Psychiatry Clerkship

Question 1

For intellectual disability (formerly known as mental retardation), patients must exhibit what two deficits?

Answer 1

1. Deficits in cognitive ability

2. Deficits in social adaptive function (ability to do daily activities)

Question 2

Intellectual disability is more prevalent in which gender?

Answer 2

Boys

Question 3

What’s the IQ and level of function of a patient with mild mental retardation?

Answer 3

IQ: 50-70
Reaches sixth grade level of education, can work and live independently, needs help in difficult or stressful situations.

Question 4

What’s the IQ and level of function of a patient with moderate mental retardation?

Answer 4

IQ: 30-50
Reaches second grade level of education, may work with supervision and support, needs help in mildly stressful situations.

Question 5

What’s the IQ and level of function of a patient with severe mental retardation?

Answer 5

IQ: 20-40

Little or no speech, very limited abilities to manage self-care.

Question 6

What’s the IQ and level of function of a patient with profound mental retardation?

Answer 6

IQ: Below 20

Needs continuous care and supervision.

Question 7

How do you treat intellectual disability (formerly known as mental retardation)? (name 4)

Answer 7

1. Genetic counseling (if applicable)
2. Treat underlying condition (if applicable)
3. Special education to improve level of function
4. Behavioral therapy to help reduce negative behaviors

Question 8

What are the autism spectrum disorders?

Answer 8

Autism, Rett’s syndrome, and Asperger’s disorder

Question 9

Autism spectrum disorders are characterized by problems in what 3 areas? At what age do you these problems tend to present?

Answer 9

Social interactions, behavior, and language problems that impair daily functioning.

These deficits include lack of social connection, poor eye contact, and problems with language, relationships, and understanding others. Other features include stereotyped or repetitive movements, inflexibility, and unusual interest in sensory aspects of the environment.

Children younger than age 3

Question 10

How do you treat autism disorder? When would you begin pharmacological treatment?

Answer 10

The goal of treating autism disorder is to improve the patient’s ability to develop relationships, attend school, and achieve independent living. Patients with autism spectrum disorders may benefit from behavioral modification programs that seek to improve language and ability to connect with others. If the patient is aggressive, use antipsychotic medications such as risperidone.

Question 11

2 y/o boy
Not speaking much
Not demonstrating much attachment to parents
Aggressive towards other children

Answer 11

Autism spectrum disorder

Autism spectrum disorder is seen more frequently in boys and usually starts by the age of 3. Children with autism tend to have problems with language and aggression, lack separation anxiety, and are withdrawn. Deafness should be ruled out if parents report that a child does not respond when his or her name is called.

Question 12

What is ADHD and how does it present?

Answer 12

Attention deficit hyperactivity disorder (ADHD) is a disorder characterized by inattention, short attention span, OR hyperactivity that is severe enough to interfere with daily functioning in school, home, or work. The symptoms must be present for more than 6 months and usually appear before the age of 7. The symptoms may persist into adulthood.

Question 13

How do you diagnose ADHD?

Answer 13

Symptoms (inattention, short attention span, or hyperactivity) must be present in at least 2 areas, such as home and school (the doctor’s office counts as a context as well). At home, children interrupt others, fidget in chairs, and run or climb excessively; are unable to engage in leisure activities; and talk excessively. At school, they are unable to pay attention, make careless mistakes in schoolwork, do not follow through with instructions, have difficulties organizing tasks, and are easily distracted.

Question 14

What is first line treatment for ADHD? What are the side effects of these medications?

Answer 14

Methylphenidate and dextroamphetamine

Side effects: insomnia, decreased appetite, GI disturbances, increased anxiety, and headache.

Question 15

ADHD medications target the activity of which 2 neurotransmitter pathways to improve attention?

Answer 15

Noradrenergic (norepinephrine) and dopamine pathways

Question 16

What is second line treatment for ADHD? (name 3 drugs)

Answer 16

Atomoxetine. This is a norepinephrine reuptake inhibitor with fewer side effects and less risk of abuse. The alpha-2 agonists clonidine and guanfacine can also been used, because they enhance cognition and attention in the prefrontal cortex.

Question 17

ADHD medications like methylphenidate and dextroamphetamine can cause side effects. What are these side effects and what medication can be used that has fewer side effects and less abuse potential?

Answer 17

Side effects: insomnia, decreased appetite, GI disturbances, increased anxiety, and headache

Atomoxetine can be chosen over the first-line ADHD treatments given its milder side effect profile and decreased abuse potential.

Question 18

Often argue with others.
Lose temper.
Easily annoyed by others.
Blame others for their mistakes.
Tends to have problems with authority figures.
Behaviors manifest during interactions with others that do not include siblings.

Answer 18

Oppositional defiant disorder

Question 19

Oppositional defiant disorder is typically noted by what age? What gender is it more often seen in?

Answer 19

Usually noted by age 8.

Seen more in boys than girls before puberty, but equal incidence after puberty.

Question 20

How do you treat oppositional defiant disorder?

Answer 20

Teach parents appropriate child management skills and how to lessen the oppositional behavior.

Question 21

Childhood/adolescent.
Persistent behavior where rules are broken. These include aggression to others such as bullying, cruelty to animals, fighting, or using weapons. Destroying property such as vandalism or setting fires. Stealing items from others or lying to obtain goods from others. Violating rules (e.g. truancy, running away from home, breaking curfew)

Answer 21

Conduct disorder

Question 22

Conduct disorder is seen more frequently in what gender? By what age is this diagnosis given?

Answer 22

Seen more frequently in boys and children whose parents have antisocial personality disorder and alcohol dependence.

Diagnosis is given ONLY to those under the age of 18 years.

Question 23

How do you treat conduct disorder?

Answer 23

Behavioral intervention using reward for prosocial and nonaggressive behavior. If aggressive, antipsychotic medications may be used.

Question 24

Chronic, severe, persistent irritability with temper outbursts and angry, irritable, or sad mood between the outbursts. These occur almost every day, are noticeable by others, and are out of proportion to the situation. The outbursts are inconsistent with developmental issues. Symptoms occur year-round; there is no period lasting > or = 3 months without all symptoms. The symptoms are severe enough to interfere with home, school, or peers.

Answer 24

Disruptive mood dysregulation disorder (DMDD)

Question 25

Disruptive mood dysregulation disorder is seen more frequently in what gender and age? At what age can this be diagnosed? What disorder are these patients at risk of developing? What disorder are they likely to not develop?

Answer 25

Seen more frequently in boys age 6-10 years. This should NOT be diagnosed before the age of 6 or after the age of 18. Children with DMDD usually do not develop bipolar disorder in adulthood but they are more likely to develop depression or anxiety.

Question 26

10 y/o boy
Behavior problems at home and school.
Frequently angry towards others.
Loses temper during class.
Parents report that at home, he refuses to comply with house rules and often stays up later than he is supposed to.
Frequently talks back to parents.

What is the most likely diagnosis?

a. Conduct disorder
b. Tourette disorder
c. Adjustment disorder
d. Oppositional defiant disorder
e. Learning disorder, not otherwise specified

Answer 26

Oppositional defiant disorder

Children with oppositional defiant disorder usually have problems with authority figures such as parents and teachers. Unlike children with conduct disorder, they DO NOT break rules of society and do not commit crimes.

Question 27

9 y/o boy
Problems at home and school.
Teacher describes temper tantrums that result in physical aggression towards peers.
Occurring almost daily since age 8, worsened in past 4 months resulting in disciplinary suspension.
Parents report same problems at home with siblings.
General mood is irritable and angry with slight improvement during summer months when not in school.

What is the most likely diagnosis?

a. Intermittent explosive disorder
b. Adjustment disorder with disturbances of conduct
c. Disruptive mood dysregulation disorder
d. Bipolar disorder
e. Oppositional defiant disorder

Answer 27

Disruptive mood dysregulation disorder

Children with intermittent explosive disorder are not aggressive on such a continuous basis; they have extended periods of good behavior. There is no mention of a stressor, ruling out diagnosis of adjustment disorder. There is no evidence of mood swings, ruling out diagnosis of bipolar disorder. Children with oppositional defiant disorder mostly have problems with authority figures, not their peers.

DMDD is characterized as chronic, severe, persistent irritability with temper outbursts and angry, irritable, or sad mood between the outbursts. These occur almost every day, are noticeable by others, and are out of proportion to the situation. The outbursts are inconsistent with developmental issues. Symptoms occur year-round; there is no period lasting > or = 3 months without all symptoms. The symptoms are severe enough to interfere with home, school, or peers.

Question 28

Tourette disorder.
Symptoms?
Duration of symptoms?
Symptoms begin by what age?
Diagnosed before what age?
Seen more often in which gender?

Answer 28

Multiple tics, lasting more than one year, and seen before the age of 18.

Motor tics: most commonly involve the muscles of the face and neck, such as head shaking and blinking.
Vocal tics: grunting, coughing, and throat clearing.

The disorder is seen more frequently in boys than in girls and will begin by the age of 7.

Question 29

Tourette disorder is more commonly seen in which gender? What age do symptoms typically begin by?

Answer 29

More frequently seen in boys than girls and will typically begin by the age of 7

Question 30

How do you treat Tourette disorder?

Answer 30

Treatment includes:

1) Dopamine antagonists, such as the antipsychotic medications haloperidol, pimozide, and risperidone
2) Alpha-2 agonist, such as clonidine, can also be used

Question 31

SIG-E-CAPS?

Answer 31

Sleep changes
Interest loss
Guilt (worthlessness)
Energy (lack)
Cognition/Concentration loss
Appetite change
Psychomotor agitation or retardation
Suicidal ideation

Question 32

First line treatment of MDD?

Answer 32

SSRIs such as fluoxetine, paroxetine, sertraline, citalopram, or escitalopram. SSRIs are chosen due to their effectiveness and relatively mild side effects. They are less toxic in overdose than other antidepressants.

Question 33

When treating MDD with an SSRI, how long should you wait to see if there is an effect before switching to another SSRI? When should you increase the dose?

Answer 33

If there is no effect after 6-8 weeks, switch to another SSRI.
If some improvement is noted by 6-8 weeks but not a full response, increase the dose of SSRI.

Question 34

What is second line treatment of MDD?

Answer 34

SNRIs such as venlafaxine, duloxetine, or desvenlafaxine.

Question 35

Hypertension and sweating. Are these side effects of SSRIs or SNRIs?

Answer 35

SNRIs

Question 36

SSRIs are first-line treatment for MDD. However, what can you give to a patient with depression with neuropathic pain? How about a patient with depression who is fearful of weight gain or sexual side effects or is trying to quit smoking?

Answer 36

Duloxetine is approved for both depression and neuropathy.

Bupropion has fewer sexual side effects and less weight gain than SSRIs. It is also approved for smoking cessation.

Question 37

45 y/o woman
Depressed mood
Lack of pleasure
Sleep problems
Decreased appetite and weight
Decreased energy
Problems with concentration
Symptoms started when she was fired from her job 4 weeks ago. Since then, she has been unable to function.

What is the most indicated treatment at this time?

a. Alprazolam
b. Paroxetine
c. Bupropion
d. Venlafaxine
e. Trazodone
f. Electroconvulsive therapy

Answer 37

Paroxetine

She has a diagnosis of major depression and the first-line treatment is the use of an SSRI medication because of a better side-effect profile compared to the other therapies. All others, except alprazolam and electroconvulsive therapy, would be useful but usually are not based on side effect profile. Alprazolam is simply a benzodiazepine and acts as an anxiolytic, not an antidepressant. Electroconvulsive therapy might be useful if initial therapy did not work or the depression was far more severe and was associated with psychotic features.

The choices on the USMLE Step 2 may include an SSRI and another antidepressant medication. Pick the cleanest, which is the SSRI.

Question 38

55 y/o male
Depressed mood for over 2 months
Lack of energy
Decreased appetite
Inability to concentrate
Poor sleep
Poor sleep and focus are impairing work.

Which of the following is most indicated at this time?

a. Imipramine
b. Venlafaxine
c. Bupropion
d. Zolpidem
e. Mirtazapine

Answer 38

Mirtazapine

Although any antidepressant can be used, mirtazapine is preferable in this patient for both its antidepressant and sedative effects. Imipramine would have too many side effects and is not a first-line agent. Venlafaxine might be considered if the patient had depression alone; since insomnia is a major concern, mirtazapine is the better option. Bupropion tends to cause problems with sleep, so is not indicated. Zolpidem would help this patient sleep but would not treat his depression.

Question 39

What medication class is Imipramine (Tofranil) in?

Answer 39

TCA

Imipramine AKA Tofranil AKA Melipramine

Question 40

What are manic symptoms?

Answer 40

Manic symptoms include DIGFAST:
Distractibility - poor focus, multitasking
Insomnia - decreased need for sleep
Grandiosity - inflated self-esteem
Flight of ideas - complaints of racing thoughts
Activities - increased goal-directed activities
Speech - pressured or more talkative
Thoughtlessness - “risk-taking” behaviors (sexual, financial, travel, driving)

Question 41

When assessing a patient for bipolar disorder, what should you keep in mind?

Answer 41

Screen for drug use, such as cocaine or amphetamine use.

