Case Write-Up

Psychological and Behavioural Medicine

M Kandiah Faculty of Medicine and Health Sciences, UTAR

Student Name: Deipan A/L Arjunan

ID No: 20UMB03886
Year: 4
Name of lecturer: Dr. Seed Hon Fei
Marks allocation for Case Write-up
Chief complaints /5 Investigations /5

History chronologically clear /20 Report on management /10

from patient and progress of the
patient in the ward / on
follow up

Mental state examination and /20 Discussion and literature /10

physical examination review

Summary / Formulation /10 Proper use of English language, /5

and write-up is clear & logical

Discussion of diagnosis / /15 Total score /100

differential diagnosis with
justifications
Signature of Lecturer: ____________ Date: __________________
PATIENT IDENTIFICATION

Patient’s Initials: Ms. R R/N: -

Age: 27 y/o Gender: Female

Ethnicity: Indian Language: Tamil

Marital status: Married Occupation: Housewife

Date of clerking: 9/11/2023

CLINICAL CASE

Chief Complaint

Ms. R presented with a suicidal attempt by slashing herself with a knife.

History of Presenting Illness

Ms. R is a 27-year-old, Indian lady who was admitted 5 days ago due to suicidal attempt
where she slashed herself on her left wrist with a knife at her home. She was well until she
started having symptoms such as feeling depressed for the last two months after her first child
passed away. Immediately after the incident, Ms. R felt depressed every day about her child’s
death and excessively guilty. As time passed, she became more and more depressed and guilty
and throughout this period, she stayed at home in her room every day and avoided interacting
with other people. She had loss of energy and felt fatigued every day and spent most of her time
at home lying on her bed and being fed by her husband as she did not have the energy to eat and
had loss of appetite. She also complained of having difficulty sleeping for almost every day
where she only managed to sleep 3 to 4 hours a day and some occasions where she could not get
any sleep which is not enough for her as she used to sleep around 8 hours a day.

Throughout this time, Ms. R also had recurrent suicidal ideation but did not have a
specific plan on how she wants to commit suicide. She also did not have any suicidal attempts
until 5 days ago when she was admitted.

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 On the day of admission, Ms. R was alone at home. Ms. R wanted to end her life because
of the persistent sadness and guiltiness that she felt. Once Ms. R’s husband left to run errands,
she proceeded to slash herself with the knife that she used at home. Her husband returned home
to find her on the kitchen floor, and she was drowsy. At the emergency department in Hospital
Kuala Lumpur, Ms. R was then admitted to the psychiatry ward due to suicidal attempt.

Otherwise, Ms. R denied having any loss of interest in her hobbies, difficulty
concentrating or self-harm. She also denied having manic symptoms such as decreased need for
sleep, racing thoughts, distractibility, increase in goal-directed activity, talkativeness and
excessive involvement in activities that have a high potential for painful consequences. She did
not experience any hallucinations, delusions of grandiosity, persecutory delusion, or delusion of
control as well as any disorganized behavior. She also denied having anxiety, palpitations,
shortness of breath or restlessness. She denied having symptoms of hypothyroidism such as
constipation, cold intolerance, bradycardia, hair loss or irregular menstrual cycle.

Past Psychiatry History

Ms. R does not have any past psychiatry history.

Past Medical, Surgical and Hospital Admission History

Ms. R does not have any underlying diseases such as diabetes, dyslipidemia, or
hypertension. She also does not have any past surgical history. She had an admission for labor in
2022.

Drug and Allergy History

Ms. R is not under any medication and does not take any traditional herbs or
supplements. She does not have any drug or food allergies.

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Family History

Ms. R is the 2nd and youngest child in her family. Her are both well and healthy. There is
no history of mental illness in her family such as major depressive disorder, bipolar disorder,
schizophrenia, or other mental illnesses. Ms. R is unsure if anyone had similar symptoms as. Her
elder brother is also healthy with no known medical illnesses. Ms. R had a daughter who passed
away two months ago at the age of 1 year old.

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Social History

Mr. R lives in an apartment in Jalan Ipoh with her husband. She does not work and is a
housewife. She does not smoke, drink alcohol, or take any illicit drugs. Ms. R is a Hindu. She
walks around her apartment complex 3 times per week.

