Treatment - Part 2 of 3 Flashcards
A leading hypothesis as to why atypical antipsychotic medications are less likely than typical neuroleptic agents to cause EPS is based one which of the following properties of atypical antipsychotics?
RAPID DISSOCIATION FROM D2 RECEPTORS
35 y/o pt is started on a trial of clozapine for treatment-refractory schizoaffective disorder. During the initial medication titration, pt complains of sedation and orthostatic hypotension as well as flu-like symptoms, but seems symptomatically improved. However after a dose increase from 150 to 200mg, pt develops a fever to 102 degrees, tachycardia to 130bpm, and an acute metal status change. CXR, urine studies, and blood culture are unremarkable. A CBC reveals a WBC of 11.4, with an elevated eosinophil percent of 7%. Which known toxic risk of clozapine is the most likely Dx?
MYOCARDITIS
A 30yo w. 5yo hx of Schizophrenia, prior failed Haldol and Risperidone trial, despite adherent to meds continues to have severe psychotic symptoms. Med recommendation at this time is..
CLOZAPINE
30 yo on Clozapine for treatment resistant schizophrenia presenting with dyspnea, orthostatic hypotension and HR 130bpm. Elevated Eosinophil , EKG with non-specific T wave changes. Further most likely test to guide treatment
TROPONIN LEVEL
What lab finding is most typically associated with NMS?
INCREASED CREATINE KINASE LEVELS
Appropriate management of neuroleptic malignant syndrome:
HYDRATION AND COOLING
Antipsychotics are associated with what?
DYSTONIA, POIKILOTHERMY, LIPID SOLUBILITY, AND LOWER SEIZURE THRESHOLD
Which of the following effects is the basis for dantrolene’s efficacy in the treatment of neuroleptic malignant syndrome (aka nms)?
SKELETAL MUSCLE RELAXANT
32 y/o pt with hx of schizoaffective d/o stable on clozapine is admitted to internal medicine service for a severe GI viral infection. Pt is confused, slow, appears visibly ill and tired. Pt c/o stiffness and there is some rigidity to the movements. What should be recommended?
DISCONTINUE CLOZAPINE
Which antipsychotic has least effect on prolactin?
CLOZAPINE
A slow titration of Clozapine is required to decrease the risk of:
SEIZURES
Which neuroleptic has the weakest affinity for the dopamine D2-like receptor?
CLOZAPINE
Clozapine clearance decreased by
CIMETIDINE
Which med is contra-indicated with clozapine?
CARBAMAZEPINE
Schizophrenic on haldol 5mg presents to ED “unable to see.” Appears distressed, writhing and moaning. States “I’m unable to stop looking up.” What is the best treatment?
ADMINISTER BENZTROPINE 1MG IV NOW
What manifestations is the most common side effect of conventional antipsychotic meds?
AKATHISIA
What antipsychotic medication would be the best choice to avoid motor symptoms in Parkinson’s disease?
CLOZAPINE
What antipsychotic medication is helpful in treating Tourette’s?
HALOPERIDOL
Pt develops feelings of restlessness, an inability to relax, jitteriness, pacing, and rapid alternation of sitting and standing shortly after being started on a low dose of haloperidol. Addition of what medications would be most effective in managing these symptoms?
ATENOLOL
The therapeutic effect of 2nd generation antipsychotics on negative symptoms of schizophrenia is thought to be related to the induction of expression in what area of the brain?
PREFRONTAL CORTEX
Psych MD orders quetiapine 50 mg for an 82 y/o nursing home pt w/ dementia who has become severely agitated. Soon after, the psychiatrist receives a call from a family member who is concerned about the “black box” warnings associated with antipsychotics in the elderly. Which of the following is the most accurate information the psychiatrist could give the family member regarding the potential safety risks of this medication? (x2)
ATYPICAL ANTIPSYCHOTICS INCREASE MORTALITY; THIS MUST BE BALANCED AGAINST ANY POTENTIAL BENEFIT
Blockade of dopamine receptors in tuberoinfundibular tracts results in breast enlargement, galactorrhea, impotence, and amenorrhea. Mechanism is increase of:
PROLACTIN
Correlation of plasma drug concentration with the clinical effectiveness is best established for which antipsychotics?
CLOZAPINE AND HALOPERIDOL
Acutely psychotic pt started on risperdal 2 mg qhs. Increased to 3 mg BID over next few days. Pt becomes increasingly agitated, restless, unable to stop pacing. Most appropriate intervention?
ADD PROPRANOLOL 10 MG TID
Psychotic pt given haldol, acute laryngospasm. In addition to intubation, give:
COGENTIN
Schizophrenic OD’d on antipsychotics, has EPS and urinary retention. Tx?
AMANTADINE
Pts over 65 y/o are less likely to tolerate higher doses of antipsychotics due to:
DECREASED HEPATIC METABOLISM
25 y/o pt is brought to the ED with a sudden onset of severe spasms of the neck and eyes deviated up and to the right. The pt has had a viral illness with nausea and vomiting and was given prochlorperazine yesterday. Which of the following meds would be most appropriate to prescribe for this patient?
DIPHENHYDRAMINE
A neonate has transient hyperreflexia, irritability, and tremors followed by a period of depressed interactive behavior and poor response to environmental stimuli. What did the childs mother use?
OLANZAPINE
In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, which medication was the most effective due to its low rate of discontinuation, high reduction in psychopathology, and longest time to discontinuation of treatment
OLANZAPINE
Patient started on clozapine for treatment-resistant schizophrenia has initial ANC of 2200/mm3. How frequently should you get a CBC with diff?
WEEKLY
greatest risk factor for developing akathisia? Male sex, younger age, rapid dose escalation, lower potency agents, positive symptoms
RAPID DOSE ESCALATION
Quetiapine is known to develop diabetes, if starting metformin, this is an example of what kind of prevention? (primary, secondary, tertiary or quaternary?)
