loss.
Possibly up to 50% of people with severe visual loss.
Presentation:
The nature of the hallucination depends on the part of the brain that is activated. The hallucinations may be black and white or in colour. They may involve grids/brickwork/lattice patterns but are typically much more complex:

The hallucinations are always outside the body.
The hallucinations are purely visual – other senses are not involved.
The hallucinations have no personal meaning to the patient.
Hallucinations may last seconds, minutes or hours.
CBS tends to occur in a ‘state of quiet restfulness’. This may be after a meal or when listening to the radio (but not when dozing off).
Symptoms also have a tendency to occur in dim lighting conditions.
Patients may report high levels of distress, with some patients reporting anger, anxiety and even fear associated with the hallucinations.

Obsessive-Compulsive Disorder (OCD) is a common, chronic and long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions) and behaviours (compulsions) that he or she feels the urge to repeat over and over.
People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can interfere with all aspects of life, such as work, school, and personal relationships.

Obsessions are repeated thoughts, urges, or mental images that cause anxiety. Common symptoms include:
Fear of germs or contamination
Unwanted forbidden or taboo thoughts involving sex, religion, and harm
Aggressive thoughts towards others or self
Having things symmetrical or in a perfect order

Compulsions are repetitive behaviours that a person with OCD feels the urge to do in response to an obsessive thought. Common compulsions include:
-Excessive cleaning and/or handwashing
-Ordering and arranging things in a particular, precise way
-Repeatedly checking on things, such as repeatedly checking to see if the door is locked or that the oven is off
-Compulsive counting

Research also shows that a type of CBT called Exposure and Response Prevention (ERP) is effective in reducing compulsive behaviours in OCD, even in people who did not respond well to SRI medication. ERP has become the first-line psychotherapeutic treatment for OCD

Depressive disorders require long-term treatment with antidepressants, psychotherapy, or both. The goal of antidepressant therapy is complete remission of symptoms and return to normal daily functioning. Studies have shown that achieving remission and continuing antidepressant therapy long after the acute symptoms remit can protect against the relapse or recurrence of the psychiatric episode. Many patients, however, inadvertently or intentionally skip doses of their antidepressant, and even discontinue it, if their symptoms improve or if they experience side effects. Antidepressant discontinuation may increase the risk of relapse or precipitate certain distressing symptoms such as gastrointestinal complaints, dizziness, flu-like symptoms, equilibrium disturbances, and sleep disorders.

Pharmacologic therapy should be continued long enough to sustain remission and avoid relapses and recurrences. Recurrence refers to a return of depression at a time beyond the expected duration of the index episode (> 9 months after remission). This means that physicians and patients alike should not be too eager to discontinue medication prematurely. An interval of 6 months has been thought to be the usual duration of antidepressant therapy. New recommendations, however, suggest that treatment should continue for up to 9 months after symptoms have resolved (continuation phase) to prevent relapse and for longer to help prevent recurrence (maintenance phase).

SSRI discontinuation symptoms are similar to those of the TCAs, with dizziness, gastrointestinal symptoms, and sleep disorders common. Anecdotal reports have included complaints of “electric shock–like” sensations, flashes, and “withdrawal buzz.” The type and severity of the symptoms correlate with the relative affinities of the agents for the serotonin reuptake sites and with secondary effects on other neurotransmitters; with SRIs that also affect cholinergic systems, the symptoms possibly correlate with cholinergic rebound.

Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by stressful, frightening or distressing events.

PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, war, or natural disaster. Families of victims can also develop PTSD, as can emergency personnel and rescue workers.

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.

The goal of PTSD treatment is to reduce the emotional and physical symptoms, to improve daily functioning, and to help the person better cope with the event that triggered the disorder. Treatment for PTSD may involve psychotherapy (a type of counselling), medication, or both.

Eye Movement Desensitization and Reprocessing (EMDR) therapy was initially developed in 1987 for the treatment of posttraumatic stress disorder (PTSD) and is guided by the Adaptive Information Processing model. EMDR is an individual therapy typically delivered one to two times per week for a total of 6-12 sessions, although some people benefit from fewer sessions. Sessions can be conducted on consecutive days.

Drug treatments (paroxetine, mirtazapine, amitriptyline or phenelzine) should be considered for the treatment of PTSD when a sufferer expresses a preference to not engage in trauma-focused psychological treatment.

Post-concussion syndrome is a complex disorder in which various symptoms, such as headaches and dizziness, last for weeks and sometimes months after the injury that caused the concussion.