Systemic Review

General  Sleeping difficulty

 Weight loss of 9kg due to loss of appetite

 No night sweats

 No nausea

 No vomiting

 No dizziness

Cardiovascular system  Palpitations during cough episodes

 No chest pains

 No arrythmia

 No orthopnoea

 No paroxysmal nocturnal dyspnoea

 No pitting oedema

Respiratory system  No haemoptysis

 No wheezing

 No cough

 No nasal discharge

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Gastrointestinal system  No gum bleeding

 No oral ulcers

 No dysentery

 No abdominal pain

 No diarrhoea

Genitourinary system  No change in frequency and urine output

 No pain during urination

 No haematuria

 No change in urine appearance

 No foul-smelling urine

Nervous system  No tinnitus

 No blurred vision

 No fitting

 No numbness

 No pin and needles sensation

Dermatology  No skin rashes

Endocrine system  No heat or cold intolerance

 No voice changes

 No excessive sweating

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 MENTAL STATE EXAMINATION (MSE)

Appearance

Ms. R appeared as a young Indian lady in her late 20s with medium build. She has long wavy
hair which is tied into a ponytail. She was dressed in hospital attire with fair hygiene.
Throughout the interview, she appeared calm and was cooperative while able to maintain good
eye contact. There was no aggressive or hostile behaviour and no hallucinatory behaviour as
well.

Speech

Ms. R spoke in Tamil with slow speed and slow response to questions however had normal
tone and volume. She was not talkative. Her speech was coherent and relevant.

Mood and Affect

Ms. R feels sad. Her affect was appropriate to thought content.

Thoughts and Perceptions

Ms. R wanted to go home and did not want to stay any longer in the psychiatric ward. She also
had suicidal ideations. Her continuity of thought was relevant. She denied hallucinations.

Cognitive Assessment

Consciousness and Alertness

Ms. R was conscious and alert.
Orientation
Ms. R was orientated to time, place, and person.
Attention and Concentration
Ms. R was able to perform the serial 7 subtraction test and spell “world” forward and
backward.
Memory
Ms. R’s memory was intact. She was able to tell her date of birth, what she ate for breakfast
and repeat 3 unrelated items that she was asked to remember shortly before.
General Knowledge

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Ms. R was able to name the prime minister of Malaysia.
Abstract Thinking
Ms. R’s abstract thinking was intact as she could categorize apples and oranges as types of
fruits.
Insight
Ms. R had good insight. Ms. R knows exactly what mental illness she has. She is committed to
be compliant to her medications.
Judgement
Ms. R has good judgement as when given a scenario of being caught in a building on fire, she
would get herself out and call for help

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 PHYSICAL EXAMINATION
Anthropometric Measurement

 Height: 157 cm
 Weight: 54 kg
 BMI: 21.9 kg/m2 (Normal)

Vital Signs

 Temperature: 36.7 ℃ (Normal)

 Heart rate: 68 beats per minute (Normal)
 Respiratory rate: 20 breaths per minute (Normal)
 Blood pressure: 110/71 mmHg (Normal)
 SpO2: 99% under room air (Normal)

General Examination

Ms. R was sitting comfortably on the bed with no signs of anxiousness. She is conscious,
alert and well oriented. There were no nail changes such as nicotine staining or finger clubbing
and no fine tremors noted. The capillary refill time was less than 2 seconds. There were linear
scars resembling slash marks on her left wrist. The face was symmetrical with no dysmorphic
features. There was no neck swelling and no lymph node enlargement.

Cardiovascular Examination(unremarkable)

The carotid pulse was palpable with no thrills bilaterally. Apex beat was palpable at the
left 5th intercostal space, mid-clavicular line. There were no thrills palpable and no left

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parasternal heave. First and second heart sounds were heard with no murmur and no additional
sound.

Respiratory Examination(unremarkable)

Ms. R’s chest was symmetrical and moved with respiration. There was no tracheal
deviation and no tenderness on the anterior and posterior chest. On percussion, there was
resonance all over the chest with hepatic and cardiac dullness. On auscultation, there was normal
vesicular breathing with no added sounds.

