Notes 3-13

Report
PSYCHIATRY
STEP 1 REVIEW
FEBRUARY 28, 2011
APPROACH TO QUESTIONS
• Underline/count/highlight EACH SYMPTOM
• Make note of the DURATION of the
symptoms being described
• Rule out MEDICAL causes
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
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
EGO DEFENSES (CONT’D)
• Mature…
• Altruism
• Humor
• Sublimation
• Suppression - VOLUNTARY
CHILD NEGLECT
• Any question that hints towards child neglect
and/or abuse…
REPORT to local child
protective services!!
CHILDHOOD/EARLY-ONSET
• ADHD = limited attention; poor impulse control
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•
•
•
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
CHILDHOOD/EARLY-ONSET
• Oppositional Defiant Disorder = defiant
behavior towards authority figures
• Tourette Syndrome = motor and vocal tics
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•
•
•
> 1 year
Onset < 18 y/o
Associated with OCD
Tx = antipsychotics (haldol)
• D2 receptor blockers
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
AMNESIA
• Retrograde
• Don’t remember events that occured before the
insult
• Anterograde
• No new memory
• Korsakoff
• Anterograde caused by THIAMINE deficiency
• Destruction of mamillary bodies
• Alcoholics; confabulation
DELIRIUM VS. DEMENTIA
DELIRIUM
• Waxing and waning
level of consciousness
• Acute onset
• Reversible
• Hallucinations, illusions,
misperceptions
• Abnormal EEG
DEMENTIA
• No change in level of
consciousness
• Gradual
• Irreversible
• Behavioral/personality
changes
• Normal EEG
• Caused by: Alzheimer’s,
hemorrhage, HIV, Pick’s,
CJD
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
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)
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
MAJOR DEPRESSIVE DISORDER
• 5 or more of the following symptoms
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•
•
•
•
•
•
•
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
ATYPICAL DEPRESSION
• Hypersomnia
• Overeating that leads to weight gain
• Mood reactivity
• Treatment = MAO Inhibitors
POSTPARTUM BLUES
• Benign
• Lasts up to 10 days postpartum
• Tx = watchful waiting
• If there is anhedonia, then postpartum depression
PANIC DISORDER
• Presence of panic attacks
• A discrete time period (around 10 mins long) 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
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
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
MALINGERING VS. FACTITIOUS
MALINGERING
• Consciously fakes a
disorder
• Seeking secondary
gain
• Avoids treatment
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
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
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
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
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
EATING DISORDERS
ANOREXIA NERVOSA
• Excessive dieting
• Fear of gaining weight
• Decreased bone
density
• Amenorrhea (from loss
of pulsatile secretion of
GnRH from
hypothalamus)
• Decreased LH, FSH,
estradiol
BULIMIA
• Binge eating with
purging
• Parotitis
• Enamel erosion
• Hand calluses
• “Russell’s sign”
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
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
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)
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
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)
ATYPICAL ANTIDEPRESSANTS
• Bupropion
• Can cause seizures
• Mirtazapine
• Maprotiline
• Trazodone
• Used for insomnia
• Can cause men to have a prolonged erection
(priapism)
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
PRACTICE QUESTIONS
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
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
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
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
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
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
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
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

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