Diagnoses - Part 1 of 4 Flashcards
7 y/o child is brought in by parents who report he’s been hyperactive since age 4, talks constantly, interrupts, has trouble sitting still to do homework, will not play quietly outdoors. What else do you need to make the diagnosis of ADHD? (4x)
TEACHER REPORT
Studies show effective intervention for children with ADHD is to involve their parents in what part of Tx? (4x)
BEHAVIORAL MANAGEMENT
Child w ADHD ineffective Tx with methylphenidate. Next step in management: (4x)
DEXTROAMPHETAMINE
Child w ADHD not respond to methylphenidate IR. What med to try next (4x)
MIXED AMPHETAMINE SALTS
What aspect of ADHD is most likely to improve as children age? (3x)
HYPERACTIVITY
Atomoxetine’s principal mechanism of action exerts a therapeutic action because it: (2x)
IS A SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITOR.
Atomoxetine is most likely to be considered as initial treatment in ADHD in adolescents with: (2x)
SUBSTANCE USE D/O
The multimodal Tx study of children w/ ADHD examined the comparative responses over 14 months of children to medication and intense psychosocial interventions. What did the findings of the study reveal w/ respect to ADHD symptom changes? (2x)
MEDICATION MANAGEMENT IS SUPERIOR TO COMMUNITY CARE TREATMENT
The component of ADHD that is most likely to remain in adulthood:(x2)
INATTENTION
Which perinatal factor is specifically associated with development of ADHD?
MATERNAL TOBACCO USE PRENATALLY
Which DSM-V diagnosis requires symptoms to be present in 2 or more settings?
ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)
Current thinking about relationship between ADHD in children and adults:
SIGNIFICANT NUMBER OF CHILDREN WILL GO ON TO BECOME ADULTS WITH ADHD
8 y/o boy w/ ADHD, oppositional defiant disorder, and chronic motor tic disorder has worsening of his tics on a good dose of a stimulant that seems to control his ADHD. How do you manage this further in trying to improve the tics?
MONITOR THE TICS ONLY
Which comorbid diagnosis of childhood ADHD worsens the prognosis into adolescence and adulthood to the greatest degree?
CONDUCT DISORDER
32 y/o w/ ADHD mixed type as child. As adult still has Sx. Tx:
METHYLPHENIDATE
Which med would you prescribe for 20 y/o college student being worried over his grades? He complains that he has not been able to focus on studying and that his mind wanders frequently during classes. His energy level is low. He sleeps well and his appetite is good. History indicates he was treated with stimulants since second grade.
METHYLPHENIDATE
10yo w ADHD and aggressive outburst is started on a moderate dose of a stimulant. ADHD symptoms have improved, but aggression has not. In addition to behavioral intervention, what is the next best step to manage both the ADHD and aggression?
MAXIMIZE DOSAGE OF LONG ACTING STIMULANT
Which psychiatric disorder is comorbid with ADHD?
DISRUPTIVE BEHAVIOR DISORDERS
Which of the following side effects can result from stimulant medication treatment and warrants immediate discontinuation of the medication and a reassessment of the treatment plan?
HALLUCINATIONS
Abnormal LFTs would be most commonly associated w/ what medication used to treat ADHD in children/adol?
PEMOLINE
ADHD comorbid disorder
DEPRESSION
These empirical non-stimulant meds have empirical support to treat ADHD:
CLONIDINE, BUPROPION, IMIPRAMINE, ATOMOXETINE
What procedure is necessary to diagnose childhood ADHD?
CLINICAL INTERVIEW OF PARENTS AND CHILD
Parents bring their 10 yo child for an eval due to concerns about child’s reported difficulty paying attention in a class and completing assignments in the expected time. Parents report that the child has trouble staying on task while doing homework and they are concerned that the child has an attention disorder. At the completion of the eval, the psychiatrist requests that both a parent and a teacher fill out a rating scale. The parent ratings fall into the clinical range but the teacher’s ratings do not meet criteria for a clinical problem. How should the psychiatrist account for the differences in observed ratings?
RATING DISCREPANCIES BY DIFFERENT OBSERVERS ARE COMMON IN CLINICAL PRACTICE.
Antidepressant for ADHD
BUPROPION
With respect to ADHD symptoms, the 1999 multimodal treatment study of children with ADHD was most notable for demonstrating which of the following?
