Uworld Psychiatry (step2)*****************************
Terms in this set (227)
Why does risperidone causes gynecomastia, galactorrhea and menstrual dysfunction ?
Because it blocks dopamine in the tuberoinfundibular pathways which leads to increased levels of prolactin causing the array of previosly mentioned symptoms
What does low levels of dopamine cause increase levels of prolactin?
Because dopamine is a prolactin-inhibiting factor
What is a common side effect of valproate?
What are the major contraindications for bupropion?
Eating disorders - anorexia nerviosa or bulimia nervosa
Recent use of MAO;s
Why are eating disorders contraindications for bupropion med?
Because eating disorders may cause electrolyte abnormalities which can potentially induce or increase the chance of seizures
Mechanism of action of bupropion ?
NE & Dopamine reuptake inhibitors thus increases the levels of these two hormones
How should you deliver bad news?
In a face to face visit with a comfortable and private environment
What is the SPIKES protocol for delivering bad news?
A protocol for formulating a collaborative treatment plan with the patient and physician
What does SPIKES stand for?
Set the stage - private, comfortable
Perception - open ended questions
Invitation - ask how much info they want
Knowledge - warn for bad news. Be simple
Empathy - express understanding
Summary - summarize and creat follow through plan
In schizophrenia, what does it mean delusions of reference ?
Receiving special messages from the TV or radio 📻
What is the diagnostic criteria for schizophrenia ?
> 6 months
Positive symptoms ( hallucinations, delusions, disorganized speech)
Negative symptoms (flat affect, lack of motivation, social withdrawal, anhedonia or poverty of speech)
What are the SIG E CAPS of depression
What are the clinical features of acute stress disorder
Exposure to actual or threatened trauma causes intrusive memories
Intense psychological reactions
Arousal with sleep disturbances
Hypervigilence and exaggerated startle, Impaired 
Dissociative symptoms ( amnesia or feeling of unreality)
What is the timeline for acute stress disorder ?
>3 days but < 1 month
If the symptoms for acute stress disorder last for longer than 1 month, what would the disorder be named?
What is the difference between adjustment disorder and acute stress disorder ?
Adjustment disorder's onset has to be within 3 months of life event (which is not life threatening) and cannot last longer than 6 months
Mood changes are not major as compared to acute stress disorders
What are the two psychiatric diseases that are heavily associated with genetics
What is a serious side effect and big issue with lamotrigine?
Steven Johnson's syndrome
What is antidepressant discontinuation syndrome?
Sudden onset of symptoms (dysphoria, fatigue, insomnia and myalgias, GI issues, tremors, vivid dreams) after sudden discontinuation of antidepressants
What is the best way to treat antidepressant discontinuation syndrome?
Re-instate antidepressant and taper down in 2-4 weeks
What are some of the clinical presentations a patient on cocaine main present like
Psychotic symptoms (paranoia, hallucinations)
May resemble an acute manic episode
What is the typical presentation on PE in a pt on PCP?
Common symptoms of cocaine abuse ?
What are some of the symptoms of opiod withdrawal/
Abdominal cramps + hyperactive bowel sounds
When can opioid withdrawal being ?
6-12 h s/p last intake of drug for short acting
24-48 h for long acting like methadone
What are common withdrawal symptoms found in stimulant withdrawals
Intense psychomotor retardation
Severe depression "crash"
What are common withdrawal symptoms of both OH and Benzos?
Alcohol has delirium
At what value will lithium toxicity will occur?
What are the indications of clozapine?
Treatment resistant schizophrenia
Schizophrenia associated with suicidality
Major side effects of clozapine ?
Metabolic syndrome - weight gain
what does a presentation of a pt with GI problems such as nausea, diarrhea, vomiting and later developing tremors, fasciculations, ataxia represent ?
What drugs can exacerbate and or induce lithium toxicity ?
Concurrent NSAID use
What is acute dystonia reaction
Contractions of facial muscles
What are the first line treatment for bipolar disorder ?
