Psychiatry

Mood Disorders

100

One month after her mother’s death from heart failure, a 25-year- old woman with no prior psychiatric history is still very sad and tearful. She has difficulty concen- trating and falling asleep at night and has lost three pounds. The most likely diagnosis is

What is uncomplicated bereavement. The loss of a loved one is often accompanied by symptoms reminiscent of major depression such as sadness, weepiness, insomnia, reduced appetite, and weight loss. When these symptoms do not persist beyond two months after the loss, they are considered a normal manifestation of bereavement

200

For the past six weeks, a middle-aged woman’s mood has been mostly depressed but she cheers up briefly when her grand- children visit or in coincidence with other pleasant events. She is consistently less depressed in the morning than at night. When her children fail to call on the phone to inquire about her health, her mood deteriorates even more. She sleeps 14 hours every night and she has gained 24 pounds. What is the appropriate diagnoses? What class of antidepressants have been found to be effective for its treatment?

What is atypical depression and MAOIs. Atypical depression, another variant of major depressive disorder, is characterized by mood reactivity (pleasurable events may temporarily im- prove the mood), self-pity, excessive sensitivity to rejection, reversed diur- nal mood fluctuations (patients feel better in the morning), and reversed vegetative symptoms (increased appetite and increased sleep). Approxi- mately 15% of patients with depression have atypical features. MAOIs are considered to be more effective than other classes of antidepressants in

300

As soon as she returns home from the hospital, three days after delivering a healthy baby girl, a 23- year-old woman becomes increasingly irritable and tearful. She constantly worries about the baby, fearing she won’t be an adequate mother. What is the most likely diagnosis?

What is postpartum blues. Postpartum blues are very frequent, with a prevalence estimated between 30 and 85%. Symptoms include tearfulness, irritability, anxiety, and mood lability. Symptoms usually emerge during the first two to four days after birth, peak between days 5 and 7, and resolve by the end of the second week postpar- tum. This condition resolves spontaneously and usually the only interven- tions necessary are support and reassurance.

400

A 55-year-old male without a previous psychiatric history be- comes depressed, withdrawn, and despondent. One month later, he is diagnosed with cancer. Which type of carcinoma is most likely to manifest with depressive symptoms?

What is carcinoma of the pancreas.Major depression can be the first manifestation of an occult carcinoma of the pancreas. The mechanism for this phenomenon is not known, although it may be due to humoral fac- tors secreted by the tumor that act directly on the brain.

500

At 3 A.M. a middle-aged woman arrives at the ER escorted by police. She shouts, “I love you, Jesus! Jesus is my savior!” at the top of her lungs and throws kisses to everyone. Neighbors called the police because she had been singing church hymns for six hours. The patient tells the resident on call that two weeks earlier she had flushed her medications down the toilet because they gave her pimples, and made her food taste bad. What is her diagnoses and what medication did she flush down the toilet?

What is acute elated mania and lithium. Mood elevation, mood lability, irritability, expansive behavior, increased en- ergy, decreased need for sleep, lack of insight, poor judgment, disinhibition, impulsivity, and pressured speech are characteristic symptoms of elated acute mania. Long term SE of lithium treatment are weight gain, metallic taste, acne, hypothyroidism, and polyuria.

Psychotic Disorders

100

For six weeks, a college student has survived on canned food because he is afraid of being poisoned by the mafia. He is convinced that secret cameras have been placed in his apartment and that he is being constantly watched. He can hear a man’s voice that comments on his every move. For approximately two months prior to the emergence of these symptoms he has been increasingly withdrawn, suspicious, disinterest- ed in his academic work, and un- characteristically uncaring about his appearance. What is the diagnoses?

What is schizophreniform disorder. Schizophreniform disorder and chronic schizo- phrenia differ only in the duration of the symptoms and the fact that the im- paired social or occupational functioning associated with chronic schizo- phrenia is not required to diagnose schizophreniform disorder. As with schizophrenia, schizophreniform disorder is characterized by the presence of delusions, hallucinations, disorganized thoughts and speech, and the presence of negative symptoms. The total duration of the illness, including prodromal and residual phases, is at least one month and less than six months. Approximately one-third of the patients diagnosed with schizo- phreniform disorder experiences a full recovery, while the rest progress to schizophrenia and schizoaffective disorder.

