MCQ

Mental Health care and Neurology Block-Phase II 2017

Psychosis and schizophrenia

1. Synopsis

A. A syndrome not a diagnosis

B. Symptoms and presentations in psychosis

C. Differential diagnosis and classification

D. Epidemiology

E. Aetiology

F. Management.

2. Self-test Questions

A. What is “thought broadcast”?

B. What are the core symptoms of schizophrenia according to the ICD
classification and DSM V?

C. Whatisadelusionandhowcanitbedistinguishedfromnormalexperience?

D. What is the difference between second person and third person auditory
hallucination?

E. Which forms of hallucinations are characteristic of
i. schizophrenia

ii. organic disorders

F. Why is an assessment of insight important?

G. What is “word salad”?

H. In what conditions can hallucinations occur?

3. Case study: Case: 1

Case study: 1
A 21-year-old man is brought to the emergency department by the police after he was found sitting in the middle of traffic on a busy street. By way of explanation, the patient states, “The voices told me to do it.” The patient says that for the past year he has felt that “people are not who they say they are.” He began to isolate himself in his room and dropped out of school. He claims that he hears voices telling him to do “bad things.” There are often two or three voices talking, and they often comment to each other on his behavior. He denies that he currently uses drugs or alcohol, although he reports that he occasionally smoked marijuana in the past. He says that he has discontinued this practice over the past 6 months because he can no longer afford it, and claims that marijuana helped with the voices. He denies any medical problems and is taking no medication. On a mental status examination, the patient is noted to be dirty and dishevelled, with poor hygiene. He appears somewhat nervous in his surroundings and paces around the examination room, always with his back to a wall. He states that his mood is “okay.” His affect is congruent, although flat. His speech is of normal rate, rhythm, and tone. His thought processes are tangential, and loose associations are occasionally noted. His thought content is positive for delusions and auditory hallucinations. He denies any suicidal or homicidal ideation.
Question: 1

A. What is the most likely diagnosis for this patient?

B. What conditions are important to rule out before a diagnosis can be made?

C. Should this patient be hospitalized?

Answers:

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Answer:

A. probably paranoid type.

B. Important conditions to rule out: To make a diagnosis of schizophrenia, psychosis
secondary to substance abuse and general medical conditions must be ruled out. In
addition, schizoaffective disorder and mood disorders must also be excluded.

C. Shouldthispatientbehospitalized?Yes.Heclearlyposesadangertohimself(and potentially to others based on the undetermined nature of “bad things” he is being commanded to perform) because he listens to the voices and acts on their instructions so as to put himself at risk for serious physical harm (Ie, sitting in the
middle of a busy street).

Question: 2
Which of the following symptoms is most specific to a diagnosis of schizophrenia, as opposed to other etiologies of psychosis?

A. Auditoryhallucinations

B. Belief that one has the power of an alien species

C. Catatonic symptoms

D. Depression

E. Inappropriateaffect

Answer:
B. Although all these symptoms can be seen in various psychotic disorders, the presence of a bizarre delusion is the most specific to schizophrenia. Only one psychotic symptom is needed to diagnose schizophrenia if there are bizarre delusions, auditory hallucinations commenting on the patient, or two or more voices speaking to each other.
Question: 3
Defined the following;

A. Bizarre delusions

B. Delusions

C. Flat affect

D. Ideas if reference

E. Loose of association

F. Tangentiality

G. Negative symptoms of schizophrenia

H. Positive symptoms of schizophrenia

Answer:

A. Delusions that are totally implausible (e.g., having been captured by aliens).

B. Fixed, false beliefs that remain despite clear evidence to the contrary, that are not
culturally sanctioned.

C. The absence of a noticeable emotional state (eg, no facial expression).

D. False beliefs that, for example, a television or radio performer, a song, or a
newspaper article refers to oneself.

E. Thoughts that are not connected to one another or illogical answers to questions.

F. Thoughts can be connected to each other although the patient does not come back
to the original point or answer the question.

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G. Affective flattening, alogia (diminished flow and spontaneity of speech), and avolition (lack of initiative or goals).

H. Ideas of reference, grossly disorganized speech or behavior, delusions (such as paranoia), and hallucinations.

Question: 4
Which of the patient’s symptoms are most indicative of a psychosis secondary to a general medical condition?

A. Auditoryhallucinations

B. Impairment in reality testing

C. Gustatoryhallucinations

D. Thought disorder (i.e., loose associations)

E. Visual hallucinations

Answer:

C. Auditory and visual hallucinations are common in all episodes of psychosis regardless of the cause. Gustatory hallucinations (along with olfactory and tactile hallucinations) can be more common in psychoses caused by a medical illness. It would be somewhat unusual to find problems with reality testing or thought disorders in a patient with psychosis due to a general medical condition, though this is possible. These are much more commonly seen in other psychotic disorders such as schizophrenia.

Question: 5
Which of the following medications is most likely to be helpful in treating this patient’s psychosis?

A. Lithium
B. Valproicacid C. Risperidone D. Valium
E. Sertraline

Answer:

C. Psychoses caused by general medical conditions usually respond to antipsychotic medications. There is no indication for the use of drugs used to treat mood disorders (lithium, valproic acid, or sertraline) or benzodiazepines.

Mood Disorders (Affective Disorders)

1. Synopsis

A. Symptoms of depression and bipolar disorder

B. Aetiology of mood disorders- the diathesis model

C. Classification of mood disorders

D. Epidemiology of mood disorders

E. Management.

2. Self-test Questions

A. What is dysthymia

B. Why might depression be more common in women?

C. What social factors make people vulnerable to depression?

D. What are the indications for electro-convulsive therapy (ECT)?

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E. What are the advantages and disadvantages of SSRIs as compared to tricyclic antidepressants?

3. Case study: Case: 2
Case study: 2 (for manic episode)
A 27-year-old man is brought to the emergency department by his friends and his roommate. The friends state that the patient had not slept for the past 3 or 4 weeks. They have noticed that he stays up all night cleaning his apartment. He has bought new computer equipment and a digital video disc player, although his roommate claims that the patient cannot afford these kinds of items. The patient has also been bragging to his friends that he has slept with three different women in the past week, behavior very unlike his usual self, and he has been very irritable and explosive. He has been drinking a “lot of alcohol” for the past 2 weeks, which is uncharacteristic. The friends state that they have not seen the patient using drugs, and they do not think he has any medical problems or takes any prescription medication. They are not aware of any family history of medical or psychiatric disorders. They state that the patient is a graduate student in social work. On a mental status examination, the patient is noted to be alternately irritable and elated. He is wearing a bright orange top and red slacks, and his socks are mismatched. He paces the room and refuses to sit down when asked to do so by the examiner. His speech is rapid and loud, and it is hard to interrupt him. He claims that his mood is “great,” and he is very angry with his friends for insisting that he come to the emergency department. He states that they have probably insisted that he come because “they are jealous of my success with women.” He states that he is destined for greatness. His thought processes are tangential. He denies having any suicidal or homicidal ideation, hallucinations, or delusions.

Question: 1

A. What is the next diagnostic step?

B. What is the most likely diagnosis?

C. What is the best initial treatment?

Answer:

A. Next diagnostic step: A urinalysis for drugs of abuse should be ordered, and a determination of alcohol blood level should be made as well.

B. Most likely diagnosis: Bipolar disorder, manic.

C. Best initial treatment: Admission to the hospital should be recommended,
although it is unclear whether the patient is committable at this point. At the least, he will need treatment with a mood stabilizer (lithium, carbamazepine, valproic acid) and perhaps with an antipsychotic (such as risperidone) as well.

Question: 2
A. What is involuntary commitment?
B. What is differential diagnosis for mania?

Answer:

A. Although their laws vary, all states have some sort of mechanism for placing a patient in a psychiatric hospital in the event of uncontrollable or imminently

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dangerous mental illness. Usually, patients must present an immediate danger to themselves (suicidality) or others (homicidality or extreme, violent, acting-out behavior) or be unable to care for themselves (eg, walking outside unclothed in the middle of winter, walking in traffic). Commitment to a hospital involves the signing of commitment papers by a physician. The patient must then appear in court within a specified number of days so that it can be determined if the commitment should continue or the patient should be discharged.

B. The differential diagnosis for mania is quite straightforward, but the diagnoses them-selves can be difficult to establish. For example, identical clinical presentations can result from substance-induced mood disorder, mood disorder secondary to a general medical condition, and mania; hence, illicit or prescribed agents must be ruled out as well as medical conditions. Drugs such as corticosteroids, levodopa, and stimulants such as cocaine have been known to cause manic-like behavior. General medical conditions such as metabolic disturbances caused by hemodialysis, infections, neoplastic diseases, and seizures can also cause these types of behavior. Schizophrenia must be on the differential list and must be ruled out by looking at secondary features such as family history, level of premorbid functioning, or a history of manic symptoms if the clinical features themselves do not set it apart. Schizoaffective disorder can be characterized by psychotic behavior and manic features and must be differentiated by the time courses of the two. Patients with schizoaffective disorder can exhibit mood symptoms, but psychotic symptoms precede the mood symptoms and/or can continue after the mood reverts back to euthymia.

Question: 3
If patient age 62-year and has no previous psychiatric or medical history. He denies the use of drugs or alcohol. The man states that there is nothing wrong with him, but that he has not been sleeping nearly as much as he used to, often needing less than 2 hours of sleep a night. His wife notes that he has been exceedingly irritable, has been charging excessive amounts of money on their credit cards, and has been talking about running in a marathon, although he has never expressed such an interest before. Which of the following courses of action should the physician take first?

A. Admit to the hospital.

B. Order a urinalysis for drugs of abuse.

C. Perform a complete physical examination.

D. Start a mood-stabilizing drug.

E. Start an antipsychotic drug.

Answer:

Answer is C: In a patient of this age, with no previous psychiatric or medical history, general medical conditions responsible for this new-onset behavior should be ruled out before an episode of bipolar mania is considered. While admission to the hospital might well be necessary to control the destructive behavior, making the diagnosis first is the primary concern. Both a mood stabilizer and/or an antipsychotic may well also be

 

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necessary, but again, if the mood problem is secondary to a general medical condition, treating it may resolve the psychiatric symptoms by itself.

Question: 4
If this patient is diagnosis as bipolar disorder, manic, is treated with a mood stabilizer (lithium) and haloperidol, an antipsychotic. Which of these medications should be discontinued first once her condition has been stabilized?

A. Both should be discontinued simultaneously once the patient’s condition is stable.

B. Haloperidol because of the risk of extra pyramidal side effects.

C. Haloperidol because of the risk of habituation.

D. Lithium because of the risk of renal damage.

E. Lithium because of the risk of weight gain.

Answer:

Answer is B: Because tardive dyskinesia is irreversible, and the risk of its appearance increases with continued use, antipsychotics should be discontinued as soon as the patient’s psychotic symptoms remit, and not used again as long as the patient’s condition remains stable.

