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Flashcards in Neurosis Deck (26)
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1
Q

Question 1. For 4 weeks after an automobile accident where her husband died in front of her, a schoolteacher suffers from insomnia, poor concentration and tearfulness. She has nightmares and emotional outbursts when awake. Which of the following is the most likely diagnosis?

  1. acute stress disorder
  2. adjustment disorder
  3. depressive episode
  4. dysthymia
  5. post-traumatic stress disorder
A

A.1 This is acute stress disorder, a DSM description (not acute stress reaction, which is an ICD description). For PTSD, both ICD10 criteria and DSM IV specify avoidance to be present to make a diagnosis. In addition, DSM does not recommend a diagnosis of PTSD if symptoms are seen in the first 4 weeks. ICD only recommends the symptoms must be present within 6 months of the stressor. Acute stress reaction: starts usually in an hour; resolution starts within 8 hours if the stress is hit and run or 48 hours if it is prolonged. Presence of physical exhaustion, organic factors or disease states increases the risk. The stressor is usually one that poses serious threat to security, integrity and social position. The patient may initially be dazed with narrowed attention; disorientation is not uncommon as a result. Sometimes agitation and overactivity are seen. Partial or complete amnesia for the acute stress reaction is not unheard of. Dissociative symptoms seem to predominate in some.

2
Q

Question 2.

A 28-year-old man presents for the seventh time to a GP with abdominal pain. When confronted he admits to faking symptoms. He says “I know this is wrong, but I don’t know why I do this”. Which of the following is the most likely diagnosis for this patient?

  1. conversion disorder
  2. factitious disorder
  3. hypochondriasis
  4. malingering
  5. somatization disorder
A

A.2

The patient feigns symptoms repeatedly for no obvious reason and may even inflict self-harm in order to produce symptoms or signs. The motivation is obscure and presumably internal with the aim of adopting the sick role. The disorder is often combined with marked disorders of personality and relationships according to ICD-10

3
Q

Question 3.

A 25 yr old man has irrational fear for darkness since childhood. He is not distressed about this currently and do not take special measures to avoid being in the dark. Which of the following is true?

  1. He has a specific phobia as he has an irrational fear
  2. He has a specific phobia as he has it since childhood
  3. He has a specific phobia with loss of insight
  4. He has no specific phobia as fear of darkness is common
  5. He has no specific phobia as he does not have avoidance behaviour
A

A.5

Specific phobias are restricted to highly specific situations such as proximity to particular animals, heights, thunder, darkness, flying, closed spaces, urinating or defecating in public toilets, eating certain foods, dentistry, or the sight of blood or injury. Though the triggering situation is discrete, contact with it can evoke panic as in agoraphobia or social phobia according to ICD-10

4
Q

Question 4.

One of the following specific phobias is strongly genetic

  1. Acrophobia
  2. Animal phobia
  3. Blood injury injection phobia
  4. Space phobia
  5. Spider phobia
A

Blood injury injection phobia is oddly different from other phobias in that the response to exposure is not tachycardia and sympathetically driven heart rate etc. Instead a fainting response occurs where the patient may drop fainting with low BP and bradycardia.

5
Q

Question 5.

One of the following features during trauma has capacity to predict future development of PTSD

  1. Anterograde amnesia immediately after trauma
  2. Autonomic arousal during trauma
  3. Crying during trauma
  4. Emotional numbing during trauma
  5. Panic attack during trauma
A

A.4

Emotional numbing during trauma has been reported to predict future PTSD. Similiarly dissociative experiences during trauma may also predict PTSD later on.

6
Q

Question 6.

Different types of panic disorder include all except

  1. Nocturnal panic attacks
  2. Out of blue panic attacks
  3. Situational panic attacks
  4. Situationally predisposed attacks
  5. Unilateral panic attack
A

A.5

Panic attacks cannot be unilateral. They are associated with generalised autonomic activity and not directly related to cortical seizures whcih could be unilateral.

7
Q

Question 7.

