Chapter 9. Depression and Psychosis in Neurological Practice

Question 1

Question 9-1:
Which of the psychiatric term definitions is Incorrect?
A. Abulia - keduced impulse to act and think associated with indifference about consequences of action
B. Delusion - Sensory misperception in the absence of an external stimulus
C. Dementia - Progressive mental decline which interferes with activities of daily living
D. Apathy - Dulled emotional tone with detachment or indifference

Answer 1

Answer 9-1: B.
Delusion is a false conviction or judgment
which is not in keeping with reality. The
definition given is the definition of
hallucination. Abulia and apathy seem similar
but are different, though they may coexist.
(p104)

Question 2

Questions 9-2:
Which of the following clinical features of psychiatric symptoms suggests a neurologic
rather than a primary psychiatric disorder?
A. More rapid improvement with therapy than is nonnally clinically seen
B. Late age of onset without a prior psychiatric history
C. Multiple psychosocial stressors
D. Slow-gradual progression
E. All of the above

Answer 2

Answer 9-2: B.
Late age of onset without prior psychiatric
history suggests that the psychiatric symptoms
may be due to an underlying neurologic
disease. Other indicators are lack of stressors
which would precipitate the psychiatric
disorder, acute or subacute onset, and failure
to improve with typical therapy. (p105)

Question 3

Question 9-3:
Which of the following statements is true regarding HlV associated dementia (HAD)?
A. Patients present as a cortical dementia
B. Psychotic symptoms are much less common than in other causes of dementia
C. More than 50% of HIV patients show HAD at autopsy
D. Development of HAD has no effect on prognosis
E. All are true

Answer 3

Answer 9-3: C.
More than 50% of patients with HIV show
signs of HAD al autopsy. Psychotic and
affective symptoms are very common, with
delusions. hallucinations. apathy. and major
depression being potential clinical
manifestations. Patients present with signs of
a subcortical dementia, including apathy,
bradyphenia, memory decline, and impaired
concentration.

Question 4

Question 9-4:
Which of the following psychiatric manifestations is most likely in a patient in the early stages of new variant Creutzfeldt-lakob disease?
A. Suicidal ideation
B. Obsessive features
C. Panic attacks
D. Irritability

Answer 4

Answer 9-4: D.
Irritability and anxiety are among the most
conunon early psychiatric symptoms of .
nvCJD, along with withdrawal. insomnia,
dysphoria, and loss of interest. With .
progression to later stages, cognitive decline,
aggression. and agitation are prominent.
(p108)

Question 5

Question 9-5:
Which of the following degenerative conditions is not associated with an increased incidence of psychiatric
conditions?
A. Frontotemporal dementia
B. Progressive supranuclear palsy
C. Corticobasal degeneration
D. Idiopathic basal ganglia calcifications
E. All are associated with psychiatric symptoms

Answer 5

Answer 9-5: E,
All of these are associated with increased
incidence of psychiatric conditions. The
surprise for most of us from this list is
idiopathic basal ganglia calcification. (p107).

Question 6

Question 9-6:
Which of the following are clinical features of acute
intermittent porph)na?
1. Abdominal pain
2. Peripheral neuropathy
3. Seizures
4. Hanucinations
Select: A= 1,2,3. B= 1,3. C=2,4. D= 4 only. E=AII

Answer 6

Answer 9-6: E.
All of these are clinical features of AlP.
Hallucinations are only one of the
neuropsychiatric findings; including
depression, delusions, anxiety, and confusion.
Not all of the features are seen in all patients,
however, it is unusual to have
neuropsychiatric manifestations without
peripheral neuropathy or abdominal
complaints. (p110)

Question 7

Questions 9-7:
Which of the following statements regarding cancer and psychiatric complications is not true?
A. It is rare for a patient to present with a primary psychiatric diagnosis and be found to have a brain tumor
B. Single CNS metastases rarely have neuropsychiatric implications, whereas multiple lesions commonly present with neuropsychiatric symptoms
C. Supratentorial lesions are more likely than infratentorial lesions to produce neuropsychiatric symptoms
D. The most common cancers to produce paraneoplastic syndromes are ovarian and small – cell cancer

Answer 7

Answer 9-7: B.
Neuropsychiatric symptoms are common with
solitary mass lesions, with a clinical
presentation which depends on the location.
Less than 5% of patients with primary
psychiatric diagnosis are found to have a brain
tumor. Supratentorial lesions are more likely
to produce neuropsychiatric manifestations
whereas infratentoriallesions are more likely
to produce focal deficits. Ovarian and small
cell lung cancer are the most likely to produce
a paraneoplastic syndrome; neurologic
symptoms may develop before the cancer is
diagnosed. (p110-111)

Question 8

Questions 9-8:
A 48-year-old woman presents with a history of several years of depression requiring antidepressants, though the response to treatment is unimpressive. She presents to the neurologist
after a seizure. Examination is normal except for depression, mild memory loss, and anosmia. Which is the most likely diagnosis?
A. Bifrontal infarction
B. Olfactory-groove meningioma
C. Metastatic breast cancer
D. Limbic encephalitis

Answer 8

Answer 9-8: B.
This is a typical clinical presentation of an
olfactory-groove meningioma. Patients
present with chronic depression and may
subsequently develop seizures, or other signs
of frontal lobe dysfunction. The clinical
presentation is too slow for metastatic breast
cancer or limbic encephalitis, unless the
depression was unrelated. Bifrontal infarction
would be expected to produce a more acute
development of symptoms as well. (p 111)

Question 9

Question 9-9:
Differentiation of dementia such as Alzheimer’s disease from depression-related cognitive impairment (ORCI) is an important clinical task. Which of the following statements regarding differentiation is not correct?
A. Patients with ORCI usually have normal bedside mental starus exam whereas memory deficit is evident in most patients with AD
B. Patients with ORCI are more likely to complain of memory problerns than patients with AD
C. Patients with ORCI have difficulty with attention whereas recognition is preserved; whereas in AD there are problems with recognition and attention may be normal
D. Language is preserved in DRCI whereas it is usually abnormal in patients with AD
E. All are correct

Answer 9

Answer 9-9: E.
All of these are differentiating features between AD and DRCI. Although patients with DRCI complain of memory difficulty, on formal testing, they fall down mainly in attentional tasks, and do better in recognition tasks. In contrast, patients with AD frequently do not complain of memory loss, though some do have insight into their cognitive difficulty,
and do better on attentional tasks than
recognition tasks. (P114)

Question 10

Question 9-10:
Management of psychiatric symptoms in patients with neurologic conditions is difficult because of interactions of the medications with their neurologic conditions. Which of the following are important considerations for therapy in these
patients?
A. SSRIs are used more than tricyclic antidepressants for depression in dementia Atypical neuroleptics are used more commonly than typical neuroleptics for patients with parkinsonism
C. Anticholinergic drugs should be avoided in patients with dementia
D. All are true

Answer 10

Answer 9-10: D.
All of these are hUe. SSRls are preferred for
depression with dementia since the anticholinergic properties of the tricyclics and some other drugs exacerbate the dementia. Atypical neuroleptics are preferred for patients with psychosis and parkinsonism, since typical neuroleptics may exacerbate the
movement disorder, producing increased
rigidity. (p 115)