Psych Flashcards
(102 cards)
1
Q
Eisler is one mechanism of action for prolactinemia
A) Dopamine blockade
B) THR
A
A) Dopamine blockade
Blockade of dopamine D2 receptors by typical antipsychotics and risperidone can cause hyperprolactinemia in males and females.
2
Q
Teenager who had fainting episode after influenza immunization. Presents to ED with right arm stiffening and clinic movements of one limb for 5 min. Period of sleepiness after, but able to preserve protective reflexes. Normal neurological exam. Kid doesn’t seem troubled by this.
A. Somatization
B. Post concussion seizure
C. Conversion disorder
A
C. Conversion disorder
3
Q
14 year old male presents to ED with right-sided arm movement, left sided leg twitches. Refuses to weight beat. No focal findings on abdomen. Protecting reflexes. Patient himself is not concerned with findings. What is the diagnosis ?
A. Somatization
B. Seizure
C. Conversion disorder
A
C. Conversion disorder
4
Q
12 y.o boy breaking things at home, not listening to instructions, and skipping school. He seems angry. What is the next BEST step ?
A) parent training
B) start an atypical antipsychotic
C) start an SSRI
A
A) parent training
Management of ODD
Treatment usually consists of a combination of:
-parent-management training programs and family therapy
-cognitive problem-solving skills training
-social-skills programs and school-based programs
- medication
5
Q
What makes you worried about starting fluoxetine on a teenager with depression:
A) History of cardiac surgery
B) History of anxiety
C) family history of bipolar disorder
D) family history of suicide
A
C) family history of bipolar disorder
6
Q
16 year old boy with history of ADHD on Vyvanse. His mother notes him becoming more withdrawn and secretive over the past year, wanting to spend all his time in his room and away from friends and family, in his computer. She has also noted money missing from her purse and strange charges on her credit card from an unknown source. What should she do ?
A) increase his medication dosage
B) assess him for gambling problems
C) add a mood stabilizer
D) reassure
A
B) assess him for gambling problems
Evidence suggests that a considerable subset of problem gamblers have ADHD with characteristic features of impulsivity and sustaining attention. Two disorders interact on various levels. Ie; gambling impulses are poorly controlled and ADHD symptoms such as chronic boredom, depression and low self esteem are relieved by the stimulus and reward of gambling.
7
Q
Boy with stable ADHD has been on a stable dose of stimulant for the last two years. Had started to become very aggressive when spoken to and gets easily frustrated when he doesn’t get what he wants. You’ve already ruled out psychosocial stressors. What do you want to do as your next step:
A) Benzo PRN
B) increase psychostimulant
C) Add SSRI
D) add atypical antipsychotic
A
B) increase psychostimulant
???? Need a resource
8
Q
A 9 y.o boy has been refusing to go to school for the last 3 months. He becomes upset when discussing attending school and says he wants to be homeschooled.
A) Allow him to be homeschooled this year. Return to school next year.
B) Return to school immediately following gradual protocol and desensitization
C) Start Citalopram
D) Start Fluoxetine
A
B. Return to school immediately following gradual protocol and desensitization.
9
Q
The parents of a 16 y.o boy found him threatening to kill himself with a knife. He has recently had a significant decline in school performance. He complains of hearing voices. Feels weird for minutes to hours. Family history of of depression and suicide. Likely diagnosis ?
A. Drug abuse
B. Depression
C. Schizophrenia
D. Brain tumor
A
C. Schizophrenia
- no indication that pt is presenting sx of depression
- almost any other psych disorder among first degree relatives increases the individuals risk of schizophrenia
10
Q
16 year old girl. Failing in school, used to be straight A student. Decreased need for sleep. Recently buying clothes. Family hx of suicide and depression. How do you treat?
A.Lithium
B. Fluoxetine
C. Clonidine
A
Answer A - but an atypical antipsychotic would be better answer
Bipolar disorder
11
Q
A 16 y.o boy admits to recently having repetitive thoughts of violence. He has impulses to act on these, but is able to hold off doing so. What diagnosis is most likely ?
A). Schizophrenia
B) Behavioural problem
C) OCD
D) Antisocial personality
A
Answer C- OCD - schizophrenia is usually egodystonic aka they don’t realize they have those thoughts or can suppress them
12
Q
A 13 year old boy with type 1 diabetes tells his parents that he hopes his diabetes kills him because he doesn’t want to live anymore. He’s had a lower appetite the last few months (? Also said sleeping more). Psychiatry has assessed him and feels he is not at an acute risk of self harm. What is the best thing to do now to ensure his safety?
A. Fluoxetine
B. Admit him
C. Parents to prevent constant supervision
D. Parents to take over control of his insulin injections
A
D. Parents to take over his insulin injections
- fluoxetine will take 4-6 weeks to take effect
- no need for hospital admission if no acute/active suicidality and distress or functional impairment the paediatrician can schedule a f/u appt within 1-2weeks
- best thing to do NOW for safety is to control insulin injections
13
Q
Teen is on Sertraline. She is experiencing unwanted side effects and would like to stop. What should you do ?
A. Stop cold turkey
B. Wean gradually to avoid withdrawal
C. Wean gradually to avoid serotonin syndrome
D. Switch to a benzo
A
B. Wean gradually to avoid withdrawal.
14
Q
8 year old girl with hx of asthma. She has missed 10 days of school this spring as she wakes up with a “tight” chest in the am. She has been able to continue with no problems for extracurricular activities.
What is the diagnosis ?
A. Generalized anxiety disorder
B. Separation anxiety disorder
C. Chronic asthma
D. Chronic bronchitis
A
B. Separation anxiety disorder
- in this case unlikely to be GAD as sx only occur in the AM and do not seem to interfere with other activities; and unlikely to be asthma as sx in AM and no problems with activity
15
Q
A 13 y.o boy has become more withdrawn over the last year and seems only interested in his friends and his computer. He has difficulty waking up in the morning and seems tired. He has difficulty waking up in the morning and seems tired. Which is the next step in management ?
