Differential Diagnosis • Manic episode • Hypomanic episode • Stimulant intoxication • Substance-induced bipolar disorder • Hyperthyroidism • Schizoaffective disorder • Attention-deficit/hyperactivity disorder • Anxiety-related pressured speech Key Investigations • Complete psychiatric history • Previous manic, hypomanic and depressive episodes • Medication and supplement review • Alcohol and substance-use assessment • CBC • Electrolytes and renal function • Liver enzymes • TSH • Urine toxicology when indicated • Pregnancy testing when relevant to medication selection Treatment Plan 1. Assess for dangerous or impulsive behaviour. 2. Assess suicidal and homicidal thoughts. 3. Determine whether psychosis is present. 4. Assess the patient’s ability to care for basic needs. 5. Arrange urgent psychiatric evaluation if mania is suspected. 6. Avoid starting antidepressant monotherapy when bipolar disorder is possible. Behavioural Intervention • Reduce environmental stimulation. • Use calm, simple and direct communication. • Avoid arguing with grandiose beliefs. • Involve supportive family members with consent. • Encourage restoration of regular sleep once immediate safety is addressed. Botanical Medicine Considerations Botanical treatment should not delay psychiatric assessment. Sedating herbs may interact with psychiatric medications and are not adequate treatment for an acute manic episode. Nutrition and Lifestyle • Avoid caffeine and stimulants. • Avoid alcohol and recreational drugs. • Establish a regular sleep schedule. • Maintain regular meals and hydration. Pharmacology Safety Antidepressant monotherapy may precipitate or worsen mania in susceptible patients. Medication initiation should be coordinated with an appropriately qualified mental-health prescriber. Clinical Pearl Thought process describes how the patient thinks; thought content describes what the patient thinks about. NPLEX Trap Do not diagnose anxiety or ADHD solely because the patient speaks rapidly. Decreased need for sleep, grandiosity, risky behaviour and functional impairment suggest a mood episode. References • NABNE. NPLEX Part II Clinical Sciences Study Guide. • American Psychiatric Association. DSM-5-TR. • Stahl SM. Essential Psychopharmacology.

Differential Diagnosis • Bipolar depression • Persistent depressive disorder • Adjustment disorder • Bereavement • Hypothyroidism • Anemia • Sleep apnea • Medication-induced depression • Substance-induced depression • Neurocognitive disorder Key Investigations The diagnosis is primarily clinical. Investigations should be guided by history and physical examination: • PHQ-9 for symptom severity and monitoring • Direct suicide-risk assessment • CBC • TSH • Vitamin B12 when indicated • Metabolic panel • Pregnancy testing when relevant • Medication review • Sleep apnea assessment when indicated • Alcohol and substance-use screening Treatment Plan Treatment depends on severity, patient preference, risk and previous response. • Psychoeducation • Cognitive behavioural therapy • Behavioural activation • Regular follow-up • Exercise and sleep intervention • Antidepressant therapy when clinically appropriate • Combination psychotherapy and medication for moderate-to-severe cases • Urgent referral for psychosis, catatonia, severe functional decline or suicide risk Behavioural Intervention Behavioural activation may include: • Scheduling one manageable daily activity • Reintroducing pleasurable activities gradually • Establishing regular waking and sleeping times • Tracking mood and activity • Reducing social withdrawal Botanical Medicine Considerations St. John’s wort has clinically important interactions, including interactions with: • Oral contraceptives • Anticoagulants • Antiretrovirals • Transplant medications • Anticonvulsants • Antidepressants It should not be combined casually with serotonergic medications. Nutrition and Lifestyle • Regular balanced meals • Adequate protein and fibre • Limit alcohol • Regular physical activity • Consistent sleep schedule • Correction of documented nutrient deficiencies • Increase social support Pharmacology Safety Before prescribing an antidepressant: • Screen for past mania or hypomania. • Review suicidality. • Assess potential drug interactions. • Counsel regarding early adverse effects. • Monitor for agitation, activation and worsening suicidal thoughts. • Avoid abrupt discontinuation. Clinical Pearl A diagnosis of major depressive disorder requires both sufficient symptoms and clinically meaningful distress or functional impairment. NPLEX Trap Do not diagnose unipolar depression before asking about past periods of elevated mood, decreased need for sleep, impulsivity or increased goal-directed activity. References • American Psychiatric Association. DSM-5-TR. • NICE. Depression in adults: treatment and management. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Suicide-Risk Assessment Assess: • Current thoughts • Plan • Intent • Access to means • Timing • Previous attempts • Recent losses • Substance use • Psychosis • Agitation • Hopelessness • Social supports • Reasons for living • Ability to participate in safety planning Risk Factors Present • Severe depression • Hopelessness • Specific plan • Firearm access • Intent • Refusal of support • Possible social isolation Immediate Management 1. Maintain continuous observation. 2. Remove immediate access to dangerous objects when safe. 3. Activate emergency psychiatric services. 4. Communicate the plan clearly to emergency personnel. 5. Arrange safe transportation. 6. Address firearm access through appropriate emergency and family channels. 7. Document the patient’s statements verbatim when possible. 8. Document the risk assessment and actions taken. Behavioural Intervention A collaborative safety plan is useful after immediate stabilization and may include: • Warning signs • Internal coping strategies • Safe people and locations • Support contacts • Professional crisis contacts • Restriction of access to lethal means A safety plan is not a substitute for emergency intervention in imminent risk. Botanical Medicine Considerations Botanical therapies are inappropriate as primary management during an acute suicidal crisis. Nutrition and Lifestyle Lifestyle counselling should be deferred until immediate safety and psychiatric stabilization have been achieved. Pharmacology Safety Medication quantities may need to be limited in patients at elevated overdose risk. Medication management should be coordinated with emergency and psychiatric clinicians. Clinical Pearl The combination of plan, intent and access to means indicates a high level of acute suicide risk. NPLEX Trap Do not be falsely reassured because the patient appears calm. Some high-risk patients appear calm after deciding on a suicide plan. References • National Institute of Mental Health. Adult Suicide Safety Assessment Guide. • American Psychiatric Association. Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Major depressive disorder • Persistent depressive disorder • Adjustment disorder • Bereavement • Bipolar depression • Substance-induced depression • Chronic pain-associated depression • Demoralization • Medical illness Key Investigations • PHQ-9 • Direct suicide-risk interview • Medication and substance review • CBC and TSH when indicated • Assessment of chronic pain • Evaluation for sleep disturbance • Assessment of social supports Treatment Plan • Develop a written safety plan. • Involve supportive family with patient consent. • Restrict access to lethal means. • Begin evidence-based depression treatment. • Arrange close follow-up. • Provide clear emergency instructions. • Escalate to emergency care if risk increases. Behavioural Intervention Use behavioural activation: • Schedule regular meals. • Establish a consistent wake time. • Complete one achievable activity daily. • Maintain contact with supportive people. • Track changes in suicidal thinking. Botanical Medicine Considerations Review all supplements for interactions and potential toxicity. Avoid dispensing large quantities of any potentially dangerous substance to a patient with suicidal thoughts. Nutrition and Lifestyle • Avoid alcohol and recreational drugs. • Maintain sleep regularity. • Encourage safe physical activity. • Address social isolation. • Ensure regular nutrition and hydration. Pharmacology Safety Some patients may experience agitation or activation early in antidepressant treatment. Provide clear monitoring instructions and arrange follow-up after treatment initiation or dose changes. Clinical Pearl Passive thoughts such as “I wish I were dead” are clinically significant even when the patient denies a specific plan. NPLEX Trap A patient does not need to say “I will kill myself” before a suicide-risk assessment is required. References • National Institute of Mental Health. Suicide Screening and Safety Assessment Resources. • American Psychiatric Association. DSM-5-TR. • NICE. Depression in adults.

Differential Diagnosis • Bipolar II disorder • Bipolar I disorder • Cyclothymic disorder • Substance-induced bipolar disorder • ADHD • Borderline personality disorder • Major depressive disorder • Hyperthyroidism Key Investigations • Detailed longitudinal mood history • Collateral history with consent • Family history of bipolar disorder • Substance and stimulant assessment • Medication review • TSH • CBC • Metabolic profile • Pregnancy testing when relevant • Baseline weight and metabolic measurements before certain psychiatric medications Treatment Plan • Arrange psychiatric or appropriately qualified mental-health evaluation. • Assess current suicide risk. • Avoid antidepressant monotherapy until bipolar disorder has been adequately considered. • Educate the patient about sleep regularity and mood tracking. • Assess impulsive financial, sexual and substance-related behaviour. • Develop a relapse-prevention plan. Behavioural Intervention Interpersonal and social rhythm strategies may include: • Consistent sleep and waking times • Regular meals • Monitoring early warning signs • Reducing overstimulation • Involving trusted supports • Maintaining consistent daily routines Botanical Medicine Considerations Avoid relying on botanical antidepressants in suspected bipolar depression. Some stimulating or serotonergic products may worsen agitation or interact with psychiatric medication. Nutrition and Lifestyle • Avoid sleep deprivation. • Avoid stimulant products. • Avoid recreational drugs. • Limit alcohol. • Maintain regular exercise without extreme overtraining. • Monitor weight and metabolic health if medication is initiated. Pharmacology Safety Antidepressants may contribute to mood switching in susceptible individuals. Treatment should be selected based on the bipolar diagnosis, severity and psychiatric consultation. Clinical Pearl The most important question before treating depression is often: “Have you ever had a period when you needed much less sleep and felt unusually energetic or driven?” NPLEX Trap Patients may present during depression and may not volunteer a history of hypomania unless specifically asked. References • American Psychiatric Association. DSM-5-TR. • NICE. Bipolar disorder: assessment and management. • CANMAT and ISBD bipolar disorder guidelines.

