1.

Obstructive Sleep Apnea Modafinil works on the hypocretin/orexin pathway, and has been shown to be an efficacious adjunct therapy in OSA (Eg. In addition to CPAP)

2. Which of the cell types produce myelin in the CNS? Oligodendrocytes produce myelin within the CNS. They are also a type of glia cell.

3. Which of the following statements is true regarding psychopathology and pain related psychological symptoms? Pain severity varies significantly with high levels of anger and is especially true for men with high levels of anger. Most patients with chronic pain are not easily characterized by DSM. A combination of psychiatric and behavioral medicine assessments better define psychiatric disturbances in these patients. Anxiety is significant in terms core psychopathology and pain-related psychological symptoms in chronic pain- assessment must include both review of general anxiety symptoms as well as pain specific anxiety symptoms Independent of psychopathology, patients who catastrophize symptoms often have poorer outcomes and greater disability Patients with poor coping skills do not generally employ self management strategies for pain relief

4. Which chromosome is associated with Narcolepsy? Chromosome 6

5. Which of the following pathological findings can be seen in patients with temporal lobe epilepsy? Mesial or Hippocampal sclerosis Unilateral temporal mesial or hippocampal sclerosis can be seen and there is an association between it and prolonged febrile seizures in childhood. These patients can also have hamartomas in this site.

6. In many cultures, sleep is associated with death and unconsciousness. What visual characteristics of sleep distinguish it from coma or unconsciousness? Rapid reversibility Periodicity

Rapid reversibility and periodicity are what distinguishes sleep from death or unconsciousness. Stages of sleep is a construct and not visually observable. The ability to wake up is also present in unconsciousness, and the patient is not always atonic in sleep, ruling out answer V.

7. Benztropine It is an antagonist of muscarinic receptors in the basal ganglia It reduces tremor and rigidity Can cause sedation Can cause dry mouth Can cause Mydriasis (Dilated pupils)

8. Difference between the insomnia related to generalized anxiety and major depression Patients with GAD have normal REM latency Classic changes with major depression identified on Polysomnography are: Prolonged sleep latency, Increased wake time after sleep onset, Increased early morning awakenings, Decreased total sleep time, Decreased slow wave sleep (SWS) amount, Decreased SWS as percentage of total sleep time, Reduced REM latency, Prolongation of first REM sleep period, Increased REM activity and increased REM sleep percentage.

Changes associated with GAD and insomnia are Longer sleep latency, Increase in the frequency of awakenings, and Normal REM latency

9. Pathophysiology of NMS Computed tomography (CT) of the brain and cerebrospinal fluid (CSF) studies are normal in 95% of NMS cases. Low serum iron appears to be a state-specific finding in NMS, and patients with low serum iron in the context of catatonia may be at greater risk for NMS if placed on neuroleptic medication. In 1991 Rosebush and Mazurek found decreased levels of serum iron in NMS and suggested a role for lowered iron stores in the reduction of DA-receptor function.

Other diagnostic criteria for NMS include leukocytosis and metabolic acidosis.

10. Melatonin Melatonin administered in the early evening acts as a phase advance agent or as a phase delay agent in the early morning. Larger dosing is not the right approach, and the melatonin should be administered properly in order to elicit the proper effect.

11. The peak prevalence of sleepwalking disorder occurs at what age? 12 years

12. Diagnosis and Management of Common Sleep Problems in Children Making sure the house is safe for the child during his sleepwalking episodes, protecting the child from any harm while sleepwalking is of paramount importance. Benzodiazepines are occasionally used with severe (i.e. nightly) sleepwalking for a few months, with subsequent tapers. The other measures are either unnecessary, counterproductive, or not as important of considerations.

13. Myoclonic seizure Sudden, brief muscular contractions that occur singly or repetitively Characteristically seen in West syndrome Adolescents with gray matter disease Adults with viral encephalitis and Adults with prion disease West Syndrome is a pediatric epilepsy syndrome characterized by childhood spasms, hypsarrhythmia on interictal EEG, and mental retardation. The spasms may occur up to hundreds of times per day. The cause of West syndrome is theorized to be organic brain dysfunction but the precise etiology is unknown. Gray matter diseases usually manifest as a neuronal dysfunction, and may occur from metabolic storage disease, such as (Tay-Sachs disease, Nieman-Pick disease, etc) Alzheimer's is also a disease of grey matter, although not one seen in adolescents. Gray matter is where the neuronal dendrites and cell bodies are, so it makes sense that diseases which affect the neuron would cause seizures.

Adults with viral encephalitis, such as that caused by HSV, HIV, and other viruses, can cause seizures. It is postulated that the viral infection makes changes to the neuron, and the neurons are unable to heal the changes caused, which results in abnormal functioning. Prion diseases, such as BSE, aka mad cow disease, or Kuru, affect the proteins in the brain, but at present the exact mechanisms by which they operate is still under debate.

