Psych QBANK #2

influence, reference

Ideas of __________, a person believes that he is being controlled by another person or external force. Ideas of __________, a person falsely believes that others (including people on TV or radio) are talking about him.

Delirium

It is the most common cause of hospital-related complications in the United States

Dysthymic Disorder (a mild, chronic form of depression. In adults, the diagnosis requires 2 years of a depressed mood, whereas in teens and adolescents it requires 1 year of symptoms to meet this criteria. Teens may manifest with irritability rather than depression. The condition may be associated with changes in appetite, sleep, and concentration, and with fatigue and hopelessness. Treatment is psychotherapy and antidepressant therapy.)

35-year-old woman comes to the health care provider for a periodic health maintenance examination. She has no physical complaints but she is concerned that she hardly ever feels happy. She says that she has basically been "down" for at least 3 years. She rarely goes out with friends and keeps to herself at work. Her work performance has been stable but she usually feels tired and "blah." Which of the following is the most likely diagnosis?

Clozapine (Clozaril- atypical agent that has been proven to be more effective than conventional antipsychotics in the treatment of patients who have resistant schizophrenia.)

41-year-old man with a long history of schizophrenia, paranoid type, has been on the inpatient unit for almost 2 weeks. This is his third admission in the past 6 months, and each time he seems to be less responsive to treatment. In the past he has been on typical antipsychotics and then risperidone (Risperdal), with limited success. His family is supportive and makes sure he takes his medication. Given his most recent poor response, which of the following is the most appropriate next step in treatment?

Imipramine (Tofranil- TCA that inhibits norepinephrine and serotonin reuptake. Like most TCAs, imipramine also has *antagonistic effects at muscarinic, histaminic, and α-adrenergic receptors*. This patient's complaint of *blurred vision is most likely caused by the antimuscarinic effects* of the medication. The blockade of muscarinic acetylcholine receptors causes mydriasis-pupillary dilation- resulting in blurred vision. Dry mouth is also caused by the anticholinergic effect of imipramine. Orthostatic hypotension is caused by the α1-adrenergic receptor blockade associated with TCAs.)

45-year-old woman comes to her primary care provider because of blurred vision. She states that this symptom started about 2 days ago. She denies any past history of significant medical or neurologic problems. She does state that several days ago she started treatment for depression with a psychiatrist because of a 2-month period during which she had several depressive symptoms. On review of systems, she admits to having increased her water consumption over the last several days because of a dry mouth. She also complains of dizziness when she stands up from lying or sitting. Her temperature is 37º C (98.6º F), blood pressure lying down is 135/75 mm Hg, blood pressure standing is 110/64 mm Hg, pulse lying down is 84/min, pulse standing is 95/min, and respirations are 16/min. Physical examination is unremarkable except for mild pupillary dilation. Which of the following medications most likely accounts for this patient's symptoms?

Cocaine

A 1,400-g infant born at 35 weeks' gestation is 42 cm in length and has a head circumference of 28 cm. One day after birth, she becomes very irritable, tremulous, and inconsolable. Her cry is high-pitched. Her pulse is 174/min. There are no dysmorphic facial features. Her mother had inconsistent prenatal care and has a history of multiple inpatient hospitalizations for substance overdoses. To which of the following substances was this newborn most likely exposed in utero?

Tourettes Disorder

A 10-year-old boy comes to the health care provider with his parents at the request of school authorities. In the past couple of months the teachers have noticed that he has become more fidgety in class and at times coughs or produces strange noises. He also makes sudden movements and touches his peers in the middle of conversation. He has always had a blinking-type tic that has recently worsened. The main reason the parents were asked to bring him in for evaluation was the boy's sudden screams, which distract and scare the other students in class. He is academically successful, very neat, with no other behavioral or emotional problems. He is initially silent in the health care provider's office and then suddenly produces "the noise." He seems very upset when it occurs and admits that he is aware that other children make fun of him and avoid him because of it but he cannot control it. Which of the following is the most likely Dx?

Conduct Disorder (diagnosis requires a pattern of behavior that violates societal rules and the basic rights of others. Common features include lying, stealing, running away, staying out without permission, setting fires, truancy, vandalism, cruelty to animals, bullying, physical aggression, and sexual aggression. At least three of these features must be present to make the diagnosis. 25-50% of these patients go on to have antisocial personality disorder as an adult.)

A 12-year-old boy is brought to the health care provider because of a pattern of behavior that has been worsening over the past year. His mother states that he has been bullying other boys at school, staying out late without permission, setting small fires in abandoned lots, and physically abusing neighborhood cats. During the examination, a speculum from the examination room drawer falls out from underneath his shirt. Which of the following is the most likely diagnosis?

Gastric Lavage (*Gastric lavage should be used in this somnolent patient*. It is best done within the first 60 minutes of ingestion of the unknown substance. It is performed by inserting a large-caliber orogastric tube and then flushing the tube with a large amount of normal saline. The saline is then aspirated from the stomach to a container in an attempt to evacuate any ingested substance that persists in the stomach cavity. Identification of the ingested substance is also very important. With certain ingested substances, gastric lavage is contraindicated. For example, the procedure should not be used if hydrocarbon ingestion is suspected because aspiration is much more likely to happen during a lavage or an induced emesis. Furthermore, ingestion of alkaline substances causes esophageal necrosis. In this setting, gastric lavage may cause esophageal perforation.)

A 17-year-old girl is found unconscious in a bathroom after ingesting a large amount of unknown sleeping pills. On arriving at the emergency department, she is somnolent; her temperature is 37.2º C (98.9º F), blood pressure is 120/74 mm Hg, pulse is 68/min, and respirations are 12/min. She responds to painful stimuli and to hearing her name loudly by opening her eyes briefly. She returns to the somnolent state immediately afterward, however. Which of the following is the most appropriate initial intervention?