Differential Diagnosis • Postpartum depression • Bipolar depression • Postpartum psychosis • Thyroid dysfunction • Anemia • Sleep deprivation • Adjustment disorder • Intimate-partner violence • Substance use • Anxiety or obsessive-compulsive symptoms Key Investigations • Edinburgh Postnatal Depression Scale or another validated tool • Direct suicide-risk assessment • Assessment for thoughts of infant harm • Screening for mania and psychosis • CBC • TSH • Medication and substance review • Breastfeeding status • Assessment of family and practical support • Intimate-partner violence screening in private Treatment Plan • Assess suicide and infant safety. • Establish a safety plan. • Arrange close follow-up. • Provide psychotherapy or referral. • Consider medication based on severity, previous response and breastfeeding considerations. • Strengthen family and practical support. • Refer urgently if psychosis, mania or intent to harm self or infant develops. Behavioural Intervention • Support sleep opportunities when another caregiver can safely assist. • Schedule small, achievable daily activities. • Reduce isolation. • Encourage nonjudgmental family support. • Address unrealistic expectations regarding parenthood. Botanical Medicine Considerations Do not assume that botanical products are safe during breastfeeding. Consider: • Transfer into breast milk • Infant age and health • Sedative effects • Contamination • Drug interactions • Lack of safety data Nutrition and Lifestyle • Regular meals • Adequate hydration • Correction of iron deficiency when confirmed • Safe gradual physical activity • Avoid excessive caffeine • Avoid alcohol or recreational substances • Mobilize social support Pharmacology Safety Medication selection should consider: • Previous treatment response • Severity of depression • Breastfeeding • Infant exposure • Maternal suicide risk • Potential bipolar disorder • Drug interactions Clinical Pearl Postpartum depression can occur during pregnancy or in the months following delivery and should not be dismissed as ordinary fatigue. NPLEX Trap Always assess for bipolar symptoms and postpartum psychosis before treating postpartum depression. References • American Psychiatric Association. DSM-5-TR. • American College of Obstetricians and Gynecologists. Perinatal Mental Health Guidance. • NICE. Antenatal and postnatal mental health.

Differential Diagnosis • Persistent depressive disorder • Chronic major depressive disorder • Bipolar depression • Personality disorder • Hypothyroidism • Chronic fatigue related to sleep apnea • Anemia • Substance use • Chronic medical illness • Demoralization Key Investigations • PHQ-9 • Longitudinal mood history • Suicide-risk assessment • Bipolar screening • CBC • TSH • Vitamin B12 when indicated • Sleep assessment • Alcohol and substance-use screening • Medication review Treatment Plan • Establish realistic treatment goals. • Consider structured psychotherapy. • Consider antidepressant treatment when appropriate. • Use behavioural activation. • Address social withdrawal. • Treat coexisting medical or sleep conditions. • Monitor for superimposed major depressive episodes. • Arrange regular follow-up. Behavioural Intervention Behavioural activation should be gradual: 1. Identify avoided activities. 2. Select one manageable activity. 3. Schedule it at a specific time. 4. Record mood before and after. 5. Reinforce progress rather than perfection. Botanical Medicine Considerations Any botanical treatment should be reviewed for: • Drug interactions • Product quality • Pregnancy or breastfeeding • Liver or kidney disease • Serotonergic effects • Risk of mood destabilization Nutrition and Lifestyle • Regular sleep-wake cycle • Routine physical activity • Balanced meals • Reduced alcohol intake • Regular daylight exposure • Increased social connection • Management of chronic pain Pharmacology Safety Chronic treatment requires monitoring for: • Adherence • Adverse effects • Emotional blunting • Sexual dysfunction • Withdrawal symptoms • Emerging hypomania • Suicidal thinking Clinical Pearl Persistent depressive disorder may be missed because patients describe the low mood as part of their personality. NPLEX Trap Do not conclude that chronic low mood is simply a personality trait without assessing duration, impairment and treatable medical causes. References • American Psychiatric Association. DSM-5-TR. • NICE. Depression in adults. • Canadian Network for Mood and Anxiety Treatments guidelines.

Differential Diagnosis • Adjustment disorder • Normal stress response • Major depressive disorder • Generalized anxiety disorder • Acute stress disorder • Bereavement • Substance use • Insomnia disorder Key Investigations Extensive laboratory testing may not be necessary when the history is clear, but consider: • Suicide-risk assessment • Substance-use screening • Sleep assessment • Review of medications • Assessment of financial and social stress • Screening for major depression • Evaluation for anxiety symptoms Treatment Plan • Validate the patient’s distress. • Provide supportive counselling. • Encourage problem-solving. • Address practical resources. • Establish sleep and activity routines. • Monitor for progression to major depression. • Arrange follow-up. • Refer if symptoms persist, worsen or significantly impair functioning. Behavioural Intervention Problem-solving therapy may include: 1. Define the most urgent problem. 2. List possible solutions. 3. Review advantages and disadvantages. 4. Select one achievable action. 5. Evaluate the result at follow-up. Botanical Medicine Considerations Avoid unnecessary medicalization of a time-limited stress response. Botanical products should not replace counselling, practical support and follow-up. Nutrition and Lifestyle • Maintain regular meals. • Avoid excessive alcohol. • Continue exercise. • Preserve social contact. • Establish sleep consistency. • Use relaxation exercises. Pharmacology Safety Medication is not automatically required. Sedative medications may cause dependence, impaired driving or rebound insomnia and should not be used casually. Clinical Pearl Adjustment disorder is diagnosed when the response to a stressor is clinically significant but does not meet criteria for another psychiatric disorder. NPLEX Trap The presence of sadness after a stressful event does not automatically establish major depressive disorder. References • American Psychiatric Association. DSM-5-TR. • NICE. Common mental health problems. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Acute grief • Major depressive disorder • Prolonged grief disorder • Adjustment disorder • Post-traumatic stress disorder • Substance misuse • Social isolation • Sleep disorder Key Assessment • Suicide-risk assessment • Degree of functional impairment • Self-esteem • Ability to experience positive emotion • Substance use • Social support • Circumstances of the death • Trauma symptoms • Persistent yearning and preoccupation • Cultural and spiritual practices Treatment Plan • Provide empathic support. • Normalize common grief reactions without minimizing distress. • Encourage connection with family, community or spiritual supports. • Monitor sleep, nutrition and substance use. • Arrange follow-up. • Refer for grief-focused therapy when symptoms are persistent, severe or disabling. • Treat major depression when full criteria are met. Behavioural Intervention • Encourage maintenance of basic routines. • Support participation in meaningful rituals. • Allow discussion of the deceased. • Encourage gradual return to activities. • Avoid pressuring the patient to “move on.” Botanical Medicine Considerations Sedating products may impair functioning or interact with other medications. Acute grief should not automatically be treated as a biochemical disorder requiring supplements. Nutrition and Lifestyle • Maintain regular meals. • Limit alcohol. • Continue gentle physical activity. • Preserve sleep routine. • Encourage community and family contact. Pharmacology Safety Avoid automatically prescribing sedatives for grief-related insomnia. Consider fall risk, dependence, cognitive impairment and interactions, especially in older adults. Clinical Pearl Grief often occurs in waves and may include preserved positive emotion. Major depression is more likely to produce pervasive low mood, anhedonia and generalized worthlessness. NPLEX Trap Bereavement does not exclude major depression. Assess the full syndrome rather than using the recent loss as the only explanation. References • American Psychiatric Association. DSM-5-TR. • World Health Organization. Guidance on bereavement and mental health. • NICE. Depression in adults.

Differential Diagnosis • Hypothyroidism • Major depressive disorder • Anemia • Vitamin B12 deficiency • Sleep apnea • Chronic kidney disease • Medication adverse effect • Perimenopause • Chronic inflammatory disease • Substance use Key Investigations • TSH • Free T4 when indicated • CBC • Ferritin when iron deficiency is possible • Vitamin B12 when indicated • Electrolytes • Renal and liver function • Glucose or HbA1c • Medication review • Sleep apnea assessment when indicated • Pregnancy testing when relevant Treatment Plan • Confirm the medical diagnosis. • Treat the underlying thyroid disorder. • Assess symptom severity and functional impairment. • Perform suicide-risk assessment when depressive symptoms are present. • Reassess mood after treatment begins. • Treat coexisting major depression separately when criteria remain present. Behavioural Intervention During medical treatment: • Establish gradual activity goals. • Address sleep routine. • Provide reassurance that symptoms have a plausible medical basis. • Monitor mood and cognition. • Avoid blaming the patient for reduced energy. Botanical Medicine Considerations Thyroid-related products may contain variable or undisclosed amounts of thyroid hormone or iodine. Excessive iodine can worsen certain thyroid disorders. Treatment should be based on confirmed thyroid disease and appropriate medical management. Nutrition and Lifestyle • Maintain adequate but not excessive iodine intake. • Review restrictive diets. • Encourage gradual physical activity as tolerated. • Address constipation with fluids, fibre and medical treatment as appropriate. • Avoid taking thyroid medication simultaneously with substances that impair absorption. Pharmacology Safety Thyroid hormone absorption can be reduced by: • Iron • Calcium • Certain antacids • Some fibre supplements • Bile-acid sequestrants Medication timing and monitoring should be reviewed carefully. Clinical Pearl Depression is a clinical diagnosis, but physical symptoms and examination findings may indicate an underlying medical disorder. NPLEX Trap Do not attribute fatigue, cognitive slowing and low mood to a psychiatric disorder before considering endocrine, hematologic, sleep-related and medication causes. References • American Thyroid Association. Hypothyroidism guidance. • American Psychiatric Association. DSM-5-TR. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Major depressive disorder • Panic disorder • Social anxiety disorder • Obsessive-compulsive disorder • Post-traumatic stress disorder • Adjustment disorder • Hyperthyroidism • Cardiac arrhythmia • Medication-induced anxiety • Stimulant or caffeine use • Alcohol or sedative withdrawal • Perimenopausal symptoms • Sleep disorder Key Investigations Generalized anxiety disorder is diagnosed clinically. Testing should be guided by the history and physical examination. Consider: • GAD-7 for baseline severity and monitoring • Suicide-risk assessment • PHQ-9 for coexisting depression • Medication and supplement review • Caffeine and stimulant intake • Alcohol and substance-use screening • TSH when thyroid disease is possible • CBC when anemia is possible • Metabolic panel when clinically indicated • ECG when palpitations or cardiac symptoms require evaluation • Sleep assessment Treatment Plan 1. Explain the diagnosis and relationship between worry, physical tension, avoidance and sleep disruption. 2. Assess symptom severity and functional impairment. 3. Offer or refer for cognitive behavioural therapy. 4. Consider structured self-help for mild symptoms. 5. Consider pharmacologic treatment when symptoms are persistent, moderate to severe or insufficiently responsive to psychotherapy. 6. Address coexisting depression, substance use and medical illness. 7. Arrange regular follow-up. 8. Refer to a mental-health specialist when symptoms are severe, diagnostically unclear or treatment resistant. CBT and appropriately selected pharmacologic treatments are established management options for generalized anxiety disorder. Behavioural Intervention A CBT-based worry intervention may include: • Identifying automatic catastrophic predictions • Distinguishing solvable problems from hypothetical worries • Scheduling a limited “worry period” • Cognitive restructuring • Gradual reduction of reassurance-seeking • Relaxation training • Behavioural experiments • Sleep-focused interventions Botanical Medicine Considerations Botanical or supplemental products should be reviewed for: • Sedation • Hepatic toxicity • Interaction with antidepressants • Interaction with alcohol or sedatives • Pregnancy and breastfeeding safety • Product contamination or variable dosing Botanical treatment should not delay assessment when anxiety is caused by hyperthyroidism, withdrawal, arrhythmia or another medical condition. Nutrition and Lifestyle • Reduce excessive caffeine. • Avoid stimulant-containing pre-workout products. • Limit alcohol. • Maintain regular meals. • Establish a consistent sleep schedule. • Use regular aerobic activity as tolerated. • Practise diaphragmatic breathing or progressive muscle relaxation. • Address social isolation and occupational stress. Pharmacology Safety Long-term benzodiazepine use may cause: • Dependence • Tolerance • Withdrawal • Cognitive impairment • Falls • Impaired driving • Additive sedation with alcohol, opioids or other sedatives SSRIs and SNRIs may initially increase restlessness or gastrointestinal symptoms. Patients should be counselled about gradual onset of benefit and monitored after initiation. Clinical Pearl Generalized anxiety involves persistent worry across multiple areas of life rather than fear limited to one object, social situation or unexpected panic attack. NPLEX Trap Do not diagnose generalized anxiety disorder without reviewing caffeine, stimulants, thyroid disease, medications, substances and withdrawal. References • NABNE. NPLEX Part II Clinical Sciences Study Guide. • National Institute of Mental Health. Anxiety Disorders. • NICE. Generalised Anxiety Disorder and Panic Disorder in Adults.

