PSYCHIATRY Step 1 review

1. PSYCHIATRY Step 1 review February 28, 2011

2. Approach to questions • Underline/count/highlight EACH SYMPTOM • Make note of the DURATION of the symptoms being described • Rule out MEDICAL causes

3. Frequently tested psychology concepts • “White Coat Syndrome” Classical Conditioning • when a natural response (increase in BP) is elicited by a conditioned stimulus (white coat) • Transference • Patient projects feelings about another person onto psychiatrist • Countertransference • Doctor projects feeling about another person onto patient

4. Ego defenses • GUARANTEE – you will be asked at least 1 question about this • Immature… • Acting Out • Dissociation – can result in multiple personality disorder • Denial – common when someone first hears of a diagnosis • Displacement – mother towards child • Fixation • Identification • Isolation of affect • Projection • Rationalization– logical reasoning to explain events • Reaction formation – think opposite • Regression • Repression – NOT voluntary (vs suppression) • Splitting – borderline personality disorder; think extremes

5. Ego defenses (cont’d) • Mature… • Altruism • Humor • Sublimation • Suppression - VOLUNTARY

6. Child neglect • Any question that hints towards child neglect and/or abuse… REPORT to local child protective services!!

7. Childhood/early-onset • ADHD = limited attention; poor impulse control • Before age 7 • two settings • Decreased frontal lobe volumes • Tx = methylphenidate, amphetamines, atomoxetine • Conduct Disorder = behaviors that violate social norms • If > 18y/o = antisocial personality disorder

8. Childhood/early-onset • Oppositional Defiant Disorder = defiant behavior towards authority figures • Tourette Syndrome = motor and vocal tics • > 1 year • Onset < 18 y/o • Associated with OCD • Tx = antipsychotics (haldol) • D2 receptor blockers

9. Pervasive developmental • Autism = repetitive behaviors, poor social interactions, language impairment • Tx = behavioral and supportive therapy • Asperger’s Disorder • Normal intelligence; no language impairment • Rett’s Disorder • X-linked; mostly girls • Normal until 4 y/o and then regress; handwringing

10. Amnesia • Retrograde • Don’tremembereventsthatoccuredbefore the insult • Anterograde • No new memory • Korsakoff • Anterograde caused by THIAMINE deficiency • Destruction of mamillary bodies • Alcoholics; confabulation

11. Delirium vs. dementia DELIRIUM DEMENTIA No change in level of consciousness Gradual Irreversible Behavioral/personality changes Normal EEG Caused by: Alzheimer’s, hemorrhage, HIV, Pick’s, CJD • Waxing and waning level of consciousness • Acute onset • Reversible • Hallucinations, illusions, misperceptions • Abnormal EEG

12. schizophrenia • 2 or more of the following symptoms… • Delusions – fixed, false belief • Hallucinations – perception in the absence of a stimulus • Disorganized Speech • Disorganized or Catatonic Behavior • “Negative Symptoms” – flat affect, social withdrawl, lack of motivation, lack of speech • Symptoms must be present for > 6 months • if < 1 month= brief psychotic disorder • If 1 – 6 months= schizophreniform disorder

13. Bipolar disorder • Presence of at least one manic or hypomanic episode • The depression will occur eventually if it hasn’t already • Mania = 3 or more of the following sympotms • Distractability • Irresponsibility • Grandiosity • Flight of ideas • Increased goal-directed activity • Decreased need for sleep • Talkativeness (pressures speech) • Symptoms must be present for 1 week

14. Bipolar disorder (cont’d) • Hypomania • Less severe form of mania that does not cause impairment • No psychosis; no hospitalization • Treatment = mood stabilizers • Lithium, valproic acid, carbamazepine • Cyclothymic Disorder • Duration of 2 years

15. Major depressive disorder • 5 or more of the following symptoms • Change in sleep habits • Loss of interest • Feeling of guilt • Decreased energy • Inability to concentrate • Change in appetite • Psychomotor retardation or agitation • Suicidal thoughts • Symptoms must be present for 2 weeks • 1st line treatment = SSRI • Dysthymia = milder form; lasting 2 years

16. Atypical depression • Hypersomnia • Overeating that leads to weight gain • Mood reactivity • Treatment = MAO Inhibitors

17. Postpartum blues • Benign • Lasts up to 10 days postpartum • Tx = watchful waiting • If there is anhedonia, then postpartum depression