Question: 5
If our patient is woman with bipolar disorder and 22 weeks pregnant. She has been taking valproic acid for her symptoms. Which of the following is the most likely abnormality that might be found on an ultrasound examination, due to the effects of the mood stabilizer?

A. Fetal abdominal wall defect

B. Fetal microcephaly

C. Fetal renal dysplasia

D. Fetal spina bifida

E. Fetal tetralogy of Fallot

Answer:

Answer is D: Maternal use of valproic acid is associated with a 1% to 2% risk of fetal neural tube defects such as spina bifida.

Case study: 2 (for depressive episode)
A 16-year-old student is brought to the emergency department by her parents. She says that for the past 6 weeks, she feels as if she “just can’t cope with all the pressure at school.” She broke up with her boyfriend 6 weeks ago. Since that time, she cannot sleep more than 3 or 4 hours a night. She lost 15 lb without trying to, and her appetite decreased. She says that nothing interests her and that she cannot even concentrate long enough to read a magazine, much less her textbooks. Her energy level is very low. She is not doing things with her friends like she was in the past and says that when she is with them “things just aren’t fun like they used to be.” She tends to be irritable and gets angry with slight provocations. On a mental status examination, she is observed to be a well-dressed teenager with good hygiene. She notes that her mood is very depressed, 2 on a scale of 1 to 10. Her affect is dysphoric and constricted. She admits to hearing a voice telling her that she is “no

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good.” She has heard this voice at least daily for the past week. She admits to having had thoughts of suicide frequently over the past several days but denies that she would act on these thoughts because it would be a “sin.” She does not have a suicide plan. No delusions are present, and she is alert and oriented to person, place, and time.

Question: 1
A. What is the most likely diagnosis? B. What is the next step?

Answer:

A. Most likely diagnosis: Major depression with psychotic features (auditory hallucinations).

B. Besttreatment:Sheshouldbeofferedapsychiatricadmissionbecausehermajor depression is severe. Although she is not committable, she could still be hospitalized by her parents because she is a minor. She should be started on a selective serotonin reuptake inhibitor (SSRI) and an atypical antipsychotic medication. When stabilized, the patient should be seen weekly for at least 4 weeks by the physician or qualified mental health professional to assess for any increase in suicidal thinking in compliance with current Food and Drug Administration (FDA) warnings for antidepressant use in children.

Question: 2
Defined the following:

A. Anhedonia

B. Mood-congruent delusions or hallucinations

C. Psychosis

D. Somatic delusion

E. Vegetative symptoms

Answer:

A. Loss of a subjective sense of pleasure

B. The content of the delusions or hallucinations reflects the nature of the illness. For
example, in major depression, delusions and hallucinations are often about being
defective, deficient, diseased, or guilty and deserving of punishment.

C. A syndrome characterized by hallucinations and/or delusions (fixed, false beliefs).
The individual’s ability to assess reality is impaired.

D. Falsebeliefsaboutone’sbody;indepression,thesearebeliefsregardingillness,for
example, that one has cancer and is about to die.

E. Symptoms of depression that are physiologic or are related to body functions, such
as sleep, appetite, energy, and sexual interest. Other symptom categories for depression are cognitive (poor concentration, low self-esteem) and emotional (crying spells).

Question: 3
A. What are differential diagnosis?

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Answer:

A. Major depression is 0.3% in preschoolers, 3% in elementary school children, and 6% to 7% in adolescents. Genetic factors, loss of a parent at an early age (before the age of 11), and adverse early life experiences are significant predictors for major depression in childhood and adulthood. Diagnosis is often complex because there are many comorbid disorders such as anxiety disorders, disruptive behavior disorders, or substance abuse that can confuse the picture. Similarly, many personality disorders can begin to be seen in adolescence and need to be considered as well. Many medical conditions and substances can also cause mood disorders.

B. Bipolar disorder has several episodes of depression before the first episode of mania, and examining a carefully recorded family history and a clinical history can raise the clinician’s suspicion of bipolar disorder.

C. Schizoaffective disorder includes both depressive and psychotic symptoms; knowledge of the history and course of the illness is often necessary to make a diagnosis. Patients with schizophrenia can experience episodes of depression, but they usually develop later in the course of the illness, and the predominant picture is one of psychosis and negative symptoms.

D. An active substance dependence makes the diagnosis of depression difficult because depressive and psychotic symptoms accompany the use of many substances (such as alcohol or cocaine); these can be indistinguishable from major depression. Often a patient must abstain from the substance for several weeks before the diagnosis can be confirmed.

E. In normal bereavement, especially during the first 2 months after the loss of a significant other, an individual can have symptoms of major depression. However, these gradually diminish with time.

Question: 4
A 42-year-old man comes to his outpatient psychiatrist with complaints of a depressed mood, which he states is identical to depressions he has experienced previously. He was diagnosed with major depression for the first time 20 years ago. At that time, he was treated with imipramine, up to 150 mg/d, with good results. During a second episode, which occurred 15 years ago, he was treated with imipramine, and once again his symptoms remitted after 4 to 6 weeks. He denies illicit drug use or any recent traumatic events. The man states that although he is sure he is experiencing another major depression, he would like to avoid imipramine this time because it produced unacceptable side effects such as dry mouth, dry eyes, and constipation.

A. What is the best therapy?
B. What are the side effects of the proposed therapy?

Answer:

A. Best therapy: A selective serotonin reuptake inhibitor (SSRI) such as sertraline, paroxetine, citalopram, fluoxetine, or fluvoxamine is one of the first-line choices of medication for this patient. Selective serotonin-norepinephrine reuptake inhibitors

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(SSNRI) such as venlafaxine and duloxetine are also first-line treatment options.

Other antidepressant options are bupropion and mirtazapine.
B. Common side effects: Gastrointestinal symptoms—stomach pain, nausea, and

diarrhea—occur in early stages of the treatment. Minor sleep disturbances—either sedation or insomnia—can occur. Other common side effects include tremor, dizziness, increased perspiration, and male and female sexual dysfunction (most commonly delayed ejaculation in men and decreased libido in women). Bupropion is one of the few antidepressants that do not cause sexual side effects.

Question: 5
In case question 4, she recently received a diagnosis of major depressive disorder and began treatment with citalopram (an SSRI) 6 weeks ago. She claims to feel “happy again,” without further depression, crying spells, or insomnia. Her appetite has improved, and she has been able to focus at work and enjoy time with her family.
Which of the following is the most appropriate next step in her treatment?

A. Consider a different class of antidepressants.

B. Discontinue the citalopram.

C. Increase the dose of citalopram.

D. Lower the dose of citalopram.

E. Maintain the current dose of citalopram.

Answer:

E. The proper strategy in the management of an episode of major depression that has recently remitted is to continue treatment at the same dose if it can be tolerated. Early discontinuation of medication can lead to an early relapse. A general rule of thumb is, “The dose that got you better will keep you well.” A reasonable duration for continuing the medication is 6 to 9 months.

Question: 6
Defined the following:

A. SSRI
B. SSNRI
C. Bupropion D. Mirtazapine

Answer:

A. An agent that blocks the reuptake of serotonin from presynaptic neurons without affecting norepinephrine or dopamine reuptake. These agents are used as antidepressants and in treating eating disorders, panic, obsessive-compulsive disorder, and borderline personality disorder (for symptom-targeted pharmacotherapy).

B. An agent that blocks reuptake of serotonin and norepinephrine. These agents are used as antidepressants and for generalized anxiety disorder. Duloxetine may also be used for painful diabetic neuropathy.

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C. An agent that blocks norepinephrine and dopamine reuptake. Bupropion is primarily used for depression, anxiety associated with depression, and smoking cessation.

D. A tetracyclic antidepressant agent believed to work through noradrenergic and serotonergic mechanisms. It is not a reuptake inhibitor. Mirtazapine is used to treat depression, anxiety disorders, and to induce sleep.

Question: 7
A 79-year-old man is brought in by his family after refusing to drink fluids for 24 hours. For the past 3 weeks, the patient has shown worsening signs and symptoms of major depression (decreased energy, crying spells, suicidal ideation, anorexia with weight loss, and guilt), culminating in a refusal to eat or drink. He continues to refuse to eat or drink, is suicidal, and is probably experiencing auditory hallucinations. He has had episodes similar to this one in the past, although no episodes of mania have been described.

A. What is the most likely diagnosis?
B. What is the best plan of action for this patient?

Answer:

A. Most likely diagnosis: Recurrent major depression with psychotic features.

B. Best plan of action: Close observation in the hospital, intravenous hydration, and consideration of electroconvulsive therapy (ECT) because of the severity and
urgency associated with this episode of depression.

Anxiety and other Neurotic Disorders:

1. Synopsis

A. The definition of neurosis and anxiety disorders

B. What disorders are included under this umbrella term?

C. Description of various anxiety disorders

2. Self-test Questions

A. What is the definition of a anxiety disorders?

B. What disorders are included under this umbrella term?

C. Please briefly describe the symptoms of the different neurotic disorders.

3. Case study: Case: 3

Case study: 3 A

A 23-year-old medical student comes to the emergency room with elevated heart rate, sweating, and shortness of breath. The student is convinced that she is having an asthma attack and that she will suffocate. The symptoms started suddenly during a car ride to school. The student has had episodes such as this on at least three previous occasions over the past 2 weeks and now is afraid to leave the house even to go to school. She has no history of asthma and, other than an increased pulse rate, physical findings are unremarkable

Questions:
1. Of the following, the most effective immediate treatment for this patient is

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A. B. C. D. E.

2. Of the A. B. C. D.

an antidepressant a support group abenzodiazepine buspirone aβ-blocker

following, the most effective long-term management for this patient is an antidepressant
a support group
abenzodiazepine

buspirone

E.
3. The neural mechanism most closely involved in the etiology of this patient’s

symptoms is

A. nucleus accumbens hyposensitivity

B. ventral tegmental hypersensitivity

C. ventral tegmental hyposensitivity

D. locus ceruleus hypersensitivity

E. peripheral autonomic hypersensitivity

Answers:

Q1. The answer is C.
Q2. The answer is A.
Q3. The answer is D.
Explanation: This patient is showing evidence of panic disorder with agoraphobia. Panic disorder is characterized by panic attacks, which include increased heart rate, dizziness, sweating, shortness of breath, and fainting, and the conviction that one is about to die. Attacks commonly occur twice weekly, last about 30 minutes, and are most common in young women, such as this patient. This young woman has also developed a fear of leaving the house (agoraphobia) which occurs in some patients with panic disorder. While the most effective immediate treatment for this patient is a benzodiazepine because it works quickly, the most effective long-term (maintenance) management is an antidepressant, particularly a selective serotonin reuptake inhibitor (SSRI) such as paroxetine (Paxil). The neural etiology most closely involved in panic disorder with agoraphobia is hypersensitivity of the locus ceruleus.

