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Psychiatry USMLE Step 3 > Section 1: Psychotic Disorders > Flashcards

Section 1: Psychotic Disorders Flashcards

1
Q

Which neurotransmitter receptors are associated with:

  1. Positive symptoms of schizophrenia
  2. Negative symptoms of schizophrenia
A
  1. Dopamine receptors
  2. Muscarinic receptors
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2
Q

List the positive symptoms of schizophrenia

A
  • Delusions (mostly bizzare)
  • Disorganized speech/behavior
  • Hallucinations
  • Agitation
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3
Q

List the negative symptoms of schizophrenia

A
  • Flattened affect
  • Social withdrawal
  • Anhedonia
  • Apathy
  • Poverty of thought
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4
Q

True or False:

Atypical antipsychotics are the most effective treatment for negative symptoms

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15144-15158). Kaplan Publishing. Kindle Edition.

A

True

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5
Q

Diagnosis:

  • Positive psychosis symptoms
  • Affects social and occupational function
  • Lasts longer than 6 months
A

Schizophrenia

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15144-15158). Kaplan Publishing. Kindle Edition.

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6
Q

Diagnosis:

  • Positive psychosis symptoms
  • Affects social and occupational function
  • Lasts longer than 1 month but less than 6 months
A

Schizophreniform disorder

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15144-15158). Kaplan Publishing. Kindle Edition.

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7
Q

Diagnosis:

  • Positive psychosis symptoms
  • Affects social and occupational function
  • Lasts less than 1 month
  • Patient returns to baseline
A

Brief psychotic disorder

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15144-15158). Kaplan Publishing. Kindle Edition.

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8
Q

Diagnosis:

  • Positive psychosis symptoms with non-bizarre delusions
  • No impairment of baseline functioning
  • Lasts for many years
A

Delusional disorder

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15144-15158). Kaplan Publishing. Kindle Edition.

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9
Q

Schizophrenia presents at a younger age in males than in females

Males?

Females?

A

15– 24 years

25– 34 years

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10
Q

What is the first step in management of any acute psychiatric condition?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15168-15170). Kaplan Publishing. Kindle Edition.

A

Determine if the patient needs hospitalization.

Hospitalize if the patient is at risk of harm to self or to others. Hospitalize against the patient’s will if the patient has suicidal or homicidal ideation.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15168-15170). Kaplan Publishing. Kindle Edition.

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11
Q

Other forms of psychosis to rule out

A

Get a drug screen to rule out substance abuse

Look for signs or symptoms of seizure. Temporal lobe epilepsy can present with hallucinations (auditory and olfactory distortions), feeling of déjà vu, or dissociation from surroundings

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15157-15170). Kaplan Publishing. Kindle Edition.

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12
Q

Watch out for suicidal ideation in schizophrenia patients and schizophreniform patients.

Fifty percent of schizophrenia patients attempt suicide in their lifetimes, and — percent of these attempts are successful.

A

10

Schizophreniform patients are at greater risk of depression and suicide after the episode of psychosis resolves.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15157-15170). Kaplan Publishing. Kindle Edition.

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13
Q

What is the greatest risk factor for progression to schizophrenia?

A

Schizophreniform disorder. Two thirds eventually progress to schizophrenia.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15171-15182). Kaplan Publishing. Kindle Edition.

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14
Q

True or False:

  1. In general, females have a better prognosis and respond better to treatment than males.
  2. Patients with paranoid schizophrenia are more responsive to treatment than those with other kinds.
A
  1. True
  2. True

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15171-15182). Kaplan Publishing. Kindle Edition.

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15
Q

List the poor prognostic features of schizophrenia

A
  • Early age of onset
  • Negative symptoms
  • Poor premorbid functioning
  • Family history of schizophrenia
  • Disorganized or deficit subtype

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15171-15182). Kaplan Publishing. Kindle Edition.

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16
Q

Outline the management of acute psychotic disorders

A
  1. If the case describes bizarre or paranoid symptoms, hospitalize the patient
  2. Give benzodiazepines for agitation and start antipsychotics
    • Antipsychotic medications are given for 6 months and are the most effective therapy to prevent further episodes
  3. Initiate long-term psychotherapy
    • Long-term antipsychotics are only given when there is a history of repeat episodes.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15185-15198). Kaplan Publishing. Kindle Edition.

