Revision questions

1. All of the following are characteristics of obsessive thoughts except

a). recurrent , persistent, intrusive thoughts

b). person attempts to ignore or suppress such thoughts

c). thoughts are imposed by an external agency

d). thoughts are not simply excessive worries about real-life problems

2. True regarding Buspirone is

a). 5-HT_1B receptor partial agonist

b). effective treatment for benzodiazepine withdrawal.

c). more effective in reducing the cognitive symptoms than somatic symptoms.

d). therapeutic effects usually evident within few days of therapy

3. The drug of choice for treatment refractory schizophrenia is

a). clozapine

b). haloperidol

c). olanzapine

d). risperidone

4. Which of the following is not a paraphilia

a). exhibitionism

b). transsexualism

c). frotteurism

d). fetishism

5). Which of the following medications is recommended for tobacco cessation

a). venlaflaxine

b). fluoxetine

c). bupropion

d). amitryptaline

6). Which of following is not predisposing vulnerability factor in Posttraumatic Stress Disorder

a). presence of childhood trauma

b). borderline personality disorder traits

c). being male

d). perception of an external locus of control (natural cause)

7). Tourette's disorder co-exists most commonly with

a). depressive disorder

b). obsessive-compulsive disorder

c). schizophrenia

d). sleep disorders

8). Use of benzodiazepines in pregnancy can lead to

a) neural tube defects

b) cleft lip and palate

c) neonatal jaundice

d) reversible goitre

9). Which of the following is not a club drug

a). MDMA

b) Nitrazepam

c) Ketamine

d) GHB

10). All of the following deficits are associated with left hemisphere damage except

a) Aphasia

b) Right–left disorientation

c) Finger agnosia

d) Anosognosia

11). Delusion of the nonexistence of the self or part of the self is

a) depersonalisation

b) derealisation

c) nilhism

d) bereavement

12). All are seen in wernicke’s encephalopathy except

a). Mental confusion

b). confabulation

c). oculomotor disturbances

d). cerebellar ataxia

13). All of the following are used in management of neuroleptic malignant syndrome except

a) . atypical antipsychotics

b). dantrolene

c). amantadine

d). electroconvulsive therapy

14). Which is most prevalent learning disorder

a). reading disorder

b). mathematics disorder

c) disorder of Written Expression

d). expressive Language Disorder

15). All of the following are good prognostic indicators in schizophrenia except

a). late onset

b). acute onset

c). family history of schizophrenia

d). family history of mood disorders

Solutions

1. All of the following are characteristics of obsessive thoughts except

a). recurrent , persistent, intrusive thoughts

b). person attempts to ignore or suppress such thoughts

c). thoughts are imposed by an external agency

d). thoughts are not simply excessive worries about real-life problems

Ans c) thoughts are imposed by an external agency

Obsessions as defined by :

1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
2. the thoughts, impulses, or images are not simply excessive worries about real-life problems
3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):

1. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

2. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation

2. True regarding Buspirone is

a). 5-HT_1B receptor partial agonist

b). effective treatment for benzodiazepine withdrawal.

c). more effective in reducing the cognitive symptoms than somatic symptoms.

d). effects usually evident within few days of therapy

Ans d). effects usually evident within few days of therapy

Buspirone

· acts as an agonist, partial agonist, or antagonist on serotonin 5-HT_1A receptors.

o most pronounced action, as a presynaptic agonist at these receptors, inhibits release of serotonin, with consequent antianxiety effects.

o Action as an agonist at postsynaptic receptors appears to account for antidepressant activity.

· narrow-spectrum antianxiety agent

o demonstrated efficacy only in the treatment of generalized anxiety disorder.

o not effective in the treatment of panic disorder, obsessive-compulsive disorder (OCD), or social phobia.

· Used as augmentation agent

o appears to have weak antidepressant activity, which has led to its use as an augmenting agent in patients who have failed standard antidepressant therapy.

o sometimes used to augment SSRIs in the treatment of OCD.

· Unlike benzodiazepines, buspirone has no immediate effects, and the patient should be told that a full clinical response may take 2 to 4 weeks. If an immediate response is needed, the patient can be started on a benzodiazepine and then withdrawn from the drug after buspirone's effects begin.