200

Name the side effect.

What is Dystonia, specifically, Opisthotonus *From the Greek opistho ("behind") and tonos ("tension") -- this is a state of severe hyperextension and spasticity Can be seen in lithium intoxication or as an extrapyramidal side effect of phenothiazines, haloperidol, and metoclopramide.

300

A young mother is involved in a car accident that claims the life of her two sons. When she is told that her two children have died from the injuries they suffered in the crash, she becomes agitated and combative. Her speech is disorga- nized and incoherent, but the ob- servers understand that she hears the voices of her children screaming to her to help them and that she be- lieves that the hospital nurses are prison guards. These symptoms remit spontaneously in one week. What is the most likely diagnosis?

What is brief psychotic disorder. Brief psychotic disorder is characterized by the sudden appearance of delusions, hallucinations, and disorganized speech or behavior usually following a severe stressor. The episode lasts at least one day and less than a month and is followed by full spontaneous remission. For the woman in the vignette, the psychotic episode was clearly precipitated by the tragic death of her sons. Schizo- phreniform disorder is differentiated from brief psychotic disorder by tem- poral factors (in schizophreniform disorder, symptoms are required to last more than one month) and lack of association with a stressor. Post- traumatic stress disorder has a more chronic course and is characterized by affective, dissociative, and behavioral symptoms.

400

A 62-year-old male who was diagnosed with schizophrenia in his early twenties is found wander- ing around his halfway house con- fused and disoriented. He is rushed to a local emergency room where his serum sodium concentration is found to be 123 mEq/L. The urine sodium concentration is 5 mEq/L. The patient has been treated with risperidone, 4 mg a day for the past three years with good symptom control. His roommate reports that the patient makes many trips to the water cooler and often complains of being thirsty. What is the most likely cause of this patient’s meta- bolic imbalance?

What is psychogenic polydipsia. Self-induced water intoxication should always be considered in the differential diagnosis of confusion- al states and seizures in schizophrenic patients. As many as 20% of patients with a diagnosis of schizophrenia drink excessive amounts of water. At least 4% of these patients suffer from chronic hyponatremia and recurrent acute water intoxication. Medications that cause excessive water retention such as lithium and carbamazepine can aggravate the symptomatology.

500

A man becomes suddenly agitated and violent after a period of brooding. The episode is self contained and the man shortly returns to his premorbid functioning level. What is the culture bound syndrome associated with this clinical vignette?

What is amok. Amok refers to a dissociative episode characterized by violent agitation and aggressive and homicidal behavior. The episode is precipitat- ed by a perceived slight or insult and it is preceded by a period of brood- ing. Amok was first described in Malaysia

A Mixed Bag

100

Name the 2 antipsychotics that cause the least weight gain.

What is aripiprazole (abilify) and ziprasidone (geodon)

200

This area of the brain has cell bodies of serotonin- releasing neurons

What is the raphe nuclei.

300

You are called in the middle of the night by the surgical service to see a 52-year-old man who was admitted to the hospital 36 hours earlier for an emergency appendectomy. The man is very agitated and is talking nonsense to the nursing staff who is unable to calm him down. You suspect alcohol withdrawal. This receptor is most closely associated with these symptoms

What is GABA-A receptor. In the CNS, GABA is an inhibitory neuro- transmitter. At the postsynaptic GABA-A receptor, GABA facilitates chloride ion influx into a cell via a chloride channel resulting in inhibition of that neuron. Alcohol and benzodiazepines both allosterically modulate the GABA-A receptor to facilitate GABAergic inhibition. Abrupt removal of alcohol or benzodiazepines after prolonged use results in a relative deficit of GABAergic inhibition, which can lead to anxiety, insomnia, delirium, and seizures. GABA-B is the site of action of the muscle relaxant baclofen.

400

An elderly gentleman wakes up from a nap in a state of great agitation. Although he appears to want to communicate, he only repeats the sentence “See you later” over and over. The right side of his face droops and he seems to have difficulties in lifting his right arm. A CAT scan shows a recent brain in farct. Where is the lesion localized?

What Broca's Area.

