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LomaLindaDepartmentofPsychiatry’s TheNinja’sGuidetoPRITE 2016Edition TheBestPRITEReview…..EVER Foreword In2007,aragamuffingroupofinternsandresidentssetouttocreateahigh-yieldPRITEguide.Equippedwith laptops,pencil-markedPRITEsfrom2001-2006,andenoughjunkfoodtofeedasmallcountry,the“Loma LindaDepartmentofPsychiatryPRITESweatshop”wasstarted.Aftermultiplerevisionstotheguideoverthe pastnineyears,TheNinja’sGuidetoPRITEcontinuestofocusonthemostimportantareastocramintoyour braininthemonthprecedingPRITE.ItissuggestedthatgoingoveroldPRITEexamsisthebestpreparation forPRITE.ThisguideprovidesacomprehensivesummaryofoldPRITEsinanattempttohelpwithamore efficientreview.Otheritemsinthisguideincludeapsychopharmacologyreview,apsychotherapyreview, andamiscellaneoustopicshigh-yieldreview.ThevariousNinjareviewscombineinformationfromthe MassachusettsGeneralHospitalPsychiatryReview,SynopsisofPsychiatryandSynopsisof PsychopharmacologybyKaplanandSadock,theAPAPsychiatryTextbookandotherexcellentsources. Rememberthatthesematerialsarecopyrighted,sopleasedonotsellthisfreelearningtool.Withthese tools,itismyhopethatyouwillcompletelyrockthePRITE. BestofNinjaLuck, MelissaPereau,MD AssociatePsychiatryResidencyTrainingDirector LomaLindaDepartmentofPsychiatry LomaLindaUniversitySchoolofMedicine GotoTableofContents 2 TableofContents Foreword.....................................................................................................................................................2 TableofContents..........................................................................................................................3 ANINJA'SGUIDETOPSYCHOPHARMACOLOGY.........................................................................................8 Antipsychotics.........................................................................................................................................8 TypicalAntipsychotics.................................................................................................................................8 AtypicalAntipsychotics..............................................................................................................................10 MoodStabilizers....................................................................................................................................13 Lithium.......................................................................................................................................................13 ValproicAcid..............................................................................................................................................14 Carbamazepine(Tegretol).........................................................................................................................15 Oxcarbazepine(Trileptal)..........................................................................................................................16 Lamotrigine(Lamictal)...............................................................................................................................17 Gabapentin(Neurontin)............................................................................................................................17 Topiramate(Topamax)..............................................................................................................................18 Antidepressants.....................................................................................................................................18 TCAs...........................................................................................................................................................18 TetracyclicAntidepressants.......................................................................................................................20 MonoamineOxidaseInhibitors.................................................................................................................21 SelectiveSerotoninReuptakeInhibitors(SSRIs)........................................................................................22 SomeObservationsontheGenericMedicationsWeNowPrescribe.......................................................25 Bupropion(Wellbutrin,Zyban)..................................................................................................................26 Venlafaxine(Effexor)andDesvenlafaxine(Pristiq)...................................................................................27 Duloxetine(Cymbalta)...............................................................................................................................28 Anxiolytics.............................................................................................................................................28 Buspirone(Buspar)....................................................................................................................................28 Benzodiazepines........................................................................................................................................29 CognitiveEnhancers...............................................................................................................................31 MiscellaneousTopics.............................................................................................................................32 TreatmentofMedicationSideEffects.......................................................................................................32 TreatmentofOverdose.............................................................................................................................32 ANINJA’SGUIDETONEUROLOGY...............................................................................................33 Cortex....................................................................................................................................................33 AnatomyOverview....................................................................................................................................33 Pereau’s“CramtheBrainUsingtheMMSE”ReviewTool........................................................................34 HighYieldPRITEReview............................................................................................................................36 AnatomyOverview....................................................................................................................................38 Pereau’s“TheBrainstemasaFace”ReviewTool.....................................................................................39 GotoTableofContents 3 HighYieldPRITEReview............................................................................................................................41 ANINJA’SGUIDETOPSYCHOTHERAPY........................................................................................48 PsychoanalyticalPsychotherapy...............................................................................................................48 ExpressivePsychotherapy(“Insight-OrientedTherapy”)..........................................................................49 BriefPsychotherapy..................................................................................................................................49 InterpersonalTherapy...............................................................................................................................50 SupportivePsychotherapy........................................................................................................................50 BehavioralTherapy....................................................................................................................................51 Biofeedback...............................................................................................................................................51 CognitiveBehavioralTherapy....................................................................................................................51 GroupTherapy..........................................................................................................................................53 FamilyTherapy..........................................................................................................................................54 CouplesTherapy........................................................................................................................................55 ANINJA’SGUIDETOFREUD&OTHERSTUFF........................................................................................57 SigmundFreud.......................................................................................................................................57 InterpretationofDreams..........................................................................................................................57 TheTopographicalModeloftheMind......................................................................................................57 InstinctandDriveTheory..........................................................................................................................58 Pleasurevs.RealityPrinciples...................................................................................................................58 Narcissism..................................................................................................................................................58 TheStructuralTheoryoftheMind............................................................................................................58 DefenseMechanisms................................................................................................................................59 PsychosexualDevelopmentalStages........................................................................................................60 ErikErikson............................................................................................................................................62 Trustvs.Mistrust(0-18months,correlateswithOral).............................................................................62 Autonomyvs.ShameandDoubt(18months-3years,correlateswithAnal)...........................................62 Initiativevs.Guilt(3-5yearsold,correlateswithphallic).........................................................................62 Industryvs.Inferiority(5-13yearsold,correlateswithlatency)...............................................................63 Identityvs.RoleConfusion(13-21yearsold,correlateswithgenital)......................................................63 Intimacyvs.Isolation(21-40yearsold).....................................................................................................63 Generativityvs.Stagnation(40-60yearsold)...........................................................................................63 Integrityvs.Despair(60yearsolduntildeath).........................................................................................64 PathologicDevelopment........................................................................................................................64 Birthto18months....................................................................................................................................64 18monthsto3years.................................................................................................................................64 3to5years................................................................................................................................................65 5to13years..............................................................................................................................................65 13yearsto20s(Adolescence)...................................................................................................................65 20sto40s..................................................................................................................................................66 40sto60s..................................................................................................................................................66 GotoTableofContents 4 60stoEndofLife.......................................................................................................................................66 IntelligenceTests.......................................................................................................................................66 PersonalityAssessment.............................................................................................................................67 CognitiveTesting.......................................................................................................................................67 ChildandAdolescentPsychologicalAssessment......................................................................................68 Statistics................................................................................................................................................68 ANINJA’SGUIDETOSUBSTANCEUSEDISORDERS...................................................................................70 Overview................................................................................................................................................70 EtiologyofSubstanceUse.......................................................................................................................70 ScreeningforAddiction..........................................................................................................................70 MotivationalInterviewing.......................................................................................................................71 SubstanceUseDisorders........................................................................................................................71 Substance-InducedDisorders..................................................................................................................73 Substance/Medication-InducedMentalDisorders...................................................................................77 Alcohol-RelatedDisorders......................................................................................................................78 Caffeine-RelatedDisorders.....................................................................................................................83 Cannabis-RelatedDisorders....................................................................................................................84 Hallucinogen-RelatedDisorders..............................................................................................................86 Inhalant-RelatedDisorders.....................................................................................................................90 Opioid-RelatedDisorders........................................................................................................................92 Sedative,HypnoticorAnxiolytic-RelatedDisorders..................................................................................96 Stimulant-RelatedDisorders...................................................................................................................98 Tobacco-RelatedDisorders...................................................................................................................102 Miscellaneous......................................................................................................................................105 ANINJA’SGUIDETOPRITEQUESTIONS2016EDITION........................................................................108 Neurology.................................................................................................................................109 Amnesia................................................................................................................................................................109 BrainLesions........................................................................................................................................................109 Catatonia..............................................................................................................................................................113 CVA.......................................................................................................................................................................113 Delirium................................................................................................................................................................118 Dementia..............................................................................................................................................................120 Seizures................................................................................................................................................................124 EEG.......................................................................................................................................................................126 Endocrine.............................................................................................................................................................127 Headaches............................................................................................................................................................127 Huntington’sDisease...........................................................................................................................................129 Memory................................................................................................................................................................129 MultipleSclerosis.................................................................................................................................................130 Muscle/NeuronalDiseases/Lesions.....................................................................................................................131 Parkinson’sDisease..............................................................................................................................................134 GotoTableofContents 5 Spine.....................................................................................................................................................................135 TardiveDyskinesia................................................................................................................................................136 GeneralNeurology...............................................................................................................................................136 Neurotransmitters...............................................................................................................................................149 Radiology..............................................................................................................................................................150 Sleep.....................................................................................................................................................................150 AxisIDisorders.........................................................................................................................154 AcuteStressDisorder...........................................................................................................................................154 ADHD....................................................................................................................................................................154 AnxietyDisorders.................................................................................................................................................157 BipolarDisorder...................................................................................................................................................159 DelusionalDisorders............................................................................................................................................162 Depression...........................................................................................................................................................163 DissociativeDisorders..........................................................................................................................................168 EatingDisorders/BodyDysmorphicDisorder.......................................................................................................169 FactitiousDisorder...............................................................................................................................................171 ImpulseControlDisorder.....................................................................................................................................172 OCD......................................................................................................................................................................172 PanicDisorder......................................................................................................................................................174 Phobias.................................................................................................................................................................175 PTSD.....................................................................................................................................................................176 Schizophrenia/Psychosis......................................................................................................................................177 SomatoformDisorders.........................................................................................................................................181 Tourette’sDisorder..............................................................................................................................................182 PersonalityDisorders...........................................................................................................................................183 Alcohol.................................................................................................................................................................185 Substances...........................................................................................................................................................190 SomaticTreatments..................................................................................................................201 Anticonvulsants....................................................................................................................................................201 GeneralAntidepressants......................................................................................................................................203 MAOI....................................................................................................................................................................206 TCA.......................................................................................................................................................................207 SSRI.......................................................................................................................................................................208 Antipsychotics......................................................................................................................................................210 Anxiolytics/Benzodiazepines................................................................................................................................214 Lithium.................................................................................................................................................................216 Methadone...........................................................................................................................................................218 GeneralPsychopharmacology..............................................................................................................................219 PsychologicalTesting...........................................................................................................................................222 MSE......................................................................................................................................................................225 PsychologicalTheory............................................................................................................................................227 EriksonianStages.................................................................................................................................................230 PsychoanalysisandFreud....................................................................................................................................231 DefenseMechanisms...........................................................................................................................................232 GotoTableofContents 6 Therapy................................................................................................................................................................234 PsychodynamicTherapy.......................................................................................................................................240 CBT.......................................................................................................................................................................243 MaritalTherapy....................................................................................................................................................245 DialecticalBehavioralTherapy.............................................................................................................................246 FamilyTherapy.....................................................................................................................................................246 GroupTherapy.....................................................................................................................................................248 Hypnosis...............................................................................................................................................................249 InterpersonalTherapy..........................................................................................................................................250 SupportiveTherapy..............................................................................................................................................251 PsychosocialTherapies........................................................................................................................................251 TherapyTerms.....................................................................................................................................................252 Geriatrics..............................................................................................................................................................255 HIV/AIDS...............................................................................................................................................................257 ECT.......................................................................................................................................................................257 ChildhoodandDevelopment.....................................................................................................259 Attachment..........................................................................................................................................................259 Development........................................................................................................................................................261 ChildPsychiatry....................................................................................................................................................269 MentalRetardation..............................................................................................................................................270 PDD/Asperger’s/Autism.......................................................................................................................................271 ConditioningandLearning.........................................................................................................272 Conditioning.........................................................................................................................................................272 Learning................................................................................................................................................................274 ResearchandStatistics..............................................................................................................275 ResearchDesign...................................................................................................................................................275 Statistics...............................................................................................................................................................278 Genetics...............................................................................................................................................................280 Epidemiology........................................................................................................................................................283 Society......................................................................................................................................285 Culture..................................................................................................................................................................285 Spirituality............................................................................................................................................................287 Ethics....................................................................................................................................................................287 LegalandForensics..............................................................................................................................................290 CaseManagement...............................................................................................................................................294 ConsultandLiaison..............................................................................................................................................296 ViolenceandAbuse..............................................................................................................................................298 EmergencyPsychiatry..........................................................................................................................................299 Suicide..................................................................................................................................................................301 Bereavement........................................................................................................................................................302 Sexuality...............................................................................................................................................................304 Miscellaneous......................................................................................................................................................306 HistoryofPsychiatry............................................................................................................................................311 GotoTableofContents 7 ANINJA'SGUIDETOPSYCHOPHARMACOLOGY Antipsychotics TypicalAntipsychotics Phenothiazinesarecompoundsderivedfromtheoriginalparentdrug,methyleneblue.Thischemicalisused inhistologicstaining,analyticchemistry,andasanantimalarialmedication(asearlyas1891).DuringWW2 methyleneblue’suseasanantimalarialduetolackofaccessinthePacifictropicsandsideeffectsofturning urinegreenandsclerablue.Theantihistaminepropertiesofmethylenebluewerefoundtobehelpfulas anestheticagents.In1951,FrenchsurgeonLaboritaskedapharmaceuticalcompanytocreateaspecialized phenothiazinetoreducepost-surgicalpsychosis.Thismedicationwaschlorpromazine.Shortlythereafter,the medicationwasusedserendipitouslyinpsychiatricpatientstoreducepsychosis.Throughfurtherresearch anddevelopment,asimilarstructure,imipraminewascreated.Thismedicationwasoneofthefirst antidepressants. Chlorpromazine Imipramine MethyleneBlue Indications:schizophrenia(improvespositivesymptoms,mayworsennegativesymptoms),acutemania, MDDwithpsychosis,hemiballismus,hiccups,Tourette’s.Highpotencyantipsychoticsarebetterusedin patientswithpsychosisduetotumor/organiccauses.Astheydecreaseseizurethreshold,usewithcautionin ETOHdetox.Lowpotencyantipsychoticsshouldbeavoidedintheelderlyandmedicallyillduetomultiple anticholinergicandcardiacsideeffects.Avoidusein1sttrimester(especiallychlorpromazine);2ndand3rd trimesteraresafer.Contraindicatedincardiacpatients,acuteangleglaucoma,andpatientswithahistoryof TD. MechanismofAction:blockadeofD2receptors GotoTableofContents 8 • • • Mesocortical/mesolimbic:diminishespsychosis Tuberoinfundibular:increasesPRL(DAdecreasesPRL;DAblockadeincreasesPRL) Nigrostriatal:basalgangliaandcaudate.MovementdisordersincludingEPS,PD,tremor DrugInteractionsandP450:typicalsaremetabolizedby2D6and3A4,thusareincreasedinthepresenceof Prozac,PaxilandLuvox.TheyarereducedbycoadministrationwithTegretol.Antacidsdecreasethe absorptionoftypicals.Anticholinergicdeliriumispossibleinthepresenceofanticholinergicmedications,low potencytypicalandTCAcoadministration.Typicalsincreasebloodconcentrationsofvalproicacid.Cigarettes decreasebloodconcentrationsoftypical.Thus,ifapatientisstabilizedonaspecificdoseofatypicaland quitssmokingthereisriskforEPSandothersideeffects. OverviewofSideEffects:EPSandnon-EPS(anticholinergic,cardiac,sedation,etc).Highpotency antipsychoticshavegreateraffinityforD2receptorsandhavelessspilloverintoothersystems(muscarinic, cholinergic).Asaresult,themoreprevalentsymptomsarenigrostriatal.Theterm“extrapyramidal”refersto motorsymptomsoutsideofthosefrommotorcortexmedullarypyramidsspinalcordmuscles.The extrapyramidalsystemworkstomodulatemotorcontrolthroughthereticularformation,nigrostriatal pathway,cerebellum,vestibularsystem,andanteriorhorncells.EPSinvolvesabnormalcoordinationof movement,includingakathisia,akinesia,pseudoparkinsonsymptoms,andacutedystonia(musclespasms). ExtrapyramidalSideEffects(MoreCommoninHighPotency) • • • • • Pseudoparkinson:bradykinesia,rigidity,maskedface,cogwheeling,tremor.Womenare2xmore likely.Treatwithanticholinergics,Benadryl,oramantadine Dystonia:musclespasmsofjaw,tongue,eyes.Laryngospasmspossible.Morecommoninyoung males.TreatwithanticholinergicsorBenadryl Akathisia:pacing,restlessness,describedasfeelingtheurgetomovearoundorhaving“crawling” sensationunderskin.Treatedwithpropranolol,BZD,orclonidine TardiveDyskinesia:occurabout6monthsafterinitiationofthemedication.Isrelatedtoincreased sensitivitytoDAduetoreceptorchanges.Thusappearstobeclosertoamovementdisorderthat occursduetoexcessDAdespitepresenceofDAblockingmedication.Presentswithabnormal muscularjerkingoflimbs,trunkandperiorbital.Increaseswithstress.Morecommoninolder females.Treatbydecreasingthemedicationordiscontinuing.AnticholinergicsworsenTD NeurolepticMalignantSyndrome:fever,musclerigidity,autonomicsymptoms,increasedCPKand acutementalstatuschange.Morecommoninmales.Canbelethal.Treatwithcooling,dantroleneor bromocriptine,anddiscontinuetheincitingmedication Non-EPSSideEffects(MoreCommoninLowPotency) • • • • • • • AlphaBlockade:orthostatichypotension Anticholinergic:drymouth(treatwithsugarlessgum),constipation,sorethroat,urinaryretention (treatwithbethanechol),blurredvision,confusion Antihistamine:weightgainandsedation Prolactin:sexualsideeffectslikeerectiledysfunction,priapism,increasedtimetoejaculation, gynecomastia,impotence,andanorgasmia Hepatic:jaundiceandelevatedLFTs(lessseverethanwithatypicals) Cardiac:arrhythmiaandprolongedQTc Agranulocytosis(monitorforfever,sorethroat) GotoTableofContents 9 • • • Epilepsyduetoloweredseizurethreshold Skindiscolorationandphotosensitivityinchlorpromazine Retinitispigmentosaandblindnessinthioridazine Categories • • • HighPotency:fluphenazine(Prolixin),haloperidol(Haldol),thiothixine(Navane),trifluoperazine (Stellazine) MediumPotency:perfenazine(Trilafon),molindone(Moban),loxipine(Loxitane) LowPotency:chlorpromazine(Thorazine),thioridazine(Mellaril) ChoosingBetweenTypicals • • • • • • • • Cardiacpatients:avoidlowpotency,especiallythioridazine(Mellaril) Elderly:avoidlowpotencyduetoanticholinergicconfusion Weightgain:molindone(Moban)andloxipine(Loxitane)havetheleastweightgain.Highpotency haslessweightgain.P:Currentlymolindoneisoffthemarketduetolackofhighvolumeclinicaluse Sexualsideeffects:mostcommoninthioridazine(Mellaril) Sleep:chlorpromazineisasedatingtypicalandisagoodchoiceforaidingsleepinapatientwith maniaorpsychosis Mood:loxipine(Loxitane)hasmild5HTantagonism,makingitsimilartoatypical.Additionally,itis metabolizedtotheTCAamoxepine.P:usefulwhenapatientcannotgetquetiapineoraripiprazole duetocost.DAblockadeissimilartoquetiapineandthemoodcomponentislikearipiprazole. Additionally,Stahlnotestheuseofloxipinefortheaugmentationofschizophreniamanagementwith anatypicalantipsychotic. Haloperidolhasadepotformulationthatlasts3-4weekstoensurecompliance.Fluphenazine (Prolixin)hasadepotformulationthatlasts2weeks.P:alwaysdoanoraltestdosebeforegivinga depotinjectionduetoriskofirreversibleEPSoncedepotisgiven.Consideravoidingfluphenazine depotinmed-naïveyoungmuscularmalesduetoEPSrisk. HaloperidolhasaliquidformulationtoaidineaseofadministrationandanIVformulation.Reminder thatIVformulationsaremuchhigherpotencyduetolackoffirstpassintheliver.Thusstartwith lowerdosesthanwoulduseinPOorevenIM(2-5mgIV). AtypicalAntipsychotics DuetotheprevalenceofEPSwithtypicalantipsychotics,theatypicalswerecreated.IfexcessiveDAblockade leadstoEPS,thenlesssevereDAblockadewouldcauselessEPS.Thebestwayfoundtomodulatethe amountofDAblockadewasthrough5HT.Normally,serotoninbindsto5HTreceptorsonDAneuronsand inhibitsDArelease.Byblockingthese5HTreceptors,DAreleaseisnotinhibited.ThecombinationofDA receptorblockadeplus5HTblockade(lessinhibition)leadstoanetincreaseinfreeDAcomparedwith straightDAblockadeinthetypicals.Thus,theatypicalshavelessEPS.Additionally,theybettertreatthe negativesymptomsofschizophreniathanthetypicalsdo.However,theatypicalsappeartohavemore metabolicsideeffects(weightgain,diabetes)thanthetypicalsdoduetoeffectsonotherreceptors. Additionally,theatypicalsmayhavemorelivereffectsandleukopeniathanthetypicalsdo.Themajorityof theatypicalsarealsoapprovedbytheFDAfortreatingbipolarmaniaandmonotherapyforbipolardisorder. GotoTableofContents 10 Clozapine Quetiapine Loxapine Clozapine(derivedfromimipramine,adibenzazepine)isadibenzoxazepineOtherdibenzoxazepinesare quetiapineandloxapine.Thesemedicationsallimprovemoodinadditiontopsychosis. Risperidone(Risperdal):thefirstatypicaltobecomegeneric,thuslowercost.Inadditiontomaniaand psychosis,itisapprovedforthetreatmentofaggressionandself-injuriousbehaviorinautisticchildren.Can beusedinchildrenwithticdisorders(consideralsousinghaloperidol)orimpulsive/disruptivebehaviors. Half-lifeis20hours;thusonce-dailydosingisfine.EquivalenttohaloperidolinD2bindingaffinitywithless incidenceofEPSwhenkeptbelow6mgperday.Minimalalphaandmuscarinicaffinity.Hasanactive metabolitethatisformedby2D6,thusinhibiting2D6(paroxetine,fluoxetine)leadstolessefficacyof risperidone.HasmostPRLincreaseofallantipsychotics.WatchforpedaledemaandincreasedLFTs.Weight gainis#3afterclozapineandolanzapine.Formulationincludespill,dissolvingMTabs,andRisperdalConsta (depotpreparationlasting2weeks.Note:needoralrisperidonex3weeksafterstartConsta).P:usefulin severeOCD,impulsecontrolissues,andbodydysmorphicsymptoms. Paliperidone(Invega):theisolatedactivemetaboliteofrisperidone(i.e.,risperidoneisconvertedto Paliperidoneinthelivernormally),whichmaybeabetterchoiceinhepaticallyimpairedpatients.Whileitis consideredtohavelesssideeffectsthanrisperidone,paliperidonehasmoreQTcprolongationandrequires lowerdosinginrenalimpairedpatients(asitisexcretedunchangedthroughthekidneys).Itexistsasan immediatereleaseandadelayedreleasemedication(avoidingastricbypass)andalsooccursinadepot formulation(Sustenna).Sustennarequiresnocontinuedoraldosingoncethedepotisgiven.Injectioninto deltoidhasnearly30%higherplasmaconcentrationthatgluteal.Mostlikelyisa“metoo”drugwithnomajor benefitoverrisperidone. Olanzapine(Zyprexa):half-lifeaverages31hours,leadingtoonce-dailydosingisfine.Metabolizedby1A2, thusfluvoxamine,cimetidine,andciprofloxacinincreaseolanzapineconcentrations(inhibitorsof1A2),while carbamazepinereducesolanzapine.Weightgainandmetabolicsideeffectsarecommon(#2afterclozapine). Canbeverysedatingandalcoholcoadministrationleadstoanincreasedolanzapineabsorptionby25%, worseningsedation.Becomesgenericinlate2011.Formulationincludespill,dissolvingZydistabs,IM,and depotRelprevv(injectionsq2-4weeks). Quetiapine(Seroquel):half-lifeis7hours,thusBIDorTIDdosingisrecommended.WhileithaslessEPSthan otheratypicals,itissedatingandhasweightgain.Isusedofflabelforthemanagementofanxiety,PTSDand sleep.Hasorthostatichypotensioncommonly.HasanXRformulationwithequivalentbioavailability.Dilantin increasesQuetiapine’sclearance5fold,thusconsiderhigherdosinginpatientsonDilantin.P:weightgain appearstobesomewhatdosedependent.Ifusingitforsleep,onceexceeding200mgconsiderchangingto GotoTableofContents 11 anothermedicationforsleep,likeTrazodone,VistarilorDoxepin.Additionally,becausetheweightgainis metabolicinorigin,tellingthepatientthatthemedicationwillcauseweightgainduetoappetiteincrease aloneisinaccurate.Itisimportanttohavethepatientmonitortheirweightwhileonmostoftheatypicals. Ziprasidone(Geodon):half-lifeis5-10hours,thusBIDdosingneeded.Bioavailabilitydoubleswhentaken withfood,preferablya500caloriemeal.Dueto5HT1AagonismandSSRI/SNRIproperties,ithassome benefitintreatingoraugmentingdepressiontreatment.HaslessweightgainandEPSthanotheratypicals. CommonsideeffectsincludesedationandQTcprolongation(morethanotheratypicals).ZiprasidonehasBID dosingandexistsasacapsule(cannotbebrokeninhalf),liquid,andIM.P:whileziprasidoneisnotahighly potentatypical,itisusefulintreatingMDDwithpsychosis. Clozapine(Clozaril):likelythemosteffectiveantipsychotic.Half-lifeof12hours.Consideredtohavehigher affinityforlimbicthanstriatalareas,comparedwithatypicals.Ismetabolizedprimarilyby1A2(increasedin presenceoffluvoxamineorciprofloxacin).Sideeffectsincludeseveresedation,weightgain,sialorrhea, agranulocytosis,QTcprolongation,andrequiresweeklyblooddrawsfor6monthstomonitortheANC. DosingisheldifWBC<3000orgranulocytes<1500.Additionally,thismedicationisonlydispensedatcertain pharmaciesandrequiresproofoflabstodispense.Thereisanationalclozapineregistrywhereallpatientson themedicationarefollowedandtheirlabsreported.Inordertostartclozapine,thepatient’sinformation mustbegiventotheregistryandpretreatmentlabsmustbenormal(lipids,CBCwithANC,Chem13and EKG).Theriskofagranulocytosisis<1%inthefirstyearoftreatmentwithclozapine.TheriskofTDis incrediblylowanditisthebesttreatmentforpsychosisthathasnotrespondedtootheragents.Itoccursin pillanddissolvingtabletformulationsandisBIDdosing.Dosingstartsat25mgBIDandcanincreaseby25mg perdaymaximum.Sialorrheamayrespondtoclonidine.Likerisperidone,isgeneric.P:lithiumcanbeusedto raisetheANCinordertohelpwithclozapinetitration.Asimpledosingof600mgatnightofLicanhelp improvetheANCenoughtostartorcontinueclozapine. Aripiprazole(Abilify):unliketheotheratypicals,isaD2partialagonist,competingwithendogenousDA (bothpostsynapticandpresynaptic)andbindslessrobustly.ThisisconsideredtobemodulationoftheDA receptorratherthanblockade.ThenetresultisdiminishedDAactivityinthelimbicsystem(whichiselevated inschizophrenia)andincreasedDAactivityinthefrontalandprefrontalareas(whichisconsideredlowin schizophrenia).Inadditiontomaniaandpsychosis,itisindicatedforaugmentationofdepressiontreatment. Thehalf-lifeisabout75hours;thusonce-dailydosingisfine.Metabolizedby3A4and2D6.Isastrong5HT2C agonist(unliketheotheratypicals),whichmeanslessweightgain.Itisalsoastrong5HT-7antagonist, improvingmood.Sideeffectsincludeakathisia,orthostatichypotension(alphablockade),nausea/GIeffects, somnolenceorinsomnia. Asenapine(Saphris):likeclozapine,hashigheraffinityforD3andD4receptorsthanD2receptors.Ithas minimalanticholinergicsideeffects.Isassociatedwithakathisia,dizziness,sedation,andweightgain (histamineaffinity).Metabolizedby1A2andisdosedBIDinasublingualformulation.Thepatientmaynot eatordrinkfor10minutesafterdosing.Preliminarydrugcompanydatareportsresultsfrom1,500patients butthereispaucityofpublisheddataonactualefficacy(themainpublishedstudyonlyevaluated174 patients).Thus,asenapinehasweightgain,sedation,mustbedosedsublingually,andisveryexpensive. Thereislimitedpublisheddataontheefficacyonthismedicationascomparedwithotheratypicals. Iloperidone(Fanapt):notstructurallyrelatedtoanyotheratypicals.HasmixedD2and5HT2antagonism withlowaffinityforhistamineandmuscarinicreceptors.Metabolizedby2D6and3A4andthehalf-lifevaries between18-37hoursbasedonthestrengthof2D6enzymes(longerhalf-lifeinpoormetabolizers).Avoidin hepaticimpairment.ProlongsQTintervalasmuchasziprasidone.Itisalsoassociatedwithorthostatic hypotension(alphablockade),dizziness,andsomnolence.Iloperidonehasminimalweightgain.PRLis GotoTableofContents 12 increasedinover25%ofpatients.Duetoriskoforthostatichypotension,dosingmustbegradualover4days inBIDscheduling.Consideringthatthismedicationwasfirstintrialsin1998andtookover10yearstobe releasedaftermovingbetweenmultipledrugcompanies,likelyduetosubparefficacyresults.Thebottom line:thismedicationissimilartoziprasidoneinQTcprolongationwithlessakathisiabutmoreweightgain.It mustbetitratedslowlyduetoorthostatichypotensionandmanystudiesdonotshowittobeanybetter thanexistingatypicals. Lurasidone(Latuda):strongD2/5HT2antagonistwithminimalhistamineinteraction(thuslowweightgain). Itdoeshavesedation,whichmayberelatedtostrong5HT-7antagonism(seebelow).Metabolizedby3A4. Thereareonlyfour6-weektrialsofthismedicationsubmittedtotheFDA,thustheclinicaldataislimited. OnestudysuggestedthatitupregulatesBDNFintheprefrontalcortex,suggestingthatthemedicationmay be“pro-cognitive.”Hasonce-dailydosing,butmustbetakenwithfoodtobeabsorbed.Minimalweightgain, noQTcissues.EPSisequivalenttootheratypicals.Furtherdataonlurasidoneefficacywillshowifthis medicationisa“metoo”medication. Anoteon5HT-7:someofthenewantipsychoticsareboasting5HT-7antagonism.Whilenotfully understood,the5HT-7receptormaybeassociatedwithdepression.Medicationsthatblock5HT-7improve depression.Additionally,theymayimprovehippocampus-mediatedactions,likememory.Manyofthe atypicals(risperidone,ziprasidone)arepotent5HT-7antagonists. MoodStabilizers ThebasicmechanismofactionofthemoodstabilizersistoenhancetheactionsofGABAandreducethe actionsofglutamate.Inthisway,bothseizuresandmoodswingsarecontrolled.Additionally,mood stabilizerscanbeusedtoaidinthetreatmentofanxietyforsimilarreasons.Lithiumisthefirstknownmood stabilizer,andismechanisticallydifferentfromtheothersinthatitdoesnotalsotreatseizures. Regardinghistoricserendipity,lithiumwasfirstusedinthe1800sforthetreatmentofgout.Itwasknownto helpdissolveurate,aparticleinitiallyblamedformaniaandpsychosis.Around1900lithiumwasabandoned forthetreatmentofmaniaandwasnotrediscovereduntil1949byAustralianpsychiatristHenryCade.Due tounderstandingthatdisorderssuchasthyrotoxicosiscouldbedetectedbymetabolitesinurine,Cade examinedmanicpatients’urinefordetectableparticlesrelatedtomania.Hisstudyfocusedoninjecting guineapigswithmanicpatienturinetoseeifbehavioraldisturbanceoccurred.Longstoryshort,theguinea pigshewasinjectingwithmanicpatients’urinekeptdyingsohedecidedtoaddlithiumtotheurinetohelp breakdownurate.Ultimatelyhediscoveredthatlithiumaloneledtocalmingofmania. TheFDAdidnotapprovetheuseoflithiumforthetreatmentofmaniauntil1970.Strangely,inthe1930s- 50sifyouwantedtohaveaccesstolithium,itwasmosteasilyfoundasacommonreplacementfortablesalt inpatientswithheartdiseaseORin7-UP.Seriously.Originallylabeledas“Bib-LabelLithiatedLemon-Lime Soda,”7-UPcontaininglithiumwasmarketedspecificallyasahangovercure. ValproicAcidwasfirstsynthesizedin1882fromvalerianasasolventfororganiccompoundthatwas believedtobeinertmetabolically.Bythe1960sitwasdiscoveredthatmedicationsthathadlongbeen consideredanticonvulsanthadnoabilitytopreventseizuresandthatthevalproicacidsolventhadbeenthe activetreatment. Lithium GotoTableofContents 13 Indications:approvedforacuteandmaintenancetreatmentofmaniainadditiontoadjunctivetreatmentfor depression.Itislessusefulinrapidcyclingormixedepisodesthanvalproicacid(VPA).Additionally,data showsreductioninriskofsuicideinpatientstreatedwithlithium.Itcanbeusedinpregnancyandalthoughit hasariskofEbstein’sabnormalitywhenusedinthefirsttrimester,thisriskisrelativelyminimal(general population:1/20,000;Li:1/1,100,or0.1%).Thisriskreducesafterthefirsttrimesterandmustbeconsidered againsta5%riskofneuraltubedefectwithVPAandtheriskofdangertothepatientandfetusifmania continuesuntreated.Thusafterthefirsttrimester,lithiumisthemoodstabilizerofchoiceformaniain pregnancy. Profile:itdoesnotbindtoproteins,isnotmetabolized,andisexcretedinthekidneys.Half-lifeis18to24 hourswithsteadystatereachedinabout5days.Dosingshouldstartat300mgBIDorTIDandplasmatrough drawnafter5daysofcontinuousdosing.Formulationincludesimmediatereleaselithiumcarbonate,450mg extendedreleasetabs(Eskalith),andliquidlithiumcitrate.Therapeuticlevelaimsfor0.8-1.2andcanbe dosedBIDorTID(oroncedailywithEskalith).Priortostartinglithium,baselineCBC,Chem13(including renalfunction),TSH,EKGandHCGshouldbedone. Sideeffects:includenausea/vomiting,sedation,weightgain,tremor(P:treatwithpropranolol), hypothyroidism(15%female,4%male;P:iflithiumishelpful,consideruseoflevothyroxinetotreat hypothyroidism),renaltubulardamage,bradycardia,AVblock,sexualdysfunction(duetoincreased5HT), alopecia,acneandneurologicsymptomsincludingconfusion,coma,stupor,anddeathinthecaseoftoxicity. Regardingrenalsymptoms,lithiumisassociatedwithNephrogenicDiabetesInsipiduswherelithium antagonizestheeffectsofADHinthedistalkidney.Thesymptomsincludepolyuriaandpolydipsiaand ultimaterenalfailureifnotresolved.Theprimarytreatmentisdiscontinuationoftreatmentoradditionof HCTZ(thiazidediuretic).Thisiscounterintuitiveasthiazidesarediureticsandshouldincreasewaterloss.Itis postulatedthatlithiumcausesthedistalkidneyaquaporinstobedownregulatedandlosesensitivitytoADH. Thiazides,inadditiontoeffectsonNaintheproximalkidney,increaseexpressionofdistalaquaporins,thus reversingtheeffectsoflithium(Loffingetal).BecauseHCTZdecreasesNAreabsorption,itultimatelyleadsto increasedlithiumabsorption(apositiveion)andcanbeassociatedwithlithiumtoxicity.Thuslithium coadministeredwithHCTZmustbedecreasedindose. DrugInteractions:lithiumtoxicityismorecommoninthepresenceofNSAIDs,diuretics,ACE-Inhibitors, hyponatremia,anddehydration.Treatlithiumtoxicitywithdialysis,gastriclavageorkayexalate,notcharcoal. Caffeineisknowntodecreaselithiumbyenhancingitsrenalclearance(P:stoppingcaffeineleadstoworse lithiumtremorfromhigherplasmaconcentration).LithiumcombinedwithSSRIscancauseserotonin syndrome. ValproicAcid Indications:acutemania(includingrapidcyclingandmixedepisodes),maniasecondarytotraumaticbrain injuryandorganicissues,aggressionandimpulsivity,migraines,generalepilepsy.P:lithiumisbetterat treatingdepressionandsuicidalitywhileVPAisbetterattreatingmoresevereformsofBipolarDisorder. Additionally,theelderlymaytolerateVPAbetterduetolesscognitiveandrenaleffects. Profile:highlyproteinboundwithunbounddrugcrossingthebloodbrainbarrier.Half-lifeis10to16hours. Metabolismisprimarilybyglucuronidationwithsomeoxidativemetabolism(producinganactivemetabolite) andminimalP450metabolismonVPA.Valproicacid(Depakene)iscombinedwithasecondidentical moleculeandNatoformdivalproexsodium(Depakote)whichisavailableasanentericcoatedtabletto GotoTableofContents 14 minimizeGIsideeffects.Depakotealsoexistsin“sprinkle”formulation(itisneithercolorfulnortasty—a totalletdown),aonce-dailyExtendedReleaseFormulation(withupto30%lessbioavailability),andIV formulation. Depakeneisavailableintabletandliquidformulation.DosingisgenerallyBIDorTIDandtroughlevelsare drawn3daysaftercontinuousdosing.Therapeuticlevelsareconsideredbetween50-200fortheprevention ofseizures,withmanysideeffectsstartingaftercrossing100. ValproicAcid DivalproexSodium SideEffects:nausea/vomiting,pancreatitis,elevatedLFTs,liverfailure,tremor,sedation,neutropenia, thrombocytopenia,hairloss,weightgain,polycysticovariansyndrome,neuraltubedefectinpregnancy.P: overall,thelistofsideeffectsislongerandworsewithlithiumthanwithVPA. Drug-DrugInteractions:proteinbounddrugsdisplaceVPA,makingitmoretoxic/crossBBBmorereadily.This includesinteractionwithaspirin,carbamazepine,anddiazepam.LithiumplusVPAhasincreasedriskof tremor.AntipsychoticsplusVPAhavemorecombinedsedation(thesameistrueforalcohol).RegardingVPA andoxidationintheliver,VPAwillincreasecarbamazepine,diazepam,amitriptyline,andPhenobarbital.VPA decreasesphenytoinanddesipramine.VPAmayaugmentanticoagulantsandshouldbemonitoredclosely. FluoxetinemayincreaseVPAlevels.Mostimportantly,VPAdecreasesglucuronidationoflamotrigineleading todoubledlevelsandhighriskforStevens-Johnsonsyndrome. Carbamazepine(Tegretol) Indications:structurallysimilartoimipramine,carbamazepine(CBZ)wasintendedinitiallyasan antidepressant.Inthelate1960sitwasrecognizedastreatmentfortrigeminalneuralgiaandtemporallobe epilepsy(complexpartialseizures).Isconsideredsecond-linetreatmentforacutemaniaafterlithiumand VPA.Itcanalsobeusedinrefractorydepressionandtotreataggression.Itshouldbeavoidedinpregnancy duetocraniofacialabnormalitiesandspinabifida. Profile:theaveragehalf-lifeis26hoursanditisbetterabsorbedwithfood.CBZinduces(helps)P450enzyme 3A4.ThismeansthatanymedicationstakenwithCBZthatrequire3A4tobreakthemdownwillhave decreaseddose.Example:warfarinisbrokendownby3A4.IftakenwithCBZ,3A4actionisincreasedand warfarinisbrokendownmorethanexpected.Thiscanleadtolossofwarfarineffect(increasedblood clotting—i.e.,bad).Additionally,CBZisalsobrokendownby3A4.WithchronicadministrationofCBZ,the GotoTableofContents 15 half-lifediminishesto12hoursduetoinductionofitsownmetabolismby3A4(autoinduction).Thusafter35weeks,3A4breakdownofCBZincreases,requiringincreaseddosingandcanleadtounpredictableblood levelsofCBZduringthistimeduetoautoinduction.Afterinitialprocessingintheliver,CBZhasanactive epoxidemetabolitethatisthestrongerformofthemedication.Thisactivemetaboliteisassociatedwith betteranticonvulsantpropertiesandlikelymoresideeffectsthanrelatedmedicationoxcarbazepine(see nextsection).WhereaslithiumandVPAworktoincreaseGABAanddecreaseglutamate,CBZworksmoreon inactivatingNachannelstostopdepolarization.Duetoirregularabsorption,CBZneedstobetakenTID,even withfood.AnXRformulationexiststhatcanbetakenjustonceortwiceperday.Generallydosingstartsat 200mgBIDandincreasesby200mgevery2to3days.Thetargetdoseis1,200mgperdayandbloodlevels areoftenunreliableduetotheepoxidemetabolitenotbeingthefocusofdrugmonitoring(detectsboth parentandmetaboliteindiscriminately)andtheriskofautoinduction. SideEffects:mildnausea,sedation,vertigo,diplopiaaremostcommonandaredosedependentwith diminishingsideeffectsovertimeasthedrugdiminisheswithautoinduction.Weightgainisminimal.More seriously,itcancauseaplasticanemiaoragranulocytosisthatisnotdosedependentin1/125,000.Benign leukopeniaisseeninupto2%ofpatientsanddoesnotcorrelatewithmoreserioussideeffects.Monitorfor fever,sorethroat,rash,petechiae,bruisingandeasybleeding.Additionally,CBZcancausehepatitiswith elevatedLFTs.Upto15%ofpatientsonCBZdevelopabenignmaculopapularrashinthefirst3weeksof treatment.TheconcernistheriskoftoxicepidermalnecrolysisandStevenJohnson’s,whichalsomay presentwitharash.StoppingCBZremovestherashandinpatientswithsignificantresponsetothe medicationmaybere-trialedonCBZaslongasrashwastheonlypresentingsymptom(nomalaise,oral lesions,flusymptoms).CBZcancreatesymptomsoppositeoflithiumwithhyponatremiaandwaterloading (similartoSIADH),butcannotcorrectabnormalitiesinlithiumuse.BeforestartingCBZ,CBC,Chem13 includingrenalfunction,andHCGareneeded. Drug-DrugInteractions:duetoCYP3A4induction,itreducestheconcentrationsofmanydrugs,including antipsychotics(haloperidol,clozapine,olanzapine,aripiprazole,quetiapine),TCAs(amitriptyline, clomipramine,desipramine,doxepin,imipramine),benzodiazepines(alprazolam,clonazepam),seizure meds/moodstabilizers(lamotrigine,VPA,phenytoin,ethosuximide)andothers(warfarin,Tylenol, methadone,doxycycline,oralcontraceptives).Medicationsthatinhibit3A4causeCBZtoxicity,including fluoxetine,fluvoxamine,cimetidine,verapamil,diltiazem,gemfibrozil,andgrapefruitjuice.CBZisdiminished byphenytoinandETOH(3A4inducers).WhencombinedwithVPA,CBZisdisplacedfromplasmaproteins, leadingtoincreasedriskoftoxicity.P:generally,ontests,whenaskedaboutCBZ,thecorrectansweristhatit decreasesthedoseofwhatevermedicationadministeredwith. Oxcarbazepine(Trileptal) Indications:approvedfortreatmentofepilepsy,NovartispledguiltyinSeptember2010formarketing oxcarbazepineforthetreatmentoftrigeminalneuralgiaandBipolarDisorderwithoutapprovalorsufficient data. Profile:unlikeCBZ,absorptionisrapidanddoesnotrequirefood.Theactivemetaboliteisamonohydroxide withahalf-lifeof9hours.Intrials,dosingwasstartedat300mgatnightandincreasedtoatotalof1,200mg perdayinBIDdosing. SideEffects:sedation,nausea,dizziness,vertigoarecommon.DoesnothavetheserioussideeffectsofCBZ. Hyponatremiacanoccurin3%ofpatientsandmustbemonitoredcloselyinitiallyasitmaynotpresentwith symptomsandcanleadtoseizuresandconfusion. GotoTableofContents 16 Drug-DrugInteractions:minimalcomparedwithCBZ.Mayinduce3A4mildly,thusavoiduseoforal contraceptivesasprimaryformofbirthcontrol.PhenytoinandETOHwilldecreasethedoseof oxcarbazepine. Lamotrigine(Lamictal) Indications:helpfulinreducingdepressiveepisodesinmaintenancetreatmentofBipolarDisorder,partial epilepsyandLennox-Gastautseizures.OtherreportsusinglamotrigineforaggressioninRhett’sdisorder, Alzheimer’sandinmentallyretardedpatients.Thereisnodatatoshowthatitcanmanageeitheracute bipolardepressionormania. Profile:initiallydevelopedasafolateantagonist(elevatedfolateinducesseizures),wasnotedtoblockNa voltagechannelslikeCBZ/Trileptal.Additionally,itinhibits5HTreuptaketoincrease5HTconcentrations. Half-lifeis25hoursandhas98%bioavailability.Lamotrigineismainlymetabolizedbyglucuronidationinthe liver.Duetoavariedrateofabsorption,BIDdosingisrecommended.Noefficacyhasbeenseenindoses above200mgforthetreatmentofbipolardisorder.Alone,itisdosed25mgadayfor2weeks,then50mga dayfor2weeksthen100mgadaybyweek4.WhengivenwithCBZ(induces/decreaseslamotrigine),the abovedosingscheduleisdoubled(i.e.startwith50mgperday).WhencoadministeredwithVPA(increases lamotrigine),thedosingscheduleischangedto25mggiveneveryotherdayfor2weeks,then25mgperday for2weeks,then50mgbyweekfourtoincreaseby25mgperweek.Lamotrigineexistsinanorally dissolvingtablet(ODT)andinchewabletablets. SideEffects:overalliswell-tolerated.Minimalsedationorweightgain.Milddizzinessandnauseaare possible.Somedatashowsthattakinglamotrigineafter5pmleadstodisruptionofstage3sleep(restorative sleepandwheremostparasomniasoccur).ThemainconcernisrashassociatedwithStevenJohnson’s syndrome.About8%ofpatientsonlamotriginedevelopabenignmaculopapularrashwithinthefirst4 monthsoftreatment.Theriskofaseriousrashisabout0.08%.Despitethislowrate,thepresenceofany rashshouldleadtodiscontinuationofthemedication.TreatmentwithconcomitantVPAandtreatmentin patientsunderage16isassociatedwithhigherriskofseriousrash. Drug-DrugInteractions:asmentioned,VPAincreaseslamotrigineconcentrationsandshouldbemonitored closelyoravoided.CBZ,phenytoin,andPhenobarbitaldecreaselamotriginebyupto50%.Inthepresenceof oralcontraceptives,lamotrigineitselfmaybedecreased,butnotthereverse. Gabapentin(Neurontin) Legal:discussionshouldbeginhere.Over90%ofprescribedNeurontinisoff-labeluse.Seriously. Additionally,Pfizerwasfined$430MILLIONincriminalfinesrelatedtoillegalmarketingofthemedicationfor off-labelusein2004.Afterpayingthat,continuedoff-labeluseandmarketingledtoaKaiserPermanente suitforanadditional$141MILLIONinMarch,2010.Thus,gabapentinhasbeenmarketedforBipolar Disorder,migraines,fibromyalgia,sleep,anxiety,diabeticneuropathy,andHIVneuropathy.TheFDAhasonly everapprovedgabapentinforadd-ontherapyforthetreatmentofseizures.JustasidenoteaboutPfizer:in September2009theUnitedStatesDepartmentofJusticeforcedPfizertopleadguiltytothelargestcriminal penaltyeverimposedinAmericanhistory:$2.3BILLIONincivilandcriminalchargesforillegalmarketingof fourmedications,includingGeodonandLyrica. Indications:addontherapyfortreatmentofseizures.Otheroff-labelusesareabove. GotoTableofContents 17 Profile:unboundbyproteinsandisnotappreciablymetabolized.Eliminatedrenally.IncreasesGABAand 5HT.Dosingisusuallystartedat100mgTIDandgraduallyincreasedforatotalof2,700mgperday.Existsas capsules100,300,and400mgaswellas600and800mgtablets(usefulingastricbypass).Dosageis decreasedinpatientswithimpairedrenalfunction.Bioavailabilitydiminishesby20%whengivenwith antacids. SideEffects:somnolence,ataxia,diplopia,anddizziness.Sideeffectsaredosedependent. Pregabalin:has6xtheGABAbindingaffinityofgabapentin,isthefirstmedicationeverapprovedbytheFDA specificallyforthetreatmentoffibromyalgia.Standarddosingis50mgBIDorTIDandcomesincapsulesor strawberryflavoredsyrup.HastheabilitytopotentiatebenzodiazepinesandopiatesandisaScheduleV drug. Topiramate(Topamax) Indications:antiepileptic,migraines,smokingcessation(especiallyinalcoholics),tremor,bulimiaandbinge eating,somestudiesshowdecreasedself-mutilatorybehaviorinborderlinepersonalitydisorder, managementofanxiety Profile:isrenallyexcreted70%andneedstobedecreasedindoseinpatientswithrenalissues.Half-life24 hours.IncreasescerebralGABA.Dosingbeginsat25mgatbedtimeandgraduallyincreasestoBIDdosing. SideEffects:paresthesia(P:especiallynumbnessandtinglinginfingertipsandperipheralextremities. Sometimesimprovedbyqhsdosing),weightloss,sedation,dizziness,word-findingdifficulties(P:generally, above100mgthisisseen.Patientscallit“dopamax”),lowersserumbicarbonatethroughcarbonic anhydraseinhibition(causingcardiacarrhythmiasandrenalstonesin1.5%). Drug-DrugInteractions:increasesphenytoinandVPAlevels.CBZandphenytoindecreasetopiramatelevels. Avoidwithothermedicationsthatarecarbonicanhydraseinhibitors(acetazolamide/Diamox-glaucoma, altitudesickness,pseudotumorcerebri). Antidepressants TCAs Structurallyrelatedtothetypicalantipsychoticchlorpromazine,imipraminewasinitiallydesignedasa medicationtomanageschizophrenia.However,itwasnotedthatthenewmedicationinexacerbatedmania (upto25%ofpatientswithpre-existingBipolarDisorderwillhavemaniaorhypomaniawhenon imipramine).Afterthiswasdiscovered,imipraminewasusedinthelate1950sasanantidepressant.Manyof theTCAsarestructurallyrelatedtoimipramine,whichisinitiallyderivedfromtheantihistaminemethylene blue.Theterm“tricyclic”and“tetracyclic”referstothe3and4ringsinthechemicalstructuresofthese medications. GotoTableofContents 18 TCAbasics:thethreeringedTCAsaredividedintotertiaryandsecondaryamines.Tertiaryamineshavehigh affinityforblocking5HTreuptake.SecondaryamineshavehighaffinityforblockingNEreuptake. Interestingly,tertiaryaminesaremetabolizedtosecondaryaminesintheliver.Thus,apersontakingthe tertiaryTCAamitriptylineisgettingamedicationthatisstronglyserotonergicyetstillsomewhat noradrenergic.Inthisway,theCAsserveasthefirstSNRIs. Tertiary Secondary Clomipramine(Anafranil) Amitriptyline(Elavil)→ Nortriptyline(Pamelor) Trimipramine(Surmontil) Imipramine(Tofranil)→ Desipramine(Norpramin) Doxepin(Sinequan) Protriptyline(Vivactil) Indications:MDD(butaremorelikelytoinducemaniathanSSRIs),PanicDisorderwithAgoraphobia (imipramineisbest),GeneralizedAnxietyDisorder(especiallyimipramineanddoxepin),OCD(clomipramine isFDAapproved),andchronicpainandmigraine(amitriptylineisusedmostforthis).Imipraminecanbeused totreatchildhoodenuresisbutduetoreportsofsuddendeathinchildrenandadolescents,TCAsshouldbe avoidedinthispopulationifpossible. Profiles:inadditiontoinhibitingreuptakeof5HTandNE,TCAscanantagonizemuscarinicacetylcholine, histamine,andalpha1and2receptors.Additionally,NaandCachannelscanbeblocked,leadingtocardiac GotoTableofContents 19 sideeffects.TCAsaremorelikelytocauseanticholinergicsideeffectsthanSSRIsbutarelesslikelytocause sexualsideeffects,weightgain,andsleepdisturbancethanSSRIs. • • • • • • Clomipramine:mostserotonergic Amitriptyline:mostanticholinergicandalpha Desipramine:mostnoradrenergic,lowanticholinergic Nortriptyline:lowanticholinergic Doxepin:mostantihistamine Protriptyline:closesttonortriptylinebutmaybemorenoradrenergic Pharmacokinetics:absorptioninsmallintestineisrapid.Half-livesvaryfrom10-70hourswithmostTCAs abletobegivenonce-daily.Nortriptylineanddoxepinexistinliquidsolutions. Metabolism:hepaticmetabolismfocusesprimarilyondemethylationandhydroxylation.ThetertiaryTCAs aredemethylatedby2C19andotherenzymes,leadingtotheformationofsecondaryTCAs.Example: clomipramine→desmethylclomipramine,asecondaryTCA.Inthecaseofamitriptylineandimipramine,they areconvertedtothesecondaryTCAsnortriptylineanddesipramine.Secondaryaminesareactivecompounds thatarehydroxylatedinthelivertoactivehydroxymetabolites.Duetothemultiplemetabolitesfloating aroundandthehighvariabilityfrompersontoperson(think:differentenzymenumbersandfunctionality), mostoftheTCAscannotbemeasuredinserumreliably.ThemainTCAsthatareassociatedwithareliable serumlevelthatcorrelatestotherapeuticresponsearedesipramine,nortriptyline,andimipramine.P:For nortriptyline,plasmalevelsbetween50-150aremoreeffectivethanlevelsbeloworabove.Thisiscalleda curvilineartherapeuticwindow.Inthepresenceof2D6inhibitors,TCAscanraisetotoxiclevels(fluoxetine, paroxetine,sertraline,cimetidine). SideEffects: • • • • • • CNS:deliriumduetoanticholinergicandantihistamineeffects,especiallywithamitriptyline. Increasedriskofseizures,upto2%withclomipramine Anticholinergic:drymouth,blurredvision,constipation,urinaryretention.Symptomsmaybe reversedwithbethanechol.Amitriptylineandclomipraminearemostcommon.Avoidinnarrowangleglaucoma(isfineinchronicopen-angleglaucoma) Antihistamine:doxepinismostpotent(butstilllessthanmirtazapineandolanzapine); Cardiovascular:orthostatichypotensionduetoalpha1blockadeispresentwithmanyTCAs.Least withnortriptyline.Asaclass,theTCAshavetypeIantiarrhythmicqualitieswithQTcprolongationand shouldbeavoidedincardiacpatients Hepatic:increasedLFTsareassociatedwithimipramineanddesipramine.Generallyassociatedwith AST>>ALT.Acutehepatitiscanbefatalandmaybeseenin0.1%ofpatients Overdose:deathoccursastheresultofcardiacarrhythmia.Afteracetaminophen,TCAsarethemost lethalcauseofODintheUS,withamitriptylinedeathsexceedingtotalfatalitiesofallTCAscombined. Today,ODonSSRIsis4.5xmorecommonthanTCAs.However,theratesofdeathsofSSRIsinOD(1.5 deaths/1,000OD)aremuchlowerthanTCAs(8.5deaths/1,000OD). TetracyclicAntidepressants SimilartotheTCAs,thetetracyclicsbindto5HTandNEtransporterstopreventreuptake.Amoxapineis consideredbysometobeatricyclicantidepressantasitstructurallyhas3ringswithafourthringasaside group. GotoTableofContents 20 Amoxapine Maprotiline Amoxapine(Asendin):derivedfrommid-potencyantipsychotic,loxapine.Amoxapineincreases5HT,NE,and blocksDA.ItistheonlyTCA/tetracyclicwithbothantidepressantandantipsychoticproperties.Hasanactive metabolite.Half-lifeis8hours,buttheactivemetabolitehasahalf-lifeof>30hours.MayhaveTDandmay havegreaterriskofseizuresthanotherTCAs. Maprotiline(Ludiomil):greatlydiffersfromtheothersinthatitlacks5HTreuptakeinhibitionandprimarily actstoinhibitNEreuptake.Isastrongantihistamine,thusissedating.Islessanticholinergicandalpha blockingthanamitriptyline.Half-lifeis30--60hours. MonoamineOxidaseInhibitors Inthe1950sanantituberculosisdrug,isoniazid(INH),wasfoundtohaveantidepressantproperties. Ultimately,INHshowedquickresistancetoactiveTBandisgenerallyusedinpreventionandaugmentation oftreatmenttoday.Additionally,INHhasnoMAOinhibition.Isoniazidwasaltered(simpleadditionofNisopropylgroup)tocreateiproniazid(Euphozid)andapprovedforthetreatmentofdepressionin1958.This medicationwasanMAOI,andwasthefirstantidepressantevermarketed,beatingimipraminenarrowly. Threeyearslaterin1961itwasremovedfromthemarketduetohepatotoxicity.Thismedicationpavedthe wayforotherMAOIswhichwereusedsteadilyuntiltheadventoftheSSRIs.Thesecond-linestatusofthe MAOIscurrentlyisrelatedtosafetyandsideeffectprofile,notefficacy.Currently,MAOIsavailableinclude phenelzine(Nardil),isocarboxazid(Marplan),tranylcypromine(Parnate),rasagiline(Azilect),moclobemide (Manerix)andselegiline(Eldepryl).In2006,atransdermaldeliveryofselegilineforthetreatmentof parkinsonismwasintroduced. ReviewofMAO:theseenzymesarefoundontheoutermitochondrialmembranes,wheretheydegrade monoamineneurotransmitters(NE,5HT,DA,Epi,Tyramine).MAOImedicationsactintheCNS,theGI system,theliver,andthesympatheticnervoussystem.MAO-AbreaksdownNE,5HT,andEpinephrine.DA andtyraminearebrokendownbyMAO-AandMAO-B. Indications:MDD,somedatamayshowthatphenelzinemaybettertreatatypicaldepression(hypersomnia andhyperphagia)thanTCAs,maytreatdepressioninBipolarDisorderbetterthanTCAswithless hypomania/mania,anxiety,phobias,pain,migraines,depressionassociatedwithTBI.Tranylcyprominewas includedintheSTAR*Dtrialsasaneffectiveoptionintreatment-resistantdepression. Profile:phenelzine,tranylcypromine,andisocarboxazidhavehalf-livesrangingfrom2-3hoursbuthave tissuehalf-liveswithlongertimes.TheyirreversiblyinactivateMAOIs,thustheeffectcanlastupto2weeks, evenwithasingledose.MoclobemideisareversibleMAO-Ainhibitor,andhaslesssideeffectsandless GotoTableofContents 21 dietaryrestrictions.ItisnotapprovedforuseintheUnitedStatesatthistime.Selegiline,phenelzine,and tranylcyprominearestructurallyrelatedtoamphetamines,thushavestimulanteffectsinthebrain. SideEffects:orthostatichypotension,insomnia,weightgain,paresthesia(possiblyfrompyridoxine deficiency),andinductionofmania.WhenswitchingfromanirreversibleMAOItoanotherantidepressant,it isimportanttogivea14-daywashoutperiodduetolossofMAO. DietaryEffects:firstnotedasheadaches,seenmorecommonlyintranylcypromineandlessinphenelzine. Tyramine,presentinmanyfoods,isusuallybrokendownbyMAO.InthepresenceofMAOIs,itisnotbroken down,leadingtohypertensivecrisisandothersymptoms.Symptomsmayincludehypertension,sweating, chills,headache,nausea,pyrexia,dilatedpupils,stiffneck,andrestlessness.Thiscanprogresstoalterationof consciousness,fever,cerebralhemorrhage,anddeath(0.02%).TreatmentwithCachannelblocker, nifedipine,ishelpful.Foodstoavoidincludecheese(exceptcreamcheese),favabeans,overripefruit,sherry, sauerkraut,MSG,pickedfoods,redwine,andtousecaffeine,coffee,chocolate,tea,andbeerinmoderation. Selegiline(Emsam,L-deprenyl,Eldepryl):anirreversibleMAO-BinhibitorusedprimarilytotreatParkinson’s asanadjuncttoL-Dopatreatment.IntestinaltyramineinteractionswithMAO-BaremuchlessthanMAO-A andasaresult,selegilinerequireslessfoodrestrictions.Sideeffectsofnauseaandlightheadednessare minimal.DuetobeingmetabolizedtoL-methamphetamine,themedicationwillhaveapositiveUDS.In additiontoaregulartablet,itexistsasanorallydissolvingtabandatransdermalpatchthatdeliversasteady 6mgper24hours,marketedunderthenameEMSAMforthetreatmentofdepression.Thetheorybehind selegilinefordepressionisrelatedtostudiesfromthe1960swheretheD-isomerofselegiline(D-deprenyl) showedstrongantidepressantpropertieswhenhighdosesofselegilinewereused.NEandDAincreaseswere notedwiththeisomer.Inrecenttrialsusingoralselegilineforthetreatmentofdepression,requiredhigh dosesledtoalossofselectivityforMAO-B,thushavingaffinityforMAO-BandintestinalMAO-A,leadingto tyramineinteractions.ThetransdermalpatchwasastrategycreatedtobypasstheintestinalMAO-A responsiblefortyraminereactions.Resultsforthetreatmentofdepressionwiththepatcharemixed,with somestudiesshowingefficacyandsomeshowingnobenefitoverplacebo. SelectiveSerotoninReuptakeInhibitors(SSRIs) In1970,EliLillyandCompanybeganresearchon3-Phenoxy-3-phenylpropylamine,astructuresimilarto diphenhydramine(knownatthetimetohavesomeantidepressantproperties).Overthenext2years,many derivativesofthiscompoundwerecreating,ultimatelyleadingtothediscoveryoffluoxetine.Themedication enteredthemarketin1986.Lillyresearcherspublishedapaperentitled“Prozac,thefirstselectiveserotonin reuptakeinhibitorandanantidepressantdrug.”Forthenext20years,EliLillystronglymarketedProzacinto popularcultureasthefirstSSRI.Inactuality,thefirstSSRIwaszimelidine(nowbannedforcausingGuillainBarresyndromeandothersometimesfatalsideeffects).Interestingly,fluvoxamineenteredthemarket2 yearspriortofluoxetine.Thus,“Prozac,thefirstSSRI”continuesinpublicknowledgedespitetheinaccuracy (“Prozac,thefirstSSRImarketedintheUSA”wouldbeaccurate). GotoTableofContents 22 Diphenhydramine(Benadryl) Fluoxetine(Prozac) Indications:MDD(allexceptfluvoxamineareapprovedbytheFDAforMDD),depressioninpregnancyand postpartumdepression(over70%ofpatientswithMDDrelapseintodepressionupondiminishingor discontinuingtheirSSRIduringpregnancy.Studiesfollowingchildrenexposedtofluoxetineinuteroshowno relateddecreasesinIQ,language,orbehavioralissues),depressionintheelderly(P:avoidparoxetinedueto anticholinergic),OCD(fluvoxamine,paroxetine,sertraline,andfluoxetineareFDAapproved.P:usehigher dosesthanusedinMDD),panicdisorder(paroxetine,sertraline),PTSD,GAD,BulimiaNervosa(fluoxetine, generallyover60mg),Anorexia(lessdropoutfromtreatmentandbettertreatmentofcomorbiddisorders withfluoxetine),PremenstrualDysphoricDisorder(EliLillymarketedfluoxetineasSarafemintheearly1990s asthepatentforProzacexpired.Literallypinkandpurplefluoxetinecapsulewithanewlogo.Intrials, sertralineandfluoxetineworkequallywell).Inchildren,theFDAhasapprovedfluoxetineforthetreatment ofdepressionandfluoxetine,fluvoxamine,andsertralineforthetreatmentofOCD. BlackBox:in2004theFDAissuedablackboxwarningfortheuseofSSRIsinpatientsundertheageof24. Thiswasbaseduponmeta-analysesthatshowedincreasedriskofsuicidalthoughtsandbehaviors,in additiontoaggressionandhostilityinchildrentreatedwithSSRIs.Whilenotissuedinthetreatmentofthe adults,theblackboxiswell-knowntomanypatientsandisasubjectofconcerninthegeneralpublic.All depressedpatientsshouldbecloselymonitoredinthefirst1-2weeksofSSRItreatment. Pharmacokinetics:seethesecondchartbelowforthehalf-livesofthevariousSSRIs.RegardingCYP interaction,fluvoxaminehasthemostinteractionwith1A2,2C,and3Ainhibition(withminimal2D6 inhibition).Fluoxetineandparoxetinearethestrongest2D6inhibitors,withsertralinehavingmoderate inhibition. GotoTableofContents 23 Pharmacodynamics:citalopramandescitalopramarethemostselectiveinhibitorof5HTreuptake,having littleinhibitionofDA,NE,histamine,orGABA.FluoxetineweaklyinhibitsNEreuptakeandbindsto5HT2C. SertralineweaklyinhibitsNEandDAreuptake.Paroxetinehassignificantanticholinergicactivityathigher doses. DrugInteractions:2D6inhibitorswillslowthemetabolismofcarbamazepine,diazepam,phenytoin,and antineoplasticagents.Sertralinemaydisplacewarfarinfromproteins,leadingtoincreasedPTT.Fluvoxamine GotoTableofContents 24 increasesconcentrationsofmultipleBZD,warfarin,clozapine,carbamazepine,methadone,propranolol,and diltiazem.Ithaslittleinteractionwithlorazepam. SideEffects: • • • • • Sexualsideeffects:themostcommonsideeffectwithlong-termuseoftheSSRIs,withincidenceof 50-80%.Treatmentincludesdecreasingthedose,addingbupropion(increasesDA)orbuspirone (antagonismof5HTviaautoreceptor),oruseofsildenafil. GI:nausea,diarrhea,vomitingaremostcommonwithsertralineandfluvoxamine.Medicated through5HT3.Paroxetineisassociatedwithconstipation(anticholinergic).Upto30%ofpatientson SSRIwillgainweight,especiallywithparoxetine. CNS:increasedanxiety(fluoxetine),insomnia(fluoxetine)andsedation(variedwithmanyofthe SSRIs),emotionalblunting(feelingsofapathy,inabilitytocry,“zombie”effect),seizures(0.2%),and EPS. Hematologic:caninhibitplateletbinding,leadingtobruising(P:seencommonlywithsertraline) Serotoninsyndrome:apotentiallyfatalconditioninvolvingdiarrhea,restlessness,agitation, autonomicinstability,hyperthermia,myoclonus,rigidity,delirium,andcoma.P:onexaminations, clinicallydistinguishingbetweenNMSandSerotoninSyndromegenerallycomesdowntomyoclonus inSerotoninSyndrome.Treatmentisremovaloftheoffendingagents,nitroglycerine,dantrolene, BZD,cooling,andpossiblyventilation. PereauBasicsonSSRIs:duetothemajorityoftheSSRIsexistingingenericformulation(exception: escitalopram),themedicationswecommonlyprescribetodaydonothavethesamesideeffectsandprofiles oftheoriginalbrandmedications.AgenericmedicationisrequiredbytheFDAtohave70%bioavailabilityof theoriginalbrandmedication.Thus,whenapatientswallowscitalopram,theamountofdrugintheserum hastobe70%ofwhatwouldbepresenthadtheyswallowedCelexa.That’sit.Agenericmedicationdoesnot havetobemadewiththesamematerials,isnotrequiredtohaveasimilarsideeffectprofile,andmaynot havethesameefficacyduetothepossibilityof30%lessbioavailable.ImagineapatientstableonWellbutrin XL300mg(maxdose).Afewyearslaterthemedicationbecomesgenericandthepatient’sinsurance changestothegenericbudeprionXLduetolowercost.Theinsurancecompanyisnotrequiredtocontinueto providethepatientwithWellbutrinXLbecausetheFDAhasapprovedthegenericbudeprionXLasequivalent tothebrandmedication.Asaresult,thepatientnownotesthathefeelsmoredepressed(lossof30%ofhis medication)despitemaxdoseofthemedication.Hehasterribleheadachesandirritabilitythatwerenever presentontheoriginalmedication.Hecallshispsychiatristandsaysthathewantstogobackonthebrand WellbutrinXL.Heisinformedthathisinsurancecompanywillnotpayforthemedicationasitnowhasa genericformulationandthathecaninsteadpay$140amonthoutofpockettogetWellbutrinXL.Generics suck.Butit’shardtoarguewith$4aprescription. SomeObservationsontheGenericMedicationsWeNowPrescribe Fluoxetine(originallyProzac):havenotedthatsomepatientsgettiredonthemedicationandbenefitfrom pmdosing.Whileconsideredactivating,thegenericmaynotbe.Anothernoteisthateachbrandofgenerics isdifferent;thesideeffectsofgenericfluoxetinecapsulesmadebyonecompanydifferfromanother company.Islikelythesafestmedicationusedinpregnancywithasignificantamountofclinicaldatapresent. Forbreastfeedingmothers,sertralinemaybeabetterchoicethanfluoxetine. Citalopram(originallyCelexa):sexualsideeffectsaresevere.Theyappeartobedosedependentandmaybe equaltoparoxetine.AnumberofpatientsgettiredonitsoIgenerallynowstartitatnight.Inadditionto GotoTableofContents 25 hyponatremia,SIADHhasbeenseenanumberoftimeswithcitalopram.Headachessimilartogeneric Wellbutrinarealsoseenwithcitalopram.Additionally,accordingtoareportfromtheFDA(8/24/11) “Citalopramcausesdose-dependentQTintervalprolongation.Citalopramshouldnolongerbe prescribedatdosesgreaterthan40mgperday” Thislikelywillimpactprescriptionofthiscommonmedication. Sertraline(originallyZoloft):commonlyhasbruisingandhairloss.Theoriginalmedicationwasoften sedating,leadingtopmdosing.Thegenericoftenhastheoppositeeffect,withpatientsinitiallyexperiencing feelingsofrestlessness,anxiety,andhypervigilance(whichareproblematicconsideringsertralineisusedfor anxiety).Haveseenacouplecasesofbruxismwhichimproveswithbuspirone.SeenTorsadesand neutropeniax1recentlywithsertraline.Sertralineisprobablythebestmedicationtousewhenbreastfeeding asaminimalamountisexpressedinbreastmilk. Paroxetine(originallyPaxil):Iavoidedthismedicationforalongtimeduetofearofweightgainandsexual sideeffects.Nowthatthesideeffectsofcitalopramaremoreapparent,Iamlesshesitanttouseparoxetine (amedicationthatmayhavebetterefficacythatcitalopram).Asassociatedwithpulmonaryhypertensionin newbornswhenusedduringpregnancy. Takehomepoint:whenyourpatientcomplainsofaSSRIsideeffect,believethem.Unlesstheyendorsethe sideeffectof“MyrightindexfingerisnumbeveryotherThursday,”gowithit.Sideeffectsoftenresolve1014daysafterinitiationofthemedication.Iftheydonot,considermanagingthesideeffectsordiscontinuing themedication.PuttinggenericSSRIsatnightseemstohaveafewlessnotedsideeffects. VilazodoneHCL(Viibryd) StructurallysimilartoTrazodone,thisisaselectiveserotoninreuptakeinhibitorinadditionto5HT1Aagonist (likebuspirone).Thus,itissimilartocombiningcitalopram+buspirone.Thismedicationhaslesssexualside effectsandweightgainthanotherSSRIs.Half-lifeis25hoursanddosingstartsat10mgtoincreaseby10mg perweektoagoalof40mg.Discontinuationsymptomsmayoccurifstoppingquickly.Ismetabolizedby CYP3A4.GIsideeffectsaremostcommon.TheremaybeQTcprolongationawellindosesatorabove80mg. Thismaybea“metoo”medication;morestudiestofollow. Bupropion(Wellbutrin,Zyban) ApprovedbytheFDAandmarketedin1985(ayearbeforefluoxetine).Theoriginalrecommendeddosewas 400-600mg.Thisdosingwasassociatedwithariskofseizuresandresultedinthedrugbeingpulledfor3 yearsbeforebeingreintroducedwitharecommendedmaxdosageof450mg.In2007,inresponseto multiplepatientreportsaboutthegenericBudeprionXLhavingmoresideeffectsandbeinglessefficacious thatWellbutrinXL,theFDAconcludedthatthediscrepancywasdueto“naturalmoodvariation.” Indications:MDDandseasonalaffectivedisorder,smokingcessation(underZybanbrandname,generally usedincombinationwithnicotinesubstitutes),BMD(lesslikelytoprecipitatemaniainBMDIthanTCAsand inBMDIIthanmostotherantidepressants),ADHD,cocainedetoxification(reducingcravings),hypoactive sexualdesiredisorderduetoSSRIs. Profile:availableinimmediatereleaseIR(BIDorTID),sustainedreleaseSR(usedBID),andextendedrelease ER(oncedaily).Theactiveingredientisthesameineach.TheIRreachespeakconcentrationin2hours,SRin 3hoursandERin5hours.Thehalf-lifeis12hours.Mechanistically,bupropioninhibitsthereuptakeofDA GotoTableofContents 26 andNE.IsmetabolizedtoactivemetabolitehydroxybupropionbyCYP2B6(inhibitedbyfluoxetine). Hydroxybupropionitselfinhibits2D6.BupropionhasaffinityforDAtransporterswhilehydroxybupropionhas moreselectiveaffinityforNEtransporters.BupropionmayhaveafalsepositiveUDSforamphetamines. SideEffects:seizureriskis2%with600mgand0.1%with300-450mg(theSRandERatsamedoseshasrisk of0.05%,equivalenttotheotherantidepressants).Sideeffectsmostcommonincludeheadache,insomnia, drymouth,tremor,andnausea.Severeanxietyandpanicdisordercanbeworsenedbybupropion.Can worsenpsychosisanddeliriumduetodopaminergicactivity.Haveseenseverepsychosiswithuseof bupropioninpregnancy. Mirtazapine(Remeron) Atetracyclicantidepressantthatisbothserotonergicandnoradrenergicthroughamechanismdifferentfrom serotoninreuptakeblockadeormonoamineoxidaseinhibition. Mirtazapine Indications:MDD(especiallywithinsomniaorweightloss),reductionofsideeffectsassociatedwith chemotherapy,augmentationofantidepressanttherapy. Profile:half-lifeof30hours.Clearanceisimpairedinhepaticimpairedpatientsby30%,inrenalimpaired patientsby50%,andisimpairedintheelderly(by40%inmalesand10%infemales).Mechanistically, mirtazapineworkstoincrease5HTatthe1Areceptor(themainsitefortheantidepressantactionsofmost antidepressants).Itdoesthisbyblockingthe5HT2A,5HT2Cand5HT3receptors,resultinginallserotonin beingdirectedtothe5HT1Areceptor.Asaresult,therearelesssexualandGIsideeffectsthanother antidepressants.Additionally,itincreasesNEandDAtransmission(recall5HT2CnormallyinhibitsDA—think atypicalantipsychoticmechanismofaction).Stronghistamineaffinitycausessedationandweightgain.There isminimalanticholinergiceffect.Startingdoserangesfrom7.5to15mg.Increasingdoseabove30mgleads tohigherNEeffectsandlesssedation.Metabolizedby2D6and3A4. SideEffects:somnolenceoccursin>50%(worsenedbyalcoholorothersedatives),increasesappetiteand cholesterol,reductionofANC(monitorforfever,chills,sorethroat),andagranulocytosis. Venlafaxine(Effexor)andDesvenlafaxine(Pristiq) Indications:MDD,GAD,PanicDisorder.Hasbeenusedfordiminishingsymptomsofmenopause,treating chronicpain,anddualdiagnosisofMDDandcocainedependence. GotoTableofContents 27 Profile:inhibitsreuptakeof5HTandNEwithoutmuchinteractionatothersites.Existsasimmediaterelease IR(BIDdosing)andextendedreleaseXR(oncedaily).Duetoshorthalf-life,adiscontinuationsyndromemay existifabruptlystopped.Metabolizedby2D6toactivemetabolitedesvenlafaxine(nowmarketedasPristiq). Patientswithpoor2D6activitymayhavehighersideeffectprofile,leadingtotheisolationandmarketingof themetaboliteastreatment(orsotheysay).TheIRismostassociatedwithnauseaandoftenisstartedin lowdosesof37.5mgtwicedaily(useintheamandat1pmduetoriskofinsomniaiftakenatbedtime).As doseincreases,affinityforNEtransporterincreases.Asaresult,HTNandanxietyaremoreassociatedwith higherdosesofthemedication.WhentakenastheXR,themaximumdoseis375mg.Desvenlafaxinehasa therapeuticdoseof50mg(whichhappenstobethestartingdose)withnosignificantdatatosupport improvedefficacyof100mg. SideEffects:nauseaandsexualdysfunctioninupto30%areserotonergicsideeffects.Whileappearing anticholinergic,sideeffectsofheadache,insomnia,dizziness,constipation,sweating,andnervousnessare duetoNEeffects.HTNoccurswithhigherdoses.Discontinuationsyndromeappearsasdizziness,insomnia, nausea,anddiarrhea. Duloxetine(Cymbalta) Indications:MDDandNeuropathicpainassociatedwithdiabetes(firstdrugFDAapproved).Forthe treatmentofstressincontinence,duloxetineincreasesthetoneoftheurethralsphincterandwillbe marketedasYantreve(importanttoknowifyourpatientistakingYantreveakaduloxetine,especiallybefore youstartthemonSSRIorSNRI). Profile:similartovenlafaxine,buthasequalaffinityfor5HTandNEtransportersatalldoses.Thereislittle datatoshowgreaterclinicalefficacyindosesabove60mgforthetreatmentofdepression.BIDdosingmay reducesideeffectsseenwithonce-dailydosing.Startingdoseis20or30mg. SideEffects:similartovenlafaxine,includingnausea,dizziness,constipation,insomnia,andsexual dysfunction.LesslikelytocauseHTN.MayincreaseHgbA1cinlongtermtreatment.Potentiallyincreases LFTs(especiallyinhepaticallycompromisedpatients).Discontinuationsyndromecanoccur. Anxiolytics Buspirone(Buspar) Indications:GAD(notpanic,OCD,orsocialphobia).Mayreduceaggressionandhostilityinanxietybetter thanBZD.LesseffectiveinmanagingsomaticsymptomsofanxietythanBZD.Canbeusedtotreatsexualside effectsandbruxismcausedbySSRIs(throughinhibitionof5HT2andviaDAagonism). Profile:half-life2-11hourssoisdosedTID.Hasanactivemetabolitethatis20%lesspotentbut30%more concentratedinthebrainthantheparentcompound.Primarymechanismis5HT1Aagonist,helpingwith anxiety(think:5HT2isactivating,5HT1iscalming).Dosingbeginsat5mgTIDandmaximumdoseis60mg. Metabolizedby3A4.Grapefruitjuiceincreasesbuspironeconcentrations. SideEffects:doesnotcauseweightgain,sedation,orsexualsideeffects(no5HT2orH1).Mainsideeffects areheadache,nausea,anddizziness.Safeinoverdose(nodeathshavebeenreported)andtheestimated lethaldoseis>300xtherecommendeddailydose. GotoTableofContents 28 Benzodiazepines Indications:GAD,Panic,acutemania,agitation,shorttermmanagementofinsomnia,anticonvulsant, akathisia.Theycanbeusedfortheshorttermmanagementofanxietyandpanic(1-2weeks)whilealong termagentisinitializing(SSRI).ChronicusemustbemonitoredcloselyandgenerallyBZDwithlonghalf-life andgradualonsetofactionarelesslikelytobeabused. Profile:anxiolyticpropertiesareduetomodulationofGABA.Allarelipid-soluble,allowingthemtocrossthe bloodbrainbarrier.ThemostaddictiveBZDarehighlylipophilicwithashortonsetofaction(patientnotices theeffectsquickly).Tolerancewithalprazolam,forexample,canoccurwithin1-2weeks.Seechartonnext page. SideEffects:sedation,ataxia,dizziness,respiratorydepressioninCOPDorsleepapnea,dependencetoBZD (especiallywithrapidonset)andriskofwithdrawal,whichcanbefatalifnotmanaged.Mostrecentstudies donotshowfetalcleft/palateabnormalitiesorcardiacmalformations.UseofBZDinthe3rdtrimestercan resultinwithdrawalsymptoms,decreasedAPGARSandpoorfeedinginthenewborn. GotoTableofContents 29 Generic TRADE Equivalent Dose/ Class Peak Level/Absorb Rate Average* Active Half-life Metabolites (hr) Comments InitialDose UsualDose Range MaxDose SHORTACTING:morereboundanxietyeffect&withdrawalreactions,bettersedative/hypnotic;preferredoverlongactinginelderly(less accumulation)&patientswithliverdisorders(easiermetabolized).MOREADDICTIVE Alprazolam 0.5mg 1-2 Medium 12 (9-20) Minor Oxidation Anxiety,Panicattacks XANAX Lorazepam 1mg 3-Hydroxy 1-4 Medium 15 (8-24) None Conjugation Anxiety,Preanesthetic; 15mg 3-Hydroxy 1-4 Medium 8 (3-25) None Conjugation Anxiety,alcoholwithdrawal 0.5mg 0.5-2mg potid 10mg 15-30mg poqhs 120mg 10mg 3-Hydroxy 2-3 Medium 11 (3-25) None Conjugation Sedative/hypnotic;noREM suppression RESTORIL Triazolam 0.25-0.5mg potid 10mg SERAX Temazepam 4-10mg ATIVAN Oxazepam 0.25mg 15mg 15-30mg poqhs 60mg 0.25mg Triazolo 1-2 Rapid 2 (1.5-5) None Conjugation Sedative/hypnotic HALCION 0.125mg 0.5mg 0.1250.25mg poqhs LONGACTING:lessreboundsymptoms;betterchoicewhentaperingoffofBZDs,LESSADDICTIVE Chlordiazepoxide 25mg 2-Keto 1-4 Medium 100 Yes Oxidation Anxiety,preanesthetic,alcohol withdrawal LIBRIUM Clonazepam 0.25mg Nitro 1-4 Medium 34 (19-60) 5mg 2-Keto 1-2 Rapid 100 None Oxidation& Nitro reduction Anticonvulsant,panicattack; RLS,neuralgia 25-50mg potid Yes Oxidation Anxiety,musclerelaxant, seizures,alcoholwithdrawal 0.25mg 0.5-2mg potid 10-20mg VALIUM Lorazepam 200-400mg KLONOPIN Diazepam 5mg 2mg 2-5mg potid 40mg 15mg 2-Keto DALMANE 0.5-1 Rapid 100 (40-250) Yes Oxidation Sedative/hypnotic;can accumulate 15mg 15-30mg poqhs 60mg Flumazenil:reversestheeffectsofBZDandcanbeusedincasesofOD.Usewithcautionasitmaycause rapidsymptomsofBZDwithdrawal. GotoTableofContents 30 CognitiveEnhancers In1993,tacrine(Cognex)becamethefirstmedicationapprovedbytheFDAforthetreatmentofAlzheimer’s Dementia.InitiallycreatedinMelbourne,AustraliaduringWW2,itsinitialfunctionwasasananaleptic (stimulatesrespiratorymusclestoaidrecoveryfromanesthesia.Yeah,Ihadtolookthatoneup).Ultimately, itwasfoundtoassistincognitioninAlzheimer’spatients.Ithassincebeenremovedfromthemarketdueto livertoxicity,butitsmechanismofinhibitionofthebreakdownofacetylcholine(Ach)ledtocreationofother cognitiveenhancers. Longbeforetacrine,ancientGreektextsrefertothecommonsnowdropflower(Galanthusnivalis)being usedtoreversepoisonsthatwereneurotoxic.Additionally,practitionersinEasterEuropeandSouthwest Asiahavedocumenteduseoftheflowerfortreatmentofmyopathyandsensorydysfunction.Fromthe Galanthusflowerandotherbotanicalproducts(likedaffodils),Bulgarianpharmacologistsinthe1950s synthesizedgalantamine.Currently,galantaminecontinuestobeproducedfromacombinationoforganic synthesistechniquesandcombinationwithnaturalresources(daffodilsfromWales,UK). Indications:treatmentofmildtomoderatecognitiveimpairmentinAlzheimer’sDementia.Theyslowthe progressionofmemorylossanddiminishapathy,depression,hallucinations,andmoodreactivity.Theymay alsohelptodelaytheneedfornursinghomeplacement.Donepezilandrivastigminearealsousedin Parkinson’sandLewyBodyDementiainadditiontobeingusedforcognitiveeffectsrelatedtotraumatic braininjury.Useinvasculardementiamayproduceimprovementbutnotinallcases. Profile:Alzheimer’sisduetodestructionandimpairedproductionofacetylcholine.Thecholinesterase inhibitorsreversiblyinhibittheenzymesthatbreakdownAch,increasingsynapticconcentrationsofAch especiallyinthehippocampusandcerebralcortex.BlockingthebreakdownofAchintheperipheryleadsto nausea,diarrhea,vomiting,andcardiacabnormalitiesincludingbradycardia.Sideeffectsincludenausea, diarrhea,vomiting,bradycardia,andsyncope.Avoidwithbethanecholandalsoavoidwithother anticholinergicmedications(likeparoxetine). Donepezil:hasahalf-lifeof70hoursintheelderlyandistakenoncedaily.Cirrhosisreducestheclearanceby 20%.DonepezilworksselectivelyintheCNSwithlessactivityintheperipheryoncholinesterases(lessGI symptomsetc).Donepezilstartsat5mgqhswithamaximumdoseof10mg.Metabolizedby2D6and3A4. Highlyproteinboundbutdoesnotdisplaceothermedications.Benefit:leastGIsideeffectsandmaybemore effectivethangalantamineintreatmentofcognitivedisorders. Rivastigmine:hasa1-hourhalf-life,butitremainsboundtocholinesterases,leadingtoeffectivedosefor10 hours.Rivastigminehasmoreperipheralactivityandinhibitsbothacetylcholinesteraseand butyrylcholinesterase.Asaresult,ithasmoreGIandcardiaceffects.Rivastigminestartsat1.5mgBIDand graduallyincreasesto3mgBIDgraduallyoverthecourseofamonth.Thecreationofarivastigminepatch hasledtomoreeffectivetreatmentwithlessperipheraleffects.Unboundtoproteinsandhasminimaldrugdruginteractionsasitisnotmetabolizedintheliver.Benefit:patchgoodinpatientswithdifficulty swallowingorwithquestionablecompliance. Galantamine:isextractedfromdaffodilsandhasahalf-lifeof6hours.Sideeffectsareminimalandtransient. Itisdosedat4mgBIDperdayfor4weeksandanysubsequentdoseincreasesshouldoccurat4-week intervals.Maximumdoseis16mgBID.Metabolizedby2D6and3A4likedonepezil.Isanallostericagonistat GotoTableofContents 31 thenicotinicreceptor,similartothewaythatBZDworkonGABAreceptors,inadditiontostoppingthe breakdownofAch?Benefit:leastexpensiveofthecognitiveenhancerswithminimalsideeffects. MiscellaneousTopics TreatmentofMedicationSideEffects • • • • • • TardiveDyskinesia:discontinuethemedication,someindicationforVitaminE Akathisia:propranololorBZD NMS:dantrolene,bromocriptine,coolingmeasures Sexualsideeffects:changeSSRI,addbupropion,buspirone,sildenafil Anticholinergicsideeffects:takewithfood(GI),sugarlessgumandpilocarpinemouthwash(dry mouth),pilocarpineeyedrops(blurredvision),bethanechol(urinaryretention) Orthostatichypotension:increasefluidintake,decreasecaffeine,increasesodiumifapprovedby PMD,tedhose,considerchangingHTNmeds TreatmentofOverdose • • • • • • • • • • • BZD:emesis,lavage,charcoal,flumazenil Bupropion:lavage,charcoal,prophylacticBZDtopreventseizures Clozaril:charcoalandsorbitol Antipsychotics:lavage,charcoal,norepinephrineforhypotension,monitorEKG SSRI:lavage,charcoal,monitorEKG Lithium:emesis,lavage,dialysis(nocharcoal),0.9%NaClifNadepletioncausedtoxicity MAOI:emesis,lavage,charcoal,pressors,BZDtopreventseizures,phentolamineforhyperthermia, AVOIDDEMEROL TCAs:lavage,charcoal,telemetry,EKG,anti-arrhythmiamedications,BZDtopreventseizures Thyroidhormones:emesis,lavage,charcoal,cholestyramine,propranolol Opiates:naltrexone,monitorforrespiratorydepressionandmaintainairway ETOH:bananabagforvolumeandnutrientdepletion,BZDtopreventseizure,maintainairway GotoTableofContents 32 ANINJA’SGUIDETONEUROLOGY Cortex AnatomyOverview FrontalLobes:primarymotorcortex(precentralgyrus),impulsecontrol/judgment(orbitofrontalcortex) socialization,executivefunctioning,workingmemory,languageproduction(Broca’sArea) ParietalLobes:primarysensorycortex(postcentralgyrus),knowledgeofnumbers,visuospatialprocessing, R-Lorientation TemporalLobes:primaryauditorycortex,containsthehippocampus(memory),Wernicke’sarea (understandinglanguage),comprehension/naming,recognitionoffaces,visualprocessing Occipital:primaryvisualcortex,lesionsleadtovisualfieldabnormalities Cerebellum:sensoryperception,motorcoordination/learning,proprioception,equilibrium,posture GotoTableofContents 33 BasalGanglia:composedofstriatum(putamen/caudate/nucaccumbens),globuspallidus,subthalamic nucleus,andsubstantianigra.Isassociatedwithcoordinationofmovement.Motortractsgothroughthe striatum.AbnormalitiesofBGincludePD,Tourette’s,CP,dystonia,OCD,andTD Pereau’s“CramtheBrainUsingtheMMSE”ReviewTool Ok,somostofusknowtheMiniMentalStatusExaminationbyheart.AstheMoCAbeginstotake prevalence,thismaychange.Butforthetimebeing,let’scapturethatknowledgeoftheMMSEtoreview partsofthebrain.EachquestionoftheMMSEisdesignedtotestadifferentregioninthebrain,including cortexlocationsandbasalganglia. Orientation:“PleasenametheYear,Season,Date,DayoftheWeek,andMonth,”and“Wherearewe:State, City,Suburb,Hospital,Floor” • • FrontalLobe:canthepatientpayattentioninthisquestion?Cantheyreasonthroughthedate/day oftheweekifitisnotreadilyintheirmind?HowmanytimesdoIaskthepatientthisquestionand thenfranticallytrytorecallthedate?Ok,let’ssee…yesterdaywasthe11th,sotodayisthe12th. Frontallobetotherescue!Medialprefrontalisassociatedwithorientationtoperson TemporalLobe:doesthepatientrememberthedate,asinaretheystoringmemoryonadaytoday basis?Thefrontallobe’sabilitytoreasonthatyesterdaywasthe11thsotodaymustbethe12this onlydoableifyourememberwhatthedatewasyesterday.Doesthepatientrememberhowtheygot totheroomtheyarespeakingtoyounowin?Thistestsspatialmemory GotoTableofContents 34 Recall:Name3objects.