Ch. 16 Psych

Question 1

What are the three indications for involuntary hospitlization?

Answer 1

■ Mental illness with impaired self-control, judgment, and/or discretion
■ Dangerousness to self or others in the setting of mental illness
■ Grave disability, ie, inability to provide basic needs of food, clothing, and shelter

Question 2

What are demographics that put someone at higher risk for suicide?

Answer 2

male gender, white race, adolescent or age > 65 years old

Question 3

What are social factor that put someone at greater risk for suicide?

Answer 3

Divorced,
lives alone,
unemployed,
homeless,
recent personal loss,
lack of religious or community involvement,
access to firearms

Question 4

What is the definition of Major Depression?

Answer 4

Depressed mood (or irritability in children and adolescents) and/or loss of interest or pleasure along with 4 or more of the following depressive symptoms:
■ Change in weight (unintentional) or appetite
■ Change in sleep (insomnia or hypersomnia)
■ Psychomotor agitation or retardation
■ Fatigue or loss of energy
■ Feelings of worthlessness or guilt
■ Decreased concentration or indecisiveness
■ Recurrent thoughts of death or suicide

Symptoms (1) must be present almost every day for at least 2 weeks; (2) must be associated with significant impairment in daily functioning; and (3) must NOT be due to general medical condition (eg, hypothyroidism) or substance abuse.

Question 5

What is pseudodementia?

Answer 5

In older patients, depression may present with memory loss, inattention, social withdrawal, confusion, and poor hygiene

Question 6

What is the definition of dysthymic disorder?

Answer 6

Persistent depressed mood for > 2 years that does not meet criteria for major depression and has no symptom-free period lasting > 2 months.

Question 7

What is the mneomic for depression risk stratification screening?

Answer 7

Sex (male) 1
Age (< 19 or > 45 y) 1
Depression or hopelessness 2
Previous suicide attempts or psychiatric care 1
Excessive alcohol or drug use 1
Rational thinking loss 2
Separated, divorced or widowed 1
Organized or serious attempt 2
No social supports 1
Stated future intent 2

Question 8

How is bipolar disorder diagnosed?

Answer 8

■ Symptoms
(1) must be for at least 2 weeks;
(2) must be associated with significant impairment in daily functioning; and
(3) must NOT be due to general medical condition (eg, hyperthyroidism) or substance abuse.

■ Bipolar I: One or more manic episode(s) cycling with depressive episodes
■ Bipolar II: One or more hypomanic episode(s) cycling with depressive episodes

Question 9

How is a hypomanic episode defined?

Answer 9

characterized by symptoms of mania without marked impairment in daily function, need for hospitalization, or psychotic features.

Question 10

What is first line treatment for bipolar disorder?

Answer 10

mood stabilizers (eg lithium, valproic acid, lamotrigine).

Question 11

What is the definition of acute psychosis?

Answer 11

Disturbed perception of reality characterized by delusions, hallucinations, and disorganized speech or behavior.

Question 12

How are delusions defined?

Answer 12

erroneous beliefs that involve misinterpretation of perceptions
or experiences

Question 13

How are hallucinations defined?

Answer 13

sensory experience that exists only in the mind of the person
experiencing it; may be auditory, visual, olfactory, gustatory, or tactile

Question 14

How is catatonic behavior defined?

Answer 14

Motor immobility and unresponsiveness to external
stimuli

Question 15

What is disorganized speech?

Answer 15

Loosening of associations (rapid switching from topic to unrelated topic), neologisms (nonsense words invented by patient), perseverations, word salad

Question 16

What are neologisms?

Answer 16

nonsense words invented by patient

Question 17

How is disorganized behavior defined?

Answer 17

Unpredictable agitation and absence of goal directed behavior

Question 18

How is brief psychotic disorder defined?

Answer 18

Psychotic symptoms lasting > 1 day but < 1 month

Question 19

How is schizophrenia defined?

Answer 19

Psychotic symptoms present ≥ 6 months

Question 20

How is delusional disorder defined?

Answer 20

Non-bizarre delusions (eg involving situations that
occur in real life, such as being followed, poisoned, etc) lasting > 1 month without functional impairment

Question 21

How is mood disorder with psychotic features defined?

Answer 21

Psychosis during mood episode
only

Question 22

How is schizoaffective disorder defined?

