AKT – Mental health (Psychiatry)

Benjamin Adams, aged 27, presents with a 6-week history of low mood, anhedonia, early morning wakening, poor appetite and difficulty concentrating at work. He denies any psychotic features or suicidal ideation. He has no history of mood disorders and no family history of psychiatric illness. He drinks socially on weekends and does not use recreational drugs.

He is not on any medications and has no allergies. There is no significant past medical history.

On examination, he appears subdued with poor eye contact. Physical examination is unremarkable.

What is the most appropriate initial management?

Lucinda Ng, aged 34, presents with 2 months of intrusive thoughts about harming her child, which she finds distressing and out of character. She reports frequently checking that her child is safe, and avoids being alone with them due to fear she might lose control. She has insight and feels ashamed of her thoughts. She has no history of psychiatric illness.

She is not taking any medications. Past history unremarkable.

Mental state examination shows an anxious woman with no evidence of psychosis. Thought content reveals intrusive ego-dystonic thoughts.

What is the most likely diagnosis?

Colin Freeman, aged 76, is brought in by his daughter due to increasing forgetfulness and difficulty managing his finances. He has become more withdrawn and recently got lost walking to the local shop. There is no history of stroke or major medical illness.

He takes perindopril for hypertension. No allergies.

On examination, he is pleasant but struggles with recall. GPCOG score is 5/9.

What is the most appropriate next step in management?

Maria Velasquez, aged 21, presents with a panic attack at university. She reports several episodes over the past month with palpitations, chest tightness, dizziness and a fear of dying. Symptoms resolve within 20 minutes. She has started avoiding lectures. She denies substance use or medical conditions.

Her examination and ECG are normal. Thyroid function is normal.

What is the most appropriate next step in management?

Peter Rawlins, aged 48, presents with alcohol dependence. He drinks approximately 12 standard drinks daily and has done so for several years. He reports morning tremors that are relieved by alcohol. He has had previous unsuccessful attempts to quit. No seizures or delirium tremens in history. He is willing to attempt outpatient withdrawal with support.

Physical exam reveals a tremor but is otherwise normal. LFTs show mild derangement.

What is the most appropriate pharmacotherapy for withdrawal in this setting?

Kylie Hassan, aged 17, presents with self-harming behaviour over the past month. She reports cutting her arms superficially after arguments with her parents. She denies suicidal ideation and states it helps her feel in control. She has a history of bullying at school and poor self-esteem. No substance use. She is not currently seeing a counsellor.

Mental state examination reveals a flat affect but good eye contact. There are multiple superficial cuts noted on both forearms.

What is the most appropriate next step in management?

James Tran, aged 59, presents with chronic insomnia. He has difficulty falling asleep and wakes multiple times overnight. This has been ongoing for 8 months. He denies depression or anxiety but describes ongoing stress at work. He drinks 2–3 glasses of wine most evenings and often checks his phone in bed. He has tried over-the-counter sleep aids without success.

Physical exam and screening blood tests are normal.

What is the most appropriate initial management?

Meena Ramesh, aged 35, presents with tearfulness, guilt and low self-worth two weeks after giving birth to her first child. She reports poor sleep and anxiety about her baby’s health despite normal checks. She says she feels like a bad mother and cries daily. She has support at home but feels isolated. No suicidal ideation or psychotic symptoms.

On examination she is tearful but engaged. Baby appears well cared for.

What is the most appropriate next step?

Ahmed Noor, aged 44, presents with ongoing irritability, nightmares, and hypervigilance following a workplace assault 4 months ago. He avoids the site of the assault and has become socially withdrawn. These symptoms are affecting his work and family life. He has no prior psychiatric history and denies suicidal ideation. He has not sought any counselling to date.

Mental state examination shows guarded affect and anxious mood. No psychotic features.

What is the most likely diagnosis?

Eliza Connors, aged 63, is brought in by her husband who is concerned about her low mood and decreased interest in activities since retirement 6 months ago. She sleeps poorly, has low energy, and has lost 5 kg unintentionally. She denies suicidal ideation but says she feels she has ‘nothing to look forward to’. No previous mental health history.

