Differential Diagnosis of a Patient with Depressive Symptoms

Depression is a common mental health condition that can present with a variety of symptoms. In this vignette, the patient shows signs of anhedonia, change in appetite, early morning awakening, psychomotor retardation, decreased sexual drive, poor concentration, ideas of worthlessness or guilt, and thoughts of death and suicide. To diagnose and classify depression, various assessment tools are available, such as the PHQ-9, Hospital Anxiety and Depression (HAD) Scale, and Beck Depression Inventory.

Other possible diagnoses that need to be ruled out include acute alcohol withdrawal, acute psychosis, hypomania, and schizophrenia. Acute alcohol withdrawal typically manifests with psychomotor agitation, anxiety, tremor, insomnia, nausea, vomiting, hallucinations, seizures, and autonomic instability. Delirium tremens is a severe complication of alcohol withdrawal that can be life-threatening. Acute psychosis is characterized by delusions, hallucinations, or thought disorder. Hypomania is a milder form of mania that features elated mood, pressure of speech, increased energy, activity, appetite, sexual desire, and pain threshold, but does not cause significant impairment. Schizophrenia is a chronic and severe mental disorder that involves a range of cognitive, emotional, and behavioral symptoms, including hallucinations, delusions, disorganized speech, and social withdrawal.

Therefore, a thorough evaluation of the patient’s history, physical examination, and mental status is necessary to arrive at an accurate diagnosis and develop an appropriate treatment plan. Collaborating with a mental health specialist may also be beneficial in managing complex cases of depression or other mental health conditions.

Understanding Prognostic Factors in Schizophrenia

Schizophrenia is a complex mental illness that can have a significant impact on a person’s life. While there is no cure for schizophrenia, early diagnosis and treatment can help manage symptoms and improve outcomes. Understanding prognostic factors can also be helpful in predicting the course of the illness and developing appropriate treatment plans.

One important factor to consider is the premorbid history of the patient. A prolonged history of social withdrawal is predictive of more severe and long-lasting psychopathology. Additionally, a family history of schizophrenia in first-degree relatives can have a negative impact on prognosis, while a history in second-degree relatives has little significance.

The onset of illness is also an important factor to consider. In schizophrenia, a sudden onset of illness has a more favourable prognosis than an insidious one. However, if the patient presents with catatonic symptoms, this is actually an indicator of a relatively good prognosis.

Finally, MRI changes are associated with more severe symptoms and clinical course in people with schizophrenia. While it is not fully clear whether these changes are fixed or progress over time, they can be an important factor to consider in developing a treatment plan.

Overall, understanding these prognostic factors can help clinicians develop appropriate treatment plans and provide better support for patients with schizophrenia.

After a myocardial infarction, Sertraline is the preferred SSRI due to its extensive research in this patient population compared to other SSRIs. It is important to note that the patient may also be taking antiplatelets and should be cautioned about the potential for dyspepsia and gastrointestinal bleeding. Co-prescribing a proton pump inhibitor should be considered.

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as the first-line treatment for depression. Citalopram and fluoxetine are the preferred SSRIs, while sertraline is recommended for patients who have had a myocardial infarction. However, caution should be exercised when prescribing SSRIs to children and adolescents. Gastrointestinal symptoms are the most common side-effect, and patients taking SSRIs are at an increased risk of gastrointestinal bleeding. Patients should also be aware of the possibility of increased anxiety and agitation after starting a SSRI. Fluoxetine and paroxetine have a higher propensity for drug interactions.

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning regarding the use of citalopram due to its association with dose-dependent QT interval prolongation. As a result, citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram is now 40 mg for adults, 20 mg for patients older than 65 years, and 20 mg for those with hepatic impairment.

