Day # 127: Review Quiz-> Psychosomatic Disorders Part 2

Today will be our final review quiz for the psychosomatic disorders theme. Take a few minutes and check your learning.

1) Compared to psychogenic non-epileptiform seizures (PNES), which of the following are more suggestive of a true epileptiform seizure?

a) Eye opening or widening

b) Side-to-side head movements

c) Opisthotonic posturing

d) Rapid recovery after the episode

2) Which of the following medications is commonly used off-label in the treatment of fibromyalgia (not FDA approved for this condition)?

a) Pregabalin

b) Amitriptyline

c) Milnacipran

d) Duloxetine

3) Which of the following are the three core/required symptoms to diagnose chronic fatigue syndrome?

a) Profound fatigue and reduced ability to perform activities

b) Un-refreshing sleep

c) Orthostatic intolerance

d) Post-exertional malaise

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ANSWERS

Question 1:

From day #122

Answer: a

Eye opening or widening

Explanation: 1, 2

It can sometimes be difficult to distinguish an epileptic vs non-epileptic seizure by clinical features alone, however there are important differences/clues that can help you. I have summarized these features below.

Epileptic seizures

• Abrupt onset

• Loss of awareness

• Eye opening/widening

• Tongue biting or other significant injury

• Incontinence

• *Post-ictal confusion/sedation*

• May occur during sleep

Non-Epileptic seizures (PNES)

• Resistance to anti-epileptic drugs

• Emotional triggers - such as stress, conflict, becoming upset, pain, sounds, lights.

• Suggestibility / Inducible - episodes tend to occur in the presence of an audience. They may frequently occur in the doctor's office or waiting room or during monitoring. They may be able to be provoked by induction techniques (see diagnosis section below).

• Bilateral clonic movements without loss of consciousness - preserved awareness during bilateral motor seizures is highly suggestive of PNES.

• *Absence of post-event confusion/lethargy (prompt recovery)* - the notable exception here is a specific type of seizure called absence seizures which are characterized by staring spells with prompt recovery without a post-ictal period.

• Variable responsiveness or preserved awareness.

• Discontinuous ("stop and go") motor activity; Out of phase movements of extremities.

• Complex motor movements such as pelvic thrusting or bicycling or opisthotonic posturing.

• Side to side head movements.

• Eye closure or eye flutter.

• Stuttering, weeping, postictal whispering.

• Usually do not occur during sleep.

• Physical exam and mental status exam: watch for overly dramatic behavior or suggestibility.

Question 2:

From day #125

Answer: b

Amitriptyline

Explanation: 3

• General approach of pharmacotherapy in chronic pain: The priority should be treating the underlying condition, if present. For patients with inadequate control of pain despite nonpharmacologic therapies, then augmentation with medications should be considered and carefully selected based on the type of pain. Initial treatment for chronic neuropathic pain and/or fibromyalgia generally involves either selected antidepressants (TCAs or SNRIs) or anti-epileptics (gabapentin or pregabalin) with adjunctive topical therapies. Goals should be to improve function and quality of life and not just improvement of pain.

• Antidepressants: Tricyclic antidepressants (TCAs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) are effective in neuropathic pain, fibromyalgia, migraines, other central sensitization syndromes, and even has some evidence for chronic low back pain and osteoarthritis. TCAs-> Amitriptyline has been the most widely studied TCA in chronic pain but others have also been used effectively including doxepin, nortriptyline, imipramine, and despiramine. It also improves sleep disturbances in patients with chronic pain. SNRIs-> Duloxetine has the largest evidence base of the antidepressants to support analgesic efficacy and is also FDA approved for fibromyalgia. Venlafaxine, at higher doses, also has some evidence for neuropathic pain. Milnacipran is FDA approved for the treatment of fibromyalgia and has been shown to improve pain and fatigue in these patients.

• Antiepileptics (AEDs): Gabapentin and pregabalin have proven efficacy verses placebo in several neuropathic pain conditions. Have also shown improvement in pain and sleep in fibromyalgia and pregabalin is commonly used first-line in this condition. Carbamazepine or oxcarbazepine is the first-line therapy for trigeminal neuralgia. Other AEDs have been used anecdotally and in randomized trials with limited evidence and should be reserved for specialty care third line treatments. These include topiramate, lamotrigine, levetiracetam, valproate, zonisamide, tiagabine, and the benzodiazepine clonazepam.

Question 3:

From day #126

Answer: c

Orthostatic intolerance

Explanation: 4

• Diagnostic criteria of chronic fatigue syndrome (CFS): There are multiple case definitions, however the Institute of Medicine (IOM) diagnostic criteria focuses on the most specific features of the disease.

• There are three core/required symptoms to diagnose CFS:

• ≥ 6 months of significantly reduced ability to perform activities that were normal before the illness. This reduced ability to engage in activities is also associated with profound fatigue and not substantially alleviated by rest. The extent of fatigue was not a problem before becoming ill. Activities may include occupational, family, social, or physical tasks and responsibilities.

• Post-exertional malaise (PEM): worsening of CFS symptoms after physical, emotional, or mental exertion that would not have caused a problem before the illness. Patients often describe PEM as a "crash", "collapse", or "relapse". Symptoms of PEM may last days or even weeks. Example-> attending a child's school event may leave someone house-bound for days in a row and be unable to perform home tasks like cooking or laundry.

• Un-refreshing sleep: may not feel better or less tired, even after a full night of sleep. Some people with CFS may have problems falling asleep or staying asleep.

• In addition to the three core symptoms, one of the following two symptoms is required for diagnosis:

• Cognitive impairment: problems with thinking, memory, attention, information processing, or executive functioning. Most individuals with CFS have trouble thinking quickly, remembering things, and paying attention to details. Patients may describe this problem as "brain fog". All of these symptoms can be exacerbated by exertion, effort, stress, or prolonged upright posture.

• Orthostatic intolerance: patients with CFS experience a worsening of symptoms while standing or sitting upright. Symptoms may include feeling lightheaded, dizzy, weak, fainting, headaches, nausea, blurry vision, or increased fatigue or cognitive worsening. Symptoms may improve, but not necessarily fully resolve, with lying down. They may have objective heart rate and blood pressure abnormalities while standing and have abnormal orthostatic vital signs or head-tilt testing.

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CONCLUSION

Nice work. If you want to see all of the weekly quizzes you can see them here. Next up we will discuss psychogenic non-epileptiform seizures (PNES).

If you are looking for more reading materials then check out our recommended resources.