PANCE Psych

Management of Parkinsonlike effect due to high-potency antipsychotics

- Reduce dosage - Add antihistamine or anticholinergic agent - Add anti-Parkinsonian agent - Most commonly used agent: benztropine (Cogentin)

ADR of Quetiapine

- risk of cataracts in beagles - human pts need slit lamp exam q 6 mos

ADRs of Olanzapine:

- weight gain - hyperlipidemia - hepatotoxicity

Tricyclics ADRs:

-Antihistaminic, antiadrenergic, anticholinergic properties cause: - Sedation, increased appetite→ weight gain - Orthostatic hypotension, tachycardia, arrhythmias; prolonged QT in overdose - Dry mouth, blurred vision, constipation

Which of the following indicates a poor prognosis for someone diagnosed with schizophrenia?

A younger age of onset/diagnosis along with an insidious onset, social isolation, family history of schizophrenia, and negative symptoms (affective flattening, alogia, apathy, anhedonia) all portend a poor prognosis. To the contrary, acute onset, late diagnosis, positive symptoms (hallucinations, delusions, disordered thought processes, etc.), and a concomitant mood disorder actually lend to a better prognosis.

• Neuroleptic agents - Phenothiazines • Atypical antipsychotics

Antipsychotic agents

clozapine (Clozaril) olanzapine (Zyprexa) quetiapine (Seroquel) risperidone (Risperdal)

Atypical antipsychotics

- may cause extrapyramidal effect

Atypical antipsychotics- Risperidone

Which personality disorder clinical findings include impulsiveness, unstable and intense interpersonal relationships, lack of self control, suicidal ideations, aggressive behavior, and a high drug abuse rate.

Borderline

- Not a benzodiazepine - Very low potential for abuse - Takes longer to work than a benzodiazepine (1-2 weeks) - Partial 5-HT receptor agonist

Buspirone (BuSpar)

Typical Anti-psych med

Chlorpromazine (Thorazine) Haloperidol (Haldol Loxapine (Loxitane) Molindone (Moban)

is a disturbance in fluency where the speaker meanders on many side topics before returning to the topic at hand.

Circumstantiality

seen in someone who eventually gets to the point after a delay in the thought process.

Circumstantiality

is a rapid transition from thought to thought, leading to the speaker losing track of the original idea.

Flight of ideas

What type of pharmacological agent would be used as a first-line medication to treat obsessive compulsive disorder?

Fluvoxamine, paroxetine, and sertraline are all approved for the treatment of obsessive compulsive disorder. Use of an SSRI in combination with behavioral therapy is recommended.

when the ideas shift between subjects that are totally unrelated to each other.

Looseness of association

- chlorpromazine (Thorazine) - thioridazine (Mellaril) • Higher risk of Parkinson-like effect • Higher risk of cholinergic and histaminic effect

Low-potency antipsychotics

• Indirectly increase amount of norE in synapses • Affect both MAO-A and MAO-B - MAO-A decreases amts of S - MAO-B decreases amts of norE - Both decrease amt of dopamine

Monoamine oxidase inhibitors

• Lithium • Carbamazepine (Tegretol) • Valproic acid (Depakote)

Mood stabilizers

Which personality disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention.

Narcissistic

the creation of new words

Neologisms

Phenothiazines

Neuroleptic agents

S/S: tremor; catatonia; autonomic instability - Hyperthermia - Labile BP and pulse • Stupor, increase in CK; myoglobinemia (breakdown of muscle) Caused by: high doses of potent antipsychotics

Neuroleptic malignant syndrome

ADRs are primarily due to histamine receptor antagonist properties • Significant weight gain • Sedation - May also cause agranulocytosis - Greater norE effect at higher doses→decreases sedation

Norepinephrine and serotonin antagonists (NASAs) • Mirtazapine (Remeron)

ADRs include seizure Contraindicated in pts with h/o seizure d/o

Norepinephrine/dopamine reuptake inhibitors (NDRIs) Bupropion (Wellbutrin)

Does NOT cause sexual dysfunction Also used for smoking cessation, ADHD

Norepinephrine/dopamine reuptake inhibitors (NDRIs) Bupropion (Wellbutrin)

is a fixed focus returning again and again to the same thought.

Perseveration

Which type of schizophrenia is characterized by an episode that warrants a diagnosis of schizophrenia, but there are no current psychotic symptoms present; however, they continue to exhibit milder signs, such as social withdrawal, flat affect, and eccentric behaviors.

Residual schizophrenia

Fluoxetine (Prozac) sertraline (Zoloft) citalopram (Celexa)

SSRIs

Most common treatment for depression Increases S at synapses by blocking neuronal transport May take up to 6 weeks

SSRIs

has symptoms that last at least a month, but no longer than 6 months.

Schizophreniform

What personality d/o is characterized by being superstitious, socially isolated, and suspicious, and having limited interpersonal ability, odd speech, and eccentric

Schizotypal disorder

ADRs include sedation and priapism • Secondary to cerebral α-adrenergic and histamine receptor blockade

Serotonin antagonist and reuptake inhibitors Trazodone (Desyrel) Nefazodone (Serzone)

- Acts as an SSRI at low doses - At higher doses, norE effect increases - Can cause elevated BP - Avoid in pts with h/o HTN

Serotonin-norepinephrine reuptake inhibitors - Venlafaxine (Effexor)

refers to a disturbance in continuity where the speaker shifts from one thought to another that may be only vaguely related.

