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USMLE Step 2 CK Flash Cards > Psychiatry > Flashcards

Psychiatry Flashcards

1
Q

FDA approved first-line drugs for smoking cessation treatment

A
  • Nicotine replacement therapy→transdermal patch, gum, lozenge, inhaler, nasal spray►↓nicotine withdrawal symptoms
  • Varenicline→alpha 2, Beta 4 nicotinic acetylcholine receptor partial agonist►↓nicotine cravings (associated with mood changes, suicidality, CV events)
  • Bupropion→norepinephrine and dopamine reuptake inhibitor►smoking cessation aid
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2
Q

Most common comorbid conditions in Tourette syndrome

A
  • Attention-Deficit hyperactivity disorder (ADHD)

- Obsessive-compulsive disorder (OCD)

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3
Q

Probable side effects of some over-the-counter cold preparations and why?

A

Because they may contain:

  • Antihistamines (diphenhydramine, doxylamine)→anticholinergic►confusion and hallucinations
  • Alpha-adrenergic agents (pseudoephedrine, phenylephrine)→sympathomimetic►agitation and psychosis
  • Dextromethorphan→NMDA antagonist►dissociative symptoms and hallucinations

*Effects seen in combination, excess or prescribed doses in sensitive individuals

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4
Q

Which is the most common method to commit suicide? Why is important?

A
  • Firearms (men and women)

- Ask about access to guns (avoid access in patients with suicide ideation)

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5
Q

How can you differentiate primary psychiatric disorders from chronic methamphetamine abuse?

A

Methamphetamine abuse:

  • Persistent psychosis→Visual and tactile hallucinations are more common in substance-induced psychotic disorder
  • Weight loss
  • Dental problems (“meth mouth”)→brown discoloration, tooth decay, cracked teeth
  • Excoriations due to chronic skin picking
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6
Q

Main features of delusional disorder

A
  • ≥1 Persistent delusion and no other prominent psychotic symptoms (hallucinations, negative symptoms, disorganization)
  • Functioning is not markedly impair
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7
Q

Key to differentiate personality disorders (paranoid, schizoid and schizotypal) from delusional disorder

A

Personality disorders do not have delusions

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8
Q

Common early side effects of SSRIs in anxiety disorder patients? What to do?

A
  • Stimulating effects: new-onset anxiety in nonsocial situations, insomnia
  • Temporary reduction in dosage

*Should generally start with lower doses than usual (depressive disorders)→Half normal starting dose and gradual increase

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9
Q

Early side effects of SSRIs

A

Nausea, diarrhea, increased anxiety or insomnia (activating or stimulating effects), somnolence

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10
Q

How do you differentiate schizoaffective disorder from bipolar disorder or major depressive disorder with psychotic features?

A
  • Psychotic symptoms in major depressive or bipolar disorder occur exclusively during mood episodes
  • Schizoaffective disorder =>2 weeks of delusions or hallucinations without major depressive or manic episode
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11
Q

Dominant person’s delusion transferred to a more submissive partner

A

Shared psychotic disorder (folie á deux)

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12
Q

First measure to approach shared psychotic disorder

A

Separate the individuals to determine the degree of impairment in each

*Also Tx to break the cycle of mutual reinforcement

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13
Q

Pharmacology treatment for aggressive autism spectrum disorder

A

Risperidone or Aripiprazole

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14
Q

First and second line of treatment for Attention Deficit Hyperactivity Disorder

A
  • First line: Methylphenidate, Dextroamphetamine (Affect noradrenergic and dopaminergic pathways)
  • Second line:
  • Atomoxetine (NE reuptake inhibitor)
  • Clonidine, Guanfacine (alpha-2 agonists)→↑Cognition and attention in prefrontal cortex (limited use in adults)
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15
Q

Pharmacology treatment for Tourette disorder

A
  • Dopamine-depleting agents→tetrabenazine►VMAT-2 inhibitor►↓monoamines uptake
  • Preferred over dopamine-blocking agents; not cause tardive dyskinesia
  • Dopamine antagonists (Antipsychotics)→Haloperidol, Pimozide, Risperidone
  • Alpha-2 agonist→Clonidine
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16
Q

Best alternative in a patient with depression and neuropathic pain

A

Duloxetine→SNRI

*Also tricyclic antidepressant (amitriptyline)

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17
Q

Best indications of Bupropion in a patient with major depressive disorder

A
  • Fearful of weight gain with SSRI
  • Fearful of sexual side effects or SSRI-induced sexual side effects
  • Smoker trying to quit
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18
Q

Indications of Electroconvulsive therapy in depression

A
  • Initial therapy did not work

- Severe depression associated with psychotic symptoms

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19
Q

When do you use Mirtazapine for major depressive disorder? How does it work?

