Psychiatry: Top 5 Cases
Kishwar Basith, MS4, Class of 2024
Consult information: depression and suicidal ideation
Mr. Joe Smith is a 20 y/o male with no significant PMH and substance history of
remote marijuana use presents to the ED c/o suicidal ideations x1 day.
Case 1
• He was brought to the ED by his roommate who has become concerned about his
behavior and saw a gun on his nightstand this morning. Pt denies mental health
history or any psychiatric hospitalizations.
• During the interview, he notes that 6 months ago his girlfriend of 2 years died
suddenly. Initially, he felt quite down but over the past 3 weeks he has been
experiencing the following symptoms: he has been sleeping 10-12 hours per day, has
low energy, has not been interested in working out, has noticed difficulty focusing on
studies, eating only 1-2 small meals per day. In addition, he has been feeling
depressed. He also relays that for the past week he has been hearing a voice in his
head telling him he is worthless and a failure and commanding that he kill himself.
• Of note, the patient has not been to class in 2 weeks due to “feeling too low.” He
expresses feeling at fault for the death of his girlfriend because she died in a car
accident on the way to pick up food for the two of them. The patient notes that since
the loss of his girlfriend he has occasionally wished that he were dead so that he could
be with her again. However, over the past day or so the patient states he has been
thinking about ”listening to the voice in his head and killing himself.” On further
questioning, the patient notes that yesterday evening when he went back home to
visit his family, he took the gun and ammunition from his Father’s lock box and is now
storing it in his dorm room.
• ROS is significant for weight change (loss of 10 lbs in 6 months), decreased appetite.
Otherwise negative aside from the symptoms mentioned in the HPI.
• Medical History: no significant medical history, no current medications, UTD on immunizations, NKDA
• Developmental History: full term birth, no prolonged hospitalizations during childhood/adolescence,
no noted developmental delays, reached all developmental milestones on appropriate timeline
• Psychiatric History: no significant history, no history of psychiatric hospitalization or previous suicide
attempts, does not follow with a psychiatrist or therapist
• Substance Use History: remote history of marijuana use, social alcohol use – 1-2 beers weekly, denies
use of other substances
• Family History: mother –depression, paternal uncle – opioid use disorder with 2 unsuccessful
attempts at treatment; no other history of mental illness, substance use disorder, or suicidality in
family
History
• Social History: born and raised in Detroit, MI, grew up with Mom (Eileen) and Dad (Chris), main
caretaker was Mom and a part-time nanny for about 5 years in childhood, Mom works as a high
school principal, Dad works as an engineer at Ford Motor, no siblings, describes relationship with
parents as “good but sometimes stressful due to pressure to excel”, two best friends (one at university,
one from childhood), no history of childhood trauma
• Not currently in a relationship, was in a long-term monogamous relationship (2 years) with
girlfriend (Natalie) before her death. She died 6 months ago in a car accident.
• Currently in school at Wayne State University (Junior year) – studying criminology, had a 3.95
GPA at the end of last semester, notes that this semester he has been averaging C’s on most of
his assignments/tests and has not been to class in ~2 weeks.
• No significant legal history
• No history of military service
• Currently lives on campus in a dorm (with one roommate), visits home at least once per week
because “his parents get angry if he does not see them weekly”
• Support network includes his two best friends (though he notes that one of them moved to
Texas for school and they have not had much contact in the past year) and his parents
• Hobbies include working out (he used to work out every day but has not felt up to it recently),
reading Sci-Fi
Physical
Exam
(Mental
Status
Exam)
• Appearance: 21 y/o male, appears stated age, white skin complexion, numerous freckles on
face, medium length dark blond hair and brown eyes, thin body habitus, wearing sweatpants
and wrinkled t-shirt, fair hygiene and unkempt grooming, sitting slumped in chair, facial
expression appears sad, does not look up upon interviewer entering the room
• Attitude/Behavior: cooperative but slow to answer questions, tearful throughout encounter
• Psychomotor: no psychomotor retardation or agitation
• Eye contact: poor eye contact, makes minimal eye contact with interviewer
• Movement/Tremor/Mannerisms: maintains eye contact on his lap or the floor for majority of
interview, frequently covers face with hands and adjusts hood on sweatshirt
• Speech: slow rate, monotonous rhythm with little inflections, soft volume, articulates clearly,
little spontaneity to speech – briefly answers questions without expounding
• Mood: “okay”
• Affect: stable affect, constricted range – remained sad/depressed throughout entire
conversation, overall depressed affect, appropriate to content
• Thought Content: depressive cognitions – frequently spoke of worthlessness, guilt over death
of girlfriend, and hopelessness as related to future; frequent suicidal ideations with plan and
means (firearm in dorm); no homicidal ideations; depressive delusions suggested by patient
stating on multiple occasions that he is at fault for his girlfriend’s death and that because of this
he deserves to be dead
• Thought Process: appears slowed, easily distracted and loses train of thought; but overall
coherent, logical, and goal directed
• Perceptions: does not appear to be responding to internal stimuli; however,
pt does describe an internal voice that he hears multiple times per day
telling him he is worthless, a failure, and commanding him to kill himself –
suspect command hallucinations
Physical
Exam
(Mental
Status
Exam)
Continued…
.
