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PANCE prep JQ > Psychiatry/behavioral > Flashcards

Psychiatry/behavioral Flashcards

1
Q

Delusional disorder

A

1 or more delusions lasting more than a month without other psychotic symptoms

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2
Q

Brief psychotic disorder

A

1 or more psychotic symptoms with onset and remission <1month

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3
Q

Schizophreniform disorder

A

Meets criteria for schizophrenia but duration <6month

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4
Q

Schizoaffective disorder

A

Schizophrenia with a mood disturbance

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5
Q

Schizophrenia

A

2 or more of the following:
Positive sx-hallucinations, delusions, disorganized speech/thinking, abnormal behavior
Negative sx-flat affect, social withdrawal, avolition

For 6 months or more with at least 1 month acute symptoms

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6
Q

Who gets schizophrenia?

A

MC in males with family hx, presents in early 20s

Presents in late 20s in women

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7
Q

1st line treatment for schizophrenia

A

2nd gen antipsychotics: risperidone, olanzapine, quetiapine

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8
Q

Typical 1st gen antipsychotics

A

BUTYROPHENONES: haloperidol and droperidol

PHENOTHIAZINES: fluphenazine, perphenazine, chlorpromazine, thioridazine

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9
Q

Side effects of antipsychotics

A

Extrapyramidal sx, neuroleptic malignant syndrome, QT prolongation, arrhythmias, sedation, anticholinergic sx, dermatitis, increased prolactin, weight gain

EPS and increased prolactin worse in 1st gen/typical antipsychotics

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10
Q

Chlorpromazine and thioridazine have less __________ symptoms but more ___________ symptoms

A

Extrapyramidal

Anticholinergic

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11
Q

Describe extrapyramidal symptoms

A
  1. dystonic reaction (intermittent spasms with sustained involuntary muscle contraction) occurs hours to days after initiating antipsychotics
  2. Tardive dyskinesia (akathisia) seen with long term use of antipsychotics
  3. Parkinsonism (rigidity, tremor, Bradykinesia)
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12
Q

Akathisia

A

Restlessness

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13
Q

Tx for dystonic reaction

A

IV diphenhydramine

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14
Q

Describe neuroleptic malignant syndrome (NMS)

A

D2 inhibition leads to mental status change, muscle rigidity, tremor, autonomic instability-tachycardia, tachypnea, hyperthermia

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15
Q

Tx for NMS

A

Stop offending agent

lower temp with cooling blankets

dopamine agonist: bromocriptine, amantadine, levodopa/carbidopa, dantrolene

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16
Q

When does NMS usually occur?

A

In young adults within 90d of antipsychotic initiation/dose increase

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17
Q

C/I-cautions for Haldol

A

Parkinson’s disease, anticoagulant use, severe cardiac disease

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18
Q

Describe anticholinergic symptoms

A

Dry mouth, blurred vision(dilated pupils), urinary retention, constipation, dry skin, flushing, tachycardia, fever, htn, and delirium

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19
Q

Atypical 2nd generation antipsychotics

A

Quetapine (Seroquel)
Olanzapine (zyprexa)
Clozapine
Loxapine

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20
Q

Unique side effects of clozapine

A

Agranulocytosis (CBC monitored weekly)

Myocarditis, QT prolongation

Seizures

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21
Q

Unique side effects of olanzapine

A

Weight gain and diabetes mellitus

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22
Q

Benzioxazoles

A

Risperidone (Risperdal)

Ziprasidond (Geodon)

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23
Q

Indications for benzisoxazoles

A

Schizophrenia, bipolar, psychosis

*Risperdal also used in Tourette’s

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24
Q

Indication for Abilify

A

Psychotic disorders

*sometimes called a 3rd generation antipsychotic

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25
Q

Indication for lithium

A

Bipolar disorder -acute mania

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26
Q

SE of lithium

A 
Hypothyroidism
Diabetes insipidus 
Hyperparathyroidism 
Seizures
HA
Tremor
Sedation
Arrhythmia
N&amp;V
Diarrhea
Weight gain

*narrow therapeutic index. Monitor q 4-8wk

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27
Q

Anticonvulsants used to suppress impulsive or aggressive behavior

A

Valproate and carbamazepine

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28
Q

How long must you have depressed mood/anhedonia/loss of interest in activities to be dx with MDD?

