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1352 Cards in this Set

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Question
Answer
Amnesia preceded by epigastric sensation and fear are associated with electrical abnormality where?
Temporal lobe
Memory loss pattern in dissociative amnesia
Memory loss occurs for a discrete period of time
Amnesia characterized by loss of memory of events that occur after onset of etiologic condition or agent
Anterograde
What psychoactive drug produces amnesia?
Alcohol
Visual problem in pituitary tumor compressing optic chiasm
Bitemporal Hemianopsia
32 y/o pt 1-month history of worsening headaches, episodic mood swings and occasional hallucinations with visual, tactile and auditory content. CT head reveals tumor where:
Temporal lobe
Syndrome characterized by fluent speech, preserved comprehension, inability to repeat, w/o associated signs. Location of lesion in the brain?
Supramarginal gyrus or insula
Acute onset of hemiballismus of LUE & LLE. MRI is most likely to show lesion located where?
Subthalamic nucleus
Left sided hemi-neglect is associated with lesion located where?
Right Parietal Lobe
60M right-handed, getting lost, only writes on right half of paper. Where is lesion
Right parietal
Which hormone secreted in functional pituitary adenoma:
Prolactin
CT & MRI show ventriculomegaly are out of proportion to sulcal atrophy. This is suggestive of what diagnosis?
Normal Pressure Hydrocephalus
5 y/o with 4 month history of morning HA, vomiting, and recent problems with gait, falls, and diplopia
Medulloblastoma
20 y/o with 1 yr of bitemporal headaches, polydipsia, polyuria, bulimia. For 2 months emotional outburst aggressive and transient confusion neuro exam normal. What will MRI of brain show?
Hypothalamic tumor
Previously pleasant mom becomes profane and irresponsible over 6 months:
Frontal lobe
Unilateral hearing loss with vertigo, unsteadiness with falls and headaches, mild facial weakness and ipsilateral limb ataxia is most commonly associated with tumors in what locations:
Cerebellopontine angle
52 y/o with h/o unipolar depression is brought to ED with a first episode of catatonia. Patient is on no meds, UDS is neg. Further w/u should initially focus on what factor?
Metabolic disorders
Which term describes state of immobility that is constantly maintained?
Cataplexy
Ability of catatonic pt to hold same position
Catalepsy
Chronic Afib develops aphasia and R hemiparesis at noon. ER exam notes weakness of R extremities and severe dysfluent aphasia, but CT at 1:30 PM has no acute lesion. Most appropriate treatment:
TPA
Young adult gained 70 lbs in last year c/o daily severe headaches sometimes assoc with graying out of vision. Papilledema present. CT and MRI brain no abnormalities but ventricles smaller than usual. Goal of treatment in this case:
Prevent blindness
Patient with hypertension develops vertigo, nausea, vomiting, hiccups, left sided face numbness, nystagmus, hoarseness, ataxia of the limbs, staggering gait, and is falling to the left. Dx?
Lateral medullary stroke
Rapid onset of right facial weakness, left limb weakness, diplopia
Brain Stem Infarction
Transient symptom associated with carotid stenosis: ***
Monocular blindness
62 y/o M w DM is not making sense, saying “thar szing is phrumper zu stalking”. Normal intonation but no one in the family can understand it. He verbally responds to questions with similar utterances but fails to successfully execute any instruction. ****
Wernicke’s aphasia
58 y/o M h/o HTN, cig smoking and sudden inability to speak. Face drooping on R and dragging R leg. In ER examined within 40 mins of onset: Aphasic, unable to understand or repeat verbal commands. Unintelligable sounds for speech. Alert but appeared frustrated. R hemiplegia with arm and face weaker than leg. CT head showed no hemorrhage. Pathology type and area:
Thromboembolic stroke L MCA (middle cerebral artery)
Abulia refers to impairment in ability to:
Spontaneously move and speak
Sudden-onset left hemiparesis with deviation of eyes to the right
Right putaminal hemorrhage
Sudden onset vertigo/nausea, hoarseness/dysphagia, right sided face numbness, diminished gag reflex on right, decreased pinprick and temp sensation on left
Right medullary infarction
65 y/o diabetic presents to ED c/o acute L sided weakness, deviation of gaze to R, L hemiplegia and hemisensory deficit, and L homonymous hemianopsia. 12 hrs later, pt is unconscious, L pupil enlarged and unreactive. CT will show what?
R MCA infarct w/ edema and uncal herniation
Pt with acute onset vertigo, what will suggest R lateral medullary infarct?
R facial loss of touch + temp sensation
46 y/o M w/ double vision + pain R eye. Exam: ptosis R eyelid, inability to elevate or adduct R eye + R pupillary dilation. This is caused by:
Post. Communicating artery aneurysm
Aphasia w/ effortful fragmented, dysfluent, telegraphic speech, is seen in a lesion where?
Post frontal lobe
39 year old with h/o of multiple miscarriages develops an acute left sided hemiparesis. Work up revels elevated anticardiolipin titers and no other risk factors for stroke. Appropriate intervention at this point is?
Plasmapheresis
Abnormal elevated metabolic findings associated with increased risk of stroke in patients under 50
Plasma homocysteine
73 y/o found on floor, unaware of L UE/LE. Flaccid L arm, but denies anything wrong and when asked to raise L arm raises R. When asked which arm is her L, she replies “yours.” Dx?
Parietal lobe CVA
CT scan with occipital and intraventricular hyperintensities
Parenchymal hemorrhage
Which med has secondary prevention against embolic stroke in patients with Afib?
Oral warfarin
As opposed to strokes caused by arterial embolism or thrombosis, those caused by cerebral vein or venous sinus thrombosis are
More often associated with seizures at onset
Atrophy of right temporal lobe on cross section associated with occlusion of:
Middle cerebral artery
Loss of ability to execute previously learned motor activities (which is not the result of demonstrable weakness, ataxia or sensory loss) is associated with lesions of?
Left parietal cortex
58 y/o s/p CABG – anomia for fingers and body parts, errors involving right and left, inability to write thoughts/take notes/make calculations. Fluent speech and excellent comprehension
Left medial temporal stroke
Visual disturbances associated with occlusion of the right posterior cerebral artery?
Left homonymous hemianopsia
65 y/o with HTN collapsed. In ED is stuporous, R hemiparesis + hemisensory deficit, eyes deviate to L. CT would show intraparenchymal hemorrhage in:
Left basal ganglia
Higher frequency & greater severity of depression associated w/ cortical & subcortical strokes
Left anterior frontal
Pt with hypertension develops painless vision loss on the left eye. PE revels blindness in the left eye and afferent papillary defect on the left. MRI shows several T2 hyperintensities in the white matter periventricularly. No corpus callosum lesions. No enhancement with gadolinium. Dx?
Ischemic optic neuropathy
63 y/o with new onset aphasia and R hemiparesis, 2 days ago had milder/similar symptoms that resolved in 30 minutes, yesterday had similar episode x45 minutes. Current sx started 1.5 hrs ago. CT shows no stroke or hemorrhage. Tx?
Intravenous thrombolytic agents
Lower facial weakness w/ relative sparing of forehead can be stroke in
Internal capsule
Prosopagnosia is:
Inability to recognize faces
57 y/o diabetic w/ HTN c/o several episodes of visual loss “curtain falling” over his L eye, transient speech and language disturbance, and mild R hemiparesis that lasted 2 hrs. Suggests presence of what?
Extracranial L internal carotid stenosis
Head injury with LOC followed by lucid interval for a few hours then rapidly progressing coma. What hemorrhage?
Epidural
5 days after CABG a 47 yr M is disoriented in time and place. He identifies his right and left but not that of the examiners. Can draw square and circle but not a clock. This is:
Dyspraxia
Pt in ED with sudden HA and collapsing, some lethargy. Exam shows rigid neck, no papilledema, no focal CN or motor signs. The initial test should be?
CT Head
Post stroke depression in an 80 y/o pt who is R handed is associated with cognitive impairments that
Correlate with left hemispheric involvement
Fluent speech with preserved comprehension but inability to repeat statements is consistent with what type of aphasia?
Conduction
Normal Romberg w eyes open but loses balance with eyes closed. Where is abnormality?
Cerebellar vermis
65 y/o with h/o HTN, Meniere’s with sudden vertigo, N/V, worse with head movement, R beating nystagmus on lateral gaze, finger to nose testing is ataxic, poor balance and dysarthria. Dx?
Cerebellar infarct
66 y/o M in ED w/ sudden occipital HA, dizziness, vertigo, N/V, unable to stand, mild lethargy, slurred speech. Exam shows small reactive pupils, gaze deviated to the R, nystagmus, w/ occasional ocular bobbing, R facial weakness, decreased R corneal reflex, truncal ataxia, b/l hyperreflexia, b/l Babinski. Dx?
Cerebellar hemorrhage
Motor speech paradigm activation task on fMRI – hyperactivity in right temporal lobe. Damage is where?
Calcarine fissure
Inability to recognize objects by touch:
Astereognosis
In managing acute ischemic stroke, administer this within 48 hrs of onset of stroke for beneficial effect in reducing risk of recurrent stroke, disability and death:
Aspirin
70 y/o w/ attacks of “whirling sensations” w/n/v, diplopia, dysarthria, tingling of lips. Occurs several times daily for 1 minute, severe that pt collapses and is immobilized when symptoms start. No residual s/s, no tinnitus, hearing impairment, ALOC or association with any particular activity. Dx?
Vertebrobasilar insufficiency
Component of type A behavior most reliable risk factor for CAD
Hostility
70 y/o F sudden onset paralysis R foot and leg. R arm and hand lightly affected. No aphasia or visual field deficit. Over weeks found with loss bladder control, abulia and lack of spontaneity. Which vascular area:
Anterior cerebral artery (left)
Complications of a cerebellar hemorrhage?
Acute hydrocephalus
Multifocal myoclonus in a comatose patient indicates:
Metabolic Encephalopathy
50M male w/ progressive dementia, ataxia, dysarthria, EEG w/ sharp waves
Subacute Spongiform Encephalopathy
79 y/o with decreasing mental state over 3 weeks has an exaggerated startle response with violent myoclonus that is elicited by turning on the room lights, speaking loudly, or touching the patient. Myoclonic jerks occur spontaneously. Dx?
Spongiform Encephalopathy
Two days after bowel surgery, 53 y/o is delirious. Correctly draws a square when asked, but then continues to draw squares when asked to draw other shapes. MSE would reveal:
Perseveration
75 y/o F is 8 days s/p total hip replacement and has delirium. Her diazepam and doxepin were discontinued just prior to surgery. She is getting meperidine for pain, diphenhydramine for sleep and a renewed prescription for doxepin. Her confusion is likely due to: medication toxicity, diazepam WDRL, electrolyte imbalance, atypical depression, UTI.
Medication toxicity, diazepam withdrawal, electrolyte imbalance, atypical depression, or UTI.
Best recommendation for pt with delirium? Minimize contact with family members or limit sleep meds to diphenhydramine, or maximize staff continuity assigned to pt?
Maximize staff continuity assigned to pt
Delirium in HIV patients treated with what parental agent?
Low dose of a high-potency antipsychotic
Mild confusion, lethargy, thirst, polydipsia
Hyponatremia
Cancer patient on chemo is disoriented and agitated. Afebrile VSS. Neg neuro exam. Poor attention, cog impairment. Held for observation. CT neg, EEG diffuse slowing. Treat with:
Haldol
A 70 y/o +HIV heroin abuser is treated with Lopinavir and Ritonavir and fluoxetine for MDD. Hep C was dx and treated 2 months ago. Since then pt is more irritable, insomnia, and diarrhea. Why?
Drug-drug interaction
A consult is requested for an inpatient on a medical ward who is agitated and hallucinating. Pt appears to be flushed and hot with dry skin, mydriasis, a rapid pulse and diminished bowel sounds. What is your first recommendation?
Discontinue anticholinergic drugs
52 y/o w/ depression and HTN, severe headaches, “not himself” x 10 days. Poor eye contact, inattentive, picking at clothes, muttering, nodding off
Delirium
Suggests delirium rather than dementia
Clouding of consciousness
65 y/o M 6 months confusion episodes, disorientation, visual hallucinations of children playing in his room. Hallucinated images are fully formed, colorful, vivid and pt has little insight into their nature. No AH. Wife says he is normal between episodes. Exam: Normal language, memory, mod diff with trails test, mild diff with serial subtractions, mild symmetric rigidity and bradykinesia. Brain MRI unremarkable. CSF, routine labs and UDS normal. Diagnosis:
Lewy body dementia
Dementing illness with limb and axial rigidity tremor, fluctuations in cognitive function, confusion states, hallucinosis and other symptoms of psychosis. Dx?
Diffuse lewy body disease
70 y/o woman has dementia, abnormal proprioception, and dysesthesia. Lab studies reveal macrocytic anemia most likely caused by a deficiency of
Vitamin B12
74F PI, suspicious, poor ADL’s
Pick’s disease
Safest heterocyclic antidepressant for a 78 y/o with depression, agitation and dementia is:
Nortriptyline
What cognitive enhancers is an NMDA receptor antagonist?
Memantine
Neuronal damage from excitotoxicity secondary to glutamate sensitivity. Treat with:
Memantine
75 y/o with mild intermittent forgetfulness, hallucinations, delusions, confusion. Frequent falls and dizziness when getting out of bed. BP laying down 135/90, standing 100/55. BL limb and axial rigidity without tremor. Dx?
Lewy Body disease
Detection of 2 Apolien e4 alleles is useful in dx dementia b/c
Increases probability of dx of Alzheimers
Neurofibrillary tangles in Alzheimer’s are composed of:
Hyperphosphorylated tau proteins
80 y/o Alzheimer’s with increasingly combative behavior. Family wants to keep at home. Give what med?
Haldol
Dementia characterized by personality change, attention deficits, impulsivity, affect lability, indifference, perseveration, loss of executive function. Assoc with dysfunction in what area of the brain?
Frontal lobe
Alzheimer’s disease risk – Apolipoprotein E phenotype
ɛ4ɛ4
Binswanger disease has pseudobulbar state, gait disorder, AND:
Dementia
An 80yo pt with Alzheimer’s is brought in for increasingly combative behavior. Daughter would like to keep the pt at home if possible. What interventions would be most helpful in this situation?
Assessing for caregiver burnout
Which meds have best results for treating agitation in dementia?
Anti-psychotics
Clock drawing test is quickly administered and sensitive screen for which d/o?
Alzheimer’s
Amyloid precursor protein in
Alzheimer’s Disease
Most common cause of dementia:
Alzheimer’s disease
Individuals over 40yo with Down’s syndrome frequently develops:
Alzheimer’s
What baseline labs should be taken before starting tacrine?
ALT and AST (baseline and f/u)
Known risk factors for dementia:
Age, family hx, female, Down Syndrome
Neuronal enzyme that is the target of drugs to treat Alzheimer’s i.e. galantamine and rivastigmine
Acetyl cholinesterase
19 yr old woman has bouts of motor agitation, often followed by intense, seemingly meaningless writing; also mood lability, tactile & olfactory hallucinations. During the interview, patient abruptly stops paying attention and begins rapidly pacing around the room. What should be the next step?
Wait 15 mins, then obtain prolactin level
Which procedure confirms the diagnosis of non-epileptic seizures? Video telemetry or EEG between episodes?
Video telemetry (CL: Should be more accurately called EEG Video telemetry)
Antiepileptic for juvenile myoclonic epilepsy
Valproic Acid
Complex partial seizures are differentiated from simple partial seizures by:
Simple seizures have no loss of consciousness but have altered responsiveness to outside stimuli.
Convulsive episode with leftward eye deviation, tonic contracture of left side. Postictally, eyes deviate to right w/ hemiparesis of left side
Seizure focus right frontal region
28 female w/ HA, hyperventilates, asynchronous tonic-clonic sz, no LOC during Sz
Psychogenic Seizure
In young pt w/ epilepsy, tx depression w/
Prozac
Lack of prolactin elevation after szs suggests what kind of szs:
Non-epileptic
32 y/o with partial complex seizures refractory to treatment, picture of MRI shown. (picture)
Mesial temporal sclerosis
Drug-addicted healthcare professional experiences seizure that is not a withdrawal phenomenon. Cause?
Meperidine
What is the diagnostic value of transient paresis or aphasia after a seizure?
Localizes the focus of seizure
Complex partial epilepsy aura has what symptom?
Lip smacking
Head & eyes deviate to right and right arm extends immediately before a generalized tonic-clonic seizure
Left cerebral hemisphere
Gustatory special sensory seizures (auras) localize where?
Insular cortex
First sz with focal onset and second generalization in a 58 y/o patient is most likely the consequence of what?
Glioblastoma multiforme
10 y/o child freq episodes brief lapses of consciousness without premonitory sxs. Lasts 2-10 seconds, followed by immediate and full resumption of consciousness without awareness of what has happened. These ictal episodes most likely caused by what kind szs:
Absence
3 days s/p cardiac arrest and CPR, a 73-year-old man is comatose. His eyes are open but he does not fix and follow with his eyes. Doll’s eyes elicits full horizontal eye movements. His spontaneous limb movements are symmetrical. The reflexes are mildly hyperactive. The EEG shows?
Burst suppression pattern
8 y/o observed to have brief episodes (seconds) of interruption of consciousness. Associated with automatism such as lip smacking. What is EEG likely to show?
Burst od 3 cycles per second spike & wave activity
EEG that reveals posterior alpha and anterior beta activity is most likely to have been obtained from whom?
A relaxed adult with eyes closed
73 y/o man w/ onset of fatigue, weight gain, constipation, cold intolerance, depressed mood. Which organic caused needs to be ruled out?
Thyroid
Physical finding associated with Hypothyroidism:
Slow relaxation of deep tendon reflexes
A 32 y/o s/p thyroidectomy presents c/o frequent panic attack, progressive cognitive inefficiency, perceptual disturbances, severe muscle cramps, and carpopedal spasm. PE shows alopecia and absent DTR. DX?
Hypoparathyroidism
35 y/o M awakens frequently middle of night with severe headaches, which sometimes occurs nightly and lasts approx 1-2 hrs. Headaches are so severe that pt is afraid to go to sleep. Located around L eye and assoc with lacrimation, ptosis and miosis. Likely dx is:
Cluster headaches
In treating migraines, triptans should NOT be given to:
Patients with CAD
Flashing lights traveling slowly from left to right in left visual field persist 30 minutes followed by difficulty with expression and concentration that subsides after 30 minutes, followed by headache and nausea. PE and MRI are normal. Dx?
Migraine w/ aura
Young pt new onset headaches w/ periods of visual obscuration. Papilledema. MRI nml. Best test:
Lumbar puncture
26 y/o male is awakened by early morning headaches that last 60-90 minutes. Sharp stabbing sensation in left nostril, severe retro-orbital pain, tearing of the left eye and rhinorrhea. Dx?
Cluster headaches
Man awakens 4am with severe HA, excruciating, lasts 1 hr, unilateral lacrimation, rhinorrhea, ptosis. No association w stress.
Cluster headaches
29 y/o awakened by headaches in middle of night. Unilateral, periorbital, + lacrimation and rhinorrhea, swelling of face. Asymmetry of pupils, hyperesthesia of face
Cluster headaches
Treatment of Huntington’s chorea
Haloperidol
98 y/o M in ER, unconscious after choking on chicken. Pt had a progressive neuro condition presented in his early 30’s w involuntary irregular movements of all extremities and face but after 15 yr course evolved into rigid, akinetic condition w diff swallowing and speaking. Also progressive dementia and full time care. After obstruction was relieved pt remained unconscious, had cardiac arrest and died. PM exam showed generalized brain atrophy. (Path picture of brain atrophy). Diagnosis:
Huntington’s disease
Cross section of the brain picture with generalized atrophy:
Huntington’s disease
Treatment for Huntington’s disease:
High potency antipsychotics
Confabulation is:
Unconscious filling in of memory gaps
45 y/o with nystagmus and ataxia, short term memory loss and believes wife is possessed by demons. Most appropriate treatment?
Thiamine
A conscious memory that covers for another memory that is too painful to hold in the consciousness is:
Screen memory
Example of declarative memory
Retention and recall of facts
In patients with pronounced defects in recent memory, remote memory is:
Often deficient on close examination even when it seems well preserved
“My father was very involved in my life. I remember going to football games in the snow with him” is an example of memory associated with what part of the brain?
Medial temporal lobe
What is the role of the hippocampus and parahippocampal gyrus?
Declarative memory (facts)
Parkinson’s tx w/ levodopa. Visual hallucinations. Recommendations?
Reduce dose of levodopa
Implantation of deep brain stimulation electrodes is an effective tx for Parkinson’s. Optimal location for electrodes?