Answer 22

Mood episode plus psychosis, with psychosis present at least 2 weeks prior to onset of mood episode

Question 23

What is a risk factor for schizophrenia?

Answer 23

marijuana use is an independent risk factor for schizophrenia in genetically susceptible individuals

Question 24

What are positive symptoms of schizophrenia?

Answer 24

Delusions, hallucinations, disorganized speech, or behavior

Question 25

What are negative symptoms of schizophrenia?

Answer 25

Flat affect, poverty of speech, social withdrawal, inability to achieve goal-directed tasks

Question 26

How is schizoid personality disorder?

Answer 26

Voluntary social withdrawal with no signs of psychosis

Question 27

How is schizotypal personality disorder defined?

Answer 27

Odd, magical thinking with no signs of psychosis

Question 28

How is the diagnosis of schizophrenia made?

Answer 28

6 months of continuous signs of disturbance with at least 1 month of 2 or more active symptoms (delusions, hallucinations, disorganized speech, disorganized behavior, or negative symptoms). Only 1 symptom is required if delusions are bizarre or hallucinations consist of a running commentary. - must have a marked deterioration from prior level of functioning - symptoms must not be caused by substance abuse, medication, or general medical condition.

Question 29

What do you call a discrete period of sudden onset of intense apprehension, fear, terror?

Answer 29

Panic attack

Question 30

What is the treatment for panic attacks?

Answer 30

Verbal deescalation/reassurance, benzodiazepines

Question 31

What do you call 6 mo of persistent and excessive anxiety/worry about a broad range of topics?

Answer 31

Generalized anxiety disorder

Question 32

What is the treatment for GAD?

Answer 32

CBT, group therapy, long-acting benzodiazepines, buspirone, SSRI

Question 33

What do you call recurrent, unexpected panic attacks AND at least 1 mo of worry (or behavior modification) surrounding the attacks or over subsequent attacks?

Answer 33

Panic disorder

Question 34

What is the treatment for panic disorder?

Answer 34

SSRI, short-acting benzodiazepines, β-blockers, desensitization, “flooding” therapy (CBT)

Question 35

What do you call a significant anxiety provoked by exposure to a specific feared object or situation; leads to avoidance behavior?

Answer 35

Phobic disorder

Question 36

What is the treatment for phobic disorder?

Answer 36

CBT (exposure-response prevention therapy), desensitization, SSRI, short-acting benzodiazepines, β-blockers (eg, propranolol)

Question 37

What is the diagnosis for someone with repetitive thoughts (obsessions) that cause marked anxiety or distress and lead to mannerisms (compulsions) that serve to neutralize and relieve anxiety?

Answer 37

OCD

Question 38

What is the treatment for OCD?

Answer 38

CBT (exposure-response prevention therapy), SSRI, clomipramine; higher doses than those for depression usually required

Question 39

Your patient describes re-experiencing an extremely traumatic event associated with symptoms of: increased arousal, hypervigilance, and avoidance of stimuli associated with the trauma. What is the diagnosis?

Answer 39

Post-traumatic stress disorder

Question 40

What is the treatment for PTSD?

Answer 40

CBT, individual/group therapy (especially helpful), SSRI, sleep agents, long-acting benzodiazepines.

Question 41

What are somatoform disorders?

Answer 41

conditions in which psychological stress is expressed as physical symptoms

Question 42

How do somatoform disorder differ from factitious disorders?

Answer 42

In contrast to factitious disorders, somatoform disorder symptoms are not intentionally produced or faked.

Question 43

What is La Belle Indifference?

Answer 43

refers to an apparent lack of concern shown by patients with conversion disorder toward their symptoms

Question 44

How is somatization disorder defined?

Answer 44

■ History of medically unexplained physical symptoms beginning before age 30 ■ Presence of all of the following at any time during disorder: (1) 4 pain symptoms (different sites or body functions), (2) 2 gastrointestinal (GI) tract symptoms, (3) 1 sexual symptom, and (4) 1 pseudoneurologic symptom

Question 45

What is conversion disorder?

Answer 45

■ Abnormalities or deficits in voluntary motor or sensory function that are not medically explained (eg, pseudoseizures, pseudoparalysis, movement disorders, blindness) ■ Symptoms do not fit an anatomic distribution or diagnosis

Question 46

What is pain disorder?

