The preferred method for diagnosing psychogenic nonepileptic seizures is:
Correct Answer D:
Inpatient video-electroencephalography (vEEG) monitoring is the preferred test for the diagnosis of psychogenic nonepileptic seizures (PNES), and is considered the gold standard (SOR B). Video-EEG monitoring combines extended EEG monitoring with time-locked video acquisition that allows for analysis of clinical and electrographic features during a captured event. Many other types of evidence have been used, including the presence or absence of self-injury and incontinence, the ability to induce seizures by suggestion, psychologic tests, and ambulatory EEG. While useful in some cases, these alternatives have been found to be insufficient for the diagnosis of PNES.
Elevated postictal prolactin levels (at least two times the upper limit of normal) have been used to differentiate generalized and complex partial seizures from PNES, but are not reliable (SOR B). While prolactin levels are often elevated after an epileptic seizure, they do not always rise, and the timing of measurement is crucial, making this a less sensitive test than was previously believed. Other serum markers have also been used to help distinguish PNES from epileptic seizures, including creatine phosphokinase, cortisol, WBC counts, lactate dehydrogenase, pCO2, and neuron specific enolase. These also are not reliable, as threshold levels for abnormality, sensitivity, and specificity have not been determined.
MRI is not reliable because abnormal brain MRIs have been documented in as many as one-third of patients with PNES. In addition, patients with epileptic seizures often have normal brain MRIs.
A 58-year-old male presents with recent behavior and personality changes, and you suspect dementia.
Which one of the following is most likely to present in this manner?
Frontotemporal dementia is the second most common cause of early-onset dementia. It often presents with behavioral and personality changes. Examples include disinhibition, impairment of personal conduct, loss of emotional sensitivity, loss of insight, and executive dysfunctions. Alzheimer’s disease presents with memory loss and visuospatial problems. Vascular dementia is associated with risk factors for stroke, or occurs in relation to a stroke, with a stepwise progression. Alzheimer’s disease and vascular dementia can occur together, with features of both. Progressive supranuclear palsy is characterized by early falls, vertical (especially downward) gaze, axial rigidity greater than appendicular rigidity, and levodopa resistance.
When obtaining informed consent from a patient, which one of the following is NOT required for a patient to legally have decision-making capacity?
Correct Answer A:
Patients with mental illness may have decision-making capacity if they are able to understand and communicate a rational decision. The key factors to consider in determining decision-making capacity include whether the patient can express a choice, understand relevant information, appreciate the significance of the information and its consequences, and engage in reasoning as it relates to medical treatment.
Treatment with donepezil is associated with an increased risk for:
Correct Answer C:
A large population study has established a significant increased risk of bradycardia, syncope, and pacemaker therapy with cholinesterase inhibitor therapy. Elevation of liver enzymes with the potential for hepatic dysfunction has been seen with tacrine, but it has not been noted with the other approved cholinesterase inhibitors. Cataract formation and thrombosis with pulmonary embolism do not increase with this therapy. Although improvement in mental function is often marginal with cholinesterase inhibitor therapy, the therapy has not been shown to increase the need for institutionalization.
A 37-year-old male who has been treated for a mood disorder for the last 6 months, presents with a complaint of some "personal problems." On questioning, he reports that he noticed he has had decreased libido and delayed ejaculation during intercourse.
Which of the following medications is the patient most likely taking?
This patient’s mood disorder he has been treated for is probably the major depression. He has been, most likely, on a selective serotonin reuptake inhibitor (SSRI) such as Sertraline (choice D). While the mechanisms by which SSRIs cause sexual dysfunction has yet to be clarified, it has been postulated that reduced hypothalamic-pituitary-testis axis function and decreased testosterone levels are the changes most likely involved.
→ Lithium (choice A) and Sodium Valproate (choice E) are also mood stabilizers used in the treatment of bipolar disorder. They are not associated with sexual dysfunction. Lithium is associated with nephrogenic diabetes insipidus and congenital heart defects in children of mothers who used it during pregnancy. Sodium valproate is also associated with neural tube defects in children whose mother used it during pregnancy.
→ Mirtazapine (choice B) is a noradrenergic and specific serotonergic antidepressant, it is not considered to have some of the risk factors seen in SSRIs such as sexual dysfunction.
→ Bupropion (choice C) is one of the few antidepressant medications without sexual dysfunction side effects. Bupropion, however, reduces the seizure threshold, and should be avoided in alcoholics and other patients with seizure risk factors.
Key point:
Selective serotonin reuptake inhibitors (SSRIs) have been reported to reduce libido in women and men, to cause anorgasmia in women, and to increase ejaculation latency in men.
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