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New BOFs

1. A 62-yr-old female is a cting bizarrely o n the ward. After assessing her youbelieve she is n ot acutely co nfused b ut is p sychotic. The presence of

which of the following features w ould provide evidence that the patient isacutely p sychotic.

A. DisorientationB. Hypnogogic hallucinationC. EchopraxiaD. Gustatory ha llucinationsE. Tardive dyskinesia

2. A 44-yr-old man is b eing investigated for a rapid decline in cognitive

function and abnormal behaviour. A MRI brain scan is o rdered. Each ofthe following conditions c an present with psychiatric s ymptoms a nd areassociated with abnormalities o n MRI brain scanning except

A. Munchausens syndromeB. Huntingtons diseaseC. DepressionD. Picks diseaseE. Schizophrenia

3. A 19-yr-old man attends w ith his ca rer and is p resenting with dyspnoea.The carer explains t hat the patient has l earning difficulties, but is u nsure ofthe exact cause. Which one of the following would support a diagnosis o fFragile X syndrome?

A. Absence of secondary male sexual characteristicsB. Micro-orchidismC. MicrognathismD. Single palmar creaseE. Strabismus

4. A 40-yr-old woman is r eferred for initiating treatment for depression. Shetells you that she suffers from an endocrine disease and is r egularlyfollowed up by the Endocrine unit. Which one of the following endocrinedisorders is least associated with depression?

A. Addisons disease

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B. Cushings s yndromeC. HyperparathyroidismD. HyperthyroidismE. Hypothyroidism

5. A 55-yr-old m an p resents w ith weight loss a nd p oor appetite. His w ife s aidthat since he was made redundant he has b ecome very d ifficult to live withas h e gets a ngry ve ry e asily a nd feels g uilty a bout many issues p ast andpresent. He stopped playing badminton and rarely v isits h is f riends.Physical examination was unremarkable a part from a documented eight kgweight loss i n the last four months. He was p rescribed antidepressantmedication. Each of the following s tatements i s t rue, except

A. He should feel better in o ne to three monthsB. Patients w ho respond sh ould b e treated for six to 12 monthsC. Suicide r isk m ay increase early a fter using antidepressantD. The psychomotor retardation responds well to uoxetineE. Venlafaxine works b est in patients w ith loss o f appetite as t he main

feature

Answers:1. Gustatory hallucinations: psychosis is de ned a s the presence o f

delusions, hallucinations a nd specic abnormalities o f behaviour,such as ca tatonia, severe psychomotor retardation or overactivity.Autochthonous d elusions a re rst rank sym ptoms o f schizophrenia.Hallucinations o f any modalityincluding gustatoryare a featureof psychosis. Hypnogogic h allucinations a re an e xception as t heyrefer specically t o auditory h allucinations e xperienced as o ne driftsto s leep. Echopraxia i s a f eature of cognitive impairment. T argetthis kind in sheer may be a result of long-term antipsychoticmedication, but does n ot indicate c urrent psychosis. Disorientationis t he hallmark o f acute confusional state.

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2.Munchausens syndrome: brain scans i n Alzheimers d iseasemay s how cerebral atrophy, particularly in temporal lobe structures.Picks d isease may sh ow bilateral atrophy o f frontal lobes. InHuntingtons d isease varies a trophy o f the caudate and

frontotemporal regions. I n sch izophrenia the m ost common ndingis e nlargement of the lateral ventricles. Studies i n depressivedisorders h ave also shown temporal lobe changes. In elderlydepressives white matter hyperintensities have been reported.

3.Single Palmar Crease

4. Hyperthyroidism: more associated with anxiety.

5. Venlafaxine works best in patients with loss of appetite a s t hemain feature : when patients t ake prescribed antidepressants asdirected, most can expect to feel better in one to three months.Patients w ho respond to treatment should be treated for 6-12months f rom the day when they felt like they u sed to feel. Bothelderly pa tients w ho h ave had o ne e pisode o f depression a nd thosewho have h ad two o r more p revious ep isodes sh ould takeantidepressants i ndenitely b ecause the risk o f relapse may bemore than 80 percent.

For patients w ho do not respond to two or more trials o f antidepressants, referralfor augmentation with other psychiatric a gents o r treatment with electroconvulsivetherapy is indicated. P sychotherapy, when a vailable, remains a g ood a ddition tothe t reatment regimen. M aintaining a n effective s ystem for psychotherapyreferral may a lso increase the patients c hances o f feeling better and reduce therisk of relapse. It is i mportant to keep in mind that the suicide risk may increase ifa patient feels a boost in e nergy before achieving relief from hopelessness a ndsuicidal thinking. This r isk is a lso high if antidepressant therapy s toppedprematurely a nd negative thinking returns q uickly. F or those with symptoms o fpsychomotor retardation one of the more activating antidepressants ( e.g.,uoxetine, venlafaxine, bupropion) might be a good choice, while in thosepatients i n great need of sleep, therapy w ith Mirtazapine, Nefazodone, Paroxetineor uvoxamine may be considered. Sertraline and Citalopram cause littleagitation o r sedation and remain g ood m iddle-of-the-road c hoices. Mirtazapine

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and paroxetine are good choices for patients w ho can benet from a stimulatedappetite. Fluoxetine, venlafaxine and Bupropion are good choices for patientswho have hyperphagia o r who are wary of possible weight gain.