Depression and Bipolar Disorder
1. A 56-year-old man is admitted to the coronary care unit and is diagnosed as having a non–Q wave myocardial infarction. The patient is aggressively managed and is clinically stable. During his admission, he describes to his treating physician that he has struggled with depression in the past but has been reluctant to share this with his local doctor. His recent symptoms include insomnia, unintentional weight loss, and depressed mood. He also has not been performing well at work and blames his poor performance on “being tired” and being incapable of concentrating. He has stopped playing golf with his friends on Saturday morning because it is not fun anymore.
Which of the following statements regarding depression is true?
A. The patient is not at increased risk for committing suicide
B. Genetics plays no role in depression
C. The incidence of depression decreases with age
D. The mortality 6 months after a myocardial infarction is five times higher for depressed patients than for nondepressed patients
Key Concept/Objective: To be able to recognize and treat depression in patients with medical problems
A broad array of antidepressants are available for the treatment of depression. Mood disorders are present in 50% to 70% of all cases of suicide, and patients with recurrent, serious depression (i.e., depression requiring hospitalization) have an 8% to 15% suicide rate. The strongest known risk factors for the development of depression are family history and previous episodes of depression. The risk of depressive disorders in first-degree relatives of patients with depression is two to three times that of the general population. If one parent has a mood disorder, a child’s risk of a mood disorder is 10% to 25%; if both parents are affected, the risk roughly doubles. Depression is widespread in the elderly. Depression in late life is a serious public health concern; comorbidity of depression with other illnesses, both medical and psychiatric, is particularly problematic in older persons. The prevalence of depressive symptoms in those 65 years of age and older has been estimated to be 16.9%. Depression is a major risk factor for both the development of cardiovascular disease and death after an index myocardial infarction. The mortality 6 months after a myocardial infarction has been reported to be more than five times higher in depressed patients than in those without depression. (Answer: D—The mortality
6 months after a myocardial infarction is five times higher for depressed patients than for nondepressed patients)
2. A 73-year-old man who was recently diagnosed with depression returns for a follow-up visit. The patient was diagnosed 3 weeks ago and was started on fluoxetine. The patient reports no improvement in his depressive symptoms. He has a fixed income and does not want to pay for medication that is not effective. He is hopeful that something will work, and he says that his sister took sertraline and it “cured” her depression.
Which of the following statements concerning this patient is false
A. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs)
are safe in overdose
B. Treatment is recommended for at least 4 to 6 weeks before efficacy is determined
C. Sexual side effects are uncommon causes of poor compliance in patients being treated with SSRIs
D. Therapy should be discontinued as soon as the patient reports improvement of depressive symptoms
Key Concept/Objective: To know to inquire about sexual side effects in patients taking SSRIs
SSRIs offer several important advantages over the older medications. Perhaps most importantly, these medications are safe in overdose. The patient’s medical history and personal or family history of response often help predict response and side effects. Treatment of depression is recommended for at least 4 to 6 weeks before a decision regarding efficacy can be made. Sexual side effects have been widely recognized as a major cause of poor compliance with SSRI regimens, particularly after improvement of depressed mood. Improvement of the illness should not be interpreted by the patient or the physician as indicating that antidepressants are no longer necessary. The continuation phase of treatment consists of 16 to 20 weeks of continued treatment (using the same antidepressant that was used in the acute phase) after remission, with the goal of preventing the relapses that typically occur in untreated patients. (Answer: D—Therapy should be discontinued as soon as the patient reports improvement of depressive symptoms)
3. A 36-year-old man with a history of bipolar disorder presents to a local emergency department in police custody. A family member called the police after the patient stole her credit card and charged almost $10,000 worth of clothes. The patient had locked himself in his home and is now accusing his family of being “out to get him.” The police report that there were no drug paraphernalia in the home. The emergency department physician consults psychiatry for evaluation of mania with psychotic features and inpatient management. Results of laboratory testing on admission are all within normal limits.
Which of the following statements concerning pharmacologic therapy for this patient’s mania is true?
A. Valproic acid appears most effective for classic bipolar disorder
B. Carbamazepine is an approved treatment of acute mania
C. Olanzapine has been shown to be an effective treatment of acute mania
D. Evidence from clinical trials documents the efficacy of topiramate in acute mania
Key Concept/Objective: To be familiar with different drugs available for the treatment of bipolar disorder and mania
Lithium is most effective in classic bipolar disorder, which consists of discrete episodes of mania and depression with symptom-free periods between episodes. Serum levels of lithium must be monitored. Valproic acid/divalproex sodium appears to be more effective for manias that are dysphoric or mixed and for patients who experience four or more episodes a year. Carbamazepine is not approved in the United States for the treatment of mania and may be associated with a number of pharmacokinetic drug-drug interactions because of its induction of microsomal P-450 enzymes. Olanzapine, an atypical antipsychotic agent, has been shown to be effective for the treatment of acute mania. Other atypical antipsychotics, including risperidone, quetiapine, ziprasidone, and aripiprazole, may be efficacious as well. Early evidence suggested that topiramate may be an effective mood stabilizer, but three randomized controlled clinical trials in acute mania failed to demonstrate any efficacy. (Answer: C—Olanzapine has been shown to be an effective treatment of acute mania)
