Psychiatry VI

Question 1

What is the first-line pharmacotherapy for treatment of Tourette disorder?

Answer 1

α2-adrenergic agonists

e.g. guanfacine, clonidine; other treatment options include antipsychotics and tetrabenazine

Question 2

What is the first-line treatment for agoraphobia?

Answer 2

CBT and/or SSRIs

second line treatment is MAOIs

Question 3

What is the first-line treatment for atypical depression?

Answer 3

CBT and SSRIs

MAOIs are second-line treatment

Question 4

What is the first-line treatment for generalized anxiety disorder (GAD)?

Answer 4

CBT + SSRIs/SNRIs

second-line treatments include benzodiazepines and buspirone

Question 5

What is the first-line treatment for major depressive disorder with psychotic features?

Answer 5

antidepressant + antipsychotic or ECT

Question 6

What is the first-line treatment for major depressive disorder?

Answer 6

CBT + SSRIs

Question 7

What is the first-line treatment for patients with acute stress disorder?

Answer 7

Trauma-focused CBT

SSRIs are first-line treatment for post-traumatic stress disorder, not ASD

Question 8

What is the first-line treatment for post-traumatic stress disorder (PTSD)?

Answer 8

CBT + SSRIs/SNRIs

Question 9

What is the greatest risk factor for committing homicide in adolescents?

Answer 9

Access to firearms

Question 10

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.

Answer 10

Cocaine use disorder

Question 11

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.

Answer 11

Nightmare disorder

occurs during REM sleep

Question 12

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.

Answer 12

Sleep terror disorder

cause unknown, but triggers include emotional stress, fever, or lack of sleep; usually self-limited

Question 13

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?

Answer 13

Neuroleptic malignant syndrome

secondary to antipsychotic medications; creatine kinase and WBC levels may be elevated as well

Question 14

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.

Answer 14

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

Question 15

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.

Answer 15

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)

Question 16

What is the likely diagnosis in a patient that develops seizures, tremulousness, diaphoresis, and autonomic instability one day after having an emergency surgery?

Answer 16

Alcohol withdrawal

Question 17

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.

Answer 17

Specific phobia

versus panic disorder and agoraphobia which presents with unexpected panic attacks (not related to a specific stimuli)

Question 18

What is the likely diagnosis in a patient that experiences two-weeks of insomnia, nightmares, and flashbacks after seeing a traumatic event?

Answer 18

Acute stress disorder

Question 19

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.

Answer 19

Methamphetamine abuse

severe tooth decay and excoriations due to skin picking are common signs of chronic methamphetamine abuse

Question 20

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.

Answer 20

Drug-induced parkinsonism

typically presents with bradykinesia, rigidity, and tremor

Question 21

What is the likely diagnosis in a patient with a lengthy history of bipolar disorder that presents with immobility, mutism, and resistance to movement?

Answer 21

Catatonia

Question 22

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?

Answer 22

Tardive dyskinesia

may appear during treatment or following antipsychotic dose reduction or discontinuation

Question 23

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?

Answer 23

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”

Question 24

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.

Answer 24

Inhalant abuse (e.g. glue, toluene)

perioral skin changes (glue sniffer’s rash) is classic

Question 25

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.

Answer 25

Anabolic steroid abuse

other possible symptoms include acne, hepatic dysfunction, virilization, and altered lipid profile (e.g. decreased HDL)

Question 26

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?

Answer 26

Bipolar disorder

an episodic course is more consistent with bipolar disorder than ADHD (chronic symptom)

Question 27

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.

Answer 27

Binge eating disorder

Question 28

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.

Answer 28

Anorexia nervosa

anorexia may involve binge eating with compensatory behavior, similar to bulimia, however BMI is < 18.5 kg/m2

Question 29

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.

Answer 29

Bulimia nervosa

involves recurrent binge eating and restrictive or purging compensatory behavior in a patient that is normal weight or overweight

Question 30

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.

Answer 30

REM sleep behavior disorder

involves dream enactment that occurs during REM sleep if muscle atonia is absent

Question 31

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?

Answer 31

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

Question 32

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?

Answer 32

Lithium toxicity

Question 33

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?

Answer 33

Tricyclic antidepressants

TCA overdose is characterized by altered mental status, seizures, cardiac conduction delay, and anticholinergic toxicity

Question 34

What is the likely underlying cause of psychosis in a young female that presents with psychosis and arthralgia? Laboratory findings include thrombocytopenia and hematuria.

Answer 34

Systemic lupus erythematosus (SLE)

other medical conditions that can cause psychosis include thyroiditis, metabolic or electolyte disorders, CNS infection, and epilepsy

Question 35

What is the likely underlying pathophysiologic mechanism of tardive dyskinesia?

Answer 35

D2 receptor upregulation and supersensitivity

Question 36

What is the mode of inheritance of Rett syndrome?

Answer 36

X-linked dominant

occurs almost exclusively in females (typically fatal in utero for males)

Question 37

What is the most effective nonpharmacological treatment for Tourette disorder?

Answer 37

Habit reversal training (a form of CBT)

pharmacotherapy is considered when HRT is ineffective or when symptoms interfere with social/occupational functioning

Question 38

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?

Answer 38

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)

Question 39

What is the next step in management for a depressed patient with an inadequate response to SSRI therapy after 8 weeks?

Answer 39

Switch to another first-line treatment

e.g. different SSRI, SNRI, buproprion, mirtazapine, or serotonin modulators

Question 40

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?

Answer 40

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)

Question 41

What is the next step in management for a patient that presents with severe mania with acute agitation?

Answer 41

Administer an antipsychotic +/- a mood stabilizer

antipsychotics act more rapidly than lithium and other mood stabilizers

Question 42

What is the next step in management for a patient that presents with unstable vital signs and hypokalemia secondary to suspected anorexia nervosa?

Answer 42

Hospitalization for nutritional rehabilitation

indications for hospitalization include unstable vital signs, cardiac dysrhythmias, electrolyte derangements, and severely low body weight