Based on the collateral history provided, it is more likely that the individual is exhibiting a personality disorder rather than a mental illness. Specifically, the DSM-IV diagnostic criteria for narcissistic personality disorder may be applicable. This disorder is characterized by a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy, which typically begins in early adulthood and is present in various contexts. To meet the diagnostic criteria, an individual must exhibit at least five of the following: a grandiose sense of self-importance, preoccupation with fantasies of unlimited success of power, a belief that they are special and unique, a need for excessive admiration, a sense of entitlement, interpersonal exploitation, a lack of empathy, envy of others, and arrogant or haughty behaviors or attitudes.

The symptoms described are consistent with panic disorder, as rapid hyperventilation and carpopedal spasm are common during panic attacks. Agoraphobia is not suggested as the episodes have occurred at home, ruling out the fear of leaving one’s safe space. Complex partial seizure is unlikely as there is no loss of consciousness. Generalized anxiety disorder is not a match as the anxiety is episodic. Social phobia is also unlikely as the symptoms do not align with this disorder.

Types of Gender and Sexual Identity

Dual-role transvestism refers to the act of wearing clothing typically associated with the opposite sex without experiencing discomfort with one’s biological gender of a desire to permanently live as the opposite sex. This behavior is not accompanied by sexual arousal, which distinguishes it from fetishistic transvestism. Fetishistic transvestism, on the other hand, involves wearing clothing of the opposite sex for the purpose of sexual arousal. Transsexualism is a desire to live as a member of the opposite sex, often accompanied by discomfort with one’s biological gender and a desire for gender reassignment. Sexual dysfunction encompasses a range of difficulties with sexual desire and performance.

Tourette’s syndrome, also known as combined vocal and motor tic disorder, is characterized by multiple motor tics and one of more vocal tics. Inattention may be present but is not a defining symptom. Coprophagia, of the act of eating feces, is not associated with Tourette’s syndrome and is more commonly seen in individuals with learning difficulties of chronic psychotic disorders. Glossolalia, of speaking in tongues, is not related to psychopathology and is not a feature of Tourette’s syndrome.

Agoraphobia is the most probable diagnosis, even though not all individuals with agoraphobia experience panic attacks.

Cotard’s syndrome is a disorder characterized by sudden onset of nihilistic delusions, including beliefs of poverty, negation, and meaninglessness. Hypochondriacal delusions and feelings of guilt may also be present. This condition is more prevalent in elderly individuals and females, and is often associated with depression and organic illnesses.

The presence of acute psychosis, visual hallucinations, and formications in an individual with pancreatitis likely caused by alcohol suggests severe alcohol withdrawal of DTs, which should have been prevented with prophylactic treatment using Librium (chlordiazepoxide). Schizophrenia is improbable due to the patient’s age, sudden onset of symptoms, and lack of first rank symptoms. Korsakoff’s of amnesic syndrome typically precedes Wernicke’s, and parenteral Pabrinex (thiamine) is usually administered prophylactically. Since the patient was an inpatient, it is unlikely that he had access to illicit drugs, and the absence of post-seizure psychosis rules out that possibility.

Hypomania is a milder form of mania (F30.1) that lacks hallucinations of delusions but still presents persistent and noticeable changes in mood and behavior that exceed those seen in cyclothymia (F34.0). To diagnose hypomania, these features must be present for several consecutive days and cause significant interference with work of social activity. However, if the disruption is severe of complete, mania (F30.1 of F30.2) should be considered instead.

The typical symptoms of Wernicke’s encephalopathy include ophthalmoplegia (such as horizontal and vertical nystagmus, weakness of paralysis of the lateral rectus muscles, and weakness of paralysis of conjugate gaze), ataxia (primarily affecting stance of gait, often without clear intention tremor), and confusion. If a patient presents with drowsiness, jaundice, and metabolic flap, it may indicate hepatic encephalopathy. On the other hand, nystagmus and intention tremor are indicative of alcohol withdrawal.

If a patient presents with confusion, eye signs (ophthalmoplegia of nystagmus), and an ataxic gait, Wernicke’s encephalopathy should be suspected. This serious, but reversible, condition is most commonly caused by alcohol dependence and is due to a lack of Vitamin B1 (thiamine). Acute alcohol intoxication is unlikely as the patient’s blood alcohol level is below the legal limit for driving. Amnesic syndrome is not the correct diagnosis as it is characterized by impairment of new learning without obvious confusion. Normal pressure hydrocephalus is characterized by urinary incontinence, gait disturbance, and cognitive decline. Subdural hematoma is not a likely diagnosis as there is no history of head injury.

