Neuropeptides/transmitters
The primary inhibitory neurotransmitter, [gamma]-aminobutyric acid (GABA),in the brain is notably depleted in which of the following neuropsychiatric disorders?
A. Pick's disease
B. Vascular dementia
C. Creutzfeldt-Jakob disease
D. Huntington's disease
E. Normal pressure hydrocephalus
The answer is D
This degeneration characteristically results in a depletion of GABA, the brain's major inhibitory neurotransmitter, and acetylcholine. Huntington's disease is an autosomal-dominant neurodegenerative disorder characterized by cognitive and physical decline. Its etiology involves an abnormal expansion of a trinucleotide repeat on chromosome 4. MRI classically reveals bilateral atrophy of the caudate nucleus and putamen of the basal ganglia. CT scan further reveals a prominence of the lateral ventricles as a result of surrounding atrophy. Huntington's disease has a gradual onset between the ages of 30 to 50 years. Key features of the disease include progressive subcortical dementia, chorea (rapid, involuntary, dance-like movements), depression, and psychosis. Dysfunction of GABAergic neurotransmission has further been implicated in anxiety disorders, schizophrenia, alcohol dependence, and seizure disorders. Pick's disease is due to an accumulation of tau proteins, which lead to degeneration of the frontal and temporal lobes. Onset of Pick's disease is between the ages of 40 to 60 years and initial signs include personality change, language impairment, and memory loss. Vascular or multi-infarct dementia presents acutely with cognitive decline following a cerebrovascular event and has a stepwise progression. Creutzfeldt-Jakob disease is a rare spongiform encephalopathy accompanied by rapidly progressive dementia and hallucinations. It is caused by an accumulation of prions leading to nerve cell death. Normal-pressure hydrocephalus clinically presents with the triad of dementia, incontinence, and gait disturbance. It is due to poor reabsorption of CSF and characterized by widening of the lateral ventricles.
Structural MRI findings associated with schizophrenia include all of the following except
A. reductions in cortical gray matter
B. reductions in cortical white matter
C. risk genes influencing MRI findings
D. progressive deviation of regional cortical volumes in childhood onset cases
E. decreased striatum volume
The answer is E
Structural MRI finding associated with schizophrenia do not include decreased striatum volume. Structural MRI has been useful for characterizing features of the heritable risk for schizophrenia. Family members of individuals with schizophrenia show a pattern of reductions in cortical gray and white matter volume that resembles, but is milder than, that associated with schizophrenia. Among healthy individuals and patients diagnosed with schizophrenia, risk genes appear to influence MRI findings. Structural MRI has also provided some insights into the progressive course of this disorder and the impact of antipsychotic treatment. The most striking findings have been in childhood onset schizophrenia, where a series of neuroimaging studies using a variety of MRI approaches have clearly shown that the development and evolution of schizophrenia are associated with a progressive deviation of regional cortical volumes from those of healthy comparison populations.
The most common mental disorder associated with cerebrovascular disease is
A. Depression
B. Anxiety
C. Psychosis
D. Alcoholism
E. Mania
The answer is A
Depressive disorders are probably the most common emotional disorder associated with cerebrovascular disease. The prevalence depends upon whether community based samples or hospitalized patients are examined or whether patients with acute stroke or those with chronic stroke are evaluated. Mania and generalized anxiety disorder (GAD) occur much less frequently than depression following stroke.
A 76-year-old male develops a left-side resting tremor. His physical examination is significant for masked facies, shuffling gait, and rigidity. All of his motor symptoms respond well to levodopa; however, during the ensuant seven years, he starts to have significant cognitive decline. The patient dies from sepsis, secondary to a urinary tract infection. His family requests autopsy. Which one of the following elements would the neuropathologist most likely see on examination?
