Psychiatry Clerkship Flashcards

Question

Disruptive mood dysregulation disorder is seen more frequently in what gender and age? At what age can this be diagnosed? What disorder are these patients at risk of developing? What disorder are they likely to not develop?

Answer 1

Seen more frequently in boys age 6-10 years. This should NOT be diagnosed before the age of 6 or after the age of 18. Children with DMDD usually do not develop bipolar disorder in adulthood but they are more likely to develop depression or anxiety.

Answer 2

Oppositional defiant disorder Children with oppositional defiant disorder usually have problems with authority figures such as parents and teachers. Unlike children with conduct disorder, they DO NOT break rules of society and do not commit crimes.

Answer 3

Disruptive mood dysregulation disorder Children with intermittent explosive disorder are not aggressive on such a continuous basis; they have extended periods of good behavior. There is no mention of a stressor, ruling out diagnosis of adjustment disorder. There is no evidence of mood swings, ruling out diagnosis of bipolar disorder. Children with oppositional defiant disorder mostly have problems with authority figures, not their peers. DMDD is characterized as chronic, severe, persistent irritability with temper outbursts and angry, irritable, or sad mood between the outbursts. These occur almost every day, are noticeable by others, and are out of proportion to the situation. The outbursts are inconsistent with developmental issues. Symptoms occur year-round; there is no period lasting > or = 3 months without all symptoms. The symptoms are severe enough to interfere with home, school, or peers.

Answer 4

Multiple tics, lasting more than one year, and seen before the age of 18. Motor tics: most commonly involve the muscles of the face and neck, such as head shaking and blinking. Vocal tics: grunting, coughing, and throat clearing. The disorder is seen more frequently in boys than in girls and will begin by the age of 7.

Answer 5

More frequently seen in boys than girls and will typically begin by the age of 7

Answer 6

Treatment includes: 1) Dopamine antagonists, such as the antipsychotic medications haloperidol, pimozide, and risperidone 2) Alpha-2 agonist, such as clonidine, can also be used

Answer 7

``` Sleep changes Interest loss Guilt (worthlessness) Energy (lack) Cognition/Concentration loss Appetite change Psychomotor agitation or retardation Suicidal ideation ```

Answer 8

SSRIs such as fluoxetine, paroxetine, sertraline, citalopram, or escitalopram. SSRIs are chosen due to their effectiveness and relatively mild side effects. They are less toxic in overdose than other antidepressants.

Answer 9

If there is no effect after 6-8 weeks, switch to another SSRI. If some improvement is noted by 6-8 weeks but not a full response, increase the dose of SSRI.

Answer 10

SNRIs such as venlafaxine, duloxetine, or desvenlafaxine.

Answer 11

Duloxetine is approved for both depression and neuropathy. | Bupropion has fewer sexual side effects and less weight gain than SSRIs. It is also approved for smoking cessation.

Answer 12

Paroxetine She has a diagnosis of major depression and the first-line treatment is the use of an SSRI medication because of a better side-effect profile compared to the other therapies. All others, except alprazolam and electroconvulsive therapy, would be useful but usually are not based on side effect profile. Alprazolam is simply a benzodiazepine and acts as an anxiolytic, not an antidepressant. Electroconvulsive therapy might be useful if initial therapy did not work or the depression was far more severe and was associated with psychotic features. The choices on the USMLE Step 2 may include an SSRI and another antidepressant medication. Pick the cleanest, which is the SSRI.

Answer 13

Mirtazapine Although any antidepressant can be used, mirtazapine is preferable in this patient for both its antidepressant and sedative effects. Imipramine would have too many side effects and is not a first-line agent. Venlafaxine might be considered if the patient had depression alone; since insomnia is a major concern, mirtazapine is the better option. Bupropion tends to cause problems with sleep, so is not indicated. Zolpidem would help this patient sleep but would not treat his depression.

Answer 14

TCA Imipramine AKA Tofranil AKA Melipramine

Answer 15

Manic symptoms include DIGFAST: Distractibility - poor focus, multitasking Insomnia - decreased need for sleep Grandiosity - inflated self-esteem Flight of ideas - complaints of racing thoughts Activities - increased goal-directed activities Speech - pressured or more talkative Thoughtlessness - "risk-taking" behaviors (sexual, financial, travel, driving)

Answer 16

Screen for drug use, such as cocaine or amphetamine use.

Answer 17

Severity of symptoms, level of functioning, and duration. Manic episode: symptoms are more severe, lasts more than 1 week unless hospitalized, marked impairment in social or occupational functioning or hospitalization necessary, may have psychotic features. Psychotic features makes it a manic episode automatically. Hypomanic episodes last more than 4 days but typically less than a week, do not severely affect functioning but have an observable change in functioning from the patient's baseline, and are not severe enough to warrant hospitalization. No psychotic features.

Answer 18

Bipolar disorder type 1 is mania and depression. Bipolar disorder type 2 is hypomania and depression.

Answer 19

Bipolar disorder type 1 This patient is exhibiting mania, as shown by her pressure speech, decreased sleep, increased libido, and inappropriate behavior. The symptoms are severe enough that her level of functioning is affected. Bipolar disorder occurs more frequently in young individuals.

Answer 20

1st line treatment for acute mania: lithium, valproic acid, and atypical antipsychotics. If acute mania, consider use of atypical antipsychotics due to shorter onset of action. If bipolar depression, treat with lithium, quetiapine, lurasidone, or lamotrigine. Lurasidone is approved for bipolar depression and is the only medication in pregnancy category B indicated for the disorder.

Answer 21

Atypical antipsychotic

Answer 22

Lurasidone (latuda)

Answer 23

Olanzapine The patient is exhibiting mania and you do not need to verify the lithium level given that his symptoms are acute. He apparently has been noncompliant with medications and obtaining a level is not the correct answer. He needs to be medicated, and antipsychotics are considered first-line treatment for bipolar patients, especially if acutely and severely manic. Admitting an agitated patient to the psychiatric unit is not as important as administering adequate treatment. “Refer to psychiatry” is never the correct answer on Step 2 CK.

Answer 24

``` Chronic depressed mood > or = 2 years (1 year in children/adolescents) No symptom-free period for > 2 months Presence of at least 2 of the following: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness ```

Answer 25

Antidepressant medications and psychotherapy

Answer 26

Cyclothymia is characterized by the presence of hypomanic episodes and mild depression. Symptoms must be present for more than 2 years.

Answer 27

Lithium, valproic acid, or antipsychotic medication, and psychotherapy

Answer 28

Atypical depression is characterized by: - reverse vegetative changes (increased sleep, increased weight, and increased appetite) - interpersonal rejection sensitivity that results in significant social or occupational impairment. - mood tends to be worse in the evening - patient may complain of extremities feeling "heavy"

Answer 29

SSRIs (fluoxetine, sertraline, paroxetine, citalopram, or escitalopram) or MAOIs (phenelzine, isocarboxazid, or tranylcypromine) MAOIs are typically the correct answer on USMLE for the treatment of atypical depression.

Answer 30

Characterized by seasonal changes in mood during fall and winter. Symptoms include weight gain, increased sleep, and lethargy.

