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USMLE Step 3 > Psychiatry > Flashcards

Psychiatry Flashcards

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USMLE® Step 1 flashcards
1
Q

Positive sxs in psychotic disorders are associated with which type of receptor?

A

dopamine

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2
Q

Negative sxs in psychotic disorders are associated with which type of receptor?

A

muscarinic

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3
Q

Best initial test in patients w/ psychosis?

A

drug tox screen

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4
Q

What is the first step in management of any patient w/ an acute psychiatric condition?

A

determine if the patient needs hospitalization - i.e. if patient poses a risk to self or others (SI or HI)

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5
Q

Management of psychosis?

A
  1. If case describes bizarre or paranoid sxs –> hospitalize
  2. Give benzos for agitation and start antipsychotics (duration 6 mo if one time; long-term if h/o repeat episodes).
  3. Initiate long-term psychotherapy
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6
Q

Give examples of conventional HIGH potency antipsychotics.

A
  • fluphenazine

- haloperidol

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7
Q

Advantages of HIGH potency antipsychotics?

A
  • less sedating
  • fewer anticholinergic effects
  • less hypotension
  • useful as depot injections (e.g. haloperidol decanoate, fluphenazine) for noncompliant or delirious patients
  • give IM for acute psychosis when patient can’t take PO
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8
Q

DISadvantages of HIGH potency antipsychotics?

A

greatest a/w extrapyramidal sxs (EPS)

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9
Q

Name some low potency conventional antipsychotics.

A

Thioridazine, chlorpromazine

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10
Q

What are the advantages of low potency conventional antipsychotics?

A

less likely to cause EPS

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11
Q

What are the DISadvantages of conventional low potency antipsychotics?

A

greater anticholinergic effects, more sedation, more postural hypotension

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12
Q

Name some atypical antipsychotics.

A

risperidone, olanzapine, quetiapine, clozapine

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13
Q

What are the advantages of the atypical antipsychotics?

A
  • drug of choice for initial therapy
  • greater effect on NEGATIVE symptoms
  • little or no risk of EPS
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14
Q

What are the disadvantages of the atypical antipsychotics?

A

Clozapine is reserved for treatment-resistant patients due to risk of agranulocytosis - check baseline CBC. If ok after 6 mo, can decrease monitoring to bimonthly, then monthly.

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15
Q

What side effects is thioridazine a/w?

A
  • prolonged QT and arrythmias

- abnormal retinal pigmentation (after years of therapy) - get routine eye exams

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16
Q

What are common reasons for noncompliance with conventional low-potency antipsychotics in men? In women?

A
  • Men: impotence, inhibition of ejaculation (alpha blocker effect)
  • Women: weight gain (due to hyperprolactinemia)
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17
Q

Which antipsychotic has the greatest weight gain a/w it?

A

Olanzapine

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18
Q

What are good antipsychotics for insomnia?

A

Olanzapine, quetiapine, ziprasidone, aripiprazole

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19
Q

When sedation is a problem w/ antipsychotic meds, which med to try?

A

Risperidone

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20
Q

If acute dystonia 2/2 antipsychotic develops, what is the management?

A
  • Reduce dose of antipsychotic.

- Prescribe: anticholinergics (benztropine, diphenhydramine, trihexyphenidyl)

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21
Q

When bradykinesia (Parkinsonism) develops 2/2 antipsychotic, what is the management?

A
  • Reduce dose of antipsychotic.

- Prescribe: anticholinergics (benztropine, diphenhydramine, trihexyphenidyl)

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22
Q

When akathisia develops 2/2 antipsychotic med, what is the management?

A
  • reduce dose
  • add *beta-blockers or benzos
  • switch to newer antipsychotics
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23
Q

If tardive dyskinesia develops 2/2 antipsychotics, what is the management?

A
  • stop older antipsychotics

- switch to newer antipsychotics (e.g. clozapine)

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24
Q

If neuroleptic malignant syndrome occurs 2/2 antipsychotic, what is the managment?

A

stop the antipsychotic, transfer to ICU for monitoring (20% mortality!)

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25
Q

Tx of panic disorder?

A
  • CBT
  • relaxation training/desensitization
  • meds: SSRIs (e.g. fluoxetine), benzos (e.g. alprazolam, clonazepam), imipramine, MAOIs (e.g. phenelzine)
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26
Q

Tx of phobic disorders? Of social phobia in particular?

A

Phobic disorders:

  • exposure therapy (aka conditioning) –> habituation
  • benzos and beta blockers helpful prior to exposure

Social phobias: exposure therapy + SSRIs, buspirone

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27
Q

Tx of OCD?

