PSYCHIATRY • CLINICAL ACUMEN
🧠 Clinical Decision Pathways
50 presentation-led pathways for common Psychiatry OPD and Emergency encounters. Start with safety and organic mimics, discriminate the syndrome, then move toward a defensible working diagnosis and management direction.
Clinical use: Educational decision support for qualified clinicians. Emergency stabilization, local protocols, mental-health law and specialist referral requirements always take priority.
50 pathways
01Low mood: depression or something else?Mood & Anxiety
Presentation
Persistent low mood, anhedonia, fatigue, sleep/appetite or cognitive change.
Persistent low mood, anhedonia, fatigue, sleep/appetite or cognitive change.
Decision pathway
Establish duration and impairment → ask directly about self-harm/suicide → screen past mania/hypomania → review substances/medicines and medical mimics → characterize psychotic, melancholic or atypical features.
Do not miss
⚠️ Bipolar depression, bereavement/adjustment, hypothyroidism, anaemia, medication/substance effects, delirium in older adults.
Management direction
Match severity and preference to psychoeducation, psychological treatment and/or antidepressant treatment; urgent specialist care for severe risk, psychosis, catatonia or inability to maintain safety.
Clinical pearl
💡 A depressive presentation is not safely labelled “unipolar” until lifetime mania/hypomania has been actively sought.
02The patient who sleeps only two hours—and feels wonderfulMood & Anxiety
Presentation
Reduced need for sleep with increased energy, talkativeness, confidence, spending, irritability or disinhibition.
Reduced need for sleep with increased energy, talkativeness, confidence, spending, irritability or disinhibition.
Decision pathway
Assess immediate risk and behavioural control → distinguish mania from hypomania by severity/impairment/psychosis → map previous depression → exclude stimulant, steroid and medical causes → obtain collateral history.
Do not miss
⚠️ Substance-induced state, hyperthyroidism, delirium, frontal/neurological disease, antidepressant-associated switch.
Management direction
Severe mania generally needs urgent specialist assessment; reduce stimulation, address safety, stop aggravating substances/medicines where appropriate, and use guideline-based antimanic treatment with physical-health/reproductive considerations.
Clinical pearl
💡 “Not tired despite little sleep” is more discriminating for mania than ordinary insomnia.
03A racing heart at 2 AMMood & Anxiety
Presentation
Abrupt episodes of intense fear with palpitations, dyspnoea, trembling, chest discomfort or fear of dying.
Abrupt episodes of intense fear with palpitations, dyspnoea, trembling, chest discomfort or fear of dying.
Decision pathway
First decide whether the episode could be a medical emergency → characterize abrupt peak and recurrence → ask anticipatory anxiety/avoidance → review caffeine, stimulants and substances → diagnose panic disorder only when recurrent unexpected attacks plus persistent concern/behaviour change fit.
Do not miss
⚠️ ACS/arrhythmia, asthma/PE when clinically plausible, hyperthyroidism, hypoglycaemia, stimulant use, withdrawal.
Management direction
Explain the panic cycle after appropriate medical assessment; CBT is central and an SSRI/SNRI may be considered for persistent disorder. Avoid making long-term benzodiazepines the default.
Clinical pearl
💡 A panic attack is a syndrome; panic disorder is a longitudinal diagnosis.
04Worry that never clocks outMood & Anxiety
Presentation
Excessive difficult-to-control worry across several domains with tension, restlessness, poor sleep and concentration.
Excessive difficult-to-control worry across several domains with tension, restlessness, poor sleep and concentration.
Decision pathway
Clarify breadth and chronicity → quantify impairment → distinguish worry from obsessions, panic and depressive rumination → review substances/medical causes → assess depression and suicide risk.
Do not miss
⚠️ Hyperthyroidism, stimulant/caffeine excess, medication effects, OCD, PTSD, depression.
Management direction
Use stepped care: education and active monitoring for mild symptoms; CBT/applied relaxation and/or guideline-supported antidepressant treatment when impairment persists.
Clinical pearl
💡 Ask what the patient does because of worry—avoidance and reassurance-seeking often reveal severity better than “Do you feel anxious?”
05The fear of being watchedMood & Anxiety
Presentation
Marked fear of scrutiny, embarrassment or negative evaluation in social/performance situations.
Marked fear of scrutiny, embarrassment or negative evaluation in social/performance situations.
Decision pathway
Define feared situations → distinguish fear from paranoid belief → assess avoidance and function → screen depression, alcohol self-medication and autism-spectrum traits when relevant.
Do not miss
⚠️ Panic disorder, agoraphobia, body dysmorphic disorder, psychosis, avoidant personality traits.
Management direction
Individual CBT with exposure/cognitive work is a core treatment; pharmacotherapy can be considered when indicated.
Clinical pearl
💡 Social anxiety is not simply shyness: clinically significant distress/avoidance and impairment matter.
