Psych Flashcards
A 27-year-old man with a history of panic disor-
der and generalized anxiety disorder is brought
to the emergency department after being found unconscious in his room by his parents.
He is lethargic and can barely be aroused. He nods “yes” when asked if he has had any alco-hol and “yes” when asked if he has taken any
pills. His parents are sure the only pills in the
house are those prescribed by his psychiatrist.
His vital signs are normal, and his pupils are
dilated to 2 mm and normally reactive. His
blood alcohol level is 100 mg/dL. Results of
the urine toxicology screen are pending. All of
a sudden, his breathing slows and his oxygen
saturation drops significantly. What should the
physician give to treat this patient’s condition?
(A) Benztropine
(B) Flucytosine
(C) Flumazenil
(D) Naloxone
(E) Naltrexone
The correct answer is C. This patient is ex-
hibiting symptoms of central nervous system
(CNS) depression that cannot be explained by his blood alcohol level alone (this level of CNS depression would typically be seen in a
nonchronic drinker at blood alcohol levels of 250-300 mg/dL). It is reasonable, based on his
psychiatric diagnoses, to think he may have ingested a benzodiazepine along with the alcohol, resulting in a synergistic effect. To reverse
the effect of the benzodiazepine, the drug of choice is flumazenil, a competitive GABA antagonist.
Answer A is incorrect. Benztropine is a centrally acting anticholinergic agent that acts as an acetylcholine receptor antagonist. It is used to treat parkinsonism as well as extrapyramidal
and dystonic reactions. It is not used to treat benzodiazepine overdose.
Answer B is incorrect. Flucytosine is a potent antifungal.
Answer D is incorrect. Naloxone is used to reverse opioid overdose.
Answer E is incorrect. Naltrexone, an opioid receptor antagonist, is used to treat opiate addiction.
. A 22-year-old man presents to his family physi-
cian with complaints of insomnia. He was re-
cently honorably discharged from the army af-
ter finishing an 18-month tour of duty in Iraq.
He states that the insomnia began about seven
months ago after a fierce night-time battle. He
reports having nightmares and flashbacks of
the battle and is easily startled by loud noises.
Which of the following pharmacologic agents, along with psychotherapy, would be most appropriate to treat this patient’s condition?
(A) Buspirone
(B) Carbamazepine
(C) Fluoxetine
(D) Propranolol
(E) Trazodone
The correct answer is C. This patient meets
the criteria for diagnosis of posttraumatic stress
disorder (PTSD). He has experienced an event that involved actual death of or threatened death to self or others; the traumatic event is persistently re-experienced through nightmares
and flashbacks; he suffers from insomnia; and he has an exaggerated startle response. Other
symptoms of PTSD include difficulty concentrating, hypervigilance, and dissociative symptoms. In PTSD, symptoms are present for longer than one month, whereas in acute stress
disorder, symptoms last between two days and one month.
Selective serotonin reuptake inhibitors such as fluoxetine are first-line medi-
cations for the treatment of PTSD. Side effects include nausea, headache, anxiety, agitation, insomnia, and sexual dysfunction.
Answer A is incorrect. Buspirone is a partial agonist at the 5-HT1S receptor that is com- monly used as an alternative to benzodiazepines in the treatment of generalized anxiety disorder. Although its onset of action is slower than that of benzodiazepines, it does not potentiate the CNS depression of alcohol, and has little potential for abuse and addiction.
Answer B is incorrect. Carbamazepine is an anticonvulsant medication that also can be used as a mood stabilizer in bipolar mood disorder.
Answer D is incorrect. Propranolol is a non- specific β-blocker. It is useful in the treatment of panic disorder and simple phobia.
Answer E is incorrect. Trazodone is a heterocyclic antidepressant with sedative qualities that is used in the treatment of depression complicated by insomnia. It works by inhibit- ing serotonin reuptake, but also acts as a partial serotonin agonist. Male patients should be warned of its potential to cause priapism.
A 42-year-old man presents to the local crisis
center requesting alcohol detoxification. He has a 20-year history of heavy drinking, with the longest period of abstinence being four months. His last drink was two nights ago, and he now complains of discomfort and anxiety.
Physical examination reveals coarse tremors, facial flushing, palmar erythema, and spider angiomas. His blood pressure is 145/95 mm Hg, his pulse is 115/min, and his temperature
is 38.3°C (100.9°F). Thiamine is adminis-tered. Which of the following drugs is indi-cated for the treatment of this patient’s condi-tion?
(A) Chlordiazepoxide (B) Disulfiram (C) Haloperidol (D) Methadone (E) Naltrexone
The correct answer is A. This patient is showing signs of alcohol withdrawal, manifested by tachycardia, fever, nausea, vomiting, tremors, and hypertension, and is at risk for delirium tremens. Delirium tremens is an extreme and life-threatening form of withdrawal characterized by perceptual disturbances and confusion. Intravenous benzodiazepines, such as chlordiazepoxide, are indicated in the treatment of both mild withdrawal and delirium tremens. Used early, they can prevent progression to withdrawal-induced seizures, psychosis, and coma. Chlordiazepoxide is a long-acting benzodiazepine that works via stimulation of GABA receptors. Other drugs in the same class include lorazepam, oxazepam, and diazepam, each of which could be used in this scenario.
Answer B is incorrect. Disulfiram inhibits ac- etaldehyde dehydrogenase, which causes ac- cumulation of acetaldehyde with ingestion of alcohol. This buildup of alcohol byproducts leads to extremely unpleasant adverse effects, including flushing, headache, diaphoresis, nausea, and vomiting. This drug is given to alcoholics to help them maintain sobriety.
Answer C is incorrect. Haloperidol is a typical antipsychotic. It can be used in patients withdrawing from alcohol who suffer psychotic symptoms such as hallucinations.
