Organic Psychiatry Flashcards
A man is admitted to accident and emergency after being found semi-conscious
in the street. He is unkempt and does not have any information on his person; he
appears to be street homeless. In accident and emergency he has a tonic clonic
seizure which is self-limiting after 3 minutes. The man is post-ictal for a short
time but soon becomes restless, tremulous and sweaty. His speech is rambling,
and he complains about the bed sheets being filthy and ‘filled with mites’. He
is tachycardic with a blood pressure of 186/114mmHg. What is the most likely
diagnosis?
A. Alcoholic hallucinosis
B. Delirium tremens
C. Cocaine withdrawal
D. Diabetic ketoacidosis
E. Opiate overdose
B. Delirium tremens
Delirium tremens (B) is a syndrome caused by alcohol withdrawal in
patients with a long history of alcohol consumption, or more likely alcohol
dependence. It is a medical emergency and is characterized by autonomic
instability, nausea and vomiting, altered mental state (‘delirium’), tremor
(‘tremens’), and sometimes seizures. The first symptoms usually appear
within 6–12 hours of the last drink and peak at around 24–48 hours.
Patients may also complain of hallucinations, usually visual, which take
the form of seeing small insects. Note, this is not the same as formication,
which technically is the physical sensation of feeling insects crawling
over one’s skin. This is commonly seen in cocaine intoxication, but rarely
can also be seen in cocaine withdrawal (C). However, cocaine withdrawal
is not usually associated with autonomic instability or fitting. Alcoholic
hallucinosis (A) is a syndrome also caused by withdrawal from alcohol in
those dependent on it. Hallucinosis can also occur in those that continue
to drink, although this is rarer. Alcoholic hallucinosis is sometimes taken
to mean a relatively rare condition where verbal auditory hallucinations
occur alone and in clear consciousness, and is often mistaken for
schizophrenia. Whichever definition is taken, the presence of autonomic
instability and fits would rule out alcoholic hallucinosis. Diabetic
ketoacidosis (D) may present with confusion, although sweating would
be uncommon. Patients may complain of severe thirst, and possibly chest
or abdominal pain. On examination, patients will appear dehydrated and
may have a distinctive smell of ketones on the breath. Fits would be
relatively uncommon compared to a decreased level of consciousness.
Opiate overdose (E) would not present in this way – patients would
exhibit respiratory and central nervous system depression.
You order a full set of bloods on this man. Which of the following results would
be most indicative of the underlying cause of his delirium?
A. Elevated serum glucose
B. Elevated serum potassium
C. Low mean corpuscular volume (MCV)
D. Low serum vitamin B12
E. Raised platelets
D. Low serum vitamin B12
This question relates to the likely blood results in chronic alcohol misuse.
Chronic alcohol dependence is associated with vitamin B12 deficiency
(D), both as a result of poor nutritional intake and a direct toxic effect
of alcohol on bone marrow. B12 is involved in DNA synthesis and this
leads to an impairment in erythrocyte metabolism, resulting in larger cell
volumes before they divide. This will be evident on a full blood count
with a raised, not lowered, MCV (C). Other effects of alcohol on blood
and blood chemistry include a decrease in platelet count, known as
thrombocytopenia, as opposed to thrombocytosis (raised platelet count)
(E). This results from both vitamin deficiency (B12/folate) and again
a direct toxic effect of alcohol. The low platelet count is not usually
symptomatic. Alcohol is also generally associated with hypoglycaemia
as opposed to hyperglycaemia (A), although the latter can also occur.
Therefore, serum glucose would be less helpful in diagnosing chronic
alcohol abuse. Alcohol also causes hypokalaemia as opposed to
hyperkalaemia (B). There may be numerous causes for this, such as
decreased intake through poor nutrition or vomiting, but it is also thought
to occur through decreased tubular reabsorption of potassium secondary
to a low magnesium level.
A 73-year-old woman is admitted to hospital with an infective exacerbation of
chronic obstructive pulmonary disease (COPD). Apart from COPD and hypertension
she has no other medical problems. On the third day of her admission, she becomes
acutely confused. During the night she is awake, shouting constantly for her
husband, claiming that the nurses are prison guards and that they are keeping her
against her will. She is slightly calmer the day after. You are the FY1 on call and
are asked to come and see her over the weekend as the nurses are worried it will
happen again at night. What should your initial management be?