Question 42

What’s the difference between a manic episode and a hypomanic episode?

Answer 42

Severity of symptoms, level of functioning, and duration.

Manic episode: symptoms are more severe, lasts more than 1 week unless hospitalized, marked impairment in social or occupational functioning or hospitalization necessary, may have psychotic features. Psychotic features makes it a manic episode automatically.

Hypomanic episodes last more than 4 days but typically less than a week, do not severely affect functioning but have an observable change in functioning from the patient’s baseline, and are not severe enough to warrant hospitalization. No psychotic features.

Question 43

What’s the difference between bipolar disorder type 1 and type 2?

Answer 43

Bipolar disorder type 1 is mania and depression. Bipolar disorder type 2 is hypomania and depression.

Question 44

21 y/o college student taken to university clinic after she was found to be acting bizarrely in class.
Talking fast.
Reported that she hasn’t slept for 4 days.
Appears to be giggling and not paying attention in class.
Roommate reports that she had been drinking alcohol excessively over the past few days and had many sexual contacts with unknown men.

What is the most likely diagnosis?

a. Alcohol-induced mood disorder
b. Bipolar disorder type I
c. Bipolar disorder type II
d. Major depression with psychosis
e. Cyclothymia

Answer 44

Bipolar disorder type 1

This patient is exhibiting mania, as shown by her pressure speech, decreased sleep, increased libido, and inappropriate behavior. The symptoms are severe enough that her level of functioning is affected. Bipolar disorder occurs more frequently in young individuals.

Question 45

Treatment of bipolar disorder depends on if the patient is acutely manic or not. How do you treat if the patient is acutely manic? (3) How do you treat bipolar depression? (4)

Answer 45

1st line treatment for acute mania: lithium, valproic acid, and atypical antipsychotics. If acute mania, consider use of atypical antipsychotics due to shorter onset of action.

If bipolar depression, treat with lithium, quetiapine, lurasidone, or lamotrigine. Lurasidone is approved for bipolar depression and is the only medication in pregnancy category B indicated for the disorder.

Question 46

If kidneys are compromised, with bipolar medication should you avoid?

Answer 46

Lithium

Question 47

True or False: Lithium is the correct answer to most bipolar questions.

Answer 47

True

Question 48

What drug class is lurasidone (latuda)?

Answer 48

Atypical antipsychotic

Question 49

What is the only bipolar medication that is safe for pregnancy?

Answer 49

Lurasidone (latuda)

Question 50

33 y/o man taken to ED by police
Family informed doctor that he has been diagnosed with bipolar disorder and was recently started on lithium.
While in the ER, he became combative and punched a nurse.

What is the next step in the management of this patient? a. Obtain lithium level

b. Admit to psychiatric unit
c. Refer to psychiatry
d. Add valproic acid
e. Olanzapine

Answer 50

Olanzapine

The patient is exhibiting mania and you do not need to verify the lithium level given that his symptoms are acute. He apparently has been noncompliant with medications and obtaining a level is not the correct answer. He needs to be medicated, and antipsychotics are considered first-line treatment for bipolar patients, especially if acutely and severely manic. Admitting an agitated patient to the psychiatric unit is not as important as administering adequate treatment. “Refer to psychiatry” is never the correct answer on Step 2 CK.

Question 51

What is persistent depressive disorder (formerly known as dysthymia)?

Answer 51

Chronic depressed mood > or = 2 years (1 year in children/adolescents)
No symptom-free period for > 2 months
Presence of at least 2 of the following:
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness

Question 52

How do you treat persistent depressive disorder?

Answer 52

Antidepressant medications and psychotherapy

Question 53

What is cyclothymic disorder? How long do symptoms have to be present to be diagnosed?

Answer 53

Cyclothymia is characterized by the presence of hypomanic episodes and mild depression. Symptoms must be present for more than 2 years.

Question 54

How do you treat cyclothymic disorder?

Answer 54

Lithium, valproic acid, or antipsychotic medication, and psychotherapy

Question 55

What is major depressive disorder with atypical features?

Answer 55

Atypical depression is characterized by:

• reverse vegetative changes (increased sleep, increased weight, and increased appetite)
• interpersonal rejection sensitivity that results in significant social or occupational impairment.
• mood tends to be worse in the evening
• patient may complain of extremities feeling “heavy”

Question 56

How do you treat major depressive disorder with atypical features?

Answer 56

SSRIs (fluoxetine, sertraline, paroxetine, citalopram, or escitalopram) or MAOIs (phenelzine, isocarboxazid, or tranylcypromine)

MAOIs are typically the correct answer on USMLE for the treatment of atypical depression.

Question 57

What is major depressive disorder with seasonal pattern (formerly seasonal affective disorder)?

Answer 57

Characterized by seasonal changes in mood during fall and winter. Symptoms include weight gain, increased sleep, and lethargy.

Question 58

How do you treat major depressive disorder with seasonal pattern?

Answer 58

Phototherapy and bupropion or SSRIs.

In phototherapy, patients should be 12-18 inches from a source of 10,000 lux of white fluorescent light without UV wavelengths for 30 minutes each morning. The patient’s eyes should be kept open, but it is not necessary to stare at the light.

Question 59

What are symptoms of postpartum blues (aka "baby blues")?
Prevalence?
Time of onset?
Mother's feelings towards the baby?
Treatment?

Answer 59

Symptoms: mild depression, mood lability, tearfulness
Prevalence: 40-80%
Onset: 1-3 days after birth up to 2 weeks
Mother’s feelings toward baby: no negative feelings
Treatment: supportive, usually self-limited (reassurance and monitoring)

Question 60

What are symptoms of depressive disorder with peripartum onset?
Prevalence?
Time of onset?
Mother's feelings towards the baby?
Treatment?

Answer 60

Symptoms: depressed mood, weight changes, sleep disturbances, and excessive anxiety
Prevalence: 8-15%
Onset: within 1-3 months after birth
Mother’s feelings toward baby: may have negative feelings toward baby
Treatment: antidepressant medications and psychotherapy

Question 61

What are symptoms of bipolar disorder with peripartum onset and brief psychotic disorder with peripartum onset?
Prevalence?
Time of onset?
Mother's feelings towards the baby?
Treatment?

Answer 61

Symptoms: depression, mania, hallucinations, delusions, and thoughts of harm
Prevalence: 0.1% - 0.2%
Onset: during pregnancy up to 4 weeks after birth
Mother’s feelings toward baby: may have thoughts of harming baby
Treatment: Hospitalization! Do not leave the mother alone with the infant due to risk of infanticide. Treat with antipsychotic medication, lithium, and possibly antidepressants.

Question 62

Death of loved one.
Sadness.
Worrying about the deceased.
Irritability.
Sleep disturbance.
Poor concentration.
Tearfulness

Answer 62

Normal bereavement/grief

Question 63

How long does normal bereavement/grief typically last?

Answer 63

6 months to 1 year, but can go longer

Question 64

How do you treat normal bereavement/grief?

Answer 64

Supportive psychotherapy. Pharmacotherapy is the WRONG ANSWER.

Question 65

True or False:
A patient is suffering from normal bereavement/grief after losing a loved one. You can use pharmacotherapy, such as antidepressants, temporarily to help the patient through the difficult months.

Answer 65

FALSE. Pharmacotherapy is the wrong answer when it comes to normal bereavement/grief.

Question 66

65 y/o man
Hopeless and helpless since wife died 3 months ago.
Daughter is worried about his isolative behavior.
Lack of appetite.
Expresses feelings of worthlessness.
Has lost over 30 pounds since.
Not interested in getting better and believes he should have died with his wife.

What is the most likely diagnosis?

a. Bereavement
b. Persistent depressive disorder
c. Major depressive disorder
d. Adjustment disorder
e. Bipolar disorder

Answer 66

Major depressive disorder

Although it has been less than 6 months since his wife died, his symptoms are severe enough to warrant a diagnosis of major depression. He has no interest in things, has lost weight, feels hopeless and helpless, and believes he should have died as well. He needs to be treated with antidepressants, and you must ensure that he is not suicidal since he is at high risk.

Remember SIG-E-CAPS when determining if presentation is MDD. Normal bereavement includes sadness, worrying about the deceased, irritability, sleep disturbance, poor concentration, and tearfulness. This patient has feelings of worthlessness, signs of anhedonia, and is expressing suicidal ideation.

Question 67

Name 3 tricyclic antidepressants

Answer 67

Amitriptyline
Nortriptyline
Imipramine

Question 68

Name 3 monoamine oxidase inhibitors

Answer 68

Phenelzine
Isocarboxazid
Tranylcypromine

Question 69

Name 6 serotonin selective reuptake inhibitors

Answer 69

Fluoxetine
Paroxetine
Sertraline
Citalopram
Escitalopram
Fluvoxamine

Question 70

Name 3 serotonin norepinephrine reuptake inhibitors

Answer 70

Venlafaxine
Duloxetine
Desvenlafaxine

Question 71

Name 3 atypical antidepressant medications

Answer 71

Bupropion
Mirtazapine
Trazodone

Question 72

What are the adverse effects of tricyclic antidepressants? (8)

Answer 72

Hypo/hypertension
Dry mouth
Constipation
Confusion
Arrhythmias
Sexual side effects
Weight gain
GI disturbances

Question 73

What is the main adverse effect of monoamine oxidase inhibitors? What foods should you avoid? Give some examples of safe and unsafe foods.

Answer 73

Tyramine rich food causes hypertensive crisis
Safe foods: white wine and processed cheese
Unsafe foods: red wine, aged cheese, chocolate

Question 74

What are the adverse effects of serotonin selective reuptake inhibitors? (4)

Answer 74

Headaches
Weight changes
Sexual side effects
GI disturbances

Question 75

What are the adverse effects of serotonin norepinephrine reuptake inhibitors? (5)

Answer 75

Hypertension
Blurry vision
Weight changes
Sexual side effects
GI disturbances

Question 76

What is the classic side effect of bupropion?

Answer 76

Increased seizure risk

Question 77

What is the classic side effect of trazodone?

Answer 77

Priapism

Question 78

What is the classic side effect of mirtazapine?

Answer 78

Weight gain and sedation

Question 79

What are the side effects of lithium? (7)

What happens with lithium toxicity? (4)

Answer 79

Tremors
Weight gain
GI disturbances
Nephrotoxic
Teratogenic
Leukocytosis
Diabetes insipidus
Severe toxicity gives confusion, ataxia, lethargy, and abnormal reflexes.

Question 80

What are the side effects of valproic acid? (6)

What happens with valproic acid toxicity? (3)

Answer 80

Tremors
Weight gain
GI disturbances
Alopecia
Teratogenic
Hepatotoxic
Must monitor levels; toxicity causes hyponatremia, coma, or death.

Question 81

What is the main side effect to look out for with lamotrigine?

Answer 81

Stevens-Johnson syndrome

Question 82

What are the side effects of electroconvulsive therapy? (2)

Answer 82

Headaches

Transient memory loss

Question 83

What is the single most effective treatment for depression?

a. Electroconvulsive therapy
b. Fluoxetine
c. Venlafaxine
d. Imipramine
e. Phenelzine

Answer 83

Electroconvulsive therapy

Although ECT is usually used for suicidal patients or those who do not respond to treatment, it is considered the best treatment for depression. All others are equally efficacious, but the SSRIs are used more frequently due to side-effect profiles.

Question 84

What is serotonin syndrome? What causes it?

Answer 84

Serotonin syndrome is a potentially life-threatening disorder occurring as a result of therapeutic drug use of SSRIs, often with inadvertent interactions between drugs, overdose, or recreational use of drugs that are serotonergic in origin.

Question 85

What are common symptoms of serotonin syndrome?

• cognitive effects (4)
• autonomic effects (6)
• somatic effects (2)

Answer 85

Cognitive effects: agitation, confusion, hallucinations, hypomania
Autonomic effects: sweating, hyperthermia, tachycardia, nausea, diarrhea, shivering
Somatic effects: tremors, myoclonus

Question 86

How do you treat serotonin syndrome? (3)

Answer 86

1. Stop SSRI medication
2. Symptomatic treatment of fever, diarrhea, hypertension
3. Cyproheptadine (serotonin antagonist)

Question 87

What is the serotonin antagonist that’s used for treating serotonin syndrome?

Answer 87

Cyproheptadine

Question 88

What are the symptoms and duration of symptoms for brief psychotic disorder?

Answer 88

Symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior

Duration: more than 1 day but less than 1 month

Question 89

What are the symptoms and duration of symptoms for schizophreniform disorder?

Answer 89

Symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (flat affect, poor grooming, social withdrawal)

Duration: more than 1 month but less than 6 months

Question 90

What are the symptoms and duration of symptoms for schizophrenia?

Answer 90

Symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (flat affect, poor grooming, social withdrawal). Severely affects level of function.

Duration: more than 6 months

Question 91

How do you treat brief psychotic disorder? How about schizophreniform? Schizophrenia?

Answer 91

Antipsychotic medications

Question 92

The ONLY thing that distinguishes brief psychosis, schizophreniform, and schizophrenia is the duration of symptoms. However, if no time is mentioned, what is typically the correct answer for “the most likely diagnosis”?

Answer 92

Schizophrenia

Question 93

Is schizophrenia more commonly seen in men or women?

