100 Cases in Psychiatry

Barry Wright, Subodh Dave, Nisha Dogra

• Publisher: CRC Press
• Year: 2017
• Print ISBN: 9781138373761
• eBook ISBN: 9781315351582
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The new edition of this best-selling title from the popular 100 cases series explores common psychiatric and mental health scenarios that will be encountered by the medical student and junior doctor during practical training on the ward, in the emergency department, in outpatient clinics and in the community, and which are likely to feature in qualifying examinations. The book covers a comprehensive range of presentations from hallucinations to self-harm, organized by sub-specialty area for ease of reference. Comprehensive answers highlight key take home points from each case and provide practical advice on how to deal with the challenges that occur when practising psychiatry at all levels.

Case 1: How can you assess mental state?

History

A 42-year-old woman comes into hospital for a laparoscopic cholecystectomy. The admitting doctor has concerns about her mental state. There are concerns about whether she is healthy enough to cope with an operation and the recovery from it. The doctor takes a psychiatric history.

Question

In addition to the history what assessment will give more information about this woman’s mental health, before a decision about whether to proceed with surgery or whether to ask a psychiatrist to see her?

Answer 1

The mental state examination is equivalent to the physical examination in medicine or surgery, but a different system is being examined. It takes place through observation and through probing questions designed to elicit psychopathology. It is structured and follows a procedure. It is put together with the history and investigations. The mental state examination contributes to the formulation, which is a summary of the mental health problems and their relation to other aspects of life. Formulation includes a diagnosis and may include a multi-axial diagnostic understanding (see Cases 24 and 79). Formulation uses information from the history and mental state examination to describe the three Ps: predisposing factors, precipitating factors and perpetuating factors. The mental state examination includes

Appearance: assess this woman’s appearance. Look at hygiene, clothing, hair and make-up. Do the clothes suggest any subcultural groups? Are there any signs of neglect, perfectionism or grandiosity?

Behaviour: observe behaviour throughout. Look for evidence of rapport or empathy. Are movements slow or rapid? Is she agitated or is there psychomotor retardation? Each may be a possible signal for disorder. For example, the latter may be a sign of depression, hypothyroidism or parkinsonism. Are there invasions of personal space seen in autism spectrum disorders, mania, schizophrenia and personality disorder? Does the person sit still or move about? Is the person calm, or impulsive and distractible? Is the person monitoring or watchful of anything and if so what? A spider phobic may be looking out for spiders; a person with schizophrenia may be listening to unseen voices; a person with obsessive-compulsive disorder may be carrying out rituals in relation to the environment; a person with autism spectrum disorder may be examining environmental detail.

Speech: assess the volume, flow, content, pitch and prosody of speech. A person with mania may be loud, have flight of ideas, pressure of speech and use puns. A person with schizophrenia may be ‘un-understandable’ if he or she has formal thought disorder. There may be limited speech or short answers in depression, hypothyroidism or with negative symptoms of schizophrenia. A person with autism spectrum disorder may have little communication or may speak only on one subject at length with poor conversational reciprocity.

Mood: assess what this is like subjectively and objectively. How does the person describe his or her mood and is it congruent with what you see and experience in the room? This will include questions about enjoyment, worthlessness, hopelessness, suicidality and risk (see Case 33).

Thoughts: assess content and whether there is any formal thought disorder, or evidence of rumination or intrusive thoughts. Do thoughts race as in mania? Are they negative as in depression? Are they resisted as in obsessive-compulsive disorder? Are they interfered with as in the thought passivity of schizophrenia (see Cases 16 and 42)? Assess beliefs such as delusions (see Case 16) which can occur in psychosis, dementia and organic brain damage.

Perception: assess perceptual experiences by observation and questioning. Is the person responding to the visual hallucinations of delirium tremens or organic brain disorder, or the auditory hallucinations of schizophrenia, organic illness or psychotic depression? Are perceptions heightened as when abusing certain drugs or dulled as when abusing other drugs? Are there pseudohallucinations as in bereavement? Hallucinations (see Case 16) are important markers of mental illness.

Cognitive function should be carefully assessed (see Case 64) and will uncover organic disorders or the pseudodementia of depression. Do they have capacity (see Case 73)?

Finally assess insight. Who/what do they attribute their problems to? How do they see their problems and the need for treatment?

Key Points

•Mental state examination is the equivalent of an examination of a physical system, but is an examination of the mind.

•It is more than a history. It requires careful observation.

Case 2: He doesn’t listen to me

History

A 43-year-old pharmaceutical representative has been referred by his general practitioner (GP) as he is concerned that he may be suffering from attention deficit hyperactivity disorder (ADHD). His elder son, 11, was diagnosed with ADHD at the age of 8 – the same age when he recalls developing his own symptoms.

He has been reading up about ADHD and has completed an online screening tool. He recalls being a hyperactive child – he had difficulty playing or engaging in leisure activities quietly, often spoke excessively and out of turn, was constantly fidgeting and squirming when seated in the class, would make frequent excuses to leave the classroom or when at the cinema and was generally ‘running about’ everywhere as if ‘wired to a motor’. He also recalls being quite impulsive and impatient, so much so that he had difficulty waiting in line for his turn and would blurt out responses out of turn. He remembers being disorganized and inattentive – he was easily distractible and had difficulty focusing or concentrating; he was constantly making silly errors in school work, losing things and had difficulty completing assignments on time.

His hyperactivity has calmed down over the years though he still finds it difficult to relax when doing nothing and can feel quite restless when inactive. He has changed several jobs and finds himself getting bored easily. He often comes up with ‘brilliant ideas’ in team meetings but has poor motivation in following them through. He starts many new projects but then fails to complete them. He finds it hard to carry out mundane tasks: he has never managed to claim his travel expenses and tends to become drowsy in lectures or more worryingly when driving long distances. His 360-degree feedback at work included positive comments about his inexhaustible energy and initiative but also referred to his failure to complete tasks and his tendency to talk over others or to become quite impatient and frustrated with colleagues.