Past medical history includes hypertension and osteoarthritis. She takes amlodipine.

Mental state examination reveals a flat affect and minimal speech.

What is the most appropriate initial management?

Samuel Joyce, aged 40, presents with concerns about his gambling. He reports betting on sports apps daily and has started borrowing money from family to cover debts. He has lost over $10,000 in the past 3 months. He feels unable to stop despite multiple attempts. He denies substance use or depressive symptoms. He is employed full time.

He requests help but does not want medication.

What is the most appropriate management option?

Helen Vukovic, aged 71, presents with recent onset visual hallucinations of ‘children playing in the yard’ which she recognises are not real. She has a 10-year history of Parkinson’s disease and takes levodopa/carbidopa and pramipexole. No history of cognitive impairment or psychiatric illness. Examination reveals bradykinesia and postural instability.

What is the most appropriate next step in management?

Ashleigh Moore, aged 29, presents with rapid mood swings, impulsive spending, and three recent sexual partners within the past week. She feels euphoric and is sleeping only 2–3 hours a night but does not feel tired. Her speech is pressured. She has no known psychiatric history. She denies substance use.

What is the most appropriate initial management?

Gurpreet Singh, aged 52, is referred by his cardiologist after expressing anxiety during rehab. He reports persistent worry about his health and family, difficulty concentrating, and muscle tension. Symptoms have been present for over 6 months. He sleeps poorly and often feels restless. No panic attacks or depressive symptoms are reported.

What is the most likely diagnosis?

Layla Atkinson, aged 22, presents with disorganised speech, odd behaviour and social withdrawal over the past month. Her flatmates report she believes she is being watched through her phone. She has poor sleep and has stopped attending university. She has no past psychiatric history or drug use.

On mental state exam, she is guarded and gives tangential answers. There is no evidence of mood disorder.

What is the most likely diagnosis?

Daniel Curran, aged 50, presents at the request of his wife due to personality changes over the past year. He has become disinhibited, apathetic, and lacks empathy. He recently made an inappropriate sexual comment to a neighbour. His memory appears intact and he manages his finances without difficulty. No psychiatric history or substance use.

Mental state exam shows flat affect and poor social insight. MMSE is 29/30.

What is the most likely diagnosis?

Emily Zhao, aged 32, presents with excessive handwashing and showering for the past 6 months. She spends several hours daily on these behaviours due to a fear of contamination. She recognises the behaviours are excessive but cannot resist them. She is otherwise well and has no other psychiatric history.

What is the most appropriate initial treatment?

Marcus El-Nour, aged 37, presents after his family noticed he has become withdrawn and suspicious. He believes his neighbours are spying on him and controlling his thoughts through the TV. He has no insight into these beliefs. There is no known substance use. This is his first presentation to a GP for mental health concerns.

What is the most appropriate next step?

Claudia Dimitriou, aged 62, presents with difficulty concentrating, low energy, and tearfulness for several months. She has also experienced occasional headaches, poor sleep, and reduced appetite. Her husband recently died, and she feels life is meaningless. She denies suicidal ideation. No past psychiatric history. No medical comorbidities.

What is the most appropriate management?

Victor Hanson, aged 47, presents with agitation, insomnia, and increased energy. He claims he has discovered a cure for cancer and has been emailing the health minister daily. His speech is pressured and he becomes irritable when interrupted. He has not slept for 3 days. No history of mental illness.

What is the most likely diagnosis?

Nicole Benson, aged 25, presents reporting persistent feelings of being detached from herself and her surroundings. She describes feeling like she’s watching her life from outside her body. These symptoms worsen under stress. She has a history of childhood trauma but no substance use. No psychosis or mood symptoms are evident.

Mental state exam is unremarkable except for blunted affect and vague speech.

What is the most likely diagnosis?

David King, aged 45, presents with low mood, fatigue and poor sleep over the past 3 months. He was recently diagnosed with type 2 diabetes and says he feels overwhelmed. He reports poor concentration and appetite but no suicidal ideation. He has never had counselling or psychiatric treatment before.