A

2wks

*symptoms must cause distress or impairment and mania or hyponania must be absent

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29
Q

Key symptom in atypical depression

A

Mood reactivity

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30
Q

Tx of atypical depression

A

MAO inhibitors

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31
Q

How prevalent is suicide in depression?

A

15% of pts commit suicide

Especially men 25-30 and women 40-50

Higher rates in pts with detailed plan, White males >45, and concurrent substance abuse

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32
Q

PHQ 2

A
  1. Little interest/enjoyment of things

2. Feeling down, depressed, or hopeless

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33
Q

PHQ 9

A
  1. Little interest
  2. Feeling down/hopeless
  3. Difficulty sleeping/hypersomnia
  4. Fatigue/low energy
  5. Appetite or weight changes
  6. Self disappointment
  7. Trouble concentrating
  8. Psychomotor changes (slow movement or speech, irritability, restlessness)
  9. Passive or active suicidal thoughts
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34
Q

Tx of MDD

A

1st line: SSRI or SNRI

2nd line: Bupropion or mirtazapine

3rd line: TCAs or MAO inhibitors

Continue for a minimum 3-6wk to determine efficacy

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35
Q

Selective serotonin reuptake inhibitors(SSRIs)

A 
Citalopram (Celexa)
Ecitalopram (Lexapro)
Paroxetine (Paxil)
Fluoxetine (Prozac)
Sertraline (Zoloft)
Fluvoxamine (Zyvox)

*1st line for depression and anxiety

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36
Q

SE of SSRIs

A

GI upset, sexual dysfunction, HA, changes in energy, anxiety, insomnia, weight changes, SIADH

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37
Q

Avoid using citalopram in pts with ___________.

A

Long QT syndrome

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38
Q

SSRI + MAO inhibitor =

A

Serotonin syndrome

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39
Q

SNRI + St. John’s Wart=

A

Serotonin syndrome

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40
Q

MAOI + TCA=

A

Delirium and hypertension

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41
Q

Sx of serotonin syndrome

A 
Acute AMS
seizures
Restlessness
Diaphoresis
Tremor
Hyperthermia 
N&amp;V
Abd pain
Mydriasis
Tachycardia
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42
Q

Serotonin Norepinephrine Reuptake inhibitors (SNRIs)

A

Venlafaxine (Effexor)
Desvenlafaxine (Pristiq)
Duloxetine (cymbalta)

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43
Q

SNRIs are particularly good first line agents for MDD in patients with ______________ or ______________

A

Significant fatigue

Pain syndromes

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44
Q

SE of SNRIs

A

Same as SSRIs plus htn and dizziness

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45
Q

Mirtazapine (Remeron)

A

Antidepressant with less sexual dysfunction

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46
Q

SE of Mirtazapine

A 
Sedation
Dry mouth
Constipation
Weight gain
Agranulocytosis
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47
Q

Bupropion indication

A

Wellbutrin for depression *less GI distress and sexual dysfunction than SSRIs

Zyban for smoking cessation

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48
Q

SE of bupropion

A 
Seizures
Agitation
Anxiety
Restlessness
Weight loss
HTN
HA
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49
Q

Bupropion C/I

A

Seizure disorders
Eating disorders
MAOI use
ETOH/drug detox

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50
Q

Tricyclics antidepressants (TCAs)

A 
Amitriptyline
Clomipramine
Desipramine
Doxepin
Imipramine
Nortriptyline
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51
Q

SE of TCAs

A

Anticholinergic, sedation, weight gain, prolonged QT

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52
Q

TCA overdose

A

Wide complex tachycardia
Neurological symptoms
ARDS
SIADH

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53
Q

MAO inhibitors

A

Non selective: phenelzine, tranylcypromine, isocarboxazid

Selective: selegiline

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54
Q

SE of MAOI

A 
Insomnia 
Anxiety
Orthostatic hypotension
Weight gain
Sexual dysfunction
Hypertensive crisis
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55
Q

Pts on MAOIs must avoid these foods or it may lead to hypertensive crisis

A

Tyramine-containing foods

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56
Q

Bipolar I disorder

A

1 or more manic or mixed episode which often cycles with occasional depressive episodes

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57
Q

Strongest risk factor for bipolar I

A

Family history/1st degree relative

*the earlier the onset the poorer the prognosis and more likely to develops psychotic features

