Psych Pearls

AVH Paranoia Depersonalization Dissociation Catatonia

Spice can cause what type of psychosis?

Amitriptyline

Nortriptyline is an active metabolite of which TCA?

Serotonin

Obsessive-compulsive disorder is associated with abnormality of which one of the following neurotransmitters? A. NE B. Serotonin C. Melatonin D. Acetylcholine E. Dopamine

It makes you stop thinking so much about the stuff that makes you anxious (decreases ruminations) making it a little easier for you to handle it.

What does an SSRI do for anxiety, in layman's terms?

Preserved response to noxious stimuli

The persistent vegetative state is not characterized by which one of the following? A. Preserved eye opening B. Preserved response to noxious stimuli C. Preserved eye tracking D. Preserved swallowing E. Preserved sleep-wake cycles

Substance-induced mood disorder

A 21-year-old patient experiences a single brief manic episode after initiating an SSRI for low mood, anxiety at work, and difficulty concentrating. At this point, the patient meets the diagnostic criteria for which of the following? A. Bipolar II disorder B. Cyclothymic disorder C. Substance-induced mood disorder

The relative does require to achieve a certain effect

The potency of medication refers to what property of that medication?

Anti-phospholipid

The presence of which antibodies has been most consistently shown to substantially increase the risk of Neuropsychiatric symptoms in lupus?

Competence

The primary psychological task of school-age children is achieving which of the following? A. Identity B. Autonomy C. Attachment D. Competence E. Individuation

Trails

Which of the following tests primarily measures flexibility and shifting cognitive sets? A. Trails B. Boston naming C. Digits backwards D. Rey complex figure E. Pantomime use of objects

Oral contraceptives containing estrogens decreased serum levels of Lamotrigine

A 26 year old, sexually active woman with bipolar 2 disorder, agrees to a first time trial of Lamotrigine. Before deciding on a target dose, her psychiatrist asks what kind of contraception she use. What is the reason for asking this question?

1-40 mg/day Can give up to 100 mg/day. However, Haldol is frequently dosed too high. Higher doses may actually worsen negative symptoms (blocks D2 receptors in mesolimbic pathway thus worsening negative and cognitive symptoms)

Usual dosage range for Haldol?

No, some people can't be hypnotized Hypnotizability is a measurable trait and some are more likely than others. There are no significant EEG differences between hypnotic state and the awake state.

Do all normal adults have the capacity to be hypnotized? Can hypnotizability be measured? What EEG changes do you get in hypnosis?

Usually not. They either lack insight (psychosis) or enjoy it (mania). More likely to be feigning but not always

Do manic/psychotic people ask for meds?

Yes, you should slowly do it over 6-8 weeks. I'd done too rapidly, may worsen symptoms or lead to rebound psychosis

Do you have to down-titrate Haldol when you discontinue it?

No, you may have to give IV for more serious withdrawal symptoms like extreme agitation, seizures, DT

Do you only give BZDs orally for alcohol withdrawal?

Zoloft

Does Zoloft or Prozac cause more weight gain?

Psychological dependence can develop after a single use. It's a powerful positive reinforcer of behavior Some physiological dependence may occur which can result in a mild withdrawal

Does cocaine cause dependence and withdrawal?

It does not pose a HIGH RISK of dependence and abuse according to an expert panel. But yes to withdrawal symptoms Kinda confusing in my opinion but begs the question whether I fear BZD too much or is this a ploy by big pharma

Does long-term use if BZDs for treatment if anxiety disorders pose a high risk of dependence and abuse? What about withdrawal symptoms?

Nonetheless, using the moderate sizes of drinks, clinicians can estimate that a single drink increases the blood alcohol level of a 150-pound man by 15 to 20 mg/dL, which is about the concentration of alcohol that an average person can metabolize in 1 hour.

An average drink will increase the blood alcohol concentration in a person by how much? How long does it take to metabolize an average drink?

Sedatives

An increase in the relative amount of beta frequency in an awake EEG may be explained by the effects of which of the following types of medications? A. Antipsychotics B. Sedatives C. Anti-depressants D. Stimulants E. Cognitive enhancers

Medroxyprogesterone acetate It is useful in any sexual disorder in which the patients are extremely hypersexual to the point of being out of control or dangerous

A 30-year-old male is brought to the emergency room after being arrested for exposing his genitals to women on the train. He states that he has impulses to expose himself that he can't control, and that he finds the whole experience very sexually exciting. Which one of the following medications would be an appropriate treatment for this patient? A. Medroxyprogesterone acetate B. Lorazepam C. Ziprasidone D. Duloxetine E. Chlorpromazine

Persons with opioid dependence seldom die from opioid withdrawal, unless they have a severe preexisting physical illness such as cardiac disease

Does opioid withdrawal result in death?

D

A 30-year-old man on imipramine complains of difficulty urinating and impotence. What should his doct A. Increase the dose of imipramine B. Tell the patient to decrease fluid intake C. Tell the patient to stop all sexual activity D. Prescribe bethanechol E. Prescribe melatonin

Social anxiety disorder

An individual utilizes cash transactions for all purchases, including large purchases such as major appliances and automobiles. This behavior is the result of substantial discomfort writing checks or signing credit card receipts in the presence of others due to what the individual perceives as embarrassingly messy handwriting. What is the most likely diagnosis?

Order a pregnancy test

36-year-old female with schizophrenia who has been treated with olanzapine is discovered to have a prolactin level of 354 ng/ml (normal: 3-30). Which of the following action should be taken first? Order an MRI scan Recheck prolactin level in one month Check the olanzapine level Order bone densitometry Order a pregnancy test

Antisocial personality disorder

An interpersonal psychodynamic group compromised of people with heterogenous diagnoses and levels of functioning has room to take a new member. When considering patients to refer to the group, which if the following diagnoses would be a relative contraindication? A. Bipolar disorder B. MDD C. Antisocial PD D. Dependent PD C. Narcissistic PD

Uncommon psychotic side effects of mefloquine

A 34-year-old patient is being treated for malaria after returning from a trip to Kenya. The patient has a history of schizoaffective disorder, which has been well-controlled for more than a decade with a combination of risperidone and lithium. The patient is given a single dose of mefloquine, however after one week the patient reports feeling anxious. This escalates over the next week to psychomotor agitation and persecutory delusions. The most likely cause of the patient's psychotic symptoms is what?

No change in neuronal density

Anatomical studies of neuronal sell density and schizophrenia consistently show what?

A

5. Which one of the following statements is true regarding atypical antipsychotics? A. Ziprasidone is an agonist at the serotonin (S-HT) 1A receptor and an inhibitor of reuptake of both serotonin and norepinephrine B. Risperidone is a significantly weaker antagonist of the dopamine D2 receptor than haloperidol C. Quetiapine is known for its high incidence of extrapyramidal symptoms D. Olanzapine has been associated with weight loss in the majority of patients E. Clozapine has been shown to increase suicidality in chronically ill patients

After 4 months

50% of patients taking BZD develop tolerance after how long of being on the med?

Thiamine

55-year-old patient undergoes a gastric bypass surgery and several weeks later, develops gait ataxia and diplopia. Family members report that the patient has been confused, and attentive, and apathetic. On examination, the patient has decreased eye movements in all directions, prominent horizontal nystagmus and marked difficulty with tandem walking. These findings are consistent with a deficiency of what?

C

A 10 year old with attention-deficit hyperactivity disorder (ADHD) and a long history of aggressive outbursts is evaluated by the psychiatrist. Since starting a moderate dosage of a stimulant medication, the ADHD symptoms have improved but the impulsive aggression has not. In addition to providing behavioral intervention, which of the following is the best step for the psychiatrist to take next in order to manage both the child's ADHD and aggression? A. Continue stimulant and add an atypical antipsychotic B. Discontinue stimulant and start atypical antipsychotic C. Maximize dosage of a long-acting stimulant chi D. Discontinue stimulant and start divalproex E. Continue stimulant and add clonidine

Inhalants

A 15-year-old patient is brought to the ER by friends due to aggression and impaired judgment while intoxicated. On examination, the patient has a mild tremor, nystagmus, slurred speech, unsteady gait and hypoactive deep tendon reflexes. The patient complains of dizziness and appears uncoordinated. Which substance did the patient most likely use?

Schizotypal

A 16-year-old adolescent is being evaluated for possible schizophrenia. A family history of which of the following personality disorders is most strongly associated with this diagnosis? A. Avoidant B. Paranoid C. Schizoid D. Borderline E. Schizotypal

Energy drinks

A 17-year-old patient is brought by family to the emergency department due to severe symptoms of restlessness, nervousness, facial flushing, muscle twitching, and tachycardia. Family became most concerned on the patient began to have rambling flow of thought and speech, and was becoming agitated. The patient has most likely been drinking a large quantity of: A. Ginger ale B. Sarsaparilla C. Energy drinks D. Ginseng soda E. Pomegranate juice

Ciprofloxacin It Inhibits cytochrome P450 enzymes involved in the metabolism of methadone

A 35-year-old patient who has been stabilized on methadone maintenance treatment for five years is brought by family to the ER due to the patient's lethargy and confusion. During assessment, the patient becomes obtunded with respiratory depression. The family reports that the patient recently began a new medication. Which of the following medications is most likely to be responsible for the patient's symptoms and why? A. Risperidone B. Ciprofloxacin C. Spironolactone D. Carbamazepine E. Saint johns wort

Paranoid personality disorder

A 43-year-old patient seeks psychotherapy after his wife threatens to divorce him due to his constant accusations that she is having affairs. The patient acknowledges monitoring his wife's emails and text messages, and tracing phone calls from numbers he does not recognize on their home phone. The patient asserts that all of the couple's friends are "on my wife's side" and refuses to confide in them due to doubts about their loyalty, and belief that shared information will be used against him in divorce proceedings. The patient also refuses communication with his brother who suggested marital therapy several years ago. The patient has no changes in sleep, appetite or energy level. What is the most likely diagnosis?

Magnesium

A 54 year old patient who takes Prozac 60 mg daily for MDD is evaluated for worsening migraines. The patient calls the psychiatrist several days later and reports fever, diarrhea and feeling that "my muscles are tightening up." Which of the following medications is most likely to cause these symptoms when taken with Prozac? A. Atenolol B. Ibuprofen C. Magnesium D. Sumatriptan E. Acetaminophen

Amantadine

A 60-year-old patient with chronic schizophrenia who takes Benztropine for neuroleptic induced parkinsonism has begun to develop increasing urinary retention and confusion. What are the following medications would be the best alternative for treating the patient's condition? A. Amantadine B. Trihexyphenidyl C. Clonazepam D. Gabapentin E. Propranolol

Primidone

A 65-year-old patient with a history of asthma presents for treatment of essential tremor. What is the most appropriate first line therapy?

Apathy

A 71 year old patient who was diagnosed with Parkinson's disease three years ago is brought to the clinic for changes in mood and thinking. The patient's motor symptoms are well-controlled on carbidopa/levodopa. The patient's spouse states that the patient has trouble getting up and motivated to do anything, and the patient does not expressed interest in attending social events. There has also been a recent slowness in the patient's thinking, with the symptoms remaining stable throughout the day. There are no reports of sadness, worthlessness, or suicidal ideation. Cognitive evaluation is unremarkable except for slow processing. What is the most likely explanation for the patient's symptoms?

Ramelteon It's a melatonin receptor agonist

A 78-year-old patient with a medical history significant only for mild dementia complains of chronic difficulty falling asleep. Sleep hygiene training has not been helpful, and a number of sleep medications, including temazepam and zolpidem were discontinued because they caused daytime sedation and confusion in the patient. Which of the following medications is most likely to be helpful for this patient while causing the fewest side effects? A. Trazodone B. Ramelteon C. Mirtazapine D. Quetiapine E. Diphenhydramine

D

A 91-year-old hospice patient with severe cachexia, end-stage dementia, and renal impairment has stopped eating and drinking. Which of the following comfort measures would be most appropriate? A) Total parenteral nutrition B) IV hydration C) NG tube feeding D) Frequent small sips of water E) Appetite-inducing medications

Lithium can cause some people to feel as if their thinking has slowed down or "feel numb"as side effects

A bipolar patient on lithium shows good response in stabilization of mood but reports feeling dull, slow, and unable to concentrate. Why is this happening?

