Psychiatry/Behavioral Medicine

Question 1

child abuse

Answer 1

• hx of abuse in caregiver’s childhood, inapprop effect of caregiver , inc severity or number injuries, stress or crisis in fam, children <3yo
• MC form of child abuse = neglect
• shaken baby syndrome: lethargy, coma, seizure, V, resp distress
• sxs: implausible mech of inj, evolving or absent hx, delay in seeking care, event marks loss of control of caregiver, social/physical isolation of caregiver or child, unrealistic expectations of caregiver for child, behavior changes in kid
• signs: retinal hemorrhage from shaking violently, bruises, bites, abrasions, alopecia, dental trauma, lacs, scars, burns, fx, head trauama, abd inj in mult stages of healing, patterns found in soft tissue areas, toddlers bruises over bony prominences, lacs of frenulum or tongue and bruising of lips, burns in stocking or glove dist.
• dx: XR, CT, MRI
• tx: home visitor services to fams, anticipatory guidance

Question 2

major depressive disorder

Answer 2

• one or more major depressive eps, MC psychiatric disorder in gen pop, MDD is more frequent in families of bipolar indivs, but the reverse is not true, increases risk of developing CAD, 66% present with somatic complaints (HA, back probs, chronic pain)
• sxs: syndrome with >/= 5 sxs lasting >/= 2 consecutive wk (depressed mood nearly qd, most of day), loss of interest/pleasure nearly qd, appetite disturbance (significant wt loss or gain), sleep disturbance (insomnia or hypersomnia), psychomotor disturbance (restlessness or feeling slowed down), fatigue, feelings of shame, guilt/worthlessness, hopelessness, impaired concentration, SI, abnl self-perception, not attributable to seasonal affective disorder, schizophrenia, schizophreniform disorder, delusional disorder, absence of manic or hypomanic ep (differs from bipolar)
• dx: clinical (CBC, CMP, UA, hCG, urine tox, TSH, vitB12, folate, EKG)
  
  • screening: PHQ9, PHQ2, beck depression inventory for primary care
• ​tx: SSRI (first line), bupropion (wellbutrin), TCA, MAOIs, psychotherapy
  
  • tx for . 6-12 wks before deciding if . med effective

Question 3

suicide

Answer 3

• men over age 50 are more likely to complete a suicide because of their tendency to attempt suicide with more violent means (guns)
• women make more attempts but are less likely to complete a suicide
• suicide is 10x more prevalent in pts with schizophrenia than the gen pop with jumping from bridges the most common means of attempted suicide
• inc suicide rate among age 15-35 and pts w/ CA, resp illness, AIDS, and hemodialysis pts
• having a gun in the home inc the likelihood of suicide 5-fold

Question 4

generalized anxiety disorder

Answer 4

• onset before 20yo
• hx childhood fears, social inhib, F 2x > M
• all anxiogenic agents work on GABA-A receptor/chloride ion channel complex
• sxs: chronic, excessive anxiety, worry about job performance, health, marital relatinships, social life (duration >/=6 mo, usually lifetime)
  
  • 3 out of 6 sxs: restlessness, irritability, muscle tension, easily fatigued, dec concentration, disturbed sleep (insomn, restless sleep)
  • not attributable to physiologic effects of a substance
• dx: clinical dx, CBC< CMP, TSH, UA, EKG, urine or serum tox
• tx: SSRI/SNRI (1st line), CBT, buspirone (second line adjunct or monotherapy, TID dosing), pregabalin (Off-label), short acting benzos (adjunct or monotx), mirtazapine, antipsychotics (quetiapine), long acting benzos
  
  • Time to onset = 4-6 weeks
  • if no response to first SSRI/SNRI, taper and start different one
  • if robust response, continue for at least 12 mos
• screening: GAD7

Question 5

ADHD

Answer 5

• two subcategories: (1) inattention and (2) hyperactivity and impulsivity
• begins in childhood, associated = ODD, conduct disorder, specific learning disorder; 5% children and 2.5% of adults
• RF: VLBW (<1500g), smoking during preg, first degree relative, M (2x) > F
• hx: may include abuse, neglect, mult foster placements, lead exposure, enceph, alc exposure in utero, several inattentive or hyperactive impulsive sxs present PRIOR to age 12 (motoric hyperactivity in preschool, inattention more in elementary, hyperact less common in adolescence, impulsivity remains problematic in adulthood)
  
  • several sxs present in 2 or more settings (home, school, work; with friends or relatives), sxs interfere with or reduce quality of social, academic, or occupational fn, do not occur exclusively during course of schizophrenia or another psychotic/mental disorder
• prognosis: inc risk suicide attempt (when comorbid mood, conduct, or substance use disorders)

Question 6

ADHD inattention

Answer 6

• 6 or more of following for at least 6mo:
  
  • no close attention to detail or makes careless mistakes at school, work, etc.
  • difficulty sustatining attention in tasks or play activities
  • doesn’t seem to listen when spiken to directly
  • doesn’t follow through on instructions, fails to finish homework, chores, or duties in workplace
  • difficulty organizing tasks and activities
  • avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
  • often loses things necessary for tasks or activities
  • often distracted by extraneous stimuli
  • forgetful in daily activities

Question 7

ADHD hyperactivity and impulsivity

Answer 7

• 6 or more of the following for at least 6mo:
  
  • fidgets, taps hands/feet or squirms
  • leaves seat in situations when remaining seated is expected
  • runs about or climbs in situations where inappropriate
  • often unable to play or engage in leisure activities quietly
  • often “on the go” or “driven by a motor”
  • talks excessively
  • blurts out answers before question has been completed
  • difficulty waiting for his/her turn
  • interrupts or intrudes on others

