by Prof Dr Ramli Musa under Exam Question April 8 2009
1. Based on the short explanation above, list down 4 psychiatric differential diagnoses.
The patient persistently denied having weird experiences such as hearing voices or first rank Schneiderian symptoms. A part from having multiple body complaints as mentioned earlier, there was no other body pain, neurological symptom or sexual dysfunction. She developed many somatic symptoms after her divorce 6 months ago. Her appetite was reduced and most of the time she would toss and turn in bed for some time before falling asleep. With lack of social support, she felt that life was so demanding and she did not think she could go through this difficult situation. There were times she had thought of ending her life.
3. What is your provisional diagnosis of this case? Give 3 supporting evidences of your above diagnosis. (7 marks)
Further assessment revealed she had symptoms of melancholia such as anhedonia. The diagnosis of Major Depressive Disorder was ascertained by the psychiatrist. Due to the risk of harming herself, she had to be admitted to psychiatric ward. After 1 week on treatment, she defaulted her follow-up and treatment.
5. Give 5 other melancholic features of depression. (5 marks)
Common mistakes done by students when they answer:
Somatoform disorder – wrong (non-specific)
Anxiety disorder – wrong (non-specific)
Factitious, Malingering disorder – wrong (should not think along this line first, not fair to your patient)
Please bear in mind that among middle aged and elderly women in Asia, they tend to present with many somatic symptoms but in actual fact they are having major depression). Even the presentation of depression is commonly with somatic complaints.
Statistics on the result;
60% of students (12 students) answered major depressive disorder
15% (3) answered Adjustment Disorder (not accurate answer due to suicidal thought)
15% answered Somatization disorder (wrong it is clearly mentioned no other body complaint)
5% Conversion (0 mark – commonly conversion presents with neurological deficit e.g. paralysis)
5% (1 student) answered mixed anxiety and depressive symptoms (I’m speechless and no comment on the answer because it is not the diagnosis and the mark is definitely 0)
Common mistake made by students
Common mistakes/wrong answers by students:
Feeling low mood every day, feeling low mood most of the time (this is a core symptom depression not melancholic feature)
Loss of emotional reactivity
Students did not lay out the bio-psychosocial and spiritual model.
ECT is correct answer but if you mention ECT as the first choice, then it is wrong
When students answered depot injection (antidepressant has no depot form!!!!!!)
CBT or psychodynamic psychotherapy (they are targeting on cognitive errors not for insight enhancement!!!)