Diazepam (Valium= is used for treatment of agitation related to phencyclidine -PCP- intoxication. Benzodiazepines may be effective in treating violent behavior. Cranberry juice or ascorbic acid may be useful in acidifying the urine and speeding up the elimination of the drug.)

A 24-year-old student is brought to the emergency department because of a sudden change in behavior. His friends report that he has been acting "weird" and confused and has been talking about "flying above the floor." He laughs without a reason and then burst into tears. He had been at a party the night before and may have used some drugs. He appears hot and has uncoordinated movements. He has horizontal nystagmus, ataxia, and muscular rigidity. He becomes very agitated and combative during the examination. He is placed in a nonstimulating environment. Which of the following agents should be administered at this time to treat his agitation?

Schoid Personality Disorder (characterized by restricted emotions and social detachment. Patients are distant from other individuals, and in contrast to those who have avoidant personality disorder, do not desire contact with other individuals in social situations. They usually have a very narrow range of interests.)

A 25-year-old man comes to a mental health care provider after being referred by his primary care provider for evaluation of possible depression. During the interview, the patient states that he lives alone and works as the film projectionist at a local movie theater. He has no outside interests, but claims that he is comfortable living alone and has not had any changes in appetite or sleep. He describes how he ignores social invitations from some of his co-workers and spends most of his leisure time watching television and reading comic books. Which of the following is the most likely diagnosis?

Psychomotor Agitation (The diagnosis of bipolar depression requires that the patient have also had a manic episode of bipolar disorder. Bipolar depression is associated with less psychomotor agitation compared with unipolar depression (major depressive disorder), and thus the patient's agitation is more consistent with a major depressive disorder diagnosis than with the depression of bipolar disorder.)

A 25-year-old moderately obese woman with a history of bipolar disorder diagnosed at age 19 complains to her health care provider that her recent struggles with her weight and eating have caused her to feel depressed. She states that she has recently had increased difficulty sleeping, has felt excessively anxious and agitated, and has had increasing thoughts of suicide. She often finds herself fidgety and unable to sit still for extended periods of time. Her family tells her that she is increasingly irritable. She has never attempted suicide. Her current medications include lithium carbonate (Lithobid) and zolpidem (Ambien) as needed for sleep. Which of the following is more consistent with a diagnosis of major depressive disorder than bipolar depression in this patient during this episode?

Clonazepam (Klonopin= patient's symptoms suggest that he has panic disorder, which is most appropriately treated acutely with a benzodiazepine with a medium length half-life and duration of action, such as clonazepam.)

A 26-year-old man comes to his primary care provider complaining that he has been more and more afraid to leave his house because he has been having frequent anxiety attacks that occur without warning. He is worried that he will have an attack at some time while he is in public. He has no other medical conditions. Physical examination is unremarkable. Which of the following is the most appropriate initial medication for this patient in an acute situation?

Decrease Dosage of Risperidone (pt is having Akathesia=sense of restlessness and psychomotor agitation= and need to decrease dose.)

A 27-year-old man with schizophrenia, chronic paranoid type comes to the clinic for a follow-up visit. He has been stably maintained on risperidone (Risperdal) 3 mg twice a day for a few months, but the dose was recently changed to 6 mg twice a day when he was hospitalized for pneumonia. In the clinic he is alert, oriented, well related, and his thought process is completely organized. He is not complaining of any auditory hallucinations and does not seem to be responding to internal stimuli. He has psychomotor agitation and has difficulty staying in his chair during the interview. When specifically questioned about the agitation, he says that he constantly feels like he has to move around. He denies any suicidal or homicidal intent, ideation, or plan. Which of the following is the most appropriate next step in management?

Nortriptyline (Pamelor- Tricyclic Antidepressant- which is lethal in overdose and is the leading cause of overdose-related deaths in the psychiatric population. Overdose is associated with prolongation of the QT interval, leading to cardiac arrhythmia and death.)

A 29-year-old woman comes to her new primary care provider requesting medication to help with her recent spells of anxiety and depression. She wishes to be started on a medication that will not cause too much sedation. Examination of the patient's old records reveals 2 previous suicide attempts by overdose, once with acetaminophen at age 16 and another with aspirin during college. She is otherwise healthy and does not smoke cigarettes or drink alcohol. She is not currently taking any medication. Given this history, which of the following antidepressant medications would most likely be contraindicated for this patient?

Somatization Disorder (The physical complaints are usually vague and not adequately explained by a physical disorder.)

A 30-year-old woman has had a history since adolescence of multiple vague physical complaints, including headaches, nausea, bloating, abdominal pain, dysmenorrhea, fatigue, fainting, and dysuria. She is now being seen in a health care provider's office, where she describes her current abdominal symptoms as "the worst imaginable." On physical examination no abdominal stiffness or masses are noted. Tenderness on palpation of the abdomen is elicited, but the site varies and is not reproducible, even a minute or so later. On talking with the patient, she does not seem concerned about any specific life events. Which of the following is the most likely diagnosis?

Phenytoin (Dilantin- Diplopia, gingival hyperplasia, and hirsutism are classic side effects of phenytoin. Other side effects include nystagmus, sedation, ataxia, and enzyme induction. Phenytoin is used in the treatment of grand mal and tonic-clonic seizures. It is not used for absence seizures.)

A 30-year-old woman with a history of tonic-clonic seizures complains of double vision, thickened gums, and growth of facial hair since starting a new medication. Which of the following anticonvulsant medications is most likely responsible for her symptoms?

