Week 3 (everything else...) Flashcards
(230 cards)
1
Q
What is the definition of substance intoxication?
A
recent ingestion of a substance
+
clinically significant problematic behavior and/or psychological changes attributable to the physiological effects of the substance on the CNS
+
fits an intoxication syndrome profile
+
not attributable to other causes
2
Q
What is the definition of substance withdrawal?
A
prolonged use of a substance
+
cessation of the substance and specific signs/symptoms associated with cessation
+
signs/symptoms cause clinically significant distress or impairment
+
symptoms not attributable to another cause
3
Q
What factors influence intoxication and withdrawal?
A
timing (chronic vs. acute)
route of administration
duration of action/potency
metabolism
mechanism of action
4
Q
What is the mechanism of alcohol intoxication?
A
interferes with membrane fluidity and affects function of ion channels and receptors
enhances nicotinic acetylcholine channels, GABA-A receptors, and increased inhibition of glutamate receptors and voltage-gated calcium channels
5
Q
What are the symptoms of alcohol intoxication?
A
slurred speech
incoordination
unsteady gait
nystagmus
impaired memory and concentration
stupor
coma
6
Q
What are the symptoms of alcohol withdrawal?
A
autonomic instability
nausea
vomiting
anxiety
sweats
hallucinations
tremor
headache
disorientation
7
Q
What are the four stages of alcohol withdrawal?
A
autonomic nervous system instability (occurs 6-48 hours into withdrawal)
seizures (occurs 12-48 hours into withdrawal)
hallucinosis (arises 12-24 hours into withdrawal and lasts up to 3 days)
delirium tremens (arises 3-7 days into withdrawal)
8
Q
What is ANS instability in alcohol withdrawal? What causes it?
A
insomnia, tremor, anxiety, agitation
GI distress, headaches, diaphoresis, palpitations
cause: surge in catecholamines that were suppressed by presence of alcohol
9
Q
What type of seizures are associated with alcohol withdrawal? What causes them?
A
generalized tonic-clonic seizures
cause: decreased GABA-A transmission, increased glutamate NMDA receptor signaling
10
Q
What types of hallucinations are associated with alcohol withdrawal? What causes them?
A
typically visual hallucinations with full orientation
cause: hypothesis is that it is related to increased dopamine signaling
11
Q
What is delirium tremens? Who is at high risk for this?
A
the final stage of alcohol withdrawal in some cases
leads to delirium, perception changes, diaphoresis, agitation
higher risk: sustained use prior to withdrawal, history of delerium tremens, comorbid illness, withdrawal signs when alcohol is still in system
mortality is 15%
12
Q
What are the causes of mortality associated with delirium tremens?
A
cardiovascular or respiratory collapse
13
Q
What is the mechanism of action of sedatives, hypnotics, and CNS depressants?
A
agonism of the GABA-A receptor (which is coupled to a chloride ion channel)
14
Q
What is the difference between mechanism of barbituates and benzodiazepines?
A
benzodiazepines: increase frequency of GABA-A chloride channel opening (plateaus)
barbituates: increases duration of GABA-A chloride channel opening (risk of toxicity)
15
Q
What are the symptoms of sedative/hypnotic/CNS depressant toxicity?
A
similar to alcohol and is dose dependent
small doses: motor incoordination, impaired cognition
high doses: impaired gait, speech, nystagmus, coma/death
16
Q
What are the symptoms of sedative/hypnotics/CNS depressants withdrawals?
A
autonomic hyperactivity, tremor, nausea, vomiting, insomnia, perceptual changes, anxiety, seizures, delirium
17
Q
Which benzodiazepines carry the greatest risk of withdrawal symptoms?
A
ones with short half-lives (temazepam, lorazepam, alprazolam)
18
Q
What is the mechanism of action of cocaine?
A
it inhibits the reuptake of dopamine (via dopamine reuptake transporter 1) into the presynaptic neuron
it also affects reuptake of norepinephrine and serotonin
19
Q
What is the mechanism of action of amphetamines?
A
two mechanisms:
causes release of dopamine from vesicles in the presynaptic neuron into the cytosol
reverses the flow of dopamine reuptake transporter 1 (increases synaptic dopamine)
20
Q
What parts of the brain do cocaine and amphetamines act on?
A
ventral tegmental areas (nucleus accumbens) and prefrontal cortex
21
Q
What are the symptoms of stimulant withdrawal?
A
dysphoric mood, depression, fatigue, vivid/unpleasant dreams, hypersomnia, low energy, increased appetite, psychomotor changes, cognitive slowing, suicidal ideation
22
Q
What are the symptoms of stimulant intoxication?
A
tachycardia, mydriasis, hypertension, perspiration, chills, nausea, vomiting, anorexia, psychomotor agitation or increased energy, aggression, increased libido, cardiac arrhythmias, seizures, chest pain, bruxism, decreased need for sleep, dyskinesias, dystonias, psychosis, bruxism, delirium
23
Q
What is the mechanism of action of hallucinogens?
A
variable
some are agonists at the serotonin 2A receptor
MDMA affects serotonin and monoamines system
PCP and ketamine antagonize the glutamate NMDA receptor
24
Q
What are the symptoms of PCP intoxication?