Case study: 3 B

For each of the following cases, select the disorder which best fits the clinical picture. (A) Post-traumatic stress disorder
(B) Hypochondriasis
(C) Obsessive–compulsive disorder

(D) Panic disorder

aβ-blocker

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(E) Somatization disorder
(F) Generalized anxiety disorder (G) Body dysmorphic disorder (H) Conversion disorder
(I) Specific phobia
(J) Social phobia
(K) Adjustment disorder
(L) Masked depression

Q1. A 45-year-old woman has a 20-year history of vague physical complaints including nausea, painful menses, and loss of feeling in her legs. Physical examination and laboratory workup are unremarkable. She says that she has always had physical problems but her doctors never seem to identify their cause.

Q2. Three months after moving, a teenager who was formerly outgoing and a good student seems sad, loses interest in making friends, and begins to do poor work in school. His appetite is normal and there is no evidence of suicidal ideation.

Q3. A 29-year-old man experiences sudden right-sided hemiparesis, but appears unconcerned.
He reports that just before the onset of weakness, he saw his girlfriend with another man. Physical examination fails to reveal evidence of a medical problem.

Q4. A 41-year-old man says that he has been “sickly” for most of his life. He has seen many doctors but is angry with most of them because they ultimately referred him for psychological help. He now fears that he has stomach cancer because his stomach makes noises after he eats. Physical examination is unremarkable and body weight is normal.

Q5. A 41-year-old man says that he has been “sickly” for the past 3 months. He fears that he has stomach cancer. The patient is unshaven and appears thin and slowed down. Physical examination, including a gastrointestinal workup, is unremarkable except that there is an unexplained loss of 15 pounds since his last visit 1 year ago.

Q6. A 28-year-old woman seeks facial reconstructive surgery for her “sagging” eyelids. She rarely goes out in the daytime because she believes that this characteristic makes her look “like a grandmother.” On physical examination, her eyelids appear completely normal.

Q7. A 29-year-old man is upset because he must take a client to dinner in a restaurant. Although he knows the client well, he is so afraid of making a mess while eating that he says he is not hungry and sips from a glass of water instead of ordering a meal.

Q8. A 29-year-old man tells the doctor that he has been so “nervous” and upset since his girlfriend broke up with him 1 month ago that he had to quit his job and stay at home. The man has no history of medical or psychiatric disorders, although his father has a history of

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bipolar disorder, his mother has a history of alcoholism, and his younger brother was in rehab for drug abuse the previous year.

Answers and explanation:

Q1. The answer is E. This woman with a 20-year history of unexplained vague and chronic physical complaints probably has somatization disorder. This can be distinguished from hypochondriasis, which is an exaggerated worry about normal physical sensations and minor ailments (see also answers to Questions 2–8).

Q2. The answer is K. This teenager, who was formerly outgoing and a good student and now seems sad, loses interest in making friends, and begins to do poor work in school, probably has adjustment disorder (with depressed mood). It is likely that he is having problems adjusting to his new school. In contrast to adjustment disorder, in masked depression the symptoms are more severe and often include significant weight loss or suicidality (see also answer to Question 8).

Q3. The answer is H. This man, who experiences a sudden neurological symptom triggered by seeing his girlfriend with another man, is showing evidence of conversion disorder. This disorder is characterized by an apparent lack of concern about the symptoms (i.e., la belle indifférence).

Q4. The answer is B. This man, who says that he has been “sickly” for most of his life and fears that he has stomach cancer, is showing evidence of hypochondriasis, exaggerated concern over normal physical sensations (e.g., stomach noises) and minor ailments. There are no physical findings nor obvious evidence of depression in this patient.

Q5. The answer is L. This man probably has masked depression. In contrast to the hypochondriacal man in the previous question, evidence for depression in this patient includes the fact that, in addition to the somatic complaints, he shows symptoms of depression (e.g., he is not groomed, appears slowed down [psychomotor retardation], and has lost a significant amount of weight).

Q6. The answer is G. This woman probably has body dysmorphic disorder, which is characterized by over-concern about a physical feature (e.g., “sagging” eyelids in this case), despite normal appearance.

Q7. The answer is J. This man probably has social phobia. He is afraid of embarrassing himself in a public situation (e.g., getting food on his face while eating dinner in front of others in a restaurant).

Q8. The answer is K. The most likely explanation for this clinical picture that includes symptoms of anxiety which begin after a life stressor (e.g., a romantic break-up) is adjustment disorder (with anxiety). The absence of a previous history and the brief duration indicates that this is not an anxiety disorder and the fact that the stressor was not life- threatening rules out PTSD and ASD. The family history is not likely to be related to this patient’s symptoms in this case.

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Personality Disorders:

1. Synopsis
A. What is a personality disorder?
B. How are they described and classified?

2. Self-test Questions

A. Why are patients with dependent personalities at risk of developing
depression?

B. Why is the diagnosis of personality disorder potentially a dangerous one to
make?

C. What are “simple phobias”?

D. What defines someone’s personality?

E. How would you define a personality disorder?

F. Please describe the symptoms of a paranoid personality disorder, an
emotionally unstable personality disorder and a dissocial personality
disorder.

3. Case study: Case 4

Case: 4 A

A 28-year-old law student is admitted to the hospital for gallbladder problems. He is stubborn and rigid and expects staff to adhere to his exact ways of doing things. He refuses to stop working on school papers. He reports that his girlfriend has threatened to leave him unless he changes his inflexible ways and throws out some of a large collection of useless junk.

Questions:

1. Which personality disorder diagnosis appears most appropriate?
A. Antisocial
B. Avoidant
C. Histrionic
D. Obsessive-compulsive E. Schizotypal

2. You expect the patient may act out in which of the following fashions when under stress in the hospital?

A. Strange behavior may put off caregivers

B. Sees hospitalization as a threat to his control

C. Can be charming but in a manipulative fashion; resists rules

D. Uses splitting, possibly dividing the staff, who might take sides

E. Likely to be cooperative and do well with the attention

3. You might recommend which of the following interventions to the staff regarding the patient?

A. Set firm limits; consider an antidepressant.

B. Set firm limits on patient and staff roles; remain noncritical.

C. Odd behavior may make staff uneasy, but avoid ridicule.

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D. Similar patients generally do well, but avoid criticism.
E. Share control with the patient in as many ways as possible.

Answers and explanation:

1. The answer is D. Some diagnostic criteria for obsessive-compulsive personality disorder include preoccupation with details, perfectionism interfering with task completion, excessive devotion to work, scrupulousness, and inability to discard collected belongings, reluctance to delegate, miserly spending style, rigidity, and stubbornness.

2. The answer is B. In the medical–surgical setting, persons with obsessive-compulsive personality disorder may become even more inflexible because the illness is perceived as a threat to their need for control.

3. The answer is E. In the medical treatment of persons with obsessive-compulsive personality disorder, sharing control with the patient may obviate the perceived threat to their need for control.

Case: 4 B

A 19-year-old man with a 7-year history of legal charges is admitted for treatment of phlebitis secondary to intravenous drug abuse. On the ward, he was initially quite charming to the staff but became irritable and aggressive when denied requests for more pain medication. He is demanding to be discharged. When changing his bed, staff found syringes and needles he had taken from the drug cart when a nurse was tending to another patient. When the nurse was reprimanded by her supervisor, the patient showed no remorse for the consequences of his action.

Questions:

1. Which personality disorder diagnosis appears most appropriate? A. Antisocial
B. Narcissistic C. Paranoid D. Schizoid
E. Schizotypal

2. You expect this patient may act out in which of the following fashions when under stress in the hospital?

A. Aloof; may want to leave against medical advice

B. Strange behavior may put off caregivers

C. Will likely be charming and fascinating; his sense of attractiveness may be
threatened by illness

D. Might suffer feelings of abandonment and helplessness

E. Can be charming but in a manipulative fashion; resists rules

3. You might recommend which of the following interventions to the staff for the patient?

A. Set firm limits and consider an antidepressant.

B. Odd behavior may make staff uneasy, but avoid ridicule.

C. Set firm limits; anticipate a demand for discharge against medical advice.

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D. Be straightforward, explain everything, and expect distrust.

E. Share control with patient in as many ways as possible.
4. You would recommend which of the following courses of treatment for this patient

after discharge?

A. Treatment with benzodiazepines to reduce anxiety

B. Individual therapy focusing on building a strong patient–therapist relationship

C. Tell the patient there is no hope for treatment and you will not take his money

D. Group therapy with a particular therapist and patients

E. Volunteer work in a pain clinic to help develop more empathy

Answers and explanation:

1. The answer is A. Some diagnostic criteria for antisocial personality disorder include evidence of conduct disorder with onset before age 15 years, a pattern of disregard for or violation of the rights of others, irritable and aggressive behavior, deceitfulness, recklessness, and lack of remorse.

2. The answer is E. In the medical–surgical setting, persons with antisocial personality disorder may give the impression of being quite charming but in a manipulative fashion. They may resist hospital rules and be noncompliant, and when challenged, they may leave treatment against medical advice.

3. The answer is C. In the treatment of persons with antisocial personality disorder, setting fi rm limits is important but often triggers a demand to leave treatment against medical advice.

4. The answer is D. Antisocial personality disorder can respond to treatment. Group psychotherapy can be effective, but an experienced therapist and a particular group of patients are needed. Controlled substances may be abused by some persons with antisocial personality disorder.

Case: 4 C

A 35-year-old single man is admitted to the hospital for deep vein thrombosis. He has been inappropriately provocative and seductive toward the female staff. Dramatic and suggestible, he appears obsessed with his attractiveness. He exaggerates his familiarity with some staff members and displays shallow, shifting emotions.

Questions:

1. Which personality disorder diagnosis appears most appropriate?
A. Antisocial
B. Avoidant
C. Histrionic
D. Obsessive-compulsive E. Paranoid

2. You expect this patient may act out in which fashion when under stress in the hospital?

A. Aloof; may want to leave against medical advice

B. Will likely be charming and fascinating; his sense of attractiveness may be
threatened by illness

C. Very guarded, suspicious, and quarrelsome

D. Will use splitting, possibly dividing the staff, who might take sides

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E. Will see hospitalization as a threat to his control
3. For this patient, you might recommend which of the following interventions to the

staff?

A. Be straightforward, explain everything, and expect distrust.

B. Set firm limits and consider an antidepressant.

C. Similar patients generally do well, but avoid criticism.

D. Share control with the patient in as many ways as possible.

E. Set firm limits on patient and staff roles; remain noncritical

Answers and explanation:

1. The answer is C. Some diagnostic criteria for histrionic personality disorder include a need to be the center of attention, inappropriate seductive or provocative behavior, obsession with physical attractiveness, dramatic behavior and impressionistic speech, suggestibility, and exaggeration of the importance of relationships.

