UWorld Review Flashcards
(118 cards)
1
Q
What effects do antipsychotics (dopamine antagonists) elicit based on their action in the mesolimbic, nigrostriatal, and tuberoinfundibular tracts.
A
- mesolimbic: antipsychotic effect
- nigrostriatal: extrapyramidal symptoms of akathisia, parkinsonism, and dystonia
- tuberoinfundibular: hyperprolactinemia
2
Q
What are the three clinical features of autism spectrum disorder?
A
- deficits in social communication and interactions with onset in early development, often presenting as impaired “joint attention”
- restricted, repetitive patterns of behavior
- occurring with or without language and intellectual impairment
3
Q
How do we define status epilepticus and what is the most significant consequences of this prolonged seizure activity?
A
- defined as seizure activity lasting more than 5 minutes or a cluster of seizures without recovering normal mental status in between
- associated with a risk of developing permanent injury, specifically cortical laminar necrosis, due to excitatory cytotoxicity
4
Q
What is REM sleep behavior disorder and what diagnosis is it suggestive of?
A
- it consists of violent and automatic complex motor behaviors during the night reflecting dream enactment
- it is a consequence of incomplete or absent muscle atone during REM and thus occurs more frequently in the second half of the night
- it has a very strong association with the future development of alpha-synuclein neurodegenerative disorders such as Parkinson disease
5
Q
What is pseudotumor cerebri, how does it present, and how is it treated?
A
- it is idiopathic intracranial hypertension
- it presents with features of increased intracranial pressure, 6th nerve palsy, and normal CSF except for opening pressure
- it should be initially managed with acetazolamide which inhibits CSF production
- steroids and serial LPs can be used as bridging therapy until surgery (LP shunt) can be performed if medical therapy is ineffective or patients have progressive vision loss
6
Q
Mannitol is useful in the treatment of what etiology of increased intracranial pressure?
A
cerebral edema (not other types)
7
Q
Describe the presentation, diagnosis, and treatment of homocystinuria.
A
- marfanoid body habits including pectus deformity, decreased upper:lower segment ratio, joint hyper laxity, scoliosis, and skin hyperelasticity
- distinguished from Marfan’s based on intellectual disability thrombosis, megaloblastic anemia, fair complexion, and downward lens dislocation
- diagnosis is made based on elevated homocysteine and methionine levels
- treat with vitamin B6, B12, and folate supplementation alongside anticoagulation therapy
8
Q
What is the best treatment for a pregnant patient with bipolar disorder?
A
lamotrigine, which has the lowest teratogenicity of the mood stabilizers
9
Q
Which medication is often implicated in new-onset psychosis?
A
high-dose glucocorticoids
10
Q
What are Wernicke encephalopathy and Korsakoff syndrome? What neurologic lesions is each associated with?
A
- Wernicke encephalopathy is due to thiamine deficiency and characterized by a triad of encephalopathy, ataxia, and oculomotor dysfunction
- it is associated with mamillary body atrophy and dorsomedial thalamic neuron loss
- Korsakoff syndrome is a complication of this characterized by amnesia, confabulation, apathy, and lack of insight
- it is associated with lesions to the anterior and medial thalami and to the corpus callosum
11
Q
What is kleptomania?
A
- an impulse control disorder in which the individual is unable to resist the urge to steal, typically objects of little value and which are not needed
- patients describe increasing tension prior to the theft and pleasure or relief when committing the act
- they may even have guilt
12
Q
How are the following antipsychotic extrapyramidal effects treated:
- acute dystonia
- akathisia
- parkinsonism
- tardive dyskinesia
A
- acute dystonia: diphenhydramine or benztropine
- akathisia: beta blockers, benzodiazepines, or benztropine
- parkinsonism: benztropine or amantadine
- tardive dyskinesia: valbenazine
13
Q
What is the most common psychiatric complication of multiple sclerosis?
A
depression has been found in up to ⅔ of patients
14
Q
What are childhood-onset fluency disorder and speech sound disorder?
A
- fluency disorder is stuttering
- sound disorder is a problem with articulation
15
Q
What is selective mutism?
A
patients with intact verbal and nonverbal communication who do not speak in a specific setting such as at school
16
Q
what are the indications for treating depression with ECT?
A
- treatment resistance
- psychotic features
- emergency conditions such as pregnancy, refusal to eat or drink, or imminent risk for suicide
17
Q
How are social anxiety and performance anxiety treated?
A
- social anxiety is often treated with an SSRI
- performance anxiety requires only situational therapy and thus beta-blockers are the preferred treatment
18
Q
Describe the presentation and treatment of bulimia nervosa.