A
dissociation, depersonalization, derealization, vertical nystagmus, hypertension, numbness or decreased pain responses, ataxia, dysarthria, rigidity, seizures, severe aggression
25
What are the symptoms of hallucinogen intoxication?
hallucinations, depersonalization, derealization, ideas of reference, paranoia, anxiety, mydriasis, tachycardia, daphoresis, ataxia, vomiting, tremor, hyperreflexia, seizure, micro/macroscopia, synesthesias, light trails, intense perceptions
26
What is the mechanism of action of opioids?
primary effects via the mu-opioid receptor, though some secondary effects through the kappa and delta opioid receptors
27
What are the symptoms of opioid intoxication?
analgesia, meiosis, respiratory depression, constipation, decreased arousal, bradycardia, seizures, myoclonus
28
What are the symptoms of opioid withdrawal?
tachycardia, diaphoresis, anxiety, restlessness, mydriasis, myalgias, arthralgias, GI cramping/nausea, vomiting, lacrimation, rhinorrhea, tremor, yawning, irritability, piloerection
29
What is the mechanism of action of cannabinoids?
agonism of endogenous cannabinoid receptors
30
What is cyclic vomiting syndrome?
a syndrome that can result from prolonged use of cannabis
vomiting that is worse with food and relieved by hot baths
31
What are the symptoms of cannabis intoxication?
conjunctival injection, increased appetite, dry mouth, tachycardia, impaired motor coordination, euphoria, sense of slowed time, impaired judgement, social withdrawal
32
What are the symptoms of cannabis withdrawal?
irritability, anger, depression, anxiety, insomnia, disturbing dreams, anorexia, weight loss, restlessness, depression, abdominal pain, tremors, sweating, fever, chills, headache
33
What is the mechanism of action of tobacco?
agonists at the nicotinic acetylcholine receptor (higher affinity in the brain)
34
What are the symptoms of nicotine withdrawal?
irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, depression, insomnia
35
What is the mechanism of action of caffeine?
antagonism of adenosine receptors
36
What are the symptoms of caffiene intoxication?
restlessness, nervousness, excitement, insomnia, flushing, diuresis, GI upset, rambling speech, tachycardia, inexhaustibility, agitation
37
What are the symptoms of caffiene withdrawal?
headache, marked fatigue, drowsiness, dysphoria, depression, irritability, difficulty concentrating, nausea, vomiting, muscle stiffness
38
A patient presents with vomiting, diffuse myalgias, arthralgias, diarrhea, anxiety, mydriasis, irritability, and restlessness. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen withdrawal
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
h) opioid withdrawal
39
A patient presents with paranoia, high energy, irritability, dilated pupils, restlessness, hyperverbality, and skin excoriations? What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen withdrawal
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
c) stimulant intoxication
40
A patient presents with anxiety, restlessness, paranoia, nausea, headaches, diaphoresis, tremor, disorientation, and visual hallucinations. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen withdrawal
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
i) alchol withdrawal
i) alcohol withdrawal
41
A patient presents with fighting, irritability, yelling, stripping off clothes, unsteady gait, agitation, paranoia, dysarthria, and vertical nystagmus. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen intoxication
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
i) alchol withdrawal
j) hallucinogen withdrawal
e) hallucinogen intoxication
42
A patient presents with nausea and vomiting (3-4 episodes per hour) that is relieved by hot showers, weakness, difficulty focusing, signs of dehydration, injected conjunctivae, tachycardia, and dysphoric mood. What is this presentation most consistent with?
a) alcohol intoxication
b) cannabinoid intoxication
c) stimulant intoxication
d) opioid intoxication
e) hallucinogen intoxication
f) cannabinoid withdrawal
g) stimulant withdrawal
h) opioid withdrawal
i) alchol withdrawal
j) hallucinogen withdrawal
f) cannabinoid withdrawal
43
What is anorexia nervosa?
restriction of energy intake resulting in significantly low body weight as it relates to age/sex/development/physical health
+
intense fear of gaining weight or persistent behavior interfering with weight gain
+
distorted body image
44
What are the subtypes of anorexia nervosa?
restricting type (only restrictive behaviors)
binging/purging type (binges followed by compensatory purging)
45
What is bulimia nervosa?
a condition marked by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to "undo" the binge episode
occurs in the setting of being normal weight or overweight
occurs at least 1x/week for at least 3 months
46
What are the subtypes of bulemia?
purging type (compensation is self-induced vomiting)
non-purging type (compensation is something other than vomiting)
47
What is binge eating disorder?
an eating disorder marked by recurrent episodes of binge eating (at least 1x/week for 3 months) in which two binges include at least three of the below features:
eating until uncomfortably full
eating alone
sense of loss of control
eating in a state of self-disgust and shame
48
What is orthorexia?
an obsession with eating "healthy" foods that leads to impairingrules around foods that they can eat
49
What is avoidant/restrictive food intake disorder?
apparent lack of interest in eating or food, avoidance based on sensory characteristics, concern about aversiveness of food
includes inability to meet nutritional needs
*common in children with sensory issues*
50
What is the gender disparity of eating disorders?
much more prevalent in women across the board
51
Which eating disorder has the worst prognosis?
anorexia has higher rate of remaining highly symptomatic and highest mortality rate
52
What psychiatric disorders commonly co-occur with anorexia?
social phobia, OCD, MDD
53
What psychiatric disorders commonly co-occur with bulemia?
MDD, BPD, substance abuse, anxiety disorders
54
What psychiatric disorders commonly co-occur with binge eating disorder??
panic disorder/agoraphobia, MDD, PTSD, personality disorders
55
What are the medical complications of anorexia?
bradycardia, hypotension, hypothermia, dehydration
hypoglycemia, anemia, electrolyte abnormalities (hypophosphatemia, metabolic alkalosis, hypochloremia, hypokalemia)
decreased GI motility, lanugo hair, hair loss, amenorrhea, osteopenia
56
What are the medical complications of bulemia?
dehydration, orthostatic hypotension
metabolic alkalosis (vomiting), metabolic acidosis (laxative abuse)
dental enamel erosion, parotid gland enlargement, esophageal tears
57
What are the medical complications of binge eating disorder?
obesity, diabetes, hypertension, hormone irregularities, skeletal/muscular problems
58
What is the social theory of eating disorders?
emphasis on social pressures and unrealistic body ideals with reinforcement from media and culture
consistent with the higher rate of eating disorders in industrialized countries
59
What is the family theory of eating disorders?
