Vignette: Most Effective Treatment for a Man with Sudden Episodes of Anxiety

A 30-year-old man presented with episodes of sudden anxiety, palpitations, chest tightness, and a feeling of impending doom. These episodes occur about 4-5 times per month for the last 7 months and last about 10 minutes on average. They have carried his physical examination and laboratory evaluation out, which is inconclusive about biological causation for his condition. 

What would be the most effective treatment option?

1. Cognitive therapy 
2. Fluoxetine
3. Imipramine
4. Amitriptyline 
5. Cognitive Behavior Therapy

Controlled studies have shown that cognitive therapy is at least as effective as antidepressant medication in the treatment of the panic disorder (Mitte, 2005). Combined treatment with medication and psychotherapy may cause a better response in the acute phase than either treatment modality given alone, but probably not in the longer term. In the longer-term medication alone may have a less good outcome than either psychotherapy alone or combined treatment. However, not all studies agree on this point (Furukawa and Watanabe, 2006; van Apeldoorn et al., 2010).

Corticobasal Degeneration

Corticobasal ganglionic degeneration present with asymmetric basal ganglia (akinesia, rigidity, dystonia) and cerebral cortical (apraxia, cortical sensory loss, alien limb) manifestations. We see the alien limb with parietal lobe, medial frontal lobe, and corpus callosum pathology. Dementia is a variable but may be the presenting symptom. 

Oculomotor involvement like that in progressive supranuclear palsy may occur. But the major difference between PSP and corticobasal degeneration is that the latter is with limb coordination problems, and the former is with balance and walking problems. 

Prognosis

Survival ranges from 2.5 to 12 years, with a median of about 8 years. 

Neuropathology

Corticobasal degeneration pathology shows abundant ballooned, achromatic neurons, and focal cortical atrophy predominating in medial frontal and parietal lobes, plus degeneration of the substantia nigra. We also see astrocytic plaques in the cortex. corticobasal degeneration: neuronal tau pathology shows wispy, fine-threaded tau incus. Magnetic resonance imaging may show asymmetric atrophy in the frontal and parietal lobes contralateral to the dominantly affected limbs. 

Treatment

We have limited treatment options for corticobasal degeneration, with only a minority of patients responding to L-dopa preparations given for parkinsonism. Myoclonus may respond to benzodiazepines, particularly clonazepam. No specific treatment for dementia is available, but it may not be cholinergic, suggesting that cholinesterase inhibitors are of limited value. Depression is common in corticobasal degeneration, but few data exist on treatment response. 

Clinical Manual of Neuropsychiatry, 2017

Schizophrenia as a Disorder of Disorganized Focus of Attention ONLY. 

Schizophrenia is THE psychiatric condition with variable manifestations involving all the major areas of a mental state examination, appearance and behaviour, thoughts and speech, cognitions, perceptions, mood, and most commonly, insight or reality-testing. Studies have long proposed schizophrenia being related to impaired regulation of attention; we propose a model explaining the entire range of manifestations as the result of a disorganized focus of attention. 

Explaining delusions

The cognitive model of depression proposes that patients with dysfunctional beliefs maintain these because of their selective attention to evidence that confirms these beliefs and their tendency to ignore the evidence against it. In the most severe cases, these dysfunctional beliefs may progress to delusions in which case they absolutely do not attend to evidence against their delusional beliefs and are preoccupied with the evidence and thoughts that confirm their belief system. In the case of schizophrenia, this regulation of attention is not mood dependent, it is disorganised but persistent.

Autochthonous Ideas

Described as cognitive interference, the intrusive thoughts are often influenced by environmental cues (for example, thinking about alternative hypotheses of schizophrenia when reading a new one) or mood state (as in the case of anxiety or mood disorders where patients are preoccupied with worries or sad memories). The cognitive theory of obsessive-compulsive disorder proposes not the occurrence but the obsessional patient’s inability to control intrusive thoughts, which is the intrusive thoughts are normal in humans, but the inability to shift attention from them is not.  A sudden delusional idea in patients with schizophrenia strongly favours the disorganized focus of attention in these patients. Objectively, ideas do not COME to mind, patients do not DEVELOP them, instead of the mind shifts (the focus of) attention to ideas. 

