Psychiatry 4

Question 1

When does NMS happen after beginning an antipsychotic?

Answer 1

May occur at any time, but usually develops within the first 2 weeks of treatment

Question 2

What are the cardinal features of NMS?

Answer 2

Severe hyperthermia
Autonomic instability
Muscular (lead-pipe) rigidity
Altered sensorium

Question 3

Lab findings in NMS?

Answer 3

Elevated creatinine phosphokinase level and WBC count

Question 4

Known complication of NMS?

Answer 4

Rhabdomyolysis, followed by myoglobinuria that can cause acute renal failure

Question 5

What medication can be used to treat severe cases of serotonin syndrome?

Answer 5

Cyproheptadine (5-HT antagonist)

Question 6

Clinical features of ADHD?

Answer 6

Inattentive and/or hyperactive/impulsive symptoms for 6+ months
-Inattentive: difficulty focusing, distractible, does not listen or follow instructions, disorganized, forgetful, loses/misplaces objects
-Hyperactive/impulsive symptoms: fidgety, unable to sit still, “driven by a motor,” hyper-talkative, interrupts, blurts out answers
Several symptoms present before age 12
Symptoms occur in at least 2 settings and cause functional impairment

Question 7

Treatment of ADHD?

Answer 7

1. Stimulants - methylphenidate, amphetamines
2. Non-stimulants - atomoxetine, alpha-2 adrenergic agonists
3. Behavioral therapy

Question 8

Although ADHD is more common in boys, girls are more likely to present with predominantly ___ features.

Answer 8

Inattentive

Question 9

When is atomoxetine indicated in treating ADHD?

Answer 9

History of illicit substance use

Strong family preference against stimulant medication

Question 10

When are alpha-2 adrenergic agonists indicated in treating ADHD?

Answer 10

Poor response to/intolerable side effects from stimulants

Coexisting conditions like tic disorders

Question 11

List the 4 manifestations of alcohol withdrawal syndrome and the onset since last drink (hours).

Answer 11

1. Mild withdrawal - 6-24 hours
2. Seizures - 12-48 hours
3. Alcoholic hallucinosis - 12-48 hours
4. Delirium tremens - 48-96 hours

Question 12

Symptoms/signs of mild alcohol withdrawal?

Answer 12

Anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation

Question 13

Symptoms/signs of seizures from alcohol withdrawal?

Answer 13

Single or multiple generalized tonic-clonic

Question 14

Symptoms/signs of alcoholic hallucinosis?

Answer 14

Visual (predominant), auditory, or tactile hallucinations
Intact orientation
Alert sensorium
Relatively stable vital signs

Question 15

Symptoms/signs of DT?

Answer 15

Confusion, agitation, fever, tachycardia, HTN, diaphoresis, hallucinations

Question 16

Hallmark of delirium tremens?

Answer 16

Disorientation and global confusion

Question 17

Metabolic effects of SGAs?

Answer 17

Metabolic syndrome - weight gain, dyslipidemia, hyperglycemia (including new-onset diabetes)

Question 18

Highest risk SGAs for metabolic effects?

Answer 18

Clozapine

Olanzapine

Question 19

Monitoring guidelines for SGAs with metabolic effects?

Answer 19

Baseline and regular follow-up of BMI, fasting glucose and lipids, blood pressure, and waist circumference

Question 20

Features of antidepressant discontinuation syndrome?

Answer 20

Sudden onset dysphoria, fatigue, insomnia, myalgias

Dizziness, flu-like and GI symptoms, tremor, neurosensory disturbances (electric shock and rushing sensations in the head, paresthesias, hyper-responsivitiy to light and noise, vivid dreams)

Question 21

What is the best approach to manage discontinuation syndrome from antidepressants?

Answer 21

Restart the same antidepressant and taper the dose gradually over 2-4 weeks or longer in severe cases

Question 22

Indications for clozapine?

Answer 22

Treatment-resistant schizophrenia

Schizophrenia associated with suicidality

Question 23

Clinical features of antisocial personality disorder?

Answer 23

Violates rights of others, social norms, laws
Impulsive, irritable, aggressive (fights, assaults)
Consistently irresponsible, lies, is deceitful
Lack of remorse
Age 18+
Evidence of conduct disorder before age 15

Question 24

Management of antisocial personality disorder?

Answer 24

Psychotherapy for milder forms (monitor for manipulation of therapeutic relationship)
Treat comorbid psychiatric disorders

Question 25

Although NMS is not fully understood and the involvement of multiple NT has been proposed, it is thought to be primarily due to dysregulation of ___ caused by ___.

Answer 25

Dopamine; D2 receptor antagonism

Question 26

Dopamine antagonism in the ___ pathway may lead to the diffuse "lead-pipe" rigidity seen in NMS.

Answer 26

Nigrostriatal

Question 27

What antipsychotics are available in LAI formulations?

Answer 27

FGA - haloperidol, fluphenazine | SGAs - risperidone, paliperidone, olanzapine, aripiprazole

Question 28

Features of a grief reaction (vs. MDD)?

