U-World: Block 9 (Psych)

Question 1

Pattern of arguing and defiance toward authority figures for > 6 months.

Answer 1

Oppositional defiant disorder (ODD)

Question 2

Violating social norms (aggression to people and animals, destruction of property, theft) in a kid < 18 is called what? How about in an adult > 18?

Answer 2

<18 —> Conduct Disorder

>18 —> Antisocial Personality Disorder

Question 3

Sleepwalking can occur during what phase of sleep? What sleep waves are going on at this time?

Answer 3

Stage N3 (non-REM) aka “slow-wave sleep” (this is when you’re in your deepest sleep—sleepwalking, night terrors, and bed wetting can happen at this time in the sleep cycle) 
Delta waves

Question 4

1st line treatment for depression? What should you screen for before prescribing it and why?

Answer 4

SSRI’s!
Screen for manic episodes in their history (suggesting Bipolar, not just depression) because you never want to give an SSRI to a Bipolar patient because they can trigger a manic episode! (SSRI’s bring you from sad to happy but can make them too happy)

Question 5

Diaphoresis means what?

Answer 5

Sweating

Question 6

What are symptoms of “autonomic dysregulation” (such as in serotonin syndrome)?

Answer 6

Sweating (diaphoresis), inc BP (hypertension), inc HR (tachycardia), inc temp/ fever (hyperthermia), vomiting, and diarrhea

Question 7

What is the presentation of serotonin syndrome (3 A’s)?

Answer 7

Activity (hyperreflexia, tremor, seizure)
Autonomic instability (hyperthermia/ fever, diaphoresis/ sweating, diarrhea, etc.)
Altered mental status

Question 8

Lady comes in with an empty bottle of SSRIs prescribed to her for depression. She presents with a fever, high BP, high HR, disoriented, tremor, sweating, abdominal cramps and diarrhea, dilated pupils, and hyperreflexia. What does she have?

Answer 8

Serotonin syndrome

Question 9

What amino acid is the precursor for serotonin synthesis?

Answer 9

Tryptophan

Question 10

Kid has behavioral and coordination issues. Small height, weight, and head circumference. Short palpebral fissures, smooth philtrum, and thin upper lip. Diagnosis?

Answer 10

Fetal alcohol syndrome (was exposed to alcohol from mom in utero)

Question 11

Patient is taking SSRIs for depression. What 3 things could cause serotonin syndrome in this patient?

Answer 11

Too much serotonin—> serotonin syndrome

1. Overdosing on SSRI’s or combining with another Serotonergic medication (like SNRI, tricyclic antidepressant, or tramadol)
2. Taking a MAO Inhibitor (MAO is the enzyme that breaks down Serotonin in the synaptic cleft before it is taken back up by the pre-synaptic neuron, so if you block that process, you increase the serotonin in the cleft)
3. Taking the antibiotic Linezolid (acts LIKE an MAO inhibitor)

Question 12

Anecdote for serotonin syndrome?

Answer 12

Cyproheptadine

A 1st gen anti-histamine with 5-HT1 and 5-HT2 antagonist properties

Question 13

What is a short-term drug class used to treat Panic disorder that also has muscle relaxant and anti-convulsant properties?

Answer 13

Benzodiazepines (Benzo’s- CNS depressants)
*note that SSRIs and SNRIs are 1st line for panic disorder, but they take 1-2 months to work, so Benzos are ideal for short-term therapy

(Sketchy: Ben’s diner)

Question 14

What’s the mechanism of action of Benzodiazepines?

Answer 14

Increased frequency of chloride channel opening

They bind to and enhance the activity of GABA-A receptors (Sketchy Ben’s diner: cab-A and Pam cake delivery will enhance the activity of the cab driver). GABA-A receptors are inhibitory (“take it easy”) and are Chloride channels (“Clo-rider”). SO, Benzo’s lead to increased frequency of chloride channel opening (“now open more frequently”).
*note that GABA is inhibitory and Benzo’s stimulate these neurotransmitters, so Benzo’s are CNS depressants (specifically, the influx of chloride will hyperpolarize and stabilize the membrane, making it less excitable)

Question 15

What class of meds is good for treating alcohol withdrawal syndrome as well as short-term treatment of anxiety disorders?

Answer 15

Benzodiazepines (Ben’s diner in Sketchy)

Question 16

Unresponsive to pain, constricted pupils, cyanosis bc he’s barely breathing. What drug did the patient overdose on?

Answer 16

Opioids (CNS depressant that binds mu receptors)

Question 17

What drug is given to reverse acute opioid toxicity/ overdose?

Answer 17

Naloxone (“no lax zone” in Sketchy Utopia Resort sketch)

*it mainly targets mu receptors (where opioids bind to) and antagonizes them

Question 18

Asking the patient to say their name, location, and date tests for what?

Answer 18

Orientation

Question 19

Asking a patient to follow multistep commands tests for what?

Answer 19

Comprehension

Question 20

Asking a patient to recite months of the year backwards tests for what?

Answer 20

Concentration

This is a longer task that requires one to stay focused as opposed to a brief 3-step instruction, for example

Question 21

Asking a patient to recall 3 unrelated words after 5 min passed tests for what?

Answer 21

Short-term memory

Question 22

Asking a patient to recall details of significant life events tests for what?

Answer 22

Long-term memory

Question 23

Asking a patient to write a complete sentence with noun-verb agreement tests for what?

Answer 23

Language

Question 24

Asking a patient to draw intersecting pentagons tests for what?

Answer 24

Visual-spatial cognition

Question 25

Asking a patient to draw a clock oriented to a specific time tests for what?

Answer 25

Executive function

Question 26

Asking the patient to spell the word “WORLD” backwards, counting down from 100 by 7’s, or reciting months of the year backwards tests for what?

Answer 26

Assesses attention and concentration/ intellect

Question 27

What is the main condition anti-psychotics treat?

Answer 27

Schizophrenia

Question 28

A women with Schizophrenia (taking Risperidone to manage symptoms) comes in to your clinic bc she stopped having periods and her breasts are sore. What is probably causing her symptoms?

Answer 28

Medication side effect.
Risperidone is an anti-psychotic used to treat Schizophrenia. It inhibits D2 dopamine receptors—> increased prolactin (bc dopamine normally inhibits prolactin, but you are putting the brake on dopamine so that it cannot in turn put the brake on prolactin)—> excess prolactin inhibits GnRH—> amenorrhea

Question 29

What is the way to remember key differences in cluster A, B and C personality disorders?

Answer 29

“Weird (cluster A), Wild (cluster B), and Worried (cluster C)”

Question 30

Diagnostic criteria for Major Depressive Disorder (MDD)?

Answer 30

Episodes lasting 2 or more weeks with at least 5 of the 9 “SIG E CAPS” depression symptoms.
(SIG E CAPS= 1. depressed mood, 2. Sleep disturbance, 3. loss of Interest, 4. Guilt of feelings of worthlessness, 5. Energy loss and fatigue, 6. Concentration problems, 7. Appetite and weight changes, 8. Psychomotor retardation or agitation (inc or dec motor activity), 9. Suicidal ideation)

Question 31

What are the 9 symptoms of depression/ Major Depressive Disorder (MDD) remembered by “SIG E CAPS?”
*remember, you need episodes lasting 2 weeks or more with 5 or more of these 9 symptoms.

Answer 31

1. depressed mood
2. Sleep disturbance
3. loss of Interest
4. Guilt of feelings of worthlessness
5. Energy loss and fatigue
6. Concentration problems
7. Appetite and weight changes
8. Psychomotor retardation or agitation (inc or dec motor activity)
9. Suicidal ideation)

Question 32

Patient is depressed. Before making a diagnosis, what do you want to rule out (a medical reason, rather than psychiatric reason, that may be responsible for the depression)?

Answer 32

Hypothyroidism (check those TSH levels)

Question 33

How do we diagnose “adjustment disorder?”

Answer 33

Patient has emotional symptoms (anxiety, depression) after (within 3 mo) something happens that triggers it (a stressor like they got a divorce, got diagnosed with an illness, got a new job). (If symptoms last 6 months or more, however, we call it GAD or generalized anxiety disorder).
Note that it is a diagnosis of exclusion. In other words, if the patient is depressed after getting a new job and meets the criteria for MDD (major depressive disorder), they have MDD NOT adjustment disorder! If they don’t meet the criteria for anything (less severe depression/ anxiety following a life event) we can then call it adjustment disorder.

Question 34

Patient has little energy and feels hopeless for 4 years. Diagnosis?

Answer 34

Persistent depressive disorder (dysthymia)

Remember, it’s called persistent if it goes on for more than 2 years

Question 35

Criteria for diagnosing persistent depressive disorder (dysthymia)?

Answer 35

Milder depression (sometimes only 2 depressed symptoms) lasting MORE THAN 2 YEARS (no more than 2 months w/o depressive symptoms).

Question 36

Girl cuts her celery in the same sized pieces before eating. Eats very little. Brushes her hair 21 times per side and brushes teeth for exactly 11 minutes each morning. Feels like she has to or something will happen to her. Diagnosis?

Answer 36

OCD (obsessive compulsive disorder)

(Note these people do rituals/ routines that are unproductive but they feel like they have to or something bad will happen)

Question 37

What is the best step for preventing suicide completion?

Answer 37

Making sure firearms are not available to the patient (patients are far more likely to COMPLETE suicide if a gun is available in their home vs. having to find one and having time to get in a better mental state/ change their mind about suicide by the time they do)

Question 38

After the STEP 1 exam, you decided to stop thinking about it because “worrying won’t help.” What defense mechanism is this?

Answer 38

Suppression (voluntarily choosing to not think about something bc you can’t handle it)

*note: this is a “mature” defense, meaning it’s a healthy coping mechanism. Contrast this to Repression (involuntarily forgetting a memory bc you can’t handle it), which is NOT a mature defense (not a healthy coping mechanism).

Question 39

What are the mature defense mechanisms? (Note: mature means it is a healthy coping mechanism/ not associated with harm)

Answer 39

“Mature adults wear a SASH”

SUBLIMATION (using negative emotions in a positive way like channeling anger toward step 1 into studying like a pro)
ALTRUISM (caring for others to decrease your own stress/ anxiety like helping a pre-med student with the application process to feel good about yourself during med school stress)
SUPPRESSION (choosing to not think about something like not thinking about step 1 until the test results come back bc it’s out of your control for the time being and you can’t handle the thought)
HUMOR (joking about the boards)

Question 40

Child has parents going through a divorce. Now starts misbehaving at school. Defense mechanism? Mature or immature?

Answer 40

Acting out. Immature.

Question 41

A patient was just diagnosed with cancer. She stops answering phone calls from her doctor and resumes her work schedule despite being warned of her critical need for treatment. Defense mechanism? Mature or immature?

Answer 41

Denial. Immature.

Question 42

Your preceptor yells at you for not asking your patient the right questions. You go home and yell at your mom for not having dinner ready for you. Defense mechanism? Mature or immature?

Answer 42

Displacement (transferring feelings to a less threatening object/ person). Immature.

Question 43

Patient was sexually abused. Now has incomplete memory of the event and seems numb and detached when exposed to her abuser. Defense mechanism? Mature or immature?

Answer 43

Dissociation (temporary, drastic change in personality, memory, consciousness, or motor behavior to avoid emotional stress. No or incomplete memory of traumatic event.) immature.

Question 44

An adult lives with her mom and relies on her to wake her up in the morning.
A surgeon throws a tantrum in the OR when the surgery runs late.
These are examples of what type of defense mechanism? Mature or immature?

Answer 44

Fixation (partially remaining at a more childish level of development). Immature.

Question 45

A patient boasts about his doctor and how he does EVERYTHING amazing, ignores all flaws. Defense mechanism? Mature or immature?

Answer 45

Idealization (expressing extremely positive thoughts about self or others while ignoring negative thoughts). Immature.

Question 46

Dr. Amazing, your attending, wears his stethoscope in his pockets and says “my pleasure” to all his patients. You’re now wearing your stethoscope in your pocket and greeting your patients like him. Defense mechanism? Mature or immature?

Answer 46

Identification (largely unconscious mimicking or behavior/ traits of another person). Immature.

Question 47

You are diagnosed with cancer. Now you are talking about the statistics of diagnosis and the pathophysiology of the disease. Defense mechanism? Mature or immature?

Answer 47

Intellecualization (using facts/ logic/ non-emotional aspects to distance yourself from feelings). Immature.

Question 48

Describing a murder in detail without expressing emotion. Defense mechanism? Mature or immature?

Answer 48

Isolation (or affect) (separating feelings from ideas and events). Immature.

Question 49

You hate your boss so you show up late to work everyday. Defense mechanism? Mature or immature?

Answer 49

Passive aggression (being rude/ expressing hostility in a round-about, not direct, way). Immature.

Question 50

Your annoying co-worker (who you think is egotistical) says let’s start working together on this project at 10am sharp. You say “ok, whatever time is time is works for YOU” (in a rude tone of voice). Defense mechanism? Mature or immature?

Answer 50

Passive aggression (being rude/ expressing hostility in a round-about, not direct, way). Immature. 
*you’re trying to get to her w/o being upfront and honest about how you feel

Question 51

Your roommate always annoys you…never takes out the trash, leaves a mess, steals your stuff. You know the one thing he hates is being distracted while studying so you play his least favorite song loudly while he’s studying. Defense mechanism? Mature or immature?

Answer 51

Passive aggression (being rude/ expressing hostility in a round-about, not direct, way). Immature. 
*you are trying to get back at him w/o being upfront and honest about how you feel (he needs to pick up after himself)

Question 52

A man cheats on his wife. The next day accuses his wife of being unfaithful. Defense mechanism? Mature or immature?

