Download Behavioral Neurology and Psychiatry

Behavioral Neurology and
Psychiatry
ANDREW STEIN
Question 1
 A 63-year-old man is brought to the physician by his daughter because she is
concerned about his memory loss over the past year. Yesterday, he could not
remember his 18-month-old granddaughter's name. Although he denies any
problem, she says he has been forgetful and becomes easily confused. He has lost his
weight twice while driving the last few months. There is no history of alcohol abuse.
His temperature is 37°C, blood pressure is 118/84, pulse is 77 beats per minute, and
respirations are 12 per minute. On mental status examination, his mood is normal.
He is oriented to person and place, but initially gives the wrong month, which he is
able to correct. He recalls from his youth in great detail, but only recalls 1 of 3 words
after 5 minutes. He has difficulty recalling names of common objects and does not
remember the name of the current US president. Physical examination, laboratory
studies, and thyroid function tests show no abnormalities. What is the most likely
diagnosis?
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A. masked depression
B. Alzheimer's dementia
C. Normal age associated memory decline
D. Delirium because of her medical condition
E. Depression
Answer 1
 Correct answer B. Alzheimer's dementia
 Typical early symptoms of Alzheimer's dementia include
memory loss, inability to use judgment and make
decisions, getting lost in familiar places, difficulty
learning and remembering new information, difficulty
expressing oneself, and decreased ability to full perform
tasks like cooking a meal or managing finances. I also
develop new behavior changes and withdrawal from
friends and family. Hallucinations, delusions, and
paranoia can occur in some people become verbally or
physically aggressive or abusive. Eventually they become
unable to perform basic tasks such as eating, dressing,
and bathing. Some patients (less than 5%) can have
seizures and end-stage disease.
Question 2
 "Witzelsucht" is a neurological symptom occurring
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secondary to lesions affecting which the following
locations?
A. Left parietal
B. Right parietal
C. Hypothalamic area
D. Orbital frontal cortex
E. Anterior singular gyrus
Answer 2
 answer D. Orbital frontal cortex
 "Witzelsucht"is a set of neurological symptoms
characterized by the patient's uncontrollable
tendency to pun, tell inappropriate jokies, and
pointless or other irrelevant stories at inappropriate
times. the patient usually finds these utterances
particularly amusing. it is associated with small
lesions of the orbital frontal cortex.
Question 3
 When a person acts intentionally to produce a
symptom without obvious personal or financial
benefit, it is called:
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 A. malingering
 B. Factitious disorder
 C. Conversion
 D. Gancer syndrome
 E.Munchausene by proxy
Answer 3
 Correct answer: B. Factitious disorder
 It is important to distinguish between these diagnoses. factitious disorder is an
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umbrella term to describe conditions were patient's intentionally act as physically or
mentally ill without obvious benefits.
Malingering is present when the person has obvious secondary benefits from his or
her sick role.
Conversion is when the patient unconsciously produces psychological symptoms.
Gancer syndrome is a disorder that has been classified as a factitious disorder or
dissociative disorder. It is characterized by pseudo-stupidity, and it has also been
named "the syndrome of approximate answers". Answers given by the patient will
roll or silly, but approximately close enough to the question to give an indication
that the patient understood the question.
Munchausen syndrome is when the person makes up symptoms of illness in him or
herself to obtain sympathy and comfort for others. It is by proxy, when a parent,
usually the mother, presents with frequent hospital visits for nonexisting complaint
with her child. mother is often a healthcare provider and a dysfunctional family
situation is present. The mother seems to be gaining sympathyor comfort from
others.
Question 4
 A 68-year-old male is referred to you in clinic for progressive memory loss and
visual hallucinations. His wife photocopies him today at the visit explains that his
symptoms started about one year ago. At that time, he insists T-cell car parked
outside his house and he was sure that it was his son's car. The wife explains it was
no car outside and that his son lives 100 miles away and has not visited them in a
while. She also describes that he has been having difficulty managing the finances.
One peculiar aspect of her husband's behaviors that at times he appears completely
lucid, but a couple hours later he would be staring at her not responding to her
questions. He has a history of hypertension and asthma. His vital signs are normal.,
He is well groomed and pleasant and cooperative. It is remarkable for mild rigidity
of the upper extremities. He is unable to copy a clock or 2 intersecting pentagon
figures. The type of dementia that you are suspecting has, pathologic features which
are the following disorders?
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A. Alzheimer's disease
B. Inclusion body myositis
C. Parkinson's disease
D. Cortical Basal ganglionic degeneration
E. Pick's disease
Answer 4
 C. Parkinson's
 dementia with Lewy bodies (DLB) is being
described.both this and Parkinson's disease has
Lewy bodies. With DLB lewy bodies are in the
substantia nigra and in the locys cerykeys, dorsal
raphe nuclei, and throughout the neocortex.
