Chelsea, 20, says she’s “going mad with anxiety.”

Onset with VCE exams; now pervasive worry, decision paralysis, and no depressive features.

You suspect GAD. 

What would you do to confirm this? 👇 Nature of Anxiety.
 
Worry is frequent, excessive, hard to switch off, and out of keeping with threat, often without a trigger.

It persists even when things are going well and becomes the problem, not the topic [Andrews et al., 2018].

Females with ADHD constitute a silent minority, with a propensity towards underdiagnosis and undertreatment.

There is evidence to suggest that there is a significant discrepancy in the ratio of males to females diagnosed with ADHD. [Berry et al., 1985]

Let’s explore why ADHD manifests differently in females👇 ADHD is diagnosed far more often in males than females.

Early studies show teachers are more likely to refer boys for assessment, even when girls show identical symptoms.
(Young et al., 2020)

Lamotrigine prolongs the time between mood episodes and is particularly effective in preventing depressive relapses in bipolar I disorder.

Unlike lithium or antipsychotics, lamotrigine has no significant effect on acute mania but is a first-line option for bipolar depression (RANZCP Guidelines)​.

How does lamotrigine work? Let's explore its efficacy in bipolar disorder and important prescribing considerations. 🧵👇 Mechanism of Action

● Increases GABA release, supporting inhibitory neurotransmission​.

● Inhibits voltage-gated sodium (Na+) channels, reducing glutamate excitotoxicity​.

● Putative anti-kindling effects may help stabilise mood over time​.

The dual action on GABAergic and glutamatergic pathways may explain lamotrigine’s effectiveness in bipolar depression but lack of efficacy in mania.

A 53-year-old man with schizoaffective disorder on clozapine (700mg/day) had severe abdominal pain and vomiting to the ER.

Let’s walk through his case and explore why Clozapine induced Constipation (CIC) affects up to 60% of patients. 🧵👇 Background:

Clozapine is highly effective for treatment-resistant psychosis, but its anticholinergic and antiserotonergic effects slow gut motility.

If untreated, CIC can progress to ileus, sepsis, or death.

Lithium: still the most distinctive mood stabiliser we have.

70 years in practice with compelling evidence in mania, acute bipolar depression, and prophylaxis, yet its mechanisms remain multifaceted.

Here’s what makes Lithium so different and it’s mechanisms of action 🧵👇 Lithium is a unique agent that has been used for over half a century for the treatment of bipolar affective disorder.

Lithium has compelling evidence in the treatment of mania, acute bipolar depression and prophylaxis in bipolar
affective disorder.

Despite its first discovery in 1949 and its subsequent use, the exact mechanisms of action in lithium are unclear.

Lithium’s Action On Neurotransmitters:

Studies suggest that up to 50% of adults with ADHD meet criteria for an anxiety disorder (Fu et al., 2025).

Anxiety is not simply “comorbid”; it is embedded in ADHD’s neurobiology and developmental trajectory.

Let’s explore how anxiety and ADHD intersect, and why recognising this link can improve diagnostic clarity, treatment planning, and patient outcomes. 👇🧵

Note: image is a conceptual illustration (uncertainty ↔ arousal ↔ anxiety), not a validated biomarker/model. Across studies, anxiety co-occurs with adult ADHD in ~25–50% of cases; representative samples report ~47–56%.

Comorbidity tracks with earlier onset and greater impairment.

Borderline Personality Disorder (BPD) isn’t just “emotion dysregulation.”

It can be usefully conceptualised as a predictive-processing problem where salience, reward prediction errors (RPEs), and the endogenous opioid system (EOS) bias social learning.

Here’s how clinicians can help patients update predictions and reduce volatility. 🧵👇 Prediction errors = expectation vs outcome

Rapid, phasic dopamine/serotonin signalling in reward/salience networks encodes PEs, guiding attention, belief updating and affect regulation.

Why does ADHD frequently co-occur with sleep dysfunction and sometimes mimic other sleep disorders?