Cognitive Behavioral Therapy (In many cases of panic disorder, effective treatment involves the use of cognitive behavior therapy, which incorporates exposing the patient to disturbing stimuli in an attempt to develop coping mechanisms in response to the stimuli. It should be continued for at least 12 weeks. *SSRIs* are also approved as dual first-line therapy for this condition. SNRI agents are also indicated for treatment. Short-term benzodiazepine treatment can also be given until the SSRI or SNRI becomes fully functional.)

A 32-year-old man with a history of panic disorder who works as a salesman returns to his health care provider after several weeks of treatment with paroxetine (Paxil). Although he has noted significant improvement in his symptoms, he still notes residual anxiety when put into social situations in which he has to speak in public or become the center of attention. He has been taking the medication as prescribed and has not missed any doses. Given that he had some improvement on his current medication regimen, which of the following would be the most appropriate next step in management?

Social Phobia (an anxiety disorder characterized by a patient fearing situations in which he or she is the object of attention. Many patients who have social phobia are, like this patient, unable to advance professionally because of professional demands including public interaction.)

A 32-year-old man with no past history of mental health treatment has "occupational problems." He feels that he has not advanced professionally in his job as a financial analyst; however, he is able to perform above expectations in the work that he performs privately. He is "paralyzed by fear" when he gives presentations at work. He is also unable to concentrate and develops palpitations around strangers at parties for work and social occasions. Which of the following is the most likely diagnosis?

Generalized Anxiety Disorder (unrealistic worry about life events for a period longer than 6 months, during which time a person is worried most days. It also includes at least 6 symptoms of the following types: easy fatigability, difficulties falling asleep, restlessness, difficulties concentrating, irritability, and muscle tension. The symptoms are not caused by other psychiatric or medical conditions and they cause significant impairment in everyday functioning.)

A 32-year-old woman comes to a mental health provider because she "worries too much." She admits that over the past 7 months she has experienced extreme fatigue, muscle tension, and irritability. She has difficulties falling asleep, partly because of worrisome thoughts about her husband and children. She keeps worrying that something bad is going to happen to them. In the past month, she has had episodes of shortness of breath, dizziness, and restlessness, and has been unable to go to work or do anything at home. Her physical examination and laboratory tests, as well as her electrocardiogram, are unremarkable. Which of the following is the most likely diagnosis?

Finger Stick Glucose of 20 (When blood glucose level drops ≤25 mg/dL, as in this case, cerebral glucose reserves are quickly depleted. In response, protein and lipid components of neurons are metabolized, which can lead to--> irreversible brain damage. Prompt treatment with *IV glucose* is therefore critical in this patient's initial management. Without Tx can cause Seizures and Coma)

A 33-year-old woman with bipolar disorder and history of alcohol and drug abuse is brought to the emergency department after being found at home. She was found unresponsive to voice and touch, with 16 empty packets of medication next to her, each containing 50 mg of diphenhydramine. There was also an empty bottle of acetaminophen and a half-empty whiskey bottle near her bed. A suicide note was present on a nearby table. In the field, her temperature was 36º C (96.8º F), blood pressure 90/55 mm Hg, pulse 140/min and regular, and respirations 8/min. Additional data obtained in the field included a finger stick glucose of 20 mg/dL and an oxygen saturation of 87% on room air. Of the data available in the field, which of the following findings is most immediately threatening to her outcome?

Challenge the patients negative beliefs (The patient has many cognitive distortions and negative beliefs about herself. The most appropriate and efficient technique to use would thus be to apply cognitive therapy and challenge the negative beliefs.)

A 34-year-old woman comes to the health care provider because she feels like she is an "absolute loser" in everything she does. She recently started a new job in accounting but made a miscalculation last week and had a terrible conflict with her boss. She felt like an idiot at the time and has continued to feel that whatever she does is not adequate. As an example of her inadequacy, she continues to provide a list of all her mistakes and failures. She ends the interview by stating that she must be the unluckiest person in the world, because it seems that all these problems happen only to her. She has been depressed in the past but she does not know if medication can change her life events and make her feel differently about herself. Which of the following is the most appropriate management?

Benztropine (Cogentin- acute dystonic reaction, which is a form of extrapyramidal side effect (EPS) associated with antipsychotic medications. These side effects are related to antagonism of dopamine receptors in the nigrostriatal pathway. The patient is likely taking a conventional antipsychotic agent plus a prophylactic anticholinergic agent (such as benztropine, diphenhydramine [Benadryl], or trihexyphenidyl [Artane]). Upon stopping the anticholinergic, the dystonic reaction was more likely to occur. The appropriate initial management of this patient would include immediate IM administration of an anticholinergic agent, such as 2 mg of benztropine or 50 mg of diphenhydramine.)

A 35-year-old man is brought to the emergency clinic by his mother because of an episode of slurred speech associated with the uncomfortable sensation that his tongue is thick and curling up. The episode started suddenly 30 minutes ago. The patient is noted to be holding on to his tongue with his thumb and forefinger. When asked about this, the patient responds with dysarthria, saying that his medication has caused this once before and that he needs a shot to make it go away. His mother reports that the patient has had schizophrenia for 10 years and consistently takes 2 medications prescribed by his psychiatrist. Several days ago he ran out of one of his medications, but has continued to take the other one. Administration of which of the following should be included in the initial step in the management of this patient?