Explaining the Disorganised Behaviour and Speech

The most obvious evidence for a disorganised focus of attention in patients with schizophrenia is their disorganised speech and thoughts. Patients with the loosening of the association are said to “jump from topic to topic with now link between them.” We propose their disorganised focus of attention causes them to switch topics, much less influenced by environmental cues unlike in patients with mania, who exhibit a flight of ideas influenced by their distractibility and abundance of ideas. Patients exhibiting self-laugh or self-talk are not able to attend to the environment, despite being fully conscious. Patients with loss of self-care or avolition, in general, are not able to attend to their needs.

Explaining Mood

The mood is highly intervened with the focus of attention both influencing each other. A patient with anxiety focuses attention on anxiety-related cues, a patient with infectious joviality focuses attention on cues of pleasure. In patients with schizophrenia, there is often a disconnect between the mood and their attention. A patient with incongruent affect may be describing (attending to) depressing events while smiling. 

Explaining Hallucinations

Affect illusions are mild perceptual abnormalities, for example, a person preoccupied with fears walking in the dark may misperceive a bush for a monster. Their perceptual abnormalities occur along a spectrum of severity. Patients with delirium may exhibit any of these, for example in a state of fear, misinterpreting a stethoscope for a snake or seeing giant scorpions on the wall.  

Interlinking with Biology

Attention, executive control of attention, cognitive interference are higher cognitive functions primarily ascribed to the prefrontal cortex. Dopaminergic medications, as in patients with attention deficit hyperactivity disorder, help sustain their attention. Hyperdopaminergia favours the persistence of attention to the delusional ideas and the hallucinatory voices in patients with schizophrenia unlike in patients with mood disorders in whom the delusions and hallucinations are fleeting. 

1. Fuster JM. Human Neuropsychology. 2015:183-235.

Posner MI, Early TS, Reiman E, Pardo PJ, Dhawan M. Asymmetries in hemispheric control of attention in schizophrenia. Arch Gen Psychiatry. 1988 Sep;45(9):814-21. doi: 10.1001/archpsyc.1988.01800330038004. PMID: 3415424.

FCPS-2 October 2014, College of Physicians and Surgeons Pakistan

Q.4 A student of BSc diagnosed with borderline personality disorder presented in an emergency after attempting self-harm following a quarrel with a boyfriend.

1. What signs and symptoms require urgent medical treatment?
2. What care we should take in managing this patient in the ward
3. What psychosocial support you will activate
4. Give instructions on discharge regarding follow-ups.

Q.5 What are the various points that differentiate between the various anxiety disorders in terms of their prevalence and clinical features?

Q.6 A 39-year-old woman is diagnosed with severe depression years after the death of her husband. She is suicidal and has active suicidal ideations and symptoms of psychosis and is not responding to treatment with antidepressants. The psychiatrist plans ECT on this patient. 

1. What are the other indications to start ECT in severe depressive disorder
2. What are the indications for ECT other than severe depression?
3. Enlist the therapeutic interventions the physician can not advise that according to the Mental Health Act 2001?

7.  A 19-year-old girl had gone to spend her summer vacations at her uncle’s house in the other city. One day, about 15 days back, her uncle's son shows her some porn videos and seduced her to have sexual relations with him. On refusal, she was abused sexually. When she returned home, she had complaints of nightmares, jumping in bed on the opening of the door, persistent dull lower abdominal pain, irrelevant talks, over-familiarity, grandiosity, hyperactivity, distractibility, disinhibition with decreased sleep.  

1. What are the mental health sequelae to sexual abuse at an early age?
2. What are the three most likely differential diagnoses?
3. What non-pharmacological options are there to manage the latter on an individual who has been subjected to sexual abuse and with the aim of these non-pharmacological treatments?

Q.10 Mr. Y is an admitted case in the Jail ward of psychiatry de undergoing treatment as a patient in pursuance of an order authority. Two days back, the parents of the patient met the consultant and requested discharge urgently as he is symptom-free. 

1. What section of the Mental Health Act 2001 is concerned with such a patient?
2. What does that section say? 
3. What are the sections concerned with the admission to and treatment according to the Mental Health Act 2001?