• Suicidal Ideations/Homicidal Ideations: suicidal ideations present –
mentioned on multiple occasions during the interview that he would be
better off dead and that he has been having thoughts of shooting himself
recently; his plan is to go home and wait until his roommate leaves to shoot
himself with his Dad’s gun; no homicidal ideations
• Orientation: awake, alert, and oriented to person, place, time, and situation
• Cognition: mild impairment of immediate and recent memories (unable to
correctly recall more than 3 digits from digit span, only able to recall 1 of 3
random object), remote memory intact
• Judgment: fair judgment as evidenced by patient’s concern that he has a
mental illness
• Insight: poor insight as evidenced by patient taking father’s firearm and not
seeking help of his own volition despite thoughts of suicide and lethal
means
Labs/Imagin
g
• CT head: unremarkable
• Labs:
• UA, CBC, CMP – all within normal limits
• Thyroid tests and urine drug screen - pending
• Based on the HPI and MSE what are 3 differential
diagnoses that fit this patient’s presentation? What is
your top differential at this time?
Differential
Diagnoses
• Major depressive episode with psychotic
features
• Schizoaffective disorder
• Prolonged grief vs normal bereavement
• If Mr. Smith’s lab work comes back with thyroid
abnormalities and positive for amphetamines, are there
other differential diagnoses you would want to add?
• Mood disorder due to a medical condition
• Substance-induced mood disorder
• If you suspect Mr. Smith has MDE/MDD, what is your management strategy?
• In the ED – assess safety of patient (self) and others, and patient’s
ability to care for themselves
• At this time, Mr. Smith is depressed, actively suicidal, has a plan in
place, and the means to complete his plan – he is NOT safe to
release home and should be placed on suicide precautions while in
the ED, 1:1 sitter, and admitted to inpatient psychiatry for further
assessment and management
Management
• Longer-term management – treatment goal is remission
• Biopsychsocial model
• Biological:
• Antidepressant (i.e. SSRI or SNRI) for depression, plus…
• Antipsychotic - because he also has psychotic features
(depressive delusions and command hallucinations)
• Psychological: psychotherapy should be combined with
pharmacological treatment
• Social: what social factors can be addressed to aid his
recovery? Family support, safe storage or getting rid of
firearms, minimize school stressors for the time being,
support from friends, physical activity, nutrition
• General Principles
• Assess/ closely monitor patients presenting with depression with psychotic
features for – suicidal ideations, suicidal plan, and psychotic symptoms that
put them at risk (i.e. auditory hallucinations commanding patient to kill
themselves)
• First line treatment
• Antidepressant plus antipsychotic
• Some combinations that have demonstrated efficacy in trials when
compared to monotherapy of antidepressants, antipsychotics, or
placebo include
Guidelines
•
•
•
•
Sertraline (Zoloft) + Olanzapine (Zyprexa)
Fluoxetine (Prozac) + Olanzapine
Venlafaxine (Effexor) + Quetiapine (Seroquel)
Other combos acceptable too
• Treat for 4-6 weeks at target drug doses before assessing effectiveness,
monitor for adverse effects and change regimen as needed
• Psychotherapy
• ECT may be used for severe presentations for patients at imminent risk of
harm, severe suicidality, or malnutrition 2/2 food refusal or
resistant/refractory to previous treatment attempts
• Depression with psychotic features resistant to treatment
• Add lithium to regimen
• Specific forms of psychotherapy – i.e. Acceptance and Commitment therapy
Case 2
• 27-year-old man in law school presents to PCP’s office d/t inc stress. Difficulty sleeping at night,
fatigues, and has muscle tension. Symptoms have been persistent over the years but have
worsened recently. Has a girlfriend and plans to get married after law school. Has been worried
about boards, school, wedding planning, and staying connected with his parents. He had a difficult
childhood, and his parents got divorced. He worries that his own marriage may end in divorce. He
worries about not landing a job and his student loans. All these stresses have prevented him from
performing as well as he wants to on his schoolwork. He denies any other psychiatric symptoms, as
well as psychiatric history or medical problems. Denies any alcohol or drug use. Denies family
history of psychiatric history.