2. The answer is B. In the medical–surgical setting, persons with histrionic personality disorder may give the impression of being charming and fascinating. The patient’s dependence on his sense of attractiveness may be threatened by illness.

3. The answer is E. In the treatment of persons with histrionic personality disorder, setting firm limits on patient and staff roles is critical. At the same time, staff should try to remain noncritical of behavior symptomatic of the disorder.

Suicide and Para-suicide (deliberate self-harm) & assessment of risk:

1. Synopsis

A. Definitions of suicide, para-suicide and deliberate self-harm

B. Methods of self-harm

C. Epidemiology and health trends

D. Clinical variables

E. Social variables

F. Assessment of risk

2. Case study: Case 5

Case: 5 A
1. Joe is a 27-year-old male who requires more alcohol and cocaine to get the same high.

He is hanging out with a rough crowd and engaging in riskier behavior to obtain drugs. He has tried to quit but can’t seem to stop. He thinks he may have even had a seizure on one occasion. He has stolen from his parents to get high. He has been getting in trouble with the law and shows little remorse. All of the following features of Joe’s addiction meet the criteria for substance dependence EXCEPT:

A. Overwhelming involvement in seeking and using a drug

B. Physical dependence

C. Attempts to quit

D. Antisocial behavior

E. Tolerance and withdrawal
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Case: 5 B
2. A patient presents to the emergency room after overdosing on phenobarbital. Which of

the following symptoms is indicative of barbiturate intoxication?

A. Agitation

B. Confusion

C. Disorientation

D. Nystagmus

E. Postural hypotension

Case: 5 C
3. A patient presents to the emergency room with a blood alcohol level of 10 mg/100 ml,

but there is no clinical evidence of intoxication. It is a reasonable assumption that the patient:

A. Is tolerant to opioids

B. Is dependent on alcohol

C. Has pancreatitis

D. Is impotent

E. Has cerebral atrophy

Case: 5 D
4. A patient with depressed reflexes, decreased respirations, pinpoint pupils, hypotension,

and lethargy is carried into a walk-in clinic by a friend. What is the most likely cause of the emergency?

A. Alcohol intoxication

B. Cocaine intoxication

C. Opiate intoxication

D. Marijuana intoxication

E. Benzodiazepine intoxication

Case: 5 E

5. A law school student suddenly starts acting quite bizarre while studying for a major exam in the library. His friends have become concerned that he could be “buying” amphetamine salts to get through school. All of the following would be expected if he were having a stimulant-induced psychosis EXCEPT:

A. Clear sensorium

B. Depression

C. Looseassociations

D. Paranoia

E. Tactile hallucinations

Case: 5 F
6. You are working in an outpatient drug and alcohol rehabilitation clinic. You are

counseling a long-term marijuana user who believes that marijuana is a “safe drug.” He should be concerned about possible long-term negative consequences of his use, which include all of the following EXCEPT:

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A. Physical dependence can develop.

B. Its use increases the likelihood of narcotic use.

C. Overdose causes seizures.

D. Chronic use causes a motivational state.

E. It causes tachycardia.

Case: 5 G
7. A patient is in the hospital for heroin detoxification. He just received his first injection

of buprenorphine. Thirty minutes later, he begins vomiting, sweating, and cramping. What happened?

A. He is allergic to buprenorphine.

B. He does not really use heroin.

C. He lied about when he last used.

D. He has the stomach flu.

E. E The nurse gave him disulfiram instead of buprenorphine.

Answers and explanations:

1. The answer is D. While personality disorders are often common in alcohol and drug dependency problems, their presence is not necessary in order to confirm a diagnosis. Physical dependence, tolerance, withdrawal, and increasing time spent acquiring substances are all seen with alcohol and drug dependency problems.

2. The answer is D. Both intoxication and withdrawal from barbiturates may cause confusion, delirium, anxiety, agitation, and postural hypotension. If caused by withdrawal, these signs improve with administration of a barbiturate. Nystagmus, which is a sign of intoxication but not of withdrawal, may appear.

3. The answer is B. Absence of intoxication in the presence of a high blood alcohol level indicates that the patient is tolerant to the central nervous system depressant effects of alcohol, which is a major criterion for alcohol dependence. Pancreatitis, impotence, and cerebral atrophy are complications of alcoholism that should be investigated, but these are not diagnosed by a blood alcohol level. Because opioids and alcohol are not cross- tolerant, tolerance to alcohol does not provide any information about tolerance to opioids.

4. The answer is C. Similar to alcohol, barbiturates, and benzodiazepines, narcotics can produce depression of consciousness, reflexes, blood pressure, and respiration. Narcotics cause constricted rather than dilated pupils. Opioid intoxication can be diagnosed with intravenous naloxone.

5. The answer is B. Stimulant psychosis often is associated with paranoia and loose associations in a clear sensorium, which may make it indistinguishable from schizophrenia. Tactile hallucinations and delusions of infestation with parasites also may occur. Depression is usually associated with stimulant withdrawal, not stimulant intoxication.

6. The answer is C. Contrary to popular wisdom, physical dependence on marijuana may occur, and withdrawal symptoms may appear with discontinuation. Marijuana has been found to be a “gateway drug” that lowers the threshold for use of “harder” drugs. Marijuana use can produce tachycardia and a motivational state. Overdose can cause distortions in time sense and injected conjunctivae, but not seizures.

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7. The answer is C. The patient is going into acute opiate withdrawal 30 minutes after receiving his first buprenorphine injection. He most likely told the nursing staff and physician that he had used his last dose of heroin several hours earlier from the time of his admission than he actually did. He probably feared going into withdrawal and did not wait long enough for withdrawal signs to appear before getting his first dose of buprenorphine. As a result, buprenorphine’s antagonistic properties knocked off the maining heroin still attached to the mu receptors and put the patient into acute opiate withdrawal.

Psychiatric drugs:

1. Synopsis
(This lecture will complement the psychopharmacology covered in Phase 1)

A. Pharmacokinetics

B. Classes of psychotropic drugs:- antidepressant, antimanic, anxiolytic,
antipsychotic

C. Indications for use

D. Making treatment decisions

2. Self-test Questions

A. What problems are associated with the long term use of benzodiazepines?

B. Why are anticholinergic drugs used to treat Parkinsonism?

C. What is neuroleptic malignant syndrome?

D. What are the side effects of tricyclic antidepressants?

E. Why should chlorpromazine be avoided in the elderly?

F. What are the extrapyramidal effects of antipsychotics?

G. What are the dangers of rapid tranquillisation?

H. What are the symptoms of lithium toxicity?

3. Case study: Case 6
Questions: 1-2

1. A 22-year-old man with schizophrenia who has been taking an antipsychotic for the past 3 months reports that recently he has experienced an uncomfortable sensation in his arms and legs during the day and must constantly move them. Because of this, he can sit still for only a few minutes at a time. This medication side effect is best described as

A. restless legs syndrome

B. neuroleptic malignant syndrome

C. akathisia

D. tardive dyskinesia

E. acute dystonia

F. pseudoparkinsonism

2. The antipsychotic agent that this patient is most likely to be taking is A. risperidone
B. thioridazine C. olanzapine D. haloperidol E. clozapine

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Answer and explanation:

Question 1, the answer is C. question 2. The answer is D. The symptom that this patient describes is akathisia, a subjective, ncomfortable feeling of motor restlessness related to use of some antipsychotics. Restless legs syndrome also involves uncomfortable sensations in the legs, but it is a sleep disorder (see Chapter 10), which causes difficulty falling and staying asleep. Other antipsychotic side effects include neuroleptic malignant syndrome (high fever, sweating, increased pulse and blood pressure, and muscular rigidity), pseudoparkinsonism (muscle rigidity, shuffling gait, resting tremor, and mask-like facial expression), and tardive dyskinesia (involuntary movements including chewing and lip- smacking). Highpotency antipsychotics, such as haloperidol, are more likely to cause these neurologic side effects than low-potency agents such as thioridizine, or atypical agents, such as risperidone, olanzapine, and clozapine.

Questions 3-4

A 54-year-old woman with schizophrenia who has been taking a high-potency antipsychotic agent for the past 5 years has begun to show involuntary chewing and lip- smacking movements.

3. This sign indicates that the patient is experiencing a side effect of antipsychotic medication known as

A. restless legs syndrome

B. neuroleptic malignant syndrome

C. akathisia

D. tardive dyskinesia

E. acute dystonia

F. pseudoparkinsonism

4. The side effect described in question 3 is best treated initially

A. by changing to a low-potency or atypical antipsychotic agent

B. with an antianxiety agent

C. with an antidepressant agent

D. with an anticonvulsant

E. by stopping the antipsychotic agent

Answer and explanation:

Question 3, the answer is D. question 4. the answer is A. These involuntary chewing and lip-smacking movements indicate that the patient has developed tardive dyskinesia, a serious side effect of treatment with antipsychotic medication (see also answer to Question 1). Tardive dyskinesia usually occurs after at least 6 months of starting a high-potency antipsychotic and is best treated by changing to a low-potency or atypical agent; stopping the antipsychotic medication will exacerbate the symptoms.

5. A 45-year-old woman presents with the symptoms of a major depressive episode. The patient has never previously taken an antidepressant. Her physician decides to prescribe fluoxetine (Prozac). The most likely reason for this choice is that, when compared to a heterocyclic antidepressant, fluoxetine

A. is more effective

B. works faster

C. has fewer side effects

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D. is less likely to be abused

E. is long lasting

Answer and explanation:

The answer is C. The doctor decides to give this patient fluoxetine because, when compared to a heterocyclic antidepressant, SSRIs such as fluoxetine have fewer side effects. Heterocyclics and SSRIs have equal efficacy, equivalent speed of action, and equivalent length of action. Neither SSRIs nor heterocyclics are likely to be abused.

6. A 57-year-old male patient with a history of alcoholism has decided to stop drinking. Of the following, the agent most commonly used to treat anxiety and agitation associated with the initial stages of alcohol withdrawal is

A. zaleplon
B. flurazepam
C. clonazepam
D. buspirone
E. chlordiazepoxide F. bupropion

Answer and explanation:

The answer is E. Because it is long acting and has relatively low abuse potential for a BZ, chlordiazepoxide is the antianxiety agent most commonly used to treat the anxiety and agitation associated with the initial stages of alcohol withdrawal.

7. An 80-year-old man is brought to the emergency room by his wife. The man, who has a history of depression and suicidal behavior, refuses to eat and states that life is not worth living anymore. Consultations with his primary care physician and a consulting psychiatrist reveal that the patient has not responded to at least three different antidepressant medications that he has taken in adequate doses and for adequate time periods in the past 2 years. The most appropriate next step in the management of this patient is to recommend

A. diazepam

B. electroconvulsive therapy (ECT)

C. psychotherapy

D. buspirone

E. lithium

Answer and explanation:

The answer is B. The most appropriate next step is to recommend a course of electroconvulsive therapy (ECT) for this elderly, severely depressed patient. ECT is a safe, fast, effective treatment for major depression. Diazepam, lithium, buspirone, and psychotherapy will not be effective as ECT in relieving this patient’s suicidal depression quickly

8. What is the most appropriate agent for a doctor to recommend for a 34-year-old, overweight, depressed patient who needs to take an antidepressant but is afraid of gaining weight?

