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UWorld > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

2 warnings for patients using St. John’s Wort?

A

Lack of herbal regulation in US, Drug interactions

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2
Q

What accounts for frequent drug interactions during use of St. John’s Wort?

A

SJW = P450 inducer … OCPs, HAART

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3
Q

Additional AE of St. John’s Wort?

A

Serotonin Syndrome

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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

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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

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6
Q

What differentiates schizoaffective disorder from schizophrenia?

A

Schizoaffective disorder = presence of mood symptoms during a significant portion of psychotic illness

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7
Q

Best treatment for patients with bipolar depression and psychotic features or persistent suicidality?

A

ECT

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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

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9
Q

___ refers to feeling of inner restlessness, with inability to sit still

A

Akathisia

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10
Q

Medication that most commonly results in Akathisia?

A

First-generation anti-psychotics

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11
Q

Initial treatment option for Akathisia?

A

Reduction in anti-psychotic use

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12
Q

3 treatment options for Akathisia?

A

b blockers (propranolol), benzodiazepines, benztropine

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13
Q

Role of antipsychotics in schizophrenia?

A

Decreases (+) symptoms, but does not touch (–) symptoms

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14
Q

Example of (+) symptoms in schizophrenia?

A

Hallucinations, delusions

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15
Q

3 examples of (–) symptoms in schizophrenia?

A

Flat affect, amotivation, social withdrawal

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16
Q

Best management of (–) symptoms in schizophrenia?

A

Social skills training

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17
Q

Description of factitious disorder?

A

Psychiatric condition in which patient assumes the sick role WITHOUT obvious external benefit

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18
Q

Best management of lithium-induced hypothyroidism?

A

Do not stop lithium … Continue lithium, add treatment with levothyroxine

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19
Q

4 aspects of clinical presentation of stimulant toxicity?

A

Dilated pupils, tachycardia, HTN, diaphoresis

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20
Q

How can you distinguish anticholinergic toxicity from stimulant toxicity?

A

Anticholinergic toxicity = dry skin; Stimulant toxicity = diaphoresis

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21
Q

Description of Somatic Symptom Disorder?

A

Excessive worry over 1+ unexplained symptom

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22
Q

Description of Illness Anxiety Disorder?

A

Preoccupation with idea of having a serious (specific) illness

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23
Q

Best management of Somatic Symptom Disorder?

A

Regularly scheduled PCP visits

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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)

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25
Q

Most common type of cardiac arrhythmia seen in TCA overdose?

A

QT prolongation

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26
Q

DOC for prevention of cardiac arrhythmia in setting of TCA overdose?

A

Sodium bicarbonate

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27
Q

MOA of Sodium bicarbonate in prevention of Sodium bicarbonate cardiac arrhythmia in setting of TCA overdose?

A

Inhibits fast sodium channels in His-Purkinje tissue

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28
Q

2 alternative DOC for prevention of cardiac arrhythmia in setting of TCA overdose?

A

Mg2+, lidocaine

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29
Q

Duration of SSRI treatment for patient with 1 episode of Major Depressive Disorder (MDD)?

A

6 months

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30
Q

Duration of SSRI treatment for patient with recurrent Major Depressive Disorder (MDD), chronic episodes (2+ years), strong FHX, suicide attempt?

A

1-3 years

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31
Q

2 most common factors that increase a patient’s susceptibility to delirium?

A

Advanced age, Underlying brain disorder

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32
Q

Initial evaluation of patient with delirium?

A

Physical exam, CBC + UA

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33
Q

DOC for treatment of combative patient with delirium?

A

Low-dose haloperidol

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34
Q

Haloperidol belongs to class of …

A

Anti-psychotics

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35
Q

Diagnostic criteria for Tourette Syndrome?

A

2+ motor tics AND 1+ verbal tic

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36
Q

Examples of motor tics seen in Tourette Syndrome?

A

Should shrugging, blinking, grimacing

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37
Q

Examples of verbal tics seen in Tourette Syndrome?

