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Psychiatry 1 Flashcards

1
Q

What are the clinical features of persistent depressive disorder (dysthymia)?

A 
Chronic depressed mood for 2+ years (1 year in children/adolescents)
No symptom-free period for >2 months
Presence of 2+ of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making decisions
6. Feelings of hopelessness
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2
Q

What are the 3 specifiers for persistent depressive disorder (dysthymia)?

A
  1. With pure dysthymic syndrome - criteria for major depressive episode never met
  2. With intermittent major depressive episodes
  3. With persistent major depressive episodes (criteria for major depressive episode met throughout previous 2 years)
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3
Q

Patients with ___ personality disorder exhibit a lifelong pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

A

Avoidant

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4
Q

What are the characteristics of chronic fatigue syndrome (aka systemic exertion intolerance disease)?

A

Relatively sudden onset of overwhelming fatigue, often associated with an infection such as mononucleosis

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5
Q

What is cyclothymic disorder?

A

2+ years of numerous periods with fluctuating subclinical/mild hypomanic and depressive symptoms that do not meet the full criteria for hypomanic or major depressive episodes

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6
Q

In bipolar manic episodes, the predominant mood may be ___ rather than elevated or euphoric.

A

Irritable

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7
Q

Patients with bipolar disorder may exhibit ___ and ___ that are difficult to distinguish from ADHD.

A

Distractibility; hyperactivity

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8
Q

Diagnostic criteria for anorexia nervosa?

A

Significantly low weight
Fear of weight gain
Distorted view of body weight and shape

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9
Q

CV complications of anorexia nervosa?

A

Myocardial atrophy, bradycardia, hypotension, arrhythmias

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10
Q

Renal complications of anorexia nervosa?

A

Poor urinary concentration, dehydration

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11
Q

Neurological complications of anorexia nervosa?

A

Seizures, cognitive impairment

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12
Q

Dermatological complications of anorexia nervosa?

A

Dry skin, lanugo

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13
Q

Gynecological complications of anorexia nervosa?

A

Amenorrhea, infertility

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14
Q

GI complications of anorexia nervosa?

A

Gastroparesis, constipation

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15
Q

Hematologic complications of anorexia nervosa?

A

Cytopenia

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16
Q

Other complications of anorexia nervosa?

A

Electrolyte depletion, osteopenia, hypercholesterolemia, hypercarotenemia

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17
Q

What causes edema in anorexia nervosa?

A

Nutritional deficiency (commonly seen in the ankles and around the eyes)

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18
Q

What causes osteopenia in anorexia nervosa?

A

Various endocrine abnormalities, hypercortisolism, GH resistance

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19
Q

What electrolyte abnormalities may be seen in anorexia nervosa?

A

Magnesium, potassium, sodium, and phosphate may be normal or depleted

Hypokalemia due to self-induced vomiting is a common feature in patients with the binge-eating/purging subtype

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20
Q

What causes hypercarotenemia in anorexia nervosa?

A

Due to excessive consumption of low-calorie, carotene-rich foods with impairment in hepatic clearance

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21
Q

Euthyroid sick syndrome is commonly seen in anorexia nervosa due to the body’s adaptation to chronic nutritional depletion - what are the levels of T3/T4 and TSH?

A

Low levels of T3 and/or T4; TSH is usually normal or low

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22
Q

Indications for lithium therapy?

A

Acute mania

Bipolar maintenance

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23
Q

Contraindications to lithium therapy?

A

Chronic kidney disease
Heart disease
Hyponatremia or diuretic use
Pregnancy (teratogenic)

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24
Q

What baseline studies should be performed when starting lithium therapy?

A

BUN, Creatinine, Ca2+, urinalysis
Thyroid function tests
EKG in patients with coronary risk factors (DM, HTN, smoking)
Pregnancy test (women of childbearing age)

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25
Q

Acute adverse effects of lithium?

A 
Course tremors, ataxia, weakness
Polyuria, polydipsia
N/V, diarrhea
Cognitive impairment/altered mental status
Weight gain
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26
Q

Chronic adverse effects of lithium?

A

Nephrogenic DI
Chronic kidney disease
Thryoid dysfunction (most often hypothyroidism)
Hyperparathyroidism with hypercalcemia

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27
Q

What type of medication is bupropion?

A

Antidepressant

NE and DA reuptake inhibitor

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28
Q

Contraindications to bupropion use?

A

Seizure disorders (seizures are a potential AE, especially at high doses)
Bulimia and anorexia nervosa (Eating disorders can cause electrolyte abnormalities that can precipitate seizures)
Recent use of MAOIs (past 2 weeks) - risk of HTN crisis

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29
Q

What common antidepressant side effects are not commonly seen with bupropion?