TERTIARY
What psychotropic can cause a decrease in benzo plasma levels? (6x)
CARBAMAZEPINE
Which benzo accumulates with repeated administration, should be avoided in chronic renal failure, and most likely to accumulate with repeated dosing? (3x)
DIAZEPAM
Which of the following medications would be preferable for use in an anxious patient with pulmonary disease? (3x)
BUSPIRONE
If prescription benzo is necessary for a patient w/ severe hepatic dysfunction which of the following is most appropriate choice to avoid elevated serum levels. (2x)
LORAZEPAM
Which benzo is reliably absorbed given IM? (2x)
LORAZEPAM
Which of the following reverses the effects of benzodiazepines? (2X)
FLUMAZENIL
47 yo with well controlled epilepsy well controlled on monotherapy develops nausea, ataxia, and diplopia when treated with erythromycin. Which antiepileptic?
CARBAMAZEPINE
Decreases congenital malformations in women taking anti-epileptic medications
FOLIC ACID
The use of flumazenil for treating benzo OD is limited by …
THE RISK OF INDUCING WITHDRAWAL SEIZURES IN BENZO- DEPENDENT PTS
75 y/o pt with cirrhosis should be given which of the following meds:
TEMAZEPAM
False positive urine toxicology screen for Benzodiazepines?
SERTRALINE
Buspirone is thought to exert anxiolytic effects primarily due to its actions at which receptor?
5HT-1A
Benzo half-life < 6 hrs
TRIAZOLAM
Pharmacokinetic property most related to relative abuse potential of benzos
TIME TO ONSET OF ACTION
Benzodiazepam absorbed PO or IM
LORAZEPAM
Benzo w/o active metabolites
LORAZEPAM
Longest half-life amongst alprazolam, flurazepam, lorazepam, temazepam and triazolam
FLURAZEPAM (DALMANE) USED FOR INSOMNIA
Most common side effect of benzos
DROWSINESS
Which of the following benzos has an active metabolite?
CHLORDIAZEPOXIDE
Which of the following sleep changes is produced by all benzos?
DECREASE IN REM
Breakthrough panic anxiety in a patient treated with short-acting benzodiazepines can be managed by switching the pt to what medication?
CLONAZEPAM
75 y/o pt has developed tolerance to clonazepam over many years, now taking 5mg clonazepam at night but still with poor sleep. Pt denies any mood or anxiety symptoms, no drug problems. Next step:
SLOWLY WITHDRAW THE PT’S CLONAZEPAM AND REEVALUATE
Pts on chronic benzos develop:
AMNESIA
Benzo that would be the safest to prescribe for a 70y/o pt:
LORAZEPAM
35 yo patient presents with frequent panic attacks, which begin with feelings of dread, sweating, shaking, fear of doom and death lasting 20 min. Which medication provides immediate relief:
LORAZEPAM
How likely is escalation of benzodiazepine dose when prescribed for long term use?
MOST PATIENTS WILL MAINTAIN A STABLE DOSE OVER TIME
FDArequiresthatgenericsnotbesignificantlydifferentfromtheparentcompoundsinwhat way? (6x)
BIOEQUIVALENCE
After OD, pt has fever, confusion, tachycardia, dry mouth, urinary retention, dilated and unresponsive pupils. Which medication would treat this? (Anticholinergic toxicity) (4x)
PHYSOSTIGMINE
Pt presents to ED c/o ringing in ears, abdominal pain, and is found to have mild metabolic acidosis. Overdose of what substance? (4x)
ASPIRIN
Hepatitis C treatment with interferon can cause what psychiatric symptom? (3x)
DEPRESSION
Which of the following agents used to treat patients with Alzheimers disease has a mechanism of action related to an antiglutaminergic mechanism? (x2)
MEMANTINE
In addition to life support, which class of meds to consider for the treatment of neuroleptic malignant syndrome? (2x)
DOPAMINE AGONISTS (bromocriptine)
What medication may cause mood d/o in pts being treated for melanoma? Also worsens fatigue and cognitive inefficiency: (2x)
INTERFERON
What med is effective in tx of motor/vocal tics associated w Tourette syndrome refractory to tx with antipsychotics and alpha adrenergic agonists? (x2)
TETRABENAZINE
Pt confused, disoriented, dry mouth, dilated unresponsive pupils. Likely ingested: (2x)
BENZTROPINE
Flumazenil is used to treat: (2x)
BENZO INTOXICATION
This is a relative contraindication for interferon treatment in pt’s with Hepatitis C: (2x)
DEPRESSION WITH SUICIDAL IDEATION
The effects of caffeine on which of the following results in increased dopaminergic activity? (x2)
ADENOSINE RECEPTOR
A pt with cancer, pain, depressed mood, poor appetite, fatigue, impaired concentration, prognosis is less than three weeks. What should you treat with?
METHYLPHENIDATE
Contraindication for treatment for psychostimulants
UNDERLYING HEART DEFECT
54 yo female takes prozac 60 mg for MDD, having worsening migraines then fever, diarrhea, and “muscles are tightening up”. Which medicine is causing these sx?
SUMATRIPTAN
84 yo pt goes to ED with fever, dry mouth, visual hallucinations. Is found tachycardia, restless, toxicity of what medication most likely caused symptoms?
BENZTROPINE
Prolonged ingestion of high doses pyridoxine causes:
SUBACUTE SENSORY NEUROPATHY
Physostigmine is useful in treating toxic syndrome from overdose with:
SCOPOLAMINE
Pt in ED for treatment of OD – was found 4 hrs ago after ingesting 10 cold med packs of 650mg Tylenol, antihistamine, and alpha 1 agonist decongestant. Pt is pale and vomiting. How do you decide whether to use N-acetylcysteine as an antidote?