What is a patients hx of recurrent spontaneous anxiety attacks and development of avoidance behavior most consistent with?
What can you typically develop if having panic disorders?
How are agoraphobia and panic disorders treated?
Do patients with social anxiety disorder experience spontaneous panic attacks?
Do not experience spontaneous panic attacks
What is the classical presentation of intermittent explosive disorder ?
Isolated episodes of assaultive or destruction behavior but usually there is no hx of childhood conduct disorder or other features of antisocial personality disorder
How old must individuals be to be diagnosed with antisocial personality disorder
What type of hallucinations may occur with alcohol hallucinosis?
What are the differences in timelines between delirium tremens and alcoholic hallucinosis
Alcoholic hallucinosis 12- 24h but 48 h after last drink
Delirium tremens 48-96 h
What is the timeline for brief psychotic disorder ?
>1 day but <1month
What are the symptoms of cocaine withdrawal ?
What characterizes alcoholic hallucinosis?
In a pt who has gone through a traumatic event and has had symptoms associated with it, yet does not want to talk about it, what should be the initial step?
Initial step is to provide education on the range of reactions that will normalize their experience AKA acute and PTSD disorders and encourage to seek help these symptoms persist
What is the first line treatment for acute stress disorder?
Trauma focused CBT
What do they mean by agranulocytosis ?
What are the different types of dysthymia depressive disorders
Dysthymia with either persistent or intermittent major depressive episodes
What are individuals with gender dysphoriua at an increased risk for?
Explain some of the key characteristics of gender dysphoria
persistent > 6 months incongruente between assigned and felt gender
Desires to be the other gender
Uncomfortable with own anatomy
What should be the initial treatment or rather approach for gender dysphoria ?
Multidisciplinary and psychological evaluation
What are the commonly used drugs for maintenance treatment for bipolar disorder?
How could you differentiate schizoaffective vs schizophrenia and bipolar disorder
Schizoaffective mood symptoms are present for significant parts of the illness while schizophrenia has mood symptoms for small portions of the illness and bipolar disorder has mood symptoms only during manic episodes or depressive episodes
What is important while diagnosing schizoaffective disorder ?
The timeline for which a depressed mood is present
What is cyclothymic disorder?
chronic mood of highs and lows for at least 2 years.
View it as a bipolar spectrum
What is the criteria for bipolar personality disorder ?
Pervasive pattern of impulsivity and unstable relationships
At least 5 of the following
Unstable self image
Difficulty controlling anger
Recurrent SI and attempts
Impulsivity in at least two potential harmful ways
Frantic efforts to avoid real or imagined abandonment
What is the treatment for BPD?
DBT which includes CBT, mindfulness, skills and group therapy
What is the criteria for bipolar II?
Hypomanic episodes which is less severe than manic
>1 major depressive episode
How long do hypomanic episodes last?
>4 consecutive days
Does hypomanic episodes have psychotic features ?
What is the DSM5 criteria for persistent depressive disorder? Dysthymia
Chronic depressed mood >2 years
No symptoms free period >2 mo
Presence of >2 of:
- poor appetite / overeating
- insomnia or hypersomnia
- low energy level
- poor 
- low self esteem
- feelings of hopelessness
What is the first line treatment for major depressive disorder with psychotic features?
Antidepressant + antipsychotics
What are both the acute and chronic presentations of lithium toxicity
Acute: GI (nause, vomiting, diarrhea)
Chronic: Ataxia, tremors/fasciculations, agitation, confusion
What is the specific symptom that differentiates Serotonin syndrome vs neuroleptic malignant syndrome?
Serotonin syndrome has clonus
What does acute dystonia present like?
Sudden, SUSTAINED and painful contraction of the neck, mouth, tongue & eye muscles
Think of muscle spasms
How do you treat acute dystonia ?
What is akathisia?
Feeling of relentless or inability to sit still
What is the treatment for akathisia?
Benzos (lorazepam [medium action])
What is the treatment for Parkinsonism 2/2 antipsychotics ?
What is tardive dyskinesia?
