Psychological medicine

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22 Psychological medicine

Questions

Question 1

What investigations are recommended in a 70-year-old patient presenting with auditory and visual hallucinations with amnesia?

Question 1

Could you explain the definitions of pseudohallucinations and quasipsychotic episodes?

Question 3

What is the ‘condensation’ and ‘displacement’ that might underlie formal thought disorder?

Question 4

Is sulpiride of value in the treatment of conversion disorder?

Question 5

How does typhoid psychosis manifest? How often does psychosis accompany typhoid fever?

Question 6

What is the treatment for a case of typhoid psychosis?

Question 7

Can you please explain to me what changes take place in the body to cause a person to have chronic fatigue syndrome (CFS). I am having difficulty understanding the pathology of this condition.

Question 8

What is the best treatment for primary insomnia? Could benzodiazepines be used continuously?

Question 9

Does tolerance develop to the hypnotic effect of trazodone and mianserin? Do these play a role in the treatment of primary insomnia?

Question 10

Is there a specific treatment for night terror disorders?

Question 11

Can you suggest possible causes for a 55-year-old female waking regularly at midnight three to four times a month, feeling that she is going to die and feeling an urge to meet people at that time. She has no breathlessness.

Question 12

What is the modern treatment and prognosis for manic depressive disorder? Is there a malfunction of a metabolic pathway that causes it? Can it be remedied by treatment with neurotransmitter-stimulating drugs? If so which drugs are the most effective apart from lithium carbonate and carbamazepine?

Question 13

Is lamotrigine as effective a mood stabilizer as lithium?

Question 14

Is it safe to prescribe lithium for a patient with bipolar mood disorder with biliary cirrhosis and 40% blockage of the main coronary system?

Question 15

How long should the period of active and maintenance treatment last with mood stabilizers in a patient presenting with his first manic episode?

Question 16

Do lithium and selective serotonin re-uptake inhibitors (SSRIs) have an anti-impulse effect?

Question 17

Can any of the antipsychotics clozapine, olanzepine and quetiapine be used as mood stabilizers in bipolar affective disorder?

Question 18

Is hypothyroidism secondary to chronic lithium therapy in the treatment of bipolar affective disorder, reversible on discontinuation of lithium or its substitution by another mood stabilizer?

Question 19

In bipolar affective disorder in patients who are well controlled on lithium, is it possible to prescribe thiazide diuretics when hypertension is difficult to control?

Question 20

Are antipsychotics recommended as the most effective treatment for trichotillomania?

Question 21

I would like to know when and where antidepressants are used, because I am confused with selective serotonin re-uptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs) and tricyclics.

Question 22

You have written that the serotonin syndrome results from sudden discontinuation of selective serotonin re-uptake inhibitors (SSRIs) with a short half-life, whereas other books I have read say that serotonin syndrome results from an overdose of SSRI or from combination with monoamine oxidase inhibitors (MAOIs) or serotonin agonists. Please clarify.

Question 23

What is the safest antipsychotic and antidepressant to give during pregnancy?

Question 24

How frequently should patients receiving chronic lithium therapy be evaluated for thyroid and renal function?

Question 25

Is lithium generally associated with bone demineralization, especially in children?

Question 26

Is lithium recommended in childhood bipolar affective disorder?

Question 27

Is buspirone as effective as serotonin re-uptake inhibitors (SSRIs) in the treatment of a generalised anxiety disorder?

Question 28

Can diethylpropion be used to treat children with attention deficit hyperactivity disorder (ADHD)? If so, what is the recommended dose and at what age can it safely be administered?

Question 29

Can khat (norpseudoephedrine) be given to children with attention deficit hyperactivity disorder and, if so, from what age?

Question 30

Are selective serotonin re-uptake inhibitors (SSRIs) and venlafaxin effective in the treatment of attention deficit hyperactivity disorder (ADHD)? How efficient are they in comparison with imipramine?

Question 31

1. Why is weight monitored in infants on methylphenidate for the treatment of attention deficit hyperactivity disorder (ADHD)? Is this to prevent them losing weight, or is losing a certain amount of weight acceptable?

