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Psychiatry Vignette-Based Review Questions Adapted from the practice question pdf posted to learn@uw “INS 2016 Psychiatry Practice Questions” Format 3-step review: ① Vignette-Style Question ② Discussion: Answer and Explanation ③ High yield follow-up review (Follow-up for most, not all questions) Some pertinent animations. See the notes under the slides for additional info. Correspondence to [email protected] 1. An 18yow presents to the ED because of increasing depression and hopelessness for several months. She has had great difficulty adjusting to life in college, and has fallen behind on her schoolwork. She has recently felt that life is not worth living. Today, she is considering killing herself, though she is not sure how she would do so. She does not have access to a gun and does not keep any medications or knives in her dorm room. In your documentation of the MSE, how would you describe her SI? A. Active SI, with intent and plan to harm herself B. Active SI, with intent, plan and means to harm herself C. Active SI, with intent to harm herself D. No SI E. Passive SI 1. Answer & Explanation • C. Pt considers “killing herself” (active SI, with intent) but has no plan or access to means. Passive vs. Active SI: – Passive SI: “belief that life is not worth living or wish that (s)he would be dead” – Active SI: includes at least “an intent to harm oneself” 1. High yield f/u: Suicide risk factors 1. Gender: – Men 4x more likely to complete – Women 3x more to attempt 2. Marital status: – Single/divorced/widowed/separated men (2-5x) 3. Age (see next slide) 4. FH: first-degree relative (3.5x) 5. Mental illness: psychiatric Hx in 95% suicide deaths – MDD, BP d/o, SUDs, Anxiety d/o, Schizophrenia, BPD – Q: Most important risk for completion in MDD? Suicide by Age*Gender 1. High yield f/u: suicide risk factors (cont’d) 6. Other medical illnesses: - HIV/AIDS, HD, cancer, TBI, seizures, SC injury 7. Suicidal ideation: *Note: Hx prior attempt far greater predictive value 8. Mental status: - Anxiety, agitation, despair, hopelessness - Feelings of loss of control, shame, and anger 9. Social and environmental stressors: - Loss/lack of social support - Q: Protective factors? 10. Biological factors: - Lower serotonin 2. A 21yow presents to your clinic with a six-month history of depression. She reports that these symptoms began after she started graduate school, which was much more difficulty than she had anticipated. She has no past psychiatric or medical history. She has a strong FH of mood and anxiety disorders, and reports having been physically abused as a child. What genetic finding is this patient most likely to have? A. Autosomal dominant mutation of amyloid precursor protein B. CAG trinucleotide repeat C. Deletion of q11 region of chromosome 22 D. E4 allele of apolipoprotein E E. Short allele of serotonin transporter 2. Answer & Explanation • E. Well established gene-environment interaction in depression: short allele of the SE transporter gene (5-HTTPR) and childhood maltreatment predicts higher risk of depression. Rule out the other options: • The autosomal dominant mutation of APP is found in rare familial versions of AD. • An expansion of the CAG trinucleotide repeat is found in HD. • Deletion of the q11 region of chromosome 22 causes velocardiofacial syndrome (DiGeorge syndrome), which can have symptoms similar to schizophrenia. • The most common polymorphism associated with AD is the e4 allele of apoE; carrying one e4 allele doubles the risk of AD. 3. A 67yom presents to your clinic with a 2-year history of anxiety. He says that he was always a “worrier,” but this has become worse since he retired. He finds it difficult to control his worries, and this in turns has led to insomnia. His wife, who is present, notes that seems to get upset much more easily. On MSE, he is restless and has a hard time sitting still; his cognitive testing is normal, with a SLUMS of 30/30. His PMH includes only HTN, which is well controlled with atenolol. A recent TSH was normal. What medication would you recommend? A. B. C. D. E. Bupropion Diazepam Methylphenidate Quetiapine Sertraline 3. Answer & Explanation • E. First step is Dx = GAD. Normal SLUMS = r/o cognitive disorder. Normal TSH = r/o thyroid disorder. EBT’s for GAD = SSRIs, SNRIs, buspirone, and CBT. Thus, the SSRI sertraline is the most correct choice on the list. SSRIs are first-line (efficacy, safety, tolerability). • BZDs used less commonly (concerns for tolerance and withdrawal). BZD use is limited to short periods and when anxiety is severe. Can prescribe an SSRI with a BZD, and stop the BZD once the SSRI has taken effect. Q: What is this SSRI property called? 3. Answer & Explanation (cont’d) Rule out the other options: • Bupropion is one of the few antidepressants that is not helpful for anxiety – it may cause or exacerbate anxiety. • BZDs such as diazepam may be useful in the short-term treatment of severe anxiety disorders (not first line). • Methylphenidate is a psychostimulant and would therefore not be indicated for an anxiety disorder. • Atypical antipsychotics such as quetiapine are sometimes used for severe or treatment-refractory anxiety disorders, but they have too ADRs to be first-line. 3. High yield f/u: GAD Mnemonic “Worry WARTS” Worry that is difficult to control, feeling wound-up or irritable Absentmindedness or having difficulty concentrating Restlessness, feeling tired Muscle Tension Sleep disturbance 4. A 21yom with schizophrenia is referred to your clinic for treatment. A trial of the antipsychotic ziprasidone was not effective. His brother, who accompanies to him to the visit, wonders about a trial of haloperidol. What side effect is haloperidol more likely to cause than an atypical antipsychotic? A. B. C. D. E. Agranulocytosis Dyslipidemia Hyperglycemia Tardive dyskinesia Weight gain 4. Answer & Explanation • D. Two main categories of antipsychotics: typicals (older; MOA = D2 mesocorticolimbic blockade) and atypicals (newer; variety of MOAs). • The classic side effects of typicals (i.e., EPS) are due to DA blockade: tremor, bradykinesia, akathisia, dystonia, TD. Rule out the other options: • Atypicals are less likely to cause EPS, and more likely to cause metabolic side effects, e.g., dyslipidemia, hyperglycemia, and weight gain. • Agranulocytosis is a rare but potentially fatal complication of treatment with the atypical antipsychotic clozapine. – This is a high-yield association! 