06The thought that will not leaveObsessive / Trauma
Presentation
Intrusive unwanted thoughts/images/urges with repetitive checking, washing, counting, reassurance or mental rituals.
Intrusive unwanted thoughts/images/urges with repetitive checking, washing, counting, reassurance or mental rituals.
Decision pathway
Identify obsession → identify compulsion/neutralising act → assess insight, time consumed and avoidance → separate from psychotic conviction and generalized worry → assess depression/suicide risk.
Do not miss
⚠️ Psychosis, OCPD traits, illness anxiety, tic-related phenomena, depressive rumination.
Management direction
Exposure and response prevention-based CBT and SSRIs are established options; severe/refractory illness merits specialist review.
Clinical pearl
💡 Content can be shocking; ego-dystonic intrusive thoughts do not by themselves imply intent.
07After the accident, the danger never endedObsessive / Trauma
Presentation
Intrusions/nightmares, avoidance, negative mood/cognitions and hyperarousal after trauma.
Intrusions/nightmares, avoidance, negative mood/cognitions and hyperarousal after trauma.
Decision pathway
Confirm qualifying traumatic exposure and timeline → assess four symptom domains → ask dissociation, substance use, depression and suicide risk → identify ongoing threat/safeguarding issues.
Do not miss
⚠️ Acute stress responses, depression, panic, TBI, substance use, complicated grief.
Management direction
Use trauma-informed care; trauma-focused psychotherapy is central. Medication may be used according to symptoms and guideline recommendations; avoid forced debriefing.
Clinical pearl
💡 Do not make the patient repeatedly retell trauma merely to prove the diagnosis.
08The body keeps sending alarmsSomatic / Functional
Presentation
Multiple persistent bodily symptoms with disproportionate distress, health anxiety or repeated healthcare use.
Multiple persistent bodily symptoms with disproportionate distress, health anxiety or repeated healthcare use.
Decision pathway
Review symptom trajectory and prior work-up → look for new objective red flags → assess thoughts/behaviours around symptoms → screen depression/anxiety/trauma → coordinate one coherent care plan.
Do not miss
⚠️ Undiagnosed medical disease, medication adverse effects, illness anxiety, functional neurological disorder, factitious disorder.
Management direction
Validate suffering, avoid “nothing is wrong,” schedule planned reviews, set functional goals and reduce repeated low-value testing while reassessing genuinely new red flags.
Clinical pearl
💡 Somatic symptom disorder is defined by maladaptive response to symptoms—not by proving symptoms medically unexplained.
09Weakness that does not follow anatomySomatic / Functional
Presentation
Motor or sensory symptoms suggesting neurological disease but showing positive features of functional neurological disorder (FND).
Motor or sensory symptoms suggesting neurological disease but showing positive features of functional neurological disorder (FND).
Decision pathway
Stabilize/assess acute neurological red flags → neurological examination seeking positive inconsistency/incongruence signs → diagnose positively, not solely by normal tests → explore comorbidity without implying fabrication.
Do not miss
⚠️ Stroke, myelopathy, neuropathy, MS, seizure disorders and other neurological disease.
Management direction
Explain FND as a genuine disorder of nervous-system functioning; coordinate neurology/psychiatry/rehabilitation and symptom-specific therapy.
Clinical pearl
💡 “Normal scan” is not the diagnostic criterion; positive clinical signs are more persuasive.
10The seizure with a different rhythmSomatic / Functional
Presentation
Recurrent seizure-like episodes with atypical semiology or discordance with epilepsy.
Recurrent seizure-like episodes with atypical semiology or discordance with epilepsy.
Decision pathway
Treat first unexplained convulsive event safely → obtain witness/video history when available → identify semiological clues without overconfidence → neurological evaluation/EEG strategy → consider functional seizures only after appropriate assessment.
Do not miss
⚠️ Epileptic seizures, syncope, metabolic events, sleep disorders, movement disorders.
Management direction
Communicate diagnosis nonjudgmentally; avoid unnecessary antiseizure medication when epilepsy is excluded; psychotherapy and coordinated neurological care may help.
Clinical pearl
💡 Functional seizures and epilepsy can coexist—one diagnosis does not automatically exclude the other.
11I was there, but it did not feel like meSomatic / Functional
Presentation
Episodes of depersonalization, derealization, amnesia or altered identity/awareness.
Episodes of depersonalization, derealization, amnesia or altered identity/awareness.
Decision pathway
Clarify phenomenology and triggers → assess orientation/attention → screen trauma, panic and substances → neurological review when atypical → evaluate safety and function.
Do not miss
⚠️ Delirium, focal seizures, intoxication, PTSD, panic, psychosis.
Management direction
Grounding, psychoeducation and treatment of comorbid conditions are useful; complex/persistent dissociation benefits from specialist psychotherapy.
Clinical pearl
💡 Preserved reality testing helps distinguish depersonalization/derealization from psychosis.
