Medical Psychiatry

Question 1

What cardiac condition, apparent on EKG, can occur in otherwise healthy young adults and is characterized by a regular rapid heart rate (150-200 bpm), with sudden onset and usually abrupt termination? Symptoms include intense anxiety, feelings of panic, palpitations, chest discomfort, and dizziness.

Answer 1

Paroxysmal Supraventricular Tachycardia (PSVT)

Question 2

What cardiac condition, the most common cardiac tumor, has an estimated prevalence of 0.3% in the general population and can present without physical findings and may cause transient somatic symptoms that may be misattributed to anxiety or other psychiatric symptoms? Psychosis has also been reported to occur. EKG has high sensitivity for the diagnosis.

Answer 2

Atrial Myxoma

Question 3

What cardiac condition causes orthopnea, paroxysmal nocturnal dyspnea, or diminished cardiac output and cardiac reserve? It may cause anxiety, sleep disturbance, cognitive dulling, low energy, and depressed or irritable mood.

Answer 3

Heart Failure

Question 4

What condition is an acute, transient, reversible illness characterized by chest pain, reduced left ventricular function, and apical ballooning? It can be triggered by positive or negative stressors.

Answer 4

Takotsubo cardiomyopathy

Question 5

Acute anger has been found to be the trigger in what percentage of myocardial infarctions?

Answer 5

5% (Chida and Steptoe 2009; Jiang 2015)

Question 6

What psychotherapy treatment has been found to reduce risk of recurrent coronary events in post-MI patients (Gulliksson et al. 2011)?

Answer 6

CBT focused on diminishing anger

Question 7

Batelaan et al. (2016), in a meta-analysis of 37 studies involving more than 1 million patients and follow-up from 1 to 24 years, found that anxiety was a risk factor for cardiovascular disease with what hazard ratio (HR)?

Answer 7

1.52, 95% CI 1.36-1.71

Question 8

What is the increased incidence of coronary disease with history of depressive symptoms or MDD (Lichtman et al. 2008, 2014)?

Answer 8

double incidence

Question 9

Per Webster and Holroyd (2000), what fraction of delirium cases present with psychosis?

Answer 9

about half

Question 10

Per Kimura et al. (2010), what neuronal protein was found in the sera of 80% of patients with SLE and psychosis, and none of the patients with SLE but no psychosis?

Answer 10

Rab guanosine diphosphate dissociation inhibitor

Question 11

In patients with SLE and psychosis, what treatment is generally successful at treating the psychosis?

Answer 11

immunosuppressive therapy

Question 12

In active flare-ups of SLE, what percentage of patients exhibit psychosis? (Pego-Reigosa & Isenberg 2008)

Answer 12

3%

Question 13

In active flare-ups of SLE treated with high-dosage corticosteroids, presence of psychosis increases to what percentage? (Pego-Reigosa & Isenberg 2008)

Answer 13

30-90%

Question 14

Per Pego-Reigosa & Isenberg (2008), do patients with SLE-induced psychosis typically need longer term treatment with antipsychotics after treatment with immunosuppression?

Answer 14

no

Question 15

What disorder is characterized by an encephalopathic clinical picture in the setting of autoimmune thyroiditis?

Answer 15

Hashimoto’s encephalopathy

Question 16

Diagnosis of Hashimoto’s encephalopathy is facilitated by what findings?

Answer 16

EEG with diffuse slowing (90% of pts), serum antibodies vs thyroid peroxidase and thyroglobulin, high protein contentration in CSF (71% of pts) (deHolanda et al. 2011; Wilcox et al. 2008)

Question 17

What treatment typically results in full resolution of symptoms in Hashimoto’s encephalopathy?

Answer 17

corticosteroids

Question 18

What condition, associated with small-cell lung cancer and other cancers, can manifest with psychosis, depression, anxiety, confusion, memory deficits, and seizures? 50-60% of patients have antibodies vs onconeural antigens (Foster and Caplan 2009).

