Bipolar disorder — MCQs

10 questions

A 58-year-old man presents with progressive memory loss and behavioral changes over 10 months. MRI shows asymmetric frontotemporal atrophy. What is the most appropriate symptomatic treatment?

A 53-year-old woman presents with progressive memory loss and personality changes over 8 months. MRI shows frontotemporal atrophy. CSF shows elevated tau but normal amyloid-β42. What is the most likely diagnosis?

A 59-year-old man presents with progressive memory loss and behavioral changes. MRI shows frontotemporal atrophy. What is the most likely diagnosis?

A 68-year-old man presents with progressive memory loss and parkinsonism. He has visual hallucinations and fluctuating cognition. What is the most likely diagnosis?

A 70-year-old man presents with confusion, agitation, and visual hallucinations that fluctuate throughout the day. He has a shuffling gait and mild tremor. His daughter reports he often falls asleep during conversations. What is the most likely diagnosis?

A 60-year-old man presents with progressive memory loss and behavioral changes over 8 months. MRI shows frontotemporal atrophy. What is the most likely diagnosis?

A 78-year-old man presents with confusion and falls. His wife reports he has been increasingly forgetful over the past year. MMSE score is 18/30. What is the most appropriate initial investigation?

A 27-year-old woman presents with amenorrhea, weight loss, and excessive exercise. She has fine lanugo hair and her BMI is 16 kg/m². She denies having an eating disorder. What is the most likely diagnosis?

A 52-year-old woman presents with progressive memory loss and personality changes over 8 months. MRI shows frontotemporal atrophy. CSF shows elevated tau but normal amyloid-β. What is the most likely diagnosis?

Q10

A 68-year-old man presents with progressive memory loss and behavioral changes. He has difficulty with language and shows disinhibited behavior. MRI shows frontotemporal atrophy. What is the most likely diagnosis?

Bipolar disorder UK Medical PG Practice Questions and MCQs

Question 1: A 58-year-old man presents with progressive memory loss and behavioral changes over 10 months. MRI shows asymmetric frontotemporal atrophy. What is the most appropriate symptomatic treatment?

A. Cholinesterase inhibitors
B. Memantine
C. Antipsychotics for behavior
D. Supportive care only (Correct Answer)
E. Antidepressants

Explanation: ***Supportive care only*** - Frontotemporal dementia (FTD), characterized by **progressive memory loss**, **behavioral changes**, and **asymmetric frontotemporal atrophy** on MRI, currently lacks disease-modifying treatments. - Management focuses on **supportive care**, including symptom management for agitation, sleep disturbances, and nutritional needs, alongside comprehensive caregiver support. *Cholinesterase inhibitors* - These medications, like donepezil or rivastigmine, are primarily used in **Alzheimer's disease** to enhance cholinergic neurotransmission. - They are generally **ineffective** in FTD and can potentially worsen behavioral symptoms in some patients. *Memantine* - Memantine is an **NMDA receptor antagonist** approved for moderate to severe **Alzheimer's disease**. - Its efficacy in FTD has **not been established**, and it is typically not recommended as a primary symptomatic treatment. *Antipsychotics for behavior* - While **antipsychotics** can be used cautiously to manage severe behavioral disturbances like aggression or psychosis in FTD, they are not a primary symptomatic treatment for the core disease process. - Their use carries **significant risks**, including increased mortality in elderly dementia patients, and should be reserved for severe, refractory symptoms. *Antidepressants* - **Antidepressants** may be used to address co-occurring **mood symptoms** such as depression or anxiety, which can be present in FTD. - They do not directly treat the core cognitive or behavioral aspects of FTD and are not considered a primary symptomatic treatment for the dementia itself.

Question 2: A 53-year-old woman presents with progressive memory loss and personality changes over 8 months. MRI shows frontotemporal atrophy. CSF shows elevated tau but normal amyloid-β42. What is the most likely diagnosis?

