A 15-year-old boy is brought by his parents with a complaint of involuntary excessive blinking and twitching of hand muscles that has increased in frequency in the last 2 months and is interfering with preparation for his exams. Involuntary blinking (almost daily) and occasional repetitive vocalizations have been present since he was seven years old. He can suppress the movements sometimes if he tries hard. The episodes are not associated with loss of consciousness. Electroencephalography is normal.
Which one of the following conditions is the most common comorbidity associated with the disorder?
Correct Answer D:
Tics are abnormal movements or vocalizations involving one or more muscles; resulting in blinking of eye, nose sniffing, coughing, neck twitching or jerking, abnormal phonation, and jerking of limbs. Unlike seizures, the tics are suppressible for some time with conscious effort. When both motor and phonic tics are present for more than a year, as in this patient, the condition is described as Tourette syndrome (TS).
TS is a genetic neurological condition and is often associated with attention deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). Over half of the patients with TS also have significant obsessive-compulsive symptoms, and approximately 30% meet the diagnostic criteria for OCD (choice D). The pattern of co-morbidity indicates that the TS gene may be responsible for a spectrum of disorders, including OCD and ADHD.
→ Autism (choice A) is a neuro-developmental disorder of impaired social interaction and communication, and of restricted and repetitive behavior. The movements in autism are purposeful and repetitive unlike in TS.
→ Bipolar disorder (choice B), also known as manic-depressive disorder, is a mood disorder characterized by changes in mood, energy and activity levels affecting ability to carry out daily tasks. It is not known to be present with TS.
→ Chorea (choice C) is a state of excessive, spontaneous movements, irregular, non-repetitive, randomly distributed and abrupt in character. TS does not have an association with chorea.
→ Schizophrenia (choice E) is a thought disorder characterized by abnormal social behavior due to failure to recognize what is real. Thought is not affected in TS and TS is not associated with schizophrenia.
Key point:
In Tourette syndrome, trying to suppress the tics produce anxiety and tension that can only be relieved by allowing the tics to occur, whereas In OCD, the repetitive compulsive behaviors are performed to relieve anxiety caused by an obsession. Neuroimaging studies suggest that both disorders involve defect in the basal-ganglia thalamo-cortical pathways, explaining the co-morbidity.
A 19-year-old receptionist presents to her gynecologist with mild symptoms of anxiety and shyness. On physical examination she notices that the patient has only penciled-in eyebrows and no eyelashes. The remainder of the physical examination is normal.
The most likely diagnosis is which of the following?
Correct Answer E:
Trichotillomania is the irresistible urge to pull out one’s hair. There is some gratification or relief upon pulling out the hair, but the disturbance causes distress or impairment socially. Onset of this condition usually occurs in the teenage years and is four times more common in females. Some mental health experts consider trichotillomania a variant obsessive-compulsive disorder, and it is not uncommon to uncover other ritualistic behaviors or obsessions. The clinical course is varied and since the hair pulling may result in chewing or swallowing hair, trichobezoars may be present in the GI tract, resulting in abdominal complaints, iron deficiency anemia, and hair in the stools.
A 40-year-old man presents to the emergency room with rapid speech, grandiose delusions, insomnia, and hypersexual behaviour of several weeks duration. The history reveals similar past episodes interspersed with periods of psychomotor retardation, hypersomnia, weight gain, and poor job performance.
Which one of the following drugs is most likely to be of long-term benefit for this patient?
Correct Answer C:
A manic episode is defined as ≥ 1 week of a persistently elevated, expansive, or irritable mood, accompanied by ≥ 3 additional symptoms: inflated self-esteem or grandiosity, decreased need for sleep, greater talkativeness than usual, persistent elevation of mood, flight of ideas or racing of thoughts, distractibility, increased goal-directed activity, and excessive involvement in pleasurable activities with a higher risk of undesirable consequences (eg, injury, loss of money). Symptoms impair functioning.
Typically, mood stabilizers are used to induce remission in patients with acute mania or hypomania. Lithium, acts as a mood stabilizer and is similarly effective.
A 28-year-old female complains of insomnia, irritability, increased psychomotor activity, and impulsivity.
Which one of the following is the most likely diagnosis?
Mania is characterized by excessive physical activity and feelings of extreme elation that are grossly out of proportion to any positive event. Hypomania is a less severe form of mania. Manic symptoms typically develop rapidly over a few days. In the early (milder) stages of mania, the person feels better than normal, exuberant, and energetic.
A person who is manic may be irritable, cantankerous, or hostile. He typically believes he is quite well. A lack of insight into his condition, along with a huge capacity for activity, can make the person impatient, intrusive, meddlesome, and aggressively irritable when crossed. Mental activity speeds up (a condition called flight of ideas). The person is easily distracted and constantly shifts from one theme or endeavor to another.
The person may believe he is being assisted or persecuted by others or have hallucinations, hearing and seeing things that are not there. The need for sleep decreases. A manic person is inexhaustibly, excessively, and impulsively involved in various activities (such as risky business endeavors, gambling, or perilous sexual behavior) without recognizing the inherent social dangers. In less severe mania, hospitalization may be needed during periods of overactivity to protect the person and his family from ruinous financial or sexual behavior.
All of the following have been found in association with manic behaviour, except:
Correct Answer B:
Mania can occur by chance association during drug treatment, particularly in patients predisposed to mood disorder. Drugs with a definite propensity to cause manic symptoms include levodopa, corticosteroids and anabolic-androgenic steroids. Antidepressants of the tricyclic and monoamine oxidase inhibitor classes can induce mania in patients with pre-existing bipolar affective disorder.
Drugs which are probably capable of inducing mania, but for which the evidence is less scientifically secure, include other dopaminergic anti-Parkinsonian drugs, thyroxine, iproniazid and isoniazid, sympathomimetic drugs, chloroquine, cimetidine, baclofen, alprazolam, captopril, amphetamine and phencyclidine.
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