4. High yield f/u: EPS & EPS Tx -EPS: acute dystonia (spasms of tongue, face, neck, back), parkinsonism (i.e., bradykinesia, tremors, shuffling gait), akathisia (uncontrollable urge to be in motion: pacing, restlessness), perioral tremor ("rabbit syndrome”: involuntary, fine, rhythmic motions of the mouth). -Treatment: anticholinergic agents, why? In the striatum, there is an ACh-DA balance. With decreased DA function, ACh starts to run away unchecked. By administering an anticholinergic, excess Ach is blocked, ACh-DA balance is restored. *Note: Tardive dyskinesia: most significant EPS (worm-like twisting movements of tongue, mouth, face). Has no reliable tx, often irreversible, even w/ DC of the drug. 5. A 72yom presents to your clinic for evaluation of depression. He reports that, for the last 5 years, his symptoms have been worse in the winter; his depression remits in the spring. He has never been suicidal, and the depression has only moderately affected his functioning. What treatment has the best balance of risk and benefit? A. B. C. D. E. Deep Brain Stimulation Electroconvulsive Therapy Lithium Phototherapy Transcranial Magnetic Stimulation 5. Answer & Explanation • D. First step = Dx = seasonal depression, where episodes typically begin in fall or winter and remit in spring. • Seasonal depression: uniquely responsive to phototherapy Rule out other options: • DBS of the PFC is an experimental procedure that may be effective for treatment-refractory depression. • ECT is the most effective treatment for severe depression and psychotic depression. • Lithium is a useful augmentation agent. • TMS also has a limited role in the treatment of depression. 5. High yield f/u: MDD subtypes -Psychotic: ~20% of severely depressed pts experience psychotic depression; often requires hospitalization and treatment with med combinations (antidepressant plus antipsychotic) or ECT. -Seasonal: AKA “Seasonal Affective Disorder.” Typical symptoms: include low energy, hypersomnia, overeating, craving for carbohydrates, and weight gain. Women, younger persons, and those living at higher latitudes are at increased risk. -Peripartum: NOT “Baby blues,” or transient, low-level mood changes within 10 days of the birth of a child. Peripartum depression is a full MDE that begins during pregnancy OR within one month of delivery. 6. A 72yom presents to your clinic with a four-month history of severe depression, his first episode ever. He is eating poorly, and has lost 20 pounds. He is having difficulty caring for himself. He has command auditory hallucinations telling him to harm himself. He is currently taking sertraline and quetiapine, which have not been effective and have caused many side effects. What treatment would you recommend next? A. B. C. D. E. Deep Brain Stimulation Electroconvulsive Therapy Lithium Phototherapy Transcranial Magnetic Stimulation 6. Answer & Explanation • B. Vignette = severe depression with psychotic features (among most severe forms of depression). High suicide risk because of the command AH. Thus, a highly effective and rapid treatment is indicated, namely ECT. Rule out other options: • DBS could be an option for severe depression in the future. • Adding lithium would be a reasonable, but will not work as quickly as ECT and may be difficult for a 72yo pt to tolerate. • Phototherapy can work for non-seasonal depression, but ECT is likely more effective and more rapidly effective. • TMS is likely not as effective as ECT. 7. A 32yom presents to your clinic with panic attacks of increasing severity and frequency (at least twice daily). He has never been on medications, but would now like to try something because the panic attacks are affecting his work and his relationship with his partner. He has trouble sleeping because he ruminates about going to work the next day. What advantage does a selective serotonin reuptake inhibitor (SSRI) have over a benzodiazepine? A. Less likely to cause physiologic dependence B. More likely to be sedating and therefore help with insomnia C. More rapid onset of anxiolytic effect D. Three-times-a-day dosing results in more consistent effect 7. Answer & Explanation • A. First step = Dx = Panic d/o, which includes recurrent unexpected panic attacks. First-line txs include SSRIs, SNRIs and CBT. BZDs can be effective in preventing panic attacks, but because of tolerance and withdrawal concerns, their use is limited to short periods of time. SSRIs are less likely than BZDs to cause physiological dependence. Rule out the other options: • BZDs are more sedating than SSRIs. • BZDs are more immediately effective than SSRIs (hours to days, rather than weeks). • No SSRIs require more than once-daily dosing (other than the rarely used fluvoxamine). 7. High yield f/u: MOA BZDs vs. Barbiturates (BBs) -While both enhance GABA-mediated neuronal inhibition, BBs & BZDs have different binding sites on the GABAA receptor, thus, different MOAs. -BZD "agonists" are positive modulators; they increase the affinity of the GABAA receptor for GABA and increase the frequency of GABA-induced Clchannel openings; do not directly activate GABAA receptor. *Note: *Because they are positive modulators, in the absence of GABA, BZDs have NO EFFECT! Nomenclature "agonist" really isn't correct. -BBs are true agonists; they increase the duration of GABA-induced channel openings and, at high concentrations, directly activate the GABAA receptor. -SUMMARY: The effects of both classes of drugs on Cl- flux result in the neuron becoming hyperpolarized and therefore less excitable. I.e., both make the neuron LESS LIKE TO FIRE via hyperpolarization. 