A

Grunting, coughing, throat clearing

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38
Q

2 co-morbidities seen in Tourette Syndrome?

A

ADHD, OCD

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39
Q

Best treatment of Tourette Syndrome?

A

Habit-reversal psychotherapy + medication

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40
Q

DOC for treatment of Tourette Syndrome?

A

1st generation antipsychotics, 2nd generation antipsychotics, a2 agonists

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41
Q

2 examples of a2 agonists used in treatment of Tourette Syndrome?

A

Clonidine, Guanfacine

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42
Q

2 examples of 2nd generation antipsychotics used in treatment of Tourette Syndrome?

A

Risperidone, Aripiprazole

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43
Q

2 examples of 1st generation antipsychotics used in treatment of Tourette Syndrome?

A

Fluphenazine, Haloperidol

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44
Q

3 treatment options for bipolar I disorder in pregnant females?

A

1st generation anti-psychotics, Lithium, 2nd generation anti-psychotics

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45
Q

1st generation anti-psychotic of choice for pregnant females with bipolar I disorder?

A

Haloperidol

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46
Q

2 drugs that should be avoided in pregnant females with Bipolar I disorder?

A

Valproate, Carbamazepine

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47
Q

Duration of full trial of anti-depressants?

A

6 weeks

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48
Q

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?

A

Assess for substance use … (ETOH, stimulants, opioids)

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49
Q

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?

A

Disclose the minimum necessary information … “patient is medically-stable to return to work” … disclosing + suggesting that patient has HX of depression, substance is inappropriate

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50
Q

Description of pseudodementia?

A

Late-life depression that frequently presents with reversible cognitive impairment

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51
Q

Late-life depression (pseudodementia) is associated with an increased risk of …

A

Alzheimer dementia

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52
Q

32 yo female presents with new-onset psychosis (hallucinations); Reports weight loss, swollen wrists bilaterally, LE edema – diagnosis?

A

SLE

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53
Q

Initial step of diagnosis for SLE?

A

ANA

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54
Q

In addition to psychosis, what are 2 other aspects of clinical presentation seen in Acute Intermittent Porphyria (AIP)?

A

Abdominal pain, Peripheral neuropathy

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55
Q

Best management of antidepressant-induced hypomania?

A

Discontinuation of antidepressants

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56
Q

2 mood stabilizers that can be used for patients with bipolar disorder?

A

Valproate, Lithium

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57
Q

Patients with severe manic episodes in bipolar disorder can also be treated with ___, in addition to a mood stabilizer

A

Anti-psychotic

58
Q

Best initial test for patients presenting with new-onset psychosis?

A

Rule-out substance abuse

59
Q

Clinical presentation for opioid withdrawal?

A

Rhinorrhea, diarrhea, lacrimation

60
Q

2 pharmacologic treatment options for opioid withdrawal?

A

Opioid agonists, Clondine

61
Q

2 examples of opioid agonists used in treatment of opioid withdrawal?

A

Methadone, Buprenorphine

62
Q

When patient refuses to comply with inpatient/outpatient methadone treatment, what is next best option for treatment of opioid withdrawal?

A

Clonidine

63
Q

Best management of acute delirium + severe agitation, which poses a risk to safety of patient + care team?

A

Haloperidol

64
Q

Description of Histrionic Personality Disorder?

A

Attention-seeking behavior; Inappropriate, sexually provocative behavior

65
Q

2 comorbid conditions associated with Tourette Syndrome?

A

OCD, ADHD

66
Q

Best management of OCD?

A

SSRI + Cognitive Behavioral Therapy (CBT)

67
Q

Specific type of CBT that is effective for treatment of OCD?

A

Exposure and response prevention therapy

68
Q

In addition to SSRIs, what is another medication that can be helpful in treatment of OCD?

A

TCAs, Clomipramine

69
Q

Reproductive condition that SSRIs can treat?

A

Premature ejaculation … due to their ability to cause delayed ejaculation

70
Q

Timing required for diagnosis of acute stress disorder?

A

3 days – 1 month

71
Q

Timing required for diagnosis of PTSD?

