RECALL: SUDs + Schizophrenia + Anxiety

Question 1

“10- 1 day, myalgias, muscle ache, fatigue, diaphoresis, nausea, diarrhea. Withdrawal in opiates, what most likely to use to improve withdrawal sx?
a. Clonidine
b. Buprenorphine
c. Diazepam “

Answer 1

“B)
Buprenorphine is initiated when pt is in opioid withdrawal and it will help w/d sx.

Clonidine only helps for auntonomic symptoms.
should be used in conjuction with other meds such as loperamide and analgesics”

Question 2

what med has best efficacy in doctors for OAT

Answer 2

naltrexone

Question 3

“11- Anesthesiologist opiates use disorder. Abstinent. Wants to help him stay abstinent. Does not want a replacement therapy.
a. Naltrexone
b. Naloxone
c. Buprenorphine
d. Somehting else”

Answer 3

“A) Naltrexone

Best efficacy in doctors. Naloxone is short-acting. Buprenorphine IS replacement therapy.

Do not put someone on OAT (opiod replacement) if they are not currently taking opioids as you are making them dependent (exceptional circumstances you can). OAT will also impair physician work.”

Question 4

how does the mechanism of action of cocaine compare to the mechanism of action of amphetamines

Answer 4

cocaine blocks DAT only

amphetamines block DAT and ALSO reverse its function + trigger release of dopamine in vesicles

Question 5

“113. Nicotine dependence:
a. Nicotine is an indirect agonist of the dopamine receptor
b. Nicotine is a selective agonist of the nicotinic cholinergic receptor
c. Nicotine is a selective antagonist of the nicotinic cholinergic receptor
d. Nicotine is a partial agonist and antagonist of the acetylcholine receptor”

Answer 5

“A) Nicotine is an indirect agonist of the dopamine receptor = TRUE

DA, reward, VTA… mechanism of dependence
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2946180/

B) FALSE.
This is the MoA (although see D)
Selective agonist at nicotinic cholinergic receptor
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2946180/
- KSS 11e p682

C) FALSE

D) FALSE.
But is this the MoA?
KS Full 10e p1345
““nicotine may actually act as much as an antagonist as an agonist at the nicotinic acetylcholine receptor”” . maybe the partial part rules this out.”

Question 6

“114) what is most indicative of Amphetamine intoxication?
a) persecutory Delusions
b) hallucinations
c) other options I cannot remember, sorry.”

Answer 6

“A) Persecutory delusions

Perceptual changes during intoxication present as paranoia in 50-70% of cocaine users and 30% of meth users. If paranoia/ psychotic features are beyond what would be expected of an intoxication to stimulants then stimulant-induced psuchotic d/o is appropriate. “

Question 7

what is first choice treatment med for AUD

Answer 7

naltrexone, unless contraindicated (i.e liver failure, on opioids)

Question 8

what are first line and second line meds for AUD

Answer 8

first line: naltrexone, acamprosate

second line: topiramate, disulfram

Question 9

LSD act on which neurotransmitter

Answer 9

serotonin

Question 10

which is WORSE for the kidneys, acamprosate or naltrexone?

Answer 10

acamprosate is WORSE–> AKI is a side effect, contraindicated in severe renal impairment and precaution in moderate renal impairment

(note that renal impairment is also a precaution in naltrexone but is not as bad as acamprosate)

Question 11

what is a contraindication to acamprosate use

Answer 11

renal failure

Question 12

list predictors of relapse after liver transplant for AUD

Answer 12

Lack of social supports, psychiatric comorbidity, cigarette smoking, and noncompliance with pre-transplant care were predictos of relapse after transplant.

(the abstinent for 6 months prior to transplant rule is no longer true)

Question 13

which AUD med is contraindicated in acute hepatitis/liver failure

Answer 13

naltrexone

Can still be used in mild liver disease. Dose adjustment not generally necessary for mild impairment. Contraindicated in acute hepatitis or liver failure.