8. A 23yow with newly diagnosed bipolar disorder presents to your clinic to discuss treatment options. Which of the following has the LEAST evidence supporting its efficacy in bipolar disorder? A. B. C. D. E. Lamotrigine Modafanil Oxcarbazepine Risperidone Valproic acid 8. Answer & Explanation • B. All of the agents except Modafanil have been shown to be effective in various phases of BP d/o. Rule out the other options: • Lamotrigine has antidepressant properties and thus may be effective in BP depression and in preventing depressive episodes. • Oxcarbazepine and valproic acid are anticonvulsants effective for manic and mixed episodes. • Risperidone (like other atypical antipsychotics) is effective for mania, mixed episodes, depression, and maintenance treatment. 8. High yield f/u: BP d/o tx 9. An 82yom with his first episode of MDD presents to your clinic. He has never been treated with an antidepressant. He has stable coronary artery disease (for which he takes aspirin and betablocker), but is otherwise healthy. Which of the following is the patient LEAST likely to tolerate? A. B. C. D. E. Bupropion Citalopram Duloxetine Nortriptyline Sertraline 9. Answer & Explanation • D. Older adults are more sensitive to ADRs. The most concerning medication on the list is nortriptyline, a TCA. TCAs can increase the risk of cardiac arrhythmias, in particular in pts with cardiac disease. The anticholinergic side effects include constipation, urinary retention, sedation, and confusion. Thus, nortriptyline should be avoided. Rule out the other options: • The other medications can also cause significant ADRs in older adults, but less frequently than TCAs. Monoamine Hypothesis 9a. High yield f/u: MDD (1) Pts treated with reserpine for HTN became very depressed. Reserpine blocks the VMAT, which normally acts to transport MAs into vesicles, which release the NTs into synapses. Thus, reserpine decreased MA release, connecting decreased MAs with depressive symptoms. Thinking became: if not enough MA led to depression, perhaps boosting MA can lessen/treat depression. (2) Genetic variation 5-HTT (SERT) (3) People given a diet deficient in tryptophan (precursor of MA biosynthesis) tend to have a recurrence of depressive symptoms, especially pts that respond well to SSRIs. Neurotrophic Hypothesis 9b. High yield f/u: MDD Nerve growth factors (e.g., BDNF) are critical in neural plasticity. Evidence suggests depression is associated with the loss of neurogenesis, and effective antidepressant therapies increase synaptic connectivity (e.g., in the hippocampus): (1) Stress and pain are associated with a drop in BDNF, contributing to hippocampal atrophy. (2) MDD is associated with 5-10% loss of hippocampal volume. (3) Human studies: depression appears to be associated with a drop in BDNF levels (i.e., in CSF and serum). Conversely, antidepressants increase BDNF levels in clinical trials and may be associated with an increase in hippocampal volume. 10. A 27yo veteran of the Iraq war presents with severe anxiety and insomnia. You suspect a diagnosis of post-traumatic stress disorder. Which of the following is NOT required to make this diagnosis? A. B. C. D. E. Avoidance behavior Psychotic symptoms Exposure to a traumatic event Hyperarousal symptoms Intrusive symptoms 10. Answer & Explanation • B. PTSD requires exposure to trauma and includes 4 major criteria: – re-experiencing symptoms (e.g., flashbacks) – avoidance of stimuli associated with the trauma – negative alterations in cognitions and mood – hyperarousal (e.g., hypervigilance) • Psychotic symptoms are not part of PTSD. 10. High yield f/u: PTSD Psychotherapy Prolonged Exposure Therapy (PET) Theory: people learn to fear thoughts, feelings, and situations that remind them of past trauma. Practice: By talking about the trauma repeatedly, the pt learns not to fear the memories and to change how they react to these memories. Cognitive processing therapy (CPT) Theory: PTSD affects how people think about and interpret subsequent events in their lives. Practice: Written exposure in which pts write about the impact of trauma and how they think differently about safety, trust, esteem, power/control, and intimacy. Therapist challenges pt’s interpretations, helps identify “cognitive distortions,” and replace them with accurate interpretations. 11. A 51yow with chronic and severe depression presents to your clinic. She has reported intermittent SI. What is most likely to reduce her risk of suicide? A. Implanting a deep brain stimulator B. Involving her support systems C. Prescribing a benzodiazepine D. Reminding her that suicides go to hell 11. Answer & Explanation • B. Modifiable suicide risk factors include mental symptoms (depression, anxiety, agitation, despair, hopelessness, feelings of loss of control, shame, and anger), lack of social supports, and access to means of suicide (guns, pills, etc.). Rule out the other options: • DBS is an experimental procedure for severe depression; its effect on suicide risk is not yet known. • A BZD could relieve anxiety, but would not address her depression, and could be used in a suicide attempt. • Pts sometimes indicate they would not commit suicide because of religious beliefs; it would be unethical and possibly culturally inappropriate to invoke this. 11. High yield f/u: Meds for suicide prevention? Same question, but this time, a list of medications for answer options. What would you pick? Lithium: FDA approved for BP d/o, but also used in unipolar depression augmentation for suicidality. 12. A 56yow presents to your clinic for follow-up of MDD. She has been successfully treated with deep brain stimulation. What CNS structure is this treatment directed toward? A. B. C. D. E. Amygdala Hippocampus Medial temporal cortex Prefrontal cortex Parietal cortex 12. Answer & Explanation • D. DBS is directed towards the PFC (specifically, subgenual PFC). Critical point: PFC is involved in MDD pathophysiology and is thus an intervention target. Rule out the other options: • The amygdala is involved primarily in fear responses. • The hippocampus and the medial temporal cortex encode new memories and link memory with emotion. • Parietal cortex has a variety of functions related to attention, visuospatial processing, and self-awareness. Subgenual PFC: Extremely rich in 5-HT transporters; influences changes in appetite and sleep, mood and anxiety, memory formation, and selfesteem. This region is particularly implicated in the normal processing of sadness. 