Psychiatry Flashcards
1
Q
2 warnings for patients using St. John’s Wort?
A
Lack of herbal regulation in US, Drug interactions
2
Q
What accounts for frequent drug interactions during use of St. John’s Wort?
A
SJW = P450 inducer … OCPs, HAART
3
Q
Additional AE of St. John’s Wort?
A
Serotonin Syndrome
4
Q
What is the best way to counsel a patient who is being involuntarily committed to psych unit?
A
Patient-centered approach; Physician explains that the primary goal hospitalization = alleviate suffering, provide treatment in a safe environment
5
Q
What is required for a diagnosis of schizoaffective disorder?
A
Patient must have 2+ weeks of psychotic symptoms in the absence of mood disorder
6
Q
What differentiates schizoaffective disorder from schizophrenia?
A
Schizoaffective disorder = presence of mood symptoms during a significant portion of psychotic illness
7
Q
Best treatment for patients with bipolar depression and psychotic features or persistent suicidality?
A
ECT
8
Q
Why is ECT preferred for patients with bipolar depression and psychotic features or persistent suicidality … vs. lithium?
A
Lithium takes longer to titrate to effective dose
9
Q
___ refers to feeling of inner restlessness, with inability to sit still
A
Akathisia
10
Q
Medication that most commonly results in Akathisia?
A
First-generation anti-psychotics
11
Q
Initial treatment option for Akathisia?
A
Reduction in anti-psychotic use
12
Q
3 treatment options for Akathisia?
A
b blockers (propranolol), benzodiazepines, benztropine
13
Q
Role of antipsychotics in schizophrenia?
A
Decreases (+) symptoms, but does not touch (–) symptoms
14
Q
Example of (+) symptoms in schizophrenia?
A
Hallucinations, delusions
15
Q
3 examples of (–) symptoms in schizophrenia?
A
Flat affect, amotivation, social withdrawal
16
Q
Best management of (–) symptoms in schizophrenia?
A
Social skills training
17
Q
Description of factitious disorder?
A
Psychiatric condition in which patient assumes the sick role WITHOUT obvious external benefit
18
Q
Best management of lithium-induced hypothyroidism?
A
Do not stop lithium … Continue lithium, add treatment with levothyroxine
19
Q
4 aspects of clinical presentation of stimulant toxicity?
A
Dilated pupils, tachycardia, HTN, diaphoresis
20
Q
How can you distinguish anticholinergic toxicity from stimulant toxicity?
A
Anticholinergic toxicity = dry skin; Stimulant toxicity = diaphoresis
21
Q
Description of Somatic Symptom Disorder?
A
Excessive worry over 1+ unexplained symptom
22
Q
Description of Illness Anxiety Disorder?
A
Preoccupation with idea of having a serious (specific) illness
23
Q
Best management of Somatic Symptom Disorder?
A
Regularly scheduled PCP visits
24
Q
2 aspects of clinical presentation for TCA overdose?
A
Anticholinergic effects (can’t see, can’t pee, can’t spit, can’t sh*t); Cardiotoxicity (arrhythmias)
25
Most common type of cardiac arrhythmia seen in TCA overdose?
QT prolongation
26
DOC for prevention of cardiac arrhythmia in setting of TCA overdose?
Sodium bicarbonate
27
MOA of Sodium bicarbonate in prevention of Sodium bicarbonate cardiac arrhythmia in setting of TCA overdose?
Inhibits fast sodium channels in His-Purkinje tissue
28
2 alternative DOC for prevention of cardiac arrhythmia in setting of TCA overdose?
Mg2+, lidocaine
29
Duration of SSRI treatment for patient with 1 episode of Major Depressive Disorder (MDD)?
6 months
30
Duration of SSRI treatment for patient with recurrent Major Depressive Disorder (MDD), chronic episodes (2+ years), strong FHX, suicide attempt?
1-3 years
31
2 most common factors that increase a patient’s susceptibility to delirium?
Advanced age, Underlying brain disorder
32
Initial evaluation of patient with delirium?
Physical exam, CBC + UA
33
DOC for treatment of combative patient with delirium?
Low-dose haloperidol
34
Haloperidol belongs to class of …
Anti-psychotics
35
Diagnostic criteria for Tourette Syndrome?
2+ motor tics AND 1+ verbal tic
36
Examples of motor tics seen in Tourette Syndrome?
Should shrugging, blinking, grimacing
37
Examples of verbal tics seen in Tourette Syndrome?