Can still use naltrexone with liver enzymes 3-5x normal, but monitor for worsening

Question 14

“157. CL post-op patient after cardiac procedure who is presenting with confusion every time the anesthetist tries to decrease the propofol and midazolam. What information must you obtain? (2013)
a. History of alcohol use
b. Past medical history
c. Past psychiatric history
d. Past personal history
e. Cognitive functioning”

Answer 14

“A) History of alcohol use = TRUE

Risk of alcohol withdrawal

A) TRUE
B) FALSE. Not at as immediately important.
C) FALSE. Not at as immediately important.
D) FALSE. Not at as immediately important.
E) FALSE. Not at as immediately important.

Propofol works on GABA, need higher doses for alcoholics:
https://www.openanesthesia.org/propofol_mechanism_of_action/#:~:text=Like%20most%20intravenous%20anesthetics%2C%20Propofol,resulting%20hyperpolarization%20of%20cell%20membranes.

Midaz works on GABA:
https://chemm.nlm.nih.gov/countermeasure_midazolam.htm#:~:text=Midazolam%20binds%20to%20the%20GABA,and%20reduction%20of%20seizure%20activity.

”

Question 15

“16. Man with alcohol use disorder wants to quit. Had gastric varices and severe liver damage. What is your choice for pharmacotherapy for AUD?
A) Naltrexone
B) Acamprosate
C) Pregabalin”

Answer 15

“B) acamprosate = true

Naltrexone contraindicated due to severe liver disease”

Question 16

“16. What is minimum optimal time for treatment of substance use disorders?
a. 1 month
b. 3 months
c. 6 months
d. 12 months”

Answer 16

“B) 3 months

Qbank says 3 months. & Ottawa D5_Crockford says 3 months – typical amount of time to change behaviours
[WHO International Standard 2017, https://www.who.int/substance_abuse/activities/msb_treatment_standards.pdf]
For long-term residential treatment, evidence >3 months → better outcomes
[NIDA, https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-long-does-drug-addiction-treatment]
Less than 3 months limited effectiveness. MMT 12 month minimum.”

Question 17

are kidney stones a contraindication for acamprosate

Answer 17

no

Question 18

what medication, used to AUD, causes kidney stones

Answer 18

topiramate

Question 19

“19. In MDMA, the neurotransmitter responsible for its hallucinogenic effect is:
a. Glutamate
b. Serotonin
c. Norepinephrine
d. Dopamine”

Answer 19

“B) Serotonin (psychogenic effects)

5HT & 5HT2A – taken up presynaptically by 5-HT transporter & releases 5-HT from presynaptic stores. Also acts as reuptake inihibitor.

”

Question 20

“24. You meet a 25 year-old male who had problems with cocaine use in the past. He has resumed intake of cocaine and thinks this is not a problem. He says:
“I don’t think it’s a problem. It used to be a problem but now I only take it weekly with my friends. However, it’s true that I could lose my good job if my boss finds out. Maybe I should stop…”
In which stage of change is this patient?
a. Precomtemplation
b. Contemplation
c. Preparation
d. Action”

Answer 20

“B) Contemplation = TRUE

PRECONTEMPLATION - no intention to act foreseeable future (6 mo), often unaware behaviour is problem/negative consequences, underestimate pros of changing, oto much emphasis on cons of changing

CONTEMPLATION - intending to start healthy behavior in foreseeable future (6 mo), recognize behavior may be problematic, more thoughtful and practical consideration of the pros and cons of changing behavior, may still be ambivalent

PREPARATION (Determination) - ready to act next 1 mo, start to take small steps, and believe changing behavior can lead to healthier life.

ACTION - recently changed their behavior (within past 6 mo), intend to keep changing

MAINTENANCE - sustained change for a while (> 6 mo) and intend to maintain change, work to prevent relapse

TERMINATION - no desire to return to unhealthy behaviors, are sure won’t relapse, rarely reached .: people tend to stay in maintenance stage

”

Question 21

what is a way to remember how naltrexone and acamprosate are metabolizes

Answer 21

naLtrexone = Liver

aCamprosate = K(C)idney

Question 22

“41. Man presents to ER with substance intoxication. After 12 hours of observation, he is still severely agitated, hallucinating, diaphoretic and has a high BP. What is the most likely substance? (no mention of nystagmus, dilated pupils)
A) Cocaine
B) Phencyclidine
C) Amphetamines
D) Psilocybin”

Answer 22

“C) Amphetamines.