12. High yield f/u: MDD neurocircuitry review “Although depressed mood is normal in response to adversity in all individuals, what distinguishes those vulnerable to MDD is their inability to effectively regulate negative mood… During an effortful affective-reappraisal task…these findings indicate that a key feature underlying the pathophysiology of MDD is lack of engagement of left lateral vmPFC circuitry important for the down-regulation of amygdala responses to negative stimuli. 13. A 26yow presents to your clinic because of fatigue and insomnia for the last 8 months. She also complains of difficulty concentrating, irritability and worrying all the time. As a result, she has been having trouble at work. She denies palpitations and weight change. Her PMH is unremarkable, vital signs are within normal limits, and her PE shows no focal abnormalities, but she is quite restless. What is the most likely diagnosis? A. Anxious temperament B. Attention-deficit/hyperactivity disorder C. Generalized anxiety disorder D. Hyperthyroidism E. Social phobia 13. Answer & Explanation • C. Classic symptoms of GAD (Recall, “Worry WARTS” in #3). Rule out the other options: • AT is not a diagnosis, but a risk factor for anxiety disorders. • Both GAD and ADHD present with difficulties concentrating. But this pt does not have the other sxs of ADHD. • Hyperthyroidism is on the DDx of GAD and Panic d/o, but she does not have other hyperthyroidism sxs (palpitations, weight loss, heat intolerance). It may remain prudent to check TSH. • Social phobia is a “strong, persisting fear of situations in which embarrassment can occur.” Is not this presentation. 13. High yield f/u: Distinguishing similar presentations MDD (2 weeks) • Depressed mood/irritability • Anhedonia • Δ weight/appetite • Sleep disturbance • Psychomotor agitation/retardation • Fatigue/energy loss • Worthlessness/guilt • Difficulty concentrating/indecisivenes s • SI GAD (6 months) • Anxiety/worry • Difficulty to control worry • ^Associated with: – – – – – – Restlessness Fatigue Difficulty concentrating Irritability Muscle tension Sleep disturbance *DSM-5: both cause clinically significant distress/impairment; must rule out substance-induction, and other mental disorders & medical conditions 13. High yield f/u (cont’d): Buspirone vs. SSRI for GAD Dr. Walaszek: For GAD pts, buspirone won't work as well as an SSRI, which are simply more effective. Buspirone can be used for pts with moderate anxiety because it tends to be better tolerated compared to an SSRI. 14. A 44yow with schizophrenia is admitted to an inpatient psychiatric unit. She is adamant that she is married to the New Zealand pop sensation, Lorde. When others point out to her that she is not married to Lorde, she scoffs and says that they are “just jealous.” Her behavior is otherwise not influenced by this belief. What is the name of this MSE finding? A. B. C. D. E. Amnesia Anhedonia Delusion Hallucination Obsession 14. Answer & Explanation • C. A delusion is a “fixed false belief that cannot be explained on the basis of the pt’s cultural or spiritual background.” The pt’s belief that she is married to Lorde is false and does not respond to evidence to the contrary (i.e., it is fixed). Rule out the other options: • Amnesia is an impairment in storing/retrieving memories. • Anhedonia is the loss of interest or enjoyment in activities. • A hallucination is a sensory perception in the absence of a stimulus. • An obsession is a recurrent, persistent idea, thought, impulse or image. 15. A 45yom who has received long-term treatment for schizophrenia has recently been noted to display involuntary movements that include lateral deviations of the jaw and “flycatching” motions with his tongue. Which of the following agents is the most likely cause of his involuntary movements? A. B. C. D. E. Clozapine Haloperidol Lithium Quetiapine Selegiline 15. Answer & Explanation • B. Key: recognize involuntary movements as TD, “a usually irreversible neurological side effect that includes abnormal movements of the mouth, trunk and limbs.” TD is most associated with the class of typical antipsychotics, to which haloperidol belongs. Rule out the other options: • The atypical antipsychotics quetiapine and clozapine are much less likely to cause TD. • TD is a rare side effect of lithium and a very rare side effect of selegiline. 15. High yield f/u: Typical vs. Atypical Antipsychotics How are all atypicals different from typicals? While all effective antipsychotics reduce dopaminergic D2 neurotransmission, all atypicals also block 5-HT2A receptors, and are more potent antagonists at 5-HT2A receptors than at D2 receptors. 16. A 35yom with a history of depression presents to the ED with flushing, diarrhea, sweating & muscle rigidity. He says that he began seeing a new psychiatrist because sertraline was not working for him. His new doctor gave him a different medication, but he decided to use both medications to “really get rid of this depression.” Which medication, in combination with sertraline, is most likely to cause these symptoms? A. B. C. D. E. Citalopram Lithium Nortriptyline Tranylcypramine Trazodone 16. Answer & Explanation • D. Key: Recognize pt has serotonin syndrome (SS). The classic combination of meds causing SS is an SSRI plus an MAO inhibitor. Thus, the correct answer is tranylcypramine (an MAOi), which the pt took with sertraline (an SSRI). • Neuroleptic malignant syndrome is on the DDx, but is more commonly associated with antipsychotics (“neuroleptics”). 