Sample Questions
1. The family of a 75-year-old retired physician solicits a psychiatric consultation because she has begun to have visual hallucinations that agitate and confuse her. During the periods of hallucinations, which consist of different but familiar scenes and people, she remains fully alert, lucid, and aware that they are not "real." The problem began several months before, following unsuccessful ocular surgery that left her blind. She is fully aware of her loss of sight, makes allowances for it, and has no cognitive impairment. Which is the most likely explanation for the patient’s hallucinations?
a. Anton’s Syndrome
b. Charles Bonnet syndrome
c. Partial complex seizures
d. Occipital seizures
e. Dementia
Answer b: In keeping with the general rule that sensory deprivation leads to hallucinations, blindness leads to visual hallucinations. The Charles Bonnet syndrome, a classic neuropsychiatric disorder, consists of visual hallucinations provoked by the onset of blindness from either ocular or occipital injury. Visual hallucinations may occur only in the "blind field" of patients with homonymous hemianopsia as well as in the entire field of vision of individuals who are completely blind. Anton syndrome, another neuropsychiatric disorder, consists of denial of blindness and usually involves patients confabulating and acting as though their sight were normal. This patient’s hallucinations are probably not seizures because they differ from episode to episode. In addition, they are probably not partial complex seizures because her level consciousness remains intact.
2. In the patient described in the previous question, after nonpharmacologic methods did not suppress the hallucinations, which medication or category of medication should the psychiatrist prescribe?
a. Antiepileptic drug
b. Modafinil
c. Antipsychotic
d. Benzodiazepine
Answer c. Small doses of an antipsychotic will usually suppress these hallucinations. The other medications will not help except to sedate her or make her oblivious to the hallucinations.
3. The school psychologist refers the 9-year-old student in this sketch for a psychiatric examination. The boy, who has had epilepsy for several years, has begun to slip in his interpersonal skills, language ability, and academic aptitude. Moreover, he has begun a rocking movement in class. Which is the most likely diagnosis?
a. Autistic spectrum disorder
b. Mental retardation (intellectual disability)
c. Tuberous sclerosis
d. Antiepileptic drug toxicity
Answer c. Although antiepileptic drugs might impair his cognitive abilities and interpersonal skills, the combination of facial adenomata, epilepsy, and autistic symptoms indicate that tuberous sclerosis is the most likely diagnosis. A CT of his head and genetic testing would prove it. Fragile X, Angelman, and Rett syndromes as well as tuberous sclerosis produce symptoms of autism.
4. A 70-year-old retired police officer, who has had Parkinson disease for 12 years, had hallucinations, paranoid ideation, and physical agitation. In conjunction with a psychiatrist, the neurologist reduced his Parkinson medication regimen; however, that change and similar strategies eliminated the psychosis but left him rigid and immobile. During the day, he had numerous periods of being "on" and, more frequently, "off." Which therapy should the neurologist suggest?
a. Restore the Parkinson medication regimen but add an antipsychotic
b. Add an antidepressant
c. Give a course of electroconvulsive therapy (ECT)
d. Refer for deep brain stimulation (DBS)
Answer d. DBS has been a major advance in treatment of Parkinson disease, dystonia, and essential tremor. Used in Parkinson disease, DBS enhances "on" periods and allows a reduction of the medications, which reduces iatrogenic psychosis. If depression had been present and unresponsive to conventional antidepressants, ECT would improve the patient’s mood and reverse his rigidity and bradykinesia.
5. The wife of a 65-year-old retired screen actor brings him for a consultation because he has developed cognitive impairment and occasional daytime visual hallucinations. Sometimes during sleep he swings his arms as though he were boxing. If she wakes him during these movements, he explains that has been dreaming that he is defending them from attack. He has no personal or family history of neurologic or psychiatric illness, use of medications or illicit drugs, systemic symptoms, or exposure to HIV risk factors. Neurologic examination reveals that he has a flat affect, moderate cognitive impairment, rigidity, and bradykinesia. Of the following, which is the most likely cause of his illness?
a. Parkinson disease
b. Alzheimer disease
c. Delirium
d. Dementia with Lewy bodies
Answer d. Parkinsonism accompanying the onset of dementia indicates that the underlying problem is dementia with Lewy bodies. The occasional daytime visual hallucinations and the nocturnal flailing, which is probably REM behavior disorder, are also characteristic of this illness. This situation is not Parkinson disease because dementia is a relatively late complication of that illness. Dementia is almost never one of its presenting features. This situation also does not indicate Alzheimer disease because he presents with motor impairments. He does not have delirium because he has been lucid and has no autonomic symptoms or signs.
6. In the preceding case, which is the most likely neuropathology?
a. Beta-amyloid deposits
b. Accumulation of alpha-synuclein
c. Abnormalities in tau
d. Multiple small cerebral infarctions
Answer b. Accumulation of alpha-synuclein characterize dementia with Lewy bodies and Parkinson disease. Beta-amyloid deposits from plaques in Alzheimer disease. Tau accumulates in frontotemporal dementia. Multiple small cerebral infarcts cause vascular dementia.