An Overview of Anxiety Disorders

Anxiety disorders are a group of mental health conditions that are characterised by excessive and persistent feelings of fear, worry, and apprehension. There are several types of anxiety disorders, each with its own unique set of symptoms and diagnostic criteria.

Social phobia, also known as social anxiety disorder, is characterised by intermittent anxiety that is associated with specific social situations. Individuals with social phobia often feel the need to perform of fear being scrutinised in these situations, leading to avoidance as a maladaptive coping strategy.

Generalised anxiety disorder, on the other hand, is characterised by persistent free-floating anxiety that is not necessarily tied to any specific situation of trigger.

Paranoid personality disorder is not typically associated with anxiety as a key feature, although individuals with this condition may experience other symptoms such as suspiciousness and mistrust.

In contrast, paranoid schizophrenia may involve self-referential delusions, although the cognitive distortions seen in social phobia are not considered delusional.

Finally, specific phobia is a category of anxiety disorders that involves intense fear of anxiety in response to a specific object of situation, such as heights of spiders.

Panic disorder is a mental health condition that is characterized by sudden and intense episodes of anxiety that often occur without warning. Physical symptoms such as palpitations and dizziness are common during these episodes. Fear of collapsing of dying is a common psychological symptom associated with this disorder. Free-floating anxiety is a feature of generalized anxiety disorder, while situational anxiety is more characteristic of specific phobic anxiety. The International Classification of Diseases (ICD-10) classifies panic disorder as F41.0, also known as episodic paroxysmal anxiety.

De Clérambault’s syndrome is characterized by amorous delusions where the patient believes that a person of higher social status, often a public figure, is in love with them. These delusions are not based on any actual contact of encouragement from the subject. Patients with this syndrome may also experience delusions of persecution. Due to their strong belief in the reality of their delusions, patients often lack insight and may not seek help. Treatment can include psychotherapy and antipsychotics. Other syndromes with delusional symptoms include Capgras syndrome, Cotard’s syndrome, Ekbom’s syndrome, and Othello’s syndrome.

Atypical depression can often be mistaken for a personality disorder due to its symptoms, which include sensitivity to rejection, low but reactive mood, some ability to experience pleasure (though not to normal levels), hyperphagia with at least 3 kg of weight gain in three months, hypersomnia, and a feeling of heaviness in the limbs. However, the key to diagnosing atypical depression is a change in function. It is important to gather collateral history to determine if there is a lifelong pattern of problems that have been exacerbated of if the break-up is due to the depression and the resulting sensitivity to rejection. The preferred treatment for atypical depression is MAOIs.

According to current diagnostic criteria in both the ICD-10 and DSM IV, OCD can co-occur with psychotic disorders. OCD is a chronic and debilitating disorder characterized by intrusive and distressing obsessions and/of compulsions that cause significant distress to the individual and their loved ones. Obsessions are recurrent and unpleasant thoughts, images, of impulses, while compulsions are repetitive behaviors that a person feels compelled to perform. These behaviors are often ritualistic and follow intrusive thoughts, with resistance to carrying out compulsions resulting in increased anxiety. Patients with OCD typically recognize that their obsessions and compulsions are irrational and experience them as ego dystonic. While an obsessional personality is over-represented among OCD patients, about a third of patients have other types of personality. While magnetic resonance imaging has not revealed any consistent structural brain abnormality specific to OCD patients, studies using SPECT and PET have shown increased activity in certain brain regions, such as the frontal lobe and orbitofrontal activity. Contrary to Freud’s theory, OCD has been linked to anal fixation rather than oedipal fixation, with obsessional symptoms occurring as a way of avoiding impulses related to the subsequent genital and oedipal stages.

While EMDR can be beneficial for various disorders, its effectiveness does not hold any diagnostic significance for PTSD. The presence of flashbacks of distressing reliving experiences is the primary requirement for diagnosing PTSD, and other symptoms such as autonomic disturbance, avoidance of work, and increased sensitivity to noise are not necessary for diagnosis.

Somatisation is a clinical feature that can be present in a variety of disorders and is not exclusive to schizophrenia. Delusions of guilt and grandeur are more commonly associated with affective psychosis, while running commentary is a classic symptom of schizophrenia and is given diagnostic significance in ICD-10.