Subthalamic nucleus
Gait disturbance w/ involuntary acceleration
Parkinson’s disease
Lewy bodies visualized
Parkinson’s disease
Gait consisting of : postural instability, festination, & truncal rigidity is seen in what condition?
Parkinson’s disease
Motor dysfunction in Parkinson’s associated with:
Increased activity in subthalamic nucleus and pars interna of globus pallidus
Characteristics of Parkinson’s tremor
Being Inhibited with Volitional Movement
New-onset back pain after shoveling – left paraspinal muscle spasm, negative straight leg raise, reflexes symmetric, no weakness, no sensory deficit. Management:
Conservative (bed rest) with NSAIDS
Protein 50mg, +oligoclonal bands, nucleated cells 10.
Order MRI scan of the lumbar spine
77 y/o gets numbness and aching in buttocks and thighs down to legs when walking > 100 ft. Better after sitting down. How to Dx?
MRI of lumbar spine
50 y/o male with acute neck pain radiating down L arm, gait problems, urinary incontinence. What test should be ordered?
MRI of C spine to r/o cord compression
Patient treated conservatively with analgesics and muscle relaxants, continues to have back pain radiating to R leg, increased by coughing/sneezing. Tenderness in lumbar paravertebral area, decreased R ankle jerk, weak flexion of right foot. Next step in management:
MRI lumbar spine
68 y/o pain in buttocks while walking, shooting down legs, w/ weakness and numbness. Relieved by sitting, pain persists with standing. Dx?
Lumbar spinal stenosis
Loss of pain and temp sensation on one side with motor paralysis and propioception on the other. Spinal syndrome is:
Hemisection
Brown-Sequard syndrome includes:
Contralateral loss of pain and temp sensation beginning below lesion
Fall from a ladder with persistent back pain and inability to void. Bilateral leg weakness, decreased pinprick in sacral and perianal area. Dx?
Cauda equina compression
The single most consistently documented and significant risk factor in the epidemiology of tardive dyskinesia is?
Advanced age
Risk factor for TD
Presence of mood disorder
TD in 63 y/o w/ end stage renal failure. Culprit:
Metoclopramide
Which gender has a higher risk for tardive dyskinesia (TD)?
Female
Persistent numbness n the L hand, decreased sensation in 4th/5th digits (palmar/dorsal), weak finger abduction/adduction especially 5th digit:
Ulnar nerve entrapment at the elbow
Injury R upper extremity in 29 y/o M, difficulty holding pencil in R hand. Reflexes intact, weakness of opponens R thumb and adduction of 4th and 5th digits. Decreased sensation R 4th and 5th digits extending into palm of hand and ending at crease of wrist. Cause:
Ulnar nerve
Right neck pain, tends to rotate neck to left – touching the chin prevents deviation – prominent right SCM spasm. Tx?
Treat with botulinum toxin
Severe occipital HA, BL papilledema and no other abnormalities. Chronic acne treated with isotretinoin. Lumbar puncture elevated opening pressure with no cells, 62 mg/dl glucose, and 22mg/dl protein. CT is normal.
Pseudotumor cerebri
Internuclear ophthalmoplegia is an ocular motility disorder often seen in patients with:
Multiple Sclerosis
During 2nd trimester, a pregnant 38 y/o F has numbness in both hands, particularly thumb, forefinger, middle finger bilaterally. Dorsal part of hand unaffected. Arms aches in morning from shoulders to hands. Diagnosis:
Median neuropathy at the wrist
Mechanism of action of botulinum toxin at neuromuscular junction:
Inhibition of acetylcholine from presynaptic terminals
Benign intracranial HTN etiology:
Hypervitaminosis A
Fever, HA, seizures, confusion, stupor, and coma, evolving over several days. EEG with lateralized high-voltage sharp waves arising in the L temporal region, with slow wave complexes repeating at 2-3 second intervals. CT low-density lesion in L temporal lobe.
Herpes Simplex Encephalitis
Severe spasms and rigidity of limbs intermittently and later more persistent/continuous:
Antiglutamic and anidecarboxylase (anti-GAD) antibodies
Progressive weakness over several days – absent reflexes worse in lower extremities – slow conduction velocity, conduction block
Acute inflammatory polyneuropathy
Patient with pain behind the left ear progressing to numbness of the left side of the face, tearing of the left eye, discomfort with low frequency sounds, and left facial weakness on exam. Dx?***
Idiopathic Bells palsy
Stiffness of legs while walking and spasms of LE while sleeping. Stiff legged gait, adducts legs while walking. Increased LE tone/spastic catch, hyperactive knee jerks, ankle jerk clonus. Increased Romberg sway. ***
Cervical spondylosis
Upper motor neuron lesions have:
Weakness and spasticity
Pt c/o pain when walking that radiates from lower back and is severe in the calves. Pain relieved by stopping for a couple of minutes, then resuming. No sensory or motor deficits. Test most likely to yield Dx?
Vascular evaluation of lower extremities
Closed TBI, initially no LOC, then 20 minutes later LOC. Patient recovers in 5 minutes.
Vasovagal syncopal attack
81 y/o, 3 days fever, malaise and severe pain L ribcage. Red rash with clear vesicles overlaid in T5 dermatome. Causal agent:
Varicella Zoster Virus
58M truck driver w/ weakness/numbness of left hand
Ulnar neuropathy
Weakness of opponens of thumb and adduction of 4th, 5th digit, decreased sensation in 4th, 5th digits extending into palm and ending at crease of wrist, caused by
Ulnar nerve lesion
Severely sensitive, lancinating pain on the cheek
Trigeminal neuralgia
What condition is a forerunner of MS?
Transverse Myelitis
23 y/o develops tingling paresthesias in the lower extremities, followed several days later by progressive weakness, R>L. PE shows sensory level at T10 to pinprick, +3/5 weakness of LE, slightly weaker on R. Knee and ankle jerks are hyperactive, b/l babinski. Pt has difficulty walking with broad-based, stiff-legged gait. Dx?
Transverse myelitis
Severe jabbing pain, lasts few seconds, triggered by light touch on face
Tic douloureux
Irregular, unequal, small pupils nonreactive, do not dilate, but do constrict to accommodation
Syphilis
Most common symptom in narcoleptics
Sleep attacks
49 y/o with gradual hearing loss. A tuning fork used during the Weber test reveals a failure to lateralize, and the woman's perception of air conduction is better than that of bone conduction. She has trouble discriminating words “fat” “cat” “mat”. Dx?
Sensorineural hearing loss (b/l)
Which drug for the tx of parkinsonism has been associated with sudden sleep attacks?
Ropinirole
65 y/o M trouble falling asleep 2/2 unpleasant aching and drawing sensations in calves and thighs. Also creeping and crawling sensations in legs. Urge to move legs can be suppressed voluntarily for short while but is ultimately irresistible. Most likely dx is:
Restless Legs syndrome
Tremor decreasing with volitional movements and appears primarily in an attitude of repose:
Resting tremor
Gait abnormality, slow movement, asymmetric UE rigidity. Difficulty in voluntary vertical upward/downward gaze. Slowness/rigidity improved slightly with levodopa. Later has problems with horizontal&vertical gaze. Oculocephalic reflexes normal.
Progressive Supranuclear Palsy
Poor vertical eye movement, involuntary saccades
Progressive Supranuclear Palsy
Mucosal lesion that heals and then pt has pain in trigeminal nerve area
Post-herpetic Neuralgia
Unilateral foot drop with steppage gait indicates:
Peroneal nerve compression
49 y/o w/ DM2 presents with severe burning of soles of feet and insomnia b/c the touch of the sheet against the feet is painful. Exam shows decreased sensation to pin and touch up to ankle, 50% reduction in vibratory sense at ankle and impaired proprioception at toes. Ankle jerks are absent, but knee jerks present. Dx?
Peripheral neuropathy
14 year old after a demanding physical test becomes extremely weak and unable to stand. PE is positive for depressed DTR’s. Labs: K=2.8. h/o similar episodes after strenuous exercises. EKG: minimally prolonged PR, QRS, QT interval. Father and grandfather had similar episodes. Dx?
Periodic paralysis
Best pharmacologic tx for Restless Legs Syndrome?
Pergolide
Resting, non-intentional tremor
Parkinson’s disease
25 y/o female with L eye pain which increases with moving the eye. Diminished acuity in L eye, pupils constrict well with light on R eye, but only constrict weakly with light on L eye. Dx?
Optic neuritis
75 y/o WWII veteran w gradual onset forgetfulness, intellectual deterioration, fast/slurred speech, gait impaired, CT with normal atrophy. LP=35 WBCs (most lymph), protein 110, increased gamma globulin. Dx?
Neurosyphilis
Brief episodes of sudden loss of muscle tone, with intense emotion are characteristic of:
narcolepsy
Term for sudden, irrepressible shock-like contraction of a muscle triggered by an event in CNS?
Myoclonus
Neoplasms of the thymus are associated with:
Myasthenia Gravis
20 y/o occasional double vision when looking to R and normal acuity in each eye alone. L ptosis and difficulty keeping L eye adducted. Pupils round and reactive. Speech nasal and neck flexors weak. No paresis or reflex abnormalities in extremities. Dx?
Myasthenia Gravis
Female with vertigo and diplopia, when looks left has isolated L eye nystagmus, and cannot adduct R eye. Dx?
Multiple Sclerosis
41 y/o chronic fatigue, cognitive impairment, reduced perceptual motor speed, poor effort maintenance, and irritability (MRI shows hyperintensity in frontal lobe and what looks like a finger protrusion)
Multiple Sclerosis
Horner’s syndrome is characterized by?
Miosis, ptosis, & anhidrosis of forehead
DM patient with creeping paresthesias and burning pain in L anterolateral thigh. DTRs normal, no weakness. Dx?
Meralgia paresethetica
Recurrent deafness, tinnitus then vertigo
Meniere’s disease
22 year old with pain in the right hand that radiates into the forearm and bicep muscle. Paraesthesias in the palm of the hand, thumb, index, middle ring finger. Sensory systems in the ring finger split the ringer finger longitudinally. Dx?
Median nerve entrapment at the wrist.
Hippocampal atrophy has been identified in all of the following disorders:
Major depression, Alzheimer's disease, PTSD. (NOT dissociative amnesia)
Patient s/p surgery develops weakness and wasting of small muscles of the hand and sensory loss of the ulnar border of the hand and inner forearm. Dx?
Lower brachial plexus paralysis
Pt with double vision when looking to the left shows her eyes on primary gaze. On left gaze the right eye fails to adduct and there is nystagmus in the left eye. On right gaze and vertical gaze the eyes move normally. Dx?
Internuclear ophthalmoplegia
Which med reduces accumulation of plaques and disability in pt’s with relapsing remitting MS:
Interferon beta-1a
3 month progressive limb weakness L>R, problems swallowing. Normal CN, weakness in neck extensor muscles, in distal and proximal muscles (quadriceps, feet dorsal flexors, extensor pollicis longus) and in wrist/finger flexors. DTRs normal. Motor tone/coordination/gait normal. Elevated CK.
Inclusion Body Myositis
Spinal fluid of patient w/ acute inflammatory polyneuropathy shows:
High protein, normal cell count
49 year old develops seizure disorder that is difficult to control. CSF shows lymphocytic pleocytosis and many RBC’s. MRI shows T2 hyperintensity in the Left temporal lobe, with gadolinium enhancement in this area in T1 weighted image. EEG shows periodic discharges. Dx?
Herpes Simplex Encephalitis
Young adult w/ headache behind left ear. 2 days later twisting of face. Impaired taste sensation. Paralysis of forehead, lower face on left, incomplete closure of left eye w/ blinking. No sensory deficit or other cranial nerve deficit. MRI shows:
Gadolinium enhancement of left facial nerve
Treatment of Trigeminal Neuralgia:
Gabapentin
Electrophysiologic signs of denervation:
Fibrillation and positive sharp waves
Shaking hands, increased when using hands/writing/volitional activities. Stress worsens, wine improves. Is familial.
Essential tremor
Most common cause of aseptic meningitis:
Enteric virus
What does the cerebellum do in the human adult brain?
Diverse roles in movement, behavior, and learning
25 y/o male with 7 months of depression, forgetfulness, weight loss, insomnia, and painful tingling in both feet and incoordination. Involuntary choreic movements of BL UE, is apathetic and monosyllabic. Labs normal. EEG mild diffuse slowing. CT/MRI normal. During admission he develops severe akinetic mutism and seizures and dies. Brain autopsy shows:
diffuse amyloid plaques, spongiform neuronal degeneration, and severe astrogliosis
55 y/o with DM and HTN develops R periorbital pain and diplopia. Exam=paralysis of abduction of R eye.
Diabetic 6th nerve palsy
Orbital pain with L eye paralysis of adduction and elevation of the eye but normal pupil function. Dx?
Diabetic 3rd nerve palsy
25 y/o pt with pain in L periorbital region, followed by blurring then loss of vision in left eye. Exam normal but no reaction when light shone on L eye. This is consistent w:
Demyelinating lesion of L optic nerve
Seen in electrophysiologic testing in myasthenia gravis
Decremental response to repetitive stimulation
Involuntary set of flowing jerky movements in multiple joints describe:
chorea
34 y/o with persistent numbness in thumb/forefinger/middle finger/palm in the fourth month of pregnancy. Pain radiates to forearm, clumsiness and weakness with holding objects. Dx?
Carpal tunnel syndrome
Drug for trigeminal neuralgia (most effective in treatment)
carbamazepine
53 y/o with insidious onset of blurred vision, diplopia x1 day, ptosis, 6th nerve palsy, unreactive pupils, hoarse voice, dysarthria, weak neck muscles. EMG has increased amplitude with repetitive nerve stimulation. Dx?
Botulism
5 y/o cannot maintain eyes open, attempts to look at person/object results in tonic eyelid closure. Can watch television without difficulty. Extraocular movements normal. Dx?
Blepharospasm
Adult LP with opening pressure 190, protein 110, glucose 27, leukocytes 5,000. Dx?
Bacterial meningitis
Inability to carry out motor activites on verbal command despite intact comprehension & motor function indicates?
apraxia
55 y/o hx of weakness and clumsiness x several months. Difficulty w/ fine motor tasks. Arm muscles twitch and cramp easily, weakening, atrophy. Sensory, coordination, cranial nerve exams wnl. Underlying illness affects neuronal bodies where?
Anterior horn of spinal cord, medial brainstem and cortex
45 year old with gradual progressive weakness over the past 3-4 months, particularly in the LUE.
Amyotrophic lateral sclerosis
Atrophy of the intrinsic muscles of the right arm and forearm. Reflexes are generally brisk, plantar reflexes are extensor. Electrophysiology shows widespread fasciculations, fibrillation and sharp waves. Dx?
Amyotrophic lateral sclerosis
Gradually progressive weakness of legs and dysarthria over months – fasciculations of tongue – prominent left upper extremity weakness – muscle spasticity – brisk reflexes – normal sensation
Amyotrophic lateral sclerosis
Fasciculations, fibrillations, positive sharp waves on EMG + progressive weakness over several weeks
Amyotrophic lateral sclerosis
Young pt recovering from flew-like illness w/ progressive weakness and numbness of legs and feet. Weakness and numbness below middle of thorax. Increased LE DTR’s, extensor plantar reflexes. Urinary incontinence. LP 23 mononuclear cells, protein level 37, nml glucose
Acute transverse myelitis
Weakness in limbs 2 weeks after a viral gastroenteritis. Weakness in UE/LE, absent DTRs. Spinal fluid shows no cells and elevated protein.
Acute inflammatory polyneuropathy
Essential criterion for the declaration of brain death prior to organ donation requires?
A positive apnea test
41 y/o without family h/o corticocerebellar degeneration presents with 3-month h/o ataxia of gait/limbs, dysarthria, and progressive nystagmus. MRI and CSF normal. 1) Antibody panel with presence of ? 2) What type of tumor is likely present?
1) anti-Yo 2) Ovarian Carcinoma
Where are the major clusters of cell bodies containing serotonin in brain?
Raphe nucleus in brain stem
DA release in which structure represents a common final event associated with the reinforcing effects of opiates, cocaine, amphetamines, nicotine, PCP, and alcohol?
Nucleus Accumbens
What neurotransmitters has been associated with anxiety?
Norepinephrine
Positive allosteric modulators of neurotransmitter-gated, multimeric ion channels do what?
Increase probability of opening in presence of a ligand.
What area of the body has the most serotonin?
GI tract
Neurotransmitter assoc w/ reward & reinforcement in nicotine dependence
Dopamine
Neuroimaging that measures neuronal glucose metabolism
PET scan
CT scan is better then MRI for what?
Differentiating hemorrhaging from edema.
What does functional MRI measure?
Detects blood flow
5 y/o with screaming/crying for no reason about 1 hour after falling asleep. Sits up in bed with eyes open, trembling, sweating, mother cannot gain his attention for 5 minutes. No new stressors. Boy has no memory of the event. PE normal. Dx?
Sleep-terror episode
Paralysis when awakening, lasts several minutes. Can see/hear but cannot move during episodes. Disappears spontaneously or when called by his wife. No hallucinations, nightmares, daytime sleepiness or h/o falls. Neuro exam normal.
Sleep paralysis
MDD has what sleep abnormality?
Shortened REM latency, decreased stage 4 sleep, increased awakenings in the second half of the night
REM sleep behavior disorder associated with which pathology:
Parkinson’s disease
Involuntary jerking of legs while falling asleep, not uncomfortable, stops with falling asleep
Normal phenomenon, nonpathological
Age-related sleep pattern change
Greater wakefulness intermixed with sleep
Predominantly non-REM sleep problem
Enuresis
What aspect of sleep is increased in older adults?
Duration of awakenings
Sinusoidal waves at 9-11 Hz on EEG is:
Deep sleep
67 y/o with MDD doing well on SSRI but continues to have insomnia and sleepiness during day. Snores loudly, morning headaches, and night sweats. Dx?
Breathing-related sleep disorder
32 y/o with no psychiatric history brought to ER with 2 days of memory loss, insomnia, poor appetite, and difficulty performing daily routines. One week earlier pt witnessed her child being fatally injured in a motor vehicle accident. All labs and scans normal. What diagnosis is likely?
Acute stress d/o
Adult in MVA, no head trauma. Anxious, numb, detached, impaired memory for accident
Acute stress d/o
What symptom is more likely to occur in acute stress d/o than in PTSD?
Reduction in awareness of surroundings
Acute stress d/o differentiated from PTSD by
Duration of sx’s
A 7 y/o child BIB parents report he’s been hyperactive since age 4, talks constantly, interrupts, has trouble sitting still to do homework, will not play quietly outdoors. What else do you need to make the dx of ADHD?
Teacher report
Child w ADHD ineffective tx with methylphenidate. Next step in management:
Dextroamphetamine
The multimodal tx study of children w/ ADHD examined the comparative responses over 14 months of children to medication and intense psychosocial interventions. What did the findings of the study reveal w/ respect to ADHD symptom changes?
Medication management superior to community care treatment
Current thinking about relationship between ADHD in children and adults:
Significant number of children will go on to become adults with ADHD
Abnormal LFTs would be most commonly associated w/ what medication used to treat ADHD in children/adol?
Pemoline
8 y/o boy with ADHD, oppositional defiant disorder, and chronic motor tic disorder has worsening of his tics on a good dose of a stimulant that seems to control his ADHD. How do you manage this further in trying to improve the tics?
Monitor the tics only
Which med would you prescribe for 20 y/o college student being worried over his grades? He complains that he has not been able to focus on studying and that his mind wanders frequently during classes. His energy level is low. He sleeps well and his appetite is good. History indicates he was treated with stimulants since second grade.
Methylphenidate
32 y/o w/ ADHD mixed type as child. As adult still has symptoms. Tx:
Methylphenidate
Which psychiatric disorders is co morbid with ADHD?
Disruptive behavior disorders
ADHD comorbid disorder
Depression
These empirical non-stimulant meds have empirical support to treat ADHD:
clonidine, bupropion, imipramine, atomoxetine
What procedure is necessary to diagnose childhood ADHD?
Clinical interview of parents and child
Antidepressant for ADHD
Buproprion
Studies show effective intervention for children with ADHD is to involve their parents in what part of tx?
Behavioral management
What med used for ADHD has been associated with liver damage?
Atomoxetine (Strattera)
Failing grades, poor organization, spending sprees, spontaneous trips ditching class, fidgety, euthymic. No change in sleep, appetite, no anhedonia. Dx?