A. Venlafaxine

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B. Tranylcypromine C. Trazodone
D. Doxepin
E. Amoxapine

F. Fluoxetine G. Nortriptyline H. Imipramine

Answer and explanation:

The answer is F. In contrast to most antidepressant agents, which are associated with weight gain, fluoxetine (Prozac) is associated with some weight loss. Thus it is the most appropriate antidepressant agent for a patient who is afraid of gaining weight.

9. Which of the following antidepressant agents is most likely to cause gynecomastia and parkinsonian symptoms in a 45-year-old male patient?

A. Venlafaxine
B. Tranylcypromine C. Trazodone
D. Doxepin
E. Amoxapine
F. Fluoxetine
G. Nortriptyline

Answer and explanation:

The answer is E. Amoxapine has antidopaminergic action and, thus, is the agent most likely to cause gynecomastia as well as parkinsonian symptoms in this patient.

10. A 45-year-old man presents in the emergency room with sinus tachycardia (112/bpm), flattening of T waves and prolonged QT interval. The patient tells the physician that he is taking “nerve pills.” Which of the following medications is this patient most likely to be taking?

A. Bupropion B. Fluoxetine C. Lorazepam D. Valproic acid E. Imipramine

Answer and explanation:

The answer is E. TCAs such as imipramine cause sinus tachycardia, flat T waves, prolonged QT interval and depressed ST segments. Bupropion, fluoxetine, lorazepam, and valproic acid are less likely to cause these cardiovascular effects.

11. A 45-year-old woman with schizophrenia has been taking an atypical antipsychotic for the past year. Since starting the medication she has gained 35 pounds, has developed diabetes mellitus, and shows a prolonged QT interval. Because of these medication side effects her physician would like to switch her to a different atypical agent. Of the following atypical agents, which is likely to be the best choice for this patient?

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A. Quetiapine B. Ziprasidone C. Aripiprazole D. Clozapine E. Olanzapine

Answer and explanation:

The answer is C. Because of her weight gain, type 2 diabetes and cardiovascular problem, the best choice of atypical antipsychotic agent for this patient now is aripiprazole. Clozapine and olanzapine carry high risk and ziprasidone and aripiprazole carry low risk for weight gain and diabetes. However, ziprasidone prolongs the QT interval and so should be avoided in this patient.

Introduction to the Mental Health Act (1983):

1. Synopsis

A. Guiding principles of the Act

B. Criteria for implementation of the Act

C. Definition of mental disorder within the Act

D. Sections of the Act

2. Self-test Questions

A. What is the difference between an ‘approved clinician’ and a ‘responsible
clinician’?

B. Who can apply a Section 5(2)?

C. Who can apply a Section 5(4)?

Psychotherapy:

Psychotherapy 1. Synopsis

A. What is psychotherapy?

B. Common characteristics of all forms of psychotherapy

C. What is available in the NHS?

D. Explanation different models of psychotherapy

E. Indications for psychotherapy

2. Self-test Questions

A. Why is regular supervision important for a psychotherapist?

B. What are the potential advantages of therapeutic community treatment
over individual psychotherapy?

C. What are the symptoms of obsessive-compulsive disorder and how are
they treated with CBT?

Psychodynamic psychotherapy:

1. Synopsis

A. transference

B. defencemechanisms

C. resolution of unconscious conflict

D. inter-personal (relationship) difficulties

Behavioural and Cognitive therapies (cognitive-behavioural therapy =CBT): 1. Synopsis

  

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2. A 52-year-old man is hospitalized for triple CABG and subsequently develops a delirium. He has a history of one closed head injury with loss of consciousness, as well as past alcohol abuse with 7 years of sobriety under his belt. Which of the following factors is most likely the prime contributory factor in the development of his delirium?

A. His age

B. Hospitalization

C. Status post–cardiac surgery

D. History of head injury

E. History of alcohol abuse

Answer and explanation

C. Advanced age is a major risk factor, with 60% of nursing home residents over age 75 experiencing repeated episodes of delirium. Of all medically ill, hospitalized patients, 10% to 30% exhibit delirium. However, some studies indicate that 90% of postcardiotomy patients experience delirium. Preexisting brain damage, prior history of delirium, alcohol dependence, diabetes, cancer, sensory impairment, and malnutrition may also contribute.

3. An 82-year-old man with a history of vascular dementia is brought to the hospital for increased agitation and urinary tract infection (UTI). Which of the following features most distinguishes effects of a delirium from dementia?

A. Altered level of consciousness

B. Behavioral disturbances

C. Cognitive deficits

D. Disorientation

E. Presence of hallucinations

Answer and explanation

A. Both delirium and dementia can result in behavioral disturbances, cognitive deficits, and poor orientation. However, in all cases of delirium there is an alteration (reduction) in the level of consciousness, whereas in dementia (in the early stages) there is an alert, stable level of consciousness.

4. In the previous case, the patient is determined to have a delirium due to infection, overlying his dementia. Which of the following is the most important treatment approach in treating his delirium?

A. Detection and correction of the underlying abnormality

B. Environmental strategies to help with orientation

C. Treatment with an antipsychotic medication for hallucinations

D. Physical restraint to protect the patient from injury

E. Treatment with a benzodiazepine to reduce agitation

Answer and explanation

A. Although environmental strategies and pharmacologic and physical interventions can be helpful and necessary to help orient patients or protect them from harm, the most essential treatment approach in all cases of delirium is to detect and correct the underlying cause of the disorder. The occurrence of an episode of delirium itself suggests a poor prognosis, meaning these patients have a signifi cantly elevated future incidence of mortality. In the elderly, antipsychotic agents should be used h

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caution given some increased risk of mortality, and benzodiazepines may cause disinhibition, oversedation, or paradoxical excitation.

Drugs and Alcohol Disorders:

1. Synopsis

A. Epidemiology

B. Assessment of disorders

C. Physical complications of addiction disorders

D. Psychosocial management

E. Prescribing in addiction disorders

F. Relationship between health and social care treatment systems

G. Law and crime

H. Family and social consequences

2. Self-test Questions

A. In what ways may excessive use of alcohol present to the psychiatrist?

B. What are the health risks (physical and psychosocial) of illicit opioid use?

C. What is meant by “harm minimisation?”

D. What is the recommended safe weekly intake of alcohol (a) for men (b) for
women?

E. What are the symptoms of acute alcohol withdrawal (delirium tremens)?

F. Which illicit drugs may produce a schizophrenia-like state?

3. Case study: Case 8

Case: 8 A

A 29-year-old man comes to the emergency department complaining of stomach cramps, agitation, severe muscle aches, and diarrhoea. Physical examination reveals that the patient is sweating, has dilated pupils, a fever, and a runny nose, and shows goose bumps on his skin.

1. Of the A. B. C. D.

E.

following, the most likely cause of this picture is alcohol use
alcohol withdrawal
heroin use

heroin withdrawal amphetamine withdrawal

2. Of the symptoms is

following, the most effective immediate treatment for relief of this patient’s

A. naloxone

B. naltrexone

C. an antipsychotic

D. a stimulant

E. clonidine

Answer and explanation:

One. the answer is D. two. The answer is E. The most likely cause of this patient’s symptoms of sweating, muscle aches, stomach cramps, diarrhoea, fever, runny nose, goose bumps, yawning, and dilated pupils is heroin withdrawal. While alcohol withdrawal may be associated with pupil dilation, alcohol use and withdrawal and amphetamine withdrawal

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are less likely to cause this constellation of symptoms. Of the choices given, the most effective immediate treatment for heroin withdrawal is clonidine to stabilize the autonomic nervous system. Psychotic symptoms are uncommon in opioid withdrawal and this patient does not need an antipsychotic. Naloxone and naltrexone as well as stimulants will worsen rather than ameliorate the patient’s withdrawal symptoms.

Case: 8 B
Physician is doing an employment physical on a 40-year-old male patient. The physician suspects that the patient has a problem with alcohol. The next step that the physician should take is to

A. check his liver function

B. ask him if he has a problem with alcohol

C. call his previous employer for information

D. ask him the CAGE questions

E. check for the stigmata of alcoholism

F. (e.g., stria, broken blood vessels on the nose)

Answer and explanation:

The answer is D. The next step in management is for the physician to ask this patient the CAGE questions. Positive answers to any two of these questions or to the last one alone indicate that he has a problem with alcohol. Patients with such problems typically use denial as a defense mechanism and so rarely believe or admit that they have a problem with alcohol. Liver function problems or presence of the stigmata of alcoholism (e.g., stria, broken blood vessels on the nose) do not necessarily indicate the patient currently has a problem with alcohol. It is inappropriate for the doctor to call the previous employer for information.

Case: 8 C
A 20-year-old female patient tells the doctor that she has little interest in going back to school or in getting a job. She also reports that she often craves snack food and has gained over 10 pounds in the past 4 months. What substance is this patient most likely to be using?

A. Phencyclidine (PCP)

B. Lysergic acid diethylamide (LSD)

C. Marijuana

D. Cocaine

E. Heroin

Answer and explanation:

The answer is C. The motivational syndrome (e.g., lack of interest in getting a job or going to school) and increased appetite, particularly for snack foods, are characteristically seen in chronic users of marijuana. Use of cocaine, heroin, phencyclidine (PCP), or lysergic acid diethylamide (LSD) may cause work-related problems, but are less likely to increase appetite.

Case: 8 D
A 60-year-old man is brought to the hospital after a fall outside of a neighbourhood bar. Radiologic studies indicate that the patient has a fractured hip and surgery is performed immediately. Two days later, the patient begins to show an intense hand tremor and

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tachycardia. He tells the doctor that he has been “shaky” ever since his admission and that the shakiness is getting worse. The patient states that while he feels frightened, he is comforted by the fact that the nurse is an old friend (he has never met the nurse before). He also reports that he has started to see spiders crawling on the walls and can feel them crawling on his arms. The doctor notes that the patient’s speech seems to be drifting from one subject to another. Of the following, what is the most likely cause of this picture?

A. Alcohol use

B. Alcohol withdrawal

C. Heroin use

D. Heroin withdrawal

E. Amphetamine withdrawal

Answer and explanation:

The answer is B. The most likely cause of tremor, tachycardia, illusions (e.g., believing the nurse is an old friend), and visual and tactile hallucinations (e.g., formication—the feeling of insects crawling on the skin) in this patient is alcohol withdrawal, since the use of alcohol during the past few days of hospitalization is unlikely. His fractured hip may have been sustained in the fall while he was intoxicated. Heroin use and heroin and amphetamine withdrawal generally are not associated with psychotic symptoms.

