MODEL ANSWERS

Behaviour and Appearance:

Bill is a European man in his 30’s who presented unshaven with uncombed hair. His right fingers were fidgety. Eye contact was good but rapport was quite poor. He was hostile to the interviewer.

Orientation and Cognition:

Orientation and cognition were not formally tested. He, however, appeared oriented and cognitively intact.

Affect and Mood:

Affect was restricted in the angry/hostile range. It was very intense. Affect was appropriate to the content. His mood was objectively angry and irritated. Subjective mood was not asked. Neurovegetative symptoms elicited include poor sleep and concentration.

Thought Form:

He was logical and coherent. His answers to questions were goal directed.

Speech:

He had normal volume, rate and rhythm. Speech was punctuated many times with swear words.

Though Content:

Bill talked about several things which include work problems, his wife leaving him, her having an affair, fights with several people in the neighbourhood and in the store. There was no clear evidence for paranoia, phobias, obsessions and compulsions. The report on his wife having an affair could be a delusion but this was not assessed fully.

Perceptual Disturbances:

There was no evidence for hallucinations.

Insight and Judgment:

Bill is aware that his difficulties arose after his wife left him. Despite this, his insight is impaired as he does not acknowledge that he may have a psychological problem. Judgment is impaired as his recent actions have been dangerous. He has been unduly angry to people around him. He has hit his child and recently was checking out a gun shop.

Safety Concerns:

He denied having current thoughts of suicide or harm to others. However, he did admit to having thoughts of wanting to kill himself and his family. He also was recently violent towards his child.

MODEL ANSWERS

Preferred Diagnosis in Axis 1 includes Alcohol Abuse and Major Depressive Disorder.

Differential Diagnosis includes 1) rule out Alcohol Dependence, 2) Bipolar Disorder, currently depressed, 3) Major Depressive Disorder with psychotic features.

MODEL ANSWERS

Safety issues:

Bill has very high risk for harming himself and his family. He had recent altercations with his neighbours, had just hit his son, had visited a gun shop and recently thought of killing himself and his family. On examination, his anger was intense. A hospital admission is indicated. Goals for admission would be to treat his depression, and protect himself and his family. If necessary, he may need to be committed to the acute psychiatric ward. Ideally, his wife should be made aware of the risks posed by Bill towards herself and the child.

Gathering more information and establishing the diagnosis:

More information should be obtained from Bill’s wife and workmates. Information should focus on previous diagnosis, recent behaviours, alcohol use and baseline functioning. Reason for wife leaving Bill is also crucial in clarifying the issue of delusional jealousy.

Baseline medical examination is recommended. Signs and symptoms of alcohol withdrawal should be monitored.

Biopsychosocial management:

1. Though it will be difficult, the treating doctor must attempt to develop a good therapeutic relationship with Bill.

2. He should be educated regarding the working diagnosis and treatment recommendations.

3. Regarding his alcohol use, motivational interviewing is indicated. A 12 step programme like AA should be offered.

4. Cognitive behavioural therapy or Interpersonal Psychotherapy for depression is potentially helpful.

5. Medications, in particular, an SSRI antidepressant should be used first line. Side effects should be explained and monitored.

6. If he shows signs of alcohol withdrawal, an appropriate withdrawal regime should be started.

7. If it turns out that he is delusional, atypical antipsychotics should be used. ECT is also recommended for psychotic depression.

8. One should involve his family and supports in his care.