2. Should the electroencephalogram (EEG) be monitored in patients on methylphenidate for ADHD treatment? Should this be stopped if there is some epileptic discharge?

Question 32

What is the safest typical and atypical antipsychotic, antidepressant and serotonin re-uptake inhibitor (SSRI) used to treat obsessive-compulsive disorder (OCD) that can be used during pregnancy?

Question 33

What is the rationale for combining serotonin re-uptake inhibitor (SSRIs) and clomipramine in patients with obsessive-compulsive disorder (OCD)? Is this combination more effective than any agent when given alone?

Question 34

Is sertraline superior to fluoxetine in the treatment of obsessive-compulsive disorder and, if so, why?

Question 35

I want to find out if there is really a correlation between all cases of delirium tremens (DT) and thiamine deficiency. DT is meant to be a withdrawal state and I assume it can happen in well-nourished alcoholics, as not all alcoholics are malnourished. My friends and I have seen the question that DT is associated with thiamine deficiency in question papers and it has really proved a thorny issue.

Question 36

1. How long should a doctor treat a patient with the first episode of schizophrenia with regard to the active phase and maintenance therapy?
2. In a patient presenting with the third psychotic episode fulfilling the criteria of schizophrenia, for how long should antipsychotic treatment be continued?

Question 37

Is there a rationale for treating a patient presenting with his first psychotic episode fulfilling the criteria for schizophrenia, with atypical antipsychotics?

Question 38

What is the rationale for giving a patient with resistant schizophrenia a combination of typical and atypical antipsychotics?

Question 39

Do selective serotonin re-uptake inhibitors (SSRIs) have an anti-aggression effect and what is the best anti-aggression drug to be given to schizophrenics and to those suffering from other mental illnesses?

Question 40

Is depot fluphenazine alone sufficient to treat the active phase of schizophrenia and, if so, what dose is recommended?

Question 41

Is sulpiride as effective as haloperidol in reducing the positive symptoms of schizophrenia? If yes, what is the most effective dose?

Question 42

What is the effective daily dose of pimozide? Should it be combined with an anticholinergic? If yes, how long should this combination be continued before giving pimozide on its own?

Question 43

What percentage of patients receiving chronic conventional antipsychotic treatment develops acute extrapyramidal side-effects and tardive dyskinesia?

Question 44

How often is risperidone associated with acute extrapyramidal side-effects?

Question 45

What is the cause of frequent ‘freezing’ in a schizophrenic patient who shows constant tics and suffers delusions of grandeur, but shows no symptoms of dementia?

Question 46

Is risperidone more likely to cause tardive dyskinesia than other atypical antipsychotics?

Question 47

How frequently should patients on clozapine be evaluated for agranulocytosis?

Question 48

What is meant by ‘bipolar spectrum’ disorders? Do these include atypical depression and recurrent depressive episodes?

Question 49

It’s becoming popular among psychiatrists in my country to treat bipolar affective disorder with more than one mood stabilizer or with a mood stabilizer and an atypical antipsychotic. What is your opinion and what is the evidence for this?

Question 50

Where can I find information about chronic fatigue syndrome, its causes and its management?

Answers

Answer 1

All such patients with new symptoms should have simple blood tests and CT/MRI imaging (Box 22.1).

Box 22.1 Investigations required in a patient suffering from hallucinations with amnesia

Blood tests

• Full blood count
• Erythrocyte sedimentation rate
• Urea and electrolytes
• C-reactive protein
• Blood glucose
• Liver biochemistry
• Serum calcium
• Vitamin B12, folate
• Thyroid hormones: thyroid-stimulating hormone, tri-iodothyronine (T3), thyroxine (T4)
• Syphilis serology
• HIV antibodies

Imaging

• Chest X-ray
• Computed tomography scan
• Magnetic resonance imaging

Other

• Electroencephalogram
• Cerebrospinal fluid
• Brain biopsy

Answer 2

Pseudohallucinations are usually auditory and are either true externally sited hallucinations but with insight into their imaginary nature, or are sited within internal space. They do not indicate a psychosis; quasipsychotic is used to describe a type of personality disorder in someone who is not psychotic.

