Author: Neelam Maurya

Adjustment Disorder

ADJUSTMENT DISORDER


ADJUSTMENT DISORDER

  • Disorders characterized by emotional responses to stressful events like financial problems, medical illness, relationship problems or death of a loved one.

Symptoms:

  • Symptom complex includes anxiety & depressive symptoms.
  • Depressed mood
  • Worry
  • Feeling of inability to cope.
  • Disturbance in individuals daily functioning.

Differential diagnosis:

Depression – 

  • Depression follows negative life event.
  • Differentiated by delineating uncomplicated bereavement/grief reactions.

In uncomplicated bereavement:

  • Symptoms & dysfunctions developing are within expected limits.

In adjustment disorder:

  • Symptoms & dysfunction are beyond expectable reaction to stressor.

Other differential diagnosis:

  • PTSD
  • Brief psychotic disorders.
  • Diagnoses should be given precedence if their diagnostic criterion are met, irrespective of stressors presence.

Treatment:

  • Psychotherapy – Treatment of choice.
    • Supportive psychotherapy commonly used.

Medications

  • Adjuvant to psychotherapy.
  • Antidepressants & antianxiety drugs.

Exam Important

  • Disorders characterized by emotional responses to stressful events like financial problems, medical illness, relationship problems or death of a loved one.
Don’t Forget to Solve all the previous Year Question asked on ADJUSTMENT DISORDER

Module Below Start Quiz

Bipolar Disorders

BIPOLAR DISORDERS

Q. 1

All of the following conditions on it’s own can be considered for the diagnosis of Bipolar disorder, EXCEPT:

 A

Hypomania

 B

Depression

 C

Mania and Depression

 D

Mixed Affective State

Q. 1

All of the following conditions on it’s own can be considered for the diagnosis of Bipolar disorder, EXCEPT:

 A

Hypomania

 B

Depression

 C

Mania and Depression

 D

Mixed Affective State

Ans. B

Explanation:

Either mania or hypomania are required for a diagnosis of Bipolar Affective Disorder. 
 
Bipolar 1 – Mania and Depression
Bipolar 2 – Hypomania (mild mania) and Depression
Bipolar 3 – Anti-depressant induced Mania or Hypomania
Mixed affective States: Both Mania and Depressive symptoms coexist
Rapid Cycling Bipolar: 4 or more mood cycles in a years time.
 
As a rule most of the times mania or hypomania will be followed by depression. However in unipolar depression, mania is not a feature.  
 
Ref: Kaplan & Sadock’s Synopsis of Psychiatry 9th Edition, Page 542,534-60; Harrison’s Principles of Internal Medicine 16th Edition, Page 2556; A short textbook of Psychiatry by Neraj Ahuja 5th Edition, Page74; Current Diagnosis & Treatment In Psychiatry Page 312-322; Shorter Oxford Textbook of Psychiatry, 5th Edition, Page 227, 247-251

Q. 2

Which of the following is the characteristic feature of Bipolar disorder II?

 A

Hypomania plus mania

 B

Depression alone

 C

Mania and depression

 D

Hypomania and depression

Q. 2

Which of the following is the characteristic feature of Bipolar disorder II?

 A

Hypomania plus mania

 B

Depression alone

 C

Mania and depression

 D

Hypomania and depression

Ans. D

Explanation:

Bipolar disorder is a chronic mood disorder characterized by the presence of mania (bipolar I disorder) or hypomania and depression (bipolar II disorder). Manic episodes are distinct periods of abnormally and persistent moods that can be euphoric, expansive, or irritable.

Ref: Textbook of Family Medicine: Expert Consult – Online and Print By Robert E Rakel, M.D., David Rakel, 2011, Page 1064.


Q. 3

According to DSM IV, Mania of Bipolar Disorder will fulfil the diagnostic criteria if the symptoms persist for what period of time in a young lady who is not hospitalised?

 A

1 week

 B

2 week

 C

3 week

 D

4 week

Q. 3

According to DSM IV, Mania of Bipolar Disorder will fulfil the diagnostic criteria if the symptoms persist for what period of time in a young lady who is not hospitalised?

 A

1 week

 B

2 week

 C

3 week

 D

4 week

Ans. A

Explanation:

Ans. A. 1 week

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary) is the minimum time for the diagnosis for manic illness, according to DSM-IV-TR criteria. 

During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  • More talkative than usual or pressure to keep talking
  • Flight of ideas or subjective experience that thoughts are racing
  • Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
  • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  • Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

Quiz In Between


Q. 4

Chromosome associated with bipolar disease‑

 A

Chromosomel6

 B

Chromosome 13

 C

Chromosome 14

 D

Chromosome 11

Q. 4

Chromosome associated with bipolar disease‑

 A

Chromosomel6

 B

Chromosome 13

 C

Chromosome 14

 D

Chromosome 11

Ans. B

Explanation:

B i.e. Chromosome 13


Q. 5

All of the following are included in diagnosis of Bipolar disorder except:

 A

Mania alone

 B

Depression alone

 C

Mania and depression

 D

Mania and anxiety

Q. 5

All of the following are included in diagnosis of Bipolar disorder except:

 A

Mania alone

 B

Depression alone

 C

Mania and depression

 D

Mania and anxiety

Ans. B

Explanation:

B i.e. Depression alone


Q. 6

Bipolar type II disorder includes combination of

 A

Hypomania & dysthymia

 B

Hypomania & subsyndromal depression

 C

Hypomania & subsyndromal depression

 D

Mania & subsyndromal depression

Q. 6

Bipolar type II disorder includes combination of

 A

Hypomania & dysthymia

 B

Hypomania & subsyndromal depression

 C

Hypomania & subsyndromal depression

 D

Mania & subsyndromal depression

Ans. C

Explanation:

C i.e. Hypomania & Depression

Quiz In Between


Q. 7

Bipolar II disorder includes

 A

Cyclothymic disorder

 B

Dysthemia

 C

Single manic episode

 D

Major depression & hypomania

Q. 7

Bipolar II disorder includes

 A

Cyclothymic disorder

 B

Dysthemia

 C

Single manic episode

 D

Major depression & hypomania

Ans. D

Explanation:

D i.e. Major depression & hypomania


Q. 8

True about bipolar disorder type II is-

 A

Recurrent depression

 B

Recurrent mania

 C

Repetitive depression & mania

 D

Repetitive depression & hypomania

Q. 8

True about bipolar disorder type II is-

 A

Recurrent depression

 B

Recurrent mania

 C

Repetitive depression & mania

 D

Repetitive depression & hypomania

Ans. D

Explanation:

D i.e. Repetitive depression & hypomania


Q. 9

Which of the following is/are included in bipolar disease:

 A

Hypomania

 B

Cyclothymia

 C

Paranoid disorder

 D

A & B

Q. 9

Which of the following is/are included in bipolar disease:

 A

Hypomania

 B

Cyclothymia

 C

Paranoid disorder

 D

A & B

Ans. D

Explanation:

A >> B i.e. Hypomenia >> Cyclothymia

–  Bipolar disorder (or manic-depressive psychosis = MDP) encompasses recurrent manic episodedsQ, or recurrent episodes ofsevere (major) depression and mania (Bipolar I = BPI)/ hypomania (Bipolar II = BP II)Q. In the intervening period the patient is normalQ.

–  The patients with depression alone are not included in bipolar disorderQ. Patients who are afflicted only with major depressive episodesQ are said to have – major depressive disorder or unipolar depression.

