CBLE CA Psychiatry
Examples Exercise
Example-1
A 9-year old boy becomes fearful and senseless after exposure to thunder 5 days back. Worried parents consult with a neurologist who refers the boy to psychiatry OPD. Parents say that similar event first happens 9 month back in face of thunder. Gradually the child fears of storm, cloud, loud sound, and noises and avoids such situations. Parents close doors and windows particularly during storm and thunder and give earplug to block the noise with the aim of reducing his fear. However, these efforts do not work and child is increasingly fearful and unwilling to go school though he is studious boy.
| a) Explain the psychopathology of this case. | 6 |
| b) Outline the treatment plan. | 4 |
Extraction
- The boy has specific fear with avoidance
- His senselessness is mixture of psychic and somatic anxiety that misinterpreted as fit attack
- Parents over anxiety exaggerates the child’s problems and that also causes inappropriate help seeking behaviour
Tasks
a) Psychopathology
- Natural unconditioned stimulus-response of thunder-fear pairing becomes conditioned
- Stimulus generalization causes subsequent fear of storm, cloud, loud sound, and noises
- Fear-avoidance is negative reinforcement further increased by positive reinforcement by parental over concerned behaviour
- Inappropriate help seeking behaviour and medical intervention further reinforced the child’s behaviour
- Strong possibility of having cognitive distortion of overall situation
Tasks
b) Rx plan
- Explanation support and advice to the child and parents
- Explain the role of parents to elevate problems
- Breath holding exercise training
- Systematic desensitization followed by in vivo exposure
- Wellness treatment-pear play, home based recreational activities
- Restring child’s normal life
Example-2
A 3-year old child is not talking and said to appear not to understand what his parents say.
| a) Give outline of differential diagnosis you will consider | 5 |
| b) List the required examinations and investigations necessary to clarify the diagnosis. | 5 |
Extraction
- The boy has no age appropriate communication
- Lack of understanding of others talk possibly due to combined social-communication impairment and low IQ
- It is expected that this problem will be reflected in peer relationship, group play and child’s own activities that needs to be explored
- His problems are quit noticeable as the parents clearly observed
- Parental concern at this age crates the opportunity of early assessment and diagnosis and intervention
Tasks
a) D/D
- ASD
- Developmental speech and language disorder
- Intellectual disability
- Global developmental delay
- Developmental brain disorder
Tasks
a) Examination and investigations
- Through general examination-weight, height, head circumference, signs of developmental anomaly, deformation, anomalies
- Details neurological examination
- Mental status examination
- IQ Test, Adaptive behaviour assessment test, Developmental assessment test, language assessment test
- Routine laboratory investigations
- Hearing test- audiometry
- Neuroimaging
Example-3
A 13- year old boy is referred by GP who episodically cries, fears, rapidly breaths, chews, walking about, searches things and talks incoherently in sleep since two years for 5-15 minutes duration. The boy cannot recall the events when he is asked about. EEG finding for this boy was found normal. Parents are worried for the boy as the problem persists and increases gradually. Subsequently, the boy defies, demands things, does not do study, engages more with mobile gaming and watching TV.
| a) What is the most likely diagnosis? | 5 |
| b) Outline treatment plan. | 5 |
Extraction
- Repeated awakening with described behavours is parasomnic features
- Inability to recall the events is the event amnesia and strongly indicative that these behavours happen in NREM
- Walking with complex behaviour-Sleep walking
- Fear arousal, crying, screaming, rapid breathing ( autonomic arousal)- Sleep terrors
- Not Night Mare, Panic, ODD-CD
- Normal EEG-general exclusion of Seizure as well as evidence of prior nonpsychiatric consultation
- Parental worries are rational and reinforced by past interventional failure
- The boy’s disruptive features is most likely due to reinforcement from parents and previous intervention and channelling of his distress
Tasks
a) Dx- NREM Sleep Arousal disorders, both Sleepwalking and Sleep Terror type (Night Terror, Somnambumism)
b) Rx plan
- Explanation, support, reassurance and advice
- Applying ADL-restoring premorbid life
- Safety measures
- Getting extra 30-40 minutes sleep at night
- Measures for managing desruptive behaviour
- Drugs- low dose BDZ (DZP,CZP).Low dose TCA
- Periodic follow up
Example-4
A 4-year old boy is referred to psychiatry OPD from paediatric OPD for stunted growth and marked language backwardness inappropriate to age for which no organic aetiology was identified.
| a) Outline your assessment plan. | 5 |
| b) What intervention you will offer for this Case? | 5 |
Extraction
- Developmental backwardness- no organic aetiology found
- Psychiatric referral further strengthens its nonorganic cause
- Stunted growth and language delay is the most common features of NOFTT
- NOFTT is usually associated with child maltreatment
Tasks
a) Assessment plan
- Finding the reason of maltreatment
Child raring practice-home or institutional
Attachment status- insecure? Absent of primary attachment figure, if so reasons. Frequent change of attachment features? Family- Disorganized? Chaotic? Discorded parents? Divorce? Parental physical and mental illness
- Assessing developmental status of the child
Degree of physical underachievement Extent of language impairment
Any other developmental backwardness including intelligence Applying developmental assessment tools
Tasks
a) Assessment plan
- Assessing mental status of the child
Temperament-difficult?
Social interaction
Engagement
Externalizing and internalizing problems Assessing impact and risk - Assessing impact
Tasks
b) Intervention
- Decision of child staying and placement
Home with caregivers-with home support Alternative care-community safe house, foster care - Hospitalization- if severe malnutrition
- Multidisciplinary professional engagement
Tasks
b) Intervention
- Parent focused treatment
Domiciliary support
Parent/caregiver counselling
Parenting training
Treatment of parental psychiatric disorder-if present
- Child focused treatment
Nutritional catch up and ensuring adequate nutrition Play and recreational activities
Behaviour therapy
Speech therapy
Peer involvement- day care
Example-5
A 17-year old boy is brought to emergency by his father because of his son is found “abnormal and non communicative”. Father suspects the boy is addict. Preliminary examination shows the boy to be drowsy,
with slurred speech, pupilary constriction, lethargy and generally positive effect.
| a) Based on the initial presentation what could be possible diagnosis? | 4 |
| b) How will you proceed for diagnostic confirmation? | 2 |
| c) What is your immediate management plan for this boy? | 4 |
Extraction
- Presenting features indicative of substance intoxication
- Pupillary constriction and lethargy-signs of opiates intoxication
- Father’s suspect- strongly indicative of addiction
- No such information of other causes of confusion
- No better explained other substance intoxication
Tasks
a) Dx- Opiates intoxication
b) Assessment for Dx confirmation
- Toxicological test
Immediate Rx plan
- Hospitalization
- Maintenance of nutrition, fluid, electrolytes
- Checking and monitoring vitals
- Measures of confessional state
- Details history, clinical exams and lab investigations for diagnostic confirmation
- Detoxification