When initiating antidepressant therapy, patients should be reviewed by a doctor after 2 weeks. Patients under the age of 25 years or at an increased risk of suicide should be reviewed after 1 week. If a patient responds well to antidepressant therapy, they should continue treatment for at least 6 months after remission to reduce the risk of relapse. When stopping a SSRI, the dose should be gradually reduced over a 4 week period, except for fluoxetine. Paroxetine has a higher incidence of discontinuation symptoms, including mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

When considering the use of SSRIs during pregnancy, the benefits and risks should be weighed. Use during the first trimester may increase the risk of congenital heart defects, while use during the third trimester can result in persistent pulmonary hypertension of the newborn. Paroxetine has an increased risk of congenital malformations, particularly in the first trimester.

Schizophrenia is a mental disorder that is characterized by various symptoms. Schneider’s first rank symptoms are divided into four categories: auditory hallucinations, thought disorders, passivity phenomena, and delusional perceptions. Auditory hallucinations can include hearing two or more voices discussing the patient in the third person, thought echo, or voices commenting on the patient’s behavior. Thought disorders can involve thought insertion, thought withdrawal, or thought broadcasting. Passivity phenomena can include bodily sensations being controlled by external influence or actions/impulses/feelings that are imposed on the individual or influenced by others. Delusional perceptions involve a two-stage process where a normal object is perceived, and then there is a sudden intense delusional insight into the object’s meaning for the patient.

Other features of schizophrenia include impaired insight, incongruity/blunting of affect (inappropriate emotion for circumstances), decreased speech, neologisms (made-up words), catatonia, and negative symptoms such as incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), and avolition (poor motivation). It is important to note that schizophrenia can manifest differently in each individual, and not all symptoms may be present.

Understanding Alcohol Dependence: Symptoms and Screening Tools

Alcohol dependence is a serious condition characterized by a strong compulsion to drink, withdrawal symptoms, tolerance, and loss of control over alcohol use. This vignette illustrates a classic scenario of alcohol dependence, with features of tolerance, withdrawals, neglect of other pleasures, and low mood associated with heavy chronic alcohol consumption. While depression can be a symptom of alcohol dependence, it is not the primary diagnosis.

The term alcohol abuse is being replaced by alcohol-use disorder or harmful drinking to describe patterns of alcohol use that cause physical or mental health damage. In this vignette, the woman likely has harmful use of alcohol, but the overall picture points to a diagnosis of alcohol dependence.

Withdrawal symptoms are a common feature of alcohol dependence, and the woman in this vignette would likely experience them if she suddenly stopped drinking. Social withdrawal is also an indicator of alcohol dependence, but it does not explain the entire pattern of symptoms and behavior presented.

A useful screening test for alcohol-use disorders is the CAGE questionnaire, which asks about cutting down, annoyance from others, guilt, and needing a drink first thing in the morning. Answering yes to two or more questions may indicate the presence of an alcohol-use disorder. Other screening tools include the FAST and AUDIT tests, which can be administered quickly in busy medical settings.

Overall, understanding the symptoms and screening tools for alcohol dependence is crucial for early detection and intervention.

Understanding Seasonal Affective Disorder

Seasonal affective disorder (SAD) is a type of depression that typically occurs during the winter months. It is important to treat SAD in the same way as depression, following the guidelines set out by the National Institute for Health and Care Excellence (NICE). This involves starting with psychological therapies and monitoring the patient’s progress after two weeks to ensure that their symptoms have not worsened. If necessary, an SSRI can be prescribed.

It is important to note that sleeping tablets should not be given to patients with SAD, as this can exacerbate their symptoms. While light therapy is often suggested as a treatment option, the evidence supporting its effectiveness is limited. As a result, it is not routinely recommended.

In summary, SAD is a form of depression that requires careful management and treatment. By following the appropriate guidelines and avoiding certain medications, patients can receive the support they need to manage their symptoms and improve their quality of life.

Sectioning under the Mental Health Act is a legal process used for individuals who refuse voluntary admission. This process excludes patients who are under the influence of drugs or alcohol. There are several sections under the Mental Health Act that allow for different types of admission and treatment.