A. Distinctive, enlarged vacuolar neurons with argentophilic neuronal inclusions in the cytoplasm
B. Aggregates of hyperphosphorylated tau
C. Large, spherical, brightly eosinophilic inclusion bodies
D. Degeneration of large anterior horn cells of the spinal cord
E. Granulovacuolar degeneration and eosinophilic rod-like bodies
The correct answer is:
C. Large, spherical, brightly eosinophilic inclusion bodies
Explanation:
This patient has classic Parkinson's disease (including resting tremor and rigidity) which responds well to levodopa. Neurocognitive disorder due to Parkinson's disease develops years into the disease, whereas in neurocognitive disorder with Lewy bodies cognitive decline occurs prior to, together with, or less than 12 months following the motor symptoms of Parkinson's disease. One would expect to see the classic Lewy bodies (single large, spherical, brightly eosinophilic inclusion bodies within neuronal cytoplasm) on neuropathologic examination. Pick cells (distinctive, enlarged vacuolar neurons with argentophilic neuronal inclusions in the cytoplasm bodies) are seen in neurocognitive disorder due to frontotemporal lobar degeneration (as known as frontotemporal neurocognitive disorder). Neurofibrillary tangles (aggregates of hyperphosphorylated tau) are seen in Alzheimer's disease and tauopathies. Degeneration of the large anterior horn cells of the spinal cord is seen in amyotrophic lateral sclerosis. Hirano bodies (granulovacuolar degeneration and eosinophilic rod-like bodies) can be seen in Alzheimer's disease.
A 19-year-old man comes to the clinic with concerns of mood and attention problems ever since he was in a terrorist bombing six months ago. He recalls that it happened in the playground where he used to do football practice. He survived because he was out of the vicinity on the bleachers, but he hit his head hard against the ground. He lost consciousness and was taken to the emergency department where mild cortical contusions were found on CT scan of the brain. He is reported to have been disoriented and confused following the event and had posttraumatic amnesia. Ever since then, the patient feels irritable, anxious with reduced attention and insomnia. He is unable to concentrate on anything and finds himself forgetting routine tasks and expresses difficulty in learning new things. He also reports feeling extremely angry at one moment and hopelessly sad the next. He does not have a history of any psychiatric illness. What is the most important differential diagnosis of neurocognitive disorder due to traumatic brain injury in this patient?
A. Major depressive disorder
B. Posttraumatic stress disorder
C. Neurocognitive disorder due to substance use
D. Generalized anxiety disorder
E. Sequelae of neurological complications
The correct answer is:
B. Posttraumatic stress disorder
Explanation:
This patient fulfills the diagnostic criteria of neurocognitive disorder due to traumatic brain injury. He has evidence of traumatic brain injury as apparent from posttraumatic amnesia and neuroimaging demonstrating brain contusions. The criterion for the mild neurocognitive disorder is met along with the presentation of NCD immediately after the occurrence of traumatic brain injury and persistence past the acute post-injury period. The most important differential diagnosis, in this case, is posttraumatic stress disorder (PTSD) because it also presents with cognitive impairments after a psychologically or physically traumatic event. This case has not presented with symptoms reported in PTSD so it is not likely in this patient but the possibility should always be considered in trauma patients. Major depressive disorder is not the most critical differential because the patient's predominant symptoms are of anxiety and impaired cognition. Neurocognitive disorder due to substance use is possible, but because no hints are present in the history that point to substance abuse and patient's onset of cognitive complaints began after the traumatic event, it is more important to keep PTSD on the top of the differential. Generalized anxiety disorder also comes lower down in the differential because this patient has clear precipitating traumatic event and gradual yet progressive mood and cognitive complaints; so after considering NCD due to traumatic brain injury, posttraumatic stress disorder and NCD due to substance use, primary psychiatric disorders like generalized anxiety disorder should be considered.
The neuropeptides are primarily related to which of the following central nervous systems?
A. Serotonin neurotransmitter system
B. Norepinephrine and Epinephrine system
C. Acetylcholine system
D. Hypothalamic regulation system
E. Catecholamines system
The answer is D
Neuropeptides represent the most diverse class of signaling molecules in the CNS. They have a role in the hypothalamic regulation of pituitary hormone secretion. They also have an array of direct or neuromodulatory effects, ranging from modulating neurotransmitter release and neuronal firing patterns to the regulation of emotionality and complex behavior. More than 100 unique biologically active neuropeptides have been identified in the brain
Research efforts have demonstrated that there are no electroencephalographic (EEG) abnormalities associated with the use of which psychopharmacological agent?
