Saturday, 30 July 2016

Morphine paradoxically prolongs neuropathic pain in rats by amplifying spinal NLRP3 inflammasome activation

Opioid use for pain management has dramatically increased, with little assessment of potential pathophysiological consequences for the primary pain condition. Here, a short course of morphine, starting 10 d after injury in male rats, paradoxically and remarkably doubled the duration of chronic constriction injury (CCI)-allodynia, months after morphine ceased. No such effect of opioids on neuropathic pain has previously been reported. Using pharmacologic and genetic approaches, we discovered that the initiation and maintenance of this multimonth prolongation of neuropathic pain was mediated by a previously unidentified mechanism for spinal cord and pain-namely, morphine-induced spinal NOD-like receptor protein 3 (NLRP3) inflammasomes and associated release of interleukin-1β (IL-1β). As spinal dorsal horn microglia expressed this signaling platform, these cells were selectively inhibited in vivo after transfection with a novel Designer Receptor Exclusively Activated by Designer Drugs (DREADD). Multiday treatment with the DREADD-specific ligand clozapine-N-oxide prevented and enduringly reversed morphine-induced persistent sensitization for weeks to months after cessation of clozapine-N-oxide. These data demonstrate both the critical importance of microglia and that maintenance of chronic pain created by early exposure to opioids can be disrupted, resetting pain to normal. These data also provide strong support for the recent "two-hit hypothesis" of microglial priming, leading to exaggerated reactivity after the second challenge, documented here in the context of nerve injury followed by morphine. This study predicts that prolonged pain is an unrealized and clinically concerning consequence of the abundant use of opioids in chronic pain.

Full text

Wednesday, 27 July 2016

Report- Clinico-pathological Conference on Liaison Psychiatry

The Institute of Psychiatry, Benazir Bhutto Hospital, World Health Organization Collaboration Centre, organised a Clinico-Pathological Conference (CPC), on the theme of Liaison Psychiatry, at the New Teaching Block, Rawalpindi Medical College, on the 27th of July 2016. The CPC sought to appraise the medical students, psychologists, and various physicians and surgeons in attendance, about the intricate relationship between the various disciplines of health care.

The proceedings ensued, with Dr Yousaf Raza reciting from the Holy Qur’an and welcoming the attendees on behalf of the Institute. He introduced the audience to the layout of the presentations and the theme at hand. Dr Sundus Fatima, Academic Registrar at the Institute, then took the stage to present the first case history. She gave a detailed history of a 13-year-old girl who developed psychiatric complications as part of post-encephalitic sequelae; depressive and dissociative symptoms. In addition, she also had pica. She’d had a disturbed childhood marred by inter-parental conflicts and the inability of her mother to respond to her emotional needs.

Dr Ayesha Minhas, Assistant Professor of Psychiatry and Head of the Child Psychiatry Unit at the Institute, was then called up on stage to discuss and elaborate upon the case presented by Dr Sundus. She began her presentation by alluding to the historical background of psychiatry stating that it owes its origins to the philosophy of Rene Descartes and his separation of the mind and body; originally seen by neurologists, we saw psychiatric disorders as separate entities demanding a separate speciality in the aftermath of Cartesian philosophy. She highlighted that an expanding collection of causes, from head trauma, stroke, tumor, demyelination and many others cause symptom complexes that overlap with classic psychiatric disorders. More recently, she said, neuro-inflammatory and immunological abnormalities have been documented in patients with classical psychiatric disorders. She briefly described encephalitis as an acute inflammation of the brain caused by viruses. Occasionally, she said, it may present with psychiatric manifestations. She then elaborated upon depression and dissociation with particular emphasis on their interrelation. She spoke about the dissociation as the process by which we move thought, feelings, and information out of awareness as a human defence mechanism. Depression, she said, triggers dissociative coping, and dissociative coping allows depression to gain momentum. Dissociation and depression exacerbate each other! She also shed light on pica; persistent ingestion of nonnutritive substances for at least 1 month at an age for which this behaviour is developmentally inappropriate. She spoke about how pica might result from a specific nutrient deficiency and also of its relationship to OCD. She concluded by discussing the management of the case, specifically highlighting the importance of maintaining a liaison with the physicians for a follow-up on her encephalitis. They discussed the need for antidepressants in the case with family therapy. In the end, Dr Ayesha alluded to the possibility of a merger between neurology and psychiatry with the advances in neuroscience.