Answer 31

Phototherapy and bupropion or SSRIs. In phototherapy, patients should be 12-18 inches from a source of 10,000 lux of white fluorescent light without UV wavelengths for 30 minutes each morning. The patient's eyes should be kept open, but it is not necessary to stare at the light.

Answer 32

Symptoms: mild depression, mood lability, tearfulness Prevalence: 40-80% Onset: 1-3 days after birth up to 2 weeks Mother's feelings toward baby: no negative feelings Treatment: supportive, usually self-limited (reassurance and monitoring)

Answer 33

Symptoms: depressed mood, weight changes, sleep disturbances, and excessive anxiety Prevalence: 8-15% Onset: within 1-3 months after birth Mother's feelings toward baby: may have negative feelings toward baby Treatment: antidepressant medications and psychotherapy

Answer 34

Symptoms: depression, mania, hallucinations, delusions, and thoughts of harm Prevalence: 0.1% - 0.2% Onset: during pregnancy up to 4 weeks after birth Mother's feelings toward baby: may have thoughts of harming baby Treatment: Hospitalization! Do not leave the mother alone with the infant due to risk of infanticide. Treat with antipsychotic medication, lithium, and possibly antidepressants.

Answer 35

Normal bereavement/grief

Answer 36

6 months to 1 year, but can go longer

Answer 37

Supportive psychotherapy. Pharmacotherapy is the WRONG ANSWER.

Answer 38

FALSE. Pharmacotherapy is the wrong answer when it comes to normal bereavement/grief.

Answer 39

Major depressive disorder Although it has been less than 6 months since his wife died, his symptoms are severe enough to warrant a diagnosis of major depression. He has no interest in things, has lost weight, feels hopeless and helpless, and believes he should have died as well. He needs to be treated with antidepressants, and you must ensure that he is not suicidal since he is at high risk. Remember SIG-E-CAPS when determining if presentation is MDD. Normal bereavement includes sadness, worrying about the deceased, irritability, sleep disturbance, poor concentration, and tearfulness. This patient has feelings of worthlessness, signs of anhedonia, and is expressing suicidal ideation.

Answer 40

Amitriptyline Nortriptyline Imipramine

Answer 41

Phenelzine Isocarboxazid Tranylcypromine

Answer 42

``` Fluoxetine Paroxetine Sertraline Citalopram Escitalopram Fluvoxamine ```

Answer 43

Venlafaxine Duloxetine Desvenlafaxine

Answer 44

Bupropion Mirtazapine Trazodone

Answer 45

``` Hypo/hypertension Dry mouth Constipation Confusion Arrhythmias Sexual side effects Weight gain GI disturbances ```

Answer 46

Tyramine rich food causes hypertensive crisis Safe foods: white wine and processed cheese Unsafe foods: red wine, aged cheese, chocolate

Answer 47

Headaches Weight changes Sexual side effects GI disturbances

Answer 48

``` Hypertension Blurry vision Weight changes Sexual side effects GI disturbances ```

Answer 49

Increased seizure risk

Answer 50

Weight gain and sedation

Answer 51

``` Tremors Weight gain GI disturbances Nephrotoxic Teratogenic Leukocytosis Diabetes insipidus Severe toxicity gives confusion, ataxia, lethargy, and abnormal reflexes. ```

