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Psychiatry 3 Flashcards

1
Q

Presentation of Parkinson disease dementia?

A

Executive and visuospatial dysfunction (eg, impaired attention and planning, inability to recognize grandchildren, getting lost in familiar locations) with only mild memory impairment early on; visual hallucinations, delusions, sleep disorders (occur at higher rates in PDD, though may occur in Parkinson disease without dementia)

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2
Q

Rx Parkinson Disease Dementia?

A

Cholinesterase inhibitors (eg, donepezil)

Psychotic symptoms - dose reduction of antiparkinsonian agents and/or low-potency antipsychotics

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3
Q

About ___ of patients with Parkinson disease have evidence of PDD.

A

1/3

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4
Q

Clinical features of Alzheimer disease?

A

Early, prominent memory impairment accompanied by executive and visuospatial dysfunction

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5
Q

Differentiate between Dementia with Lewy Bodies and PDD?

A

PDD is diagnosed when parkinsonism predates cognitive impairment by >1 year

In DLB, cognitive impairment would develop before or at the same time as parkinsonism

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6
Q

Progressive supranuclear palsy is a rare syndrome that presents with what symptoms?

A

Falls, impaired vertical gaze, parkinsonism

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7
Q

Presentation of vascular dementia?

A

Mild memory impairments, prominent executive dysfunction, and focal neurologic deficits corresponding to cerebrovascular pathology

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8
Q

Seizures are a potential dose-dependent side effect of dopamine/norepinephrine reuptake inhibitor ___ and ___. They are more likely to be seen in patients susceptible to seizures.

A

Bupropion; TCAs (such as clomipramine)

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9
Q

MOA of mirtazapine?

A

Alpha-2 receptor antagonist (antidepressant)

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10
Q

Abrupt discontinuation of what 2 medications has been associated with antidepressant discontinuation syndrome (acute of dysphoria, fatigue, dizziness, GI distress, flu-like symptoms)?

A

Paroxetine and venlafaxine

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11
Q

Patients with depression or underlying psychiatric issues frequently come to their primary care physician with ___ symptoms.

A

Physical

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12
Q

Characteristics of delirium?

A

Fluctuating disturbance in attention and arousal that can develop acutely in the context of an underlying medical illness

May be associated with psychotic symptoms, particularly visual hallucinations, in addition to sleep and behavioral changes

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13
Q

Common causes of delirium?

A

Postoperatively
New or worsening infections
New medications

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14
Q

To diagnose psychotic disorder due to a medical condition, ___ must be absent. In addition, there must be a ___ link between psychotic symptoms and a medical condition, and the psychosis cannot be better explained by another condition.

A

Delirium; causal

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15
Q

Presentation of OSA with depressive symptoms?

A

Fatigue, sleep disturbance with multiple awakenings, impaired concentration, irritability, and low mood

Excessive daytime sleepiness, snoring

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16
Q

Risk factors for OSA?

A

Male gender, obesity, HTN

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17
Q

Following abrupt discontinuation of benzos, early rebound effects of ___ and increased ___ are common.

A

Insomnia; anxiety

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18
Q

Characteristics of malingering?

A

Feigned or grossly exaggerated physical or psychological symptoms with the intention of obtaining secondary gain (financial compensation, leave from work, narcotics, etc.)

Usually a marked disparity between the patient’s disability and the objective findings

Should be suspected when the patient is reluctant to be examined or treated

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19
Q

Characteristics of conversion disorder?

A

Typically preceded by an emotional trigger

Unexplained neurological symptoms that are incompatible with recognized neurological conditions

No external incentive

Symptoms not intentionally produced

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20
Q

Characteristics of factitious disorder?

A

Intentional production of false physical or physiological signs or symptoms to assume the sick role

No secondary gain

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21
Q

3 causes of lithium toxicity?

A
  1. OD
  2. Volume depletion (decreased GFR)
  3. Drug interactions
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22
Q

4 drugs that can cause lithium toxicity?

A
  1. Thiazide diuretics (decreased renal clearance)
  2. NSAIDs (not aspirin)
  3. ACEIs
  4. Tetracyclines, metronidazole
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23
Q

Features of acute lithium toxicity?

A

GI - NV/, diarrhea

Late neurologic sequelae

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24
Q

Features of chronic lithium toxicity?

