Which one of the following is least recognized as a potential adverse effect of electroconvulsive therapy?
Correct Answer B: Although electroconvulsive therapy, by definition, causes a controlled seizure there is no increased risk of epilepsy in the long-term.
Electroconvulsive therapy:
Electroconvulsive therapy is a useful treatment option for patients with severe depression refractory to medication or those with psychotic symptoms. The only absolute contraindications is raised intracranial pressure.
Short-term side-effects:
Long-term side-effects:
A 24-year-old man is brought to the Emergency Department by his brother who is concerned about his odd behaviour. Over the past two weeks he has started to tell his brother that he can hear people talking about him on the radio. He denies any auditory hallucinations. During the consultation he scores 10/10 on the mini-mental state examination. When asked to explain the meaning of the statement 'people in glass houses shouldn't throw stones' he replies 'you may break the glass'.
What is this an example of?
Correct Answer C: This is an example of concrete thinking where a patient cannot use abstraction to understand the meaning of a sentence. It is more common in schizophrenia. Literal thinking is of course a feature of autism but this would not explain his delusional perception and is unlikely to present in a sub-acute fashion at this age.
Schizophrenia: features:
Schneider's first rank symptoms may be divided into auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions:
Auditory hallucinations of a specific type:
Thought disorder*:
Passivity phenomena:
Delusional perceptions:
Other features of schizophrenia include:
*occasionally referred to as thought alienation.
A 16-year-old girl is brought for review by her father. She is talented violinist and is due to start music college in a few weeks time. Her parents are concerned she has had a stroke as she is reporting weakness on her right side.
Neurological examination is inconsistent and you suspect a non-organic cause for her symptoms. Despite reassurance about the normal examination findings the girl remains unable to move her right arm.
What is the most appropriate term for this behaviour?
Correct Answer D: This is a typical conversion disorder. There may be underlying tension regarding her musical career which be manifesting itself as apparent limb weakness.
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:
Which one of the following selective serotonin reuptake inhibitors has the highest incidence of discontinuation symptoms?
Correct Answer A: Paroxetine - higher incidence of discontinuation symptoms.
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 6months 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:
You review a 55-year-old woman who has become dependent on temazepam, which was initially prescribed as a hypnotic. She is keen to end her addiction to temazepam and asks for help. Her current dose is 20mg on.
What is the most appropriate strategy?
Correct Answer E:
Benzodiazepines:
Benzodiazepines enhance the effect of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). They therefore are used for a variety of purposes:
Patients commonly develop a tolerance and dependence to benzodiazepines and care should therefore be exercised on prescribing these drugs. The Committee on Safety of Medicines advises that benzodiazepines are only prescribed for a short period of time (2-4 weeks).
The BNF gives advice on how to withdraw a benzodiazepine. The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given:
If patients withdraw too quickly from benzodiazepines they may experience benzodiazepine withdrawal syndrome, a condition very similar to alcohol withdrawal syndrome. This may occur up to 3 weeks after stopping a long-acting drug. Features include:
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