General Psychiatry Flashcards
Which DSM edition was the first to provide explicit inclusion and exclusion criteria, offer extensive information beyond the criteria sets to help clinicians understand the described disorders, and eliminate the term “neurosis”?
DSM-III (1980).
A 65-year-old man presents with memory problems after a recent stroke in the right hemisphere. What type of deficit would be most expected with a right hemispheric lesion?
Visuospatial memory deficits
What type of memory deficits are associated with left hemispheric lesions?
Verbal memory deficits
What labs are followed for carbamazepine treatment?
Carbamazepine treatment screening tests initially include a CBC with platelets, liver function tests (LFTs), and BUN/creatinine. Follow-up CBC with platelets, LFTs, and BUN/creatinine are needed once a maintenance dose is achieved. Potassium is not specifically monitored for patients on carbamazepine.
What labs are checked on initiation of Lithium?
At initiation of treatment, lithium requires laboratory values for sodium, potassium, calcium, phosphate, blood urea nitrogen (BUN), creatinine, thyroid-stimulating hormone (TSH), thyroxine (T4), complete blood count (CBC), urinalysis, beta–human chorionic gonadotropin if appropriate, and an ECG in a
patient older than 40 years or with a preexisting cardiac condition, but LFTs are not required.
A 48-year-old British man is admitted to the inpatient unit for progressive cognitive decline and abnormal jerky movements in his left leg over the last 2 months. The clinician suspects Creutzfeldt-Jakob disease (CJD). Which laboratory study could be helpful in confirming the diagnosis?
The cerebrospinal fluid 14-3-3 protein is useful for confirmation of CJD in a patient with rapidly progressive dementia and pathognomonic neurological symptoms (i.e., myoclonic jerks).
What are the PET and SPECT findings for Alzheimer’s disease?
Alzheimer’s disease is often associated with bilateral, symmetric, posterior temporal, and parietal lobe perfusion defects
Ainsworth’s seminal “Strange Situation” research on patterns of attachment examined the quality of the mother-child relationship in children of what age?
Ainsworth’s seminal research on patterns of attachment examined the secure base behaviors in 12- to 18-month-old children in order to assess the quality of the mother-infant relationship (Ainsworth et al. 1978).
At what age do most children begin to develop a gendered sense of self?
By around the age of 2 years, most children begin to acquire a gendered sense of self. They accurately label themselves as boy or girl; positive and negative self-feelings accrue to the toddler’s notion of male and female.
At what age do children typically develop a theory of mind?
The acquisition of a theory of mind, or understanding of mental states, is a transformational process in development, usually demonstrable by the age of 4 years.
In the “still-face” experiment, the sudden loss of an affectively reciprocal interaction with the parent would likely cause a healthily attached infant to exhibit what?
Acute distress, crying, and averting the gaze.
At around what age do children begin to look at and attempt to “read” the facial expressions of others to obtain emotional clues to guide their own behavior?
Between 8 and 10 months.
In Ainsworth’s “strange situation,” a child with secure attachment would be expected to behave in what way?
Secure babies acclimate to the unfamiliar room and explore comfortably while the mother is near, evidence distress during separation, and are comforted by the parent’s return.
At around what age do children become able to recognize themselves in a mirror?
Age 18 months. Empirically, this major leap of self-awareness is illustrated via mirror self recognition, a clever experiment wherein children are placed in front of a mirror after their noses are surreptitiously rouged; beginning at around 18 months, toddlers tend to smile and attempt to remove the marks from their own noses rather than merely pointing toward their reflections (Lewis and Brooks-Gunn 1979).
What is an example of a “negative oedipal complex”?
A son longing for his father.
What is a predominant defense of the pre-oedipal phase?
Pre-oedipal implies poor anxiety tolerance, reliance on splitting as a predominant defense, superego pathology, and impulsivity.
A child observes an experiment in which water is poured from a narrow container into one with a much wider shape. In which of Piaget’s phases of cognitive maturation would the child insist that because the second container is wider, it must contain more liquid?
Preoperational phase.
What is a major developmental goal of adolescence?