Question 8

ADHD tx

Answer 8

• stimulants, nonstimulants, antidepressants, antihypertensives, modafinil
  
  • methylphenidate (ritalin, concerta, metadate) - can cause growth retardation, psychosis
  • amphetamine
  • antihypertensives more effective for hyperactivity and impulsivity - clonidine, guanfecine

Question 9

conduct disorder

Answer 9

• mostly male, 2-10% prevalence, comorbidities = ADHD, ODD, learning disorders, 90% of children with conduct disorder have had ODD
• sxs: patient violates basic rights of others
  
  • at least 3 of the 15 criteria in past 12mo w/ at least 1 in last 6mo:
    
    • aggression to people and animals; bullies, threatens, intimidates others; initiates physical fights; used a weapon that cuases harm to others; physically cruel to people or animals; stolen while confronting a victim; forced someone into sexual activity; destruction of property; engaged in fire-setting with intention of causing damage; deliberately destroyed others’ property; deceitfulness or theft; broken into house, building or car; lies to obtain goods or favors or to avoid obligations; stolen items of nontrivial value without confronting victim; serious violations of rules; stays out at night despite parental prohibitions; runs away from home overnight at least 2x while living in home or once without returning for lengthy period; truant from school

Question 10

oppositional defiant disorder (ODD)

Answer 10

• precursor to conduct disorder, prevalence = 1-11%, M>F, average age of onset 6yo
• comorbidities: anxiety, depression, substance use disorder
• sxs: pattern of angry/irritable mood, argumentative or defiant behavior, or vindictiveness lasting at least 6mo with at least 4 sxs:
  
  • angry or irritable mood; loses temper, touchy or easily annoyed, angry and resentful; argumentative and defiant behavior; argues with authority figures, actively defies rules or refuses to comply with requests; deliberately annoys others; blames others for his or her mistakes; spiteful or vindictive at least twice during past 6mo
• tx: children <12, effective parenting, positive attention with praise and reinforcement of desirable behavior, ignore inappropriate behavior, give clear, brief commands, reduce task complexity, eliminate competing influences, family tx if >18
• prognosis: 25% will develop conduct disorder

Question 11

autism spectrum disorders

Answer 11

• 1% gen pop
• RF: advanced parental age, low birth weight, fetal exposure to Valproate, 15% have known genetic mutation, M 4x >F, AA, associated with anxiety, depression, mental retardation
• sxs: typically observed during second year of life, but may be seen <12mo
  
  • persistent deficits in social communication and interaction (deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors, deficits in developing, maintaining, and understanding relationships (i.e. sharing imaginative play, etc.)
  • restricted, repetetive patterns of behavior, interests, activities
    
    • 2 of the following: stereotyped or repetetie motor mvmts, insistence on sameness, fixated interests that are abnl in intensity or focus, hyper or hyporeactivity to sensory input
• signs: motor deficits (odd gait, clumsiness, abnl motor signs), self-injury (head banging, biting the wrist), disruptive or challenging behaviors
• complications: seizures
• tx: edu and behavioral intervention, focus on speech and language tx, communication skills and vocab
  
  • meds: abilify, risperdal, SSRIs
  • psychotx
  • good prognosis if fnal language by age 5, poor prognosis if epilepsy as comorbidity

Question 12

anorexia nervosa

Answer 12

• MC F 14-21yo, F:M (3:1), homosexual men, child sex abuse, OCD, childhood/parental obesity
• starvation induces protein and fat catabolism → loss of cellular volume and atrophy in kidneys, brain, heart, liver, intestines, and muscles
• restriction of energy intake, intense fear of gaining weight, distorted perception of body weight and shape, palpitations, dizziness, weakness, exertional fatigue, cold intolerance, amen, abd pain or bloating, early satiety, const, swelling of feet
• signs: bradycardia, ortho hoTN, BMI <17.5, hypotherm, hypoactive bowel sounds, brittle hair, hair loss, xerosis (dry skin), lanugo, abd distention
• dx: EKG (inc PR interval, 1st def heart block, ST-T wave abnl, QT prolong.), CBC (anem leukopen, thrombocytopen), hypoK, hypoMg, hypophosph, hypoNa, Cr low, elevated bili/alkphos/AST/ALT, low T3/T4, low FSH/LH, high cholesterol
• tx: psychotherapy, nutritional . rehab, avoid bupropion

Question 13

bulemia nervosa

Answer 13

• F:M 3:1
• RF: childhood trauma
• sxs: recurrent eps of binge eating, compensatory behavior to prevent wt gain (vomiting, laxatives, diuretics, fasting, excessive exercise)
  
  • both of these occur at least 1x/wk for 3mo
  • excessive concern about body wt and shape, lethargy, irreg menses, abd pain, bloating, const
• signs: tachycardia, hoTN, xerosis, parotid gland swelling, erosion of dental enamel, + Russel sign (scarring or calluses on knuckles or back of hands)
• dx: serum alb low, hypoK, met alkalosis, hypoCl, hypoNa, hypoMg
• tx: psychotx, nutritional rehab, pharm (SSRIs, TCAs/MAOIs)

Question 14

indications for hospitalization in anorexia or bulemia

Answer 14

• unstable vitals (ortho inc in pulse >20bpm or dec in syst BP >20mmHg, bradycardia <40 and hypotension or lightheadedness, hypotherm (<35C or 95F)
• cardiac dysrhytmia r any rhythm other than sinus brady
• weight <70% ideal body weight or BMI <15
• marked dehydration
• acute complication of malnourishment: syncope, seizures, cadiac fialure, liver failure, pancreatitis, hypoglycemia, or electrolyte disturb
• moderate to severe refeeding syndrome: marked edema, serum phosph <2
• poor response as outpt