“Canyourepeatthese3words?”“Inafewminutes,Iwillaskyoutorememberthe words.”“Canyourepeatthe3wordsItoldyouearlier?” • • Immediaterecall(seconds):youhavejustaskedapatienttorepeatwords.First,theymusthavean intactWernicke’sinTempo/Parietalareainordertocomprehendwhatyou’vejustasked(think: parietal=understandwords).Second,thepatientmustbeabletoconnectwordcomprehensionwith mechanicalreproductionofwords.TheArcuateFasciculusconnectsWernicke’s(comprehend)to Broca’s(saythewords)inordertorepeatwords.Finally,Broca’sinthefrontallobehelpstoproduce words(think:motorstripinfrontal=makewords) Delayedrecall(2-3minutes):requireshippocampustoconvertimmediatememorytolongterm memoryandmedialtemporallobetoactuallystorememory Attention:“SpellWORLDbackwards” • • • • Prefrontal:canthepatientconcentratewhiledoinganunfamiliartask? FrontalDorsolateral:workingmemory.Canthepatientrecallwhatletterswerealreadyused,and whichonecomesnext? InferiorParietal:spelling,language,syntax Temporal:storageofhowtospellanything Attention:Serial7s • • • • Prefrontal:canthepatientconcentrateonadifficulttask,filteringoutdistractions? FrontalDorsolateral:workingmemory.Canthepatientrecallwhatnumbershavebeenusedand whichonescomenext? LeftParietal:understandingofnumbers,math,andcalculation Temporal:storageofwhatnumbersareandhowtheyrelatetoeachother Naming:Showthepatient3objects“Canyounamethisobject?” • • LeftParietal:language,grammar LeftTemporal:storageoflearnednames Repetition:“Repeatnoifs,ands,orbuts” • SeeaboveImmediateRecall,involvesWernickeàArcuateàBroca FollowCommand:Askthepatienttofollowa3stepcommand • • • • Frontal:attention,planning.Motorcortexcoordinatesmovement Temporal:recallthe3commandsfromafewsecondsagotodotheminsequence LeftParietal:right-leftorientation BasalGanglia:additionalmotorcoordination,finemotorcoordination GotoTableofContents 35 ReadingComprehension:“Closeyoureyes” • • • Occipital:abilitytoread/seethewords Leftparietal:wordrecognition,grammarsothatthewordsmakesenseandareacommand Temporal:storageofwordslearnedpreviously Writing:“Writeasentence” • • • • Occipital:abilitytoread/seewhatiswritten Frontal:attention,motorcortexcoordinatesmovement Leftparietal:words,grammar,syntax Basalganglia:finemotorcoordination.Isthereatremor? DesignCopy:“Copythisdesign” • • Frontal:attention,planning.Motorcoordination Rightparietal:construct,gestalt.Damageleadstohemineglect Thus,knowingwhyeachquestionoftheMMSEisthereisausefulreviewofthefunctionsofthecortexand basalganglia.Ratherthanjustrelyingoncramming,usingtheMMSEasareviewtoolcanserveasan overviewforallregionscommonlytestedonPRITE.Additionally,useofClockDrawingcanbeasimilarreview ofbrainregions. HighYieldPRITEReview Q:Apreviouslypleasantmotherbecomesprofaneandirresponsibleover6months.Whereisthelesion? GotoTableofContents 36 A:FrontalLobe.Thefrontallobeisassociatedwithimpulsecontrol,judgment,sexualbehavior,socialization, andmemory/languageproduction.Thispatienthasevidenceoffrontallobedysfunctionasevidencedbynew onsetofsociallyunacceptablebehaviors. Q:A62-year-oldmalewithDMspeaksinnonsense,saying“tharszingisphrumperzustalking.”Normal intonationbutnobodyinthefamilycanunderstandhim.Hecannotfollowinstructions.Diagnosis? A:Wernicke’sAphasia.Thepatienthasfluentaphasia(alsoknownasreceptiveaphasia)duetodamageto Wernicke’sareainthesuperiortemporalgyrus.Thepatientcanproducenonsensicalwordswithproper intonation,butcomprehensionisimpaired.Temporallobeisassociatedwithhearingandlanguage comprehension.ThisisdifferentfromBroca’saphasia,whichisalsoknownasexpressive/non-fluentaphasia duetodamagetotheinferiorfrontalregionofthebrain(usuallytheLside).Thefrontallobeisassociated withmotorabilityandformingwords.Thesepatientscannotproducelanguagebuthavenormal comprehension.ConductionaphasiaisproducedbydisruptionofthepathwaysconnectingBroca’sand Wernicke’sareas,leadingtoapatientbeingabletorepeatphrasesdespiteintactcomprehensionand languageability. Q:60-year-oldmale(Rhanded)whofrequentlygetslost,andonlywritesontherighthalfofpaper.Whereis thebrainlesion? A:RightParietalLobe.ThisisanexampleofLeft-sidedhemi-neglect.Theparietallobesareassociatedwith “deploymentofattention”ofthecontralateralspace.Thisisasensorydeficitthathaslackofattentionto itemsintheleftvisualfield.Damageofrightparietallobeismorecommonlyassociatedwithhemineglect thanleftparietallobes. Q:A55-year-oldfemalepresentswithinabilitytowrite,calculateordoarithmetic,andinabilitytodistinguish thedifferentfingersonherhands.Whereisthelesion? A:LeftParietalLobe.Thisisanexampleof“Gerstmannsyndrome”andthecollectionofsymptomsindicate abnormalitiesinleftparietallobe(dysgraphia,dyscalculia,fingeragnosia). Q:A28-year-oldpatientpresentswithalossofvisioninthebilateraltemporalvisualfieldsandabnormalities inprolactin.Whereisthelesion? A:Pituitaryadenoma.Thislesioncompressestheopticchiasmleadingtobitemporalhemianopsia.In addition,itleadstoabnormalprolactinlevels. Q:A22-year-oldwithfever,headache,seizures,confusion,stupor,andcomaevolvingoverafewdays.EEG haslateralizedhigh-voltagesharpwavesarisingintheLtemporalregion,withslowwavecomplexes repeatingat2-3secondintervals.CTshowslow-densitylesioninLtemporallobe.Diagnosis? A:HerpesSimplexEncephalitis.RetrogradetransmissionofHerpesvirusfromaperipheralsiteintotheCNS alonganerveaxon.Canliedormantinthetrigeminal(CNV)ganglion.Targetsthetemporallobesofthe GotoTableofContents 37 brain,leadingtoseizureswithhigh-voltagesharpwavesandslowwavecomplexes.Diagnosisismade throughEEG,CT,andCSFPCRforherpessimplexDNAorCSFviralculture(CSFhaslymphocyticpleocytosis). Treatmentincludesacyclovirandsupportivetreatment. BrainstemandSpinalCord AnatomyOverview Midbrain(CNIII-V):upperpartofbrainstem,hasnucleifor • • • CNIII:oculomotor–eyemovementexceptSOandLRmuscles;E-W–autonomicfunctionslike pupillarydilation CNIV:trochlear–SOmusclewhichturnseyedown/in CNV:trigeminalsensory–facialsensation Pons(CNV-IX):middlebrainstem,hasnucleifor • • CNV:trigeminalmotor–motorbranchesofmandibularnerveforbiting,chewing,swallowinghasBL innervation,thusdeficitincentrallesionisrare CNV:spinalsensory GotoTableofContents 38 • • • • CNVI:abducens–LRmusclelaterallymoveseye CNVII:facial–facialmotor CNVIII:vestibular–balance/equilibrium(Dysfunctionleadstovertigoandnystagmus);Cochlear– hearing Salivarynuclei:Inferiornucleus–IXforparasympatheticparotid;Superiornucleus–VIIfor submandibular/sublingualsalivation Medulla(CNIX-XII):lowestportionofbrainstem,isthelocationfordecussationofmotortractsand dorsolateralcolumn(proprioception/finetouch).Nucleifor • • • • SpinalCNV:sensory SolitaryNucleus:VII–tastetoanterior2/3tongue;IX–tastetoposterior1/3tongueandinfofrom carotidbaroreceptors/carotidbodychemoreceptors;X–sensationfromouterear NucleusAmbiguous:motornucleusforIX,X,XI;IX–LMNforstylopharyngeus;X–larynx/pharynx;XI –accessorynerveformovementofneckmuscles HypoglossalNucleus:XII–movestongue Pereau’s“TheBrainstemasaFace”ReviewTool GotoTableofContents 39 ForthepurposeofquickreviewpriortoPRITE,simplifythecranialnerves&nucleitomatch3facialzones • • • Zone1:"Eyeballs."CNIII-V.Midbrainlesionscauseabnormalityineyemovement(CNIII)andface sensation(V) Zone2:"MiddleFace."CNV-IX.Ponslesionscauseabnormalitiesinfacialmovement(VII),chewing (V),salivaproduction(IX),hearing/balance(VIII) Zone3:"NeckStuff."CNIX-XII.Medullalesionsaffecttonguemovement(XII),taste(VII,IX) swallowing(IX,X)andneckmovement(XI) Whilenotperfectmodel(VIoutofplace,Vfacialsensationishigherthanexpected),thisisaquickwayto isolatebrainstemlesionsinPRITEvignettes.Rememberthatthecerebellumhasconnectionsatalllevelsof thebrainstem.Thus,ataxia/nystagmuscanoccurinanyZone GotoTableofContents 40 HighYieldPRITEReview Q:A35-year-oldfemalepresentswithunilateralhearingloss,unsteadiness,falls,headaches,mildfacial weakness,andipsilaterallimbataxia.Whereisthelesion? A:Cerebellopontineangle.Thepatienthasclearsymptomsofcerebellardysfunction(ipsilateralataxiais specificforcerebellum).ThePonshasmultipleCNnuclei,includingthefacialnerve(facialweakness)and vestibularnerve(unilateralhearingandbalance).Zone2:MiddleFace=Pons Q:A48-year-oldwithhistoryofhypertensiondevelopsvertigo,nausea,vomiting,hiccups,left-sidedface numbness,nystagmus,hoarseness,deficitsinpain/temperatureontherightsideofthebody,ataxiaofthe limbs,staggeringgait,andfallstotheleft.Diagnosis? A:LateralMedullaryStroke.AlsocalledWallenberg’sSyndromeandPosteriorInferiorCerebellarArtery Syndrome.OcclusionofthePICAleadstolateralmedullaryinfarct.Thesymptomsinclude:contralateral deficitsinpain/temperature(lateralspinthalamictract,whichcrossedearlyinspinalcord),ipsilateralloss pain/temperaturetoface(trigeminalnucleus),dysphagia/hoarsenessanddiminishedgagreflex(Nucleus Ambiguous:vagusandglossopharyngeal),vertigo/nystagmus(vestibular),ipsilateralHorner’s(descending sympathetics),ipsilateralataxia,andhiccups.Zone3:NeckStuff=Medulla.WhileVIIIsymptomsarepresent, theZone3symptomsindicatemedullaandwouldnotbeseeninponslesions. Q:ApatientpresentswithpainbehindtheleftearprogressingtonumbnessoftheLface,tearingoftheL eye,discomfortwithlowfrequencysounds,andLfacialweaknessonexam.Diagnosis? GotoTableofContents 41 A:Bell’sPalsy.AbnormalityofCNVIIwithLMNparalysis,isrelatedtoLymediseaseandHerpesZoster.Thisis isolatedVIIlesion.AZone2lesionwouldhaveissueswithchewing,saliva,hearing,etc.Inflammationofthe facialnerveasitexitstheskullleadstosymptomsoffacialparalysis.Oftenthetrigeminalnervemaybe involved,leadingtonumbness.TinnitusistheresultofinvolvementwithCNVIII.CNVIIhasbilateral innervationoftheforehead(2nerveinnervationforeachsideoftheforehead).InUMNlesions,theforehead maybesparedduetothisBLinnervation.However,inLMNconditions(Bell’s)theforeheadisaffecteddueto theBLinnervationgetsinflamedgoingthroughthecanal.Treatmentissteroidsortreatmentofunderlying Herpes. Q:A38-year-oldwithseverelysensitive,lancinatingpainonthecheek,lastingafewseconds,andistriggered bylighttouchontheface.Diagnosis? A:TrigeminalNeuralgia.AlsocalledTicdoloureux.Neuropathicdisorderofthetrigeminalnerve(CNV)that causesintensepainintheeyes,lips,nose,scalp,forehead,andjaws.Associatedwithhighratesofsuicide duetosignificantpain.SuspectedcauseissuperiorcerebellararterycompressingCNVnearitsconnection withthepons.PerPRITE,treatmentiscitedtobecarbamazepineorgabapentin. Q:A48-year-oldpresentswithunsteady,lurching,broad-basedgait,appendicularataxiainLEonly,and normaleyemovement.Henotedprogressivelegweaknessandclumsinessoverthepastyear.Diagnosis? A:AlcoholicCerebellarDegeneration.IrreversiblealcoholtoxicityinPurkinjecells,relatedtoglutamate abnormalitiesandpossiblynutritionaldeficiency.Presentswithtremor,unsteadygait,andtruncalataxia. PredominantintheLE.Irreversible,evenafterETOHisstopped.Symptomsevolvefromweekstomonths.On MRIthereiscerebellarshrinkage.Thalamusandperiaqueductalgraymatterareintact,andcognitionis normal(vs.Wernicke’sEncephalopathy).Treatmentincludeimprovednutrition,thiamine,andcessationof alcohol. Q:A62-year-oldpresentswithparalysisofeyemovement,ataxia,andglobalconfusion.Healsohasshort termmemoryimpairment.Diagnosis? A:Wernicke’sEncephalopathy.Severesyndromeduetochronicalcoholism,precipitatedbythiamine deficiency.Damageiscausedtothemammillarybodies,medialthalamicnuclei,andperiaqueductalareas. Clinicaltriadincludeconfusion,truncalataxia/gaitimbalance,andopthalmoplegia(extraocularparalysisof CN,especiallyCNVI).MRIshowsabnormalhyperdensityofmammillarybodiesandperiaqueductalgrey matter.CanprogresstoKorsakoff’sSyndrome(anterograde/retrogradeamnesia,confabulation,andapathy) andcoma/death.Treatmentisthiaminereplacement.DONOTadministerglucosebeforethiamine,leadsto celldeathbyprovidingsubstratesforbiologicpathwayswithoutsufficientcoenzymes(thiamine).IV thiamine/nutritionalreplacementisneededaswellassupportivecare.Mainstayoftreatmentiscessationof ETOHuse. Q:A65-year-oldmalewith6-monthsofepisodicconfusion,disorientation,VHofchildrenplayinginhis room,noAH,andisnormalbetweenepisodes.Exam:normallanguage/memory,difficultywithtrailstestand serialsubtractions,andsymmetricrigidity/bradykinesia.MRI,labs,UDS,andCSFarenormal.Diagnosis? GotoTableofContents 42 A:LewyBodyDementia:overlapsAlzheimer’sDementiaandPD.Triadofabnormalproteinaceous cytoplasmicinclusions(Lewybodies),abnormalDAneuronsinsubstantianigra(likePD),andlossofAchproducingneuronsinBasalNucleusofMeynart(likeAlzDementia)leadtotheclassicsymptomsofVH, Parkinson’sfeatures,andcognitivedeficits.Treatmentincludesuseofcholinesteraseinhibitors. Q:A36-year-oldmaleprogressiveinvoluntary,irregularmovementsofallfourextremities,bradykinesia, unsteadygait,maskedfacies,gradualinabilitytochew/talk,cognitivedifficulties,andsignificantchangein personality,includingdepression,agitation,andimpulsivity.Thepatienthasrelativeswhohadpresented withsimilarsymptoms.Diagnosis? A:Huntington’sDisease.Autosomaldominantdisorderwithtrinucleotide(CAG)repeatleadingtoneuronal celldeath.OnPRITE,thisvignetteoftenshowsasignificantlyatrophiedcrosssectionofthebrain.Themore CAGrepeats,theearliertheonsetofthedisorder,thuseachsuccessivegenerationdevelopsthedisease earlier(calledanticipation).Hallmarksofthediseaseincludesymptomsduetodegenerationofthebasal ganglia/striatum/caudate(chorea,unsteadygait,bradykinesia,inabilitytochew/swallow)andsymptomsdue tofrontallobedegeneration(deficitsincognition,executivefunctioning,abstractthinking,memoryand psychologicalsymptomslikeagitation,depression,impulsivity,hypersexuality,compulsion).Suicideis commoninthesepatients.Genetictestingcandetectthetrinucleotiderepeat,helpingfamilyplanning. Mainstayoftreatmentincludeshaloperidolandotherhighpotencyantipsychotics(perPRITE),andother symptomatictreatment. Q;A54-year-oldpatientpresentswithshufflinggaitandinvoluntaryacceleration,posturalinstability, festination,andtruncalrigidity.Hehastremoratrestthatdecreaseswithvoluntarymovement,cogwheeling rigidity,drooling/dysphagia,andmaskedfacies.Diagnosis? A:Parkinson’sDisease.IncreasedactivityinthesubthalamicnucleusandGPleadstoDAinhibitionand movementdisorder.Symptomsincludebradykinesia,tremorthatdecreaseswithvoluntarymovement, rigidity/cogwheeling,shufflinggait,dystonia,festinatingspeech(rapid,soft,poorly-intelligible),drooling(due toinfrequentswallowing),dysphagia,fatigue,maskedface,andmoodsymptomslikedepression.Treatment isLevodopa,adopamineagonist.IntheeventofthedevelopmentofVHonLevodopa,decreasethedose. Anothertreatmentisdeepbrainelectrodestimulationinsubthalamicnucleus. Q:A35-year-oldmaleawakensfrequentlyinmiddleofnightwithsevereheadacheslasting1-2hours. Headachesaresopainfulthatthepatientisafraidtogotosleep.LocatedaroundLeyeandassociatedwith lacrimation,ptosis,andmitosis.Diagnosis? A:ClusterHeadaches.Vascularheadacheswithintensepaincausedbydilationofbloodvesselsleadingto pressureonTrigeminalnerve.MaybeassociatedwithHorner’ssyndrome(sympatheticchainlesion,leading todeficiencyofsympathetictone:ptosis,lacrimation,miosis,rhinorrhea,andsweatingonaffectedsideof face).TreatmentwithNSAIDsisrarelyhelpful.Mainstayoftreatmentaretriptans(abortive)orcooling measures(coldshower,breathingcoldair).ThereissomesupportfortheuseofTopamaxorLithiumfor treatment,inadditiontoCachannelblockersorsteroids. GotoTableofContents 43 Q:A22-year-oldfemalehasgained70lbs.inthepastyearandnowpresentswithdailysevereheadaches sometimesassociatedwithgrayingoutofvision.Papilledemaispresentonexam.Diagnosis? A:PseudotumorCerebri.Associatedwithincreasedintracranialpressure,andincreasedopeningpressureon LP.Thisleadstosignificantheadachesandpapilledema/visualproblemsthatcaneventuallycauseblindness. TheCSFcompositionandneuroimagingarenormal.Treatmentisweightloss,therapeuticLP,andTopamax (inhibitscarbonicanhydraseleadingtodecreasedCSFproductionandloweringofintracranialpressure.Itis alsohelpfulinweightloss). Q:A23-year-oldsafterrecoveringfromaflu-likeillness,developstinglingparesthesiainthelower extremities,followedseveraldayslaterbyprogressiveweaknessR>L.Examshowsdecreasedsensationat T10topinprick,3/5weaknessofLE(weakeronR),kneeandanklejerksarehyperactiveandthereis+BL Babinski.Patienthasdifficultywalkingandhasabroadbasedstiff-leggedgait.Hasurinaryincontinence. Diagnosis? A:TransverseMyelitis.Inflammatoryprocessofthegray/whitematterofspinalcordleadingtoaxonal demyelination.MaybeaforerunnerofMSorimmune-mediatedreactiontoavirus.Longtractsareaffected first(LE).Sensationisaffected.Cervicalinvolvementcanleadtorespiratoryparalysis;Thoraciclesionscan producespasticparaplegia;andLumbarlesionsleadtocombinationUMN/LMNsymptoms.Symptoms generallypresentrapidly,firstwithsensorysymptomsandprogresstospasticity.Hyperactivereflex/+ BabinskiisUMN.CSFhaselevatedproteinduetodemyelinationandmononuclearcells.Diagnosisismade withMRIdetectinglesions.Treatmentissteroidstodecreaseswellingandcompression. Q:A28-year-oldwithdiplopia,isolatedLeyenystagmuswhenlookingL,inabilitytoadducttheReye.She hassymptomsofdepressionandhistoryofepisodicdysarthria/dysphagia.Hasrecentdecreasedsensationin thearms,unsteadygait,andproblemswithbalance.CSFshowselevatedprotein,oligoclonalbands,and nucleatedcells.Diagnosis? A:MultipleSclerosis.Chronic,demyelinatingdiseaseaffectingtheCNS.Canleadtoachangeinsensation, visualproblems,muscleweakness,depressionandproblemswithgait/balance.Transversemyelitisisa forerunner.InternuclearopthalmoplegiaisaproblemwiththecommunicationbetweenCNIII(moveseyes medially)andCNVI(moveseyelaterally).InINO,thereisinabilityforbotheyestotracktogether(when lookingtotheL,theLeyeabductsproperlywithLRmuscle[CNVI],butReyedoesnotadductdueto abnormalMRmuscleinnervation[CNIII]).Thisleadstonystagmus.DiagnosisisobtainedthroughMRI detectionofdemyelinatinglesions.Treatmentissteroids(acuteexacerbation)andinterferons,inadditionto newermedicationsthatstimulateTcellstofightinflammation(Copaxone).Courseisrelapsing/remitting, withexacerbationscausedbyinfections(commoncold,URI),heat,pregnancy,andemotionalstress. Q:PatientpresentswithspasmsofLEwhilesleeping.Hasstiff-leggedgait,adductslegswhilewalking, increasedLEtone/spasticcatch,hyperactivekneejerksandanklejerkclonus.IncreasedRombergsway. Diagnosis? A:CervicalSpondylosis.Spinaldeformitywhentwovertebraecompressanerveroot,resultinginsensory andmotordeficit.Thisleadstocervicalpathologyandradicularsigns(LMN).Overtime,thespinalcordmay becompressed,leadingtohyperreflexia,andotherUMNsymptoms.Mayfeel“electricshocks”goingdown arms/legs.DiagnosisisthroughMRI.Treatmentissymptomaticorsurgical.Distinguishedfromtransverse myelitisbycourse(TMisrapidonset),CSF(TMhaselevatedprotein)andMRI(spondylosishascompression). GotoTableofContents 44 Q:A32-year-oldpatientrecoversfromaGIviralinfection,andnowpresentswithnewonsetlowerlimb weakness,areflexiainlowerlimbs,graduallyleadingtoflaccidparalysis,anddecreasedsensation.All symptomshavestartedina“stocking-glove”pattern,ascendingupthebody.Nerveconductionstudies showslowedconductionvelocityandconductionblock.Diagnosis? A:Guillain-BarreSyndrome.AlsocalledAcuteInflammatoryPolyneuropathy.Oftenprecededbyaninfection thattriggersandautoimmuneresponseagainstperipheralnervemyelin.ThesymptomsarepurelyLMN,with paresthesiasintheLEthatascendtoarmsandevendiaphragm.LMNsignsalsoincludeareflexiaandsensory loss.Theautonomicsystemcanbeeffectedbyorthostatichypotension,andrarelyareCNinvolved,leading toBLfacialweakness.CSFhaselevatedproteins,withoutanincreasedcellcount.EMGandNCSshowslowed conductionduetolossofmyelin.Treatmentincludesplasmapheresis,andtreatmentwithimmunoglobulins. Q:A43-year-oldmalehasgradualprogressiveweaknessover3-4months,atrophyofextremitymuscles, briskreflexes,plantarreflexesareextensor,spasticity,fasciculations,fibrillations,positivesharpwaveson EMG,anddysarthria.Diagnosis? A:AmyotrophicLateralSclerosis.Aprogressive,fatalneurodegenerativediseaseinvolvingtheanteriorhorn cells,leadingtobothUMN(increasedreflexes,Babinski,clonus)andLMNsymptoms(atrophy, fasciculations).Sensationisnormal.AffectLMNinthebrainstem(particularlymedulla—nucambiguous,and hypoglossalnucleus)leadingtodysarthriaanddysphagia.EMGismosthelpfuldiagnostictest,withactive fibrillationsandchangesaffectingonlythemotornervefibers.SensorynervesNOTaffected(vs.TMand spondylosis).Mostpatientsdiewithin4yearsandtreatmentispurelysymptomatic GotoTableofContents 45 Q:A85-year-oldwithgaitabnormality,slowmovement,asymmetricUErigidity,anddifficultyinvoluntary verticalupward/downwardgaze.Improvedslightlywithlevodopa.Laterthepatienthasinvoluntaryvisual saccades,anddifficultywithhorizontal/verticalgaze.Occulocephalicreflexisnormal.Diagnosis? A:ProgressiveSupranuclearPalsy.AtypicalParkinsonianmovementdisorder.Itaffectsgaitandbalance generallyfirst,withprogressivedegeneration.Themostobvioussignisparalysisofverticalgaze.Thereare associatedmoodandbehavioralsymptomsinadditiontoprogressivedementia.Treatmentiscurrently symptomatic. Q:A52-year-oldwithinsidiousonsetofblurredvision,diplopiax1day,ptosis,6thnervepalsy,unreactive pupils,hoarsevoice,dysarthria,weakneckmuscles,andincreasedamplitudewithrepetitivenerve stimulationonEMG.Diagnosis? A:Botulism.Aparalyticillnesscausedbythenervetoxin,botulin.ItpreventsthepresynapticreleaseofAch anddisablesbothmuscarinicandnicotinicreceptors.Presentswithmotorparalysis(nicotinic)and autonomicsymptoms(muscarinic)ofconstipation,blurredvision(dilatedpupils—MGhasnormalpupils),dry mouth,nausea,andvomiting.Respiratoryfailurecanbelethal.Diagnosisisbytestingbloodorstoolfor toxin.Treatmentismainlysupportive. Q:A43-year-oldpresentswithprogressiveweaknessofextremities,mildptosis,drymouth,impotence,and reducedreflexes.NCSshowsincrementalresponsetorepetitivenervestimulation.Diagnosis? A:LambertEatonSyndrome.Progressiveweaknessastheresultofantibodiesdirectedagainstpresynaptic Cachannels,preventingthereleaseofAch.Hasbothmotorweaknessandautonomicsymptoms,like Botulism.However,facialmusclesanddiaphragmarerarelyaffected.Reducedreflexes(notseeninMG). Maybeassociatedwithsmallcelllungcancer,andapproximately50%ofLEhasidentifiablemalignancy. DiagnosisthroughchestX-ray(lungmalignancy),serumantibodiestoCachannels,andincrementalresponse ofmusclefiberstorepeatedstimulation(MG=decremental).Treatmentisfocusedonunderlyingmalignancy andsteroids. Q:A20-year-oldwithoccasionaldoublevisionwhenlookingtotheRandnormalacuityineacheyealone.L ptosisanddifficultykeepingtheLeyeadducted.Pupilsareroundandreactive,speechisnasalandneck flexorsareweak.Noparesisorreflexabnormalities.Diagnosis? A:MyastheniaGravis.AutoimmunedisordercausedbyIgGantibodiestothepostsynapticAchreceptor, inhibitingstimulationofAch.AdequateAchisreleased,(vs.botulismandLE),butthepost-synapticgatesare blocked.Thefirstsymptomstodevelopareocular(3rdnervepalsysymptomsofptosisandinabilityto adduct)orbulbar(dysarthria,dysphagia).Later,extremitiesdevelopweakness,proximal>distal.Doesnot affectmuscarinic(autonomics)sothepupilisNOTaffected(vs.LEandBotulism).Fatigabilityisahallmark, andsymptomsareworselaterinthedayandafterexertion.Diagnosiscanbemadebytensiontest(AchesteraseinhibitorincreasestheavailableAch,showingtemporaryimprovement),EMG(repetitive stimulationcausesdecrementalresponse),andAchreceptorantibodiesinserum.Treatmentincludes anticholinesterasemedications,thymectomy(associatedwiththymusabnormality,85%ofpatientshave improvementafterthisprocedure),andsteroids.AcutemanagementofMyasthenicCrisisincludes plasmapheresisandairwayprotection. Q:A23-year-oldwithpersistentnumbnessoftheLhand,decreasedsensationinthe4th/5thdigits(palmar dorsal),weakfingeradduction/abductionespeciallyinthe5thdigit.Cause? A:UlnarNerveEntrapmentattheElbow.CubitalTunnelSyndromeoccurswhentheulnarnerveis GotoTableofContents 46 entrappedalongtheouteredgeoftheelbow.Compressionleadstoulnarnervesymptoms,including weaknessofabduction/adductionoffingersandsensorydeficitin4th/5thdigits,whichisthenormal distributionoftheulnarnerve.Generally,alteringsleepingpositionswillrelievesymptoms. GotoTableofContents 47 ANINJA’SGUIDETOPSYCHOTHERAPY Disclaimer:Thistherapyguideisnotdesignedtobeacomprehensivereviewofpsychotherapy.Thepurpose ofthisguideistointroduceyoutotermsassociatedwithvarioustherapiestohelpwithPRITEmultiplechoicequestions.Notallofthisishigh-yield,butitmayhelpfillinanygapsinyourtherapyeducationto date.Ifnothingelse,youmaylearncommontermsthatgotogetherinPRITE(CBT:automaticnegative thoughts,Psychodynamic:transference,MelanieKlein:objectrelations)topickuppoints.Thismaterialisa summaryfromKaplanandSadoktextsandtheMassGeneralPsychiatryReview. First,anoverviewofthespectrumoftechniquesusedintherapy,frommorepsychoanalytictomore supportive: InterpretationàConfrontationàClarificationàEncouragetoelaborateàEmpathicvalidationà Advice/PraiseàAffirmation MorePsychoanalytic: • • • Interpretation:bringingtheunconsciousthoughtstothesurface(conscious) Confrontation:openlyaddressingsuppressionthroughconfrontingthepatient Clarification:reformulation,“Sodoyoumeantosay….” MoreSupportive: • • • • Encouragetoelaborate:requestmoreinformation Empathicvalidation:“Thatmustbereallyhardforyou” Advice/Praise:therapistgivesconcreteadviceordirectpraisetothepatient Affirmation:“uh-huh,”“Isee” ThespectrumgoesfromMostPsychoanalytic(“couchtherapy”)toMostSupportive,withInterpretation beingmorepsychoanalyticandAffirmationbeingprimarilysupportive.Psychoanalytictherapytendstohave moreneutralinteractionsbetweenthetherapistandpatient(praise,advice,andvalidationarenotgenerally psychoanalytictechniques),whilemoresupportiveformsoftherapyusemorepraiseandencouragementin therapy. PsychoanalyticalPsychotherapy Overview:BasedonFreudiantraditionofuncoveringunconsciousaspectsofapatient’smentallife.Focuses onunconsciousconflicts,repressedfeelings,familyissuesfromearlyinapatient’slife,anddifficultywith currentrelationships.Occur5-6xperweekx1hourfor3-5years. Therapist:maynotbevisibletothepatient,sometimesacouchisused,andthetherapistremainsneutral. Patient:mustbeverymotivated,goodfrustrationtolerance,andhaveminimalpathology Goals/Techniques:resolveinternalconflictandsymptomreliefthroughexaminationoftransferenceasa meansofunlockingunconscious.Closeattentionispaidto: GotoTableofContents 48 • • • • Transference:thepatient’sunconsciousredirectionoffeelingsfromthepasttowardtherapist. Unconsciously,“Heythistherapistremindsmeofmyoverbearingmother.” Countertransference:thetherapist’sunconsciousassociationoffeelingsfromthepastdirectedat thepatient.Unconsciously,“Hey,thispatientremindsmeofmyjerkex-husband.” Resistance:unconsciousandconsciousforceswithinapatientthatresisttreatment.Ex:patient repeatedlycomestosessionslateduetounconsciouslyresistingtreatment FreeAssociation:undirectedexpressionofconsciousthoughtsandfeelingsasanattemptto“tap into”theunconscious.Basically,saythefirstthingthatcomestoyourmind,asitmayberelatedto unconsciousstuff. FourSubtypesofpsychoanalytictherapy(HighYieldPRITEFamousPeopleassociations): 1. ClassicalPsychotherapy:Freud 2. Egopsychology:AnnaFreud 3. Objectsrelationspsychotherapy:MelanieKlein(Objectrelationsarerelatedtodrives;“ego splitting;”infant-motherrelationships;“depressive/paranoid/schizoidpositions”)andDonald Winnicott(transitionalobject;“goodenoughmother”) 4. Self-psychology:HeinzKohut(“mirroring;”stuffonnarcissism) ExpressivePsychotherapy(“Insight-OrientedTherapy”) Overview:samegoalsandtechniquesusedinPsychodynamictherapywithafewdifferences.Occur3x/week for30-50minutes Therapist:face-to-faceinteraction,modifiedneutrality Patient:cantoleratefrustration,hasintactrealitytesting,goodimpulsecontrol,andongoingsignificant emotionalsuffering Goals/Techniques:focusesonacurrentinterpersonaltransferenceinanattempttoreorganizepersonality, resolveconsciousconflict,andincreaseinsightintointerpersonalevents.Improveobjectrelations.Uses “hereandnow”interpretation,confront/clarification.Mayusemedications(asopposedtoPsychodynamic psychotherapy,whichgenerallydoesn’tusemeds). BriefPsychotherapy Overview:Mainfocusisonbrevity(limited#ofsessionsunderstoodatthebeginning),patientselection (rigidcriteria),aspecifictreatmentfocus(onespecificthingtobeworkedon/resolved),andhighlevelsof therapistactivity. FamousPRITEPeople:FranzAlexanderfirststartedtoaltertraditionalpsychodynamictherapybyshortening sessions,decreasingfrequency,andothermeasurestodevelopmodernshort-termtherapy.Otherpeople involvedinconceptualizingthisformoftherapywereMann,Malan,Sifneos. EssentialFeaturesofBriefTherapy:Patientsselectedwithspecificinclusioncriteria(moderateemotional distress,desireforrelief,aspecificproblemtoworkon,functional,abilitytocommittotreatment)and exclusioncriteria(nopsychosis,substanceabuse,orriskofself-harm).Limitedto12-20hourlongsessions, afterwhichtherapyisterminated GotoTableofContents 49 Therapist:mustkeeptreatmentfocusedandmovingforwardastherearepre-establishedlimited#of sessions.Sessionsbeginwithsummaryoflastsession,andrestatingfocus.Homeworkisgiven.Clarificationis important.Transferencemustbequicklyidentifiedandworkedthrough. Patient:seeaboveexclusionandinclusioncriteria.Mainly,thepatientmusthaveaspecificareatoworkon (loss,conflict)andunderstandthat#ofsessionsislimited. Goals/Techniques:fourcommonfociarelosses,beingoutofstepwithexpecteddevelopmentalstage, interpersonalconflicts,andsymptomreduction.Brieftherapyworksontransferenceissues,exploresspecific pasttrauma,reestablishesdefensemechanisms,andresolutionofwhatinitiallybroughtthepatientto therapy.Threephasesoftherapy: 1. Initialphase:(evaluationthrusession3)evaluatesthepatient,selectsfocus,andestablishedworking alliance 2. Middlephase:(session4-9)wherepatientstartstoworrytherewon’tbeenoughtimeintreatment, issuesofseparationandaloneness,feelsworseduringthisphase 3. Terminationphase:(sessions8-16)patientacceptstreatmentending,discussterminationoftherapy relationship. InterpersonalTherapy Overview:developedbyKlerman,utilizedbyHarryStackSullivan,itisabrieftherapythataddresses relationshipsinthe“hereandnow.”Primarilyusedtotreatdepression.Occursfor12-16weekswithmonthly maintenancethereafter. Patient:mostcommonlytreatsMDD Goal/Techniques:Interpersonaltherapyworkstoimproveinterpersonalcommunication,clarifyfeelings,and providereassurance.Maybecombinedwithmedicationmanagement.Improveinterpersonalskillsby examining4problemareas: • • • • Unresolvedgrief:facilitategrievingprocess Socialroledisputes:makeplanofactiontosolveinterpersonalroledisputes(conflictwithco-worker, spouse,etc) Socialroletransitions:mournandacceptthelossofanoldrole(demotioninjob,childrenmoveout ofhome)andearnself-esteeminmasteringanewrole. Interpersonaldeficits:learntoestablishhealthyrelationshipsanddecreasesocialisolation SupportivePsychotherapy Overview:Usuallybrief,withanactivefocusonhelpingthepatientdealwithalifecrisis.Especiallyeffective foracutegriefreactions.Occurs1x/weekfor30-50minutes,canlastmonths Therapist:face-to-facewithpatient,non-neutral,providesadvice,sympathy,andsupportwhilereinforcing thepatient’sstrengths. Patient:maybeundergoingalifecrisis,poorrealitytesting,lowleveloffrustrationtolerance,impaired objectrelations,poorimpulsecontrol,mayhaveegodeficits.Thesepatientsaregenerallylessfunctional thatpatientparticipatingintheotherabovetypesoftherapy. GotoTableofContents 50 Goals/Techniques:formatherapeuticalliance,focusonconsciousexternalevents(noanalysisof transference),reintegrationofcopingskills,andstrengthendefenses.Usesrealitytesting,advice,empathy, andcognitiverestructuring. BehavioralTherapy Overview:focusesonreducingovertbehaviorsthataresymptomsofmentalillness. Usesconditioningandmodeling.DevelopedbyJohnWatson. TypesofBehavioralTherapy: • • • • • SystematicDesensitization(Wolpe):counterconditioningtodecreasemaladaptiveanxiety.Workson decreasingresponsetoanxiety-provokingstimuli.Treatsphobias.Ex:patienthasfearofheights. Makeahierarchyofleastfearedtomostfeared.Thinkaboutlessfearedanduserelaxation techniques(mentalimagery,relaxingmusclesanddecreasingautonomicresponses)todesensitize selftofear/anxiety.Nowgouponthehierarchy(increasedanxiety-provoking)andrepeattheabove todesensitizegraduallyupthehierarchy. Flooding:Similartosystematicdesensitizationinthatastimulusispresentedandthegoalisto desensitizeoneselftofear/anxiety.However,nohierarchy,norelaxationtechniques,andhasin-vivo exposure(actuallypresentedwithrealfearratherthanimaginingit).Ex:patientfearofheights,goto topofhighestbuildingandsitthereuntilfearsubsides. EMDR:saccadiceyemovementsusedtotreatPTSD Positivereinforcement:usinga“tokeneconomy”torewardpatientsfordesiredbehavior.Gooduse inSchizophrenics.Canalsobeusedinaddicts,similartomethadonemaintenance,whereabstinence fromillicitdrugsleadstopositivereinforcementwithmethadone. DialecticalBehavioralTherapy:treatsBPD/personalitydisordersusingcombinationof supportive/cognitive/behavioraltechniques.Workstoimproveinterpersonalskills,anddecrease self-destructivebehaviors.Addressesambivalence,increasesmotivation,seekstonotreinforce maladaptivebehaviors,learnnewskills,andrestructurethepatient’senvironment.Useshomework, advice,andconfrontation. Biofeedback Overview:DesignedbyMillertoassumevoluntarycontroloftheautonomicnervoussystemandother biologicsystemsusingoperantconditioning. Conditionstreated:includeReynaud’s,tensionHA,migraines,TMJ,epilepsy,asthma,arrhythmias,fecal incontinence,HTN,andmanyothers. Methods:usesEMG,skintemperature,BP,andothermeasurementstomonitorphysiologicstates.The patientusesrelaxationtechniquestoself-modifyautonomicfunctionstoproduceresolutionofmultiple symptoms. CognitiveBehavioralTherapy Overview:focusesontheinterplayofmaladaptivethoughts,feelings,andbehaviorsthatcausemental disorders.Basically,maladaptivethoughtsandfeelingsleadtounhealthybehaviors.CBTcombinescognitive therapy(identifyingandchallengingunderlyingcognitiveerrors)withbehavioraltherapy(removing unwantedbehaviors).Occursoverthecourseof15-20weeks GotoTableofContents 51 Therapist:thegoalistoteachthepatienttobecometheirowntherapistthroughaseriesofassignments, homework,andcloseinteractionbetweentherapistandpatient Patient:CBTisproventohelpwithpatientswithMDD,BMD,PanicDisorder,SocialAnxietyDisorder,GAD, OCD,Phobias,EDO,PsychoticDisorders,andSubstanceAbuse. Goals:identifyandalter“cognitivedistortions”thatmaintainsymptoms.Thecognitivetriadis: 1. negativeselfperception 2. patientseestheworldasanegativeplace 3. patientexpectsfailureandhardship. CBTstrivestoidentifynegative“automaticthoughts”thataregeneratedby“cognitivedistortions.”Example: patientbelievesheistoofattohavefriends.Thisisanautomaticnegativethoughtthatistheresultofa maladaptivecognitivedistortion/error. Techniques:3maincomponents 1. Didactics:teachthepatientabouttheirmentaldisorder,thecognitivetriad,theirfaultylogic,and cognitivedistortions 2. Cognitivetechniques:elicitautomaticthoughts,testlogicofautomaticthoughts,identifycognitive distortion,testvalidityofcognitivedistortion.Ex:afterherboyfriendbreaksupwithher,apatient believesnobodywilleverloveher(automaticnegativethought).Therapiststatesthiscognitive distortionis“overgeneralization”andisuntruethatNOBODYwilleverlovethepatient.Thenthe patientworkstodisprovethedistortion(testvalidity) 3. Behavioraltechniques:varioushomeworkwithactivitiestoimproveself-relianceandfindnew healthywaystocope(replacingsubstances,suicidality,eatingdisorderswithexercise,art,etc) TechniquesforSpecificDisorders • • • • • • MDD:provideseducation(informationalintervention),activityscheduling(behavioralmodification ofanhedoniaandPMR),cognitiverestructuring(challengenegativeviewsofself),andproblem solving(assertivenesstraining) BMD:stressmanagement,monitoringmoodtoearlydetectdestabilization,improvingregularityof circadiansystemthroughhealthybehaviors(exercise,diets,etc),problem-solvingskillstoimprove compliancewithcare PanicDisorder:educationtostopthe“fear-of-fear”cycleandstopcatastrophicmisinterpretations(“I amhavingaheartattack”),cognitiverestructuring(decreasenegativityandcatastrophizing), interoceptiveexposure(exposuretophysiologicsymptomsofanxietythroughrunninginplaceor hyperventilating,similartodesensitization),desensitization,relaxationtraining SocialAnxietyDisorder:education,cognitiverestructuring(monitoringand“catching”thoughtsthat precipitateanxiety.Ex:“AllthesepeoplethinkI’manidiot.”),exposureintervention(desensitization exercises),socialskillstraining,andsomeinteroceptiveexposures(asusedinpanicd/o) GAD:education,cognitiveinterventions(examinecognitivedistortionsandnegativity),imaginal exposuretoworries,relaxationtechniques OCD:education,exposureandresponseprevention(desensitizationandflooding),cognitive interventionstohelpbreakintrusivethoughts/ritualisticbehaviors GotoTableofContents 52 • • • • • • • PTSD:education,cognitiveinterventionstochallengeperpetualfearofdanger,imaginalexposure (narratetrauma,extinguishextremeemotionalresponse,learntofeelsafe),desensitizationin-vivo, relaxationtechniques Phobias:exposureinterventions,participantmodeling(therapistexemplifiesabehavior[touchinga snake]andencouragespatienttocopythebehavior) BulimiaNervosa:education(includinghealtheducation),self-monitoringandreportingEDO behaviors,stimulus-control(decreasingtriggers[ex:don’teatinmallwithallskinnyfriends]), cognitiverestructuringbodyimageandchallengingnegativethoughtsaboutbody,problem-solving (findnewwaystocopewithstressorsratherthanbinge/purge) AnorexiaNervosa:positiveandnegativereinforcementproceduresinitiallytoprotecthealthand decreasehospitalization/decompensation.AlsousetheabovetechniquesforBulimia Substanceabuse:motivationalinterviewing,functionalanalysis(examinefunctionbeforevs.after substanceabuse),self-monitoring,cognitiveinterventionstochallenge“allornothing”thoughts(“I hadonedrink,Iblewit,Imightaswellcontinue”)andotherdysfunctionalthinking,problem-solving (identifynewmeansofcopingwithstressors),andcontingencymanagement(contracts,positive reinforcement) PsychoticDisorders:education,cognitiveinterventionstopromotemedicationcompliance,social skillstraining,stressmanagement Personalitydisorders(needlongertreatmentCBTthanAxisId/o):emotionalregulation(identify, tolerateandmodifyemotions),reductionoftherapy-interferingbehaviors(resistance),challenge cognitivedistortions,stressmanagementandproblem-solving(newcopingskillsratherthan unhealthymechanisms) GroupTherapy Overview:grouptherapyofferstheopportunityforpurposefullycreated,closelyobserved,andskillfully guidedinterpersonalinteractioninacollectionofpatientsbroughttogetherbyaleaderforashared therapeuticgoal. Therapist:plansandorganizesgroupafteridentifyingspecificgoalsofthegroup. Patients:patientsselectedforagroupbasedonneeds/diagnosis/goalsofgroup.ActiveSI,manic,psychotic, andemotionallysadomasochisticindividualsarecontraindicated.Groupsneedtobesomewhat homogeneousinegodevelopmentforpsychodynamicgroups. Goals:Re-establishpre-morbidlevelsoffunctioninginpeoplewithacutedistress,supporttargeted populations(medicalillnesslikecancer,ormentalillnesssupportgroups),providerelieffortargetsymptoms (ex:eatingdisorders),encourageandstimulatecharacterchange(helpsidentifymalignantcharacterdeficits inapatientthroughgroupreflection,andtopromotehealthychange). TherapeuticFactorsinGroupTherapy(PRITEquestionsinpast): • • • • • Abreaction:unearthrepressedemotions,andrelivethemtoincreaseinsight Acceptance:feelingofbeingacceptedbythegroup,absenceofcensureanddifferenceofopinionis tolerated. Altruism:onememberhelpsanother,helpstoestablishcohesion Cohesion:groupisworkingtogetherforacommongoal. Contagion:expressionofanemotioninonememberelicitstheexpressionofemotioninanother member GotoTableofContents 53 • CorrectiveFamilialExperience:groupre-createsfamilyoforiginforonemembertohelpthemwork throughoriginalconflict • Empathy:groupmembercanputhimselfinthepsychologicalframeworkofanothermemberand understandthethinking,feeling,andbehavior. • Imitation:emulationormodelingofone’sbehaviorafteranotherperson • Inspiration:impartingasenseofoptimismtogroupmembers • RealityTesting:person’sabilitytoevaluatetheworldoutsideofthemselvesandperceivereality accurately • Universalization:theideathatanindividualisnotalonewiththeirproblems • Ventilation:expressionofsuppressedfeelings,ideas,oreventstogroupmemberstoamelioratea senseofshameorguilt(akaselfdisclosure) TypesofGroupTherapy: • • • • Supportive:weeklyovermonths,shareduniversaldilemmas,helpsadapttoenvironment. UniversalizationandRealityTesting Psychodynamic:1-3x/weekforyears,forneuroticdisorders,workonpresent/pastlifesituations, focusoninterpretunconsciousconflicttochallengedefensesandreduceshame.Catharsis,Reality testing,ExamineTransference CBT:weeklyupto6months,phobiasorcompulsionstreated,worksoncognitivedistortionsto relievespecificpsychiatricsymptoms.Reinforcement,Cohesion,Conditioning Inpatient:dailygroupswithrapidturnoverofpatients,heterogeneousgroups,emphasisonthe “hereandnow,”problemsolving,educationontreatment.EmpathyandRealityTesting FamilyTherapy Overview:seekstoresolvefamilyconflict,meetsfamilymembers’individualneeds,establishhealthyrole relationships,copewithdestructiveforcesinsideandoutsidethefamily,andintegratethefamilyinto society.Occursweeklyfor1-2hours.Familymaypresentwithasinglefamilymemberidentifiedasthe “problem”butthedynamicislikelymuchmorecomplexthanthat. Goals:alterinteractionsandimprovefunctionalityofthefamilyasaunitofindividuals.Bringtolighthidden patternsandunderstandthepurposeofthesepatterns. Techniques:collectathoroughhistory,includingafamilylifechronologyinthefirst2sessions.Understand howtheparentsoperatefrommodelsfromtheirownparents/families.Onetechniqueusedis“reframing” (ex:“Thischildisimpossible,”canbechangedto“Thischildistryingtodistractyoufromanunhappy marriage). TypesofFamilyTherapy: • • Behavioral/CBT:coreconceptsarefunctionalanalysis,sociallearning,andcommunication.Goalsare toresolveproblemsbyimprovingcommunicationandproblem-solvingskillswhilebalancingchange vs.acceptance.Thisisthe#1empiricallysupportedfamily/couplestherapy BowenFamilySystems:coreconceptsaredifferentiationofself,triangulation,familyemotional system,andsiblingorder.Goalsaretoincreasefamilymemberdifferentiation,decrease triangulation,andmanageanxiety.Usesgenograms GotoTableofContents 54 • • • • • • • Experimental/Humanistic:coreconceptsareattachmenttheoryand“psychotherapyoftheabsurd” (seriously).Goalsarecreativity,increasingself-esteemandfosteringcohesionthroughwacky activitieslikefamilysculpture.Mayhave2therapists MilanSystem:coreconceptsareneutrality,circularinteractionbetweenfamilyandtherapists, familiesgetstuckinpatternsofinteraction,solutionsresidewiththefamily,notthetherapist,“longtermbrieftherapy”(longsessionwithamonthbetweensessions).Goalsareunmaskingthe“family game,”changingmaladaptivepatterns.Techniquesincludetherapistteambehindaone-waymirror, “hypothesizing,”“counterparadoxicalinterventions”(intentionallyengageinunwantedbehaviorsto increaseinsight),and“circularquestions”designedtoimproveempathy(“Whatdoyouthink concernsyourwifemostaboutyourillness”).Thisissuperfamousfamilytherapyandsometimes getstested Narrative:coreconceptsarenarrativestoriesofthefamilysystemdesignedtomakeothers understandthedynamic,understandingthefamilysysteminthecontextofanarrativestory.Goals arecreationofnewer,moreusefullifestories,externalizeproblemsratherthanblamingsingle membersforproblems,enhancecommunicationthroughtherapeuticletters Psychodynamic:coreconceptsareprojectiveidentification(projectingyourundesirable characteristicsontoanotherperson),splitting,scapegoating,andchangeoccursthroughconscious insightintounconsciousprocesses.Goalsincludeincreasinginsight/empathy,disentangle interlockingpathologies,identifytransferencewithinthefamilydynamic,andchallengeresistance. Creationofa“holdingenvironment.” Psychoeducational:coreconceptsareexpressedemotion,engagementwiththefamily,education workshops,andrehabilitation.Goalsincludeimprovingsocialskillsandcommunications,problemsolving,relapseprevention.Thisisthe#1familybasedtherapyforfamilieswithamemberwith schizophreniaoranothermajorpsychiatricdisorder Structural:coreconceptsareboundaries,familyhierarchy,coalition/alliance,and engagement/enmeshment.Goalsareimprovingflexibility/adaptability,findingabalancebetween connectednessanddifferentiation,andhomeworkbasedproblemsolving Strategic:coreconceptsarepower/control,familylifecycletransitions,rolechanges,adaptingto change.Believeindividualcannotchangeuntilthesystemthatsustainsthemchanges.Goalsare problem-solvingwithidentificationof“exceptiontotherules,”addressdoublebinds,disrupting sequencesofbehaviorthatperpetuateproblems,“paradoxicaldirectives.” CouplesTherapy Overview:focusesonthepatternofinteractionsbetweentwopeoplewhiletakingintoaccountthe individualhistoryofeachmember. BasicPrinciples:monitorforprojectiveidentificationandre-enactmentofchildhoodattachmentissueswith spouse.Acouple’srelationshiphasalifecyclecontext,withinthecontextofchangesintheindividualand changesinthefamily.Lifecycleimpliesthattransitionfromonelifecycletoanotherhasthehighestriskfor divorceandconflict(midlifecrisis,aging,etc).Communicationskillsareessential.Contraindicatedincasesof domesticviolence,psychosis,orwhendivorcesisactivelybeingsoughtout. TheInterview:componentsshouldincludeevaluationofeachpartner’smotivationtoparticipatein treatment,providingasafeenvironmentinthefirstsession,identifyingeachmember’sviewofwhatthe problemis,assessingforinfidelity,andidentifythebiggestsourcesofconflict. GotoTableofContents 55 Goals:alleviatedistress,promotewell-beingasaunit,problem-solving,promoteaccountabilityand responsibility. TreatmentInterventions:interpretationofunconsciousprocesses,communicationskillstraining(including learningactivelisteningskillsandlearningtofightconstructivelywithspecificrules),roleplaying(role reversaltoincreaseempathy),andparadoxicalinterventions(reversepsychologystuffwhereatherapisttells memberNOTtochange,leadingtochange). GotoTableofContents 56 ANINJA’SGUIDETOFREUD&OTHERSTUFF SigmundFreud Associatedwiththetermsresistance,transference,countertransference,parapraxes(“Freudianslips”), abreaction(recoveringrepressedfeelingstoremovesymptoms),catharsis,repression(hidingdistressing materialintheunconscious)andmanymore. InterpretationofDreams Basedonthepremisethatdreamsareunconsciouswishes(potentiallychildhoodwishes)thatarenot accessibleinwakinglife.ThefollowingtermsaresometimesseenonPRITE,requestingadefinition. • • • • • • • Twolayersindreams:manifestlayeriswhatisremembered/recalledofdream;latentlayeristhe unconsciouswishthatisnotrecalled Condensation:severalunconsciousimpulsesareattachedtoonemanifestdreamimage(example,a manwithafacemadeofbreadplayingatrumpetmaybethedreamer’sfearofmenconsuming creativeinstincts…orsomethinglikethat) Displacement:intensitytowardanobjectisredirectedtoamoreneutral/acceptableobject (example:dreamerunconsciouslywantstokilltheirmother;inthedreamtheywanttokillan unknownfemalestranger[moreacceptableobject]) Projection:dreamer’sunacceptablewishesareputontoanotherpersoninthedream(example: dreamerwantstorobabank,indreamtheyareconcernedabouttheirbrother’sdesiretoroba bank) Symbolicrepresentation:innocentsymbolrepresentsacomplexsetoffeelings(example:dreamer seesapuppy,whichactuallyrepresentstheirfeelingsofvulnerabilityandfearofbeing castrated/neutered….orsomethinglikethat) Primaryprocess:theaboveincoherentesotericcharacteristicsofthemanifestlayer(nonsensical dreamaspectsthatarerecalled) Secondaryrevision:rationalportionsofdreamsthatresemblewakinglife(dreamsactingout work/homescenarios,beingoncall,etc) TheTopographicalModeloftheMind Basedonprinciplethatthemindisdividedintolayers.Freudusedthistheorytoidentifytheworkingsofthe consciousandunconsciousmind. • • • Conscious:ideas/thoughtsareintheconsciousminddueto“psychicenergy”(attentioncathexis), whichpushesthesethoughtsintotheconsciousforefront Preconscious:thisistheareawherethoughtsareheldbeforebeingpushedintotheconsciousmind. Unacceptableunconsciouswishesheldheremaybepushedintoconsciousnessbypsychicenergy Unconscious:theareaoftheprimaryprocess(seeabovedefinition)thatisincoherentand representswishfulfillment.Memoriesareseparatefromwords,andpsychotherapyhelpstoattach wordstounconsciousthoughtsandbringthemtotheconsciousmind GotoTableofContents 57 InstinctandDriveTheory Afterdevelopingthetopographicalmodelofthemind,Freudbegantoconsiderinstincttheory.Instinct referstoapatternofgeneticallyderivedbehaviorthatisindependentoflearning.Theinstincthas4basic characteristics:thesource(partofbodyfromwhichinstinctarises),theimpetus(intensityofinstinct),the aim(generallyanactiontowarddecreasingtension),andtheobject/targetoftheinstinct.Specifictypesof instinctarelibido,ego,andaggression. • • • LibidoInstinct:sexual/pleasuredrives EgoInstinct:non-sexualinstincts/drives Aggression:dualinstincttheoryreferstothebalancebetweenlibidoandaggression,where aggressionaimstodestroy Pleasurevs.RealityPrinciples ThePleasureprincipleisthathumansavoidpainandseekpleasure.TheRealityprincipleisthatwhich delays/postponesthepleasureprinciplewhenitisnotappropriate.TheRealityprincipleisgenerallylearned. Narcissism Basicprincipleisthattheperson’slibidoisinvestedintheegoratherthaninotherpersons.Therecanbea lossofrealitytestingandgrandiosity.Freudregardedhomosexualityasanarcissisticformofobjectchoice, whenapersonfallsinlovewithanidealizedversionofthemselvesprojectedontosomeoneelse. • • Primarynarcissism:afterbirththeneonateiscompletelynarcissistic,withalllibidoinvestedin meetingtheirownneeds.Theadditionofthemotherfigureleadstowithdrawalofthelibidofrom selfandredirectedontotheexternalobject(mom).Thisisobjectattachment. Secondarynarcissism:ifafterobjectattachmentoccurswiththemother,thereisalatertrauma,the libidoiswithdrawnfromthemother(object)andreinvestedintheperson’sego.It’saregression. TheStructuralTheoryoftheMind Freudmovedfromthetopographicalmodelofthemindtothestructuraltheoryofthemind,whichfocused ontheego,id,andsuperego. • • • Id:unorganizedinstinctualdrivesthatarepartoftheprimaryprocess(seeabove).Occurs unconsciously Ego:spansallthreeareasofthemind(conscious,preconscious,andunconscious).Itisresponsible forlogic/abstraction(conscious),defensemechanisms(unconscious),perception,contactwith reality,anddelay/modificationofdrives(tomakethemsociallyacceptable).Theegohelpstomodify theid,whichsometimesleadstoconflict Superego:establishesandmaintainsthemoralconscience,basedonvaluesinternalizedfrom parents.Proscribeswhatapersonshouldnotdo FunctionsoftheEgo • • Controlsinstinctualdrives:mediatesbetweentheidandtheexternalworldanddelaysdrivesis sociallyunacceptable Judgment:anticipatestheconsequencesofactions GotoTableofContents 58 • • Relationtoreality:mediatesbetweeninternalworldandexternalworld.Developsasenseofreality (distinguishinsidebodyvs.outsidebody),realitytesting(distinguishbetweenfantasyandreality), andadaptationtoreality(adapttochange) Objectrelations:developingsatisfyingrelationshipsstemsfromearlyinteractionswithparentsand otherearlysignificantfigure. DefenseMechanisms TheseareverycommononPRITE,andbasicallyaregroupedfromthemostprimitive(likeprojection)tomost mature(likesublimation). Narcissistic(MostPrimitive) • • • Denial:abolishesexternalreality(“Idon’thavecancer”) Distortion:reshapesrealitytosuitinternalneeds(delusions,hallucinations) Projection:endowingyourfeelingsontosomeoneelse(“Whyismomsoangrytoday?”whenreally YOUareangry).Canincludeparanoiddelusionsanddelusionaldisorders,whichputsone’sfeelings ontoothers(“Theywanttoharmme”) Immature • • • • • • • • Actingout:givingintoanimpulsetorelievetension(burningdownahouse) Blocking:inhibitingorblockingthoughts,pushingthemintotheunconscious.Blockingthoughtscan leadtoincreasedtension Hypochondriasis:overemphasizingillness,isaregressiontoavoidguiltandresponsibility Introjection:internalizinganobject’squality.Anexampleisidentificationwithanaggressor (internalization)leadingtobeliefthattheaggressionisunderone’scontrol.(“Poorthief,heprobably reallyneedsacar.LookhowbenevolentIam”) Passiveaggressivebehavior:indirectaggressionthatisnotovert(likeprocrastinationthatmakes someoneelsesuffer) Regression:returntoalessdevelopedphase(“Iwantmyteddybear”) Schizoidfantasy:autisticretreattoavoidconflict.Repelsothersandavoidintimacy Somatization:transformconsciousorunconsciousconflictintobodysensations/symptomstoavoid dealingwithit.(Kidwithstomachpainontestdays) Neurotic • • • • • • Controlling:obsessivemanagementofexternalenvironmenttodecreaseanxietyandresolveconflict Displacement:shiftemotionfromoneobjecttoanother(baddayatwork,gohomeandyellatyour spouse) Externalization:generalizedprojectionwheretheentireworld/externalenvironmentisattributed withpersonalelements(feelingangry,“Thewholeworldisanangryplace!”“Thisjobisso uncaring!”) Inhibition:renounceegofunctionstodecreaseanxiety Intellectualization:useintellecttoavoidanemotional/affectiveexperience(getcancer,spendall yourtimeoninternetlearningaboutittoavoidemotionallyexperiencinghavingcancer) Isolation:separateanideafromanaffect(“isolationofaffect”PRITEquestionhasapatientwho blanklytellstherapistthat,asachild,hisdadkickedapuppytodeath.Noaffectintellingstory) GotoTableofContents 59 • Rationalization:usingrationalexplanationstojustifyanunacceptablebehaviororbelief(“I’m allowedtotakestacksofnapkinshomefromMcDonald’sbecausethey’lljustthrowthemaway anyway”) • Disassociation:modifyone’scharacter/identitytoavoidemotionaldistress.(“dissociativefugue”is whenapersongoesplaces/doesthingsbutretainsnomemoryandappearsconfusedafterwards. Disassociationisoftenusedbypatientswithborderlinepersonalitydisorder,andisanumbingof sensoriuminresponsetotrauma) • Reactionformation:unacceptableimpulse/emotionisconvertedtoanacceptableimpulse(youhate yourneighborbecausetheyarenoisyatallhoursofthenight,butthishatredfeels unacceptable/elicitsguilt.Asaresult,yougogiveyourneighborapresenteventhoughtyouhate them) • Repression:putanundesirablethought/feelingintotheunconscioustoavoiddealingwithit.Thisis differentfromsuppression,whichconsciouslyavoidsthethought(Repression:forgetting (unconscious)arapeattheageof5.Suppression:choosingnottothinkabouttherapethat happenedatage5).Repressionissimilartothoughtblocking,exceptnotensionisobservedwith repression • Equalization:makinganeutralobjectsexualtodecreaseanxietyrelatedtoaprohibitedimpulse(No clue.Havefunwiththatone….) MatureDefenses • • • • • • Altruism:providingagratifyingservicetoothersforthevicariousexperience(volunteeringtoraise moneyforcancermakesyoufeelallwarmandfuzzyinside) Anticipation:anticipatefuturediscomfort(comingupwitharealisticback-upplanforproblemsin thefuture,likeanearthquakesafetykitinthegarage) Asceticism:gratificationthroughlimitationandrenunciation Humor:usinghumortotolerateterribleexperience.Thisdefensemechanismactuallyfocusesonthe experience(“Well,nowthatI’velostbothmylegs,I’llsaveloadsofmoneyonshoes.”) Sublimation:impulsegratificationbyconvertingsociallyunacceptableimpulsestoacceptableactions (gardening,painting).Feelings/impulsesareacknowledgedandmodified Suppression:consciouslypostponingdiscomfort(onechildincaraccident,ratherthanfirstrushingto ER,suppressesfearandcallstheotherkidsathometomakesuretheyaresafeandcaredfor,then goestoER) PsychosexualDevelopmentalStages Basically,theseareFreudianDevelopmentalstagesthatoftenaretestedonPRITE.Thegoalistoprogress throughthesestageslinearly,confrontingpathologyspecifictoeachstage,leadingtoresolutionof conflict/pathologyandmovingontothenextstageinlife.Failingtoresolvepathologyleadstoincomplete passagethrougheachstage,andthepersonwillcontinuetostrugglewithunresolvedissuesfromprevious stages.Example:Apersonwhodoesnotresolvetheissuesofovercontrolvs.undercontrolintheanalstage (age1-3years)willforeverstrugglewithautonomyissuesandbalanceofcontrol(makingthem“anal retentive”andovercontrolling).Therapyseekstofindtheseunresolvedissuesandbringresolutiontowards bettermentalhealth.Whilesometheoryseemsabitweird(penisenvy,castrationfears),theoverall principleofworkingthroughunresolvedearly-lifeissuesisreasonable.ThesestagescorrelatewithEriksonian Stages(discussednext). Oral(0-18months):conceptsofthirst,hunger,andsatiation.Libido(oraleroticism)vs.Aggression(oral sadism,biting,devouring,anddestroying). GotoTableofContents 60 • • • • Goal:developtrustanddependenceandgratifylibidowithoutconflictwithaggression. Pathology:narcissism,pessimism,dependenceonobjects/peopleforself-esteem,envy,jealousy Resolutionofthisstage:learntogiveandreceivewithoutexcessivedependency/envyandbuild trust/self-reliance. Commondefensemechanisms:projectionanddenialinearlyoral,displacementand“turnagainst self”inlateroral. Anal(1-3yearsold):conceptsofcontrol(overanalsphincter),increasingaggressivedrives,andtheshift fromapassive/dependentphase(oral)toanactivephase. • • • • Goal:separation,individualization,maintainingabalancebetweenovercontrol/undercontrol. Relatedtoautonomy/independencewithagoodbalanceofcontrolvs.shame/self-doubtduetolack ofcontrol. Pathology:overcontrolleadstobeingoverlyneat/orderly,stubborn,andwillful.Lossofcontrolleads tomessiness,ambivalence,anddefiance.Obsessive-compulsiveneurosispathologydevelopsinthis stage. Resolution:autonomy,initiativewithoutguilt,self-determiningbehaviorswithoutshameanddoubt. Commondefensemechanisms:undoing,reactionformation,regression,andisolation. UrethralTransitionStage(betweenanalandphallicstages):releasevs.retention.Thereisthepotentialfor regressioninthistransitionfromanalstage(balanceofcontrol,autonomy)movingontophallicstage. Regressiveenuresiscanoccurhere. • • Pathology:competitiveness/ambition,feminineshameduetolackofstrongurinestream (seriously…) Resolution:prideandself-competence,setsthestageforgenderidentity. Phallic(3-5yearsold):sexualinterest,stimulation,andexcitement.Unconsciousoedipalissues(boy’s competitionwithfatherforthemother’slove)andcastrationanxiety. • • • • Goals:genderidentity,overcomeoedipalissuesfororganizationofcharacter. Pathology:neurosis,castrationanxietyinmales,penisenvyinfemales,abnormaldevelopmentof humancharacter. Resolution:abilitytomaintaincuriositywithoutembarrassment,initiationwithoutguilt,sexual identity,regulationofdriveimpulses,generatesuperegobasedonidentificationwithparentofthe samesex. Commondefensemechanisms:Intellectualizationvs.repression Latency(5/6-11/13yearsold):developmentofthesuperegointhephallicstageleadstoinstinctcontrol.In latency,thelibidogetssublimated(directedintosociallyacceptablebehaviors).Starttoplayandlearnwhile fightingovercontrolandobsessions. • Goals:finishtheworkstartedinthephallicstagebyfurtherintegratingoedipalidentificationand consolidatingsexroles.DevelopEgoandbegintomasterskills. GotoTableofContents 61 • • • Pathology:Issuesofcontrol(likeinanalstage),withproblemswithovercontrol/undercontrol. Overcontrolleadstoclosure/stuntingofpersonalitydevelopment.Undercontrolleadstonot focusingonlearninginthisstage. Resolution:integratingpsychosexualdevelopment,masteringtasks/objects,becomingautonomous, andlearningtotakeinitiative. Commondefensemechanisms:sublimation. Genital(11/13-Adulthood):physicalmaturity,hormonaldevelopment,increasingdrives.Thereisastruggle againstregressionandthisstagemayreopenallconflictsinpreviousstages,leadingtotheneedtore-resolve them. • • • Goals:separatefromdependenceonparents,developmatureobjectrelations,developadultroles, andacceptculturalvalues. Pathology:reopening/reworkingpreviousdevelopmentandpotentialforregression;previous unsuccessfulresolutionleadstopathologyinadulthood. Resolution:reintegrationandresolutionofpreviouslyunresolvedconflictsleadstomaturationof personalityandcapacityforself-realization. ErikErikson AdaptedsomeofFreud’stheoriesofdevelopmenttoformulateatheoryofdevelopmentthatcoversthe entirespanofthelifecycle,frominfancyandchildhoodthrougholdageandsenescence.Epigenetic principle:developmentoccursinsequential,clearlydefinedstages,andthateachstagemustbesatisfactorily resolvedfordevelopmenttoproceedsmoothly.Avirtueisassociatedwitheachstage. “Ifeverythinggoesbacktochildhood,theneverythingissomebodyelse’sfaultandtaking responsibilityforoneselfisundermined." Trustvs.Mistrust(0-18months,correlateswithOral) Startingtotakeintheworldandlearntrustbasedonqualitymaternalrelationship.“Takingandholdingonto things.” • • • Defensemechanisms:projectionandintrojection Virtue:hope Pathology:schizophrenia(aggravatedcrisisduetofailingtodevelophope),depression(feeling empty,nogood),addictionsissues Autonomyvs.ShameandDoubt(18months-3years,correlateswithAnal) Developingasenseofjusticeandmaintainingabalancebetweengoodwill/cooperativenessandwillfulness. Self-certainvs.self-conscious.Regulatethewill.Willtobeoneselfvs.self-doubt.“Holdingonandlettinggo.” • • Virtue:will Pathology:persecutoryparanoia(stuckbetweentrust/autonomouswillandmistrust/doubt),OCPD (conflictwithholdon/letgo,leadingtodoubt>autonomyandaharshconscience),impulsivity. Initiativevs.Guilt(3-5yearsold,correlateswithphallic) GotoTableofContents 62 Exploration,conquest,curiosity,competitive,aggressive,preoccupationwithgenitals.Competewithsame sexparent,jealousy,andrivalry.Failureleadstoguilt.Roleanticipationvs.roleinhibition.Thesuperegois developedtoregulateinitiative.Oedipalimpulseisovercomeandthechildcanthencompeteintheoutside worldandlearntoleadanactiveadultlife.“Beingonthemake.” • • Virtue:purpose Pathology:overcompensationfortheconflictbetweeninitiativeandguilt.Thiscancauseconversion disorder,inhibition,paranoia,andpsychosomaticillnesses. Industryvs.Inferiority(5-13yearsold,correlateswithlatency) Learningnewskills,pride,workethic,anddiligence.Identifywithteachers.Learntofindroleinsociety.Task identificationvs.senseoffutility. • • Virtue:competence Pathology:failuretocompletepreviousstagesleadstomistrust/pessimism,imbalancebetween overcontrol/undercontrol,poordevelopmentofthesuperegoandguilt.Ifthereisnodevelopment oftrust/balanceofcontrol/creationofsuperego,thechildwillnotintegratewellintosociety.In addition,theywillnotlearnnewskillsandbecomecompetent.Thisallleadstocreativeinhibition andconformity. Identityvs.RoleConfusion(13-21yearsold,correlateswithgenital) Puberty,compareselfwithothersandcarehowothersperceivethem,cliques.Failureleadstoidentity diffusionandroleconfusion.Intoleranceofindividualdifferencesisthewaytheyouthwardsoffasenseof theirownidentityloss.Fallinginloveservestoclarifyone’ssenseofidentityprojectingyouridentityonto anotherperson. • • Virtue:fidelity,sustainingloyaltiestoothersdespitecontradictionofvaluesystems(accepting peopleforwhotheyare). Pathology:roleconfusionensueswhenthepersoncannotformulateasenseofidentity.Thisresults indelinquency,gender-relatedidentitydisorders,andborderlinepsychoticepisodes. Intimacyvs.Isolation(21-40yearsold) Looksatthevirtueoflovewithinabalancedidentity.Intimacyistiedtofidelity,tomakecompromiseandto self-sacrifice.Egolossoccurswhenbecomingclosertoothers;thereactionmaybetobecomedetachedand self-absorbed. • • Virtue:love Pathology:isolationanddetachedstates,includingschizoidpersonalitydisorder. Generativityvs.Stagnation(40-60yearsold) Establishingandguidingthenextgeneration,notjustspecificallyyourownoffspring.Personhasalready learnedtoformintimaterelationships,andthisstageservestobroadensocialscopetoincludegroups, organizationsandsociety.Importanceoffeelingneeded.Failureofgenerativityleadstostagnation, escapisms(alcoholandothersexualinfidelity),andmid-lifecrisis. • Virtue:care GotoTableofContents 63 • Pathology:alcoholism,divorce,witheringofleadershiproles/destructionofcompanies,premature invalidism. Integrityvs.Despair(60yearsolduntildeath) Acceptingresponsibilityforone’sownlife,holdingontointegrity,anda“detachedyetactiveconcernwith life.” • • Virtue:wisdom Pathology:failingtoattainintegrityleadstobecomingdeeplydisgustedwiththeexternalworldand contemptuousofpersonsandinstitutions.Disgustsmasksthefearofdeathandasenseofdespair that“timeisnowtooshortfortheattempttostartanotherlifeandtryoutalternateroutesto integrity.” “Healthychildrenwillnotfearlifeiftheireldershaveintegrityenoughnottofeardeath.”ErikErikson PathologicDevelopment InbothFreudandErikson’sdevelopmentaltheoriesoneconceptiscentral:failuretoresolveconflictand maturethrougheachstageleadstosignificantresidualpathology.Plainlystated,ifyoudon’tresolvethebad stuffineachstage,youwillgoontothenextstagewithunresolvedbaggageandcontinuethroughlifewith thatbaggage.Apersonwhodoesnotresolveoral/trust/mistruststageswillhavealifelongstrugglewith dependence,trust,hopelessnessandmentalpathology.Thissectionisnothigh-yieldforPRITE,butitisvery usefulforprovidinggoodcareforyourpatients,understandingtherootsofpathology,andmakingakickass bio-psycho-social-spiritualformulationfororalexaminationsinresidency. Birthto18months Freud:Oralstage(feeding,nutrition,needs,narcissism,objectrelations),trust/give/receive. Erikson:Trustvs.Mistrust(takingandholdingontothings),HOPE,projection Pathology:Impairedtrustleadstomistrust.Associatedconditions: • • • • Separationininfancyleadstodepression,hopelessness,dysthymia Projection(defensemechanismassociatedwiththisstage)leadstosocialmistrust,paranoia, delusionaldisorders,schizoidpersonalitydisorder,andparanoidschizophrenia. Socialmistrustleadstooraldependencyandsubstanceabuseduetothefeelingsofemptinessand hunger. Feelingstarvedandemptyalsoleadstothrillseekingbehaviors 18monthsto3years Freud:Analstage(controlofsphincters),balancebetweenovercontrol/undercontrol,individualization Erikson:Autonomyvs.ShameandDoubt(holdingonvs.lettinggo),independenceandthedevelopmentof will Pathology:developswhenshameanddoubtdominateautonomy GotoTableofContents 64 • • • • • • • Doubt>autonomyleadstoobsessivepersonality Shame>autonomyleadstofeelingdirty,delinquentbehaviorandparanoiaaboutcontrol Rigoroustoilettrainingleadstoexcessivecleanlinessandcompulsions Overcontrolleadstoobsessions/compulsions,willfulnessandanalretention Undercontrolcausesambivalence,messiness,andsadomasochism Mistrust(inearlierstage)PLUSshameanddoubtleadstopersecutorydelusions Refusaltobecontrolledcausesimpulsivity 3to5years Freud:phallicstage(issuesofoedipalconflict,genderidentity,penisenvy/castrationanxiety),identification withparentsleadingtothedevelopmentofsuperegotoregulatedrives. Erikson:Initiativevs.Guilt(expedition,competitionwithparent),conscience,purpose,childlearnsvalues andrecognizestheexternalworld,guiltsecondarytodrivesvs.initiative. Pathology:guiltrelatedtoimpulsesanddesiresleadstosymptomformation. • • • Guiltleadstoanxietydisorders,phobias,sexualinhibition(duetofearofpunishment) Punishmentforimpulsesleadstoconversiondisorderduetooedipalwishes,andsexual inhibition/impotence Fearofnotfulfillingone’spurposeleadstopsychosomaticdisease 5to13years Freud:Latencystage(superegodevelopedinphallicstagenowcontrols/regulatesdesiresandwishes),sexual identity,learning,masteryofskills Erikson:Industryvs.Inferiority(learnskills,begintoestablishidentity),competence,integrationintosociety Pathology:developmentofinferiorityduetoproblemscompletinggoals • Workinhibition,feelinginadequate,compensatorydriveformoney/power/prestigelaterin adulthoodattheexpenseofintimacy(laterstagessufferduetoincompletionofthisstage) 13yearsto20s(Adolescence) Freud:Genitalstage(maturation,reworkingconflict),separation/independence,emphasisisonreworking unresolvedissuesfromthepreviousstages. Erikson:Identityvs.RoleConfusion(puberty,egoidentity),roles,fidelitytooneself. Pathology:identityconfusion • • • Lossofidentitythroughoveridentificationwithothersandformulationofcliques Ifunabletoleavethehome,theremaybeprolongeddependence Roleconfusionleadstoconductdisorder,genderidentitydisorder,anddisruptivebehavior GotoTableofContents 65 20sto40s Freud’slastsagewasthegenitalstage,whichfocusedoncontinuingtoworkthroughpreviousconflict throughoutadulthood.TheremainingdiscussionondevelopmentofpsychopathologywillfocusonErikson. Erikson:Intimacyvs.Isolation(maintainingidentitywhileestablishingintimacy),sacrifice/compromise,love. Pathology:theinabilitytotakerisks,capacitytoloveandisolationleadstoschizoidpersonalitydisorder 40sto60s Erikson:Generativityvs.Stagnation(guidingthenextgeneration),triballeaders,caring,newlyachieved personalintimacywithsocialgroups,knowledgeandskills. Pathology:developswhenapersoncannotgenerateofskillsandshareknowledgewiththenextgeneration • • • Stagnationleadsto“escapism”intoalcohol/substances,infidelityandmid-lifecrisis Societysuffers,thepatientsuffers,leadingtodepressionanddisappointment Contemplationofpastfailures,currentproblems,andlosinghopeforthefuture. 60stoEndofLife Erikson:Integrityvs.Despair(acceptthelifecycleandtheproximityofdeath),healthydetachmentand wisdom Pathology:theknowledgethattimehasrunout,nogenerativity,andinabilitytoacceptlife • • Decliningphysicalhealthleadstoanxiety,psychosomaticillness,hypochondriaanddepression. Lackinggenerativityandacceptanceoftenleadstosuicide NeuropsychologicTesting ThisisahighlytestedareaonPRITE.Examplesarequestionsaskingyoutochoosethe“projectivetest”or willgiveyouthenameofthetestandaskyouitsfunction.Reliabilityreferstotheabilitytoreproducethe testresults.Validityshowsifatestcanaccuratelytestwhatitissupposedto. TypesofTests: • • Objective:typicallypencil-and-papertestswithspecificquestionsthatcanyieldnumericscorestobe analyzed.AnexampleistheMMPI. Projective:ambiguousstimulithatthepatientrespondstoandtheresponseistheninterpreted.An exampleistheRorschachtest.P:projectivetests“detectthepresenceofsubtlepsychoticthought processes.” IntelligenceTests TheIQtestwasintroducedin1905byAlfredBinet.Theintelligencequotient(IQ)istheratioofmental age/chronologicalage,whichismultipliedby100.AnIQof100wouldimplythatyourmentalage(thinking ability)matchesyourchronologicalage(howoldyouare).TheaverageIQis100. GotoTableofContents 66 WechslerAdultIntelligenceScales(WAIS)isthemostwidelyusedintelligencetest.Thelatestrevisionisthe WAIS-III.ItusesverbalIQ(previouslylearnedfactualinfo)andperformanceIQ(visuospatial/visuomotor skills).AnIQof90-100isnormal,50-70ismildMR,andbelow20isprofoundMR.P:theWAIShashigh reliabilityandtheWAIS-IIvocabularytestmoststronglycorrelateswithpre-morbidfunctioninginapatient withearlydementia. PersonalityAssessment ObjectiveTests • • • MMPI:uses10scalesinaconfigurationalapproach(seeanicelittlegraphbasedonresponsesin10 categories)to“identifymajorareasofpsychopathologicfunctioning”andmeasurestest-taking attitudesduringtheexamination(candetectmalingering,answeringquestionsfalsely,etc.It’ssuper cool). MillionClinicalMultiaxialInventory:testwithbriefadministrationtimeandcorrelateswellwith DSM-III.PerPRITE,itisthetest“themosthelpfulinconfirmingapersonalitydisorder.” StructuredClinicalDiagnosticAssessments:theseareteststhatgiveanumericalscoretoshow severityofaparticularillness.IncludesHamiltonRatingScaleforDepression,Yale-BrownObsessiveCompulsiveScale(YBOCS),andtheSCID.TheBeckDepressionInventory,P:“mostappropriatebrief screeninginstrumentthatapatientcanfilloutaloneataphysician’sofficetoscreenfordepression.” ProjectiveTests • • • • • RorschachTest:setof10inkblotsareastimulusforassociations,halfareblackandwhite,theyare showninaparticularorder,andreactiontimesarerecorded.Interpretationofresponsesrequiresan experiencedclinician.Itisthemostwidelyusedprojectivetest ThematicApperceptionTest(TAT):P:“atestinwhichapatientisshownpicturesofsituationsand askedtodescribewhatisgoingonineachpicture”(anexampleisawomanseatedonacouch lookingupatanolderman).P:Italsoservesto“infermotivationalaspectsofbehavior” SentenceCompletionTest(SCT):hassentencestemsthatthepatientcompletes(“SometimesI wish,”“Mygreatestfearis”) Word-AssociationTechnique:createdbyJung,patientispresentedwithawordandmustgivethe firstwordthatcomestomind.Thisissimilartofreeassociationandbringsunconscioustoconscious. Draw-a-PersonTest:firstusedtotestintelligenceinchildren,thepatientdrawsaperson(showsa representationoftheexpressionoftheself) CognitiveTesting ExecutiveFunctioning • WisconsinCardSortingTest(WCST):assesses“abstractreasoningandflexibilityinproblemsolving” perPRITE.Cardsaresortedintogroups(color,suit)thatthepatientisnotawareof,withthegoalof learningthegroupsthroughtrialanderror • TrailMakingTest:patientconnectslettersandnumberstogetherinsequentialordertotest concentrationandexecutivefunctioning VisuomotorCoordination GotoTableofContents 67 • BenderGestaltTest:testsvisuomotorcoordinationbycopyingdesignsonpaper.Hastwophases, firstwiththepatientallowedtocopythedesignwiththeoriginaldesigninfrontofthem,andthena memorytestingportionwheretheoriginaldesignisremovedandthepatientmustcopythedesign fromvisualmemory.Helpsscreenfororganicdysfunction.P:determinesneuropsychologic impairment. ReceptiveandExpressiveLanguage • • TokenTest:examinespatient’sabilitytocomprehendverbalinstructions,grammaticalcomplexity, andattentionspan BostonNamingTest:examinesverbalconfrontationandnaming.P:“discriminatescognitive difficultiesinAlzheimer’sdiseasefromthoseindepression.” TestBatteries • Halstead-ReitanBatteryofNeuropsychologicalTests:determinesneuropsychologicimpairment,is composedof10separatetestthatfunctiontodifferentiatebraindamagedpatientsfromthosewho areneurologicallyintact.Schizophrenicsfunctionsimilartochronicbraindamagedpatients. ChildandAdolescentPsychologicalAssessment Intelligence • WechslerIntelligenceScaleforChildren-III(WISC-III):WAIS-IIIcanbemodifiedforchildrenages5-15 intheWISC-III.P:isclosesttotheoriginalStanfordBinet.Forpreschoolers,thereistheWechsler PreschoolandPrimaryScaleofIntelligence-Revised(WPPSI-R). Achievement • Woodcock-JohnsonPsychoeducationalBattery-Revised(W-J):scoresreadingandmathematics, writtenlanguage,andothermeasuresofacademicachievement.P:thistesthelpstomore specificallyidentifylearningdisabilitywithchildrenthathaveotherwisenormalIQ. • WideRangeAchievementTest-3(WRAT-3):screenfordeficitsinreading,spellingandmath.P:thisis ausefultesttoscreenacademicperformance. AdaptiveBehavior • VinelandAdaptiveBehavioralScales:evaluatesadaptivebehavior,communicationskills,livingskills, socialization,andmotordomains.Canbemodifiedtotestthosewithvisualandhearing impairments. Statistics HerearesomebasicstatisticsthatwillbehelpfulforPRITEquestions.PleasealsorefertotheNinja’sGuide toPRITEQuestionsforallstatisticsquestionsusedsince2001. GotoTableofContents 68 • • • • • • • • • • • CohortStudies:followawell-definedpopulationoveralongperiodoftime(longitudinal),oftenwill seeatvariousintervals(2y,3y,15y,20y,etc). RetrospectiveStudies:looksatpastdata/events CrossSectionalStudies:looksforinformationaboutprevalenceofacertaindiseaseinapopulation ClinicalTrials:somepatientsaretreatedandcomparedwithacontrolpopulationwhoarenot receivingtreatment.Randomassignment. Cross-over:astudywheretheplacebogroupeventuallygetstreatmentandthegrouppreviously treatedgetsplacebo.Thiscandecreasestudybias. ANOVA:analysisofvariancethatcompares2ormoregroups ChiSquared:evaluatestherelativefrequency/proportionofeventsinawelldefinedpopulation Zscore:deviationofthescorefromthegroupmean.TheunitsofaZ-scorearestandarddeviations (ex:2standarddeviationsabovethemean) Ttest:compares2setsofobservations Type1error:rejectingthenullhypothesis(statesthereisNOdifferencebetweenthethingsbeing observed)falsely.Thisisstatingthatthenullhypothesisisfalse,andthatthereISadifference betweentwothingswhenthereisn’t. Type2error:keepingafalsenullhypothesis,whenthereISadifferencebetween2groups. GotoTableofContents 69 ANINJA’SGUIDETOSUBSTANCEUSEDISORDERS Overview Substanceusedisordersareprevalentamongpatientsinallclinicalsettings.Regardlessofmedicalspecialty, aclinicianshouldbeabletorecognizethesignsandsymptomsofsubstanceusedisorders,whilekeepingin mindpossibleunderlyingemergentconditions(withdrawal,delirium,seizures,etc.).Thereishighcomorbiditybetweensubstanceusedisordersandotherpsychiatricdisordersandmedicalconditions. Empathicandnon-judgmentalcareforpatientswithsubstanceusedisordersleadstoasignificantdecrease inmorbidityandmortality.Substancerelateddisordersarebrokendownintotwocategories:Substance UseDisordersandSubstance-InducedDisorders. EtiologyofSubstanceUse Multifactorial,including: Psychodynamic(substanceusetotreatdepression/escapereality) Behavioral(positivereinforcement) Genetic(twinstudies,adoptionstudies) Neurochemical(abnormalreceptor/neurotransmittersleadingtosubstancemodulationof neurochemistry;rewardpathwaysinvolvingdopamine(DA)inthenucleusaccumbensandventral tegmentalarea) Comorbidity • • • • • • • AntisocialPersonalitydisorder Depression/Mooddisorder,Anxietydisorders,Schizophrenia Suicide:peoplewhoabusesubstancesare25xmorelikelytodiebysuicidethanthegeneral population.15%ofalcoholicshavebeenreportedtocommitsuicide ScreeningforAddiction Wheninterviewingapatient,askabouteachchemicalfromthestandpointoftheleastlikelydrugtocause denialtothemostlikelydrugtocausedenial.Example:prescriptionmeds(BZDs),thentobacco,thenEtOH, thenillicitdrugs. CAGEQuestions(EtOHScreening) 1. 2. 3. 4. HaveyoueverfelttheneedtoCutdownonyouruseofEtOH? HavepeopleAnnoyedyoubycriticizingyouruseofEtOH? HaveyoueverfeltbadorGuiltyaboutyouruseofEtOH? Haveyoueverhadadrinkinthemorningtosteadyyournervesorgetridofahangover(Eyeopener)? GotoTableofContents 70 Each“yes”answerisscored1point.One“yes”raisessuspicionofanEtOHuseproblem;morethanone “yes”isastrongindicationthataproblemexists. AbbreviateCAGE: 1. Haveyoueverusedasubstancemorethanyouintended? 2. Haveyoueverfelttheneedtocutdown? Yestobothis80%sensitiveandspecific. Alwaysobtainahistoryofconsequencesofsubstanceuse.Theseincludemedical,legal,occupational, family/relationships,andemotionalconsequencesofuse.Thisallowsyoutofindobjectivemarkersof problematicusedespitethepatient’sdenial.*IfapatienthasahistoryofDUI,they’reprobablyNOTjusta socialdrinker. MotivationalInterviewing Thisisaformofinterviewingtohelpmaximizethepatient’sintrinsicdesiretochange.Example:“Currently youmotivationtoquitsmokingisata4/10.Whatwouldittaketogetittoa5/10?Whatarethe advantages/disadvantagesofsmokingforyou?”Thestagesofchangeinclude: • • • • • Precontemplation:patientdoesnotintendtochangebehaviorintheforeseeablefuture.Apatient atthisstagemaybeunawareoronlyvaguelyawareofhis/herproblem Contemplation:patientisawareoftheproblemandisseriouslyconsideringchangingbehaviorbut doesnotmakeacommitmenttotakeaction.Patientsatthisstageoftenfeelambivalentaboutthe senseoflosstheymayfeeldespitetheperceivedgainofovercomingtheirproblem Planning/Preparation:patientintendstotakeactionwithinthenext30daysandhastakensome stepstowardtreatment.Thisstagecombinesintentionandbehavioralcriteria(suchasmakingsmall modificationstobehaviorthatsignaladecisiontochange) Action:patientchangesbehaviorandcommitsaconsiderableamountoftimeandenergyto overcomingtheproblem.Thisstagelastsfromthetimeoftheinitialactionto6months Maintenance:thepatientcontinuestomeetthegoalssetupintheplanning/actionstageanduses copingskillstoavoidrelapse SubstanceUseDisorders Anessentialfeatureisaclusterofcognitive,behavioral,andphysiologicalsymptomsthatoccurduetoa substancedespiteconsequences.Ingeneral,thediagnosisofsubstanceusedisorderrequiresthepresence ofatleast2criteriaovera12monthperiodoftime.Theseverityofthedisorderisdeterminedbythe numberofdiagnosticcriteriapresent.Forallsubstances,theDSM5criteriaforsubstanceusedisordercanbe groupedintoimpairedcontrol,socialimpairment,riskyuse,andpharmacologicalcriteria.Ingeneral,the substanceusecriteriaareorganizedassuch: GotoTableofContents 71 • • • • ImpairedControl 1. Theindividualtakesthesubstanceinlargeramountsoroveralongerperiodoftime thanintended 2. Theindividualexpressesapersistentdesiretocutdownorregulatethesubstance useormayhavemultipleunsuccessfulattemptstodecreaseordiscontinueuse 3. Individualspendsagreatdealoftimeobtaining,using,orrecoveringfromtheeffects ofasubstance 4. Cravingismanifestedbyanintensedesireorurgeforthedrugatanytimebutis morelikelyinanenvironmentwherethedrugwaspreviouslyobtainedorused (classicalconditioning) SocialImpairment 1. Recurrentsubstanceuseleadstofailuretofulfillmajorroleobligationsatwork, school,orhome 2. Continueduseofthesubstancedespitesocialorinterpersonalproblemscausedby useofthesubstance 3. Importantsocial,occupational,orrecreationalactivitiesaregivenuporreduceddue tosubstanceuse RiskyUse 1. Recurrentsubstanceuseinsituationsthatarephysicallyhazardous 2. Continuedusedespiteknowledgeofhavingapersistentorrecurrentphysicalor psychologicalproblemcausedbyorexacerbatedbythesubstance PharmacologicalCriteria 1. Tolerance:requiresamarkedlyincreaseddoseofthesubstancetogetthedesired effectorthereisamarkedlyreducedeffectwhentheusualdoseisconsumed 2. Withdrawal:asyndromethatoccurswhenbloodortissueconcentrationsofa substancedeclineinanindividualwhohadmaintainedprolongedheavyuseofthe substance.Theindividualmayconsumethesubstancetoremovewithdrawal symptoms 3. Note:appropriatemedicaltreatmentwithaprescribedmedication(opiates, stimulants,etc)oftenleadstorequiringmoremedicationtogeteffectorwithdrawal upondiscontinuation.Thisisnotcountedindiagnosingasubstanceusedisorder. Thereisnormal,expectedpharmacologicaltoleranceandwithdrawalwithmany commonlyprescribedmedications,leadingtoerroneousdiagnosisof“addiction” whenthesearetheonlysymptomspresent.Iftoleranceandwithdrawalaretheonly symptomspresent,adiagnosisofsubstanceusedisorderisnotmade Severityofthesubstanceuseisdeterminedbythenumberofsymptomspresent.Forindividualswith2-3of theabovesymptoms,itisconsideredmildsubstanceuse.Moderatesubstanceusediagnosedinthepresence of4-5symptoms,andseveresubstanceuseisdiagnosedinthepresenceof6ormoreoftheabove symptoms. Thediagnosisofasubstanceusedisorderiscodedbythespecificsubstance.Thus,youwouldnotdiagnosea patientwith“BenzodiazepineUseDisorder,Moderate.”Instead,thediagnosiswouldbe“Moderate AlprazolamUseDisorder.”Thewordaddictionisnotused,withthefocusonthemoreneutralterm substanceusedisordertoeliminatenegativeconnotation. GotoTableofContents 72 Substance-InducedDisorders Thiscategoryincludesintoxication,withdrawal,andothersubstanceormedication-inducedmentaldisorders (suchasasubstancecausingpsychosisordepression). SubstanceIntoxication Criteriaarespecifictosubstance,aseachsubstancehasitsownintoxicationprofile.Themostcommon behavioralchangesincludedisturbanceinperception,wakefulness,thinking,attention,judgment, psychomotorbehavior,andinterpersonalbehavior.Short-termintoxicationcanpresentverydifferentlythan long-term,chronicintoxication.Forexample,acuteuseofcocaineleadstooutgoing,gregariousbehavior. Dailyusecanactuallycauseirritabilityandsocialwithdrawal.Thepresenceofphysiologicalsymptomsalone maynotmeetcriteriaforintoxication.Forexample,ifthepersonhasmethamphetamine-induced tachycardia,butthatistheonlysymptompresent,itwouldnotbeconsideredintoxication.Substance intoxicationcanbepresentinindividualswhodonototherwisemeetcriteriaforasubstanceusedisorder (i.e.,persongetsdrunkoncebutdoesnototherwisehavecriteriaforAlcoholUseDisorder).Thebasiccriteria forintoxicationareasfollows: A. Areversible,substance-specificsyndromeduetotherecentingestionofasubstance B. Duringorshortlyafterusingasubstance,therearephysiologicaleffectsofthesubstanceon theCNS,causingproblematicbehaviororpsychologicalchanges C. Thesymptomsarenotduetoanothermedicalconditionormentaldisorder Routesofadministrationthatproducemorerapidandefficientabsorptionintotheblood(smoking,snorting, injecting)tendtohavemoreintenseintoxicationandahigherlikelihoodofanescalatingpatternof substanceuseleadingtowithdrawal.Rapidly-actingsubstancesaremorelikelythanslower-acting substancestoproduceimmediateintoxication. Drugsthatarehighpotency,haverapidonsetofaction,arelipohilic,andhaveashorthalf-lifehavethe greatestliabilityforabuse. SubstanceWithdrawal Likeintoxication,thepresenceofphysiologicwithdrawalalonedoesnotmeanthatasubstanceusedisorder mustbediagnosed.However,unlikeintoxication,thepresenceofwithdrawalisusuallyassociatedwitha substanceusedisorder.Mostindividualswithwithdrawalhaveanurgetore-administerthesubstanceto reducethesymptoms.Thebasiccriteriaforintoxicationareasfollows: A. Thedevelopmentofasubstance-specificbehavioralchange,withphysiologicalandcognitive components,duetocessationorreductionofsubstanceusethatwaspreviouslyheavyand prolonged B. Syndromecausessignificantdistressorimpairmentinsocialoroccupationalfunctioning C. Thesymptomsarenotduetoanothermedicalconditionormentaldisorder GotoTableofContents 73 Short-actingsubstancestendtohavehigherpotentialfordevelopmentofwithdrawalthandolong-acting substances.However,longer-actingsubstancestendtohavealongerdurationofwithdrawal(daysor weeks).Thelongerthedurationofaction,thelongerthetimebetweendrugcessationandonsetof withdrawalsymptomsandtheoveralldurationofwithdrawalislonger.Example:discontinuingclonazepam (longhalf-life,longdurationofaction)maynothaveinitiationofwithdrawalsymptomsfor1-2daysafter stoppinguse,andthesymptomsofwithdrawalmayremainpresentforaweekorlonger. Intoxicationandwithdrawaldiagnosesarecodedbythenameofthespecificsubstance.Thus,aperson intoxicatedwithmethamphetaminewouldnotbediagnosed“StimulantIntoxication,”butwouldbe diagnosed“MethamphetamineIntoxication.”Apersonwithdrawingfromdiazepamwouldnotbediagnosed “BenzodiazepineWithdrawal,”butwouldbediagnosed“DiazepamWithdrawal.”TheICD10codingsystemin 2014willrequirewithdrawaldiagnosestobeassociatedwithaSubstanceUseDisorder,showingthe associationbetweenwithdrawalandlikelysubstanceuseproblems. ReviewofIntoxicationandWithdrawal Intoxication A) B) C) D) Recentingestionofthesubstance. Maladaptivebehavioral/psychologicalchangesafteringestion. Listofdrug-specificintoxicationsymptoms(seechartbelow). SymptomsareNOTduetoamedicalconditionormentaldisorder. Withdrawal A) B) C) D) Cessation/reductionofthesubstanceinaheavyuser. Listofdrug-specificwithdrawalsymptoms(seechartbelow). Causessignificantdistressinsocial/work/importantareasoffunctioning. SymptomsareNOTduetoamedicalconditionormentaldisorder OverviewofSubstanceIntoxication/WithdrawalSymptoms Drug Alcohol Amphetamine, Intoxication 1.Clinicalsignificantdysfunctionalbehavior: • Disinhibition • Agitation/Aggression • MoodLability • ImpairedJudgment 2.Oneormoreofthefollowing: • SlurredSpeech • Incoordination • UnsteadyGait • Nystagmus • Memory/AttentionImpairment • ↓edConsciousness(stupor/coma) Severe:Hypotension,Hypothermia,DepressedGagReflex 1.Clinicallysignificantdysfunctionalbehaviororperceptualabnormality: Withdrawal 1.Twoormoreofthefollowing: • AutonomicHyperactivity (Sweating,Tachycardia,HTN) • TremorofTongue,Eyelids,or OutstretchedHands(asterixis) • Insomnia • Nausea/Vomiting • TransientVisual,Tactile,or AuditoryHallucinations,or Illusions • PsychomotorAgitation • Anxiety • Generalizedtonic-clonic seizures 2.CANBELETHAL 1.Dysphoricmood+twoofthefollowing: GotoTableofContents 74 Cocaine,andother Stimulants Caffeine • Euphoria&Sensationof↑edEnergy • Hypervigilance • Changedsociability • Abusive/Aggressive • MoodLability • RepetitiveStereotypedBehaviors • ImpairedJudgment 2.Twoormoreofthefollowing: • Tachycardia • PupillaryDilatation • HTN • Sweating/Chills • Nausea/Vomiting • WeightLoss(2/2↓edAppetite) • PsychomotorAgitation • MuscularWeakness • ChestPain,Arrhythmias • RespiratoryDepression • Seizures,Dystonias,Dyskinesias • Confusion,Coma Fiveormoreofthefollowing: • Restlessness/Anxiety • Excitement • Insomnia • FlushedFace • Diuresis • GIDisturbance • MuscleTwitching • RamblingFlowofThoughtandSpeech • TachycardiaorCardiacArrhythmias(PVCs) • PeriodsofInexhaustibility • PsychomotorAgitation Thereisnorecognizednicotineintoxicationstate. Tobacco • • • • • LethargyandFatigue Vivid,DisturbingDreams Insomnia/Hypersomnia IncreasedAppetite Psychomotor Retardation/Agitation Threein24hours: • Headache • MarkedFatigueandDrowsiness • MarkedAnxietyorDepression • Nausea/Vomitingormuscle aches Fourormorewithin24hoursofstopping: • Dysphoric/DepressedMood • Insomnia • Irritability/Frustration/Anger • Anxiety • DifficultyConcentrating • Restlessness • ↑edAppetite/WeightGain Drug Cannabinoids Intoxication 1.Clinicallysignificantdysfunctionalbehaviororperceptualabnormality: • Euphoria&Disinhibition • AnxietyorAgitation • TemporalSlowing(i.e.FeelslikeTimePassesSlowly) • ImpairedJudgment • Socialwithdrawal 2.Twoormoreofthefollowing: • ConjunctivalInjection • IncreasedAppetite(“Munchies”) • DryMouth • Tachycardia Withdrawal Afterdailyuseforafewmonths,hasthree ormorewithinthefirstweekafter stopping: • Anger/Irritability • Anxiety • Insomnia • DecreasedAppetite • Restlessness • Depressedmood • One:tremor,sweating,fever, chills,headache,abdominalpain GotoTableofContents 75 Hallucinogens Inhalants& VolatileSolvents 1.Clinicallysignificantdysfunctionalbehaviororperceptualabnormality: • Anxiety • Ideasofreference • Fearofllosingone’smind • Paranoid • Impairedjudgment Perceptualchangesdespitewakefulnessandalertness 2.Twoormoreofthefollowing: • PupilsDilated • Tachycardia • Sweating/Chills • Palpitations • BlurredVision • Tremors • Incoordination Thereisnorecognizedhallucinogen withdrawalstate. 