Concussion is a mild traumatic brain injury that usually happens after a blow to the head. It can also occur with violent shaking and movement of the head or body. You don’t have to lose consciousness to get a concussion or post-concussion syndrome. In fact, the risk of post-concussion syndrome doesn’t appear to be associated with the severity of the initial injury.

Post-concussion symptoms include:
Headaches
Dizziness
Fatigue
Irritability
Anxiety
Insomnia
Loss of concentration and memory
Ringing in the ears
Blurry vision
Noise and light sensitivity
Rarely, decreases in taste and smell

Citalopram is an antidepressant medication that works in the brain. It is approved for the treatment of major depressive disorder (MDD). Stopping citalopram abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paraesthesia (prickling, tingling sensation on the skin).

When discontinuing antidepressant treatment that has lasted for >3 weeks, gradually taper the dose (e.g., over 2 to 4 weeks) to minimize withdrawal symptoms and detect re-emerging symptoms. Reasons for a slower titration (e.g., over 4 weeks) include use of a drug with a half-life <24 hours (e.g., paroxetine, venlafaxine), prior history of antidepressant withdrawal symptoms, or high doses of antidepressants.

Major depression (MD) often occurs after MI and has been shown to be an independent predictor of poor cardiovascular (CV) outcome.

Results of a randomized trial confirm that the antidepressant sertraline can be used safely in patients with recent MI or unstable angina and is effective in relieving depression in these patients.

Adverse effects to note:
Sertraline – Diarrhoea (13-24%), Nausea (13-30%), Headache (20-25%),
Insomnia (12-28%)
Imipramine – ECG changes, orthostatic hypotension, tachycardia
Confusion, extrapyramidal symptoms (EPS), dizziness, paraesthesia, tinnitus
Flupentixol – seizures, irregular/fast heartbeat, increased sweating
Paroxetine – Hypertension, Tachycardia, Emotional lability, Pruritus
Venlafaxine – Abnormal vision (4-6%), Hypertension (2-5%), Paraesthesia (2-3%), Vasodilation (2-6%), Aneurism, Deep vein thrombophlebitis, Takotsubo cardiomyopathy

The most probable diagnosis in this patient is De Clerambault’s syndrome, also known as erotomania, which is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.

Other options:
– Bouffée délirante is an acute psychotic disorder in which hallucinations, delusions or perceptual disturbances are obvious but markedly variable, changing from day to day or even from hour to hour.
– Fregoli delusion is the mistaken belief that some people currently present in the deluded person’s environment (typically a stranger) is a familiar person in disguise.
– Capgras delusion is the belief that significant others have been replaced by impostors, robots or aliens.
– Couvade is the common but poorly understood phenomenon whereby the expectant father experiences somatic symptoms during the pregnancy for which there is no recognized physiological basis.

Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a number of different things. People with GAD may anticipate disaster and may be overly concerned about money, health, family, work, or other issues. Individuals with GAD find it difficult to control their worry. They may worry more than seems warranted about actual events or may expect the worst even when there is no apparent reason for concern.

GAD is diagnosed when a person finds it difficult to control worry on more days than not for at least six months and has three or more symptoms.

Treatment usually consists of a combination of pharmacotherapy and/or psychotherapy. Antidepressant agents are the drugs of choice in the treatment of anxiety disorders, particularly the newer agents, which have a safer adverse effect profile and higher ease of use than the older tricyclic antidepressants (TCAs), such as selective serotonin reuptake inhibitors (SSRIs).

Blurring of vision and dry mouth are antimuscarinic side-effects that are more common with imipramine than other types of tricyclic antidepressants.

Tricyclic antidepressants (TCAs) are used less commonly now for depression due to their side-effects and toxicity in overdose. They are however used widely in the treatment of neuropathic pain, where smaller doses are typically required.

Mechanism of action: Tricyclic antidepressants impose their therapeutic effects by inhibiting presynaptic reuptake of norepinephrine and serotonin in the central nervous system (this, may give rise to seizures).

Common side-effects:
Drowsiness
Dry mouth
Blurred vision
Constipation
Urinary retention

Low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headaches (both tension and migraine).
Lofepramine has a lower incidence of toxicity in overdose
Amitriptyline and dosulepin (dothiepin) are considered the most dangerous in overdose.

The most probable diagnosis in this patient is conversion disorder.