Meets all criteria of stimulant intox with perceptual disturbances and half-life of amphet can be 9-24h so longer course more in line with amphet use. If someone presents to ER with this presentation, it’s probably meth more than any other drug.

avg length of CM intox is 6-8h, then cocaine 0.5-1h

A) FALSE - Effect rarely lasts beyond 2h

B) FALSE - Toxidrome does not match: In DSM: (behav changes (impulsive/violent), nystagmus, htn, numbness, ataxia, dysarthria, rigidity, sz, hyperacusis) – no mention of psychosis, diaphoresis…? Psychoactive component of PCP is short-lived (1-3h)

C) TRUE

D)FALSE- Toxidrome similar to PCP - not to the one presented”

Question 23

can opioids cause a withdrawal delirium

Answer 23

yes, per DSM5

Question 24

does opioid withdrawal usually need hospitalization

Answer 24

no, usually does NOT require hospitalization

Question 25

does varenicline has suicide risk

Answer 25

CPA guidelines still note suicide risk with varenicline BUT more recent reviews have not found risk and the black box warning has been REMOVED

(risk is still noted in drug monograph)

Question 26

are typical or atypical antipsychotics better for smoking cessation

Answer 26

there is one review that says atypicals are better for smoking cessation

Question 27

“58. Schizophrenic wants to quit smoking, what antipsychotic would be most raised:
a. Ziprasidone
b. Olanzapine
c. Risperidone
d. Quetapine”

Answer 27

“B) Olanzapine (most raised)

A) Ziprasidone → 3A4 substrate
B) Olanzapine → 1A2 substrate
C) Risperidone → 2D6 substrate
D) Quetiapine → 3A4 substrate

Olanzapine, clozapine, haldol, chlopromazine”

Question 28

“59. An older man with EtOH use disorder drinks 750ml of liquor daily, has history of withdrawal seizures. Comes into hospital diaphoretic, tremulous, and agitated. What’s the best management?
a. Thiamine 100mg IM daily + Chlordiazepoxide 50 BID
b. Thiamine 1000mg PO daily + lorazepam 2mg q4h PRN
c. Thiamine 100mg IM daily + diazepam 5mg q4h PRN
d. Thiamine 1000mg PO daily + clonazepam 2mg TID”

Answer 28

“A) Thiamine 100mg IM daily + Chlordiazepoxide 50 BID

High risk withdrawal, would need regular benzo NOT PRN. Also diazepam 5mg q4h is way too little (total daily 30mg). Chlordiazepoxide 50mg BID is better. Parenteral thiamine needed.

A) TRUE
B) FALSE. PO thiamine
C) FALSE. Too little diazepam
D) FALSE. PO thiamine”

Question 29

“64) What would you tell ppl about adolescents and cannabis?
123. What is true about cannabis with respect to adolescence? What could you tell an adolescent or their family?
a) increased use is associated with decreased perception of risk
b) rate of use is decreasing
c) is the most frequently used substance in teens
d) smoking nicotine is more prevalent in the adolescent population”

Answer 29

“A) increased use is associated with decreased perception of risk

A) TRUE.
B) FALSE. Increasing.
C) FALSE, Alcohol is.
D) FALSE. 1) Alcohol, 2) Cannabis, 3) Nicotine”

Question 30

what is the most commonly used substance in teenagers

Answer 30

alcohol

then cannabis, then nicotine

Question 31

“78. Most suitable for inpatient addictions treatment? (repeat)

a) Guy who does a lot of coke, lots of relapses, lives with other people who do lots of coke
b) Married man with stable marriage and alcohol use disorder
c) guy who has frequent relapse and lives alone
d) ?”