PT’S SERUM N-ACETYL-P-AMINOPHENOL (APAP) LEVEL OVER TIME
Tx of pts w/ substance abuse who have acute pain
PATIENT-CONTROLLED ANALGESIA
Which of the following agents has been shown to moderate weight gain in some pts treated w/ valproate and atypical antipsychotic?
METFORMIN
Pt took 20 tabs 500mg acetaminophen tabs 6 hours ago. Pt is 52kg, pulse 96, BP 135/65. Pt alert and in NAD. Serum acetaminophen level is 60 Ug/ml. Liver fxn test are minimally elevated. Most appropriate action?
N-ACETYL-CYSTEINE
A post-op pt’s was receiving 75mg IM meperidine. After switching to meperidine 100mg po pt reports inadequate pain relief. She has no past psych and abuse issues. This is due to:
THE LOWER POTENCY OF PO MEPERIDINE COMPARED TO IM
Acetylcysteine is Tx of choice for OD of:
ACETAMINOPHEN
OD on sleeping pill. Hot skin, blurry vision, urinary retention, dry mucous membranes, tachycardia, decreased bowel sounds. What is the pill?
DIPHENHYDRAMINE
Risk of hepatotoxicity will peak in how many hours after acetaminophen overdose?
72 TO 96 HOURS
MC complication of corticosteroid therapy?
MOOD DISORDER
Molecular targets for improving cognition in schizophrenia have shown promise via which of the following mechanisms?
D1 RECEPTOR AGONISM
Which med is helpful in Tourette Syndrome who can’t tolerate clonidine?
GUANFACINE
Guanfacine’s primary effect is through what mechanism of action?
PRESYNAPTIC ALPHA2 ADRENERGIC RECEPTOR ACTIVATION
Key element in emergency treatment of pt w serotonin syndrome, beyond stopping offending agent is:
SUPPORTING VITAL FUNCTIONS
Restlessness, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, and confusion are compatible with which diagnosis?
SEROTONIN SYNDROME
Research on the use of psychostimulants to treat pts w/ secondary depressive symptoms in medical setting suggest:
WHEN TREATED WITH THESE AGENTS, PT MAY ENGAGE IN REHABILITATION SOONER.
A psychiatry consult is placed regarding a patient with SI. History of Bipolar disorder and admitted for VRE bacteremia. BP of 171/95, temp of 100.9. Has tremors, hyperreflexia, myoclonic jerks, not oriented at all, has visual hallucinations. Meds include linezolid, lithium, sertraline, Risperdal. What is diagnosis?
SEROTONIN SYNDROME
What drug has been known to cause hypertensive crisis?
PHENELZINE
African Americans tend to have higher activity of which of the following cytochrome p450 enzymes?
3A4
Sudden death in children taking which medication?
TRICYCLICS
47 yo pt presents with fever, confusion, and tremor and found to be tachy and diaphoretic. Clonus easily elicited on exam. Pt suspected to have serotonin syndrome, is taking Celexa and Lithium. What additional medication may have contributed to syndrome?
ST. JOHN’S WORT
Autonomic instability, nonfocal neurological signs, and elevated temp associated with which elevated lab value?
CREATININE PHOSPHOKINASE (CPK)
Drug-drug interactions in pts taking HIV meds are particularly problematic with which medication:
METHADONE
In addition to benzos, which class of meds is assoc with falls in pts older than 60?
ANTIDEPRESSANTS
The potency of medication refers to which of the following properties of a medication?
RELATIVE DOSE REQUIRED TO ACHIEVE A CERTAIN EFFECT
60 yo pt with chronic schizophrenia takes cogentin for neuroleptic induced parkinson now has increased urine retention and confusion. What medication would be the best alternative for treating this patient’s condition?
AMANTADINE
Most of the body’s serotonin is located where?
GI TRACT
Common side effect of acetylcholinesterase inhibitors
DIARRHEA
Diphenhydramine’s ability to treat acute dystonia is due to action on which receptor?
MUSCARINIC-1
28 y/o with BMDII wants to use phototherapy for depressive Sx treatment in winter. What should you advise?
CAN BE USED BUT REQUIRES VIGILANCE AND CAREFUL TITRATION OF DOSE
Which med is used to treat hep C viral infection and is associated with depression, anxiety, and cognitive impairment?
INTERFERON-ALPHA
In pts who surreptitiously use excess sulfonylurea, which of the following substances can be administered to r/o possible insulinoma?
TOLBUTAMIDE
Which of the following medications inhibits the enzyme ETOH acetaldehyde dehydrogenase?
DISULFIRAM
Buprenorphine’s advantages over clonidine, in the management of patients with opioid withdrawal, include better control of which of the following symptoms?
CRAVINGS
Therapeutic index is a relative measure of which of the following characteristics of a medication?
RELATIVE MEASURE OF DOSING TOXICITY TO SAFETY
Pharmacokinetic factor that declines w/ aging?
GLOMERULAR FILTRATION RATE
Patients >65 y/o are more sensitive to psych meds. What physiologic change occurs with aging?
DECREASED PHASE 1 OXIDATION
Agitated pt gets rapid tranquilization in ED. Using oral concentrate instead of IM or IV has what advantage?
DECREASED FEELINGS OF HELPLESSNESS
What herbal (phytomedicinal) is used as a hypnotic?
VALERIAN
The FDA requires that pharmaceutical companies demonstrate that a generic drug is not significantly different from the parent compound in which way?
BIOEQUIVALENCE
What is the underlying mechanism of action of sildenafil in erectile dysfunction?
ENHANCEMENT OF NITRIC OXIDE
What substance is associated with a risk of bleeding when taken with anti-platelet drugs or warfarin?
GINGKO BILOBA
Clonidine mechanism of action:
ALPHA-2 AGONIST
42 y/o pt has primary insomnia. Pt complains of difficulty falling asleep, but then sleeps through the night. Which of the following would be the best medication to prescribe for this pt after addressing sleep issues:
ZALEPLON
Combined use of Lithium and SSRI is known to increase the risk of which of the following conditions?