A. TSH
B. Tox screen
C. Refer to psychology
A
Controversial: c. Refer to psychology vs reassure (not listed)
None of these - this is normal
Teenage behaviour. Key to knowing it’s normal is “interested in his friends”. If it said ‘ not interested in friends’ - that would be more concerning. Tired in the morning - not red flag for teenager. Answer likely remembered wrong is “reassurance” or “do nothing”
16
Q
A 12 year old girl has been uninterested in activities she usually enjoys over the last 9 months. She has had less energy than usual and has had a decreased appetite. In addition to CBT, which of the following is the most appropriate treatment for her ?
A. Lithium
B. Fluoxetine
C. Amitryptiline
A
B. Fluoxetine
17
Q
13y.o F in foster care has been losing weight, decreased appetite, and occasional emesis. On exam you see that she is pale and has patchy areas of hair loss. What is the most likely diagnosis ?
A. Trichobezoar
B. Anorexia nervosa
C. Celiac disease
D. Lead poisening
A
A. Trichobezoar
18
Q
An adolescent female presents to the ER because her mother found out that she has been making superficial cuts on her arms. What would reassure you that she is not suicidal ?
A. The cutting makes her feel better
B. Her boyfriend just dumped her
Or
Teen who has tried cutting herself a lot - what would make you LEAST worried about suicide? A. She was cutting to get relief of sx B. Sleeping x 2 weeks C. Using marijuana D. Boyfriend just broke up with her
A
A. The cutting makes her feel better
19
Q
13 year old boy with several episodes of irritability, swearing a lot, difficulty sleeping over the last 2 years. He has gotten into trouble at school because of them and has been suspended. What do you treat him with ?
A. Clonidine
B. Methylphenidate
C. Valproate
D. Fluoxetine
A
Controversial question - I am going with D) fluoxetine
- would be used for depression./anxiety
- sx of irritability and difficulty sleeping = depression or anxiety; less likely to be a/w searing
- sx of irritability and seating = disruptive mood dysregulation disorder but not sleeping difficulties
A. Clonidine - would be used for tax of : ADHD/aggression, disruptive behaviours in ODD
B. MPH= would be used for tax of ADHD, but sx not in keeping with this dx
C. Valproate = can be used for bipolar. First line is antipsychotics, then lithium, valproate would only be used as adjunctive tx. Sick kids worrying about bipolar dx.
20
Q
Boy writing out his sentences by going over the letters 3 times, what does he have ?
A. OCD
B. Anxiety
C. ADHD
A
A. OCD
21
Q
Mother of 13 y.o boy comes to your office presenting with concerns about his behaviour. He stays in his room, not active in sports, and his school performance has declined. He likes working on his computer and being with his few friends. His physical exam is normal. He states he has smoked before, but denies alcohol use. What is the most appropriate management?
A. Reassure
B. Toxicology screen
C. TSH
D. Psychological assessment
A
Controversial: psychological assessment vs reassure
22
Q
What is the greatest risk for suicide attempt?
A. Living alone
B. Prior spontaneous suicide attempt
A
B. Prior spontaneous suicide attempt
23
Q
13 year old girl sleepless, distractible, irritated, wears provocative clothing, spends more money. Dad worried. Maternal history of suicide attempt. Brother has ADHD. What would you recommend?
A. Lithium
B. Fluoxetine
C. Stimulant
D. Substance abuse treatment program
A
A. Lithium - first line is atypical antipsychotic for bipolar.
24
Q
Kid with ODD. What do you suggest for management ?
A. Start Risperidone
B. Start stimulant medication
C. Parent skills training
D. Put him in a “special Program” (don’t remember how they worded it )
A
Answer: C parent skills training
25
15 year old girl has a headache, then syncope at school for several minutes. She is brought to hospital. Can’t walk because of numbness in her legs. Exam is normal, plantar reflexes normal, DTR normal. Initial loss of sensation to L4, the next day she has sensation to S1. Able to walk leaning heavily on your hands, feet spaced 8cm apart. What is your next step in management?
A. EEG
B. MRI head and spine
C. Confrontation and explanation that her symptoms are not organic
D. Patient should be included in management
D. Patient should be included in management - conversion disorder
26
Child with complex medical history and all examination is normal. Complaints of abdo pain for 1 hour in the morning but resolved quickly. Is ok to play soccer. What do you tell the child to do ?
A. Go back to school, doesn’t matter about the pain
B. Home school
C. Get the needed school work and then go back when the pain is gone
D. Don’t need to go to school
A. Go back to school, doesn’t matter about the pain
Functional abdominal pain/separation anxiety.
27
Male bully, has used a knife, picks fights
A. Conduct disorder
B. ADHD
C. Antisocial personality disorder
A. Conduct disorder
28
5 year old girl with rapid onset episodes characterized by intense fear and discomfort lasting a few minutes to a few hours. Which of the following will help establish the diagnosis:
A. Episodes occur post specific anxiety provoking situations
B. Previous emotional trauma
C. Episodes occur unexpectedly and she would fear more of these episodes
D. Obsessions and compulsions
Answer C. Episodes occur unexpectedly and she would fear more of these episodes
29
Parents are divorcing and would like you to give them guidance
A. Joint custody decision at this time is most important
B. Sole parental custody is best
C. Boys fare better than girls in their psychological adjustment
D. Parental emotions discordance can have big impact
D. Parental emotions discordance can have big impact
30
7 y.o male, separation anxiety, spends time with mother, refuses to go to school. What to do ?
A. Send back to school immediately
B. Send back to school gradually, with mom going to school
C. Give SSRI and send back to school
Or
Child has history of separation anxiety and is having difficult time going to school.
A. Graded exposure, and gradually prolong parents leaving
Controversial question
A. Send back to school immediately - lecturer said depends how long it’s been going on
So maybe A or B depending on timeline
Gen says A - mom should not go to school with him
31
Parents, children and divorce - what is true ?