Abdominal Examination(unremarkable)

The abdomen was flat and moved with respiration. There was no flank fullness. There
was. There were no other scars, surgical wound, striae, prominent veins, or abnormal pulsation
seen. On palpation, there was no tenderness or abnormal mass felt. There was no
hepatosplenomegaly and kidneys were not ballotable. On percussion, Traube’s space was
resonant. Shifting dullness and fluid thrill were negative. On auscultation, bowel sounds were
normal. There were no aortic bruit, renal bruit, hepatic bruit and splenic bruit heard.

Neurological Examination(unremarkable)

Ms. R’s mental status was intact and was able to understand and answer questions
logically. There was no slurring of speech. Ms. R was able to understand and follow commands.
There were no scars, muscle wasting, involuntary movement or fasciculation of the upper and
lower limbs noted. On neuromuscular examination, muscle tone was normal on both upper and
lower limbs. The power is 5/5 bilaterally for both upper and lower limbs. All reflexes were
normal. Sensation of upper and lower limbs were intact, and gait was normal. All cranial nerves
were intact.

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Musculoskeletal Examination(unremarkable)

On inspection, there were no deformities, limb length discrepancy or muscle wasting

noted. Upon palpation, there was no localized rise in temperature or tenderness noted. No
abnormal structure or bony prominences palpable. Active and passive range of movement were
all within the normal range.

SUMMARY OF CASE

Ms. R, a 27-year-old, Indian lady was admitted due to suicide attempt. She was well until
2 months ago after her first child passed away, where she started to have depressed mood every
day. Her depressed mood was associated with feelings of excessive guilt, fatigue or loss of
energy, loss of appetite and insomnia. Throughout this period, she also had recurrent suicidal
ideations but did not have any specific plan on how to commit suicide. Otherwise, Ms. R denied
having loss of interest in her hobbies and difficulty concentrating. She also denied any history of
manic symptoms, anxiety symptoms or symptoms of hypothyroidism. She also did not have any
hallucinations, delusions of grandiosity, persecutory delusion, or delusion of control as well as
any disorganized behaviour. On MSE, Ms. R spoke in slow speed with slow response to
questions. Throughout the interview, she felt sad and had suicidal ideations. She had ongoing
auditory hallucinations during the interview. She also had good insight towards her condition and
good judgement. On physical examination, there was multiple slash marks on her left wrist.

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 PROVISIONAL DIAGNOSIS

Major depressive disorder (MDD)

Supporting evidence
 Suicide attempt on the day of admission
 Felt depressed every day for 2 months following miscarriage.
 Loss of appetite
 Insomnia
 Fatigue and loss of energy.
 Feeling of excessive guilt
 Recurrent suicidal ideation without a specific plan and suicide attempt
 Impairment in social functioning
 MSE: psychomotor retardation, suicidal ideations
 She was sad and had suicidal ideations in the ward and poor insight of her illness.
 PE: slash wounds seen on her left wrist.
Evidence against
 No loss of interest in previously enjoyed activities such as singing.
 No difficulty concentrating

DIFFERENTIAL DIAGNOSIS
1. Bipolar disorder in major depressive episode
Supporting evidence
 Depressed mood for 2 months
 Loss of appetite
 Insomnia
 Fatigue and loss of energy
 Feeling of excessive guilt
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  Recurrent suicidal ideation without a specific plan and suicide attempt
 MSE: psychomotor retardation, auditory hallucinations, suicidal ideations
 PE: slash wounds seen on her left wrist
Evidence against
 No history of manic symptoms

2. Schizoaffective disorder
Supporting evidence
 Major depressive episode for 2 months
 Presence of negative symptom such as asociality
Evidence against
 No persecutory delusion, grandiose delusion or delusion of control
 No hallucinations
 No disorganized speech
 No disorganized behaviour

3. Hypothyroidism
Supporting evidence
 Depressed mood
 Fatigue
 Loss of appetite

Evidence against
 No constipation
 No cold intolerance
 No bradycardia
 No hair loss
 No irregular menstrual cycle