ADHD
Differential Dx of anxiety in the ER typically includes
Pulmonary Embolism
Treatment for severe performance anxiety
Propranolol
36 y/o with several episodes of palpitations, sweating, trembling, SOB. Work suffering due to anxiety. Initial tx regimen:
Paroxetine and CBT
Weight loss, 3-month hx of anxiety, mild depression, & insomnia, thin, elevated HR, low BP, mild tremor
Hyperthyroidism
Prevalence of separation anxiety d/o and GAD in children follows what pattern with regard to age?
GAD increases/Sep anxiety decreases with age
18 y/o restless, feels mind going blank, poor concentration, irritability, insomnia, fatigue > 1 yr, used to be good student up until 2-3 yrs ago, no substance use
GAD
Core feature of GAD
Excessive worrying
35 y/o truck driver dx’ed w/ GAD. Does not want med that causes sleepiness
Buspar
What predicts bipolarity in adolescent with depression?
Psychotic symptoms
Which med is treatment of choice for bipolar with rapid cycling?
Valproate
Bipolar pt w/ 2 hospitalizations for mania taking lithium
Needs lifetime lithium tx
First-degree relatives of patient with BMD II have a higher incidence of what disorder?
MDD
What drug is good for acute mania?
Lithium
32 y/o with diarrhea x2 weeks, is anxious, and not oriented to date/time of day. Taking “some drug” for BMD and patient doubled her dose a month ago when she felt she wasn’t getting better fast enough. What med caused these sx?
Lithium
BMD II with rapid cycling have higher prevalence of what endocrinologic dysfunction?
Hypothyroidism
What symptoms are seen in a manic episode but not in MDE?
Flight of ideas
Suggest underlying bipolar in 27 y/o female who presents w/ first major depressive episode
Family hx of bipolar
Tx of acute mania w/ lithium. What is the best adjunctive agent?
ECT
Bipolar w/ 4+ manic episodes / yr for 3 years. Treatment of choice?
Carbamazepine, 1200 mg daily
40 y/o w/ 6 kids: insomnia, poor appetite, dizziness/nausea, thinks husband is poisoning her. Despite all classes of meds marked fluctuations from sadness to euphoria 5x during the year. Dx?
Bipolar w/ rapid cycling
DSM-IV defines h/o major depression plus h/o mixed manic and depressive episode as:
Bipolar disorder, type I
Marked fluctuations of mood from sadness to euphoria five times over course of one year. Paranoid delusion that husband is trying to kill her. Which diagnosis likely:
Bipolar disorder w/ rapid cycling
Hx of MDD, irritable, restless, distractible, insomnia, poor appetite, guilt, impulsive spending
Bipolar d/o, mixed
Term for unreasonable and sustained belief that patient acknowledges may not be true when challenged
Overvalued idea
Length of time criteria for delusional d/o
One month
Body dysmorphic d/o vs. Delusional d/o somatic type:
Intensity with which pt insists on perceived body deficits
Complaints of skin infection with insects, neg med w/u
Delusional d/o, somatic type
Normal M except is paranoid about wife cheating on him
Delusional d/o
Patient believes he is the Son of God. This sx is called:
Delusion
60 y/o w/ depressive syndrome has memory problems. Incorrect on date, messes up serial sevens, spells backwards, but slowly. After 4 wks of trazadone, both mood and cognition are improved. Dx?
Pseudodementia
Which depressive symptom is a melancholic feature specifier in DSM-IV?
Lack of pleasure
Depression increases risk of mortality from what dz?
Ischemic heart disease
Hepatitis C treatment with interferon can cause what psychiatric symptom?
Depression
An important distinction between depressive symptoms in patients with cancer as compared to those patients with depression but no cancer is that the patients with cancer?
Usually maintain intact self esteem
WHO study 1990, what is 2nd worldwide leading source of years of healthy life lost to premature death/disability (#1 is ischemic heart disease):
Unipolar Major Depression
17 y/o with depressed mood, low self esteem and poor concentration possibly has dysthymia. Which feature would support the dx?
Sxs > 1 year
10 y/o child with 2-month h/o irritability, inattention, sleep disturbance, and withdrawal. Child attempted to run in front of a car. No family h/o psychiatric d/o. On examination, no eye contact and has psychomotor agitation. What medication should treat?
SSRI
Compared to older adolescents with depression, 8-12 year-olds w/ depression most often show what?
Somatic complaints
27 y/o M seen in ED c/o insomnia, hopelessness, anorexia, decreased concentration for 2 weeks and is now acutely suicidal. Pt has h/o ETOH use daily for the past 3 months. What is the most likely Dx?
SIMD
First-line tx for 9y/o w/ depression
Sertraline
Women at highest risk of MDD during:
Reproductive years
M w/ HTN and MI, has stressors and depression, tx?
Relaxation Training
Pancreatic cancer patient just diagnosed, tells nurses he wishes he was dead. Distant with psychiatrist. Several month hx of depressive sx’s, no support system. “The only family at home is my gun”
Place on suicide precautions
An effective antidepressant for depression w/ atypical features is
phenelzine
Child must have depressed or irritable mood for what length of time in order to meet criteria for dysthymic do?
One year
Dexamethasone suppression test for diagnosing mood disorders:
Not useful in routine clinical practice
50 y/o individual with depression believe he is responsible for the destruction of the world. This is an example:
Mood-congruent delusion
Depressed pt believes responsible for destruction of world
Mood-congruent delusion
61 y/o with left frontal lobe damage secondary to cerebrovascular accident may be predisposed to which psychiatric syndrome?
MDD
9 y/o with increased irritability and aggression for 3 mo. Used to be easygoing. Grades dropping. No insomnia or poor appetite. AH of voice telling him he is bad.
MDD
60 y/o with depression & paranoia treated with 50mg Zoloft and 6mg risperidone. On follow up pt c/o slow thinking & excessive salvation. On PE masked faces and cogwheel rigidity present. Mood and paranoia have greatly improved. What is the next step?
Lower Dose of Antipsychotic Meds.
What is a characteristic of atypical depression?
Leaden paralysis
Major depressive episode in children presents as:
Irritability
What medications may cause mood d/o in pts being treated for melanoma?
Interferon
Fatigue, depression, and cognitive inefficiency are worsened by what medication?
Interferon
77 yr F whose husband died 6 wks ago complains about the length of time it took for the dress. She sounds irritable, looks fatigued. “I can't accept he is gone…. I should have been able to save him”. She says “When the real darkness descends on me specially in the middle of the night I don’t want to call anyone." What is more indicative of MDD rather than uncomplicated bereavement
Having thoughts of suicide
Treatment of Adolescent Depression Study showed what modality to be best treatment of depression?
Fluoxetine and CBT
Cognitive triad of depression: negative self-perception, experience the world as self-defeating, AND?
Expectation of continued failure
What augmentation strategies for treatment-refractory depression has shown the highest efficacy and replicability?
Electroconvulsive therapy (ECT)
Tx for worsening depression, severely weight loss, dehydration, catatonia
Electroconvulsive therapy (ECT)
Depression, according to Beck's model is a manifestation of:
Distorted negative thoughts
Which disease is most likely to present as pain disorder
Depression
34 yr woman presents “unable to reach her potential” with mood switches frequently (day to day and sometimes within one day) from mildly to moderately. Depressed to happy in the morning. No episodes meeting criteria for mania. Hx suggests most likely dx?
Cyclothymic disorder
Pt w/ unipolar depression has had 3 recurrence of depression each separated by 1 yr, after successful treatment w/ imipramine 200 mg qd. Which prophylactic treatment should be recommended:
Continue imipramine 200 mg x 5yrs
Suicidal thoughts, constant worrying, feels depressed, guilt, lacks energy, hypersomnia, feels ineffective at work. Tx?
Consider tx w/ antidepressant
Prophylactic Treatment for a pt with severe delusional depression following a course of ECT includes what?
Combination of antipsychotics and antidepressants
Beck says primary defect in depression
Cognitive distortion
Presence/severity of depressive sx in MS is correlated with:
Cerebral involvement
29 y/o M h/o recurrent depression & 1.5 PPD smoking. Medication?
Bupropion
8 days after hip surgery a 75 W has episodes of disorientation, sleeplessness, and crying especially at night. Also little frogs in her room. In mid morning she is ok. Was dx w/ MDD several months ago and taking doxepin 25 mg tid and diazepam 5 mg tid were d/c before surgery. Currently on meperidine, diphenhydramine. The recent confusion is NOT caused by
Atypical depressive disorder
Melancholia is characterized
anhedonia
Pt whose spouse had left 5 days before reports sleep problems, loss of appetite, poor concentration, loss of energy, anhedonia, sadness, despair, SI. Functioning fine until spouse left. Dx?
Adjustment d/o with depressed mood
35 y/o pt presents with severe depression with episodes of anxiety for 9 months that have become so bad he can no longer leave the house, has severe weight loss, hyperpigmentation of exposed skin, and cold tolerance. Dx?
Addison’s disease
How many symptom-free weeks must be between two episodes of depression for them to be considered separate and therefore recurrent according to DSM-IV?
8 symptom free weeks
Focused attention and altered consciousness usually seen in pts with dissociative disorders is called
Trance
Whenever the culture of western med has been a focus of inquiry by anthropologists, what diagnoses has been seen as a culture bound syndrome in north America?
Dissociative identity do
Patient with memory lapses, talks like an adult at times then like a scared child at other times. Dx?
Dissociative identity disorder
Psychiatrist asks, “Do you find things in your possession that you cannot explain?” Trying to elicit:
Dissociation
Detachment of emotional component from perception
Derealization
20 y/o in MVA, no injuries – speaks softly, feels calm, dim vision, mechanical movements, feels detached
Depersonalization
Pts that “cut” as a form of self-mutilation typically _.
Claim to feel no pain
The primary focus of behavior therapy in the treatment of anorexia nervosa is to
Restore weight
Dehydrated bulimic w/ BP 100/60 and orthostasis HR 60. Stat lab test:
Potassium
Abdominal pain, diarrhea, hypokalemia, weight loss, steatorrhea, skin pigmentation. Possible laxative abuse. Measure:
Phenolphthalein
Complication of anorexia nervosa least likely to resolve after restoring weight is?
Osteoperosis
Bulimia comorbid with
MDD
What electrolyte abnormality is most seen in bulimics?
Hypochloremic alkalosis with hypokalemia
In overcoming the resistance to treatment often encountered with patients who have anorexia nervosa, what is it most useful for the psychiatrist to emphasize?
Emphasize how treatment will allow the patient to focus energy on other matters.
What metabolic abnormality is commonly found in pts with anorexia nervosa, purging subtype?
Decreased serum potassium
Bulimia and depression. Contraindicated:
Bupropion
What test findings are associated with anorexia and bulimia?
Bradycardia, amenorrhea, hypokalemia, and elevated serum amylase
Bulimia nervosa presents in which personality d/o?
Borderline
Which enzymes can be increased in serum of pt’s with bulimia:
Amylase
Anorexia dx requires wt below what percentage of normal wt
85 percent
At 30 years after presentation for treatment, mortality rates for anorexia nervosa are:
0.2
What factor differentiates malingering from factitious disorder?
Having external incentive
Psychiatrist is evaluating frequent liar. Pt's lies are grandiose and extreme, Pt appears to believe the stories. This is called
Pseudologia fantastica
25 y/o prisoner claiming to be depressed is hospitalized after he swallowed some razor blades. Razor blades were carefully wrapped with surgical tape before swallowing. Confesses he wanted some time out of prison. Dx?
Factitious disorder
What condition shows motivation to assume the sick role?
Factitious disorder
24 y/o M seen in ED with chest pain claims to have a rare connective tissue d/o and said he required a recent heart transplant due to aorta dissection. He provides the MD with a list of immunosuppressive meds and requests that a transesophageal echo be done. He has no sternotomy scar and outside records indicate his story is false. Is this likely factitious d/o or malingering?
Factitious d/o (malingerers usually avoid invasive tests)
What is a very common impulse control d/o NOS?
Pathologic gambling
Comorbid condition w/ pathological gambling
Major depression
Pathological gambling in what grouping
Impulse Control d/o
Hx of OCD, Zoloft only partially effective. Next:
Try another SSRI
A genetic susceptibility for OCD is suggested by evidence that there is a familial link with
Tic disorders
Anterior capsulotomy and/or cingulotomy are indicated and demonstrated effective for pts with what severe incapacitating disorder?
OCD
Which condition is least likely to respond to hypnosis?
OCD
Persistently intrusive inappropriate idea, thought, impulse, or image that causes marked distress is
Obsession
Obsessive-compulsive symptoms are characterized by which defense mechanism?
Isolation and undoing
What infectious agent can exacerbate or cause initial manifestation of OCD in children?
Group A beta-hemolytic streptococcus
M obsesses about killing his g/f. Instead of killing, picks his face w/ a pin. Medication
Fluvoxamine
Patient with contamination fears and hand washing rituals is treated with response prevention combined with:
Exposure therapy
Principal behavioral technique for OCD
Exposure & response prevention
Repetitive behaviors that the pt feels impelled to perform ritualistically, while recognizing the irrationality and absurdity of the behaviors, describes:
Compulsions
25 y/o with OCD diagnosed 2 years ago is likely to benefit from what medicine (in addition to psychotherapy)?
Clomipramine
35M w/ severe OCD, failed multiple meds, CBT and ECT, what next?
Cingulotomy
Patient presents to PMD thinking he has contracted infectious disease. Constant worrying, interferes with work, repetitively counts to 100 to distract from worry. No drug or past psych/med hx. What section on PET will have increased activity?
Caudate
Pediatric Autoimmune Disorder Associated with Streptococcus (PANDAS) is associated with what disorder?
OCD
Children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) often manifest:
Choreiform movements and OCD symptoms
What is the principle goal of the cognitive-behavioral therapy of panic d/o?
Using restructured interpretation of disturbing sensations
Hyperthyroidism should be ruled out as part of the DDx of what psychiatric d/o’s
Panic d/o
Which clinical feature distinguishes panic disorder from pheochromocytoma?
Anticipatory anxiety (in panic d/o)
Panic attack reaches peak in
A few minutes
Once it becomes effective, pharmacological tx of pts with panic d/o should generally continue for what length of time?
8-12 mos
Diagnosis for child w/ behavioral inhibition
Social Phobia
10 y/o is seen in outpt clinic w/ hx of extreme fear of using the bathroom at school. He states to be afraid that other children will laugh if they hear or smell him in the bathroom. Dx?
Social phobia
Avoids interpersonal situations due to anxiety and panic attacks
Social phobia
28 y/o M episodic anxiety, palpitations, flushing, shaking, chest tightness. Mostly at work or w/ group of friends. Embarrassed, afraid to go to work, avoiding people
Social phobia
Principle aim of treatment of child with school phobia is:
Return child to school
Most effective approach in behavioral treatment of phobias:
In-vivo exposure
What symptom commonly develops relatively late in children with PTSD?
Sense of foreshortened future
12 y/o disclosed to counselor hx of sexual abuse by relative. Report made to authorities. During eval, pt reports anxiety, inability to concentrate due to thinking about event, irritability, sleep problems, crying frequently. Grades have fallen significantly in period after abuse began and peer relations have suffered as well. Dx?
PTSD
10 y/o fearful, poor sleep, repetitive play. Hears indistinct voices saying name
PTSD
30 y/o impulse to cut, anxious, social phobia, dissociation. No psychotic sx’s. Flashbacks of childhood abuse.
PTSD
38 y/o lost leg in accident 1 mo ago. Insomnia, nightmares, intrusive thoughts
PTSD
Sx for F 2 months after traumatic experience
Increased arousal and intrusive thoughts
Schneiderian first-rank symptom of schizophrenia:
Hearing voices arguing about oneself
What factor is a good prognostic indicator in schizophrenia?
Female gender
Successful psychosocial interventions in schizophrenics:
Assertive community treatment
16 y/o boy treated as outpatient for Schizophrenia after recent inpatient first break. Parents concerned re: anhedonia, withdrawn. No psychosis. Goal of outpatient eval:
Address patient’s feelings of depression and screen for SI
Late-onset schizophrenia is more common in men or women?
women
44 y/o pt with schizophrenia is admitted to an inpatient psychiatric unit. After several days pt has muscle tremor, ataxia, twitching, diarrhea, restlessness, vomiting, polyuria, and stupor. Dx?
Water intoxication
Dysprosody is an abnormality of
Speech
What is a negative sx of schizophrenia?
Social inattentiveness
20 y/o avoids everyone but parents. Stopped going to school. Feels everyone watching him. Always quiet, sits at home doing nothing, mumbles to self, some bizarre movements, flat affect. Denies depression or substance use.
Schizophreniform
Characterizes schizophrenics that smoke
Require more neuroleptic med
29 y/o 1 wk euphoria, insomnia, pressured speech, grandiose. Delusions, AH. Need what else for dx schizoaffective d/o
Psychotic sx’s x 2 wks in absence of mood sx’s
Subtype of schizophrenia less severe and starts older
Paranoid
Most closely correlates w/ social fx in schizophrenics:
Negative symptoms
Communication d/o assoc w/ neurological and psych d/o
Mutism
28F mute, rigid, catatonic. Not on meds. What tx?
Lorazepam
What condition in patients with schizophrenic or schizophreniform psychosis is associated with poor prognosis?
Initial onset during adolescence
Most common eye tracking movement abnormality in pts with schizophrenia?
Inappropriate saccades (saccadic intrusions)
No additional criterion A symptoms are required for the diagnosis of schizophrenia if the patient has which symptom?
Hallucinations of two or more voices conversing
What is the term for senseless repetition in schizophrenics?
Echolalia
What is associated with poor prognosis in schizophrenics?
Early age onset, negative symptoms, lack of precipitating factors
Schizophreniform disorder differs from schizophrenia primarily in
Duration
Schizophrenic with poor response to 3 trials of antipsychotic meds, next step?
Crossover to clozapine
What are the characteristics of childhood-onset schizophrenia?
Chronic course, unfavorable prognosis, hallucinations, delusions
Schizophrenic on haldol 10 develops acute EPS. Cause?
Cessation of smoking
Schizophrenic stabilized on haldol 10. Return of psychotic sx’s after starting med for another condition. Cause?
Carbamazepine
Identical-appearing imposter has replaced Dad
Capgra’s syndrome
Schizophrenic with VH, restlessness, marked thirst, agitation, elevated temperature, dilated pupils, dry skin. Dx?
Anticholinergic intoxication
Poverty of speech and content are
Alogia
Good prognostic feature in schizophrenia
Acute onset
Preoccupation and fear of having contracted serious disease based on misinterpretation of bodily sxs despite medical eval and reassurance
Hypochondriasis
25 y/o referred by plastic surgeon, claims that part of her face is swollen
Body dysmorphic disorder
Multiplicity of complaints, multiple organ systems
Somatization d/o
What is commonly associated with conversion d/o?
Low intelligence
Somatic sx/complaint, negative medical workup, negative psych eval
Look again for organic etiology
Main clinical factor of hypochondriasis vs. somatization d/o?
Fear of having a disease
24 y/o w/ sudden onset stumbling and pain in legs, negative neuro workup – saw a counselor previously for protracted grief after father’s death – increased conflict with husband
Conversion
What symptoms are most commonly associated with Tourette’s syndrome?
Obsessions and compulsions
Pathologic findings in brain of Tourette’s?
No abnormality
What antipsychotic medication is helpful in treating Tourette’s?
Haloperidol
which med is helpful in Tourette Syndrome who can't tolerate clonidine?
Guanfacine
One of the earliest sx of Tourette’s:
Eye-blinking and head jerking
Comorbid condition w/ Tourette’s in kids:
ADHD
Which disorder has greatest co-incidence of alcohol abuse and dependence?
Antisocial personality disorder
Which personality d/o should be considered in diff dx of cyclothymic d/o?
Histrionic
Which intervention is helpful in dealing with a borderline pt on a medical ward?
Setting firm limits with the pt on the structure of the medical care
What is useful information to confirm diagnosis of antisocial personality d/o (APD) in 20 y/o patient?
School counseling records
Saccadic smooth pursuit eye movements are more frequent in which personality disorder?
Schizotypal
40 y/o M, emotional detachment, little interest in sex, no close friends. What DSM IV Axis II Dx?
Schizoid PD
Common symptoms of paranoid personality disorder
Preoccupation w/ unjustified doubts of loyalty/trustworthiness of friends/associates
20 yr man with poor performance in college, before was very good student except for not been able to finish assigned projects at college. Classmates have described bizarre behavior, such counting loudly or repeating words silently. He does not want to follow others rules but his owns, he believes nobody understands him and are against him. Most likely dx?
Obsessive Compulsive personality disorder
Patient with body dysmorphic d/o may have what personality d/o?
