Severe Mental Illness

Severe Mental Illness UK Medical PG Question 1: A 30-year-old woman presents with episodes of feeling detached from herself and her surroundings, as if watching herself from outside her body. These episodes last 10-15 minutes and cause significant distress. What is the most likely diagnosis?

• A. Panic disorder
• B. Dissociative disorder (Correct Answer)
• C. Schizophrenia
• D. Depression
• E. Anxiety disorder

Severe Mental Illness Explanation: ***Dissociative disorder***- The presenting symptoms of feeling detached from oneself (**depersonalization**) and surroundings (**derealization**) are pathognomonic features of **Depersonalization/Derealization Disorder**, a type of dissociative disorder.- These episodic experiences, lasting 10-15 minutes and causing distress, clearly align with the diagnostic criteria for this condition.*Panic disorder*- Characterized by recurrent, unexpected **panic attacks** that include severe physical symptoms like **palpitations**, shortness of breath, and chest pain, peaking within minutes.- Although depersonalization/derealization can occur during a panic attack, the core complaint here is pure detachment, not an overwhelming surge of **physical anxiety** or intense fear.*Schizophrenia*- Schizophrenia is primarily characterized by **psychotic symptoms** such as **hallucinations** (e.g., auditory) and **delusions**, which are absent in this presentation.- The disorder requires a minimum duration of symptoms and active phase criteria (e.g., disorganized speech or behavior) distinct from isolated episodic detachment.*Depression*- Core features of depression involve persistent **depressed mood** and **anhedonia** (loss of pleasure or interest), along with changes in sleep, appetite, and energy.- While sometimes associated with severe mental illness, episodic dissociation is not the defining criterion for Major Depressive Disorder.*Anxiety disorder*- This term is broad, but common diagnoses like Generalized Anxiety Disorder (GAD) involve persistent, excessive, and uncontrollable **worry** about various life events.- The clinical picture involves profound subjective detachment rather than chronic high levels of pervasive **anxiety** or restlessness.

Severe Mental Illness UK Medical PG Question 2: A 40-year-old woman presents with recurrent episodes of palpitations, sweating, and tremor lasting 10-15 minutes. These occur 2-3 times per week with no obvious trigger. Physical examination and ECG during an episode are normal. What is the most likely diagnosis?

• A. Hyperthyroidism
• B. Panic disorder (Correct Answer)
• C. Cardiac arrhythmia
• D. Pheochromocytoma
• E. Caffeine excess

Severe Mental Illness Explanation: ***Panic disorder***- The sudden, recurrent, brief attacks (10–15 minutes) of intense fear with physical symptoms like **palpitations**, **sweating**, and **tremor**, in the absence of an underlying medical condition (normal ECG), are characteristic of a **panic attack**.- The unpredictable nature ("no obvious trigger") and recurrence (2–3 times per week) fulfill the diagnostic criteria for **Panic Disorder**.*Hyperthyroidism*- While hyperthyroidism causes symptoms like **palpitations**, **sweating**, and **tremor**, these are typically persistent and chronic, not episodic and brief (10-15 minutes) as described.- A physical examination would likely reveal additional signs such as **goiter**, **exophthalmos**, or sustained **tachycardia**, which are absent here.*Cardiac arrhythmia*- Arrhythmias, even paroxysmal ones (e.g., PSVT), almost always cause demonstrable **ECG changes** (e.g., tachycardia, rhythm irregularity) during an episode, which are explicitly stated as normal in this patient.- The prominence of diffuse **sweating** and **tremor** alongside palpitations, in the context of a normal ECG, points away from a primary cardiac etiology.*Pheochromocytoma*- Paroxysms due to pheochromocytoma (episodic catecholamine release) typically involve severe, episodic **hypertension** and intense **headaches** along with palpitations, findings not mentioned in this clinically normal presentation.- While attacks can mimic panic, the underlying pathology often results in profound physiological changes (e.g., significant BP surge) that would likely be detected or at least suspected during physical examination.*Caffeine excess*- Symptoms from caffeine excess are often continuous or predictable based on **recent high consumption**, rather than occurring spontaneously 2–3 times per week with "no obvious trigger."- Significant caffeine intoxication would usually present with more sustained **tremor**, **restlessness**, or high resting heart rate, symptoms inconsistent with a completely normal physical exam.

Severe Mental Illness UK Medical PG Question 3: 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

Severe Mental Illness 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.

Severe Mental Illness UK Medical PG Question 4: 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

Severe Mental Illness 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.

Severe Mental Illness UK Medical PG Question 5: 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

Severe Mental Illness 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.

Severe Mental Illness Flashcard 1 of 5

Question: Dopamine agonists (e.g. pramipexole, ropinirole) may _____ impulsive activities such as gambling, hypersexuality, shopping, & binge eating

Answer: ↑

Severe Mental Illness Flashcard 2 of 5

Question: _____ is a feature of schizophrenia

Answer: Insomnia

Severe Mental Illness Flashcard 3 of 5

Question: The risk of developing schizophrenia if one monozygotic twin is affected is approx _____

Answer: 50%

Severe Mental Illness Flashcard 4 of 5

Question: A long prodromal phase of _____ is associated with poor prognosis in schizophrenia

Answer: social withdrawal

Severe Mental Illness Flashcard 5 of 5

Question: Schizophrenic patient seen stopping voluntary movement or staying still = _____

Answer: catatonia