Answer 93

There is equal incidence in men and women but it affects men earlier due to earlier age of onset.

Question 94

What should be ruled out when working up schizophrenia?

Answer 94

Cocaine or amphetamine use

Question 95

How do you treat an acutely psychotic patient? (6)

Answer 95

1. hospitalize
2. ensure patient safety
3. use atypical antipsychotic as first-line agent (E.g. risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, asenapine, iloperidone, or lurasidone)
4. In any emergency situation where intramuscular medication is needed, consider the use of short-acting medications such as olanzapine or ziprasidone; haloperidol is still used, but has more side effects, so if given the choice, pick the atypical antipsychotic.
5. If noncompliant with medication, consider a long-acting antipsychotic medication such as risperidone or paliperidone as first-line treatment. Haloperidol and fluphenazine are still used but have more side effects.
6. Clozapine is only used when patients do not respond to an adequate trial of typical or atypical antipsychotics; never used as a first-line treatment

Question 96

Name 7 atypical antipsychotic medications

Answer 96

1. Olanzapine
2. Clozapine
3. Quetiapine
4. Risperidone
5. Ziprasidone
6. Lurasidone
7. Aripiprazole

Question 97

Atypical antipsychotics share similar side effect profiles. However, what are the specific adverse effects of olanzapine? (2)
Who should you avoid giving this to? (2)

Answer 97

Greater incidence of diabetes and weight gain

Avoid in diabetic and obese patients

Question 98

Atypical antipsychotics share similar side effect profiles. However, what are the specific adverse effects of risperidone? (2)

Answer 98

1) breast formation and galactorrhea
2) Greater incidence of movement disorders, especially at higher doses. Extrapyramidal symptoms include acute dystonia, akathisia, parkinsonism, and tardive dyskinesia.

Question 99

Atypical antipsychotics share similar side effect profiles. Quetiapine has a lower incidence of what adverse effect? (1) Who can you consider giving this to?

Answer 99

Lower incidence of movement disorders

Appropriate for use in patients with existing movement disorders

Question 100

Atypical antipsychotics share similar side effect profiles. However, what is the specific adverse effect of ziprasidone? (1) Who should you avoid giving this to? (1)

Answer 100

Increased risk of QT prolongation.

Avoid in patients with conduction defects.

Question 101

Atypical antipsychotics share similar side effect profiles. However, what is the specific adverse effect of clozapine? (2) What needs to be monitored on a regular basis? When should you use this drug?

Answer 101

1) High risk of agranulocytosis.
Need to monitor CBC on a regular basis.
2) Myocarditis (same rate as agranulocytosis)

Clozapine is only used when patients do not respond to an adequate trial of typical or atypical antipsychotics; never used as a first-line treatment due to side-effect profile

Question 102

What is unique about aripiprazole as an atypical antipsychotic medication?

Answer 102

It is a partial dopamine agonist, approved as adjunct treatment for major depressive disorder

Question 103

What is unique about lurasidone as an atypical antipsychotic medication?

Answer 103

It is the only antipsychotic in pregnancy category B. It is safer for use in pregnant patients.

Question 104

What is the pro tip for remembering side effects for atypical antipsychotic medications?

Answer 104

• pines (olanzapine, quetiapine, asenapine, clozapine) have increased risk of weight gain, metabolic syndrome, and diabetes.
• dones (risperidone, lurasidone, ziprasidone, iloperidone) have increased risk of movement disorders and cardiac conduction problems.

Question 105

22 y/o woman
Recently diagnosed with schizophrenia
30 lbs overweight
Suffers from type 2 diabetes
She is concerned about medications and asks for your advice

Which of the following would be most indicated in this patient?

a. Aripiprazole
b. Olanzapine
c. Quetiapine
d. Clozapine
e. Risperidone

Answer 105

Aripiprazole and ziprasidone are the LEAST LIKELY to cause weight gain, diabetes, and metabolic syndrome.

Olanzapine and clozapine have the HIGHEST RISK of metabolic abnormalities.

Quetiapine and risperidone have medium risk.

Question 106

Which 2 atypical antipsychotic medications are least likely to cause weight gain, diabetes and metabolic syndrome?

Answer 106

Aripiprazole and ziprasidone

Question 107

Acute dystonia is an adverse effect of antipsychotic medications. What are the symptoms of acute dystonia? (4) Onset of symptoms? Treatment? (3)

Answer 107

Symptoms: muscle spasms, torticollis, laryngeal spasms, occulogyric crisis

Onset: hours to days

Treatment: benztropine, trihexyphenidyl, diphenhydramine

Question 108

Akathisia is an adverse effect of antipsychotic medications. What are the symptoms of akathisia? Onset of symptoms? Treatment? (4)

Answer 108

Symptoms: generalized restlessness, pacing, rocking, inability to relax

Onset: weeks

Treatment: reduce dose, beta blockers, switch to atypical antipsychotic, benzodiazepine

Question 109

Tardive dyskinesia is an adverse effect of antipsychotic medications. What are the symptoms of tardive dyskinesia? Onset of symptoms? Treatment? (1)

Answer 109

Symptoms: abnormal involuntary movements of head, limb, and trunk. Perioral movements are the most common.

Onset: rare before 6 months

Treatment: switch to atypical antipsychotic. Clozapine has least risk.

Question 110

Which antipsychotic medication has the lowest risk for tardive dyskinesia?

Answer 110

Clozapine

Question 111

Neuroleptic malignant syndrome is an adverse effect of antipsychotic medications. What are the symptoms of neuroleptic malignant syndrome? Onset of symptoms? Treatment?

Answer 111

Symptoms: muscular rigidity, fever, autonomic changes, agitation, and obtundation

Onset: not time limited

Treatment: dantrolene or bromocriptine

Question 112

23 y/o man diagnosed with schizophrenia and started on haloperidol.
Within a few hours, he develops muscle stiffness, and his eyes roll upward and he cannot move them down.

What is the most likely diagnosis?

a. Tardive dyskinesia
b. Neuroleptic malignant syndrome
c. Akathisia
d. Serotonin syndrome
e. Acute dystonia

Answer 112

Acute dystonia

Acute dystonia develops within hours of the use of medications. This side effect is typical for haloperidol. The treatment of choice is benztropine or diphenhydramine, which can be given with the haloperidol or after should side effects occur.

Question 113

What is delusional disorder?

Answer 113

Characterized by prominence of non-bizarre delusions for more than one month and no impairment in level of functioning (e.g. the patient may believe the country is about to be invaded, but he or she still obeys the law, goes to work, and pays bills). Hallucinations, if present, are not prominent and are related to the delusional theme.

Question 114

How do you treat delusional disorder? (2)

Answer 114

1. Atypical antipsychotic (first-line therapy)

2. Psychotherapy to help promote reality testing

Question 115

What is panic disorder?

Answer 115

Experience of intense anxiety along with feelings of dread and doom. Accompanied by at least 4 symptoms of autonomic hyperactivity such as diaphoresis, trembling, chest pain, fear of dying, chills, palpitations, shortness of breath, nausea, dizziness, dissociative symptoms, and paresthesias. These sensations typically last LESS THAN 30 MINUTES and may be accompanied by agoraphobia, defined as fear of places where escape is felt to be difficult.

Question 116

What is agoraphobia?

Answer 116

Fear of places where escape is felt to be difficult

Question 117

Is panic disorder typically seen in men or women?

Answer 117

Women

Question 118

True or False: panic disorder can occur at any time and usually has no specific stressor

Answer 118

True

Question 119

What should you rule out when working up panic disorder? (3)

Answer 119

Must rule out thyroid disease, hypoglycemia, and cardiac disease

Question 120

How do you treat panic disorder?

Answer 120

1) SSRIs (typically fluoxetine, paroxetine, and sertraline) are indicated for this disorder
2) Along with SSRIs, patients may benefit from benzodiazepines (such as alprazolam, clonazepam, or lorazepam). You can begin with both SSRIs and benzodiazepines, then taper and discontinue the benzodiazepine given the potential for abuse.
3) Behavioral and individual therapy are also helpful IN CONJUNCTION with medication (not as a sole treatment).

Question 121

Which is considered to be first-line treatment for panic disorder?

a. Alprazolam
b. Buspirone
c. Sertraline
d. Imipramine
e. Fluvoxamine

Answer 121

Sertraline

SSRIs are considered to be 1st line treatment for panic disorder. If the question is panic attack, then alprazolam is the correct answer; if a single panic attack is the diagnosis, a benzodiazepine is the treatment.

Question 122

How do you determine between panic attack vs. panic disorder? How do you choose treatment?

Answer 122

When determining most likely diagnosis in cases involving panic symptoms, distinguish between direct presentation and patient history. If the patient is presenting with autonomic hyperactivity, then panic attack is the most likely diagnosis and benzodiazepines are the correct treatment. If the patient is telling the doctor a story about the panic attacks, the diagnosis is most likely panic disorder and the treatment of choice is an SSRI.

Question 123

What is a phobia?

Answer 123

A phobia is the fear of an object or situation and a need to avoid it.

Question 124

Specific phobia vs social phobia?

Answer 124

Specific phobia = fear of an object, such as animals, heights or cars

Social fobia = fear of a situation, such as public restrooms, eating in public, or public speaking. These involve situations where something potentially embarrassing may happen.

Question 125

How do you diagnose phobias?

Answer 125

The diagnosis is usually made by obtaining a good history where patients indicate anxiety symptoms in specific situations or when in contact with feared objects.

Question 126

How do you treat phobias?

Answer 126

Behavioral modification techniques such as systemic desensitization, in which the patient while relaxed is exposed, often only in imagination, to progressively more frightening aspects of the feared objects.
Patients are also taught relaxation techniques such as breathing or guided imagery.

Question 127

True or False: beta blockers can be used for phobias.

Answer 127

False.

Beta blockers such as atenolol or propranolol are used for performance anxiety such as stage fright. They are given 30-60 minutes before the performance. They are not indicated for treatment of phobias.

Question 128

40 y/o man
Referred to psychiatrist by PCP because he is “too shy”.
Problems going to parties.
Feels anxious about getting close to others.
Stays hom in fear that others would laugh at him.
When confronted by others, he develops severe anxiety as well as hyperventilation and increased sweating.

Which is the most likely diagnosis?

a. Panic disorder
b. Social anxiety
c. Generalized anxiety disorder
d. Specific phobia
e. Acute stress disorder

Answer 128

Social anxiety

Social anxiety is characterized by fear of embarrassment in social situations. These patients have problems going out in fear that others will laugh at them.

Question 129

What is obsessive compulsive disorder?

Answer 129

This is a disorder where patients typically experience either obsessions alone or, most commonly, a combination of obsessions and compulsions typically affecting the individual’s level of functioning.

Question 130

What is the difference between obsessions and compulsions?

Answer 130

Obsessions are thoughts that are intrusive, senseless, and distressing to the patient, thus increasing anxiety. These include fear of contamination.

Compulsions are rituals, such as counting and checking, that are performed to neutralize obsessive thoughts. These are time consuming and tend to lower anxiety.

Question 131

What age does OCD typically present? Gender incidence?

Answer 131

OCD is seen more frequently in young patients.

There is equal incidence in men and women.

Question 132

True or False: OCD can coexist with Tourette disorder

Answer 132

True

Question 133

How do you treat obsessive compulsive disorder? (2)

Answer 133

1. SSRIs are the treatment of choice. Fluoxetine, paroxetine, sertraline, citalopram, or fluvoxamine are most commonly used as 1st line agents.
2. Behavioral therapy of exposure and response prevention.

Question 134

If all the answer choices offered as pharmacotherapy for obsessive-compulsive disorder are TCAs, which do you choose?

Answer 134

Clomipramine

Question 135

What is hoarding disorder?

Answer 135

Individuals with hoarding disorder have problems discarding their possessions, leading to persistent accumulations of possessions such that the home is overwhelmed by clutter. The hoarding affects the individual’s level of functioning and impairs his/ her ability to maintain a safe environment.

Question 136

How do you treat hoarding disorder?

Answer 136

1) SSRIs

2) Patients benefit from behavioral modification techniques or psychotherapy (like CBT)

Question 137

What is body dysmorphic disorder?

Answer 137

Individuals with body dysmorphic disorder believe that some body part is abnormal, defective, or misshapen, although others do not see these perceived defects. These beliefs significantly impair in the patient’s level of functioning. Patients spend excessive time checking the mirror and seeking reassurance.

Question 138

How do you treat body dysmorphic disorder?

Answer 138

SSRIs combined with individual psychotherapy are the treatment of choice.

Question 139

What do PTSD and acute stress disorder have in common? What’s different about them?

Answer 139

• exposed to a stressor to which they react with fear and helplessness
• continually relive the event and avoid anything that reminds them of the event
• stressors are usually overwhelming and involve such events as war, rape, hurricanes, or earthquakes
• symptoms adversely affect the patient’s level of functioning.
• other symptoms include increased startle response, hypervigilance, sleep disturbances, anger outbursts, and concentration difficulties.

PTSD is when symptoms last for more than 1 month.
Acute stress disorder is 2 days to 1 month in duration and occurs within 1 month of the traumatic event.