A. Olanzapine
B. Clozapine
C. Quetiapine
D. Pherphenazine
E. Risperidone
The answer is C
Electroencephalographic (EEG) abnormalities have been reported with the use of clozapine (47 percent), olanzapine (38.5 percent), trifluoperazine and mesoridazine (about 35 percent), risperidone (28 percent), fluphenazine and thiothixene (just above 20 percent), pherphenazine, chlorpromazine and thioridazine (just about 10 percent), and haloperidol (just below 10 percent). There were, however, no abnormalities observed with quetiapine or loxapine. The clinical significance of EEG abnormalities associated with psychopharmacological agents, particularly in the absence of any indications of seizures or encephalopathic effects, remain an open research question.
Epilepsy patients are prone to have which of the following psychiatric conditions?
A. Psychosis
B. Depression
C. Personality Disorders
D. Hyposexuality
E. All of the above
The answer is E (all)
Epidemiological studies from communities, psychiatric hospitals, and epilepsy clinics report a 20 to 60 percent prevalence of psychiatric problems among epilepsy patients. Epilepsy patients are prone to psychosis, depression, personality disorders, hyposexuality, and other behavioral disorders. These problems are approximately equally divided between those that occur ictally or periictally and those that occur interictally or are variably related to the ictus. The percentage of epilepsy patients in psychiatric hospitals was all higher than the general prevalence of epilepsy and ranged from 4.7 percent of all inpatients in a British psychiatric hospital to 9.7 percent in a U.S. Veterans Affairs psychiatric facility.
Which of the following tests is considered a part of every assessment for a suspected neurocognitive disorder?
A. Chest X-ray
B. Cortisol level
C. Lumbar puncture
D. Positron emission tomography
E. Thyroid-stimulating hormone level
The correct answer is:
E. Thyroid-stimulating hormone level
Explanation:
The correct response is thyroid-stimulating hormone levels. In order to get to the root cause of a neurocognitive disorder, it is important to do a thorough evaluation of the patient. This includes a detailed history starting from baseline with their daily routine, and any changes they might have noticed in their day-to-day functioning, such as their concentration, personality, mood, and skills. This is followed by a mental status examination to assess various skills and cognitive abilities. When assessing any individual, it is important to keep medical conditions and cerebral diseases in mind which can lead to psychopathological disturbances that can present in a similar manner to neurocognitive disorders. By keeping these conditions in mind, several screening laboratory tests can be performed, which include complete blood count, electrolytes, glucose, liver function tests, urinalysis, thyroid function tests (thyroid-stimulating hormone levels), and drug levels. Chest X-ray, cortisol level, lumbar puncture, positron emission tomography are tests which can be done on a case-by-case basis depending on the differential diagnosis.
An 80-year-old woman has fluctuating levels of attention and cognition. All causes of delirium have been assessed for and excluded. What type of neurocognitive disorder is she most likely to have?
A. NCD due to Alzheimer's disease
B. NCD with Lewy bodies
C. NCD due to HIV infection
D. NCD due to Pick's disease
E. Vascular NCD
The correct answer is:
B. NCD with Lewy bodies
Explanation:
The correct response is NCD with Lewy bodies. Dementia with lewy bodies (DLB) is the second most common cause of dementia in the elderly, which is characterized by a progressive decline in cognitive function. Its features include fluctuating levels of cognition (patients particularly experience great deviations in their level of alertness and attention), visual hallucinations, and motor features of Parkinsonism. In NCD due to Alzheimer's disease, patients progressively and gradually lose cognitive and behavioral function. Patients with vascular NCD may present with fluctuating decline in cognition, however, there would be a history of stroke or multiple infarcts, presence of neurological defects, or evidence of abnormalities on neuroimaging. Stroke or hemorrhage can also present with delirium, but as this patient was already assessed for all causes of delirium and they were excluded, it is unlikely she has vascular NCD. Similarly, NCD due to HIV infection can also have a fluctuating course of cognitive dysfunction but would be excluded during her assessment to rule out infection as a cause of delirium. Picks disease usually causes NCD in patients younger than 65 years of age and causes a progressive decline in function. Functional impairments usually exceed cognitive disturbances, which is not seen here.
