Kaplan and Sadock's Study Guide and Self-Examination Review in Psychiatry, 9th Ed.

719 Pages·2012·5.59 MB·English

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1
Neural Sciences
The human brain is responsible for cognitive abilities, emotions, and behaviors.
During the \"decade of the brain\" in the 1990s, major advances in neural
sciences took place, and the brain was finally recognized as the biological
substrate for all normal and abnormal mental functions. It is possible to
conceive a biologically based diagnostic system for psychiatric disorders. This
approach will also permit and advance brain oriented investigational efforts to
produce better psychiatric treatments and, thus, improve the quality of care of
psychiatric patients. In most fields of medicine, diagnoses are based on
physical signs, symptoms, a comprehensive medical history, and laboratory,
radiological, and other relevant tests and procedures. In psychiatry, however,
the diagnoses are based primarily on the clinical impression of the patient's
interpretation of his or her thoughts and feelings.
If the brain is the site of focus for psychiatric disorders, one should attempt
to develop a classification system on the understanding of biological factors
rather than primarily patient's symptoms. Neural sciences focus primarily on
brain biology. It is, therefore, essential that one start to focus more
intensively on the functions of the brain from a mental illness viewpoint.
Besides understanding the functions and dysfunctions of lobal regions, basal
ganglia, limbic structures, hypothalamus, and other relevant areas of the brain,
one should understand the ultra structure of individual brain cells. Of further
importance are the synaptic connectivity and the functional organization of the
brain, as well as the behavioral consequences of pathological processes that
take place in the central nervous system (CNS). At the same time, the role of
genetics is very relevant in this regard; particularly, insofar as psychiatric
disorders are concerned. Thus, knowledge about gene expression, DNA replication,
messenger RNA synthesis and translation into protein, as well as the outcomes of
mutations at each of these stages are quite relevant in this context.
Knowledge of clinical psychopharmacology is essential, including neurotransmitters,
brain location of the biogenic amine neurotransmitter nuclei, and the distribution
of the axonal projections. The roles of glutamate, [gamma]-aminobutiric acid
(GABA), monoamine neurotransmitters, such as serotonin, dopamine, norepinephrine,
epinephrine, histamine, and acetylcholine, as well as the peptide neurotransmitters
such as endorphins and enkephalins, are all crucial to the understanding of the
use of psychopharmacological agents.
Also of crucial importance is the knowledge of the major neuroimaging techniques,
as well as the clinical limitations of these neuroimaging techniques. They
include magnetic resonance imaging (MRI), computed tomography (CT), magnetic
resonance spectroscopy (MRS), single photon emission computed tomography
(SPECT), proton emission tomography (PET), electroencephalography (EEG), and
magnetoencephalography (MEG), as well as others.
Without question, medical students and psychiatric physicians need to be
familiar and have knowledge about the field of neuroscience. The following
questions and answers will permit them to assess their knowledge in this regard.
Helpful Hints
The student should know the following terms, theoreticians, and concepts.
Acetylcholine
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Animacy
Apoptosis
Ascending pathways
Broca's area
Catecholamines
Caudate nucleus
Chronobiology
Circadian Rhythm
Decoding emotions
Deep brain stimulation (DBS)
Dopamine
Electroconvulsive therapy (ECT)
Endophenotypes
Epigenetics
Genetic factors in cognition, temperament and personality
Genome
Globus pallidus
Glutamic acid
Histamine
Limbic system
Locus ceruleus
Metabolic syndrome
Neuropeptides
Neurotropic factors
Nitric Oxide
Norephinephrine and Epinephrine
Population genetics
Putamen
Receptors
REM and NREM sleep
Repetitive transcranial magnetic stimulation (RTMS)
Seasonal affective disorder and circadian rhythm
Self
Serotonin
Substania Nigra
P.2
Subthalamic nucleus
Syndromes of pain
Transcriptome
Transporters
Vagal nerve stimulation (VNS)
Wakefullness
[gamma]-aminobutyric acid (GABA)
Questions
Directions
Each of the questions or incomplete statements below is followed by five
suggested responses or completions. Select the one that is best in each case.
1.1. The nature of an endophenotype is biologically defined on which of the
following?
A. Neuropsychological
B. Cognitive
C. Neurophysiological
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D. Biochemical
E. All of the above
View Answer
1.1. The answer is E (all)
The nature of an endophenotype is biologically defined on the basis of
neuropsychological, cognitive, neurophysiological, neuroanatomical, biochemical,
and brain data. Endophenotype is an internal phenotype, which is a set of
objective characteristics of an individual that are not visible to the unaided
eye. A given phenotype would not be limited to a patient with a particular
diagnosis; for instance, schizophrenia might also be found in patients with
other diagnoses, such as depression or bipolar disorder.
