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MCCQE > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

Treatment for acute psychosis in an emergency setting:

4 options

A

1) Haloperidol 5 mg IM +/- lorazepam 2 mg
2) Loxapine PO +/- Lorazepam
3) Olanzapine PO/IM
4) Risperidone

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2
Q

What is trichotillomania?

A

Hair-pulling disorder

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3
Q

Most effective antypsychotic drug and its classification

A

Clozapine, atypical

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4
Q

Side effects of Clozapine, routine blodwork when using this drug

A 
Agranulocytosis
Anticholinergic activityh
Cardiomyopathy
Myocarditis
* Check CBC because of the risk of agranulocytosis
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5
Q

Name some typical antipsychotics (6 drugs)

A 
Haloperidol
Fluphenazine
Zuclopenthixol
Perphenazine
Loxapine
Chlorpromazine
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6
Q

Name some atypical antypsychotics (8 drugs)

A

1) Risperidone
2) Paliperidone
3) Olanzapine
4) Asenapine
5) Ziprasidone
6) Aripiprazole
7) Quetiapine
8) Clozapine

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7
Q

Clusters of personality disorders

A

Cluster A: “Mad” personality disorders
Cluster B: “Bad” personality disorders
Cluster C: “Sad” personality disorders

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8
Q

Cluster A personality disorders: characteristics, family history and typical defence mechanisms

A

(Cluster A: “Mad” personality disorder)
Characteristics: Patient seems odd, eccentric and withdrawn
Family history of psychotic disorders
Defence mechanisms: intellectualization, projection, magical thinking

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9
Q

Which personality disorders belong to Cluster A personality disorders? (3 disorders)
BONUS point for the mnemonic!

A

Cluster A: “Mad” personality disorder

1) Paranoid personality disorder (SUSPECT)
2) Schizotypal personality disorder (ME PECULIAR)
3) Schizoid personality disorder (DISTANT)

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10
Q

Which personality disorders belong to Cluster B personality disorders? (4 disorders)
BONUS point for the mnemonic!

A

Cluster B: “Bad” personality disorders.

1) Borderline personality disorder (IMPULSIVE)
2) Narcissistic personality disorder (GRANDIOSE)
3) Antisocial personality disorder (CORRUPT)
4) Histrionic personality disorder (ACTRESSS)

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11
Q

Which personality disorders belong to Cluster C personality disorders? (3 disorders)
BONUS point for the mnemonic!

A

Cluster C: “Sad” personality disorders.

1) Avoidant personality disorder (CRINGES)
2) Obsessive-compulsive personality disorder (SCRIMPER)
3) Dependent personality disorder (RELIANCE)

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12
Q

Cluster B personality disorders: characteristics, family history and typical defence mechanisms

A

Cluster B: “Bad” personality disorders.
Characteristics: Patient is dramatic, emotional, inconsistend
Family history of mood disorders
Defence mechanisms: Denial, acting out, regression, splitting, projective identification, idealization/devaluation

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13
Q

Cluster C personality disorders: characteristics, family history and typical defence mechanisms

A

Cluster C: “Sad” personality disorders
Characteristics: Patient is anxious and fearful
Family history of anxiety disorders
Defence mechanisms: isolation, avoidance hypochondriasis

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14
Q

Characteristic of dependent personality disorder

A

Pervasive and excessive need to be taken care of, excessive fear of separation, clinging and submissive behaviors.
Difficulty making everyday decisions.
Useful to set regulated treatment schedule (regular, brief visits) and being firm about in between issues. Encourage patient to do more for themselves, engage in own problem-solving.

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15
Q

Characteristics of Obsessive-Compulsive Personality Disorder

A

Preoccupation with orderliness, perfectionism, and mental and interpersonal control. Is inflexible, closed-off, and inefficient.