Thiamine (pt has Wernicke encephalopathy, which is caused by a *deficiency of thiamine* that is quite common in chronic alcoholic patients. Symptoms of Wernicke encephalopathy include *oculomotor disturbances, cerebellar ataxia, and mental confusion.* Treatment consists of giving at least 3 days of thiamine, 100 mg IV or IM three times daily, along with magnesium sulfate given before loading with glucose. Patients in this situation should also be given niacin and pyridoxine -vitamin B6- since most of these patients are also deficient in these water-soluble vitamins.)

A 36-year-old woman with a long history of alcoholism presents to the emergency department intoxicated. On physical examination she is disoriented and confused, and has dysarthria and oculomotor paralysis. She is unable to coordinate muscle activity during voluntary movement. Which of the following intravenous substances should most likely be administered first?

Schizoid Personality Disorder (BATMAN!=inability to form relationships and difficulty experiencing and expressing emotions. Affected individuals do not seek intimacy and approval from others; they prefer to be alone and may perform well in socially isolated jobs. The incidence is thought to be very high, however it is not known, because these individuals generally do not seek help.)

A 37-year-old man lives alone and has no close friends. He works during the night shift at the post office and has little interaction with others. He has not engaged in sexual activity since he was age 18, but he feels little desire. He maintains a close relationship with his sister, but he seeks out no relationships with others. People have told him that he seems "detached" and that he has difficulty experiencing or expressing emotion. Which of the following is the most likely diagnosis?

Paroxetine (Paxil- SSRIs are currently the first-line agents for the treatment of depression This pt has MDD sx )

A 38-year-old woman comes to her primary care provider with complaints of fatigue and insomnia. Review of systems reveals no medical symptoms, but the patient does endorse several symptoms on the psychiatric review of systems. She describes feeling tired most of the day, having difficulty falling asleep as well as waking up too early, poor appetite, frequent crying spells, poor concentration, and a recent loss of interest in her hobbies. Physical examination and routine laboratory studies including thyroid stimulating hormone are within normal limits. Which of the following is the most appropriate initial pharmacologic intervention?

Cocaine (sympathic stimulation, including tachycardia, hypertension, and sweating. The mood is elated and euphoric while intoxicated, and there is restlessness and pressured speech. Psychotic symptoms can occur with prolonged use.)

A 39-year-old businessman with no prior medical problems is rushed to the emergency department following the sudden onset of dizziness, shortness of breath, and palpitations. His blood pressure on admission is 190/110 mm Hg, pulse 124/min, and he is diaphoretic. His wife says that his behavior has changed over the past couple month since he became CEO of his company. He has become moody. At times he seems energetic, euphoric, or irritable; then he seems "to be down" for no reason. He just returned from one of many business meetings and again spent more money than ever before. The patient is smiling inappropriately and denies any alcohol or drug abuse. Which of the following will most likely be found on a urine drug screen?

Conditioned Avoidance (term that describes the pairing of an unpleasant stimulus with the stimulus that causes maladaptive behavior. This aversive conditioning technique makes it uncomfortable or painful, in order to have the patient avoid the behavior that is trying to be eliminated.)

A 49-year-old man comes to a mental health care provider for depressive symptoms. He talks about his past psychiatric problems. He also mentions he is an alcoholic and has been taking disulfiram (Antabuse) for some time to keep sober. He once tried to drink after taking the drug and ended up being terribly sick. Which of the following principles best describes the particular treatment for alcoholism?

decrease, 5-7 (once medication treatment has started include gradual discontinuation of smoking and stopping smoking after 5-7 days of treatment. While the dose is titrated up after the first three days of therapy. Because bupropion *-Zyban-* is effective in cutting down cravings, the patient who is slowly titrating down smoking patterns will be more effective as the clinical effects of bupropion are seen.)

A 49-year-old veteran comes to the health care provider to discuss smoking cessation. He was recently diagnosed with high blood pressure, hypercholesterolemia, and coronary artery disease, and he now realizes that it is finally time to quit. He has been a heavy smoker for years and finds it impossible to stop on his own, but his wife has heard about the use of bupropion (Zyban) for the treatment of nicotine dependence. After discussing the pros and cons of starting bupropion (Zyban), the patient agrees to give it a try. Which of the following instructions should be given to the patient about the use of this medication and its relationship to smoking cessation? He should _________ smoking after ____-____ days of treatment

Tardive Dyskinesia

A 55-year-old woman was diagnosed with schizophrenic disorder, paranoid type at age 23. She has been on neuroleptic medications for the majority of time since diagnosis. Which of the following conditions would be most likely to appear at this time as a consequence of her treatment?

Adjustment Disorder (the development of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor. These symptoms or behaviors are clinically significant as evidenced by marked distress in excess of what would be expected from exposure to the stressor, or by significant impairment in social or occupational functioning. In this case, the stressor is the diagnosis of pancreatic cancer, which impairs the patient's ability to function in the health care provider-patient relationship without denial.)

A 64-year-old man with generalized abdominal pain and jaundice is told by his health care provider after an extensive workup that he has pancreatic adenocarcinoma. In the days following the diagnosis, the patient states to his doctors that, "I don't have cancer—all I need is a vitamin B12 shot and I will feel better fast." The patient is oriented at all times, scoring 29/30 on a Mini-Mental Status Examination, but refuses all chemotherapy medications and adamantly refuses to be seen by the hospital oncologist, because "he is a cancer doctor and I don't have cancer." Which of the following diagnoses would be most applicable in this case?

Ideas of Influence (constitute a type of delusion in which a person believes that he or she is being controlled by another person or external force.)