Patients with both manic and depressive episodes or patient with manic episodes alone are said to have bipolar disorder. The term unipolar mania, pure mania, or euphoric mania are sometimes used for bipolar patients who do not have depressive episodes.

Bipolar disorders (i.e. disorder with 2 poles) can be conceptualized into 3 entities : 1) Bipolar I disorder, consisting of episodes of mania cycling with depessive episodes; 2) Bipolar II disorder, consisting of episodes of hypomania cycling with depressive episodes; and 3) Cyclothymic disorder, consisting of hypomania and less severe (sub syndromal) episodes of depression. Very few patients have only manic episodesQ (but not includes only depression).

Quiz In Between


Q. 10

Bipolar disorder is a:     

TN 11

 A

Mood disorder

 B

Neurotic disorder

 C

Behavior disorder

 D

Personality disorder

Q. 10

Bipolar disorder is a:     

TN 11

 A

Mood disorder

 B

Neurotic disorder

 C

Behavior disorder

 D

Personality disorder

Ans. A

Explanation:

Ans. Mood disorder


Q. 11

Personality associated bipolar disorder –

 A

Antisocial

 B

Anakastic

 C

Borderline

 D

Narcissistic

Q. 11

Personality associated bipolar disorder –

 A

Antisocial

 B

Anakastic

 C

Borderline

 D

Narcissistic

Ans. D

Explanation:

Ans. is ‘d’ i.e., Narcissistic

Symptoms of Narcissistic personality disorder can be confused with manic phase of bipolar disorder”.

Narcissistic personality disorder

  • Narcissistic patients are grandiose and require admiration from other.
  • This is characterized by Ideas of grandiosity & inflated sense of self importance; lack of empathy with others; attention seeking behavior; exploitation of others; and an arrogant, haughty attitude.

Quiz In Between



Bipolar Disorders

BIPOLAR DISORDERS


BIPOLAR DISORDERS

  • Characterized by episodes of both mania & depression.
  • Equally prevalent in men & women.
    • Manic episodes – More common in men; depressive episodes – More common in women.
    • More commonly seen in divorced and single persons.
  • Onset age – 30 yrs (average). 
Causes:

Neurotransmitters:

  • Increased dopamine levels for manic episode.

Genetic factors:

  • Chromosomes 18q & 22q – Strongest evidence linked to bipolar disorder.
  • Chromosome 21q involved.

Subtypes:

  • Bipolar 1/2 = Schizobipolar disorder (schizoaffective disorder)
  • Bipolar I = Mania with depression (or mania alone).
    • Bipolar I 1/2 = Depression with protracted hypomania.
  • Bipolar ll = Depression with discrete hypomanic episodes.
    • Bipolar ll 1/2 = Depression superimposed on cyclothymia.
  • Bipolar lll = Depression plus induced hypomania 
    • (e.g. hypomania occurring solely in association with antidepressants or other somatic treatment.
    • Bipolar lll 1/2 = Bipolar disorder associated with substance use
  • Bipolar lV = Depression superimposed on hyperthymic temperament.

Symptoms:

Symptoms of manic episode:

  • Elevated mood – Undue happiness or irritable mood.
  • Increased self-esteem or grandiosity.
  • Decreased need for sleep (e.g. patient feels rested after 2 hours of sleep)
  • Over-talkativeness.
  • Flight of ideas.
  • Distractibility (not able to concentrate on task in hand).
  • Increased goal-directed activities (overactivity, hypersexuality overfamiliarity).
  • Psychomotor agitation.

Diagnostic criteria:

  • Symptoms should last for at least 7 days.
  • Must cause marked impairment in social & occupational functioning.

Psychotic symptoms:

  • Delusions & hallucination.
  • Maybe mood congruent (delusion of grandiosity)/incongruent (delusion of persecution).

Diagnostic criteria:

  • Must exhibit manic episode with psychotic symptoms.

Hypomania:

  • Symptoms similar to mania with lesser severity & reduced social & occupational functioning impairment.
  • Duration criterion = 4 days.

Mixed episodes:

  • Presents with both manic & depressive symptoms.
  • Duration = Min. 7 days.

TREATMENT:

  • Mood stabilizer: Lithium (prototyplcal mood stabilizer), valproate, carbamazepine, oxcarbazepine & lamotrigine (For bipolar depression).
  • Antipsychotics.
  • Benzodiazepines (lorazepam & clonazepam) – Used in acute mania due to their calming effect.
  • Antidepressants – Only as combination drug.

Exam Important

  • Chromosomes 18q & 22q have strongest evidence linked to bipolar disorder.
  • Symptoms of manic episode includes distractibility, flight of ideas & decreased need for sleep.
  • Diagnostic criteria for manic episode is that symptoms should last for at least 7 days.
  • Lithium is considered “prototypical mood stabilizer”.
Don’t Forget to Solve all the previous Year Question asked on BIPOLAR DISORDERS

Module Below Start Quiz

Suicide – Psychiatric Inputs

SUICIDE – PSYCHIATRIC INPUTS

Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Ans. A

Explanation:

Female REF: Kaplan and sadock’s synopsis in psychiatry 10th ed p. 529

Risk factors of suicide in depression are:

  • At end( involutional) or beginning of depression
  • Mood disorders , personality disorders , psychosis , hypochondriac
  • >45yrs male, unemployed, single, divorced, chronically ill, widowed, recently bereaved
  • Family history

Q. 2

A 60 year male is brought by his wife. He thinks that he had committed sins all through his life. He is very much depressed and has considered committing suicide but has not through hot do go about it. He had also attached sessions with a spiritual guru. He is not convinced by his wife that he has lead a pious life. He does not want to hear anything on the contrary. How will you treat him?

 A

Antipsychotic + Anti depressant

 B

Antidepressant with cognitive behavioural therapy

 C

Guidance & recounselling with guru+Anti depressant

 D

Anti depressant alone

Q. 2

A 60 year male is brought by his wife. He thinks that he had committed sins all through his life. He is very much depressed and has considered committing suicide but has not through hot do go about it. He had also attached sessions with a spiritual guru. He is not convinced by his wife that he has lead a pious life. He does not want to hear anything on the contrary. How will you treat him?

 A

Antipsychotic + Anti depressant

 B

Antidepressant with cognitive behavioural therapy

 C

Guidance & recounselling with guru+Anti depressant

 D

Anti depressant alone

Ans. A

Explanation:

A i.e. Antipsychotic + Anti depressant

The patient is presenting with features of depression, hypochondrial preoccupation & delusional guilt suggesting the diagnosis of depression with psychotic features (i.e. psychotic depression). It should be managed with a combination of antipsychotic (SNRIs or TCA rather than SSRI) and antidepressantQ. ECT is an alternative perhaps more effective than pharmacotherapy.


Q. 3

Suicide is most common in ‑

 A

Depression

 B

Alcohol dependence

 C

Dementia

 D

Schizophrenia

Q. 3

Suicide is most common in ‑

 A

Depression

 B

Alcohol dependence

 C

Dementia

 D

Schizophrenia

Ans. A

Explanation:

Ans. is ‘a’ i.e., Depression

Causes/Risk factors for suicide

  • Psychiatric disorders : – Depression (most common), alcoholism (2nd mc), Drug/Substance dependence, Schizophrenia, Dementia.
  • Physical illness : – Cancer, AIDS, Multiple sclerosis, Head trauma.
  • Psychosocial factors : – Failure in love, marital difficulties, family dispute, illegitimate pregnancy.
  • Biological factors : – Decrease in serotonin
  • Other – Male sex, Age > 40 years, Single (Unmarried, divorced or widowed), previous suicide attempt, social isolation.