Answer 52

Projection (attributing your own unacceptable feelings to another). Immature.

Question 53

You get fired from your job. They you say “I hated that job anyway and don’t care I was fired.” Defense mechanism? Mature or immature?

Answer 53

Rationalization (justifying behavior to avoid difficult truths or to avoid blaming yourself). Immature.

Question 54

An abusive parent hates their kid but now throws them a birthday party and shows extreme love. Defense mechanism? Mature or immature?

Answer 54

Reaction formation (showing opposite behavior of unwanted/ unacceptable feelings that you have—bc you feel guilty about the true feelings you have). Immature.

Question 55

Potty-trained kid starts peeing their pants again now that baby brother was born. Defense mechanism? Mature or immature?

Answer 55

Regression (turning back the clock to deal with stress in the world). Immature.

Question 56

Believing that all nurses are terrible and all doctors are wonderful. Defense mechanism? Mature or immature?

Answer 56

Splitting (believing people are all good or all bad, no gray area). Immature.

Question 57

A teen is angry at his parents for having such high expectations. He takes his anger out on the court and excels at basketball. Defense mechanism? Mature or immature?

Answer 57

Sublimation (channeling impulses to socially acceptable behaviors). Mature (“mature adults wear a SASH”).

Question 58

A cancer survivor starts an organization to help patients recently diagnosed with cancer. Defense mechanism? Mature or immature?

Answer 58

Altruism (turning negative feelings into generosity/ caring for others to decrease your own stress and anxiety). Mature (“mature adults wear a SASH”).

Question 59

You take the USMLE STEP 1 exam and are now waiting for your scores. Until you find out, you chose to not think about it bc worrying won’t help. Defense mechanism? Mature or immature?

Answer 59

Suppression (choosing to not worry/ think about something). Mature (“mature adults wear a SASH”).

Question 60

You are joking with friends about the boards and laughing about the questions they try to get you on. Defense mechanism? Mature or immature?

Answer 60

Humor. Mature (“mature adults wear a SASH”).

Question 61

You are stressed out about medical school but you take a little time out to volunteer for the MMI day to help those incoming students feel comfortable and answer questions they have about what it’s like to be a medical student. Defense mechanism? Mature or immature?

Answer 61

Altruism (turning negative feelings into generosity/ caring for others to decrease your own stress and anxiety). Mature (“mature adults wear a SASH”).

Question 62

Old person has a UTI. Now presents with mental status changes, is confused and aggressive toward nurses. What’s going on? How do we treat this patient?

Answer 62

Delirium
Treat the underlying cause of the delirium (in this case, the UTI) plus treat with an anti-psychotic (to treat the agitation and make the patient sleepy and calm like sedative) if the patient is at risk for harming their self or others (such as in this case- the patient’s delirium has gotten so bad she is psychotic and aggressive to nurses).

Question 63

What is delirium?

Answer 63

Brain inflammation—> mental status changes (after surgery, infection, while on certain drugs)

Question 64

Old person gets a UTI, now has mental status changes (going in and out of normal thought and confusion/ agitation/ passing out). What is going on?

Answer 64

Delirium

Question 65

Old person comes into your clinic complaining of memory loss. Forgetting to take medication, forgetting names of grandchildren, forgetting to turn off the stove…also says he feels worthless. Diagnosis?

Answer 65

Depression-related cognitive impairment

Always rule out depression in a person presenting with dementia-like symptoms! Treat the depression and the memory impairment should go away.

Question 66

Patient is taking anti-psychotic medication. For step 1, what can you pretty much assume the patient has?

Answer 66

Schizophrenia

Question 67

What medication do we give to patients with treatment-resistant schizophrenia (not responding to anti-psychotic medications) or schizophrenia with suicidal thoughts?

Answer 67

Clozapine

Not first line bc has nasty side effects- agranulocytosis, seizures, myocarditis, and metabolic syndrome

Question 68

What antibiotic can cause Serotonin syndrome if taken concurrently with a Serotonin increasing medication (like an SSRI)?

Answer 68

Linezolid
It acts like a MAO inhibitor (meaning it blocks the MAO enzyme that normally breaks down serotonin before its re-uptake by the pre-synaptic neuron—> no breakdown of serotonin means more serotonin at the synaptic cleft)
If you’re already on an SSRI (blocking serotonin re-uptake—> increasing serotonin at the synaptic cleft), another med that also leads to more serotonin can lead to TOO MUCH serotonin= serotonin syndrome (life-threatening).

Question 69

Guy is depressed and one time while depressed, also heard a voice telling him he doesn’t deserve to live. Diagnosis?

Answer 69

Major depression with psychotic features

The psychosis is occurring during the depression

Question 70

Person is hearing voices, having delusions. What’s this called?

Answer 70

Psychosis

Question 71

What’s psychosis?

Answer 71

Hearing voices, having delusions

Question 72

Do you hear voices in Bipolar disorder?

Answer 72

No. They are “on top of the world” like walking around naked at night, not sleeping for 2 weeks and not tired, spending all their money, calling the president bc they think the president will talk to them bc they’re so important…but not hearing voices/ having psychosis.

Question 73

Highly functioning person but has weird thought like my neighbor is out to steal all my stuff (even though the neighbor is perfectly normal). Diagnosis?

Answer 73

Delusional disorder

Question 74

How do you diagnose MDD (major depressive disorder) with psychotic features?

Answer 74

Patient meets criteria for depression (episodes of depression lasting at least 2 weeks with at least 5 out of the 9 SIG E CAPS depression symptoms) AND has psychosis (delusions and/ or hallucinations) WITH the depression (psychosis is never occurring on its own/ in the absence of depression).

Question 75

Patient was diagnosed with schizophrenia and started on anti-psychotic therapy. Comes back a few weeks later complaining of being anxious and you observe the patient is fighting and unable to stay in the same position. What’s going on?

Answer 75

Akathisa (restlessness and inability to remain in 1 position)= extrapyramidal side effect of anti-psychotic medication.
(Fix this problem by decreasing the dose of her medication, or supplement with a beta-blocker.)

Question 76

What is Akathisia?

Answer 76

Restlessness, inability to stay in 1 position

An extrapyramidal side effect of anti-psychotic medications (if dose is too high for the patient)

Question 77

Best drugs to treat alcohol withdrawal? Give drug class and 2 specific drug names.

Answer 77

Benzodiazepines
1. Diazepam
2. Chlordizepoxide
(The long-acting benzo’s that allow for smooth withdrawal/ taping off the drug)

Question 78

Chlordiazepoxide. What class of drugs does it belong to? Use to treat what?

Answer 78

Benzo’s (note: most benzodiazepines end in “-Pam” but this is an exception)
This is a long-acting Benzo used to treat alcoholic withdrawal (allows for smooth tapering off drug)

Question 79

Why are benzo’s useful in treating alcohol withdrawal (explain the mechanism)?

Answer 79

Both benzodiazepines and alcohol bind to GABA-A receptors (they enhance GABA inhibitory/ CNS depressant effects, but bind to different sites on the GABA-A receptors). So, if an alcoholic quits alcohol and gets put on a Benzo, the Benzo will take the place of the alcohol in binding to the GABA receptor to avoid withdrawal symptoms and the patient will slowly get tapered off the drug.

Question 80

Patient had a good friend die of pancreatic cancer. Now is worried she may have it, even though she has zero symptoms and all tests are normal. Psych diagnosis?

Answer 80

Illness anxiety disorder (aka hypochondriasis)

Question 81

What’s somatic symptom disorder?

Answer 81

They have a symptom (ex: minor abdominal pain) and they are convinced it’s something crazy that it is not (ex: pancreatic cancer).

Question 82

Illness anxiety disorder VS. somatic symptom disorder?

Answer 82

Illness anxiety disorder (aka hypochondriasis)—> no symptoms, yet convinced they have something (ex: perfectly healthy but sure they have pancreatic cancer)
Somatic symptom disorder—> have a symptom, but convince they have something it’s not (ex: minor abdominal pain but sure it is pancreatic cancer)

Question 83

What is facctitious disorder imposed on self aka Munchausen syndrome?

Answer 83

Patient fakes illness because they like playing the “sick role” and getting medical attention

Question 84

Menchausen syndrome (Factitious disorder imposed on self) vs. Menchausen syndrome by proxy (Factitious disorder imposed on others)?

Answer 84

Menchausen—> pretend to be sick (or make self sick) a lot bc like playing “sick role” and getting medical attention
Menchausen by proxy—> pretends their kid or elder is sick (or makes them sick) to get medical attention

Question 85

Mechanism of SSRIs?

Answer 85

(SSRI= selective serotonin reuptake inhibitor)
Block the serotonin transporters (on the pre-synaptic cleft to prevent re-uptake and thus increase serotonin in the synaptic cleft)

(*note: SSRIs do NOT block serotonin receptors on the post-synaptic side)

Question 86

What are Schizoid people like?

Answer 86

They like to be alone, more comfortable that way (a cluster A “weird” personality disorder)
“SchizOID like to avOID people”

Question 87

Schizoid vs. Schizotypal? What personality cluster do both these fall under and what’s the difference between them?

Answer 87

Cluster A personality disorder (“weird”)
Schizoid—> They like to be alone, more comfortable that way (“SchizOID like to avOID people”)
Schizotypal—> They have odd beliefs/ magical thinking/ superstitious

Question 88

Antisocial, borderline, histrionic, and narcissistic all belong to what cluster of personality disorders? State the definitions/ differences between these 4.

Answer 88

Cluster B (“wild”)

Antisocial- disregard the rights of others, criminal, often end up in jail (“conduct disorder” if <18 years old) (“Bad”)

Borderline- unstable mood and relationships, splitting (see things/ people as all good or all evil), fear of abandonment, can be suicidal, self-mutilation, emotional emptiness (“Borderline”)

Histrionic- attention-seeking, dramatic, sexually provocative (“flamBoyant”)

Narcissistic- sense of entitlement, lacks empathy, thinks they’re the best, doesn’t respond well to criticism (“Best”)

Question 89

Avoidant, obsessive-compulsive, and dependent belong to what cluster of personality disorders? Explain what they mean.

Answer 89

Cluster C (“Worried”)

Avoidant- afraid of rejection, avoid people bc worried people won’t like them, hypersensitive to rejection and criticism (“lonely and longing”- they want relationships but too afraid they are inadequate)

Obsessive-compulsive personality disorder- loves to-do lists, always needs a plan, perfectionist, OCD-type of behaviors however, they are productive/ all helping to achieve a goal

Dependent- excessive need for support, low self-confidence, often stuck in abusive relationships

Question 90

Woman believes to have magical powers. Her jewelry predicts the future. She has few friends. Diagnosis?

Answer 90

Schizotypal personality disorder (cluster A- “weird”)

*note: don’t confuse with another disorder based on her having no friends—her weird behaviors are leading to her having no friends

Question 91

Lady dreams about getting married but is single. Eats lunch alone everyday bc she fears her co-workers will not like her personality and sense of humor. Avoids people. Personality disorder?

Answer 91

Avoidant personality disorder (cluster C- “worried”)

“Lonely and longing”-wants relationships but think they are inadequate/ people won’t like them

Question 92

Jen is ready to die and to have a chance at saving her, you’d need to intubate. The advanced directive states Jen does not want intubation, however the family insists that she wrote this a long time ago and her grandchild was just born that she’d want to meet…they are sure her wishes as of today would be to permit life-saving procedures. What do you do?

Answer 92

Do not intubate. You must always follow the advanced directive (if there is one).

Question 93

A patient was feeling down, no interest in activities she usually enjoyed, lack of appetite, etc. She was started on treatment. A few weeks later, she is brought in by a loved one to be seen bc she went 3 days without sleeping and does not feel tired and spent a huge sum of money to purchase plane tickets so she could travel the world to promote world peace. What happened?

Answer 93

She initially presented with depression symptoms only and was given an SSRI. But she really had Bipolar (make sure to screen for this in depressed patients before starting them on an SSRI by asking if they’ve ever had a time in their life where they feel on top of the world/ go days without sleeping/ do irrational things). So the SSRI triggered a manic episode! (SSRIs are contraindicated in bipolar patients for this reasons…think of it as they make sad people happy and too much happy for a bipolar patient—> mania. They need mood stabilizers instead.)

Question 94

Fluoxetine, Paroxetine, Sertraline, and Citalopram all belong to what class of drugs?

Answer 94

SSRIs (selective-serotonin re-uptake inhibitors)

Fluoxetine (Sketchy: “fly out” banner)
Paroxetine (“parrot air”)
Sertraline (“desert airline”)
Citalopram (“city”)

Question 95

What type of drug is Fluoxetine?

Answer 95

SSRI (selective-serotonin re-uptake inhibitors)

Fluoxetine (Sketchy: “fly out” banner)
Paroxetine (“parrot air”)
Sertraline (“desert airline”)
Citalopram (“city”)

Question 96

What type of drug is Paroxetine?

Answer 96

SSRI (selective-serotonin re-uptake inhibitors)

Fluoxetine (Sketchy: “fly out” banner)
Paroxetine (“parrot air”)
Sertraline (“desert airline”)
Citalopram (“city”)

Question 97

What type of drug is Sertraline?

Answer 97

SSRI (selective-serotonin re-uptake inhibitors)

Fluoxetine (Sketchy: “fly out” banner)
Paroxetine (“parrot air”)
Sertraline (“desert airline”)
Citalopram (“city”)

Question 98

What type of drug is Citalopram?

Answer 98

SSRI (selective-serotonin re-uptake inhibitors)

Fluoxetine (Sketchy: “fly out” banner)
Paroxetine (“parrot air”)
Sertraline (“desert airline”)
Citalopram (“city”)

Question 99

Earliest age we can diagnose ADHD?