A 24 year old lady suddenly develops bilateral blindness. She has patchy tunnel like vision on field testing. She appears not to be bothered by the problem. This is described as

  1. Anosognosia
  2. Anton’s syndrome
  3. La belle indifference
  4. Loss of insight
  5. Malingering
A

A.3

Conversion / hysterical disorder is called dissociative disorder of motor movement and sensations. The degree of disability in this disorder is very variable. La belle indifference is not universal, but common. The patients are distressed or concerned by the disability. Close friends or relatives might have had the actual organic illness whose symptoms are present in conversion disorder patient. A milder and transient variety is seen in adolescent girls

8
Q

Question 8.

Which one of the following diagnosis best applies to an 18 year old girl who suddenly developed akinetic mutism, narrowed consciousness within few hours? She has no history of previous depression.

  1. Acute stress reaction
  2. Brief psychotic episode
  3. Depressive stupor
  4. Dissociative stupor
  5. Manic stupor
A

A.4

Dissociative stupor is diagnosed on the basis of a profound diminution or absence of voluntary movement and normal responsiveness to external stimuli such as light, noise, and touch, but examination and investigation reveal no evidence of a physical cause. In addition, there is positive evidence of psychogenic causation in the form of recent stressful events or problems according to ICD -10

9
Q

Question 9.

Mr. Z has a history of acrophobia (fear of heights). Although he is terrified of heights, his long-term ambition in life was to become a pilot and work for the air force. Which of the interventions given below is most likely to be successful for his condition?

  1. Benzodiazepines
  2. Cognitive therapy
  3. Problem solving therapy
  4. SSRIs
  5. Systematic desensitisation
A

A.5

Systematic Desensitisation (Wolpe): It consists of three steps: relaxation training, hierarchy construction, and desensitisation of the stimulus. Patient is exposed to a graded hierarchy of anxiety-provoking situations in stepwise fashion . Other behaviour therapy techniques would include implosion (imaginal flooding) and ‘flooding’. In flooding (in vivo) real life exposure takes place without any hierarchy. No relaxation exercises are used. Escaping from an anxiety-provoking experience in fact reinforces the anxiety through avoidance conditioning; in flooding this conditioning is targeted. The success of flooding depends on exposing patients for reasonable duration until mastery and calm composure is gained. Premature withdrawal will reinforce the avoidance. In implosion (in vitro) or imaginal flooding, the phobic situation is confronted through imagination, not in real life. Ref: Kaplan & Sadock’s Synopsis of Psychiatry: Behavioural Sciences/Clinical Psychiatry, 10th Edition. Lippincott Williams & Wilkins 2007

10
Q

Question 10.

A lady comes to your outpatient unit with a diagnosis of OCD made by her GP. Which of the following symptoms is most likely in this patient?

  1. Checking
  2. Cleaning
  3. Counting
  4. Hoarding
  5. Rearranging items on the table
A

A.1

11
Q

Question 11.

The odds of having panic disorder is increased in first degree relatives of patients with panic disorder compared to general population by a factor of

  1. 10-12 times
  2. 18-20 times
  3. 2-3 times
  4. 4-8 times
  5. No increase in prevalence
A

A.4

12
Q

Question 12.

A man who recently witnessed his colleague’s death in an unfortunate road traffic accident presents with weakness of both legs. He is not able to balance himself when asked to stand and needs help to support him. On physical examination no consistent neurological signs are noted. Most likely diagnosis is

  1. Conversion disorder
  2. Malingering
  3. PTSD
  4. Somatisation disorder
  5. Somatoform disorder
A

A.1

13
Q

Question 13.

A man brings his mother to stay with his family permanently, following her retirement. Soon after this, his wife becomes mute and aphonic. Physical examination reveals no neurological explanation. Most likely diagnosis is

  1. Conversion disorder
  2. Hypochondriasis
  3. Malingering
  4. Somatisation disorder
  5. Somatoform disorder
A

A1

This is conversion, defined as a loss of normal neurological function due to psychological reasons. In somatisation, multiple, non -specific and new physical symptoms (e.g. pain) are noted.

14
Q

Question 14.