1.Clinicallysignificantdysfunctionalbehavior: • Apathy&Lethargy • Argumentativeness/Abusiveness/Aggression • ImpairedJudgment,Attention,andMemory 2.Twoormoreofthefollowing: • Dizziness • Nystagmus • Incoordination • SlurredSpeech • UnsteadyGait • Lethargy • DepressedReflexes • PsychomotorRetardation • Tremor • GeneralizedMuscleWeakness • Diplopia • StupororComa • Euphoria Severe:Hypotension,Hypothermia,DepressedGagReflex Thereisnorecognizedsolvent/inhalant withdrawalstate. Intoxication 1.Clinicallysignificantdysfunctionalbehavior: • InitialEuphoriaFollowedbyApathy&Sedation • PsychomotorRetardationorAgitation • ImpairedJudgment 2.PupillaryConstrictionANDoneofthefollowing: • DrowsinessorComa • SlurredSpeech • ImpairmentinAttentionorMemory Severe:RespiratoryDepression,Hypoxia,Hypotension,Hypothermia.In SEVEREOD,AnoxiaLeadstoDILATEDPupils. Withdrawal Occursaftercessationinheavyopiateuse oradministrationofopioidantagonist Threeormoreofthefollowing: • DysphoricMood • Nausea/Vomiting • MuscleAches • LacrimationorRhinorrhea(“The Sniffles”) • PupillaryDilation • Piloerection(“ColdTurkey”) • Sweating • Diarrhea • Yawning • Fever • Insomnia MayPresentWithTachycardiaandHTN. ThereisnorecognizedPCPwithdrawal state. Drug Opiates Phencyclidine (PCP) 1.Clinicallysignificantdysfunctionalbehavior: • Belligerence/Assaultive • Impulsivity/Unpredictability • PsychomotorAgitation • ImpairedJudgment 2.TwoorMoreoftheFollowing: • Vertical/HorizontalNystagmus GotoTableofContents 76 Sedatives, Hypnoticsand Anxiolytics (BZDs, Barbuturates) • HTN/Tachycardia • NumbnessorDiminishedResponsivenesstoPain • Ataxia • Dysarthria • MuscleRigidity • Hyperacusis • SeizuresorComa 1.Clinicallysignificantdysfunctionalbehavior: • Abusiveness/Aggression • MoodLability • Impairedjudgment 2.Oneormoreofthefollowing: • SlurredSpeech • Incoordination • UnsteadyGait • Nystagmus • ImpairmentinAttentionorMemory • ↓edLevelofConsciousness(Stupor/Coma) Servere:Hypotension,Hypothermia,DecreasedGagReflex Twoormoreofthefollowing: • AutonomicHyperactivity (Sweating,↑edHR,HTN) • TremorofTongue,Eyelids,or OutstretchedHands(Asterixis) • Insomnia • Nausea/Vomiting • TransientVisual,Tactile,or AuditoryHallucinations/ Illusions • PsychomotorAgitation • Anxiety • GrandMalSeizures CanBeLETHAL Substance/Medication-InducedMentalDisorders Toreview,Substance-InducedDisordersincludeintoxication,withdrawal,andthedevelopmentofspecific mentaldisordersduetothepresenceofthesubstanceormedication.TheSubstance-InducedMental Disordersarepotentiallysevere,usuallytemporary(butcanpersist)CNSsyndromesthatdevelopduetothe influenceofsubstances,medications,ortoxins.AsopposedtotheSubstanceUseDisorders,whichare attributedto10classesofdrugs/medications,theSubstance/Medication-InducedDisorderscanbedueto manydifferentagents,includingmedicinesandtoxins.Anexampleofthisispsychosisduetotheuseof corticosteroidstotreatCrohn’sDisease.Whenduetodruguse,Substance-inducedmentaldisordersusually developwithinthecontextofintoxicationorwithdrawal.Theconditionisusuallytemporaryandlikelyto disappearwithinonemonthaftercessationofacutedrugintoxication/withdrawalorwithinonemonthafter stoppingtheoffendingmedication.Thebasiccriteriaareasfollows: A. Thedisorderrepresentsaclinicallysignificantsymptomaticpresentationofarelevantmental disorder(depression,psychosis) B. Thereisevidencefromhistory,physicalexam,orlabfindingsofboth: 1. Disorderdevelopedwithin1monthofsubstanceintoxicationorwithdrawal,or takingamedication;and 2. Theinvolvedsubstance/medicationiscapableofproducingthementaldisorder C. Thedisorderisnotbetterexplainedbyanindependentmentaldisorder.Evidenceofan independentmentaldisordercouldinclude: 1. Mentaldisorderprecededtheonsetofintoxication/withdrawalorexposuretothe medication;or 2. Thefullmentaldisorderpersistedforatleast1monthafterthecessationofthe acuteintoxication/withdrawalfromthesubstanceormedication.Thisdoesnotapply tohallucinogensorsubstance-inducedneurocognitivedisorders(likeWernicke’s Encephalopathy)thatpersistbeyondcessationofacuteintoxication/withdrawal D. Disorderisnotexclusivelypartofdelirium GotoTableofContents 77 E. Disordercausesclinicallysignificantdistressorimpairmentinsocial,occupational,orother importantareasoffunctioning Sedatingmedicationsaremorelikelytoproduceprominentandclinicallysignificantdepressivedisorders duringintoxication,followedbyanxietysymptomsinwithdrawal.Intoxicationwithstimulantstendstobe associatedwithpsychoticdisordersandanxietydisorders,withsubstance-induceddepressivedisordersin withdrawal.Ifdeliriumispresent,otherpsychiatricsyndromesshouldnotbediagnosed(likesubstanceinducedpsychosis). Alcohol-RelatedDisorders Epidemiology • • • • • • • LifetimeEtOHUseDisorderis10%forwomenand20%formen Commoncausesofdeathincludesuicide,cancer,heartdisease,andhepaticdisease Drunkendriversareinvolvedin55%ofallautofatalitiesand75%offatalitiesinlate-evening accidents EtOHuseisassociatedwith50%ofallhomicidesand75%ofallsuicides. Reduceslifeexpectancyby10years Alcohol-relateddisordersoccuracrossallsocioeconomicclasses o WhiteshavehighestrateofEtOHuse o Men>Women2:1 o Associatedwithhigherlevelofeducation(contrastwithillicitdruguse) 60-80%ofEtOHUseDisorderinpatientswillbemissedbytheirPMD Comorbidity • • • • AntisocialPersonalityDisorder MoodDisorders AnxietyDisorders Suicide Etiology • • • • ChildhoodHistory:ADHD,ConductDisorder,andotherpersonalitydisorderspredisposetoEtOHrelateddisorders Sociocultural:dormitories/militarybasesleadtoexcessivedrinking.Somecultures(Asians, conservativereligions)aremorerestrained Behavioral/Learning:parentaldrinkinghabitsmaypredispose.Positivereinforcement(euphoria) associatedwithEtOHencouragesuse Genetics:closefamilymembershavefourfoldincreasedrisk.Identicaltwinshigherriskthanfraternal twins.Adopted-awaychildrenofalcoholicparentsstillhavefourfoldhigherrisk GotoTableofContents 78 EffectsofAlcohol • • • • • • • Absorption:10%instomach,90%insmallintestine Metabolism:90%oxidizedinliver.Bodymetabolizes~1drinkanhour(1drink=12oz.beer=5oz. wine=1.5oz.80-proofliquor) Neurochemistry:enhancesGABA,ACh,5-HT;inhibitsGlutamate Gender:womentypicallyaremoreaffectedbyEtOHthanmen.Theaveragewomantypicallyhasa smallerbodysize,lessbloodvolume,andmorebodyfat.Asbodyfathaslesswater,thereisless waterforEtOHtodilutein;thereforeahigherbloodalcoholcontent(BAC)isachieved.Womenalso havedecreasedesophagealandgastricoxidationofEtOHandlessEtOHdehydrogenase.Thus,they metabolizeEtOHmoreslowly Behavior:aBAC0.4-0.5willleadtosevereneurologicaldepression,resultingincoma.HigherBACs leadtorespiratorydepressionanddeath Sleep:decreasesREM/Stage4sleepandleadstosleepfragmentation Physical:liver,GI,heart,lipids,cancer,possibledeathifcombinedwithsedatives AlcoholEquivalents • • • • Onedrink=a12oz.beer,4oz.wine,or1¼oz.of80-proofliquor Astandardbeeris4-9%EtOH,whichis8-18proof(%x2=proof).Liquortypicallyhas40%EtOH(i.e. 80proof) 1drinkis0.02-0.025%BAC;thelegallimitis0.08%BAC.1drinkismetabolizedeachhour,thusBAC dropsby0.02%eachhour At0.05%BACthereisexhilarationanddecreasedinhibition/judgment;0.10%hasslurredspeechand staggeringgait;0.3%hasconfusionanddecreasedreflexes;0.4%hasstupor/LOC;0.5%hascoma; 0.6%leadstorespiratoryparalysisanddeath DiagnosticMarkers GGT>35isasensitivemarkerforheavydrinking,andoftenisthefirstabnormalmarker.Atleast70% ofindividualswithanelevatedGGTarepersistentheavydrinkers(8ormoredrinksdaily) • ElevatedMCVistheresultoftoxiceffectofalcoholonerythropoiesis.However,itisapoormethod ofmonitoringduetothelonghalf-lifeofredbloodcells • ElevatedLFTsaretheresultoftoxicinjurytotheliverasaconsequenceofheavydrinking AlcoholUseDisorder • ThediagnosisofAlcoholUseDisorderismadebyapplyingthecriteriapresentedonpage5totheuseof alcohol.Thesymptomsmustbepresentfor12months,withaminimumof2criteriapresenttodiagnose MildAlcoholUseDisorder.Specifiersforremissionexist,withearlyremissionbeingatleast3monthswithno symptomsbutnotyet12monthsinsobriety.Sustainedremissioniswhennocriteriahavebeenmetin12 months.Cravingsmaybepresentduringthistimeaslongastheyaretheonlysymptompresent.Thusa personmaybeconsideredinremissionwiththepresenceofcravingsstillthere(asubstanceusedisorder criteria).Anotherspecifierisifthepatientisinacontrolledenvironment(soberliving,jail,lockedunit). GotoTableofContents 79 AlcoholIntoxication Afteringestionofalcohol,thereisclinicallysignificantdysfunctionalbehavior: • Disinhibition • Agitation/Aggression • MoodLability • ImpairedJudgment Oneormoreofthefollowing: • SlurredSpeech • Incoordination • UnsteadyGait • Nystagmus • Memory/AttentionImpairment • DiminishedConsciousness(stupor/coma) Severe:Hypotension,Hypothermia,DepressedGagReflex AlcoholWithdrawal Aftercessationofalcoholusethathasbeenheavyandprolonged,therearetwoormoreofthefollowing: • • • • • • • • AutonomicHyperactivity(Sweating,Tachycardia,HTN) TremorofTongue,Eyelids,orOutstretchedHands(asterixis) Insomnia Nausea/Vomiting TransientVisual,Tactile,orAuditoryHallucinations,orIllusions PsychomotorAgitation Anxiety Generalizedtonic-clonicseizures Spectrumofwithdrawal:6-8hours=tremor/autonomicsymptoms,8-12hours=hallucinations,12-24hours =seizures,72hours–1week=DeliriumTremens(DTs). Complications • • • WithdrawalSeizures:stereotyped,tonic-clonicseizures. o Treatment:BZDs–includingChlordiazepoxide(Librium)POtaperoranotherlong-actingBZD (e.g.Diazepam)orIVLorazepam.Inpatientswithliverdamage,aBZDwithoutactive metabolites(lorazepam)ispreferred. DeliriumTremens:deliriumoccurringwithin1weekofabstinence. o Symptoms:rapid-onset,cloudingconsciousness,insomnia,disturbanceofcognitionPLUS autonomichyperactivity,hallucinations(usuallytactile),andpsychomotoractivity fluctuation.Canbefatal. o Treatment:preventwithBZDs(ChlordiazepoxidePOq4hrsorLorazepamIV).Avoid antipsychotics(loweredseizurethreshold)ifpossible LethalWithdrawal:BothEtOHandBZD/Barbituratewithdrawalcanleadtoseizuresanddeath. Gettingagoodhistoryisthemostimportantfirststepinpreventingthesecomplications.Findout GotoTableofContents 80 • • • • theaveragedailyquantityconsumedandthetimeoftheirlastdrink,asthiswillhelpdeterminethe riskofseizures/complicatedwithdrawal o Treatment:usetheseizurepreventionmeasuresaboveaswellasobtainoptimalfluidand electrolytebalance.Patientsmayrequiremedicalinpatient/ICUadmissionifsevere Wernicke’sEncephalopathy:secondarytothiaminedeficiency(acofactorforenzymesinvolvedin axonalconduction).Lesionsareseeninthemammillarybodies.Symptoms:ataxia,dizziness, confusion,nystagmus/gazepalsy o Treatment:thiamine(PO/IV),alwaysgivenbeforeadministeringglucose Korsakoff’sSyndrome:chronicamnesticsyndromefollowinguntreatedWernicke’sEncephalopathy. Symptoms:anterogradememoryloss(difficultyformingnewmemories)withconfabulation(madeupmemoriestofillthegaps).Fewpatientsrecover ElevatedBiomarkers:macrocytosis(2/2folatedeficiency),↑edGGT,↑edASTandALT(AST:ALTratio of2:1),↑edcarbohydratedeficienttransferrin(CDT) FetalAlcoholSyndrome(FAS):inhibitionofintrauterinegrowth.Symptoms:microcephaly, craniofacialmalformations(thinupperlipwithnophiltrum),limbandheartdefects.Shortadult statureandadultmaladaptivebehaviorsarealsoassociatedwithFAS Prognosis GoodPrognosticIndicators: • • • Absenceofpre-existingAntisocialPersonalityDisorder Lifestability:havingajob,healthyfamilyrelationships,andnolegalproblems Fullcourserehabilitationprogram(2-4weeksminimum) Treatment Thelong-termgoalsoftreatmentarethesameforallsubstanceusedisorders:abstinence,relapse prevention,andrehabilitation. • • InpatientDetoxification:preventseizures(useBZDs)andlessenwithdrawalsymptoms(ß-blockers andclonidinetreatautonomichyperactivity;antipsychoticstreatdeliriumagitation,andaggression) Post-DetoxificationOutpatientTreatment:intensiveoutpatientcarewithfrequentvisitsordayhospitaltreatmentinearlyphases.Multiplestudiesshowthatgoodaftercarefollowinginpatient treatmentisassociatedwiththelowestratesofrelapse MedicationManagement MosttreatmentfocusesondecreasingcravingforEtOHthroughmodulationofneurotransmitters(DA, Glutamate)andreceptors(NMDA,Opioid).TreatmentmayalsodecreasereinforcementofEtOHthrough inhibitionofrewardpathways. • Naltrexone:competitiveantagonistatthemuandkappaopioidreceptors.POorDepotformulation. Decreasescravingsandblocksdopaminerewardpathways,therebydecreasingreinforcingeffectsof use(i.e.useislessenjoyable) GotoTableofContents 81 SideEffects:nausea(10%),headache(7%),dizziness(4%),insomnia(3%),anxiety(2%),and sleepiness(2%).Serioussideeffectsincludehepatotoxicity(rare).CheckLFTsbefore initiating Acamprosate:blocksglutamateNMDAreceptorsandactivatesGABA-Areceptors.EtOHisinhibitory andchronicuseleadstoupregulationofNMDAreceptors.WithdrawalofEtOHleadstoglutamate excitation(i.e.seizures,tachycardia,etc).ByblockingNMDAreceptors,acamprosatedecreasesthe sign/symptomsofwithdrawalaswellasdecreasingglutamate-drivencravings o SideEffects:mainlyGIinnature Disulfiram:inhibitsacetaldehydedehydrogenaseleadingtoincreasedacetaldehydeafter consumptionofEtOH.Theincreasedacetaldehydeleadstosymptomsofpalpitations,flushing, nausea,vomiting,andheadache.Itisanaversivetreatment o SideEffects:seeabove.Raresymptomsofcardiotoxicity,MI,pulmonarydysfunction,and hepatotoxicity.Contraindicatedinpatientsonmetronidazole(whichhasdisulfiramlikeeffects)orpatientswithcardiovascular,pulmonary,orhepaticdiseaseorwithchronicrenal failure.CheckLFTsbeforeinitiating Anticonvulsants:inhibitionofmesocorticolimbicDAreleaseleadingtodecreasedcraving. Topiramatehasbeststudiestodate o SideEffectsoftopiramate:dizziness,somnolence,cognitiveslowing,andweightloss.Rare sideeffectsincludemetabolicacidosisandrenalstones.Becarefulwithdrug-drug interactions SSRIs:mayreducecomorbidpsychiatricsymptoms(anxiety/depression)thatinfluencedrinking behavior o • • • • PsychosocialTreatments • • • • • • MotivationalInterviewingtechniquesareuseful(seeabovesectioninMotivationInterviewing) CBT:aimedatimprovingself-controlthroughgoalsetting,rewards,andlearningalternatecoping strategies.Usesproblemsolvinginsteadofusingavoidanceasacopingstrategy BehavioralTherapies:combinationdisulfiramandbehavioraladherenceprogram(EtOH-freesocial environments,communityreinforcement,etc) Self-HelpGroupsand12-StepTreatment:AAisa“spiritualbutnonreligiousprogramrequiringbelief insomethingbeyondoneself”thatprovidestoolstomaintainsobriety.Toolsincludethe12steps, groupidentification,andmutualhelp.MultiplestudiesshowgoodsupportforAAasviabletreatment MaritalandFamilyTherapy Al-Anon(friendsandfamilyofalcoholics),Alateen(teensofalcoholics),andAdultChildrenof Alcoholicsallhelpfamilymembersbyteachingtoavoidenablingbehaviorsandimproveself-care Thebesttreatmenthasbeenshowntobeacombinationoftherapy/supportgroupsandmedication management. GotoTableofContents 82 Caffeine-RelatedDisorders Epidemiology • • • • Estimated85%ofadultsinUSAconsumecaffeineregularly Isthemostwidelyusedbehaviorallyactivedrugintheworld Averageconsumptionis200mg/day,with20-30%consuming>500mg/day(1cup=100-150mg) About2/3rdsofthosewhoconsumelargeamountsofcaffeinedailyalsousesedativeandhypnotic drugsforsleepandanxiety Neuropharmacology Caffeineisamethylxanthinethathastimetopeakconcentrationin30-60minutes Readilycrossestheblood-brainbarrier Half-lifeis4-6hours AntagonizesadenosinereceptorsleadingtoanincreaseincAMP Athigherconcentrations,caffeinemayactivatedopaminergicandnoradrenergicneurons DifferentialDiagnosisofCaffeineIntoxication • • • • • GeneralizedAnxietyDisorder,PainDisorderwith/withoutAgoraphobia,BipolarTypeII,ADHD, Cocaine/Amphetamineabuse,Hyperthyroidism,Pheochromocytoma,andSleepDisorders. ThereisnoCaffeineUseDisorder,onlyintoxicationandwithdrawalinadditiontoCaffeine-InducedDisorders. CaffeineIntoxication Recentconsumptionofcaffeine(usually>250mg)andfiveormoreofthefollowing: • • • • • • • • • • • Restlessness/Anxiety Excitement Insomnia Flushedface Diuresis GIdisturbance Muscletwitching Ramblingflowofthoughtandspeech Tachycardiaorcardiacarrhythmias(PVCs) Periodsofinexhaustibility Psychomotoragitation Consumptionof>1gramleadstoramblingspeech,confusion,cardiacarrhythmias,agitation,tinnitus,and mildvisualhallucinations(lightflashes). Consumptionof>10gramsleadstogeneralizedtonic-clonicseizures,respiratoryfailure,anddeath. GotoTableofContents 83 CaffeineWithdrawal Afterprolongeddailyuseofcaffeine,abruptcessation/reductioninuseleadstothreeormoreofthe followingin24hours: • • • • Headache Markedfatigueordrowsiness Dysphoricmood,depressedmood,orirritability Flu-likesymptoms(nausea/vomiting,musclepain) Withdrawaloccurswithin12-24hoursafterlastdose,symptomspeakbetween24-48hours,andresolve within1week. Complications • Possiblecardiacarrhythmiasinthosewithpre-existingcardiacdisease • Increasedriskofgastriculcersduetoincreasedgastricacidsecretion Treatment • • MedicationManagement:analgesics(NSAIDs)forheadachesandmuscleaches.RarelyBZDsareused forwithdrawalanxiety TaperingCaffeineUsage:patientskeepdailyfooddiarynotingallformsofcaffeineaswellas quantity.Thepatientandphysiciancanthenworkonataperingscheduleforconsumption,witha 10%decreaseeveryfewdays.Beveragesubstitutionisrecommended.Thediaryismaintainedto trackprogress.“ColdTurkey”isNOTrecommendedduetopossiblewithdrawalsymptoms,as50%of userswillhaveheadacheandothersymptoms Cannabis-RelatedDisorders Epidemiology • • • • Worldwide,cannabisisthemostcommonlyusedillicitdrug AccordingtotheNationalHouseholdSurveyofDrugAbuse,thelifetimeprevalenceofcannabisuse increaseswithagegroupupuntilage34,thedecreasesgradually.Betweentheagesof18-21,25% hadusedinthepastyearand14%inthepastmonth Males>Females(2:1)inthose26yearsandolder Whites>Blacks>>Hispanics(under35yearsold) Neuropharmacology • • • • IndianhempplantCannabisSativaisanherbknowninCentralAsiaandChinaforatleast4,000years Hempiscut,dried,chopped,androlledintocigarettescalledjoints Commonnamesaremarijuana,grass,pot,weed,tea,sticky-icky,andMaryJane Containsthepsychoactivesubstance∆9-tetrahyrdocannibinol(∆9-THC),whichismostpotentinthe floweringtopsoftheplantorfromthedriedresinexudatesfromtheleaves(hash,hashish) GotoTableofContents 84 • • • Activemetaboliteis11-hydroxy-∆9-THC,whichbindstoacannabinoidGiprotein-linkedreceptor(Gi= inhibitorGprotein)thatinhibitsadenylylcyclaseandaffectsGABAneurons Thecannabinoidreceptorismosthighlyconcentratedinthebasalganglia,hippocampus,cerebellum, andcortex(lowerconcentrationsthanothers).Thecannabinoidreceptorisnotfoundinthe brainstem,thusmarijuanahasminimaleffectsonrespiratoryandcardiacfunction Whensmoked,euphoriaoccursinminutes,peaksat30minutes,andlasts2-4hours ClinicalFeatures • • • • • Mostcommoneffectsaredilationofconjunctivalbloodvessels(“redeye”),mildtachycardia,dry mouth,andincreasedappetite(“munchies”) Themostseriousadverseeffectischronicrespiratorydiseaseinheavychronicusersdueto inhalationofcarcinogenichydrocarbons(samecompoundsintobacco) Canprecipitatepsychosisandisassociatedwithanearlierageoffirstonsetofschizophreniainmales (6.9yearsearlierthaninnon-cannabisusers) Pregnancy:negativeeffectsonfetalgrowth,behavioral/cognitive/academicdifficulties,impulsivity, andinattentionnotedaswell.Childhoodlearningdeficitsasaresultofin-uteroexposure Highcomorbidityofothersubstanceuse,including>50%meetingcriteriaforAlcoholUseDisorder CannabisUseDisorder AswithotherSubstanceUseDisorders,cannabisusemustbeassociatedwithatleast2symptomsof substanceuseovera12monthperiodoftime.Functionally,thedisorderisassociatedwithamotivational syndrome,manifestedbychroniclowmotivationandreductioningoal-directedactivity. CannabisIntoxication During,orshortlyafteruse,thereisclinicallysignificantdysfunctionalbehaviororpsychologicalchanges: • Impairedmotorcoordination • Euphoria • Anxiety • Sensationofslowedtime • Impairedjudgment • Socialwithdrawal Twoormorewithin2hours: • • • • ConjunctivalInjection IncreasedAppetite(“Munchies”) DryMouth Tachycardia GotoTableofContents 85 CannabisWithdrawal Cessationofusethathasbeenheavyandprolonged(dailyorneardailyovermonths)withthreeormore within1weekofstoppinguse: • • • • • • • Irritability,angeroraggression Nervousnessoranxiety Insomnia Decreasedappetiteorweightloss Restlessness Depressedmood Atleastoneofthefollowingcausingsignificantdiscomfort:abdominalpain,tremors,sweating, fever,chills,orheadache NewtotheDSM5istheunderstandingthatdailyorneardailyuseofTHCovermonthscancause withdrawal.Thisisafactorcontributingtodifficultyinquittinguse.Between50-95%ofheavyusershave reportedwithdrawalsymptoms.Onsetofwithdrawalisinthefirst24-72hoursandmaylastupto2weeks. Treatment Thelong-termgoalsoftreatmentarethesameforallsubstanceusedisorders:abstinence,relapse prevention,andrehabilitation. TreatmentSetting:outpatientsetting,eitherindividuallyoringroups. Alwaysmonitorforanunderlyingdepression(leadingtoTHCuse)thatmayrequiretreatmentwith antidepressants. PsychosocialTreatments • • • • Therapieswiththebestresultscombinemotivationaltherapywithcopingskillsdevelopmentto promoteabstinenceandpreventrelapse. Giventhelackofusefulpharmacotherapyandhighrelapserates(67%by6monthsinonestudy), additionalgrouptherapyandotherbehavioralinterventionsarerecommendedtodecreasetherate ofrelapse. Hallucinogen-RelatedDisorders DSM5separateshallucinogendisordersinto“PCP”and“Other”whichincludeLSD,mescaline,andothers. Phencyclidine(PCP) Epidemiology • PrevalenceofPCPuseisunknown.Onlyabout2.5%ofthepopulationhasreportedusingPCP.Males makeup75%ofusers GotoTableofContents 86 • • • • Phencyclidine(PCP),alsoknownas“angeldust,”isadissociativeanestheticthatisnolongerusedfor anesthesiaduetodisorientation,agitation,andhallucinationsonawakening Relatedcompound,Ketamine(“specialK”),isstillusedintheUSasananesthetic Similareffectsashallucinogens,includingLSD Easytosynthesizeandinexpensivetobuyonthestreets.HighestuseisinWashington,D.C.where PCPaccountsfor18%ofallsubstance-relateddeaths Neuropharmacology • • • • Soldascrystallinepowder,paste,liquid,ordrugsoakedpaper,andisoftenanadditiveincannabis cigarettes.Cansmoke,snort,oruseIV.EffectsofsmokedPCPoccurin5minutesandplateauin30 minutes.Half-lifeis20hours PrimaryeffectisNMDAantagonistatglutamatereceptors.AlsoaffectsDAneuronsinventral tegmentalareatothecerebralcortexandlimbicarea Detectedintheurineupto8daysafteringestion Nowithdrawalsyndromerecognized PCPUseDisorder AproblematicpatternofPCPuseasmanifestedby2criteriaforsubstanceuseover12months.Withdrawal symptomsarenotrecognizedforPCP,sothiscriterionwouldnotapplytowardthediagnosis.Consequences ofuseincludephysicalevidenceofinjuries,suchasaccidents,fights,andfalls.Chronicuseisassociatedwith memory,speechandcognitivedeficits. PCPIntoxication RecentuseofPCPorsimilarsubstanceleadingtoclinicallysignificantproblematicbehavioralchanges developedduringorshortlyafteruse: • Belligerence/assaultiveness • Impulsivity/unpredictability • Psychomotoragitation • Impairedjudgment Twoormorewithinonehour(lessifsnorted,smoked,orusedIV): • • • • • • • • Verticalorhorizontalnystagmus HTNortachycardia Numbnessordiminishedresponsivenesstopain Ataxia Dyarthria Musclerigidity Hyperacusis Seizuresorcoma GotoTableofContents 87 Treatment • • • • • ForacutePCPintoxication,treatmentissymptomatic.DONOTattempttotalkthepatientdown. ThismayleadtosignificantpersonalinjuryasthePCP-intoxicatedpatientmaybeagitatedor confused,andwhencombinedwithincreasedstrengthandpoorresponsetophysicalpain,makes foraverydangeroussituation Treatacutepsychosis/agitationwithantipsychoticsandBZDs Treatmedicalabnormalitiesasnecessary(includingcommonphysicalinjuriesthepatienthas sustainedwhileintoxicated),monitorBP,temperature,andmuscleactivity.Respiratorydepression mayoccur,monitorclosely Ammoniumchlorideintheearlystage,andcranberryjuiceorascorbicacidlateronarehelpfulin acidifyingthepatient’surine,leadingtoimprovedeliminationofthedrug Patientmayneedinpatientpsychiatrichospitalizationaftermedicalclearanceduetopersisting psychosis Hallucinogens Ofallsubstanceusedisorders,isoneoftherarest Mostcommoninyoungwhitemales(whites:blacks=2:1) Highestusein26-34y/o(15.5%ofthisagegrouphaveusedatleastonce) WesternUS>EasternUS Lessmorbidityandmortalitythanothersubstances(1%substance-relatedERvisitsvs.40%for cocaine) Neuropharmacology • • • • • • • • • Schedule1Drugs:manyarenaturallyoccurringinmushrooms(psilocybin),cactus(mescaline),and otherplants.LysergicAcidDiethylamide(LSD)wasfirstsynthesizedin1938 Actontheserotoninsystem,possiblyasapartialagonistonpost-synapticreceptors Onsetofactionwithinanhour,peaksin2-4hoursandcanlastupto12hours Rapidtolerancethatreversesquickly.Nophysicalwithdrawal ClinicalFeatures Sympathomimeticsymptomsincludetachycardia,tremors,HTN,hyperthermia,blurredvision,and mydriasis.DeathcanoccurduetoHTN,hyperthermia,andphysicalinjuryduetoimpairedjudgment • Synesthesia:colorsheardorsoundsseen.Canhavevisualandauditoryhallucinations,intense emotionallability,introspectivereflection,andheightenedsuggestibility HallucinogenUseDisorder • Aproblematicpatternofhallucinogenuseasmanifestedby2criteriaforsubstanceusewithin12months. WithdrawalsymptomsarenotrecognizedforPCP,sothiscriterionwouldnotapplytowardthediagnosis. Consequencesofuseinclude GotoTableofContents 88 HallucinogenIntoxication 1.During,orshortlyafterhallucinogenusethereisclinicallysignificantbehaviororpsychologicalchanges: Anxietyandfearfulness ParanoidIdeation Ideasofreference Fearoflosingone’smind Moodlability Depersonalization/Derealization 2.Perceptualchangesinastateoffullwakefulnessandalertnessthatdevelopduringorshortlyafteruse (mayincludeauditory,visual,ortactilehallucinations,illusions,orsynesthesia) • • • • • • 3.Twoormoreofthefollowing: • • • • • • • Pupilsdilated Tachycardia Sweating/Chills Palpitations Blurredvision Tremor Incoordination Hallucinogen-RelatedDisorders • • HallucinogenPersistingPerceptionDisorder:followingcessationoftheuseofahallucinogen,the personre-experiencesoneormoreoftheperceptualsymptomsthatwereexperienceswhile intoxicatedwiththehallucinogen.Mayincludegeometrichallucinations,falseperceptionof movementintheperiphery,trailsofimages,halosaroundobjects,andpositiveafterimages.These “flashbacks”areexperiencedbyupto4%ofusers.Flashbacksarespontaneous,transitory recurrencesofthesubstance-inducedexperiencelastingsecondstominutes,likelydueto hallucinogenstorageinfatwithmetabolizationatalatertime.Canbetriggeredbystress, EtOH/drugs,orsensorydeprivation(monotonousdriving) Hallucinogen-InducedPsychoticDisorder:a“badtrip”withacutepanicandpsychosis. Treatment Treatmentfocusesonabstainingfromhallucinogenuse,treatmentofsymptoms,reducehospital/ERvisits, development,preservationofsocialrelationships,andtreatingco-morbidillnesses(Alcoholism,depression, etc). • • • Providesupportivecarefortheremainderoftheintoxication.UseBZDsforacuteanxietyifnecessary TreatmentofHallucinogenPersistingPerceptionDisorder(flashbacks)includesBZDsor anticonvulsanttherapy.Unfortunately,thereisnocompletelysuccessfultreatment o AvoidEtOH,caffeine,orotherdrugsthatmayprecipitateflashbacks Treatpsychosiswithshort-termantipsychotics,withthemainstayoftreatmentbeingprevention GotoTableofContents 89 Inhalant-RelatedDisorders Epidemiology Easilyavailable,legal,andinexpensive.Highlyusedbyadolescentsandthepoor About10%of13year-oldAmericanshaveusedatleastonce Highestuseinadolescents(onestudyshowedthatatleast18%ofhighschoolseniorshadusedat leastonce) • 20%ofusersdevelopInhalantUseDisorder • WhitesmorecommonthanblacksorHispanics • Malesaccountfor80%ofuse • Only1%ofallsubstance-relateddeathsandlessthan0.5%ofsubstance-relatedERvisits • AssociatedwithanincreasedlikelihoodofConductDisorderandAntisocialPersonalityDisorder Neuropharmacology • • • • • • • • • • • Includessolvents,glues,adhesives,aerosolpropellants,paintthinners,andfuels.Specificexamples include:gasoline,varnishremover,lighterfluid,airplaneglue/superglue,rubbercement,cleaning fluid,spraypaint,andshoeconditioners Activechemicalsincludetoluenes,propanes,ethylenes,andhalogenatedhydrocarbons. Usedwithatube,can,plasticbag,oraninhalantsoakedragthroughwhichtheusercaninhalethe fumesthroughthenoseormouth(“huffing”) TolerancecandevelopbutthereisnoDSM5recognizedwithdrawaldisorder Rapidlyabsorbedthroughthelungsanddeliveredtothebrain.Effectsappearwithin5minutesand last30minutesuptohoursbasedonthesubstance/dose BloodconcentrationincreasedwhencombinedwithEtOH One-fifthisexcretedunchangedbythelungs,therestismetabolizedintheliver.Detectableinthe bloodfor4-10hours AdditiveeffectswithotherCNSdepressants(EtOH,BZDs) o MAOmaybethroughenhancingtheGABAsystem InhalantUseDisorder Aproblematicpatternofuseofahydrocarbon-basedinhalantsubstancemeetingatleast2criteriafor substanceusewithin12months.Nowithdrawalisrecognized,andthisisremovedfromthesubstanceuse criteria.Consequencesincludetoxicity,arrhythmia,andfatality. InhalantIntoxication Recentshort-term,high-doseexposuretoaninhalantcausingclinicallysignificantproblematicbehavioralor psychologicalchangesduringorshortlyafteruse: • • Apathy&lethargy Argumentativeness/Abusiveness/Aggression GotoTableofContents 90 Moodlability Impairedjudgment,attention,andmemory Twoormore: • • • Dizziness • Nystagmus • Incoordination • Slurredspeech • Unsteadygait • Lethargy • Depressedreflexes • Psychomotorretardation • Tremor • Generalizedmuscleweakness • Diplopia • Stupororcoma • Euphoria Severe:Hypotension,Hypothermia,DepressedGagReflex Inhalant-RelatedDisorders InhalantIntoxicationInducedDelirium:behavioraldisturbanceduetohypoxiaorinteractionswith othersubstances.Treatment:short-termantipsychoticsforagitation.AvoidBZDs,whichcanworsen respiratorydepression • Inhalant-InducedPersistingDementia:duetoprolongedhypoxia,inhalantneurotoxicity,orheavy metals(i.e.lead)usesininhalants.Dementiaispermanent • Inhalant-InducedMoodDisorder,PsychoticDisorder,andAnxietyDisorder AdverseEffectsofInhalants • • • • • • • Short-TermSymptoms:pulmonary/cardiovascular(chestpain,bronchospasm),GI(N/V, hematemesis),andneurological(peripheralneuritis,headache,andleadencephalopathy) Irreversiblehepaticorrenaldamage(includingRTA) o Permanentmuscledamageassociatedwithrhabdomyolysiscanalsocauserenaldamageas wellaslong-termmotorimpairment Organicsolventsarecombinedwithcopper,zinc,andheavymetals,whichcanleadtobrainatrophy, temporallobeepilepsy,loweredIQ,andEEGchangesifingested CongenitalanddevelopmentalabnormalitiesthatresembleFetalAlcoholSyndromeifinhalantsare usedduringpregnancy Ifapatientisabruptlystartledduringintoxication,cardiacarrestanddeathcanoccur Deathisduetorespiratorydepression,cardiacarrhythmias,asphyxiation,aspirationofvomitus,or accidentalinjury GotoTableofContents 91 Treatment • • • Medicallytreatcoma,bronchospasm,laryngospasm,cardiacarrhythmias,trauma,orburns.Provide reassurance,quietsupport,andattentiontovitalsigns/LOC Mayrequirepsychiatrichospitalizationifinhalant-inducedpsychosisissevere.Treatwithshort-term antipsychotics.Sedativesmayaggravatethepsychosis.Monitorforanxiety,depression,andSI Streetoutreachandextensivesocialservicesupportfortheseverelydeteriorated/homeless.Family supportiscrucial Opioid-RelatedDisorders Overview • • • • • • Opioidshavebeenusedfor3,500years,andin1806morphinewasfirstisolated.Heroinisthemost abusedopioidindevelopedcountries Derivedfromtheopiumpoppy,Papavarsomniferum Syntheticopioidsincludemeperidine(Demerol),methadone,andpropoxyphene(Darvocet) Lifetimeprevalenceofheroinuseis1%,male-to-femaleuseis3:1,andaheroinhabitcancost hundredsofdollarsperday,leadingtocriminalactivitiesandprostitution.Thisaccountsformuchof thespreadofHIV(prostitutionandIVheroinuse) 90%ofpatientswithopioiddependencehaveanadditionalpsychiatricdisorder,mostcommonly MDD,ETOHaddiction,antisocialPD,andanxietydisorders 15%ofopioiddependentpatientsattemptsuicideatleastonce Neuropharmacology • • • • • • Primaryeffectsareonopioidreceptors:μ-opioidreceptorsmediate/regulateanalgesia,respiratory depression,constipation,anddependence;κ-opioidreceptorsareassociatedwithanalgesia,diuresis andsedation;δ-opioidreceptorsmaybeassociatedwithanalgesia Endogenousopioidsinthebrainincludeenkephalinsandendorphins,involvedinneuronal transmissionandpainsuppression Theaddictiverewardingpropertiesoftheopioidsaremediatedthroughtheactivationoftheventral tegmentalareawithDAneuronsprojectingtothecortexandlimbicsystem Heroinisthemostcommonlyabusedopioidandismorepotentandlipidsolublethanmorphine. Crossestheblood-brainbarrierfasterandhasmorerapidonsetofactionthanmorphine Opioidscanbetakenorally,snortedintra-nasally,andinjectedIV Detectedintheurinefor12-36hours.Fentanylisnotdetectedintheurine ToleranceandDependence • • Long-termuseofopioidsresultsinchangesinthenumberandsensitivityofopioidreceptors,which leadtosomeoftheeffectsoftolerance/withdrawal Long-termuseisassociatedwithincreasedsensitivityoftheDA,cholinergic,andserotonergic systems GotoTableofContents 92 • Theprimarymediatorofwithdrawalisopioideffectonnoradrenergicneurons.Short-termuse decreasesnoradrenergicneuronsinthelocusceruleus(LC),whilelong-termuseleadstogene alterationandincreasedLCexcitabilitybyNE.ToleranceforopioidsresultsfromthisincreasedLC excitability.Withdrawalofopioidsleadstoreboundhyperactivity/increasedNE Etiology • • Psychosocialfactors:childrenofdivorcedparentsorsingleparentsareathigherriskfordependence Biological/Geneticfactors:monozygotictwins>dizygotictwins OpioidUseDisorder Aproblematicpatternofopioiduseleadingtomeetingatleast2ofthesubstanceusecriteriawithin12 months.Recallthatthediagnosiscannotbemetiftheonlycriteriapresentaretoleranceandwithdrawal withinthecontextofbeingmedicallyprescribed.Consequencesofuseincludemultiplemedical comorbidities,increasedriskforsuicideandassociationwithcriminalactivity. OpioidIntoxication Duringorshortlyafterusethereisclinicallysignificantproblematicbehaviororpsychologicalchanges: • Initialeuphoriafollowedbyapathyandsedation • Disinhibition • Psychomotorretardation • Impairedjudgment Pupillaryconstriction(ordilationaftersevereoverdose)ANDoneofthefollowing: • Drowsinessorcoma • Slurredspeech • Impairmentinattentionormemory Severe:respiratorydepression,hypoxia,hypotension,andhypothermia.InsevereODanoxialeadsto DILATEDpupils. OpioidWithdrawal 1.Presenceofeither:cessation/reductioninheavyandprolongeduseORadministrationofanopioid antagonistafteraperiodofopiateuse 2.Threeormore: • • • • • • • • Dysphoricmood Nausea/vomiting Muscleaches Lacrimationorrhinorrhea Pupillarydilation,piloerection,orsweating Diarrhea Yawning Fever GotoTableofContents 93 • Insomnia Withdrawalofmorphineandheroinoccurswithin6-8hours,andsubsideswithin7-10days.Thekeypointis thatwhileopiateoverdoseorintoxicationcanbefatal,withdrawalisrarelyfatal(asopposedtoEtOHand BZDwithdrawal,whichcanbefatal). AdverseEffects Mostcommonandmostseriousadverseeffectispotentialtransmissionofhepatitis,bacterial endocarditis,tuberculosis,andHIVthroughcontaminatedneedles • Combiningmeperidine(Demerol)andMAOIscanproducecoma,seizures,anddeath • Chronicabscessesfromsubcutaneousinjections(“skinpopping”)andvisibleneedletrackscanbe notedonphysicalexamination • Deathfromopioidoverdoseoccursthroughrespiratorydepressioninthebrainstem.Consider opioidoverdosewithclinicaltriadofrespiratorydepression,pinpointpupils,andcoma • Pregnancy:malnutrition/vitamindeficiency,HIV/sexuallytransmitteddiseases,HTN,pre-eclampsia, miscarriage,prematureruptureofmembranes,lowbirthweight,prematurity,stillbirth,neonatal dependenceonopioids(50%),andSIDS.Buprenorphineandmethadonearepreferredtreatmentin pregnantwomenwithopioiddependence TreatmentandRehabilitation • TreatmentofOverdose Maintainandadequateairway.Mechanicallyventilateuntilnaloxone,aspecificopioidantagonist, canbeadministered.Monitorvitalsignsandstabilizebeforeconsideringtreatmentofopioid dependence/rehabilitation TreatmentSettings • Fivesettings:inpatienthospital,outpatientclinics,opioidtreatmentprograms,self-helpprograms,and therapeuticcommunities • • • • • Inpatienthospitalization:afteroverdose,inpatientmedicalhospitalizationisrequiredfor stabilization.Reversalofopioideffectsthroughtheshort-actingopioidantagonistnaloxoneis needed,andtreatmentofwithdrawalcanbedoneinamedicalsettingoraninpatientpsychiatric hospital Outpatientclinics:mayusegrouppracticesandmedicationmanagementforthetreatmentofopioid dependence Opioidtreatmentprograms:includemethadonemaintenanceclinicsthatoperateunderspecial federalandstateregulations.Theseprogramscanbehighlyeffective.Arecoveringheroinaddict mustberegisteredwiththeDEAinatreatmentprogramtoreceiveopioids Self-helpprograms:NarcoticsAnonymousiseffectiveintreatingdependence,especiallywhen combinedwithmedicationmanagementandothertreatmentsettings Therapeuticcommunities(likeasoberlivinghome)participateinarigidprogramwithother substanceusers GotoTableofContents 94 MedicationManagement Managementofwithdrawalissymptomatic,includinguseofclonidine(centralα2-adrenergicagonist decreasesNEbystimulatingautoreceptors),anti-nauseamedications,NSAIDSforanalgesia,musclerelaxants,andshort-termBZDs(foranxietyandinsomnia).Methadoneandbuprenorphineand highlyeffectiveintreatingsymptomsofwithdrawal • MethadoneandLAAM:botharescheduleIIfullmuagonists.LAAMisstructurallyrelatedto methadonebuthaslongerdurationofaction(takenofftheUSmarketduetocardiacarrhythmias). Methadoneiscurrentlyonlyavailablethroughspeciallylicensedopioidtreatmentprogramsthatare heavilyregulated.Goalsoftreatmentare:suppresswithdrawal,decreasecraving,blocksillicit opioids,stoppingillicitopioiduse,andenlistthepatientinprogramdesignedtopromote rehabilitation.Sideeffectsincludeconstipation,sweating,andsexualdifficulties.Thebenefits includereductioninthespreadofHIVthroughIVdruguse,gainfulemployment/lesscriminal activity,andproducesminimaleuphoriaordepression.Thedisadvantagesarecontinued dependenceonacontrollednarcotic • Buprenorphine:partialµ-agonist/κ-antagonistthathashigherbindingaffinityforµ-receptorsthan illicitopioids/fullagonists(knocksillicitopioidsoff).Itislessaddictiveduetolessagonist/partial agonisteffect(painmanagementwithouteuphoriaorrespiratorydistress)andentersthe bloodstreammoreslowlythanotheragonists.Goodsublingualbioavailability.Treatsopioid withdrawalandchronicpainmanagement.However,itcanstillbeabusedifinjected.Asaresult, combinationwithnaloxone(opiateantagonist)leadstolessabusepotential(naloxonehasbetter parenteralbioavailability.Ifthedrugisinjectedtoabuse,naloxoneblocksthereceptor). • Naltrexone:opioidantagonistsimilartonaloxonewithlongerdurationofaction(72hours). Blockingopioidagonisteffects,particularlyeuphoria,naltrexonediscourages/deconditions substance-seekingbehavior.Similartodisulfram,thismedicationisusedtotreatdependence,not withdrawal.Sideeffectsincludedysphoria,anxiety,GIdistress,andinhigherdoses,elevatedLFTs PsychosocialTreatments • Allclinicaltrialsforpsychosocialinterventionshavetakenplaceinprogramsthatalsoprovideopioidagonist maintenance(likemethadone)oropioidantagonists(likenaloxoneornaltrexone).Therapyalonemaynot beaviableoptionfortreatment. • • • • CBT:helpfulinpatientswithMDDorotherco-morbidpsychiatricissues.Inaddition,mayreduce high-riskHIVbehaviorsanddecreasecriminalbehaviors Behavioraltherapies:usesreinforcers/rewards(commonlymethadone)contingentonabstinence. Canenhanceadherencewithnaltrexone Familytherapyenhancestreatmentadherence Self-helpgroupsand12-step-orientedtherapies:NarcoticsAnonymousisbeneficialbyproviding peersupport,decreasingsubstance-abusingpeers,providingaccountability,confrontingdenial,and interveningearlyinpreventingrelapse GotoTableofContents 95 Sedative,HypnoticorAnxiolytic-RelatedDisorders Overview IncludesBZDs,barbiturates,methaqualone(Qualudes),andmeprobamate.Thesedrugsareantiepileptics,muscle-relaxants,anesthetics,andareadditivetotheeffectsofEtOH • Sedativesaredrugsthatreducetensionandinducementaltranquility,synonymouswithanxiolytics (i.e.theyreduceanxiety).Hypnoticsaredrugsusedtoinducesleep.However,atvarieddoses sedativescanproducesleepandhypnoticscanproducetranquility • BZDs:rapidonsetisassociatedwiththemostaddictionpotential o Long-Acting:diazepam(rapidonset),clonazepam,flurazepam,chlordiazepoxide o Short-Acting:lorazepam(rapidonset),oxazepam,temazepam o Ultra-ShortActing:alprazolam(rapidonset)andtriazolam • Barbiturates:beforeintroductionofBZDs,barbiturateswerefrequentlyprescribed,butarehighly abusedandaremuchmorelethalthanBZDsduetorespiratorydepression,especiallywhen combinedwithEtOH o Long-Acting:phenobarbital(acommonanti-epileptic)andbarbital o Intermediate-Acting:amobarbital(Amytal)useinthe“Amytalinterview”toaidinconversion reactions,andtodifferentiatethestuporofdepression,schizophrenia,andstructuralbrain lesions o Short-Acting:secobarbital(“reds”)andpentobarbital(Nembutal,“yellowjackets”).Inthe “PentobarbitalChallengeTest,”atestdoseofpentobarbitalisgivenorallytodeterminethe extentofbarbituratetoleranceinordertoadequatelytreatwithdrawal o Maybetakenorally(commoninmiddleaged/middleclassandprescribedbyFamilyMDfor insomniaoranxiety)orIV(moresevereformofabuse,usuallyinyoungadults,with increasedratesofHIV,cellulitis,andinfection).TheIVformhasarapidandprofound tolerance/dependenceinadditiontoseverewithdrawal Epidemiology • • • Thehighestprevalenceofsedativeabuseisinthe26-34yearoldagegroup Femaletomaleratiois3:1,whitetoblackis2:1 Neuropharmacology • • • AllhaveprimaryeffectsonGABAtypeAreceptors,actingtoallostericallystrengthentheGABA signal.Thisleadstomoreinfluxofnegativelychargedchloride,inhibitingneurons.Theoveralleffect iscalming ToleranceisunderstoodthroughchronicGABAstimulationonGABA-Areceptors,leadingtoless sensitivity/lesschlorideinfluxinthepresenceofthedrug.This“downregulationofreceptor response”isnotduetodecreasedreceptornumberordecreasedaffinityforGABA.Itappearstobe duetodecreasedefficiencyofcouplingwiththechloridechannel,leadingtotolerance Maybedetectedintheurineupto1weeklaterinlongeractingmedications GotoTableofContents 96 Sedative,Hypnotic,orAnxiolyticUseDisorder Aproblematicpatternofsedative,hypnotic,oranxiolyticuse,meetingatleast2criteriaforsubstanceuse overa12monthperiod.Recallthatthediagnosiscannotbemetiftheonlycriteriapresentaretoleranceand withdrawalwithinthecontextofbeingmedicallyprescribed. Sedative,Hypnotic,orAnxiolyticIntoxication Duringorshortlyafterusethereisclinicallysignificantmaladaptivebehaviororpsychologicalchanges: • Abusiveness/Aggression • Moodlability • Impairedjudgment Oneormore: • Slurredspeech • Incoordination • Unsteadygait • Nystagmus • Impairmentinattentionormemory • Diminishedlevelofconsciousness(Stupor/Coma) Servere:Hypotension,Hypothermia,DecreasedGagReflex Clinically,thesyndromeofintoxicationisindistinguishablefromEtOHintoxication. Sedative,Hypnotic,orAnxiolyticWithdrawal Aftercessationofprolongeduse,therearetwoormore: • • • • • • • • Autonomichyperactivity(Sweating,tachycardia,HTN) Tremoroftongue,eyelids,oroutstretchedhands(asterixis) Insomnia Nausea/vomiting Transientvisual,tactile,orauditoryhallucinations/illusions Psychomotoragitation Anxiety Grandmalseizures CanbeLETHAL,justlikeEtOHwithdrawal BZDwithdrawaloccurswithinthefirst3daysofcessation,withseizuresdevelopingonthe2ndor3rdday. Shorteractingsubstanceshaveonsetofwithdrawalsooner.Forbarbiturates,thesymptomsofwithdrawal usuallydon’toccuruntil2-3daysaftercessation(orwithlongeractingdrugs,upto5-6dayslater). AssociatedDisorders • Deliriumpresentswithintoxicationorwithdrawal,andcanbeindistinguishablefromDTsinEtOH withdrawal(morecommoninbarbituratewithdrawal) GotoTableofContents 97 PsychoticDisordersaremorecommoninwithdrawalfrombarbituratesthanBZDs,andmaybe undistinguishablefromEtOH-relatedDTs • Sedativesandhypnoticscaninducemooddisorders,anxietydisorders,sleepdisorders,andsexual dysfunction Treatment • Overdose • • • Treatmentfocusesongastriclavage,activatedcharcoal,andmonitoringvitals/CNSactivity.ODmay requiremechanicalventilationduetorespiratorydistress BZDs:muchsaferinODthanbarbituratesduetominimalrespiratorydepressioninBZDs.Ifcombined withEtOH,thereissignificantlyincreasedriskforlethality.Lethaldoseis200:1.Treatwithflumazenil (BZDantagonist)intheER Barbiturates:highlylethalinoverdoseduetorespiratorydepression.LikeBZDs,haveadditivelethal effectswithEtOHorothersedative-hypnotics.Lethaldoseis3:1to30:1 Withdrawal • • BZDs:topreventseizures,thedoseshouldbegraduallyreduced.Detoxificationgenerallyoccursin aninpatientsetting,switchingtoalong-actingBZDforwithdrawalandgraduallytaperingoff. Symptomsofwithdrawalaretreatedwithclonidine,andthereissomedatatosuggest carbamazepinemaybeusefulintreatingsymptomsofwithdrawal Barbiturates:withdrawalcanbehighlylethal,requiringinpatienthospitalization.Apentobarbital challengetestisdonetoascertainthestartingdoseofbarbituratesrequiredfordetoxification.Longactingbarbiturates,likePhenobarbital,areusedfordetoxification.Taperingoffismuchmore gradualthanwithBZDs PsychosocialTreatments • • • • Outpatienttreatmentprogramsfocusonrehabilitationinasafeenvironment,utilizingCBT, behavioraltherapies,grouptherapies,andself-helpgroups Treatanyunderlyingpsychiatricdisorders(SSRIsfordepression,anxiety,panicdisorder,etc) Familysupportandeducationareimportant PMDneedstobeactivelyinvolvedinthetreatmentplan,as“MDshopping”iscommonamongthese patients,leadingtorelapse Stimulant-RelatedDisorders PharmacologicalPreparations • MajoramphetaminesinUSA:dextroamphetamine(Dexedrine),methamphetamine,mixed detroamphetamine-methamphetaminesalt(Adderall,Ritalin),anddesigneramphetamineslike MDMA(“ecstasy”) o Nicknamesincludeice,crystalmeth,meth,andspeed GotoTableofContents 98 o Canbesmoked,snorted,ingested,orinjected • Cocaine:consumedascocaleaves,snortedorsmokedascocainehydrochloride,orconvertedintoan alkaloidthrough“freebasing”tomakecrackcocainetosmoke Epidemiology • • • Highestuseisinpersons18-25and26-34 Males>Females(2:1) Allracesandsocioeconomicgroupsareaffectedequally Comorbidity • • AnxietyDisorders,ADHD,andAntisocialPersonalityDisorderoftenprecedeuse.Oftenmood disordersandEtOHdependencearetheresultofresultofstimulantabuse Commonlyassociatedpsychiatricdisordersinclude:MDD(>30%ofcocaineusers),Cyclothymia (20%),BipolarDisorder,AnxietyDisorders,andAntisocialPersonalityDisorder Neuropharmacology:Amphetamines • • • • Rapidlyabsorbedandrapidonsetofaction(1hourorally,immediatelywhenintravenously) Primaryeffectsareproducedthroughpresynapticreleaseofcatecholamines(DA),especiallyinthe limbicandcerebralcortex,whichinfluencetherewardpathways.Thisdiffersfromcocaine,which inhibitsthereuptakeofDA MDMAandotherdesigneramphetaminescausereleaseofcatecholaminesANDserotonin(leading tohallucinations) Detectedintheurine1-3days,withhairsamplesabletodetectuseforupto90days Neuropharmacology:Cocaine AlkaloidderivedfromtheSouthAmericanshrubErythroxylonCoca.Itwasfirstusedasananesthetic in1880(currentlyusedstillinENTsurgeries).WasusedbySigmundFreudandwidelyusedasa “cure-all”until1914whenitsaddictivepropertieswererecognized • Mostcommonmethodofuseis“snorting”(i.e.intra-nasally).OthermethodsincludeIVorsmoking (“freebasing”).Freebasingmixesstreetcocainewithpurecocainealkaloid(freebase)toincrease effect.Crackisasmokedfreebaseformofcocaineandishighlyaddictive • CompetitiveblockadeofDAreuptake,therebyincreasingDAinsynapticcleftandincreasedD1/D2 receptoractivation • AlsohaseffectsonNorepinephrine,Serotonin,cerebralbloodflow,andcerebralglucoseuse • Behavioralaffectsarefeltimmediatelyandlast30-60minutes,requiringrepeateddosingfor continuedintoxication.Canstayinurine1-3days,andupto12daysindailychronicusers StimulantUseDisorder • Apatternofamphetamine-typesubstance,cocaine,orotherstimulantusemeetingatleast2criteriafor substanceusewithinthepast12months. GotoTableofContents 99 StimulantIntoxication Duringorshortlyafterusethereareclinicallysignificantproblematicbehavioralorpsychologicalchanges: • Euphoria&sensationofincreasedenergy • Hypervigilance • Increasedsociability • Abusive/Aggressivebehavior • Moodlability • Repetitivestereotypedbehaviors • Interpersonalsensitivity • Impairedjudgment Twoormore: • • • • • • • • • Tachycardiaorbradycardia Pupillarydilatation HTN Sweating/Chills Nausea/Vomiting Weightloss Psychomotoragitationorretardation Muscularweakness,chestpain,arrhythmias,orrespiratorydepression Seizures,dystonia,dyskinesia,confusion,orcoma StimulantWithdrawal Aftercessation/reductionofuse,thereisdysphoricmoodplusatleasttwoofthefollowingwithinafew hourstoseveraldays: • • • • • Lethargyandfatigue Vivid,disturbingdreams Insomnia/Hypersomnia Increasedappetite Psychomotorretardationoragitation Withdrawalpeaksin2-4daysandisusuallyresolvedby1week.Themostseriouswithdrawalsymptomis depressionbecauseitcanleadtosuicidalideation. AdverseEffectsofStimulantUse • • • Common:nasalcongestion/ulceration/bleeding/perforationofnasalsepta(snorting),damage bronchialpassages(smoking),infection/embolism/HIV(IVuse),acutedystonia,tics,andmigraines Two-thirdsofacutetoxiceventsoccurwithinonehourofintoxication,withmajorcomplications beingcerebrovascular,epileptic,andcardiac Cerebrovascular:nonhemorrhagiccerebralinfarctionmostcommon,TIA,andspinalcord hemorrhages GotoTableofContents 100 Seizures:occurin3-8%ofcocaine-relatedERvisits.Cocaineisthe#1abusedsubstanceassociated withseizures,amphetaminesis#2.Partialcomplexstatusepilepticusisseen • Cardiac:MIandarrhythmias.Long-termuseisassociatedwithcardiomyopathy • Pregnancy:withamphetaminesandcocaine,riskoflowbirthweight,smallheadcircumference, prematuredelivery,growthretardation,fetaldemise,andabruptioplacentae.Withcocaineinutero specifically,seeCNSirritabilityinthenewbornwithdecreasedIGandattentionspandeficits • IVUse:HIV,hepatitisB/C,lungabscess,endocarditis,andnecrotizingangiitis. • Stimulant-InducedPsychoticDisorder:paranoia,hallucinations,hypersexuality,hyperactivity,and confusion.CanbedistinguishedfromschizophreniainthatinamphetaminepsychosishasNOalogia, flatteningofaffect,disorganizedthinking(i.e.looseassociations).Treatment:shorttermuseof antipsychoticslikehaloperidoloratypicalantipsychotics Treatment • Thelong-termgoalsoftreatmentarethesameforallsubstanceusedisorders:abstinence,relapse prevention,andrehabilitation. • TreatmentSetting:oncemedicallycleared,inpatienttreatmentisrarelyneeded.Mostpatientscan betreatedeffectivelyinanintensiveoutpatientprogram.Foracutepsychotic/agitatedpatients, inpatientcaremaybenecessarytomonitorforsafetyandprovideshort-termtreatmentwith antipsychotics PsychosocialTreatments • • • MultiplestudiesshowthatCBTisoneofthemosteffectivetreatmentmodalities Familytherapyisanessentialcomponentoftreatment,focusingontheconsequencesofthe patient’suseandgoalsforahealthyfuture.Itempowersfamiliestohelptheaddictpreventrelapse ParticipationinNA,CocaineAnonymous,orother12-stephelpgroupspredictslessstimulant use/relapse MedicationManagement • • • • Treatintoxicationsymptomatically:α-blockersbeforeß-blockerstopreventunopposedαactivity, BZDsforagitation,antipsychoticsforseverepsychosis Studiesfortreatmentofcocainedependence:buprenorphine(opiatepartialagonist),topiramate, baclofen(GABABagonist),tiagabine(GABAreuptakeinhibitor).Allofthesemedicationshavesome datatoshowefficacyintreatmentofcocainedependence/withdrawal Bupropion(decreasesDAreuptake)hasbeenusedafteramphetaminewithdrawaltoreduce dysphoriaandproducefeelingsofwell-being Treatingunderlyingpsychiatricconditionsthatcontributetostimulantuseisalsoimportant GotoTableofContents 101 Tobacco-RelatedDisorders Epidemiology • • • • • • • • • • WHOestimates1billionsmokersworldwide;25%ofAmericanssmoke.Tobaccokillsmorethan3 millionpeopleayear Tobaccoisthemostcommonformofnicotine.Tobaccocanbefoundincigarettes,cigars,pipes, snuff,andchewingtobacco Over75%ofsmokershavetriedtoquit,andabout40%attempttoquiteachyear.Inattemptingto quit,only30%canremainabstinentforeven2days About20%ofthepopulationdevelopsnicotinedependenceatsomepoint,makingitthemost prevalentpsychiatricdisorder Women=Men Moreprevalentinlowersocioeconomicgroups,thelowereducated,andinminorities 70%ofpatientswithBipolarDisorderand90%ofschizophrenicssmoke.Inpatientswith schizophrenia,nicotinecanreducetheirextraordinarysensitivitytooutsidesensorystimuliand increasetheirconcentration Associatedwith25%ofalldeathsintheUnitedStates.Deathsoccurfrombronchitis/emphysema, cerebrovasculardisease,cardiovasculardisease,andalmostallcasesofCOPDandlungcancer. Chewingtobaccoandcigarsareassociatedwithoropharyngealcancer Secondhandsmokeincreasestheriskofheartdiseaseandcancerby30% Dependenceisenhancedbystrongsocialfactorsthatencouragesmokingandtheeffectsoftobacco companyadvertising.Somestudiessuggestageneticpredispositiontowardnicotinedependence Neuropharmacology • • • Nicotineactsasanagonistatthenicotinicsubtypeofacethycholine(ACh)receptors.Itactivatesthe DApathwayprojectingfromtheventraltegmentalareatothecerebralcortexandthelimbicsystem (i.e.thesameareasinvolvedincocaine/amphetaminedependence),resultinginpositivereinforcing andaddictiveproperties InadditiontoactivatingtheDArewardsystem,nicotinecausesincreasedconcentrationsofNE, epinephrine,vasopressin,ß-endorphin,ACTH,andcortisol.ThisresultsinCNSstimulation 25%oftheinhalednicotinereachesthebloodstreamandbrainwithin15seconds.Thehalf-lifeof nicotineis2hours TobaccoUseDisorder Aproblematicpatternoftobaccouse,meetingatleast2criteriaofsubstanceusewithin12months.Thereis norecognizedintoxicationstatefortobacco. GotoTableofContents 102 TobaccoWithdrawal Afterdailyuseoftobaccoforatleastseveralweeks,within24hoursofreducingorceasingusethereareat leastfourofthefollowing: • Dysphoric/depressedMood • Insomnia • Irritability/frustration/anger • Anxiety • Difficultyconcentrating • Restlessness • IncreasedAppetite/weightgain CancauseslowingofEEGactivity,decreasedcortisol,decreasedcatecholaminelevels,andadeclinein metabolicrate.Heartratedecreasesby5-12BPMinthefirstfewdaysafterstoppingsmoking.Weightmay increaseanaverageof4-7lbsaftercessation.Mayhaveincreasedcravingsforsugaryfoods. Withdrawalsymptomspeak24-48hoursaftercessationandmaycontinuefor4weeks.Hungerandcraving fortobaccocanlastupto6monthsinsomepatients. AdverseEffects • • • • Adverseeffectsafterwithdrawal: o BenzopyrenesintobacconormallyinhibitthehepaticP450CYP1A2system.Medications metabolizedbythissystem(includingclozapine,haloperidol,BZDs,TCAs,andpropranolol) willincreasesubstantiallyaftersmokingcessation.Monitorformedicationtoxicityafter quittingsmoking o Smokingincreasescaffeinemetabolism,thussmokingcessationincreasescaffeinelevelsby 50-60%,increasingriskforcaffeinetoxicity.Reducingcaffeineintakewhenquittingsmoking mayberecommended Nicotinetoxicity:inlowdoses,thesignsandsymptomsoftoxicityincludenausea,vomiting,pallor, weakness,abdominalpain,diarrhea,dizziness,HA,HTN,tachycardia,tremorandcoldsweats.High dosesofnicotineaffectconcentrationandcanleadtoconfusion NicotineisassociatedwithdecreasedREMsleep Smokingduringpregnancyisassociatedwithincreasedincidenceoflowbirthweightbabiesand newbornswithpersistentpulmonaryhypertension.Quittingsmokingbyhethirdtrimesterreduces riskoflowbirthweightbabiestoequalnonsmokers Assessment • • Assessmentofdegreeofdependenceisveryimportant,ashighly-dependentindividualsaremore likelytoneedmoreintensivetherapy,especiallypharmacotherapy FagerstromTestforNicotineDependence:widelyusedassessmenttoolwithprovenreliability/ validity.Canpredictwhichsmokersarelikelytoquitsmokingandwhichmaybenefitfromnicotine replacementtherapy(NRT).Questionsinclude:cigarettes/day,morningsmoking,howsoonafter awakeninghavefirstcigarette,difficultytorefrainfromsmokinginplaceswhereitisforbidden, smokingwhenill/bedridden.Morningsmokingandsmokingrightafterawakeningareknowntobe highlyassociatedwithdifficultyquitting GotoTableofContents 103 • • Indicatorsofuse:nicotinelevelsinblood/urine/saliva(detectableforfewhours),cotinine (metaboliteofnicotine)detectableforupto7days,carbonmonoxidelevel(measuredbybreath) reflectssmokingoverlastfewhoursandisusefultoverifycessationinpatientsusingNRT) Assesspreviouscausesofrelapsetohelppreventfuturerelapse Treatment • Generalapproachtotreatment: a. Establishingandmaintainingatherapeuticalliance.Thisisachronicrelapsingdisorderwith mostsmokersrequiring5-7attemptsbeforequittingforgood.Mostpatientsarenotawareof this,andareeasilydemoralizedbyrelapse.Goodtherapeuticallianceisessentialinencouraging thepatienttowardabstinence,usingandnon-judgmentalandempathicapproach b. Increasingreadinessandmotivationforsmokingcessation.Enhancingmotivationanddealing withanticipatedbarrierstocessationareimportant,especiallyinambivalentpatients.Stages-ofchangeapproachesandmotivationalenhancementmodels(seeMotivationalinterviewing)help toenhanceapatient’smotivationandchallengeambivalence.Lookingatthepatient’s consequencesofuse(healthissues,socialpressures,andspecialsituations[pregnancy,living withachildwithasthma])cansometimesmotivatesmokerstoquit.DuringMDvisits,frequent revisitingoftheseissuesandevaluatingthebenefitsofquittingisassociatedwithincreased readinesstoquit c. Overcomingbarrierstosmokingcessation.Addressingthepatient’sfearsrelatedtoquitting (weightgain,fearofwithdrawal,fearoffailure)isimportant.Mayneedtodetermineother smokingcohabitatingfamilymembers’willingnesstoquit,asthismaybeabarriertothe patient’ssmokingcessation d. Elicitingpatientpreferencesabouttreatment.Includesdiscussingmethodoftreatment(NRT, variouspsychosocialtherapies,etc) e. Determiningtimingofsmokingcessation.Besttimingiswhenpatientispsychiatricallystable,no urgentproblems,andnorecentchangesinmedications.Smoking-relatedillnessmaynecessitate moreimmediatecessation f. Determiningwhethercessationwillbeabruptorgradual.Mostdatashowsnodifference betweenabruptvs.gradualcessation g. Settingaquittingdate.Evenifusinggradualquitapproach,adateforcompletecessationofuse isrecommended.Ifpatientisnotreadytosetaquitdate,frequentrevisitingtheissueon subsequentvisitsishelpful h. Developingaplanofpsychosocialandpharmacologictreatment.Frequentbrieffollow-upafter thequitdateisrecommended,especiallytoidentifysymptomsofwithdrawal,andmonitorfor exacerbationofpsychiatricsymptoms i. Providingeducationandenhancingadherence.Keypointsincludeinformingpatientsthatmost smokerstrytoquitmultipletimesbeforesucceeding,remainingabstinentfor3monthsis associatedwithlowratesofrelapse,andeducationonwithdrawalsymptoms.Weightgaincan bepreventedthroughphysicalactivityandhealthierdietchoices.DiminishingETOHintakeis recommendedasitisariskofrelapse.Praiseshouldbeprovidedevenafterarelapseforany timeremainedabstinent j. Determiningapproachesforpatientswhodonotrespondtoinitialtreatment.Afterarelapseitis importanttodetermineiftreatmentwasappropriateandadequatelyimplemented.Ifso,then rescreeningthepatientforco-occurringdisorders(othersubstanceuseorpsychiatricdisorders) GotoTableofContents 104 isindicated.MayrequiretrialofdifferentNRTifinitialtreatmentinadequate.Ifstressfullife eventleadtorelapse,therapymaybeindicated MedicationManagement • • • • • Nicotinereplacementtherapies(NRT):5currentFDAapprovedarepatch,gum,lozenge(theseare OTC),nasalspray,andinhaler(prescription).Optimaldurationisvariable,somepatientsstayon theseagentsfor>6months.TheeasiestNRTtoadheretomaybethepatch,startedathighdose21 mg.Patientswhosmoke<15cigarettes/daymaybenefitfromintermediatepatch(11or14mg). Durationofpatchtherapyshouldbe6-12weeks.Withtheuseofgum/lozenges,scheduleddosing withgradualtaperingoffover6-12weeksismosteffective.Combinationwithbupropionor psychosocialtherapiesmayimproveoutcome Bupropion:sustainedreleasebupropionisafirst-linetreatmentforsmokingcessation.Doublesquit rates,andusewithNRThasevenhigherratesofsuccess.Increasedinastep-wisetitrationover3-4 dayswithatargetof300mg/day.MechanismofactionisthroughdecreasingreuptakeofDA (reward/seekingsystem)andnon-competitiveinhibitionofnicotinicacetylcholinereceptors (interfereswithaddictiveactionsofnicotine).Sideeffectsincludejitteriness,insomnia,andGI symptoms.Avoidinpatientswithhistoryofseizuresoraneatingdisorder(duetohigherriskof seizures) Nortriptyline:second-linetreatmentthathassupportivedataintheeventtheabovetreatmentsare ineffective.However,canbetoxicinoverdose,usewithcaution Clonidine:α2-adrenergicagonistattheNEautoreceptordecreasessympathetictoneinlocus ceruleustoabatewithdrawalsymptoms.Second-linetherapy Otheragents:acupuncture,naltrexone,buspirone,MAOIs,andSSRIsmaybeofsomeuse,but efficacyisnotwellestablished PsychosocialTreatments • • • • • Socialsupportisarecommendedtreatmentforsmokingcessation Behavioraltherapiessubstitutehealthybehaviors(walking,exercising)forsmoking Brieftherapieswithmotivationalapproachesarehelpful CBTarehelpfulforsmokerswithco-morbidpsychiatricdisordersorETOH/substanceabuse.May alsohelpwithweightconcerns Self-helpmaterialsandsupportgroupscanaidsmokingcessation Miscellaneous AnabolicSteroidAbuse • • • Includestestosteroneandsyntheticanaloguesoftestosteronethatpossessanabolic(musclebuilding)andandrogenic(masculinizing)effects.Thesedrugsareusedillegallytoenhancephysical performanceandincreasemusclebulk Neuropharmacology:oraltestosteroneismetabolizedintheGImucosaandliver,leadingto decreasedbioavailability.Syntheticandrogensarelessextensivelymetabolized Mayinitiallyinduceeuphoriaandhyperactivity.However,overtime,canleadtoincreased aggression(“roidrage”),irritability,anxiety,anddepression GotoTableofContents 105 • • Whenusersstoptaking,theycanbecomedepressedandover-concernedabouttheirphysical appearance,evenwhennochangecanbeobjectivelyseen AdverseEffects: o Anabolicsteroidsleadtorapidenhancementofmusclebulk,butalsohaveacne,premature balding,yellowingoftheskin/eyes,gynecomastia,decreasedsizeoftesticles/prostate,and stuntedgrowthinadolescents.Womenusingsteroidsdevelopadeepervoice,shrinking breasts,clitoralenlargement,andirregularmenses.AlsocausesabnormalLFTs,decreased HDL/increasedLDL,decreasedspermatogenesis,andmaycauseMI/cerebrovasculardisease o DHEAandandrostenedioneareOTCadrenalandrogenfoodsupplements.Theyaresteroid precursorsandarenotedtocauseincreasedphysicalandpsychologicalwell-being.Theirside effectsaresimilartoanabolicsteroids Illicit“ClubDrugs” Ecstasy(MDMA=methylene-dioxy-methamphetamine • • • Syntheticmethamphetaminepopularatclubsand“Rave”parties.Somestudiessuggestthatitleads topermanentserotonindepletioninthebrain Intoxication:euphoria,hyper-verbal,lossofinhibition,hypersexuality,bruxism,alteredvisual perception Adverseeffects:hyperthermia,dehydration,CHF,pulmonaryedema,andreporteddeaths.Theuser willoverexertthemselves,unawareofdehydrationandhyperthermia,leadingtosignificant morbidityandmortality Rohypnol(Flunitrazepam) • • ABZD,alsoknownas“roofies,”the“daterapedrug.” Usedbydissolvingthepillintoabeverage,Rohypnolcausessedation,amnesia,musclerelaxation, andaslowingofpsychomotorresponses.Sedationoccurs20-30minutesafteradministrationand lastsforseveralhours.Commonlyusedtocommitsexualassault,however,currentlyGHBismore widelyusedforthispurpose GHB(Gamma-hydroxy-butyrate) • • • CombinesGBL(asolventinfloorcleaningproducts,nailpolish,andsuperglueremovers)withNaOH orKOH.Itisaclearliquidthatiseasilymixedintobeverages Intoxication:euphoria,increasedenergy,hyper-verbal,increasedsocialization,disinhibition, hypersexuality,musclerelaxation,andlossofcoordinationduetolossofmuscletone.Otherside effectsincludenausea/vomiting,amnesia,poorconcentration,lossofgagreflex,andevendeath Canalsobeusedasasedativeandhasanabolicbodybuildingeffects.Commonlyusedasadaterape drug CommonlyAbusedOver-the-CounterMedications Dextromethorphan(DM) GotoTableofContents 106 D-isomerofthecodeineanaloglevorphanol(centralacting,however,isnotananalgesic)usedto suppresscough • Presentinmanycough/coldformulations,specificallyRobitussinDMandCoricidinHBP(which contains3xmoreDMthanRobitussin) • Commonlyabusedbyteensforthe“high”ofheightenedawareness,dizziness,visualhallucinations, alteredperceptionoftimeanddrowsiness.DMisveryinexpensiveandeasytoacquire.Patientswith ahistoryofEtOHorsubstanceabuseissuesshouldbemonitoredforDMabuse • SymptomsofOD:HTN,tachycardia,hallucinations,slurredspeech,sedation,seizures,dilatedpupils, temporaryblindness,severeflushing,coma,anddeath Coricidin • • • • Cough/coldpreparationsthatcontainanantihistamine(Chlorpheneramine),adecongestant(like pseudoephedrine),and/oracoughsuppressant(DM) CoricidinD,containingpseudoephedrine,ishighlyabusedduetotheeaseofconverting pseudoephedrinetomethamphetamine.Anyproductscontainingpseudoephedrinearenowclosely monitoredandnewdecongestantswithlessaddictivepropertiesarebeingmanufactured. Pseudoephedrineisacentralnervoussystemstimulant,whichcanproducesymptomsofshakiness, HTN,andtachycardia Coricidincomesinpillformulation,makingingestionoflargequantitiesofDMeasierthandrinking multiplebottlesofRobitussintogetthesameeffect UrineDrugScreen Drug EtOH Amphetamines Barbiturates BZDs Cannabis Cocaine Codeine/Morphine Heroin/Methadone PCP LengthofTimeinUrine 1drinkmetabolized/hour 2days 1day(short-acting),3weeks(long-acting) 3days,longerwithlong-actingagents 3daysto4weeks(chronicuse) 6-8hours,metabolitesstay2-4days 2days 2-3days 8days GotoTableofContents 107 ANINJA’SGUIDETOPRITEQUESTIONS2016EDITION ByMelissaPereau Thankyoutoallwhohavecontributedto“ANinjaGuidetoPRITE”since2007 • • • • • • • • • • • • Classof2008:AndyHayton,BryanWick,LuciaCheng,TaoYan,MelissaPereau Classof2009:SerinaSrikureja,KatieRoman Classof2010:TimothyLee,ChristoffLeRoux,AimeeEllison,DamanBrar Classof2011:NickMahaffey,TaujaiWilliams,NabiLatif,CarolinaOsorio Classof2012:FrankRandall,SerafinLalas Classof2013:ClaudiaCarmona,JosephLiu Classof2015:DarcyTrenkle,JaredGorsuch Classof2016:PiotrPelc,JDLii,MartinWu Classof2017:MelissaUrquhart,ShannonRemick,LauraObit,RachelNguyen,RebeccaWhite,Tagbo Arene Classof2018:JamianReed,MaryellenEller,BrentWillard,TanyaJosic,MohsinRajani,PharezRolle Classof2019:RajivJohnson,AaronHeffner,NeilAbidi,AndrewDornan,SamAlthauser,RayekNafiz Classof2020:HansVonWalter,AaronGilmore Aspecialthankstothe“LomaLindaSPEROMedicalStudentSweatshop”: • • • Classof2015:LisaKim,AnthonyBui,DebbieChoi,JessicaCvetko,JoshuaGoh,RachelHuso,Joy Jones,AllysonOshiro,MichaelSigsworth Classof2016:MarkArd,StudentProjectLeader.CaseyHarms,EricMcDonald,JacksonBrammer, JeyoonJung,AmyAppleby Classof2017:BiancaRebolledo,StudentProjectLeader.JoEverett,AprilSchindler,EdwinDeKock, ShelbyTanguay,MoniqueHarrison,CalebHo-a-shoo ThisguidecontainsallPRITEquestionsfrom2001-2015.Itisdividedintosectionsbasedonrelevanceand furthercategorizedbyfrequencyofquestions.Ifaquestionhasbeenfeaturedmorethanonce,a(#x) appearsattheendofthequestion.Thus,aquestionwith(4x)meansthequestionhasbeenfeaturedin4 PRITEexams.Allquestionsthatweredisputedorhavemorethanoneacceptedanswerhavebeendeleted. Whilethequestionsaresummaries,theanswersaretheactualanswersfromthePRITEexams.Therefore, someofthesedonotmakegoodflashcards(e.g.Question:Ariskfactorforchildabuse?Answer:Financial stress).Theseshouldbereadthrough,especiallytheoneswithmultipliers,forexposureandprimingof recall. GotoTableofContents 108 Neurology Amnesia Whatcharacterizesthememorylossinpatientswithdissociativeamnesia?(2x) EPISODIC Amnesiaprecededbyepigastricsensation/fearareassocwelectricalabnorm where? TEMPORALLOBE Memorylosspatternindissociativeamnesia OCCURSFORADISCRETEPERIODOFTIME Amnesiacharacterizedbylossofmemoryofevents,occurafteronsetofetiologic conditionoragent ANTEROGRADE Whatpsychoactivedrugproducesamnesia? ALCOHOL Ptw/strangebehavioranswersappropriatelywfluentspeechbutnoabilityto retainnewinfo.Episodelasts6hrsthenbacktonormal.Norecollectionofevents. TRANSIENTGLOBALAMNESIA Dx? A61yowithmemoryproblemthatstartedabout2hrspriortoEDpresentation, unabletorememberrecentevents,anxiousandfrustrated Transientglobalamnesia Ptreportshearingvoicesofsomeonenotpresent;stopsmoving,staresblankly, repetitivelypicksatclothing,doesnotrespondtoQs/commandsxseveralmin.The COMPLEXPARTIALSEIZURE confusionresolvesafter15minsbutpthasnorecollectionofevents.Likelywhat? 55y/optBIBfamilyafterepisodeofamnesia/bewildermentlastingseveralhrs. CVA ruledout.Ptkeepsaskingwhatishappening.Whatmedtoadministeratthis point? OBSERVATIONWITHNOPHARMACOLOGICAL INTERVENTION Whichofthefollowingdiagnosesinvolvesasenseoflossofidentity,often DISSOCIATIVEFUGUE followingatraumaticexperienceandassociatedwithinabilitytorecallone'spast? Contralaterallegweaknesswithsparingofthefaceandarms.Urinaryincontinence ANTERIORCEREBRALARTERY andabulia.Whereisthelesion? BrainLesions 80-yoptwithHTH,HLDdevelopssudden-onsetdifficultyspeakingand understandingwrittenwords.Whereisthelesion? Corpuscallosum Visualprobleminpituitarytumorcompressingopticchiasm(10x) BITEMPORALHEMIANOPSIA GotoTableofContents 109 60y/oright-handedM,gettinglost,onlywritesonrighthalfofpaper.Left-sided RIGHTPARIETALLOBE hemi-neglect.Whereisthelesion?(8x) 66y/oc/ofrequentfalls,several-monthhxofanxiety,unwillingnesstoleave home.Onexam,mildimpairmentofverticalgazeonsmoothpursuit/saccades, mildaxialrigidity&minimalrigidityofupperextremities,alongwmildslowness PROGRESSIVESUPRANUCLEARPALSY ofmovementonfingertapping,handopening&wristopposition.Posturenml. Gaittentative/awkward,butw/oshuffling,ataxia,tremor.Ptisslowinarising fromachair.Mostlikelydx:(6x) 65y/optfellseveraltimespast6mos.MSEnml.Smoothpursuit,saccadic movementsimpaired.Worsewverticalgaze.FullROMwdollheadmaneuver. Mildsymmetricrigidity/bradykinesia,notremor.MRI/CSF/labsunremarkable. Dx?(4x) PROGRESSIVESUPRANUCLEARPALSY 26y/owHA,clumsinessofrighthandxweeks.Struggleswrapidalternating movementsofRhand,overtintentiontremorwfinger-to-nose,mildlydysmetric CEREBELLUM finger-tapping.CNsnml,nopapilledema.DamagetowhatisseenonMRI?(3x) 9y/oFhas3monthh/oseeminglyunprovokedboutsoflaughter.Worsewhen not sleepingwell.Ptdoesnotfeelhappyduringtheseepisodes.Started menstruating 6monthsago,andatTannerstage4.Dx?(2x) HYPOTHALAMICHAMARTOMA 5y/owith4monthhistoryofmorningHA,vomiting,andrecentproblemswith gait,falls,anddiplopia:(2x) MEDULLOBLASTOMA 75yopatientevaluatedforprogressivegaiturineincontinenceandcognitive decline.Afterremovalofcsf,thereisimprovementingaitandbalance.What wouldCTshow? ENLARGEMENTOFTHEFRONTALHORNS 70y/optdevelopsconfusion,lethargy,andgeneralizedtonic-clonicseizure.Lab revealsserumsodiumof95mEq/L.Thisismostlikelyacomplicationofexcessively CENTRALPONTINEMYELINOLYSIS rapidcorrectionofwhichmetabolicproblem? Whichlesioncausesbilateralcoarsenystagmusworseningwithvisualfixationand BRAINSTEM presentwithhorizontalandverticalgaze? 32y/opt1-monthhxofworseningheadaches,episodicmoodswingsand occasionalhallucinationswithvisual,tactileandauditorycontent.CTheadreveals TEMPORALLOBE tumorwhere: Syndromecharacterizedbyfluentspeech,preservedcomprehension,inabilityto repeat,w/oassociatedsigns.Locationoflesioninthebrain? SUPRAMARGINALGYRUSORINSULA AcuteonsetofhemiballismusofLUE&LLE.MRIismostlikelytoshowlesion locatedwhere? SUBTHALAMICNUCLEUS 43y/onewlyAIDSpthasincreasingsocialwithdrawalandirritabilityoverseveral weeks.Can’trememberphonenumber,unabletodochores,appearsdistracted. PROGRESSIVEMULTIFOCALLEUKOENCEPHALITIS Mildrighthemiparesis,leftlimbataxia,andbilateralvisualfielddefects.LP:normal cellcounts,protein,andglucose.T2Scanisshown.Whatisthediagnosis: GotoTableofContents 110 Unconsciousnesscanbeinducedbyasmallareaofdamagewhere? RETICULARFORMATION PtwhowasadmittedtotheERafteraMVAreceivesIVdextrose5%toprovide accessforadministrationofparenteralmeds.Later,ptexperiencesconfusion, oculomotorparalysis,anddysarthria.Symptomswerelikelycausedby: WERNICKE’SENCEPHALOPATHY Ptreportsheadachesandperipheralvisualloss.Visualfielddefectsinvolvingthe temporalfieldsofbotheyesaredetected.AnMRIscanislikelytoreveal? AMASSINTHESELLATURCICA A35yoFpatienthasdiscoidlupuswhichhaslongbeencontrolledwithastable doseoforalprednisone.Sheabruptlydevelopsincreasedfatigue,inflamedjoints, anddiffusemyalgias.Ptalsoexhibitsdepressedmoodandcognitiveimpairment. Shehasnopriorpsychiatrichistoryandnofocalneurologicalsigns.Whichofthe followingisthemostlikelyetiology? DISEASEINDUCEDCEREBRITIS AC&LpsychiatristseesasickpatientwithAMS.Haspersecutorydelusionsand AH/VH.Malarrashandproteinuria,fever,pancytopeniapresent.Whatiscause LUPUSCEREBRITIS ofAMS? 25y/optreportsdoublevisionandsomedifficultywithbalance.Onrightlateral gaze,thereisweaknessoftheleftmedialrectus,withnystagmusoftherighteye. MULTIPLESCLEROSIS Onleftlateralgaze,thereisweaknessoftherightmedialrectus,withnystagmusof thelefteye.Thereisalsomildfingertonoseataxiaontheright.Dx: 52y/oMpresentswithachiefcomplaintofgaitdifficulties.Onexam:mild dysarthria,verymildfingertonoseataxiaandminimalheeltoshinataxia. Rombergtest:negative,butveryunsteadywhilewalkingandwalkswithabroadCEREBELLARVERMISATROPHY based,lurchinggait.Theplantarreflexesareflexor.Imagingstudiesaremostlikely todemonstrate: Theclinicalsyndromeassociatewithocclusionofthecorticalbranchofthe posteriorcerebralarterywouldresultinwhichofthefollowing? HOMONYMOUSHEMIANOPIAWITHALEXIAWITHOUT AGRAPHIA 34y/oMisreferredforpsychiatricevaluation5yearsaftersustainingaheadinjury atwork.Priortotheaccident,hewasastable,happilymarriedman.Sincethe accident,hehasbeendescribedasoverlytalkativeandrestless.Hiswifedivorced himbecausehewasactingirresponsibly,whichalsoresultedinterminationfrom FRONTALLOBE hisjob.Psychometrictestingrevealsthatthemanhasaverageintelligenceandno detectablememorydeficits.Pt’sclinicalpresentationismostconsistentwith damagetowhichothefollowingbrainareas? yostartskindergarten,parentsreportchildismoreemotionallyreactiveand regressionathome.Teachersayskidisnormalatschool.Whatfactorlikely accountsforchangenotedbyparents? NORMATIVERESPONSETOSTRESSASSOCIATEDWITH THESCHOOLTRANSITION Whichcancerhasthehighestlikelihoodofgoingtobrain? LUNG Whichhormoneissecretedinfunctionalpituitaryadenoma: PROLACTIN GotoTableofContents 111 CT&MRIshowventriculomegalyareoutofproportiontosulcalatrophy.Thisis suggestiveofwhatdiagnosis? NORMALPRESSUREHYDROCEPHALUS 20y/owith1-yearh/obitemporalheadaches,polydipsia,polyuria,andbulimia plus 2-monthh/oemotionaloutbursts,aggression,andtransientconfusion.Neuro examnormal.WhatwillMRIofbrainshow? HYPOTHALAMICTUMOR Previouslypleasantmombecomesprofaneandirresponsibleover6months.Most FRONTALLOBE likelyapathologyin: Unilateralhearingloss,vertigo,unsteadiness,falls,headaches,mildfacial weaknessandipsilaterallimbataxiaismostcommonlyassociatedwithtumorsin whatlocations? CEREBELLOPONTINEANGLE 38y/oFwithmusclespasmoftheproximallimbsandtrunk,lumbarlordosiswhile walking,w/oEMGabnormalityandwithserumantiglutamicacidantibodiesis STIFF-PERSONSYNDROME sufferingfrom: Apituitarytumorthatprotrudesthroughthediaphragmaticsellaismostlikelyto cause? BITEMPORALHEMIANOPSIA Conductionaphasiaoftenoccursasaresultofdamagetowhichstructure? ARCUATEFASCICULUS 70y/odevelopsflaccidparalysisfollowingseverewaterintoxication.He developsdysphagiaanddysarthriawithoutothercranialnerveinvolvement. CENTRALPONTINEMYELINOLYSIS Sensoryexamislimitedbutgrosslynormal,DTR’saresymmetric,andcognitionis intact.Likelydx:(X2) MRIfindingforwomanwithmemorydecline,urinaryincontinence,andtrouble walking DILATIONOFVENTRICLES Ptdrawsclockwithhemiagnosia.Whereisthestroke? PARIETALLOBE Effortful,nonfluentspeechwithdecreasedspeechoutput ANTERIORFRONTALGYRUS GotoTableofContents 112 A43y/opatientwithnewlydiagnosedAIDShasincreasedirritability,can’t rememberphonenumbers.Mildrighthemiparesis,leftataxiaandvisualfield defectsapparent.LPisnormal.MRIabove.Whatisdiagnosis? Progressivemultifocalleukoencephalitis A50yoBIBEDforSAbybeinginaclosedgaragewiththecarsrunningfor severalhours.CTbrain2weekslaterwouldshow Lesioninglobuspallibus Catatonia Whichtermdescribesstateofimmobilitythatisconstantlymaintained?(Ability ofacatatonicpttoholdthesameposition)(2x) CATALEPSY 52y/owithh/ounipolardepressionisbroughttoEDwithafirstepisodeof catatonia.Ptisonnomeds,UDSisneg.Furtherw/ushouldinitiallyfocusonwhat factor? METABOLICDISORDERS Amonginpatients,availabledataindicatesthatcatatoniamostfrequentlyoccursas MAJORDEPRESSIVEDISORDER afeatureofwhatillness? 21y/orecentlydiagnosedwithschizophreniabecomeslargelymuteand occasionallyrepeatswordsinaparrot-likemanner.Thisisasubtypeof schizophreniacalled: CATATONIC Symptomsthatmaydominatepictureofmooddisorderswcatatonia? EXCESSIVEPURPOSELESSMOTORACTIVITYNOT INFLUENCEDBYEXTERNALSTIMULI CVA 62y/oMw/DMisnotmakingsense,saying“tharszingisphrumperzustalking”. Normalintonationbutnooneinthefamilycanunderstandit.Heverbally WERNICKE’SAPHASIA respondstoQswsimilarutterancesbutfailstosuccessfullyexecuteany instruction.(8x) GotoTableofContents 113 66y/owithHTNdevelopsvertigo,diplopia,nausea,vomiting,hiccups,Lface numbness,nystagmus,hoarseness,ataxiaoflimbs,staggeringgait,andtendency LATERALMEDULLARYSTROKE tofalltotheleft.Dx?(8x) ChronicA-fibdevelopsaphasiaandRhemiparesisatnoon.ERexamnotes weaknessofRextremitiesandseveredysfluentaphasia,butCTat1:30PMhas noacutelesion.Mostappropriatetreatment:(4x) TPA Rapidonsetofrightfacialweakness,leftlimbweakness,diplopia:(2x) BRAINSTEMINFARCTION Alifethreateningcomplicationofcerebellarhemorrhageis:(2x) ACUTEHYDROCEPHALUS A72yopatienthadanembolicinfarctinthemiddlecerebralarteryterritory.ECG showsnostructuralabnormalities.Dopplerstudiesoftheneckarteriesreveal lessthan50%occlusiononbothcarotidarteries.AnEKGrevealsAFib.Whichof ANTICOAGULATIONWITHWARFARIN thefollowingstrategieshasthebestlikelihoodofreducingrecurrentstrokesin thispatient?(2x) Youngadultgained70lbsinlastyearc/odailysevereheadachessometimes assocwithgrayingoutofvision.Papilledemapresent.CTandMRIbrainno abnormalitiesbutventriclessmallerthanusual.Goaloftreatmentinthiscase: (2x) PREVENTBLINDNESS 68y/optw/hypertensiondevelopsrapidlyprogressingrightarmandleg weakness,withdeviationoftheeyestotheleft.Within30minutesoftheonset ofthisdeficit,ptbecameincreasinglysleepy.Twohoursaftertheonset,the patientbecameunresponsive.Onexam:denserighthemiplegia,eyesdeviatedto LEFTPUTAMINALHEMORRHAGE theleft,pupils:equalandreactive,arightfacialweaknesstogrimaceelicitedby noxiousstimuli.Coughandgagreflexes:present.WhichCTfindingismostlikely? (2x) Superiorhomonymousquadranticdefectsinthevisualfieldsresultfromlesions towhichofthefollowingstructures?(2x) TEMPORALOPTICRADIATIONS 78y/opthadanischemicstrokethatlefthimwitharesidualmildhemiplegia.Pt appearedtobeunawarethattherewasaproblemofweaknessontonesideof thisbody.Whenaskedtoraisetheweakarm,thepatientraisedhisnormalarm. Whenthefailuretoraisetheparalyzedarmwaspointedouttopt,headmitted RIGHTPARIETALLOBE thatthearmwasslightlyweak.Healsoneglectsthesideofthebodywhen dressingandgrooming.Ptdidnotshaveonesideofhisface,haddifficulty puttingashirtonwhenitwasturnedinsideout.Areaofbrainlikelyaffectedby stroke?(2x) Apthasmultiplestokelikesymptomsofshortdurationoverseveraldays.And hasnewonsetsymptomsforthelast90minutes.CTscanshowsnoevidenceof strokeorhemorrhage.Whatistheappropriatetreatment?(2x) INTRAVENOUSTHROMBOLYTICAGENTS MRIscanofheadrevealsaninfarctindistributionofleftanteriorcerebralartery. WEAKNESSOFCONTRALATERALFOOTANDLEG Ptmostlikelyexhibits:(2x) Puresensorydeficitextendingtomidlineandinvolvingface,arm,trunk,andleg causedbylacunarinfarctwhere? LATERALTHALAMUS GotoTableofContents 114 HeadCTw/lens-shapedhyperdensity EPIDURALHEMATOMA 50y/optrecentlybeganhavingVHofchildrenplaying.VHarefullyformed, colorfulandvivid,butwithnosound.Ptisnotscaredordisturbed,butrather amused.Onexam,normallanguage,memory,cranialnerves,noweaknessor involuntarymovement,nosensorydeficits.DTR:symmetric.CSF/UDSnml. POSTERIORCEREBRALARTERYISCHEMIA 124.Bilaterallowerextremityweakness,abulia,mutism,urinaryincontinence aremostlikelytoresultfromocclusionofwhichofthefollowingarteries? Anteriorcerebral Right-sidepalsywithequalinvolvementoftheface,armandlegcombinedwith thirdnervepalsyismostlikelyduetoocclusionofabranchofwhichartery? POSTERIORCEREBRAL Hemisensorylossfollowedbypainandhyperpathiainvolvingallmodalitiesand reachingthemidlineoftrunkandheadismostconsistentwithischemiainthe distributionofwhichofthefollowingarteries? POSTERIORCEREBRAL Whatisthemostcommonmanifestationofacuteneurosyphillis? STROKE 65y/optwakesupwithright-sidedhemiparesisandmotoraphasia.Ptis immediatelybroughttotheemergencydepartmentandanevaluationis completedwithin1hour.Neurologicalexam:noadditionalabnormalities.HeadCT ASPIRIN w/ocontrast:noadditionalabnormalities.Whichistheappropriatenextstepin management? 65y/opthasastrokewhichcauseshimtofall.Onexam,weaknessoftherightleg, withonlyminorweaknessoftherighthand,noweaknessoftheface,nosensory LEFTANTERIORCEREBRALARTERY deficit.Speechisnotaffected,butptseemsunusuallyquietandpassive.The strokemostlikelyinvolvesthe: 58y/oMh/oHTN,cigsmokingandsuddeninabilitytospeak.FacedroopingonR anddraggingRleg.InERexaminedwithin40minsofonset:Aphasic,unableto understandorrepeatverbalcommands.Unintelligiblesoundsforspeech.Alertbut THROMBOEMBOLICSTROKEOFLEFTMCA appearsfrustrated.Rhemiplegiawitharmandfaceweakerthanleg.CThead:no hemorrhage.Pathologytypeandarea: Abuliareferstoimpairmentinabilityto: SPONTANEOUSLYMOVEANDSPEAK Suddenonsetvertigo/nausea,hoarseness/dysphagia,rightsidedfacenumbness, diminishedgagreflexonright,decreasedpinprickandtemperaturesensationon left: RIGHTMEDULLARYINFARCTION 65y/odiabeticptpresentstoEDc/oacuteLsidedweakness,deviationofgazeto R,Lhemiplegiaandhemisensorydeficit,andLhomonymoushemianopsia.12hrs later,ptisunconscious,Lpupilenlargedandunreactive.CTwillshowwhat? RMCAINFARCTW/EDEMAANDUNCALHERNIATION Ptwithacuteonsetvertigo,whatwillsuggestRlateralmedullaryinfarct? RIGHTFACIALLOSSOFTOUCHANDTEMPERATURE SENSATION 46y/oMw/doublevision+painReye.Exam:ptosisReyelid,inabilitytoelevate oradductReye+Rpupillarydilation.Thisiscausedby: POST.COMMUNICATINGARTERYANEURYSM Aphasiaw/effortfulfragmented,non-fluent,telegraphicspeech,isseeninalesion POSTERIORFRONTALLOBE where? GotoTableofContents 115 39y/optwithhxofmultiplemiscarriagesdevelopsanacuteleftsidedhemiparesis. Workuprevealselevatedanticardiolipintitersandnootherriskfactorsforstroke. PLASMAPHERESIS Appropriateinterventionatthispointis? Abnormalelevatedmetabolicfindingsassociatedwithincreasedriskofstrokein patientsunder50 PLASMAHOMOCYSTEINE 70y/optwashospitalizedbecauseofamiddlecerebralarterystroke.The psychiatristwasaskedtoevaluatethept.Thepthasnon-fluentaphasia.Which mostlikelycharacterizedthept’sinteractionwiththepsychiatrist? THEPTWASABLETOFOLLOWTHEVERBALREQUEST, “CLOSEYOUREYES.” Acuteonsetofdensesensorimotordeficitinthecontralateralfaceandarm,with milderinvolvementofthelowerextremity,associatedwithgazedeviationtoward SUPERIORDIVISIONOFTHEMCA theoppositesideofthedeficit,likelyindicatesocclusionof: Weaknessofextensionatkneeinvolvesalesioninwhichnerve? FEMORAL CTscanwithoccipitalandintraventricularhyper-intensities: PARENCHYMALHEMORRHAGE WhichmedhassecondarypreventionagainstembolicstrokeinptswithA-fib? ORALWARFARIN Asopposedtostrokescausedbyarterialembolismorthrombosis,thosecausedby ASSOCIATEDWITHSEIZURESATONSET cerebralveinorvenoussinusthrombosisare: Atrophyofrighttemporallobeoncrosssectionassociatedwithocclusionof: MIDDLECEREBRALARTERY Lossofabilitytoexecutepreviouslylearnedmotoractivities(whichisnotthe resultofdemonstrableweakness,ataxiaorsensoryloss)isassociatedwithlesions LEFTPARIETALCORTEX of? 58y/os/pCABG–anomiaforfingersandbodyparts,errorsinvolvingrightand left,inabilitytowritethoughts/takenotes/makecalculations.Fluentspeechand excellentcomprehension LEFTMEDIALTEMPORALSTROKE Visualdisturbancesassociatedwithocclusionoftherightposteriorcerebralartery? LEFTHOMONYMOUSHEMIANOPSIA 65y/ow/HTNcollapsed.InEDisstuporous,Rhemiparesis+hemisensorydeficit, eyesdeviatetoL.CTwouldshowintraparenchymalhemorrhagein: LEFTBASALGANGLIA Lowerfacialweaknessw/relativesparingofforehead,strokein? INTERNALCAPSULE Higherfrequency&greaterseverityofdepressionassociatedw/cortical& subcorticalstrokes: LEFTANTERIORFRONTAL 68y/optisdepressedfollowingahipsurgery.Ptiswithdrawn,looksblank,shows dysarthria,weakness,PMR,hyperreflexia,andhastroubleswallowing.MRIofthe PERIVENTRICULARWHITEMATTERDEMYELINATION headwillshow: Prognosisofacuteinflammatorydemyelinatingpolyneuropathyispoorestifthe diseaseprocessinvolveswhichofthefollowing? PROXIMALAXON GotoTableofContents 116 PtwithHTNdevelopspainlessvisionlossinthelefteye.Exam:blindnessinLeye andafferentpupillarydefectontheleft.MRI:severalT2hyperintensitiesinthe whitematterperiventricularly.Nocorpuscallosumlesions.Noenhancementwith gadolinium.Dx? ISCHEMICOPTICNEUROPATHY 63y/owithnewonsetaphasiaandRhemiparesis,2daysagohadmilder/similar symptomsthatresolvedin30minutes,yesterdayhadsimilarepisodex45minutes. INTRAVENOUSTHROMBOLYTICAGENTS CurrentSxstarted1.5hrsago.CTshowsnostrokeorhemorrhage.Tx? Prosopagnosiais: INABILITYTORECOGNIZEFACES 57y/odiabeticpt=w/HTNc/oseveralepisodesofvisualloss,“curtainfalling”over hisLeye,transientspeechandlanguagedisturbance,andmildRhemiparesisthat EXTRACRANIALLEFTINTERNALCAROTIDSTENOSIS lasted2hrs.Suggestspresenceofwhat? Headinjury,LOC->lucidintervalxhours->rapidprogressingcoma.Hemorrhage? EPIDURAL 5daysafterCABGa47y/oMisdisorientedtotimeandplace.Heidentifieshis rightandleftbutnotthatoftheexaminers.Candrawsquareandcirclebutnota clock.Thisis: DYSPRAXIA PtinEDwithsuddenHAandcollapsing,somelethargy.Examshowsrigidneck,no CTHEAD papilledema,nofocalCNormotorsigns.Theinitialtestshouldbe? Poststrokedepressionin80yopt(Rhanded)isassocwcognitiveimpairments that: CORRELATEWITHLEFTHEMISPHERICINVOLVEMENT Fluentspeechwpreservedcomprehension,inabilitytorepeatstatementsis consistentwithwhattypeofaphasia? CONDUCTION NormalRombergw/eyesopenbutlosesbalancewitheyesclosed.Whereisthe abnormality? CEREBELLARVERMIS 65y/ow/hxofHTN,Meniere’swithsuddenvertigo,N/V,worsewithhead movement,Rbeatingnystagmusonlateralgaze,fingertonosetestingisataxic, poorbalanceanddysarthria.Dx? CEREBELLARINFARCT 66y/oMinEDw/suddenoccipitalHA,dizziness,vertigo,N/V,unabletostand, mildlethargy,slurredspeech.Exam:smallreactivepupils,gazedeviatedtotheR, nystagmus,w/occasionalocularbobbing,Rfacialweakness,decreasedRcorneal reflex,truncalataxia,b/lhyperreflexia,b/lBabinski.Dx? CEREBELLARHEMORRHAGE MotorspeechparadigmactivationtaskonfMRI–hyperactivityinrighttemporal lobe.Damageiswhere? CALCARINEFISSURE Inabilitytorecognizeobjectsbytouch: ASTEREOGNOSIS Inmanagingacuteischemicstroke,administerthiswithin48hrsofonsetofstroke ASPIRIN forbeneficialeffectinreducingriskofrecurrentstroke,disabilityanddeath: GotoTableofContents 117 70y/optw/attacksof“whirlingsensations”w/n/v,diplopia,dysarthria,tinglingof lips.Occursseveraltimesdailyfor1minute,severethatptcollapsesandis VERTEBROBASILARINSUFFICIENCY immobilizedwhensymptomsstart.Noresiduals/s,notinnitus,hearing impairment,ALOCorassociationwithanyparticularactivity.Dx? ComponentoftypeAbehaviormostreliableriskfactorforCAD HOSTILITY Vascularlesionmostcharacteristicofsuddensevereheadache,vomiting,collapse, relativepreservationofconsciousness,fewornolateralizingneurologicalsigns, SUBARACHNOIDHEMORRHAGE andneckstiffness: HeadCTdemonstrateswhichdx(grainypicturewithdiffusespecklinginposterior region,unilateral) SUBARACHNOIDHEMORRHAGE Ptw/suddenonsetofLhemiparesis,Lhomonymoushemianopsia,tendencyto gazetoright,andneglectleftsidedstimuliaredeficitsmostlikelyresultof occlusionof: RIGHTMIDDLECEREBRALARTERY 70y/oFsuddenonsetparalysisRfootandleg.Rarmandhandslightlyaffected. Noaphasiaorvisualfielddeficit.Overweeksfoundwithlossofbladdercontrol, abuliaandlackofspontaneity.Whichvasculararea: ANTERIORCEREBRALARTERY(LEFT) 70yroldhospitalizedduetoMCAstroke,psycheval,pthasnon-fluentaphasia, whatcharacterizesptsinteractionwithpsychiatrist? theptwasabletofollowthecommandtocloseyour eyes Ptsinalockedinstatefollowingbasilararteryocclusiontypicallyretainwhat movement? eyelidsandverticalgaze Delirium 72w/recentbehavior/memoryproblems.Disrobing,notsleeping,irritable. Waxingandwaningconsciousness.Dx?