Answer 46

Persistent pain in one or more anatomic site(s) that limits daily functioning and cannot be pathophysiologically explained

Question 47

What is hypochondriasis?

Answer 47

■ Preoccupation with the belief that one has a serious medical disease despite medical evaluation and physician reassurance ■ Patients typically demonstrate physical symptoms disproportionate to any apparent organic disease, conviction that they have a serious medical illness, preoccupation with their body, and relentless pursuit of medical care, often with doctor shopping.

Question 48

What is the treatment for hypochondriasis?

Answer 48

Acknowledge symptoms and attempt to provide reassurance via explanation of symptoms.

Question 49

What do you call it when patients create symptoms to secure some external motivator such as disability, avoiding jail or work time, pain medication, etc., known as secondary gain?

Answer 49

malingering

Question 50

What do you call it when a patient feigns or creates symptoms for primary gain of adopting the “sick role,” with attention from nursing staff, physicians, etc.?

Answer 50

Munchausen Syndrome

Question 51

What do you call the disorder in which an adult, most commonly the biological mother (98%), intentionally creates symptoms in a child (or rarely elderly person) in order to have contact with health care and to assume the role of the concerned caregiver (primary gain)?

Answer 51

Munchausen Syndrome by Proxy

Question 52

What personality disorder is characterized by pervasive distrust and suspicion that others are exploiting, harming, or deceiving him or her. Reluctant to confide in others and bears grudges easily?

Answer 52

Paranoid personality disorder

Question 53

What personality disorder is characterized by pervasive detachment from social relationships and restricted range of emotional expression; Neither desires nor enjoys close relationships and prefers solitude?

Answer 53

Schizoid Personality disorder

Question 54

What personality disorder is characterized by pervasive social and interpersonal deficits with reduced capacity for close relationships along with cognitive or perceptual distortions and eccentricities, such as odd or magical thinking (Does NOT meet criteria for schizophrenia)?

Answer 54

Schizotypal Personality disorder

Question 55

What personality disorder is characterized by pervasive and excessive emotionality and attention-seeking; Consistently uses physical appearance to draw attention to self with inappropriate provocative behavior?

Answer 55

Histrionic Personality disorder

Question 56

What personality disorder is characterized by pervasive inflation of self-worth, pattern of grandiosity, and need for admiration; Believes that he or she is “special” and has a strong sense of entitlement?

Answer 56

Narcissistic Personality disorder

Question 57

What personality disorder is characterized by pervasive instability of interpersonal relationships, self-image, and affects, with marked impulsivity, emotional lability, and compromised empathy and intimacy; Often associated with recurrent suicidal behavior, gestures, and self-harm?

Answer 57

Borderline Personality disorder

Question 58

What personality disorder is characterized by pervasive disregard for and violation of the rights of others. Marked deceitfulness, impulsivity, aggressiveness, and reckless disregard for safety of others with lack of remorse. High prevalence of imprisonment.

Answer 58

Antisocial Personality disorder

Question 59

What personality disorder is characterized by pervasive social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation; Avoids interaction due to fear of criticism, disapproval, or rejection?

Answer 59

Avoidant Personality disorder

Question 60

What personality disorder is characterized by pervasive need to be taken care of leading to submissive and clinging behavior; has difficulty making decisions without reassurance and excessive fears of being alone?

Answer 60

Dependent Personality disorder

Question 61

What personality disorder is characterized by pervasive preoccupation with orderliness; perfectionist at the expense of flexibility, openness, and efficiency?

Answer 61

Obsessive Compulsive Personality disorder

Question 62

Which eating disorder is characterized by 1. Refusal to maintain body weight at or above 85% of the age-adjusted expected body weight 2. Intense fear of gaining weight or becoming fat despite being underweight

Answer 62

Anorexia Nervosa

Question 63

What are the two types of anorexia nervosa?

Answer 63

restricting (eg excessive dieting, starvation), binge eating/purging (eg vomiting, laxatives, diuretics, excessive exercise)

Question 64

What is refeeding syndrome?

Answer 64

Reintroduction of food triggers metabolic increase with rapid consumption of already depleted electrolytes causing profound hypophosphatemia, hypokalemia, and hypomagnesemia with severe cardiopulmonary and neurologic sequelae.