Tangentiality

Athetoid or tic-like movements of mouth and tongue - More common in older pts

Tardive dyskinesia

usually appears months or years after starting neuroleptic medication, and consists of involuntary stereotyped movements of the face, mouth, tongue, trunk, and limbs.

Tardive dyskinesia

A 45-year-old male comes to your primary care office complaining of recurrent panic attacks that have led to a disabling fear of being in places from which escape might be difficult, such as a bus or a train. He now finds he can barely leave his home. You diagnose him with panic disorder and which of the following complications? A. Agoraphobia B. Generalized anxiety disorder C. Obsessive-compulsive disorder

The answer is A. EXPLANATION: Agoraphobia (A) is a complication of panic disorder in which the attacks are associated with being in a crowd or around others. Generalized anxiety disorder (B) is a more overarching term, but does not necessarily include panic attacks. Obsessive-compulsive disorder (C) involves recurrent intrusive thoughts and rituals. Social phobia (E) is more focused on performance in normal social situations and post-traumatic stress (D) requires a traumatic trigger event.

Which nonnicotine related agent has been approved by the FDA as a first-line medication in the treatment of smoking cessation?

The answer is C. EXPLANATION: Bupropion SR has been approved by the U.S. Food and Drug Administration (FDA) for smoking cessation. The drug has been successful in doubling cessation rates. Side effects include dry mouth, agitation, insomnia, and headache.

Which disorder is characterized by episodes of hypomania and depression for greater than 2 years?

The answer is C. EXPLANATION: Cyclothymia is characterized by symptoms of depression and hypomania for at least 2 years. Symptoms are milder than a regular depressive or manic episode. Occasionally, patients will have regular depressive or manic symptoms at which time they need to be reclassified as bipolar.

A 25-year-old male has a history of schizophrenia, and was brought to the emergency department by ambulance after he was found wandering along the highway. Which of the following is considered a positive symptom of schizophrenia? A. CatatoniaB. Diminished sociabilityC. HallucinationsD. Poverty of speechE. Restricted affect

The answer is C. EXPLANATION: Hallucinations, delusions, and formal thought disorders are classified as positive symptoms of schizophrenia. Negative symptoms of schizophrenia include restricted affect, diminished sociability, and poverty of speech.

A 33-year-old woman treated with trifluoperazine for the past 3 months is seen in the emergency department because of recent-onset fever, stiffness and tremor, as reported by her accompanying sister. The patient also appears to be mildly confused when asked about location, day, and time. Her temperature is 104.5°F, and her serum creatine kinase (CK) level is markedly elevated. Which of the following has most likely occurred? A. a delayed allergic reaction has occurred with trifluoperazine B. tardive dyskinesia has begun to develop in the patient C. the patient has developed neuroleptic malignant syndrome D. the patient has developed serotonin syndrome

The answer is C. EXPLANATION: Neuroleptic malignant syndrome is an uncommon but serious complication with therapeutic doses of antipsychotic drug therapy, particularly the first-generation (typical) class. Cardinal signs and symptoms include a body temperature above 100.4°F, altered state of consciousness, autonomic dysfunction, and rigidity.

A 14-year-old boy is brought to your primary care office as a new patient. He is new to the area and having a little bit of difficulty adjusting to school. He denies feeling depressed or being bullied. You wish to screen him for suicidality. Which is the best first question to ask? A. "Do you have a gun at home?" B. "Do you have friends who have committed suicide?" C. "Do you sometimes feel life is not worth living? "\D. "Do you sometimes want to jump off a bridge"

The answer is C. EXPLANATION: Suicide risk should be routinely assessed. This is best done by asking a general question such as in (C), then following up with more specific questions about means, such as (A), or plans, such as (D). Having friends who have committed suicide (B) may increase risk, but is not helpful as a screening question. Questions should focus on the patient, not on family or friends as in (E).

A 55-year-old male presents to the emergency department because he believes that his son may have poisoned his food earlier today. During the encounter, he shows limited interpersonal ability and has odd speech. There is nothing to substantiate his concern for poisoning, as the patient ate prepackaged food this morning that had not been opened. A penny is on the floor and he picks it up, stating, "it was on heads, that's good luck." Upon further questioning, you note that he is suspicious of a lot of people in his life and he appears to be socially isolated. What is the most likely classification of this personality disorder? A. Borderline B. Narcissistic C. Paranoid D. Schizoid E. Schizotypal

The answer is E. EXPLANATION: Schizotypal clinical findings include being superstitious, socially isolated, and suspicious, and having limited personality ability, odd speech, and eccentric behaviors.

Antidepressants

Tricyclic antidepressants Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors(SSRIs)

Inhibit reuptake of norE and 5-HT, making more available at synapses. Potentially deadly if used in suicide attempt

Tricyclics

Also used to tx neuropathic pain from DM,

Tricyclics-- amitriptyline (Elavil) nortriptyline (Pamelor) desipramine (Norpramin)

Management of NMS

Tx: dantrolene - tx of malignant hyperpyrexia d/t anesthesia bromocriptine - a dopamine agonist

The risk of extrapyramidal side effects (pseudoparkinsonism) and tardive dyskinesia is associated with which class of medications?