The strongest evidence for a role for neurotrophins in psychiatric diseases has come from the pathophysiology of which of the following psychiatric disorders?
A. Schizophrenia
B. Panic disorder
C. Major depressive disorder
D. Obsessive-compulsive disorder
E. Antisocial personality disorder
The answer is C
The strongest evidence for a role for neurotrophins among psychiatric disorders has come from the pathophysiology of depression, especially depression associated with stress. For depression, it is believed that there is a fundamental dysregulation of synaptic plasticity and neuronal survival in regions of the brain, such as the hippocampus. In animal models, restraint stress leads to a decreased expression of the brain-derived neurotrophic factor (BDNF) in the hippocampus. In addition, chronic physical or psychosocial stress leads to atrophy and death of hippocampus neurons, especially in the CA3 region in rodents and primates. Also, MRI studies have shown that patients with depressive or post-traumatic stress disorders exhibit a small decrease in hippocampal volume. It is unclear though, whether the atrophy and/or death of these neurons is directly related to the decreased availability of BDNF.
Recent research has provided a basis for clinical indications of PET and SPECT radiotracer imaging for the diagnosis and management of several neuropsychiatric disorders. Among them, we found all of the following except
A. movement disorders
B. schizophrenia
C. mood disorders
D. anxiety disorders
E. antisocial personality disorder
The answer is E
Over the past two decades, radio tracer imaging with PET and SPECT have gained merit as tools to image brain functioning and neurochemistry in living humans and have provided the foundation necessary to begin to identify the neurochemical signatures and neuropsychiatric disorders that result from abnormal brain chemistry. Radio tracer imaging can also help to assess the relationship between occupancy of specific various receptors in the brain and clinical efficacies of various psychotropic drugs. For instance, imaging of dopamine Dz receptors provides critical information for the differential diagnosis of movement disorders and schizophrenia, and also for the assessment of receptor occupancy by neuroleptic drugs. Imaging of serotonin receptors and the serotonin transporter is useful in the diagnosis of mood and anxiety disorders, as well as the assessment of antidepressant efficacy. Imaging of nicotinic acetylcholine receptors and acetylcholinesterase may serve as markers of cognitive and memory impairment.
Which of the following infectious agents have been associated with the
onset of obsessive-compulsive disorder (OCD)?
A. Streptococcal infection
B. Borrelia Burgdorferi
C. Retrovirus
D. Influenza virus
E. Varicella zoster virus
The answer is A
Evidence links streptococcal infections with the onset of obsessive-compulsive disorder (OCD) as well as tic disorders in children. Borrelia burgdorferi is the spirochete that causes Lyme disease and may lead to psychosis and cognitive impairment in the late stage of infection. Retroviruses such as human immunodeficiency virus (HIV) may lead to a host of neuropsychiatric problems, most notably AIDS dementia, which begins with memory impairment and may progress to aphasia in the later stages. Varicella zoster virus may rarely progress to encephalitis, especially in immunocompromised patients. Studies have linked Influenza A and Influenza B to the onset of encephalitis (acute or postinfectious) with a basis in immune modulation.
A 58-year-old man presents with his daughter for 3 years of progressive behavioral and functional decline. His daughter describes significant behavioral changes characterized by foul language and inappropriately taking off his clothes in public, as well as constantly eating sweets to the point that his daughter put a lock on the refrigerator. Family history is significant for an older brother who was institutionalized for an unknown psychiatric disorder and died in his early 50s. Which one of the following neuropathological findings is most likely to be found on autopsy?