Quiz In Between



Suicide – Psychiatric Inputs

SUICIDE – PSYCHIATRIC INPUTS


SUICIDE – PSYCHIATRIC INPUTS

Cause:

  • Low CSF levels of 5-hydroryindoleacetic acid (5 HIAA).
  • 5-hydroryindoleacetic acid (5 HIAA)- Serotonin metabolite associated with higher suicide risk.

Psychiatric illnesses & suicide risks:

  • Depressive disorder
  • Schizophrenia
  • Alcohol dependence & other substance dependence.
  • Personality disorders (especially borderline personality disorder & antisocial personality disorder).

Suicidal risk factors:

  • Male sex
  • Age > 45 years
  • Divorced, widowed
  • Unemployed
  • Chronic illness
  • Family history of suicide
  • Poor social support.

Exam Important

  • Lower levels of 5-hydroryindoleacetic acid (5 HIAA), a serotonin metabolite is associated with higher suicide risk.
  • Males are more prone to have suicidal risk.
Don’t Forget to Solve all the previous Year Question asked on SUICIDE – PSYCHIATRIC INPUTS

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Lithium – Psychiatric Usage

LITHIUM – PSYCHIATRIC USAGE

Q. 1 Treatment of choice in acute Bipolar disorder
 A Valproate
 B Lamotrigine
 C Lithium
 D All of the above
Q. 1 Treatment of choice in acute Bipolar disorder
 A Valproate
 B Lamotrigine
 C Lithium
 D All of the above
Ans. C

Explanation:

Lithium


Q. 2 Lithium is not used in treatment of which of the following?
 A Major depression
 B Vascular headache
 C Neutropenia
 D Generalized anxiety disorder
Q. 2 Lithium is not used in treatment of which of the following?
 A Major depression
 B Vascular headache
 C Neutropenia
 D Generalized anxiety disorder
Ans. D

Explanation:

Generalized anxiety disorder


Q. 3

Which of the following represent the theraputic level of Lithium in serum?

 A

0.8 – 1.2 meq/l

 B

0.6 – 1.2 meq/l

 C

>2 meq/l

 D

None

Q. 3

Which of the following represent the theraputic level of Lithium in serum?

 A

0.8 – 1.2 meq/l

 B

0.6 – 1.2 meq/l

 C

>2 meq/l

 D

None

Ans. A

Explanation:

Lithium is most commonly used in the treatment of bipolar depression. It has a low toxic : therapeutic ratio.

The therapeutic level of Lithium in serum is 0.8 – 1.2 mEq/L.

Lithium toxicity occur when serum lithium levels exceed 1.5 to 2 mEq/L.

Hence frequent bood tests are done to monitor the drug levels.

Lithium is fully metabilised by the kidney. Hence, dehydration could cause the drug levels to rise.

Ref: Current Medical Diagnosis and Treatment 2013, chapter 38.

Quiz In Between


Q. 4

The current agent of choice for treatment of bipolar affective (manic-depressive) disorder is:

 A

Chlorpromazine

 B

Haloperidol

 C

Diazepam

 D

Lithium carbonate

Q. 4

The current agent of choice for treatment of bipolar affective (manic-depressive) disorder is:

 A

Chlorpromazine

 B

Haloperidol

 C

Diazepam

 D

Lithium carbonate

Ans. D

Explanation:

Lithium carbonate is the current agent of choice, particularly during the manic phase. Because the onset of action is slow, concurrent use of antipsychotic agents such as chlorpromazine or haloperidol may be necessary to control mania.
Concurrent use of tricyclic antidepressants may be necessary in the depressive phase.
Monitoring of lithium levels is necessary because of the serious nature of the adverse effects (neurologic, renal, cardiac).
 
Ref: Ropper A.H., Samuels M.A. (2009). Chapter 57. Depression and Bipolar Disease. In A.H. Ropper, M.A. Samuels (Eds), Adams and Victor’s Principles of Neurology, 9e.

Q. 5

Manic-depressive illness.Which is the the most appropriate pharmacotherapeutic agent?

 A

Triazolam

 B

Tranylcypromine

 C

Methylphenidate

 D

Lithium carbonate

Q. 5

Manic-depressive illness.Which is the the most appropriate pharmacotherapeutic agent?

 A

Triazolam

 B

Tranylcypromine

 C

Methylphenidate

 D

Lithium carbonate

Ans. D

Explanation:

Lithium carbonate prevents the mood swings characteristic of manic-depressive illness and is used in long-term therapy.
Triazolam is a benzodiazepine used as a hypnotic to facilitate sleep in insomnia characterized by difficulty “falling” asleep.
Methylphenidate is an amphetamine congener with a paradoxical calming effect in children with attention-deficit hyperactivity disorder.
 
Ref: Ropper A.H., Samuels M.A. (2009). Chapter 57. Depression and Bipolar Disease. In A.H. Ropper, M.A. Samuels (Eds), Adams and Victor’s Principles of Neurology, 9e.

Q. 6

A patient with bipolar disorder started lithium therapy. The maximum therapeutic level of lithium in serum is:

 A

0.1 meq/L

 B

0.4 meq/L

 C

1.0 meq/L

 D

1.8 meq/L

Q. 6

A patient with bipolar disorder started lithium therapy. The maximum therapeutic level of lithium in serum is:

 A

0.1 meq/L

 B

0.4 meq/L

 C

1.0 meq/L

 D

1.8 meq/L

Ans. C

Explanation:

Concentrations considered to be effective and acceptably safe are between 0.6 and 1.5 mEq/L. The range of 1.0-1.5 mEq/L is favored for treatment of acutely manic or hypomanic patients. Serum concentrations of Li+ have been found to follow a clear dose-effect relationship between 0.4 and 1.0 mEq/L, but with a corresponding dose-dependent rise in polyuria and tremor as indices of adverse effects.

 
Ref: Meyer J.M. (2011). Chapter 16. Pharmacotherapy of Psychosis and Mania. In B.C. Knollmann (Ed), Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 12e.

Quiz In Between


Q. 7

Lithium is treatment of choice for

 A

Unipolar MDP prophylaxis

 B

Bipolar MDP prophylaxis

 C

Schizophrenia

 D

Acute mania

Q. 7

Lithium is treatment of choice for

 A

Unipolar MDP prophylaxis

 B

Bipolar MDP prophylaxis

 C

Schizophrenia

 D

Acute mania

Ans. B

Explanation:

B i.e. Bipolar MDP prophylaxis 

Lithium: Indications:

  • Established indications:
  • Treatment of acute mania 
  • Prophylaxis of bipolar mood disorder.
  • Possible clinical indications:
    •  Treatment of the schizo-affective disorder
    •  Prophylaxis of unipolar mood ilisorder
    • treatment of cyclothymia
    • Treatment if acute depression(as an adjuvant for refractory depression)
    • Treatment of chronic akoholism(in presence of significant depressive symptoms) 6 psychoactive use disorders(e’g cocaine dePendence)
    • Treatment of impulsive aggression.
    • eatment of Keine-Levin syndrome

Q. 8

Which is the drug of choice for maintenance therapy in uncomplicated bipolar disorder ?

 A

Sodium valproate

 B

Carbamazepine

 C

Lithium

 D

Lamotrigine

Q. 8

Which is the drug of choice for maintenance therapy in uncomplicated bipolar disorder ?