There may be underlying tension regarding her musical career which could be manifesting as apparent limb weakness.

Conversion disorder typically involves loss of motor or sensory function. The patient doesn’t consciously feign the symptoms (factitious disorder) or seek material gain (malingering). Patients may be indifferent to their apparent disorder – la belle indifference – although this has not been backed up by studies.

Other options:
Unexplained symptoms
There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:

Somatization disorder
Multiple physical symptoms present for at least 2 years
the patient refuses to accept reassurance or negative test results

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

Dissociative disorder
Dissociation is a process of ‘separating off’ certain memories from normal consciousness
Unlike conversion disorder, it involves psychiatric symptoms e.g. amnesia, fugue, stupor
Dissociative identity disorder (DID) is the new term for multiple personality disorder as is the most severe form of dissociative disorder

Munchausen’s syndrome
Also known as factitious disorder
The intentional production of physical or psychological symptoms

Malingering
Fraudulent simulation or exaggeration of symptoms with the intention of financial or another gain.

Lithium acts by:
– I inhibiting postsynaptic D2 receptor super sensitivity
– Altering cation transport in nerve and muscle cells and influencing reuptake of serotonin or norepinephrine
– Inhibiting phosphatidylinositol cycle second messenger systems

The NICE guidelines for depression and bipolar disorder both recommend Lithium as an effective treatment; patients who take lithium should have regular blood tests to monitor the amount of lithium in their blood (every 3 months), and to make sure the lithium has not caused any problems with their kidneys or thyroid (every 6 months).

Lithium adverse effects include:
– Leucocytosis (most patients) which is when the white cells are above the normal range in the blood.
– Polyuria/polydipsia (30-50%)
– Dry mouth (20-50%)
– Hand tremor (45% initially, 10% after 1 year of treatment)
– Confusion (40%)
– Decreased memory (40%)
– Headache (40%)
– Muscle weakness (30% initially, 1% after 1 year of treatment)
– Electrocardiographic (ECG) changes (20-30%)
– Nausea, vomiting, diarrhoea (10-30% initially, 1-10% after 1-2 years of treatment)
– Hyperreflexia (15%)
– Muscle twitch (15%)
– Vertigo (15%)

Among the given options, cognitive-behavioural therapy is the most likely to benefit a patient with schizophrenia.

Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.

Clinical features:
Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:

Auditory hallucinations of a specific type:
Two or more voices discussing the patient in the third person
Thought echo
Voices commenting on the patient’s behaviour

Thought disorder:
Thought insertion
Thought withdrawal
Thought broadcasting

Passivity phenomena:
Bodily sensations being controlled by external influence
Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by others

Other features of schizophrenia include
Impaired insight (a feature of all psychoses)
Incongruity/blunting of affect (inappropriate emotion for circumstances)
Decreased speech
Neologisms: made-up words
Catatonia
Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).

Treatment:
For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
Clozapine is used in case of treatment resistance.

The given clinical scenario is highly suggestive of a borderline personality disorder.

Borderline personality disorder is marked out by instability in moods, behaviour, and relationships. The diagnosis is confirmed by the presence of at least 5 of the following symptoms;
1) Extreme reactions including panic, depression, rage, or frantic actions to abandonment, whether real or perceived
2) A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love to extreme dislike or anger
3) Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
4) Impulsive and often dangerous behaviours, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating
5) Recurring suicidal behaviours or threats or self-harming behaviour, such as cutting, intense and highly changeable moods, with each episode lasting from a few hours to a few days
6) Chronic feelings of emptiness and/or boredom
7) Inappropriate, intense anger or problems controlling anger
8) Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.

Other options:
There are no features consistent with endogenous depression, such as early morning wakening or loss of appetite.
There are also no features consistent with hypomania such as pressure of speech, a flight of ideas, or over-exuberant behaviour.
The lack of history of drug abuse rules out drug-induced psychosis.
An anti-social personality disorder is characterized by a failure to conform to social norms and repeated lawbreaking. There is consistent irresponsibility, impulsivity, and disregard for both their safety and that of others. This is not the case in the given scenario.

The most probable diagnosis considering hypochloraemia and the mild metabolic alkalosis as well as the history of GERD (requiring a high dose of PPI to control) would be bulimia.

Other options:
Diuretic abuse tends to give a hypochloraemic acidosis.
Gitelman syndrome also fits the diagnosis but, it is very rare compared to bulimia.
Inhaled steroid use and stress would not be responsible for such marked electrolyte derangement.