Answer 28

Normal reaction to loss (bereavement) Sadness more specific to thoughts of the deceased "Waves" of grief at reminders Worthlessness, self-loathing, guilt less common Functional decline less severe Thoughts of dying involve wish to join the deceased; active suicidality uncommon Intensity decreases over time

Question 29

True or false - a major depressive episodes is diagnosed regardless of an existing precipitant, including bereavement.

Answer 29

True

Question 30

Although it is rare in comparison with postpartum blues and depression, postpartum psychosis is a medical emergency, with an increased risk of both ___ and ___.

Answer 30

Suicide; infanticide

Question 31

Pediatric depression often presents with symptoms of ___ rather than depressed mood.

Answer 31

Irritability

Question 32

Evidence shows that SSRIs are most effective for pediatric depression; among them, ___ is considered the medication of choice based on several meta-analyses.

Answer 32

Fluoxetine (least potential to cause weight gain)

Question 33

Many OTC cold preparations contain antihistamines (eg, diphenhydramine, doxylamine) that decrease nasal discharge but also have ___ properties that can cause confusion and hallucinations. Alpha-adrenergic agents (eg, phenylephrine, pseudoephedrine) constricts blood vessels, decreasing nasal congestion, but can result in agitation and psychosis via their ___ properties. The cough suppressant dextromethorphan, which is an ___ antagonist, can result in dissociative symptoms and halluciations.

Answer 33

Anticholinergic; sympathomimetic; NMDA

Question 34

Hepatoxicity is most commonly associated with what mood stabilize?

Answer 34

Valproate

Question 35

AE - valproate?

Answer 35

Hepatotoxicity Tremor Thrombocytopenia Alopecia

Question 36

Which low-potency antipsychotic has been associated with cholestatic jaundice?

Answer 36

Chlorpromazine

Question 37

Which psychotropic medication has been associated with the rare adverse effect of priapism?

Answer 37

Trazodone

Question 38

Clinical features of conversion disorder (functional neurological symptom disorder)?

Answer 38

Neurological symptoms (eg, weakness/paralysis, nonepileptic seizures, sensory disturbances) Not intentionally produced (vs . factitious disorder or malingering) Findings incompatible with recognized neurological conditions Symptoms cause significant functional impairment Often precipitated by psychological stressor

Question 39

Rx for conversion disorder?

Answer 39

Education about the disorder CBT Physical therapy for motor symptoms

Question 40

Signs and symptoms of a sedative-hypnotic overdose (benzos alone vs. co-ingestion)?

Answer 40

Benzodiazepines (isolated): altered level of consciousness, ataxia, slurred speech, arousable, normal vitals Co-ingestion: bradycardia, hypotension, respiratory depression, hyporeflexia

Question 41

Clinical features of intermittent explosive disorder?

Answer 41

Recurrent episodes of impulsive verbal or physical aggression; behaviors are unplanned and out of proportion to the provocation

Question 42

Rx - intermittent explosive disorder?

Answer 42

CBT and SSRIs

Question 43

Clinical features of disruptive mood dysregulation disorder?

Answer 43

Disproportionate verbal or physical outbursts, persistent irritability or anger between episodes, onset before age 10, not diagnosed after age 18

Question 44

Medications used to treat psychosis?

Answer 44

1. SGAs 2. FGAs 3. Adjunctive benzos for agitation

Question 45

Most common physical manifestations of PMS?

Answer 45

Bloating, fatigue, headaches, breast tenderness

Question 46

Common psychological symptoms of PMS?

Answer 46

Mood swings, anxiety, difficulty concentrating, decreased libido, and irritability

Question 47

Timing of symptoms in PMS?

Answer 47

Usually begin a week prior to menses and resolve within a few days after menses start; symptom free during the follicular phase

Question 48

What is PMDD?

Answer 48

Severe variant of PMS with prominent irritability, hopelessness, depressed mood, self-critical thoughts, anger, and greater psychosocial impairment

Question 49

First-line Rx for moderate to severe PMS/PMDD?

Answer 49

SSRIs

Question 50

Clinical features of OCD?

Answer 50

``` Obsessions (recurrent, intrusive, anxiety-provoking thoughts, urges, or images) Compulsions (response to obsessions with repeated behaviors or mental acts, behaviors not connected realistically with preventing feared event) Time consuming (>1 hr/day) or causing significant distress or impairment ```

Question 51

Rx - OCD?

Answer 51

SSRIs | CBT (ERP)

Question 52

Some medications used to treat dementia target this NT, involved in attention, memory, and executive functions

Answer 52

ACh (via acetylcholinesterase inhibitors)

Question 53

Primary NT targeted by benzos?

Answer 53

GABA

Question 54

Although antipsychotic medication is the primary treatment for schizophrenia, integrating ___ into a broader treatment program can improve outcomes.

Answer 54

Psychosocial interventions (specifically family therapy and psychoeducation)