Answer 99

4 or 5 years (cannot diagnose before that bc normal toddler behavior is “ADHD” like)

Question 100

3 year old boy is unable to dress himself or wipe himself. He is disruptive in his preschool class and constantly gets out of his chair to move around. What’s going on?

Answer 100

Nothing- this is normal development. Children are not expected to be fully potty trained and capable of dressing themselves until age 5. Also, ADHD is not even considered as a diagnosis until age 4-5 because normal toddler behavior is low attention span.

Question 101

Girl seemed to develop normally as a baby. Now she’s a little over 1 year old and wringing her hands (twists them together until they are red, dry, and painful). She is unable to sit up without support/ being held up. Her head circumference has decreased. Diagnosis?

Answer 101

Rett syndrome
-neurodevelopmental disorder in girls, presents similarly to Autism (due to MECP2 mutation on the X chromosome)
Deceleration of head growth (brain not growing normally), repetitive hand movements, they start out having normal development and regress)

Question 102

College student is excessively tired. Is falling asleep randomly throughout the day, despite 10 hours of sleep at nighttime. Has episodes of muscle paralysis for some time after waking up. Diagnosis? What substance would be elevated in his CSF?

Answer 102

Narcolepsy (disorder of sleep-wake cycles)

hypocretin-1 (aka Orexin) in CSF

Question 103

Narcolepsy (disorder of sleep cycles characterized by excessive daytime sleepiness) can be associated with Hypnagogic or Hypnopompic hallucinations. What’s the difference?

Answer 103

HypnaGOgic—> hallucinations just before GOing to sleep

HypnoPOMPic—> hallucinations just before awakening (get POMPed up in the morning)

Question 104

Most common side effect of SSRIs?

Answer 104

Sexual dysfunction (occurs in 50% of patients on SSRIs)

*other side effects (less common): weight gain, drowsiness, seizures, SIADH/ hyponatremia

Question 105

Girl is obsessed over her thighs. She is thin, but concerned her thighs are fat. Does lots of leg workouts and wears baggy pants to cover them up. Spends hours every single day researching how to have hot thighs. Diagnosis?

Answer 105

Body dysmorphic disorder (a subtype of OCD where you’re obsessed over your appearance and engage in repetitive things like hours of research on thighs in order to reduce anxiety)

Question 106

Guy is worried about flunking out of med school. Worried about never graduating. Worried about what his friends think of him. Worried about his social life. Worried about his health. So worried it is interfering with his ability to concentrate on his studies. Diagnosis?

Answer 106

GAD (generalized anxiety disorder)

Question 107

Diagnostic criteria for GAD (generalized anxiety disorder)?

Answer 107

Excessive anxiety and worry about different aspects of life (work, school, children) for most days of 6 months or more.
Need 3 or more of the following 6 symptoms for adults, 1 or more for kids: (1) restlessness, (2) irritability, (3) sleep disturbance, (4) fatigue, (5) muscle tension, (6) difficulty concentrating.

Question 108

1st line treatment for OCD?

Answer 108

SSRIs (Remember the obsessively neat dude in Sketchy: the office “serotonin sitcom” scene)

Question 109

13 year old boy is a good student but has behavioral problems at school. He is uncomfortable with new social situations, socially awkward. Insists on sitting in the same seat everyday and yells at the teacher if she tells him to switch seats. Is very interested in the solar system and has trouble conversing about anything but this. Diagnosis?

Answer 109

Autism (ASD)
-poor social interactions, communication problems, repetitive behaviors (need sameness), may have intellectual disability and unusual gifts/ abilities (savants), more common in boys and usually presents early childhood

Question 110

A teen girl binge eats and forces herself to vomit. Her BMI is 17.5. Diagnosis?

Answer 110

Anorexia nervosa (binge eating/ purging type)

*remember, the diagnosis of anorexia vs. bulimia is based on BMI. If < 18.5–> anorexia, NOT bulimia

Question 111

A patient has generalized anxiety disorder (GAD), but wants a drug that gets out of her system quickly so she’s clear-headed for work the next day. What should you prescribe?

Answer 111

Benzodiazepine (1st line= SSRIs, but Benzos are good for short-term anxiety treatment and kick in/ get out of the system faster)

Question 112

Diagnostic criteria for manic episode?

Answer 112

3 or more of the “DIG FAST” symptoms:
Distractibility
Impulsivity (do crazy things like spend all their money w/o thinking of the consequences)
Grandiosity (inflated self-esteem, think they can do anything)
Flight of ideas (racing thoughts)
Activity (doing a bunch of stuff that’s not productive but they think they’re working toward a goal)/ agitation
Sleep- they don’t need it
Talkativeness or slurred speech

Question 113

When do nightmares occur? Sleep terror episodes?

Answer 113

Nightmares—> REM sleep (“REMembering a bad dream”)

Night terrors (screaming episodes in the night that you DON’T remember)—> N3 (deepest sleep, slow-wave) (“wee and flee in N3”)

Question 114

Bed wetting, sleep terrors, and sleepwalking all occur in what phase of the sleep cycle?

Answer 114

N3 (deepest sleep)

“Wee and flee in N3”

Question 115

Muscle paralysis, inc brain oxygen use, variable pulse, inc ACh, dreaming, nightmares, penile/ clitorus tumescence (erection) and memory processing all happen during what phase of the sleep cycle?

Answer 115

REM sleep

Question 116

What sleep cycle phase do we spend the most time in?

Answer 116

N2 (almost half your sleep is in this phase)

Question 117

What are all the sleep cycle phase names and their EEG waveform appearances?

Answer 117

1. Awake (eyes open)- beta waves
2. Awake (eyes closed)- alpha waves
   NON-REM
3. N1- theta waves
4. N2- sleep spindles and K complexes
5. N3 (deepest sleep, slow-wave)- delta waves
6. REM SLEEP- beta waves
   *remember “at night BATS Drink Blood”—B (beta), A (alpha), T (theta), S (sleep spindles and K complexes), D (delta), B (beta)

Question 118

Generalized anxiety disorder vs. panic disorder?

Answer 118

Generalized anxiety disorder (GAD)- excessive worry for at least 6 mo about multiple issues
Panic disorder- multiple panic attacks with physical symptoms, anxious thought is more specific, sometimes no obvious trigger

Question 119

Conduct disorder vs. oppositional defiance disorder?

Answer 119

Oppositional defiance disorder- kids not respecting authority
Conduct disorder- kids showing aggression toward people/ animals, committing crime like theft, destruction of property (more severe violations of the basic rights of others)

Question 120

Woman starts hearing noises in house, is anxious, and avoids social interaction for 2 months after her divorce. Diagnosis?

Answer 120

Adjustment disorder (anxiety/ depression within 3 mo of a stressor and does not meet the criteria for another disorder like MDD or GAD)

Question 121

What is acute stress disorder?

Answer 121

Like PTSD, but only lasting between 3 days- 1 month (flashbacks following a traumatic life event)

Question 122

A guy with treatment-resistant depression presents with a BP of 200/100, tachycardia, tremor, and sweats. He recently ate meat, cheese, and drank some beer with his friends. What med was he likely on and what is going on?

Answer 122

MAO inhibitor
Tyramine consumption—> hypertensive crisis

Remember that MAO inhibitors block the breakdown of monoamines (serotonin, NE, dopamine) by MAO (the point is to increase serotonin at the synaptic cleft—> make the depressed person happy). BUT, they also block the breakdown of Tyramine (in meats, cheeses, and beer), so consumption of Tyamine on a MAO inhibitor—> build up of Tyramine, which enters systemic circulation—> HTN crisis (note this is why MAO inhibitors are rarely used for depression treatment— serotonin syndrome and Tyramine HTN crisis are bad side effects, so use only in treatment-resistant depression.)

Question 123

Amitriptyline belongs to what class of meds?

Answer 123

Tricyclic antidepressants

Sketchy: tripping

Question 124

Nortriptyline belongs to what class of meds?

Answer 124

Tricyclic antidepressants

Sketchy: tripping

Question 125

Imipramine belongs to what class of meds?

Answer 125

Tricyclic antidepressants 
(Sketchy: imprint on face)

Question 126

Imipramine, Amitriptyline, and Nortriptyline belong to what class of meds?

Answer 126

Tricyclic Antidepressants
(Sketchy: “I want to ride my tricycle” recess scene. Imipramine= imprint on face. Amitriptyline and Nortriptyline= tripping.)

Question 127

Anti-muscurinic symptoms include dry mouth, constipation, blurred vision, urinary retention, confusion, inc HR, dilated pupils, dec sweat, inc temp. Explain how I can think about these symptoms.

Answer 127

Anti-muscurinic means the muscurinic (parasympathetic) receptors are blocked. So, you’d expect to see sympathetic (fight or flight) symptoms.
Dry mouth—> you aren’t producing saliva when running from a bear (you produce it when resting and DIGESTING)
Constipation—> no time to poop when running from a bear
Urinary retention—> no time to pee when running from a bear
Confusion—> ?
Inc HR—> heart beats faster when running from a bear
Dilated pupils—> gotta let in more light to see better when running from a bear
Dec sweat—> this is opposite of what you’d expect…bc sweat glands have muscurinic receptors, even though sweat is a sympathetic function
Inc temp—> body heats up from the energy/ ATP spike while running from a bear

Question 128

What type of drug is Buspirone? How long to take effect? Any big side effects?

Answer 128

Non-benzodiazepine anxiolytic (but not in Sketchy)
Used to treat GAD (Generalized Anxiety Disorder)
Takes 1-2 weeks to work
No major side effects—does NOT cause sedation, addiction, or tolerance and does not interact with alcohol.

Question 129

4 mood stabilizers we can give to Bipolar patients?

Answer 129

1. Lithium (stabilizing chair LIFT)
2. Valproate (winter festiVAL)
3. Carbamazepine (classic CAR carving)
4. Lamotrigine (Llama)
   (Remember the Lithium “Ski Mania” sketch in Sketchy)

Question 130

Is it ok to give Sertraline, Paroxetine, Fluoxetine, or Citalopram to a Bipolar patient?

Answer 130

NO! These are all SSRIs, which can trigger a manic episode in a bipolar individual (think of it as: SSRIs take the sad patient and make them happy. They are capable of taking the bipolar patient and making them too happy= mania)

Question 131

What general class of drugs do you typically use to treat a Schizophrenia?

Answer 131

Anti-psychotics

Question 132

What general class of drugs do you typically use to treat a Bipolar patient?

Answer 132

Mood stabilizers

Question 133

Diagnostic criteria for Schizophrenia?

Answer 133

At least 2 of the following symptoms (with at least 1 being from symptom #1-3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Disorganized behavior
5. Negative symptoms (flat affect, apathy, anhedonia/ can’t feel pleasure, alogia/ poverty of speech, social withdrawal)
Has to have been going on for at least 6 months with at least 1 month of continuous symptoms

Question 134

Most common type of hallucination in schizophrenic patients?

Answer 134

Auditory hallucinations (hear voices)
(Olfactory and tactile hallucinations, where patients smell or feel things, are seen more in substance abuse and other neurological problems)

Question 135

What are positive and negative and cognitive symptoms of Schizophrenia?

Answer 135

POSITIVE- hallucinations, delusions, unusual thought processes, disorganized speech, bizarre behavior
NEGATIVE- flat or blunted affect, apathy, anhedonia (can’t feel pleasure), alogia (poverty of speech), social withdrawal
COGNITIVE- reduced ability to understand or make plans, dec working memory, inattention

Question 136

How should somatic symptom disorder be managed?

Answer 136

Have regularly scheduled doctor visits with the SAME doctor (avoid referrals and unnecessary testing)

*remember somatic symptom disorder is when a patient has a symptom and is convinced it’s something that it’s not (ex: tummy ache and believes he/ she must have pancreatic cancer, despite normal test results)

Question 137

What are the earliest symptoms of alcohol withdrawal (8-12 hrs hours since last drink)?

Answer 137

Insomnia, tremor (“the shakes”), anxiety, autonomic hyperactivity like inc BP and HR

Question 138

What are the symptoms of alcohol withdrawal: (1) 8-12 hrs hours since last drink, (2) 12-48 hrs since last drink, and (3) 48-96 hrs since last drink?

Answer 138

8-12 hrs—> Insomnia, tremor (“the shakes”), anxiety, autonomic hyperactivity like inc BP and HR
12-48 hrs—> seizures
48-96 hrs—> delirium tremors (DT) (fever, disorientation, severe agitation)

Question 139

When do children usually understand that death is permanent?

Answer 139

Age 7
(Before this, kiddos may think the dead person will magically come back to life and they may also think the grief of others is their fault. This is NOT a “complicated grief reaction”, but is “age-appropriate behavior.”)

Question 140

What is depersonalization/ derealization disorder?

Answer 140

Feelings of detachments…feeling like you’re watching yourself/ outside of your own body

Question 141

What is dissociative amnesia?

Answer 141

Inability to recall important personal information following trauma/ stress (but usually reversible).

Question 142

What is dissociative identity disorder? What is it also known as?

Answer 142

When a person takes on 2 or more distinct identities/ personality states
(Associated with sexual abuse, PTSD, depression, substance abuse, borderline personality, and somatoform conditions)
aka MULTIPLE PERSONALITY DISORDER

Question 143

Depression + days of feeling overly optimistic, juggling multiple jobs, feeling great despite only 3 or so hours of sleep. Diagnosis?

Answer 143

Bipolar II
Note: these are hypOmanic episodes, not full-on manic episodes, so bipolar II not I. Mania (bipolar I) would involve more severe symptoms…the person would not be able to work jobs but would engage in meaningless “work” running around naked thinking they’re king of the world type of behavior.