Grunting, coughing, throat clearing
38
2 co-morbidities seen in Tourette Syndrome?
ADHD, OCD
39
Best treatment of Tourette Syndrome?
Habit-reversal psychotherapy + medication
40
DOC for treatment of Tourette Syndrome?
1st generation antipsychotics, 2nd generation antipsychotics, a2 agonists
41
2 examples of a2 agonists used in treatment of Tourette Syndrome?
Clonidine, Guanfacine
42
2 examples of 2nd generation antipsychotics used in treatment of Tourette Syndrome?
Risperidone, Aripiprazole
43
2 examples of 1st generation antipsychotics used in treatment of Tourette Syndrome?
Fluphenazine, Haloperidol
44
3 treatment options for bipolar I disorder in pregnant females?
1st generation anti-psychotics, Lithium, 2nd generation anti-psychotics
45
1st generation anti-psychotic of choice for pregnant females with bipolar I disorder?
Haloperidol
46
2 drugs that should be avoided in pregnant females with Bipolar I disorder?
Valproate, Carbamazepine
47
Duration of full trial of anti-depressants?
6 weeks
48
Patient with recent HX of depression improves while taking SSRIs; Several weeks after beginning SSRI, returns to clinic; Complains of worsening depressive symptoms – first step in workup?
Assess for substance use … (ETOH, stimulants, opioids)
49
Patient is treated for major depressive disorder; HX of substance abuse; His work contacts you to inquire about ‘return to work’ status; Patient has signed a release of information, authorizing physician to provide information to employer – what should physician tell employer?
Disclose the minimum necessary information … “patient is medically-stable to return to work” … disclosing + suggesting that patient has HX of depression, substance is inappropriate
50
Description of pseudodementia?
Late-life depression that frequently presents with reversible cognitive impairment
51
Late-life depression (pseudodementia) is associated with an increased risk of …
Alzheimer dementia
52
32 yo female presents with new-onset psychosis (hallucinations); Reports weight loss, swollen wrists bilaterally, LE edema – diagnosis?
SLE
53
Initial step of diagnosis for SLE?
ANA
54
In addition to psychosis, what are 2 other aspects of clinical presentation seen in Acute Intermittent Porphyria (AIP)?
Abdominal pain, Peripheral neuropathy
55
Best management of antidepressant-induced hypomania?
Discontinuation of antidepressants
56
2 mood stabilizers that can be used for patients with bipolar disorder?
Valproate, Lithium
57
Patients with severe manic episodes in bipolar disorder can also be treated with ___, in addition to a mood stabilizer
Anti-psychotic
58
Best initial test for patients presenting with new-onset psychosis?
Rule-out substance abuse
59
Clinical presentation for opioid withdrawal?
Rhinorrhea, diarrhea, lacrimation
60
2 pharmacologic treatment options for opioid withdrawal?
Opioid agonists, Clondine
61
2 examples of opioid agonists used in treatment of opioid withdrawal?
Methadone, Buprenorphine
62
When patient refuses to comply with inpatient/outpatient methadone treatment, what is next best option for treatment of opioid withdrawal?
Clonidine
63
Best management of acute delirium + severe agitation, which poses a risk to safety of patient + care team?
Haloperidol
64
Description of Histrionic Personality Disorder?
Attention-seeking behavior; Inappropriate, sexually provocative behavior
65
2 comorbid conditions associated with Tourette Syndrome?
OCD, ADHD
66
Best management of OCD?
SSRI + Cognitive Behavioral Therapy (CBT)
67
Specific type of CBT that is effective for treatment of OCD?
Exposure and response prevention therapy
68
In addition to SSRIs, what is another medication that can be helpful in treatment of OCD?
TCAs, Clomipramine
69
Reproductive condition that SSRIs can treat?
Premature ejaculation … due to their ability to cause delayed ejaculation
70
Timing required for diagnosis of acute stress disorder?
3 days – 1 month
71
Timing required for diagnosis of PTSD?
> 1 month
72
SSRI that treats with depression and insomnia?
Citalopram
73
72 yo male presents 6 weeks after diagnosed with major depressive disorder; Trial of fluoxetine caused 80% resolution of symptoms, but caused jitteriness and insomnia – which medication should be attempted next?
Another SSRI
74
Best management of SSRI-induced sexual dysfunction in patients with excellent response to SSRI?
Addition of bupropion or sildenafil
75
Best management of SSRI-induced sexual dysfunction in patients with modest response to SSRI?