16. High yield f/u: SS v NMS 16. High yield f/u: ADRs 17. A 28yow presents to the ED because of persistent sore throat and fevers. Her speech is difficult to follow, since she is continually shifting conversation topics, talking about being from Mars, and claiming she is the President of the U.S. Her affect is flat. She reports that her doctor recently prescribed a new medication to “help her mind.” Which antipsychotic medication is most likely to be implicated in the etiology of the sore throat and fevers? A. B. C. D. E. Aripiprazole Clozapine Haloperidol Risperidone Ziprasidone 17. Answer & Explanation • B. First, think Dx: Given her delusions and disorganized speech, this patient is most likely suffering from a psychotic disorder. Next, think Tx: Most common txs are antipsychotics. The combination of sore throat and fever is a rare side effect of antipsychotics, with one important exception: agranulocytosis due to clozapine (MOA: agranulocytosis diminishes the immune system, increasing susceptibility for infection and sequalae like sore throat and fever). 17. High yield f/u: Clozapine ANC Monitoring Patients on clozapine must have weekly monitoring of hematologic tests (ANC: absolute neutrophil count) for the first six months of treatment, followed by monitoring every other week for six months, followed by monthly monitoring for life. 18. A 7yo boy is brought to his pediatrician by his mother after a troubling parent-teacher conference. The teacher informed the mother that the child is disruptive in class and generally does not finish his homework. The mother reports that the child’s room is always messy and that he has difficulty completing chores in a timely fashion. In the office, the child is restless and interrupts his mother often. What is the most likely diagnosis? A. Antisocial personality disorder B. Anxious temperament C. Attention-deficit/hyperactivity disorder D. Autism spectrum disorder E. Bipolar disorder 18. Answer & Explanation • C. The pt’s symptoms include being disruptive in class, not finishing homework, not completing chores, being disorganized, restlessness and interrupting others. This cluster of symptoms is most consistent with ADHD. Rule out the other options: • ASPD cannot be diagnosed in a 7yo. • AT is a risk factor for anxiety disorders, not a disorder itself. • ASD classic triad includes problems with communication, repetitive behavior, and impaired social skills. • A child with BP d/o may have similar sxs, but with waxing and waning; pediatric BP d/o is far less common. 18. High yield f/u: ADHD Tx Pharmacological treatments: -First-line (stimulants): methylphenidate and amphetamine -Second-line (non-stimulant): atomoxetine; not as effective *Recall, Modafinil is NOT approved for the tx of ADHD Psychosocial interventions and accommodations in school can increase levels of attention and functioning: • Structure classroom environment to minimize distraction, increased assistance with organizational skills, and emphasis on the development of appropriate study skills. • Interventions to improve social functioning, including social skills training. 19. A 15yo girl is brought to the ED by her mother after experiencing her first seizure. The thin-appearing girl has a heart rate of 55, signs suggestive of dehydration, and fine, velvety hair covering her arms and legs. Her BMI is 16. When the patient’s mother leaves the room, the patient admits that she has been depressed lately, and that for the past week she has been taking one of her friend’s antidepressant medications. Which antidepressant is most likely to have caused the seizure? A. B. C. D. E. Bupropion Citalopram Fluoxetine Mirtazapine Selegiline 19. Answer & Explanation • A. First step = Dx: combination of very low weight, bradycardia, dehydration and lanugo (fine, soft hair) suggests anorexia nervosa. Bupropion in general has a higher risk of causing seizures than other antidepressants. Pts with eating disorders, perhaps because of associated electrolyte disturbances, are even more likely to get seizures with bupropion. Rule out the other options: • The other antidepressants on the list can also cause seizures, but less so than bupropion. 20. A 72yom presents to your clinic with a 3-month history of difficulty concentrating, poor memory and inability to make decisions. You recommend treatment with an antidepressant. What condition do you suspect? A. B. C. D. E. Attention-deficit/hyperactivity disorder Bipolar disorder Dysthymic disorder Major depressive disorder Substance-induced mood disorder 20. Answer & Explanation • D. Key issue: “In older adults, depression may cause such severe impairment as to make the pt appear to have dementia” aka “pseudodementia.” Rule out other options: • Treating BP d/o with an antidepressant could induce mania. • Treatment of substance-induced mood disorder begins with removing the offending substance. • ADHD does not arise this late in life. • Dysthymic disorder requires 2+ years of symptoms. 21. A 10yo girl presents to your clinic after a recent diagnosis of ADHD. Her 11yo brother also has ADHD, successfully treated with methylphenidate. Which is the most accurate statement about her prognosis? A. Depression and anxiety will make her ADHD symptoms more likely to persist B. Distractibility is the first symptom to remit, while hyperactivity is the last to remit C. Little is known about the natural history of ADHD, making prognosis difficult D. The fact that her brother also has ADHD has no impact on her prognosis E. There is an 80% chance that her symptoms will spontaneously remit before age 12 21. Answer & Explanation • A. “ADHD sxs may persist into adolescence and adulthood, but they also can remit after puberty. Hyperactivity is the first symptom to remit, with distractibility being the last to remit. Persistence is predicted by FH of ADHD, negative life events, and comorbidity with conduct disorder, depression, or anxiety symptoms. If sxs do remit, remission generally occurs between ages 12-20. In 15-20% of children with ADHD, symptoms persist into adulthood.” 