Involuntary rapid repetitive movements that involves the face, and tongue 👅
Think tardive for tongue
How do you treat tardive dyskinesia ?
What is a common presentation of acute dystonia?
Oculogyric crisis which is forced sustained elevation of the eyes in an upward position
What are the treatment for PTSD?
SNRI or SSRI
Plazo sin for nightmares
trauma focused CBT
What is the difference between panic disorders and panic attacks 2/2 phobia induced
Panic attacks in specific phobias are always triggered by the phobic stimulus unlike panic disorders where the panic attacks occur randomly
What is the first line treatment for phobia induced panic attacks?
CBT that includes exposure to the trigger
What is the timeline necessary for diagnosis of phobia?
What is the clinical feature of specific phobias?
Marked anxiety about an object or situation
Causes avoidance behavior
Upon giving bad news, what should a physician do right away?
Provide any necessary support and stay with them not prematurely provide reassurance, suggesting management or referring to other professionals
What is the difference between obsessive compulsive disorder and obsessive personality disorder (OCPD)
Patients with obsessive compulsive disorder have ego-dystonia belief (they know they do these crazy things) while OCPD are ego-syntonic meaning the controlling and perfectionism is normal and not problematic for them. Also OCPD lacks true obsessions and compulsions while obsessive compulsive disorder an obsession causes anxiety which leads to a compulsion as a reaction
Key features of DSM-5 personality disorder's table
What are avoidant personality disorder individuals like
Hypersensitivity and fearful of rejection
Feelings of inadequacy
Occupational dysfunction due to difficulties interacting with coworkers
What will you find with opiod overdose?
Miosis pupils <2-3 mm
Decreased bowel sounds
Does not respond to naloxone
What is naloxone
Which opiod does not cause miosis?
Mepiridine which causes mydriasis
What are the short acting Benzos? Mnemonic
What is the difference went naloxone and naltrexone?
Naloxone is short acting while naltrexone is long acting for opiod relapse prevention
what causes wernicke-korsakoff syndrome
thiamine deficiency B1
Can medical records be release if inquired by someone other than a patient?
Health insurance portability and accountability act (HIPAA) states that only patients have the legal right to obtain a copy that is not the original. Most places require a patients signatures for the medical records to be release
How long should you treat a pt w/ severe bipolar disorder type I?
Life long pharmacological maintenance
Weight gain and metabolic side effects is a common complication of treatment with what type of antipsychotics?
Second gen aka atypical
Major side effects of lithium
What is continuation phase treatment?
Continuing antidepressant treatment for an additional 6 months s/p resolution of symptoms
When a pt has tardive dyskinesia 2/2 antipsychotics and is not feasible to discontinue the antipsychotic, what should be the best way to go about this
Switch the pt to clozapine as this antipsychotic is least likely to cause EPS (quetiapine is another option)
What are the first line treatment of psychotic depressions ?
Antidepressants + antipsychotics or ETC
In what situations would you use ETC for depression
Emergency conditions such as:
Refusal to eat or drink
Imminent risk for suicide
Why should be careful when prescribing Benzos to elderly?
Because as they metabolized drugs slower an increase risk of adverse effects like confusion and falls will occur
What are side effects of Benzos in elderly?
Paradoxical agitation - confusion, aggression and disinhibition
What is the mechanism of action of donazepil ?
Acetylcholinesterase inhibitor, typically used in acetylcholine antagonist overdose such as atropine, pralidoxine
What is an adequate trial for antridepresents ?
What is the DSM 5 criteria for delusional disorder?
>1 delusions >1 month with no other psychotic symptoms and normal functioning apart from direct impact of delusions
Describe illness anxiety disorder
Experience of excessive anxiety about having or acquiring a serious illness but pt's actually have few or no somatic symptoms
What is conversion disorder?
Development of a neurological symptom that is inconsistent with recognized neurological disease
What is somatic disorder
Having extreme anxiety about a present symptom
What are the treatments for Bipolar I disorder ?
What is dissociative identity disorder?