Section 2 allows for admission for assessment for up to 28 days, which is not renewable. An Approved Mental Health Professional (AMHP) or the nearest relative (NR) can make the application on the recommendation of two doctors, one of whom should be an approved consultant psychiatrist. Treatment can be given against the patient’s wishes.

Section 3 allows for admission for treatment for up to 6 months, which can be renewed. An AMHP and two doctors, both of whom must have seen the patient within the past 24 hours, can make the application. Treatment can also be given against the patient’s wishes.

Section 4 is used as an emergency 72-hour assessment order when a section 2 would involve an unacceptable delay. A GP and an AMHP or NR can make the application, which is often changed to a section 2 upon arrival at the hospital.

Section 5(2) allows a doctor to legally detain a voluntary patient in hospital for 72 hours, while section 5(4) allows a nurse to detain a voluntary patient for 6 hours.

Section 17a allows for Supervised Community Treatment (Community Treatment Order) and can be used to recall a patient to the hospital for treatment if they do not comply with the conditions of the order in the community, such as taking medication.

Section 135 allows for a court order to be obtained to allow the police to break into a property to remove a person to a Place of Safety. Section 136 allows for someone found in a public place who appears to have a mental disorder to be taken by the police to a Place of Safety. This section can only be used for up to 24 hours while a Mental Health Act assessment is arranged.

Considering the patient’s increasing symptoms of psychosis, it is possible that non-compliance with their risperidone medication is an issue. In such cases, it is recommended to consider once monthly IM antipsychotic depot injections for patients with poor oral compliance. However, the patient’s risperidone dose would need to be re-titrated to their previous level.

Clozapine is typically used for treatment-resistant psychosis after trying two other antipsychotics. However, there is no evidence of the patient having tried multiple antipsychotics, and it appears that risperidone was effectively controlling their symptoms. If risperidone is not effective, quetiapine could be tried before considering Clozapine, provided there are no contraindications.

While cognitive behavioural therapy (CBT) can be helpful in reducing symptoms of psychosis, it is less likely to be effective than monthly depot injections.

Based on the patient’s history, there is no indication that they pose a risk to themselves or others that would warrant admission. Therefore, efforts should be made to manage the patient in the community.

Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

Differentiating Anxiety Disorders: A Vignette Analysis

The following vignette describes a patient with symptoms of anxiety in a social situation. To properly diagnose the patient, it is important to differentiate between various anxiety disorders.

Social Phobia: This disorder is characterized by anxiety in public, particularly when feeling scrutinized. It typically starts in adolescence and is equally prevalent in men and women. Some patients have a specific social phobia, while others have a more diffuse type. Treatment is mainly with psychological interventions.

Generalized Anxiety Disorder (GAD): GAD is characterized by non-specific and persistent anxiety. Patients feel anxious most days for periods of at least several weeks, and may experience a variety of worries that are not objectively warranted by their circumstances. Autonomic and motor overactivity are also common.

Panic Disorder: Panic attacks are recurrent episodes of severe anxiety that occur unpredictably and under unrestricted circumstances. A diagnosis of panic disorder can be given only if several panic attacks have occurred in about 1 month in situations that do not pose an objective danger, in unrestricted circumstances and with relative freedom from symptoms of anxiety between attacks.

Separation Anxiety Disorder: This disorder is mainly diagnosed in children, although an adult form has been increasingly recognized. Symptoms include anxiety and fear when separated from emotionally attached individuals, and avoidance of being alone.

Conduct Disorder: This disorder is a precursor to dissocial personality disorder and presents as a persistent and repetitive pattern of dissocial behavior beyond the expected mischief and rebelliousness of childhood and adolescence.

In the vignette, the patient’s anxiety is specific to certain situations and therefore predictable, which excludes the diagnosis of panic disorder. The patient’s symptoms do not fit the criteria for GAD or separation anxiety disorder. The most likely diagnosis is social phobia, which is characterized by anxiety in public situations.