22. A 58yom presents to your clinic, accompanied by his distressed wife. Over the last year, he has had a marked decline in his ability to care for himself and had to stop working. He has become apathetic, and has started making inappropriate comments to neighbors. Prior to one year ago, he had no medical problems. He does not drink alcohol or use illicit drugs. Which diagnosis is most likely? A. Alzheimer’s disease B. Frontotemporal dementia C. Huntington’s disease D. Lewy body disease E. Vascular dementia 22. Answer & Explanation • B. The combination of functional decline and change in behavior suggests dementia. Most common dementia is AD, but in this relatively young patient (< 65 yo), FTD is more likely. The inappropriate comments (disinhibition) suggest an impairment of frontal lobe function, consistent with FTD. Rule out the other options: • Vascular dementia is a possibility, but the progression is usually step-wise and the age range is typically 65-75yo. • HD could present this way, but is rarer; would also expect FH. • LBD typically presents with the combination parkinsonism, visual hallucinations, a fluctuating levels of consciousness. – This is the LBD triad 23. A 10yo boy presents to your clinic for the treatment of ADHD. You recommend to his parents that he be prescribed methylphenidate. Which of the following statements about methylphenidate is most accurate? A. Causes about a ten percent decrease in the height that the child will attain in adulthood. B. Decreases hyperactivity in ADHD by inducing a slight degree of drowsiness. C. Increases attention span and decreases impulsivity in patients with ADHD. D. Increases the risk of cocaine abuse after the child becomes an adult. 23. Answer & Explanation • C. Rule out the other options: • Psychostimulants can affect height and weight, but not to the extent described in option A. • Psychostimulants are generally not associated with drowsiness. • While amphetamine and methylphenidate can be reinforcing, appropriate use of stimulants in children has not been found to increase risk of cocaine abuse later in life. 23. High yield f/u: MOA, ADRs Psychostimulants MOA: increase monoamine (MA) function through (i) inhibiting MA uptake and (ii) evoking transporter-mediated MA release. ADRs: -CNS: insomnia, restlessness, anorexia -CV: tachycardia, angina -Overdose may produce anxiety, agitation, biting, delirium, hallucinations, paranoia, psychosis, tremor, diaphoresis, flushing, pallor, hyperthermia, labile BP and HR (hypotension or HTN), palpitations, tachypnea, mydriasis, blurred vision Methylphenidate: More central DA uptake blockage than catecholamine releasing activity; thus, more mild ADR profile vs. amphetamine. 24. To assist teachers with identifying children who may have ADHD, you partner with the local school to create a checklist of symptoms. Which combination of symptoms would be consistent with a diagnosis of ADHD? A. Being easily distracted, constantly worrying, being afraid to go to school, feeling irritable, problems falling asleep, feeling tense B. Depressed mood, difficulties concentrating, difficult sustaining attention, decreased interest in activities, problems falling asleep, losing weight C. Fidgeting and squirming, feeling irritable, decreased need for sleep, interrupting others, rapid shifts in affect, restlessness D. Making careless mistakes, being easily distracted, having difficulty organizing tasks, being forgetful in daily activities, not following instructions, losing things 24. Answer & Explanation • D. Rule out the other options: • The cluster in A is most consistent with GAD. • The cluster in B is most consistent with MDD. • The cluster in C is consistent with a hypomanic or manic episode. 25. A 25yom who is addicted to heroin presents to your clinic for treatment. Which neurotransmitter is most likely to be involved in the persistence of this disorder even after successful detoxification from heroin? A. B. C. D. E. Acetylcholine Dopamine Endorphin Norepinephrine Serotonin 25. Answer & Explanation • B. All of the NTs listed, except perhaps ACh, may be involved in addiction. Because this pt is addicted to heroin, the endogenous opioid system (including endorphins) would certainly be implicated, especially in the acute euphoria and in withdrawal. However, DA has been implicated in the long-term risk of relapse. DA may be responsible for the “wanting” (or craving) of drugs (incentive-sensitization hypothesis) and for the overlearning of behaviors and stimuli associated with drug use (reward-learning hypothesis). 25. High yield f/u: Striatal mediumspiny neurons • Integrates top-down glutamate information from the cortex and bottom-up DA information from the midbrain. • The medium-spiny neurons (the "integrators") are GABAergic neurons, i.e., information leaving the striatum is expressed via GABA neurotransmission. 25. High yield f/u (cont’d): “Wanting” vs. “Liking” • The term ‘reward’ perhaps too broad to be meaningful • 2 distinct reward processes: "Wanting" and "Liking” – “Wanting” process: mediated by DA transmission in the Nucleus accumbens; process of identifying which goals (i.e., salient reinforcers) to pursue and energizing behaviors to achieve these goals. – “Liking” process: the subjective emotional experience of reward (i.e., pleasure) upon interacting with the reinforcer. *Seems to be DA-insensitive. Nucleus accumbens is still relevant for liking, but it appears that the relevant chemical is not DA, but instead, opioids. • E.g., If you have a rat eating tasty foods (e.g., our equivalent of a chocolate cake), and you inject opioid receptor blockers, you greatly reduce the palatable food intake. 26. A 40yom presents to your clinic after an occupational accident wherein he sustained damage to the prefrontal cortex. Which of the following memory deficits is he most likely to have? A. Anterograde amnesia B. A reduction in long-term potentiation C. Confabulation, but no true memory problem D. Deficits in the strategic retrieval of information from long-term memory 26. Answer & Explanation • D. Damage to the PFC can result in impaired retrieval and recall of memories due to ineffective strategies being used. Rule out the other options: • Anterograde amnesia is more likely due to damage to structures in the medial temporal lobe, including the hippocampus, and is the core symptom of AD. • An LTP deficit would not be localized to a particular structure, as LTP is a process that takes place globally at the cellular level. LTP underlies the formation of memory. • Confabulation, the unconscious fabrication of memories, is a classic finding in thiamine deficiency due to severe alcohol use (i.e., Wernicke-Korsakoff syndrome). 