Evidence shows that infants are hard more by having a depressed mother than being exposed to Sertraline

A breast-feeding patient taking sertraline wants to test her breast milk and the babies blood for levels of the drug. The position explained to the patient that testing is not indicated. What is a rational for the physicians advice?

Learned helplessness Learned helplessness is a behavioral model for depression developed by Martin Seligman. He took dogs and gave them electric shocks from which they could not escape. Eventually they gave up and stopped trying to escape. In time this spread to other areas of functioning, until they were always helpless and apathetic. This behavioral pattern has also been seen in humans with repeated setbacks or failures in their lives, as the question stem demonstrates.

A child in school fails test after test. No matter how hard he studies, he fails. Over time he views himself as destined to fail and stops trying. Which one of the following theories best applies to this child's situation? A. The epigenetic principle B. Industry theory C. Cognition theory D. Learned helplessness E. Sensory deprivation Explain

B In disinhibited social engagement disorder, a child actively approaches and interacts with unfamiliar adults. There is reduced or absent reticence in approaching unfamiliar adults, overly familiar verbal or physical behavior, diminished or absent checking back with adult caregivers after venturing away even in unfamiliar settings, and a willingness to go off with unfamiliar adults with minimal or no hesitation. These behaviors are not limited to impulsivity, as would be found in ADHD. The child has experienced a pattern of insufficient care, such as social neglect or deprivation, repeated changes of primary caregivers that impair formation of stable attachments, or rearing in unusual settings that severely limit opportunities to form selective attachments. In reactive attachment disorder the patient would be the opposite of what was described in the musion. He or she would have a pattern of inhibited, emotionally withdrawn behavior toward aduls and can al social or emotional responsivenes to others. However, he or she would share a history of insufficient care characterized by social neglet or deprivation, change in primary caregivers, or rearing in unusual settings

A child who actively approaches and interacts with unfamiliar adults after experiencing social neglect or deprivation is most accurately diagnosed as having: A. Posttraumatic stress disorder B. Disinhibited social engagement disorder C. Reactive attachment disorder D. Attention deficit hyperactivity disorder E. Rumination disorder

I cannot be trusted to make good decisions

A college student who does well in classes repeatedly seeks reassurance and advice from parents, friends, and roommates. The students roommates become exacerbated after the fourth question about the font the student is using in a presentation. If the excessive reassurance - seeking is a compensatory strategies, what core belief might this student have?

Imipramine

A patient with panic disorder has failed trials with two different selective serotonin reuptake inhibitors (SSRIs). Which of the following medications should be tried next? A. Bupropion B. Imipramine C. Mirtazapine D. Gabapentin E. Phenelzine

Long term abstinence would reduce risk significantly

A female patient who drinks alcohol lightly (1 standard drink a day) is concerned about cancer risk after her father, who was a heavy drinker leveloped an aggressive, upper digestive tract tumor. She Wants to now if she should stop drinking to decrease her risk of cancer. Which of he following statements in the best evidence-based response? A. Only male drinkers are at risk. B. Only heavier drinking elevates risk in women C. Long-term abstinence would reduce risk significantly D. There is no association between alcohol use and risk E. Light use is not associated with elevated risk in either gender.

Cocaine

A neonate exhibited transient hypertonia, hyperreflexia, irritability, and tremors at birth. This phase was followed by a period of depressed interactive behavior and poor response to environmental stimuli. Use of which drug by the child's mother is suggested by this presentation?

Cocaine withdrawal Since cocaine blocks dopamine reuptake and prolactin secretion is regulated, in part, by dopaminergic inhibitory mechanisms, cocaine withdrawal may induce rebound supersensitivity of prolactin secretion. Findings obtained in this study suggest that cocaine-related derangements in prolactin secretion may be a biologic marker of a protracted cocaine abstinence syndrome.

A non-pregnant, premenopausal patient in the emergency department complains of galactorrhea and is found to have elevated prolactin levels. The patient insists that she has never had a seizure, nor has she ever taken antipsychotic drugs. Which of the following conditions could explain this result? A. Depression B. Anorexia nervosa C. Cocaine withdrawal D. Heavy cannabis use E. Hypoactive sexual desire disorder Explain the pathophysiology of the answer

Classical conditioning

A patient experiences a severe GI virus after eating meat loaf. The patient subsequently develops a strong aversion to meat loaf despite knowing that the meal had nothing to do with the virus. This is an example of what?

Cimetidine

A patient in a methadone maintenance program who has recently begun taking a medication for reflux presents with increased sedation. Which of the following medications was most likely recently started? Cimetidine Esomeprazole Omeprazole Ranitidine Sucralfate

Tics

A patient in the movement disorder clinic is evaluated for complaints if involuntary movements in the upper extemrires which are described as sudden jerks, sometimes preceded by an urge to move. The movements are followed by a sense of relief. Thae movements are best characterized as?

Disulfiram

A patient is brought to the ED after a syncopal episode with hyperthermia, headache, Flushing, and tachycardia. The patient has significant hypertension require fluid resuscitation. According to family, the patient has a history of schizophrenia, GAD, and alcohol use disorder. An interaction with which of the following medications is most likely to have caused the patient's symptoms? A. Amitriptyline B. Disulfiram C. Fluoxetine D. Haloperidol E. Lorazepam

Wait about two weeks then start tapering (500 mg tapered per day). If however, the patient worsens then continue the Depakote

A patient is on Depakote for Bipolar disorder. His mood hasn't been stabilized with it and you start Lithium. When should you taper Depakote?

Dissociative identity disorder Dissociative identity disorder (DID), formerly known as multiple personality disorder, is a complex, chronic condition characterized by disruption in autobiographical memory and in the sense of having a unified identity. The disorder has been most commonly conceptualized as originating in the context of severe trauma during the patient's childhood. Dissociative identity disorder (DID) is one of several dissociative disorders. Dissociation has been defined as a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior [1]. When one or more of these functions are disrupted, characteristic impairments can be seen in these functions: ●Consciousness - Impaired consciousness is characterized by decreased responsiveness to external stimuli. ●Memory - Memory impairment, referred to as "dissociative amnesia," affects the ability to recall autobiographical information, which is often of a traumatic or stressful nature. ●Identity - Dissociation can cause confusion about or discontinuities in one's identity. ●Awareness of body, self, or environment - Symptoms of impairment include depersonalization and derealization. Patients with DID may report somatoform symptoms - physical symptoms that suggest a general medical illness that cannot be explained by a presence of a general medical condition, substance use, or other mental disorder. Many individuals with DID report auditory hallucinations, for example, a voice giving suggestions or commands. The hallucinations have been described as chronic and typically present since childhood [90]. These hallucinations may reflect autohypnotic phenomena, rather than a psychotic process - they have been conceptualized as representing communication among dissociated states. This is consistent with reports that they are typically unaffected by antipsychotic medication

A patient presents for evaluation of "memory problems." The patient reports frequent episodes of ending up somewhere with her any memory of getting there. The patient also occasionally forgets how to perform job functions, and has gaps in memories of high school. In Addition, the patient endorses the occasional experience of observing the self from outside of the body, and notes periods of being suddenly overcome by unexpected emotions. Recently the patient began hearing a child's voice. Which of the following is the most likely diagnosis? A. Malingering B. Dissociate amnesia C. Dissociative identity disorder D. BPD E. Depersonalization/derealization disorder? Describe the answer

Dissociation

A patient presents to the ER after witnessing a tragic motor vehicle accident in which an individual was killed. Presence of which of the following symptoms immediately following the event would increase the patient's risk of ultimately developing PTSD? A. Depression B. Dissociation C. Intense fear D. Low level of arousal E. Inability to stop thinking about the incident

Phenelzine Increased appetite, weight gain, and increased sleep make this question a case of atypical depression. The treatment of choice for atypical depression is the monoamine oxidase inhibitors (MAOIs). As such, phenelzine is the answer, because it is the only MAOI listed.

A patient presents with decreased energy, increased appetite, weight gain, increased sleep, decreased mood, lack of interest in usual activities, and social withdrawal. Which one of the following medications would be the best choice to treat him? A. Citalopram B. Lithium C. Desipramine D. Phenelzine E. Venlafaxine

B Ganser syndrome is a rare dissociative disorder characterized by nonsensical or wrong answers to questions and other dissociative symptoms such as fugue, amnesia or conversion disorder, often with visual pseudohallucinations and a decreased state of consciousness.[1] The syndrome has also been called nonsense syndrome, balderdash syndrome, syndrome of approximate answers, hysterical pseudodementia or prison psychosis.

A patient who is not malingering but is believed to be producing the symptoms and signs of confusion or dementia involuntarily or unconsciously and believes that the symptoms are real is thought to have which one of the following conditions? A. Conversion disorder (functional neurological symptom disorder) B. Ganser's syndrome C. Capgras' syndrome D. Illness anxiety disorder E. Folie-à-deux Explain

Switch to methadone prior to surgery

A patient who takes buprenorphine is admitted following a motor vehicle accident and requires surgery to repair a femur fracture. Which of the following is the most appropriate step in treatment of the patient's pain? A. Continue buprenorphine at a lower dose. B. Switch to methadone prior to the surgery. C. Switch to an NSAID D. Continue buprenorphine at maintenance dose. E. Discontinue pain medication and treat withdrawal symptoms symptomatically.

25 mg Daily and follow standard initial titration schedule

A patient with bipolar disorder has been clinically stable on lamotrigine 200 mg daily for the past six months. The patient contacts the psychiatrist to request a refill of lamotrigine, explaining that, "I ran out five days ago but kept forgetting to call." The patient denies any mood symptoms or physical complaints. What is the most appropriate next step to restart the Lamotrigine?

Vitamin B1

A patient with known alcohol dependence presents to the emergency department with confusion, ataxia, nystagmus, and ophthalmoplegia. High doses of which vitamin could have prevented the syndrome?

A complete blood count (CBC) would be the first test to order because of the risk of significant side effects on the hematopoietic system. Carbamazepine can cause decreased white blood cell count, agranu-locytosis, pancytopenia, and aplastic anemia. Carbamazepine also has a vasopressin-like effect and can cause water intoxication and hyponatremia. Carbamazepine interacts significantly with the cytochrome P450 system and as such has many interactions with many drugs. Great care should be taken when prescribing carbamazepine with other medications.

A patient you put on carbamazepine has weakness and a rash. Which laboratory test would you order first? A. Liver profile B. Electrolytes, blood-urea-nitrogen (BUN), creatinine, glucose (Chem-7) C. Complete blood count D. Thyroid function tests E. Venereal Disease Research Laboratory (VDRL)

B

A psychiatrist has diagnosed a patient with MDD. The treatment plan includes antidepressant medications provided by the psychiatrist and interpersonal therapy provided by a psychologist. In this situation, responsibility and accountability rests with the psychiatrist: A) for medication treatment only and the psychologist for psychotherapy only B) for all treatment and the psychologist for psychotherapy only C) and the psychologist equally for medication treatment and psychotherapy

Actual Medical condition

A psychiatrist is asked to see a general medical inpatient for reported hypochondriacus. What is the most important differential diagnostic consideration?

A Only the medical chart should be turned over to the court. The law treats the medical chart separately from psychotherapy notes. The medical chart is the official record of the patient's care. The patient has a right to see it, and it can be subpoenaed into a legal proceeding. Psychotherapy notes belong to the therapist. They are the therapist's own notes to him- or herself that serve as a reminder of the details of the sessions. They are not considered part of the medical record and are not part of the official record of care. As such, they cannot be subpoenaed. They should not be turned over in this situation. Although it is always a good idea to get signed permission from the patient to release records, when presented with a subpoena from a court you do not have the right to withhold the records from the court. However, you should not release anything more than is specifically requested.