Dr Ayesha Nasir presented the next case, a first-year trainee at the Institute. She spoke about a patient who suffered a head injury and presented to the ER with vomiting and abdominal pain a day later. Surgery, medicine, ophthalmology, psychiatry, gynaecology saw her and finally passed away in the medical ICU. The physicians and surgeons initially thought her overturned hands and feet to be a case of conversion disorder. However, her deranged vitals and labs showed serious physical problems.

Dr. Asad Nizami, Assistant Professor of Psychiatry at the Institute, then took up the discussion of the case. He too began his presentation with a detour to the history of psychiatric illnesses. He alluded to the French neurologist Jean-Martin Charcot and his description of conversion symptoms. Dr Nizami alluded to the fact that usually a patient presenting in the ER with behavioural symptoms is assumed to be suffering from a psychiatric ailment without consideration that there are multiple organic problems that might present with behavioural issues. He went to detail conversion disorder as a presentation of neurological or medical symptoms that can’t be traced to a neurological or medical aetiology. He enlisted various sensory and motor symptoms for conversion. He highlighted the importance of identifying a psychological cause for a definitive diagnosis. Dr Nizami alluded to a study that showed how patients diagnosed with conversion disorder followed for a 9-year period was diagnosed with organic disease. Another study showed that 11.5 % of patients diagnosed with conversion disorder actually had neurological disorders and a systematic review showed a decline in the mean rate of misdiagnosis from the 1950s to the present day.

Prof. Fareed A. Minhas, Head of the Institute & Professor of Psychiatry, then took the stage and presented his paper published in the British Journal of Psychiatry on the development of psychiatric services in Pakistan. The study was a longitudinal descriptive survey presented to the consultation-liaison psychiatry service provided by the Institute of Psychiatry they evaluated to teaching hospitals in Rawalpindi during the first two years of its functioning. He described how the liaison registers are meticulously maintained and all cases seen by on-call trainees are discussed in detail in every morning meeting. He raised the concern that of the three teaching hospitals associated with RMC, only BBH had a psychiatric service and 96 % of the referrals were from the BBH Emergency; how are the psychiatric patients presenting to the other two hospitals being dealt with, he asked. The second highest referral rate, after the emergency, was from the medical unit. This illustrates, he said, the importance of the people working in those departments to have an experience in psychiatry and be cognisant of its nuts and bolts to efficiently identify psychiatric illnesses from organic illnesses. He also highlighted an alarming fact that we may ignore a lot of the medical and surgical problems in those departments if a presumptive suggestion of a psychiatric illness is made by the attendants or the patient. He appreciated the efforts of CPSP in mandating neurology and medicine trainees to rotate for three months in psychiatry and proposed that paediatric trainees do the same in child psychiatry seconding Prof. Rai Asghar’s suggestion, which he gave at an earlier symposium. Similarly, he said, the rotations of psychiatric trainees in the medicine and neurology department are equally important. Prof. Minhas closed the session with a vote of gratitude to all those in attendance.

This CPC provided the audience with an excellent overview of liaison psychiatry in Pakistan. The case histories presented provided the pragmatic challenges in the field. In the end, the most important message delivered was to build bridges between specialities by understanding the other more for the benefit of the patients.

Report prepared by Dr Yousaf Raza, Post-Graduate Resident at the Institute of Psychiatry.

Friday, 22 July 2016

Most Common Cause of Excessive Daytime Sleepiness

Most Common Cause of Excessive Daytime Sleepiness

What is the most common cause of excessive daytime sleepiness?

Sleep deprivation
Drug effects

Comments: If u mean "Jet lag" from sleep deprivation, then the common cause is narcolepsy. It really depends on age. In children the most common cause is nightmares, in young people it can both be a psychiatric disorder or a manifestation of their daytime routine, in middle age and elderly it is mostly Obstructive Sleep Apnea Syndrome.

Correct Answer: 
Sleep deprivation

Alcoholics may have impaired performance on cognitive tasks:

Alcoholics may have impaired performance on cognitive tasks especially (name the cognitive domain) ?


Salma Sultan; Euphoria

Abbas Sepah; Memory

Samra Kyinat; Attention n concentration,perception

Sheikh Anzi; Executive functioning planning reasoning decision making judgment all associated with pre frontal lobe

Correct Answer:

executive functioning is the correct answer.

Parents with Low intelligence has higher risk of abusing their child:

Parents with low intelligence have a higher risk of abusing their child?