Sleep dysfunction isn’t just a secondary issue in ADHD.

It often reflects deeper interactions with emotion, arousal, and circadian regulation.

Here’s what you need to know about REM-atonia and how its disruption contributes to complex sleep issues in ADHD with comorbidities. 👇🧵 REM atonia: What happens in healthy REM sleep?

Normal REM sleep includes:

• Subcoeruleus (SLD) activation

• GABA/glycine release

• Motor inhibition

This suppresses movement during dreams, essential for sleep quality and neurological regulation.

ADHD isn’t just an “attention” problem.

It’s impaired prefrontal regulation across distributed circuits (PFC–striatal–cerebellar–salience networks) that shape attention, inhibition, and emotion.

Here’s how these circuits interact and what clinicians need to know about the neurobiology behind ADHD 🧵👇 The prefrontal cortex (PFC) directs top-down attention, choosing what’s relevant, suppressing distraction, and maintaining goal-oriented focus.

When this system falters, stimulus-driven (“bottom-up”) networks dominate, explaining distractibility and inconsistent attention in ADHD.

75% of anti-NMDA receptor encephalitis cases first present to psychiatrists, not neurologists.

Could a manic or psychotic episode be an immune-mediated brain ‘attack’?

Here’s what psychiatrists need to know about identifying and managing neuroinflammation.

1/10🧵 Atypical First-Episode Mania

A 21-year-old woman presents with:

• Pressured speech

• Disinhibition

• Decreased need for sleep

No prior psychiatric, substance, or trauma history.

Viral prodrome + non-response to antipsychotics.

2/10🧵

A 17-year-old student was brought to the clinic with a one-week history of unusual behaviour and beliefs.

He was convinced his laptop and phone were controlling his actions, and refused to use them.

Let’s walk through his case and explore what it teaches us about internet use, emerging psychosis, and psychiatry in the digital age.

1/15🧵 Initial Presentation

He believed unknown groups were tracking him through electronic devices.

As a result, he became reluctant to leave the house.

Mood was perplexed; insight partial.

2/15🧵

Why do many people with BPD feel constant discomfort in their own body?

French psychoanalyst Didier Anzieu used the “skin ego” as a metaphor—a psychological “container” that helps hold the self together.

In BPD, that container can feel fragile, porous, or easily disrupted.

Here’s how early experiences can shape self-boundaries and affect regulation and why recognising these patterns can improve care.

1/12🧵 Many people with BPD describe distress as a bodily experience: crawling skin, burning face, the urge to escape their body.

These may reflect disrupted self-boundaries and affect containment not just a dermatological problem.

2/12🧵

Cariprazine is a third-generation antipsychotic with D3-preferring D3/D2 partial agonism and 5-HT1A partial agonism. (Kiss et al., 2019)

Its unique receptor profile is associated with improved motivation, mood, and cognitive functioning.

Here’s what clinicians need to know about its mechanism, pharmacokinetics, and clinical application. 🧵👇 Mechanism of Action Overview

Cariprazine’s receptor activity includes:

• Partial agonism at D3 and D2 receptors
• Partial agonism at 5-HT1A receptors
• Antagonism at 5-HT2A receptors

D3 receptor engagement is linked to negative-symptom improvement; cognitive benefits remain postulated.

Why do two patients respond so differently to the same antidepressant?

Psychotropic efficacy isn’t just about dose or diagnosis. It’s also about how the drug is metabolised.

Here’s what you need to know about CYP450 metabolism in psychiatry, and how it can improve treatment outcomes and reduce adverse effects. 👇🧵 The CYP450 enzyme system metabolises many psychotropics.

Each patient inherits a metabolism “speed” for key enzymes:

 • Poor → slower clearance = ↑ side effects
 • Ultrarapid → faster clearance = ↓ efficacy

Same drug, same dose, different outcomes.

Are we reliably identifying comorbid Autism and ADHD in clinical assessments?

