Usmle step 2 Psychiatry

cognitive behavioral therapy

challenges small job to thoughts that underlie emotional reactions Target's avoidance with behavioral techniques (relaxation ,exposure, behaviormodification)

opioid misuse prevention

check the state'se prescription drug monitoring program data for undisclosed co-prescriptions before random urine drug screens schedule frequent follow-up visits at least once in 3 months

REM sleep behavior disorder

condition involving dream-related vocalizations and motor behavior that occur during REM sleep the sleeper acts out his or her dreams.

The period lasting from the moment you fall asleep to the first REM period. Lasts approximately 90 minutes in most individuals. However, several disorders will shorten REM latency

depression, narcolepsy

What is the most common cause of erectile dysfunction due to a medical condition?

diabetes #2 alcohol

a physician with recently diagnosed cancer is overly concerned about his children's health state

displacement

a boy with gender dysphoria

that's okay to refer him to a counselor

Amitriptyline

tricyclic antidepressant, is sedating and is not considered a first line antidepressant due to its side effect (cardiotoxicity, danger in overdose)

motivational interviewing

used in substance use disorder addresses ambivalence and enhances motivation to change non-judgmental, acknowledges resistance There are specific therapeutic strategies that are likely to elicit and support change talk in MotivationalInterviewing: 1.Ask"Evocative"Questions:"Ask!an!open!question,!the!answer!to!which!is!likely!to!be!change! talk. 2." Explore" Decisional" Balance:" Ask! for! the! pros! and! cons! of! both! changing! and! staying! the! same. 3. Good" Things/Not So Good" Things:! Ask! about! the! positives! and! negatives! of! the! target! behavior. 4." Ask" for"Elaboration/Examples:"When!a! change! talk! theme!emerges,!ask! for!more! details.! "In!what!ways?" "Tell!me!more?" "What!does!that!look!like?"!"When!was!the!last!time!that! happened?" 5." Look"Back:"Ask!about!a!time!before!the!target!behavior!emerged.!How!were!things better,! different? 6." Look" Forward:"Ask! what!may! happen! if! things! continue! as! they! are! (status! quo).! Try the! miracle!question:!If!you!were!100%!successful!in!making!the!changes!you!want, what!would! be!different?!How!would!you!like!your!life!to!be!five!years!from!now? 7." Query" Extremes:" What! are! the! worst! things! that! might! happen! if! you! don't! make! this change?!What!are!the!best!things!that!might!happen!if!you!do!make!this!change? 8." Use"Change"Rulers:"Ask:!"On!a!scale!from!1!to!10,!how!important!is!it!to!you!to change![the! specific!target!behavior]!where!1!is!not!at!all!important,!and!a!10!is!extremely!important? Follow!up:!"And!why!are!you!at!___and!not!_____! [a!lower!number! than!stated]?"!"What! might!happen!that!could!move!you!from!___!to![a!higher!number]?" Alternatively,!you!could!also!ask!"How!confident!are!that!you!could!make!the!change!if!you! decided!to!do!it?" 9. Explore"Goals"and"Values:"Ask!what!the!person's!guiding!values!are.!What!do!they want!in! life?!Using!a!values!card!sort!activity!can!be!helpful!here.!Ask!how!the!continuation!of target! behavior!fits!in!with!the!person's!goals!or!values.!Does!it!help realize!an!important!goal!or! value,!interfere!with!it,!or!is!it!irrelevant? ""10. Come"Alongside:"Explicitly!side!with!the!negative!(status!quo)!side!of!ambivalence. "Perhaps!_______is!so!important!to!you!that!you!won't!give!it!up,!no!matter!what!the!cost."

antidepressant augmentation

useful for partial responders to antidepressant therapy you can add an antidepressant with a different mechanism of action (i.e bupropion if pt also wants to lose weight) OR Li, T3 (not T4!), 2nd generation antypsychotic, psychotherapy

_____(mood stabilizer)can cause drug-induced liver injury

valproate

which drugs are associated with SSRIs discontinuation syndrome?

venlafaxine, paroxetine (short acting) fluoxetine has no scs after discontinuation because if his very long half life

Benzodiazepines Clinical Guidelines

• Avoid abrupt changes in benzodiazepine dosage. • Use lower dosages for the elderly. • Do not mix with alcohol or other sedative-hypnotic medications. • Consider dependency potential. • May cause confusion, problems with memory, and falls (especially in the elderly) • Abrupt discontinuation may cause seizures

antidepressant that inhibit reuptake of NE and S, approved for depression and neuropathic pain

