Which ONE of the following is an important feature of somatization disorder when differentiating it from conversion disorder, malingering or hypochondriasis?
Answer: A: Although somatoform disorders are not common psychiatric conditions they are important as these patients occasionally present to the ED. Lack of awareness regarding these disorders may lead to difficulties in detection and appropriate interventions. Four types of specific disorders are collectively called somatoform disorders. They are:
The symptoms of somatoform disorders are not under the voluntary control of the patient. They genuinely believe their symptoms are due to real physical disease. This is not the case in malingering and factitious disorder, where the symptoms are under the conscious control of the patient.
Somatization means the patient’s experience and communication of their psychological distress manifests as physical complaints or symptoms without identifiable pathology to explain the symptoms. Depression and anxiety disorder are often present in these patients. They often present with multiple symptoms rather than a few specific symptoms. Most patients may not strictly fulfill the DSM-IV diagnostic criteria for somatization disorder. The diagnosis is usually not made but can be suspected in the ED.
The following seven symptoms can be used as a rapid screening test for somatization in the ED setting:
In a conversion disorder there is a sudden and dramatic onset of a single symptom without associated pathophysiological or anatomical explanation. The typical symptoms are that of a non-painful neurological disorder such as pseudoseizure, syncope, coma, paralysis of a single limb, tremors and sensory loss in a limb. Patients describe these symptoms with apparent lack of concern for their gross symptoms.
The presence of physical symptoms that are disproportionate to demonstrable organic disease is a characteristic of hypochondriasis.
Reference:
Which ONE of the following statements is TRUE regarding neuroleptic malignant syndrome?
Answer: D: Neuroleptic malignant syndrome is a rare but potentially fatal condition associated with the use of dopamine antagonists. It most commonly occurs as an idiosyncratic reaction to antipsychotic medication but can be due to abrupt discontinuation of antiparkinsonian medication (e.g. by abrupt withdrawal of the dopamine precursor levodopa). The estimated incidence is two per 1000 patients treated with typical antipsychotics. Atypical antipsychotics such as olanzapine, risperidone, clozapine and aripiprazole can also cause this syndrome. It has a mortality rate of 10–20%. The onset of symptoms can be rapid or gradual. The development of symptoms is not dose dependent.
Other symptoms include:
Early identification of the condition is paramount. Patients who are on antipsychotics who have increased risk to develop neuroleptic malignant syndrome include those who are dehydrated, severely ill patients, catatonic patients and those who have had neuroleptic malignant syndrome previously. When some or all of the above features are present in a patient who is on antipsychotic medication, the diagnosis should be actively considered until proven otherwise and the offending agent should be promptly withdrawn.
These patients often require aggressive supportive therapy including intravenous fluid resuscitation and measures to control temperature. Early consideration should be given for intubation as this will reduce contraction of muscles and production of heat and fever. Use of drugs such as dantrolene (along with supportive care) should be considered, especially in patients with severe muscular rigidity.
References:
A young woman is brought in by ambulance to the ED 6 weeks after the birth of her first child. She had called the ambulance service herself, stating her baby was dying and wanted help. Both mother and child were brought to the ED for further assessment. She mentions fears for her baby. She gives a very vague history. She looks tired and rundown. On examination, other than a mild dehydration, the baby appears to be in good health.
Which ONE of the following issues is LEAST likely to be involved in this situation?
Answer: D: The range of postpartum psychiatric disorders is wide and includes:
The first three conditions are the most common. ‘Postnatal blues’ is a very common mild disorder that requires no treatment. The onset is soon after child birth and is short lasting (hours to 2 days). Postnatal depression is most appropriately described as depression that has its onset within 3–6 months following childbirth. This is less frequent than postnatal blues but it may be the most frequent major psychiatric disorder seen after childbirth. In addition to maternal morbidity and mortality, postnatal depression can lead to reduced interaction with children and family.
It is more likely to be present in mothers with previous depression, little family or social supports, unplanned pregnancy, high parity, complications during pregnancy and/or delivery. It can also be triggered by difficult temperament of the baby and presence of colic or reflux. Common presenting features are continuing postnatal blues symptoms, negative feelings about the baby, not wanting to hold baby, lack of eye contact, inability to sleep or excessive sleep, feeding difficulties, and anger and frustration about life circumstances. These symptoms may lead to child neglect. When treated, postnatal depression has a good prognosis.
With obsessions of child harm after child birth, the mother experiences repeated thoughts about harming the child but may take precautions. The mother may avoid staying alone with the child. This is another area that should be explored in the above scenario. Morbid preoccupations may occur in the postpartum period. Some of these are due to the mother’s perception about body image. She may become distressed about the changes in her body due to the pregnancy and childbirth such as weight gain, stretch marks and scars. However, this is the least likely issue in this scenario.
Regarding amphetamine-induced psychiatric disorders, all of the following statements are true EXCEPT:
Answer: B: Amphetamine-induced psychotic disorder or intoxication delirium is usually seen in individuals who have used high amounts of amphetamine over a prolonged period. It can also be seen as a recurrence in individuals who had previous similar episodes. The recurrence can frequently occur as a result of re-exposure to small amounts of amphetamine. In the very acute stage, in addition to mood and delusional symptoms, the psychotic patient may have disturbances to their consciousness with confusion and disorientation (a delirium syndrome). After recovery from both the psychotic and delirium syndromes these patients typically have amnesia to the whole or part of the episode.
In addition to psychosis, amphetamines may induce manic or hypomanic symptoms during intoxication, and depression during withdrawal. Other issues include amphetamine-induced sleep disorder, anxiety disorder, sexual dysfunction and other psychological and physical symptoms. Among the psychological symptoms, mood swings, lack of concentrating ability, paranoia and hallucinations are frequent. Amphetamine-induced aggression and violent episodes are important management issues in the ED.
Olanzapine rapid dispersing formulation (wafer) is frequently used in the ED to manage acutely agitated patients with a mental disorder.
Which ONE of the following statements is TRUE regarding olanzapine wafer?
Answer: B: Olanzapine is frequently used in acutely agitated psychiatry patients in the ED. It is a serotonin and dopamine receptor blocker (specifically 5 HT2A and D2 receptors). It is available in oral, rapid dispersible (wafer) and intramuscular preparations. In the ED, the rapid dispersible preparation is particularly valuable in settling acutely agitated patients due to its rapid absorption through the oral mucosa and resulting rapid somnolence. Both oral and rapid dispersible preparations are considered bioequivalent.
Olanzapine is a first-line antipsychotic agent and effective in the treatment of schizophrenia because it is effective for both positive and negative symptoms. This may be less important in an acutely agitated patient but its ability to cause somnolence seems to be important. Olanzapine has a favourable side-effect profile – it causes somnolence and orthostatic hypotension but causes less extrapyramidal side effects than with haloperidol.
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