Hyponatraemia is a known side effect of SSRIs, with sertraline being the specific medication associated with this condition. Other drugs that can cause low sodium levels include chlorpropramide, carbamazepine, tricyclic antidepressants, lithium, MDMA/ecstasy, tramadol, haloperidol, vincristine, desmopressin, and fluphenazine.

Understanding the Side-Effects and Interactions of SSRIs

SSRIs, or selective serotonin reuptake inhibitors, are commonly prescribed antidepressants that can have various side-effects and interactions with other medications. The most common side-effect of SSRIs is gastrointestinal symptoms, and patients taking these medications are at an increased risk of gastrointestinal bleeding. To mitigate this risk, a proton pump inhibitor should be prescribed if the patient is also taking a NSAID. Hyponatraemia, or low sodium levels, can also occur with SSRIs, and patients should be vigilant for increased anxiety and agitation after starting treatment.

Fluoxetine and paroxetine have a higher propensity for drug interactions, and citalopram has been associated with dose-dependent QT interval prolongation. The Medicines and Healthcare products Regulatory Agency (MHRA) has advised that citalopram and escitalopram should not be used in patients with congenital long QT syndrome, known pre-existing QT interval prolongation, or in combination with other medicines that prolong the QT interval. The maximum daily dose of citalopram has been reduced for certain patient populations.

SSRIs can also interact with other medications, such as NSAIDs, warfarin/heparin, aspirin, and triptans. It is important to review patients after starting antidepressant therapy and to gradually reduce the dose when stopping treatment to avoid discontinuation symptoms. These symptoms can include mood changes, restlessness, difficulty sleeping, unsteadiness, sweating, gastrointestinal symptoms, and paraesthesia.

In summary, understanding the potential side-effects and interactions of SSRIs is crucial for safe and effective treatment of depression and other mental health conditions. Patients should be closely monitored and counseled on the risks and benefits of these medications.

Understanding the Difference between Hypomania and Mania

Hypomania and mania are two terms that are often used interchangeably, but they actually refer to two different conditions. While both conditions share some common symptoms, there are some key differences that set them apart.

Mania is a more severe form of hypomania that lasts for at least seven days and can cause significant impairment in social and work settings. It may require hospitalization due to the risk of harm to oneself or others and may present with psychotic symptoms such as delusions of grandeur or auditory hallucinations.

On the other hand, hypomania is a lesser version of mania that lasts for less than seven days, typically 3-4 days. It does not impair functional capacity in social or work settings and is unlikely to require hospitalization. It also does not exhibit any psychotic symptoms.

Both hypomania and mania share common symptoms such as elevated or irritable mood, pressured speech, flight of ideas, poor attention, insomnia, loss of inhibitions, increased appetite, and risk-taking behavior. However, the length of symptoms, severity, and presence of psychotic symptoms help differentiate mania from hypomania.

Understanding Conduct Disorder and Differential Diagnoses

Conduct disorder is a psychiatric condition characterized by persistent and severe antisocial behaviors that violate social norms and the rights of others. These behaviors may include excessive fighting, cruelty to people or animals, destruction of property, persistent disobedience, and repeated lying. However, conduct disorder can be easily confused with other psychiatric conditions that present with similar symptoms. Here are some differential diagnoses to consider:

Depression: While depressive disorders can present with oppositional symptoms, they are usually accompanied by disturbances to appetite, sleep, and anhedonia, which are not seen in conduct disorder. However, depression can coexist with conduct disorder.

Adjustment reaction: Conduct disturbance can also be a reaction to an external stressor, such as divorce, bereavement, abuse, or trauma. However, these symptoms usually occur within three months of the stressor and can last up to six months. If there is no mention of an external stressor, conduct disorder is more likely.