Answer D is incorrect. Methadone is a potent, long-acting opioid agonist used in the treatment of opioid addiction. This patient is an alcoholic and does not require a methadone taper.
Answer E is incorrect. Naltrexone is an opioid antagonist used to help maintain opioid sobriety. It also is used to help prevent alcohol relapses in alcohol dependence. This patient, however, requires acute care, not maintenance treatment.
A 24-year-old woman is brought to the emergency department by ambulance after she is found collapsed and unresponsive on the street. It is not known how long she was lying on the street. Physical examination reveals constricted pupils and a heart rate of 55. Administration of which of the following drugs would be most appropriate? (A) Chlordiazepoxide (B) Flumazenil (C) Fomepizole (D) N-acetylcysteine (E) Naloxone (F) Naltrexone (G) Phenobarbital
.The correct answer is E. This patient has signs
indicating opioid overdose: she is comatose with miosis and bradycardia. Naloxone, an opioid antagonist given intravenously, should quickly reverse the effects of the overdose.
Answer A is incorrect. Chlordiazepoxide is a long-acting benzodiazepine used in the man- agement of alcohol withdrawal. Though patients with alcohol intoxication can become unresponsive, alcohol tends to cause pupillary dilation, not constriction as seen with this patient. Additionally, there is no mention of the smell of alcohol on the patient’s breath or clothing, which can be a clue to alcohol intox- ication in an unresponsive patient.
Answer B is incorrect. Flumazenil is an an- tagonist at benzodiazepine receptors and is used to reverse benzodiazepine intoxication. Though benzodiazepines can cause pupillary changes, respiratory depression along with hypotension are more likely to be noted in a patient with overdose.
Answer C is incorrect. Fomepizole is an inhibitor of alcohol dehydrogenase, and is used to prevent the conversion of ethylene glycol and methanol to the toxic substances oxalic acid and formic acid, respectively. Thus it is mainly used as an antidote for methanol or ethylene glycol poisoning. There is no evi-
dence that this patient ingested methanol or
ethylene glycol.
Answer D is incorrect. N-acetylcysteine is used in cases of acetaminophen poisoning. It also has an indication for relieving mucus
thickening in cystic fibrosis patients.
Answer F is incorrect. Naltrexone, like naloxone, is an opioid receptor antagonist; however,
it is not indicated for reversal of acute opioid overdose. Naltrexone is more commonly used to treat alcohol and opioid dependence.
Answer G is incorrect. Phenobarbital is a long-acting barbiturate useful in patients with
seizure disorders.
- After several failed trials of various antipsychotic drugs, a 46-year-old woman is switched
to a new medication for her schizophrenia. However, a few weeks later, she develops pneumonia. A complete blood count is or-
dered and reveals a significantly reduced number of neutrophils, basophils, and eosinophils.
Which of the following agents is the most likely cause of this clinical picture?
(A) Chlorpromazine
(B) Clozapine
(C) Haloperidol
(D) Risperidone
(E) Thioridazine
Clozapine is an
atypical antipsychotic used to treat schizophrenia that is refractory to traditional therapy. It is considered atypical because it blocks serotonin receptors, in addition to the dopamine blockade common to all typical antipsychotics. This dual action may be useful in the treatment of the positive and negative symptoms of schizo- phrenia. Perhaps the most dangerous adverse effect of clozapine is bone marrow suppression, specifically agranulocytosis. This neces- sitates frequent monitoring of the WBC count for all patients who are started on this drug. A sudden increase in infections or bouts of ill- ness in a patient on clozapine should raise concern about the development of agranulocytosis. If laboratory tests indicate this is the case, the drug must be discontinued immediately and the patient should be monitored carefully.
Answer A is incorrect. Chlorpromazine, a traditional antipsychotic, has a adverse-effect profile similar to that of haloperidol. Agranulocy- tosis can occur with its use, but occurs much more commonly as an adverse effect of clozapine.
Answer C is incorrect. Haloperidol is a tradi- tional antipsychotic that acts by blocking do- pamine receptors and is not associated with agranulocytosis. It is best known for causing extrapyramidal adverse effects.
Answer D is incorrect. Risperidone, another atypical antipsychotic agent, has a mechanism of action similar to that of clozapine. It does not, however, produce the adverse effect of agranulocytosis. Significant adverse effects of risperidone include QT-interval prolongation and metabolic aberrations.
Answer E is incorrect. Thioridazine is a traditional antipsychotic that has an adverse-effect profile similar to that of haloperidol and chlorpromazine. Although agranulocytosis is pos-
sible, it is much less frequent than with clozapine.
A 60-year-old African-American man has been
reclusive, rarely leaving his home for the past
40 years. His family describes him as an emo-tionally cold person with few friends. Growing up, he preferred solitary activities like reading to engaging in activities with others. Members of his church have delivered groceries to his front door once a week for the past 20 years, but he never opens the door to greet them.
Which of the following is the most likely diag-nosis?
(A) Avoidant personality disorder
(B) Paranoid personality disorder
(C) Schizoid personality disorder
(D) Schizophrenia
(E) Schizophreniform disorder
(F) Schizotypal personality disorder
The correct answer is C. This man has schizoid personality disorder, marked by a lifelong pattern of social withdrawal. Patients with this disorder experience discomfort with human interaction, so they avoid close relationships, and engage in solitary activities. These patients often are viewed as eccentric, isolated, lonely, and emotionally cold. Unlike those with other cluster A personality disorders, which are schizotypal and paranoid, those with *schizoid personality disorder are not more likely to have relatives with schizophrenia. Men are twice as likely as women to be affected.
Answer A is incorrect. Avoidant patients are like schizoid patients in their pervasive pattern of social inhibition. However, they do desire companionship; an intense fear of rejection leads to avoiding any situation where there is a perceived risk of rejection. Think avoidant personality disorder in patients inhibited by feel- ings of inadequacy and social ineptness to the extent they will participate socially only when they are certain to be liked.