Question 65

Which eating disorder is characterized by: 1. Normal weight or overweight 2. Episodes of binge eating with sense of loss of control followed by compensatory behaviors, either purging type (eg, self-induced vomiting, laxatives, diuretics) or nonpurging type (eg, excessive exercise, fasting, dieting) 3. Binges and compensatory behavior at least twice per week for 3 or more months

Answer 65

Bulimia Nervosa

Question 66

What is Russell sign?

Answer 66

callus formation over the dorsal aspect of fingers due to acidic vomit

Question 67

What is first line treatment for anorexia and bulimia nervosa?

Answer 67

First-line treatment is psychotherapy (especially cognitive-behavioral therapy) plus selective serotonin reuptake inhibitors (SSRIs). Admission criteria similar to those for anorexia nervosa (see

Question 68

Which antibiotic is a reversible inhibitor of MAO?

Answer 68

Linezolid

Question 69

What are signs and symptoms of serotonin syndrome?

Answer 69

■ Autonomic dysfunction: Hyperthermia, diaphoresis, tachycardia, tachypnea ■ Neuromuscular symptoms: rapid onset of muscle rigidity (greater in lower extremities), tremor, ataxia, clonus/hyperreflexia ■ CNS dysfunction: confusion/disorientation, agitation, seizures, coma

Question 70

What is the treatment for serotonin syndrome?

Answer 70

■ Supportive care: Benzodiazepines for muscle rigidity, agitation, and seizures; sodium bicarbonate for QRS widening > 100 milliseconds; and intravascular (IV) fluids for rhabdomyolysis. ■ Consider cyproheptadine (5-HT2A antagonist) in severe cases. ■ Up to 25% of cases will require intubation and mechanical ventilation. In hyperthermic patients, use a nondepolarizing agent.

Question 71

What is the pathophysiology behind neuroleptic malignant syndrome?

Answer 71

■ Dopamine receptor blockade in hypothalamus → hyperthermia, dysautonomia ■ Dopamine receptor

Question 72

What are the signs and symptoms of neuroleptic malignant syndrome?

Answer 72

■ Fever and muscle rigidity (cogwheel or lead-pipe) developing over hours to days ■ Altered mental status: Lethargy, agitation, coma ■ Autonomic dysfunction: Diaphoresis, labile blood pressures, tachycardia ■ CNS dysfunction: Tremor, dysphagia, mutism, incontinence

Question 73

What is the treatment for NMS?

Answer 73

Primary treatment is removal of the offending drug and aggressive supportive care with IV fluids, external cooling, antihypertensive agents (consider vasodilators to facilitate cooling), benzodiazepines for aggression, prophylactic anticoagulation, and mechanical ventilation and/or antiarrhythmic agents as needed. use of dantrolene and dopaminergic agents such as bromocriptine and amantadine is controversial.

Question 74

How can NMS be distinguished from serotonin syndrome?

Answer 74

NMS can be distinguished from serotonin syndrome by its lack of hyperreflexia/clonus and usually normal, rather than dilated, pupil size.

Question 75

What causes extrapyramidal symptoms?

Answer 75

Blockade of dopamine receptors in the basal ganglia due to antipsychotic medications

Question 76

What do you call intermittent, involuntary motor tics and spasms of the face, neck, back, and extremities that begins within hours of starting antipsychotic treatment?

Answer 76

acute dystonia

Question 77

What are examples of acute dystonic reactions?

Answer 77

1. oculogyric crisis (blepharospasm, periorbital twitches, protracted staring episodes) and 2. laryngeal dystonia (potentially life-threatening laryngospasm).

Question 78

What do you call the sensation of restlessness associated with objective motor hyperactivity that begins within days of starting treatment?

Answer 78

Akathisia

Question 79

What is the diagnosis in someone who exhibits bradykinesia, masked faces, muscular rigidity, resting tremor that begins within months of starting treatment?

Answer 79

Parkinsonian syndrome

Question 80

What do you call the chronic movement disorder involving involuntary tics of the face, extremities, or trunk that begins after years of antipsychotic treatment?

Answer 80

Tardive dyskinesia (often permanent and not responsive to treatment)

Question 81

What do you call the unpleasant, potentially life-threatening reaction due to elevated serum acetaldehyde that occurs in patients who consume alcohol while taking certain meds, most notably metronidazole?

Answer 81

DIsulfiram reaction

Question 82

What is the pathophysiology behind the disulfiram reaction?