A. Males respond better to divorce in the immediate post divorce period than females
B. CHildren do better in a 1 parent custody setting without seeing the other parent
C. The best predictor of the child’s response is post separation parental conflict and depression rather than custody issues
A- AAP Divorce and Adjustment of
Children - meta analysis indicate few consistent effects of age at the time of the divorce and only scattered effects for sex
B. CPS statement of supporting mental health of children and youth separating parents:
Children whose parents effectively share joint custody tend to be better adjusted after separation or divorce
C. CPS statement: the three most significant factors that impact children’s well- being during the process of parental separation or divorce are: the quality of parenting; the quality of parent- child interaction; and the degree, frequency, intensity and duration of hostile conflict.
32
Boy with ++ worries about his mom, then walks to school and steps over cracks but if he doesn’t he has to walk around a car three times. What would be most helpful for him ?
A. Desensitization
B. Fluoxetine
Or
Young boy who constantly worries about his mother’s safety, and always late for school because he worries about his mother. Other features of OCD like taking long route home to avoid dog etc. Etc. Management ?
A. Fluoxetine
B. Family therapy
C. Desensitization
Answer: Desensitization
Debated question. His OCD sounds pretty bad so I don’t think starting meds would be wrong but some some sort of CBT would be best. So if that is what they mean by desensitization then ok.
33
11 year old with severe symptoms of separation anxiety. Very worried about something happening to his parents (and to him). Best treatment ?
A. Desensitization
B. SSRI
C. Parent therapy
Answer: desensitization
Controversial some say c or b as well.
CBT should be first
34
Describe a kid who has a change in behaviour over the last year. No longer gets As. Not interested in sports. Parents divorced 2 years ago. Picks on sister. Most likely diagnosis ?
A. Adjustment disorder
B. Major depressive disorder
C. Substance abuse
D. ADHD
Answer: ?
A. Adjustment disorder - has to be symptoms are < 6 months from stressor
B major depressive disorder - need > 5 more symptoms in a 2 week period but only 2 in question
- diminishes interest
- diminished concentration - bad grades
C. Substance abuse - maybe
35
Depressive teen on medication. What is likelihood of recurrence of symptoms in the following 2 years ?
A. 5%
B. 10%
C. 40%
D. 70 %
Answer: C - 40%
Depression has a high rate of recurrence, reaching 20-60% by 1-2years after remission and up to 70% after 5 years of remission.
36
Teachers are worried about a child who is shy, has no friends, does not generate conversation spontaneously, does not make eye contact with teacher, and plays on his own. At home, mother is not as concerned, as he speaks to both his parents all right. Diagnosis ?
A. Selective mutism
B. Autism
C. Language delay
A. Selective mutism
37
17 y.o girl who is very socially inhibited and gets very upset with criticism, and is very sensitive about herself. Her diagnosis is:
A. Avoidant personality disorder
B. Anxiety disorder
C. Schizophrenia
D. Specific phobia
Controversial:A. Avoidant personality disorder (MAC)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts
But diagnosis can only be given if > 18 = looked it up
And you can diagnose avoidant personality disorder under 18 if traits are pervasive, persistent and unlikely limited to a particular developmental stage or an episode of an Axis 1 disorder. To dx you need to have features present for 1 year
Vs
B- anxiety disorder (CHEO)
Social anxiety (social phobia)
38
10 y.o boy knifes cars, doesn’t listen to parents, very disruptive in classroom and has been in trouble legally. Most likely diagnosis ?
A. Anxiety
B. Depression
C. Oppositional defiant disorder
D. Conduct disorder
D. Conduct disorder
39
Some kid is getting in fights starting at 8 years of age. Now carrying a knife around. Has been charged for stealing and arson (but he isn’t killing cats)
A. Oppositional- defiance disorder
B. ADHD
C. Conduct disorder
D. Behaviour disorder
C. Conduct disorder
40
Father comes to you regarding concern over 13 year old’s behaviour recently. Parents just separated. Brother has ADHD and mother has depression. Girl has declining school performance, buys provocative clothing and swears a lot. She is in attentive most days. You would most likely prescribe:
A. Methylphenidate
B. Fluoxetine
C. Lithium
D. CBT
C. Lithium (MAC answer)
Vs D - CBT (cheo answer)
-would need more information to be able to say wether or not this is bipolar disorder
Rebecca’s group felt that this was bipolar- don’t feel like this is enough information to diagnose mania
41
Teen with a manic episode (from history). You treat with:
A. Lithium
B. SSRI
A. Lithium - but atypical antipsychotic is first line in teenagers
42
Girl who is shopping lots, irritable, decreased need for sleep and wearing provocative clothing. Family history of suicide. What’s the treatment ?
A. TCA
B. Paroxetine
C. Lithium
D. Fluoxetine
C. Lithium
Bipolar disorder
43
Who has the highest risk of suicide completion ?
A. Cerebral palsy
B. Homosexual
C. Child who’s just been through parental divorce
Answer B: homosexual
44
Teen after suicide attempt. Which is the strongest risk factor that he is going to complete suicide in the next 24h:
A. Homosexuality
B. Wrist slashing
Answer A- homosexuality (mac)
Vs
B. Wrist slashing (cheo)
45
Who is at greatest risk for suicide?
A. Recent breakup with boyfriend
B. Teen with a history of superficial cutting
C. Homosexual teenager
C. Homosexual
46
A 16 y.o old. Suicidal, threatening with a knife. Poor school performance recently. Hears voices. Feels weird for minutes to hours. Family history of depression and suicide. Likely diagnosis ?
A. Drug abuse
B. Depression
C. Schizophrenia
D. Brain tumor
C. Schizophrenia
47
Parents found a boy trying to hang himself and they have brought him in for an assessment. This is a young man troubled by violent thoughts of hurting others. Has been able to deal with them for now, but isn’t sure if he can do so in the future. What does he have?