Narcissistic
Which personality disorder is characterized by a style of speech that is excessively impressionistic and lacking in detail?
Histrionic
What personality disorder results in displays of rapidly shifting and shallow expression of emotions in patients?
Histrionic
22 y/o borderline splitting inpatient staff. You should:
Educate staff about splitting
Avoidant PD differs from Schizoid PD by:
Desire for social relationships
DDx of histrionic personality disorder includes what other personality d/o?
Dependent personality disorder
Which personality d/o should be in the dif dx of agarophobia
Dependent personality disorder
23M w/ Borderline. Had fight w/ g/f now psychotic, cutting, AH w/ command to harm self. What level of care
Brief Inpatient Hospitalization
Which personality d/o has chronic feelings of emptiness?
Borderline
Personality d/o w/ transient psychotic symptoms
Borderline
22 y/o M w/ self-mutilation, depression, stress-related paranoia. Dx?
Borderline
29 y/o w/ rapid mood swings minutes to hours. +impulsivity, tumultuous relationships, poor self-image, occasional cocaine. Brief paranoia and AH after a break-up. Constant SI, cutting
Borderline
Pts w/ this personality d/o most likely to have 1st degree relatives with depression
Borderline
Pts with which personality d/o sees themselves socially inept, personally unappealing, or inferior to others?
Avoidant
What personality disorders should be the main consideration in differential Dx of schizotypal personality disorder?
Avoidant
50 y/o w/ ETOH dependence admitted to ER for confusion, oculomotor disturbances, ataxia, and dysarthria. First step in acute management is…
Thiamine
What is the function of Al-anon
Helps relatives cope with alcoholics drinking
Evidence that alcoholism is hereditary
Adopted Siblings
Fetal alcohol syndrome associated with:***
Fetal Alcoholism is associated with facial dysmorphisms, postnatal growth retardation, intrauterine growth retardation and learning difficulties.
CAGE ***
Cut down, Annoyed, Guilty, Eye opener
Unsteady gait, appendicular ataxia in LE only and normal eye movement. Walks with lurching broad-based gait. *****
cerebellar degeneration (alcoholic)
Can alcohol fumes at work (brewery) cause a pt on disulfiram headaches?
Yes
Sixth cranial nerve palsy is associated with which alcohol-related syndrome?
Wernicke’s encephalopathy
In ER following MVA, receives IV dextrose 5%. Experiences confusion, oculomotor paralysis, and dysarthria
Wernicke’s encephalopathy
Tests for detecting excessive drinking
Triglycerides, MCV, SGGT, SGOT
Pattern of drinking in women alcoholics (as opposed to males):
Solitary drinking
Which complication of heavy EtOH use likely to persist beyond first week of withdrawal?
Sleep fragmentation
What is the principle problem with disulfiram in the treatment of alcoholics?
Patient can stop taking it and resume drinking
Verbally and physically aggressive after a small amount of ETOH. What is dx?
Pathological intoxication
Wernicke’s dz triad
Ophthalmoplegia, ataxia, global confusion
Drinking ETOH while taking disulfiram is most likely to produce what symptoms?
Nausea and vomiting
Alcohol on disulfiram reports alcohol cravings. What drug will likely decrease these?
Naltrexone
Lab elevated in alcoholics
MCV
Equal dose of alcohol corrected for body weight lead to higher BAL in woman than me.. Why?
Lower levels of alcohol dehydrogenase in gastric mucosa
Avoid which drug in patient intoxicated with alcohol or a sedative drug?
Lorazepam
Characteristic of Cloninger’s type 1 alcoholism
Late onset
Individual psychotherapy for alcoholics is most effective when focusing on?
Interactions with people
What is the most serious complication for a pt who ingests ETOH while on disulfiram.
Hypotension
Alcoholic, AH on and off alcohol, extreme agitation. During withdrawal give benzo plus
Haldol
What is decreased with heavy ETOH intake
Glucose
Alcohol intoxication causes what sleep abnormalities
Fragmentation of stage 4 sleep
Characteristic of female as opposed to male alcoholics
Faster progression of disorder
60 y/o alcoholic with 4 day h/o unstructured, maligning AH and clear sensorium. Dx?
ETOH-induced psychotic d/o
Comorbid disorder in men with PTSD
ETOH abuse/dependence
What is a side effect of both naltrexone and disulfiram?
Elevated LFTs
A 25 y/o pt has been dx'd with ETOH dependence. Pt has neither had ETOH to drink nor met any of the criteria for alcohol dependence in the past 6 mos. What remission specifiers would apply to the dx of ETOH dependence?
Early full remission
Individuals who consume ETOH at night usually develop:
Decreased sleep latency
In comparison to men, woman who abuse EtOH are more likely to also have…
Axis I diagnosis
An idiosyncratic, physiologic rxn to ETOH including rash, nausea, tachycardia, and hypotension occurs in what ethnic group?
Asians
Alcohol abuse in men is commonly associated with what comorbid mental disorder?
Antisocial personality
Characteristic of alcohol-induced blackouts
Anterograde amnesia for time while heavily intoxicated but awake
Priority of treatment: Marital problems, Depression, vs. Alcoholism.
Alcoholism detox and abstinence
Pts over 65 who experience chronic insomnia are most likely to have what comorbid psych conditions
Alcohol abuse
Primary characteristic of Wernicke encephalopathy
Acute onset
Alcoholic hallucinosis differs from DTs in that alcoholic hallucinosis is characterized by what?
A clear sensorium
Eval of which lab test is most specific for chronic heavy alcohol consumption
%CDT Percent Carbohydrate deficient transferring
Motivational interviewing is often used as part of the treatment of which conditions?
Substance abuse
After Cannabis ingestion (in chronic use) cannabis can be detected in urine how long?
One Month
What is NOT likely to be an effective intervention for a physician with a substance abuse problem?
Observing the physician until the physician becomes motivated to seek treatment
Which drug causes euphoria, a feeling like “flying above the dance floor”, social withdrawal, nystagmus?
Ketamine
Acute caffeine withdrawal symptoms include:
Headache
What does the pentobarbital challenge test do?
Estimates the starting dose of pentobarbital used for barbiturate detoxification
Person who smokes a pack of cig/day stops smoking and has need for cig after every meal. This is…
Environmental trigger
Tachycardia, HTN, excessive perspiration, pupils dilated in college student after attending a party. Drug?
Cocaine
What drug is used to treat autonomic sxs associated with heroin withdrawal?
Clonidine
22 y/o female confused, disoriented, dry mouth, dilated unresponsive pupils. Likely ingested:
Benztropine
Motivational interviewing of patients with addictive disorders addresses what?
Ambivalence about becoming drug free
Maximum duration of PCP in the urine:
8 days
Maximum time cocaine metabolites detectable in urine?
4 Days
What is perceptual abnormality in which hallucinogenic drugs cause moving objects to appear as a series of discrete and discontinuous images?
Trailing
Most often abused hallucinogens associated with
Tolerance to euphoric effects
What technique may be dangerous in managing patient with PCP intoxication?
Talking the patient down
While intoxicated, “seeing sounds” and “patterns of colors” associated w/ actual auditory stimuli
Synesthesia
For polysubstance dependence need criteria for:
Substances as a group, but not for any particular substance
How should Buprenorphine and the buprenorphine/nalaxone combo be administered?
Sublingually
Prolonged ingestion of high doses pyridoxine causes:
Subacute sensory neuropathy
Most common cause of organic paranoid symptom
Stimulant abuse
Physostigmine is useful in treating toxic syndrome from overdose with:
scopolamine
Which dx criteria helps to establish dx of substance dependence vs. abuse?
Recurrent unsuccessful efforts to control use
15 y/o is found unresponsive by parents after pt returns from a party, friend confirms pt used heroin. What are signs?
Pupillary constriction
After OD pt has fever, confusion, tachycardia, dry mouth, urinary retention, dilated and unresponsive pupils. Which medication would treat this?
Physostigmine
What medication treats anticholinergic toxicity?
Physostigmine
Naltrexone prevents relapse of opioid dependency most effectively in which group?
physicians
Ataxia, nystagmus, muscular rigidity, normal or small pupils suggests intoxication with what?
PCP
Tx of pts w/ substance abuse who have acute pain
Patient-controlled analgesia
Abstinence compliance increases with random UDS. This is an example of:
Partial reinforcement
What terms best describes buprenorphine's action at the mu opioid receptor?
Partial agonist
UDS performed on pt who eats poppy seed bagels may yield false positives for?
Opiates
Area of brain associated w/ reward effects of cocaine
Nucleus accumbens
At what receptors does phencyclidine's major action occur?
n-methyl-d-aspartate acid (NMDA)
What is the most commonly abused substance among patients with schizophrenia?
Nicotine
Check for residual physical dependence of opiates by administering:
naloxone
Pt took 20 500mg acetaminophen tabs 6 hours ago. Pt is 52kg, pulse 96, BP 135/65. Pt alert and in NAD. Serum acetaminophen level is 60 uG/ml. Liver fxn test are minimally elevated. Most appropriate action?
N-acetyl-cysteine
Causes long-term inhibition of new serotonin synthesis and decrease in serotonin terminal density
Methylenedioxymethamphetamine (MDMA)
Lab to get prior to starting naltrexone
LFT’s
9 y/o child with apathy, decreased appetite, irritability, dizziness, confusion, ataxia, and HA. Recently moved to older house in an industrial city. Which lab test helpful for dx?
Lead serum levels
Dissociative compound, sense of fragmentation and detachment during intoxication
Ketamine
Common cause of acute cerebellar ataxia in adults
Intoxication with antiepileptics
Abrupt withdrawal of nicotine is followed by what symptom?
Insomnia
What substance can cause dementia w/ long-term use
Inhalants
16 year-old adolescent with burns to the face 2/2 playing with a spray paint can that ignited. Grades dropped from A’s to F’s. The mother is concerned about hearing problems. No other health problems. Dx?
Inhalant abuse
What symptoms of nicotine withdrawal may persist in a patient for up to 6mos?
Increased appetite
In treatment of recovering addict, rehearsal strategies help with what?
Identifying internal high-risk relapse factors
Symptom of cocaine withdrawal
Hypersomnolence
Speedball
Heroin and cocaine
Miosis (pupillary constriction) due to OD on:
Heroin
Methadone prescription in heroin dependence is called what kind of strategy?
Harm reduction
Needle exchange is an example of what types of reduction strategies
Harm reduction
Apathetic and nervous, sees halos, flashes of color, recent ETOH and LSD, unemployed, never hospitalized
Hallucinogen persisting perception d/o
Recovering addict in relapse prevention therapy, and has many risk factors. Rather than developing a coping strategy for each risk factor, do what?
Focus on skill training, cognitive reframing, and lifestyle interventions
Opioid NOT detected in standard UDS
Fentanyl
What substance is only detected in urine for 7-12 hours after ingestion?
ETOH
Use of levomethadyl acetate hydrochloride (LAAM) for management of pt w/ opioid dependence allows for
Elimination of need to take home doses
In nicotine dependence, neurotransmitter most associated w/ reward and reinforcement is
Dopamine
OD on sleeping pill. Hot skin, blurry vision, urinary retention, dry mucous membranes, tachycardia, decreased bowel sounds. What is the pill?
Diphenhydramine
35 y/o hypoventilates, blue lips, pinpoint pupils, crackles on lung exam, and mild arrhythmia on EKG. Intoxicated with:
Codeine
2 days s/p hospitalization dysphoric, fatigued, hypersomnic, vivid dreams, requesting double portions
Cocaine
22 y/o with sudden onset anxiety, SOB, palpitations, dizziness, lightheadedness, and sweaty palms x2 days. Paranoid, fears college police will know participated in weekend “hash-bash festival.” What is diagnosis?
Cannabis induced anxiety disorder
What substance is a common cause of flashbacks?
Cannabis
Acute anxiety, restless, flushed, irritable, nauseous, worse diuresis and insomnia – attributes everything stress at work
Caffeine intoxication
Has intoxication syndrome but not a substance of abuse
Caffeine
What med is not used in tx of opioid maintenance and relapse prevention?
Bupropion (naltrexone, methadone, buprenorphine and clonidine are used)
What is the mu opioid partial agonist approved by the FDA for the treatment of patients with opioid dependence?
Buprenorphine
Phenobarbital tolerance test is helpful in detox from what?
Benzodiazepines
Flumazenil is used to treat:
Benzo intoxication
Pt presents to ED c/o ringing in ears, abdominal pain, and is found to have mild metabolic acidosis. Overdose of what substance?
Aspirin
Tachycardia, dilated pupils, hypervigilance, anger, HTN, and chills. UDS shows?
Amphetamines
20 y/o with acute onset belligerence, distortion of body image, depersonalization, and cloudy sensorium following ingestion of a street drug. Horizontal nystagmus, ataxia, and slurred speech, pupils not dilated. Management:
Administer ammonium chloride
What is a characteristic of hallucinogens?
Addictive craving is minimal
Acetylcysteine is Tx of choice for OD of:
Acetaminophen
The risk of hepatotoxicity will peak in how many hours after acetaminophen overdose?
72 to 96
A clinically significant increase in the concentration of lamotrigine may occur if it is co-administered with:
Valproic Acid
A pt w/ treatment-resistant mania and h/o rapid cycling is being treated w/ carbamazepine and thyroxine. After adding Clozapine the pt is clinically stabilized. The pt’s most recent WBC is below 3,000. Intervention?
D/C carbamazepine
Carbamazepine should be DC'd if the absolute neutrophil count is below
3000
Coarsening of facial features and hirsuitism are SE of what med?
VPA
Drug prophylactic for treatment of migranes
Valproic Acid
Adequate for monotherapy generalized tonic clonic szs:
Valproate
Antiepileptic drug that can cause renal stones
Topirimate
Prophylaxis of adult migraines
Topiramate
Teratogenic effect of both VPA and carbamazepine:
Neural tube defects
8 y/o dx’d w/ Bipolar d/o is about to start valproic acid. What needs to be monitored frequently?
Liver function
Which antibiotic may significantly raise carbamazepine levels and precipitate heart block?
Erythromycin
Side effect more frequent in carbamazepine than lithium
Dizziness
Hair loss + weight gain are SE of which anticonvulsant
Divalproex sodium
Lancinating face pain, triggered by minor sensory stimuli, best treated initially with:
Carbamazepine
Which drug used in the treatment of patients with epilepsy is associated with hyponatremia?
Carbamazepine
Antidepressant less likely to cause sexual dysfunction
Buproprion
38 y/o taking imipramine 300mg qday for recurrent MDD. After 3 weeks, mood is improved, but has difficulty passing urine and mild erectile dysfunction. Appropriate action?
Bethanechol 25 tid
Which is a muscarinic SE of antidepressants?
Urinary retention
What antidepressant is known to have caused hypertension?
Venlafaxine
Phenylethylamine antidepressant that targets serotonin and norepinephrine reuptake inhibition
Venlafaxine
What pharmacological treatment should be used for long-term insomnia in patients with dementia over 65 years of age?
Trazodone
Antidepressant w/ shortest elimination half-life
Trazodone
Key element in emergency treatment of pt w serotonin syndrome, beyond stopping offending agent is:
Supporting vital functions
Mirtazepine (vs other antidepressants) has low incidence of what side effect?
Sexual SE
Orthostatic hypotension is least likely to occur as a S/E with what antidepressants?
Sertraline. (Nortriptyline, imipramine, amitriptyline and trazodone may cause orthostatic hypotension.)
Which antidepressant has active metabolites that extend its effective half-life?
Sertraline
50 y/o fireman became clinically depressed after sustaining a myocardial infarction. What is an appropriate medication to prescribe?
Sertraline
27 y/o depressed patient treated with SSRI and tranylcypromine and now presents with VH, mild confusion, and myoclonic jerks:
Serotonin Syndrome
Restlessness, myoclonus, hyperrreflexia, diaphoresis, shivering, tremor, and confusion are compatible with:
Serotonin syndrome
Confusion, lethargy, flushing, sweating, restless – recently started on Prozac, can’t remember other meds. Temp 101.5, tremor, myoclonus
Serotonin syndrome
20 y/o lethargic, restless, confused, diaphoretic, flushing, tremors, receiving antidepressant
Serotonin syndrome
MDD patient with good response to venlafaxine presents with dysphoria, agitation, nausea, poor balance after running out of medication. Cause of sx?
Serotonin discontinuation syndrome
Which med for pt w/ severe social phobia who failed fluoxetine and venlafaxine
Phenelzine
Effective for OCD
Paroxetine, phenelzine, fluvoxamine, clomipramine. (NOT bupropion)
Receptor blocked by antidepressants -> blurred vision
Muscarinic
Which antidepressant has strongest histamine-R affinity?
Mirtazapine
What antidepressant has plasma level that correlates with therapeutic response?
Imipramine
45 y/o with first episode MDD, on Paxil and insight-oriented therapy, but depression worsens over months. Takes Paxil only occasionally, as he is worried about becoming dependent on it (a friend was addicted to Valium). Best intervention?
Educate patient on the differences between antidepressants like Paxil and benzodiazepines, like Valium.
Antidepressant preferable for >65 yo
Desipramine
Antidepressant blood levels
Desipramine
What antidepressant increases REM sleep?
Bupropion
What antidepressant has an FDA pregnancy use B rating?
Bupropion
What meds could be helpful in the treatment of depression in persons over the age of 65 because it does not produce orthostatic hypotension
Bupropion
Which antidepressant is well suited for Rx of depression in older pts with cardiovascular disease.
Bupropion
Antidepressant with low risk of weight gain
Bupropion
37 yo in 125 daily of imipramine. Urinary retention. Tx?
Bethanecol
Antidepressant causes Parkinson’s sx
Amoxapine
45 y/o woman on phenelzine for MDD, takes OTC medication for cold sx and develops hypertensive crisis. Which OTC medication would most likely cause this?
Pseudoephedrine
What drug is contraindicated for a pt receiving MAOI?
Meperidine
2 wk waiting period recommended when switching from phenelzine to tranylcypromine because:
Tranylcypromine is an amphetamine derivative
Which med is irreversible MAO-B inhibitor?
Selegiline
What drug has been known to cause hypertensive crisis?
Phenelzine
2 week washout of which med is needed before starting fluoxetine
Phenelzine
Which MAOI is least likely to cause drug-food interaction in therapeutic antidepressant doses
Moclobemide
Pt taking phenelzine is treated in ED for chest pain. While treated, pt develops hyperreflexia, HTN, goes into coma. Which med is most likely cause?
Meperidine (Demerol)
At 10 mg selegiline does not require dietary restriction b/c
MAO-B is not involved with intestinal tyramine reaction
Most frequent side effect of MAOI’s
Hypotension
MAOIs affect catecholamines by directly retarding:
Deactivation
Minimum recommended washout period for fluoxetine prior to starting MAOI
5 weeks
What drug has a curvilinear therapeutic window?
Nortriptyline
Optimal strategy in maintenance treatment with tricyclics for pt w/ recurrent MDD
Full-dose antidepressant therapy
Monitor tricyclic (TCA) overdose by:
EKG
Most frequent cause of death following TCA overdose
Arrhythmia
What drug is useful in the Rx of uninary retention secondary to TCA therapy ***
Bethanechol
Sudden death in children taking which medication?
Tricyclics
Increased PR, QRS, or QT on ECG
Tricyclics
Psychiatrist plans to add nortriptyline as adjunct to fluoxetine. He should proceed how?
Start nortryptyline at lower than norm dose
Useful blood levels can be obtained for which TCA?
Desipramine
Which of the following TCAs should be avoided in pts w/ Parkinson’s?
Amoxapine
Dry mouth, blurred vision, constipation, urinary retention. S/E of what psychotropic?
Amitriptyline
Do NOT use in pt w/ narrow-angle glaucoma
Amitriptyline
Orthostatic hypotension associated with TCAs is caused by blockade of what receptor?
Alpha1-adrenergic
Fluoxetine should NOT be prescribed with what?
Phenelzine
Which of the following SSRIs has mild anticholinergic activity?
Paroxetine
The SSRI most likely to cause discontinuation syndrome:
Paroxetine
Most typical SE of fluoxetine
Nervousness, restlessness, anxiety
Discontinuation syndrome associated with SSRI consists of:
Malaise, nausea, parasthesias, dizziness, mood symptoms, and headache
Serotonergic antidepressants are appropriate treatment for depression in 54 yr old patient with recent coronary artery bypass graft surgery because they:
Inhibit platelet functioning
Which is a common side effect leading to discontinuation of SSRI’s early in treatment?
GI distress
Which of the following SSRIs has longest half-life?
Fluoxetine
Which of the SSRI antidepressants has the longest mean half-life?