A psychiatrist keeps a medical chart and a separate set of psychotherapy notes for one of her patients. The patient's records are subpoenaed by a court. Which of the following is true? A. The medical chart only must be turned over to the court B. Both the medical chart and the psychotherapy notes must be turned over to the court C. Only the psychotherapy notes should be turned over to the court D. Neither record should be turned over unless a HIPAA (Health Insurance Portability and Accountability Act) release is signed by the patient E. The psychotherapy notes should be turned over to the court only if specifically subpoenaed EXPLAIN

Dopaminergic

A researcher is involved in testing a new environmental pollutant found to be a neurotoxin. After injecting the agent into the experimental animal brain, the levels of tyrosine hydroxylase dramatically decrease. Which type of neuron is most likely to be impaired by this neurotoxin?

Corpus Callosum

A right handed patient with a history of intractable seizures underwent neurosurgical treatment. In follow-up testing, the blindfolded patient was unable to name objects placed in the left hand, but had no difficulty naming the objects when they were displayed on the screen. What was the site of the surgical intervention?

Latency

A school each boy does well academically but most of his energy is channeled at the basketball and he states that he hopes to become a professional baseball player. It is us girls at school but mostly plays with boys. Which of Freud psychosexual stages of development do these characteristics correspond?

Reading with the child

A seven-year-old child is referred for a psychiatric evaluation due to difficulties learning. The information that would be most helpful is the family's approach to and history of: A. Discipline and a child rearing B. Occupational achievement C. Reading with the child D. Psychiatric disorders E. Daycare and preschool

Resolves spontaneously by adulthood

A six-year-old child prefers opposite gender clothing and play scenarios. If this child were to develop symptoms of gender dysphoria, what would be the most common causes of symptoms? A. Worsens during adolescence B. Remain stable into adulthood C. Continues until reassignment surgery D. Resolve spontaneously by adulthood E. Waxes and wanes throughout adulthood

Cognitive preservation

Aspects of successful older age include independent living, positive adaptation, mastery, and growth. Which of the following factors is most important in achieving that success? A. Economic security B. Emotional well-being. C. Cognitive preservation D. Lack of physical disability E. Active social engagement.

10%

At any given time, approximately what proportion of medical students, worldwide, report having suicidal ideation?

Birth

At what age do children demonstrate a preference for the human voice and speech over other sounds?

45

At what age is it considered late-I sent schizophrenia?

Unipolar major depression

According to the WHO, what is the number one psychiatric cause of most years of healthy life as measured by disability-adjusted years for individuals between the ages of 15-40?

People with ADHD show a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development: Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities. Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted Is often forgetful in daily activities. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person's developmental level: Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often "on the go" acting as if "driven by a motor". Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting their turn. Often interrupts or intrudes on others (e.g., butts into conversations or games) In addition, the following conditions must be met: Several inattentive or hyperactive-impulsive symptoms were present before age 12 years. Several symptoms are present in two or more settings, (such as at home, school or work; with friends or relatives; in other activities). There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder. Based on the types of symptoms, three kinds (presentations) of ADHD can occur: Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.

ADHD DSM V diagnostic criteria?

Zyprexa - orthostasis Ativan - respiratory depression and sedation Haldol - QTc prolongation (likely not an issue in acute scenarios) and orthostasis (not as bad as Zyprexa)

AE of major meds used in acute agitation/aggression

Mindfulness

According to the standard DBT approach, which skill should be taught to patients first and regularly practiced in order to facilitate learning of other skills?

Cerebellum

Abnormal emotional expression such as pathological laughter or crying is most likely caused by lesions affecting cortical-subcortical circuits linking the frontal cortex, pons, and what?

Synaptic pruning

Abnormality of what Neurodevelopmental process has been linked to fragile X syndrome and schizophrenia?

Three months

According to DSM-V, for a patient to be diagnosed with insomnia disorder, the sleep difficulty should be present for at least what length of time?

E

According to Erikson, in addition to raising children, which of the following is another way to be generative? A. Enhancing ones career status B. Maintaining a youthful appearance C. Meeting new people in multiple venues D. Having a satisfying comfortable routine E. Being involved and creative community projects

The anima and animus are described in Carl Jung's school of analytical psychology as part of his theory of the collective unconscious. Jung described the animus as the unconscious masculine side of a woman, and the anima as the unconscious feminine side of a man, each transcending the personal psyche. Jung's theory states that the anima and animus are the two primary anthropomorphic archetypes of the unconscious mind, as opposed to the theriomorphic and inferior function of the shadow archetypes. He believed they are the abstract symbol sets that formulate the archetype of the Self.

According to Jung, anima and animus refers to what?

It is best to crossed taper when switching from one another person to another. However, if you're switching an antidepressant from a specific class, i. e. SSRI, to another antidepressant that is also of that same class, then a direct switch is possible. Also, when switching from an SNRI to an SSRI or vice versa, direct switch as possible, given similarities a mechanism of action. Cross tapering would be recommended when switching from an SSRI or SNRI to Wellbutrin or mirtazapine or vice versa

According to Maudslay, how should you switch anti-depressants?

TCAs

According to Maudsley, what class of drugs is the first choice in the treatment of psychotic depression?

1. Addicts (ask do you smoke, how much do you drink, do drugs, etc) 2. Elderly 3. Liver, renal disease 4. People on chronic opioids He doesn't seem to villainize BZDs like people do. It seems that if these 4 traits are absent then BZD can be considered

According to McEvoy, when should you avoid BZDs?

Mirroring

According to Winnicott, a "good enough" parent is attuned to the infant's mental state most of the time. The parent communicates this understanding to the infant via what process?

Should be above 500

According to neuro, how high should vitamin B12 be?

Adverse effects offset advantages in the efficacy of atypical antipsychotics

According to the CATIE-AD trial, how effective are atypical antipsychotics in managing psychosis, aggression, or agitation in Alzheimer's dementia?

OCD

According to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5), catatonia may not be used as a specifier to which one of the following diagnoses? A. Major depressive disorder (MDD) B. Bipolar disorder C. Schizophreniform disorder D. Hepatic encephalopathy E. OCD

Lithium

Administration of charcoal is ineffective in the management of patient with an overdose of which of the following medications? A. Fluoxetine B. Lithium C.Valproic acid D. Haloperidol E. Lorazepam

The child risk of completed suicide is elevated relative to other adoptees

Adoptive parent of a child whose birth mother died by suicide ask the psychiatrist about the child's relative risk for future suicidal behavior. What is this child risk for future suicidal behavior?

Advantages of Daytrana include an alternative for children who have difficulties swallowing pills, and that the patch can individualize how many hours per day a given child with ADHD is receiving medication. This is important because a child with ADHD who needs the medication in the late afternoons to do homework but develops insomnia if the medication is still present after dinner, is able to remove the patch at the desired time.

Advantage of Daytrana patch?

Potential Advantages • Depressive stages of bipolar disorder (bipolar depression) • To prevent recurrences of both depression and mania in bipolar disorder Potential Disadvantages • May not be as effective in the manic stage of bipolar disorder

Advantages vs disadvantages of Lamotrigine?

Availability of peer support

After a child survives a natural disaster, which of the following social factors is most likely to be Protective against developing post-traumatic symptoms? A. Availability of peer support B. Timely relocation to a safer location C. Access to counseling and mental health services D. Validation of the importance of the event through media coverage

CSF evaluation

After an injection with haloperidol, a patient appears tremulous, dystonic, confused, and has a fever of 101.8 F. Which of the following would be an essential part of the diagnostic work up for this patient? A. Serum haloperidol level B. EMG C. EEG D. CSF evaluation E. MRI

4 weeks

After discontinuing clozapine due to WBC count less than 2.0 or ANC less than 1.0, for how long must the patient continue to have a weekly CBC performed once WBC count returns to more than 3.5?

Orbitofrontal cortex (OFC)

After head injury, a patient is observed to have personality changes, including increased impulsivity and euphoria. Which of the following is the most likely site of injury? A. Amygdala B. Cerebellum C. Ventral stratum D. Orbitofrontal cortex E. Anterior cingulate cortex

Concurrent psychosis

Aggressive behavior in patients with Alzheimer disease is most often associated with what?

Agitation - excessive motor or verbal activity Aggression - hostile, injurious, or destructive behavior. Can be verbal or physical Violence - physical aggression by people against other people

Agitation vs Aggression vs Violence

Panic disorder

Agoraphobia commonly occurs with what disorder?

Akathisia - Occurs day and night - The sensation to move usually arises in the midline/chest Restless leg syndrome - Occurs at night - They feel the sensation to move in their legs

Akathisia versus restless leg syndrome

48 hours

Alcohol withdrawal symptoms generally peaked within how many hours of cessation of alcohol use?

GABA-A

Alcohol, benzodiazepine sedative-hypnotic agents, and barbiturates all predominantly exert their clinical effects on the brain at which one of the following receptor sites? A. Cholinergic nicotinic B. NMDA C. Glycine D. GABA-A E. GABA-B

Zofran 4 mg IV —> Promethazine 12.5-25 mg IV —> Haldol 2.5-5 mg IM/IV

Algorithm to manage opioid withdrawal nausea and vomiting

Naltrexone first then add or replace with Acamprosate

Algorithm to treat alcohol use disorder?

OCD

Altered functional connectivity between the medial prefrontal cortex and the amygdala has been implicated in the neurology of what disorder?

Amnestic vs. Non-Amnestic MCI: In amnestic MCI, memory is significantly impaired. Other cognitive functions are spared. Alzheimer's disease is believed to cause amnestic MCI. In non-amnestic MCI, memory remains intact, but one (single domain) or more (multiple domain) other cognitive abilities (e.g., language, visual-spatial skills, executive functioning) are significantly impaired.

Amnestic vs non-amnestic mild cognitive impairment?

Substance use disorder

Among individuals with anorexia nervosa, those with binging-purging type are more likely than those with restrictive type to present with what comorbidity?

MDD

Among inpatients, does data indicate that catatonia most frequently occurs with MDD or bipolar disorder?

Monoamine oxidase A

Among neurodevelopmental risk factors for aggression in male children, the evidence is strongest for a gene/environment interaction between maltreatment and genes for what?

3-6 mg It helps people stay asleep. Doesn't help people fall asleep

At what dose dose Doxepin act as a sleep aid? How does it help improve sleep?

Some people may confuse ARFID and anorexia or use the terms interchangeably, as both disorders are based on the extreme restriction of food. However, ARFID does not include a fear of being fat or distress about weight, body shape or size

Anorexia nervosa vs avoidant/restrictive food intake disorder

OCD

Anterior capsulotomy and/or cingulotomy are indicated and demonstrated effective for patients with which severe, incapacitating disorder?

Calcium

Apoptosis mediated by the N-methyl-D-aspartate (NMDA) receptor complex is most likely caused by ele lular levels of which one of the following ions? A. Calcium B. Magnesium C. Sodium D. Potassium E. Chloride

Mirtazapine

Are SSRIs or Mirtazapine less likely to cause diarrhea as a side effect?

The problem is more appropriate because it has fewer side effects and if you were drug interactions as compared to SSRIs

Are SSRIs or bupropion more appropriate for geriatric patients? Why?