THE EQUIVALENCE OF COMBINED METHYLPHENIDATE AND PSYCHOSOCIAL TREATMENT COMPARED TO MEDICATION ALONE
Which of the following instruments is most helpful in the assessment of children suspected of having ADHD?
CONNERS TEACHER RATING SCALE
What med used for ADHD has been associated with liver damage?
ATOMOXETINE (STRATTERA)
11 y/o with reading disability. Most likely comorbid dx:
ADHD
Describes the relationship of stimulant treatment of children with ADHD and the emergence and/or presence of tic d/o:
TREATMENT WITH STIMULANTS HAS BEEN SHOWN TO REDUCE TICS IN CHILDREN WITH COMORBID ADHD AND TIC D/O.
What DSM-IV-TR disorder requires symptoms to be present in two or more settings?
ADHD
12 yo comes in for worsening attention, impulsive, and hyperactive. He is snoring and hard to wake in the AM. Central adiposity, broad based neck and enlarged tonsils. exam is unremarkable. In child with ADHD and sleep problems, what is the most accurate about ADHD and sleep in this patient?
CORRECTING THE UNDERLYING SLEEP DISORDER CAN IMPROVE ADHD SYMPTOMS
5 y/o is evaluated for ADHD. Parents complain that the child has multiple symptoms of hyperactivity, impulsivity, inattention, and distractibility. Parents also bring teacher feedback reports that confirm these symptoms and state child is failing academically and having social problems. In psych MD office child is quiet, calm and cooperative, and very engaging . The difference in clinical presentation from parent and school reports is most likely because:
CHILDREN WITH ADHD CAN PRESENT WITH BRIEF PERIODS OF HEIGHTENED FOCUS AND CALM, ESPECIALLY IN A STRUCTURED SETTING.
Failing grades, poor organization, spending sprees, spontaneous trips ditching class, fidgety, euthymic. No change in sleep, appetite, no anhedonia. Dx?
ADHD
When compared to the other subtypes of ADHD, children with the inattentive subtype have higher rates of anxiety and somatic complaints and
LEARNING DISORDERS
DSM 5 prior age of presentation ADHD symptoms
12 YEARS OLD
Increased rate of comorbidity with ADHD?
ANXIETY OR OPPOSITIONAL DEFIANT DISORDER
10yr old child, 3 yr hx of involuntary movements and vocalizations, symptoms wax and wane but never disappeared, child is aware of symptoms and only mildly distressed, academic performance is below average, what is the co-occurring disorder most likely causing this functional impairment at school?
ADHD
What distinguishes ADHD in children vs adults?
HYPERACTIVITY
What aspects of ADHD is likely to improve as children age?
HYPERACTIVITY
Best neuropsych test of sustained attention
CONNER’S CONTINUOUS PERFORMANCE TEST
A diagnostic feature of panic attack is: (2x)
DEREALIZATION
Respiratory illness is most clearly a risk factor for developing which anxiety disorder? (2x)
PANIC DISORDER
Differential diagnosis of pt presents at ED with panic d/o: (x2)
PULMONARY EMBOLISM
28 y/o pt presentes with one year history of agoraphobia. Pt is able to drive to the local drug store, but only with considerable pre-travel apprehension. Pt will venture alone no further than within approximately 5 miles of home. Personal hx of panic attacks or depression is denied, although family hx is positive for depression and alcoholism. Pt has had no previous treatment. The best initial treatment and one that offers the best long term prognosis is? (x2)
CBT INCLUDING EXPOSURE & SSRI AND BENZO
Repeat ED visits for CP, negative, most important
H/O OF PAIN ON EXERTION RELIEVED BY REST
Tx for med student w/ chronic anxiety and sense of inadequacy?
BRIEF PSYCHODYNAMIC THERAPY
When compared to younger adults, anxiety disorders in adults over age 65 have:
LESS COMORBIDITY WITH ALCOHOL ABUSE
Which of the following strategies exemplifies use of reciprocal inhibition by a patient to attenuate anxiety associated with a party?
REHEARSING MENTAL IMAGES OF PLEASURABLE EXPERIENCES WHILE ATTENDING THE PARTY
Best therapy for patient with illness anxiety disorder
CBT
The parent of a 43 y/o pt died 5 years ago from pancreatic cancer. 4 years ago patient began feeling full after eating large fatty meals, fearing it was pancreatic cancer. Constantly weighs himself so that he is not losing weight. Now avoids going to doctor to avoid being diagnosed with cancer. No other psychiatric symptoms. What is diagnosis?