The search for self-selected “new developmental objects” (i.e., adults available for idealization and identification) is guided in the college or employment setting by the young person’s more conscious and deliberate interests and beliefs: the choice of a mentor facilitates the gradual revision of the superego that is the work of late adolescence. Another task of this period is containment and integration of sexuality to facilitate intimate relationships.
In the landmark case Rennie v. Klein (1978), the court recognized the right of psychiatric patients to refuse treatment but concluded that this right could be overridden in which of the following circumstances?
The patient is a danger to himself or others.
If a patient commits suicide, what circumstances renders the psychiatrist most vulnerable to a wrongful death claim?
Psychiatrists are not automatically liable whenever an outpatient commits suicide (Speer v. United States 1981). Instead, the reasonableness of the psychiatrist’s efforts is determinative. A failure either to reasonably assess a patient’s suicide risk or to implement an appropriate precautionary plan after the suicide potential becomes foreseeable is likely to render a practitioner liable if the patient is harmed because of a suicide attempt.
A psychiatrist is most likely to be sued successfully when a patient commits suicide in which clinical setting?
Psychiatrists are more likely to be sued successfully when a psychiatric inpatient commits suicide. The law permits the fact finder to conclude that the opportunities to foresee (i.e., anticipate) and control (i.e., treat and manage) suicidal patients are greater in the hospital (Hofflander v. St. Catherine’s Hospital 2003).
A managed care company refuses to authorize payment for an extended hospital stay for a patient who is deemed violent by the hospital’s doctors. Which entity is most likely to carry the burden of liability if this patient commits a violent act soon after discharge?
The inpatient psychiatrist.
Describe the guidelines for therapeutic boundaries in psychiatry.
Therapeutic boundaries are important in any type of clinical work, but they are especially important in the intimacy of the psychotherapeutic relationship. Such boundaries include temporal and spatial limits: therapeutic encounters typically occur at the physician’s office during business hours, except in crisis situations. Limits are also observed in the nature of the relationship, which involves the psychiatrist being paid for services and acting as a fiduciary, a professional who is worthy of the patient’s trust. Nontherapeutic encounters, including business arrangements, social relationships, and sexual activity, are forbidden. Within the therapeutic relationship, limits are also observed. The patient is encouraged to share intimate feelings, thoughts, and memories, whereas the physician generally avoids self disclosure and adopts a posture of neutrality. Physical contact other than handshakes is avoided.
Serious boundary violations such as sexual contact with patients are associated with which physician risk factors?
Inadequate training, isolation from colleagues, and narcissistic pathology.
When considering the diagnosis of speech sound disorder, it is important to know that the speech of a young child should be fully intelligible by the age of ___, and full mastery of speech sounds of one’s native language should occur by the age of ___.
Full mastery of the speech sounds of one’s native language should occur by age 8 years; however, the speech of a young child should be fully intelligible by age 4 years.
A 10-year-old girl with a seizure disorder has an IQ of 50, becomes agitated by bright light, and has limited interest in social interaction. What is the most likely diagnosis?
Autism spectrum disorder.
A 6-year-old girl is noted to have poor motor coordination for her age. She often bumps into objects and is unable to catch a ball. Although her mother works with her, practicing skills, her play is significantly impacted. These symptoms seemed to have started before the age of 3. What is the most likely diagnosis?
Developmental coordination disorder.
According to DSM-5, by what age must symptoms be present for a child to be diagnosed with attention-deficit/hyperactivity disorder (ADHD)?
Age 12 years.
What fraction of children with ADHD can be expected to no longer exhibit symptoms in adulthood?
Roughly one-third of individuals appear to no longer exhibit symptoms of ADHD during adulthood.
What is considered the “gold standard” diagnostic tool for direct assessment of symptoms of autism spectrum disorders (ASD)?
Autism Diagnostic Observation Scale.
A patient with chronic schizophrenia has had five hospitalizations and three additional emergency room visits over the past year, mostly in the context of treatment nonadherence. She has a history of multiple medical problems requiring treatment by various specialty providers and has experienced difficulty in maintaining housing. Which of the treatment modalities is most appropriately suited to this patient?