Severe chronic condition in which 2 or more distinct identities or personality states take control of an individual
What is dissociative identity disorder associated w/?
Severe trauma/abuse, specially in childhood
Do patients with dissociative identity disorder have auditory hallucinations?
Yes, however; unlike those found in psychotic disorders, these voices are present within the patients head and not come from the outside like TV, radio etc.
What is dissociative amnesia ?
Inability ro recall important information usually of a traumatic or stressful nature
What is depersonalization/derealization disorder?
Persistent or recurrent experiences of 1 or both of
Depersonalization (feeling detachment from or being an outside observer of your body
Derealization (experiencing surrounds as unreal)
In addition to PTSD, what other trauma increases the lifetime risk for major depression, contemplation of suicide or actual attempts?
Sexual assault victims
What is capacity ?
Ability of a patient to understand the illness, treatment options and consequences as well as express a choice
What is the pharmacological treatment for neuroleptic malignant syndrome?
Bromocriptine or even amantidine if refractory
What are the cardinal features of NMS?
Muscular led pipe rigidity
What are the first line treatment medications for EtOH abuse?
When would you use disulfiram when dealing with alcohol abuse?
Abstinent patients who are highly motivated
And is a second line treatment for alcohol abuse after naltrexone and acamprosate
What is folie a deux?
A shared psychotic disorder or delusion of two closely related individuals
What is intellectualization?
Psychological defense mechanism which allows a person to avoid anxiety by focusing on the intellectual portion of the problem
What is altruism?
unselfish regard for the welfare of others
What is the mechanism of action of risperidone?
Besides serotonin and dopamine antagonistic effects, what other receptors does SGA have?
Alpha and anti-H1 receptors
What is special about the mechanism of action of aripiprazole ?
Partial agonist at D2 receptor
What is the mechanism of action of TCA's?
Serotonin and norepinephrine reuptake inhibitors
Which class of drugs have the same mechanism of action as SNRI's?
When insomnia is impairing, what is the first nonpharmacological interventions ?
What is ramelteon?
Melatonin agonist agent
What is the mechanism of action of mirtazapine?
Alpha 2, 5HT2, 5HT3 and H1 receptors antagonist
When is motivational interview indicated?
Behaviors in patients who are not ready to change
What are the techniques used in motivational interviewing?
Open ended questions
What are the 5 stages of change in overcoming substance abuse
What is the definition of social anxiety disorder?
Anxiety restricted to social or performance situations which causes fear of scrutiny and embarrassment
What is displacement ?
Transfer of feelings or impulses towards a safer, more acceptable person or situation.
What are the pharmacological first line therapies for smoking cessation
Nicotine replacement therapy
Mechanism of action of varenicline?
Alpha 4 beta 2 nicotine acetylcholine receptor partial agonist
What is varenicline been associated with ?
Cardiovascular events in pre-existing cardio disease
In order to meet the criteria for MDD, what should a pt meet
>2 weeks + 5/9 of SIG E CAPS and significant functional impairment
What is the treatment of choice for psychotherapy ?
Describe the characteristics of major depressive disorder with seasonal patterns
Depression that begins in the fall and ends in the spring/summer.
Atypical characteristics such as:
What is the first line treatment for major depressive disorder with seasonal pattern ?
Antidepressants + bright light therapy
What is bright light therapy?
bright light correlates with better mood thus 10,000 lux light box is administer shortly after walking up
When is MAO's typically used for?
Treatment resistant depression
What is the greatest risk factor in completing homicide ?
Access to firearms
List of homicide factors
What should your advice be to a recently s/p stroke pt?
Treatments for depression can help you feel better
What does research say about early treatment w/ antidepressants s/p stroke?
Improved physical and cognitive recovery
What does neuroimaging show in pt's with schizophrenia ?
Cortical tissue volume loss and cerebral ventricle enlargements
What is the most common finding in neuroimaging of a schizophrenic patient?
Lateral ventricular enlargement
What is associated with atrophy of the caudate?