A. Anxiety
B. Antisocial personality disorder
C. Schizophrenia
D. Depression
C. Schizophrenia
- we answered OCD to similar question. He wouldn’t be able to suppress them if it was schizophrenia
Vs
A. Anxiety - OCD is under anxiety disorder so A can be the right answer
48
Child with a knife wants to kill himself. Decreased school performance and personal appearance for the last 6 months. Hearing voices which are upsetting to him when it occurs. Family hx of depression and suicide. Most likely diagnosis ?
A. Depression
B. Schizophrenia
C. Substance abuse
Answer B. Schizophrenia- again similar question but this one doesn’t mention more about the thoughts and if he can suppress them.
I think the key word here is hearing voices and has a prodrome of decreased school performance and personal appearance.
49
A teenage boy is having difficulties functioning because he constantly has to wash his hands and has obsessive thoughts. Which of the following medications may help him?
A. Amitriptyline
B. Clonazepam
C. Clozapine
D. Fluoxetine
D. Fluoxetine
OCD - start to with either CBT some or in combination with SSRI, when symptoms are moderate to severe
50
A 7 year old had a renal transplant 3 months ago. She had quite a few complications including pneumonia and a possible rejection. As a result she has missed a lot of school. She now complains of non-specific abdominal pain in the morning time. What would be the best management strategy?
A. Tell teacher to give you her homework and keep her home until she no longer has abdominal pain
B. Go back to school despite the abdominal pain
C. Refer her to nephrology
Answer B: go back to school despite the abdo pain - SAD
But really with a transplant pt and possible rejection I wouldn’t just ignore abdo pain (my comment)
51
12 year old adolescent took 10 regular strength Tylenol. What does this act signify ?
A. Plan to die
B. Unconscious desire to hurt her parents
C. Conscious desire to change something in her life
Controversial question:
A. Plan to die (MAC)
Vs
C? Conscious desire to change something in her life (CHEO) - weird question with weird options and not enough info
While the patient may have only intended to self harm or elicit help the intent is currently unknown and this the answer can it be determined.
52
11 year old irritable and not sleeping (<5h/night), with mother who has mood disorder. Diagnosis ?
A. Bipolar disorder
B. Substance abuse
C. ADHD
D. Conduct disorder
Answer - A (mac and cheo chose this one) - is what was chosen with the information given currently but he’s pretty young for that diagnosis. Although they can present more irritable than elevated mood
B- substance abuse - I hope not
C. ADHD
D. Conduct disorder - really no indication for this in the stem
53
10 year old causing trouble, including fire setting, killed family cat (repeat)
A. Conduct disorder
B. ADHD
C. ODD
Answer A- conduct disorder
54
7 y.o boy known to have separation anxiety, with no other conditions according to parents and school. What would be the best treatment:
A. Immediate return to school
B. Gradual return to school accompanied by parents, with gradual withdrawal of parents
C. Return to school with SSRI treatment
D. Return to school with benzodiazepine treatment
A. Immediate return to school - cheo answer - also the one I pick as parent should not accompany to school
Vs
B. Gradual return to school accompanied by parents, with gradual withdrawal of parents - Mac answer
55
A teenage boy admits to having violent thoughts that overwhelm him. He says the thoughts are frequent and that he has not hurt anyone yet but fears he will soon. What diagnosis is most likely ?
A. Behavioural problem
B. OCD
C. Schizophrenia
D. Antisocial personality
Answer B: OCD - clear in Nelson’s. I also choose this one
- they seem to be eluding to intrusive thoughts like an obsession. And he has insight into them which would be consistent with OCD.
Controversial with
C. Schizophrenia - but not hearing voices, hallucinations etc
56
9 year old boy presents with suicidal ideation; what conditions could be associated with this behaviour ?
A. Parental divorce
B. Bullying
C. Impulsive behaviour
D. Depression
Answer: D depression but B,C,D all right according to CPS statement and A could be right according to Nelson’s.
57
9 year old boy with depression and suicidal ideation. What could be a reason?
A. Parental divorce
B. Poverty
C. Bullying at school
C. Bullying at school - from CPS statement but others could be right too
58
10 year old boy presents with school absenteeism and recurrent abdominal pain. Has missed 40% of classes but still able to get As. Growth plotted on growth chart and is normal, with physical exam likewise unremarkable. Now has headache consistently in the afternoons which have not changed in severity over the past 12 weeks. What is the likely diagnosis ?
A. Cow’s milk protein allergy
B. Inflammatory bowel disease
C. CNS neoplasm
D. Anxiety
D. Anxiety
Younger anxious children who refuse to attend school are more likely to have SAD, whereas older anxious children usually refuse to attend school because of SP. Somatic symptoms, especially abdo pai. And headaches are common
59
Girl with family history of bipolar disorder. Now she is restless, irritable and only sleeping 5hours a night. Most likely diagnosis ?
A. New onset ADHD
B. Bipolar disorder
B. Bipolar disorder
60
A 10 year old boy comes in with a history or resistance to following instruction, arguing with parents and teachers, and often gets into fights. What is his likely diagnosis ?
A. Oppositional defiant disorder
B. ADHD
C. Conduct disorder
D. Depression
A. Oppositional defiant disorder
61
Child presents with recurrent episodes of tachypnea, tachycardia, diaphoresis, nausea and vomiting. This occurs 2x weekly, never at school, for six months. What is the cause ?
A. Panic attack
B. Social phobia
C. Arrythmia
A. Panic attack
62
Young boy who is referred to you for query ADHD. On history you discover that he goes over his letters 3-4 times after writing each word. He does this at school and at home. He does not have disruptive behaviour and no signs of inattention, hyperactivity or problems with peer relationships. What is his diagnosis ?