Answer 52

``` Tremors Weight gain GI disturbances Alopecia Teratogenic Hepatotoxic Must monitor levels; toxicity causes hyponatremia, coma, or death. ```

Answer 53

Stevens-Johnson syndrome

Answer 54

Headaches | Transient memory loss

Answer 55

Electroconvulsive therapy Although ECT is usually used for suicidal patients or those who do not respond to treatment, it is considered the best treatment for depression. All others are equally efficacious, but the SSRIs are used more frequently due to side-effect profiles.

Answer 56

Serotonin syndrome is a potentially life-threatening disorder occurring as a result of therapeutic drug use of SSRIs, often with inadvertent interactions between drugs, overdose, or recreational use of drugs that are serotonergic in origin.

Answer 57

Cognitive effects: agitation, confusion, hallucinations, hypomania Autonomic effects: sweating, hyperthermia, tachycardia, nausea, diarrhea, shivering Somatic effects: tremors, myoclonus

Answer 58

1. Stop SSRI medication 2. Symptomatic treatment of fever, diarrhea, hypertension 3. Cyproheptadine (serotonin antagonist)

Answer 59

Cyproheptadine

Answer 60

Symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior Duration: more than 1 day but less than 1 month

Answer 61

Symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (flat affect, poor grooming, social withdrawal) Duration: more than 1 month but less than 6 months

Answer 62

Symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (flat affect, poor grooming, social withdrawal). Severely affects level of function. Duration: more than 6 months

Answer 63

Antipsychotic medications

Answer 64

Schizophrenia

Answer 65

There is equal incidence in men and women but it affects men earlier due to earlier age of onset.

Answer 66

Cocaine or amphetamine use

Answer 67

1. hospitalize 2. ensure patient safety 3. use atypical antipsychotic as first-line agent (E.g. risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, paliperidone, asenapine, iloperidone, or lurasidone) 4. In any emergency situation where intramuscular medication is needed, consider the use of short-acting medications such as olanzapine or ziprasidone; haloperidol is still used, but has more side effects, so if given the choice, pick the atypical antipsychotic. 5. If noncompliant with medication, consider a long-acting antipsychotic medication such as risperidone or paliperidone as first-line treatment. Haloperidol and fluphenazine are still used but have more side effects. 6. Clozapine is only used when patients do not respond to an adequate trial of typical or atypical antipsychotics; never used as a first-line treatment

Answer 68

1. Olanzapine 2. Clozapine 3. Quetiapine 4. Risperidone 5. Ziprasidone 6. Lurasidone 7. Aripiprazole

Answer 69

Greater incidence of diabetes and weight gain Avoid in diabetic and obese patients

Answer 70

1) breast formation and galactorrhea 2) Greater incidence of movement disorders, especially at higher doses. Extrapyramidal symptoms include acute dystonia, akathisia, parkinsonism, and tardive dyskinesia.

Answer 71

Lower incidence of movement disorders Appropriate for use in patients with existing movement disorders

Answer 72

Increased risk of QT prolongation. Avoid in patients with conduction defects.

Answer 73

1) High risk of agranulocytosis. Need to monitor CBC on a regular basis. 2) Myocarditis (same rate as agranulocytosis) Clozapine is only used when patients do not respond to an adequate trial of typical or atypical antipsychotics; never used as a first-line treatment due to side-effect profile

Answer 74

It is a partial dopamine agonist, approved as adjunct treatment for major depressive disorder

Answer 75

It is the only antipsychotic in pregnancy category B. It is safer for use in pregnant patients.

Answer 76

- pines (olanzapine, quetiapine, asenapine, clozapine) have increased risk of weight gain, metabolic syndrome, and diabetes. - dones (risperidone, lurasidone, ziprasidone, iloperidone) have increased risk of movement disorders and cardiac conduction problems.

Answer 77

Aripiprazole and ziprasidone are the LEAST LIKELY to cause weight gain, diabetes, and metabolic syndrome. Olanzapine and clozapine have the HIGHEST RISK of metabolic abnormalities. Quetiapine and risperidone have medium risk.

Answer 78

Aripiprazole and ziprasidone

Answer 79

Symptoms: muscle spasms, torticollis, laryngeal spasms, occulogyric crisis Onset: hours to days Treatment: benztropine, trihexyphenidyl, diphenhydramine

Answer 80

Symptoms: generalized restlessness, pacing, rocking, inability to relax Onset: weeks Treatment: reduce dose, beta blockers, switch to atypical antipsychotic, benzodiazepine

Answer 81

Symptoms: abnormal involuntary movements of head, limb, and trunk. Perioral movements are the most common. Onset: rare before 6 months Treatment: switch to atypical antipsychotic. Clozapine has least risk.

Answer 82

Symptoms: muscular rigidity, fever, autonomic changes, agitation, and obtundation Onset: not time limited Treatment: dantrolene or bromocriptine

Answer 83

Acute dystonia Acute dystonia develops within hours of the use of medications. This side effect is typical for haloperidol. The treatment of choice is benztropine or diphenhydramine, which can be given with the haloperidol or after should side effects occur.

Answer 84

Characterized by prominence of non-bizarre delusions for more than one month and no impairment in level of functioning (e.g. the patient may believe the country is about to be invaded, but he or she still obeys the law, goes to work, and pays bills). Hallucinations, if present, are not prominent and are related to the delusional theme.

Answer 85

1. Atypical antipsychotic (first-line therapy) | 2. Psychotherapy to help promote reality testing

Answer 86

Experience of intense anxiety along with feelings of dread and doom. Accompanied by at least 4 symptoms of autonomic hyperactivity such as diaphoresis, trembling, chest pain, fear of dying, chills, palpitations, shortness of breath, nausea, dizziness, dissociative symptoms, and paresthesias. These sensations typically last LESS THAN 30 MINUTES and may be accompanied by agoraphobia, defined as fear of places where escape is felt to be difficult.

Answer 87

Fear of places where escape is felt to be difficult

Answer 88

Must rule out thyroid disease, hypoglycemia, and cardiac disease

Answer 89

1) SSRIs (typically fluoxetine, paroxetine, and sertraline) are indicated for this disorder 2) Along with SSRIs, patients may benefit from benzodiazepines (such as alprazolam, clonazepam, or lorazepam). You can begin with both SSRIs and benzodiazepines, then taper and discontinue the benzodiazepine given the potential for abuse. 3) Behavioral and individual therapy are also helpful IN CONJUNCTION with medication (not as a sole treatment).

Answer 90

Sertraline SSRIs are considered to be 1st line treatment for panic disorder. If the question is panic attack, then alprazolam is the correct answer; if a single panic attack is the diagnosis, a benzodiazepine is the treatment.

Answer 91

When determining most likely diagnosis in cases involving panic symptoms, distinguish between direct presentation and patient history. If the patient is presenting with autonomic hyperactivity, then panic attack is the most likely diagnosis and benzodiazepines are the correct treatment. If the patient is telling the doctor a story about the panic attacks, the diagnosis is most likely panic disorder and the treatment of choice is an SSRI.

Answer 92

A phobia is the fear of an object or situation and a need to avoid it.

Answer 93

Specific phobia = fear of an object, such as animals, heights or cars Social fobia = fear of a situation, such as public restrooms, eating in public, or public speaking. These involve situations where something potentially embarrassing may happen.

Answer 94

The diagnosis is usually made by obtaining a good history where patients indicate anxiety symptoms in specific situations or when in contact with feared objects.

Answer 95

Behavioral modification techniques such as systemic desensitization, in which the patient while relaxed is exposed, often only in imagination, to progressively more frightening aspects of the feared objects. Patients are also taught relaxation techniques such as breathing or guided imagery.

Answer 96

False. Beta blockers such as atenolol or propranolol are used for performance anxiety such as stage fright. They are given 30-60 minutes before the performance. They are not indicated for treatment of phobias.

Answer 97

Social anxiety Social anxiety is characterized by fear of embarrassment in social situations. These patients have problems going out in fear that others will laugh at them.

Answer 98

This is a disorder where patients typically experience either obsessions alone or, most commonly, a combination of obsessions and compulsions typically affecting the individual's level of functioning.

Answer 99

Obsessions are thoughts that are intrusive, senseless, and distressing to the patient, thus increasing anxiety. These include fear of contamination. Compulsions are rituals, such as counting and checking, that are performed to neutralize obsessive thoughts. These are time consuming and tend to lower anxiety.

Answer 100

OCD is seen more frequently in young patients. There is equal incidence in men and women.

Answer 101

1. SSRIs are the treatment of choice. Fluoxetine, paroxetine, sertraline, citalopram, or fluvoxamine are most commonly used as 1st line agents. 2. Behavioral therapy of exposure and response prevention.

Answer 102

Clomipramine

Answer 103

Individuals with hoarding disorder have problems discarding their possessions, leading to persistent accumulations of possessions such that the home is overwhelmed by clutter. The hoarding affects the individual’s level of functioning and impairs his/ her ability to maintain a safe environment.

Answer 104

1) SSRIs | 2) Patients benefit from behavioral modification techniques or psychotherapy (like CBT)

Answer 105

Individuals with body dysmorphic disorder believe that some body part is abnormal, defective, or misshapen, although others do not see these perceived defects. These beliefs significantly impair in the patient’s level of functioning. Patients spend excessive time checking the mirror and seeking reassurance.

Answer 106

SSRIs combined with individual psychotherapy are the treatment of choice.

Answer 107

- exposed to a stressor to which they react with fear and helplessness - continually relive the event and avoid anything that reminds them of the event - stressors are usually overwhelming and involve such events as war, rape, hurricanes, or earthquakes - symptoms adversely affect the patient’s level of functioning. - other symptoms include increased startle response, hypervigilance, sleep disturbances, anger outbursts, and concentration difficulties. PTSD is when symptoms last for more than 1 month. Acute stress disorder is 2 days to 1 month in duration and occurs within 1 month of the traumatic event.

Answer 108

1) determining the time period when the traumatic events occurred in relationship to the symptoms 2 + 3) depression and substance abuse must be ruled out, because both worsen the diagnosis.

Answer 109

1) depressive type | 2) bipolar type

Answer 110

Schizoaffective

Answer 111

Borderline personality disorder DBT combines standard cognitive behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be generally effective in treating borderline personality disorder. The first randomized clinical trial of DBT showed reduced rates of suicidal gestures, psychiatric hospitalizations, and treatment drop-outs when compared to treatment as usual. A meta-analysis found that DBT reached moderate effects in individuals with borderline personality disorder.

Answer 112

1) Haloperidol 2) Chlorpromazine 3) Perphenazine 4) Fluphenazine

Answer 113

Risperidone (as it increases prolactin secondarily by blocking dopamine)

Answer 114

True. It can cause death from torsades.

Answer 115

It has been demonstrated by head to head trials to be more effective than other antipsychotics. However, due to its serious side effects, it is only used after failed adequate trials of other antipsychotics.

Answer 116

Serotonin syndrome has clonus and neuroleptic malignant syndrome doesn't. Either can have fever and either can be acute.

Answer 117

Paroxetine or sertraline

Answer 118

Prazosin (alpha 1 blocker)

Answer 119

1) Relaxation techniques 2) Hypnosis 3) Psychotherapy to develop coping techniques and acceptance of the event

Answer 120

Excessive anxiety and worry ABOUT MOST THINGS, lasting MORE than 6 months. The anxiety is typically out of proportion to the event and is accompanied 3 or more of the following symptoms: fatigue, concentration difficulties, sleeping problems, muscle tension, and restlessness. Patients typically complain of feeling anxious for as long as they can remember.

Answer 121

SSRIs such as fluoxetine, paroxetine, sertraline, or citalopram. Venlafaxine and buspirone are also effective. Psychotherapy and behavioral therapy are beneficial as well, but are not considered first-line agents in most patients.

Answer 122

Generalized anxiety disorder The main feature of GAD is the chronic worrying about things that do not merit concern. It is also accompanied by other symptoms of anxiety, as well as sleep and concentration problems.

Answer 123