(8x) DELIRIUM 79y/optw/decreasingmentalstateover3weekshasanexaggeratedstartle responsewithviolentmyoclonusthatiselicitedbyturningontheroomlights, speakingloudly,ortouchingthepatient.Myoclonicjerksoccurspontaneously, ataxia,EEG:sharpwaves.Dx:(5x) SUBACUTESPONGIFORMENCEPHALOPATHY 52y/optw/hxofdepression&HTNhospitalized,beingevaluatedbypsych resident.HisfamilyreportshehadsevereHA&“hasnotbeenhimself”for10 days.Onexam,pthaspooreyecontactandisinattentive,muttering,pickingat his clothes,occasionallydozingoffalthoughitismidday.Dx:(4x) DELIRIUM Mildconfusion,lethargy,thirst,polydipsia:(2x) HYPONATREMIA GotoTableofContents 118 Multifocalmyoclonusinacomatosepatientindicates:(2x) METABOLICENCEPHALOPATHY 70y/owithmildAlzheimer’sliveswithfamilyandprescribedSSRIfordepression. AlsohasHTN,adultonsetDM,andRA,whicharestable.Theptdevelopsacute ELECTROLYTES confusionbutnoothermedorpsychsymptomswhichtestshouldbeordered first?(2x) Whattestismosthelpfultodistinguishdementiavsdelirium EEG Alcoholicp/w2daysconfusion,AH/VH,disorientation,distractibility,withfever, tachycardia,andtremor.EEGshowslow-voltagefastwavessuperimposedonslow DELIRIUMA/WETOHWITHDRAWAL waves.Long-termolanzapinetreatmentforschizoaffectived/o.Dx? MostcommonEEGfindinginmetabolicencephalopathy?(questionrequires assigningdiagnosistoEEG) GENERALIZEDSLOWING Twodaysafterbowelsurgery,53y/oisdelirious.Correctlydrawsasquarewhen asked,butthencontinuestodrawsquareswhenaskedtodrawothershapes.MSE PERSEVERATION wouldreveal: 75y/oFptis8dayss/ptotalhipreplacementandhasdelirium.Herdiazepamand doxepinwerediscontinuedjustpriortosurgery.Sheisgettingmeperidineforpain, diphenhydramineforsleepandarenewedprescriptionfordoxepin.Herconfusion islikelyduetowhichofthefollowing:medicationtoxicity,diazepamWDRL, electrolyteimbalance,atypicaldepression,UTI. MEDICATIONTOXICITY,DIAZEPAMWITHDRAWAL, ELECTROLYTEIMBALANCE,ATYPICALDEPRESSION,OR UTI. (ALLOFTHEABOVE) PtwithICUpsychosismostlikelyhaswhatcondition? DELIRIUM Bestrecommendationforptwithdelirium?Minimizecontactwithfamilymembers orlimitsleepmedstodiphenhydramine,ormaximizestaffcontinuityassignedto MAXIMIZESTAFFCONTINUITYASSIGNEDTOPT pt? DeliriuminHIVpatientstreatedwithwhatparenteralagent? LOWDOSEOFAHIGH-POTENCYANTIPSYCHOTIC A34yopatientisbeingtreatedformalariaafterreturningfromatriptoKenya. Thepatienthasahistoryofschizoaffectivedisorderwhichhasbeenwellcontrolled formorethanadecadewithacomboofRisperdalandLithium.Theptisgivena UNCOMMONSEOFTHEANTIMALARIALTREATMENT singledoseofmefloquine,howeverafter1weekthepatientreportsfeeling anxious.ThisescalatesoverthenextweektoPMAandpersecutorydelusions.The mostlikelycauseofthept’spsychoticsymptomsis: Cancerpatientonchemoisdisorientedandagitated.AfebrileVSS.Negneuro exam.Poorattention,cogimpairment.Heldforobservation.CTneg,EEGdiffuse slowing.Treatwith: HALDOL 70y/o+HIVheroinabuseristreatedwithLopinavirandRitonavirandfluoxetine forMDD.HepCwasdxandtreated2monthsago.Sincethenptismoreirritable, insomnia,anddiarrhea.Why? DRUG-DRUGINTERACTION Aconsultisrequestedforapatientonamedicalwardwhoisagitatedand hallucinating.Ptappearstobeflushedandhotwithdryskin,mydriasis,arapid pulseanddiminishedbowelsounds.Whatisyourfirstrecommendation? D/CANTICHOLINERGICDRUGS GotoTableofContents 119 Suggestsdeliriumratherthandementia: CLOUDINGOFCONSCIOUSNESS 85y/onursinghomeptw/hxofdementiabeingmoreconfusedandscreaming “fire” wheneverthelightnexttothebedisturnedon.Nextstep? URINALYSIS Ptw/hxofCPSpresentedtoEDwithhightemp,tachycardia,dilatedandpoorly reactivepupils,VH,agitation,constipation,anddryskin.Dx: ANTICHOLINERGICDELIRIUM Whichofthefollowingisthemostcommonpsychiatricpresentationfollowinga stroke? Thismajorsymptomofdeliriummayrequirethattheptreceivepharmacological treatment: 57y/owAMSoverseveralhours,followedbyabruptreturntonormal.No recollection,patientobservedtobeconfused,oriented.Ptkeepsaskingsame question,otherwiseneuroexamnormal,noweakness,lossofbalance,speech impairment.Whatistypicalofthiscondition? Doctorexamines81-year-oldpttwicedaily,midmorningandlateafternoon. Comparingthetwoassessments,whatfindingssuggestthatthepatientis delirious? Depression INSOMNIA Recurrentepisodesrare Logical,coherentspeechonfirstexam,disorganized speechonsecond Dementia 65y/oMwith6moh/oconfusionepisodes,disorientation,VHsofchildren playinginhisroom.Hallucinatedimagesarefullyformed,colorful,vividandpt haslittleinsightintotheirnature.NoAH.Wifesaysheisnormalbetween episodes.Exam:Normallanguage,memory,moddiffwithtrailstest,milddiff withserialsubtractions,mildsymmetricrigidityandbradykinesia.BrainMRI unremarkable.CSF,routinelabsandUDSnormal.Diagnosis:(7x) LEWYBODYDEMENTIA WhichisalimitationoftheMMSE?(7x) MAYFAILTODETECTVERYMILDCOGNITIVE IMPAIRMENT Whencombinedwithfunctionalneuroimaging,whichofthefollowing biomarkersismostlikelytoidentifythosegeriatricptswithmildcognitive impairmentmostatriskfordevelopingAlzheimer’sdisease?(6x) E-4APOLIPOPROTEINEALLELE Whichofthefollowingisthemostspecificfactorfordistinguishingdeliriumfrom FLUCTUATINGAROUSAL dementiaoftheAlzheimertype?(2x) 72yoearlydementia.Paranoid+VH.Lightheaded+socialinappropriate.Risperdal LEWY-BODYDEMENTIA .25x2days->confusion/sedation/rigidity.dx? Inadditiontoorientation,attention,calculation,languageandregistration,what othercognitivedomaindoesthemmsetest? Whatisbeingassessedwhenpatientisaskedtorepeatwords"Apple,table, penny"? RECALL Registration GotoTableofContents 120 Pictureoftaustainingforptwithprogressivedementia.Dx? ALZHEIMER'S 80y/owithVHandworseninggait,episodicconfusion,disturbedsleep,fightingin sleep,bilateralrigidity,maskedfacies.Levodopa/carbidopaimprovedmovement DEMENTIAWITHLEWYBODIES temporarily.Diagnosis? 80yop/winsidiousforgetfulnessf/bprogressivelanguageimpairment2yrlater withdifficultyusingcommontools/appliances.Dx? WhatmedicineinterfereswithefficacyofDonepezil? Alzheimer’sDisease OXYBUTYNIN Aptwhohasbeenreceivingdialysistxforyearshasbecomemoredisoriented,has memoryloss.Physicalexamnormal,nursingstaffreportthatpthasbeguntohave DIALYSISDEMENTIA seizures.Bloodlabtestingshowsnoobviousetiology,neurodiagnosticsshowno suggestivefindings.Whatmostlikelyaccountsforthispresentation? Whichtestcorrelatesmoststronglywithpre-morbidfunctioninginptw/early dementia: WECHSLERADULTINTELLIGENCESCALEIVVOCABULARY TEST(WAIS-IV) 71Y/Onursinghomeresidentwithsx:Parkinsoniangait,prominentdelusions, fluctuatingattention,visualhallucinations,sensitivitytoEPSeffectsof antipsychoticmeds.Dx? DEMENTIAWITHLEWYBODIES FTDwithmutationinchromosome17isassocwithabnormalintraneuronal depositionofwhichprotein? TAU NeuropsychologicaltestmostusefulintheearlydiagnosisofAlzheimerdisease: 10-ITEMWORDLISTLEARNINGTASK. Adocmeetswithaptandfamilytodiscusstreatmentofpt’smildAlzheimer’s disease.Therearenootherneurologicalorpsychiatricsymptomsorfindings.The mostappropriatecourseofactionwouldbeto: BEGINCHOLINESTERASEINHIBITORTREATMENT 74y/o,right-handedpatientpresentswithsignificantmemoryloss,expressive aphasia,andleftplantarextensorresponse.Themostlikelydiagnosisis: VASCULARDEMENTIA SxmostlikelyrelatedtoexcessiveuseofvitaminB12 BURNINGSENSATIONS 60y/oFwith10monthhxofapathyanddepressionhashyperchromicmacrocytic VITAMINB12LEVEL anemia.Besttesttoordernext: EarliestevidenceofcelllossinptswithAlzheimer’sDztypicallyoccursinwhichof thefollowingareasofthebrain? ENTORHINALCORTEX AptwithEtOH-dependencepresenttoEDwithconfusion,ataxia,nystagmusand ophthalmologist.Highdosesofwhichofthefollowingvitaminscouldhave preventedthissyndrome? VITAMINB1 MedicationhelpfulinearlyHIVdementiabutispotentiallytoxiclaterinthe disease? METHYLPHENIDATE 74y/oFsuspicious,poorADLs,personalitychanges,mostlikelydx: PICK’SDISEASE GotoTableofContents 121 80y/optw/nopriorpsychhx,moreforgetful,havingdifficultywithADLs. However,ptisabletoconductroutinesocialactivitiessothatcasualacquaintances ALZHEIMERDEMENTIA don’tnoticeabnormalities.Whatisthedx? Safestheterocyclicantidepressantfor78y/owdepression,agitation&dementia is: NORTRIPTYLINE WhatcognitiveenhancerisanNMDAreceptorantagonist? MEMANTINE Neuronaldamagefromexcitotoxicitysecondarytoglutamatesensitivity.Treat with: MEMANTINE Acamprosateworksthroughwhichneurotransmittersystem? GLUTAMATE NeurofibrillarytanglesinAlzheimer’sarecomposedof: HYPERPHOSPHORYLATEDTAUPROTEINS 80y/oAlzheimer’swithincreasinglycombativebehavior.Familywantstokeepat home.Givewhatmedication? HALDOL Dementiacharacterizedbypersonalitychange,attentiondeficit,impulsivity,affect lability,indifference,perseveration,andlossofexecutivefunction.Assoc.with FRONTALLOBE dysfunctioninwhatareaofthebrain? Binswangerdiseasehaspseudobulbarstate,gaitdisorder,AND: DEMENTIA 80y/optwithAlzheimer’sisbroughtinforincreasinglycombativebehavior. Daughterwouldliketokeeptheptathomeifpossible.Whatinterventionswould bemosthelpfulinthissituation? ASSESSINGFORCAREGIVERBURNOUT EarlystageHIVtypeIassociateddementiaascomparedtoearlyonsetdementia haswhichofthefollowingdeficits? DECREASEDPROCESSINGSPEED Whichmedshavebestresultsfortreatingagitationindementia? ANTIPSYCHOTICS Clockdrawingtestisquicklyadministeredandsensitivescreenforwhichd/o? ALZHEIMER’SDZ Amyloidprecursorproteininwhatcognitivedisorder? ALZHEIMER’SDZ Mostcommoncauseofdementiainpts>65yrsofage: ALZHEIMER’SDZ Individualsover40yowithDown’ssyndromefrequentlydevelop: ALZHEIMER’SDZ CharacteristicMRIscanfindinginAlzheimerdisease: REDUCEDHIPPOCAMPALVOLUMES. Knownriskfactorsfordementia: AGE,FAMHX,FEMALE,DOWN’SSYNDROME NeuronalenzymethatisthetargetofdrugstotreatAlzheimer’si.e.galantamine andrivastigmine ACETYLCHOLINESTERASE Ptwithvasculardementiatypicallyhasneuropathologicalchangesassocwith: BASALGANGLIA GotoTableofContents 122 An82-yopthasfalls,opthalmoplegia,parkinsonismandprogressivedementia. Autopsyshows: Taupositiveneurofibrillarytangles 83yoptwithmildHTNcomesinwithnewonsetheadacheandlefthemiparesis. MRIshowsrightparietallobehemorrhage,smalloccipitalhemorrhageand AMYLOIDANGIOPATHY evidenceofprevioushemorrhageinrighttemporalandleftparietalregions.What islikelyetiologyforthesefindings? 65y/oisbroughttotheEDwithdisorientationandmildagitation,andis experiencingvividVHofseveralchildrenplayinginsidethehouse.Twosimilar episodesinthepast,normalinbetweenepisodes.Normallanguageandmemory, DEMENTIAWITHLEWYBODIES normalCN,mildsymmetricrigidityandbradykinesia,nodeficits.MRI,drugscreen, CSFnormal: Amedthatismostlikelytoslowtheprogressionofvasculardementia: ASPIRIN BestrationaleforusingcholinesteraseinhibitorsinptswithAlzheimer: TOREDUCENEUROPSYCHSYMPTOMS HIV+ptw/memoryloss,inattention,lackofmotivation,&poorcoordination. NormalLP.CTscanshowsatrophy.MRIshowsdiffuse&confluentwhitematter changesinT2,w/oanymasseffectorgadoliniumenhancement.Dx? HIV-ASSOCIATEDDEMENTIA Themostimportanttoolforevaluationofearlyandmoderatedementia: MMSE A62yoptisreferredforcomplaintsofmemoryproblems.Thepatientreports feelingmoreforgetfulandgivesexamplesof“losingmykeys,handbag,or forgettingthenamesofaquaintances.”Theptdeniesanyotherneurocognitive symptoms.Familymembersconfirmthepatient’sreport,andfeelthatthishas beenagradualchangeoverthelastyear.Familymembersreportthattheptisa HASACEILINGEFFECTFORWELL-EDUCATEDPERSONS formerhxprofessorwhocontinuestoenjoyintellectualactivitiesandtheyneedto prepareifthepatientisgoingtolosethesecapabilitiesasaresultofdementia.The standardMMSEwouldbearelativelyinsensitiveinstrumentforthispatient because: 65y/optbroughtinbyfamilyforgradualonsetandveryslowprogressionof mentalconfusionwithrespecttoplaceandtime,anomia,slownessof comprehension,neglectofpersonalhygieneandgrooming,apathy,andalterations FRONTOTEMPORALDEMENTIAORALZHEIMER ofpersonalityandbehavior,impairmentofgaitanduprightstance,andprominent DEMENTIA graspandsuckreflexes.Dx?Theclockdrawingtestisaquicklyadministeredand sensitivescreen for: 65y/ohighschoolgradhasaMMSEscoreof23,thisscorewouldsuggestwhichof DEMENTIA,MILDCOGNITIVEIMPAIRMENT thefollowing: Overcourseofseveralmonth46yoptwnopastpsychhxbecomesemotionally labile/irritable.Ptundergoespersonalitychanges,isobservedtolaugh inappropriatelywhenneighborkidstauntstraycat.Within2yrsptisconvincedall FRONTOTEMPORALDEMENTIA foodhasgerms.Memoryispreserved.Ptisnolongerabletowork/live independently.Neuropsychtestingshowsimpairedlanguage/attn. Dementiaratherthandepressioninregardstomemoryhas… NAMINGDEFICITS(RATHERTHANIMPAIRED NONVERBALINTELLIGENCE) GotoTableofContents 123 BilatlossofneuronsintheCA1segmentofthehippocampusisthemostcommon ALZHEIMERDEMENTIA histologicfindinginpatientswith: 65yoptlivesalone,increasinglyforgetfuloverthepastyear,lifelongdifficulty recallingnamesofacquaintances,nowhasdifficultywithphonecallsand rememberingappts.livesindependently,drives,preparesmeals,MSEwithdelayed AMNESTICMILDCOGNITIVEIMPAIRMENT recallof4words,otherwisenormal.Ptupsetbydifficultyandisnotdepressed. symptomsmostconsistentwith…? Mostcommongeneticabnormalityleadingtointellectualdisability DOWN’SSYNDROME PatientisAlzheimer’sdementiainclinic.Patient’sdaughterisfrustratedwith havingtocareforhermothermoreandisconsideringremovingherfromher churchgroupbecauseofit.Whatisthemostinitialresponsebythepsychiatrist? TELLHERTOCONTINUEGOINGTOHERCHURCHGROUP Brainoffootballplayerwhodiedbysuicidehasfindingstypicalofchronic traumaticencephalopathy,whatismosttypicalpathologyforthisbehavior? TAUPATHY PETscanshowsbitemporoparietalhypoperfusioninearlystagesofwhich dementia? Alzheimer 54yroldptdiesfromrapidlyprogressingdementiaassociatedwithmyoclonus, whatismostlikelyfindingatautopsy? microvacuolationofgliaandneuronaldendrites Seizures 16y/optbroughttopsychiatrist’sattnafterhavingsinglegrandmalsz.Pt’s parentshavenotedonoccasionpthassuddenjerksofentirebody,resultingin droppingobjects.EEG:rare4-6HZirregularpolyspike/wavebursts.Diagnosis? (9x) JUVENILEMYOCLONICEPILEPSY 8y/ohasepisodesofstaringintospaceandthenblinkingforafewseconds.EEG willshow?(7x) 3CYCLESPERSECONDSPIKEANDWAVEACTIVITY 40y/ohasepisodesofflailingofthearmsandtonicposturesdescribedas “fencing.”EEGconfirmsseizure.Whichseizuretype?(4x) FRONTALLOBE 10y/ochildfreqepisodesbrieflapsesofconsciousnesswithoutpremonitorysxs. Lasts2-10seconds,followedbyimmediateandfullresumptionofconsciousness ABSENCE withoutawarenessofwhathashappened.Theseictalepisodesmostlikely causedbywhatkindszs?(4x) 1stseizurewithfocalonsetandsecondarygeneralizationina58y/optislikely theconsequenceofwhat?(2x) GLIOBLASTOMAMULTIFORME Whatisthediagnosticvalueoftransientparesisoraphasiaafteraseizure?(2x) LOCALIZESTHEFOCUSOFSEIZURE 6yochildw/briefepisodesofstaringandfast,rhythmicblinding.Besttreatment? VALPROICACIDETHOSUXIMIDE 40yonew-onsetszb/lthrashingmovement.Whatsuggestsnon-epilepticcause? FOLLOWINGCOMMANDS GotoTableofContents 124 Whichofthefollowingbestdescribesthecharacteristicsofthenormaladultalpha INTERMITTENTANDPOSTERIORDOMINANT rhythmseenonanEEGrecording? Whichofthefollowingsurgicalprocedurescanbeusedinthetreatmentof epilepsyrefractorytomeds? ELECTRICALSTIMULATIONOFTHEVAGUSNERVE 19y/oFhasboutsofmotoragitation,oftenfollowedbyintense,seemingly meaninglesswriting;alsomoodlability,tactile&olfactoryhallucinations.During theinterview,patientabruptlystopspayingattentionandbeginsrapidlypacing aroundtheroom.Whatshouldbethenextstep? WAIT15MINS,THENOBTAINPROLACTINLEVEL A73yoMptisseenforfollowuptreatmentforaseizuredisorder.Onexamination theptisfoundtohavegumhypertrophy,cerebellarataxiaandhirsutism.Whichof PHENYTOIN/DILANTIN thefollowingmedicationisthepttaking(mostlikely)? Ptw/h/oDepressionandwell--controlledepilepsyrespondedtobupropionafter failingonseveralantidepressants.Pthadnottriedimipramine,nortriptyline, duloxetine,andselegiline.NoSzhaveoccurredonbupropion100mgBID. CONTINUEBUPROPION Insurancerecommendschangingmedduetoreducedszthresholdwithbupropion. Whatisappropriateresponsefrompsychiatrist? MostserioussideeffectofrTMS SEIZURES Whichprocedureconfirmsthediagnosisofnon-epilepticseizures?Videotelemetry EEGVIDEOTELEMETRY orEEGbetweenepisodes? Antiepilepticforjuvenilemyoclonicepilepsy: VALPROICACID Complexpartialseizuresaredifferentiatedfromsimplepartialseizuresby: SIMPLESEIZURESHAVENOLOSSOFCONSCIOUSNESS BUTHAVEALTEREDRESPONSIVENESSTOOUTSIDE STIMULI. Convulsiveepisodewithleftwardeyedeviation,toniccontractureofleftside. Postictally,eyesdeviatetorightw/hemiparesisofleftside SEIZUREFOCUSRIGHTFRONTALREGION 28y/oFw/HA,hyperventilates,asynchronoustonic-clonicsz,noLOCduringSz: PSYCHOGENICSEIZURE Inyoungptw/epilepsy,Txdepressionw/: PROZAC Whyistherearelativelyhighrateofsuicideinepileptics? COMORBIDPSYCHIATRICDISORDERS Lackofprolactinelevationafterszssuggestswhatkindofszs: NON-EPILEPTIC 32y/owithpartialcomplexseizuresrefractorytotreatment,pictureofMRIshown. MESIALTEMPORALSCLEROSIS (picture) Drug-addictedhealthcareprofessionalexperiencesseizurethatisnotawithdrawal MEPERIDINE phenomenon.Cause? Complexpartialepilepsyaurahaswhatsymptom? LIPSMACKING GotoTableofContents 125 Head&eyesdeviatetorightandrightarmextendsimmediatelybeforea generalizedtonic-clonicseizure.Seizurefocus: LEFTCEREBRALHEMISPHERE Gustatoryspecialsensoryseizures(auras)localizewhere? INSULARCORTEX Whichofthefollowingsurgicalprocedurescanbeusedinthetreatmentof epilepsyrefractorytomedication? ELECTRICALSTIMULATIONOFTHEVAGUSNERVE Ptw/episodesofalteredbehaviorlasting1-2minutes.Duringepisodesptmakes chewingmovements.Pthasnorecollection.MRIisnormal.Dx? COMPLEXPARTIALSEIZURES 28y/ofemalereferredtopsychd/trecentonsetepisodesofalteredbehavior lasting1to2minutes.Husbandnotesifoccurswhencookingptwillplacethe cleansilverwarebackindishwasher.Alsonotesshedoesdrawingmovementsheis COMPLEXPARTIALSEIZURES unabletointerrupt.Pthasnorecollectionoftheevents.MRIscanisnormal. Diagnosis? 32PtreportsAHofsomeonenotpresent,thenstopsmoving,staresblankly, repetitivelypicksclothing,anddoesnotrespondforseveralminutes.Symptoms Complexpartial resolveafter15minbutpthasnorecollectionofevents.Thisrepresentswhattype ofseizure? 16y/optw/newonsettonicclonicseizures.Ptreportshavingjerkymovements whichcausehimtodropobjects.EEGshowspolyspikepattern.Whichantiepileptic VALPROICACID medication? 15y/optw/partialcomplexseizuresw/secondarygeneralization,mental retardation,andadenomasebaceum.Dx? TUBEROUSSCLEROSIS Whatisthemedicationforadequateinitialtreatmentofabsenceseizuresin children? VALPROICACID Gelasticseizuresarea/wwhichbrainfoci? Hypothalamus EEG EEGthatrevealsposterioralphaandanteriorbetaactivityismostlikelytohave beenobtainedfromwhom?(4x) ARELAXEDADULTWITHEYESCLOSED TheEEGfindingof4-6hzirregularpolyspikeactivityinapatientwithgeneralized JUVENILEMYOCLONIC seizuresischaracteristicofwhichofthefollowingformsofepilepsy?(2x) 3dayss/pcardiacarrestandCPR,73y/omaniscomatose.Hiseyesareopenbut hedoesnotfixandfollowwithhiseyes.Doll’seyeselicitsfullhorizontaleye BURSTSUPPRESSIONPATTERN movements.Hisspontaneouslimbmovementsaresymmetrical.Reflexes:mildly hyperactive.TheEEGshows?(2x) AnincreaseinbetafrequencyduringanawakeEEGiscausedbywhattypeof medication? SEDATIVES WhatEEGfindingsareexpectedinacomatoseptwithhepaticencephalopathy? Triphasicwaves GotoTableofContents 126 Endocrine 28y/owithemotionallabilityandimpulsivity.LFT’selevated.Closerelativehad similarsxanddiedat30y/ofromhepaticfailure.Whichbloodlevelwouldbe diagnostic?(3x) CERULOPLASMIN 25yoptwseveralyearcognitivedecline,dysarthria,dysphagia,andslow movements.Hashandtremorwhichincreasesinamplitudeonarmextension.Also CERULOPLASMIN hashepaticdiseaseofunknownetiology.Ocularexamrevealsgoldenbrownring aroundcornea.Canconfirmdiagnosiswbloodtestfor? 73y/oMw/onsetoffatigue,weightgain,constipation,coldintolerance, depressedmood.Whichorganiccausedneedstoberuledout? THYROID Physicalfindingassociatedwithhypothyroidism: SLOWRELAXATIONOFDEEPTENDONREFLEXES Forwhichpatientwouldorderingaserumceruloplasminbeindicated? AYOUNGADULTMALEWITHNEWONSETEMOTIONAL LABILITYANDMOVEMENTDISORDER Ptwithbipolardisorderwhohasbeenonlithiumfor2yearsdevelopsrapidcycling. THYROIDFUNCTIONTEST Whatlabprocedureshouldbeperformed? 32y/os/pthyroidectomypresentsc/ofrequentpanicattack,progressivecognitive inefficiency,perceptualdisturbances,severemusclecramps,andcarpopedal HYPOPARATHYROIDISM spasm.PE:alopeciaandabsentDTR.Dx? 55yop/wdepression,fatigue,wtgain,&somnolencex1mo.HxMI3moago (VTach),onamiodarone,HCTZ,&metformin.Management? Irregularasymmetricsmall(1-2mm)pupilswhichreactstoaccommodationbut nottolight. TSH&T4level Diabeticautonomicneuropathy Headaches 35y/oMawakensfrequentlymiddleofnightwithsevereHAs,whichsometimes occursnightlyandlastsapprox1-2hrs,soseverethatptisafraidtogotosleep, CLUSTERHEADACHES locatedaroundLeyeandassocwithlacrimation,ptosis,&miosis.Likelydxis: (12x) YoungptwithnewonsetsevereHAsassocwithperiodsofvisualobscuration. Neuroexamisnormalexceptforpapilledema.MRI:normalandshowsnomass effect.Nexttest?(7x) LUMBARPUNCTURETOMEASUREPRESSURE Abortivetreatmentofcommonmigrainesisbestachievedw/whichmedication? RIZATRIPTAN (6x) GotoTableofContents 127 WhichofthefollowingischaracteristicofpostlumbarpunctureHA?(4x) HAWORSEW/SITTINGUPRIGHT 25y/ohasHAandvomiting.Painisdullandinoccipitalregion,worsewhenlying down.+severepapilledemab/l.LPshowsopeningpressureof80w/normalCSF SAGITTALSINUSTHROMBOSIS chemistry,and120RBC’sinlasttube.D-dimer,FDPinbloodareelevated.CT normal.(3x) 24yomwithnocturnalHAresultinginearlyamwaking.ROS+rhinorrhea,nostril blockingandipsilateraleyetearingandfacialswelling.HApersists45-60min. CLUSTERHA Likelydx:(2x) 35y/oreportsepisodesofflashinglightstravelingslowlyfromLtoRintheleft visualfield,symptomspersistingforabout30minutes,followedbydifficulty expressingselfandconcentrating.Afterabout30minutes,theseneurologic symptomsseemtosubside,andptdevelopsapoundingheadacheassociated withnausea.BothphysicalexamandMRIarenormal.(2x) MIGRAINEWITHAURA 30y/owithintermittentHAs,eachattacklastingapprox1hour.Attacksw/ sharp,stabbingpainaroundeye,tearing,andnasalcongestion.Mosteffective abortivetreatment?(2x) OXYGEN Theeffectivetreatmentforacutemigraine:(2x) SUMATRIPTAN 25y/ow/VH–similartothewavydistortionsproducedbyheatrisingfromasphalt –affectingthewholeofbothvisualfields,+vertigo,dysarthria,tinglinginboth BASILARMIGRAINE handsandfeetandaroundbothsidesofmouthfollowedbyoccipitalheadache. Mostlikelydx: Pharmacologicmechanismsoftopiramateinclude:inhibitionoffiringofvoltage- dependentsodiumchannels,antagonismofkainitebindingtothealpha-amino-3- hydroxy-5-methyl-4-isoxazolepropionicacid(AMPA)receptor&potentiationat whichreceptor? GABA-A 28y/oFreportsepisodesofsevereHAswnausea/vomiting.HAscanbe incapacitating,oftenprecededbyflashesoflightintherightvisualfield.During TOPIRAMATE headache,ptsometimeshasdifficultyexpressingherself.Whichmedwouldbethe appropriatetopreventtheseepisodes? 26y/oFw/3-dayhxofseverecontinuousnon-throbbingheadache,hasnot improvedonNSAID,hasmildbilateralpapilledema.AheadCTwandw/ocontrast SAGITTALSINUSTHROMBOSIS isshown. Ptc/oseveredullandconstantheadachenotassociatedwithN&V.+visionlossin lefteye.+painandstiffnessoflimbs.MRIshowsperiventricularwhitematter hyperintensitiesonT2.Elevatedsedrate.Nextstep? HIGHDOSEPREDNISONE Abortivetreatmentofcommonmigraine: RIZATRIPTAN 35ptisevaluatedforheadachesyndromecharacterizedbyparoxysmsofsharp painaroundtheeyesandsideoftheheadlasting5minandhappening10x/day. PROPRANOLOL Headachesareaccompaniedbyrhinorrheaandconjunctivalerythema.Whichmed ismostlikelytogiverelief? GotoTableofContents 128 68yowithdullR-sidednon-throbbingHA’sworseatnightandwithprolonged chewing.Bestinitialtx? Prednisone Huntington’sDisease 42y/oMwithagraduallyprogressivecognitivedeficitalsodevelopsjerking movementsoftheextremities,head,andtrunk.Imagingshowsatrophyofthe caudatenucleibilaterally.Pt’sfatherhadasimilarillnessthatstartedatage50. Whichofthefollowingtestsismostlikelytoconfirmthediagnosis?(6x) DNAANALYSISFORCAGREPEATS WhatMRIfindingwouldmostspecificallyindicateadiagnosisofHuntington’s Disease?(5x) CAUDATEHEADATROPHY TreatmentofHuntington’schorea(3x) HALOPERIDOL 98y/oMinER,unconsciousafterchoking,hadprogressiveneurocondition presentedinhisearly30’swinvoluntaryirregularmovementsofallextremities &facebutafter15yrcourseevolvedintorigid,akineticconditionwdiff swallowing,speaking.Alsoprogressivedementia&fulltimecare.After HUNTINGTON’SDISEASE obstructionwasrelievedptremainedunconscious,hadcardiacarrest&died.PM examshowedgeneralizedbrainatrophy.(Pathologypictureshowingbrain atrophy).Dx:(3x) 35y/optw/2yrhxofcognitivedeterioration,difficultyatwork,andirritability. Exam:restlessw/slow,writhingmovementsinmostmusclegroupsandfrequent HUNTINGTON’SDISEASE blinking.Pt’sfatherandpaternalgrandpahadsimilarsxanddiedintheir50s.Dx: (2x) Ptw/depression,3yrhxofchangeinpersonality,irritability,impulsive outbursts, &eccentricorinappropriatesocialinteractions.Hesubsequentlylosthisjob&is HUNTINGTON’SDISEASE nowwithdrawn&fidgety.Pthasincreasedeyeblinking,markedtongue impersistence,mildbradykinesia,akinesia&mildhyperreflexiaw/oclonus.The pt’sdaddiedofseveredementiaat55.Dx?(2x) Dzw/trinucleotiderepeatexpansion HUNTINGTON’S TreatmentforHuntington’sdisease: HIGHPOTENCYANTIPSYCHOTICS Huntington’sdiseaseetiogeneisclassifiedasapolymorphismduetowhat property? THEREGIONHASMANYALLELESDIFFERINGINTHE NUMBEROFGACREPEATS Memory Roleofthehippocampusandparahippocampalgyrus?(4x) DECLARATIVEMEMORY(FACTS) Exampleofdeclarativememory(2x) RETENTIONANDRECALLOFFACTS Confabulationis: UNCONSCIOUSFILLINGINOFMEMORYGAPS GotoTableofContents 129 45y/owithnystagmusandataxia,shorttermmemorylossandbelieveswifeis possessedbydemons.Mostappropriatetreatment? THIAMINE Aconsciousmemorythatcoversforanothermemorythatistoopainfultoholdin theconsciousnessis: SCREENMEMORY Inptswithpronounceddefectsinrecentmemory,remotememoryis: OFTENDEFICIENTONCLOSEEXAMINATIONEVEN WHENITSEEMSWELLPRESERVED “Myfatherwasveryinvolvedinmylife.Iremembergoingtofootballgamesinthe MEDIALTEMPORALLOBE snowwithhim”isanexampleofmemoryassociatedwithwhatpartofthebrain? Workingmemoryrequiresprefrontalcortex,dorsalthalamusandwhatotherarea HIPPOCAMPUS ofthebraintofunction? Askingaptwhattheptateforbreakfastyesterdaytests: RECENTMEMORY Questiontoevaluateimmediaterecall? CANYOUREPEATTHESESIXNUMBERS? Askingpttoremember3thingsandrepeattheminafewminutesistesting: SHORT-TERMMEMORY MultipleSclerosis WhichisthemostreliablefindingfromCSFanalysisforaptwithmultiple sclerosisinthechronicprogressivephaseofthedz?(2x) PRESENCEOFOLIGOCLONALBANDS WhatconditionisaforerunnerofMS?(2x) TRANSVERSEMYELITIS Acuteonsetoffever,sorethroat,diplopia,&dysarthria.Examrevealsan inflamedthroat,leftadductornervepalsyw/impairmentofverticalpursuit, diffusehyperreflexiaw/bilateralclonus,lowerextspasticity,&mildright hemiparesis.CTisuninformative.Spinalfluidhasproteinof24,10mononuclear cells,andglucoseof70.Dx?(2x) MULTIPLESCLEROSIS Ptw/acuteonsetofpainanddecreasedvisionintheReye.Colorslookfaded whenviewedthroughtheReye.Onexam,hasaRafferentpupillarydefectanda MULTIPLESCLEROSIS swollenrightopticdisc.Ptspontaneouslyrecoversoverthenext6wks.Likelyto developlater:(3x) 25y/optwithdiplopia,difficultywithbalance.OnRlateralgaze,weaknessofL medialrectuswithnystagmusofReye.OnLlateralgaze,weaknessofRmedial rectuswithnystagmusofLeye.Mildfingertonoseataxia.Whatisthemost likelydx?(2x) MULTIPLESCLEROSIS Diagnosisof32yowomanw/vertigoandINO MULTIPLESCLEROSIS TheMRIofthebrainofa35yowomanwnewonsetLarmandLlegnumbnessis shown. MULTIPLESCLEROSIS GotoTableofContents 130 Muscle/NeuronalDiseases/Lesions Myastheniagravisassociatedw/whichEMGfinding?(6x) DECREASEDAMPLITUDEWITHREPETITIVEMOTOR NERVESTIMULATION 37y/otruckdriverwnumbnessofLhand,incseverityinpast2yrs.Reduced pinpricksensationonLlittle/ringfingers,atrophyofhypothenarmuscle.(6x) ULNARNERVELESION Whichofthefollowingwouldbeseeninelectrophysiologictestingofpatients withmyastheniagravis?(3x) DECREMENTALRESPONSETOREPETITIVE STIMULATION Mechanismofactionofbotulinumtoxinatneuromuscularjunction:(3x) INHIBITIONOFACETYLCHOLINEFROMPRESYNAPTIC TERMINALS Myastheniagraviscanbediagnosedin80-90%ofcasesbyidentificationofserum ACETYLCHOLINERECEPTORS antibodiesagainstwhat?(3x) During2ndtrimester,apregnant38y/oFhasnumbnessinbothhands, particularlythumb,forefinger,middlefingerbilaterally.Dorsalpartofhand unaffected.Armsacheinthemorningfromshoulderstohands.Diagnosis:(3x) MEDIANNEUROPATHYATTHEWRIST 30y/odevelopspainbehindleftear.Thefollowingdayptcomplainsof numbnessontheLsideoftheface,tearingfromLeye,anddiscomfortwithlow frequencysounds.ExamshowsLfacialweakness,butnosensorydeficit.Likely diagnosis:(2x) IDIOPATHICBELL’SPALSY OnemonthafteraMVA,a21y/ocopersistentpainintheleftshoulderandarm, withsharppainradiatingintotheleftthumb.Examshowsweaknessofthe C-6RADICULOPATHY biceps.Thebicepsreflexontheleftisabsent.Themostlikelydiagnosisis?(2x) Ptc/oprogressiveweaknessofseveraldays.Exam+forgeneralizedweakness andabsentreflexes.Nerveconductionstudiesshowslowingofvelocities.Dx? (2x) ACUTEPOLYNEUROPATHY 65yoptwithprogressiveweakness,worsewhensquattingandstandingfroma chair.C/odecreasedstrengthinrighthand.Onexam,prominentweaknessofthe quadricepsbilaterallyandonoppositionofthethumbintherighthand.Atrophy MYOTONICDYSTROPHY offoremanmuscleswithnormalDTRs.Nootherweaknessnotedonexam. Sensoryexamnormal.ROSnegative.LabsshownormalCKandnegforantitransferRNAsynthaseantibodies(Jo1).Whatisthemostlikelydx?(2x) Whatchemoagentismostcommonlyassocwithdistalsensorypolyneuropathy? CISPLATIN (2x) Ptpresentswithpersonalitychanges,cognitivedifficulties,affectivelability,and olfactoryandgustatoryhallucinations.Themostlikelymedicalcauseofthis HERPESSIMPLEXVIRUS(HSV)INFECTION presentationis:(2x) ConductionblockinNCSindicateswhat? FOCALDEMYLENATION GotoTableofContents 131 Polyneuropathycanbecausedbyeitherdeficiencyorextremeexcessofwhichof thefollowingBvitamins? 45yopwgradualprogressiveweaknessfor3-4moinLUE,atrophyinRUEintrinsic mm,andbriskreflexesandextensorplantarresponses.EMGwithwidespread fasciulations,fibrillations,and+sharpwaves.Dx? 57y/oofficeworkerwnumbnessin4th/5thdigitofrighthand,whichwakes patientinmiddleofnight.Nerveconductionstudyfindingmostlikelytoexplain syndrome? VITAMINB6 ALS SLOWEDCONDUCTIONVELOCITYACROSSTHEELBOW INTHEULNARNERVE 45y/oreportslowerbackpainalongw/painandnumbnessinRlegandfootw/ difficultywalkingx4wks.Exam:limitedduetobackpain,footdroponrightside. Nerveconductionstudies:normalmotorandsensoryinleg.EMG:decreased L-5RADICULOPATHY recruitmentandspontaneousactivityinrighttibialisanteriorandtibialisposterior muscles.Otherwisenormal.Dx: A54yoptcomplainsofintermittentdoublevisionthathasworsenedoverthelast 3wks.Thept’scoworkeralsonotedthatattimesthepatienthada“droopiness”of theeyelidsasifsleepy.Examinationrevealsbilateralptosis,mildesotropia,and doublevisiononlyaftertheptisaskedtomaintainanupwardgazefor2minutes. EDROPHONIUMTEST Thereisnodysarthria,butamild4/5weaknessisfoundintheproximalarm musclesbilaterally.Whatismostappropriatetesttoperformnexttoestablishthe diagnosis? Whichofthefollowingantibioticsismostlikelytocauseorprecipitateacute myasthenia? CIPROFLOXACIN 15y/ohashxofseizuresbeginningattheageof9years,followedbyprolonged motororsensorydeficitslastingdaystoweeks.Thepatternoftheseizuresandthe MITOCHONDRIALENCEPHALOMYOPATHY,LACTIC focaldeficitshaschangedovertime.Theptalsohashemicranialheadaches.No ACIDOSISANDSTROKE. familyhxofsimilarsymptoms.Mostlikelydiagnosis? Ahyperextensionlesionoftheshoulderresultinginweaknessofabduction, internalrotation,flexion,andadductionoftheextendedarmmostlikelyincludes whichnerveroots? C5,C6 55y/oMpresentsw/hxofweaknessandclumsiness.Symptomsbeganseveral monthsearlierwithdifficultybuttoninghisclothes,gettingthecarkeysinthe ignition,andperformingotherfinemotortasks.Henoticedthatthemusclesinhis armandforearmtwitchedunderthesurface,andcrampedeasily.Overthepast ANTERIORHORNOFTHESPINALCORD,MEDIAL fewmonthshisarmshavecontinuedtoweakenandlosemusclemass.Onexam, BRAINSTEM,ANDPREROLANDICCORTEX hehasdiffusewastingandweaknessofBUE,fasciculations,slightspasticityon armsandlegs,andhyperreflexiawithextensorplantarresponses.Sensory, coordination,andCNexamsarenormal.Theunderlyingpathologicalprocess affectsneuronalbodiesinwhichofthefollowingstructures? 13y/oMwtroublekeepingupwP.E.class.Onexam:symmetricweaknessinlegs/ arms,worseinproximalmuscles,mostprominentinquadriceps/hamstrings.Both X-LINKED calvesenlarged,painfulwexercise.Serumcreatinekinaselevelis13,000.Muscle bxrevealsabnormalitiesindystrophinproteinstaining.Patternofinheritanceis? GotoTableofContents 132 Neoplasmsofthethymusareassociatedwith: MYASTHENIAGRAVIS Hyperkalemicperiodicparalysisischaracterizedbyepisodesofgeneralized weaknessoffairlyrapidonset.ItisalsoassociatedwithariseinserumK,with SODIUMCHANNELINACTIVATION weaknesstypicallyappearingafteraperiodofrestfollowingexercise.Whichofthe followingmoleculardeficitsunderliesthisdisease? Ptwashitfrombehindwhiledriving&awokew/painradiatingintohisleftankle. Weaknessofplantarflexionanddecreasedanklejerk.Straightlegraisingreveals painbeyond45degreesonleft.Dx? S-1RADICULOPATHY Myastheniagravisptwithmildrespiratoryinfectiondevelopssevererespiratory fatigue,restlessness,anddiaphoresis.Ptappearsanxiousandtremulous.Tx? MECHANICALVENTILATION Ptc/oleftfootslappingfloorwhenhewalks.Hehastostephightoavoidtripping. Weaknessofdorsiflexionofleftfoot,w/smallareaofnumbnessinthedorsumof PERONEALNERVEPALSY theleftfoot.Normalankleandkneejerks,andhamstringreflexes.Dx? Alesioninwhatstructureisassociatedwithptosis,lackofsweatingonsameside oftheface,andconjunctivalinjection? SUPERIORCERVICALGANGLION Whichofthefollowingisthemosteffectivetreatmentofspasmodictorticollis? BOTULINUMTOXIN 50y/ootherwisehealthyptwhoisasecretarynoticescrampingandstiffeningof handsonlywhilewriting,stiffnessceaseswhenptstopswriting.Occasionally handswilltremor.WhichofthefollowingIsmosteffectivetherapy BOTULINUMTOXIN Rneckpain,usuallyrotatingnecktoleft.Correctedbytouchingchin.SpasmofR SCMonPE.Treatment? BOTOX 70Y/Optwithconfusion,lethargy,fever.DxofencephalitisismadeafterCSF analysis.WhatclinicalfeaturesuggestsWestNilevirus? MONOPARESIS 55y/optc/oofmildmuscularachesandstiffnessforwhichsteroidtreatmentwas previouslygiven.Hxofhypercholesterolemiaandhypertriglyceridemia,andwas STATIN-INDUCEDMYELOPATHY treatedwithatorvastatinandgemfibrozilwithapositiveresponse.Serumcreatine kinaselevelisslightlyelevated.Whichofthefollowingisthemostlikelydiagnosis? A63y/optwithinsidiousonsetofneckpain,progressivelimbweakness,falls,and urinaryincontinence.Onexam,pthasdecreasedneckROM,milddistaland proximallimbweakness,briskDTRswithankleclonus,andupgoingplantar CERVICALMYELOPATHY reflexes.Increasemuscletoneinlegs.Restofexamisnormal.Whatismostlikely dx? A25yroldptdevelopsprogressivehearingloss,hasacousticneuromasandcaféau NEUROFIBROMATOSISTYPE2 laitspots,diagnosis? Gaitpatterninwhichonesideofpelvisisdroppedisassociatedwithwhich neurologicalcondition? MUSCULARDYSTROPHY GotoTableofContents 133 Parkinson’sDisease Parkinson’sDiseasetreatedw/levodopa.Visualhallucinations. Recommendations?(5x) REDUCEDOSEOFLEVODOPA MedicationusefulinmanagementoforthostatichypotensioninParkinson’s(3x) FLUDROCORTISONE Gaitconsistingof:posturalinstability,festination,&truncalrigidity.Lewybodies PARKINSON’SDISEASE visualized.Alsowithinvoluntaryaccelerationisseeninwhatcondition?(3x) Pictureshowingsubstantianigrachanges,whatneurologicaldiseasewouldbe expected? PARKINSON'SDISEASE Thenewonsetofpathologicalgambling,increasedlibido,andhypersexualityina PRAMIPEXOLE patientwithParkinsondiseaseislikelytobesecondaryto:(3x) 80yomaleevaluatedforgaitimbalanceandfalls.wifeexplainsthathekicksand screamswhilesleeping,hereportsdreamsofbeingchased.Ptlikelyhas/will develop? PARKINSON'SDISEASE 67y/orecentlyretiredptwithParkinsons,nootherpsychhx,hastaken Pramipexoleforseveralyearswithoutcognitivedecline.Pthassincestarted gamblingexcessively.Ptdoesnotdrinkoruseillicitsubstances.Whatisthemost likelycause? USEOFDOPAMINERGICAGENTS MostappropriateinitialtxforidiopathicParkinsondzinan81y/opt CARBIDOPA/LEVODOPA 66y/oc/ofrequentfalls,mildaxialandLUErigidity,mildslownessoffinger tapping,handopening,andwristopposition(allworseonleft),normalposture, slowgaitwithshortsteps,doesnotswingleftarm,slowrisingfromchair.Whatis thedx? PARKINSON’SDISEASE ImplantationofdeepbrainstimulationelectrodesisaneffectivetxforParkinson’s. SUBTHALAMICNUCLEUS Optimallocationforelectrodes? Deepbrainstimulationinwhichbrainstructureisausefultreatmentforprimary generalizeddystonia? GLOBUSPALLIDUS MotordysfunctioninParkinson’sassociatedwith: INCREASEDACTIVITYINSUBTHALAMICNUCLEUSAND PARSINTERNAOFGLOBUSPALLIDUS CharacteristicsofParkinson’stremor BEINGINHIBITEDWITHVOLITIONALMOVEMENT ClinicalsyndromethatismostcommonlycomorbidwithParkinson’sdisease: DEPRESSION TypicalofIdiopathicParkinson’sdisease,ratherthananotherParkinsonian syndrome:(x2) ASYMMETRICALONSETANDPROGRESSIONOF MOTORSYMPTOMS. Ptw/Parkinson’sdiseaseexperiencesvisualhallucinationsonlevodopa/carbidopa QUETIAPINE therapy.Whichmedwouldbethemostappropriateintervention: GotoTableofContents 134 Spine 26y/optw/suddenonsetbackpain.SpasmsinRparaspinalmusclesinthe lumbarregion.StraightlegraisingontheRislimitedbysharppainat45degrees. ORDERMRISCANOFTHELUMBARSPINE AnklejerkonLisdiminished.Nomuscleweakness,nosensorydeficit.Nextstep? (3x) Contralaterallossofpainandtempsensationwithmotorparalysisand proprioceptionlossontheother.Dx?(2x) BROWN-SEQUARDSYNDROME(HEMISECTION) Subacutecombineddegenerationoftheposteriorcolumnofthespinalcordis associatedwithadeficiencyof:(2x) VITAMINB12DEFICIENCY T2MRIfigureinptwithcervicalmyelopathy.Mostconsistentwithwhatdx? DEGENERATIVECERVICALSPONDYLOSIS New-onsetbackpainaftershoveling–leftparaspinalmusclespasm,negative straightlegraise,reflexessymmetric,noweakness,nosensorydeficit. Management? CONSERVATIVE(BEDREST)WITHNSAIDS 50y/oMw/acuteneckpainradiatingdownLarm,gaitproblems,urinary incontinence.Whattestshouldbeordered? MRIOFCSPINETOR/OCORDCOMPRESSION 23y/oCaucasianFinofficeforf/uafteranERvisit2daysearlierforsudden diplopia,Rlegweaknessandshaking,difficultyw/speechwhichresolvedaftera fewhours.Pthadfever103.1FandwastxforUTI.Currentexam:normalCN& PROTEIN:50mg,+OLIGOCLONALBANDS,NUCLEATED sensory,minimalRlegweakness,briskDTRandmusculocutaneousreflexes CELLS:10 throughout,andequivocalplantarreflexonL.Rtoeisdowngoing.Hxofseveral episodesoftransientneurologicaldeficitsthatresolvedspontaneouslyafterafew days.Herspinalfluidismostlikelytoshowwhat? 68y/ow/paininbuttockswhilewalking,shootingdownlegs,w/weaknessand numbness.Relievedbysitting,painpersistswithstanding.Dx? LUMBARSPINALSTENOSIS Whereisthelesionwhenapictureofafemalepatientwithptosisisshown? SUPERIORCERVICALGANGLION 55y/oMwithchangesinhisvoice,orthostatichypotensionandoneimmobile vocalcordoninspectionsuffersfrom: SHY-DRAGERSYNDROME Ayoungptw/afewdaysofprogressiveweaknessandnumbnessofbothlegsand feetafterrecoveringfromaflu-likeillness.Exam:weaknessandlossofsensation toallsensorymodalitiesbelowthemiddleofthethorax.DTR:briskeronthelower ACUTETRANSVERSEMYELITIS extremities,plantarreflexesareextensor.Pthashadseveralepisodesofurinary incontinence.Otherneuroexamandvital:normal.LP:23mononuclearcells, proteinlevel:37mg/dl,andnormalglucose.Dx: 28y/ococaineusercomplainsofLBP,numbnessinbothlegsandfeet,thighs, buttocks,abdomen,andsaysRlegisweakandclumsy,Llegistired.Hasurinary incontinenceanddifficultywalking.Decreasedlighttouch,pinprick,and temperature.Normalvibrationandproprioception.DTRishardtoelicit.Muscle toneisnormal.DecreasedstrengthinB/LLEbutworseonright.Diagnosis? ANTERIORSPINALARTERYINFARCTION GotoTableofContents 135 Fallfromaladderwithpersistentbackpainandinabilitytovoid.B/llegweakness, CAUDAEQUINACOMPRESSION decreasedpinprickinsacralandperianalarea.Dx? 35-yearoldptwithnewonsetofnumbnessandtinglinginthelegs.Thept complainsofaband-likesensationaroundthemidchestandreportsepisodesof urinaryincontinence.Whichofthefollowingtestsshouldbeorderednext? MRIOFTHESPINE Fluctuatingachingpaininlowerback,buttocks,andsciaticdistributionelicitedby standingorwalking,andrelievedbysittingwithnumbnessinasimilardistribution, Spinalstenosis lossofanklereflexes:whatdx? TardiveDyskinesia Thesinglemostconsistentlydocumentedandsignificantriskfactorinthe epidemiologyoftardivedyskinesiais? ADVANCEDAGE RiskfactorforTD PRESENCEOFMOODDISORDER TDin63y/ow/endstagerenalfailure.Culprit: METOCLOPRAMIDE Whichgenderhasahigherriskfortardivedyskinesia(TD)? FEMALE GeneralNeurology 36y/optwpainbehindLearprogressingtonumbnessofLsideofface,tearing ofL eye,discomfortwlowfrequencysounds,leftfacialweaknessonexam.Dx?(9x) IDIOPATHICBELL’SPALSY Fever,HA,seizures,confusion,stupor,andcoma,evolvingoverseveraldays.EEG withlateralizedhigh-voltagesharpwavesarisingintheLtemporalregionwslow HERPESSIMPLEXENCEPHALITIS waverepeatingat2-3secintervals.CTlow-densitylesioninLtemporallobe.(8x) SevereoccipitalHA,BLpapilledemaandnootherabnormalities.Chronicacne treatedwithisotretinoin.Lumbarpunctureelevatedopeningpressurewithno cells,62mg/dlglucose,and22mg/dlprotein.CTisnormal.(7x) PSEUDOTUMORCEREBRI TreatmentofTrigeminalNeuralgia:(6x) GABAPENTIN(BUTMOSTEFFECTIVEIS CARBAMAZEPINE) 22y/owithpainintherighthandthatradiatesintotheforearmandbicep muscle.Paresthesiasinthepalmofthehand,thumb,index,middleringfinger. Sensorysystemsintheringfingersplittheringerfingerlongitudinally.Dx?(6x) MEDIANNERVEENTRAPMENTATTHEWRIST GotoTableofContents 136 StiffnessoflegswhilewalkingandspasmsofLEwhilesleeping.Stiffleggedgait, adductslegswhilewalking.IncreasedLEtone/spasticcatch,hyperactiveknee jerks,anklejerkclonus.IncreasedRombergsway.(5x) CERVICALSPONDYLOSIS Atrophyoftheintrinsicmusclesoftherightarmandforearm.Reflexesare generallybrisk,plantarreflexesareextensor.Electrophysiologyshows widespreadfasciculations,fibrillationandsharpwaves,normalsensation,muscle AMYOTROPHICLATERALSCLEROSIS spasticity. PositivesharpwavesonEMG.(5x) 79y/optwithadeterioratingmentalstateovera3-weekperiodhasan exaggeratedstartleresponsewithviolentmyoclonusthatiselicitedbyturning ontheroomlights,speakingloudly,ortouchingthept.Myoclonicjerksarealso seen.Diagnosis:(5x) SPONGIFORMENCEPHALOPATHY 54y/opthasseveraldaysoflowgradefever,malaiseandseverepainintheright sideoftheribcage.Examinationrevealsanerythematousrashwithclustersof tensevesicles,withclearcontent,onabeltdistributionfromthefrontofthe VARICELLAZOSTERVIRUS chesttothebackunderthenipple,limitedtotherightside.Likelycausalviral agent?(4x) PersistentnumbnessintheLhand,decreasedsensationin4th/5thdigits (palmar/dorsal),weakfingerabduction/adductionespecially5thdigit:(4x) ULNARNERVEENTRAPMENTATTHEELBOW Rightneckpain,tendstorotatenecktoleft–touchingthechinprevents deviation –prominentrightSCMspasm.Tx?(4x) BOTULINUMTOXIN 54y/opthasseveraldaysoflowgradefever,malaiseandseverepainintheright sideoftheribcage.Examinationrevealsanerythematousrashwithclustersof tensevesicles,withclearcontent,onabeltdistributionfromthefrontofthe VARICELLAZOSTERVIRUS chesttothebackunderthenipple,limitedtotherightside.Likelycausalviral agent?(4x) 17y/opthasaninsidiousonsetofunusualbehaviorandargumentativeness. Exam,themouthisheldslightlyopen.Pthasmilddysarthriaandhoarseness, generalizedslowness,rigidity,andamildrestingtremoroftheleftarmandhead. URINARYCOPPEREXCRETION ruleoutdrugand/oralcoholabuse.Liverfunctiontestsshowelevated transaminases.AnincreaseinwhichlaboratorytestismostlikelytoconfirmDx? (4x) Progressiveweaknessoverseveraldays–absentreflexesworseinlower extremities–slowconductionvelocity,conductionblockA54-year-oldpatient hadaviralupperrespiratoryinfection2weeksagoandnowpresentswitha3dayepisodeofprogressive,symmetricweaknessinthelegs,andtinglinginthe toesandfingers.Onexam,Achillesandpatellardeeptendonreflexesare diminished.Nerveconductionstudiesdemonstratedecreasedconduction velocityanddecreasedamplitudeofactionpotentials.ThemostlikelyDx:(4x) ACUTEINFLAMMATORYDEMYELINATING POLYNEUROPATHY 14y/optafterademandingphysicaltestbecomesextremelyweakandunableto stand.PEispositivefordepressedDTR’s.Labs:K=2.8.Hxofsimilarepisodesafter PERIODICPARALYSIS strenuousexercises.EKG:minimallyprolongedPR,QRS,QTinterval.Fatherand grandfatherhadsimilarepisodes.Dx?(3x) GotoTableofContents 137 Severespasmsandrigidityoflimbsintermittentlyandlatermore persistent/continuous:(2x) ANTIGLUTAMICANDANTIDECARBOXYLASE ANTIBODIES(anti-GAD)antibodies Ptwithhxofherpessimplexandseizured/oundergoingEEGmonitoringthat recordednoepilepticactivityduring,afterandbeforeaconfusedstatewherein ptsuddenlyawokefrightened.Thenextdayptwithbaselinedemeanorhasno memoryaboutthatepisode.(2x) AMNESTICDISORDER Gaitabnormality,slowmovement,asymmetricUErigidity.Difficultyinvoluntary verticalupward/downwardgaze.Slowness/rigidityimprovedslightlywith PROGRESSIVESUPRANUCLEARPALSY levodopa.Laterhasproblemswithhorizontal&verticalgaze.Oculocephalic reflexesnormal.Involuntarysaccades.(2x) Ptc/ounpleasantachinganddrawingsensationsincalvesandthighsassociated withacrawlingfeeling,forcinghimtomovelegs,bringingtransientrelief.Sxs worsenedbyfatigue.Examnl.Bestmedtx?(2x) PERGOLIDE(FORRESTLESSLEGSYNDROME) Themostcommonpossiblecauseofaposteriorcerebralarteryinfarctin36y/oF ORALCONTRACEPTIVES withhxofmigraine:(2x) BenignintracranialHTNetiology:(2x) HYPERVITAMINOSISA AnIVmethuserdevelopsseverebackpain,followedafterseveraldaysby bilaterallowerextremityweakness/sensoryloss,bladderincontinence,low gradefever,tendernesstopercussionoverthe2ndand3rdlumbarvertebrae, paraparesisandlossofsensationtolighttouchandpinprickinbothlegs, buttocks&sacralregion.(3x) SPINALEPIDURALABSCESS Ptw/episodesofsevere,intermittent,lancinatingpaininvolvingtheposterior tongueandpharynx,w/radiationtodeepearstructures.Triggedbyswallowing ofcoldliquidsandtalking.Workup:normal.Dx?(2x) GLOSSOPHARYNGEALNEURALGIA Ptpresentswithaslowlyprogressivegaitdisorder,followedbyimpairmentof mentalfunction,andsphinctericincontinence.Nopapilledemaorheadachesare NORMALPRESSUREHYDROCEPHALUS reported.Likelydiagnosis?(3x) FirstlinetreatmentofvocalticsinTourettesyndrome:(2x) ALPHA2ADRENERGICAGONIST WhichdrugfortheTxofparkinsonismhasbeenassociatedwithsuddensleep attacks?(2x) ROPINIROLE Weaknessinlimbs2weeksafteraviralgastroenteritis.WeaknessinUE/LE, absentDTRs.Spinalfluidshowsnocellsandelevatedprotein.EMGshowsslow conductionvelocity,prolongeddistalmotorlatency,andconductionblock.(2x) ACUTEINFLAMMATORYPOLYNEUROPATHY PtwithseveraldaysoffeverandsevereheadachespresentstoEDb/o generalizedseizure.Ptisconfusedandsomnolent.Alsoreportedtohavebeen irritableandhasc/ofoulsmells.T2MRIdisplayed(hyperintensityofleft temporal):(2x) HERPESENCEPHALITIS Themostcommoncomplicationoftemporalarteritisiscausedbyocclusionof the:(2x) OPHTHALMICARTERY GotoTableofContents 138 Tremorwithafrequencyofaround3Hz,irregularamplitude,mostevident towardstheendofreachingmovements:(2x) CEREBELLARTUMOR Chiropracticadjustmentsareaknownprecipitantforwhichofthefollowing acuteconditions?(2x) VERTEBRALARTERYDISSECTION HistologyconsistentwithJakob-Creutzfeldtdisease CYTOSOLICVACUOLATIONOFNEURONSANDGLIA WITHPRIONINCLUSIONS 22yofemaleishospitalizedwithparanoia,hallucinations,abdominalpainworse withperiods,physicalexamshowsreducedstrengthinupperandlower PORPHOPBILINOGEN extremitiesandreducedtendonreflexes.Whichofthefollowinglabvaluesislikely tobeelevatedandexplainhersymptoms? Dxforptw/new-onsetsz,multiplesubQnodules,frecklingofaxilla? NFTYPEI Lesionsinmammalarybodieswillproducewhatsymptom? AMNESIA,CONFABULATION,LACKOFINSIGHT Whatisthefirststeptomangerestlesslegsyndrome? CHECKFORIRONDEFICIENCY DxforIVdruguserw/severebackpain,BLEweakness,LE/buttock/sacralsensory loss,bladderincontinence,fever,TTPoversecond/thirdvertebrae. SPINALEPIDURALABSCESS 25y/optc/osevereHAandvomiting.Painisdullandmostlyinoccipitalregion. Exam:b/lseverepapilledema,otherwiseWNL.LP:openingpressure:200mmH2O, PSEUDOTUMORCEREBRI nocells,62mg/dlglucose,31mg/dlprotein.CT:normal.Dx? 55yoptcomplainsofnumbnessin4th/5thdigitRhand.Sxsworsewhenptspeaks NERVECONDUCTIONSTUDIES onphone,awakenswparesthesiasinsamefingers.Testtoconfirmthedx? A66yocomplainsoffrequentfalls.ONexam,thepthasdifficultywithupward gaze,andhassevereaxialrigiditywhichislessapparentinupperorlower extremities.Thereismildslownessofmovementonfingertapping,handopening andwristoppositionandthepatient’sfingersacquirecrampedpastureswiththe effortofthetask.Thept’sneckpostureisextended.Gaitissomewhatslow,with shortsteps,andTheptisslowwhenarisingfromachair.Whatismostlikely diagnosis? Whichofthefollowingismostlikelytoreducepaininpostherpeticneuralgia 45y/oM,withrecurrentepisodesofLOCwhilewearingashirtwithatightcollar, hasfeelingoffaintnessaccompaniedbypallor,followedbycollapseandLOC,and severalsecondslaterbyafewbilateraljerksofthearmsandlegs.Entireepisode lastedlessthanoneminute.Mostlikelyexplanation? PROGRESSIVESUPRANUCLEARPALSY Capsaicin CAROTIDSINUSSYNCOPE Dxfor68yoc/ofalls.PEshowsuprightrigidposture,stiffgait,extendedknees,and PROGRESSIVESUPRANUCLEARPALSY pivotingwhileturning. Theimagebelowrepresentsadiplopiaevaluationusingtheredglasstechnique.A redglassisplacedoverthept’srighteyeandalightisflashedatadistanceof1 meter.Theimagesaredescribedfromtheperspectiveoftheptwhenlookingto RIGHTMEDIALRECTUS the6cardinaldirections.Theseresultsaremostconsistentwithpalsyinwhichof thefollowingintrinsicmuscles? GotoTableofContents 139 75y/owithhxofextensivetobaccosmokingpresentswithsubacuteprogressive ataxicd/ooverseveralmonths.MRIbrainisunremarkable.CSFshowsmild pleocytosis.Foundpositiveforanti-Yoantibody.Whattestshouldbeordered next? CTCHEST MostcommonsolidtumoroftheCNSinkids NEUROBLASTOMA 2yearsafterMVAwithrear-endcollision,ptdevelopsBUEweaknesswithsome musclewasting,lossofDTRsinarms,lossofsensationtopainandtempin neck/arms/shoulders,intactsensationtotouch.Mostlikelycause?(X2) SYRINGOMYELIA PtwithchronicmusclewastinginbothUE,lossoflighttouch,pain,and temperaturesensationinshoulders,upperarms,andback,andpainful paresthesiasoverthesamedistribution,diagnosis? SYRINGOMYELIA Etiologyofmeningitisassocwithfever,HA,CSFpleocytosiswithlymphocyte predominance,slightlyelevatedCSFprotein,andnormalCSFglucose COXSACKIEVIRUS Wordthatptmakesupis… NEOLOGISM Thetermforabnormallyslowspeechseenindepression BRADYLALIA 5y/opresentsw/suddenonsetofslurredspeechandgaitdifficulty.Examshows truncalataxiaandnystagmus,milddysarthriaandextensorplantarresponses. Recenth/omeasles.MRI,UA,bloodworkunremarkable.Dx? ACUTECEREBELLITIS Termforburningdysesthesiawithshock-likeparoxysms: NEUROPATHIC Adultonsetopsoclonus-myoclonus-ataxiaisassociatedwithwhichformofcancer? BREASTCARCINOMA Patientreportsthatanidentical-appearingimpostorhasreplacedhisfather.What CAPGRASSYNDROME isthenameofthisdelusion? 28y/owithacuteurinaryincontinenceandunsteadygait.Alsoreports1weekh/o numbnessprogressingfrombothfeetuptoabdomen.Lighttouch,temperature, andpinprickarereducedbelowthemid-thoracicregion.Vibrationandposition ACUTETRANSVERSEMYELITIS sensationinbothfeetareabsent.Musclebulkandtonearenormal.Strengthin BLEarereduced,R>L.BriskDTRsinBLEwith+Babinski’s.What’stheDx? 33y/owithinsomnia,fatigue,nervousness,irritability,anddepressedmood.Has scalydermatitisinsun-exposedareas,apathy,andmildmemoryimpairment. Whichvitaminisptdeficientin? NIACIN Whichfindingwouldyouexpectifsomeoneisdiagnosedwithulnarneuropathyat LOSSOFSENSATIONINTHEFOURTHANDFIFTHDIGIT theelbow? ANDWEAKNESSOFINTRINSICHANDMUSCLES Inhibitorsofenzymecatechol-O-methyltransferaseareusedinParkinsondisease toaddresswhichdisease-associateproblem? WEARINGOFFOFLEVODOPAEFFECT 43y/optw/memorylossx8monthsassociatedwithabdpain,wtloss,joint CEREBROSPINALFLUIDWITHPAS+CELLSINFECTED distention/pain,fever,lymphadenopathy,hyperpigmentationofskin,decrease WITHTROPHERYMA hemoglobin,andfatinstool.Whichtestresultislikelytobefoundinthispatient? GotoTableofContents 140 BlockingRPCA(posteriorcerebralartery)causeswhichvisualdisturbance? LEFTHOMONYMOUSHEMIANOPSIA 72y/opthadalacunarinfarctinthemiddlecerebralarteryterritory.Echois normal.Dopplerstudiesofneckarteriesreveallessthan50%occlusiononboth carotidarteries.EKGisnormal.Thebeststrategiestoreducerecurrentstroke: ANTIPLATELETTHERAPYWITHASPIRINAND DIPYRIDAMOLE 60y/optw/progressiveproximalarmandlegweakness,elevatedcreatinekinase SMALL,SHORTDURINGMOTORUNITONNEEDLEEXAM level.MDsuspectsamyopathyandordersEMG.WhichfindingsonEMG: 76y/optcomplainsofbilateral,severe,persistentheadachew/lossofvisionand scalptenderness,andstiffnessofproximalmusculature.Sedimentationrate: 96mm/hr.Whichdiagnosticprocedure: BIOPSY OpiatesinhibitCampdependentproteinphosphorylationin: LOCUSCERULEUS Themostfrequencycauseofsimultaneous,bilateralfacialnervepalsies BORRELIABURGDORFERI 45y/optw/weaknessofhipsandthighs,andlesserextenttheshoulderandneck. Alsoextremelydifficulttorisefromasquattingorkneelingposition,Nomuscle POLYMYOSITIS pain.Notender.DTR:normal.Dx: 15y/optfelltothegroundafterbeinghitintheheadwhileplayingsoccer.Ptdid notloseconsciousness,butwasconfusedforfollowing20min.Thenextday,pt reportedaheadacheandirritable,neuroexamnormal.Bestrecommendationto familyabout pt: SHOULDBEEXAMINEDIN2WKSBEFORERESUMING PLAY Adislocationofshoulderjointresultinginweaknessofabductionofarm,wasting ofdeltoidmuscleandslightimpairmentofsensationonthelateralaspectof shoulder,involveswhichnerves: AXILLARY 2y/ochildw/hxofupperrespiratoryinfections,mostlikely: HAEMOPHILUSINFLUENZA Unilateraldistalweaknessinonelimb,oftenassociatedw/musclewastinginthe samedistribution,themostcommonDx: AMYOTROPHICLATERALSCLEROSIS(ALS) 52y/optwithEtOHdependencepresentwithseveraldaysofsevereheadache, nausea,andlowgradefever.Physicalexamrevealsmilddisorientation,nuchal rigidity,andmildspasticityinthelowerextremities.AheadCTisunrevealing.LP: 55/mm3leukocytes(mostlylymphocytes),45mg/dlglucose,protein:43mg/dl, andpresenceofoccasionalgrampositivesphericalcells.Themostlikelycausative organismis: CRYPTOCOCCUSNEOFORMANS 49y/optwithETOHdependenceisbroughttotheEDwithaone-weekhistoryof malaise,headache,diplopia,lethargyandconfusion.Onexamination,thepthasa tempof38.2C,stiffneck,medicaldeviationoftherighteyewithimpaired TUBERCULOUS abductionandhoarseness.CSF:114leukocytes,predominantlymonocytes,a proteinof 132mg/dl,andglucoseof29mg/dl.Likelytypeofmeningitis: ClosedTBI,initiallynoLOC,then20minuteslaterLOC.Patientrecoversin5 minutes. VASOVAGALSYNCOPALATTACK GotoTableofContents 141 Ptwho5daysagoexperiencedarupturedaneurysmlocatedintheleftmiddle cerebralarterydevelopsafluctuatingaphasiaandhemiparesiswithnosignificant headaches.Underlyingevent: VASOSPASM 45y/opthasrecurrentepisodesofLOC.Adetaileddescriptionbyfamily:pt reportingafeelingoffaintnessaccompaniedbypallor,followedbycollapseand LOC,andseveralsecondslaterbyafewbilateraljerksofthearmsandlegs.Priorto CARDIACSYNCOPE recovery,thept’sfaceandchestareflushed.Noprecipitatingfactorsare identified.Whichofthefollowingisthemostlikelyexplanation: SevereoccipitalHA,BLpapilledemaandvomiting.Juststartedbirthcontrolpills. Lumbarpunctureelevatedopeningpressurewithnocells,62mg/dlglucose,and 31mg/dlprotein,RBC400.CTisnormal. SAGITTALSINUSTHROMBOSIS Previouslyreliable,conscientiousmanbecomesincreasinglyprofane,irascible, irresponsibleover6months.Sxssuggesttumormostlikelytobefoundwhere? FRONTALLOBE Conditionmostlikelytoaccountforthepresenceofcognitiveimpairmentinapt withuntreatedHepC(HCV)infectionandnormalammonialevelwhoisHIVsero- negative: HCVINFECTIONOFBRAIN Ptc/opainwhenwalkingthatradiatesfromlowerbackandissevereinthecalves. Painrelievedbystoppingforacoupleofminutes,thenresuming.Nosensoryor VASCULAREVALUATIONOFLOWEREXTREMITIES motordeficits.TestmostlikelytoyieldDx? Akineticmutismcanresultfrombilateralinfarctionsofwhichofthefollowing structures: ANTERIORCINGULATEGYRUS Whichofthefollowingisthemosteffectivetreatmentofblepharospasm?(x2) BOTULINUMTOXIN AconditionwithincreasedfrequencyinptswithHIVonlongtermHAART: HEPATOTOXICITY Viralagentsfrequentlyassociatedwithidiopathicunilateralfacialnervepalsy: HERPESSIMPLEX 62yoprogressivepersonalitychanges,hasdullemotions,lackofinitiative,and apathy.Anautopsyislikelytoshowatrophyof…? FRONTALLOBE Weaknessofopponensofthumbandadductionof4th,5thdigit,decreased sensationin4th,5thdigitsextendingintopalmandendingatcreaseofwrist, causedby: ULNARNERVELESION Severelysensitive,lancinatingpainonthecheek TRIGEMINALNEURALGIA 52y/owrecurrentstabbingpainoverrightcheekandjawforcinghimtofrown. Stoppedshavingorbrushingteethd/tfearofpain.Episodeslastlessthan1 minute.Onlyexamabnormalityispainuponrepeatedtouchingofpt’sface.Most likelyexplanationofsymptoms? TRIGEMINALNEURALGIA 23y/odevelopstinglingparesthesiasinthelowerextremities,followedseveral dayslaterbyprogressiveweakness,R>L.PEshowssensorylevelatT10topinprick, TRANSVERSEMYELITIS +3/5weaknessofLE,slightlyweakeronR.Kneeandanklejerksarehyperactive, b/lcongenit.Pthasdifficultywalkingwithbroad-based,stiff-leggedgait.Dx? GotoTableofContents 142 Severejabbingpain,lastsfewseconds,triggeredbylighttouchonface TICDOULOUREUX Irregular,unequal,smallpupilsnonreactive,donotdilate,butdoconstrictto accommodation: SYPHILIS Mostcommonsymptominnarcoleptics: SLEEPATTACKS 49y/owithgradualhearingloss.AtuningforkusedduringtheWebertestreveals afailuretolateralize,andthewoman’sperceptionofairconductionisbetterthan SENSORINEURALHEARINGLOSS(b/l) thatofboneconduction.Shehastroublediscriminatingwords“fat”“cat”“mat”. Dx? 65y/oMtroublefallingasleep2/2unpleasantachinganddrawingsensationsin calvesandthighs.Alsocreepingandcrawlingsensationsinlegs.Urgetomovelegs RESTLESSLEGSYNDROME canbesuppressedvoluntarilyforshortwhilebutisultimatelyirresistible.Most likelyDxis: Tremordecreasingwithvolitionalmovementsandappearsprimarilyinanattitude RESTINGTREMOR ofrepose: Mucosallesionthathealsandthenpthaspainintrigeminalnervearea POST-HERPETICNEURALGIA Unilateralfootdropwithsteppagegaitindicates: PERONEALNERVECOMPRESSION 49y/ow/DM2presentswithsevereburningofsolesoffeetandinsomniab/cthe touchofthesheetagainstthefeetispainful.Examshowsdecreasedsensationto PERIPHERALNEUROPATHY pinandtouchuptoankle,50%reductioninvibratorysenseatankleandimpaired proprioceptionattoes.Anklejerksareabsent,butkneejerkspresent.Dx? Resting,non-intentionaltremor PARKINSON’SDISEASE 25y/oFwithLeyepainwhichincreaseswithmovingtheeye.Diminishedacuityin Leye,pupilsconstrictwellwithlightonReye,butonlyconstrictweaklywithlight OPTICNEURITIS onLeye.Dx? 75y/oWWIIveteranw/gradualonsetforgetfulness,intellectualdeterioration, fast/slurredspeech,gaitimpaired,CTwithnormalatrophy.LP:35WBCs(most lymph),protein110,increasedgammaglobulin.Dx? NEUROSYPHILIS Briefepisodesofsuddenlossofmuscletone,withintenseemotionare characteristicof: NARCOLEPSY Termforsudden,irrepressibleshock-likecontractionofamuscletriggeredbyan eventinCNS? MYOCLONUS 20y/ooccasionaldoublevisionwhenlookingtoRandnormalacuityineacheye alone.LptosisanddifficultykeepingLeyeadducted.Pupilsroundandreactive. Speechnasalandneckflexorsweak.Noparesisorreflexabnormalitiesin extremities.Dx? MYASTHENIAGRAVIS Firststepinthemanagementofacutemyastheniccrisis: MECHANICALVENTILATION GotoTableofContents 143 Diagnosticvalueassocw(+)transientparesisofarm/aphasiaafterepileptic seizure: HELPSLOCALIZETHEFOCUS Triptandrugsshouldnotbegiveninabortivetreatmentofmigraineinptswith: CAD Femalewithvertigoanddiplopia,whenlookslefthasisolatedLeyenystagmus, andcannotadductReye.Dx? MULTIPLESCLEROSIS 41y/ochronicfatigue,cognitiveimpairment,reducedperceptualmotorspeed, pooreffortmaintenance,andirritability(MRI:hyperintensityinfrontallobeand whatlookslikeafingerprotrusion) MULTIPLESCLEROSIS Horner’ssyndromeischaracterizedby? MIOSIS,PTOSIS,ANDANHIDROSISOFFOREHEAD A57yoptdevelopsdroopingoftheReyelidfollowingmildnecktrauma.The patient’sneurologicalexamisremarkableforasymmetricpupils,smallerontheR, HORNER’SSYNDROME mildeyelidptosisanddecreasedsweatingovertheRface.Thesefindingsare consistentwithwhichofthefollowing? DMptwithcreepingparesthesiasandburningpaininLanterolateralthigh.DTRs normal,noweakness.Dx? MERALGIAPARESTHETICA Recurrentdeafness,tinnitusthenvertigo: MENIERE’SDISEASE Hippocampalatrophyhasbeenidentifiedinallofthefollowingdisorders: MDD,ALZHEIMER’SDISEASE,PTSD.(NOTDISSOCIATIVE AMNESIA) Pts/psurgerydevelopsweaknessandwastingofsmallmusclesofthehandand sensorylossoftheulnarborderofthehandandinnerforearm.Dx? LOWERBRACHIALPLEXUSPARALYSIS Ptwithdoublevisionwhenlookingtotheleftshowshereyesonprimarygaze.On leftgazetherighteyefailstoadductandthereisnystagmusinthelefteye.On INTERNUCLEAROPHTHALMOPLEGIA rightgazeandverticalgazetheeyesmovenormally.Dx? Whichmedicationreducesaccumulationofplaquesanddisabilityinpt’swith relapsingremittingMS? INTERFERONBETA-1A 3monthprogressivelimbweaknessL>R,problemsswallowing.NormalCN, weaknessinneckextensormuscles,indistalandproximalmuscles(quadriceps, feetdorsalflexors,extensorpollicislongus)andinwrist/fingerflexors.DTRs normal.Motortone/coordination/gaitnormal.ElevatedCK. INCLUSIONBODYMYOSITIS Spinalfluidofpatientw/acuteinflammatorypolyneuropathyshows: HIGHPROTEIN,NORMALCELLCOUNT 49y/optdevelopsseizuredisorderthatisdifficulttocontrol.CSFshows lymphocyticpleocytosisandmanyRBC’s.MRI:T2hyperintensityintheLeft temporallobe,withgadoliniumenhancementinthisareainT1weightedimage. EEG:periodicdischarges.Dx? HERPESSIMPLEXENCEPHALITIS ProteinmutationassociatedwithAlzheimerdiseaseinpeopleyoungerthan60yo AMYLOIDPRECURSOR GotoTableofContents 144 Hyperkalemicperiodicparalysisandparamyotoniacongenitalareduetomutations SODIUM inthegeneforwhichofthefollowingionchannels? Rightshoulderweaknessoninitialabductionandexternalrotationofthearmat theshoulderjoint,aftercarryingsandbags.Affectnerve: SUPRASCAPULAR MentalstatuschangesafterCABG,fluentspeechandexcellentcomprehension, inabilitytonamefingersandbodyparts,rightandleftorientationerrorsinability towritedownthoughtsandcalculation,butwithgoodreadingcomprehension: ANEMBOLICSTROKEAFFECTINGLEFTANGULARGYRUS ReducesSxsduringacuteexacerbationofMS: METHYLPREDNISONE MirtazapinemediatesincreasedreleaseofNEandandserotoninthroughwhat mechanism? ALPHA-2ADRENERGICBLOCKADE Youngadultw/headachebehindleftear.2dayslatertwistingofface.Impaired tastesensation.Paralysisofforehead,lowerfaceonleft,incompleteclosureofleft GADOLINIUMENHANCEMENTOFLEFTFACIALNERVE eyew/blinking.Nosensorydeficitorothercranialnervedeficit.MRIshows: Electrophysiologicsignsofdenervation: FIBRILLATIONANDPOSITIVESHARPWAVES Shakinghands,increasedwhenusinghands/writing/volitionalactivities.Stress worsens,wineimproves.Isfamilial.DX: ESSENTIALTREMOR Mostcommoncauseofasepticmeningitis: ENTERICVIRUS Whatdoesthecerebellumdointhehumanadultbrain? DIVERSEROLESINMOVEMENT,BEHAVIOR,AND LEARNING 25y/oMw7monthsdepression,forgetfulness,weightloss,insomnia,painful tinglinginbothfeet+incoordination.InvoluntarychoreicmovementsofB/LUE, apathetic,monosyllabic.Labsnormal.EEG:milddiffuseslowing.CT/MRInml. Duringadmissiondevelopssevereakineticmutism,seizures,dies.Brainautopsy shows: DIFFUSEAMYLOIDPLAQUES,SPONGIFORMNEURONAL DEGENERATION,ANDSEVEREASTROGLIOSIS 55y/ow/DMandHTNdevelopsRperiorbitalpainanddiplopia.Exam:paralysisof DIABETIC6THNERVEPALSY abductionofReye. OrbitalpainwithLeyeparalysisofadductionandelevationoftheeyebutnormal pupilfunction.Dx? DIABETIC3RDNERVEPALSY 25y/optwithpaininLperiorbitalregion,followedbyblurringthenlossofvisionin lefteye.ExamnormalbutnoreactionwhenlightshoneonLeye.Thisisconsistent DEMYELINATINGLESIONOFLEFTOPTICNERVE with: Seeninelectrophysiologictestinginmyastheniagravis DECREMENTALRESPONSETOREPETITIVESTIMULATION Involuntarysetofflowingjerkymovementsinmultiplejointsdescribe: CHOREA 34y/optwpersistentnumbnessinthumb/forefinger/middlefinger/palmin4th mopregnancy.Painradiatestoforearm,clumsiness&weaknesswholdingobjects. CARPALTUNNELSYNDROME Dx? GotoTableofContents 145 53y/ow/insidiousonsetofblurredvision,diplopiax1day,ptosis,CN6palsy, unreactivepupils,hoarsevoice,dysarthria,weakneckmuscles.EMG-incampwith BOTULISM repetitivenervestimulation.Dx? Dxfor45yowomanw/pins&needlesfeelinginhandatnightanduponawakening CARPALTUNNELSYNDROME 5y/ocannotmaintaineyesopen,attemptstolookatperson/objectresultsintonic eyelidclosure.Canwatchtelevisionw/odifficulty.ExtraocularmovementsNML. BLEPHAROSPASM Dx? AdultLPwithopeningpressure190,protein110,glucose27,leukocytes5,000.Dx? BACTERIALMENINGITIS 75y/oM,Koreanwarveteran,withgradualdevelopmentofforgetfulnessand cognitivedeterioration,presentswithveryfast/slurredspeechandimpairedgait. AheadCTshowssomegeneralizedatrophy,unusualforhisage.TheLPshow35 NEUROSYPHILIS WBC,lymphocytosisandtheproteinlevelis110mg/Dlandelevatedgamma globulin.Dx: Inabilitytocarryoutmotoractivitesonverbalcommanddespiteintact comprehension&motorfunctionindicates? APRAXIA 55y/optw/hxofweaknessandclumsinessxseveralmonths.Difficultyw/fine motortasks.Armmusclestwitchandcrampeasily,weakening,atrophy.Sensory, coordination,cranialnerveexamswnl.Underlyingillnessaffectsneuronalbodies where? ANTERIORHORNOFSPINALCORD,MEDIALBRAINSTEM ANDCORTEX Youngptrecoveringfromflu-likeillnessw/progressiveweaknessandnumbnessof legsandfeet.Weaknessandnumbnessbelowmiddleofthorax.IncreasedLE ACUTETRANSVERSEMYELITIS DTR’s,extensorplantarreflexes.Urinaryincontinence.LP23mononuclearcells, proteinlevel37,nmlglucose Essentialcriterionfordeclarationofbraindeathpriortoorgandonationrequires? APOSITIVEAPNEATEST 41y/optw/ofamilyh/ocorticocerebellardegenerationpresentswith3-month h/oataxiaofgait/limbs,dysarthria,andprogressivenystagmus.MRIandCSF normal.1)Antibodypanelwithpresenceof?2)Whattypeoftumorislikely present? 1)ANTI-YO 2)OVARIANCARCINOMA TheusualtargetforDeepBrainStimulationinEssentialTremor: VENTRALINTERMEDIATETHALAMUS 72-year-oldptpresentswithsubacuteonsetofprogressiveataxiaofgaitandlimbs. Labtestingrevealsthepresenceofananti-Yoantibodyinserum.Whichofthe CTSCANOFTHECHEST,ABDOMEN,ANDPELVIS followingtestsshouldbeorderednext? 62y/optevaluatedforfrequentfallsw/olossofconsciousness.Ptwrigidity, hallucinations.Threeepisodesofhallucinationsresolvedw/osequelae.Cause? RISPERIDONE Chronicperipheralneuropathyofinsidiousonset,symmetric,moreprominent distallyinlimbs,legsmorethanarmsaffected,slowlyprogressive,withgreater sensorythanmotorinvolvement,withinvolvementofperipheralsympathetic nerves,andvariablelossofDTR,ismostlikelycausedbyagent: ALCOHOL GotoTableofContents 146 AmedicationtotreatMSisanintegrinantagonistthatprimarilyactsbyblocking lymphocytesandmonocytesadhesiontotheendothelialcells: NATALIZUMAB Delayedneurologicaldeteriorationfollowingcarbonmonoxide-inducedcomais mostlikelymanifestedby: PARKINSONISM Autosomalrecessivetrinucleotiderepeatexpansionisthemolecularetiologyof: FRIEDRICHATAXIA Distinguishingabsenceseizuresfrompartialcomplexseizures: LACKOFPOSTICTALMANIFESTATIONS Oneyearafterachievingmethamphetamineabstinence,thesecravingwillmost likely: DECREASEININTENSITY Ptrecoveringfromsurgeryofanintracranialhemorrhage2/2arterialaneurysm, developsasuddenonsetofheadache,vomitingandprogressivedeclineof consciousness.Pupilsaremiotic,andabducensmusclesareweakbilaterally. Etiology: ACUTEHYDROCEPHALUS 50y/omanwacutonsetofnickpainradiatingdownleftarm,progressinggait difficulty,urinaryincontinence.Whichtestshouldbeadministeredimmediately? MRIofheadtoexcludedxofacutehydrocephalus Neurotransmittermaintainsconsistentlevelswithage: SEROTONIN Whichneurotransmittersarereducedinquantity,uptakeandturnoveris spasticity? GLYCINE&GABA ThecognitiveenhancementassociatedwithexperimentalD-cycloserinetreatment inpt’swithschizophreniahasbeenattributedtoenhancementofNMDAreceptor GLYCINE activitybywhichofthefollowingneurotransmitters? Medicationforrestlesslegsyndrome: RestlessLegssyndrome2/2medication LocationofcharacteristiclesionsseeninCTscansofptwithcarbonmonoxide poisoningassociatedcomas? BROMOCRIPTINE Antidepressants GLOBUSPALLIDUS Acuteonsetofleftfacialweaknessinvolvingtheforehead&perioralmusculature. Onsetoffacialweaknesswasprecededbypaininleftearandmastoid,andby BELL’SPALSY sensationofdiscomfortintheleftearw/loudnoisesorlowpitchsounds.Dx? Ptc/oinabilitytositstillanddescribesfeelinganinnertension.Examnotesptis constantlyshiftingbodyandlegs.Pacedhallcontinuously.Receivedacourseof neurolepticsuntilrecently.Dx? AKATHISIA Electrodiagnostictestfindingmostindicativeofademyelinatingneuropathic process? CONDUCTIONBLOCK Ptdisplaysspasticgaitinwhichlegsarestiff,feetscrapeagainstfloor,andlegs circumductwhicheachstep.Reflexesareincreasedandplantarresponsesare extensorbilaterally.Dx? CERVICALSPONDYLOSIS GotoTableofContents 147 Causativeagentofprogressivemultifocalleukoencephalopathy(PML): JCVIRUS Ptpresentwithprogressiveweaknessofleftupperextremity,followedbytheright upperextremity.+Musclewastingofbilateralarms.Upperandlowerextreflexes AMYOTROPHICLATERALSCLEROSIS increased,andplantarresponseareextensor.Normalnerveconductionstudies. EMG:fibrillationsinarmandlegmuscles.Dx? Ptc/ohearinglossonrightside.Whentuningforkheldatvertexofskull,pthears soundbetterontheright.Whenforkisheldinfrontofthept’sears,ptreports hearingitbetterontheleft.Dx? CONDUCTIVEHEARINGLOSSONTHERIGHT Pthassevereposturaltremorofupperextremitiesanddystonicposturingofthe hands.Ptvoiceismildlydysarthric.Eyeshaveagoldenbrownlimbicring.Deep tendonreflexesaremarkedlyincreased.ElevatedLFT’s.Dx? WILSON’SDISEASE 14y/o@summercampdevelopssevereheadacheandfever,drowsiness,stiffness ofneckonpassiveforwardflexion,petechialrashandskinpallor.Spinaltapreveals MENINGOCOCCUS openingpressure200mmH20,84%neutrophils(7,000nucleatedcells),glucose levelof128mg/dl,andproteinlevelof33mg/dl.Mostlikelycausativeagent? Transcutaneouselectricalnervestimulation(TENS) FORPERIPHERALNEURALGIA 2monthsafterseverebraininjury,ptopenstheeyesforprolongedperiodsbut remainsinattentive,doesnotspeak,andshowsnosignsofawarenessofthe environmentorinnerneed.Ptiscapableofsomerudimentarybehaviorssuchas MINIMALLYCONSCIOUSSTATE followingasimplecommand,gesturing,orproducingsinglewordsorbriefphrases, alwaysinaninconsistentwayfromoneexamtoanother.Whichofthefollowingis themostaccuratedescriptionofthept’scondition? Abundanthyperpigmentationspotspresentatbirthwithcutaneousand subcutaneoustumorsappearingduringearlyandlatechildhoodandhamartomas oftheirisarediagnosticofamutationinwhichgene? NF-1(NEUROFIBROMATOSIS-IGENE) Whywouldbrains>65yearsoldorahistoryofalcoholismmoresusceptibleto chronicsubduralhematoma? CORTICALATROPHY(LONGERDISTANCEFORBRIDGING VEINSTOBEDAMAGED) WhichofthefollowingtestsisrecommendedbytheAmericanAcademyof Neurologytoestablishthediagnosisofbraindeath? APNEATEST 26-year-oldobeseptpresentstoERwithsevereheadache.Ptisotherwisehealthy anddoesnottakeanymeds.HeadCTandbrainMRIareunrevealing.Theonly IDIOPATHICINTRACRANIALHYPERTENSION findingonexamisshowninthefundoscopicimagesbelow(blurredopticdisk). Whatisdiagnosis? Apatientwithdaytimesleepiness,frequentnaps.Sleepstudiesshowsthatpt entersREMwithin5minutesandwakesfrequentlyatnight.Whichtreatmentis appropriate? MODAFINILGIVENDOSEINTHEMORNING ProgressiveLEstiffness&hyperreflexia(ankleclonus)withextensorplantar responsesanddecreasedlight-touch&vibration/proprioceptioninb/lstocking pattern? Cobalamindeficiency GotoTableofContents 148 106.Immunocompromisedpatientwithconfusionandmildheadache,b/l papilledemaandcerebellarataxia.CSFstainshowspleocytosis,inc.protein,low glucose?Indiainkstainshownbelow.Whatisdiagnosis? Cryptococcus 119.Whichoffollowingisinvariablythefirstmanifestationofneurosyphilis? Meningitis Neurotransmitters DAreleaseinwhatstructurerepresentscommonfinaleventassocwreinforcing NUCLEUSACCUMBENS effectsofopiates,cocaine,amphetamines,nicotine,PCP,andalcohol?(3x) Principalmechanismofterminationofsynapticactivityofdopamineinprefrontal cortex? DIFFUSION Wherearethemajorclustersofcellbodiescontainingserotonininbrain? RAPHENUCLEUSINTHEBRAINSTEM Aderivativeofwhichofthefollowingvitaminsisanecessarycofactorforthe functionoftheenzymeglutamicaciddecarboxylase? PYRIDOXINE Whichofthefollowingneurohormonesisknowntomodulateimmunefunction, hasanalgesicproperties,isderivedfromtheserotoninmolecule,andisapotent antioxidantandfree-radicalscavenger? MELATONIN Whatneurotransmittershasbeenassociatedwithanxiety? NOREPINEPHRINE Positiveallostericmodulatorsofneurotransmitter-gated,multimericionchannels dowhat? INCREASEPROBABLILITYOFOPENINGINPRESENCEOF ALIGAND Asubstanceofabusewithpowerfulreinforcingeffect: COCAINE Whichofthefollowingistheprimarymechanismthroughwhichamphetamine secrettheirstimulanteffect? RELEASEOFCATECHOLAMIMES NeurotransmitterthatchangesintheCSFofptswithIED: SEROTONIN Whatareaofthebodyhasthemostserotonin? GITRACT EEGfindingsinStageII(N2)sleep K-COMPLEXESANDSLEEPSPINDLES Neurotransmitterassocw/reward&reinforcementinnicotinedependence DOPAMINE 25y/optwithsevereheadache,visualloss,vomiting,bilateralbabinski,andthen becomesdrowsy: EPENDYMOMAOFTHEFOURTHVENTRICLE Whichneurotransmitterispredominantlyinhibitory? GLYCINE Inaddiction,dopaminergicneuronsprojecttonucleusaccumbens.Cellbodiesof theseneuronsresideinwhichareaofbrain? VentralTegmentalArea GotoTableofContents 149 Radiology WhichisanadvantageforCTheadvsMRI? DIAGNOSINGACUTEEPIDURALHEMORRHAGE GadoliniumcontrastinMRIscansismostspecificallyusefulfordiagnosingpatients BLOODBRAINBARRIER withdiseasesaffectingwhichofthefollowingstructures? CTispreferableoverMRIinwhichsituation? 70Y/OFEMALEWHOFELLATHOMEANDNOWHAS DEPRESSEDLEVELOFCONSCIOUSNESS Neuroimagingthatmeasuresneuronalglucosemetabolism PETSCAN CTscanisbetterthanMRIforwhat? DIFFERENTIATINGHEMORRHAGINGFROMEDEMA 65y/ohasfirstgeneralizedtonic-clonicSzseenbyspouseandtheyhavebeen confusedandlethargicsince.Episodebeganw/repetitiveshakingofrightarm. Bloodtestsunremarkableandnohxofotherrecentsymptoms,trauma,or metabolicdisorders.Whatstudywilllikelyrevealcause? BRAINMRI WhatdoesfunctionalMRImeasure? DETECTSBLOODFLOW 50y/optisintheEDforacuteonsetofneckpainradiatingdowntheleftarm, progressivegaitdifficulty,andurinaryincontinence.Thistestshouldbe administeredimmediately: MRISCANOFTHECERVICALSPINETOEXCLUDEA DIAGNOSISOFSPINALCORDCOMPRESSION. Sleep 5y/owithscreaming/cryingfornoreasonabout1hourafterfallingasleep.Sits upinbedwitheyesopen,trembling,sweating,mothercannotgainhisattention SLEEPTERROR for5minutes.Nonewstressors.Boyhasnomemoryoftheevent.PEnormal. Dx?(4x) Paralysiswhenawakening,lastsseveralminutes.Cansee/hearbutcannotmove duringepisodes.Disappearsspontaneouslyorwhencalledbyhiswife.No SLEEPPARALYSIS hallucinations,nightmares,daytimesleepinessorh/ofalls.Neuroexamnormal (4x) Whatsleepstageisthemostimportantinrestoringthealteredfunctionsthat resultfromprolongedsleepdeprivation?(3x) STAGE4,NON-RAPIDEYEMOVEMENT Medicalstudentasksforsomethingtohelpw/oattentionandalertness.Takinga 2-weekboardreviewcourseandstrugglestokeepupw/thepace.Sleeping DYSSOMNIANOS 4hrs/night.Usuallysleeps8hr/night.Dx?(2x) Age-relatedsleeppatternchange(2x) GREATERWAKEFULNESSINTERMIXEDWITHSLEEP Whataspectofsleepisincreasedinolderadults?(2x) DURATIONOFAWAKENINGS GotoTableofContents 150 WhatmedicationisbestfordecreasingnightmaresinPTSDpts?(2x) PRAZOSIN A35yorecurrentepisodesofawakeningduringsleepwakingupwithapanicked screamandsweating,racingHR.cantremember,daytimedrowsinessaffecting functioning,EEGnormal.Whatisthediagnosis? SLEEPTERRORS MosteffectivetreatmentforOSA POSITIVEPRESSURETHERAPY REMsleepisfirstevidentatwhichstageofdevelopment? INUTERO Ptworkingovertimedevelopsfrighteningnocturnalepisodescharacterizedby semi-wakefulnessandinabilitytomove,accompaniedbythesensethatan intruderispresent.Theptdeniesdaytimesleepattacksorsuddenlossofmotor control.Bestinitialtx? GETTINGSUFFICIENTSLEEP Apatientreportsfeeling“irritable”withinabilitytosleepmorethananhourat nightoneweekafterreceiving80mgprednisonedailyforapoisonivyrash. BEGINTOGRADUALLYTAPERTHEPATIENTOFFOFTHE PREDNISONE MosteffectivetreatmentforREMsleepbehaviordisorders. CLONAZEPAM Whichofthefollowingaspectsofsleepisincreasedinolderadults? SUBJECTIVEQUALITY MDDhaswhatsleepabnormality? SHORTENEDREMLATENCY,DECREASEDSTAGE4SLEEP, INCREASEDAWAKENINGSINTHESECONDHALFOFTHE NIGHT REMsleepbehaviordisorderassociatedwithwhichpathology: PARKINSON’SDISEASE Involuntaryjerkingoflegswhilefallingasleep,notuncomfortable,stopswith fallingasleep NORMALPHENOMENON,NONPATHOLOGICAL Predominantlynon-REMsleepproblem: ENURESIS Sinusoidalwavesat9-11HzonEEGis: DEEPSLEEP Mostcommonexplanationgivenbyindividuals>65yearsfordifficultymaintaining NOCTURIA sleep? Whichofthefollowingisacharacteristicschangeonpolysomnogramassociated withmajordepression? SHORTREMLATENCY 67y/owithMDDdoingwellonSSRIbutcontinuestohaveinsomniaandsleepiness BREATHING-RELATEDSLEEPDISORDER duringday.Snoresloudly,morningheadaches,andnightsweats.Dx? Whichofthefollowingmeasuresofrapideyemovement(REM)istypicallyreduced SLEEPONSETTOREMONSET inMDD? AccordingtoDSM5,Lengthoftimeofsleepdifficultyfordiagnosisofinsomnia 3months InsomniasecondarytodepressionwillmoreconsistentlyaffectREMsleepinwhich REDUCEDLATENCYTOREMSLEEP ofthefollowingways? GotoTableofContents 151 17y/oMexperiencesa2monthperiodoflowenergy,drowsinesswithincreased sleepdurationupto18hoursormoreaday.TheEEGshowsthatNREMandREM cyclesarenormal,exceptforincreaseddurationofsleep.Mostlikelydiagnosis: KLEIN-LEVINSYNDROME Pts>65y/owchronicinsomniaaremostlikelytohavewhichpsychcomorbidity? ALCOHOLABUSE 35y/optwithchronicinsomniahassleeptest,itshowsptfellasleepin10min, slept 7hrswith90%efficiencywithfewawakenings.Ptreportsittook1hrtofallasleep PARADOXICALINSOMNIA withfrequentnighttimeawakeningsandlessthan2hrsofsleep.Medicaland psychworkupneg.Whatexplainsdifferentbetweensleeplabfindingsandpt report? EEGcharacteristicofREMstageofsleep: LOWVOLTAGEMIXEDFREQUENCYACTIVITYONEEG Ptc/o6monthsofdifficultyfallingasleep.Despiteattemptstogotobedat 11:00pm,theptisunabletosleepbefore4:00am.Shethensleepswithout interruptionbutcannotawakebefore11:00am.Thisresultsinproblemswith tardinessatwork.Ptendorsesdaytimefatiguebutdenieschangesinmood, appetiteorinterest.Dx? CIRCADIANRHYTHMSLEEPDISORDER Somnambulismduringchildhoodisassociatedwithwhichofthefollowingstages ofsleepmeasuredbyanEEG? STAGEIV Nightterrorstypicallyappearwheninlife? CHILDHOOD 42y/oanesthesiologistwithrepeatedepisodesoffallingasleepintheOR,mild depression,irritabilityandmildcognitivetroubles.UDSisnegative.Hegained substantialweightin18months,whichheattributestopooreatinghabits.Most likelyDx: BREATHING-RELATEDSLEEPD/O REMsleepbehaviordisorderiscommonlyassociatedwithabnormalinclusions containingwhichofthefollowingproteins?(2X) SYNUCLEIN Acharacteristicofnon-REMsleep? DECREASEDRECALLOFDREAMACTIVITY Whichmedicationismosteffectiveinthetreatmentofcataplexy? CLOMIPRAMINE(TCAs2/2TOINCNE) 51y/optw/dysthymicdisorderhasrespondedwelltocitalopram.However,thept continuestocomplainofmorningheadaches,anxietyanddaytimefatigue.The psychiatristprescribesclonazepamandtheptimmediatelyreportsprofound SLEEPAPNEA daytimesedation.Thedifferentialdx,inadditiontoadirectsedativeeffectofthe drug,shouldinclude: Ptp/wcomplaintsofexcessivedaytimesleepiness,morningheadaches,and OBSTRUCTIVESLEEPAPNEA excessivenighttimesweating.Symptomsareconsistentwithwhichsleepdisorder? Whichofthefollowingischaracteristicofsleepinindividualsovertheageof65,as INCREASEDFRAGMENTATION comparedtothatofyoungadults? GotoTableofContents 152 Ptreportsinsomnia,frequentnighttimeawakenings,andexcessivedaytime sleepiness.Sleepstudyrevealsbrieflowerexternaljerkswithbriefrepeated arousals.Ptisunawareofthesemovements.Whichdxismostconsistentwithpt presentation? PERIODICLIMBMOVEMENTS Aptpresentswithahxofirresistibleepisodicsleepinessthatisaccompaniedbya vivid,dreamlikestateattheonsetofanepisode.Whichofthefollowingadditional SLEEPPARALYSIS sleepsymptomsarelikelytobepresent? 10yoboyprimarynocutrnalenuresis,isdrydurringday,nourgency,frequency, dysuria.Fatherhadsameatage12.Nootherissues,wantstostopbedwettingto gotocamp.Whatisthenextstep? TrialofDDAVP Whichmedicationforinsomniaismostlikelytocauseamnesticcognitive impairment? TEMAZEPAM 17yowithincreasedsleepdurationto18hours,lethargyandcognitiveslowing. SleepEEGisnormal. KLINE-LEVINSYNDROME Theevidencesuggeststhataftercompletingtreatmentforinsomnia,longterm outcomesarebetteramongpatientswithwhichmedication/theray? CBT EEGbiofeedbackmoreeffectivethanprogressivemusclerelaxationintreating? INSOMNIA 35y/owdailyheadachesoverlastseveralweekslastinganhour.Sharp,severe, boringpainintorighteye.Anotherelementofthisheadache? OccursduringREM TreatmentforRLS Pramipexole 65yop/wpillow-punching(xseveralmonths)inhissleepwithsuddenawakening fromdreamsinvolvingpursuitbyassailants.Dx? REMbehaviord/o 16yroldhearsmusicandhisnameatnight,duringwhichofthefollowingstagesof N1 sleepifhypnagogichallucinations? PhysiologicchangesduringREMsleep IncreasedHeartRate,increasedeyemovements, decreasedmuscletone GotoTableofContents 153 AxisIDisorders AcuteStressDisorder 32y/ow/nopsychiatrichistorybroughttoERwith2daysofmemoryloss, insomnia,poorappetite,anddifficultyperformingdailyroutines.Subjectivesense ofnumbing,detachment,andanxiety.Oneweekearlierptwitnessedherchild ACUTESTRESSDISORDER beingfatallyinjuredinamotorvehicleaccident.Alllabsandscansnormal.Dx? (4x) Whatsymptomismorelikelytooccurinacutestressd/othaninPTSD? REDUCTIONINAWARENESSOFSURROUNDINGS Importantdeterminantfactortowhetheranindividualwhowasexposedtotrauma SEVERITYANDPROXIMITYOFTRAUMA willdevelopPTSD? Acutestressd/odifferentiatedfromPTSDby DURATIONOFSYMPTOMS 29y/optreportshavingbeenrobbedatknifepointalmostamonthago.Ptescaped unharmed,buthasbeenexperiencingasenseofunreality,detachment,and ACUTESTRESSDISORDER dampenedemotionsthatisinterspersedwithperiodsofintensephysiological arousal.Thesesymptomsarecausingdifficultiesatwork.ThemostlikelyDx? ADHD 7y/ochildBIBparentsreporthe’sbeenhyperactivesinceage4,talksconstantly, interrupts,hastroublesittingstilltodohomework,willnotplayquietlyoutdoors. TEACHERREPORT WhatelsedoyouneedtomaketheDxofADHD?(4x) StudiesshoweffectiveinterventionforchildrenwithADHDistoinvolvetheir parentsinwhatpartofTx?(4x) BEHAVIORALMANAGEMENT ChildwADHDineffectiveTxwithmethylphenidate.Nextstepinmanagement:(4x) DEXTROAMPHETAMINE ChildwADHDnotrespondtomethylphenidateIR.Whatmedtotrynext(3x) MIXEDAMPHETAMINESALTS WhataspectofADHDismostlikelytoimproveaschildrenage?(3x) HYPERACTIVITY Atomoxetine’sprincipalmechanismofactionexertsatherapeuticactionbecause ISASELECTIVENOREPINEPHRINEREUPTAKE it:(2x) INHIBITOR. AtomoxetineismostlikelytobeconsideredasinitialtreatmentinADHDin adolescentswith:(2x) SUBSTANCEUSED/O GotoTableofContents 154 ThemultimodalTxstudyofchildrenw/ADHDexaminedthecomparative responsesover14monthsofchildrentomedicationandintensepsychosocial interventions.Whatdidthefindingsofthestudyrevealw/respecttoADHD symptomchanges?(2x) MEDICATIONMANAGEMENTISSUPERIORTO COMMUNITYCARETREATMENT WhichperinatalfactorisspecificallyassociatedwithdevelopmentofADHD? MATERNALTOBACCOUSEPRENATALLY ThecomponentofADHDthatismostlikelytoremaininadulthood: INATTENTION WhichDSM-Vdiagnosisrequiressymptomstobepresentin2ormoresettings? ATTENTION-DEFICITHYPERACTIVITYDISORDER(ADHD) CurrentthinkingaboutrelationshipbetweenADHDinchildrenandadults: SIGNIFICANTNUMBEROFCHILDRENWILLGOONTO BECOMEADULTSWITHADHD 8y/oboyw/ADHD,oppositionaldefiantdisorder,andchronicmotorticdisorder hasworseningofhisticsonagooddoseofastimulantthatseemstocontrolhis ADHD.Howdoyoumanagethisfurtherintryingtoimprovethetics? MONITORTHETICSONLY WhichcomorbiddiagnosisofchildhoodADHDworsenstheprognosisinto adolescenceandadulthoodtothegreatestdegree? CONDUCTDISORDER 32y/ow/ADHDmixedtypeaschild.AsadultstillhasSx.Tx: METHYLPHENIDATE Whichmedwouldyouprescribefor20y/ocollegestudentbeingworriedoverhis grades?Hecomplainsthathehasnotbeenabletofocusonstudyingandthathis mindwandersfrequentlyduringclasses.Hisenergylevelislow.Hesleepswelland hisappetiteisgood.Historyindicateshewastreatedwithstimulantssincesecond grade. METHYLPHENIDATE 10yowADHDandaggressiveoutburstisstartedonamoderatedoseofastimulant. ADHDsymptomshaveimproved,butaggressionhasnot.Inadditiontobehavioral MAXIMIZEDOSAGEOFLONGACTINGSTIMULANT intervention,whatisthenextbeststeptomanageboththeADHDandaggression? WhichpsychiatricdisorderiscomorbidwithADHD? DISRUPTIVEBEHAVIORDISORDERS Whichofthefollowingsideeffectscanresultfromstimulantmedicationtreatment andwarrantsimmediatediscontinuationofthemedicationandareassessmentof thetreatmentplan? HALLUCINATIONS AbnormalLFTswouldbemostcommonlyassociatedw/whatmedicationusedto treatADHDinchildren/adol? PEMOLINE ADHDcomorbiddisorder DEPRESSION Theseempiricalnon-stimulantmedshaveempiricalsupporttotreatADHD: CLONIDINE,BUPROPION,IMIPRAMINE,ATOMOXETINE WhatprocedureisnecessarytodiagnosechildhoodADHD? CLINICALINTERVIEWOFPARENTSANDCHILD GotoTableofContents 155 Parentsbringtheir10yochildforanevalduetoconcernsaboutchild’sreported difficultypayingattentioninaclassandcompletingassignmentsintheexpected time.Parentsreportthatthechildhastroublestayingontaskwhiledoing homeworkandtheyareconcernedthatthechildhasanattentiondisorder.Atthe RATINGDISCREPANCIESBYDIFFERENTOBSERVERSARE completionoftheeval,thepsychiatristrequeststhatbothaparentandateacherfill COMMONINCLINICALPRACTICE. outaratingscale.Theparentratingsfallintotheclinicalrangebuttheteacher’s ratingsdonotmeetcriteriaforaclinicalproblem.Howshouldthepsychiatrist accountforthedifferencesinobservedratings? AntidepressantforADHD BUPROPION THEEQUIVALENCEOFCOMBINEDMETHYLPHENIDATE WithrespecttoADHDsymptoms,the1999multimodaltreatmentstudyofchildren ANDPSYCHOSOCIALTREATMENTCOMPAREDTO withADHDwasmostnotablefordemonstratingwhichofthefollowing? MEDICATIONALONE Whichofthefollowinginstrumentsismosthelpfulintheassessmentofchildren suspectedofhavingADHD? CONNERSTEACHERRATINGSCALE WhatmedusedforADHDhasbeenassociatedwithliverdamage? ATOMOXETINE(STRATTERA) 11y/owithreadingdisability.Mostlikelycomorbiddx: ADHD DescribestherelationshipofstimulanttreatmentofchildrenwithADHDandthe emergenceand/orpresenceofticd/o: TREATMENTWITHSTIMULANTSHASBEENSHOWNTO REDUCETICSINCHILDRENWITHCOMORBIDADHDAND TICD/O. WhatDSM-IV-TRdisorderrequiressymptomstobepresentintwoormoresettings? ADHD 12yocomesinforworseningattention,impulsive,andhyperactive.Heissnoring andhardtowakeintheAM.Centraladiposity,broadbasedneckandenlarged tonsils.examisunremarkable.InchildwithADHDandsleepproblems,whatisthe mostaccurateaboutADHDandsleepinthispatient? CORRECTINGTHEUNDERLYINGSLEEPDISORDERCAN IMPROVEADHDSYMPTOMS 5y/oisevaluatedforADHD.Parentscomplainthatthechildhasmultiplesymptoms ofhyperactivity,impulsivity,inattention,anddistractibility.Parentsalsobring CHILDRENWITHADHDCANPRESENTWITHBRIEF teacherfeedbackreportsthatconfirmthesesymptomsandstatechildisfailing PERIODSOFHEIGHTENEDFOCUSANDCALM, academicallyandhavingsocialproblems.InpsychMDofficechildisquiet,calmand ESPECIALLYINASTRUCTUREDSETTING. cooperative,andveryengaging.Thedifferenceinclinicalpresentationfromparent andschoolreportsismostlikelybecause: Failinggrades,poororganization,spendingsprees,spontaneoustripsditchingclass, ADHD fidgety,euthymic.Nochangeinsleep,appetite,noanhedonia.Dx? WhencomparedtotheothersubtypesofADHD,childrenwiththeinattentive subtypehavehigherratesofanxietyandsomaticcomplaintsand LEARNINGDISORDERS Evidencebasedtherapytreatmentforticdisorderinchildren HABITREVERSALTHERAPY DSM5priorageofpresentationADHDsymptoms IncreasedrateofcomorbiditywithADHD? 12yo AnxietyorOppositionaldefiant GotoTableofContents 156 3010yroldchild,3yrhxofinvoluntarymovementsandvocalizations,symptoms waxandwanebutneverdisappeared,childisawareofsymptomsandonlymildly distressed,academicperformanceisbelowaverage,whatistheco-occurring disordermostlikelycausingthisfunctionalimpairmentatschool? ADHD WhatdistinguishesADHDinchildrenvsadults? Hyperactivity AnxietyDisorders Whichofthefollowingstrategiesexemplifiesuseofreciprocalinhibitionbyapatient Rehearsingmentalimagesofpleasurableexperiences toattenuateanxiety? whileattendingtheparty Adiagnosticfeatureofpanicattackis:(2x) DEREALIZATION Whichofthefollowingistheinitialtreatmentofchoiceformildanxietydisorders PSYCHOTHERAPYALONE inchildren?(2x) Thekeydistinctioninthedifferentialdiagnosisofsocialphobiaversus agoraphobiais:(2x) NATUREOFTHEFEAREDOBJECT Besttherapyforpatientwithillnessanxietydisorder CBT DifferentialDxofanxietyintheERtypicallyincludes: PULMONARYEMBOLISM Theparentofa43y/optdied5yearsagofrompancreaticcancer.4yearsago patientbeganfeelingfullaftereatinglargefattymeals,fearingitwaspancreatic cancer.Constantlyweighshimselfsothatheisnotlosingweight.Nowavoids goingtodoctortoavoidbeingdiagnosedwithcancer.Nootherpsychiatric symptoms.Whatisdiagnosis? Illnessanxietydisorder Treatmentforsevereperformanceanxiety PROPRANOLOL 36y/owithseveralepisodesofpalpitations,sweating,trembling,SOB.Work sufferingduetoanxiety.InitialTxregimen: PAROXETINEANDCBT WhichofthefollowingagentshasbeenshowntoaugmenttheeffectsofCBTon anxietydisorders? D-CYCLOSERINE A28yoptpresentswitha1yearhistoryofagoraphobia.Theptisabletodriveto thelocaldrugstore,butonlywithconsiderablepre-travelapprehension.Theptwill venturealonenofurtherthenwithin~5milesofhome.Personalhistoryofpanic attacksordepressionisdenied,althoughfamilyhistoryispositivefordepression andalcoholism.Thepthashadnoprevioustreatment.Thebestinitialtreatment, andonethatoffersthebestlong-termprognosisforthispatientis? SSRIandBZD Weightloss,3-monthhxofanxiety,milddepression,&insomnia,thin,elevatedHR, HYPERTHYROIDISM lowBP,mildtremor Prevalenceofseparationanxietyd/oandGADinchildrenfollowswhatpatternwith GADINCREASESWITHAGEWHILESEPARATIONANXIETY regardtoage? DECREASESWITHAGE GotoTableofContents 157 28y/optpresentsw/1yrhxofagoraphobia.Ptisabletodrivetothelocaldrug store,butonlywithconsiderablepre-travelapprehension.Ptwillventurealoneno furtherthanwithinapproximately5milesofhome.Personalhistoryofpanicattacks CBT,INCLUDINGEXPOSURE ordepressionisdenied,althoughfamilyhistoryispositivefordepressionand alcoholism.Pthashadnoprevioustreatment.Thebestinitialtreatment,andone thatoffersthebestlong-termprognosisforthisptis: 14y/optwithalong-standingh/oofperfectionismhasrecentlydevelopedafearof talkinginclassafterforgettingherlinesinaschoolplay.Ptsays,“Idon’tliketalking SOCIALPHOBIA tootherkids”andpracticesreadingaloudoverandoverso“IrememberwhatIam saying.”Dx: Ptpresentswithchappedandreddenedhands.Uponquestioning,ptadmitsto washingthehandsmanytimesadaybecause“Iworkinahospitalcafeteriaandam SPECIFICPHOBIA intenselyafraidofcontractingaflesh-eatingbacterialinfection.”ThemostlikelyDx: InsomeJapaneseandKoreancultures,ratherthananintensefearofembarrassing oneselfsocially,socialphobiasymptomsmayinsteadmanifestwithintensefearof what? OFFENDINGOTHERS Whichofthefollowingisacommonmedicalcauseofanxietyinaptdyingofcancer? POORLYCONTROLLEDPAIN Ptswithbloodphobiahave2stageresponsewhenexposedtostimulus.Firstis increasedanxietyandelevatedBP.2ndresponse? HYPOTENSION 6y/ochildgenerallyhealthythrowsafiteverytimefamilygoeshiking.Exposureto snakeononehikeledchildtobecomeloud,agitated.Nowchildhasintensedistress SPECIFICPHOBIA whenhiking,pleadstostaywithparentsatalltimes.Dx? 18y/orestless,feelsmindgoingblank,poorconcentration,irritability,insomnia, fatigue>1yr,usedtobegoodstudentupuntil2-3yrsago,nosubstanceuse GAD CorefeatureofGAD EXCESSIVEWORRYING PtwithOCDresistanttoenteringtreatmentisacandidatefor: MOTIVATIONALINTERVIEWING 35y/otruckdriverdiagnosedw/GAD.Doesnotwantmedthatcausessleepiness: BUSPAR EpisodicOCDwithvariableseverityofSxs,independentofTx,ismorecommonin: BIPOLARMOODDISORDER WhichTCAhasconsistentlybeenfoundtobeusefulinlongtermtreatmentand relapsepreventionofOCD? CLOMIPRAMINE TheChild-AdolescentAnxietyMultimodalStudy(CAMS)comparedsertraline,CBT, andcombinationtherapyinchildren/adolescentswithmoderate/severeGAD,SAD, andSocialPhobia.Primaryfindings? COMBINATIONTREATMENTSUPERIORTO MONOTHERAPY PsychMDwasconsultedforanxietyanddepression.Ptreportsseverepainand indicatesthatdoctorsrefusetoprescribeenoughmedicationtocontrolpain.A factorimportantforpsychiatristtoconsider: ACUTEPAINISOFTENUNDERTREATED,ANDPOORPAIN MANAGEMENTCANCONTRIBUTETOANXIETYAND DEPRESSION. Ptwithleukemiaunderwentmarrowtransplant.Psychconsulted.Ptmoreanxious ADJUSTMENTDISORDERWITHANXIETY GotoTableofContents 158 andfearfulaboutleavinghospital.Havingtroublesleeping.MSEunremarkable.Dx? 7y/ogirldislikesgoingtoherfriend’shouse,preferringherfriendscometoher home.Shehasrecentlyhadastomachacheinthemorningbeforeattendingschool andsometimescriesuncontrollablyifhermotherinsistssheattends.Teachers reportsafterhermomleavesheusuallysettlesdownanddoesacademicallywell. Dx? SEPARATIONANXIETYDISORDER Diagnoseachildwhopersistentlyrefusestoattendschoolorsleepinbedalone, complainingofsomaticsymptomswithnophysiologicalorigin? SEPARATIONANXIETY Whichofthefollowingisamanifestationofunresolvedgriefinaschool-agechild whohasexperiencethelossofasibling? SEPARATIONANXIETYFROMPARENTS A45yroldpt,terminatedtreatmentwithpreviousPCP"becausehedidn’ttakemy concernsseriously."Ptbelieveshehasdreadedillnessandstomachcancer,denies allsymptomsandlabsarenormal,diagnosis? ILLNESSANXIETYDISORDER Generalizedanxietydisorderischaracterizedbyexcessiveworryingalongwithwhat BEINGEASILYFATIGUEDANDFEELINGKEYEDUP combinationofsymptoms? Childhooddisorderwithgreatestgeneticassociationforadultonsetpanicattacks? separationanxietydisorder EEG-biofeedbacktrainingisefficaciousforwhatd/o? GAD 8yop/w“alwaysworried”andfearinggettinglostorbeingkidnapped,frequently insistingonsleepinginparent’sroom(doeswellacademically&interactswithcircle Separationanxietydisorder offriends,butfrequentlyc/oHAandvisitingschoolnurseofficetocallparent) A19-yocollegestudentcomplainsof“difficultyconcentratingandmymindgoing blankwhenItrytostudy.”Shefeelsrestless,keyedupandworriesexcessively.DoesGeneralizedanxietydisorder notusesubstances. 