Attention-deficit hyperactivity disorder (ADHD): Children with ADHD exhibit symptoms of inattention associated with hyperactivity and impulsiveness, which can affect social and academic functioning. However, unlike conduct disorder, these behaviors do not usually violate societal norms or the rights of others. ADHD can also coexist with conduct disorder.

Autism spectrum disorder: Children with autism spectrum disorder may present with emotional lability, aggressive outbursts, and destructive behavior, usually in response to an unexpected change in routine or sensory overload. However, there are typical features of autism, such as sensory hypersensitivity, that are not mentioned in conduct disorder. Autism can also coexist with conduct disorder.

In conclusion, conduct disorder is a serious psychiatric condition that requires early identification and intervention. However, it is important to consider other differential diagnoses to ensure accurate diagnosis and appropriate treatment.

If a patient is under section 2 or 3, treatment can be administered even if they refuse it. Patients who are detained under section 3 can be treated against their will, regardless of their capacity. However, after three months, if the patient still refuses treatment, an impartial psychiatrist must review the proposed medication and agree with the treating team’s plan. The Mental Health Act takes precedence over the Mental Capacity Act, so a best interests meeting is not necessary. The treating team must consider the patient’s best interests, and in this case, they believe that medication is necessary for Rosie’s mental health. While benzodiazepines can alleviate agitation and distress, they are unlikely to improve her psychotic symptoms, so they are not a suitable option. If Rosie continues to refuse treatment after three months under section 3, a second opinion will be required.

Sectioning under the Mental Health Act is a legal process used for individuals who refuse voluntary admission. This process excludes patients who are under the influence of drugs or alcohol. There are several sections under the Mental Health Act that allow for different types of admission and treatment.

Section 2 allows for admission for assessment for up to 28 days, which is not renewable. An Approved Mental Health Professional (AMHP) or the nearest relative (NR) can make the application on the recommendation of two doctors, one of whom should be an approved consultant psychiatrist. Treatment can be given against the patient’s wishes.

Section 3 allows for admission for treatment for up to 6 months, which can be renewed. An AMHP and two doctors, both of whom must have seen the patient within the past 24 hours, can make the application. Treatment can also be given against the patient’s wishes.

Section 4 is used as an emergency 72-hour assessment order when a section 2 would involve an unacceptable delay. A GP and an AMHP or NR can make the application, which is often changed to a section 2 upon arrival at the hospital.

Section 5(2) allows a doctor to legally detain a voluntary patient in hospital for 72 hours, while section 5(4) allows a nurse to detain a voluntary patient for 6 hours.

Section 17a allows for Supervised Community Treatment (Community Treatment Order) and can be used to recall a patient to the hospital for treatment if they do not comply with the conditions of the order in the community, such as taking medication.

Section 135 allows for a court order to be obtained to allow the police to break into a property to remove a person to a Place of Safety. Section 136 allows for someone found in a public place who appears to have a mental disorder to be taken by the police to a Place of Safety. This section can only be used for up to 24 hours while a Mental Health Act assessment is arranged.

Olanzapine, an atypical antipsychotic, often leads to weight gain as a prevalent negative outcome.

Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

Differentiating between Mental Disorders: Tourette’s Syndrome, Malingering, Conduct Disorder, Dissocial Personality Disorder, and Schizophrenia

Tourette’s Syndrome is a tic disorder that usually develops in childhood or adolescence, characterized by multiple motor tics and one or more vocal tics. The vocal tics need not be complete words or phrases and are often throat-clearing and grunting. Anti-psychotics such as pimozide, risperidone, and sulpiride have been shown to be of benefit.

Malingering is the act of fabricating symptoms for some sort of secondary gain, such as financial, manipulative, avoidance of school, obtaining drugs, or gaining sympathy or attention.

Conduct Disorder is a mental disorder diagnosed before or after the age of 10, characterized by a persistent and repetitive pattern of behavior that violates either the basic rights of others or goes against age-developmental norms. Childhood onset disorder can be linked to attention deficit/hyperactivity disorder (ADHD) type symptoms.