A. Alzheimer's disease
B. Frontotemporal dementia (Correct Answer)
C. Lewy body dementia
D. Vascular dementia
E. Creutzfeldt-Jakob disease

Explanation: ***Frontotemporal dementia***- The clinical presentation of progressive **personality changes** and prominent **frontotemporal atrophy** on MRI is highly specific for FTD, particularly the behavioral variant (bvFTD).- The CSF profile of **elevated tau** with **normal amyloid-β42** is consistent with FTD, as amyloid-β42 is typically normal, unlike in Alzheimer's disease.*Alzheimer's disease*- AD typically begins with profound **episodic memory loss**, and early atrophy is usually centered in the **medial temporal lobes** (hippocampi), not primarily frontotemporal.- The CSF profile for established AD usually shows **low amyloid-β42** (due to amyloid plaque deposition) and high tau/phospho-tau; this patient's *normal* amyloid-β42 makes typical AD pathology less likely.*Lewy body dementia*- This diagnosis requires at least two of the following core features: **fluctuating cognition**, recurrent detailed **visual hallucinations**, or spontaneous **parkinsonism**, none of which are detailed here.- While atrophy can occur, profound frontotemporal atrophy and primary personality change are less characteristic of LBD compared to FTD.*Vascular dementia*- Vascular dementia is strongly associated with cerebrovascular risk factors and typically demonstrates **stepwise decline** or imaging evidence of multiple **infarcts** or extensive white matter disease.- The smooth progression over 8 months, coupled with atrophy focused specifically on the frontal lobes rather than diffuse vascular damage, argues against this diagnosis.*Creutzfeldt-Jakob disease*- CJD usually presents with very **rapid progression** (weeks to a few months) leading quickly to death, often accompanied by **myoclonus** (involuntary jerking).- Although CJD can present atypically, the 8-month course is too protracted for classic CJD, and the lack of characteristic MRI findings (e.g., DWI hyperintensities) makes it improbable.

Question 3: A 59-year-old man presents with progressive memory loss and behavioral changes. MRI shows frontotemporal atrophy. What is the most likely diagnosis?

A. Alzheimer's disease
B. Frontotemporal dementia (Correct Answer)
C. Vascular dementia
D. Lewy body dementia
E. Normal pressure hydrocephalus

Explanation: ***Frontotemporal dementia***- This diagnosis is strongly supported by the combination of **behavioral changes** (often presenting as apathy or disinhibition) and the specific radiographic finding of predominant **frontotemporal atrophy** on MRI.- FTD typically affects individuals under 65 (like this 59-year-old man) and is characterized by early decline in **personality**, social conduct, or **language abilities**, often before severe memory impairment.*Alzheimer's disease*- While memory loss is present, AD typically presents with early and predominant decline in **episodic memory** (new learning and recalling recent events).- The classic MRI finding in AD is atrophy primarily affecting the **medial temporal lobes** and **hippocampi**, not the anterior frontal and temporal lobes.*Vascular dementia*- This condition is typically associated with a history of **cerebrovascular disease** and imaging evidence of **multiple infarcts** or significant **ischemic white matter lesions**.- The course of decline is often abrupt or **stepwise**, corresponding to specific vascular events, rather than the gradual, smooth progression seen in primary neurodegenerative diseases.*Lewy body dementia*- Core features differentiating LBD include recurrent **well-formed visual hallucinations**, profound **fluctuations** in attention and alertness, and spontaneous **Parkinsonism**.- While memory and behavior are affected, the absence of these three hallmark symptoms makes **Lewy body dementia** less likely than FTD given the frontotemporal atrophy.*Normal pressure hydrocephalus*- NPH is characterized by the classic triad of **gait disturbance** (ataxia), **urinary incontinence**, and dementia, which is not fully described here.- MRI shows **ventriculomegaly** (enlarged ventricles) with often minimal or normal sulcal atrophy, a distinct finding from localized cortical atrophy.

Question 4: A 68-year-old man presents with progressive memory loss and parkinsonism. He has visual hallucinations and fluctuating cognition. What is the most likely diagnosis?

A. Alzheimer's disease
B. Parkinson's disease dementia
C. Lewy body dementia (Correct Answer)
D. Vascular dementia
E. Frontotemporal dementia