True or false


Afshan Malik; True,,,,it also depends on families background and culture...families with upper class can also abuse their children...

Mehdi Intisar; False it more relay on environmental circumstances

Abbas Sepah; True but a few of them has proved to be very caring if social support is present otherwise your statement is True

Correct Answer:

Ok yes it true. Please note that risk factor is just a risk factor. It does CAUSE ANYTHING. it increases the chance, just that

Tuesday, 19 July 2016

Incidence of down syndrome decreased:

Why has the incidence of down syndrome decreased ?


Sanam Munir; It has..coz of perinatal tests available to detect it.. n early termination of pregnancy

Immo Mani; Yes,prenatal tests during pregnancy

Correct Amswer:

Correct detection through amniocentesis and then subsequent termination of pregnancy and its 1 in 650 live births.

Temperament, people with down syndrome:

What kind of temperament do people with down syndrome have ?


Immo Mani; Mild

Correct Answer:

Placid temperament

Learning disability in down syndrome:

Learning disability in down syndrome is

  1. Mild to moderate

  2. Moderate to severe

  3. Severe to profound

  4. Moderate

 Correct Amswer:

 Moderate to severe

Fastest growth of IQ of down syndrome:

Fastest growth of IQ of down syndrome occur at the age of

a) First six months
b) 6 months to 1 year
c) 1 to 2 years

Correct Answer:

6 month to 1 year

Inflammation on Contrast enhanced CT:

Inflammation on Contrast enhanced CT appears

  1. White

  2. Black


Sarmad Mushtaq; Black

Correct Answer:

Contrast agents enter areas of inflammation or tumors well. more quantity of contrast agent means more quantity of radiation being absorbed, which in turn make areas of inflammation bright appearing on CT scan.

MRI pulses create images similar to CT:

Which MRI pulses create images similar to CT


Correct Answer:

T1 images is the correct answer. T1 pulses are brief and the data is collected for brief amount of time. Areas with high hydrogen in hydrophillic environment appear Dark.

e.g. CSF. Fat tissue on the other hand appear dark. T1 is also the only MRI technology that can be enhanced by contrast agent Gadolinium.

Difference between Flight of ideas & Pressure of thoughts:

What is the difference between flight of ideas and pressure of thoughts.


Abbas Sepah; This usually is used in the same context but I think Flight of ideas is related with abnormality of thoughts while the other is abnormality of speech

Sanam Munir; flight of ideas as seen in mania.. there is a continuous stream of thoughts or ideas going from one to another.. while pressure of thoughts I believe is that the person can not say everything thy want to..

 Correct answer:

 Pressure of thoughts is considered a disorder of stream of thoughts. Ideas passing through the mind quickly and in abundance. If the patient speaks them as they come, it is then known as pressure of speech. Flight of ideas is considered a disorder of form of thought. The basic error is that patient is jumping from topic to topic, which are connected to each other.

Sunday, 17 July 2016

Friday, 15 July 2016

Most common themes of obsessions Mneomonic


  • R     Religion

  • O     Orderliness

  • S     Sex

  • I      Illness

  • D    Dirt and contamination 

  • A    Aggression

Wednesday, 13 July 2016

Tourette Syndrome

Tourette Syndrome

Clinical features

>> Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.

  • Multiple vocal and motor tics 
  • Starting before the age of 18 and 
  • Persisting for a duration of at least one year
  • We have excluded other causes of tics.
Learning difficulties 
Social problems 
Emotional disturbances

Maudsley Prescribing Guidelines (13th Edition) 

They recommend alpha-2 agonists such as Clonidine or Guanfacine as the first-line pharmacological treatment for Tics and Tourette Syndrome 

American Family Physicians and Canadian Guidelines

Antipsychotics possess a variety of serious adverse effects (Pringsheim et al., 2012) and even though the evidence base for them is strong, we use them in cases not responding to alpha-2 agonists.


  1. Taylor, D. (2018). The Maudsley Prescribing Guidelines. The Maudsley Prescribing Guidelines. 
  2. Kenney, C., Kuo, S.-H., & Jimenez-Shahed, J. (2008). Tourette’s syndrome. American Family Physician, 77(5), 651–658. Retrieved from
  3. Pringsheim, T., Doja, A., Gorman, D., McKinlay, D., Day, L., Billinghurst, L., … Sandor, P. (2012). Canadian Guidelines for the Evidence-Based Treatment of Tic Disorders: Pharmacotherapy. The Canadian Journal of Psychiatry, 57(3), 133–143. 