Answer B is incorrect. Patients with paranoid personality disorder tend to be more socially engaged than those with schizoid personality disorder, even though they have a lifelong history of suspiciousness and mistrust of other people. Examples include recurrent suspicion of a sexual partner’s fidelity or blaming others for their problems.
Answer D is incorrect. Patients with
schizophrenia exhibit a formal thought disorder with hallucinations, or delusional thinking. In contrast, patients with schizoid personality disorder have intact reality testing.
Answer E is incorrect. Schizophreniform disorder is identical to schizophrenia except that symptoms last for at least one month but less than six months. Patients with schizophreniform disorder have a better prognosis than do most patients with schizophrenia, and may return to their baseline mental functioning.
Answer F is incorrect. Schizotypal and schizoid personality disorder are rather similar, but the former is distinguished in that these patients tend to be more similar to schizophrenics. Patients with schizotypal disorder are strikingly odd, with peculiar notions, ideas of reference, illusions, magical thinking, and derealization.
A 27-year-old man is brought to the emer-
gency department by ambulance. Paramedics
report that he was found sitting on the sidewalk speaking as though engaged in a heated argument, but nobody else was around. They say that the patient appeared to be in distress
and that he was quite disheveled. The man is evaluated by a psychiatrist, admitted to the hospital, and started on a medication to treat his
symptoms. Two days later a medical student notices that the patient has painful spasms in his neck muscles. Which of the following is
the most appropriate treatment for this man’s condition?
(A) Benztropine
(B) Dantrolene
(C) Diazepam
(D) Fluphenazine
(E) Prochlorperazine
EPS
The correct answer is A. The patient has classic signs of schizophrenia and was likely given haloperidol, a typical antipsychotic agent that acts by blocking dopamine receptors. Haloperidol has a high affinity for the D2- dopaminergic receptor. The patient is experiencing an acute dystonic reaction soon after receiving the medication. The painful muscle spasm of the neck is known as torticollis. This acute extrapyramidal adverse effect is the result of unopposed cholinergic activity in the CNS following blockade of dopaminergic transmission. The treatment for this adverse effect is initiation of an anticholinergic agent such as benztropine.
Answer B is incorrect. Dantrolene is effective in the treatment of neuroleptic malignant syndrome. Dantrolene acts by preventing the re- lease of calcium from the endoplasmic reticulum.
Answer C is incorrect. Diazepam can be used as an hypnotic, a sedative, an anticonvulsant, and a muscle relaxant. As a muscle relaxant, diazepam is used to treat chorea, an involuntary abnormal movement disorder or dyskinesia that is a hallmark of Huntington disease.
Answer D is incorrect. Fluphenazine, like haloperidol, can induce potent D2-dopaminergic receptor blockade. It is a high-potency typical antipsychotic that is sometimes used as an al-
ternative to haloperidol for patients suffering from schizophrenia or bipolar disorder. Admin-
istration of fluphenazine will likely exacerbate this patient’s symptoms rather than alleviate them.
Answer E is incorrect. Prochlorperazine is a typical antipsychotic agent with potent antidopaminergic effects. It can also be used to treat nausea because of its weak anticholinergic and antihistaminic effects. In this case it would be of no benefit for the patient, and could make his symptoms worse.
A 19-year-old man is brought to the emergency
department by his friends after suffering a seizure. He is sweating, paranoid, tachycardic, and his pupils are dilated. His friends say that he has a history of using illicit drugs. What is the mechanism of action of the drug that is causing the patient’s symptoms?
(A) Blocks NMDA receptors
(B) Increases GABA activity by increasing the duration of chloride channel opening
(C) Prevents reuptake of norepinephrine, do-pamine, and serotonin by presynaptic pumps
(D) Prevents the fusion of the presynaptic vesi- cle with the presynaptic surface membrane
(E) Prevents the uptake of acetylcholine at cholinergic synapses
The correct answer is C. The patient’s symp-
toms are caused by cocaine. Cocaine prevents the reuptake of norepinephrine, dopa-
mine, and serotonin by presynaptic transporter pumps in the central and peripheral nervous systems.
Answer A is incorrect. Phencyclidine causes aggressive and impulsive behavior, nystagmus, and tachycardia. It acts as an NMDA receptor antagonist.
Answer B is incorrect. Barbiturates cause res piratory depression and act by increasing GABA activity by increasing the duration of chloride channel opening.
Answer D is incorrect. Bretylium and guanethidine prevent the fusion of presynaptic vesicles with the presynaptic membrane, resulting in an inhibition of the release of norepineph-
rine into the synapse.
Answer E is incorrect. Cocaine works on noradrenergic neurons; it does not work on cholinergic neurons.
A 45-year-old man who has received long-term
treatment for schizophrenia recently has been
displaying involuntary facial movements that include lateral deviations of the jaw and “fly catching” motions of the tongue. Which of the following agents is the most likely cause of his involuntary movements?
(A) Clozapine
(B) Fluphenazine
(C) Lithium
(D) Selegiline
(E) Ziprasidone
The correct answer is B. This patient is displaying signs of tardive dyskinesia, a complication of long-term antipsychotic use thought to be the result of increased dopamine recep- tor synthesis in response to long-term receptor blockade by antipsychotics. Abnormal movements such as tongue-thrusting and jaw deviations, as seen in this patient, are the result of relative dopamine excess affecting motor path- ways. This complication is encountered more commonly with use of older, typical antipsychotic medications such as fluphenazine and haloperidol.
Answer A is incorrect. Clozapine, an atypical antipsychotic that modulates both serotonin- ergic and dopaminergic neurons in the CNS, has a relatively low risk of inducing tardive dyskinesia. The most concerning adverse effect of clozapine is agranulocytosis, which can be fa- tal if left untreated.