Question 140

When investigating PTSD/acute stress disorder, what are the main things you are looking out for? (3)

Answer 140

1) determining the time period when the traumatic events occurred in relationship to the symptoms
2 + 3) depression and substance abuse must be ruled out, because both worsen the diagnosis.

Question 141

What are the 2 types of schizoaffective disorder?

Answer 141

1) depressive type

2) bipolar type

Question 142

Psychotic features and a mood disorder, either bipolar or depression, but does not strictly meet diagnostic criteria for either alone.

Answer 142

Schizoaffective

Question 143

What is dialectical behavior therapy (DBT) and what is it good for treating?

Answer 143

Borderline personality disorder

DBT combines standard cognitive behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be generally effective in treating borderline personality disorder. The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.

Question 144

Name 4 typical first generation antipsychotics

Answer 144

1) Haloperidol
2) Chlorpromazine
3) Perphenazine
4) Fluphenazine

Question 145

Which antipsychotic is associated the side effect of breast formation and sometimes milk discharge?

Answer 145

Risperidone (as it increases prolactin secondarily by blocking dopamine)

Question 146

True or False: NEVER give haloperidol through IV

Answer 146

True. It can cause death from torsades.

Question 147

How does clozapine compare to other antipsychotics in efficacy?

Answer 147

It has been demonstrated by head to head trials to be more effective than other antipsychotics. However, due to its serious side effects, it is only used after failed adequate trials of other antipsychotics.

Question 148

How can you tell the difference between serotonin syndrome and neuroleptic malignant syndrome?

Answer 148

Serotonin syndrome has clonus and neuroleptic malignant syndrome doesn’t. Either can have fever and either can be acute.

Question 149

What two drugs are first-line treatment for PTSD?

Answer 149

Paroxetine or sertraline

Question 150

What drug can be used to reduce the incidence of nightmares in PTSD?

Answer 150

Prazosin (alpha 1 blocker)

Question 151

Aside from medications, what can be done to help PTSD patients? (3)

Answer 151

1) Relaxation techniques
2) Hypnosis
3) Psychotherapy to develop coping techniques and acceptance of the event

Question 152

What is Generalized Anxiety Disorder?

Answer 152

Excessive anxiety and worry ABOUT MOST THINGS, lasting MORE than 6 months. The anxiety is typically out of proportion to the event and is accompanied 3 or more of the following symptoms: fatigue, concentration difficulties, sleeping problems, muscle tension, and restlessness. Patients typically complain of feeling anxious for as long as they can remember.

Question 153

Is generalized anxiety disorder more common in men or women?

Answer 153

Women

Question 154

Treatment for generalized anxiety disorder?

Answer 154

SSRIs such as fluoxetine, paroxetine, sertraline, or citalopram. Venlafaxine and buspirone are also effective.
Psychotherapy and behavioral therapy are beneficial as well, but are not considered first-line agents in most patients.

Question 155

35 y/o woman
Palpitations, dizziness, and increased sweating for at least 8 months.
Visited numerous physicians and none have been helpful.
Husband is concerned because she cannot relax and worries about everything.
She worries about her parents’ health even though they are healthy. She worries about her finances, although her husband assures her they are financially secure.

What is the most likely diagnosis?

a. Generalized anxiety disorder
b. Phobias
c. Panic disorder
d. Adjustment disorder
e. Social anxiety

Answer 155

Generalized anxiety disorder

The main feature of GAD is the chronic worrying about things that do not merit concern. It is also accompanied by other symptoms of anxiety, as well as sleep and concentration problems.

Question 156

What are adverse effects of benzodiazepines? (5)

Answer 156

Sedation
Confusion
Memory deficits
Respiratory depression
Increased addiction potential

Question 157

What are adverse effects of buspirone? (3)

Answer 157

Headaches
Nausea
Dizziness

Question 158

What class of medication is chlordiazepoxide?

Answer 158

Benzodiazepines

Question 159

Which benzodiazepine is frequently used in emergency situations because it can be given intramuscularly?

Answer 159

Lorazepam (ativan)

Question 160

Which benzodiazepine may be used if addiction is a concern given its longer half-life?

Answer 160

Clonazepam (klonopin)

Question 161

Which benzodiazepines (3) may be used in treatment of alcohol withdrawal?

Answer 161

Chlordiazepoxide
Oxazepam
Lorazepam

Question 162

Which benzodiazepines are the drugs of choice in patients with liver problems?

Answer 162

Oxazepam
Lorazepam

(remember “O”ld “L”iver)

Question 163

Which benzodiazepine is frequently used in panic attack and panic disorder?

Answer 163

Alprazolam (xanax)

Question 164

Which benzodiazepines are approved as hypnotics?

Answer 164

Flurazepam, temazepam, triazolam

but benzodiazepines are rarely used as hypnotics

Question 165

What can cause seizures in benzodiazepine-dependent patients?

Answer 165

Flumazenil (benzodiazepine antagonist)

It causes acute withdrawal, which can be tremor or seizures similar to delirium tremens (alcohol withdrawal).

Question 166

When is flumazenil used?

Answer 166

With acute benzodiazepine overdose AND you are certain that there is no chronic dependence.

When used in benzodiazepine-dependent patients, it causes acute withdrawal, which can be tremor or seizures similar to delirium tremens (alcohol withdrawal).

Question 167

What is substance use disorder?

Answer 167

Maladaptive pattern of use of substances that leads to engaging in hazardous situations, legal problems, inability to fulfill obligations, and continued use despite adverse consequences and cravings.

Question 168

Signs of alcohol intoxication?

Answer 168

Talkative, sullen (gloomy/sulky), gregarious (sociable), moody, disinhibited

Question 169

Treatment of alcohol intoxication?

Answer 169

Mechanical ventilation if severe

Question 170

Signs of alcohol withdrawal?

Answer 170

Tremors, hallucinations, seizures, delirium tremens

Question 171

Treatment of alcohol withdrawal?

Answer 171

Benzodiazepines, thiamine, multivitamins, folic acid

Question 172

Signs of amphetamine and cocaine or bath salts intoxication?

Answer 172

Euphoria, hyper vigilance, autonomic hyperactivity, weight loss, pupillary dilation, perceptual disturbances

Question 173

Treatment of amphetamine, cocaine, and bath salt intoxication

Answer 173

Antipsychotics and/or benzodiazepines and/or antihypertensives

Question 174

Signs of amphetamine, cocaine, and bath salt withdrawal?

Answer 174

Anxiety, tremulousness, headache, increased appetite, depression, risk of suicide

Question 175

Treatment of amphetamine, cocaine, and bath salt withdrawal?

Answer 175

Bupropion (norepinephrine-dopamine reuptake inhibitor)
and/or
Bromocriptine (dopamine agonist)

Question 176

Signs of cannabis (synthetic forms: K2 and spice) intoxication?

Answer 176

Impaired motor coordination, slowed sense of time, social withdrawal, increased appetite, conjunctival injection

Question 177

Treatment for cannabis intoxication?

Answer 177

Consider use of antipsychotics if patient is psychotic

Question 178

Signs and symptoms of cannabis withdrawal?

Answer 178

Irritability, anger, anxiety, sleep problems, restlessness, appetite problems

Question 179

Treatment with cannabis withdrawal?

Answer 179

Symptomatic management

Question 180

Signs of hallucinogen intoxication?

Answer 180

Ideas of reference, perceptual disturbances, possible increase in psychosis, impaired judgment, tremors, incoordination, dissociative symptoms

Question 181

Treatment for hallucinogen intoxication?

Answer 181

Antipsychotics and/or benzodiazepines and/or talking down

Question 182

Signs of hallucinogen withdrawal? Treatment?

Answer 182

None, none

Question 183

Signs of inhalant intoxication?

Answer 183

Belligerence, apathy, aggression, impaired judgment, stupor, or coma

Question 184

Treatment of inhalant intoxication?

Answer 184

Antipsychotics

Question 185

Signs of inhalant withdrawal? Treatment?

Answer 185

None, none

Question 186

Signs of opiate intoxication?

Answer 186

Apathy, dysphoria, pupillary constriction, drowsiness, slurred speech, coma, or death

Question 187

Treatment for opiate intoxication?

Answer 187

Naloxone

Question 188

Signs and symptoms of opiate withdrawal?

Answer 188

Fevers, chills, lacrimation, abdominal cramps, muscle spasms, diarrhea

Question 189

Treatment for opiate withdrawal?

Answer 189

Clonidine, methadone, or buprenorphine

Question 190

What is PCP? What are signs of phencyclidine (PCP) intoxication?

Answer 190

PCP is a dissociative anesthetic that can cause hallucinations, dissociative feelings, agitation, confusion, pupillary dilation, tachycardia, and NYSTAGMUS (horizontal, vertical, or rotatory). In many cases, intoxication can lead to psychotic and violent behavior, diminished pain perception, and subsequent physical injuries. The drug’s onset of action is rapid and the duration of action is generally less than 8 hours. High doses can cause severe hypertension, seizures, and life-threatening hyperthermia.

Question 191

Treatment for phencyclidine (PCP) intoxication?

Answer 191

Antipsychotics and/or benzodiazepines and/or talking down

Question 192

Signs of phencyclidine (PCP) withdrawal? Treatment?

Answer 192

None, none

Question 193

Signs of anabolic steroid intoxication?

Answer 193

Irritability, aggression, mania, psychosis

Question 194

Treatment of anabolic steroid intoxication?

Answer 194

Antipsychotics

Question 195

Signs of anabolic steroid withdrawal?

Answer 195

Depression, headaches, anxiety, increased concern over body’s physical state

Question 196

Treatment for anabolic steroid withdrawal?

Answer 196

SSRIs

Question 197

What is the CAGE test?

Answer 197

This is the test to give someone who is an alcoholic. Tow positive responses to the four questions is considered positive and indicate that further assessment is warranted.

C: Have you ever tried to cut down on your drinking?
A: Have you ever gotten annoyed by others who have criticized your drinking?
G: Have you ever felt guilty about your drinking?
E: Have you ever used alcohol as an eye-opener? (drinking first thing in the morning)

Question 198

What is detoxification vs rehabilitation?

Answer 198

Detoxification: 5-10 days, mostly in hospital settings to assure safe detoxification

Rehabilitation: usually 28 days or more, with focus on relapse prevention techniques

Question 199

Name 3 pharmacologic treatments for helping alcoholics abstain.

Answer 199

1) Disulfiram (acetaldehyde dehydrogenase inhibitor)
2) Naltrexone (opioid receptor antagonist)
3) Acamprosate

Question 200

65 y/o engineer taken to ER after MVA.
Suffered fracture of the femur and some cuts and bruises.
Admitted to the medicine floor and started on oxycodone.
The day after admission, he appears confused and has observable tremors in both extremities.
He becomes concerned about “bugs on the walls” in his room and asks for your help.

What is the most likely explanation for his symptoms?

a. brain concussion
b. alcohol withdrawal
c. oxycodone intoxication
d. brief psychotic disorder
e. schizophrenia

Answer 200

Alcohol withdrawal

Most withdrawal questions are asked in a hospital setting on the next day after admission. The patient presents with uncomplicated alcohol withdrawal, characterized by visual hallucinations and tremors.

Question 201

What is somatic symptom disorder?

Answer 201

> or = 1 somatic symptom(s) causing distress and functional impairment.
Excessive thoughts or behaviors related to somatic symptoms. Unwarranted, persistent thoughts about seriousness of symptoms. Persistent anxiety about health or symptoms. Excessive time and energy devoted to symptoms. Greater than or equal to 6 months duration.

Question 202

What age and gender does somatic symptom disorder typically affect?

Answer 202

Most commonly young women

Question 203

How do you treat somatic symptom disorder?

Answer 203

• Regularly scheduled visits with the same provider
• Limit unnecessary workup & specialist referrals
• Legitimize symptoms but make functional improvement the goal
• Focus on stress reduction and improving coping strategies
• Mental health referral if patient will accept

Question 204

What is illness anxiety disorder (formerly hypochondriasis)?

Answer 204

Patients believe that they have some specific disease despite constant assurance

Question 205

What is conversion disorder?

Answer 205

Typically affects voluntary motor or sensory functions that are indicative of a medical condition but are usually caused by psychological factors. Can be associated with “la belle indifference”, where the patient is unconcerned about his or her impairment.

Question 206

35 y/o married woman
3 children
Taken to doctor’s office after daily complaints of dizziness, nausea, and headache for the past 6 months.
She is intensely bothered by her symptoms to the point that she now stays home and avoids both going to work and caring for her children.
She has been tried on numerous medications but none have proven to be beneficial. A neurologic exam finds some abnormalities.

Which of the following would be most indicated in this patient?

a. Lorazepam
b. Sertraline
c. Individual psychotherapy
d. Lithium
e. Risperidone

Answer 206

Individual psychotherapy

This patient has somatic symptom disorder, which is treated with individual psychotherapy given that psychological issues are the cause of her symptoms. She should have one primary caretaker and not be sent to specialists. Lorazepam, a benzodiazepine, treats anxiety disorder. SSRIs such as sertraline treat fibromyalgia and depression. Lithium treats bipolar disorder. Risperidone is for psychosis.

Question 207

What is factitious disorder?