A. Synucleinopathy
B. TDP-43 proteinopathy
C. Lacunar infarcts
D. Neuritic plaques
E. Diffuse axonal swelling
The correct answer is:
B. TDP-43 proteinopathy
Explanation:
This patient has frontotemporal dementia (DSM-4) / neurocognitive disorder due to frontotemporal lobar degeneration (DSM-5), characterized by behavioral and personality changes, frequently with an onset before 65 years of age. Hyperorality, particularly for carbohydrates, is also common. There is a significant genetic component; family members with neurocognitive disorder due to frontotemporal lobar degeneration are often frequently misdiagnosed with psychiatric disorders. In patients with neurocognitive disorder due to frontotemporal lobar degeneration, TDP-43 proteinopathy is often seen on autopsy. Synucleinopathy is seen in Parkinson's disease, Lewy body disease, and REM sleep behavior disorder. Patients with synucleinopathy often have signs of Parkinsonism (rigidity, bradykinesia, and resting tremor); cognitive decline occurs significantly later after the presentation of motor symptoms in Parkinson's disease, whereas cognitive decline presents fairly early in Lewy body disease. Behavioral symptoms can occur in synucleinopathies, but these are usually characterized more by hallucinations, depression, and anxiety. Lacunar infarcts can be seen in vascular dementia (DSM-IV) / neurocognitive disorder due to vascular disease (DSM-5). Patients with neurocognitive disorder due to vascular disease have significant cognitive slowing and may also have focal neurologic symptoms if their neurocognitive disorder is secondary to stroke. Neuritic plaques can be seen in Alzheimer's disease. Patients with Alzheimer's disease usually present initially with progressive memory loss and loss of language; behavioral symptoms such as paranoia and agitation develop in the moderate stages of the disease. Diffuse axonal swelling can be seen in traumatic brain injury. Patients with traumatic brain injury (TBI) have a wide range of symptoms, depending on the severity of injury. Patients with mild TBI may complain of only intermittent headache, tinnitus, depression, poor attention, and impaired ability to multitask and handle complex tasks.
A 67-year-old man is brought in by his wife with complaints of slowness of movements, tremors, unstable gait, and recent onset of "visions," such as a snake in the house and bats in their bedroom. He was so scared that they had to leave the house for a few nights. While open to the consideration that these animals didn't exist, he describes these experiences as "terrifying" and "very real" when they were happening. He has a remote psychiatric history of depression, but denies recent changes in mood. His past medical history is significant for hyperlipidemia and hypertension. His medications include ibuprofen, atorvastatin, and amlodipine. He has no history of substance abuse. His tremor has been present for about a year, and his wife adds that the visions started within the last 2 months. On exam, he has a resting tremor, cogwheel rigidity, masked facies, and stooped posture, but he is alert and fully oriented. Provided that the workup for any acute medical illness is negative, what would be the best treatment for his visions?
A. Risperidone
B. No treatment is necessary
C. Quetiapine
D. Pimavanserin
E. Carbidopa-levodopa
The correct answer is:
D. Pimavanserin
Explanation:
The patient likely has Parkinson's disease, its cardinal features being rigidity, tremor, bradykinesia, and postural instability. Psychotic symptoms are highly prevalent in Parkinson's disease. Treatment is necessary given the patient's distress about his visual hallucinations, and significant impact on his and his family's routine. While carbidopa-levodopa may be prescribed as treatment of his movement disorder, it won't treat visual hallucinations. Risperidone could decrease psychotic symptoms, but has a tendency to exacerbate motor symptoms and may increase mortality in Parkinson's disease. Quetiapine has some demonstrated efficacy in treatment of psychosis in Parkinson's disease, but it also has significant metabolic effects which may impact someone with already diagnosed hyperlipidemia. In comparison, pimavanserin has a unique mechanism of action among antipsychotics and won't increase cholesterol or lipids. It's the only FDA-approved medication for treatment of psychosis in Parkinson's disease.
Manipulation of one of the novel neurotransmitters, nitric oxide, is thought to have a therapeutic effect in which of the following psychiatric conditions?