Other potential signs of bulimia nervosa would be parotid gland swelling and dental enamel erosion induced by regular vomiting.

Results of a randomized trial confirm that the antidepressant sertraline can be used safely in patients with recent MI or unstable angina and is effective in relieving depression in these patients.

There are theoretical reasons for believing that selective serotonin reuptake inhibitors (SSRIs), widely used to treat depression, might increase the risk of gastrointestinal bleeding. Gastroprotective drugs are advocated for high risk patients taking non-steroidal anti-inflammatory drugs, another class of drug that causes gastrointestinal bleeding.

Serotonin is released from platelets in response to vascular injury and promotes vasoconstriction and a change in the shape of the platelets that leads to aggregation. Platelets cannot themselves synthesise serotonin. SSRIs inhibit the serotonin transporter, which is responsible for the uptake of serotonin into platelets. It could thus be predicted that SSRIs would deplete platelet serotonin, leading to a reduced ability to form clots and a subsequent increase in the risk of bleeding.

The well established association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal bleeding is estimated to result in 700-2000 deaths/year in the UK. This has led to the recommendation that patients in high risk groups should receive gastroprotection in the form of an H2 antagonist, proton pump inhibitor (lansoprazole), or misoprostol.

Proton pump inhibitors have been shown to reduce endoscopically diagnosed mucosal damage and heal ulcers induced by non-steroidal anti-inflammatory drugs but not to reduce the incidence of severe gastrointestinal bleeds.

Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a cycle of bingeing and compensatory behaviours such as self-induced vomiting designed to undo or compensate for the effects of binge eating.

According to the DSM-5, the official diagnostic criteria for bulimia nervosa are:
Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).
Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
Self-evaluation is unduly influenced by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa.

Antidepressants as a group – particularly selective serotonin reuptake inhibitors (SSRIs) – are the mainstay of pharmacotherapy for bulimia nervosa. These may be helpful for patients with substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms. They may be particularly good for patients who have not benefited from or had suboptimal response to suitable psychosocial therapy or who have a chronic, difficult course in combination with other treatments.

Food and Drug Administration (FDA) approved treatments
Fluoxetine (Prozac): Initial dose 20 mg/d with advance over 1–2 weeks to 60 mg/d in the morning as tolerated. Some patients may need to begin at a lower dose if side effects are intolerable. A maximum dose of 80 mg/d may be used in some cases.

The most probable diagnosis of this patient is Cotard syndrome with major depressive disorder.

Cotard syndrome is a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary. Cotard syndrome is often associated with severe depression and psychotic disorders (like schizophrenia).

Other delusional syndromes:
– Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this. It can often result in violence and controlling behaviour.
– De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of higher social or professional standing is in love with them. Often this presents with people who believe celebrities are in love with them.
– Capgras syndrome is characterised by a person believing their friend or relative had been replaced by an exact double.
– Couvade syndrome is also known as ‘sympathetic pregnancy’. It affects fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.
– Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin. This can vary from the classic psychosis symptoms in narcotic use where the user can ‘see’ bugs crawling under their skin or can be a patient who believes that they are infested with snakes.

Malingering is not considered a mental illness. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), malingering receives a V code as one of the other conditions that may be a focus of clinical attention. The DSM-5 describes malingering as the intentional production of false or grossly exaggerated physical or psychological problems. Motivation for malingering is usually external (e.g., avoiding military duty or work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs).

Malingering should be strongly suspected if any combination of the following factors is noted to be present: (1) medicolegal context of presentation; (2) marked discrepancy between the person’s claimed stress or disability and the objective findings; (3) lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen; and (4) the presence in the patient of antisocial personality disorder (ASPD).

This patient is be pretending to be sick in order to get morphine.

Most new moms experience postpartum baby blues after childbirth, which commonly include mood swings, crying spells, anxiety and difficulty sleeping. Baby blues typically begin within the first two to three days after delivery, and may last for up to two weeks.

Signs and symptoms of baby blues may include:
Mood swings
Anxiety
Sadness
Irritability
Feeling overwhelmed
Crying
Reduced concentration
Appetite problems
Trouble sleeping

The exact cause of the “baby blues” is unknown at this time. It is thought to be related to the hormone changes that occur during pregnancy and again after a baby is born. These hormonal changes may produce chemical changes in the brain that result in depression.
Although the experience of baby blues is unpleasant, the condition usually subsides within two weeks without treatment. All the mom needs is reassurance and help with the baby and household chores.

