questions_Psychiatry

Educational objective: Review interpretation of tests used in evaluation of polyuria.

Interpretation of the tests used in evaluation of polyuria

Plasma and urine osmolality –

A urine osmolality less than that of plasma is consistent with neurogenic or nephrogenic diabetes insipidus; if both urine and plasma are dilute, that is consistent with psychogenic polydipsia.
Dehydration test: If serum osmolality is less than 295 mosm/kg, allow no fluids for 12-18 h. Measure urine flow, urine specific gravity, urine and plasma osmolality every 2 hours. Terminate study if body weight falls more than 3%.

A rise in urine osmolality above that of plasma osmolality indicates psychogenic polydipsia. Urine specific gravity of less than 1.005 (or 200 mosm/L) indicates either neurogenic or nephrogenic diabetes insipidus.

Serum vasopressin level at the conclusion of dehydration test –

Normal or high vasopressin level usually indicates nephrogenic diabetes insipidus.

Inject 5 units of aqueous vasopressin or 1 µg DDAVP subcutaneously. Measurement of urine flow and urine and plasma osmolality is done.

Rise in urine osmolality above that of the plasma indicates neurogenic diabetes insipidus; failure of urine osmolality to rise indicates nephrogenic diabetes insipidus.

It is important to have in mind that plasma osmolality is usually low with psychogenic polydipsia and SIADH, while it is high with any form of diabetes insipidus.

Distinguishing characteristics of ten personality disorders:

Schizoid: Detachment from social relationships and restricted range of expression of affect.

Schizotypal: Acute discomfort with close relationships, distorted thinking and eccentric behavior.

Antisocial: Disregard for and violation of rights of others.

Paranoid: Distrust and suspiciousness causing one to interpret others' motives as malevolent.

Histrionic: Excessive emotionality and attention- seeking.

Borderline: Instability in interpersonal relationships, impulsive behavior and poor sense of self.

Avoidant: Social inhibition, hypersensitivity to criticism, feeling of inadequacy.

Obsessive-compulsive: Preoccupation with control, orderliness and perfectionism.

Dependent: Submissive and clinging behavior related to excessive need to be taken care of.

Narcisstic: Grandiosity, lack of empathy and need for admiration.

For the diagnosis of personality disorder it is necessary also to establish that the patient’s history shows an enduring pattern of behavior that is inflexible and pervasive and that the patient experiences clinically significant distress or impairment in functioning. In addition, it is important to establish that behavior is not a result of another mental disorder, substance abuse or a general medical condition.

Distinguishing characteristics of ten personality disorders:

Schizoid: Detachment from social relationships and restricted range of expression of affect.

Schizotypal: Acute discomfort with close relationships, distorted thinking and eccentric behavior.

Antisocial: Disregard for and violation of rights of others.

Paranoid: Distrust and suspiciousness causing one to interpret other’s motives as malevolent.

Histrionic: Excessive emotionality and attention- seeking.

Borderline: Instability in interpersonal relationships, impulsive behavior and poor sense of self.

Avoidant: Social inhibition, hypersensitivity to criticism, feeling of inadequacy.

Obsessive-compulsive: Preoccupation with control, orderliness and perfectionism.

Dependent: Submissive and clinging behavior related to excessive need to be taken care of.

Narcisstic: Grandiosity, lack of empathy and need for admiration.

For the diagnosis of personality disorder it is necessary also to establish that the patient’s history shows an enduring pattern of behavior that is inflexible and pervasive and that the patient experiences clinically significant distress or impairment in functioning. In addition, it is important to establish that behavior is not a result of another mental disorder, substance abuse, or a general medical condition.

Distinguishing characteristics of ten personality disorders:

Schizoid: Detachment from social relationships and restricted range of expression of affect.

Schizotypal: Acute discomfort with close relationships, distorted thinking and eccentric behavior.

Antisocial: Disregard for and violation of rights of others.

Paranoid: Distrust and suspiciousness causing one to interpret other’s motives as malevolent.

Histrionic: Excessive emotionality and attention- seeking.

Borderline: Instability in interpersonal relationships, impulsive behavior and poor sense of self.