Assertive community treatment
What has been found in neuroimaging studies of patients with schizophrenia?
The most reproducible findings are a slight overall decrease in brain volume and an increase in size of ventricles. Localized findings are less reproducible, but among the most robust are decreased size of the hippocampus, superior temporal lobe, prefrontal cortex, and thalamus. Many of these deficits are present at first psychotic break and in nonaffected relatives with high genetic risk for schizophrenia, suggesting that they contribute to susceptibility to disease rather than result from disease and treatment (Fornito et al. 2009; Vita et al. 2006).
A 19-year-old patient begins treatment following his first episode of psychosis. His parents ask about their son’s long-term prognosis. Which of the following prognostic statements about this patient would be most accurate?
One in five patients achieves sustained recovery. Ultimately, about one-third of patients achieve a relatively good outcome with only mild symptoms and functional impairments, with the remainder having moderate to severe symptoms and functional impairments.
According to historical evidence from before the antipsychotic era, which positive symptom is most common among individuals with schizophrenia?
Historical evidence (from before the antipsychotic era) shows that 91% of hospitalized patients had delusions (47% marked/severe), 87% had bizarre behavior (40% marked/severe), 66% had hallucinations (28% marked/severe), and 66% had thought disorder (8% marked/severe) (Fenton and McGlashan 1991).
What are risk factors for suicide among patients with schizophrenia?
Risk factors for suicide among people with schizophrenia include younger age, younger age at symptom onset, high premorbid functioning,high personal expectations, awareness that life’s expectations are unlikely to be met, awareness of symptoms (especially if aware of delusions, anhedonia, asociality, blunted affect), and a negative attitude toward or noncompliance with treatment.
Describe the stages of schizophrenia over the lifespan.
Premorbid, prodromal, progressive, and chronic-residual
stages. The progressive stage of schizophrenia can be said to begin when overt psychotic symptoms develop. Five to 10 years after entering the progressive stage of schizophrenia, patients typically enter what may be called the chronic-residual stage, which is characterized not by inexorable progression but rather by the persistence of residual symptoms and disability.
What is the relationship between primary and secondary negative symptoms in schizophrenia?
Secondary negative symptoms are caused by positive
symptoms. For example, a person who is socially withdrawn due to paranoia might increase social activities when less paranoid.
What nongenetic risk factor for developing schizophrenia has the highest OR?
Chronic psychostimulant use (OR=10) (MacDonald and Schulz 2009).
In what gender is Bipolar II disorder more common?
Women
Rank three mood stabilizers in highest to lowest propensity for weight gain?
Valproate > lithium > lamotrigine
What is the most common side effect of aripiprazole in adults?
Akathisia.
What would be the most likely diagnosis for a child presenting with persistent, chronic irritability and frequent episodes of extreme behavioral dyscontrol?
Disruptive mood dysregulation disorder (DMDD).
A 6-year-old girl with a chronic negative mood and frequent and severe verbal and behavioral outbursts in response to common stressors is most likely to go on to develop which disorder in adulthood?
Major depressive disorder.
What symptoms are less commonly associated with bereavement and can indicate a major depressive episode even in light of a significant loss?
feelings of worthlessness, suicidal ideation (distinct from wanting to join a deceased loved one), psychomotor retardation, and severe impairment in overall functioning
What diagnoses cannot co-exist with DMDD, according to Criterion J?
oppositional defiant disorder, IED, or bipolar disorder
What are atypical features of depression?
Hypersomnia is considered to be an atypical feature of depression, as is increased appetite, a heightened sensitivity to interpersonal rejection, and leaden paralysis. Mood reactivity, such as mood brightening in response to positive events, is also considered to be an atypical feature of depression.
What would be the most appropriate diagnosis for a child who has frequent temper outbursts but no evidence of persistent mood disruption between outbursts?
Intermittent explosive disorder (IED).
What is the lifetime prevalence of panic disorder in the U.S. general population?
3.8%.
What is the lifetime comorbidity of anxiety disorders with other mental disorders among adults in the U.S. population?
90%
According to twin studies, what is the estimated heritability of panic disorder?
40%.