14. What physical findings might one find in a person with a sleep apnea syndrome? Heart failure Neuropathy Elevated BMI Obesity Elevated blood pressure Narrowed patency of airways Clubbing has not been shown to be related to sleep apnea, but heart failure, neuropathy and subsequent RLS, elevated BMI, obesity, elevated blood pressure and narrowed patency of airways all have. It should be noted that the mechanism behind clubbing is not completely understood, and that it is seen in diseases for which current explanations are insufficient. 15. Medications that lower seizure threshold Buspirone, Bupropion, The tricyclics, Amoxapine, Clomipramine should all be avoided

16. Damage to which structure is likely to result in disturbed sleep-wake cycles? Pons Damage to this structure can also cause personality changes, language problems, memory loss, and psychosis. Damage to the Cerebellum is more likely to cause problems in fluency of movements and balance. Damage to the Frontal Lobes may cause a variety of symptoms, such as personality changes and motor deficits. Damage to the temporal lobes may cause language problems and the inability to recognize objects or faces.

17. Transient Ischemic Attacks (TIA) The transient ischemia is characterized by its reversibility and lasts less than 24 hours. The attacks due to embolism usually tend to last longer. Fibromuscular dysplasia of the Basilar Artery is associated with TIAs. Some TIAs, especially Vertebrobasilar TIAs, may have a hemodynamic basis including transient hypotension. This is one of the common neurologic causes of syncope. The Subclavian Steal Syndrome is often accompanied by symptoms of left-arm claudication.

18. Homeostatic sleep drive is at its lowest when a person wakes up in the morning, then increases throughout the day, only to lessen once the person is asleep. Why doesn't a person wake up in the middle of the night, as the homeostatic drive lessens again? As Homeostatic Drive decreases, circadian sleep drive increases, and this is what maintains sleep for the second half of the night

19. Sleep terror disorder usually begins in children in what age range? 4-12 years

20. Phenelzine & Sumatriptan interaction in a patient with Migraines & Depression Phenelzine, a MAOI with the addition of the triptan can contributed to the development of Serotonin syndrome. Clinical features of serotonin syndrome are: agitatation, tachycardic, hypertension, hypertonia and hyperreflexia greater in lower extremities, diaphoresis, and tremor. Treatment includes removing the offending agents, supportive care for blood pressure and hyperpyrexia, benzodiazepines for myoclonic jerking, antihypertensive agents for increased blood pressure and IV hydration to prevent renal failure. Respiratory failure rarely occurs, but if it does artificial ventilation may be required. Benzodiazepines also reduce autonomic tone thus decreasing fever and contributing to higher survival. Specific serotonin antagonists like Cyproheptadine, a 5-HT2A antagonist, has been utilized as well as Mirtazapine, a 5-HT3 and 5-HT2 antagonist. Physical restraints should be avoided as they can cause lactic acidosis and increase body temperature.

Besides the classic offenders like SSRIs, MAOIs and TCAs these drugs also increase serotonin: Cocaine, Amphetamines, Fenfuramine, Dextromethorphan, Meperidine, 3,4Methylenedioxymethamphetamine (MDMA, ecstasy) and Sibutramine. Medications that inhibit serotonin catabolism include: Isocarboxazid, moclobemide, phenelzine, selegiline and Tranylcypromine.

21. In a recent seizure Serum prolactin levels are increased for 5-30 times, if measured within 20 minutes of generalized tonic clonic seizures. This level helps in excluding pseudo seizures in few patients.

22. Which of the cell types forms the blood-brain barrier and help in neuronal migration during development? Astrocytes are one type of glia cells, responsible for the development and framework of the neurons. They also form the blood-brain barrier

23. A 28-year old woman diagnosed with generalized anxiety disorder 1 year ago and treated with sertraline for 2 months. Which of the following drugs will not have any interactions with her medication? A. L-Tryptophan B. Lorazepam C. Tramadol D. Sumatriptan. E. Dextromethorphan Ans. Lorazepam L-Tryptophan is a precursor for serotonin production and thus increases the substrate available for its synthesis. Tramadol inhibits serotonin reuptake and can cause serotonin syndrome. This medication should be used in caution with an SSRI, but is not an absolute contraindication. Sumatriptan is a serotonin agonist and can cause serotonin syndrome. Dextromethorphan inhibits serotonin reuptake and can cause serotonin syndrome.

All increase Serotonin.