12The voice in an otherwise clear roomPsychosis
Presentation
Hallucinations, delusions, thought disorder or marked behavioural change.
Hallucinations, delusions, thought disorder or marked behavioural change.
Decision pathway
Check delirium/medical instability first → establish substance/medication exposure → map psychosis against mood episodes → document MSE and risk → obtain collateral history and targeted physical investigations.
Do not miss
⚠️ Delirium, intoxication/withdrawal, mood disorder with psychosis, neurological/endocrine disease, primary psychotic disorder.
Management direction
First-episode psychosis warrants prompt specialist assessment; combine antipsychotic treatment when indicated with family/psychosocial care and physical-health monitoring.
Clinical pearl
💡 Time course and relation to mood/substances often discriminate better than the bizarre quality of a symptom.
13The first psychotic episodePsychosis
Presentation
New delusions/hallucinations/disorganization in a person without established psychotic illness.
New delusions/hallucinations/disorganization in a person without established psychotic illness.
Decision pathway
Safety and capacity → delirium/organic screen → substance history and toxicology when indicated → collateral timeline and functional decline → mood symptoms → baseline metabolic/physical assessment before treatment.
Do not miss
⚠️ Substance-induced psychosis, bipolar mania, severe depression, autoimmune/neurological illness when red flags exist.
Management direction
Use early-intervention principles, shared decision-making and low-burden antipsychotic strategy; arrange close follow-up and family education.
Clinical pearl
💡 Never let a psychiatric label cancel a new neurological red flag.
14Psychosis plus a mood storyPsychosis
Presentation
Psychotic symptoms occurring with prominent depression or mania.
Psychotic symptoms occurring with prominent depression or mania.
Decision pathway
Build a longitudinal timeline: mood episodes versus psychosis → ask whether psychosis ever persists outside mood episodes → review substances → assess suicide/violence risk.
Do not miss
⚠️ Bipolar disorder with psychotic features, major depression with psychosis, schizoaffective disorder, schizophrenia.
Management direction
Treatment depends on the longitudinal diagnosis and severity; psychotic depression and severe mania generally need specialist biological treatment.
Clinical pearl
💡 The diagnosis lives in the timeline, not in one cross-sectional MSE.
15The patient who stopped movingPsychosis / Emergency
Presentation
Mutism, stupor, posturing, negativism, rigidity, excitement or other catatonic signs.
Mutism, stupor, posturing, negativism, rigidity, excitement or other catatonic signs.
Decision pathway
Treat as medical/psychiatric emergency → assess vital signs, hydration and complications → review medicines/substances and neurological/medical causes → structured catatonia assessment → urgent specialist input.
Do not miss
⚠️ NMS, serotonin toxicity, non-convulsive status, encephalitis, severe depression, psychosis, metabolic disease.
Management direction
Supportive medical care is essential; benzodiazepine challenge/treatment and ECT are specialist-established treatments depending on context and response.
Clinical pearl
💡 Catatonia is a syndrome across psychiatric and medical illnesses—not synonymous with schizophrenia.
16The agitated patient at the doorPsychiatric Emergencies
Presentation
Pacing, shouting, threats, aggression or severe behavioural disturbance.
Pacing, shouting, threats, aggression or severe behavioural disturbance.
Decision pathway
Safety/team/environment first → rapidly check ABCs, glucose, oxygenation and delirium/medical causes → verbal de-escalation → assess intoxication, psychosis, mania and risk → medication/restraint only when necessary under local protocol.
Do not miss
⚠️ Hypoxia, hypoglycaemia, delirium, head injury, intoxication/withdrawal, akathisia.
Management direction
Use the least restrictive effective intervention; monitor closely after rapid tranquillisation and document indication, observations and response.
Clinical pearl
💡 Agitation is a presentation, not a diagnosis.
17“I do not want to wake up tomorrow”Psychiatric Emergencies
Presentation
Suicidal thoughts, intent, planning, recent attempt or escalating hopelessness.
Suicidal thoughts, intent, planning, recent attempt or escalating hopelessness.
Decision pathway
Immediate medical needs after self-harm → private compassionate assessment → current thoughts, intent, plan, access to means, past attempts and dynamic stressors → mental state/substances → protective factors/supports → collaborative safety and disposition.
Do not miss
⚠️ Intoxication, severe depression, psychosis, mixed/manic states, acute psychosocial crisis.
Management direction
Do not use a risk score alone to decide discharge. High/imminent risk, inability to collaborate on safety, severe mental illness or unsafe environment requires urgent specialist assessment.
Clinical pearl
💡 Asking directly about suicide does not “put the idea” into someone’s mind.
18After the tablets were swallowedPsychiatric Emergencies
Presentation
Intentional self-poisoning or self-injury.
Intentional self-poisoning or self-injury.
Decision pathway
Medical stabilization and toxicology management first → psychosocial assessment once able to engage → understand intent/function and circumstances → assess ongoing risk and safeguarding → aftercare plan before discharge.