ILLNESS ANXIETY DISORDER
Treatment for severe performance anxiety
PROPRANOLOL
36 y/o with several episodes of palpitations, sweating, trembling, SOB. Work suffering due to anxiety. Initial Tx regimen:
PAROXETINE AND CBT
Which of the following agents has been shown to augment the effects of CBT on anxiety disorders?
D-CYCLOSERINE
Weight loss, 3-month hx of anxiety, mild depression, & insomnia, thin, elevated HR, low BP, mild tremor
HYPERTHYROIDISM
Prevalence of separation anxiety d/o and GAD in children follows what pattern with regard to age?
GAD INCREASES WITH AGE WHILE SEPARATION ANXIETY DECREASES WITH AGE
What disorder is most likely to be comorbid in pts w trichotillomania?
MOOD DISORDER
In some Japanese and Korean cultures, rather than an intense fear of embarrassing oneself socially, social phobia symptoms may instead manifest with intense fear of what?
OFFENDING OTHERS
Which of the following is a common medical cause of anxiety in a pt dying of cancer?
POORLY CONTROLLED PAIN
18 y/o restless, feels mind going blank, poor concentration, irritability, insomnia, fatigue > 1 yr, used to be good student up until 2-3 yrs ago, no substance use
GAD
Core feature of GAD
EXCESSIVE WORRYING
35 y/o truck driver diagnosed w/ GAD. Does not want med that causes sleepiness:
BUSPAR
Psych MD was consulted for anxiety and depression. Pt reports severe pain and indicates that doctors refuse to prescribe enough medication to control pain. A factor important for psychiatrist to consider:
ACUTE PAIN IS OFTEN UNDERTREATED, AND POOR PAIN MANAGEMENT CAN CONTRIBUTE TO ANXIETY AND DEPRESSION.
Pt with leukemia underwent marrow transplant. Psych consulted. Pt more anxious and fearful about leaving hospital. Having trouble sleeping. MSE unremarkable. Dx? (x2)
ADJUSTMENT DISORDER WITH ANXIETY
A 45yr old pt, terminated treatment with previous PCP “because he didn’t take my concerns seriously.” Pt believes he has dreaded illness and stomach cancer, denies all symptoms and labs are normal, diagnosis?
ILLNESS ANXIETY DISORDER
Generalized anxiety disorder is characterized by excessive worrying along with what combination of symptoms?
BEING EASILY FATIGUED AND FEELING KEYED UP
A 19-yo college student complains of “difficulty concentrating and my mind going blank when I try to study.” She feels restless, keyed up and worries excessively. Does not use substances.
GAD
55yr old Hispanic American brought to psychiatrist by family, spells of uncontrollable shouting, crying, trembling, insomnia, pt feels chest heat going up to head, pt and family believe pt is suffering ataque de nervios, pt meets criteria for?
ANXIETY DISORDER
What is the principle goal of the cognitive-behavioral therapy of panic d/o?
USING RESTRUCTURED INTERPRETATION OF DISTURBING SENSATIONS
Which clinical feature distinguishes panic disorder from pheochromocytoma?
ANTICIPATORY ANXIETY (in panic d/o)
Panic attack reaches peak in
A FEW MINUTES
Psych MD in the ED evaluates a 67 y/o pt w/ h/o depression who c/o panic attacks since the death of her spouse 1 month ago. Pt has frequent episodes of acute-onset palpitations, chest tightness, nausea, shortness of breath, and intense anxiety lasting several minutes, with no specific triggers. This morning it woke her up from her sleep. Exam: overweight, pale, anxious appearing, and mildly diaphoretic. Her BP is 140/90, pulse 106. Most appropriate next step in management?
EKG
Pt w panic disorder failed 2 SSRI trials. Which med should be used next?
IMIPRAMINE
32yo h/o panic disorder, phobias, numerous failed trials of antidepressants. On clonazepam 0.5mg bid with good response. 1mo later response still good but not as good. Dose increased to 1mg bid, on 3rd visit pt reports some loss of benefit again. What is the appropriate course of action?
INCREASE TO 1.5MG PER DAY
Compared to pharmacotherapy, advantage of CBT in tx of panic disorder is
LOWER RATE OF RELAPSE FOLLOWING D/C OF TREATMENT
Once it becomes effective, pharmacological tx of pts with panic d/o should generally continue for what length of time?