A

Confusion, agitation, ataxia, tremors/fasciculations, seizures

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25
Management of lithium toxicity?
Hemodialysis for severe cases
26
Major AE of lamotrigine?
SJS
27
Major AEs of valproic acid?
GI symptoms, hepatitis, pancreatitis, hepatic encephalopathy
28
Clinical features of anorexia nervosa?
1. Significantly low weight 2. Intense fear of weight gain 3. Distorted views of body weight/shape
29
Subtypes of anorexia nervosa?
1. Binge/purge | 2. Restricting
30
Clinical features of bulimia nervosa?
1. Recurrent episodes of binge eating 2. Compensatory behavior (vomiting, exercise, fasting, misuse of laxatives, enemas, diuretics, diet pills) to prevent weight gain 3. Excessive worry about body shape and weight 4. Maintains normal body weight Binges and inappropriate compensatory behaviors must occur at least once a week for 3 months for the diagnosis
31
Clinical features of binge eating disorder?
1. Recurrent binge eating with lack of control | 2. No compensatory bheaviors
32
True or false - self-induced vomiting is necessary for the diagnosis of bulimia nervosa.
False
33
Signs of bulimia?
1. Hypotension 2. Tachycardia 3. Dry skin 4. Menstrual irregularities If vomiting regularly: electrolyte abnormalities (hypokalemia, hypochloremia, metabolic alkalosis), erosion of dental enamel, parotid hypertrophy
34
Treatment of bulimia?
Nutritional rehabilitation CBT Pharamcotherapy with fluoxetine
35
What is the key distinction between anorexia and bulimia nervosa?
Patients with bulimia nervosa have normal to increased weight; those with anorexia nervosa have significantly low body weight
36
Clinical features of avoidant/restrictive food intake disorder?
Typically begins in infancy or early childhood Characterized by food avoidance due to a dislike of the sensory components of certain foods or the experience of eating
37
Clinical features of BDD?
Intense preoccupation with a perceived defect in physical appearance Patient does not meet the criteria for an eating disorder
38
Characteristics of OCPD?
Pervasive pattern of preoccupation with orderliness, perfectionism, and control present in a variety of contexts.
39
Clinical features of autism spectrum disorder?
1. Deficits in social communication and interactions with onset in early development (sharing of emotions or interests, non-verbal communication, developing and understanding relationships) 2. Restricted, repetitive patterns of behavior (repetitive movements or speech, insistence on sameness/routines, intense fixated interests, adverse responses to sensory input) 3. May occur with or without language and intellectual impairment
40
Assessment and management of autism spectrum disorder?
1. Early diagnosis and intervention 2. Comprehensive, multimodal treatment (speech, behavioral therapy, educational services) 3. Adjunctive pharmacotherapy for psychiatric comorbidities
41
True or false - ADHD frequently persists into adulthood.
True
42
Most effective treatment for adult ADHD? Contraindication?
Stimulants (amphetamines, methylphenidate); patients with a history of SUD due to potential for misuse or addiction
43
What is the treatment of choice among nonstimulant options for adult ADHD?
Atomoxetine (norepinephrine reuptake inhibitor) Other options - bupropion, TCAs
44
Nonstimulant treatment options for children and adolescents with ADHD?
Alpha-2 adrenergic agonists (clonidine, guanfacine)
45
Rx opioid withdrawal?
Supportive care and medications (alpha-2 adrenergic agonists, methadone, or buprenoprine)
46
What are the 3 mature defense mechanisms?
Altruism, Sublimation, Suppression
47
Defense mechanism - expressing unacceptable feelings through actions
Acting out
48
Defense mechanism - behaving as if an aspect of reality does not exist
Denial
49
Defense mechanism - putting unwanted feelings aside to cope with reality
Suppression
50
Defense mechanism - sublimation
Channeling impulses into socially acceptable behaviors
51
Defense mechanism - transferring feeling to less threatening object/person
Displacement
52
Defense mechanism - experiencing a person/situation as either all positive or all negative
Splitting
53
Defense mechanism - focusing on non-emotional aspects to avoid distressing feelings
Intellectualization
54
Defense mechanism - reverting to earlier developmental stage
Regression
55
Defense mechanism - avoiding conflict by expressing hostility covertly