Answer 207

An individual FAKES an illness in order to get attention and emotional support in the patient role. This can either be a psychological or physical illness. Psychological symptoms include hallucinations, delusions, depression, and bizarre behavior. Physical symptoms include abdominal pain, fever, nausea, vomiting, or hematomas. At times these individuals may inflict life-threatening injuries on themselves in order to get attention. This behavior may be compulsive at times. When a caretaker fakes signs and symptoms in another person (usually a child) in order to assume the sick role, the diagnosis is fictitious disorder imposed on others. When signs and symptoms are faked on oneself, the diagnosis is factitious disorder imposed on self.

Question 208

Factitious disorder cannot be diagnosed without first confirming what?

Answer 208

First confirm that a legitimate medical illness is not present

Question 209

How do you treat factitious disorder?

Answer 209

No specific therapy has been proven to be effective in these patients. When a child is involved in factitious disorder imposed on others, child protective services should be contacted to ensure the child’s safety.

Question 210

What is malingering?

Answer 210

Malingering is characterized by the conscious production of signs and symptoms for an obvious gain, such as avoiding work, evading criminal prosecution, or achieving financial gain. Malingering is not a mental illness.

Question 211

True or False: Malingering is a mental illness.

Answer 211

False.. Malingering is not a mental illness.

Question 212

Malingering is more frequently seen in what 2 populations of people?

Answer 212

Prisoners and military personnel

Question 213

How is malingering typically diagnosed? How do you treat?

Answer 213

It is typically diagnosed when there is discrepancy between the patient’s complaints and the actual physical or laboratory findings. If medical evaluation reveals malingering, then confront the patient with the outcome.

Question 214

A lack of cooperation from patients is characteristic of?

Answer 214

Malingering

Question 215

What is adjustment disorder?

Answer 215

A maladaptive reaction to an identifiable stressor, such as loss of job, divorce, or failure in school. The symptoms usually occur within 3 months of the stressor and must remit within 6 months of removal of the stressor. The symptoms include anxiety, depression, or disturbances of conduct. They are severe enough to cause impairment in functioning.

Question 216

How do you treat adjustment disorder?

Answer 216

Psychotherapy is the treatment of choice. Both individual and group therapy have been used effectively.

Question 217

Paranoid personality disorder?

Answer 217

Suspicious, mistrustful, secretive, isolated, and questioning of the loyalty of family and friends

Question 218

Schizoid personality disorder?

Answer 218

Choice of solitary activities, lack of close friends, emotional coldness, no desire for or enjoyment of close relationships.

Question 219

Schizotypal personality disorder?

Answer 219

Ideas of reference, magical thinking, odd thinking, eccentric behavior, increased social anxiety, brief psychotic episodes

Question 220

Histrionic personality disorder?

Answer 220

Must be the center of attention, inappropriate sexual behavior, self-dramatizination, uses physical appearance to draw attention to self

Question 221

Antisocial personality disorder?

Answer 221

Failure to conform to social rules, deceitful, lack of remorse, impulsive, aggressive towards others, irresponsible, must be over the age of 18, must have history of conduct disorder

Question 222

Borderline personality disorder?

Answer 222

Unstable relationships, impulsive, recurrent suicidal behaviors, chronic feelings of emptiness, inappropriate anger, dissociative symptoms when severely stressed, brief psychotic episodes

Question 223

Narcissistic personality disorder?

Answer 223

Grandiose sense of self, belief that they are special, lack empathy, sense of entitlement, requires excessive admiration

Question 224

Avoidant personality disorder?

Answer 224

Unwilling to get involved with people, views self as socially inept, reluctant to take risks, feelings of inadequacy

Question 225

Dependent personality disorder?

Answer 225

Difficulty making day-to-day decisions, unable to assume responsibility, unable to express disagreement, fear of being alone, seeks relationship as source of care

Question 226

Obsessive compulsive personality disorder?

Answer 226

Preoccupied with details, rigid, orderly, perfectionistic, excessively devoted to work, inflexible

Question 227

How do you treat personalty disorders?

Answer 227

Psychotherapy. Medications if mood or anxiety symptoms are present.

Question 228

Which of the personality disorders have been associated with positive psychotic symptoms? When do they occur?

Answer 228

Borderline and schizotypal personality disorders may have short-lived psychotic episodes that are brief and usually occur after stressful situations.

Question 229

15 y/o girl.
Found vomiting in bathroom.
Mother reports that girl vomits daily after meals.
Sometimes observed exercising excessively.
Numerous calluses on her hands as well as cavities.
Low BMI.

What is her most likely diagnosis?

a. bulimia nervosa
b. anorexia nervosa
c. eating disorder not otherwise specified
d. obesity
e. atypical depression

Answer 229

Anorexia nervosa

The main focus of this question is the reduced BMI. This is indicative of the weight loss seen in anorexia nervosa. She obviously purges and as a result has calluses and cavities. Amenorrhea, significant weight loss, and abnormal preoccupation with body image are the key to the diagnosis of anorexia.

Question 230

How is anorexia characterized?

Answer 230

Failure to maintain a normal body weight, fear of and preoccupation with gaining weight, and body image disturbance. There is an unrealistic self-evaluation as overweight. These patients tend to deny their emaciated condition. They show great concern with appearance and frequently examine and weight themselves. They typically lose weight by maintaining strict caloric control, excessive exercise, purging, and fasting, with laxative and diuretic abuse.

Question 231

Anorexia is typically seen in what gender and age?

Answer 231

Teenage girls between age 14 and 18

Question 232

What is the main difference between anorexia and bulimia?

Answer 232

Severe weight loss in anorexia.

Most people with bulimia are of NORMAL WEIGHT but do have a history of obesity.

Question 233

What is the most common cause of death in anorexics?

Answer 233

Cardiac arrhythmias from potassium deficiency

Question 234

How do you treat anorexia?

Answer 234

1) hospitalization to prevent dehydration, starvation, electrolyte imbalances, and death
2) psychotherapy
3) behavioral therapy
4) SSRIs have been used to promote weight gain

Question 235

How is bulimia characterized?

Answer 235

Frequent binge eating.
Lack of control of overeating episodes.
Accompanied by compensatory behavior to prevent weight gain in the form of purging, miss of laxative and diuretics, fasting, and excessive exercise.
The patient’s self-evaluation is unduly influenced by body shape and weight.

Question 236

Bulimia is seen more frequently in what gender and age?

Answer 236

More frequently seen in women and occurs later in adolescence than anorexia nervosa.

Question 237

How do you treat bulimia?

Answer 237

1) does not require hospitalization unless severe electrolyte abnormality is present
2) psychotherapy
3) SSRIs

Question 238

What is binge eating disorder?

Answer 238

Recurrent episodes of binge eating that occur at least 3 times per week for more than 3 months.
Patients are overweight and they usually lack a sense of control over their eating habits. The binge eating episodes are associated with eating faster than usual, eating until feeling uncomfortably full, eating large amounts of food in the absence of hunger, eating alone, and feeling disgusted with oneself after the eating episode.

Question 239

What is the treatment for binge eating disorder?

Answer 239

Topiramate has been proven efficacious for binge eating disorder. SSRIs may have limited benefits.

Psychotherapy is indicated, including cognitive behavioral therapy, interpersonal psychotherapy, and dialectic behavioral therapy.

Question 240

True or False: first-line treatment of binge eating disorder is SSRIs

Answer 240

False. Topiramate is first line treatment.

Question 241

What is eating disorder not otherwise specified?

Answer 241

A designation of eating disorder not otherwise specified is used when patients do not meet criteria for either anorexia nervosa or bulimia nervosa. Examples include:
criteria for anorexia present in girls but menstruation is normal. Anorexic patient with normal weight. Use of compensatory behavior after eating normal amounts of food.

Question 242

What criteria are key to diagnoses of anorexia? (3)

Answer 242

1. Amenorrhea
2. Significant weight loss
3. Abnormal preoccupation with body image

Question 243

What is narcolepsy? 4 specific features?

Answer 243

Disorder characterized by excessive daytime sleepiness and abnormalities of REM sleep.
Specific features:
1) sleep attacks (episodes of irresistible sleepiness and feeling refreshed upon waking)
2) cataplexy (sudden loss of muscle tone. Considered pathognomonic and may be precipitated by loud noise or emotions)
3) hypnogogic and hypnopompic hallucinations (hallucinations that occur as the patient is going to sleep and waking up)
4) sleep paralysis (patient is awake but unable to move; this typically occurs upon waking)

Question 244

What age does narcolepsy typically begin?

Answer 244

Young adulthood

Question 245

How do you diagnose narcolepsy?

Answer 245

Sleep studies and careful history

Question 246

How do you treat narcolepsy?

Answer 246

No therapy has been found to be curative. The patient is managed with forced naps during the day and modafinil is used to maintain alertness. Therapy can also include methylphenidate and dextroamphetamine. Gamma-hydroxybutyrate (GHB) may be given at bedtime to induce symptoms of narcolepsy and contain them at night.

Question 247

Hypnogogic vs hypnopompic?

Answer 247

Hypnogogic: before sleep
Hypnopompic: upon waking

Question 248

How do you treat sleep apnea? (4)

Answer 248

1) continuous positive airway pressure (bipap cpap)
2) weight loss
3) corrective surgery
4) avoidance of sedatives and alcohol

Question 249

Treatment for insomnia? (2)

Answer 249

1) Sleep hygiene techniques (first-line)

2) Zolpidem, eszopiclone, or zaleplon

Question 250

Sleep hygiene techniques?

Answer 250

1) going to bed and waking up at the same time
2) avoiding caffeine
3) avoiding daytime naps
4) using bed only for sleeping and not for reading, watching TV, or eating

Question 251

What is impotence? How do you treat it?

Answer 251

Impotence is persistent or recurrent inability to attain or maintain an erection until completion of the sexual act.

Treatment: rule out medical causes or medication, psychotherapy, couples sexual therapy

Question 252

What is premature ejaculation? How do you treat it?

Answer 252

Ejaculation before penetration or just after penetration, usually due to anxiety

Treatment: psychotherapy, behavioral modification techniques (stop and go, squeeze), SSRI medication

Question 253

What is genitopelvic pain disorder (formerly dyspareunia)? How do you treat it?

Answer 253

Pain associated with sexual intercourse, not diagnosed if due to medical condition. Treat with psychotherapy.

Question 254

What is penetration disorder (formerly vaginismus)? How do you treat it?

Answer 254

Involuntary constriction of the outer third of the vagina preventing penile insertion.

Treat with psychotherapy and dilator therapy

Question 255

What are paraphilic disorders (formerly paraphilias?)

Answer 255

Paraphilias are a group of disorders that are recurrent, sexual arousing, and seen more frequently in men. They focus on humiliation, non consenting partners, or use of nonliving objects. Must occur for more than 6 months and cause distress as well as adversely affect level of functioning. Do not diagnose if done in experimentation.

Question 256

How do you treat paraphilias?

Answer 256

1) Individual psychotherapy
2) Behavioral modification techniques such as aversive conditioning
3) Antiandrogens or SSRIs to reduce sex drive

Question 257

What is gender dysphoria (formerly gender identity disorder)?

Answer 257

This is a disorder characterized by the persistent discomfort and sense of inappropriateness regarding the patient’s assigned sex.

Question 258

How do you treat gender dysphoria?

Answer 258

Sexual reassignment surgery if approved. Individual psychotherapy. Hormone therapy.

Question 259

How does gender dysphoria manifest?

Answer 259

Manifests by wearing the opposite gender’s clothes, using toys assigned to the opposite sex, play with opposite-sex children when young, and feeling unhappy about the person’s own sexual assignment. Patients will take hormones when older to deepen voice, if female, or soften voice, if male. Women may bind their breasts and men may hide their penis and testicles. This is seen more frequently in young men.

Question 260

Risk factors of suicide?

Answer 260

Men
Older adults
Social isolation
Presence of psychiatric illness/drug abuse
Perceived hopelessness
Previous attempts

Question 261

Homicide risk factors? (9)

Answer 261

1) young male
2) unemployed
3) impoverished
4) access to firearms (greatest risk factor)
5) substance abuse
6) antisocial personality disorder
7) history of violence or criminality
8) history of childhood abuse
9) impulsivity

Question 262

True or False: Although postpartum psychosis is rare in comparison with postpartum blues and postpartum depression, it is a medical emergency and requires hospitalization of the mother.

Answer 262

True.

There is an increased risk of both suicide and infanticide in patients with postpartum psychosis. They must be hospitalized to ensure safety and antipsychotic medication should be started. Treatment of any underlying pre-existing disorders is necessary as well.

Question 263

What should a primary care physician consider when a patient often presents with headaches or other physical complaints (e.g. fatigue, insomnia, nonspecific aches and pains)?

Answer 263

Patients with depression often present to a primary care physician with headaches or other physical complaints (e.g. fatigue, insomnia, nonspecific aches and pains). The physician should consider depression on the differential diagnosis and specifically inquire about depressive symptoms (e.g. depressed mood, anhedonia, etc). If the patient is suffering from depression, physical symptoms will likely improve with adequate treatment.

Question 264

How do you diagnose bipolar 1 disorder? Bipolar 2 disorder?