Mental Status Exam
• Casually dressed w/ good hygiene
• Cooperative but avoids eye contact
• Appears to choke on his words, then has periods of fast but not pressured speech
• Trembling hands, and tightly crosses the fingers of both hands
• Restless, shaky, taps his foot on the floor
• Mood is reported as overwhelming
• Affect is anxious and restless
• Thought process is linear, logical, and goal directed w/ a preservation of future worries
• Thought content is focused on how he will manage all the worries of his life
• No SI or HI, and no auditory or visual hallucinations
Labs/Imaging
• UDS
• Vitals
Diagnosis
• Diagnostic Criteria for Generalized Anxiety Disorder
• Persistent, excessive, uncontrollable anxiety/worry for 6+ months
• Struggles to control the worry
• At least 3 of the following:
•
•
•
•
•
•
Disrupted Sleep
Fatigue
Impaired Concentration
Irritability
Muscle Tension
Restlessness
• Sx not better explained by another psychiatric disorder
• Not caused by direct effects of a substance or medication or medical illness
• Clinically significant distress or impairment of psychosocial functioning
Treatment
• Most effective: Two-pronged approach
• Psychotherapy: Cognitive behavioral therapy
• Identifying and changing dysfunctional thought patterns in order to positively impact one’s emotions and
behaviors
• First-line meds: SSRIs
• If no response to first one, switch to another
• Consider SNRIs or TCAs
• Full benefit can be seen after 4 to 8 weeks
• Second-line meds for augmentation: benzodiazepines, hydroxyzine, buspirone, mirtazapine
• Word of caution with benzos: addictive, sedative, cognitive impairment
• Fall risk in the elderly
• May develop tolerance and experience withdrawal or rebound anxiety
Case 3: Bipolar Disorder
• Overview:
• Mood
• Energy
• Activity
• Sleep
• Cognition
• Behavior
Definitions
• Manic episode
• ≥ 7 days
• Elevated, expansive, or irritable mood
• + ≥ 3 of:
•
•
•
•
•
•
•
Inflated self-esteem
Decreased need for sleep
Pressured speech
Flight of ideas
Distractibility
Increased goal-directed activity
Excessive risky behavior/activities
• Hypomanic episode
• Same as above except ≥ 4 consecutive days and absent significant impairment in
functioning/hospitalization
Mnemonic
• DIG FAST =
•
•
•
•
•
•
•
Distractibility
Irresponsibility
Grandiosity
Flight of ideas
Activity increase
Sleeplessness
Talkativeness
Definitions, continued
• Major depressive episode
• ≥ 2 weeks of ≥ 5 of:
•
•
•
•
•
•
•
•
•
Depressed mood
Anhedonia
Change in appetite
Feelings of worthlessness/guilt
Insomnia/hypersomnia
Diminished concentration
Psychomotor agitation/retardation
Fatigue
Suicidal ideation
• (at least one of five must be anhedonia or depressed mood)
Mnemonic 2
• SIG E CAPS =
•
•
•
•
•
•
•
•
Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicide
Bipolar I
• At least one manic episode
• Major depressive and hypomanic episodes often accompany, but are not required for diagnosis
Bipolar II
• At least one hypomanic episode AND one major depressive episode
• Absence of veritable mania required to make diagnosis
Rapid Cycling
• ≥ 4 episodes of depression, mania, or hypomania within a single year
Cyclothymia
• Persistent instability of mood with periods of depression and hypomania
• Symptoms not severe or persistent enough to diagnose bipolar
• ≥ 2 years of symptoms, present at least half the time, never absent more than 2 months at a time
Labs
• UDS
•
•
•
•
•
•
Alcohol
Phencyclidine
Amphetamine
Cocaine
Benzodiazepines
Glucocorticoids
Differential
• Bipolar I
• Bipolar II
• Cyclothymia
• Substance-/medication-induced bipolar and related disorders
• Bipolar and related disorders due to another medical condition