suggests that anorexics come from more rigid, enmeshed families
suggests that bulimics come from more disengaged and chaotic families
60
What is the cognitive-behavior theory of eating disorders?
the idea that even "safe" dietining can create increased cravings and increased self-punishment for lapses
restricting makes a person feel successful, purging makes a person feel less guillty after relapse or afraid of weight gain
61
What are the biologic theories of eating disorders?
emphasis on how satiety is biologically mediated in the brain and genetically predetermined
emphasis on how undercontrol and overcontrol impulses may have a genetic component
62
What is the treatment for eating disorders?
multidisciplinary approach: medical, nutrition, family therapy, individual therapy, psychiatry (group and residential)
first treatment goal: medical and nutritional stabilization, weight restoration
after stabilization, psychotherapy is the primary treatment
63
What are the warning signs of anorexia?
excessive weight loss
odd food rituals
lack of menstrual cycles
fine hair on face/arms/torso
wearing baggy clothing
vigorous exercise at oddhours
paleness, dizziness, fainting
64
What are the indications for hospitalization in anorexia nervosa?
severe malnourishment
dehydration, electrolyte imbalance (beware of refeeding syndrome)
physically threatening complications
suicidal thoughts, psychosis
acute refeeding
65
What medication may be effective for anorexia nervosa?
olanzapine
66
What medications may be beneficial for bulemia nervosa?
fluoxetine
## Footnote
*bupropion is contraindicated due to seizure risk*
67
What is somatic symptom disorder?
a disorder where patients have complaints in many different organ systems (often dramatically out of proportion to symptoms) that are more common in times of stress, but there is no clear explanation or identifiable disorder
68
What are the biggest medical complications of somatic symptom disorder?
iatrogenic (secondarily aquired) medical problems due to overly aggressive workups
69
What is the pain specifier subtype of somatic symptom disorder?
a subcategory of somatic symptom disorder for patients with complaints of pain where psychological factors are felt to be either partial or ocmplete basis of the onset, severity, or maintenance of the pain
70
What social history factors are often linked to the pain specifier subtype?
childhood maltreatment, guilt, punishment
71
What is conversion disorder?
A disorder with abrupt onset of neurologic symptoms (other than pain) in the setting of a normal neuro exam and workup
often follows a triggering event
may be related to abnormal brain connectivity
72
What is are the demographics associated with conversion disorder?
appears at any age with no gender preponderance
more common in the neurologically impaired
73
What is illness anxiety disorder?
a disorder where patients have persistent, unreasonable worries about specific symptoms or that they have a particular serious medical condition in absence of evidence of a known disorder
74
What are the goals of management in patients with somatic symptoms and related diseases?
increasing: trust in physician, understanding of causes of symptoms, ability to deal with uncertainty, functioning/activity
conservative medical management
lifestyle modification
decreasing: invasive/risky low yield procedures, doctor shopping, secondary gain, psychosocial difficulties
75
What demographics are associated with illness anxiety disorder?
occurs at any age without gender predominance
associated with obsessive-compulsive or paranoid traits
76
When should patients with somatic symptom disorders be referred to a psychiatrist?
no clear time point where this should happen
ideally the patient will have some understanding of their diagnosis in order to accept/benefit from the referral
77
What are the diagnostic pitfalls in conversion disorder?
presenting symptoms are usually not consistent with definable neurological disease
brain imaging/EEG can be helpful
78
What is the cognitive distortion in somatic symptom disorder and how is it targeted by CBT?
the cognitive distortion often involves a misreading of bodily symptoms and/or an incorrect assumption that disease condition is present
79
What is the general gender and age prevalence of somatization disorder?
increased rates in women
usually onset between decade following puberty and age 30
80
What is the differential diagnosis for somatic symptom disorder?
lupus, MS, porphyria, sarcoidosis
any psychiatric disorder
81
What is factitious disorder vs. malingering?
factitious disorder: intentional act of faking symptoms/disease with an unconscious motivation and a primary gain of being in a sick role (more likely to agree to invasive tests)
malingering: intentional act with a conscious motivation and a secondary gain (less likely to agree to invasive tests)
82
What are the DSM criteria for a paraphilic disorder?
recurrent intense sexual arousal from specific fantasies, urges, or behaviors for at least 6 months
+
has acted on the urges with a non-consenting person or causes clinically significant distress or impairment
83
What are the types of paraphilic disorders?
fetishism, pedophilia, exhibitionism, voyeurism, masochism, sadism, frotteurism, transvestism
84
What is the gender and age preponderance of paraphilic disorders?
more common in men, develop in adolescence
85
What are the treatments of paraphilic disorders?
behavioral, cognitive, psychotropic medications, hormonal, 12-step addiction model
86
What are the Masters and Johnson stages of normal sexual response?
excitement: mental and physical
plateau: high level of excitement prior to orgasm
orgasm: muscular contraction
resolution: return to resting state
87
What are the Kaplan stages of normal sexual response?
desire
excitement
orgasm
pain
88
What are the gender differences in sexual responses?
men: more genitally focused, automatic, rapid and fixed
women: less genitally focused, slower, interpersonally-oriented and plastic
89
What physical factors can lead to sexual dysfunction?
aging
neurological, endocrine, vascular, gynecological or urological conditions
90
What are immediate causes of sexual dysfunction?
anxiety, lack of arousal
failure to engage in appropriate behavior, failure to communicate, partner's sexual dysfunction
91
What are remote causes of sexual dysfunction?
ambivalence, depression, stress
anger, avoidance of intimacy, communication difficulties
92
What are the subtypes of etiologies of sexual dysfunction?
secondary to medical conditions
secondary to substances/medications
93
What are the etiologies of sexual desire disorders?
hormones, pain, illness, depression, anxiety, stress, relationship conflict, other causes
94
What are examples of sexual desire disorders?
