Mental health for AMC MCQ

A 22 year old man is brought in by his family, who describe eight months of increasingly odd behaviour. He believes his neighbours are broadcasting his thoughts, hears voices commenting on his actions, and has withdrawn from friends and stopped attending university. His speech is at times hard to follow. His urine drug screen is negative and his bloods are normal. What is the most likely diagnosis?

1. Psychotic depression Depression with false beliefs that match the low mood. The mood problem comes first and is the main driver. But the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen does not point to it.
2. Schizoaffective disorder Mood symptoms and psychosis happening together, each severe enough to count on its own. That does not match the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen.
3. Schizophrenia correct Correct. Eight months of false beliefs, hearing voices talking about him, jumbled thinking and flat, withdrawn mood, with drug and physical causes ruled out, is schizophrenia.
4. Bipolar affective disorder Psychosis that happens alongside a mood episode, either a high (mania) or a severe low, rather than with a clear, normal mood. Here, the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen points elsewhere.
5. Substance use disorder Psychosis brought on by stimulant drugs, cannabis, or coming off a drug. It clears up as the drug leaves the body. It does not fit the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen.

The point: Schizophrenia is a mental illness with psychosis (losing touch with what is real). It has 'positive' symptoms: false beliefs (delusions), hearing or seeing things that are not there (hallucinations), and jumbled thinking. It also has 'negative' symptoms: flat emotions, low motivation, and pulling away from others. Thinking and memory can be affected too. To diagnose it, symptoms must last at least six months, with one month of them being severe. The first time someone has psychosis, doctors must rule out other causes first, such as drugs, delirium (confusion from a physical illness), or a problem in the brain. Antipsychotic medicines are the main treatment. Newer (second-generation) antipsychotics are usually tried first, picked by their side effects. Weight gain, diabetes and high cholesterol from these medicines must be watched closely, because they are a big reason people with schizophrenia die earlier than others. Clozapine is kept for illness that has not responded to two other antipsychotics tried properly. It needs regular blood tests, because it can cause a dangerous drop in white blood cells (agranulocytosis) and heart muscle inflammation (myocarditis). Getting help early, talking therapy and family support all improve how people do. Doctors always check the risk of harm to the person or others, and remember that suicide is far more common in this illness. A long-acting injection (depot) can help when taking tablets every day is hard.

Source: RANZCP — Clinical practice guidelines for the management of schizophrenia and related disorders RANZCP · tier 2, specialty society or college

A 22 year old man is brought in by his family, who describe eight months of increasingly odd behaviour. He believes his neighbours are broadcasting his thoughts, hears voices commenting on his actions, and has withdrawn from friends and stopped attending university. His speech is at times hard to follow. His urine drug screen is negative and his bloods are normal. What is the most appropriate initial investigation?

1. Mental state examination and risk assessment correct Correct. This looks closely at his psychosis and checks his risk, which matters because suicide is common early in schizophrenia.
2. Baseline metabolic monitoring Checks weight, waist size, blood sugar and cholesterol before and during antipsychotic treatment. Here, the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen points elsewhere.
3. Collateral history Talking to family or carers helps build the timeline and shows how the person has been coping, plus any drug use. That does not match the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen.
4. Bloods and organic screen Blood tests, including a full blood count, metabolic and thyroid tests, and an infection check, to rule out a physical cause. But the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen does not point to it.
5. Neuroimaging where indicated A brain scan, done if there are unusual signs on exam, an unusual pattern of illness, or warning features in a first episode. It does not fit the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen.

The point: Schizophrenia is a mental illness with psychosis (losing touch with what is real). It has 'positive' symptoms: false beliefs (delusions), hearing or seeing things that are not there (hallucinations), and jumbled thinking. It also has 'negative' symptoms: flat emotions, low motivation, and pulling away from others. Thinking and memory can be affected too. To diagnose it, symptoms must last at least six months, with one month of them being severe. The first time someone has psychosis, doctors must rule out other causes first, such as drugs, delirium (confusion from a physical illness), or a problem in the brain. Antipsychotic medicines are the main treatment. Newer (second-generation) antipsychotics are usually tried first, picked by their side effects. Weight gain, diabetes and high cholesterol from these medicines must be watched closely, because they are a big reason people with schizophrenia die earlier than others. Clozapine is kept for illness that has not responded to two other antipsychotics tried properly. It needs regular blood tests, because it can cause a dangerous drop in white blood cells (agranulocytosis) and heart muscle inflammation (myocarditis). Getting help early, talking therapy and family support all improve how people do. Doctors always check the risk of harm to the person or others, and remember that suicide is far more common in this illness. A long-acting injection (depot) can help when taking tablets every day is hard.

Source: RANZCP — Clinical practice guidelines for the management of schizophrenia and related disorders RANZCP · tier 2, specialty society or college

A 22 year old man is brought in by his family, who describe eight months of increasingly odd behaviour. He believes his neighbours are broadcasting his thoughts, hears voices commenting on his actions, and has withdrawn from friends and stopped attending university. His speech is at times hard to follow. His urine drug screen is negative and his bloods are normal. What is the most appropriate next step in management?

1. Second-generation antipsychotic correct Correct. A newer antipsychotic, chosen by its side effects, is the first treatment for his false beliefs and hallucinations.
2. Depot antipsychotic for poor adherence A long-acting injection, used when taking tablets every day is not reliable. That does not match the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen.
3. Clozapine for treatment-resistant illness Used after two antipsychotics have been tried properly and have not worked, with blood tests to watch for a dangerous drop in white cells and heart inflammation. It does not fit the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen.
4. Metabolic monitoring and lifestyle support Weight, blood sugar and cholesterol are tracked and managed, because these drive earlier death in this group. But the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen does not point to it.
5. Treat an underlying substance or organic cause If the psychosis is caused by a drug or a physical illness, that is treated directly, rather than assuming it is schizophrenia. Here, the picture of eight months of delusions, hallucinations and withdrawal with a negative drug screen points elsewhere.

The point: Schizophrenia is a mental illness with psychosis (losing touch with what is real). It has 'positive' symptoms: false beliefs (delusions), hearing or seeing things that are not there (hallucinations), and jumbled thinking. It also has 'negative' symptoms: flat emotions, low motivation, and pulling away from others. Thinking and memory can be affected too. To diagnose it, symptoms must last at least six months, with one month of them being severe. The first time someone has psychosis, doctors must rule out other causes first, such as drugs, delirium (confusion from a physical illness), or a problem in the brain. Antipsychotic medicines are the main treatment. Newer (second-generation) antipsychotics are usually tried first, picked by their side effects. Weight gain, diabetes and high cholesterol from these medicines must be watched closely, because they are a big reason people with schizophrenia die earlier than others. Clozapine is kept for illness that has not responded to two other antipsychotics tried properly. It needs regular blood tests, because it can cause a dangerous drop in white blood cells (agranulocytosis) and heart muscle inflammation (myocarditis). Getting help early, talking therapy and family support all improve how people do. Doctors always check the risk of harm to the person or others, and remember that suicide is far more common in this illness. A long-acting injection (depot) can help when taking tablets every day is hard.

Source: RANZCP — Clinical practice guidelines for the management of schizophrenia and related disorders RANZCP · tier 2, specialty society or college