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16
Q

Characteristics of Avoidant Personality Disorder

A

Timid and socially awkward with a pervasive sense of inadequacy and fear of criticism. Fear of
embarrassing or humiliating themselves in social situations so remain withdrawn and socially
inhibited

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17
Q

Characteristics of Histrionic Personality Disorder

A

Attention-seeking behaviour and excessively emotional. Are dramatic, flamboyant, and extroverted. Cannot form meaningful relationships. Often sexually inappropriate

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18
Q

Characteristics of antisocial personality disorder

A

Lack of remorse for actions, manipulative and deceitful, often violate the law. May appear charming on first impression. Pattern of disregard for others and violation of others’ rights must be present before age 15; however, for the diagnosis of ASPD patients must be at least 18. Strong association with Conduct Disorder, history of trauma/abuse common

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19
Q

Characteristics of narcissistic personality disorder

A

Sense of superiority, needs constant admiration, lacks empathy, but with fragile sense of self. Consider themselves “special” and will exploit others for personal gain

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20
Q

Characteristic of borderline personality disorder

A

Unstable moods and behaviour, feel alone in the world, problems with self-image. History of repeated suicide attempts, self-harm behaviours. Inpatients commonly report history of sexual abuse. Tends to fizzle out as patients age.

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21
Q

Characteristic of schizoid personality disorder

A

Neither desires nor enjoys close relationships including being a part of a family; prefers to be alone. Lifelong pattern of social withdrawal. Seen as eccentric and reclusive with restricted affect

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22
Q

Characteristic of schizotypal personality disorder

A

Pattern of eccentric behaviours, peculiar thought patterns

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23
Q

Characteristics fo paranoid personality disorder

A

Pervasive distrust and suspiciousness of others, interpret motives as malevolent. Blame problems on others and seem angry and hostile.

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24
Q

Name the types of delusions (7) and explain them

A

1) Persecutary delusions: Others are trying to harm them
2) Delusions of grandeur: Believes that they have special powers, talents or abilities
3) Somatic delusions: Belief that they have a physical disorder/defect
4) Delusions of reference: Interpreting publicly known events/celebreties as having a direct reference to them.
5) Nihilistic delusions: Belief that things do not exist, are meaningless or nothing is real
6) Erotomania: belief that another is in love with them
7) Religious: receiving instructions/powers from a higher being, believes to be a higher being

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25
Q

Symptoms of TCA overdose + findings on ABG

A

Palpitations, chest pain, hypotension, arrhythmias, decreased mental status, respiratory depression, increased temperature, flushing, dilated pupils.
ABG: Acidosis and hypoxia

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26
Q

Tourette’s syndrome: preferred medications (2 options)

A

Dopamine-receptor-blocking agents are most effective.
Pimozide (antipsychotic)
Clonisine (alpha 2 agonist)

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27
Q

5 risk factors for delirium

A

1) Impaired vision/hearing
2) Dehydration
3) Immobility
4) Cognitive impairment
5) Sleep deprivation

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28
Q

Symptoms of serotonin syndrome

A

1) Mental status: anxiety, restlessness
2) Increased autonomic activity: tachycardia, hypertension, fever, shivering, diaphoresis
3) Increased neuromuscular activity: tremor, rigidity

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29
Q

Causes of serotonin syndrome

A 
SSRI+SNRI
SSRI/SNRI+MAOI
SSRI/MAOI+tryptophan
MAOI+meperidine
Tramadol+MAOI/SSRI
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30
Q

Treatment of serotonin syndrome

A

Supportive treatment.
(Benzodiazepines)
Cyproheptadine - serotonin antagonist (not used often)

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31
Q

Indications to use electroconvulsive treatment (6)

A

1) Depression: poor response to antidepressants, psychotic features, catatonic features, when medications may be unsafe or rapid response is needed
2) Catatonia: refractory, severe or life-threatening
3) Schizophrenia: acute symptoms with poor response to antipsychotics, catatonia, history of NMS
4) Mania: refractory, severe or life-threatening situation
5) Personal or family history of good response to ECT
6) Inconclusive evidence for OCD

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32
Q

Antidepressant for children

A

Fluoxetine (SSRI), is the only indicated drug for patients aged 8-17 years

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33
Q

Indications for methylphenidate. Also class of drug + trade name

A

1) ADHD
2) Narcolepsy
3) Terminal patients with depression (decreased mood and suicidal thoughts with short life expectancy)
4) Fatigue in MS patients

It’s a CNS stimulant. AKA Ritalin

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34
Q

Management of a patient with a high risk of suicide

A

1) Hospitalization (if he/she refuses - complete form for involuntary admission)
2) Do not leave alone, remove dangerous objects from the room.