Answer C is incorrect. Lithium is a mood stabilizer that is used primarily to treat episodes of mania in patients with bipolar disorder. Adverse effects of lithium include nephrogenic diabetes insipidus, nausea, anorexia, and mild diarrhea.
Answer D is incorrect. Selegiline is a monoamine oxidase B inhibitor that is used to treat Parkinson disease by decreasing the breakdown of dopamine. It has no role in the treatment of schizophrenia. Selegiline has the opposite effect of antipsychotics; it blocks the effects of dopamine. Adverse effects of selegiline include gastrointestinal (GI) upset, nausea, heartburn, and dry mouth.
Answer E is incorrect. Ziprasidone, like clo- zapine, is an atypical antipsychotic and has a lower incidence of tardive dyskinesia when compared to typical antipsychotics. More often than other atypical antipsychotics, it has been associated with QT prolongation and the risk of malignant ventricular arrhythmias.
A 28-year-old man who has been experienc-
ing delusions, hallucinations, and thought disorders for the past six months now begins to display flattening affect, lack of motivation, and social withdrawal. Which of the following
agents would address his newest symptoms?
(A) Olanzapine
(B) Haloperidol
(C) Lithium
(D) Fluphenazine
(E) Phenelzine
The correct answer is A. Olanzapine is an atypical antipsychotic that blocks both serotonin and dopamine receptors. Drugs in this class are noted for their ability to treat both positive symptoms of schizophrenia (ie, hal- lucinations and delusions) and negative symp- toms (ie, blunted affect and social withdrawal). With the onset of negative symptoms, addition of an atypical antipsychotic such as olanzap- ine, can effectively treat both positive and negative symptoms of this disorder. Answer B is incorrect. Haloperidol, another typical agent, would be less effective at mitigat-
ing the patient’s negative symptoms compared to olanzapine.
Answer C is incorrect. Lithium is a mood stabilizer that is used to treat the acute manic phases of bipolar disorder. It is not used in the treatment of schizophrenia and thus would have no effect on this patient’s negative symptoms.
Answer D is incorrect. Fluphenazine is a typical antipsychotic that blocks only dopamine receptors. Agents in this class are more effective at mitigating positive symptoms of schizophrenia, but are less effective at relieving the negative symptoms such as flattened affect and
catatonia.
Answer E is incorrect. Phenelzine, a monoamine oxidase (MAO) inhibitor, is used to treat depression in patients who are unresponsive to tricyclic antidepressants or who experience concomitant anxiety. Such agents are not used to treat schizophrenia.
. A 35-year-old man with depression has been treated with medication for the past seven years. Recently he began seeing a new psy-chiatrist who suggested changing this medica-tion to a newer class of antidepressants that has proven effective for many of her patients. Two weeks later he presents to the emergency de-partment because of flushing, diarrhea, sweat-ing, and muscle rigidity. During the physicalexamination, he admits that he was a bit suspicious of the new medication he was givento treat his depression since he was told he no longer needed to avoid certain foods. He decided to use both medicines just to “make sure” the new one was working. Which of the following medications did the new doctor most likely prescribe for this patient?
The correct answer is D. This patient has
likely been taking a MAO inhibitor for the past seven years since he was told he had to avoid certain foods. Sertraline is a selective serotonin reuptake inhibitor (SSRI) that can lead to serotonin syndrome when taken in con- junction with MAO inhibitors. Serotonin syn- drome is the result of excess serotonin in the nervous system and is characterized by mental status changes, autonomic changes (eg, fever, diaphoresis, tachycardia), and neuromuscular changes (eg, tremor or rigidity). The treatment of serotonin syndrome consists of prompt dis- continuation of the implicated agent(s) and supportive care including intravenous fluids, benzodiazepines for control of delirium, cool- ing measure for hyperthermia, and neuromus- cular blockers such as dantrolene for hyper- thermia, muscle rigidity, and the prevention of rhabdomyolysis.
Answer A is incorrect. Lithium is typically used to treat bipolar disorder. Its use has been associated with tremor, hypothyroidism, and nephrogenic diabetes insipidus. While lithium is considered an effective adjunctive therapy for depression in combination with a second antidepressant, lithium prescribed as monotherapy for depression is not recommended.
Answer B is incorrect. Nortriptyline is a tricyclic antidepressant associated with the “3 Cs:” Convulsions, Coma, and Cardiotoxicity (conduction defects and arrhythmias). Tricyclic antidepressants primarily have anticholinergic adverse effects as well, including dry mouth, mydriasis, constipation, and urinary retention.
Answer C is incorrect. Phenelzine is an MAO inhibitor. There is no evidence that two MAO inhibitors lead to serotonin syndrome when taken together. Adverse effects of phenelzine include postural hypotension, headache, dry mouth, sexual dysfunction, weight gain, and sleep disturbances.
Answer E is incorrect. Trazodone is a heterocyclic associated with sedation, nausea, pria pism, and postural hypotension.
A 20-year-old man is seen by a physician for
the third time in three months. At the first
visit he was brought to the emergency depart-
ment by his mother after swallowing toilet
bowl cleaner. He told the doctor that he took
the cleaning product to “cleanse his body from
the aliens” that had “forced their entry” and
“possessed” him. Today the patient appears un-
clean and disheveled, and his mother reports
that he has become progressively withdrawn
and expressionless. Four months ago the pa-tient witnessed the gruesome death of his fa-ther in a drive-by shooting incident. Prior to this incident, he had a normal and healthy life.
Which of the following is the most likely diag-nosis?
