1. Which of the following statements regarding rapid cycling bipolar disorder is true?
A. Often responds to tricyclic antidepressants.
B. Hospitalisation of these patients is rare.
C. More common in men than women.
D. Alcohol, stimulants or caffeine use is risk factors.
E. Defined as at least 4 episodes per month.
2. true statements about structural brain abnormalities in patients with schizophrenia include:
A. Abnormalities have not been correlated with cognitive deficits.
B. Abnormalities are present from birth.
C. Abnormalities are present in a minority of patients.
D. None
E. Cortical involvement is multifocal rather than diffuse.
3. Memory for knowledge and facts , like the first president of the united states:
A. Episodic memory.
B. Recent past memory.
C. Immediate memory.
D. Semantic memory.
E. Implicit memory.
4. A 45-year-old woman attends her GP surgery complaining of poor sleep. On closer questioning she says she avoids leaving the house because she is scared of people looking at her, and 2 weeks ago at a restaurant she had an episode of tachycardia and breathlessness with intense fear. What is the likely diagnosis?
A. Agoraphobia
B. Social phobia
C. Panic disorder
D. Generalised anxiety disorder
E. Depression
5. 4. A 25-year-old man is started on chlorpromazine having been diagnosed as suffering from paranoid schizophrenia. Two months later he is seen in clinic as an emergency due to concerns from his friends over an apparent deterioration in his mental state. The patient complains of an extremely distressing sense of restlessness and a complete inability to remain still. On examination he shifts constantly in his chair and fidgets with his coat. There is a slight increase in tone on the right side and a detectable resting tremor in the hands. He describes some vague feelings of 'being watched' but there are no other psychotic symptoms elicited. Which one of the following is the MOST likely diagnosis?
a. Acute dystonic reaction due to chlorpromazine
b. Breakthrough of his psychotic symptoms
c. Akathisia
d. Tardive dyskinesia
e. Tardive dystonia
2 comments:
1.D 2.D 3.D 4.B 5.C
1. Other factors include female gender, as this subtype is much more common in women than men. Most antidepressants readily induce excited episodes and thus aggravate the rapid cycling pattern. Rapid cycling is defined as the occurrence of at least 4 episodes of depression and hypomania/mania per year (not per month). Hospitalisation of these patients is often frequent, in order to stabilize medication and achieve compliance.
2. Structural abnormalities in schizophrenia, such as enlarged ventricles and reduced cortical volume are a prominent feature. It is unclear whether cortical involvement is multifocal or diffuse. Temporal and frontal lobe regions are certainly involved. These abnormalities are present very early in the illness. It is too early to say, however, whether they are present from birth or develop at later stage. Structural abnormalities may be present in a majority of patients, although the exact percentage is unknown. The prevalence is most apparent when compared to ideally matched genetic controls. Structural abnormalities are correlated to some degree with clinical aspects of illness, such as cognitive deficits. A key issue remains unresolved: what neurobiological processes account for these enigmatic changes?
3. Immediate (or short term) memory may be defined as the reproduction, recognition, or recall of perceived material within a period up to 30 seconds after presentation. It is most often assessed by digit repetition and reversal (auditory) and memory-for-designs (visual) tests. Both an auditory-verbal task, such as digit span or memory for words or sentences, and nonverbal visual task, such as memory for designs or for objects or faces, should be given to assess a patient’s immediate memory. Patients can also be asked to listen to a standardised story and then repeat it as accurately as possible. Patients with lesions of the right hemisphere are likely to show more severe defects on visual nonverbal tasks than on auditory verbal tasks. Conversely, patients with left hemisphere disease, including those who are not aphasic, are likely to show severe deficits on the auditory verbal tests, with variable performance on the visual nonverbal tasks. Recent past memory concerns the retention of information over the past few months. Patients can be asked questions about current events.
Remote memory is the ability to remember events in the distant past.
It is commonly believed that remote memory is well preserved in patients who show pronounced defects in recent memory, but the remote memory of senile and amnestic patients is usually significantly inferior to that of normal persons of comparable age and education. Even patients who appear to be able to recount their past fairly accurately show gaps and inconsistencies in their recitals o close examination. Memory theorists have described three other types of memories: episodic, for specific events (eg a telephone message): semantic, for knowledge and facts (e.g. the first president of the United States): and implicit, for automatic skills (eg speaking grammatically or driving a car). Semantic and implicit memory do not decline with age, and persons continue to accumulate information over a lifetime. A minimal decline is episodic memory with aging may relate to impaired frontal lobe functioning.
4. A social phobic feels anxiety in public, particularly if they feel they are being scrutinised eg when eating in front of others in a restaurant. Agoraphobics fear situations where they can not escape, and, although this can occur in a restaurant setting, the vignette suggests it is scrutiny that is the root cause of this patient's anxiety. A diagnosis of panic disorder can only be given if the panic attack occurs 'out of the blue' and if for at least one month following the attack there is a fear of recurrence or behavioural change to avoid a further attack. Although anxiety is often seen in association with depression, there are no features specific to depression in this vignette – sleep disturbance can occur in the setting of anxiety (where it is usually trouble getting to sleep) and in depression the disturbance is classically early-morning waking.
5. Movement disorders are a common and distressing side effect of antipsychotic drugs. The most immediate complication is acute dystonia which can arise hours to days after starting medication. This presents as fixed muscle postures with intense spasm. The most classic presentation is of an oculogyric crisis- with the eyes deviated upwards and the head thrown backwards with a gaping mouth. Treatment is with an Anticholinergic. Extra-pyramidal side effects appear days to weeks after onset of medication. There is rigidity, bradykinesia and increased tone, with a festinant gait and mask-like facies. Treatment is again with an Anticholinergic or switching to one of the newer atypical antipsychotics (such as Risperidone, Olanzapine or Quetiapine) which are less likely to cause Parkinsonism. Akathisia is described above and is an intensely unpleasant combination of inner and outer restlessness. Treatment is by reducing the dose of the antipsychotic, switching to a newer agent or with Propranolol or a benzodiazepine. Anticholinergics do not help. Tardive dyskinesia presents with orofacial dyskinesia with lip smacking, tongue protrusion and choreoathetoid movements of the head, neck and trunk. It appears months to years after starting medication. Treatment includes reducing all antipsychotic medication if possible or switching to clozapine (an atypical antipsychotic). It is often mistaken for a worsening of the underlying psychotic illness with a disastrous increase in the dose of antipsychotic medication. Tardive dystonia presents with dystonic posturing and is characterised by its late onset months to years after starting medication.
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