Typical antipsychotics (eg, haloperidol, chlorpromazine, fluphenazine) can produce pseudoparkinsonism via blockade of dopamine (D2) receptors in the nigrostriatum. Symptoms can include akinesia, bradykinesia, mask-like facial expression, tremor, cogwheel rigidity, and postural abnormalities. Tardive dyskinesia may also occur, as the reported incidence with first generation antipsychotics ranges from 0.5% to 62%.

• ADRs: - sedation - weight gan - thrombocytopenia

Valproic acid

a symptom of schizophrenia and other psychotic disorders that consists of repetition of senseless words or phrases, but is not a side effect of neuroleptic medication.

Verbigeration

a mixture of words and phrases that are incoherent.

Word salad

Negative symptoms include

affective flattening, alogia and avolition.

Tricyclics

amitriptyline (Elavil) nortriptyline (Pamelor) desipramine (Norpramin)

has symptoms that last for 1 day to 1 month.

brief psychotic disorder

Signs of a what personality disorder include someone who lacks confidence and self-esteem, has difficulty making decisions, and is passive and overaccepting. behaviors.

dependant

Positive symptoms of schizophrenia also include

disorganized or catatonic behavior and disorganized speech as well as delusions and hallucinations.

Tardive dyskinesia may be suppressed with:

high potency antipsychotic - atypical antipsychotic (clozapine) - reserpine (depletesdopamine) - Cogentin

Which of the following is the primary mechanism by which benzodiazepines exert their sedative and anxiolytic effects?

increasing GABAA receptor-mediated chloride conductance EXPLANATION: Benzodiazepines bind to GABAA receptors, which consist of many peripheral subunits that form chloride channels at their core. GABA is one of the major inhibitory neurotransmitters in the brain; hence, benzodiazepines enhance this inhibitory influence to produce sedation and calm.

Tremor, coma, seizure, death Possible thyroid enlargement

lithium

Clinical findings of someone who with what personality disorder would include defensiveness, being overly sensitive, secretive, suspicious, and hyper-alert, and having a limited emotional response.

paranoid personality

A/E of Clozapine

risk of agranulocytosis (1% of all pts) • requires weekly CBC

depression or mania develop along with schizophrenic symptoms.

schizoaffective disorders

Clinical findings of what personality disorder consist of being shy, introverted, withdrawn, and avoiding close relationships.

schizoid personality disorder

Most common ADR of all SSRIs

sexual dysfunction, esp. delayed/impaired orgasm (in ♂and ♀) insomnia, weight loss; weight gain

which type of schizoprhenia are the symptom not specific enough to allow for categorization in any of the other subtypes

undifferentiated schizophrenia

ADRs of traditional antipsychotics

• Weight gain • Elevated LFTs • Retinal pigmentation • Corneal deposits • Seizures • Antihistaminic effect • Probably hypersensitivity rxn • Seen with high doses of Mellaril; irreversible • Caused by promethazine • Antipsychotics increase

haloperidol (Haldol) fluphenazine (Prolixin) trifluoperazine (Stelazine) perphenazine (Trilafon)

High-potency antipsychotics

High risk of extrapyramidal effects - Dystonia of neck, tongue - Parkinsonism: rigidity, pill-rolling

High-potency antipsychotics haloperidol (Haldol) fluphenazine (Prolixin) trifluoperazine (Stelazine) perphenazine (Trilafon)

Clinical findings of what personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile.

Histronic

ADRs • Sedation • Impairment - motor function - mental impairment • Blurred vision, headache • Potential for paradoxical effect - Increased anxiety

Benzodiazepines

Intermediate acting Alprazolam (Xanax) Lorazepam (Ativan)

Benzodiazepines

Long acting - clonazepam (Klonopin) - diazepam (Valium) - flurazepam (Dalmane)

Benzodiazepines

- originally used to tx tic doloreaux - now used as an antiseizure agent - blocks Na+ channels (like Li+)

Carbamazepine

• ADRs include hematologic dyscrasias • agranulocytosis • thrombocytopenia • aplastic anemia • 1/100,000 • Check CBC before starting tx - Also teratogenic: do not use in pregnancy

Carbamazepine

describes a state in which a person is withdrawn and shows minimal bodily movement, or one in which there is severe excitement and the person shows purposeless and stereotyped movements.

Catatonia

which type of schizophrenia is characterized by severe psychomotor disturbances of either rigidity with mutism or excitement?

Catatonic schizophrenia

Which type of schiozphrenia is characterized by persecutory or grandiose delusions, often accompanied by hallucinations?

Paranoid schizophrenia

A 19-year-old male is brought by his mother to your primary care office. She is at her wits' end as he has just gotten out of juvenile detention but continues to engage in the behaviors that resulted in his incarceration. He lies, cheats, steals, and seems to disregard the rights and needs of others to the point of endangering their safety. This pattern has been present since early childhood, since at least age four. He does not feel that there is a problem, but his family and others around him are disturbed by his attitudes and behaviors. What is the most likely diagnosis? A. Antisocial personality disorder B. Borderline personality disorder C. Histrionic personality disorder

The answer is A. EXPLANATION: All personality disorders involve a persistent pattern of behavior in which there is a disturbance in impulse control, interpersonal behavior, interpretation of people and events, and/or emotional response that begins no later than adolescence. Antisocial PD involves a reckless disregard for others, usually manifesting in lawlessness, lying, cheating, and a lack of remorse. Borderline PD (B) involves interpersonal reactivity and impulsivity often focused on perceived abandonment. Histrionic PD (C) involves a need to be the center of attention, often manifesting in behavior that is theatrical or seductive. Narcissistic PD (D) involves a lack of empathy and grandiosity. Schizoid PD (E) involves symptoms similar to schizophrenia.