Symptoms result mainly from frontal lobe
dysfunction. Distinguishing features of this are
 1. fluctuations in cognitive function
 2. visual and non-visual hallucinations
 3, extrapyramidal features (such as rigidity, tremor)
Question 5
 40-year-old woman comes to off sadness and frequent crying
spells. she reports difficulty sleeping, decreased appetite, and
generalized fatigue. She reports loss of pleasure for daily
activities. She denies suicidal ideations. There is no apparent
immediate precipitating factor for the symptoms. According
to the DSM-IV criteria, how long do these symptoms have to
be present for the diagnosis of major depression?
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A. 1 week
B. 2 weeks
C. 1 month
D. 2 months
E. 6 weeks
Answer 5
 Answer: B: 2 weeks.
Question 6
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Psychiatry was consulted for 26-year-old mother of 2. She is admitted under the
trauma service after suffering second-degree burns to the back of her neck and
arms. 3 days back she was returning home from the corner store after buying
groceries when she was assaulted by an unknown male. following this, Salter
reported a chemical, likely acid, on her neck causing the burns. She says that during
these events, she felt change we dissociated from the events and felt that these
events were happening to "another person". once in the hospital, she started
developing flashbacks. She would wake up from sleep in a cold sweat and could
feel his fingers on her neck and his breath on her face.she found it difficult to go
back to sleep and reports decreased appetite. There is no apparent primary or
secondary gain. Examination reveals a mildly obese lady who is dysphoric. She has a
labile affect, but has no delusions or hallucinations. Her thought content is
appropriate and she has a clear sensorium. She has second-degree burns on the
back of her neck. Which of the following is the likely diagnosis?
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A. acute stress reaction
B. PTSD
C. Malingering
D. Schizophrenia
E. Somatization Disorder
Answer 6
 The correct answer is A. Acute stress reaction
 Acute stress reaction: requires a dramatic event, which
was experienced or exposed to and a feeling of
helplessness. There also must be a feeling of
dissociation from the event (depersonalization,
amnesia, derealization) . There is also reexperience
as intrusive thoughts of flashbacks, avoidance of the
stimulus, marked anxiety, and resulting in significant
social or functional disability. symptoms occur within 4
weeks and need to be present for 2 days to 4 weeks.
 PTSD is similar , but dissociation is not needed to make
the diagnosis. The symptoms must also be present
for more than 1 month.
Question 7
 A 72-year-old man is brought to attention because of his
unusual behavior for the past 6 months. His family noticed a
change from previously normal behavior. He now frequently
curses, has sudden mood changes, and bursts easily until after
tears without apparent cause. neuro imaging reveals
prominent frontotemporal atrophy. This is characteristic of
which are the following conditions?
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A. Alzheimer's dementia
B. schizophrenia
C. factitious disorder
D. diffuse lewy body disease
E. Pick disease
Answer 7
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Answer: E Pick Disease
 Pick disease is one of frontotemporal dementias. It
presents with behavioral changes and difficulty with
organization and executive function. Imaging usually
shows atrophy predominantly the frontal and
temporal lobes.
Question 8
 Aprosodia has been associated to lesions involving
which of the following brain regions?
 A. left parietal
 B. right occipital
 C. left frontal
 D. right frontal
 E. anterior cingulate
Answer 8
 Correct answer D: Right frontal
 Aprosodia is lack of variation and normal speech,
characterized just, such as speed, tone, and varied
since. Clinical and imaging studies suggest that this
localizes to the posterior inferior frontal lobe of the
nondominant hemisphere.
Question 9
 Which of the following is the most common
psychiatric condition associated with catatonia?
 A. Bipolar disorder
 B. major depression
 C.schizophrenia
 D. dementia not otherwise specified
 E. bereavement
Answer 9
 Correct Answer: A. Bipolar Disorder
 An excited state of catatonia is usually associated with bipolar
disorder. This is generally characterized by impulsivity,
combativeness, and autonomic instability. Catatonia is a symptom
which can be seen in psychiatric diagnosis is characterized by
immobility and rigid tone in the property of "waxy flexibility", which
implies that you can change the position of a limb, the patient
maintains that position. patient's can remain in abnormal flexed
positions for hours to months.
 We commonly associated conditions with catatonia or
schizophrenia, mood disorders, and general medical conditions. The
most common is mood disorders (25-50%) followed by
schizophrenia (10-15%). Among the mood disorders, bipolar is most
commonly associated with catatonia.