Question 144

Feeling anxious lately, sweaty, palpitations, losing weight w/o trying. Diagnosis?

Answer 144

Hyperthyroidism (this is seeming to involve more systemic symptoms, not just generalized anxiety disorder where you lose weight w/o trying…if you lost weight from anxiety it’d be due to a change in appetite from stress, not you kept up with your normal eating routine and just noticed you’re shedding pounds).

Question 145

Selegiline, Tranylcypromine, Phenelzine, and Isocarboxazid belong to what class of drugs?

Answer 145

MAO inhibitors 
(Sketchy: Selegiline= sledge hammer,
Tranylcypromine= “try a sip of wine,”
Phenelzine= funnel, 
Isocarboxazid= boxed wine)

Question 146

What class of drugs does it belong to? Selegiline.

Answer 146

MAO inhibitor (sledge hammer in Sketchy)

Question 147

What class of drugs does it belong to? Tranylcypromine.

Answer 147

MAO inhibitor (“Try a sip of wine” in Sketchy)

Question 148

What class of drugs does it belong to? Phenelzine.

Answer 148

MAO inhibitor (funnel in Sketchy)

Question 149

What class of drugs does it belong to? Isocarboxazid.

Answer 149

Isocarboxazid (boxed wine in Sketchy)

Question 150

Which MAO inhibitor is a selective MAO-B inhibitor?

Answer 150

Selegiline (sledge hammer in Sketchy)

Question 151

What does lacrimation mean?

Answer 151

Tears

Question 152

These drugs are antidotes for what medication overdose? Physostigmine. Flumazenil. Naloxone. Cyproheptadine.

Answer 152

Physostigmine—> antidote for anticholinergic agent overdose
Flumazenil—> antidote for benzo overdose
Naloxone—> antidote for opioids overdose
Cyproheptadine—> antidote for serotonin syndrome/ overdose on serotonergic agents (SSRIs, SNRIs, TCAs, MAOIs)

Question 153

Anecdote for benzodiazepine overdose?

Answer 153

Flumazenil (fluffy dog wearing a muzzle in Sketchy. It is a competitive antagonist at benzo receptor site)

Question 154

What is the safest drug to give an elderly patient needing pharmacological treatment for insomnia?

Answer 154

Ramelton (Sketchy: “Melt Away” sign for Melatonin and Ramelton= melatonin receptor agonist)

Question 155

Are benzos safe to give to elderly patients?

Answer 155

No, not the best idea. They are more prone to symptoms such as confusion, falls, delirium, disorientation…

Question 156

Difference between classical and operant conditioning?

Answer 156

Classical conditioning- learning by associating a stimulus with something (ex: Palvot’s dogs became conditioned to think the bell meant food).
Operant conditioning- learning by punishment/ rewards.

Question 157

What’s the pharmacological treatment for narcolepsy (if good sleep hygiene doesn’t do the trick)?

Answer 157

Daytime stimulants: amphetamines or Modafinil

And/or nighttime sodium oxybate (GHB)

Question 158

Narcolepsy is due to decreased levels of ??? Production in the lateral hypothalamus—> dysregulated sleep-wake cycles.

Answer 158

Orexon (aka hypocretin)

Question 159

How do the following drugs help with alcohol quitting? Benzodiazepines, Naltrexone, Acamprostate, and Disulfiram.

Answer 159

Benzos—> provide CNS depression in place of alcohol (bind a different site on GABA-A receptors) and allow for tapering off the drug
Naltrexone—> Block mu-opioid receptors to reduce cravings
Acamprostate—> modulates glutamate neurotransmission at the NMDA (glutamate) receptors
Disulfiram—> blocks aldehyde dehydrogenase enzyme—> build up of acetylaldehyde—> you feel sick and lousy if you drink alcohol while on this drug

Question 160

A nurse presents with lesions on her arms and it’s found to have fecal material. She has been in and out of the hospital a lot. Psych diagnosis?

Answer 160

Factitious disorder imposed on self (aka Munchasusen syndrome)

She is injecting herself with fecal material (E.Coli is not usually found in the arms) + she is a healthcare worker (more likely to get this bc of access to things like…fecal material). She is making herself sick because she likes the medical attention.

Question 161

What are the main receptors that 1st gen anti-psychotics block? 2nd gen (there are 2 big ones for 2nd gen)?

Answer 161

1st gen anti-psychotics—> block D2 dopamine receptors

2nd gen anti-psychotics—> block D2 dopamine receptors (to a lesser degree) and serotonin (5-HT 2A) receptors
*the fact that they block D2 to a lesser degree makes them less likely to cause extrapyramidal side effects

Question 162

25 year old healthy female has chest pain, SOB, palpitations, sweating, feels like she’s going to die. EKG and vitals are normal. Diagnosis?

Answer 162

Panic attack

Question 163

How do we treat panic attacks? (Name the 2 first line drugs and the drug of choice in an acute setting like the patient is in the ER for a panic attack and needs treatment).

Answer 163

1st line—> SSRIs and Venlafaxine (another antidepressant) (along with cognitive behavioral therapy)
Acute setting—> benzos (why? Bc SSRIs will take a few weeks to kick in and you need to do something right now for your patient that feels like he/ she is having a heart attack it’s so bad)

Question 164

A guy is acting crazy, having delusions. Also has a high HR and BP and dilated pupils. What’s probably going on?

Answer 164

Cocaine toxicity (delusions + sympathetic signs) 
*you wouldn’t get dilated pupils in a primary psych disorder

Question 165

Old man becomes agitated and violent while on dialysis. He has a fever. He has had mild memory loss and history of vascular issues. Diagnosis?

Answer 165

Delirium (waxing and waiting level of consciousness that is acute, reversible).
*not vascular dementia bc onset of this man’s agitation is abrupt and there’s fever (possibly infection), some underlying pathology going on.

Question 166

Schizophrenia is diagnosed by having at least 2 of the following symptoms, at least 1 being from the top three for 6 months (and at least one month of continuous symptoms). (1) delusions, (2) hallucinations, (3) disorganized speech, (4) disorganized behavior, (5) negative symptoms (flat affect, apathy, poverty of speech, social withdrawal).
What is brief psychotic disorder?
What is Schizophreniform disorder?

Answer 166

Brief psychotic disorder—> 1 positive symptom lasting < 1 mo. (Usually stress-related like you just had a death in the family you’re not coping well with)

Schizophreniform disorder—> 2 symptoms lasting 1-6 mo. (Milder Schizophrenia that hasn’t lasted 6 months).

Question 167

A guy comes into the ER after saying there are people chasing after him, he’s hearing voices of people threatening to kill him. 2 weeks ago he was fired from his job and his sister died. Diagnosis?

Answer 167

Brief psychotic disorder (1 schizophrenia symptom lasting < 1 mo after stress)

Question 168

What are the 5 stages of change (important to assess in motivational interviewing)?

Answer 168

1. Pre-contemplation (not thinking about a behavior modification= denial that you have a problem)
2. Contemplation (thinking about a behavior modification= accepting you have a problem)
3. Preparation (preparing for a behavior modification= planning to make a change)
4. Action (putting the plan into action)
5. Maintenance (keeping up with the behavioral modification)

Question 169

An alcoholic acknowledges they drink too much and need to change and started looking into ways to make a change. What stage of change are they in?

Answer 169

Preparation stage (preparing for a behavior modification= planning to make a change)

Question 170

A guy was beat in the head. Now he is rude and irritable to others. What part of the brain has been affected?

Answer 170

Orbitofrontal cortex (involved with behavioral and emotional regulation)

Question 171

The orbitofrontal cortex of the brain is involved with what?

Answer 171

Behavioral and emotional regulation

Question 172

What meds do we use to treat PTSD? What’s the one specifically to help prevent nightmares?

Answer 172

SSRIs
Prazosin for nightmares
(Also cognitive behavioral therapy is first line!)

Question 173

A teenager has euphoria (gets high), lethargy, ataxia, and loss of consciousness. He is taken to the hospital, but within 45 minutes he feels completely normal and vital signs are normal. A rash is noted around his mouth and nostrils. What’s he doing?

Answer 173

Inhalant use disorder
He’s sniffing up inhalants like white out or paint to get high. The rash is known as “glue sniffer’s rash.” Causes these problems, but has prompt recovery (within 45 min).

Question 174

A guy drops out of college and has behavioral changes. This has been going on for 7 months now. He stopped showering and socializing with others. He has no motivation to get a job. He is paranoid that there are evil people coming after him and locks himself inside to do research. Diagnosis?

Answer 174

Schizophrenia
He has paranoid delusions and negative symptoms (lack of hygiene, social withdrawal, lack of motivation). That’s at least 2 of the symptoms on the diagnostic list lasting > 6 mo.

Question 175

Schizophrenia drugs are what class? Main receptors they block?

Answer 175

Anti-psychotics (1st or 2nd generation). Block dopamine D2 receptors (2nd gen also block serotonin receptors, but D2 dopamine are the primary receptors blocked that all anti-psychotics have in common).

Question 176

Duration of acute stress disorder?

Answer 176

Lasts between 3 days- 1 month. If goes on longer than 1 month, it’s termed PTSD.

Question 177

Patient has PTSD symptoms, but it’s only been going on for < 1 month. Diagnosis?

Answer 177

Acute stress disorder

After 1 mo we call it PTSD

Question 178

What are “serum transaminases?”

Answer 178

ALT and AST (liver enzymes)

Question 179

A boy comes into the office because he’s been paranoid lately, had personality changes, and is not doing as well in school. He also has a tremor and elevated serum transaminases (ALT/ AST). Diagnosis?

Answer 179

Wilson disease
(Autosomal recessive mutation in copper-transporting enzyme—> copper accumulation and deposition. This condition commonly presents in childhood. They can get copper deposits in the liver—> high liver enzymes, brain—> psych symptoms, and cornea—> Kaiser-Fleischer rings.)
*These kids may get misdiagnosed with a primary psych disorder but the other pathologic findings can give it away

Question 180

A guy in his 20’s no longer maintains hygiene or socialized with friends. He also thinks his food is poisoned. This has been going on for 2 months. Diagnosis?

Answer 180

Schizophreniform disorder (2 symptoms of Schizophrenia lasting 1-6 months, so less severe than Schizophrenia which involves >2 of the symptoms to make a diagnosis + going on > 6 mo.) 
This guy in particular is showing delusions and negative symptoms (lack of hygiene and social withdrawal)

Question 181

A guy has episodes of explosive verbal and physical aggression. For example, you warn him to show up earlier for work and he starts yelling and can’t stop yelling and hits you. Diagnosis?

Answer 181

Intermittent explosive disorder

Question 182

A lady thinks you are the best person in the entire world one day and the world person who ever lived the next. Defense mechanism?

Answer 182

Splitting (categorizing into extreme positives and extreme negatives, characteristic of borderline personality disorder because these ppl have unstable relationships)

Question 183

A girl is obsessed over her body weight, thinks she’s fat, but BMI is normal and healthy. What diagnosis do you have to be suspicious of?

Answer 183

Bulimia nervosa (forcing herself to vomit at least weekly over the past 3 months)
(Note that if she had this description and were forcing herself to vomit but BMI were LOW, it would be called anorexia nervosa binge-eating/ purging type)

Question 184

What signs can you see in a Bulemic patient?

• related to the parotid gland
• related to the teeth
• related to electrolytes
• pH
• on the hands
• HR
• BP

Answer 184

• parotid gland hypertrophy (these glands enlarge from repeated vomiting)
• enamel erosion (from repeated vomiting staining the teeth)
• electrolyte disturbance (vomit—> loss of H+, Cl-, and K+) (hypokalemia/ low K+, hypochloremia/ low Cl-)
• metabolic alkalosis (loss of H+ so losing acid—> blood is basic)
• dorsal hand calluses from induced vomiting (Russell sign)
• tachycardia (inc HR)
• hypotension (dec BP)

Question 185

Lanugo hair growth (really soft hair) occurs in what eating disorder?

Answer 185

Anorexia nervosa

Question 186

How do the first line meds for ADHD work? Say the mechanism and what part of the brain they act on.

Answer 186

Stimulants (like methylphenidate and amphetamines)
Work by blocking NE and dopamine retuptake at synapses in the prefrontal cortex—> more NE and dopamine

(By providing more NE and dopamine you are stimulating the prefrontal cortex to do its job)

Question 187

How long do you have to be on SSRIs and still get depression symptoms before you can say the drugs don’t work for you?

Answer 187

Adequate clinical trial= 4-6 weeks

They take this long to achieve maximal clinical effect

Question 188

Girl has stomachaches and anxiety over going to school. She hyperventilates, worries about attending social events, is shy, and worried of “looking stupid” around others. Her symptoms got worse ever since her friend moved away a month ago. Diagnosis?

Answer 188

Social anxiety disorder

(Don’t get tricked and think adjustment disorder with anxiety just bc this girl’s symptoms worsen when her friend leaves! The onset of her symptoms was before this—she did not start having anxiety after the friend left—and it’s normal for an anxiety disorder to get worse when a tough thing happens in life like your friend moves away)

Question 189

What is agoraphobia?

Answer 189

Fear of going out into public places

Question 190

What is priapism?

Answer 190

Persistent erection of the penis for > 4 hrs not associated with sexual excitement (medical emergency bc if not treated it can result in permanent damage to the penile tissue and erectile dysfunction)

Question 191

What is a antidepressant that is commonly used to treat insomnia and has a serious, rare side effect of priapism (erection > 4hrs)?

Answer 191

Trazodone

Question 192

What prevents neural tube defects in babies?

Answer 192

Folate vitamin supplementation

Question 193

What are the 2 major uses of valproate?