A 26-year-old female is returning for a follow-up visit for gastroesophageal reflux disease. She has been seen in the office frequently over the past three months for symptoms associated with reflux, but she has also exhibited signs and symptoms that are consistent with a personality disorder. In particular, she is withdrawn, shy, introverted, and avoids close relationships. These signs are most consistent with which personality disorder? A. Avoidant B. Dependent C. Histrionic

The answer is A. EXPLANATION: Avoidant personality disorder presents clinically as someone who fears rejection, overreacts to rejection and failure, and has poor social endeavors and low self-esteem.

A 58-year-old male comes to your primary care office complaining of sadness, insomnia, loss of appetite, weight loss, and feelings of guilt or hopelessness for the past month. On further questioning you find that his wife of 30 years died of breast cancer shortly before the onset of symptoms. Which of the following is the most likely diagnosis? A. Bereavement B. Dysthymia C. Depressive episode

The answer is A. EXPLANATION: Bereavement (A) is the normal grief response experienced after a significant loss and includes all the symptoms of depression and, by definition, lasts no longer than two months, although many will suffer from some symptoms for longer. Dysthymia (B) is a longstanding depressed mood for at least two years but not meeting the full criteria for a depressive episode (C). Major depression (E) requires at least one depressive episode, which requires at least five of the symptoms, one of which is depressed mood (D).

Which of the following are predictive or diagnostic of anorexia nervosa? A. having a weight that is 85% less than predicted normal weight B. homosexual orientation in females C. promiscuity

The answer is A. EXPLANATION: Diagnostic criteria for anorexia nervosa include a weight loss to 85% of the required body weight. Homosexual orientation in men, not women, is considered a predisposing factor. Anorexia is associated with amenorrhea and decreased interest in sex.

Generally, patients who are malingering: A. use illness to attain a goal B. have avoidant personalities C. follow prescribed treatment regimens

The answer is A. EXPLANATION: Patients who are malingerers do not want to improve until their goal is met. Goals may be financial, occupational, or legal. These patients will act differently when they think they are not being observed. They may fake their symptoms in order to be admitted to a hospital or to obtain drugs. These patients have an antisocial personality disorder.

A patient presented to your office with multiple somatic complaints. During the mental status exam, you notice that the patient loses the thread of conversation and discusses irrelevant topics based on an external stimulus. The patient never gets back to the main point he or she was trying to express. What is this thought process called? A. tangentiality B. circumstantiality C. looseness of association D. word salad E. neologisms

The answer is A. EXPLANATION: Tangentiality is a disturbance in thought causing the person to start a train of thought, but never getting to the point. Circumstantiality is seen in someone who eventually gets to the point after a delay in the thought process. Word salad is a mixture of words and phrases that are incoherent. Looseness of association is when the ideas shift between subjects that are totally unrelated to each other. Neologisms are the creation of new words

A 24-year-old male is brought to the clinic by his mother, who is concerned because her son believes that a local TV news anchor is in love with him. The mother states that this thought has been persistent for the last two to three months, and that he goes around town telling everyone about their relationship; however, she knows that her son does not even know the TV news anchor. The mother notes that this belief has not impaired his daily functioning, but has significantly affected his social functioning. The patient is exhibiting signs most consistent with which of the following psychiatric disorders? A. Delusional disorder B. Histrionic disorder C. Paranoid disorder D. Schizoid disorder

The answer is A. EXPLANATION: This patient is exhibiting signs most consistent with delusional disorder. Delusional disorder is a psychosis in which the person has persistent beliefs that are non-bizarre, such as being persecuted, being related to or loved by a well-known person, or that their partner is unfaithful. In this disorder, the delusions tend not to affect the patient's intellectual and occupational activities, but social and marital functioning are significantly affected. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Clinical findings of someone who has paranoid personality disorder would include defensiveness, being overly sensitive, secretive, suspicious, and hyper-alert, and having a limited emotional response. Schizoid personality disorder is characterized by shyness, introversion, being withdrawn, and avoiding close relationships. Schizotypal disorder is characterized by being superstitious, socially isolated, and suspicious, with limited interpersonal ability, odd speech, and eccentric behaviors.

What diagnosis should be given to a patient who has nonbizarre delusions for at least a month and no other symptoms? A. schizoaffective disorder B. delusional disorder C. brief psychotic disorder

The answer is B. EXPLANATION: A delusional disorder presents with nonbizarre delusions for at least a month. The disorder does not present with any other symptoms related to schizophrenia or a mood disorder.

