Mental illness

2015

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Clinical Challenge

Volume 44, No.11, 2015 Pages 863-864

Questions for this month’s clinical challenge are based on articles in this issue. The clinical challenge is endorsed by the RACGP Quality Improvement and Continuing Professional Development (QI&CPD) program and has been allocated 4 Category 2 points (Activity ID:33801).Answers to this clinical challenge are available immediately following successful completion online at http://gplearning.racgp.org.au. Clinical challenge quizzes may be completed at any time throughout the 2014–16 triennium; therefore, the previous months’ answers are not published.

Each of the questions or incomplete statements below is followed by four or five suggested answers or completions. Select the most appropriate statement as your answer.

Case 1

Adam, 19 years of age, sees you to request a referral to a plastic surgeon. You have looked after Adam for many years and are somewhat surprised by this request. Adam reveals that he is very unhappy with his nose. He spends 1–2 hours per day worrying about it and thinking of ways to hide the perceived defect. Adam does not want to talk much about the issue and just wants you to write a referral to the surgeon.

You suspect Adam has body dysmorphic disorder (BDD).

Question 1

At what age does the onset of BDD typically occur?

  1. Early teens
  2. Mid-teens
  3. Late teens
  4. Early 20s
  5. Late 20s

Question 2

Which of the following is an example of a behaviour exhibited by individuals with BDD?

  1. Avoiding comparison of self with other people’s bodies
  2. Refusing to touch the disliked part of the body
  3. Avoiding grooming the disliked body part
  4. Camouflaging an area by repeatedly applying makeup

Question 3

You decide to screen Adam for BDD using the seven-item Dysmorphic Concern questionnaire.

Which of the following questions are included on this questionnaire?

  1. Have you been very concerned about some aspect of your physical appearance?
  2. Have you considered your body to be malfunctional in some way?
  3. Have you consulted or felt you needed to consult a plastic surgeon, dermatologist or physician about these concerns?
  4. Have you spent a lot of time worrying about a defect in your appearance or bodily functioning?
  5. All of the above

Adam is reluctant to accept the diagnosis of BDD but does agree to see you again to discuss it further. He returns one month later with some questions relating to the treatment of BDD. In particular, he is curious about the role of medication in treating the condition.

Question 4

Which class of medication is the most studied for treating BDD?

  1. Selective serotonin reuptake inhibitors
  2. Antipsychotics
  3. Benzodiazepines
  4. Tricyclic antidepressants
  5. Monoamine oxidase inhibitors

Adam agrees to try medication and counselling to treat BDD. He then tells you that his friend John also has concerns about his body. He says that John constantly says that he is not muscular enough despite appearing very muscular. Adam says that John has been using anabolic steroids, going to the gym for approximately two hours per day and has been following a very strict high-protein diet. Adam rarely sees John anymore as this routine limits John’s social life.

Question 5

On the basis of this history, what is the most correct diagnosis for John?

  1. Body dysmorphic disorder
  2. Muscle dysmorphia
  3. Eating disorder, not otherwise specified
  4. Obsessive compulsive disorder
  5. Social anxiety disorder

Case 2

Mal, aged 44 years, has schizophrenia and sees you every month for his depot injection of olanzapine. His symptoms are well controlled on this regimen. He smokes 20 cigarettes per day and does not drink alcohol. Mal has no other medical conditions but does think he has gained weight recently. His body mass index today is 32 kg/m2 and his waist circumference is 110 cm.

Mal understands that olanzapine often causes weight gain. He wants to know about other antipsychotic medications that may suit him better, including possible side effects.

Question 6

Which atypical antipsychotic medication is most likely to cause sedation, anticholinergic effects and postural hypotension?

  1. Amisulpride
  2. Quetiapine
  3. Risperidone
  4. Olanzapine
  5. Paliperidone

Question 7

Which of the following antipsychotic medications is most likely to cause weight gain?

  1. Risperidone
  2. Paliperidone
  3. Ariprazole
  4. Ziprasidone
  5. Clozapine

Question 8

How frequently should people with schizophrenia and a BMI >25 kg/m2 have their weight checked ?

  1. Baseline, then every six months
  2. Baseline, then every 12 months
  3. Baseline, then every three months for first year, then every six months
  4. Baseline, then every three months for first year, then every 12 months
  5. Baseline, then every six months for first year, then every 12 months

While you are on the topic of monitoring physical health, Mal asks you whether it is time for another electrocardiogram (ECG).

Question 9

How often should people with schizophrenia have an ECG done while on antipsychotic medication?

  1. Baseline, then every six months
  2. Baseline, then every 12 months
  3. Baseline, then every six months and at each change of antipsychotic dose
  4. Baseline, then every 12 months and at each change of antipsychotic dose
  5. Baseline, then every 24 months and at each change of antipsychotic dose

Question 10

Quitting smoking is an important way to decrease cardiovascular risk for people with schizophrenia who smoke. Which is the safest smoking cessation intervention for Mal?

  1. Nicotine replacement therapy
  2. Varenicline
  3. Buproprion
  4. Psychological strategies

Case 3

Lily, 18 years of age, is a university student whom you have looked after for many years. She has no significant past medical history and takes no medications. She seems nervous during the consultation today and finally tells you that she has felt uncomfortable in her body since she went through puberty. On further questioning, she tells you she feels she is male and is distressed that she looks like a female. She has not worn male clothes before and has recently started binding her chest to try to hide her breasts.

Question 11

What is the most likely explanation for Lily’s presentation?

  1. Body dysmorphic disorder
  2. Gender dysphoria
  3. Transvestic disorder
  4. Borderline personality disorder
  5. Psychosis

Case 4

Jake, 25 years of age, has autism spectrum disorder (ASD). He lives with his parents and works 1–2 days per week at the local fish and chips shop. You have established a good rapport with Jake in previous consultations by allowing him plenty of time to express himself and by using clear English.

Jake’s mother has brought him in today, worried about his recent behaviour.

Question 12

Which is considered an example of ‘challenging behaviour’ in an adult with ASD?

  1. Aggression
  2. Tantrums
  3. Self-injury
  4. Pica
  5. All of the above

Correspondence afp@racgp.org.au

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Type

Clinical challenge

2015