Otras terapias somaticas Flashcards
22.1.
What type of seizure activity must be induced to be
therapeutically effective in electroconvulsive therapy (ECT)?
A. Absence
B. Partial simple
C. Partial complex
D. Generalized
22.1. D. Generalized
The induction of a generalized seizure is necessary to obtain the
beneficial effects of ECT. Bilateral seizure activity is necessary, which
by definition means it cannot be a partial seizure. Therapeutic
efficacy also requires tonic–clonic movements or contractions
(without muscle relaxants), which means it cannot be an absence
seizure
22.2.
A 27-year-old man presents to the mental health center
because he has experienced a depressed mood for the last 2
months. He first felt “a little down and just couldn’t feel happy,
even when I played video games, which I like more than
anything.” He noticed a week later that he had to force himself
to eat. He then started calling out sick to work a couple weeks
later because he could not get out of bed. Despite feeling
continually “run-down,” he found himself waking 2 hours
earlier than usual. He spent the next few weeks watching
television, even though he could not stay focused on the show.
He denies suicidal ideation. He has never experienced these
symptoms before and has never been on psychotropic
medication. He has no medical illnesses and is on no
medications. What is the most effective treatment for his
condition?
A. A monoamine oxidase (MAO) inhibitor
B. Cognitive behavioral therapy and selective serotonin
reuptake inhibitor (SSRI)
C. Electroconvulsive therapy (ECT)
D. Transcranial magnetic stimulation
E. An SSRI and an atypical medication
22.2. C. Electroconvulsive therapy (ECT)
ECT is the most effective treatment available for major depressive
disorder, but due to side effects and stigma, it is rarely used first line.
It is now usually used when patients have failed multiple medication
trials, are acutely suicidal, have melancholic features, or refuse to
eat.
22.3.
What medication used in the treatment of bipolar disorder is
relatively contraindicated for a person who may undergo
electroconvulsive therapy (ECT) treatment?
A. Quetiapine XR
B. Olanzapine
C. Quetiapine
D. Aripiprazole
E. Lithium
22.3. E. Lithium
ECT should not be used for a patient who is on lithium, as the
medication can both lower seizure threshold and predispose the
patient to postictal delirium. As an antiepileptic medication,
divalproex would raise the seizure threshold, making the induction
of a therapeutic seizure more difficult. Aripiprazole, both forms of
quetiapine, and olanzapine are fine to use in combination with ECT.
22.5.
A 64-year-old woman is being treated with electroconvulsive
therapy (ECT) for severe depression which began 1 month ago.
She has lost 15 lb due to decreased appetite. She is on
desvenlafaxine and methamphetamine. She is on no other
medications and has no other illnesses. After being
anesthetized, the electrical stimulus is delivered, which results
in a 50-second duration of a seizure visualized on
electroencephalography (EEG). What should be the next step
in the treatment session?
A. Repeat the stimulus at a higher power
B. Administer IV diazepam
C. Repeat the stimulus at the current power
D. Conclude the session
22.5. D. Conclude the session
A seizure needs to last at least 25 seconds to be effective. If the
seizure is too short, up to four more attempts may be tried during the
session. If it lasts over 180 seconds, the patient is in status
epilepticus, and more of the anesthetic agent or IV diazepam can be
given to break the seizure. A seizure length of 50 seconds falls within
the therapeutic safe range, so the session should end.
22.4.
What medication is used during electroconvulsive therapy
(ECT) to decrease the risk of bone fractures during seizure
activity?
A. Atropine
B. Methohexital
C. Succinylcholine
D. Etomidate
E. Glycopyrrolate
22.4. C. Succinylcholine
The risk of bone fractures during ECT comes from muscle
contractions during the seizure. To minimize that risk, muscle
relaxants such as succinylcholine are used. Atropine and
glycopyrrolate are anticholinergic muscarinic drugs that are
sometimes used prior to ECT to minimize oral and respiratory
secretions, and to block bradycardia and asystole. Methohexital and
etomidate are anesthetics that can be used prior to the procedure
22.6.
A 43-year-old man with a 20-year history of schizophrenia is
on day 35 of hospitalization. He was admitted due to
intractable command hallucinations telling him that all foods
were radioactive. As a result, he had lost 8 lb in the 2 weeks
prior to hospitalization and has lost another 10 since then. The
voices have prevented him from getting more than 4 hours of
sleep at night. He has been tried on numerous first- and
second-generation antipsychotic medications, all with minimal
effect. Over the past 3 weeks, he has undergone
electroconvulsive therapy (ECT) sessions three times a week
with no apparent improvement. Electrodes were placed
bilaterally and the dose delivered was up to twice the seizure
threshold. He is on no medications that would lower seizure
threshold or pose increased risk. What should be the next step
in treatment?
A. Retry previous medications
B. Switch to unilateral electrode placement
C. Increase weekly frequency of treatments
D. Retry ECT with an increased dose
E. Continue current treatment for at least 2 more weeks
22.6. D. Retry ECT with an increased dose
If a patient has not improved after 6 to 10 sessions of ECT, bilateral
placement and treatment at three times the seizure threshold should
be tried next before ECT can be deemed a failure. Treatment
frequency is usually two to three times a week. More frequent
treatments are associated with greater memory impairment, but not
necessarily greater efficacy. Previous medications can be retried after
ECT has failed, as anecdotally, they may now be helpful after a
course of ECT
22.7.
What is an absolute contraindication for electroconvulsive
therapy (ECT)?