Answer 193

Bipolar disorder and epilepsy

Question 194

Valproate use in pregnant mom (for bipolar or epilepsy) can cause what in baby?

Answer 194

Neural tube defects

Question 195

What drugs are known to cause neural tube defects in babies when mom takes them during pregnancy?

Answer 195

Antiepileptic Drugs *some also used in bipolar (like valproate, carbamazepine, phenytoin, phenobarbital) and folate antagonists (methotrexate, TMP-SMX)

Question 196

Side effects of stimulants used for ADHD?

Answer 196

Decreased appetite—> weight loss and insomnia

“People with ADHD don’t eat and don’t sleep”

Question 197

What ion enters pre-synaptic neurons and stimulates presynaptic vesicles to fuse with the plasma membrane (dock by SNARE proteins) to release their NT?

Answer 197

Calcium

Question 198

A patient is acting crazy, stayed up all night studying for exams, didn’t sleep. Has high BP, high HR, sweating, dilated pupils. Diagnosis?

Answer 198

Substance-induced psychotic disorder
Patient is abusing stimulants, like cocaine. This is not a manic episode bc you wouldn’t get other sympathetic symptoms like high HR, BP, and dilated pupils in mania.

Question 199

A man is psychotic. He is given meds. 3 weeks later he comes into clinic complaining of muscle stiffness and shaking of his hand. What is going on?

Answer 199

Drug-induced Parkinsonism (this is a extrapyramidal side effect of drugs that block D2 dopamine receptors= anti-psychotics)

*treat with Benztropine or Amantadine (anti-cholinergic meds)

Question 200

10 year old immigrant. Ataxia, myoclonus, vision problems. Brain biopsy shows RNA virus with hemagglutinin. Diagnosis?

Answer 200

Subacute sclerosis panencephalitis from Measles virus (rubeola)

*This is a rare complication of Measles that occurs many years after you recover from the initial infection. Your brain basically melts. Measles virus antibodies would be found in the CSF of these patients.

Question 201

Patient has panic disorder. How do we treat these panic attacks in an outpatient setting? Acute/ inpatient setting?

Answer 201

Outpatient give SSRIs (SSRIs + cognitive behavioral therapy= first line)
Inpatient/ acute panic attack give benzos (we don’t send patients home with benzos but do use them to treat acute attacks in the hospital)

Question 202

Is it a good idea to send patients home with a bottle of prescription benzos?

Answer 202

No. They are addictive, so used sparingly. For example, use in an acute panic attack like patient comes into the ER feeling like they’re going to die (don’t give out for panic attacks in an outpatient setting- use the first line SSRIs). Or use in a hospital for a patient going through alcoholic withdrawal (don’t just give to an alcoholic trying to taper off of alcohol- use other meds to reduce cravings, etc.)

Question 203

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening reaction to anti-psychotic meds (especially high-potency 1st gen ones: Haloperidol, Trifluoperazine, and Fluphenazine). It is characterized by symptoms with the mnemonic “Malignant FEVER.” What are they?

Answer 203

Myoglobinuria
Fever
Encephalopathy
Vitals unstable
Enzymes increased (high CK due to rhabdomyolysis)
Rigidity in muscles (“lead pipe” rigidity)

Question 204

A patient overdosed on anti-psychotics and now presents with the life-threatening neuroleptic malignant syndrome (NMS). Besides stopping the anti-psychotic what are the 2 options of anecdotes you can give?

Answer 204

1. Dantrolene (RyR receptor antagonists that blocks Ca2+ release from the SR of skeletal muscle)
   * makes sense bc rhabo/ muscle breakdown is part of NMS
2. Bromocriptine (or another dopamine agonist)
   * makes sense bc anti-psychotics block D2 dopamine receptors, so you are trying to restore dopamine to make up for the overdose

Question 205

Dantrolene can be used as an anecdote for what 2 conditions?

Answer 205

1. Malignant hyperthermia (toxicity of inhaled anesthetics and succinylcholine)
2. Neuroleptic Malignant Syndrome (NMS) (toxicity of anti-psychotic drugs)

(Dantrolene= trampoline in Sketchy)

Question 206

Patient with history of doing drugs is having vivid, disturbing dreams, is tired and depressed to the point of suicidal ideation. Did he overdose on benzos, cannabis, cocaine, or opiates?

Answer 206

Cocaine

This is a stimulant, so going off of it gives the following withdrawal symptoms: inc appetite, hypersonia (inc sleeping), psychomotor retardation, severe depression (“crash”- the opposite of being high), vivid dreams

Question 207

What does hyperphagia mean?

Answer 207

Increased appetite/ eating

Question 208

What does dysphoria mean?

Answer 208

Feeling lousy

The opposite of “euphoria” or getting high

Question 209

Diagnostic criteria for pica?

Answer 209

Consumption of non staple “foods” (ice, paint chips, dirt, hair, etc.) for > 1 month

Question 210

What is the difference between an illusion and hallucination?

Answer 210

Hallucinations—> you see something that’s not there (ex: you see an alien and there’s no aliens in the room)

Illusions—> you misinterpret something you see (ex: there’s a person in the room but you look at them and see an alien)

Question 211

Delusion vs. hallucination?

Answer 211

Delusion—> you’re perception of something if off (ex: you think your roommates are always talking about you, you think your neighbor is out to get you, you think you’re married to a celebrity that you aren’t, you think you’re as good as Kobe Bryant at basketball when you really suck)

Hallucination—> you hear/ see something that’s not really there (ex: you are talking to an imaginary friend but you think they’re real)

Question 212

Diagnostic criteria for delusion disorder?

Answer 212

1 or more delusion lasting >1 month without a mood disorder or other psychotic symptoms

Question 213

A man thinks his neighbors are out to get him and are implanting dangerous toxins in his backyard. Besides this belief, he works a normal job and is married. This has been going on for 5 years. Diagnosis?

Answer 213

Delusional disorder (1 or more delusion lasting >1 month without a mood disorder or other psychotic symptoms)

*not paranoid personality disorder, as this would involve excessive mistrust in others and not beliefs that are delusional

Question 214

Benzo withdrawal symptoms?

Answer 214

Anxiety, tremor, difficulty sleeping, sympathetic hyperactivity (sweating, palpitations), seizures if severe *bc you took away the CNS depression your body got used to

Question 215

What is conversion disorder aka functional neurologic symptom disorder?

Answer 215

Neuro symptoms (loss of sensory or motor function) following an acute stressor, but neuro exam is 100% normal 
(*They’re not consciously making it up like in factitious disorder/ Münchausen syndrome...the symptom actually may be distressing to them. They are also not excessively anxious about a symptom being a particular thing like in somatic symptom disorder.)

Question 216

What drug class does the following drug belong to?
Olanzapine

Answer 216

2nd gen anti-psychotic

Question 217

What drug class does the following drug belong to?
Quetiapine

Answer 217

2nd gen antipsychotic

Question 218

What drug class does the following drug belong to?
Risperidone

Answer 218

2nd gen anti-psychotic

Question 219

What drug class does the following drug belong to?
Aripiprazole

Answer 219

2nd gen anti-psychotic

Question 220

What drug class does the following drug belong to?
Ziprasidone

Answer 220

2nd gen anti-psychotic

Question 221

What drug class does the following drug belong to?
Clozapine

Answer 221

2nd gen antipsychotic

Question 222

What drug class do the following drugs belong to?
Quetiapine, Olanzapine, Risperidone, Aripiprazole, Ziprasidone, and Clozapine.

Answer 222

Quetiapine—> “quiet”
Olanzapine—> “only”
Risperidone—> “whispering”
Aripiprazole—> “appropriate”
Ziprasidone—> zipper
Clozapine—> closet

Question 223

Most concerning side effects of first gen anti-psychotics? 2nd gen?

Answer 223

1st gen—> extrapyramidal side effects

2nd gen—> metabolic effects (weight gain, dyslipidemia, hyperglycemia, inc DM risk)

Question 224

What does transference mean? Countertransference?

Answer 224

Transference—> you project feelings about someone else onto your physician (ex: you are mad at your dad for neglecting you in the past so you get mad at your psychiatrist for cancelling an appointment on you bc it subconsciously reminds you of your dad that wasn’t there for you, or you see your psychiatrist like your mom)

Countertransference—> how the doctor feels about the patient (ex: patient reminds doctor of their sister)

Question 225

How long for postpartum blues to resolve?

Answer 225

2 weeks
(This is self-resolving, normal due to hormonal changes)

Question 226

A mom is depressed after having a baby. Diagnosis within 2 week frame? Diagnosis after that point?

Answer 226

Within 2 weeks—> postpartum blues

After that—> postpartum depression

Question 227

What class of drugs are these in? Zotpidem, Zaleplon, and esZopiclone?

Answer 227

Non-benzo hypnotic agents (use for insomnia to help you sleep)

• they are non-benzos but still bind the same GABA-A receptor site and work as an agonist of it—> CNS depression, but less side effects bc chemically distinct
• remember “ZZZ mattresses” in Sketchy

Question 228

If a patient doesn’t have an advanced directive and loses decision-making capacity, who decides what to do? State the “next of kin” order between siblings, parents, adult children, other relatives, and spouse.

Answer 228

Spouse—> adult children—> parents—> siblings—> other relatives
(“The spouse ChiPS in”)

Question 229

Woman was sexually assaulted 2 months ago. Since then, she does not feel safe, spaces out and feels like she’s back at the scene of her assault, hears the voice of the guy that assaulted her, and sometimes feels disconnected from her body. Diagnosis?

Answer 229

PTSD

*NOT depersonalization/ derealization Disorder bc she has a cluster of symptoms (not just this) involving flashbacks too and it’s be > 1 mo, meets PTSD criteria

Question 230

What is the age the children typically understand death is permanent?

Answer 230

Age 7

Question 231

A 5 year old girl has been seeing her grandma and talking to her ever since grandma passed away 2 months ago? Diagnosis?

Answer 231

Normal behavior 
(Hallucinations can be normal and comforting in the bereavement process. Plus she’s only 5 and doesn’t understand the permanence of death yet.)

Question 232

A man is going through a divorce and mad at his wife for pursuing full custody over their kids. He comes into your office for a checkup and starts yelling at the office staff. Defense mechanism—is this acting out or displacement?

Answer 232

Displacement

(He is transferring negative feelings toward his wife onto the office staff. Acting out would be like if he key‘d his wife’s car to get her back)

Question 233

A friend of yours asks you if Jill is your patient bc he’s concerned about Jill after hearing she was diagnosed with cancer. She is your patient. How should you respond?

Answer 233

Something like “sorry, I cannot say whether or not she is my patient.” Do NOT say yes she’s my patient but I can’t tell you about her health…patient confidentiality includes not saying WHO your patients are. Don’t lie (no need to say “no she’s not my patient”), but don’t confirm or deny!

Question 234

An elderly lady has pneumonia and requires antibiotics. She refuses them, despite being counseled that should could die from the infection w/o treatment. She voices understanding of her illness and the consequences of no treatment and still refuses, saying she lived “long enough.” She is oriented, but doesn’t know the date on mental status examination. Who gets to make the decision on whether or not to give antibiotics?

Answer 234

She does!
Decision-making capacity requires that the patient communicates a choice, understands the info provided on the condition and treatment option, appreciates the consequences, and gives a rationale for a decision. She did all of these. Mild cognitive impairment (forgetting the date) does NOT automatically mean lack of decision-making capacity!

Question 235

Medicare vs. Medicaid?

Answer 235

Medicare is for elderly patients >65, disabled, or end-stage renal diseases (mediCARE= care for the elderly)

Medicaid is for low-income patients (medicAID= aid for poor)

Question 236

Elderly patient needs to be intubated. He has no advanced directive or proxy. His friend is there with him and says he thinks the patient wouldn’t want that. The patient has no family at the hospital, but a sister he lost touch with is in the area. What do you do?

Answer 236

Attempt to contact the sister

Without an advanced directive or designated proxy (patient picks someone to makes decisions on their behalf), decision making goes to “next of kin” (spouse—> adult children—> parents—> kids—> other relatives). If there is NO family available, THEN friends may act as a substitute and make a decision on behalf of the patient.

Question 237

Old lady needs CPR. She has a designated proxy- her friend. Her friend states not to give CPR. But her husband is also there and says give CPR! What do you do?

Answer 237

Do not give CPR

Even though the “next of kin” order would allow the husband to make a decision on the patient’s behalf over the friend, this lady filled out a form designating her friend to be her decision-making in a situation like this which takes precedence. Always follow the advanced directive/ proxy first if there is one!!

Question 238

Requirement for getting hospice care?

Answer 238

Prognosis < 6 mo.

Question 239

A guy overdosed a drug. He is agitated, violent, has tachycardia and hypertension, nystagmus and hallucinations. When the drug wears off he forgot the episode. What drug? Mechanism of action?

Answer 239

PCP (“angel dust”)
Blocks NMDA (glutamate) receptors (—> hallucinations and inhibits reputable of dopamine, NE, and serotonin—> more sympathetic activity)

Question 240

A depressed patient is started on SSRIs but he is not okay with the decreased libido he experiences on the drug. What is a good alternate option to treat his depression?

Answer 240

Bupropion (an atypical antidepressant with a good sexual profile, it is a NE-dopamine reuptake inhibitor)

Question 241

Patient is admitted to the hospital for pneumonia. His condition improves with antibiotics, but now he develops abdominal pain, diarrhea, severe muscle aches, anxiety, dilated pupils, lacrimation, and yawning. He admits to abusing recreational drugs. What drugs does he do that are causing him to have withdrawal symptoms now that he’s in the hospital not getting these drugs anymore?