Do not miss
⚠️ Accidental poisoning, intoxication-related impulsivity, domestic violence/coercion, severe mental illness.
Management direction
Coordinate medical and mental-health care; provide means-safety counselling and timely follow-up.
Clinical pearl
💡 The apparent lethality of an act and future suicide risk are related but not interchangeable.
19Confused, seeing things, pulling the IVPsychiatric Emergencies
Presentation
Acute fluctuating confusion, inattention, altered arousal and perceptual disturbance.
Acute fluctuating confusion, inattention, altered arousal and perceptual disturbance.
Decision pathway
Assume delirium until proven otherwise → establish baseline and fluctuation → identify precipitant with focused history/exam/tests → correct reversible causes → environmental orientation and safety.
Do not miss
⚠️ Primary psychosis, dementia, intoxication/withdrawal, non-convulsive seizures.
Management direction
Treat the underlying cause; use non-pharmacological measures first where possible. Medication is reserved for selected severe distress/risk situations under appropriate guidance.
Clinical pearl
💡 Inattention and fluctuation are major clues that the “psychiatric” presentation is delirium.
20Fever, rigidity, and a psychiatric prescriptionPsychiatric Emergencies
Presentation
Hyperthermia, severe rigidity, autonomic instability and altered mental state after dopamine-blocking medication.
Hyperthermia, severe rigidity, autonomic instability and altered mental state after dopamine-blocking medication.
Decision pathway
Emergency ABCs → stop suspected causative drug → urgent medical assessment with CK/renal/electrolyte evaluation and complications → distinguish NMS from serotonin toxicity and other hyperthermic syndromes.
Do not miss
⚠️ Serotonin syndrome, malignant catatonia, sepsis, heat illness, anticholinergic toxicity.
Management direction
Supportive critical care and specialist toxicology/medical management; specific treatments depend on severity and local protocol.
Clinical pearl
💡 NMS is a medical emergency; do not attribute fever and rigidity to “agitation.”
21Clonus after a medication changePsychiatric Emergencies
Presentation
Agitation, autonomic overactivity and neuromuscular hyperactivity after serotonergic exposure.
Agitation, autonomic overactivity and neuromuscular hyperactivity after serotonergic exposure.
Decision pathway
Stop serotonergic agents → assess temperature/ABC → look for clonus/hyperreflexia and exposure combinations → evaluate severity and complications → distinguish from NMS.
Do not miss
⚠️ NMS, anticholinergic toxicity, sympathomimetic toxicity, sepsis.
Management direction
Supportive care and benzodiazepines are common principles; severe hyperthermia requires emergency critical care.
Clinical pearl
💡 Clonus/hyperreflexia favour serotonin toxicity; lead-pipe rigidity favours NMS, though real cases require full assessment.
22No sleep, grand plans, escalating riskPsychiatric Emergencies
Presentation
Severe mania with disinhibition, aggression, psychosis or dangerous behaviour.
Severe mania with disinhibition, aggression, psychosis or dangerous behaviour.
Decision pathway
Safety/capacity → organic/substance screen → assess hydration, sleep, risky acts and psychosis → collateral history → determine need for admission.
Do not miss
⚠️ Stimulant intoxication, delirium, hyperthyroidism, steroid-induced mania.
Management direction
Urgent specialist treatment with antipsychotic/mood-stabilizing strategy as appropriate; reduce stimulation and protect finances/relationships/safety.
Clinical pearl
💡 Behavioural consequences can become the emergency even when vital signs are normal.
23A drink every morning to stop the shakesSubstance Use
Presentation
Tremor, sweating, anxiety, nausea or autonomic symptoms after reducing/stopping alcohol.
Tremor, sweating, anxiety, nausea or autonomic symptoms after reducing/stopping alcohol.
Decision pathway
Establish last drink and dependence severity → prior seizures/DT → vital signs and withdrawal severity → glucose/nutrition/electrolytes and comorbidity → choose outpatient versus supervised/inpatient withdrawal.
Do not miss
⚠️ Sepsis, hypoglycaemia, thyrotoxicosis, sedative withdrawal, head injury.
Management direction
Benzodiazepine-based withdrawal management and thiamine are standard principles, adapted to severity and comorbidity; monitor for seizures and delirium.
Clinical pearl
💡 Previous complicated withdrawal strongly changes the threshold for supervised care.
24The room fills with insects on day threeSubstance Use / Emergency
Presentation
Severe alcohol withdrawal with delirium, agitation, hallucinations and autonomic hyperactivity.
Severe alcohol withdrawal with delirium, agitation, hallucinations and autonomic hyperactivity.
Decision pathway
Emergency medical assessment → confirm withdrawal timeline but search competing causes → monitor vitals, hydration/electrolytes → benzodiazepine-based treatment under monitored protocol → thiamine and complication prevention.