 A

Sodium valproate

 B

Carbamazepine

 C

Lithium

 D

Lamotrigine

Ans. C

Explanation:

Ans. is ‘c’ i.e., Lithium

Quiz In Between


Q. 9

Drug of choice for prophylaxis of mania is

 A

Lithium

 B

Haloperidol

 C

Clozapine

 D

Carbamazepine

Q. 9

Drug of choice for prophylaxis of mania is

 A

Lithium

 B

Haloperidol

 C

Clozapine

 D

Carbamazepine

Ans. A

Explanation:

Ans. is ‘a’ i.e., Lithium


Q. 10

A patient of maniac depressive psychosis is on lithium, clozapine and fluphenazine. During the course of treatment, he developed seizures and tremors. He is drinking water heavily and had recurrent episodes of urination. Which drug is responsible for these complications:          

March 2012

 A

Lithium

 B

Clozapine

 C

Fluphenazine

 D

None of the above

Q. 10

A patient of maniac depressive psychosis is on lithium, clozapine and fluphenazine. During the course of treatment, he developed seizures and tremors. He is drinking water heavily and had recurrent episodes of urination. Which drug is responsible for these complications:          

March 2012

 A

Lithium

 B

Clozapine

 C

Fluphenazine

 D

None of the above

Ans. A

Explanation:

Ans: A i.e. Lithium

Drugs for Schizophrenia and side-effects

  • Dose related side effects of lithium includes polyuria/polydypsia, weight gain, tremor etc.
  • Common side effects of clozapine are anticholinergic, antiadrenergic etc. Potentially life threatening side effects includes fatal agranulocytosis, fatal myocarditis, fatal pulmonary embolism etc.
  • Side effect of antipsychotic, include sedation, weight gain, extra-pyramidal side effects, postural hypotension etc.

Quiz In Between



Lithium – Psychiatric Usage

LITHIUM – PSYCHIATRIC USAGE


LITHIUM – PSYCHIATRIC USAGE

Indications of lithium in psychiatric disorders:

  • Used for treatment of acute episodes (both mania & depression).
    • Effective treatment for acute mania – Effective serum concentration for acute mania treatment is 1.0-1.5 mEq/ dl.
  • Antimanic efficacy of lithium is more than its antidepressive efficacy.
  • Prophylaxis in bipolar disorder.
  • Maintenance treatment with lithium decreases frequency, severity & duration of manic & depressive episodes in patients with bipolar disorders.
    • Serum concentration required for maintenance treatment is 0.6-1.2 mEq/dl.
  • In schizoaffective disorders.
  • As an adjuvant to antidepressants in major depressive disorder.

Other uses:

  • Obsessive-compulsive disorder
  • Aggression
  • Headache (cluster, migraine)
  • Gout
  • Epilepsy
  • Movement disorders
  • Neutropenia
  • Ulcerative colitis.

Exam Important

  • Lithium is used in effective treatment for acute mania & its effective serum concentration is 1.0-1.5 mEq/ dl.
  • Serum lithium concentration required for maintenance treatment is 0.6-1.2 mEq/dl.
  • Lithium is also used for headache (cluster, migraine) & neutropenia.
Don’t Forget to Solve all the previous Year Question asked on LITHIUM – PSYCHIATRIC USAGE

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Extrapyramidal Side Effects

EXTRAPYRAMIDAL SIDE EFFECTS

Q. 1

Raj Mohan has recently been on an increased regime of anti-psychotics for Schizophrenia. The following complications are associated with combined use of more than one anti-psychotic, EXCEPT:

 A

Neuroleptic Malignant Syndrome

 B

Renal Tubular Necrosis

 C

Paralytic illeus

 D

QTc Prolongation in ECG

Q. 1

Raj Mohan has recently been on an increased regime of anti-psychotics for Schizophrenia. The following complications are associated with combined use of more than one anti-psychotic, EXCEPT:

 A

Neuroleptic Malignant Syndrome

 B

Renal Tubular Necrosis

 C

Paralytic illeus

 D

QTc Prolongation in ECG

Ans. B

Explanation:

Neuroleptic Malignant SyndromeParalytic illeusQTc Prolongation in ECG, Seizures (GTC) and Sudden death from Arrythmias are recognised complications of polydrug therapy in psychosis.

Most of the side effects are a result of cumulative side effects of individual drugs. Renal toxicity is not a common side effect of antipsychotics and hence the option can be eliminated. 

Ref: Maudley prescribing guidelines, 10th Edition


Q. 2

A 26-year-old man with schizophrenia and tardive dyskinesia. Which is the most appropriate pharmacotherapeutic agent?

 A

Clozapine

 B

Valproic acid

 C

Haloperidol

 D

Paroxetine

Q. 2

A 26-year-old man with schizophrenia and tardive dyskinesia. Which is the most appropriate pharmacotherapeutic agent?

 A

Clozapine

 B

Valproic acid

 C

Haloperidol

 D

Paroxetine

Ans. A

Explanation:

Valproic acid is an anticonvulsant used as a mood stabilizer. It is found useful in the treatment of mania in a bipolar disorder.

It has also been valuable in the treatment of rapid cycling bipolar patients.

Paroxetine is an example of a selective serotonin reuptake inhibitor (SSRI), which is a newer form of antidepressant.

The SSRis are being found to be as effective as the tricyclic antidepressants.

Haloperidol is an example of a neuroleptic or antipsychotic medication useful in the management of acute psychosis, as well as long-term care. Clozapine is a newer atypical antipsychotic medication.

It is not associated with tardive dyskinesia as are the older neuroleptics.

This makes it a drug of choice for individuals who have developed signs of tardive dyskinesia after using other neuroleptics.

Problems with agranulocytosis prevent clozapine from being used as a “first line” neuroleptic.  

Ref: Meltzer H.Y., Bobo W.V., Heckers S.H., Fatemi H.S. (2008). Chapter 16. Schizophrenia. In M.H. Ebert, P.T. Loosen, B. Nurcombe, J.F. Leckman (Eds),CURRENT Diagnosis & Treatment: Psychiatry, 2e. 


Q. 3

Adverse effect of clozapine:

 A

Hypertension

 B

Sialorrhea

 C

Extrapyramidal S/E

 D

Neuroleptic malignant syndrome

Q. 3

Adverse effect of clozapine:

 A

Hypertension

 B

Sialorrhea

 C

Extrapyramidal S/E

 D

Neuroleptic malignant syndrome

Ans. B

Explanation:

B i.e. Sialorrhea

Quiz In Between


Q. 4

A patient with acute psychosis, who is on haloperidol 20mg/day for last 2 days, has an episode characterized by tongue protrusion, oculogyric crisis, stiffness and abnormal posture of limbs and trunk without loss of consciousness for last 20 minutes before presenting to casualty. This improved within a few minutes after administration of diphenhydramine HC1. The most likely diagnosis is:

 A

Acute dystonia

 B

Akathisia

 C

Tardive dyskinesia

 D

Neuroleptic malignant syndrome

Q. 4

A patient with acute psychosis, who is on haloperidol 20mg/day for last 2 days, has an episode characterized by tongue protrusion, oculogyric crisis, stiffness and abnormal posture of limbs and trunk without loss of consciousness for last 20 minutes before presenting to casualty. This improved within a few minutes after administration of diphenhydramine HC1. The most likely diagnosis is:

 A

Acute dystonia

 B

Akathisia

 C

Tardive dyskinesia

 D

Neuroleptic malignant syndrome

Ans. A

Explanation:

