Which of the following is the most common psychiatric manifestation of Cushing’s syndrome?
A. Full depressive syndrome has been reported in up to 70% of people with Cushing’s syndrome. The most common cause of Cushing’s syndrome is pharmacological. Cushing’s disease is a primary pituitary tumour, which secretes an excess of adrenocorticotropic hormone (ACTH). Psychiatric manifestations may be due to the direct effects of elevated corticosteroids on the neurons or due to hypothalamic dysfunction. The neocortex and hippocampus have glucocorticoid receptors, the action on which could explain the cognitive and mood disorder seen in these patients. Cushing’s disease has been associated with a reduction in hippocampal volume, which is reversed on correction of steroid levels. There is also some evidence to show that stress could be associated with exacerbation of the illness.
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A 60-year-old woman who recently underwent radiation therapy to her neck presented with ‘painful bones, renal stones, abdominal groans, and psychic moans’.
Which of the following condition is she most likely to be suffering from?
A. This patient shows the classical features of hyperparathyroidism leading to hypercalcaemia, possibly precipitated by the irradiation to the neck. The psychic moans are most commonly due to depression and cognitive symptoms. These have been correlated with the degree of calcium elevation. In severe cases, confusion, catatonia, agitation, psychosis, and coma can occur. Most patients improve with treatment and correction of calcium levels.
The prevalence of major depressive disorder in patients with Huntington’s disease is around:
D. Huntington’s disease is an autosomal dominant disorder resulting from a mutation on chromosome 4, which leads to an increased number of CAG trinucleotide repeats from 6–34 to 39–86. Patients with longer trinucleotide repeat lengths have an earlier age of onset and more rapid progression than those with fewer repeats. It is seen that those who inherit the disease from the paternal side have a greater number of repeats and hence show an earlier age of onset, a phenomenon called genetic anticipation. Clinically, Huntington’s disease is manifested by the triad of chorea, dementia, and psychiatric symptoms. Approximately 40% of patients exhibit major depressive disorders or meet criteria for dysthymia. Approximately 10% of patients exhibit hypomania and a few may have manic episodes. Apathy, irritability, and disinhibition may be present independent of a mood disorder. Sexual misconduct is more common, occurring in up to 20% of Huntington’s disease patients. The rate of suicide is increased up to four times in patients with Huntington’s disease.Psychiatric symptoms do not correlate with the CAG repeat length.
Which of the following is a feature of cognitive dysfunction in Huntington’s disease?
D. Verbal recognition is relatively spared compared with recall, which suggests a retrieval problem rather than an encoding problem. Problems with verbal memory and visuospatial function appear early in Huntington’s disease, but don’t progress as much as in patients with Alzheimer’s. The picture is typical of a subcortical dementia involving frontal subcortical circuits. Patients with Huntington’s disease show a typical loss of procedural memory. Executive function is lost early in the disease. They also show psychomotor slowing and attentional deficits that correlate with activities of daily living (ADL). Unlike psychiatric symptoms, cognitive symptoms correlate with the number of trinucleotide repeats. Speech comprehension is maintained late into the disease well after intelligible speech production is lost.
Which of the following is a feature of amnestic mild cognitive impairment (MCI)?
E. MCI is a syndrome characterized by the presence of cognitive decline greater than that expected for age and education level along with normal ADL. It is, thus, distinct from dementia, in which cognitive deficits are more severe and widespread and have a significant effect on daily function. A further subtype of MCI, amnestic subtype, has a higher rate of conversion to Alzheimer’s disease. They characterized by memory complaints, corroborated by an informant: the presence of memory impairment relative to age- and education-matched healthy people; typical general cognitive function; largely intact ADL; and not clinically demented. Prevalence in population-based epidemiological studies ranges from 3% to 19% in adults older than 65 years. Compared with people with dementia and normal controls, individuals with MCI have intermediate amounts of Alzheimer’s disease pathology, including amyloid deposition and tau-positive tangles in the mesial temporal lobes.
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