· Buspirone does not cause weight gain, sexual dysfunction, discontinuation symptoms, or significant sleep disturbance compared to SSRI’s. It does not produce sedation or cognitive and psychomotor impairment compared to BZD .

3. The drug of choice for treatment refractory schizophrenia is

a). clozapine

b). haloperidol

c). olanzapine

d). risperidone

Ans a). clozapine

Clozapine

· Special indications

o most effective drug treatment for patients who have failed on standard therapies.

o shown to benefit patients with severe tardive dyskinesia.

· Side effects

o most common drug-related adverse effects are sedation, dizziness, syncope, tachycardia, hypotension, electrocardiogram (ECG) changes, nausea, and vomiting.

o Other common adverse effects include fatigue, weight gain, various GI symptoms (most commonly, constipation), anticholinergic effects, and subjective muscle weakness.

o Sialorrhea, or hypersalivation, is a side effect that begins early in treatment and is most evident at night.

o risk of seizures is about 4 percent in patients taking dosages above 600 mg a day.

o Leukopenia, granulocytopenia, agranulocytosis, and fever occur in about 1 percent of patients.

· The only contraindications to the use of clozapine are

o a white blood cell (WBC) count below 3,500/mm³ cells

o a previous bone marrow disorder

o a history of agranulocytosis during clozapine treatment

o the use of another drug that is known to suppress the bone marrow, for example, carbamazepine.

4. Which of the following is not a paraphilia

a). exhibitionism

b). trans-sexualism

c). frotteurism

d). fetishism

Ans b). trans-sexualism

Paraphilias include

· Exhibitionism: recurrent urge to expose the genitals to a stranger or to an unsuspecting person. Sexual excitement occurs in anticipation of the exposure, and orgasm is brought about by masturbation during or after the event.

· Fetishism: the sexual focus is on objects (e.g., shoes, gloves, pantyhose, and stockings) that are intimately associated with the human body.

· Frotteurism: usually characterized by a man's rubbing his penis against the buttocks or other body parts of a fully clothed woman to achieve orgasm.

· Pedophilia: involves recurrent intense sexual urges toward, or arousal by, children 13 years of age or younger, over a period of at least 6 months.

· Sexual Masochism: recurrent preoccupation with sexual urges and fantasies involving the act of being humiliated, beaten, bound, or otherwise made to suffer.

· Sexual Sadism: recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts (real, not simulated) in which the psychological or physical suffering (including humiliation) of the victim is sexually exciting to the person.

· Voyeurism(Scopophilia): recurrent preoccupation with fantasies and acts that involve observing persons who are naked or engaged in grooming or sexual activity

· Transvestic Fetishism: fantasies and sexual urges to dress in opposite gender clothing as a means of arousal and as an adjunct to masturbation or coitus

Trans-sexualism is a disorder of gender identity (not paraphilia)

5). Which of the following medications is recommended for tobacco cessation

a). venlaflaxine

b). fluoxetine

c). bupropion

d). amitryptaline

Ans c). bupropion

Psychopharmacological Therapies for nicotine quitting

· Nicotine Replacement Therapies

o double cessation rates, presumably because they reduce nicotine withdrawal.

o Nicotine gum is an OTC product that releases nicotine via chewing and buccal absorption.

o Nicotine lozenges: offer the highest level of nicotine of all nicotine replacement products.

o Nicotine patches (available OTC)

o Nicotine nasal spray

o The nicotine inhaler

· Non-nicotine Medications

o Bupropion

§ antidepressant medication that has both dopaminergic and adrenergic actions.

§ Daily dosages of 300 mg doubles quit rates in smokers with and without a history of depression.

o Nortriptyline

§ appears to be effective for smoking cessation and is recommended as a second-line drug.

o Clonidine

§ decreases sympathetic activity from the locus ceruleus and, thus, is thought to abate withdrawal symptoms.

§ scientific database for the efficacy of clonidine is neither as extensive nor as reliable as that for nicotine replacement

· A nicotine vaccine that produces nicotine-specific antibodies in the brain is under investigation at the National Institute on Drug Abuse (NIDA).