Not necessarily. It's important to ask questions to understand the nature of the hallucinations. Asking them to describe the content of voices, gender of voices, number of voices, what makes them disappear (usually working, lying down, walking, taking meds), what makes them worse (watching tv or listening to radio). Sometimes patients could be lying or misinterpreting intrusive thoughts as hallucinations. Example of true and suspect auditory hallucinations: 1. Auditory hallucinations are usually perceived as words or sentences heard by the patient as remarks or comments concerning him or her. 2. Hallucinations from drugs are commonly described as unformed noises. 3. In a study of 100 consecutive patients with hallucinations (61%) were schizophrenic, detailed phenomenology was studied (Nayani and David 1996) a. Internal vs. external hallucinations: 49% of the sample heard the voices through their ears as external stimuli. 38% heard them in internal space. 12% heard them in both variably. b. The most common encountered hallucinated utterances were simple terms of abuse (60%) Female subjects described words of abuse conventionally directed at women (e.g. slut). Male subjects described "male" insults such as those imputing homosexuality. 4. Strategies to decrease hallucinations-Ask what the person does to make the voices go away. In one study, 76% of patients were able to identify at least one activity, 10 either cognitive or behavioral-which helped them in dealing with auditory hallucinations. Frequent coping strategies in actual schizophrenics are: a. Specific activities (working) b. Changes in posture (lie down or walk) c. Seeking out interpersonal contact d. Taking medication Activities that have been shown to make voices worse: a. 80% of those with hallucinations stated that being alone worsened their hallucinations (Nayani and David, 1996) b. The two things that made voices worse were listening to the radio or watching television (Leudar et al. 1997) TV programs were particularly hallucinogenic. Voices sometimes comment about the program. 5. Summary of suspect auditory hallucinations: a. Continuous rather than intermittent b. Vague or inaudible hallucinations c. Not associated with delusions d. Stilted language e. No strategies to diminish voices f. Claim that all instructions are obeyed

Are auditory hallucinations always a sign of psychosis?

In general, brief interventions (e.g., a few weeks of detoxification, whether in or out of a hospital) used for persons who are severely dependent on illicit opioids have limited effect on outcome measured a few months later. Substantial reductions in illicit drug use, antisocial behaviors, and psychiatric distress among patients dependent on cocaine or heroin are much more likely following treatment lasting at least 3 months. Such a time-in-treatment effect is seen across very different modalities, from residential therapeutic communities to ambulatory methadone maintenance programs. Although some patients appear to benefit from a few days or weeks of treatment, a substantial percentage of users of illicit drugs drop out (or are dropped) from treatment before they have achieved significant benefits. Such generalizations concerning programs serving illicit drug users may not hold for programs dealing with those seeking treatment for alcohol, tobacco, or even cannabis problems uncomplicated by heavy use of illicit drugs. In such cases, relatively brief periods of individual or group counseling can produce long-lasting reductions in drug use.

Are brief interventions (I.e. programs lasting a few weeks) to manage substance use effective?

Partial agonist of dopamine 2 receptors (theoretically reduces dopamine output when it's high and thus reduces positive symptoms and theoretically increases dopamine output in areas where it's low and thus improves cognitive, negative, and mood symptoms) Partial agonist of serotonin receptors too

Aripiprazole MOA?

Meperidine (Demerol) An opioid that is known to causes seizures. As such, it's use has declined

As a result of drug addiction, a healthcare professional experiences a seizure that is not over withdrawal phenomenon. Which of the following could be a cause of this reaction? A. Alcohol B. Butalbital C. Meperidine D. Oxazepam E. Fentanyl

It is activating at low doses. For activating side effects at low doses, raise the dose. Dosing many patients at 20-40 mg twice a day is too low and in fact activating, perhaps due to potent 5HT2C antagonist properties ✽ Paradoxically, such activation is often reduced by increasing the dose to 60-80 mg twice a day, perhaps due to increasing amounts of dopamine 2 receptor antagonism

At what dose is Geodon activating? How can you manage this considering this info?

Best efficacy in schizophrenia and bipolar disorder is at doses >120 mg/day, but only a minority of patients are adequately dosed in clinical practice

At what dose is best efficacy of Geodon in schizophrenia and bipolar disorder seen at?

Structural brain damage, dementia, or mental retardation

Ativan can cause paradoxical disinhibition in agitated patients with what?

Inhibition of norepinephrine transport

Atomoxetine MOA

Substance use disorders

Atomoxetine is most likely to be considered as an initial treatment for ADHD in adolescents with what?

Attachment, which is the emotional dependence of the infant on its mother, involves resources and sec rity, because the infant depends on the mother for these things. Attachment theory was developed by Job Bowlly and says that a secure attachment between mother and child affects the child's ability to for healthy relationships later in life. Attachment occurs when there is a warm, intimate, and continuous rel fionship between child and mother. The attachment gives the infant a feeling of security. Bonding refers the mother's feelings for her infant. The mother does not rely on her baby for food and protection; ther fore bonding does not involve resources and security. It is thought that bonding occurs with skin-to-sk contact between infant and mother. All other choices given are true regarding attachment theory.

Attachment versus bonding

No and no Due to its anticholinergic effects, its effective at treating hypersalivation but it hasn't been approved by the FDA. Avoid in the elderly due to anticholinergic effects (increased risk of falls and delirium)

Is Glycopyrrolate FDA approved for hypersalivation? Can it be given to the elderly?

Recent work has shown that it causes an increase in the size of the anterior cingulate cortex. It's assumed that TMS induces gene expression of growth factor proteins, like BDNF, and this in turn increases dendritic branching and synapse formation, which increases the size of the gray matter in the anterior cingulate.

Does successful antidepressant course of TMS cause any brain changes?

Notable Side Effects ✽ Sedation, fatigue, depression ✽ Dizziness, ataxia, slurred speech, weakness ✽ Forgetfulness, confusion ✽ Hyperexcitability, nervousness • Rare hallucinations, mania • Rare hypotension • Hypersalivation, dry mouth Life-Threatening or Dangerous Side Effects • Respiratory depression, especially when taken with CNS depressants in overdose • Rare hepatic dysfunction, renal dysfunction, blood dyscrasias

BZD AE?

Cannabis acts on cannabinoid receptors. The cannabinoid receptor is found in highest concentrations in the basal ganglia, the hippocampus, and the cerebellum, with lower concentrations in the cerebral cortex (Figure 20.4-2). This receptor is not found in the brainstem, a fact consistent with cannabis's minimal effects on respiratory and cardiac functions.

Based on MOA, why is cannabis not lethal?

Clomipramine and venlafaxine

Besides SSRIs, what are other affective antidepressants they can treat OCD?

Memantine It modulates glutamate like NAC and a recent study showed it was effective at reducing trichotillomania and skin-picking. Start at 10 mg/day then increase to 20 mg/day after 2 weeks.

Besides SSRIs/SNRIs, NAC, and Naltrexone, what else can be used to treat trichotillomania and skin-picking? What dose?

H1 blockers (ex. Ranitidine) Have an anticholinergic effect

Besides anticholinergics and BZDs, what's another class of drug to discontinue in delirium?

Migraine prophylaxis

Besides mania and seizures, what is another major use for Depakote?

"Who can I speak to you?" "Can you give me the number of .... so I can call them?"

Best way to ask if you can ask a patient to speak to family?

4 and 5 years

Between what ages goes gender identity become consolidated?

Chronic insomnia

Bio feedback maybe helpful in treating which of the following conditions? A. Narcolepsy B. Chronic insomnia C. Nightmare disorder D. Sleepwalking disorder E. Restless leg syndrome

Operant conditioning

Biofeedback is a treatment modality used across multiple disorders to help patients achieve greater control over specific physiological functions via which mechanism?

Bipolar 1 - requires one manic episode, hypomanic and depressive episodes can occur but they are not required for diagnosis Bipolar 2 - requires at least one episode of depression and at least one episode of jypomania

Bipolar 1 vs. Bipolar 2?

A boundary crossing is a deviation from classical therapeutic activity that is harmless, non-exploitative, and possibly supportive of the therapy itself. In contrast, a boundary violation is harmful or potentially harmful, to the patient and the therapy. Possible examples of boundary crossings include shaking a client's extended hand upon first meeting or extending the time of a treatment session for a client who is in crisis Boundary violation means crossing verbal, physical, emotional, and social lines that an educator must maintain in order to ensure structure, security, and predictability in an educational environment.

Boundary crossing versus boundary violation

Vivitrol (Naltrexone) ReVia

Brand names of naltrexone?

NOTECARD https://www.dana.org/wp-content/uploads/2019/08/anatomy-function-brain-areas-basics-large.jpg

Briefly identify parts of the brain

Cytochrome metabolism

By what mechanism can you explain the primary effect of a grapefruit juice on the bioavailability of some drugs?

Childhood onset: meet criteria for schizophrenia + symptoms start before the age of 13 Early onset schizophrenia: symptoms start between 13-18 yo

Childhood onset schizophrenia vs early onset schizophrenia?

Panic disorder

Childhood physical and sexual abuse has been shown to be a risk factor for which anxiety disorder?

Anxiety and depression

Children with DMDD are at highest risk of developing what in adulthood?

Classical conditioning involves associating an involuntary response and a stimulus, while operant conditioning is about associating a voluntary behavior and a consequence. In operant conditioning, the learner is also rewarded with incentives, while classical conditioning involves no such enticements.

Classical conditioning CS operant conditioning

CK: increased Fe: decreased

CK and Fe levels in malignant catatonia?

Hippocampus

Clear evidence for adult neurogenesis has been established in which area of the brain?

Nucleus accumbens

Dopamine release in which brain structure represents a common final event associated with the reinforcing effects of opiates, cocaine, amphetamines, nicotine, PCP, and alcohol?

In contrast to the barbiturates and the barbiturate-like substances, the benzodiazepines have a large margin of safety when taken in overdoses, a feature that has contributed significantly to their rapid acceptance. The ratio of lethal dose to effective dose is about 200 to 1 or higher, because of the minimal degree of respiratory depression associated with the benzodiazepines. Even when grossly excessive amounts (more than 2 g) are taken in suicide attempts, the symptoms include only drowsiness, lethargy, ataxia, some confusion, and mild depression of the user's vital signs. A much more serious condition prevails when benzodiazepines are taken in overdose in combination with other sedative-hypnotic substances, such as alcohol

Can BZD overdose kill you?

Normally, we discontinue BZD in delirium because they can worsen it. However, if the delirium is due to alcohol withdrawal or to hallucinogen, cocaine, PCP toxicity, BZD should be used to treat the underlying cause

Can BZDs treat delirium?

Yes

Can Borderline patients achieve remission?

Best to avoid it becAuse it interacts with many CYP450 enzymes and geriatrics are usually on a bunch of meds

Can Prozac be given in geriatrics?

Yes

Can odd movements occur in schizophrenia in the absence of medication-induced movement disorders?

Another serious adverse effect (serotonergic syndrome)is an idiosyncratic drug interaction between meperidine and monoamine oxidase inhibitors (MAO Is), which can produce gross autonomic instability, severe behavioral agitation, coma, seizures, and death. Opioids and MAO Is should not be given together for this reason.

Can opioids be given with MOAIs?

Yes! Use antidepressants, typically SSRIs

Can somatic symptom disorder be treated pharmacologically?

No. These deficits are associated with abnormalities in sensory perception, motor functioning, and cognitive performance along with a loss of brain volume. They are missing parts of their brain and those parts can't just be grown. As a result, these patients require a lot of support in the form of medication, therapy, social support (modifications/less work, accommodations/put them at the same level, and prosthesis/take them to the park)

Can the deficits in schizophrenia be reversed? What implications does this have?

Tolerance for LSD and other hallucinogens develops rapidly and is virtually complete after 3 or 4 days of continuous use. Tolerance also reverses quickly, usually in 4 to 7 days. Neither physical dependence nor withdrawal symptoms occur with hallucinogens, but a user can develop a psychological dependence on the insight-inducing experiences of episodes of hallucinogen use.

Can tolerance, dependence, or withdrawal occur with LSD use?

Yes, as long as they are on anti hypertension meds

Can venlafaxine be given to hypertensives?

NO! It would cause hypotension

Can you give Ativan IM and Zyprexa IM together?

Based on Beers Criteria, it should be avoided. As patients age, the number of anticholinergic receptors in the brain decrease. Benadryl in these patients can result in more side effects, sedation, falls, and delirium/agitation

Can you give Benadryl to a geriatric patient?