4. A 67-year-old man, 3 months after a myocardial infarction (MI), reports problems with severe insomnia.
He cannot fall asleep easily and wakes up at about 4:30 A.M. each morning. He has had increased fatigue since his MI, is more forgetful, and has problems with concentration. His other medical problems include reflux esophagitis, benign prostatic hyperplasia (BPH), and a history of stroke with a related seizure disorder. Medications include aspirin, simvastatin, atenolol, and enalapril.
Which of the following drugs would you recommend for treatment of this patient’s symptoms?
A. Zolpidem
B. Amitryptiline
C. Nortryptiline
D. Paroxetine
E. Bupropion
Key Concept/Objective: To know how to select antidepressant medications for patients with multiple comorbid medical illnesses
This patient has a major depression shortly after an MI. This is not uncommon; up to
20% to 30% of patients may develop depression after MI. This patient also has BPH and a history of a seizure disorder. Tricyclic antidepressants should be avoided because of the risk of cardiac arrhythmia, as well as the increased risk of urinary retention in this patient because of his BPH. Bupropion should be avoided because of his known seizure disorder. An SSRI (paroxetine in this case) is a safe choice, given his comorbid medical illnesses. (Answer: D—Paroxetine)
5. A 38-year-old man with a diagnosis of depression presents for follow-up. He has had a good response to treatment with sertraline but would like to stop treatment because of sexual side effects (delayed ejaculation). He has been on antidepressant therapy for 6 weeks.
Which of the following would you recommend for this patient?
A. Stop sertraline
B. Stop sertraline, begin paroxetine
C. Stop sertraline, begin fluoxetine
D. Stop sertraline, begin bupropion
E. Stop sertraline, begin amitriptyline
Key Concept/Objective: To know the sexual side-effect profiles of antidepressant medications
This patient is concerned about the sexual side effects he is experiencing from sertraline. He has been treated for only 6 weeks, which is too short a course for treatment of a major depression. Patients who discontinue treatment within the first 16 weeks of therapy are at much higher risk for relapse. Sexual side effects are a class effect of SSRIs and unlikely to be much reduced with fluoxetine or paroxetine. The antidepressant medications with the least likelihood of sexual side effects are bupropion, nefazodone, and mirtazapine. (Answer: D—Stop sertraline, begin bupropion)
6. A 49-year-old woman presents for follow-up of depression. She has been treated with fluoxetine for the past 12 weeks. She started on 20 mg a day and had only a minimal response. At 6 weeks her dose was raised to 40 mg. She reports that her fatigue has improved, and she is no longer suicidal. She still has marked anhedonia and problems with concentration. She reports that she has not been missing doses of her medication.
Which of the following would you recommend for this patient?
A. Stop fluoxetine; begin paroxetine
B. Stop fluoxetine; begin psychotherapy
C. Stop fluoxetine; refer for ECT
D. Add lithium to current regimen
E. Add buspirone to current regimen
Key Concept/Objective: To be able to recognize partial response to antidepressant therapy and to understand how to augment the response
This patient has had a partial response to treatment of her depression with fluoxetine. She has had an appropriate increase in dose from 20 mg to 40 mg and an appropriate interval (6 weeks) for observation of response at the higher drug dose. This patient is a good candidate for augmenting the response by the addition of another drug. The most common drugs used for this purpose are lithium and bupropion. (Answer: D—Add lithium to current regimen)
For more information, see Compton MT, Nemeroff CB, Rudorfer MV: 13 Psychiatry: II Depression and Bipolar Disorder. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, December 2003
Alcohol Abuse and Dependency
7. A 47-year-old man presents with cold symptoms. In giving his social history, the patient reports drinking six beers nightly to relieve stress. He admits to having been arrested once for driving while under the influence of alcohol, but he denies that there is any evidence of alcohol withdrawal or tolerance. He also denies having any thoughts of controlling his drinking or that he spends a great deal of time obtaining alcohol, using alcohol, or recovering from his drinking. He further denies having any psychological or physical problems related to his drinking.
Which of the following statements regarding this patient is false?