A) Factitious disorder
(B) Schizophreniform disorder
(C) Schizophrenia
(D) Schizoaffective disorder
(E) Shared delusional disorder
The correct answer is B. Over the course of
two visits, the patient has exhibited psychotic and residual symptoms characteristic of schizophrenia and related disorders. A diagnosis of schizophrenia, however, requires active phase (“positive”) symptoms, and may include “nega- tive” ones as well, over a period of >6 months. In this case, the patient’s symptoms have lasted <4 months, and were potentially incited by a traumatic event and its repercussions. If the symptoms had lasted <1 month, a diagnosis of brief psychotic disorder would be accurate; in such a diagnosis, most patients make a full recovery. In this patient, symptoms with a du- ration of >1 month but <6 months yield a di- agnosis of schizophreniform disorder. Negative symptoms, as seen here, worsen the prognosis of a patient with schizophreniform disorder.
Answer A is incorrect. There is no evidence that either the patient or his mother is actively seeking the attention of medical personnel, or that the symptoms experienced were falsified for secondary gain of tangible items such as food, shelter, or money, as would be the case in malingering.
Answer D is incorrect. The diagnosis of a schizoaffective disorder requires the symptoms of schizophrenia (often both “positive” and “negative” symptoms) as well as those of a mood disorder (ie, depression, mania). These patients typically have less cognitive impairment than those with strict psychotic disorders.
Answer E is incorrect. Delusions are fixed, false beliefs or ideas by a patient that are not shared by other individuals. Delusional disorder refers to a pathologic state whereby construct(s) of delusions impair one’s social and/or cognitive functioning. Shared delusions
are those transmitted from one person to an-
other in a parent-to-child or spouse-to-spouse relationship. There is no evidence presented that the patient’s mother shares the false beliefs
of her son.
A 43-year-old woman comes to the clinic with
complaints of pruritus and burning of both forearms that initially looked like sunburn. On physical examination the affected skin appears thickened and hyperpigmented. A similar le-
sion is seen on the neck. The patient states that she has recently began to have diarrhea, and at times during the interview she forgets what she was saying. For the past six months she has been following a new low-calorie fad diet. A defect in the absorption of which amino acid would cause similar symptoms?
(A) Arginine
(B) Histidine
(C) Phenylalanine
(D) Tryptophan
(E) Tyrosine
The correct answer is D. The patient has pellagra due to niacin (vitamin B3) deficiency. Niacin is found in unrefined and enriched grains, cereal, milk, and lean meats. Niacin is required for adequate cellular function and metabolism as an essential component of nicotinamide adenine dinucleotide and nico- tinamide adenine dinucleotide phosphate. Because cellular functions in multiple organs and tissues are impacted by niacin deficiency, there is a systemic clinical expression of pel- lagra involving the skin, GI tract, and CNS. The symptoms of pellagra progress through the 3 D’s: Dermatitis, Diarrhea, and Dementia. If untreated, it can result in the fourth D: Death. Pellagra is Italian for thickened skin, and it is usually seen in sun-exposed areas of the body. Since niacin is derived from tryptophan, a decrease in tryptophan absorption or an increase in tryptophan metabolism can produce similar symptoms.
Answer A is incorrect. Arginine is a precursor of creatine, urea, and nitric oxide.
Answer B is incorrect. Histidine is a precursor of histamine.
Answer C is incorrect. Phenylalanine is a pre-cursor of tyrosine, dopamine, norepinephrine, and epinephrine.
Answer E is incorrect. Tyrosine is a precursor of dopamine, norepinephrine, and epineph-
rine.
. A 28-year-old woman presents to her primary care provider complaining of difficulty sleeping. Although she reports trouble falling asleep despite waking up “before the sun” every morning, her major complaint is awaken-ing from sleep multiple times each night. She also complains of decreased energy and moti-vation to complete tasks at work. Polysomnog- raphy reveals >25% of total sleep time is spent in REM sleep and <25% of total sleep time is spent in stages 3 and 4 sleep. Which of the fol-
lowing is the most appropriate treatment?
A) Avoidance of caffeine
(B) Continuous positive airway pressure
(C) Fluoxetine
(D) Methylphenidate
(E) No intervention is necessary; these are nor-mal polysomnographic findings in a young adult
The correct answer is C. Depression is often
associated with disrupted sleep. Specifically, sleep studies performed in patients with de- pression reveal increased time spent in REM sleep, decreased REM latency, and decreased delta waves, which are characteristic of stages 3 and 4 sleep. Patients with depression often experience decreased daytime energy and motivation to complete tasks; these are com- monly misdiagnosed as side effects of poor sleep rather than warning signs of depression. Fluoxetine, an SSRI, is an appropriate first-line agent for patients with depression. This pro- vider should also consider referral to a psychi- atrist for management of this patient’s depres- sion.
Answer D is incorrect. Methylphenidate is used to treat narcolepsy, or sudden sleep at- tacks during the day despite normal nighttime sleep.
Answer E is incorrect. Normal sleep patterns in young adults include 25% of total sleep time spent in REM sleep and 25% of total sleep time is spent in delta wave (stages 3 and 4) sleep.
A 23-year-old man is brought to the emergency
department because his friends heard him say
that he was talking to president Kennedy about
a secret spy mission in the Soviet Union. He
appears quite anxious, agitated, and restless.
Physical examination reveals dilated pupils.
His pulse is 80/min and his blood pressure is 120/80 mm Hg. What is the most likely cause of his symptoms?
(A) Alcohol
(B) Cocaine
(C) Lysergic acid diethylamide
(D) Marijuana
(E) Phencyclidine
The correct answer is C. This patient is expe-
riencing hallucinations, delusions, and dilated pupils, but very few observable behavioral changes. These are symptoms consistent with lysergic acid diethylamide (LSD) abuse. LSD is a hallucinogenic drug that can cause marked anxiety, depression, nausea, weakness, and paresthesias.
Answer A is incorrect. Alcohol abuse is characterized by a general disinhibition, slurred speech, and ataxia. It does not usually cause patients to hallucinate or become delusional.
Benzodiazepines can be used to prevent delirium tremens and other signs of alcohol withdrawal.
Answer B is incorrect. Cocaine can cause many of the symptoms this patient is experiencing. However, patients with recent cocaine use are usually hypertensive and tachycardic because of its stimulant effects.