Passive aggression
56
Defense mechanism - transforming unacceptable feelings/impulses/desires into their extreme opposite
Reaction formation
57
Defense mechanism - attributing one's own feelings to others
Projection
58
Defense mechanism - justifying behavior to avoid difficult truths
Rationalization
59
___ are normal features of human behavior that enable individuals to navigate social relationships in a way that preserves self-esteem, limits anxiety, and creates a feeling of control. They can be pathological if they become ___ or interfere with ___.
Defense mechanisms; fixed; self-development
60
Defense mechanism - managing unpleasant emotions through service to others, which provides gratification
Altriusm
61
Patients with panic attacks frequency develop agoraphobia - clinical features?
Anxiety and avoidance of 2+ situations in which it may be difficult to escape or get help in the event of a panic attack
62
Rx - agoraphobia?
CBT
63
What is a shared psychotic disorder (aka folie a deux)?
Rare manifestation of delusional disorder in which the same delusion is present in individuals who share a close relationship; usually the dominant individual becomes delusional and transfers the delusion onto the second, more submissive person, who may or may not meet full criteria for delusional disorder
64
What is the first step in addressing shared psychotic disorder?
Separate the pair to disrupt the mutually reinforcing nature of the shared delusion and to enable a more careful assessment of each individual's pathology; the dominant individual typically requires psychiatry treatment, whereas the more submissive individual less frequently requires formal treatment
65
Which SGA is most likely to cause EPS?
Risperidone
66
Mechanism of benztropine?
Anticholinergic
67
Mechanism of amantadine?
Dopaminergic, weak NMDA antagonist
68
When dopamine is blocked in the ___ pathway, the production of prolactin increases, which can result in ___, ___, and ___.
Tuberoinfundibular; galactorrhea; menstrual irregularities; infertility
69
Which two SGAs are least likely to cause hyperprolactinemia?
Aripiprazole (partial D2R agonist) and quetiapine (low-potency D2R antagonist)
70
AE of carbamazepine?
Aplastic anemia | SIADH
71
How can concurrent use of NSAIDs cause lithium toxicity?
Decreased renal clearance of lithium
72
DDx - dementia subtypes (6)?
1. Alzheimer disease 2. Vascular dementia 3. Frontotemporal dementia 4. Dementia with Lewy bodies 5. Normal pressure hydrocephalus 6. Prion disease
73
DDx features of Alzheimer disease?
Early, insidious short-term memory loss Language deficits and spatial disorientation Later personality changes
74
DDx features of vascular dementia?
Stepwise decline Mild memory impairments Early, prominent executive dysfunction Focal neurologic deficits corresponding to cerebrovascular pathology Cerebral infarction and/or deep white matter changes on neuroimaging
75
DDx features of frontotemporal dementia?
Early personality changes Memory impairment is generally mild in early FTD Apathy, disinhibition, compulsive behavior, hyperorality, lack of insight, executive dysfunction Frontotemporal atrophy on neuroimaging
76
DDx features of dementia with Lewy bodies?
Visual hallucinations Spontaneous parkinsonism Fluctuating cognition REM sleep behavior disorder
77
DDx features of normal pressure hydrocephalus?
Ataxia early in disease Urinary incontinence Dilated ventricles on neuroimaging
78
DDx features of prion disease?
``` Behavioral changes Rapid progression Myoclonus and/or seizures Hypokinesia Cerebellar dysfunction ```
79
FTD typically presents around age ___, affects males and females at ___ (rate?), and follows an ___ pattern of inheritance in up to 25% of cases.
60; equal rates; AD
80
Average length of survival following diagnosis of FTD?
5-10 years
81
Behavioral variant FTD is associated with the accumulation of ___ in the hippocampi, temporal lobes, and frontal lobes.
Tau protein inclusions known as Pick bodies
82
What medications have demonstrated some benefit in the management of neuropsychiatric symptoms of FTD?
SSRIs, trazodone
83
Presentation of behavioral variant FTD?
Compulsive behavior, hyperorality, apathy, executive dysfunction, disinhibition
84
Clinical features of acute mania?