Avoidant: Social inhibition, hypersensitivity to criticism, feeling of inadequacy.

Obsessive-compulsive: Preoccupation with control, orderliness and perfectionism.

Dependent: Submissive and clinging behavior related to excessive need to be taken care of.

Narcisstic: Grandiosity, lack of empathy and need for admiration.

For the diagnosis of personality disorder it is necessary also to establish that the patient’s history shows an enduring pattern of behavior that is inflexible and pervasive and that the patient experiences clinically significant distress or impairment in functioning. In addition, it is important to establish that behavior is not a result of another mental disorder, substance abuse, or a general medical condition.

Distinguishing characteristics of ten personality disorders:

Schizoid: Detachment from social relationships and restricted range of expression of affect.

Schizotypal: Acute discomfort with close relationships, distorted thinking and eccentric behavior.

Antisocial: Disregard for and violation of rights of others.

Paranoid: Distrust and suspiciousness causing one to interpret other’s motives as malevolent.

Histrionic: Excessive emotionality and attention- seeking.

Borderline: Instability in interpersonal relationships, impulsive behavior and poor sense of self.

Avoidant: Social inhibition, hypersensitivity to criticism, feeling of inadequacy.

Obsessive-compulsive: Preoccupation with control, orderliness and perfectionism.

Dependent: Submissive and clinging behavior related to excessive need to be taken care of.

Narcisstic: Grandiosity, lack of empathy and need for admiration.

For the diagnosis of personality disorder it is necessary also to establish that the patient’s history shows an enduring pattern of behavior that is inflexible and pervasive and that the patient experiences clinically significant distress or impairment in functioning. In addition, it is important to establish that behavior is not a result of another mental disorder, substance abuse, or a general medical condition.

Distinguishing characteristics of ten personality disorders:

Schizoid: Detachment from social relationships and restricted range of expression of affect.

Schizotypal: Acute discomfort with close relationships, distorted thinking and eccentric behavior.

Antisocial: Disregard for and violation of rights of others.

Paranoid: Distrust and suspiciousness causing one to interpret other’s motives as malevolent.

Histrionic: Excessive emotionality and attention- seeking.

Borderline: Instability in interpersonal relationships, impulsive behavior and poor sense of self.

Avoidant: Social inhibition, hypersensitivity to criticism, feeling of inadequacy.

Obsessive-compulsive: Preoccupation with control, orderliness and perfectionism.

Dependent: Submissive and clinging behavior related to excessive need to be taken care of.

Narcisstic: Grandiosity, lack of empathy and need for admiration.

For the diagnosis of personality disorder it is necessary also to establish that the patient’s history shows an enduring pattern of behavior that is inflexible and pervasive and that the patient experiences clinically significant distress or impairment in functioning. In addition, it is important to establish that behavior is not a result of another mental disorder, substance abuse, or a general medical condition.

Distinguishing characteristics of ten personality disorders:

Schizoid: Detachment from social relationships and restricted range of expression of affect.

Schizotypal: Acute discomfort with close relationships, distorted thinking and eccentric behavior.

Antisocial: Disregard for and violation of rights of others.

Paranoid: Distrust and suspiciousness causing one to interpret other’s motives as malevolent.

Histrionic: Excessive emotionality and attention- seeking.

Borderline: Instability in interpersonal relationships, impulsive behavior and poor sense of self.

Avoidant: Social inhibition, hypersensitivity to criticism, feeling of inadequacy.

Obsessive-compulsive: Preoccupation with control, orderliness and perfectionism.

Dependent: Submissive and clinging behavior related to excessive need to be taken care of.

Narcisstic: Grandiosity, lack of empathy and need for admiration.

For the diagnosis of personality disorder it is necessary also to establish that the patient’s history shows an enduring pattern of behavior that is inflexible and pervasive and that the patient experiences clinically significant distress or impairment in functioning. In addition, it is important to establish that behavior is not a result of another mental disorder, substance abuse, or a general medical condition.