Case: 8 E
A 40-year-old female patient who has been taking a benzodiazepine daily in moderate doses over the past 5 years abruptly stops taking the drug. When a physician sees her 2 days after her last dose, she is most likely to show

A. hypersomnia
B. tremor
C. lethargy
D. respiratorydepression E. sedation

Answer and explanation:

The answer is B. Withdrawal from benzodiazepines is associated with tremor, insomnia, and anxiety. Respiratory depression and sedation are associated with the use of, not withdrawal from, sedative drugs.

Case: 8 F
A 35-year-old man is brought to the emergency department confused and anxious. The man reports that someone is trying to kill him but he does not know who the person is. Initial physical examination reveals elevated heart and respiration rates. While in the emergency room the patient has a seizure and then develops life-threatening cardiovascular symptoms. The drug that this patient is most likely to be withdrawing from is

A. phencyclidine (PCP)

B. lysergic acid diethylamide (LSD)

C. heroin

D. secobarbital

E. marijuana

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Answer and explanation:

The answer is D. This 35-year-old patient is most likely to be withdrawing from secobarbital, a barbiturate. Barbiturate withdrawal symptoms appear about 12–20 hours after the last dose and include anxiety, elevated heart and respiration rates, psychotic symptoms (e.g., the belief that someone is trying to kill him), confusion, and seizures, and can be associated with life-threatening cardiovascular symptoms. There are few physical withdrawal symptoms associated with marijuana, phencyclidine (PCP), or lysergic acid diethylamide (LSD), and those associated with heroin are uncomfortable but rarely physically dangerous.

Case: 8 G
A 43-year-old man with a 5-year history of HIV tells his physician that he has been smoking marijuana a few times a day to treat his symptoms of nausea and lack of appetite. To obtain the marijuana, the patient notes that he grows it in his backyard. The doctor’s best response to this patient’s revelation is

A. “I am sorry but growing or using marijuana is illegal and I must notify the police”

B. “I have read about other patients growing marijuana”

C. “Are you aware that marijuana can cause respiratory problems?”

D. “There are a number of medications that I can prescribe to help alleviate your
nausea and lack of appetite in place of marijuana”

E. “Do you think that using marijuana has negative long-term effects?”

Answer and explanation:

The answer is D. The best response to this patient’s revelation about growing and using marijuana is to recommend effective but safer substitutes, for example, prescription medications to treat his nausea and lack of appetite. It is neither appropriate nor necessary for a physician to report the patient’s actions to the police. Also, this HIV-positive patient is likely to be more concerned about feeling ill in the short-term than long-term consequences of marijuana use such as respiratory problems.

Child & Adolescent Mental Health:

You will be given a separate handbook for Child & Adolescent Mental Health at the start of the teaching session.

Eating Disorders:

1. Synopsis

A. Description of main eating disorders

B. Epidemiology

C. Aetiology

D. Medical complications

E. Management based on NICE guidelines

F. Outcome in eating disorders

2. Self-test Questions:
A. What are the diagnostic features of bulimia nervosa? B. What is the cause of amenorrhoea in anorexia nervosa?

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Mental Health care and Neurology Block-Phase II 2017

C. What drugs are used in the treatment of bulimia nervosa?

D. Whattypesofpsychotherapyareusedinthetreatmentofanorexianervosa?

E. Why are tricyclic antidepressants potentially dangerous in anorexia
nervosa?

F. What are the most serious physical complications of anorexia nervosa?

Liaison Psychiatry – Physical Illness and Psychiatry:

1. Synopsis

A. The interface between physical and psychiatric illness

B. What is the role of a liaison psychiatrist?

C. How can physical illness cause psychiatric illness?

D. How can psychiatric illness produce physical symptoms?

E. Overview of medically unexplained symptoms (somatoform disorders)

2. Self-test Questions
A. What are the common causes of acute confusional states? B. What is the cause of Wernicke’s encephalopathy?

Learning Disabilities:

1. Synopsis

A. Taking a history from a person with a learning disability

B. Concepts and causes of learning disability

C. Down syndrome

D. Epilepsy

E. Autism and Asperger syndrome

2. Self-test Questions

A. Why are psychiatric disorders difficult to diagnose in people with learning
disability?

B. What is a “behavioural phenotype”?

C. What are the features of Down syndrome?

D. What is Fragile X syndrome?

E. What are the diagnostic features of autism?

Ethics:

1. Synopsis

A. Revision of ethical frameworks

B. Ethics in relation to psychiatry

C. Ethicalcasestudies

In this block you will come across a variety of ethical issues. Some of these relate directly to patient care, some to the system in which care is given, and some relate to more diverse themes that impact on mental health care. You may face new and challenging situations that cause you to reflect. What does it means to be a patient with a mental health problem; to be a carer for someone with a mental health problem; to be a professional involved in that care?

As part of the block there is a half-day workshop looking at psychiatric ethics, in which, amongst other things, there is the opportunity to discuss an ethical dilemma that you have

74

Mental Health care and Neurology Block-Phase II 2017

faced in the block. In this workshop, you are able to bring your own material for discussion, which adds to the diversity of the ethical and legal areas that are covered.

2. The aim
The aim of the Ethics and Law worksheet in this module is to enable you to reflect on what you have learned in the block, and how you have used the learning opportunities that you have been given. It would therefore be most useful to complete this in the final week of the block.

3. Self-test Questions

A. What areas covered in the half-day psychiatric ethics workshop did you find
most challenging? Why do you think this was?

B. What did you learn about yourself and your values by taking part in the
workshop?

C. Whatpersonalknowledgegapsdidyouidentifybytakingpartintheworkshop
and how did you address them?

4. Medical law

A. What opportunities have you been given to look into mental health law?
How did you use these?

B. What have you learned about the impact of mental health law on patient
care?

5. Further learning

A. How confident do you feel about the following?

B. How has your confidence changed in these areas over the block? Why do you think this is?

6. Useful resources
A. http://www.gmc-uk.org/guidance/a_z_guidance/guidance_list/list_m.asp B. http://www.gmc-uk.org/guidance/current/library/consent.asp#19
C. http://www.gmc-uk.org/publications/valuing_diversity/index.asp

Extremely confident

 

Very confident

Confident

Reasonably confident

Not at all confident

Assessing the mental state of a patient

Assessing mental capacity

 

 

 

Assessing the risk of self-harm

Communicating with a person with a moderate learning disability

 

  

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Tasks answer of psychiatry

Psychosis and schizophrenia

Case study: 1 Question: 1

A. Most likely diagnosis: Schizophrenia, probably paranoid type.

B. Important conditions to rule out: To make a diagnosis of schizophrenia, psychosis secondary to substance abuse and general medical conditions must be ruled out. In addition, schizoaffective disorder and mood disorders must
also be excluded.

C. Should this patient be hospitalized? Yes. He clearly poses a danger to
himself (and potentially to others based on the undetermined nature of “bad things” he is being commanded to perform) because he listens to the voices and acts on their instructions so as to put himself at risk for serious physical harm (ie, sitting in the middle of a busy street).

Question: 2

B. Although all these symptoms can be seen in various psychotic disorders, the presence of a bizarre delusion is the most specific to schizophrenia. Only one psychotic symptom is needed to diagnose schizophrenia if there are bizarre delusions, auditory hallucinations commenting on the patient, or two or more voices speaking to each other.

Question: 3

A. BIZARRE DELUSIONS: Delusions that are totally implausible (eg, having been captured by aliens).

B. DELUSIONS: Fixed, false beliefs that remain despite clear evidence to the contrary, that are not culturally sanctioned.

C. FLAT AFFECT: The absence of a noticeable emotional state (eg, no facial expression).

D. IDEAS OF REFERENCE: False beliefs that, for example, a television or radio performer, a song, or a newspaper article refers to oneself.

E. LOOSE ASSOCIATIONS: Thoughts that are not connected to one another or illogical answers to questions.

F. TANGENTIALITY: Thoughts can be connected to each other although the patient does not come back to the original point or answer the question.

G. NEGATIVE SYMPTOMS OF SCHIZOPHRENIA: Affective flattening, alogia (diminished flow and spontaneity of speech), and avolition (lack of initiative or goals).

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H. POSITIVE SYMPTOMS OF SCHIZOPHRENIA: Ideas of reference, grossly disorganized speech or behavior, delusions (such as paranoia), and hallucinations.

Question: 4

C. Auditory and visual hallucinations are common in all episodes of psychosis regardless of the cause. Gustatory hallucinations (along with olfactory and tactile hallucinations) can be more common in psychoses caused by a medical illness. It would be somewhat unusual to find problems with reality testing or thought disorders in a patient with psychosis due to a general medical condition, though this is possible. These are much more commonly seen in other psychotic disorders such as schizophrenia.

Question: 5

C. Psychoses caused by general medical conditions usually respond to antipsychotic medications. There is no indication for the use of drugs used to treat mood disorders (lithium, valproic acid, or sertraline) or benzodiazepines.

Mood Disorders (Affective Disorders)

Case study: 2 (for manic episode) Question: 1

A. Next diagnostic step: A urinalysis for drugs of abuse should be ordered, and a determination of alcohol blood level should be made as well.

B. Most likely diagnosis: Bipolar disorder, manic.
C. Best initial treatment: Admission to the hospital should be recommended,

although it is unclear whether the patient is committable at this point. At the least, he will need treatment with a mood stabilizer (lithium, carbamazepine, valproic acid) and perhaps with an antipsychotic (such as risperidone) as well.

Question: 2

A. INVOLUNTARY COMMITMENT: Although their laws vary, all states have some sort of mechanism for placing a patient in a psychiatric hospital in the event of uncontrollable or imminently dangerous mental illness. Usually, patients must present an immediate danger to themselves (suicidality) or others (homicidality or extreme, violent, acting-out behavior) or be unable to care for themselves (eg, walking outside unclothed in the middle of winter, walking in traffic). Commitment to a hospital involves the signing of commitment papers by a physician. The patient must then appear in court within a specified number

 

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of days so that it can be determined if the commitment should continue or the

patient should be discharged.
B. The differential diagnosis for mania is quite straightforward, but the diagnoses

themselves can be difficult to establish. For example, identical clinical presentations can result from substance-induced mood disorder, mood disorder secondary to a general medical condition, and mania; hence, illicit or prescribed agents must be ruled out as well as medical conditions. Drugs such as corticosteroids and levodopa and stimulants such as cocaine have been known to cause manic-like behavior. General medical conditions such as metabolic disturbances caused by hemodialysis, infections, neoplastic diseases, and seizures can also cause these types of behavior. Schizophrenia must be on the differential list and must be ruled out by looking at secondary features such as family history, level of premorbid functioning, or a history of manic symptoms if the clinical features themselves do not set it apart. Schizoaffective disorder can be characterized by psychotic behavior and manic features and must be differentiated by the time courses of the two. In an episode of mania, an elevated mood and grandiosity can appear without psychotic symptoms, which in any case must not precede such symptoms. Patients with schizoaffective disorder can exhibit mood symptoms, but psychotic symptoms precede the mood symptoms and/or can continue after the mood reverts back to euthymia.

