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Week 3 (everything else...) Flashcards

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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

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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

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3
Q

What factors influence intoxication and withdrawal?

A

timing (chronic vs. acute)

route of administration

duration of action/potency

metabolism

mechanism of action

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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

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5
Q

What are the symptoms of alcohol intoxication?

A

slurred speech

incoordination

unsteady gait

nystagmus

impaired memory and concentration

stupor

coma

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6
Q

What are the symptoms of alcohol withdrawal?

A

autonomic instability

nausea

vomiting

anxiety

sweats

hallucinations

tremor

headache

disorientation

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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)

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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

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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

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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

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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%

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12
Q

What are the causes of mortality associated with delirium tremens?

A

cardiovascular or respiratory collapse

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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)

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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)

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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

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16
Q

What are the symptoms of sedative/hypnotics/CNS depressants withdrawals?

A

autonomic hyperactivity, tremor, nausea, vomiting, insomnia, perceptual changes, anxiety, seizures, delirium

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17
Q

Which benzodiazepines carry the greatest risk of withdrawal symptoms?

A

ones with short half-lives (temazepam, lorazepam, alprazolam)

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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

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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)

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20
Q

What parts of the brain do cocaine and amphetamines act on?

A

ventral tegmental areas (nucleus accumbens) and prefrontal cortex

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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

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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

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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

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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

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25
Q

What are the symptoms of hallucinogen intoxication?

A

hallucinations, depersonalization, derealization, ideas of reference, paranoia, anxiety, mydriasis, tachycardia, daphoresis, ataxia, vomiting, tremor, hyperreflexia, seizure, micro/macroscopia, synesthesias, light trails, intense perceptions

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26
Q

What is the mechanism of action of opioids?

A

primary effects via the mu-opioid receptor, though some secondary effects through the kappa and delta opioid receptors

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27
Q

What are the symptoms of opioid intoxication?

A

analgesia, meiosis, respiratory depression, constipation, decreased arousal, bradycardia, seizures, myoclonus

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28
Q

What are the symptoms of opioid withdrawal?

A

tachycardia, diaphoresis, anxiety, restlessness, mydriasis, myalgias, arthralgias, GI cramping/nausea, vomiting, lacrimation, rhinorrhea, tremor, yawning, irritability, piloerection

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29
Q

What is the mechanism of action of cannabinoids?

A

agonism of endogenous cannabinoid receptors

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30
Q

What is cyclic vomiting syndrome?

A

a syndrome that can result from prolonged use of cannabis

vomiting that is worse with food and relieved by hot baths

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31
Q

What are the symptoms of cannabis intoxication?

A

conjunctival injection, increased appetite, dry mouth, tachycardia, impaired motor coordination, euphoria, sense of slowed time, impaired judgement, social withdrawal

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32
Q

What are the symptoms of cannabis withdrawal?

A

irritability, anger, depression, anxiety, insomnia, disturbing dreams, anorexia, weight loss, restlessness, depression, abdominal pain, tremors, sweating, fever, chills, headache

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33
Q

What is the mechanism of action of tobacco?

A

agonists at the nicotinic acetylcholine receptor (higher affinity in the brain)

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34
Q

What are the symptoms of nicotine withdrawal?

A

irritability, frustration, anger, anxiety, difficulty concentrating, increased appetite, restlessness, depression, insomnia

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35
Q

What is the mechanism of action of caffeine?

A

antagonism of adenosine receptors

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36
Q

What are the symptoms of caffiene intoxication?

A

restlessness, nervousness, excitement, insomnia, flushing, diuresis, GI upset, rambling speech, tachycardia, inexhaustibility, agitation

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37
Q

What are the symptoms of caffiene withdrawal?

A

headache, marked fatigue, drowsiness, dysphoria, depression, irritability, difficulty concentrating, nausea, vomiting, muscle stiffness

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38
Q

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

A

h) opioid withdrawal

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39
Q

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

A

c) stimulant intoxication

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40
Q

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

A

i) alcohol withdrawal

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41
Q

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

A

e) hallucinogen intoxication

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42
Q

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

A

f) cannabinoid withdrawal

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43
Q

What is anorexia nervosa?

A

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

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44
Q

What are the subtypes of anorexia nervosa?

A

restricting type (only restrictive behaviors)

binging/purging type (binges followed by compensatory purging)

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45
Q

What is bulimia nervosa?

A

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

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46
Q

What are the subtypes of bulemia?