SEIZURES
28 y/o pt wants to stop smoking with the help of a nicotine replacement product. Pt plans to have orthodontia within the next 2 months; has psoriasis; and has multiple environmental allergies that often cause nasal stuffiness, sore throats, and itchy, watery eyes. Nicotine replacement best?
NICOTINE LOZENGES
Prepubertal children differ from adolescents and adults with regards to dosing of liver metabolized medication requiring?
HIGHER WEIGHT ADJUSTED DOSES OF MEDICATION
Effective for OCD
PAROXETINE, PHENELZINE, FLUVOXAMINE, CLOMIPRAMINE (NOT BUPROPION)
This is an effective pharmacologic treatment for symptoms of OCD?
CLOMIPRAMINE
What pharmacokinetic property remains most stable with age
ABSORPTION
Irreversible effect of chronic anabolic steroid use
HIRSUTISM
What does current evidence show regarding psychiatrists using pharmacogenomics testing in clinical practice?
RESEARCH SHOWS PROMISE FOR CLINICAL UTILITY, BUT REPLICATED EVIDENCE ABOUT OUTCOMES IS LACKING
Bipolar II patient w/ CDK, HTN, DMII, obesity has uncontrolled depressive episodes. Currently euthymic on mood stabilizer with significant SE. What med should be trialed: Lithium, Quetiapine, Olanzapine, Lamotrigine, Divalproex?
LAMOTRIGINE
Medication caused syncopal episode with hyperthermia, headache, flushing, and tachycardia with hypotension requiring IV fluids in a patient who has a history of schizophrenia, GAD, and EtOH Use Disorder
DISULFIRAM
9 year old with ADHD not responding to methylphenidate, next medication?
DEXTROAMPHETAMINE
Methadone patient gets pregnant. Best recommendation?
CONTINUE METHADONE MAINTENANCE
Marker of autonomic activity and biofeedback:
HEART RATE VARIABILITY
What medication can lead to serotonin syndrome if combined with fluoxetine
LINEZOLID
First line treatment for restless leg syndrome: Carbamazepine, Clonazepam, Pramipexole, Gabapentin, Imipramine.
PRAMIPREXOLE
Which of the following ADHD meds has a black box warning for suicidal ideation in children and adolescents (Modafinil, Atomoxetine, Methylphenidate, Lisdexamfetamine, Dextroamphetamine)
ATOMOXETINE
Which is an alpha-2 adrenergic agonist: atomoxetine, buspirone, modafinil, guanfacine, memantine
GUANFACINE
Reason for IV atropine administration to patient prior to triggering the electrical stimulus during ECT
PREVENT BRADYCARDIA AND ASYSTOLE
Clinically significant increase in lamotrigine concentration may occur if co-administered with: (8x)
VALPROIC ACID
Teratogenic effect of both VPA and carbamazepine: (3x)
NEURAL TUBE DEFECTS
Carbamazepine should be D/C’ed if the absolute neutrophil count is below: (2x)
3,000
Pt w/ treatment-resistant mania and h/o rapid cycling is being treated w/ carbamazepine and thyroxine. After adding clozapine the pt is clinically stabilized. The pt’s most recent WBC is below 3,000. Intervention? (2x)
D/C CARBAMAZEPINE
Which of the following anticonvulsants may be associated with kidney stones? (2x)
TOPIRAMATE
Pt with treatment resistant, rapid cycling bipolar disorder who recently started lamotrigine develops a rash on the face. Pt admits to a mild sore throat and thinks he may have a fever. Which of the following is the best recommendation for the psychiatrist to make to the pt? (2x)
DISCONTINUE LAMOTRIGINE AND COME TO THE APPROPRIATE ER
Which med decreases the efficacy of oral contraceptive? (2x)
OXCARBAZEPINE
Drug prophylactic for treatment of migraines: (2x)
VALPROATE AND TOPIRAMATE
Interaction between valproic acid and lamotrigine that causes severe derm reactions?
VALPROIC ACID INHIBITS GLUCONURONIDATION
Associated with neural tube defect in first trimester of pregnancy:
VALPROATE
Which of the following meds is associated with benign maculopapular rash in approximately 10-15% of pt’s within the first 3 weeks of treatment?
CARBAMAZEPINE
After psychiatrist adds new med, pt turns bright red w/ sunburn like rash, similar to SJS. Which med caused this?
LAMOTRIGINE
Inducer and substrate of CYP3a4 (ie may require dose increase after several weeks to maintain steady state)
CARBAMAZEPINE
Lancinating face pain, triggered by minor sensory stimuli, best treated initially with:
CARBAMAZEPINE
Which drug used in the treatment of patients with epilepsy is assoc w hyponatremia?
CARBAMAZEPINE
Coarsening of facial features and hirsuitism are SE of what med?
VALPROATE
Acute onset of hematuria and lumbago? Side effect of which anticonvulsant?
TOPIRAMATE
Pt taking carbamazepine for BMD presents with weakness and pallor. The psychiatrist notes the presence of a non-blanching rash on the patient’s arms. The most immediate lab test to order is:
CBC
Lamotrigine is effective treatment for what mood disorder?
BIPOLAR DEPRESSION
Fetal exposure to valproate during pregnancy increases risk of:
NEURAL TUBE DEFECTS
8 y/o Dx w/ Bipolar d/o is about to start valproic acid. What needs to be monitored frequently?
LIVER FUNCTION
Which antibiotic may significantly raise carbamazepine levels and precipitate heart block?
ERYTHROMYCIN
What justifies using Valproate more commonly that lithium for BMD in pts > age 65?