24. Somatoform disorders Conversion disorder is defined as a pain syndrome that mimics a physical disorder with a significant loss or change in physical function. Secondary gain is also involved in the disorder Patients with somatoform disorders often present with vague pain complaints that is similar to visceral pain in organic disorders such as cancer and post inflammatory pain processes The psychiatrist role in working with a hypochondriac includes establishing a therapeutic alliance, evaluating for psychotic somatic beliefs and reassuring the patient. A complete history and differential diagnosis to rule out disease is a part of the process Pain disorder is also known as pain behavior, psychogenic pain disorder and somatoform pain disorder- there are 3 subtypes, psychological factors predominating, non-psychiatric pain associated with a medical disorder, and a combination of the two There is no effective treatment for factitious disorder with physical symptoms. Intentional creation of physical symptoms distinguishes factitious disorder from somatoform disorders-psychological etiology is the need to take on the sick role-Although the behavior is bizarre, patients with factitious disorders are not psychotic

25. Which is NOT a good way to differentiate between migraine sufferers and a patient with epilepsy? Presence of headache Presence of typical aura preceding episode Headache is not a differentiating symptom, as nearly all epileptic patients have migrainous headaches, and migraines may occur without headache. Presence of aura preceding episode, can be seen in both temporal lobe seizures or in migraines. Presence of flickering lights or flashing colors (usually red or white) can be seen in seizure activity and are distinct from the zig-zag pattern of light seen in migraines. Presence of zigzag pattern of light is distinct for migraine. An abnormal EEG may be seen in migraine as well, but a normal EEG while the episode of migraine is occurring, is reassuring.

26. Cortical dementia vs. Subcortical dementia Subcortical dementia features greater impairment in recall memory than learning, decreased verbal fluency without anomia, no aphasia, slowed thinking, depressed mood,

affective lability, apathy, and decreased attention/concentration, chorea, tremors, tic, dystonias with impaired coordination and motor functions Diseases associated with cortical dementia are Alzheimer's disease, vascular dementia, Creutzfeldt-Jakob disease, Binswanger's disease, and Pick's disease

Diseases associated with subcortical dementia are Parkinsonism, Huntingtons disease, Lewy body disease, Binswangers syndrome, and HIV dementia 27. An Elderly presenting with lethargy, 2 episodes of generalized seizure, elevated blood pressure, tachycardia, dyspnea, vomiting and fever. Clinical examination revealed hyperreflexia and hypertonia. psychiatrist increased the Paxil dose just 3 days before these symptoms started. There was no sign of infection, the chest X-ray and the brain CT scan was normal. What blood test it is most likely to be found abnormal in this patient? Ans: Hypocalcemia This patients symptoms started 3 days after his SSRI was increased and together with the negative imaging and lab studies, the diagnosis of serotonin syndrome can be made. Leukocytosis, rhabdomyolysis, and liver function test abnormalities have all been reported in serotonin syndrome, along with hyponatremia, hypomagnesaemia, and hypocalcemia. HYPO-Na, Mg, Ca 28. The solitary tract is critical for what part of sleep? NREM sleep The solitary tract projects ventrally through the basal forebrain to the cortex through the thalamus. It is progressive hyperpolarization of corticothalamic circuits during NREM sleep which underlie the characteristic delta waves through which this deep sleep is recognized. 29. According to DSM-IV, core features of dementia are: Multiple cognitive deficits such as aphasia, apraxia, agnosia, or disturbance in executive functioning

Dementia is a serious loss of cognitive ability, and intellectual functioning usually because of underlying progressive degenerative brain disease. Multiple cognitive deficits such as aphasia, apraxia, agnosia, or disturbance in executive functioning are core features of dementia according to DSM-IV-TR. Cortical and subcortical are dementia subtypes specified in DSM-IV-TR. 30. Rx of Pain and co-occurring Psychiatric disorders Combining pharmacological and psychotherapeutic modalities is more effective in treating pain patients with anxiety and depression than pharmacologic modalities alone. Independent analgesics are medications that are effective in treating pain and psychiatric symptoms- the pain efficacy component is independent of mood efficacy component Co-occurring psychiatric disorders can be successfully treated if pain does not improve. Major depressive disorder is seen in 15% of people with chronic pain- in pain clinics that percentage may be as high as 50% Subthreshold depression does impact physical impairment associated with chronic and should be treated accordingly 31. Huntington's disease usually appears between the ages of 35 and 45 years. Huntingtons disease is a neuro-degenerative disorder characterized by chorea, lack of coordination, progressive dementia, and neuropsychiatric manifestations like comorbid mood disturbance, anxiety, obsessive-compulsive symptoms, and high risk for personality change, irritability, aggressive behavior, and suicide. Deficits in sustained attention, memory retrieval, ability to acquire new skills, and visuospatial skills are predominant and early manifestations of the disorder. The dementia results from cell loss in primary sensory and association areas, entorhinal cortex, caudate nucleus, and putamen. Multi-infarct dementia is characterized by abrupt onset, decreased executive functioning, gait disturbance, affective lability, and parkinsonian symptoms with risk factors like increased age, hypertension, diabetes mellitus, atherosclerotic heart disease, hypertriglyceridemia, and hyperlipidemia. Parkinson's disease manifests slowness of movements, impaired balance, tremors, muscle rigidity, mask like face, and poor retrieval memory and attention deficits. Multiple sclerosis is an autoimmune disease, which is damaging the myelin sheath with clinical features of muscle weakness, poor coordination, thinking and memory problems, numbness, problem with swallowing, and cognitive deficit. Wilson's disease has characteristic features of involuntary shaking, dystonias, and clumsiness, and depression, difficulty in speaking, swallowing and walking, jaundice, with liver disease.