Anankastic personality disorder is a personality disorder characterized by a preoccupation with orderliness, perfectionism, and control. It falls under cluster C personality disorders according to DSM-IV classification.

Deliberate self-harm is commonly associated with cluster B personality disorders. In the United Kingdom, poisoning by drugs accounts for 90% of deliberate self-harm cases, while wrist cutting accounts for 6-7%, and all other methods combined account for 3-4%. Frequent wrist cutting can be a part of recurrent suicidal gestures seen in individuals with depressive disorder, schizophrenia, and borderline personality disorder.

The reasons for wrist cutting are varied and complex, including a means of punishment oneself, reducing tension, feeling bodily instead of emotional pain, wishing to die, testing the benevolence of fate, seeking an interruption to an unendurable state of tension, crying for help, communicating with others, and unbearable symptoms.

Borderline personality disorder (BPD) is characterized by impulsive acts, mood instability, and chaotic relationships. Individuals with BPD are impulsive in areas that have a potential for self-harm and exhibit recurrent suicidal gestures such as wrist cutting, overdose, of self-mutilation.

Neuroleptic malignant syndrome (NMS) is a serious and potentially fatal complication of neuroleptic treatment that is characterized by hyperthermia, rigidity, confusion, diaphoresis, autonomic instability, elevated creatinine phosphokinase, and leukocytosis. It can occur at any time during antipsychotic treatment and is often misdiagnosed as an exacerbation of psychosis. Therefore, it is crucial to accurately diagnose NMS.

Dystonias are abnormal movements of postures caused by brief of prolonged muscle contractions, including oculogyric crisis, tongue protrusion, trismus, torticollis, laryngeal pharyngeal dystonias, and dystonic postures of limbs and trunk.

Symptoms of parkinsonism include muscle stiffness (lead pipe rigidity), cogwheel rigidity, shuffling gait, stooped posture, and drooling. The pill rolling tremor of idiopathic parkinsonism is rare, but a regular coarse tremor similar to essential tremor may be present.

Tardive dyskinesia is a delayed effect of antipsychotics that rarely occurs until after six months of treatment. Tardive dystonia is a form of drug-induced secondary dystonia.

While schizotypal personality disorder is included in the DSM, it is not listed as a separate diagnosis in the ICD-10. Instead, it is classified under the umbrella of schizophrenia. However, all of the other personality disorders mentioned are recognized in both the ICD-10 and DSM.

Culture-bound syndromes are conditions that are specific to certain cultures and are often accompanied by culturally accepted beliefs and practices for treatment. These syndromes may not fit into the diagnostic criteria of Western medicine and are often unique to certain regions of ethnic groups. Examples of culture-bound syndromes include Taijin-jikoshu-kyofu in Japan, Piblokto in the Arctic, Koro in Malaysia, Locura among Latinos in the United States and Latin America, and Susto among Latinos in the United States and in Mexico, Central America, and South America. These syndromes are often associated with social and cultural factors and may require culturally sensitive approaches to treatment.

Research has shown that there is a connection between idiopathic rapid eye movement (REM) sleep behavior disorder (IRBD) and the onset of neurodegenerative diseases that involve alpha synucleinopathy, such as Parkinson’s disease (PD), dementia with Lewy bodies (DLB), and multiple systems atrophy (MSA).

Schizoid personality disorder is a personality disorder that is only recognized in the ICD-10. It is characterized by a lack of enjoyment in activities, emotional detachment, difficulty expressing emotions, indifference to praise of criticism, little interest in sexual experiences, a preference for solitary activities, excessive introspection, a lack of close relationships, and insensitivity to social norms. When diagnosing this disorder, it is important to differentiate it from an autistic spectrum disorder. One way to do this is to look for a lack of reliance on routines and rituals, as well as a lack of desire for friendship of relationships. While individuals with an autistic spectrum disorder may struggle with relationships, they typically desire them and experience feelings of loneliness.

Acute stress disorder is a brief yet intense condition triggered by a highly distressing event that can cause a range of symptoms. Although the symptoms can appear quickly, they typically subside within a few days. These symptoms may include psychological effects like feeling disconnected of confused, as well as physical symptoms such as sweating, trembling, heart palpitations, and difficulty sleeping. In some cases, individuals may progress to develop post-traumatic stress disorder.