18. Panic disorder • Presence of panic attacks • A discrete time period (around 10 minslong) in which at least 4 of the following are experienced • Palpitations • Paresthesia • Abdominal discomfort • Nausea • Intense fear of dying • Light-headedness • Chest pain • Chills • Choking • Sweating • Shaking • Shortness of breath • Associated with hyperventilation and decreased pCO2

19. PTSD • Traumatic event must have involved actual or threatened death and/or harm • Symptoms include… • Nightmares • Flashbacks • Intense fear • Helplessness • Easily startled • Symptoms must be present for at least 1 month; and it must be 1 month after the event • if 2 days – 1 month = acute stress disorder

20. Generalized anxiety disorder • Uncontrollable anxiety/worrying that is UNRELATED to anything • If RELATED to something, then it is a specific phobia • Lasting at least 6 months

21. Malingering vs. factitious MALINGERING FACTITIOUS DISORDER Consciously creates symptoms seeking primary gain Willingness to receive treatment “Munchausen’s syndrome” “by proxy” when illness in a child is caused by caregiver • Consciously fakes a disorder • Seeking secondary gain • Avoids treatment

22. Somatoform disorders • Physical symptoms without a physical cause • Unconsciously driven • Somatization disorder • At least 4 pain, 2 GI, 1 sexual and 1 pseudoneurologic complain over a period of years • Conversion disorder • Motor or sensory symptoms following an acute stressor • Hypochondriasis • Body dysmorphic disorder • Pain disorder

23. Cluster a personality disorders • Think “weird” • Paranoid • Schizoid • Socially isolated and withdrawn • Content about the above • Limited emotional expression • Schizotypal • Eccentric • Magical thinking • Odd beliefs

24. Cluster b personality disorders • Think “wild” • Antisocial • Criminality • REMEMBER….if < 18y/o = conduct disorder • Borderline • Unstable mood; impulsivity • Unstable relationships • Self-mutilating • REMEMBER…splitting • Histrionic • Attention seeking • Narcissistic • grandiose thinking; lacks empathy

25. Cluster c personality disorders • Think “worried” • Avoidant • Socially inhibited but desires relationships • Obsessive compulsive • Preoccupation with perfectionism • Dependent • Excessive need to be taken care of

26. Eating disorders ANOREXIA NERVOSA BULIMIA Binge eating with purging Parotitis Enamel erosion Hand calluses “Russell’s sign” • Excessive dieting • Fear of gaining weight • Decreased bone density • Amenorrhea (from loss of pulsatile secretion of GnRH from hypothalamus) • Decreased LH, FSH, estradiol

27. Substance abuse • Alcohol… • Serum GGT is a sensitive indicator of alcohol use • Tx for overdose = naltrexone, disulfiram • Tx for withdrawl/DT = benzodiazepines • Opiods (morphine, heroin, methadone)… • Overdose leads to pinpoint pupils • Tx for overdose = naloxone, naltrexone • Tx for withdrawl = methadone • Barbiturates… • Overdose can cause respiratory depression • Benzodiazepines… • Tx for overdose = flumazenil

28. Substance abuse (cont’d) • Amphetamines… • Overdose causes pupillary dilation • Cocaine… • Tx of overdose = benzodiazepines • Nicotine… • Tx of withdrawl = bupropion/varenicline • PCP… • Overdose leads to: belligerence (aggressiveness), nystagmus and homicidality • LSD… • Overdose leads to: hallucinations, flashbacks

29. antipsychotics • Typical = haloperidol + “azines” (ex: thioridazine) • Block dopamine D2 receptors • Used to treat: positive symptoms of schizophrenia, psychosis, acute mania, Tourette’s • Toxicity… • Hyperprolactinemia that can lead to galactorrhea and amenorrhea • NMS – fever, muscle rigidity, unstable vitals; tx = dantrolene • Tardive dyskinesia – oral/facial movements from long-term use • Atypical = olanzapine, clozapine, risperidone • Used to treat: positive AND NEGATIVE symptoms of schizophrenia • Toxicity… • Clozapine can cause agranulocytosis (weekly WBC monitoring)

30. Lithium • Mood stabilizer used in the treatment of bipolar disorder • Many side effects… • ADH antagonist characteristics so can cause nephrogenic diabetes insipidus • HYPOthyroidism • Tremors • Teratogenic