Differential Diagnosis • Acute coronary syndrome • Panic attack • Pulmonary embolism • Cardiac arrhythmia • Aortic dissection • Pneumothorax • Asthma exacerbation • Hypoglycemia • Thyrotoxicosis • Pheochromocytoma • Stimulant intoxication • Alcohol or sedative withdrawal Key Investigations Depending on the clinical setting: • Vital signs • Oxygen saturation • Point-of-care glucose • Cardiovascular and respiratory examination • ECG • Cardiac biomarkers • Chest imaging when indicated • CBC • Electrolytes • TSH when indicated • Toxicology assessment when relevant • Pulmonary embolism risk assessment Treatment Plan 1. Stabilize airway, breathing and circulation when necessary. 2. Evaluate urgent cardiopulmonary causes. 3. Treat the identified medical cause. 4. When the medical evaluation is reassuring, explain the possibility of a panic attack. 5. Arrange follow-up for psychiatric and medical reassessment. 6. Ask about recurrent episodes, anticipatory fear and avoidance. 7. Assess substance, stimulant and caffeine use. Behavioural Intervention After medical stabilization: • Explain the physiologic fear response. • Teach slow diaphragmatic breathing. • Discourage rapid deep breathing, which can worsen hypocapnia. • Identify catastrophic interpretations of bodily sensations. • Consider CBT if attacks recur. • Avoid reinforcing repeated unnecessary emergency testing once an adequate medical evaluation has been completed. Botanical Medicine Considerations Do not administer sedating or anxiolytic botanical products before excluding acute cardiopulmonary disease. Some products may alter heart rate, blood pressure or medication metabolism. Nutrition and Lifestyle After urgent causes are excluded: • Reduce excessive caffeine. • Avoid stimulant products. • Maintain regular meals to reduce hypoglycemic symptoms. • Limit alcohol. • Maintain adequate hydration. • Address smoking cessation. Pharmacology Safety Benzodiazepines may reduce acute anxiety but can cause sedation, impaired driving, falls, tolerance and dependence. They should not be used as a substitute for urgent medical evaluation. Clinical Pearl The correct first diagnosis in a first-time panic-like presentation with cardiac risk factors is not necessarily panic—it is “chest pain requiring medical assessment.” NPLEX Trap Never assume that chest pain is psychiatric merely because the patient reports fear or hyperventilation. References • National Institute of Mental Health. Panic Disorder: When Fear Overwhelms. • NICE. Generalised Anxiety Disorder and Panic Disorder in Adults. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Cardiac arrhythmia • Hyperthyroidism • Hypoglycemia • Asthma • Vestibular disorder • Seizure disorder • Stimulant use • Alcohol or sedative withdrawal • Generalized anxiety disorder • Social anxiety disorder • PTSD • Somatic symptom disorder Key Investigations When medically indicated: • ECG • CBC • Electrolytes • Glucose • TSH • Medication and supplement review • Substance and caffeine assessment • Respiratory evaluation • Pregnancy testing when relevant to treatment Avoid repeating extensive testing indefinitely after an adequate medical assessment unless symptoms or risk factors change. Treatment Plan • Provide psychoeducation about panic physiology. • Offer or refer for CBT. • Use interoceptive exposure when delivered by a trained clinician. • Address avoidance behaviours. • Consider an SSRI or SNRI when indicated. • Arrange follow-up to monitor symptom frequency and functioning. • Screen for depression and suicide risk. • Assess agoraphobia. CBT-based treatments and antidepressant medication are established longer-term options. NICE advises against routine benzodiazepine treatment for panic disorder because of poorer long-term outcomes. Behavioural Intervention Interoceptive exposure may gradually reproduce feared but safe bodily sensations, such as: • Increased heart rate through supervised exercise • Mild dizziness through controlled turning • Breathlessness through safe exertion The goal is to reduce catastrophic interpretations and avoidance. These exercises should be selected after appropriate medical assessment and conducted within the practitioner’s competence. Botanical Medicine Considerations Avoid combining sedative botanicals with alcohol, benzodiazepines, antihistamines, sleep medications or opioids. Botanical treatment should not reinforce the belief that normal bodily sensations are dangerous. Nutrition and Lifestyle • Reduce caffeine. • Avoid stimulant-containing supplements. • Maintain regular meals. • Resume graded exercise after medical clearance. • Avoid using alcohol to suppress panic symptoms. • Maintain regular sleep. Pharmacology Safety SSRIs may temporarily increase anxiety during the initial treatment period. A low starting dose and gradual titration may be appropriate under qualified supervision. Abrupt discontinuation may cause withdrawal symptoms that patients could misinterpret as recurrent panic. Clinical Pearl Panic disorder is maintained partly by fear of the panic symptoms themselves. NPLEX Trap A panic attack is not synonymous with panic disorder. Panic attacks can occur in multiple psychiatric disorders and medical conditions. References • National Institute of Mental Health. Panic Disorder. • NICE. Generalised Anxiety Disorder and Panic Disorder in Adults. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Panic disorder • Social anxiety disorder • Specific phobia • Vestibular disorder • Cardiac disease • Functional neurologic symptoms • PTSD • Major depressive disorder with withdrawal • Separation anxiety • Psychotic disorder with paranoia Key Investigations • Determine whether panic attacks occur. • Clarify the specific feared consequence. • Assess duration and functional impairment. • Review medical causes of dizziness or syncope. • Review medications and substances. • Screen for depression and suicide risk. • Assess home safety and degree of isolation. Treatment Plan • Provide psychoeducation. • Refer for CBT with graded exposure. • Construct an exposure hierarchy. • Reduce safety behaviours gradually. • Consider pharmacologic treatment when appropriate. • Address coexisting panic disorder. • Arrange practical support without reinforcing permanent avoidance. • Refer when the patient is effectively housebound or unable to access essential care. Behavioural Intervention A graded exposure hierarchy might progress from: 1. Standing outside the home briefly 2. Walking to the end of the street with support 3. Entering a small store during a quiet period 4. Entering the store alone 5. Taking a short bus trip 6. Entering a crowded location Exposure should be collaborative, repeated and gradual—not forced or humiliating. Botanical Medicine Considerations Sedating products may increase dizziness, impaired balance and reliance on a companion. They may also reinforce the belief that exposure is unsafe without taking a substance first. Nutrition and Lifestyle • Maintain hydration. • Avoid prolonged fasting. • Reduce excessive caffeine. • Resume physical conditioning gradually. • Maintain regular sleep. • Address deconditioning caused by prolonged avoidance. Pharmacology Safety Long-term reliance on rapidly acting sedatives may become a safety behaviour and interfere with exposure-based learning. Medication decisions should be individualized and coordinated with qualified prescribers. Clinical Pearl In agoraphobia, the central fear is often being unable to escape or obtain help, not the location itself. NPLEX Trap Do not confuse agoraphobia with social anxiety. A patient with agoraphobia fears entrapment or lack of help; a patient with social anxiety fears judgment or humiliation. References • NICE. Generalised Anxiety Disorder and Panic Disorder in Adults. • National Institute of Mental Health. Anxiety Disorders. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Avoidant personality disorder • Panic disorder • Generalized anxiety disorder • Autism spectrum disorder • Body dysmorphic disorder • Major depressive disorder • Substance-induced anxiety • Essential tremor • Hyperthyroidism • Normal performance anxiety Key Investigations • Assess feared social situations. • Clarify the feared outcome. • Determine avoidance and functional impairment. • Review alcohol or sedative use before social events. • Screen for depression and suicide risk. • Evaluate developmental history when autism is possible. • Evaluate tremor, palpitations or endocrine symptoms when indicated. • Consider a validated social-anxiety screening tool. Treatment Plan • Offer individual CBT specifically designed for social anxiety. • Use cognitive restructuring and behavioural experiments. • Incorporate graduated exposure to feared situations. • Address anticipatory anxiety and post-event rumination. • Consider pharmacologic treatment when appropriate. • Treat coexisting depression or substance use. • Refer when occupational, educational or social functioning is substantially impaired. Behavioural Intervention A behavioural experiment may involve: 1. Predicting what will happen during a short conversation 2. Entering the situation without excessive rehearsal 3. Reducing safety behaviours such as avoiding eye contact 4. Observing the actual response of others 5. Comparing the outcome with the original prediction Botanical Medicine Considerations Avoid using alcohol or sedating botanical products as “social confidence” treatments. These may produce dependence-like behavioural patterns, sedation and impaired performance. Nutrition and Lifestyle • Reduce excessive caffeine before social exposure. • Maintain adequate hydration and meals. • Avoid alcohol as a coping strategy. • Practise regular sleep. • Participate in graded social activities. • Consider supervised communication or public-speaking practice. Pharmacology Safety Medications used only before performances may be inappropriate in patients with: • Asthma • Bradycardia • Hypotension • Conduction disorders • Certain medication interactions Medication treatment should be individualized by an appropriately qualified clinician. Clinical Pearl The defining concern in social anxiety is negative evaluation by others. NPLEX Trap Do not label a patient as introverted or unmotivated when fear of scrutiny is causing clinically important avoidance. References • NICE. Social Anxiety Disorder: Recognition, Assessment and Treatment. • National Institute of Mental Health. Anxiety Disorders. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Panic disorder • Agoraphobia • PTSD • Social anxiety disorder • Obsessive-compulsive disorder • Generalized anxiety disorder • Normal situational fear • Vestibular or motion-sickness disorder Key Investigations • Identify the exact feared stimulus. • Assess the feared consequence. • Determine severity of avoidance. • Ask about panic attacks. • Assess previous traumatic experiences. • Determine whether the fear is limited or part of a broader disorder. • Evaluate medication and substance use. Laboratory testing is not routinely necessary unless suggested by other symptoms. Treatment Plan • Explain the avoidance-anxiety cycle. • Develop a graded exposure hierarchy. • Begin with manageable exposure. • Repeat exposure until distress decreases. • Progress gradually. • Minimize unnecessary safety behaviours. • Consider virtual exposure when appropriate. • Refer to a clinician trained in exposure therapy when needed. Behavioural Intervention A flying-related hierarchy could include: 1. Reading about air travel 2. Viewing photographs of aircraft 3. Watching takeoff videos 4. Visiting an airport 5. Sitting in a stationary aircraft simulation 6. Taking a short accompanied flight The patient should participate voluntarily and understand the purpose of each step. Botanical Medicine Considerations Using sedating products before every exposure may interfere with learning that the situation can be tolerated without a “rescue” substance. Sedation may also create safety concerns during travel. Nutrition and Lifestyle • Avoid excessive caffeine before exposure. • Maintain sleep before travel. • Eat regularly. • Avoid excessive alcohol. • Practise slow breathing without using it as a rigid safety ritual. Pharmacology Safety Sedative medications may impair coordination, judgment and memory. Combining them with alcohol can cause dangerous additive central nervous system depression. Clinical Pearl Effective exposure is gradual, planned, repeated and collaborative. It is not forced flooding without consent. NPLEX Trap Relaxation alone does not correct the central maintaining factor when persistent avoidance is driving the phobia. References • National Institute of Mental Health. Anxiety Disorders. • NICE. Anxiety Disorders Quality Standard. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Generalized anxiety disorder • Illness anxiety disorder • Obsessive-compulsive personality disorder • Psychotic disorder • Autism spectrum disorder • Body dysmorphic disorder • Depression with rumination • Normal hygiene practices Key Investigations • Identify obsessions and compulsions. • Assess time consumed each day. • Determine insight. • Evaluate functional impairment. • Assess skin damage or infection. • Screen for depression and suicide risk. • Ask about tic disorders. • Review medications and substances. • Determine whether beliefs are obsessional or delusional. Treatment Plan • Provide psychoeducation about the obsession-compulsion cycle. • Refer for CBT with exposure and response prevention. • Consider an SSRI when indicated. • Monitor response using a validated symptom scale. • Treat skin complications. • Involve family members carefully to reduce accommodation of rituals. • Refer for specialist care when symptoms are severe, disabling or treatment resistant. Behavioural Intervention A gradual hierarchy may include: 1. Touching a personally owned object without immediate washing 2. Delaying washing for several minutes 3. Touching a mildly feared household surface 4. Extending the delay 5. Progressing to more feared surfaces 6. Eliminating ritualized washing sequences The goal is not to prove that no risk ever exists, but to tolerate uncertainty without compulsive behaviour. Botanical Medicine Considerations Botanical sedatives may reduce distress temporarily but do not directly interrupt the obsession-compulsion cycle. Review interactions carefully if the patient is receiving serotonergic medication. Nutrition and Lifestyle • Maintain regular sleep. • Reduce excessive stimulant intake. • Address malnutrition when rituals interfere with eating. • Use appropriate skin care for excessive washing. • Maintain normal—not excessive—hygiene practices. Pharmacology Safety OCD may require different medication dosing and a longer therapeutic trial than uncomplicated depression. Medication changes should be supervised. Combining serotonergic supplements with serotonergic medication may increase adverse-effect risk. Clinical Pearl Obsessions increase anxiety; compulsions provide temporary relief but reinforce future obsessions. NPLEX Trap Do not participate in repeated reassurance or unnecessary cleaning rituals. Clinician accommodation can maintain OCD. References • National Institute of Mental Health. Obsessive-Compulsive Disorder. • NICE. Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Normal acute stress response • Acute stress disorder • PTSD • Adjustment disorder • Mild traumatic brain injury • Delirium • Substance use • Major depressive disorder • Panic disorder • Traumatic grief Key Investigations • Assess the details and timing of the trauma. • Evaluate head injury and neurologic symptoms. • Assess pain, sleep and medications. • Ask about suicidal and homicidal thoughts. • Assess dissociation and ability to function. • Screen for substance use. • Determine safety in the home environment. • Assess social support. Treatment Plan • Ensure physical safety and medical stabilization. • Provide psychological first aid and practical support. • Educate the patient about common early trauma reactions. • Encourage safe social support and restoration of routines. • Arrange close follow-up. • Refer for trauma-focused therapy when symptoms are substantial or persistent. • Monitor for progression to PTSD, depression, substance misuse or suicide risk. • Avoid forcing the patient to give a detailed trauma narrative immediately. The current VA/DoD guideline addresses both acute stress disorder and PTSD and emphasizes evidence-based assessment and management. Behavioural Intervention Early care may include: • Grounding during dissociation • Sleep support • Gradual return to safe activities • Controlled breathing • Education about avoidance • Identification of supportive people • Practical problem-solving Routine compulsory psychological debriefing immediately after trauma is not the same as evidence-based trauma-focused therapy. Botanical Medicine Considerations Sedating products may worsen cognitive impairment after head injury or interact with analgesics, alcohol and sleep medications. Do not use them before neurologic and medication-related causes of altered awareness are assessed. Nutrition and Lifestyle • Maintain regular meals and hydration. • Limit caffeine when hyperarousal is severe. • Avoid alcohol and recreational drugs. • Establish a regular sleep-wake schedule. • Resume movement gradually as medically appropriate. • Maintain supportive contact. Pharmacology Safety Avoid using benzodiazepines routinely as a trauma-prevention strategy. Sedatives may cause dependence, cognitive impairment and additive central nervous system depression. Medication should target specific severe symptoms only after an individualized assessment. Clinical Pearl Acute stress disorder and PTSD share trauma-related features; duration is a major distinguishing factor. NPLEX Trap Do not diagnose PTSD within the first few weeks solely because trauma-related symptoms are present. References • VA/DoD. Clinical Practice Guideline for Management of PTSD and Acute Stress Disorder. • National Institute of Mental Health. PTSD. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Acute stress disorder • Major depressive disorder • Generalized anxiety disorder • Panic disorder • Adjustment disorder • Traumatic brain injury • Substance-induced disorder • Prolonged grief disorder • Psychotic disorder • Borderline personality disorder Key Investigations • Confirm exposure to trauma. • Assess intrusion, avoidance, mood and arousal symptoms. • Determine duration and impairment. • Assess suicide and self-harm risk. • Screen for depression. • Screen for alcohol and substance use. • Evaluate sleep. • Assess traumatic brain injury when applicable. • Determine whether the patient remains exposed to violence. • Assess social supports. Treatment Plan • Establish physical and emotional safety. • Provide trauma-informed education. • Refer for an evidence-based trauma-focused psychotherapy. • Treat coexisting depression, substance use and sleep disorders. • Develop a crisis plan when risk is elevated. • Consider medication when psychotherapy is unavailable, declined or insufficient. • Coordinate care among medical and mental-health professionals. Prolonged exposure gradually helps patients approach trauma-related memories, emotions and situations that have been avoided. EMDR is also supported as an effective trauma-focused treatment when provided by a qualified clinician. Behavioural Intervention Trauma-focused treatment may include: • Education about trauma responses • Breathing retraining • In-vivo exposure to safe avoided situations • Structured processing of trauma memories • Identification of trauma-related beliefs • Reduction of maladaptive avoidance • Restoration of valued activities Botanical Medicine Considerations Botanical products may interact with: • Antidepressants • Sedatives • Anticoagulants • Alcohol • Sleep medication Adjunctive products should not replace evidence-based trauma therapy or delay crisis assessment. Nutrition and Lifestyle • Avoid alcohol as a sleep or anxiety treatment. • Maintain regular sleep and waking times. • Use gradual physical activity. • Maintain regular meals. • Reduce excess caffeine. • Strengthen safe social connections. • Address chronic pain without excessive sedative use. Pharmacology Safety Before medication treatment: • Assess bipolar history. • Review suicidal thoughts. • Review substance use. • Review pregnancy and breastfeeding when relevant. • Counsel about delayed onset of antidepressant benefit. • Monitor activation and adverse effects. • Avoid abrupt discontinuation. Clinical Pearl Avoidance reduces distress temporarily but prevents corrective learning and maintains PTSD symptoms. NPLEX Trap Mindfulness, supplements and general supportive counselling may be adjunctive, but they are not substitutes for appropriate trauma-focused care in disabling PTSD. References • VA/DoD. Clinical Practice Guideline for Management of PTSD. • National Center for PTSD. Overview of Psychotherapy for PTSD. • National Institute of Mental Health. Post-Traumatic Stress Disorder.