Answer 241

Opioids

Question 242

Do you see hypo or hyper reflexes in NMS (neuroleptic malignant syndrome)? Serotonin syndrome?

Answer 242

NMS (life-threatening reaction to first generation anti-psychotics)—> hypOreflexia (decreased reflexes) *diffuse rigidity (“lead-pipe”)

Serotonin syndrome (life-threatening reaction to too many SSRIs/ serotonin promoting meds)—> hypERreflexia (increased reflexes), *includes Clonus

Question 243

A patient has bipolar disorder. He comes into the hospital with a really high fever, high BP, high HR, sweating, and rigid extremities. What’s going on?

Answer 243

NMS (neuroleptic malignant syndrome)= life-threatening relation to first gen anti-psychotics (used to treat bipolar)

Characterized by: “lead-pipe” rigidity in muscles, hyporeflexia, hyperthermia, sympathetic hyperactivity (high BP, HR), and mental status changes.

Question 244

Single strongest risk factor for suicide completion

Answer 244

Previous suicide attempt

Question 245

Manic episode. Bipolar I or II?

Answer 245

Bipolar I

Remember, Bipolar I is 1 manic episode plus or minus a hypomanic or depressive episode (“bipolar I patients think they’re number 1” from grandiosity in manic episodes)
Bipolar II is hypomania + depression (no mania)

Question 246

Manic episode + delusions (like believing you’re the king of the world) or hallucinations (like hearing a voice say you need to sacrifice your life) is called what?

Answer 246

Bipolar I with psycotic features

Question 247

Patient has bipolar and is being treated. Now has new-onset constipation, dry skin, hair loss, and weight gain. What med is she taking?

Answer 247

Lithium (mood stabilizer)

Can cause hypothyroidism—> wight gain, dry skin, hair loss, constipation

Question 248

Why should you monitor TSH and BUN + Creatinine in a patient taking Lithium (mood-stabilizer) for Bipolar?

Answer 248

Lithium can cause hypOthyroidism and DI (diabetes insipidus)

Question 249

You are taking a MAO-inhibitor for depression, now your doc switches you to an SSRI. You are instructed to wait 2 weeks from the time you start the MAO-inhibitor before you can begin treatment with the SSRI. Why?

Answer 249

You have to allow time for MAO to regenerate (bc MAO inhibitors IRREVERSIBLY inhibit MAO…and that way it’s re-established to break down serotonin…otherwise, you’d be taking the SSRI which increases serotonin in the cleft and no MAO to break it down—> serotonin syndrome)

Question 250

The mnemonic “ADAPT” can be used to remember the extrapyamidal side effects of 1st gen antipsychotics (particularly the high-potency ones: haloperidol, Trifluoperazine, and Fluphenazine). What does it stand for? Define them.

Answer 250

Acute Dystonia (sudden muscle stiffness)
Anesthesia (restlessness)
drug-induced Parkinsonism (cogwheel rigidity, slow movement)
Tardive dyskinesia (involuntary jerky, repetitive movements like sticking out the tongue)

Question 251

What effects do anti-muscurininc drugs have on the following?

• mind
• mouth
• gut
• temp
• urination

Answer 251

• confusion
• dry mouth
• constipation, intestinal ileus
• hyperthermia, flushing
• urinary retention

Question 252

Can Amitriptyline be used to treat insomnia?

Answer 252

Yes. It is a TCA (tricyclic antidepressant) and blocks the following receptors: serotonin and NE reuptake, fast Na+ channels, muscarinic ACh receptors, alpha-1 receptors, and H1 histamine receptors.
Since it blocks histamine receptors, it causes sedation/ sleepiness and can therefore be used (though not often) for insomnia (problems getting to sleep).

Question 253

A patient is taking a TCA (tricyclic antidepressant) and develops urinary incontinence. Why?

Answer 253

TCA’s block the following receptors: serotonin and NE reuptake, fast Na+ channels, alpha-1 receptors, H1 histamine receptors, and cholinergic ACh receptors.
Since they block muscurinic ACh receptors, they cause confusion, dry mouth, constipation, hyperthermia, and URINARY RETENTION.
Think of it as blocking the PNS, so you get sympathetic effects= not peeing.

Question 254

A patient has Bipolar I + epilepsy. Good med to use to treat both at the same time?

Answer 254

Valproate (it is a mood-stabilizer and a broad spectrum anti-epilepsy medication)

Question 255

Uses of Valproate? Mechanism of action?

Answer 255

Valproate= anti-epileptic medication and mood stabilizer

Blocks voltage-gated Na+ channels and enhances availability of (increases) GABA

Question 256

A mom has been feeling down ever since her kid moved away to college 2 months ago. She’s sad and just talking about her kids, but her feelings are not affecting her productivity at work. Diagnosis?

Answer 256

Normal sadness/ depressed mood

*this is NOT adjustment disorder bc although the sadness happened after a life adjustment and it does not meet the criteria, it’s not affecting her productivity/ functioning either. Impaired social and occupational functioning is a criteria for most psych disorders, including adjustment disorders!

Question 257

Best treatment for phobia (ex: fear of elevators)?

Answer 257

Cognitive behavioral therapy (CBT) that is exposure-based

*2nd line= short-acting benzos to calm you down

Question 258

What phobia often develops in people who get panic attacks?

Answer 258

Agoraphobia

This means they get anxiety/ fear about leaving the house and going to public/ crowded situations where they feel trapped and helpless in the even of a panic attack

Question 259

2 year old boy avoids eye contact, isn’t progressing in verbal communication, is obsessed with playing with the same toy truck. Diagnosis?

Answer 259

Autism spectrum disorder (ASD)

*characterized by impaired social communication/ interaction + repetitive interests/ behaviors (with or w/o language and intellectual impairment)

Question 260

What are the extrapyramidal side effects of anti-psychotic drugs (esp the 1st generation high-potency ones)? Name them and say what they mean.

Answer 260

“ADAPT”

Acute Dystonia (sudden muscle stiffness)
Akesthesia (restlessness)
drug-induced Parkinsonism (cogwheel rigidity, slow movements)
Tardive dyskinesia (involuntary jerky movements, like sticking out the tongue)

Question 261

Male patient is having sexual dysfunction. Specifically, he’s getting an orgasm within a minute or less. He’s taking insulin for his diabetes and Trazodone for his depression. What’s his problem and what’s the cause?

Answer 261

Premature ejaculation (he’s having early ejaculation/ loss of control)

NOT sexual dysfunction due to DM bc that would cause erectile dysfunction (impaired blood flow through small penile vessels) not this problem he’s having. NOT depression causing it bc he currently doesn’t report depressed symptoms. NOT the Trazodone causing it—it has a side effect of priapism (sustained erection), not the problem he’s having.

Question 262

Mechanism of the antidepressant Buproprion?

Answer 262

Inhibits reuptake of NE and dopamine—> increased NE and dopamine in cleft
(“NET DAT ball pro” where “ball pro” helps you remember Buproprion and NET DAT helps you remember NE transmitter and dopamine transmitters are blocked)

Question 263

Can you give Bupropion (atypical antidepressant) to an anorexia nervosa or bulemia patient?

Answer 263

NO! Contraindicated due to seizure risk/ side effect.

Question 264

What is cyclothymic disorder?

Answer 264

Chronic, fluctuating mood disturbance involving many periods of hypomanic and depressive symptoms, but doesn’t meet criteria for hypomanic or major depressive episodes.

Question 265

A teen girl is brought to the office. Her mom says she’s moody, uses swear words now and then, yelled at her for looking hideous, and requests to keep her shirt on for the exam. Diagnosis?

Answer 265

This is normal adolescent behavior

*this is NOT body dysmorphic disorder. To make this diagnosis, we’d need info like she’s obsessing over how she looks in the mirror or researching her thighs 8 hrs/ day…

Question 266

What is pyromania?

Answer 266

Intentional and repeated fire setting w/o an obvious motive (however, if other destruction of property, etc is going on, then it is conduct disorder)

Question 267

What is delirium?

Answer 267

Acute-onset state with fluctuating levels of consciousness, impaired attention, and disorientation that occurs when there’s an underlying medical condition.
Often seen after surgery, infection, or onset of new medications (elderly also at higher risk)

Question 268

Can you treat bulemia with SSRIs? Anorexia nervosa?

Answer 268

Bulemia- yes, SSRIs help

Anorexia nervosa- no

Question 269

As you age, how does your sleep pattern change?

Answer 269

Decreased total sleep time (you wake up more in the middle of the night/ more fragmented sleep, wake up earlier, and nap more/ feel more tired throughout the daytime)

Question 270

How to medically treat social anxiety disorder aka social phobia?

Answer 270

SSRI/ SNRI

Question 271

A girl has a “sensitive stomach” that got worse when she moved to a new school. She has to go to the nurse’s office many times each day due to stomach ache. It gets better when mom comes to pick her up. She has friends but doesn’t like sleepovers where she’s away from mom. Diagnosis?

Answer 271

Separation anxiety disorder

(Note that this is NOT adjustment disorder with anxiety bc, even though the symptoms got worse after they moved, she had symptoms before too so the onset wasn’t due to the move.)

**for this diagnosis, separation anxiety symptoms must be present for at least 4 weeks in kids, 6 months in adults.

Question 272

Can you diagnose dependent personality in a kid?

Answer 272

No. We don’t diagnose personality disorders in kids bc their personalities are still developing.

Question 273

The majority of overdose deaths in the US are caused by what?

Answer 273

Opioids (this includes prescription analgesics and heroin)

Question 274

What’s the difference between anorexia nervosa, bulimia nervosa, and binge eating disorder? Based on weight and based on

Answer 274

Anorexia nervosa—> underweight, intense fear of weight gain/ distorted image of self, can be binge/purge (eat and throw it up) type or restricting type (stop eating)

Bulimia nervosa—> normal or overweight, episodes of binge eating followed by behavior to compensate (vomiting, exercise, fasting) to prevent weight gain, worry about body shape and weight

Binge eating disorder—> recurrent binge eating with lack of control but NO COMPENSATORY BEHAVIORS (after they binge eat, they do NOT force them self to vomit)

Question 275

What 2 drugs can be given to reduce cravings to help a patient with opioid use disorder? Say how they work.

Answer 275

1. Methadone (“done timer” in Sketchy)
   - it is a full mu-opioid receptor agonist
2. Buprenorphine (“blueprint” in Sketchy)
   - it is a partial mu-opioid receptor agonist

Both of these drugs have a long half life (long tapering flag in Sketchy), which allows it to suppress cravings and withdrawal symptoms from opioids

Question 276

Why are anorexia nervosa patients at increased risk for osteoporosis/ fracture?

Answer 276

Being super thin shuts off GnRH (your body knows you cannot sustain a pregnancy)—> low estrogen—> less protective effect against osteoclasts= more osteoclasts breaking down bone

Question 277

Patient is thin and has lanugo (really soft hair on the body) and an enlarged parotid gland. What diagnosis should you be suspicious of?

Answer 277

Anorexia nervosa binge/purge type

• enlarged parotid (overstimulation of salivary glands) is consistent with causing yourself to vomit
• lanugo is seen in anorexia nervosa

Question 278

Compared to 1st gen anti-psychotics, 2nd gen anti-psychotics have a lower risk of what?

Answer 278

Extrapyramidal symptoms (EPSs)

Question 279

How much should a 2 year old be talking?

Answer 279

At age 2, a child should be able to use 2-word phrases.

Question 280

Drugs that get metabolized where could interact with lithium?

Answer 280

In the kidneys (for example: Thiazide diuretics)

Bc lithium is metabolized in the kidneys

Question 281

Chronic lithium toxicity can present with what neurological symptoms?

Answer 281

Ataxia and tremor

Question 282

What is bipolar with psychotic features?

Answer 282

You get psychosis (like hearing voices) DURING mania (or depressed) states

Question 283

What is MDD (major depression disorder) with psychotic features?

Answer 283

You get psychotic (like hearing voices) DURING the time you are depressed

Question 284

Schizophrenia vs. Schizoaffective vs. MDD with psychotic features?

Answer 284

Schizophrenia does NOT involve mood issues (no Bipolar/ mania or depression)

Schizoaffective shares symptoms of Schizo + mood disorder (bipolar/ mania or depression). It means your are psychotic/ hearing voices (Szhizo symptoms) in the absence of mood symptoms (at times when your mood is stable and you are not manic or depressed), so the Schizo and mood symptoms don’t have to be going on at the same time

MDD with psychotic features means you are psychotic/ hearing voices but ONLY WHILE you are depressed (at times when your mood is back to being stable, you’re not getting any more psychosis)

Question 285

What are mood disorders?

Answer 285

Bipolar (mania) and depression

Question 286

What are the 4 dopaminergic pathways and their associations?

Answer 286

1. Mesocortical- less activity—> negative symptoms of Schizo (remember cortical sounds like “court” which is a negative thing) *anti-psychotics that block D2 dopamine receptors don’t really affect this pathway
2. Mesolimbic- more activity—> positive symptoms of Schizo (remember limbic sounds like “limbo” which is a positive thing) *anti-psychotics that block D2 dopamine receptors target this pathway, so blocking this pathway means less positive symptoms
3. Nigrostriatal- less activity—> extrapyramidal symptoms (acute dystonia, akathisia, Parkinsonism, tardive dyskinesia) *anti-psychotics block D2 dopamine receptors, and therefore decrease activity of this pathway—> less EPS’s
4. Tuberoinfundibular- less activity—> more prolactin *blocking dopamine= less inhibition on prolactin= more prolactin= dec libido, sexual dysfunction, galactorrhea, gynecomastia in men

Question 287

Decreased activity of the mesocortical dopamine pathway leads to what?