ADHD occurs in 30–80% of people with ASD, while ASD occurs in 20–50% of people with ADHD (Lau-Zhu, 2019; Young et al., 2020). Yet the pair is still missed too often.

Here’s what every clinician needs to know about their overlap, and what to do when it shows up in your practice. 🧵👇 Historically, these conditions were seen as mutually exclusive.

ASD was listed as an exclusion for ADHD until DSM-5 revised this in 2013 (APA, 2013).

Now, dual diagnosis is not only permitted, it’s essential.

Is dissociation in PTSD just a symptom, or the brain’s survival strategy?

Around 15–30% of patients with PTSD experience dissociative symptoms such as depersonalisation or derealisation.

Let’s discover why recognising dissociation is critical for tailoring therapy and improving outcomes. 👇🧵 Two PTSD phenotypes:

1️⃣ Emotional undermodulation → hyperarousal, re-experiencing.

2️⃣ Emotional overmodulation → numbing, detachment, dissociation.

Understanding these helps match interventions: 

- grounding for hyperarousal
- stabilisation before trauma processing in dissociation.

A woman was admitted with acute psychosis, marked by fixed somatic delusions.

She was convinced that parasites were crawling under her skin.

With no prior psychiatric history, her condition deteriorated rapidly as new syndromes emerged.

Let’s walk through her case and examine what it teaches us about the interface between neurology and psychiatry. 

1/16🧵 Initial presentation

The first phase was psychosis, dominated by delusions of infestation.

Her affect was disturbed, but she remained oriented and responsive.

There was no background of schizophrenia, bipolar disorder, or substance misuse.

2/16🧵

Sleep isn’t just “off.”

The locus coeruleus (LC), the brain’s noradrenaline hub, stays active in a patterned way, shaping when we sleep deeply, dream, or wake too easily. (Osorio-Forero 2022)

Here’s why it matters clinically.

1/11🧵 Classic view: LC goes quiet at night.

Revised view: it’s state-dependent.

• NREM: activity is low but rhythmic.
• REM: LC neurons are almost completely silent.

2/11🧵

Up to 90% of patients with ADHD experience at least one comorbidity, from anxiety to substance use disorders (Kessler et al., 2006).

These overlaps complicate diagnosis and treatment, making it essential for clinicians to recognise and address them effectively.

Here are 10 key ADHD comorbidities and evidence-based strategies to navigate them. 👇🧵 1. Behavioural Disorders & ADHD

Oppositional Defiant Disorder (ODD) overlaps with ADHD (irritability, reactivity) but includes defiance and vindictiveness.

→ Mild: Start with stimulants (e.g., methylphenidate).
→ Moderate-severe: Add CBT or parental training. 
→ Severe: Consider risperidone.

Conduct Disorder (CD) involves persistent aggression or deceit, risking antisocial outcomes.

→ Combine stimulants with therapy. 
→ Severe: Use SSRIs or antipsychotics like risperidone.

Why do two patients with the same trauma history follow such different paths, one recovers, while the other remains ‘stuck’?

Research shows PTSD is not a single disorder but a heterogeneous condition with distinct phenotypes and mechanisms.

Here are 10 clinician insights that explain these differences and can guide better outcomes in practice. 👇🧵 #1 PTSD is heterogeneous

Not all PTSD looks the same.

Fear, dysphoria, and distress contribute differently to each patient’s presentation.

Recognising this heterogeneity is the first step to tailoring treatment.

How many patients treated for depression are actually struggling with undiagnosed Obstructive Sleep Apnea (OSA)?

Up to 20% of the general population has OSA, and studies show a strong bidirectional link with major depressive disorder (MDD).

Here’s how OSA and depression overlap, and what clinicians can do to detect and treat it earlier. 👇🧵 Shared symptoms

OSA and depression often look alike:

● Fatigue, daytime sleepiness

● Poor concentration

● Irritability, psychomotor slowing

● Weight changes

This overlap blurs diagnosis and may delay appropriate treatment.