Answer 31

“A) Guy who does a lot of coke, lots of relapses, lives with other people who do lots of coke

Very unstable home environment.
A and C both have frequent relapses (Level 3 ASAM Criteria)
““Environment disruptive to treatment”” = Level 3 ASAM Criteria, vs living alone (C) is Level 2 ASAM Criteria

B) FALSE. can do outpatient/day treatment program
C) FALSE. May be suitable for outpatient

”

Question 32

“79. Best candidate for methadone maintenance treatment?
a) 29 year old woman, 6 months pregnant, 8 month history of IV heroin use
b) 27 year old male, 9 month history of IV heroin use
c) 32 year old male with cocaine dependence
d) ?”

Answer 32

“A) 29 year old woman, 6 months pregnant, 8 month history of IV heroin use = TRUE

Outdated question. Now both Methadone and Suboxone are considered safe in pregnancy and should be offered to pregnant women with opioid use disorder

But, in psych –> methadone = pregnancy

B) Suboxone
C) No OAT

More detail in other versions”

Question 33

per ottawa review course, what are the 3 pathways to relapse in SUD

Answer 33

Ottawa Rev lists 3 pathways for relapse:
*Stress including anxiety & depression result in increased amygdala activity (CRF, NE)
*Cues activate glutamatergic pathways including prefrontal cortex leading to cascade effect
* Low dose or other substance use re-initiates use via D2/3 pathways

Question 34

is there a cannabis induced mood disorder in DSM

Answer 34

no, only anxiety

Question 35

how is acamprosate dosed

Answer 35

TID

Question 36

“10. Paranoid PD, which is true? (repeated in French exam)
a. Prevalence 10%
b. More common in females
c. Usually only mild impairment
d. Are indifferent to the opinion of others”

Answer 36

“C) Usually only mild impairment = TRUE
or at least best answer in this bad Q

A) FALSE (prevalence 2-4%, DSM5)
B) FALSE (more common in MALES, DSM5)
C) ? (not as impairing as a psychotic disorder I guess)
D) FALSE (perceives attack on his/her character, suspicion regarding fidelity of spouse, DSM5). D is probably more referring to schizoid (““appears indifferent to praise or criticism of others””)”

Question 37

what are the cognitive deficits of SCZ

Answer 37

Per DSM5, cognitive deficits:
- Declarative memory, working memory
- Language, executive function
- Slowed processing, sensory processing
- Inhibitory capacity, attention
- Social deficits: theory of mind, misinterpretation (explanatory delusions)

Question 38

“112. All are risks for tardive dyskinesia except:
a. Female
b. Age
c. Neurological illness
d. Lack of affective component”

Answer 38

“D) Lack of affective component = NOT RISK FACTOR
[KS]
A) TRUE. Females MORE likely
B) TRUE. Older age MORE likely (>50 yo)
C) TRUE. Brain damange MORE likely
D) FALSE. Lack of affective component LESS likely (mood disorder HIGHER risk)”

Question 39

“129. Head CT scans and schizophrenia / neuroimaging and first episode schizophrenia:
a. More atrophy predicts poor long-term
b. 50% have focal abnormalities that do not require clinical attention
c. One third have abnormalities that do require attention”

Answer 39

“A) More atropy predicts POOR long-term outcomes (TRUE)

2-6% have focal abnormalities that do not require clinical attention
30-40% have abnormalities that do NOT require attention

[CJP Schizophrenia Guidelines 2005]
K&S p.1469”

Question 40

what are the most replicated neuroimaging findings in SCZ

Answer 40

Most replicated neuroimaging findinds:
-Enlarged lateral ventricules
-Volumetric reduction in medial temporal lobe (amygdala, hippocampus, parahippocampal gyrus, proximal neocortical areas)

Question 41

“40. Patient started on clozapine for treatment refractory schizophrenia. Develops tachypnea, tachycardia, chest pain, pulmonary edema. Afebrile, auscultation reveals basilar crackles bilaterally. Inverted T-waves on ECG. Most likely Dx?
a) Clozapine-induced tachycardia
b) MI
c) Clozapine-induced myocarditis
d) Pneumonia due to agranulocytosis”

Answer 41

“C) Clozapine-induced myocarditis

Myocarditis has variable presentation. Can look like acute ACS, heart failure, etc. These are merged symptoms. Clozapine-induced myocarditis more common earlier than later (80% within 4 weeks)”

Question 42

“46. In the general population, males commit about 10 times more aggressive actions than females. Which statement is true about aggressive behaviors in schizophrenia?
a. Males commit twice as many aggressive behaviors than females
b. Males commit 10 times more aggressive behaviors than females
c. Females commit twice as many aggressive behaviors than males
d. The rate of aggressive behaviors is the same in both genders”

Answer 42

“B) Males commit 10x more aggressive behaviours than females
vs
A) Males commit 2x vs F

M def > F

OR2021 said B was answer. Drugs+++ in M, ties ++ to aggression, .: differences still big.