A i.e. Acute dystonia


Q. 5

A 30-year-old man who was recently started on haloperidol 30mg/day developed hyperpyrexia, muscle rigidity, akinesia, mutism, sweating, tachycardia and increased blood pressure. The investigations showed increased VVBC count, increased creatinine phosphokinase. There is no history of any other drug intake or any signs of infection. The most likely diagnosis is:

 A

Drug overdose

 B

Neuroleptic malignant syndrome

 C

Drug induce Parkinsonism

 D

Tardive dyskinesia

Q. 5

A 30-year-old man who was recently started on haloperidol 30mg/day developed hyperpyrexia, muscle rigidity, akinesia, mutism, sweating, tachycardia and increased blood pressure. The investigations showed increased VVBC count, increased creatinine phosphokinase. There is no history of any other drug intake or any signs of infection. The most likely diagnosis is:

 A

Drug overdose

 B

Neuroleptic malignant syndrome

 C

Drug induce Parkinsonism

 D

Tardive dyskinesia

Ans. B

Explanation:

B i.e. Neuroleptic malignant syndrome


Q. 6

A 31 year old male, with mood disorder, on 30 mg of haloperidol and 100 mg of lithium, is brought to the hospital emergency room with history of acute onset of fever, excessive sweating, confusion, rigidity of limbs and decreased communication for a day. Examination reveals tachycardia and labile blood pressure and investigations reveal increased CPK enzyme levels and lecocytosis. He is likely to have developed.

 A

Lithium toxicity

 B

Tardive dyskinesia

 C

Neuroleptic malignant syndrome

 D

Hypertensive encephalopathy

Q. 6

A 31 year old male, with mood disorder, on 30 mg of haloperidol and 100 mg of lithium, is brought to the hospital emergency room with history of acute onset of fever, excessive sweating, confusion, rigidity of limbs and decreased communication for a day. Examination reveals tachycardia and labile blood pressure and investigations reveal increased CPK enzyme levels and lecocytosis. He is likely to have developed.

 A

Lithium toxicity

 B

Tardive dyskinesia

 C

Neuroleptic malignant syndrome

 D

Hypertensive encephalopathy

Ans. C

Explanation:

C i.e. Neuroleptic malignant syndrome

Quiz In Between


Q. 7

Extrapyramidal side-effect least seen with ‑

 A

Clozapine

 B

Haloperidol

 C

Thioridazine

 D

Fluphenozine

Q. 7

Extrapyramidal side-effect least seen with ‑

 A

Clozapine

 B

Haloperidol

 C

Thioridazine

 D

Fluphenozine

Ans. A

Explanation:

Ans. is ‘a’ i.e., Clozapine

o Antipsychotics with no extrapyramidal effects.

1. Clozapine                  2. Aripiprazole                      3. Quetiapine

o Amongst typical antipsychotics, thioridazone has least extrapyramidal effects.


Q. 8

Which drug is the most useful in treating an episode of antipsychotic induced acute dystonia

 A

Lorazepam

 B

Haloperidol

 C

Promethazine

 D

Phenobarbitone

Q. 8

Which drug is the most useful in treating an episode of antipsychotic induced acute dystonia

 A

Lorazepam

 B

Haloperidol

 C

Promethazine

 D

Phenobarbitone

Ans. C

Explanation:

Ans. is ‘c’ i.e., Promethazine

o Antihistaminics have central anticholinergic property (e.g. promethazine) and central anticholinergic is the drug of choice for acute dystonia.


Q. 9

A female suffering from psychosis, taking phenothiazines now complains of sudden onset of high grade fever, muscle rigidity and altered sensorium. The diagnosis is –

 A

Malignant hyperthermia

 B

Neuroleptic malignant syndrome

 C

Tardive dyskinesia

 D

Akathesia

Q. 9

A female suffering from psychosis, taking phenothiazines now complains of sudden onset of high grade fever, muscle rigidity and altered sensorium. The diagnosis is –

 A

Malignant hyperthermia

 B

Neuroleptic malignant syndrome

 C

Tardive dyskinesia

 D

Akathesia

Ans. B

Explanation:

Ans. is ‘b’ i.e., Neuroleptic malignant syndrome

o History of intake of antipsychotic drugs and high grade fever, muscle rigidity, altered sensorium suggests Neuroleptic Malignant Syndrome.

Quiz In Between


Q. 10

A 40 year old adult man on medication for psychiatric illness for the last 2 weeks, suddenly develops marked rigidity, immobility, fever, fluetuating BP and heart rate. Most likely diagnosis

 A

Akathisia

 B

Parkinsonism

 C

Malignant neuroleptic syndrome

 D

Catatonic schizophrenia

Q. 10

A 40 year old adult man on medication for psychiatric illness for the last 2 weeks, suddenly develops marked rigidity, immobility, fever, fluetuating BP and heart rate. Most likely diagnosis

 A

Akathisia

 B

Parkinsonism

 C

Malignant neuroleptic syndrome

 D

Catatonic schizophrenia

Ans. C

Explanation:

Ans. is ‘c’ i.e., Malignant neuroleptic syndrome


Q. 11

Hyperthermia is seen in :

 A

Malignant neuroleptic syndrome

 B

Cannabis poisoning

 C

Opium intoxication

 D

Hypothyroidism 

Q. 11

Hyperthermia is seen in :

 A

Malignant neuroleptic syndrome

 B

Cannabis poisoning

 C

Opium intoxication

 D

Hypothyroidism 

Ans. A

Explanation:

Answer is A (Malignant neuroleptic syndrome) :

‘Malignant Neuroleptic Syndrome is an important cause of Hyperthermia Syndromes’ – Harrisons

Causes of Hyperthermia

  • Heat Stroke
  • Exertional : Exercise in higher-than-normal heat and/or humidity
  • Nonexertional : Anticholinergics, including antihistamines; antiparkinsonian drugs; diuretics; phenothiazines
  • Drug Induced Hyperthermia
    • Amphetamines, cocaine, phencyclidine (PCP), methylendioxymethamphetamine (MDMA; “ectasy”), lysergic acid diethylamide(LSD), salicylates, lithium, anticholinergics, sympathomimetics
  • Neuroleptic Malignant Syndrome
    • Phenothiazines, butyrophenones, including haloperidol and bromoperidol; fluoxetine; loxapine; tricyclic dibenzodiazepines; metoclopramide; domperidone; thiothixene; molindone; withdrawal of dopaminergic agents
  • Serotonin Syndrome
    • Selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), trycyclic antidepressants
  • Malignant Hyperthermia
    • Inhalational anesthetics, succinylcholine
  • Endocraniopathy
    • Thyrotoxocosis, pheochromocytoma
  • Central Nervous System Damage
  • Cerebral hemorrhage, status epilepticus, hypothalamic injury

Q. 12

Antidepressant    drug  that  can  cause  neuroleptic malignant syndrome and tardive dyskinesia is:

March 2009

 A

Amineptin

 B

Carbamazepine

 C

Amoxapine

 D

Trazodone

Q. 12

Antidepressant    drug  that  can  cause  neuroleptic malignant syndrome and tardive dyskinesia is:

March 2009

 A

Amineptin

 B

Carbamazepine

 C

Amoxapine

 D

Trazodone

Ans. C

Explanation:

Ans. C: Amoxapine

One of major metabolites of amoxapine, 7-hydroxyamoxapine, has a dopamine receptor blocking effect, making this drug a common cause of neuroleptic malignant syndrome.

Amoxapine is also associated with acute extrapyramidal symptoms and tardive dyskinesia.

