Psychiatry (OEPSY): Assessment, Psychopharmacology and Legal-Ethical Decisions
The Psychiatry domain of the OEPSY tests how you turn a presenting complaint into a defensible formulation: mental state examination (MSE), risk, organic differential, and a plan that fits Oman's legal and cultural setting. Expect psychosis, mood disorders, psychotropic monitoring, capacity, involuntary care and consultation-liaison presentations.
Assess before you diagnose
- Cover every MSE domain: appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition, insight, judgement.
- Risk is a structured enquiry: suicide, self-harm, violence, self-neglect, safeguarding, access to means.
- Obtain collateral from family with consent where possible; in Oman relatives often hold key history and aftercare.
- Exclude organic causes: delirium, substances, thyroid disease, B12, HIV/syphilis, medication effects, epilepsy.
Rules that decide answer options
- Diagnose on DSM-5 or ICD criteria plus time course, not one symptom.
- Before any antidepressant, screen for past mania or hypomania; antidepressant monotherapy in bipolar depression risks switch and rapid cycling.
- Antipsychotics need baseline and follow-up weight, BMI, glucose or HbA1c, lipids, prolactin, and ECG where QT risk exists.
- Clozapine is for treatment-resistant schizophrenia and requires regular full blood count monitoring for neutropenia.
- Distinguish serotonin syndrome (clonus, hyperreflexia, tremor, diarrhoea, onset within hours) from neuroleptic malignant syndrome (rigidity, reduced reflexes, autonomic instability, raised creatine kinase, onset over days).
- Capacity is decision-specific: understand, retain, weigh, communicate.
Worked example
A 32-year-old man has three weeks of insomnia, grandiose delusions and agitation; he has stopped eating and threatens his brother. Formulation: acute psychotic episode with high risk. Reasoning: exclude delirium and substances, assess capacity and risk, start an antipsychotic with benzodiazepine cover, admit involuntarily only if the law's criteria (disorder plus risk) are met, and use the least restrictive option.
Traps
- Missing delirium in an older patient.
- Starting an antidepressant without screening for bipolarity.
- Calling psychosis spiritual possession without assessment.
- Skipping metabolic monitoring.
- Disclosing information to relatives without consent unless risk justifies it.