26. High yield f/u: Patient H.M. • Intractable epilepsy • Bilateral medial temporal removal – Seizure free, but… – Long-term memory consequences • Anterograde amnesia 26. High yield f/u (cont’d): H.M. 26. High yield f/u (cont’d): H.M. 27. A 38yow presents with a several day history of excessive energy and altered mood. You suspect she has bipolar disorder, and you wish to determine whether she has a hypomanic or manic episode. Which of the following features is characteristic of a hypomanic episode, but not a manic episode? A. Decreased need for sleep B. Elevated, expansive or irritable mood C. Increased goal-directed activity D. Functioning remains intact E. Not caused by a medical problem 27. Answer & Explanation • D. Almost all psychiatric disorders cause functional impairment and/or emotional distress. Hypomania can be an exception to this. Many pts with hypomania feel “better than normal” and enjoy increased productivity – i.e., their functioning remains intact or even gets transiently better. • *The downside is that hypomania may lead to mania, which does result in functional impairment, sometimes quite severe. 27. High yield f/u: Bipolar I vs. II 28. A 32yow with bipolar disorder experiences total sleep deprivation for one night due to international travel. What is the most likely result? A. Enhanced memory and attention B. Exacerbation of depressive symptoms C. Increased side effects from lithium therapy D. Induction of an episode of mania E. Transient suicidal ideation 28. Answer & Explanation • D. Maintaining regular sleep-wake cycles is critical in the prevention of mood episodes in patients with BP d/o. “BP d/o is particularly sensitive to sleep disturbance. Sleep deprivation and travel-related time-zone changes have been associated with the onset of mania.” Rule out the other options: • Worsening depression and suicidal ideation are less likely. • If the pt develops hypomania rather than mania, it is conceivable she could have enhanced cognitive function (but the effects of sleep deprivation would likely offset any benefit). • It is possible that a pt who gets dehydrated on a long flight could experience lithium toxicity, but this would not necessarily be related to sleep deprivation. 29. A 21yow presents to the college health clinic for treatment of abnormal eating patterns. In a patient with binge-eating and purging behaviors, which of the following symptoms is more consistent with bulimia nervosa than with anorexia nervosa? A. Excessive exercise B. Misuse of laxatives C. Normal body weight D. Self-induced vomiting 29. Answer & Explanation • C. A hallmark of anorexia nervosa is “refusal to maintain body weight at or above a minimally normal weight,” whereas many pts with bulimia nervosa have normal or higher weight. • Pts with anorexia or bulimia may misuse laxatives or induce vomiting to control weight. 29. High yield f/u: Anorexia nervosa DSM-5 subtypes Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behavior. This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise. Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). 30. A 38yom presents to your clinic with a complaint of chronic insomnia. You would like to teach him the principles of sleep hygiene. Which of the following is NOT part of sleep hygiene? A. Get regular exercise each morning or early afternoon B. Develop a relaxing routine before bedtime C. Increase exposure bright light during the day D. Minimize or avoid the use of caffeine, alcohol and nicotine E. Use of laptop computer in bed is allowed, as long as it’s not stressful 30. Answer & Explanation • E. Exposure to light at bedtime, including from a computer screen, will impair sleep. Rule out the other options: • The elements of sleep hygiene include daily exercise (preferably earlier in the day), keeping the bedroom dark, quiet and set to a comfortable temperature, and avoiding stimulants and alcohol around bedtime. Exposure to bright light during the day can reset circadian rhythms and thus improve sleep. 31. A 30yow presents to your clinic because of excess sleepiness. You suspect a disorder that is due to loss of hypocretin function in the hypothalamus. What disorder do you suspect? A. Delayed sleep phase disorder B. Narcolepsy C. REM sleep behavior disorder D. Restless legs syndrome E. Sleep apnea 31. Answer & Explanation • B. All of the disorders on the list could cause excess daytime sleepiness. However, narcolepsy is the only one linked to hypocretin: narcolepsy is caused by the loss of hypocretin-producing cells in the hypothalamus. 32. A 32yom presents to your clinic with 6 months of increased anxiety. He finds himself to be restless, irritable and tense. He has difficulty falling asleep because he worries so much about his job, and as a result he has been drinking more to help fall asleep. He would like treatment for his anxiety, and is not interested in medications. How would you describe how psychotherapy works to this patient? A. By helping the pt to find a stable and safe place to live. B. By providing the pt a set of guiding principles outlining a course of action for recovery from addiction, compulsion, or other behavioral problems. C. By teaching the pt strategies and giving him tools to deal with stress and unhealthy thoughts and behaviors. D. By using the pt’s relationship to the content of books and poetry and other written words as therapy. 32. Answer & Explanation • C. Pt meets criteria for GAD, and may have a SUD, too. The psychotherapeutic treatment of choice for GAD is CBT, which includes analyzing and changing thoughts, emotions, and behaviors. Rule out the other options: • The other approaches listed are psychosocial rehabilitation for schizophrenia (A), 12-step programs for SUDs (B) which the pt may eventually need, and bibliotherapy (D). 