55yroldHispanicAmericanbroughttopsychiatristbyfamily,spellsofuncontrollable shouting,crying,trembling,insomnia,ptfeelschestheatgoinguptohead,ptand ANXIETYDISORDER familybelieveptissufferingataquedenervios,ptmeetscriteriafor? 9yrwithbehavioralproblemsfor4yrs,athomeandschool,irritability,anger,verbal outbursts,waspreviouslysocial,askedtoleaveteams,uncooperativewithparents, anxiety whichdisorderwillhehavebythetimehereachedyoungadulthood? BipolarDisorder Whatpredictsbipolarityinadolescentwithdepression?(2x) PSYCHOTICSYMPTOMS 40y/ow/6kids:insomnia,poorappetite,dizziness/nausea,thinkshusbandis poisoningher.Despiteallclassesofmedsmarkedfluctuationsfromsadnessto euphoria5xduringtheyear.Dx?(2x) BIPOLARW/RAPIDCYCLING GotoTableofContents 159 24-year-oldw/1monthincreasingfatigue,difficultyfallingasleep,poormotivation, andtroublepayingattentioninnightschool.Nopersonalorfamilyhxofdepression. RxMirtazapine15mgqhs.Aftertwodoses,ptbecomeseuphoric,hyperactive, SUBSTANCE-INDUCEDBIPOLARDISORDER talkative,andfullofcreativeideas.Ptstoodonachairatnightschoolandoffered heartycongratulationstoteacherforcontributingtopt’scertainfuturesuccess. Mostlikelydx? Lamotrigineiseffectivetreatmentforwhatmooddisorder? BIPOLARDEPRESSION Whichmedistreatmentofchoiceforbipolarwithrapidcycling? VALPROATE Psychiatrististreatingptwithbipolardisorderwhoseconditionisrelativelystable, recentlyreportsfeelingdepressed.Thepsychiatristisconsideringadding lamotrigine,howeverisconcerneditmayinteractwithptscurrentmeds.Which medicationinteractionispsychiatristconcernedabout? VALPROATE Manicepisodewhileoncarbamazepine.Goodresponsein2wks.4wksrecurrence. AUTOINDUCTIONOFEPOXIDEPATHWAY Whatismosteffectiveandrapidintreatmentofmania? COMBINEDANTIPSYCHOTICMEDICATIONWITH LITHIUMORVALPROATE Bipolarptw/2hospitalizationsformaniatakinglithium NEEDSLIFETIMELITHIUMTREATMENT First-degreerelativesofpatientwithBMDIIhaveahigherincidenceofwhat disorder? MDD Whatdrugisgoodforacutemania? LITHIUM Thenaturalcourseofanuntreatedmanicepisodelastsapproximatelywhatlength oftime? 3MONTHS Whichofthefollowingbaselinelevelsshouldbeassessedpriortostartinglithium treatment? TSH Thepresenceofadverselifeeventshasbeenassociatedwithprecipitationofwhich DEPRESSIVEEPISODE ofthefollowingaspectsofbipolardisorder? AccordingtotheAACAPPracticeParameters,diagnosisofbipolardisorder,typeIin ADISTINCTPERIODOFABNORMALMOODAND childrenrequireswhichofthefollowing? EPISODICSYMPTOMS Onecontroversyaboutpediatricbipolardisorderiswhethersevereirritabilityand emotionaldysregulationare: PREDICTIVEOFCLASSICBIPOLARDISORDERIN ADULTHOOD 32y/ow/diarrheax2wks,isanxious,andnotorientedtodate/timeofday.Taking “somedrug”forBMDandpatientdoubledherdoseamonthagowhenshefeltshe LITHIUM wasn’tgettingbetterfastenough.WhatmedcausedtheseSx? GotoTableofContents 160 42y/optwithepisodesoffeeling“sadanddown”accompaniedbydecreased energy/interestinactivities.Ptestimatestheseepisodesoccurredatleastfourtimes inhislife,lasting2-3weeksatatime.Duringepisodes,spendsmostofthetimein bed.Mostrecentepisodeofsxended1weekago.Sincethen,ptreportsfeeling BIPOLARIIDISORDER energeticand“ontopoftheworld.”Henowsleepsonly1-2hoursanight,wakes feelingrefreshed.Friendsremarkptseemsflighty,butptnotesnodeleteriouseffect ofthemoodchangeandfindsthathisproductivityatworkisthebestithasever been.MostlikelyDx: 29y/optisadmittedtothehospitalwitha1weekhistoryofeuphoria,insomnia, pressuredspeech,andgrandiosity.PthasdelusionsofbeingmonitoredbytheFBI, andthestaffobservesptrespondingtounseenothers.Inadditiontothese symptoms,whatisrequiredfordiagnosisofSCHIZOAFFECTIVEdisorder? PresenceofPSYCHOTICSYMPTOMSforatleast2 WEEKSintheABSENCEofMOODSYMPTOMS WhichmedhasFDAapprovalfortxofmaniainchildren12yearsofageorolder? LITHIUM 27y/optw/BMDI,hasbeenstabilizedasanoutptonemonthfollowinga hospitalization,andisnowreceivingweeklymedmanagementandsupportive CALLTHEPTTOEXPRESSCONCERNANDFINDOUTWHY psychotherapy.Pthasbeeneuthymicforthepast2wks,buttodaydoesnotshow THEPTDIDNOTMAKETHEAPPOINTMENT upforascheduledappointment.Themostappropriateresponsebythepsychiatrist is? BMDIIwithrapidcyclinghavehigherprevalenceofwhatendocrinologic dysfunction? HYPOTHYROIDISM Thisisariskfactorfortherapidcyclingformofbipolardisorder FEMALESEX WhatsymptomsareseeninamanicepisodebutnotinMDE? FLIGHTOFIDEAS Suggestunderlyingbipolarin27y/oFwhopresentsw/firstmajordepressive episode: FAMILYHXOFBIPOLAR Txofacutemaniaw/lithium.Whatisthebestadjunctiveagent? ECT Bipolarw/4+manicepisodes/yrfor3yrs.Treatmentofchoice? CARBAMAZEPINE,1200mgDAILY DSM-IVdefinesh/omajordepressionplushxofmixedmanicanddepressive episodeas: BIPOALRDISORDER,TYPEI Unlikeadultswithbipolardisorder,prepubertalchildrenwithbipolardisorderare believedtohave: PREDOMINANTLYCHRONICMIXEDMANICSTATES HxofMDD,irritable,restless,distractible,insomnia,poorappetite,guilt,impulsive spending BIPOLARD/O,MIXED Postpartumpsychosisisoftenassociatedwithwhichofthefollowingdisorders? (x2) BIPOLAR Maleandfemaleprevalenceratesarecomparableforwhichofthefollowing disorders? BIPOLARDISORDER Medicationthatincreasesserumleveloflamictal? VALPROATE GotoTableofContents 161 DelusionalDisorders 80yomaletellsPCPhethinkshiswifeof55yearsishavinganaffair,wifeandtwo middleagedchildrendisagree.Ptacknowledgesnoclearevidenceofhisbelief.Ptis DELUSIONALDISORDER healthy,nopsychhistory,nohallucinations,cognitivetestingisnormalforage. Whatishismostlikelydiagnosis? Termforunreasonableandsustainedbeliefthatpatientacknowledgesmaynotbe truewhenchallenged OVERVALUEDIDEA Lengthoftimecriteriafordelusionald/o ONEMONTH Bodydysmorphicd/ovs.Delusionald/osomatictype: INTENSITYWWHICHPTINSISTSONPERCEIVEDBODY DEFICITS Complaintsofskininfectionwithinsects,negativemedicalw/u: DELUSIONALD/O,SOMATICTYPE Normalmale,exceptthatheisparanoidaboutwifecheatingonhim: DELUSIONALD/O 26yoptthinkshisbrowbridgeistooprominentandlookslikeaneanderthal. PhysicianfindsbrowbridgeprominentbutWNL.Ptwantsplasticsurgeryconsult. Whatbestdescribesthept’sbelief? OVERVALUEDIDEA Erotomaniareferstowhichofthefollowingconditions? DELUSIONSOFASECRETLOVER Isolatederotomaniaisaformofwhat? DELUSIONALD/O Ptscomplainofhavinglostnotonlypossessions,status,andstrength,butalso heart,blood,andintestinesufferfromwhichofthefollowingsyndromes? COTARD PtbelievesheistheSonofGod.ThisSxiscalled: DELUSION Immediateinterventionincaseofaptwithparanoiddelusionandideaofreference: ASKINGFORDETAILSOFPERCEPTIONTHATLEDTOTHIS DISTRESSINGDISCOVERY. Themostimportantriskfactorfordevelopingpostpartumpsychosis: PREVIOUSPOSTPARTUMPSYCHOSIS Ptreportsthecontinuingsuspicionthatthespouseiscommittingadultery,but acknowledgesthepossibilityofbeingwrongsincethereisnoevidencetosupport OVERVALUEDIDEA thept’sbelief:(x2) 20yoJapaneseAmericanpatientpresentofcomplainingofpersonalbodyodorthat SOCIALPHOBIA,BODYDYSMORPHICDISORDER, isoffensivetootherpeople.ThisismostoftencomparedtothisDSMdiagnosis? DELUSIONALDISORDER(SOMATICTYPE) Apatientwithsomaticdelusionaldisorderrefusingtoseeapsychiatristbutseesa SUGGESTTHATTHEDERMATOLOGISTASKABOUT dermatologistregularly.Whatshouldthepsychiatristrecommendthedermatologist DRUGUSE do? Beliefthattelevisionissendingyouspecialmessages Delusionofreference GotoTableofContents 162 A20y/ofemalepatientreportsmensesstopped4monthsagoandshe’s pregnant.Reportsmorningsicknessandvomiting,biggerbreasts.Pregnancytest PSEUDOCYESIS negative,ultrasoundnegative,stillthinksshe’spregnant.What’sthediagnosis Depression Whichisassociatedw/worsenedretrogradeamnesiaduringECT?(5x) BILATERALELECTRODEPLACEMENT Inlearnedhelplessnessmodel,thebehavioraldeficitsinanimalsexposedto uncontrollablestressisreversedby?(4x) ANTIDEPRESSANTS 65y/ohadMDDbutwastreatedw/CBTtoremission.Usuallyhas1glassofwine w/dinner.Samelevelofdrinkingformanyyears.Familyh/odementiainboth parents.Advice?(3x) CONTINUETHEALCOHOLASLONGASTHEPATTERN OFUSEDOESNOTCHANGE Whichd/oistreatedw/lighttherapy?(3x) SEASONALAFFECTIVEDISORDER 79y/oasksforevalforSTD.Upsetandguiltyaboutanaffair.Spousesaysaffair happenedmanyyearsago.Ptissadbutnotconfused.Dx?(2x) MAJORDEPRESSIONWITHPSYCHOSIS WhichdepressivesymptomisamelancholicfeaturespecifierinDSM-IV?(2x) LACKOFPLEASURE 60y/ow/depressivesyndromehasmemoryproblems.Incorrectondate,messes upserialsevens,spellsbackwards,butslowly.After4wksoftrazodone,both PSEUDODEMENTIA moodandcognitionareimproved.Dx?(2x) Depressionincreasesriskofmortalityfromwhatdisease?(2x) ISCHEMICHEARTDISEASE HepatitisCtreatmentwithinterferoncancausewhatpsychiatricsymptom?(3x) DEPRESSION 50y/oPTw/depressionbelievesthatheisresponsibleforthedestructionofthe world.Thisisanexampleof:(2x) MOOD-CONGRUENTDELUSION Insteadofdepressedmood,childrenwMDDmayprimarilyshow:(2x) IRRITABILITY Whatmedicationmaycausemoodd/oinptsbeingtreatedformelanoma?Also worsensfatigueandcognitiveinefficiency:(2x) INTERFERON Thetreatmentforadolescentswithdepressionstudyrecommendedwhichofthe followingtreatmentsforpatientswithmoderatetoseveredepression?(2x) FLUOXETINEANDCBT Depression,accordingtoBeck’smodelisamanifestationof:(2x) DISTORTEDNEGATIVETHOUGHTS(COGNITIVE DISTORTIONS) Whichofthefollowingcharacteristicsisconsideredparticularlylikelytobefound INTERPERSONALREJECTIONSENSITIVITY inpatientswithMDDwithatypicalfeatures?(2x) 34y/oFpresents“unabletoreachherpotential”wmoodswitchesfrequently (daytoday,sometimeswithinoneday)frommildlytomoderately.Depressedto happyinthemorning.Noepisodesmeetingcriteriaformania.Hxsuggestsmost likelyDx?(2x) CYCLOTHYMICDISORDER GotoTableofContents 163 Melancholiaischaracterizedas(2x): ANHEDONIA ThemostcommonreasonthatpeoplediscontinuetheuseofSSRI:(2x) GISIDEEFFECTS AccordingtoJointCommission,whatisprimaryriskfactorforcompletedsuicidesin Increasethedose medicallyhospitalizedpts? Firstlinerxforptwithdilatedcardiomyopathywhoisdepressedandhasnorelief withfluoxetine.Ptdoesnotwantsideeffects BUPROPION Theoryofkindlingofdepressiveepisodesissupportedbywhatphenomenain some? RECURRENTWITHOUTASTRESSOR 47yooverweightfemaleoncelexawsexualsideeffects.Whatmedtoswitchto? BUPROPION Ptwithlowmood,middleinsomnia,impairedconcentrationandmemoryx3mons, onsetshortlyafteradultchildwasconvictedwithfelonyandimprisonedx10years. ADJUSTMENTD/OWITHDEPRESSEDMOOD MostlikelyDx? Bonemarrowtransplantforleukemia.Moreanxious,fearfulthanhewasbefore transplant.Troublesleeping,fearfulaboutleavinghospital.Whatisdx? ADJUSTMENTD/OWITHANXIETY BluntedresponsetoTRHstimulationtestcorrelateswith… DEPRESSION Mostcommonpsychd/othatoccursinptss/porgantransplant MAJORDEPRESSION ThemooddisturbanceofPMDDischaracterizedby… ITCANBEASSEVEREASINMDD Definingfeatureofmoodinatypicaldepression REACTIVE 27y/oF,1weekpostpartum,hassuddenemotionaloutbursts;notsad,wantsthe baby.What’sgoingon? MATERNITYBLUES WhichdietarysupplementhasdemonstratedsomeefficacyinTxofdepression? S-ADENOSYL-L-METHIONINE(SAME) Thebestdescribesdataonsuicideriskfrommeta-analysisofclinicalstudiesof depressedchildrenandadoltreatedw.SSRI: MOREYOUTHAPPEARTOFAVORABLYRESPONDTO MEDSTHANSPONTANEOUSLYREPORTSUCIDALITY Learnedhelplessnessisamodelfor: DEPRESSION Learnedhelplessnessisbasedonprinciplesof: CLASSICALCONDITIONING ImplantationofDBSelectrodeshasbeenshowntoleadtoremissioninabouthalfof patientswithtreatment-refractorydepression.Toobtainthiseffect,theelectrodeis SUBGENUALCINGULATECORTEX placedinthe: Whatdisorderismostlikelytobecomorbidinptswtrichotillomania? MOODDISORDER Importantdistinctionbetweendepressivesymptomsinptswithcancerascompared USUALLYMAINTAININTACTSELF-ESTEEM tothosepatientswithdepressionbutnocanceristhatthepatientswcancer? GotoTableofContents 164 WHOstudyin1990,whatisthe2ndworldwideleadingsourceofyearsofhealthy lifelosttoprematuredeath/disability(#1isischemicheartdisease): UNIPOLARMAJORDEPRESSION 17y/owithdepressedmood,lowselfesteemandpoorconcentrationpossiblyhas dysthymia.WhichfeaturewouldsupporttheDx? SYMPTOMS>1YEAR 10y/ochildwith2-monthh/oirritability,inattention,sleepdisturbance,and withdrawal.Childattemptedtoruninfrontofacar.Nofamilyh/opsychiatricd/o. Onexamination,noeyecontactandhaspsychomotoragitation.Whatmed? SSRI Comparedtoolderadolescentswithdepression,8-12year-oldsw/depressionmost SOMATICCOMPLAINTS oftenshowwhat? 27y/oMseeninEDc/oinsomnia,hopelessness,anorexia,decreasedconcentration for2weeksandisnowacutelysuicidal.PthashxofETOHusedailyforthepast3 SIMD months.ThemostlikelyDx? First-lineTxfor9y/ow/depression SERTARALINE 65y/omorbidlyobeseptwithnewonsetofdepressionendorsesfatigueand hypersomnia.HeisnotonmedsandhasnoPMH.Whattest? POLYSOMNOGRAPHY First-lineTxforadolescentsw/majordepression FLUOXETINE 40y/oMreportslonghxofcontinuousdysphoriaandinsomnia(dysthymia). Recentlyhefeelsworseandreportspoorenergy,hopelessnessandSI.Dx: DOUBLEDEPRESSION Dxfor40yomalew/mildchronicdysphoria,insomnia,fatigue,andlessenedjob performance,nowwithdespondency,tearfulness,lackofenergy,skippingwork, hopelessness,psychomotoragitation,andSI DOUBLEDEPRESSION StrongestpredictorinptfollowingMI(everstrongerthanEF): DEPRESSION PtwOCDstartedon100mgsertraline,at4weekf/uincreasedto150mgb/ono response.Week10,ptreportednoimprovement.Nextstep? INCREASESERTRALINETO200MG 59y/oERphysicianwithalcoholproblemanddepressedmood,lesstoleranttoday RECOMMENDRELIEFFROMTHENIGHTSHIFT andnightshift.InadditiontoabstinencefromETOH,whatisnextstep? WomenathighestriskofMDDduring: REPRODUCTIVEYEARS Mw/HTNandMI,hasstressorsanddepression,Tx? RELAXATIONTRAINING Pancreaticcancerpatientjustdiagnosed,tellsnurseshewisheshewasdead.Distant withpsychiatrist.SeveralmonthhxofdepressiveSx’s,nosupportsystem.“Theonly PLACEONSUICIDEPRECAUTIONS familyathomeismygun” Aneffectiveantidepressantfordepressionw/atypicalfeaturesis: PHENELZINE Childmusthavedepressedorirritablemoodforwhatlengthoftimeinorderto meetcriteriafordysthymicdo? ONEYEAR GotoTableofContents 165 Dexamethasonesuppressiontestfordiagnosingmooddisorders: NOTUSEFULINROUTINECLINICALPRACTICE 61y/owithleftfrontallobedamagesecondarytocerebrovascularaccidentmaybe predisposedtowhichpsychiatricsyndrome? MDD 9y/ow/increasedirritabilityandaggressionfor3mons.Usedtobeeasygoing. Gradesdropping.Noinsomniaorpoorappetite.AHofvoicetellinghimheisbad. MostlikelyDx: MDD 60y/ow/depression¶noiatreatedwith50mgZoloftand6mgrisperidone.On followupptc/oslowthinking&excessivesalvation.OnPEmaskedfacesand LOWERDOSEOFANTIPSYCHOTICMEDS cogwheelrigiditypresent.Moodandparanoiahavegreatlyimproved.Whatisthe nextstep? Whatisacharacteristicofatypicaldepression? LEADENPARALYSIS 77y/oFwhosehusbanddied6wksago,complainsaboutthelengthoftimeittook forhertodress.Shesoundsirritable,looksfatigued.“Ican’tacceptheisgone….I shouldhavebeenabletosavehim”.Shesays“Whentherealdarknessdescendson HAVINGTHOUGHTSOFSUICIDE. mespeciallyinthemiddleofthenightIdon’twanttocallanyone.”Whatismore indicativeofMDDratherthanuncomplicatedbereavement: Cognitivetriadofdepression:negativeself-perception,experiencetheworldasself- EXPECTATIONOFCONTINUEDFAILURE defeating,AND? Whyisl-methylfolatepreferabletofolateinadjunctivetxofdepression? IncreasetransferacrossBBB Whataugmentationstrategiesfortreatment-refractorydepressionhasshownthe highestefficacyandreplicability? ELECTROCONVULSIVETHERAPY(ECT) Txforworseningdepression,severeweightloss,dehydration,catatonia. ELECTROCONVULSIVETHERAPY(ECT) MostcommonlylimitstheuseofECT: COGNITIVEIMPAIRMENT Whichofthefollowingmedicationsshouldbestoppedorreducedbeforestartinga LITHIUM patientonECT? Whichdiseaseismostlikelytopresentaspaindisorder DEPRESSION Ptw/unipolardepressionhashad3recurrenceofdepressioneachseparatedby1 yr,aftersuccessfultreatmentw/imipramine200mgqd.Whichprophylactic treatmentshouldberecommended: CONTINUEIMIPRAMINE200MGX5YRS Suicidalthoughts,constantworrying,feelsdepressed,guilt,lacksenergy, hypersomnia,feelsineffectiveatwork.Tx? CONSIDERTXW/ANTIDEPRESSANT ProphylacticTreatmentforaptwithseveredelusionaldepressionfollowingacourse COMBINATIONOFANTIPSYCHOTICSAND ofECTincludeswhat? ANTIDEPRESSANTS Presence/severityofdepressiveTxinMSiscorrelatedwith: CEREBRALINVOLVEMENT GotoTableofContents 166 29y/oMh/orecurrentdepression&1.5PPDsmoking.Medication? BUPROPION 8daysafterhipsurgerya75y/opthasepisodesofdisorientation,sleeplessness, andcryingespeciallyatnight.Alsolittlefrogsinherroom.Inmidmorningsheisok. WasDxw/MDDseveralmonthsagoandtakingdoxepin25mgtidanddiazepam5 ATYPICALDEPRESSIVEDISORDER mgtidwered/cbeforesurgery.Currentlyonmeperidine,diphenhydramine.The recentconfusionisNOTcausedby: Researchontheuseofpsychostimulantstotreatptsw/secondarydepressive symptomsinmedicalsettingsuggest: WHENTREATEDWITHTHESEAGENTS,PTMAYENGAGE INREHABILITATIONSOONER. PsychMD.Consultedfordepressionafteranabortion.Ptreportssheisrelieved abouttheabortionb/cshewasinabusiverelationship,notemotionally/financially preparedtohavechild.Psychmustbeawarethat: STRONGESTPREDICTOROFDEPRESSIONAFTER ELECTIVEABORTIONISHISTORYOFPRE-PREGNANCY DEPRESSION 21y/oFhospitalizedforexcessivebleedingfollowingelectivefirsttrimester abortion.Ptreportshavinganxietyaboutbleeding,butisrelievedaboutabortion.Pt HXOFPRE-PREGNANCYDEPRESSION reportsthatbaby’sfatherisabusivebutdoesnotwanttoleavehim.Whatisthe strongestpredictorofdepression? Pthaspartialresectionofbowel.Hasnotresumedambulationdespite encouragement.Pthaslowmood,poorsleep,andanhedonia.Dx? PSYCHOLOGICALFACTORSAFFECTINGGENERAL MEDICALCONDITION 6y/opresentswitha3yrshxofdisruptivebehaviorsathomeandschool.Parents reporthehasdifficultypayingattentionandcompletingtasks.Recentlypthasb/c DEPRESSION moreoppositionalandangrywithadultsandpeers.Heoftenstates,“Iamnogood.” Whatcomorbidconditionismostlikelyexplanationforthechildrecentbehaviors? 50y/optisbeingtreatedforsadness,anorexia,poorenergy,anddifficulty concentrating.Fluoxetine20mgisprescribedandtheptachievesfullremission. Laterptadmitsthatshehadvisualandauditoryhallucinations.Thisimprovedwith treatmentandptcurrentlydeniesanyhallucinations.Dx? MDDWITHPSYCHOTICFEATURES 25y/optreportsexperiencingintenseperiodsofprofoundtirednessoverthepast 2- 3weeks.Duringtheseperiodsshehasincreasedneedforsleepandspendmuchof MDDWITHATYPICALFEATURES dayinbed.Ptalsoreportsincreasedappetite.Theseepisodesoftenoccurinsetting ofinterpersonaldiscord.Dx? AccordingtotheWorldHealthOrganization,whatisthenumberonepsychiatric causeoflossofyearsofhealthylifeasmeasuredbydisability-adjustedlifeyearsfor UNIPOLARMAJORDEPRESSION individualsbetweenagesof15and40years? Ptisinitiatinglighttherapyforseasonaldepression.Whatstatementaccurately representswhatisknownaboutthetype,dose,andtimingofeffectivetreatment? MORNINGLIGHTTREATMENTAPPEARSTOBEMORE EFFECTIVETHANMID-AFTERNOONEXPOSURE. WhichantidepressantisLEASTLIKELYtoproducesexualdysfunction? BUPROPION CharacterizesdepressioninptwithMS: RESPONDSTOANTIDEPRESSANTS GotoTableofContents 167 PtpresentstoEDwith5-dayhxofN/V,diarrhea,HRof90,BP150/92,andtemp 100,sweating,tremor,hyperreflexiaanddistractibility,normallabsanandCThead, TRAMADOL andyearsofFluoxetineuse.Oneweekagoanewmedisstarted: 35y/optpresentswithseveredepressionwithepisodesofanxietyfor9months thathavebecomesobadhecannolongerleavethehouse,hassevereweightloss, hyperpigmentationofexposedskin,andcoldtolerance.Dx? ADDISON’SDISEASE Howmanysymptom-freeweeksmustbebetweentwoepisodesofdepressionfor themtobeconsideredseparateandthereforerecurrentaccordingtoDSM-IV? 8SYMPTOM-FREEWEEKS Whichofthefollowingfunctionsismostlikelytonormalizeinan80y/opt successfullytreatedfordepression? IIFORMATIONPROCESSINGSPEED 19y/optpresentsforevaluationofdepression.Ptreportsagenerallyverylow mood,althoughitbrightensupbrieflywhensomethinggoodhappens.Ptreports feelingbestinthemorning.Pthasbeensleepingandeatingmorethanusual,and complainsoffeelingsofheavinessintheextremities.Ptreportsalwaysbeingvery sensitivetoperceivedrejectionbyothers.Trialswithtwoselectiveserotonin reuptakeinhibitors(SSRIs)havefailed.Whichofthefollowingtreatmentsmaybe particularlyeffectiveforthispt? TRANYLCYPROMINE Inptswithrecurrentdepression,successfultreatmentwithantidepressantsshould befollowedbywhichtreatmentstrategy? CONTINUINGANTIDEPRESSANTSATTHESAMEDOSAGE 35y/oFptpresentstothephysiciancomplainingofdecreasedinterestinsexual activityanddifficultybecomingarousedbyherspouseoverthelast3months.Upon furtherquestioning,thepatientalsoreportsanhedonia,difficultysleeping,fatigue, SYMPTOMOFAMAJORDEPRESSIVEEPISODE anddecreasedappetiteoverthesametimeperiod.Medicalhistoryandworkupare otherwiseunremarkable,andptisnotcurrentlytakinganymedications.According totheDSM-IV-TR,pt’sdecreasedinterestinsexismostlikelyassocwwhich? Patientwithdepressiononadmission.Whichriskfactorsuggestsneedfor maintenancepsychotherapy?(2X) 3ORMOREEPISODESOFDEPRESSIONINALIFETIME A/wimprovedoutcomeinlate-lifedepression? Familyhistoryofdepression DissociativeDisorders Focusedattention,alteredconsciousnessusuallyseeninptswdissociativeD/O (2x) TRANCE Thissymptomisessentialtosupportadiagnosisofdissociativeidentitydisorder (2x) EXTENSIVEINABILITYTORECALLPERSONAL INFORMATION Ptbroughttoedbyfamilybecauseofconcernforptsabilitytorecognizethemsince TBIonemonthago.PthadLOCaftertrauma.TendernessandswellingoverL DISSOCIATIVEAMNESIA temporalarea.Neuroexamnormal.Ptknowsownname,butunabletoidentify familymembersoreventsrelatedtofamily.Whatisdiagnosis? GotoTableofContents 168 Wheneverthecultureofwesternmedhasbeenafocusofinquiryby anthropologists,whatdiagnosishasbeenseenasacultureboundsyndromein northAmerica? DISSOCIATIVEIDENTITYD/O Ptwmemorylapses,talkslikeadultattimes&likeascaredchildatothertimes.Dx? DISSOCIATIVEIDENTITYD/O Psychiatristasks,“Doyoufindthingsinyourpossessionthatyoucannotexplain?” Tryingtoelicit: DISSOCIATION Detachmentofemotionalcomponentfromperception DEREALIZATION Ptswithdissociativeidentitydisorderarealsomostlikelytomeetthediagnostic criteriaforwhichofthefollowingdisorders? PTSD 20y/oinMVA,noinjuries–speakssoftly,feelscalm,dimvision,mechanical movements,feelsdetached: DEPERSONALIZATION Depersonalizationisclassifiedasdisturbanceofwhichofthefollowing? PERCEPTION 44y/optreportshxofrepeatedepisodesofself-mutilationandsuddenchangesin relationships.Afterseveralmonthsofpsychotherapy,theptspeaksinunusual accent,isirritable,andhaslittleawarenessofin-sessiondiscussions.PsychMDhas DISSOCIATIVEIDENTITYD/O pastrecordsthatstatepthasbeenDxwithborderlinepersonalitydisorderandhasa sexualtraumahistory.Dx? Ptsthat“cut”asaformofself-mutilationtypically: CLAIMTOFEELNOPAIN Newlymarried22-year-oldptisstronglyencouragedbyhusbandtoseekevaldueto abruptchangesinpt’sattitudesandbehaviors.Ptdeniesawarenessofthis,butdoes acknowledge“missingtime”thatmadeherfeellikeherlifeis“scatteredonthefloor ofafilmeditor’sstudioafterpieceswerecutandtheendssplicedbacktogether.” DISSOCIATIVEIDENTITYD/O Oldgfofhusbandhasthreatenedtofilecharges2/2hostiletelephonemessages thathavebeentracedtopt’sphone.Ptdeniesmemoryofmakingcalls.Whatisthe d/o? 45y/optwlungcanceranddepression.Physicalandemotionalsymptomsare stable,ptworriesthat"familyalwaysseemsonedgewme."Familymeetingshows childrenfearlosingfather,frustratedthatlivesseem"onhold".Daughterfeelsshe can'tinvitefriendsoveroutoffearof"stressingherfather."Fatherfeelsguilty aboutthisbutdoespreferquietenvironment.Beststrategicsystemicapproachto problem? Taskfamilywithcomingupwpracticalschedule EatingDisorders/BodyDysmorphicDisorder Episodesofunrestrainedeatingw/ocompensatorybehaviorsofbulimia.Dx?(5x) BINGE-EATINGDISORDER Metabolicabnormalitycommonlyfoundwanorexianervosa/purgingsubtype? (4x) DECREASEDSERUMPOTASSIUM Dehydratedbulimicw/BP100/60andorthostasisHR60.Statlabtest:(3x) POTASSIUM GotoTableofContents 169 ComplicationofanorexianervosaLEASTlikelytoresolveafterrestoringweightis? OSTEOPOROSIS (2x) Adiagnosisofanorexianervosarequiresthatthepatienthasmaintainedaweight 85% belowwhatpercentageofaminimallynormalweightforageandheight?(2x) Ptwithsignificantmedicalhxadmittedtoinpatientpsychunit.Labsshow:lowK andCl,elevatedHCO3andamylase,andnormallipase.Dx:(2x) BULIMIANERVOSA,PURGINGTYPE TheproposedDxofbingeeatingd/odiffersfrombulimianervosainthatptsw/ bingeeatingd/o: USUALLYDONOTMAINTAINANORMALWEIGHT Duringtheacuteinitialrefeedingphaseoftxforptw/severeanorexianervosa, whichismosthelpfulfocusofpsychotherapeuticinterventionswiththept? COACHING,SUPPORT,ANDPOSITIVEBEHAVIORAL REINFORCEMENT Whichofthefollowingmedshasbeenextensivelystudiedandfoundtobeeffective, FLUOXETINE incombinationwithCBT,intxofbulimianervosa? 23y/optw/excessivepreoccupationwithbodyshape.Ptisinnoapparent distress,butadmitstobingeeatingepisodesfollowedbypurgingtwiceweeklyfor BULIMIANERVOSA past6months,Bodyweight:normal.Dx:(x2) Abdominalpain,diarrhea,hypokalemia,weightloss,steatorrhea,skinpigmentation. PHENOLPHTHALEIN Possiblelaxativeabuse.Measure: Patientwithanorexianervosaisadmittedtoinpatientunitandhasbeguntreatment withhighcaloricoralfeedings;2daysafteradmissionanEKGshowsventricular PHOSPHATE tachycardia.Whichtestswouldbestdeterminesthelikelycauseofarrhythmia? Theprimaryfocusofbehaviortherapyinthetreatmentofanorexianervosaisto: RESTOREWEIGHT Bulimiaiscomorbidwith: MDD Frequentlyamedicalsx/signinptswithanorexia: REPRODUCTIVEHORMONEDYSFUNCTION Duringtheacuteinitialrefeedingphaseoftreatmentforapatientwithsevere anorexianervosa,whichofthefollowingisthemosthelpfulfocusof psychotherapeuticinterventionswiththepatient? COACHING,SUPPORT,ANDPOSITIVEBEHAVIORAL REINFORCEMENT Whatelectrolyteabnormalityismostseeninbulimics? HYPOCHLOREMICALKALOSISWITHHYPOKALEMIA 32y/optrevealsalong-standingpreoccupationwiththeshapeofhermothand teeth,thoughshesaysthatherfriendsandspousehaveassuredherthather feelingsareinappropriate.Ptreportsthatsheoftenspendsanhourcleaningher teeth,sothattheabnormalitywillbelessnoticeable.Attimessheavoidssocial contact,fearingthatpeoplewillsilentlycriticizetheappearanceofhermouth.She hasnootherobsessionsoncleaningrituals.Bestdxforpt’slong-standing preoccupation? BODYDYSMORPHICDISORDER GotoTableofContents 170 Aplasticsurgeonasksthepsychiatristtoevaluatea15yoptwhoisrequesting rhinoplasty.Thesurgeoniswillingtoperformtheoperationbutisconcernedbythe pt’syoungage.Theptiswithherparents.Theptexplains“Ibrokemynoseplaying hockey2yearsagoandithasbotheredmeeversince”Onexam,hernoseis noticeableasymmetrical.Patientshowsnoobviouspsychologicaldistressotherthan ANIMPROVEMENTINQUALITYOFLIFE concernforherappearance.Ptstates“Ijustwanttolooknormalagain”.Parents reportchildhashadpoorselfesteemsincetheinjuryandtheyarehopingthe operationwillhelpherselfconfidence.Whichofthefollowingisthemostlikely psychologicaloutcomeforthisptfollowingcosmeticsurgery? 25-year-oldptwithnopreviouspsychhistoryhasanewpreoccupationwith imagineddefectsinappearance,whichisacauseofexcessiveconcern.Thepthasa FLUOXETINE normalmedicalworkupand,otherthanthedistressoverappearance,theptdoes nothaveotherpsychsx.Whichofthefollowingmedsismostappropriate? Inovercomingtheresistancetotreatmentoftenencounteredwithpatientswho haveanorexianervosa,whatisitmostusefulforthepsychiatristtoemphasize? EMPHASIZEHOWTREATMENTWILLALLOWTHE PATIENTTOFOCUSENERGYONOTHERMATTERS. Bulimiaanddepression.Contraindicated: BUPROPION Enlargedparotidglandsinaptbeingtreatedforanorexianervosawouldsuggest whichofthefollowing?(2x) SELF-INDUCEDVOMITING Whattestfindingsareassociatedwithanorexiaandbulimia? BRADYCARDIA,AMENORRHEA,HYPOKALEMIA,AND ELEVATEDSERUMAMYLASE Bulimianervosapresentsinwhichpersonalityd/o? BORDERLINE Whichenzymescanbeincreasedinserumofpt’swithbulimia? AMYLASE At30yearsafterpresentationfortreatment,mortalityratesforanorexianervosa are: 0.20% Labfindinginptwithbingeingandpurgingbx: QTANDTWAVECHANGES WhatisassociatedwithflatteningofTwavesanddevelopmentofUwavesonEKG? purgingbehavior Psychotherapythathasbeenshowntobeeffectiveinbulimianervosa: CBT Whatmedhasshownsomeefficacyinreducingbinging+purginginbulimia nervosa?(x2) FLUOXETINE WhichSSRIusedtotreatdiscontinuationsyndromecausedbySSRItermination? FLUOXETINE FactitiousDisorder Whatfactordifferentiatesmalingeringfromfactitiousdisorder?(2x) HAVINGEXTERNALINCENTIVE Whatconditionshowsmotivationtoassumethesickrole?(2x) FACTITIOUSDISORDER GotoTableofContents 171 Centralcharacteristicoffactitiousdisorder THEREISMOTIVATIONTOASSUMETHESICKROLE Psychiatristisevaluatingfrequentliar.Pt’sliesaregrandioseandextreme.Pt appearstobelievethestories.Thisiscalled: PSEUDOLOGIAFANTASTICA 25y/oprisonerclaimingtobedepressedishospitalizedafterheswallowedsome razorblades.Razorbladeswerecarefullywrappedwithsurgicaltapebefore swallowing.Confesseshewantedsometimeoutofprison.Dx? FACTITIOUSDISORDER Incontrasttoptswithfactitiousdisorder,ptswithmalingeringarecharacterizedby MOTIVATIONFORSECONDARYGAIN. having: Ptcomplainingofaninabilitytomovehisarm.Ptisbecomingenragedathiswife and,onseveraloccasions,fearedhemightstrikeher.Shortlyafteroneargument, hisarmbecamelimp.Dx: PRIMARYGAIN PsychMDisaskedtorecommendtreatmentinterventionsfora16y/optwitha presumptivediagnosisofconversiondisorder.Whichoftheffismostlikelytobe bothacceptedbytheptandresultinfunctionalimprovement: REHABILITATIVETREATMENT 24y/oMseeninEDwithchestpainclaimstohavearareconnectivetissued/oand saidherequiredarecenthearttransplantduetoaortadissection.Heprovidesthe FACTITIOUSD/O(MALINGERERSUSUALLYAVOID MDwithalistofimmunosuppressivemedsandrequeststhatatransesophageal INVASIVETESTS) echobedone.Hehasnosternotomyscarandoutsiderecordsindicatehisstoryis false.Isthislikelyfactitiousd/oormalingering? Hallucinationsinpatientswithconversiondisorderarecharacterizedby? HAVINGACHILDISH,FANTASTICQUALITY Whatkeyfactordistinguishesfactiousdisorderfrommalingering MOTIVATIONTOBEIDENTIFIEDASILL ImpulseControlDisorder AccordingtoDSM-IV-TR,compulsiveskinpickingwouldbe: IMPULSECONTROLD/ONOS Comorbidconditionw/pathologicalgambling MAJORDEPRESSION Whatisaverycommonimpulsecontrold/oNOS? PATHOLOGICGAMBLING Pathologicalgamblingisincludedinwhatgrouping: IMPULSECONTROLD/O Ptishoarding,homefilledwithfilth,acknowledgesissheiskeepalotofthings (hoarding) HoardingDO OCD AgeneticsusceptibilityforOCDissuggestedbyevidencethatthereisafamilial linkwith(4x) TICDISORDERS PrincipalbehavioraltechniqueforOCD(2x) EXPOSURE&RESPONSEPREVENTION GotoTableofContents 172 25y/owithOCDdiagnosed2yearsagoislikelytobenefitfromwhatmedicine(in CLOMIPRAMINE additiontopsychotherapy)?(2x) HxofOCD,Zoloftonlypartiallyeffective.Next: TRYANOTHERSSRI Whatisaneffectivetreatmentforobsessivecompulsivedisorder? ESCITALOPRAM Anteriorcapsulotomyand/orcingulotomyareindicatedanddemonstratedeffective OCD forptswithwhatsevereincapacitatingdisorder? Whichconditionisleastlikelytorespondtohypnosis? OCD Persistentlyintrusiveinappropriateidea,thought,impulse,orimagethatcauses markeddistressis OBSESSION Obsessive-compulsivesymptomsarecharacterizedbywhichdefensemechanism? ISOLATIONANDUNDOING 40y/optcomplainsofrepetitive,continuoushand-washingthroughoutdaytothe pointofchaffingskin.Ptdeniesfearofgermsoranyobsessivethoughts,cannot explaincontinuouswashing.Dx? OCD A20yearoldmaleptpresentstohisphysicianforaphysicalexaminationbecause he isworriedthathemayhavecontractedaninfectiousdisease.Hestatesthathis worryisinterferingwithhisabilitytocompleteworkassignments.Hestatesthathe CAUDATE countsto100repetitivelyinordertodistracthimselffromthisworry.Hehasno priormedicalorpsychiatrichistory.Hedoesnotabusesubstancesandisnot involvedinanyrelationships.Whichofthefollowingregionsofthept’sbrainismost likelytoshowincreasedactivityonPETscan? ChildOCD.WhichcomorbiddiagnosisisassociatedwithpoorresponsetoSSRI? TICDISORDER PsychMDasksapatient,“aretherethingsyoumustdoinaparticularwayor order?” whichthisquestion,psychMDistryingtoelicit? COMPULSIONS WhichofthefollowingistheinitialtreatmentofchoiceforchildrenwithOCD? CBTALONE WhatinfectiousagentcanexacerbateorcauseinitialmanifestationofOCDin children? GROUPABETA-HEMOLYTICSTREPTOCOCCUS Manobsessesaboutkillinghisg/f.Insteadofkilling,pickshisfacew/apin. Medication: FLUVOXAMINE Ptwithcontaminationfearsandhandwashingritualsistreatedwithresponse preventioncombinedwith: EXPOSURETHERAPY WhatisthemostcommonpatternofobsessionsinptswithOCD? CONTAMINATION Repetitivebehaviorsthattheptfeelscompelledtoperformritualistically,while recognizingtheirrationalityandabsurdityofthebehaviors,describes: COMPULSIONS GotoTableofContents 173 35Mw/severeOCD,failedmultiplemeds,CBTandECT,whatnext? CINGULOTOMY WhatconditionisfrequentlyassociatedwithOCD? TOURETTESYNDROME PtpresentstoPMDthinkinghehascontractedinfectiousdisease.Constant worrying,interfereswithwork,repetitivelycountsto100todistractfromworry.No CAUDATE drugorpasthxofpsych/med.WhatsectiononPETwillhaveincreasedactivity? Whatprincipalbehaviortechniqueisusedinthetreatmentofptsw/OCD? EXPOSUREANDRESPONSEPREVENTION Whatstatementreflectscurrentthinkingaboutneurologicalproceduresfor intractableOCD? ATPRESENT,THEREISLITTLEEVIDENCETOSUGGEST THATANYONEPROCEDUREISSUPERIORTOANOTHER. PediatricAutoimmuneDisorderAssociatedwithStreptococcus(PANDAS)is associatedwithwhatdisorder? OCD Childrenwithpediatricautoimmuneneuropsychiatricdisordersassociatedwith streptococcalinfection(PANDAS)oftenmanifest: CHOREIFORMMOVEMENTSandOCDSYMPTOMS PanicDisorder Respiratoryillnessismostclearlyariskfactorfordevelopingwhichanxiety disorder?(2x) PANICDISORDER Whatistheprinciplegoalofthecognitive-behavioraltherapyofpanicd/o? USINGRESTRUCTUREDINTERPRETATIONOF DISTURBINGSENSATIONS DiffdiagnosisofptpresentsatEDwithpanicd/o: PULMONARYEMBOLISM HyperthyroidismshouldberuledoutaspartoftheDDxofwhatpsychiatricd/o PANICD/O Whichclinicalfeaturedistinguishespanicdisorderfrompheochromocytoma? ANTICIPATORYANXIETY(inpanicd/o) Panicattackreachespeakin AFEWMINUTES Presenceofwhatdisorderputsachildatgreatestriskfordevelopingpanicdisorder SEPARATIONANXIETYDISORDER asanadult? Childhoodphysicalandsexualabuseincreasestheriskforwhichanxietydo? PANICDISORDER Thoughmanysymptomscanbeassociatedwithapanicattack,thecardinal symptomthatappearstobecentraltothepathophysiologyofthesyndromeis: HYPERVENTILATION PsychMDintheEDevaluatesa67y/optw/h/odepressionwhoc/opanicattacks sincethedeathofherspouse1monthago.Pthasfrequentepisodesofacute-onset palpitations,chesttightness,nausea,shortnessofbreath,andintenseanxiety lastingseveralminutes,withnospecifictriggers.Thismorningitwokeherupfrom EKG hersleep.Exam:overweight,pale,anxiousappearing,andmildlydiaphoretic.HerBP is 140/90,pulse106.Mostappropriatenextstepinmanagement? GotoTableofContents 174 ptwpanicdisorderfailed2SSRItrials.Whichmedshouldbeusednext? IMIPRAMINE 32yoh/opanicdisorder,phobias,numerousfailedtrialsofandtidepressants.On clonazepam0.5mgbidwithgoodresponse.1molaterresponsestillgoodbutnotas INCREASETO1.5MGPERDAY good.Doseincrto1mgbid,on3rdvisitptreportssomelossofbenefitagain.What istheappropriatecourseofaction? Comparedtopharmacotherapy,advantageofCBTintxofpanicdisorderis LOWERRATEOFRELAPSEFOLLOWINGD/COF TREATMENT Onceitbecomeseffective,pharmacologicaltxofptswithpanicd/oshouldgenerally 8-12MONTHS continueforwhatlengthoftime? Thisstatementbestcharacterizescurrentinformationontherecommendedinitial treatmentofpsychotherapyorpharmacotherapyforaptwithpanicdisorder: THEREAREINSUFFICIENTDATATOCHOOSEONE TREATMENTOVERANOTHER,ORCOMBINATIONOVER MONOTHERAPY 42y/osurgeonexperiencedintensestomachcrampsandpalpitationswhenunable toimmediatelyfindtherightinstrumentwhenperforminganappendectomy.The surgeonwasextremelyalarmedbythisandbegantoworryaboutthesymptoms AGORAPHOBIAWITHOUTPANIC recurring.ThesurgeonthentradedallEDcallssoastoavoidthesesituations,began toavoidothercrowdedandnoisyenvironments,andavoidedavarietyofsocialand professionalsettings.Likelydiagnosis: Adiagnosisofpanicd/orequireswhichofthefollowing? ATLEASTSOMEANXIETYATTACKSTHATARE UNPROVOKED 10montholdchilddistressedwhenparentsleavehimwiththebabysitter.The parentssaygoodbyeandleavequicklywithoutdisplayofaffection.Whatismost likelytoobservedlaterinlife? INCREASEDCLINGINGANDAVOIDANTBEHAVIOR TOWARDSBEHAVIOR First-linetreatmentofpanicdisorder? FLUOXETINE Phobias Ptreportshavingafearofdrivingandexperiencesfeelingofpanic,SOB,heart racing,sweating,andclamminesswhenanticipatingadrivedownstreetroads.Pt acknowledgesgoingoutofthewaytoavoidthissituation.PtdeniedsimilarSxin othersettings.Dx: SPECIFICPHOBIA Thecaseof“LittleHans”ledFreudtodevelopapsychologicaltheoryofthe formationofwhichofthefollowingsymptoms? PHOBIA Diagnosisforchildw/behavioralinhibition SOCIALPHOBIA First-linetreatmentinpanicattacks: FLUOXETINE 10y/oisseeninoutptclinicw/hxofextremefearofusingthebathroomatschool. Hestatestobeafraidthatotherchildrenwilllaughiftheyhearorsmellhiminthe SOCIALPHOBIA bathroom.Dx? GotoTableofContents 175 Avoidsinterpersonalsituationsduetoanxietyandpanicattacks SOCIALPHOBIA 28y/oMepisodicanxiety,palpitations,flushing,shaking,chesttightness.Mostlyat SOCIALPHOBIA workorw/groupoffriends.Embarrassed,afraidtogotowork,avoidingpeople: Principalaimoftreatmentofchildwithschoolphobiais: RETURNCHILDTOSCHOOL 42y/opthashadchronicabdominalpain,constipationandnauseaforthepast 14months.Extensivemedicalwork-uphasrevealednoorganiccause,butthept insiststhatthesearesymptomsofaseriousdisease.Mostlikelydiagnosis: HYPOCHONDRIASISWITHPOORINSIGHT Mosteffectiveapproachinbehavioraltreatmentofphobias: IN-VIVOEXPOSURE Thismedicationiscommonlyusedinsocialphobiaassociatedwithperformance situations,shortlybeforeexposuretoaphobicstimulus? ATENOLOL Theparentsofan18y/oadolwhoisoverweightnoticethattheirchildisavoiding highcaloricfoods,suchasmeatandpasta.Whentheparentsinquireaboutthis,the teensays,“Iamafraidofeating.”Theevaluatingpsychiatristaskswhentheeating behaviorchanged,andtheteenreportshavinghadanepisodeofpanicwhich SPECIFICPHOBIA occurredwhileeatingandwasaccompaniedbychokingfeelings.Afearofchoking whileeatingandawishtoavoidfoodsthatmightcausechokingdeveloped.The teendeniesotherepisodesofpanic.Dx? Parentsof18yroldfindchildavoidinghighcaloriefoodsduetofearofeating,andpt linksthefeartoandepisodeofpanicthatoccurredwhileeatingaccompaniedby SPECIFICPHOBIA choking,deniesotherepisodesofpanic,diagnosis? PTSD 12y/odisclosedtocounselorhxofsexualabusebyrelative.Reportmadeto authorities.Duringeval,ptreportsanxiety/inabilitytoconcentrateduetothinking PTSD aboutevent/irritability/sleepproblems/cryingfrequently.Gradesfellsignificantly afterabusebegan&relationshipssuffered.Dx?(5x) 40y/ohashyperarousalafterseeingbadMVA.Hasnightmares,avoidsfreeways, isolatingathome.Therapyonlymoderatelyhelpful.Whichmedication?(3x) WhichofthefollowingisthebestuseofhypnosisinapatientwithchronicPTSD withseveredissociativesymptomsduetochildhoodabuse? 28y/ograduatestudentBIBwifeandreportsachangeinhisbehaviorsincehe witnessedafatalmotorvehiclecollision3wksago.Ptfeltfeelingofhelpless, horrifiedattimeofaccident.Nowptfeelslike“hisspiritleaveshisbody.”Andfeels numbanddetached,anddreamsaboutevents.Dx: SERTRALINE Learningtogainvolitionalcontroloverdissociation ACUTESTRESS GotoTableofContents 176 A28yopatientpresentstotheEDafterexperiencingasexualassault1weekearlier. Althoughthepatientcannotrecallallaspectsoftheevent,sheremembersfeeling helpless,detached,andasifhersurroundingswerenotrealduringtheassault.For thepastweekthepthashasdifficultysleepingduetonightmaresabouttheassault ACUTESTRESSDISORDER andhasnotbeenabletotalkabouttheeventwithanyofherfriends.Sheisalso experiencingintermittentepisodesofpalpitations,SOB,dizziness,andnausea throughouttheday.Dx? HowwouldasocialbiologistdescribeadaptivebenefitofPTSD? HYPERVIGILANCEALLOWSFORQUICKSENSINGOFREAL THREATS ApatientpresentstotheEDafterwitnessingatragicMVAinwhichtheywitnesseda death.Whatsymptompresentimmediatelyfollowingtheeventincreasesthe DISSOCIATION individual’sriskofdevelopingPTSD? WhatsymptomcommonlydevelopsrelativelylateinchildrenwithPTSD? SENSEOFFORESHORTENEDFUTURE Whichofthefollowingisthebestpredictorofwhetherornotapatientwho sustainedasignificanttraumawilldevelopearlyPTSDmorbidity? THENATUREANDSEVERITYOFTHETRAUMA Sxforapt2monthsaftertraumaticexperience: INCREASEDAROUSALANDINTRUSIVETHOUGHTS AddingwhichclassofmedicationtoanSSRIisaneffectiveaugmentationfor treatmentofPTSD? ATYPICALANTIPSYCHOTICS Studentpresentsforpsychevalwithcontinuedanxiety,hyperalertness,flashbacks, andsocialavoidanceafterbarelyescapinganattacker1monthago.These 4WEEKS symptomsareexpectedtolastnolongerthan___? Howtoprovepatientnotcriminallyresponsibleforattackingneighbor’shousein middleofnightwithshotgunafterhearingimaginarygunfire. Flashbackpreventedpatientfromunderstanding wrongfulnessofhisact. Schizophrenia/Psychosis Schneiderianfirst-ranksymptomofschizophrenia:(3x) HEARINGVOICESANDARGUINGABOUTONESELF Whatfactorisagoodprognosticindicatorinschizophrenia?(2x) FEMALEGENDER Successfulpsychosocialinterventionsinschizophrenics:(2x) ASSERTIVECOMMUNITYTREATMENT 16y/oboytreatedasoutpatientforSchizophreniaafterrecentinpatientfirst break.Parentsconcernedre:anhedonia,withdrawn.Nopsychosis.Goalof outpatienteval:(2x) ADDRESSPT’SFEELINGSOFDEPRESSIONANDSCREEN FORSI 19y/optreportedhearingavoicethattalkedaboutwhatptwasthinking.Thept’s speechhasanormalrateandrhythm,butsaysthingssuchas,“Itiswhite,very ALOGIA white.Iknow.Thingsarethatway.Theyare.Iam.”(Povertyofspeechand content)Thisspeechisanexampleof:(2x) Subtypeofschizophrenialesssevereandstartsolder:(2x) PARANOID GotoTableofContents 177 Late-onsetschizophreniaismorecommoninmenorwomen?(2x) WOMEN Schizophrenicwithpoorresponseto3trialsofantipsychoticmeds,nextstep?(2x) CROSSOVERTOCLOZAPINE Dysprosodyisanabnormalityof(2x) SPEECH PtwithCPShospitalized6xinthepastyear,hxofnonadherecetotreatment, difficultymaintaininghousing,andmultmedprobs–whichtreatmentmost appropriateforthispatient?(3x) ASSERTIVECOMMUNITYTREATMENT 75y/omalebroughtinbyfamilyforpsycheval,familyreportsnopastpsych history,hasgottensuspicious,withdrawn,hostile.Talkstoself,talksaboutbeing controlledbyaliens,believesaliensareputtingthoughtsinhishead.28/30on MOCA,MRIshowsage-relatedchanges.Diagnosis? OnlyonecriterionisnecessaryforDxofschizophreniaifthereporteddelusionis: SCHIZOPHRENIA BIZARRE 23y/optw/nopreviouspsychhxBIBfamily.Parentsreportsthatpthasstopped seeingfriendsforthelast6months,isafraidwhencarspassbyonthestreet,seems SCHIZOPHRENIA tobetalkingtoselfandtelevision.Ptalsohasunusualmovementsofarmsattimes, flapandwaveontheirownaccord.Whatisthediagnosis? Whichofthefollowingisanon-DSMtermforthecategoryofschizophreniawhen thedxisbasedsolelyondeficitornegativesymptoms? SIMPLESCHIZOPHRENIA Whichofthefollowingstatementscharacterizeslate-onsetschizophrenia? OCCURSMOREFREQUENTLYINWOMENTHANMEN Assessingwhetheraschizophreniccriminaldefendantmaymeetstandardfor insanitydefense,whatdoyouask? “WHATWERETHEVOICESSAYINGTOYOUATTHETIME OFTHECRIME?” Whichdifferentiatesdeterioratived/ofromschizophrenia? ABSENCEOFPROMINENTPOSITIVESYMPTOMS Schizophreniawithonsetinchildhoodisdifferentfromadult-onsetbecause… ITISMORELIKELYTOHAVEAGRADUALONSET Thoughrecentresearchhasdemonstratedthatthebluntedemotionalexpressionin schizophreniadoesnotimplythatapatientisanhedonic,individualswith SOCIALINTERACTIONS schizophreniadoexperiencelossofinterestorpleasureassociatedwith? Focusforoutpatientpsychotherapeuticgroupsforschizophrenia? SOCIALSKILLSDEVELOPMENT WhichTxmodalitiesprovidescareforseriouslymentalillptsincommunityviaa multidisciplinaryTxteam: ASSERTIVECOMMUNITYTREATMENT 24y/optw/hxofepilepsysincechildhoodhasseveralseizuresinrapidsuccession. FollowingSzs,ptdevelopedparanoiaandhallucination,butresolvedoveramatter ofdays.Dx: INTERICTALPSYCHOSIS Whencomparedwithadult-onsetschizophrenia,childrenwithschizophreniahave: SIMILARDEFICITSINATTENTION,LEARNINGAND (x2) ABSTRACTION NoadditionalcriterionAsymptomsarerequiredforthedxofschizophreniaifthept HALLUCINATIONSOF2ORMOREPEOPLECONVERSING haswhichofthefollowingsymptoms: GotoTableofContents 178 44y/optwithschizophreniaisadmittedtoaninpatientpsychiatricunit.After severaldayspthasmuscletremor,ataxia,twitching,diarrhea,restlessness, vomiting,polyuria,andstupor.Dx? WATERINTOXICATION Whatisanegativesxofschizophrenia? SOCIALINATTENTIVENESS 20y/oavoidseveryonebutparents.Stoppedgoingtoschool.Feelseveryone watchinghim.Alwaysquiet,sitsathomedoingnothing,mumblestoself,some bizarremovements,flataffect.Deniesdepressionorsubstanceuse. SCHIZOPHRENIFORM Characterizesschizophrenicsthatsmoke REQUIREMORENEUROLEPTICMEDS 29y/o1wkeuphoria,insomnia,pressuredspeech,grandiose.Delusions,AH.Need whatelseforDxschizoaffectived/o PSYCHOTICSX’SX2WKSINABSENSEOFMOOD SYMPTOMS Mostcloselycorrelatesw/socialfxinschizophrenics: NEGATIVESYMPTOMS 55y/optw/hxofETOHdependencereportshearingvoicesforthepast6weeks.Pt reportsthatthelastepisodeofETOHintoxicationwas1monthprior,withmoderate drinkingsincethattime.Thereisnopriorhxofpsychosis.Onexam,ptisalertand ALCOHOLINDUCEDPSYCHOTICDISORDER oriented.Onlaboratoryevaluation,pthasaGGTof54,anMCVof110,andan AST/ALTratioof2.1.themostlikelycauseofthispt’shallucinationsis: Healthy37y/oFbusinessexeclearnsthatherbrotheriskilledinaMVAandis decapitated.Threedaysafterthefuneral,shespotsamandrivingacarjustlikeher brothersandisnowconvincedheisnotdead.Shebelievessheisthevictimofa conspiracyinwhichothersaremanipulatingherintolosinghermindonorderto takeoverherbusiness.Shehearsabuzzingnoiseonherphoneatworkandbelieves BRIEFPSYCHOTICDISORDER herlineistapped.Athome,shethinksthelightinherneighbor’swindowisasign thatsheisundersurveillance.Shecallsthepoliceandbegsthatactionbetaken.A monthaftertreatment,hersymptomsaregoneandwithin3monthsshehas returnedtonormalfunction.Thediagnosisis: 45y/oFptwithvaguecomplaintsof“notfeelinggood,”notsleepingwellX1 month.Ptdisclosesfear/anxietyover“weirdthingshappeningtome,”including believingthatsomepersonalpossessionsaremysteriouslymissingoraltered.Pt aware“thisallsoundscrazy,”butcannothelpfeelingfrightenedthat“someoneis messingwithmymind,maybemyex-husband.”Ptcalledpoliceseveraltimes,but OBTAINAGENERALMEDICAL/NEUROLOGICAL theyneverfoundanythingsuspicious.Pthadbeenasuccessfulinsuranceagent,and WORKUP expressesworrythathisdistressisdistractingandmaynegativelyaffectwork performance,whichcouldresultinjobloss.Deniespastpsychiatrichx,exceptfor feelingdepressedforseveralmonthsafterthedivorceafewyearsago=resolved withouttreatment.Whichcourseofactionwouldbestclarifythediagnosis? Whichmedicalconditionislikelytoincludepsychosisinthesymptomcomplex? SYSTEMICLUPUSERYTHEMATOSUS A35yoFpatienthasdiscoidlupuswhichhaslongbeencontrolledwithastable doseoforalprednisone.Sheabruptlydevelopsincreasedfatigue,inflamedjoints, anddiffusemyalgias.Ptalsoexhibitsdepressedmoodandcognitiveimpairment. Shehasnopriorpsychiatrichistoryandnofocalneurologicalsigns.Whichofthe followingisthemostlikelyetiology? DISEASEINDUCEDCEREBRITIS MCcomplicationofcorticosteroidtherapy? Mooddisorder GotoTableofContents 179 PositiveSxsofschizophrenia: PARANOIA,AH,THOUGHTINSERTION,DELUSIONS AnegativeSxofschizophrenia: BLUNTEDAFFECT Communicationd/oassocw/neurologicalandpsychd/o MUTISM 28Fptmute,rigid,catatonic.Notonmeds.WhatTx? LORAZEPAM Whatconditioninpatientswithschizophrenicorschizophreniformpsychosisis associatedwithpoorprognosis? INITIALONSETDURINGADOLESCENCE Mostcommoneyetrackingmovementabnormalityinptswithschizophrenia? INAPPROPRIATESACCADES(saccadicintrusions) NoadditionalcriterionAsymptomsarerequiredforthediagnosisofschizophreniaif HALLUCINATIONSOF2ORMOREVOICESCONVERSING thepatienthaswhichsymptom? Whatisthetermforsenselessrepetitioninschizophrenics? ECHOLALIA Whatisassociatedwithpoorprognosisinschizophrenics? EARLYAGEOFONSET,NEGATIVESYMPTOMS,LACKOF PRECIPITATINGFACTORS Schizophreniformdisorderdiffersfromschizophreniaprimarilyin DURATION Whatarethecharacteristicsofchildhood-onsetschizophrenia? CHRONICCOURSE,UNFAVORABLEPROGNOSIS, HALLUCINATIONS,DELUSIONS 35yoptstabilizedonmethadonemaintenancetx5yrsisBIBfamilytoEDbcptis lethargic/confused.Duringassessmentptbecomesobtunded/respdepression. Familyreportsptrecentlybegannewmed.Whichmedislikelyresponsible? CARBAMAZEPINE Schizophreniconhaldol10developsacuteEPS.Cause? CESSATIONOFSMOKING Schizophrenicstabilizedonhaldol10.ReturnofpsychoticSx’safterstartingmedfor CARBAMAZEPINE anothercondition.Cause? Identical-appearingimpostorhasreplacedDad: CAPGRA’SSYNDROME SchizophrenicwithVH,restlessness,markedthirst,agitation,elevatedtemperature, ANTICHOLINERGICINTOXICATION dilatedpupils,dryskin.Dx? Notalikelycharacteristicofchildhood-onsetschizophrenia: ACUTEONSET Whatfactorisassociatedwithabetterlong-termprognosisinptswschizophrenia? ONSETAFTER35YEARSOFAGE Goodprognosticfeatureinschizophrenia ACUTEONSET Moleculartargetsforimprovingcognitioninschizophreniahaveshownpromisevia D1RECEPTORAGONISM whichofthefollowingmechanisms? GotoTableofContents 180 Whichofthefollowingantipsychoticmedsismostlikelytobeeffectiveinptswith refractoryschizophreniawhohavefailedtoimprovewithotherantipsychotics? CLOZAPINE (2X) Schizophrenicstopstakingantipsychotic.Statesthatnothingiswrong.Whatisthis behavior? A22y/optisbroughttotheEDbyfamilymemberswhoreportunusualbehavior thathasworsenedoverafewweeks.Disorganizedanddifficulttointerview– stating“Theworldisending!Youmustrepentnow!”Patientisactively respondingtounseenothersandaccusesfamilyofbeing“devils”.Nofamily historyandnopriorpsychhistoryforpt.Behaviorbegantwomonthsagofollow gradfromcollege.Whatisdx Schizophrenicpatientbecomingcatatonicwithwaxyflexibility.Whichisthemost appropriatemedication? Whichofthefollowingismorecommoninpatientsexperiencingafirstepisode psychoticdepressionatoldagecomparedtoyoungerage? POORINSIGHT Schizophreniformdisorder LORAZEPAM NIHILISTICDELUSIONS SomatoformDisorders 32y/ocannotmovetherightleg.Examdoesnotfindacause.Dxislikelytobe conversiond/oifwhichofthefollowingisfound?(6x) SYMPTOMSNOTINTENTIONALLYPRODUCED Preoccupationandfearofhavingcontractedseriousdiseasebasedon misinterpretationofbodilysxsdespitemedicalevalandreassurance.(3x) HYPOCHONDRIASIS 25y/oreferredbyplasticsurgeon,claimsthatpartofherfaceisswollen.(2x) BODYDYSMORPHICDISORDER Evokedpotentialtestingmaybeusefulintheevalofwhichcondition? PSYCHOGENICBLINDNESS IntheUS,ptsmeetingthediagnosticcriteriaforneurasthenicoftenmeetcriteriafor somatoformdisorderdepressionedisorderandwhichofhefollowingcategoriesof ANXIETY disorders? Psychconsultedre:43y/owhoc/o“lumpinthroat,”headaches,bloating,backpain, diarrhea,chestpain,painfulurination,sexualindifference;complaintsdoNOT SCHEDULEREGULARVISITSWITHAPHYSICALEXAM matchobjectivefindingsfromdxworkup.Whatshouldberecommendedtopt’s PCP? Multiplicityofcomplaints,multipleorgansystems SOMATIZATIOND/O Whatiscommonlyassociatedwithconversiond/o? LOWINTELLIGENCE 40-year-oldcannotspeakafterascreamingargumentwithspouse.Patientwrites,“I havebeentryingtospeak,butcannotmakeasinglesound.”Throatexamisnormal. CONVERSIONDISORDER Thereisanoccasionalloudcough.Diagnosis? Somaticsx/complaint,negativemedicalworkup,negativepsycheval LOOKAGAINFORORGANICETIOLOGY Mainclinicalfactorofhypochondriasisvs.somatizationd/o? FEAROFHAVINGADISEASE GotoTableofContents 181 Hallucinationsinptwithconversiond/oarecharacterizedas: HAVINGCHILDISH,FANTASTICQUALITY Primaryfocusofptwithhypochondriasis: DISEASE Thepresenceofwhichofthefollowingwouldsuggestthatapatienthas somatizationdisorderratherthanageneralmedicalcondition? COMPLAINTSINVOLVINGMULTIPLEORGANSYSTEMS Characterizedmainlybycognitiveratherthanperceptualpreoccupation HYPOCHONDRIASIS Psychiatristisaskedtoseeageneralmedicalinpatientforreportedhypochondriasis. MEDICALCONDITION Whichofthefollowingisthemostimportantdifferentialdiagnosticconsideration? Ptisevaluatedforunilaterallowerextremityweaknesswithnoapparentphysiologic THEREISARISKTHATRELEVANTNEUROLOGICILLNESS explanation. WILLBEIDENTIFIEDINTHEFUTURE. Apatienthasperiodicpelvicpainforpasttwoyears.Hadlaparoscopy,diagnosed withendometriosis,startedoralcontraceptivesandanalgesicswithsomerelief, stillhassymptoms.Thepatientreportsworrythatshewillquitjobduetopain. Callsdoctoreveryfewdaystoaskwhethernewtxshouldbeconsideredorshe mayhavecancer?.Whatisdiagnosis: Somaticsymptomsdisorder 18y/optpresentswithanacuteonsetofblindnessafterwitnessingthemurderofa SYMPTOMSWILLFULLYRESOLVEINAMATTEROFDAYS closefriend.Neurologicalexaminationisinconsistentwithlossofvisionbut ORWEEKS. otherwiseunremarkable.Whatismostprobableoutcomeforthispt? 24y/optw/suddenonsetstumblingandpaininlegs,negativeneuroworkup–saw acounselorpreviouslyforprotractedgriefafterfather’sdeath–increasedconflict CONVERSIOND/O withhusband.Dx? Neurasthenia,anacceptedconditioninEuropeandAsia,correspondstowhichof thefollowinginDSM-IV-TR? UNDIFFERENTIATEDSOMATOFORMDISORDER Whatisthekeyelementforsuccessfulmanagementofsomatoformdisorders? ENSURINGREGULARFOLLOWUPFROMPCP Tourette’sDisorder WhatsymptomsaremostcommonlyassociatedwithTourette’ssyndrome? OBSESSIONSANDCOMPULSIONS PathologicfindingsinbrainofTourette’s? NOABNORMALITY WhatantipsychoticmedicationishelpfulintreatingTourette’s? HALOPERIDOL WhichmedishelpfulinTouretteSyndromewhocan’ttolerateclonidine? GUANFACINE Guanfacine’sprimaryeffectisthroughwhatmechanismofaction? Presynapticalpha2adrenergicreceptoractivation Nameforticscomprisedofobscenegestures COPROPRAXIA OneoftheearliestsxofTourette’s: EYE-BLINKINGANDHEADJERKING Initialapproachforchildwithnew-onsetticdisorder CLINICALMONITORING GotoTableofContents 182 Whatmediseffectiveintxofmotor/vocalticsassociatedwTourettesyndrome refractorytotxwithantipsychoticsandalphaadrenergicagonists?(x2) TETRABENAZINE Comorbidconditionw/Tourette’sinkids: ADHD Ticseveritybeginstodecreaseduringwhichageperiod? PsychotherapytechniqueforchildrenwithTourette’ssyndrome. ADOLESCENCE Habitreversal PersonalityDisorders Whichtesttoconfirmpersonalitydisorder? MillonClinicalMultiaxialInventory(MCMI-III) Personalityd/owchronicfeelingsofemptiness,transientpsychoticsx,mood swings,tumultuousrelationships,self-mutilation,poorself-image,impulsivity? (5x) BORDERLINE WhichisatargetofDBTinolderadultsthatisnototherwiseincludedinthe standardDBTprotocol?(3x) EMOTIONALCONSTRICTION Whatpersonalityd/oisassociatedwithtransientpsychoticsymptoms(2x) BORDERLINE Whichdisorderhasgreatestco-incidenceofalcoholabuseanddependence?(2x) ANTISOCIALPERSONALITYDISORDER Personalityd/oshouldbeconsideredinddxofcyclothymicd/o?(2x) HISTRIONIC Whatpersonalitydisorderresultsindisplaysofrapidlyshiftingandshallow expressionofemotionsinpatients?(3x) HISTRIONIC Ptswithwhichpersonalityd/oseesthemselvessociallyinept,personally unappealing,orinferiortoothers?(2x) AVOIDANT Ptprominentlyusesthedefensesofisolationofaffect&intellectualization. Descriptionoflifeeventsappearstoinvolvereactionformation.Whatpersonality OBSESSIVE-COMPULSIVE traitismostlikelytocharacterizethispt?(2x) Anotherpsychiatristreferstoaptbysayingthisptis“special”andneedreally goodtreatment.Youneedtobecarefulwiththeptto:(2x) ANTICIPATETHEPOTENTIALFORSPLITTINGBETWEEN THEREFERRINGMDANDYOURSELF. AvoidantPDdiffersfromSchizoidPDby:(2x) DESIREFORSOCIALRELATIONS WhicharethedimensionsoftheFiveFactorModelofPersonality? NEUROTICISM,EXTRAVERSION,OPENNESS, AGREEABLENESS,CONSCIENTIOUSNESS Whichsymptomisassociatedwithschizophreniaspectrumdisorders(clusterA personalitydisorders) SOCIALWITHDRAWAL Whichpersonalitydisorderismostassociatedwithalcoholism? ANTISOCIAL GotoTableofContents 183 Whichinterventionishelpfulindealingwithaborderlineptonamedicalward? SETTINGLIMITSWITHTHEPTONTHESTRUCTUREOF THEMEDICALCARE Extremelydemandingpatientrepeatedlycallspsychiatrist’sofficeandberatesstaff SETLIMITSWITHTHEPATIENT inoffensiveterms.Whichstepshouldthepsychiatristtakefirst? Usefulinfotoconfirmdiagnosisofantisocialpersonalityd/o(APD)in20y/opatient? SCHOOLCOUNSELINGRECORDS Interpersonalexploitativenessisadiagnosticfeatureof(2x): NARCISSISTICPERSONALITYDISORDER 29y/oFw/moodswings-moodchangesveryrapidly,sometimeswithout prompting,fromelationtodepressionorintenseanger.Thesemoodslastminutes tohours.Herhistoryissignificantforpromiscuity,spendingsprees,tumultuous relationships,unstableself-image,andoccasionaluseofcocaine.Hxofabrief BORDERLINEPERSONALITYD/O periodofparanoiaandAH?Duringandemotionalbreak-upwithherlastboyfriend, whichremittedaftera2-dayadmissiontothepsychunit.WhenaskedaboutSI,she reportsthatitisalwaysinhermindandthat,wheneversheisunderstress,shecuts herarmswithasharpbladetorelieveastrongfeelingofemptiness.MostlikelyDx? Personwithcovertobstructionism,procrastination,stubbornness,andinefficiency maybeclassifiedassufferingfromwhichpersonalityd/ooutsideofcurrentDSM classification? PASSIVE-AGGRESSIVE 40y/oMemotionaldetachment,littleinterestinsex,noclosefriends.AxisIIDx? SCHIZOIDPD Commonsymptomsofparanoidpersonalitydisorder PREOCCUPATIONW/UNJUSTIFIEDDOUBTSOF LOYALTY/TRUSTWORTHINESSOFFRIENDS/ASSOCIATES Underlyingdynamicofmuchofthebehaviorofptswithparanoidpersonalityd/o: ADEVELOPMENTALFAILURETOACHIEVEOBJECT CONSTANCY 20y/oMwithpoorperformanceincollege,beforewasverygoodstudentexceptfor notbeingabletofinishassignedprojectsatcollege.Classmateshavedescribed bizarrebehavior,suchascountingloudlyorrepeatingwordssilently.Hedoesnot OBSESSIVECOMPULSIVEPERSONALITYDISORDER wanttofollowothersrulesbuthisowns,hebelievesnobodyunderstandshimand areagainsthim. Ptwithbodydysmorphicd/omayhavewhatpersonalityd/o? NARCISSISTIC Whichpersonalitydisorderischaracterizedbyastyleofspeechthatisexcessively impressionisticandlackingindetail? HISTRIONIC 40y/ohandsurgeonhascomeintoconflictwiththehospitaladmin.Thoughthe hospitalwentoutofitswaytorecruitthissurgeon,hehasfeltconsistently betrayedandhasaccusedtheadministrationoftryingtoexploithimbyexpecting thatheshouldtakemorecalls,thoughthishasneverbeenstated.ThedoctorPARANOIDPERSONALITYDISORDER hospitalrelationshipdeterioratedfurtherwhenpeerreviewraisedaquestion aboutoneofthesurgeon’scases.Thesurgeonbelievesthatnoneofhiscomplaints havebeensatisfactorilyresolved.Hehasbecomemoreunforgivingandisolated: (2x) GotoTableofContents 184 Ptbecomespanickyanddistressedeverytimepsychiatristgoesonvacation,this patternismostlikelyacharacteristicof: DEPENDENTPERSONALITY Ptwithhistrionicpersonalityd/ostormsinhispsychodynamicsessionandafew minuteslate,clearlyinrage.Heexpresseshopelessnessanddeclaresvehemently thathemustdivorcehiswife.Nextbestintervention: ENCOURAGETHEPTTOREFLECTMOREONWHATHAS HAPPENEDTOTRIGGERSUCHPAINFULFEELINGS. 22y/oborderlinesplittinginpatientstaff.Youshould: EDUCATESTAFFABOUTSPLITTING DDxofhistrionicpersonalitydisorderincludeswhatotherpersonalityd/o? DEPENDENTPERSONALITYDISORDER Whichpersonalityd/oshouldbeinthedifdxofagoraphobia: DEPENDENTPERSONALITYDISORDER 23y/oMw/Borderline.Hadfightw/g/fnowpsychotic,cutting,AHw/commandto BRIEFINPATIENTHOSPITALIZATION harmself.Whatlevelofcare: Ptsw/thispersonalityd/omostlikelytohave1stdegreerelativeswithdepression BORDERLINE AccordingtoDSM-IV-TR,whatpersonalitydisorderinadultsrequiresevidenceof anotherspecificpsychiatricdiagnosispriortoage15? ANTISOCIAL Ptrepeatedlybecomesdistressedafterwhatseems,eventothept,tobeminor disappointments.Ptalsoseemstosufferfromextremenarcissisticvulnerability.A therapistutilizingself-psychologywouldbemostlikelytointerpretthisasdueto? ALACKOFDEVELOPMENTALLYAPPROPRIATE EMPATHICCAREGIVERS. DBThasbeenshowntobeeffectiveinthetreatmentofwhatpersonalitydisorder? BORDERLINE Whatpersonalitydisordersshouldbethemainconsiderationindifferentialdxof schizotypalpersonalitydisorder? AVOIDANT 16-year-oldadolescentisbeingevaluatedforpossibleschizophrenia.Afamily historyofwhichofthefollowingpersonalityd/oismoststronglyassociatedwith thisdx? SCHIZOTYPAL 25y/ohospitalizedforappy.Ptreportsbeing"botheredbysurgeon'saura".Lives alone,noclosefriends,getsonwebsitesaboutaurasandcrystalwork.Pt'smother affirmshe's"alwaysbeenthisway."Whichpersonalitydisorder? SCHIZOTYPAL DBTpatientarriveslatewithrecentrelapseondrugsandcuttingaftermarital fight.Highestpriorityofsessionshouldfocusonwhat? SelfInjuriousBehavior Alcohol Ptwhois2monthssoberondisulfiram,whatlabstudiesshouldbedoneatbaseline Transaminases andafter2monthsoftreatment? Unsteadygait,appendicularataxiainLEonlyandnormaleyemovement.Walks withlurchingbroad-basedgait.(8x) CEREBELLARDEGENERATION(ALCOHOLIC) GotoTableofContents 185 Ptw/oaddictionandsocialanxietyd/odiscussestheirpainfulexperienceof anxietyduringtheirfirstAAmeeting.Whatreplyisconsistentwith12-step facilitationtherapy?(7x) Usingcashonlyd/tsubstantialdiscomfortwhilewritingchecksorsigningcredit cardreceiptsinthepresenseofothers(becauseofmessyhandwriting)? “YOUDIDTHEMOSTIMPORTANTTHING,YOUWENT TOTHEMEETING.ITWILLGETEASIER.” Socialanxietydisorder WhatdoesCAGEstandfor?(7x) CUTDOWN,ANNOYED,GUILTY,EYEOPENER FetalAlcoholSyndromeisassociatedwith:(5x) FACIALDYSMORPHISMS,POSTNATALGROWTH RETARDATION,INTRAUTERINEGROWTH RETARDATIONANDLEARNINGDIFFICULTIES. Evalofwhichlabtestismostspecificforchronicheavyalcoholconsumption?(5x) %CDT(PERCENTCARBOHYDRATEDEFICIENT TRANSFERRING) 50y/owithalcoholdepatEDforconfusion,oculomotordisturbances,ataxia,and THIAMINE dysarthria.Givewhichmedfirst?(5x) WhatisthefunctionofAl-anon?(2x) HELPSRELATIVESCOPEWITHALCOHOLICSDRINKING Evidencethatalcoholismishereditary?(2x) ADOPTEDSIBLINGS Labparameteroftenelevatedinpatientswithalcoholdependence?(2x) MEANCORPUSCULARVOLUME AlcoholichallucinosisversusDT:alcoholichallucinosisincludeswhat?(3x) ACLEARSENSORIUM Thebestwaytoaskadolescentaboutalcoholabuse?(2x) HAVEYOUEVERRIDDENINACARDRIVENBY SOMEONEINCLUDINGYOURSELF,WHOWASHIGHOR HADBEENUSINGALCOHOLORDRUGS? 44y/optwETOHdependence/cirrhosisinquiringaboutmedtostopdrinking.Ptis disappointedindrinkingbehaviorbutotherwiseshowslittleevidenceofamood ACAMPROSATE D/O.Whichmedshashismostfavorablerisk/benefitprofileforETOHcessation? (2x) AlcoholicondisulfiramreportsEtOHcravings.Whatdrugwilllikelydecrease these?(3x) NALTREXONE Whichmedreducesacetaldehydedehydrogenasefunction?(2x) DISULFIRAM Characteristicofalcohol-inducedblackouts(2x) ANTEROGRADEAMNESIAFORATIMEWHILEHEAVILY INTOXICATEDBUTAWAKE Aftergastricbypasssurgery,continuedabuseofwhatsubstancecanbemorelife threateningthanbeforesurgery? Alcohol Typicalfeatureofepilepticactivityinalcoholicptwithseizure12hafterEtOH cessation MULTIPLEEPISODES Molecularmechanismofethanolcausesintoxication? NMDAANTAGONISMANDGABAAGONISM Alcoholwithdrawalsymptomspeakinhowlong? 48HOURS GotoTableofContents 186 Activatingwhatreceptorcausesalcohol’santi-anxiety,motorimpairing,and sedative-hypnoticeffects? GABA-A ComparedtoEtOHdependenceinyoungpts,EtOHdependenceinpts>65yois: LESSCOMMON BestcharacterizestheroleofspiritualityinabstinenceinalcoholicswhoattendAA? THEREISLIMITEDEVIDENCESUPPORTINGTHEROLEOF SPIRITUALLTYINABSTINENCE Mostcommonsubstanceofabuseinadolescents: ALCOHOL 40yofemalepresentswithnewonsetparanoiddelusionaswellasAHandVH,no SI.DenieshxofmaniaorMDD.PthasprevioushospitaladmissionforMDDand anxietysymptomsandhadtakencitalopram,sertralineandquetiapinebutwasnon- ALCOHOL-INDUCEDMOODDISORDER compliant.Hxrevealschronicalcoholusewigheavydrinkingoneweekago.Whatis themostlikelycauseofherparanoia? WhatisaSEcommontobothnaltrexoneanddisulfiram? ELEVATEDLIVERENZYMES 72y/owchronichepatitisinEDfortreatmentofongoingalcoholwithdrawal. Hospitalprotocolistousechlordiazepoxide,butpsychsuggestlorazepambecause METABOLIZEDTHROUGHGLUCURONIDECONJUGATION ElectrolyteimbalancecommoninchronicheavyEtOHuse? HYPOMAGNESEMIAANDHYPOPHOSPHATEMIA PsychiatristrecommendsAAtoptwhoabusesalcohol,butptreluctant.Nextstep? RECOMMENDPATIENTSPEAKTOACURRENTAA MEMBER Dysfunctionalprocessinsystemictherapyillustratedbymothertelling15yosonto confronthisfatherabouthisexcessivedrinking. Triangulation Whichisthemostsensitiveandspecificlabtestforidentifyingheavydrinkingand monitoringTx? CARBOHYDRATEDEFICIENTTRANSFERASE(CDT) Womendifferfrommenindrinkingbehaviorandindevelopmentandeffectsof alcoholused/o,comparedw/men,women: HAVEAFASTERPROGRESSIONFROMFIRSTDRINKTO ALCOHOLDEP MostclearlypredictiveofalcoholabstinenceforalcoholicswhoattendAAmeeting: OBTAININGASPONSOR Coreprincipleofmotivationalinterviewingthatisusedtotreataddictivebehaviors: DEVELOPDISCREPANCY Exampleofaharmreductiontechniqueusedinpeoplewithopioiddependence: NEEDLEEXCHANGE 50y/optwETOHdependenceadmittedtoEDforconfusion,oculomotordeficits, ataxia,anddysarthria.Thefirststepinacutemanagementofthispt’scondition: ADMINISTRATIONOFTHIAMINE Canalcoholfumesatwork(brewery)causeaptondisulfiramheadaches? YES Sixthcranialnervepalsyisassociatedwithwhichalcohol-relatedsyndrome? WERNICKE’SENCEPHALOPATHY InERfollowingMVA,receivesIVdextrose5%.Experiencesconfusion,oculomotor paralysis,anddysarthria: WERNICKE’SENCEPHALOPATHY GotoTableofContents 187 Testsfordetectingexcessivedrinking TRIGLYCERIDES,MCV,SGGT,SGOT Patternofdrinkinginwomenalcoholics(asopposedtomales): SOLITARYDRINKING Non-specifichematologicalmarkerforheavydrinking MCV ComplicationofheavyEtOHlikelytopersistbeyondfirstweekofwithdrawal? SLEEPFRAGMENTATION Ptwithalonghistoryofsubstanceabuseisadmittedtothehospitalforshortnessof breath.Theptisfoundtohavemultiplegranulomasinbothlungs;abiopsyreveals METHYLPHENIDATE thepresenceoftalcwithinthegranulomas.Ptmostlikelyabusingwhatsubstance? 32y/optwcocainedependenceprescribeddesipraminebyanotherMDfor withdrawal-assocdepression.Psychiatristshouldwarnptofwhatadverseeffects thatmightresultfromaninteractionbetweendesipramineandcocaine? HYPERTENSION Whatistheprincipleproblemwithdisulfiraminthetreatmentofalcoholics? PTCANSTOPTAKINGITANDRESUMEDRINKING VerballyandphysicallyaggressiveafterasmallamountofETOH.Dx? PATHOLOGICALINTOXICATION Wernicke’sdiseasetriad: OPHTHALMOPLEGIA,ATAXIA,GLOBALCONFUSION DrinkingETOHwhiletakingdisulfirammostlikelytoproducewhatsx NAUSEAANDVOMITING EqualdoseofalcoholcorrectedforbodyweightleadtohigherBALinwomanthan me.Why? LOWERLEVELSOFALCOHOLDEHYDROGENASEIN GASTRICMUCOSA Avoidwhichdruginaptintoxicatedwithalcoholorasedativedrug? LORAZEPAM CharacteristicofCloninger’stype1alcoholism: LATEONSET Individualpsychotherapyforalcoholicsmosteffectivewhenfocusingon INTERACTIONSWITHPEOPLE <ostseriouscomplicationforaptwhoingestsEtOHwhileondisulfiram HYPOTENSION Alcoholic,AHon&offalcohol,extremeagitation.Duringwithdrawalgivebenzoand HALDOL WhatisdecreasedwithheavyETOHintake GLUCOSE 41y/optinEDw/bloodalcohollevelof0.425.Ptisstuporous,thepulseis75,BPis 110/70.UDSisnegative.Whatistheimmediateconcern? RESPIRATORYFAILURE Alcoholintoxicationcauseswhatsleepabnormalities? FRAGMENTATIONOFSTAGE4SLEEP Characteristicoffemaleasopposedtomalealcoholics: FASTERPROGRESSIONOFDISORDER 60y/oalcoholicwith4dayh/ounstructured,maligningAHandclearsensorium.Dx? ETOH-INDUCEDPSYCHOTICD/O ComorbiddisorderinmenwithPTSD ETOHABUSE/DEPENDENCE GotoTableofContents 188 Whatisasideeffectofbothnaltrexoneanddisulfiram? ELEVATEDLFTs LFTafter8weeksisrequiredinptswithalcoholdependencetreated: NALTREXONEANDDISULFIRAM 25y/opthasbeenDxw/ETOHdependence.PthasneitherhadETOHtodrinknor metanyofthecriteriaforalcoholdependenceinthepast6months.Whatremission EARLYFULLREMISSION specifierswouldapplytotheDxofETOHdependence? Duringtreatmentofalcoholdependence,thepsychiatristworkswithapatienton planningforemergenciesanddrinkrefusalskills.Thisisusingwhattherapeutic mentality? CBT IndividualswhoconsumeETOHatnightusuallydevelop: DECREASEDSLEEPLATENCY Incomparisontomen,womenwhoabuseETOHaremorelikelytoalsohave… AXISIDIAGNOSIS Anidiosyncratic,physiologicrxntoEtOHincludingrash,nausea,tachycardia,and hypotensionoccursinwhatethnicgroup? ASIANS AlcoholabuseinmencommonlyassocwwhatcomorbidmentalD/O ANTISOCIALPERSONALITY Priorityoftreatment:Maritalproblems,Depression,vs.Alcoholism. ALCOHOLISMDETOXANDABSTINENCE Typicaldurationforalcoholdetoxusingbenzodiazepinewithdrawal? 3TO5DAYS Whatisonedisadvantageofusingshorterhalf-lifebenzodiazepinesinthetreatment INCREASEDLIKELIHOODOFGRANDMALSEIZURES ofalcoholwithdrawal? Ptsover65y/owhoexperiencechronicinsomniaaremostlikelytohavewhat comorbidpsychconditions ALCOHOLABUSE PrimarycharacteristicofWernickeencephalopathy ACUTEONSET Inptswithself-injuriousbxandSI,thedecisiontoadmittotheinpatientunitwould RECENTALCOHOLABUSE bestronglysupportedbyhxof: TheroleofthesponsorinAAcharacterizedby: ANAAMEMBERWHOPROVIDES1:1GUIDANCEIN WORKINGTHEAAPROGRAM. 84y/optwhxofchronicalcoholism&amnesiawillneed,inadditiontoabstinence, ENSURINGAGOODNUTRITIOUSDIET thefollowinginterventiontopreventaprogressiontoalcohol-relateddementia: Disadvantageofusingshorterhalf-lifebenzodiazepinesinthetxofEtOH withdrawal: INCREASEDLIKELIHOODOFGRANDMALSEIZURES 55y/optpresentsfordetoxafteralcoholbinge.Ptreports“mildliverdisease.”Labs CHLORDIAZEPOXIDE revealALTis80andAST70.Whatwouldbethepreferredagentfordetox? Drugofabusethatdoesnotdependonspecificneuronalmembranebindingsites: ALCOHOL GotoTableofContents 189 54y/optwithgastriculcerundergoesemergentsurgeryand30hrspost-op becomesconfused,agitatedandrespondstointernalstimuliandsuffersa generalizedtonic-clonicseizure:Dx: DELIRIUMTREMENS 44yoMfoundwanderingaimlessly,broughtintoED,BPis200/132,HR112and regular.Ptisbelligerent,pickinghisskin,feelslikeinsectscrawlingonhisskin. Orientedonlytoname,tremulous,isdiaphoretic,dilatedpupils,palmarerythema, andspiderangiomataonchest.Whatexplainshissymptoms? DELIRIUMTREMENS Naltrexoneisclassifiedas?(Mechanismofaction) OPIATEANTAGONIST 42yroldptevalfordepression,drinks3drinks/night,>3onweekends,ptreports readinesstoquitas"3/10",whatisthemosthelpfulresponseformotivational interviewing? WHYA3ANDNOTA0 Substantiallyincreaserateofsustainedabstinencea/wDisulfiramuse? Involvepatient’spartnerinmedicationadministration Substances 84yoptgoestoEDwithfever,drymouth,visualhallucinations.Isfound tachycardia,restless,toxicityofwhatmedicationmostlikelycausedsymptoms? Caffeineresultsindopaminergicactivity,where? Benztropine AdenosineReceptor 23y/oinERafteraparty.Dehydration,dilatedpupils,HTN,elevatedCPK.Which drugdidhetake?(7x) MDMA 35y/optinEDpresentswhypoventilation,bluelips,pinpointpupils,crackleson lungauscultation,mildarrhythmiaonEKG.Mostlikelydrugofabuse:(4x) CODEINE AfterOD,pthasfever,confusion,tachycardia,drymouth,urinaryretention, dilatedandunresponsivepupils.Whichmedicationwouldtreatthis? (Anticholinergictoxicity)(4x) PHYSOSTIGMINE Astateofgeneralfatigue,hypersomnolence,anddepressionmaybeseenduring COCAINE apatient’swithdrawalfrom:(4x) WhatisthemuopioidpartialagonistapprovedbytheFDAforthetreatmentof patientswithopioiddependence?Administeredsublingually:(3x) BUPRENORPHINE PtpresentstoEDc/oringinginears,abdominalpain,andisfoundtohavemild metabolicacidosis.Overdoseofwhatsubstance?(4x) ASPIRIN AfterCannabisingestion(inchronicuse)itcanbedetectedinurinehowlong?(3x) ONEMONTH Mostcommonlyabusedsubstanceamongpatientswithschizophrenia?(2x) NICOTINE Thefirstsymptomreportedbypatientswithemergingamphetaminepsychosisis: PARANOIDIDEATION (2x) GotoTableofContents 190 Motivationalinterviewingoftenusedaspartofthetreatmentofwhich conditions?(2x) SUBSTANCEABUSE ThelargenumberofCB1cannabinoidreceptorsfoundinthehippocampusbest explainscannabis’negativeeffectson:(2x) SHORTTERMMEMORY Acutecaffeinewithdrawalsymptomsinclude:(2x) HEADACHE WhatisNOTlikelytobeaneffectiveinterventionforaphysicianwithasubstance OBSERVINGTHEPATIENTUNTILHE/SHEBECOMES abuseproblem?(2x) MOTIVATEDTOSEEKTREATMENT Whichdrugcauseseuphoria,afeelinglike“flyingabovethedancefloor,”social withdrawal,nystagmus?(2x) KETAMINE Whatdoesthepentobarbitalchallengetestdo?(2x) ESTIMATESTHESTARTINGDOSEOFPENTOBARBITAL USEDFORBARBITURATEDETOXIFICATION Personwhosmokesapackofcig/daystopssmokingandhasneedforcigafter everymeal.Thisis…(2x) ENVIRONMENTALTRIGGER Tachycardia,HTN,excessiveperspiration,pupilsdilatedincollegestudentafter attendingaparty.Drug?(2x) COCAINE Whatdrugisusedtotreatautonomicsxsassociatedwithheroinwithdrawal?(2x) CLONIDINE Ptconfused,disoriented,drymouth,dilatedunresponsivepupils.Likelyingested: BENZTROPINE (2x) Motivationalinterviewingofpatientswithaddictivedisordersaddresseswhat? (2x) AMBIVALENCEABOUTBECOMINGDRUGFREE MaximumdurationofPCPintheurine:(2x) 8DAYS Whileintoxicatedwithapsychomimeticdrug,ayoungmanreports“seeing sounds”and“patternsofcolorslikefireworksorcoloredflames”associatedwith realauditorystimuli.Whatbestdescribesthistypeofsensoryexperience?(2x) SYNESTHESIA Whichofthefollowingareasofthebrainismostassociatedwiththereward effectsofcocaine?(2x) NUCLEUSACCUMBENS Tachycardia,dilatedpupils,hypervigilance,anger,HTN,psychoticsxs,andchills. UDSshows?(2x) AMPHETAMINES Maximumtimecocainemetabolitesdetectableinurine?(2x) 4DAYS Ptwhobecameaddictedtocodeinehasalongh/omultiplerelapses.Pthas completeda2wksdetoxand2wksfollowingthat,isabouttostartacourt mandatedmaintenanceonnaltrexone.Priortostartingthemaintenancetherapy, NALOXONE psychiatristshouldcheckforresidualphysicaldependencebyadministeringwhat? (2x) GotoTableofContents 191 Whatshouldleadaprovidertoincreaseconcernforpatienthavingasubstance usedisorder? HxofmisusingotherdrugsorEtOH 40y/odentistisreferredforevaluationbystaffmemberswhoareconcerned abouthiserraticbehavior,stayingexcessivelylateattheofficeandproblemswith NITROUSOXIDE dexterityintreatingpts.Hecomplainsofnumbnessandweaknessoflimbs,lossof dexterity,andlossofbalance.Whichdrugsisthedentistmostlikelyabusing?(2x) A25yearoldbodybuildercomestoedwitheuphoria,peripheralvisionlossand hallucinations. GHB ptstatestheseoccurredafteringestingaliquidnutritionalsupplementanhourago. UDSandBALarenegative.Whatdidheingest? 21-year-oldmaleatEDisagitated,believescomputersareflashingmessagesat him,andsays“Ineedmyknifetoprotectmyself.”WhichsubstanceonUDS?(2x) AMPHETAMINES Bestdescribestheinterventiongoalassociatedwithcontemplationstageof substanceabusetreatmentusingmotivationalenhancementtherapy:(2x) ACKNOWLEDGEAMBIVALENCEANDEVOKEREASONS TOCHANGE NeurotoxicityassociatedwithMDMAisassociatedwithdeficitsinneuronsthat producewhichofthefollowingneurotransmitters?(2x) SEROTONIN Whattermbestdescribesbuprenorphine’sactionatthemuopioidreceptor?(2x) PARTIALAGONIST 18y/optinERw/acloudedsensorium,agitationandhyperactivity,mild paranoia,pressuredspeech,andeuphoric,thoughlabilemood.Onexam:HTN, tachycardia,andverticalnystagmus.Themostlikelyused?(2x) PHENCYCLIDINE(PCP) Flumazenilisusedtotreat:(2x) BENZOINTOXICATION 17y/optisbroughttotheERbyfriendswhoreportthatheingestedadrug2 hoursearlier.Pt’sbehaviorafterthedrugingestionasrelaxedandtranquilbut talkative.Soonafter,theptc/odrowsiness,dizziness,andnausea.Onexam,pt hasamimpairedbutlabilelevelofconsciousness.Thedrugscreenisnegativefor GAMMA-HYDROXYBUTYRATE(GHB) benzodiapzepines,barbiturates,andopioids.PsychMDalertsEDtothepossibility ofimminentrespiratorydifficulty.Whatdrugmostlikelycausedthiscondition? (2x) Substancefoundinseveralover-the-countersymptomcoldremediesandis abusedtoproduceadissociativefeeling:(2x) DEXTROMETHORPHAN Psychotherapyforaddictionutilizesadisease-modelapproachandemphasizes acceptanceofthediseaseandsurrendertohelpbeyondoneself:(2x) 12-STEPFACILITATION Drugofabuseassociatedwithsxsofbruxism,anorexia,diaphoresis,decreased abilitytoorgasm,andhotflashes:(2x) MDMA/ECSTASY Healthcareprofessionalhasseizureasaresultofdrugaddiction,seizureisnotfrom Meperidine withdrawal.Whatsubstancearetheyusing? GotoTableofContents 192 22y/optwithsuddenonsetanxiety,SOB,palpitations,dizziness,lightheadedness, andsweatypalms2xdays.Paranoid,fearscollegepolicewillknowparticipatedin weekend“hash-bashfestival.”Whatisdiagnosis? CANNABIS-INDUCEDANXIETYDISORDER Whatisthemostefficacioustreatmentoftobacco-usedisorder? Verenicline Heavysmokingwilllikelyaffectthedosingofwhichofthefollowingmedications? OLANZAPINE Guydrinks12-15cupsofcoffeeaday,Hasinsomniaandheadachesrelievedby drinkingcoffee.Irritableandpoorconcentrationifhedoesn’tdrinkcoffee.Howto Cutcaffeineby25%weekly treat? Aneonatehastransienthyperreflexia,irritability,andtremorsfollowedbyaperiod ofdepressedinteractivebehaviorandpoorresponsetoenvironmentalstimuli. OLANZEPINE Whatdidthechildsmotheruse? Psychotherapyforalcoholismthattargetsptambivalence MOTIVATIONAL-ENHANCEMENTTHERAPY Smokingcessationstrategywithhighestsuccessrate BUPROPIONPLUSGROUPTHERAPY Howmanyhoursafteringestiondoamphetaminesreachpeaklevels? 2HOURS Otherthannicotinereplacementtherapies,evidencemoststronglysupportstheuse VERENICLINE ofwhichofthefollowingagentsforsmokingcessation? Whatisthemechofactionofverniclineinthetreatmentoftobaccousedisorders? BLOCKSREINFORCINGEFFECTOFNICOTINE Molecularmechanismofketamine? ANTAGONISTATNMDARECEPTORS Whichdiagnosisisassociatedwiththehighestriskofpersontopersonviolence? ALCOHOLUSEDISORDER Urinetoxicologyinaptonbupropionmayproduceafalse-positivescreeningtestfor AMPHETAMINE whichsubstances? ThepsychiatristasksptwEtOHdependencetoratereadinesstoquitdrinkingon scaleof1-10.Whenptresponds“3,”psychiatristasks,“Whya3insteadofa1?”The MOTIVATIONALENHANCEMENTTHERAPY psychiatristisusingwhichofthefollowingmodalities? 19yocollegestudentatEDatepostagestampsizedLSD,nowdistressed,beggingfor ADMINISTRATIONOF20MGDIAZEPAM help,saysthingsaren'tright.Whatisthetreatment? A24yoptwhoisintoxicatedwithPCPpresentstotheED.Theptisverbally aggressive,threateningtostaff,andactivelyhallucinating.Pt’sbehaviorhas ADMINISTERHALDOL5MGIM escalateddespiteredirectionandplacementinaquietseclusionroom.Whichofthe followingisthebesttreatmentformanagingthispatient’sacutepresentation? Needleexchangeisanexampleofwhattypeofreductionstrategies? HARM LSDmayleadtoperceptionofdiffcolorswhenhearingvariousmusicaltones. Phenomenon? SYNESTHESIA GotoTableofContents 193 Ptpresentshighlyanxiouswithseizures,Has,emotionallability,irritability,dizziness, andconfusion.MRIrevealsmultiplesubcorticaldemyelinatinglesions.Themost TOLUENE likelysxisexposuretowhichofthefollowingsubstances? A32yoptpresentstoEDwithacuteonsetparanoia,AHandhypervigilance.On examptistachycardic,HTNandhasPMAandanxiety.NopastpsychhxorPMH. URINETOXICOLOGY ROSis+intermittentsubsternalCP.WhichtestismosthelpfulindevelopingaDDX? Chronicrxopioiduseaffectswhichhormone? TESTOSTERONE NopregnantpremenopausalptinEDhasgalactorrhea,elevatedprolactinlevel,pt deniesseizuresorantipsychoticmeds.Whatconditioncouldexplainthis? COCAINEWITHDRAWAL Ptwhoisdependentoncannabishadaperiodofcancellingapptsfrequentlybutis nowshowingupconsistentlyandacknowledgesthatthenegativecostsofmarijuana CONTEMPLATION outweightheanxiolyticeffectandiscommittingtoalteringhisuse.Ptisatwhich stageofchange? 17y/oreceivingcounselingforschooltruancy.Studentunderstandtruancyisnota desirablebehaviorandisdiscusseswaystoimproveschoolattendance.Whatstage PREPARATION ofchangeisstudentin? Dosefor2ppdsmoker? 42mg/day. Asmokerstates"Ineedtoquit,butI'mnotreadyyet."Whatistheptsstageof change? CONTEMPLATION Theclassofmedswithgreatestprevalenceforprescriptiondrugabuse PAINRELIEVERS Whatisreasonthatopioidantagonistnaloxonecanbeco-administeredwith buprenorphinesublinguallywithnoadverseeffect? POORSUBLINGUALABSORPTIONOFNALOXONE Ataminimum,statephysicianhealthprogramsprovidewhichservicestoimpaired physician? STRUCTUREDMONITORINGPROGRAM Coreprincipleofmotivationalinterviewingwhenusedtotreataddictivedisorder: DEVELOPDISCREPANCY Stimulant-inducedcravingfordrugsofabuseismostfrequentlymediatedbywhich GLUTAMATE neurochemicals? Withdrawalfromwhichsubcanconstitutealife-threateningmedicalemergency? SEDATIVE-HYPNOTICS Whichofthefollowingisusuallythefirststepintreatingadolescentswithsubstance ENGAGINGTHEPTANDFAMILYINSTEPSTODIMINISH abusedisorders? DRUG-SEEKINGBEHAVIOR Apersonwhosmokesapackofcigarettesperdaystopssmokingandexperiences theneedforacigaretteaftereverymeal.Exampleof: ANENVIRONMENTALTRIGGER Whichofthefollowingshouldleadapsychiatristtobeconcernedabout benzodiazepineabuseordependence? HISTORYOFABUSEOFOTHERDRUGSORALCOHOL. GotoTableofContents 194 Whichofthefollowingdiagnosticcriteriahelpstoestablishadiagnosisofsubstance RECURRENTUNSUCCESSFULEFFORTSTOCONTROLUSE dependenceratherthansubstanceabuse? MosteffectiveinitialtreatmentforptswithPCPintoxication: URINEACIDIFICATION 17y/optinERafterreportingrecentcocaineusetoateacher.Ptisagitated,hyper- aroused,andunabletoconcentrateontheinterview.Ptdeniesfrankhallucinations, LORAZEPAM2mg butappearsverydistractibleandfrightened.Onexam:HRof100withNSR.The mostappropriateinterventionwouldbetogivewhichmed? 21y/optpresentstotheEDafterusingmarijuanaforthefirsttime.Theptreports poundingheart,sweating,fearofdyingandshaking.Themostappropriatenextstep LORAZEPAM toadminister: 45y/optw/hxofMDDrecentlyhadCitalopramtwofold,withadditionof Trazodone 100mg/nightforsleep.Tendayslater,ptpresentstoEDwithsevererestlessness, nausea,vomiting,anddiarrhea.Serumtoxnegative.Onexam,ptconfused,mildly agitated,febrileto100.8,andtachyto108.Neuroexam=nystagmus,B/L hyperreflexia,andankleclonus.Tonewithoutrigidity.Inadditiontostoppingall meds&startingsupportivecare,whatmedshouldbegiven? LORAZEPAM Theimmediatephaseofamphetaminewithdrawalischaracterizedbydysphoriaand anhedoniaaswellaseuphoricrecallofdruguseandcravingforthedrug.The 2-4MONTHS anhedoniaanddysphoriaareusuallymuchimprovedinwhichofthefollowingtime frames? Whichofthefollowingsubstancesismostlikelytocauseapatienttodevelop persistentdementiawithlong-termuse? Bestinitialtreatmentofacutepsychosissymptoms2/2inhalantsuse,best INHALANTS Watchfulwaiting 21y/optatEDafterhavingnausea,sweating,andhematemesis,alsoreportsrecent headachesandnumbnessintheextremities.CTshowsgeneralizedbrainatrophy, INHALANTS labsshowrenaltubularacidosisandCPKof3120.Consistentwithchronicuseof? Medusedasstandardtreatmentofopioiddetox: CLONIDINE 23y/optisadmittedtothehospwithrhabdomyolysisandrenalfailure.On examination,ptisnotedtohaveataxiaandperipheralneuropathy.Following treatmentofthept’sacutemedicalproblems,itbecomesapparentthatthepthas dementia.MRI:cerebellaratrophyanddiffusewhitematterchanges.Whichlong standingsubstanceofabuse: TOLUENE Amuscularmalepatientpresentstoanoutpatientpsychiatriccliniccomplainingof discomfortinpublicplacesandexcessiveirritability.Thoughwarmoutside,the patientisdressedinheavy,baggyclothes,makinghimappearbiggerthanheis. ANABOLIC-ANDROGENICSTEROIDABUSE Thepatient’sbeliefthatheisshrinkinggreatlydistresseshim.Whichofthe followingisthemostlikelydiagnosisforthepatient?(2x) WhichofthefollowingsubjectiveeffectsisthebasisoftheappealofMDMA? CONNECTEDNESSTOOTHERS GotoTableofContents 195 20y/omalecollegestudentwhoisaweightlifterandstarplayeronthefootball team,isbroughttotheEDbyroomatesbecauseoftheirconcernregardingthept’s increasedirritabilityandaggressivenessoverthelastseveralweeks,including threatstoharmparticularclassmates.Theroommatesreportthatthepatienthas beenexercisinginthegymmorefrequentlythaNusual.Theydonotthinkhehas beendrinkingalcoholexcessively,usingcannabisorotherillicitsubstancesandhe hasneverdonesointhepast. ANABOLICSTEROIDUSE Whatisperceptualabnormalityinwhichhallucinogenicdrugscausemovingobjects TRAILING toappearasaseriesofdiscreteanddiscontinuousimages? Medicalspecialtywithhighestrateofsubstanceused/o: EMERGENCYMEDICINE Mostoftenabusedhallucinogensassociatedwith: TOLERANCETOEUPHORICEFFECTS WhattechniquemaybedangerousinmanagingpatientwithPCPintoxication? TALKINGTHEPATIENTDOWN Forpolysubstancedependenceneedcriteriafor: SUBSTANCESASAGROUP,BUTNOTFORANY PARTICULARSUBSTANCE Howshouldbuprenorphineandthebuprenorphine/naloxonecombobe administered? SUBLINGUALLY Prolongedingestionofhighdosespyridoxinecauses: SUBACUTESENSORYNEUROPATHY Mostcommoncauseoforganicparanoidsymptom STIMULANTABUSE Formication,agitation,stereotypicaloralmovements,¶noia? Stimulantintoxication Physostigmineisusefulintreatingtoxicsyndromefromoverdosewith: SCOPOLAMINE Whichdxcriteriahelpstoestablishdxofsubstancedependencevs.abuse? RECURRENTUNSUCCESSFULEFFORTSTOCONTROLUSE 15y/optisfoundunresponsivebyparentsafterptreturnsfromaparty,friend confirmsptusedheroin.Whataresigns? PUPILLARYCONSTRICTION Withdrawalsymptomsinchronicheroinuserspeakafterwhatperiodoftime 36HOURS Naltrexonepreventsrelapseofopioiddependencymosteffectivelyinwhichgroup? PHYSICIANS Ataxia,nystagmus,muscularrigidity,normalorsmallpupilssuggestsintoxication withwhat? PCP Txofptsw/substanceabusewhohaveacutepain PATIENT-CONTROLLEDANAGESIA AbstinencecomplianceincreaseswithrandomUDS.Thisisexof: PARTIALREINFORCEMENT Apost-oppt’swasreceiving75mgIMmeperidine.Afterswitchingtomeperidine THELOWERPOTENCYOFPOMEPERIDINECOMPARED 100mgpoptreportsinadequatepainrelief.Shehasnopastpsychandabuseissues. TOIM Thisisdueto: UDSperformedonptwhoeatspoppyseedbagelsmayyieldfalse(+)for? OPIATES GotoTableofContents 196 Mechanismresponsiblefortheeuphoriceffectsofmethamphetamine: DOPAMINERELEASEINTHENUCLEUSACCUMBENS Atwhatreceptorsdoesphencyclidine’smajoractionoccur? N-METHYL-D-ASPARTATEACID(NMDA) Checkforresidualphysicaldependenceofopiatesbyadministering: NALOXONE Pttook20tabs500mgacetaminophentabs6hoursago.Ptis52kg,pulse96,BP 135/65.PtalertandinNAD.Serumacetaminophenlevelis60Ug/ml.Liverfxntest areminimallyelevated.Mostappropriateaction? N-ACETYL-CYSTEINE Causeslong-terminhibitionofnewserotoninsynthesisanddecreaseinserotonin terminaldensity: METHYLENEDIOXYMETHAMPHETAMINE(MDMA) Labtogetpriortostartingnaltrexone LFT’s 9y/ochildwapathy,decreasedappetite,irritability,dizziness,confusion,ataxia,and HA.Recentlymovedtoolderhouseinanindustrialcity.Whichlabtesthelpfulfor LEADSERUMLEVELS dx? Dissociativecompound,senseoffragmentationanddetachmentduringintoxication KETAMINE PtrecentlyemigratedfromEastAfricapresentstoestablishcareatahealthcenter. Ptdeniesuseofalcohol,tobacco,orcommonstreetdrugs,howevernotesthat, priortoimmigrating,heroutinelychewedleavesofalocalplanttoimprove KHAT concentrationandhelphimstayawakewhileworkinglonghours.Whichplantdidpt mostlikelyuse? Commoncauseofacutecerebellarataxiainadults: INTOXICATIONWITHANTIEPILEPTICS Abruptwithdrawalofnicotineisfollowedbywhatsymptom? INSOMNIA Whatsubstancecancausedementiaw/long-termuse? INHALANTS 16y/oadolescentwithburnstotheface2/2playingwithaspraypaintcanthat ignited.GradesdroppedfromA’stoF’s.Themotherisconcernedabouthearing problems.Nootherhealthproblems.Dx? INHALANTABUSE 15year-oldptisbroughttoERbyfriendsduetoaggressionandimpairedjudgment whileintoxicated.Onexamthepthasamildtremor,nystagmus,slurredspeech, INHALANTS unsteadygaitandhypoactivedeeptendonreflexes.Theptcomplainsofdizziness andappearsuncoordinated.Whichofthefollowingsubstancesdidtheptuse? 13yoptisreportedbyparentstobesleepyduringtheday,outofit,dazed, decreasedappetite,nauseated,redeyes,runnynose,redsoresaround mouth.Whichsubstanceisplayingarole? AEROSOLINHALANTS Whatsymptomsofnicotinewithdrawalmaypersistinapatientforupto6mos? INCREASEDAPPETITE Intreatmentofrecoveringaddict,rehearsalstrategieshelpwithwhat? IDENTIFYINGINTERNALHIGH-RISKRELAPSEFACTORS Speedball HEROINANDCOCAINE GotoTableofContents 197 MiosisduetoODon: HEROIN PtintheEDisinwithdrawalfromasubstance.Symptomsincludemuscleaches, lacrimation,yawning,anddiarrhea.Whatsubstancewithdrawn? HEROIN Methadoneprescriptioninheroindependenceiscalledwhatkindofstrategy? HARMREDUCTION Needleexchangeisanexampleofwhattypesofreductionstrategies? HARMREDUCTION Apatheticandnervous,seeshalos,flashesofcolor,recentETOHandLSD, unemployed,neverhospitalized.Dx? HALLUCINOGENPERSISTINGPERCEPTIOND/O Recoveringaddictinrelapsepreventiontherapy,andhasmanyriskfactors.Rather thandevelopingacopingstrategyforeachriskfactor,dowhat? FOCUSONSKILLTRAINING,COGNITIVEREFRAMING, ANDLIFESTYLEINTERVENTIONS OpioidNOTdetectedinstandardUDS: FENTANYL Whatsubstanceisonlydetectedinurinefor7-12hoursafteringestion? ETOH Useoflevomethadylacetatehydrochloride(LAAM)formanagementofptw/opioid ELIMINATIONOFNEEDTOTAKEHOMEDOSES dependenceallowsfor: Whatistheadvantageofbuprenorphinecomparedtomethadonetaperin detoxificationfromopiatedependence? LESSRISKOFRESPIRATORYSUPPRESSION Innicotinedependence,neurotransmittermostassociatedw/rewardand reinforcementis: DOPAMINE ODonsleepingpill.Hotskin,blurryvision,urinaryretention,drymucous membranes,tachycardia,decreasedbowelsounds.Whatisthepill? DIPHENHYDRAMINE 35y/optw/hypoventilates,bluelips,pinpointpupils,cracklesonlungexam,and mildarrhythmiaonEKG.Intoxicatedwith: CODEINE 2dayss/phospitalizationdysphoric,fatigued,hypersomnic,vividdreams, requestingdoubleportions: COCAINE Whatsubstanceisacommoncauseofflashbacks? CANNABIS Useofwhichsubstanceinadolescenceisassociatedwithdevelopmentof schizophrenia? CANNABIS Acuteanxiety,restless,flushed,irritable,nauseous,worseahlersandinsomnia– attributeseverythingstressatwork CAFFEINEINTOXICATION Hasintoxicationsyndromebutnotasubstanceofabuse CAFFEINE LSDandmescalineshowagonistatwhichofthereceptors? 5HT2A Themostcommonmoodalteringsubstanceworldwide: CAFFEINE GotoTableofContents 198 Whatmedisnotusedintxofopioidmaintenanceandrelapseprevention? Patientinsustainedopioidremissionisnow10wkpregnant,howtomanage? BUPROPION(NALTREXONE,METHADONE, BUPRENORPHINEANDCLONIDINEAREUSED) Continuemethadonecurrentdose Phenobarbitaltolerancetestishelpfulindetoxfromwhat? BENZODIAZEPINES Anursew/24hrhxofanxietyandinsomniahasageneralizedtonic-clonicseizure. Dx? LORAZEPAMWITHDRAWAL 35y/oEDphysicianisreferredforpsychiatricevaluationbyEDmedicaldirectorwho hasnotedrecentchangesinthephysicianincludingramblingspeech,psychomotor agitation,aflushedandexcitedappearance,andrestlessdemeanor.Oneval, physiciancomplainsofhavingtoworkexcessiveanddifferentshiftsduetoseveral CAFFEINEINTOXICATION membersofthegroupbeingoutonvacationorsick.Physicianalsocomplainsof palpitations.Thephysicianadmitstousingalcoholtoinitiatesleepandmore caffeinetostayalert.Dx? Howlongafteringestionisamphetaminedetectableinurine? 