What other neuroimaging finding is associated with schizophrenia
Decrease volume of hippocampus & amygdala
What is the characteristic presentation of Parkinson's disease dementia
Shortened stride (shuffling gate)
Impaired executive and visuospacial dysfunction
How can you differentiate between dementia with body Lewy bodies VS Parkinson's disease dementia?
PDD diagnosed when Parkinsonism predates cognitive impairment by >1 year
What is HIV associated dementia ?
its an HIV associated neurocognotive disorder 2/2 macrophage-mediated toxicity in the signaling pathways leading to neuronal dysfunction
What is the course presentation of symptoms of HIV-associated dementia ?
Subcortical degeneration - basal ganglia and nigrostriatal leading to motor slowing
Followed by cortical neuronal loss and memory loss
What are the first line medications for social anxiety discover ?
Beta blockers or Benzos for performance only
What changes occur with depression as far as sleep goes?
Decrease in REM latency & restorative sleep
What is the first line treatment for specific phobia
CBT which involves exposure to the phobic stimulus in a controlled setting
Are beta blockers used for specific phobia treatment ?
No, mainly used for performance associated social anxiety disorder
What are some of the features of sleep terrors?
Abrupt arousals form sleep typically unresponsive to comfort and associated with screaming, crying, tachycardia, flushing and fear
Little to no recall the next morning
What is the management of sleep terrors ?
What is the management for frequent sleep terrors that are persistent and distressing ?
Low dose benzo at bedtime
In what sleeping phase do sleep terrors occur in?
When do nightmares occur as far as sleep phase?
Occur during REM sleep
What is the management of postpartum blues?
Reassurance and monitoring
What is the treatment of postpartum depression?
What is the treatment for postpartum psychosis ?
Hospitalization + antipsychotics + antidepressants or mood stabilizers
What is the first line treatment for acute manic episodes ?
Benzos + lithium
Lithium + antipsychotics ' Benzos
All should be considered to be on Benzos + mood stabilizers w/ or w/o antipsychotics
What is the preferred pharmacotherapy treatment for acute episodes of psychosis?
Second gen antipsychotics due to having less side effects of EPS however you can also use
First gen antipsychotics
May also add Benzos for agitations PRN
Which mood stabilizer would you use in a pt with bipolar disorder for long term maintenance who has an elevated Cr?
Valproate as lithium is nephrotoxic
Which clue is the best predictor of complications due to overdose on TCA?
Prolonged QRS complex
What is the treatment of TCA overdose ?
What is crucial for schizophrenic patients in regards to treatment besides antipsychotics ?
Minimizing conflict and stress at home.
Aka family psychosocial interventions and education about the symptoms the pt may be experiencing and what they mean
What is fictitious disorder?
Intentional falsification or inducement of symptoms with a goal to assume sick role
What is the difference between malingering and factitious disorder?
Malingering is driven by an external incentive or secondary gain and procedures are avoided while factitious disorder the pt's sole motivation is to assume the sick role and procedures are involved
What is the first line therapy for OCD?
CBT + SSRI's
What personality disorder does dialectical behavioral therapy is prescribed for?
What is the goal of psychodynamic psychotherapy?
Traces problems back to their origins in childhood and unconscious conflict
What is the characteristic of obsessions in OCD?
Recurrent intrusive and anxiety provoking thoughts that causes urges or images
What is the characteristic of compulsions in OCD?
Response to obsessions with repeated behaviors or mental acts
Time consuming >1 h per day or causing significant distress or impairment
A hx of what is commonly seen in borderline personality disorder?
When is atomoxetine recommended for the treatment of ADHD?
In individuals w/ hx of substance abuse
What is Buspirone used for?
Which disorder is associated with acute psychotic episodes, thrombocytopenia, hematuria and protenuria ?
Table of differentials for acute onset psychosis in children & adolescents
What is the pharmacological treatment for performance only social anxiety?
What is the social anxiety disorder DSM 5 criteria?
Marked anxiety >1 social situation
Fear of scrutiny by others or humiliation
Social situations avoided or endured w/ intense distress
What is it called when an individual is unable to recall important personal information usually of a traumatic or stressful nature?