31. antidepressants • TCAs = end in “pramine” or “triptyline” • Also used for the treatment of fibromyalgia • Anticholinergic side effects • Toxicity…Convulsions, Coma, Cardiotoxicity • SSRIs = fluoxetine, paroxetine, sertraline, citalopram • Can cause sexual dysfunction • Serotonin Syndrome • Hyperthermia, muscle rigidity, cardiovascular collapse, flushing, diarrhea, seizures • tx. = cyproheptadine • SNRIs = venlafaxine, duloxetine • MAO inhibitors = phenelzine, selegiline • Hypertensive crisis with tyramine ingestion (wine and cheese)

32. Atypical antidepressants • Bupropion • Can cause seizures • Mirtazapine • Maprotiline • Trazodone • Used for insomnia • Can cause men to have a prolonged erection (priapism)

33. Know your transmitters • Anxiety • Decreased: NE, GABA, serotonin • Depression • Decreased: NE, serotonin, dopamine • Alzheimer’s • Decreased: ACh • Huntington’s Disease • Decreased: GABA, Ach • Schizophrenia • Increased: dopamine • Parkinson’s • Decreased: dopamine • Increased ACh

34. Practice questions

35. A 24-yeal-old man with chronic schizophrenia is brought to the emergency room after his parents found him in his bed and were unable to communicate with him. On examination, the man is confused and disoriented. He has severe muscle rigidity and a temperature of 103F. His BP is elevated and he has a leukocytosis. Which of the following is the best first step in the pharmacologic treatment of this man? A – haloperidol B – lorazepam C – dantrolene D – benztropine E – lithium

36. A 19-year-old man is brought to the physician by his parents after he called them from college, terrified that the mafia was after him. He is convinced that the mafia has put cameras in his dormitory room. He occasionally hears the voices of two men talking when no one is around. His roommate states that for the past 2 months he has been increasingly withdrawn and suspicious. What is the most likely diagnosis? A – delusional disorder B – schizoaffective disorder C – schizophreniform disorder D – schizophrenia E – PCP intoxication

37. A 27-year-old woman has been feeling blue for the past 2 weeks. She has little energy and has trouble concentrating. She states that 6 weeks ago she had been feeling very good, with lots of energy and no need for sleep. She says that this pattern ahs been occurring for at least the past 3 years, though the episodes have never been so severe that she couldn’t work. What is the most likely diagnosis? A – borderline personality disorder B – seasonal affective disorder C – cyclothymic disorder D – major depression, recurrent E – bipolar disorder

38. A 13-year-old girl grunts and clears her throat several times in an hour, and her conversation is often interrupted by random shouting. She also performs idiosyncratic, complex motor activities. She can prevent these movements for brief periods of time, with effort. Which of the following is the most appropriate treatment for this disorder? A – psychotherapy B – lorazepam C – methylphenidate D – haloperidol E – imipramine

39. A 26-year-old woman comes to the psychiatrist with a 1-month history of severe anxiety. The patient states that 1 month ago she was as “normal, laid-back person”. Since that time she rates her anxiety an 8 on a scale of 1 to 10, and also notes she is afraid to leave the house unless she checks that the door is locked at least 5 times. Which of the following medical conditions could commonly cause this kind of symptom presentation? A – hyperglycemia B – Crohn’s disease C – hyperparathyroidism D – fibromyalgia E – peptic ulcer disease

40. A 20-year-old woman comes to her primary care doctor with multiple symptoms which are present across several organ systems. She has seen five doctors in the past 3 months and has had 6 surgeries since the age of 18.What is the most likely diagnosis? A – somatization disorder B – conversion disorder C – hypochondriasis D – body dysmorphic disorder E – pain disorder

41. A young librarian has been exceedingly shy and fearful of people since childhood. She longs to make friends, but even casual social interactions cause her a great deal of shame and anxiety. She has never been to a party, and she has requested to work in the least active section of her library, even though this means lower pay. She cannot look at her rare customers without blushing, and she is convinced that they see her as incompetent and clumsy. Which of the following personality disorders is most likely? A – schizotypal B – avoidant C – dependent D – schizoid E – paranoid

42. Three policemen, with difficulty, drag an agitated and very combative young man into an emergency room. Once there, he is restrained because he reacts with rage and tries to hit anyone who approaches him. When it is finally safe to approach him, the resident on call notices that the patient has very prominent vertical nystagmus. Shortly thereafter, the patient has a generalized seizure. Which of the following substances of abuse is most likely to produce this presentation? A – amphetamine B – PCP C – cocaine D – meperidine E - LSD