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 INVESTIGATIONS
Biological Investigations
Investigation Indication

Full Blood Count  As a baseline investigation for monitoring drug

therapy

Renal Profile and Serum  As a baseline investigation to assess the renal

Electrolytes function for drug clearance

Liver function test  As a baseline investigation to assess the liver function

for drug clearance

Thyroid Function Test  To rule out hypothyroidism

Fasting Blood Glucose  As a baseline investigation for monitoring drug

therapy as atypical antipsychotic such as olanzapine
Lipid Profile can cause metabolic syndrome

Urine Toxicology  To rule out substance use

ECG  To rule out any existing prolonged QT and evaluate

the risk of torsade de pointes

Urine Pregnancy Test  To assess whether patient is pregnant to aid in

management

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 1. Full blood count
Reference
Blood Components Results Interpretation
Range

Red blood cell (x10^6/µL) 3.9-5.6 4.4 Normal

Haemoglobin (g/dL) 11.5-16.0 13.5 Normal

Haematocrit (%) 37-47 42 Normal

Mean cell volume(fL) 76-96 87 Normal

Mean cell haemoglobin (pg) 27-32 28.9 Normal

Mean cell haemoglobin concentration (g/dL) 30-36 34 Normal

Platelet count (K/µL) 150 - 400 253 Normal

Red cell distribution width (%) 11.5-15.0 13.3 Normal

White blood cell (K/µL) 4-11 7.5 Normal

Interpretation: All parameters are within the normal range.

2. Renal profile and serum electrolytes

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 Parameters Reference Range Results Interpretation

Urea (mmol/L) 3.20 – 8.20 3.9 Normal

Sodium (mmol/L) 135-148 140 Normal

Potassium (mmol/L) 3.5-5.0 4.0 Normal

Chloride (mmol/L) 95-105 99 Normal

Creatinine (µmol/L) 52.2-91.9 70 Normal

Calcium (mmol/L) 2.12-2.6 2.32 Normal
Magnesium (mmol/L) 0.78 – 1.65 1.03 Normal
Phosphate inorganic (mmol/L) 0.75-1.05 0.84 Normal
Interpretation: All parameters are within the normal range.

3. Liver function test

Parameters Reference Range Results Interpretation
Total bilirubin (µmol/L) 3-17 10 Normal
Total protein (g/L) 60-80 67.5 Normal
Albumin (g/L) 35-50 41.3 Normal
Alkaline phosphatase (U/L) 30-130 45 Normal
Alanine transaminase (U/L) 5-35 17 Normal
Aspartate transaminase (U/L) 5-35 22 Normal

Interpretation: All parameters are within the normal range.

Psychological Investigations

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 Investigation Indication

Hamilton Depression Rating

 To assess the severity of depressive symptoms
Scale (HAM-D)

Beck suicide intent scale  To assess the level of suicidal intent or the intensity
(BSIS) of the attempter's wish to die at the time of the
attempt.

Sad Person Scale  To assess the suicidal risk of the patient

Hamilton Anxiety Rating  To assess for general anxiety symptoms and

Scale (HAM-A) determine the severity of the anxiety symptoms.

Social Investigation
Investigation Indication

Collaborative history from  To have a more detailed history of Ms. R’s behaviour
family members at home, socioeconomic status, and financial support.

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 MANAGEMENT

I would approach this case through the biopsychosocial approach. According to Clinical
Practice Guidelines (CPG) Malaysia for the management of MDD, the general principles of
management of MDD are as follows:

 to relieve symptoms
 to reduce the morbidity and disability
 to limit risks of self-harm and fatality

Criteria of admission of patients with MDD are indicated when there is risk of harm to self,
psychotic symptoms, inability to care for self, lack of impulse control and danger to others. In
this case, admission is indicated as Ms. R was at risk of harming herself. Admission can be
voluntary or involuntary according to the Mental Health Act (2001).

The modalities of treatment in MDD are pharmacotherapy, psychotherapy, psychosocial

intervention, physical and others. Treatment of MDD is offered based on the severity of the
disease (mild, moderate, and severe) in both acute and maintenance phases.