1.2. Which of the following morphological regions is a part of the neuron?
A. Cell body
B. Dendrites
C. Axon
D. Axon terminals
E. All of the above
View Answer
1.2. The answer is E (all)
The human brain contains approximately 100 billion nerve cells or neurons. In
general, neurons are composed of four morphologically identified regions: (1)
the cell body or soma, which contains the nucleus and can be considered the
metabolic center of the neuron; (2) the dendrites, which are processes that
arise from the cell body, branch extensively, and serve as the major recipient
zones of input from other neurons; (3) the axon, which is a single process that
arises from a specialized portion of the cell body (the axon hillock) and
conveys information to other neurons; and (4) the axon terminals, which are fine
branches near the end of the axon and that form contacts (synapses) generally
with the dendrites or the cell bodies of other neurons, release neurotransmitters,
and provide a mechanism for interneuronal communication. Most neurons in the
human brain are considered to be multipolar in that they give rise to a single
axon and several dendritic processes.
1.3. A reduced density of interneurons in layer 2 of the prefrontal cortex has
been observed among patients with
A. Bipolar disorder
B. Major depression
C. Obsessive-compulsive disorder
D. Schizophrenia
E. Panic disorder
View Answer1.3. The answer is D
Research has shown that in a significant number of patients with schizophrenia,
the prefrontal cortex exhibits a reduced density of interneurons in layer 2.
Additionally, these patients show an upregulation of GABAA receptor binding, a
potential functional compensation, as well as a relative deficiency of nitric
oxide synthase (NOS)-expressing neurons. These observations have led to the
hypothesis that schizophrenia is due to reduced GABAergic activity. The origin
of GABA interneurons from the ganglionic eminences and their association with
specific patterning genes raises new genetic models of disease causation and
possible strategies for disease intervention.
1.4. The cell bodies of the serotonergic neurons are located in what region of
the brain?
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A. Midline raphe nuclei of the brainstem
B. Midbrain substania nigra and ventral tegmental area
C. Locus ceruleus and the lateral tegmental noradrenergic nuclei
D. The tuberomamillary nucleus of the posterior hypothalamus
E. The basal forebrain complex and the mesopontine complex
View Answer
1.4. The answer is A
The cell bodies of the serotonergic neurons are located in the midline raphe
nuclei of the brainstem. The dopamine neurons are located in the midbrain
substantia nigra and the ventral tegmental areas as well as in the periaqueductal
gray, hypothalamus, olfactory bulb, retina, and kidney. The norepinephrine and
epinephrine producing neurons are found in the pons and medulla in two major
clusters: the locus ceruleus and the lateral tegmental noradrenergic nuclei.
These neurons are also found in the adrenal medulla. Histaminergic cell bodies
are located within the region of the posterior hypothalamus termed the
tuberomammillary nucleus.
1.5. The primary inhibitory neurotransmitter, [gamma]-aminobutyric acid (GABA),
in the brain is notably depleted in which of the following neuropsychiatric
disorders?
A. Pick's disease
B. Vascular dementia
C. Creutzfeldt-Jakob disease
D. Huntington's disease
E. Normal pressure hydrocephalus
View Answer
1.5. The answer is D
This degeneration characteristically results in a depletion of GABA, the brain's
major inhibitory neurotransmitter, and acetylcholine. Huntington's disease is an
autosomal-dominant neurodegenerative disorder characterized by cognitive and
physical decline. Its etiology involves an abnormal expansion of a trinucleotide
repeat on chromosome 4. MRI classically reveals bilateral atrophy of the caudate
nucleus and putamen of the basal ganglia. CT scan further reveals a prominence
of the lateral ventricles as a result of surrounding atrophy. Huntington's
disease has a gradual onset between the ages of 30 to 50 years. Key features of
the disease include progressive subcortical dementia, chorea (rapid, involuntary,
dance-like movements), depression, and psychosis. Dysfunction of GABAergic
neurotransmission has further been implicated in anxiety disorders, schizophrenia,
alcohol dependence, and seizure disorders. Pick's disease is due to an
accumulation of tau proteins, which lead to degeneration of the frontal and
temporal lobes. Onset of Pick's disease is between the ages of 40 to 60 years
and initial signs include personality change, language impairment, and memory
loss. Vascular or multi-infarct dementia presents acutely with cognitive decline
following a cerebrovascular event and has a stepwise progression. Creutzfeldt-Jakob
disease is a rare spongiform encephalopathy accompanied by rapidly progressive
dementia and hallucinations. It is caused by an accumulation of prions leading
to nerve cell death. Normal-pressure hydrocephalus clinically presents with the
triad of dementia, incontinence, and gait disturbance. It is due to poor
reabsorption of CSF and characterized by widening of the lateral ventricles.