A. Mood disorders
B. Addictive disorders
C. Anxiety disorders
D. Personality disorders
E. Dissociative disorders
The answer is A
Recently, it was discovered that gases can function as neurotransmitters. In this context, it was found that Nitric Oxide has a neurotransmitter property vis-a-vis a few psychiatric disorders. Mood Disorders is one of the groups of psychiatric illnesses in which Nitric Oxide has a positive role as a neurotransmitter. NOS-expressing neurons are well represented in areas implicated in depression, including the dorsal raphe nucleus and prefrontal cortex. A role for Nitric Oxide has been suggested in antidepressant response as selective serotonin reuptake inhibitor (SSRI) antidepressants can directly inhibit NOS activity.
Detects neuronal activity by measuring brain blood flow using a glucose analog
functional MRI
Psychopharmacological agents that appear to help patients with fibromyalgia
include
A. Pregabalin
B. Duloxetine
C. SSRIs
D. SNRIs
E. All of the above
The answer is E (all)
There is a significant overlap and comorbidity between patients with symptoms of fibromyalgia and other psychiatric conditions, such as depression, panic and anxiety, and posttraumatic stress syndromes. The significance of this comorbidity is not understood in terms of understanding how the symptomatology arises, but these secondary psychiatric syndromes can provide therapeutic targets for psychopharmacology. There is also significant comorbidity between patients with fibromyalgia and rheumatologic arthritis, systemic lupus, and others. Despite this comorbidity, the acute symptomatology of fibromyalgia does not correlate well with disease activity of associated medical diseases. When such diseases are present, however, varieties of psychotropic drugs are commonly prescribed for fibromyalgia, especially antidepressants. The antiepileptic agent pregabalin has recently been approved by the U.S. Food and Drug Administration (FDA) for the treatment of pain associated with fibromyalgia. A wide spectrum of analgesics is also prescribed for such patients. The selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) antidepressant, duloxetine, has been reported to be effective in treating patients with this disorder. However, experience suggests that benefits from such therapies are neither long lasting nor associated with return to employment.
The wife of a 67-year-old man brings him for evaluation. He is mildly disoriented, has facial tremors, an enlarged liver, and an enlarged beefy tongue. On neurologic exam, his gait is unsteady, especially when the lights are lowered. Tactile sensation is decreased, especially in the legs, and he has generalized weakness with spasticity and increased reflexes. Most likely diagnosis?
A. Neurosyphilis
B. Pernicious anemia – vitamin B12 deficiency
C. Multiple sclerosis
D. Cerebellar degeneration from alcoholism
E. Multi-infarct vascular disease
The correct answer is:
B. Pernicious anemia – vitamin B12 deficiency
Explanation:
The correct response is pernicious anemia – vitamin B12 deficiency. This patient most likely suffers from pernicious anemia, the most common cause of vitamin B12 deficiency. This can manifest with non-specific symptoms of anemia, such as fatigue and cognitive impairment, as well as glossitis, where the inflamed tongue is enlarged, sore and 'beefy' red. Neurological manifestations result from defective myelin synthesis, and include numbness and paresthesias in the hands and feet, loss of vibration and position sense, diffuse hyperreflexia, absent Achilles reflexes, and a progressive spastic weakness. Subacute combined degeneration of the spinal cord is the classic neurological finding in patients with vitamin B12 deficiency. Cognitive changes including irritability, forgetfulness, severe dementia and even psychosis. Behavioral changes and optic atrophy may also occur. Multiple sclerosis is a relapsing and remitting demyelinating disease, where attacks occur at variable times and in different locations, not seen here. Similarly, there is no history of alcohol intake or strokes, making cerebellar degeneration and multi-infarct vascular disease less likely. Late neurosyphilis can present with tabes dorsalis (ataxia, paresthesia, areflexia, loss of sensations) as well as cognitive changes; however, hepatomegaly and glossitis make vitamin B12 deficiency due to pernicious anemia more likely.
A 49-year-old man is an unrestrained driver in a motor vehicle crash. He sustains complicated mild musculoskeletal injuries as well as traumatic brain injury (TBI). Which pre-morbid modifiable risk factor affects his chance of developing post-TBI major depression?