Do not miss
⚠️ Sepsis, hepatic encephalopathy, head injury, other intoxication/withdrawal, primary psychosis.
Management direction
This generally requires inpatient monitored care; treat as a medical emergency, not simply hallucinosis.
Clinical pearl
💡 Delirium tremens includes delirium—impaired attention/awareness—not hallucinations alone.
25He wants to stop alcohol—but what happens after detox?Substance Use
Presentation
Alcohol dependence after acute withdrawal has settled.
Alcohol dependence after acute withdrawal has settled.
Decision pathway
Assess goals/readiness → quantify pattern and consequences → medical/psychiatric comorbidity → psychosocial supports → discuss relapse-prevention medication suitability and therapy → follow-up plan.
Do not miss
⚠️ Untreated depression/anxiety, cognitive impairment, other substance use.
Management direction
Combine psychosocial intervention with appropriate relapse-prevention pharmacotherapy when indicated; mutual-help and family supports may add value.
Clinical pearl
💡 Detoxification treats withdrawal, not the dependence syndrome.
26Pinpoint pupils and slow breathingSubstance Use / Emergency
Presentation
Reduced consciousness with respiratory depression and suspected opioid exposure.
Reduced consciousness with respiratory depression and suspected opioid exposure.
Decision pathway
ABC and ventilation first → naloxone when indicated → reassess because opioid duration may exceed naloxone → identify co-ingestants/complications → transition to substance-use care after recovery.
Do not miss
⚠️ Sedative overdose, pontine lesion, hypoglycaemia, mixed poisoning.
Management direction
Emergency supportive care takes priority; after stabilization offer evidence-based opioid-use-disorder treatment and harm-reduction counselling.
Clinical pearl
💡 The endpoint of naloxone is adequate ventilation, not necessarily complete arousal.
27The patient who cannot get through a day without opioidsSubstance Use
Presentation
Compulsive opioid use, tolerance/withdrawal and persistent use despite harm.
Compulsive opioid use, tolerance/withdrawal and persistent use despite harm.
Decision pathway
Assess current use and overdose risk → withdrawal/intoxication → other substances and infections → readiness/goals → discuss opioid agonist maintenance versus detoxification pathways → psychosocial support.
Do not miss
⚠️ Chronic pain without OUD, sedative co-use, depression/PTSD.
Management direction
Opioid agonist maintenance with methadone or buprenorphine is evidence-based where available; detox alone has high relapse risk and needs ongoing treatment planning.
Clinical pearl
💡 Recovery planning should include overdose prevention, especially after loss of tolerance.
28Sleepless, suspicious, and using stimulantsSubstance Use
Presentation
Agitation, insomnia, paranoia or psychosis after stimulant use.
Agitation, insomnia, paranoia or psychosis after stimulant use.
Decision pathway
Safety/vitals → hyperthermia/chest pain/seizure screen → substance timeline → distinguish intoxication from persistent psychosis → assess suicide/violence risk → observe course.
Do not miss
⚠️ Mania, primary psychosis, thyrotoxicosis, delirium.
Management direction
Acute severe toxicity requires medical management; psychosocial interventions such as CBT/contingency management are evidence-supported for stimulant dependence.
Clinical pearl
💡 Psychosis can be substance-induced, but persistence after abstinence demands longitudinal reassessment.
29Cannabis and the first psychotic breakSubstance Use
Presentation
Psychotic symptoms in a person using cannabis.
Psychotic symptoms in a person using cannabis.
Decision pathway
Define potency/frequency and temporal relation → assess other substances → establish symptoms before use and persistence after abstinence → family history and functional decline → risk.
Do not miss
⚠️ Primary schizophrenia-spectrum disorder, bipolar disorder, other substance-induced psychosis.
Management direction
Stop cannabis, manage acute psychosis according to severity, and arrange follow-up because diagnosis may evolve over time.
Clinical pearl
💡 Temporal association is important, but “uses cannabis” does not automatically prove causation.
30Anxiety after the sleeping pills run outSubstance Use
Presentation
Anxiety, tremor, insomnia, perceptual disturbance or seizures after reducing sedative-hypnotics.
Anxiety, tremor, insomnia, perceptual disturbance or seizures after reducing sedative-hypnotics.
Decision pathway
Identify agent/dose/duration and last use → seizure/delirium risk → other CNS depressants → supervised taper strategy rather than abrupt cessation when dependence exists.
Do not miss
⚠️ Alcohol withdrawal, panic, thyrotoxicosis, stimulant use.
Management direction
High-risk withdrawal needs medically supervised management; gradual individualized tapering is generally safer than abrupt discontinuation.
Clinical pearl
💡 Benzodiazepine withdrawal can be medically dangerous, not merely uncomfortable.
31The smoker who is ready this timeSubstance Use
Presentation
Tobacco dependence with motivation to quit.
Tobacco dependence with motivation to quit.