A. Prescribe clozapine 25mg bd regularly
B. Prescribe haloperidol 2mg intravenously immediately
C. Prescribe lorazepam 0.5mg orally just before bedtime
D. Prescribe lorazepam 0.5mg orally twice daily regularly
E. Prescribe nothing at this stage
E. Prescribe nothing at this stage
This is a clear case of delirium, or acute confusional state characterized
by a recognized causative factor (infection), older age and fluctuating
confusion. Acute confusional states are extremely common in medical
inpatients (perhaps in the region of 30 per cent of those over 65 in
hospital). It is extremely important that it is managed well – while it has
traditionally been considered a transient syndrome with no sequelae,
there is growing evidence that delirium leads to increased psychiatric
and physical morbidity. When managing delirium, the first steps should
be conservative (E) unless the patient is putting themselves or others at
significant risk of harm. While this scenario is distressing (at least for the
nursing staff), there is no evidence that this is the case. Therefore, initially
patients should be treated with intensive nursing interventions. These may
include nursing the patient in a side room, keeping lighting appropriate
to the time of day, repeated reassurance, the use of prominently visible
clocks to orient the patient. Only if the patient continues to become
very distressed should medication be considered.
Which of the following medications is most likely to be associated with an organic
depressive disorder?
A. Prednisolone
B. Sertraline
C. Thyroxine
D. Tramadol
E. Tryptophan
A. Prednisolone
Prednisolone (A) is a corticosteroid with numerous uses, including
autoimmune and inflammatory disorders. It has long been observed
that corticosteroids can cause psychiatric side effects. While this is most
commonly thought of as mania (‘steroid psychosis’), they also may cause
depressive disorders. Mania is probably more common than depression,
but the two may coexist. Depression may result from the acute use,
chronic use or discontinuation of corticosteroids. This is thought to be
mediated by the hypothalamo-pituitary adrenal axis, which has a complex
but undoubted role in the regulation of mood – depression is commonly
seen in Cushing’s disease, probably as a direct result of a state of chronic
hypercortisolism. Sertraline (B) is a selective serotonin reuptake inhibitor
(SSRI), the most commonly prescribed class of antidepressants. There has
been widespread debate about whether SSRIs cause an increase in suicidal
thoughts. The NICE guidelines on depression indicate that there may be
a small increase in suicidality in the very early stages of antidepressant
use
A 27-year-old man is involved in a road traffic accident. During rehabilitation
his family have become very upset as they feel he has ‘changed’. They report
that his concentration is poor and at times he is saying very hurtful things to his
wife, which they say is extremely out of character. He has also begun eating large
quantities of junk food, whereas before he was extremely fit and careful with his
diet. Which part of the brain is most likely to have suffered an injury?
A. Basal ganglia
B. Frontal lobe
C. Limbic structures
D. Parietal lobe
E. Occipital lobe
B. Frontal lobe
This man is exhibiting signs consistent with a frontal lobe (B) injury, and
more specifically an orbitofrontal insult. The frontal lobe is extremely
vulnerable in traumatic brain injury. Frontal lobe syndromes can take
many forms, but often involve changes in personality including:
- Inappropriate or ‘fatuous’ affect
- Lability and irritability of mood
- Hypersexuality
- Hyperphagia, or overeating
- ‘Childishness’ or prankish joking (known as ‘Witzelsucht’)
There is usually no insight into this change in behaviour. Other
changes include poor concentration and ‘forced utilization’ – a strange
phenomenon when patients will use objects they see in front of them
irrespective of whether they need to use them or not, e.g. patients may
get undressed and go to bed on entering a bedroom in the middle of the
day despite not being tired. There may also be the emergence of primitive
reflexes, such as the grasp reflex.
A 28-year-old woman is admitted to hospital systemically very unwell, with
a reduced level of consciousness, headache, fever, nausea and vomiting and
dysphasia. This is followed by several seizures. Initial cerebrospinal fluid (CSF)
analysis shows the CSF is clear, with raised protein, raised mononuclear cell count,
no polymorphs and normal glucose. Her partner says that for the preceding few
days she had been acting strangely, seeing things that were not there, accusing him
of leaving the gas on and getting very agitated. She then became drowsy and he
called the ambulance. Your initial management should be based on which being
the most likely diagnosis?