CHANGES IN RENAL CLEARANCE MAKES LITHIUM DOSING PROBLEMATIC
Side effect more frequent in carbamazepine than lithium:
DIZZINESS
Hair loss + weight gain are SE of which anticonvulsant:
DIVALPROEX SODIUM
Which of the following baseline labs should be obtained for pt being treated with valproate?
LIVER FUNCTION TESTS
What CBC value is most important to follow when on Depakote?
PLATELETS
What is the most common reason pts discontinue valproate?
WEIGHT GAIN
Adequate as a monotherapy for juvenile myoclonic epilepsy:
VALPROATE
Adequate for monotherapy generalized tonic clonic szs:
VALPROATE
Of these meds (topiramate, lamotrigine, valproic acid, levetiracetam, Oxcarbazepine), which is most likely to be free of any significant interaction with other antiepileptic medications?
LEVETIRACETAM
Valproate’s epigenetic modifying properties due to effect on ___?
HISTONE DE-ACETYLASE
Treatment of choice for lithium intoxication who manifests impaired consciousness, neuromuscular irritability, and seizures is (10x)
HEMODIALYSIS
Which med is thought to have a protective effect independent of its mood- stabilizing effect against suicide risk in pts w mood disorder? (4x)
LITHIUM
Psoriasis exacerbated by: (3x)
LITHIUM
32 y/o F pt w/ BMD has been treated with lithium. Pt reveals to her psychiatrist that she is now pregnant. Attempts to dc lithium in the past have led to relapses of the pt’s disorder, with severe associated morbidity. A trial of an antipsychotic in the past resulted in NMS, and pt has since refused to use them. Which of the following would be the best option for treatment during the pregnancy? (3x)
CONTINUE LITHIUM
A pt who was previously stable on Lithium presents with symptoms of toxicity after their PMD starts them on a HTN medicine. Which of the following is the is the most likely mechanism of interaction between the lithium and the HTN medication (X3)?
REDUCED RENAL CLEARANCE
What lab test should be conducted prior to initiation of lithium tx (x3)?
TSH
A 32 yo F comes to the ED with CC of 2 weeks of diarrhea. On exam she is anxious and tremulous and is not oriented to date or time of the day. She states she is taking “some drug” for Bipolar disorder and adds that she started doubling her dose a month ago because she “wasn’t getting better fast enough.” She denies use of drugs/ETOH. Which medication would most likely cause the symptoms described? (x2)
LITHIUM
62 y/o F w bipolar d/o develops altered mental status, dysarthria, ataxia in hosp after meds are added in hospital to her lithium. What medication could cause this? (2x)
INDOMETHACIN COMPETES WITH LITHIUM FOR EXCRETION AND CAUSES LITHIUM TOXICITY SYMPTOMS
Lithium exposure in first trimester of pregnancy increases risk of congenital abnormalities in which organ? (2x)
HEART
Lithium can be removed via hemodialysis because? (2x)
HAS NO METABOLITES
Stable, steady state Lithium levels are generally obtained within: (2x)
4-5 DAYS
Which of the following factors is a predictor of a poor response to lithium? (2x)
RAPID CYCLING
What factor is thought to predict a poor response to lithium treatment for pts with bipolar disorder? (2x)
MIXED MANIC/DEPRESSED EPISODE
Giving charcoal is an ineffective treatment for pt who OD’d on (x2):
LITHIUM
Which of the following medications was first used as a treatment for gout and later promoted by john cade for treatment of unstable mood? (X2)
LITHIUM
What can decrease Li levels
CAFFEINE
Li induced polyuria tx with least effect on Li level?
AMILORIDE
Bipolar pt on lithium and Zoloft for 3 yrs. Level 0.8. More depressed and fatigued, low energy level. Increasing Zoloft ineffective. Next step:
OBTAIN TSH LEVEL
This cardiovascular disturbance is most common for Lithium:
BENIGN T WAVE CHANGES.
Medication most likely to cause cognitive side effects, even seizures, if taken at same time as ECT?
LITHIUM
A psychotropic with same pharmacokinetic properties in Asian Americans and White Americans
LITHIUM
Lithium serum levels should be monitored by evaluating:
TROUGH LEVELS 12 HOURS AFTER LAST DOSE
Which med can decreased serum concentration of lithium
AMINOPHYLLINE
BMD Tx with Li x 2 years develops rapid cycling. What lab test should be done?
THYROID FUNCTION TESTS
SE of toxic serum lithium levels
ST DEPRESSION, QTC PROLONGATION, ATAXIA, TREMOR, DYSARTHRIA, NEPHROTOXIC SX, STATUS EPILEPTICUS
24 y/o F in 2nd trimester now manic w/ no psychotic fx’s. Hx of 1 episode of mania, diagnosed bipolar I. D/C lithium when she decided to have kids. Willing to begin Tx.
RESTART LITHIUM
The most common cause of severe polyuria with lithium is:
NEPHROGENIC DIABETES INSIPIDUS
While taking lithium patients should:
MAINTAIN SODIUM INTAKE
A CNS structure that is likely to suffer permanent damage following lithium toxicity:
CEREBELLUM
Interferes w/ clearance of lithium
IBUPROFEN
Cardiac effects of lithium resemble what on EKG
HYPOKALEMIA (LOW T WAVES)
Predictor of positive response to lithium prophylaxis:
HISTORY OF GOOD INTER-EPISODE FUNCTION
In patients on lithium, what type of thyroid dysfunction can occur?
HIGH PREVALENCE OF THE PRODUCTION OF THYROID AUTOANTIBODIES
Intake of this increases lithium levels
FLUOXETINE
Which of the following laboratory tests is essential prior to prescribing lithium?
BUN AND CREATININE
55 y/o pt with guilt, anhedonia, insomnia, and sad mood has been treated for 10 wks with fluoxetine 60mg qam. His mood and appetite have improved, though he still has difficulties with concentration, hopelessness, and tearfulness. He denies a h/o manic or psychotic symptoms. The medication most likely to augment the antidepressant effect of his current regimen would be:
LITHIUM
Pt on lithium and paxil. Lithium is ineffective despite a therapeutic level. What do you do?
