A sudden onset of chorea is least likely in which of the following conditions?
E. The onset of Huntington’s disease is invariably insidious and gradually progressing. Acute onset of chorea is suggestive of a metabolic cause or secondary to toxins. Huntington’s disease is an autosomal dominant disease with full penetrance, that is every person with the mutant gene will develop the full form of the disease if they live long enough. Huntington’s disease also exhibits genetic anticipation,that is each successive generation suffers progressively earlier onset. Huntington’s is a disease of trinucleotide repeat sequences in genetic coding. The pathogenesis is an excess CAG repeats in the IT15 gene on chromosome 4p. The age of onset depends on the actual number of trinucleotide repeats. Symptoms of Huntington’s disease consist of a triad – motor, cognitive, and psychiatric problems. The prevalence of Huntington’s is around 4–7 per 100,000 with average life expectancy less than 15 years after symptomatic clinical presentation.
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Which of the following is NOT a feature of subacute combined degeneration of the spinal cord?
A. Features suggestive of subacute combined degeneration of the cord (SACD) include paraesthesias, diffi culties with gait and balance, and signs of posterior column dysfunction. This results in sensory ataxia with a positive Romberg’s sign and bladder atony. Pain and temperature sensations are usually intact. Bilateral corticospinal tract dysfunction in SACD results in spasticity, hyper-refl exia, and bilateral Babinski’s signs. However, refl exes may be lost or hypoactive because of superimposed peripheral neuropathy.
Which of the following physical symptoms is seen in factitious disorder?
E. Factitious disorder is a condition where clinical symptoms are consciously and intentionally produced by the patient. But interestingly the only gain for the patient from such symptom production is the adoption of a patient’s role, without any clear monetary or employment gains. In malingering, symptoms are consciously and intentionally produced, but the goal is a material or concrete gain, for example claiming employment compensation or avoiding military duty. In somatoform disorders, such as somatization, the symptoms are not produced intentionally and the origin remains unconscious.
A man admitted to the psychiatric intensive care unit with a manic episode, received 10 mg of haloperidol intramuscularly as he had turned violent. He became unresponsive shortly afterwards. On examination, there is evidence of:
What is the most important differential diagnosis?
B. Neuroleptic malignant syndrome is a medical emergency that can occur when treating a patient with antipsychotics. Symptoms and signs include muscular rigidity, altered consciousness, akinesia, mutism, and agitation. Autonomic symptoms include hyperthermia (temperature >38°C), sweating, labile pulse rate, and fl uctuating blood pressure. Altered consciousness is not seen in tardive dyskinesia or akathisia.
Which of the following questionnaires is used to identify psychiatric ‘caseness’ in the general population:
C. General health questionnaire (GHQ) is used to define psychiatric ‘caseness’ in epidemiological studies. In community surveys where a large population is screened, the best technique to detect psychiatric illness consists of two phases. Initially, potential cases are identified using a self-rated questionnaire, such as GHQ. Once ‘caseness’ is suspected, detailed interviews or other diagnostic tools are used to confirm a diagnosis. MMPI stands for Minnesota Multiphasic Personality Inventory. It is a detailed questionnaire used to measure various personality traits (not disorders). HDRS stands for Hamilton Depression Rating Scale. It is a commonly used, clinician administered mood rating scale after a diagnosis of depression is made. Young’s Mania Rating Scale (YMRS) is used to measure severity of mania or hypomania.
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