A. Bacterial meningitis
B. Herpes simplex encephalitis
C. Neuropsyphilis
D. Sporadic Creutzfeld–Jakob disease (CJD)
E. Temporal lobe epilepsy
B. Herpes simplex encephalitis
While there are no pathognomonic features of herpes simplex virus
(HSV) encephalitis (B), the clinical history is strongly suggestive of
an encephalitic picture. It is important to have an extremely low
threshold for treating presumed HSV encephalitis, in part because if
left untreated there is an extremely high (approximately 70 per cent)
mortality rate, and the treatment (intravenous aciclovir) is relatively
non-toxic. HSV encephalitis nearly always targets the temporal lobes
and orbitofrontal structures. This is the most likely explanation for
the preponderance of unusual behaviour or psychotic symptoms in the
early stages of the illness, as can be seen here. The woman accusing her
partner of leaving the gas on is most likely an olfactory hallucination,
which are common in temporal lobe disorders. The rapidly advancing
neurological signs indicate a generalizing cerebral infection. The
CSF analysis is also typical of viral encephalitis (or meningitis) –
showing markedly raised protein, normal or slightly low glucose, a
clear appearance and a preponderance of mononuclear cells
A 76-year-old man with squamous cell lung carcinoma attends accident and
emergency with his wife who is his full-time carer. She has become concerned as
he has become extremely depressed over the last couple of weeks, along with being
extremely thirsty and having little energy. Up until then he was coping very well
with his diagnosis. What is the most likely cause of these symptoms?
A. Hypercalcaemia
B. Hypocalcaemia
C. Hyperkalaemia
D. Hypokalaemia
E. Hypophosphataemia
A. Hypercalcaemia
Hypercalcaemia (A) is a common complication of squamous cell
carcinoma. The likely cause of this is due to the tumour releasing
large amounts of parathyroid-related peptide leading to increased bone
turnover. There may also be direct bone destruction from tumour invasion.
Hypercalcaemia typically results in the classic syndrome of ‘stones’ (kidney
stones), ‘bones’ (bone pain), ‘groans’ (constipation), ‘psychic moans’
(depression, aesthenia, confusion). Thirst is also a common symptom
exacerbated by osmotic diuresis, as are nausea, vomiting and anorexia.
If depression is the main presenting feature, it is extremely important to
rule out metabolic disturbances in patients with cancer. Do not assume
that the depression is a psychological reaction to the diagnosis of cancer
(although of course this is also extremely possible) – hypercalcaemia
is very correctable and symptoms will reduce quickly as the calcium
level drops.
A 14-year-old boy, with no prior psychiatric or medical history, is noted to be
seriously slipping in his A-level course work, after previously being a ‘Grade A’
student. He has also started behaving recklessly, going out late whereas previously
he had been shy with few friends. He is getting into frequent fights at school. Other
changes include the onset of tremor and strange writhing movements in his arms.
His mother has also noticed that his skin appears to have taken on a yellow tinge.
What is the most likely diagnosis?
A. Huntington’s disease
B. Multiple sclerosis
C. Multiple system atrophy
D. Wilson’s disease
E. Young-onset Parkinson’s disease
D. Wilson’s disease
Wilson’s disease (D), also known as hepatolenticular degeneration, is a
rare autosomal recessive disorder of copper metabolism. The mutation
(of which there are over 200 described) occurs in a gene on chromosome
13q (designated ATP7B), which encodes for a protein that is responsible
for transporting copper for excretion in bile. Dysfunction of this protein
therefore leads to copper accumulation in numerous tissues in the body,
particularly the liver (causing jaundice) and the nervous system. Another
extremely suggestive feature is the presence of Kayser–Fleischer rings,
which are greenish-gold or brownish rings in the cornea resulting
from copper deposition. Note that Kayser–Fleischer rings are now no
longer thought of as purely pathognomonic of Wilson’s disease as
they may occur in other disorders such as primary biliary cirrhosis.
Neuropsychiatric consequences of Wilson’s disease include aggression,
reckless behaviour, disinhibition and sometimes self-harming behaviours.
There are also prominent neurological symptoms, including the ones
detailed above.
Which of the following is the most common psychiatric manifestation following
stroke?
A. Anxiety symptoms
B. Delusions
C. Depressive symptoms
D. Hallucinations
E. Obsessive–compulsive (OCD) symptoms
C. Depressive symptoms
Depression (C) is extremely common in stroke, with estimates in the
literature of a prevalence of either early or late depression at 1/3. This is
higher than would be expected as a result of chronic disease alone and
suggests some causative mechanism of the disease process itself. Of course,
many of the symptoms of stroke may make the diagnosis more difficult
(e.g. apathy, emotional lability, poor concentration). Equally, depression
may easily be missed in aphasic patients, who will be particularly at risk
because of the added isolation of being unable to communicate. There
is of course now growing evidence about the phenomenon of ‘vascular
depression’, in which depressive disorders are thought to be directly related
to accumulative cerebrovascular disease rather than clinically significant
or recognized episodes of stroke. Psychotic disorders, including the
experience of delusions (B) or hallucinations (D), have been less studied
than depression in stroke patients. However, they are thought to occur in
approximately 1–2 per cent of stroke sufferers. In patients with co-morbid
dementia, care must be taken when deciding on management of psychosis
in stroke given the association of antipsychotics with increased risk
of death in these patients. Anxiety symptoms (A) are common, and a
generalized anxiety disorder may be seen in up to one-quarter of patients.