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35
Q

Difference between brief psychotic, schizophreniform disorders and schizophrenia

A

Time
< 1 month: Brief psychotic disorder
1-6 months: Schizophreniform disorder
> 6 months: Schizophrenia

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36
Q

Symptoms of psychosis and how many are needed

A

Criterion A for Schizophrenia (psychotic symptoms) 2 or more are needed:

1) Delusions
2) Hallucinations
3) Disorganized speech
4) Grossly disorganized or catatonic behaviour
5) Negative symptoms (diminished emotional expression or avolition)

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37
Q

Differentiate the psychotic disorders (symptoms and duration) (7 disorders)

A
  • Psychotic symptom = Criterion A symptoms
    1) Brief psychotic disorder: 1 + psychotic symptom for < 1 month
    2) Schizopheniform disorder: Psychotic symptoms 1-6 months
    3) Schizophrenia: psychotic symptoms >6 months
    4) Schizoaffective disorder: psychotic symptoms + major mood episode (but > 2 weeks psychotic without mood symptoms). durations >1 month
    5) Delusional disorder: Non-bizarre delusions (+/- hallucinations) >1 month
    6) Substance-induced psychotic disorder: delusions/hallucinations that resolves <1 mo after drug use
    7) Secondary to mood disorder: Mood symptoms are dominant + delusions/hallucinations
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38
Q

Investigations for psychotic patients

A
  • CBC, electrolytes, creatinine, glucose, urinalysis, urine drug screen, TSH, vitamin B12
  • Baseline before antipsychotics: LFTs, fasting lipids, HbA1C, ECG
  • If indicated clinically: infectious work-up, inflammatory markers, brain imaging
39
Q

Management of schizophrenia (groups of drugs + psychosocial)

A

1) Antipsychotics. Adjunctives: Mood stabilizers (for aggression/impulsiveness), Anxiolytics, ECT.
2) Psychotherapy, CBT, Assertive community treatment
3) Social skills training, employment programs, disability benefits
4) Housing.

40
Q

Duration of pharmacological treatment for schizophrenia

A

1-2 years after first episode

At least 5 years after multiple episodes

41
Q

Medical work-up for mood disorders

A

Physical exam
CBC, extended electrolytes, renal, liver and thyroid function tests, drug screen
Medication list
Additional: B12 in elderly, neurological consultation, chest X-ray, ECG, head imaging

42
Q

Difference between a full manic episode and hypomanic episode

A

Hypomanic episode lasts > 4 days. Does not cause marked impairment in social/occupational function
If the patient has psychotic features: this is a manic episode

43
Q

Risk factors for major depressive disorder (7)

A

1) Sex: female
2) Family history of depression, alcohol abuse, suicide attempt or completion
3) Childhood experiences: Loss of parent before 11 yrs, negative home environment (abuse, neglect)
4) Personality: neuroticism, insecure, dependent, obsessional
5) Recent stressors: Illness, financial, legal, relational, academic
6) Lack of intimate, confiding relationships or social isolation
7) Low socioeconomic status

44
Q

Treatments for major depressive disorder (pharmacological groups + nonpharmacological) (6)

A

1) Lifestyle: aerobic exercises, mindfulness-based stress reduction
2) Pharmacological: SSRIs, SNRIs, other antidepressants
3) Somatic: ECT. rTMS (repetitive transcranial magnetic
stimulation) . Phototherapy
4) Psychological: Individual (e.g CBT), group or family therapy
5) Social: Vocational rehabilitation, social skills training
6) Experimental: magnetic seizure therapy, deep brain stimulation, ketamine

45
Q

Difference between major depressive disorder and persistent depressive dis order

A

Persistent depressive disorder lasts for > 2 years with less than 2 continuous months without depressive symptoms.