Acute Phase

In mild to moderate MDD, psychosocial intervention and psychotherapy should be offered.

Pharmacotherapy can also be started as an initial measure in certain cases such as when there is
previous history of moderate to severe depression, patient’s preference, previous response to
antidepressants or lack of response to non-pharmacotherapy interventions.

In moderate to severe MDD, combination of pharmacotherapy and psychotherapy should be

offered. Pharmacotherapy is the mainstay of treatment for moderate to severe depression.

Continuation and Maintenance Phase

Psychosocial intervention and psychotherapy are offered during this phase. Pharmacotherapy is
also offered with the aim of preventing relapse and recurrence. The duration of maintenance
phase treatment is between 6 to 9 months after remission. Maintenance phase treatment must be
considered for 2 years or more if the risk of relapse and remission is high.

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Risks of relapse and recurrence of MDD:

1. Frequent, recurrent episodes

2. Severe episodes (psychosis, severe impairment, suicidality)
3. Chronic episodes
4. Presence of comorbid psychiatric or other medical conditions
5. Presence of residual symptoms
6. Difficult-to-treat episodes

Biological Approach

Pharmacotherapy is the mainstay of treatment for moderate to severe depression. Most

second-generation antidepressants may be considered as the initial treatment medication
considering efficacy and side effects. Types of second-generation antidepressants include SSRIs,
SNRIs, NaSSAs, melatonergic agonist and serotonergic antagonist, NRDIs and multimodal
antidepressant which can be considered for initial treatment while older antidepressants such as
TCAs and MAOIs can be considered as subsequent choices. In this case, Ms. R can be given
sertraline as it is more effective than fluoxetine and has lesser side effects compared to
paroxetine and amitriptyline.

Benzodiazepines can also be given as adjunct to antidepressant treatment in MDD with

anxiety, agitation, or insomnia. As Ms. R has insomnia, benzodiazepine can be prescribed.
However, it should only be used as needed and must not be used longer than 2 to 4 weeks to
avoid dependency.

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Psychosocial Approach

Psychoeducation

Psychoeducation is given by delivering information to the patient and their family on

pharmacotherapy and psychological measure which consists of the following topics:

o Symptoms and course of depression

o The biopsychosocial model of aetiology
o Pharmacotherapy for acute phase and maintenance
o Drug side effects and complications
o Importance of medication adherence
o Early signs of recurrence
o Management of relapse and recurrence

Psychoeducation is an important component in the treatment of depression. It is provided early

and continuously throughout the management of the condition.

Psychotherapy

1. Cognitive behavioural therapy (CBT)

CBT focuses on the impact a person’s unhelpful thoughts have on the current behavior and
functioning, through cognitive restructuring and behavioural approach.

2. Interpersonal psychotherapy (IPT)

IPT focuses on interpersonal relationship to help patients improve their social support network
and manage interpersonal distress that may be associated with the depression.

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 DISCUSSION

Introduction

Major depressive disorder (MDD) is an episodic mood disorder primarily characterized

by depressed mood and anhedonia lasting for at least two weeks. The aetiology is multifactorial,
including both biological and psychological factors. Reduced levels of neurotransmitters
(serotonin, noradrenaline, dopamine) are believed to be the pathophysiological basis in most
cases. Other symptoms of MDD include sleep disturbance, loss of appetite, and thoughts of
suicide. Subtypes of MDD are characterized by additional symptoms. MDD with atypical
features is additionally characterized by weight gain and increased appetite, while MDD with
psychotic features is characterized by hallucinations and delusions. Presentations may also vary
in special patient groups, e.g., pregnant patients, older patients, children and adolescents, and
patients receiving palliative care. Treatment of all forms of MDD is multifaceted and often
requires psychotherapy, pharmacotherapy (most commonly SSRIs), and lifestyle changes.

Epidemiology

MDD is more common in female with a lifetime prevalence of 10-20% and the peak age of
onset is more common in 3rd decade of life.

Aetiology

 Biological factors

o Monoamine hypothesis: Most antidepressants work by inhibiting the reuptake

of monoamines (e.g., serotonin, noradrenaline, dopamine), indicating that a lack
of monoamines plays a major role in the pathophysiology of depression (and
other mood disorders).

o Genetic factors

 First-degree relatives of patients with depression are at increased risk of

developing depression.