``` Sedation Confusion Memory deficits Respiratory depression Increased addiction potential ```

Answer 124

Headaches Nausea Dizziness

Answer 125

Benzodiazepines

Answer 126

Lorazepam (ativan)

Answer 127

Clonazepam (klonopin)

Answer 128

Chlordiazepoxide Oxazepam Lorazepam

Answer 129

Oxazepam Lorazepam (remember "O"ld "L"iver)

Answer 130

Alprazolam (xanax)

Answer 131

Flurazepam, temazepam, triazolam | but benzodiazepines are rarely used as hypnotics

Answer 132

Flumazenil (benzodiazepine antagonist) It causes acute withdrawal, which can be tremor or seizures similar to delirium tremens (alcohol withdrawal).

Answer 133

With acute benzodiazepine overdose AND you are certain that there is no chronic dependence. When used in benzodiazepine-dependent patients, it causes acute withdrawal, which can be tremor or seizures similar to delirium tremens (alcohol withdrawal).

Answer 134

Maladaptive pattern of use of substances that leads to engaging in hazardous situations, legal problems, inability to fulfill obligations, and continued use despite adverse consequences and cravings.

Answer 135

Talkative, sullen (gloomy/sulky), gregarious (sociable), moody, disinhibited

Answer 136

Mechanical ventilation if severe

Answer 137

Tremors, hallucinations, seizures, delirium tremens

Answer 138

Benzodiazepines, thiamine, multivitamins, folic acid

Answer 139

Euphoria, hyper vigilance, autonomic hyperactivity, weight loss, pupillary dilation, perceptual disturbances

Answer 140

Antipsychotics and/or benzodiazepines and/or antihypertensives

Answer 141

Anxiety, tremulousness, headache, increased appetite, depression, risk of suicide

Answer 142

Bupropion (norepinephrine-dopamine reuptake inhibitor) and/or Bromocriptine (dopamine agonist)

Answer 143

Impaired motor coordination, slowed sense of time, social withdrawal, increased appetite, conjunctival injection

Answer 144

Consider use of antipsychotics if patient is psychotic

Answer 145

Irritability, anger, anxiety, sleep problems, restlessness, appetite problems

Answer 146

Symptomatic management

Answer 147

Ideas of reference, perceptual disturbances, possible increase in psychosis, impaired judgment, tremors, incoordination, dissociative symptoms

Answer 148

Antipsychotics and/or benzodiazepines and/or talking down

Answer 149

None, none

Answer 150

Belligerence, apathy, aggression, impaired judgment, stupor, or coma

Answer 151

Antipsychotics

Answer 152

None, none

Answer 153

Apathy, dysphoria, pupillary constriction, drowsiness, slurred speech, coma, or death

Answer 154

Fevers, chills, lacrimation, abdominal cramps, muscle spasms, diarrhea

Answer 155

Clonidine, methadone, or buprenorphine

Answer 156

PCP is a dissociative anesthetic that can cause hallucinations, dissociative feelings, agitation, confusion, pupillary dilation, tachycardia, and NYSTAGMUS (horizontal, vertical, or rotatory). In many cases, intoxication can lead to psychotic and violent behavior, diminished pain perception, and subsequent physical injuries. The drug's onset of action is rapid and the duration of action is generally less than 8 hours. High doses can cause severe hypertension, seizures, and life-threatening hyperthermia.

Answer 157

Antipsychotics and/or benzodiazepines and/or talking down

Answer 158

None, none

Answer 159

Irritability, aggression, mania, psychosis

Answer 160

Antipsychotics

Answer 161

Depression, headaches, anxiety, increased concern over body's physical state

Answer 162

This is the test to give someone who is an alcoholic. Tow positive responses to the four questions is considered positive and indicate that further assessment is warranted. C: Have you ever tried to cut down on your drinking? A: Have you ever gotten annoyed by others who have criticized your drinking? G: Have you ever felt guilty about your drinking? E: Have you ever used alcohol as an eye-opener? (drinking first thing in the morning)

Answer 163

Detoxification: 5-10 days, mostly in hospital settings to assure safe detoxification Rehabilitation: usually 28 days or more, with focus on relapse prevention techniques

Answer 164

1) Disulfiram (acetaldehyde dehydrogenase inhibitor) 2) Naltrexone (opioid receptor antagonist) 3) Acamprosate

Answer 165

Alcohol withdrawal Most withdrawal questions are asked in a hospital setting on the next day after admission. The patient presents with uncomplicated alcohol withdrawal, characterized by visual hallucinations and tremors.

Answer 166

> or = 1 somatic symptom(s) causing distress and functional impairment. Excessive thoughts or behaviors related to somatic symptoms. Unwarranted, persistent thoughts about seriousness of symptoms. Persistent anxiety about health or symptoms. Excessive time and energy devoted to symptoms. Greater than or equal to 6 months duration.

Answer 167

Most commonly young women

Answer 168

- Regularly scheduled visits with the same provider - Limit unnecessary workup & specialist referrals - Legitimize symptoms but make functional improvement the goal - Focus on stress reduction and improving coping strategies - Mental health referral if patient will accept

Answer 169

Patients believe that they have some specific disease despite constant assurance

Answer 170

Typically affects voluntary motor or sensory functions that are indicative of a medical condition but are usually caused by psychological factors. Can be associated with "la belle indifference", where the patient is unconcerned about his or her impairment.

Answer 171

Individual psychotherapy This patient has somatic symptom disorder, which is treated with individual psychotherapy given that psychological issues are the cause of her symptoms. She should have one primary caretaker and not be sent to specialists. Lorazepam, a benzodiazepine, treats anxiety disorder. SSRIs such as sertraline treat fibromyalgia and depression. Lithium treats bipolar disorder. Risperidone is for psychosis.

Answer 172

An individual FAKES an illness in order to get attention and emotional support in the patient role. This can either be a psychological or physical illness. Psychological symptoms include hallucinations, delusions, depression, and bizarre behavior. Physical symptoms include abdominal pain, fever, nausea, vomiting, or hematomas. At times these individuals may inflict life-threatening injuries on themselves in order to get attention. This behavior may be compulsive at times. When a caretaker fakes signs and symptoms in another person (usually a child) in order to assume the sick role, the diagnosis is fictitious disorder imposed on others. When signs and symptoms are faked on oneself, the diagnosis is factitious disorder imposed on self.