The given clinical scenario warrants urgent admission and psychiatric evaluation as the mother seems to be suffering from puerperal psychosis.

Post-partum mental health problems can range from the ‘baby-blues’ to puerperal psychosis.

The Edinburgh Postnatal Depression Scale may be used to screen for depression:
A 10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a ‘depressive illness of varying severity’
sensitivity and specificity > 90%. It includes a question about self-harm

Postpartum psychosis has a complex multifactorial origin. Risk factors include a history of bipolar disorder, history of postpartum psychosis in a previous pregnancy, a family history of psychosis or bipolar disorder, a history of schizoaffective disorder or schizophrenia and discontinuation of psychiatric medications during pregnancy.
Incidence rate: 2.6 per 1000 births.
Onset usually within the first 2-3 weeks following birth
Symptoms of puerperal psychosis include confusion, lack of touch with reality, disorganized thought pattern and behaviour, odd effect, sleep disturbances, delusions, paranoia, appetite disturbances, a noticeable change in the level of functioning from baseline, hallucinations and suicidal or homicidal ideation.
The safety of the patient and new-born is of utmost importance, and thus, immediate hospitalization is warranted if there is a risk of harm to either one.
Cognitive-behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe – whilst they are secreted in breast milk it is not thought to be harmful to the infant
There is around a 20% risk of recurrence following future pregnancies

In a patient with chronic alcoholism, one can expect confabulations, which point towards a diagnosis of Korsakoff’s syndrome.

Korsakoff’s is characterized by confabulation and amnesia, typically occurring in alcoholics secondary to chronic vitamin B1 (thiamine) deficiency.

Other options:
Dysthymia refers to mild depression.
Hydrophobia is a feature of rabies
Lilliputians may be observed in delirium tremens.
Perseveration is repetitive speech patterns, commonly seen after traumatic brain injury.

According to the Caine criteria, the presence of any two among the four following criteria can be used to clinically diagnose Wernicke’s Encephalopathy:
Dietary deficiency
Oculomotor abnormalities
Cerebellar dysfunction
Either altered mental status or mild memory impairment
Korsakoff psychosis:
Altered mental status – disorientation, confabulations
Oculomotor findings – most often horizontal nystagmus, ophthalmoplegia, cranial nerve IV palsy, conjugate gaze
Ataxia – wide-based gait

Treatment:
The mainstay of treatment in an acute presentation is thiamine replacement.
Electrolyte abnormalities should be corrected and fluids replaced.
In particular, magnesium requires replacement, as thiamine-dependent enzymes cannot operate in a magnesium-deficient state.
After the acute phase of vitamin and electrolyte replacement, memory rehabilitation is beneficial in Korsakoff syndrome.

A patient with a gradual onset of schizophrenia is to be associated with a poor prognosis.

Schizophrenia is a functional psychotic disorder characterized by the presence of delusional beliefs, hallucinations, and disturbances in thought, perception, and behaviour.

Clinical features:
Schneider’s first-rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions:

Auditory hallucinations of a specific type:
Two or more voices discussing the patient in the third person
Thought echo
Voices commenting on the patient’s behaviour

Thought disorder:
Thought insertion
Thought withdrawal
Thought broadcasting

Passivity phenomena:
Bodily sensations being controlled by external influence
Actions/impulses/feelings – experiences which are imposed on the Individual or influenced by others

Other features of schizophrenia include
Impaired insight (a feature of all psychoses)
Incongruity/blunting of affect (inappropriate emotion for circumstances)
Decreased speech
Neologisms: made-up words
Catatonia
Negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation).

Treatment:
For the initial treatment of acute psychosis, it is recommended to commence an oral second-generation antipsychotics such as aripiprazole, olanzapine, risperidone, quetiapine, etc.
Once the acute phase is controlled, switching to a depot preparation like aripiprazole, paliperidone, zuclopenthixol, fluphenazine, haloperidol, pipotiazine, or risperidone is recommended.
Cognitive-behavioural therapy (CBT) and the use of art and drama therapies help counteract the negative symptoms of the disease, improve insight, and assist relapse prevention.
Clozapine is used in case of treatment resistance.

The most probable diagnosis in the given scenario would be body dysmorphic disorder or dysmorphophobia

It is a mental disorder where patients have a significantly distorted body image.