Answer 287

Negative symptoms of Schizohrenia

Question 288

Increased activity of the Mesolimbic pathway lead to what?

Answer 288

Positive symptoms of Schizophrenia

Question 289

Decreased activity of the Nigrostriatal pathway leads to what?

Answer 289

EPS (extrapyramidal symptoms)

Question 290

Decreased activity of the Tuberoinfundibular pathway leads to what?

Answer 290

Increased prolactin (—> decreased libido, sexual dysfunction, galactorrhea, gynecomastia in men)

Question 291

What is dysthymic disorder?

Answer 291

Persistent depressive disorder

Milder depression, 2+ depressive symptoms (don’t need 5/9 of the SIG E CAPS), but it’s lasting 2+ years (no more than 2 months w/o depressive symptoms)

Question 292

What is cyclothymic disorder?

Answer 292

Milder form of bipolar. Mild depression + hypomania. Must last 2+ years with symptoms at least half the time (remission no longer than 2 months).
*this differs from Bipolar II (depression + hypomania) bc the depressive symptoms are milder and don’t meet the MDD requirements. Also, hypomanic symptoms are milder.

Question 293

Give a simple definition for dysthymic disorder and cyclothymic disorder.

Answer 293

Dysthymic disorder- aka persistent depressive disorder. A milder depression that goes on 2+ years.

Cyclothymic disorder- milder bipolar disorder (milder depression + hypomania)

Question 294

Lady has severe headache, palpitations, tremulousness. She just ate a whole cheese pizza before the onset of her symptoms. Her meds include Phenelzine. What’s going on? How do we treat her?

Answer 294

Phenelzine (funnel in Sketchy)= MAO inhibitor (treats atypical depression).
She ate pizza= lots of cheese! Cheeses and meats are a no no when you’re on a MAO inhibitor bc MAO inhibitors block MAO. While this prevents degradation of serotonin, NE, and dopamine so there’s more in the cleft, it also prevents breakdown of Tyramine so eating Tyramine-rich products can lead to too much Tyramine floating around in the blood—> HTN crisis.
Treat with Phentolamine (Phantom of the Alpha guy in Sketchy)

Question 295

How to treat a HTN crisis caused by a patient taking a MAO-inhibitor and eating a truck load of cheese?

Answer 295

Phentolamine

Question 296

What’s a normal pupil size?

Answer 296

2-4mm

Question 297

What does catatonia mean?

Answer 297

Abnormal movement and behavior from schizophrenia or other disturbed mental state

Question 298

A young man has felt sad, had sleep disturbance, and weight loss for a week since he broke up with his girlfriend. He says “my life is over. She meant everything to me.” Diagnosis?

Answer 298

Adjustment disorder with depressed mood (depression symptoms within 3 months of a stressors)

(Not MDD bc MDD requires 5/9 SIG E CAPS symptoms for at least 2 weeks. This has only been going on 2 weeks, is due to an acute stressor= breaking up with gf)

Question 299

Buspirone can be used to treat what?

Answer 299

Generalized anxiety disorder (GAD)

Question 300

What is somatization disorder?

Answer 300

Just another name for somatic symptom disorder!
Patient has a vague symptom and has anxiety over it/ thinks they must have something serious
Ex: stomach ache—> think they have pancreatic cancer
(*vs. illness anxiety disorder where patient has zero symptoms, but still thinks they’ve got something)

Question 301

What are the 4 main hallucinogens people abuse?

Answer 301

1. LSD (Lysergic acid diethylamine) aka “acid”
2. Marijuana (cannabinoid) aka cannabis aka pot
3. Ecstasy (MDMA)
4. PCP (Phencyclidine)

Question 302

What are the 4 main depressants people abuse?

Answer 302

1. Alcohol
2. Barbiturates
3. Benzodiazepines
4. Opioids

Question 303

What are the 4 main stimulants people abuse?

Answer 303

1. Amphetamines (like meth)
2. Caffeine
3. Cocaine
4. Nicotine

Question 304

What are 3 major drugs of abuse that cause pupil dilation?

Answer 304

Amphetamines (like meth), cocaine, LSD

Question 305

What does “sclera icterus” mean?

Answer 305

Yellowed eyes from jaundice

Question 306

6 side effects of Valproic acid (the anti-epileptic/ mood-stabilizer drug)?

Answer 306

1. GI distress (emperor guy ready to throw up in Sketchy)
2. Inc appetite, weight gain (the emperor is fat)
3. Tremor (guy in the back of the line shaking the baseball bat thing)
4. Liver hepatotoxicity (the liver spot on the cow)
5. Neural tube defects (tarantula teratogen and lady playing tubes with baby on her back)
6. Pancreatitis (squeezing the sponge)

Question 307

Developmental retardation, microcephalic (small head), smooth philturm, thin vermillion border, small pelpebral fissures, hear defects like ASD, VSD, or Tetrology of fallout, limb dislocation. What developmental disorder does this describe?

Answer 307

Fetal alcohol syndrome

Question 308

Ok to give a TCA (tricyclic antidepressant) to elderly?

Answer 308

No. Contraindicated in elderly patients due to severe anti-cholinergic (dry mouth, constipation, blurry vision, urinary retention, confusion…) and anti-histamine effects (sedation, etc.).

Question 309

A guy is psychotic, hearing voices. He’s on Clozapine. His leukocyte count is high and he has DM. What is the next step in managing his case?

Answer 309

Discontinue clozapine treatment

Though we want to treat his psychosis, we need to get him off this med first! Then we can figure out an alternate anti-psychotic med. why? He is getting agranulocytosis (a really dangerous side effect of the med). On top of that 2nd gen antipsychotics (like Clozapine) are known for causing metabolic side effects like dyslipidemia and hyperglycemia, making diabetes a worse problem.

Question 310

Guy believes he can predict the future. Has no friends. Not depressed, no changes in appetite. Personality disorder?

Answer 310

Schizotypal- has odd beliefs/ magical thinking

Part of cluster A “weird” side effects

Question 311

Protruding ears, prominent jaw, low IQ in a boy. What is the developmental disorder, inheritance pattern, and how does it occur?

Answer 311

Fragile X syndrome

X-linked dominant
Trinucleotide repeat in FMR1 gene (Fragile mental retardation gene) CGG repeats—> protruding Chin, Giant Gonads, intellectual disability (2nd most common cause after Downs)

Question 312

A guy has to re-fold all his clothes each morning and has difficulty making decisions. Diagnosis?

Answer 312

OCD

Question 313

A guy is psychotic, hearing voices. Right now, he’s not psychotic but is experiencing another depression episode. Diagnosis?

Answer 313

Schizoaffective disorder 
(Schizo symptoms + mood= depression/ mania symptoms, but not always occurring at the same time)

*This is NOT MDD with psychotic features. If it were, the guy would be psychotic only when having depression. They would be happening together! (Never psychotic in the absence of depression)

Question 314

What type of drug is modafinil?

Answer 314

Stimulant

Question 315

Patient is brought in with paranoid symptoms, threatening people, has agitation, sweating, nystagmus, myoclonus, combativeness. What drug is he intoxicated with?

Answer 315

PCP

Nystagmus gives away that it’s PCP intoxication

Question 316

What kind of drug is Tranylcypromine?

Answer 316

MAO inhibitor (“try a sip of wine” in Sketchy)

Question 317

What psych drugs can be used to manage Tourette’s syndrome?

Answer 317

1st gen anti-psychotics or 2nd gen anti-psychotics, especially Risperidone!

Question 318

Obsessed with being early to every event. Thinks his way is the only way. Difficulty making decisions. Personality disorder?

Answer 318

Obsessive-compulsive personality disorder

Question 319

Chlorpromazine is what kind of med?

Answer 319

1st gen antipsychotic, low-potency (“color pro” pains in Sketchy)

Question 320

Imipramine is what type of drug?

Answer 320

TCA (tricyclic antidepressant)

Imprint in Sketchy

Question 321

What kind of drug is Bupropion?

Answer 321

Atypical antidepressant, also used for smoking cessation
(NET DAT ball pro in Sketchy, where ball pro helps you remember Buproprion and NET DAT helps you remember it blocks the NE Transporter and DA/ dopamine Transporter—> inc NE, dopamine in cleft)

Question 322

A man is being treated for bipolar with lithium. Presents with tremor. His lithium concentration is within the therapeutic range and he’s having no other side effects. What add’l med can you give him for the tremor/ anxiety symptoms?

Answer 322

A beta-blocker

Question 323

Mechanism of cocaine?

Answer 323

Inhibits reputable of NE, dopamine, and serotonin (similar to SSRIs, SNRIs, and TCAs)

Also vasoconstricts (NE= sympathetic NT, so has this effect on vessels)

Question 324

What kind of drug is Buprenophine? It’s use?

Answer 324

Long-actin partial Mu-opioid agonist (blueprint in Sketchy)

Used to help patients with opioid addiction taper off of them/ get clean

Question 325

What kind of drug is Methadone?

Answer 325

Long-acting opioid used to attenuate withdrawal symptoms (done timer in Sketchy)

Question 326

Has bipolar. Is urinating a lot. What’s probably the reason for this?

Answer 326

Lithium treatment—> causing DI (nephrogenic diabetes insipidous where the kidneys aren’t responding to ADH, so not retaining water, just peeing it out)

Question 327

Guy has schizophrenia. Has been treated 3 times before finding a med that worked for him. What is it? What needs to be monitored?

Answer 327

Clozapine

This is a “big gun” good for treatment-resistant schizophrenia (you want to use other 2nd/ 1st gen anti-psychotics before you resort to this due to nasty side effects)

Monitor neutrophils! Why? Agranulocytosis is a dangerous side effect!

Question 328

True or false? MDD (major depression) is associated with increased serum cortisol levels.

Answer 328

True

Question 329

50 year old lady. For 2 hrs has been having heart palpitations, is tachycardic. Feels like things are moving slowly around her. Has dry skin, injected conjunctiva (red eyes). What drug is she intoxicated with?

Answer 329

Marijuana

(Think of a stoner…red eyes, in la la land/ things are moving slow to them. Remember that Marijuana is the “weird drug” in that it calms you but makes your heart race.)

Question 330

35 year old woman has fatigue, blurry vision, numbness in legs, and decreased sensation for 1 year. Disease? What would you see on imaging?

Answer 330

MS (Multiple Sclerosis)
-autoimmune inflammation and demyelination of the CNS—> relapsing and remitting symptoms

Focal white matter lesions (makes sense bc white matter= axons, which is the part of the neuron with myelin, and therefore the part affected by demyelination)

Question 331

What type of drug is Doxepin?

Answer 331

TCA (tricyclic anti-depressant)

Question 332

A teenager is hiding in the closet, paranoid that the FBI is out to get her. This has been going on ever since she returned from a party. She has a high HR, normal sized pupils, conjunctivae are injected, is oriented. What’s going on?

Answer 332

She’s intoxicated with marijuana

(Note the red eyes like a stoner, high HR bc pot causes your heart to race even though you get calmed by it, and it’s acute onset after a party so not a psychiatric diagnosis)

Question 333

What 3 drugs are contraindicated when taking Lithium (for Bipolar)?

Answer 333

1. Thiazides
2. ACE inhibitors
3. NSAIDs
   *and any other drug that interferes with renal function
   Because lithium is excreted by the kidneys!

Question 334

Lady has Bipolar, is being treated. She comes in with a seizure and some other problems. There haven’t been any changes to her routine except she’s been taking some ibuprofen for arthritis pain. What is going on?

Answer 334

Lithium toxicity—> seizure

From the NSAIDs, which interfere with renal function. These are contraindicated in patients on lithium (along with ACE inhibitors, thiazides, and any other drugs that act on the kidneys) since lithium is excreted by the kidneys!

Question 335

1st line treatment for Alzheimer’s disease? Name the class of drugs.

Answer 335

AChE inhibitor (blocks the ACh Esterase enzyme that breaks down ACh—> more ACh)

• this is a cholinergic (ACh) drug
• useful because there is found to be decreased ACh levels in AD

Here are the specific names of the drugs: Donepezil, Rivastigmine, Galantamine (“Dona River dances at the Gala”)
**2nd line= Memantine (NMDA/ glutamate receptor antagonist)

Question 336

What do you find in the urine of someone who drank ethylene glycol/ antifreeze?

Answer 336

Oxalate crystals (enveloped shaped)

Question 337

What brain region is involved in movement?

Answer 337

Substantia nigra

Question 338

Low birth weight baby who was adopted. Has narrow palpebral fissures, epicanthic folds, thin upper lip, indistinct nasal philtrum, and single palmar crease on hand. Most likely diagnosis?

Answer 338

Fetal alcohol syndrome
(Low birth weight, adopting mom meaning we don’t know her background and if she drank, and distinct facial features point to fetal alcohol syndrome. Don’t let the single palmar crease make you think must be Downs!)

Question 339

Older man is having bizarre behavior at night. He gets out of bed and punches into the air, but doesn’t recall doing this in the morning. Diagnosis?

Answer 339

REM sleep behavior disorder (seen in Lewy body dementia)

Question 340

A guy was found in the alley unaware of his surroundings or his name. He has gynecomastia, palmar erythema, palpable liver. What vitamin is he most likely deficient in?

Answer 340

Vitamin B1/ thiamine

He is an alcoholic—> liver cirrhosis—> gynecomatia due to increased estrogen (not getting broken down in the liver), palmar erythema (coag factors not getting made)

Question 341

Patient requests a med to prevent anxiety before her speech in 3 days. His medical history includes asthma, he takes albuterol for it. What can you give him?