33. A 72yom presents to your clinic for treatment of long-standing difficulties with falling asleep. Which of the following behavioral changes would be LEAST likely to address insomnia? A. B. C. D. Exercise each morning. Go to bed only when sleepy. Have one drink of alcohol at bedtime. Keep the bedroom dark, quiet and set to a comfortable temperature. E. Limit the time spent in bed to actual sleep time. 33. Answer & Explanation • C. Alcohol is likely to have negative effects on sleep quality. Rule out the other options: • The treatment of choice for chronic insomnia includes psychotherapeutic approaches, such as sleep hygiene. These include regular exercise, going to bed only when sleepy, keeping the room dark and comfortable, and limiting time spent in bed to actual sleep time. 34. The parents of a 4yo girl bring her to you for an evaluation of her hearing. Over the last year, she has not been as responsive to others as she used to be, and her speech is delayed relative to other children in the neighborhood. She is not interested in listening to stories at bedtime. Her parents describe her as “shy,” since she displays little interest in playing with others. She spends much of the day playing with light switches and doorknobs around the house. What is the most likely diagnosis? A. Absence seizures B. Attention-deficit hyperactivity disorder C. Autism spectrum disorder D. Cerebral palsy E. Generalized anxiety disorder 34. Answer & Explanation • C. This patient demonstrates the classic features of an ASD, namely impairments in communication and social interactions, and repetitive behaviors. Rule out the other options: • GAD could explain the pt being “shy,” but would not account for the other behaviors. • Absence seizures typically present with more episodic findings, rather than persistent behaviors. • Though autism may be comorbid with either ADHD or cerebral palsy, there is no evidence here to support the latter two diagnoses. 34. High yield f/u: “Delayed” “Is this normal?” Every developmental skill has a mean, and ±1-2 SDs, just like any lab. • “Delayed” means > 2 SDs below the mean • The rate of development is important, not the number of months. E.g., a 6-month-old with skills of a 3-month-old is NOT “3 months behind” but rather “50% delayed.” • Delayed does not imply eventual “catch up”! 35. You care for a 28yom with MDD. His depression symptoms remitted one month ago with the combination of psychotherapy and sertraline. Today, his very concerned wife calls to report that for the last week he has been acting erratically. He is up all night working on projects in his workshop; he has made a number of extravagant purchases; he has been driving recklessly and nearly caused a car accident. What is the most likely cause of his symptoms? A. Caffeinism B. Generalized anxiety disorder C. Antidepressant-induced mania D. Serotonin syndrome E. SSRI discontinuation syndrome 35. Answer & Explanation • C. The symptoms of decreased need for sleep and impulsivity (making extravagant purchases, driving recklessly) lasting for a week or more are consistent with a manic episode. Whenever a person treated with antidepressants develops a manic episode, concern arises for the possibility of antidepressant-induced mania, which necessitates stopping the antidepressant. 35. High yield f/u: Tx for depressive phase of BP disorder 36. A 53yom presents to your clinic for an evaluation of long-standing anxiety. You suspect a diagnosis of OCD. Which of the following cluster of symptoms is most consistent with this diagnosis? A. Discrete episodes of intense fear, palpitations, sweating, and fear of dying B. Excessive worry, restlessness, irritability, muscle tension, insomnia C. Low mood, restlessness, loss of interest, low energy, insomnia D. Recurrent and intrusive thoughts, accompanied by repetitive behaviors E. Traumatic event followed by hyperarousal, re-experiencing and avoidance 36. Answer & Explanation • D. The core symptoms of OCD are obsessions (intrusive thoughts that cause anxiety, e.g., fear of contamination) and compulsions (repetitive behaviors that are meant to allay anxiety, e.g., frequent hand washing). Rule out the other options: • Discrete episodes of intense fear, palpitations, sweating, and fear of dying (Panic disorder) • Excessive worry, restlessness, irritability, muscle tension, insomnia (GAD) • Low mood, restlessness, loss of interest, low energy, insomnia (MDD) • Traumatic event followed by hyperarousal, re-experiencing and avoidance (PTSD) 36. High yield f/u: OCD Tx • Exposure and response prevention = effectiveness to SSRIs. • Pharmacotherapy: SSRIs are first-line. Some clinicians regard clomipramine, a potently serotonergic TCA as the gold-standard. However, its ADRs usually result in SSRIs being tried first. Effective OCD tx often requires higher doses of SSRIs given for longer periods of time. • Psychotherapy: OCD also responds very well to CBT. The classic CBT approach to OCD is called exposure and response prevention. In this tx, the pt is exposed to a feared situation, event, or stimulus and then prevented from engaging in the corresponding compulsion. Family therapy can also be important for OCD. 37. A 34yow presents to your clinic for an evaluation of stress. She relates to you recent stressful events in her life, such as the death of her cat, losing her job, and facing eviction. You notice that she laughs quite a bit, and does not appear disturbed or upset by these events. How would you describe her affect? A. B. C. D. E. Apathetic Flat Incongruent Labile Perseverative 37. Answer & Explanation • C. Incongruent – The content of her discussion is stressful and depressing, but her outward appearance is unconcerned or even jovial. 37. High yield f/u: Affect vs. Mood • Affect: outward appearance of the pt’s emotional state (how we see their mood) • Mood: pt’s own experience of their emotional state (it is what the pt tells you it is) – Alexithymia: Inability to describe own emotional state