A
  • behavioral psychotherapy

- pharmacotherapy: SSRIs and clomipramine (latter = a TCA)

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28
Q

Tx of Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD)?

A
  • benzos acutely for anxiety
  • SSRIs and other antidepressants for long-term therapy
  • group counseling is most effective to prevent PTSD following traumatic event
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29
Q

Tx of generalized anxiety disorder?

A
  • supportive psychotherapy (incl relaxation training, biofeedback)
  • meds: SSRIs, venlaxafine (an SNRI also used for depression), buspirone, benzos
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30
Q

Tx of adjustment disorder w/ anxious mood?

A

-benzos with brief psychotherapy

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31
Q

Put these in order from shortest to longest half-life:

  • lorazepam
  • Alprazolam
  • diazepam
A

Alprazolam (Xanax) < lorazepam (Ativan) < diazepam (Valium)

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32
Q

MoA of buspirone

A

5HT 1A receptor partial agonist

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33
Q

Advantages of buspirone?

A

can be used safely w/ other sedative-hypnotics (no additive effect), best option for people w/ occupations where driving or machinery is involved (no sedation or cognitive impairment), no withdrawal syndrome

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34
Q

What other conditions should you screen for when you are considering diagnosing a patient with major depressive disorder?

A
  • Hypothyroidism (TSH, free T4)
  • Parkinson’s disease
  • meds: corticosteroids, beta-blockers, antipsychotics (esp. elderly), reserpine
  • substance disorders
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35
Q

Tx of MDD?

A
  • admit if SI/HI or paranoia
  • Begin antidepressant (SSRI = tx of choice)
  • Give benzos if agitated
  • ECT is best choice if patient suicidal
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36
Q

In patients with unipolar psychotic depression, what drug combo is most effective?

A

antidepressant + antipsychotic

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37
Q

Tx for dysthymic d/o?

A
  • do NOT hospitalize unless there is suicidal ideation
  • long-term individual, insight-oriented psychotherapy
  • if psychotherapy fails, trial of SSRIs
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38
Q

Tx of seasonal affective disorder?

A

phototherapy or sleep deprivation

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39
Q

What is rapid cycling bipolar d/o?

A

> 4 episodes of mania/year

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40
Q

Tx of bipolar disorder?

A
  • 1st line: monotherapy w/ Li+, Lamotrigine, or risperidone (PO or IM)
  • 2nd line: aripiprazole, divalproex, quetiapine, olanzapine, ?carbamazepine
  • patients w/ multiple recurrences need combo therapy
  • psychotherapy and CBT are always a part of it
  • avoid teratogenic drugs (e.g. Li+, valproate, carbamazepine) in female patients
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41
Q

What problems can Li+ therapy lead to?

A

Ebstein’s anomaly and diabetes insipidus, hypothyroidism

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42
Q

What are the steps in management of acute mania?

A
  1. hospitalize
  2. mood stabilizers (Li+ = drug of choice)
  3. antipsychotics until acute mania is controlled (risperidone = drug of choice)
  4. IM depot phenothiazine in noncompliant severely manic patients
  5. antidepressants only when a h/o recurrent episodes of depression and ONLY w/ mood stabilizers
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43
Q

How is rapid cycling bipolar d/o managed?

A

gradually stop all antidepressants, stimulants, caffeine, benzos, alcohol

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44
Q

What other conditions predispose a patient to rapid cycling bipolar d/o?

A

hypothyroidism - check TSH, replace thyroid hormones if needed

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45
Q

What drug has been shown to prevent suicidal ideation in bipolar d/o?

A

lithium

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46
Q

If bipolar patient on lithium becomes pregnant, how do you manage?

A

D/C lithium, start ECT in 1st trimester, switch to lamotrigine in 2nd or 3rd trimester

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47
Q

Management of cyclothymia?

A
  1. psychotherapy

2. divalproex when functioning is impaired

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48
Q

Tx of postpartum depression?

A

antidepressants

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49
Q

Sxs of postpartum psychosis?

A

psychotic sxs + severe depressive sxs

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50
Q

Tx of postpartum psychosis?

A

mood stabilizers or antipsychotics + antidepressants; if patient breastfeeding, choose ECT

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51
Q

Tx of acutely suicidal patient?

A
  1. hospitalize (usu at least 2 weeks)
  2. psychotherapy and antidepressants (SSRIs are first choice)
  3. for acute severe risk of self-harm, treatment of choice is ECT
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52
Q

Indications of ECT?