1.6. The neuropeptides are primarily related to which of the following central
nervous systems?
A. Serotonin neurotransmitter system
B. Norepinephrine and Epinephrine system
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C. Acetylcholine system
D. Hypothalamic regulation system
E. Catecholamines system
View Answer
1.6. The answer is D
Neuropeptides represent the most diverse class of signaling molecules in the
CNS. They have a role in the hypothalamic regulation of pituitary hormone
secretion. They also have an array of direct or neuromodulatory effects, ranging
from modulating neurotransmitter release and neuronal firing patterns to the
regulation of emotionality and complex behavior. More than 100 unique biologically
active neuropeptides have been identified in the brain, a subset of which is
presented in Table 1.1.
Table 1.1 Selected Neuropeptide Transmitters
Adrenocorticotropin hormone (ACTH)AngiotensinAtrial natriuretic peptideBombesinCalcitoninCalcitonin
gene-related peptide (CGRP)Cocaine and amphetamine regulated transcript
(CART)Cholecystokinin (CCK)Corticotropin-releasing factor (CRF)Dynorphinß-EndorphinLeu-enkephalinMet-
enkephalinGalaninGastrinGonadotropin-releasing
hormone (GnRH)Growth hormoneGrowth hormone-releasing hormone (GHRH; GRF)InsulinMotilinNeuropeptide
SNeuropeptide Y (NPY)NeurotensinNeuromedin NOrphanin FQ/NociceptinOrexinOxytocinPancreatic
polypeptideProlactinSecretinSomatostatin (SS; SRIF)Substance KSubstance
PThyrotropin-releasing hormone (TRH)Urocortin (1, 2, and 3)Vasoactive intestinal
polypeptide (VIP)Vasopressin (AVP; ADH)
1.7. The strongest evidence for a role for neurotrophins in psychiatric diseases
has come from the pathophysiology of which of the following psychiatric
disorders?
A. Schizophrenia
B. Panic disorder
C. Major depressive disorder
D. Obsessive-compulsive disorder
E. Antisocial personality disorder
View Answer
1.7. The answer is C
The strongest evidence for a role for neurotrophins among psychiatric disorders
has come from the pathophysiology of depression, especially depression
associated with stress. For depression, it is believed that there is a
fundamental dysregulation of synaptic plasticity and neuronal survival in
regions of the brain, such as the hippocampus. In animal models, restraint
stress leads to a decreased expression of the brain-derived neurotrophic factor
(BDNF) in the hippocampus. In addition, chronic physical or psychosocial stress
leads to atrophy and death of hippocampus neurons, especially in the CA3 region
in rodents and primates. Also, MRI studies have shown that patients with
depressive or post-traumatic stress disorders exhibit a small decrease in
hippocampal volume. It is unclear though, whether the atrophy and/or death of
these neurons is directly related to the decreased availability of BDNF.
1.8. Manipulation of one of the novel neurotransmitters, nitric oxide, is
thought to have a therapeutic effect in which of the following psychiatric
conditions?
A. Mood disorders
B. Addictive disorders
C. Anxiety disorders
D. Personality disorders
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E. Dissociative disorders
View Answer
1.8. The answer is A
Recently, it was discovered that gases can function as neurotransmitters. In
this context, it was found that Nitric Oxide has a neurotransmitter property
vis-a-vis a few psychiatric disorders. Mood Disorders is one of the groups of
psychiatric illnesses in which Nitric Oxide has a positive role as a neurotransmitter.
NOS-expressing neurons are well represented in areas implicated in depression,
including the dorsal raphe nucleus and prefrontal cortex. A role for Nitric
Oxide has been suggested in antidepressant response as selective serotonin
reuptake inhibitor (SSRI) antidepressants can directly inhibit NOS activity.
1.9. The potential role of homeostatic neuronal plasticity as a therapeutic
mechanism in certain psychiatric disorders is currently explored with the use of
which of the following treatments?