Quiz In Between


Q. 13

Amongst the following, extrapyramidal side effect is commonest with which drug :          

September 2006

 A

Thioradizine

 B

haloperidol

 C

Clozapine

 D

Ziprasidone

Q. 13

Amongst the following, extrapyramidal side effect is commonest with which drug :          

September 2006

 A

Thioradizine

 B

haloperidol

 C

Clozapine

 D

Ziprasidone

Ans. B

Explanation:

Ans. B: Haloperidol

Extrapyramidal disturbances are the major dose limiting side effects of neuroleptics; more prominent with high potency drugs like fluphenazine, haloperidol, pimozide etc., least with thioridazine, clozapine, and all other atypical antipsychotics, except high doses of risperidone.


Q. 14

Which of the following extrapyramidal effect is seen on chronic use of antipsychotic ‑

 A

Dystonia

 B

Akathisia

 C

Tardive dyskinesia 

 D

Parkinsonism

Q. 14

Which of the following extrapyramidal effect is seen on chronic use of antipsychotic ‑

 A

Dystonia

 B

Akathisia

 C

Tardive dyskinesia 

 D

Parkinsonism

Ans. C

Explanation:

Ans. is `c’ i.e., Tardive dyskinesia 

Quiz In Between


Q. 15

Antidepressant causing Tardive dyskinesia is ‑

 A

MAO inhibitors

 B

Mianserin

 C

Imipramine

 D

Amoxapine

Q. 15

Antidepressant causing Tardive dyskinesia is ‑

 A

MAO inhibitors

 B

Mianserin

 C

Imipramine

 D

Amoxapine

Ans. D

Explanation:

Ans. is ‘d’ i.e., Amoxapine

  • Amoxapine is the only antidepressant which blocks D2 receptors along with inhibition of NA reuptake → has mixed antidepressant + neurolepic property.
  • Due to blockade of D, receptors it causes extrapyramidal side effects -4 Parkinsonism, Tardive dyskinesia, Akathesia, neuropeptic malignant syndrome.

Q. 16

Drug effective in Tardive dyskinesia

 A

Central anticholinergic 

 B

Dantroline

 C

Succinylcholine

 D

Terabenazine

Q. 16

Drug effective in Tardive dyskinesia

 A

Central anticholinergic 

 B

Dantroline

 C

Succinylcholine

 D

Terabenazine

Ans. D

Explanation:

Ans. is ‘d’ i.e., Tetrabenazine

[Ref: Clinical Pharmacology Ip. 108; www.ncb.nlm.nih.gov)

  • There is currently no satisfactory treatment for tardive dyskinesia other than discontinuation of drug.
  • Tetrabenazine (TBZ) is currently considered as a first line and most effective medication for treatment of persistent and disabling tardive dyskinesia.
  • Reserpine is an alternative to tetrabenazine.

Quiz In Between



Extrapyramidal Side Effects

EXTRAPYRAMIDAL SIDE EFFECTS


EXTRAPYRAMIDAL SIDE EFFECTS

  • Caused by antipsychotics.
    • More common with high-potency typical antipsychotics (compared to atypical antipsychotics).
  • Various movement disorders caused are collectively referred to as “extrapyramidal symptoms/extrapyramidal side effects”.

Mechanism:

  • Due to dopamine receptor blockade in nigrostriatal tract (neural pathway from substantia nigra to striatum).

TYPES OF MOVEMENT DISORDERS:

  • Acute dystonia.
  • Acute akathisia
  • Drug-induced parkinsonism
  • Tardive dyskinesia
  • Neuroleptic malignant syndrome

1. Acute dystonia:

  • Earliest side effect.
  • Occurs within minutes (more with injectable antipsychotic).

Features:

  • Characterized by sudden contraction of muscle group –
  • Symptoms like torticollis, trismus (contraction of jaw muscles), eyeballs deviation (oculogyric crisis due to extraocular muscle contraction) & laryngospasm.

Management:

  • Immediate administration of parenteral anticholinergicsa (benztropine, promethazine or diphenhydraminea).
  • Prevent prophylactic use of oral anticholinergics during typical antipsychotics prescription.

2. Acute akathisia:

  • Commonest side effect of antipsychotics.

Features:

  • Characterized by an inner sense of restlessness along with objective.
  • Observable movements (fidgeting of legs, pacing around, inability to sit or stand in one place for a long time).

Management:

  • Beta-blockers (propranolol DOC)
  • Anticholinergics
  • Benzodiazepines.
  • Prevented by changing to 2nd generation or low potency 1st-generation antipsychotics (lesser incidence of akathisia).

3. Drug induced parkinsonism:

Features:

  • Characterized by triad – Rigidity, bradykinesia & resting tremors.

Management:

  • Anticholinergics.
  • Changing to 2nd gen. antipsychotics or low-potency 1st gen. antipsychotics.
  • Dose reduction can be tried.
  • Prevented by prophylactic anticholinergic use.

4. Tardive dyskinesia:

  • “Tardive” refers to features developing after prolonged exposure.
  • Tardive dyskinesia develops after long-term antipsychotics treatment.

Features:

  • Involuntary movements of tongue (e.g. twisting, protrusion), jaw (e.g. chewing), lips (e.g. smacking, puckering), trunk or extremities.
  • Rapid, jerky movements (choreiform movements) or slow, sinusoid movements (athetoid movements).

Management:

  • Change to 2nd gen. antipsychotics.

5. Neuroleptic malignant syndrome: 

  • Fatal side effect of antipsychotics.

Features: 

  • Characterized by,
    • Muscle rigidity.
    • Elevated temperature (greater than 38°C). Increased CPK (creatine phosphokinase) levels.

Other symptoms: 

  • Diaphoresis, tremors, confusion, autonomic disturbances, liver enzyme elevation & leukocytosis.

Mechanism: 

  • D2 antagonism at various levels.
  • D2 receptors blockade in corpus striatum→ Causes muscle contraction & rigidityInitiating heat generation.
  • Continuing muscle damage→ Result in myoglobinuria & renal failure.
  • D2 receptors blockade in hypothalamus interferes with heat regulation.
  • D2 receptors blockade of spinal neurons causes autonomic disturbances.
    • Increased CPK indicates muscle injury.

Management:

  • Early recognition of symptoms & prompt withdrawal is paramount importance.

Treatment:

  • Skeletal muscle relaxants (dantrolene).
  • Dopamine agonists (amantadine & bromocriptine).

Supportive measures:

  • Adequate hydration.
  • During antipsychotics treatment is restarted – 2nd gen. antipsychotics should be used.

NOTE: ALL EXTRAPYRAMIDAL SIDE EFFECTS ARE ALSO CAUSES BY ATYPICAL ANTI-PSYCHOTICS BUT WITH LESSER INCIDENCE.

