Psychiatry VI Flashcards
What is the first-line pharmacotherapy for treatment of Tourette disorder?
α2-adrenergic agonists
e.g. guanfacine, clonidine; other treatment options include antipsychotics and tetrabenazine
What is the first-line treatment for agoraphobia?
CBT and/or SSRIs
second line treatment is MAOIs
What is the first-line treatment for atypical depression?
CBT and SSRIs
MAOIs are second-line treatment
What is the first-line treatment for generalized anxiety disorder (GAD)?
CBT + SSRIs/SNRIs
second-line treatments include benzodiazepines and buspirone
What is the first-line treatment for major depressive disorder with psychotic features?
antidepressant + antipsychotic or ECT
What is the first-line treatment for major depressive disorder?
CBT + SSRIs
What is the first-line treatment for patients with acute stress disorder?
Trauma-focused CBT
SSRIs are first-line treatment for post-traumatic stress disorder, not ASD
What is the first-line treatment for post-traumatic stress disorder (PTSD)?
CBT + SSRIs/SNRIs
What is the greatest risk factor for committing homicide in adolescents?
Access to firearms
What is the like diagnosis in a young woman that presents with irritability, weight loss, and decreased sleep? The patient says she has lots of energy and isn’t eating because she’s not hungry. Physical exam reveals erythema of the turbinates and nasal septum. BMI is 19.5 kg/m2.
Cocaine use disorder
What is the likely diagnosis in a child that frequently wakes up screaming in the middle of the night? The child is easily consolable and recalls a scary dream.
Nightmare disorder
occurs during REM sleep
What is the likely diagnosis in a child that frequently wakes up screaming in the middle of the night? The child is inconsolable and has no recall of dream content.
Sleep terror disorder
cause unknown, but triggers include emotional stress, fever, or lack of sleep; usually self-limited
What is the likely diagnosis in a patient being treated in the psychiatric ER that develops confusion, high-grade fever, autonomic instability, and muscle rigidity?
Neuroleptic malignant syndrome
secondary to antipsychotic medications; creatine kinase and WBC levels may be elevated as well
What is the likely diagnosis in a patient that believes someone has been trying to poison her food for the past 6 months? As a result, the patient refuses to eat any food that is not pre-packaged. The patient is otherwise normal, with no social dysfunction and no other psychotic symptoms.
Delusional disorder
characterized by > 1 delusions for > 1 month without other psychotic symptoms in an otherwise high-functioning individual; this patients delusions are of the persecutory type
What is the likely diagnosis in a patient that develops agitation and visual hallucinations 12 hours after hospitalization? Vital signs are within normal limits. The patient has a history of cocaine, marijuana, and alcohol abuse.
Alcoholic hallucinosis
typically develops within 12-24 hours and resolves within 24-48 hours; vital signs are stable and sensorium is intact (versus delirium tremens)
What is the likely diagnosis in a patient that develops seizures, tremulousness, diaphoresis, and autonomic instability one day after having an emergency surgery?
Alcohol withdrawal
What is the likely diagnosis in a patient that experiences panic attacks while driving over bridges for the past year? The patient takes great effort to avoid bridges.
Specific phobia
versus panic disorder and agoraphobia which presents with unexpected panic attacks (not related to a specific stimuli)
What is the likely diagnosis in a patient that experiences two-weeks of insomnia, nightmares, and flashbacks after seeing a traumatic event?
Acute stress disorder
What is the likely diagnosis in a patient that presents with agitation, insomnia, paranoid delusions, and tactile hallucinations? On physical exam, the patient appears thin and has poor dentition and multiple sores on his face and body.
Methamphetamine abuse
severe tooth decay and excoriations due to skin picking are common signs of chronic methamphetamine abuse
What is the likely diagnosis in a patient that presents with symmetric resting tremor in both hands, muscle stiffness, and slow finger movements? The patient has a history of bipolar disorder controlled with valproate and risperidone.
Drug-induced parkinsonism
typically presents with bradykinesia, rigidity, and tremor
What is the likely diagnosis in a patient with a lengthy history of bipolar disorder that presents with immobility, mutism, and resistance to movement?
Catatonia
What is the likely diagnosis in a patient with a long history of schizoaffective disorder that presents with lip smacking, sticking out his tongue, and squirming movements of the torso?
Tardive dyskinesia
may appear during treatment or following antipsychotic dose reduction or discontinuation
What is the likely diagnosis in a previously healthy individual that presents with anxiety, irritability, and insomnia, as well as abdominal pain and paresthesias of the right hand?
Acute intermittent porphyria
AIP should be suspected in patients with unexplained abdominal pain and new-onset neuropsychiatric symptoms (e.g. neuropathies, mood changes, psychosis); the symptoms of AIP may be remembered with the “5 P’s”
What is the likely diagnosis in a teenage boy that presents after having an episode of unconsciousness followed by drowsiness and headache? The symptoms resolved within one hour. Physical exam is significant for a mild rash around the patient’s mouth. Routine toxicology screen is negative.