DISCONTINUE PAXIL
Which nervous system structure is likely to suffer permanent damage from lithium OD?
CEREBELLUM
Lithium can raise what serum electrolyte?
CALCIUM
Tx of acute mania w/ lithium. What is the best adjunctive agent?
ECT
Characteristic that makes lithium readily dialyzable:
LOW MOLECULAR WEIGHT
When used at a therapeutic dose during pregnancy, the dose of which medicine should be reduced in the postpartum period to minimize ASE’s? Lithium, Lamotrigine, Carbamazepine, Topiramate, Valproate
LITHIUM
What is a pharmacological effect of lithium?
GLYCOGEN SYNTHASE KINASE-3 INHIBITION
Most likely to be enhanced by the strategies of putting the pt at ease, finding the pt’s pain and expressing compassion, evaluation pt’s insight, and showing expertise: (5x)
RAPPORT
The factor most consistently associated with therapy outcome in psychotherapy research: (3x)
STRENGTH OF THERAPEUTIC ALLIANCE
A set of feelings that a patient reenacts in the therapeutic relationship are called: (x2)
TRANSFERENCE
Business executive hospitalized for bleeding ulcer repeatedly argues with a well-liked head nurse and threatens to leave AMA. Best action for C&L psychiatrist is: (2x)
LISTEN TO PT’S COMPLAINTS ACKNOWLEDGE HIS DISCOMFORT WITH THE PASSIVE POSITION THAT HE IS UNACCUSTOMED TO
Common theme in psychotherapy in the elderly: (2x)
LOSS
As opposed to long-term psychotherapy, time-limited therapy more likely to: (2x)
SELECT CENTRAL ISSUE AS FOCUS
For the treatment of pts with compulsive sexual behavior, the best results have been seen with which of the following approaches? (2x)
TWELVE STEP GROUPS
Two most powerful predictors of outcome in any form of psychotherapy are: (2x)
EMPATHY AND THERAPEUTIC ALLIANCE
The best response to a pt who reports a fixed false belief that his neighbor is poisoning his dog and sitting all day at the window monitoring is: (2x)
EMPATHIZE WITH THE PT, BUT AVOID DIRECT CONFRONTATION ABOUT THE DELUSION
Psychotherapy where pts realistically evaluate their interactions w others & therapist offers direct advice/helps pts make decisions/ignores transference issues. (2x)
INTERPERSONAL PSYCHOTHERAPY (IPT)
Most likely represents an acceptable boundary crossing by a therapist as opposed to a boundary violation: (2x)
RECEIVING COOKIES AS AN EXPRESSION OF GRATITUDE BY A PT NEAR TERMINATION.
Therapeutic empathy is best described as the therapist’s ability to: (2x)
GRASP PT’S INNER EXPERIENCE FROM PT’S PERSPECTIVE
Motivational interviewing often used as part of the treatment of which conditions? (2x)
SUBSTANCE ABUSE
Therapeutic technique where therapist instructs the patient to hold onto a symptom: (2x)
PARADOXICAL INTERVENTION
Without evident distress, pt calmly reports to the psychiatrist, “Since I was last here, my significant other dumped me.” The doctor responds by pointing out the discrepancy between the pt’s affect and the content described. This response is an example of: (2x)
CONFRONTATION
Psych resident dislikes alcoholic pts and avoids working with them. In discussing the problem, says that pts are hopeless and unmotivated and she can’t empathize with them. Example of? (2x)
COUNTERTRANSFERENCE
Catharsis is: (2x)
VERBAL EXPRESSION OF SURPRESSED TRAUMATIC EXPERIENCES AND FEELINGS
barrier to widespread use of telepsychiatry
PHYSICIAN DISSATISFACTION
Example of behavioral analysis strategy
“AT WHAT POINT DURING THE DAY DID YOU FIRST NOTICE YOU WERE THINKING ABOUT CUTTING
Pt BIB police to ED with disorganized behavior. Pt askes “are you a real psychiatrist?” Best response?
I’M A RESIDENT WHICH MEANS I AM A PHYSICIAN WHO IS RECEIVING SPECIALTY TRAINING IN PSYCHIATRY.
Recent meta- analyses have suggested what with regard to the use of psychotherapy to treat depression?
OTHER PSYCHOTHERAPIES HAVE EFFICACY COMPARABLE TO CBT
Psychiatrist’s mind wanders during sessions, what should the psychiatrist do?
EXAMINE INNER THOUGHTS AND FEELINGS
What theory is the basis of mentalization-based therapy?
BOWLBY’S ATTACHMENT THEORY
During initial psych interview, pt tearfully discusses painful ending of romantic relationship. What should Dr. say to establish therapeutic alliance?
IT SOUNDS LIKE THIS HAS BEEN VERY DIFFICULT FOR YOU.
HOW ARE YOU COPING?
Psychiatrist behavior of raising eyebrows, leaning towards pt, saying “Uh-huh”
FACILITATION
Redirecting discussion by talking about irrelevant stuff
RESISTANCE
During a clinical interview, the physician recapitulates what the pt has said so far and says to pt “I just want to make sure that I’ve got everything right up to this point”. This is an example of:
SUMMATION
When psychiatrist asks about mania, pt responds, “that sounds exactly like my cousin,” and proceeds to tell long story about cousin but doesn’t answer the psychiatrist’s request. This is an example of:
TANGENTIALITY
In initial psych interview, pt frustrated that his last psychiatrist had brief visits & “just gave me another pill every time.” Interviewing psychiatrist responds “so you would like your psychiatrist to listen & understand you before adjusting your meds.”