A. Pregnancy
B. A space-occupying central nervous system (CNS) lesion
C. Increased intracerebral pressure
D. A recent myocardial infarction
E. There are no absolute contraindications
22.7. E. There are no absolute contraindications
There are no absolute contraindications, but there are several
conditions that can place a patient at higher risk for complications
from ECT, which can often be mitigated by closer monitoring. In
cases of high-risk pregnancy, fetal monitoring may be necessary.
There is a risk for edema and herniation after ECT for someone with
a space-occupying CNS lesion, which can be mitigated with
dexamethasone pretreatment if the lesion is small. Patients with
increased intracerebral pressure are at higher risk due to increased
cerebral blood flow during the seizure. This risk can be lessened by
controlling the blood pressure during treatment. The risk to a patient
with a recent myocardial infarction is greatly diminished 2 weeks
after the event, and further diminished 3 months afterward.
22.8.
A 53-year-old man has completed his 10th and final
electroconvulsive therapy (ECT) treatment for major
depressive disorder. He reports the course of ECT as
successful, as measured by the resolution of anhedonia and
suicidal ideation, resumption of daily activities, and return of
appetite, concentration, and energy. However, he continues to
complain of problems remembering new information since the
treatments began. What is the most likely prognosis regarding
his memory over the next 6 months?
A. Memory impairment will remain at its current state
B. Memory will return to baseline
C. Memory impairment will continue to increase
D. Memory impairment will increase over the next 2 months,
then slowly improve
22.8. B. Memory will return to baseline
Memory impairment is the most common complaint from patients
following ECT. Anterograde amnesia often resolves within a couple
months. Within 6 months, the patient is likely to be back at their
cognitive baseline.
22.9.
What is a commonality between electroconvulsive therapy
(ECT) and transcranial magnetic stimulation (TMS)?
A. The requirement of anesthesia
B. The induction of a seizure
C. An electrical effect on neurons
D. Electrode placement on the scalp
E. Bilateral brain stimulation
22.9. C. An electrical effect on neurons
TMS involves the induction of electricity through magnetic
stimulation. As such, there are no electrodes to place bilaterally.
Instead, the TMS device delivers magnetic pulses via a coil that is
held on the scalp. The procedure is noninvasive and does not require
anesthesia. Seizures are the most severe side effect of TMS, not a
therapeutic requirement.
22.10.
Vagus nerve stimulation is indicated for what mental
disorder?
A. Obsessive compulsive disorder
B. Panic disorder
C. Schizophrenia
D. Posttraumatic stress disorder
E. Major depressive disorder
22.10. E. Major depressive disorder
Vagus nerve stimulation is indicated for long-term adjunctive
treatment of chronic or recurrent depression in adults. The
depression episode being treated can be due to a unipolar or bipolar
disorder. The efficacy in other disorders is unknown
22.11.
Neurosurgical ablative treatments are reserved for the most
severe major depression and what other mental illness?
A. Schizophrenia
B. Obsessive compulsive disorder (OCD)
C. Generalized anxiety disorder
D. Bipolar disorder
E. Panic disorder
22.11. B. Obsessive compulsive disorder (OCD)
Surgical intervention is predominantly used only in intractable cases
of major depression and OCD. Even then, approval must go through
a
multidisciplinary committee. Current techniques can yield
improvement in 40% to 70% of cases
22.12.
A 55-year-old woman is brought to the emergency
department by EMS after being talked out of jumping off of a
local bridge 30 minutes ago. She has been hospitalized
dozens of times for suicide attempts and has a 40-year
history of major depressive disorder. She states that she has
been on “every antidepressant ever made” except for MAOIs,
as she is diagnosed with hypertension. She is also diagnosed
with borderline personality disorder, and states that she has
had three full courses of dialectical behavior therapy (DBT),
as well as cognitive behavioral therapy (CBT), and that “I
know all the skills.” She has had two courses of 14 rounds of
electroconvulsive therapy (ECT) with minimal improvement
over the last 2 years. She is currently on lisinopril,
desvenlafaxine, bupropion, and brexpiprazole. She lives in a
boarding home and is treated by a psychiatrist on an
assertive community treatment (ACT) team. After telling the
physician that she wants to die because “I can’t go on living
like this anymore,” she is involuntarily committed to
inpatient treatment. On hospital day 3, she refuses to take
any of her medications and tells the treatment team, “I’m
done! No more meds, no more therapy, no more nothing!
Don’t touch me! I want to die in peace!” She does not speak
for the next 2 days. The team considers deep brain
stimulation. What is an absolute contraindication to the
procedure in this patient?
A. The diagnosis of borderline personality disorder
B. The diagnosis of hypertension
C. Not having yet tried monoamine oxidase inhibitors (MAOI)
D. Refusal to give informed consent
E. Living in a boarding home
22.12. D. Refusal to give informed consent
There are several relative contraindications to psychiatric
neurosurgery for the treatment of mental illness, including
cardiopulmonary comorbidities, severe personality disorders, and
not having tried a wide variety of previous treatments. A patient
must have access to follow-up, postoperative care following the
surgery. This patient has been on numerous trials of medication
throughout the years, and would have adequate follow-up through
the ACT team. Living in a boarding home is not in itself a
contraindication if the patient is able to follow up with postop care.
Borderline personality disorder and hypertension are relative, not
absolute, contraindications. The single absolute contraindication is if
informed consent is not given, as psychiatric neurosurgery should
never be performed on an unwilling patient.
22.13.
Ablative procedures for the treatment of severe mental
illness are expected to show results after what period of time
at the earliest?
A. Immediately following surgery
B. 4 weeks
C. 3 months
D. 6 months
E. 1 yea
22.13. D. 6 months
Results from ablative surgeries are not expected to show until at least
6 months, and may take up to 2 years.