-Good prognostic factors for schizophrenia include:

• Female gender
• Married status
• Good premorbid functioning
• Late onset disease (>45 years of age)
• Affective symptoms
• High quotient of intelligence
• Predominantly positive symptoms
• Acute onset of disease with precipitating factor
• Few prior episodes of schizophrenia
• Phasic pattern of episodes and remissions
• Paranoid subtype schizophrenia
• No family history of schizophrenia
• Family history of affective disorder
• Good support systems

Poor prognostic signs in patients with schizophrenia include the following:

• Young age at onset of the disease
• Insidious onset
• Family history of schizophrenia
• Single, divorced, or widowed status
• Absence of precipitating factors at onset
• Poor premorbid functioning
• Negative symptoms
• Neurologic signs and symptoms
• No remissions in 3 years
• History of many relapses
• Poor support systems

Criteria for substance abuse include a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one (or more) of the following occurring within a 12 month period:

• 1- Recurrent substance use in situations in which it is physically hazardous (driving a car or operating machinery under the influence of the substance).
• 2- Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (absenteeism, poor work performance, suspensions or expulsions from work or school and neglect of children or household).
• 3- Recurrent substance-related legal problem (arrests or substance related disorderly conduct).
• 4- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (physical fights or arguments with spouse.

Criteria for substance dependence include a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period.

• 1- Tolerance, as defined by either of the following;
  • (a)A need for markedly increased amounts of the substance to achieve intoxication or desired effect.
  • (b)Markedly diminished effect with continued use of the same amount of the substance.
• 2- Withdrawal, as manifested by either of the following;
  • (a)The characteristic withdrawal syndrome for the substance.
  • (b)The same or closely related substance taken to relieve or avoid withdrawal symptoms.
• 3- The substance is often taken in larger amounts and for a longer period of time than initially intended.
• 4- There is a persistent desire or there are unsuccessful efforts to cut down or control substance use.
• 5- A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects (visiting multiple doctors or driving long distances, chain smoking, etc.)
• 6- Important social, occupational, or recreational activities are given up or reduced because of substance use.
• 7- The substance is used despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (continuing to drink despite recognition that an peptic ulcer was made worse by alcohol use, etc.).

In this case patient missed his grandfather funeral because of drinking. This suggests dependence and further inquiry is necessary to determine if he is indeed dependent on alcohol.

Symptoms of tricyclic antidepressant overdose include agitation, hallucinations, urinary retention, confusion, hypothermia, hypotension, ventricular tachycardia (preceded by prolongation of the QRS complex and QTc interval), and seizures.

Prolonged QRS complex (>0.10 sec) or QTc interval (>0.42 sec) should be treated with sodium bicarbonate. Ventricular arrhythmias often respond to phenytoin (15-20 mg/kg for adults) with concurrent systemic alkalinization. If there is no response to this therapy, lidocaine (1 mg/kg IV followed by a titrated infusion) may be used. Physostigmine (1-2 mg IV slowly-for adults or 0.5 mg IV lowly for children) may be indicated in reversing cardiac arrhythmias that are due to vagal blockade or for anticholinergic effects. Seizures usually respond to IV boluses of diazepam (0.2 mg/kg).

Although peptic ulcer disease and malignancy must be considered in the differential diagnosis of this patient, those are less likely with this constellation of symptoms.

This patient is highly unlikely to suffer from dementia, and vision problems usually do not develop so suddenly in otherwise healthy elderly (although this may precipitate depression symptoms).

Educational objective: Emphasize importance of medications as cause of clinical depression in elderly.

The DSM-IV includes categories for mood disorders due to “a general medical condition” or “due to substance use.” These two categories are particularly relevant to geriatric patients whose mood disorders often occur in the context of medical and neurologic illnesses requiring multiple drugs.

Once depression is diagnosed in an elderly patient, a medical diagnostic evaluation is undertaken to identify diseases or medications that may cause or aggravate depression. Treatment of the underlying medical or neurologic illness or removal of a drug may alleviate the mood symptoms by itself.

After diagnosis of depression has been made, specific age of the elderly patient, sex, length of stay in the long-term facility, and body weight are not of value in the assessment of the disease.

Educational objective: Review conditions that may aggravate depression.