A

Weight gain

Sexual dysfunction

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30
Q

Compare memory loss seen in normal aging vs. dementia.

A

Normal aging: pt can provide details about incidents of forgetfulness, pt is concerned about memory loss, recent memory for important events and conversations is intact

Dementia: cannot remember specific instances of forgetfulness, family is more concerned than patient, has notable decline in memory for recent important events and conversations

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31
Q

Compare word-finding difficulty seen in normal aging vs. dementia.

A

Normal aging: occasional (expressive aphasia), no receptive aphasia

Dementia: frequent, with substitutions, some receptive aphasia

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32
Q

Compare independence and functioning seen in normal aging vs. dementia.

A

Normal aging: maintains independence in ADLs, is able to operate common appliances, maintains interpersonal social skills, does not get lost in familial territory (may have to pause briefly to reorient)

Dementia: becomes dependent on others for ADLs, is unable to operate common appliances, loses interest in social activities, can get lost for hours in familiar territory while driving or walking

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33
Q

___ is a stimulant that produces increased energy, decreased appetite, and reduced need for sleep. Those who abuse this drug often have mood changes and weight loss secondary to decreased appetite.

A

Cocaine

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34
Q

What is a common physical finding in individuals who snort cocaine?

A

Erythema of the nasal mucosa

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35
Q

In addition to mood disturbances, list 4 other psychiatric complications of cocaine use.

A

Anxiety
Panic attacks
Grandiosity
Psychosis (delusinos and hallucinations)

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36
Q

___ involves lack of interest and avoidance of eating based on the sensory characteristics of food, with typical onset in infancy or early childhood.

A

Avoidant/restrictive food intake disorder

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37
Q

Abuse of what drug should be suspected in an individual with weight loss, behavioral changes, and erythema of the nasal mucosa?

A

Cocaine

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38
Q

What is acute intermittent porphyria (AIP)?

A

Hereditary disorder involving alterations in heme biosynthesis; characterized by intermittent neurovisceral symptoms

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39
Q

What presentation suggests AIP?

A

New onset of psychiatric and neurologic abnormalities, accompanied by unexplained acute abdominal pain and a family history of similar symptoms

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40
Q

Clinical manifestations of acute intermittent porphyria?

A 
Abdominal pain (most common symptom) - neuropathic (tenderness may not be present)
Vomiting, constipation, sensory and motor neuropathies, tachycardia
Psychiatric symptoms may be nonspecific and may include anxiety, insomnia, restlessness, mood fluctuations, and psychotic symptoms

Acute symptoms may last for days to weeks and usually resolve between attacks

Age of onset - 30s or 40s

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41
Q

Lab abnormality in acute intermittent porphyria?

A

Elevated urinary porphobilinogen

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42
Q

Findings in Lyme disease?

A

Erythema migrans, nonspecific systemic symptoms, carditis (earlier)
Arthritic symptoms (later)
Common neurologic manifestations of Lyme disease include radiculopathies, meningitis, and cranial neuropathies

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43
Q

What is Wilson disease?

A

Disorder of copper transport, leading to copper accumulations that cause hepatic, psychiatric, and neurologic dysfunction

Findings include dysarthria, dystonia, tremor, parkinsonism, and copper deposits in the cornea (Kayser-Fleischer rings)

Depression is the most common psychiatric manifestation

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44
Q

The National Institute on Alcohol Abuse and Alcoholism has found evidence of negative health effects for women of all ages and men age 65+ who consume ___ drinks in a week or ___ in a day.

A

8+; 4+

men <65: 15+, 5+

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45
Q

What lab abnormalities may be seen in a patient with alcohol use disorder?

A

Abnormal liver enzymes (AST/ALT ratio 2:1 or higher)

Macrocytosis

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46
Q

Individuals with alcohol use disorder frequently seek primary care due to ___ and/or ___ symptoms from mild withdrawal.

A

Sleep disturbance; anxiety (use alcohol to fall asleep; as the blood alcohol level drops, CNS hyperarousal occurs and results in awakenings)

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47
Q

What is a frequent complication of Parkinson disease?

A

Psychotic symptoms (most commonly visual hallucinations and paranoid delusions)

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48
Q

What is the strongest predictor of nursing home placement in patients with Parkinson disease?

A

Psychotic symptoms

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49
Q

Although PD psychosis can occur as a result of the underlying disease process, the risk increases in patients treated with ___ medications (give examples).