1-2DAYS AbenzodiazepinereliablyabsorbedwhenadministeredPOorIM: LORAZEPAM 20y/optw/acuteonsetbelligerence,distortionofbodyimage,depersonalization, andcloudysensoriumfollowingingestionofastreetdrug.Horizontalnystagmus, ataxia,andslurredspeech,pupilsnotdilated.Management: ADMINISTERAMMONIUMCHLORIDE Whatisacharacteristicofhallucinogens? ADDICTIVECRAVINGISMINIMAL Contraindicationtotheuseofclonidineinmanagingopiatewithdrawal: AORTICINSUFFICIENCY Conjunctivalinjectioninapatientwithasubstanceusedisorderismostsuggestive of: CANNABISINTOXICATION Drugofabusethatexertsiteffectsprimarilythoughserotoninreleaseandreuptake METHYLENEDIOXYMETHAMPHETAMINE(MDMA) inhibition: Developingaplanformanagingafuturelapseorrelapseofaddictiveillnessismost HELPLIMITTHEEXTENTANDLENGTHOFDRUGUSE likelyto: Phenomenaismosttypicalofhallucinogenuse? ILLUSIONS Sideeffectcommontobothnaltrexoneanddisulfiram: ELEVATEDLIVERENZYMES Themostcommonacuteeffectofrecreationalketamineuse: DISSOCIATION Inrelapsepreventiontherapy,teachingarecoveringptw/anaddictionthatrelapse WARNINGSIGNSPRECEDESUBSTANCEUSE isaprocessratherthananeventconveyswhat? Duetotheincreasedriskofstrokeandsuddendeath,theU.S.FDAhasdetermined thatwhatsubstanceisunsafewhenusedincombinationwithephedra? CAFFEINE GotoTableofContents 199 Reducingtheintensityofanaddict’sreactiontoenvironmentalremindersofdrug useisagoalofwhatintervention? CUEEXPOSURETREATMENT Havingapt’sfriendorspousemonitordisulfiramadministrationandreporttothe treatingpsychMDisanexampleof: NETWORKTHERAPY Follow-upstudiesontheDrugAbuseResistanceEducation(DARE)programfor elementarystudentshavereportedwhatfinding? SMALLTONON-MEASURABLEDECREASESIN SUBSTANCEUSEBYPARTICIPANTS Whatdrugismostappropriateinemergencytreatmentofanticholinergictoxicity? HALOPERIDOL 17yoptbroughttoEDafterreportingrecentcocaineusetoteacher.InEDptis agitated,hyperaroused,unabletoconcentrateoninterview.Ptdenies hallucinations,howeverappearsverydistractible,frightened.Physicalexamshows HR100,normalrhythm.Whatismostappropriateinterventiontogive? LORAZEPAM2MG Emergencymanagementofptwphencyclidine(PCP)toxicityshouldinclude? HALDOL,BENZODIAZEPINES,CLOSESUPERVISIONAND RELATIVELYDARK,QUIETSURROUNDINGS. AcetylcysteineisTxofchoiceforODof: ACETAMINOPHEN Riskofhepatotoxicitywillpeakinhowmanyhoursafteracetaminophenoverdose? 72to96HOURS Formication,agitation,stereotypicaloralmovementsandparanoiaaresxof intoxicationwithwhichofthefollowingsubstances?Intherewardpathways implicatedintheneurobiologyofaddiction,dopaminergicneuronsprojecttothe nucleusaccumbens.Thecellbodiesoftheseneuronsresideinwhatareaofbrain? VENTRALTEGMENTALAREA An18y/optpresentstotheEmergencyDeptwithacloudedsensorium,agitation, hyperactivity,mildparanoia,pressuredspeechandeuphoricthoughlabilemood. PhysicalexamnotableforHTN,tachycardiaandverticalnystagmus.Cause? PCP Inlong-termopioidtherapyformanagementofchronicpain,thesignmost indicativeofaddictionis? ADMINISTRATIONBYNON-PRESCRIBEDROUTES 26yopresentstoEDduetoPMR,slurredspeech,constrictedpupils.Intoxicated with...? OPIODS Ptarrestedforposessionofcocaine,spends2daysinjail,aftermissingappswith subsabusecounselor.Interventionisreferredtoas…? DRUGCOURT GotoTableofContents 200 SomaticTreatments Anticonvulsants Clinicallysignificantincreaseinlamotrigineconcentrationmayoccurifco- administeredwith:(6x) VALPROICACID CarbamazepineshouldbeD/C’ediftheabsoluteneutrophilcountisbelow:(2x) 3,000 25y/optreceiveshaldolanddevelopslaryngospasm:Tx?(2x) BENZTROPINE Ptw/treatment-resistantmaniaandh/orapidcyclingisbeingtreatedw/ carbamazepineandthyroxine.Afteraddingclozapinetheptisclinicallystabilized. D/CCARBAMAZEPINE Thept’smostrecentWBCisbelow3,000.Intervention?(2x) Whichofthefollowinganticonvulsantsmaybeassociatedwithkidneystones?(2x) TOPIRAMATE Ptwithtreatmentresistant,rapidcyclingbipolardisorderwhorecentlystarted lamotriginedevelopsarashontheface.Ptadmitstoamildsorethroatandthinks DISCONTINUELAMOTRIGINEANDCOMETOTHE hemayhaveafever.Whichofthefollowingisthebestrecommendationforthe APPROPRIATEER psychiatristtomaketothept?(2x) Whichmeddecreasestheefficacyoforalcontraceptive?(2x) OXCARBAZEPINE TeratogeniceffectofbothVPAandcarbamazepine:(3x) NEURALTUBEDEFECTS Drugprophylacticfortreatmentofmigraines:(2x) VALPROATEandTOPIRAMATE Interactionbetweenvalproicacidandlamotriginethatcausesseverederm reactions? VALPROICACIDINHIBITSGLUCONURONIDATION Whichmedwouldallowforlargerdailyreductioninbenzotaperfrom supratherapeuticrange? Valproate Mosteffectivemedmosteffectiveformigraineprophylaxis TOPIRAMATE Acuteonsetofhematuriaandlumbago?Sideeffectofwhichanticonvulsant? Topiramate Whichofthefollowingagentshasbeenshowntomoderateweightgaininsomepts METFORMIN treatedw/valproateandatypicalantipsychotic? PttakingcarbamazepineforBMDpresentswithweaknessandpallor.The psychiatristnotesthepresenceofanon-blanchingrashonthepatient’sarms.The mostimmediatelabtesttoorderis: CBC Adequateasamonotherapyforjuvenilemyoclonicepilepsy: VALPROATE GotoTableofContents 201 Fetalexposuretovalproateduringpregnancyincreasesriskof: NEURALTUBEDEFECTS CoarseningoffacialfeaturesandhirsuitismareSEofwhatmed? VALPROATE Adequateformonotherapygeneralizedtonicclonicszs: VALPROATE 8y/oDxw/Bipolard/oisabouttostartvalproicacid.Whatneedstobemonitored frequently? LIVERFUNCTION Whichantibioticmaysignificantlyraisecarbamazepinelevelsandprecipitateheart block? ERYTHROMYCIN Sideeffectmorefrequentincarbamazepinethanlithium DIZZINESS Hairloss+weightgainareSEofwhichanticonvulsant DIVALPROEXSODIUM Lancinatingfacepain,triggeredbyminorsensorystimuli,besttreatedinitiallywith: CARBAMAZEPINE InducerandsubstrateofCYP3a4(iemayrequiredoseincreaseafterseveralweeks tomaintainsteadystate) Carbamazepine Whichdrugusedinthetreatmentofpatientswithepilepsyisassocw hyponatremia? CARBAMAZEPINE Whichofthefollowingbaselinelabsshouldbeobtainedforptbeingtreatedwith valproate? LIVERFUNCTIONTESTS Whatmedicationstrategiesismosteffectiveandrapidinthetreatmentofsevere bipolarillness,manicphase? ANTIPSYCHOTICMEDICATION+LITHIUMOR VALPROATE Associatedwithneuraltubedefectinfirsttrimesterofpregnancy: VALPROATE Whichofthefollowingmedsisassociatedwithbenignmaculopapularrashin approximately10-15%ofpt’swithinthefirst3weeksoftreatment? CARBAMAZEPINE WhatuniquebindingpropertyofAbilify(Aripiprazole)distinguishesitfromother antipsychotics? PARTIALAGONISTACTIVITYATD2RECEPTORS Howdoesabilifyreverseneurolepticinducedhyperprolactinemia? PartialD2agonist Afterpsychiatristaddsnewmed,ptturnsbrightredw/sunburnlikerash,similarto LAMOTRIGINE SJS.Whichmedcausedthis? WhatCBCvalueismostimportanttofollowwhenonDepakote? platelets GotoTableofContents 202 GeneralAntidepressants 27y/odepressedpatienttreatedwithSSRIandtranylcypromine(andwith5- hydroxytryptophan)nowpresentswithVH,mildconfusion,myoclonicjerks, diaphoretic,flushing,restless:(6x) SEROTONINSYNDROME WhichantidepressantmedismostlikelytocauseHTN?(5x) VENLAFAXINE Whichantidepressantmedisbesttominimizeriskoforthostasisinan84y/o?(4x) NORTRIPTYLINE Antidepressantpreferredfor>65y/oforwhichbloodlevelsareclinicallyuseful (3x) DESIPRAMINE 62y/optwithhxchestpainhasanddepression,onemonthagostartedon paroxetine,presentswithnewonsetoflethargyandheadache,lowNaandBUN, normalK,andCrof0.4.Nexttest:(2x) URINEOSMOLALITY 38y/otakingimipramine300mgqdayforrecurrentMDD.After3weeks,moodis improved,buthasdifficultypassingurineandmilderectiledysfunction. Appropriateaction?(2x) BETHANECHOL25MGTID Antidepressantlesslikelytocausesexualdysfunction:(2x) BUPROPION WhichisamuscarinicSEofantidepressants?(2x) URINARYRETENTION 30y/opthasbeentreatedforunreasonablefearofeatinginpublicplaces,feeling ofembarrassmentinpublicplaces,andangeroverthepossibilityofbeing scrutinized.Pthasnotrespondedtohighdosesofparoxetine,citalopram, PHENELZINE buspirone,andalprazolam,eachofthemadministeredfor4-6wks.Whichmeds wouldbeappropriatefornext?(2x) Whatmedscouldbehelpfulinthetreatmentofdepressioninpersonsoverthe ageof65becauseitdoesnotproduceorthostatichypotension:(2x) BUPROPION Whatantidepressanthasplasmalevelthatcorrelateswiththerapeuticresponse? (3x) IMIPRAMINE 62y/optwithhxchestpainhasanddepression,onemonthagostartedon paroxetine,presentswithnewonsetoflethargyandheadache,lowNaandBUN, normalK,andCrof0.4.Nexttest:(2x) URINEOSMOLALITY Whichofthefollowingantidepressantmedsisconsideredtobethemosteffective PAROXETINE inthetxofprematureejaculation?(x2) WhichSSRIisrecommendedforpostpartummothersbreastfeeding? A34-yoptwithepilepsyhascontrolledseizuresbutdevelopsdepression.Whichis themostappropriatedepressionmed? SERTRALINE SERTRALINE GotoTableofContents 203 Pton2mgrisperdalisstartedonProzac20mgtotreatcomorbiddepressive InhibitionofCYP2D6 symptoms.Ptthendevelopsacutesystolicreaction.Whichmechanismresponsible? 70yowdepressionplusconfusionx2wkfollowingthestartoffluoxetine.An adverseeffectissuspectedbutneuroexamnormal.Whatevaluationwouldbemost UREAANDELECTROLYTES usefultoconfirmsuspicionofanadverseeffect? Rareoccurrencesofpriapismaremostfrequentlyassociatedwith: TRAZODONE WhatisthebestreasonforpreferringtheuseofSSRIantidepressantsoverTCAsin txofptsw/depressionwhoare>65yo? LESSLIKELYTOCAUSEORTHOSTATICHYPOTENSION ApsychiatristwishedtostartaninpatientonaTCAbuttheptisreluctantdueto hearingthesedrugsmaycausedrymouth,constipation,blurredvisionandurinary retention.WhatTCAwouldhavetheleastsideeffects? DESIPRAMINE 25yoCFstartedondesipramine50mgQday.SEofconstipation,drymouth,visual POORMETABOLISMOFCYTOCHROMEP450 difficulties,tremorandagitatedfeeling.Notonanyothermedications.Bloodlevelis SUBSTRATES 400ng/ml.Mostlikelycause? WhichsideeffectoccurslessfrequentlyinptstreatedwithmirtazapinevsSSRIs? DIARRHEA Mirtazapineisanantagonistatwhichreceptor? ALPHA-2-ADRENERGIC 46y/oFptpresentswincreasingdysphoria,progressivelyincreasedfrequency withwhichshewashesherhandstothepointofexcoriation,doserangefor effectiveTx:(x2) FLUVOXAMINE200-300MGDAILY Dermatologistasksforpsychconsulton38y/opt.5yearsagoptbeganhaving concernsofperceivedskinirregularityshecalls“bumps.”Overtimeincreasingly moredifficultforhertoignore“bumps”andpicksatthem.Severaldermatologists havebeenunabletoconvinceptitisnotadermatologicalissue.Asidefromthisno evidenceofothermoodorthoughtd/o.First-linetreatmentforpt? FLUVOXAMINE Theriskofincreasedpsychosisforptswithpsychoticdisorderswhotakebupropion DOPAMINE isattributabletoenhancementof: Thesideeffectsofsedationandweightgainareassociatedwithmirtazepine’s antagonismofwhichofthefollowingreceptors? H1 Pttakingvenlafaxineformonthsstopsabruptlyandcallspsychiatrist3dayslater withnausea,insomnia,muscleaches,anxiety,dizziness,andtransient“electric shock”sensations.Themostlikelycause: ANTIDEPRESSANTWITHDRAWAL 58y/optisstartedoncitalopram20mgforMDD.After3wksptreportssome improvementinvegetativesxsbutremainsdysphoric.Whatisthenextstep? CONTINUECITALOPRAMATTHEPRESENTDOSEWITH NOADDITIONALMED Antidepressantw/shortesteliminationhalf-life: TRAZODONE Phenylethylamineantidepressantthattargetsserotoninandnorepinephrine reuptakeinhibition VENLAFAXINE GotoTableofContents 204 Whatpharmacologicaltreatmentshouldbeusedforlong-terminsomniainptswith TRAZODONE dementiaover65yearsofage? Keyelementinemergencytreatmentofptwserotoninsyndrome,beyondstopping SUPPORTINGVITALFUNCTIONS offendingagentis: Mirtazepine(vsotherantidepressants)haslowincidenceofwhatsideeffect? SEXUALSIDEEFFECTS OrthostatichypotensionisleastlikelytooccurasaS/Ewithwhatantidepressants? SERTRALINE.NORTRIPTYLINE,IMIPRAMINE, AMITRIPTYLINE,TRAZODONE◊ORTHOSTATIC HYPOTENSION Whichantidepressanthasactivemetabolitesthatextenditseffectivehalf-life? SERTRALINE 50y/ofiremanbecameclinicallydepressedaftersustainingamyocardialinfarction. SERTRALINE Whatisanappropriatemedicationtoprescribe? MDDpatientwithgoodresponsetovenlafaxinepresentswithdysphoria,agitation, SEROTONINDISCONTINUATIONSYNDROME nausea,poorbalanceafterrunningoutofmedication.Causeofsx? EffectiveforOCD PAROXETINE,PHENELZINE,FLUVOXAMINE, CLOMIPRAMINE(NOTBUPROPION) Receptorblockedbyantidepressants->blurredvision MUSCARINIC Whichantidepressanthasstrongesthistamine-Raffinity? MIRTAZAPINE 45y/optw/firstepisodeMDD,onPaxilandinsight-orientedtherapy,but depressionworsensovermonths.TakesPaxilonlyoccasionally,asheisworried aboutbecomingdependentonit(afriendwasaddictedtoValium).Best intervention? EDUCATEPATIENTONTHEDIFFERENCESBETWEEN ANTIDEPRESSANTS,LIKEPAXIL,ANDBENZODIAZEPINES, LIKEVALIUM. WhatantidepressantincreasesREMsleep? BUPROPION WhatantidepressanthasanFDApregnancyuseBrating? BUPROPION Antidepressantwithlowriskofweightgain BUPROPION 40y/optexperienceddelirium,tremor,diaphoresis,rigidity,hyperpyrexia,and myoclonusinmakingthetransitionfromtheuseofclomipraminetophenelzine.Pt ismostlikelyexperiencing: SEROTONINSYNDROME AntidepressantthatcausesParkinson’ssx: AMOXAPINE Wptsover65wMDD,BupropionhaswhatadvantageoverSSRIs? FEWERDRUGINTERACTIONS Trazodonerequireslargerdosestobeusedasanantidepressantduetolower potencyaffinitytowhichreceptor? SEROTONICTRANSPORTER Restlessness,myoclonus,hyperreflexia,diaphoresis,shivering,tremor,and confusionarecompatiblewithwhichdiagnosis? SEROTONINSYNDROME GotoTableofContents 205 ApsychiatryconsultisplacedregardingapatientwithSI.HistoryofBipolar disorderandadmittedforVREbacteremia.BPof171/95,tempof100.9.Has tremors,hyperreflexia,myoclonicjerks,notorientedatall,hasvisual hallucinations.Medsincludelinezolid,lithium,sertraline,Risperdal.Whatis diagnosis? SEROTONINSYNDROME MAOI Whichofthefollowingopioidshasapotentiallylethalinteractionwith monoamineoxidaseinhibitors(MAOIs)?(4x) MEPERIDINE 45y/oFptonphenelzineforMDD,takesOTCmedicationforcoldsxanddevelops PSEUDOEPHEDRINE hypertensivecrisis.WhichOTCmedicationwouldmostlikelycausethis?(3x) MinimumrecommendedwashoutperiodforfluoxetinepriortostartingMAOI(2x) 5WEEKS TreatmentforpatientswithMAOIrelatedhypertensivecrisisintheERmay involvetheadministrationofwhichofthefollowingmeds?(2x) PHENTOLAMINE WhichmediscomparativesafetyduringTxw/MAOI? FENTANYL Fatalreactionshaveoccurredwhenmonoamineoxidaseinhibitors(MAOIs)are combinedwithwhichofthefollowingmedications? FENTANYL 2wkwaitingperiodrecommendedwhenswitchingfromphenelzineto tranylcyprominebecause: TRANYLCYPROMINEISANAMPHETAMINEDERIVATIVE PtstakingMAOIsshouldusecautionwhenconsumingwhat? FAVABEANS WhichmedisirreversibleMAO-Binhibitor? SELEGILINE Whatdrughasbeenknowntocausehypertensivecrisis? PHENELZINE 2wkswashoutofwhichmedisneededbeforestartingfluoxetine PHENELZINE MAOIleastlikelytocausedrug-foodinteractionintherapeuticantidepressantdoses MOCLOBEMIDE PttakingphenelzineistreatedinEDforchestpain.Whiletreated,ptdevelops hyperreflexia,HTN,goesintocoma.Whichmedismostlikelycause? MEPERIDINE(DEMEROL) At10mgselegilinedoesnotrequiredietaryrestrictionb/c MAO-BISNOTINVOLVEDWITHINTESTINALTYRAMINE REACTION MostfrequentsideeffectofMAOI’s HYPOTENSION WhichofthefollowingisanegativepredictorresponsetotreatmentwithETinpts withMDD? BORDERLINEPERSONALITYDISORDER 42y/optwithhxofHTNtreatedwithHCTZandlisinoprilpresentsforf/uofsevere melancholicandvegetativedepression.Thepatient,whileadherenttoallmed regimens,hasfailedmultiplecombosofantidepressantsandiscurrentlyona ITISANIRREVERSIBLEMAO-A&MAO-BINHIBITORAND CANONLYBESTARTED5WEEKSAFTERDISCONTINUING FLUOXETINETODECREASERISKOFSEROTONIN GotoTableofContents 206 regimenthatincludesfluoxetine.Thepsychiatristplanstodiscontinuefluoxetine andstartselegiline.Themostimportantconsiderationtobemadebeforestarting? SYNDROME MAOIsaffectcatecholaminesbydirectlyretarding: DEACTIVATION Ptw/MDDhasbeenunresponsivetopriortrialswithaTCAandSSRIs.Pthas1st BEGINTXWITHPHENELZINE degreerightbundlebranchblockandpoorlycontrolledHTN.Ptw/noSI.Nextstep? WhatinhibitorofmonoamineoxidaseisalsousefulinthetreatmentofParkinson’s disease? SELEGILINE TCA Whatdrughasacurvilineartherapeuticwindow?(6x) NORTRIPTYLINE WhatdrugisusefulintheRxofurinaryretentionsecondarytoTCAtherapy(5x) BETHANECHOL AfteranODonAmitriptyline,whattestisneeded?(4x) EKG MostfrequentcauseofdeathfollowingTCAoverdose:(2x) ARRHYTHMIA OptimalstrategyinmaintenancetxwithTCAforpatientwithrecurrentMDD(2x) FULLDOSEANTIDEPRESSANTTHERAPY MonitorTCAoverdoseusing(2x) EKG Bloodlevelsfortherapeuticandpotentiallytoxiceffectscanroutinelybeassessed forwhichmed? NORTRIPTYLINE Suddendeathinchildrentakingwhichmedication? TRICYCLICS IncreasedPR,QRS,orQTonEKG: TRICYCLICS Psychiatristplanstoaddnortriptylineasadjuncttofluoxetine.Heshouldproceed how? STARTNORTRIPTYLINEATLOWERTHANNORMALDOSE ThebesttimetoobtainECGinthetreatmentofchildrenwithTCA: BEFORETREATMENT,FORALLCHILDREN,TOESTABLISH BASELINE ThisisaneffectivepharmacologictreatmentforsymptomsofOCD? CLOMIPRAMINE Whichantidepressantissuccessfullyusedtotreatpainsyndromes? AMITRIPTYLINE NortriptylineistheactivemetaboliteofwhichofthefollowingTCAs? AMITRIPTYLINE Whichtricyclicantidepressanthasthemostpotentantihistaminiceffect? DOXEPIN WhichTCAshouldbeavoidedinptsw/Parkinson’s? AMOXAPINE GotoTableofContents 207 Drymouth,blurredvision,constipation,urinaryretention.S/Eofwhat psychotropic? AMITRIPTYLINE DoNOTuseinptw/narrow-angleglaucoma AMITRIPTYLINE 85y/optw/hxofHTNandCOPDreportsfeelingdepressed.Thepthasanepisode ofdepression20yrsago,whichwassuccessfullytreatedwithnortriptyline.Thept’s HTNiscurrentlywellmanagedwithhydrocholorothiazide.Thephysicianprescribes PT’SADVANCEDAGE nortriptyline25mgqday.After1wk,theptcallsandreportsfeelingnobetter.What wouldbeanappropriatereasontoobtainanortriptylinelevel? 32y/optw/hxoftreatmentresistantdepressionwasbroughttoERafteroverdose onimipramine.Ptreportedwantingtodie,butthenchangedhermindandthen calledforhelp.Pt’sregularpsychMDhadrecentlyaddedimipraminetothept’s partiallyeffectiveregimenoffluoxetine80mgqday.Ptisafebrile,BPis100/58and INSISTONFURTHERCARDIACMONITORINGINEITHER HRis96andregular.Ptisvagueaboutthedetailoftheattempt,butreportsno THEEDORICU longerfeelingsuicidal.Medicalresidentrecommendsadmissiontoapsychunit. RequestforaTCAbloodlevelandEKGaredeferred.Medicalresidentassertsthat thept’scombinedimipramineanddesipraminelevelof750ng/mlisnotinthe cardiotoxicrange.WhatisthebestcourseofactionforthepsychMDtotake? 50yoreferredtopsychfollowingnegativemedicalworkupofabdpain.Ptappears depressedandinconstantpain.Whatisthepreferredpsychintervention? Whatcausesthecardiactoxicityofimipramineinoverdose? OrthostatichypotensionassociatedwithTCA’siscausedbyblockadeofwhat receptor? STARTLOWDOSEIMIPRAMINE BLOCKADEOFVOLTAGE-GATEDSODIUMCHANNELS ALPHA-1-ADRENERGIC 80yroldptwithMDDhastriedSSRIsandSNRIswithnoimprovement,wantstostart TCA,nocardiachxandEKGisnormal,whichmedicationismostappropriatedueto Desipramine thesideeffectprofile? SSRI WhichSSRIhasmildanticholinergicactivityduetosomeaffinityatthemuscarinic PAROXETINE receptors?(3x) FluoxetineshouldNOTbeprescribedwithwhat?(2x) PHENELZINE 21y/optexperiencesabriefmanicepisodeafterstartinganSSRI.TheptmeetsDx SUBSTANCE-INDUCEDMOODDISORDER criteriaforwhatdisorder?(2x) Serotonergicantidepressantsareappropriatetreatmentfordepressionin54y/o ptwithrecentcoronaryarterybypassgraftsurgerybecausethey:(2x) INHIBITPLATELETFUNCTIONING WhichSSRIhasthegreatestpotentialfordiscontinuationsyndromewithmissed doses? PAROXETINE SSRIwithshortesthalflife FLUVOXAMINE GotoTableofContents 208 Ptw/hxofMDDhasbeentakingFluoxetine40mgPOQDayforoneyearsince achievingremissionofthirddepressiveepisode.Ptwantstostopmedication becauseofsexualsideeffectsresponsivetoSildenafil100mgPRN.Whatshould psychiatristrecommendtopt? CONTINUETHEFLUOXETINEASLONGASITISEFFECTIVE Whichofthefollowinghasthelongestmeanhalf-life:citalopram,paroxetine, venlafaxine,fluvoxamine,trazodone? CITALOPRAM InstudiesthatcompareSSRIantidepressantswithTCAs,whichofthefollowingis thebestdocumentedadvantageofSSRIsoverTCAs? LOWERDROPOUTRATESDUETOSIDEEFFECT TheSSRImostlikelytocausediscontinuationsyndrome: PAROXETINE MosttypicalSEoffluoxetine: NERVOUSNESS,RESTLESSNESS,ANDANXIETY DiscontinuationsyndromeassociatedwithSSRIconsistsof: MALAISE,NAUSEA,PARESTHESIAS,DIZZINESS,MOOD SYMPTOMS,ANDHEADACHE WhichisacommonsideeffectleadingtodiscontinuationofSSRI’searlyin treatment? GIDISTRESS WhichofthefollowingSSRIshaslongesthalf-life? FLUOXETINE BlackboxwarningonSSRIswithregardtochildrenandadolescents: SUICIDALIDEATION Whichofthefollowingwouldrepresentaconcernifadministeredconcomitantly withaSSRI? HYPERICUMPERFORATUM WhichoftheSSRIantidepressantshasthelongestmeanhalf-life? CITALOPRAM SSRIw/noormildinhibitionofmajorP450isoenzymesof1A2,2C9,2C19,2D6,3A4 CITALOPRAM Africanamericanstendtohavehigheractivityofwhichofthefollowingcytochrome 3A4 p450enzymes? Increasespaxilconcentration: CIMETIDINE WhatisasleepdisturbancelikelytooccurafterinitiatingatrialofanSSRI? BRUXISM Whichofthefollowingmedshasthelowestlikelihoodofdiscontinuationsymptoms FLUOXETINE ifthemedicationisabruptlystopped? 45y/optwhoisingoodphysicalhealthreportsincreasedfatigue,decreased appetite,andaninabilitytotakepleasureinusualactivities.Ptisbegunon fluoxetine20mg/day,andpt’smoodimprovesoverthecourseof2weeks.However, BEGINPROPRANOLOL10MGTID ptnownotesanewonsetofanxietysymptoms,includingrestlessnessinthearms andlegs.Ptisobservedtofidgetandseemsunabletositstillfortheexam. Neurologicalexam:unremarkable.WhichcoursesofTxwouldbemostappropriate? Whatmedhassomeevidenceofeffectivenessinbothpsychotic/nonpsychotic subtypesofbodydysmorphicdisorder? FLUOXETINE GotoTableofContents 209 ThisSSRIisusedtotreatthediscontinuationsyndromecausedbyterminationof otherSSRI’s: FLUOXETINE 50y/ofiremanbecameclinicallydepressedaftersustainingamyocardialinfarction. SERTRALINE Mostappropriatemedicationtoprescribe: PtwhorespondedinthepasttoSSRIsrequestsadrugfromthisclasswhen subsequentlyseenforanotherepisodeofdepression.However,ptreportsconcerns thatwhenthepreviousmedicationwastapered,ptexperiencedfatigue,insomnia, FLUOXETINE abdominaldistress,flu-likesymptoms,anddizziness.Whatmedswouldbe appropriateforthispt? Whatmedismostpotentinhibitorofthenorepinephrinetransporter? PAROXETINE 36y/optc/odysphoria,insomnia,fatigue,poorconcentration.Ptisstartedon sertraline50mg,increasedto100mgin2weeks.2monthsafterdoseincrease,pt reportsmoodgreatlyimproved.However,ptnotesnewonsetofsxofdelayed ejaculation,frequentlytopointofanorgasmia.Hebelievesthisbeganalmost immediatelyafterdoseincrease.Firststepinmanagementofproblemwouldbe? DECREASETHESERTRALINEDOSAGETO50MG/DAY CytochromeP450(CYP450)subenzyme,inhibitedby______,increasesTCAlevels ____ FLUOXETINE,2D6 SSRIswiththegreatestpotentialforslowingorblockingmetabolismofother medications? LUVOX FalsepositiveurinetoxicologyscreenforBenzodiazepam? SERTRALINE Antipsychotics 60y/oon6mgrisperidone,50mgsertraline.Slowedthinking,drooling,cog- wheeling,maskedfacies.Mood/paranoiaimprovedonmeds.Whattodo?(4x) DECREASEDOSEOFTHEANTIPSYCHOTIC Howdoantipsychoticmedselevateprolactin(PRL)?(4x) PRLISUNDERTONICINHIBITORYCONTROLBY DOPAMINE 25y/opthospitalizedforanacutepsychoticbreak,beginstocomplainof thickenedspeech.Physicalexamrevealseyesdeviatedtotheupperright, grimacing,andposturingofthearms.Theonlymedstakenwerehaldoland clonazepam.Themosthelpfultreatmentatthispointwouldbe:(3x) DIPHENHYDRAMINE Periodicallyassessneurolepticsideeffectsusing?(italsoshowspt’sawarenessof AIMS sideeffects)(2x) Afteraninjectionwithhaldol,apatientappearstremulous,dystonic,confused, andhasafeverof38.8degreesC.Whichofthefollowingwouldbeanessential partofthediagnosticworkupforthispatient?(2x) CSFEVALUATION Whichmedreducestheacutesxofneurolepticinducedakathisia?(2x) BETABLOCKERS(PROPRANOLOL,ATENOLOL) GotoTableofContents 210 Apatienthasaseizuresecondarytoasupratherapeuticlevelofclozapine.What changesinapatient’slifecouldaccountforthisfinding?(2x) SMOKINGCESSATION Inadditiontolifesupport,whichclassofmedstoconsiderforthetreatmentof neurolepticmalignantsyndrome?(2x) DOPAMINEAGONISTS(bromocriptine) WhatdidtheClinicalAntipsychoticTrialsofInterventionEffectiveness(CATIE) demonstrateabouteffectivenessof2ndgen.antipsychoticsfortxof schizophrenia?(2x) SECONDGEN.ANTIPSYCHOTICSWERENOMORE EFFECTIVETHANFIRSTGENERATIONS A75yowithbaselinedementiaadmittedfornewonsetconfusion,disorientedto timeandplace,workupnegative,startedonHaldol.After3daysptismuch improvedandminimallysomnolencebutstilldisoriented,whatisthenext pharmacologicaltreatmentapproach D/CHALDOL 47yoptpresentswithfever,confusion,andtremorandfoundtobetachyand diaphoretic.Clonuseasilyelicitedonexam.Ptsuspectedtohaveserotonin syndrome,istakingCelexaandLithium.Whatadditionalmedicationmayhave contributedtosyndrome? ST.JOHN’SWORT Whichantipsychoticmedisassocwithdecreasedpsychoticsxs,decreased substanceuse,andincreasedabstinenceinptswithschizophreniaandaddictive d/o? CLOZAPINE Superiorefficacyforatypicalantipsychoticsovertypicalantipsychoticsinthe treatmentofpsychosishasbeenconsistentlydemonstratedinwhatmedications? CLOZAPINE 36y/oFptw/schizophreniahasbeentreatedw/olanzapineisdiscoveredprolactin ORDERAPREGNANCYTEST level:354ng/ml(normal:3-30).Thefirstactionis: Previousdualantipsychoticfailure.ToleratingClozapine200mgforamonth.What shouldbenextstepinmedicationmanagement? ContinueClozapinebyItself WhichantipsychoticmedhasthelargestnumberofstudiessupportingitsuseforTx RISPERIDONE ofexplosivenessandreactiveangerinyouth? Antipsychoticdrugadrenergiceffectcausingorthostatichypotension Α1-BLOCKADE WhichmedhasincreasedriskofhyperglycemiaandDM? OLANZAPINE Autonomicinstability,nonfocalneurologicalsigns,andelevatedtempassociated withwhichelevatedlabvalue? CREATININEPHOSPHOKINASE(CPK) Whichatypicalantipsychoticcausesleastweightgain? ZIPRASIDONE Whathematologicalfindingnecessitatesimmediatedcofclozaril? WBC2000-3000,GRANULOCYTES1000-1500 Withtheuseof2ndgenantipsychotics,alphareceptorantagonismisassociated withwhatsideeffects? TACHYCARDIA Retinalpigmentationfromlong-termTxwith: THIORIDAZINE GotoTableofContents 211 MechanismbywhichrisperidonecauseverylittleEPSdespitebindingw/high affinitytoadopaminergicD2receptor SEROTONERGIC5HT2ANTAGONISM Whatisamajorsideeffectofclozapine? SEIZURES Ptonmethadonemaintenancestartedtakingarefluxdrugandnowissedated. Whatmedwasrecentlyadded? CIMETIDINE 55y/opsychiatricallyhospitalizedptwithchronicschizophreniastabilizedon Clozapine.Twoweeksafterd/cptp/wimpendingsignsofpsychoticrelapse. RESUMPTIONOFHEAVYSMOKING Assumingptadherencetomedsandnegativeserum/urinetoxscreens,whatismost likelyexplanationforrelapse? Mostcommonsideeffectwithclozapinetxis SEDATION Antipsychoticassociatedwithdevelopmentofcataracts QUETIAPINE Blockadeofdopaminereceptorsintuberoinfundibulartractsresultsinbreast PROLACTIN enlargement,galactorrhea,impotence,andamenorrhea.Mechanismisincreaseof: Recentschizophrenicmedadjustment,nowwithfever,diaphoresis,stiffness, tachycardia,confusion.Dx? NEUROLEPTICMALIGNANTSYNDROME Apatientwhoisprescribedahigh-doseoffluphenazinedevelopsafeverof103F, tachycardiaandAMS.Whichtestismostlikelytobehelpful? CREATINEKINASE IVHaldolrelatedtorsadesdepointesisassociatedwithwhat? LOWMAGNESIUMLEVELS WhichofthefollowingwouldbeofmostconcernafterinitiatingtreatmentwithIV haldolforan82y/optwithdelirium? PROLONGEDQTCINTERVAL Whichofthefollowingagentsismostlikelytobehelpfulinthetreatmentofvisual hallucinationsandpsychosisassociatedwithadvancedParkinson’sdisease? QUETIAPINE Aleadinghypothesisastowhyatypicalantipsychoticmedicationsarelesslikelythan typicalneurolepticagentstocauseEPSisbasedonewhichofthefollowing RAPIDDISSOCIATIONFROMD2RECEPTORS propertiesofatypicalantipsychotics? 35y/optisstartedonatrialofclozapinefortreatment-refractoryschizoaffective disorder.Duringtheinitialmedicationtitration,ptcomplainsofsedationand orthostatichypotensionaswellasflu-likesymptoms,butseemssymptomatically improved.Howeverafteradoseincreasefrom150to200mg,ptdevelopsafeverto MYOCARDITIS 102degrees,tachycardiato130bpm,andanacutemetalstatuschange.CXR,urine studies,andbloodcultureareunremarkable.ACBCrevealsaWBCof11.4,withan elevatedeosinophilpercentof7%.Whichknowntoxicriskofclozapineisthemost likelyDx? A30yow.5yohxofSchizophrenia,priorfailedHaldolandRisperidonetrial, despiteadherenttomedscontinuestohaveseverepsychoticsymptoms.Med recommendationatthistimeis.. 30yoonClozapinefortreatmentresistantschizophreniapresentingwithdyspnea, orthostatichypotensionandHR130bpm.ElevatedEosinophil,EKGwithnonspecificTwavechanges.Furthermostlikelytesttoguidetreatment CLOZAPINE TROPONINLEVEL GotoTableofContents 212 WhatlabfindingismosttypicallyassociatedwithNMS? INCREASEDCREATINEKINASELEVELS Appropriatemanagementofneurolepticmalignantsyndrome: HYDRATIONANDCOOLING Antipsychoticsareassociatedwithwhat? DYSTONIA,POIKILOTHERMY,LIPIDSOLUBILITY,AND LOWERSEIZURETHRESHOLD ThesesymptomsmakeadiagnosisofNMSmorelikelythanotherneurologicaland FEVERANDSEVEREMUSCLERIGIDITY generalmedicalconditions:(x2) Whichofthefollowingeffectsisthebasisfordantrolene’sefficacyinthetreatment SKELETALMUSCLERELAXANT ofneurolepticmalignantsyndrome(akanms)? 32y/optwithhxofschizoaffectived/ostableonclozapineisadmittedtointernal medicineserviceforasevereGIviralinfection.Ptisconfused,slow,appearsvisibly illandtired.Ptc/ostiffnessandthereissomerigiditytothemovements.What shouldberecommended? DISCONTINUECLOZAPINE Whichantipsychotichasleasteffectonprolactin? CLOZAPINE Reducesthesuiciderateinadultswithschizophrenia: CLOZAPINE AslowtitrationofClozapineisrequiredtodecreasetheriskof: SEIZURES WhichneuroleptichastheweakestaffinityforthedopamineD2-likereceptor? CLOZAPINE Clozapineclearancedecreasedby CIMETIDINE Whichmediscontra-indicatedwithclozapine? CARBAMAZEPINE Whatisthetreatmentofacutedystonia? BENZTROPINE Schizophreniconhaldol5mgpresentstoED"unabletosee."Appearsdistressed, writhingandmoaning.States"I'munabletostoplookingup."Whatisthebest treatment? ADMINISTERBENZTROPINE1MGIVNOW Whatmanifestationsisthemostcommonsideeffectofconventionalantipsychotic meds? AKATHISIA Whatantipsychoticmedicationwouldbethebestchoicetoavoidmotorsymptoms CLOZAPINE inParkinson’sdisease? Antipsychoticdrugselevateprolactinduetowhat? PROLACTINISUNDERTONICINHIBITORYCONTROLBY DOPAMINE Ptdevelopsfeelingsofrestlessness,aninabilitytorelax,jitteriness,pacing,and rapidalternationofsittingandstandingshortlyafterbeingstartedonalowdoseof ATENOLOL haloperidol.Additionofwhatmedicationswouldbemosteffectiveinmanaging thesesymptoms? GotoTableofContents 213 60y/optw/depressionandparanoiaisbeingtreatedwith50mgofsertralineand 6mgofresperidone.Atf/uappointment,ptc/oslowedthinkingandexcessive salivation.Onexam,theptexhibitsamaskedfaciesandcogwheelrigidity.Mood andparanoiahavesignificantlyimproved.ThenextstepforthepsychMD? LOWERTHEDOSEOFTHEANTIPSYCHOTICMEDICATION Thetherapeuticeffectof2ndgenerationantipsychoticsonnegativesymptomsof schizophreniaisthoughttoberelatedtotheinductionofexpressioninwhatareaof PREFRONTALCORTEX thebrain? PsychMDordersquetiapine50mgforan82y/onursinghomeptw/dementia whohasbecomeseverelyagitated.Soonafter,thepsychiatristreceivesacallfrom ATYPICALANTIPSYCHOTICSINCREASEMORTALITY; afamilymemberwhoisconcernedaboutthe“blackbox”warningsassociated THISMUSTBEBALANCEDAGAINSTANYPOTENTIAL withantipsychoticsintheelderly.Whichofthefollowingisthemostaccurate BENEFIT informationthepsychiatristcouldgivethefamilymemberregardingthepotential safetyrisksofthismedication?(x2) Whichofthefollowingmedicationsismostlikelytoprecipitateamanicswitchina patientwithbipolarIdisorder Correlationofplasmadrugconcentrationwiththeclinicaleffectivenessisbest establishedforwhichantipsychotics? Acutelypsychoticptstartedonrisperdal2mgqhs.Increasedto3mgBIDovernext fewdays.Ptbecomesincreasinglyagitated,restless,unabletostoppacing.Most appropriateintervention? 6yearoldwithautismspectrumisreferredtopsychiatristforirritability, aggression,andhittingself.ChildhasnotrespondedtoRisperdal.Whichhasthe mostevidenceformanagingirritabilityandaggression? DESIPRAMINE CLOZAPINEANDHALOPERIDOL ADDPROPRANOLOL10MGTID ARIPIPRAZOLE Anxiolytics/Benzodiazepines Whatpsychotropiccancauseadecreaseinbenzoplasmalevels?(6x) CARBAMAZEPINE Ptw/h/obipolarpresentswimmobility,posturing,echopraxia.Firstlinetx?(5x) LORAZEPAM Whichbenzoaccumulateswithrepeatedadministration,shouldbeavoidedin chronicrenalfailure,andmostlikelytoaccumulatewithrepeateddosing?(3x) DIAZEPAM Ifprescriptionbenzoisnecessaryforapatientw/severehepaticdysfunction whichofthefollowingismostappropriatechoicetoavoidelevatedserumlevels. (2x) LORAZEPAM Whichofthefollowingmedicationswouldbepreferableforuseinananxious patientwithpulmonarydisease?(2x) BUSPIRONE WhichbenzoisreliablyabsorbedgivenIM?(2x) LORAZEPAM Whichofthefollowingreversestheeffectsofbenzodiazepines?(2X) FLUMAZENIL Buspironeisthoughttoexertanxiolyticeffectsprimarilyduetoitsactionsatwhich receptor? 5HT-1A GotoTableofContents 214 Benzohalf-life<6hrs TRIAZOLAM Pharmacokineticpropertymostrelatedtorelativeabusepotentialofbenzos TIMETOONSETOFACTION 75y/optwithcirrhosisshouldbegivenwhichofthefollowingmeds: TEMAZEPAM Whichbenzodiazepineismetabolizedthroughglucuronidation(phaseII metabolism) intheliver? LORAZEPAM BenzodiazepamabsorbedPOorIM LORAZEPAM Benzow/oactivemetabolites LORAZEPAM Longesthalf-lifeamongstalprazolam,flurazepam,lorazepam,temazepamand triazolam FLURAZEPAM(DALMANE)USEDFORINSOMNIA Mostcommonsideeffectofbenzos DROWSINESS Whichofthefollowingbenzoshasanactivemetabolite? CHLORDIAZEPOXIDE Whichofthefollowingsleepchangesisproducedbyallbenzos? DECREASEINREM Alcoholuseisassociatedwithwhatchangesinsleep? DECREASEDREMSLEEP Breakthroughpanicanxietyinapatienttreatedwithshort-actingbenzodiazepines canbemanagedbyswitchingthepttowhatmedication? CLONAZEPAM 75y/opthasdevelopedtolerancetoclonazepamovermanyyears,nowtaking5mg SLOWLYWITHDRAWTHEPT’SCLONAZEPAMAND clonazepamatnightbutstillwithpoorsleep.Ptdeniesanymoodoranxiety REEVALUATE symptoms,nodrugproblems.Nextstep: Ptsonchronicbenzosdevelop: AMNESIA Benzothatwouldbethesafesttoprescribefora70y/opt: LORAZEPAM 22y/optsuffersatraumaticbraininjuryfollowingaskiingaccident,andisadmitted toaninpatientrehabilitationfacility.There,pthasfrequentepisodesofsudden angerandaggressiondirectedtowardstaff.Onpsychiatricevaluation,ptisawareof theseepisodes,saying,“Ican’thelpit,Ijustseered.”Ptdeniessymptomsof PROPRANOLOL depressionoranxiety,andthereisnoevidenceofacuteconfusiononexamination. Therehabilitationstaffreportthatallbehavioralstrategieshavefailed,andthatpt’s outburstsareintimidatingthestaff.Whichofthefollowingmedicationshasthebest evidenceforefficacy? Treatmentofcatatonia(hallucinationswithmutismandunusualposturing) Ativan 35yopatientpresentswithfrequentpanicattacks,whichbeginwithfeelingsof dread,sweating,shaking,fearofdoomanddeathlasting20min.Which medicationprovidesimmediaterelief LORAZEPAM GotoTableofContents 215 Lithium Treatmentofchoiceforlithiumintoxicationwhomanifestsimpaired consciousness,neuromuscularirritability,andseizuresis(10x) HEMODIALYSIS SerumLilevelscanincreasesignificantlywhengivenwwhichHTNmed?(3x) HCTZ Whichmedisthoughttohaveaprotectiveeffectindependentofitsmood- stabilizingeffectagainstsuicideriskinptswmooddisorder?(4x) LITHIUM 32y/oFptw/BMDhasbeentreatedwithlithium.Ptrevealstoherpsychiatrist thatsheisnowpregnant.Attemptstodclithiuminthepasthaveledtorelapsesof thept’sdisorder,withsevereassociatedmorbidity.Atrialofanantipsychoticin CONTINUELITHIUM thepastresultedinNMS,andpthassincerefusedtousethem.Whichofthe followingwouldbethebestoptionfortreatmentduringthepregnancy?(3x) 62y/oFwbipolard/odevelopsalteredmentalstatus,dysarthria,ataxiainhosp INDOMETHACINCOMPETESWITHLITHIUMFOR aftermedsareaddedinhospitaltoherlithium.Whatmedicationcouldcausethis? EXCRETIONANDCAUSESLITHIUMTOXICITY (2x) SYMPTOMS Lithiumexposureinfirsttrimesterofpregnancyincreasesriskofcongenital abnormalitiesinwhichorgan?(2x) HEART Lithiumcanberemovedviahemodialysisbecause?(2x) HASNOMETABOLITES Stable,steadystateLithiumlevelsaregenerallyobtainedwithin:(2x) 4-5DAYS Whichofthefollowingfactorsisapredictorofapoorresponsetolithium?(2x) RAPIDCYCLING Whatfactoristhoughttopredictapoorresponsetolithiumtreatmentforptswith MIXEDMANIC/DEPRESSEDEPISODE bipolardisorder?(2x) Psoriasisexacerbatedby:(3x) LITHIUM LiinducedpolyuriatxwithleasteffectonLilevel? AMILORIDE Lithium-inducedtremorisusuallyreducedbywhichmed? PROPRANOLOL Whichofthefollowingmedicationswasfirstusedasatreatmentforgoutandlater promotedbyjohncadefortreatmentofunstablemood? LITHIUM Medicationmostlikelytocausecognitivesideeffects,evenseizures,iftakenat sametimeasECT? LITHIUM ThiscardiovasculardisturbanceismostcommonforLithium: BENIGNTWAVECHANGES. GotoTableofContents 216 A32yoFcomestotheEDwithCCof2weeksofdiarrhea.Onexamsheisanxious andtremulousandisnotorientedtodateortimeoftheday.Shestatessheistaking “somedrug”forBipolardisorderandaddsthatshestarteddoublingherdosea LITHIUM monthagobecauseshe“wasn’tgettingbetterfastenough.”Shedeniesuseof drugs/ETOH.Whichmedicationwouldmostlikelycausethesymptomsdescribed? AptwhowaspreviouslystableonLithiumpresentswithsymptomsoftoxicityafter theirPMDstartsthemonaHTNmedicine.Whichofthefollowingistheisthemost REDUCEDRENALCLEARANCE likelymechanismofinteractionbetweenthelithiumandtheHTNmedication? Whatlabtestshouldbeconductedpriortoinitiationoflithiumtx? TSH Lithiumserumlevelsshouldbemonitoredbyevaluating: TROUGHLEVELS12HOURSAFTERLASTDOSE Whichmedcandecreasedserumconcentrationoflithium AMINOPHYLLINE BMDTxwithLix2yearsdevelopsrapidcycling.Whatlabtestshouldbedone? THYROIDFUNCTIONTESTS SEoftoxicserumlithiumlevels STDEPRESSION,QTCPROLONGATION,ATAXIA, TREMOR,DYSARTHRIA,NEPHROTOXICSX,STATUS EPILEPTICUS 24y/oFin2ndtrimesternowmanicw/nopsychoticfx’s.Hxof1episodeofmania, RESTARTLITHIUM diagnosedbipolarI.D/Clithiumwhenshedecidedtohavekids.WillingtobeginTx. Lithiuminducedtremorisusuallyreducedbywhichofthefollowingmeds? PROPRANOLOL BipolarptonlithiumandZoloftfor3yrs.Level0.8.Moredepressedandfatigued, lowenergylevel.IncreasingZoloftineffective.Nextstep: OBTAINTSHLEVEL Themostcommoncauseofseverepolyuriawithlithiumis: NEPHROGENICDIABETESINSIPIDUS Whiletakinglithiumpatientsshould: MAINTAINSODIUMINTAKE ApsychotropicwithsamepharmacokineticpropertiesinAsianAmericansandWhite LITHIUM Americans Administrationofactivatedcharcoalisineffectiveinoverdoseof: LITHIUM ACNSstructurethatislikelytosufferpermanentdamagefollowinglithiumtoxicity: CEREBELLUM Interferesw/clearanceoflithium IBUPROFEN CardiaceffectsoflithiumresemblewhatonEKG HYPOKALEMIA(LOWTWAVES) Predictorofpositiveresponsetolithiumprophylaxis HISTORYOFGOODINTER-EPISODEFUNCTION Inpatientsonlithium,whattypeofthyroiddysfunctioncanoccur? HIGHPREVALENCEOFTHEPRODUCTIONOFTHYROID AUTOANTIBODIES Intakeofthisincreaseslithiumlevels FLUOXETINE GotoTableofContents 217 Ptwhohasbeentreatedwithlithiumforbipolarshowsagoodresponsein stabilizationofmood,butreportsfeelingdull,slow,andunabletoconcentrate. Lithiumsideeffect? ABSOLUTELY! 57y/optw/hxofbipolardisorderhasbeenstableonlithiumfor10years,with averagelevelof0.8mEq/L.PtnowpresentstoERc/ofeelingnauseous.Ptisnoticed tobetremulousandtohaveanunstablegait.Shewasrecentlyprescribeda REDUCEDRENALCLEARANCE medicationforHTN.Lithiumlevelisfoundtobe1.5mEq/L.Itisassumedthatthis increasedlevelisduetoaninteractionbetweenthelithiumandthenew medication.Whatisthemostlikelymechanismforthisinteraction? Whichofthefollowinglaboratorytestsisessentialpriortoprescribinglithium? BUNANDCREATININE 55y/optwithguilt,anhedonia,insomnia,andsadmoodhasbeentreatedfor10 wkswithfluoxetine60mgqam.Hismoodandappetitehaveimproved,thoughhe stillhasdifficultieswithconcentration,hopelessness,andtearfulness.Hedeniesa h/omanicorpsychoticsymptoms.Themedicationmostlikelytoaugmentthe antidepressanteffectofhiscurrentregimenwouldbe: LITHIUM Ptonlithiumandpaxil.Lithiumisineffectivedespiteatherapeuticlevel.Whatdo youdo? DISCONTINUEPAXIL Whichnervoussystemstructureislikelytosufferpermanentdamagefromlithium OD? CEREBELLUM Lithiumcanraisewhatserumelectrolyte? calcium Methadone 22y/oheroindependentfemalediscoverssheispregnantandwantstodetox. Whatwaywouldyourecommend?(4x) METHADONEMAINTENANCEUNTILDELIVERYTHEN DETOXIFICATION Whatavgdoserangeofmethadoneyieldsbestresultsindecreasingillicituse?(3x) 60-100MG Ptinmethadonetxearnsnumberoftake-homedosesbasedoncompliancewith attendanceandparticipationingroups.Whatkindofinterventionisthis?(2x) CONTINGENCYMANAGEMENT Pregnantptdependentonheroinpresentsfortreatment,wantstodowhat’sbest METHADONEMAINTENANCEFORTHEDURATIONOF forbaby.Whatissafesttreatmentforbothmotherandunbornbaby?(2x) THEPREGNANCY Medthathaspotentialtodecreasemethadonebloodlevel:(2x) CARBAMAZEPINE Federaleligibilityrequirementsformaintenancetreatmentwithmethadonespecify thatanindividualmusthavebeendependentonopioidsforatleastwhatlengthof 1YEAR time? Adolattendsa“pharmparty”,takes2methadonetabs,laterfoundtohave decreasedrespirationsandisrushedtotheED.Whichmedcouldcausean interactionwhichcouldcausethisresponse? SERTRALINE GotoTableofContents 218 FactormostpredictiveofeffectivemethadoneTx TOTALDAILYDOSE Whichofthefollowingproducesbestoutcomeintermsofdrugconsumptionand criminalbehaviorforheroin-dependents? MAINTAININGOFMETHADONE 28y/optonmethadonemaintenancetherapydevelopsworseninganxietyandflu- likesymptomssinceswitchedfromvalproatetocarbamazepineforseizurecontrol2 INCREASETHEMETHADONEDOSE weeksago.Whatshouldbethenextstepinmanagement? 20y/optw/cancerpainisonamethadonemaintenanceprogram.Stafffeels GIVEPTMOREOPIOIDMEDTOACHIEVEADEQUATE requestforadditionalnarcoticsrepresentdrug-seekingbehavior.Recommendation? PAINCONTROLB/COFPT’STOLERANCE Duetoitsrateoforalabsorption,whatmostenhancestheeuphoriaproducedby benzodiazepineswithmethodone? DIAZEPAM Drug-druginteractionsinptstakingHIVmedsareparticularlyproblematicwith whichmedication: METHADONE Whatisthelowestdoseofmethadonethatsuppressesopioiddrughungerand inducesacrosstoleranceofillicitopiates? 80-120mg GeneralPsychopharmacology FDArequiresthatgenericsnotbesignificantlydifferentfromtheparent compoundsinwhatway?(5x) BIOEQUIVALENCE Twoantidepressantsaretestedaloneandasacombotreatmentagainstawaitlist controlgroupinptswithtreatmentresistantMDD.Bothmedsarefoundtohavea TWOTREATMENTSMAINEFFECTSANDAN significanttherapeuticeffectindividually,andthecombotreatmentismore INTERACTIONEFFECT efficaciousthanthesummedeffectsofeachmedgivenalone.Whathasbeen demonstrated?(2x) First-linetreatmentforrestlesslegsyndrome(2x) PRAMIPEXOLE Firstpasseffectreferstowhichofthefollowingaspectsofamed’smetabolism? (2x) PRESYSTEMICELIMINATION WhichisanNMDAreceptorantagonist?(2x) MEMANTINE Psychiatristiscalledtoevalaptonamedicalfloorwhohasdevelopedacute dysarthriaw/protrudingtongueandtorticollis.Whichmedissuspect?(2x) METOCLOPRAMIDE Ptwithflashbacks,nightmares,andinsomniar/tsexualtraumaisimproving slightlywithZoloftbutstillhavingnightmares,nextstepinmgmt.? Inptsw/recurrentdepression,successfulTxwithantidepressantsshouldbe followedbywhichTxstrategies? Prazosin CONTANTIDEPRESSANTATSAMEDOSE GotoTableofContents 219 TheuseofflumazenilfortreatingbenzoODislimitedby… THERISKOFINDUCINGWITHDRAWALSEIZURESIN BENZO-DEPENDENTPTS Inadditiontobenzos,whichclassofmedsisassocwithfallsinptsolderthan60? ANTIDEPRESSANTS Thepotencyofmedicationreferstowhichofthefollowingpropertiesofa medication? RELATIVEDOSEREQUIREDTOACHIEVEACERTAIN EFFEC 60yoptwithchronicschizophreniatakescogentinforneurolepticinduced parkinsonnowhasincreasedurineretentionandconfusion.Whatmedicationwould AMANTADINE bethebestalternativefortreatingthispatient’scondition? PtwithmultiplepastmedtrialsreportingextensiveSEswiththosemedshasbeen startedonfluoxetineandnowreportsseveresweating.Pt’sdepressionandanxiety ADDTERAZOSINTOPT’SMEDREGIMEN havesignificantlyimprovedon10mgdailybutptreports“mybeddingisdrenched everydaywhenIwakeup”.Mostappropriatenextcourseofaction? Mosteffectivetxfor“writer’scramp”(focaldystoniaassocw/writing) BOTULINUMTOXIN Mostofthebody’sserotoninislocatedwhere? GITRACT Commonsideeffectofacetylcholinesteraseinhibitors DIARRHEA Diphenhydramine’sabilitytotreatacutedystoniaisduetoactiononwhich receptor? MUSCARINIC-1 28y/owithBMDIIwantstousephototherapyfordepressiveSxtreatmentinwinter. CANBEUSEDBUTREQUIRESVIGILANCEANDCAREFUL Whatshouldyouadvise? TITRATIONOFDOSE Mirtazapine’ssideeffectsofsedationandweightgainarecausedbybindingto whichreceptors? HISTAMINE WhichmedisusedtotreathepCviralinfectionandisassociatedwithdepression, anxiety,andcognitiveimpairment? INTERFERON-ALPHA Inptswhosurreptitiouslyuseexcesssulfonylurea,whichofthefollowingsubstances TOLBUTAMIDE canbeadministeredtor/opossibleinsulinoma? Concurrentuseofphenelzineandmeperidinecancausehypermetabolicreaction secondarytowhat? INDIRECTPHARMACODYNAMICEFFECTSATA COMMONBIOACTIVESITE WhichofthefollowingmedicationsinhibitstheenzymeETOHacetaldehyde dehydrogenase? DISULFIRAM Buprenorphine’sadvantagesoverclonidine,inthemanagementofpatientswith opioidwithdrawal,includebettercontrolofwhichofthefollowingsymptoms? CRAVINGS Theeffectsofcaffeineonwhichofthefollowingresultsinincreaseddopaminergic activity? ADENOSINERECEPTOR GotoTableofContents 220 Therapeuticindexisarelativemeasureofwhichofthefollowingcharacteristicsofa SAFETY medication? WhichofthefollowingagentsusedtotreatpatientswithAlzheimersdiseasehasa mechanismofactionrelatedtoanantiglutaminergicmechanism? MEMANTINE FreeRBCsprotoporphyrintestinthescreeningforintoxifiicationwith: LEAD Whatisthemostcommonreasonptsdiscontinuevalproate? WEIGHTGAIN Asafemedforthefetusofpregnantwomanduringagitationofamanicepisode: HALDOL Pharmacokineticfactorthatdeclinesw/aging? GLOMERULARFILTRATIONRATE Patients>65y/oaremoresensitivetopsychmeds.Whatphysiologicchangeoccurs DECREASEDPHASE1OXIDATION withaging? AgitatedptgetsrapidtranquilizationinED.UsingoralconcentrateinsteadofIMor IV haswhatadvantage? DECREASEDFEELINGSOFHELPLESSNESS Psychoticptgivenhaldol,acutelaryngospasm.Inadditiontointubation,give: COGENTIN Differenceintherateandextenttowhichabrandnamevsagenericdrugbecomes BIOEQUIVALENCE availabletothesiteofaction,giventhesamedoseandcondition,ismeasuredas: Ptonmethadonescreenpositiveforalcohol,achieveabstinenceofalcoholby coadministeringwhatwithmethadone? Disulfram SchizophrenicOD’donantipsychotics,hasEPSandurinaryretention.Tx? AMANTADINE Amantadineisconsideredeffectiveintreatingptswhohavewhichsideeffectsof antipsychotics? PARKINSONISM Whichmedreducestheacutesymptomsofneuroleptic-inducedakathisia? PROPRANOLOL Whatherbal(phytomedicinal)isusedasahypnotic? VALERIAN TheFDArequiresthatpharmaceuticalcompaniesdemonstratethatagenericdrugis BIOEQUIVALENCE notsignificantlydifferentfromtheparentcompoundinwhichway? Thetherapeuticindexofadrugreferstothe: RELATIVEMEASUREOFDOSINGTOXICITYTOSAFETY Whatistheunderlyingmechanismofactionofsildenafilinerectiledysfunction? ENHANCEMENTOFNITRICOXIDE Initialpsychiatricinterventionfor50-year-oldmarriedmanwithEDduringsexbut normalmasturbatoryability,otherwisegoodmarriage,andnormalevaluationby PCP? ASKPTTOBRINGWIFETODISCUSSBEHAVIORAL EXERCISES GotoTableofContents 221 Whatsubstanceisassociatedwithariskofbleedingwhentakenwithanti-platelet drugsorwarfarin? GINGKOBILOBA Clonidinemechanismofaction: ALPHA-2AGONIST 42y/opthasprimaryinsomnia.Ptcomplainsofdifficultyfallingasleep,butthen sleepsthroughthenight.Whichofthefollowingwouldbethebestmedicationto prescribeforthisptafteraddressingsleepissues: ZALEPLON CombineduseofLithiumandSSRIisknowntoincreasetheriskofwhichofthe followingconditions? SEIZURES 28y/optwantstostopsmokingwiththehelpofanicotinereplacementproduct.Pt planstohaveorthodontiawithinthenext2months;haspsoriasis;andhasmultiple NICOTINELOZENGES environmentalallergiesthatoftencausenasalstuffiness,sorethroats,anditchy, wateryeyes.Nicotinereplacementbest? Prepubertalchildrendifferfromadolescentsandadultswithregardstodosingof livermetabolizedmedicationrequiring? 35yearoldwomanreportshistoryofrecurrentdepressionalwaysbeginningin fall/earlywinterandremitbyspring.Sheistryingtobecomepregnant,what’s besttx? HIGHERWEIGHTADJUSTEDDOSESOFMEDICATION LIGHTTHERAPY PsychologicalTesting Whattestwouldbeconsideredmostusefultospecificallyevaluateconcept formation,reasoning,andexecutivefunctioning?(4x) WISCONSINCARDSORTINGTEST(WCST) Mostappropriatebriefscreeninginstrumentthataptcanfillbyhim/herselfat physician’sofficetoscreenfordepressionis(3x) BECKDEPRESSIONINVENTORY Whichtestisanobjectivemeasureofpersonalityinadultsandishelpfulin confirmingdiagnosisofpersonalitydisorder?(3x) MILLONCLINICALMULTIAXIALINVENTORY(MCMI) Whichofthefollowingtestswouldbeconsideredmostusefultospecifically evaluateconceptformationwithsetshifting?(2x) WISCONSINCARDSORTINGTEST(WCST) MMPIdoeswhat?(2x) IDENTIFIESMAJORAREASOFPSYCHOPATHOLOGIC FUNCTIONING 15y/optw/physicalcomplaints,decreasedappetite,irritability,thoughtsof death,anhedonia.WhichmedisFDA-approvedforfirstlinetx?(2x) ESCITALOPRAM Wisconsincardsortingtest(WCST)assesses(2x) ABSTRACTREASONINGANDFLEXIBILITYINPROBLEM SOLVING Anappropriatepurposeforprojectivetestingisto:(2x) DETECTINGTHEPRESENCEOFSUBLEPSYCHOTIC THOUGHTPROCESSES Whatpsychologicaltestdeterminesneuropsychologicimpairment?(2x) HALSTEAD-REITANBATTERY GotoTableofContents 222 Abroad-basedratingscaleforpsychiatricsymptomsinchildren?(2x) CHILDBEHAVIORCHECKLIST(CBCL) Whatpsychologicaltestsmeasuretest-takingattitudesattimeofexam(2x) MMPI(MINNESOTAMULTIPHASICPERSONALITY INVENTORY)VALIDITYSCALE Whatmostseriouslythreatenstheexternalvalidityofaresearchstudy?(2x) ASTUDYPOPULATIONTHATISNOTREPRESENTATIVE OFTHEPOPULATIONTOBETREATED Whatisthemostcommonbiologicalcauseofprenatalneurotoxicitylinkedtothe developmentofintellectualdisability(mentalretardation)? ALCOHOLEXPOSURE Mostspecifictestforassessingexecutivefunctioning?x2 WISCONSINCARDSORTINGTEST(WCST) Whatneuropsychtestreliesoninhibitionoftheoverlearnedbehaviorstoassess executivefunctioning? STROOPCOLORWORDTEST PtistakingMMPI-2intentionallyendorsesitemsthatreflectsocialdesirability. Whichscalestocatchthispatternofitemendorsement? LIESCALE Researcherdevelopingtestforworkingmemoryinschizophrenics.Inadditionto measuringimmediatememory,whatelseshouldtestmeasure? ATTENTION SomeonetakingtheContinuousPerformanceTest(CPT)isaskedtopressakey wheneveranyletterexcept“X”isdisplayedonthescreen.Theletter“F”isdisplayed ATTENTION andthepatientfailstopressakey.Mostlikelyaproblemwith… Whyistherelimitedvalueofserialsevensasatestofconcentration? SUCCESSFULPERFORMANCEREQUIRESARITHMETIC SKILL Nameoftestwhereptistoldtonamethecolorsinwhichthewordsareprinted ratherthanreadingthewordsthemselves STROOPCOLORWORDTEST Whattestrequiresrapidandefficientintegrationofattention,visualscanning,and cognitivesequencing? TRAIL-MAKINGTESTTMT WheninterpretingIQtestresults,whatindicatesneedforfurtherassessment? VERBALSCORESIGNIFICANTLYHIGHERTHAN NONVERBALSCORE IQscoresgenerallyconsideredtobestablebeginningat: 7YEARSOLD Toobtainadditionalaboutunconsciousdrivesandpsychodynamicprocesses,which THEMATICAPPRERCEPTIONTEST(TAT) testwouldbemosthelpful? Whichofthefollowingtestsisusedforassessmentofexpressivelanguage? BOSTONNAMINGTEST TesttodiscriminatecognitivedifficultiesinAlzheimer’sfromthoseindepression BOSTONNAMINGTEST TestforanxietythatdoesnotincludeQsaboutphysicalsxsuchastachycardiaand diaphoresiswouldbeconsideredlackinginwhat? CONTENTVALIDITY Thisisconsideredasanunstructuredpsychologicaltest: RORSCHACHINKBLOT GotoTableofContents 223 Psychiatristwishestoassessapt’spremorbidintellectualfunctioning.Whichofthe READINGSUBSETOFTHEWIDERANGEACHIEVEMENT followingtestswouldbebestforthispurpose? TEST Awarenessofownsymptomsratedby: GLOBALASSESSMENTSCALE Whichofthefollowingisthebesttestforgeneralassessmentofapatient’s psychiatricsymptompatterns? SYMPTOMCHECKLIST-90-REVISED(scl-90) Measuresattention,concentration,andfreedomfromdistractibility: WECHSLERADULTINTELLIGENCESCALE(WAIS) Whichofthefollowingstatementsspecificallytestsconcentration? SAYTHELETTERSOFTHEALPHABETBACKWARDS STARTINGWITH“Z” Judgmentbyexpertsthatitemsonatest“makessense”isanexample FACEVALIDITY Bender-Gestaltdiagramsassesses: NEUROPSYCHOLOGICALIMPAIRMENT Whichtestassessesabilitytoattendtoataskwhileinhibitinginterferingstimuli? STROOPCOLORWORDTEST Whatwouldbeausefulscreeningtesttoevaluatean8y/ochild’sacademic performance? WIDERANGEACHIEVEMENTTEST(WRAT) Whatdoestheclockdrawingtasktest? ATTENTION,VISUOSPATIAL,PLANNING,EXECUTIVE FUNCTION(NOTorientation) PtscoresonrevisedWechsleradultintelligencescale(WAIS-R)subtestsforpicture arrangementandblockdesignareverylowcomparedtoscoresonothersubtests. Mostsuggestiveof: LESIONINNONDOMINANTHEMISPHERE Testtoassessintelligencein4y/o? STANFORD-BINET Stanford-Binetmostsimilarto WECHSLERINTELLIGENCESCALEFORCHILDREN–III Whichassessmentinstrumentbestmeasurescognitivefunctioningina4yearold child? WECHSLERPRESCHOOLANDPRIMARYSCALEOF INTELLIGENCE-REVISEDWPPSI-R Testmorespecifictoidentifyspecificlearningdisabilityinchildw/fullscaleIQof93 WOODCOCK-JOHNSONPSYCHO-EDUCATIONAL onWISC-III BATTERY–REVISED 25y/oMscoresinMMPIareallnormalexceptforelevatedscoresonthe depressionandpsychastheniascales.Thissuggests: HASDEPRESSIONWITHANXIETYANDOTHERNEUROTIC SYMPTOMS Objectivepsychologicaltest MMPI Measurestest-takingattitudes MMPI Thematicapperceptiontestisusedfor INTERFERINGMOTIVATIONALASPECTSOFBEHAVIOR Whatpsychtestswouldbeconsideredthemostunstructured? RORSCHACHINKBLOT GotoTableofContents 224 Whichtestscanbeusedforprojectivepersonalitytesting? RORSCHACH,DRAWAPERSON,THEMATIC APPERCEPTION(NOTMMPI) WhichisaProjectiveAssessmenttest: THEMATICAPPERCEPTIONTEST(TAT) Thepersonalitytestinwhichaptisshownpicturesofsituationsandaskedto describewhatishappeningineachpictureis: THEMATICAPPERCEPTIONTEST(TAT) Thistoolbestmeasuresthedegreeofself-careinchildrenwithMR: VINELANDADAPTIVEBEHAVIORSCALE 8yochildrecentlyhadWechslerIntelligenceScaleforChildren(WISC-IV)and receivedfullscaleIQof60.Whichadditionaltestswoulddetermineifchildmeets criteriaforintellectualdisability(mentalretardation)? VINELANDADAPTIVEBEHAVIORSCALES,2NDEDITION (VABS-II) Apsychologicaltestthatdemonstrateshighreliability: WECHSLERADULTINTELLIGENCESCALE(WAIS) Testcorrelatesmoststronglywpremorbidfcninptwearlydementia WECHSLERADULTINTELLIGENCESCALEIIVOCABULARY TEST AknownlimitationoftheMinnesotaMultiphasicPersonalityInventory? NORMSDONOTACCOUNTFOROUTCOMESBASEDON RELIGIONANDRACE Computerassistedcontinuousperformancetestingisusedtoassesswhat? ATTENTION Neuropsychologicaltestthatspecificallyevaluatesimpairmentsinfrontallobe functioninadults? WISCONSINCARDSORTINGTASK(WCST) Onwhattestwouldperseverativeerrorbeconsideredaspecificoutcomeofclinical WISCONSINCARDSORTINGTEST(WCST) relevance? 75y/optpresentswithsymptomsofdementia.Especiallypoorperformanceon whichofthefollowingneuropsychologicaltestsmightsuggestaDxofvascular dementiaratherthanAlzheimer’sdementia? Anappropriatepurposeforprojectivetestingisto: Whichofthefollowingisaptself-reportedquestionnaire? Patientisshownapictureofapersonstandingnexttowindowandisaskedto describewhathappened.Whattest? WISCONSINCARDSORTINGTEST(WCST) Detectthepresenceofsubtlepsychoticthought processes BECKANXIETYINVENTORY THEMATICAPPERCEPTIONTEST(TAT) MSE Questiontoaskwhenevaluatingforimmediaterecall(3x) CANYOUREPEATTHESESIXNUMBERS? Termforthoughtsconnectedbysound/wordsratherthanbytheirmeaningandis CLANGASSOCIATION classifiedasanimpairmentinthoughtprocess:(3x) Whattaskisusefulinevaluatingapt’sabilitytoconcentrate?(2x) PERFORMINGSERIAL7’S WhichareaofMSEreliesprimarilyonpatientreport? MOOD GotoTableofContents 225 PsychMDaskedpt“whatwouldyoudoifyoulostyourprescription?”Thisquestion JUDGMENT primarilyassesses: Whenpsychiatristasksaboutmania,ptresponds,“thatsoundsexactlylikemy cousin,”andproceedstotelllongstoryaboutcousinbutdoesn’tanswerthe psychiatrist’srequest.Thisisanexampleof: TANGENTIALITY Biologicalconsequencesofpsychologicalstressaffectwhichmechanism? NEURO-IMMUNO-ENDOCRINEFUNCTION “WhenIhearthenews,thenewscasteristalkingaboutme.”Thisrepresents? IDEASOFREFERENCE Disharmonybetweenfeelingtoneandspeechcontent INAPPROPRIATE Psychiatristasks“Howmanyquartersarein$15?”,examiningwhatability COGNITION Whichofthefollowingisthemostsignificantproblemwiththeuseoftheglobal assessmentoffunctioningscale? ITCONFOUNDSSYMPTOMSANDFUNCTIONING Povertyofspeechandpovertyofcontentareaspectsofwhichofthefollowing conditions? ALOGIA Whichofthefollowingrepresentsadisorderofthecontentofthought? OBSESSIONS Askingapatienttoreciteaseriesofnumbersinreverseorderisastandardtestof: CONCENTRATION Thedifferencebetweenanideaofreferenceandadelusionofreferenceisthatthe HELDWITHLESSCONVICTION formeris: Aprofoundbreakdowninboththelogicalconnectionbetweenideasandtheoverall DERAILMENT senseofgoal-directednessofspeechiscalled: Thepurposeofaskingapttostartat100andcountbackwardsby7’sistomeasure CONCENTRATION whichofthefollowing? Aptwithchronicmotorandvocalticsmakesrecurrentobscenegestureswhichare intrusiveandnotrelatedtotheconversationoranystimuliintheenvironment.The COPROPRAXIA gesturesarebestdescribedas: Adisorderofcontentofthought PARANOIA OnMSE,thoughtprocesswithlackofgoaldirectedness,excessivedetails,and difficultywithclosuredescribesathoughtpatternof: CIRCUMSTANTIALITY Askingapt,“whichonedoesnotbelonginthefollowinggroup:13pennies,apiggy bank,andacow?”isatestofwhichdomain: ABSTRACTREASONING Askingthepatient“howareanappleandanorangealike?”assesseswhichofthe followingcognitivefunctions? ABSTRACTREASONING Askingapatienttointerpretthephrase“Don’tcryoverspilledmilk”testswhat? ABSTRACTTHINKING GotoTableofContents 226 Aptreports,“undercoveragentsareallthere,andthey’regonnakillme.”Pt’s commentisbestdescribedas: ADELUSION Ptisnonsensicalbutisrhyming.Whatisthiscalled? CLANGASSOCIATION Askingptwhattheywoulddoinahypotheticalsituationistestingwhat? JUDGMENT DisorderofwhatelementofMSEisevidencedbypatientrepeatedlyreferringback totheanswertoapreviousquestion? THOUGHTPROCESS Elderlyptwithprofoundapathy,howdoyoudistinguishdepressionfromexecutive CLOCKDRAWING dysfunction? “It’sverynicetoreadyou” Paraphasia PsychologicalTheory Psychicdeterminismis(2x) BEHAVIORSRESULTFROMUNCONSCIOUSMIXOF DRIVES,DEFENSES,OBJECTRELATIONSHIPS,SELFDISTURBANCES Mostimportantprotectivefactordeterminingpreschoolchild’sreactionto disaster(2x) PARENTALFUNCTIONING Riskfactorinfluencingpsychologicaloutcomeofchildfollowingdeathofparent: (2x) PRIORCONFLICTUALRELATIONSHIPBETWEENCHILD ANDDECEASEDPARENT Piaget’scontributiontodevelopmentwasatheoryexplainingwhatphenomenon? HOWINDIVIDUALSLEARNANDUNDERSTANDTHE (2x) WORLD 8y/oboysees2bottleswsameamountofliquid.Thecontentofoneispouredin shorterwiderglassandtheothertoalongernarrowglass.Whenaskedwhichhas CONSERVATION moreliquidhesaysit’sthesame.AccordingtoPiagetheisexhibiting:(2x) Bestdescribestheroleoftheobservingego: MOBILIZESDEFENSEMECHANISMSINRESPONSETO SIGNALANXIETY Accordingtothetheoryofself-psychology,amajorcauseofmentalillnessis: ABSENCEOFAGE-SPECIFICMIRRORINGRESPONSES Accordingtopsychoanalytictheory,thetermprimaryprocessthinkingrefersto mentalactivityexemplifiedby? UNCONSCIOUSTHOUGHTSTHATDONOTMAINTAIN LOGICALCONNECTIONS Acentralpremiseofobjectrelationstheory: THEMINDISINHABITEDBYMENTALREPRESENTATIONS OFSELFANDOTHERS Psychologicalfunctionofamedication ACTSASACONTAINERFORTHEPATIENT’SPROJECTED ANXIETIESABOUTBEINGDEFECTIVE Accordingtosociobiologictheory,whattermdescribesbehaviorsatthelevelofthe ALTRUISM individualthatmaximizefitnessatthelevelofthegene? GotoTableofContents 227 OttoKernberg’smodelfortxofpatientswithnarcissisticpersonalitydisorderdiffers INTEGRATINGIDEALIZATIONANDTRUSTWITHRAGE fromthatofKohutinthatinKernberg’smodel,thegoalsofpsychotherapyinclude: ANDCONTEMPT Asconceptualizedbyself-psychology,whichofthefollowingisthemostproblematic SHAME reactionapatientcanhavewhenattemptingtofulfillaself-objectneed? AccordingtoAaronBeck,theprimarydefectindepressioninvolveswhichofthe following? COGNITIVEDISTORTION Piagetinterestedin: HOWACHILDARRIVESATANSWERS Intermsofthenormalfunctioningofthepersonality,AnnaFreud’scontributions wereintherealmof: DEFENSEMECHANISMS Secureattachmentinaninfantisassociatedwithwhichofthefollowingoutcomes? EMOTIONALANDSOCIALCOMPETENCE Whichofthefollowingdescribescorenarcissisticcharacterpathologyaccordingto Kernberg’smodel? AFUSIONOFTHEIDEALSELF,THEIDEALOBJECT,AND THEREALSELFRESULTINGINTHEDEVALUATIONOF OTHERS 3y/ogirlhurtsherselfw/atricycle.Thenshehitthetricycleandasks,“Whydidyou ANIMISM hurtme?”Whichthoughtprocessdoesthisbehaviorexemplify? Experimentalsubjectswereaskedtomakeajudgmentbutgaveawronganswerin spiteofknowingtherightonebecausetheydidn’twanttodisagreewithresponses CONFORMITY ofotherparticipants.Thisphenomenonis: Resilientindividualswhodowellindevelopmentalcoursethroughlifedespitebeing HAVINGTHEABILITYTOFIND,USEANDINTERNALIZE athighriskfornegativeoutcomesarethoughttobeprotectedinadulthoodmost SOCIALSUPPORTS by: Accordingtotheoriesofinfantsocialization,successfulattachmentmostlikely promotessurvivalthroughwhichofthefollowing? CREATINGABONDSOTHATTHEADULTWILLPROTECT THEINFANTFROMDANGER AccordingtoC.G.Jung,animarefersto: MAN’SUNDERDEVELOPEDFEMININITY 29y/ocomplainsaboutmistreatmentfromboyfriend.Proudofgenerousnaturebut complainshowlittleshegetsback.Therapistfindsithardtomakeherself-reflective MASOCHISM aboutherroleinthis,getsfrustratedandfatigued.Patientdisplays: Childdancesformother&basksingleamofmother’seyes.Accordingtoself- psychology,experiencing: MIRRORING Earlybehavioristtheorypromotedwhat OBJECTIVEPSYCHOLOGICALRESEARCH Whattermdescribestherolethatothersperformfortheindividualinregardto mirroring,idealizing,andtwinshipneeds? SELF-OBJECT Thefundamentaldevelopmentalneedofallpersonsformirroring,validation,and affirmationiscentraltowhichpsychoanalytictheory? SELFPSYCHOLOGY GotoTableofContents 228 66y/osentthreateningletterstothepresident,thinksCIAisfollowinghim.Wife similarconvictions,dependentonhusband,passive SHAREDPSYCHOTICDISORDER Activitylevel,regularity,approach-withdrawaltonewsituations,adaptability, persistenceareexamplesof: TEMPERAMENTALVARIABLES Kohut’stheoryofpersonalityisbasedon? THEINDIVIDUAL’SNEEDFOREMPATHICINTERACTION WITHSELF-OBJECTS Theoristintroducedtheconceptsofintroversionandextroversion: CARLJUNG TherapyinterventionmostfrequentlyassocwKohut’sself-psychology: EMPATHICVALIDATION CartesiandualismfromthetheoriesofRenéDescartesrefersto POTENTIALOFHUMANNATUREFORBOTHGOODAND EVIL Studiesinwhichmonkeysareraisedinvaryingdegreesofisolationhavebeen importantincontributingtowhattheoriesofhumandevelopment? THESIGNIFICANCEOFATTACHMENT Whichoffollowingstatementsidentifieswhatbothtraditionalhealingandmodern psychotherapeuticpracticesmayhaveincommon: THETHERAPISTHELPSTHEPATIENTEXPERIENCEAN EMERGINGSENSEOFLEARNINGANDMASTERYOVER THEPROBLEM WhatisachievedinPiaget’sstageofconcreteoperations? CONSERVATION 4y/ochildupsetwhenicecreammelts.10y/oputsitinfreezerandtellshimitwill beok.4y/oinsistsitisruined.Piaget’sconceptofthisis: CONSERVATION(ALSOREVERSIBILITY) AnimisticthinkingischaracteristicofwhichofPiaget’sstagesofcognitive development? PREOPERATIONALTHOUGHT AccordingtoKohlberg,moraljudgmentmadebyolderschool-agechildrenarebased PLEASINGTHOSEINAUTHORITY largelyonwhichofthefollowing? Achildwithautismisplacedinatherapeuticfosterhomewhereaconsistent responseismadetoagivenactionwiththegoalofimprovingthechild'sfunctioning. BEHAVIORISM Thistechniquederivesfromwhichofthefollowinglearningtheories? Masturbationinadultsasviewedbycontemporarypsychiatryisbestdescribedas: PSYCHOPATHOLOGICALONLYIFITISCOMPULSIVE Normalautism,symbiosis,differentiation,andpracticingareamongthe developmentalsubphasesofseparationandindividuationproposedbywhat theorist? MARGARETMAHLER AccordingtoKohlberg,thehighestlevelofmoralreasoningisbasedon considerationof UNIVERSALETHICALPRINCIPLES Winnicott’snotionofcapacitytobealoneinpresenceofanotherpersonpertainsto: MAINTENANCEOFONE’SIDENTITYAMONGSTOTHERS GotoTableofContents 229 PerPiaget,Conservationistheabilitytodowhat? UNDERSTANDTHATOBJECTSORQUANTITIESREMAIN THESAMEDESPITEACHANGEINPHYSICAL APPEARANCE WithrespecttoRotter’ssociallearningtheory,whichofthefollowingstatements bestdescribeshavinganinternallocusofcontrol? BEHAVIORISSHAPEDBYANINDIVIDUAL’S EXPECTATIONTHATITWILLREALIZEAVALUEDGOAL. Unconsciousthoughtsthatdonotmaintainlogicalconnections ACCORDINGTOPSYCHOANALYTICTHEORY,THETERM PRIMARYPROCESSTHINKINGREFERSTOMENTAL ACTIVITYEXEMPLIFIEDBYWHICHOFTHEFOLLOWING? WhichisafirstranksymptomaccordingtoKurtSchneider? VOICESARGUING Duringtherapy,therapistcoughswhilepatientisspeaking.Ptangrilystates,"ifyou disagreewithmejusttellme,butdon'tbeapassiveaggressivejerk!"Therapist interpretsthatptisconsistentlytreatingthetherapistlikeaggressor.Whichbest describesthistherapymodality? TRANSFERENCEFOCUSEDPSYCHOTHERAPY AccordingtoWinnicott,sufficientattunementandresponsivenesstoachild'sneeds allowingthechildtobecomeawareofhisowndrivesisreferredtoas? good-enoughparent? EriksonianStages AccordingtoErikson,person>65wsenseofsatisfactionthatlifewasproductive/ worthwhilehassuccessfullymanagedpsychosocialtaskofdeveloping:(4x) INTEGRITY AccordingtoErikson,achildwhostrivestobecompetentbylearningnewskills, takingprideinresultsiswhichstage?(AlsocorrelatedwiththeFreudianstageof latency)(3x) INDUSTRYVSINFERIORITY Erikson’spsychosocialstageinwhichapersoninvestenergyintoestablishing, caringfor,andguidinginthenextgeneration?(2x) GENERATIVITYVSSTAGNATION Eriksontheorizedthatasuccessfuldevelopmentaltaskinthe40-60y/ogroupis to?(3x) FEELUSEFULTOSOCIETYTHROUGHBEHAVIORSTHAT PROTECTFUTUREGENERATIONS AccordingtoErikson,thepredominantemotionalissueinnormal,school-aged childrenis:(2x) PERSONALWORTHANDCOMPETENCE 10y/optreportshecollectsbaseballcards.Childisexcitedb/cheisonlyonein hispeergroupwhoownsseveralcards.AccordingtoErickson,what developmentaltaskaremostrelevantforthischild?(2x) INDUSTRYVS.INFERIORITY Achievingsenseofself-controlandfreewill,strugglingbetweencooperationand willfulness(Erikson) AUTONOMYVS.SHAMEANDDOUBT GotoTableofContents 230 A23yoptbeganpsychotherapyduetofeelingsofinadequacyanddepressioninthe contextofworkinginacoffeeshopsincegraduatingfromcollegeanddeferring medicalschoolacceptance.Thepthasbeenhavingconflictswithparentsoverhis IDENTITY ambivalenceinbecomingaphysician.Whichofthefollowingisthemostlikely developmentaltaskwithwhichtheptisstruggling? Compulsions&obsessionsarerelatedtodevelopmentdisturbanceduringwhichof Erikson’spsychosocialstages? AUTONOMYVSSHAMEANDDOUBT Eriksonianphasecorrespondw/Freud’sanalphase AUTONOMYVS.SHAMEANDDOUBT Eriksoniantaskduringage40-60is? Generativityvs.Stagnation PsychoanalysisandFreud Freud’spsychologicaltheoryofdevelopment(2x) DRIVETHEORY Inwhatdevelopmentalperioddoesachildseehe/sheisachildofhis/herparents& thatparentshavearelationshiptoeachothernotsolelyrelatedtotheirrolesas PHALLIC parents? AccordingtoFreud,whatisadreamthatisrememberedonwakening? MANIFESTDREAM Classicalpsychoanalytictheorysayspleasureanadultmighttakeincontrolling ANALRETENTIVE others/makingorderofchaosrelatestowhichpsychosexualstageofdevelopment? Accordingtocontemporarypsychoanalytictheory,frombirthto18months,children BIOLOGICALPROCESSESANDBODILYSENSATIONS experienceanemerging“self”asaresultofwhatevent? COMETOHAVEAPSYCHOLOGICALMEANING Whatisthecombinationofseveralunconsciousimpulses,wishes,orfeelingsthat areattachedtoasingledreamimage? CONDENSATION MelanieKleindifferedfromFreudinheremphasisonwhatfactor? EARLYOBJECTRELATIONS Freudsaysdepressionisangerturnedinwardagainstselfdueto: IDENTIFICATIONWITHTHELOSTOBJECT Freudsaysthatboysresolveoedipalcomplexby: IDENTIFYINGWITHFATHERS Whatdevelopmentalperioddoesthechildrealizehe/sheisthechildofhis/her parentsandthechild’sparentshavearelationshipwithoneanother? LATENT Freudbelievedpthadfantasiesofincestwithopposite-sexparentscoupledwith feelingsofjealousytowardthesame-sexparentduringwhichstage: PHALLIC AccordingtoFreud,whichpsychosexualstageisassociatedwithaprimaryerotic focusonthegenitalareaandunconsciousfantasiesofsexualinvolvementwiththe opposite-sexparent? PHALLIC Whichegodefenseisseenwhenanadolescentbelittlesparentsinordertodefend againstregressivepulltowardchildhood? REVERSALOFAFFECT GotoTableofContents 231 Thismodeldividesthemindintoconscious,preconscious,andunconscious? TOPOGRAPHICAL Ptabletorecallhisaddressafterbeingpromptedtodoso.AccordingtoSigmund Freud,thisinformationisstoredatwhatlevelofthetopographicmodel? PRECONSCIOUS Explorationoftransferenceneededforreparativeemotionalexperience psychotherapeutictreatment? PSYCHOANALYTICPSYCHOTHERAPY Tendencyforgroupstoarriveatmoreextremedecisionsthanforindividualgroup membersalone GROUPPOLARIZATION DefenseMechanisms Handwashingritualsaremostrelatedtowhatdefensemechanism?(4x) UNDOING Adefensemechanismcharacterizedbyaselfofobjectrepresentationthatis disavowedbyplacingitintosomeoneelse,andinducingthelatterto unconsciouslyidentifywiththeself/objectrepresentation:(4x) PROJECTIVEIDENTIFICATION Youngmanrecountshowhisfatherkickedhispuppytodeath,noemotionwhen tellingthetherapistthisdespitetherapist’supsetresponse.Defensemech?(3x) ISOLATIONOFAFFECT Semiconsciouslydivertingattentionfromaconflictinordertominimize discomfortisanexampleofwhatdefensemechanism?(3x) SUPPRESSION Whichdefensemechanismmostrelevanttoetiologyofdelusionaldisorders(like paranoia)accordingtopsychodynamictheory:(2x) PROJECTION Aparentwhojustlearnedthatherchildhasbeeninjuredandtakentothe hospital,arrangesforaneighbortocareforherotherchildrenandthenrushedto SUPPRESSION thehospital.Whatdefensemechanismdidtheparentusetohandleherownfear? (2x) Defensemechanism:atransientreturntoearlierbehaviorscharacteristicofearlier stageofdevelopmentinresponsetostress/conflict,despiteoverallmaturation REGRESSION (2x) Accordingtopsychoanalytictheory,feelingsofpersecutionaremostreflectiveof whichofthefollowingdefensemechanisms? PROJECTION Defensemechanismthatinvolvesinternalizingthequalitiesofanobject? INTROJECTION Patientwithmurderousimpulsestowardsaneighborgivestheneighborabouquet offlowers.Thisisanexampleof: REACTIONFORMATION Coupleintherapyreviewargumentatfamilyreunion,husbandtoldhissister-in-law thathiswifewassuperiortoherineveryway,thewifeexpresseddisapproval, TURNINGAGAINSTSELF husbandbecamequietandlaterfelldownaflightofstairs.Whatdefense mechanismisthis? GotoTableofContents 232 ManagementofpatientindenialimmediatelyafterMI: SUPPORTINGTHEPATIENT,UNLESSDENIALINTERFERES WITHCARE Perpsychoanalytictheory,unacceptableaffectsandimpulsesarecommonly gratifiedinsociallyacceptablewaysthrough: SUBLIMATION 30y/ointherapystruggleswithfeelingsofambivalenceaboutmom.Momnowhas SETASIDEANIGHTOFTHEWEEKTOHAVEDINNER metastaticBrCA.Ifthepatientusesanticipationasadefensemechanism,shemight: WITHMOMTODISCUSSMOM’SRXNTODIAGNOSIS MajorpsychologicaldefensemechanismthatdeterminestheformandqualityofOC REACTIONFORMATION symptomis Onegroupmemberalternatesbetweenbeingthe“scapegoat”forthegrouporthe “spokesman”forthegroup.Theseeventsareagroupversionofwhat? PROJECTIVEIDENTIFICATION Whenaskedaboutacoworkerafterarecentconflict,apatientstates“Iharbornoill feelingstowardhim,buthetrulyhatesme.”Theisexampleofwhichdefense PROJECTION mechanism? Disassociationiswhattypeofdefensemechanism? NEUROTICDEFENSE Ptisannoyedbyfamily’sexpressionofconcernforhiscondition,saying,“whatthey DEVALUING aresayingisallinthetalk.”Whatdefensemechanismisthis? 7y/ostatesheknowsDaddied,butwhydidn’thecometothebirthdayparty? Defensemechanism: DENIAL InVaillant’smodeloflifespandevelopment,whatisclassifiedasamaturedefense mechanism: HUMOR Pt’swifestateshedrinksalmosteverynight.Ptstatesheneverdrinkstoexcess, neverdrinksoutsidethehome,neverneedsaneyeopener,anddrinkingdoesnot affecthisworkperformance.Thisisanexampleofwhichdefensemechanism? DENIAL Supportivepsychotherapyclassicallyinvolvessupportingandacceptingthe patient’s: DEFENSEMECHANISMS Achildisjealousoftheoldersibling’saccomplishmentandbecomeslessjealous whenhe(thepatient)accomplishessomething.Whichdefensemechanismisthis? SUBLIMINATION GotoTableofContents 233 Therapy 32y/oFwmixedanxiety/depressionworkingwellinsupportive-expressive psychotherapyonceweeklyforpast3months.Focusonissuesrelatedto childhoodneglect/abusesheexperienced,howtheseimpactcurrentrelationships. Inonesession,silent/tearful.Withencouragementfromtherapist,reportsher18APOLOGIZEANDACKNOWLEDGETHATTHESILENCE month-olddaughterhospitalizedwmeningitis;sheisupset,worried.Therapist HADFELTHURTFULTOTHEPATIENT listenssilently.Ptleavessessionearly,missesnextsession.Followingtime,sheis angry,accusestherapistofbeinguncaring/insensitivefornotexpressingconcern aboutherchild/empathizingwherdistress.Therapist’simmediateresponse shouldbe?(2x) BusinessexecutivehospitalizedforbleedingulcerrepeatedlyargueswithawelllikedheadnurseandthreatenstoleaveAMA.BestactionforC&Lpsychiatristis: (2x) LISTENTOPT’SCOMPLAINTSACKNOWLEDGEHIS DISCOMFORTWITHTHEPASSIVEPOSITIONTHATHEIS UNACCUSTOMEDTO Commonthemeinpsychotherapyintheelderly:(2x) LOSS Psychresidentdislikesalcoholicptsandavoidsworkingwiththem.Indiscussing theproblem,saysthatptsarehopelessandunmotivatedandshecan’tempathize COUNTERTRANSFERENCE withthem.Exampleof?(2x) Asopposedtolong-termpsychotherapy,time-limitedtherapymorelikelyto:(2x) SELECTCENTRALISSUEASFOCUS Intreatinganolderptwithdepressionwhoisasuccessfulexecutive,heoffersyou sometipsoninvesting.Whatdoyoudo?Doyouaccepttheofferasawayto THELATTER validatethepatient’ssuccessORexplorethept’smeaningsandfeelingsaboutthe offerORaccepttheinformationbutdonotactonit?(2x) Forthetreatmentofptswithcompulsivesexualbehavior,thebestresultshave beenseenwithwhichofthefollowingapproaches?(2x) TWELVESTEPGROUPS Twomostpowerfulpredictorsofoutcomeinanyformofpsychotherapyare:(2x) EMPATHYANDTHERAPEUTICALLIANCE 25y/osingleAfrican-Americanman,whoisafirstyearlawstudentatanivy leagueschool,seekspsychotherapyforwhathecalls“academicparalysis.”Heis fallingbehindashespendsmoretimebroodingabouttheracialand socioeconomicdifferencesbetweenhimselfandhisclassmates.Hefeels comfortablewithhisAfricanAmericanpsychiatristandspeaksopenlyabouther racialslightsthatheexperienceseveryday.Themostimportantgoalofdynamic psychotherapywiththisptisto:(2x) USETHESHAREDETHNICBACKGROUNDTOOFFER INSIGHTTOEXPLAINHOWTHEPT’SALIENATIONMAY BEROOTEDINSOMETHINGMORETHANHISCURRENT SITUATION Thefactormostconsistentlyassociatedwiththerapyoutcomeinpsychotherapy research:(3x) STRENGTHOFTHERAPEUTICALLIANCE Couplestherapy,husbandcomplainsthatMDwifeworkstoolonghours,shesays shestayslatetomakesureeverythingis“right”checkingandrecheckingherwork. UNDOING Notesthatonceinhighschoolshewishedherstraight-Abrotherdeadandlaterhe diedonhuntingtrip.Hercheckingbehaviorisanexampleof:(2x) GotoTableofContents 234 Thebestresponsetoaptwhoreportsafixedfalsebeliefthathisneighboris poisoninghisdogandsittingalldayatthewindowmonitoringis:(2X) A16-yohighschoolstudentisplacedonacademicprobation.Whatispriorityin structuralfamilytherapy? EMPATHIZEWITHTHEPT,BUTAVOIDDIRECT CONFRONTATIONABOUTTHEDELUSION HELPINGTHEPARENTSDEFINEEXPECTATIONS Oninitialpsycheval,pttellsdraboutrecentinfidelity,wantstomakeamendswith spouse,whatresponsewouldgetadditionalinfofrompt? TELLMEMOREABOUTHOWTHISSTARTED? ParentsofchildwithADHDandODD.Theywanttoknowpsychotherapeutic approacheshowtoproceedwithkid FINDOUTWHATKIDDOLIKESANDMAKEABEHAVIOR REWARDPROGRAMFORYOURCHILDATHOMEAND SCHOOL Psychiatrist’smindwandersduringsessions,whatshouldthepsychiatristdo? EXAMINEINNERTHOUGHTSANDFEELINGS 36y/optisbeginningpsychodynamicpsychotherapyfortxoflong-standing EXPLORETHEPROCESSDURINGTHESESSIONTHAT problemsofinabilitytoestablishsatisfyingongoingrelationships.Ptexpressesmuch MIGHTBEINTERFERINGWITHTHEESTABLISHMENTOF skepticismthat“talkingaboutmypast”willhelp.Themostappropriateresponseof THETHERAPEUTICALLIANCE therapistis: Inthecontextofthepsychodynamicpsychotherapy,theterm“frame”refersto whichofthefollowingaspectsoftherapy? HOWITISORGANIZEDINTERMSOFBOUNDARIESAND CONSISTENTDEFININGRULES Whattheoryisthebasisofmentalization-basedtherapy? BOWLBY’SATTACHMENTTHEORY Whichofthefollowingapproachesislikelytoobtainthemostaccurateinformation FAMILYCOPINGSTRATEGIESINRESPONSETOPAST onthefactorsinfluencingafamily’sleveloffunctioning STRESSORS Duringtheinitialinterviewofacouplepresentingfortherapyitishelpfultopoint outthatthefocusoftherapyisprimarilyonthe: RELATIONSHIPPROBLEM Duringinitialpsychinterview,pttearfullydiscussespainfulendingofromantic relationship.WhatshouldDr.saytoestablishtherapeuticalliance? ITSOUNDSLIKETHISHASBEENVERYDIFFICULTFOR YOU. HOWAREYOUCOPING? Fpsychiatristhasbeentreatinga32y/omarriedFptwweeklyindividual psychotherapyfordepressivesx,ambivalenceaboutmarriage.Therapyprogressing well.Ptjustlearnedsheispregnant,exploresconflictedfeelingsaboutterminating pregnancyandherfearsthatunplannedpregnancywouldtrapherinmarriage. “YOUFELTIWASIMPOSINGAMORALJUDGMENT Uncharacteristically,psychiatristspeaksstronglytoptaboutreasonsnottomak ONTOYOU,AND,APPROPRIATELY,YOUOBJECTED.” suchachoice.Ptrespondsbysaying“youarenotgoingtomakemefeelguiltyabout this!”Whatstatementwouldbemostappropriatefortherapisttomakein response? GotoTableofContents 235 Ptw/BMDwhohasbeenmakingprogressinlong-termpsychodynamic psychotherapyenterssessionobviouslydistraught.Afterlisteningtoscattered seeminglyunimportantdetailsofrecentdailylife,therapistasksifptisavoiding somethingtoouncomfortabletotalkabout.Ptrespondswintenseanger/distress.“I “IAMGOINGTONEEDAMOMENTTOTHINKABOUT justheardyouaregettingadivorce,Iamsickaboutit.HereIamcountingonyouto WHATYOU’VESAIDANDAREFEELINGBEFOREICAN helpmesortoutmychaoticlifeandmessed-uprelationships,andyoucan’teven RESPOND.” keepyourownmarriagetogether!Whatareyou,somekindofhypocrite?IthinkI shouldleaveandfindsomeonewhoknowswhatthey’redoing!”Bestresponsefor thetherapisttomake? Themotivationalenhancementtherapymodelforaddictiontreatmentemphasizes whichofthefollowingfactors? THEROLEOFAMBIVALENCEINCHANGE 8yroldevaluatedforasthma,foundtohaveADHDsymptoms,putonstimulant, behavioralproblemscontinue,senttopsychiatristandpsychologist,thisisan exampleofwhatlevelofcollaborativecare? SHARED(INTEGRATED)CARE Whichofthefollowingpsychotherapeutictechniquesisbasedonthecoreprinciples ofexpressingempathy,developingdiscrepancy,avoidingarguments,rollingwith MOTIVATIONALENHANCEMENTTHERAPY resistanceandself-efficacy? 9yofbib-parentsforoutptevaluationduetobehaviordifficultiesathome.Port daughter"explodes"whenshedoesn'tgetherway.Bossywithfriend.Oninterview, SENDTHEPTHOMEWITHPARENTS childiscalm,cooperativeandinteractive,deniesSI/HIandstates"sometimesIjust getmad."Whatisthemostappropriatelevelofcare? 9yofbib-parentsforoutptevaluationduetobehaviordifficultiesathome.Port daughter"explodes"whenshedoesn'tgetherway.Bossywithfriend.Oninterview, childiscalm,cooperativeandinteractive,deniesSI/HIandstates"sometimesIjust EXPLOREREASONSFORPARENTALDIFFERENCES getmad."Atafollowupinterviewthephysicianlearnstheoutburstsarerelatedto parentaldisputes.Whatisthenexttreatmentstep? 9y/ofemalebib-parentsforoutptevaluationduetobehaviordifficultiesathome. Reportsdaughter"explodes"whenshedoesn'tgetherway.Bossywithfriend.On interview,childiscalm,cooperativeandinteractive,deniesSI/HIandstates, "sometimesIjustgetmad."Whichisthemostappropriateinitialdiagnosticstep? OBTAINATEACHERREPORT Whichofthefollowingprinciplesismostcommonlyendorsedinparent managementtrainingprogramsfortreatmentofoppositionaldefiantdisorder? PARENTALATTENTIONFORPROSOCIALBEHAVIOR Animportantcounter-transferenceissueinaninterethnicpsychotherapeutic relationshipis: DENIALOFDIFFERENCES Whichofthefollowingisthemostaccurateinformationontheuseofbiofeedback forhypertension? ITISEFFECTIVEFORHYPERTENSION,HOWEVER,ITIS LESSEFFECTIVETHANMEDICATION Anewptaskstherapist,“areyouChristian?”Whatisbestresponse? “AREYOUCONCERNEDTHATIFWEARENOTOFTHE SAMERELIGION,IWON’TBEABLETOTREATYOU PROPERLY?’ GotoTableofContents 236 Exchangeduringinitialinterviewafterpt’sformertherapistclosedhispractice:pt expressesconcernaboutnewtherapistbeingtooyoung/inexperienced,statesshe doubtsnewtherapistcanprovideanynewinsights.Bestresponsetofurthergoalof gettingtoknowpt,establishwhethertherapywnewtherapistwouldbe appropriate “ITCANBEVERYHARDTOSTARTOVERWITHANEW THERAPIST.HOWHAVEYOUBEENFEELINGABOUT HAVINGTOENDYOURTREATMENTWITHDR. BROWN?” Treatingamucholderptwhoasksabouttherapist’sage.Bestresponse: “MAYBEYOU’RECONCERNEDABOUTWHETHERIAM EXPERIENCEDENOUGHTOTREATYOU?” Intensive,short-termdynamicpsychotherapyiscontraindicatedforwhatcondition? ACUTEEXACERBATIONOFCHRONICSCHIZOPHRENIA Ptseeingnewpsychotherapistweeklyx3wkshesitantlycomplainedaboutbeing abletooverhearmuchofwhatptintheprecedingsessionwassaying.Ptassured therapistthathehadtriednottolistenandhadleftthewaitingroomtowait outsideuntiltheotherpthadleft.Whichisbestresponse? APOLOGIZEFORTHELACKOFPRIVACYANDINDICATE THATFURTHERMEASURES,SUCHASMUSICSYSTEMIN THEWAITINGROOM,WILLBEUTILIZED MDseespsychiatristwincreasingsenseofdislikeforablaming,externalizingptwho COUNTERTRANSFERENCE pitsfamilymembersagainsttheMD.WhatshouldpsychiatristdiscusswMD? Ptisseenbypsychiatristbecausehasbeendepressedfor1yrsincehewasfiredin spiteofhavinganotherjob.Thepsychiatristtellsthept:menoftenfeelthattheyare CUTOFFBYTHEPREMATUREOFFERINGOF notallowedanyfailuresbutIcantellthatyouhavemovedonfromthissuccessfully REASSURANCE andhavenoreasonstodwellinit.Theptthenwithdraws.Themostlikelycauseof ptresponseisthathefelt: Beginningphaseoftherapywchildwhowasincestvictimshouldfirstfocuson what? DEALINGWITHPRIORBETRAYALANDESTABLISHING TRUSTWITHTHETHERAPIST 5y/oenactsfightbetweentwodolls.Whatshouldtherapistdo? DESCRIBETHEDOLL’SAFFECTWITHOUTATTRIBUTING ANGERTOTHECHILD Severalmonthsofweeklyindividualpsychotx—womanwMDD,panicd/odescribes repressedmemoriesofsexualabusebystepfather.Therapistneutral,explorespt’s DOCUMENTCAREFULLYTHEUNFOLDINGPROCESSAND experience.Ptreportsincreasingconvictiondespitesisterinsistingitwasimpossible. OBTAINSUPERVISION Planstpgetlawyerifparentsdonotadmit&apologize.Whichisbestapproach? 50y/oMhospitalizedfordepressionandmelancholia.Firstfewtherapysession shouldfocuson: EDUCATEPATIENTONNATUREOFILLNESSAND TREATMENT Aptwithh/olifelongdepression&failedrelationshipscomplains(veryangry)(after EMPATHIZEWITHTHEPT’SFEARSOFTRUSTAND severalweeksoftherapy)thatsheisexpectedtotrusttheDr.withoutevenknowing FEELINGOFBEINGATADISADVANTAGE anythingabouthim(credentialsorpersonally)whatshouldtheDrsay? 62y/owithlungcancer,weightloss,fatigue,andpersistentcough.Patrefusesto acceptDxofcancerandstateswill“getoverthisinfection.”Ptrefusesallfurther testingandasksforantibioticsto“recoverinpeace.”C&Lpsychiatrist’sroleis: EVALUATEPT’SCOPINGSTYLEANDHELPTHEMEDICAL TEAMSEETHEPT’SRESPONSESINTHECONTEXTOF HERUNIQUEPERSONALITYANDLIFECIRCUMSTANCES Youngfemalestartingcognitivetherapywithafemaleresidentasksforahug. Residentshouldfirst EXPLAINWHYPHYSICALCONTACTISAVOIDED C&Lpsychiatristusesalltherapeuticapproachesexcept: EXPLORATORYPSYCHODYNAMIC GotoTableofContents 237 PtrecurrentlygoestoEDbecauseofseverechestpain.Hasbeenw/uforeverything andalltestarenormal.Hestatesthatsomethingneedstobedoneto“fix”hispain. EXPLOREPT’SFEELINGSABOUTFATHER’SDEATH Psychconsultisplaced.MSEandneuroisnormal.Pasthxrevealshisfatherdiedof lungCA.Nextinterventionaspsychiatristis: Psychiatrististreatinganolderptwhoisasuccessfulexecutive.Ptfeelsgratefulfor EXPLOREPT’SMEANINGSANDFEELINGSABOUTTHE thehelpw/hisdepressionandofferssometipsoninvestingtothepsychiatrist. OFFER Whatisthemostappropriateactionatthispointfromthepsychiatrist? Fatherisdying.Ptisnotadrinker,butwentfrombartobardrinkingdad’sfavorite drink.Barsaresimilartothosedadusedtogoto.Bestinterpretationofthis behavior: IDENTIFICATIONWITHORINCORPORATIONOF PATIENT’SFATHER Femalepsychresidentsaysptsawresidentintownoverweekend.Followedher around.Thoughtshecouldlatershopatsamestoresandeatatsamerestaurantsas INTERPRETPT’SLONGINGTOIDENTIFYWTHE hergreatlyadmiredtherapist.Nothingwronginpt’sbxormaterialsuggestingsheis PSYCHIATRIST dangerous.Ptapologizesconvincingly,sayswillnotdoagain.Hopestherapistwill notfireher.Whatisnextbeststep? Whatifptaskswhetheryou’restillintrainingduringintakeinterview? INFORMTHELEVELOFTRAINING Midwaythroughpsychotherapysession,apsychiatrist’smindwandersdespite repeatedrefocus.Bestimmediateaction: EXAMINEOWNINNERFEELINGSABOUTTHEPATIENT Thefirst-linetreatmentforretentiveencopresis: BIOFEEDBACK Ptseestherapistandmakesthreatsandbecomesagitated.Therapistfeelsuneasy, thenextstepisto: INTERRUPTINTERVIEWTOGETHELP Useofmedswithpsychodynamicpsychotherapyoptimalwhen: MEANINGSANDEFFECTSOFMEDSINTEGRATEDINTO PT’SUNDERSTANDING Whathasbeenshowntobeanevidence-basedtreatmentforindividualswith conductd/o? MULTISYSTEMICTHERAPY Youngptintherapyreturnstoschool,announcestotherapistthathecanpass classes,willgraduate.Bestresponse: OFFERINGCONGRATULATIONS Beginningtherapistfeelsgreatempathyfordepressedptfailstomaintainsufficient OVERIDENTIFICATIONWITHPATIENT distancetoobserveself-destructivepatterns.Toavoidthispayattentionto: 40y/oeatsandsleepstoomuch,cravessweets,poorconcentration,irritable, constantconflictswithhusband.States“Ialwaysfeelbetterinspring.”Whatisthe treatment? PHOTOTHERAPY Childhashigh-activitymotorlevel.Teachershould PROVIDEBRIEFERRANDSTODOWHENTHECHILDIS PARTICULARLYRESTLESS Socialskillstrainingforthosewithpersistentmentalillnessisanessentialpartof: PSYCHIATRICREHABILITATION Whichpsychotherapyusestransferenceinterpretationsandclarificationtodevelop PSYCHODYNAMICPSYCHOTHERAPY insightandresolveconflict? GotoTableofContents 238 Therapistisworkingwfamilyofschizophrenic.Strategiesincludeinformingabout illness,socialsupport,managementguidelines.Therapistencouragescalmproblem PSYCHOEDUCATIONAL solvingapproach/facilitatesstressandstigmareductionwhenpossible.Which modelistherapistusing? Biofeedbackusuallyhelpsptswithwhichsyndrome? RAYNAUD’SSYNDROME Whichofthefollowingisaneffectivetreatmentformild-to-moderatelysevere idiopathicRaynaud’sdisease? THERMALBIOFEEDBACK WhatinterventionsareconsistentwthetheoreticalassumptionsofcrisisTx? REASSURANCE,BRIEFHOSPITALIZATION, PSYCHODYNAMICINSIGHT,TREATMENTWITH PSYCHOTROPICMEDICATIONS(NOTFOCUSINGON PASTRELATIONSHIPS) Duringlastsessionofsuccessfulpsychodynamicpsychotherapy,ptwarmly expressesgratitudeforeverything,sayingthatthehelpthetherapisthasgivenhas madeabigdifference.Appropriateresponse? RESPONDBYSAYINGYOUTOOHAVEENJOYEDTHE WORK 98.Schizophrenicwmemorylossandslowedthinking,stableonclozapine,with poorresponsetohalloo,zyprexa,geodonandabillify.Whatcouldimprovethept’s symptoms COGNITIVEREMEDIATIONTHERAPY Whichisaboundaryviolation? •Investinginapt’sbusiness •Treatingthetownpharmacistinsmallruraltown •Acceptingpt’sholidaygiftofhand-madescarf •Seeingoneptatreducedfeeandchargingothersmore •Discussingapt’ssexualfeelingstowardthepsychiatristinsession INVESTINGINAPT’SBUSINESS 12y/oFnotattendingschoolforfearhermommaydieinaccident.Management? RETURNINGTHEGIRLTOHERCURRENTCLASSROOM Afterattendingseveralsessionsofindividualpsychotherapyforanxietyand depression,24y/oMrevealedhishomosexualitytohisheterosexualmale SEEKCONSULTATIONTODISCUSS psychiatrist.Therapistrealizesheisuncomfortablewhenptexpresseslongingsfora COUNTERTRANSFERENCEISSUES male.Therapistalsotendstooveremphasizeanymaterialthatmightrepresentpt’s heterosexualwishes.Thenextbeststepforthepsychiatristwouldbeto: Ptw/mildMRinprogramdesignedtodevelopnewbehaviorsbymodeling/ reinforcement,thenpracticethem. SOCIALSKILLSTRAINING Therapistpreoccupiedw/patient.Acknowledgesthisbutunabletoshakefeeling TALKTOSUPERVISOR 15y/omalebibparents,doesnotwanttospeakwithpsych THANKHIMFORCOMINGINANDASKHIMIFHE’DLIKE TOBESEENALONEORWITHHISPARENTS WhatwasmostimportantfactorindeterminingtxoutcomesinNationalInstituteof THERAPEUTICALLIANCE MentalHealthTreatmentofDepressionCollaborativeResearchProgram(1996)? Couplehassoughtcouples’therapyduetochronicepisodicfighting.Solution focusedtherapistmightmakewhichintervention? BETWEENNOW&NEXTTIME,IWANTEACHOFYOUTO THINKABOUTWHATTHETWOOFYOUAREDOING DIFFERENTLYINTIMESOFNOTARGUING GotoTableofContents 239 Intervieww/aptw/schizophreniaevokesfeelingsofconfusionandfrustrationin ACKNOWLEDGINGTHEINTERVIEWER’SFRUSTRATION theinterviewerwhentheptbecomessilent.Whatresponsebythetherapistwould ANDINQUIRINGIFTHEPTFEELSSIMILARLY bethebestapproachtoestablishingrapport? Clinicalcircumstancethatbestwarrantsconsiderationofpsychotherapyasthesole PREGNANCY,LACTATION,ORWISHTOBECOME treatmentformildtomoderatedepression: PREGNANT Whatrepresentsmajorgoalofpsychotherapyasconceptualizedbyself-psychology? IMPROVINGTHEABILITYTOUSETHEAPPROPRIATE AFFIRMINGRESPONSESFROMOTHERS Incasesofrecoveredmemory,theroleofthetherapististo: DEMONSTRATEEMPATHYFORTHEPATIENTWITHOUT ENDORSEMENTOFTHEMEMORY 24y/optwtetraplegiaafterMVAshowingnosignsofgrieforacknowledgementof poorprognosis,nosignificantdepressive/anxiousSx.Whatpsychintervention SUPPORTBUTDONOTCONFRONTTHEPTABOUTTHE preferred?Whatpsychotherapeuticschoolofthoughtemphasizeshowapthas MEDICALREALITIESEGOPSYCHOLOGY managedfeelingsofenvy/ragewparticularemphasisondefensemechanisms? Insplittreatment,theroleoftheprescribingpsychiatristis? EVALUATETHEPTSNEEDSFORMEDICATIONSWHILE MAINTAININGREGULARCONTACTWITHTHE THERAPIST Psychotherapyresearchshowswhichofthefollowingpracticesinatherapeutic relationshipismostsupportiveforimprovingoutcomes? collectingfeedbackfromtheptaboutthetreatment PsychodynamicTherapy “Deficitmodel”ofpsychologicalillnessinpsychodynamicpsychotxdefines psychopathologyas:(2x) WEAKENEDORABSENTPSYCHICSTRUCTURES 43y/oMsuccessfulexecgoestopsychiatristb/cwifethreatenedtoleaveifhe doesn’tchange.Doesn’tunderstandwife’scomplaintsthatheisperfectionist, THEDIFFICULTYOFDEMONSTRATINGTOTHEPTTHAT demanding,controlling,unavailable.Hebelievesheisjustagoodman.Informing HISEGOSYNTONICTRAITSAREMALADAPTIVE optimalinitialtxplan,considerationsforchoiceoftherapyshouldinclude:(2x) Txformedstudentw/chronicanxietyandsenseofinadequacy? BRIEFPSYCHODYNAMICTHERAPY Ininitialpsychinterview,ptfrustratedthathislastpsychiatristhadbriefvisits& “justgavemeanotherpilleverytime.”Interviewingpsychiatristresponds“soyou CLARIFICATION wouldlikeyourpsychiatristtolisten&understandyoubeforeadjustingyourmeds.” Ptreceivingweeklybriefpsychodynamicpsychotx.2monthsintotxpt acknowledgesbeingawareofmaladaptivebehaviors,reportsnowbeingableto removehimselffromsituationsthatfrustratehim.Thept’saccountisreflectiveof whichofthefollowingelementsofbriefpsychodynamicpsychotherapy? DISCREPANCY WhenpracticingDavanloo’sshort-termdynamicpsychotx,onemustconsistently… CLARIFYANDRELENTLESSLYCONFRONTTHEPT’S DEFENSES GotoTableofContents 240 25y/oFneveronadateafter6moofpsychodynamicpsychotherapy.Beganto strugglew/positivefeelingsaboutMtherapistthatshefindshardtoaccept.Atthe sametimeshestartstodate.Therapistbelievesitistransference.Therapistsaid APRACTICAL/SUPPORTIVEAPPROACH nothing,hebelievedaninterpretationmightinterferew/positivelearning experience.Thisisexampleof: Whichofthefollowingcharacteristicsiscommontoallbriefdynamic psychotherapies? PRACTICALWORKINGTHROUGHOFCONFLICTBY TRANSFERENCEINTERPRETATION Determinesifpthasegostrengthfortherapy ASSESSMENTOFQUALITYOFRELATIONSHIPS Whichofthefollowingmodelsdividethemindintoconscious,thepreconscious,and TOPOGRAPHICAL theunconscious? Goalsofbriefpsychodynamicpsychotherapycomparedtolong-termpsychodynamic DISCUSSIONOFTRANSFERENCEINTHELATTER psychotherapydifferhow Primaryinterventioninhighlyexpressivepsychotherapy: INTERPRETATION Psychiatristtellspt“Youtoldmeyourfeelingsarehurtwhenspousedoesn’tpay attentiontoyou.IthinkyoumayalsobesayingIhurtyourfeelingsduringlast sessionwhenIdidn’tletyoufinishbeforeendingsession.”Whatinterview techniqueisthis? INTERPRETATION Ptisoftentardy.Supervisorwarnsnottobelate.Pthasanxietyaboutlosingjob. Whenfatherdiesheleavestownw/otellingsupervisor.Againgivenwarning.Next dayatraincauseshimtobelate.Intherapy,theoverlappingofmultiplepotential causesfortardinessisanexampleofwhat? OVERDETERMINATION Thistreatmentgoalismostspecifictopsychoanalyticpsychotherapy:x2 BRINGINGUNCONSCIOUSCONFLICTINTO AWARENESS. A3yochildhasbeenexpressingangryfeelingsaboutthearrivalofanewsibling. Thechildhasasecureattachmenttoparentsaswellasgrandparentswhovisit frequently.Duringonesuchvisit,duringwhichthegrandparentsspendtimeholding TURNINGAGAINSTTHESELFASADEFENSEAGAINST thenewbaby,thechildbeginstobangtheheadrhythmicallyagainstatable. INTOLERABLEANGER. Accordingtopsychoanalytictheory,thisbehaviorisunderstoodaswhichofthe following? 