A. This patient meets the criteria for alcohol abuse
B. This patient does not meet the criteria for alcohol dependence
C. This patient displays moderate drinking
D. This patient displays at-risk drinking
Key Concept/Objective: To know the definitions of and criteria for alcohol-related conditions
The National Institute on Alcohol Abuse and Alcoholism has defined moderate drinking in terms of the average number of drinks consumed a day that places an adult at relatively low risk for developing alcohol-related health problems. For men younger than 65 years, moderate drinking is drinking an average of no more than two drinks a day. This 47-year-old male patient drinks six beers a day, and therefore C is the correct answer. For men older than 65 years and for all women, moderate drinking is defined as drinking less than two drinks a day. At-risk drinking occurs when those moderate drinking levels are exceeded or when the number of drinks consumed during a single occasion exceeds a specified amount (four drinks per occasion for men and three drinks per occasion for women). Alcohol abuse is defined as a maladaptive pattern of alcohol use leading to clinically significant impairment or distress, manifested in a 12-month period by one or more of the following problems: (1) failure to fulfill role obligations at work, school, or home; (2) recurrent use of alcohol in hazardous situations; (3) legal problems related to alcohol; and (4) continued use despite alcohol-related social problems. Alcohol dependence is manifested by a maladaptive pattern of use over a 12month period that includes three or more of the following problems: (1) physiologic tolerance, characterized either by an increase in the amount of alcohol consumed or by a decrease in the effects of the amount of alcohol customarily consumed; (2) symptoms of withdrawal; (3) use of greater amounts of alcohol over a longer period than intended; (4) a persistent desire or unsuccessful attempts to control use; (5) a great deal of time spent obtaining alcohol, using alcohol, or recovering from use; (6) reducing important social, occupational, and recreational activities; and (7) continued use despite knowledge of physical or psychological problems. (Answer: C—This patient displays moderate drinking)
8. A 32-year-old woman is diagnosed with gastritis. She reports that she drinks four to five glasses of mixed drinks daily and has been arrested twice for driving while under the influence of alcohol. She reports that she becomes annoyed when her husband tells her to cut down on her drinking. She reports having periods of blackouts.
Which of the following statements regarding this patient is true?
A. A comorbid psychiatric condition of affective disorder is common for this type of patient
B. This patient has an increased risk of accidents
C. This patent has an increased risk of HIV infection
D. All of the above
Key Concept/Objective: To understand alcohol-related problems
Epidemiologic surveys have demonstrated high rates of psychiatric illness in persons diagnosed with alcohol abuse or dependence. The most common disorders are anxiety and affective and antisocial personality disorders. Patients with alcohol problems require careful evaluation for comorbid psychiatric symptoms and problems. Similarly, patients with psychiatric disorders are at high risk for having comorbid substance use disorders. Alcohol use is the leading cause of accidents (most notably, automobile accidents), injuries, and trauma (e.g., drownings, head injuries, burns, and spinal cord injuries). Alcohol use is associated with more severe injury in trauma patients. Alcohol use is associated with injuries and trauma related to acts of violence; such acts include assault and homicide, as well as the domestic abuse of children and spouses. HIV seroprevalence may be higher in patients with more severe impairment from alcohol, and women may be at especially increased risk. (Answer: D—All of the above)
9. A 44-year-old man comes in for a preventive health visit. He denies having any medical problems, and he is not on any medications. He denies smoking, but he drinks “socially.” He denies having any alcohol-related problems.
For this patient, which of the following is the next step in screening for alcohol-related problems?
A. Inquire about the type, frequency, and quantity of alcohol use
B. Administer a standardized questionnaire to detect alcohol problems
C. Administer laboratory tests to detect alcohol-related medical problems
D. Inquire about criteria that meet definitions of alcohol abuse, dependence, and alcoholism
Key Concept/Objective: To understand the screening and diagnosis of alcohol-related problems
Easy-to-use techniques for screening patients for alcohol-use disorders are currently available. One such screening technique involves a four-step process for identifying and diagnosing alcohol-related problems. Step 1 is to inquire about current and past alcohol use in all patients. Steps 2 through 4 apply to all patients who report a history of alcohol use. In step 2, a more detailed history regarding quantity and frequency of alcohol use is obtained. In step 3, a standardized questionnaire is used to detect possible alcohol problems. Step 4 involves asking further questions with regard to potential alcohol problems. It is applied to those patients who were identified in steps 1 through 3 as having potential alcohol-related problems. Although not useful as screening tests for alcohol-use disorders, laboratory tests, such as liver enzyme assay, may be useful in identifying undiagnosed alcohol-related medical problems. (Answer: A—Inquire about the type, frequency, and quantity of alcohol use)
10. A 54-year-old man presents with symptoms of alcohol withdrawal. He has hypertension, fever, diaphoresis, and agitation. He reports a recent episode of binge drinking, with his last drink having been consumed 8 hours ago. He is unsure of the quantity of alcohol that he consumed during this episode of binge drinking.