A

Patient with insomnia and weight loss (appetite-stimulating)

*α2-antagonist→↑release NE, 5-HT, potent 5-HT2, 5-HT3 receptor antagonist, H1 antagonist→antidepressant and sedative effects

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20
Q

Treatment for acute mania with severe symptoms

A

Atypical antipsychotics→shorter onset of action►Olanzapine, Lurasidone, Quetiapine, etc

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21
Q

Treatment of acute mania

A

Lithium, Valproic Acid, Atypical antipsychotics

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22
Q

Best treatment for depression

A

Electroconvulsive therapy

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23
Q

Which disorder may develop in adulthood the children with disruptive mood dysregulation disorder (DMDD)?

A

Depression or Anxiety

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24
Q

What is the Disruptive mood dysregulation disorder (DMDD)?

A

Severe recurrent verbal (scream) or behavioral (physical aggression) outbursts out of proportion of the situation + persistent irritability, angry mood between outbursts for >1 year

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25
Q

Contraindication of Bupropion

A

Eating disorders and seizure disorders (↓Seizure threshold)

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26
Q

Mania or Hypomania treatment during pregnancy

A
  • Typical antipsychotics (eg, haloperidol)

- Electro Convulsive Therapy for severe or refractory mania

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27
Q

Characteristic polysomnographic finding in Major Depressive Disorder. Which are other sleep findings?

A
  • ↓REM sleep latency (time from sleep onset until the start of first REM sleep period)►biomarker of depression
  • ↓Slow-wave sleep (deep sleep), ↑REM sleep duration and density, disruptions in sleep continuity
28
Q

How can you differentiate postpartum depression from postpartum blues?

A
  • Postpartum depression➡onset since 4 wks, function impairment
  • Postpartum blues➡onset in days, self-limited to 2 wks, milder symptoms, no function compromised
29
Q

Treatment of postpartum depression

A

SSRI (Sertraline preferable during lactation) + Psycotherapy

30
Q

Treatment options of Tardive Dyskinesia

A
  • ⬇Antipsychotic dose
  • Valbenazine, Deutetrabenazine➡reverse inhibitors of the vesicular monoamine transporter 2 (VMAT2)
  • Switching (cross-tapering) to an antipsychotic with lower tendency for TD➡Quetiapine, Clozapine
31
Q

First step in patients with depression

A

Screen for suicidal risk➡ indicates appropriate treatment setting and frequency of follow-up care

  • Plan and intent to act➡Hospitalization
  • Ideation without a specific plan or intent➡intensive outpatient treatment

*Screen before initiating antidepressants drugs

32
Q

Side effects of atypical antipsychotics

A
  • “pines” (Olanzapine, Clozapine, etc)➡⬆risk of weight gain, metabolic syndrome, diabetes
  • “dones” (Risperidone, Lurasidone, etc)➡⬆risk of movement disorders (Risperi-), cardiac conduction problems (Ziprasi-)
  • Aripiprazole➡compulsive behavior (gambling)
33
Q

Specific side effects of Clozapine, what you must watch during treatment? What is its main indication?

A
  • Agranulocytosis (monitor WBCs frequently), seizures (dose-related), myocarditis
  • Resistant schizophrenia or schizoaffective disorder, and for suicidality in schizophrenia
34
Q

What is the first-line treatment for alcohol abstinence?

A

Naltrexone (block μ-opioid receptor)➡⬇the craving for alcohol
*Given to patients who are still drinking

35
Q

First-line treatment for acute bipolar depression

A
  1. Second-generation antipsychotics: Quetiapine, Lurasidone
  2. Lamotrigine, Lithium, Valproate, combination olanzapine + fluoxetine

*Avoid first-line antidepressants (fluoxetine)➡⬆risk inducing mania or hypomania

36
Q

Medications options for Binge eating disorder. What is the most effective treatment option?