A. Electroconvulsive therapy (ECT)
B. Vagal nerve stimulation (VNS)
C. Repetitive transcranial magnetic stimulation (RTMS)
D. Deep brain stimulation (DBS)
E. All of the above
View Answer
1.9. The answer is E (all)
In recent years, there has been increasing interest in the use of brain
stimulation methods as treatment for psychiatric and neurological disorders.
These methods include electroconvulsive therapy (ECT), Vagal Nerve Stimulation
(VNS), repetitive transcranial magnetic stimulation (RTMS), and deep brain
stimulation (DBS). The development of optimal stimulation parameters for these
treatments requires knowledge about the effects of electrical stimulation on
neuronal function. With respect to ECT, a major advance has been the recognition
that electrical stimulation parameters play a key role in determining therapeutic
and adverse effects. There is compelling evidence that the degree to which
electrical doses exceed the seizure threshold is of substantial importance. For
bilateral ECT, electrical doses just above threshold (approximately 1.5 times
threshold) result in a highly effective form of treatment that minimizes
cognitive impairment. For nondominant hemisphere (unilateral) ECT, electrical
doses that are five to six times threshold are required to produce a significant
benefit.
1.10. Deoxyribonucleic acid (DNA) is composed of which of the following nucleic
acids (nucleotides)?
A. Adenine
B. Cystosine
C. Guanine
D. Thymine
E. All of the above
View Answer
1.10. The answer is E (all)
DNA (deoxyribonucleic acid) is made of four nucleic acids, also known as
nucleotides: adenine, cytosine, guanine, and thymine. A genome is defined as the
total complement of DNA replicated in a living organism. A critical milestone
was reached in 2001 with the completion of the first draft of the human genome.
Currently, there are thousands of genomes sequenced. It is now evident that
there are in total about 25,000 protein-coding genes in Homo sapiens.
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1.11. Risk factors associated with the metabolic syndrome include
A. hyperglycemia
B. visceral obesity
C. hypertension
D. hyperlipidemia
E. all of the above
View Answer
1.11. The answer is E (all)
Metabolic syndrome is a disease characterized by a cluster of metabolic risk
factors, which include hyperglycemia, visceral obesity, hyperlipidemia, and
hypertension. Most notably, adverse effects of atypical antipsychotics, such as
olanzapine (Zyprexa) and clozapine (Clozaril), include weight gain and
hyperglycemia. However, aripiprazol (Abilify) and ziprasidone (Geodon) are
atypical antipsychotics that have minimal effects in this regard. Schizophrenia
patients may exhibit increased cortisol and epinephrine production even when not
medicated; therefore, monitoring protocols for patients on atypical antipsychotics
is of utmost importance. Of note, metabolic syndrome also leads to insulin
resistance and complicates glycemic control in patients with preexisting
diabetes.
P.3
1.12. The neuropsychiatric disorder that has been best characterized in terms of
the influence of the brain on the immune system and vice versa is which one of
the following?
A. Somatization disorder
B. Hypochrondriasis
C. Factitious disorder
D. Major depressive disorder
E. Depersonalization disorder
View Answer
1.12. The answer is D
The neuropsychiatric disorder that has been best characterized in terms of the
influence of the brain on the immune system and vice versa is major depressive
disorder. For many years, major depressive disorder was seen as a quintessential
example of how stress-related disorders may decrease immunocompetence. More
recently, however, it has become evident that stress also activates inflammatory
pathways, even while suppressing measures of acquired immunity.
1.13. Circadian rhythms include
A. sleep
B. temperature
C. hormone levels
D. eating
E all of the above
View Answer
1.13. The answer is E (all)
The circadian clock drives many rhythms including behavior, core body temperature,
sleep, eating, drinking, and hormonal levels. One such circadian-regulated
hormone is the indolamine, melatonin. Melatonin synthesis is controlled through
a multisynaptic pathway from the CNS to the pineal gland. Serum levels of
melatonin become elevated at night and return to baseline during the day. Light
suppresses elevated melatonin levels, immediately decreasing them to baseline
levels. Light also shifts the phase of circadian rhythms of melatonin synthesis.
Because melatonin can be assayed easily, it provides a convenient window into
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the state of the circadian pacemaker. Any perturbation of the clock is reflected
in the melatonin profile; thus, melatonin offers an output that can be used to
study the regulation of the central circadian pacemaker.
1.14. Research efforts have demonstrated that there are no electroencephalographic
(EEG) abnormalities associated with the use of which psychopharmacological
agent?