CLARIFICATION
Pt who had difficult childhood calls therapist mother’s name and quickly corrects error. What is this an example of?
PARAPRAXIS
Pt w/ BMD who has been making progress in long-term psychodynamic psychotherapy enters session obviously distraught. After listening to scattered seemingly unimportant details of recent daily life, therapist asks if pt is avoiding something too uncomfortable to talk about. Pt responds w intense anger/distress. “I just heard you are getting a divorce, I am sick about it. Here I am counting on you to help me sort out my chaotic life and messed-up relationships, and you can’t even keep your own marriage together! What are you, some kind of hypocrite? I think I should leave and find someone who knows what they’re doing!” Best response for the therapist to make?
“I AM GOING TO NEED A MOMENT TO THINK ABOUT WHAT YOU’VE SAID AND ARE FEELING BEFORE I CAN RESPOND.”
8yr old evaluated for asthma, found to have ADHD symptoms, put on stimulant, behavioral problems continue, sent to psychiatrist and psychologist, this is an example of what level of collaborative care?
SHARED (INTEGRATED) CARE
17 y/o receiving counseling for school truancy. Student understand truancy is not a desirable behavior and is discusses ways to improve school attendance. What stage of change is student in?
PREPARATION
College student in therapy, the Dean calls therapist requesting info about the student’s therapy due to recent reports from a dorm supervisor. Therapist should:
REFUSE THE DEAN’S REQUEST FOR INFORMATION
An important counter-transference issue in an interethnic psychotherapeutic relationship is:
DENIAL OF DIFFERENCES
An important counter-transference issue in an interethnic psychotherapeutic relationship is:
DENIAL OF DIFFERENCES
Abstinence compliance increases with random UDS. This is ex of:
PARTIAL REINFORCEMENT
A new pt asks therapist, “are you Christian?” What is best response?
“ARE YOU CONCERNED THAT IF WE ARE NOT OF THE SAME RELIGION, I WON’T BE ABLE TO TREAT YOU PROPERLY?’
Exchange during initial interview after pt’s former therapist closed his practice: pt expresses concern about new therapist being too young/inexperienced, states she doubts new therapist can provide any new insights. Best response to further goal of getting to know pt, establish whether therapy w new therapist would be appropriate
“IT CAN BE VERY HARD TO START OVER WITH A NEW THERAPIST. HOW HAVE YOU BEEN FEELING ABOUT HAVING TO END YOUR TREATMENT WITH DR. BROWN?”
A patient repeatedly becomes distressed after what seems, even to the pt, to be minor disappointments. The patient also seems to suffer from extreme narcissistic vulnerability. A therapist utilizing self-psychology would be most likely to interpret this due to which of the following factors?
A LACK OF DEVELOPMENTALLY APPROPRIATE EMPATHY FROM CAREGIVERS
Treating a much older pt who asks about therapist’s age. Best response:
“MAYBE YOU’RE CONCERNED ABOUT WHETHER I AM EXPERIENCED ENOUGH TO TREAT YOU?”
Pt seeing new psychotherapist weekly x3 wks hesitantly complained about being able to overhear much of what pt in the preceding session was saying. Pt assured therapist that he had tried not to listen and had left the waiting room to wait outside until the other pt had left. Which is best response?
APOLOGIZE FOR THE LACK OF PRIVACY AND INDICATE THAT FURTHER MEASURES, SUCH AS MUSIC SYSTEM IN THE WAITING ROOM, WILL BE UTILIZED
MD sees psychiatrist w increasing sense of dislike for a blaming, externalizing pt who pits family members against the MD. What should psychiatrist discuss w MD?
COUNTERTRANSFERENCE
A pt with h/o lifelong depression & failed relationships complains (very angry) (after several weeks of therapy) that she is expected to trust the Dr. without even knowing anything about him (credentials or personally) what should the Dr say?
EMPATHIZE WITH THE PT’S FEARS OF TRUST AND FEELING OF BEING AT A DISADVANTAGE
Psychotherapy technique for children with Tourette’s syndrome.
HABIT REVERSAL
62 y/o with lung cancer, weight loss, fatigue, and persistent cough. Pat refuses to accept Dx of cancer and states will “get over this infection.” Pt refuses all further testing and asks for antibiotics to “recover in peace.” C&L psychiatrist’s role is:
EVALUATE PT’S COPING STYLE AND HELP THE MEDICAL TEAM SEE THE PT’S RESPONSES IN THE CONTEXT OF HER UNIQUE PERSONALITY AND LIFE CIRCUMSTANCES
Young female starting cognitive therapy with a female resident asks for a hug. Resident should first:
EXPLAIN WHY PHYSICAL CONTACT IS AVOIDED
C&L psychiatrist uses all therapeutic approaches except:
EXPLORATORY PSYCHODYNAMIC
Psychiatrist is treating an older pt who is a successful executive. Pt feels grateful for the help w/ his depression and offers some tips on investing to the psychiatrist. What is the most appropriate action at this point from the psychiatrist?
EXPLORE PT’S MEANINGS AND FEELINGS ABOUT THE OFFER
Female psych resident says pt saw resident in town over weekend. Followed her around. Thought she could later shop at same stores and eat at same restaurants as her greatly admired therapist. Nothing wrong in pt’s bx or material suggesting she is dangerous. Pt apologizes convincingly, says will not do again. Hopes therapist will not fire her. What is next best step?
INTERPRET PT’S LONGING TO IDENTIFY W THE PSYCHIATRIST
What if pt asks whether you’re still in training during intake interview?