Answer 173

First confirm that a legitimate medical illness is not present

Answer 174

No specific therapy has been proven to be effective in these patients. When a child is involved in factitious disorder imposed on others, child protective services should be contacted to ensure the child's safety.

Answer 175

Malingering is characterized by the conscious production of signs and symptoms for an obvious gain, such as avoiding work, evading criminal prosecution, or achieving financial gain. Malingering is not a mental illness.

Answer 176

False.. Malingering is not a mental illness.

Answer 177

Prisoners and military personnel

Answer 178

It is typically diagnosed when there is discrepancy between the patient's complaints and the actual physical or laboratory findings. If medical evaluation reveals malingering, then confront the patient with the outcome.

Answer 179

Malingering

Answer 180

A maladaptive reaction to an identifiable stressor, such as loss of job, divorce, or failure in school. The symptoms usually occur within 3 months of the stressor and must remit within 6 months of removal of the stressor. The symptoms include anxiety, depression, or disturbances of conduct. They are severe enough to cause impairment in functioning.

Answer 181

Psychotherapy is the treatment of choice. Both individual and group therapy have been used effectively.

Answer 182

Suspicious, mistrustful, secretive, isolated, and questioning of the loyalty of family and friends

Answer 183

Choice of solitary activities, lack of close friends, emotional coldness, no desire for or enjoyment of close relationships.

Answer 184

Ideas of reference, magical thinking, odd thinking, eccentric behavior, increased social anxiety, brief psychotic episodes

Answer 185

Must be the center of attention, inappropriate sexual behavior, self-dramatizination, uses physical appearance to draw attention to self

Answer 186

Failure to conform to social rules, deceitful, lack of remorse, impulsive, aggressive towards others, irresponsible, must be over the age of 18, must have history of conduct disorder

Answer 187

Unstable relationships, impulsive, recurrent suicidal behaviors, chronic feelings of emptiness, inappropriate anger, dissociative symptoms when severely stressed, brief psychotic episodes

Answer 188

Grandiose sense of self, belief that they are special, lack empathy, sense of entitlement, requires excessive admiration

Answer 189

Unwilling to get involved with people, views self as socially inept, reluctant to take risks, feelings of inadequacy

Answer 190

Difficulty making day-to-day decisions, unable to assume responsibility, unable to express disagreement, fear of being alone, seeks relationship as source of care

Answer 191

Preoccupied with details, rigid, orderly, perfectionistic, excessively devoted to work, inflexible

Answer 192

Psychotherapy. Medications if mood or anxiety symptoms are present.

Answer 193

Borderline and schizotypal personality disorders may have short-lived psychotic episodes that are brief and usually occur after stressful situations.

Answer 194

Anorexia nervosa The main focus of this question is the reduced BMI. This is indicative of the weight loss seen in anorexia nervosa. She obviously purges and as a result has calluses and cavities. Amenorrhea, significant weight loss, and abnormal preoccupation with body image are the key to the diagnosis of anorexia.

Answer 195

Failure to maintain a normal body weight, fear of and preoccupation with gaining weight, and body image disturbance. There is an unrealistic self-evaluation as overweight. These patients tend to deny their emaciated condition. They show great concern with appearance and frequently examine and weight themselves. They typically lose weight by maintaining strict caloric control, excessive exercise, purging, and fasting, with laxative and diuretic abuse.

Answer 196

Teenage girls between age 14 and 18

Answer 197

Severe weight loss in anorexia. Most people with bulimia are of NORMAL WEIGHT but do have a history of obesity.

Answer 198

Cardiac arrhythmias from potassium deficiency

Answer 199

1) hospitalization to prevent dehydration, starvation, electrolyte imbalances, and death 2) psychotherapy 3) behavioral therapy 4) SSRIs have been used to promote weight gain

Answer 200

Frequent binge eating. Lack of control of overeating episodes. Accompanied by compensatory behavior to prevent weight gain in the form of purging, miss of laxative and diuretics, fasting, and excessive exercise. The patient's self-evaluation is unduly influenced by body shape and weight.

Answer 201

More frequently seen in women and occurs later in adolescence than anorexia nervosa.

Answer 202

1) does not require hospitalization unless severe electrolyte abnormality is present 2) psychotherapy 3) SSRIs

Answer 203

Recurrent episodes of binge eating that occur at least 3 times per week for more than 3 months. Patients are overweight and they usually lack a sense of control over their eating habits. The binge eating episodes are associated with eating faster than usual, eating until feeling uncomfortably full, eating large amounts of food in the absence of hunger, eating alone, and feeling disgusted with oneself after the eating episode.

Answer 204

Topiramate has been proven efficacious for binge eating disorder. SSRIs may have limited benefits. Psychotherapy is indicated, including cognitive behavioral therapy, interpersonal psychotherapy, and dialectic behavioral therapy.

Answer 205

False. Topiramate is first line treatment.

Answer 206

A designation of eating disorder not otherwise specified is used when patients do not meet criteria for either anorexia nervosa or bulimia nervosa. Examples include: criteria for anorexia present in girls but menstruation is normal. Anorexic patient with normal weight. Use of compensatory behavior after eating normal amounts of food.

Answer 207

1. Amenorrhea 2. Significant weight loss 3. Abnormal preoccupation with body image

Answer 208

Disorder characterized by excessive daytime sleepiness and abnormalities of REM sleep. Specific features: 1) sleep attacks (episodes of irresistible sleepiness and feeling refreshed upon waking) 2) cataplexy (sudden loss of muscle tone. Considered pathognomonic and may be precipitated by loud noise or emotions) 3) hypnogogic and hypnopompic hallucinations (hallucinations that occur as the patient is going to sleep and waking up) 4) sleep paralysis (patient is awake but unable to move; this typically occurs upon waking)

Answer 209

Young adulthood

Answer 210

Sleep studies and careful history

Answer 211

No therapy has been found to be curative. The patient is managed with forced naps during the day and modafinil is used to maintain alertness. Therapy can also include methylphenidate and dextroamphetamine. Gamma-hydroxybutyrate (GHB) may be given at bedtime to induce symptoms of narcolepsy and contain them at night.

Answer 212

Hypnogogic: before sleep Hypnopompic: upon waking

Answer 213

1) continuous positive airway pressure (bipap cpap) 2) weight loss 3) corrective surgery 4) avoidance of sedatives and alcohol

Answer 214

1) Sleep hygiene techniques (first-line) | 2) Zolpidem, eszopiclone, or zaleplon

Answer 215

1) going to bed and waking up at the same time 2) avoiding caffeine 3) avoiding daytime naps 4) using bed only for sleeping and not for reading, watching TV, or eating

Answer 216

Impotence is persistent or recurrent inability to attain or maintain an erection until completion of the sexual act. Treatment: rule out medical causes or medication, psychotherapy, couples sexual therapy

Answer 217

Ejaculation before penetration or just after penetration, usually due to anxiety Treatment: psychotherapy, behavioral modification techniques (stop and go, squeeze), SSRI medication

Answer 218

Pain associated with sexual intercourse, not diagnosed if due to medical condition. Treat with psychotherapy.