Medical and Neurological Conditions That May Cause Depressive Disorders

• Metabolic disorders –
  • B12 deficiency
  • Folate deficiency
  • Malnutrition
• Endocrine disorders –
  Corticosteroid withdrawal
  • Cushing’s disease
  • Hyperparathyroidism
  • Hypothyroidism
• Autoimmune disorders –
  • Polymyalgia rheumatica
  • Rheumatoid arthritis
  • Sjogren’s syndrome
  • Temporal arteritis
• Viral infections –
  • Hepatitis
  • HIV infection
• Neoplasms –
  • Carcinomas – breast, kidney, lung, ovary, and pancreas.
  • Leukemia
  • LymphomaCerebrovascular disorders –
  • Lacunar infarcts
  • Stroke
  • Vascular dementia
• Degenerative neurologic diseases –
  • Alzheimer’s disease
  • Amyotrophic lateral sclerosis
  • Huntington’s disease
  • Parkinson’s disease
  • Progressive supranuclear palsy

Educational objective: Review medications that may aggravate depression in the elderly.

Medications That May Cause a Depressive Disorder.

• Alpha Methyldopa
• Benzodiazepines
• Cimetidine
• Clonidine
• Corticosteroids
• Digitalis
• Estrogens
• Hydralazine
• Progesterone
• Propoxyphene
• Propranolol
• Psychostimulants
• Reserpine
• Tamoxifen
• Vinblastin
• Vincristine

Educational objective: Review cardiac side effects of tricyclic antidepressive medications.

Side effects of tricyclics are related to their anticholinergic, hypotensive, and quinidine-like effects. Patients with early dementia or with gross brain disease may develop delirium on tricyclic antidepressants because of central anticholinergic effects. Patients with prostatic hyperplasia may develop urinary retention because of peripheral anticholinergic effects. The quinidine-like effects of tricyclic antidepressants rarely cause heart block or arrhythmia in patients with a normal baseline ECG. However, these drugs may exacerbate existing conduction defects – 10% of patients with bundle-branch block will develop second-degree heart block.

Tricyclics also increase the risk of ventricular arrhythmia if given to patients with a significant QT prolongation (they can prolong QT interval in toxic doses, too).

All other options are also reported as side effects of tricyclic therapy, but their incidence is well below 1%.

Educational objective: Review the important features of typical and atypical neuroleptics.

Typical neuroleptics--haloperidol, trifluoperazine (Stelazine), thioridazine (Mellaril), etc.-- have been around longer and withstood the test of time; their therapeutic benefit is indeed clear; but the atypical ones - clozapine, risperidone, quetiapine, olanzapine - generally have fewer side effects and their use is considered to be associated with a reduced risk of tardive dyskinesia. Evidence exists that total treatment with atypical neuroleptics may be less expensive even though the cost of the drug itself is significantly higher. The increased compliance with treatment and apparent increased effectiveness against negative symptoms (social withdrawal, impoverishment of affect, etc.) result in fewer re-hospitalizations, which means lower total cost.

Educational objective: Review similarities and differences between delirium and dementia.

• 1- true
• 2- false: Full alertness is quite common in dementia but not in delirium, and such becomes an important factor in distinguishing between the two.
• 3- true
• 4- false: An accurate differential diagnosis between delirium and dementia is often very significant for the treatment and subsequent response to the patient.
• 5- true: A patient often has a debilitating general medical condition and is on several medications, one or more of which may cause a delirious episode.
• 6- false: A delirium does not usually include a disturbance of affect per se, and intense hallucinations, delusions, and agitation must be distinguished from numerous other psychotic episodes such as Brief Psychotic Disorder, Schizophrenia, Schizophreniform Disorder, and Mood Disorder with Psychotic Features.
• 7- false: Disturbances of affect are not included as criteria for a delirium/dementia condition.
• 8- false: Delirium tremens is a substance withdrawal syndrome.
• 9- true

Educational objective: Emphasize importance of appropriate history in psychiatric diagnosis.

The history may not fully make the diagnosis but it will certainly rule out many possible diagnoses. The crucial task is to distinguish between delirium caused by a head injury, a toxic substance, an infectious process, etc., from a schizophrenic/affective psychosis. The history is of most significance in establishing a differential diagnosis.