Switch from SSRI to bupropion or mirtazapine
76
What might account for paranoid delusions and visual hallucinations following an increase in levodopa or other medications used to treat Parkinson’s disease (amantadine)?
Increased dopamine release
77
Order in which anti-Parkinson medications should be stopped?
Everything before carbidopa/levodopa … anticholinergics, amantadine, MAO-B inhibitors, COMT inhibitors
78
If psychosis continues in patient with Parkinson’s disease (after stopping dopamine agonists), which 3 medications can be used instead?
Quetiapine, clozapine, pimavanserin
79
Clinical presentation of benzodiazepine poisoning?
Slurred speech, sedation
80
Clinical presentation of opiate poisoning?
Sedation, constricted pupils, hypoactive bowel sounds, respiratory depression
81
Clinical presentation of serotonin syndrome?
Tachycardia, nausea, vomiting, myoclonus, hyperreflexia, horizontal eye movements
82
25 yo female presents with 1 week of agitated, bizarre behavior; Reports that she has not slept in several days, working on an amazing novel; While in ED, becoming more agitated, pounding on walls, refusing medications - what is DOC for this patient?
Risperidone
83
DOC for acute mania?
Risperidone
84
First-line treatment for bipolar mania?
Valproate, lithium
85
Limitations of valproate and lithium for maintenance of bipolar mania?
Slower onset, require titration
86
3 good prognostic factors for schizophrenia?
Later age of onset, acute onset, (+) psychosis (delusions, hallucinations)
87
Timeframe needed for diagnosis of schizophrenia?
6 months
88
58 yo female presents for smoking cessation; Currently on nicotine patch, hoping to add varenicline; What is major risk of combining varenicline and nicotine?
No increased risk for serious complications
89
MOA of varenicline in smoking cessation?
Partial nicotine agonist
90
AE of varenicline?
Disordered sleep, abnormal dreams
91
What is the best initial approach to an acutely psychotic patient?
Maintain interpersonal distance, attempt to understand patient’s experience without challenging patient’s delusions
92
24 yo male presents with intoxication; PE shows aggressive behavior, nystagmus; HR 120, BP 160/110 - diagnosis?
PCP intoxication
93
MOA of PCP?
NMDA receptor antagonist
94
24 yo male presents with intoxication; PE shows aggressive behavior, nystagmus; HR 120, BP 160/110 - best next step?
Benzodiazepine
95
4 factors that are protective against suicide?
Family support, Pregnancy, Parenthood, Religion (but patient-dependent)
96
78 yo male presents with hallucinations, delusions, aggressive behavior; HX of HTN, CAD, osteoporosis; Meds include ASA, HCTZ, enalapril, acetaminophen, NSAIDs; Labs show Hgb 9.6, MCV 108 - diagnosis?
Vitamin B12 deficiency
97
Clinical presentation of Vitamin B12 deficiency in elderly patients?
Dementia, delirium
98
Treatment of choice for Borderline Personality Disorder?
Dialectical behavioral therapy
99
Mortality risk of anti-psychotics?
Both 1st and 2nd generation carry an increased risk of mortality
100
What are the most common causes of death after use of anti-psychotics?
Cardiac events, fall, CVA, aspiration PNA
101
Timing criteria for postpartum depression?
Peaks at 5 days post-partum, typically resolves within 2 weeks
102
2 DOC for postpartum depression?
Sertraline, paroxetine
103
Duration of adjustment syndrome?
Develops within 3 months of a feasible stressor; Resolves within 6 months of the stressor
104
Clinical presentation of adjustment syndrome?
Loss of normal social OR occupational functioning
105
Definition of treatment-resistant depression?
Major depressive disorder that does not respond to adequate trials of 2 different antidepressants
106
Best management for patients with little to no improvement ) or unacceptable tolerability of antidepressants (nonresponders)?
Switch to different anti-depressant
107
Best managementpartial responders patients who tolerate current antidepressant but with side effects (partial responders)?
Augmentation with additional antidepressant
108
What are 2 benefits of bupropion?
Does not cause weight gain, does not cause sexual side effects
109
MOA of bupropion?
Inhibits uptake of norepinephrine and dopamine
110
Of the following medications, which should be avoided in pregnancy – citalopram, lithium, lorazepam, quetiapine, valproate?
Valproate
111
Why should Valproate be avoided during pregnancy?