Which of the following pharmacologic therapies is the most appropriate to administer first?
A. Disulfiram
B. Benzodiazepine
C. Barbiturates
D. Carbamazepine
Key Concept/Objective: To understand the diagnosis and treatment of alcohol withdrawal symptoms
The benzodiazepines (e.g., chlordiazepoxide, diazepam, lorazepam, and oxazepam) are the safest and most effective medications for treatment of alcohol withdrawal. In addition to preventing or alleviating withdrawal symptoms, benzodiazepines may also decrease the incidence of seizures and possibly delirium tremens. Research has suggested that newer approaches using clonidine, beta blockers, and carbamazepine are effective in decreasing the severity of certain withdrawal symptoms but are not as effective as the benzodiazepines and presumably do not protect against seizures, as do benzodiazepines. Thus, these alternative treatments are generally considered to be adjuvants to benzodiazepines. Signs and symptoms of alcohol withdrawal, which can occur in alcohol-dependent persons who stop taking alcohol or who reduce their alcohol intake, include abnormalities in vital signs (e.g., tachycardia, hypertension, and fever), other symptoms of autonomic hyperactivity (e.g., tremor, diaphoresis, and insomnia), GI symptoms (e.g., nausea, vomiting, and diarrhea), and central nervous system effects (e.g., anxiety, agitation, hallucinations, seizures, and delirium). (Answer: B— Benzodiazepine)
For more information, see O’Connor PG: 13 Psychiatry: III Alcohol Abuse and Dependency. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, October 2001
Drug Abuse and Dependence
11. A 49-year-old man presents to your primary care clinic with his wife. His wife is concerned that her husband is “addicted” to alcohol. She wants him to be evaluated and treated because his father was an alcoholic. Over the past few months, he has been drinking alcohol more often, has received a traffic citation for driving under the influence of alcohol, and has missed days of work.
Which of the following statements regarding the Diagnostic and Statistical Manual of Mental Disorders—Text Revision (DSM-IVTR) definition of dependence is false?
A. Tolerance and withdrawal are criteria for dependence
B. Dependence disorders encompass psychiatric states that resemble primary psychiatric syndromes but that occur only during periods of intoxication or withdrawal from a substance
C. The inability to cut back when needed is a criterion
D. Continued use of a substance despite problems is a criterion
Key Concept/Objective: To understand the definition of dependence
The DSM-IV defines dependence as a condition of repetitive and intense use of a substance that results in repeated problems in at least three of seven areas of concern. Those problems must all occur within the same 12-month period. The categories of problems include tolerance and withdrawal (with the presence of either one justifying a diagnosis of dependence with a physiologic component), difficulty controlling use, an inability to cut back when needed, spending a lot of time taking the substance, failing to take part in important events to use the substance, and continuing use despite problems. In effect, the last of these indicates that the substance means more to the person than the problems it is causing. Substance-induced disorders encompass psychiatric states that resemble primary psychiatric syndromes (e.g., anxiety disorders, major depression, or schizophrenia) but that occur only during periods of intoxication or withdrawal from a substance. Substance-induced disorders improve rapidly and resolve completely within a few days or a month of stopping the use of the substance and can usually be treated with education, reassurance, and a cognitive-behavioral approach. (Answer: B— Dependence disorders encompass psychiatric states that resemble primary psychiatric syndromes but that occur only during periods of intoxication or withdrawal from a substance)
12. A 36-year-old woman enters the emergency department stating, “I just took too many pills.” She says she wanted to commit suicide through overdose but has since changed her mind. She does not know what she took because she got the pills from her boyfriend’s car. You have the nurse establish I.V. access, and you begin to assess the patient’s vital signs.
Which of the following statements regarding the overdose of drugs of abuse and the management of overdose is false?