Duloxetine:

Drug for bipolar disorder with psychotic features

-Lithium, valproatem quetiapine and lamotrigine

Bupropion contradictions

-associated with an increased seizure risk -contraindicated in pts with seizure disorders, anorexia, and bulimia nervosa

interpersonal psychotherapy

-for depressed with relationship conflicts -links current relationship conflicts to depressive symptoms

catatonia treatment

-lorazepam -pts stare blankly and is mute and motionless, resisit any efforts to move his limbs

psychodynamic psychotherapy

For higher functioning patients with persistent patterns of dysfunction builds inside into how unconscious conflict and past relationships cause symptoms uses transference Breaks down maladaptive defenses

Tardive dyskinesia

-occurs after prolonged exposure to antipsychotic drugs and is presented with abnormal involuntary movements of mouth, tongue, face, trunk, or extremities -when discontinuing the antipsychotic is not feasible, switch to clozapine

Cocaine use disorder

-tachycardia, pupil dilation, and tremors

normal lithium therapeutic range. li in preggos

0.8-1.2 teratogenic: 1st trimester - ebstein anomaly, 2-3 trimester - goiter and neuromuscular dysfunction

a woman taking antidepressant discontinued it and 2 days after started to feel very bad again 1) dx 2) which drugs are at highest risk 3) Rx

1) antidepressant discontinuation syndrome 2) serotoninergic antidepressant with a short elimination half-life (paroxetine, Venlafaxine), higher Doses and longer duration of treatment are associated with more severe discontinuation syndrome 3) rent instituted the same antidepressant and taper the dose gradually over 2 to 4 weeks OR substitute fluoxetine which is more easily taper due to its long half life

bipolar Rx 1) w/renal dz 2) w/ liver failure

1) avoid or adjust Li 2) avoid valproic acid

separation anxiety normally lasts up to...

18 months but it can reappear during transition periods like attending school

generalized anxiety disorder

>6 months 3 or more of the following: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances

Acute stress disorder symptoms must last for ____

>=3 days and <= 1 month following trauma exposure

Drug for alcohol dependence (initiated once abstinence is achieved)

Acamprosate dont use in renal impairment

_____present with abdominal pain, neuropathic ( psychotic symdromes)

Acute intermittent porphyria

a woman with panic disorder and agoraphobia with not fully satisfactory response to antidepressants should be prescribed...

CBT For the initial management of agoraphobia, advise psychotherapy or medication treatment based on patient preference (Strong recommendation). Consider combination therapy with counseling and medication if the patient prefers (Weak recommendation). For psychotherapy, cognitive behavioral therapy is recommended as the first-line option (Strong recommendation). First-line medications for treatment of agoraphobia include: *selective serotonin reuptake inhibitors (SSRIs), such as citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline* (Strong recommendation) selective norepinephrine reuptake inhibitors (SNRIs), such as *duloxetine or venlafaxine extended release* (Strong recommendation) Consider a benzodiazepine, such as alprazolam, clonazepam, or lorazepam, as monotherapy or in combination with antidepressants for patients with very distressing or impairing symptoms in whom rapid symptom control is critical (Weak recommendation). Second-line medications to consider for treatment of panic disorder include: a benzodiazepine, such as alprazolam, clonazepam, or lorazepam, with regular dosing (Weak recommendation) tricyclic antidepressants, such as imipramine or clomipramine (Weak recommendation) For patients who are unresponsive to the initial treatment, options include augmentation with another first-line treatment or switching to another first-line treatment (Strong recommendation). Adding a benzodiazepine to an antidepressant to target residual symptoms may also be considered (Weak recommendation). For pregnant or breastfeeding patients and for children with agoraphobia, consider cognitive behavioral therapy (CBT). Monitor patients during the follow-up for changes in symptoms and potential adverse effects of medications (Strong recommendation). If discontinuing benzodiazepine treatment, consider tapering over 2-4 months with a decrease of no more than 10% of the dose per week (Weak recommendation) while continuing to offer cognitive-based therapy.