Obsessive–compulsive symptoms (E) in stroke have not been particularly
well studied, in part because anecdotally they are rare.
A 38-year-old man is admitted with a several week history of rapidly deteriorating
memory, which he covered to some extent with extensive confabulation. He was
also found to be sleeping, drinking and eating excessively. On examination he
was pyrexial. His blood work showed a markedly raised serum osmolality. An MRI
shows an intracranial mass. Where is the most likely anatomical location for this
lesion?
A. Around the third ventricle
B. Cerebellum
C. Corpus callosum
D. Frontal lobe
E. Pons
A. Around the third ventricle
A The symptoms of amnesia and confabulation are very typical of tumours
involving the wall or floor of the third ventricle (A). Structures around this
region include the thalamus and hypothalamus, which would also explain
the other symptoms of hypersomnia, hyperphagia, pyrexia and polydipsia.
The raised serum osmolality points to cranial diabetes insipidus secondary
to tumour effects on the hypothalamus
A 34-year-old woman presents to accident and emergency claiming that the
devil has returned to earth and is hunting her through her neighbours, who are
recording her every movement. The psychiatric assessment shows florid delusions
and auditory hallucinations. She has no past psychiatric history. Her husband tells
you that she was fine up until 2 weeks ago. Her hands have also been shaking
and she has complained that the devil has been torturing her muscles. She has
widespread lymphadenopathy and an enlarged spleen. An unusual rash is present
across her cheeks and nose, which she says is the brand of the devil. What is the
most likely diagnosis?
A. Behçet’s disease
B. CREST syndrome
C. Graves’ disease
D. Systemic lupus erythematosus (SLE)
E. Wegener’s granulomatosis
D. Systemic lupus erythematosus (SLE)
SLE (D) is an autoimmune connective tissue disorder that may affect any
organ in the body. It commonly presents in women (9:1 female to male
ratio), usually in the third or fourth decades. Neuropsychiatric symptoms
may occur at the beginning of the natural course of the disorder,
without any seeming involvement of other organ systems. Unexplained
psychotic symptoms, which may closely resemble schizophrenia, may
occur, as may a dementia-like illness or affective disorders. This woman
is also displaying neurological signs, making a diagnosis of a functional
psychiatric disorder unlikely. The presence of Parkinsonism, widespread
muscle pain, lymphadenopathy and splenomegaly are all consistent
with the diagnosis. The ‘malar rash’, which is highly indicative of SLE,
is present in this woman but its absence does not negate the diagnosis.
Which of the following vitamin deficiencies is most likely to lead to a triad of
gastrointestinal disturbance, dermatological symptoms and a heterogeneous
constellation of psychiatric symptoms?
A. Niacin
B. Vitamin A
C. Vitamin B1
D. Vitamin C
E. Vitamin D
A. Niacin
Nicotinic acid, or niacin, deficiency (A) is also known as pellagra.
It classically manifests with gastrointestinal symptoms, such as
diarrhoea, anorexia and gastritis. The dermatological manifestations
include symmetrical, bilateral bullous lesions in sun-exposed areas.
The psychiatric symptoms initially manifest as apathy, depression, or
irritability. However, in later stages there are more florid symptoms
resembling delirium, psychosis or a Korsakoff-like presentation. If
identified, treatment with nicotinic acid usually leads to prompt and
dramatic improvements in mental state.
Which of the following statements regarding neuropsychiatric manifestations of
epilepsy is correct?
A. Automatisms in epilepsy are usually pre-ictal
B. Epilepsy is usually associated with enduring personality
difficulties
C. Psychosis is negatively correlated with epilepsy
D. Rates of suicide are higher in people with epilepsy than
people not
suffering with epilepsy
E. Temporal lobe epilepsy is usually associated with tonic clonic seizures
D. Rates of suicide are higher in people with epilepsy than
people not
suffering with epilepsy
Epilepsy has numerous and complex neuropsychiatric and psychological
interactions. It is undoubted that rates of suicide are higher in people
with epilepsy (D) than the general population. However, the degree of the
association is not clear. Similar risk factors appear to exist for suicide in
people with epilepsy than in the general population, such as co-morbid
psychiatric illness (which is also over-represented in people with epilepsy).