A 16-year-old Caucasian female is brought to your family practice office by her mother because she has been missing school and her mother is concerned. The patient has symptoms consistent with mild to moderate depression. She has a history of menstrual migraines and now has vague constitutional symptoms all the time and doesn't want to get out of bed in the morning. The patient confesses that over the past month she has felt that she is not important to anyone and wonders if the world will be better off without her. Of the following, which is your greatest concern when considering prescribing her a selective serotonin reuptake inhibitor (SSRI)? A. compliance to the medication regime B. increased risk of suicide as detailed in black box warnings C. nausea-related side effects as you titrate upwards D. risk of pregnancy when taking psychiatric medications E. risk of serotonin syndrome, should you need to prescribe a triptan for her migraines

The answer is B. EXPLANATION: All antidepressants have an increased risk of suicide, but this is especially so in adolescents, warranting a black box warning. Both the patient and her parents should be made aware of this and contact you immediately if the patient should exhibit any change in mood or behavior consistent with suicidal ideations.

A 27-year-old female is brought to the emergency department by her mother because she is suicidal. A history reveals the patient to be impulsive and angry with aggressive behavior, have difficulty in maintaining interpersonal relationships, and a history of drug abuse. This patient is exhibiting signs and symptoms of which of the following personality disorders? A. Avoidant B. Borderline C. Histrionic

The answer is B. EXPLANATION: Borderline personality disorder clinical findings include impulsiveness, unstable and intense interpersonal relationships, lack of self control, suicidal ideations, aggressive behavior, and a high drug abuse rate. Avoidant personality disorder presents clinically as someone who fears rejection, overreacts to rejection and failure, has poor social endeavors, and low self-esteem. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Narcissistic personality disorder presents with clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention. Clinical findings of someone who has paranoid personality disorder would include defensiveness, being overly sensitive, secretive, suspicious, hyper-alert, and a limited emotional response.

Which of the following do the majority of patients with dissociative identity disorder also meet diagnostic criteria for? A. schizophrenia B. post-traumatic stress disorder C. bipolar II disorder

The answer is B. EXPLANATION: Dissociative identity disorder (DID), formerly known as multiple personality disorder, is classified as a trauma spectrum disorder due to the strong link with early childhood trauma and/or maltreatment. As such, approximately 70% of DID patients also meet criteria for PTSD.

Mr. Smith leaves home and does not return nor does he go to work. A friend of Mr. Smith sees him in another state while on vacation. When he approaches Mr. Smith, he does not recognize him and has a total different demeanor. What type of disorder does Mr. Smith have? A. amnesia B. dissociative fugue C. schizophrenia D. dissociative identity disorder

The answer is B. EXPLANATION: Dissociative or psychogenic fugue is precipitated by a stressful event that causes the patient to develop amnesia, leave home, and assume another identity.

Your patient is a 22-year-old male who has experienced significant dysfunction for the past eight months. He exhibits only one symptom of schizophrenia, but that one symptom has been present for a significant part of each day. Which of the following would qualify the patient to be diagnosed with schizophrenia according to the DSM-IV TR? A. A firm belief that someone is following him B. An auditory hallucination in which two or more voices are conversing C. A sensation that bugs are crawling on his skin

The answer is B. EXPLANATION: Generally, two or more characteristic symptoms of schizophrenia are required in order to make a diagnosis unless the one symptom present is a bizarre delusion or an auditory hallucination (B) that consists of either a running commentary or two voices conversing. Positive symptoms of schizophrenia also include disorganized or catatonic behavior and disorganized speech as well as delusions and hallucinations. Negative symptoms include affective flattening, alogia and avolition. (A) and (D) are both potentially delusions, but neither is particularly bizarre. A sensation of bugs on the skin (C, fomication) is a type of hallucination and speaking in rhyme (E) qualifies as disorganized speech. Each of these might count as one of the two required symptoms but would not be sufficient without a second symptom.

A person with an exaggerated sense of entitlement and uniqueness and who believes they can only be understood by people of significance is described to you by a colleague. They go on to state the person is arrogant, is lacking in empathy, and can be manipulative with relationships. What personality disorder best fits this scenario? A. histrionic B. narcissistic C. antisocial

The answer is B. EXPLANATION: The scenario represents a typical "snapshot" of this diagnosis. These persons typically have fantasies of unlimited success and have a strong need for admiration from others. They can be jealous of others but commonly assume that others are extremely jealous of them. Treatment is made difficult as they do not accept criticism or any attack on their "narcissistic supply.

A 26-year-old male has a history of schizophrenia that has been characterized by marked incoherence and a silly affect. Which classification of schizophrenia does this most closely resemble? A. Catatonic B. Disorganized C. Paranoid

The answer is B. EXPLANATION: The signs and symptoms that this patient has exhibited is most consistent with disorganized schizophrenia.

You are performing a mental status exam on a 19-year-old male patient who was brought to the Emergency Department because of bizarre behavior. As you are speaking with him he keeps repeating words that rhyme with words that either you or he say, but make no sense and are unrelated to your questions. How will you document this behavior in his chart? A. Circumstantiality B. Clanging C. Flight of ideas

The answer is B. EXPLANATION: Word association based on rhyme is called clang association and may be seen in psychotic disorders.

What is a commonly shared feature of bipolar disorder and ADHD in pediatric patients? A. disruptive B. obsessed with ideas C. behavior problems D. impaired concentration

The answer is C. EXPLANATION: Behavior problems are a commonly shared feature of pediatric ADHD and bipolar disease. Disruptive and impulsive behaviors are a shared feature of conduct disorder. Disruptive behavior and being annoying to others can be found with oppositional defiant disorder; impaired attention and concentration can be found in major depression. Bipolar patients are obsessed with ideas while ADHD and conduct disorder patients are not.