Exam Important

  • Extrapyramidal side effects are caused by antipsychotics.
  • Extrapyramidal side effects by antipsychotics are due to dopamine receptor blockade in nigrostriatal tract.
  • Extrapyramidal side effects are more common with high-potency typical antipsychotics (compared to atypical antipsychotics).
  • Types of movement disorders includes acute dystonia, acute akathisia, drug-induced parkinsonism, tardive dyskinesia & neuroleptic malignant syndrome.
  • Acute dystonia is the earliest side effect.
  • Acute dystonia is characterized by torticollis, trismus (contraction of jaw muscles).
  • Immediate administration of parenteral anticholinergicsa (benztropine, promethazine or diphenhydraminea) is used for managing acute dystonia.
  • Acute akathisia is commonest side effect of antipsychotics.
  • Acute akathisia is characterized by observable movements (fidgeting of legs)
  • DOC for acute akathisia is beta-blockers (propranolol).
  • Tardive dyskinesia develops after long-term antipsychotics treatment.
  • Neuroleptic malignant syndrome is a fatal side effect of antipsychotics.
  • Neuroleptic malignant syndrome is characterized by muscle rigidity, elevated temperature (greater than 38°C) & increased CPK (creatine phosphokinase) levels.
  • Skeletal muscle relaxants (dantrolene) is used for management of neuroleptic malignant syndrome.
Don’t Forget to Solve all the previous Year Question asked on EXTRAPYRAMIDAL SIDE EFFECTS

Module Below Start Quiz

Depression – Introduction & Symptoms

DEPRESSION – INTRODUCTION & SYMPTOMS

Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Q. 1

Risk factor for suicide in depression are all EXCEPT:

 A Female
 B Male > 45 
 C Child with conduct disorder
 D Family 
Ans. A

Explanation:

Female REF: Kaplan and sadock’s synopsis in psychiatry 10th ed p. 529

Risk factors of suicide in depression are:

  • At end( involutional) or beginning of depression
  • Mood disorders , personality disorders , psychosis , hypochondriac
  • >45yrs male, unemployed, single, divorced, chronically ill, widowed, recently bereaved
  • Family history

Q. 2

Schizophrenia and depression both have A/E 

 A

Formal thought disorder

 B

Social withdrawal

 C

Poor personal care

 D

Decreased interest in sex

Q. 2

Schizophrenia and depression both have A/E 

 A

Formal thought disorder

 B

Social withdrawal

 C

Poor personal care

 D

Decreased interest in sex

Ans. A

Explanation:

A i.e. Formal thought disorder


Q. 3

Most common age for depression is

 A

Middle age men

 B

Middle age female

 C

Young girl

 D

Children

Q. 3

Most common age for depression is

 A

Middle age men

 B

Middle age female

 C

Young girl

 D

Children

Ans. B

Explanation:

B i.e. Middle age female

Quiz In Between


Q. 4

Neurotransmittors involved in depression are 

 A

GABA and Dopamine

 B

Serotonin and Norepineprine

 C

Serotonin and Dopamine

 D

Norepinephrine and GABA

Q. 4

Neurotransmittors involved in depression are 

 A

GABA and Dopamine

 B

Serotonin and Norepineprine

 C

Serotonin and Dopamine

 D

Norepinephrine and GABA

Ans. B

Explanation:

B i.e. Serotonin & Noradrenaline (Nor epinephrine)


Q. 5

Endogenous Depression is characterized by A/E

 A

Loss of Self esteem

 B

Guilt psychosis

 C

Third person hallucination

 D

Paranoid feeling

Q. 5

Endogenous Depression is characterized by A/E

 A

Loss of Self esteem

 B

Guilt psychosis

 C

Third person hallucination

 D

Paranoid feeling

Ans. C

Explanation:

C i.e. Third person hallucination


Q. 6

Suicide risk is common with which type of depression :

 A

Reactive depression

 B

Endogenous depression

 C

Endogenous depression

 D

All

Q. 6

Suicide risk is common with which type of depression :

 A

Reactive depression

 B

Endogenous depression

 C

Endogenous depression

 D

All

Ans. B

Explanation:

B i.e. Endogenous depression

Quiz In Between


Q. 7

Most common symptom of depression in India is:

March 2011

 A

Low mood

 B

Sleep disturbances

 C

Vague body aches

 D

Suicidal tendencies

Q. 7

Most common symptom of depression in India is:

March 2011

 A

Low mood

 B

Sleep disturbances

 C

Vague body aches

 D

Suicidal tendencies

Ans. C

Explanation:

Ans. C: Vague body aches

Multiple physical symptoms (such as heaviness of head, vague body aches) are particularly common in the elderly depressives and depressed patients from the developing countries (such as India)

Depression:

  • MC psychiatric disorder in India: Depression
  • Neurotransmitter involved: Serotonin and nor-epinephrine
  • MC cause of suicide: Depression
  • Risk features of suicide in depression:

— Endogenous type of depression

— Psychotic depression

  • MC type of post-purpueral psychosis: Depression
  • Nihilistic ideas: Seen in depression

Q. 8

Depression of consciousness level in hypothermia starts when the core body temperature falls below:

COMEDK 14

 A

35°C

 B

34°C

 C

33°C

 D

32°C

Q. 8

Depression of consciousness level in hypothermia starts when the core body temperature falls below:

COMEDK 14

 A

35°C

 B

34°C

 C

33°C

 D

32°C

Ans. D

Explanation:

Ans. 32°C


Q. 9

Major depression is diagnosed after minimum of:

Maharashtra 09

 A

1 week

 B

2 weeks

 C

3 weeks

 D

4 weeks

Q. 9

Major depression is diagnosed after minimum of:

Maharashtra 09

 A

1 week

 B

2 weeks

 C

3 weeks

 D

4 weeks

Ans. B

Explanation:

Ans. 2 weeks

Quiz In Between


Q. 10

The evidence-based psychological therapy of choice for depression is.

 A

Group discussion therapy

 B

Counselling

 C

Cognitive behaviour therapy

 D

Psychological psychotherapy

Q. 10

The evidence-based psychological therapy of choice for depression is.

 A

Group discussion therapy

 B

Counselling

 C

Cognitive behaviour therapy

 D

Psychological psychotherapy

Ans. C

Explanation:

Ans. c. Cognitive behaviour therapy

The evidence-based psychological therapy of choice for depression is cognitive behaviour therapy.

“Cognitive Behavioral Therapy (CBT) developed by Aron Beck, is an extremely useful and evidence based non pharmacological intervention for depression. This therapy involves identification of the cognitive errors (thinking errors) in an individual and replacing the same with alternative thoughts, which are more adaptive and healthy in nature. It is most useful in patients suffering from mild to moderate depression.”- Kaplan and Sadock 10/e pe p553

Cognitive (Behaviour) Therapy

  • It was developed by Beck and Meichenbaum, for the treatment of depression°, anxiety disorder°, panic disorder°, phobias°, eating disorders°, anticipatory anxiety°, and also for teaching problem solving skills° (methods).
  • It involves:
  • Cognitive techniques (e.g. recognizing and correcting negative thoughts, teaching reattribution techniques, increasing objectivity in perceptives, identifying and testing maladaptive assumptions, and decentering) Behaviour techniques (activity scheduling, homework assignment, graded task assignment, behavioral rehearsal, role playing, and diversion technique)

Q. 11

Treatment for unipolar depression is ‑

 A

Fluoxetine

 B

Sertaline

 C

Citaloprom

 D

All of the above

Q. 11

Treatment for unipolar depression is ‑

 A

Fluoxetine

 B

Sertaline

 C

Citaloprom

 D

All of the above

Ans. D

Explanation:

Ans. is ‘d’ i.e., All of the above

  • All the given drugs are SSRI antidepressants.

Antidepressants

  • Typical

a. Tricyclic antidepressants

  1. NA + 5HT reuptake inhibitors:- Imipramine, Trimipramine, Amitriptyline, Clomipramine.
  2. Predominantly NA reuptake inhibitors:- Desipramine, Nortriptyline, Amoxapine, Reboxetine.

b. Selective serotonin reuptake inhibitors:- Fluoxetine, Paroxetine, Sertaline, Citalopram, Scitalopram.