What is the most appropriate initial management?

Jessica Tan, aged 19, presents with concerns about body image and low weight. She restricts food intake and exercises excessively. Her BMI is 16.5 kg/m². She denies binge eating or purging but is preoccupied with being ‘fat’. Menses have been absent for 4 months. Blood tests show mild hypokalaemia.

What is the most likely diagnosis?

Pauline Stewart, aged 66, presents with confusion, visual hallucinations and fluctuating cognition. Her daughter reports episodes of unresponsiveness alternating with agitation. She has a shuffling gait and mild resting tremor. CT brain shows mild generalised atrophy. Blood tests are normal.

What is the most likely diagnosis?

Travis O’Shea, aged 28, presents following a breakup. He describes feeling abandoned and has made multiple threats of self-harm to his ex-partner. His mood fluctuates rapidly from anger to despair. He reports feeling empty and has impulsively quit his job. There is no history of psychosis.

What is the most likely diagnosis?

Natalie Roach, aged 39, presents with excessive worry about multiple life areas including work, finances, and her children. She reports muscle tension, restlessness, and trouble sleeping. These symptoms have persisted for over 6 months and affect her daily functioning. She denies panic attacks or depressive symptoms.

What is the first-line pharmacological treatment?

Leo Thompson, aged 22, presents with a 2-year history of cannabis use. He now reports hearing voices commenting on his actions and believes the television is sending him secret messages. He has become socially withdrawn and stopped attending university. No family history of psychiatric illness.

What is the most likely diagnosis?

Helen Carter, aged 68, presents with persistent low mood and poor sleep since her husband passed away 7 months ago. She reports passive suicidal ideation and feelings of worthlessness. She has lost 6 kg unintentionally. She says, ‘There’s no point in anything anymore.’

What is the most appropriate next step?

Thomas Gilbert, aged 14, is brought in by his mother due to school refusal, irritability, and excessive video gaming. He reports being bullied and has trouble sleeping. He admits to feeling hopeless and recently searched online about suicide methods, though has not made any plans. There is no previous psychiatric history.

What is the most appropriate next step?

Ella Ryan, aged 61, presents requesting benzodiazepines for ‘nerves’. She has been taking diazepam intermittently for 8 years, currently using 5 mg daily. She reports poor sleep, occasional palpitations, and generalised anxiety. She is reluctant to consider counselling or antidepressants.

What is the most appropriate next step?

Katrina Pham, aged 31, presents with ongoing nightmares, intrusive thoughts, and flashbacks of a car accident she survived 8 months ago. She avoids driving and becomes hypervigilant when in traffic. She has not sought previous psychological support. There is no suicidal ideation.

What is the most appropriate first-line psychological intervention?

Jordan Ellis, aged 57, presents with persistent low mood and fatigue for several months. His wife reports he has become socially withdrawn and irritable. He denies sadness, but admits to feeling ‘numb’. He has reduced appetite, poor sleep and has lost interest in hobbies. No suicidal ideation.

What is the most likely diagnosis?

Renee Delgado, aged 36, presents with fear of public speaking and social interactions. She avoids work meetings and has turned down a promotion due to anxiety. She describes palpitations, sweating, and blushing during social events. Symptoms have been present since her late teens.

What is the most appropriate pharmacological treatment?

Lucas Petrou, aged 42, presents after his employer raised concerns about erratic behaviour. He reports feeling unusually energetic, talking more than usual and sleeping only 3 hours a night. He has spent $8,000 on online courses and says he plans to start five businesses. There is no psychosis or suicidality.

What is the most likely diagnosis?

Felicity Wu, aged 25, presents after a breakup. She reports feeling sad, sleeping poorly, and losing interest in university work. Symptoms began 5 days ago. She denies suicidal ideation and has support from friends. She has no psychiatric history and no physical complaints.

What is the most appropriate management?

Stephen Mok, aged 34, presents requesting a refill of olanzapine 10 mg which he has been taking since a hospital admission 1 year ago for auditory hallucinations. He has been stable since, working part-time and living independently. He is unsure how long he needs to remain on medication.

What is the most appropriate advice?