Differential Diagnosis • Depersonalization • Derealization • PTSD-related dissociation • Panic attack • Vasovagal episode • Seizure • Hypoglycemia • Delirium • Psychosis • Medication or substance effect • Functional neurologic symptom Key Investigations During the immediate episode: • Pause the examination. • Reassess vital signs. • Confirm orientation. • Assess for neurologic abnormalities. • Check glucose when clinically indicated. • Review medications and substances. • Assess for immediate danger or self-harm. • Clarify whether the patient wishes to stop the examination. Further investigation depends on the history and presence of medical warning signs. Treatment Plan 1. Stop the triggering procedure. 2. Ask permission before moving closer or touching the patient. 3. Use a calm voice. 4. Orient the patient to the present environment. 5. Offer choices, including stopping or rescheduling. 6. Explain each future examination step before performing it. 7. Obtain explicit consent. 8. Offer a support person or chaperone when appropriate. 9. Refer for trauma-focused mental-health care when symptoms are recurrent or impairing. 10.Document objectively and respectfully. Behavioural Intervention Grounding techniques may include: • Naming five visible objects • Feeling both feet against the floor • Describing the current date and location • Holding a neutral textured object • Taking slow breaths • Naming sounds in the room • Repeating that the traumatic event is not occurring now Grounding should be invitational rather than forced. Botanical Medicine Considerations Sedating a patient is not a substitute for consent or trauma-informed communication. Sedative products may worsen dissociation, impaired awareness or interactions with prescribed medication. Nutrition and Lifestyle Long-term supportive measures may include: • Regular sleep • Regular meals • Limiting alcohol and recreational drugs • Safe physical activity • Grounding practice • Supportive relationships • Trauma-focused psychotherapy Pharmacology Safety Review sedatives, cannabis, alcohol and other substances that may contribute to altered perception or detachment. Medication decisions should address the underlying diagnosis and associated conditions rather than dissociation alone. Clinical Pearl Trauma-informed care asks, “What happened to this patient, and how can I preserve safety and control?” rather than, “Why is this patient being difficult?” NPLEX Trap Do not continue a non-emergency examination when the patient has withdrawn consent or is unable to participate meaningfully. References • National Institute of Mental Health. Post-Traumatic Stress Disorder. • VA/DoD. Clinical Practice Guideline for PTSD and Acute Stress Disorder. • American Psychiatric Association. DSM-5-TR. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Bipolar I disorder • Substance-induced mania • Stimulant intoxication • Hyperthyroidism • Steroid-induced mood disorder • Schizoaffective disorder • Primary psychotic disorder • Delirium • Neurologic disease Key Investigations Urgent assessment may include: • Vital signs • Blood glucose • Mental-status examination • Suicide and violence-risk assessment • Medication and supplement review • Alcohol and substance-use assessment • Urine toxicology when indicated • CBC • Electrolytes • Renal and liver function • TSH • Pregnancy testing when relevant • ECG before certain medications • Neuroimaging when neurologic signs, trauma or atypical onset are present Treatment Plan 1. Maintain a low-stimulation environment. 2. Avoid arguing with grandiose beliefs. 3. Assess immediate danger to self or others. 4. Arrange emergency psychiatric evaluation. 5. Use trained personnel if physical restraint becomes necessary. 6. Treat medical or substance-related causes. 7. Coordinate mood-stabilizing or antipsychotic treatment with an appropriate prescriber. 8. Involve supportive family members when legally and clinically appropriate. Behavioural Intervention During acute mania: • Use short, simple statements. • Set clear behavioural limits. • Avoid lengthy discussions. • Reduce environmental stimulation. • Provide food and fluids when possible. • Postpone complex psychotherapy until stabilization. Botanical Medicine Considerations Botanical sedatives are not adequate treatment for severe mania. Products with stimulating effects may worsen agitation, insomnia or cardiovascular symptoms. Nutrition and Lifestyle After stabilization: • Establish consistent sleep and waking times. • Avoid caffeine and stimulants. • Avoid alcohol and recreational drugs. • Maintain regular meals. • Use mood and sleep tracking. • Identify early warning signs of relapse. Pharmacology Safety Medication monitoring may include: • Weight and BMI • Blood pressure • Glucose or HbA1c • Lipid profile • Renal function • Thyroid function • Liver function • Pregnancy considerations • Drug interactions Clinical Pearl A manic episode causes marked functional impairment, may include psychosis and frequently requires hospitalization. NPLEX Trap Do not confuse a decreased need for sleep with insomnia. A manic patient may sleep very little without feeling tired. References • American Psychiatric Association. DSM-5-TR. • NICE. Bipolar Disorder: Assessment and Management. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Hypomania • Mania • ADHD • Normal excitement • Stimulant use • Hyperthyroidism • Antidepressant-induced mood elevation • Borderline personality disorder • Cyclothymic disorder Key Investigations • Longitudinal mood history • Previous depressive episodes • Previous hospitalization or psychosis • Family psychiatric history • Medication review • Antidepressant and steroid exposure • Caffeine and stimulant use • Substance-use assessment • TSH • Collateral information with consent Treatment Plan • Evaluate for bipolar II disorder. • Assess current and previous depressive episodes. • Assess suicide risk. • Review medications that may contribute to mood elevation. • Encourage mood and sleep tracking. • Maintain regular daily routines. • Arrange psychiatric consultation when the diagnosis is uncertain or treatment is required. Behavioural Intervention • Establish consistent sleep. • Reduce excessive commitments. • Delay major financial decisions. • Monitor spending and impulsive activity. • Involve trusted supports with consent. • Identify individual early warning symptoms. Botanical Medicine Considerations Stimulating botanicals and supplements may worsen activation or sleep loss. Review energy products, weight-loss products and supplements marketed for concentration. Nutrition and Lifestyle • Avoid caffeine excess. • Avoid recreational stimulants. • Maintain regular meals. • Avoid sleep deprivation. • Limit alcohol. • Use structured daily routines. Pharmacology Safety Antidepressant-associated activation should prompt reassessment for bipolar-spectrum illness. Medication should not be stopped abruptly without appropriate clinical guidance unless an emergency adverse reaction is present. Clinical Pearl Psychosis automatically makes an elevated mood episode manic rather than hypomanic. NPLEX Trap High productivity alone is not hypomania. There must be a distinct mood and energy change accompanied by characteristic symptoms. References • American Psychiatric Association. DSM-5-TR. • CANMAT and ISBD Bipolar Disorder Guidelines. • NICE. Bipolar Disorder.

