A 18-year-old sprinter who is currently preparing for a national athletics meeting asks to see the team doctor due to an unusual sensation in his legs. He describes a numb sensation below his knee. On examination the patient there is apparent sensory loss below the right knee in a non-dermatomal distribution. The team doctor suspects a non-organic cause of his symptoms.
This is an example of a:
Correct Answer A: Unexplained symptoms.There are a wide variety of psychiatric terms for patients who have symptoms for which no organic cause can be found:
Somatization disorder:
Hypochondrial disorder:
Conversion disorder:
Dissociative disorder:
Munchausen's syndrome:
Malingering:
A 23-year-old man presents as he is concerned about a number of recent episodes related to sleep. He finds when he wakes up and less often when he is falling asleep he is 'paralyzed' and unable to move. This sometimes associated with what the patient describes as 'hallucinations' such as seeing another person in the room. He is becoming increasingly anxious about these recent episodes.
What is the most likely diagnosis?
Correct Answer C: Sleep paralysis is a common condition characterized by transient paralysis of skeletal muscles which occurs when awakening from sleep or less often while falling asleep. It is thought to be related to the paralysis that occurs as a natural part of REM (rapid eye movement) sleep. Sleep paralysis is recognized in a wide variety of cultures.
Sleep paralysis:
Features:
Management:
A 34-year-old man originally from West Africa is seen in January with depression. There is no past medical history of note but he is known to smoke cannabis. He has had similar episodes for the past two winters.
Correct Answer C: Seasonal Affective disorder (SAD) describes depression which occurs predominately around the winter months. Bright light therapy has been shown to be more effective than placebo for patients with SAD.
You review a patient who has been taking citalopram for the past two years to treat depression. He has felt well now for the past year and you agree a plan to stop the antidepressant.
How should the citalopram be stopped?
Correct Answer E: This not necessary with fluoxetine due to its longer half-life.
Depression: selective serotonin reuptake inhibitors:
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression.
Adverse effects:
Interactions:
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks.
For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms:
Which one of the following side-effects is more common with atypical than conventional antipsychotics?
Correct Answer B: Atypical antipsychotics commonly cause weight gain.
Atypical antipsychotics Atypical: antipsychotics should now be used first-line in patients with schizophrenia, according to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
Adverse effects of atypical antipsychotics: Weight gain
Clozapine is associated with agranulocytosis (see below)
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
Examples of atypical antipsychotics:
Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason clozapine should only be used in patients resistant to other antipsychotic medication.
Adverse effects of clozapine:
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