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Clinical Atlas Prestige · Evidence-first

Psych VivasConsultation-liaison psychiatry

Psych Vivas · Consultation-liaison psychiatry

Huntington disease psychiatry — structured clinical viva

Fellowship viva on HD neuropsychiatry, suicide, irritability algorithms, and VMAT2–mood interface.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the CL psychiatry registrar. Neurology asks you to review a 50-year-old man with manifest Huntington disease who has partner-directed irritability, major depressive symptoms with passive suicidal ideation, and recent tetrabenazine titration for chorea. Discuss classification of HD neuropsychiatric syndromes (including apathy versus depression), suicide risk, differentials, stepped psychopharmacology for depression and irritability, VMAT2 cautions, psychosis management principles, predictive testing ethics if family members request testing of a minor, and multidisciplinary disposition.

Interpretation

Reveal interpretation

Leading diagnoses: HD-related major depression with passive SI plus irritability/aggression, possible apathy overlap, on background of manifest HD; consider tetrabenazine-related dysphoria after recent titration.[1][2][5]

Differentials to voice: delirium/infection; pure apathy; primary mood disorder coincidental; substance use; emerging psychosis.[3][7]

Acute plan: structured suicide assessment and safety planning; collateral for aggression; joint neurology review of VMAT2 dose; start SSRI for depression/irritability if indicated (e.g. sertraline low start); escalate to low-dose SGA if severe aggression/psychosis; non-drug structure and carer support.[2][3][4]

Chorea drugs: TETRA-HD/FIRST-HD literacy — benefit for chorea, monitor depression/parkinsonism.[5][6]

Ethics: do not casually predictively test asymptomatic minors for adult-onset HD; support adult relatives through counselling pathways.[7]

Close: multidisciplinary HD clinic, advance care planning while capacity intact, ongoing suicide surveillance.[3][7]

Key points

Suicide every visit

Elevated ideation and behaviours — not only late disease.[2]

Apathy ≠ depression

Motivational loss without dysphoria needs different emphasis.[1][3]

VMAT2 mood trap

Tetrabenazine/deutetrabenazine help chorea; watch depression.[5][6]

References

  1. [1]van Duijn E, Craufurd D, Hubers AA, et al. Neuropsychiatric symptoms in a European Huntington's disease cohort (REGISTRY) J Neurol Neurosurg Psychiatry, 2014.PMID 24828898
  2. [2]Hubers AA, van Duijn E, Roos RA, et al. Suicidal ideation in a European Huntington's disease population J Affect Disord, 2013.PMID 23876196
  3. [3]Anderson KE, van Duijn E, Craufurd D, et al. Clinical Management of Neuropsychiatric Symptoms of Huntington Disease: Expert-Based Consensus Guidelines on Agitation, Anxiety, Apathy, Psychosis and Sleep Disorders J Huntingtons Dis, 2018.PMID 30040737
  4. [4]Groves M, van Duijn E, Anderson K, et al. An International Survey-based Algorithm for the Pharmacologic Treatment of Irritability in Huntington's Disease PLoS Curr, 2011.PMID 21975525
  5. [5]Huntington Study Group Tetrabenazine as antichorea therapy in Huntington disease: a randomized controlled trial Neurology, 2006.PMID 16476934
  6. [6]Huntington Study Group, Frank S, Testa CM, et al. Effect of Deutetrabenazine on Chorea Among Patients With Huntington Disease: A Randomized Clinical Trial JAMA, 2016.PMID 27380342
  7. [7]Walker FO Huntington's disease Lancet, 2007.PMID 17240289