Cognitive Deficits in Multiple Sclerosis

Impairment of learning, abstraction, memory, and problem-solving occur in patients with multiple sclerosis. These impairments are present in 40% of patients with multiple sclerosis in the community. Sometimes, it is an early manifestation. 

  1. Mostly the impairments are seen later in the course.
  2. The impairments are mild and progress slowly. 
  3. Well-practiced verbal skills are often preserved. 
Cognitive impairment correlates with total lesion load and degree of callosal atrophy on brain imaging. 

  • Learning
  • Abstraction
  • Memory
  • Problem-solving

Features of schizoid personality, Mnemonic


  • D detached

  • A aloof

  • I introspective 

  • L lacking enjoyment 

  • E emotionally cold 

Clinical features of complex partial sezires, Mnemonic

"Pardon DJ Hell, you are Producing GAS that is AFFECting All the Fearful TEDS, CoSTing them MaDness" 


  • Distorted perceptions, Deja Vu

  • Jamais Vu

  • Hallucinations 


  • Grimacing and other body movements 

  • Automatisms

  • Stereotyped behaviors


  • Fear and anxiety

  • Euphoric or ecstatic states

Autonomic and visceral 

  • Flushing

  • Tachycrdia 

  • Epigastric aura

  • Dizziness

  • Other bodily Sensations


  • Speech disturbances

  • Thought disturbances

  • Memory disturbances

  • Depersonalization, derealization 

Skills taught in Dialectical Behavior therapy, Mnemonic


  • Mindfulness 

  • Anger control

  • Interpersonal skills

  • Ways of tolerating Distress

Elements of Dialectical Behavior Therapy, Mnemonic


  • Mindfulness

  • Aphorisms 

  • Dialectical ways of thinking

  • Cognitive and behavioral techniques 

Abnormal beleifs that cause stigma, Mnemonic

These abnormal beleifs of the people form the basis of psychiatric stigma: DUFIT

  • These people are Dangerous

  • They are Unpredictable 

  • They Feel different from the rest of us

  • They are Incurable

  • Psychiatric patients can't be Talked to or related to

Tuesday, 12 July 2016

What is the difference between negative reinforcement and punishment?

To clear the concept, these two are the major Differentiating points b/w Negative reinforcement and Punishment1) Negative reinforcement strengthen a response while punishment weaken/decreases a response.

2) Negative reinforcement involves removal of unpleasant stimulus while punishment is presentation of an unpleasant stimulus.

Better imaging study for the assement of change in behavior

Patient has change in behavior. Would it be preferable to use CT with contrast or without contrast for assessment ?LikeShow more reactions


Sarmad Mushtaq Ct withcontrast 

Immo Mani With contrast

Valeed Ahmed Yess with contrast,,, inflammation and tumors etc can create change in behavior that can be better viewed by contrast enhanced CT, contrast agents can not enter the BB barrier except in arease of inflamation where the barrier is damages ir tumor where it is not formed,,,so the contrast enters there very well, making the area distinct due to more absroption of radiation

What are the main uses of small group psychotherapy ?

The main uses of small group psychotherapy are 

  • To modify interpersonal problems

  • To to encourage adjustment to the effects of physical or mental illness 

  • As a form of supportive treatment 

Group therapy versues individual therapy; which one is superior?

There is no scientific evidence to cocnlude whether individual therapy is superior to group therapy or vice versa. However , clinical evidence suggests that group therapy is somewhat less effective that individual therapy. 

Monday, 11 July 2016

Stressors impact on health & well-being

According to richard lazarus, what kind of stressors are having most impact on health and well being ?


Inam Ul Haque Masood;Are we talking about the Lazarus or Kanner. I believe that Lazarus theory was based on the Primary Appraisal leading to Positive , Dangerous and Indifferent Threats leading to Secondary Appraisals and stress in which the Dangerous Threats were perceived to produce the stress and in Kanner hypothesis Daily Hassles had the role. Need a little elaboration

Correct Answer:

The everyday hassles rather than the big events like earthquakes, floods,,,and other disasters

Social Readjustment Scale:

On social readjustment scale, the most stressful event is ?

a) Death of spouse
b) Death of child
c) Death of parent
d) Death of sibling
e) Marriage


Isha Mughal: All
Saqib Siddique: Death of a spouse have 100 points

Nanny Marry: Death of spouse but mostly for women...