Question : 3

C. In a patient of this age, with no previous psychiatric or medical history, general medical conditions responsible for this new-onset behavior should be ruled out before an episode of bipolar mania is considered. While admission to the hospital might well be necessary to control the destructive behavior, making the diagnosis first is the primary concern. Both a mood stabilizer and/or an antipsychotic may well also be necessary, but again, if the mood problem is secondary to a general medical condition, treating it may resolve the psychiatric symptoms by itself.

Question: 4

B. Because tardive dyskinesia is irreversible, and the risk of its appearance increases with continued use, antipsychotics should be discontinued as soon as the patient’s psychotic symptoms remit, and not use again as long as the patient’s condition remains stable.

Question : 5

D. Maternal use of valproic acid is associated with a 1% to 2% risk of fetal neural tube defects such as spina bifida.

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Case study: 2 (for depressive episode) Question :1

A. Most likely diagnosis: Major depression with psychotic features (auditory hallucinations).

B. Best treatment: She should be offered a psychiatric admission because her major depression is severe. Although she is not committable; she could still be hospitalized by her parents because she is a minor. She should be started on a selective serotonin reuptake inhibitor (SSRI) and an atypical antipsychotic medication. When stabilized, the patient should be seen weekly for at least 4 weeks by the physician or qualified mental health professional to assess for any increase in suicidal thinking in compliance with current (FDA) warnings for antidepressant use in children.

Question: 2

A. ANHEDONIA: Loss of a subjective sense of pleasure.
B. MOOD-CONGRUENT DELUSIONS OR HALLUCINATIONS: The

content of the delusions or hallucinations reflects the nature of the illness. For example, in major depression, delusions and hallucinations are often about being defective, deficient, diseased, or guilty and deserving of punishment.

C. PSYCHOSIS: A syndrome characterized by hallucinations and/or delusions (fixed, false beliefs). The individual’s ability to assess reality is impaired.
D. SOMATIC DELUSIONS: False beliefs about one’s body; in depression,

these are beliefs regarding illness, for example, that one has cancer and is

about to die.
E. VEGETATIVE SYMPTOMS: Symptoms of depression that are

physiologic or are related to body functions, such as sleep, appetite, energy, and sexual interest. Other symptom categories for depression are cognitive (poor concentration,low self-esteem) and emotional (crying spells).

Question: 3

Diagnosis is often complex because there are many comorbid disorders such as anxiety disorders, disruptive behavior disorders, or substance abuse that can confuse the picture. Similarly, many personality disorders can begin to be seen in adolescence and need to be considered as well. Many medical conditions and substances can also cause mood disorders.

Other mood disorders such as bipolar illness and dysthymia can be difficult to differentiate from major depression. Sometimes a patient with bipolar disorder has several episodes of depression before the first episode of mania; and examining a carefully recorded family history and a clinical history can raise the clinician’s

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suspicion of bipolar disorder. Sometimes a patient has an episode of major depression superimposed on lifelong dysthymia, making the diagnosis difficult. Schizoaffective disorder includes both depressive and psychotic symptoms; knowledge of the history and course of the illness is often necessary to make a diagnosis. Patients with schizophrenia can experience episodes of depression, but they usually develop later in the course of the illness, and the predominant picture is one of psychosis and negative symptoms. An active substance dependence makes the diagnosis of depression difficult because depressive and psychotic symptoms accompany the use of many substances (such as alcohol or cocaine); these can be indistinguishable from major depression. Often a patient must abstain from the substance for several weeks before the diagnosis can be confirmed.

Question : 4

A. Best therapy: A selective serotonin reuptake inhibitor (SSRI) such as sertraline, paroxetine, citalopram, fluoxetine, or fluvoxamine is one of the first-line choices of medication for this patient. Selective serotonin norepinephrine reuptake inhibitors (SSNRI) such as venlafaxine and duloxetine are also first-line treatment options.

B. Common side effects: Gastrointestinal symptoms—stomach pain, nausea, and diarrhea—occur in early stages of the treatment. Minor sleep disturbances— either sedation or insomnia—can occur. Other common side effects include tremor, dizziness, increased perspiration, and male and female sexual dysfunction (most commonly delayed ejaculation in men and decreased libido in women).

Question: 5

E. The proper strategy in the management of an episode of major depression that has recently remitted is to continue treatment at the same dose if it can be tolerated. Early discontinuation of medication can lead to an early relapse. A general rule of thumb is, “The dose that got you better will keep you well.” A reasonable duration for continuing the medication is 6 to 9 months.

Question: 6

A. SSRI: An agent that blocks the reuptake of serotonin from presynaptic neurons without affecting norepinephrine or dopamine reuptake. These agents are used as antidepressants and in treating eating disorders, panic, obsessive-compulsive disorder, and borderline personality disorder (for symptom-targeted pharmacotherapy).

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B. SSNRI: An agent that blocks reuptake of serotonin and norepinephrine. These agents are used as antidepressants, and for generalized anxiety disorder. Duloxetine may also be used for painful diabetic neuropathy.

C. Bupropion, an aminoketone, blocks the reuptake of dopamine rather than 5- HT or NE. Although it is rarely lethal in overdose, it has a narrow therapeutic index and has the potential to result in seizures in higher doses. Side effects include restlessness, sweating, tremors, and constipation. The incidence of sexual side effects is low. Bupropion is contraindicated in patients with comorbid eating disorders. It does come in a sustained-release and an extended release preparation.

D. Mirtazapine, an antagonist of _2 (i.e., adrenergic, inhibitory) autoreceptors, acts presynaptically but by a different mechanism. It also blocks some postsynaptic serotonergic and histaminergic receptors. Mirtazapine results in increased noradrenergic and serotonergic activity, has fewer sexual side effects, is very sedating, and is anxiolytic.

Question: 7

A. Most likely diagnosis: Recurrent major depression with psychotic features. B. Best plan of action: Close observation in the hospital, intravenous hydration, and consideration of electroconvulsive therapy (ECT) because of the severity

and urgency associated with this episode of depression.

Anxiety and other Neurotic Disorders:

Case study: 3 A

1. The answer is C. 2. The answer is A. 3. The answer is D. This patient is showing evidence of panic disorder with agoraphobia. Panic disorder is characterized by panic attacks, which include increased heart rate, dizziness, sweating, shortness of breath, and fainting, and the conviction that one is about to die. Attacks commonly occur twice weekly, last about 30 minutes, and are most common in young women, such as this patient. This young woman has also developed a fear of leaving the house (agoraphobia) which occurs in some patients with panic disorder. While the most effective immediate treatment for this patient is a benzodiazepine because it works quickly, the most effective long-term (maintenance) management is an antidepressant, particularly a selective serotonin reuptake inhibitor (SSRI) such as paroxetine (Paxil). The neural etiology most closely involved in panic disorder with agoraphobia is hypersensitivity of the locus ceruleus.

 

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Case study: 3 B
1. The answer is E. This woman with a 20-year history of unexplained vague and chronic physical complaints probably has somatization disorder. This can be distinguished from hypochondriasis, which is an exaggerated worry about normal physical sensations and minor ailments
2. The answer is K. This teenager, who was formerly outgoing and a good student and now seems sad, loses interest in making friends, and begins to do poor work in school, probably has adjustment disorder (with depressed mood). It is likely that he is having problems adjusting to his new school. In contrast to adjustment disorder, in masked depression the symptoms are more severe and often include significant weight loss or suicidality
3. The answer is H. This man, who experiences a sudden neurological symptom triggered by seeing his girlfriend with another man, is showing evidence of conversion disorder. This disorder is characterized by an apparent lack of concern about the symptoms (i.e., la belle indifférence).
4. The answer is B. This man, who says that he has been “sickly” for most of his life and fears that he has stomach cancer, is showing evidence of hypochondriasis, exaggerated concern over normal physical sensations (e.g., stomach noises) and minor ailments.There are no physical findings nor obvious evidence of depression in this patient.
5. The answer is L. This man probably has masked depression. In contrast to the hypochondriacal man in the previous question, evidence for depression in this patient includes the fact that, in addition to the somatic complaints, he shows symptoms of depression (e.g., he is not groomed, appears slowed down [psychomotor retardation], and has lost a significant amount of weight).
6. The answer is G. This woman probably has body dysmorphic disorder, which is characterized by over-concern about a physical feature (e.g., “sagging” eyelids in this case), despite normal appearance.
7. The answer is J. This man probably has social phobia. He is afraid of embarrassing himself in a public situation (e.g., getting food on his face while eating dinner in front of others in a restaurant).
8. The answer is K. The most likely explanation for this clinical picture that includes symptoms of anxiety which begin after a life stressor (e.g., a romantic break-up) is adjustment disorder (with anxiety). The absence of a previous history and the brief duration indicates that this is not an anxiety disorder and the fact that the stressor was not life-threatening rules out PTSD and ASD. The family history is not likely to be related to this patient’s symptoms in this case.

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Personality Disorders:

Case study: Case 4 A

1. The answer is D . Some diagnostic criteria for obsessive-compulsive personality disorder include preoccupation with details, perfectionism interfering with task completion, excessive devotion to work, scrupulousness, inability to discard collected belongings, reluctance to delegate, miserly spending style, rigidity, and stubbornness.

2. The answer is B . In the medical–surgical setting, persons with obsessive- compulsive personality disorder may become even more inflexible because the illness is perceived as a threat to their need for control.

3. The answer is E . In the medical treatment of persons with obsessive-compulsive personality disorder, sharing control with the patient may obviate the perceived threat to their need for control.

Case: 4 B

1. The answer is A . Some diagnostic criteria for antisocial personality disorder include evidence of conduct disorder with onset before age 15 years, a pattern of disregard for or violation of the rights of others, irritable and aggressive behavior, deceitfulness, recklessness, and lack of remorse.

2. The answer is E . In the medical–surgical setting, persons with antisocial personality disorder may give the impression of being quite charming but in a manipulative fashion. They may resist hospital rules and be noncompliant, and when challenged, they may leave treatment against medical advice.

3. The answer is C . In the treatment of persons with antisocial personality disorder, setting firm limits is important but often triggers a demand to leave treatment against medical advice.

4. The answer is D . Antisocial personality disorder can respond to treatment. Group psychotherapy can be effective, but an experienced therapist and a particular group of patients are needed. Controlled substances may be abused by some persons with antisocial personality disorder.

Question: 4C

1. The answer is C . Some diagnostic criteria for histrionic personality disorder include a need to be the center of attention, inappropriate seductive or provocative behavior, obsession with physical attractiveness, dramatic behavior and impressionistic speech, suggestibility, and exaggeration of the importance of relationships.

