Each of the following is associated with conversion disorder, except:
Correct Answer A:
Many conversion disorder patients exhibit la belle indifference, a lack of concern regarding an apparent extreme decline in their health. This condition often presents in late adolescence or early adulthood and is more common in women with histrionic personality disorder and past history of sexual abuse during childhood. In contrast to malingering or factitious disorder, the symptoms of a conversion disorder are not intentionally produced, but rather the ego defense mechanisms of repression and dissociation are unconsciously at work. The symptoms generally begin suddenly following a period of psychological stress and in most cases end abruptly and are of a short duration.
A male patient has diabetes and hypertension for which he takes propranolol. He comes in with a complaint of progressive impotence. He states that because of this he has not had sexual intercourse with his wife for more than 6 months. He admits to you privately that he has had morning erection and also erections when he views adult magazines.
What is the appropriate next step in management?
Correct Answer B:
The most frequent physical causes of erectile dysfunction are vascular (blood vessel) diseases. Vascular diseases may cause problems involving blood flow into the penis to make it erect. They can also cause problems with holding the blood in the penis to maintain the erection. Thus, hardening of the arteries and other diseases that affect the vascular system are risk factors for erectile dysfunction.
However this patient is able to achieve erections. Therefore a psychological cause is likely. This includes stress and anxiety due to marital, financial or other personal problems. For example, a man who has lost interest in his spouse may suddenly find himself unable to have an erection with her. It is possible for the man's stress and anxiety to interfere with nerve impulses from his brain when he attempts sexual intercourse.
What would be the best treatment for Tourette's syndrome?
Tourette's syndrome is a hereditary tic disorder that begins in childhood. Symptoms include simple, complex, and vocal tics. Diagnosis is clinical. Treatment may include clonidine or antipsychotics such as pimozide (choice A).
→ Fluoxetine (choice B) is appropriate for the treatment of depression.
→ Lithium (choice C) is appropriate for the treatment of bipolar disorder.
→ Cognitive behavioral therapy (choice D) is becoming recognized as a useful treatment approach in Tourette's syndrome. Competing-response training, which is the basis of Comprehensive Behavioral Intervention for Tics (CBIT), has been shown to produce significant improvement in 50% of children. However, this is therapy is still under study and pimozide with its 80% success rate is a more effective treatment.
→ Methylphenidate (choice E) is used in the treatment of attention-deficit hyperactivity disorder, it is not appropriate for Tourette's syndrome.
A 17-year-old man presents with symptoms of constant blinking and sniffing. He has had it for several years, but lately it has worsened. He also has recently had some inappropriate loud outbursts at work.
Which of the following disorders is likely?
Tourette's syndrome is a hereditary tic disorder that begins in childhood. TS is usually diagnosed in children and adolescents aged 6-17 years. Symptoms include simple, complex, and vocal tics. The movement disorder may begin with simple tics (eg, facial grimacing, head jerking, blinking, sniffing) that progress to multiple complex tics, including respiratory and vocal ones (eg, loud, irritating vocalizations; snorting). Vocal tics may begin as grunting or barking noises and evolve into compulsive utterances that are often loud or shrill.
Patients may voluntarily suppress tics for seconds or minutes. Coprolalia (involuntary scatologic or obscene utterances) occurs in a few patients. Severe tics and coprolalia are physically and socially disabling. Echolalia (immediate repetition of one's own or another person's words or phrases) is common. Diagnosis is clinical. Treatment may include clonidine or antipsychotics.
A 12-year-old boy is brought into the office by his mother for symptoms of anxiety and checking behaviors. His mother gives a normal birth history and states that the boy’s developmental milestones were normal from birth. From age 4, she notes that he has been easily distracted and extremely overactive for his age. At age 7 he was given the diagnosis of ADHD and was treated with methylphenidate. His anxiety was noted only recently and appears to be associated with the need for symmetry and counting rituals. On evaluation, the boy displayed motor tics of excessive blinking, head turning, and repetitive foot stomping. He would frequently clear his throat and repeatedly grunt or sniff. When these behaviors were brought to the attention of the mother, she stated, “Oh yes, he does that all the time, but so does his father.”
Aside from its possible adverse effects, which of the following medications would be most helpful to treat the patient’s motor and vocal tics?
Tourette’s syndrome (TS) is characterized by chronic motor and vocal tics that begin in childhood. Comorbid psychiatric disorders that are often seen with Tourette’s syndrome include obsessive-compulsive disorder (OCD) and attention deficit disorder. Tourette’s disorder is up to nine times more common in male children than female children, and family studies suggest that tic disorders share a common genetic etiology.
The management of TS is multifaceted. The approach is primarily aimed at medical management of frequent or disabling tics, treatment of coexisting behavior symptoms, and patient and family education. Various therapeutic agents are now available to treat patients with tics, and each medication should be chosen on the basis of expected efficacy and potential adverse effects. The alpha2-adrenergic drugs clonidine and guanfacine are first-line agents in treating mild to moderate tics.
The D2 dopamine receptor-blocking medications (neuroleptics) are the most effective medications for treating tics, and many experts use the neuroleptics as the initial agent of choice for that reason. However, the side effect profile, which includes extrapyramidal symptoms/tardive dyskinesia, is often a limitation to using these agents as first-line therapy. Haloperidol and pimozide, the two most studied neuroleptics, have been approved for the treatment of tics in TS.
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