Immo Mani: Although all events are stressful but I think number one is the right answer

Ruby Malik: Death of child

Kira Awan: I think it varies from situation to situation... in case of children... its death of case of couple... its death of my case its marriage !!!

Correct Answer:

death of spouse is the right answer. The scale talks about the overall situation not about individuals. Remember this scale is based on research from real people from general population like you and me. So overall people find the death of spouse to be most difficult life change to adjust to.

Components and Principles of management of schizophrenia Mnemonic

What are the components and principles of management of schizophrenia ? 


  • CBT, cognitive remediation, clozapine, crisis resolution teams.

  • Outreach teams 

  • Needs assessment 

  • Family intervention

  • Integrated treatment for comorbid substance abuse

  • Antipsychotics

  • Therapeutic realtionship 

  • Early intervention 

Antipsychotic Groups, Mnemonic


  • Butyrphenonoes, benzisoxazole

  • Phenothiazines

  • Thioxanthenes

  • Substituted benzamides

  • Diabenzothiazepines, diabenzodiazepines

Memory Cues

  • fLOxetine has the LOngest half life among all SSRIs

  • Hunting 4 CAGs. The gene for Huntington lies on chromosome 4p and codes for the protein huntingtin and mutations causes CAG repetitions (36+) 

  • AntOn syndrome occurs in Occipital lobe syndrome 

  • T-tWo. Areas with Water appear brighter on T2 weighted MRI images e.g. CSF, tumors, inflammation.

  • HypnaGogic hallucinations occur when you are GOing to sleep. 

  • CatalePSY is associated with the PSYchiatric disorder rather than narcolePSY which is unfortunately associated with cataplexy. 

  • LEFT hippocampal damage causes VERBAL memory deficits, the SPEECH area (Broca's area) also lies on the LEFT usually.  So now, right hippocampal damage causes non verbal memory loss. 

  • PRAder WILLI patients are WILLING to PREY for food. (Insatiable appetite leading to obesity). 

  • Type I error or alpha error is what drug companies tend to commit. Drug does not work but they report it works. That is to reject the null hypothesis when in fact it is true. For example a companies null hypothesis was that paroxetine does not work for children and adolescents and they rejected it. Later on it was found that it does more harm than good. So they had wrongly commited the type 1 or alpha error.

  • Sleep Spindles Seen in Second Stage of Sleep.

Mnemonic for the Adult Traits Associated with Freud's Oral Phase of Development

According to the theory of psychosexual development, subjects develop the following traits with fixation at the oral stage of development: 
  1. Dependency
  2. Optimism
  3. Gullibility
  4. Sarcasm
  5. Hostility
  6. Aggression
  7. Pessimism, passivity



Components of Personality Mnemonic

These can help to asses premorbid personality the menomonic is CARLUP

  • Character traits

  • Attitudes and standards 

  • Relationships 

  • Leisure activities 

  • Ultimatel concern

  • Prevailing mood and emotional tone

Sunday, 10 July 2016

Terror Management Theory:

Every human is aware of the inevitable nature of death; yet people don't feel as terrified of death as expected even at old age. What mechanism reduces this terror ?

correct answer:

"One theory that explains this is terror management theory"

According to this theory, it is the culture that prevents this fear. People either keep themselves unaware of this reality or those who are aware of it most of the time ; they would be pursuing their cultural goals. In this way they would also be increasing their self esteem. These two (high self esteem, and cultural world view being defended, reduce the fear or anxiety of the inevitability of death. 

For example, Muslims would become more religious in old age and that would also elevate their self esteem and give a purpose to their lives so their death related anxiety would reduce . I think, if i am not wrong, there is a Hadith related to this as well, that we should remind ourselves about death every now and then "remind often the destroyers of pleasures"death [sunan at Tirmhdi]. wherever you are, death will find you, even if you are in towers built-up strong and high" Quran [4:78] (someone correct me). Which according to this theory would make people more religious (if they are).

Thursday, 7 July 2016

Principal features of a therapeutic community Mnemonic


  • Directness and honestly, decisions are shared.

  • Shared activities 

  • Mutual help

  • Permissiveness 

  • Informality

Component of Working Memory that acts as a bridge between short term and long term memory

According to Alan Baddely model of working memory, it has got 4 components. Which of these components of working memory acts as the interface between long term and short term memory

  • Visuospatial sketchpad

  • Phonological loop

  • Central executive 

  • Episodic buffer

The answer is D, episodic buffer. 