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58
Q

Mania

A

Abnormal & persistently elevated, expansive or irritable mood for at least 1wk with impaired function

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59
Q

Pharmaceutical treatment of bipolar I

A

1st line Mood stabilizers: LITHIUM, vampiric acid, carbamazepine

2nd line antipsychotics

Benzodiazepines can be added if psychosis or agitation develops

*antidepressants may precipitate mania

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60
Q

Bipolar II disorder

A

1 or more hypomanic disorder and 1 or more major depressive episode

Without mania or mixed episodes

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61
Q

Hypomania

A

Sx are similar to mania but no marked impairment in function

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62
Q

Persistent depressive disorder (dysthymia)

A

Chronic depressed mood in adults >2yr. Usually milder than MDD and pt is able to function

*may progress to MDD or bipolar in time. Tx same as MDD

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63
Q

Cyclothymic disorder

A

Similar to bipolar II but less severe, at least 2yr duration

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64
Q

Tx for acute panic attack

A

Benzodiazepines: lorazepam and alprazolam are 1st line

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65
Q

Panic disorder

A

Recurrent unexpected panic attacks with worry/concerns about future attacks

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66
Q

Symptoms of panic attack

A 
Dizziness
Trembling
Choking feeling
Paresthesias
Sweating
SOB
chest pain
Chills/hot flashes
Fear of loading control or dying
Palpitations/tachycardia 
Nausea or abd distress
Depersonalization/derealization
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67
Q

Agoraphobia

A

Anxiety about being in places or situations from which you cannot escape

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68
Q

Management of panic disorder

A

Long term:SSRIs or SNRIs

CBT

Acute attack: benzo

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69
Q

Generalized anxiety disorder

A

Excessive anxiety about various aspects of life for >6m

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70
Q

Management of GAD

A

1st line: SSRI or SNRI

2nd: buspirone (Buspar) -May take several weeks for improvement. Does not cause sedation
3rd: Ben is, BB, TCAs
* psychotherapy

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71
Q

Social anxiety disorder

A

Persistent fear of social or performance situations that can cause panic attacks (>6m)

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72
Q

Tx of SAD

A

Antidepressants (SSRIs or SNRI)

BB (propranolol or atenolol) for performance anxiety

Benzos if treatment very infrequent

Psychotherapy

73
Q

Tx of specific phobias

A

Exposure/desensitization therapy

*benzos or BB can be used short term in some pts

74
Q

PTSD

A

Exposure to an inciting event and 1 or more of the following:

  1. Re-experiencing for >1m
  2. Avoidance of associated stimuli
  3. Negative alternations in cognition or mood
  4. Arousal/reactivity
75
Q

Tx of PTSD

A

SSRIs are 1st line

2nd line: TCAs it MAOIs

Trazodone may be helpful in insomnia

CBT

76
Q

Acute stress disorder

A

Similar to PSTD but <1m

77
Q

Adjustment disorder

A

Disproportionate emotional or behavioral response to an identified stressor causing significant impairment in functioning

Begins w/i 3mo stressor and resolves w/i 6mo of stressor

78
Q

Tx of adjustment disorder

A

Psychotherapy

79
Q

Rule these 2 things out before dx a dissociative disorder

A

Seizures and brain tumors

80
Q

Tx of dissociative disorders

A

Psychotherapy

81
Q

Dissociative identity disorder

A

Presence of 2 or more distinct identities or states of personalities

Pts often have gaps in recall

*maybe associated with hx of sexual abuse, PTSD, or substance use

82
Q

Depersonalization/derealization disorder

A

Persistent feelings of detachment or estrangement that cause distress

83
Q

Dissociated amnesia

A

Inability to recall personal/autobiographical information that causes impairment in functioning

*often secondary to sexual abuse, stress or trauma

84
Q

Dissociative fugue

A

Abrupt change in geographical location with loss of identity or inability to recall past

85
Q

Obsessive-compulsive disorders

A

OCD, body dysmorphic disorder, hoarding, tichotillomania( hair-pulling), and excoriation disorder

86
Q

OCD

A

Anxiety disorder characterized by obsessions (recurrent or persistent thoughts/images) and compulsions (repetitive behaviors the person feels driven to perform)

87
Q

4 major OCD patterns

A
  1. Contamination
  2. Pathological doubt
  3. Symmetry/precision
  4. Intrusive obsessive thoughts without compulsions
88
Q

Tx of OCD

A

Antidepressants (SSRI, TCA, or SNRI)

CBT

89
Q

Body dysmorphic disorder

A

Preoccupation that 1 or more body parts is deformed or over exaggeration of a minor flaw

Causes shame and functional impairment

May commit repetitive acts in response

*may also have anxiety or depression

90
Q

Tx of body dysmorphic disorder

A

Antidepressants(SSRI or TCA)

Psychotherapy

91
Q

Somatic symptom disorder

A

Physical symptom without physical cause.