A. ADHD
B. Obsessive compulsive disorder
C. Anxiety disorder
B. Obsessive compulsive disorder
This kid has compulsions - repeatedly checks his letters
63
11 y.o girl is referred for assessment of possible ADHD. She has agitation; irritability, personality changes, sleeping 5hrs/night. Mom has bipolar. What is the most likely diagnosis:
A. New onset ADHD
B. Marijuana abuse/drug use
C. Bipolar disorder
C. Bipolar disorder
They are making it seem like bipolar is common in kids. Sounds like she is manic/hypomanic - to make diagnosis of bipolar you need recurrent episodes of mania or hypo mania, with depression.
ADHD can be confused with bipolar, but in ADHD rarely have euphoria, grandiosity, decreased need for sleep, hypersexual, hallucinations. ADHD tends to be more chronic whereas bipolar varies over time.
64
Teen has been depressed since being bullied at school after coming out as a homosexual. He has taken pills from his parents 4 months ago so now all meds in the house are locked up. What to do?
A. Do not tell his parents because he insists that you don’t tell them
B. Get more information from the school principal
C. He is at low risk for suicide because the pills are locked away
D. He is at increased risk for suicide because he is homosexual
D. He is at increased risk for suicide because he is a homosexual.
2-7x more likely to attempt suicide
A is wrong because homosexuality can be kept from parents, but you can disclose to parents about suicidal thoughts
B- not sure how that would help
C- access to means to attempt suicide is a potent precipitating factor - forearms, medications, illicit drugs, toxic chemicals, carbon monoxide, hanging and cutting
- this is something a parent can prevent by limiting access, but kid could come up with another way.
-also he has attempted before - so higher risk of attempting again, and completing
65
6y.o boy with 2 weeks of sudden onset OCD behaviours. Which infectious agent would you be concerned about:
```
A. Strep pneumonia
B. Group A strep
C. E.coli
D. H. Flu
E. Echovirus
```
B. Group A Strep
PANDAS
Pediatric autoimmune neuropsychiatric disorder a/w group A streptococci - term used to describe a subset of children whose symptoms of OCD or tic disorders are exacerbated by group A strep (GAS) infection.
66
Which of the following treatments have been proven to be effective:
A. Behavioural therapy in social phobia
B. Paroxetine in panic disorder
Answer A - behavioural therapy in social phobia.
CBT is efficacious for pediatric social anxiety disorder.
SSRIs in panic disorder have a good response rate (75-90%) - 3 uncontrolled trials - but don’t give paroxetine (paxil) as much to kids because has highest incidence of withdrawal symptoms on abrupt discontinuation.
67
Suicide in teens, which is not true about increasing suicide risk ?
A. Most teens who commit suicide have a psychiatric history
B. Most have a prior attempt
C. Boys complete suicide more often than girls
D. Girls take pills
B. Most have a prior attempt - according to lecture. I guess it makes sense...people have to start somewhere ie; Everyone has to have a prior attempt
A- most have psych hx - true - from CPS statement: history of mental illness is present in 90% of adolescents who die by suicide (mostly depression but can also be other things like substance use, conduct, bipolar)
B. CPS statement says that a previous suicide attempt is one of the strongest predictors of suicide in adolescents.
C. Boys complete suicide more often than girls - true from CPS statement
D. Girls take pills - Nelson’s says firearms are most common method for completing suicide for males and females are more likely to complete by poisening
68
Major depressive disorder, which is not true?
A. TCAs are proven to be beneficial over placebo
B. Associated with suicide
C. Diagnostic criteria in childhood veery much unlike that for adults
Controversial question.
A. TCAs are proven to be beneficial over placebo (mac chose this one - ref up to date = although tricyclics are efficacious for adults with depression, studies in children and adolescents often fail to demonstrate any benefit.
Cheo - true - but SSRIs are much better than TCAs so rarely use them nowadays - TCAs have limited benefits and a lot of side effects and safety concerns
B- associated with suicide - true
C- false - they are the same diagnostic criteria but there are some small differences
- for kids they have a period of depressed or irritable mood or loss of interest present for 2 weeks whereas adults need to have two weeks of depressed mood or loss of interest/pleasure
- Nelson’s says: clinical presentation of major depressive disorder in children and adolescents is similar to that in adults. The prominence of the symptoms can change with age.; somatic complaints, irritability and social withdrawal may be more common in children (who are less able to verbalize their feeling states), and psychotic and melancholic symptoms or suicidal behaviour may be more common in adolescents
69
A 10 y.o boy has been missing lots of school the last few months because of abdominal pain, recurrent headaches. These occur any time of day. Likely diagnosis ?
A. Brain tumor
B. Migraines
C. School phobia
D. Peptic ulcer disease
C. But best would be anxiety disorder
70
The following is true of post traumatic stress disorder
A. Intrusive memories
B. Vegetative symptoms
C. No emotional disturbances prior to event
A. Intrusive memories
UTD: intrusive and distressing thoughts about the traumatic event are common in children with PTSD. These thoughts and memories are experienced as involuntary and uncontrollable, ie: they occur when the child does not want to think about the traumatic event
B. Vegetative sx - false have marked alterations in arousal and reactivity a/w the traumatic event - often irritable, hypervigilant, sleep disturbance
C. No emotional disturbances prior to event - false they can have emotional disturbances before
71
Childhood toxic stress can lead to problems with mental health in adulthood.
A) Name three examples of toxic stress that a child may be exposed to.
B) what is the relationship bye toxic stress exposure and poor outcomes in adulthood ?
A. 3 examples of toxic stress that a child may be exposed to
1. Exposure to domestic violence
2. Physical hostility, especially when it is directed toward children
3. Abusive behaviour (emotional and physical) towards the child
4. Caregiver mental health problem
5. Caregiver substance use disorder
6. Chronic neglect
7. Burdens of family economic hardship
B. What is the relationship btw toxic stress exposure and poor outcomes in adulthood
The more toxic stress, the more it has a cumulative effect, with increased risk of mental health concerns (depression, etc) and decreased resilience
- decreased self esteem
- poor neurocognitive dvlp
- poor coping skills
- constant exposure to adrenaline rush and stress hormone affect growth and development
72
A 13 your old girl has panic attacks that happen 3-4 times per day, lasting a few minutes at a time.