Explanation: ***Lewy body dementia*** - The classic triad of **progressive memory loss** (dementia), **parkinsonism**, and **recurrent visual hallucinations**, along with **fluctuating cognition**, are hallmark diagnostic features of Lewy body dementia. - This condition is characterized by the presence of **Lewy bodies** in the brainstem and cortex, leading to a combination of cognitive and motor symptoms. *Alzheimer's disease* - While memory loss is prominent, **Alzheimer's disease** typically does not present with early or significant **parkinsonism** or prominent **visual hallucinations**. - Cognitive fluctuations are also not a primary distinguishing feature of Alzheimer's, which is more characterized by a gradual, progressive decline in memory and other cognitive domains. *Parkinson's disease dementia* - In **Parkinson's disease dementia (PDD)**, the **dementia** typically develops at least **one year after** the onset of well-established **parkinsonism**. - Although PDD can also feature visual hallucinations and cognitive fluctuations, the **temporal relationship** (parkinsonism preceding dementia by a significant period) is crucial for its diagnosis, unlike in LBD where symptoms often emerge concurrently or dementia precedes parkinsonism by less than a year. *Vascular dementia* - This condition is characterized by a **step-wise cognitive decline**, often associated with a history of stroke or cerebrovascular disease, and typically presents with **focal neurological deficits**. - **Parkinsonism** and **visual hallucinations** are not typical primary features of vascular dementia; cognitive decline is usually related to specific brain lesions. *Frontotemporal dementia* - **Frontotemporal dementia (FTD)** typically presents with prominent early changes in **behavior** (e.g., disinhibition, apathy) or **language difficulties**, rather than primary memory loss. - **Parkinsonism** and **visual hallucinations** are not characteristic features of FTD and would make this diagnosis less likely.

Question 5: A 70-year-old man presents with confusion, agitation, and visual hallucinations that fluctuate throughout the day. He has a shuffling gait and mild tremor. His daughter reports he often falls asleep during conversations. What is the most likely diagnosis?

A. Alzheimer's disease
B. Vascular dementia
C. Lewy body dementia (Correct Answer)
D. Frontotemporal dementia
E. Delirium

Explanation: ***Lewy body dementia***- The combination of **fluctuating cognition** (confusion, agitation, falling asleep during conversations), recurrent, well-formed **visual hallucinations**, and spontaneous **parkinsonism** (shuffling gait, mild tremor) is the classic diagnostic triad for Lewy body dementia.- It is characterized by the accumulation of **alpha-synuclein** protein deposits (Lewy bodies) in neurons, affecting both cognitive and motor functions.*Alzheimer's disease*- Typically presents with **insidious onset** of **progressive memory impairment** as the predominant symptom, rather than prominent fluctuations or early hallucinations.- Motor symptoms like parkinsonism appear very late, if at all, and are not core diagnostic features of early Alzheimer's.*Vascular dementia*- Cognitive decline often occurs in a **stepwise** fashion, frequently associated with a history of **cerebral vascular events** (strokes) or risk factors.- While gait disturbance is common, florid visual hallucinations and dramatic cognitive fluctuations are not typical or primary features of pure vascular dementia.*Frontotemporal dementia*- Primarily involves early changes in **personality**, **behavior** (e.g., disinhibition, apathy), or **language deficits**, often with executive dysfunction.- Lacks the characteristic combination of prominent visual hallucinations, rapid cognitive fluctuations, and parkinsonism seen in this patient.*Delirium*- Delirium is an **acute** and usually reversible disturbance in attention and consciousness, often triggered by underlying medical illness, infection, or medication.- While fluctuations and agitation are present, the patient's history describes chronic, progressive features consistent with a **dementia syndrome**, not an acute confusional state.

Question 6: A 60-year-old man presents with progressive memory loss and behavioral changes over 8 months. MRI shows frontotemporal atrophy. What is the most likely diagnosis?

A. Alzheimer's disease
B. Vascular dementia
C. Frontotemporal dementia (Correct Answer)
D. Lewy body dementia
E. Normal pressure hydrocephalus

Explanation: ***Frontotemporal dementia*** - The clinical presentation of **progressive memory loss** and prominent **behavioral changes** over 8 months, coupled with specific **frontotemporal atrophy** on MRI, is highly characteristic of frontotemporal dementia. - This condition is characterized by early and prominent changes in personality, behavior, or language, often preceding significant memory deficits, which aligns with the described behavioral changes. *Alzheimer's disease* - While memory loss is a primary feature, Alzheimer's typically presents with **medial temporal lobe atrophy** (e.g., hippocampus) rather than predominantly frontotemporal atrophy on MRI. - Behavioral changes usually emerge later in the course of Alzheimer's, whereas they are often a presenting and prominent symptom in frontotemporal dementia. *Vascular dementia* - This type of dementia often presents with a **step-wise cognitive decline** and is associated with cerebrovascular disease and focal neurological signs. - MRI would typically show evidence of **infarcts** or **ischemic changes**, not specific frontotemporal atrophy in isolation, making it less likely. *Lewy body dementia* - Key features include **fluctuating cognition**, **recurrent visual hallucinations**, and **parkinsonism**. - While memory loss and behavioral changes occur, the absence of these characteristic features and the specific finding of frontotemporal atrophy do not support this diagnosis. *Normal pressure hydrocephalus* - This condition presents with a classic triad of **gait disturbance**, **urinary incontinence**, and **dementia** (often executive dysfunction). - MRI would reveal **ventriculomegaly** with normal or mildly increased CSF pressure, not selective frontotemporal atrophy.