Answer 264

Bipolar 1 disorder is diagnosed by one or more manic episodes. Depressive episodes are common but not required for diagnosis.

Bipolar 2 disorder is diagnosed by one or more hypomanic episodes with one or more major depressive episodes.

For bipolar 1 disorder, depressive episodes aren’t required for diagnosis. For bipolar 2 disorder, one or more major depressive episode is required for diagnosis.

Question 265

30 y/o morbidly obese man.
“Feeling down” after being passed over for a promotion.
Feels discouraged most of the time and remembers that he first felt this way in high school.
Can only remember a few times since high school when he did not feel sad (a month or two at a time).
Works as a computer programmer.
Sleeps about 12 hours a day.
Never asked a woman out because, “I just know she will reject me because I’m fat”.
Describes feeling hopeless and copes by overeating.
Enjoys playing video games with coworkers and friends.
No other PMH or substance use. No SI.
Family history of MDD in mother and older brother.

A. adjustment disorder
B. avoidant personality disorder
C. bipolar 2 disorder
D. cyclothymic disorder
E. major depressive disorder
F. normal human behavior
G. persistent depressive disorder (dysthymia)

Answer 265

Persistent depressive disorder (dysthymia)

Patient’s chronic depression since adolescence, accompanied by overeating, hypersomnia, and low self-esteem, is consistent with persistent depressive disorder. Diagnosis requires persistent depressive symptoms for > or = 2 years and that the individual has never been without depressive symptoms for >2 months at a time. In DSM-5, persistent depressive disorder also encompasses patients who may have met the full criteria for a major depressive illness at some point during the illness; they are specified accordingly (e.g. with intermittent depressive episodes or persistent major depressive episodes).

Question 266

SAD PERSONS mnemonic for suicidality?

Answer 266

Sex (male)
Age (older)
Depression
Previous attempt
Etoh (or other substance) use
Rational thought loss (psychosis)
Social support (lack)
Organized plan
No spouse or significant other
Sickness or injury

Question 267

How do you manage a patient who has high suicide risk?

Answer 267

For patients with high imminent risk (ideation, intent, and plan):
Ensure safety by hospitalizing immediately (involuntary if necessary). Remove personal belongings and objects in the room that may present self-harm risk. Constant observation and security may be required to hold against will.

For patients with high non-imminent risk (ideation, intent, but no plan to act in the near future):
Ensure close follow-up
Treat modifiable risk factors (underlying depression, psychosis, substance abuse, pain). Recruit family or friends to support the patient. Reduce access to potential means (secure firearms, medications)

Question 268

72 y/o man.
Chronic pain. Unknown PMH.
Diminished energy and anxiety for 3 months.
Appears very sad and moves slowly.
Felt terrible since his wife died unexpectedly from brain aneurysm 4 months ago. Filled with guilt because he did not get her to the hospital sooner.
Since her death, he has had disturbed sleep, unable to enjoy his favorite activities, and drinks a bottle of wine nightly to fall asleep. He stays isolated because he does not feel like socializing anymore. He feels hopeless and wants to end his life, believing that he cannot carry on without his wife. He contemplated hanging himself and recently drove by a hardware store with thoughts of buying a rope, but ultimately did not. The patient is advised to enter a psychiatric hospital but he refuses and promises that he will try anything outpatient. What is the most appropriate next step?

Answer 268

Admit him to a psychiatric unit involuntarily.

Question 269

26 y/o graduate student.
Chronic headaches that he describes as “debilitating.
Experiences headaches at night. Difficulty falling asleep. No fevers or vomiting. Patient has had similar headaches throughout the past year. Full workup last year included brain CT and ophthalmological evaluation all came back negative. Physical examination normal. Despite reassurance from multiple physicians, the patient continues to be excessively worried and thinks he may have a brain tumor or aneurysm. He has an upcoming deadline for his dissertation and is concerned that his insomnia is affecting his productivity. He is unable to focus on his studies due to persistent worrisome thoughts. What do you do?

Answer 269

Initiate a discussion about current emotional stressors.

Somatic symptom disorder involves excessive and disproportionate preoccupation with somatic symptoms, resulting in high health care utilization and functional impairment. Because symptoms often worsen during periods of stress, patients should be asked about their current emotional stressors and counseled regarding stress reduction.

Question 270

PCP is a hallucinogenic drug that characteristically causes what physical exam finding?

Answer 270

Nystagmus

Question 271

72 y/o woman with breast cancer.
Undergone surgery and completed chemotherapy over the last 7 months and now in remission. Isn’t eating much. Isn’t any happier despite the good news. Sleeps only 2-3 hours at a time and cries frequently. Doesn’t enjoy visits from her family or activities that she used to enjoy. Feelings of hopelessness. Low energy. Difficulty concentrating. 10lb weight loss. No suicidal ideation. MOCA 25/30. What do you do next?

Answer 271

Prescribe an SSRI and/or psychotherapy

Medically ill patients who develop comorbid depression can benefit from treatment with antidepressant medications and psychotherapy to improve their quality of life.

Question 272

15 y/o boy brought to the ED after being found unconscious on his bedroom floor. Boy was drowsy and experienced dizziness and headache. The father didn’t find any drugs or drug-related paraphernalia, although the boy does have history of coming home drunk and smelling of alcohol on several occasions. When evaluated, symptoms have resolved. No PMH. Physical examination shows a mild rash around the patient’s mouth, which the father says is not new. Pupils are slightly dilated. Routine blood and urine toxicology screens are negative and blood alcohol level is 0. Liver function tests are slightly elevated. ECG is normal.

Abuse of what substance is the most likely cause of the patient’s condition?

Answer 272

Inhalant abuse.

Commonly abused inhalants include glue, toluene, nitrous oxide, amyl nitrite, and spray paints. Inhalants may be abused by sniffing, huffing (inhaled from a saturated cloth), or bagging (Bag over mouth or nose) to concentrate the inhaled substance.

Signs of acute intoxication may include brief transient euphoria and loss of consciousness and varies depending on the specific chemicals inhaled. The inhalants act as CNS depressants and may cause death.

Dermatitis (glue sniffer’s rash) due to chemical exposure can be seen around the mouth or nostrils. Inhalants are rapidly eliminated and are not included in most routine hospital toxicology screens. LFTs may be elevated with repeat use. Boys age 14-17 are at highest risk for inhalant abuse, which may go unnoticed because common household products are used and no drug paraphernalia is found.

Question 273

Drug of abuse.
Dermatitis around nose or mouth
Normal urine toxicology screens. Normal blood and blood alcohol levels.
LFTs can be slightly elevated.
Seen most commonly in boys 14-17 years old.

Answer 273

Inhalant abuse

Question 274

28 y/o woman brought to the ED after generalized tonic-clonic seizure.
Patient appears confused and is unable to answer any questions.
Sister reports that the patient has never had a seizure before and does not use alcohol or drugs.
Sister reports that the patient has been taking a medication for the past 6 months, prescribed by her primary care provider, to help with anxiety, sadness, and trouble sleeping. No family hx of seizure disorder. Sister reports that she did not take any medications since yesterday, as they were on their way to a concert in another state.

Which medication was the patient most likely taking?

a. alprazolam
b. bupropion
c. clomipramine
d. lamotrigine
e. paroxetine
f. quetiapine
g. venlafaxine

Answer 274

Alprazolam

The patient had a first seizure after missing doses of her medication for one day. Of the medications listed, alprazolam (xanax), a short-acting benzodiazepine, is the most likely to result in seizures following abrupt discontinuation. Symptoms of withdrawal from benzodiazpepines with short half-lives can appear as early as 24 hours after cessation and can include seizures, tremors, anxiety, perceptual disturbances, and psychosis.

Although benzos are often used in the tx of anxiety and depression, their use can be problematic due to their potential to result in tolerance, dependence, and abuse. Benzodiazepines with shorter half-lives, such as alprazolam, have greater risk for severe withdrawal reactions.

Question 275

Which benzodiazepines have greater risk for withdrawal reactions?

Answer 275

The ones with shorter half-lives such as alprazolam (xanax)

Question 276

What is alcoholic hallucinosis?

Answer 276

This is a type of alcohol withdrawal that is characterized by an alert sensorium, predominantly visual hallucinations (although auditory and tactile hallucinations also occur) and relatively stable vital signs. It develops 12-24 hours after the last drink and usually resolves within 24-28 hours.

Question 277

What is the hallmark of delirium tremens? (2)

Answer 277

Disorientation and global confusion

Question 278

What is the difference between somatic symptom disorder and illness anxiety disorder (formerly hypochondriasis)?

Answer 278

Somatic symptom disorder is diagnosed when significant somatic symptoms are present. In contrast, patients with illness anxiety disorder fear having a specific illness but have minimal or no physical symptoms; they are primarily concerned with the idea that they have an illness.

Question 279

33 y/o businessman w/o PMH.
Recent fatigue and weight loss over past 3 months.
Unable to sleep much. Anhedonia. Difficulty concentrating. Physical exam and TSH normal. Diagnosed with MDD and prescribed fluoxetine at a therapeutic dose. Two weeks later, he reports that he is sleeping and eating a little better but is still depressed. The patient is very discouraged about his lack of improvement and says, “I don’t feel like the medication is doing anything.”

a. add antipsychotic
b. add bupropion
c. add lithium
d. continue fluoxetine for an additional 2-4 weeks
e. discontinue fluoxetine and start a different antidepressant
f. increase dose of fluoxetine

Answer 279

Continue fluoxetine for an additional 2-4 weeks.

Antidepressants take time to work. An adequate antidepressant trial is 4-6 weeks at a therapeutic dosage. The patient should be educated that 2 weeks is considered an inadequate trial and be encouraged to remain on the medication for at least 2-4 more weeks. It would be premature to add an augmenting agent. Discontinuing fluoxetine and switching to a different antidepressant would risk losing the partial response. Inadequate antidepressant dose or duration is a common reason for perceived lack of response, and physicians must ensure that patients receive an adequate trial before recommending alternate treatments.

The patient is at a therapeutic dose of fluoxetine and has shown some signs of early improvement (in sleep and appetite). He should be encouraged to continue fluoxetine at the same dose. If the patient remains significantly depressed after a 4 to 6 week trial, increasing the dose is an option provided there are no tolerability issues.

Question 280

What drug is indicated in schizophrenic and schizoaffective patients with recent suicidality?

Answer 280

Clozapine

Question 281

What drug is indicated in treatment-resistant schizophrenia and treatment-resistant schizoaffective disorder? (patients who have failed > or = 2 antipsychotic trials)

Answer 281

Clozapine

Question 282

Antipsychotic medications cause dopamine blocked and because dopamine is a prolactin-inhibiting factor, the blockade of dopamine in which pathway can lead to hyperprolactinemia? What side effects does this cause? (4)

Answer 282

Tuberoinfundibular pathway

1. gynecomastia
2. galactorrhea
3. menstrual dysfunction
4. decreased libido

Question 283

35 y/o man having seizures from alcohol withdrawal

AST 212
ALT 224

What drug to give?

a. chlordiazepoxide
b. disulfiram
c. flumazenil
d. lorazepam
e. phenobarbital
f. phenytoin
g. propranolol

Answer 283

Lorazepam

While lorazepam and chlordiazepoxide are both benzodiazepines that are used for alcohol withdrawal, this patient has suspected liver disease so oxazepam or lorazepam (“o”ld “l”iver) should be used.

Question 284

28 y/o woman
increasing episodes of anxiety.
Anxiety, trembling, sweating, chest tightness, shortness of breath whenever she has to give a presentation.
Patient has had symptoms like this since her teens but it’s getting worse.
Nervous in staff meetings.
Afraid of making a fool of herself.
Visibly anxious throughout interview and avoids eye contact with the physician.

Answer 284

Social anxiety disorder (social phobia)

Physical symptoms similar to panic attacks which are triggered by feared social situations. Persistent anxiety and poor eye contact are also characteristic of the disorder. Social anxiety disorder is characterized by fear of one or more social situations and anxiety about acting in a way that will be humiliating or embarrassing.

Question 285

What is normal pupil size?

Answer 285

2-4 mm diameter

Question 286

22 y/o woman brought to ED after passing out at a party.
Party had alcohol and marijuana available.
Friends report use of cocaine and marijuana in the past.
Bottles of alprazolam and hydrocodone found in her bag.
Patient has no PMH and there is no evidence of trauma.
On exam, she is stuporous. 97F/110over60/54/6.
Pupils are 2mm are reactive.
Heart and lung exam is normal and bowel sounds are present.
Neuro exam: responds to painful stimuli and decreased DTRs bilaterally.
Administration of glucose, thiamine, and naloxone has no effect. What did she most likely ingest?

a. alcohol and benzodiazepines
b. alcohol and cocaine
c. alcohol and marijuana
d. alcohol and opiates
e. benzodiazepines only

Answer 286

Alcohol and benzodiazepines

Most patients with isolated benzodiazepine overdose are arousable and have normal vital signs, so E is wrong. Signs such as bradycardia, hypotension, respiratory depression, and hyporeflexia are seen so co-ingestion of another sedative-hypnotic (most common being alcohol) should be suspected.