38y/optindynamicpsychotherapyfordepressionsayssheislesbianandis SUGGESTTHATCONJOINTTHERAPYWITHTHEPATIENT dissatisfiedwithherotherwisegoodrelationshipwithherpartnerof7yrsb/cshe ANDHERPARTNERMIGHTBEAPRODUCTIVEWAYTO wantsachildandherpartnerdoesnot.Shethinksaboutleavingtherelationshipbut EXPLORETHISCOMPLICATEDISSUE thismakesherfeelsadnessandasenseofloss.Whatisbestintervention? Whatbestdescribescurrentpsychoanalyticthinkingaboutthesourceof countertransferencephenomenainthetherapist THETHERAPISTSTOTALEMOTIONALREACTIONTOTHE PATIENT GotoTableofContents 241 32y/oF,divorced3times,seesamalepsychiatrist,sayingsheneedstherapy becausesheisparalyzedaboutchoosingacareer.Pthasstartedandstopped collegetwice,heldseveralwaitressandclerkjobs.Shehopedthetherapistcouldtell herwhatjobtopursue.Intheinitialinterviewsheasksthetherapisttosendbills TRYTOGETADVICEBUTTHENBEANGRYATTHE directlytoherfather,whomanageshermoneybecauseshehasdifficultymanaging THERAPISTFORGIVINGIT billsandcreditcards.Sheexplainedshehastoliveathometosavemoney,but hatesthisbecauseshefrequentlyfightsbitterlywherfatherwhoalwayswantsto controlher.Transferenceissuethattherapistshouldexpecttobecentralthemein therapyis: “Deficitmodel”ofpsychologicalillnessinpsychodynamicpsychotherapydefine psychopathologyas: WEAKENEDORABSENTPSYCHICSTRUCTURES Inpsychodynamictx,interpretationoftransference&resistanceuntilinsightfully integratediscalled: WORKINGTHROUGH 33y/optinlongtermpsychodynamicpsychotherapyforseveralmonthsis chronicallylateforsessions.Therapistsuggeststhatthismayberesistance.Thept says“oh,don’ttakeitpersonally,Iamthiswaywitheveryone”.Thisresponsecan bebestunderstoodas: ANUNINTENDEDCONFIRMATIONOFTHEPROBABLE CORESIGNIFICANCEOFTHISBEHAVIOR. Ptreenactstherapeuticrelationship TRANSFERENCE Studiesshowthatshort-termpsychodynamicpsychodynamic(STPP)psychotherapy issuperiortosupportivetherapyinthetreatmentofcomplicatedgriefforcertain MATUREOBJECTRELATIONS pts.WhichofthefollowingptcharacteristicspredictsabetterresponsetoSTPPthan supportivetherapy? WhileassessingforDV,examinersaystopt/spouse,“Thetensionthatbuildsup betweenyoumustbeincrediblystressful.It’snotunusualthatpeoplewhoare stressedoutcanhavetroublecontrollingthemselvesorcandothingstheydidn’t intend,likescreamingatorevenhittingtheirpartner.Hasanythinglikethat happenedtoyou?”Whichtechniqueisthis? NORMALIZATION Youngfemaleinpsychodynamicpsychotxadmittedtoseeingtheresident downtownlastweekend,followedhimaround,thinkingshecouldlatershopatthe INTERPRETPATIENT’SLONGINGTOIDENTIFYWITHTHE samestoresandeatatsameplacesashergreatlyadmiredtherapist.Ptnot THERAPIST. dangerous,convincinglyapologized,statedthatshewouldneverrepeatthis behaviorandhopedtherapistwouldnot“fire”her.Nextsteptherapistshouldtake? Ptinpsychodynamicpsychotherapyrepeatedlyasksthetherapistpersonal questions.Thetherapistconsistentlyexploresthereasonsforthepatient’sasking, “IKNOWTHISCANSEEMVERYFRUSTRATING,BUTTHE andsometimestheseexplorationsarefruitful.Regardless,theptpersistsinpressing FOCUSOFTHETHERAPYSHOULDBEONYOU”. for“realanswers”.Thetherapistresponseatthispointiswhat? Ptrepeatedlyredirectingdiscussionbytalkingaboutirrelevanttopicsisexampleof: RESISTANCE Incontextofpsychodynamicpsychotx,“frame”referstowhataspectoftherapy? HOWITISORGANIZEDINTERMSOFBOUNDARIESAND CONSISTENTDEFININGRULES. GotoTableofContents 242 60y/osuccessfulbusinessmanhasstartedpsychodynamicpsychotherapywitha youngmaletherapistinoneearlysession,theptbeginsbysaying,“beforeweget started,Iwanttoletyouknowaboutapotentiallylucrativeinvestment opportunity.”Thisstatementisbestrepresents: ANATTEMPTBYPT,PROBABLYUNCONSCIOUSLY,TO SEDUCEANDTESTTHERAPIST. CBT Animportanttechniqueorgoalofcognitivetherapyis?(x2) ELICITINGANDTESTINGAUTOMATICTHOUGHTS CBTforptswithOCDinvolvesgraduallyexposingthepttoafearedstimulusand preventingtheritualizedresponse.Overtime,thisresultsindecreasedanxietyto HABITUATIONELICITINGANDTESTINGAUTOMATIC thestimulusdemonstratingwhichofthefollowingAnimportanttechniqueorgoal THOUGHTS ofcognitivetherapyis:(2x) WhichofthefollowingisaprincipalgoalofCBTforpanicd/o? USINGRESTRUCTUREDINTERPRETATIONOF DISTURBINGSENSATIONS GoalofCBTforchronicpaintxis IMPROVEFUNCTIONINGDESPITEPAIN WhatisfirstlinetxforPTSDinchildrenandadolescents? CBT 42Mbecomesdepressedafterdiscoveringhiswifeishavinganaffair.Ptdescribes angerathiswife,avoidstalkingtoher.Admitstofeelingthatthewife’sactionsare hisfault,thatheisafailureasahusband.Theptnotesthathehasbeguntodwell onhispastfailedrelationships,aswellasthedivorceofhisparents.PtbeginsCBT fordepression.Mostappropriatetargetforthistypeoftherapyinthispt? ASSUMPTIONSOFPERSONALFAILURERESULTING FROMTHISCRISIS Identifyingnewrouteshomefromworkforalcoholicpatientisexampleofwhich typeoftherapy? CBT Mostcommonlyusedcognitivetherapytechniquetouncover&modifyautomatic negativethoughts SOCRATICQUESTIONING Whichofthefollowingischaracteristicofbothinterpersonalpsychotherapy,CBT? HASAHEREANDNOWFOCUS MostappropriaterationaleforusinghumorinCBT HELPINGTOCREATEANEWPERSPECTIVEON OTHERWISEDISTORTEDCOGNITIONS Collegestudenttellspsychiatrist“IhadanexamtodayandI’msureIfailedit.NowI “LET’SMAKELISTSOFTHEEVIDENCEFORANDAGAINST willnevergraduatefromcollege”.WhichresponseisconsistentwithCBT? YOUFAILINGOUTOFCOLLEGE” Fromcognitive-behavioralperspective,whichismostresponsibleformajor depression? FEELINGSOFDEVALUATION InCBT,askpatienttokeeplogforeachhourandratesenseofmasteryandpleasure ACTIVITYMONITORING experienced.Whatisthis? Primaryfocusofacognitivetherapyapproachtosuicidalbehavior: ADDRESSINGALLORNOTHINGBELIEFSANDHELPING PTLEARNPROBLEMSOLVING GotoTableofContents 243 Programmedpractice,orexposuretherapy,isanindicatedtreatmentforwhat disorder? AGORAPHOBIA PtwithdepressionbeingtreatedwithCBTtellspsychiatristaboutwakingupand beingworriedaboutwork.Pthasbigprojectthatisdueintwoweeksandishalf done,butptissureworkwillnotbefinishedontime.Exampleofwhichcognitive error? CATASTROPHIZING Pthasseverestressandconflictatwork,therapistidentifiestheproblemof maladaptiveresponsesbasedonrigidthoughtschemasanddecidestotarget CBT automaticnegativethoughtsthroughrealitycheckingandguidedassociation.What typeoftherapyisthis? Flooding,gradedexposure,andparticipantmodeling: CONFRONTATIONOFANXIETY-PROVOKING EXPERIENCES Ptwithmultiplesocialfearsisterrifiedofpublicspeaking.Asthenextstepin treatment,thetherapistarrangesforthepttogive15minutestalktoclinicalstaff. Thisisanexampleof: FLOODING Cognitivetherapywasdevelopedby: AARONBECK Exposureandfloodingtogetherwithresponsepreventionaretechniquesof behavioraltherapyaimedatwhichofthefollowing? HASTENINGTHEEXTINCTIONOFACONDITIONEDFEAR ORANXIETYRESPONSE ElementscommontobothCBTandeyemovementdesensitizationandreprocessing CONTROLLEDEXPOSURETOTRAUMARELATED inthetreatmentofpatientswithPTSDinclude: TRIGGERS Ptwfearofheights.Ptinstructedtovisualizecrossingabridge.Whatisthe therapeutictechnique? IMAGINALEXPOSURE Whichpsychotherapeutictechniqueismostclearlyindicatedfortreatmentof simplephobia? EXPOSURETHERAPY Takeagoraphobictocrowdedplaceandstaythereuntilanxietydissipates FLOODING TheLEASTutilizedapproachusedincognitivetherapyinptw/substance dependence INTERPRETATIONOFINTERACTIONALPROCESS ACBTtherapistworkswithatherapist,amongstotherthings,toidentifyand correct: OVERGENERALIZATION Incognitivetherapy,“selectiveabstraction”iswhat? PATIENT’SFOCUSONADETAILTAKENOUTOFCONTEXT ANDCONCEPTUALIZESAEXPERIENCEBASEDONTHIS ELEMENT Cognitiveerror:whenaskedabouthisday,ptreplies,“Iwaslateforworkb/cI misplacedmykeys”then,“Ididn’tspeakupinthestaffmtg.” SELECTIVEABSTRACTION Thecognitiveerrorofarbitraryinferenceisbasedon: DRAWINGACONCLUSIONDESPITETHEABSENCEOF EVIDENCEORDESPITEEVIDENCETOTHECONTRARY GotoTableofContents 244 42y/optb/cdepressedafterdiscoveringhiswifeishavinganaffair.Ptdescribes angerathiswifeandavoidstalkingtoher.Headmitstofeelinghiswife’sactionsare ASSUMPTIONSOFPERSONALFAILURERESULTING hisfaultandthatheisafailureasahusband.Ptnoteshehasbeguntodwellonpast FROMTHISCRISIS failedrelationshipsandthedivorceofhisparents.HebeginsCBT.Themost appropriatetargetforthistypeoftherapywouldbethept’s: Thebehavioraltherapytechniqueinwhichaptisexposedtoprogressivelygreater fearinducingsituationsisreferredtoas: SYSTEMATICDESENSITIZATION Behavioraltherapywrelaxationtraining/hierarchyconstruction/visualimagery? SYSTEMATICDESENSITIZATION Allofthefollowingarestrategiesforchangeincognitivetherapy: USINGREATTRIBUTION,DEVELOPINGALTERNATIVES, QUESTIONINGTHEEVIDENCE,FANTASIZING CONSEQUENCES.(NOTEMPLOYINGINTERPRETATION) Meta-analysissuggestswhichofthefollowingforpsychotherapytotreat depression? OTHERPSYCHOTHERAPIESHAVEEFFICACY COMPARABLETOCBT Duringpsychotherapy,patientdescribessituationwhereroommateleftthe apartmentafterreceivingacall.Patientrecalls“imbeingleftoutagain”.This AUTOMATICTHOUGHTS MaritalTherapy WhichTxiscontraindicatedininitialtreatmentofptexperiencingdomestic violence?(4x) CONJOINTMARITALTHERAPY Whenconductingmaritaltherapywithacouplewhobegintotalkaboutdivorce, whatshouldthepsychiatrist’sstancebe?(2x) FOCUSONTHECOUPLE’SRESPONSIBILITYTODECIDE THEFUTUREOFTHEIRRELATIONSHIP Womanisunabletoachieveorgasmwithherpartner.Treatment=directed masturbation+? COUPLESTHERAPY DEMONSTRATINGCONFLICTSARISINGFROMEACH Thebasisforself-psychologicalstrategyinmaritaltherapyisbestindicatedbywhat? SPOUSE’SNEEDTOHAVEHIS/HERNEEDSMETBY OTHER Couplestherapy:whatisthegoalofacceptancework? EACHPARTNERTAUGHTTOUNDERSTANDOTHER’S POSITION&RELEASESTRUGGLETOCHANGEHIMOR HER Inasession,acoupleseemsblissfullycontentwhenhappybutenragedwhen frustratedbytheother.Theyalternatebetweenover-idealizinganddevaluingthe other.Thisisanexampleof? SPLITTING Duringinitialevalofanindividualforcouple’stherapy,itismostcriticaltoask about: DOMESTICVIOLENCE 28yohomosexualMreportsbeingvictimofdomesticviolenceandhasnotreported. LISTENTOPT’SCONCERNSANDEXPLORETHEM Whatisthebestresponseforthepsychiatristtomake? GotoTableofContents 245 Duringaninitialofficeevaluation,thepttellsthepsychiatrist,“myspousetoldmeI hadtobeevaluated.”Whichofthefollowingwouldbethemostempathic “HOWDOYOUFEELABOUTTHAT?” response? Anewpsychotherapypatientarrivesforafirstappointment,accompaniedbythe “CERTAINLY,IFTHATISYOURWISH,BUTI’DALSOLIKE spouse.Theptasksifthespousecanbepresentduringtheinterview.Whichofthe TOSPEAKWITHYOURPRIVATELYATSOMEPOINT.” followingisthemostappropriateimmediateresponsebythepsychiatrist? Couplesdissatisfiedwitheachotherandprogressingtowarddivorcehaswhichof thefollowing? Couplestherapyiscontraindicatedinwhichofthefollowingsituations? Besttreatmentforgenito-pelvicpain/penetrationdisorder EXPRESSIONOFCONTEMPTANDSTONEWALLING DURINGINTERACTIONS UNEQUALMOTIVATION DILATIONWITHGRADUATEDSIZEDVAGINAL DILATORS DialecticalBehavioralTherapy WhenDBTisusedtotreatpatientswithborderline,theworddialecticalrefersto treatmentstrategiesthatfocuson:(2x) SEARCHINGFORASYNTHESISBETWEENSEEMINGLY CONTRADICTORYIDEAS Dialecticalbehaviortherapyisutilizedfor: BORDERLINEPERSONALITYD/O Whichtypeoftherapyhasindividualsessionstoanalyzeself-destructive cognitions/feelings/actions,andgroupsessionswithskillstrainingtoimprove relationshipsanddecreaseimpulsivity? DIALECTICALBEHAVIORALTHERAPY AccordingtoDBTtheory,whichskillshouldbetaughttoptsfirst®ularly practicedinordertofacilitatelearningofotherskills? MINDFULNESS PurposeofDBTtodiminishwhat? PARASUICIDALTHOUGHTS IntheindividualcomponentofDBT,atherapistspendtimein: NURTURINGTHEPTANDREQUIRINGPTTOHELP HERSELF FamilyTherapy 11y/oboyhasfrequentepisodesofulcerativecolitisrequiringfrequent hospitalization.Whileinthehospital,motherneverleaveshissideandresponds toquestionsforhim,oftenreferringtodiseaseas“ourdisease.”Accordingto Minuchin’stheoryoffamilyinteractions,thisis:(3x) ENMESHED Whatbestillustratesadoublebindinafamily?(x3) BETTY’SPARENTSENCOURAGECOLLEGE,BUT COMPLAINTHATEXPENSESWILLBEAHARDSHIPFOR THEFAMILY familypsychoeducationprogramsforpsychoticdisordersreducesymptomseverity andrelapseriskbyreversingwhat? FAMILYMEMBERSEXPRESSCRITICISM,HOSTILITYAND BLAMETOWARDSTHEPATIENT Thisbestdescribesthetechniqueofreframinginfamilytherapy: NEGATIVELYEXPRESSEDFEELINGORBEHAVIORSARE EXPRESSEDINPOSTIVETERMS GotoTableofContents 246 Structuralmodeloffamilytherapycharacterizesfamilyas COMPLEXSYSTEMCOMPRISEDOFALLIANCESAND RIVALRIES Whattypeofgrouptherapyisbasedontheunitfunctioningtomaintainitsown homeostasisofinteracting? FAMILYGROUPTHERAPY Accordingtostrategicandstructuralfamilytherapies–underlyingbasisforanalysis OBSERVABLEANDREPORTEDFAMILYBEHAVIOR ofsymptomsinchildren,parents,andfamilies SEQUENCES Whatisanimportanttechniqueofstructuralfamilytherapy? OBSERVINGTHERELATIVEINFLUENCEOFEACHFAMILY MEMBERONTHEOUTCOMEOFANACTIVITY Whichpracticeiscommontoallcoupleandfamilytherapiesandcontributestoa therapeuticoutcome? CONCEPTUALIZINGDIFFICULTIESINRELATIONALTERMS Therapistvalidatesfamily’sstrengths/resourcesindealingwpt’sschizophreniaatbiENGAGEMENT weeklyfamilymeeting.Whatstageoffamilypsychoeducationalmodelisthis? Accordingtobothstrategicandstructuralfamilytherapies,whichofthefollowingis OBSERVABLEANDREPORTEDFAMILYBEHAVIOR theunderlyingbasisforanalysisofsymptomsanddysfunctioninchildren,parents, SEQUENCES andfamilies? 12yoarguingwhissingleparentmother.Motherthreatensconsequencesandchild runstograndmotherwhothenscoldsmotherforbeingtooharsh.Familydynamicis TRIANGULATION reflectiveof? Theconceptoftheidentifiedpatientintherapyrefersto: ONEFAMILYMEMBERWHOHASBEENLABELEDTHE PROBLEMBYTHEFAMILY Whattypeoffamilytherapyusesparadoxicaldirectives,suchasprescribingthe symptomorbehavioralsequence? STRATEGIC Inwhattypeoffamilytherapyaretheconceptsoffamilyhierarchies,boundaries, coalitions,andalliancesseenascoreconcepts? STRUCTURAL Contraindicationtofamilytherapy STRONGRELIGIOUSORCULTUREBELIEFSAGAINST OUTSIDEINTERVENTION Infamilytherapy,apreviouslydistantcouplebeginstocommunicatemore frequentlyandintimately.Afterthishappenedthedaughterwhousedtobecloseto TRIANGULATION mom,andhasbecomelesssoasaconsequenceofabovetherapychanges,ismore hostiletofather.Thisbehavioriscalled: Ptw/schizophreniahasrecentlybeendischargedfromthehospitalafterafirst psychoticepisode.Family-orientedtherapygoalsshouldinclude? Duringfamilymeetingfor75yoptadmittedforMI,howtoaddressfamily unwillingtoparticipateindiscussion? EDUCATINGTHEFAMILYABOUTTHEPATIENT’SILLNESS ANDPROVIDINGSUPPORTFORIMMEDIATEPROBLEMS Identifytheinabilityorunwillingnesstodiscussasone ofthefamily’sproblems GotoTableofContents 247 Accordingtostructuralfamilytherapy,whatistheindicatorofnormalfamily functioning? WELLDEFINEDBOUNDARYBETWEENPARENTSAND CHILDRENTHATPERSEVERESAUTHORITYAND FACILITATESOPENCOMMUNICATION GroupTherapy Majortaskofagrouptherapyduringinitialengagementphaseis:(2x) DETERMININGLIMITSOFEMOTIONALSAFETY Whatisamajortherapeuticgoalofself-helpgroups?(2x) OVERCOMINGMALADAPTIVEBEHAVIORS Whichcharacteristicsofself-helpgroupsdistinguishesthemfromtraditional psychotherapygroups? GOALS/OBJECTIVESDON’TADDRESSINTRAGROUP DYNAMICS Whichisamajortherapeuticgoalofself-helpgroups? OVERCOMINGMALADAPTIVEBEHAVIORS Inagroupwhohasmetfor6therapysessions,onepthasspokenatsignificant lengthforpast4sessionsaboutirrelevantissues&groupmembershaverallied againsthim.Whattherapeuticmechanismingrouppsychotxisbeingundermined? COHESIVENESS Whichstageofgroupdevelopmenthasbeenmetwhenmembersarelessafraidof revealingindividualdifferencessotheycanparticipateinexperientiallearning? NORMING Thegrouptherapistnoticesthatparticipantsinapsychotherapygroupexperience self-disclosure.Whichstageofgroupdevelopmentdoesthisdemonstrate? STORMING Atherapistplanstocreateanewoutptpsychotherapygroupshouldexcludefrom groupparticipationPtw/? ANTISOCIALPERSONALITYDISORDER Psychiatristwhousesnetworktherapytotreatpatientswithaddictivedisordersis functioningas: ATEAMLEADER Ptwithschizoidpersonalitydisorderhaselaboratefantasyrelationshipsbuthasno realfriends.Mosthelpfultherapytoassistptinformingsatisfyinginterpersonal relationships? GROUPTHERAPY Whichfactormostlikelyimpedescohesionindailygrouptherapyonlockedadult generalpsychiatryunits? PATIENTTURNOVER Intermsofgroupdynamics,theconfirmationofrealitybycomparingone’sown conceptualizationswiththoseofothergroupmembersandtherebycorrecting interpersonaldistortionsisknownaswhat? CONSENSUALVALIDATION Inthestructuralmodeloffamilytherapy,thefamilyisviewedasa: SINGLE,INTERRELATEDSYSTEMWITHANEMPHASISON BOUNDARIESBETWEENTHEGENERATIONS. Thetherapist’sinitialtasksinstartingsupportivegrouptherapyaredecidingthe logisticsoforganizingplannedmeetingsandselectingpatientswhocanparticipate ingroupwork.Whichofthefollowingwouldbetheappropriateactionforthe therapisttotakenext? CREATEANDMAINTAINATHERAPEUTICENVIRONMENT KEEPINGINMINDTHECULTUREOFTHEGROUP GotoTableofContents 248 Initialtasksinstartingsupportivegrouptherapyaredecidinglogisticsandselecting patients.Nextstep: CREATEANDMAINTAINTHERAPEUTICENVIRONMENT KEEPINGINMINDCULTUREOFTHEGROUP Stageofgroupdevelopmentwherememberstestingnorms,competingw/each other,seekingautonomy DIFFERENTIATION Excludeapatientfromaweeklyoutpatientgrouptreatmentgroupif: TENDENCYTOASSUMEDEVIANTROLE Differentiationstageofgroupdevelopmentisbestcharacterizedbywhatdynamic: TESTINGANDCOMPETITION Psychosocialtherapythathasshownefficacyinsomestudiesinimprovercancer survivalrates: GROUPTHERAPYWITHOTHERCANCERPATIENTS Whatisthetherapeuticfactoroftreatingbulimicsingrouptherapytoopenly disclosepersonalattitudestowardbodyimageandgivedetailedexperienceswith binging/purging? UNIVERSALITY Hypnosis WhathasdemonstratedefficacyforIBS?(4x) HYPNOSIS Whichofthefollowingdiagnosesisassociatedwithhighhypnotizabilitypotential? DISSOCIATIVEDISORDER (2x) Hypnotizabilitymoststronglypredictedby CAPACITYFORIMAGINATION Whichofthefollowinghypnotictechniquesisusedformostpts? ENCOURAGINGTHEPTTOUSEINNERRESOURCESFOR ADAPTIVECOPINGSTRATEGIES Abilitytogetsocaughtupinanexperiencethatonelosesawarenessof surroundings HYPNOTIZABILITY Whatstatementsregardinghypnosisiscorrect HYPNOTIZABILITYISAMEASURABLETRAIT Whenusedasatxfollowingatraumaticevent,hypnosishasbeenfoundto: SAFELYDECREASEPAINANDSTRESSINTHOSEWHO AREHYPNOTIZABLE Absorption,dissociation,andsuggestibilityconvergeduring: HYPNOTICCONCENTRATION Hypnosiswouldbecontraindicatedinthetreatmentofpatientswith: PARANOIA 32y/optisconsideringacourseofhypnosistohelpquitsmoking,butvoices concerns.Ptexpressesworryaboutpotentialharmofhypnosisifnotdoneproperly. ATRANCEPROCEDUREISBENIGNANDREVERSIBLEBY WhatwouldbethebestinitialresponseforthepsychMDtomaketoptregarding CALMREASSURANCE thisconcern? Duringahypnosissessionaptreportsreducedawarenessofsoundsandother distractionsintherapist’soffice.Ptreportisreflectiveofwhichofthefollowing componentsofhypnoticconcentration ABSORPTION GotoTableofContents 249 Mostimportantguidelinere:hypnosis HypnosishasbestevidenceofefficacyfortreatmentofGIdisorder RECORDONVIDEOTAPE IrritablebowelSyndrome InterpersonalTherapy Whichinterviewtechniqueisillustratedbyvalidatingapatient’sinappropriateED visit(eg.superficialwristlaceration)butalsotransitioningtotheiremotional needs? Confrontation Inthemiddlephaseofinterpersonalpsychotherapy(IPT),thetherapistfocuseson IPTMIDDLEPHASE:CURRENTRELATIONSHIPS thepatient’s:(4x) Psychotherapywhereptsrealisticallyevaluatetheirinteractionswothers& therapistoffersdirectadvice/helpsptsmakedecisions/ignorestransference issues.(2x) INTERPERSONALPSYCHOTHERAPY(IPT) InptwithMDDandsocialphobiatheIPTtargetssocialisolationby(2x): WORKINGWITHTHEPTTOHELPINCREASESOCIAL CONTACTS,STRENGTHENTHECURRENT RELATIONSHIPS. Interpersonalsocialrhythmtherapyinbipolarfocusesonwhat? LIFESTYLEREGULARITY Comprehensivelyresearchedtherapyformoodd/o’s INTERPERSONALPSYCHOTHERAPY IPTofadultsw/depressionbeginsw/assessmentofpt’sadjustmenttostressfullife QUALITYOFSOCIALCONNECTIONS events,roletransitionsanddisputes,and: Therapeuticfocusontheonpt’scurrentsocialfunctioningismostcharacteristicof: INTERPERSONALPSYCHOTHERAPY 26y/optwithdepressedmoodanddissatisfactionwithlife,feelingisolatedand havingfewfriendswhoisnotunderunduestressandhistoricallycopeswellwith personalproblemswouldbenefitfromwhattypeofpsychotherapy? INTERPERSONALTHERAPY Duringtheinitialphaseofinterpersonalpsychotherapy(ITP),whatproblemisthe therapistmostlikelytoidentifyfortherapeuticfocuswiththepatient? IPTINITIALPHASE:ROLETRANSITION AtreatmentmodalityexplicitlyemphasizesgivingptsaformalpsychDxand assigningthemsickrole. INTERPERSONALTHERAPY 75y/opthasbeguntoexperienceinsomniaandfatigueafterthedeathofher husband.Shedescribesfeeling“downinthedumps”.Shewaspreviouslyactivewith manyfriendsandsocialoutlets.PsychMDdecidesthattreatmentshouldfocuson INTERPERSONALTHERAPY pt’sgriefastheprimaryprobleminordertoaidmourningandfacilitatept’s reintroductionintooutsideactivitiesandrelationships.Whatmodeof psychotherapywouldbestaddressthesegoalsoftreatment? Intentionallyassigningthesickroletoaptwhichservestogivetheptthe permissionandresponsibilityinordertorecoverisatenetofwhichformof psychotherapy? INTERPERSONALTHERAPY MorelikelytobethefocusofInterpersonalPsychotherapy: ROLETRANSITIONS GotoTableofContents 250 SupportiveTherapy Mostlikelyrepresentsanacceptableboundarycrossingbyatherapistasopposed RECEIVINGCOOKIESASANEXPRESSIONOF toaboundaryviolation:(2x) GRATITUDEBYAPTNEARTERMINATION. Whichbestdefinesgoalsofsupportivepsychotherapy?(2x) STABILIZEPT’SFUNCTIONING,STRENGTHENPT DEFENSES Whichpsychotherapywouldtherapistbeinclinedtogratifypts’dependencyneeds? SUPPORTIVE Whichbestdefinesgoalsofsupportivepsychotherapy? IMPROVEMENTOFREALITYTESTINGAND REESTABLISHMENTOFTHEUSUALLEVELOF FUNCTIONING AftermildMI70y/oseenbypsychiatristfordepression.Seenforpsychotherapy, givenSSRI.Describesfearofimminentdeath.Psychiatristtellshimcardiologistis excellent,heisreceivingbestcare.Whatillustratessupportivetherapy: REASSURANCE Supportivetherapydiffersfrompsychoanalytictherapyinthatthetherapistwhois conductingsupportivetherapydoeswhat? REINFORCESEGODEFENSES Ontheexpressive-supportspectrumoftherapeuticinterventions,whichis consideredthemostsupportivetherapyintervention: ADVISING Animportanttechniqueinsupportivetherapyis… WORKINGPRIMARILYINTHEPRESENT 35youninjuredinanaccidentbutwitnesseddeathsofco-workers.Thefollowing dayreportsemotionalnumbness,intrussiveimages,inabilitytosleepsincethe accident.Mostappropriateintervention “Iunderstandwhythatfelt***”isanexampleofwhichtypeofpsychodynamic psychotherapyintervention? Normalizingstressreactionandmobilizingrelational supports. Empathicvalidation PsychosocialTherapies Mostlikelytobeenhancedbythestrategiesofputtingtheptatease,findingthe pt’spainandexpressingcompassion,evaluationpt’sinsight,andshowing expertise:(4x) RAPPORT Whichpsychosocialtherapiesforptsw/schizophreniahasbeenshowedtoreduce FAMILYPSYCHOEDUCATIONALTHERAPY relapserates?(3x) Motherof2schoolagedkidsdiesunexpectedly.Whatwithimprovepsychological outcomeforthechildren? Ensuringavailabilityofpsychosocialsupports Thetreatmentgoalofpsychoeducationinmultifamilygrouptxthatisintendedto assistfamilytocopew/stressesoflivingw/psychoticorseveremoodd/opt. PROVIDINGKNOWLEDGEANDDIRECTGUIDANCE GotoTableofContents 251 A45y/owithdysthymicd/oisundergoingacourseofbriefdynamicpsychotherapy. Inthe2ndsession,ptdiscusseshowhisfatherwasneveravailabletohim.Later, whenthetherapisthastocancelanappointmentduetounforeseentrip,thept INTERPRETTHISTRANSFERENTIALRESPONSEAND becomesirritatedandwondersaloudwhetherheshouldcontinuesessionwiththe INVITETHEPTTODISCUSSITFURTHER therapist.Whichofthefollowingwouldbethemostappropriateresponseforthe psychiatristtomaketothept’sirritation? Ptw/hxofEtOHdependenceBIBwife,whostatesthatpt’slongtermuseofETOH hasresultedinmaritalseparationandpersistentunemployment.Prrefusestostop drinking.PsychMDasksptabouthisperspectiveregardinghisuseofETOH,pt PRECONTEMPLATION responds,“Itmaybeaproblem.”PsychMDsuggestsTxandptsays,”Iwillthink aboutit.”Accordingtothestagesofchangemodel,whichstage? DBTisuniqueamongcommonlyemployedpsychotherapyinencouragingjudicious usebyptsbywhich? TELEPHONECONSULTATION Ptsadlyreportsreceivingacollegerejectionletter,andthendisparaginglypredicts thatalltheothercollegesappliedtowillrejecthimaswell.Thisisanexampleof: OVERGENERALIZATIONANDALL-OR-NONETHINKING PtwithPTSDwhowillhavethemostfavorableprognosisinCBTinvolvingexposure therapy: VICTIMOFARANDOMVIOLENTASSAULT Accordingtoameta-analysispublishedin2008includingpatientswithpersonality disorder,multiplementaldisordersandchronicmentaldisorder,whichofthe followingpsychotherapieswasconsideredmosteffectiveinimprovingoverall outcome,targetproblems,andpersonalityfunctioning? LONG-TERMPSYCHODYNAMICPSYCHOTHERAPY;CBT; DBT;FAMILYTHERAPY Negativetherapeuticreactioninpsychodynamicpsychotherapyreferstowhat Patientgetswoesinresponsetotherapist interpretationsthatareaccurateandappropriate TherapyTerms 139.Afeelingofbeingoutsideoneselfordetached Depersonalization Aperson’sinabilityordifficultytodescribeorbeawareofemotionsormoodis called:(4x) ALEXITHYMIA Therapeuticempathyisbestdescribedasthetherapist’sabilityto:(2x) GRASPPT’SINNEREXPERIENCEFROMPT’S PERSPECTIVE Therapeutictechniquewheretherapistinstructsthepatienttoholdontoa symptom:(2x) PARADOXICALINTERVENTION Ahighlymotivatedpatientinpsychodynamicpsychotherapyfindsthathehas nothingtosay,whichisanexampleof:(2x) RESISTANCE Catharsisis:(2x) VERBALEXPRESSIONOFSUPPRESSEDTRAUMATIC EXPERIENCESANDFEELINGS GotoTableofContents 252 Ptinindividualpsychotxdescribeshatredfora“mean,unfair”boss.Thistimept adds,“butactually,Ihaveheardmybosstalkingtoothersintheoffice,andhe MENTALIZATION seemsprettymuchok–evenhisvoicesoundssodifferentfromthewayIhearhim inmyhead!”AccordingtoFonagy,ptisdemonstratingwhichmentalactivity?(2x) Ptwhohaddifficultchildhoodcallstherapistmother’snameandquicklycorrects error.Whatisthisanexampleof? Parapraxis Primaryprocessthinkingischaracterizedas… MENTATIONFOCUSEDONDRIVESANDWISH FULFILLMENT Psychiatristandpatientmovefromthedayroomtoaninterviewroomwherethey havemetonseveraloccasion.Thepatientstates,“theroomlooksweirdand differenttoday;itdoesn’tfeelright.”Thisstatementisanexampleof: DEREALIZATION Ptenterspsychotherapybecauseofproblemsinhisrelationshipwithhiswife. Duringthesessions,pttalksabouthisfamilyoforigin,hisboss,andhisproblemsat RESISTANCE work,butneverdiscussesdetailsabouthiswife.Thisisanexampleofwhichofthe following? Withoutevidentdistress,ptcalmlyreportstothepsychiatrist,“SinceIwaslast here,mysignificantotherdumpedme.”Thedoctorrespondsbypointingoutthe CONFRONTATION discrepancybetweenthept’saffectandthecontentdescribed.Thisresponseisan exampleof:(2x) Theextenttowhichaninstrumentrepresentstheconstructbeingmeasuredis referredtoaswhattypeofvalidity? CONTENT Ptwithdepressionrecountstothepsychiatristeventsofthelastweekanddescries manyunpleasantexperiences,concernsaboutthesadnessofsomefriends,anda reluctancetoreadthenewspaperbecause“allthenewsisbad.”Incognitive SELECTIVEATTENTIONBIAS psychology,whichofthefollowingformulationsbestaccountsforthispatient’s presentation? 19y/optexpressesthebeliefthatshefailedarecentmidtermexamdespite studyingagreatdealforthetest.Thepatientisconvincedthatthismeansshewill losescholarshipmoneyandwillneedtodropoutofcollege.Thepatientisan CATASTROPHICTHINKING excellentstudentwhoispronetoexcessiveworrying.Herbeliefthatsheisgoingto havetodropoutofcollegebecauseshedidpoorlyonthemidtermexamisan exampleofwhichofthefollowingtypesofdistortion? Principleofconfrontation: “ITHINKYOU’DRATHERTALKABOUTYOURJOBTHAN FACETHESADNESSYOUFELTINOURLASTSESSION” Exampleofempathiccomment “YOUMUSTFEELTERRIBLERIGHTNOW.” Commonexperienceofbecomingsocaughtupinamoviethatoneignoresthe environmentisexampleofwhatcomponentofhypnoticprocess? ABSORPTION Ptingrouptherapycallsanotherpatientathometoobjecttosomethingsaidin session ACTINGOUT GotoTableofContents 253 Inpsychotherapyaptstatesthathestillfeelsdevaluedbycriticismoffather. EMPATHICVALIDATION Therapistcomment:Itmusthurtwhenyouaretreatedthatway.Thisisexampleof: Psychiatristbehaviorofraisingeyebrows,leaningtowardspt,saying“Uh-huh” FACILITATION ReplaceduseofhypnosisbyFreud: FREEASSOCIATION Attributionprocessesaredefinedprimarilyasindividual: CAUSALEXPLANATIONSOFEVENTSANDPERSONAL EXPERIENCES Menninger’striangleofinsightprovidesaframeworkforidentifyinglinksbetween thepatient’scurrentinterpersonalrelationships,early-lifeinteractionswithfamily WORKINGTHROUGH membersorotherimportantcaregivers,andthetransferentialrelationshipwiththe therapist.Whatisthisprocess? Therapytechniqueofprescribingapre-existingsxbehaviorinrelationshiptherapy PARADOXICALINTENT Whatismostlikelytobeenhancedbystrategiesofputtingtheptatease,finding RAPPORT thept’spainandexpressingcompassion,evaluatinginsight,andshowingexpertise? Redirectingdiscussionbytalkingaboutirrelevantstuff RESISTANCE Asetoffeelingsthatapatientreenactsinthetherapeuticrelationshiparecalled: TRANSFERENCE Acoupleintherapyforrelationshipdifficultiesthatarerelatedinparttoone partner’sfrequentnaggingoftheother.Thetherapistrecommendsthatthenagging partnerintentionallynagtheotherpartnerthreetimesaday,regardlessofwhether PARADOXICALINTENT thereisanurgetodosoornot.Thistechniqueofprescribingthesymptomisan exampleof: Duringaclinicalinterview,thephysicianrecapitulateswhatthepthassaidsofar andsaystopt“IjustwanttomakesurethatI’vegoteverythingrightuptothis point”.Thisisanexampleof: SUMMATION Thedoctorandpatientrelationshipisdescribedasfiduciaryrelationis: BASEDONTRUST “Whenyoumentionedyoursibling’sproblem,yourvoicecrackedand,fora moment,IthoughtIheardangerinyourvoice.”Whichinterviewingtechniquedoes FACILITATION,REFLECTION psychiatristusehere? Duringagrouptherapysessionfemaleptdescribespastexperiencesofsexualabuse byherfather.Ptstatesthatattimesshefeelsdepressedandhopeless,andhas intensethoughtsofkillingherself.Anotherptinthegroupsstates,“Ifeelthesame CONTAGION way,andI’vefeltlikethisforalongtime.”Secondpt’sadmissionisreflectiveof whichofthefollowingtherapeuticfactorsingrouptherapy? Thepurposeofreflectivestatementsduringpatientinterviewisfor ISTOENSUREWHATTHEPATIENTSAIDIS UNDERSTOOD Thoughtprocesswherethepointisnotconveyeddirectlyorcompletely. Circumstantial GotoTableofContents 254 Geriatrics 65y/ow/h/oasthmapresentsfortreatmentofessentialtremor.Whichforfirstline?(4x) PRIMIDONE 91y/ohospiceptw/cachexia,endstagedementia,andrenalimpairmenthas stoppedeatinganddrinking.Whatcomfortmeasurewouldbemostappropriate? FREQUENTSMALLSIPSOFWATER (3x) 75y/optwithADstartedonquetiapine12.5mgbidforagitation>according OmnibusBudgetReconciliationAct,theMDmust:(2x) ATTEMPTTODECREASEORSTOPTHEMEDDOSEAT LEASTEVERY3MONTHS. Whichmetabolicchangesischaracteristicofnormalaging? CREATINECLEARANCEDECLINES 80y/optwithAlzheimerdementiawholiveswithadaughterisbroughtinfor evaluationofincreasinglycombativebehavior.Thedaughterwouldliketokeepthe ASSESSINGFORCAREGIVERBURNOUT ptathomeifpossible.Whatinterventionwouldbemosthelpfulinthissituation? Pts>65yearswbipolardisorderdifferfromyoungerptswsamedx—how? MOREMIXEDEPISODES Psychevalof82y/oFwithmemoryloss(mostlyworkingmemory):shefrequently callsforhelpwithbathroombutwillurinateonherself(stafffeelptisdoingthisto SCHEDULEREGULARVOIDING,INDEPENDENTOFPT getbackatthem).Ptfrustratedwithstaffbecauseshefeelsthesuddenneedtovoid REQUESTS,ANDSUFFICIENTLYFREQUENTTO withoutmuchwarningandwishesthestaffwouldarrivesoonerbecauseshe’s ELIMINATETHEACCIDENTS embarrassedaboutthis.MSEsignificantonlyformodmemoryloss,labsarenormal. Whichbehavioralinterventionshouldbeattemptedwithpt? Whatpharmacokineticpropertyremainsmoststablewithage Absorption Neurocognitivefunctionsmostlikelytoshowdeclineinpeopleover65yearsofage? INFORMATIONPROCESSINGSPEED Whichisimportantwhenworkingw/familymemberswhoarecaregiverstopts w/dementia? •Thereneedsonlybeonecaregiveratatime •Griefworkw/famnotnecessarybeforept.dies •Allfamtoequallysharecaregivingresponsibility •Workw/famshouldenhanceeffectivenessofcaretopt. •FamshouldexploreSNFoptionsassoonasptisdiagnosed WORKW/FAMILYSHOULDENHANCEEFFECTIVENESS OFCARETOPT WhatjustifiesusingValproatemorecommonlythatlithiumforBMDinpts>age65? CHANGESINRENALCLEARANCEMAKESLITHIUM DOSINGPROBLEMATIC Mostprevalentmovementd/ointhoseover70y/o? ESSENTIALTREMOR 77y/optw/hxofBMD,stablew/bupropion300mgandvalproicacid1000mg Qday.Ptreportsfeelinglessmotivatedthanusualatwork,abletoconcentrate,but B12ANDHOMOCYSTEINELEVEL takinglongertofinishtasks.Deniedsadness.HTNiswellcontrolled.MMSEscore 26/30.Pthasmasterdegree.Themostappropriateworkup: 68y/optw/hxofschizophreniasinceearlyadulthoodandmaintainedforyrson thioridazine.Onexam:pt’stonguefrequentlyretractsonitslongitudinalaxisand GRADUALLYD/CTHIORIDAZINEANDSTARTLOWDOSE GotoTableofContents 255 movesinlateraldirections.Nootherfindings.Whentonguemovementsarepointed RISPERIDONE out,ptreportsbeingunawareofmakingthem.WhatrecommendationforbestTx: Whatcharacterizesexecutiveabilitiesinhealthyindividuals>65? SHOWNOSIGNIFICANTCHANGE Whatcharacteristicisassociatedwithbetteradaptationinindividuals>65? UNCRITICALACCEPTANCEOFIDEAS WhichisNOTcommoninpatients>65:depression,cogd/o,phobias,ETOHd/o, psychoticd/o PSYCHOTICD/O Whatcausesofdecreasedvisioninolderadultsischaracterizedbyaninabilityto focusonanobjectasaresultofretinaldamage MACULARDEGENERATION Malesexualityintheseventhdecadeischaracterizedbywhichofthefollowing? NOCHANGEINSEXDRIVE Whichcontrollingforhealthstatus,whichofthefollowingbestdescribesthe relationshipbetweenretirementandsubsequentmortalityrisk? NOINCREASEINMORTALITYRISK Whichofthefollowingisthemostpowerfulpredictoroffallinginolderadults? USEOFSEDATIVEMEDICATIONS Ptswlate-lifedepressioncomparedwearlyonsetdepressionmorelikelytoreport: PSYCHOTICSXS Ptsover65y/oarelesslikelytotoleratehigherdosesofantipsychoticsdueto: DECREASEDHEPATICMETABOLISM First-linemedforinsomniain78y/optwithdementia: ZOLPIDEM 78y/optwithAlzheimer’sdementialivingwithspouseanddaughter,startingto accusethespouseofinfidelity.Onevaluation,heassertsthatthespouseis ARRANGEFORREGULAREVALUATIONSOFTHEPTAND unfaithful.Heisalertandactscongeniallywiththespouse,heisondonepezil.Labs REASSURETHEFAMILY. andmedicalworkupisunrevealingofanydisorderoutsideofdementia.Next? Familyof75y/optisconcernedabouthissafetyb/chehasbeenforgettingtoturn offstove.PsychMDsuspectsanevolvingcognitived/o.Whatismostlikelytobethe INABILITYTORECALL3WORDSAFTERA3MINDELAY earliestimpairmenttooccurinthept? Changesw/sleepassociatedwithaging: DELTAWAVEAMPLITUDEDECREASESAND PROPORTIONALLYLESSTIMEISSPENTINSTAGE3AND 4 Whencomparedtoyoungeradults,anxietydisordersinadultsoverage65have: LESSCOMORBIDITYWITHALCOHOLABUSE Medicarepaysforhospicecarewhenaphysiciandeclaresthatapatienthasa maximumlifeexpectancyofhowlong? 6MONTHS 80y/optwithAlzheimer’sdementiawholiveswiththedaughterisbroughtinfor evaluationofincreasinglycombativebehavior.Thedaughterwouldliketokeepthe ASSESSINGFORCAREGIVERBURNOUT ptathome,ifpossible.Whichofthefollowinginterventionswouldbemosthelpful inthissituation? Innormalaging,lastcognitiveabilitiestodecline Wordknowledge GotoTableofContents 256 HIV/AIDS EndstageAIDSwithworseningfinemotormovement,fluency,andvisualspatial coordination,Dx?(2x) AIDSDEMENTIACOMPLEX HIVseropositiveptw/psychoticsymptomshasanabsoluteneutrophilcountof 950cells/mm3.Ptisonzidovudine,lamivudine,andritonavir.Whatantipsychotic CLOZAPINE wouldbecontraindicated?(2x) 34y/optw/hxofmemoryimpairmentdiesofunknowncauseforautopsy. Pathologicalexam:diffuseandmultifocalrarefactionofcerebralwhitematter accompaniedbyscantyperivascularinfiltratesoflymphocytesandclustersofafew HIV-ASSOCIATEDDEMENTIA foamymacrophages,microglialnodules,andmultinucleatedgiantcells.Mostlikely Dx: Whenisapsychiatristpermittedtonotifya3rdpartyidentifiedtobeatriskfor contractingHIVfromapatient WHENPATIENTWAIDSUNWILLING/UNABLETOTAKE AUTONOMY-PRESERVINGPRECAUTIONSLIKE ABSTINENCE AIDSpatientwithmemoryproblems,Rhemiparesis,Llimbataxia,BLvisualfield deficits,andnormalCSF.MRIT2scanshowed. PROGRESSIVEMULTIFOCALLEUKOENCEPHALITIS AIDSandprogressivehemiparesisandRhomonymousvisualfielddeficitassocw patchywhitematterlesionsonMRIwithnormalroutineCSF. PROGRESSIVEMULTIFOCALLEUCOENCEPHALOPATHY Gaycoupleseekstherapy.OnehasHIV,oneisnegative.HIVnegativefeelsbetrayed MEDIANDURATIONOFASYMPTOMATICSTAGESOFHIV andbelievesHIVpositivepartnerwasunfaithful.Whatshouldtherapistsay? INFECTIONINTHEUSIS10YEARS MostfrequentrouteforHIVtransmissioninteenagegirls HETEROSEXUALCONTACT WhatisapoorprognosticsignforHIV? DEMENTIA AIDSpt,progressiveweaknessofextremitiesoverweeks.Distalsensorydeficitfor pinprickandvibration.Slownerveconduction,butEMGshowsnodenervation CHRONICINFLAMMATORYDEMYELINATING POLYRADICULONEUROPATHY InconsideringsafesexpracticesforavoidingHIVinfection,oralsexisbest characterizedby: CANRARELYTRANSMITVIRUS PrevalenceofAIDSincreasedafterdiscoveryofAZT,bestexplanation? moreptswerelivinglonger ECT 47y/optwacutemaniaisunresponsivetopharmacotx.Pt’scurrentmedregimen includeslithium,divalproex,clonazepam,olanzapine,bupropion.ECTisbegun,pt LITHIUM iscontinuedonpreviousmedregimen.After2ECTtx,ptbecomesdelirious. Cause?(x3) WhatmedicalconditionhashighestrelativeriskforadverseeventwithECT? Congestiveheartfailure GotoTableofContents 257 PtwithMDD4-wksintosertraline200mgtrialwithoutimprovement.Duloxetine 90mgaddedforanadditional6weeksfollowedby4-weeksonphenelzine90mg.Pt ECT conttobedepressed.Whatwouldbethemostdefinitivetreatment: WhatisassociatedwithamarkedlyincreasedriskofcomplicationsfromECT? COPD Theabilityofmagneticseizuretherapytotargetspecificbrainregionsimplicatedin FEWERCOGNITIVESIDEEFFECTS depressiongivesitwhatpotentialadvantage,comparedwithtraditionalECT: 58y/owithMDDisgettingECT,developsdenseretrogradeamnesiaafter3rd treatment.Howcanthisbeameliorated? INCREASINGTHEINTERVALBETWEENECTTREATMENTS PthasnotrespondedtoadequatetrialsofSSRI,SNRI,TCA,MAOI,butfeels improvedwith8treatmentsofECT.Whatnext? CONTINUEMAINTENANCEECTFORATLEAST10WEEKS TranscranialmagneticstimulationforTxofdepressiontargetswhichbrainregions? PREFRONTALCORTEX WhichmedshouldbeheldbeforeECT? LITHIUM WhatbarbiturateisusedinECTtoproducealightcoma? METHOHEXITAL Greatestriskofdeathw/ECT: RECENTMI Indicationfortreatingamanicw/ECT: DANGEROUSLEVELSOFEXHAUSTION ECThasincreasedcomplicationsinpatientswithwhatmedicalcondition? COPD ECTisleastlikelytobeeffectiveforpatientswhohave? CHRONICSCHIZOPHRENIA WhatconditionisarelativecontraindicationtoECT? CARDIACARRYTHMIA Ptw/hxofmelancholicdepressionisseverelydehydrated,emaciated,and catatonic.Hebeganwithdrawing,talkingaboutdeath,stoppedeatinganddrinking andlost20lbs.Txofchoice? ELECTROCONVULSIVETHERAPY(ECT) Uponadmissiontothehospitalan85yearoldmanisseverelyemaciated, dehydrated,andcatatonic,andhaslost20lbs.Hehasa35-yearhistoryof melancholicdepression.4weeksagohebeganwithdrawingfromrelatives,talking constantlytalkingaboutdeathandstoppedeatingordrinkingunlesspromptedby hisdaughterinsistently.Priortoexhibitingthesesymptomsthepatientwas medicallystableandreportedlyhealthy.Whatistheappropriatetherapyoncethe patientismedicallystabilized? ELECTROCONVULSIVETHERAPY(ECT) A70y/opatientpresentswithseverepsychoticdepression.Patientstopped eatingandspeaksverylittle.Failedmultiplemedtrials.What’snext? ECT PsychMDiscounselingaptaboutrisksandbenefitsofECT.Whatstatement correctlydescribestheriskofcognitiveimpairment? HIGHDOSEUNILATERALELECTRODEREPLACEMENTIS ASSOCIATEDWITHLESSCOGNITIVEIMPAIRMENT. Medthatisassocwprolongedseizures/confusionalstateduringECT: LITHIUM WhichmedicationshouldbediscontinuedpriortoECT? BUPROPION GotoTableofContents 258 CorrelatesofapositiveresponsetoECTincludewhichofthefollowing? INCREASEDECT-INDUCEDFRONTALDELTAACTIVITY MostimportantpotentialsideeffectofECTtodiscusswith78yopatient(2x) COGNITIVEDYSFUNCTION TMSadvantagesoverECT Lackofanesthesia ChildhoodandDevelopment Attachment Adult’spatternsofinteractingwithotherspredictedbywhataccordingtoobject relationsandattachmenttheory capacitytoperceiveandthinkabouttheintentionsof others WhichneurotransmittersystemisthelasttomatureintheCNSofchildrenand adolescents?(2x) CHOLINERGIC The“strangesituation”inchilddevelopmentisusedtoassesstheinfant’sin attachmenttheory:(2x) SECURITYOFATTACHMENT Infantsaremorelikelytohaveinsecureattachmentwithpoorchildcareifprimary caretakersarealso: UNRESPONSIVETOTHEIRINFANT’SNEEDS Keycharacteristicofpreschoolerswhoaresecurelyattached TRUSTANDRECIPROCITY Whathasbeenfoundregardinginfants’attachmenttotheirparents? STRENGTHOFINFANT’SATTACHMENTISAFUNCTION ONLYOFTHEAMTOFINTERACTIONWITHTHEPRIMARY PARENT Whatstatementaboutinfant/parentinteractionsissupportedbyintegrationof clinical/experimentalobservationsinearlychilddevelopment? INFANTSAREBORNWITHSOPHISTICATEDPERCEPTUAL ABILITIESTHATFACILITATEATTACHMENT Atwhatdevelopmentalstageduekidsfirstexhibitabilitytorecognizetheir PRE-SCHOOLAGE thoughtsandfeelingsaretheirown,andthatothersmaythinkandfeeldifferently? Startingaroundage3years,childrenspontaneouslyuselanguageinwhichofthe followingways? DESCRIBEPASTEVENTS Comparedtopreschool-agechildren,aschool-agechildwithnormallanguage developmentwilldemonstratewhatability? CONSTRUCTINGSENTENCESWITHMULTIPLECLAUSES WhichofthefollowingtermswasdevelopedbyReneSpitztodescribeacommon outcomefollowingsuddenorprolongedseparationofotherwisenormallyattached ANACLITICDEPRESSION infants? GotoTableofContents 259 18m/oisvulnerabletoseparationandconstantlyconcernedaboutmother’sactual RAPPROCHEMENT location.ThisisrepresentativeofMahler’sstageof: 2y/odoesnotwanttoletgoofwoolblanketandresistsgoinganywherewithoutit. TRANSITIONALOBJECT Attachmenttypeis: Preschoolchildrenwithimaginaryfriendsare: FAIRLYNORMAL Afemalechildperformsadanceforhermotherandbasksinthegleamofher mother’seyes.Accordingtoself-psychology,thechildishavinganexperienceof: MIRRORING Whichofthefollowinginfantandtoddlertemperamentalstyleshasbeenshownto havethegreatestassociationwiththeeventualonsetofanxietysymptomsin INHIBITED childhood? Theparentsofa3y/ochildareconcernedbecauseshehasnotbegunspeak intelligently.Thechild’shearingisnormal.Doctor’sresponse: EXPRESSSOMECONCERNSBCMOSTCHILDRENTHIS AGECANEFFECTIVELYMAKETHEMSELVES UNDERSTOOD. 5y/ochildwithbehavioralproblemsinschool,inandoutoffostercareforthefirst 2yearsoflife.Friendlyandaffectionatewithothersevenwithstrangers.Parents REACTIVEATTACHMENTDISORDER don’tfeel“close”tothechildanddoesn’tseemtohaveenduringfriendships. Diagnosis: 4yoraisedinMultplefosterhomes,minimallysmiles,doesnotseekcomfort ReactiveAttachmentDO Childhood-onsetschizophreniatypicallyhaveacoursedescribedas: CHRONICANDUNREMITTING Abilityofaninfanttoutilizesymbolicrepresentationatage18monthsallowsfor: USINGLANGUAGEPROFICIENTLY ChildholdstoytelephonetofaceandspeakstoDaddy.Thisbehavioriscalled? SYMBOLICREPRESENTATION Inpreschool-agechildrenisolatedhallucinationsarecommonwith: ANXIETY Apreschoolermisseshislong-termnannywhohasrecentlymovedaway.Tohelp thischild,theparentsshould:(2x) SHOWTHECHILDPICTURESOFTHENANNY Toddlersoothedatnightbyinnermemoryofsecurerelationshipwithmother. Calledwhat(inattachmenttheory): OBJECTCONSTANCY 18montholdshowsamarkedawarenessofvulnerabilitytoseparationandseems tobeconstantlyconcernedaboutthemother’sactuallocationisexhibitingMahler’s OBJECTCONSTANCY stageof? ThetermrapprochementinMahler’sdevelopmentaltheoryreferstothe: RECONCILIATIONFOLLOWINGABRIEFATTACHMENT RUPTUREBETWEENTODDLERSANDPARENTS FinalphaseofMahler’sseparation—abilitytomaintainpositiveemotional attachmentinfaceoffrustration OBJECTCONSTANCY Followingabriefseparationfromtheparents,asecurelyattachedtoddlerismost likelytodowhichofthefollowing: SEEKCONTACTEAGERLY GotoTableofContents 260 Whichoffollowingparentaltasksbecomesimportantduringtoddlerhood? LimitSetting Development 7y/owithtempertantrums,refusestogotoschool.Stomachachesand headachesonschooldays.Nightmaresaboutbeingkidnapped,fearsparentswill die.Dx?(4x) SEPARATIONANXIETYD/O Anexampleofparallelplay:(2x) A2YOCHILDSITSNEARANOTHERTODDLERWITHA TRUCKANDPICKUPACAR. 14y/ofromjuvenilehall,gettingaggressive.Longh/obehaviorproblemsbutno EVALUATETHEPATIENTFORADDITIONAL psychormedicalhx.Inadditiontodiagnosingbehaviorproblem,whatisfirststep PSYCHOPATHOLOGY forpsychiatrist?(2x) Whichagesofchildrenareinterestedinsecrets,collecting,andparticipatingin organizedgames?(2x) ELEMENTARYSCHOOL Childargueswithmom,isangryandrude.Hasnotroubleatschoolandcompletes OPPOSITIONALDEFIANTDISORDER schoolwork.Dx?(2x) Coregenderidentityistypicallyestablishedbywhatage?(2x) 3YEARS Parentsreport3y/ohasnotbeguntotalk.Sincebirthchildhasbeendistractible. Alsoreportchildseemstohaveproblemempathizingwithsiblings.Whatquestion “HASYOURCHILD’SHEARINGBEENTESTED?” shouldthePsychMDaskfirst?(2x) 2y/oclingstomotherwhenintroducedtoanewchild,refusingtojoininplay during1stvisit.On2ndvisit,childplaysbehindmother,andon3rdvisit,she seemstocontinueherusualactivitieswhilewarilyeyeingthenewchild.What temperamentaltraitsorconstellationsbestdescribesthischild’sbehavior?(2x) SLOW-TO-WARM-UP Childrendemonstrateapreferenceforthehumanvoiceandspeechoverother soundsatwhatage?(2x) BIRTH AccordingtoFreud,whichofthefollowingisconsideredtobethemostsalient featureofnormalpsychosexualdevelopmentinchildrenbetween1-3yearsof age? CHILD-PARENTSTRUGGLESABOUTTHENEEDTODELAY GRATIFICATIONOFDESIRES A4yohasdevelopedwhatlanguageskills? STORY-TELLINGUSINGWORDS Two4-yroldsplaying,onemakesloudnoise,theotherdoesnotwanttoplayany more.Why? PLAYPRODUCEDEXCESSIVEANXIETYFORCHILD Whichofthefollowingparentbehaviorismostimportanttotoddlerslanguage development? ENGAGINGINFREQUENTCONVERSATIONAND THINKINGALOUD 10-montholdinfantbecomesdistressedwhenparentsleavechildw/babysitter withoutaffection.Whichsubsequentbehaviorpatternislikely? CLINGYANDAVOIDANTTOWARDPARENTS GotoTableofContents 261 Thefatherofa3½yearoldboywhoattendspreschoolreportsthatonseveral occasionstheboyhascomeintothebathroomwhilethefatherisintheshower interestedinobservinghisfather’sgenitalsaskingonce“whyisitsofat?”This behaviormostlikelyisanindicationof? NORMALPRESCHOOLAGESEXUALINTEREST Pretendplay,basedonabilitytosymbolize,typicallyappearsatwhichofthe followingstagesofdevelopment? TODDLERHOOD Whichgroupchildrenareatgreatestriskfordeathresultingfromchildabuse? BIRTHTO3Y/OOLD Cognitivestrategyoftypicallydevelopingschool-agechildreninresponsetotheir environment? GRADUALLYINTEGRATINGTHESENEWEXPERIENCES INTOPRE-EXISTINGMENTALCONSTRUCTS Whichofthefollowingischaracteristicofpreadolescentchildren’sphysicalgrowth? THEGROWTHRATEFORBOYSLAGSBEHINDTHE GROWTHRATEFORGIRLS A5yearoldchildwhosemotherwasinaminorcaraccidentbelievesheis responsibleforcausingtheaccidentbecauseheyelled“Ihateyou”inprotestwhen AGEAPPROPRIATEEGOCENTICTHINKING hismotherlefthimwithababysitteranhourearlier.Thisbeliefrepresentswhichof thefollowing? ChildwIQof68willlikelyhaveadjustmentissuesandstruggleswwhich developmentalstage? ADOLESCENCE 77.7yoMwagressionwasreferredbyschoolforevalafterIQof68discovered.Pt wastemperamentallyinhibitedandavoidantasaninfant,difficultyinteractingw peersandpreoccupationwithtrainsatage2.Nostereotypesortic.Whichaspeect ofthispresentationismostindicativeofautismspectrumdisorder? SYMPTOMSPRESENTBEFOREAGE3 2.5y/oobservesmothertakeanapplefromtherefrigerator,motherbrieflyturns backtothechildandbeingseating,whenmotherturnstowardchildheanimatedly AWARENESSOFBEINGASEPARATESELF grabsfortheappleandsay,“myapple,notMommy’s.”Thisbehaviorisbest describedaswhichdevelopmentalachievements? Adolescentwhowaspreviouslygettingalongwithparentsisnowbecomingmore resistanttoparentalcontrolandinsistentaboutmakinghisowndecisionsabout AWISHTOSEVERTHEPARENT-CHILDRELATIONSHIP dailylife.Feelingirritatedwithparentsandguiltyafterminorarguments.Feelingsof guiltarelikelyexplainedby? Achildwithtempertantrumsathomebeginstohavebettercontroloverher outburstsfollowingwhichinterventionbyparents? HADNEGATIVEREINFORCEMENTOFTHETANTRUMS REMOVED Theparentsofatoddlerareconcernedaboutarentincreaseinthefrequency, intensityanddurationofthechild'stempertantrums.Theparentsreportthatthe toddlergetsonthefloor,kicksandscreamswhentheysetlimits.Thechild'shealth EXPLORETHEPARENTS’CONCERNSABOUTSEEMINGLY anddevelopmentalhistoryisunremarkable.FMHxsignificantformooddisorders NORMALBEHAVIOR andADHDandODD.Whichofthefollowingwouldbemostappropriateasnext step? Apatientrepeatedlybecomesdistressedafterwhatseems,eventothept,tobe minordisappointments.Thepatientalsoseemstosufferfromextremenarcissistic vulnerability.Atherapistutilizingself-psychologywouldbemostlikelytointerpret thisduetowhichofthefollowingfactors? ALACKOFDEVELOPMENTALLYAPPROPRIATEEMPATHY FROMCAREGIVERS GotoTableofContents 262 AccordingtoWinnicott,whichisanessentialcomponentofparentinginfants? BEINGSENSITIVETOTHECHILD’SINSTINCTFOR EXPLORATIONANDGROWTH Thetemperamentaltraitofharmavoidanceisassociatedwithpolymorphismson whichcandidategenes? SEROTONINTRANSPORTER WhichcomponentofADHDmostlikelytoremainuntiladulthood? Inattention In8-11y/okids,whichmoralskillisthe1stonetofullydevelop? INTERNALIZATIONOFPARENTALVALUES 7y/oreferredforpsychevalduetolearningprobs.Mosthelpfulinfowouldbe family’sapproachtoandhx READINGWITHTHECHILD Ariskfactorforchildabuse: FINANCIALSTRESS Whichofthefollowingisariskfactorforchildabuse? PRESENCEOFASTEP-PARENT Themostcommonlearningdisabilityfoundinschool-agechildren READINGDISORDER Whatismostcommonlearning/communicationD/Oinkidsreceivingspecialed? READINGDISORDER A4thgradechildisfallingbehindpeers.ChildhasIQof92,butlowerthanexpected scoresonachievetestsandadaptivefunctioning.Teacherreportschildvoices LEARNINGDISABILITY understandingofmaterial,butstruggleswithhomework,whatischild’sdiagnosis? Achildw/selectivemutismismostlikelytohavedifficultiesinwhicharea? ATSCHOOL A5year-oldbilingualchildhasprogressiverefusaltospeakinpublic,beingvery BEHAVIORALTREATMENTTOINCREASETHECHILD’S talkativeathomeandrefusingtospeakthroughoutthedayinhiskindergarten TOLERANCEFORSPEAKINGINPUBLIC class.Heisdiagnosedwithselectivemutism.Whatistheappropriateintervention? Whatisconsideredtobethedeycomponentunderlyingthesyxofselective mutism? AVOIDANTBEHAVIOR 17½y/optmentionsdrinking“afewbeers”atpartiesandsmokingTHC “sometimeswithfriends.”Theadolisdoingwellinschool.Hasclosefriendsandhas TYPICALADOLESCENTBEHAVIOR nosignificantconflictsathome.Adol’suseofsubstanceisbestcharacterizedas: 4½y/ochildinsiststhereisasmallmonkeywhosharesthechild’sroom.Hetalksto monkey,asksotherstoconversewithmonkeyandinsiststhatmonkeyhaveaseat BEHAVIORTYPICALFORPRESCHOOLERS atdinnertable.Parentsaskiftheyshouldbeconcerned,bestresponse: Adifficultchild,accordingtoThomasandchess’scategoriesoftemperament, expectwhatcharacteristics? INTENSEEXPRESSIONOFMOOD Accordingtoneuroimagingstudiesofadol,theprefrontalcortexatthisage: PREFRONTALCORTEXDEVELOPSLATERTHANOTHER AREASOFBRAIN Capacitytoinhibitbehavioralresponsesimprovesovercourseofadolescencemost MATURATIONOFPREFRONTALCORTEX likelybecauseof GotoTableofContents 263 Pretendplayinpreschool-agedependsuponchildren’sincreasingabilityinwhich skills USEOFONEOBJECTTOREPRESENTANOTHER Whentoddlerattributesasymbolicmeaningtostuffedanimal(e.g.teddybear), imbuingitwiththequalityofbeingalive,thisisreferredtoas: ANIMISM The“falsebelief”testofyoungchildrenusestwodollsinaninteractionwhereby onedollhidesamarbleinfrontofaseconddoll,andthenmovesmarblewhile seconddollleavesthescene.Theseconddollre-enterssceneandchildsubjectis thenaskedwherethisdollbelievesmarbletobe.Thistestisusedtoassess: THEORYOFMIND 4y/ochildisadministeredthe“falsebeliefstask”inwhichtwodollsactoutascene, wherebyonedollswitchesthelocationofamarblefromonesitetoanother,while theotherdollleavesthesceneoftheaction.Whentheotherdollreturnstolookfor THEORYOFMIND themarble,thechildcorrectlypointsoutthatitwilllookintheoriginallocation. Thisresponsedemonstratesthechildisshowingevidenceof: Whichofthefollowingstatementsbestdescribesthecurrentconceptualizationof familythatinformsfamilysystemtheoriesandtreatmentapproaches? FUNCTIONINGFAMILIESTENDTOHAVECERTAIN SHAREDCHARACTERISTICATTRIBUTESRATHERTHAN COMMONSTRUCTURES Kohut’stheoryofpersonalityisbasedon: THEINDIVIDUAL’SNEEDFOREMPATHICINTERACTIONS WITHSELF-OBJECTS. Thebirthofanewsiblingisassociatedwiththerecurrenceoftoiletingaccidentsina NORMALREGRESSION 3y/owhohaspreviouslybeensuccessfullytrained: 81.AccordingtoWinnicott’stheoryofthedevelopmentofaninfant’sassertiveness ENCOURAGESSPONTANEITYWHILEPROTECTINGTHE andsenseofcompetencewhatbestdescribesthecriticalfunctionoftheholding CHILDFROMHARM environment? Atwhatagedochildrenbegintoguidetheiractionsinambiguoussituationsusing cuesfromthemother’sfacialexpressionorinhertoneofvoice? 12MONTHS Winnicottdefinedhisconceptofholdingenvironmentasthe: SAFECONTEXTPROVIDEDBYCONSISTENTAND RELIABLEPARENTING Maturationofbasalganglia/corticalmotorcircuitsismostcloselyassocw developmentof: SOCIALSMILE 3½y/ogirlhasincreasinglybecomeinterestedindressingupinhermother’s clothesandshoes,withincreasedremarksaboutbeingagirl.Itwouldbemost BASEDONMATERNALMODELINGANDBEHAVIOR consistentwithasociallearningtheoryexplanationofpsychosexualdevelopment tosaythatherbehavioris(x2): Fatherisconcernedabout6y/osonbecausechildisrubbinggenitalswhilein bathtub.Thishasnotoccurredatschoolorinpublic.Explanationofbehavior? NORMALBEHAVIOR. Aschildrenprogressthroughschoolagedevelopment,theybeginto RECOGNIZEETHNICANDRACIALSTEREOTYPES GotoTableofContents 264 Afterastrangersays“hello,”a12-month-oldchildturnsandlooksathismother beforeresponding.Whenthemothersmilesandnodsherhead,theinfantlaughs andsmilesinresponsetothestranger: SOCIALREFERENCING Theformationofsmallpeergroupswhosharevalues,speechpatterns,and mannersisfirstseenaroundwhatage? 8YEARS Aninfantwhoengagesinaninteractivegameofpeek-a-boomostclosely demonstratestheconceptofwhichcognitiveability?(2x) OBJECTPERMANENCE Achild’sparentsareveryconcernedthattheir4y/osonstillwetshimselfseveral timesaweek.Thechild’sbrotherswerepottytrainedwhentheywere3and3.5 yearsold.Thereisnoevidenceofdevelopmentaldelayandthechild’spediatrician hasfoundnothingunusual.Whichwouldbemostappropriateintervention? REASSURANCEANDMONITORING 4½y/ochild,playingaloneathomewithsometoycars,isobservedbyparentsto bespeakingoutloudwhileplaying,excitedlymakingcommentssuchas,“let’sgoso NORMATIVEASPECTOFPRESCHOOLPLAY fastthatthemonsterwillnevercatchus.”Thistypeofspeechmostlikely represents: Achildwithcancerachievesremissionafterundergoingextensiveandmultiple treatments.Twoyearslater,thechilddevelopsarecurrenceofthecancerthatis unresponsivetotreatment.Thechildsays,“I’mdying.Ijustwanttobeathome 14YEARSOLD withmymom,mydad,andmysister.”Atwhatagewouldthechildmostlikelybeto havethisresponsetothissituation? Childrenshouldplaytogetherwithsocialinteractionandroleplayingbywhatage? 4Y/O Eriksontheorizedthatasuccessfuldevelopmentaltaskinthe40-60y/ogroupisto: FEELUSEFULTOSOCIETYTHROUGHBEHAVIORSTHAT PROTECTFUTUREGENERATIONS. Sexplayfrom8-13y/oindicativeof: TYPICALCHILDREN AccordingtoKohlberg’stheoryofmoraldevelopment,a9y/ochildwouldbe expectedtoreachthedecisionthatanactioniswrongbasedonwhichofthe followingcriteria: RECOGNIZEETHNICANDRACIALSTEREOTYPES Anexampleofparallelplay:(2x) A2YOCHILDSITSNEARANOTHERTODDLERWITHA TRUCKANDPICKUPACAR. Ayoungchildtriestodeterminehowmanyseatingarrangementstherearefora TYPICALAPPROACHFORTHISSTAGEOFCONCRETE familyof5aroundatable.Thechildusesnosystemandspendshourstryingtofind OPERATIONS alloptionsrandomlyandincompletely.Thisapproachsuggests: Onsetofpubertyinboysbeginswith: TESTICULARENLARGEMENT Adoptedchildrenwhohaveabiologicalparentwithalcoholdependenceareat increasedriskofdevelopingalcoholdependencewhencomparedtotheiradoptive siblings.Thisisevidenceforwhichofthefollowingmodelsofsubstanceabuse? DISEASEMODEL GotoTableofContents 265 4y/ogirldevelopednormallyinthe1st18monthsoflife,butafterwardsdeveloped deceleratedheadgrowth,lossofpurposefulhandmovements,midlineupper RETTDISORDER extremitystereotypies(e.g.hand-wringing),severepsychomotorretardationand socialwithdrawal: Whicheventprecipitatesmidlifecrisis? RECOGNITIONOFUNATTAINABLEGOALS IntheUS,whichofthefollowingisthemostcommonprecipitantofPTSDinchildren INTRAFAMILIALVIOLENCE andadolescents? 7month-oldisnotcrawling.Pediatricianisunconcerned.Childisalert,responsive, sitsnormally,showsgoodresponsetotoys/stimuli.Psychiatristshouldtellfamily: REASSURANCEANDPROVIDEREADINGMATERIALS 5y/oadoptedatage4nowhuggingstrangers,ageappropriatevocabulary,doesn’t REACTIVEATTACHMENTD/O respondwelltolimits,easilyfrustrated. 3y/owithdiminishedappetite,slowspeechdevelopment,poorsocialinteractions; parentsaredetachedfromhim.After2weeksinhospitalisimprovingandfriendly REACTIVEATTACHMENTD/O withstaffmembers.Dx? 20-monthchildrepeatedlyreturnstohermomwhenplayingw/other2-y/o children.Thisis: RAPPROCHEMENT Askachild,“Whatmakesatraingo?”Hereplies,“Thesmokemakesitgo.”Thisis: PRE-OPERATIONALTHINKING Learningtriangularrelationships OEDIPALSTAGE Thedevelopmentoffullposturalcontrolinchildrenby4yrsoldcorrelates neuroanatomicallywiththedevelopmentalmaturityofwhat? MYELINATIONOFCEREBELLARFIBERS Therapidlearningdemonstratedbychildrenduringtheschool-ageyearsis paralleledneurodevelopmentallybywhichofthefollowingbrainprocesses? INCREASEINWHITEMATTER A10yochildremainssadandangryabouthisparent’sdivorcebutnolonger believesthathecausedtheseparation.Thiscognitivechangeisexampleofwhat mechanism? DECENTRATION Psychiatristisevaluatinga5y/ochildinkindergarten.Childdoeswellwithpuzzles andotherperformanceactivities.Teacherreportsthatthechildhasalimited vocabularyandimmaturegrammarincomparisontotheotherchildren.Child interactswellwithotherchildren.Thechildalsoseemstohavesometrouble understandingquestions.Child'shearingandvisionarenormal.Explanation? MIXEDRECEPTIVE&EXPRESSIVELANGUAGED/O Stageofdevelopmentassociatedw/settingupclubs,makingrules LATENCY Abilityofpreschoolchildrentoregulateemotionsismoststronglyenhancedbythe LANGUAGE developmentof: AccordingtoThomas&Chess’categoriesoftemperament,thedifficultchildshows INTENSEEXPRESSIONSOFMOOD whatcharacteristics? Signofpyromania FEELINGRELIEFONSETTINGAFIRE GotoTableofContents 266 Todefinelearningdisability,lookfordiscrepancybetween: INTELLECTUALPOTENTIALANDPERFORMANCE Integrationofclinicalandexperimentalobservationsinearlychildhood developmentsupportswhatstatementaboutinfant/parentinteractions? INFANTSAREBORNWITHSOPHISTICATEDPERCEPTUAL ABILITIESTHATFACILITATEATTACHMENT Incombowgrowthhormone(GH),whatisrequiredtoinitiateadolescentgrowth spurt? GONADALHORMONES Showntobecriticaltothedevelopmentofmaternal-infantbondinginanimals: OXYTOCIN AcompoundthatincreasesmusclemassbyincreasingepisodicsecretionofGH: GAMMAHYDROXYLBUTYRATE Socialreferencingisgenerallyevidentatage: 12MONTHS 3y/oapproachesacrossingstreet,looksatmother’sexpressiontodecideifitis safetocross.Thisisanexampleof:(2X) SOCIALREFERENCING 6y/ow/4wkintenseeye-blinkingandlippursing.Waxandwane,increasewith stress.FamilyHxofticd/o.Firststep: EXPLAINTOFAMILYMAYBETRANSIENT 2y/oMhasbeenpreoccupiedwithasmallblanketforseveralmonths,carriesitw/ EXPLAINTHISISNORMALANDCHILDWILLEVENTUALLY himeverywhereandbecomesupsetifanyonetriestotakeitaway.Herefusedto GIVEITUPONHISOWN. stayw/ababy-sitteruntilitwasretrieved.Thepsychiatristshould: Achild’sunderstandingofdeath,attitudes,andresponsesatapreoperationalstage EXPECTINGTHEDEADRELATIVETOWAKEUP ofcognitivedevelopmentinclude: Adolescentwithacongenitalphysicaldeformityismostvulnerabletoemotional disturbanceduringwhatperiodofdevelopment? EARLYADOLESCENCE(11-13Y/O) Apreschoolerpresentstopsychiatristafterbeingplacedonpsychotropicmedbya PCP.Parentsnotethatsincemedwasstarted,childhasshownirritability,skin DEXTROAMPHETAMINE picking,decreasedappetite,socialwithdrawal,insomnia.Whichmedischildtaking? 6y/oatschoolcriesformom,otherkidsstartcrying: CONTAGION Myelinationiscompletedinwhatdevelopmentalstages? CHILDHOOD Thefirstsignofpubertyinafemaleismostcommonly? BREASTBUDS 9y/oisevaluatedforbedwettingseveraltimesaweek.Childhasneverbeen completelydry.WhichTxmodalityislikelytobemosteffective? BELLANDPAD Normallossof25-40%ofneuronsinfetalbraininthe2ndhalfofgestationiscalled: APOPTOSIS Whatisthemechanismforregulatingcellproductionandeliminationof inappropriateaxonalconnectionsinthedevelopingbrain? APOPTOSIS DifferentialDxina6y/owithdailyfecalsoilingincludes: ANALSTENOSIS,HYPOTHYROIDISM,HIRSCHSPRUNG’S DZ,SMOOTHMUSCLEDZ GotoTableofContents 267 Thestageoflifeinwhichconsolidationofapersonallyacceptablesexualidentity generallyoccursiscalled? ADOLESCENCE Developmentalstageinwhichbrainisexperiencingpruningofhalfofitssynaptic connections,adeclineinglucoseandoxygenmetabolismanddecreaseinEEG amplitude: ADOLESCENCE INcontrasttoattachment,“bonding”isassociatedwith Thenatureofaparent’srelationshiptoaninfant Thecapacitytosetreasonablegoalsforone'sselfandtoacceptone'simperfections ADOLESCENCE andotherslimitationsistypicallyfirstrealizedduringwhichdevelopmentalstage? AggressivebehaviorinpreschoolerswotherwiseNMLdevelopmentusuallydueto: LIMITEDVERBALABILITIES Vocabularygrowthandpre-literacylanguageskillsinpreschoolersappeartobe mostassociatedwith: AMOUNTOFTALKDIRECTEDTOTHECHILD Achildrecentlybecomesadeptatrunningandjumping,inusingapincergrasp,and 6YEARSOLD knowingthedayandyearismostlikelytobeatwhatage? Processbywhichchildrenmodifyexistingschemastoadapttonewexperiencesis: ACCOMMODATION Cognitivedevelopmentaltasksofadolescenceincludeacquiringthecapacityfor: MORECOMPLEXUNDERSTANDINGOFCAUSALITY& MULTILEVELREALITIES Theageatwhichchildrentypicallyfirstusesentencesof2ormorewordsis: 24MONTHS Earliestageinfantlikestolookmoreatstronglypatternedshapeslikefaces? 1WK Whatagecaninfantrecognizemothersfaceasdistinctfromotherfaces? 1MONTH Thecorticalsynapticremodelingcharacteristicofnormaladolescenceisalso believedtobeassociatedwithwhatneurobiologicalchange? PREFERENTIALLOSSOFEXCITATORYSYNAPSES Theprimarypsychologicaltaskofschool-agechildrenisachieving: COMPETENCE 13y/omaletellspsychMD“I’mtiredofbeingtheshortestboyinmyclass.”Pt reportsmanyofthegirlsaretallerthanheis.Bothoftheparentsaretall.Whatis themostappropriateinitialapproachforthepsychiatristtotake? REVIEWWITHTHEPTTHETYPICALCOURSEOFPUBERTY INMALES 5y/ochildexperiencesdeathofgrandmother.Childasks,“WhencanItalkto Grandmaagain?”Thisreflectsanincompleteunderstandingofwhatconceptof death? IRREVERSIBILITY Rapideyemovement(REM)sleepisfirstevidencedatwhichstageofdevelopment? INUTERO Accordingtoclassicalpsychoanalytictheory,whatfactorprimarilyaccountsforthe UTILIZATIONOFDEFENSEMECHANISMSTOAVOID polarizationofsamesexpeergroups? SEXUALIMPULSES Themostimportantfeatureofpostnatalbraindevelopmentisanincreaseinwhat? NUMBEROFDENDRITICANDAXONALPROCESSES Whatcharacteristicpresentina2y/oismostlikelytopersistintoadultlife? INHIBITION GotoTableofContents 268 3y/oboywantstoplaywithhismom,butsheistiredanditisnaptime.What explanationwouldhebestunderstand? “IT’SNAPTIMENOW.” Whichofthefollowingisthemosteffectiveevidence-basedtreatmentof oppositionaldefiantdisorder(ODD): PARENTMANAGEMENTTRAINING A10yochildpresentswithexplosiveoutburstsathomewhenaskedtocomplete tasksorwhentoldno.Thesebehaviorsarenotpresentwhileplayingwithsiblings. Whichofthefollowingtreatmentshasthelargestbodyofevidencesupportingits usetotreatthiscondition? PARENTMANAGEMENTTRAINING Infantwhoengagesinaninteractivegameofpeek-a-boomostcloselydemonstrates OBJECTPERMANENCE theconceptofwhichofthefollowingcognitiveabilities? Parentsofa16y/oboydiscoverhe’sbeenvisitingadultsexsites,spendingupto 1hreveryfewwkslookingatnakedwomenandheterosexualsexualactivities.Boy DEVELOPMENTALLYAPPROPRIATECURIOSITY likesseveralfemaleclassmatesbutisshyandspendsmostofhistimewithamixed gendergroupoffriends.Whatistheexplanationofhisinterestinthesesites? Childengagedwithimaginativeplaywiththerapist,statesdollhouseonfire, therapistpretendstocall911,childsaysit’snotactuallyafireit’sjustpretend,what PRE-OPERATIONALTOCONCRETEOPERATIONALSTAGE transitioninPiaget'smodelofcognitivedevelopmentisthischilddemonstrating? Ayounggirlsays“Iamgoingtostayagirlnomatterwhat,evenifIwearblueor haveshorthair”.Whatcapacitydoesthisdemonstrate? Longtermemotionalwellbeingofachildfollowingdivorcedependsmostupon whichpost-divorcefactor? Genderconstancy Cessationofconflictbetweenparents Phaseofchilddevelopment(MelanieKlein)wheretheyareabletointegrategood& Depressiveposition badelementsofcaregiverintooneunified‘object’ AccordingtoVygotsky,objectsandinteractionalexperiencesshouldbewithin theinfant’s… Zoneofproximaldevelopment ChildPsychiatry Longitudinalstudieshasshowedthatobesityinlaterchildhood,adoland adulthoodcanbepredictedmostcommonlybypresenceofwhichpsychiatricd/o DEPRESSIVE inchildhoodandadol?(2x) Primaryadvantageoftreatingchildhoodenuresiswithbehavioralmethodsvs desmopressin(2x) LOWERRATESOFRELAPSE Whichconcernsisthemostcommonreasonforreferralofchildrenandadol(6-16 DISRUPTIVEBEHAVIOR y/o)tomentalhealthprofessionals?(2x) Whichtypeofchildmaltreatmentismostprevalent?(2x) NEGLECT Whencomparedtoadol,8-12y/ochildrenwithdepressionmostoftenshow whichsymptom?(2x) SOMATICCOMPLAINTS Mostdistinguishableaspectofchildhoodseparationanxietyd/owhencompared FEARTHATSOMETHINGBADWILLHAPPENTOTHEM GotoTableofContents 269 tootherchildhoodanxietydisorders(2x) ORTHEIRPRIMARYCARETAKER MostcommonlyreportedSEofstimulantsinkids(2x) APPETITESUPPRESSIONANDSLEEPDISTURBANCES 8y/owithpersistentdelayedsleeponsetdespitegoodsleephygiene,givenno indicationofbroaderpsychopathology,whichmedhasbestevidencetotreatthis MELATONIN problemandrestorenormalcircadianrhythm?(2x) AnassociationhasbeenreportedinadolwithBPDbetweenserotonin dysregulation,suicidalbehavior,aggressionand…(2x) AACAPDiagnosisofBipolarIinchildrenrequires? IMPULSIVITY Adistinctperioidofabnormalmoodandepisodic symptoms Dxfor9yoboyw/irritabilityandaggression,failinggrades,andhearingavoice sayingheisbad. MDD 7yochildw/emotionaloutburstsatschoolandstomachaches,reluctance,and complainingatschooltime,butwell-behavedathome,withoutstressors.Next step? PERMISSIONTOSPEAKWITHTEACHER Melatoninagonistsareusefulintreatingwhichtypeofsleepdisorder? SLEEPPHASEDELAY Followingdivorce,whichbehaviorsinnon-residentialfathercontributesmost positivelytochild’sfuturementalhealth? Whichofthefollowingistheleadingcauseofchildmaltreatmentfatalities? Whichofthefollowingisanexampleofsemanticmemoryinachild? Whenaskedtodescribewhyasame-age,same-sexpeerisa“bestfriend,”an11- year-oldchildismostlikelytocitewhichofthefollowingasmostimportant? Winnicottdefinedtheconceptofholdingenvironmentasthe: Traditionalparentingsuchashelpingwithhomework orcelebratingholidaystogether HEADINJURIES RememberingthatthetownparadeoccurseveryJuly 4th FEELINGCAREDABOUTBYTHEOTHERCHILD Safecontextprovidedbyconsistentandreliable parenting MentalRetardation Personw/MRwhoachieves1stgradeeducationfitswhichdiagnosticclassification? MODERATEMENTALRETARDATION 6y/ochildin1stgradeisdoingverypoorly.WISC-RIQscoreis60.Comparedwith otherchildrenhisagehehassig.impairmentinsocialskill,dressing,language,and feeding.WhatistheDx? MILDMENTALRETARDATION MedicationsforTxofaggressioninanindividualw/MR LITHIUM,THIORIDAZINE,HALDOL,PROPANOLOL(NOT CLONAZEPAM) 10y/oIQ69.FindingsthatwouldconfirmDxofMR? DEFICITSINSELF-CAREANDSOCIALSKILLS GotoTableofContents 270 Thenon-geneticcauseofmentalretardationintheUSis: FETALALCOHOLSYNDROME Achildwithmod-sevmentalretardationwakesfrequentlyatnight,clapsat inappropriatetimes,andhasboutsofparoxysmallaughter.Syndrome? ANGELMAN’SSYNDROME AnindividualwithafullscaleIQof65couldbeexpectedtoplateauatwhatlevelof 6THGRADE academicfunctioning? 17y/optwithIQ65andcommensuratedeficienciesinactivitiesofdailyliving, communication,andmotorskillscanbeexpectedtofunctiononwhichacademic level? SIXTHGRADE PDD/Asperger’s/Autism StrongcorrelationbetweenAsperger’sand?(7x) NONVERBALLEARNINGDISABILITY Whatismostimportantwhentryingtodifferentiatebetweenautismand Asperger’s?(6x) LANGUAGEDEVELOPMENT Whichofthefollowingisseenmostfrequentlyasacomorbidconditioninchildren MENTALRETARDATION withautism?(6x) Pharmacologicaltreatmentinautismspectrumdisorderismostlikelytohavea positiveeffecton?(4x) AGGRESSIVENESS WhichisasymptomofautisticdisorderbutNOTofAsperger’s? DELAYOFSPOKENLANGUAGEORCOMMUNICATIVE GESTURES ThemostcommondeficitunderlyingreadingdisorderinEnglish-speakingchildrenis PHONOLOGICALFUNCTIONING deficitin: 7y/oMw/poorsocialskills,cognitive,butlanguagewnl.Dx ASPERGER’SSYNDROME Thelong-termoutcomeinautismismostcloselycorrelatedwith? LANGUAGEDEVELOPMENT Mostusefulinstrumenttoassessanon-verbal3-year-oldchildwhoplaysalonein thecorner,stacking/unstackingblocks? AUTISMDIAGNOSTICOBSERVATIONSCHEDULE(ADOS) 8y/oboyhasmarkedsocialdelay,difficultymaintainingrelationshipsd/todd interpersonalstyle,preoccupiedwithsmallelectronicdevices,talksonandonabout them,andexcludesotherageappropriateinterests,hasdifficultyw/transitioning ASPERGER’SSYNDROME fromoneactivitytoanother,haspooreyecontact,andoblivioustopersonalspace. DX? AbnormalityinwhatdomainsisthemostimportantinestablishingtheDxofautistic INTERPERSONALRELATIONS do? 3y/onotspeakingintelligibly.Normalhearing.Parentsworriedaboutautism. EXPRESSSOMECONCERNTOPARENTS Decreasedattentiontosocialcuesismostcommonamongchildrenwith:(2x) AUTISM GotoTableofContents 271 Whichofthefollowingisapositiveprognosticpredictorofoveralloutcomefor childrenwithautism? MCSpeech/Languageabnormalityinautismspectrumdisorder COMMUNICATIVESPEECHBYAGE5 ImpairedProsody 8y/oisevaluatedduetoproblemsatschool.Child’svocabularyisnormalandhis conversationfocusesonvideogames.Hehassocialdifficultiesduetoinsistingon directingplayw/peersandbeingverycontrolling.Heb/cagitatedanddisruptive PERVASIVEDEVELOPMENTALDISORDERNOS whenasubstituteteacherispresentandifthereareevensmallchangesinhisdaily routine.Dx? Autismspectrumdisordersinchildrenandadolescentsaremosthighlycomorbid withwhichofthefollowingtypesofdisorder? ANXIETY Riskthatasubsequentchildwillbeautisticinafamilywithoneautisticchildis: 5% 4y/ochildisbroughtinforanevaluation.Thechildwaslap_otonicasaninfantand nowisdemonstratingdevelopmentaldelays,foragingforfood,andhavingmany PRADER-WILLISYNDROME tempertantrums.Whichofthefollowingisthemostlikelydiagnosis? 105.Achildwithintellectualdisabilityisfreeofseizuresbutdevelopsepilepsyin adolescence.Patternofonsetisoftenseenwith? AutismSpectrumDisorder ConditioningandLearning Conditioning A10-yochildisafraidofdogsandhasexposuretherapytothepointwherehecan Giventhenonclinicalsetting,thereactionisimpossible tolerateasmalldog.Aweeklater,heencountersalargedog.Whatishisresponse? topredict Accordingtooperantconditioning,behaviordecreasesinfrequencyif(4x) INCOMPATIBLEWITHAPOSITIVELYREINFORCED BEHAVIOR Behavioralfrequencyalteredbyapplicationofpositiveandnegativeconsequences OPERANTCONDITIONING (2x) Learningfromconsequencesofone’sactions(2x) OPERANTCONDITIONING Exampleoflearnedhelplessnessisachildwhostopsallattemptstoimproveafter FAILINGNOMATTERHOWHARDTHECHILDTRIES. beingpunishedforfailingorfailingnomatterhowhardthechildtries?(2x) GotoTableofContents 272 Aformoflearnedfearinwhichapersonoranexperimentalanimallearnsto respondstronglynotonlytoaharmfulstimulus,butalsotoasub-threshold stimulus,refersto:(2x) SENSITIZATION Ptwithcocaineaddictionexperiencescravingsforcocainewheneverpassingbya “crackhouse”.Thisreactionexemplifies:(2x) CLASSICALCONDITIONING Accordingtoclassicalconditioning,whatwouldbestunpairtheconditionedstimulus HAVEPATIENTREPEATEDLYLISTENTOTHESONGIN fromtheunconditionedstimulusforapatientwhofirstgotdrunkwhenacertain THEABSENCEOFALCOHOL songplayedontheradioandnowhascravingswheneverhehearsthatsong? Inbehavioralpsychology,extinctionisdefinedas: WEAKENINGOFCONDITIONEDRESPONSEDUETO WITHDRAWALOFSTIMULUS Childisshownaratanddoesnotreact.Thenshowchildratwaloudnoise.After severalpairingofratandnoise,thechildthenbecomesfearfulwhenjustrat presented.InPavlovianconditioning,whatistheconditionedstimulusinthiscase? THERAT Inbiofeedback,theautonomicnervoussystemcancomeundervoluntarycontrol throughwhichoffollowingmechanisms? OPERANTCONDITIONING Patientw/ADHDistreatedwithstimulantsandbiofeedback.Lateinthecourseof biofeedback,theptexhibitsincreasedirritability,moodiness,andhyperactivity.Best DECREASEDOSEOFSTIMULANT response? Repeatedpresentationofaconditionedstimuluswithoutbeingpairedwithits unconditionedstimuluswillresultinwhat? PARTIALREINFORCEMENT PtwhowasinfrighteningMVA,consultspsychiatristforfearsofdriving,madecar travelimpossible.Behaviorinterventionisplanned:psychiatriswillrideintraffic withptandremainwptuntilphysicalsignsoffeardiminished.Whatlearningtx? CLASSICALCONDITIONING InOperantConditioning,apartialorintermittentreinforcementscheduleresultsin: MAINTAININGABEHAVIORTHATISRESISTANTTO EXTINCTION. Reinforcingbehaviorwrewardeverythirdtimeabehaviorisdoneiscalled: FIXEDRATIO Learnedhelplessnessmodelfor DEPRESSION Systematicdesensitizationisderivedfrom CLASSICALCONDITIONINGTHEORY PtatemeatloafthenhadasevereGIvirus;developsastrongaversiontomeatloaf. CLASSICALCONDITIONING Cocainecravingtriggeredbysightofcrackhouseisexofwhattypeoflearning? CLASSICALCONDITIONING IVheroinuseruponseeingtheneedleduringablooddrawdevelopsintensecraving CLASSICALCONDITIONING isanexampleof: Anoperantconditioningreinforcementschedulethatisusedincasinoslotmachines VARIABLE-RATIO andmayplayaroleinthedevelopmentofpathologicalgambling: GotoTableofContents 273 AsresultofaMVAaptfeelingpanicbeforehavetodriveandhasbeguntoavoidit. DIRECTCONDITIONING Exampleofmechanismoffeardevelopment: Ptundergoingchemotherapy.Commonlybecomesnauseatedandvomitsinwaiting CLASSICALCONDITIONING roompriortothetreatment.Reactionisexof? Whattypeofreinforcementismosteffectiveformaintainingbehaviorthatis resistanttoextinction? PARTIAL Ifaresponseinhibitorytoanxietyoccursinthepresenceofanxiety-evokingstimuli, RECIPROCALINHIBITION itweakenstheconnectionbetweenthestimuliandtheanxiety.Thisiscalled: A79yroldmanseekstherapyfollowingstressduetouncontrolledonlineshopping, patientbeginstounderstandhoweachpurchaseimprovedmoodandimproved OPERANTCONDITIONING loneliness,thisbestexplainswhatlearningtheory? Learning 10y/ochildlearnedtocleanhisroomwithoutbeingasked.Theparentsachieved thisbyreinforcingthisbehaviorwithaone-dollarbilleverythirdtimethechild cleanedtheroomwithoutbeingasked.Thistypeofreinforcementscheduleis knownas:(4x) FIXED-RATIO 22y/oexperiencesaearthquake(7.0)duringaseminar.Inthemonthsthatfollow hedevelopsfearfulreactiontosuddenorloudnoises.Ptavoidsclassesinthe AVERSIVECONDITIONING samebuildingthattheseminarwasin.Whatisthemechanismofthebehavior? (2x) Childwhofearsbikeridingbecomeslessfearfulafterwatchingotherchildren havingfunwhilebikeriding.Whichlearningprinciple?(2x) IMPRINTING Cognitive-behavioralexplanationoftrichotillomaniasuggestshairpullingreducesan NEGATIVEREINFORCEMENT uncomfortabletensionthatthechildisexperiencing.Whatisthisanexampleof? Theevolutionofaddictionfromanimpulsivetoacompulsiveactischaracterizedby NEGATIVEREINFORCEMENT theincreasingimportanceofwhichofthefollowingfactors? Whatlearningpatternisdemonstratedbyapatient(w/panicdisordera/wpublic places)leavinganareawhenpanicattackbegins,andexperiencingcessationofsx? Negativereinforcement Worseningtempertantrumsin3y/o.Firstoccurredingrocerystoreandchildwas quietedwithcandy.Thetantrumswouldoccurathomeandwouldescalateuntil TANTRUMSWILLINCREASETHENDECREASE givencandy.Psychiatristtellsparentsnottogivecandyduringatantrumunderany circumstances.Outcome? Amedicalstudenttakesamphetaminestostayawakewhilestudyingforanexam. Whenshetakestheexamwithoutanymedication,shefindsthatshehasmuch STATE-DEPENDENTLEARNING greaterdifficultythanusualrememberingthematerial.Whatisthisanexampleof? GotoTableofContents 274 Imitatingone'svaluedmentorwhileperformingpsychotherapyisanexampleof whattypeoflearning? SOCIALLEARNING Formoflearnedfearinwhichapersonorananimallearnstorespondmorestrongly SENSITIZATION toanotherwiseinnocuousstimulusis: Achildpracticesviolintopreventparentsnagging,whatdoesthisdescribe? NEGATIVEREINFORCEMENT Amothergivesan8y/oa"timeout"forfivemininthebedroombecauseofhis misbehavior.Thisisanexampleofwhatbehavioraltechnique? PUNISHMENT Inlearningtheory,thepresentationofanaversivestimulusthatiscontingentupon theoccurrenceofaparticularresponseisknownas: PUNISHMENT Childwhofearsbikeridingbecomeslessfearfulafterwatchingotherchildrenhaving MODELING funwhilebikeriding.Whichlearningprincipal? Theoperantprocedureinwhichadesirablebehaviorpatternislearnedbythe successivereinforcementofapproximationstothatbehavioriscalled: SHAPING 30y/omorbidlyobeseptrefusestochangeeatingandexercisehabits,“I’llworry aboutmyhealthwhenIam65.”Onemonthlaterhisfather,alsoobese,diesofa myocardialinfarction.Thenowobviousdisparitybetweenpt’scurrentbehaviorand COGNITIVEDISSONANCE knowledgeofthecircumstancessurroundinghisfather'sdeathisanexampleof whichlearningtheoryprocess? 40y/optexperiencesrecurrentpanicattacksusuallyinpublicplaces.Theptleaves theareawheneverapanicattackbeginsandthenthepanicSxstop.This demonstrateswhichofthefollowingtypesoflearningpatterns? NEGATIVEREINFORCEMENT Ptreceives$20fornegativedrugtest,butlockedoutofrewardafterapositivetest contingencymanagement until3negativetests,thisisanexampleofwhichbehavioraltechnique? ResearchandStatistics ResearchDesign Whatresearchstudyexaminesagroupstudiedoveraprolongedtimeperiod?(6x) COHORT Whichstatisticalmethodattemptstoaddresstheeffectsofparticipantsdropping LASTOBSERVATIONCARRIEDFORWARD outofastudypriortocompletion?(5x) GotoTableofContents 275 Agroupofresearchersstudiedthetemperamentofagroupofchildrenatage3 months,2years,5years,and20yearstodeterminerelationshipsbetweeninitial temperamentalcharacteristicsofchildrenwhoeventuallyhadpsychiatric problems.Thisisanexampleofwhattypeofstudy?(2x) COHORT Whichofthefollowingisthemajornegativeaspectofcrossoverdesignsfor researchstudies?(2x) RESIDUALEFFECTS Whichofthefollowingtypesofstudiesisbestsuitedtodetermineprevalence? (2x) CROSSSECTIONAL Examinerelationshipbetweenexposureandeffectbycomparingpatientswith effecttopatientswithouteffect,assessingforpriorexposure.Typeofstudy? CASE-CONTROL WhatistypeIIerror? FINDINGANTIDEPRESSANTINEFFECTIVEWHENITIS ACTUALLYEFFECTIVE Whatresearchdesignwouldbethemostappropriateinestablishingacausal relationshipbetweenchildhoodvaccinationandonsetofautism? COHORT Studyreportsdifferencethatturnsouttobebychance TYPEIERROR Researchintothecomplexityofhealthcaresystemsanddistributionofresourcesis bestcarriedoutinwhichfashion? NATURALISTICSTUDY Researcherswishtostudyagroupofstudentswhowereexposedtoaterrorist attackinwhichsomeoftheirclassmateswerekilled,andcomparethestudentsto otherstudentswhohadnotundergonesuchatrauma.Forthestudytobe consideredquasi-experimental,whichofthefollowingrequirementsmustbemet? BASELINEDATAMUSTHAVEBEENCOLLECTEDBEFORE THEEVENT CompanyXdevelopsnewmedicationfordepression.Althoughtheinitialtrials revealonlymodes,statisticallyinsignificantmoodbenefits,theresearchteam decidestoanalyzethedrug’seffectsinsubgroups.Bysubgroupingthesubjectpool ANARTIFACTOFMULTIPLEANALYSES into20subgroups,theresearchersfindstatisticallysignificantmoodbenefitsfor men/womenwbirthdaysintheearlyfall.Conclusionthatcanbedrawnfromfinding isthatitis: Aresearcherdevelopsanewquestionnaireonthesubjectoftraumaticstress. Whichofthefollowingactionswouldbemostappropriatetotestthemeasure’s contentvalidity? ASKTRAUMAEXPERTSTOEVALUATEITSRELEVANCE ANDCOMPLETENESS Intheanalysisofresultsofthenationalcomorbiditystudy(1994),anonresponse adjustmentweightwasincluded.Thisinclusionwasimportantforwhatreason? NONRESPONDERSWEREFOUNDTOHAVEHIGHER RATESOFILLNESS Researchsuggeststhatthefrequencyofalcoholisminlesbiansascomparedto COHORTPHENOMENONRELATEDTOSOCIOCULTURAL heterosexualwomenwasgreateronlyinlesbiansover55yearsofage.Whichofthe ISSUES followingisconsideredtobethebestexplanationforthisfinding? Examiningrelationshipbetweenexposuretopsychotropicduringpregnancyand Epstein’sanomalybetweenwomenwithEpstein’sanomalyandagroupofwomen whohadbabiesw/othisanomalyisanexampleof CASECONTROLSTUDY GotoTableofContents 276 Acase-controlstudywouldbeappropriateinansweringanepidemiologicalquestion INCIDENCEOFTHEDISEASEISLOW whenthe: Whichstudybestaddressestherelativeinfluencesofheritabilityandenvironment? TWINADOPTIONSTUDIES Whydon’ttwinadoptionstudieshavemethodologicallimitations? ADOPTEESARENOTAREPRESENTATIVEPOPULATION SAMPLE. Whatischaracteristicoftheplaceboeffect? THEPLACEBOEFFECTISGREATERWHENTHEPT KNOWSTHEDOCTOR. Findingscanbereplicated RELIABILITY Testmeasureswhatitissupposedtomeasure(x2) VALIDITY Resultsarecombinedfromanumberofstudiesofsimilardesign.Anoverall estimateoftheeffectofavariableismadewhichincorporatestheinformation providedbyallthestudies.Theprocedureistermed? META-ANALYSIS Apsychiatristemployedbyaninstitutionwantstouseptdataforresearchlater. Howcanshegettheprogressnotes? KEEPHEROWNSEPARATERECORDS Acase-controlstudycanappropriatelyansweranepidemiologicalquestionwhen the: INCIDENCEOFDISEASEISLOW Comparedtothosedescribedas“lowreactive”inKagan’slongitudinalstudyof childhoodinhibition,childrendescribedas“highreactive”atage4monthswere characterizedby: HIGHERRATESOFSOCIALANXIETYATAGE13 SmallpilotstudymeasureschangesinMMSEscorestocomparetheefficacyoftwo ENROLLMORESUBJECTSTOOBTAINALARGERSAMPLE medsforthetreatmentofAlzheimer’s.Datasaysthere’sdifferencebetweenmeds, SIZE butnotstatisticallysignificant.Whatdoyouneedtodotoclarify? Thepurposeofdesigningstudytousethedoubleblindmethodisto: ELIMINATEBIASDUETOEXAMINEREXPECTATIONS Clinicaltrial:2studymedsin8hospitals.20receivedrug1inhospitalsA,B,C,D, while 20receivedrug2inhospitalsE,F,G,H.Drug1isprovenandindicatedtreatment. Whichcriticalconfounderbiasestheresults? DRUGASSIGNMENTDEPENDSONPARTICIPANT’S HOSPITAL. Aclinicaltrialwillassesstheimpactoftwoatypicalantipsychoticmedsonglucose intolerance.Halfoftheparticipantswillstartondrug1andthenbetreatedwith drug2,whiletheotherhalfwillstartonDrug2thendrug1.Whattypeof experimentaldesign? CROSSOVERDESIGN Psychiatristisdevelopinganewquestionnaireabouttraumaticstress.Whichof followingactionswouldbemostappropriatetotestthemeasure’sconstruct validity? COMPARETHESCOREOFHURRICANESURVIVORSTO THOSEWITHNOPRIORTRAUMA Poweranalysisisastatisticalmethodusedto: ESTIMATETHESAMPLESIZEREQUIREDTODETECT STATISTICALEFFECTOFADEFINEDSIZEFORTWOOR MOREPREDICTORS. GotoTableofContents 277 Acrossoverdesignisavariationof: DOUBLE-BLIND Adoptionresearchinonemethodtodelineategeneticversusenvironmental influencesonphenotype.Thelimitationofthisapproach: ADOPTEESARENOTREPRESENTATIVESAMPLEAND ADOPTIVEANDBIOLOGICALPARENTSMAYRESEMBLE ONEANOTHER. Typeofstudydesignsmostlikelytoeliminatethebiasofknowingwhattreatmentis DOUBLE-BLIND giventothept: TheinfanttemperamentstudiesofKaganandcolleaguesfoundstrongcorrelation betweenearlybehavioralinhibitionandsubsequentdevelopmentofd/o’sinthe areaof: ANXIETY Typeofstudytodeterminerelationshipbetweenriskfactoranddevelopmentof disease COHORTSTUDY Recentmeta-analyseshavesuggestedwhatwithregardtotheuseof psychotherapytotreatdepression? OTHERPSYCHOTHERAPIESHAVEEFFICACY COMPARABLETOCBT Whatresearchdesignbestclarifiestheroleofenvironmentinbehavioralgenetics? ADOPTIONSTUDY Twinstudiesofpatientswithschizophreniahaveconsistentlyidentifiedsubstantial proportionsofmonozygotictwinpairsthatarediscordantfortheillness.Themost likelyexplanationis: A“TWO-HIT”MODELOFPATHOGENESISEXISTSIN WHICHPREDISPOSINGENVIRONMENTALFACTORS COMBINEWITHGENETICRISKS Thereliabilityofanassessmentinstrument,suchasdiagnosticinterview,refersto theabilityofaninstrumentto: YIELDCONSISTENTRESULTSWHENUSEDBYDIFFERENT EXAMINERSORATDIFFERENTTIMES. Aresearcherdevelopsanewquestionnaireabouttraumaticstress.?ostappropriate COMPARETHESCORESWITHTHOSEOBTAINEDUSING totestthemeasure’scriterionvalidity? HAMILTONANXIETYRATINGSCALE(HAM-A) Thepurposeofdesigningastudytousethedouble-blindmethodisto: ELIMINATEBIASDUETOEXAMINEREXPECTATIONS Whatisthemethodforestimatingsamplesizerequiredtodetectstatisticaleffects ofdefinedsizeforvariableswithwell-knownvariancesisreferredtoaswhichofthe POWER followingtypesofanalysis? Whatreliesonstatisticalreview/interpretationofmultiplestudyresults? META-ANALYSIS ResearcherisreviewingaquestionnairetoscreenforMDD,noticesthatthe questionnairehasnoQspertainingtodepressedmoodbuthasafewQspertaining tospendingsprees.Whatformofvalidityismostaffected? CONTENT Statistics Groupsofptsw/MDD,dysthymicd/o,andadjustmentd/oweregivenmood scales.Inordertocomparethemeansofscoresofthesethreegroups,most appropriatestatisticalmethodsis:(3x) ANALYSISOFVARIANCE GotoTableofContents 278 Whatisusedtoreportthedeviationofavaluefromitsgroupmean,expressedin standarddeviationunits?(2x) ZSCORE 5y/oboybecomesrestless,impulsive,anddifficulttomanagewhennotgiven sufficientexercise.Teachergiveshimincreasedmotoractivity,andhisbehavior improves.Thisisanexampleof:(2x) GOODNESSOFFIT Whichstatisticmeasuresmagnitudeofdifferencebetweentwointervention groups? EFFECTSIZE Tenptsaregivendailydosesofasingleantidepressantuntiltheirmoodbecomes euthymic.Eightptsrespondto1mg,oneptrespondsto5mg,andoneptresponds MEDIAN to10mg.Thebestreflectstheskeweddistributionofeffectivedoseinthisgroupof pts? WhichresearchorstatisticalmethodologieswereusedtodeveloptheDSM-IV-TR? DATARE-ANALYSESANDFIELDTRIALS Thevalidityofanassessmentinstrumentrefersto: EXTENTTOWHICHITMEASURESWHATITINTENDSTO MEASURE. Whattermsbestdefinesthedegreeofspreadofscoresaboutthemean? STANDARDDEVIATION Aratinginstrumentissaidtohavehighreliabilitywhenwhichofthefollowing propertiesisdemonstrated:(x2) RATINGSARESIMILARAMONGDIFFERENTRATERS. Thisdescribesthestatisticalconceptofpointprevalence: THEPROPORTIONOFAPOPULATIONWITHASPECIFIC DISEASEATONESPECIFICTIME. Personestimatingusefulnessoftxstudywillusenumberneededtotreatstatisticto representnumberofptswhoneedtobetreatedtoproduceoneadditionalgood INVERSEOFTHEABSOLUTERISKREDUCTION outcomebeyondthatobtainablewcontrolforcomparisoncondition.NNTformula? Aresidentperformsaresearchstudyutilizingalloftheoutpatientswithany psychiatricdisorder,whoweretreatedduringthefirst2monthsoftheresident’s outpatientexperience.Theresidentdiscoversthatofthe47patientsdiagnosedwith THEPOINTPREVALENCEOFOCDIS6/47 anypsychiatricdisorder,sixmeetthecriteriaforOCD.Whichofthefollowing statisticbestdefinesthisinfo? Atestthatdetects98%ofthepeoplewhohaveadisease,butalsoprovidesafalse positiveresultformanyofthepeoplewithoutthedisease,wouldhavea: HIGHSENSITIVITYANDLOWSPECIFICITY Methodforestimatingsamplesizerequiredtodetectstatisticaleffectsofdefined sizeforvariableswwell-knownvariancesisreferredtoaswhichtypeofanalysis? POWER Astatisticaltermthatreferstotheproportionofptswiththeconditioninquestion thatatestaccuratelydetects: SENSITIVITY Amethodformakingapredictionbasedonobservabledatainordertoassessthe valveoftheonevariableinrelationtoanotheris REGRESSIONANALYSIS Whatstatisticalmeasureshouldbeusedtodeterminehow2independentvariables REGRESSIONANALYSIS affectthefrequencyoftheoccurrencerateofanevent? GotoTableofContents 279 Statisticalconceptofpowerisdefinedasthe PROBABILITYOFREJECTINGNULLHYPOTHESISWHENIT SHOULDHAVEBEENREJECTED Aresearcherwantstocompareanewatypicalantipsychoticmedicationtothe alreadyexistingatypicalantipsychotics.Theresearcherwantstoconductthestudy EFFECTIVENESS inroutineclinicalsituationsratherthanusinghighlyselectedsubjects.Whichofthe followingstudydesignswouldbethemostappropriate? Aneffectivenessstudydiffersfromanefficacystudybyincludingwhat? Realworldconditions Assumingthereisnosignificantdifferencebtwn2randomsamplesofpopulationis: NULLHYPOTHESIS Measureofcentraltendencythatmightbestbeusedtoanalyzeanoutcome measurewithsignificantlyskeweddistributionofitsvalues? MEDIAN Inaskeweddistributionthisisameasureofcentraltendencyandmovesfurthest awayfromthemodeinthedirectionofskewness: MEAN Specificityis: IDENTIFYINGTHE#OFPTWITHOUTTHECONDITION WHOHAVEANEGTESTRESULT Anewscreeningtestcorrectlyclassifiesearlymildimpairmentin75%and correctlyclassifiesnormalmentationin85%.Whatdoes85%referto? Specificity Testdetects98%ofpeoplew/disease,butalsohighfalsepositiverate HIGHSENSITIVITY,LOWSPECIFICITY Whichisusedtoevaluatetherelativefrequenciesorproportionsofeventsin2 populationsthatfallintowelldefinedcategories CHI-SQUARE An80y/optpresentswithsuddenonsetseizures,hallucinationsandaggressive behavior.ApreliminaryCTscanofheaddoesnotshowabnormalities.Thept’s familywantstoknowwhatisthelikelihoodthatthepthasnochangesinhisbrain giventheCTscan.Whichofthefollowingconceptswouldneedtobeusedto respondtothefamily’sconcernsabouttheCTscanresults? NEGATIVEPREDICTIVEVALUE Investigatorswishtomaximizetheprobabilityofcorrectlyrejectingthenull hypothesis.Thisprobabilityisreferredtoas: 1MINUSBETA Genetics Developmentaldisabilityassocwtriplerepeatgeneticabnormality(4x) FRAGILEXSYNDROME 13y/owdevelopmentaldelay,stereotypedbehaviors,impairedsocial interactions,hyperactivebehavior,largeantevertedears,hyperextensiblejoints, macroorchidism.Dx?(3x) FRAGILEXSYNDROME 27y/oFhasmultiplebrownpopularlesionsontheface,neck,shouldersthathave developedoveryears.Hasb/lhearingloss,b/llimbandgaitataxis.MRIw/ NF-2(NEUROFIBROMATOSIS2GENE) gadoliniumshownontestandhasb/lenhancingmasses.Ptisacarrierofa mutationinwhichgene?(3x) GotoTableofContents 280 Childpresentsw/moderateintellectualdisability,deficitsinvisual-spatial processing,highlevelsofanxiety,aphobia,andishighlysociable.Whichgenetic d/o?(2x) MICRODELETIONONCHROMOSOME7q11.23 (WILLIAMSSYNDROME) Metachromaticleukodystrophyassociatedw/mutationingeneforwhich enzyme?(2x) ARYLSULFATASE Apoptosisofcorticalneuronsdiffersfromnecrosisinthatit:(2x) INVOLVESEXPRESSIONOFSPECIFICGENES 40y/oMdevelopedgraduallyprogressivedementiaandabnormalinvoluntary movements.Olderbrotherandfatherhavesimilarillness.BestDx.test(2x) EXCESSCAGTRIPLETSINDNAANALYSIS Geneticanticipationrefersto:(2x) EARLIERONSETORWORSENINGOFILLNESSWITH EACHSUCCEEDINGGENERATIONINAPEDIGREE(WITH EACHTRANSMISSIONOFUNSTABLEDNA) Adolptswithvelcardiofacialsyndrome(chromosome22q11deletionsyndrome)are SCHIZOPHRENIA atsubstantiallyincreasedriskfordevelopingwhichpsychoticd/o? Karyotypingisamethodofgeneticanalysischaracterizedbywhichtechniques? ANALYZINGCHROMOSOMALSTRUCTURES Whataregeneticpolymorphisms? VARIANTDNASEQUENCESPREVALENTIN>1%OFA POPULATION Alogarithmicodds(LOD)scoreforagenerepresentswhat? THEMOSTLIKELYRECOMBINATIONFREQUENCY BETWEENTWOLOCIFROMPEDIGREEDATA Familialamyotrophiclateralsclerosisgenemutation: SUPEROXIDEDISMUTASE(SOD) Bilinealinheritancetypicallyreflectswhichofthefollowingevolutionarypopulation ASSORTATIVEMATING geneticfeatures? Term“endophenotype”referstowhatphenomenainbehavioralgenetics? ALTERNATEEXPRESSEDFORMSRELATEDTOADISEASE Whichofthefollowingpremisesiscentraltothesociobiologictheoryofinclusive fitness? THEKEYUNITOFSELECTIONISACTUALLYGENES RATHERTHANINDIVIDUALS 4y/ochildthatwashypotonicasaninfantisnowdemonstratingdevelopmental delays,foragingforfoodandhavingmanytempertantrums.DX?