8-12 MONTHS
This statement best characterizes current information on the recommended initial treatment of psychotherapy or pharmacotherapy for a pt with panic disorder:
THERE IS INSUFFICIENT DATA TO CHOOSE ONE TREATMENT OVER ANOTHER, OR COMBINATION OVER MONOTHERAPY
42 y/o surgeon experienced intense stomach cramps and palpitations when unable to immediately find the right instrument when performing an appendectomy. The surgeon was extremely alarmed by this and began to worry about the symptoms recurring. The surgeon then traded all ED calls so as to avoid these situations, began to avoid other crowded and noisy environments, and avoided a variety of social and professional settings. Likely diagnosis:
AGORAPHOBIA WITHOUT PANIC
A diagnosis of panic d/o requires which of the following?
AT LEAST SOME ANXIETY ATTACKS THAT ARE UNPROVOKED
First-line treatment of panic disorder?
FLUOXETINE
Using cash only due to substantial discomfort while writing checks or signing credit card receipts in the presence of others (because of messy handwriting)?
SOCIAL ANXIETY DISORDER
Boys with ___are most likely to delay first sexual intercourse until after 18 yo.
ANXIETY SYMPTOMS
College student feels embarrassed with public speaking or choosing seat in cafeteria and experiences blushing, muscle twitching, and shame. Endorses sadness about not having friends. What is dx?
SOCIAL ANXIETY DISORDER
Patient with self reported concerns of brain tumor; no symptoms suggestive of brain tumor, but states he has a cousin who died of brain tumor. PE unremarkable. Neuroimaging negative, patient repeatedly requests MRI, still concerned about tumor. Dx?
ILLNESS ANXIETY D/O
62 y/o requests antidepressant. Spouse died 6 wks ago. Crying spells, decreased appetite, poor sleep. Continues to see friends, no SI. Fam Hx of depression, no prior depressive episodes (3x)
BEREAVEMENT; ASSURE PATIENT OF NO PATHOLOGY
Which of the following factors has the most evidence to support its protective effect in bereavement following the loss of a spouse? (x2)
QUALITY OF SOCIAL SUPPORT OF THE BEREAVED
Most likely to increase risk of impairment after bereavement in 80 y/o (X2)
SIGNIFICANT DEPRESSIVE SXS SHORTLY AFTER THE LOSS
Normal bereavement in prepubertal children
WISH TO UNITE W/ DEAD LOVED ONE
Most common fear expressed by adults leaving home to go to hospice?
SEPARATION FROM LOVED ONES
5 y/o child several month after that he lost his mother in a MVA reports that his mother is watching him from sky every day is and example of:
NORMAL GRIEF
8yo w/ no hx of emotional disturbance p/w separation anxiety & over-concern for health of surviving parent.
AGE-TYPICAL PRESENTATION OF NORMAL BEREAVEMENT
For adult, death of loved one by violent means affects grieving process in what way?
EARLY BEREAVEMENT IS SIMILAR, HOWEVER, DYSPHORIA PERSISTS FOR PROLONGED PERIOD
A father wants to know if he should allow his 5 y/o child to attend the funeral of her mother. The child expresses a desire to go. To help the child through the funeral, it will be important to do which of the following?
HAVE SOMEONE FAMILIAR ACCOMPANY THE CHILD
62 y/o pt presents to psychiatrist requesting med for depression. Detailed hx reveals pt’s spouse of 35 years died suddenly 6 wks ago. Since then, pt complains of frequent crying spells, decreased appetite without weight loss, and poor sleep due to middle of the night awakening. Pt continues to attend social engagements with friends and denies SI. Pt has family hx of depression, no hx of depressive episode in past. Dx:
BEREAVEMENT
What factor is necessary to consider when deciding if a patient’s grief is defined as normal or abnormal?
CROSS-CULTURAL GRIEF PRACTICES
What symptom best differentiate chronic traumatic grief from uncomplicated bereavement?
PERSISTENT AVOIDANCE OF DEATH REMINDERS
Pt is engaged in interpersonal psychotherapy for depression. In the first several sessions, the patient and therapist identify unresolved grief after the death of the patient’s mother as the problem area, and relate these feelings to the patient’s current depression. Which of the following will be the focus of the middle phase of treatment?