• Endocrine disorders (e.g., Cushing disease)
• Autoimmune disorders (e.g., MS)
• Neurologic disorders (e.g., stroke, traumatic brain injury, delirium)
Management
• Assess for suicidal ideation and acute mania
• Both require hospitalization
• Acute mania
• Lithium
• Valproic acid
• Antipsychotics (olanzapine, quetiapine, risperidone, haloperidol)
• Acute depression
• Atypical antipsychotics (quetiapine, lurasidone) PLUS mood stabilizer (lithium, valproic acid)
Management, continued
• Long-term maintenance
• Non-pharmacologic: psychotherapy (e.g., CBT)
• Pharmacologic
•
•
•
•
•
•
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Lithium
Valproic acid
Lamotrigine
Quetiapine
Aripiprazole
Olanzapine
Carbamazepine
Oxcarbazepine
• Note: antidepressants can precipitate a manic episode in those with bipolar
Case 4
• Patient is a 34-year-old woman who presents to the ED with a
chief complaint of "heart palpitations". The patient states that she
was in her living room watching tv when out of nowhere her heart
started racing. Additional symptoms include chest pain, numbness
in her fingertips, and shortness of breath. The patient states that
she "feels like she is going to die". She says she has had similar
episodes a few times in the past and that the symptoms resolve
on their own.
History
 PMH: Asthma
 PSH: C-section
 Medications: Albuterol inhaler as needed
 Allergies: Peanuts
 Immunizations: Up to date
 FH: Depression, hypertension, CAD
 Social History: smokes ½ ppd, denies any alcohol, marijuana, or any other recreational drug use.
She works at a tech company and is seated at her desk most of the day. She denies any exercise
and says she mostly eats fast food.
Physical exam
 Vital signs and general physical examination – To evaluate for hypertension, tachycardia,
diaphoresis, dyspnea
 Non-specific and such as mild tachypnea, cool, clammy skin
Labs/Imaging
 Electrocardiogram – To evaluate for arrhythmia, evidence of coronary artery disease
 Chemistry panel including calcium – To evaluate for disturbance in fluid or electrolytes
 Complete blood count with differential
 Thyroid panel – To evaluate for thyroid disorder or dysfunction
 Urine pregnancy testing individuals of childbearing age
 Toxicology screen – To assess for substances such as stimulants, opioids, sedatives (ie,
benzodiazepines), or marijuana
Differential
Myocardial Infarction
Pulmonary Embolism
Asthma exacerbation
Panic Attack
MI
• myocardial ischemia
• High risk in older men, smokers, patients with history of CAD
• Increased troponin
• electrocardiographic (ECG) changes
• chest pain, shortness of breath, new heart failure, sudden cardiac arrest, or new changes on an
electrocardiogram should have the diagnosis considered
• Chest pain > Shortness of breath
PE
• dyspnea followed by chest pain
• Cough
• DVT
• Wells score (DVT? Tachy? Immobilization? Surgery recently? Hemoptysis? Malignancy?) Tells us
about the risk of being an actual PE with 91% specificity.
• Wells score <2: Low
• >2 and <6: Moderate
• >6: HIGH
Asthma Exacerbation
• worsening asthma symptoms and lung function
• patients with a known asthma diagnosis in response to a "trigger" such as viral upper respiratory
infection, allergen, air pollution or other irritant exposure, lack of adherence to controller
medication, or an unknown stimulus
• breathlessness, wheezing, cough, and chest tightness.
Panic Disorder
 discrete episode of intense fear that begins abruptly and lasts for several minutes to an hour
 patients experience recurrent untriggered panic attacks with one month or more of worry about
future attacks, or a maladaptive change in behavior related to the attacks.