(x4) PRADER-WILLISYNDROME Skintumors,abundantcaféaulaitspots,Lischnodulesonirisisdiagnosticof mutationonwhichgene: NF-1(NEUROFIBROMATOSIS-1GENE) Whichisthemostcommonmitochondrialdisorder(of4listed)? MITOCHONDRIALENCEPHALOPATHY,MYOPATHY, LACTICACIDOSIS,ANDSTROKE-LIKEEPISODES(MELAS) Whichisseenin90–100%ofptw/narcolepsy(genetics) HLA-DR2 Mostcommoninheritedmentalretardation: FRAGILEX GotoTableofContents 281 Mutationsinthegenethatcodesfortheparkinsonproteinaremostcommonly associatedwithwhichparkinsonism? EARLY-ONSETPARKINSON’SDISEASE Adrenogenitalsyndrome,Downsyndrome,Hurler’ssyndrome,Tay-Sachsdisease andphenylketonuriaallcausementalretardation.WhichonedoesNOThave autosomalrecessiveinheritancepattern? DOWNSYNDROME Whatneurologicalsyndromesistheresultoftrisomy21? DOWNSYNDROME Processofgeneexpression DNATRANSCRIBEDTOMRNAANDPRODUCES PROTEINS IndividualscarryinginactiveallelesoftheCYP2Agenehaveincreasedconiinelevels TOBACCO perunitofdrugingestedandarerelativelyprotectedfromaddictionto: Geneticd/oassociatedwithincreasedriskforschizophrenia: VELOCARDIOFACIAL Psychcomorbiditiesinindividualswmentalretardationvsgeneralpopulation: SAMETYPESOFPSYCHOPATHOLOGY Strongestgeneticcontribution CYCLOTHYMICDISORDER Geneticlinkagestudiesinvestigateswhatinmedico-psychiatricresearch: CO-SEGREGATIONOFGENESDURINGMEIOSIS Whatispartofroutineworkupofchildwithmentalretardationbutwithout dysmorphicfeaturesorneurologicalfindings? CHROMOSOMALANALYSIS PatternofinheritanceinWilson’sdisease AUTOSOMALRECESSIVE PatternofinheritanceinHuntington’sdisease AUTOSOMALDOMINANT Karyotypingisamethodofgeneticanalysischaracterizedbywhichtechnique ANALYZINGCHROMOSOMALSTRUCTURES Polymerasechainreaction(PCR)usedingeneticlinkagestudiesinvolves: AMPLIFICATIONOFMICROSATELLITEMARKERS WhatconditionsassociatedwMRhaveanautosomalrecessiveinheritancepattern? ADRENOGENITALSYNDROME,HURLER’S,TAY-SACHS, PHENYLKETONURIA 4y/odoesnotrun/climb,falls,hasiliopsoas/quadriceps/glutealweakness, enlargementofcalveswithfirm,“rubbery”consistency,decreasedDTRsandnormal 1)SMALL,SHORT-LASTINGMOTORUNITPOTENTIALS sensation.Widebasedstanceandwalkswaddling.Whenrisingfromtheground, WITHINCREASEDRECRUITMENT usesafour-pointpositionthroughfullextensionofallfourextremities.Hasfamily 2)DYSTROPHIN h/osimilarsxinmales.1)EMGreveals?2)Geneticmutationinwhatprotein? 14y/ogirlpresentswithdelayedonsetofpuberty,shortstatus,andahistoryof cardiacabnormalitiesandhypertension.Shehaspoorsocialskills.Psychological assessmentrevealsanormalverbalIQandabelow-normalperformanceIQ.Which ofthefollowingisthemostlikelydx? TURNERSYNDROME TheSuralnervebiopsyofaptwcharcot-marie-toothtype1isshown(image),exam DUPLICATIONOFTHEPERIPHERALMYELINPROTEIN showsdiminishedLEDTRsanddeformatiesoffeetBL.Thesedeformatiesaretypical GENE ofwhichmolecularabnormality? GotoTableofContents 282 Increaseriskforpsychopathologyinoffspring? Havingbiorelativeswithpsychiatricillness Epidemiology THEDEVELOPMENTOFOPERATIONALIZED ScientificdevelopmentthatmadeNIMHepidemiologicalcatchmentsareastudies DIAGNOSTICCRITERIAANDSTANDARDIZED possible(9x) INSTRUMENTS AccordingtoNIMHEpidemiologicCatchmentAreaProgram’sreportsonethnicity EQUALAMONGASIANS,HISPANICS,AFRICAN&preventionofmentaldisorders,thelifetimeratesofAPDare:(5x) AMERICANS,ANDWHITES. Whichofthefollowingactionsismostimportantforpreventingsuicidein adolescence? MAKEITAGUNFREEHOME Leadingcauseofneuropsychiatricdisabilityworldwide UNIPOLARMAJORDEPRESSION Whatpsychiatricillnessistheleadingcauseofdisabilityinpersons15-44y? MDD Ptswithunipolardepressiondifferepidemiologicallyfromptswithbipolard/oin whatway? THEDISCREPANCYBETWEENMALEFEMALELIFETIME PREVALENCERATESISGREATER. Whatisanexampleofsecondaryprevention? SCREENINGFORDEPRESSION. IntheInstituteofMedicineclassificationsystemdevelopedtoclarifydifferent aspectsofprevention,thecategoryof“indicatedinterventions”referstowhichof thefollowing? INTERVENTIONSTHATFOCUSONHIGH-RISK INDIVIDUALSTOENHANCERESILIENCEANDPREVENT ONSETOFTHEILLNESS Checkfastinglipidpanelsbeforestartingtreatmentbeforeatypicalantipsychotics. WhichhealthqualityimplementedaccordingtotheaimsoftheInstituteof Medicine? SAFETY Whichofthefollowingprobabilitiesmostaccuratelydescribesthelikelihoodof patientswithschizophreniacommittinghomicidecomparedwiththegeneral population? EQUALLIKELIHOOD Whichofthefollowingfactorsismostcloselyassociatedwithchildabuseand neglect? HOUSEHOLDPOVERTY Aphysicianisdisciplinedbyahospitalatwhichhepracticesforissuesrelatedtocar providedtoapt.ifthedisciplinaryactionlastsmorethan30days,thehospitalmust NATIONALPRACTITIONERDATABANK reportthephysiciantowhichoffollowing: Aphysicianwhoistestifyingasanexpertincourtisdifferentfromaregularor“fact” PROFESSIONALOPINIONS witnessinthattheexpertisallowedtotestifyaboutwhichofthefollowing? GotoTableofContents 283 Apsychiatristwhoseptisinvolvedinawork-relatedlawsuitreceivesasubpoenato producetheptsrecordsofpsychiatrictreatmentandtotestifyaboutthetreatment isacourtoflaw.Uponspeakingwiththeattorneywhoissuedthesubpoenaand FACTWITNESS whoeraresenttheopposingparty,thepsychiatrististold"youwillnotbeaskedto renderanindependentopinionrelatedtolegalquestions."Whichbestdescribesthe psychiatrist’srole. Whichofthefollowingisthemostcommonmethodofcompletedsuicideinfemale FIREARMS childrenandadolescents? IntheUS,whatisthemostcommonmethodofcompletedsuicide? SHOOTINGONESELF Theconceptoflifetimeprevalencereferstothenumberofpersons: MEASUREDATAPOINTINTIME,WHOHADAD/OAT SOMEPOINTDURINGTHEIRLIVES. Afindingregardingepidemiologyofnicotineuse: YOUNGADULTSREPORTTHEHIGHESTRATESOF SMOKING Socioeconomicstatusiscorrelatedtoriskformentalillness,suchasthosewhoare disadvantagedbysocialclassaremorelikelytodevelopamentald/o.research showsthatthiscorrelationisaccountedformainlybygreater: VULNERABILITYTOTHEIMPACTOFSTRESSFULLIFE. Thenumberofindividualswithad/oataspecifictime POINTPREVALENCE WhichpopulationhashighestprevalenceofSchizophrenia? MONOZYGOTICTWINOFSCHIZOPHRENICPT Whencomparedtoyoungeragegroups,theprevalenceestimatesofMDDin personsolderthan65yearsare: LOWERINBOTHMENANDWOMAN Prevalenceofpsychoticdisordersafterage65is: LOWERINBOTHMEN&WOMEN Whatsomatoformd/ohasmale=female? HYPOCHONDRIASIS Whatdistinguisheshypochondriasisfromdelusionald/o,somatictype? INSIGHT Leadingcauseofdeathfor15-24y/oAfricanAmericanmales? HOMICIDE Whatbestcharacterizesthecurrentexplanationforgroupdifferencesinprevalence FACTORSTHATPROMOTEVULNERABILITYTOSTRESS ofpsychiatricillness? Pastyearsannualprevalencemuchhigherthanannualincidence DISEASEISCHRONIC AccordingtotheWHO,theworld'sgreatestcauseofmortality,illhealthand sufferingiswhat? DEPRESSIONANDSUICIDE TherateofillicitdrugusageinhighschoolishighestamongwhichgroupsinUSA? CAUCASIANAMERICANS Highestprevalencepsychd/o? ANXIETYDISORDERS WhatisprevalenceofAlzheimer’sin>85y/o? 16-25% GotoTableofContents 284 LifetimeprevalencerateforETOHabuseanddependence 15% Lifetimeprevalenceofschizophrenia 1% RiskfactormostpredictiveofapthavingemergentSI: PERVASIVEINSOMNIA Assessmentinstrumentusedinepidemiologystudyreliessolelyonsubjectsreport: GENERALHEALTHQUESTIONAIRE Intimatepartnerviolenceismostcommoninwhichofthefollowingdemographics? LOWINCOMEFAMILIES Society Culture 24y/oColombian-Americanisconcernedabouthowtomaintainhisparent’s culturalheritageafterhemarriesaCaucasian.Whichtypeofacculturativestress INTEGRATION ishedealingwith?(4x) ImmigrantstoUSexperiencestress&demoralizationmostduringwhichperiod? Howisethnicitydefined?(2x) Duringfirst1-3yrincountry GROUPOFINDIVIDUALSSHARINGSENSEOFCOMMON IDENTITY,COMMONANCESTRY,SHAREDBELIEFS,&HX 20y/owesterntrainedpsychiatristofnorthernEuropeandescenthasbeenasked totreata40y/oHindupatientwhoemigratedtotheUS2yearsago.Thepatient presentswithcomplaintsofweakness,fatigue,headaches,insomnia, palpitations,anddecreasedappetite.Thepatientalsoreportsa5lbweightloss ASKTHEPATIENTWHATHEBELIEVESEXPLAINSTHE overthelastmonth,dysphoricmoodwithintermittentanxiety,andsuicidal SYMPTOMS ideation.Inadditiontoassessingthepatient’slevelofsuicidality,itwouldbe appropriateforthepsychiatristtodowhichofthefollowingwhenbeginning treatment?(2x) 22yoMptcomplainsoffatigue,abdpain,weightlossandbelievescausedby nocturnalemissionsofsemen.Whatispt’sethnicbackground? SoutheastAsian Acculturationoutcomeassociatedwithhighriskforsuicide,substanceabuse,and alcoholism LACKINGSTRONGALLEGIANCETONATIVECULTURE,ANDNOT INCORPORATINGHOSTCULTURE Pt’sfamilybelievesdepressionis2/2santeriacurse.Duringassessment,psych shouldfocuson... LEARNINGFROMPTANDFAMILYWHATTHEYBELIEVETHE COURSEOFTHISILLNESSISEXPECTEDTOBE Racial/ethnicgroupwithhighestrateofsuicide?(x2) NATIVEAMERICANS Socialpsychologicalstudyoftheviewofselfinsomewesterncultureshas delineateddifferencesfromthedefinitionofselfinmanynon-westerncultures. Whatbestdescribesthebasisforpositiveself-esteeminthosenon-western cultures?(2x) POSITIVECONTRIBUTIONSTOTHEGROUPANDHARMONIOUS RELATIONS Whichofthefollowingpsychologicaltestshasbeenvalidatedforadolescents, elderlyandethnicminoritygroups,andisrecommendedfortheassessmentof psychologicalfunctioninginpatientsfromdiversecultures? MINNESOTAMULTIPHASICPERSONALITYINVENTORY(MMPI-2) PuertoRicanandotherLatinAmericanptsaremorelikelythanthosefromwestern NERVOUSNESS culturetoreporttheirdepressionaswhat? GotoTableofContents 285 14y/oNativeAmericangirlwithvisionsofelderspiritswhoappearandgiveher advice.Parentsfeelvisionsaregiftbutareworriedaboutthechild’s preoccupationsinterferingwithschoolwork.Noh/omentald/oorsubstance abuse.Treatmentgoal: WORKONPROBLEMSINSCHOOL Genderisbestunderstoodasreferringto: WAYSINWHICHCULTURESDIFFERENTIATEROLESBASEDONSEX AnaccuratestatementregardingassessmentforculturalID: INFLUENCEDBYONE’SDEGREEOFACCULTURATION 30y/oMDwhohasemigratedfromChinatotheUScontinuestotakepridein familyrecipes,buthasrecentlyembracedAmericanballroomdancing.This representswhichofthefollowing: ACCULTURATION Acculturationoutcomesassociatedwithpt’shighriskforsuicide,substanceabuse, LACKINGSTRONGALLEGIANCETONATIVECULTUREANDNOT andalcoholism: INCORPORATINGHOSTCULTURE TheculturallyandLinguisticallyAppropriateServices(CLAS)federalstandardsfor healthcareorganizationsrequiretheorganizationsto: HAVEPT-RELATEDMATERIALSAVAILABLEINTHEPT’SNATIVE LANGUAGES. AJapanesefamilywhorecentlymovedfromJapanbringstheir6yochildforan evaluation.Theyexpressconcernsthatthechildappearsdepressed,isreluctantto gotoschool,andisfearfulthatharmwillbefalltheparents.Duringtheevaluation CULTURALNORM itisnotedthatthechildsleepsinthesameroomastheparents.Whichofthe followingisthemostlikelyexplanationofthissleepingarrangement? 14y/oNativeAmericanIndiangirlbroughttomentalhealthcenterb/cshehas visionsofspirits.Tellspsychiatristspiritsareelderswhoappear,giveheradvice.No hxsubstanceabuse/mentaldisorder.Interviewwparentsrevealstheyare DEALINGWITHHERSCHOOLPROBLEMS traditional &feeldaughter’svisionsareagift.Buttheyareworriedaboutschoolwork,which hasdeterioratedb/cshehasbeenpreoccupiedwithspirits.Txshouldfocuson: Psychiatristevaluatesrecentimmigrantwithcomplaintof“alterednerves”Clinical interpreterfrompt’sculturalbackgroundexplainsthatculturallythenervous HISPANICAMERICAN systemisbelievedtobealteredbystressfullifeevents.Whatculturalgroupdoes ptmostlikelybelongto? Whatmostaccuratelydescribesscientificunderstandingoftheconceptofrace? SOCIOPOLITICALDESIGNATIONASSIGNINGINDIVIDUALSTOA PARTICULARGROUPTHATHASMEANINGDERIVEDFROM PREVAILINGSOCIETALATTITUDES Raceisbasedonphysicalcharacteristicswhereasethnicity incorporatesmultiplefactors Howis“race”differentthan“ethnicity”? AmericanpsychiatristsoverdxinAfricanAmericanpatientswmood/psychoticsx? SCHIZOPHRENIA Whichofthefollowingisacomponentofthepsychiatrist’sformalcultural formulationofapt’sdisorder: THEPT’SEXPLANATIONOFTHEILLNESS Culture-boundsyndromeinCaribbeanandstatesborderingGulfofMexico– anxiety,GIdistress,weakness,fearofbeingpoisoned,attributedtowitchcraft ROOTWORK Familyresponsetoamemberwataquedenervioswouldmostlikelybetodo what? RALLYTOSUPPORTRELATIVEBYREMOVINGSTRESSORS Whichisthemostsignificantdisadvantageofusingafamilymemberasinterpreter PTMAYCENSORCOMMENTSTOKEEPINFOFROMTHEFAMILY forapatientwhodoesnotspeakthepsychiatrist’slanguage? MostcommoncomplaintinsoutheastAsianswhoaredxw/mentaldisorderis: MULTIPLESOMATICSYMPTOMS 50y/oCambodianwomanwith2kidssufferedcatastrophictraumafromthePol PotregimeinCambodia(rape,abuse,watchedfamilystarve,escapedrefugee GROUPTHERAPYOFPEOPLEOFTHEPATIENT’SOWN campwith BACKGROUNDWHOSHARETHESAMEEXPERIENCE 2kids).HasPTSD/MDDsxthatareincreasedwhenhernowgrowndaughterdates manpatientdoesn’tlike.Needssupportivetherapy,antidepressant,AND? GotoTableofContents 286 Acrossallcultures,whatstressfullifechangesiscorrelatedwithgreatestincrease indeathandillnessinthesubsequent2years? DEATHOFASPOUSE CultureboundinindustrializedcountriesperDSMIV BULIMIA Whatculture-boundsyndromeswouldbeDxforaptwithofinsomnia,HAs, anorexia,fears,despair,diarrhea,&anger? ATAQUEDENERVIOS PuertoRicanandotherLatinAmericanptsaremorelikelythanthosefromother westernculturestoreportdepressionas: NERVOUSNESS 29y/orecentimmigrantfromChinabelieveshispenisisshrinking;concernedhe mightdieoncehispenisretractsintohisabdomen.1)Whattypeofd/oisthis?2) Whatisbesttreatment? 1)CULTURE-BOUNDSYNDROME 2)SUPPORTIVETHERAPY Whichdemographicsindicatebothacommonancestryandasharedsenseof identity,beliefandhistory? ETHNICITY(NOTRELIGION) FirsteditionoftheDSMtoexcludehomosexualityasadiagnosis: DSM-III-R(1987) 14yonativeAmericanp/wvisionsofspiritswhoareeldersgivingadvice(nohx substanceabuseormentald/o)andwithparentswhoencouragehervisionsas beingagift.Wheretofocustreatment(assumingacademicdecline)? Dealingwithherschoolproblems Spirituality 47y/oFw/increasedpreoccupationwithquestioningherlifelongaffiliationwith herchurchandhasbeenspendingtimevisitingotherchurches.Concernedsheis RELIGIOUSORSPIRITUALPROBLEM losingherfaith,feelsguiltyandanxious.NoSI,MSEnormal,stateswouldnever actagainsthermoralbeliefs.Dx?(3x) Researchshowsdissociativesymptomsmostcommonlyrepresentwhat worldwide? NORMALPARTOFRELIGIOUS/RITUALEVENT WhatDSM-IVdiagnosisislikelyfor41y/omanwithincreasingsenseofconflict aboutchanginghisbeliefsfromwork-orientedtofaith-oriented.Nopastorpresent RELIGIOUSANDSPIRITUALPROBLEM psychsymptoms,stablevocationalhx. 48y/owithchronicsadnessandnorelationshipssincehusbanddied12yearsago. Normalgrieving,noDSM-IVcriteriaford/o,hassuccessfulcareerandclosefriends. PARTOFABELIEFSYSTEMENDORSEDBYHERRELIGION Stateshasconversationswithherdeadhusbandandhetalkstoher.Believesin heaven.Likelyclassificationoftheseexperiencesis: Ethics Routinelyinformingptsaboutconfidentialitylimitsisex.Ofwhatethicalskill? (6x) Psychiatristblogsas“Dr.Empathy.”Whyunprofessional? On-callresidentevaluatesnewpatientwithbaddementia.Realizespatientwas oneoftheresident’sformerprofessorsandmentors.Residentistheonly psychiatristontheunit.Attendingiscalledandtellsresidentthehospitaldoesn’t havearelevantpolicy.What’stheoptimalwaytohandlethis? BUILDINGETHICALSAFEGUARDSINTOWORK Thepsychiatristshouldmakehisorheridentityandcredentials clear Finishtheevaluationandprovideanyurgenttreatmentbut insistonatransferofcareassoonaspossible Whatethicalprincipleprovidesthemostappropriatebasisforpsychiatric interventioninamentallyincompetentpatient?(5x) BENEFICENCE Inethics,beneficenceis:(5x) APPLYINGONE’SABILITIESSOLELYFORTHEPATIENT’SWELLBEING.PHYSICIANACTSPATERNALISTIC Differencebetweenaboundaryviolationandboundarycrossingis?(4x) BOUNDARYVIOLATIONSARECHARACTERISTICALLY EXPLOITATIVE GotoTableofContents 287 Fptintwice-weeklypsychodynamicpsychotxwmaletherapistforthelastyear beginstodiscusssexualfantasiesaboutthetherapist.Thetherapistfeels flatteredbythesexualinterestofthispatientandnoteshisownfeelingsof attractionto her.Themostappropriatenextstepforthetherapististo:(3x) SEEKCONSULTATIONWITHACOLLEAGUE “Firstdonoharm”referstowhichofthefollowingprinciples:(3x) NONMALEFICENCE Afamousentertainercommentspubliclyabouthavingproblemscuttingdownon ETOHusedespiteknowingnegativeeffectsonfamilymembers.Well-known UNETHICALBECAUSETHEPSYCHIATRISTHASNOTEXAMINED psychiatrist,nevermettheentertainer,goesonanewsprogramandsaysthat THEENTERTAINER theentertainerismostlikelyexperiencingETOHabuse.Whatexplainsethicsof MD?(2x) WhatreflectsopinionofAPAonpracticeofchargingaptforamissed appointment(2x) SUPPORTSITIFITISCONTRACTEDWITHTHEPATIENT APArulere:psychiatristdatingsiblingofcurrentpt SHOULDBEAVOIDEDWITHANY3RDPARTY Researchcoordinatorrequestsspouseofpatienttoparticipateinstudyashealthy control.Whichfeatureofinformedconsentispotentiallybeingviolated? VOLUNTARISM MostethicalresponseandreasonwhenpatientsendstherapistaFacebookfriend DECLINE;DISRUPTSBOUNDARIESOFTHERAPEUTICFRAME request Whatcharacterizesthenatureofboundarycrossingsindoctor-ptrelationship? SHOULDBEASSESSEDACCORDINGTOCLINICALSITUATION AgitatedmanicptevalinED,resistedvoluntarypsychhospitalization.Psychiatrist said,“Youcancomeinvoluntarily&choosewhenyouwillbedischarged,orI’ll involuntarilyhospitalizeyousoyouhavenosayinhowlongyoustayinthe hospital”.PthadnoSI/HI.Whydoespsychiatrist’sdecisionnotmeetstandardof care? THEPSYCHIATRIST’SUSEOFCOERCIONINVALIDATEDINFORMED CONSENT APAaddressedethicsofsexualrelationshipsbetweenpsychiatrists&ptsbystating NOTPERMISSIBLETOHAVEASEXUALRELATIONSHIPWITHA CURRENTORFORMERPATIENT Mostappropriatetimetodiscussadvancedirectiveswithapt WHENTHEPTISCOMPETENT Ethicalstandardsdictatethatthepsychiatristshoulddowhatinchildcustody evals? INTERVIEWALLPARTIESTOTHELITIGATION Commonancestry+asharedsenseofidentity,beliefs,andhistory ETHNICITY PsychMDwishestochargeptsforappointmentsthattheydonotkeep.According ETHICALIFPTISSPECIFICNOTIFIEDINADVANCE tocodeofethicsofAPA,suchapolicyis: PsychMDisapproachedatsocialgatheringbyaneighborwhoseeksadviceabout recentSxofdepressionandanxietythatneighborhasexperiencedsincebeing firedfromwork.Whichactionwouldconstituteestablishmentofdoctor-pt relationship? ADVISINGNEIGHBORTOSTARTCBTWONEOFSEVERAL PROVIDERS Psychiatristjudgespatientundermanagedcareplanwillneedcombined psychopharmandpsychotherapyfor>1yr.Knowsthathealthplanstopspaying after20visits.Mostethicaltotellpatient: PATIENTMAYNEEDMORETXTHANINSURANCECOVERS Aninternalmedicineresidentwhoisaskedbytheresidencyprogramtotakea leaveofabsenceduetoerracticbehaviormustundergoapsychiatricassessment beforereturningtoclinicalduties.Whichofthefollowingstatementsbest describestheobligationoftheexaminingpsychiatrist? STATECLEARLYTOPTPRIORTOEVALUATIONTHEPURPOSEOF THEEVALUATIONANDTHATTHEINFORMATIONMAYBE TRANSMITTEDTOTHERESIDENCYPROGRAM AccordingtoAPA,itisunethicalforapsychiatristto: PARTICIPATEINLEGALLYAUTHORIZEDEXECUTION FactthatparticipantsdidNOTreceiveavailableindicatedtreatmentinthe Tuskegee Syphilisstudyisanethicalviolationofjustice,beneficenceornon-malfeasance? NON-MALEFICENCE GotoTableofContents 288 Psychiatristwarns24y/opt-ifptdoesnotsignintoahospitalvoluntarily,the patientwillbeinvoluntarilycommitted.Thisapproachviolatesthespiritof: INFORMEDCONSENT “Primumnonocere”(firstdonoharm)referstowhichcoreethicalprinciple? NONMALEFICENCE Apsychiatristwishestochargepatientsforappointmentsthattheydonotkeep. AccordingtothecodeofethicsoftheAPA,suchpolicyis: ETHICALIFTHEPTISSPECIFICALLYNOTIFIEDINADVANCE Psychiatristdeterminesthatfullyinformingaptoftxriskswouldnegativelyimpact pt’shealth/welfare&documentsrationalefortxthepatientwithoutinformingthe THERAPEUTICPRIVILEGE patientofalltherisks.Thispsychiatristisintendingtousewhichofthefollowing? Forcingmedonptdirectlychallengeswhichofthefollowing? AUTONOMY Providingptswithanunderstandingoftheirdisordersandoptionsfortreatmentis AUTONOMY honoringwhichofthefollowingprinciplesofethics: AdolescentwithrecentSAisabouttobedischargedfromhospital.Theparents refusearequesttoremovefirearmsfromthehouse,stating,“Ineedfirearmsto protectmyfamilyandIwillmakesuretheyaresecured.”Whichethicalprinciple CONFLICTSwiththepsychiatristmakingaCPSreport? AUTONOMY Failingtoobtaininformedconsentdefieswhichprincipleofethics? autonomy Itisethicalforapsychiatristtobillptforamissedappointmentif: IFPAYMENTFORMISSEDAPPTFALLSINCONTRACTUAL AGREEMENT. Thethreecomponentofinformedconsentinclude:thepresentationof information,thevoluntarinessofconsentonthepartofpt,and: MENTALCOMPETENCE Watson’sexperimentwith“LittleAlbert”demonstratedthatan11y/ochild,who previouslyshownnophobicresponsetoastimulus,learnedtofearthestimulus afteritwasrepeatedlypairedwithaloudnoise.Thiswouldbeunethicalb/o violationof:(2x) NONMALEFICIENCE Ptwhoispoorbuttalentedasksifhecanbarterforservices.Youlikethept’s ITISNOTRECOMMENDEDASITMAYCOMPROMISETREATMENT product.Whatdescribesthenatureofthisproposaltoacceptgoodsinlieuoffees BOUNDARIES Psychiatristwishestochargeptsforappointmentsthattheydonotkeep. ETHICALIFTHEPATIENTISSPECIFICALLYNOTIFIEDINADVANCE AccordingtocodeofethicsoftheAmericanpsychiatricassociationsuchapolicyis: PtqualifiesforECT,butdoesnotwanthisdoctotellhimtherisks.Heisa“chronic DOCUMENTTHEPT’SKNOWINGANDVOLUNTARYWAIVERAND worrier”andfearshearingtheriskswillmakehimanxious,perhapstothepointof PROCEEDWITHTREATMENT refusingtreatment,whichhebelievesheneeds.Whatisthebestresponse? Insurancecompanytellspsychiatristtoswitchgenericdrug.Youknowalternatives CONTACTINSURANCEANDASKFORNONFORMULARY maybegoodtoo.Whatdoyoudo? APPROVAL Psychiatristcallsptathome;wifeaskshowptisdoing.Whatprinciplegoverns response? CONFIDENTIALITY Howshouldapsychiatristhandleaninterviewaboutthemisbehaviorofa prominentgovernmentemployee? COMMENTONHUMANBEHAVIORGENERALLY,BUTREFUSETO OFFEROPINIONSABOUTTHESPECIFICPERSON Sonof70y/optcallspsychMDtoreportshismomhasb/cdepressedinlast6 months,butptdeniesbeingsadandrefusestoseepsychMD.Sonmentionsthat hewillbringmothertotheappointmentunderthepretenseofhavingherback painchecked.MostappropriateresponsefrompsychMDwouldbeto: TRYTODISSUADETHESONFROMUSINGDECEPTION Gag-ruleclausesinsomemanagedcareplansmayprohibitdocsenrolledintheir plansfromtakingwhichaction? ADVISINGPTSABOUTTREATMENTSNOTCOVEREDBYHMO ThepsychMDwhoreleasedmedicalrecordsandaudiotapesofthetreatmentof thepoetAnneSextontotheauthorwhowaswritingabiographyafterherdeath couldhavebeencriticizedforviolatingwhatprinciple? CONFIDENTIALITY GotoTableofContents 289 PsychMDistreatingachildwhoseparentsaredivorced.Underwhatcircumstance isitethicallyacceptableforthepsychiatristtohavearomanticrelationshipwith UNDERNOCIRCUMSTANCES thechild’sparent? Aptsuffersasaresultofthept’spsychiatristgoingonvacationw/oproviding coverage.Thepsychiatrist’sproblematicbehaviorviolateswhichofthefollowing ethicalprinciples? FIDELITY Theeffortsofpsychiatriststoachieve“parity”legislationformentalillnesscanbest JUSTICE beseenasillustratingwhichofthefollowingmoralprinciples? Paternalismcanbejustifiedbywhichofthefollowingbasicethicalprinciples (x2): BENEFICENCE Asuicidal18y/optwholiveswithhisparentsisevaluatedintheED.The psychiatristwarnstheptthatifhedoesnotsigninvoluntarilyforinpttx,the HEWASCOERCEDINTOGIVINGCONSENT psychiatristwillinvoluntarilyhospitalizethept.Theptconsentstoinptcare.The ptinthissituationhasnotgivenvalidinformedconsentbecause:(x2) Ifathirdpartyissupervisingatherapycase,theresidentshouldinformthepatient thathiscasewillbediscussed…Apsychiatristandspouseareattendingaconcert. INFORMWALKBYWITHOUTINDICATINGKNOWINGTHE Duringintermission,thepsychiatristseesthattheywillcrosspathsinthelobby PATIENTFROM,UNLESSTHEBEGINNINGPATIENTINITIATES withoneofthepsychiatrist’spatients.Whichofthefollowingwouldbethemost CONTACT. appropriateconductforthepsychiatristinthissituation? Psychiatristprescribesmedicationtoapsychotherapyptofanothermentalhealth psychiatristretainsfullresponsibilityfortheptscare professional,whatishisliabilityinthistreatmentarrangement? Ptwithhistoryofbipolardisorderhospitalized2weeksagoformaniaandSI. Improvedbut2daysbeforebeingallowedhomevisit,patientstopsallmeds. Doctorstatesifpatientrefusesmeds,cannotgohomeforvisit.Patientrelents andacceptsmedsafterhearingthis.Fromethicalstandpoint,responsefrom doctorcanbeconsidered: Coercivebutacceptableifthedoctorbelievednon-adherence wouldcausesignificantharm LegalandForensics requestmomprovidedcopyofdivorcedecreetoconfirm Motherof8yowantsADHDeval,kids’parentsaredivorced,momreportsshehas custodystatus primarycustody,willnotsignROIforchild’sdad,whatisthenextstep? Mentalcompetencyofanelderlypatientisdeterminedby:(7x) JUDICIALHEARING Testamentarycapacityreferstoperson’sabilityto(4x) MAKEAWILL Whatisprimaryroleofpsychiatricexpertwitness(4x) RENDEROPINIONBASEDONSCIENTIFICKNOWLEDGE Childcustodydeterminationsinmostjurisdictionsaremadeusingwhat principle?(4x) THEBESTINTERESTOFTHECHILD Sufficienttoestablishthatapersonisincompetenttostandtrial(3x) FAILURETOUNDERSTANDTHECHARGESONEISFACING Pt’sspousecallsthepatient’spsychiatristtoaskaboutchangesinthepatient’s medication.Whichofthefollowingwouldbeanappropriateinitialresponsefor thepsychiatristtomake?(2x) INFORMTHESPOUSETHATTHEPATIENT’SCONSENTIS REQUIREDTODISCUSSTREATMENT Whenevaluatingforcompetencetoproceedinacriminalmatter,thepsychiatric CURRENTMENTALFUNCTIONING evaluatorshouldfocusonwhichaspectofthedefendant?(2x) Whatismostimportanttoevaluate“competence”?(2x) “WHATDOYOUTHINKWILLHAPPENIFYOUDON’T UNDERTAKETHISTREATMENT?” WhichislistedonPresident’sNewFreedomCommissiononMentalHealth (2003?)(2x) ADDRESSINGMENTALHEALTHASVIGOROUSLYASPHYSICAL HEALTH Medicationcanbeadministeredwithoutapatient’sconsentunderwhichofthe followingcircumstances?(2x) ANEMERGENCYSITUATIONEXISTSANDCANBEDOCUMENTED GotoTableofContents 290 Inmalpracticesuitsagainstpsychiatrists,themostcommonallegation?(2x) INCORRECTTREATMENT Whatisthelegalprocessthatasksthecourttoimmediatelyevaluateifapthas beenhospitalizedw/odueprocessoflaw?(2x) WRITOFHABEASCORPUS Whatdocumentationwilllegallyprotectapsychiatrist,ifptdiesbysuicide?(2x) DETERMINETHELEGALINSANITYSTANDARDTOBEUSED Whatstandardofproofappliestocivilinvoluntarypsychcommitment? Clearandconvincingevidence Whatentitymandatespublicschoolsprovideeducationalservicesforchildrenwith Federalgovernment disabilities? Whatisanunethicalfeearrangementforaforensicpsychiatrist? PERCENTAGEOFPLAINTIFFSAWARD Conditionheldtostrictestlegalconfidentialitystandard? SUBSTANCEABUSE Mostethicalactionwhenpsychiatristreceivessubpoenaforrecordspertainingto patientarrestedforsellingmarijuana OPPOSESUBPOENADUETOLACKOFPTCONSENT Dementiaptwithdurablepowerofattorney,decisionsneedtobemadeby? ASSIGNEDDECISIONMAKER Individualw/schizophreniaarrestedafterbreakingintogrocerystorewouldbe foundincompetenttostandtrialifs/he: BELIEVESALLLAWYERSAREDEMONSANDREFUSESTOSPEAKTO THEM Ptarrestedforposessionofcocaine,spends2daysinjail,aftermissingappswith subsabusecounselor.Interventionisreferredtoas…? DRUGCOURT Rogersv.commissioner(1983)isalegalcasethataddressedtherighttorefuse antipsychoticmedsinnon-emergencysituations.Basedonthisruling,pts previouslyadjudicatedasincompetentmaynotrefusemedsinwhichsituation? THEREISACOURT-APPROVEDSUBSTITUTEDJUDGMENTTXPLAN Inordertobejudgedcompetenttostandtrial,adefendantmustbeabletoconsult AFACTUALANDRATIONALUNDERSTANDINGOFPROCEEDINGS withthelawyerw/areasonabledegreeofrationalunderstandandpossesswhat? AGAINSTHIM/HER Patientthreatenscriminalbehaviortowardpropertyofanother.Legalobligationof NONE psychiatrist? Whatsituationrequiresthepsychiatristtostepoutofusualtxrelationshipto protecttheptorothersfromharm? CHILDABUSE Constitutionalandcommonlawdictateprisonersmustreceivecareatthelevelor TREATMENTMUSTBEPROVIDEDTOTHOSEWHOARE abovecaretheywouldreceiveiftheywereinthecommunity.This“necessaries” PREVENTEDFROMSEEKINGTHEIROWNMEDICALCARE doctrineisjustifiedbywhichofthefollowingprinciples? Ptattemptedsuicideduringacrisiswhichwasworsenedbypt’sfeelingsabout beingunabletoreachvacationingpsychiatristwhodidnotprovidecoverage.What ABANDONMENT isthepsychiatrist’svulnerability? Whendocumentingsuicideriskassessment,keystrategyistodiscuss… WHYTHEPSYCHIATRISTREJECTEDALTERNATIVEWAYSOF RESPONDING Whichofthefollowingisthemostcommonreasonformalpracticeclaims? INCORRECTTREATMENT Psychiatristprovidespsychotherapyto22y/optwholivesw/parentsanddxw/ anxietyanddepression.Ptreportsthefatherthrew13y/osiblingacrosstheroom. TELLPTTHATTHEPSYCHIATRISTMUSTREPORTTHEABUSETO Sibwasnotinjured.Multiplesimilarepisodes.Whatisappropriateresponseforthe CHILDPROTECTIVESERVICES. psychiatrist? Appropriatesubstanceabusetreatmentintheclinicalsettinghasbeenaddressed inlandmarklegalcases.Whatistheconsensus? ITISAMONGTHERIGHTSGRANTEDASITISCONSIDEREDA PSYCHIATRICDISORDER Whichtoolscanbeusedwhenapersonwishestoassignasurrogatetomake healthcaredecisionsduringfutureperiodsofmentalincapacity? ADVANCEDIRECTIVE Ptwhosuffersfromaseriousmentald/oisadefendantinacriminalmatter.Even ifptunderstandsthenatureandobjectivesofcourtproceedings,ptmaybefound BEINGUNABLETOASSISTATTORNEYINTHEDEFENCES notcompetenttostandtrialunder: GotoTableofContents 291 Themostaccuratelydescribestheprimaryfunctionofamentalhealthcourt: DIRECTSMENTALLYILLDEFENDANTSTOTXRATHERTHAN PUNISHMENT Whichcharacterizesthedefendant’scompetencytostandtrialincriminal proceedings? ISPRESUMEDUNLESSTHEISSUEISRAISED WhichshouldraisePsychMD’sindexofsuspicionformalingeringincasesof litigationinwhichfinancialcompensationisatissue? VAGUELYDEFINEDSYMPTOMS CriterionforacovereddisabilityunderAmericanswithDisabilitiesAct: SUBSTANTIALLYLIMITSONEORMOREMAJORLIFEACTIVITIES Whatdeterminesdisability? IMPAIRMENTAFFECTSABILITYTOMEETPERSONAL,SOCIAL,OR OCCUPATIONALNEEDS Ptgettingpsychexamtodeterminesuitabilityforajobmustbeinformed: EXAMISNOTCONFIDENTIAL Indeterminingthedisclosureofpsychiatrictreatmentinformationincourt,which ofthefollowingindividualsisconsideredtoholdprivilege: PATIENT Psychiatristagreestoprescribemedicationtoaptwhoreceivesongoing PSYCHIATRISTRETAINSFULLRESPONSIBILITYFORTHEPATIENT’S psychotherapyfromanothermentalhealthprofessional.Whatisthepsychiatrist’s CARE liabilityinthistreatmentarrangement? PthasintractableOCD,withprofoundmorbidity,andconsidersbrainsurgery.The THEINFORMATIONMOSTPATIENTSWOULDWANTTOKNOW. surgeonmustdisclosethisinordertoobtainavalidinformedconsent: (REALLY?) Apsychconsultationisrequestedforapatientwhomthemedicalteambelievesis manufacturingsymptomsofanillness.Whichofthefollowingfactorswouldbe FINANCIALINCENTIVEFORILLNESS mostconsistentwithadiagnosisofmalingering? Whichofthefollowingpatientswouldautomaticallybeconsideredaslackingthe capacitytogiveinformedconsentformedicalprocedures? APATIENTWITHALZHEIMER’SDEMENTIAWHOHASASTATE DESIGNATEDGUARDIAN PatientrefusingIVantibiotics,whatisareasonhewouldnothavecapacitytodo this? DOESNOTUNDERSTANDCONSEQUENCESOFREFUSING TREATMENT Alawsuitchargesthatapsychiatricfacilityprematurelydischargedapatientwho wasnotapprovedforfurtherstaybythemanagedcarecompany.Thefinallegal responsibilitygenerallyfallstothe: PSYCHIATRIST Mostimportantfindingforapsychiatristtoconsiderindisabilitydetermination: DEGREEOFFUNCTIONALIMPAIRMENT Aresidentisdischargingapatientandnotesasignificantomissionintheresident’s WRITEANADDENDUMTOTHEPROGRESSNOTEWITHTHE last,handwrittenprogressnote.Whichofthefollowingisthebestcourseof CURRENTDATE action? Inforensicpsychiatry,theterm“standardofcare”referstotheuseoftreatments thatare: USEDBYAVERAGEREASONABLEPRACTITIONERS Inevaluatingapatient’scompetencetoconsenttoamedicaltreatment,the degreeofstrictnesswithwhichtheexaminingpsychiatristconsidersthequestionis THERISK-BENEFITRATIOOFTHETREATEMENT mostaffectedbywhichofthefollowingfactors? InformedconsentisNOTrequiredinwhichofthefollowingforensicevaluations? COMPETENCYTOSTANDTRIAL Unethicalfeearrangementforforensicpsychiatrist: PERCENTAGEOFPLAINTIFF’SAWARD Whatdocumentationwilllegallyprotectapsychiatrist,ifptdiesbysuicide? ANSUICIDERISKASSESSMENTANDPROTECTIVEFACTORS. Severalstatesestablishedthattheverdictguiltybutmentallyilltobeanoption whenadefendantpleadsnotguiltybyreasonofinsanitybecause: WHENCOMPAREDTOGUILTY,GUILTYBUTMENTALLYILLIS INTENDEDTOENSUREACCESSTOTREATMENTBUTIS ESSENTIALLYSIMILAR Inevaluatingthesanityofacriminaldefendant,theforensicpsychiatristshould focusoncurrentstateofmind,orstateofmindattimeofoffense? STATEOFMINDATTIMEOFOFFENSE Therulethatfindspeoplenotguiltybyreasonofinsanityduetomentalillnessthat impairedtheirknowledgeofthenaturequalityandconsequencesoftheiractions M’NAGHTENRULE ortheywereincapableofrealizingthattheseactswerewrongiscalledwhat? GotoTableofContents 292 Thecriminaldefendanttellsthepsychiatristdoingaforensiceval“Iknowthat killingmyfatherwasillegal.”However,thedefendantdelusionallybelievedthat APPRECIATETHEWRONGFULNESSOFHISCONDUCT thefatherwasbeingtorturedbydemonsandkillinghimwasthemoralthingtodo. Thedefendantisunabletodowhat? Atthebeginningofaradiotalkshowapsychiatriststatesheisnotenteringintoa doctor-patientrelationshipwithanyofthecallers.Herebyhedoesnothave_____ DUTY towardsapatientincaseofamalpracticesuit. Apatientrequestsanalternativetxfordepression.Hispsychiatristdoesnot practicethistxhimselfbutrefersthepttoonewhodoes.In6mothepthas complicationsfromthetxandsuesthe1stpsychiatristformalpractice.Which elementofmalpracticeismissinginthiscase? DUTY Bestprotectionagainstmalpracticelawsuit: MAINTAININGGOODDOCTOR-PTRELATIONSHIP Standardofcarereferstotreatmentsthatare USEDBYAVERAGEREASONABLEPRACTITIONERS Lawsuitsagainstpsychiatristmostfrequentlyarisefromissuesconcerning: SUICIDEATTEMPTS Thefourbasicelementsthatmustbeproveninordertosustainaclaimof malpracticeagainstaphysicianincludeadutyofcareowedtothepatient, negligence,causation,andwhat? HARMTOTHEPATIENT Bestdefenseforagainstmedicalmalpractice? Patient’sconfidentialityafterdeath Patientdidnotsufferabadoutcome. USUALLYMUSTBEMAINTAINED Collegestudentintherapy,theDeancallstherapistrequestinginfoaboutthe REFUSETHEDEAN’SREQUESTFORINFORMATION student’stherapyduetorecentreportsfromadormsupervisor.Therapistshould: Medicalresidentconsultspsychiatrybecausea38y/oFptrefuseddialysis WILLASSESSPT’SCOMPETENCYTOMAKEONE’SOWNMEDICAL secondaryto“antisocialpersonality”andtheresidentwantsyoutoconvinceherto DECISION stayfortreatment.Youransweris: Themostrelevantissueforageriatricorforensicpsychiatristincaseswerethe financesofanelderlyareindisputebetweenpartnerandchildrenis: WHETHERTHEELDERLYHASAMENTALDISORDERAND WHETHERISADEQUATELYTREATED WHENTHEREISREASONTOBELIEVETHATTHEPATIENTLACKS Whenshouldaschizophrenicadmittedtoamedicalhospitalforevaluationofchest THEABILITYTOUNDERSTAND,APPRECIATE,ORREASON painhaveaformalassessmentofdecision-makingcapacity? LOGICALLYWITHTHEINFORELEVANTTOHEALTHCARE DECISIONS Themostappropriatetimeforaphysiciantodiscussanadvancedirectivewithapt WHENTHEPTISCOMPETENT is Themostappropriatetimetodiscussadvancedirectiveis: ATTHETIMEOFADMISSIONTOTHEHOSPITAL Ifptisincompetenttomakedecisionandhasdurablepowerofattorney, treatmentrecommendationswillhavetoapprovedbythe: ASSIGNEDDECISIONMAKER Pt’sdementiaprogressedtothepointthatthept’sdrivingisaffected.Inaddition totalkingtopt,theMDshould: CONSULTSTATELAWABOUTOBLIGATIONSFORREPORTINGTHE PT’SCONDITION. 78y/ow/deterioratingpersonalhygiene,significantweightloss.Signsvoluntary admissionformbutlaterforgetsdoingthis.Potentiallyresectablemassesinlung andbrainrequiringfurtherconsentforsurgicalandoncologicaltreatment. Consentsbutcannotexplainreasonforsurgery.Legally,psychiatristshould: URGENTLYREQUESTPROBATECOURTAPPOINTGUARDIANWITH POWERTOMAKETREATMENTDECISIONS GuardianofaptwithMRwithmedication-refractoryepilepsyinsiststhatthept shouldhaveepilepsysurgery.Neurosurgeonbelievestheseizurefocuscanbe resected,butthere’sa>50%chanceofRUEparalysiswhichoutweighspotential benefitfromfreedomfromseizures.Guardianinsistsonsurgery.Whichdescribes physicianresponsibilityinthiscase? SHOULDPERFORMTHESURGERYONLYUNDERCOURTORDER Whatcharacterizesthemajorityofdefendantswithpsychiatricdisorderswhoare foundunfittostandtrial? THEYCANREGAINFITNESSINLESSTHAN90DAYS GotoTableofContents 293 Anattorneyrequestspsychiatricconsultationwhenhisdefendantwantstheworst PROBABLYMEETSCRITERIAFORFINDINGOFINCOMPETENCETO possibleoutcomefromthetrialbecausehefeelshedeservestheworst PROCEED punishmentpossible.Whatdirectionshouldyoutakeforthiscase? Whatdistinguishesforensicfromgeneralpsychevaluation? Maintenanceofconfidentiality USSupremeCourtDecisionWashingtonvHarper1990,therighttorefuse treatmentislimitedforprisoninmatesbecause: PRISONSECURITYCONCERNSOUTWEIGHINDIVIDUAL AUTONOMYINTERESTS Informedconsentrequires:presentationofinformation,voluntaryconsentfrom patient,and: MENTALCOMPETENCE Ptw/severeGIdiseaserequestsasurgicalprocedurewithquestionableefficacy andarelativelyhighriskofnegativeeffects.Levelofcompetencyapsychiatrist wouldrequiretofindptcompetenttomaketreatmentdecision? RATIONALCONSIDERATIONOFALTERNATIVES 16y/osaysshethinkshemaybepregnantbutdoesnotwanttoinvolveher parents.Whatshouldguidethepsychiatrist’sactions? THEPATIENT’SABILITYTOGIVECONSENTWILLVARYFROM STATETOSTATETOSTATE Ptswhoarecommittedtopsychiatrictreatmentinstitutionsinmoststatesare presumedto: BECOMPETENTTOMAKETHEIROWNDECISIONS Bothmenseraandactsreusearerequiredforwhichofthefollowing? CONVICTIONOFACRIME Duringanevaluationforcompetencytostandtrial,adefendanttellsthecourt- appointedforensicpsychiatristaboutbeinginvolvedinanunsolvedcrime.The psychiatristshoulddowhat? AVOIDADETAILEDDESCRIPTIONOFTHEDEFENDANT’SPAST OFFENSEHISTORY Constitutionalandcommonlawdictatethatmentalhealthcareprovidedto prisonersbeatorabovethelevelofservicesthatshouldbeavailabletothemif theywereinthecommunity.The“necessaries”doctrineisjustifiedbywhat principle? TREATMENTMUSTBEPROVIDEDTOTHOSEWHOARE PREVENTEDFROMSEEKINGTHEIROWNMEDICALCARE. Ptconsumedalargeamountofalcoholanddischargedafirearm,woundinga neighbor.Ptremembernothingoftheincident.Whatistrueaboutthept’s criminalresponsibilitypertheinsanitydefense? VOLUNTARYINTOXICATIONDOESNOTEXCUSETHECRIMINAL BEHAVIOR Whatisthefirststepwhendeterminingwhetherornotacriminaldefendantisnot DETERMINETHELEGALINSANITYSTANDARDTOBEUSED. guiltybyreasonofinsanity? WhatriskmanagementstrategyfordealingwithaptwithSIismostlikelytobe rejectedasinvalidinasubsequentmalpracticelawsuit? A“NO-HARM”ORSUICIDEPREVENTIONCONTRACTBETWEEN THEPTANDTHETHERAPIST. Ptw/severedepressionisinterviewedforenrollmentinanexperimentaltrial.Pt PRESENTINFORMATIONSEVERALTIMESUSINGDIFFERENT hasfailedmultiplemedicationsandseveralcoursesofECT.Theptiscompetentbut METHODSANDFEEDBACKTESTING clearlydistressedatthetimeofconsentfortreatment.Nextstep? Murdertrial,defendantstates“IthinkmurderiswrongbutkillingaspyfromMars whoistryingtostealthesecretoflifeisright.”Thisposesaproblemforwhattype M’NAUGHTENRULE ofevaluationofcriminalresponsibility? TheNationalPractitionerDatabankcontainsreportsaboutwhichofthefollowing typesofphysicianproblems? MALPRACTICESETTLEMENTSWHERENOWRONGWAS ADMITTED Adementedpatientwhoisdrivingproblematically.Whatdoyoudo? CONSULTSTATELAWABOUTREPORTING Toprovemedicalmalpractice,theplaintiffmustestablishduty,dereliction, damagesanddirectcausationbywhatpartofproof PREPONDERANCEOFEVIDENCE Whichstatementapatientisincompetenttostandtrial? “Iamawizardandthereforehavediplomaticimmunity” CaseManagement Bestindicationforresidentialtreatmentofsubstanceabuse?(3x) FAILURETOMAINTAINABSTINENCEAFTERTREATMENTIN INPATIENTSETTINGS GotoTableofContents 294 29y/oschizophrenicfrequentERvisitsandhospitalizations.Hallucinating, agitated,notviolentorsuicidal,cooperative.Ranoutofmedsafewdaysago. Hadbeendoingwellonolanzapineforseveralmonthsandwasdoingfairlywell instructuredlivingenvironment.DeniescommandAH.Whatshouldthenext interventionherebe?(3x) CONTACTCASEMANAGERTOVERIFYENVIRONMENTAL SUPPORT PatientwithMDD;psychiatristprescribesantidepressant,psychologistprovides interpersonaltherapy.Whoisresponsible&accountableforwhat?(2x) PSYCHIATRISTISRESPONSIBLE&ACCOUNTABLEFORALL TREATMENT;PSYCHOLOGISTJUSTFORPSYCHOTHERAPY Describethepsychiatricassertivecommunitytreatmentcasemanagement model:(2x) INTERDISCIPLINARYTEAM,SERVICESINSITU,HIGH STAFF/PATIENTRATIO,ANDINTENSIVEOUTPATIENTRESEARCH Mostcommonfactorincasesofterminationofparentalright:(2x) NEGLECTBYTHEPARENT 29y/oMptwithhxofCPS8xhospitalizationin14months,stoppedhismedsand isunabletotakecareofhimself,becomesparanoidandstaysonthestreet, eatingoutofgarbagecansandhisfamilyisunabletosupporthimanymore.The ASSERTIVECOMMUNITYTREATMENT mostappropriateinterventiontodecreasethispt’sriskoffuturehospitalizations: (2x) Aspartofcomprehensivepainmanagementteamforptwhxofnarcoticabuse,a RESOLVECONFLICTSBETWEENTHEPATIENTANDTHE consultingpsychiatristmayappropriatelybeaskedtodowhichofthefollowing? TREATMENTTEAM (2x) Ptconsultspsychiatristb/cformerpsychiatristhasretired&ptwishesto continueTxwantidepressants.Theptisseeingacounselorforweekly psychotherapyandplanstocontinue.ThepsychiatristsevalconfirmstheDxof MDDandpsychiatristfeelsthatcontinuingthept‘santidepressantisindicated. Nextstep?(2x) ESTABLISHACLEARUNDERSTANDINGOFTHEDIVISIONOF RESPONSIBILITIESBETWEENPSYCHIATRISTANDCOUNSELOR PthasphonedtheEDcomplainingofhallucinationsthatcommandthepttokill others.Psychiatrist’sfirstaction: OBTAINPHONENUMBER,ADDRESSOFPATIENT Whatare“leastrestrictivealternatives”forpatientswithseriousmentalillnesses? TREATMENTSHOULDOCCURINASETTINGTHATINTERFERES MINIMALLYWITHTHEPATIENT’SCIVILRIGHTS Pthaspsychotherapist.Ptreferredtopsychiatristwhoprescribesmedication. Psychiatrist’sresponsibilitytopt TOFOLLOWUPBYSEEINGPTATAPPROPRIATESCHEDULED INTERVALSANDBYCOMMUNICATINGREGULARLYW/ PSYCHOLOGISTABOUTPT’SCLINICALSTATUSANDTXPLAN Finallegalresponsibilityfallson PSYCHIATRIST 80y/optwasadmittedtoanursinghome,anemployeeofthefacilitynotifiedthe ptaboutthestate’slawsonadvancedirectives.Duringthatsession,thepatient THELIVINGWILL mostlikelyreceivedinformationaboutwhichofthefollowingissues: 29y/oseverelydepressedwithSI.Threatenstokillhiswifeanddaughterto“take themwithme.”Legalresponsibility: NOTIFYTHEWIFE Howdoyouresolveamixeddecisionforamongstaffandfamilyofadyingpatient MEETSEPARATELYWITHFAMILYANDSTAFFTOEXPRESSISSUES (continueTxvsletdie): OFPOLARIZATION Goalsofinitialdialoguew/docrequestingconsultexcept; MAKINGSUREFAMILYISNOTPRESENT Majorissuewithmaintainingseverelymentallyillincommunity INSUFFICIENTRESOURCES Basicconceptofcommunitypsychiatry CONTINUITYOFCARE Initialstepwhenchildisreferredforevaluation: CONSENTFOREVALFROMGUARDIAN Publicmentalhealthclinicianswhofollowpatientsthroughallphasesoftreatment CASEMANAGERS Managedcareorg.asksMDtod/captwhostillrequireshospitalization.MD should: CONTINUEADMISSIONASLONGASMEDICALLYNECESSARY Principalgoalofwraparoundservices: PREVENTHOSPITALIZATIONORRESIDENTIALPLACEMENTS GotoTableofContents 295 FORMALMENTALHEALTHSERVICESANDINFORMAL COMMUNITYSUPPORT Essentialelementofwraparoundtreatment 31y/opostpartumFdistressedbyfantasiesofsmotheringbaby,tearfullydescribes feelingoverwhelmedbytheburdenofthechildcare.ShedeniesSI/HI,but describesfeelingsomeevilexternalforcetakingherbabyaway.Requestsoutpt INVOLUNTARYADMISSION psychf/u&refusesvoluntaryadmission>herhusbandsayseverythingisfine.Next step: PtisadmittedtoICU.Ptcancommunicatebutisdeemedincompetent.Whichof thefollowingadvancedirectivesshouldbeusedtoinformthehospitalstaffofpt wishes? LIVINGWILL Howtomanagetelephoneconversationwithlabilepatientwhoendedrelationship withboyfriendandishavingSIwithplan,butiswillingtostaywithfamilyand Next-dayoutpatientf/uwithpsychiatrist allowsyoutospeakwithfamily? 50yroldptdivorcedandlaidofffromworkpresentstoEDwithSIwithplantoOD ontylenol,lackssocialsupportandhasimpulsivehistory,disposition? Inpatienthospitalization rd 24yohomelesswithSIrequestshospitalization.Thisis3 visitinspanof2 weeks.Ptisorganized,coherent.Whenaskedwhatwouldbedifferentwiththis hospitalization,attacksthedoctor.Bestnextstepofaction? Calllawenforcement ConsultandLiaison Whatresponsewouldbebasedonapurelylaisonalmodelofpsychosomatic medicinegiveforaptwhomaybedepressed? ADVISETHETEAMONHOWTOPROPERLYDIAGNOSE DEPRESSION 21y/optishospitalizedw/4wkhxofprogressiveparanoia,irritability,confusion andsleepdisturbance.PsychMDelicitspthxofviralillnessprecedingtheonsetof DELIRIUMSECONDARYTOVIRALENCEPHALITIS psychiatricSxandmentalstatuschanges.Nofamilypsychhx.Benadrylmarkedly makeSxworsened.Dx: Biologicalconsequencesofpsychologicalstressaredocumentedtoaffect… ALTERATIONOFNEURO-IMMUNO-ENDOCRINEFUNCTION 22y/optpresentstopsychfortreatmentof“internetaddiction.”Ptnoticeda patternofincreasingtimepentontheinternet,needforbettercomputer equipment,andfeelingsofangeranddysphoriawhenunabletoaccessthe Internet.Explainconceptsoftoleranceandwithdrawalinthissyndrome? BOTHTOLERANCEANDWITHDRAWALTOINTERNETUSECAN DEVELOP Whichcancertreatmentmaybefollowedbyasubcorticaldementiaduetoa leukoencephalopathywithonsetafter6monthspost-treatment? WHOLEBRAINRADIATION WhichSxismostcommoninptswithSLE? DEPRESSIONAND/ORCOGNITIVEDYSFUNCTION C&Lpsychsees58y/owidowedptmedicinewantstodischarged/tnegworkupfor abdpainandnausea.Ptrefusestoreturnhometoadultkidsbecausethefoodthey SCHEDULEMEETINGWITHTHEMEDICALTEAM,PATIENT,AND preparearemakinghersickandcausinghersxs.MSEunremarkableandnopast FAMILY psychhx.Nextstep? 45y/owithRhemiparesis,CTshowsLinternalcapsuleischemicchangesextending toadjacentbasalganglia+oldlacunarinjuryofRcaudatehead.LP–65wbcs PCN (mostlylymphocytes),78protein,63glucose,+regainantibodies.Tx? PtwhorecentlydeliveredababyBIBtoER,Ptisagitated,labile,anddemandingto leavebecauseshesaidherbabyisbeingpoisoned.Thisconditionisconsidereda INFANTICIDE psychemergencybecauseofitsassociatedw/? 35y/optw/severedepressionwithepisodesofanxietyforpast9months.Pthas severeweightloss,hyperpigmentationofexposedskin,andcoldintolerance.Dx: ADDISIONDISEASE 15y/optw/hxofatypicalseizuresthatincludepsychomotorattacksand generalizedmotorepisodes.Ptdoespoorlyinschool.Examrevealsskinlesion,no otherabnormalities.Amutationofwhichgene? TSC-1(TUBEROUSSCLEROSISGENE1) GotoTableofContents 296 Themostcommonpsychiatricsymptomassociatedwithpheochromocytoma? PANICATTACKS Psychiatristseesfamilyofaptwhoisinvegetativestate.Allstaff,exceptone nurse,&alloffamily,exceptoneadultchild,believeitis“timetoletgo.”Butnurse MEETSEPARATELYWITHFAMILYANDSTAFFTOEXPLORETHEIR &adultchildclaimsignsofrecognizing&respondingtothemdespiteallofthe ISSUESWITHPOLARIZATION evidenceofcorticalbraindeath.Mostappropriatenextstep? PsychMDtestsamedicalptwithgo/no-gotestinwhichpsychMDaskspttotap thetableonceifPsychMDtapsitonce,butnottotapthetableifpsychMDtapsit EXECUTIVEFUNCTIONING twice.PsychMDisscreeningfordeficitsin? Whichpersonalityd/oismostcommonlyfoundinptsw/severefactitiousd/o? BORDERLINEPERSONALITY Mostcommonpsychiatricpresentationfollowingastroke? DEPRESSION 61y/optpresentstoEDwithfamilywhoreportthattheptunabletoremember recentevents.Memoryproblemsstarted2hoursprior;cognitivelyintactbefore episode.Ptisalert,anxious,frustrated:“WhyamIinthehospital?”Dx: TRANSIENTGLOBALAMNESIA Onthewaytoairportforvacation,58yoFbeginstobehaveinverystrangeway. Husbandnoticeswhenhetalkstohersheanswersappropriatelywfluentspeech butseemstohavenoabilitytoretainanynewinformation.Sherepeatedlyasks TRANSIENTGLOBALAMNESIA wheretheyaregoing,evenafterhehastoldhermanytimes.Theepisodelastsfor bout6hours.Thefollowingdaysheisbacktonormalbuthasnorecollectionofthe priordayevents.Thisepisodeismostconsistwithadiagnosisof: C&Lpsychiatristseesa20y/optwithcancerpainonmethadonemaintenance program.Thestafffeelsthatthept’srequestforadditionalnarcoticsrepresent drug-seekingbehavior.Mostappropriaterecommendation: THEPTSHOULDBEGIVENMOREOPIOIDMEDICATIONTO ACHIEVEADEQUATEPAINCONTROLBECAUSEOFTHEPT’S TOLERANCE. Thisisarelativecontraindicationforinterferontreatmentinpt’swithHepatitisC: (2x) DEPRESSIONWITHSUICIDALIDEATION PsychMDsees62y/optwhohasbeenhospitalizedafteranacuteMIbecausestaff reportthat“theptisdrivinguscrazy.”Thenursescomplainthatptisconstantly requestinginfoabouthisconditionandtreatment,andwillrefusetestsand ANSWERTHEPT’SQUESTIONSANDACTIVELYINVOLVETHEPTIN medicationsifhefeelstheexplanationsarenotsufficient.Oninterviewptadmits ALLPORTIONSOFHISTREATMENT that“Iamaperfectionist”butisproudofthisfact,sayingthatitis“thesecretof mysuccess.”Ptisawareofthestaff’sfrustration,butfeelshisrequestsfor informationarereasonable.ThebestadvicetotheTxteam? 25y/oprisonerwhoclaimstobedepressedishospitalizedafterheswallowed somerazorblades.Therazorbladesarefoundtohavebeencarefullywrappedin surgicaltapebeforetheptswallowedthem.Later,theptconfessesheswallowed thebladesbecausehewantedsometimeoutofprison: MALINGERING Psychevalrequestedonmanagementof32y/optadmittedbyinternalmedicine fortxofseveregastrointestinalviralinfection—dehydration,nausea,vomiting, fever.Pthashxschizoaffectivedisorder,controlledwstabledosesofclozapine overthepastyear.Staffconcernedthatptmightbedelusional/hallucinating,aspt DISCONTINUECLOZAPINE hasappearedsomewhatconfused/inattentive.Onexam,ptisorientedtoperson, placebutnottime.Ptsomewhatslow,appearsvisiblyill/tired.Ptcomplainsof stiffness,thereissomerigiditytomovements.Psychrecommendation? PsychMDisaskedtoevaluatea37y/oFwhocomplainsofchronicvulvarpain.This painisaccompaniedbyaburningsensationwhichislocalizedtothevestibular region.Pt’shusbandreportsa12-monthlackofanysexualintercoursewithpt.on psychiatriceval,theptexpressesambivalenceaboutthelackofintimacywithher husband,andappearssomewhatannoyedathimfornotunderstandinghow INITIATENORTRIPTYLINEANDSLOWLYTITRATE. painfulsexhasbecome.Ptdeniesdepressionoranxiety,butadmitstofrustration aboutthepain.Thegynecologistreportsthatafullphysicalandlaboratoryworkup isremarkableexceptforpaininthevestibulewhichcanbeelicitedwithtouch. Whichwouldbethemostreasonableintervention? GotoTableofContents 297 Whichofthefollowingistheprincipalserviceprovidedbytheliaisoncomponentof TEACHINGPSYCOSOCIALASPECTSOFMEDICALCARETOOTHER consultation-liaisonpsychiatry? HEALTHCAREWORKERS Aneffectiveconsultation-liaisonpsychiatryprograminamedicalhospitalwillresult IMPROVEDTREATMENTCOMPLIANCE inwhichofthefollowing? 58yopatientwithbreastcancerontheC&Lservice,recentlyputonpalliativelevel anddevelopsdepression.SheishopelessbutdeniesSI.Whatisthemost VALIDATETHEPATIENT’SFEELINGS appropriateresponse? A40-year-oldptishospitalizedforevaloffever,weightlossandataxia.Psychiatric consultationisrequestedasthepatientseemsdepressed,andafamilymember reportsthatthepthasbeenexhibitingprogressivememorylossoverthelast HIV severalmonths.Whichofthefollowinglabtestsmayhelpexplainthepatient’s presentation? 85yopatientwithhxofdementiaadmittedforagitationbecomesmoreconfused andangry.Whatlabshouldyouget? UA 41yodrunkmalewhoisstuporoushasapulseof75andBPof110/70.Whatisthe RESPIRATORYFAILURE mostimmediateclinicalconcern? Consultantevaluatespatientforcapacity.Patientrefusingmeds,procedures, yellsatnurses,orderstakeoutintohospital,threatenslawsuitsifdemandsnot met.Patientaccusesdoctorofbeingabusive,screamsatdoctor,whenaskedfor explanationofbehavior“you’rejustanotherpersonheretoabuseme!”Best responseandadviceformedicalteamis? AneffectiveroleofC&Lpsychiatristconsultingonamanipulative,entitledpatient? “thepatientisadifficultpatienttoworkwith.Let’stalkabout waystomanagethepatient’sbehavior?” MODELINGANAPPROACHOFAPPEALINGTOTHEPATIENT’S ENTITLEMENT ViolenceandAbuse Whichofthefollowingsituationalandenvironmentalfactorsismostclearly associatedw/increasedinpatientassaults?(6x) CHANGEOFSHIFT PregnantwomeninvolvedinaDVrelationshipgetstruckwheremostcommonly? ABDOMEN (5x) 23y/oadmittedininpatientunitw/Dxacutepsychoticd/oafterthreateningto beatuphismother(withwhomhelives).Agreedtovoluntaryadmit,but2days IFTHEPATIENTCONTINUESTOTHREATENHISMOTHER laterdemandstosignoutAMA.Whatjustifiesinvoluntaryhospitalizationinthis pt?(2x) PthasbeensexuallyassaultedisintheERimmediatelyafterthetrauma. PSYCHOSOCIALINTERVENTIONSTOESTABLISHSAFETYFROM InitiationofwhichofthefollowingismostlikelytobehelpfulinpreventinglongFURTHERTRAUMA termpsychiatricsequelae?(2x) Whichofthefollowingcaregivercharacteristicsisthestrongestpredictivefactor ALCOHOLABUSE forelderabuse?(2x) 20y/optisbroughttoERbyfriendwhoisconcernedaboutpt’spotentialfor assaultiveness.Whichfeatureismostindicativeofthisrisk? Childabuseresultsinsmallersizeofwhichareaofthebrain? VIOLENCETOOTHERS Hippocampus Psychd/oinviolentpeople SUBSTANCERELATEDD/O Whichofthefollowingisthemostcommonpsychiatricdiagnosisassociatedwith violentacts? SUBSTANCEUSEDISORDERS Oneofthemostcommonpsychd/ofoundinindividualswhocommitviolence againstothers(evenmorethanIED,BMD,MDD,CPS): SUBSTANCERELATEDD/O GotoTableofContents 298 MptBIBtoEDbypoliceafterhethreateningtokillhiswifeandadmitsthathas thoughtsofharminghisspouseeversincelearningofherinfidelity,saying“Iwant hertohurtlikeIdonow.”Theptdoesn’tdisplaydelusionsandmoodproblems.He REFERPTBACKTOLAWENFORCEMENT admitstodrinkingoccasionally,butinthelastweekandpriortoviolence.Next step: DutyasoutlinedbyTarasoff PROTECTTHEPOTENTIALVICTIMOFADANGEROUSPATIENT Bestpredictoroffutureviolentbehavioris: PASTVIOLENTBEHAVIOR WhatdoesNOTpredictviolence? NON-VIOLENTCRIMINALACTIVITY Whatistherelationshipofviolencetomentald/o? MENTALD/OHEIGHTENSRISKINSOME,DECREASESRISKIN OTHERS Homicideandhomicidalbehaviorsaremostoftenrelatedtowhatfactors? EMOTIONSNOTASSOCIATEDWITHMENTALILLNESS Drugleasteffectiveasadjunctivetxofchronicviolentbehavior DIAZEPAM 70y/opresentswithfearfulness,angerandagitationaftermovinginwithadult child.Onfirstvisitptisresignedandtimidduringexam.Whichismostconsistent withpt’sbehaviors? PSYCHOLOGICALABUSE 18y/oFinED,justraped.Immediateintervention: PROVIDESUPPORTANDALLOWTOVENT Characteristicofwomenwithincreasedriskofbattery PREGNANCY Femaleshavecomparableratestomalesfor: DOMESTICVIOLENCE 20y/optbrings2y/ochildtoERwithmultiplebruises.Mothersayshefelldown stairs.Motherhashealingblackeyeandcutlip.Sayssheslippedoniceandhit ADMITCHILDFORCAREANDPROTECTIONDESPITEMOTHER’S head.X-rayofchild'sarmshowhairlinefxandhealingcallous.Whatactionshould OBJECTIONS psychiatristtakefirst? Afindingthatshouldraiseaconcernforchildabuse? SYMMETRICALBRUISINGINA24-MONTH-OLD PtconfidestothepsychMDthatthept’sspousehasbeenphysicallyabusingthe pt.Inallcases,thepsychMDshoulddowhatbeforetheptleavesoffice? DETERMINEWHETHERTHEPATIENTISINPRESENTDANGER WhatisthefirstpriorityinERmanagementofarapevictim? ESTABLISHINGPSYCHOLOGICALSAFETY 27y/oangry,agitatedptisadmittedtotheER.Heisevaluatedduringinitial interviewasnon-psychoticandhighriskforimminentviolence.Herefuses medication.Whatwouldbethemostappropriateinterventionatthistime? USEEXTERNALRESTRAINTWITHCALMREASSURANCE. 16y/ocaughtforshopliftingjeans.Nohxofstealing,jeansnothersize.Pt frightened,remorseful,insomnia,failinggrades,avoidingfriends.Raped2months ACRYFORHELP earlier,familyinsistedshenottellanyone.Understandstealingas: 42yroldfemalewithdepression,Spanishspeaking,usuallyseenbypsychiatrist withinterpreter,butthistimebilingualhusbandwillserveasinterpreter, psychiatristseesunexplainedinjuriesandsuspectsabusebyhusband,atnext appointmentptcomeswithclosebilingualfriendandrequestsfriendtojoin session,ptsayshusbandisparkingcarandwillbeinshortly,whatwouldbethe bestapproachtoclarifytoclarifysuspicionsofabuse? Occurrenceofsexualabuseorinappropriatesexualexposureisindicatedby? (x2) BEGINSESSIONWITPT,INTERPRETER,ANDPTSFRIENDWHILE HAVINGTHEHUSBANDREMAINOUTSIDE Pretendingtohaveintercoursewithastuffedanimal EmergencyPsychiatry 24yoptcomestoedwithwristcuts.ptreportshavingnointentiontodiebut wantedtofeelthings.Admitstootherselfharmbehaviorswhenstressed. Admissiontopsychhospitalwouldbemostsupportedbywhatinthepatients history? RECENTALCOHOLABUSE GotoTableofContents 299 25y/oFisbroughttoERafterbeingseverelybeatenbyherBF.Followingmedical stabilization,firststepinanacutepsychologicalinterventionis: HELPHERRECOGNIZETHATIMMEDIATEDANGERHASPASSED ANDSHEISINASAFEPALCE 14y/obroughttoEDaftertellingmomthatshehadbeenrapedbystepdad.On psycheval,ptreportsfeeling“okay”anddeniesacutedistress.Ptiscalmduring interviewandappearsgenerallyunaffectedbyrecenttrauma.Onfurther questioning,ptappearsconfusedandbelievessheisatafriend’shouse.Whichis thepreferableintervention? EMPLOYGROUNDINGSTRATEGIESTOORIENTPT 22y/obroughttoEDbyroommatewhofoundhimunconsciouswithasuicide note.Temp100.9,BP100/60,P124,RR8,warmanddryskin,dilatedpupilsand TCA reactivetolight,bowelsoundsdecreased,EKGwithsinustachyandQTCof589,no obvioustrauma.OnwhichdidptOD? GivingcharcoalisanineffectivetreatmentforptwhoOD’don: LITHIUM PatientcomestoEDconfused,lethargic,flushing,diaphoretic,andrestless. Recentlystartedfluoxetinebutdoesn’trecallnamesofotherpsychotropicshe’s taking.Tempis101.5,BP110/62,hastremorandmyoclonus.What’scausinghis symptoms? SEROTONINSYNDROME 25y/opresentstoEDc/ochestpain,SOB,andanxietybutappearsNADandcalmly answersquestions.Ptreportsh/opanicattacks,requestingalprazolambyname, andreports“Iusuallyneedaprescriptionforatleast2mg4xperdaytogetrelief”. SUBSTANCEABUSE Whenaskedtodescribe1stpanicattack,ptstates,“Ican’trememberwhenthey startedorthefrequency”.Whichd/oislikelypresent? PtinEDfortreatmentofOD–wasfound4hrsagoafteringesting10coldmed PT’SSERUMN-ACETYL-P-AMINOPHENOL(APAP)LEVELOVER packsof650mgTylenol,antihistamine,andalpha1agonistdecongestant.Ptispale TIME andvomiting.HowdoyoudecidewhethertouseN-acetylcysteineasanantidote? InER,whichsymptomsmoststronglysuggestageneralmedicalcondition? CLOUDEDSENSORIUM PttakingtranylcypromineforatypicaldepressioncalledPsychMD,reportsHA, vomiting,chills,palpationsoveroneday.Ptasksifhecontinuemedduringillness. Inadditiontodirectingpttostopmed,emergentTxwould1stincludewhatmed? NIFEDIPINE Patientwithlonghistoryoftreatmentresistantdepressiononphenelzine complainingofsweating,palpitations,andheadache.BP=210/118.Recently tookOTCmedicinetotreatURI.Whatisthemostappropriateintervention? NIFEDIPINE AnintoxicatedptinERthrowsafoodtrayatsecurityguard,norespondtoverbal redirectionandrefusedtotakemedsbypo.Ptisnowpacing,cursingand threateningto“hurtsomeone”.Themostappropriatemeds: LORAZEPAM2MGIM,REPEATEDIN45MINIFNORESPONSE Themostvalidcriticismofrelyingonano-harmcontracttodetermineapt’s suicidepotential: ITLACKSANYSIGNIFICANTEMPIRICALEVIDENCETOSUPPORT ITSUS Homicideandhomicidalbehaviorsaremostoftenrelatedtowhichofthefollowing EMOTIONSNOTASSOCIATEDWITHMENTALILLNESS. factors? InhelpingavictimofrapeintheED,thefirstintervention? RESTOREASENSEOFSAFETYWITHTHEPATIENT 35y/optwithhxofopioidandalcoholdependencepresentstotheemergency departmentcomplainingoftremlousness,anxiety,nauseaandvomiting.Usedlarge METHADONE amountsofheroinandalcoholthedayprior.Initialpreferredmedicationforopioid withdrawal? 27y/ouninsuredptwashospitalizedinanintensivecareunitafteranearlethalOD whichfollowedtheendingofalong-termrelationship.Ptismedicallyreadyfor INPATIENTHOSPITALIZATION discharge,butisambivalentaboutfollow-uppsychcare,noncommittalwhenasked aboutregretfulfeelingsforsurviving.Bestapproach? GotoTableofContents 300 25y/optisbroughttotheEDwithasuddenonsetofseverespasmsoftheneck andeyesdeviatedupandtotheright.Thepthashadaviralillnesswithnausea andvomitingandwasgivenprochlorperazineyesterday.Whichofthefollowing medswouldbemostappropriatetoprescribeforthispatient? DIPHENHYDRAMINE 28y/owomanwhoisat33weeksgestationandhasahistoryofbipolardisorderis broughttotheemergencydepartmentbyfamilymembersbecauseshewas runningaroundtheneighborhoodloudlyproclaiming,“IamthemotherofChrist.” Theptisinrestraints,yelling,spitting,disorganized,andtangential,withrapid HALOPERIDOL speech.Familymembersreportthattheptwasstableonvalproate,but discontinuedthemedicationwhenshelearnedshewaspregnant.Which medicationtogiveacutelyforthispt? 50y/optwithmyastheniagravisanda3-dayhxofcough,low-gradefeverand chills,presentswithgreatdifficultybreathing.Theptappearstiredandanxious, andthept’sskinisclammyandsweaty.Initialmanagement? MECHANICALVENTILATION WhenevaluatingapatientintheEDforriskofdangerousnesstoothers,thebest AHISTORYOFVIOLENTBEHAVIOR predictoroffutureviolentbehavioris(x2): AdultmalepresentstoclinicwithbrokenhandduetofirsttimeDVtowardhis same-agespouse.Bestresponsebypsychiatrist? TELLTHEPATIENTTHATVIOLENCEISHISRESPONSIBILITYANDHE NEEDSTOSTOPIT Suicide Whichd/oisthemostcommonamongptswhocompletesuicide:(4x) MOOD Noharmcontractbetweenpatientsandcliniciansare?(2x) UNHELPFULINMAKINGDECISIONS Rateofcompletedsuicidehighestforadultmaleswhen?(2x) OLDERTHAN65 Consistentpredictoroffuturesuicidalbehavior(2x) PRIORATTEMPTS Mostcommonmethodforcompletedsuicidesinadolescents(2x) FIREARMS AccordingtoJointCommission,whatisprimaryriskfactorforcompletedsuicides inmedicallyhospitalizedpts? lackofproperassessmentforsuiciderisk Baseduponlongitudinalstudies,whichriskfactorscorrelatedw/suicidemorethan HISTORYOFPRIORATTEMPTSANDHOPELESSNESS oneyearafterinitialassessment? Inthecognitivetherapymodel,whichofthefollowingismostassociatedwith suiciderisk? HOPELESSNESS Whichisaconsistentlyidentifiedriskfactorforsuicidethatisuniquetoadultswith AGELESSTHAN35YEARS schizophreniacomparedtothegeneralpopulation? Whichofthefollowingfactorscarriesthehigheststandardizedmortalityrationfor HISTORYOFPRIORSUICIDEATTEMPTS suicide Highestrateofsuicideassociatedwith HAVINGREADYACCESSTOFIREARMS Basedonepidemiologicalstudiesfrom1994-2004,whichgroupshashighest suicidecompletionrate? CAUCASIANAMERICANMENINTHEIR60S Indocumentingsuiciderisk-assessment,keyriskmanagementstrategyistodiscuss WHYTHEPSYCHIATRISTREJECTEDALTERNATIVEWAYSOF whatfactorsintherecord? RESPONDING Ptwithwhichmedicalconditionmostlikelytocommitsuicide? SYMPTOMATICHIVINFECTION Theleadingcauseofdeathamonggunbuyersinthefirstyearaftertheweapon waspurchasedis: SUICIDE WhatpsychiatricsymptomdoesnotrequirepharmacologictreatmentintheER? SUICIDALITY Alongw/depressionmostcommoncomorbiddisorderinphysiciansuicideis SUBSTANCEDEPENDENCE GotoTableofContents 301 Preventingadolescentsuicide: REMOVEFIREARMS 23y/optpresentstoEDbyambulanceforSI.Pthasalcoholodorandslurred speech.HeendorsesSIbuthisplanisincomprehensible.Nextstep: OBSERVEANDEVALUATEWHENHEISSOBER. Mostcommontimeforptw/schizophreniatoattemptsuicideisduring RECOVERYPHASEOFTHEILLNESS Whatfactorsismosthighlycorrelatedwithcompletedsuicideinadolescentmales? PREVIOUSSUICIDEATTEMPT Whichcommonlyprecipitatessuicideintheelderly? LOSS Mostpowerfulstatisticalriskfactorforcompletedandattemptedsuicide HAVINGAPSYCHILLNESS MostcommonmethodofcommittingsuicideforwomenintheUSis: FIREARMS 15y/optdepressed+suicidalhasanalcoholicfather.Priord/cfromhospitalthe nextstepshouldbe: ENSURETHATANYLETHALMEANSAREUNAVAILABLEATHOME 1993–highestrateofsuicidein75-84y/oagegroup: CAUCASIAN-AMERICANMALES Ptwithwhichdxaremostlikelytoengageinparasuicidalbehaviors? BORDERLINED/O WhenistherehighestriskofsuicideinMDDpatientsrecentlydc’dfromhospital? 0-3MONTHSAFTERDC Interminalcancerpatientswhoultimatelydiebysuicide,whichoneofthe followingcomplaintsismostfrequentlyreported? SEVEREUNCONTROLLEDPAIN PsychMDintheERevaluatesa27y/optwithnopastpsychiatrichistorywho presentswithSIfollowinganaltercationw/herboyfriend.ThepsychMDmakesa diagnosisofadjustmentdisorderwithmixedemotionalfeatures.Whatisinitially mostappropriateforthepsychMDtorecommendforthispt? CRISISINTERVENTION Whatconditionhasbeenshowntoincreasetheriskofsuicidetothegreatest degreeinpersonswithdepression? PAINSYNDROMES Whatfactormaybeprotectiveinassessingapt’sriskforsuicide? STRICTRELIGIOUSFAITH Whatdiagnosis,consideredintheabsenceofothercomorbidities,isestimatedto putoneathighestlifetimeriskforsuicide? BIPOLARDISORDER PsychiatristtoevalptwithbipolarDOwhoisexhibitingthreateningbehaviorwhile inptonCCUforcardiacischemia.Ptwasincarceratedforassaultingandofficer, disturbingthepeaceandfirearmsviolations.Ptverballythreatenstotrackdown INFORMPOLICETHATPTISINPOTENTIALDANGER hisex-girlfriendand“teachheralessonshe’llneverforget.”Psychiatristhaslegal responsibilityto… Afteraptassaultsaroommateonapsychinptunitthetxteamdecidestohavept DUTYTOOTHERHOSPITALIZEDPTS arrestedandtransferredtojail.Decisionisbasedon…? 50y/optpresentstotheERvoicingsuicidalthoughts.Theptstatestheintentto killhimselfwithaguninthewoodsbehindhishouse.Bestcourseofactionisto: ADMITTHEPTTOTHEHOSPITALFORFURTHERASSESSMENT ANDCARE. ACaucasianptwithwhatriskfactorshasthehighestriskforcompletedsuicidein the US? AGEGREATERTHAN85YEARS Prevalencerateofsuicideingeneraladolescentpopulation? 10% Bereavement 62y/orequestsantidepressant.Spousedied6wksago.Cryingspells,decreased appetite,poorsleep.Continuestoseefriends,noSI.FamHxofdepression,no priordepressiveepisodes(2x) BEREAVEMENT;ASSUREPATIENTOFNOPATHOLOGY Mostlikelytoincreaseriskofimpairmentafterbereavementin80y/o SIGNIFDEPRESSIVESXSSHORTLYAFTERTHELOSS GotoTableofContents 302 Normalbereavementinprepubertalchildren WISHTOUNITEW/DEADLOVEDONE 5y/ochildseveralmonthafterthathelosthismotherinaMVAreportsthathis motheriswatchinghimfromskyeverydayisandexampleof: NORMALGRIEF 8yow/nohxofemotionaldisturbancep/wseparationanxiety&over-concern forhealthofsurvivingparent. Age-typicalpresentationofnormalbereavement Foradult,deathoflovedonebyviolentmeansaffectsgrievingprocessinwhat way? EARLYBEREAVEMENTISSIMILAR,HOWEVER,DYSPHORIA PERSISTSFORPROLONGEDPERIOD Afatherwantstoknowifheshouldallowhis5y/ochildtoattendthefuneralof hermother.Thechildexpressesadesiretogo.Tohelpthechildthroughthe funeral,itwillbeimportanttodowhichofthefollowing? HAVESOMEONEFAMILIARACCOMPANYTHECHILD 62y/optpresentstopsychiatristrequestingmedfordepression.Detailedhx revealspt’sspouseof35yearsdiedsuddenly6wksago.Sincethen,ptcomplains offrequentcryingspells,decreasedappetitewithoutweightloss,andpoorsleep duetomiddleofthenightawakening.Ptcontinuestoattendsocialengagements withfriendsanddeniesSI.Pthasfamilyhxofdepression,nohxofdepressive episodeinpast.Dx: BEREAVEMENT Whatfactorisnecessarytoconsiderwhendecidingifapatient’sgriefisdefinedas CROSS-CULTURALGRIEFPRACTICES normalorabnormal? Whatsymptombestdifferentiatechronictraumaticgrieffromuncomplicated bereavement? PERSISTENTAVOIDANTOFDEATHREMINDERS Ptisengagedininterpersonalpsychotherapyfordepression.Inthefirstseveral sessions,thepatientandtherapistidentifyunresolvedgriefafterthedeathofthe FINDINGNEWACTIVITIESANDRELATIONSHIPSTOOFFSETTHE patient’smotherastheproblemarea,andrelatethesefeelingstothepatient’s PATIENT’SLOSS currentdepression.Whichofthefollowingwillbethefocusofthemiddlephaseof treatment? 5y/ohasbeenenureticaftermotherdiedinanMVA4daysagoandkeepssaying, THECHILDANDSIBLINGSHOULDBOTHBEALLOWEDTOATTEND "Mommywillcomehomesoon."Thefatherwondersifthechildrenshouldattend IFTHEYWANTTOGO. thefuneral.Whatisyourrecommendation? WhichsymptomwouldindicateMDDratherthanjustbereavement:Poorappetite andsleep,hearingthevoiceofthelovedone,feelingsofguiltorthoughtsof THOUGHTSOFSUICIDE suicide? Whichofthefollowingfactorshasthemostevidencetosupportitsprotective effectinbereavementfollowingthelossofaspouse? QUALITYOFSOCIALSUPPORTOFTHEBEREAVED 30y/optrecentlyDxw/Hodgkin’sdzconstantlystates,“Whyme?”Accordingto ElizabethKubler-Ross,thepatient’sreactionisconsistentwithwhatphases? SHOCKANDDENIAL Whatisasymptomofnormalbereavementina<5y/ochildafterthedeathofa parent? REGRESSIONINBOWELANDBLADDERCONTROL 4monthsagothewifeofaptdiedandptblameshimselfforherdeath.Nextstep: REASSURANCE 60y/olostspouse2wksago–sadnesscomesandgoes NORMALGRIEF 65y/optinitiallydiagnosedwbereavement.DurationofsxtodxMDD? 2MONTHS 58y/ohaveweek’sh/ointensefeelingsofsorrowandbitternessonly6mosafter wife’sdeath.“Wewouldhavebeenmarried30yrsthismonth.”Hisdaughter confirmedhisleveloffunctioningonlytookadipaweekago.Moderatediff sleepingandpoorappetiteonlyassocSxs.NoSI.Physicalexamnormal.Dx: DELAYEDGRIEF 1-monthpostdeathoflovedone.Whatwouldsuggestapathologicalgriefrxn? CONT.FEELINGSOFWORTHLESSNESS Riskfactorthatcanadverselyinfluencepsychoutcomeofchildafterdeathof parent CONFLICTUALRELATIONSHIPW/DECEASEDPARENT GotoTableofContents 303 6y/ogirlhospforsurgerytorepairfracturesustainedinMVAinwhichmotherwas injured&brotherdied.Shereportsseeingherbrotherinherroomsinceaccident, BEREAVEMENT MSEisnml.ReceivingVicodin&Benadryl.Whatexplainsptseeingbrother? 10y/oMs/pMVAsustainedburnandcrushinjuriestoRfoot4daysago,doesnot remembertheaccidentbutneverlostconsciousness,keepsaskingforhismother ASAP whowaskilledintheaccidentandhavingnightmarescryingout“Daddyhelp Mommy.”Whenshouldthechildbetoldabouthismother’sdeath? 45y/ostillgrievingformother3yearsafterherdeath.Statesshefeelshermother hoveringoverherandseesmotheratnight.Friendsareconcerned.Patienthas ANTIDEPRESSANTMEDICATIONANDPSYCHOTHERAPY normaljobfunction,cleanshouse,endorsesanhedonia.Tx? AccordingtoHolmes&Rahe,whatlifeeventisassocwhigheststress/disruption? DEATHOFASPOUSE Risksofcomplicatedbereavement: 1)AMBIVALENTRELATIONSHIPTODECEASED; 2)SIMULTANEOUSGRIEVINGFORMULTIPLEDEATHS; 3)PRE-EXISTINGLOWSELF-ESTEEM&INSECURITY; 4)RECURRENTMAJORDEPRESSION 65y/optwMDDhasdiedbysuicide.Pthadreceivedtxfromsamepsychiatristx5 CONCENTRATEONADDRESSINGTHEFEELINGSOFTHESPOUSE yrs.Psychiatristcontactsthept'sspouse.Bestwaytocommunicatethis? Whichofthefollowingispredictiveofbetteradaptationinbereavement? FINDINGMEANINGINLOSS Sexuality Txofprematureejaculation(MEN)andpremenstrualdysphoricd/o(WOMEN): (3x) FLUOXETINE 25y/oMpthasnotedsexualarousalandevenattainederectionswhilerubbing upagainstunsuspectingwomenonsubway.(2x) FROTTEURISM Ptdissatisfiedwmarriage,nosexinayeardespitehusband’sefforts,whenever husbandtriestokisshershebecomesdisgusted,uncomfortable,anxious.Avoids SEXUALAVERSIONDISORDER sexbyneglectingpersonalhygiene.Inabilitytobecomearousedbyhusband whichwasokinthepast,masturbatestoorgasm.Dx?(2x) Whathormonelevelsurgesduringorgasm? Oxytocin Malephysicianrepeatedlyaccusedbyadultfemaleptsofsittingoppositethemon hisstoolduringeyeexam,opposingkneesalternating,insuchamannerthatone FROTTEURISM ofpts’kneestouchesphysician’scrotch.Iftrue,thisisanexampleof Cross-dressingforthepurposeofsexualexcitementiscalled: TRANSVESTICFETISHISM Txfirstlinetootherwisehealthy34y/omanforprematureejaculation? TRAININGINBEHAVIORALTECHNIQUESTODELAYEJACULATION Recurrent,intensesexuallyarousingfantasies,urges,orbehaviorsincludingthe useofnonlivingobjectsaremaindxfeatureofwhatd/o FETISHISM Psychiatrististreating23yoFwlifelonginabilitytomaintainadequatelubrication- swellingresponseofsexualexcitementuntilcompletionofintercourse.Ptonno SENSATEFOCUSEXERCISE meds,doesn’tusedrugs/EtOH,hasnoothermedconditions.Mosteffectivetx? Acoupleinpsychotherapyduetosexualdysfunctionisencouragedtoexplore eachother’sbodiesexceptforbreastandgenitals.Whattechniqueisthis? SENSATEFOCUSING Whatstatementdescribesprinciplesoftxofptwsexualdysfunction? THOROUGHMEDEVALANDTREATMENTOFANYMEDICALD/O SHOULDBEPERFORMEDBEFOREENTERINGTHERAPY 26-year-oldfemalewithintenseburningpainwithintercourseforseveralweeks causinghertotenseupduringpenetration.Mostappropriateaction? REFERFORCOMPREHENSIVEGYNEXAM 25y/oMw/prematureejaculationrefusesmeds.Tx? SQUEEZETECHNIQUE GotoTableofContents 304 65y/oMwimpotence,diabetes,AFib.Psychiatristrecommendssildenafil.What doyoutellthept?1)impotenceisduetoDM.2)erectiledysfunctionparallels diabeticcomplications.3)sildenafilworksformajorityofpatientswDM. SILDENAFILWORKSFORTHEMAJORITYOFPATIENTSWITH DIABETES. 65y/optwMDDc/oanorgasmiaafterstartingtxwfluoxetine.Howtotx? SILDENAFIL Masturbationinadultsasviewedbycontemporarypsychiatryisbestdescribedas: PSYCHOPATHOLOGICALONLYIFITISCOMPULSIVE. Substanceusefulformaleerectiledysfunctionwhenadministeredeither transurethrallyorbyintracarvernosalinjection? ALPROSTADIL Retrospectiveinterviewswithhomosexualadultshaveestablishedthat,forthe majority,theirsexualorientationwasself-recognizedatwhatage? SCHOOLAGE Transienthomosexual/heterosexualexperiencesinheterosexual/homosexual adolescentsrespectivelyarebestunderstoodas? NORMALEXPERIMENTATIONINSEXUALIDENTITY Reluctancetodiscusssexissuesortakesexhistory: PHYSICIAN'SOWNANXIETY Sildenafilinhibitswhichenzyme? PHOSPHODIESTERASE5 Ptusesoralsexassolesourceofsexualgratification,refusingcoitus.Diagnosis? PARTIALISM Psychiatristconductingindependentmedicalexamforindividual’semployerto determinefitnesstoreturntoworkaftermedsuspensionduetosupervisory complaintsoferraticbehavior/lapsesinjudgment.Despitehavingbeeninformed thatresultsofexamarenotconfidential/willresultinreporttoemployer, individualrevealsbeinghomosexual,butnothaving“comeout.”Bestwayto handlethis? OMITMATERIALUNLESSITISDIRECTLYRELATEDTOTHE REPORTEDWORKPROBLEMS Pttellsdoctor:“Ifeellikeawomantrappedinman’sbody.”Mostlikelydx: GENDERIDENTITYDISORDER ApatientisadmittedtoinpatientpsychunitwithSIhasmalegenitalsandbreast implants.Alwaysidentifiedasawomanandissuicidalbecausetheycan’t GENDERDYSPHORIA becomeawoman.Whatisthediagnosis? Chronicdiseasecausingprogressiveerectilefailure: DIABETES 35y/oFreportsbeinghappilymarriedrespondswelltofluoxetinefordepression. Onfollow-up,complainsofanorgasmia.MosthelpfulTx? CYPROHEPTADINE New-onsetErectileDysfunctiondespitesatisfactorysexlifew/wife.Preoccupied w/ job,arguingmore.Normalpasthistory.Tx: COUPLESTHERAPY(INSTEADOFSOMATICTHERAPY) Explainspsychosexualininfantsandchildren,pairedwithrighthypothesis COGNITIVEDEVELOPMENT–SEXUALBEHAVIORDETERMINEDBY SELF-IMAGEANDGENDERIDENTITY Whatdopamineagonisthasbeenusedtotreatptswitherectiledysfunction? APOMORPHINE Theprevalentmalesexuald/ois: PREMATUREEJACULATION Exogenoustestosteronemaybeusefulintreatingwhatmalesexualdisorder? HYPOACTIVESEXUALDESIRE Thepatternofaperson’sbiologicalsexualcharacteristicsisknownas: SEXUALIDENTITY Notadiagnosticcriteriaforgenderidentitydisorder: PERSISTENTFANTASIESOFSEXUALACTIVITYWITHMEMBERSOF THESAMESEX Medicationtotreathypoactivesexualdesired/owhoarenotdepressed: BUPROPION Homosexualcouplew/sexualdysfunction.Consider: POSSIBILITYOFLINKBETWEENPROBLEMSOFSUBSTANCEABUSE &ACCEPTANCEOFSEXUALORIENTATION Masturbationwithavibratorisusedfortreatmentofwhichsexualdysfunction? FEMALEORGASMICDISORDER Medicationeffectiveforlowsexualdesireinpostmenopausalwomen TESTOSTERONE GotoTableofContents 305 Whatdoesa15yoboymasturbateto? Explicitsexualacts 55yroldmanreportsbeinggayhiswholelife,duringwhichphaseofhislifeheis expectedtohaveexperiencedhisfirstsexualattractiontowardsasamesex partner? earlyadolescence Miscellaneous AmultidisciplinaryteamisroundingonaMODpatientwhohasnotbeen progressingduetolimitedparticipationinphysicaltherapy.Internistbelievesthisis Ensurethatteammembersmakeexplicittheirneedforhelpand duetodepressionandwantstotransferpatienttopsychunit.Psychiatristbelieves valueforotheropinions patientisdeliriousandneedsfurtherworkup.Whichofthefollowingwouldmake itmostlikelythatotherteammemberswouldspeakupandshareopinions? Childp/wwrithingmovementsoflimbandheadturningfollowingasorethroat? Post-streptococcussequelae Harmreductioninterventionaltechniqueforthosewopioiddependence? Needleexchange AlcoholiccomestoEDwithdaysofmalaise.Flexionoftheneckworsenspain.Pt hasBLVInervepalsy.Spinalfluidanalysisshowsprotein233,glucose25,and135 nucleatedcells(43%PMN,47%lymphocytes).Likelyetiology? WHOprioritizationofwhathascausedimprovedlifespaninlow&middleincomecountries? MycobacteriumTB Trainnon-specialistproviderstoidentifyandtreatmental illness 72y/olegallyblindpt(2/2maculardegeneration)withVHandw/oanyother psychotic,cognitiveandmoodd/o.(2x) CHARLESBONNETSYNDROME Adoptiveparentsofachildwhosebirthmotherdiedfromsuicideareasking aboutthechild’srelativeriskforfuturesuicidalbehavior.Bestresponse?(2x) THECHILD’SRISKOFCOMPLETEDSUICIDEISELEVATED RELATIVETOOTHERADOPTEES 18y/oMptisbroughttotheERw/suddenonsetofanxiety.Ptreportssuddenly experiencingapoundingheartbeat,SOB,chestpain,andpalpitationslasting1hr. PAROXYSMALATRIALTACHYCARDIA Onexampulseis200andbloodpressureis90/60.Ptisinstructedtoperforma Valsalvamaneuverandheimproves.Diagnosis?(2x) 1stethicaldirectivedevelopedafterWorldWarIItoprotecthumansubjectsin researchwascalled:(2x) NIMHfoundedduringperiodofTherapeuticoptimism NUREMBERGCODE TreatmentofsoldiersduringWorldwarII Thepsychiatricassessmentofachildoradolescentshouldalwaysinclude:(2x) PARENTALINTERVIEW Whatsignifiestheabilitytoshiftbackandforthbetweengeneralconceptsand specificexamples?(2x) ABSTRACTREASONING Treatmentforapathywithoutaccompanyingdepression,whichalsohasbeen knowntoprecipitateaticdisorder:(2x) METHYLPHENIDATE Twowksafterbeginningastrictdiet,a24y/opatienthasabdominalandlimb pain.Heisanxious,paleandtachycardiaonexam.Unabletoorientandseemsto ACUTEINTERMITTENTPORPHYRIA berespondingtohallucinations.Thishappenedinthepast.Dx?(2x) 72y/olegallyblindpt(2/2maculardegeneration)withVHandw/oanyother psychotic,cognitiveandmoodd/o.(2x) CHARLESBONNETSYNDROME TreatmentwiththiscanmaskB12deficiencybynormalizingmacrocyticanemia FOLICACID Remindingpatientstogetflushots:typeofprevention? PRIMARYPREVENTION Whenusinganinterpreterduringtheinterviewofanimmigrantpatient,whatis mostimportant? USINGYOUINSTEADOFHEORSHE Psychoeducationprovidedafterthefirsthospitalizationofnewdiagnosed schizophreniawouldincludeteachingthefamily,patientwhat? IMPORTANCEOFTAKINGMEDS Absolutecontraindicationtosildenafil SUBLINGUALNITROGLYCERIN GotoTableofContents 306 Impairedphysicianfailstoobtain/benefitfromtreatmentmayrequireevalfrom administrativepsychiatrist.whatisdifferentaboutadministrationalpsychiatrist comparedtotypicalpsychiatrist? NOTBOUNDBYUSUALPARAMETERSOFCONFIDENTIALITY Goalofwrap-aroundservicesofC&A PREVENTHOSPITALIZATIONORRESIDUALPLACEMENT Whatisthemostsignificantchallengetotheclinicalapplicationoftheanalytic theoryoflibidinalstagedevelopment?(2x) STAGESAREMOREFLUIDANDLESSSTRICTLYSEQUENTIALTHAN THETHEORYSUGGESTS ImmanuelKantcontributedwhichdevelopmentofpsychiatry? PHILOSOPHICALFOUNDATIONSFORCLINICALETHICS 32y/optwithhxoftreatment-resistantdepressionpresentstoEDBIB-familyafter ODonimipramine.Ptswallowedpills,changedhermindandaskedforhelp.Pt's outptpsychiatristhadrecentlyaddedImipraminetotheptsfluoxetine80mgdaily. Ptisafebrile,BP100/58,HR96andregular.Ptisvagueregardingsuicideattempt TRANSFERPTTOAPSYCHUNITFORINVOLUNTARYDETENTION andstatesshenolongerwantstodie.EDwantstoadmittopsych,psychstatesthe ODattemptwasnotlethalandnotcardiotoxicperpt’sreportofhowmanypills shetook.Whatisthebestcourseofactionforthepsychiatristtofollow? Screeningbloodtestina72yoptadmittedforbehavioraloutbursts,progressive cognitivedeclineandataxiarevealapositiveserumvdrl.Familymemberscannot eliminatethepossibilitythattheptwasexposedtosyphilis.Thepthashada historyofallergicreactiontopenicillin.Whichofthefollowingisthemost appropriatenextstep? OBTAINCSFFORFT-ABS 80y/optwithbipolard/ostableonLithiumforyears,recentlygotstartedona new THIAZIDEDIURETIC med.Theptnowhastremulousness,dystonia,hyperreflexia,ataxia,andconfusion. Whichmedmightbecontributingtopt’spresentation A45yomanbelieveshehasgastriccancer,andreportsindigestionandreflux.The patientfindshimselfsodistressedwiththisthoughtthathehasbeenhaving REFERFORFURTHERMEDICALEVALUATION problemsathomeandatwork.Whichofthefollowingwouldbethemost reasonablestrategyforapsychiatristtoconsiderwhentreatingthispatient? Gestationalinsufficiencyofwhichhormonehasbeenassociatedwithdevelopment of THYROID severeintellectualdisability? Mostcommoncauseofbraintumorina65yr-oldM? METASTATICLUNGCARCINOMA 36Fwitheasyfatigue,weightloss,cravingsalt,nausea,hyperpigmentation,and musclecramps.Ptnotedtohaveamoddepressedmoodandappearsapathetic. Dx? ADRENALCORTICALINSUFFICIENCY Long-termnursinghomecareintheU.S.isprimarilyfundedbywhatentity? MEDICAID CNSresponsestofearstimuliaremediatedchieflythrough? CENTRALNUCLEUSOFAMYGDALA 28y/ofemalewsorethroat,muscle/jointpain,HAs,poormemory,poorsleep. Takes 1daytophysicallyrecoverafternormalexertion.Flu6monthsago.Nofamily historyofdepression.NoSI.Diagnosis: CHRONICFATIGUESYNDROME IgGelevatedinCSFandserumismostconsistentwithwhichillness? SARCOIDOSIS 35y/ofemalefailedseveralantidepressanttrialsforMDD,referredtospecialty mood ECCHYMOSES clinic.Clinicianobservesobesity,acne,andhirsuitism.Whatfindingwouldincrease suspicionforCushingsyndrome? Infectiousneuropsychiatricd/o,characterizedbypsychosisandabnormalgait,that wasoncetreatedwithmalaria-inducedfeverandaccountedforup20%ofptsin SYPHILIS mentalasylumsuntil1940s: GotoTableofContents 307 Trackingptsatisfactionforaccreditingagenciesischaracterizedaswhichtypesof administrativeactivity? CONTQUALITYIMPROVEMENT Forptswholackdecision-makingcapacity,physicianshaveabeneficence-based obligationtodowhichofthefollowing? •Hospitalizept •Applyforcourt-orderedtx •Designateptasfullcode •Seekdecision-makingsurrogates •Delivertxinpt’sbestinterests DELIVERTXINPT’SBESTINTERESTS TheTuskegeesyphilisstudyviolatedcurrentethicalprinciplesofresearchinthe selectionofparticipantsand… RISK:BENEFITRATIOFORPARTICIPATINGINTHESTUDY A75y/omanandhis72y/owifepresentrequestingmaritaltherapy.Theydescribe increasingconflictbeginningaboutadecadeagowhenthewifebeganrefusing sexualactivity.Husbandexplainsthathestilldesiresanintimaterelationshipandis frustratedandhurt.Thewifeexplainsthataftermenopauseshecouldnot SEXEDUCATION understandherhusband’sdesire.Shesuggestshefind"someyoungerwoman."He isinsultedbecausehedoesnotwanttostrayfrommarriage.Theinitialtreatment approachshouldfocuson: PhilippePinel’sATreatiseonInsanitydescribedanewapproachtotreatingthe institutionalizedmentallyillthatfocusedongeneratingatherapeuticenvironment. MORALTREATMENT Ptswerepersuadedtofollowadailyschedulethatincludededucationand occupationalactivities.Thisapproachwastermedwhichofthefollowing? Psychiatristvoicemailmessagewhileonvacationshouldclarifyhowtomanage urgentbutnotemergentclinicalmatter Callthearrangedclinicalcoverage MelanieKleindifferedfromFreudinheremphasison: EARLYOBJECTRELATIONS Whichisparaamnesia? DEJAVU Dysfunctionofwhichisspecificallyimplicatedinthepathophysiologyof narcolepsy? HYPOCRETIN 19yoptatedw/lossofvisionw/oothersyx.H/osevererecurrentabdpain.1yago pthadepisodeoflhemiparesis.Inrecentwkspthadepisodesoftransientvisual blurring/lossspontaneouslyresolved.Physicalshowsblcorticalblindness,mild SICKLECELLDISEASE pronationoflue,mildblspasticity,hyperreflexia,extensorplantarresponsesbl.No sensorychanges.Dx?(cerebralangioandmriimagesnotincluded) AccordingtoAPAguidelines,sexualrelationshipswithptsare NOTALLOWEDWITHCURRENTORFORMERPTS Barriertobroaderuseoftelepsychiatry PSYCHIATRISTSHAVEBEENRELUCTANTTOUSETHISMODEOF CAREPROVISION AccordingtoAPAguidelines,whatistheplaceofexpertopinioninevidence-based RANKSASEVIDENCECOMPARABLETOCASESTUDIES medicine? Whatisaneologism? PATIENTMAKESUPAWORD In“splittreatment,”theroleoftheprescribingpsychiatrististo: EVALUATEPT’SNEEDFORMED&PRESCRIBEACCORDINGLY WHILEMAINTAININGREGULARCONTACTWTHERAPIST. 10y/ogirlw/hepBisevaluatedforpersistentdifficultyw/schoolworksince1st grade.Oftenlooseshomework,seemsnottolistentoparentsorteachers.If neededtreatmentwhatwillyougive? METHYLPHENIDATE Initialpharmacologicaltherapyforchildwithhighenergy,impulsivity,ashortfuse METHYLPHENIDATE whenfrustrated,frequentangryoutbursts,andcarelesshomeworkmistakes. Stockholmsyndromeisdefinedas: DEVELOPMENTINHOSTAGESOFPOSITIVEEMOTIONALFEELINGS TOWARDCAPTORS GotoTableofContents 308 WhichSxscommoninptafteranabolicsteroiddiscontinuation? DEPRESSION WhichofthefollowingstatementsreflectstheAPApositionstatementon reparativeconversiontherapyforgayandlesbianindividuals? ITISCONSIDEREDUNETHICALBECAUSEHOMOSEXUALITYISNOT CONSIDEREDAMENTALDISORDERANDHARMOFTENCOMES FROMSUCHTREATMENT Empiricalstudiesofthediagnosticpsychiatricinterviewprocesshavesuggested thatthemostcomprehensiveandaccurateinformationiselicitedbywhichofthe followingapproaches? FOCUSEDINTERVIEWING,ELICITINGDETAILSOFTHECHIEF COMPLAINTANDTHENANINVENTORYOFSYMPTOMS Whichofthefollowinginstrumentswouldbemostappropriatetomeasurethe intensityofpaininyoungchildren? FACESSCALE PsychMDisattendingaseminarwhenacolleaguestates,“Iheardyouaretreating “YOUKNOW,FORCONFIDENTIALITYPURPOSESICAN’TREVEAL Mr.X.Iamsogladtohearit,becauseIknowhe’sbeenhavingalotoftroubleandI WHOISEEORDON’TSEE.” amsurethatyoucanhelphimalot.”Mostappropriateresponse? PsychMDwhoisconductingindividualpsychotherapywithapt,andfamilytherapy AVOIDINGDUALRELATIONSHIPS. withtheptandfamilyisatrisktoviolatetheethicalguideline: PsychMDacceptsagiftfromapharmaceuticalcompanythatmakesan THEGIFTCONTRIBUTESTOTHEPSYCHIATRIST’SEDUCATIONOR antidepressantmedication.Thisisconsideredethicalunderwhichofthefollowing CAREOFPATIENTS circumstances? IntheUS,mostneedsofdependentelderlypatientsarefulfilledbywhichofthe followingindividualsoragencies? ADULTCHILDREN Whichofthefollowingisthemostcommonreasonforpsychiatricconsultreferral ingeneralmedicalandsurgicalpatients? DEPRESSION Themostprominentlobbyingandsupportorganizationforfamiliesofpeoplewith NATIONALALLIANCEFORTHEMENTALLYILL(NAMI) severepsychiatricdisordersisthe: Nephrologistsmostcommonlyrequestpsychconsultonpatientswithendstage renaldiseaseforwhichofthefollowingconditions? NONCOMPLIANCE Whichofthefollowingfamilialeffectsfalselyinflatesestimatesofheritability? SHAREDDEVELOPMENTALENVIRONMENT Aresidentisaskedbyhisprogramtotakealeaveofabsenceduetoerratic behaviorandmustundergoapsychiatricevaluationbeforereturning.What statementbestdescribestheobligationoftheexaminingpsychiatricMD? STATECLEARLYTOPTPRIORTOEVALUATIONTHEPURPOSEOF THEEVALUATIONANDTHATTHEINFORMATIONMAYBE TRANSMITTEDTORESIDENCYPROGRAM. Psychiatristwhodoesnotnormallytakephonecallsduringtherapysessionshasan emergencycallputthrough30minutesintoa50minutesessionwithapt.The OFFERTORESCHEDULETHEPT’SSESSION,ANDNOTCHARGE psychiatristapologizes,explainsthatitisanemergencythatcannotwait,andasks FORTHISONETHATWASINTERRUPTED. thepttositinthewaitingroomuntilthecallisfinished,whichturnsouttobe15 mins.Nextstep: Unmarriednulliparouswomanparticipatesactivelyinrearingofhersiblings. KINSELECTION AccordingtoDarwiniantheory,suchaltruisticbehaviorexplainedbywhatconcept? WhichofthefollowingdidKurtSchneiderconsidertobeafirst-ranksymptomof schizophrenia? VOICESARGUING Ptreceivingapsychiatricexaminationtodeterminesuitabilityforajobmustbe informedthat: EXAMINATIONISNOTCONFIDENTIAL Recurrent,intensesexuallyarousingfantasies,urges,orbehaviors,includingthe useofnonlivingobjects,arethemaindiagnosticfeatureofwhichdisorder? FETISHISM Apreviouslyhealthy65yopatientpresentstoapsychiatristwithnew-onsetAH. Thepsychiatricevaluationofthispatientshouldinitiallyfocusonuncovering: ANUNDERLYINGMEDICALCONDITION Whichofthefollowingmostaccuratelydescribesanimportantcharacteristicof friendshipsduringmidlife?(x2) ARELESSDEPENDENTONBEINGCLOSEINAGE GeneticsyndromeconsideredtobeaneurodevelopmentalmodelforAlzheimer disease? DOWNSYNDROME GotoTableofContents 309 Whatoverdosecausesringingintheear,abdominalpainandmetabolicacidosis? ASPIRIN Whichofthefollowingabnormalelevatedmetabolicfindingshasbeenassociated withincreasedriskofstrokeinptsundertheageof50? PLASMAHOMOCYSTEINE Ptisadmittedtothehospitalforrenaltransplantrejection.Priortothis,thepthad beendoingwellsincethetransplantoneyearagotheptreportscompliancewith theimmunosuppressiveregimen,butbloodlevelsofcyclosporinearelow; SERTRALINE/NORTRIPTYLINE/VALIRANAOFFICINALIS/S- previously,thecyclosporinelevelswerewithinthetherapeuticrange.Thept ADENOSINYLMETHINONINE(ALLOFTHEABOVE) reportsrecentlystartingonapilltotreatdepressionandanxiety,butdeniesany othermedicationchangesornewhealthconditions.Whichistheptmostlikely taking? Whichofthefollowingtherapisttechniquesaremorecommonlyemployedin grouptherapycomparedtoindividualpsychotherapies TRANSPARENCNYANDSELFDISCLOSURE Self-disclosurebytherapistmaybeappropriateinordertodowhat? MODELAPPROPRIATEBEHAVIORANDFOSTER THERAPEUTICALLIANCE Followingtheinitiationofpost-transplantmedications,aptwhowashospitalized forakidneytransplantbecametremulousandhighlyanxious,hadtroublespeaking CYCLOSPORINE andshowedsignsofpsychosiswithhallucinations.Whichofthefollowing medicationsismostlikelytohavecausedthechangeinthepatient’sstatus? Terminallyillcancerpatientswhoexperienceconcernsabouta“baddeath”are mosttypicallyworriedaboutdyinghow? INPAIN 60-year-oldptwithliverdzpresentswithconfusion.Onexampthasasterixisof handsandhaselevatedserumammonialevel.EEGislikelytoshow: BILATERALTRIPHASICWAVES Apsychisaskedtoseeageneralmedicalinptforreportedhypochondriasis.Which MEDICALCONDITION ofthefollowingisthemostimportantdifferentialdiagnosticconsideration? Recommendedprocedureforpatienthandoffbetweenresidents? INCLUDESSUMMARYOFTREATMENTCOURSEANDRISK ASSESSMENT 65-yearoldptwithhxofMDD,hyponatremiaandlethargyisinneedofananti- hypertensivemed.Whichofthefollowingwouldbethesafestmedtotrygiventhe ATENOLOL pt’shistory? Whichofthefollowingisthecorestrategywheninitiatingtreatmentofhostilept ACKNOWLEDGE&VALIDATETHEPATIENT’SAFFECT 17yoisabletocompleteADLsbyhimselfbutrequiressomesupervision.Livesin grouphome,empliotedasgrocerystoregreeterundersupervisionofanother employee,academicskillsofa2ndgrader.whichclassificationbestrepresentsthe levelofintellectualdisability Associationb/wBetablockeranddepression NOASSOCIATIONSUPPORTED ChangesinCSFinptswithIED DECREASED5HTLEVELS Frequentepisodesoffallingasleepduringdailyactivityisassociatedwithwhichlab DECREASEDCSFHYPOCRETIN finding Bipolarpatientstableonlithiumdevelopstremors,confusion,dysarthriaand elevatedlithium.Whatmedicationcancausethis? Patientinsupportivepsychotherapyrequestingfriendshipoftreatingpsychiatrist viapersonalfacebook Beststrategytomaximizethenumberofcontributionfromseveralresidentsthat wanttocontributetobuypizzafortheirmeeting THIAZIDEDIURETIC Discussboundaries Arrangeameetingthatincludesallclubmemberstodiscuss thisplan GotoTableofContents 310 HistoryofPsychiatry Whonotedthatmajormentalillnesseshavedifferentcoursesandoutcomes; Andalsodifferentiatedbetweendementiapraecoxandmanic-depressiveillness? EMILKRAEPELIN (5x) PhineasGage,whohadanironbarshotthroughhisskullinanexplosionin1848 andsubsequentlyshowedprofoundchangesinbehavior,isstillofinteresttoday MODERATE becauseofitsimplicationsfor(4x) Whichindividualcoinedtheterm“schizophrenia”andintroducedtheterms “ambivalence”and“autism”?(3x) EUGENEBLEULER Whocharacterizedmentalillnessbasedupontheinteractionofthefourhumors? HIPPOCRATES (2x) Explicitdxcriteria&multiaxialsystemwereintroducedinwhatDSMedition? (2x) DSM-III 9y/ochildbangshishandonsofttoy,settingupsteadyrhythm&smilingw pleasure.Motherfallsintohisrhythm&says“Kaaa-bam,kaaa-bam,”with“bam” ATTUNEMENT fallingonthestroke&“kaaa”accompanyingupswingofthearm.Thisisexample of:(2x) TheapproachtodiagnosisthathasbeentakenincurrenteditionsoftheDSMis consideredtogrowfromandbeclosesttothatofwhom? EMILKRAEPELIN Whenpublishedin1980,DSM-IIIrepresentedasignificantdeparturefromearlier editionsofDSMincludingtheintroductionofwhichofthefollowing? •Prototypicaldescriptions •Dimensionalclassification •Descriptivediagnosticcriteria •Broaddefinitionofschizophrenia DESCRIPTIVEDIAGNOSTICCRITERIA WhodevelopedMoralTreatment? PHILLIPEPINEL Developedinterpersonaltheoryofpsychiatry HARRYSTACKSULLIVAN Whocoinedtheterm"contactcomfort"anddemonstratedthatnewbornRhesus monkeysseparatedfromtheirmotherschosecontactcomfortoverfoodand water? HARRYHARLOW DSMIIIdiagnosticliabilitywasachievedbystandardizing DIAGNOSTICCRITERIA In1935DrBobSmithasurgeonwalcoholismmetandwashelpedbyanindividual seekingsupportforabstinenceformEtOHwhiletravelingforbusiness.Thesetwo BILLWILSON areconsideredthefoundersofAlcoholicsAnonymous.Whoistheotherperson? Whichindividualarticulatedatheoryofpsychosocialdevelopmentalphases accordingtoapredeterminedsequence? ERIKERIKSON Whoestablishedthatlearningproduceschangesattheneuronallevel,inturn facilitatedbyalterationsingeneexpression: ERICKANDEL Atherapistconceptualizespatients’depressionasrelatedtoguiltathavingacted harmfullytowardlovedones.Whichtheoristmostlikelyinfluencedthistherapist: MELANIEKLEIN AccordingtoKlein,apersonwhoiscomfortableaccepting“thegoodwiththebad” DEPRESSIVE inrelationshipshasreachedwhichofthefollowingpositions? AnnaFreud’scontributiontochilddevelopmentbasedonconceptualizing: DEVELOPMENTALLINESIN6AREASOFADAPTIVEFUNCTIONING DSMIIcalledDysthymicdisorderaswhat? DEPRESSIVENEUROSIS Caregiver’sattemptstounderscorechild’sfeelingstate(Stern) ATTUNEMENT GotoTableofContents 311 Whichofthefollowingmajorworldeventsimmediatelyprecededandhelpedto shapethecontentofDSM-I? WORLDWARII Whomonitorsphysicianswithsubstanceabuseissues? STATEMEDICALBOARDANDSTATEPHYSICIANHEALTH PROGRAMS Ptreportsassassinsenterroom,rapeandthreatenhereverynight.Reports"police "WELL,FROMWHATYOUARETELLINGMEITSOUNDS thinkI'mmakingitup,youbelievemeright?"Whatismostappropriateresponse? TERRIFYING" TheFeighnercriteriainitiatedaparadigmshiftinAmericanpsychiatry'sapproach todiagnosingmentalillnessbecause? APPLIEDOPERATIONALCRITERIATOPSYCHIATRICDISORDERS GotoTableofContents 312