Answer D is incorrect. Marijuana can cause many of the symptoms this patient is experiencing. However, patients with recent marijuana use usually have an increase in appetite and dry mouth as well.
Answer E is incorrect. Phencyclidine is a hallucinogenic drug that is often associated with belligerence and acting out impulsively.
The parents of an 8-year-old boy bring him to see a psychiatrist because they are frustrated with his behavior. In the last two years he has become increasingly restless and moody, interrupts other children in the classroom, and often runs into the street without looking out for cars first. The psychiatrist prescribes a medication that works through which of the following
mechanisms?
(A) Increases release of norepinephrine
(B) Inhibits acetylcholine activity
(C) Inhibits reuptake of serotonin
(D) Stimulates dopamine receptors
(E) Stimulates serotonin receptors
The correct answer is A. The boy exhibits the
characteristic emotional lability and impulsiv ity seen in patients with attention deficit/hyper- activity disorder (ADHD). Methylphenidate is a first-line treatment for ADHD. It works simi- larly to amphetamines by increasing the presynaptic release of norepinephrine.
Answer B is incorrect. Antimuscarinic drugs like benztropine can be used in conjunction with typical antipsychotics in the treatment of schizophrenia to alleviate extrapyramidal symptoms. Answer C is incorrect. Selective serotonin reuptake inhibitors can be used to treat depresssion, anxiety, and obsessive-compulsive disorder.
Answer D is incorrect. Drugs that stimulate dopamine receptors are used in the treatment of Parkinson disease.
Answer E is incorrect. Buspirone is a serotonin receptor agonist that is used in the treatment of anxiety.
A 15-year-old girl is brought to the emergency
department by her mother after experiencing a first-time seizure. The thin-appearing girl has a heart rate of 55/min, signs suggestive of dehydration, and fine, velvety hair covering her arms and legs. The physician calculates her body mass index to be 16.4 kg/m². When the patient’s mother leaves the room for a moment, the patient admits to the physician that she has been feeling depressed recently and that for the past week she has been self-
medicating with normal daily doses of one of her friend’s antidepressant medications. What
antidepressant is the patient most likely taking?
(A) Amitriptyline
(B) Bupropion
(C) Fluoxetine
(D) Mirtazapine
(E) Selegiline
The correct answer is B. This patient has
physical signs consistent with anorexia nervosa, most notably a low body mass index, bradycar- dia, evidence of hypotension, fine body hair (called lanugo), and concomitant depression. Anorexia nervosa is a serious condition that re- quires intensive mental health care, as well as close medical monitoring of weight, electrolyte levels, and hydration status. The mainstay of therapy is a combination of cognitive behavioral therapy and SSRIs. Use of the antidepressant bupropion is contraindicated in patients with anorexia nervosa because it increases the risk of seizure in this population.
Answer C is incorrect. Fluoxetine is an SSRI most commonly used as an antidepressant. It has also been used to treat anorexia nervosa, although with questionable efficacy. SSRIs are not known to increase the risk of seizure in an- orexic patients.
Answer D is incorrect. Mirtazapine in an atypical antidepressant that induces weight gain, which may be beneficial in patients with weight control issues, although this has not yet been studied rigorously. Mirtazapine is not known to increase the risk of seizure in an- orexic patients.
Answer E is incorrect. Selegiline is a MAO in- hibitor most commonly used as an antidepressant; it is not typically used to manage anorexia nervosa. MAO inhibitors are not known to in- crease the risk of seizure in anorexic patients.
The image depicts a biochemical pathway oc-
curring in the nervous system. An “X” marks
the effect of a certain class of medications on
this pathway. For which condition is this class of medications an effective first-line treatment?
(basically the image is showing a block in serotonin reuptake)
(A) Bipolar disorder (B) Delerium tremens (C) Dissociative identity disorder (D) Obsessive-compulsive disorder (E) Schizophrenia
The correct answer is D. SSRIs block the
reuptake of serotonin (5-hydroxytryptamine [5-HT]) by the serotonin transport protein (STP) in presynaptic neurons; the result is an effective increase in serotonin within the synaptic space. SSRIs act at the “X” in the image by inhibiting the binding of 5-HT to STP. SSRIs have demonstrated efficacy for numerous medical and psychiatric conditions, most notably depression, anxiety, obsessive-compulsive dis-
order, and eating disorders.
Answer A is incorrect. SSRIs are not first-line treatment for bipolar disorder; a mood stabilizing agent (eg, lithium or valproic acid) would be the treatment of choice.
Answer B is incorrect. SSRIs are not first-line treatment for delirium tremens; a long-acting benzodiazepine (eg, chlordiazepoxide) would be the treatment of choice.
Answer C is incorrect. SSRIs are not first-line treatment for multiple personality disorder; an antipsychotic (eg, haloperidol or risperidone) would be the treatment of choice.
Answer E is incorrect. SSRIs are not first-line treatment for schizophrenia; an antipsychotic (eg, haloperidol or risperidone) would be the treatment of choice.
- An 18-year-old woman complains of weakness,
fatigue, decreased appetite, and insomnia over
the past month. She is no longer interested in her favorite activities, and has been unable to concentrate in school. She also reports feel-
ing guilty about not hanging out with her friends even though they ask her out almost every weekend. As part of her treatment plan, her physician prescribes a medication. On
a follow-up visit, she reports that her mood has improved, but she now feels that her face flushes more frequently and she is more sensi-tive to the hot weather outside. She is also wor-
ried that at times she feels like her heart is racing. On further questioning, she admits to some
constipation. Which of the following drugs was most likely prescribed for this patient?