A. A mild overdose with no significant change in vital signs is called intoxication and can be managed conservatively by putting the patient in a quiet room with a friend or relative
B. An overdose of a stimulant can cause tachycardia, cardiac arrhythmias, hypertension, hyperthermia, and seizures
C. Benzodiazepine overdose commonly causes pulmonary edema
D. Opioid overdose can cause life-threatening decreases in respiratory rate, heart rate, and blood pressure
E. Therapy for stimulant overdose can include intravenous benzodiazepines, cooling blankets, and intravenous nitroprusside
Key Concept/Objective: To understand common overdose states and their treatments
Intoxication involves changes in vital signs and alterations in mood and cognitive function caused by a drug. Provided that the vital signs are relatively normal, treatment of intoxication consists of controlling behavior by placing the person in a quiet room; having a friend or relative stay with the person, if possible; offering reassurance; and employing the judicious use of low doses of appropriate medications (e.g., benzodiazepines or antipsychotics). Overdoses are intoxications of such severity as to produce life-threatening changes in vital signs. As such, overdoses must be managed in an emergency department or an inpatient setting. Treatment begins with provision of general medical and psychological support, with an emphasis on normalizing vital signs and allowing the body to metabolize the drug. Depending on the drug category and the clinical manifestations, specific pharmacologic treatment may be indicated. Overdoses with stimulants typically produce tachycardia, cardiac arrhythmias, and potentially life-threatening elevations in blood pressure and body temperature; seizures may also occur. Treatment includes administration of intravenous fluids; administration of intravenous benzodiazepines for seizures; use of cooling blankets to control hyperthermia; and administration of intravenous phentolamine or nitroprusside for blood pressure control. High doses of opioids produce life-threatening decreases in respiratory rate, heart rate, and blood pressure; pulmonary edema or coma are possible. Patients who have overdosed on benzodiazepines are treated with general supportive measures and an intravenous infusion of the antagonist flumazenil. (Answer: C—Benzodiazepine overdose commonly causes pulmonary edema)
13. A 49-year-old man who has a documented history of multiple substance abuse is brought to the emergency department after being “found down.” I.V. access is obtained, and the patient undergoes volume resuscitation in the emergency department. After speaking with his family, it becomes evident that he is in a drug withdrawal state.
Which of the following statements regarding withdrawal states from drugs of abuse is false?
A. Stimulant withdrawal only requires general support; the patient will experience somnolence, hunger, an inability to concentrate, and mood swings
B. Depressant withdrawal resembles alcohol withdrawal and comprises insomnia, anxiety, and an increase in most vital signs
C. Opioid withdrawal is characterized by enhanced pain throughout the body, diarrhea, runny nose, cough, and a generalized flulike feeling
D. The only viable option to manage opioid withdrawal is to administer another opioid such as methadone
Key Concept/Objective: To understand the withdrawal states associated with common drugs of abuse
With some drugs, abrupt cessation after prolonged use is likely to result in rebound signs and symptoms that are the opposite of the drug’s acute effects. The time course of the withdrawal syndrome depends mostly on the half-life of the drug involved. Patients undergoing withdrawal from stimulants require only general support. The most prominent acute difficulties include sleepiness; hunger; difficulty focusing attention; and mood swings, with prominent feelings of sadness and frustration. A withdrawal syndrome may occur after the prolonged consumption of high doses of illicit opioids, such as heroin, or of any prescription narcotic analgesic. Opioid withdrawal is characterized by enhanced pain throughout the body, diarrhea, runny nose, cough, and a generalized flulike feeling. In addition to the usual supportive social-model approach, opioid withdrawal states can be treated by readministering an opioid such as methadone. An alternative approach focuses on providing symptomatic relief with decongestants and antidiarrheal medications such as loperamide. Relief of some autonomic symptoms can be provided with an alpha blocker such as clonidine. The withdrawal syndrome associated with depressant drugs, such as benzodiazepines or barbiturates, resembles alcohol withdrawal and comprises insomnia, anxiety, and an increase in most vital signs. About 1% to 3% of patients experience a grand mal convulsion or delirium; this complication most often occurs in patients who concomitantly use more than one drug of abuse or who use high doses of depressants or in patients with medical disorders. The treatment for withdrawal from a depressant drug (other than alcohol) usually involves readministering the specific drug involved in the dependence and tapering it over about 5 days or 3 weeks, depending on the half-life of the drug. (Answer: D—The only viable option to manage opioid withdrawal is to administer another opioid such as methadone)
14. A 19-year-old man presents to the emergency department complaining of chest pain and palpitations of 2 hours’ duration. He reports that he has no other medical history but has experienced these symptoms previously. On examination, he appears anxious. He has a pulse of 120 beats/min, and his blood pressure is 152/97 mm Hg. His ECG shows sinus tachycardia. A serum drug screen is positive for cocaine.
Which of the following is true for this patient?
A. Drug use anytime within the past 2 weeks can lead to a positive serum drug screen
B. These symptoms may be a result of cocaine withdrawal
C. These symptoms may be a result of cocaine dependence
D. This patient has a risk factor for cocaine addiction
Key Concept/Objective: To understand the characteristics of cocaine addiction
Addiction can be understood as a chronic medical illness. Addiction has identifiable risk factors, including genetic factors. The most well-established risk factors for addiction are family history and male sex. Serum and urine tests are useful when they are positive, but they are of limited utility when they are negative because of the short duration of detectability of cocaine (6 to 8 hours) and cocaine metabolites (2 to 4 days). Cocaine does not produce compensatory adaptations in brain regions that control somatic functions and therefore does not produce dependence. Dependence and, therefore, withdrawal are not produced by highly addictive compounds such as cocaine. (Answer: D—This patient has a risk factor for cocaine addiction)
15. A 45-year-old woman presents with complaints of back pain. She requests “something strong” for pain and states that various NSAIDs and nonnarcotic pain medications do not help her when she has pain. A review of her medical record shows a pattern of various musculoskeletal complaints, for which she has been given opiate-derivative pain medications on several occasions. She requests morphine for her back pain.