Excessive thoughts, feelings, or behaviors related to somatic sxs are distressing and can result in significant disruption.

*aka hypochondiasis and somatization disorder

92
Q

Management of somatic symptom disorder

A

Regular visits to healthcare provider

93
Q

Illness anxiety disorder

A

Preoccupation with fear or belief one has or will contract serious illness. Somatic sxs usually not present

*aka hypochondriac

94
Q

Management of illness anxiety disorder

A

Regular healthcare visits

95
Q

Functional neurological symptom disorder

A

Neurological dysfunction (motor or sensory) that can’t clinically be explained

Tends to be episodic and rescuers during times of stress

*aka conversion disorder

96
Q

Tx of functional neurological symptom disorder

A

Physchotherapy

97
Q

Pts with functional neurological symptom disorder often have…

A

Depression, anxiety, schizophrenia, or a personality disorder

98
Q

Factitious disorder

A

Intentional falsification or exaggeration of signs and symptoms with motivation to assume the sick role and get sympathy

Can be self imposed or imposed on another

*considered a form of premeditated abuse if imposed on another

99
Q

Things that would make you concerned that pt has factitious disorder or is malingering

A
  • willingness or eagerness to undergo surgery or painful tests repeatedly
  • extensive knowledge about medical terminology
100
Q

Tx of factitious disorder

A

None

101
Q

Münchausen syndrome

A

Severe factitious disorder characterized by predominance of physical symptoms, use of aliases and habitual lying

102
Q

Unlike factitious disorder which is done to assume sick role and for sympathy, malingering is done with the motivation of….

A

Secondary gain, wether it be financial, food, shelter, avoidance of responsibility, or drug attainment

*not a mental illness

103
Q

Perpetrator of child sexual abuse is often…

A

Male and known to pt

104
Q

Perpetrator of physical child abuse is often…

A

Primary female caregiver

105
Q

Signs of physical child abuse (7)

A 
Cigarette burns
Burns in a stocking glove distribution
Lacerations
Healed fxs on X-ray
Subdues hematoma
Multiple bruises
Retinal hemorrhages
106
Q

Signs of shaken baby syndrome

A

Retinal hemorrhages and hyphema

107
Q

Signs of child neglect (4)

A

Malnutrition
Withdrawal
Poor hygiene
Failure to thrive

108
Q

Obesity

A

BMI>30 or >20% over ideal weight

*50%associated with binge eating

109
Q

Tx of obesity

A
  1. lifestyle modification (diet and exercise) and group therapy
  2. Antidepressant if underlying depression
  3. anti-obesity meds
  4. bariatric surgery
110
Q

Anti obesity meds and MOA

A

Orlistat decreases GI fat digestion

Lorcaserin is a serotonin agonist

111
Q

Anorexia nervosa

A

Refusal to maintain minimal normal body weight due to morbid fear of fatness

*restrictive and purging types

112
Q

Anorexia is common in this population

A

Girls age 15-24 who are athletes or dancers

113
Q

Signs of anorexia nervosa

A 
BMI<17.5 or <85% expected body weight
Hypotension
Bradycardia 
Lanugo
Dry skin
Amenorrhea
Arrhythmias
Osteoporosis
114
Q

Labs in pts with anorexia nervosa may show this

A 
Leukocytosis
Leukopenia
Anemia
Hypokalemia
Increased BUN from dehydration
Hypothyroidism
115
Q

Management of anorexia nervosa

A

Hospitalize if <75% expected body weight

CBT with supervised meals and weight monitoring

SSRI if depressed and maybe atypical antipsychotics to cause weight gain

116
Q

The major difference between anorexia nervosa and bulimia nervosa is

A

pts with bulimia often have a normal body weight or are overweight

117
Q

Signs of self induced vomiting

A

Teeth putting or enamel erosion

Russell’s sign (calluses on dorsum of hand from inducing vomiting)