A

Dopaminergic medications

Dopamine agonists (pramipexole, ropinirole) have a greater risk than the dopamine precursor and gold-standard medication arbidopa-levodopa

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50
Q

Treatment of PD psychosis?

A

Dose reduction of antiparkinson medication
Medication substitution
Addition of a low-potency antipsychotic medication

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51
Q

Give examples of low-potency antipsychotics used to treat PD psychosis.

A

Quetiapine, cloazpine, pimavanserin

Minimal dopamine-2 receptor antagonism

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52
Q

Why should antipsychotics with more potent dopamine-2 receptor antagonism (haloperidol, risperidone) be avoided in PD psychosis?

A

Highest risk of EPS and will worsen Parkinson symptoms

53
Q

___, an antiviral, and ___, an MAOI are both dopaminergic agents used in the treatment of PD.

A

Amantadine; selegiline

54
Q

Clinical features of a specific phobia?

A

Marked anxiety about a specific object or situation (phobic stimulus) for >6 months
Avoidance behavior
Usually develops in childhood, often after a traumatic event

55
Q

Prevalence of specific phobias?

A

10% of population

56
Q

Treatment of specific phobias?

A

CBT with exposure (first-line)

Short-acting benzodiazepines

57
Q

Compare panic attacks that occur in panic disorder vs. specific phobias.

A

In contrast to panic disorder, panic attacks in specific phobia are always triggered by the phobic stimulus and do not occur unexpectedly

58
Q

What is HIV-associated dementia?

A

Potentially severe neurocognitive disorder, more likely to be present in untreated HIV patients with a CD4+ cell count of <200/mm^3 and in patients with long-standing HIV disease

59
Q

Pathophysiology of HIV-associated dementia?

A

Macrophage-mediated signaling pathways and associated toxicity may lead to neuronal dysfunction

60
Q

Presentation of HIV-associated dementia?

A

Onset is typically subacute and characterized by increasing apathy and impaired attention

Early subcortical dysfunction leading to slowed movement and difficulty with smooth limb movement

Significant cortical neuronal loss and memory decline

61
Q

How can the risk of developing HAD be decreased?

A

Antiretroviral therapy (resuming treatment may improve HAD symptoms)

62
Q

Diagnostic criteria for ODD?

A

Recurrent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness for 6+ months

Behaviors must be excessive compared to normative, age-appropriate behaviors and observed during interactions with individuals other than siblings

Argues with adults, defies authority figures, refuses to follow rules
Deliberately annoys others
Blames others for own mistakes or misbehavior
Easily annoyed, angry, resentful, or vindictive
Not due to another mental disorder

63
Q

Rx - ODD?

A

Parent management training
Psychotherapy (anger management, social skills training)
NO pharmacotherapy, but assess for comorbid ADHD and treat if present

64
Q

What is a common condition comorbid with ODD?

A

ADHD

65
Q

The diagnosis of antisocial personality disorder is not made in individuals under age ___.

A

18

66
Q

How is ODD different from Conduct Disorder?

A

CD involves more severe violations of basic rights

67
Q

Although benzodiazepines are often prescribed for patients with insomnia and/or anxiety, they should be used sparingly in the elderly - why?

A

Due to increased risk of adverse effects; as people age, they metabolize benzos more slowly and are more likely to experience confusion and increased risk of falls. Another adverse effect is paradoxical agitation.

68
Q

What are the characteristics of paradoxical agitation?

A

Increased agitation, confusion, aggression, and disinhibition, typically within an hour of administration

69
Q

Why should terazosin (alpha blocker) be used cautiously in the elderly?

A

It may cause orthostatic hypotension or syncope, especiallyw ith the first dose

70
Q

Discuss elements of the assessment for suicide risk (SAD PERSONS).

A

Sex
Age
Depression

Previous attempt
EtOH (or other substance) use
Rational thought loss (psychosis)
Social support lacking
Organized plan
No spouse or significant other
Sickness or injury
71
Q

Define high imminent risk of suicide.

A

Ideation, intent, and plan

72
Q

Define high non-imminent risk of suicide.

A

Ideation, intent, but no plan to act in the near future

73
Q

Management of high imminent risk of suicide?

A

Ensure safety: hospitalize immediately (involuntarily if necessary)
Remove personal belongings and objects in room that may present self-harm risk
Constant observation and security may be required to hold against will

74
Q

Management of high non-imminent risk of suicide?

A

Ensure close follow-up
Treat modifiable risk factors (underlying depression, psychosis, substance abuse, pain)
Recruit family or friends to support patient
Reduce access to potential means (secure firearms, medications)

75
Q

True or false - significant concern about the patient’s immediate safety overrides any “promises” made about agreeing to outpatient treatment.