Citalopram
SSRI w/ no or mild inhibition of major P450 isoenzymes of 1A2, 2C9, 2C19, 2D6, 3A4
Citalopram
Increases paxil concentration
Cimetidine
What is a sleep disturbance likely to occur after initiating a trial of an SSRI?
Bruxism
Cytochrome P450 (CYP450) subenzyme, inhibited by fluoxetine, increases TCA levels
2D6
Antipsychotic drug adrenergic effect causing orthostatic hypotension
α1-Blockade
Which med has increased risk of hyperglycemia and DM?
Olanzapine
Autonomic instability, nonfocal neurological signs, and elevated temp associated with which elevated lab value?
Creatine phosphokinase (CPK)
Which med reduces the acute sx of neuroleptic induced akathisia?
Beta blockers (propranolol, atenolol)
Which atypical antipsychotic causes least weight gain?
Ziprasidone
What hematological finding necessitates immediate dc of clozaril?
WBC 2000-3000, granulocytes 1000-1500
Retinal pigmentation from long-term tx with:
Thioridazine
Mechanism by which risperidone cause very little EPS despite binding w/ high affinity to a dopaminergic D2 receptor
Serotoninergic 5HT2 antagonism
What is a major side effect of clozapine?
Seizures
Most common side effect with clozapine tx is
Sedation
Antipsychotic associated with development of cataracts
Quetiapine
Blockade of dopamine receptors in tuberoinfundibular tracts results in breast enlargement, galactorrhea, impotence, and amenorrhea. Mechanism is increase of:
Prolactin
How do antipsychotic meds elevate prolactin (PRL)?
PRL is under tonic inhibitory control by DA
Recent schizophrenic med adjustment, now with fever, diaphoresis, stiffness, tachycardia, confusion. Dx?
Neuroleptic malignant syndrome
IV Haldol related torsades de pointes is associated with what?
Low magnesium levels
Galactorrhea in female pt on risperdal secondary to:
Inhibition of tuberoinfundibular dopaminergic pathway
What lab finding is most typically associated with NMS?
Increased Creatine Kinase Levels
Appropriate management of neuroleptic malignant syndrome
Hydration and cooling
Antipsychotics are associated with what?
Dystonia, poikilothermy, lipid solubility, and lower seizure threshold.
32 y/o pt with hx of schizoaffective d/o stable on clozapine is admitted to internal medicine service for a severe GI viral infection. Pt is confused, slow, appears visibly ill and tired. Pt c/o stiffness and there is some rigidity to the movements. What should be recommended?
Discontinue clozapine
23 yo hospitalized for psychotic break complains of thickened speech. Eye deviation, grimacing, posturing. Was given haldol and clonazepam. Treatment?
Diphenhydramine
Which antipsychotic has least effect on prolactin?
Clozapine
Which neuroleptic has the weakest affinity for the dopamine D2-like receptor?
Clozapine
Clozapine clearance decreased by
Cimetidine
Which med is contra-indicated with clozapine?
Carbamazepine
What is the treatment of acute dystonia?
Benztropine
What manifestations is the most common side effect of conventional antipsychotic meds?
Akathisia
Periodically assess neuroleptic side effects using
AIMS
What psychotropic can cause a decrease in benzodiazepine plasma levels?
Carbamazepine
Benzo half-life < 6 hrs
Triazolam
Pharmacokinetic property most related to relative abuse potential of benzos
Time to onset of action
75 y/o pt with cirrhosis should be given which of the following meds:
Temazepam
Which benzodiazepine is metabolized through glucuronidation (phase II metabolism) in the liver?
Lorazepam
Which benzo is reliably absorbed given IM?
Lorazepam
Benzo w/o active metabolites
Lorazepam
Longest half-life amongst alprazolam, flurazepam, lorazepam, temazepam and triazolam
Flurazepam (Dalmane) used for insomnia
Most common side effect of benzos
Drowsiness
Which benzo accumulates with repeated administration?
Diazepam
What benzo should be avoided in chronic renal failure?
Diazepam
Benzo most likely to accumulate w/ repeated dosing
Diazepam
Patients on chronic benzos develop:
Amnesia
62 y/o F with bipolar d/o develops altered mental status, dysarthria and ataxia in hosp after meds are added in hospital to her lithium. What medication could cause this?
Indomethacin competes with Li for excretion and causes Li toxicity symptoms
Lithium exposure in first trimester of pregnancy increases risk of congenital abnormalities in which organ?
Heart
Treatment of choice for lithium intoxication who manifests impaired consciousness, neuromuscular irritability, and seizures is *****
Hemodialysis
Which is the most common reason for adolescent stop lithium
Worsening acne
Lithium can cause a decrease in which blood level?
Uric acid
What lab test should be conducted prior to initiation of lithium treatment?
TSH
Li serum levels should be monitored by evaluating:
Trough levels 12 hours after last dose
BMD tx with Li x2 years develops rapid cycling. What lab test should be done?
Thyroid fxn tests
SE of toxic serum lithium levels
S-T depression, QTc prolongation, ataxia, tremor, dysarthria, nephrotoxic symptoms, status epilepticus.
24 y/o in 2nd trimester is now manic without psychotic fx’s. Hx of one episode of mania, diagnosed bipolar I. DC’d lithium when she decided to have kids. Willing to begin tx.
Restart lithium
Which of the following factors is a predictor of a poor response to lithium?
Rapid cycling
Lithium induced tremor is usually reduced by which of the following meds?
Propranolol
Bipolar pt on lithium and Zoloft for 3 yrs. Level 0.8. More depressed and fatigued, low energy level. Increasing Zoloft ineffective. Next step:
Obtain TSH level
The most cause of severe polyuria with lithium is:
Nephrogenic diabetes insipidus
While taking lithium patients should:
Maintain sodium intake
A psychotropic with same pharmacokinetic properties in Asian Americans and White Americans
Lithium
Administration of activated charcoal is ineffective in overdose of:
Lithium
Psoriasis exacerbated by:
Lithium
Obstetrician requests urgent psych office consult for 24 y/o pt in 2nd trimester of first pregnancy who is acting bizarre. Pt is manic w/o psychosis. Has previous episodes of mania and is dx'd with bipolar I. Was on lithium, but dc’d when planning pregnancy. Best recommendation:
Lithium
Interferes w/ clearance of lithium
Ibuprofen
Cardiac effects of lithium resemble what on EKG
Hypokalemia (low T waves)
Predictor of positive response to lithium prophylaxis
History of good inter-episode function
In patients on lithium, what type of thyroid dysfunction can occur?
High prevalence of the production of thyroid autoantibodies
Intake of this increases lithium levels
Fluoxetine
Pt who has been treated with lithium for bipolar shows a good response in stabilization of mood, but reports feeling dull, slow, and unable to concentrate. Lithium side effect?
Absolutely
Stable, steady state Li levels are generally obtained within:
4-5 days
Factor most predictive of effective methadone tx
Total daily dose
22 y/o heroin dependent female discovers she is pregnant and wants to detox. What way would you recommend?
Methadone maintenance until delivery then detoxification
Which of the following produces best outcome in terms of drug consumption and criminal behavior for heroin-dependents?
Maintaining on methadone
28 yr old on methadone maintenance therapy develops worsening anxiety and flu-like symptoms since switched from valproate to carbamazepine for seizure control 2 weeks ago. What should be the next step in management?
Increase the methadone dose
20 y/o pt w/cancer pain is on a methadone maintenance program. Staff feels request for additional narcotics represent drug-seeking behavior. Recommendation?
Give pt more opioid med to achieve adequate pain control b/c of pt’s tolerance
Due to its rate of oral absorption, what most enhances the euphoria produced by benzodiazepines with methodone?
Diazepam
What average dose range of methadone yields the best results in decreasing illicit use?
60-100mg
Two antidepressants are tested alone and as a combo treatment against a waitlist control group in pts with treatment resistant MDD. Both med are found to have a significant therapeutic effect individually, and the combo treatment is more efficacious than the summed effects of each med given alone. What has been demonstrated?
Two treatments main effects and an interaction effect
In pts who surreptitiously use excess sulfonylurea, which of the following substances can be administered to r/o possible insulinoma?
Tolbutamide
Psychiatrist is called to eval a pt on a medical floor who has developed acute dysarthria w/ protruding tongue and torticollis. Which med is suspect?
Metoclopramide
Concurrent use of phenelzine and meperidine can cause hypermetabolic reaction secondary to what?
Indirect pharmacodynamic effects at a common bioactive site.
Pharmacokinetic factor that declines w/ aging?
Glomerular filtration rate
Patients >65 are more sensitive to psych meds. What physiologic change occurs with aging?
Decreased phase 1 oxidation
Agitated pt gets rapid tranquilization in ED. Using oral concentrate instead of IM or IV has what advantage?
Decreased feelings of helplessness
Psychotic pt given haldol, acute laryngospasm. In addition to intubation, give:
Cogentin
Difference in the rate and extent to which a brand name vs a generic drug becomes available to the site of action, given the same dose and condition, is measured as:
Bioequivalence
Schizophrenic OD'd on antipsychotics, has EPS and urinary retention. Tx?
Amantadine
Clonidine mechanism of action:
Alpha-2 agonist
Most appropriate brief screening instrument that a pt can fill by him/herself at physicians office to screen for depression is:
Beck depression inventory
Test to discriminate cognitive difficulties in Alzheimer’s from those in depression
Boston Naming Test
A test for anxiety that does not include questions about physical symptoms such as tachycardia and diaphoresis would be considered lacking in what?
Content validity
An appropriate purpose for projective testing is to:
Detect the presence of subtle psychotic thought processes
Judgment by experts that items on a test “make sense” is an example of:
Face validity
Awareness of own symptoms rated by:
Global Assessment Scale
What psychological test determines neuropsychologic impairment?
Halstead-Reitan Battery
Which test is most helpful in confirming diagnosis of personality do?
Millon clinical multiaxial inventory
Bender-Gestalt diagrams assess
Neuropsychological impairment
Which test assesses ability to attend to a task while inhibiting interfering stimuli?
Stroop Color Word Test
What would be a useful screening test to evaluate an 8 y/o child's academic performance?
Wide range achievement test (WRAT)
What does the clock drawing task test?
Attention, visuospatial, planning, executive function (NOT orientation)
Pt scores on revised Wechsler adult intelligence scale (WAIS-R) subtests for picture arrangement and block design are very low compared to scores on other subtests. Most suggestive of:
Lesion in nondominant hemisphere
Test to assess intelligence in 4 y/o?
Standford-Binet
Stanford-Binet most similar to
Wechsler Intelligence Scale for Children – III
Which assessment instrument best measures cognitive functioning in a 4 yr old child?
Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R)
Test more specific to identify specific learning disability in child w/ full scale IQ of 93 on WISC-III
Woodcock-johnson psycho-educational battery - revised
MMPI does what?
Identifies major areas of psychopathologic functioning
What psychological tests measure test-taking attitudes at the time of examination
MMPI (Minnesota Multiphasic Personality Inventory) Validity Scale
25 y/o M scores in MMPI are all normal except for elevated scores on the depression and psychasthenia scales. This suggests:
Has depression w/ anxiety and other neurotic symptoms
Objective psychological test
MMPI
Measures test-taking attitudes
MMPI
Thematic apperception test is used for
Inferring motivational aspects of behavior
What psych tests would be considered the most unstructured?
Rorschach inkblot
What tests can be used for projective personality testing?
Rorschach, Draw-a-Person, Thematic Apperception. (NOT MMPI)
Which is a Projective Assessment test:
Thematic Apperception Test (TAT)
The personality test in which a patient is shown pictures of situations and asked to describe what is happening in each picture is:
Thematic apperception test (TAT)
A psychological test that demonstrates high reliability:
Wechsler Adult Intelligence Scale (WAIS)
Which test correlates most strongly with pre-morbid functioning in a pt with early dementia?
Wechsler adult intelligence scale II vocabulary test
Wisconsin card sorting test (WCST) assesses
Abstract reasoning and flexibility in problem solving
What tests is useful for evaluation of executive functioning?
Wisconsin card sort test
What mini mental status question tests immediate recall?
Repeating 6 numbers
What task is useful in evaluating a pt's ability to concentrate?
Performing serial 7s
Biological consequences of psychological stress affect which mechanism?
Neuro-immuno-endocrine function
Disharmony between feeling tone and speech content
Inappropriate
Psychiatrist asks “How many quarters are in $15?” examining what ability
Cognition
Psychic determinism is:
Behaviors result from unconscious mix of drives, defenses, object relationships, self-disturbances
Most important protective factor in determining preschool age child’s response to disaster is?
Parental functioning
Risk factor influencing psychological outcome of child following death of parent:
Prior conflictual relationship between child and deceased parent
Psychological function of a medication
Acts as a container for the patient’s projected anxieties about being defective
According to sociobiologic theory, what term describes behaviors at the level of the individual that maximize fitness at the level of the gene?
Altruism
3 y/o girl hurt herself w/ tricycle. Then she hit the tricycle and asks, "why did you hurt me?" Which thought process does this behavior exemplify?
Animism
Experimental subjects were ask to make a judgment but gave wrong answer in spite of knowing the right one because they didn’t want to disagree with responses of other participants. This phenomenon is
conformity
Resilient individuals who do well in developmental course through life despite being at high risk for negative outcomes are thought to be protected in adulthood most importantly by:
Having the ability to find, use and internalize social supports
Piaget interested in:
How child arrives at answers
According to C.G. Jung, anima refers to:
Man’s underdeveloped femininity
29 y/o complains about mistreatment from boyfriend. Proud of generous nature but complains how little she gets back. Therapist finds it hard to make her self-reflective about her role in this, gets frustrated and fatigued. Patient displays:
Masochism
Child dances for mother and basks in gleam of mother’s eyes. According to self-psychology, experiencing:
Mirroring
Early behaviorist theory promoted what
Objective psychological research
What term describes the role that others perform for the individual in regard to mirroring, idealizing, and twinship needs?
Self Object
The fundamental developmental need of all persons for mirroring, validation, and affirmation is central to which psychoanalytic theory?
Self psychology
66 y/o sent threatening letters to the president, thinks CIA is following him. Wife similar convictions, dependent on husband, passive
Shared psychotic disorder
Activity level, regularity, approach-withdrawal to new situations, adaptability and persistence are examples of:
Temperamental variables
Kohut’s theory of personality is based on?
The individual’s need for empathic interaction with self objects.
Cartesian dualism from the theories of René Descartes refers to
The potential of human nature for both good and evil
Studies in which monkeys are raised in varying degrees of isolation have been important in contributing to what theories of human development?
The significance of attachment
Which of following statements identifies what both traditional healing and modern psychotherapeutic practices may have in common:
The therapist helps the patient experience an emerging sense of learning and mastery over the problem
What is achieved in Piaget’s stage of concrete operations?
Conservation
8 yr boy sees 2 bottles w same amount of liquid. The content of one is poured in shorter wider glass and the other to a longer narrow glass. When asked which has more liquid he says it’s the same. According to Piaget he is exhibiting:
Conservation
4 y/o child upset when ice cream melts. 10 y/o puts it in freezer and tells him it will be ok. 4 y/o insists it is ruined. Piaget’s concept of this is:
Conservation (also reversibility)
Per Piaget, Conservation is the ability to do what?
Understand that objects or quantities remain the same despite a change in physical appearance
What best illustrates a double bind in a family?
Betty's parents encourage college, but complain that expenses will be a hardship for the family
11yo boy has frequent episodes of ulcerative colitis requiring frequent hospitalization. While in the hospital, mother never leaves his side and responds to questions for him, often referring to disease as “our disease”. According to Minuchin's theory of family interactions, this is:
Enmeshed
Erikson’s psychosocial stage in which a person invest energy into establishing, caring for, and guiding in the next generation is:
Generativity vs Stagnation
Erikson theorized that a successful developmental task in the 40-60 y/o group is to?
Feel useful to society through behaviors that protect future generations
Eriksonian stage >65 yo task
Integrity
According to Erikson, a child who strives to be competent by learning new skills, taking pride in results is which stage?
Industry vs inferiority
Erickson stage issue, 75-y/o
Finding meaning in what one has done
Achieving sense of self-control and free will, struggling between cooperation and willfulness (Erikson)
Autonomy vs. shame and doubt
Compulsions & obsessions are related to development disturbance during which of Erikson’s psychosocial stages?
Autonomy vs shame and doubt
Eriksonian phase correspond w/ Freud’s anal phase
Autonomy vs shame and doubt
According to classical psychoanalytic theory, the pleasure an adult might take in controlling others and in making order out of chaos relates to which psychosexual stage of development?
Anal retentive
According to contemporary psychoanalytic theory, from birth to 18 months, children experience an emerging “self” as a result of what event?
Biological processes and bodily sensations come to have a psychological meaning
What is the combination of several unconscious impulses, wishes, or feelings that are attached to a single dream image?
Condensation
Freud’s psychological theory of development
Drive theory
Melanie Klein differed from Freud in her emphasis on what factor?
Early object relations
Freud says depression is anger turned inward against self due to
Identification with the lost object
Freud says that boys resolve oedipal complex by:
Identifying w/ fathers
What developmental period does the child realize he/she is the child of his/her parents and the child’s parents have a relationship with one another?
Latent
Freud believed pt had fantasies of incest with opposite-sex parents coupled with feelings of jealousy toward the same-sex parent during which stage:
Phallic
Which ego defense is seen when an adolescent belittles parents in order to defend against regressive pull toward childhood?
Reversal of Affect
This model divides the mind into conscious, preconscious, and unconscious?
Topographical
Tendency for groups to arrive at more extreme decisions than for individual group members alone
Group polarization
Hand washing rituals are most related to what defense mechanism?
Undoing
Semiconsciously diverting attention from a conflict in order to minimize discomfort is an example of what defense mechanism?
Suppression
Couple in therapy review argument at family reunion, husband told his sister-in-law that his wife was superior to her in every way, the wife expressed disapproval, husband became quiet and later fell down a flight of stairs. What defense mechanism is this?
Turning against self
A parent who just learned that her child has been injured and taken to the hospital, arranges for a neighbor to care for her other children and then rushed to the hospital. What defense mechanism did the parent use to handle her own fear?
Suppression
Management of patient in denial immediately after MI:
Supporting the patient, unless denial interferes with care
Per psychoanalytic theory, unacceptable affects and impulses are commonly gratified in socially acceptable ways through:
Sublimation
30 y/o in therapy struggles with feelings of ambivalence about mom. Mom now has metastatic BrCA. If the patient uses anticipation as a defense mechanism, she might:
Set aside a night of the week to have dinner with mom to discuss mom’s rxn to diagnosis
Defense mechanism: behaviors characteristic of earlier stage of development in response to stress/conflict
Regression
Major psychological defense mechanism that determines the form and quality of OC symptom is
Reaction formation
Defense mechanism: one party acting out what other party feels
Projective identification
One group member alternates between being the “scapegoat” for the group or the “spokesman” for the group. These events are a group version of what?
Projection Identification
Which defense mechanism most relevant to etiology of delusional disorders according to psychodynamic theory:
Projection
Which defense mechanism is thought to be involved with the expression of paranoia
Projection
When asked about a coworker after a recent conflict, a patient states “I harbor no ill feelings toward him, but he truly hates me.” The is example of which defense mechanism?
Projection
Disassociation is what type of defense mechanism?
Neurotic defense
Young man recounts how his father kicked his puppy to death, no emotion when telling the therapist this despite therapist’s upset response. What defense mechanism is this?
Isolation of affect
Patient is annoyed by family’s expression of concern for his condition, saying, “what they are saying is all in the talk.” What defense mechanism is this?
Devaluing
7 y/o states he knows Dad died, but why didn’t he come to the birthday party? Defense mechanism:
Denial
Pt’s wife states he drinks almost every night. Pt states he never drinks to excess, never drinks outside the home, never needs an eye opener, and drinking does not affect his work performance. This is an example of which type of defense mechanism?
Denial
32 y/o F with mixed anxiety and depression has been working well in supportive-expressive psychotherapy once weekly for the past 3 months. Focus has been on issues related to the childhood neglect and abuse she experienced and how these impact her current relationships. In one of her regular sessions, she is silent and tearful. With encouragement from her therapist, she reports that her 18-month-old daughter has been hospitalized with meningitis and she is very upset and worried. The therapist listens silently. The patient leaves the session early, stating that she has nothing really to talk about and misses the next session. When she comes the following time, she is angry and accuses the therapist of being uncaring and insensitive for not even expressing concern about her child or empathizing with her distress. The therapist’s immediate response should be?