male hypoactive sexual desire
female sexual interest/arousal disorder
95
What are examples of sexual arousal disorders?
male erectile disorder
female sexual interest/arousal disorder
96
What are examples of orgasm phase disorders?
premature (early) ejaculation
delayed ejactulation
female orgasmic disorder
97
What are the causes of delayed ejaculation?
anxiety, over-control, constitutional causes, MS, SSRIs, spinal injury
98
What is genito-pelvic pain/penetration disorder?
difficulty with penetration during intercourse
dyspareunia (pain during intercourse)
fear or anxiety about painrelated to penetration
99
What is vaginismus?
conditioned physiological reaction, marked tensing of pelvic floor muscles usually secondary to fear, trauma, avoidance, or dyspareunia
100
What is the behavioral treatment for sexual dysfunction?
focus onsexual interactions
best done with couples if in a sexual relationship
integrates physical, psychological, and interpersonal elements of sexuality
may be coordinated with medical interventions
101
When does a paraphilia become a paraphilic disorder?
it becomes a disorder when there is problematic behavior related to the urgers
102
What is hypersexuality?
a condition also known as sex addiction, related to recurrent and intense sexual fantasies, urges, and behaviors
not published in the DSM-5
103
What are the proposed etiologies of paraphilias?
exposure to paraphilic behavior
split-off sexuality
tension reduction/self-soothing
problems in mature sexuality
problems with masculine identity
compulsivity, impulsivity, or other mental health conditions
104
Which paraphilia disorders have the highest recidivism?
patients with multiple paraphilias
patients without adult partners
patients who are resistant to treatment
patients with sociopathy
105
What aspect of gender and sexual identity forms earliest?
Sexual behavior
106
When do children usually develop the ability to label gender?
18-24 months
107
When do children usually begin to recognize sex differences and use gendered pronouns?
2-4 years
108
When do children usually report stable and consistent gender identity?
5-6 years
109
Which age groups report the largest amount of gender diversity?
younger age groups
110
What factors predict persistence of gender dysphoria into adolescence/adulthood?
a higher intensity of childhood dysphoria
a tendency to assert their gender cognitively versus affectively ("I am a boy" vs. "I feel like a boy")
111
What are psychiatric comorbidities associated with gender diversity?
basically everything
anxiety, depression, ADHD\< ASD, low self-esteem, etc.
112
What are puberty blockers?
GnRH agonists that delay puberty for youth to explore gender
they are reversible and alleviate psychological distress of developping secondary sex characteristics
113
What are the risks of GnRH agonists?
potentially decreased height
weight gain
decreased bone marrow density (catches up after starting HRT)
114
What are the effects of gender affirming hormones for transmasculine individuals? Transfeminine?
transmasculine: suppressed menstruation and breast development, deeper voice, male pattern hair, clitoral enlargement, lean muscle mass
transfeminine: development of breasts, maintenance of a higher-pitched voice, decreased male patterned hair, decreased testicular mass, avoidance of male pattern skeletal changes
115
What is impaired control in the context of substance use disorder?
taking larger amounts or for a longer period than intended
spending lots of time obtaining, using, or recovering
craving for substance
unsuccessful efforts to stop
116
What is risky use in the context of substance use disorder?
recurrent use in hazardous situations
continued use despite physical, psychological problems due to use
117
What is social impairment in the context of substance use disorder?
recurrent failure to fulfill major obligations due to use
continued use despite recurrent social or interpersonal problems due to use
important activities given up or reduced bc of substance use
118
What is pharmacologic dependence in the context of substance use disorder?
tolerance to effect of a substance
withdrawal symptoms when not using/using less
119
What factors increase risk of substance use disorder?
genes (metabolism, sensitivity, psychiatric disorders, personality traits)
personality traits
environmental contribution
120
What are the four psychosocial theories of risk for substance use disorders?
social control - low levels of social support, structure, and monitoring
social learning - role models that use substances and positive expectations of use outcomes
behavioral choice - limited other rewards available
stress and coping - high levels of exposure to stressful events and limited coping skills
121
What are the social motivations for substance use?
having a good time with friends, being sociable
122
What are the conformity related motivations for substance use?
being liked and fitting in
friends pressure to drink
123
What are the enhancement related motivations for substance use?
getting high
having fun
124
What are the coping related motivations for substance use?
forget problems/worries
help when feeling depressed/nervous
cheering up bad mood
125
What is the role of dopamine in substance use disorder?
dopamine reinforces effects of most drugs of abuse
increased dopamine transmission/levels
chronic drug use decreases dopamine release
126
What circuits are involved in the reward/salience network?
nucleus accumbens and ventral pallidum
127
What circuits are involved in the motivation/drive network?
orbital frontal cortex and subcallosal cortex
128
What circuits are involved in the memory/learning network?
amygdala and hippocampus
129
What circuits are involved in the control network?
prefrontal cortex and anterior cingulate gyrus
130
What should be considered when assessing required treatment intensity for substance use disorder?
withdrawal risk
medical/psychiatric problems
readiness for change
relapse risk
recovery environment
131
What are the direct effects of alcohol?
increases GABA-A receptor activation
decreases NMDA glutamate receptor activation
potentiate or inhibit other channels
132
What are the indirect effects of alcohol?
increase dopamine
increase beta-endorphins
133
What are the adverse effects of chronic alcohol use?
depression
cognitive deficits
Wernicke's encephalopathy
Wernicke-Korsakoff syndrome
dementia
134
What is the mechanism of GHB?
it acts at GABA-A and GABA-B receptors
135
What are the functions of CB1 vs CB2 receptors?
CB1: psychoactive (CNS)
CB2: pain mediation (immune cells, brainstem)
136
What is the mechanism of THC? CBD?