8

2. The answer is B . In the medical–surgical setting, persons with histrionic personality disorder may give the impression of being charming and fascinating. The patient’s dependence on his sense of attractiveness may be threatened by illness.
3. The answer is E . In the treatment of persons with histrionic personality disorder, setting firm limits on patient and staff roles is critical. At the same time, staff should try to remain noncritical of behavior symptomatic of the disorder.

Suicide and Para-suicide (deliberate self-harm) & assessment of risk:

Case: 5 A . The answer is D . While personality disorders are often common in alcohol and drug dependency problems, their presence is not necessary in order to confirm a diagnosis. Physical dependence, tolerance, withdrawal, and increasing time spent acquiring substances are all seen with alcohol and drug dependency problems.

Case: 5 B . The answer is D . Both intoxication and withdrawal from barbiturates may cause confusion, delirium, anxiety, agitation, and postural hypotension. If caused by withdrawal, these signs improve with administration of a barbiturate. Nystagmus, which is a sign of intoxication but not of withdrawal, may appear. Case: 5C. The answer is B . Absence of intoxication in the presence of a high blood alcohol level indicates that the patient is tolerant to the central nervous system depressant effects of alcohol, which is a major criterion for alcohol dependence. Pancreatitis, impotence, and cerebral atrophy are complications of alcoholism that should be investigated, but these are not diagnosed by a blood alcohol level. Because opioids and alcohol are not cross-tolerant, tolerance to alcohol does not provide any information about tolerance to opioids.

Case: 5D. The answer is C . Similar to alcohol, barbiturates, and benzodiazepines, narcotics can produce depression of consciousness, refl exes, blood pressure, and respiration. Narcotics cause constricted rather than dilated pupils. Opioid intoxication can be diagnosed with intravenous naloxone.

Case: 5E . The answer is B . Stimulant psychosis often is associated with paranoia and loose associations in a clear sensorium, which may make it indistinguishable from schizophrenia. Tactile hallucinations and delusions of infestation with parasites also may occur. Depression is usually associated with stimulant withdrawal, not stimulant intoxication.

Case: 5F. The answer is C . Contrary to popular wisdom, physical dependence on marijuana may occur, and withdrawal symptoms may appear with discontinuation. Marijuana has been found to be a “gateway drug” that lowers the threshold for use of “harder” drugs. Marijuana use can produce tachycardia and an amotivational state. Overdose can cause distortions in time sense and injected conjunctivae, but not seizures.

 

9

Case: 5G. The answer is C . The patient is going into acute opiate withdrawal 30 minutes after receiving his first buprenorphine injection. He most likely told the nursing staff and physician that he had used his last dose of heroin several hours earlier from the time of his admission than he actually did. He probably feared going into withdrawal and did not wait long enough for withdrawal signs to appear before getting his first dose of buprenorphine. As a result, buprenorphine’s antagonistic properties knocked off the remaining heroin still attached to the mu receptors and put the patient into acute opiate withdrawal.

Psychiatric drugs:

Case study: Case 6

1. The answer is C. 2. The answer is D. The symptom that this patient describes is akathisia, a subjective, uncomfortable feeling of motor restlessness related to use of some antipsychotics. Restless legs syndrome also involves uncomfortable sensations in the legs, but it is a sleep disorder , which causes difficulty falling and staying asleep. Other antipsychotic side effects include neuroleptic malignant syndrome (high fever, sweating, increased pulse and blood pressure, and muscular rigidity), pseudoparkinsonism (muscle rigidity, shuffling gait, resting tremor, and mask-like facial expression), and tardive dyskinesia (involuntary movements including chewing and lip-smacking). High potency antipsychotics, such as haloperidol, are more likely to cause these neurologic side effects than low-potency agents such as thioridizine, or atypical agents, such as risperidone, olanzapine, and clozapine.

3.The answer is D. 4. The answer is A. These involuntary chewing and lip- smacking movements indicate that the patient has developed tardive dyskinesia, a serious side effect of treatment with antipsychotic medication . Tardive dyskinesia usually occurs after at least 6 months of starting a high-potency antipsychotic and is best treated by changing to a low-potency or atypical agent; stopping the antipsychotic medication will exacerbate the symptoms.

5. The answer is C. The doctor decides to give this patient fluoxetine because, when compared to a heterocyclic antidepressant, SSRIs such as fluoxetine have fewer side effects. Heterocyclics and SSRIs have equal efficacy, equivalent speed of action, and equivalent length of action. Neither SSRIs nor heterocyclics are likely to be abused.

6. The answer is E. Because it is long acting and has relatively low abuse potential for a BZ, chlordiazepoxide is the antianxiety agent most commonly used to treat the anxiety and agitation associated with the initial stages of alcohol withdrawal.

 

10

7. The answer is B. The most appropriate next step is to recommend a course of electroconvulsive therapy (ECT) for this elderly, severely depressed patient. ECT is a safe, fast, effective treatment for major depression. Diazepam, lithium, buspirone, and psychotherapy will not be effective as ECT in relieving this patient’s suicidal depression quickly.

8. The answer is F. In contrast to most antidepressant agents, which are associated with weight gain, fluoxetine (Prozac) is associated with some weight loss. Thus it is the most appropriate antidepressant agent for a patient who is afraid of gaining weight.

9. The answer is E. Amoxapine has antidopaminergic action and, thus, is the agent most likely to cause gynecomastia as well as parkinsonian symptoms in this patient.

10. The answer is E. TCAs such as imipramine cause sinus tachycardia, flat T waves, prolonged QT interval and depressed ST segments. Bupropion, fluoxetine, lorazepam, and valproic acid are less likely to cause these cardiovascular effects.

11. The answer is C. Because of her weight gain, type 2 diabetes and cardiovascular problem, the best choice of atypical antipsychotic agent for this patient now is aripiprazole. Clozapine and olanzapine carry high risk and ziprasidone and aripiprazole carry low risk for weight gain and diabetes. However, ziprasidone prolongs the QT interval and so should be avoided in this patient.

Psychiatry for the Elderly:

Case study: Case 7

1. D. Although the other studies are all helpful in determining the etiology of delirium, only an EEG is sensitive in diagnosing this disorder. In almost all cases of delirium, an EEG shows generalized slowing. In cases where alcohol or sedative- hypnotic withdrawal is causing delirium, an EEG can show fast low-voltage activity. In hepatic encephalopathy, an EEG characteristically displays triphasic delta waves. Electroencephalogram findings typically remain normal early in the course of Alzheimer disease.

2. C. Advanced age is a major risk factor, with 60% of nursing home residents over age 75 experiencing repeated episodes of delirium. Of all medically ill, hospitalized patients, 10% to 30% exhibit delirium. However, some studies indicate that 90% of postcardiotomy patients experience delirium. Preexisting brain damage, prior history of delirium, alcohol dependence, diabetes, cancer, sensory impairment, and malnutrition may also contribute.

 

11

3. A. Both delirium and dementia can result in behavioral disturbances, cognitive deficits, and poor orientation. However, in all cases of delirium there is an alteration (reduction) in the level of consciousness, whereas in dementia (in the early stages) there is an alert, stable level of consciousness.

4. A. Although environmental strategies and pharmacologic and physical interventions can be helpful and necessary to help orient patients or protect them from harm, the most essential treatment approach in all cases of delirium is to detect and correct the underlying cause of the disorder. The occurrence of an episode of delirium itself suggests a poor prognosis, meaning these patients have a significantly elevated future incidence of mortality. In the elderly, antipsychotic agents should be used with caution given some increased risk of mortality, and benzodiazepines may cause disinhibition, oversedation, or paradoxical excitation.

Drugs and Alcohol Disorders:

Case: 8 A

1. The answer is D. 2. The answer is E. The most likely cause of this patient’s symptoms of sweating, muscle aches, stomach cramps, diarrhea, fever, runny nose, goose bumps, yawning, and dilated pupils is heroin withdrawal. While alcohol withdrawal may be associated with pupil dilation, alcohol use and withdrawal and amphetamine withdrawal are less likely to cause this constellation of symptoms. Of the choices given, the most effective immediate treatment for heroin withdrawal is clonidine to stabilize the autonomic nervous system. Psychotic symptoms are uncommon in opioid withdrawal and this patient does not need an antipsychotic. Naloxone and naltrexone as well as stimulants will worsen rather than ameliorate the patient’s withdrawal symptoms.

Case: 8 B
The answer is D. The next step in management is for the physician to ask this patient the CAGE questions. Positive answers to any two of these questions or to the last one alone indicate that he has a problem with alcohol. Patients with such problems typically use denial as a defense mechanism and so rarely believe or admit that they have a problem with alcohol. Liver function problems or presence of the stigmata of alcoholism (e.g., stria, broken blood vessels on the nose) do not necessarily indicate the patient currently has a problem with alcohol. It is inappropriate for the doctor to call the previous employer for information.

Case: 8 C
The answer is C. The amotivational syndrome (e.g., lack of interest in getting a job or going to school) and increased appetite, particularly for snack foods, are characteristically seen in chronic users of marijuana. Use of cocaine, heroin,

 

12

phencyclidine (PCP), or lysergic acid diethylamide (LSD) may cause work-related problems, but are less likely to increase appetite.

Case: 8 D

The answer is B. The most likely cause of tremor, tachycardia, illusions (e.g., believing the nurse is an old friend), and visual and tactile hallucinations (e.g., formication—the feeling of insects crawling on the skin) in this patient is alcohol withdrawal, since the use of alcohol during the past few days of hospitalization is unlikely . His fractured hip may have been sustained in the fall while he was intoxicated. Heroin use and heroin and amphetamine withdrawal generally are not associated with psychotic symptoms.

Case: 8 E

The answer is B. Withdrawal from benzodiazepines is associated with tremor, insomnia, and anxiety. Respiratory depression and sedation are associated with the use of, not withdrawal from, sedative drugs.

Case: 8 F
The answer is D. This 35-year-old patient is most likely to be withdrawing from secobarbital, a barbiturate. Barbiturate withdrawal symptoms appear about 12–20 hours after the last dose and include anxiety, elevated heart and respiration rates, psychotic symptoms (e.g., the belief that someone is trying to kill him), confusion, and seizures, and can be associated with life-threatening cardiovascular symptoms. There are few physical withdrawal symptoms associated with marijuana, phencyclidine (PCP), or lysergic acid diethylamide (LSD), and those associated with heroin are uncomfortable but rarely physically dangerous.

Case: 8 G
The answer is D. The best response to this patient’s revelation about growing and using marijuana is to recommend effective but safer substitutes, for example, prescription medications to treat his nausea and lack of appetite. It is neither appropriate nor necessary for a physician to report the patient’s actions to the police. Also, this HIV-positive patient is likely to be more concerned about feeling ill in the short-term than long-term consequences of marijuana use such as respiratory problems.

Collected from references by : ALI SALIM

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