32. Somatosensory seizures and migraines may mimic transient ischemic attacks of the middle cerebral artery.

A partial seizure of the Sylvian region is a motor seizure that involves the tongue, mostly seen in adolescents, at night. A partial seizure of the temporal gyrus often leads to an auditory seizure, typically with tinnitus, in a hissing, buzzing, or roaring form.

33. EEG Patterns Spike and wave pattern with a frequency of 3 cycles per second: Absence seizures Slow spikes and waves (or polyspikes and waves) Akinetic seizures: As well as being seen in other seizure disorders An EEG finding considered typical for Lennox-Gestalt syndrome This finding could even be normal in a child 2-6 years of age, but only with drowsiness and sleep. Hypsarrhythmia is a dangerous EEG pattern seen in status epilepticus and in West syndrome (childhood spasms), among others. Phantom spike and waves are a normal EEG variant. 1 Hz spikes over the temporal lobes may be associated with a variety of seizure types, or mental retardation.

34. Is Tracheostomy ever indicated for obstructive sleep apnea? yes, Tracheostomy bypasses the upper airway and can be used in patients who do not tolerate CPAP/BiPAP. Surgical therapy is indicated in a small subset of patients. The surgical options available are divided into two categories: Tracheostomy: in which a bypass of the upper airway is achieved and upper airway reconstruction. They are not synonymous. Furthermore, this is not a common intervention. Failing a sleep study is immaterial to the effect of treatment, except that it tells us that someone is having sleep events. They will continue to have those events until we are able to give them corrective therapy. Many patients don't like their CPAP/BiPAP machines, but they continue to use them because they are effective therapy. Tracheostomy was the original treatment for OSA. Tracheostomy is used with reconstructive surgery, when in fact they are two different surgical treatments, and do not rely on one another for efficacy.

35. Which of the following areas is involved in dysphasic psychic aura? Left perisylvian area Left perisylvian language areas are involved in dysphasia as there is problem in speech and language. Frontal association cortex lesion results in cognitive psychic aura. Illusions are the characteristic feature of left superior temporal neocortex. 36. Brain metastases Non-small cell lung cancer is the most common primary lesion leading to a brain metastasis, But Melanoma and Small cell lung cancer have the greatest propensity to metastasize to the brain. Other primary cancers that commonly spread to the brain include breast, renal, and gastrointestinal (GI) cancers.

37. Post Operative Delirium Post op-delirium is associated with some important predictors such as advanced age, fluid electrolyte imbalance, hypoxia, decreased cardiac output, infections, sepsis, prior cognitive impairment, depression, blood loss, alcohol withdrawal, narcotics, benzodiazepine, and neuroleptics. One of the most common precipitants of delirium is medication. Tylenol has some anticholinergic effects but it is not closely linked with delirium. 38. risk factors contributing to Alzheimers dementia As many as 40% of people with AD have a positive family history ApoE-4 contributes to about 5% of all of the total cases of AD. The gene for amyloid precursor gene, the major contributing protein product of AD, resides on chromosome 21 and people with Trisomy 21 produce more as they have three copies of this gene.

39. What is the prevalence of dementia after age 85? 20-40% After the age of 65 the prevalence is 5%. 40. In hypoxic encephalopathy model, dopamine release was shown to increase 500-fold, whereas GABA release was increased only five-fold. In delirium, there is a reduction in acetylcholine activity, and an excess of dopamine activity. Dopamine is considered to have important role in:

Attention Mood Motor activity Perception

41. A 32 year old pregnant woman presents with involuntary asymmetric rapid non-rhythmic movements of her arms, legs, and trunk. The likely diagnosis is thought to be related to which of the following disease? Sydenhams Chorea Chorea gravidarum is characterized by rapid non-rhythmic movements of her arms, legs, and trunk and occurs due to elevated estrogen (pregnancy or estrogen administration), The symptoms usually disappear after the estrogen levels return to baseline, and it is thought to be of autoimmune origin (related to Sydenhams Chorea). 42.

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