Diagnostic and Statistical Manual (DSM) IV criteria:
Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Treatment:
Cognitive-behavioural therapy (CBT) is the most commonly used and most empirically supported intervention to improve body image.
Several drugs have been targets of study in anorexia nervosa treatment, including selective serotonin reuptake inhibitors, antidepressants, antipsychotics, nutritional supplementation, and hormonal medications.

Charles Bonnet syndrome (CBS) involves visual hallucinations due to eye disease, usually associated with a sharp decline in vision. The phenomenon is seen in patients with moderate or severe visual impairment. It can occur spontaneously as the vision declines or it may be precipitated, in predisposed individuals, by concurrent illness such as infections elsewhere in the body.

It is not clear why CBS develops or why some individuals appear to be predisposed to it. It is particularly noted in patients with advanced macular degeneration. It has been suggested that reduced or absent stimulation of the visual system leads to increased excitability of the visual cortex (deafferentation hypothesis). This release phenomenon is compared to phantom limb symptoms after amputation.

CBS is much more common in older patients because conditions causing marked visual loss are more common in older people. However, it can occur at any age and has been described in children.
The prevalence is hard to assess due to considerable under-reporting, perhaps because patients frequently fear that it is a sign of mental illness or dementia. However, it is thought to occur in:
About 10-15% of patients with moderate visual loss.
Possibly up to 50% of people with severe visual loss.
Presentation:
The nature of the hallucination depends on the part of the brain that is activated. The hallucinations may be black and white or in colour. They may involve grids/brickwork/lattice patterns but are typically much more complex:

The hallucinations are always outside the body.
The hallucinations are purely visual – other senses are not involved.
The hallucinations have no personal meaning to the patient.
Hallucinations may last seconds, minutes or hours.
CBS tends to occur in a ‘state of quiet restfulness’. This may be after a meal or when listening to the radio (but not when dozing off).
Symptoms also have a tendency to occur in dim lighting conditions.
Patients may report high levels of distress, with some patients reporting anger, anxiety and even fear associated with the hallucinations.

Risk factors specific to depression:
-Family history of mental disorder.
-History of previous suicide attempts (this includes self-harm).
-Severe depression.
-Anxiety.
-Feelings of hopelessness.
-Personality disorder.
-Alcohol abuse and/or drug abuse.
-Male gender.

Protective Factors for Suicide.
Protective factors buffer individuals from suicidal thoughts and behaviour. To date, protective factors have not been studied as extensively or rigorously as risk factors. Identifying and understanding protective factors are, however, equally as important as researching risk factors.

Protective Factors:
-Effective clinical care for mental, physical, and substance abuse disorders
-Easy access to a variety of clinical interventions and support for help seeking
-Family and community support (connectedness)
-Support from ongoing medical and mental health care relationships
-Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes
-Cultural and religious beliefs that discourage suicide and support instincts for self-preservation

Othello syndrome (OS) is a type of paranoid delusional jealousy, characterized by the false absolute certainty of the infidelity of a partner, leading to preoccupation with a partner’s sexual unfaithfulness based on unfounded evidence. OS has been associated with psychiatric and neurological disorders including stroke, brain trauma, brain tumours, neurodegenerative disorders, encephalitis, multiple sclerosis, normal pressure hydrocephalus, endocrine disorders, and drugs.

Anorexia nervosa is an eating disorder characterized by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight. People with anorexia place a high value on controlling their weight and shape, using extreme efforts that tend to significantly interfere with their lives.

The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or for
children and adolescents, on BMI percentile. The ranges below are derived from World Health
Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles
should be used. The level of severity may be increased to reflect clinical symptoms, the degree of
functional disability, and the need for supervision.
Mild: BMI > 17 kg/m2
Moderate: BMI 16-16.99 kg/m2
Severe: BMI 15-15.99 kg/m2
Extreme: BMI < 15 kg/m2 Anorexia nervosa is more common in women than in men, with a female-to-male ratio of 10-20:1 in developed countries. The prognosis of anorexia nervosa is guarded. Morbidity rates range from 10-20%, with only 50% of patients making a complete recovery. Of the remaining 50%, 20% remain emaciated and 25% remain thin. The main change in the diagnosis of Anorexia Nervosa was to remove the criterion of amenorrhea (loss of menstrual cycle). Removing this criterion means that boys and men with Anorexia will finally be able to receive an appropriate diagnosis.
Similarly, girls and women who continue to have their period despite other symptoms associated with Anorexia, such as weight loss and food restriction, will now be eligible for a diagnosis of Anorexia.