A
  • SSRI, Lisdexamfetamine, Topiramate

- Cognitive-behavioral therapy

37
Q

What is the paradoxical agitation adverse effect of benzodiazepines? Which is the management?

A
  • Recurrent episodes of ⬆ agitation, confusion, aggression, and disinhibition within one hour of administration
  • Taper and discontinuation

*⬆Risk in elderly

38
Q

Treatment for Major depressive disorder with psychotic features

A
  • Nonemergency➡Antidepressant + antipsychotic (Ex, sertraline + risperidone)
  • Emergency (severe suicidality, refusing to eat, dehydration)➡Electroconvulsive therapy (ECT)

*Antipsychotic monotherapy or antidepressant monotherapy is not well effective

39
Q

Maintenance treatment for severe bipolar disorder with frequent mood episodes

A

First-line combination therapy: Lithium or Valproate + second-generation antipsychotic (ex, quetiapine)

40
Q

Best next step when patients have no significant response or unacceptable tolerability with first-line antidepressant trial

A
  • Switch to a different antidepressant rather than augmentation with a second agent
  • Add second agent in partial response with first drug and without side effects

*Decision-based upon specific depressive symptoms and side effects; Ex: SSRI (no response and/or sexual dysfunction)🔄Bupropion

41
Q

Treatment for ADHD

A
  • 4–5 years of age: Best initial treatment➡Behavior therapy. Add drugs if no improvement
  • ≥ 6 years of age: Best initial treatment: Pharmacologic therapy + behavior therapy
    ■ First line: CNS stimulants (methylphenidate, dextroamphetamine)
    ■Alternatives: Nonstimulants
    *Atomoxetine (norepinephrine reuptake inhibitor): Might be first-line to avoid side effects of CNS stimulants
    *Clonidine/guanfacine (α2-agonist) [limited use in adults], bupropion, TCAs
42
Q

What is selective mutism?

A

Refusal to speak in a specific social situation (Ex, school)

*Dx requires >1 month. Considered Anxiety disorder, frequently comorbid with social anxiety disorder

43
Q

What abnormality in the CSF of depressive patients with suicidal behavior you may find?

A

⬇Hydroxyindoleacetic acid (5-HIAA)➡associated with suicidal behavior

*Primary metabolite of serotonin➡ modulates mood and behavior

44
Q

Marker of narcolepsy in the CSF

A

⬇Hypocretin-1/Orexin-A

45
Q

What is the REM sleep behavior disorder?

A

Complex motor behaviors during REM sleep

  • Degeneration of brainstem nuclei that inhibits spinal motor neurons during REM sleep➡⬇or❌muscle atonia▶dream enactment
  • Latter half of the night in older adult men
  • Easy to awake alert and oriented, recall the dreams
46
Q

Which diseases might be associated with REM sleep behavior disorder (RBD)?

A

Prodromal sign of α-synuclein neurodegenerative disorders➡ Parkinson’s disease, dementia with Lewy bodies, multiple system atrophy

*Look for other signs/symptoms of neurodegeneration▶subtle motor deficits (slowed gait), anosmia, constipation

47
Q

What type of sleep disorders are sleep terrors and sleepwalking? How do you identify them?

A
  • Non-REM sleep arousal disorder
  • Younger patients, slow-wave (N3) non-REM sleep
  • First third of the sleep period, long period of confusion, do not recall concurrent dreams
48
Q

Antipsychotics with the highest potential to cause infertility

A
  • First-generation: Haloperidol, fluphenazine
  • Second generation: Risperidone, palliperidone (metabolite of risperidone)

Dopamine-2 receptor blockers➡⬆Prolactin➡menstrual irregularities, galactorrhea, infertility

49
Q

Antipsychotics with lower probability to produce infertility

A
  • Aripiprazole (partial DR2 agonist)
  • Quetiapine (low potency DR2 antagonist)