A 78-year-old woman is complaining to the health care provider in her nursing home about her new problems. She reports that her old boyfriend from 50 years ago called her and is now harassing her by controlling her blood pressure, movements, and thoughts. She is convinced that he was initially doing this through the phone by sending special signals with a device that the CIA uses, but now he is able to control her through his thoughts. She stated that she couldn't tell the police because they probably would not believe her. This patient most likely has which of the following thought disorders?

Delirium (psychotic level disorder -the patient is hallucinating- she has a fluctuating level of consciousness and is disoriented. Also, there is a clear history of a febrile condition that developed rather rapidly, all of which suggest delirium.)

A man brings his 45-year-old wife to the emergency department. He states she has been ill for 3 days and has had a temperature 37.6-38.05° C (99.8-100.5° F). Today she is having difficulty staying awake and talking to persons who are not there. At times, she appears to be frightened of something. She is restless and somewhat combative when restrained. What is the most likely diagnosis?

Dissociative fugue

A man who appears to be in his 20s is brought to the emergency department by the police after being found wandering around a local airport. The patient claims not to know how he got to this city and states repeatedly that everything he sees in the environment is unfamiliar. He has no identification or baggage and cannot remember his name. He is well-groomed and in no apparent distress. His process of thought is logical and he denies any mood complaints or perceptual disturbances. Physical examination, metabolic and toxicology screenings, neuroimaging, and electroencephalography are all within normal limits. Which of the following is the most likely diagnosis?

Somatization Disorder

A mental health care provider on a consult team is asked to see a 32-year-old woman for depression. She was admitted to the hospital for a workup of nausea, vomiting, and abdominal pain. The medical team has so far found no reason for these symptoms. In talking to the patient, the mental health care provider learns that she has had many medical problems and, over the past 10 years, has been in the hospital more than 10 times. She reports having had excessive menstrual bleeding and a miscarriage, as well as difficulty becoming aroused during sexual intercourse. She cannot tolerate high-fiber foods and has heartburn and bloating. Two years ago, she had a lump in her throat and had difficulty swallowing, but nothing was found during that admission. In the past couple of years, she has had frequent migraine headaches and blurred vision and has seen several neurologists. She also hurt her back and now has chronic back pain. Which of the following is the most likely diagnosis?

Gender Identity (a person's sense of maleness or femaleness. The formation of gender identity is based on many cultural influences, physical characteristics, and parental attitudes. The standard and healthy outcome in the development of gender identity is a relatively secure sense of identification with one's biological sex. Individuals may be diagnosed with gender identity disorder when the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.)

An 8-year-old boy is brought to see a child and adolescent health care specialist because of his mother's complaint that he repeatedly states that he wants to be a girl. She also notes that he has always seemed to prefer girls' clothes and frequently gets upset in the mornings when his mother dresses him in typical boy clothes for school. His play activities are characterized by games more frequently enjoyed by girls, and he prefers to play with girls. When his mother reminds him that he is a boy and should act like a boy, he gets upset and sometimes has a temper tantrum. The boy has no significant past medical history, and physical examination is within normal limits. Into which of the following areas is this boy's difficulty best classified?

Wernicke encephalopathy, Korsakoff psychosis (Thiamine--> Then Glucose!)

An alcoholic patient tends to obtain the majority of his or her caloric intake from the alcohol intake and not from nutritious intake of calories. Patients may develop ____________, which will need thiamine to prevent ____________. If the patient is given a sugar load with glucose prior to giving thiamine, exacerbations and Korsakoff psychosis can occur.

Cognitive Behavioral, SSRIs or SNRIs, Benzos

Patients who have panic attacks with agoraphobia are best treated with _______________ Therapy. Medical treatment involves ________ or _________ as first-line treatment. Patients are also given _________ acutely, because it takes several weeks for the SSRIs and SNRIs to become effective.

Tourettes Disorder

Patients with Tourette syndrome have an early childhood onset with a worsening of symptoms in late childhood and early adolescence. Symptoms of ______________ include stereotypical repetitive movements that are accompanied by an urge to perform these movements. There are stereotypical repetitive phonic sounds accompanied by a need to perform those sounds. These patients typically will have an otherwise normal neurologic examination. Symptoms typically worsen under stressful conditions and typically improve when the patient is focused on other tasks

Cocaine (United States occurs in approximately 2% of the adult population. Infants born to cocaine-addicted mothers are small in gestational size (probably because of vasoconstriction of the arteries supplying the fetus in utero), have neurodegenerative abnormalities, have microcephaly, and can have seizures. Detoxification procedures should be done to support the infant after birth during this withdrawal period.)

Pregnant Mothers abusing ___________ cause: Infants are usually small for gestational age (SGA) and sometimes have microcephaly and neurodevelopmental abnormalities. Exposed infants are *very irritable and inconsolable* in the withdrawal period. Their *cries are often high-pitched*. They are also at *increased risk for sudden infant death syndrome (SIDS).* *Periventricular leukomalacia* (a CNS ischemic lesion) is also associated with this exposure.

Alcohol (Fetal Alcohol Syndrome)

Pregnant Mothers abusing ___________ cause: failure to thrive, cardiac defects, facial dysmorphic features (such as narrow forehead, microphthalmia, short palpebral fissures, and micrognathia), and neurologic abnormalities.

Opiate

Pregnant Mothers abusing ___________ cause: high incidence of obstetric complications, such as placental abruption, preterm labor, and fetal growth restriction. +Tremors, irritability, vomiting, and diarrhea present in the neonatal period.

Barbiturate

Pregnant Mothers abusing ___________ cause: limb anomalies, mental retardation, nail hypoplasia, and some dysmorphic features, such as a short nose and a low nasal bridge. It is not usually associated with low birth weight and microcephaly.