High risk of congenital malformations, NTDs
112
42 yo female presents for repeated episodes of CP, dizziness, SOB; States that she’s worried that she may have some type of heart condition; Reports sudden-onset sweating, palpitation; Cardiac workup has been negative so far – diagnosis (panic disorder vs. illness anxiety disorder)?
Panic disorder
113
Best chronic management of Panic disorder?
SSRI
114
Best management of acute distress in Panic disorder?
Benzodiazepine
115
3 key features of symptoms in panic disorder?
Avoidance behavior, anticipatory anxiety, unexpected onset of attacks
116
36 yo female presents for smoking cessation counseling; Reports multiple unsuccessful attempts at quitting; HX of seizure disorder, but discontinued anticonvulsant therapy 5 years ago after several years of being seizure-free – what is best treatment for this patient?
Behavioral therapy + nicotine combination replacement
117
Utility of combination nicotine replacement therapy?
Decreased cravings and withdrawal symptoms
118
Utility of varenicline therapy?
More effective than bupropion and combination nicotine replacement therapy
119
AE of varenicline therapy?
Disordered sleep and nightmares
120
Utility of bupropion therapy?
Decreased post-cessation weight gain; Good choice for patients with depression
121
AE of bupropion therapy?
Contraindicated in patients with seizures or eating disorders
122
What is the long-acting modality in combination nicotine replacement therapy?
Patch
123
What is the short-acting modality in combination nicotine replacement therapy?
Gum, lozenge, nasal spray
124
4 factors that are protective against suicide?
Family support, Pregnancy, Parenthood, Religion (but patient-dependent)
125
Best management of acute pain in patient with HX of opioid abuse, but abstinent now?
Non-opioid analgesics first, adjuvant medications, regional anesthesia, partial opioid agonist (buprenorphine)
126
59-year-old female presents after her son found her anxious, confused, shaking, sweating profusely, unsteady on feet; history of smoking, depression; patient took fluoxetine for years with only partial improvement in depression; was recently started on phenelzine, after fluoxetine was discontinued 1 month ago; vitals show T101, BP 160/90, HR 116; on exam, patient agitated, diaphoretic, tremulous; bowel sounds are increased, muscular rigidity in lower extremities -- diagnosis?
Serotonin syndrome
127
59-year-old female presents after her son found her anxious, confused, shaking, sweating profusely, unsteady on feet; history of smoking, depression; patient took fluoxetine for years with only partial improvement in depression; was recently started on phenelzine, after fluoxetine was discontinued 1 month ago; vitals show T101, BP 160/90, HR 116; on exam, patient agitated, diaphoretic, tremulous; bowel sounds are increased, muscular rigidity in lower extremities --what accounted for development of serotonin syndrome in this patient?
Combined use of SSRI and MAOI without sufficient 5-week washout
128
38 yo male with schizophrenia presents for deterioration in overall functioning; PE reveals cataplexy - what is best management?
Lorezepam
129
In addition to benzodiazepines, what is an alternate treatment for cataplexy?
ECT
130
Test that may be performed to confirm diagnosis of cataplexy?
Lorazepam challenge
131
What is best management for steroid-induced psychosis?
Reduce dose of steroids
132
65 yo female is brought to ED by son; Hx of mood disorders, currently on lithium, risperidone, escitalopram; Recently diagnosed with HTN and OA, treated with tylenol and chlorithaladone; BP 150/90, HR 52; PE shows unsteady gait, hand tremor - diagnosis?
Lithium toxicity due to interaction between lithium and chlorithalidone
133
Therapeutic lithium range?
0.8-1.2
134
3 classed of drugs that classically cause lithium toxicity?
Thiazide diuretics, ACEIs, NSAIDs
135
How do thiazide diuretics cause lithium toxicity?
Increase Na excretion in distal tubule ... causing increased Li retention in proximal tubule
136
3 indications for HD as treatment for lithium toxicity?
Lithium level > 4; Lithium 2.5-4 with severe neurologic symptoms; Rising Lithium levels despite volume resuscitation
137
Best management of acute ETOH withdrawal?
Benzodiazepines (lorazepam)
138
Timing of onset for mild ETOH withdrawal?
6-24 hours
139
Timing of onset for seizures in ETOH withdrawal?
12-48 hours
140
Timing of onset for halucinations in ETOH withdrawal?
12-48 hours
141
Timing of onset for delirium tremens in ETOH withdrawal?
48-96 hours
142
Best management of patient requesting refills of lorazepam in patient with negative UDS for benzodiazepines?
Confirmatory testing with gas chromatography with mass spectroscopy