46
Q

Risk factors for postpartum depression (major depressive disorder with peripartum onset) (8)

A

1) Previous history of mood disorder
2) Family history of mood disorder
3) Stressful life events
4) Unemployment
5) Marital conflict
6) Lack of social support
7) Unwanted pregnancy
8) Colicky or sick infant

47
Q

Treatment of postpartum depression (major depressive disorder with peripartum onset)

A

1) Psychotherapy (CBT or IPT - interpersonal therapy)
2) SSRIs (safe for breastfeeding short-term, long-term unknown)
3) If severe or with psychotic symptoms: ECT

48
Q

Which disorder is strongly associated with sleep walking?

A

Thyrotoxicosis

49
Q

Which NSAIDs can be used with Lithium?

A

Aspirin and sulindac

50
Q

Common interactions with lithium

A

1) NSAIDs, ACE-inhibitors and thiazides increase serum levels of lithium.
2) Mannitol and aminophylline decrease serum levels of lithium.
3) Anticonvulsants: additive neurotoxicity
4) Neuroleptics: additive extrapyramidal side effects
5) Lithium increases duration of action of NM-blocking agents
6) Increases risk of delirium with ECT (pause lithium before ECT)

51
Q

Disorders associated with persistent depressive disorder

A 
Major depression
Social phobias
Personality disorders
Cerebrovascular accidents
MS
AIDS
PMS
Hypothyroidism
52
Q

Treatment for Tourette’s disorder

A 
Fluphenazine, pimozide
Tetrabenazine
Clonidine
Clonazepam
Deep brain stimulation
53
Q

What is the difference between Bipolar 1 and Bipolar 2?

A

Bipolar 1: More manic episodes. Requires at least 1 manic episode for diagnosis.
Bipolar 2: Hypomanic episodes instead of manic episodes. Requires 1 major depressive episode, 1 hypomanic episode, and 0 manic episodes.

54
Q

Risk factors of bipolar disorder:

A

1) Family history of major mood disorder
2) These characteristics of major depressive episode (MDE): Age <25 yrs, several MDEs, psychotic symptoms, onset postpartum, anxiety, antidepressant failure, early
impulsivity and aggression, substance abuse, cyclothymic temperament

55
Q

Medications for bipolar disorder

A

Lithium
Lamotrigine
Lurasidone
Seroquel

56
Q

Treatment for manic episode:

A

Lithium (mood stabilizer), divalproex (anticonvulsant), carbamazepine (antiepileptic, 2nd line), 2nd gen antipsychotics, ECT, benzodiazepines

57
Q

Prevention of mania

A

Lithium, divalproex, carbamazepine (2nd line), SGA (second generation antipsychotics).
Lower doses than when treating an manic episode

58
Q

Treatment of bipolar depression

A

The 4 Ls: Lithium, lurasidone, quetiapine (seroqueL), lamotrigine.
Antidepressants (never as monotherapy in bipolar)
ECT

59
Q

First line drug for treating depression in Bipolar type 2:

A

Quetiapine (seroqueL)

60
Q

What is cyclothymia

A

Periods of hypomanic an depressive symptoms, that do not meet the criteria for full hypomanic episode or major depressive episodes. For diagnosis this state has to last for 2 yrs, never more than 2 months without symptoms

61
Q

General treatment for cyclothymia

A

Mood stabilizers
Psychotherapy
Avoid antidepressants in monotherapy
Treat comorbid substance use disorder

62
Q

Bupropion is contraindicated in which patients and why

A

Bulimia and anorexia due to higher incidence of seizures

63
Q

What is anxiety associated with?

A

Depression

Substance abuse

64
Q

Workup of patient presenting with symptoms of anxiety

A

Routine: Physical exam, CBC, electrolytes, thyroid function test, ECG.
Additional screening: Extended electrolytes, vit B12, folate, chest x-ray, head imaging, neurological consultation. Other tests to exclude differential diagnoses

65
Q

Risk factors of Anxiety disorders

A
  • Somatic: Endocrine disorders (hyperthyroidism), respiratory conditions (asthma, COPD), CNS conditions (temporal lobe epilepsy, substances/medications, chronic medical illness.
  • Family history
  • Personal previous anxiety or mood disorder
  • Female
  • early childhood trauma, current stress, early parental loss
66
Q