Decision pathway
Assess dependence and previous attempts → identify triggers → set quit strategy → offer behavioural support plus appropriate pharmacotherapy → arrange early follow-up and relapse plan.
Do not miss
⚠️ Untreated depression/anxiety and other substance use that may undermine cessation.
Management direction
Combination behavioural support and evidence-based cessation medication improves quit success; tailor to contraindications and preference.
Clinical pearl
💡 A lapse is information for the next attempt, not proof that treatment failed.
32The person everyone calls “difficult”Personality & Behaviour
Presentation
Recurrent interpersonal crises, impulsivity, unstable self-image or maladaptive enduring patterns.
Recurrent interpersonal crises, impulsivity, unstable self-image or maladaptive enduring patterns.
Decision pathway
Do not diagnose from one crisis → establish longitudinal pattern since adolescence/early adulthood → assess trauma, mood, substance use and neurodevelopment → evaluate self-harm/violence → formulation of triggers and maintaining factors.
Do not miss
⚠️ Bipolar disorder, PTSD, ADHD, autism, substance use, acute situational crisis.
Management direction
Use consistent boundaries, collaborative crisis planning and evidence-based psychotherapy; medication targets comorbidity/specific symptoms rather than the personality disorder itself.
Clinical pearl
💡 A formulation is often more clinically useful than a pejorative label.
33Repeated self-harm and rapidly shifting relationshipsPersonality & Behaviour
Presentation
Emotion dysregulation, unstable relationships, abandonment sensitivity, impulsivity and recurrent self-harm.
Emotion dysregulation, unstable relationships, abandonment sensitivity, impulsivity and recurrent self-harm.
Decision pathway
Assess current self-harm medically → suicide risk without assuming “attention seeking” → longitudinal personality pattern → trauma/dissociation/substances → collaborative crisis plan.
Do not miss
⚠️ Bipolar disorder, PTSD, ADHD, depressive disorders.
Management direction
Structured psychological treatments are central; avoid fragmented polypharmacy and repeated unplanned admissions when not clinically required.
Clinical pearl
💡 Recurrent self-harm still requires fresh assessment—past survival does not guarantee current safety.
34Rules, perfection, and no room to bendPersonality & Behaviour
Presentation
Pervasive perfectionism, control, rigidity and preoccupation with order that impair function.
Pervasive perfectionism, control, rigidity and preoccupation with order that impair function.
Decision pathway
Differentiate personality traits from ego-dystonic OCD obsessions/compulsions → assess impairment across settings → identify anxiety/depression → consider cultural/occupational context.
Do not miss
⚠️ OCD, autism-spectrum traits, anxiety disorders.
Management direction
Psychotherapy may target rigidity and interpersonal/function consequences; treat comorbid disorders on their own merits.
Clinical pearl
💡 OCPD is not “severe OCD”; the phenomenology is different.
35Memory loss in a patient who is “depressed”Organic / Special
Presentation
Cognitive complaints with low mood, slowed thinking or loss of function.
Cognitive complaints with low mood, slowed thinking or loss of function.
Decision pathway
Establish objective decline and baseline → screen depression → collateral history → medication/medical review → cognitive assessment → investigate reversible causes and dementia when indicated.
Do not miss
⚠️ Delirium, dementia, depression-related cognitive impairment, hypothyroidism, B12 deficiency, medication effects.
Management direction
Treat identified depression while following cognition longitudinally; progressive objective decline warrants neurocognitive evaluation.
Clinical pearl
💡 Depression and dementia can coexist; improvement in mood does not end cognitive follow-up if decline persists.
36The older patient who changed overnightOrganic / Special
Presentation
Abrupt behavioural, sleep or perceptual change in an older adult.
Abrupt behavioural, sleep or perceptual change in an older adult.
Decision pathway
Delirium screen first → infection/metabolic/medication/pain/retention/constipation review → attention and fluctuation → collateral baseline cognition → only then consider primary psychiatric diagnosis.
Do not miss
⚠️ Delirium, dementia with behavioural symptoms, medication toxicity, stroke.
Management direction
Correct precipitant and provide supportive delirium care; minimize deliriogenic drugs and unnecessary restraints.
Clinical pearl
💡 New late-life “psychosis” deserves an organic search before a primary psychiatric label.
37The student who has never been able to sit through a taskOrganic / Special
Presentation
Lifelong inattention and/or hyperactivity-impulsivity impairing study/work and relationships.
Lifelong inattention and/or hyperactivity-impulsivity impairing study/work and relationships.
Decision pathway
Establish childhood onset and cross-setting impairment → collateral/school history when possible → screen sleep, anxiety, mood and substance use → assess functional targets.
Do not miss
⚠️ Anxiety, depression, sleep deprivation, substance use, bipolar disorder.
Management direction
Diagnosis and medication initiation should follow appropriate specialist/local pathways; behavioural and organizational interventions remain important.