Venlafaxine, Duloxtine, Bupropion

SSRIs are considered to be first-line agents used in the management of major depression. They are highly effective and have a strong safety profile. Other first-line agents include *SNRIs* such as ________ (Effexor) and __________ (Cymbalta) and agents that effect *norepinephrine and dopamine* such as __________ (Wellbutrin).

Cocaine

The most commonly abused drug by pregnant mothers is cocaine.st commonly abused drug by pregnant mothers is ___________

Cocaine (especially crack cocaine an extremely potent, freebase form that is sold in small, ready-to-smoke amounts is associated with the withdrawal symptoms described in this case. After cessation of the use of cocaine, or after acute intoxication, a *post-intoxication depression (crash) often occurs*. This depression is associated with dysphoria, anhedonia, anxiety, irritability, fatigue, hypersomnolence, intense craving, and suicidal ideation.)

The mother of a 35-year-old man calls her health care provider for advice on a drug treatment program for her son. She states that he has lived with her since the loss of his job and apartment 4 months ago. She reports that he goes out on weekends and uses drugs heavily. When he returns home, usually on Monday mornings, he sleeps for the entire day and seems very depressed. He is also very irritable and anxious over the course of the next day. She knows of no other withdrawal symptoms. She believes that he uses the drug throughout the week, but with more intense binges on the weekends. On several occasions he has called her from the local psychiatric emergency center after admitting himself for suicidal ideation after use of the drug. Which of the following drugs is most likely responsible for this man's withdrawal state?

Bupropion, 300 (given as 150 mg, 2x daily-->Dosing should begin at 150 mg/day for the first 3 days and should be increased to 300 mg/day thereafter.)

The recommended dosage of ________ for *Smoking Cessation* is _____ mg/day. Initiate treatment while the patient is still smoking and set a target date for smoking cessation after 5-7 days of treatment. Continue therapy for 7-12 weeks. If the patient has not reduced smoking by the 7th week, it is unlikely that he will quit during that attempt, and therapy should be discontinued.

Schizoid personality disorder

These patients enjoy loner activities. More men have this type of personality disorder than women. Personality disorders have a chronic pattern of both internal perception and observable behavior. Patients who have personality disorders are most likely to come to the attention of medical providers when they are treated for another comorbid condition such as depression.

TCA (Imipramine, Clomipramine, Amitryptyline, Doxepine, Nortryptyline, Desipramide)

This Class of Antidepressants- __________- are efficacious in the treatment of depression. They are not currently first-line agents, however, because of their potential lethality in overdose, need for pre-treatment electrocardiographic monitoring, and significant side-effect profile (because of antiadrenergic, antihistaminic, and antimuscarinic effects). These may have a role in chronic pain management.

MAOI (phenelzine [Nardil], tranylcypromine [Parnate], isocarboxazid [Marplan])

This Class of antidepressants- __________- are rarely used and would never be considered a first-line agent. Patients taking these must follow a diet that restricts tyramine because of the potential for a hypertensive crisis when ingested with tyramine-containing foods. Potential lethality in overdose is also a concern. These agents should only be prescribed by practitioners who are very familiar with their use.

Delirium (called acute confusional state. It is very common in hospitalized and institutionalized elderly individuals. It is characterized by a rapid onset of impaired cognition, altered level of consciousness, disturbances in attention and psychomotor activity, and altered sleep-wake cycles. The symptoms tend to fluctuate and it is usually reversible when the underlying disorder is identified and treated.)

Three hours after an uneventful appendectomy, a previously healthy (except for appendicitis) 78-year-old man becomes disoriented and confused. He repeatedly asks the nurses where he is, and his speech pattern is disorganized and rambling. His temperature is 37º C (98.6º F), blood pressure 120/80 mm Hg, pulse 70/min, and respirations 18/min. The patient is uncooperative but shows no physical abnormalities. Mental status examination is not possible because of an altered level of consciousness. Laboratory studies show no abnormalities. Which of the following is the most likely diagnosis?

SSRI and Cognitive Behavioral Therapy

What is the first line therapy for Social Phobia? ___________ and ____________

Fugue (the person has an abrupt change of geographic location or identity without alterations in consciousness or memory changes.)

Which of the following disorders is most likely to be missed even by someone experienced in managing patients with psychiatric disorders?

Echolalia

________- is the psychopathologic repetition of words or phrases of one person by another, and tends to be repetitive and persistent.

Echopraxia

_________- is the pathologic imitation of movements of one person by another.

Cocaine

__________ withdrawal is characterized by dysphoria, anhedonia, anxiety, irritability, fatigue, hypersomnolence, intense craving, and suicidal ideation.

Cognitive therapy

__________- can be utilized in the management of several psychiatric conditions such as major depression, anxiety disorders, phobias, and distortions of self with low self-esteem. It can be used in concert with medical therapy and can be used to help the patienst to gain insight into their psychiatric issues so that thought redirection can be made.

Thought blocking

__________- is a term used to describe a process by which a patient starts a conversation, stops, and then restarts the conversation about a totally unrelated topic. It is a feature that can occur in schizophrenia and some other psychotic disorders. Patients may also have verbigeration, in which they have a repetition of words in the absence of stimuli, and perserveration, which is a repetition of the same response to different stimuli.

Conduct disorder

__________- is defined as a repetitive pattern of behavior in which the basic rights of others or major age-appropriate societal rules or norms are violated, often with accompanying aggression to people and animals, destruction of property, deceitfulness, or theft. Patients who have this disorder may be diagnosed with antisocial personality disorder as adults.