Answer 219

Involuntary constriction of the outer third of the vagina preventing penile insertion. Treat with psychotherapy and dilator therapy

Answer 220

Paraphilias are a group of disorders that are recurrent, sexual arousing, and seen more frequently in men. They focus on humiliation, non consenting partners, or use of nonliving objects. Must occur for more than 6 months and cause distress as well as adversely affect level of functioning. Do not diagnose if done in experimentation.

Answer 221

1) Individual psychotherapy 2) Behavioral modification techniques such as aversive conditioning 3) Antiandrogens or SSRIs to reduce sex drive

Answer 222

This is a disorder characterized by the persistent discomfort and sense of inappropriateness regarding the patient's assigned sex.

Answer 223

Sexual reassignment surgery if approved. Individual psychotherapy. Hormone therapy.

Answer 224

Manifests by wearing the opposite gender's clothes, using toys assigned to the opposite sex, play with opposite-sex children when young, and feeling unhappy about the person's own sexual assignment. Patients will take hormones when older to deepen voice, if female, or soften voice, if male. Women may bind their breasts and men may hide their penis and testicles. This is seen more frequently in young men.

Answer 225

``` Men Older adults Social isolation Presence of psychiatric illness/drug abuse Perceived hopelessness Previous attempts ```

Answer 226

1) young male 2) unemployed 3) impoverished 4) access to firearms (greatest risk factor) 5) substance abuse 6) antisocial personality disorder 7) history of violence or criminality 8) history of childhood abuse 9) impulsivity

Answer 227

True. There is an increased risk of both suicide and infanticide in patients with postpartum psychosis. They must be hospitalized to ensure safety and antipsychotic medication should be started. Treatment of any underlying pre-existing disorders is necessary as well.

Answer 228

Patients with depression often present to a primary care physician with headaches or other physical complaints (e.g. fatigue, insomnia, nonspecific aches and pains). The physician should consider depression on the differential diagnosis and specifically inquire about depressive symptoms (e.g. depressed mood, anhedonia, etc). If the patient is suffering from depression, physical symptoms will likely improve with adequate treatment.

Answer 229

Bipolar 1 disorder is diagnosed by one or more manic episodes. Depressive episodes are common but not required for diagnosis. Bipolar 2 disorder is diagnosed by one or more hypomanic episodes with one or more major depressive episodes. For bipolar 1 disorder, depressive episodes aren't required for diagnosis. For bipolar 2 disorder, one or more major depressive episode is required for diagnosis.

Answer 230

Persistent depressive disorder (dysthymia) Patient's chronic depression since adolescence, accompanied by overeating, hypersomnia, and low self-esteem, is consistent with persistent depressive disorder. Diagnosis requires persistent depressive symptoms for > or = 2 years and that the individual has never been without depressive symptoms for >2 months at a time. In DSM-5, persistent depressive disorder also encompasses patients who may have met the full criteria for a major depressive illness at some point during the illness; they are specified accordingly (e.g. with intermittent depressive episodes or persistent major depressive episodes).

Answer 231

``` Sex (male) Age (older) Depression Previous attempt Etoh (or other substance) use Rational thought loss (psychosis) Social support (lack) Organized plan No spouse or significant other Sickness or injury ```

Answer 232

For patients with high imminent risk (ideation, intent, and plan): Ensure safety by hospitalizing immediately (involuntary if necessary). Remove personal belongings and objects in the room that may present self-harm risk. Constant observation and security may be required to hold against will. For patients with high non-imminent risk (ideation, intent, but no plan to act in the near future): Ensure close follow-up Treat modifiable risk factors (underlying depression, psychosis, substance abuse, pain). Recruit family or friends to support the patient. Reduce access to potential means (secure firearms, medications)

Answer 233

Admit him to a psychiatric unit involuntarily.

Answer 234

Initiate a discussion about current emotional stressors. Somatic symptom disorder involves excessive and disproportionate preoccupation with somatic symptoms, resulting in high health care utilization and functional impairment. Because symptoms often worsen during periods of stress, patients should be asked about their current emotional stressors and counseled regarding stress reduction.

Answer 235

Prescribe an SSRI and/or psychotherapy Medically ill patients who develop comorbid depression can benefit from treatment with antidepressant medications and psychotherapy to improve their quality of life.

Answer 236

Inhalant abuse. Commonly abused inhalants include glue, toluene, nitrous oxide, amyl nitrite, and spray paints. Inhalants may be abused by sniffing, huffing (inhaled from a saturated cloth), or bagging (Bag over mouth or nose) to concentrate the inhaled substance. Signs of acute intoxication may include brief transient euphoria and loss of consciousness and varies depending on the specific chemicals inhaled. The inhalants act as CNS depressants and may cause death. Dermatitis (glue sniffer's rash) due to chemical exposure can be seen around the mouth or nostrils. Inhalants are rapidly eliminated and are not included in most routine hospital toxicology screens. LFTs may be elevated with repeat use. Boys age 14-17 are at highest risk for inhalant abuse, which may go unnoticed because common household products are used and no drug paraphernalia is found.

Answer 237

Inhalant abuse

Answer 238

Alprazolam The patient had a first seizure after missing doses of her medication for one day. Of the medications listed, alprazolam (xanax), a short-acting benzodiazepine, is the most likely to result in seizures following abrupt discontinuation. Symptoms of withdrawal from benzodiazpepines with short half-lives can appear as early as 24 hours after cessation and can include seizures, tremors, anxiety, perceptual disturbances, and psychosis. Although benzos are often used in the tx of anxiety and depression, their use can be problematic due to their potential to result in tolerance, dependence, and abuse. Benzodiazepines with shorter half-lives, such as alprazolam, have greater risk for severe withdrawal reactions.

Answer 239

The ones with shorter half-lives such as alprazolam (xanax)

Answer 240

This is a type of alcohol withdrawal that is characterized by an alert sensorium, predominantly visual hallucinations (although auditory and tactile hallucinations also occur) and relatively stable vital signs. It develops 12-24 hours after the last drink and usually resolves within 24-28 hours.

Answer 241

Disorientation and global confusion

Answer 242

Somatic symptom disorder is diagnosed when significant somatic symptoms are present. In contrast, patients with illness anxiety disorder fear having a specific illness but have minimal or no physical symptoms; they are primarily concerned with the idea that they have an illness.

Answer 243

Continue fluoxetine for an additional 2-4 weeks. Antidepressants take time to work. An adequate antidepressant trial is 4-6 weeks at a therapeutic dosage. The patient should be educated that 2 weeks is considered an inadequate trial and be encouraged to remain on the medication for at least 2-4 more weeks. It would be premature to add an augmenting agent. Discontinuing fluoxetine and switching to a different antidepressant would risk losing the partial response. Inadequate antidepressant dose or duration is a common reason for perceived lack of response, and physicians must ensure that patients receive an adequate trial before recommending alternate treatments. The patient is at a therapeutic dose of fluoxetine and has shown some signs of early improvement (in sleep and appetite). He should be encouraged to continue fluoxetine at the same dose. If the patient remains significantly depressed after a 4 to 6 week trial, increasing the dose is an option provided there are no tolerability issues.