Educational objective: Emphasize danger of sexual dysfunction with SSRI’s.

Although studies have reported sexual dysfunction in the <20% range, clinical experience seems to point to a higher incidence of same, particularly as patients become educated to the symptoms of sexual dysfunction and become aware of the presence of these symptoms in their experience. Although men do report higher incidence of sexual dysfunction than women, the incidence may well be equal in both sexes. Multiple factors likely contribute to the "reporting", including social/personal inhibitions to the open discussion of such matters. Due to multiple factors including that patients are so grateful to be feeling hopeful and happy again that they consider sexual dysfunction symptoms to be worth accepting for the benefits derived from the antidepressants, patients may not be aware of reduced interest in sexual activity.

Educational objective: Review common inappropriate strategies in depressive patients.

The first option is not reasonable in that given the degree of her distress and that you know nothing about her suicidality, giving her a hypnotic is risky and not likely to be of much help. It may be even more of a danger to her. In addition, you have not checked her labs for any possible underlying dysfunction. She runs a press and is at risk when drowsy.

Option 2 is not reasonable although it may be defensible if you inform your psychiatrist colleague that you have done no physical exam or lab evaluation and that you expect him to arrange such.

The third option may be reasonable in that you know something of the strains she faces at home and the lack of support she gets when ill. Hospitalizing her may serve the purpose of getting her out of the situation such that an intervention is possible and the psychiatrist can do an evaluation in that setting. However, you will likely face a denial of coverage by her insurance company.

Option 4 is not reasonable since referring her in this way makes it highly unlikely that she will get the comprehensive physical, metabolic evaluation that she needs and likely expects from you.

The fifth option might be reasonable but is somewhat risky in that you don't know the presence and/or significance of suicidal ideation. At least you have done the physical and metabolic evaluation and a trial of an antidepressant is initiated. A one-week follow up or a phone call in a few days after asking about suicidality might be a sound strategy. If suicidality is present, then an emergent referral to your psychiatrist colleague is highly warranted.

Educational objective: Review features of Mini Mental Status examination of Folstein.

Folstein’s Mini Mental Status Examination is heavily weighted on orientation of patient since 10 points are related to temporal and spatial orientation. Three points are assigned to registration (ability to repeat three objects). Attention and calculations are tested by serial 7s subtractions from 100 and are worth 5 points. Recall is tested by repeating three objects from first part of test and may bring three points. Language is tested by naming two common things, repetition of ‘No ifs, ands, or buts” and by following three step command. All these tasks are worth 6 points. Obeying written command brings one point, as well as writing the sentence and copy design (intersecting pentagons or clock face).

Educational objective: Review appropriate use of different antidepressant medications.

Decision Guide for Medication Selection in Geriatric

• Major Depression
• Nortriptyline or desipramine
  • -Severe melancholic depression
  • -Patients with history of favorable response to tricyclics with minimal side effects.
• Selective Serotonin Reuptake Inhibitors (SSRI-s)
  • -Mild to moderate depression
  • -Nonmelancholic depression
  • -Patients with heart conduction defects
  • -Patients with prostatic hypertrophy
  • -Patients with glaucoma who are noncompliant
• Monoamine oxidase inhibitors (MAO inhibitors)
  • -Depression accompanied with panic attacks
  • -Depression that failed other classes of antidepressants
• Bupropion
  • -Cardiac patients
  • -Patients with prominent apathy
  • -Depression that failed other classes of antidepressants
• Venlafaxine
  • -somatic pain
• Mirtazepine
  • -Patients with prominent insomnia and anorexia
• Psychostimulants
  • -Medically or surgically ill, apathetic, depressed patients
  • -As initial therapy until more traditional antidepressants effects become therapeutic.

Educational objective: Review appropriate use of different antidepressant medications.