(A) Amitriptyline
(B) Clonazepam
(C) Lithium
(D) Sertraline
(E) Venlafaxine
The correct answer is A. This patient is being
treated for depression. Amitriptyline, a tricyclic anti-depressant, is as effective as the selective serotonin reuptake inhibitors, but often is not prescribed as a first-line agent because of its many adverse effects. These include sedation, α-blocking effects, and, most commonly, ANTICHOLINERGIC effects such as dry mouth, blurry vision, tachycardia, urinary retention, constipation, confusion, and dry, hot skin. These adverse effects can be remembered with the following: red as a beet (flushing), dry as a bone (anhidrosis), hot as a hare (overheating secondary to anhidrosis), blind as a bat (blurry vision), mad as a hatter (hallucinations or de- lirium), and full as a flask (urinary retention).
Of note, MAO inhibitors, another class of antidepressants, do not have anticholinergic properties, but can cause adverse effects similar to
those of anticholinergic medications, including dry mouth and urinary retention. MAO inhibitors often are associated with tyramine crises on the USMLE exam, especially when the patient described has consumed tannin-rich foods, such as red wines and aged cheeses.
Answer B is incorrect. Clonazepam is a benzodiazepine sometimes prescribed as an anxiolytic at the initiation of anti-depressant therapy.
The most commonly reported adverse effects are those associated with CNS depression, such as sedation or respiratory depression at higher doses. Dependence and rebound anxi-
ety can result from benzodiazepine abuse.
Answer C is incorrect. Lithium is a mood stabilizer used to treat bipolar affective disorder.
It indirectly inhibits the reuptake of serotonin and norepinephrine by inhibiting the phosphatidylinositol second messenger system. Adverse effects include CNS depression, diz-
ziness, nephrogenic diabetes insipidus, acne, edema, and hypothyroidism, as well as many others.
Answer D is incorrect. Sertraline and other SSRIs are associated with adverse effects related to CNS stimulation such as headache, anxiety, tremor, insomnia, anorexia, nausea, and vomiting. Weight gain and sexual dysfunction are also frequently reported with SSRI use.
Answer E is incorrect. Venlafaxine is a serotonin/norepinephrine reuptake inhibitor. It has adverse effects similar to those of selective
serotonin reuptake inhibitors, plus additional adverse effects due to the norepinephrine, such as dizziness and diaphoresis. Venlafaxine
is also known to cause hypertension.
A 20-year-old woman is brought to the emer- gency department by her roommate because she was “walking funny,” had difficulty breathing, and slurred her speech. She was recently diagnosed and given medication for panic disorder. Her blood pressure is 110/75 mm Hg, pulse is 58/min, and respiratory rate is 8/min.
She is afebrile. Her mucous membranes are moist and pupil size is normal. Serum laboratory studies are negative for evidence of ethanol, organophosphate, or opioid ingestion. The agent that would be used to reverse the effects of the patient’s anxiety medication works by which of the following mechanisms?
(A) Activating an enzyme responsible for the termination of a drug’s inactivation
(B) Amplifying the effect of an endogenous neurotransmitter by inhibiting its breakdown
(C) Displacement of the drug from its binding site
(D) Inhibiting the formation of a toxic metabolites
(E) Inhibiting the storage of a neurotransmitter
The correct answer is C. This patient has evidence of benzodiazepine intoxication. This is the most likely scenario given her recent diagnosis and treatment for panic disorder, in addition to the exclusion of other causes with similar presentations. Benzodiazepines are relatively safe in overdose; however, shorter-acting benzodiazepines such as temazepam, triazolam, and alprazolam pose a greater risk for morbidity and mortality. Competitive antagonists work by displacing a drug from its binding site. Flumazenil is a competitive antagonist that can be used in the case of benzodiazepine overdose, and naloxone is a competitive antagonist that is used to reverse symptoms of opiate overdose. When using flu- mazenil, be aware that rapid reversal of benzodiazepine overdose may lead to rebound seizure activity. In clinical practice flumazenil is rarely used except in children.
Answer A is incorrect. Pralidoxime, a cholinesterase regenerator, is indicated in cases of organophosphate poisoning. Organophosphates such as parathion and malathion are indirect- acting cholinomimetics that inhibit acetylcholinesterase by forming a very stable bond with it. This results in general cholinergic CNS stimulation (incontinence, bronchoconstriction, miosis, and bradycardia). Pralidoxime has a greater affinity for binding to organophosphates than acetylcholinesterase. As such, it is thought of as an organophosphate “chemical antagonist.”
Answer B is incorrect. Physostigmine is an indirect-acting cholinomimetic that inhibits the action of acetylcholinesterase, thereby am- plifying the effect of endogenous acetylcholine. It is indicated in cases of anticholinergic (but not tricyclic) poisoning, which would present with the classic picture described by the mne- monic “red as a beet, blind as a bat, mad as a hatter, dry as a bone, and hot as a hare.” One would expect fever, flushing, delirium, dry mu- cous membranes, and miosis on physical exam.
Answer D is incorrect. Ethanol is indicated in cases of toxic alcohol ingestion (eg, metha- nol or ethylene glycol). Toxic metabolites are formed when alcohol dehydrogenase metabo- lizes methanol or ethylene glycol. Ethanol works by inhibiting the formation of these harmful substances by competing for binding sites on alcohol dehydrogenase.
Answer E is incorrect. Reserpine inhibits the storage of norepinephrine in adrenergic nerve terminals, thereby depleting the neuron of its stores. It has been classified as a postganglionic sympathetic nerve terminal blocker, and is rarely used as an antihypertensive medication.
your grave is DUG
The classic triad of normal pressure hydrocephalus, note that there is no headache.
Dementia (of varying degrees):
Urinary incontinence: May present as urgency, frequency, or a diminished awareness of the need to urinate.
Gait disturbance: Usually the first symptom; magnetic gait.