Which brain structure is involved in the intense somatic sensations experienced by patients with panic disorder?
Insula.
What is the minimum duration of symptom persistence required for a diagnosis of generalized anxiety disorder (GAD)?
Six months.
What is an exposure technique used in the treatment of panic disorder?
Hyperventilation.
What is the best-established pharmacotherapy for treatment of specific phobia?
Benzodiazepines.
The efficacy of buspirone in the treatment of anxiety disorders is limited to which disorder?
Generalized anxiety disorder.
Which of the anxiety disorders has the youngest median age at onset?
Among the anxiety disorders, social anxiety disorder (social phobia) has the youngest median age at onset, at 15 years.
Which of the anxiety disorders has the lowest lifetime prevalence?
Among the anxiety disorders, agoraphobia has the lowest lifetime prevalence, at 2.5%.
Onset of worry, nervousness, tearfulness, and suicidal ideation in a previously healthy person most likely represents what?
Major depressive disorder (MDD).
Which of the anxiety disorders has the oldest median age at onset?
Among the anxiety disorders, generalized anxiety disorder has the oldest median age at onset, 30 years.
Behavioral treatment for obsessive-compulsive disorder (OCD) typically includes what?
Exposure and response prevention
Shortly after becoming ill with a respiratory infection, a 10-year-old boy begins to display symptoms of checking. What organism is most likely to be responsible for his infection and psychiatric symptoms?
Group A beta-hemolytic streptococcus (Streptococcus pyogenes). In PANS, children affected by streptococcus may exhibit obsessive compulsive and related symptoms that sometimes (but not always) resolve after effective treatment of the streptococcal infection. Studies have found that the basal ganglia must be affected by the infection in order for PANS to occur.
What is the approximate lifetime prevalence of obsessive-compulsive disorder (OCD) in the U.S. general population?
2.5%.
List some common compulsive behaviors.
Common compulsive behaviors include excessive
cleaning (e.g., hand washing), checking, ordering, rearranging, counting, repeating, and mental rituals.
Among individuals with obsessive-compulsive disorder (OCD), what is the most common comorbid psychiatric diagnosis?
Major depressive disorder.
What is the concordance rate of obsessive-compulsive disorder (OCD) in monozygotic twins?
A review of twin studies found that there is a strong heritable component to OCD, with concordance rates of 80–87% in monozygotic twins compared with 47%–50% in dizygotic twins (van Grootheest et al. 2005).
What neuroanatomical mechanisms is posited to be involved in the pathophysiology of obsessive-compulsive disorder (OCD)?
Hyperactivity in the ventral cognitive loop (orbitofrontal
cortex, caudate nucleus, dorsomedial thalamus).
People with body dysmorphic disorder (BDD) often seek care from practitioners of what medical specialty?
Many will seek care from dermatologists and/or cosmetic surgeons.
Findings from studies examining psychiatric comorbidity in individuals with body dysmorphic disorder (BDD) show that approximately what percentage will experience obsessive-compulsive disorder (OCD) at some point in life?
33%.
What is the most common psychiatric comorbidity with body dysmorphic disorder?
Major depressive disorder, with a lifetime prevalence of 75%, is the most common comorbid diagnosis.
Which psychotropic medication class can cause substance-induced obsessive-compulsive and related symptoms?
Atypical antipsychotics. The substances most commonly
reported as potentially causing obsessive-compulsive and related symptoms are the stimulants (including amphetamines and cocaine).
What is the first-line therapy for hoarding disorder?
Behavioral therapy is considered the first-line treatment
for hoarding disorder.
In which gender is skin picking disorder more prevalent?
Women
In a child with reactive attachment disorder (RAD), which area is least likely to improve with treatment?
Social development
What is the most replicated functional neuroimaging abnormality in posttraumatic stress disorder (PTSD)?
Hyporesponsivity of ventromedial prefrontal cortex.
What is the earliest developmental age at which reactive attachment disorder (RAD) may be diagnosed?
9 months
What is the only class of medication shown to be effective in reducing the full range of posttraumatic stress disorder (PTSD) symptoms?
Selective serotonin reuptake inhibitors (SSRIs).