Dissocial Personality Disorder is characterized by a long-term disregard for others or the violation of others. Its precursor is conduct disorder. Antisocial personality disorder can be diagnosed when the patient reaches the age of 18 and has a history of conduct disorder in childhood or adolescence.

Schizophrenia does not typically present with involuntary movements. There is also no history of hallucinations, auditory or visual, or confused thinking.

Monitoring is crucial for detecting the life-threatening side effect of clozapine, which is agranulocytosis/neutropenia.

Atypical antipsychotics are now recommended as the first-line treatment for patients with schizophrenia, as per the 2005 NICE guidelines. These medications have the advantage of significantly reducing extrapyramidal side-effects. However, they can also cause adverse effects such as weight gain, hyperprolactinaemia, and in the case of clozapine, agranulocytosis. The Medicines and Healthcare products Regulatory Agency has issued warnings about the increased risk of stroke and venous thromboembolism when antipsychotics are used in elderly patients. Examples of atypical antipsychotics include clozapine, olanzapine, risperidone, quetiapine, amisulpride, and aripiprazole.

Clozapine, one of the first atypical antipsychotics, carries a significant risk of agranulocytosis and requires full blood count monitoring during treatment. Therefore, it should only be used in patients who are resistant to other antipsychotic medication. The BNF recommends introducing clozapine if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs, one of which should be a second-generation antipsychotic drug, each for at least 6-8 weeks. Adverse effects of clozapine include agranulocytosis, neutropaenia, reduced seizure threshold, constipation, myocarditis, and hypersalivation. Dose adjustment of clozapine may be necessary if smoking is started or stopped during treatment.

This woman is experiencing the common postpartum mood disorder known as baby-blues, which affects approximately two-thirds of women. Although lack of sleep can be a symptom of depression, it is a normal occurrence for new mothers.

Understanding Postpartum Mental Health Problems

Postpartum mental health problems can range from mild ‘baby-blues’ to severe puerperal psychosis. To screen for depression, healthcare professionals may use the Edinburgh Postnatal Depression Scale, which is a 10-item questionnaire that indicates how the mother has felt over the previous week. A score of more than 13 indicates a ‘depressive illness of varying severity’, with sensitivity and specificity of more than 90%. The questionnaire also includes a question about self-harm.

‘Baby-blues’ is seen in around 60-70% of women and typically occurs 3-7 days following birth. It is more common in primips, and mothers are characteristically anxious, tearful, and irritable. Reassurance and support from healthcare professionals, particularly health visitors, play a key role in managing this condition. Most women with the baby blues will not require specific treatment other than reassurance.

Postnatal depression affects around 10% of women, with most cases starting within a month and typically peaking at 3 months. The features are similar to depression seen in other circumstances, and cognitive behavioural therapy may be beneficial. Certain SSRIs such as sertraline and paroxetine may be used if symptoms are severe. Although these medications are secreted in breast milk, they are not thought to be harmful to the infant.

Puerperal psychosis affects approximately 0.2% of women and requires admission to hospital, ideally in a Mother & Baby Unit. Onset usually occurs within the first 2-3 weeks following birth, and features include severe swings in mood (similar to bipolar disorder) and disordered perception (e.g. auditory hallucinations). There is around a 25-50% risk of recurrence following future pregnancies. Paroxetine is recommended by SIGN because of the low milk/plasma ratio, while fluoxetine is best avoided due to a long half-life.

Hoover’s sign is a useful clinical tool that can quickly differentiate between organic and non-organic leg paresis. In cases of non-organic paresis, pressure is felt under the affected leg when the unaffected leg is lifted against pressure. This is due to involuntary contralateral hip extension.

Based on this scenario, the likely diagnosis is a conversion disorder, which is characterized by the loss of motor function in the leg without any organic cause. The positive result of Hoover’s sign supports this diagnosis.