A
- presents as recurrent episodes of binge eating with compensatory behaviors
- patients have excess worry about body shape and weight and maintain a normal to increased body weight
- treat with CBT, nutritional rehab, and an SSRI
19
Q
Describe the presentation and treatment of binge-eating disorder.
A
- patients present with recurrent episodes of binge eating and have no compensatory behaviors
- treat with CBT, an SSRI, lisdexamfetamine, and behavioral weight loss therapy
20
Q
What is the key difference between binge-eating disorder and bulimia nervosa?
A
binge-eating disorder does not involve any compensatory behaviors like bulimia nervosa does
21
Q
Describe the presentation and treatment of anorexia nervosa.
A
- patients have a BMI less than 18.5, intense fear of weight gain, and a distorted view of body shape
- treat with CBT, nutritional rehab, and olanzapine (for weight gain)
22
Q
How long should treatment of MDD last?
A
- the typical duration is 6 months of therapy
- if patients have 2 or more episodes, age of onset before 18, persistent residual symptoms, or a comorbid psychiatric disorder, consider maintenance therapy for 1-3 years
- if patients have 3 or more episodes, chronic episodes lasting more than 2 years, severe ongoing psychosocial stressors, or severe episodes, they are candidates for lifelong therapy
23
Q
Describe the presentation of fetal alcohol syndrome.
A
- patients have behavioral difficulties, growth retardation, and intellectual disability
- facial dysmorphism includes small palpebral fissures, midface hypoplasia, a smooth philtrum, and a thin vermilion border
24
Q
What is pseudocyesis?
A
- the somatization of stress causing early pregnancy symptoms which are misinterpreted
- the end result is a non psychotic patient who believes she is pregnant
25
What is the treatment for acute mania?
antipsychotics are the preferred treatment in acute situations because they take effect quickly as opposed to anti-convulsants and lithium which have a longer time to effect
26
Which forms of therapy have been shown effective in the treatment of schizophrenia?
psychoeducation and family therapy in order to help make home a nonstressful environment
27
How should neuroleptic malignant syndrome be treated?
- start by discontinuing the causative agent
- utilize supportive treatment
- use dantrolene, dopamine agonists, and benzodiazepines if patients do not respond
28
What is disruptive mood dysregulation disorder?
- poor frustration tolerance and persistent irritability that results in frequent temper outbursts out of proportion to the situation
- differs from intermittent explosive disorder in that DMDD has an onset before age 10 and is characterized by persistent irritability or anger in between episodes
29
What are the most commonly used benzodiazepines for alcohol withdrawal? Which are safe for patients with evidence of active liver disease?
- most common are chlordiazepoxide, diazepam, and lorazepam
- safe for those with liver disease are "LOT": lorazepam, oxazepam, and temazepam
- diazepam and chlordiazepoxide have long half-lives and active metabolites that risk buildup and toxicity in liver patients
30
Describe postpartum blues and appropriate management. How does this contrast with postpartum depression?
- blues present within 2-3 days, consist of mild depression, tearfulness, and irritability, and resolves within 14 days
- it should be treated with reassurance and monitoring
- by contrast, postpartum depression is an MDD presenting within 4-6 weeks postpartum and is treated with antidepressants and psychotherapy
31
What is social pragmatic communication disorder?
a persistent difficulty in the social use of verbal and nonverbal communication
32
Describe the presentation of bath salts intoxication.
- presents with tachycardia, severe agitation, combativeness, delirium, and psychosis
- in contrast to other stimulants, the effects take several days to subside
33
When transition from a particular antidepressant to an MAOI, what is the typical protocol?
should discontinue the original antidepressant for 2 weeks before beginning the MAOI to avoid serotonin syndrome
34
How does the use of dopamine antagonists lead to tardive dyskinesia?
prolonged used of dopamine antagonists leads to D2 receptor up regulation and supersensitivity
35
What are the diagnostic criteria for adjustment disorder?
onset within 3 months of the identifiable stressor, marked distress or functional impairment, and does not meet criteria for another diagnosis
36
How does a normal stress response differ from adjustment disorder?
a normal stress response involves changes that are in line or appropriate for the severity of the stressor and do not lead to significant functional impairment
37
When are separation anxiety and stranger anxiety normal?
separation anxiety between 9-24 months of age and stranger anxiety between 6-24 months of age
38
How can pheochromocytoma be differentiated from panic disorder?
pheochromocytoma is more likely to present with drug-resistant hypertension, hyperglycemia, and episodic pounding headache
39
What is the best treatment for panic disorder?