A. Alcohol dependence
B. Depression at time of injury
C. Depression prior to injury
D. Genetic polymorphisms
E. Psychosocial risk factors
The correct answer is:
A. Alcohol dependence
Explanation:
Risk factors for major depression in the aftermath of TBI are similar to those for endogenous major depression in the general population. Option A is correct since alcoholism is correlated with both increased risk for TBI and depression and is a modifiable risk factor. Options B and C are incorrect because depression is not a modifiable risk factor, and there is some equivocation in the literature concerning the relation of pre-TBI affective disorder to post-TBI depression (though there appears to be a trend toward correlation). Options D and E are both incorrect as there is insufficient evidence at present to draw a correlation. In addition, one's genes are not considered modifiable, and psychosocial variables may not necessarily be modifiable.
The potential role of homeostatic neuronal plasticity as a therapeutic mechanism in certain psychiatric disorders is currently explored with the use of which of the following treatments?
A. Electroconvulsive therapy (ECT)
B. Vagal nerve stimulation (VNS)
C. Repetitive transcranial magnetic stimulation (RTMS)
D. Deep brain stimulation (DBS)
E. All of the above
The answer is E (all)
In recent years, there has been increasing interest in the use of brain stimulation methods as treatment for psychiatric and neurological disorders. These methods include electroconvulsive therapy (ECT), Vagal Nerve Stimulation (VNS), repetitive transcranial magnetic stimulation (RTMS), and deep brain stimulation (DBS). The development of optimal stimulation parameters for these treatments requires knowledge about the effects of electrical stimulation on neuronal function. With respect to ECT, a major advance has been the recognition that electrical stimulation parameters play a key role in determining therapeutic and adverse effects. There is compelling evidence that the degree to which electrical doses exceed the seizure threshold is of substantial importance. For bilateral ECT, electrical doses just above threshold (approximately 1.5 times threshold) result in a highly effective form of treatment that minimizes cognitive impairment. For nondominant hemisphere (unilateral) ECT, electrical doses that are five to six times threshold are required to produce a significant benefit.
Imaging modality used to study levels of lithium concentration in the brain?
Magnetic Resonance Spectroscopy (MRS)
Whereas routine MRI detects hydrogen nuclei to determine brain structure, magnetic resonance spectroscopy (MRS) can detect several odd-number nuclei. The ability of MRS to detect a wide range of biologically important nuclei permits the use of the technique to study many metabolic processes. MRS can be used to measure concentrations for psychotherapeutic drugs in the brain. One study used MRS to measure lithium concentrations in the brains of patients with bipolar disorder and found that lithium concentrations in the brain were half those in the plasma during depressed and euthymic periods but exceeded those in the plasma during manic episodes.
Prematurity is associated with which of the following psychiatric
conditions?
A. Anxiety
B. Aggression
C. Schizophrenia
D. Conduct disorder
E. All of the above
The answer is E (all)
A large prospective cohort study of 2,032 adolescents found that those born premature with low birth weight were 11-fold more likely to develop a depressive disorder. Prematurity was also associated with elevated risk of anxiety, social isolation, conduct disorder, aggression, thought disorders, and schizophrenia.
A 38-year-old man comes to the clinic with his wife for a consult regarding recently noticeable changes in mood and behavior. The wife explains that for the past two months, she has noticed her husband to be more irritable in mood, aggressive in behavior, and is unwilling to openly communicate with no apparent triggering factors. They live alone with their dog, and the husband has had a stable job as a salesman for the past ten years. She has also noticed that her husband has gotten clumsier; he drops things and has difficulty with multitasking. Upon questioning the husband, he agrees to the mood issues and seems confused. He has difficulty in verbal expression of his views. He is anxious regarding his gradually progressive motor incoordination, and agrees that he needs help. The patient was adopted at birth, so biological family history could not be retrieved. What is the most important differential diagnosis of neurocognitive disorder due to Huntington's disease in this patient?