Studies have shown that cessation of use in daily cannabis users results in withdrawal symptoms within 1 to 2 weeks of cessation. Withdrawal symptoms include irritability, cannabis cravings, nervousness, anxiety, insomnia, disturbed or vivid dreaming, decreased appetite, weight loss, depressed mood, restlessness, headache, chills, stomach pain, sweating, and tremors.

Can you withdraw from cannabis? If so, what are the manifestations?

Clozapine

Carbamazepine will not lower the levels or the efficacy of which one of the following agents? A. Warfarin B. Clozapine C. Alprazolam D. Propranolol E. Citalopram

60-120 mg/day in 1-2 doses Usually start at 30-40 mg/day

Dosage range for Cymbalta? How do you start it?

D2

Clozapine is thought to result in a lower rate of medication-induced parkinsonism due to its low affinity for which of the following receptors? D1 D2 D3 D4 D5

Cocaine: blocks reuptake of monoamines (dopamine, NE, epinephrine, serotonin) MDMA: increases serotonin release into synapse and blocks its reuptake Meth: increases release of monamines and blocks their reuptake Of note: MDMA = methylenedioxymethamphetamine

Cocaine MOA vs MDMA MOA vs Meth MOA

Cocaine use disorder is more non-stigmatizing. It's important to avoid stigmatizing language bc it makes the patient feel better and also reduces bias

Cocaine use disorder vs. cocaine abuse disorder

Notable Side Effects • Sexual dysfunction (men: delayed ejaculation, erectile dysfunction; men and women: decreased sexual desire, anorgasmia) • Gastrointestinal (decreased appetite, nausea, diarrhea, constipation, dry mouth) • Mostly CNS (insomnia but also sedation, agitation, tremors, headache, dizziness)

Common AE of SSRIs?

The amygdala plays a role in processing and integrating information related to emotion and motivation. It is constantly scanning the external environment and protecting us by activating certain emotional processes, Such as fear, along with related autonomic nervous system response. Think of Dr. Rosenquist's analogy of the amygdala being like the Georgia bulldog (the amUGAdala). The insula does what the amygdala does but it scans the internal environment and activates appropriate emotional processes and related nervous system responses. This is the part of the brain that gets active when you ask a person "tell me, how are you really doing?" The insula scans the body and formulates s response

Compare the amygdala and insula in terms of their function?

Nonaggressive behaviors: restlessness (akathisia, fidgeting), wandering, loud/excited speech, pacing, frequently changing body positions, inappropriate behavior (disrobing, intrusive repetitive questioning) Aggressive behaviors: physical (combativeness, punching walls, throwing or grabbing objects, destroying items, clenching hands into fists, posturing, self-injury) and verbal (cursing, screaming)

Component behaviors of agitation

Defense mechanisms are involuntary cognitive responses to stressors and coping mechanisms are voluntary behavioral actions, i.e. Asking help from appropriate others involuntary cognitive efforts like information gathering, anticipating danger, and reversing responses to danger.

Coping mechanisms versus defense mechanisms?

Zyprexa: 5-10 mg IM and 15-30 min Haldol: 2 - 10 mg IM/IV and 30-60 min (much faster if IV) Ativan: 2 mg IM and 15-45 min Ziprasidone: 10-20 mg IM and 15-30 min

Dose and onset to efficacy of Zyprexa, Haldol, Ativan, and Ziprasidone in agitation

Alzheimer's disease

Down syndrome is associated with defect in chromosome 21. This is a feature also shared by what disease?

Drunk drivers are involved in about 50 percent of all automotive fatalities, and this percentage increases to about 75 percent when only accidents occurring in the late evening are considered

Drunk drivers are involved with what percentage of car accidents in the US?

Spice. It is a full agonist of CB1 (cannabinoid) receptors in the brain whereas THC is a partial agonist. This results in greater chance of psychosis

Is Spice or THC more likely to cause psychosis?

This is an approach to understanding private, distressing events patients experience. It's an acronym for Thoughts, Emotions, Action tendencies (urges), Memories, and Sensations in the body. The approach helps clinicians isolate the individual components of distressing private spaces reported by clients.

In ACT, what is the TEAMS model and how is it beneficial?

Manic

Is Depakote more effective at treating manic or depressive symptoms of bipolar?

Depakote, takes a few days

Is Depakote or Lithium faster at stabilizing acute mania?

CBT

During the treatment of a patient with alcohol dependence, the therapist works with the patient to identify new routes home from work in order to minimize exposure to high-risk situations, ex. the local bar, that might lead to a relapse. This is an example of which of the following types of therapy? A. Cognitive behavioral B. Motivational enhancement C. 12 step facilitation D. Contingency management E. Network

Preschool age

During which stage do children usually first exhibit The ability to recognize that their thoughts and feelings are their own, and that others may think and feel differently?

NMS

ECT may be recommended for treatment-refractory presentations of which of the following? A. Delirium B. Tardive dyskinesia C. Borderline personality Disorder D. NMS E. Obsessive-compulsive disorder

Insomnia disorder

EEG bio feedback has been found to be more effective than progressive muscle relaxation in the treatment of which condition?

Decreased processing speed

Early stage of HIV type-1 associated dementia complex, as compared to early-stage Alzheimer's dementia, is associated with what deficit?

It can decrease levels and thus patients may require higher dosing if they begin or increase smoking

Effect of cigarette smoking on Olanzapine?

Anxiety, muscle spasm, seizure: 2-10 mg, 2-4 times/day Alcohol withdrawal: initial 10 mg 3-4 times/day then 5 mg 3-4 times/day then as needed

How do you dose oral diazepam for its various uses?

If AST rises by 3x normal and if bilirubin rises by 2x normal

How do you know if a drug is hepatotoxic?

1. Stop the offending agent 2. Immediately transfer to hospital 3. Supportive care (ex. fluids) 4. Dopaminergic agonists: bromocriptine

How do you manage NMS

It can be used to reduce symptoms acute psychotic mania but it has not proven to be effective as a mood stabilizer or maintenance treatment in bipolar disorder. After reducing acute psychotic symptoms in mania, switch to a mood stabilizer and/or an atypical antipsychotic for mood stabilization and maintenance

How is Haldol used to treat mood disorders?

E

During the acute initial refeeding phase of treatment for a patient with severe anorexia nervosa, which of the following is the most helpful focus of psychotherapeutic interventions with the patient? A. Framing the use of disordered eating behavior as a maladaptive coping mechanism B. Identifying triggers for relapse and developing plans to prevent relapse C. Exploring developmental, familial, and cultural antecedents to the illness D. Challenging cognitive distortions and negative core beliefs E. Coaching, support, and positive behavioral reinforcement

Clozapine and haloperidol

Correlation of plasma drug concentrations with clinical effectiveness is best established for which antipsychotic medications?

Crack, a freebase form of cocaine, is extremely potent. It is sold in small, ready-to-smoke amounts, often called "rocks." Crack cocaine is highly addictive; even one or two experiences with the drug can cause intense craving for more

Crack vs cocaine?

1. Fear of being in places where escape might be difficult 2. Efforts to avoid such places

Criteria to diagnose agoraphobia

C

Current evidence regarding the efficacy of family therapy as a treatment for eating disorders reports that it is: A. Is superior to Individual therapy for patients of all ages B. Is efficacious for adults, but adolescents are less likely to respond C. Is superior to individual therapy for adolescents 6-12 months after treatment D. Improves remission rates for adults in anorexia nervosa but not in bulimia nervosa E. Is superior to individual therapy at the end of treatment, but effects are not sustained

1. Sedation, dizziness, ataxia, asthenia, headache, dose-dependent tremor 2. Abdominal pain, N/V, diarrhea, constipation, dyspepsia, weight gain 3. Alopecia 4. Hepatotoxicity, pancreatitis, DRESS, tachy/bradycardia, thrombocytopenia

Depakote AE?

Autonomy vs. Shame and Doubt

Developmental disturbance during which if Erikson's psychosocial stage is related to compulsions and obsessions?

Domestic violence

During the initial evaluation of an individual for couples therapy, it is most critical to ask about what?

They do improve objective and subjective sleep latency but only to a small degree (the effect does not meet the criterion for clinical significance). However when combined with the placebo effect, it does result in significant improvement. Thus, psychological interventions are very important and deserve increased attention

Do Z drugs actually improve sleep?

Paraventricular nucleus

During the stress response in humans, corticotropin-releasing hormone is released from which nucleus of the hypothalamus?

Parasucidal acts

DBT is primarily designed to help patients diminish: A. Depressive symptoms B. SI C. Parasuicidal acts D. Dependence on psych services E. Feelings of hopelessness

Telephone consultation DBT attempts to reduce self-harm. The goal of allowing all these phone calls is that the patient should call counselor if their own coping skills are not enough to prevent self-harm. However, if the patient does self-harm then the counselor will not entertain them and tell them to go to ED and hang up (they don't want to reward self injury)

DBT is unique among commonly employed psychotherapies in encouraging judicious use by patients of what?

Disruptive mood dysregulation and intermittent explosive disorder are both characterized by recurrent, severe, angry outbursts [29]. However, patients with disruptive mood dysregulation disorder are angry or irritable most of the day, nearly every day, in between the angry outbursts, whereas the diagnosis of intermittent explosive disorder does not require a mood disturbance between outbursts. In addition, angry outbursts in disruptive mood dysregulation disorder occur on average three times per week; in intermittent explosive disorder, verbal aggression occurs on average twice per week. Disruptive mood dysregulation disorder requires 12 months of active symptoms, in contrast to intermittent explosive disorder, which requires only 3 months of symptoms.

DMDD vs IED

Anorexia Nervosa A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

DSM-5 diagnostic criteria for anorexia nervosa

Working memory

Deficit in which neurocognitive skill is the most highly correlated with schizophrenia?

Autism spectrum disorder (ASD) is a biologically based neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction and restricted, repetitive patterns of behavior, interests, and activities. ●DSM, Fifth edition criteria - According to the DSM, Fifth edition Text Revision (DSM-5-TR) criteria, a diagnosis of ASD requires all of the following [30]: •Persistent deficits in social communication and social interaction in multiple settings; demonstrated by deficits in all three of the following (either currently or by history): -Social-emotional reciprocity (eg, failure to produce mutually enjoyable and agreeable conversations or interactions because of a lack of mutual sharing of interests, lack of awareness or understanding of the thoughts or feelings of others) -Nonverbal communicative behaviors used for social interaction (eg, difficulty coordinating verbal communication with its nonverbal aspects [eye contact, facial expressions, gestures, body language, and/or prosody/tone of voice]) -Developing, maintaining, and understanding relationships (eg, difficulty adjusting behavior to social setting, lack of ability to show expected social behaviors, lack of interest in socializing, difficulty making friends even when interested in having friendships) •Restricted, repetitive patterns of behavior, interests, or activities; demonstrated by ≥2 of the following (either currently or by history): -Stereotyped or repetitive movements, use of objects, or speech (eg, stereotypies such as rocking, flapping, or spinning; echolalia [repeating parts of speech]; repeating scripts from movies or prior conversations; ordering toys into a line) -Insistence on sameness, unwavering adherence to routines, or ritualized patterns of verbal or nonverbal behavior (eg, difficulty with transitions, greeting rituals, need to eat the same food every day) -Highly restricted, fixated interests that are abnormal in strength or focus (eg, preoccupation with certain objects [trains, vacuum cleaners, or parts of trains or vacuum cleaners]); perseverative interests (eg, excessive focus on a topic such as dinosaurs or natural disasters) -Increased or decreased response to sensory input or unusual interest in sensory aspects of the environment (eg, adverse response to particular sounds; apparent indifference to temperature; excessive touching/smelling of objects) •The symptoms must impair function (eg, social, academic, completing daily routines). •The symptoms must be present in the early developmental period. However, they may become apparent only after social demands exceed limited capacity; in later life, symptoms may be masked by learned strategies. •The symptoms are not better explained by intellectual disability (formerly referred to as mental retardation) or global developmental delay.

