Psychosexual, Sleep + Eating Disorders Flashcards
A 25-year-old man recently married having abstained from sex until marriage. He
reports becoming very anxious during sexual intercourse and is gripped by a ‘fear
of failure’. Consequently he finds himself monitoring his performance and as a
result he cannot maintain an erection. What is the most likely diagnosis?
A. Sexual aversion disorder
B. Hypoactive sexual desire disorder
C. Premature ejaculation
D. Erectile dysfunction
E. Orgasmic disorder
D. Erectile dysfunction
Erectile dysfunction (ED) (D) is defined as the inability to develop or
maintain an erection during sexual intercourse. Factors that can contribute
to ED include previous negative sexual experiences contributing to
performance anxiety. Use of recreational drugs, alcohol, stress and
fatigue can also cause ED. Sexual aversion disorder (A) is characterized
by a depressed sexual desire. Hypoactive sexual desire disorder (B) is a
milder form of aversion disorder, associated with a lack of interest in
sex. Premature ejaculation (C) is a condition in which a male ejaculates
too soon, leading to diminished sexual pleasure. Orgasmic disorder (E)
is characterized by a persistent or recurrent difficulty in achieving an
orgasm following a normal excitation phase of sex. This may manifest as
a delayed orgasm or an absence of orgasm altogether.
A 49-year-old man has been successfully treated for anxiety and depression. He
is struggling to reach an orgasm during sex although his sexual desire is normal.
What is the most likely cause of his current problem?
A. Citalopram
B. Trazodone
C. Lithium
D. Chlorpromazine
E. Clonazepam
A. Citalopram
Citalopram (A) is an antidepressant drug that has a selective serotonin
reuptake inhibition mechanism. It is indicated for the treatment of
major depression. Side effects related to sexual dysfunction include a
delayed ejaculation and anorgasmia. Trazodone (B) is a 5HT2a receptor
antagonist. It is associated with priapism but rarely causes delayed
ejaculation. Priapism is a medical emergency as ischaemic changes can
result in impotence or, in serious cases, gangrene of the penis. Lithium (C)
is a mood stabilizer used in the treatment of mania. Side effects of the
drug specific to sexual dysfunction include diminished sexual interest as
well as erectile dysfunction. Chlorpromazine (D) is a typical antipsychotic
is associated with causing priapism. Clonazepam (E) is a benzodiazepine
indicated in the treatment of anxiety disorders, mania and parasomnias.
It is associated with loss of libido.
A 35-year-old man is picked up by the transport police after reports that he had
been rubbing his erect penis against several female passengers on a train. The
female victims were unknown to the offender. What is the most likely diagnosis?
A. Exhibitionism
B. Voyeurism
C. Frotteurism
D. Sexual masochism
E. Transvestic fetishism
C. Frotteurism
Frotteurism (C) is defined as the paraphilic activity of touching and
rubbing against another person’s body for sexual pleasure. Frotteurs are
usually males and the action is usually committed in a crowded public
arena, for example on public transport. Exhibitionism (A) is characterized
by indecent exposure of genitals in a public place. The penis may be erect
or flaccid. Voyeurism (B) includes watching others have sex or undress.
Mechanisms of voyeurism include using hidden cameras and peep-holes.
Sexual masochism (D) is defined as the pleasure of receiving pain through
sexual acts. Transvestic fetishism (E) is associated with attaining sexual
arousal from cross-dressing. In transvestic fetishism there is no link to
gender identity disorder.
A 62-year-old female with a history of rheumatoid arthritis complains that when
she attempts to sleep, she feels an urge to move her legs due to uncomfortable
sensations. Movement does ease the distress. What is the most likely diagnosis?
A. Obstructive sleep apnoea
B. Periodic limb movement disorder
C. Restless legs syndrome
D. Nocturnal eating syndrome
E. Nocturnal leg cramps
C. Restless legs syndrome
Restless legs syndrome (C) (Wittmaack–Ekbom syndrome) is characterized
by uncomfortable, often painful sensations in the legs, that is relieved
by movement. The condition is either idiopathic or familial in most
cases. It is associated with a number of medical conditions including
rheumatoid arthritis, uraemia and iron deficiency anaemia. Obstructive
sleep apnoea (A), usually associated with obese patients, features periods
of upper airway obstruction during sleep causing apnoea (no longer
than 90 seconds). It is associated with loud snoring and daytime fatigue.