A
  • major depressive episodes unresponsive to meds
  • high risk for immediate suicide
  • contraindications to using antidepressant meds
  • good response to ECT in past
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53
Q

Guidelines for Use of Antidepressants:

What antidepressant is usu first line therapy?

A

SSRIs - think of first for patients w/ MDD, BPD, anxiety d/os, bulimia

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54
Q

Guidelines for Use of Antidepressants:

Which should be avoided?

A

TCAs (e.g. amitriptyline) - risk of toxicity

55
Q

Guidelines for Use of Antidepressants:

Which is most helpful in atypical depressive d/os?

A

MAOIs

56
Q

Guidelines for Use of Antidepressants:

What should you do if patient does not respond to med after 8 weeks or does not tolerate SFX?

A

switch to another antidepressant

57
Q

Guidelines for Use of Antidepressants:

For how long should you treat? Then what?

A

6 mo; then attempt to taper; consider long-term therapy for multiple episodes of depression

58
Q

Guidelines for Use of Antidepressants:

Which med best when trying to lose or maintain weight?

A

Buproprion (a/w mild weight loss; but also a/w seizures)

59
Q

Guidelines for Use of Antidepressants:

Which med best when trying to gain weight for the patient?

A

mirtazapine (a/w weight gain)

60
Q

Guidelines for Use of Antidepressants:

Which med good for chronic pain?

A

amitriptyline

61
Q

Guidelines for Use of Antidepressants:

Which med good for enuresis?

A

imipramine

62
Q

Guidelines for Use of Antidepressants:

Which med good for severe insomnia?

A

trazodone (doxepin also has sedating effects)

63
Q

Guidelines for Use of Antidepressants:

Which meds ok in pregnancy?

A

SSRIs and TCAs (except paroxetine i.e. Paxil)

64
Q

Which meds a/w seizures?

A

bupropion, TCAs

65
Q

A woman is brought into ED w/ confusion, disorientation, hypotension, tachycardia, dilated pupils, dry mucous membranes, facial flushing - which prescription med did she OD on?

A

TCAs - they have anticholinergic FX and are an alpha blocker

66
Q

A woman is brought into ED w/ confusion, disorientation, hypotension, tachycardia, dilated pupils, dry mucous membranes, facial flushing - what is most important test to run?

A

EKG - look out for prolonged QRS, QT, PR. Most serious complication is Vtach, Vfib

67
Q

A woman is brought into ED w/ confusion, disorientation, hypotension, tachycardia, dilated pupils, dry mucous membranes, facial flushing - which antidote should be given?

A
  1. sodium bicarb - alkalinizes the blood, uncouples TCA from myocardial sodium channels, increases extracellular Na+ concentration, improving gradient across the channel
  2. for mgmt of arrythmias: give lidocaine
68
Q

SFX of lithium?

A
  • acne
  • weight gain
  • dose-related tremors, GI distress, HA
  • hypothyroidism
  • polyuria 2/2 med-induced DI
69
Q

SFX of carbamazepine?

A

agranulocytosis, sedation

70
Q

SXS of Li+ OD?

A

-N/V, disorientation, tremors, increased DTRs, seizures

71
Q

Tx of Li+ OD?

A

dialysis

72
Q

SXS of NMS?

A

high fever, tachycardia, muscle rigidity, altered consciousness, autonomic dysfunction

73
Q

Tx of NMS?

A
  • ICU transfer
  • D/C antipsychotic
  • bromocriptine (to overcome DA receptor blockade)
  • give muscle relaxants dantrolene or diazepam to reduce muscle rigidity
74
Q

SXS of serotonin syndrome?

A

h/o SSRI use, use of migraine meds (triptan) or MAOI; agitation, hyperreflexia, hyperthermia, muscle rigidity w/ volume contraction 2/2 sweating and insensible fluid losses

75
Q

Tx of serotonin syndrome

A
  • IVF
  • cyproheptadine to decrease serotonin production
  • benzos to decrease muscle rigidity
76
Q

Typical history of MAOI Hypertensive Crisis?

A

-patient w/ acute HTN, h/o MAOI use, and either antihistamines, nasal decongestants, consumption of tyramine-rich foods (cheeses, pickled foods)

77
Q

Tx of MAOI hypertensive crisis?

A

treat as hypertensive crisis

78
Q

Requirements for Dx of somatization d/o?

A
  • 4 pain sxs
  • 2 GI sxs
  • 1 sexual symptom
  • 1 pseudoneurologic symptom
79
Q

What is conversion d/o?

