A 50-year-old male with a history of methamphetamine abuse requests medication to treat this problem. According to evidence-based studies, which one of the following would be most likely to help this patient overcome methamphetamine dependence?
Correct Answer E:
Methamphetamine dependence is very difficult to treat. No medications have been approved by the FDA for the treatment of this problem, nor have any studies shown consistent benefit to date. The standard therapy for methamphetamine dependence is outpatient behavioral therapies, especially with case management included. Therapy must be individualized. Support groups and 12-step drug-treatment programs may be helpful.
A 36-year-old female has been seen multiple times in the past several months for various pain-related complaints. On each occasion, no physical or laboratory findings were found to explain the symptoms. The patient is involved in a worker’s compensation case and could make a significant amount of money if it is demonstrated that her physical complaints are related to work conditions.
Which one of the following diagnoses characterizes her unexplained physical symptoms?
Correct Answer D:
This patient most likely is malingering, which is to purposefully feign physical symptoms for external gain. Factitious disorder involves adopting physical symptoms for unconscious internal gain, such as deriving comfort from taking on the role of being sick. Somatization disorder is related to numerous unexplained physical symptoms that last for several years and typically begin before 30 years of age. Conversion disorder involves a single voluntary motor or sensory dysfunction suggestive of a neurologic condition, but not conforming to any known anatomic pathways or physiologic mechanisms.
Which one of the following is the most common psychiatric complication of insulin-dependent diabetes mellitus?
Correct Answer B:
Psychological morbidity is increased with diabetes, as it is in children with other chronic illnesses. Initial adjustment to diabetes is characterized by sadness, anxiety, withdrawal, and dependency, and 30% of children develop a clinical adjustment disorder in the 3 months after diagnosis. Such difficulties often resolve within the first year, but poor adaptation in this initial phase places children at risk for later psychological difficulties.
Mood disorders such as major depressive disorder and dysthymia are the most frequently reported diagnoses in youth with type 1 diabetes, with a cumulative probability of 27.5% by the 10th year of type 1 diabetes duration.
An 11-year-old boy was brought to the psychiatric clinic after refusing to go to school. His parents believe that this behaviour is probably related to the frequent involuntary shoulder shrugging that appeared in the last 13 months. The patient admitted that he is embarrassed by this and feels shy and that is why he does not want to go to school. The shoulder shrugging habit started after a bout of sore throat but it has become worse lately. No other symptoms could be elicited. The boy was performing well in school. Patient has no past history of mental disorder or drug use. On examination, the patient looks well, not pale jaundiced or cyanosed. He does not seem anxious or tense. During history taking, he shrugged his shoulder many times but irregularly. Whenever he shrugged his shoulder he also produced a barking sound.
The most likely diagnosis is:
The typical features of Tourette’s disorder (choice D) are shown by this patient, namely stereotypical nonrhythmic movements (shoulder shrugging) and vocalization (barking sound). In some children, the disorder follows beta hemolytic streptococcal infection.
→ Tardive dyskinesia (choice A) is an abnormal movement that results from prolonged use of antipsychotic drugs. The patient has no history of use of these drugs. In addition, tardive dyskinesia is not associated with vocalization (the barking sound).
→ Although, the preceding streptococcal infection might suggest Sydenham's chorea (choice B), the presenting symptoms are not typical of this disorder. In Sydenham's chorea, the movements are non-repetitive and seem to jump from one muscle group to the other. In addition, chorea is also not associated with vocalization. Deterioration in handwriting would be the most likely presentation in a school child with Sydenham's chorea.
→ Akathisia (choice C) is another complication of antipsychotic drugs. The anxiety and tension typical of Akathisia are not observed in our patient. In addition, akathisia is not associated with vocalization (the barking sound). Furthermore, the drug history is negative.
→ A child with ADHD (choice E) is not expected to perform well in school. In addition, ADHD usually presents at younger age. The patient of ADHD fidgets, moves from one place to the other or touches things and all these movements are purposeful.
Key point:
A good history and examination might be all that is required to differentiate between different types of abnormal movements.
You make a diagnosis of depression in a 26-year-old female. Her BMI is 32 kg/m² and she has been trying to lose weight.
Which one of the following antidepressants would be least likely to cause her to gain weight?
Correct Answer C:
Bupropion is the antidepressant least likely to cause weight gain and may induce modest weight loss. All of the other choices are more likely to cause weight gain. Among SSRIs, paroxetine is associated with the most weight gain and fluoxetine with the least. Mirtazapine has been associated with more weight gain than the SSRIs.
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