Liam Foster, aged 19, presents with sudden-onset chest pain, dizziness, and tingling in his hands. He thought he was dying. The episode lasted 20 minutes and resolved spontaneously. He has had 3 similar episodes in the past month. Cardiac and respiratory evaluations have been normal.

What is the most likely diagnosis?

Angela D’Souza, aged 46, has a longstanding diagnosis of major depressive disorder. Despite adequate trials of SSRIs and SNRIs, her symptoms persist. She sleeps poorly, has low energy, and experiences significant functional impairment. She is not suicidal.

What is the most appropriate next step?

Chloe Stephenson, aged 9, is brought in due to ongoing difficulty paying attention in class, forgetfulness, and fidgeting. Her teacher reports she is often distracted and doesn’t complete tasks. At home, she loses things and frequently interrupts conversations. These behaviours have been present for over 6 months in both settings.

What is the most likely diagnosis?

Martin Greaves, aged 55, presents with difficulty falling asleep and early morning waking since being made redundant 3 months ago. He reports low mood, reduced appetite, and loss of interest in hobbies. He drinks alcohol nightly to help with sleep. No suicidal ideation is present.

What is the most appropriate initial management?

Antonia Russo, aged 44, presents requesting help to stop drinking. She has 8–10 standard drinks daily and experiences tremors and anxiety in the morning. She drinks to avoid withdrawal. She has no seizures or past detox attempts. She is otherwise physically well and motivated for change.

What is the most appropriate next step?

Michael Youssef, aged 24, presents with difficulty forming relationships and a belief that others are out to harm him. He has few friends, avoids social events, and has odd speech patterns. He denies hallucinations but believes in telepathy. He is unemployed and lives with his parents.

What is the most likely diagnosis?

Yasmin Khan, aged 63, is brought in by her son who is concerned about memory lapses and word-finding difficulties over the past year. She has become more irritable and once got lost walking to the local shops. She is independent in daily activities. MMSE score is 25/30.

What is the most appropriate initial investigation?

George Tasiopoulos, aged 58, has schizophrenia and lives in supported accommodation. He has been stable on clozapine for 4 years. He presents with fever, sore throat and fatigue. On exam: temp 38.4°C, HR 98 bpm. You order a full blood count.

What result would necessitate urgent cessation of clozapine?

Ayesha Mahmood, aged 30, presents with anxiety and frequent visits to multiple doctors. She believes she has a serious illness despite normal investigations. She is fixated on the idea of bowel cancer despite colonoscopy 6 months ago showing no abnormalities. She checks her body for lumps daily and researches symptoms online for hours.

What is the most likely diagnosis?

Gavin Reynolds, aged 62, presents after his partner noticed he speaks slowly and shows little expression. He has been sleeping excessively and feels physically heavy. He denies sadness but says he is unable to enjoy anything. These symptoms began 6 weeks ago and affect his ability to function.

What is the most likely diagnosis?

Sarah Ling, aged 48, presents requesting help managing stress at work. She reports feeling tense, irritable and unable to relax. She has no significant past medical history. On further questioning, she describes episodes of sweating, palpitations, and trembling in social situations, especially when presenting to clients.

What is the most appropriate non-pharmacological first-line management?

Tamara Brooks, aged 35, presents after her GP noticed elevated liver enzymes. She admits to drinking a bottle of wine most nights and finds it difficult to stop. She denies withdrawal symptoms but feels guilty about her drinking. She has a history of anxiety and uses alcohol to cope.

What is the most appropriate pharmacotherapy to support alcohol abstinence?

Oscar Nguyen, aged 29, presents after being suspended from work due to erratic behaviour. He believes he can communicate with aliens through his phone and that he has a special mission. He is animated and dismissive of concerns. He has no prior psychiatric history and is not using substances.

What is the most appropriate next step in management?

Rita Holden, aged 76, presents with tearfulness and poor appetite since entering residential aged care 3 months ago. Staff report she is socially withdrawn and has lost 4 kg. She denies suicidal ideation and has no cognitive impairment. No previous psychiatric history.

What is the most appropriate next step?