A 13 year old boy was sent from school by his teacher as he smelt of alcohol. The GP refers the family to child psychiatric services where his dad reports that his son is less interested in exploring new things. He never joins in on a conversation when there are visitors at home; he gets distressed and sweats profusely when attending parties and other occasions. Most likely diagnosis is

  1. Agoraphobia
  2. Alcohol dependence
  3. Depression
  4. Social phobia
  5. Specific phobia
A

A.4

15
Q

Question 15.

A 53-year-old lawyer is concerned about a recent change in the nature of his heart rhythm. He has been to his GP who has referred him to different cardiologists who were all unable to find any abnormalities in ECG, stress test, perfusion scan, echocardiogram and 24 hour Holter monitoring. But the lawyer feels that something sinister has been missed and continues spending many hours consulting various books, journal and Internet sources regarding his problems. He has even stopped working. The most likely diagnosis is

  1. Conversion disorder
  2. Hypochondriasis
  3. Munchausen disorder
  4. PTSD
  5. Somatisation disorder
A

A.2

16
Q

Question 16.

Which of the following is a normal stage of grief?

  1. Ambivalence
  2. Anger
  3. Bargaining
  4. Mourning
  5. Protest
A

A.5

The classic work on stages of grief came from Erich Lindemann at Massachusetts General Hospital who studied 101 bereaved people. He wrote an article, published in 1944, titled “Symptomology and Management of Acute Grief.” In this article he described a set pattern: After an unexpected death, there is initial shock that lasts 10-14 days. After the initial shock comes a period of intense sadness, and the grieving person may withdraw from social contact. Next comes ‘protest’, as the grieving person seems to show resistance against the unexpected death. Finally, within a year or so, the grief is resolved and the person returns to normal.

Anger is not a recognised stage of grief. Protest is a defined stage in which anger can be seen. The ‘best’ answer is protest when it is listed in the choices.

17
Q

Question 17.

Ganser syndrome is included in ICD under

  1. Anxiety disorders
  2. Other dissociative disorders
  3. Other neurotic disorders
  4. Reaction to stress and adjustment disorder
  5. Somatoform disorders
A

A.2

Ganser syndrome is included in ICD under other dissociative disorder. F 44.80.

18
Q

Question 18.

A 21-year-old man moved from London to Scotland, a month ago. He is complaining of uneasiness, difficult to concentrate and a feeling of inability to cope since the move. The diagnosis is

  1. Acute stress reaction
  2. Adjustment disorder
  3. Generalized anxiety disorder
  4. Neurasthenia
  5. Social phobia
A

A.2

Adjustment disorder is a state of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arising in the period of adaptation to a significant life change or to the consequences of a stressful life event. It usually occurs within 1 month of the stressful event and the duration of symptoms does not usually exceed 6 months.

19
Q

Question 19.

Astasia-Abasia is mostly associated with

  1. Conversion disorder
  2. Depressive pseudodementia
  3. Dissociative fugue
  4. Phobic anxiety disorder
  5. Schizophrenia
A

A.1

The Greek term astasia-abasia literally translates to mean inability to stand and to walk. Although today we would classify the syndrome as a conversion disorder, it was considered a separate disease by Paul Blocq (1860-1896), who described this phenomenon as the inability to maintain an upright posture, despite normal function of the legs in the bed. (From Okun & Koehler, Mov Disord. 2007 Jul 30;22(10):1373-8.)

20
Q

Question 20.

A 30-year-old man is involved in a motorcycle accident, in which his friend (passenger) dies. He presents with paralysis of his left arm, stating he cannot ride a motorcycle again. The doctors find no organic cause.

  1. Acute stress reaction
  2. Adjustment disorder
  3. Hypochondriasis
  4. Motor dissociative disorder
  5. Neurasthenia
A

A.4

Dissociative disorders are presumed to be “psychogenic” in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. The onset and termination of dissociative states are often reported as being sudden and the symptoms usually develop in close relationship to psychological stress. The commonest varieties are loss of ability to move the whole of part of a limb or limbs. Paralysis may be partial, with movements being weak or slow, or complete. Various forms and variable degrees of incoordination (ataxia) may be evident, particularly in the legs, resulting in bizarre gait or inability to stand unaided (astasia-abasia).