A. What are two elements on history that would qualify this as a panic disorder (4pts)?
B. What are two treatment/management modalities (2points)
C. What would you suggest for her to do when she next experiences an attack ?
A. What 2 elements on history would you need to qualify as a panic disorder
1) . Persistent concern or worry about additional panic attacks or their consequences (ie; losing control, having a heart attack, going crazy
2) . A significant maladaptive change in behaviour related to the attacks
B. What are two treatment/management modalities ?
1) . CBT
2) . SSRI
C. What would you suggest for her to do when she next experiences an attack ?
- breathe slowly in a paper bag
- relaxation technique
- belly breathing (breathe slow and deep)
- think positive
73
What are the DSM- 5 criteria for panic disorder ? (I added )
A. Recurrent unexpected panic attacks
B. At least one of the attacks has been followed by a month or more of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (ie: losing control)
2. A significant maladaptive change in behaviour related to the attacks (ie; behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)
C. The disturbance is not better explained by another medical disorder
74
A 16 year old girl with history of significant depression, started on risperidone a few months ago. She presents to you with galactorrhea.
A. What are 3 investigations you should do as part of your management of a patient on risperidone?
B. She reports to you that her mood is significantly improved since starting the medication and she feels much better. What are two modifications you would suggest to her medication regimen?
A. What are 3 investigations you should do as part of your management of pt on risperidone?
Screen for metabolic disorder
- fasting serum glucose
- fasting or non fasting lipid profile
- weight and BMI
- blood pressure
- LFTs (AST, ALT)
B. 2 modifications to medication regimen
1. Gradual decrease of the dose to the lowest effective level
2. Trial non antipsychotic med such as SSRI or prolactin -soaring depot antipsychotic medication - aripiprazole and olanzapine or quetiapine
3. Addition of meteor in may reduce the prolactin level
75
A 15 year old boy presents with refusal to go to school. He spends all his time in his bedroom. He has cut ties with his friends. He seems preoccupied and says odd comments.
A. Name 4 possible diagnoses to explain this presentation.
B. What is 1 important thing to assess for his safety before he leaves your office ?
A. Name 4 possible diagnosis
1. Depression +\- psychotic features
2. Schizophrenia
3. Social anxiety disorder
4. Medical cause
5. Substance abuse
B. What is one important thing to assess for his safety before he leaves your office ?
Suicidal ideation
76
Name 5 things that would make you suspect the diagnosis of Munchausen by proxy.
5 things that would make you suspect Munchausen by proxy (also called medical child abuse)
1. History out of keeping with physical findings- the reported history varies from what is observed or does not make sense
2. Inconsistent history - histories may vary significantly by different observers and suggest that the perpetrator’s history is distorted
3. Unusual evolution of the disease and failure of medical treatment - the illness is often recurrent, unexplained, unusual, or prolonged and does not respond to treatment as expected. If the child has a specific diagnosis , it may be extremely rare. However, a significant portion of victims of MCA also have a chronic illness or disability.
4. Family history of suspicious events -May indicate siblings who have died or who have similar illnesses
5. The patient is subjected to a large amount of health care without improvement in reported signs or symptoms including:
- repeated office visits and examinations
- multiple diagnostic tests
- multiple medical interventions (medications and/or surgery)
- management by multiple subspecialists
- signs or symptoms only begin in the presence of the caregiver
6. In children with induced or fabricated illness, clinical improvement often occurs when they are separated from their caregiver
77
Teenage girl with suicide attempt who took Tylenol. Ready to leave it’s Friday and she lives in remote area w/no access to services on weekend. Name 5 components to the safety plan you would establish with her prior to her being seen next ?
Name 5 components to the safety plan you would establish with her prior to her being seen next.
1. Help her identify her own triggers and situations that put her at greater risk
2. Work with her to list and practice whatever coping skills she has available
3. Identify individuals in her social circle (parents, friends, counsellors, teachers) that can provide distraction, support/help in times of crisis; clear instructions on the importance of communicating suicidal thoughts and behaviours to identified trusted person/adult (contigency plan)
4. Parents and/or guardians should be encouraged to allow open communication with the adolescent, particularly regarding negative feeling states and suicidal thoughts
5. Parents to ensure all high risk items out of house/locked up (weapons, meds- rx and non-rx, substances of abuse) and restricting access to modes of lethal self- harm
6. Practitioner to assess the type and availability of mental health support available to her in her community and ascertain that ( i) she is willing to follow up with this individual (ii) she views the connection as positive and supportive.
7. Schedule follow up with mental health clinician planned for within a few days before discharge home
8. Identify availability of trusted crisis services and telephone lines (kids help phone )
9. Locate nearest ED in case of crisis and instruct to use ED if necessary
78
10 year old boy who is inattentive, impulsive and getting poor grades in school. He’s been on ADHD med with good compliance X 2 years with no improvement in his symptoms. Name 5 other possible diagnosis
Name 5 ddx of ADHD
1. Anxiety
2. ODD
3. Learning disability
4. Depression
5. Medical illness (hypothyroidism)
6. Hearing/visual impairment
7. Bipolar
I added alcohol fetal syndrome
79
A teen comes out to you that he is gay. Name 5 social/emotional/psychological conditions he’s at risk for
Topic sexual orientation 5 factors
1. Verbal or physical assault - in Highschool, assault reported by 1/2 of gay men and 1/5 of lesbians; 2-4x more likely to be threatened with a weapon at school
2. School drop out- harassment at school leads to a higher risk or dropping out
3. Homelessness - harassment at home, and are more likely to be kicked out of their homes and living on the streets
4. Substance use - more likely to start using tobacco, alcohol and other elicit substances at an earlier age
5. Mood disorders: depression, anxiety, poor self-esteem
6. Suicide: 2-7x more likely to attempt suicide; highest risk when:
- teen acquires a gay identity at a young age
- when there is a family conflict
- the teen has run away or been thrown out of the house
- if he or she is conflicted about his or her orientation
Or if he or she has not been able to disclose his or her orientation to anyone
80
Kid with shortness of breath, tingling sensation in fingers; just moved to the area.