Question 7: A 78-year-old man presents with confusion and falls. His wife reports he has been increasingly forgetful over the past year. MMSE score is 18/30. What is the most appropriate initial investigation?

A. CT head (Correct Answer)
B. MRI brain
C. Lumbar puncture
D. EEG
E. PET scan

Explanation: ***CT head*** - Given the patient's age (78 years), confusion, falls, and cognitive decline (MMSE 18/30), an initial **CT head** is crucial to rapidly rule out **reversible causes** of dementia and acute structural pathologies. - It efficiently identifies conditions like **subdural hematoma**, **normal pressure hydrocephalus (NPH)**, or **mass lesions** (e.g., tumors, large strokes) that require urgent management and can present with cognitive symptoms and falls. *MRI brain* - While **MRI brain** provides superior resolution for detecting subtle structural changes, such as **vascular disease**, **small infarcts**, or **white matter lesions**, it is often reserved for a more detailed evaluation after initial screening. - It is less available, more time-consuming, and not the primary initial choice when urgent exclusion of acute, potentially life-threatening causes is paramount. *Lumbar puncture* - This invasive procedure is typically indicated for the investigation of **rapidly progressive dementia**, suspected **infectious causes** (e.g., neurosyphilis, chronic meningitis), or **inflammatory conditions**. - It is not a routine initial investigation for gradual cognitive decline unless there are specific clinical features suggestive of these conditions. *EEG* - **Electroencephalography (EEG)** assesses brain electrical activity and is primarily used to investigate **seizure disorders** (e.g., non-convulsive status epilepticus mimicking confusion) or specific types of dementia like **Creutzfeldt-Jakob disease (CJD)**. - It does not provide the structural information needed to identify lesions or hydrocephalus that can cause acute confusion and falls. *PET scan* - **Positron Emission Tomography (PET)** scans (e.g., FDG-PET or amyloid-PET) are specialized functional imaging modalities used later in the diagnostic process to help differentiate specific types of dementia (e.g., **Alzheimer’s disease** from **frontotemporal dementia**). - It is a costly, advanced investigation and is not appropriate as the initial screening tool for structural brain pathology or reversible causes of cognitive impairment.

Question 8: A 27-year-old woman presents with amenorrhea, weight loss, and excessive exercise. She has fine lanugo hair and her BMI is 16 kg/m². She denies having an eating disorder. What is the most likely diagnosis?

A. Hyperthyroidism
B. Anorexia nervosa (Correct Answer)
C. Depression
D. Celiac disease
E. Addison's disease

Explanation: ***Anorexia nervosa***- The triad of significantly **low BMI** (<17.5 kg/m² indicating severe restriction), **amenorrhea** due to HPO axis suppression, and **lanugo hair** (a compensatory mechanism for body temperature regulation in starvation) is highly specific for anorexia nervosa.- The presence of excessive exercise alongside severe weight loss strongly indicates the behavioral pathology of this disorder, even with the patient's denial, which is common.*Hyperthyroidism*- Although hyperthyroidism causes weight loss, it is typically accompanied by symptoms like **tachycardia**, **tremors**, goiter, and heat intolerance, which are absent here.- Hyperthyroidism does not cause the development of **lanugo hair**, which is a sign of chronic severe malnutrition.*Depression*- Depression can cause weight change and sometimes secondary amenorrhea, but it lacks the specific combination of the **low BMI**, excessive exercise, and physiological signs of starvation like **lanugo hair**.- The focus on weight-related behaviors (excessive exercise) points primarily toward an **eating disorder** rather than an isolated mood disorder.*Celiac disease*- Celiac disease leads to weight loss primarily through **malabsorption**, often associated with GI symptoms like chronic diarrhea or abdominal pain.- It does not explain the behavioral feature of **excessive exercise** or the dermatological finding of **lanugo hair** due strictly to gluten intolerance.*Addison's disease*- Addison's disease causes weight loss and fatigue but is classically characterized by **hyperpigmentation** (primary adrenal insufficiency) and volume depletion.- It does not typically present with the specific severe **malnutrition** signs (BMI 16, lanugo hair) or the core psychopathology of restricted intake and **excessive exercise** seen in this patient.