Satyriasis

__________- is the excessive and compulsive need for coitus in a man. Its corollary in a female is termed nymphomania.

Fugue

__________- the person has an abrupt change of geographic location or identity without alterations in consciousness or memory changes. Pt will leave an area and assume a new identity in another location. Except for the concept of self, the patient is fully alert and able to answer questions appropriately. Because the patient is acting appropriately, it is difficult for a health care provider to identify this condition unless the patient's previous identity was known.

Benzodiazepine

___________ withdrawal can range from tremulousness, diaphoresis, hyperreflexia, elevated blood pressure, pulse, and respiratory rates, and anxiety, to altered mental status, hallucinations, autonomic instability, seizures, and possibly death.

Ideas of reference

___________- are delusions in which a person has a false belief that others (including people on TV or radio) are talking about him or her. In a broader sense, the behavior of others refers to oneself, other persons, or objects that have special significance and meaning.

Autistic disorder

___________- is a pervasive developmental disorder starting in early childhood. It is manifested by qualitative impairment in social interaction, communication, and restricted repetitive and stereotyped patterns of behavior or interests. Delay or abnormal functioning with onset before 3 years of age is seen in the areas of social interaction, language, and communication or symbolic play.

Delirium

___________- is an acute, fluctuating change in mental status that is associated with inattention and fluctuating levels of consciousness. It is a potentially life-threatening disorder. It is seen most often in hospitalized elderly patients. By definition, patients need to have a disturbance in consciousness (reduced clarity of the environment), abrupt change in cognition, and acute presentation of condition that is caused by a general medical condition, substance abuse, or substance withdrawal.

Buspirone

___________- is an anxiolytic medication that has NOT been shown to be effective in the treatment of panic attack. It usually has a delayed onset of activity, and patients with panic disorder need to have medications that can work with a first-dose effect.

ADD (Attention deficit disorder)

___________- is more frequently seen in males and is characterized by inattention, hyperactivity, or impulsivity persisting at least 6 months. The symptoms cause significant impairment in social, academic, or occupational functioning. The symptoms are not caused by any pervasive developmental disorder or other mental disorder.

Flumazenil (Romazicon)

___________- is used to treat benzodiazepine overdose.

Tourettes

____________ Disorder- belongs to the group of tic disorders with onset before age 18. It is more common in boys. Multiple motor and vocal tics are present during the illness many times a day, every day for more than a year. The patient must not have had a tic-free period for more than 3 months. The disturbance is not caused by a general medical condition or effects of substance. Coprolalia and echolalia typically occur later.

Anticholinergic

____________ symptoms, such as dry mouth, blurred vision, constipation, and weight gain, usually appear early in the course of treatment, and the patient becomes tolerant to these effects.

Clozapine (Clozaril)

____________- Its most serious side effect: agranulocytosis. Cardiomyopathy and myocarditis are also known side effects of this medication. It requires regular blood count monitoring because of this serious but rare side effect.

Dissociative fugue

____________- disorder is a condition in which patients will have prolonged psychogenic amnesia with a sudden loss of personal identity and with events regarding the personal past. At the same time, patients can recall other memories and learn new material; they may be able to function at a high level as long as their identity is not being threatened by their lack of remembering who they are and how they got to a certain point in their lives. These episodes last hours to days but could last weeks to months wherein the person may take on a new identity. Upon recovery, the patient has residual amnesia for the fugue state.

Munchausen syndrome

____________- involves more elaborate and deliberate mimicking of medical conditions. These symptoms are voluntarily produced. The aim of producing these symptoms is typically to get attention that the sick role will produce.

Akathisia

____________- is a condition in which the person feels compelled to keep moving and is constantly restless. It is usually well controlled by reduction of the dose of antipsychotic medication and the addition of beta-adrenergic receptor antagonists or anticholinergic drugs and benzodiazepines. It can occur early in the course of treatment.

Oppositional defiant disorder

____________- is a disorder of childhood consisting of a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which at least 4 of the following symptoms must be present: loss of temper, arguments with adults, blaming others for one's own mistakes, deliberately annoying others, and refusing to comply with rules

Dissociative identity disorder

____________- is a dissociative condition that is defined by the presence of *multiple discrete personalities* that manifest in the same individual. This patient does not demonstrate evidence of multiple distinct personalities.

Tardive dyskinesia

____________- is a result of long-term treatment with neuroleptic medications and is seen more frequently in older women. The condition presents with abnormal choreoathetoid movements, often involving the face and mouth in adults and the limbs in children. Once it develops, there is no known treatment to mitigate the symptoms. In order to prevent this long-term sequela, patients may be placed on a *drug holiday* or are placed on the smallest effective dose in order to control symptoms.

Generalized anxiety disorder

____________- is characterized by excessive worrying about real life circumstances and physical signs of anxiety such as tension headache and fatigue. This does not apply to the patient's presentation.

Somatization Disorder

____________- is characterized by multiple medical complaints resulting in significant diagnostic testing and medical interventions and causing impaired social and occupational functioning. The *symptoms cannot be explained* by medical findings, include pain in at least 4 sites, one pseudoneurologic symptom, one sexual dysfunction symptom, and at least two or more GI symptoms.

OCD (Obsessive-compulsive disorder)

____________- is characterized by recurrent intrusive thoughts or impulses that cause stress. The person unsuccessfully attempts to ignore or neutralize through action the recurrent thoughts or impulses, even though he or she is aware that those thoughts are the product of his or her own mind. Compulsions are repetitive behaviors that the person needs to perform as a result of obsessions or to decrease the stress related to intrusive thoughts. The disorder causes significant impairment in everyday functioning and is not caused by other psychiatric or medical conditions.