A 22-year-old graduate student presents to University Counseling Services for anxiety. She worries often about her schoolwork, her future, her family, and relationship issues. She feels tense, has difficulty concentrating, has frequent headaches, and has been sleeping poorly. She has felt this way most of the day, most days of the week over the past year. She thought this was normal considering the amount of stress in her life, but is now concerned that she is getting “too edgy” with her friends and is inadvertently pushing them away.
Generalized anxiety disorder
A 20-year-old man presents to the emergency room via ambulance with shortness of breath, sudden onset of chest pain, and anxiety starting about 15 minutes ago. He says, “Help me! I’m going to die!” Examination reveals an elevated pulse rate and blood pressure, diaphoresis and facial flushing. EKG shows sinus tachycardia. You administer 1 milligram of lorazepam intramuscularly. Vital signs stabilize and he is asymptomatic within 15 minutes. He then tells you that he has been having these spells several times a month, and they happen without warning.
Panic Attack (possibly panic disorder)
You are considering referring a 35-year-old man with an anxiety problem to a psychiatrist after the patient failed a trial of Prozac 20 mg per day. His symptoms strike you as peculiar: whenever he is driving and hits a pothole or a branch, he worries that he ran someone over. He knows this makes no sense, and he has never been in an accident with bodily injury before, but he feels overwhelming anxiety unless he circles around the block, sometimes two or three times, to verify that nobody was injured.
OCD
You are working in an outpatient primary care clinic. A 31-year- old woman presents with “depression” since a motor vehicle accident six months ago. She was the driver and survived, but her eight-year-old son, who was unbuckled, was seriously injured. She has not driven since the accident and finds no enjoyment in her activities. She thinks about the crash several times a day and has nightmares at least twice a week about losing her son. She thinks that her “nerves are shot” because she is easily startled. She has started to drink two to four glasses of wine after dinner.
PTSD
A 34-year-old woman had been involved in a car accident that did not necessitate hospitalization. Following the accident she experienced episodic headaches, dizziness, neck pain, and upper back pain. Over the past five years, her condition worsens and she is evaluated by two neurologists, a “neuro- opthalmologist”, a physiatrist, an endocrinologist, and a psychiatric pain specialist. Once she was diagnosed with epilepsy based on minor EEG abnormalities. She required an admission to the ICU for a severe allergic reaction to an anti- epileptic medication. Her symptoms and functional limitations did not resolve when her personal injury case was settled.
Somatic Symptom disorder = you have symptoms that are extremely bothersome, disproportionate to how they feel about it.
A 25-year-old man is brought into the emergency room by police after he knocked on the window of the police cruiser and threatened to kill himself. He looks ill and distressed. He tells you that he had been feeling depressed for the last two weeks. He has had poor energy, difficulty concentrating, poor appetite, “no sleep,” and thoughts to “end it all.” He confides that he plans to overdose on heroin. On review of symptoms he has runny nose, cough, stomach cramping, diarrhea, and cold intolerance. His blood pressure is 165/100 and pulse is 104. He has multiple tattoos and “goose-pimples” on his skin. He has a coarse tremor visible on his tongue and in his arms when they are outstretched. As you conclude your evaluation, he asks, “Hey, are you going to give me something?”
Opiate withdrawal
- malingering suicidality
- alcohol is another worry, major depression is possible but active use of substances is not a good time to diagnose that.
Course tremor shows he is in acute alcohol withdrawal, if you don’t notice that he can seize and die. The main motivation is to get treatment for substance use disorder. It is important to look past the malingering
A 28 yo married woman, who works as a second year resident is high achieving and can be quite self critical. In the last month, the patient has felt increasingly fatigued with difficulty concentrating. On the floors she is noted to be quite irritable at times. She has come to feel guilty that she can’t perform at work up to her standards. She is waking up by 4:30am every day and doesn’t have much interest in eating. She has lost ten pounds. At home, her husband describes her as having little interest in their relationship and sex. Finally, she has begun to wonder if life is worth living and has had thoughts of how she might end her life.
Major Depressive Disorder (melancholy)
SIG E CAPS
35 yo single man went to his EAP after he became very upset at his
annual performance review. He gives the history of his first depression
at age 13 when his dad became hospitalized. Since then he has felt
depressed on and off throughout his life and has never felt as if he met
his potential at work. Despite these feelings he seldom had trouble
sleeping or eating, felt he could concentrate at work, did enjoy his time
outdoors, and although he sometimes wondered if life was worth living,
he had never had active suicidal thoughts. Finally, he stated that
although his symptoms have waxed and waned over his lifetime, the last
time he felt well was three years ago. He has no history of
hypomanic/manic symptoms or substance abuse.
depressed on and off throughout his
-he seldom has trouble sleeping or eating, he sometimes thought if life is worth living, no active suicidal thoughts, the last time he felt well was 3 years ago, has no history of hypomanic/manic symptoms or substance abuse
Persistent Depressive Disorder
40 yo man stated that he hasn’t been well for 6 months. He
has felt guilty and has been either very withdrawn or irritable.
He feels down/w low energy, has trouble sleeping, has lost
interest in his very stressful job and admitted he has been
using cocaine very regularly. He is not suicidal. He clarified he
had been stressed at work for about a year, but only
experienced the above symptoms 6 mos ago (3 mos after
starting cocaine use). The symptoms are present every day.
He has no previous psychiatric history.
Stressed at work about a year, above sympoms 6montsh ago, 3 months after starting cocaine use. No previous psych history.
He has depression and meets substance use
Substance/Medication use Depressive Disorder
A 79 yo man was diagnosed with Parkinson’s disease
six years ago. He had done well until 3 months ago,
when he began declining invites, feeling
withdrawn/less interested and noticing more trouble
with concentration/memory, had a 15 pound wt loss
and trouble staying asleep. He didn’t really feel sad
or more worried but knew he wasn’t’ himself. He
had no thoughts of suicide. His Parkinson symptoms
were worsening. He had no history of substance use
problems.
Depressive Disorder due to another medical condition,
and you have to treat both