Differential Diagnosis • Schizophreniform disorder • Schizophrenia • Brief psychotic disorder • Bipolar disorder with psychotic features • Major depression with psychotic features • Schizoaffective disorder • Substance-induced psychosis • Delirium • Seizure disorder • Autoimmune encephalitis • Thyroid or metabolic disease • Medication-induced psychosis Key Investigations • Complete physical and neurologic examination • Mental-status examination • Suicide and violence-risk assessment • CBC • Electrolytes • Renal and liver function • Glucose • Calcium • TSH • Vitamin B12 when indicated • Urine toxicology • Pregnancy testing when relevant • Infectious testing based on risk • Neuroimaging when presentation is atypical or neurologic signs are present • Additional testing for encephalitis or seizures when clinically indicated Treatment Plan 1. Determine whether emergency hospitalization is necessary. 2. Arrange early psychosis or psychiatric referral. 3. Treat medical or substance-related causes. 4. Use calm and nonconfrontational communication. 5. Address sleep, nutrition and self-care. 6. Involve family with appropriate consent. 7. Coordinate antipsychotic treatment and monitoring. 8. Develop a relapse and crisis plan. Behavioural Intervention • Validate emotional distress without confirming the delusion. • Say, “I understand that this feels frightening,” rather than agreeing that the belief is true. • Reduce stimulation. • Avoid challenging beliefs aggressively. • Use simple questions. • Assess command hallucinations directly. Botanical Medicine Considerations Botanical treatment should not delay urgent psychiatric evaluation. Cannabis and stimulant-containing products can precipitate or worsen psychosis. Nutrition and Lifestyle • Avoid cannabis and recreational substances. • Avoid stimulant products. • Restore regular meals and hydration. • Establish sleep routines. • Monitor weight and metabolic health during treatment. • Support gradual return to education or work. Pharmacology Safety Before and during antipsychotic treatment, monitor as appropriate: • Weight • Waist circumference • Blood pressure • Glucose or HbA1c • Lipids • Movement disorders • Prolactin-related symptoms • QT-prolongation risk Clinical Pearl The duration of untreated psychosis should be minimized, but diagnostic evaluation must still be thorough. NPLEX Trap Do not directly argue that a delusion is false. Maintain rapport while avoiding reinforcement of the belief. References • NICE. Psychosis and Schizophrenia in Adults. • American Psychiatric Association. DSM-5-TR. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Schizoaffective disorder • Bipolar disorder with psychosis • Major depression with psychosis • Substance-induced psychosis • Autism spectrum disorder • PTSD • Delirium • Neurocognitive disorder • Neurologic disease • Endocrine or metabolic illness Key Investigations • Complete psychiatric history • Physical and neurologic examination • Substance-use assessment • CBC • Metabolic panel • TSH • Toxicology testing • Pregnancy testing when relevant • ECG when indicated • Baseline metabolic measurements • Neuroimaging or other testing for atypical features Treatment Plan • Coordinate psychiatric care. • Use antipsychotic medication when indicated. • Provide psychoeducation. • Offer family intervention. • Support education, housing and employment. • Address substance use. • Monitor physical health. • Assess adherence and adverse effects. • Consider long-acting medication when clinically appropriate. • Develop an emergency and relapse-prevention plan. Behavioural Intervention Psychosocial interventions may include: • Family education • Social-skills training • Cognitive behavioural therapy for psychosis • Supported employment • Cognitive remediation • Medication-adherence support • Relapse-sign monitoring Botanical Medicine Considerations Avoid combining unreviewed supplements with antipsychotic medication. Products may alter sedation, blood pressure, glucose, liver metabolism or cardiac conduction. Nutrition and Lifestyle • Monitor weight and waist circumference. • Promote regular physical activity. • Reduce sugar-sweetened beverages. • Address smoking. • Maintain regular sleep. • Avoid cannabis and stimulants. • Screen for food insecurity. Pharmacology Safety Potential adverse effects include: • Metabolic syndrome • Extrapyramidal symptoms • Akathisia • Tardive dyskinesia • Hyperprolactinemia • Orthostatic hypotension • QT prolongation • Sedation • Neuroleptic malignant syndrome Clinical Pearl Negative symptoms can cause greater long-term functional impairment than positive symptoms. NPLEX Trap Social withdrawal and low motivation are not always depression. Consider negative symptoms when psychotic illness is present. References • American Psychiatric Association. DSM-5-TR. • NICE. Psychosis and Schizophrenia in Adults. • World Health Organization. Schizophrenia.