 The concordance rate in identical twins is ∼ 50%.

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 o Increased production of stress hormones (e.g., dysfunction of the hypothalamic-
pituitary-adrenal axis)

 Psychological factors: traumatic and stressful experiences, behavioural factors (e.g.,

learned helplessness)

 Comorbidities: neurodegenerative diseases (e.g., Alzheimer disease), chronic

inflammatory diseases (e.g., systemic lupus erythematosus or inflammatory bowel
disease), and other psychiatric disorders (e.g., panic disorder)

Diagnostic Criteria

To diagnose MDD, according to the DSM-5, the following criterias must be met:

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In this case, Ms. R fulfils criteria A whereby for the past 2 months, she has depressed mood
most of the day, nearly every day, loss of appetite, insomnia, psychomotor retardation, fatigue or
loss of energy, feelings of excessive guilt and suicide attempt and recurrent suicidal ideation. She
also fulfils criteria B whereby there was significant impairment in her social functioning as she
stayed in her room most of the day avoiding interaction with other people. Ms. R also fulfils
criteria C whereby she denied any substance abuse, or any signs and symptoms of
hypothyroidism. Criteria D is fulfilled as Ms. R denied symptoms of psychosis. She also did not
have disorganized behaviour or speech. Criteria E is also fulfilled as she did not have any manic
or hypomanic episode before.

Ms. R fulfils all criteria, she can be given the diagnosis of major depressive disorder.

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Investigation

Investigation of MDD can be approached using a biopsychosocial model:

Bio

Although there is no definitive test to diagnose depression, routine laboratory testing is

carried out to rule out organic or medical causes of depression. This includes screening for drugs
associated with medication-induced depressive disorder. Lab tests that can be done are thyroid
function tests, serum and urine toxicology and HIV testing. Neuroimaging can also be
considered to evaluate structural brain disease based on clinical presentation. Polysomnography
(PSG) can be done of a concurrent primary sleep disorder is suspected.

Psycho

Screening tools can be used to screen for depression and assess the severity of
depression. The common tools used in Malaysia for screening of depression are Beck Depression
Inventory (BDI), Depression, Anxiety and Stress Scale (DASS), Patient Health Questionnaire-9
(PHQ-9), and Hospital Anxiety Depression Scale (HADS). Another tool that has been validated
locally is the Whooley Questions which is a shorter tool used to screen for depression. The
Whooley Questions may be considered in people who may have depression particularly in those
with a past history of depression or a chronic physical health problem with associated functional
impairment.

Social

It is important to investigate the social factors that may be impacting the patient’s
depression. This involves assessment of the patient’s social support network and the quality of
their relationships with family, friends, and significant others. It is also important to identify any
recent or past significant life events, such as trauma, loss, or major changes, that may be
contributing to the development of depression. We must also assess environmental factors and
carry out evaluation of the patient’s living situation, work environment, socioeconomic status,
and any other contextual factors that may impact their mental health.

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Treatment (As discussed above)

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 REFERENCES

AMBOSS. (2023). Major depressive disorder. Retrieved from

https://next.amboss.com/us/article/PP0WUT?q=major%20depressive
%20disorder#2nYTsp.

American Psychiatry Association. (2016). Desk reference to the diagnostic criteria from DSM-5.
5th ed. Arlington: American Psychiatric Association.

Bains, N & Abdijadid, S. (2023). Major Depressive Disorder. Retrieved from

https://www.ncbi.nlm.nih.gov/books/NBK559078/.

Halverson, J. L. (2023). Depression. Retrieved from

https://emedicine.medscape.com/article/286759-overview#a1.

Ministry of Health Malaysia. (2019). Clinical Practice Guidelines: Management of Major

Depressive Disorder (second edition). Retrieved from
https://www.moh.gov.my/moh/resources/Penerbitan/CPG/Psychiatry%20&%20Mental
%20health/CPG_Management_of_MDD_(Second_Edition)_04092020.pdf.

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