17
Q

List the indications for antipsychotic medications

A
  1. Acute psychosis
  2. For sedation when benzodiazepines are contraindicated
  3. As an adjunct during anasthesia
  4. For movement disorders to suppress tics and vocalization
    • Huntington’s disease
    • Tourette disorder
18
Q

True or False

Antipsychotics are chosen based on side effect profile, not efficacy

A

True

19
Q

List examples, advantages and disadvantages of high potency conventional antipsychotics

A
  1. Examples:
    • Fluphenazine
    • Haloperidol
  2. Advantages
    • Less sedating
    • Fewer anticholinergic effects
    • Less hypotension
    • Useful as depot injections (e.g., haloperidol decanoate) for noncompliant patients
    • Give IM route for acute psychosis when patient is unable or unwilling to take PO
  3. Disadvantages
    • Greatest association with extrapyramidal systems (EPS)

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15203-15235). Kaplan Publishing. Kindle Edition.

20
Q

List examples, advantages and disadvantages of low potency conventional antipsychotics

A
  1. Examples
    • Thioridazine
    • chlorpromazine
  2. Advantages
    • Less likely to cause EPS
  3. Disadvantages
    • Greater anticholinergic effects
    • More sedation
    • More postural hypotension

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15203-15235). Kaplan Publishing. Kindle Edition.

21
Q

List examples, advantages and disadvantages of atypical antipsychotics

A
  1. Examples
    • Risperidone
    • Olanzapine
    • Quetiapine
    • Clozapine
  2. Advantages
    • Drug of choice for initial therapy
    • Greater effect on negative symptoms
    • Little or no risk of EPS
  3. Disadvantages
    • Clozapine is reserved for treatment-resistant patients because of risk of agranulocytosis.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15203-15235). Kaplan Publishing. Kindle Edition.

22
Q

Clozapine is associated with agranulocytosis (1 percent). Always check — (1) — with — (2) — both before initiating therapy and — (3) — after starting therapy.

A
  1. CBC
  2. Differential
  3. Weekly

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15237-15258). Kaplan Publishing. Kindle Edition.

23
Q

Adverse effects of low potency antipsychotics

Next best step with these side effects

A

Low-potency antipsychotics have the highest risk of causing

  • Orthostatic hypotension (alpha blockade)
  • Acute urinary retention
  • Dry mouth
  • Blurry vision
  • Delirium (anticholinergic effect)

Change to an atypical antipsychotic if these symptoms are present

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15237-15258). Kaplan Publishing. Kindle Edition.

24
Q

Adverse effects of thioridazine

Precautions to take

A

Adverse effects:

  • Prolonged QT
  • Arrhythmias
  • Abnormal retinal pigmentation after many years of use

Precautions:

  • Always get an EKG if the case describes chest pain, shortness of breath, or palpitations in a patient taking thioridazine

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15237-15258). Kaplan Publishing. Kindle Edition.

25
Q

Impotence and inhibition of ejaculation (α-blocker effect) are common reasons for noncompliance in males.

Weight gain (due to hyperprolactinemia) is a common reason for noncompliance in females. Also ask about galactorrhea and amenorrhea

A

True

True

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15237-15258). Kaplan Publishing. Kindle Edition.

26
Q
  1. A newly diagnosed schizophrenic patient complains of insomnia. What is the most appropriate antipsychotic to initiate therapy?
  2. A schizophrenic patient has been maintained on olanzapine for the past 6 months. He complains of daytime sedation, and he has lost 2 jobs in the past month because of impaired performance. What is the next step in management?
A
  1. Olanzapine, quetiapine, zisprasidone, aripiprzole are first-choice medications when insomnia is a problem
  2. Prescribe risperidone, a first-choice medication for the Rx of schizophrenia when sedation is a problem

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15237-15258). Kaplan Publishing. Kindle Edition.

27
Q

What is the most common reason for failure to comply with therapy?

A

Extrapyramidal symptoms (ESP)

28
Q

Acute dystonia

  1. Occurs within what period of medication
  2. CF
  3. Rx
A
  1. Occurs in the first week
  2. Muscle spasms (e.g., torticollis), difficulty swallowing TIP: Young men are at higher risk
  3. Reduce the dose; Anticholinergics
    • Benztropine
    • Diphenhydramine
    • Trihexyphenidyl

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15268-15310). Kaplan Publishing. Kindle Edition.

29
Q

Bradykinesia (Parkinsonism)

  1. Occurs within what period of medication
  2. CF
  3. Rx
A
  1. Within weeks
  2. Bradykinesia, tremors, rigidity, and other signs of parkinsonism TIP: Elderly are at higher risk
  3. Reduce the dose; Anticholinergics
    • Benztropine
    • Diphenhydramine
    • Trihexyphenidyl

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15268-15310). Kaplan Publishing. Kindle Edition.