THC: partial agonist at CB1/2
CBD: antagonist at CB1/2
137
What are unique characteristics of synthetic cannabinoids?
full agonists
not detected on urine toxicology
138
What are the adverse effects of marijuana?
addiction risk (also for other drugs)
bronchitis symptoms
diminished lifetime achievement
schizophrenia risk
depression/anxiety
abnormal brain development
139
Which way of consuming cocaine has the largest potency?
intravenous crack
140
What is the mechanism of MDMA?
methamphetamine derivative
5HT and NE \> DA release
141
What are bath salts?
a cathinone product similar to MDMA or methamphetamines
142
What are serotonergic vs. dissociative hallucinogens?
serotonergic (ex. LSD): agonists of serotonin receptors
dissociative (ex. PCP): NMDA glutamate receptor antagonists
143
What drugs can be used to treat alcohol addiction? Contraindications
naltrexone - hepatitis, liver failure, opioid use
acamprosate - renal disease
disulifiram - monitor liver function and heart disease
144
What drugs can be used to treat opioid addiction?
methadone
buprenorphine
naltrexone
145
What is the utility of methadone for treating opioid addiction?
used inpatient for withdrawal
used in methadone clinics for treating addiction
146
What is the utility of the screener and opioid assessment for patients with pain short form? How is it interpreted?
It helps assess risk for misuse of opioid prescriptions
a score of 4+ indicates risk of misuse
147
If a patient who was prescribed hydrocodone gets a screening drug test that comes back positive for cocaine and negative for opiates. How would you interpret these results?
she's almost definitely using cocaine, she might not be taking hydrocodone
148
What is the primary use of a urine drug screen vs. pain management drug test?
urine drug screen: detect illicit drugs
pain management drug test: monitor patient adherence to pain management plan
149
What is typically included in a urine drug screen vs. pain management drug test?
urine drug screen: opiates, opioids, cocaine, amphetamines, benzos, cannabinoids
pain management: opiates, opioids, metabolites, commonly used illicit drugs
150
What is typical testing method of a urine drug screen vs. pain management drug test?
urine drug screen: immunoassay
pain management drug test: chromatography/mass spec or immunoassay
151
What is the cost of urine drug screens?
$20-100 for basic screen by immunoassay
$150-350 for expanded screen by mass spectrometry
152
Compare and contrast immunoassays vs. chromatography/mass spectrometry for drug screens?
immunoassay: cheaper, faster, measures drugs/metabolites indirectly, positive vs. negative results, significant false negatives and false positives (cross-reactivity)
chromatography/mass spec: costlier, slower, used to confirm immunoassay results, measures drugs/metabolites directly, may be qualitative or quantitative, minimizes false positives and false negatives
153
What is the effect of chronic use on the detection of marijuana in urine?
increases it by several weeks
154
What does a negative urine drug screen mean?
a patient may be taking the drug, but they cannot detect it
155
What are causes of false negative urine drug screens?
low concentration of drug in urine (relative to assay cutoff)
poor analytical sensitivity/wrong test choice
speciment tampering
156
Why does the amphetamine urine immunoassay have a high false positive rate?
numerous cross-reactivities
157
What is the efficacy of marijuana urine immunoassays?
cannot detect synthetic cannabinoids or CBD
low false positive rate (5-10%)
158
What is the utility of cocaine urine immunoassays?
measures cocaine's main metabolite
minimal cross-reactivity, few false positives
159
What is the utility of benzodiazepine urine immunoassays?
high false negative rate
low false positive rate
160
What are the major differences between using urine vs. hair or saliva for drug screening?
time where test will be positive
urine is shorter time than saliva or hair
161
How is mental health care funded?
public sources - medicaid, medicare, etc.
private sources - private insurance, out of pocket
162
What is the mental health parity and addiction equity act of 2008?
a federal law that prevented group health plans/health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those rather than on medical/surgical benefits
163
What did the affordable care act do to the Mental Health Parity and Addiction Equity Act of 2008?
it expanded it to include individual health insurance coverage (instead of just group)
164
What are community mental health treatment options?
medications, psychotherapy, assertive community treatment, intensive case management, psychiatric rehabilitation
165
An 81-year-old patient is admitted to the general medicine service with altered mental status. Clinical history reveals a 6-month history of forgetfulness prior to admission. Labs on admission reveal metabolic dysfunction and low B12 levels. Is a neuropsychology consult indicated at this time?
no - not until appropriate reversible causes of cognitive impairment have been corrected
166
A 32-year-old patient of estimated average premorbid intelligence (IQ = 98) undergoes a neuropsychological exame 3 weeks post mild traumatic brain injury. Results reveal a working memory Standard Score of 78 and processing speed Standard Score of 65. Are these scores grossly normal or abnormal?
abnormal - both fall below 1.3 SDs of the normative mean (mean = 100, SD = 15)
167
A 77-year-old patient presents with the primary complaint of progressively worsening forgetfulness x 2 years. Lab workup for reversible causes of dementia (B12, TSH, RPR) is unremarkable. Brain MRI shows minimal microvascular ischemic changes within the periventricular subcortical white matter and generalized volume loss. You refer the patient for a neuropsychological evaluation. Results reveal mild deficits in language and problem solving, and a moderate-to-severe memory dysfunction characterized by normal encoding of information but very poor delayed retrieval and recognition. What is the most likely diagnosis?
a) dementia of the Alzheimer's type
b) vascular dementia
c) retrograde amnesia
d) frontotemporal dementia
a) dementia of the Alzheimer's type
## Footnote
* characterized by rapid forgetting (mesial temporal lobe dysfunction)*
* b and d both would have impaired spontaneous retrieval of new info, but preserved retention over time*
* retrograde amnesia would present with problems recalling past autobiographical information*
168
How are standardized test scores interpreted for the neuropsychological exam?
normal range = 1.3 SDs around the mean
169
How is premorbid ability assessed in neuropsychological exams?
word reading ability + demographics
170
What does the Cattell-Horn-Carroll model test for?
intellectual functions
## Footnote
*fluid reasoning, comprehension-knowledge, visual processing, short-term memory, long-term storage and retrieval, processing speed, auditory processing*
171
What conditions are associated with intellectual impairment?
neurodevelopmental disorders, chromosomal abnormalities, toxicity/infections, metabolic conditions, schizophrenia
172
What conditions are associated with abnormal results on attention and processing speed evaluations?