At home, his wife complains that she has to mother him and that she is like his personal assistant – organizing things for him, finding things that he has misplaced and reminding him of his responsibilities. She feels particularly upset about the fact that he doesn’t listen when she is speaking to him and she has to constantly repeat what she has said to him. He has been irritable at home and his wife is contemplating a separation. He enjoys adventure sports and ‘online shopping binges’ but has periods when he gets sullen and withdrawn. He does not misuse tobacco, alcohol or any other illicit substance.

Examination

Physical examination is unremarkable. On mental state examination, he appears worried and anxious to be given a diagnosis of ADHD. His mood is euthymic but he seems fidgety during the interview. There is no thought or perceptual disturbance.

Questions

•What is the differential diagnosis?

•What treatments should you offer?

Answer 2

The clinical picture is strongly suggestive of ADHD. He reports at least five symptoms of inattention (avoiding mundane tasks, having difficulty finishing projects, losing belonging...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface
• Acknowledgements
• Case 1: How can you assess mental state?
• Case 2: He doesn’t listen to me
• Case 3: ‘Stressed’
• Case 4: Sick note
• Case 5: Checking
• Case 6: Having a heart attack
• Case 7: Going through a bad patch
• Case 8: I’m putting weight on
• Case 9: Unresponsive in the emergency department
• Case 10: Feeling Empty
• Case 11: I don’t want pills, I want someone to talk to
• Case 12: Never felt better
• Case 13: Aches and pains and loss of interest
• Case 14: Constantly tearful
• Case 15: Voices comment on everything I do
• Case 16: I only smoked a bit of cannabis and took a couple of Es
• Case 17: Unusual persecutory beliefs
• Case 18: Abdominal pain in general practice
• Case 19: There is something wrong with him
• Case 20: A drink a day to keep my problems at bay
• Case 21: Paracetamol overdose
• Case 22: Fear of spiders
• Case 23: Déjà vu and amnesia
• Case 24: Self-harming, substance misuse and volatile relationships
• Case 25: My husband won’t let me go out
• Case 26: Intensely fearful hallucinations
• Case 27: Flashbacks and nightmares
• Case 28: Unsteady gait
• Case 29: This pain just won’t go away
• Case 30: Can’t concentrate after his daughter died
• Case 31: Something’s not quite right
• Case 32: Tricyclic antidepressant overdose
• Case 33: Suicidal risk assessment
• Case 34: Suspicious and jerky movements
• Case 35: My nose is too big and ugly
• Case 36: Can I Treat Her Against Her Will?
• Case 37: Disinhibited and behaving oddly
• Case 38: What is going on in this consultation?
• Case 39: Things are getting worse
• Case 40: Diarrhoea and vomiting after irregular eating
• Case 41: Fever and confusion
• Case 42: ‘Alien impulses’ and risk to others
• Case 43: Feels like the room is changing shape
• Case 44: Unable to open my fists
• Case 45: Intense fatigue
• Case 46: Hallucinations in someone with epilepsy
• Case 47: I’m impotent
• Case 48: I love him but I don’t want sex
• Case 49: Heroin addiction
• Case 50: Exhibitionism
• Case 51: Irritable, aggressive and on a mission
• Case 52: What happens when he’s 18?
• Case 53: Thoughts of killing her baby
• Case 54: My wife is having an affair
• Case 55: A man in police custody
• Case 56: Stalking
• Case 57: An angry man
• Case 58: The treatment isn’t working
• Case 59: The drugs aren’t helping
• Case 60: Low mood and tired all of the time
• Case 61: A profoundly deaf man ‘hearing voices’
• Case 62: I am sure I am not well
• Case 63: Repeating the same story over and over again
• Case 64: Increasingly forgetful, confused and suspicious
• Case 65: Seeing flies on the ceiling
• Case 66: Cognitive impairment with visual hallucinations
• Case 67: I think my wife is poisoning my food
• Case 68: Acute agitation in a medical inpatient
• Case 69: She is not eating or drinking anything
• Case 70: A restless postoperative patient who won’t stay in bed
• Case 71: Mood changes
• Case 72: She is refusing treatment. Her decision is wrong. She must be mentally ill
• Case 73: Low mood
• Case 74: My wife is an impostor
• Case 75: Marked tremor, getting worse
• Case 76: He can’t sit still
• Case 77: Socially isolated
• Case 78: Killed his friend’s hamster and in trouble all the time
• Case 79: I only fainted: don’t fuss and leave me alone
• Case 80: Cutting on the forearms
• Case 81: Feelings of guilt
• Case 82: Intense feelings of worthlessness
• Case 83: Seeing things that aren’t there
• Case 84: She is so clingy. It’s like having a shadow
• Case 85: Soiling behind sofa
• Case 86: She won’t say anything at school
• Case 87: Checking
• Case 88: Not eating, moving or speaking
• Case 89: He’s only being friendly isn’t he?
• Case 90: Tantrums
• Case 91: He wants to be a girl
• Case 92: Blood in the urine of a healthy girl
• Case 93: Can I get the pill?
• Case 94: He doesn’t play with other children
• Case 95: Trouble in the classroom
• Case 96: Restlessness
• Case 97: A man with Down syndrome is not coping
• Case 98: Learning difficulties, behaviour problems and repetitive behaviour
• Case 99: Malaise and high blood pressure
• Case 100: Compulsive and aggressive behaviour in a man with Down syndrome
• Index