Answer 3

Condensation is a single symptom or word that is associated with the emotional content of several words.

Displacement is a psychological defence mechanism in which there is an unconscious shift of emotions, affect or desires from the original subject to a more acceptable substitute.

Answer 4

No.

Answer 5

A psychosis can occur in the third week of a typhoid illness along with apathy and confusion. Typhoid psychosis is unusual. It is described in Ali et al (1997).

Reference

Ali G et al. (1997) Spectrum of neuropsychiatric complications in 791 cases of typhoid fever. Tropical Medicine and International Health2: 314.

Answer 6

Typhoid psychosis is treated by nursing the patient in a single room. Rehydration is required and the fever is treated with cooling fans and cold water sponging. Appropriate antibiotics are given. Psychoactive drugs should be avoided if possible but in severe psychosis haloperidol 15 mg is the best choice.

Answer 7

There are no definite pathological features in patients with chronic fatigue syndrome (as most patients don’t die of this disease).

Answer 8

Insomnia is best treated without drugs (see K&C 7e, p. 1198).

Benzodiazepines, as well as other hypnotics, should only be used for 2 weeks to help relieve an acute situation.

Answer 9

Mianserin is not a hypnotic and is not used for insomnia. Trazodone is used for insomnia and tolerance does develop.

Answer 10

Psychotherapy and low-dose benzodiazepines.

Answer 11

No explanation, I’m afraid!

Answer 12

Manic depressive disorder is a bipolar disorder in which patients suffer from bouts of depression and mania. The treatment usually involves drugs and the ones you mention are first-line therapy. There is no definite metabolic pathway malfunction in manic depressive disorder.

Answer 13

No, lamotrigine is not as effective as lithium.

Answer 14

With careful monitoring, lithium could, if indicated, be used in such a patient.

Answer 15

Six months after the first episode in bipolar disorders. There is a case, however, to continue for 2 years as relapse is high. Withdrawal of lithium should be slow because of evidence of rebound mania.

Answer 16

DSM-IV-TR describes an impulse disorder as ‘the failure to resist an impulse, drive or temptation to commit an act that is harmful to the individual and others’. Both lithium and SSRIs have been effective in individual patients. There are no trials.

Answer 17

Antipsychotics have been used as second- or third-line therapy particularly in acute mania. They should only be used by experts in the field.

Answer 18

It is usually reversible.

Answer 19

Both loop and thiazide diuretics reduce the excretion of lithium, and increase the plasma concentrations of lithium with consequent toxicity occur. This is more severe with thiazide diuretics, which should be avoided. This is a difficult problem, which might require a change of therapy.

Answer 20

The most effective treatment is cognitive behavioural therapy and a selective serotonin re-uptake inhibitor; this is the treatment of first choice.

Answer 21

Tricyclic antidepressants are still commonly used as first-line pharmacotherapy in patients with depression. They have been available for many years and are therefore familiar to many practitioners. Tricyclic-related drugs, e.g. trazodone, have a lower incidence of antimuscarinic effects (e.g. constipation and dry mouth), common side-effects of tricyclics.

The SSRIs, e.g. paroxetine, also have fewer antimuscarinic effects and are safe in overdose, although no more effective than tricyclics. They are being used more and more in the same situations for which you would use tricyclics.

MAOIs, e.g. phenelzine have interactions with other drugs and some foods and are much less commonly used, except by experienced physicians usually when tricyclics are ineffective.

Answer 22

‘Serotonin syndrome’ is a toxic hyperserotonergic state. It is, as you say, typically the result of combining a serotonergic agent with a monoamine oxidase inhibitor (see K&C 7e, p. 1202). This is, however, not always the case (see Sternbach 1991). Remember: there is also a ‘discontinuity syndrome’ and patients must reduce SSRIs slowly.

Reference

Sternbach H (1991) The serotonin syndrome. American Journal of Psychiatry148: 705–713.