*Less likely to produce hyperprolactinemia

50
Q

Type of tremor associated with lithium side effects vs lithium toxicity

A
  • Lithium side effect▶Physiologic tremor: fine action tremor that worsens with stress (⬆sympathetic activity or medications), symmetric, upper limbs➡⬆iron accumulation in substantia nigra
  • Lithium toxicity▶irregular, coarse tremor in multiple parts of the body + GI or more neurologic symptoms (require dialysis)
51
Q

Treatment of choice for alcohol withdrawal in patients with significant liver disease

A
  • Benzodiazepines without active metabolites and with hepatic metabolism via phase II glucuronidation instead of cytochrome P450 oxidation
  • Oxazepam, temazepan, lorazepan (IV presentation)
52
Q

Inability to restrain aggressive impulses resulting in verbal or physical aggression that is out of proportion of the provocation, impulsive outburst episodes lasting <30 minutes with immediate relief followed by remorse, dysphoria and embarrassment

A

Intermittent explosive disorder

*Impulse-control disorder

53
Q

First-line treatment for obsessive-compulsive disorder (OCD)

A
  • SSRI (Fluoxetine, Fluvoxamine, Sertraline)

- Cognitive-behavioral therapy (CBT)

54
Q

Clinical presentation of cocaine withdrawal

A

Acute onset depression with pronounced fatigue (crash) following a period of increased energy (high)

  • Severe depression with suicidal ideation
  • Psychomotor slowing
  • Hypersomnia
  • ⬆dreaming
  • Hyperphagia
  • ❌concentration
  • Intense drug craving
55
Q

Pharmacologic therapy for patients with alcohol use disorder

A
  • First line:
  • Naltrexone (mu-opioid receptor antagonist)➡contraindicated in liver disease and opioid use
  • Acamprosate (glutamate modulator)➡preferred in liver disease or opioid use (requires adjustment in renal failure)
  • Second line
  • Disulfiram (aldehyde dehydrogenase inhibitor)➡second-line therapy in highly motivated patients
56
Q

Physical examination and laboratory findings suggesting heavy alcohol use

A

Macrocytic anemia, AST:ALT >2:1, parotid gland enlargement

57
Q

Most common deficient minerals in patients with alcohol use disorder

A
  • Hypomagnesemia
  • Zinc
  • Iron

*Relative hyponatremia and hypocalcemia can happen as well but less common

58
Q

Treatment for posttraumatic stress disorder-related nightmares

A

Prazosin▶⬇adrenergic hyperactivity➡⬇nightmares frequency

*Helpful as an adjunct to SSRI and SNRI

59
Q

Best next step when a patient has responded to oral antipsychotic but relapses frequently due to medication nonadherence

A

Long-acting injectable antipsychotic

60
Q

Treatment for Body dysmorphic disorder

A
  • SSRI (first line), eg, Escitalopram. Typically significantly high doses
  • Cognitive-behavioral therapy
61
Q

Best next step if office urine drug screen comes out positive for PCP, and patient is taking control prescription correctly and refuses to be using recreational drugs or PCP

A

Obtain additional urine study➡Confirmatory testing (gas chromatography with mass spectroscopy)

*Common OTC (dextromethorphan, diphenhydramine, ibuprofen) can cause false-positive for PCP [might forget to reveal]

62
Q

Best next step for a patient with the first trial of SSRI failure, and history of bulimia nervosa

A
  • SNRI (Venlafaxine) if had adequate first trial (adequate dose ≥ 6 weeks)
  • Bupropion is wrong because increases the risk of seizures in patients with active or historical bulimia or anorexia (potential electrolyte disturbance)
63
Q

Most commonly associated inherited syndrome with autism spectrum disorder

A

Fragile X syndrome

*Unstable trinucleotide (CGG) repeat expansion in the FMR1 gene on the X chromosome

64
Q

Best next step in an acutely psychotic patient who already received an antipsychotic dose and persists with agitation. Patient has an ECG with QTc interval 505ms.

A
  • Given the potential class effect of antipsychotics on the QTc interval (increasing risk of dysrhythmias), benzodiazepine should be used (Lorazepam)
  • Physical restraints only is wrong, they should be accompanied by chemical sedation
65
Q

Polysomnography finding characteristic for Narcolepsy

A

Decreased REM latency

*Decreased REM density is wrong, it has Increased REM density

USMLE Step 2 CK Flash Cards (17 decks)

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