ADHD
MS
vascular dementia
frontotemporal dementia
Parkinson's disease
concussion
chemo brain
anxiety
depression
173
How is attention and processing speed assessed?
with tests like trailmaking, digit span, or letter/number sequences
174
What abilities are tested as executive functions?
problem solving
cognitive control
behavior regulation
175
What conditions are associated wtih abnormalities in executive functions examinations?
pre-frontal cortex lesions
frontal lobe epilepsy
schizophrenia
OCD
ADHD
frontotemporal dementia
Parkinson's disease
moderate-severe traumatic brain injury
176
What abilities are assessed in language neuropsychological testing?
expression, comprehension, repetition, naming, verbal fluency, reading, writing
177
What conditions are associated with an abnormal language testing screen?
primary progressive aphasia
MCA stroke
verbal learning disorder
auditory processing disorder
low educational attainment, early environmental depravation
178
How is anterograde memory tested?
visually and verbally to test encoding, delayed recall, and recognition memory
179
What conditions are associated with an abnormal anterograde memory screen?
Alzheimer's disease
vascular dementia
temporal lobe epilepsy
mesial temporal sclerosis
ACoA aneurysm
depression
anxiety
180
What aspects of visuospatial functions are tested in visuospatial function testing?
visuoperceptual and visuoconstructional abilities
181
What conditions are associated with abnormal visuospatial function screening results?
posterior circulation strokes
parietal lobe lesions
visual agnosia
nonverbal learning disorder
cortical blindness
posterior cortical atrophy
182
What aspects of motor functions are tested with neuropsychological testing?
strength, speed, dexterity
183
What conditions are associated with an abnormal motor function screening result?
neuromuscular disorders
myotonic dystrophy
posterior frontal lesions
multiple sclerosis
parkinson's disease
neurodevelopmental disorders
184
How are personality/psychopathological traits evaluated in neuropsychological testing?
with self-report questionnaires that are compared to healthy and clinical samples
some scales are clinically derived based on groups of patients, others are theoretically derived from theoretical descriptions of syndromes
185
When is a neuropsychology consultation appropriate?
Yes: specific decision-making capacity assessment, suspected dementia, cognitive sequelae of TBI, suspected developmental disorder, pre-post treatment baseline, cognitive sequelae of conditions affecting cognition
No: delirium (need to asses reversible causes), agitation/uncooperative patient, reversible causes of altered mental state have not been ruled out or corrected, significant visual/motor/expressive limitations, acute psychiatric symptoms requiring inpatient treatment
186
An 87 y.o. woman comes to clinic concerned about her memory. You perform a MoCA and find that she is unable to repeat 3 numbers in reverse order. This indicates a deficit in:
a) executive function
b) attention
c) memory
d) naming
b) attention
187
A patient is brought to the ED from a music festibal. On exam you note that they have altered mental status, hyperthermia, and tachycardia. Their friends admit they were all taking "Molly" but a urine drug screen is negative. If the patient's symptoms and history are consistent with presumed ingestion of MDMA, why is their urine drug screen negative?
a) the amphetamine assay only detects MDMA by cross-reactivity
b) amphetamine is not commonly included in urine drug screens
c) the amphetamine cutoff is too low for detection of illicit drug use
d) MDMA metabolites are only detectable in the urine for 24 hours after use
a) the amphetamine assay only detects MDMA by cross-reactivity
188
A 66 y.o. man comes to clinic two weeks after the death of his wife. He says "I just can't believe shes gone. We were marreid 45 years. The other night I thought she was in the room with me. I stood up to go to her but realized it was just the curtain."
This is called a/an:
a) delusion
b) hallucination
c) illusion
d) obsession
c) illusion
189
After interviewing a patient, you note that the patient presents with detached coldness, social withdrawal, as well as eccentricity and magical thinking.
This presentation is consistent with extremes of which of the following personality factors in the Five Factor model?
a) high neuroticism, low agreeableness
b) low conscientiousness, low extraversion
c) high agreeableness, high conscientiousness
d) low extraversion, high openness
d) low extraversion, high openness
190
A patient with known BPD is determined by her doctor to have a recurrence of hypomania. Which of the following is **NOT** consistent with this assessment?
a) reduced sleeping
b) distractability and overactive thoughts
c) irritability
d) increased goal directed behaviors
e) excessive eating and weight gain
e) excessive eating and weight gain
191
Which one of the following agents is the most appropriate pharmacotherapy to treat a patient for EtOH withdrawal in the setting of underlying liver disease?
a) diazepam
b) flurazepam
c) lorazepam
d) flumitrazepam
e) alprazolam
c) lorazepam
192
Haloperidol has been used for many years to treat symptoms of delirium. Which of the following findings regarding the use of haloperidol in the treatment of delirium is accurate?
a) in patients on mechanical ventilation, use of haloperidol was superior to palcebo in reducing number of days free of delirium/coma, but did not affect length of ICU stay
b) despite the 2007 warning by the FDA regarding IV haloperidol, there are no findings that support QTc prolongation by oral haloperidol
c) for patients that are delirious due to acute respiratory failure or shock, ziprasidone is superior to haloperidole in reducing days free of delirium/coma
d) while haloperidol does not change the length of stay for patients who are delirious while mechanically ventilated, it has been associated with lower Richmond Agitation-Sedation Scale scores and reduced agitation
e) when haloperidol is used to address agitation in delirium, both BP and HR must be closely monitored due to significant side effects on both
d) while haloperidol does not change the length of stay for patients who are delirious while mechanically ventilated, it has been associated with lower Richmond Agitation-Sedation Scale scores and reduced agitation
193
Medications FDA approved for use in teen depression include which of the following?