Answer 23

Conventional ‘typical’ antipsychotics, e.g. promazine, haloperidol. Selective serotonin re-uptake inhibitors, e.g. paroxetine, are the safest for depression in pregnancy. All drugs must only be given if absolutely necessary in pregnancy.

Answer 24

Every 3–6 months.

Answer 25

No.

Answer 26

Yes. Several short-term studies show benefit.

Answer 27

SSRIs or venlafaxine are first line-treatments. Buspirone is the second choice.

Answer 28

No. Diethylpropion should not be used under 12 years of age and there are no data on its use in ADHD.

Answer 29

It might help but the only accepted drugs used in this condition are methylphenidate and atomoxetine. They should not be used under 6 years of age.

Answer 30

Desipramine 200 mg daily has been shown to be better than a placebo. SSRIs are not helpful, but studies are small.

Answer 31

1. Anorexia and weight loss occur and weight should be monitored.
2. EEG monitoring is not normally required but methylphenidate should not be given to epileptics.

Answer 32

OCD should be treated with cognitive behavioural therapy (CBT), and drugs should be avoided in pregnancy. If drug treatment is essential, an SSRI, e.g. paroxetine, should be used.

Answer 33

SSRIs have replaced clomipramine; there is no rationale for combining the two.

Answer 34

Both are SSRIs and are probably of similar effect.

Answer 35

Thiamin deficiency is not a cause of DT, which is part of the withdrawal state, but many patients who suffer from DTs are severe alcoholics who may well be thiamin deficient. It is therefore advised that thiamine be given to the patient but not directly for the management of DT.

Answer 36

1. Long-term treatment of a patient who definitely has schizophrenia is frequently necessary even after one episode. This is because withdrawal of treatment can produce severe relapses, which occur at unpredictable intervals. Therefore, long-term maintenance therapy is required.
2. Certainly, after three psychotic episodes, lifetime therapy would be indicated; withdrawal would only be done under very careful supervision.

Answer 37

There is more and more emphasis on using the so-called atypical antipsychotics. Risperidone at a starting dose of 2 mg twice daily increasing to 10 mg daily would be a commonly used drug.

Answer 38

The only time this should happen is when an atypical antipsychotic is being added to eventually replace the typical drug. By and large, there is no advantage in giving more than one drug in schizophrenia.

Answer 39

SSRIs are not useful as an anti-aggressive drug. The best treatment is zuclopenthixol acetate 50–150 mg by deep IM injection.

Answer 40

Fluphenazine, initially 2.5–10 mg rising to 20 mg daily, can be used but extrapyramidal symptoms are a problem. There is a move to use so-called ‘atypical antipsychotics’ instead.

Answer 41

Yes, possibly better. A high dose of sulpiride is needed: 2.4 g daily.

Answer 42

Start with 2 mg daily, increasing at weekly intervals up to 16 mg if necessary.

Routine antimuscarinics are not justified because not all patients have side-effects, and they may unmask or worsen tardive dyskinesia.

Answer 43

Over 50% will get side-effects, usually reversible.

Answer 44

We can’t give a figure but less often than with the usual antipsychotic drugs.

Answer 45

‘Freezing’ occurs in schizophrenia but the mechanism is unclear. However, positron emission tomography (PET) scan studies show abnormalities in dopamine receptors.

Answer 46

No; at low daily doses (<6 mg) extrapyramidal side-effects are uncommon.

Answer 47

White cell count every week for 18 weeks; every 2 weeks up to 1 year; then monthly.

Answer 48

Bipolar disorders are divided into two subgroups:

• a history of one manic episode with or without a depressive episode
• a history of at least one depressive episode and one hypomanic episode.

The term embraces the whole spectrum of mania with or without depression but is not used for depression alone.

Answer 49

Clinical trials have shown that a combination of a mood stabilizer and an atypical antipsychotic drug is better than a mood stabilizer alone.

Further reading

Scherk H et al. (2007) Second-generation antipsychotic agents in the treatment of acute mania. Archives of General Psychiatry64(4): 442–455.

Answer 50

Chronic fatigue syndrome is discussed on p. 1192 of Kumar and Clark Clinical Medicine 7th edition. References are given on p. 1284.

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