For this patient, which of the following statements is false?
A. Opiates can cause addiction
B. Opiates can cause dependence
C. Opiates function by blocking norepinephrine reuptake
D. Pharmacologic therapy is available for treatment of opiate addiction
Key Concept/Objective: To understand opiate abuse
All addictive drugs share the property of activating a subcortical brain circuit that normally functions to motivate the pursuit of goals with positive survival value, such as obtaining food and sexual partners. This circuit extends from the ventral tegmental area (VTA) of the midbrain to the nucleus accumbens (NAc), which is the ventral portion of the striatum and uses dopamine as its neurotransmitter. The opiates mimic endogenous opioid neurotransmitters (e.g., enkephalins), which disinhibit the VTA, leading to dopamine release, but can also act directly on the NAc, thus bypassing dopamine release. Opioids can produce physical dependence and withdrawal; detoxification from opioids is usually effected by substitution of a cross-reactive agent such as methadone or other long-acting opioids for heroin. For opiate detoxification, addition of alpha2-adrenergic agonist compounds, such as clonidine, blocks emergent withdrawal symptoms and permits more rapid detoxification. (Answer: C—Opiates function by blocking norepinephrine reuptake)
16. A 47-year-old man with hypertension, diabetes, and a 20-pack-year history of cigarette smoking requests assistance in smoking cessation. He has tried to quit several times in the past but has always resumed smoking within a week.
Which of the following has the best results for smoking cessation?
A. Nicotine replacement therapy
B. Behavioral therapy and counseling
C. Bupropion therapy
D. A combination of all of the above
Key Concept/Objective: To understand the principles of smoking cessation
Cessation of cigarette smoking is aided by currently available pharmacotherapies. Effective therapies, including nicotine replacement therapy in the form of nasal spray, inhaler, gum, or patch, as well as the atypical antidepressant bupropion (300 mg/day for 7 to 12 weeks), have shown a success rate of smoking cessation twice that of placebo. Although bupropion is an antidepressant, the presence or absence of depression does not influence its effectiveness for smoking cessation. The combination of a nicotine replacement therapy with bupropion may be more effective than either modality alone. The addition of behavior therapy and social support counseling to pharmacotherapy further increases the cessation rate. (Answer: D—A combination of all of the above)
For more information, see Shuckit MA: 13 Psychiatry: VI Drug Abuse and Dependence. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, May 2004
Schizophrenia
17. A 29-year-old male patient is referred to you by his psychiatrist for treatment of hypertension and diabetes. The patient denies having headaches, chest pain, shortness of breath, edema, blurry vision, or change in sensation of his extremities. His medical record describes his initial presentation of schizophrenia.
For this patient, which of the following statements is consistent with the clinical manifestations of schizophrenia?
A. The patient was known to have depression and mania with associated delusions
B. The patient did not exhibit prodromal symptoms before his initial episode of acute psychosis
C. Between psychotic episodes, no residual symptoms are present
D. The patient had restricted affect, low drive, and a poverty of speech
Key Concept/Objective: To understand the clinical manifestations of schizophrenia
The diagnosis of schizophrenia should be considered in a patient who presents with hallucinations and delusions. The presence of disorganized thought and behavior increases the likelihood of schizophrenia. In the absence of other known causes of such symptoms (e.g., substance abuse, temporal lobe epilepsy), the principal diagnostic task is to discriminate between severe mental illnesses. If the patient does not have a mood disorder and the psychotic symptoms are accompanied by restricted affect, low drive, and poverty of speech, the probability of schizophrenia is high. The diagnosis can be made with greatest confidence, however, on the basis of the longitudinal pattern of the disorder, which includes the occurrence of prodromal symptoms before the initial episode, residual symptoms between psychotic episodes, and psychotic episodes that cannot be attributed to mood disturbance (e.g., manic or depressive psychosis) or other known causes of psychotic behavior. (Answer: D—The patient had restricted affect, low drive, and a poverty of speech)
18. A 31-year-old woman presents to your office with a chief complaint of hearing voices. She says that she can hear people telling her, “You’re a failure,” and being very critical of her actions. She also relates that she believes she is being watched carefully by the FBI and that your conversation with her is probably being monitored. It is clear that she has psychotic features that are consistent with schizophrenia, but you also consider other disorders that can cause psychotic symptoms.
Which of the following statements regarding disorders that can cause psychotic symptoms is true?