A

when one or more neurologic symptoms that cannot be explained by any medical or neuro d/o

80
Q

How long must sxs be present for dx of hypochondriasis?

A

6 mo

81
Q

Tx of anorexia nervosa AND bulimia nervosa?

A
  1. hospitalize for IV hydration if electrolyte disturbances present
  2. olanzapine in anorexia patients (helps w/ weight gain)
  3. SSRIs (esp fluoxetine) prevents relapses
  4. behavioral psychotherapy
82
Q

Tx of body dysmorphic d/o

A

high dose SSRIs

83
Q

Tx of intermittent explosive d/o?

A

SSRIs and mood stabilizers

84
Q

Tx of pathologic gambling?

A

group psychotherapy

85
Q

Tx of personality disorders?

A
  • psychotherapy
  • For Cluster B (mood lability, dissociative sxs, preoccupation w/ rejection): mood stabilizers and antidepressants is sometimes useful
86
Q

What should you order when the case describes someone with alcohol abuse?

A
  • blood and urine tox screen
  • look for secondary FX of EtOH: AST, ALT, LDH, ?GGTP
  • if s/o IV drug use (e.g. track marks): HIV, hep B, hep C, PPD tests
87
Q

What is the inpatient management of acute alcohol withdrawal?

A
  1. Look for withdrawal sxs.
  2. IV or IM thiamine and Mg2+ ASAP, B12, folate: to prevent Wernicke-Korsakoff (ataxia, nystagmus, ophthalmoplegia, amnesia)
  3. benzos: diazepam or chlordiazepoxide; if patient has severe liver disease, choose short-acting benzo - lorazepam or oxazepam
  4. no seizure PPX - treat SZs w/ diazepam

HALDOL IS NEVER THE ANSWER (REDUCES SEIZURE THRESHOLD)

88
Q

What is the chronic management of EtOH dependence?

A
  1. Refer to inpatient rehab or outpatient group therapy (AA)
  2. Never give drug therapy without group psychotherapy
  3. naloxone and acamproate decrease relapse rate ONLY when given w/ psychotherapy
  4. disulfiram has poor compliance and hasn’t shown to be effective
89
Q

Alcohol Withdrawal:

What is seen 6 hours after last drink? Tx?

A
  • minor sxs: insomnia, tremulousness, mild anxiety, HA, diaphoresis, palpitations
  • Tx: give thiamine, folate, MVI, glucose
90
Q

Alcohol Withdrawal:

What is seen 12-24 hours after last drink?

A

-sxs: visual hallucinations, +/- auditory or tactile hallucinations

91
Q

Alcohol Withdrawal:

What is seen 48 hours after last drink? Mgmt tip?

A
  • tonic-clonic SZs

- Get CT scan if repeated seizures to r/o structural or infectious cause

92
Q

Alcohol Withdrawal:

What is seen 48-96 hours after last drink?

A

-DELIRIUM TREMENS! (hallucinations, disorientation, tachycardia, HTN, low-grade fever, agitation, diaphoresis)

93
Q

Signs/sxs of amphetamine and cocaine intoxication?

A

euphoria, hypervigilance, hyperactivity, weight loss, pupil dilatation, disturbed perception, stroke, MI

94
Q

Tx of amphetamine and cocaine intoxication?

A
  • short-term use of antipsychotics
  • benzos
  • inderal
  • Vitamin C to promote excretion
95
Q

Signs/sxs of amphetamine and cocaine withdrawal?

A

anxiety, tremors, HA, increased appetite, depression, risk of suicide

96
Q

Tx of amphetamine and cocaine withdrawal?

A

antidepressants

97
Q

Signs/sxs of cannabis intoxication?

A

impaired motor coordination, impaired time perception, social withdrawal, increased appetite, dry mouth, tachycardia, conjunctival redness

98
Q

Tx of cannabis intoxication or withdrawal?

A

none!

99
Q

Signs/sxs of hallucinogen (e.g. LSD) intoxication?

A

ideas of reference, hallucinations, impaired judgment, dissociative sxs, pupil DILATATION, panic, tremors, incoordination

100
Q

Tx of hallucinogen (e.g. LSD) intoxication?

A
  • supportive counseling
  • antipsychotics
  • benzos
101
Q

Signs/sxs and Tx of hallucinogen (e.g. LSD) withdrawal?

A

None!

102
Q

Signs/sxs of inhalant intoxication?

A

belligerance, apathy, assaultiveness, impaired judgment, blurred vision, coma, stupor

103
Q

Tx of inhalant intoxication?

A

antipsychotics if delirious or agitated

104
Q

Signs/sxs and Tx of inhalant withdrawal?