A 38-year-old female is at a follow-up visit for hypertension. She is accompanied by her husband. During the clinical visit the patient is noted to be passive, letting her husband do most of the talking. She also appears to lack confidence and self-esteem. The husband ends up making the decisions, and she is over-accepting of his dominance. What is the most likely classification of this personality disorder? A. Avoidant B. Borderline C. Dependent D. Histrionic E. Schizotypal

The answer is C. EXPLANATION: The clinical findings of dependent personality disorder are the most consistent with the given clinical scenario. Avoidant personality disorder presents clinically as someone who fears rejection, overreacts to rejection and failure, has poor social endeavors, and low self-esteem. Borderline personality disorder clinical findings include impulsiveness, unstable and intense interpersonal relationships, lack of self control, suicidal ideations, aggressive behavior, and a high drug abuse rate. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Schizotypal clinical findings include being superstitious, socially isolated, and suspicious, and having limited personality ability, odd speech and eccentric behaviors.

Your patient is a 72-year-old male who comes to your clinic complaining of multiple physical symptoms, including intermittent headaches, fatigue, and constipation, that began 4-6 months ago. After a careful history and physical exam, including a mental status exam, CBC, and thyroid function studies, you find no abnormality. You prescribe a trial of SSRIs and within two weeks his physical symptoms are resolved and his concentration and memory are improved. What is your most likely diagnosis? A. Hypochondriasis B. Malingering C. Masked depression D. Pain disorder E. Somatization disorder

The answer is C. EXPLANATION: The correct diagnosis is masked depression (C) based on the rapid response to treatment with an SSRI. Depression often manifests as physical symptoms, particularly in older patients. Somatization disorder (E), pain disorder (D), and hypochondriasis (A) all involve physical symptoms that the patient perceives as illness despite a psychiatric etiology of the symptoms. The diagnostic criteria for each of these entities requires that the symptoms not be better explained by another, such as depression. Optimal treatment involves comprehensive management that includes good coordination between psychiatry and the medical team. Malingering (B) is a volitional depiction of physical symptoms for personal gain.

What primitive, or immature, defense mechanism is demonstrated by a patient who attributes their own, unacknowledged, feelings onto others while they search for perceived wrongdoings, no matter how small? A. acting out B. isolation C. projection

The answer is C. EXPLANATION: These patients are sensitive to any criticism and are constantly searching for any insult or mistreatments, no matter how small or unintentional they may be. Confrontation is to be avoided as it is only counterproductive and will reinforce their beliefs. This is commonly seen in paranoid personality disorders.

A 73-year-old man is brought into your office by his adult children with a concern of memory loss. They report their father's memory has been declining since the death of their mother a few months ago but are now concerned because he is losing weight, sleeping during the daytime, and is not keeping up with current events like he usually does. This type of behavior is most associated with which of the following? A. Pick disease B. Creutzfeldt-Jakob disease C. depression

The answer is C. EXPLANATION: This patient's symptoms are most consistent with situational depression over the loss of his spouse. Transient memory problems can be a component of depression as a result of decreased attention and interest. Dementia is a progressive impairment of higher cognitive function, and initially, the patient's social graces are preserved. It has many causes, of which Pick disease, Creutzfeldt-Jakob disease, and Alzheimer disease are irreversible. Vitamin B12 deficiency can cause reversible form of cognitive impairment, in which the elderly are susceptible, so serum analysis of vitamin B12 should be performed in diagnostic evaluations of dementia in this population.

Your patient is a 42-year-old female diagnosed with depression. She has taken two different serotonin reuptake inhibitors (SSRIs) at the usual dosage, each for 3 weeks, and reports again that there have been no ill effects but that she doesn't feel that this medication has helped either. What is the most likely problem with her therapy? A. She has a genetic resistance to the medication B. The dosage was too low C. The medication was discontinued too soon D. The wrong diagnosis was made

The answer is C. EXPLANATION: Treatments for depression generally require from 2 to 6 weeks of therapy in before effects can be evaluated (C). Too low a dose (B) is another common problem, but an increase in dose should not be considered until the medication has had time to take effect. The effect of these agents can be highly variable from one individual to another, but no specific genetic resistance (A) is known. There is always a possibility of making the wrong diagnosis (D), but there is no indication of this from the information given, and SSRIs are the first line therapy for depression (E), best combined with counseling.

While interviewing a 29-year-old computer programmer, you find that he denies any close friends or prior sexual relationships and has no interest in developing them. He describes little enjoyment in any activities except role play video games. He denies past emotional difficulties or stressors. His exam reveals a flat affect throughout the visit but is otherwise normal. Which is the most likely diagnosis in this scenario? A. antisocial personality disorder B. adjustment disorder C. seasonal affective disorder D. schizoid personality disorder

The answer is D. EXPLANATION: A patient with ambivalence toward sexual relationships, no close contacts, and no desire for either, along with anhedonism and flat affect are typical for this disorder. The preference for solitary activities and use of fantasy furthers this picture. The lack of aggressiveness and risk-taking behavior lessons the antisocial diagnosis. The patient denied any precipitating event that would lend the problem to an adjustment disorder and the lack of variance, seasonal or otherwise, lessens the seasonal affective disorder diagnosis.