Differential Diagnosis • Schizophrenia • Bipolar disorder with psychotic features • Major depression with psychotic features • Substance-induced psychosis • Medication-induced psychosis • Delirium • Neurocognitive disorder Key Investigations The most important diagnostic tool is a careful longitudinal timeline of: • Mood symptoms • Psychotic symptoms • Substance use • Medication exposure • Functional decline • Hospitalization • Treatment response Additional testing should exclude medical and substance-related causes. Treatment Plan • Arrange psychiatric management. • Assess suicide risk. • Treat psychosis. • Treat depressive or manic symptoms. • Monitor medication adverse effects. • Address adherence. • Involve family and social supports. • Develop a crisis plan. • Address housing, employment and substance use. Behavioural Intervention • Use supportive therapy. • Teach relapse signs. • Maintain sleep and routine. • Reduce stress. • Provide family education. • Avoid direct confrontation of delusions. • Encourage structured rehabilitation. Botanical Medicine Considerations Avoid unsupervised serotonergic, stimulating or sedating products. Some supplements may destabilize mood or interact with antipsychotic and mood-stabilizing medication. Nutrition and Lifestyle • Regular meals and sleep • Exercise • Smoking cessation support • Avoid cannabis and stimulants • Cardiometabolic monitoring • Adequate hydration Pharmacology Safety Treatment may involve antipsychotic medication with mood-directed treatment. Interaction risks and metabolic monitoring are essential. Clinical Pearl The diagnostic distinction depends on the relationship between mood episodes and psychotic symptoms over time. NPLEX Trap A single interview may not distinguish schizophrenia, schizoaffective disorder and mood disorder with psychosis. Construct a longitudinal timeline. References • American Psychiatric Association. DSM-5-TR. • NICE. Psychosis and Schizophrenia. • Stahl SM. Essential Psychopharmacology.

Differential Diagnosis • Stimulant-induced psychosis • Stimulant intoxication • Acute mania • Schizophrenia • Delirium • Thyroid storm • Anticholinergic toxicity • Serotonin toxicity • Alcohol withdrawal • Neurologic emergency Key Investigations • Airway, breathing and circulation • Continuous vital-sign monitoring • Temperature • ECG • Blood glucose • Electrolytes • Renal function • Creatine kinase • Liver enzymes • Urinalysis • Toxicology testing • Cardiac biomarkers when indicated • Pregnancy testing when relevant • Assessment for trauma • Suicide and violence-risk assessment Treatment Plan 1. Arrange emergency transfer. 2. Reduce environmental stimulation. 3. Use trained personnel for agitation management. 4. Treat hyperthermia and dehydration. 5. Monitor cardiovascular and neurologic status. 6. Treat complications. 7. Reassess psychosis after intoxication resolves. 8. Arrange addiction and psychiatric follow-up. Behavioural Intervention After stabilization: • Use motivational interviewing. • Identify triggers. • Develop relapse-prevention strategies. • Connect the patient with addiction services. • Address sleep, housing and social support. • Provide harm-reduction education. Botanical Medicine Considerations Avoid stimulant botanicals, weight-loss products and unknown performance-enhancing supplements. Products marketed as “natural energy boosters” may worsen sympathetic activation. Nutrition and Lifestyle During recovery: • Restore hydration and nutrition. • Establish sleep routines. • Avoid caffeine and all stimulants. • Address dental and nutritional complications. • Encourage structured recovery support. Pharmacology Safety Combining stimulants with decongestants, caffeine, antidepressants or other sympathomimetics may worsen cardiovascular and psychiatric toxicity. Clinical Pearl Visual hallucinations and marked autonomic activation should increase suspicion for intoxication, withdrawal or a medical cause. NPLEX Trap A positive substance history does not eliminate the need for a complete medical assessment. Intoxication may produce fatal complications. References • Substance Abuse and Mental Health Services Administration. • American Psychiatric Association. DSM-5-TR. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Delirium due to infection • Medication-induced delirium • Dementia • Stroke • Hypoglycemia • Electrolyte disturbance • Hypoxia • Alcohol or sedative withdrawal • Pain • Urinary retention • Constipation • Seizure • Intracranial injury Key Investigations • Vital signs • Oxygen saturation • Blood glucose • Medication review • CBC • Electrolytes • Renal and liver function • Urinalysis and culture when indicated • ECG • Chest imaging when indicated • Bladder scan • Assessment for constipation • Neurologic examination • Neuroimaging for focal signs, trauma or unexplained reduced consciousness • Validated delirium assessment tool Treatment Plan 1. Identify and treat the underlying cause. 2. Stop unnecessary deliriogenic medications. 3. Correct hypoxia, glucose abnormalities and electrolyte disturbances. 4. Treat pain appropriately. 5. Support hydration and nutrition. 6. Provide orientation aids. 7. Ensure hearing and visual aids are available. 8. Promote daytime activity and nighttime sleep. 9. Avoid unnecessary restraints. 10.Use medication for severe agitation only when safety requires it. Behavioural Intervention • Calm reassurance • Visible clock and calendar • Familiar family members • Adequate lighting • Reduced nighttime noise • Frequent reorientation • Mobilization when safe • Consistent caregivers when possible Botanical Medicine Considerations Sedating or anticholinergic botanical products may worsen delirium. Review all nonprescription products. Nutrition and Lifestyle • Restore hydration. • Correct malnutrition. • Ensure dentures are available. • Prevent constipation. • Encourage safe mobility. • Maintain sleep-wake cues. Pharmacology Safety Common deliriogenic medication groups include: • Anticholinergics • Sedative-hypnotics • Opioids • Corticosteroids • Dopaminergic drugs • Some antihistamines • Polypharmacy combinations Clinical Pearl Inattention is the central cognitive feature of delirium. NPLEX Trap Do not prescribe a sedative simply because an older patient is agitated. First identify hypoxia, infection, medication toxicity, pain, retention or metabolic disturbance. References • NICE. Delirium: Prevention, Diagnosis and Management. • American Psychiatric Association. DSM-5-TR. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Alzheimer disease • Vascular neurocognitive disorder • Lewy body dementia • Frontotemporal dementia • Depression • Medication effects • Hypothyroidism • Vitamin B12 deficiency • Normal-pressure hydrocephalus • Brain tumour • Subdural hematoma • Sleep apnea Key Investigations • Collateral history • Functional assessment • Mini-Cog, MoCA or another validated tool • Neurologic examination • CBC • Electrolytes • Renal and liver function • TSH • Vitamin B12 • Glucose • Medication review • Depression screening • Brain imaging when indicated • Hearing and vision assessment Treatment Plan • Confirm the diagnosis. • Identify reversible contributors. • Assess medication management. • Assess driving safety. • Review fall risk. • Establish advance-care planning. • Support caregivers. • Address home safety. • Coordinate appropriate medication treatment. • Monitor behavioural symptoms. • Arrange community resources. Behavioural Intervention • Use consistent routines. • Provide written reminders. • Label commonly used items. • Simplify tasks. • Maintain safe physical activity. • Avoid unnecessary environmental changes. • Use caregiver education. Botanical Medicine Considerations Products marketed for memory may have limited evidence and may interact with anticoagulants, antiplatelet agents, diabetes drugs or cardiovascular medications. Nutrition and Lifestyle • Mediterranean-style eating pattern • Regular physical activity • Social and cognitive engagement • Blood-pressure management • Diabetes management • Smoking cessation • Adequate sleep • Hearing correction • Fall prevention Pharmacology Safety Patients with cognitive impairment are vulnerable to: • Anticholinergic effects • Sedation • Orthostatic hypotension • Medication duplication • Incorrect dosing • Adverse drug interactions Clinical Pearl Functional loss—not a low screening score alone—distinguishes major from mild neurocognitive disorder. NPLEX Trap A cognitive screening test does not independently diagnose dementia. Interpret it with history, education, language, culture, sensory function and daily functioning. References • American Psychiatric Association. DSM-5-TR. • NICE. Dementia: Assessment, Management and Support. • Alzheimer’s Association. Clinical Practice Resources.

Differential Diagnosis • Parkinson disease dementia • Alzheimer disease • Delirium • Medication-induced parkinsonism • Vascular neurocognitive disorder • Normal-pressure hydrocephalus • Psychotic disorder • Charles Bonnet syndrome Key Investigations • Detailed cognitive and functional history • Neurologic examination • Medication review • Cognitive assessment • Sleep history • Laboratory evaluation for reversible causes • Brain imaging when appropriate • Specialist neurologic or geriatric assessment Treatment Plan • Arrange specialist assessment. • Avoid unnecessary antipsychotic exposure. • Treat contributing delirium or pain. • Address fall risk. • Manage sleep and autonomic symptoms. • Support caregivers. • Review driving safety. • Use environmental and behavioural approaches for hallucinations when possible. Behavioural Intervention • Maintain good lighting. • Reduce visual misinterpretations. • Use calm reassurance. • Avoid arguing about hallucinations. • Maintain familiar routines. • Address overstimulation. • Improve sleep safety. Botanical Medicine Considerations Sedating products may increase falls, confusion and orthostatic hypotension. Products affecting dopamine or acetylcholine may interact with prescribed therapy. Nutrition and Lifestyle • Adequate hydration • Regular meals • Fall-prevention strategies • Safe exercise • Constipation management • Sleep-environment safety • Caregiver support Pharmacology Safety Patients with Lewy body dementia may have severe sensitivity to dopamine-blocking antipsychotics. Potential reactions include: • Marked rigidity • Sedation • Confusion • Immobility • Neuroleptic malignant syndrome-like reactions Clinical Pearl Early visual hallucinations plus fluctuating cognition and parkinsonism strongly suggest Lewy body dementia. NPLEX Trap Do not automatically treat visual hallucinations in dementia with a high-potency antipsychotic. References • Dementia with Lewy Bodies Consortium. • NICE. Dementia Guideline. • American Psychiatric Association. DSM-5-TR.