Typical Quit Rates of Common Therapies

Therapy Rate (%) Self-quit 5 Self-help books 10 Physician advice 10 Over-the-counter patch or gum 15 Medication plus advice 20 Behavior therapy alone 20 Medication plus group therapy 30

6). Which of following is not predisposing vulnerability factor in Posttraumatic Stress Disorder

a). presence of childhood trauma

b). borderline personality disorder traits

c). being male

d). perception of an external locus of control (natural cause)

Ans c). being male

· Predisposing Vulnerability Factors in Posttraumatic Stress Disorder

· Presence of childhood trauma

· Borderline, paranoid, dependent, or antisocial personality disorder traits

· Inadequate family or peer support system

· Being female

· Genetic vulnerability to psychiatric illness

· Recent stressful life changes

· Perception of an external locus of control (natural cause) rather than an internal one (human cause)

· Recent excessive alcohol intake

· principal clinical features of PTSD are

o painful reexperiencing of the event

o a pattern of avoidance and emotional numbing

o hyperarousal.

· Selective serotonin reuptake inhibitors (SSRIs), such as sertraline and paroxetine are considered first-line treatments for PTSD.

7). Tourette's disorder co-exists most commonly with

a). depressive disorder

b). obsessive-compulsive disorder

c). schizophrenia

d). sleep disorders

Ans b). obsessive-compulsive disorder

· Tics are abnormal movements or vocalizations that most commonly affect the muscles of the face and neck, such as eye-blinking, head-jerking, mouth-grimacing, or head-shaking.

· The most widely known and most severe tic disorder is Gilles de la Tourette syndrome, also known as Tourette's disorder.

o tics in Tourette's disorder are multiple motor tics and one or more vocal tics.

o One half to two thirds of children with Tourette's disorder exhibit a reduction or complete remission of tic symptoms during adolescence.

o Obsessive-compulsive symptoms or disorder (OCD) has been found to coexist in one third to two thirds of children and adolescents with Tourette's disorder, and about one third of adults with Tourette's disorder have persistent OCD into adulthood.

o obsessive-compulsive symptoms most likely to occur in those individuals with Tourette's disorder are characteristically related to ordering, symmetry, counting and repetitive touching, whereas OCD disorders in the absence of tic disorders are characterized by symptoms more often associated with fears of contamination and fears of harming others.

8). Use of benzodiazepines in pregnancy can lead to

a) neural tube defects

b) cleft lip and palate

c) neonatal jaundice

d) reversible goitre

Ans) b). cleft lip and palate

cleft lip and palate :Benzodiazepine such as diazepam (Valium), cross the placenta throughout gestation, and use of diazepam has been associated with cleft lip and palate.

reversible goitre: Lithium crosses the placenta freely, and maternal and fetal plasma concentrations are similar. Reversible goiter from transplacental lithium poisoning can occur.

Neural tube defects: valproate and carbamazepine use has been associated with a 1 to 5 percent incidence of spina bifida or other neural tube defects. The risk is thought to be higher with valproic acid.

Neonatal jaundice: The pediatrician should be alert to the possibility of transient perinatal syndromes (motor restlessness, tremor, hypertonicity, abnormal movements, difficulty with feeding, and possible neonatal jaundice and functional bowel obstruction) with antipsychotic use in mother during pregnancy that generally resolve within days, but may last up to 10 months after birth.

9). Which of the following is not a club drug

a). MDMA

b) Nitrazepam

c) Ketamine

d) GHB

Ans) b) Nitrazepam

Flunitrazepam is a club drug, not nitrazepam.

Club drugs are Methlenedioxymethamphetamine (MDMA), flunitrazepam, ketamine hydrochloride and gamma-hydroxybutyrate(GHB).