A

True (especially when there is no established therapeutic alliance or relationship between patient and physician)

76
Q

True or false - there is evidence that a “no-harm” contract is effective in reducing suicide.

A

False - there is little evidence that a “no-harm” contract is effective in reducing suicide

77
Q

Common symptoms of alcohol withdrawal?

A

Tremors, agitation, anxiety, delirium, psychosis

78
Q

Common symptoms of benzodiazepine withdrawal?

A

Seizures, tremors, anxiety, perceptual disturbances, psychosis, insomnia, psychomotor agitation, dysphoria

79
Q

Common physical exam findings seen in alcohol and benzodiazepine withdrawal?

A

Seizures, tachycardia, palpitations

80
Q

Common symptoms of heroin/opioid withdrawal?

A

Nausea, vomiting, abdominal cramping, diarrhea, muscle aches (myalgias, arthralgias),

81
Q

Common physical exam findings seen in heroin/opioid withdrawal?

A

Dilated pupils, yawning, piloerection, lacrimation, hyperactive bowel sounds, rhinorrea, diaphoresis

Afebrile, alert and oriented

82
Q

Common symptoms of stimulant (eg, cocaine, amphetamines) withdrawal?

A

Increased appetite, hypersomnia, intense psychomotor retardation, severe depression (“crash”), fatigue, vivid dreams

Minimal physical symptoms

83
Q

Common symptoms of nicotine withdrawal?

A

Dysphoria, irritability, anxiety, increased appetite

84
Q

Common symptoms of cannabis withdrawal?

A

Irritability, anxiety, depressed mood, insomnia, decreased appetite

85
Q

Common physical exam findings of stimulant/nicotine/cannabis withdrawal?

A

No significant findings

86
Q

Discuss the time course of opioid withdrawal symptoms.

A

Symptoms present within 6-12 hours (short-acting), can peak within 36-72 hours, and may continue for several days

24-48 hours after the last dose of lacrimation

87
Q

Discuss the time course of alcohol withdrawal symptoms.

A

Develops 6-24 hours after the last drink, delirium tremens 2-4 days after the last drink if untreated

88
Q

Benzodiazepine withdrawal presents with symptoms similar to alcohol withdrawal, but with less…

A

…predictability in time of onset and duration of symptoms.

89
Q

___-acting benzodiazepines are likely to have later onset and a longer course of withdrawal symptoms.

A

Long (withdrawal from short-acting benzos can occur as early as 24 hours after cessation)

90
Q

Diphenhydramine is an antihistamine with ___ effects. Withdrawal symptoms are rare - what would these be?

A

Anticholinergic; cholinergic rebound symptoms such as bradycardia and miosis

91
Q

Compare a manic vs. hypomanic episode.

A

Manic:
Symptoms more severe
1 week unless hospitalized
Marked impairment in social or occupational functioning or hospitalization necessary
May have psychotic features; makes episode manic by definition

Hypomanic:
Symptoms less severe
4+ consecutive days
Unequivocal, observable change in functioning from patient’s baseline
Symptoms not severe enough to cause marked impairment or necessitate hospitalization
No psychotic features

Both require elevated/irritable mood and increased energy, plus 3 symptoms (or 4 if mood is irritable)

92
Q

Define Bipolar I.

A

Manic episodes

Depressive episodes common but not required

93
Q

Define Bipolar II.

A

Hypomanic episodes

1+ major depressive episodes

94
Q

Diagnosis of hypomanic/manic episodes?

A

Requires elevated/irritable mood and increased energy + 3 of the following (or 4 if mood is irritable):

DIGFAST
Distractibility
Impulsivity (high-risk behaviors)
Grandiosity (delusions)
Flight of ideas/racing thoughts
Activity (increased goal-directed activity/psychomotor agitation)
Sleep (decreased need)
Talkativeness/pressured speech
95
Q

How is a manic episode differentiated from a hypomanic episode in general?

A

Severity of symptoms, duration, and degree of functional impairment

96
Q

If ___ symptoms are present, an episode is manic by definition.

A

Psychotic

97
Q

What types of drugs are more likely to induce manic symptoms during intoxication?

A

Stimulants and cocaine

98
Q

What is clozapine?

A

Second-generation antipsychotic used in treatment-resistant schizophrenia and schizoaffective disorder (failed 2+ antipsychotic trials), and in schizophrenic and schizoaffective patients with recurrent suicidality

99
Q

Significant/key adverse affect of clozapine that requires monitoring?