A

> 1 month

72
Q

SSRI that treats with depression and insomnia?

A

Citalopram

73
Q

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?

A

Another SSRI

74
Q

Best management of SSRI-induced sexual dysfunction in patients with excellent response to SSRI?

A

Addition of bupropion or sildenafil

75
Q

Best management of SSRI-induced sexual dysfunction in patients with modest response to SSRI?

A

Switch from SSRI to bupropion or mirtazapine

76
Q

What might account for paranoid delusions and visual hallucinations following an increase in levodopa or other medications used to treat Parkinson’s disease (amantadine)?

A

Increased dopamine release

77
Q

Order in which anti-Parkinson medications should be stopped?

A

Everything before carbidopa/levodopa … anticholinergics, amantadine, MAO-B inhibitors, COMT inhibitors

78
Q

If psychosis continues in patient with Parkinson’s disease (after stopping dopamine agonists), which 3 medications can be used instead?

A

Quetiapine, clozapine, pimavanserin

79
Q

Clinical presentation of benzodiazepine poisoning?

A

Slurred speech, sedation

80
Q

Clinical presentation of opiate poisoning?

A

Sedation, constricted pupils, hypoactive bowel sounds, respiratory depression

81
Q

Clinical presentation of serotonin syndrome?

A

Tachycardia, nausea, vomiting, myoclonus, hyperreflexia, horizontal eye movements

82
Q

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?

A

Risperidone

83
Q

DOC for acute mania?

A

Risperidone

84
Q

First-line treatment for bipolar mania?

A

Valproate, lithium

85
Q

Limitations of valproate and lithium for maintenance of bipolar mania?

A

Slower onset, require titration

86
Q

3 good prognostic factors for schizophrenia?

A

Later age of onset, acute onset, (+) psychosis (delusions, hallucinations)

87
Q

Timeframe needed for diagnosis of schizophrenia?

A

6 months

88
Q

58 yo female presents for smoking cessation; Currently on nicotine patch, hoping to add varenicline; What is major risk of combining varenicline and nicotine?

A

No increased risk for serious complications

89
Q

MOA of varenicline in smoking cessation?

A

Partial nicotine agonist

90
Q

AE of varenicline?

A

Disordered sleep, abnormal dreams

91
Q

What is the best initial approach to an acutely psychotic patient?

A

Maintain interpersonal distance, attempt to understand patient’s experience without challenging patient’s delusions

92
Q

24 yo male presents with intoxication; PE shows aggressive behavior, nystagmus; HR 120, BP 160/110 - diagnosis?

A

PCP intoxication

93
Q

MOA of PCP?

A

NMDA receptor antagonist

94
Q

24 yo male presents with intoxication; PE shows aggressive behavior, nystagmus; HR 120, BP 160/110 - best next step?

A

Benzodiazepine

95
Q

4 factors that are protective against suicide?

A

Family support, Pregnancy, Parenthood, Religion (but patient-dependent)

96
Q

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?

A

Vitamin B12 deficiency

97
Q

Clinical presentation of Vitamin B12 deficiency in elderly patients?

A

Dementia, delirium

98
Q

Treatment of choice for Borderline Personality Disorder?

A

Dialectical behavioral therapy

99
Q

Mortality risk of anti-psychotics?

A

Both 1st and 2nd generation carry an increased risk of mortality

100
Q

What are the most common causes of death after use of anti-psychotics?

A

Cardiac events, fall, CVA, aspiration PNA

101
Q

Timing criteria for postpartum depression?

A

Peaks at 5 days post-partum, typically resolves within 2 weeks

102
Q

2 DOC for postpartum depression?

A

Sertraline, paroxetine

103
Q

Duration of adjustment syndrome?

A

Develops within 3 months of a feasible stressor; Resolves within 6 months of the stressor

104
Q

Clinical presentation of adjustment syndrome?

A

Loss of normal social OR occupational functioning

105
Q

Definition of treatment-resistant depression?

A

Major depressive disorder that does not respond to adequate trials of 2 different antidepressants

106
Q

Best management for patients with little to no improvement ) or unacceptable tolerability of antidepressants (nonresponders)?