A 24-year-old male has an eight-month history of loose thought associations, social withdrawal, auditory hallucinations, and deterioration in his personal appearance and hygiene. Upon examination, he is noted to have a flat affect, perceptual distortions, and behaves like he is detached from his own actions. An atypical antipsychotic medication is chosen for this patient. Which of the following medications is classified as an atypical antipsychotic? A. Chlorpromazine (Thorazine) B. Haloperidol (Haldol C. Loxapine (Loxitane) D. Molindone (Moban) E. Olanzapine (Zyprexa)

The answer is E. EXPLANATION: Olanzapine is the only atypical antipsychotic listed in the given answers. The remainder of the medications listed are typical antipsychotic medications.

A 32-year-old male presents to your office with the complaint of low back pain for 7 months. The patient states he was initially injured on the job while trying to lift a 50-pound barrel off a truck. He denies any paresthesias or bowel/bladder problems associated with the low back pain. The patient states that he had been given NSAIDs and a muscle relaxer, followed by physical therapy treatments. X-rays that were taken 5 months ago were reported as normal. He was placed on light duty at that time. The patient has seen many practitioners who have "not helped him." Another person who works with this patient was at the clinic and stated the patient has had problems with one of his other coworkers. You consider trying the patient on an antidepressant first and then possibly sending him to a pain clinic if there is no success. What is the most likely diagnosis? A. conversion disorder B. hypochondriasis C. drug addiction D. somatoform pain disorder E. schizophreniform

The answer is D. EXPLANATION: Somatoform pain disorder is a focus on pain for greater than 6 months. The subjective findings outweigh the objective findings. Pain in the neck, pelvic, or low back areas are frequent sites, as well as headaches. The disorder may be precipitated by an injury. The patient will have a history of seeing multiple providers and possibly many medical and surgical treatments. The patient is unresponsive to treatment. Stressors can aggravate or precipitate the pain. There may be an expectation of secondary gains. Age of onset is around 30s and 40s. Treatment consists of placing the patient on an antidepressant and sending the patient to a pain clinic.

Your patient is a 4-year-old boy whose father brings him to your primary care office concerned about behavioral problems. He cannot seem to sit still in school. He seems to have a great deal of difficulty focusing for any length of time. Which of the following is required in order to make the diagnosis of attention deficit/hyperactivity disorder (ADHD) according to the DSM-IV-TR? A. He exhibit more symptoms of inattention than hyperactivity B. He must be at least 10-years-old C. He behaves aggressively towards others on at least some occasions D. Some impairment from the symptoms is present in two or more settings E. Symptoms of inattention be present on a daily basis for 3 months

The answer is D. EXPLANATION: The diagnosis of ADHD requires symptoms of both hyperactivity/impulsivity and of inattention (D). It does not require more or more prominent symptoms (A) of one or the other. Aggression (C) is seldom involved, although the impulsivity may manifest as lack of concern for others. The symptoms must be present before the age of seven (B) and must have been present for at least 6 months (E).

A 15-year-old female comes into your office with multiple symptoms of an eating disorder. What is the single feature that would lead you to diagnose anorexia rather than bulimia or binge eating disorder? A. Binge eating behaviors B. Compensatory measures such as purging C. Preoccupation with body weight D. Refusal to maintain normal body weight

The answer is D. EXPLANATION: The diagnosis of anorexia requires that the patient refuse to maintain a normal body weight (D). All the other behaviors mentioned (A, B, C, E) may be shared between anorexia and bulimia. People with binge eating disorder (not fully recognized in the DSM IV-TR) display binge eating without compensatory measures, resulting in obesity.

An 82-year-old male is brought to the emergency room by ambulance. He was found wandering the streets, incoherent and sometimes belligerent. You are able to ascertain that he had wandered away from the nursing home where he was staying. What piece of information from the nursing home staff would confirm in your mind the diagnosis of delirium rather than dementia? A. He has a family history of Alzheimer's B. He has a history of prostate cancer C. He is being treated for diabetes and hypertension D. He was entirely coherent this morning

The answer is D. EXPLANATION: The key differentiating features between delirium and dementia is that delirium is sudden in onset, often waxing and waning, and has a specific precipitating cause, most often infection or medications (including illicit drugs). The two conditions share features of significant cognitive impairment and decline in function. Dementia is a more slowly progressing condition in which problems with memory is often the first and most significant feature.

What type of disorder develops within 3 months of an identified stressor such as finances, going to school, divorce, or illness in their life. The stressor causes impairment in their job and relationships, but the symptoms resolve within 6 months. What is the most likely diagnosis? A. depression B. bereavement C. post-traumatic stress disorder D. personality disorder E. adjustment disorder

The answer is E. EXPLANATION: A response to a stressor that disturbs the mood of the patient causes impairment in function. The symptoms occur within 3 months of the stressor and last no longer than 6 months. Anxiety, depression, or combination is associated with adjustment disorders.