Define autism and what is the DSM 5 diagnostic criteria?

DR = delayed release; the release of the active ingredient is delayed until after it has crossed the stomach to prevent it from being metabolized by stomach acid ER = extended release: the release of the active ingredient is prolonged over a period of time Depakote DR: released immediately after passing stomach. Usually given twice in a day. Easier to swallow. Available in 125, 250, and 500 mg formulation Depakote ER: released over a prolonged period of time. Only needs to be taken once a day. Bigger pill to swallow. Available in 250mg and 500 mg formulation. Also, ER formulations reduce the chance of side effects since they're given less frequently. *Do not crush these pills bc they are coated with material that protects them enterically

Depakote DR vs Depakote ER

It blocks voltage gated sodium channels by an unknown mechanism and increases brain concentrations of GABA by an unknown mechanism

Depakote MOA

Irritable mood

Depressed mood is one symptom that has to be present to diagnose MDD. What alternative symptom to this is accepted in children and adolescents?

Freud (1900, 1905) developed a topographical model of the mind, whereby he described the features of the mind's structure and function. Freud used the analogy of an iceberg to describe the three levels of the mind. Freud (1915) described the conscious mind, which consists of all the mental processes of which we are aware, and this is seen as the tip of the iceberg. For example, you may be feeling thirsty at this moment and decide to get a drink. The preconscious contains thoughts and feelings that a person is not currently aware of, but which can easily be brought to consciousness (1924). It exists just below the level of consciousness, before the unconscious mind. The preconscious is like a mental waiting room, in which thoughts remain until they 'succeed in attracting the eye of the conscious' (Freud, 1924, p. 306). This is what we mean in our everyday usage of the word available memory. For example, you are presently not thinking about your mobile telephone number, but now it is mentioned you can recall it with ease. Mild emotional experiences may be in the preconscious but sometimes traumatic and powerful negative emotions are repressed and hence not available in the preconscious. Finally, the unconscious mind comprises mental processes that are inaccessible to consciousness but that influence judgments, feelings, or behavior (Wilson, 2002). According to Freud (1915), the unconscious mind is the primary source of human behavior. Like an iceberg, the most important part of the mind is the part you cannot see. Our feelings, motives and decisions are actually powerfully influenced by our past experiences, and stored in the unconscious. Freud applied these three systems to his structure of the personality, or psyche - the id, ego and superego. Here the id is regarded as entirely unconscious whilst the ego and superego have conscious, preconscious, and unconscious aspects.

Describe Freud's topographic model of consciousness

Kohlberg's theory of moral development is a theory that focuses on how children develop morality and moral reasoning. Kohlberg's theory suggests that moral development occurs in a series of six stages. The theory also suggests that moral logic is primarily focused on seeking and maintaining justice. Kohlberg's theory is broken down into three primary levels. At each level of moral development, there are two stages. Similar to how Piaget believed that not all people reach the highest levels of cognitive development, Kohlberg believed not everyone progresses to the highest stages of moral development. Level 1. Preconventional Morality Preconventional morality is the earliest period of moral development. It lasts until around the age of 9. At this age, children's decisions are primarily shaped by the expectations of adults and the consequences for breaking the rules. There are two stages within this level: - Stage 1 (Obedience and Punishment): The earliest stages of moral development, obedience and punishment are especially common in young children, but adults are also capable of expressing this type of reasoning. According to Kohlberg, people at this stage see rules as fixed and absolute.7 Obeying the rules is important because it is a way to avoid punishment. - Stage 2 (Individualism and Exchange): At the individualism and exchange stage of moral development, children account for individual points of view and judge actions based on how they serve individual needs. In the Heinz dilemma, children argued that the best course of action was the choice that best served Heinz's needs. Reciprocity is possible at this point in moral development, but only if it serves one's own interests. Level 2. Conventional Morality The next period of moral development is marked by the acceptance of social rules regarding what is good and moral. During this time, adolescents and adults internalize the moral standards they have learned from their role models and from society. This period also focuses on the acceptance of authority and conforming to the norms of the group. There are two stages at this level of morality: - Stage 3 (Developing Good Interpersonal Relationships): Often referred to as the "good boy-good girl" orientation, this stage of the interpersonal relationship of moral development is focused on living up to social expectations and roles.7 There is an emphasis on conformity, being "nice," and consideration of how choices influence relationships. - Stage 4 (Maintaining Social Order): This stage is focused on ensuring that social order is maintained. At this stage of moral development, people begin to consider society as a whole when making judgments. The focus is on maintaining law and order by following the rules, doing one's duty, and respecting authority. Level 3. Postconventional Morality At this level of moral development, people develop an understanding of abstract principles of morality. The two stages at this level are: - Stage 5 (Social Contract and Individual Rights): The ideas of a social contract and individual rights cause people in the next stage to begin to account for the differing values, opinions, and beliefs of other people.7 Rules of law are important for maintaining a society, but members of the society should agree upon these standards. - Stage 6 (Universal Principles): Kohlberg's final level of moral reasoning is based on universal ethical principles and abstract reasoning. At this stage, people follow these internalized principles of justice, even if they conflict with laws and rules.

Describe Kohlber's theory of moral development

After stimulant intoxication, a "crash" occurs with symptoms of anxiety, tremulousness, dysphoric mood, lethargy, fatigue, nightmares (accompanied by rebound rapid eye movement [REM] sleep), headache, profuse sweating, muscle cramps, stomach cramps, and insatiable hunger. The withdrawal symptoms generally peak in 2 to 4 days and are resolved in 1 week. The most serious withdrawal symptom is depression, which can be particularly severe after the sustained use of high doses of stimulants and which can be associated with suicidal ideation or behavior. A person in the state of withdrawal can experience powerful and intense cravings for cocaine, especially because taking cocaine can eliminate the unpleasant withdrawal symptoms.

Describe a withdrawal from stimulants (cocaine and amphetamines)

●Immune-mediated encephalitis includes the classic paraneoplastic encephalitis syndromes and the encephalitis syndromes associated with antibodies against neuronal cell surface/synaptic proteins, referred to as "autoimmune encephalitis." ●Paraneoplastic encephalitis can involve the limbic system (limbic encephalitis), brainstem (brainstem encephalitis), spinal cord (myelitis), or the entire neuraxis (encephalomyelitis). In most cases, symptoms have an acute to subacute onset and are accompanied by evidence of inflammation in the cerebrospinal fluid (CSF). (See 'Paraneoplastic encephalitis' above.) ●Examples of classic antibody-mediated paraneoplastic encephalitis syndromes include anti-Hu encephalomyelitis, often associated with small cell lung cancer (SCLC), Ma2-associated encephalitis related to testicular cancer, and anti-collapsin-responsive mediator protein-5 (CRMP5) encephalomyelitis related to SCLC or thymoma (table 1). (See 'Specific antibody-associated syndromes' above.) ●The autoimmune encephalitis syndromes have a wide clinical spectrum that ranges from typical limbic encephalitis to syndromes with complex neuropsychiatric symptoms such as deficits of memory, cognition, psychosis, seizures, abnormal movements, or coma (table 2). These disorders are associated with antibodies to neuronal cell surface/synaptic proteins and may occur in the presence or absence of cancer. (See 'Autoimmune encephalitis' above.) ●Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a well-characterized autoimmune encephalitis with prominent psychiatric manifestations and cognitive dysfunction, speech dysfunction, seizures, dyskinesias and other movement abnormalities, decreased level of consciousness, and autonomic instability (table 3). The disorder affects primarily children and adults up to age 45 years; females may have an associated ovarian teratoma. (See 'Anti-NMDA receptor encephalitis' above.) ●Patients with suspected paraneoplastic or autoimmune encephalitis (table 5) should have neuroimaging, electroencephalogram (EEG), lumbar puncture, and antibody testing on serum and CSF. Although antibody studies can confirm the diagnosis, initiation of treatment should not be delayed while waiting for antibody results. A provisional diagnosis should be based on the medical history and clinical features, laboratory and radiologic evidence of central nervous system (CNS) inflammation, and exclusion of infection and other alternative etiologies. (See 'Diagnostic approach' above.) Most common - NMDA receptor enchephalitis (antibodies are positive in up to 5% of people presenting to the hospital in psychosis)

Describe immune-mediated encephalitis

A pediatrician's technique called "inquiry into lost dreams." As quoted in Shea's book, "I find it useful with my kids with asthma to ask them this question or a variation of it, 'Is there anything that your asthma is keeping you from doing that you really wish you could do again?' What I find with this age group is that there is often a quick answer to this question, and the answer is often related to a sport, say, football or soccer." You can readily adopt this technique to psychiatric issues: "Is there anything that your anxiety is keeping you from doing, that you wish you could do again?" The answer may help your patient better appreciate the potential benefits of medications.

Describe the "inquiry into lost dreams" technique for boosting medication adherence

A. Capgras syndrome is characterized by a delusional belief that a person has been replaced by an imposter. It has been described in psychiatric and neurological (neurodegenerative and nonneurodegenerative) diseases. B. De Clerambault in 1885 is reviewed and a case is presented. Popularly called erotomania, the syndrome is characterized by the delusional idea, usually in a young woman, that a man whom she considers to be of higher social and/or professional standing is in love with her. C. Dorian Gray Syndrome (DGS) denotes a cultural and societal phenomenon characterized by an excessive preoccupation with the individual's own appearance (dysmorphophobia) accompanied by difficulties coping with the aging process and with the requirements of maturation. D. The syndrome of subjective doubles is a rare delusional misidentification syndrome in which a person experiences the delusion that they have a double or Doppelgänger with the same appearance, but usually with different character traits, that is leading a life of its own. E. Lycanthropy, (from Greek lykos, "wolf "; anthropos, "man"), mental disorder in which the patient believes that he is a wolf or some other nonhuman animal. ... Both the superstition and the psychiatric disorder are linked with belief in animal guardian spirits, vampires, totemism, witches, and werewolves.

Describe the following: A. Capgras syndrome B. De Clerambault syndrome C. Dorian Gray syndrome D. Doppelgänger syndrome E. Lycanthropy