Inhalant abuse (e.g. glue, toluene)
perioral skin changes (glue sniffer’s rash) is classic
What is the likely diagnosis in a young male that presents with several months of agitation and irritability? On physical exam, the patient has a receding hair line and palpable tissue underneath the nipples bilaterally.
Anabolic steroid abuse
other possible symptoms include acne, hepatic dysfunction, virilization, and altered lipid profile (e.g. decreased HDL)
What is the likely diagnosis in a young patient with a history of ADHD that presents with two weeks of decreased sleep, irritability, distractibility, and excessive involvement in new projects?
Bipolar disorder
an episodic course is more consistent with bipolar disorder than ADHD (chronic symptom)
What is the likely diagnosis in a young woman that presents with periods of binge eating with no compensatory behavior? Physical exam is unremarkable. Her BMI is 30 kg/m2.
Binge eating disorder
What is the likely diagnosis in a young woman that presents with periods of binge eating, followed by guilt, depression, and excessive fasting/exercise? Physical exam is unremarkable. Her BMI is 18.0 kg/m2.
Anorexia nervosa
anorexia may involve binge eating with compensatory behavior, similar to bulimia, however BMI is < 18.5 kg/m2
What is the likely diagnosis in a young woman that presents with periods of binge eating, followed by guilt, depression, and excessive fasting/exercise? Physical exam is unremarkable. Her BMI is 19.5 kg/m2.
Bulimia nervosa
involves recurrent binge eating and restrictive or purging compensatory behavior in a patient that is normal weight or overweight
What is the likely diagnosis in an elderly male that presents after months of agitated behavior/moving around in his sleep in the early morning hours? The patient is easily arousable and confused for only a few moments after awakening. He describes a recurrent dream where he feels trapped.
REM sleep behavior disorder
involves dream enactment that occurs during REM sleep if muscle atonia is absent
What is the likely diagnosis in an elderly patient that presents with insomnia, agitation, paranoid delusions, and fluctuating level of consciousness a few days after having surgery?
Delirium
delirium-induced psychosis is differentiated from primary psychotic disorders by fluctuating level of consciousness, acuity of onset, and association with an underlying condition and/or offending medications
What is the likely diagnosis in an elderly patient with bipolar disorder that develops confusion, tremors, ataxia, vomiting, and seizures two weeks after beginning atenolol and hydrochlorothiazide?
Lithium toxicity
What is the likely ingested substance in a patient that attempted suicide by overdose that presents with hypotension, seizures, mydriasis, dry, flushed skin, and QRS prolongation?
Tricyclic antidepressants
TCA overdose is characterized by altered mental status, seizures, cardiac conduction delay, and anticholinergic toxicity
What is the likely underlying cause of psychosis in a young female that presents with psychosis and arthralgia? Laboratory findings include thrombocytopenia and hematuria.
Systemic lupus erythematosus (SLE)
other medical conditions that can cause psychosis include thyroiditis, metabolic or electolyte disorders, CNS infection, and epilepsy
What is the likely underlying pathophysiologic mechanism of tardive dyskinesia?
D2 receptor upregulation and supersensitivity
What is the mode of inheritance of Rett syndrome?
X-linked dominant
occurs almost exclusively in females (typically fatal in utero for males)
What is the most effective nonpharmacological treatment for Tourette disorder?
Habit reversal training (a form of CBT)
pharmacotherapy is considered when HRT is ineffective or when symptoms interfere with social/occupational functioning
What is the next step in management for a depressed patient with a partial response to SSRI therapy that complains of fatigue and weight gain?
Add buproprion
in patients with a partial response, augmentation with another form of treatment is beneficial (versus non-responders, who would benefit from switching to another antidepressant)
What is the next step in management for a depressed patient with an inadequate response to SSRI therapy after 8 weeks?
Switch to another first-line treatment
e.g. different SSRI, SNRI, buproprion, mirtazapine, or serotonin modulators
What is the next step in management for a patient that develops fatigue, insomnia, and myalgias after abruptly discontinuing paroxetine due to undesirable side effects?
Restart paroxetine and taper gradually over several weeks
this patient is experiencing antidepressant discontinuation syndrome, which can result in variable psychological and/or physical symptoms; more common with antidepressants with a shorter half-life (e.g. paroxetine, venlafaxine)
What is the next step in management for a patient that presents with severe mania with acute agitation?
Administer an antipsychotic +/- a mood stabilizer
antipsychotics act more rapidly than lithium and other mood stabilizers
What is the next step in management for a patient that presents with unstable vital signs and hypokalemia secondary to suspected anorexia nervosa?
Hospitalization for nutritional rehabilitation
indications for hospitalization include unstable vital signs, cardiac dysrhythmias, electrolyte derangements, and severely low body weight