Answer 82

Disulfiram inhibits aldehyde dehydrogenase, preventing the breakdown of the acetaldehyde generated by the metabolism of ethanol.

Question 83

What are signs and symptoms of a disulfiram reaction?

Answer 83

■ Skin flushing, nausea/vomiting, headache, chest pain, abdominal discomfort, diaphoresis, vertigo, palpitations, and confusion may occur within 15-30 minutes after alcohol use. ■ Severe reactions may cause hypotension, seizures, and dysrhythmias.

Question 84

What is the treatment for disulfiram reaction?

Answer 84

Supportive care with IV fluids, antiemetics, and rarely dopamine for hypotension

Question 85

Ethanol is metabolized to acetaldehyde in the liver by alcohol hydrogenase via ____-order kinetics

Answer 85

zero-order kinetics (eg, at a constant rate independent of concentration).

Question 86

What is the average rate of alcohol metabolism?

Answer 86

10-20 mg/dL/h (up to 40 mg/dL/h in alcoholics)

Question 87

_____________ is an acute, life-threatening disorder (10%-20% mortality) caused by thiamine (vitamin B1) deficiency, most often seen in chronically malnourished patients such as heavy alcohol drinkers.

Answer 87

Wernicke encephalopathy

Question 88

Neurological disorder with persistent anterograde and retrograde memory impairment, apathy, and often confabulation (pathologic lying about invented memories)

Answer 88

Korsakoff syndrome

Question 89

When giving thiamine, what else should you co-administer other than glucose?

Answer 89

Remember to give magnesium! Magnesium is a cofactor required for utilization of thiamine.

Question 90

In alcoholics, thiamine or glucose first?

Answer 90

Theoretically, one should give thiamine before glucose supplementation to avoid precipitating acute thiamine deficiency.

Question 91

How does alcoholic hallucinosis differ from delirium tremens?

Answer 91

Unlike delirium tremens, alcoholic hallucinosis is NOT associated with global clouding of the sensorium and vital signs are often normal.

Question 92

What is the treatment for cocaine overdose?

Answer 92

■ Primary treatment is benzodiazepines, which restore inhibitory tone to the CNS ■ Aggressively treat hyperthermia with rapid evaporative cooling and IV fluids ■ Use nitroglycerin, nitroprusside, or phentolamine for uncontrolled hypertension.

Question 93

What drug use is commonly associated with hyponatremia?

Answer 93

MDMA / Ecstasy / Molly

Question 94

Which opioid receptor is primary receptor for analgesia, euphoria, and addiction?

Answer 94

Mu receptor

Question 95

Which opioid receptor is primary receptor for spinal analgesia, respiratory depression?

Answer 95

Delta receptors and Kappa receptors

Question 96

What is the mechanism of action of PCP?

Answer 96

Acts as a noncompetitive antagonist of N-methyl-d-aspartate (NMDA) receptors; inhibits reuptake of dopamine, norepinephrine, and serotonin; and acts as an anticholinergic

Question 97

What are signs and symptoms of PCP use?

Answer 97

■ Tachycardia, hypertension, hyperthermia ■ CNS effects range from bizarre behavior, agitation, violent behavior, and seizures to sedation, unresponsiveness, and coma. ■ Vertical, horizontal, and rotatory nystagmus is often present. Pupil size is variable.

Question 98

What street drug is associated with Mydriasis, sympathomimetic symptoms, bruxism, ataxia, dry mouth, nausea?

Answer 98

MDMA

Question 99

What street drug is derived from fungus Claviceps purpurea?

Answer 99

LSD

Question 100

Which benzodiazepines are renally excreted and therefore safe in liver failure patients?

Answer 100

oxazepam, temazepam, and lorazepam

Question 101

Individual who intentionally ingest large amounts of wellpackaged product, typically for smuggling purposes.

Answer 101

body packer

Question 102

Individual who swallows a poorly wrapped quantity of drug, usually in an attempt to avoid arrest or detection.

Answer 102

Body stuffer

Question 103

What is the treatment for body packers?

Answer 103

Treat asymptomatic patients with polyethylene glycol to expedite passage. If rupture is suspected, obtain immediate surgical consult for laparotomy.

Question 104

What is the treatment for body stuffers?

Answer 104

Treat with activate charcoal (1 g/kg), close monitoring, and symptomatic treatment as in acute intoxication. Consider whole-bowel irrigation if severe toxicity is suspected.