Decision Guide for Medication Selection in Geriatric

• Major Depression
• Nortriptyline or desipramine
  • -Severe melancholic depression
  • -Patients with history of favorable response to tricyclics with minimal side effects.
• Selective Serotonin Reuptake Inhibitors (SSRI-s)
  • -Mild to moderate depression
  • -Nonmelancholic depression
  • -Patients with heart conduction defects
  • -Patients with prostatic hypertrophy
  • -Patients with glaucoma who are noncompliant
• Monoamine oxidase inhibitors (MAO inhibitors)
  • -Depression accompanied with panic attacks
  • -Depression that failed other classes of antidepressants
• Bupropion
  • -Cardiac patients
  • -Patients with prominent apathy
  • -Depression that failed other classes of antidepressants
• Venlafaxine
  • -somatic pain
• Mirtazepine
  • -Patients with prominent insomnia and anorexia
• Psychostimulants
  • -Medically or surgically ill, apathetic, depressed patients
  • -As initial therapy until more traditional antidepressants effects become therapeutic.

Educational objective: Review appropriate use of different antidepressant medications.

Decision Guide for Medication Selection in Geriatric

• Major Depression
• Nortriptyline or desipramine
  • -Severe melancholic depression
  • -Patients with history of favorable response to tricyclics with minimal side effects.
• Selective Serotonin Reuptake Inhibitors (SSRI-s)
  • -Mild to moderate depression
  • -Nonmelancholic depression
  • -Patients with heart conduction defects
  • -Patients with prostatic hypertrophy
  • -Patients with glaucoma who are noncompliant
• Monoamine oxidase inhibitors (MAO inhibitors)
  • -Depression accompanied with panic attacks
  • -Depression that failed other classes of antidepressants
• Bupropion
  • -Cardiac patients
  • -Patients with prominent apathy
  • -Depression that failed other classes of antidepressants
• Venlafaxine
  • -somatic pain
• Mirtazepine
  • -Patients with prominent insomnia and anorexia
• Psychostimulants
  • -Medically or surgically ill, apathetic, depressed patients
  • -As initial therapy until more traditional antidepressants effects become therapeutic.

Educational objective: Review appropriate use of different antidepressant medications.

Decision Guide for Medication Selection in Geriatric

• Major Depression
• Nortriptyline or desipramine
  • -Severe melancholic depression
  • -Patients with history of favorable response to tricyclics with minimal side effects.
• Selective Serotonin Reuptake Inhibitors (SSRI-s)
  • -Mild to moderate depression
  • -Nonmelancholic depression
  • -Patients with heart conduction defects
  • -Patients with prostatic hypertrophy
  • -Patients with glaucoma who are noncompliant
• Monoamine oxidase inhibitors (MAO inhibitors)
  • -Depression accompanied with panic attacks
  • -Depression that failed other classes of antidepressants
• Bupropion
  • -Cardiac patients
  • -Patients with prominent apathy
  • -Depression that failed other classes of antidepressants
• Venlafaxine
  • -somatic pain
• Mirtazepine
  • -Patients with prominent insomnia and anorexia
• Psychostimulants
  • -Medically or surgically ill, apathetic, depressed patients
  • -As initial therapy until more traditional antidepressants effects become therapeutic.

Educational objective: Review appropriate use of different antidepressant medications.

Decision Guide for Medication Selection in Geriatric

• Major Depression
• Nortriptyline or desipramine
  • -Severe melancholic depression
  • -Patients with history of favorable response to tricyclics with minimal side effects.
• Selective Serotonin Reuptake Inhibitors (SSRI-s)
  • -Mild to moderate depression
  • -Nonmelancholic depression
  • -Patients with heart conduction defects
  • -Patients with prostatic hypertrophy
  • -Patients with glaucoma who are noncompliant
• Monoamine oxidase inhibitors (MAO inhibitors)
  • -Depression accompanied with panic attacks
  • -Depression that failed other classes of antidepressants
• Bupropion
  • -Cardiac patients
  • -Patients with prominent apathy
  • -Depression that failed other classes of antidepressants
• Venlafaxine
  • -somatic pain
• Mirtazepine
  • -Patients with prominent insomnia and anorexia
• Psychostimulants
  • -Medically or surgically ill, apathetic, depressed patients
  • -As initial therapy until more traditional antidepressants effects become therapeutic.

Educational objective: Review the role of electroconvulsive therapy for depression.

