by Prof Dr Ramli Musa under Exam Question April 8 2009

Here is the recent end block PMP question that I prepared and marked recently. There are a lot of things that you can learn and also could be a “muhasabah” to me as well……. The answers and comments are right at the bottom…..
Trigger I
Time 20 minutes

Mrs. G is a 45 year-old lady was referred by a physician when her series of blood investigations and endoscopic examination performed revealed normal findings. She frequently visited many doctors for many somatic symptoms such as body ache, epigastric burning sensation, non-specific headache and insomnia for the last 6 months. Occasionally she would feel that her heart was beating too fast when she thought of her physical symptoms. When her physician suggested her to meet a psychiatrist, she was initially skeptical as she did not feel that she had any psychiatric ailments.

1. Based on the short explanation above, list down 4 psychiatric differential diagnoses.


2. What 6 other relevant information would you try to acquire to ascertain the diagnosis?


Trigger II

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)


4. What is one relevant laboratory investigations would you order for this patient to help you come to the diagnosis?


Trigger III (20 min)

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)

6. Outline the management of this case. (10 marks)


7. List down your strategies to ensure her compliance to her treatment. (3 marks)


Q1 Answer:
Somatization disorder – top on the list
Major Depressive disorder with prominent somatic symptoms – good answer
Pain disorder
Generalized anxiety disorder
Substance abuse/dependence- ½ mark (hardly they present with above symptoms)

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)

Q2 The answer is based on your diagnoses in question 1:
Any episode of persistent feeling depressed
Other depressive symptoms such as hopelessness, or melancholic features
For somatization disorder; other form of pain; sexual complaint, neurological symptoms (numbness)
Any drug abuse
Family history of similar symptoms or psychiatric disorder
Any recent stressor
Many students failed to get the right answer although the presentation is very clear.
The correct answer is Major depressive disorder with prominent somatic symptoms.
Supporting evidences:
No other symptoms of somatization disorder
There are a lot of pessimistic ideas about her current and future life.
There is thought of dying.

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

Q4 Acceptable answers; Thyroid function test or cortisol

Q5 Answer:
Early morning awakening (more than 2 hours from usual time)
Diurnal variation of mood (feeling depressed esp in early morning)
Excessive guilt
Psychomotor retardation/agitation

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
Poor sleep

Q6 Answer
Bio-psychosocial spiritual model of management
Antidepressant SSRI
Family psychoeducation
Community or social welfare helps

Common mistake;
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

Q7 Answer:
To develop therapeutic relationship and good rapport with the patient
Psychoeducation to the patient and family
Single dose antidepressant
Prescribe less side effect medicine.
Explanation on early relapse symptoms and possible side effects
Ensure good social support

Common mistakes:
When students answered depot injection (antidepressant has no depot form!!!!!!)
CBT or psychodynamic psychotherapy (they are targeting on cognitive errors not for insight enhancement!!!)


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