Babinski’s sign is a reflex that involves dorsiflexion of the big toe upon plantar stimulation. It is indicative of an upper motor neuron lesion of the corticospinal tract.

Brudziński’s sign is a reflex that involves the flexion of the hips with forced flexion of the neck. It is typically associated with meningitis but can also be present in patients with subarachnoid hemorrhage and encephalitis.

The glabellar tap sign, also known as Myerson’s sign, involves tapping the area above the nose and between the eyebrows (glabella) repeatedly. Healthy patients usually blink in response to the first 2-3 taps, but if a patient is unable to resist blinking beyond this, it can be indicative of early Parkinson’s disease.

The straight leg raise test, also known as Lasègue’s sign, involves raising the straight leg to reproduce radiating leg pain. A positive result indicates a likely lumbar disc herniation.

Psychiatric Terms for Unexplained Symptoms

There are various psychiatric terms used to describe patients who exhibit symptoms for which no organic cause can be found. One such disorder is somatisation disorder, which involves the presence of multiple physical symptoms for at least two years, and the patient’s refusal to accept reassurance or negative test results. Another disorder is illness anxiety disorder, which is characterized by a persistent belief in the presence of an underlying serious disease, such as cancer, despite negative test results.

Conversion disorder is another condition that involves the loss of motor or sensory function, and the patient does not consciously feign the symptoms or seek material gain. Patients with this disorder may be indifferent to their apparent disorder, a phenomenon known as la belle indifference. Dissociative disorder, on the other hand, involves the process of ‘separating off’ certain memories from normal consciousness, and may manifest as amnesia, fugue, or stupor. Dissociative identity disorder (DID) is the most severe form of dissociative disorder and was previously known as multiple personality disorder.

Factitious disorder, also known as Munchausen’s syndrome, involves the intentional production of physical or psychological symptoms. Finally, malingering is the fraudulent simulation or exaggeration of symptoms with the intention of financial or other gain. Understanding these psychiatric terms can help healthcare professionals better diagnose and treat patients with unexplained symptoms.

Understanding Phobias and Dissociative Disorders

Phobias and dissociative disorders are two types of mental health conditions that can significantly impact a person’s daily life. Phobias are intense and irrational fears of specific objects or situations, while dissociative disorders involve a disconnection from reality as a coping mechanism.

Agoraphobia is a common and severe phobia that affects mostly women and involves a fear of open spaces and crowded places. Social phobia, on the other hand, is a fear of being scrutinized in public and tends to start in adolescence. Acrophobia is a specific phobia that involves a fear of heights.

Treatment for phobias often involves psychological interventions such as cognitive-behavioral therapy. Dissociative disorders, on the other hand, typically require more intensive therapy to address the underlying trauma that led to the dissociation.

It’s important to seek professional help if you or someone you know is struggling with a phobia or dissociative disorder. With the right treatment and support, it is possible to manage these conditions and improve overall quality of life.

Duration of Antidepressant Treatment for Depression

It is recommended that a single episode of depression should be treated for at least six months after recovery to prevent relapse. Recurrent episodes warrant at least 12 months of treatment after recovery. Stopping antidepressant treatment immediately on recovery puts patients at a high risk of relapse, with 50% of patients experiencing a relapse of their depressive symptoms. During the recovery phase, adults should receive the same dose used for the treatment of the acute phase. The medication should then be tapered off over a few weeks, according to the type of antidepressant used.

Stopping medication prematurely, such as after one month or six weeks, would put the patient at a high risk of relapse. If the patient has been using antidepressants over a very short term and has found it maximally effective, they may be able to come off medication sooner than six months. However, this should be managed with caution and only recommended if there are other extenuating factors which would cause them to want to stop, such as side-effects or poor compliance. In this case, the patient has been using sertraline for four months already, has not indicated poor compliance, and there is no indication of issues with side-effects.