Opioid overdose can also result in altered consciousness and respiratory depression. However, this patient’s failure to respond to the opioid antagonist naloxone, normal pupils, and presence of normal bowel sounds makes opioid intoxication less likely.

Question 287

How do you diagnose schizoaffective disorder?

Answer 287

Major depressive or manic episode concurrent with symptoms of schizophrenia.
Lifetime history of delusions or hallucinations for > or = 2 weeks in the absence of major depressive or manic episode.
Mood symptoms are present for the majority of the illness.
Not due to substances or another medical condition.

Schizoaffective disorder is characterized by a significant mood episode (depressive or manic) with concurrent psychotic symptoms in addition to psychosis without mood symptoms for at least two weeks.

Differentiating schizoaffective disorder from bipolar disorder, major depression with psychotic features, and schizophrenia requires determining the temporal relationship of psychotic symptoms to mood symptoms. In bipolar disorder and major depression with psychotic features, psychotic symptoms occur exclusively during manic or depressive episodes. When the patient’s mood is stable, there are no psychotic symptoms. In schizophrenia, if mood symptoms occur, they are present for a small portion of the illness.

Question 288

Expressing unacceptable feelings through impulsive actions

Which psychological defense mechanism? Mature or immature?

Answer 288

Acting out. Immature.

Question 289

Behaving as if an aspect of reality does not exist

Which psychological defense mechanism? Mature or immature?

Answer 289

Denial. Immature.

Question 290

Transferring feelings to a more acceptable or safer object

Which psychological defense mechanism? Mature or immature?

Answer 290

Displacement. Immature.

Question 291

Using intellect to avoid uncomfortable feelings

Which psychological defense mechanism? Mature or immature?

Answer 291

Intellectualization. Immature.

Question 292

Avoiding conflict by expressing hostility covertly

Which psychological defense mechanism? Mature or immature?

Answer 292

Passive aggression. Immature.

Question 293

Attributing one’s own feelings to others

Which psychological defense mechanism? Mature or immature?

Answer 293

Projection. Immature.

Question 294

Justifying behavior to avoid difficult truths

Which psychological defense mechanism? Mature or immature?

Answer 294

Rationalization. Immature.

Question 295

Responding in a (extreme) manner opposite to one’s actual feelings

Which psychological defense mechanism? Mature or immature?

Answer 295

Reaction formation. Immature.

Question 296

Reverting to earlier developmental stage

Which psychological defense mechanism? Mature or immature?

Answer 296

Regression. Immature.

Question 297

Seeing others as all bad or all good

Which psychological defense mechanism? Mature or immature?

Answer 297

Splitting. Immature.

Question 298

Channeling impulses into socially acceptable behaviors

Which psychological defense mechanism? Mature or immature?

Answer 298

Sublimation. Mature.

Question 299

Putting unwanted feelings aside to cope with reality

Which psychological defense mechanism? Mature or immature?

Answer 299

Suppression. Mature.

Question 300

What are psychological defense mechanisms? Immature vs mature?

Answer 300

Psychological defense mechanisms are unconscious means of responding and adapting to different situations while preserving self-image. These mechanisms serve to decrease anxiety associated with shame and vulnerability and ensure a feeling of safety in the face of disappointments. Immature defense mechanisms are more commonly used in children and adolescents but can also be seen in adult psychopathology (e.g. in personality disorders) or in adults in times of stress. Immature defense mechanisms provide short-term relief but often result in long-term complications. Mature defense mechanisms are most often used by well-adjusted individuals and allow for a “healthy” and more constructive approach to reality.

Question 301

What is tyramine? What is its significance in psychiatric care?

Answer 301

Tyramine is a sympathomimetic monoamine that can facilitate the release of other sympathomimetic monoamines, such as adrenaline. Tyramine may be present in aged cheeses, aged or cured meats, aged or fermented soy products, overripe fruits, and some alcoholic beverages. Tyramine metabolism is inhibited in the presence of MAOIs, which causes an increased sympathomimetic effect that can result in severe hypertensive crisis. This commonly presents first as headache but can lead to intracranial bleeding, stroke, and death.

Question 302

Which SSRI has the longest half life?

Answer 302

Fluoxetine (Prozac)

So, you almost never see discontinuation syndrome with fluoxetine.

Question 303

Which SSRI has the highest rate of QTc prolongation?

Answer 303

Citalopram (Celexa)

Question 304

Which SSRI is most associated with discontinuation syndrome?

Answer 304

Paroxetine (Paxil)

Question 305

Why are GI side effects so common with SSRIs?

Answer 305

80-85% of serotonin receptors are in the GI tract

Question 306

How long is an “adequate” SSRI trial?

Answer 306

Usually at least 6-8 weeks at dose expected to be effective

Question 307

Are SSRI starting doses typically higher or lower in children and elderly patients?

Answer 307

Lower

Question 308

True or False: When giving SSRIs, start low and go slow.

Answer 308

True

Question 309

True or False: SSRIs are generally best when combined with therapy

Answer 309

True. On exams, always choose the SSRI that is paired with a therapy over a SSRI that’s alone.

Question 310

What is the most common side effect of all psychiatric medications? (except for stimulants)

Answer 310

GI distress.

30-40% of patients will experience GI distress from psychiatric medications. The GI distress goes away in 3-5 days in the majority of these patients (80%)
By 3 weeks, 98% of patients have resolution of GI symptoms.

Question 311

True or False: you can sometimes have an improvement in sexual function with SSRIs

Answer 311

True. Lack of sleep, anxiety, depression, etc can all cause decreased sexual function. Sometimes SSRI can increase sexual function, even though a common side effect of SSRIs is sexual dysfunction.

Question 312

When should a primary care physician consult psychiatry for SSRIs? (4)

Answer 312

1. failed 2 adequate trials of SSRI
2. high severity
3. many medications
4. co-morbid psychiatric disorders

Question 313

How do you choose your first SSRI? (4)

Answer 313

1. cost
2. clinical experience
3. family hx of response or side effects to SSRIs
4. adherence of patient (think about half-life)

Question 314

Electric shock feelings/zaps in their head or extremities.

Answer 314

Discontinuation syndrome.

Happens with SSRI withdrawal

Question 315

Which SSRI has the shortest half life? how about longest?

Answer 315

Shortest: Fluvoxamine (Luvox)
Longest: Fluoxetine (Prozac)

You can remember this because the v in the fluvoxamine looks like a down arrow. Both start with “flu”.

Question 316

What is the only eating disorder that has been shown to be helped by SSRI treatment?

Answer 316

Bulimia nervosa

Question 317

True or False: SSRIs can cause an increased risk of suicidal thoughts for patients age 12-18.

Answer 317

True, there is a real risk but the absolute risk is low. About 1 in 100. It should be discussed with patients but the data is controversial about whether or not suicidal action is increased by SSRIs. Above 25 years old, SSRIs are protective of suicide (because you’re treating depression… which causes suicidal thoughts).

Standard of care is to treat with SSRI with psychotherapy. Suicide is one of the S’s in SIGECAPS. It’s a serious risk for depression.

Question 318

True or False: most suicide completion is impulsive

Answer 318

True

Question 319

Which ADHD symptom improves when the patient gets older?

Answer 319

Hyperactivity

ADHD lasts your whole life but the hyperactivity typically gets better.

Question 320

True or False: ADHD is highly genetically bound

Answer 320

True

Question 321

Most common side effect of stimulants?

Answer 321

Decreased appetite

Question 322

17 y/o girl brought into the office by her mother.
Mother concerned about daughter’s weight loss and mood changes. Girl has lost 10 lb in the past 2 months and has been uncharacteristically irritable.
Daughter not sleeping enough.
Patient denies not having any problems and feels “fine” and just has a lot of energy.
Daughter, “isn’t it healthy to be thin and fit? I don’t understand what my mother is worried about”.
Patient is 5’2’’ 105 lb. Physical examination shows a thin girl with erythema of the turbinates and nasal septum and mild facial acne.

A. anorexia nervosa
B. avoidant/restrictive food intake disorder
C. bipolar 2 disorder
D. bulimia nervosa
E. cocaine use disorder
F. marijuana use disorder
G. MDMA (ecstasy) use disorder

Answer 322

Cocaine use disorder

Cocaine is a stimulant that produces increased energy and decreases appetite and need for sleep. Individuals who abuse cocaine often present with mood changes (e.g. euphoria, irritability) and weight loss secondary to decreased appetite. The diagnostic hallmark in this scenario is erythema of the turbinates and nasal septum, which is a common finding in individuals who snort cocaine. In severe cases, perforation of the nasal septum can occur. In addition to mood disturbance, other psychiatric complications of cocaine use include anxiety, panic attacks, grandiosity, and psychosis (delusions and hallucinations).

Question 323

Diagnostic physical exam hallmark of cocaine use?

Answer 323

Erythema of the nasal turbinates and septum. In severe cases, perforation of the nasal septum can occur.

Question 324

Neuroimaging finding in schizophrenia?

Answer 324

Enlargement of the lateral cerebral ventricles

Question 325

Bloating, fatigue, headaches, and breast tenderness.
Mood swings, anxiety, difficulty concentrating, decreased libido and irritability. No recent change in sleep pattern or interest in activities, or feelings of hopelessness or guilt. No medications and physical exam is normal.
Episodes have been occurring for years. What to do?

A. cognitive-behavioral therapy
B. fluoxetine
C. gluten-free diet
D. luteal-phase-only fluoxetine
E. menstrual diary
F. valproate
G. vitamin B6

Answer 325

Menstrual diary

Premenstrual syndrome (PMS) includes physical manifestations of PMS including bloating, fatigue, headaches, and breast tenderness. Psychological symptoms may include mood swings, anxiety, difficulty concentrating, decreased libido, and irritability. Symptoms usually begin a week prior to menses and resolve within a few days after menses starts. Patients are symptom free in the follicular phase.

Question 326

What is premenstrual dysphoric disorder?

Answer 326

Premenstrual dysphoric disorder is a severe variant of PMS, with prominent irritability, hopelessness, depressed mood, self-critical thoughts, anger, and greater psychosocial impairment.

Question 327

How do you treat mild PMS? How do you treat moderate to severe PMS/PMDD?

Answer 327

Mild PMS: exercise and stress reduction

Moderate to severe PMS/PMDD (premenstrual dysphoric disorder): SSRIs (e.g. fluoxetine) are first-line treatment

Question 328

How do you assess if symptoms are from PMS/PMDD?

Answer 328

Menstrual diary can determine the relationship of symptoms to the menstrual cycle phases.

Question 329

19 y/o female
Avoiding social interactions
Hypersensitive to rejection
Feelings of inadequacy 
Shy
Intense fear of embarrassment or rejection

What personality disorder?

Answer 329

Avoidant

Question 330

43 y/o man
Long history of schizophrenia.
Hospitalized after attacking neighbor with a shovel.
Hears voices coming from radio.
Listens to walls for messages from secret agents.
Patient does not believe he has an illness.
Family reports that he responded well in the past to risperidone and olanzapine.
He usually stabilizes quickly but then relapses when he stops taking medications.
Frequent relapses and hospitalizations.

What is the most appropriate thing to do?

a. augment olanzapine with social skills training and family therapy
b. augment risperidone with lithium
c. long-term hospitalization
d. prescribe clozapine
e. prescribe quetiapine
f. prescribe risperidone long-acting injectable antipsychotic

Answer 330

Risperidone long-acting injectable antipsychotic

Frequent relapses and repetitive hospitalizations due to medication non adherence should be managed with long-acting injectable antipsychotics. LAI antipsychotics eliminate the need to take oral medication daily and are administered every 2-4 weeks intramuscularly.

Question 331

Which antipsychotics are available in long-active injectable form?

Answer 331

Both first-generation (haloperidol, fluphenazine) and second-generation antipsychotics (risperidone, paliperidone, olanzapine, aripiprazole) are available in LAI formulations.

Question 332

24 y/o woman brought to ED for depression and SI.
Roommate became alarmed when patient did not get up for work as usual and reported feeling so depressed that she wants to die. No current SI, but describes being depressed, exhausted, and unable to concentrate. She appears distracted and speaks slowly. The roommate reports that they just partied for 3 nights where there was “alcohol and other stuff”. Afterwards, the patient slept for 18 hours, had difficulty getting out of bed, and missed work.

Answer 332

Cocaine withdrawal

Patient’s acute onset of depression with pronounced fatigue following a period of increased energy is suggestive of cocaine withdrawal. Individuals often use cocaine in binges, taking the drug repeatedly over a short period to maintain their high. Following abrupt cessation, a crash typically occurs. This initial period can include severe depression with SI and psychomotor slowing with milder symptoms that resolve within 2 weeks.

Question 333

Name the 4 types of extrapyramidal symptoms

Answer 333

Acute dystonia, akathisia, parkinsonism, tardive dyskinesia

Question 334

Patient started on antipsychotic and is experiencing gradual-onset tremor, bradykinesia, rigidity, and mask-like facies. What do you do?

Answer 334

Add benztropine (anti-cholinergic) or amantadine (dopaminergic medication, weak NMDA receptor antagonist)

Question 335

True or False: minimizing conflict and stress in the home decreases the risk of relapse in patients with schizophrenia.

Answer 335

True.

Family psychosocial interventions are indicated for patients with a recent psychotic episode who have significant ongoing contact with family members.