Mr. Addley is a 69-year-old, recently retired accountant who comes to you in your family practice, accompanied by his wife, for a routine follow-up of his blood pressure. During his visit he comments that he is concerned about his memory. He notes that he is having some difficulty remembering where he left his car keys, the day of the week, and names of people immediately after being introduced to them. When his wife is asked, she has noticed nothing regarding any change in his mental status or his ability to perform activities of daily living. You perform a mini-mental state exam (MMSE) and he scores 25 out of 30. What is the most appropriate working diagnosis for Mr. Addley? A. mild to moderate depression B. mild Alzheimer's disease C. moderate Alzheimer's disease D. Lewy body dementia E. mild cognitive impairment

The answer is E. EXPLANATION: Because your patient notices symptoms but family members, friends, and coworkers do not, and his MMSE is slightly below normal, your patient meets the diagnostic criteria for Mild Cognitive Impairment, or MCI. Metabolic causes should be ruled out before making a definitive diagnosis. This may or may not progress to Alzheimer's and there are no FDA-approved medications for MCI, although some clinicians do utilize acetylcholinesterase-inhibitors after discussions with patients and their families.

You are asked to see a patient who was admitted to the hospital. Upon attempts to obtain a history, you notice the patient states words that sound similar, but do not have the same meaning. He also does some rhyming of his words. What type of thought process would this be? A. flight of ideas B. circumstantiality C. looseness of association D. word salad E. clanging

The answer is E. EXPLANATION: Clanging is a disturbance in thought in which the person selects words that are similar by sound, but do not mean the same. Sometimes the person will rhyme the words. Flight of ideas is rapid transitioning between subjects, but tends to be connected. Looseness of association is when a person changes subjects, but there is no connection between the subjects. Circumstantiality is where the person has a point and eventually gets to that point, but with delay in the thought process. Word salad is a mixture of words that have no sense.

A 24-year-old woman comes to your office complaining of episodic chest pains that have been occurring over the past several months. She experiences shortness of breath with each occurrence and feels like "I'm going to die." She denies cough, fever, or sputum production and has noticed the episodes occur when she is in a crowd. Her current examination is normal and she feels well between episodes. You suspect panic disorder, but want to rule out the most likely organic causes. Which of the following tests will you include in your initial work-up? A. Arterial blood gases B. CBC C. Chest x-ray D. Sputum culture E. Urine toxicology screen

The answer is E. EXPLANATION: The differential diagnosis of panic disorder includes many cardiac, pulmonary, and endocrine conditions, but in a young woman without any symptoms or signs between episodes, drug use, as detected on a urine toxicology screen (E), is the most likely cause. An EKG might also be considered to rule out a cardiac cause. CBC (B) and sputum culture (D) might be helpful if infection is a consideration, but she has no fever or other signs of infection. Chest x-ray (C) and blood gases (A) would not be helpful without symptoms or signs suggesting particular etiologies.

A 39-year-old male presents to the clinic with a concern for a sexually transmitted infection. He suspects his wife has been having an affair. He denies any penile pain or discharge. This is the third time he has been into the office with this concern in the past four months. All of the STD tests have been negative thus far. Upon further questioning, he is noted to be defensive, extremely sensitive, and quite secretive. He also has suspicions that his neighbor is throwing fallen leaves from a tree into his yard. This patient is exhibiting symptoms most consistent with which of the following personality disorders? A. Antisocial B. Borderline C. Narcissistic D. Obsessive compulsive E. Paranoid

The answer is E. EXPLANATION: This patient is exhibiting symptoms consistent with paranoid personality disorder. Antisocial personality disorder is characterized by selfishness, callousness, promiscuity and impulsive behavior, inability to learn from experience and legal problems. The clinical findings of borderline personality disorder include impulsiveness, unstable and intense interpersonal relationships, lack of self control, suicidal, aggressive behavior and a high drug abuse rate. Clinical findings of obsessive-compulsive disorder include being a perfectionist, egocentric, indecisive, with rigid thought patterns and a need for control. Narcissistic personality disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention.

A 52-year-old male, who is a known alcoholic, is admitted to the hospital for GI bleed. Librium is ordered, but he must be monitored for early signs of alcohol withdrawal as his total daily intake of alcohol prior to admission is unknown. Which of the following symptoms might occur as an early sign of withdrawal rather than a later sign? A. Delusions B. Hallucinations C. Nausea and vomiting D. Seizures E. Tremulousness

The answer is E. EXPLANATION: Tremulousness (E) and agitation are early signs of alcohol withdrawal, occurring within the first few hours. These symptoms can progress to nausea and vomiting (C) along with hallucinations (B), delusions (A), and seizures (D) after several hours. Seizures generally occur 12-48 hours after the last drink and full delirium tremens occurs after 48-72 hours.

Which of the following medications used in treatment of this disease has the risk of prolonging the QTc interval? A. Aripiprazole (Abilify)B. Chlorpromazine (Thorazine)C. Loxapine (Loxitane)D. Quetiapine (Seroquel)E. Ziprasidone (Geodon)

The answer is E. EXPLANATION: Ziprasidone is the only medication of the ones listed that is known to prolong the QTc interval. An ECG is recommended for patients at risk for cardiac sequelae.

ADRs of monoamine oxidase inhibitors

• Hypertensive crisis precipitated by taking MAOIs and ingesting: - red wine,certain meats, fava beans, cheese • Serotonin syndrome - caused by taking SSRIs and MAOIs - begins with lethargy, confusion, flushing→rhabdomyolysis, ARF, coma, death

Li intoxication management

• Supportive tx • Dialysis to remove Li if >4.0 mEq/l