A

purging type (compensation is self-induced vomiting)

non-purging type (compensation is something other than vomiting)

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47
Q

What is binge eating disorder?

A

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

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48
Q

What is orthorexia?

A

an obsession with eating “healthy” foods that leads to impairingrules around foods that they can eat

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49
Q

What is avoidant/restrictive food intake disorder?

A

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

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50
Q

What is the gender disparity of eating disorders?

A

much more prevalent in women across the board

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51
Q

Which eating disorder has the worst prognosis?

A

anorexia has higher rate of remaining highly symptomatic and highest mortality rate

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52
Q

What psychiatric disorders commonly co-occur with anorexia?

A

social phobia, OCD, MDD

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53
Q

What psychiatric disorders commonly co-occur with bulemia?

A

MDD, BPD, substance abuse, anxiety disorders

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54
Q

What psychiatric disorders commonly co-occur with binge eating disorder??

A

panic disorder/agoraphobia, MDD, PTSD, personality disorders

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55
Q

What are the medical complications of anorexia?

A

bradycardia, hypotension, hypothermia, dehydration

hypoglycemia, anemia, electrolyte abnormalities (hypophosphatemia, metabolic alkalosis, hypochloremia, hypokalemia)

decreased GI motility, lanugo hair, hair loss, amenorrhea, osteopenia

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56
Q

What are the medical complications of bulemia?

A

dehydration, orthostatic hypotension

metabolic alkalosis (vomiting), metabolic acidosis (laxative abuse)

dental enamel erosion, parotid gland enlargement, esophageal tears

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57
Q

What are the medical complications of binge eating disorder?

A

obesity, diabetes, hypertension, hormone irregularities, skeletal/muscular problems

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58
Q

What is the social theory of eating disorders?

A

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

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59
Q

What is the family theory of eating disorders?

A

suggests that anorexics come from more rigid, enmeshed families

suggests that bulimics come from more disengaged and chaotic families

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60
Q

What is the cognitive-behavior theory of eating disorders?

A

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

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61
Q

What are the biologic theories of eating disorders?

A

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

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62
Q

What is the treatment for eating disorders?

A

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

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63
Q

What are the warning signs of anorexia?

A

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

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64
Q

What are the indications for hospitalization in anorexia nervosa?

A

severe malnourishment

dehydration, electrolyte imbalance (beware of refeeding syndrome)

physically threatening complications

suicidal thoughts, psychosis

acute refeeding

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65
Q

What medication may be effective for anorexia nervosa?

A

olanzapine

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66
Q

What medications may be beneficial for bulemia nervosa?

A

fluoxetine

bupropion is contraindicated due to seizure risk

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67
Q

What is somatic symptom disorder?

A

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

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68
Q

What are the biggest medical complications of somatic symptom disorder?

A

iatrogenic (secondarily aquired) medical problems due to overly aggressive workups

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69
Q

What is the pain specifier subtype of somatic symptom disorder?

A

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

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70
Q

What social history factors are often linked to the pain specifier subtype?

A

childhood maltreatment, guilt, punishment

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71
Q

What is conversion disorder?

A

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

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72
Q

What is are the demographics associated with conversion disorder?

A

appears at any age with no gender preponderance

more common in the neurologically impaired

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73
Q

What is illness anxiety disorder?

A

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

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74
Q

What are the goals of management in patients with somatic symptoms and related diseases?

A

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

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75
Q

What demographics are associated with illness anxiety disorder?

A

occurs at any age without gender predominance

associated with obsessive-compulsive or paranoid traits

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76
Q

When should patients with somatic symptom disorders be referred to a psychiatrist?

A

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

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77
Q

What are the diagnostic pitfalls in conversion disorder?

A

presenting symptoms are usually not consistent with definable neurological disease

brain imaging/EEG can be helpful

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78
Q

What is the cognitive distortion in somatic symptom disorder and how is it targeted by CBT?

A

the cognitive distortion often involves a misreading of bodily symptoms and/or an incorrect assumption that disease condition is present

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79
Q

What is the general gender and age prevalence of somatization disorder?

A

increased rates in women

usually onset between decade following puberty and age 30

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80
Q

What is the differential diagnosis for somatic symptom disorder?

A

lupus, MS, porphyria, sarcoidosis

any psychiatric disorder

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81
Q

What is factitious disorder vs. malingering?

A

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)

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82
Q

What are the DSM criteria for a paraphilic disorder?

A

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

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83
Q

What are the types of paraphilic disorders?