Question 9: A 52-year-old woman presents with progressive memory loss and personality changes over 8 months. MRI shows frontotemporal atrophy. CSF shows elevated tau but normal amyloid-β. What is the most likely diagnosis?

A. Alzheimer's disease
B. Frontotemporal dementia (Correct Answer)
C. Lewy body dementia
D. Vascular dementia
E. Normal pressure hydrocephalus

Explanation: ***Frontotemporal dementia***- The combination of progressive **personality changes** and memory loss, particularly with **frontotemporal atrophy** on MRI, is highly characteristic of Frontotemporal Dementia (FTD).- CSF showing **elevated tau** but **normal amyloid-β** further supports FTD (specifically tauopathies), as low amyloid-β is typically seen in Alzheimer's disease.*Alzheimer's disease*- While memory loss is prominent, **personality changes** are usually not the initial or most prominent symptom in early Alzheimer's compared to FTD.- **CSF amyloid-β** is typically **low** in Alzheimer's disease due to its deposition in plaques, which contradicts the normal amyloid-β finding in this patient.*Lewy body dementia*- This condition presents with a classic triad of **fluctuating cognition**, **recurrent visual hallucinations**, and **parkinsonism**, none of which are described.- MRI in LBD typically shows less specific atrophy, and CSF markers alone are not usually sufficient for differentiation without the characteristic clinical features.*Vascular dementia*- Vascular dementia is characterized by a **step-wise decline** in cognitive function, often associated with stroke or cerebrovascular disease, not typically a progressive decline over 8 months with frontotemporal atrophy.- Imaging would show evidence of **infarcts** or **white matter lesions**, which are not mentioned.*Normal pressure hydrocephalus*- The classic triad for NPH includes **gait disturbance**, **urinary incontinence**, and **dementia**, with MRI showing **ventriculomegaly**.- The patient's presentation of prominent personality changes and frontotemporal atrophy does not align with NPH.

Question 10: A 68-year-old man presents with progressive memory loss and behavioral changes. He has difficulty with language and shows disinhibited behavior. MRI shows frontotemporal atrophy. What is the most likely diagnosis?

A. Alzheimer's disease
B. Frontotemporal dementia (Correct Answer)
C. Vascular dementia
D. Lewy body dementia
E. Normal pressure hydrocephalus

Explanation: ***Frontotemporal dementia*** - The combination of **progressive memory loss** along with significant **behavioral changes** (specifically **disinhibited behavior**), **difficulty with language**, and **frontotemporal atrophy** on MRI, is highly indicative of frontotemporal dementia (FTD). - FTD is characterized by early and prominent alterations in personality, behavior, and/or language, often preceding significant memory deficits, unlike Alzheimer's. *Alzheimer's disease* - While memory loss is a primary feature of Alzheimer's, it typically presents with early and predominant **episodic memory impairment** and often involves **hippocampal/medial temporal atrophy** first. - Severe social disinhibition and early language difficulties (non-amnestic presentation) are less typical initial features of AD compared to FTD, which directly affects these frontal and temporal functions. *Vascular dementia* - This diagnosis is characterized by a **stepwise decline** in cognitive function and is associated with evidence of **cerebrovascular disease** (e.g., infarcts, white matter lesions) on imaging. - The case description does not mention a stepwise decline or history of strokes, nor does the MRI show classic vascular lesions but rather frontotemporal atrophy. *Lewy body dementia* - Key features of Lewy body dementia (LBD) include **fluctuating cognition**, recurrent detailed **visual hallucinations**, and spontaneous **parkinsonism**. - While behavioral changes and cognitive deficits occur, the specific presentation of prominent language difficulty and disinhibition, without the classic LBD triad, makes it less likely. *Normal pressure hydrocephalus* - Normal pressure hydrocephalus (NPH) is characterized by the classic triad of **gait disturbance**, **urinary incontinence**, and dementia. - MRI in NPH typically shows **ventriculomegaly** disproportionate to sulcal atrophy, not focal frontotemporal cortical atrophy as described in the patient's MRI.

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