All of the following indicate a better treatment response to ECT except:
E. Medication resistance and chronicity of depression are two often noted factors that predict lower response rates to ECT. Though ECT can provide significant benefit for patients who are resistant to medication, the degree of response may be less than in depressed patients who are not considered to have such resistance. Similarly, patients with longer durations of continuous depressive illness are less likely to respond to ECT. Post-ictal suppression and ictal amplitude are two main EEG-related features during ECT treatment that are associated with positive efficacy. Post-ictal suppression refers to the acute fall in EEG amplitude immediately after the ECT-induced seizure terminates. Ictal EEG amplitude or power measured as voltage is felt to be related to seizure strength or intensity. Bipolar depression does not respond to ECT differently from unipolar depression when other variables are controlled for.
References:
While treating social anxiety disorder with SSRIs, an adequate treatment trial should probably extend to:
C. SSRIs are now widely used as first-line agents in social anxiety disorder – both limited and generalized subtypes. An adequate trial of treatment with SSRIs in social anxiety must extend to 12 weeks, with a minimum of 6–8 weeks at the highest tolerated doses administered before considering a switch. It may take many months to consolidate a full treatment response and achieve a full remission. If the treatment is effective, it is recommended that it be continued for at least for a year, and then very gradually tapered off.
A 32-year-old woman presents with concerns regarding her ‘ugly appearance’. She had been convinced for a long time that her appearance was defective and was particularly worried about her ‘streak’ eyes. She admitted spending at least 14–16 hours a day thinking about her appearance and comparing herself with other people or seeking reassurance from others.
Which of the following is true with regard to the treatment of this condition?
A. The amount of evidence for treatment of body dysmorphic disorder (BDD) is limited, but it is accepted that serotonin reuptake inhibitors (SSRIs) and cognitive–behavioural therapy (CBT) are the treatments of choice. Antidepressants, antipsychotics, or electroconvulsive therapy are not efficacious for BDD, even though the data are limited. BDD symptoms of delusional patients appear as likely as symptoms of non-delusional patients to respond to an SSRI. SSRIs improve preoccupations, distress, and insight with an associated reduction in BDD-related behaviours such as mirror-checking, etc. The patient need not have depression to experience the beneficial effect. Although data are limited with respect to dose-finding studies, it is accepted that BDD often requires higher SSRI doses than those typically used in the treatment of depression, with variable response times ranging from 4–5 weeks to 9 weeks. Many patients may thus require longer than the usual treatment trial.
Reference:
A 17-year-old girl is admitted to a medical unit following a prolonged period of repeated bingeing and vomiting. She induces vomiting at least six times a day but does not use laxatives or diuretics.
Which of the following laboratory finding is most likely in this patient?
E. Elevations of serum amylase have been reported in 25–60% of anorexic/bulimic patients who repeatedly vomit. This amylase appears to derive from the salivary fraction and not the pancreas. Thus it may be associated with a clinical finding of parotid gland enlargement. The use of serum amylase measurement as an index of clinical symptomatology in eating disorders is currently limited as the correlation between amylase levels and symptom severity is poor. Low urea levels are seen in restricting the type of anorexia; they may be increased in those who vomit repeatedly. Hypokalaemia is a feature of laxative abuse or repeated vomiting in anorexia. High bicarbonate levels are associated with vomiting whereas low levels are seen in laxative abuse. Thyroid hormone (T3) is reduced in anorexia; basal TSH values and thyroxine levels may be normal (low T3 syndrome).
A 54-year-old African-Caribbean man had systematized persecutory delusions that prevented him from eating for 5 weeks. Following admission to a medical unit he was started on realimentation, despite which he developed diplopia, bilateral horizontal nystagmus and right sixth cranial nerve palsy. He had no past history of alcohol use. On transfer to a psychiatric ward, he was started on a normal diet but soon his phosphate levels were markedly reduced (0.26 mmol/L).
The most likely diagnosis is:
C. Refeeding syndrome refers to severe electrolyte and fluid shift associated with metabolic abnormalities in patients with malnutrition undergoing realimentation. Refeeding syndrome can occur in people with eating disorders and alcoholism but it is often missed in psychiatric units. This patient has developed features of low phosphate and thiamine deficiency following realimentation. The clinical features are related to the shift in metabolism that occurs on refeeding. A change from fat to carbohydrate-based energy production occurs. A glucose load stimulates insulin release, causing increased cellular uptake of glucose, phosphate, potassium, magnesium, and water. This will result in hypophosphataemia, which in turn may cause a deficit in adenosine triphosphate (ATP) with widespread neuromuscular and haematolgical consequences. Thiamine deficiency occurs due to increased cellular utilization of thiamine in response to carbohydrate refeeding and is associated with the precipitation of Wernicke’s encephalopathy.
Catani, M and Howells, R. Risks and pitfalls for the management of refeeding syndrome in psychiatric patients. Psychiatric Bulletin 2007; 31: 209–211.
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