Clinical pearl
💡 Adult ADHD is developmental—new-onset adult inattention requires another explanation.
38A lifetime of social difference, now called anxietyOrganic / Special
Presentation
Persistent social-communication differences, restricted interests/routines or sensory features recognized in adulthood.
Persistent social-communication differences, restricted interests/routines or sensory features recognized in adulthood.
Decision pathway
Developmental history → current function and masking → distinguish social anxiety/psychosis/OCD → assess ADHD, mood, sleep and support needs.
Do not miss
⚠️ Social anxiety, schizoid traits, OCD, ADHD.
Management direction
Use neurodiversity-affirming assessment and individualized supports; treat comorbid psychiatric disorders without trying to “medicate autism away.”
Clinical pearl
💡 The developmental timeline prevents many misdiagnoses.
39Not eating, but not because of appetiteOrganic / Special
Presentation
Restriction, weight/shape concerns, bingeing, purging or compulsive exercise.
Restriction, weight/shape concerns, bingeing, purging or compulsive exercise.
Decision pathway
Medical stability first → weight trajectory and behaviours → electrolytes/ECG when indicated → psychiatric risk → determine level of care → multidisciplinary treatment.
Do not miss
⚠️ GI/endocrine disease, depression, ARFID, substance use.
Management direction
Medical instability requires urgent care; psychological and nutritional treatment are central and should be coordinated.
Clinical pearl
💡 A “normal” BMI does not exclude a serious eating disorder or dangerous weight loss.
40Insomnia: symptom, disorder, or warning sign?Organic / Special
Presentation
Difficulty initiating/maintaining sleep or early waking.
Difficulty initiating/maintaining sleep or early waking.
Decision pathway
Ask sleep opportunity/schedule → screen mania, depression, anxiety, substances and medications → look for OSA/RLS clues → identify perpetuating behaviours → diagnose insomnia disorder only when persistent with daytime impact.
Do not miss
⚠️ Bipolar mania, OSA, substance use, circadian disorder, hyperthyroidism.
Management direction
CBT-I is first-line for chronic insomnia; hypnotics require selective short-term use and risk assessment.
Clinical pearl
💡 Reduced need for sleep without fatigue is not ordinary insomnia.
41Nightmares, flashbacks, or psychosis?Obsessive / Trauma
Presentation
Distressing perceptual-like experiences related to trauma, especially at night or around triggers.
Distressing perceptual-like experiences related to trauma, especially at night or around triggers.
Decision pathway
Clarify whether re-experiencing is tied to trauma memory → reality testing and context → assess dissociation → screen psychotic symptoms outside trauma states → substances/sleep phenomena.
Do not miss
⚠️ PTSD, psychotic disorder, sleep paralysis, substance-induced phenomena.
Management direction
Treat the underlying syndrome; trauma-focused therapy for PTSD, antipsychotic strategy only when a psychotic disorder is established/indicated.
Clinical pearl
💡 Phenomenology and context matter more than the single word “voices.”
42The patient convinced a disease has been missedSomatic / Functional
Presentation
Persistent fear of serious illness despite appropriate evaluation, often with checking or avoidance.
Persistent fear of serious illness despite appropriate evaluation, often with checking or avoidance.
Decision pathway
Assess actual symptoms and red flags → quantify health anxiety and reassurance cycle → review healthcare use/internet checking → screen anxiety/OCD/depression → agree boundaries for follow-up.
Do not miss
⚠️ Undiagnosed disease, somatic symptom disorder, OCD, delusional disorder somatic type.
Management direction
CBT-oriented management and consistent planned medical review can reduce reassurance cycles; investigate new objective findings appropriately.
Clinical pearl
💡 Reassurance can briefly soothe anxiety while reinforcing the cycle when repeated endlessly.
43A fixed belief about the bodyPsychosis
Presentation
Unshakeable somatic belief held with delusional conviction.
Unshakeable somatic belief held with delusional conviction.
Decision pathway
Assess conviction and cultural context → examine for genuine medical pathology → look for other psychotic symptoms and mood syndrome → substance/neurological review → risk from self-treatment or refusal of care.
Do not miss
⚠️ Illness anxiety, OCD, body dysmorphic disorder, medical disease.
Management direction
Treat underlying psychotic/mood disorder and maintain medical collaboration; avoid confrontational argument about the belief.
Clinical pearl
💡 The distinction from health anxiety rests heavily on conviction and capacity to consider alternatives.
44Depression after childbirth: when is it more than “baby blues”?Mood & Anxiety
Presentation
Persistent depressive symptoms after delivery with impaired function, guilt, anxiety or thoughts of harm.
Persistent depressive symptoms after delivery with impaired function, guilt, anxiety or thoughts of harm.
Decision pathway
Timeline/severity → suicide and infant-safety assessment → ask psychotic symptoms and past bipolarity → supports/sleep/medical factors → urgent escalation if psychosis, mania or severe risk.