A. Tardive dyskinesia
B. Sydenham's chorea
C. Wilson's disease
D. Neurocognitive disorder due to Parkinson's disease
E. Neuroferritinopathy
The correct answer is:
C. Wilson's disease
Explanation:
Differential diagnosis of Huntington's disease varies according to the clinical presentation of the patient, as it presents with a triad of symptom - motor, cognitive, and psychiatric. The motor component includes chorea and incoordination, the cognitive component includes mild or major neurocognitive disorder criteria (as stated in the DSM-V manual), and the psychiatric component includes mood disturbances, anxiety, and agitation. This patient presents with early neuropsychiatric and motor symptoms. Diagnosing Huntington's disease requires genetic testing if there is clinical suspicion. Since the patient does not have knowledge of biological family history, the patient should be screened for Huntington's. The most important differential diagnosis for this patient is Wilson's disease because of the age of onset, gradual progression of symptoms, and neuropsychiatric symptoms including irritability, aggression, clumsiness and difficulty multitasking. Sydenham's chorea presents with rapid jerky movements. It has an infectious etiology and presents with symptoms of rheumatic fever. Tardive dyskinesia is motor disturbance caused by prolonged use of antipsychotic medications, which is unlikely in this case. Neurocognitive disorder due to Parkinson's disease presents after motor symptoms (bradykinesia, rigidity, and tremors), which does not fit with this patient's presentation. Neuroferritinopathy is a genetic disorder of iron accumulation in the brain. It has a predominant motor component of focal dystonia, chorea, and parkinsonism with psychiatric and cognitive ailments presenting late in the disease.
A 69-year-old man in a wheelchair is brought to the clinic by his son who has recently started noticing a decline in his father's attention span, aggressive mood with social disinhibition, and badmouthing on trivial matters, which is unlike him. However, memory and complex executive functions like calculating, billing, and assorting medications are retained. His son states that his father was diagnosed with Lou Gehrig's disease five years ago; he developed gradual-onset weakness in extremities that started from lower limbs, and has now progressed to upper limbs as well. His lower limbs are completely paralyzed, but he is able to move his upper limbs slowly and with effort. His neurologist had ordered an MRI recently that showed medial-frontal and anterior-temporal lobe atrophy. The patient also has concurrent type II diabetes mellitus, hypertension, and a past history of inferior wall myocardial infarction fifteen years ago, for which he is on metformin, amlodipine/valsartan, atorvastatin, aspirin, and atenolol. What is the best treatment option for the psychiatric complaints of this patient?
A. Initiating low dose citalopram
B. Initiating paroxetine with low dose quetiapine
C. Non-pharmacological environmental interventions
D. Reduce dose of aspirin
E. Initiate riluzole
The correct answer is:
C. Non-pharmacological environmental interventions
Explanation:
This patient has frontotemporal dementia. The best treatment option is non-pharmacological environmental intervention. It includes decreasing noise, limiting stimulation by simplifying social parameters, and removing complicated daily activities that confuse the patient and lead to agitation. Three major factors apparent in the case must be taken into account to approach suitable treatment. The first factor is that the constellation of psychiatric symptoms presented by his son fit the criteria for mild neurocognitive disorder. Next are the patient's age and comorbidities that point towards the underlying causative factors of his behavioral disturbances, and third is taking into consideration all the medications that patient is stable on currently. These three factors must prompt one to think that starting an SSRI (either citalopram or paroxetine) is not a preferred option. Even though recent studies show substantial psychiatric improvement in patients with amyotrophic lateral sclerosis (ALS) by SSRI/antipsychotics, the matter is different in elderly patients with comorbidities who are in mild stages of neurocognitive decline due to frontotemporal dementia, which is the most common association of ALS. Reducing the dose of aspirin will not help the psychiatric symptoms of this patient, but it will help if his cognition further deteriorates and an SSRI needs to be initiated. Aspirin increases bleeding risk, and so do SSRIs, so dose adjustment is a priority in the future if an SSRI is indicated. Riluzole is the only drug approved for ALS at the moment; it helps deter motor weakness only mildly, delaying it by two months or so, and is not of proven importance in psychiatric ailments.