10). All of the following deficits are associated with left hemisphere damage except

a) Aphasia

b) Right–left disorientation

c) Finger agnosia

d) Anosognosia

Ans) d) Anosognosia

Selected Neuropsychological Deficits Associated with Left or Right Hemisphere Damage

Left Hemisphere Right Hemisphere Aphasia Visuospatial deficits Right–left disorientation Impaired visual perception Finger agnosia Neglect Dysgraphia (aphasic) Dysgraphia (spatial, neglect) Dyscalculia (number alexia) Dyscalculia (spatial) Constructional apraxia (details) Constructional apraxia (gestalt) Limb apraxia Dressing apraxia Anosognosia 11). Delusion of the nonexistence of the self or part of the self is a) depersonalisation b) derealisation c) nilhism d) bereavement Ans) c) nilhism Nihilism · Delusion of the nonexistence of the self or part of the self; also refers to an attitude of total rejection of established values or extreme skepticism regarding moral and value judgments. nihilistic delusion · Depressive delusion that the world and everything related to it have ceased to exist. Depersonalization · sensation of unreality concerning oneself, parts of oneself, or one's environment that occurs under extreme stress or fatigue · Seen in schizophrenia, depersonalization disorder, and schizotypal personality disorder. Derealisation · Sensation of changed reality or that one's surroundings have altered. · Usually seen in schizophrenia, panic attacks, and dissociative disorders. Bereavement · Feeling of grief or desolation, especially at the death or loss of a loved one. 12). All are seen in wernicke’s encephalopathy except a). Mental confusion b). confabulation c). oculomotor disturbances d). cerebellar ataxia Ans d) confabulation Wernicke's encephalopath · is the associated syndrome of confusion, ataxia, and ophthalmoplegia. · the neuropathological findings include hyperplasia of the small blood vessels · amnestic syndrome either accompanies or follows untreated Wernicke's encephalopathy in approximately 85 percent of all cases. Korsakoff's syndrome · Confabulation, apathy, and passivity are often prominent symptoms in the syndrome. · Approximately one third to one fourth of all patients recover completely. So, confabulation is seen in korsakoff’s syndrome and not in Wernicke's encephalopathy. 13). All of the following are used in management of neuroleptic malignant syndrome except a) . atypical antipsychotics b). dantrolene c). amantadine d). electroconvulsive therapy Ans) a) atypical antipsychotics Treatment of neuroleptic malignant syndrome · Amantadine: Beneficial as monotherapy or in combination; decrease in death rate · Bromocriptine: Mortality reduced as a single or combined agent · Levodopa/carbidopa: Case reports of dramatic improvement · Electroconvulsive therapy: Effective when medications have failed; also may treat underlying psychiatric disorder · Dantrolene: Benefits may occur in minutes or hours as a single agent or in combination · Benzodiazepines: Has been reported effective when other agents have failed · Supportive measures (IV hydration, cooling blankets, ice packs, ice-water enema, oxygenation, antipyretics) : Often effective as initial approach early in the episode 14). Which is most prevalent learning disorder a). reading disorder b). mathematics disorder c) disorder of Written Expression d). expressive Language Disorder Ans a) reading disorder Learning disorders in a child or adolescent are characterized by · academic underachievement in reading, written expression, or mathematics in comparison with the overall intellectual ability of the child. · affect at least 5 percent of school-age children · Reading disorders are present in approximately 75 percent of children and adolescents with learning disorders. · Dyslexia was used extensively for many years to describe a reading disability syndrome that often included speech and language deficits and right-left confusion. o Reading disorder is frequently accompanied by disabilities in other academic skills, and the term dyslexia has been replaced by broader terms, such as learning disorder. 15). All of the following are good prognostic indicators in schizophrenia except a). late onset b). acute onset c). family history of schizophrenia d). family history of mood disorders Ans c) Family history of schizophrenia Features Weighting Toward Good to Poor Prognosis in Schizophrenia Good Prognosis Poor Prognosis Late onset Young onset Obvious precipitating factors No precipitating factors Acute onset Insidious onset Good premorbid social, sexual, and work histories Poor premorbid social, sexual, and work histories Mood disorder symptoms (especially depressive disorders) Withdrawn, autistic behavior Married Single, divorced, or widowed Family history of mood disorders Family history of schizophrenia Good support systems Poor support systems Positive symptoms Negative symptoms Neurological signs and symptoms History of perinatal trauma No remissions in 3 years Many relapses History of assaultiveness