a) fluoxetine and sertraline
b) fluoxetine and citalopram
c) fluoxetine and escitalopram
d) sertraline and citalopram
e) certraline and excitalopram
c) fluoxetine and escitalopram
194
Which one of the following has been implicated as a direct risk factor for ADHD?
a) sugary diet
b) too much TV/screen time
c) low SES
d) low birth weight
d) low birth weight
195
A 27 y.o. man with schizophrenia appears restless, a bit agitated, and unable to sit still. When seated, he bounces his knees and wrings his hands. He gets up to pace, and refuses your offer to take a seat again. He tells you that this began shortly after the dose of one of his meds was increased. Assuming this is a side effect, which medication is the most likely cause?
a) valproic acid
b) haloperidol
c) olanzapine
d) quetiapine
b) haloperidol
196
A 35 y.o. man, after suffering the tragic loss of his son in a car accident, is experiencing trouble falling asleep. The doctor wishes to treat him with a drug that is a selective MT1 agonist with minimal MT2 effects. What should be prescribed?
a) diphenhydramine
b) melatonin
c) eszopiclone
d) oxazepam
e) ramelteon
e) ramelteon
197
A 25 y.o. patient with an unplanned pregnancy learns at her 20-week ultrasound that her fetus has a neural tube defect. Earlier that year, she had been hospitalized for episodes of not sleeping, thinking she is the president's wife, and increased energy. She was prescribed a medication to help manage these symptoms. What medication was she most likely taking?
a) valproic acid
b) lithium
c) quetiapine
d) lamotrigine
e) haloperidol
a) valproic acid
198
Although the reliability of diagnosis of mental disorders has improved significantly, the development of the validity of many disorders in the DSM lags behind. What is the justification for continuing to use poorly validated criteria for mental disorders? To
a) medicalize normal human suffering
b) establish improved communication among practitioners and researchers
c) make patients feel better about their illness
d) decrease stigma of mental disorders
b) establish improved communication among practitioners and researchers
199
What neuropsychiatric treatment modality can be considered homeopathic?
a) transcranial magnetic stimulation
b) electroconvulsive therapy
c) benzodiazepine class of medications
d) interpersonal therapy
e) SSRI class of antidepressants
b) electroconvulsive therapy
200
Which of the following traits is specific to ASD and not social (pragmatic) communication disorder?
a) difficulty with changes in routine
b) difficulty in reading non-verbal cues of other individuals
c) difficulty in making friends
d) using language that is overly formal
e) normal language development but presenting as non-verbal in the presence of unfamiliar individuals
a) difficulty with changes in routine
201
A patient recently treated successfully with medication for MDD experiences an abrupt and severe worsening of depression when given a tryptophan depletion diet as part of a clinical study.
What type of medication is the patient most likely taking? A/an
a) benzodiazepine
b) norepinephrine reuptake inhibitor
c) anticonvulsant mood stabilizer
d) serotonin reuptake inhibitor
e) atypical antipsychotic
d) serotonin reuptake inhibitor
202
A 30 y.o. woman with BPD type I enters a manic episode with psychotic features. Prominent symptoms include insomnia, agitation, auditory hallucinations, and grandiose delusions. Her treating psychiatrist wishes to manage all of her symptoms with one medication. Which one of the following medications would effectively treat both manic symptoms and psychotic symptoms?
a) carbamazepine
b) lamotrigine
c) lithium
d) olanzepine
e) valproic acid
d) olanzepine
## Footnote
* a/b/e are all anticonvulsants, some of which can treat mania but not psychosis*
* lithium is first line for BPD, but does not work for psychotic symptoms*
203
A child runs through the kitchen wearing a superhero costume, which they had put on their self but could not fasten the ties. The child waves a sword and challenges their baby sibling to a duel. In the child's excitement, they knock over a glass of milk from the table. When the mother comes into the room, the child positions themself between their mother and the spill. When the mother asks about it, the child says "it fell." The child is likely at what Ericksonian stage of development?
a) trust vs. mistrust
b) autonomy vs. shame and doubt
c) initiative vs. guilt
d) industry vs. inferiority
e) generativity vs. stigmatization
c) initiative vs. guilt
204
What is the learning paradigm that utilizes rewards and punishments in increasing the desirable behavior or decreasing the undesirable behavior using different frequencies/ratios?
a) operant conditioning
b) learned helplessness
c) sensitization
d) classical conditioning
e) modeling
a) operant conditioning
205
While there are considerable differences in the techniques that psychodynamic and cognitive behavioral therapists use, there are certain common factors which they share. In addition to acknowledging the importance of this therapeutic alliance, effective therapists in both modalities:
a) speak clearly and give directed advice
b) ask the patient to announce when treatment goals have been met
c) are empathetic listeners
d) give homework assignments
c) are empathetic listeners
206
Which of the following is TRUE regarding the DSM-5 criteria for OCD?
a) both obsessions and compulsions are required to meet criteria
b) obsessions related to cleanlieness are present in only about 10% of cases
c) surgical options appear to have moderate benefit for refractory cases
d) it can present in children following infection by Staph Aureus
e) a majority of patients present with psychotic deterioration
c) surgical options appear to have moderate benefit for refractory cases
207
Mrs. Jones presents to the ED with headache, visual changes, palpitations, and fever. She has a long history of depression and passive thoughts of death. She tells you that her psychiatrist has tried several medications over the years but nothing has worked. Four days ago, her physician prescribed a new antidepressant whose name the patient does not recall. The patient was feeling well until this morning. She reports that last night she went out to dinner at a new French restaurant with her husband and wonders whether or not she has food poisoning, but her husband is feeling fine. On exam, she has a fever of 102, BP is 180/100 mmHg. She has a resting tremor and myoclonic jerks. Which of the following antidepressants did her psychiatrist most likely prescribe?