Key Assessment Ask the patient to explain: • The current medical problem • The recommended intervention • The expected benefits • The important risks • The alternatives • The likely outcome of refusing • The reason for the decision Use an interpreter when needed and correct hearing, vision, pain or communication barriers. Treatment Plan • Document the capacity assessment. • Confirm that refusal is informed and voluntary. • Offer less burdensome alternatives when possible. • Provide clear return precautions. • Reassess capacity if mental status changes. • Seek legal or ethical consultation when uncertainty remains. • Follow jurisdiction-specific substitute decision-making law when the patient lacks capacity. Behavioural Intervention • Use plain language. • Present information in small sections. • Ask the patient to repeat information in their own words. • Avoid coercive or threatening communication. • Allow time for questions. • Include trusted supports with the patient’s permission. Botanical Medicine Considerations Supplements with sedative, anticholinergic or psychoactive effects may impair cognition and should be included in the capacity-related medication review. Nutrition and Lifestyle Address reversible contributors such as: • Dehydration • Hypoglycemia • Malnutrition • Sleep deprivation • Sensory impairment • Medication timing Pharmacology Safety Capacity may fluctuate after: • Sedative administration • Opioid use • Anticholinergic medication • Intoxication • Withdrawal • Severe glucose abnormalities Assessment should occur when the patient is as medically and cognitively optimized as possible. Clinical Pearl Capacity is a clinical assessment. Competence is generally a legal determination. NPLEX Trap Do not equate an unconventional or risky decision with incapacity. Evaluate the patient’s decision-making process. References • American Medical Association. Decision-Making Capacity. • American Psychiatric Association. DSM-5-TR. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Alcohol use disorder • Hazardous alcohol use without established disorder • Major depressive disorder • Generalized anxiety disorder • Insomnia disorder • Post-traumatic stress disorder • Bipolar disorder • Other substance-use disorder • Alcohol-induced mood disorder Key Investigations • Quantity, frequency and pattern of alcohol use • Time of the last drink • Previous withdrawal symptoms • History of seizures or delirium tremens • AUDIT-C or another validated screening tool • CBC • Electrolytes • Renal function • Liver enzymes • Bilirubin • Albumin and INR when liver dysfunction is suspected • Glucose • Magnesium • Folate and vitamin B12 when indicated • Pregnancy testing when relevant • Suicide-risk assessment Treatment Plan 1. Determine whether abrupt cessation could cause dangerous withdrawal. 2. Assess the patient’s readiness to change. 3. Use motivational interviewing. 4. Discuss treatment goals, including abstinence or clinically appropriate harm reduction. 5. Arrange medically supervised withdrawal when indicated. 6. Refer to addiction services. 7. Offer behavioural treatment. 8. Consider evidence-based medication through an appropriate prescriber. 9. Address depression, anxiety, trauma and sleep disorders. 10.Arrange ongoing relapse-prevention follow-up. Behavioural Intervention Use the OARS approach: • O: Open-ended questions • A: Affirmations • R: Reflective listening • S: Summaries Example reflection: “Alcohol helps you unwind, but you are also concerned about your health and relationship.” Botanical Medicine Considerations Avoid recommending sedating botanicals to a patient who continues drinking. Combining alcohol with sedatives may increase: • Respiratory depression • Falls • Impaired driving • Confusion • Liver injury Nutrition and Lifestyle • Assess for malnutrition. • Encourage regular meals. • Correct documented deficiencies. • Support hydration. • Avoid substituting alcohol with excessive sugar or caffeine. • Encourage structured evening routines. • Strengthen social and recovery supports. Pharmacology Safety Alcohol may interact dangerously with: • Benzodiazepines • Opioids • Sedating antihistamines • Sleep medications • Antipsychotics • Anticonvulsants • Some diabetes medications • Hepatotoxic drugs Clinical Pearl Motivational interviewing does not mean agreeing with continued harmful use. It means guiding the patient toward personally meaningful reasons for change. NPLEX Trap Do not advise a heavy daily drinker to stop abruptly without first assessing withdrawal risk. References • American Psychiatric Association. DSM-5-TR. • SAMHSA. Motivational Interviewing and Substance Use Disorders. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Alcohol withdrawal • Sedative-hypnotic withdrawal • Stimulant intoxication • Thyrotoxicosis • Sepsis • Hypoglycemia • Panic attack • Serotonin toxicity • Delirium from another medical cause • Intracranial pathology Key Investigations • Airway, breathing and circulation • Vital signs • Oxygen saturation • Blood glucose • Withdrawal-severity assessment • CBC • Electrolytes • Magnesium • Phosphate • Renal and liver function • ECG • Blood alcohol concentration when relevant • Toxicology assessment • Pregnancy testing when relevant • Assessment for trauma, infection and gastrointestinal bleeding Treatment Plan 1. Arrange urgent medical evaluation. 2. Monitor vital signs and mental status. 3. Provide evidence-based withdrawal medication through an appropriate medical service. 4. Administer thiamine according to medical protocols, particularly before or with carbohydrate administration in high-risk patients. 5. Correct dehydration and electrolyte abnormalities. 6. Monitor for seizure, hallucinations and delirium. 7. Treat concurrent medical illness. 8. Arrange addiction treatment after stabilization. Behavioural Intervention After acute stabilization: • Identify withdrawal triggers. • Develop a relapse-prevention plan. • Arrange mutual-support or structured recovery services. • Use motivational interviewing. • Address stress, trauma and sleep without sedative dependence. Botanical Medicine Considerations Botanical products should not be used to manage moderate or severe alcohol withdrawal. They cannot reliably prevent seizures or delirium. Nutrition and Lifestyle Patients with chronic alcohol use may have deficiencies involving: • Thiamine • Folate • Magnesium • Phosphate • Protein and calories Nutritional rehabilitation should occur carefully, with monitoring in severely malnourished patients. Pharmacology Safety Alcohol withdrawal treatment must consider: • Liver dysfunction • Respiratory disease • Concurrent opioids • Sedative use • Fall risk • Pregnancy • Previous withdrawal complications Clinical Pearl A history of withdrawal seizure or delirium tremens is one of the strongest indicators that withdrawal should be medically supervised. NPLEX Trap Do not give glucose alone to a severely malnourished alcohol-dependent patient without considering thiamine deficiency. References • American Society of Addiction Medicine. Alcohol Withdrawal Management Guideline. • SAMHSA. Treatment of Alcohol Withdrawal. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Opioid overdose • Sedative-hypnotic overdose • Intracranial hemorrhage • Hypoglycemia • Carbon monoxide poisoning • Postictal state • Alcohol intoxication • Clonidine toxicity • Brainstem stroke Key Emergency Assessment • Airway • Respiratory rate and effort • Oxygen saturation • Circulation • Blood glucose • Level of consciousness • Temperature • Evidence of trauma • Other substances used • Possible fentanyl or long-acting opioid exposure Treatment Plan 1. Activate emergency medical services. 2. Open and support the airway. 3. Provide ventilation and oxygen. 4. Administer naloxone according to emergency protocols. 5. Repeat naloxone when clinically indicated. 6. Monitor for recurrent respiratory depression. 7. Transfer for emergency evaluation. 8. Assess for aspiration, pulmonary edema and trauma. 9. After stabilization, offer opioid-use-disorder treatment and overdose-prevention planning. Behavioural Intervention After recovery: • Use nonjudgmental communication. • Discuss overdose risk. • Ask about readiness for treatment. • Provide harm-reduction education. • Encourage treatment with evidence-based medications. • Address housing, pain, trauma and mental-health needs. • Develop a relapse and overdose-response plan. Botanical Medicine Considerations No botanical product reverses opioid-induced respiratory depression. Botanical therapies must never delay naloxone and ventilation. Nutrition and Lifestyle After stabilization: • Assess nutritional status. • Screen for infectious disease risks where appropriate. • Address constipation. • Encourage regular sleep and meals during recovery. • Provide safer-use education if abstinence is not immediately achievable. Pharmacology Safety Naloxone may precipitate acute withdrawal, including: • Agitation • Vomiting • Sweating • Pain • Tachycardia These effects are secondary to the lifesaving goal of restoring ventilation. Clinical Pearl Naloxone does not replace ventilation. The patient may require breathing support before naloxone takes effect. NPLEX Trap Do not assume that naloxone’s duration equals the duration of the opioid. Recurrent respiratory depression can occur. References • World Health Organization. Community Management of Opioid Overdose. • SAMHSA. Opioid Overdose Prevention. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Opioid use disorder • Physical dependence during medically appropriate treatment • Undertreated pain • Malingering • Somatic symptom disorder • Depression • PTSD • Other substance-use disorders Key Investigations • Complete substance-use history • Overdose history • Prescription-monitoring review where available • Urine drug testing when clinically appropriate • CBC • Renal and liver function • Pregnancy testing when relevant • HIV and hepatitis testing based on risk • Mental-health assessment • Suicide-risk assessment • Pain and functional assessment • Assessment of housing and social supports Treatment Plan • Refer to an addiction-trained clinician. • Discuss evidence-based medication treatment. • Provide or prescribe naloxone according to local scope and regulations. • Address overdose prevention. • Treat coexisting pain using a multimodal plan. • Address depression, PTSD and anxiety. • Provide behavioural counselling. • Coordinate primary and addiction care. • Monitor relapse and recovery without punitive responses. • Encourage safe storage of medications. Behavioural Intervention Motivational interviewing questions may include: • “What are your main concerns about your opioid use?” • “How has opioid use affected the things that matter most to you?” • “What would need to change for treatment to feel worthwhile?” Botanical Medicine Considerations Avoid unregulated products marketed as opioid-withdrawal cures. They may be ineffective, contaminated, psychoactive or associated with dependence and toxicity. Nutrition and Lifestyle • Restore regular nutrition. • Treat constipation. • Encourage hydration. • Establish sleep routines. • Use graded physical rehabilitation for chronic pain. • Strengthen recovery-oriented social support. Pharmacology Safety Overdose risk increases with: • Benzodiazepines • Alcohol • Sedating sleep medication • Reduced tolerance after abstinence • Fentanyl exposure • Variable illicit-drug potency • Respiratory disease Clinical Pearl Physical dependence can occur during appropriate opioid treatment, but loss of control and continued use despite harm support opioid use disorder. NPLEX Trap Do not treat addiction as a moral failure. It is a clinical disorder requiring continuing care. References • American Society of Addiction Medicine. National Practice Guideline. • SAMHSA. Medications for Opioid Use Disorder. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Cannabis-induced psychotic disorder • Schizophreniform disorder • Schizophrenia • Bipolar mania with psychosis • Stimulant-induced psychosis • Delirium • Neurologic illness • Medication-induced psychosis Key Investigations • Detailed cannabis-use history • Product potency and frequency • Other substance use • Toxicology assessment • Vital signs • Blood glucose • Mental-status examination • Suicide and violence-risk assessment • CBC and metabolic testing when indicated • TSH • Pregnancy testing when relevant • Neurologic evaluation • Collateral history Treatment Plan 1. Assess immediate safety. 2. Arrange emergency evaluation when the patient cannot remain safe. 3. Stop cannabis use. 4. Treat severe agitation or psychosis through appropriate medical services. 5. Monitor symptoms after intoxication resolves. 6. Arrange early psychosis follow-up when symptoms persist. 7. Provide substance-use counselling. 8. Educate the patient and family about recurrence risk. Behavioural Intervention • Use motivational interviewing. • Identify triggers for cannabis use. • Build alternative coping strategies. • Address peer and environmental influences. • Develop a relapse-prevention plan. • Support sleep restoration. Botanical Medicine Considerations Cannabis is a botanical substance, but “natural” does not mean free of psychiatric risk. Products vary widely in potency and composition. Nutrition and Lifestyle • Restore sleep. • Avoid stimulants and other psychoactive substances. • Maintain hydration and regular meals. • Reduce sensory stimulation during recovery. • Involve supportive family or friends with consent. Pharmacology Safety Combining cannabis with sedatives may worsen cognitive impairment. Cannabis may also affect adherence and response to psychiatric medications. Clinical Pearl A substance-induced diagnosis should be considered when symptoms develop during or shortly after substance exposure, but persistent symptoms require reassessment for a primary disorder. NPLEX Trap Do not dismiss cannabis-related psychiatric symptoms because cannabis is legal or prescribed in some settings. References • American Psychiatric Association. DSM-5-TR. • National Institute on Drug Abuse. Cannabis and Mental Health. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Anorexia nervosa • Avoidant/restrictive food intake disorder • Major depressive disorder • Hyperthyroidism • Gastrointestinal disease • Malignancy • Diabetes mellitus • Substance use • Body dysmorphic disorder Key Investigations • Weight, height and BMI • Orthostatic vital signs • ECG • CBC • Electrolytes • Magnesium • Phosphate • Calcium • Renal and liver function • Glucose • TSH • Pregnancy testing when relevant • Bone-health evaluation • Suicide and self-harm assessment • Assessment of purging, laxative and diuretic use Treatment Plan 1. Arrange urgent medical assessment. 2. Stabilize cardiovascular and metabolic abnormalities. 3. Assess refeeding-syndrome risk. 4. Use multidisciplinary eating-disorder care. 5. Provide supervised nutritional rehabilitation. 6. Offer evidence-based psychotherapy. 7. Restrict excessive exercise during instability. 8. Monitor weight, electrolytes and cardiac status. 9. Address osteoporosis and endocrine complications. 10.Assess family and social support. Behavioural Intervention Treatment may include: • Structured meal support • Cognitive behavioural treatment • Family-based treatment for adolescents and young adults • Reduction of compulsive exercise • Body-image work • Exposure to feared foods • Relapse-prevention planning Botanical Medicine Considerations Avoid appetite suppressants, stimulant-containing products, laxative botanicals and diuretics. These may worsen malnutrition, arrhythmia and electrolyte disturbance. Nutrition and Lifestyle Nutritional rehabilitation must be: • Structured • Monitored • Progressive • Coordinated with medical assessment Rapid unsupervised refeeding in a severely malnourished patient may be dangerous. Pharmacology Safety Malnutrition can alter: • Drug metabolism • QT interval • Blood pressure • Seizure threshold • Renal clearance • Medication protein binding Clinical Pearl Eating disorders are psychiatric illnesses with potentially life-threatening medical complications. NPLEX Trap Do not rely on body appearance alone. A patient can have severe eating-disorder pathology and medical instability at different body weights. References • American Psychiatric Association. Eating Disorders Practice Guideline. • NICE. Eating Disorders: Recognition and Treatment. • American Psychiatric Association. DSM-5-TR.