Elevated, irritable, labile mood Increased energy and activity, decreased need for sleep Pressured speech, racing thoughts, distractibility Grandiosity, risky behavior Marked impairment, may have psychotic symptoms
85
Management of acut emania?
Antipsychotics Lithium (avoid in renal disease) Valproate (avoid in liver disease) Combinations in severe mania (eg, antipsychotic + Lithium or valproate) Adjunctive benzos for insomnia, agitation
86
Management of agitated patients with acute mania consists of ___ to control behavioral disturbances.
Antipsychotic medication (administered IM if needed)
87
Separation anxiety disorder is more common in children under age ___ but can occur at any age.
12
88
First-line treatment of PTSD?
Trauma-focused CBT and SSRIs/SNRIs
89
List the 6 common SGAs.
``` Aripiprazole Olanzapine Risperidone Ziprasidone Clozapine Quetiapine ```
90
Compare the risk of weight gain/metabolic syndrome in the 6 common SGAs.
``` Aripiprazole - Low Olanzapine - VERY HIGH Risperidone - High Ziprasidone - Low Clozapine - VERY HIGH Quetiapine - High ```
91
Compare the risk of EPS in the 6 common SGAs.
All low except for Risperidone (High)
92
Compare the risk of prolonged QTc in the 6 common SGAs.
All low except for Risperidone and Ziprasidone (High)
93
Rx - GAD?
CBT | SSRIs or SNRIs
94
DDx - anxiety disorders
1. Social anxiety disorder (social phobia) - anxiety restricted to social and performance situations, fear of scrutiny and embarrassment 2. Panic disorder - recurrent, unexpected panic attacks 3. Specific phobia - excessive anxiety about a specific object or situation (phobic stimulus) 4. GAD - chronic multiple worries, anxiety, tension
95
Onset of narcolepsy typically occurs around what ages?
Adolescence or the early 20's
96
Diagnostic evaluation of narcolepsy?
Polysomnography (r/o other sleep disorders) Multiple sleep latency test that demonstrates decreased sleep latency and sleep-onset REM periods Rule out other sleep disorders that can present with excessive daytime sleepiness
97
Clinical features of circadian rhythm sleep-wake disorder with delayed sleep phases?
Inability to fall asleep for 2+ hours and awakening later than the desired time
98
List the 3 clusters of personality disorders and a brief descriptor.
Cluster A - odd/eccentric Cluster B - dramatic/erratic Cluster C - anxious/fearful
99
List the Cluster A personality disorders and compare them briefly.
1. Paranoid - suspicious, distrustful, hypervigilant 2. Schizoid - prefers to be a loner; detached, unemotional 3. Schizotypal - unusual thoughts, perceptions, and behaviors
100
List the Cluster B personality disorders and compare them briefly.
1. Antisocial - disregard and violation of the rights of others, lack of remorse 2. Borderline - chaotic relationships, abandonment fears, labile mood, impulsivity, inner emptiness, self-harm 3. Histrionic - superficial, theatrical, attention-seeking 4. Narcissistic - grandiosity, lack of empathy
101
List the Cluster C personality disorders and compare them briefly.
1. Avoidant - avoidance due to fears of criticism and rejection 2. Dependent - submissive, clingy, needs to be taken care of 3. Obsessive-compulsive - rigid, controlling, perfectionistic
102
Clinical features of schizoid personality disorder?
Lack of desire for close relationships Preference for solitary activities Few friends by choice Show little interest in intimacy or sexual experiences Emotionally detached Flat affect Apparent indifference to praise or criticism
103
Patients with minimal to no improvement with initial antidepressant treatment can be... (pharmacologic management)?
Switched to another antidepressant
104
What antidepressant is contraindicated in a patient with (or with a history of) bulimia nervosa?
Bupropion
105
What is MDMA?
Synthetic amphetamine with mild hallucinogenic properties that causes an increase in synaptic NE, DA, and 5-HT. Causes euphoria, increases sociability, empathy, and sexual desire Also known as ecstasy or molly
106
Intoxication with MDMA?
1. Amphetamine toxicity (HTN, tachycardia, hyperthermia) 2. Serotonin toxicity (Serotonin syndrome = autonomic dysregulation, high fever, altered mental status, neuromuscular irritability, seizures; hyponatremia)
107
Compare MDMA to bath salts.
Bath salts are amphetamine analogs; may cause serotonin syndrome More likely to cause agitation, combativeness, and acute psychosis Less likely to be associated with hyponatremia

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