Lithium toxicity

Concurrent use of thiazide diuretics (as well as ACEI, tetracyclines, metronidazole and nonsteroidal antiinflammatory drugs) with lithium can increase serum lithium levels and lead to symptoms of lithium toxicity, including gastrointestinal symptoms, confusion, ataxia, tremor and seizures

Drug for acute dystonic reaction due to haloperidol (a sustained contraction of his neck to the right side)

Diphenhydramine or benztropine

Drugs treatment for delirium

Haleperidol, quetiapine, risperidone

4 drugs for maintenance bipolar disorder

Lithium, Valproic acid, Quetiapine, lamotrigine

_______are first line maintenance treatments for bipolar disorder

Lithium, valproate, quetiapine and lamotrigine

Immediate drug for panic disorder

Lorazepam

Drug for alcohol use disorder (decrease alcohol craving, heavy drinking)

Naltrexone don't use in current opioid abusers and in those with liver Disorder

Narcolepsy clinical presentations

Narcolepsy is characterized by excessive daytime sleepiness, cataplexy and REM sleep-related phenomena (hyponagogic/hypnopormpic hallucinations), sleep paralysis -Hypnagogic- intrusions of REM sleep phenomena on falling asleep -Hypnopompic- intrusion of REM sleep phenomenon on awakening

for which psychiatric disorder eye movement desensitization and reprocessing treatment is used?

PTSD

Genito-pelvic pain disorder

Pain associated with sexual intercourse in either male or female. Not diagnosed when organic cause has been found or if due to lack of vaginal lubrication address her anxiety issues

Migraine prophylaxis

Propranolol, timolol, methysergide, valproic acid, and topiramate (Topamax) have been approved by the FDA for migraine prophylaxis

antipsychotic w\lowest risk of movement disorders

Quetiapine

treatment of bipolar depression

Quetiapine lurasidone lamotrigine Li, valproic acid, and the combination of olanzapine and fluoxetine have also demonstrated advocacy

Drug for Tourette disorder (facial grimacing, blinking, head/neck jerking etc)

Risperidone

treatment of social anxiety disorder

SSRIs/SNRIs !!! BBS for performance subtype CBT

A 20-year-old nurse was recently admitted after reporting auditory hallucinations, which have occurred during the last few days. She reports marriage difficulties and believes her husband is to blame for the problem. She has several scars on her wrists and has a history of substance abuse

borderline

dialectical behavioral therapy

borderline personality disorder or self-injury improve emotional regulation and mindful awareness, builds distress tolerance manages self-harm group therapy confident

Mrs. Smith has been married for 10 years, and during all of those years she remembers being sick all of the time. According to her husband, she constantly takes medications for all of her ailments. She has visited numerous physicians and none have been able to correctly diagnose her condition. Today she presents in your office complaining of shortness of breath, chest pain, abdominal pain, back pain, double vision, difficulty walking due to weakness in her legs, headaches, constipation, bloating, decreased libido, and tingling in her fingers.

Somatization disorder. MC women inversely related to SES. Usually begins by the age of 30. Within families, male relatives tend to have antisocial personality disorder, whereas female relatives tend to have histrionic personality disorder. sxs: • Many physical symptoms affecting many organ systems • Excessive thoughts, feelings, or behaviors related to the somatic symptoms • Long, complicated medical histories • Interpersonal and psychologic problems • Patients will usually seek out treatment and have significant impairment • Commonly associated with MDD, PDs, substance-related disorders, GAD, and phobias Treatment. regularly scheduled brief monthly visits. Should increase the patient's awareness of the possibility that the symptoms are psychological in nature. Individual psychotherapy

type of psychotherapy used in treatment of specific phobia

Treatment overview exposure therapies appear to be most effective treatment for specific phobia exposure therapy appears to remain effective at > 6 months after treatment for animal phobias, height phobias, and claustrophobia - virtual reality exposure plus cognitive-based therapy appears effective for fear of flying - muscle tensing techniques appear more effective than exposure therapy and as effective as muscle relaxing techniques for treatment of blood-injury-injection phobia - single-session cognitive behavior therapy may be effective for pediatric phobia patients role of medications limited but may provide symptomatic relief benzodiazepines appear to allow patient to cope during exposure to feared situation or object, but not to cure irrational fear paroxetine appears effective in reducing symptoms of specific phobia at 4 weeks