30
Q

Akathisia

  1. Occurs within what period of medication
  2. CF
  3. Rx
A
  1. Weeks to chronic use
  2. Motor restlessness Do not mistake for anxiety for agitation TIP: Always review medication list
  3. Reduce the dose; Add benzodiazepines or beta-blockers; Switch to newer antipsychotics

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15268-15310). Kaplan Publishing. Kindle Edition.

31
Q

Tardive Dyskinesia

  1. Occurs within what period of medication
  2. CF
  3. Rx
A
  1. Weeks to chronic use
  2. Choreoathetosis and other involuntary movements after chronic use Often irreversible
  3. Stop older antipsychotics; Switch to newer antipsychotics (e.g., clozapine) TIP: Symptoms commonly worsen after medication discontinuation

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15268-15310). Kaplan Publishing. Kindle Edition.

32
Q

Neuroleptic Malignant Syndrome

  1. Occurs within what period of medication
  2. CF
  3. Rx
A
  1. Anytime
  2. Muscle rigidity, hyperthermia, volatile vital signs, altered LOC, ↑ WBC & CK
  3. Stop antipsychotic TIP: Transfer to ICU for monitoring, mortality rate is 20%

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15268-15310). Kaplan Publishing. Kindle Edition.

33
Q

A 35-year-old male presents with poor adherence to chlorpromazine and haloperidol. He complains of tics and other uncontrolled movements. His wife reports that even when he takes his medications, they don’t appear to help his paranoia. What is the next step in management?

a. Add risperidone
b. Add diphenhydramine
c. Change to clozapine
d. Increase the dose of chlorpromazine
e. Increase the dose of haloperidol

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15312-15331). Kaplan Publishing. Kindle Edition.

A

C. The case describes 2 main problems in management, poor response to therapy prescribed and movement disorder as a side effect from the regimen. Clozapine is the most effective antipsychotic for schizophrenia and also has no incidence of movement disorders. It is a second-line therapy because of the risk of seizures and agranulocytosis. Remember to monitor CBC to watch for bone marrow suppression

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15312-15331). Kaplan Publishing. Kindle Edition.

34
Q

A 78-year-old male with a slow-growing stomach tumor in palliative care is brought in by the family, who have noticed increased sedation and difficulty eating. They are concerned because he continues to lose more weight. On examination, he has repetitive movements of his lips and tongue. He has limited facial expression. His medications include morphine, metoclopramide, and hydrochlorothiazide. Which of the following is the most appropriate management?

a. Decrease morphine
b. Discontinue metoclopramide
c. Start omeprazole
d. Start prochlorperazine
e. Place NG tube for supplemental feedings

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15312-15331). Kaplan Publishing. Kindle Edition.

A

B. Chronic use of dopamine antagonists, including antimetics (metoclopramide, prochlorperazine), can result in tardive dyskinesia. Management includes discontinuing the offending drug and, if indicated, beginning a newer antipsychotic. Tardive dyskinesia can be treated with benztropine.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kaplan Medical Usmle Master the Boards Step 3) (Kindle Locations 15333-15346). Kaplan Publishing. Kindle Edition.

35
Q

Specific adverse effects of atypical antipsychotics

  • Olanzapinee
  • Risperidone
  • Quetiapine
  • Ziprasidone
  • Clozapine
A
  • *Olanzapine**: Greater incidence of diabetes and weight gain; avoid in diabetic and obese patients
  • *Risperidone:** Greater incidence of movement disorders
  • *Quetiapine:** Less incidence of movement disorders
  • *Ziprasidone:** Increased risk of prolongation of QT interval; avoid in patients with conduction defects
  • *Clozapine:** High risk of agranulocytosis; need to monitor CBC on regular basis; never used as first-line treatment given side-effect profile

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 515). Kaplan Medical Test Prep. Kindle Edition.

36
Q

A 22-year-old woman was recently diagnosed with schizophrenia. She is 30 pounds overweight and suffers from diabetes Type 2. She is concerned about her medications and asks for your advice. Which of the following would be most indicated in this patient?

a. Aripiprazole
b. Olanzapine
c. Quetiapine
d. Clozapine
e. Risperidone

A

A. Aripiprazole and ziprasidone are the least likely to cause weight gain, diabetes, and metabolic syndrome. Clozapine and olanzapine have the highest risk of
metabolic abnormalities. Risperidone and quetiapine have medium risk.

Fischer, Conrad (2012-11-01). Master the Boards USMLE Step 2 CK (Page 515). Kaplan Medical Test Prep. Kindle Edition.

Psychiatry USMLE Step 3 (7 decks)

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