Periodic limb movement disorder (B) is most common in the elderly and
is characterized by repetitive limb movements during sleep. The result is
excessive daytime sleepiness. Nocturnal eating syndrome (D) is primarily
a paediatric condition associated with excessive late-night consumption
of food. The disorder has been linked to depression and anxiety. Nocturnal
leg cramps (E) result in defined periods of painful muscular tension in the
foot or calf which wakes the patient. The condition is associated with
diabetes, pregnancy and arthritis
A 23-year-old medical student is nearing her final examination. She feels
as though she should study as much as possible and consequently has been
revising into the early hours of the morning, drinking up to six cups of coffee
per day as well as an energy drink. She has little difficulty getting to sleep
but wakes intermittently during the night. She does not wake refreshed and
feels tired the next day. There are no other symptoms. What is the most likely
diagnosis?
A. Inadequate sleep hygiene
B. Environmental sleep disorder
C. Depression
D. Adjustment sleep disorder
E. Limit setting sleep disorder
A. Inadequate sleep hygiene
Inadequate sleep hygiene (A) is associated with factors that do not allow
a good quality of sleep. These include high levels of caffeine consumption
and frequent late nights. There is also a concurrent negative effect on the
following day’s productivity. Environmental sleep disorder (B) is caused by
aspects of the surroundings that are not conducive to sleep. For example,
lights, noise, heat and cold will reduce the ability to sleep. Depression (C)
can cause sleep disorder, especially early morning wakening, but would
be associated with other symptoms of depression. Adjustment sleep
disorder (D) is associated with stress, conflict or environmental change,
for example changing jobs. It is usually only temporary and once anxiety
is diminished, sleep quality is restored. Limit setting sleep disorder (E) is
primarily a paediatric condition that occurs when a caregiver imposes
strict bedtime rules to a child with subsequent refusal by the child.
A 20-year-old male patient is taken to see a GP by his father. The patient has had
three distinct periods of binge eating coupled with long periods (lasting up to 18
hours) of sleep over the past 3 months. Each attack lasts a few days or so and then
spontaneously resolves. What is the most likely diagnosis?
A. Post-traumatic hypersomnia
B. Narcolepsy
C. Insufficient sleep syndrome
D. Depression
E. Kleine–Levin syndrome
E. Kleine–Levin syndrome
Kleine–Levin syndrome (E) is characterized by distinct periods of extreme
somnolence and excessive hunger. Males are far more affected than
females. Other symptoms which may manifest include sexual disinhibition,
confusion, irritability, euphoria, hallucinations and delusions. Posttraumatic
hypersomnia (A) may occur after there has been trauma to
the brainstem or posterior hypothalamus. Although hypersomnia may
occur, head trauma is more often associated with insomnia. Narcolepsy
(B) features a classical tetrad of symptoms: (often brief) periods of
sudden deep sleep, cataplexy (sudden bilateral loss of muscle tone), sleep
paralysis and hypnagogic (onset of sleep) hallucinations. Insufficient
sleep syndrome (C) is defined as the failure to obtain sufficient nocturnal
sleep to support daytime activities. It is associated with professions
that have unsociable working hours, such as doctors and long-distance
lorry drivers. Although atypical depression (D) may be associated with
hypersomnia and hyperphagia, the pattern would be more prolonged than
a few days and other depressive symptoms would be evident
A 45-year-old businessman, who travels regularly as part of his work, visits
the corporate physician complaining of difficulty in getting to sleep as well
as daytime fatigue and reduced performance during presentations. He also has
periodic headaches that are relieved by paracetamol. What is the most likely
diagnosis?
