The wife of a 45-year-old executive says that over the past 6 months her husband has been accusing her of having an extramarital affair. He has been phoning her work place, checking her mail and phone calls. She says that there is absolutely no truth to the allegation, but despite the efforts of herself and his family to reassure him, he continues to accuse her.
Which one of the following is the likely cause?
Correct Answer A:
Delusional Disorder is relatively uncommon in clinical settings, with most studies suggesting that the disorder accounts for 1%-2% of admissions to inpatient mental health facilities.
The essential feature of Delusional Disorder is the presence of one or more nonbizarre delusions that persist for at least 1 month . Auditory or visual hallucinations, if present, are not prominent. Tactile or olfactory hallucinations may be present (and prominent) if they are related to the delusional theme Apart from the direct impact of the delusions, psychosocial functioning is not markedly impaired, and behavior is neither obviously odd nor bizarre. If mood episodes occur concurrently with the delusions, the total duration of these mood episodes is relatively brief compared to the total duration of the delusional periods. The delusions are not due to the direct physiological effects of a substance (e.g., cocaine) or a general medical condition (e.g., Alzheimer's disease, systemic lupus erythematosus).
Psychosocial functioning is variable. Some individuals may appear to be relatively unimpaired in their interpersonal and occupational roles. In others, the impairment may be substantial and include low or absent occupational functioning and social isolation. When poor psychosocial functioning is present in Delusional Disorder, it arises directly from the delusional beliefs themselves.
Which one of the following is true regarding the treatment of generalized anxiety disorder?
Cognitive-behavioral therapy has been shown to be at least as effective as medication for treatment of generalized anxiety disorder (GAD), but with less attrition and more durable effects. Many SSRIs and SNRIs have proven effective for GAD in clinical trials, but only paroxetine, escitalopram, duloxetine, and venlafaxine are approved by the FDA for this indication. Benzodiazepines have been widely used because of their rapid onset of action and proven effectiveness in managing GAD symptoms. SSRI or SNRI therapy is more beneficial than benzodiazepine or buspirone therapy for patients with GAD and comorbid depression.
A 73-year-old white male is brought to your office by his family. He had uncontrolled hypertension and was found to have renal artery stenosis, but became normotensive following stent placement. Since then he has lost 6 kg (13 lb) and has no appetite. He is 165 cm (68 in) tall and currently weighs 59 kg (130 lb). He has been feeling anxious, and during a recent home repair he cut a hole in a wall and noticed a white material, which he believes is asbestos. He is concerned that the news media will find out about this, that his home will be condemned, and that the whole world will know. His affect is flat, and his eye contact is poor. However, he is alert and oriented. The remainder of the examination is normal. He is given an adequate trial of paroxetine (Paxil) and venlafaxine (Effexor) with no relief of symptoms, and continues to lose weight.
Which one of the following would be the most effective treatment at this time?
Correct Answer E:
This patient has late-life psychotic depression, as indicated by his delusional thinking. Psychotic depression is often resistant to standard antidepressant regimens. Aggressive pharmacotherapy is required, with best results in young adults.
Available evidence suggests that most elderly patients who have depression with pronounced psychotic features either cannot tolerate adequate doses of conventional medications or do not respond to them. For severe depression that is persistent and refractory to psychotherapy and pharmacotherapy, electroconvulsive therapy (ECT) is the most effective treatment. ECT has therefore become the standard for treatment of late-life psychotic depression.
A 65-year-old male presents for a follow-up visit for severe depression. His symptoms have included crying episodes, difficulty maintaining sleep, and decreased appetite. He has suicidal ideations and states that he has a gun in his home. He also thinks his wife is having an affair, but she is present and is adamant that this is not true. His symptoms have not been relieved by maximum doses of sertraline (Zoloft), venlafaxine (Effexor), or citalopram (Celexa). He currently is taking duloxetine (Cymbalta), which also has failed to relieve his symptoms.
Which one of the following would most likely provide the quickest relief of his symptoms?
Correct Answer D:
This patient has psychotic depression with suicidal ideations and has not responded to maximum doses of several antidepressants. He is more likely to respond to electroconvulsive therapy than to counseling or a change in medication.
An elderly woman is admitted to a psychiatric unit for workup of possible depression. Her symptoms consist primarily of lethargy and indifference. She appears to ignore the left side of her body in her daily activities, and when questioned about this, she denies any difficulties.
This patient should be suspected of having a:
Correct Answer B:
The parietal lobes can be divided into two functional regions. One involves sensation and perception and the other is concerned with integrating sensory input, primarily with the visual system. The first function integrates sensory information to form a single perception (cognition). The second function constructs a spatial coordinate system to represent the world around us. Individuals with damage to the parietal lobes often show striking deficits, such as abnormalities in body image and spatial relations.
Damage to the left parietal lobe can result in what is called "Gerstmann's Syndrome." It includes right-left confusion, difficulty with writing (agraphia) and difficulty with mathematics (acalculia). It can also produce disorders of language (aphasia) and the inability to perceive objects normally (agnosia).
Damage to the right parietal lobe can result in neglecting part of the body or space (contralateral neglect), which can impair many self-care skills such as dressing and washing. Right side damage can also cause difficulty in making things (constructional apraxia), denial of deficits (anosognosia) and drawing ability.
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