- first line maintenance therapy is an SSRI or SNRI along with cognitive behavioral therapy
- acute management is with benzodiazepines
40
What are the core features of atypical depression?
- mood reactivity and hypersensitivity to rejection
- weight gain and hypersomnia
- leaden paralysis
41
What are the important features of a suicide risk assessment?
- evaluate ideation: frequency, duration, intensity, controllability, and nature
- evaluate intent: strength of intent and ability to control impulsivity
- evaluate plan: specific details, lethality of method, and likelihood of rescue
42
What is delayed sleep phase?
- a syndrome of inability to fall asleep at normal bedtimes, difficulty waking in the morning, and excessive early daytime sleepiness
- on weekends when allowed to set their own schedule, these patients have normal sleep quality and duration for age
43
What is the utility of a contract for safety?
their efficacy has not been demonstrated and may provide a false sense of security
44
What constitutes delusional disorder?
- one or more delusions lasting one month or more which are not obviously bizarre
- delusions in the absence of other prominent psychotic symptoms
45
What is a brief psychotic disorder?
the sudden onset of one or more psychotic symptoms that last less than 1 month
46
How can delusional disorder be differentiated from paranoid personality disorder?
paranoid personality disorder is a lifelong pattern whereas delusional disorder arises later in life in most circumstances and have a greater delusional intensity
47
What is reactive attachment disorder?
a pattern of emotional and social withdrawal stemming from past experiences of neglect or abuse leading to insecure attachment to caregivers
48
How is intellectual disability different from a learning disorder?
while a learning disorder is a difficulty in acquiring and using core academic skills, intellectual disability is a combination of intellectual deficits and deficits in adaptive functioning (e.g. dressing, feeding, socializing)
49
How is psychosis in Parkinson's disease managed?
- begin by reducing the dose of dopamine precursors and dopamine agonists
- if patients do not improve or cannot tolerate this reduction due to resurgent motor symptoms, you may add a low-potency second-generation antipsychotic
50
What can be used as a medical trigger for panic disorder and is occasionally used in research as a diagnostic tool?
lactate infusion can provoke panic attacks
51
When patients are put on atypical antipsychotics, what monitoring must be completed?
must monitor BMI, fasting glucose, fasting lipids, blood pressure, and waist circumference
52
What is the first line treatment for MDD?
an SSRI and psychotherapy
53
Clozapine is indicated for which patients?
those with treatment-resistant schizophrenia or schizophrenia associated with suicidality
54
What is reaction formation? How does reaction formation differ from altruism?
- reaction formation is an immature coping mechanism in which a persons transforms unacceptable impulse or feelings into the opposite though he or she may not gain any gratification from it
- altruism is a mature defense mechanism in which a person manages unpleasant emotions through service to others and in contrast to reaction formation, this action provides the individual with gratification
55
What is the treatment for neuroleptic malignant syndrome?
- stop antipsychotics or restart dopamine agents
- supportive care including hydration and cooling
- use bromocriptine or dantrolene if still refractory
56
What are three things that help differentiate pseudodementia from dementia?
- the time course: pseudodementia is more likely to arise over weeks to months and be episodic whereas dementia arises over months to years and is progressive
- accompanying symptoms: pseudodementia will be accompanied bye features of depression
- awareness: those with pseudodementia are usually more aware of their cognitive deficits than are patients with true dementia
- cognitive domains: pseudodementia is more likely to affect attention and episodic memory than other cognitive domains
57
Fatigue, constipation, myalgia, and bradycardia are most likely adverse effects associated with what psychotropic medication?
these symptoms are consistent with lithium-induced hypothyroidism
58
What is a key difference between the presentation of MDD in adolescents compared to adults?
adolescents are more likely to present with irritability rather than sadness
59
What is disruptive mood dysregulation disorder?
persistent irritability and frequent temper outbursts that begin prior to age 10 and are grossly out of proportion to the situation and inconsistent with developmental level
60
What is the difference between somatic symptom disorder and illness anxiety disorder?
- somatic symptom disorder is seen in patients with unexplained symptoms, and these cause excessive anxiety
- illness anxiety disorder is excessive anxiety related to the fear of having a serious illness despite few or no symptoms
61
What is considered a high, imminent suicide risk and what is considered a high, non-imminent suicide risk? How are they managed differently?
- imminent means they have ideation, intent, and plan, whereas non-imminent means they have only ideation and intention but not plan
- high imminent risk patients should be hospitalized with a CO
- high non-imminent risk patients must have close follow-up and you should recruit family or friends to support the patient
62
What is the mnemonic for suicide risk?