A. What’s the diagnosis ?
B. What 3 things can you do for management ?
```
A. Anxiety/panic attack
B. 3 things on management
- Educate patient on diagnosis
- relaxation techniques
- CBT
- SSRI
- rule out organic cause
```
Non-specific treatments include activities that decrease stress, improve mood, and support well-being, including sleep hygiene, healthy eating, regular exercise, predictable routine and social supports
81
Patient presenting with a diagnosis of ODD.
A. Not including pharmacologic therapy, state two behavioural recommendations for the parents:
B. What are 2 co-morbidities he is at risk for ?
A. Two behavioural recommendations
1. Parent- management training
2. Cognitive problem- solving skills training
B. 2 co-morbidities
1. ADHD
2. Anxiety disorders
3. Mood disorders
4. Learning disorders
5. Language disorders
82
Girl with suicidal ideation, admitted. You, the parents and the patient all agree that she is now ready for discharge. The family lives in a remote community, and there are no mental health resources available over the weekend. List 5 things you would recommend to keep her safe over the weekend before she can be re-evaluates on Monday ?
5 things
1. Remove high risk materials from home - firearms, meds, sharps
2. Create safety plan - what to do if suicidal ideation occurs
3. Provide information on crisis services - kids Help phone, nearest ED
4. Discuss relaxation techniques
5. Have parents check in often and do not leave youth alone for long periods of time.
83
List four behaviours suggestive of conduct disorder.
4 behaviours of conduct disorder
1. Aggression to people and animals
2. Destruction of property
3. Deceitfullness or theft
4. Serious violations of rules
```
TRAP
T- theft
R- rule breaking
A- aggression towards people and animals
P- property destruction
```
84
What are 2 features of an obsession in OCD that distinguish it from everyday worries
2 features of an obsession in OCD
1. Recurrent
2. Intrusive
3. Attempts to ignore or suppress obsessions by performing a compulsion
4. Ego systolic
5. Impairs function
6. Take more than one hour a day
85
A kid with a past history of anxiety, expressed as headaches and abdominal pains. Has an appendectomy and is off school for 10 days. Now refusing to go back to school. Is otherwise well. What 4 steps do you take in getting him back to school.
1. Go back to school right away
2. Exposure based CBT
3. Introduce coping strategies, relaxing techniques etc
4. Speak with the teacher to make sure they are aware of the situation and can provide space in case they need to calm down.
86
The parents of a 16 year old boy are concerned because for the last few weeks he says odd things and is spending a lot of time in his room. He does not want to go to school anymore and doesn’t want to see his friends. What are 4 possible diagnosis ?
4 ddx
1. Anxiety
2. Depression
3. Schizophrenia
4. Social phobia
87
What are 4 risk factors in an adolescent male for suicide ?
4 risk factors in adolescent male for suicide
1. Previous attempt
2. Family history
3. Homosexuality
4. Impulsive behaviour
88
A). Define obsession and give an example (1 line for each)
B) Define compulsion and give an example (1 line for each)
C) what is the most important feature needed for the diagnosis of OCD ?
A. Define obsession + example
- recurrent and persistent intrusive thought that causes distress
- example - fear of germs
B. Compulsion + example
- repetitive behaviour that the individual feels compelled to do in response to an obsession to reduce distress
- example - hand washing
C. Most important feature is for diagnosis
- obsessions or compulsions are time consuming (>1h per day) or cause clinically significant distress or impairment in social, occupations, or other important areas of functioning.
89
Define Munchausen by proxy, and 3 typical features
A. Definition
- Munchausen by proxy - situation in which parent or other caregiver simulates or causes disease in child
- intentional production or feigning of physical/psychological signs or symptoms in another person who is under that person’s care
B. Typical features
1. Usually mother involved
2. Reported symptoms noted by only one parent
3. Symptoms in child a/w proximity of offending caregiver to the child
4. Perpetrator often has health care related experience
5. Unresponsive to the child when unaware of being observed despite appearing very interesting in child’s condition
6. Appropriate testing fails to confirm a diagnosis
7. Seemingly appropriate treatment is ineffective
8. Child’s symptoms, course, or response to treatment may be incompatible with any recognized disease
9. Atypical clinical course and inconsistent lab results at odds with the seeming health of the child
10. Preschool age, preverbal children most common
11. Common presentations
- bleeding, seizures, apnea, vomiting, diarrhea, sepsis with intentionally contaminated body fluid samples, skin
90
8 y.o boy is manipulative, argumentative and vindictive. He gets suspended from school. He throws temper tantrums. Diagnosis ? Give 2 management strategies
A. Diagnosis = ODD
B. 2 management strategies
1. Parent management training
2. Social emotional skills training directed at child or cognitive problem skills training
* meds only for comorbidities
91
15 y.o male brought in by parents because locked in room, hearing voices. Broke up with girlfriend two weeks ago.