A

fetishism, pedophilia, exhibitionism, voyeurism, masochism, sadism, frotteurism, transvestism

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84
Q

What is the gender and age preponderance of paraphilic disorders?

A

more common in men, develop in adolescence

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85
Q

What are the treatments of paraphilic disorders?

A

behavioral, cognitive, psychotropic medications, hormonal, 12-step addiction model

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86
Q

What are the Masters and Johnson stages of normal sexual response?

A

excitement: mental and physical
plateau: high level of excitement prior to orgasm
orgasm: muscular contraction
resolution: return to resting state

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87
Q

What are the Kaplan stages of normal sexual response?

A

desire

excitement

orgasm

pain

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88
Q

What are the gender differences in sexual responses?

A

men: more genitally focused, automatic, rapid and fixed
women: less genitally focused, slower, interpersonally-oriented and plastic

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89
Q

What physical factors can lead to sexual dysfunction?

A

aging

neurological, endocrine, vascular, gynecological or urological conditions

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90
Q

What are immediate causes of sexual dysfunction?

A

anxiety, lack of arousal

failure to engage in appropriate behavior, failure to communicate, partner’s sexual dysfunction

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91
Q

What are remote causes of sexual dysfunction?

A

ambivalence, depression, stress

anger, avoidance of intimacy, communication difficulties

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92
Q

What are the subtypes of etiologies of sexual dysfunction?

A

secondary to medical conditions

secondary to substances/medications

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93
Q

What are the etiologies of sexual desire disorders?

A

hormones, pain, illness, depression, anxiety, stress, relationship conflict, other causes

94
Q

What are examples of sexual desire disorders?

A

male hypoactive sexual desire

female sexual interest/arousal disorder

95
Q

What are examples of sexual arousal disorders?

A

male erectile disorder

female sexual interest/arousal disorder

96
Q

What are examples of orgasm phase disorders?

A

premature (early) ejaculation

delayed ejactulation

female orgasmic disorder

97
Q

What are the causes of delayed ejaculation?

A

anxiety, over-control, constitutional causes, MS, SSRIs, spinal injury

98
Q

What is genito-pelvic pain/penetration disorder?

A

difficulty with penetration during intercourse

dyspareunia (pain during intercourse)

fear or anxiety about painrelated to penetration

99
Q

What is vaginismus?

A

conditioned physiological reaction, marked tensing of pelvic floor muscles usually secondary to fear, trauma, avoidance, or dyspareunia

100
Q

What is the behavioral treatment for sexual dysfunction?

A

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
Q

When does a paraphilia become a paraphilic disorder?

A

it becomes a disorder when there is problematic behavior related to the urgers

102
Q

What is hypersexuality?

A

a condition also known as sex addiction, related to recurrent and intense sexual fantasies, urges, and behaviors

not published in the DSM-5

103
Q

What are the proposed etiologies of paraphilias?

A

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
Q

Which paraphilia disorders have the highest recidivism?

A

patients with multiple paraphilias

patients without adult partners

patients who are resistant to treatment

patients with sociopathy

105
Q

What aspect of gender and sexual identity forms earliest?

A

Sexual behavior

106
Q

When do children usually develop the ability to label gender?

A

18-24 months

107
Q

When do children usually begin to recognize sex differences and use gendered pronouns?

A

2-4 years

108
Q

When do children usually report stable and consistent gender identity?

A

5-6 years

109
Q

Which age groups report the largest amount of gender diversity?

A

younger age groups

110
Q

What factors predict persistence of gender dysphoria into adolescence/adulthood?

A

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
Q

What are psychiatric comorbidities associated with gender diversity?

A

basically everything

anxiety, depression, ADHD< ASD, low self-esteem, etc.

112
Q

What are puberty blockers?

A

GnRH agonists that delay puberty for youth to explore gender

they are reversible and alleviate psychological distress of developping secondary sex characteristics

113
Q

What are the risks of GnRH agonists?

A

potentially decreased height

weight gain

decreased bone marrow density (catches up after starting HRT)

114
Q

What are the effects of gender affirming hormones for transmasculine individuals? Transfeminine?

A

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
Q

What is impaired control in the context of substance use disorder?

A

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
Q

What is risky use in the context of substance use disorder?

A

recurrent use in hazardous situations

continued use despite physical, psychological problems due to use

117
Q

What is social impairment in the context of substance use disorder?

A

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
Q

What is pharmacologic dependence in the context of substance use disorder?