Apologize and acknowledge that the silence had felt hurtful to the patient
Business executive hospitalized for bleeding ulcer repeatedly argues with a well-liked head nurse and threatens to leave AMA. Best action for C&L psychiatrist is:
Listen to patient’s complaints and acknowledge his discomfort with the passive position that he is unaccustomed to
Common theme in psychotherapy in the elderly:
Loss
As opposed to long-term psychotherapy, time-limited therapy more likely to:
Select central issue as focus
In treating an older patient with depression who is a successful executive, he offers you some tips on investing. What do you do? Do you accept the offer as a way to validate the patient’s success OR explore the patient’s meanings and feelings about the offer OR accept the information but do not act on it?
The latter
A new pt asks therapist, “are you Christian?” what is best response?
“Are you concerned that if we are not the same religion, I won't be able to treat you properly?”
Exchange during initial interview after patient’s former therapist closed his practice: patient expresses concern about new therapist being too young and inexperienced, states she doubts new therapist can provide any new insights. Best response to further goal of getting to know patient and establish whether therapy w/ new therapist would be appropriate
“It can be very hard to start over with a new therapist. How have you been feeling about having to end your treatment with Dr. Brown?”
Treating a much older patient who asks about therapist’s age. Best response:
“Maybe you’re concerned about whether I am experienced enough to treat you?”
Intensive, short-term dynamic psychotherapy is contraindicated for what condition?
Acute exacerbation of chronic schizophrenia
Pt seeing new psychotherapist weekly x3 wks hesitantly complained about being able to overhear much of what the patient in the preceding session was saying. Pt assured therapist that he had tried not to listen and had left the waiting room to wait outside until the other pt had left. Which is best response?
Apologize for the lack of privacy and indicate that further measures, such as a music system in the waiting room, will be utilized
Psych resident dislikes alcoholic pts and avoids working with them. In discussing the problem, says that pts are hopeless and unmotivated and she can't empathize with them. Example of?
Countertransference
MD sees psychiatrist with increasing sense of dislike for a blaming, externalizing patient who pits family members against the MD. What should the psychiatrist discuss with the MD?
Countertransference
Pt is seen by psychiatrist because has been depressed for 1 yr since he was fired in spite of having another job. The psychiatrist tells the pt: men often feel that they are not allowed any failures but I can tell that u have moved on from this successfully and have no reasons to dwell in it. The pt then withdraws. The most likely cause of pt response is that he felt
Cut off by the premature offering of reassurance
The beginning phase of therapy with a child who was an incest victim should first focus on what?
Dealing with prior betrayal and establishing trust with the therapist
5 y/o enacts fight between two dolls. What should therapist do?
Describe doll’s affect without attributing anger to the child
After several months of weekly individual psychotherapy, woman with MDD and panic d/o describes repressed memories of being sexually abused by stepfather. Therapist responds neutrally, explores pt's experience of them. Pt reports increasing conviction despite sister insisting it was impossible and she plans on getting lawyer if parents do not admit and apologize. Which is best approach?
Document carefully the unfolding process and obtain supervision
50 y/o man hospitalized for depression and melancholia. First few therapy session should focus on:
Educate patient on nature of illness and treatment
A pt with h/o lifelong depression & failed relationships complains (very angry) (after several weeks of therapy) that she is expected to trust the Dr. without even knowing anything about him (credentials or personally) what should the Dr say?
Empathize with the Pt’s fears of trust and feeling of being at a disadvantage.
Two most powerful predictors of outcome in any form of psychotherapy are
Empathy and therapeutic alliance
62 y/o with lung cancer, weight loss, fatigue, and persistent cough. Patient refuses to accept dx of cancer and states will “get over this infection.” Patient refuses all further testing and asks for antibiotics to “recover in peace.” C&L psychiatrist’s role is:
Evaluate patient’s coping style and help the medical team see the patient’s responses in the context of her unique personality and life circumstances
Young female starting cognitive therapy with a female resident asks for a hug. Resident should first
Explain why physical contact is avoided
C&L psychiatrist uses all therapeutic approaches except:
Exploratory psychodynamic
Pt who recurrently goes to ED because of severe chest pain. Has been worked up for everything and all test are normal. He states that something needs to be done to “fix” his pain. Psych consult is placed. MSE and neuro is normal. Past hx reveals his father died of lung CA. Next intervention as psychiatrist is:
Explore pt's feelings about father's death.
Psychiatrist is treating an older pt who is a successful executive. pt feels grateful for the help w/ his depression and offers some tips on investing to the psychiatrist. What is the most appropriate action at this point from the psychiatrist?
Explore the pt meanings and feelings about the offer
Father is dying. Pt is not a drinker, but went from bar to bar drinking dad’s favorite drink. Bars are similar to those dad used to go to. Best interpretation of this behavior:
Identification with or incorporation of patient’s father
What do you do if a patient asks whether you’re still in training during an intake interview?
Inform of level of training
Patient sees therapist and makes threats and becomes agitated. Therapist feels uneasy, the next step is to:
Interrupt interview to get help
Use of meds with therapy optimal when:
Meanings and effects of meds integrated into pt’s understanding
What has been shown to be an evidence-based treatment for individuals with conduct d/o?
Multisystemic therapy
Young pt in therapy returns to school, announces to therapist that he can pass classes, will graduate. Best response:
Offering congratulations
Beginning therapist feels great empathy for depressed pt. fails to maintain sufficient distance to observe self-destructive patterns. To avoid this pay attention to:
Overidentification w/ patient
40 y/o eats and sleeps too much, craves sweets, poor concentration, irritable, constant conflicts with husband. States “I always feel better in spring.” What is the treatment?
Phototherapy
Child has high-activity motor level. Teacher should
Provide brief errands to do when child particularly restless
Social skills training for those with persistent mental illness is an essential part of:
Psychiatric Rehabilitation
Which psychotherapy uses transference interpretations and clarification to develop insight and resolve conflict?
Psychodynamic psychotherapy
Therapist is working with the family of a schizophrenic. Strategies include informing about illness, social support, management guidelines. Therapist encourages a calm, problem solving approach and facilitates stress and stigma reduction when possible. Which model is therapist using?
Psychoeducational
Biofeedback usually helps pts with which syndrome?
Raynauds syndrome
What interventions are consistent w/ the theoretical assumptions of crisis tx?
Reassurance, brief hospitalization, psychodynamic insight, treatment with psychotropic medications (not focusing on past relationships)
What most likely represents an acceptable boundary crossing by a therapist as opposed to a boundary violation?
Receiving cookies as an expression of gratitude by a patient near termination
During last session of successful psychodynamic psychotherapy, pt warmly expresses gratitude for everything, saying that the help the therapist has given has made a big difference. Appropriate response?
Respond by saying that you too have enjoyed the work
A 12 y/o F refuses to attend school b/c she fears her mother may die in an accident. Initial management should include:
Returning the girl to her current classroom
After attending several sessions of individual psychotherapy for anxiety and depression, a 24 y/o M revealed his homosexuality to his heterosexual male psychiatrist. The therapist realizes he is uncomfortable when the pt expresses longings for a male. The therapist also tends to overemphasize any material that might represent the pt’s heterosexual wishes. The next best step for the psychiatrist would be to:
Seek consultation to discuss countertransference issues
Pt w/ mild MR in tx program designed to develop new behaviors by modeling and reinforcement, then practice them
Social skills training
Therapist preoccupied w/ patient. Acknowledges this but unable to shake feeling
Talk to supervisor
15 y/o male bib parents, does not want to speak with psych
Thank him for coming in and ask him if he’d like to be seen alone or w/ his parents
One of chief factors in predicting outcome of therapy is:
Therapeutic alliance
Couples therapy, husband complains that MD wife works too long hours, she says she stays late to make sure everything is “right” checking and rechecking her work. Notes that once in high school she wished her straight-A brother dead and later he died on hunting trip. Her checking behavior is an example of:
Undoing
25 y/o AA M 1st year law student seeks therapy for “academic paralysis” brooding about racial and socioeconomic differences between himself and roommates. Comfortable w/ AA psychiatrist, open about racial slights. Most important goal:
Use shared ethnic background to offer insight as how patient’s alienation may be rooted in something more than current situation
“Deficit model” of psychological illness in psychodynamic psychotherapy define psychopathology as:
Weakened or absent psychic structures
43 y/o m very successful executive goes to psychiatrist because wife has threatened to leave if he doesn’t change. He does not understand wife's complaints that he is driven, perfectionist, demanding, controlling and unavailable. He believes he is just a good man. In recommending optimal initial treatment plan, key considerations for choice of therapy should include:
The difficulty of demonstrating to the pt that his ego syntonic traits are maladaptative.
25 y/o F never on a date after 6 mo of psychodynamic psychotherapy. Began to struggle w/ positive feelings about M therapist that she finds hard to accept. At the same time she starts to date. Therapist believes it is transference. Therapist said nothing, he believed an interpretation might interfere w/ positive learning experience. This is example of:
A practical/supportive approach
Determines if pt has ego strength for therapy
Assessment of quality of relationships
Goals of brief psychodynamic psychotherapy compared to long-term psychodynamic psychotherapy differ how
Discussion of transference in the latter
Primary intervention in highly expressive psychotherapy:
Interpretation
pt is often tardy. Supervisor warns not to be late. Pt has anxiety about losing job. When father dies he leaves town w/o telling supervisor. Again given warning. Next day a train causes him to be late. In therapy, the overlapping of multiple potential causes for tardiness is an example of what?
Overdetermination
38 y/o patient in dynamic psychotherapy for depression says she is lesbian and is dissatisfied with her otherwise good relationship with her partner of 7 yrs b/c she wants a child and her partner does not. She thinks about leaving the relationship but this makes her feel sadness and a sense of loss. What is best intervention?
Suggest that conjoint therapy with the patient and her partner might be a productive way to explore this complicated issue
What best describes current psychoanalytic thinking about the source of countertransference phenomena in the therapist
The therapists total emotional reaction to the patient
32 y/o F, divorced 3 times, sees a male psychiatrist, saying she needs therapy because she is paralyzed about choosing a career. The patient has started and stopped college twice, held several waitress and clerk jobs. She hoped the therapist could tell her what job to pursue. In the initial interview she asks the therapist to send bills directly to her father, who manages her money because she has difficulty managing bills and credit cards. She explained she has to live at home to save money, but hates this because she frequently fights bitterly with her father who always wants to control her. A transference issue that the therapist should expect to be a central theme in the therapy is that the patient will:
Try to get advice but then be angry at the therapist for giving it
“Deficit model” of psychological illness in psychodynamic psychotherapy define psychopathology as:
Weakened or absent psychic structures
In psychodynamic therapy, interpretation of transference and resistance until insight fully integrated is called:
Working through
Primary focus of a cognitive therapy approach to suicidal behavior:
Addressing all or nothing beliefs and helping pt learn problem solving
Programmed practice, or exposure therapy, is an indicated treatment for what disorder?
Agoraphobia
Pt with depression being treated with CBT tells psychiatrist about waking up and being worried about work. Pt has big project that is due in two weeks and is half done, but pt is sure work will not be finished on time. Example of which cognitive error?
Catastrophizing
Patient has severe stress and conflict at work, therapist identifies the problem of maladaptive responses based on rigid thought schemas and decides to target automatic negative thoughts through reality checking and guided association. What type of therapy is this?
CBT
Flooding, graded exposure, and participant modeling:
Confrontation of anxiety-provoking experiences
An important technique or goal of cognitive therapy is?
Eliciting and testing automatic thoughts
Which psychotherapeutic technique is most clearly indicated for treatment of simple phobia?
Exposure therapy
Take agoraphobic to crowded place and stay there until anxiety dissipates
Flooding
The LEAST utilized approach used in cognitive therapy in pt w/ substance dependence
Interpretation of interactional process
A CBT therapist works with a therapist, amongst other things, to identify and correct:
Overgeneralization
In cognitive therapy, “selective abstraction” is what?
Patient’s focus on a detail taken out of context and conceptualizes a experience based on this element
Cognitive error: when asked about his day, pt replies “I was late for work b/c I misplaced my keys” then “I didn’t speak up in the staff mtg.”
Selective abstraction
What behavioral therapy has relaxation training, hierarchy construction, and visual imagery of stimulus?
Systematic desensitization
All of the following are strategies for change in cognitive therapy:
Using reattribution, developing alternatives, questioning the evidence, fantasizing consequences. (NOT employing interpretation)
When conducting marital therapy with a couple who begin to talk about divorce, what should the psychiatrist’s stance be?
Focus on the couple’s responsibility to decide the future of their relationship
Which tx is contraindicated in initial treatment of pt experiencing domestic violence?
Conjoint marital therapy
The basis for a self-psychological strategy in marital therapy is best indicated by what?
Demonstrating the conflicts arising from each spouse’s need to have his or her self-object needs met by the other
Couples therapy: what is the goal of acceptance work?
Each partner taught to understand the other’s position and release the struggle to change him or her
In a session, a couple seems blissfully content when happy but enraged when frustrated by the other. They alternate between overidealizing and devaluing the other. This is an example of?
Splitting
Dialectical behavior therapy is utilized for
Borderline personality do
Which type of therapy has individual sessions to analyze self-destructive cognitions/feelings/actions, and group sessions with skills training to improve relationships and decrease impulsivity?
Dialectical Behavioral Therapy
Purpose of DBT to diminish what?
Parasuicidal Thoughts
Structural model of family therapy characterizes family as
Complex system comprised of alliances and rivalries
What type of group therapy is based on the unit functioning to maintain its own homeostasis of interacting?
Family group therapy
According to strategic and structural family therapies – underlying basis for analysis of symptoms in children, parents, and families
Observable and reported family behavior sequences
What is an important technique of structural family therapy?
Observing the relative influence of each family member on the outcome of an activity
The concept of the identified patient in therapy refers to:
One family member who has been labeled the problem by the family
Contraindication to family therapy
Strong religious or culture beliefs against outside intervention
In family therapy, a previously distant couple begins to communicate more frequently and intimately. After this happened the daughter who used to be close to mom, and has become less so as a consequence of above therapy changes, is more hostile to father. This behavior is called:
Triangulation
Major task of a group therapy during initial engagement phase is:
Determining limits of emotional safety
A psychiatrist who uses network therapy to treat patients with addictive disorders is functioning as:
A team leader
What factor is thought to be most important for promotion of healing in a group psychotherapy setting
Cohesion
In terms of group dynamics, the confirmation of reality by comparing one's own conceptualizations with those of other group members and thereby correcting interpersonal distortions is known as what?
Consensual validation
Initial tasks in starting supportive group therapy are deciding logistics and selecting patients. Next step:
Create and maintain therapeutic environment keeping in mind culture of the group
Stage of group development where members testing norms, competing w/ each other, seeking autonomy
Differentiation
What is a major therapeutic goal of self-help groups?
Overcoming maladaptive behaviors
Exclude a patient from a weekly outpatient group treatment group
Pt has tendency to assume deviant role
Differentiation stage of group development is best characterized by what dynamic:
Testing and competition
What is the therapeutic factor of treating bulimics in group therapy to openly disclose personal attitudes toward body image and give detailed experiences with binging/purging?
Universality
Ability to get so caught up in an experience that one loses awareness of surroundings
Hypnotizability
What statements regarding hypnosis is correct
Hypnotizability is a measurable trait
Psychiatric disorders with high hypnotizability include
Hypnotizability: Dissociative disorders
Most important guideline re: hypnosis
Record on videotape
Comprehensively researched therapy for mood d/o’s
Interpersonal psychotherapy
Therapeutic focus on the on pt's current social functioning is most characteristic of:
Interpersonal psychotherapy
Psychotherapy where patients realistically evaluate their interactions with others and the therapist offers direct advice/helps patients make decisions while ignoring transference issues is:
Interpersonal psychotherapy (IPT)
A 26 y/o pt with depressed mood and dissatisfaction with life, feeling isolated and having few friends who is not under undue stress and historically copes well with personal problems would benefit from what type of psychotherapy?
Interpersonal therapy
During the initial phase of interpersonal psychotherapy (ITP), what problem is the therapist most likely to identify for therapeutic focus with the patient?
IPT initial phase: Role transition
In the middle phase of interpersonal psychotherapy (IPT), the therapist focuses on the patient's:
IPT middle phase: Current relationships
Which best defines goals of supportive psychotherapy?
Improvement of reality testing and reestablishment of the usual level of functioning
After mild MI 70 y/o seen by psychiatrist for depression. Seen for psychotherapy, given SSRI. Describes fear of imminent death. Psychiatrist tells him cardiologist is excellent, he is receiving best care. What illustrates supportive therapy:
Reassurance
Supportive therapy differs from psychoanalytic therapy in that the therapist who is conducting supportive therapy does what?
Reinforces ego defenses
Therapeutic technique where therapist instructs the patient to hold onto a symptom:
Paradoxical intervention
A highly motivated patient in psychodynamic psychotherapy finds that he has nothing to say, which is an example of:
Resistance
Catharsis is:
Verbal expression of suppressed traumatic experiences and feelings
Principle of confrontation:
“I think you’d rather talk about your job than face the sadness you felt in our last session”
Example of empathic comment
“You must feel terrible right now.”
Common experience of becoming so caught up in a movie that one ignores the environment is example of what component of hypnotic process?
Absorption
Patient in group therapy calls another patient at home to object to something said in session
Acting out
A person’s inability or difficulty to describe or be aware of emotions or mood is called
Alexithymia
In psychotherapy a pt states that he still feels devalued by criticism of father. Therapist comment: It must hurt when you are treated that way. This is example of:
Empathic validation
Psychiatrist behavior of raising eyebrows, leaning towards pt, saying “Uh-huh”
Facilitation
Replaced use of hypnosis by Freud
Free association
Therapeutic empathy is best described as the therapist's ability to:
Grasp the patient's inner experience from the pt's perspective
Therapy technique of prescribing a pre-existing sx behavior in relationship therapy
Paradoxical intent
What is most likely to be enhanced by strategies of putting the pt at ease, finding the pt's pain and expressing compassion, evaluating insight, and showing expertise?
Rapport
Redirecting discussion by talking about irrelevant stuff
Resistance
A set of feelings that a patient reenacts in the therapeutic relationship are called:
Transference
What characteristic is associated with better adaptation in individuals >65?
Uncritical acceptance of ideas
What characterizes executive abilities in healthy individuals >65?
Show no significant change
Which is NOT common in patients >65: depression, cog d/o, phobias, ETOH d/o, psychotic d/o
Psychotic d/o
What causes of decreased vision in older adults is characterized by an inability to focus on an object as a result of retinal damage
Macular degeneration
Medicare pays for hospice care when a physician declares that a patient has a maximum life expectancy of how long?
6 months
End stage AIDS with worsening fine motor movement, fluency, and visual spatial coordination, dx?
AIDS Dementia Complex
When is a psychiatrist permitted to notify a 3rd party identified to be at risk for contracting HIV from a patient
When patient with AIDS unwilling or unable to take autonomy-preserving precautions, such as abstinence
AIDS patient with memory problems, R hemiparesis, L limb ataxia, BL visual field deficits, and normal CSF. MRI T2 scan showed.
Progressive multifocal leukoencephalitis
AIDS and progressive hemiparesis and R homonymous visual field deficit assoc w patchy white matter lesions on MRI with normal routine CSF.
Progressive multifocal leucoencephalopathy
Gay couple seeks therapy. One has HIV, one is negative. HIV negative feels betrayed and believes HIV positive partner was unfaithful. What should therapist say?
Median duration of asymptomatic stages of HIV infection in the US is 10 years
Most frequent route for HIV transmission in teenage girls
Heterosexual contact
What is a poor prognostic sign for HIV?
Dementia
AIDS pt, progressive weakness of extremities over weeks. Distal sensory deficit for pinprick and vibration. Slow nerve conduction, but EMG shows no denervation
Chronic inflammatory demyelinating polyradiculoneuropathy
In considering safe sex practices for avoiding HIV infection, oral sex is best characterized by:
Can rarely transmit virus
Greatest risk of death w/ ECT
Recent MI
What barbiturate is used in ECT to produce a light coma?
Methohexital
Indication for treating a manic w/ ECT
Dangerous levels of exhaustion
ECT has increased complications in patients with what medical condition?
COPD
ECT is least likely to be effective for patients who have?
Chronic schizophrenia
What condition is a relative contraindication to ECT?
Cardiac arrythmia
The “strange situation” in child development is used to assess the infant’s ____ in attachment theory:
Security of attachment
2 y/o does not want to let go of wool blanket and resists going anywhere without it. Attachment type is:
Transitional object
Toddler soothed at night by inner memory of secure relationship with mother. Called what (in attachment theory):
Object constancy
An 18 month old shows a marked awareness of vulnerability to separation and seems to be constantly concerned about the mother’s actual location is exhibiting Mahler’s stage of?