Question 10
 Which findings has been most consistently seen in
schizophrenic patients?
 A. increase in ventricular size
 B. decrease in ventricular size
 C. frontal atrophy
 D. temporal and occipital atrophy
 E. frontal and hippocampal atrophy
Answer 10
 Correct answer: A Increase in ventricular size
 studies have demonstrated anatomical abnormalities
in patients with schizophrenia. Bilateral
ventriculomegaly occurs medial temporal areas such
as the hippocampus and amygdala show decreased
brain volume.
Question 11
 65-year-old right-handed man presents with an acute onset of inability to
speak. He has hypertension and diabetes and was in otherwise good state of
health. His wife who accompanies him reports that he was playing chess in
the morning when his Center rest of speaking cannot make intelligible
sounds. On examination, his vitals are pulse of 92 bpm and blood pressure
of 130/70. His fundus and eye exam otherwise normal. There is mild right
facial paresis of the upper motor neuron type and a 4+ out of 5 weakness in
the right arm. He is unable to speak any words, but has intact
comprehension. He is able to repeat sentences. He is able to clearly write
what a full sentences with intact grammar.Which of following describes this
phenomena?
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A. Broca's aphasia
B. Wernicke's aphasia
C. Aphemia
D. Amusia
E. Aprosodia
Answer 11
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Correct answer: C. Aphemia.
 This is caused by a lesion, usually vascular, involving the
dominant frontal lobe. This is characterized by complete
inability to speak, but preserved comprehension and
repetition and ability to read and write. There is a good
prognosis usually and there is often complete recovery in
aperiod of weeks to months. Amusia is an inability
appreciate music is caused by a lesion in the
nondominant hemisphere analogous to the one just area
on the dominant side. Aprosodia is the lack of musicality
of speech, and is caused by a lesion in the non-dominant
hemisphere analagous to the Broca's area on the
dominant side.
Question 12
 You are seeing a 35-year-old woman in your clinic with the diagnosis of
epilepsy. She has been suffering from complex partial seizures since the age
of 5. Today, she complains of sadness and frequent crying spells, difficulty
sleeping, decreased appetite and generalized fatigue. She denies suicidal
ideation. Which of the following statements is true regarding the likely
diagnosis?
 A. depression is the most common psychiatric disorder among patients
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with epilepsy
B. after anxiety disorder, depression is the 2nd most common psychiatric
disorder among patients with epilepsy
C. epilepsy patients rarely have depression
D. depression and bipolar are the most common psychiatric disorders
among patients with epilepsy
E. after bipolar disorder, depression is the 2nd most common psychiatric
disorder among patients with epilepsy
Answer 12
 Correct answer: A. Depression is most common
 depression is a common disorder among epileptic
patients and constitutes the most frequent
psychiatric condition in these patients. The
relationship between depression and epilepsy is
bidirectional, since patients with major depression
also have a high-risk of epilepsy.
Question 13
 An 8-year-old boy is brought to office by his mother who states that he is constantly
getting in trouble at school. His teacher states that he keeps getting out of his seat at
inappropriate times, fidgets with things in his tests and does not pay attention in
class. This was poorly on examinations, but his mother thinks he is very small. At
home he is very active, was playing outside, but only watch TV for a few minutes at
time and does not appear to be listening when she reads some stories. He constantly
forgets his backpack at school and sometimes forgets to get off the bus at his normal
stop. He has a normal physical examination and is age-appropriate
developmentally. He does not stay still in the examination room and consonant
most running climbs on and off the examination table. He seems very bright and
inquisitive, but is easily distracted. An appropriate step in treatment would be
A. behavioral modifications including goalsetting, and sense of some punishment's
B. methylphenidate
C. behavioral modifications and methylphenidate
D. no treatment is necessary at this time as this is normal behavior for an 8-year-old
boy
 E. psychiatric consult
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Answer 13
 Correct answer: C Behavioral modifications and
methylphenidate
 this is classic ADHD. The standard treatment is with
stimulant drugs and behavioral modifications.
Question 14
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The 58-year-old wife of this 60-year-old patient is contemplating divorce from her
husband of almost 40 years. She says that beginning about a year ago, they had to
stop going out with her friends as her husband was in embarrassment to be around
him public. He will be combative when he disagreed with friends opinions and
would yell obscenities at waiters when kept waiting to have his order taken. In the
past month, he has stopped showering, and has reread his favorite novel over 10
times. In a last ditch effort to save their marriage, his wife brings him to couples
counseling, with a psychologist refers her to note the neurology clinic at the local
hospital. Which of the following is a likely diagnosis?