A

tolerance to effect of a substance

withdrawal symptoms when not using/using less

119
Q

What factors increase risk of substance use disorder?

A

genes (metabolism, sensitivity, psychiatric disorders, personality traits)

personality traits

environmental contribution

120
Q

What are the four psychosocial theories of risk for substance use disorders?

A

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
Q

What are the social motivations for substance use?

A

having a good time with friends, being sociable

122
Q

What are the conformity related motivations for substance use?

A

being liked and fitting in

friends pressure to drink

123
Q

What are the enhancement related motivations for substance use?

A

getting high

having fun

124
Q

What are the coping related motivations for substance use?

A

forget problems/worries

help when feeling depressed/nervous

cheering up bad mood

125
Q

What is the role of dopamine in substance use disorder?

A

dopamine reinforces effects of most drugs of abuse

increased dopamine transmission/levels

chronic drug use decreases dopamine release

126
Q

What circuits are involved in the reward/salience network?

A

nucleus accumbens and ventral pallidum

127
Q

What circuits are involved in the motivation/drive network?

A

orbital frontal cortex and subcallosal cortex

128
Q

What circuits are involved in the memory/learning network?

A

amygdala and hippocampus

129
Q

What circuits are involved in the control network?

A

prefrontal cortex and anterior cingulate gyrus

130
Q

What should be considered when assessing required treatment intensity for substance use disorder?

A

withdrawal risk

medical/psychiatric problems

readiness for change

relapse risk

recovery environment

131
Q

What are the direct effects of alcohol?

A

increases GABA-A receptor activation

decreases NMDA glutamate receptor activation

potentiate or inhibit other channels

132
Q

What are the indirect effects of alcohol?

A

increase dopamine

increase beta-endorphins

133
Q

What are the adverse effects of chronic alcohol use?

A

depression

cognitive deficits

Wernicke’s encephalopathy

Wernicke-Korsakoff syndrome

dementia

134
Q

What is the mechanism of GHB?

A

it acts at GABA-A and GABA-B receptors

135
Q

What are the functions of CB1 vs CB2 receptors?

A

CB1: psychoactive (CNS)

CB2: pain mediation (immune cells, brainstem)

136
Q

What is the mechanism of THC? CBD?

A

THC: partial agonist at CB1/2

CBD: antagonist at CB1/2

137
Q

What are unique characteristics of synthetic cannabinoids?

A

full agonists

not detected on urine toxicology

138
Q

What are the adverse effects of marijuana?

A

addiction risk (also for other drugs)

bronchitis symptoms

diminished lifetime achievement

schizophrenia risk

depression/anxiety

abnormal brain development

139
Q

Which way of consuming cocaine has the largest potency?

A

intravenous crack

140
Q

What is the mechanism of MDMA?

A

methamphetamine derivative

5HT and NE > DA release

141
Q

What are bath salts?

A

a cathinone product similar to MDMA or methamphetamines

142
Q

What are serotonergic vs. dissociative hallucinogens?

A

serotonergic (ex. LSD): agonists of serotonin receptors

dissociative (ex. PCP): NMDA glutamate receptor antagonists

143
Q

What drugs can be used to treat alcohol addiction? Contraindications

A

naltrexone - hepatitis, liver failure, opioid use

acamprosate - renal disease

disulifiram - monitor liver function and heart disease

144
Q

What drugs can be used to treat opioid addiction?

A

methadone

buprenorphine

naltrexone

145
Q

What is the utility of methadone for treating opioid addiction?

A

used inpatient for withdrawal

used in methadone clinics for treating addiction

146
Q

What is the utility of the screener and opioid assessment for patients with pain short form? How is it interpreted?

A

It helps assess risk for misuse of opioid prescriptions

a score of 4+ indicates risk of misuse

147
Q

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?

A

she’s almost definitely using cocaine, she might not be taking hydrocodone

148
Q

What is the primary use of a urine drug screen vs. pain management drug test?

A

urine drug screen: detect illicit drugs

pain management drug test: monitor patient adherence to pain management plan

149
Q

What is typically included in a urine drug screen vs. pain management drug test?

A

urine drug screen: opiates, opioids, cocaine, amphetamines, benzos, cannabinoids

pain management: opiates, opioids, metabolites, commonly used illicit drugs

150
Q

What is typical testing method of a urine drug screen vs. pain management drug test?