Question 336

True or False: Gender dysphoria that begins in early childhood is more likely to persist than if beginning during puberty.

Answer 336

False.

Gender dysphoria in early childhood does not always persist; when experienced through adolescence, and especially into puberty, gender dysphoria is more likely to be enduring.

Question 337

Treatment for treatment-resistant schizophrenia?

Answer 337

Clozapine

Question 338

Aggression
Accelerated male pattern baldness
Gynecomastia

Answer 338

Anabolic (androgenic) steroid use

Anabolic steroids (e.g. testosterone, trenbolone, boldenone, stanozolol, nandrolone) are popular among young people and athletes looking to improve their physical appearance and performance.

Anabolic steroid side effects include impaired endogenous testicular function and decreased testicular size and sperm count.

Question 339

Dream enactment. If awakened, patients become fully alert and recall their dreams.

Answer 339

Rapid eye movement (REM) sleep behavior disorder.

REM sleep behavior disorder involves dream enactment that occurs during REM sleep if muscle atone is absent. If awakened, patients become fully alert and recall their dreams. In older patients, these behaviors may be a sign of neurodegeneration. If frequent and recurrent, it may be a prodromal sign of neurodegeneration in patients with parkinson disease or dementia with lewy bodies.

Question 340

Excessively dependent
Submissive behaviors
Indecisiveness
Fear of being left alone

Answer 340

Dependent personality disorder

Question 341

Dependent personality disorder and avoidant personality disorder are both characterized by feelings of inadequacy, fear of rejection, and need for reassurance. What’s a clear difference between the two disorders?

Answer 341

Individuals with avoidant personality disorder typically avoid relationships, whereas patients with dependent personality disorder have a pattern of seeking and clinging to relationships.

Question 342

Contraindications to bupropion? (4)

Answer 342

1) seizure disorders
2) bulimia nervosa
3) anorexia nervosa
4) use of monoamine oxidase inhibitors in the past 2 weeks

Individuals with eating disorders are at increased risk as they frequently develop electrolyte abnormalities that can precipitate seizures.

Question 343

Myalgias
Arthralgias
Nausea and vomiting
Diarrhea
Abdominal cramps
Rhinorrhea
Lacrimation
Sweating
Restless
Irritable
Elevated HR and BP
Pupillary dilation
Piloerection
Yawning

Answer 343

Opiate withdrawal

Question 344

What is the mechanism of action for second-generation antipsychotics?

Answer 344

Serotonin and dopamine antagonists

Question 345

True or False: Bipolar disorder is a highly recurrent illness that requires long-term and often life-long maintenance pharmacotherapy to decrease the risk of recurrent mood episodes.

Answer 345

True.

Patients often struggle with the idea of taking medication for their entire life. A strong therapeutic alliance, psychoeducation, and adjunctive psychotherapy can help the patient accept the chronic nature of the illness and enhance adherence.

Question 346

Occasional forgetfulness
Word-finding difficulty
Doesn’t impact activities of daily living

Answer 346

Normal age-related cognitive changes

Question 347

True or False: normal age-related changes should not impair daily functioning (e.g. self-care, finances, medication management) etc.

Answer 347

True.

This helps distinguish normal aging from mild neurocognitive disorder

Question 348

52 y/o man with schizophrenia brought to the ED by group home staff.
He was started on a new antipsychotic for auditory hallucinations a month ago, and the dose was gradually increased. The voices disappeared after 2 weeks but the patient has since become increasingly agitated. Dose escalations do not appear to be calming him. Staff reports that he has been leaving the group home in the mornings and walking all day in the neighborhood. He becomes aggressive if he is asked to remain in the group home. In the ED, the patient is restless but shows no localized abnormal movements. He attempts to walk around the department and into other patient’s rooms. What is the most appropriate next step?

A. decrease the antipsychotic dose and administer propranolol
B. discontinue the antipsychotic and administer haloperidol
C. discontinue the antipsychotic and administer lorazepam
D. increase the antipsychotic dose and administer lorazepam
E. maintain the antipsychotic dose and administer benztropine

Answer 348

A. decrease the antipsychotic dose and administer propranolol

The patient is experiencing akathisia, a type of extrapyramidal symptom associated with antipsychotic medications. Patients describe a subjective sense of inner restlessness that may manifest as pacing and an inability to sit still. Although more common with high-potency first-generation antipsychotic use, akathisia also occurs with use of some second-generation antipsychotics. In severe cases, the patient may become extremely distressed, resulting in increased agitation and overall global worsening.

Clinicians must be able to differentiate akathisia from worsening psychotic agitation, as akathisia is dose dependent; an increase in the antipsychotic dosage would make akathisia worse.

Question 349

Antidepressant with mild stimulant effects, approved for smoking cessation, helps with weight loss, and does not cause sexual side effects.

Answer 349

Bupropion.

Particularly helpful for depressed patients with low energy, impaired concentration, hypersomnia, and weight gain.

Question 350

Delusions
Tactile hallucinations (bugs crawling under the skin)
Aggressive behavior
Severe insomnia
Physical findings of poor dentition and skin sores
Weight loss
Psychotic symptoms
Excoriations due to skin picking

Answer 350

Chronic methamphetamine abuse

Question 351

True or False: some chronic methamphetamine users can develop persistent psychosis that may be difficult to distinguish from primary psychiatric disorders.

Answer 351

True

Visual and tactile hallucinations tend to be more common in substance-induced psychotic disorders while auditory tend to be more common in schizophrenia.

Question 352

What is the most effective treatment for hoarding disorder?

Answer 352

Cognitive-behavioral therapy

Although SSRIs are often tried based on their efficacy in treating OCD, their efficacy in treating hoarding behavior without OCD is limited.

Question 353

46 y/o man
Physician notes that his mood seems low.
Patient reports being “stressed out” for the past 2 months due to work.
He has been unable to exercise or eat healthily recently.
He feels irritable and tense at work and has noticed some neck and shoulder paint.
The patient notes difficulty falling asleep and feels tired during the day.
Although he hates his job, he has no choice but to stay. He continues to get his work done and enjoys social activities, including playing golf on weekends.
The patient drinks 2-3 cans of beer on weekends and smokes MJ twice a month.

a. acute stress disorder
b. adjustment disorder with depressed mood
c. generalized anxiety disorder
d. insomnia disorder
e. major depressive disorder
f. no diagnosis - normal stress response
g. substance-induced mood disorder

Answer 353

F. no diagnosis - normal stress response.

He does not meet full criteria for any disorder. Most importantly, he exhibits no impairment of social and occupational functioning, which is a DSM-5 requirement for the diagnosis of all psychiatric disorders.

Question 354

Chronic low-grade depression that lasts for years

Answer 354

Persistent depressive disorder (dysthymia)

Question 355

How do you treat persistent depressive disorder (dysthymia)?

Answer 355

Antidepressants and/or therapy

Question 356

Abdominal pain
New-onset neuropsychiatric symptoms including neuropathies, anxiety, mood changes, and psychosis. Symptoms can be episodic and last days to weeks.

Answer 356

Acute intermittent porphyria

This is a hereditary disorder involving alterations in heme biosynthesis and is characterized by intermittent neurovisceral symptoms.

Urinary porphobilinogen is elevated in acute porphyria.

Question 357

Conjunctival injection
Dry mouth
Tachycardia
Increased appetite
Slowed reaction time
Incoordination
Impaired short-term memory
Slurred speech
Poor concentration
Possible social withdrawal, anxiety, and paranoia. Perceptual disturbances such as AVH may also occur.

Answer 357

Cannabis intoxication

Question 358

Chronic, fluctuating mood disturbances since adolescence. Periods vary in length from days to weeks and have no clear relationship to situations in the patient’s life.

Answer 358

Cyclothymic disorder

Question 359

True or False: diagnosis of panic disorder REQUIRES that at least some of the episodes not be triggered or expected (e.g. at home watching TV, relaxing with friends)

Answer 359

True

Question 360

Unexpected anxiety attacks accompanied by chest pain, shortness of breath, sweating, dizziness.
Persistent worry about future attacks.

Answer 360

Panic disorder

Question 361

Neuroleptic malignant syndrome vs serotonin syndrome?

Answer 361

Serotonin syndrome is characterized by neuromuscular irritability (tremor, hyperreflexia, myoclonus) rather than the rigidity in neuroleptic malignant syndrome.

Question 362

Delirium
High fever
Autonomic instability
Severe rigidity
Elevated creatinine kinase
Leukocytosis

Answer 362

Neuroleptic malignant syndrome

Question 363

Treatment for MAOI hypertensive crisis?

Answer 363

Phentolamine (reversible nonselective a-adrenergic antagonist.. primary action is vasodilation due to a1 blockade)

Question 364

How do you treat catatonia?

Answer 364

Benzodiazepine or ECT

Question 365

What drug class is Doxepin in?

Answer 365

Tricyclic antidepressants

Question 366

47 y/o woman brought to ED by husband.
Confusion during past 2 days.
Generalized tonic-clonic seizure lasting 4 minutes on arrival to ED.
PMH of bipolar disorder treated with medications, but husband is unsure of names. He knows that she sometimes takes ibuprofen for mild arthritis pain caused by exercise.
No hx seizure disorder.
On physical exam, she is tremulous and somnolent.
Bilateral nystagmus.
ECG shows 2nd degree AV block.

Answer 366

Lithium toxicity

NSAIDs increase lithium levels.

Question 367

2 y/o adopted girl presents with developmental delay.
Not yet walking and not yet talking.
Born at term to a 41-year-old woman.
No information about pregnancy and delivery.
Patient is 40th percentile length and 80th percentile for weight.
Exam shows epicentral folds, prominent tongue, small low-set ears, and short extremities.

Answer 367

Down syndrome

Physical exam findings, developmental delay, 41 y/o mother (increased risk after age 35)

Question 368

One week ago: 52 y/o man with schizophrenia presents for follow-up exam. Physician notices the patient has tongue occasionally protruded. When asked, the patient is unaware of this movement, but is able to voluntarily prevent it. The patient has been taking risperidone for 5 years. The physician decides to stop the risperidone due to the tongue movements.
Now: examination shows worsening tongue movements and writhing choreoathetoid movements in the upper extremities. What’s going on?

a) atrophy of the caudate nucleus
b) increased acetylcholine
c) increased sensitivity of the dopamine receptors
d) loss of volume in the basal ganglia
e) vascular changes in the small vessels

Answer 368

Increased sensitivity of the dopamine receptors

Chronic treatment with antipsychotics up regulates the dopamine receptors. Sudden discontinuation may cause exaggerated tardive dyskinesia due to increased dopamine sensitivity.

Question 369

What are polysomnography findings for narcolepsy?

Answer 369

Decreased REM latency (decreased time between falling asleep and entering REM. This means that narcoleptics enter REM stage sleep very quickly. A typical person takes about 90 minutes to enter REM while a narcoleptic takes about 10)
Increased REM density (increased frequency of eye movements during REM sleep)

Question 370

Treatment for performance anxiety? What if the patient has asthma?

Answer 370

Propranolol. If the patient has asthma, beta blockers are contraindicated. Use a benzodiazepine like lorazepam instead.

Question 371

What serum lab finding is found in patients with binge-eating and self-induced vomiting?

Answer 371

Increased amylase.

Amylase is an enzyme active in the digestion of carbohydrates and is a useful marker of purging behavior. Hyperamylasemia is common in patients who purse (both bulimia and anorexia with purging) due to increased salivary production. Pancreatic amylase elevation is not seen. Amylase fractionation can be useful in determining the source of amylase. An increase in amylase, particularly originating from the parotid glands, is suggestive of purging behavior.

Question 372

Top 2 risk factors for delirium?

Answer 372

1) prior episode of delirium

2) medications

Question 373

True or False: an episode of delirium has been correlated with an increase in 1-year all-cause mortality by 50% (for the following year).

Answer 373

True

Question 374

True or False: delirium precautions are more effective at treating delirium than any medications

Answer 374

True

Question 375

If an individual does not tolerate a trial of dextroamphetamine/amphetamine for treatment of ADHD, the next step of treatment is a trial of which medication?

Answer 375

Methylphenidate (extended release)

Try atomoxetine if you have failed 2 different stimulants. E.g. tried methylphenidate and then dextroamphetamine or vice versa.

Question 376

Patient on ziprasidone for 4 weeks and hasn’t had any effects. What do you ask the patient?

Answer 376

Ask about caloric intake. Ziprasidone needs 500+ calories daily in order to work.

Question 377

68 y/o man
On bipolar disorder treatment.
PMH: CHF, HTN treated with thiazide diuretic
Dry mucous membranes, bloodshot eyes, upper extremity tremor, diarrhea, trouble walking.

What medication is likely causing these side effects?

a) haloperidol
b) lithium
c) ziprasidone
d) valproic acid
e) paroxetine

Answer 377

Lithium

Patient is showing classic signs and symptoms of lithium toxicity. Excessive urination caused by renal tubular thickening during lithium treatment results in dehydration (dry mucous membranes, bloodshot eyes). Nausea, vomiting, diarrhea, tremor, and ataxia are common for lithium toxicity.

Thiazide diuretics can cause lithium toxicity.