Do not miss
⚠️ Baby blues, postpartum psychosis, bipolar episode, thyroid disease.
Management direction
Use perinatal guideline-based psychological/pharmacological treatment balancing severity, feeding and patient preference; postpartum psychosis is an emergency.
Clinical pearl
💡 Always screen bipolar and psychotic symptoms in severe postpartum mood presentations.
45The mother who has not slept and says the baby has a missionPsychiatric Emergencies
Presentation
Rapid-onset postpartum mania, psychosis, confusion or bizarre beliefs.
Rapid-onset postpartum mania, psychosis, confusion or bizarre beliefs.
Decision pathway
Immediate mother-and-infant safety → urgent psychiatric assessment → bipolar/psychosis history → medical/neurological causes → determine admission, ideally specialist perinatal care where available.
Do not miss
⚠️ Delirium, eclampsia-related/neurological illness, substance/medication causes, severe depression with psychosis.
Management direction
Postpartum psychosis requires urgent specialist treatment and close safeguarding; do not manage as routine postnatal anxiety.
Clinical pearl
💡 The postpartum context lowers the threshold for emergency escalation when psychosis or mania appears.
46Anxiety with a thyroid-shaped clueOrganic / Special
Presentation
Anxiety, tremor, palpitations, weight change and insomnia with possible endocrine features.
Anxiety, tremor, palpitations, weight change and insomnia with possible endocrine features.
Decision pathway
History/exam for thyroid signs → medication/substance review → thyroid testing when clinically indicated → assess whether anxiety persists after medical treatment.
Do not miss
⚠️ Primary anxiety disorder, stimulant use, arrhythmia, menopause-related symptoms.
Management direction
Treat the medical driver when present; psychiatric treatment is added according to residual syndrome and impairment.
Clinical pearl
💡 A psychiatric symptom can be real and still have a medical cause.
47The “depressed” patient taking steroidsOrganic / Special
Presentation
Mood lability, insomnia, depression, mania or psychosis after corticosteroid exposure.
Mood lability, insomnia, depression, mania or psychosis after corticosteroid exposure.
Decision pathway
Establish temporal relation and dose change → severity/risk → exclude delirium/infection/metabolic effects → liaise with prescribing team before altering essential steroid therapy.
Do not miss
⚠️ Primary bipolar/depressive disorder, delirium, underlying inflammatory/CNS disease.
Management direction
When clinically feasible adjust causative medication with treating team; severe psychiatric symptoms may need specialist symptomatic treatment.
Clinical pearl
💡 Medication chronology belongs in every psychiatric history.
48Hearing voices after a seizureOrganic / Special
Presentation
Psychotic symptoms temporally related to epilepsy/seizures.
Psychotic symptoms temporally related to epilepsy/seizures.
Decision pathway
Clarify seizure timing and postictal interval → neurological status/medications → delirium screen → EEG/imaging strategy through neurology when indicated → psychiatric risk.
Do not miss
⚠️ Primary psychosis, postictal confusion, antiseizure-drug effects, substance use.
Management direction
Coordinate neurology and psychiatry; treatment must consider seizure threshold and drug interactions.
Clinical pearl
💡 Temporal relationship to seizures can radically change formulation.
49A new personality after a head injuryOrganic / Special
Presentation
Irritability, disinhibition, apathy, mood change or cognitive problems after TBI.
Irritability, disinhibition, apathy, mood change or cognitive problems after TBI.
Decision pathway
Injury severity/timeline → focal neurological/cognitive assessment → sleep/pain/substances → depression/PTSD → collateral functional change → rehabilitation needs.
Do not miss
⚠️ Primary mood disorder, PTSD, substance use, frontal neurodegeneration.
Management direction
Rehabilitation and environmental strategies are central; medications target defined syndromes/symptoms with attention to cognitive and seizure risks.
Clinical pearl
💡 Behavioural change after brain injury should not be reduced to “personality.”
50The patient who cannot stop gamblingPersonality & Behaviour
Presentation
Persistent gambling despite financial, relational or occupational harm.
Persistent gambling despite financial, relational or occupational harm.
Decision pathway
Assess loss of control and chasing losses → debt/safeguarding → suicide risk → screen bipolar mania and substance use → triggers/access → treatment motivation.
Do not miss
⚠️ Manic spending/gambling, substance use, impulsivity disorders.
Management direction
Psychological interventions and practical harm-reduction/financial barriers are key; treat comorbidities and escalate suicide risk.
Clinical pearl
💡 Ask about debt directly—shame often hides the severity.
Guideline foundation
These pathways are educational clinical-reasoning aids, not a substitute for local emergency protocols, specialist assessment or individualized prescribing. They were editorially aligned with WHO mhGAP clinical-decision principles and relevant NICE guidance for depression, anxiety/panic, psychosis/schizophrenia, bipolar disorder, self-harm and substance-use complications. Local law, formulary and referral pathways take precedence.