Treatment for panic disorder

A

CBT
1st line: SSRIs: fluoxetine, citalopram, esscitalopram, proxetine, setraline fluvoxamine. SNRIs: Venlafaxine
2nd line: Mirtazapine, MAOIs, benzodiazepines

67
Q

Diagnostic criteria for agoraphobia

A

Marked fear for at least 2: public transport, open spaces, being in enclosed places, being in a crowd/standing in line, being outside alone

68
Q

Treatment for generalized anxiety disorder

A

1) Lifestyle: Avoid alcohol and caffeine. Sleep hygiene
2) CBT, relaxation techniques, mindfulness
3) SSRIs, SNRIs, pregabalin
4) 2nd line: benzodiazepines

69
Q

Common comorbidities to OCD

A 
Anxiety disorders
Depression
Obsessive-compulsive personality disorder
Tic disorders
Body dysmorphic disorder
Trichotillomania
Excoriation disorder
70
Q

Risk factors for OCD (5)

A

1) Neurological dysfunction
2) Family history
3) Adverse childhood experiences
4) Traumatic events
5) Group A streptococcal infection

71
Q

Pharmacological treatment of OCD

A 
SSRIs/SNRIs: 12-16 weeks trials, higher doses than in depression
Clomipramine
Adjunctive antipsychotics (risperidone)
72
Q

Disorders related to OCD

A

1) Body dysmorphic disorder
2) Hoarding disorder
3) Trichotillomania (hair-pulling disorder)
4) Excoriation disorder (skin-picking disorder)

73
Q

What is body dysmorphic disorder?

A

Preoccupation with 1 + flaws in physical appearance not observed by others. Repetitive behaviors

74
Q

Which disorders must be excluded before diagnosing hoarding disorder? (8)

A

1) Brain injury
2) Cerebrovascular disease
3) Prader-Willi syndrome
4) OCD
5) MDD (major depressive disorder)
6) Psychotic disorder (delusions)
7) Neurocognitive disorder
8) ASD (restricted interests) (autism spectrum disorder)

75
Q

What is excoriation disorder?

A

Skin-picking disorders

76
Q

What is the difference between acute stress disorder and PTSD?

A

Time. Acute stress disorder: 3 days after trauma, up to 1 month. May be a precursor to PTSD .
PTSD: Symptoms for more than 1 month

77
Q

PTSD: Treatment

A

CBT, trauma therapy.
Eye movement desensitization and reprocessing (EMDR).
Pharmacological: 1st line: Fluoxetine, paroxetine, sertraline (SSRIs), venlaflaxine XR (SNRI).
Prazosin - nightmares (alpha 1 receptor blocker)
Benzodiazepines - acute anxiety
Adjunctive atypical antipsychotics - risperidone, olanzapine

78
Q

What is adjustment disorder?

A

Acute emotional/behavioral symptoms that resemble less severe versions of other psychiatric conditions. Occurs due to difficulty dealing with stressful live event/situations. Does not last more than 6 months after the stressor is removed.

79
Q

Risk factors of poor bereavement outcomes

A

Poor social supports
Unanticipated death or lack of preparation for death
Highly dependent relationship with deceased
High initial distress
Other concurrent stresses and losses
Death of a child
Pre-existing psychiatric disorders (esp depression and separation anxiety)

80
Q

Symptoms that may indicate abnormal grief or presence of major depressive disorder

A

Excessive guilt
Excessive thoughts if death/worthlessness
Marked psychomotor retardation, functional impairment
Hallucinatory experiences other than hearing the voice/transiently seeing the image of the deceased person.
Pervasive dysphoria, absence of mood reactivity.