Electroconvulsive therapy (ECT) is effective in treating both geriatric depression and mania. It should be favored in patients with severe mood syndromes who may be unable to tolerate the long waiting imposed by gradual introduction of antidepressants or mood stabilizers and slow onset of drug action. ECT also may be prescribed for patients with conduction heart deficits, prostatic hypertrophy, or glaucoma. The average number of ECT-s required for treatment of major depression is nine. Administration of three treatments weekly appears to work more rapidly than once weekly. Less frequent ECT is associated with less prominent cognitive impairment, but no difference was found at 1 month after treatment between once weekly or three times weekly therapy.

In summary – electroconvulsive therapy should be considered for the following patients:
Patients with psychotic depression,
Patients with very high suicide risk,
Patients with contraindications for drug treatment.

Person in question has psychotic features, is high suicide risk, and therapy with fluoxetine appears not to be effective.

Educational objective: Review diagnostic criteria for major depression.

- Diagnostic Criteria for Major Depression

Depressed mood or loss of interest of pleasure of 2 weeks’ duration accompanied by four or more of the following:

• Appetite change or weight loss
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Loss of energy
• Feelings of worthlessness or guilt
• Difficulties with concentration or decision making
• Recurrent thoughts of death or suicide

Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition – 1994.

Educational objective: Emphasize lack of sexual side effects with bupropion therapy.

All of the above can be used effectively to treat depressive symptoms. However bupropion is not associated with sexual dysfunction and the others serotonin reuptake inhibitors (SSRI’s), are all associated with sexual side effects. This patient already has sexual dysfunction and hence would derive the most benefit from treatment with bupropion.

Educational objective: Review the features of Alzheimer’s type dementia.

Stepwise progression suggests vascular or “multi-infarct” dementia. All other options are seen in Alzheimer’s type dementia.

Educational objective: Review diagnostic criteria for major depressive disorder.

Major Depression is a common psychiatric condition. To qualify for a diagnosis of a major depressive episode, five (or more) of the following symptoms need to be present during the same 2-week period and represent a change from previous functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

• (1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
• (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
• (3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
• (4) Insomnia or hypersomnia nearly every day.
• (5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
• (6) Fatigue or loss of energy nearly every day.
• (7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
• (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
• (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Ref: American Psychiatric Press Textbook of Psychiatry, Chapter 13, Mood Disorders

Educational objective: Review important facts about major depressive disorder.

All of the above are true.

Ref: American Psychiatric Press Textbook of Psychiatry, Chapter 13, Mood Disorders

Educational objective: Review the features of panic disorder.

Panic disorder is characterized by recurrent panic attacks. These attacks typically occur suddenly and unexpectedly when the patient is engaged in a routine activity. The attacks are typified by both extreme anxiety (fear, terror) as well as peripheral (somatic) symptoms of anxiety. These include dyspnea, palpitations, chest pain or discomfort, choking or smothering sensations, dizziness or unsteady feelings, feelings of unreality (derealization and/or depersonalization), paresthesias, hot and cold flashes, sweating, faintness, trembling and shaking, and a fear of dying, going crazy, or losing control of oneself. Panic attacks typically last no more than 20 minutes and rarely last as long as an hour. Treatment consists of a combination of psychotherapy (cognitive-behavior) and medications. Antipsychotic medications should not be used for anxiety disorder.

Educational objective: Review important features of delirium.

A fluctuating clinical picture, along with confusion, a global impairment of cognitive functions, disorganized thinking, hallucinations, and sleep/wake disturbances are characteristic of delirium. It is often clearly associated with an offending organic agent. Delirium should be considered a medical emergency. Every effort should be made to identify (and reverse) the underlying cause. The very young, the very ill, and the elderly are particularly susceptible to delirium.

Educational objective: Review important epidemiological facts about alcoholism.

53% of all Americans use alcohol at least once a month. The remaining statements are all correct.

Educational objective: Review antipsychotic side effects.

Haloperidol, a high potency typical antipsychotic medication, poses the greatest risk of extrapyramidal side effects (EPS). Chlorpromazine is a low potency typical antipsychotic and Loxapine is a mid-potency antipsychotic. Risperidone and Olanzapine are atypical antipsychotics and associated with lower risk of EPS.