500

An 82-year-old woman at the late stage of dementing disorder roams her nursing home touching and licking everything she passes, over and over again. She is placid and nothing seems to frighten her.She also displays sexual disinhibition, often walking out of her room without her pants on.What part of the brain is lesioned and syndrome does she have?

What is amygdala and Kluver Bucy Syndrome. Klüver-Bucy syndrome presents with docility, lack of fear response, anterograde amnesia, hyperphagia, and hypersexuality.

PD is killing me

100

An off-Broadway actor consistently bores his friends and acquaintances by talking incessantly about his exceptional talent and his success on the stage. He does not seem to realize that other people do not share his high opinion of his acting talent and are not interested in his monologues. When his director criticizes the way he delivers his lines during a rehearsal, the actor goes into a rage and accuses him of trying to jeopardize his career out of jealousy.

What is Narcissistic PD. The essential feature of this personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood. Individuals with this disorder overestimate their abilities, inflate their accomplishments, and expect others to share the unrealistic opinion they have of themselves. They believe they are special and unique and attribute special qualities to those with whom they associate

200

A demanding 25-year-old woman begins psychotherapy stating she is both desperate and bored. She reports that for the past five or six years she has experienced peri- odic anxiety and depression and she has made several suicidal gestures. She also reports a variety of impulsive and self-defeating behaviors and sexual promiscuity. She wonders if she might be a lesbian, though most of her sexual experiences have been with men. She has abruptly terminated two previous attempts at psychotherapy. In both cases she was enraged at the therapist because he was unwilling to prescribe anxiolytic medications.

What is borderline PD. The patient’s history and presenting symptoms are classic for the diagnosis of borderline personality disorder. Patients with borderline person- alities present with a history of a pervasive instability of mood, relationships, and self-image beginning by early adulthood. Their behavior is often impul- sive and self-damaging; their sexuality is chaotic; sexual orientation may be uncertain; and anger is intense and often acted out. Recurrent suicidal ges- tures are common. The shifts of mood usually last from a few hours to a few days. Patients often describe chronic feelings of boredom and emptiness.

300

A 25-year-old man is a concern to his neighbors. He dresses in odd, outdated clothes; seems to utter his own language; and although he tends to keep to himself, he has told neighborhood children that witches who live down the road have it in for them

What is schizotypal PD. This patient is most likely suffering from schizotypal personal disorder. This personality disorder with its attendant social isolation and subtle distortions of reality may indeed resem- ble schizophrenia in remission; the diagnosis can be sorted out by a thorough history. Frank hallucinations of any type are uncommon; only subtle distortion of environmental cues is seen. Although men may be slightly more at risk for being diagnosed with schizotypal personality disorder, the disparity is not stark

400

A young librarian has been exceedingly shy and fearful of people since childhood. She longs to make friends but even casual social interactions cause her a great deal of shame and anxiety. She has never been at a party and she has requested to work in the least- active section of her library, even though this means lower pay. She cannot look at her rare customers without blushing and she is convinced that they see her as incompetent and clumsy.

What is avoidant personality d/o. Avoidant personality disorder is characterized by pervasive and excessive hypersensitivity to negative evaluation, social inhibition, and feelings of in adequacy. Impairment can be severe due to social and occupational difficulties. Males and females are equally affected.

500

What personality disorder is based on symptoms being ego-syntonic rather than ego-dystonic

What is OCPD.

Psych in the Cinema

100

2002’s A Beautiful Mind explored the life of Nobel prize this winning economist and his struggles with a psychiatric disorder. Name the economist and d/o.

What is John Nash, Paranoid Schizophrenia

200

1993 memoir by Susanna Kaysen about her treatment for Borderline Personality Disorder in a New England Psychiatric Hospital in the 1960s that was made into a film starring Winona Rider and Angelina Jolie.

What is Girl, Interrupted.

300

Leonardo DiCaprio portrayed this real-life person who suffered from a mental illness that Leonardo DiCaprio himself has. This person is also the basis for Tony Stark's (Iron Man) dad.

Who is Howard Hughes (The Aviator)?

400

Pulitzer prize winning poet and author of The Bell Jar who likely suffered from debilitating Bipolar Depression ended her life by suicide at age 31 in 1963.

Who is Sylvia Plath.

500

Joker depicts this animal in The Dark Knight.

What is a dog?