81
Q

Risk factors for delirium

A

Polypharmacy, infection, dehydration, immobility, malnutrition, bladder catheters.
Hospitalization (of frail and surgical patients). Previous delirium, nursing home residents, old age (esp males), severe illness, resent anesthesia or surgery.
pPre-existing neurologic or neurocognitive disorder, substance abuse, past psychiatric illness

82
Q

Work up of delirious patient

A

CBC + differential. Electrolytes (+ ca2+,mg2+, po43-), glucose, BUN, Cr, TSH/T4, LFTs, vit B12, folate, albumin, urinalysis, urine C&S.
If indication: ECG, CXR, head CT/MRI, toxicology/heavy metal. VDRL, HIV, LP, blood cultures, EEG

83
Q

Treatment of delirium

A

Manage underlying cause
Reorient and optimize the environment
Low dose haloperidol. Or risperidone, olanzapine, quetiapine, aripiprazole.
Benzodiazepines are only used in substance withdrawal delirium.
Minimize drugs with anticholinergic effects.

84
Q

How to preform the “Mini Cog” rapid assessment

A

3 words immediate recall
Clock drawn to 10 past 11
3 words delayed recall

85
Q

Difference between Alzheimer’s, frontotemporal degeneration, Lewy body disease, vascular disease, normal pressure hydrocephalus (NPH)

A

Alzheimer’s disease: Memory and learning issues
Frontotemporal degeneration: language type (early preservation), behavioral type (apathy, disinhibition, self-neglect)
Lewy body disease: recurrent, soft visual hallucinations (e.g rabbits), autonomic impairment (falls, hypotension), EPS, poor response to pharmacy, fluctuating degree of cognitive impairment
Vascular disease: Vascular risk factors, focal neurological signs, abrupt onset, stepwise progression
NPH: abnormal gait, early incontinence, rapidly progressive

86
Q

Do you have to inform the Ministry of Transportation about a demented person’s inability to drive?

A

Yes

87
Q

Pharmacological therapy for dementia

A 
Cholinesterase inhibitors (donepezil, rimestigmine, galantamine). 
NMDA receptor antagonist (memantine). 
Low-dose antipsychotics (risperidone, aripripazole), escitalopram (SSRI), trazodone: for behavioral or emotional symptoms.
88
Q

Which screening questionnaire would you use for alcohol use disorders?

A

CAGE.
Ever felt the need to Cut down on your drinking?
Ever felt Annoyed at criticism of your drinking?
Ever feel Guilty about your drinking?
Ever need a drink first think in the morning? (Eye opener)

89
Q

Symptoms of delirium tremens

A 
Autonomic hyperactivity (diaphoresis, tachycardia, increased respiration) 
Hand tremor
Insomnia
Psychomotor agitation
Anxiety
Nausea/vomiting
Tonic-clonic seizures
Visual/tactile/auditory hallucinations
Persecutory delusions
90
Q

Stages of alcohol withdrawal

A

1: 4-12 h. tremor, sweating, agitation, anorexia, cramps, diarrhea, sleep disturbance, anxiety, insomnia, headache.
2: 12-24h: alcoholic hallucinosis: visual, auditory, olfactory or tactile hallucinations.
3: 24-48 h: Seizures - tonic-clonic, non-focal, and brief.
4: 48-72 h: delirium tremens, confusion, hallucinations, delusions, agitation, tremors, autonomic hyperactivity (fever, tachycardia, HTN).

91
Q

Management of alcohol withdrawal

A

According to CIWA-A scale:
Diazepam 20 mg every 1-2 h until CIWA-A <10. If >65 yrs, severe liver or respiratory disease: lorazepam
Thiamine 100 mg IM, then 100 mg PO OD for 3d.
Hallucinations: Haloperidol
Hydration and nutrition.

92
Q

Brain disorders caused by alcohol overuse and causes of these disorders

A

Wernicke-Korsakoff syndrome because of thiamine deficiency.
Wernicke’s encephalopathy (acute, reversible): Triad - oculomotor dysfunction (nystagmus), gait ataxia, confusion
Korsakoff’s syndrome (chronic, 20 % reversible): Anterograde amnesia, confabulation. Must persist beyond intoxication/withdrawal

93
Q

Pharmacological treatment for alcohol use disorder

A

Naltrexone (opioid antagonist): reduce the “high”, cravings, can be started while still consuming.
Acamprosate (NMDA glutamate receptor antagonist): Maintaining abstinence and decreasing cravings.
Disulfiram (antabuse): toxic and potentially fatal reaction if patient drinks alcohol.

MCCQE (4 decks)

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