A

None!

105
Q

Signs/sxs of opiate intoxication?

A

apathy, dysphoria, CONSTRICTED pupils, drowsiness, slurred speech, impaired memory, coma, death

106
Q

Tx of opiate intoxication?

A

naloxone

107
Q

Signs/sxs of opiate withdrawal?

A

fever, chills, lacrimation, runny nose, abd cramps, muscle spasms, insomnia, yawning, MYDRIASIS

108
Q

Tx of opiate withdrawal?

A

clonidine, methadone or buprenorphine (opioid)

109
Q

Signs/sxs of PCP intoxication?

A

panic reactions, assaultiveness, agitation, nystagmus, HTN, seizures, coma, hyperacusis

110
Q

Tx of PCP intoxication?

A
  • talking down
  • benzos
  • antipsychotics
  • support respiratory function
111
Q

Signs/sxs and Tx of PCP withdrawal?

A

none!

112
Q

Signs/sxs of benzo and barbiturate intoxication?

A

inappropriate sexual or aggressive behavior, impaired memory or concentration

113
Q

Tx of benzo and barbiturate intoxication?

A

flumazenil

114
Q

Signs/sxs of benzo and barbiturate withdrawal?

A

autonomic hyperactivity (increased HR, BP, T), tremors, insomnia, seizures, anxiety, confusion, disorientation

115
Q

Tx of barbiturate withdrawal?

A
  • short-acting benzos (lorazepam or diazepam IV)

- substitute short-acting with long-acting barbiturates (chlordiazepoxide or phenobarbital)

116
Q

Pharmacologic agents that cause sexual dysfunction; Name what these cause:

  • alpha 1 blockers
  • SSRIs
  • beta-blockers
  • trazodone
  • DA agonists
  • neuroleptics
A
  • alpha 1 blockers: impaired ejaculation
  • SSRIs: inhibited orgasm, decreased libido, impaired ejaculation
  • beta-blockers: ED
  • trazodone: priapism
  • DA agonists: increased erection and libido
  • neuroleptics: ED
117
Q

Tx of paraphilias?

A
  • individual psychotherapy and aversive conditioning

- if severe: antiandrogens or SSRIs

118
Q

What is schizoaffective d/o?

A

schizophrenia + MOOD sxs (depression or mania) present at least 2 weeks

119
Q

Tx of catatonic-type schizophenia?

A

benzos and/or ECT

120
Q

What black box warning do the atypical antipsychotics carry re: the elderly?

A

may increase mortality (PNA, cardiovascular). Not FDA approved but benefits may outweigh risks.

121
Q

What antidepressants are a/w weight gain? Weight loss?

A
  • Weight gain: Mirtazapine, paroxetine, sertraline, citalopram, imipramine, amitriptyline
  • Weight loss: Buproprion, fluoxetine
122
Q

How long do sxs last in acute stress d/o? In PTSD?

A

< 1 mo; > 1 mo

123
Q

What comorbidities are a/w MDD?

A

CAD/MI

124
Q

What SFX are a/w valproic acid/valproate?

A

liver dysfunction (check LFTs!)

125
Q

Name some SSRIs.

A

Fluoxetine, paroxetine, citalopram, sertraline

126
Q

Name some TCAs.

A

imipramine, nortriptyline, amitriptyline

127
Q

SFX of TCAs?

A

anticholinergic, orthostatic, sedative, weight gain, sexual dysfunction, prolonged QT

128
Q

Name a MAOI.

A

phenelzine

129
Q

SFX of MAOIs.

A

hypotension, dry mouth, GI sxs, fatigue, sedation, sexual dysfunction

130
Q

When treating a patient with an antihypertensive who’s already on Li+, what to consider?

A

Any med/factor which decreases excretion of Li+ (e.g. diuretics [e.g. thiazides, ACE-Is, ARBs, loop diuretics, NSAIDs, ACE-Is) can precipitate toxicity. Thiazides esp have known interaction. Choose a beta-blocker or CCB instead.

131
Q

What to do when transitioning a patient from SSRI to MAOI?

A

allow one drug-free month in between to avoid serotonin syndrome

132
Q

Tx of narcolepsy?

A
  • scheduled naps

- amphetamines (e.g. methylphenidate) if above fails

133
Q

What other conditions are patients with Tourettes at risk for?

A
  • ADHD

- OCD

134
Q

Tx of Tourette syndrome?

A

DA receptor blockers (e.g. fluphenazine, pimozide, tetrabenazine)

USMLE Step 3 (7 decks)

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