What are the PE findings of anorexia nervosa?
Calluses in the knuckles (Russell sign)
What are the two types of anorexia nervosa?
Binge eating/purging subtype
Restricting subtype - fast and exercise excessively
What is a commonly measured of BMI to determine anorexia in children/adolescents?
BMI below the 5th percentile
What is Catalonia?
Syndrome of immobility and mutism and posturing
In what situations can Catalonia occur in?
Mood disorders w/ psychotic features
Medical conditions (infectious, metabolic, neurological)
What is the treatment for Catalonia?
Benzodiazepines specifically lorazepam (medium actin benzo)
What is the treatment of choice in patients w/ Catalonia who do not respond to Benzos?
What is a lorazepam challenge test?
IV lorazepam 1-2 mg resulting in partial temporary relief
What does panic disorder involves?
Panic attacks and persistent concern about additional attacks or a change in behavior to avoid having another attack
What are the preferred long term treatment for panic disorders?
What is the DSM-5 diagnostic criteria for GAD?
>6 months of excessive worrying
Difficulty w/ 
What is the first line treatment for GAD?
SNRI's/SSRI's and CBT
What is the second line treatment for GAD?
What is suggestive of bulimia nervosa as far as behaviour
Person who binge eats, and then goes through a compensatory behavior of not eating or vomiting and exercising excessively or abuse of laxatives or enemas or even diuretics and diet pills
Excessively worried about body shape and weight
What is the difference between bing eating disorder VS bulimia nervosa?
Binge eating disorder does NOT have a compensatory behavior, they just dont give a ****
What regarding the hypothalamic-pituitary-adrenal axis is associated with major depressive disorder ?
Increased serum cortisol level
What part of sleep is affected with depression ?
Decrease in both:
REM sleep latency
What do patients with depression typically have associated
What are the electrolyte abnormalities associated with bulimia nervosa
What is factitious disorders?
Deliberate fabrication of symptoms with goals of assuming the sick role
Which debase has many neurovisceral symptoms and psychiatric symptoms ?
What is the presentation of an ACÁ infarct
-Contralateral somatosensory & motor deficits (more so on LE)
-Lack of will or initiative
-Dyspraxia, emotional disturbances URINARY INCONTINECE
What is the presentation of MCA occlusion ?
Contralateral somatosensory and motor deficit
Conjugate eye deviation towards eye of infarct
Aphasia if dominant hemisphere
Hemineglect if no dominate hemisphere
Picture of circus of Willy's circulation
What is the presentation of vertebrobasilar lesion ?
Alternate syndromes with contralateral hemiplegia and ipsilateral CN involvement
What is dystonia?
Abnormal muslce contraction
In what disease do you find athethosis movements
How long does it typically take for foodborn botulism to arise?
Within 36 hours
What is the typical presentation of foodborn botulism ingestion toxicity
B/L cranial neuropathic (blurred vision, diplopia, facial weakness, dysarthria and dysphagia
Symmetric descending muscle weakness
What is the treatment for foodborn botulism toxicity
Equine serum heptavalent botulism antitoxin
What is the biggest risk factor for lacunae infarcts ?
Lacunae infarcts are commonly associated with HTN, what is the name given to arteriolar sclerosis changes?
Lacunar stroke table
What is the most common sellar mass?
What are the visual effects of a sellar mass on vision?
Bilateral peripheral vision loss
Table describing different peripheral vision loses according to location of insult
What is optic neuritis and what disease is it associated with ?
How does it present?
Inflammatory demyelination disease associated with multiple sclerosis
Presents with acute to subacute painful vision loss and abnormal pupillary response to light
Lesion in what location causes bilateral hemianopsia?
What type of test should patients with myasthenia gravis undergo ? And why
Chest imaging (CT/MRI)
Because autoantibodies develop in the thymus and MG is associated with thymomas
What it's the edrophonium (tensilon) test used for?
Support the diagnosis of myasthenia gravis
What is edrephonium?