Our research/deducation suggests A.
- Schizophrenia ““attenuates”” differences a bit (more EXTRA aggression in F vs M)
- Baseline 10x –> attenuated difference becomes 2x

_________________

2009 systematic review and meta-analysis:
- Man with schizophrenia, 4-5x more likely to commit violence than man from genpop
- Women with schizophrenia had OR 8.2 vs genpop, but much greater variation
- that schizophrenia/psychosis did not appear to add any additional risk to that conferred by SUBSTANCE ABUSE alone
- ““this present systematic review has shown that risk of violence by gender is reversed compared with general population prevalence rates of violence””

2013 study showed among schizophrenia, males had OR 12.8 of aggression vs females.
2011 study showed among schizophrenia, males had OR 1-7 vs males without schizophrenia.
Females with schizophrenia OR 4-29 vs females without schizophrenia.

"”Schizophrenia attenuates differences a little bit”” ?

”

Question 43

“47. Which is the following medical condition is increased in frequency in schizophrenia?
a. Hyperthyroidism
b. Rheumatoid arthritis
c. HIV
d. Type I diabetes mellitus”

Answer 43

“C) HIV

"”Patients with schizophrenia appear to have a risk of HIV infection that is 1.5 to 2 times that of the general population. This association is thought to be due to increased risk behaviors, such as unprotected sex, multiple partners, and increased drug use.”” [KS synopsis 10e, pg316]

A) FALSE
B) FALSE. 1/3rd of risk of RA vs gen pop.
C) TRUE
D) FALSE. Incr freq of T2DM.”

Question 44

“57. Regarding schizophrenia in the elderly:
a. By age 65, 20% have no symptoms
b. They may have more visual than auditory hallucinations
c. They have more negative symptoms”

Answer 44

“A) By age 65, 20% have no sx = TRUE

"”About 20 percent of persons with schizophrenia show no
active symptoms by age 65”” -KSS 11e p.1347

B) FALSE. VH elderly maybe > VH adult, but AH > VH still.

C) FALSE. More positive sx (vs younger)”

Question 45

“92) What guy came up with all the A’s of schizophrenia?
a) Bleuler
b) schnider
c) Kraeplin”

Answer 45

“A) Bleuler

https://psycnet.apa.org/record/2009-06968-002

4 Αs of schizophrenia
loosening of associations
disturbances of affectivity
ambivalence
autism

Kraeplin = dementia praecox
Schneider = first-rank sx (auditory hallucinations;
thought withdrawal, insertion and interruption; thought broadcasting; somatic hallucinations; delusional perception; feelings or actions as made or influenced by external agents)

”

Question 46

what are the 4 As of schizophrenia

Answer 46

4 Αs of schizophrenia
loosening of associations
disturbances of affectivity
ambivalence
autism

Question 47

“Which of the following groups should get an EEG before starting clozapine?
a. Those with a history of alcohol use disorder
b. Children and adolescents
c. Anyone over 65
d. Parkinsons disease”

Answer 47

“B) children and adolescents = true

At BC Children’s Hospital, and in the UK for children 16 or younger, it is routine to obtain EEG at baseline and when clozapine at optimal dose. Children higher risk for seizure w/ clozapine.”