Parotid hypertrophy

118
Q

This medication has been shown to reduce the binge-purge cycle

A

Fluoxetine

119
Q

Cluster A personality disorders

A

Characterized by social detachment with weird, odd eccentric behavior

Includes: schizoid, schizotypal, and paranoid

120
Q

Cluster B personality disorders

A

Dramatic, wild, erratic, impulsive, and emotional

Includes: antisocial, borderline, histrionic, narcissistic

121
Q

Cluster C personality disorders

A

Anxious worried and fearful

Includes: avoidant, defendant, and obsessive-compulsive

122
Q

Who has cluster A personality disorders?

A

They are MC in men

Schizotypal and paranoid onset is usually early adulthood

Schizoid onset is usually early childhood

123
Q

Conduct disorder in childhood may progress to…

A

Antisocial personality disorder in adulthood

*3xMC in males

124
Q

Management of cluster A personality disorders

A

1st line: psychotherapy

Short term low dose use of antipsychotics, antidepressants, or benzos

125
Q

Describe schizoid personality disorder

A

Voluntary social withdrawal and anhedonic introversion

“Hermit-like behavior”/prefers to be alone

Little enjoyment if close relationships or intimacy

126
Q

Describe schizotypal personality disorder

A

Odd, eccentric and peculiar thought patterns without psychosis/delusions

“Magical thinking”

May talk to self in public

127
Q

Describe paranoid personality disorder

A

Pervasive pattern of distrust and suspicious of others

Bears grudges, doesn’t forgive and blames others for problems

128
Q

Describe antisocial personality disorder

A

Deviates sharply from social norms, values, and laws

Disregard and violation of rights of others

Criminal acts, promiscuous, extremely manipulative and lacks remorse

129
Q

Describe borderline personality disorder

A

Unstable unpredictable mood, affect, self image, and relationships

Cannot tolerate being alone/fear of abandonment

Black& white/all-or-nothing thinking

Self-damaging behaviors

130
Q

Borderline personality amity disorder is MC in

A

Women

131
Q

Describe histrionic personality disorder

A

Overly emotional, dramatic and seductive

Attention seeking/needs to be center of attention

Self absorbed temper tantrums

132
Q

Describe narcissistic personality disorder

A

Grandiose excessive sense of self-importance but fragile self-esteem

Needs praise and admiration

Reacts to criticism/rejection with rage

May become depressed

Lacks empathy for others

133
Q

Narcissistic personality disorder is MC in

A

Men

134
Q

Management of cluster C personality disorders

A

1st line: paychotherapy

BB, anxiolytics, and antidepressants as needed

135
Q

Describe avoidant personality disorder

A

Desires relationships but avoids them due to inferiority complex

Lacks confidence

136
Q

Describe dependent personality disorder

A

Very needy/clingy submissive behavior

Needs constant reassurance

Will not initiate things and may volunteer for unpleasant tasks

137
Q

Describe obsessive-compulsive personality disorder

A

Perfectionist who require great deal of control and order

Change in routine may lead to anxiety

Preoccupation with minute details

May avoid intimacy

138
Q

Is autisim more common in boys or good?

A

Boys 4:1

139
Q

Clinical manifestation of Autisim

A

Social interaction difficulties

Impaired communication

Restrictive, repetitive, stereotypes behaviors

140
Q

Describe oppositional defiant disorder

A

Defiant behavior to adults characterized by irritable mood, defiant behavior and vindictiveness for at least 6m

*may progress to conduct disorder

141
Q

Describe conduct disorder

A

Sharper deviation form age-appropriate Norns and violation of the rights of others

Social and academic difficulty

*may violate laws, be cruel to animals, destroy property, and lie

142
Q

How many pts with conduct disorder eventually develop antisocial personality disorder?

A

40%

143
Q

Onset of ADD or ADHD usually occurs when?