A. Olanzapine
B. Clozapine
C. Risperidone
D. Pherphenazine
E Quetiapine
View Answer
1.14. The answer is E
Electroencephalographic (EEG) abnormalities have been reported with the use of
clozapine (47 percent), olanzapine (38.5 percent), trifluoperazine and
mesoridazine (about 35 percent), risperidone (28 percent), fluphenazine and
thiothixene (just above 20 percent), pherphenazine, chlorpromazine and
thioridazine (just about 10 percent), and haloperidol (just below 10 percent).
There were, however, no abnormalities observed with quetiapine or loxapine. The
clinical significance of EEG abnormalities associated with psychopharmacological
agents, particularly in the absence of any indications of seizures or encephalopathic
effects, remain an open research question.
1.15. Structural MRI findings associated with schizophrenia include all of the
following except
A. reductions in cortical gray matter
B. reductions in cortical white matter
C. risk genes influencing MRI findings
D. progressive deviation of regional cortical volumes in childhood onset cases
E. decreased striatum volume
View Answer
1.15. The answer is E
Structural MRI finding associated with schizophrenia do not include decreased
striatum volume. Structural MRI has been useful for characterizing features of
the heritable risk for schizophrenia. Family members of individuals with
schizophrenia show a pattern of reductions in cortical gray and white matter
volume that resembles, but is milder than, that associated with schizophrenia.
Among healthy individuals and patients diagnosed with schizophrenia, risk genes
appear to influence MRI findings. Structural MRI has also provided some insights
into the progressive course of this disorder and the impact of antipsychotic
treatment. The most striking findings have been in childhood onset schizophrenia,
where a series of neuroimaging studies using a variety of MRI approaches have
clearly shown that the development and evolution of schizophrenia are associated
with a progressive deviation of regional cortical volumes from those of healthy
comparison populations.
1.16. Recent research has provided a basis for clinical indications of PET and
SPECT radiotracer imaging for the diagnosis and management of several neuropsychiatric
disorders. Among them, we found all of the following except
A. movement disorders
B. schizophrenia
C. mood disorders
D. anxiety disorders
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E. antisocial personality disorder
View Answer
1.16. The answer is E
Over the past two decades, radio tracer imaging with PET and SPECT have gained
merit as tools to image brain functioning and neurochemistry in living humans
and have provided the foundation necessary to begin to identify the neurochemical
signatures and neuropsychiatric disorders that result from abnormal brain
chemistry. Radio tracer imaging can also help to assess the relationship between
occupancy of specific various receptors in the brain and clinical efficacies of
various psychotropic drugs. For instance, imaging of dopamine Dz receptors
provides critical information for the differential diagnosis of movement
disorders and schizophrenia, and also for the assessment of receptor occupancy
by neuroleptic drugs. Imaging of serotonin receptors and the serotonin
transporter is useful in the diagnosis of mood and anxiety disorders, as well as
the assessment of antidepressant efficacy. Imaging of nicotinic acetylcholine
receptors and acetylcholinesterase may serve as markers of cognitive and memory
impairment.
1.17. Populations genetics encompasses all of the following except
A. quantitative genetics
B. genetic epidemiology
C. genetic demography
D. molecular genetics
E. evolutionary genetics
View Answer
1.17. The answer is D
Population genetics, which deals with the mathematical properties of genetic
transmission in families and populations, can be subdivided into the partially
overlapping fields of evolutionary genetics, genetic demography, quantitative
genetics, and genetic epidemiology. The primary goal of evolutionary genetics is
to understand changes in gene frequency across generations. Genetic demography
is primarily concerned with differential mortality and fertility in human
populations, while genetic epidemiology deals with the distribution of
disease-associated genes across human subpopulations. The goal of quantitative
genetics is to partition the observed variation of phenotypes into its genetic
and environmental components.
1.18. The most successful application of gene-mapping strategies relates to
which of the following psychiatric disorders?
A. Alzheimer's disease
B. Bipolar disorder
C. Schizophrenia
D. Panic disorder
E. Obsessive-compulsive disorder
View Answer
1.18. The answer is A
The most successful application of gene-mapping strategies applies to Alzheimer's
disease, which is the most common form of dementia and is characterized by a
progressive decline in memory, aphasia, apraxia, agnosia, and diminished
excessive functioning. Abnormal deposition of beta-amyloid protein and
neurofibrillary tangles are the major pathophysiological characteristics of
Alzheimer's disease. Associated genes include autosomal dominant forms of the
APOE4 allele on chromosomes 1, 14, 19, and a mutation of the P-App gene (amyloid
precursor protein gene) on chromosome 21. Genetic alterations may be responsible
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