A. Depression and mania are not associated with psychotic features
B. Schizotypal personality disorder is similar to schizophrenia in that people with this personality disorder have persistent psychotic symptoms
C. Drug abuse is an uncommon cause of psychotic symptoms
D. Rarely, a brain tumor or temporal lobe epilepsy may be misdiagnosed as schizophrenia; in such cases, MRI or electroencephalography can help make the diagnosis
Key Concept/Objective: To know the common disorders that can mimic schizophrenia and to know how to differentiate between them
Because schizophrenia is defined as a psychotic illness with functional impairments, distinguishing schizophrenia from normalcy is usually not difficult. However, differentiating schizophrenia from other disorders with psychotic features can be a challenge. Schizotypal personality disorder shares some of the clinical characteristics of schizophrenia, such as social and physical anhedonia, suspiciousness, magical thinking, blunting of affect and emotional experience, and poor functioning. However, schizotypal patients do not experience overt and persistent psychotic symptoms, although rare and brief psychotic symptoms may occur. In a patient with persistent psychosis, the differential diagnosis consists mainly of affective disorders with psychosis, substance abuse, and delusional disorders. Psychosis that coincides with depression is typically associated with such affective features as delusions of poverty or accusatory voices. Similarly, delusions of grandeur are common during manic episodes. Psychotic symptoms in affective disorders typically follow the emergence of depression or mania and fade once the affective symptoms recede. The history and toxicology screen can rule out psychosis caused by drug abuse, such as use of PCP or long-term abuse of steroids. Delusional disorder is diagnosed on the basis of nonbizarre, persistent, and circumscribed delusions in the absence of the other characteristics of schizophrenia. Rarely, neurologic conditions such as brain tumor or temporal lobe epilepsy may be misdiagnosed as schizophrenia. When such conditions are suspected, MRI and EEG can help with the diagnosis. (Answer: D—Rarely, a brain tumor or temporal lobe epilepsy may be misdiagnosed as schizophrenia; in such cases, MRI or electroencephalography can help make the diagnosis)
For more information, see Carpenter WT, Thaller GK: 13 Psychiatry: VII Schizophrenia. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, June 2004
Anxiety Disorders
19. A 37-year-old woman presents to the emergency department with chest pain. The pain started 20 minutes ago. It is severe and is located in her right chest; it does not radiate. Onset was not associated with physical activity. The patient also complains of shortness of breath, shakiness, palpitations, diaphoresis, and nausea. The patient has visited the hospital three times over the past 4 months with similar symptoms. She used to run 3 miles a day 3 days a week, but she has stopped running because of concerns of dying of a heart attack. Lately, she has been spending more time at home because she is concerned she would be helpless if she suffered a heart attack outside her house. One month ago, she underwent a stress test, the results of which were normal. The patient does not smoke; she drinks one glass of wine a night. Her father died of a heart attack when he was 60 years of age. On physical examination, the patient’s heart rate is 130 beats/min; her respiratory rate is 28 breaths/min; diaphoresis and distal tremors are noted. The rest of the examination is unremarkable. An electrocardiogram shows sinus tachycardia.
Which of the following is the most likely diagnosis, and which therapeutic intervention constitutes first-line therapy for this disorder?
A. Panic disorder with agoraphobia; start a benzodiazepine
B. Panic disorder without agoraphobia; start a selective serotonin reuptake inhibitor (SSRI)
C. Panic disorder with agoraphobia; start cognitive-behavioral psychotherapy
D. Panic disorder without agoraphobia; refer to psychiatry
Key Concept/Objective: To understand the diagnosis and treatment of panic disorder
This patient has panic disorder with agoraphobia. The pathognomonic feature of panic disorder is unexpected panic attacks, which are characterized by sudden onset and rapid escalation of somatic symptoms referable to the autonomic nervous system (e.g., chest pain, shortness of breath, heart palpitations, and dizziness), along with fear and apprehension. The diagnosis of panic disorder requires recurrent panic accompanied by significant worry about panic, its consequences, or a change in usual behavior. Panic disorder has four common clinical presentations: physical symptoms, anxiety and tension, hypochondriachal concerns, and medical conditions such as asthma. Agoraphobia is a fear of situations in which the person would feel trapped or alone should a panic episode occur. Drug therapy can be markedly effective for panic disorder. SSRIs are firstline therapy for panic disorder. Targeted cognitive-behavioral psychotherapy is as effective as medication in treating panic disorder. (Answer: C—Panic disorder with agoraphobia; start cognitive-behavioral psychotherapy)
20. A 68-year-old man comes to your clinic for a follow-up visit. He was discharged from a local hospital 3 months ago after a long stay in the intensive care unit for multiple medical problems, including pneumonia that required mechanical ventilation for 3 weeks, acute renal failure, sepsis, and amputation of his right foot as a result of a vascular event. He requires home oxygen therapy, but he says his breathing is slowly improving. He has no active complaints. His wife says he has had insomnia since he was discharged from the hospital. She also says the patient has been waking up in the middle of the night sweating and very anxious. The patient has been having recurrent dreams in which he is hospitalized in the ICU.