Answer 341

A short-acting benzo like Lorazepam
(Beta-blockers are first line for performance anxiety, but not suitable for an asthmatic who needs their beta-agonist/ albuterol. Plus an SSRI would take 4-6 weeks to kick in and their speech is in 3 days. Also not appropriate treatment bc the patient doesn’t have Generalized Anxiety Disorder, just anxiety over the speech like social phobia for public speaking)

Question 342

What kind of drugs can cause extrapyramidal symptoms?

Answer 342

Any drugs that block dopamine (antipsychotics, GI anti-emetics)

Extrapyramidal side effects are just side effects caused by dopamine receptor blockade

Question 343

What does “decreased REM latency” mean?

Answer 343

The patient is entering REM phase sooner (shorter sleep cycles)

Question 344

A Q stem presents a psychotic patient that’s on some recreational drug making him/ her psychotic. Would you consider benzodiazepine or alcohol intoxication as answers?

Answer 344

No, probably not. These 2 aren’t associated with psychosis…

Question 345

What’s another name for dissociative personality disorder?

Answer 345

Multiple personality disorder

Question 346

Why can’t you inject an IV of food into a patient with anorexia nervosa to help them immediately?

Answer 346

Risk of re-feeding syndrome

If you give a bunch of calories to a significantly malnourished patient—> glucose spike—> HUGE increase in insulin (body is in a mode to store all it can since it’s so deprived of calories) that can lead to electrolyte imbalances that can be deadly (low phosphate, low K+, low Mg—> cardiac issues, rhabdo, seizures)

Question 347

EEG shows “periodic sharp waves.” Diagnosis?

Answer 347

Creutzfeldt- Jakob disease (Spongiform Encephalopathy)

-prion disease (rapidly progressive dementia with myoclonus within weeks to months from prion infection of brain)

Question 348

What do you see on EEG of a patient with Creutzfeldt-Jakob disease (spongiform encephalopathy/ prion disease)?

Answer 348

Periodic sharp waves

Question 349

What class of drugs does Olanzapine belong to?

Answer 349

2nd gen anti-pscyhotics (“only” in Sketchy)

Question 350

What is polysomnography?

Answer 350

Sleep study

Question 351

A lady has schizoaffective disorder and is being treated. The last week she’s had jaundice and her liver enzymes are through the roof. What drug was she likely treated with?

Answer 351

Valproic acid (hepatotoxicity is a side effect- remember cow with liver spots in Sketchy)

Remember that Valproic acid is a anti-epilepsy drug, but also used as a mood stabilizer (for bipolar). This lady doesn’t have bipolar, but Schizoaffective means Schizo/ psychotic symptoms + mood symptoms (depression or mania). So its reasonable to think Valproic acid could have been given to treat her mania/ mood symptoms—> hepatotoxicity.

Question 352

What is cataplexy?

Answer 352

A symptom of narcolepsy- loss of muscle tone following a strong emotional stimulus like laughing (you laugh and bam! All the sudden you pass out asleep)

Question 353

Lady was given corticosteroids. Now she’s having visual hallucinations. Has no psych history. Diagnosis?

Answer 353

Corticosteroid-induced psychotic disorder

**there is also a such thing as histamine-induced psychotic disorder

Question 354

Guy is being treated with antipsychotic drugs. Now feels anxious, having a hard time focusing, has difficulty urinating, dry mouth, flushed skin, tachycardia. Diagnosis?

Answer 354

Delirium (confusion) due to anticholinergic med

He was given an antipsychotic. These block muscurinic receptors—> anti-muscurinic side effects (example: urinary retention bc blocking PNS receptors, so get sympathetic symptoms, no time to pee when running from a bear)

Question 355

In Alzheimer’s disease, there are low levels of what neurotransmitter? This neurotransmitter is synthesized in what region of the brain?

Answer 355

Low ACh

Basal nucelus of Meynert

Question 356

ACh is synthesized in what region of the brain?

Answer 356

Basal nucleus of Meynert

Question 357

Dopamine is synthesized in what region of the brain?

Answer 357

Central tegmentum and Substantia nigra (SN pars compacta)

Question 358

GABA is synthesized in what region of the brain?

Answer 358

Nucleus acumbens/ caudate nucleus

Question 359

NE is synthesized in what region of the brain?

Answer 359

Locus ceruleus (pons)

Remember people with lots of NE are having an adrenaline high and are loco

Question 360

Serotonin is synthesized in what region of the brain?

Answer 360

Raphe nucleus (medulla)

Remember going to Ralphs to get food makes you happy= serotonin

Question 361

What 3 neurotransmitter changes occur in anxiety?

Answer 361

1. Decreased GABA (less CNS depression)
2. Increased NE (like more adrenaline)
3. Decreased Serotonin (not as happy, why SSRI works)

Question 362

What 3 neurotransmitter changes occur with depression?

Answer 362

1. Decreased dopamine
2. Decreased NE
3. Decreased serotonin

(Antidepressants raise levels of these)

Question 363

What neurotransmitter change occurs with schizophrenia?

Answer 363

Increased dopamine

This is why antipsychotics block D2 dopamine receptors

Question 364

What neurotransmitter change occurs with Alzheimer’s disease?

Answer 364

Decreased ACh

Question 365

What 3 neurotransmitter changes occur with Huntington’s disease?

Answer 365

1. Decreased ACh (can reason this bc is assoc with dementia)
2. Increased dopamine (aggression that can be misinterpreted as psychosis/ substance abuse)
3. Decreased GABA (degeneration of GABAergic neurons in the caudate nucleus of the basal ganglia)

Question 366

What 3 neurotransmitter changes are seen in Parkinson’s?

Answer 366

1. Increased ACh
2. Decreased dopamine (we treat with L-DOPA)
3. Decreased serotonin

Question 367

40 year old guy has had personality changes, aggression, sexually disinhibited (sexually aggressive). Involuntarily jerks and moves tongue. Diagnosis? What part of the brain is most affected?

Answer 367

Huntington’s disease
Caudate nucleus (there is degeneration of GABAergic neurons in the caudate nucleus of the basal ganglia)

Question 368

What finding is seen on brain imaging of a Schizophrenia patient?

Answer 368

Ventriculomegaly/ enlargement of the ventricles (lateral and 3rd) on CT scan of the head

Question 369

Patient has a high CK (creatinine kinase) and is on haloperidol for schizophrenia. What’s going on?

Answer 369

NMS (neuroleptic malignant syndrome, which includes rhabdo)

Question 370

How would heroin intoxication present?

Answer 370

Super sedated, sitting down (not running around) 
Breathing slowly (CNS depressant) 
Constricted pupils (in same class as opioids)

Question 371

Guy wants a drug to help him with his fear of flying (phobia). His business trip is in 2 days. He has no history of drug abuse. What can you give?

Answer 371

Short-acting benzo like Lorazepam (better than a beta-blocker in this case, also consider it’s okay for him to be sedated/ knocked out by a benzo bc he just needs to sit in the plane…you wouldn’t give a benzo for performance or test anxiety bc that would impair performance/ cognition…you’d give a beta-blocker)

Question 372

What does hyperpyrexia mean?

Answer 372

Really high fever (>104 degrees)

Question 373

Patient who abused a drug is aggressive, has nystagmus. What drug is it?

Answer 373

PCP

Question 374

What class of drugs is Fluvoxamine?

Answer 374

SSRI (it is a new SSRI!)

Question 375

EEG shows 3 spikes. What seizure is it?

Answer 375

Absence seizure

Question 376

Woman has been unable to sleep until 2-3am, so when she wakes up early morning to go to work, she’s exhausted and falls asleep at times throughout the day. On weekends she doesn’t have a problem bc she can sleep in until noon. She’s emotional/ Geary, but otherwise appears normal. Most likely diagnosis?

Answer 376

Circadian rhythm sleep disorder
(Her sleep cycle is messed up)

*not enough criteria met for MDD (she’s emotional/ teary but this could be due to sleep deprivation), not narcolepsy (no hallucinations before bed/ when waking up and she’s not abruptly passing out asleep like after laughing…plus, when she can sleep in she feels fine)

Question 377

Embarrassed when speaking in front of a group of friends, major anxiety when public speaking. Diagnosis?

Answer 377

Social phobia

Question 378

50 year old woman has had personality changes. She’s become irritable, sexually uninhibited, loud, makes dirty jokes. She makes jerky movements she can’t control. Her father had similar symptoms at age 55. Diagnosis? MRI of the brain would show what?

Answer 378

Huntington’s disease
(Note the family history and each generation gets it earlier, jerky movements, the type of behavior change/ aggression)

Caudate nucleus atrophy

Question 379

Mechanism of haloperidol?

Answer 379

1st gen antipsychotic

Blocks D2 dopamine receptors—> decreased binding of dopamine at postsynaptic receptors

Question 380

A guy sis taking an SSRI to treat his depression. He recently strained his back so found some Tramadol to take to relieve the pain. He comes into your office anxious and wearing. Has a 104 degree fever, tachycardia, inc BP, hyperreflexia, muscle righty, dilated pupils. Diagnosis?

Answer 380

Serotonin syndrome

SSRI + Tramadol (weak mu-opioid agonist that inhibits NE and serotonin Rey-take—> inc NE and serotonin in cleft…the tram in the distance of the opioid Sketchy)
—> too much serotonin! Should NOT be taking Tramadol while on an SSRI

Question 381

Escitalopram belongs to what class of drugs?

Answer 381

SSRI (citalopram city in Sketchy)

Question 382

How to treat OCD with meds?

Answer 382

1st line—> SSRIs

2nd line—> Clomipramine, Venlafaxine (SNRI)

Question 383

An alcoholic comes to the hospital complaining of lack of sleep. He’s irritable. He cut back on his alcohol intake a bit, but is not interested in quitting and does not see 6 bottles of beer a day as being a problem to his health. What’s your next step—recommend alcohol rehabilitation or give a benzo?

Answer 383

Recommend alcohol rehabilitation

Don’t give a benzo when the patient isn’t experiencing withdrawal symptoms and getting off the alcohol (in fact, if you give a benzo and he’s drinking behind your back, you cause worse CNS depression that can be fatal). First step is always to get them to realize they have an alcohol problem. Exception is if he came into the hospital with severe tremors, sweating, having seizures due to alcohol withdrawal. Then you have to give a benzo to supply that CNS depression and prevent these dangerous effects (if no benzo is available, old school way would be give them alcohol bc these symptoms can be fatal).

Question 384

Patient comes in agitated, thinks bugs are crawling all over his skin. He is running a fever, high HR, high BP, prolonged QT interval on ECG. Urine toxicology screening is positive for benzoylecgonine. What is benzoylecgonine? What’s wrong with this guy? How do we treat?

Answer 384

Cocaine breakdown product
He’s intoxicated with cocaine (stimulant)
We give him a benzo (does the opposite/ CNS depression)

Question 385

Old guy has dementia. He is hallucinating/ talking to people not really there. His gait is slow. He has a history of coronary artery disease. Diagnosis?

Answer 385

Lewy body dementia

-visual hallucinations, REM sleep behavior disorder (thrashing/ hitting in their sleep), and Parkinsonism (slow movement, shuffling)—> think Lewy body dementia

**don’t get fooled by CAD in the history and think it must be vascular dementia! That’s a step-wise progression (ex: get a stroke—> decline in memory, get another stroke—> memory gets even worse…)

Question 386

What’s the difference in diagnosis of the following 2 cases?

1. Patient has cognitive (dementia) and motor symptoms (slow movement, shuffling) occurring less than 1 year apart
2. Patient has motor symptoms (slow movement, shuffling) and more than 1 year gets cognitive problems (dementia)

Answer 386

1. Lewy body dementia (it is associated with Parkinsonism)

2. Dementia secondary to Parkinson’s disease (they were diagnosed with Parkinson’s and then got dementia later from it)

Question 387

A patient is on an SSRI for depression. 2 weeks later they come to you saying they feel a little better, but still having trouble sleeping. What do you do? Add a drug or see them back? When do you want to see them back?

Answer 387

Schedule a follow-up in the next month. Remember that SSRIs take 4-6 weeks to reach maximal effect! You can’t say they aren’t working until you wait this time, so don’t go changing the meds yet.

Question 388

What psych disorder is associated with the following finding: enlargement of the ventricles in the brain?

Answer 388

Schizophrenia

Question 389

What stage does neurosyphillis occur in?

Answer 389

Any stage (primary, secondary, or tertiary) of syphilis infection! 
*can present like meningitis

Question 390

What does dissociative fugue mean?

Answer 390

Abrupt travel/ wandering around associated with traumatic circumstances (can be seen in dissociative amnesia, where patient cannot remember important personal information following trauma/ stress)

Question 391

What does Trichotillomania mean? How to treat?

Answer 391

Pulling out one’s own hair

In addition to CBT (cognitive behavioral therapy), can give Clomipramine (TCA) or SSRIs

Question 392

What 2 drugs can you give to treat Acute Dystonia?

Answer 392

1. Benztropine
2. Diphenhydramine
   (Acute Dystonia= extrapyramidal symptom, sudden sustained contraction of muscles like torticollis of the neck or severe back arching)

Question 393

State what drugs you can give to treat each of the extrapyramidal symptoms that can result as side effects of antipsychotics (dopamine receptor blockade):

1. Acute Dystonia (sudden muscle spasm/ stiffness like torticollis, back arching)
2. Akathisia (restlessness)
3. Parkinsonism (slow movement, cogwheel rigidity)
4. Tardive dyskinesia (chorea/ involuntary jerking movements, sticking out tongue)

Answer 393

1. Acute Dystonia—> benztropine, diphenhydramine
2. Akathisia—> benztropine, beta-blocker, benzo
3. Parkinsonism—> benztropine, amantadine
4. Tardive dyskinesia—> atypical antipsychotics (clozapine), valbenazine, deutetrabenazine