Educational objective: Review important facts about Wernicke-Korsakoff syndrome.

All of the above describe Wernicke's syndrome.

Educational objective: Review important facts about delirium and dementia.

Impaired attention is one of the hallmarks of delirium. The onset of dementia is normally insidious, while the onset of delirium is sudden. Chlorpromazine is significantly anticholinergic and can exacerbate a delirium. Haloperidol or lorazepam are the preferred medications for control of delirium. An EEG is most often diffusely slowed in a delirious patient and can be normal or moderately slowed in a patient with early dementia.

Educational objective: Emphasize sexual dysfunction as an important side effect of MAOI’s.

Sexual dysfunction is a well-known side effect of MAOI’s. The other statements are correct.

Educational objective: Review symptoms of lithium toxicity.

Nausea, vomiting, diarrhea, coarse tremor, sleepiness, sluggishness, vertigo and dysarthria are symptoms of mild lithium toxicity. Cardiac arrhythmias, impaired consciousness, hyperreflexia, nystagmus, seizures and coma can follow with increasing serum levels. Tinnitus is not seen in lithium toxicity.

Educational objective: Review pathogenesis of Alzheimer’s disease.

The pathophysiology of Alzheimer’s disease is clearly linked to amyloid. By definition the one pathologic abnormality required for the diagnosis of definite AD is sufficient frequency of amyloid plaques. Of the common isoforms of Apolipoprotein E (ApoE), the E4 allele is over-represented in groups of both familial and sporadic cases of AD. In incidence studies correcting for other variables, (varying life expectancies and degree of cerebrovascular disease), it was found that the female sex is an independent risk factor.

Ref: Clinical Diagnosis and Management of Alzheimer’s Disease, Second Edition, Serge Gauthier M.D. editor

Educational objective: Review pharmacologic facts about fluoxetine.

Fluoxetine (Prozac) was the first commercially available selective serotonin reuptake inhibitory available in the U.S. (1988). Several others have been released subsequently. The effect exerted by these medications is inhibition of serotonin reuptake. The half-life of fluoxetine in healthy adults is 72 hours, and there is an active metabolite (norfluoxetine) which has a longer half-life. The principle drug interactions pertinent in SSRI’s surround the inhibition of the cytochrome p-450 isoenzymes in the liver, causing elevations of other drugs, including tricyclic antidepressants. Fluoxetine overdose is generally not life threatening. The clinical effect of any antidepressant rarely occurs until the second or third week of therapy.

Educational objective: Review contraindications to ECT.

Electroconvulsive therapy is used as a treatment for severe or treatment-resistant major depression and less frequently for manic and psychotic disorders. Despite negative and often inaccurate portrayals of the procedure in the media, ECT has proven effective and even life-saving in certain psychiatric conditions where other treatments have failed. Although there are no absolute contraindications to ECT, there are certain clinical conditions in which the procedure is associated with substantially increased risk.

These conditions include conditions with increased intracranial pressure, recent myocardial infarction, recent intracerebral hemorrhage, unstable AVM’s, retinal detachment, pheochromocytoma or any other condition associated with increased risk of anesthesia.

Educational objective: review medications influencing hepatic cytochrome P450 enzyme system.

If the active form of a drug is eliminated largely by biotransformation, inhibition of its metabolism leads to reduced clearance, prolonged half-life, and accumulation of the drug during maintenance therapy. Fluoxetine and cimetidine are potent inhibitors of the oxidative metabolism of many drugs via inhibition of the cytochrome P450 enzyme system. Cigarette smoking, phenobarbital, rifampin, carbamazepine, alcohol and chloral hydrate induce hepatic metabolism, reducing effective concentration of the drugs.

Educational objective: Review features of panic disorder.

It is not an adjustment disorder since her symptoms are so pervasive and serious, with the disturbing thoughts suggesting significant internal disruption and instability. With the varied nature of her symptoms she exudes an air of fragility and instability of mental functioning. Something major is in the offing, and it needs to be taken very seriously. Suicide risk is high and must be attended to in any diagnostic and treatment situation.