Question 48

children with separation anxiety disorder are more likely to develop what disorder in adulthood

Answer 48

panic disorder

Question 49

rank anxiety disorders from youngest to oldest at age of onset

Answer 49

Separation Anx < Selective Mutism < Specific Phobia < SAD < Panic < Agoraphobia < GAD

Question 50

“119. Boy with separation anxiety symptoms. Parents separated, sleeps in mom’s bed, doesn’t want to leave them, abdo pain etc. What is he most likely to develop as a adult?
A) Generalized anxiety disorder
B) Somatic symptom disorder
C) PTSD
D) Social anxiety
E) Specific phobia”

Answer 50

“C) PTSD
debate, A) GAD also considered

separation anxiety –>
panic > depression > anxiety (?PTSD > GAD)

TR2021 said for PTSD, you need an additional trauma AND need to develop disorder, which will lower your chances. also GAD is very comorbid with everything. Just go with GAD.

BUT, even just lifetime prevalence rates for PTSD higher (9% vs 6%), so how sound is the above argument, though it makes intuitive sense.

DSM5 p.211 says separation anxiety NOT a consistent risk factor for panic (published after the 2008 AACAP paper), but that paper is all we got.”

Question 51

“13. Which of the following statement about the pharmacological treatment of panic disorder is true according to the CPA guidelines?
a. Mirtazapine is a first-line treatment
b. propranolol is recommended as an adjunct treatment
c. Buspirone is not recommended in monotherapy
d. Citalopram is not recommended as a first-line option”

Answer 51

“C) Buspirone is NOT recommended as monotherapy = TRUE

[Canadian Anxiety Guidelines 2014 - Table 15 p.12]
Buspirone is NOT recommended at all.

A) FALSE. Mirtazapine is 2L.
B) FALSE. Propranolol is NOT recommended.
C) TRUE
D) FALSE. Citalopram is 1L.”

Question 52

what is the central fear in agoraphobia

Answer 52

not being able to escape

Question 53

“52. A patient has failed a first-line treatment for social anxiety disorder, all of the following are potential options except?
a. Phenelzine
b. Imipramine”

Answer 53

“B) Imipramine = NOT potential option

A) Phenelzine is second-line for SAD
B) Imipramine is NOT recommended for SAD

Not recommeded in SAD: Atenolol, buspirone, imipramine, levetiracetam, propranolol, quetiapine
*Beta-blockers have been successfully used in clinical practice for performance situations such as public speaking.
“

Question 54

“64. 25yo woman who is anxious about conversing and eating in public for past 6 years. She gets episodes of intense anxiety where she has fear of losing control, shakiness, sweatiness, paliptations and shortness of breath. She avoids places due to worries that these episodes will happen to her and she is very embarassed about these sx. Her avoidance has led to her failing university classes. What is the Dx?
A) Agoraphobia with panic attacks
B) Unspecified eating disorder
C) Panic disorder
D) Social anxiety disorder with panic attacks”

Answer 54

“D) Social anxiey with panic attacks = TRUE

Meets criteria for both SAD and panic attacks.

CORE FEAR = negative scrutiny in social situations.

A) FALSE. does not describe agorophobia (CORE FEAR = unable to escape/get help in case of sx)
B) FALSE. does not resemble any of the eating disorders
C) FALSE. not having recurrent, unexpected PAs.
D) TRUE
“

Question 55

what is the most common psychiatric disorder overall

Answer 55

anxiety disorders

Question 56

“88- Woman has had a few panic attacks in public social settings, and now avoids going out because of a fear of stuttering and being judged
a. Social anxiety with panic attacks
b. Agoraphobia with panic attacks
c. Panic disorder
d. GAD”

Answer 56

“A) SAD with panic attacks

Core fear: being judged
= SAD

”

Question 57

“90) 75 year old lady. Fell a few months ago. Now afraid to go out to the mall because she might fall again. Denies depressive symptoms. What medication do you give her?
a. SSRI
b. Benzodiazepine
c. Antipsychotic
d. Cholinesterase inhibitor”

Answer 57

“A) SSRI
But we’re not happy with it

If specific phobia –> no meds. SSRI has some evidence.
If GAD –> VESP PAD (includes SSRIs) are first line

A) TRUE
B) FALSE. Second-line. Falls risk. Elderly
C) FALSE. Quetiapine is second-line. No psychosis.
D) FALSE. Not in recommendations. No NCD evidence”