Answer 244

Tuberoinfundibular pathway 1. gynecomastia 2. galactorrhea 3. menstrual dysfunction 4. decreased libido

Answer 245

Lorazepam While lorazepam and chlordiazepoxide are both benzodiazepines that are used for alcohol withdrawal, this patient has suspected liver disease so oxazepam or lorazepam ("o"ld "l"iver) should be used.

Answer 246

Social anxiety disorder (social phobia) Physical symptoms similar to panic attacks which are triggered by feared social situations. Persistent anxiety and poor eye contact are also characteristic of the disorder. Social anxiety disorder is characterized by fear of one or more social situations and anxiety about acting in a way that will be humiliating or embarrassing.

Answer 247

2-4 mm diameter

Answer 248

Alcohol and benzodiazepines Most patients with isolated benzodiazepine overdose are arousable and have normal vital signs, so E is wrong. Signs such as bradycardia, hypotension, respiratory depression, and hyporeflexia are seen so co-ingestion of another sedative-hypnotic (most common being alcohol) should be suspected. Opioid overdose can also result in altered consciousness and respiratory depression. However, this patient's failure to respond to the opioid antagonist naloxone, normal pupils, and presence of normal bowel sounds makes opioid intoxication less likely.

Answer 249

Major depressive or manic episode concurrent with symptoms of schizophrenia. Lifetime history of delusions or hallucinations for > or = 2 weeks in the absence of major depressive or manic episode. Mood symptoms are present for the majority of the illness. Not due to substances or another medical condition. Schizoaffective disorder is characterized by a significant mood episode (depressive or manic) with concurrent psychotic symptoms in addition to psychosis without mood symptoms for at least two weeks. Differentiating schizoaffective disorder from bipolar disorder, major depression with psychotic features, and schizophrenia requires determining the temporal relationship of psychotic symptoms to mood symptoms. In bipolar disorder and major depression with psychotic features, psychotic symptoms occur exclusively during manic or depressive episodes. When the patient's mood is stable, there are no psychotic symptoms. In schizophrenia, if mood symptoms occur, they are present for a small portion of the illness.

Answer 250

Acting out. Immature.

Answer 251

Denial. Immature.

Answer 252

Displacement. Immature.

Answer 253

Intellectualization. Immature.

Answer 254

Passive aggression. Immature.

Answer 255

Projection. Immature.

Answer 256

Rationalization. Immature.

Answer 257

Reaction formation. Immature.

Answer 258

Regression. Immature.

Answer 259

Splitting. Immature.

Answer 260

Sublimation. Mature.

Answer 261

Suppression. Mature.

Answer 262

Psychological defense mechanisms are unconscious means of responding and adapting to different situations while preserving self-image. These mechanisms serve to decrease anxiety associated with shame and vulnerability and ensure a feeling of safety in the face of disappointments. Immature defense mechanisms are more commonly used in children and adolescents but can also be seen in adult psychopathology (e.g. in personality disorders) or in adults in times of stress. Immature defense mechanisms provide short-term relief but often result in long-term complications. Mature defense mechanisms are most often used by well-adjusted individuals and allow for a "healthy" and more constructive approach to reality.

Answer 263

Tyramine is a sympathomimetic monoamine that can facilitate the release of other sympathomimetic monoamines, such as adrenaline. Tyramine may be present in aged cheeses, aged or cured meats, aged or fermented soy products, overripe fruits, and some alcoholic beverages. Tyramine metabolism is inhibited in the presence of MAOIs, which causes an increased sympathomimetic effect that can result in severe hypertensive crisis. This commonly presents first as headache but can lead to intracranial bleeding, stroke, and death.

Answer 264

Fluoxetine (Prozac) So, you almost never see discontinuation syndrome with fluoxetine.

Answer 265

Citalopram (Celexa)

Answer 266

Paroxetine (Paxil)

Answer 267

80-85% of serotonin receptors are in the GI tract

Answer 268

Usually at least 6-8 weeks at dose expected to be effective

Answer 269

True. On exams, always choose the SSRI that is paired with a therapy over a SSRI that's alone.

Answer 270

GI distress. 30-40% of patients will experience GI distress from psychiatric medications. The GI distress goes away in 3-5 days in the majority of these patients (80%) By 3 weeks, 98% of patients have resolution of GI symptoms.

Answer 271

True. Lack of sleep, anxiety, depression, etc can all cause decreased sexual function. Sometimes SSRI can increase sexual function, even though a common side effect of SSRIs is sexual dysfunction.

Answer 272

1. failed 2 adequate trials of SSRI 2. high severity 3. many medications 4. co-morbid psychiatric disorders

Answer 273

1. cost 2. clinical experience 3. family hx of response or side effects to SSRIs 4. adherence of patient (think about half-life)

Answer 274

Discontinuation syndrome. Happens with SSRI withdrawal

Answer 275

Shortest: Fluvoxamine (Luvox) Longest: Fluoxetine (Prozac) You can remember this because the v in the fluvoxamine looks like a down arrow. Both start with "flu".

Answer 276

Bulimia nervosa

Answer 277

True, there is a real risk but the absolute risk is low. About 1 in 100. It should be discussed with patients but the data is controversial about whether or not suicidal action is increased by SSRIs. Above 25 years old, SSRIs are protective of suicide (because you're treating depression... which causes suicidal thoughts). Standard of care is to treat with SSRI with psychotherapy. Suicide is one of the S's in SIGECAPS. It's a serious risk for depression.

Answer 278

Hyperactivity ADHD lasts your whole life but the hyperactivity typically gets better.

Answer 279

Decreased appetite

Answer 280

Cocaine use disorder Cocaine is a stimulant that produces increased energy and decreases appetite and need for sleep. Individuals who abuse cocaine often present with mood changes (e.g. euphoria, irritability) and weight loss secondary to decreased appetite. The diagnostic hallmark in this scenario is erythema of the turbinates and nasal septum, which is a common finding in individuals who snort cocaine. In severe cases, perforation of the nasal septum can occur. In addition to mood disturbance, other psychiatric complications of cocaine use include anxiety, panic attacks, grandiosity, and psychosis (delusions and hallucinations).

Answer 281

Erythema of the nasal turbinates and septum. In severe cases, perforation of the nasal septum can occur.

Answer 282

Enlargement of the lateral cerebral ventricles

Answer 283

Menstrual diary Premenstrual syndrome (PMS) includes physical manifestations of PMS including bloating, fatigue, headaches, and breast tenderness. Psychological symptoms may include mood swings, anxiety, difficulty concentrating, decreased libido, and irritability. Symptoms usually begin a week prior to menses and resolve within a few days after menses starts. Patients are symptom free in the follicular phase.

Answer 284

Premenstrual dysphoric disorder is a severe variant of PMS, with prominent irritability, hopelessness, depressed mood, self-critical thoughts, anger, and greater psychosocial impairment.

Answer 285

Mild PMS: exercise and stress reduction | Moderate to severe PMS/PMDD (premenstrual dysphoric disorder): SSRIs (e.g. fluoxetine) are first-line treatment

Answer 286

Menstrual diary can determine the relationship of symptoms to the menstrual cycle phases.