Serotonin syndrome

VS NMS: in NMS no diarrhea, there is muscular rigidity

prolongation of Qt interval

Ziprasidone:

a man who turns psycho over a few months, has abdominal pain, vomiting constipation and sensory and motor neuropathies

acute intermittent porphyria urinary porphobilinogen is elevated

PTSD treatment

antidepressents such as escitalopram

rx of night terrors and sleep walking if meds are considered

bdz to decrease rem

PCP associated agitation treatment of choice

benzodiazepines parenterally not haloperidol! it's 2nd line. it's also relatively contraindicated in seizure disorder as all antypsychotics ⬇ seizure threshold

Treatment of choice for rapid-cycling bipolar disorder, or when lithium is ineffective, impractical, or contraindicated

divalproex • Increasingly popular in emergency settings, may give loading dose • Time course of treatment response is similar to lithium. • Efficacy for prophylaxis is unclear. • Untoward effects: sedation, cognitive impairment, tremor, GI distress, hepatotoxicity, weight gain, possible teratogenicity (spina bifida), and alopecia.

OCD CBT type meds?

exposure and response prevention HIGH dose SSRIs (eg, fluvoxamine) and prolonged course is needed (gradual up-titration) #2 clomipramine or augmentation with antipsychotic #3 deep brain stimulation bupropion and other antidepressants which don't affect serotonin are NOT effective!!!

Restless leg treatment

first line:Dopamine agnoists: pramipexole, dopamine -Alternate: Alph-2-delta calcium channel ligans: gabapentin enacarbil

supportive psychotherapy

for lower functioning patients, those who are in crisis or psychotic reinforces coping skills and builds up adaptive defenses

depression in a patient with cancer

give SSRIs. don't say it's normal

MDMA overdose

hypertension, tachycardia, hyperthermia, serotonin syndrome (autonomic dysregulation, high fever, altered mental status, neuromuscular irritability, seizures), HYPONATREMIA MDMA IS NOT DETECTED BY ROUTINE TOXICOLOGY SCREENS

A 22-year-old woman convinced that she has a brain tumor. She reports frequent headaches that are not alleviated with aspirin. She has been to numerous physicians and all have told her that there is nothing wrong with her. She expects that you can help her because she knows that there is something wrong and that you can adequately treat her condition.

illness anxiety disorder sxs: • Preoccupation with diseases • The preoccupation persists despite constant reassurance by physicians. • The belief is not delusional. • The preoccupation affects the individual's level of functioning. • Duration at least 6 months Treatment. Psychotherapy to help relieve stress and help cope with illness. Frequent, regularly scheduled visits to patient's medical doctor

Cocaine intoxication

increased appetitis, hypersomnia, intense psychomotor retardation, severe depression

changes in sleep and normal aging

increased sleep latency, decrease REM latency, decrease slow wave sleep if pt doesn't feel a significant impairment in activities of daily living or cognition, no further workup is necessary and patient should be reassured that these changes are normal

Penetration disorder

involuntary constriction of the outer one-third of the vagina that interferes with the sexual act Behavioral techniques, such as the use of dilators and relaxation. Address issues of fear of impregnation, strict upbringing, religion, etc.

pediatric depression

it can present with symptoms of irritability rather than depressed mood treatment options include Psychotherapy and antidepressants and fluoxetine is the drug of choice

lamotrigine role in Rx of bipolar disorder

it is used to treat bipolar depression

what can help patients with schizophrenia to cope better?

keeping family stresses and conflicts to a minimum gradual (not immediate) return to school/work encourage establishment of social connections

Patients with bulimia nervosa have an increased incidence of...

kleptomania

a man with major depressive disorder is convinced that it has brain cancer and that he deserves all that suffers due to his sins

major depression with psychotic features first line therapy is combination of antidepressant and antipsychotic or electroconvulsive therapy

an elderly woman with severe asthma after the exacerbation was prescribed with a new medication. after that she started to see very strange things and act strangely. during cognitive examination she seems normal, has normal attention and is oriented in time and space. diagnosis?

medication induced psychosis this is because of high-dose glucocorticoids in Delirium and patient has impaired cognitive abilities and disorientation in time and space

if patient has had a history of DM, you should not prescribe him...