Long-term Consequences of Maternal Deprivation Mnemonic

Long-term Consequences of Maternal Deprivation Mnemonic


The Mnemonic PAID can help memorise and recall the longterm effects of maternal deprivation as described in the theory of attachment (Bowlby)
  • Psychopathy (affectionless)
  • Aggression (increased)
  • Intelligence (being low)
  • Depression, delinquency 

Tuesday, 5 July 2016

Explicit consent

Explicit consent is

Oral and written
Written only
Oral only


AnswerOral and verbal both are explicit consent

Consent by a diabetic patient who appears incompetent

A 55-year old woman with diabetes is diagnosed to have gangrene on both feet. She was brought to the hospital. She told the doctor the she is feeling fine and she has no medical problems. Can she give consent for the amputation of both legs?


Anam Najam no

Hajira Mehboob No she needs psychological treatment...

Valeed Ahmed The patient appears incompetent as she says she is fine and there is nothing wrong with her, so her consent is not acceptable

Hospitalizing autism patient who is not resisting

You are working in the UK as a consultant psychiatrist. A 20 year old Patient is suffering from autism. You think he should be admitted to autism treatment center. Guardians are not willing to hospitalize him although the patient himself is not actively refusing to be hospitalized. What is the most appropriate step to take ?

Admit him to the hospital
Treat on out patient basis
Refer to best interests assessor


Bournewood Gap

An adult patient who was suffering from autism was admitted to bounwood hospital because he by himself was not resisting to be admitted although his carers were not willing for this. This case indicated a “gap” in the law i.e. Failure to protect an individual’s liberty if he can not resist.

Deprivation of liberty safeguards

Bournewood case lead to deprivation of liberty safeguards act in 2007, according to which such patients will be asses by a ‘best interests assessor’ before such action is taken to make sure it is in the best interest of the patient. The act itself is complicated.

Down's Syndrome Original Name

Down syndrome was originally known as ?


Sanam Munir Trisomy 21

Valeed Ahmed Not trisomy 21,,,trisomy was discovered much later than down syndrome itslef,,,,,

Immo Mani Than what?

Valeed Ahmed Mongolism

Immo Mani Yes,right

Exception to the rule of consent to treatment

Which of the following cannot be considered as an exception to direct informed consent?
A. Waiver
B. Detention under mental health act
C. Emergencies where full information cannot be given
D. Incompetent patient
E. Passively compliant patient


Valeed Ahmed The answer is E, passive compliance is not an exception, rather an implied consent is.

The situations in which explicit consent is not required are :

Implied consent given
Necessity (harm likely, competency doubted)

What is Waiver

A competent adult patient who is suffering from malignant cancer does not want to know about his prognosis. What is this known as ?


Valeed Ahmed This is known as waiver in legal terms. 

Consent for pregnancy by adolescent

A 15-year old girl recently becomes pregnant. She went to a doctor for abortion. She told the doctor not to tell her parents about this pregnancy. What is the nest appropriate step in management ?

Inform the parents for the consent
Do not inform the parents and deal with abortion per local laws
Obtain a court order for the abortion
Deny abortion and don't inform the patient


Anam Najam Inform the parents for the consent

Anam Najam correct ans please Valeed Ahmed?

Valeed Ahmed The correct answer is b. In such cases as pregnancy, if the adolescent does not want their parents to know then do not inform them, termination of pregnancy or abortion is then subject to local laws

Anam Najam Does the same rule apply in our country as well?

Inam Ul Haque Masood Local laws may be adhered

A Vignette for Discussion

An 18 year old man comes with presenting complaints of irritability, severe headache, increased religious orientation, frequent cleaning of clothes, auditory hallucinations, and delusions of persecution. These symptoms started almost six weeks ago but aggression, irritability and loss of interest in daily activities were prevalent since one year. 

What could be the possible diagnosis of this case?


Hypomania does not have psychotic features. 
Could be. Ocd wd psychotic features.
MDD with psychotic features comorbid with OCD.
This patient should be explored for psychosis first as it a year-long illness with delusions and hallucinations and social dysfunction. If you can rule out psychosis then it can be mood disorder or other. Obsessional symptoms may be part of psychosis. The patient needs detailed history and serial MSE to confirm the diagnosis

But if you see the history. Hallucination and delusions started off later. Initially, the patient exhibited symptoms of depression. Hence its a high probability that depression over the course of time intensified resulting in the emergence of psychotic features.