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A. Tourette syndrome
B. schizophrenia
C. normal aging
D. Alzheimer's disease
E. frontotemporal dementia
Answer 14
 Correct answer: E. frontotemporal dementia
 This usually presents from age 40-60 with gradual
progressive changes in behavior or gradual,
progressive language dysfunction. The most common
presentation is change in social and personal
contact, characterized by difficulty modulating
behavior to social commands. As the disease
progresses, criminal behavior like shoplifting may
develop
Question 15
 Which of the following types of dementia is
associated with the development of new musical and
artistic abilities?
 A. Alzheimer's disease
 B. Lewy body dementia
 C. frontotemporal dementia
 D. Huntington disease
 E. corticobasal ganglionic degeneration
Answer 15
 Answer: C. Frontotemporal dementia
 Frontotemporal dementias characterized by apathy,
disinhibition, planning and organizing difficulties.
Curiously the development of new musical and
artistic ability has been associated with frontal
temporal dementia.
Question 16
 Which are the following is most characteristic
feature of borderline personality disorder?
 A. obsessive-compulsive disorder
 B. dependency
 C. irritability
 D. instability of mood
 E. flat affect
Answer 16
 Answer D. Instability of mood
 Borderline personality disorder includes instability
of mood, extreme splitting, unstable interpersonal
relationships.
Question 17
 Familial forms of Alzheimer's disease associated with
presenilin 1 and 2 are linked to which of the following
chromosomes?
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A. Chromosome 21
B. Chromosome 1 and 14
C. Chromosome 19
D. Chromosome 21 and 19
E. Chromosome 7
Answer 17
 Correct answer B: Chromosome 1 and 14.
 this accounts for less than 7% of all cases of
Alzheimer's disease. Mutations of presenilin 1 gene
(on chromosome 14) and prenilin 2 (on chromosome
1) are linked to familial cases of Alzheimer's disease.
Question 18
 A 45-year-old HIV positive man presents to the office with a six-
month history of progressive memory loss and difficulty writing. He
is currently taking Zidovudine and a protease inhibitor. CD4 count
is 25. Neurological exam elicits psychomotor delay and impairment
in fine motor control. MRI demonstrates moderate brain atrophy,
but no focal lesions. Laboratory results of his CSF analysis are
within normal limits. What is the most likely diagnosis?
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A. CMV encephalitis
B. cryptococcal meningoencephalitis
C. HIV encephalopathy
D. primary primary lymphoma
E. progressive multifocal leukoencephalopathy
Answer 18
 Answer: C. HIV encephalopathy
 HIV encephalopathy is also known his AIDS dementia
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complex, which is a subacute inflammatory infiltration of the
brain caused by direct spread of HIV to the CNS. It is
characterized by cognitive impairment, psychomotor delay,
incontinence, impairment of motor skills, and confusion.
CMV encephalitis typically affects the periventricular white
matter and retina.
CSF analysis and cryptococcal meningitis would demonstrate
organisms.
Primary brain lymphoma would present as a mass on MRI.
Progressive multifocal leukoencephalopathy would present
with multifocal white matter lesions on MRI.
Question 19
 A 55-year-old male presents the doctor with headache and
personality change over the past 3 months. Neurologic exam reveals
right upper extremity weakness. Neuroimaging reveals a 5 cm, welldefined mass in the left frontal white matter. T1-weighted
postcontrast MRI images of the brain reveal heterotopic jean Easley
ring enhancing lesion, while T2 demonstrates significantly
surrounding edema. Laboratory data are within normal limits,
including a negative HIV test. Which of the following is the most
likely diagnosis?
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A. cerebral toxoplasmosis
B. demyelinating disease
C. glioblastoma multiforme
D. infarct
E. primary brain lymphoma
Answer 19
 Correct answer C. Glioblastoma multiforme.
 This is a classic presentation of glioblastoma
multiforme. Typically patients present with
symptoms less than 3 months duration. Metastasis
and abscess should also be in the differential.
cerebral toxoplasmosis is unlikely given the patient is
HIV negative,
Question 20
 20. which are the following is included in the cluster
B personality disorders?
 A. schizoid
 B. schizotypal
 C. paranoid
 D. borderline
 E. dependent
Answer 20
 Correct answer: D. Borderline
 in the DSM-IV, personality disorders are classified into a,
B, and C clusters.
 Cluster A disorders are the "odd" or "eccentric" group
and include schizoid, schizotypal, and paranoid.
 Cluster B disorders are the "dramatic" group and include
borderline, histrionic, antisocial, and narcissistic
varieties.
 Cluster C disorders are the "fearful/anxious" group and
include Avoidant, Depentent, and Obsessive-compulsive
types.
 Thank you for coming.
 Questions are from neuroprep
 Any questions?