Object constancy
7 y/o with temper tantrums, refuses to go to school. Stomachaches and headaches on school days. Nightmares about being kidnapped, fears parents will die. Dx?
Separation anxiety d/o
Which ages of children are interested in secrets, collecting, and participating in organized games?
Elementary school
Sex play from 8-13 yo indicative of:
Typical children
Young child tries to determine how many seating arrangements there are for a family of 5 around a table. Uses no system, spends hours trying to find all options randomly and incompletely. This approach suggests:
Typical approach for this stage of concrete operations
Onset of puberty in boys begins with
Testicular enlargment
2 y/o clings to mother when introduced to new child, refuses to play at first visit, second visit stays with mom, third visit continues normal activities while warily eyeing other child. What temperamental trait is this?
Slow to warm up
Occupied w/ rules, understands others have separate feelings and motivations
School-age
Which event precipitates midlife crisis?
Recognition of unattainable goals
7 month old not crawling. Pediatrician is unconcerned. Child is alert, responsive, sits normally, shows good response to toys/stimuli. Psychiatrist should tell family:
Reassurance and provide reading materials
5 y/o adopted at age 4 now hugging strangers, age appropriate vocabulary, doesn’t respond well to limits, easily frustrated.
Reactive attachment d/o
3 y/o with diminished appetite, slow speech development, poor social interactions, parents are detached from him. After 2 weeks in hospital is improving and friendly with staff members. Dx?
Reactive attachment d/o
20-month child repeatedly returns to her mom when playing w/ other 2-y/o children
Rapprochement
Ask a child “What makes a train go?” He replies “The smoke makes it go.” This is:
Pre-operational thinking
Child argues with mom, is angry and rude. Has no trouble at school and completes schoolwork. Dx?
Oppositional Defiant Disorder
Learning triangular relationships
Oedipal stage
The development of full postural control in children by 4 yrs old correlates neuroanatomically with the developmental maturity of what?
Myelination of cerebellar fibers
Supported by ethologic perspective of moral development
Moral principles inherited as a species; development is innate
Psychiatrist is evaluating a 5 y/o child in kindergarten. Child does well with puzzles and other performance activities. Teacher reports that the child has a limited vocabulary and immature grammar in comparison to the other children. Child interacts well with other children. The child also seems to have some trouble understanding questions. Child's hearing and vision are normal. Explanation?
Mixed receptive & expressive language d/o
Stage of development associated w/ setting up clubs, making rules
Latency
Ability of preschool children to regulate emotions is most strongly enhanced by the development of:
Language
According to Thomas and Chess’ categories of temperament, the difficult child shows what characteristics?
Intense expressions of mood
To define learning disability, look for discrepancy between:
Intellectual potential and performance
Integration of clinical and experimental observations in early childhood development supports what statement about infant/parent interactions?
Infants are born with sophisticated perceptual abilities that facilitate attachment
In combo with growth hormone (GH), what is required to initiate the adolescent growth spurt?
Gonadal hormones
Sign of pyromania
feeling relief on setting a fire
6 yo w/ 4 wk intense eye-blinking and lip pursing. Wax and wane, increase with stress. Family Hx of tic d/o. first step:
Explain to family may be transient
A 2 y/o M has been preoccupied with a small blanket for several months, carries it w/ him everywhere and becomes upset if anyone tries to take it away. He refused to stay w/ a baby-sitter until it was retrieved. The psychiatrist should:
Explain this is normal and child will eventually give it up on his own.
A child’s understanding of death, attitudes, and responses at a preoperational stage of cognitive development include:
Expecting the dead relative to wake up
Adolescent with a congenital physical deformity is most vulnerable to emotional disturbance during what period of development?
Early adolescence (11-13 y/o)
A preschooler presents to psychiatrist after being placed on psychotropic med by a PCP. Parents note that since med was started, child has shown irritability, skin picking, decreased appetite, social withdrawal, and insomnia. Which med is child taking?
Dextroamphetamine
6 yo at school cries for mom, other kids start crying
Contagion
Myelination is completed in what developmental stages?
Childhood
The first sign of puberty in a female is most commonly?
Breast buds
9 yo is evaluated for bedwetting several times a week. Child has never been completely dry. Which tx modality is likely to be most effective?
Bell and pad
Normal loss of 25-40% of neurons in fetal brain in the 2nd half of gestation is called:
Apoptosis
What is the mechanism for regulating cell production and elimination of inappropriate axonal connections in the developing brain?
Apoptosis
Differential dx in a 6 y/o with daily fecal soiling includes:
Anal stenosis, hypothyroidism, Hirschsprung’s dz, smooth muscle dz
The stage of life in which consolidation of a personally acceptable sexual identity generally occurs is called?
Adolescence
Process by which children modify their existing schemas to adapt to new experiences is:
Accommodation
Cognitive developmental tasks of adolescence include acquiring the capacity for:
A more complex understanding of causality and multilevel realities
The age at which children typically first use sentences of 2 or more words is:
24 months
Gender identity becomes consolidated between what ages?
2-3 years
Earliest age infant likes to look more at strongly patterned shapes like faces?
1 wk
What age can infant first recognize mother’s face as distinct from other faces?
1 month
3 yr old boy wants to play with his mom, but she is tired and it is naptime. What explanation would he best understand?
“It’s naptime now.”
Person w/ MR who achieves 1st grade education fits which diagnostic classification?
Moderate Mental Retardation
6 y/o child in 1st grade is doing very poorly. WISC-R IQ score is 60. Compared with other children his age he has sig. impairment in social skill, dressing, language, and feeding. What is the Dx?
Mild Mental Retardation
Medications for tx of aggression in an individual w/ MR
Lithium, thioridazine, haldol, propanolol (not clonazepam)
10 yo IQ 69. findings that would confirm dx of MR?
Deficits in self-care and social skills
What is most important when trying to differentiate between autism and Asperger’s?
Language development
An 8 y/o boy has marked social delay, difficulty maintaining relationships d/t odd interpersonal style, preoccupied with small electronic devices, talks on and on about them, and excludes other age appropriate interests, has difficulty w/ transitioning from one activity to another, has poor eye contact, and oblivious to personal space. DX?
Asperger’s syndrome
7M w/ poor social skills, cognitive and language wnl. Dx
Asperger’s syndrome
What d/o occurs most frequently in pts with autistic d/o?
Mental retardation
The long-term outcome in autism is most closely correlated with?
Language development
Abnormality in what domains is the most important in establishing the dx of autistic do?
Interpersonal relations
3 yo not speaking intelligibly. Normal hearing. Parents worried about autism.
Express some concern to parents
Risk that a subsequent child will be autistic in a family with one autistic child is:
5%
Learning from consequences of one’s actions
Operant conditioning
Behavioral frequency altered by application of positive and negative consequences
Operant conditioning
Example of learned helplessness is a child who stops all attempts to improve after being punished for failing or failing no matter how hard the child tries?
Failing no matter how hard the child tries.
According to operant conditioning, behavior decreases in frequency if:
Incompatible with a positively reinforced behavior
Repeated presentation of a conditioned stimulus without being paired with its unconditioned stimulus will result in what?
Partial reinforcement
Biofeedback training to treat tension headache is an example of what type of learning?
Operant conditioning
Reinforcing behavior with reward every third time a behavior is done is called:
Fixed Ratio
Learned helplessness model for
Depression
Systematic desensitization is derived from
Classical conditioning theory
Patient ate meat loaf then had a severe GI virus; then develops a strong aversion to meat loaf.
Classical conditioning
Cocaine craving triggered by sight of crack house is an example of what type of learning?
Classical conditioning
Pt undergoing chemotherapy. Commonly becomes nauseated and vomits in waiting room prior to the treatment. This reaction is example of
Classical conditioning
22 y/o experiences a earthquake (7.0) during a seminar. In the months that follow he develops fearful reaction to sudden or loud noises. Pt avoids classes in the same building that the seminar was in. What is the mechanism of the behavior?
Aversive conditioning
If a response inhibitory to anxiety occurs in the presence of anxiety-evoking stimuli, it weakens the connection between the stimuli and the anxiety. This is called:
Reciprocal inhibition
Worsening temper tantrums in 3 y/o. First occurred in grocery store and child was quieted with candy. The tantrums would occur at home and would escalate until given candy. Psychiatrist tells parents not to give candy during a tantrum under any circumstances. Outcome?
Tantrums will increase then decrease
A medical student takes amphetamines to stay awake while studying for an exam. When she takes the exam without any medication, she finds that she has much greater difficulty than usual remembering the material.
State-dependent learning
Imitating one's valued mentor while performing psychotherapy is an example of what type of learning?
Social learning
Form of learned fear in which a person or an animal learns to respond more strongly to an otherwise innocuous stimulus is:
Sensitization
A mother gives an 8 y/o a "time out" for five min in the bedroom because of his misbehavior. This is an example of what behavioral technique?
Punishment
In learning theory, the presentation of an aversive stimulus that is contingent upon the occurrence of a particular response is known as:
Punishment
Child who fears bike riding becomes less fearful after watching other children having fun while bike riding. Which learning principal?
Modeling
During a certain time in development an animal is sensitive to a stimulus that provokes a behavior pattern at that time but not later. This is called:
Imprinting
30 y/o morbidly obese pt refuses to change eating and exercise habits, “I’ll worry about my health when I am 65.” One month later his father, also obese, dies of a myocardial infarction. The now obvious disparity between pt’s current behavior and knowledge of the circumstances surrounding his father's death is an example of which learning theory process?
Cognitive dissonance
Which research studies examine a group studied over a prolonged time period? ***
Cohort
Study reports difference that turns out to be by chance
Type I error
Which study best addresses the relative influences of heritability and environment?
Twin adoption studies
What is characteristic of the placebo effect?
The placebo effect is greater when the pt knows the doctor.
Findings can be replicated
Reliability
Results are combined from a number of studies of similar design. An overall estimate of the effect of a variable is made which incorporates the information provided by all the studies. The procedure is termed?
Meta-analysis
A psychiatrist employed by an institution wants to use pt data for research later. How can she get the progress notes?
Keep her own separate records
A case-control study can appropriately answer an epidemiological question when the:
Incidence of disease is low
Compared to those described as “low reactive” in Kagan’s longitudinal study of childhood inhibition, children described as “high reactive” at age 4 months were characterized by:
Higher rates of social anxiety at age 13
Small pilot study measures changes in MMSE scores to compare the efficacy of two meds for the treatment of Alzheimer’s. Data says there’s difference between meds, but not statistically significant. What do you need to do to clarify?
Enroll more subjects to obtain a larger sample size
The purpose of designing study to use the double blind method is to:
Eliminate bias due to examiner expectations
Clinical trial: 2 study meds in 8 hospitals. 20 receive drug 1 in hospitals A,B,C,D, while 20 receive drug 2 in hospitals E,F,G,H. Drug 1 is proven and indicated treatment. Which critical confounder biases the results?
Drug assignment depends on participant’s hospital.
A clinical trail will assess the impact of two atypical antipsychotic meds on glucose intolerance. Half of the participants will start on drug 1 and then be treated with drug 2, while the other half will start on Drug 2 then drug 1. What type of experimental design?
Crossover design
Psychiatrist is developing a new questionnaire about traumatic stress. Which of following actions would be most appropriate to test the measure’s construct validity?
Compare the score of hurricane survivors to those with no prior trauma
Type of study to determine relationship between risk factor and development of disease
Cohort Study
Chess and Thomas studied temperamental characteristics of a group of children at ages 3 months, 2, 5, and 20 years to determine relationships between initial characteristics of the infant and a subgroup of children who eventually had psychiatric problems. Type of study?
Cohort
5 yr old boy becomes restless, impulsive, and difficult to manage when not given sufficient exercise. Teacher gives him increased motor activity, and his behavior improves. This is an example of:
Goodness of fit
The deviation of x from its mean, which expressed in standard deviation units, is called?
Z-score
The validity of an assessment instrument refers to:
The extent to which it measures what it intends to measure.
What terms best defines the degree of spread of scores about the mean?
Standard deviation
A statistical term that refers to the proportion of pts with the condition in question that a test accurately detects:
Sensitivity
A method for making a prediction based on observable data in order to assess the valve of the one variable in relation to another is
Regression analysis
Statistical concept of power is defined as the
Probability of rejecting null hypothesis when it should have been rejected
The assumption that there is no significant difference between two random samples of population is called:
Null hypothesis
What is a measure of central tendency that might best be used to analyze an outcome measure with significantly skewed distribution of its values?
Median
Specificity is
Identifying the # of pt without the condition who have a neg test result
Test detects 98% of people w/ disease, but also high false positive rate
High sensitivity, low specificity
Which is used to evaluate the relative frequencies or proportions of events in 2 populations that fall into well defined categories
Chi - square
Groups of pt with MDD, dysthymia, and adjustment d/o were given mood scales. In order to compare the means of the scores of these groups, what statistical methods would be most appropriate?
Analysis of variance
Apoptosis of cortical neurons differs from necrosis in that it:
Involves expression of specific genes
13y/o with developmental delay, stereotyped behaviors, impaired social interactions, hyperactive behavior, large anteverted ears, hyperextensible joints, macroorchidism. Dx?
Fragile X
40 y/o man developed gradually progressive dementia and abnormal involuntary movements. Older brother and father have similar illness. Best Dx test
Excess CAG triplets in DNA analysis
Genetic anticipation
Earlier onset or worsening with each generation (with each transmission of unstable DNA)
What are genetic polymorphisms?
Variant DNA sequences prevalent in >1% of a population
A logarithmic odds (LOD) score for a gene represents what?
The most likely recombination frequency between two loci from pedigree data
Familial amyotrophic lateral sclerosis gene mutation
Superoxide dismutase (SOD)
A 4 y/o child that was hypotonic as an infant is now demonstrating developmental delays, foraging for food and having many temper tantrums. DX?
Prader-Willi syndrome
Skin tumors, abundant café au lait spots, Lisch nodules on iris is diagnostic of mutation on which gene:
NF-1 (neurofibromatosis-1 gene)
Which is the most common mitochondrial disorder (of 4 listed)?
Mitochondrial encephalopathy, myopathy, lactic acidosis, and stroke-like episodes (MELAS)
Which is seen in 90 – 100% of pt w/ narcolepsy (genetics)
HLA-DR2
Developmental disability syndromes associated with a triple repeat genetic abnormality:
Fragile X syndrome
MR, long ears, narrow face, short stature, connective tissue d/o, enlarged aortic root, high arched palate
Fragile X
Most common inherited mental retardation:
Fragile X
What d/o is due to triple repeat gene defect?
Fragile X
Mutations in the gene that codes for the parkinson protein are most commonly associated with which parkinsonism?
Early-onset Parkinson’s disease
Adrenogenital syndrome, Down syndrome, Hurler’s syndrome, Tay-Sachs disease and phenylketonuria all cause mental retardation. Which one does NOT have autosomal-recessive inheritance pattern?
Down syndrome
What neurological syndromes is the result of trisomy 21?
Down syndrome
Process of gene expression
DNA transcribed to mRNA and produces proteins
Strongest genetic contribution
Cyclothymic disorder
Genetic linkage studies investigates what in medico-psychiatric research:
Co-segregation of genes during meiosis
What is part of routine workup of child with mental retardation but without dysmorphic features or neurological findings?
Chromosomal analysis
Pattern of inheritance in Wilson’s disease
Autosomal recessive
Pattern of inheritance in Huntington’s disease
Autosomal dominant
Karyotyping is a method of genetic analysis characterized by which technique
Analyzing chromosomal structures
Polymerase chain reaction (PCR) used in genetic linkage studies involves:
Amplification of microsatellite markers
What conditions associated with MR have an autosomal recessive inheritance pattern?
Adrenogenital syndrome, Hurler’s, Tay-Sachs, Phenylketonuria
4 y/o does not run/climb, falls, has iliopsoas/quadriceps/gluteal weakness, enlargement of calves with firm, “rubbery” consistency, decreased DTRs and normal sensation. Wide based stance and walks waddling. When rising from the ground, uses a four-point position through full extension of all four extremities. Has family h/o similar sx in males. 1) EMG reveals? 2) Genetic mutation in what protein?
1) Small, short-lasting motor unit potentials with increased recruitment 2) Dystrophin
Scientific development that made NIMH epidemiological catchments area studies possible ***
The development of operationalized diagnostic criteria and standardized instruments
According to NIMH Epidemiologic Catchment Area Program’s reports on ethnicity and prevention of mental disorders, the lifetime rates of APD are: ***
Equal among Asians, Hispanics, African-Americans, and whites.
What scientific developments made the NIMH epidemiological catchment area studies possible: ***
Developing operationalized diagnostic criteria and standardized instruments
Leading cause of neuropsychiatric disability worldwide
Unipolar major depression
Pts with unipolar depression differ epidemiologically from pts with bipolar d/o in what way?
The discrepancy between male female lifetime prevalence rates is greater.
What is an example of secondary prevention?
Screening for depression.
The number of individuals with a d/o at a specific time
Point prevalence
Which population has highest prevalence of Schizophrenia?
Monozygotic twin of schizophrenic pt
When compared to younger age groups, the prevalence estimates of MDD in persons older than 65 years are:
Lower in both men and woman
Prevalence of psychotic disorders after age 65 is:
Lower in both men & women
What somatoform d/o has male=female?
Hypochondriasis
Leading cause of death for 15-24 y/o African American males?
Homicide
What best characterizes the current explanation for group differences in prevalence of psychiatric illness?
Factors that promote vulnerability to stress
Past years annual prevalence much higher than annual incidence
Disease is chronic
According to the WHO, the world's greatest cause of mortality, ill health and suffering is what?
Depression and suicide
The rate of illicit drug usage in high school is highest among which groups in USA?
Caucasian Americans
Highest prevalence psych d/o?
Anxiety disorders
What is prevalence of Alzheimer’s in >85 y/o?
16-25%
Lifetime prevalence rate for ETOH abuse and dependence
15%
Lifetime prevalence of schizophrenia
1%
How is ethnicity defined?
Groups of individuals sharing a sense of common identity, a common ancestry, and shared beliefs and history
14 y/o Native American girl with visions of elder spirits who appear and give her advice. Parents feel visions are gift but are worried about the child’s preoccupations interfering with schoolwork. No h/o mental d/o or substance abuse. Treatment goal:
Work on problems in school
Gender is best understood as referring to:
Ways in which cultures differentiate roles based on sex
Which of following most accurately describes scientific understanding of the concept of race?
Sociopolitical designation assigning individuals to a particular group that has meaning derived from prevailing societal attitudes
American psychiatrists tend to overdiagnose what in African American patients with mood and psychotic sx?
Schizophrenia
Culture-bound syndrome in Caribbean and states bordering Gulf of Mexico – anxiety, GI distress, weakness, fear of being poisoned, attributed to witchcraft
Rootwork
A family response to a member with ataque de nervios would most likely be to do what?
Rally to support the relative by removing stressors in her life.
Which is the most significant disadvantage of using a family member as interpreter for a patient who does not speak the psychiatrist’s language?
Pt may censor comments to keep info from the family
Most common complaint in southeast Asians who are dx w/ mental disorder is:
Multiple somatic symptoms
50 y/o Cambodian woman with 2 kids suffered catastrophic trauma from the Pol Pot regime in Cambodia (rape, abuse, watched family starve, escaped refugee camp with 2 kids). Has PTSD/MDD sx that are increased when her now grown daughter dates man patient doesn’t like. Needs supportive therapy, antidepressant, AND?
Group therapy of people of the patient’s own background who share the same experience
Across all cultures, what stressful life changes is correlated with greatest increase in death and illness in the subsequent 2 years?
Death of a spouse
Culture bound in industrialized countries per DSM IV
Bulimia
What culture-bound syndromes would be Dx for a pt with of insomnia, HAs, anorexia, fears, despair, diarrhea, & anger?
Ataque de nervios
29 y/o recent immigrant from China believes his penis is shrinking; concerned he might die once his penis retracts into his abdomen. 1) What type of d/o is this? 2) What is best treatment?
1) Culture-bound syndrome, 2) Supportive therapy
What DSM-IV diagnosis is likely for 41 y/o man with increasing sense of conflict about changing his beliefs from work-oriented to faith-oriented. Has no past or present psych symptoms, stable vocational hx.
Religious and spiritual problem
47 y/o with increased preoccupation with questioning her lifelong affiliation with her church and has been spending time visiting other churches. Concerned she is losing her faith, feels guilty and anxious. No SI, MSE normal, states would never act against her moral beliefs. Dx?