Answer 287

Risperidone long-acting injectable antipsychotic Frequent relapses and repetitive hospitalizations due to medication non adherence should be managed with long-acting injectable antipsychotics. LAI antipsychotics eliminate the need to take oral medication daily and are administered every 2-4 weeks intramuscularly.

Answer 288

Both first-generation (haloperidol, fluphenazine) and second-generation antipsychotics (risperidone, paliperidone, olanzapine, aripiprazole) are available in LAI formulations.

Answer 289

Cocaine withdrawal Patient's acute onset of depression with pronounced fatigue following a period of increased energy is suggestive of cocaine withdrawal. Individuals often use cocaine in binges, taking the drug repeatedly over a short period to maintain their high. Following abrupt cessation, a crash typically occurs. This initial period can include severe depression with SI and psychomotor slowing with milder symptoms that resolve within 2 weeks.

Answer 290

Acute dystonia, akathisia, parkinsonism, tardive dyskinesia

Answer 291

Add benztropine (anti-cholinergic) or amantadine (dopaminergic medication, weak NMDA receptor antagonist)

Answer 292

True. Family psychosocial interventions are indicated for patients with a recent psychotic episode who have significant ongoing contact with family members.

Answer 293

False. Gender dysphoria in early childhood does not always persist; when experienced through adolescence, and especially into puberty, gender dysphoria is more likely to be enduring.

Answer 294

Anabolic (androgenic) steroid use Anabolic steroids (e.g. testosterone, trenbolone, boldenone, stanozolol, nandrolone) are popular among young people and athletes looking to improve their physical appearance and performance. Anabolic steroid side effects include impaired endogenous testicular function and decreased testicular size and sperm count.

Answer 295

Rapid eye movement (REM) sleep behavior disorder. REM sleep behavior disorder involves dream enactment that occurs during REM sleep if muscle atone is absent. If awakened, patients become fully alert and recall their dreams. In older patients, these behaviors may be a sign of neurodegeneration. If frequent and recurrent, it may be a prodromal sign of neurodegeneration in patients with parkinson disease or dementia with lewy bodies.

Answer 296

Dependent personality disorder

Answer 297

Individuals with avoidant personality disorder typically avoid relationships, whereas patients with dependent personality disorder have a pattern of seeking and clinging to relationships.

Answer 298

1) seizure disorders 2) bulimia nervosa 3) anorexia nervosa 4) use of monoamine oxidase inhibitors in the past 2 weeks Individuals with eating disorders are at increased risk as they frequently develop electrolyte abnormalities that can precipitate seizures.

Answer 299

Opiate withdrawal

Answer 300

Serotonin and dopamine antagonists

Answer 301

True. Patients often struggle with the idea of taking medication for their entire life. A strong therapeutic alliance, psychoeducation, and adjunctive psychotherapy can help the patient accept the chronic nature of the illness and enhance adherence.

Answer 302

Normal age-related cognitive changes

Answer 303

True. This helps distinguish normal aging from mild neurocognitive disorder

Answer 304

A. decrease the antipsychotic dose and administer propranolol The patient is experiencing akathisia, a type of extrapyramidal symptom associated with antipsychotic medications. Patients describe a subjective sense of inner restlessness that may manifest as pacing and an inability to sit still. Although more common with high-potency first-generation antipsychotic use, akathisia also occurs with use of some second-generation antipsychotics. In severe cases, the patient may become extremely distressed, resulting in increased agitation and overall global worsening. Clinicians must be able to differentiate akathisia from worsening psychotic agitation, as akathisia is dose dependent; an increase in the antipsychotic dosage would make akathisia worse.

Answer 305

Bupropion. Particularly helpful for depressed patients with low energy, impaired concentration, hypersomnia, and weight gain.

Answer 306

Chronic methamphetamine abuse

Answer 307

True Visual and tactile hallucinations tend to be more common in substance-induced psychotic disorders while auditory tend to be more common in schizophrenia.

Answer 308

Cognitive-behavioral therapy Although SSRIs are often tried based on their efficacy in treating OCD, their efficacy in treating hoarding behavior without OCD is limited.

Answer 309

F. no diagnosis - normal stress response. He does not meet full criteria for any disorder. Most importantly, he exhibits no impairment of social and occupational functioning, which is a DSM-5 requirement for the diagnosis of all psychiatric disorders.

Answer 310

Persistent depressive disorder (dysthymia)

Answer 311

Antidepressants and/or therapy

Answer 312

Acute intermittent porphyria This is a hereditary disorder involving alterations in heme biosynthesis and is characterized by intermittent neurovisceral symptoms. Urinary porphobilinogen is elevated in acute porphyria.

Answer 313

Cannabis intoxication

Answer 314

Cyclothymic disorder

Answer 315

Panic disorder

Answer 316

Serotonin syndrome is characterized by neuromuscular irritability (tremor, hyperreflexia, myoclonus) rather than the rigidity in neuroleptic malignant syndrome.

Answer 317

Neuroleptic malignant syndrome

Answer 318

Phentolamine (reversible nonselective a-adrenergic antagonist.. primary action is vasodilation due to a1 blockade)

Answer 319

Benzodiazepine or ECT

Answer 320

Tricyclic antidepressants

Answer 321

Lithium toxicity NSAIDs increase lithium levels.

Answer 322

Down syndrome Physical exam findings, developmental delay, 41 y/o mother (increased risk after age 35)

Answer 323

Increased sensitivity of the dopamine receptors Chronic treatment with antipsychotics up regulates the dopamine receptors. Sudden discontinuation may cause exaggerated tardive dyskinesia due to increased dopamine sensitivity.

Answer 324

Decreased REM latency (decreased time between falling asleep and entering REM. This means that narcoleptics enter REM stage sleep very quickly. A typical person takes about 90 minutes to enter REM while a narcoleptic takes about 10) Increased REM density (increased frequency of eye movements during REM sleep)

Answer 325

Propranolol. If the patient has asthma, beta blockers are contraindicated. Use a benzodiazepine like lorazepam instead.

Answer 326

Increased amylase. Amylase is an enzyme active in the digestion of carbohydrates and is a useful marker of purging behavior. Hyperamylasemia is common in patients who purse (both bulimia and anorexia with purging) due to increased salivary production. Pancreatic amylase elevation is not seen. Amylase fractionation can be useful in determining the source of amylase. An increase in amylase, particularly originating from the parotid glands, is suggestive of purging behavior.

Answer 327

1) prior episode of delirium | 2) medications

Answer 328

Methylphenidate (extended release) Try atomoxetine if you have failed 2 different stimulants. E.g. tried methylphenidate and then dextroamphetamine or vice versa.

Answer 329

Ask about caloric intake. Ziprasidone needs 500+ calories daily in order to work.

Answer 330

Lithium Patient is showing classic signs and symptoms of lithium toxicity. Excessive urination caused by renal tubular thickening during lithium treatment results in dehydration (dry mucous membranes, bloodshot eyes). Nausea, vomiting, diarrhea, tremor, and ataxia are common for lithium toxicity. Thiazide diuretics can cause lithium toxicity.

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