Question 16#

Which of the following is a feature of systemic lupus erythematosus (SLE)?

A. Late involvement of the central nervous system (CNS)

C. Psychiatric manifestations are common in SLE. Up to 90% of patients have some neuropsychiatric manifestation. In most patients, CNS complications present early in the illness, and studies that have looked into it have found no relationship between systemic disease activity and neuropsychiatric manifestations. In fact, neuropsychiatric causes are second only to renal causes as far as mortality is concerned in these patients. These complications include stroke, seizures, transverse myelitis, etc. Cognitive deficits are the most common neuropsychiatric manifestation in these patients. It is present in up to 80% of the patient sample. These have been correlated with the presence of anticardiolipin antibody. In this way, most psychiatric illnesses have been correlated with the presence of an antibody in the blood. Depression has been reported in up to 40% of people with SLE. Psychiatric symptoms in SLE have been attributed to direct CNS involvement, infections, side-effects of medications, reactions to chronic illness and primary psychiatric illness. Similarly, stress has been linked to exacerbation of SLE. This is said to be mediated through the immune system.

References:

1. Levenson JL. Essentials of Psychosomatic Medicine, 1st edn. American Psychiatric Press, 2006, 139–141.
2. Stojanovicha L, Zandman-Goddardb G, Pavlovicha S and Sikanichd N. Psychiatric manifestations in systemic lupus erythematosus Autoimmunity Reviews 2007; 66: 421–426.

Question 17#

Which of the following is a characteristic feature of paediatric autoimmune neuropsychiatric disorder due to group A streptococcal infection (PANDAS)? 

A. Arthritis

E. PANDAS is a controversial disease. In fact, Levinson says that it is not a diagnosis, but a syndrome where obsessive compulsive disorder and tics have been exacerbated in children following a group A beta-haemolytic streptococcal (GABHS) infection. The diagnostic criteria for PANDAS that were proposed by Swedo et al. in 1998 include the following: OCD and/or chronic tic disorder (Tourette’s, chronic motor, or vocal tic disorder) that meets the DSM-IV diagnostic criteria; age at onset between 3 years and the onset of puberty; clinical course with an abrupt onset of symptoms and/or a pattern of dramatic recurrent exacerbations and remissions; temporal relation between GABHS infection and onset and/or exacerbations of clinical symptoms; and neurologic abnormalities such as motoric hyperactivity, tics, or choreiform activity during an exacerbation.

References:

1. James L. Levenson Essentials of Psychosomatic Medicine, 1st edn. American Psychiatric Press, 2006, p. 181.
2. Swedo SE, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. American Journal of Psychiatry 1998; 155: 264–271.

Question 18#

Which of the following is the most common psychiatric manifestation of hyperthyroidism?

A. Major depression

A. Despite the fact that anxiety is a cardinal feature of hyperthyroidism, anxiety disorders are observed in only up to 15% of the patients. Major depression is the most common psychiatric manifestation, seen in up to 25% of the people diagnosed with hyperthyroidism. Cognitive disturbance is seen in around 7.5% of patients. Mania and hypomania are less common, with a prevalence of around 2%, and psychosis occurs in around 2% of the population with hyperthyroidism.

Reference:

1. Hales RE and Yudofsky SC. The American Psychiatric Publishing Textbook of Neuropsychiatry and Clinical Neurosciences, 4th edn. American Psychiatric Press, 2002, pp. 858–860.

Question 19#

Which of the following is the most commonly reported psychiatric symptom in hypothyroidism?

A. Depression

B. Patients with hypothyroidism present with all of the above symptoms. But the most commonly reported psychiatric symptoms are that of cognition, which occurs in around 45% of the patients. This can extend from mild subjective slowing to delirious and even encephalopathic states. Delirium is the most severe manifestation of hypothyroidism. Depression is the second most frequent psychiatric syndrome. Anxiety disorder is present in around 30% of the patients, and although myxoedema madness ‘psychosis’ is one of the most common symptoms reported in the literature, it represents only around 5% of psychiatric morbidity in these patients.

Reference:

1. Hales RE and Yudofsky S.C. The American Psychiatric Publishing Textbook of Neuropsychiatry and Clinical Neurosciences, 4th edn. 2002, p. 856–857.

Question 20#

Regarding corticosteroid-induced neuropsychiatric complications, which of the following statements is true?

A. Predominantly affective illness

E. Nearly all steroids have been implicated. Psychiatric symptoms are mostly affective in nature, more specifically elation. Psychosis, delirium, and anxiety have been reported. Steroid induced psychosis may be secondary to delirium, an exacerbation of pre-existing psychosis or frank psychosis precipitated by steroids (this includes mania). The prevalence of psychiatric disturbance in patients who have been administered corticosteroids is said to be dose related. Various strategies to prevent the onset of steroid-induced psychiatric manifestations include administering the medication in divided doses, enteric coated preparations, lithium, and valproate prophylaxis for those with a previous history. Tricyclic antidepressants (TCAs) are best avoided as these have been associated with an exacerbation of symptoms.

Reference:

1. Hales RE and Yudofsky SC. The American Psychiatric Publishing Textbook of Neuropsychiatry and Clinical Neurosciences, 4th edn. American Psychiatric Press 2002, p. 863.