A. Shift work disorder
B. Time zone change syndrome
C. Irregular sleep-wake syndrome
D. Delayed sleep phase syndrome (DSPS)
E. Advance sleep phase syndrome
B. Time zone change syndrome
Time zone change syndrome (B) is characterized by difficulty initiating
and maintaining sleep as well as daytime fatigue. Feelings of apathy and
irritability may also ensue. Physical symptoms may manifest as altered
appetite, muscle aches or headaches. Shift work disorder (A) occurs
in patients who conduct shift work; patients who constantly change
day/night shift patterns are particularly susceptible to insomnia or
hypersomnia. Patients may present with physical symptoms rather than
a sleep disorder. Irregular sleep-wake syndrome (C) is characterized by
sleeping at irregular times. The disruption of the circadian rhythm leads
to insomnia and frequent naps during the daytime. Medical associations
include: Alzheimer’s disease, head injury and hypothalamic tumours.
DSPS (D) occurs when sleep begins late, leading to difficulties in waking
up. Patients may adapt to the condition by taking evening or night jobs.
Advance sleep phase syndrome (E) is the opposite of DSPS with early
sleep occurrence and early awakening. It is more common in elderly
patients
A 20-year-old female student visits her GP complaining of suddenly waking with
a ‘feeling of falling’. What is the likely diagnosis?
A. Rhythmic movement disorder
B. Somniloquy
C. Nocturnal leg cramps
D. Hypnic jerks
E. Somnambulism
D. Hypnic jerks
Hypnic jerks (D) (sleep starts) occur at the onset of sleep and are
associated with contractions of the limbs, neck or body. When wakened
by the jerks there is a characteristic feeling of falling into space. Rhythmic
movement disorder (A) is characterized by the repetitive movement of the
head before sleep and is sustained into sleep. It is most common in young
children and prevalence declines with age. Somniloquy (B), also known as
sleep talking, is primarily a condition of childhood. It is associated with
the utterance of words or sounds during sleep with no distinguishable
meaning. Nocturnal leg cramps (C) causes the sufferer to awaken due to
painful muscular tension in the foot or calf. The condition is associated
with diabetes, pregnancy and arthritis. Somnambulism (E), or sleep
walking, causes patients to arise during sleep and execute activities
usually performed during the day.
Which of the following features would indicate a diagnosis of anorexia nervosa
rather than bulimia nervosa?
A. Fear of fatness
B. Amenorrhoea
C. Being at least 15 per cent below the expected weight
D. Recurrent episodes of overeating
E. Self-induced vomiting
D. Recurrent episodes of overeating
Bulimia and anorexia nervosa, while distinct conditions, share certain
features in common. However, the hallmark of bulimia nervosa is
recurrent episodes of overeating, or ‘bingeing’, involving the consumption
of large quantities of food over a short time (D). This is followed by efforts
to control weight, often by vomiting, using appetite suppressants and
periods of starvation. A fear of fatness (A) occurs in both anorexia and
bulimia. Amenorrhea (B), while it may occur in bulimia, is a diagnostic
criteria for a anorexia nervosa. Equally, having a low weight (C) is a
feature of both disorders (but not diagnostic for bulimia, in which weight
may be normal or even increased). For a diagnosis of anorexia, sufferers
must be at least 15 per cent below expected body weight. Self-induced
vomiting (E) is very common in bulimia nervosa, but equally occur in
anorexia in an attempt to control weight.
Which of the following is not a recognized complication of sustained anorexia
nervosa?
A. Bradycardia
B. Heart failure
C. Hypercholsterolaemia
D. Parotid gland enlargement
E. Thrombocytosis
E. Thrombocytosis
A low platelet count may be found in anorexia nervosa, but not an
increased count (E). There may also be a pancytopenia. Bradycardia (A),
as well as a host of other arrhythmias, are a common complication of
anorexia nervosa. The aetiology is multiple, but includes hypokalaemia.
Heart failure (B) may also occur in anorexia, both as a result of the
disorder and occasionally as a result of refeeding, although the reason for
this is not completely understood. Hypercholesterolaemia is a surprising
finding in anorexia nervosa, but is by no means uncommon. The exact
mechanism is still unclear (C). Parotid enlargement occurs as a result of
nutritional deficiencies as well as purging behaviour (D).