Which of the following is the most likely diagnosis, and what therapy should be started for this patient?
A. Panic disorder; start an SSRI
B. Posttraumatic stress disorder (PTSD); start an SSRI
C. Generalized anxiety; start cognitive-behavioral psychotherapy
D. Hospital phobia; start a benzodiazepine
Key Concept/Objective: To understand PTSD and its treatment
Diagnostic criteria for PTSD include exposure to an event that posed a risk of death or serious physical injury, along with subsequent symptoms of reexperiencing the event, avoidance, and arousal. Dissociative symptoms may also be present. In addition to violence, events that can trigger PTSD include frightening or painful medical illness or procedures. SSRIs are efficacious in the treatment of PTSD. An intensive form of cognitivebehavioral psychotherapy can also be effective. Panic disorder is characterized by recurrent panic attacks. Generalized anxiety is characterized by persistent excessive and uncontrollable worry about everyday life situations. Specific phobias are irrational fears, usually accompanied by avoidance of the feared stimulus. (Answer: B—Posttraumatic stress disorder [PTSD]; start an SSRI)
21. A 34-year-old man comes to your clinic complaining of a recurrent headache. The headache is located posteriorly and is constant, dull, and nonthrobbing. The patient says that it lasts for several hours and that the use of acetaminophen provides some relief. He has been experiencing these symptoms for the past 8 months. On review of systems, the patient reports that he has been having difficulty falling asleep at night and that he has been experiencing fatigue. He says he is concerned about the headaches. He describes himself as a stressed person but denies feeling depressed. The patient smokes cigarettes and drinks alcohol socially. His physical examination is unremarkable. Basic laboratory studies, including a complete blood count, a metabolic profile, and thyroid function tests, are normal.
What therapeutic intervention would you recommend for this patient?
A. Start a beta blocker for headache prophylaxis
B. Start venlafaxine
C. Start a benzodiazepine
D. Reassurance
Key Concept/Objective: To know the different presentations of generalized anxiety disorder (GAD), as well as its treatment
The defining characteristic of GAD is persistent excessive and uncontrollable worry about everyday situations. GAD can be highly debilitating and may predispose to the development of other anxiety or mood disorders. GAD is the most common anxiety disorder seen in primary care settings; patients often present with sleep disturbance or somatic symptoms such as muscle aches and tension headaches. GAD is similar to other anxiety disorders in that it often goes undiagnosed and untreated. Venlafaxine is considered by most experts to be the first-line treatment. SSRIs have been found efficacious, and benzodiazepines have also been used to treat GAD. However, these drugs are generally not used as first-line treatments. Although cognitive-behavioral psychotherapy for GAD has been less studied than for other anxiety disorders, this approach appears promising. (Answer: B—Start venlafaxine)
22. A 29-year-old medical resident is often late for daily rounds. When asked for an explanation, he blames the traffic and his need for taking care of different issues at home before coming to the hospital. It has been noticed that he disappears during rounds, and he has been found several times washing his hands for several minutes before coming back to rounds.
What is the most likely diagnosis for this resident, and what would be the best therapeutic intervention to try first?
A. Obsessive-compulsive disorder (OCD); start clomipramine
B. Substance abuse; refer for psychotherapy
C. Schizophrenia; start an atypical antipsychotic
D. Social phobia; start an SSRI
Key Concept/Objective: To understand OCD and its treatment
OCD is characterized by repeated intrusive thoughts, ideas, or images (obsessions) and by repeated ritualistic behaviors (compulsions). Affected individuals recognize the irrationality of their thoughts but are powerless to control them. OCD is diagnosed when obsessions and compulsions are present for at least an hour a day or at a level that interferes with functioning. It is important to note that this disorder is often associated with considerable shame, and patients who have it may be reluctant to reveal their habits. Serotonin-active antidepressants, including clomipramine, are the first-line agents for OCD. Fluoxetine, sertraline, fluvoxamine, paroxetine, and citalopram also have demonstrated efficacy in the treatment of OCD. Cognitive-behavioral therapy is also highly effective. Social phobia and substance abuse are in the differential diagnosis of this patient. However, the presence of ritualistic behaviors (washing of hands) makes OCD more likely. In this patient, no diagnostic criteria for schizophrenia are present. (Answer: A—Obsessive-compulsive disorder [OCD]; start clomipramine)
For more information, see Shear MK: 13 Psychiatry: VIII Anxiety Disorders. ACP Medicine Online (www.acpmedicine.com). Dale DC, Federman DD, Eds. WebMD Inc., New York, August 2003