B. Atypical :- Trazodone, Mianserine, Mitrazapine, Venalafaxin, Duloxetine, Tianeptine, Amineptine, Bupropion.

C. MAO inhibitors :Tranylcypramine, Meclobemide, Clorgyline


Q. 12

All are required to diagnose major depression except ‑

 A

Depressed mood

 B

Isomnia

 C

Nihlistic ideas

 D

Decreased concentration

Q. 12

All are required to diagnose major depression except ‑

 A

Depressed mood

 B

Isomnia

 C

Nihlistic ideas

 D

Decreased concentration

Ans. C

Explanation:

Ans. is ‘c’ i.e., Nihlistic ideas

Diagnostic criteria for major depression

  • 5 or more of following symptoms should be present most of the day for at least 2 weeks: ‑
  1. Depressed mood
  2. Loss of interest or pleasure in all activities.
  3. Decrease/increase appetite or loss/gain of weight.
  4. Insomnia or hypersomnia (Increased or decreased sleep).
  5. Psychomotor retardation or agitation (decreased or increased psychomotor activity).
  6. Fatigue or loss of energy (weakness or lethargy).
  7. Feelings of worthlessness or excessive guilt.
  8. Diminished concentration
  9. Recurrent thoughts of death or recurrent suicidal ideation or suicidal attempt.
  • At least one of symptoms should be either :‑
  1. Depressed mood or 2) Loss of interest or pleasure —) These two (1 & 2) are essential criteria. Therefore 1 essential criterian and 4 other criteria (total 5) should be persent.

Quiz In Between


Q. 13

Classical triad of symptoms of depression includes all except ‑

 A

Depressed mood

 B

Slowed thinking

 C

Distractibility

 D

Psychomotor retardation

Q. 13

Classical triad of symptoms of depression includes all except ‑

 A

Depressed mood

 B

Slowed thinking

 C

Distractibility

 D

Psychomotor retardation

Ans. C

Explanation:

Ans. is ‘c’ i.e., Distractibility

Clinical features of depression

  • The classical triad of depression is depressed mood, psychomotor retardation, and slowed-down thinking.
  1. Mood : Mood is characteriztically low and sad. There is loss of interest and pleasure in almost all activities, which result in social withdrawal, avolition,occupational dysfunction. In severe cases there may be anhedonia (inability to experience pleasure).
  2. Thoughts (Thinking) : – Pesimistic thoughts conerning the patients past, present and future occur which results in Hopelessness, Helplessness, and worthlessness. Other thought problems may be guilt-feeling, Loss of self esteem, Suicidal ideas, Delusion of nihlism (World has come to an end, Intestines has been rotated away, No brain in head), Hypochondriacal delusions [Patient believes that he has severe (cancer) or incurable disease (eg. AIDS)]. Other delusions that may occur in elderly include paranoid or persecutory delusion, and delusional jealousy.
  3.  Psychomotor activity : – There is psychomotor retardation —> Movements are sluggish & laboured, lack of initiative & energy, Easy fatiguability. In severe form, the patient becomes stuporous (depressive stupor). In older patient there may be agitation and restlessness.
  4. Cognition : – There is poor concentration, which may lead the patient to think (mistakenly) that the memory is also impaired (However, memory is normal). In old patients depression may present similar to dementia, i.e., Pseudodementia.
  5. Somatic symptoms & biological disturbances : – Multiple physical symptoms are common in elderly patient. Symptoms include heaviness of head, generalized ache & pain, Loss of sexual drive and amenorrhea, severe disturbance in biological function is called somatic syndrome (melancholia). Somatic syndrome (melanocholia) is characterized by :-
  • Decrease in appetite or weight
  • Early morning awakening, at least 2 hours before usual time.
  • Diurnal variation, depession is worse in morning
  • Loss of interest and loss of reactivity to pleasurable stimuli, and loss of pleasure in all activities.
  • Psychomotor agitation or retardation.
  • Excessive or inappropriate guilt.

6. Psychotic symptoms (Psychotic depression) : – Occur in 15-20% of patients. Symptoms include 2″a person auditory hallucinations, delusions, grossly inappropriate behavior. These symptoms may be mood congruent (e.g., nihilistic delusions, delusions of poverty or guilt) which are understandable in the light of depressed mood or can be mood incongruent (e.g., delusion of control) which are not directly related to depressive mood. Psychotic depression usually occur later in life and is associated with severe depression.


Q. 14

Intense depression & misery without any cause is?

 A

Melancholia

 B

Major depressive disorder

 C

Mania

 D

Schizophrenia

Q. 14

Intense depression & misery without any cause is?

 A

Melancholia

 B

Major depressive disorder

 C

Mania

 D

Schizophrenia

Ans. A

Explanation:

Ans:A. Melancholia


Q. 15

Depression is associated with which of the following neurological condition ‑

 A

Cerebro-vascular disorder

 B

Multiple sclerosis

 C

Epilepsy

 D

None of the above

Q. 15

Depression is associated with which of the following neurological condition ‑

 A

Cerebro-vascular disorder

 B

Multiple sclerosis

 C

Epilepsy

 D

None of the above

Ans. A

Explanation:

Ans. is ‘a’ i.e. Cerebro-vascular disorder

[Ref: Oxford Textbook of Stroke and Cerebrovascular Disease p. 2461]

important causes of depression

  • General medical/neurological/endocrine disorders: – Cerebrovascular disorders, CNS infection, Parkinson’s disease, Dementia (Alzheimer’s disease), Hyperthyroidism, Hypothyroidism,Cushing’s disease or Addison’s disease, Hypopituitarism, Acromegaly, Hyperparathyroidism, Hypoparathyroidism, Postpartum period, Menses related disorders, Cancer, Tuberculosis

Quiz In Between


Q. 16

Beck’s cognitive triad of depression includes :

 A

Self

 B

Future

 C

Past experience

 D

World and environment 

Q. 16

Beck’s cognitive triad of depression includes :

 A

Self

 B

Future

 C

Past experience

 D

World and environment 

Ans. A:B:D

Explanation:

Ans. A,Self B,Future & D,World and environment 

  • Aaron Beck postulated a cognitive triad of depression.

Consists of,

  • Views about tlw self-a negative self precept.
  • About environment-a tendency to experience the world as hostile and.demanding.
  • About future – expectation of suffering and failure.

Therapy consists of modifying these distortions.

  • Cognitive triad :Beliefs about oneself, the world, and the future.

Q. 17

Essential criteria for major depression are all except –

 A

Delusion of grandeur

 B

Loss of pleasure

 C

Insomnia

 D

Hypersomnia

Q. 17

Essential criteria for major depression are all except –

 A

Delusion of grandeur

 B

Loss of pleasure

 C

Insomnia

 D

Hypersomnia

Ans. A

Explanation:

Ans. A. Delusion of grandeur

[Ref Niraj Ahaia p. 7l-72; Keplarn and Sadsck  p. 357]

Diagnostic criteria for major depression

  • 5 or more of the following symptoms should be present most of the day for at least 2 weeks: –
  • Depressed mood
  • Loss of interest or pleasure in all activities.
  • Decrease/increase appetite or loss/gain of weight.
  • Insomnia or hypersomnia (Increased or decreased sleep).
  • Psychomotor retardation or agitation (decreased or increased psychomotor activity).
  • Fatigue or loss of energy (weakness or lethargy).
  • Feelings of worthlessness or excessive guilt.
  • Diminished concentration
  • Recurrent thoughts of death or recurrent suicidal ideation or suicidal attempt.

Quiz In Between



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