Naltrexone (Revia)

____________- is used in opioid detoxification and significantly shortens the detoxification time when combined with Clonidine. It is a long-acting oral opioid antagonist that is also used in helping to maintain abstinence for up to several months

Somatization Disorder

_____________ Dx- The physical complaints are usually vague and not adequately explained by a physical disorder. Formal criteria for the diagnosis have been defined and include onset before age 30, symptoms involving at least 4 different body parts, two or more GI symptoms, at least one reproductive or sexual symptom, and at least one neurologic symptom other than pain. Patients may have coexistent personality disorders, notably histrionic, borderline, and antisocial. Treatment is difficult, and the condition tends to wax and wane throughout life. Suicide is a definite risk with overtly depressed patients who have longstanding disease.

Cocaine

_____________ intoxication leads to short-term states of autonomic arousal. Chronic use can harm the heart with scarring and myocardial hypertrophy (to overcome high blood pressure and systemic vascular resistance). The intoxication can lead to lethal arrhythmias and sudden death. Prolonged QT intervals can also occur as the normal heart repolarizing process is upset. Chest pain related to use is a common complaint seen in emergency medicine practices but rarely causes acute myocardial infarction unless there is pre-existing pathology. Mental status changes can include "excited delirium" with an agitated confusional state that can be associated with lethal hyperthermia.

Haldol

_____________- is a conventional high-potency antipsychotic agent that would be likely to cause EPS such as dystonia.

Brief psychotic disorder

_____________- is characterized by the abrupt onset of psychotic symptoms, including hallucinations, delusions, and disorganized thinking with impaired functioning. It is present for more than 1 day, but less than 1 month. It is usually preceded by a stressful life event.

Generalized anxiety disorder

_____________- is defined by an unrealistic or excessive worry about activities or life events lasting at least 6 months. In addition, 6 of the following types of symptoms must be present: fatigability, muscle tension, irritability, troubles falling or staying asleep, difficulty concentrating, and restlessness. The symptoms cause significant impairment in everyday functioning.

Lorazepam

_____________- is, a benzodiazepine. It is commonly used in the acute management of severe anxiety and agitation.

Generalized anxiety disorder

_____________-is a mental condition in which the patient experiences chronic, excessive worry for at least 6 months that causes impairment in functioning. To meet the criteria, patients should have restlessness or nervousness, easy fatigability, poor concentration, irritability, muscle tension, or sleep disturbance. Treatment involves cognitive behavioral therapy. For patients who need additional medication, SSRIs are considered the medication of choice.

Dissociative fugue

_____________-is a rare dissociative disorder involving sudden travel and amnesia about one's identity or the circumstances preceding arrival at one's destination. The etiology is unknown, though a correlation with recent life stressors may exist. The condition is usually self-limited. Patients are clear mentally except for who they are and how they arrived at the place where they are found to be lost.

somnambulism

_____________-the patient walks while asleep. These patients are unresponsive to outside persons or questions.

Heroin

______________ withdrawal includes myalgias, nausea, vomiting, diarrhea, lacrimation, rhinorrhea, piloerection, anxiety, insomnia, irritability, and intense craving.

Neuroleptic malignant syndrome

______________- is a life-threatening condition that can occur at any point in treatment with Antispychotics. It is characterized by muscle rigidity, hyperpyrexia, and increased blood pressure. Bromocriptine (Parlodel) and dantrolene (Dantrium) are used to treat this disorder.

Alprazolam

______________- is a short-acting, high-potency benzodiazepine commonly used for the short-term management of anxiety.

Somatization disorder

________________-is a non-intentionally produced condition that is commonly seen in primary care practice. These symptoms cannot be explained from a physiologic standpoint and multiple tests reveal no organic cause or explanation for these symptoms. Despite these symptoms not having a readily explainable cause, patients are not reassured of their benign nature regardless of the negative workup of these symptoms. If the patient is reassured that this is a benign constellation of symptoms, the symptoms typically will abate with time. Risk factors for this condition include female sex and having a history of sexual abuse. Multiple body systems are involved.

Dysthymic Disorder

a mild, chronic form of depression. In adults, the diagnosis requires 2 years of a depressed mood, whereas in teens and adolescents it requires 1 year of symptoms to meet this criteria. Teens may manifest with irritability rather than depression. The condition may be associated with changes in appetite, sleep, and concentration, and with fatigue and hopelessness. Treatment is *psychotherapy and antidepressant therapy.*

Obsessions

are pathologically persistent intrusive thoughts or impulses that cannot be eliminated from consciousness by logical effort and thus cause anxiety. The person is aware that they are not imposed from the outside but are a product of his or her own mind.

Antisocial personality disorder

is a pattern of behavior that is characterized by a complete disregard for the rules of society. These individuals lie, steal, and endanger others. They rarely feel remorse and typically end up in prison.

Antisocial Personality Disorder

is characterized by a repetitive disregard for the rules and laws of society. These patients rarely experience remorse. It is more common in men. More than half of these men have been arrested. It is the adult equivalent of conduct disorder.

Somatoform Disorder (include both Conversion D/p and Somatization)

patients experience distressing physical symptoms that are not fully explained by other medical or psychiatric disorders. These symptoms occur from psychologic stress that is unconsciously expressed in a physical way. Risk factors include being female, having been abused or at least having a lot of childhood difficulties, and difficulty expressing emotions. These symptoms can lead to significant functional impairment and distress. Diagnosis is made after evaluating the patient for an explainable physical cause. Treatment is primarily done with cognitive behavioral therapy.

Noesis

refers to the feeling of revelation in which a person experiences illumination associated with a sense of being chosen as a leader.