A

Switch to different anti-depressant

107
Q

Best managementpartial responders patients who tolerate current antidepressant but with side effects (partial responders)?

A

Augmentation with additional antidepressant

108
Q

What are 2 benefits of bupropion?

A

Does not cause weight gain, does not cause sexual side effects

109
Q

MOA of bupropion?

A

Inhibits uptake of norepinephrine and dopamine

110
Q

Of the following medications, which should be avoided in pregnancy – citalopram, lithium, lorazepam, quetiapine, valproate?

A

Valproate

111
Q

Why should Valproate be avoided during pregnancy?

A

High risk of congenital malformations, NTDs

112
Q

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)?

A

Panic disorder

113
Q

Best chronic management of Panic disorder?

A

SSRI

114
Q

Best management of acute distress in Panic disorder?

A

Benzodiazepine

115
Q

3 key features of symptoms in panic disorder?

A

Avoidance behavior, anticipatory anxiety, unexpected onset of attacks

116
Q

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?

A

Behavioral therapy + nicotine combination replacement

117
Q

Utility of combination nicotine replacement therapy?

A

Decreased cravings and withdrawal symptoms

118
Q

Utility of varenicline therapy?

A

More effective than bupropion and combination nicotine replacement therapy

119
Q

AE of varenicline therapy?

A

Disordered sleep and nightmares

120
Q

Utility of bupropion therapy?

A

Decreased post-cessation weight gain; Good choice for patients with depression

121
Q

AE of bupropion therapy?

A

Contraindicated in patients with seizures or eating disorders

122
Q

What is the long-acting modality in combination nicotine replacement therapy?

A

Patch

123
Q

What is the short-acting modality in combination nicotine replacement therapy?

A

Gum, lozenge, nasal spray

124
Q

4 factors that are protective against suicide?

A

Family support, Pregnancy, Parenthood, Religion (but patient-dependent)

125
Q

Best management of acute pain in patient with HX of opioid abuse, but abstinent now?

A

Non-opioid analgesics first, adjuvant medications, regional anesthesia, partial opioid agonist (buprenorphine)

126
Q

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?

A

Serotonin syndrome

127
Q

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?

A

Combined use of SSRI and MAOI without sufficient 5-week washout

128
Q

38 yo male with schizophrenia presents for deterioration in overall functioning; PE reveals cataplexy - what is best management?

A

Lorezepam

129
Q

In addition to benzodiazepines, what is an alternate treatment for cataplexy?

A

ECT

130
Q

Test that may be performed to confirm diagnosis of cataplexy?

A

Lorazepam challenge

131
Q

What is best management for steroid-induced psychosis?

A

Reduce dose of steroids

132
Q

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?

A

Lithium toxicity due to interaction between lithium and chlorithalidone

133
Q

Therapeutic lithium range?

A

0.8-1.2

134
Q

3 classed of drugs that classically cause lithium toxicity?

A

Thiazide diuretics, ACEIs, NSAIDs

135
Q

How do thiazide diuretics cause lithium toxicity?

A

Increase Na excretion in distal tubule … causing increased Li retention in proximal tubule

136
Q

3 indications for HD as treatment for lithium toxicity?

A

Lithium level > 4; Lithium 2.5-4 with severe neurologic symptoms; Rising Lithium levels despite volume resuscitation

137
Q

Best management of acute ETOH withdrawal?

A

Benzodiazepines (lorazepam)

138
Q

Timing of onset for mild ETOH withdrawal?

A

6-24 hours

139
Q

Timing of onset for seizures in ETOH withdrawal?

A

12-48 hours

140
Q

Timing of onset for halucinations in ETOH withdrawal?

A

12-48 hours

141
Q

Timing of onset for delirium tremens in ETOH withdrawal?

A

48-96 hours

142
Q

Best management of patient requesting refills of lorazepam in patient with negative UDS for benzodiazepines?

A

Confirmatory testing with gas chromatography with mass spectroscopy

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