FINDING NEW ACTIVITIES AND RELATIONSHIPS TO OFFSET THE PATIENT’S LOSS
5 y/o has been enuretic after mother died in an MVA 4 days ago and keeps saying, “Mommy will come home soon.” The father wonders if the children should attend the funeral. What is your recommendation?
THE CHILD AND SIBLING SHOULD BOTH BE ALLOWED TO ATTEND IF THEY WANT TO GO.
Which symptom would indicate MDD rather than just bereavement: Poor appetite and sleep, hearing the voice of the loved one, feelings of guilt or thoughts of suicide?
THOUGHTS OF SUICIDE
30 y/o pt recently Dx w/ Hodgkin’s dz constantly states, “Why me?” According to Elizabeth Kubler-Ross, the patient’s reaction is consistent with what phases?
SHOCK AND DENIAL
What is a symptom of normal bereavement in a <5 y/o child after the death of a parent?
REGRESSION IN BOWEL AND BLADDER CONTROL
4 months ago the wife of a pt died and pt blames himself for her death. Next step:
REASSURANCE
60 y/o lost spouse 2 wks ago – sadness comes and goes
NORMAL GRIEF
65 y/o pt initially diagnosed w bereavement. Duration of sx to dx MDD?
2 MONTHS
58 y/o have week’s h/o intense feelings of sorrow and bitterness only 6 mos after wife’s death. “We would have been married 30 yrs this month.” His daughter confirmed his level of functioning only took a dip a week ago. Moderate diff sleeping and poor appetite only assoc Sxs. No SI. Physical exam normal. Dx:
DELAYED GRIEF
1-month post death of loved one. What would suggest a pathological grief rxn?
CONTINUED FEELINGS OF WORTHLESSNESS
Risk factor that can adversely influence psych outcome of child after death of parent
CONFLICTUAL RELATIONSHIP W/ DECEASED PARENT
6 y/o girl hosp for surgery to repair fracture sustained in MVA in which mother was injured & brother died. She reports seeing her brother in her room since accident, MSE is nml. Receiving Vicodin & Benadryl. What explains pt seeing brother?
BEREAVEMENT
10 y/o M s/p MVA sustained burn and crush injuries to R foot 4 days ago, does not remember the accident but never lost consciousness, keeps asking for his mother who was killed in the accident and having nightmares crying out “Daddy help Mommy.” When should the child be told about his mother’s death?
ASAP
45 y/o still grieving for mother 3 years after her death. States she feels her mother hovering over her and sees mother at night. Friends are concerned. Patient has normal job function, cleans house, endorses anhedonia. Tx?
ANTIDEPRESSANT MEDICATION AND PSYCHOTHERAPY
Risks of complicated bereavement:
1) AMBIVALENT RELATIONSHIP TO DECEASED; 2) SIMULTANEOUS GRIEVING FOR MULTIPLE DEATHS;
3) PRE-EXISTING LOW SELF-ESTEEM & INSECURITY;
4) RECURRENT MAJOR DEPRESSION
65 y/o pt w MDD has died by suicide. Pt had received tx from same psychiatrist x 5 yrs. Psychiatrist contacts the pt’s spouse. Best way to communicate this?
CONCENTRATE ON ADDRESSING THE FEELINGS OF THE SPOUSE
Which of the following is predictive of better adaptation in bereavement?
FINDING MEANING IN LOSS
Pt w/ h/o bipolar presents w immobility, posturing, echopraxia. First line tx? (5x)
LORAZEPAM
What predicts bipolarity in adolescent with depression? (2x)
PSYCHOTIC SYMPTOMS
What medication strategies is most effective and rapid in the treatment of severe bipolar illness, manic phase? (X2)
ANTIPSYCHOTIC MEDICATION + LITHIUM OR VALPROATE
40 y/o w/ 6 kids: insomnia, poor appetite, dizziness/nausea, thinks husband is poisoning her. Despite all classes of meds marked fluctuations from sadness to euphoria 5x during the year. Dx? (2x)
BIPOLAR W/ RAPID CYCLING
First line to treat bipolar depression
QUETIAPINE
What med can you add to lithium for tx resistant bipolar depression and is least likely to induce rapid cycling/mixed state?
BUPROPION
Pts > 65 years w bipolar disorder differ from younger pts w same dx—how?
MORE MIXED EPISODES