A

Before the age of 12

144
Q

Tx of ADD or ADHD

A

Behavior modification with

Sympathomimetics/stimulants: (Methylphenidate, amphetamine/deztroamphetamine, or dexmethylpgenidate)

OR

No stimulants: (atomoxetine)

145
Q

Clinical manifestations of nicotine withdrawal

A

Restlessness, anxiety, irritability, withdrawal, sleep abnormalities, desperation, cravings

146
Q

Tx of nicotine dependence

A
  1. nicotine tapered therapy
  2. bupropion (zyban)
  3. Varenicline (Chantix)
147
Q

Signs and symptoms of opioid intoxication

A 
Euphoria
Sedation
Pupillary constriction
Resp depression
Biot’s breathing 
Bradycardia
Hypotension
148
Q

Signs of opioid withdrawal

A 
Lacrimation
N&amp;V 
Hypertensioa
Abd cramps
Sweating
Diarrhea
Piloerections
Pupil dilation
Rhinorrgea
Myalgia/joint pain
149
Q

Tx for acute opioid intoxication

A

Naloxone (Narcan)

*IM onset of action 5min. 30-60min duration

150
Q

Management of opioid withdrawal

A

Clinicians to decrease sympathetic symptoms

Loperamide first diarrhea

NSAIDs for joint and muscle cramps

151
Q

Long term management options for opioid dependence

A

Methadone

Suboxone (buprenorphine and naloxone)

152
Q

Tx for benzodiazepine intoxication

A

Flumazenil

153
Q

Wernick’s encephalopathy

A

Triad: ataxia, confusion, oculomotor palsy

Due to thiamine/B1 deficiency caused by chronic alcohol consumption

154
Q

Korsakoff syndrome

A

Retrograde and antegrade amnesia due to alcohol

155
Q

Signs of cocaine/stimulant intoxication

A

Euphoric mood and psychosis

156
Q

Treatment of cocaine intoxication

A

Benzodiazepines

157
Q

When do alcohol withdrawal seizures occur?

A

6-48hr after last drink

*MC occurs as a single episode

158
Q

When do alcoholic withdrawal hallucinations occur?

A

12-48hrs after last drink

*pt has clear sensorium and normal vitals

159
Q

When do delirium tremendous occur?

A

2-5d after last drink

*altered sensorium/delirium and abn vitals(tachycardia, hypertension, and fever)

160
Q

Management of alcohol withdrawal

A

IV benzodiazepines

IV thiamine and Mg before glucose administration

161
Q

Management of alcohol intoxication

A

Acute intoxication - observation

IV thiamine and magnesium prior to glucose administration

Haloperidol of psychosis or severe aggression

162
Q

Alcohol dependence screening

A

CAGE

Cutdown
Annoyed
Guilt
Eye opener

*2 or mire considered positive

163
Q

Normal grief reaction

A

Resolved within 1yr and does not have psychosis or suicidal ideation

164
Q

Types of delusions

A 
Bizarre 
Non-bizarre
Paranoid/persecutory 
Grandiose
Reference (high power communication)
Somatic
Erotomanic (celebrity loves them)
Jealous
165
Q

Types of hallucinations

A 
Auditory (commands?)
Visual
Tactile
Olfactory
Gustatory
166
Q

Types of disorganized speech

A 
Derailment
Tangential
Incoherent/word salad
Neologism (combining words)
Echolalia (repaying you back)
Blocking/paucity
167
Q

Psychosis differential

A 
Substance intoxication/withdraw
Meds (steroids, stimulants, anticholinergic)
Delirium
Dementia
Hyperthyroidism
CNS infection
Epilepsy
B12 deficiency 
Lupus
Huntington’s
Wilson’s
Psychiatric disorders
168
Q

DTS

A

Danger to self

169
Q

DTO

A

Danger to others

170
Q

MC type of elder abuse

A

Neglect

171
Q

SSRIs with low CYP450 interactions

A

Sertraline and escitalopram

172
Q

Pharmaceutical Tx for male hypoactive sexual desire disorder

A

Testosterone or bupropion

173
Q

Tx for female sexual interest/arousal disorder

A

Lubricants

Flibanserin

Therapy

174
Q

Exhibitionism

A

Indecent exposure/flashing

175
Q

Voyeurism

A

Observing unsuspecting person get undressed or engage in sexual behavior

176
Q

Frotteurism

A

Rubbing against or touching a non-consenting person

177
Q

Fetishism

A

Sexual arousal/fantasies involving non-living objects or non-genital body parts

178
Q

Masochism

A

Sexual arousal from being humiliated, beaten, bound, or otherwise made to suffer

179
Q

Sadism

A

Sexual arousal from causing a non-consenting person physical or psychological harm

**associated with ASPD

PANCE prep JQ (15 decks)

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