olanzapine

PCP onset and duration of action

onset is rapid duration <8h bdz are used to treat severe psychomotor agitation ketamine has shorter duration of action metamphetamine has longer duration of action (~20hrs)

panic disorder vs social phobia

panic disorder is unexpected panic attack whereas in social phobia Panic like symptoms present only before performance or any other social situation also in panic disorder there is a fear of panic attack itself, not of social situations

biofeedback

physical symptoms like pain disorders improve awareness and control over psychological reactions lowers stress levels integrates mind and body

ADHD in girls

predominantly inattentive features

Treatment for performance anxiety

propranolol

the doctor with pancreatic cancer says that he can't transfer his patients because other health care providers don't know their health conditions and will treat them poorly

rationalization

you have a patient with acute stress disorder. how to treat her?

recommending Psychotherapy or medication is immature and unlikely to be well received. the best initial approach used to provide education on symptoms and the course of acute and post-traumatic stress disorders as well as to encourage the patient to seek help if the symptoms persist normalizing the stress response while explaining the symptoms can sometimes cause distress and impairment would be helpful. indicating the patient that alcohol is likely to disrupt her sleep is also indicated -------------------------- Treatment overview thorough clinical assessment trauma-focused cognitive BT - 1st line cognitive behavior therapy and structured writing therapy may be effective propranolol and hypnotic drugs reported to be effective (level 3 [lacking direct] evidence) psychiatric referral may be necessary Activity thorough clinical assessment including(1) assessment of physical, psychological, social, and occupational functioning risk of self-harm risk of suicide risk of harm to others if possible, interview with a family member or friend

clomipramine in OCD

second line after SSRIs

false positive test for amphetamines

selegiline bupropion

Sigecaps (Acronym for depression)

sleep interests guilt energy concentration appetite psychomotor agitation suicidal ideation

Buspirone

• Effective in the treatment of generalized anxiety disorder and social phobia • Lag time of about 1 week before clinical response • No additive effect with sedative-hypnotics • No withdrawal syndrome • No sedation or cognitive impairment • Headache may occur

Li Toxicity Management

• Keep plasma levels <1.5 mEq/L; optimal 1.0 mEq/L • Dehydration and hyponatremia predispose to lithium toxicity by increasing serum lithium levels. • Tremor at therapeutic levels may respond to decreased dosage. • Lithium levels may increase with ACE inhibitors, NSAIDs, loop and thiazide diuretics

Second-line choice for treatment of bipolar disorder when lithium and divalproex are ineffective or contraindicated

• Rare but serious hematologic and hepatic side effects and significant sedation make carbamazepine less useful. • May cause agranulocytosis, hypocalcemia, anemia, SJS, SIADH

Characteristics of Sleep from Infancy to Old Age

• Total sleep time decreases. • REM percentage decreases. • Stages 3 and 4 tend to vanish.

a woman worries about her children and complaints about poor sleep. she drinks wive before going to bed, awakes in the middle of the night and, unable to fall asleep anymore, lies and worries about a lot of things CBC shows mild macrocytosis mild ⬆LFTs

▶alcohol use disorder ▶patients with chronic alcohol use frequently present in primary care with sleep disturbance and anxiety symptoms due to mild withdrawal ▶patients may use alcohol to help fall asleep but as the blood alcohol level drops, central nervous system hyperarousal occurs and results in Awakenings AST/ALT>2!!! ⬆GGT, pancytopenia, macrocytosis, ⬆ carbohydrate-deficient transferrin

how to deliver the bad news

▶face-to-face visit in a comfortable private setting ▶provide empathy and emotional support ▶assess the patient's understanding of the condition and ▶how much the patient actually wants to know (open ended questions) ▶warn the patient and family the bad news is coming ▶speak in simple and straightforward terms ▶stop and check for understanding gain an understanding of cultural or educational or religious issues, ▶making medical information understandable to the patient, and ▶formulating a collaborative treatment plan ▶summarize a follow-through plan including end-of-life discussions if applicable

grief reaction

⚰normal reaction to loss ⚱feeling of loss and emptiness 🔮symptoms revolve around the deceased ⚖functional decline less severe 🚬waves of grief at reminders (the usually nice mixed in with positive memories vs MDD when sadness is constant) 🗡worthlessness self-loathing deal suicidality less common⚠ 🔫thoughts of dying involves joining the deceased 📉intensity decreases overtime

cocaine& amphetamines withdrawal sxs

⬆ appetite, hypersomnia, *intense psychomotor retardation, severe depression ("crush")*