Q.11 A 65 years old retired business manager has been brought in an emergency in a wheelchair with two days history of drowsiness, generalized rigidity of the body marked tremors, and irrelevant talking. He has a history of bipolar mood disorder for 12 years. Because of his increasing agitated behavior, they increased his lithium dose from 800 mg to 1200 mg per day, haloperidol from 7.5 mg to 15 mg per day, and lorazepam from 1 mg to 3 mg per day. He had diarrhea four days ago, which lasted for 2 days. On examination, he was disorientated and dysarthric with pulse 80/min, BP 160/90 mm, Hg, and temperature 100'F. He was confused and drowsy with diminished tendon jerks and equivocal planters. 

1. Discuss the differential diagnosis.
2. What further investigations will you carry out? 
3. Give justification for each.
4. What initial and long-term management would you advise?

Q.12 A 38-year-old lady is brought to the psychiatric outdoor clinic in a state of stupor a) What possibilities will you consider in the differential diagnosis? b) What investigations would you like to ask for? c) How will you manage her?

Q.13 In its 65" assembly, the World Health Organization adopted a resolution of the need for a comprehensive and coordinated response from health and social sectors as the mental health action plan. 

1. What are the objectives of this plan?
2. Highlight 5 specific ways to promote mental health in the community

Q.14 There is serious concern about the long-term use of benzodiazepine among older persons owing to adverse outcomes. However, the prevalence of benzodiazepine use in older people remains high. Considering recent advances: 

1. Enumerate the adverse effects of benzodiazepines in the elderly. 
2. Enumerate the reasons.
3. What are some evidence-based interventions for withdrawal in the elderly population according to recent advances?

Q.15 What points will you keep in mind while delivering a lecture on these topics:

1. Indication for behavior therapy
2. Indications for family therapy.
3. Role of the therapist in psychoanalytic psychotherapy. 
4. Nonspecific factors in psychotherapy. 
5. Complications of psychotherapy.

Q.16 There has been substantial uncertainty regarding the incidence of children and adolescents exposed to trauma. A recent meta-analysis evaluated this issue.  

1. Regarding recent advances, what is the overall rate of children and adolescents exposed to trauma?
2. Enlist the potential moderating factors in the development of children and adolescents.
3. What are other mental health consequences in children and ad exposed to traumatic events?

Q.17 A 22 years old female patient presented to psychiatric e patient presented to psychiatric OPD with complaints of weight loss over 20%, and Body mass index. On her mental state examination, they revealed it she has real fatness, therefore she avoids food and shows a behavior aimed to lose weight by vomiting. purging excessive exercise and the use of appetite suppressants and diuretics. She also complains of the absence of menstruation for the last few months. 

1. Enlist 10 specific questions that you would ask this patient for the assessment of eating disorder?
2. Considering the above scenario, what is your provisional diagnosis?
3. How will you manage this case?

18. A man is brought to a psychiatric emergency. His pulse is 100/min, BP is 170/95 mm Hg, and he is profusely sweating. He is shaky and has difficulty in giving his history. He has had difficulty falling asleep for two nights and sees spiders walking on the walls. He has been a drinker for 10 years but has had no drink for the last 3 days. 

1. What is the most likely diagnosis?
2. Name three psychometric scales that are used for alcohol dependence or withdrawal?
3. Mention ten social hazards that can result from chronic alcohol abuse?

Q.19 What strategies you could employ to treat the sexual side effects in a 30-year-old male receiving treatment with an SSRI.

Q.20 A 34-year-old woman who had been married for some time is pregnant for the first time. 4 weeks after delivery, she appears to be agitated. In this state, she drowned the child in the bath and slashed her wrists. 

1. What is the most likely differential diagnosis? 
2. How would you manage this case?
3. What medico-legal issues are likely to be involved here?

 

Post-Traumatic Stress Disorder: Sample CASC

So, I have been asked by your GP to have a chat with you because you are having some difficulties in judging. So, as far as I know, you have, you were in an accident. A few months ago and since then you've been having some difficulties. But if it's okay, I'll let you explain what led you to come in here already.

Yeah, I just had an accident about six months ago. And ever since then, I just can't get out of my head.

was it was a serious accident?

Yeah, it was it could have been, you know, the car was all messed up in a way you

know to sort of concussion

to split a whiplash room in the car was really hard.