Differential Diagnosis • Bulimia nervosa • Binge-eating disorder • Anorexia nervosa, binge-purge type • Gastrointestinal disease • Substance use • Borderline personality disorder • Major depression • Body dysmorphic disorder Key Investigations • Electrolytes • Bicarbonate • Magnesium • Phosphate • Renal function • ECG • Dental assessment • Pregnancy testing when relevant • Assessment of laxative and diuretic use • Suicide and self-harm assessment • Substance-use screening • Evaluation for esophageal injury when symptoms suggest it Treatment Plan • Refer for eating-disorder-focused psychotherapy. • Establish regular structured eating. • Stop purging and laxative misuse. • Correct electrolyte abnormalities. • Provide dental care. • Monitor cardiac risk. • Treat comorbid depression and anxiety. • Consider medication through an appropriate prescriber. • Arrange urgent care for hematemesis, syncope, severe weakness or arrhythmia. Behavioural Intervention CBT-based treatment may include: • Regular meal scheduling • Monitoring binge triggers • Challenging rigid dietary rules • Reducing body checking • Developing alternatives to purging • Relapse-prevention planning Botanical Medicine Considerations Avoid stimulant laxatives and “detox” products. Chronic use can cause: • Electrolyte imbalance • Dehydration • Dependence • Colonic dysfunction • Cardiac arrhythmia Nutrition and Lifestyle • Use regular meals and snacks. • Avoid prolonged fasting. • Restore hydration. • Correct electrolyte abnormalities medically. • Limit excessive exercise. • Address dental hygiene after vomiting without immediately brushing damaged enamel. Pharmacology Safety Purging-related electrolyte abnormalities can increase arrhythmia risk, especially with medications that prolong the QT interval. Clinical Pearl Normal body weight does not exclude a serious eating disorder. NPLEX Trap Do not recommend dieting to a patient with recurrent binge-purge behaviour. Restriction often worsens the cycle. References • American Psychiatric Association. DSM-5-TR. • NICE. Eating Disorders. • Academy for Eating Disorders. Medical Care Standards.

Differential Diagnosis • Bipolar disorder • PTSD • Complex trauma • Major depressive disorder • Substance-use disorder • ADHD • Histrionic personality disorder • Dissociative disorder Key Assessment • Current suicidal thoughts • Plan and intent • Access to means • Severity of injury • Previous attempts • Substance use • Recent interpersonal loss • Dissociation • Psychosis • Protective factors • Ability to use a safety plan Treatment Plan • Treat injuries. • Complete a suicide-risk assessment. • Develop a collaborative safety plan. • Maintain clear and consistent boundaries. • Refer for evidence-based psychotherapy. • Coordinate communication among clinicians. • Avoid reinforcing crisis behaviour while still responding compassionately. • Treat comorbid depression, PTSD or substance use. • Arrange emergency care when risk is imminent. Behavioural Intervention Dialectical behaviour therapy skills may include: • Distress tolerance • Emotion regulation • Mindfulness • Interpersonal effectiveness • Crisis-survival strategies • Identification of triggers • Replacement behaviours for self-harm Botanical Medicine Considerations Avoid dispensing large quantities of potentially toxic substances to patients with recurrent self-harm. Review supplements for overdose toxicity and interactions. Nutrition and Lifestyle • Maintain regular sleep and meals. • Avoid alcohol and recreational drugs. • Use planned exercise. • Develop safe sensory grounding strategies. • Strengthen stable social supports. Pharmacology Safety Medication does not directly treat the full personality pattern. Polypharmacy should be avoided when possible. Limit access to potentially dangerous quantities when overdose risk is present. Clinical Pearl A patient may engage in nonsuicidal self-injury without intending death, but suicide risk must still be assessed every time. NPLEX Trap Do not confuse the rapid mood shifts of borderline personality disorder with the sustained episodes of bipolar disorder. References • American Psychiatric Association. DSM-5-TR. • NICE. Borderline Personality Disorder. • Linehan MM. Dialectical Behavior Therapy.

Differential Diagnosis • Antisocial personality disorder • Substance-use disorder • Intermittent explosive disorder • Bipolar mania • Psychotic disorder • Traumatic brain injury • Narcissistic personality disorder • Malingering Key Assessment • Immediate violence risk • Access to weapons • Intoxication • Withdrawal • Psychosis • Mania • History of assault • Specific threats • Medication misuse • Prescription-monitoring information • Staff and clinic safety Treatment Plan • Use calm, direct communication. • Establish clear behavioural expectations. • Avoid unnecessary argument. • Use clinic safety procedures. • Document objectively. • Do not falsify records. • Do not prescribe outside safe clinical standards. • Involve security or emergency services when credible threats are present. • Coordinate addiction or psychiatric care when indicated. • Follow ethical procedures if terminating care. Behavioural Intervention Communication should be: • Brief • Neutral • Specific • Consistent across staff • Focused on observable behaviour • Free of moral judgment Example: “I cannot alter the record or issue an early refill without a clinical indication. I can review your symptoms and discuss safe options.” Botanical Medicine Considerations Do not substitute unregulated sedatives for controlled medications simply to end conflict. This may create additional toxicity or misuse risk. Nutrition and Lifestyle Lifestyle counselling may be appropriate for coexisting illness but is not the immediate priority during threats, intoxication or unsafe medication demands. Pharmacology Safety Controlled-substance prescribing should include: • Clear indication • Risk-benefit assessment • Monitoring • Safe quantities • Review of interactions • Documentation • Consistent policies Clinical Pearl Empathy does not require surrendering professional boundaries. NPLEX Trap Do not use stigmatizing labels in the medical record. Document specific observed behaviour and statements. References • American Psychiatric Association. DSM-5-TR. • Federation of State Medical Boards. Safe Prescribing Principles. • NABNE. NPLEX Part II Clinical Sciences Study Guide.

Differential Diagnosis • Gambling disorder • Bipolar mania • Antisocial personality disorder • Substance-use disorder • Obsessive-compulsive disorder • ADHD-related impulsivity • Normal recreational gambling • Financial fraud or coercion Key Assessment • Amount of debt • Access to shared finances • Suicide and self-harm risk • Depression • Substance use • Mania or hypomania • Legal problems • Family impact • Domestic conflict • Employment consequences • Previous treatment attempts Treatment Plan • Complete suicide-risk assessment. • Refer for gambling-focused psychotherapy. • Use motivational interviewing. • Consider CBT. • Encourage financial safeguards with informed consent. • Treat depression, substance use or bipolar disorder. • Provide debt and legal-resource referrals. • Encourage self-exclusion from gambling platforms and venues where available. • Involve supportive family members with the patient’s consent. • Arrange close follow-up during acute financial crisis. Behavioural Intervention Strategies may include: • Identifying gambling triggers • Blocking gambling applications and websites • Self-exclusion • Limiting access to cash and credit • Delaying urges • Replacing gambling with structured activities • Challenging beliefs about probability and recovering losses • Mutual-support programs Botanical Medicine Considerations Botanical products do not treat the cognitive distortions, impulsivity and reinforcement cycle that maintain gambling disorder. Nutrition and Lifestyle • Restore regular sleep and meals. • Avoid alcohol during high-risk periods. • Increase structured activity. • Reduce isolation. • Address stress without gambling. • Develop accountability supports. Pharmacology Safety Assess whether medication-related activation, untreated mania or stimulant use is contributing to gambling behaviour. Clinical Pearl “Chasing losses” means returning to gamble in an attempt to recover money already lost and is a characteristic warning sign. NPLEX Trap Do not focus exclusively on debt management. Assess suicide risk, mood disorder, substance use and behavioural addiction. References • American Psychiatric Association. DSM-5-TR. • National Council on Problem Gambling. Clinical Resources. • NABNE. NPLEX Part II Clinical Sciences Study Guide.