Religious or spiritual problem
48 y/o with chronic sadness and no relationships since husband died 12 years ago. Normal grieving, no DSM-IV criteria for d/o, has successful career and close friends. States has conversations with her dead husband and he talks to her. Believes in heaven. Likely classification of these experiences is:
Part of a belief system endorsed by her religion
What ethical principle provides the most appropriate basis for psychiatric intervention in a mentally incompetent patient? ***
Beneficence
In ethics, beneficence is: ***
Applying one’s abilities solely for the patient’s well-being. Physician acts Paternalistic
Psychiatrist judges patient under managed care plan will need combined psychopharm and psychotherapy for > 1yr. knows that health plan stops paying after 20 visits. Most ethical to tell patient:
Patient may need more tx than insurance covers
According to APA, it is unethical for a psychiatrist to:
Participate in legally authorized execution
The fact that participants did NOT receive available indicated treatment in the Tuskegee Syphilis study is an ethical violation of justice, beneficence or non-malfeasance?
Non-maleficence
What are the core psychiatric principles?
Justice, Beneficence, Autonomy, Nonmaleficence
Pt who is poor but talented asks if he can barter for services. You like the pt's product. What best describes the nature of this proposal to accept goods in lieu of fees
It is not recommended as it may compromise treatment boundaries
Psychiatrist wishes to charge pts for appointments that they do not keep. According to code of ethics of the American psychiatric association such a policy is:
Ethical if the patient is specifically notified in advance
Pt qualifies for ECT, but does not want his doc to tell him the risks. He is a “chronic worrier” and fears hearing the risks will make him anxious, perhaps to the point of refusing treatment, which he believes he needs. What is the best response?
Document the pt's knowing and voluntary waiver and proceed with treatment
Insurance company tells psychiatrist to switch from working drug to generic. You know alternatives may be good too. What do you do?
Contact insurance and ask for nonformulary approval
Psychiatrist calls pt at home, wife asks how pt is doing. What principle governs response?
Confidentiality
How should a psychiatrist handle an interview about the misbehavior of a prominent government employee?
Comment on human behavior generally, but refuse to offer opinions about the specific person
Gag-rule clauses in some managed care plans may prohibit docs enrolled in their plans from taking which action?
Advising pts about treatments not covered by HMO
What is the primary role of the psychiatric expert witness? ***
Render an opinion based on scientific knowledge
Criterion for a covered disability under Americans with Disabilities Act:
Substantially limits one or more major life activities
What determines disability?
Impairment affects ability to meet personal, social, or occupational needs
Pt getting psych exam to determine suitability for a job must be informed:
Exam is not confidential
Testamentary capacity refers to a person’s ability to? ***
Make a will
Mental competency of elderly pt determined by? ***
Judicial hearing
Psychiatrist is treating a 34 yo for anxiety and cocaine abuse. She is suing her employer for sexual harassment and is using her anxiety disorder as proof of the damage she has suffered as a consequence of the harassment. The psychiatrist has to inform her that if he is subpoenaed to court, he would have to do what?
Testify about all her psychiatric problems (cocaine abuse)
A physician who is testifying as an expert in court is different from a regular or “fact” witness in that the expert is allowed to testify about what?
Professional opinions
Several states established that the verdict guilty but mentally ill to be an option when a defendant pleads not guilty by reason of insanity because:
When compared to guilty, guilty but mentally ill is intended to ensure access to treatment but is essentially similar
In evaluating the sanity of a criminal defendant, the forensic psychiatrist should focus on current state of mind, or state of mind at time of offense?
State of mind at time of offense
The rule that finds people not guilty by reason of insanity due to mental illness that impaired their knowledge of the nature quality and consequences of their actions or they were incapable of realizing that these acts were wrong is called what?
M’Naghten rule
The criminal defendant tells the psychiatrist doing a forensic eval “I know that killing my father was illegal.” However, the defendant delusionally believed that the father was being tortured by demons and killing him was the moral thing to do. The defendant is unable to do what?
Appreciate the wrongfulness of his conduct
At the beginning of a radio talk show a psychiatrist states he is not entering into a doctor-patient relationship with any of the callers. Hereby he does not have ___ towards a patient in case of a malpractice suit.
Duty
Standard of care refers to treatments that are
Used by Average Reasonable Practitioners
Lawsuits against psychiatrist most frequently arise from issues concerning:
Suicide Attempts
The four basic elements that must be proven in order to sustain a claim of malpractice against a physician include a duty of care owed to the patient, negligence, causation, and what?
Harm to the patient
Patient’s confidentiality after death
Usually must be maintained
College student in therapy, the Dean calls therapist requesting info about the student’s therapy due to recent reports from a dorm supervisor. Therapist should:
Refuse the Dean’s request for information
Medical resident consults psychiatry because a 38 y/o F pt refused dialysis secondary to “antisocial personality” and the resident wants you to convince her to stay for treatment. Your answer is:
Will assess pt's competency to make one’s own medical decision
The most relevant issue for a geriatric or forensic psychiatrist in cases were the finances of an elderly are in dispute between partner and children is:
Whether the elderly has a mental disorder and whether is adequately treated
When should a schizophrenic admitted to a medical hospital for evaluation of chest pain have a formal assessment of decision-making capacity?
When there is reason to believe that the patient lacks the ability to understand, appreciate, or reason logically with the info relevant to healthcare decisions
The most appropriate time for a physician to discuss an advance directive with a pt is
When the pt is competent
78 yo w/ deteriorating personal hygiene, significant weight loss. Signs voluntary admission form but later forgets doing this. Potentially resectable masses in lung and brain requiring further consent for surgical and oncological treatment. Consents but cannot explain reason for surgery. Legally, psychiatrist should:
urgently request probate court appoint guardian with power to make treatment decisions
What characterizes the majority of defendants with psychiatric disorders who are found unfit to stand trial?
They can regain fitness in less than 90 days
An attorney requests psychiatric consultation when his defendant wants the worst possible outcome from the trial because he feels he deserves the worst punishment possible. What direction should you take for this case?
Probably meets criteria for finding of incompetence to proceed
US Supreme Court Decision Washington v Harper 1990, the right to refuse treatment is limited for prison inmates because:
Prison security concerns outweigh individual autonomy interests
Informed consent requires: presentation of information, voluntary consent from patient, and:
Mental competence
Murder trial, defendant states “I think murder is wrong but killing a spy from Mars who is trying to steal the secret of life is right.” This poses a problem for what type of evaluation of criminal responsibility?
M’Naughten Rule
Patient with MDD; psychiatrist prescribes antidepressant, psychologist provides interpersonal therapy. Who is responsible & accountable for what?
Psychiatrist is responsible & accountable for all treatment; psychologist just for psychotherapy
Describe the psychiatric assertive community treatment case management model:
Interdisciplinary team, services in situ, high staff/patient ratio, and intensive outpatient research
Pt consults a psychiatrist because a former psychiatrist has retired and the pt wishes to continue tx with antidepressants. The pt is seeing a counselor for weekly psychotherapy and plans to continue. The psychiatrists eval confirms the dx of MDD and psychiatrist feels that continuing the pt ‘s antidepressant is indicated. Next step?
Establish a clear understanding of the division of responsibilities between psychiatrist and counselor
29 yo schizophrenic frequent ER visits and hospitalizations. Hallucinating, agitated, not violent or suicidal, cooperative. Ran out of meds a few days ago, had been stable and doing well. Best intervention:
Contact case manager to verify environmental support
In ED evaluating a 29 yo F with frequent ED visits and psych admits for chronic schizophrenia. Actively hallucinations, agitated but not violent or suicidal and cooperative w interview. Stopped taking meds days ago because prescription ran out and caseworker was unavailable to get new one. Had been doing well on olanzapine for several months and was doing fairly well in structured living environment. Denies command AH. What should the next intervention here be?
Contact case manager and ensure she has environmental support
What are “least restrictive alternatives” for patients with serious mental illnesses?
Treatment should occur in a setting that interferes minimally with the patient’s civil rights
Pt has psychotherapist. Pt referred to psychiatrist who prescribes medication. Psychiatrist’s responsibility to pt
To follow up by seeing pt at appropriate scheduled intervals and by communicating regularly w/ psychologist about pt’s clinical status and tx plan
Final legal responsibility falls on
Psychiatrist
29 y/o severely depressed with SI. Threatens to kill his wife and daughter to “take them with me”. Legal responsibility:
Notify the wife
How do you resolve a mixed decision for among staff and family of a dying patient (continue tx vs let die):
Meet separately with family and staff to express issues of polarization
Goals of initial dialogue w/ doc requesting consult except;
Making sure family is not present
Major issue with maintaining severely mentally ill in community
Insufficient resources
Basic concept of community psychiatry
Continuity of Care
Initial step when child is referred for evaluation:
Consent for eval from guardian
Public mental health clinicians who follow patients through all phases of treatment
Case managers
23 y/o admitted in inpatient unit w dx acute psychotic d/o after threatening to beat up his mother (with whom he lives). Agreed to voluntary admit, but 2 days later demands to sign out AMA. What justifies involuntary hospitalization in this patient?
If the patient continues to threaten his mother
20 y/o pt is brought to ER by friend who is concerned about pt’s potential for assaultiveness. Which feature is most indicative of this risk?
Violence to others
Psych d/o in violent people
Substance related d/o
Duty as outlined by Tarasoff
Protect the Potential Victim of a Dangerous Patient
Best predictor of future violent behavior is:
Past violent behavior
What does NOT predict violence?
Non violent criminal activity
What is the relationship of violence to mental d/o?
mental d/o heightens risk in some, decreases risk in others
Homicide and homicidal behaviors are most often related to what factors?
Emotions not associated with mental illness
Drug least effective as adjunctive tx of chronic violent behavior
Diazepam
70 y/o presents with fearfulness, anger and agitation after moving in with adult child. On first visit pt is resigned and timid during exam. Which is most consistent with pt’s behaviors?
Psychological abuse
18 yo in ED, just raped. Immediate intervention:
Provide support and allow to vent
Characteristic of women with increased risk of battery
Pregnancy
Females have comparable rates to males for:
Domestic violence
20yo pt brings 2yo child to ER with multiple bruises. Mother says he fell down stairs. Mother has healing black eye and cut lip. Says she slipped on ice and hit head. Xray of child's arm show hairline fx and healing callous. What action should psychiatrist take first?
Admit child for care and protection despite mother’s objections
16 y/o caught for shoplifting jeans. No hx of stealing, jeans not her size. Pt frightened, remorseful, insomnia, failing grades, avoiding friends. Raped 2 mo earlier, family insisted she not tell anyone. Understand stealing as:
A cry for help
No harm contract between patients and clinicians are?
Unhelpful in making decisions
Rate of completed suicide highest for adult males when?
Older than 65
Most common method for completed suicides in adolescents
Firearms
In documenting suicide risk-assessment, key risk management strategy is to discuss what factors in the record?
Why the psychiatrist rejected alternative ways of responding
Pt with which medical condition most likely to commit suicide?
Symptomatic HIV infection
The leading cause of death among gun buyers in the first year after the weapon was purchased is:
suicide
What psychiatric symptom does not require pharmacologic treatment in the ER?
Suicidality
Along w/ depression most common comorbid disorder in physician suicide is
Substance dependence
Preventing adolescent suicide:
Remove firearms
Most common time for pt w/ schizophrenia to attempt suicide is during
Recovery phase of the illness
Consistent predictor of future suicidal behavior
Prior attempts
What factors is most highly correlated with completed suicide in adolescent males?
Previous suicide attempt
Which d/o is most common among pts who complete suicide
mood
Which commonly precipitates suicide in the elderly?
Loss
Most powerful statistical risk factor for completed and attempted suicide
Having a psych illness
Most common method of committing suicide for women in the US is:
Firearms
15 y/o pt depressed + suicidal has an alcoholic father. Prior d/c from hospital the next step should be:
Ensure that any lethal means are unavailable at home
1993 – highest rate of suicide in 75-84 y/o age group:
Caucasian-American males
Pt with which dx are most likely to engage in parasuicidal behaviors?
Borderline d/o
When is there the highest risk of suicide in MDD patients recently dc’d from hospital?
0-3 months after dc
Prevalence rate of suicide in general adolescent population?
10%
62 y/o requests antidepressant. Spouse died 6 wks ago. Crying spells, decreased appetite, poor sleep. Continues to see friends, no SI. FamHx of depression, no prior depressive episodes. Dx and Tx?
Bereavement. Assure patient of no pathology
Normal bereavement in prepubertal children
Wish to unite w/ dead loved one
A 5 y/o has been enuretic after mother died in an MVA 4 days ago and keeps saying, "Mommy will come home soon." The father wonders if the children should attend the funeral. What is your recommendation?
The child and sibling should both be allowed to attend if they want to go.
Which symptom would indicate MDD rather than just bereavement? Poor appetite and sleep, hearing the voice of the loved one, feelings of guilt or thoughts of suicide?
SI
A 30 y/o patient recently dx w/ Hodgkin’s dz constantly states, “Why me?” According to Elizabeth Kubler-Ross, the patient’s reaction is consistent with what phases?
Shock and denial
What is a symptom of normal bereavement in a <5 y/o child after the death of a parent?
Regression in bowel and bladder control
60 y/o lost spouse 2 wks ago – sadness comes and goes
Normal grief
58 yo have week’s h/o intense feelings of sorrow and bitterness only 6 mos after wife’s death. “We would have been married 30 yrs this month.” His daughter confirmed his level of functioning only took a dip a week ago. Moderate diff sleeping and poor appetite only assoc sxs. No SI. Physical exam normal. Diagnosis:
Delayed grief
1-month post death of loved one. What would suggest a pathological grief rxn?
Cont. feelings of worthlessness
Risk factor that can adversely influence psychological outcome of a child following death of a parent?
Conflictual relationship w/ deceased parent
A 6 y/o girl hospitalized for surgery to repair a fracture sustained in a MVA in which her mother was injured an brother died. She reports seeing her brother in her room since the accident, otherwise MSE is normal. She is receiving vicodin and benadryl. What explains pt seeing brother in her room?
Bereavement
10 y/o M s/p MVA sustained burn and crush injuries to R foot 4 days ago, does not remember the accident but never lost consciousness, keeps asking for his mother who was killed in the accident and having nightmares crying out “Daddy help Mommy.” When should the child be told about his mother’s death?
ASAP
45 y/o still grieving for mother 3 years after her death. States she feels her mother hovering over her and sees mother at night. Friends are concerned. Patient has normal job function, cleans house, endorses anhedonia. Tx?
Antidepressant medication and psychotherapy
Risk of complicated bereavement
1) ambivalent relationship to deceased; 2) simultaneous grieving for multiple deaths; 3) pre-existing low self-esteem & insecurity; 4) recurrent major depression
25yo male pt has noted sexual arousal and even attained erections while rubbing up against unsuspecting women on subway. This is:
Frotteurism
Treatment of premature ejaculation:
Fluoxetine
Cross-dressing for the purpose of sexual excitement is called:
Transvestic fetishism
What treatment should be offered first to otherwise healthy 34 y/o man for premature ejaculation?
Training in behavioral techniques to delay ejaculation
What statement describes principles of treatment of pt with sexual dysfunction?
Thorough med eval and treatment of any medical cause or d/o should be performed before entering therapy
25 yo M w/ premature ejaculation refuses meds. Tx?
Squeeze technique
65 yo M with impotence has diabetes and AF. A psychiatrist recommends sildenafil after an internist said pt is safe from cardiac standpoint to have sexual activity. Do you tell pt his impotence is due to diabetes or erectile dysfunction parallels diabetic complications or that sildenafil works for the majority of patients with diabetes?
Sildenafil works for the majority of patients with diabetes
65 y/o patient w MDD c/o anorgasmia after starting treatment with fluoxetine. Which is the best treatment for his problem?
Sildenafil
Patient dissatisfied with marriage, no sex in year despite husband’s efforts, whenever husband tries to kiss her she becomes disgusted, uncomfortable, anxious. Avoids sex by neglecting personal hygiene. Dx?
Sexual aversion disorder
Masturbation in adults as viewed by contemporary psychiatry is best described as:
Psychopathological only if it is compulsive
Homosexual couple w/ sexual dysfunction. Consider:
Possibility of link between problems of substance abuse and acceptance of sexual orientation
Reluctance to discuss sex issues or take sex hx
Physician’s own anxiety
Sildenafil inhibits which enzyme?
Phosphodiesterase 5
Pt uses oral sex as sole source of sexual gratification, refusing coitus. Diagnosis?
Partialism
Psychiatrist conducting and independent medical exam for individual’s employer to determine fitness to return to work after med suspension due to supervisory complaints of erratic behavior and lapses in judgment. Despite having been informed that the results of the exam are not confidential and will result in a report to the employer, the individual reveals being homosexual, but not being “out” in workplace. Best way to handle material is:
Omit the material unless it is directly related to the reported work problems
8 y/o boy is sexually seductive to other children, openly display sexual behavior, and to sexualize play activities. This is most likely a manifestation of?
Normal sexual behavior
Pt tells Dr “ I feel like a woman trapped in man’s body” most likely dx
Gender identity disorder
Chronic disease causing progressive erectile failure
Diabetes
35 y/o woman who repots being happily married responds well to fluoxetine for depression. On follow-up, complains of anorgasmia. Most helpful tx?
Cyproheptadine
New-onset ED despite satisfactory sex life w/ wife. Preoccupied w/ job, arguing more. Nml PHx
Couple psychotherapy (instead of somatic therapy)
Explains psychosexual in infants and children, paired with right hypothesis
Cognitive development – sexual behavior determined by self-image and gender identity
What dopamine agonist has been used to treat pts with erectile dysfunction?
Apomorphine
Two weeks after beginning a strict diet, a 24 yo patient has abdominal and limb pain. He is anxious, pale and tachycardic on exam. Unable to orient and seems to be responding to hallucinations. Friends said this happened similarly from time to time. Diagnosis?
Acute Intermittent Porphyria
According to APA guidelines, what is the place of expert opinion in evidence-based medicine?
Ranks as evidence comparable to case studies
What is a neologism?
Patient makes up a word
Tx apathy d/o without accompanying depression
Methylphenidate
What medication has been known to precipitate a tic disorder?
Methylphenidate
10 y/o girl w/ hep B is evaluated for persistent difficulty w/ schoolwork since 1st grade. Often looses homework, seems not to listen to parents or teachers. If needed treatment what will you give?
methylphenidate
Stockholm syndrome is defined as:
Development in hostages of positive emotional feelings toward captors
Which sxs common in pt after anabolic steroid discontinuation?
Depression
20 y/o football player injured, in hospital is irritable, aggressive, grandiose. Cause?
Anabolic steroids
Who characterized mental illness based upon the interaction of the four humors?
Hippocrates
Who noted that major mental illnesses have different courses and outcomes?
Emil Kraepelin
Who developed Moral Treatment?
Phillipe Pinel
Developed interpersonal theory of psychiatry
Melanie Klein
Who coined the term "contact comfort" and demonstrated that newborn Rhesus monkeys separated from their mothers chose contact comfort over food and water?
Harry Harlow
Which individual coined the term “schizophrenia” and introduced the terms “ambivalence” and “autism”?
Eugene Bleuler
Which individual articulated a theory of psychosocial developmental phases according to a predetermined sequence?
Erik H. Erikson
Who established that learning produces changes at the neuronal level, in turn facilitated by alterations in gene expression:
Eric Kandel
The approach to diagnosis that has been taken in current editions of the DSM is considered to grow from and be closest to that of whom?
Emil Kraepelin
Who first differentiated between dementia praecox and manic-depressive illness?
Emil Kraepelin
Anna Freud’s contribution to child development based on conceptualizing:
Developmental lines in six areas of adaptive functioning
DSM II called Dysthymic disorder what?
Depressive neurosis
Caregiver’s attempts to underscore child’s feeling state (Stern)
Attunement
23 y/o CF in office for f/u appt after an ER visit 2 days earlier for sudden diplopia, R leg weakness and shaking, difficulty w/ speech which resolved after a few hours. Pt had fever 103.1 F and was tx for UTI. Current exam shows normal CN & sensory, minimal R leg weakness, brisk DTR and musculocutaneous reflexes throughout, and equivocal plantar reflex on L. R toe is downgoing. Review of hx reveals several episodes of transient neurological deficits that resolved spontaneously after a few days. Her spinal fluid is most likely to show what?
Protein 50mg, +oligoclonal bands, nucleated cells 10.
26 year old with sudden onset back pain. Spasms in the right paraspinal muscles in the lumbar region. Straight leg raising on the right is limited by sharp pain at 45 degrees. Ankle jerk on Left is diminished. No muscle weakness, no sensory deficit. Next step?
Order MRI scan of the lumbar spine