INFORM THE LEVEL OF TRAINING
Midway through psychotherapy session, a psychiatrist’s mind wanders despite repeated refocus. Best immediate action:
EXAMINE OWN INNER FEELINGS ABOUT THE PATIENT
Pt sees therapist and makes threats and becomes agitated. Therapist feels uneasy, the next step is to:
INTERRUPT INTERVIEW TO GET HELP
Young pt in therapy returns to school, announces to therapist that he can pass classes, will graduate. Best response:
OFFERING CONGRATULATIONS
Beginning therapist feels great empathy for depressed pt fails to maintain sufficient distance to observe self-destructive patterns. To avoid this pay attention to:
OVERIDENTIFICATION WITH PATIENT
Social skills training for those with persistent mental illness is an essential part of:
PSYCHIATRIC REHABILITATION
Therapist is working w family of schizophrenic. Strategies include informing about illness, social support, management guidelines. Therapist encourages calm problem solving approach/facilitates stress and stigma reduction when possible. Which model is therapist using?
PSYCHOEDUCATIONAL
Biofeedback usually helps pts with which medical syndrome?
RAYNAUD’S SYNDROME
What interventions are consistent w the theoretical assumptions of crisis Tx?
REASSURANCE, BRIEF HOSPITALIZATION, PSYCHODYNAMIC INSIGHT, TREATMENT WITH PSYCHOTROPIC MEDICATIONS (NOT FOCUSING ON PAST RELATIONSHIPS)
During last session of successful psychodynamic psychotherapy, pt warmly expresses gratitude for everything, saying that the help the therapist has given has made a big difference. Appropriate response?
RESPOND BY SAYING YOU TOO HAVE ENJOYED THE WORK
What is an example of a boundary violation?
INVESTING IN A PT’S BUSINESS
After attending several sessions of individual psychotherapy for anxiety and depression, 24 y/o M revealed his homosexuality to his heterosexual male psychiatrist. Therapist realizes he is uncomfortable when pt expresses longings for a male. Therapist also tends to overemphasize any material that might represent pt’s heterosexual wishes. The next best step for the psychiatrist would be to:
SEEK CONSULTATION TO DISCUSS COUNTERTRANSFERENCE ISSUES
Pt w/ mild MR in program designed to develop new behaviors by modeling/reinforcement, then practice them.
SOCIAL SKILLS TRAINING
Therapist preoccupied w/ patient. Acknowledges this but unable to shake feeling
TALK TO SUPERVISOR
15 y/o male bib parents, does not want to speak with psych
THANK HIM FOR COMING IN AND ASK HIM IF HE’D LIKE TO BE SEEN ALONE OR WITH HIS PARENTS
What was most important factor in determining tx outcomes in National Institute of Mental Health Treatment of Depression Collaborative Research Program (1996)?
THERAPEUTIC ALLIANCE
While assessing for DV, examiner says to pt/spouse, “The tension that builds up between you must be incredibly stressful. It’s not unusual that people who are stressed out can have trouble controlling themselves or can do things they didn’t intend, like screaming at or even hitting their partner. Has anything like that happened to you?” Which technique is this?
NORMALIZATION
Pt repeatedly redirecting discussion by talking about irrelevant topics is example of:
RESISTANCE
Core principle of motivational interviewing that is used to treat addictive behaviors:
DEVELOP DISCREPANCY
Individual psychotherapy for alcoholics most effective when it focuses on:
INTERACTIONS WITH PEOPLE
Programmed practice, or exposure therapy, is an indicated treatment for what disorder?
AGORAPHOBIA
Pt with multiple social fears is terrified of public speaking. As the next step in treatment, the therapist arranges for the pt to give 15 minutes talk to clinical staff. This is an example of:
FLOODING
Exposure and flooding together with response prevention are techniques of behavioral therapy aimed at which of the following?
HASTENING THE EXTINCTION OF A CONDITIONED FEAR OR ANXIETY RESPONSE
Elements common to both CBT and eye movement desensitization and reprocessing in the treatment of patients with PTSD include:
CONTROLLED EXPOSURE TO TRAUMA RELATED TRIGGERS
Pt w fear of heights. Pt instructed to visualize crossing a bridge. What is the therapeutic technique?
IMAGINAL EXPOSURE
Meta-analysis suggests which of the following for psychotherapy to treat depression?
OTHER PSYCHOTHERAPIES HAVE EFFICACY COMPARABLE TO CBT
During an initial office evaluation, the pt tells the psychiatrist, “my spouse told me I had to be evaluated.” Which of the following would be the most empathic response?
“HOW DO YOU FEEL ABOUT THAT?”
The concept of the identified patient in therapy refers to:
ONE FAMILY MEMBER WHO HAS BEEN LABELED THE PROBLEM BY THE FAMILY
Psychosocial therapy that has shown efficacy in some studies in improver cancer survival rates:
GROUP THERAPY WITH OTHER CANCER PATIENTS
Comprehensively researched therapy for mood d/o’s
INTERPERSONAL PSYCHOTHERAPY
Therapeutic focus on the on pt’s current social functioning is most characteristic of:
INTERPERSONAL PSYCHOTHERAPY
26 y/o pt with depressed mood and dissatisfaction with life, feeling isolated and having few friends who is not under undue stress and historically copes well with personal problems would benefit from what type of psychotherapy?
INTERPERSONAL THERAPY
Which psychotherapy would therapist be inclined to gratify pts’ dependency needs?
SUPPORTIVE
Pt enters psychotherapy because of problems in his relationship with his wife. During the sessions, pt talks about his family of origin, his boss, and his problems at work, but never discusses details about his wife. This is an example of which of the following?
RESISTANCE
Principle of confrontation:
“I THINK YOU’D RATHER TALK ABOUT YOUR JOB THAN FACE THE SADNESS YOU FELT IN OUR LAST SESSION”
Example of empathic comment
“YOU MUST FEEL TERRIBLE RIGHT NOW.”
Recovering addict in relapse prevention therapy, and has many risk factors. Rather than developing a coping strategy for each risk factor, do what?
FOCUS ON SKILL TRAINING, COGNITIVE REFRAMING, AND LIFESTYLE INTERVENTIONS