 Presents with non-specific symptoms and labs are usually normal
Management
• First line: CBT (cognitive behavioral therapy) and or/ Medication (no advantage of one over the
other although relapse less common in CBT)
• First line med: SSRIs (intubation period of 4-6 weeks)
• Patient who cannot last 4-6 weeks take long-acting benzo before bed (clonazepam). After that
period, taper down clonazepam
• If SSRIs adequate, continue for 12 months or longer
• If SSRIs inadequate and no substance use history, add clonazepam to SRI
• If SSRIs inadequate and substance use history or benzos inadequate, gabapentin, pregabalin,
nortriptyline, mirtazapine
Case 5
• 26-year-old woman in medical school with no prior psych Hx referred to your office by the dean of
students. Her friends are concerned that she has not been going to classes for over a month. Over
the past 6 months, she hasn’t been acting like herself, she’s been more withdrawn, and she doesn’t
seem to be doing as well in her classes. When her friends went to go check on her, they were
alarmed to see their apartment filthy, aluminum foil taped over all the windows, and the patient
kept telling them to leave ‘before they become targets too’. She appears disheveled as though she
hasn’t showered or brushed her hair in over a week. She’s holding a notebook to her chest with all
the ‘proof of the conspiracy’ written inside. When asked to see the notebook, you see that it is
covered in random scribbles. She reports feeling depressed because ‘they will eventually capture
her and torture her for information’. She denies changes in sleep or appetite but has been too
scared to leave her apartment to get groceries. She used to love playing basketball, but states that
she no longer has time as she needs to to ‘protect the secrets.’
Mental Status Exam
• Unkempt, poor eye contact, eyes constantly darting around the room
• Affect is blunted
• Suspicious, asking you several times if ‘you are in on it?’
• Denies hearing voices but you notice her turning to the side and mumbling
• Denies using drugs or alcohol because ‘I’ve got to stay sharp and ahead of them!’
• Denies SI and HI
Differential Diagnosis
• Substance intoxication/withdrawal
• Substance or medication induced psychosis
• Psychotic disorder d/t other medical condition
• Primary psychotic disorder
Schizophrenia Diagnostic Criteria
• 2+ of the following Sx for at least 1 month
•
•
•
•
•
Delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behavior
Negative Symptoms
• Significant social/occupational dysfunction
• Some Sx required to be present for at least 6 months, can include only negative Sx or less intense
positive Sx
• Schizoaffective disorder and mood disorder w/ psychotic features need to be ruled out
• Condition cannot be d/t a substance or another medical condition
Labs/Imaging
• USD, med history, serum drug levels, ask about OTC medications and supplements
• Screen for endocrinopathies, neurologic diseases
•
•
•
•
•
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Blood glucose
UA
CBC
CMP
TSH
Pregnancy test
Differentiate Further
• Mood disorders w/ psychotic features
• Psychosis only in the context of mood symptoms (depression/mania/mixed)
• Schizoaffective Disorder
• Psychotic symptoms occur at least 2 weeks without mood Sx
• Mood Sx must also be present for 2 weeks without psychotic Sx
• Prognosis: mood disorder w/ psychotic features, schizoaffective, schizophrenia
Important Definitions
• Active phase: presence of positive and negative symptoms
• Catatonia: a neuropsychiatric syndrome that presents w/ 3+ psychomotor Sx
• Stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, grimacing, mannerism, stereotypy,
agitation, echopraxia, echolalia
• Delusions: fixed false beliefs that lack cultural sanctioning
• Disorganized speech: expressions of thoughts lacking logical connections
• Hallucinations: false perceptions in any sensory modality w/o an external stimulus
• Auditory are most common in schizophrenia spectrum disorders, usually in the form of voices
• Ideas of reference: misinterpretation of aspects of external environment having particular
significance for the patient
• Ex: special messages from the TV or radio
Important Definitions Continued
• Negative Symptoms
•
•
•
•
•
Lack of emotional responses and thought process seen in the general population
Decreased expression of emotions
Flattening of affect
Alogia (decreased spontaneous speech)
Avolition (decreased motivation)
• Positive Symptoms
•
•
•
•
•
Symptoms experienced by the patient not experienced by others in the population
Hallucinations
Delusions
Ideas of reference
Disorganized speech and behavior
Treatment
• Holistic Approach – Psychoeducation is crucial
• Assess the patient’s home life and support system
• Provide information to their families and loved ones, and how to manage
• Case manager, local community resources
• Craft medication regimens tailored to the patient
• Atypical antipsychotics: less side effects, increased efficacy w/ negative symptoms
• General side effects: metabolic syndrome
• Clozapine is most effective BUT is only used after failed trials of two other medications
• Agranulocytosis
• Olanzapine
• Typical Antipsychotics: higher chance of extrapyramidal symptoms (akathisia, dystonias, parkinsonism)
• Hyperprolactinemia, tardive dyskinesia
• Neuroleptic malignant syndrome: AMS, fever, dysautonomia, muscle rigidity