A

urine drug screen: immunoassay

pain management drug test: chromatography/mass spec or immunoassay

151
Q

What is the cost of urine drug screens?

A

$20-100 for basic screen by immunoassay

$150-350 for expanded screen by mass spectrometry

152
Q

Compare and contrast immunoassays vs. chromatography/mass spectrometry for drug screens?

A

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
Q

What is the effect of chronic use on the detection of marijuana in urine?

A

increases it by several weeks

154
Q

What does a negative urine drug screen mean?

A

a patient may be taking the drug, but they cannot detect it

155
Q

What are causes of false negative urine drug screens?

A

low concentration of drug in urine (relative to assay cutoff)

poor analytical sensitivity/wrong test choice

speciment tampering

156
Q

Why does the amphetamine urine immunoassay have a high false positive rate?

A

numerous cross-reactivities

157
Q

What is the efficacy of marijuana urine immunoassays?

A

cannot detect synthetic cannabinoids or CBD

low false positive rate (5-10%)

158
Q

What is the utility of cocaine urine immunoassays?

A

measures cocaine’s main metabolite

minimal cross-reactivity, few false positives

159
Q

What is the utility of benzodiazepine urine immunoassays?

A

high false negative rate

low false positive rate

160
Q

What are the major differences between using urine vs. hair or saliva for drug screening?

A

time where test will be positive

urine is shorter time than saliva or hair

161
Q

How is mental health care funded?

A

public sources - medicaid, medicare, etc.

private sources - private insurance, out of pocket

162
Q

What is the mental health parity and addiction equity act of 2008?

A

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
Q

What did the affordable care act do to the Mental Health Parity and Addiction Equity Act of 2008?

A

it expanded it to include individual health insurance coverage (instead of just group)

164
Q

What are community mental health treatment options?

A

medications, psychotherapy, assertive community treatment, intensive case management, psychiatric rehabilitation

165
Q

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?

A

no - not until appropriate reversible causes of cognitive impairment have been corrected

166
Q

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?

A

abnormal - both fall below 1.3 SDs of the normative mean (mean = 100, SD = 15)

167
Q

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

a) dementia of the Alzheimer’s type

  • 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
Q

How are standardized test scores interpreted for the neuropsychological exam?

A

normal range = 1.3 SDs around the mean

169
Q

How is premorbid ability assessed in neuropsychological exams?

A

word reading ability + demographics

170
Q

What does the Cattell-Horn-Carroll model test for?

A

intellectual functions

fluid reasoning, comprehension-knowledge, visual processing, short-term memory, long-term storage and retrieval, processing speed, auditory processing

171
Q

What conditions are associated with intellectual impairment?

A

neurodevelopmental disorders, chromosomal abnormalities, toxicity/infections, metabolic conditions, schizophrenia

172
Q

What conditions are associated with abnormal results on attention and processing speed evaluations?

A

ADHD

MS
vascular dementia

frontotemporal dementia

Parkinson’s disease

concussion

chemo brain

anxiety

depression

173
Q

How is attention and processing speed assessed?

A

with tests like trailmaking, digit span, or letter/number sequences

174
Q

What abilities are tested as executive functions?

A

problem solving

cognitive control

behavior regulation

175
Q

What conditions are associated wtih abnormalities in executive functions examinations?

A

pre-frontal cortex lesions

frontal lobe epilepsy

schizophrenia

OCD
ADHD
frontotemporal dementia

Parkinson’s disease

moderate-severe traumatic brain injury

176
Q

What abilities are assessed in language neuropsychological testing?

A

expression, comprehension, repetition, naming, verbal fluency, reading, writing

177
Q

What conditions are associated with an abnormal language testing screen?

A

primary progressive aphasia

MCA stroke

verbal learning disorder

auditory processing disorder

low educational attainment, early environmental depravation

178
Q

How is anterograde memory tested?

A

visually and verbally to test encoding, delayed recall, and recognition memory

179
Q

What conditions are associated with an abnormal anterograde memory screen?

A

Alzheimer’s disease

vascular dementia

temporal lobe epilepsy

mesial temporal sclerosis

ACoA aneurysm

depression

anxiety

180
Q

What aspects of visuospatial functions are tested in visuospatial function testing?

A

visuoperceptual and visuoconstructional abilities

181
Q

What conditions are associated with abnormal visuospatial function screening results?

A

posterior circulation strokes

parietal lobe lesions

visual agnosia

nonverbal learning disorder

cortical blindness

posterior cortical atrophy

182
Q

What aspects of motor functions are tested with neuropsychological testing?