Epilepsy is not usually associated with enduring personality difficulties
(B). Automatisms (A) are unusual and sometimes complex repetitive
motor activities observed in nearly all forms of epilepsy, but commonly
associated with complex partial seizures (such as temporal lobe epilepsy).
They are nearly always observed during a seizure (ictal) or in the postseizure
delirium (post-ictal). Psychotic symptoms are positively correlated
with epilepsy (C). This is particularly true of temporal lobe epilepsy, but
probably is also over-represented in other types of epilepsy. Temporal
lobe epilepsy (E) is associated with psychological and psychiatric
symptoms such as aura, sensory disturbances and depersonalization or
derealization. Unusual symptoms such as déjà vu or jamais vu may also
occur.
Which of the following regarding early-onset dementia (or young-onset dementia
(YOD)) is correct?
A. Alzheimer’s disease in younger patients is not associated with a family
history
B. Alzheimer’s disease is an uncommon cause of YOD
C. Dementia is under-represented in Down’s syndrome
D. Pick’s disease is classically associated with personality changes
E. YOD is usually caused by prion diseases
D. Pick’s disease is classically associated with personality changes
Pick’s disease (D) is a relatively uncommon dementia, classified as one of
the frontotemporal dementias. It commonly presents in the sixth decade
of life, e.g. earlier than the typical onset of other neurodegenerative
disorders such as Alzheimer’s disease. Because of its predilection for
frontal and anterior temporal parts of the brain, it tends to present with
changes in behaviour and personality before amnesic symptoms are
obvious. This can lead to devastating consequences for those affected
and their families. Alzheimer’s disease in younger people ((A) and (B)) is
often associated with specific familial inherited genetic mutations. There
are numerous mutations, affecting the APP gene on chromosome 21 and
the presenelin 1 and 2 genes on chromosomes 14 and 1, respectively.
Alzheimer’s disease is still the major cause of YOD. Down’s syndrome
(C) confers a much greater risk of dementia, with a prevalence estimated
at around 50 per cent of those with Down’s syndrome in those aged 60
or above. Prion diseases (E) are certainly a cause of YOD, usually with a
rapid clinical course. However, they are still rare, probably accounting for
only about 1.5 per cent of the total of cases of YOD.
A 19-year-old white woman presents to accident and emergency with abdominal
pain, arm weakness and diminished reflexes. She is also extremely agitated and is
responding to auditory hallucinations. You are unable to get a history from her,
and you call her GP – there is little of note in her history, although she has only
been in the practice for a few months as she is a first year student. The only recent
entry is a new prescription for the oral contraceptive pill (OCP). What is the most
likely diagnosis?
A. Acromegaly
B. Acute intermittent porphyria
C. Diabetic ketoacidosis
D. Heroin intoxication
E. Sickle cell anaemia
B. Acute intermittent porphyria
The features described are typical of acute intermittent porphyria (B),
a relatively rare autosomal dominant inherited disorder, typically
presenting in the second to fourth decades. It is a disorder of haem
metabolism resulting in a build up of porphyrins and their precursors.
Attacks are usually precipitated by one of a number of factors, including
menstruation, alcohol, poor nutrition and certain drugs, such as the OCP.
Porphyria can often be mistakenly diagnosed as a primary psychiatric
disorder. Abdominal pain in any patient with psychiatric symptoms
should always prompt further investigation. Acromegaly (A) is a disorder
caused by increased growth hormone secretion, usually by a growth
hormone-secreting tumour of the pituitary. It would usually present
slightly later than adolescence/early adulthood. There are no psychiatric
disorders commonly associated with this condition. Diabetic ketoacidosis
(C) could present with abdominal pain but peripheral neuropathy would
be unusual in a person of this age. Psychosis itself would also be
uncommon, although of course confusion and clouding of consciousness
are very highly associated with ketoacidosis. Heroin intoxication (D)
would not present in this way. Opiate withdrawal may present with
abdominal cramps and muscle aches, but frank weakness and changes
in reflexes would be uncommon. Sickle cell anaemia (E) often does
present with abdominal crises. However, it would be very rare in a white
individual and would normally have presented long before the age of 19.
Vaso-occlusion causes widespread and numerous symptoms, including
stroke, but the picture here does not fit that of sickle cell disease.