a) amitryptyline
b) citalopram
c) venlafaxine
d) phenelzine
d) phenelzine
## Footnote
* this drug is an MAO-I, and the symptoms are probably due to eating tyramine rich foods at a french restaurant*
* a is a tricyclic*
* b is an SSRI*
* c is an SNRI*
208
The prevalence of schizophrenia in the US is closest to:
a) 0.001%
b) 0.1%
c) 1%
d) 5%
e) 9%
c) 1%
209
Among the following, which is the strongest predictor of completed suicide?
a) recent discharge from inpatient psych unit
b) major life change
c) diagnosis of pancreatic cancer
d) recent suicide attempt
e) suicidal ideation
d) recent suicide attempt
210
A 25 y.o. woman with a history of drug abuse and depression presents to the ED after taking ten fluoxetine tablets. She reports that her boyfriend broke up with her. She states that he was all that mattered to her. She describes feeling very unsure of what to do now that she is alone. She looks up at the evaluator with hopeful eyes, and asks, "will you help me figure out what to do?"
This patient most likely has which of the following personality disorders:
a) borderline
b) avoidant
c) paranoid
d) schizoid
e) dependent
e) dependent
211
According to Goffman, which one of the following could be considered a "discreditable" stigma?
a) race/ethnicity
b) gender
c) physical disability
d) HIV infection
d) HIV infection
## Footnote
*all the others are discredited because they are visible*
212
Which of the following is NOT a potential approach to improving the integration of mental health and physical health care?
a) training providers to provide interdisciplinary care (ex. CBT for depression and diabetes self-care)
b) linking clinical information systems so that a pts health info can be shared across providers
c) co-locating mental health and physical health services in a single clinic
d) uncoupling health insurance benefits so that patients have separate plans for mental health and physical health
e) reorganizing financial incentives to promote care for co-morbid conditions
d) uncoupling health insurance benefits so that patients have separate plans for mental health and physical health
213
"Playing down" the impact of a known stigma is often considered to be:
a) covering
b) passing
c) assimilation
d) conversion
a) covering
214
What is allostatic load?
the ability of an organism to adapt over time
215
What is the response of humans to normal stressors? Overwhelming stressors?
normal stressors: initial "fight or flight" response, but resilience over time
overwhelming stressors: impaired memory, impaired learning, downregulation of somatic nervous system, abnormalities in HPA axis, cardiovascular disease, immune disorders
216
What is the diagnostic criteria for acute stress disorder?
- person has been exposed to a traumatic event that involved actual or threatened death/serious injury or a threat to physical integrity of self or others
- person has three or more of these symptoms during or directly after event: numbing/detachment/emotionless, reduced awareness of surroundings, derealization, depersonalization, dissociative amnesia
- trauma is persistently re-experienced (flashbacks, nightmares, etc.)
- avoidance of stimuli that arouse memories
- symptoms of anxiety or arousal
- clinically significant distress
- distrubance lasting between 2 days to 4 weeks
- disturbance not due to substance or medical condition
217
What are the diagnostic criteria for PTSD?
- person survived a trauma (same type as acute stress disorder)
- traumatic event persistently reexperienced
- persistent avoidance of stimuli
- persistent symptoms of increased arousal
- duration of symptoms more than one month
- disturbance causes significant distress or impaired functioning
218
What is acute PTSD vs. chronic PTSD vs. delayed onset PTSD?
acute: \< 3 months
chronic: \> 3 months
delayed onset: onset of symptoms occurs more than 6 mo after stressor
219
What are pre-trauma PTSD risk factors?
previous psych illness/behavioral problems
female gender
homozygous short alleles of 5HTTP transporter
low intelligence
living in violent, poorly functioning community
lmited previous mastery of life challenges
early childhood maltreatment
220
What are peri- and post-trauma PTSD risk factors?
severity of trauma
length of exposure
level of perceived stress
intensity of trauma
social supports/emergency response
221
What is the lifetime prevalance of PTSD in the US? For veterans?
8% for all of US
20% of veterans
222
What is the likelihood of comorbid conditions with PTSD?
almost always 1 or 2 comorbid psychiatric conditions (depression, pain, substance dependence)
## Footnote
*if you see it diagnosed alone, be suspicious*
223
What are the most frequent types of trauma in the US?
sudden, traumatic death of a loved one
witnessing somebody be badly injured or killed
being in a life threatening accident
men: accidents, attacks, combat experiences, weapon threats
women: rape, sexual molestation, childhood maltreatment
224
What are the components of a PTSD assessment?
history, mental status exam, physical exam
PTSD rating scales
corroborative history
rule out other conditions
225
How is PTSD treated?
non-pharmacological: establish safe environment, allow patient to tell story, psychotherapy
pharmacological: SSRI, sympathetic blockers, small doses of anti-psychotics
226
What is the utility of SSRIs in treating PTSD?
helpful for intrusive memories, numbing, hypervigilance, and comorbid depression
227
What is the utility of drugs like prazosin, propanolol, clonidine, and guanfacine for treating PTSD?
they are sympathetic blockers
they help with hypervigilance and insomnia
228
What is the utility of benzodiazepines for PTSD?
not helpful, do not prescribe !
they prolong course of PTSD, worsen outcomes of psychoterapy, and can cause aggression
229
What is the utility of antipsychotics in the management of PTSD?
small doses of atypical antipsychotics can help with sleep and dissociative hallucinosis
230
What is psychogenic amnesia? How can it be distinguished from transient global amnesia?
retrograde amnesia without anterograde amnesia with a psychogenic cause that can be associated with trauma
in psychogenic amnesia, identity is retained and there is no anterograde amnesia