Yes if psychosis is ruled out after a detailed history review then depression with psychotic features is the most probable diagnosis. Other possibilities Mixed affective episode ? . I feel the initial symptoms can also be prodromal symptoms of psychosis / negative symptoms / depressive symptom.

This is just an ill-sorted hodgepodge of signs and symptoms. This isn't how psychiatry works. Find out the predominant hue the patient carries and establish the progress of the illness for the last one year. Take a detailed history and MSE. From what appears here, it could be anything from Schizophrenia to BAD Manic episode. Find out, for instance, if the patient really has paranoid delusions or is he merely expressing apprehension about something. You didn't mention his mood. Is the irritability episodic or sustained? Is there declining social and occupational functioning?

When you enlist symptoms, you must juxtapose them against certain differentials.
Major depressive disorder with psychotic features along with OCD

Ocd with psychotic features, I think so

High scores on PANS (positive and negative scale both). Plus 31 on MMSE Which depicts cognitive dysfunction as well. As far as history is concerned I am more in favor of bipolar 1 with psychotic features...

Psychotic features started off six weeks ago, Delusions are paranoid. The mood remains irritable consistently. Social/occupational decline is also consistent for six weeks.

Cognitive impairment is a bummer. The rest of the picture, of course, fits bipolar with psychotic features but since there is some cognitive impairment, an organic illness has to be ruled out. Bipolarity with cognitive impairment And at this age especially is rare. Even generally, by diagnostic conventions, organicity has to be ruled out before considering a functional etiology of the psychosis.,,, You mentioned 31 on MMSE. I am assuming that's a typo.

Fahad Khan Shenwari Very interesting scenario Neha Khan. Is it what u saw urself or taken from somewhere?!  As far as the scenario I would say you always have to employ exclusion and inclusion criteria. The patient was initially experiencing prodrome symptoms of psychosis and then enter into a full-blown psychotic episode with positive symptoms of delusion and hallucinations and odd behavior
Syed Mehdi Raza Its psychotic depression fr sure as depressive features appeared first followed by psychotic
Fahad Khan Shenwari In psychotic depression u see mood-congruent phenomena
Syed Mehdi Raza Maybe but where is a mood incongruent phenomenon in this scenario? Irritability and loss of interest common in depression since it is from one yrs and from six weeks psychotic features so according to this info psychotic depression is the only diagnosis to be made
Abbas Sepah It's a mixture of multiple disorders and can not be fitted into just one..

Psychotherapy session is ending abruptly

pllz give your ideas

Read the following case scenario carefully

Khalid came to Mr. Jamil, a counselor working in a local hospital, with the presenting complaints of having anger, difficulty in maintaining relationships, feeling of being alone and lack of interest in daily activities. Khalid also reported himself to be restricting in his social activities since the death of his wife. Counselor developed a management plan for Kahlid for six sessions in which he used different behavioral and cognitive techniques. On the sixth session (the last session) with Khalid the counselor told him that today he will terminate the counseling however he can come for the follow up sessions. But Khalid told the counselor that still he does not find himself able enough to quit counseling sessions. However counselor was of the view that six sessions were more than enough to get out of his problem and now he should practice what he had learned during the course of counseling. Now answer the following questions about the above mentioned case scenario.
1. What flaws or lack of counseling skills you can identify in the current scenario and its
2. What suggestions you can give to the counselor for dealing with the client


Waleed Ahmed The patient should be informed at the start about the number of sessions and should also be educated that he may possibly find it difficult to quit but this will be a requirement . Suddenly informing a patient at the last session, he will be unprepared

Asma Irum: termination at least 3 session k darmyan honi chahe ,,,aur phly se informed ho

Farheen Asif: Average sessions r btw 6 to 12. During sessions new problems start coming to surface in most of the cases. Keeping the intensity of those problems u decide how many sessions will this particular patient need. Also , u need to keep a check on prognosis .If u feel it's a slow prognosis, u will have to increase the no of sessions. Sticking to the no u stated in first session is .... Absurd, specially when even the pt does not feel he is ready for termination. However, if u think pt is asking for more sessions cause u have inculcated dependency in him , then u may consider termination.

 The biggest flaw : 'counsellor thought 6 sessions r sufficient for this problem.' Take 10 ppl with same problem. All 10 of em will respond to the therapy differently in terms of pace of the prognosis. U don't fix session no keeping in view the problem ... Rather session no is determined keeping in mind the risk n resilient factors of the pt.... Cause these 2 factors play pivotal role in determining prognosis which in turn determines how many sessions will be needed.