Answer 18

Paraneoplastic Limbic Encephalitis (PLE)

Question 19

In what percentage of cases of Paraneoplastic Limbic Encephalitis do psychotic symptoms precede oncological diagnosis? (Foster and Caplan 2009)

Answer 19

up to 70%

Question 20

What percentage of patients with Anti-NMDAR Encephalitis are female? (Dalmau et al. 2007; Titulear et al. 2013)

Answer 20

80%

Question 21

Per Dalmau et al. (2007) and Titulear et al. (2013), what is the primary cause of paraneoplastic anti-NMDAR encephalitis in women?

Answer 21

ovarian teratoma

Question 22

Patients with what autoimmune condition can present with a “viral” prodrome for weeks, including fever and fatigue, before demonstrating psychosis, including delusions, AVH, and bizarre or aggressive behavior? This can progress to cognitive impairment, seizures, catatonia, hemiparesis, and autonomic instability (Kuppuswamy et al. 2014).

Answer 22

Anti-NMDAR encephalitis

Question 23

What is the patient profile that should raise suspicion of Anti-NMDAR encephalitis?

Answer 23

young women with relatively rapid onset of psychotic illness that seems discontinuous from prior clinical history

Question 24

What is the prevalence of 22q11.2 deletion syndrome (VCFS) in infants born in the US?

Answer 24

1 in 3000 (Kobrynski and Sullivan 2007)

Question 25

What is the rate of psychotic illness in adults with VCFS (22q11.2 deletion)?

Answer 25

30% (Monks et al. 2014)

Question 26

Per Heinrich and Graham (2003), what percentage of patients with myxedema have psychosis?

Answer 26

5-15%

Question 27

What antipsychotic should be avoided in myxedema psychosis, per Hynicka (2015)?

Answer 27

Quetiapine, as it can cause hypothyroidism

Question 28

Actual incidence of psychosis with hyperthyroidism is around what percentage, per Bevenga et al. (2003) & Brownlie et al. (2000)?

Answer 28

1%

Question 29

Per Brownlie et al. (2000), what is the typical affective character of psychosis from hyperthyroidism?

Answer 29

mania as frequently as depression

Question 30

What endocrine disorder is characterized by weakness, fatigue, weight loss, nausea, vomiting, myalgias, and hyperpigmentation of skin and mucosae with mood/behavioral symptoms and rarely psychosis?

Answer 30

adrenal insufficiency

Question 31

What endocrine disorder is characterized by "moon facies," truncal obesity, abdominal striae, peripheral wasting, and hirsutism? Psych symptoms can include psychosis, irritability, depression, mania, or cognitive impairment.

Answer 31

hypercortisolism (i.e. Cushing's)

Question 32

Per Owe-Larson et al. (2009) & Watkins and Treisman (2012), new onset psychosis occurs in what percent of patients with HIV?

Answer 32

0.2-15%, usually with CD4 < 200

Question 33

Without treatment, up to what percent of patients with syphilis develop neurosyphilis (Rahman et al. 2011)?

Answer 33

40%

Question 34

What is the most common sporadic viral encephalitis, affecting 1 in 2,000 adults in the US (Beck & Tompkins 2016)?

Answer 34

Herpes Simplex (most HSV-1)

Question 35

What viral illness can manifest with personality changes, mood lability, bizarre behavior, gustatory or olfactory hallucinations, and ultimately seizures (Kennedy and Chaudhuri 2002)?

Answer 35

Herpes Simplex Encephalitis

Question 36

What abnormal brain findings are present in more than 90% of cases of HSE (Rabinstein 2017)?

Answer 36

T2-FLAIR hyperintensity in the anterior & mesial temporal lobes, inferior frontal lobes, and insular cortex

Question 37

What CSF findings are typically present with HSE?

Answer 37

lymphocytic pleocytosis, normal glucose, increased protein