```
Sex (male)
Age (adolescent or elderly)
Depression
Previous attempt
Ethanol abuse (or other drugs)
Rational thinking loss (delirium or command hallucinations)
Social support deficit
Organized plan
No spouse
Sickness (other chronic illness)
```
63
What is the preferred treatment for adjustment disorder?
psychotherapy
64
How is acute stress disorder differentiated from PTSD?
ASD is the diagnosis when symptoms last less than one month and PTSD is the diagnosis when they last longer
65
What is the key difference between acute stress disorder and adjustment disorder?
- ASD results in symptoms that are more consistent with PTSD following a trauma
- adjustment disorder is more of a mood disorder that is elicited by the stressor
66
What are the diagnostic criteria for delusional disorder?
- 1 or more delusions persisting longer than 1 month
- absence of other psychotic symptoms (hallucinations, disorganization, negative symptoms, etc.)
- behavior is not odd or bizarre and functioning is not impacted
67
Which opioids do not appear on a UDS and why?
- a typical UDS screens for morphine metabolites and will be positive for morphine or codeine
- therefore, it only identifies natural opioids
- synthetic and semisynthetic opioids do not trigger a positive result
68
What can cause a false positive for amphetamines on a UDS?
- atenolol or propanolol
- bupropion
- nasal decongestants
69
What can cause a false positive for PCP on a UDS?
- dextromethorphan
- diphenhydramine
- ketamine
- tramadol
- venlafaxine
70
What are the features of nightmare disorder?
- recurrent episodes of awakening from sleep with recall of frightening dream content
- on waking, the child is fully alert, remembers the dream, and can be consoled
71
What cognitive changes are a part of normal aging?
- forgetfulness about details
| - occasional word-finding difficulty
72
For which patients is there an increased risk for suicide during the course of antidepressant therapy?
for those under age 25
73
What are features that may suggest a diagnosis of HIV-associated dementia?
- a subacute onset
| - apathy and impaired attention as well as subcortical dysfunction in the form of movement disorder
74
What is the typical presentation for someone abusing inhalants?
- most often a boy age 14-17
- they typically appear intoxicated for 15-45 minutes
- they have CNS depression
- they often have a dermatitis known as glue sniffer's rash around their mouth or nostrils
75
Which antipsychotics are most likely to cause hyperprolactinemia?
first generation and risperidone
76
If a patient with anxiety is being treated with an SSRI and they begin to feel more anxious, what should the first step in treatment be?
reduce the dose of the SSRI as these can often times be stimulating at higher doses
77
What are the most significant risk factors for homocide?
```
young male
unemployed and impoverished
with access to firearms
substance abuse
antisocial personality disorder or history of violence
history of childhood abuse
impulsivity
```
78
How is PCP intoxication managed?
with primarily supportive care and benzodiazepines for agitation (antipsychotics are second-line)
79
Which SSRI is most appropriate for use in a patient who is post-MI?
sertraline and escitalopram are preferred because they carry the lowest risk of cardiac compromise or interaction with cardiac drugs
80
What are anti-Hu antibodies?
those found in the CSF of patients with paraneoplastic encephalomyelitis, a syndrome associated with small cell lung cancer, which presents with seizures, brainstem symptoms, and diffuse sensory impairments
81
What is 14-3-3 protein?
a protein found in elevated levels in patients with Creutzfeldt-Jakob disease
82
How should parkinson diseases psychosis be treated?
use an atypical antipsychotic, specifically one that has low-potency for the D2 receptor such as quetiapine or clozapine; typically should be avoided due to their EPS
83
How should you approach a patient who has had a stillbirth?
- your role is to stay in the room and give patients time to express grief or ask any questions they may have
- do not discuss management options or refer them to others until this time has been given
84
What is the preferred inpatient treatment for alcohol withdrawal and why?
lorazepam because it is intermediate-acting, can be given intravenously, and is safer in patients with poor liver function because it has no active metabolites
85
What is the first-line treatment for ADHD?
behavioral therapy and stimulant medications
86
What is atomoxetine?
a non-stimulant, NET inhibitor appropriate for treating ADHD in patients with a history of illicit substance use or patients who are strongly against stimulant medications
87
Name two non-stimulant medications useful in the treatment of ADHD and when you would use them.
- atomoxetine, a NET inhibitor, used to treat those with a history of substance abuse or who are against stimulants
- guanfacine and clonidine, a2-agonists, used to treat those with refractory ADHD, who have intolerable side effects from stimulants, or have a comorbid tic disorder (not effective in the adult population)
88
How should body dysmorphic disorder be treated?