I can see where you're getting a bit anxious even talking about it. If you find questions difficult to answer It's okay, we can move on. And you can take your time, too, if you're feeling anxious. So you had this unfortunate accident you said that, although you will not seriously injure the car was quite badly damaged, and you make the most depending on how long you have to be in the hospital.

Just a couple of days.

Yeah.

And you mentioned the competition, did you suffer any kind of memory loss or any confusion? And so this happened, about six months ago. And when did you experience the problems in your programs?

In the beginning, it was normal, you know,

it was really, really horrible.

But it just keeps going on. It just seems to get worse. Get rid of it. It's just taken over my life now.

Difficult. And so, can you describe what has been happening, what sort of experiences have you been to. Have you been experiencing?

And the newest thing is a sort of the last one, really I just sort of. I'll be at work or be out with your friends or anything, I just start hearing. Like screeching tires or metal.

This off. I can hear it and then it's like it's happening all over again. I just feel completely sort of paralyzed. So you've got a couple of minutes. It just seems like a lifetime.

Sounds really scary and some people, when they experience, have this kind of experience they also sometimes have nightmares of these incidents. And is it quite frequent the nightmares?

Yeah, so most nights really seem to get worse. Okay. But now it's sort of every night and it's just sort of stuck in the same thing I'm just reliving it up to where it happens and it's often what we find is a traumatic incident like that, avoid situations that might lead to a similar thing, avoid doing the things that happen on the day of seeing that happen in your case.

And now I'm going to drive with anybody else in the car.

Right. My friend.

I just keep thinking that I could have killed her.

Are you able to drive with no kind of emotional

Avoid at all costs, but I need to keep working. If I can avoid doing anything more than I have to do. I'm late every morning because it's just such a workout to get myself in the car to go.

And are you doing anything to deal with all these problems? And when you say drinking is more than community drink after the incident. Did you use to drink before?

I sort of had a glass of wine after work, but now it's just so I just have another one and then another one. I'm just so worried about going to sleep. So I just, I just have a couple more drinks and it just helps me. It helps me get to sleep.

How much do you drink?

Probably. Probably, um, maybe a bottle of wine.

So asking this, but you won't be using any other substances, middle class, here. So, your drinking has gone up You said that you were feeling quite anxious and agitated. Do you also find that you have become a bit more snappy, irritable, with people?

He says I'm a different person now. He thinks I'm just angry all the time. I get mortgage irritated, the normal, a film just got shorter views than I did before.

And you also are quite easy to be always vigilant about what's going on around you.

You know, if I have to sit in the car with my boyfriend's driving to somewhere. I'm constantly on edge I'm looking around for other cars and any sort of hazards, constantly jumping or saying oh slow down or things like that. Yes.

I think all of this must be quite draining on you, how do you say your mood has been in the last few weeks.

I just feel so tearful all the time. On the verge of crying because I just seem so frustrated, but it's still, still going on.

Do you have any happy times in between the lives of many you're doing anything specific?

that already enjoy much,

Because you feel constantly alone and not enjoying things as well. What would you say your energy levels are like

guess just because on the edge all the time we're just taking a lot out from this what

Do you find the most interesting things that you used to enjoy? And you mentioned trying to sleep. Because you are afraid of sleeping, you have been drinking the evening. But when you go to sleep. Go to sleep.

Wake up a lot. Having these dreams gets to a point. So it's all happening again with the car, and then it gets to a point and then a shock. Wake up and then go back to sleep and it just happens.

So good focus on being able to look after yourself. Eat. Look after food and diet.

And since you've been feeling stressed, I mean, do you find that you've had any specific negative thoughts towards where you're not wanting to live anymore or felt like harming yourself or something.

Oh yeah, I don't, I don't want to live like this anymore. I don't kill myself, that's

Been asking lots of questions and you've been very patient with me Thank you very much. I need to speak to my team, and especially the psychologists in my team, because from what you're paying, what you're doing. Today, it seems like you are experiencing symptoms of post-traumatic stress disorder, commonly known as PTSD, and your concern appears below. So, I would speak to the Secretary of State and see if what the missed approach would be because we need to have. We go for psychological therapy first or try combination therapy and medication. But we have a discussion with the team and arrange another appointment for you so I can discuss more what the plan will be.