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 He believes his neighbours are broadcasting his thoughts, hears voices commenting on his actions, and has withdrawn from friends and stopped attending university.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 mood-congruent delusions, distinguished by the primacy of the mood disturbance. Eight months of delusions, hallucinations and withdrawal with a negative drug screen argues for a mood focus.
2. Schizoaffective disorder Concurrent mood and psychotic symptoms meeting criteria for both. Eight months of delusions, hallucinations and withdrawal with a negative drug screen suggests it.
3. Schizophrenia correct Correct. Eight months of delusions, third-person auditory hallucinations, thought disorder and negative symptoms, with organic and drug causes excluded, is schizophrenia.
4. Bipolar affective disorder (including mania/hypomania) Psychosis in the context of a mood episode, mania or severe depression, rather than in clear consciousness. Eight months of delusions, hallucinations and withdrawal with a negative drug screen points to it.
5. Substance use disorder Psychosis induced by stimulants, cannabis or withdrawal, which resolves as the drug clears. Eight months of delusions, hallucinations and withdrawal with a negative drug screen makes a drug history essential.

The point: Schizophrenia is a psychotic disorder with positive symptoms of delusions, hallucinations and thought disorder, negative symptoms of blunted affect, avolition and social withdrawal, and cognitive impairment, persisting for at least six months with a month of active symptoms. A first episode of psychosis needs organic and drug-induced causes excluded, including substance use, delirium and an intracranial cause. Antipsychotics are the mainstay: second-generation agents are usually first-line, chosen by their side-effect profile, and the metabolic effects of weight gain, diabetes and dyslipidaemia must be monitored because they drive the reduced life expectancy in this group. Clozapine is reserved for treatment-resistant illness, meaning failure of two adequate antipsychotic trials, and it requires monitoring for agranulocytosis and myocarditis. Early intervention, psychological therapy and family support improve outcomes. Assess risk to self and others, and remember the markedly raised suicide rate. Depot antipsychotics help where adherence is poor.

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. It characterises the psychosis and assesses his risk, which matters because the suicide rate in early schizophrenia is high.
2. Baseline metabolic monitoring Weight, waist, glucose and lipids before and during antipsychotic treatment. Eight months of delusions, hallucinations and withdrawal with a negative drug screen makes it essential.
3. Collateral history Family or carer accounts clarify the timeline, function and substance use. Eight months of delusions, hallucinations and withdrawal with a negative drug screen makes it necessary.
4. Bloods and organic screen Full blood count, metabolic and thyroid tests and infection screen to exclude organic causes. Eight months of delusions, hallucinations and withdrawal with a negative drug screen makes it routine.
5. Neuroimaging where indicated For focal signs, an atypical presentation or a first episode with red flags. Eight months of delusions, hallucinations and withdrawal with a negative drug screen indicates it.

The point: Schizophrenia is a psychotic disorder with positive symptoms of delusions, hallucinations and thought disorder, negative symptoms of blunted affect, avolition and social withdrawal, and cognitive impairment, persisting for at least six months with a month of active symptoms. A first episode of psychosis needs organic and drug-induced causes excluded, including substance use, delirium and an intracranial cause. Antipsychotics are the mainstay: second-generation agents are usually first-line, chosen by their side-effect profile, and the metabolic effects of weight gain, diabetes and dyslipidaemia must be monitored because they drive the reduced life expectancy in this group. Clozapine is reserved for treatment-resistant illness, meaning failure of two adequate antipsychotic trials, and it requires monitoring for agranulocytosis and myocarditis. Early intervention, psychological therapy and family support improve outcomes. Assess risk to self and others, and remember the markedly raised suicide rate. Depot antipsychotics help where adherence is poor.

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 second-generation antipsychotic chosen by side-effect profile is first-line for his positive symptoms.
2. Depot antipsychotic for poor adherence A long-acting injectable where oral adherence is unreliable. Eight months of delusions, hallucinations and withdrawal with a negative drug screen makes it practical.
3. Clozapine for treatment-resistant illness After two adequate antipsychotic trials fail, with monitoring for agranulocytosis and myocarditis. Eight months of delusions, hallucinations and withdrawal with a negative drug screen makes it the escalation.
4. Psychological therapy and family intervention Cognitive therapy and family support reduce relapse alongside medication. Eight months of delusions, hallucinations and withdrawal with a negative drug screen makes it complementary.
5. Treat an underlying substance or organic cause Where the psychosis is drug-induced or organic, that is addressed rather than assuming schizophrenia. Eight months of delusions, hallucinations and withdrawal with a negative drug screen redirects it.

The point: Schizophrenia is a psychotic disorder with positive symptoms of delusions, hallucinations and thought disorder, negative symptoms of blunted affect, avolition and social withdrawal, and cognitive impairment, persisting for at least six months with a month of active symptoms. A first episode of psychosis needs organic and drug-induced causes excluded, including substance use, delirium and an intracranial cause. Antipsychotics are the mainstay: second-generation agents are usually first-line, chosen by their side-effect profile, and the metabolic effects of weight gain, diabetes and dyslipidaemia must be monitored because they drive the reduced life expectancy in this group. Clozapine is reserved for treatment-resistant illness, meaning failure of two adequate antipsychotic trials, and it requires monitoring for agranulocytosis and myocarditis. Early intervention, psychological therapy and family support improve outcomes. Assess risk to self and others, and remember the markedly raised suicide rate. Depot antipsychotics help where adherence is poor.

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