SSRIs and CBT
89
What is the key difference between bulimia nervosa and binge eating disorder?
those with bulimia engage in compensatory behaviors while those who have binge eating disorder do not
90
What are four risk factors for prescription drug misuse?
- age less than 45
- comorbid psychiatric disorder
- personal or family history of substance use disorder
- legal history
91
Name three measures physicians can implement to reduce the risk of prescription drug misuse?
- use a prescription drug-monitoring program
- perform random urine drug screening
- schedule frequent follow-up visits every 3 months
92
If a patient has new onset abdominal pain and neuropsychiatric symptoms as well as a family history of similar symptoms, what condition should be suspected?
acute intermittent porphyria
93
What baseline labs should be drawn prior to initiating lithium therapy?
- BUN and creatinine
- calcium
- UA
- thyroid function tests
94
What are the indications for CBT?
- Depression
- GAD
- PTSD
- Panic Disorder
- OCD
- Eating Disorders
- Negative Thought Patterns
95
What is the primary indication for interpersonal psychotherapy?
depression driven by interpersonal stressors
96
What is the primary indication for psychodynamic psychotherapy?
personality disorders
97
What is the primary indication for motivational interviewing?
substance use disorders
98
What is the primary indication for DBT?
borderline personality disorder
99
What is the primary indication for biofeedback?
those with prominent physical symptoms or pain disorders
100
What is the indication for the following:
- CBT
- interpersonal psychotherapy
- psychodynamic psychotherapy
- motivational interviewing
- DBT
- biofeedback
- CBT: depression, GAD, panic disorder, PTSD, OCD, eating disorders, negative thought patterns
- interpersonal psychotherapy: depression
- psychodynamic psychotherapy: personality disorders
- motivational interviewing: substance use disorders
- DBT: borderline personality disorder
- biofeedback: prominent physical symptoms/pain disorders
101
What is the strongest single factor predictive of suicide?
a prior suicide attempt
102
What is the treatment for akathisia?
reduction of the antipsychotic dose and propanolol
103
What is Dhat syndrome?
a culture-bound syndrome of South Asia in which psychological and somatic symptoms are attributed to a loss of semen
104
Describe TCA overdose.
- mental status changes
- seizures
- tachycardia, hypotension, cardiac conduction delay
- anticholinergic effects
105
What is the best predictor of complications due to TCA overdose?
QRS duration over 100ms
106
What are the symptoms of anabolic steroid use?
aggression, accelerated male pattern baldness, gynecomastia, decreased testicular size and sperm count
107
What duration of therapy constitutes an adequate antidepressant trial?
4-6 weeks
108
Adjustment disorder is bounded by what time constraints?
onset within 3 months of the identifiable stressor and resolution within six months
109
What is unique about the following atypical antipsychotics:
- risperidone
- olanzapine
- ziprasidone
- clozapine
- risperidone: most likely to cause EPS and hyperprolactinemia
- olanzapine: most likely to cause metabolic effects
- ziprasidone: least likely to cause metabolic effects
- clozapine: most likely to have anticholinergic, neutropenia/agranulocytosis, seizures, cardiotoxicity
110
What are the criteria for a manic episode?
elevated/irritable mood and 3/4 of the following:
- Distractibility
- Insomnia
- Grandiosity
- Flight of ideas/racing thoughts
- Activity increase
- Speech (pressured)
- Thoughtlessness/impulsivity
111
How is somatic symptom disorder differentiated from conversion disorder?
- conversion disorder has a more acute onset while somatic symptom disorder must have a duration greater than 6 months
- the anxiety of somatic symptom disorder may be tied to a symptom that can be explained by a recognized disease process while that of conversion disorder cannot
112
Sexual assault is a risk factor for what psychiatric illness?
depression and suicidal ideation
113
What is a key difference between antisocial and narcissistic personality disorders?
those with narcissistic tendencies are unlikely to break the law or violate others' rights unlike those with antisocial traits
114
Before treating always do what?
gather more information
115
What are the key adverse effects possible for those taking MAOIs?
- tyramine induced hypertensive crisis
| - serotonin syndrome when used in combination with other serotonergic agents
116
How should tardrive dyskinesia be treated?
- discontinue the causative medicine
- switch to an atypical antipsychotic if an antipsychotic is required
- treat with valbenazine or deutetrabenazine
117
How would you differentiate opioid withdrawal from cocaine intoxication?
- remember that opioid withdrawal will take 3-5 days while cocaine intoxication is likely to resolve in the course of an ED visit
- opioid withdrawal is also unlikely to be characterized by psychosis whereas delusions are more common with cocaine intoxication
118
What is the preferred treatment for catatonia?
benzodiazepines or ECT