A

Risk of neutropenia and life-threatening agranulocytosis (complete absence of neutrophils) in ~1% of patients

Regular monitoring of ANCs before dispensing the drug

100
Q

Additional AE of clozapine?

A

Weight gain, metabolic syndrome, seizures, ileus, myocarditis, hypotension

LEAST likely (compared to other antipsychotics) to cause EPS, has not been shown to cause TD

101
Q

List 7 primary indications for CBT.

A 
Depression
GAD
PTSD
Panic disorder
OCD
Eating disorders
Negative thought patterns
102
Q

Features of CBT?

A

Evidence-based, standardized modality of psychotherapy that targets persistent maladaptive thought patterns and behaviors
Combines cognitive and behavioral therapy
Challenges maladaptive cognitions
Targets avoidance with behavioral techniques (relaxation, exposure, behavior modification)

103
Q

List 1 primary indication for interpersonal psychotherapy.

A

Depression

104
Q

Features of interpersonal psychotherapy?

A

Links symptoms to current relationship conflicts and interpersonal skill deficits

105
Q

List 2 primary indications for supportive psychotherapy.

A
  1. Lower functioning; psychotic disorders

2. Patients in crisis

106
Q

Features of supportive psychotherapy?

A

Maintains hope; provides encouragement

Reinforces coping skills, adaptive defenses

107
Q

List 2 primary indications for psychodynamic psychotherapy.

A
  1. Higher functioning

2. Personality disorders

108
Q

Features of psychodynamic psychotherapy?

A

Builds insight into unconscious conflicts and past relationships
Uses transference
Breaks down maladaptive defenses

109
Q

List 1 primary indication for motivational interviewing.

A

SUDs

110
Q

Features of motivational interviewing?

A

Nonjudgmental; acknowledges ambivalence and resistance

Enhances intrinsic motivation to change

111
Q

List 1 primary indication for DBT.

A

Borderline personality disorder

112
Q

Features of DBT?

A

Improves emotion regulation, distress tolerance, mindfulness

Decreases self-harm, builds skills

113
Q

List 1 primary indication for DBT.

A

Prominent physical symptoms; pain disorders

114
Q

Features of Biofeedback?

A

Improves control over physiological reactions to emotional stressors

115
Q

Victims of sexual assault are at increased risk for what medical problems?

A

Major depression, contemplation of suicide, suicide attempts

STDs, pelvic pain, fibromyalgia, functional GI disorders, cervical cancer (may be linked to an avoidance of pelvic examinations)

116
Q

___ personality disorder is characterized by a lifelong pattern of unstable interpersonal relationships, emotions, and self-identity through a range of contexts.

A

Borderline

117
Q

Survivors of sexual assault are at high risk for developing ___, ___, and ___.

A

PTSD; depression; suicidality

118
Q

Features of intoxication with phenchyclidine (PCP)?

A

Dissociative anesthetic causes hallucinations, dissociative feelings, agitation, confusion, tachycardia, and nystagmus (any time)

Can lead to psychotic and violent behavior, diminished pain perception, and subsequent physical injury

119
Q

Onset and duration of action of PCP?

A

Rapid onset

Duration < 8 hours

120
Q

Symptoms of high dose PCP intoxication?

A

Severe HTN, seizures, rigidity, and life-threatening hyeprthermia

121
Q

Features of alcohol intoxication?

A

Disinhibition, disorientation, horizontal nystagmus, slurred speech, unsteady gait

122
Q

Features of cocaine intoxication?

A

Elevated BP and HR, euphoria, increased alertness

123
Q

Features of Jimson weed intoxication?

A

Anticholinergic atropine-containing plant, manifests as anticholinergic poisoning

Hallucinations/delirium, hyperthermia, tachycardia, nonreactive mydriasis, dry and red skin

124
Q

Features of lysergic acid diethylamide (LSD) intoxication?

A

Visual hallucinations and illusions, euphoria or dysphoria, and depersonalization, mild HTN and tachycardia

Orientation is often intact

125
Q

Features of methamphetamine intoxication?

A

Severe psychomotor agitation, hallucinations, tachycardia, HTN

126
Q

Duration of action of methamphetamine?

A

<20 hours (longer than PCP)

127
Q

True or false - bipolar I disorder is a lifelong illness that requires maintenance pharmacotherapy to reduce the risk of recurrent mood episodes.

A

True

128
Q

If a patient with bipolar I disorder insisted on stopping lithium, what would be the first step in management? If he refused all pharmacotherapy?

A

Cross-taper to another antimanic agent; slowely taper over weeks to months and frequently monitor for early signs and symptoms of recurrence

129
Q

Upper end of therapeutic lithium level range?

A

1.2+ mmol/L

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