21
Q

Question 21.

A 55-year-old woman with suspected multiple sclerosis presents with loss of function in one arm. She does not seem concerned by this defect. This is best described as

  1. Bouffee delirante
  2. Echo de la pensee
  3. La belle indifference
  4. Moria
  5. Palimpsest
A

A.3

La belle indifference is a surprisingly lack of concern for, or denial of, apparently severe functional disability. It is often seen in patients with hysteria and in medical illness e.g. cerebro vascular accident. It is a rare and non-specific symptom of no diagnostic value.

22
Q

Question 22.

Risk factors for PTSD include which one of the following?

  1. Anankastic traits
  2. Being male
  3. Cigarette smoking
  4. External locus of control
  5. Religious affiliation
A

A.4

Lack of internal locus of control is a contributor to the development of PTSD. Being female, high degree of neuroticism and low sense of security also increase the risk of PTSD after a trauma. Religious affiliation is seen as protective in various studies. Most studies showed a positive relationship between PTSD and smoking and nicotine dependence, with odds ratios ranging between 2.04 and 4.52. Specific PTSD symptoms may contribute to smoking and disrupt cessation attempts. But there is no evidence that smoking itself elevates the risk of PTSD after exposure to trauma. http://apt.rcpsych.org/content/13/5/369.full Nicotine Tob Res (2007) 9 (11): 1071-1084.

23
Q

Question 23.

The symptoms of adjustment disorder resolve within;

  1. 1 month of termination of the stressor
  2. 1 week of termination of the stressor
  3. 2 weeks of termination of the stressor
  4. 3 months of termination of the stressor
  5. 6 months of termination of the stressor
A

A.5

Adjustment disorder requires a stressor and that the symptoms should resolve within 6 months of termination of the stressor or its consequences.

24
Q

Question 24.

Neurasthenia is classified under which of the following categories in ICD-10?

  1. Other anxiety disorders
  2. Other neurotic disorders
  3. Somatoform disorders
  4. Unspecified mood disorders
  5. Unspecified non organic disorders
A

A.2

According to ICD-10, Neurasthenia is classified under ‘Other neurotic disorders’ F48.0. Note that Depersonalization-Derealisation syndrome is also classified under Other neurotic disorders in ICD-10.

25
Q

Question 25.

A man who has always had an anxious disposition has been feeling increasingly on the edge, has symptoms of breathlessness, chest pain and nausea, which have been worsening over the last 6 months. What is the most likely diagnosis?

  1. Adjustment disorder
  2. Agoraphobia with panic disorder
  3. Da Costa syndrome
  4. Generalised anxiety disorder
  5. Mixed anxiety and depressive disorder
A

A.4

Generalised anxiety disorder is characterized by prominent tension, excessive worry with generalised free-floating persistent anxiety and feelings of apprehension about everyday events leading to significant stress and functional impairment. Physical symptoms and features of autonomic arousal are usually seen in GAD. The ICD-10 list contains 22 physical symptoms of anxiety whilst there are only 6 in the DSM-4 list. Common physical symptoms include breathing difficulties, choking sensations, chest pain, nausea/abdominal distress. The symptoms of autonomic arousal include sweating, palpitations, trembling and dry mouth.

26
Q

Question 26.

Which of the following statements regarding PTSD is true?

  1. Autonomic hyperarousal symptoms are usually rare
  2. Previous history of neurotic illness precludes the development of PTSD features
  3. PTSD is associated with hypersomnia
  4. PTSD symptoms usually occur within 6 months of the perceived trauma
  5. Specific EEG changes occur in chronic PTSD
A

A.4

PTSD symptoms usually occur within 6 months of the perceived trauma. The essential features are autonomic hyperarousal, re-experiencing of aspects of the stressful event and active avoidance of cues that remind of the trauma. Anhedonia may also be seen; dramatic acute bursts of anxiety may present as exaggerated startle and hyperarousal. Insomnia is common. Predisposing factors include maladaptive personality traits (e.g. anankastic) or previous history of neurotic illnesses.