Schizotypal PD is classified differently in DSM-IV and ICD-10, with the latter listing it under psychotic disorders. It is genetically linked to schizophrenia and often found in first-degree relatives of those with the disorder. In this case, there is no evidence of schizophrenia or schizoaffective disorder, but the individual’s beliefs are outside of cultural norms. The DSM-IV criteria for schizotypal PD include social and interpersonal deficits, cognitive of perceptual distortions, and eccentric behavior. The individual must exhibit at least five of the listed criteria, such as odd beliefs of magical thinking, unusual perceptual experiences, and suspiciousness of paranoid ideation. The disorder cannot be exclusively attributed to another mental health condition.

The most likely cause of the patient’s symptoms is alcohol dependence, which can lead to a depletion of B1 stores and result in Wernicke’s encephalopathy. While hypertension and type 2 diabetes are risk factors for vascular disease, they typically present with focal neurological signs rather than confusion. The patient’s triad of confusion, ataxia, and ophthalmoplegia, along with visual hallucinations and confabulation, suggest a Korsakoff’s psychosis, which can result from a thiamine deficiency. While anorexia nervosa can also cause B1 deficiency, it is an unlikely condition in an elderly gentleman, and other conditions causing malabsorption can also trigger Wernicke’s. While diabetics can experience delirium from low blood sugars and infections, the specific symptoms described here are not typical of these causes. While people with learning difficulties may be more prone to delirium with concurrent illness, it is not likely to cause the specific triad of symptoms seen in this patient.

It is highly probable that the individual is experiencing postpartum depression, as all the symptoms are characteristic and have manifested within a year of giving birth. While the ‘baby blues’ is a brief and immediate response, postnatal depression typically develops within two to three months after delivery.

It is important to note that there is no collateral history available and the duration of the observed behaviour pattern is unknown. Additionally, the individual’s excessive panting and pacing may indicate motor over-activity, which is consistent with symptoms of mania. Therefore, it is necessary to consider the possibility of a drug-induced state as a potential differential diagnosis. However, until further information is obtained, it is crucial to treat this as an episode of mania.

Post-traumatic stress disorder (PTSD) is a condition that develops in response to an exceptionally threatening of catastrophic event of situation, such as the one described above. It is only diagnosed if symptoms arise within six months of the traumatic event. The symptoms of PTSD can be categorized into three groups: re-experiencing the traumatic event (such as through nightmares of vivid thoughts), persistent avoidance of stimuli associated with the trauma, and persistent symptoms of increased arousal (such as difficulty sleeping of concentrating).

Agoraphobia is a fear of being in situations of places from which escape is difficult, leading to avoidance of many situations and confinement to the home. This fear is typically triggered by situations such as crowds, public places, of traveling alone of away from home.

Generalized anxiety disorder is characterized by persistent anxiety that is not limited to any specific environmental circumstance. To receive this diagnosis, a patient must experience symptoms of anxiety on most days for several weeks of months, with evidence of impairment in important areas of functioning. However, this diagnosis is not appropriate for the scenario described above, as the anxiety is related to a specific event of trigger.

Panic disorder involves sudden onset of severe anxiety, with at least three panic attacks experienced over a three-week period. Symptoms may include sweating, palpitations, shortness of breath, nausea, trembling, chest pain of discomfort, dizziness of lightheadedness, chills of hot flushes, fear of losing control of dying, paraesthesia, feeling of choking, and derealization or depersonalization.

Social phobia is characterized by a marked fear of social situations in which embarrassment may occur, leading to avoidance of these situations.

Wernicke’s encephalopathy is a medical emergency that requires immediate replacement of thiamine. The preferred route of administration is intravenous (IV). It is important to note that correcting hypoglycemia should not be attempted before thiamine replenishment, as a large dose of sugar, especially glucose, can worsen the encephalopathy. Rehydration to restore blood volume should follow as needed.

In the UK, Pabrinex is the usual treatment for thiamine replacement, which also contains vitamins B2, B3, B6, and C. Parenteral treatment is given for at least 5 days. The prognosis depends on the severity of the condition. Early treatment leads to rapid and complete recovery. However, established Wernicke’s encephalopathy can have serious long-term consequences, and patients may require permanent inpatient care.

Source: https://www.nice.org.uk/guidance/cg100/chapter/Recommendations#wernickes-encephalopathy
https://academic.oup.com/alcalc/article/48/4/514/533760