A

strength, speed, dexterity

183
Q

What conditions are associated with an abnormal motor function screening result?

A

neuromuscular disorders

myotonic dystrophy

posterior frontal lesions

multiple sclerosis

parkinson’s disease

neurodevelopmental disorders

184
Q

How are personality/psychopathological traits evaluated in neuropsychological testing?

A

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
Q

When is a neuropsychology consultation appropriate?

A

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
Q

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

A

b) attention

187
Q

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

a) the amphetamine assay only detects MDMA by cross-reactivity

188
Q

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

A

c) illusion

189
Q

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

A

d) low extraversion, high openness

190
Q

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

A

e) excessive eating and weight gain

191
Q

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

A

c) lorazepam

192
Q

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

A

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
Q

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

A

c) fluoxetine and escitalopram

194
Q

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

A

d) low birth weight

195
Q

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

A

b) haloperidol

196
Q

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

A

e) ramelteon

197
Q

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

a) valproic acid

198
Q

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

A

b) establish improved communication among practitioners and researchers

199
Q

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

A

b) electroconvulsive therapy

200
Q

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

a) difficulty with changes in routine

201
Q

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

A

d) serotonin reuptake inhibitor

202
Q

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

A

d) olanzepine

  • 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
Q

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

A

c) initiative vs. guilt

204
Q

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

a) operant conditioning

205
Q

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

A

c) are empathetic listeners

206
Q

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

A

c) surgical options appear to have moderate benefit for refractory cases

207
Q

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

A

d) phenelzine

  • 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
Q

The prevalence of schizophrenia in the US is closest to:

a) 0.001%
b) 0.1%
c) 1%
d) 5%
e) 9%

A

c) 1%

209
Q

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

A

d) recent suicide attempt

210
Q

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

A

e) dependent

211
Q

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

A

d) HIV infection

all the others are discredited because they are visible

212
Q

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

A

d) uncoupling health insurance benefits so that patients have separate plans for mental health and physical health

213
Q

“Playing down” the impact of a known stigma is often considered to be:

a) covering
b) passing
c) assimilation
d) conversion

A

a) covering

214
Q

What is allostatic load?

A

the ability of an organism to adapt over time

215
Q

What is the response of humans to normal stressors? Overwhelming stressors?

A

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
Q

What is the diagnostic criteria for acute stress disorder?

A
  • 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
Q

What are the diagnostic criteria for PTSD?

A
  • 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
Q

What is acute PTSD vs. chronic PTSD vs. delayed onset PTSD?

A

acute: < 3 months
chronic: > 3 months

delayed onset: onset of symptoms occurs more than 6 mo after stressor

219
Q

What are pre-trauma PTSD risk factors?

A

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
Q

What are peri- and post-trauma PTSD risk factors?

A

severity of trauma

length of exposure

level of perceived stress

intensity of trauma

social supports/emergency response

221
Q

What is the lifetime prevalance of PTSD in the US? For veterans?

A

8% for all of US

20% of veterans

222
Q

What is the likelihood of comorbid conditions with PTSD?

A

almost always 1 or 2 comorbid psychiatric conditions (depression, pain, substance dependence)

if you see it diagnosed alone, be suspicious

223
Q

What are the most frequent types of trauma in the US?

A

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
Q

What are the components of a PTSD assessment?

A

history, mental status exam, physical exam

PTSD rating scales

corroborative history

rule out other conditions

225
Q

How is PTSD treated?

A

non-pharmacological: establish safe environment, allow patient to tell story, psychotherapy

pharmacological: SSRI, sympathetic blockers, small doses of anti-psychotics

226
Q

What is the utility of SSRIs in treating PTSD?

A

helpful for intrusive memories, numbing, hypervigilance, and comorbid depression

227
Q

What is the utility of drugs like prazosin, propanolol, clonidine, and guanfacine for treating PTSD?

A

they are sympathetic blockers

they help with hypervigilance and insomnia

228
Q

What is the utility of benzodiazepines for PTSD?

A

not helpful, do not prescribe !

they prolong course of PTSD, worsen outcomes of psychoterapy, and can cause aggression

229
Q

What is the utility of antipsychotics in the management of PTSD?

A

small doses of atypical antipsychotics can help with sleep and dissociative hallucinosis

230
Q

What is psychogenic amnesia? How can it be distinguished from transient global amnesia?

A

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

Psych (6 decks)

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