As you sleep, your brain cycles through four stages of sleep. - Stages 1 to 3 are what's considered non-rapid eye movement (NREM) sleep, also known as quiet sleep. - Stage 4 is rapid eye movement (REM) sleep, also known as active sleep or paradoxical sleep. The entire sleep cycle repeats itself several times a night with every successive REM stage increasing in duration and depth of sleep.1 A) Entering Sleep During the earliest phases of sleep, you are still relatively awake and alert. At this time, the brain produces what are known as beta waves—small and fast brainwaves that mean the brain is active and engaged. As the brain begins to relax and slow down, it lights up with alpha waves. During this transition into deep sleep, you may experience strange and vivid sensations, known as hypnagogic hallucinations. Common examples of this phenomenon include the sensation of falling or of hearing someone call your name. There's also the myoclonic jerk; if you have ever startled suddenly for seemingly no reason at all, then you have experienced this. B) NREM Stage 1 The first stage of the sleep cycle is a transition period between wakefulness and sleep. If you awaken someone during this stage, they might report that they were not really asleep. - During stage 1 sleep: + Your brain slows down + Your heartbeat, your eye movements, and your breathing slows with it + Your body relaxes and your muscles may twitch This brief period of sleep lasts for around five to 10 minutes. At this time, the brain is still fairly active and producing high amplitude theta waves, which are slow brainwaves occurring mostly in the frontal lobe of the brain.2 C) NREM Stage 2 According to the American Sleep Foundation, people spend approximately 50% of their total sleep time during NREM stage 2, which lasts for about 20 minutes per cycle.4 - During stage 2 sleep: + You become less aware of your surroundings + Your body temperature drops + Your eye movements stop + Your breathing and heart rate become more regular The brain also begins to produce bursts of rapid, rhythmic brain wave activity, which are known as sleep spindles. They are thought to be a feature of memory consolidation—when your brain gathers, processes, and filters new memories you acquired the previous day. While this is occurring, your body slows down in preparation for NREM stage 3 sleep and REM sleep—the deep sleep stages when the brain and body repairs, restores, and resets for the coming day. D) NREM Stage 3 (aka: deep sleep) Deep, slow brain waves known as delta waves begin to emerge during NREM stage 3 sleep—a stage that is also referred to as delta sleep. This is a period of deep sleep where any noises or activity in the environment may fail to wake the sleeping person. Getting enough NREM stage 3 sleep allows you to feel refreshed the next day.1 - During NREM stage 3 sleep: + Your muscles are completely relaxed + Your blood pressure drops and breathing slows + You progress into your deepest sleep It is during this deep sleep stage that your body starts its physical repairs.Meanwhile, your brain consolidates declarative memories—for example, general knowledge, facts or statistics, personal experiences, and other things you have learned. E) REM Sleep While your brain is aroused with mental activities during REM sleep, the fourth sleep stage, your voluntary muscles become immobilized. It's in this stage that your brain's activity most closely resembles its activity during waking hours. However, your body is temporarily paralyzed—a good thing, as it prevents you from acting out your dreams.1 REM sleep begins approximately 90 minutes after falling asleep. - At this time: + Your brain lights up with activity + Your body is relaxed and immobilized + Your breathing is faster and irregular + Your eyes move rapidly + You dream Like stage 3, memory consolidation also happens during REM sleep. However, it is thought that REM sleep is when emotions and emotional memories are processed and stored. Your brain also uses this time to cement information into memory, making it an important stage for learning. It's important to realize that sleep does not progress through the four stages in perfect sequence. When you have a full night of uninterrupted sleep, the stages progress as follows: 1. Sleep begins with NREM stage 1 sleep. 2. NREM stage 1 progresses into NREM stage 2. 3. NREM stage 2 is followed by NREM stage 3. 4. NREM stage 2 is then repeated. 5. Finally, you are in REM sleep Once REM sleep is over, the body usually returns to NREM stage 2 before beginning the cycle all over again.

Describe the stages of sleep

% carbohydrate deficient transferrin

Elevation of what lab value is most specific for chronic heavy alcohol consumption?

Amygdala

Emotional memory localizes to the: A. Amygdala B. Hippocampus C. Primary auditory cortex D. Nucleus basalis of Meynert E. Pons

Amphetamines

Ephedrine, pseudoephedrine are like what other illicit substance?

Temporal lobe

Episodes of amnesia preceded by an epigastric sensation and fears are most commonly associated with an electrical abnormality in which lobe?

A lot of the manifestations seen in schizophrenia are secondary to a primary pathological process that is not fully understood. These primary process results in sensory disturbances, motor dysfunction, and cognitive deficits. As a result, the mind responds with secondary reactions such as delusions, negative symptoms, or catatonic. For example, schizophrenics may experience visual disturbances that make it seem that objects shrink and grow. As a result, they develop a delusion that they can change the shape of objects with their mind. Or sometimes schizophrenics experience thought blocking or aphasias causing them to experience much anxiety in social settings. As a result, they socially withdraw and avoid people. Not all secondary reactions are conscious decisions and as these secondary reactions persist they become permanent and subconscious

Explain secondary reactions in schizophrenia in context to the primary perception and cognition deficits

If they're on Depakote DR, you can try Depakote ER (just remember higher dosing would be required since it's less bioavailable than DR) or try another mood stabilizer like lithium

If someone is experiencing too many GI side effects from Depakote, what can you do?

Many times, when you see a patient for the first time, you see them at their worst. Based on that initial 15-45 min interaction, you might feel ready to diagnose them with a major mental illness (ex. MDD, schizophrenia). However, it is important to understand that this is the patient at their worst level. You need to get to know the patient more, learn more about their life and recent stressors before making such a stigmatizing and often difficult to redact (due to medico-legal reasons) diagnosis. Many patients are reacting appropriately to the environment (feeling stressed and afraid about Covid or possible job loss) and they will improve as time passes or with some encouragement or increased psychosocial support. By under-diagnosing patients (as much as is allowed by insurance companies), you avoid giving them such a stigmatizing and difficult to remove diagnosis. "Always right your diagnosis in pencil, not pen"

Explain under-diagnosing a patient

Suprachiasmatic nucleus

Exposure to light helps entrain the circadian system by activating nonvisual retinal photoreceptors that project to what brain structure?

Sertraline Paroxetine Venlafaxine XR

FDA approved drugs for social anxiety disorder

Borderline personality disorder

Fear of abandonment is a core feature of which of the following disorders? A. Agoraphobia B. Delusional disorder C. Separation anxiety disorder D. Avoidant personality disorder E. Borderline personality disorder

Flight of ideas - if you ask them what they want to do, I.e. after they're out of the hospital, they'll tell you so many different things: "go back to school, write a book, create music, teach children, move to Alaska, etc. Racing thoughts - they have so many thoughts firing in their head that it comes out as pressured hyper-verbal speech. The outward manifestation is sometimes called flight of ideas

Flight of ideas vs. racing thoughts?

Seek contact eagerly

Following a brief separation from the parents, a securely attached toddler is most likely to do which of the following A. Seek contact eagerly B. Express distress C. Express anger D. Appear indifferent E. Appear startled

Maintena: 14 days Aristada: 21 days

For how long do you have to continue PO Abilify once you give its LAI?

Within the 1st year

For how long is the suicide risk the highest after a SA in a child?

Phallic (3-6 years)

Freud believed patients had fantasies of incest with the opposite-sex parent coupled with feelings of jealousy toward the same-sex parent during which of following stages?

Parkinson's disease

Gait characterized by postural instability accompanied by festination and truncated rigidity is seen in?

School age children

Gradually integrating new experiences into pre-existing mental constructs describes the cognitive strategy of what age group?

Clonidine is more sedating. May prefer Guanfacine as a result

Guanfacine vs Clonidine for ADHD?

Insular cortex The insular cortex (also insula and insular lobe) is a portion of the cerebral cortex folded deep within the lateral sulcus (the fissure separating the temporal lobe from the parietal and frontal lobes) within each hemisphere of the mammalian brain.

Gustatory special sensory seizures (aura) are localized to a focus in which of the following brain structures? Where is the structure in the brain?

Sleep onset

HPA axis related cortisol production is less active during which of the following sleep-related activities? A. REM sleep B. Sleep onset C. Sleep deprivation D. Morning awakening E. Nocturnal awakening

The two types of non-associative learning are habituation and sensitization. Habituation is a decreased response with repeated exposure to the stimulus. Sensitization is an increasingly strong response with repeated exposure to the stimulus.

Habituation vs sensitization

33 hrs

Half life of Lamotrigine

Having a childish, fantastic quality

Hallucinations and patience with conversion disorder characterized as: A. Having a childish, fantastic quality B. Involving a single sensory modality C. Being one of many psychotic symptoms D. Being described only reluctantly to the examiner E. Rarely being psychologically meaningful to the patient

Hallucinosis refers to the presence of hallucinations in an otherwise normal mental state, without confusion, disorientation, or psychosis. Trailing: perceptual abnormality associated with hallucinogenic drugs in which moving objects are seen as a series of discrete and discontinuous images. Ex. object in motion leaving frozen copies in its wake.

Hallucinosis vs trailing

HAM-D: the most widely used clinician-administered depression assessment scale. Beck: also one of the most widely used scales for depression but is self-reported (patients can do it themselves)

Hamilton Rating Scale for Depression (HAM-D) vs. Beck Depression Inventory

Tuberomammillary

Histaminergic neurons that regulates sleep originate in which brain nuclei?

Can be difficult To distinguish. Borderline personality disorder is more likely to have suicide attempts, identity diffusion, and brief psychotic episodes

Histrionic vs Borderline?

MDD

Hoarding disorder is most commonly accompanied by which disorder?

They can be used for their sedative side effects

How are antipsychotics used off-brand to treat agitation in dementia?

1. Metabolic side effects (ex. DKA) 2. Arrhythmias 3. Seizures 4. Ileus (presents as constipation, can result in toxic megacolon; according to Surya, this is a VERY common cause of death)

How can clozapine cause death?

Quality of the parent-child attachment

In 2 to 3 year old children the capacity to tolerate frustration is primarily influenced by what?

Viibryd. It is more calming than Trintillex so should be preferred for depression and anxious patients

Is Viibryd or Trintillex better for depression and anxiety?

Rarely

Is Wellbutrin overdose lethal?

There are some studies to suggest that osteopathic medicine can help treat depression, anxiety, ADHD, ASD. However, nothing concrete. But practically it could have lots of potential. You could add a DO to your private practice to offer different stretching and movements that help alleviate some depression/anxiety and charge cash for it. You could also use some techniques to alleviate associated problems (ex. Pedal pump to help alleviate constipation caused by antipsychotics instead of giving more meds). And finally, you can teach patients some techniques to try at home (ex. Laying on the floor with a tennis ball over the occipital where the head and neck intersect to reduce headaches, improve lymphatic flow, and increase relaxation)

How can osteopathic medicine be used in psychiatry?

Serum prolactin is elevated following epileptic seizures. It will not be elevated after a non-epileptic seizure.

How can serum prolactin be helpful in differentiating epileptic versus non-epileptic seizure?

Which one does not belong: -pair of scissors - canary - spider Why?

How can you assess abstract reasoning?

1. Fluency: full command of the English language or not (range- minimum to full) 2. Amount: increased (hyperverbal), decreased (hypoverbal), normal 3. Tone (think of a mom saying, "Don't take that tone with me): irritable, anxious, timid 4. Volume: loud, quiet, normal

How can you describe speech in the MSE?

Dementia is a diagnosis of history. It can't be done during one evaluation with an assessment like MOCA. You need to see progression. An abnormal MOCA in one setting will reflect delirium

How can you diagnose dementia in an inpatient setting?

Malignant catatonia — Most problematic in the differential diagnosis of NMS, malignant catatonia shares clinical features of hyperthermia and rigidity with NMS. However, in this syndrome, there is usually a behavioral prodrome of some weeks that is characterized by psychosis, agitation, and catatonic excitement.

How can you differentiate NMS from malignant catatonia?

In delirium, attention is impaired, and all of the cognitive processes are therefore also impaired. In dementia, attention is intact, but the cognitive processes, particularly memory, are impaired. A delirious patient has difficulty sustaining his attention for a significant period. As in Chapter 21, I discourage reliance on traditional and unproved tests of attention, such as the subtraction of serial sevens test (SSST), and instead encourage you to rely on your patient's ability to respond to routine questions

How can you differentiate dementia from delirium based on the mental status alone? What is the best way to note this distinction?

Drug induced is symmetric in presentation and doesn't respond to anti-Parkinsonism drugs. Treated by discontinuing causative drug.

How can you differentiate drug induced Parkinsonism from idiopathic Parkinsonism

ID will appear earlier in life (school-years. They're more likely to be in special Ed classes). Cognitive decline will become more apparent in adult years in schizophrenia

How can you differentiate intellectual disability from schizophrenia?

Patients with mood disorders are usually higher functioning (graduated high school/college, hold jobs, more independent). Their illness is episodic in nature therefore they are able to do more. This differs from schizophrenia spectrum disorders bc those symptoms are more constant

How can you differentiate mood disorders with psychotic features from schizophrenia spectrum disorders based on social history?

True seizures do not have eye closure.

How can you differentiate seizures from psychogenic seizures based on eyes?

In distinguishing grief from a major depressive episode (MOE), it is useful to consider that in grief the predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and the inabil ity to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease an intensity over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated with thoughts or reminders of the deceased. The depressed mood of MDE is more persistent and not tied to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The thought content associated with grief generally features a preoccupation with thoughts and memories of the deceased rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-derogatory ideation is present in grief, it typically involves perceived failings vis-a-vis the deceased (e.g., not visiting frequently enough, not tell ing the deceased how much he or she was loved). If a bereaved individual thinks about death and dying, such thoughts are general focused on the deceased and possibly "joining" the deceased, whereas in MDE, such thoughts are focused on ending one's own life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.