A. What is the differential diagnosis ? List 4
B. List four non- psychiatric diagnoses for psychosis/delirium
Psychosis - an impairment in reality testing that may present as hallucinations, delusions, disorganized speech or behaviour
A) Psych DDx for psychosis
1. Major depressive episode with psychotic features
2. Bipolar disease/mania + psychosis
3. OCD
4. PTSD
5. Substance use disorder
6. Brief psychotic disorder
- due to an extreme stressor, resolves within one month, usually return to baseline level of functioning
7. Schizophrenia - but need symptoms for one month
month
B) ddx for medical, non psych causes of psychosis
1. Lupus with CNS involvement - auditory/tactile hallucinations
2. Anti- NMDA encephalitis
3. Temporal lobe epilepsy - audio and visual hallucinations
4. Medications - ie; steroid induced psychosis
5. Toxic ingestion (ie; anticholinergic)
6. Any serious CNS infection
7. Subacute sclerosing panencephalitis - rare complication of measles
8. Urea cycle defects
9. Wilson’s disease
10. Acute intermittent porphyria
11. Post part in psychosis
12. Electrolyte disturbance
13. Hepatic encephalopathy from hepatic failure
14. Uremic encephalopathy from renal failure
15. Hashimoto encephalopathy- a/w thyroditis
16. Thyroid storm
Etiology “ I WATCH DEATH”
Infection- encephalitis, meningitis, sepsis
Withdrawal - sedative - hypnotics
Acute metabolic - electrolyte disturbance, hypoglycaemia
Trauma - head injury, post-op, severe burns
CNS pathology- infection, seizures, postictal, vasculitis
Hypoxia
Deficiencies
Endocrine - thyrotoxicosis
Acute vascular - shock, stroke
Toxins or drugs - medications (opioids, anticholinergics)
Heavy metals - mercury
92
A teenager is suspected of having depression by her parents. What five questions would you ask her to make your diagnosis of depression?
DSM V
- Need low or irritable mood OR loss of interest PLUS at least 4 of the following nearly every day for > 2 weeks
1. Sleep changes - more or less
2. Guilt or worthlessness
3. Energy decrease
4. Concentration problems
5. Appetite or weight changes
6. Psychomotor retardation or agitation
7. Suicidal ideation/ thoughts of death
- You also need to clarify that these are impairing function
- r/o medical condition and substance use
I am not sure if the point of this question is to ask 5 symptoms of depression or to also try to ask the other questions about duration, rule out other medical problems etc. I am thinking they just want you to get the diagnostic criteria
93
Name 3 diagnostic criteria for ADHD -inattentive subtype. Name 3 diagnostic criteria for ADHD hyperactive/impulse subtype
Diagnostic criteria
Inattention: 6+ for at least 6 months
1. Fails to give close attention to detail, careless mistakes
2. Difficulty sustaining attention in tasks or play
3. Does not seem to listen when spoken to directly
4. Does not follow through on instructions, fails to finish schoolwork
5. Difficulty organizing tasks and activities
6. Avoids/dislikes/reluctant to engage in tasks that require sustained mental effort
7. Often loses things
8. Easily distracted by extraneous stimuli
9. Often forgetful in daily activities
Hyperactivity and impulsivity: 6+ for at least 6 months
1. Fidgets with or taps hand or feet or squirms in seat
2. Difficulty remaining seated
3. Runs or climbs inappropriately
4. Unable to play or engage is leisure activities quietly
5. Often “on the go” acting as of “driven by a motor”
6. Talks excessively
7. Blurts our answers
8. Difficulty waiting turn
9. Interrupts or intrudes on others
- Mixed subtype requires 6+ symptoms on each category ( 12 total)
- symptoms must be present prior to age 12 (previously age 7)
- symptoms present in 2+ settings
- interferes with or reduce quality of functioning
9% boys, 3% girls
- comorbidity = conduct disorder, anxiety, mood disorder, learning disorder
94
How many criteria are needed for a diagnosis of ADHD mixed subtype ?
- mixed subtype requires 6+ symptoms in EACH category (12 total )
95
4 y.o child with symptoms of autism. What is the diagnosis ?
What 2 neurological disorders are a/w this ?
```
A. Diagnosis - autism
B. 2 neurologic disorders a/w autism
1. Global developmental delay
2. Rett syndrome
3. Fragile X
4. Angelman
5. Prader Willi
Or
```
Epilepsy
96
Teen wit panic attacks(described). What is the likely diagnosis ? What are 2 treatment modalities.
A. Diagnosis - panic attacks
| B. CBT and SSRI
97
2019 question: 7 year old male with difficulties leaving mother, along with refusal to go to school. What treatment would you advise ?
A. CBT
B. Benzo PRN
C. Antipsychotic
D. Family therapy
Both parent training/family therapy and CBT for the kid - gradual exposure therapy are correct !!!!😣😣😣
98
2019 question: 7 y.o girl with abdominal pain in the morning before school, and physical exam normal. What to do?
A. Send to school
B. Homeschool
C. Changes schools then gradually send to school
D. Fluoxetine
A. Send to school
99
2019 question: At what age are most children sure of their gender identity ?
A. 4
B. 6
C. 8
D. 10
Answer: A 4 y.o
Most resources on internet said gender identity happens around 3-4 years old
100
2019 question: 15 y.o boy with depression. What would make you hesitate in prescribing fluoxetine ?
A. Family history of suicide
B. Family history of bipolar disorder
C. Personal history of cardiac surgery
D. Personal history of anxiety
B. Family history of bipolar disorder
101
Teenager took 15 tabs of an oral hypoglycaemic and hospitalized. 48h later is stabilized. Demanding to leave. She is homeless and lives on the street. What is her greatest risk factor for repeated suicide attempt ?
A. Mechanism of suicide attempt
B. Female
C. Being alone
D. Spontaneous suicide attempt
Maybe c. Being alone
A. Mechanism of suicide attempt - firearm worse than pills
B. Female - males most often complete suicide and females have more attempts
D. Spontaneous suicide attempt - planned is worse
102
2O19 question : Teen girl with symptoms of generalized anxiety disorder
A. What is the most evidenced based psychotherapy treatment for anxiety ?
B. Her anxiety worsens and she agrees to start a medication. What is your first line pharmacological treatment for this patient ?
C. This medication is known to have side effects and a black box warning; list 2 ways you would approach tax and management ?
A. CBT
B. SSRI/ fluoxetine
C. 2 ways approach treatment and management of Medication
1. Begin treatment with fluoxetine and start with a low dose and titrate to minimum therapeutic dose over 1-2weeks (can take 4-6 weeks to see effect)
2. Monitor for suicidality, adverse medication effects, triggering of mania or hypomania, signs and symptoms of serotonin syndrome on a weekly basis for the first 4 weeks then every other week from weeks 5-12, then after week 12 as clinically indicated (q4weeks)