 Iqra Munawar: its may posible that patient dont want to move away from that situation and therapist...due to fact of emotionly attachment.thats why he make refuses to leave therapist should creat such environment in which he can judge client's origional behaviour ,,intrst

Types of learning theories in this case

Valeed Ahmed's photo.


 Valeed Ahmed Apart from observational learning theory,is there any other theory applicable here

 Rabia Jihan Classical Conditioning

Sanam Munir Operant learning

Precious Faimii opernt conditionning, *punishment

 Valeed Ahmed Operant? Punishment is not a reinforcer

 Precious Faimii 4 types of reinforcemnt,, negative reinforcer, positive reinforcer, punishment and extinction.,,,  if i m not wrong

 Valeed Ahmed Yep u r right

 Noor Noor Classical conditioning

Angel's Dua Classical conditioning,  first of all its important to evaluate the problem of the child before applying any technique, i.e to see what is the cause of his this beh,,, then according to the problem solve the issue,,,, u may apply positive reinforcement to encourage the positive beh and negative reinforcement to reduce negative beh

 Brothers Doll Operant therapy as well as observation is too much important... bcoz through observation we know better those factors which disturb the client...

And behavior therapy is also good option in that case..

 Aneesa Batool Abbasi classical conditioning

Unconditioned stimulus- school bag.
unconditioned response- shouting and beating
conditioned stimulus -school bag
conditioned response- abdominal pain.,,,,
 If we want to prevent this behaviour then 

obeservational theory
operant learning -with reward
( give chocolate or his favourite lunch etc)

Pathological jealousy; a symptom or syndrome ?

Pathological jealousy is a paranoid symptom or syndrome ?


Inam Ul Haque Masood I believe it is a syndrome as it is a constellation of symptoms which gives uniqueness to the syndrome

Abbas Sepah The other name is Othello's syndrome, so it's a syndrome

Valeed Ahmed Yeah othello s :D,  Have heard this name dozens of times. ok it is a syndrome as there is a group of systematized symptoms consitent with the central theme of the delusion and not just the delusion

Mentally ill patient needs medical treatment

An adult patient is severely depressed refuses get treated for HCV infection. How should this patient be dealt with ?

First treat depression and then for HCV
Treat for HCV and depression without consent
Obtain a court order to treat for both


Anam Najam First treat depression and then for HCV

Waleed Ahmed When a mentally ill patient refuses consent to medical treatment, the steps are

Step 1 treat the psychiatric condition

Step 2 treat the medical condition
If psychiatric condition can not be treated, consider legal action e.g. Court order or consent from relative

Angel's Dua agreed

Mechanism of Dementia in Downs Syndrome

Which of the following is responsible for dementia seen in adults with Down’s syndrome?

A. Loss of genetic material in chromosome 21
B. Extra genetic material in chromosome 21
C. Genetic material lost from chromosome 14
D. Loss of genetic material corresponding to presenilin -1
E. Loss of genetic material corresponding to Apoe4

Ok extra genetic material is the correct answer. The gene that codes for b amyloid is located on chromosome 21. Since down syndrome is due to trisomy 21 so there is increased amount of genetic material that production of its product proteins. Product protein of the APP gene located on chromosome 21 is beta amyloid that is central to the aetiology of alzheimers

Sensory stimulation therapies for dementia


  • White noise

  • Aroma therapy

  • Music therapy, Massage

  • Bright light therapy

Implied consent

You are about to check a patients Blood pressure. As you Reach the bedside and open your BP apparatus, the patient extends her arm to let you check her BP although you have not asked for a consent yet. What is the best next step

Take verbal consent
Check her BP without asking


Immo Mani  Immo Mani Check without asking

Salma Sultan Salma Sultan Obviously without asking

Valeed Ahmed Valeed Ahmed Extending her arm when she sees a bp apparatus is implicit consent which obviates the need for an explicit consent. The other exceptions for explicit consent are emergency and neccessity (harm likely, competency in doubt)

Misbah Mustafa Misbah Mustafa Means explicit consent should still be taken right?

Valeed Ahmed  Valeed Ahmed No. It is not needed.

Inam Ul Haque Masood Inam Ul Haque Masood Her extending the arm so that you can take blood pressure is a sign of consent and I believe that taking verbal consent is not mandatory

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