How can you distinguish grief from MDD?

Be careful not to confuse the sleeolessness of depression or anxiety with mania. Patients with mania stay awake because they have so much to think about and do, whereas depressed patients stay awake because they feel tortured by their feelings. Therefore, be sure to ask patients what sorts of things they do when they can't sleep. Patients with mania will report productive activities, whereas depressed patients will read or watch television as they wait for the solace of sleep.

How can you distinguish insomnia of depression from sleeplessness of mania?

A good way to distinguish manic racing from anxious racing is to ask: "Were your thoughts racing in a good way or in an unpleasant, worried, or depressed way?" Patients experiencing manic episodes often have a sense of an "accelerated" thought process that is like a joyride in a stolen car. Patients with anxiety or depression will feel very differently.

How can you distinguish racing thoughts of mania from racing thoughts of anxiety/depression?

Ask them how they were before they started using. How was their sleep, mood, any hallucinations before sub use? If not, more likely to be sub-induced

How can you distinguish substance-induced psych disorder from independent psych disorder?

Short acting. There are less side effects such as falls.

Is a long acting or short acting BZD preferred in the elderly? Why?

There are four major defense mechanisms: mature, neurotic (transitional), immature, and psychotic. You can broadly view these categories based on the level of awareness of the negative emotion and the effect that defense mechanisms have on the individual and others around them. Mature defense mechanisms, which includes suppression, altruism, sublimation, humor, is broadly characterized by an awareness of the negative emotion and a healthy psychological reaction to it, i.e. being conscious of an emotion but suppressing it at a later time or expressing the emotion in a humorous way. Neurotic mechanisms are less healthy than mature and are characterized by the individual being not fully aware of the negative emotion and psychologically reacting in a way that can result in future pain. Examples of neurotic mechanisms are denial, repression, reaction formation, displacement, rationalization. These defense mechanisms tend to not hurt others rather hurt the individual. Immature defenses I characterized by the individual not being fully aware of the negative emotion and associated with a negative impact on people around the individual. Examples include passive aggression, acting out, dissociation, projection, splitting. Psychotic defenses are self-explanatory and include denial of extra reality and distortion of external reality.

How can you distinguish the three major types of defense mechanisms?

NOTECARDS

How can you examine a patient for catatonia based on the Bush Francis Scale?

How does one get beyond the "I don't know" syndrome? One way is to give the patient permission to plead the fifth: "Look, if you really don't know something, that's fine. But if you don't want to tell me something, that's okay too. Just say, "I don't want to say."" Another strategy is to ask the "fly on the wall" question: "If I were a fly on the wall when you get into one of your moods, what would I see?" or, a slight variation, "What would your friend look like if he looked like you in one of your moods?" These questions invite the patient to describe his behavior, a less threatening proposition than describing a subjective state.

How can you handle a patient who repeatedly says "I don't know" to your questions?

Start Terazosin

How can you manage excessive sweating caused by SSRIs?

Clinical strategies to manage insomnia include use of diphenhydramine (25 to 75 mg), low dose of trazodone (25 to 50 mg), or the addition of an a-adrenergic agent, such as guanfacine. In some cases, insomnia may attenuate on its own after several months of treatment.

How can you manage insomnia caused by stimulants for ADHD?

For interdose symptoms of anxiety, can either increase dose or maintain same total daily dose but divide into more frequent doses, or give as extended-release formulation

How can you manage interdose anxiety when a patient is on BZD?

With CBT or with an mTORC inhibitor (Rapamycin) They both increases synaptic connectivity

How can you prolong the duration of ketamine?

Dosing (24-hour patch) After 4-6 weeks of smoking abstinence, taper every 2-4 weeks in 7-14 mg steps as tolerated.

How can you taper nicotine patches?

Stop the offending agent Drugs (varying efficacy and minimal evidence of effectiveness) 1. Anticholinergics 2. Beta blockers 3. Amantadine 4. Mirtazapine 5. Clonidine

How can you treat akathisia?

Phototherapy typically involves exposing the affected patient to bright light in the range of 1 ,500 to 10,000 lux or more, typically with a light box that sits on a table or desk. Patients sit in front of the box for approximately 1 to 2 hours before dawn each day, although some patients may also benefit from exposure after dusk. Alternatively, some manufacturers have developed light visors, with a light source built into the brim of the hat.

How can you use phototherapy to treat depression?

It is postulated that they cause hyponatremia due to the syndrome of inappropriate ADH secretion.

How do I SSRIs cause hyponatremia?

1. Disulfiram (Antabuse): - Builds up acetaldehyde 2. Naltrexone (ReVia) - Reduces craving and reduces reward in response to drinking 3. Acamprosate (Campral) - Unknown

How do the only drugs FDA approved to treat alcohol disorder treat it?

Check BP and HR while the patient lies supine, then sitting upright, then standing. These vitals should be checked ASAP after changing positions. BP drop of 20/10 or more and HR increase of 20 or more is considered orthostatic.

How do you check orthostatic vitals? At what point does a patient have orthostatic vitals?

NOTECARDS

How do you conduct an MSE per Dr. McEvoy?

The diagnosis of disruptive mood dysregulation disorder requires each of the following criteria [29]: ●Severe, recurrent verbal (eg, screaming) or behavioral (eg, physical aggression) angry outbursts that are grossly out of proportion to the provocation. ●The outbursts are not appropriate for the patient's developmental level. ●The outbursts occur, on average, at least three times per week. ●The outbursts occur in at least two settings from among home, school, or with peers. ●Persistently irritable or angry mood most of the day, nearly every day, between outbursts. ●Symptoms have occurred for at least 12 months. Symptom free periods can occur, but may not exceed three months during the one year timeframe. ●Age at onset <10 years. The diagnosis cannot be given for the first time before age 6 years or after age 18 years. ●The patient has never had a period lasting more than one day during which the full symptom criteria for mania or hypomania, except duration, have been met. ●Symptoms do not occur solely during unipolar major depressive episodes, and are not better explained by other mental disorders (eg, autism). ●The symptoms are not attributable to the physiologic effects of a substance or medication, or to another medical disorder. (See 'Substance/medication induced depressive disorder' below and 'Depressive disorder due to another medical condition' below.)

How do you diagnose Disruptive Mood Dysregulation Disorder?

They both has same symptoms (DIG FAST) but in hypomania they have to last at least 4 days (vs 1 week) and hypomania is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization.

How do you distinguish hypomania from mania?

✽ Bipolar disorder (monotherapy, see chart): for the first 2 weeks administer 25 mg/day; at week 3 increase to 50 mg/day; at week 5 increase to 100 mg/day; at week 6 increase to 200 mg/day; maximum dose generally 200 mg/day Slow titration may reduce incidence of skin rash

How do you dose Lamotrigine? Why is this titration so slow?

A) Supportive measures - Fluid and nutrition (multivitamins, thiamine, B12, etc) - Reorientation or memory cues (calendar, clocks, family photos) - Stable, quiet, and well-lit environment - Correct sensory deficits (if they wear eyeglasses or use hearing aids make sure they have them) - Support from family or a familiar nurse - Avoid physical restraints and rather use constant supervision (sitter) B) TREAT THE UNDERLYING CAUSE C) Pharmacological management - Only used to treat agitation and hallucinations - 1st choice: Haldol 1-2 mg BID (0.5-1 mg BID if elderly). Adv. can be given IV, IM, PO - Other options: Risperidone and Olanzapine (can't give them IV bc if orthostatic hypotension risk)

How do you manage delirium?

✽ If patient develops signs of a rash with benign characteristics (i.e., a rash that peaks within days, settles in 10-14 days, is spotty, nonconfluent, nontender, has no systemic features, and laboratory tests are normal): • Reduce lamotrigine dose or stop dosage increase • Warn patient to stop drug and contact physician if rash worsens or new symptoms emerge • Prescribe antihistamine and/or topical corticosteroid for pruritis • Monitor patient closely ✽ If patient develops signs of a rash with serious characteristics (i.e., a rash that is confluent and widespread, or purpuric or tender; with any prominent involvement of neck or upper trunk; any involvement of eyes, lips, mouth, etc.; any associated fever, malaise, pharyngitis, anorexia, or lymphadenopathy; abnormal laboratory tests for complete blood count, liver function, urea, creatinine): • Stop lamotrigine (and valproate if administered) • Monitor and investigate organ involvement (hepatic, renal, hematologic) • Patient may require hospitalization • Monitor patient very closely Lamotrigine rashes usually occur within 1-12 weeks of treatment Risk of serious rash = 1% and benign rash = 10% Lamotrigine can be tried again after a patient develops a benign rash given the limited treatment options for bipolar depression. If it is re-tried, use a very slow titration.

How do you manage rash side effect of Lamotrigine? When does a rash due to Lamotrigine usually develop? What is the risk of serious and benign rash and can you restart Lamotrigine after a rash develops?

Start at 500 mg QD and then you can increase to 500 mg BID then 850 mg BID (usually max)

How do you prescribe metformin when treating metabolic syndrome caused by second generation antipsychotics?

If you restart it <2 days after they stopped it, restart with last dose If you restart it >2 days after they stopped it, you have to start from scratch but you can retitrate faster (increase by 50 every two days or by 25-50 every day. The speed depends on several factors)

How do you retitrate clozapine after a patient who was prescribed it stops taking it?

Taper over at least 2 weeks because rapid Discontinuation can increase the risk of relapse in bipolar disorder

How do you stop Lamotrigine?

Ativan taper - 1 mg q4h x 24 hrs then - 1 mg q6h x 24 hrs then - 1 mg q8h x 24 hrs then - 1 mg q12h x 24 hrs then -1 mg q24 h Valium taper - 10 mg q6h x 24 hrs then - 10 mg q8h x 24 hrs then - 10 mg q12h x 24 hrs then - 10 mg q24h x 24 hrs then - 5 mg q24h x 24 hrs

How do you taper Ativan or Valium for alcohol withdrawal?

Paroxetine and venlafaxine Gradually taper over 2-4 weeks

How do you taper antidepressants with half-life <24 hrs? Which drugs are these?

Average schedule (may vary among patients) - 120 mg plus 60 mg q4hr PO on day 1 - 60 mg q6hr on day 2 - 60 mg q8hr on day 3 - 60 mg q12 hr on day 4 - 60 mg on day 5 - Stop Horizontal nystagmus develops if they have enough phenobarbital. You don't have to go up on dose then.

How do you taper phenobarbital for alcohol withdrawal? What is a good physical sign that a patient has enough phenobarbital

50% reduction for three days then another 50% reduction for three days and discontinuation.

How do you taper venlafaxine to avoid withdrawal symptoms?

DMDD is treatable, usually with behavioral therapy or a combination of behavioral therapy and medication. Psychotherapeutic: The goal in DMDD treatment is to help children learn to regulate their emotions and avoid extreme or prolonged outbursts. A combination of dialectical behavior therapy for children (DBT-C) and parent management training has been found to be very effective in treating disruptive mood dysregulation disorder. Pharmacological: Medication can be prescribed when therapy and parent training are not available, or not effective alone. Stimulant medication, which helps kids rein in impulses, and an antidepressant with mild side effects, like SSRIs, are usually a first step when medication seems necessary. If that combination doesn't work, or if there's an urgency to the situation, a low dose of an atypical antipsychotic such as Risperdal can be prescribed.

How do you treat DMDD?

1st give IV or IM anticholinergic (Benadryl, Benzatropine, Trihexyphenidyl) 2nd give a short course of oral anticholinergic for some time Avoid the causative agent moving forward

How do you treat acute dystonia?

Ideal treatment consists of removing the offending agent, decreasing the dose of the offending agent, or switching to a less potent antipsychotic drug. Can also switch antipsychotics to ones that are less likely to cause it like Seroquel and Clozapine (same as TD). There are no highly effective symptomatic therapies for drug-induced parkinsonism. In patients with severe symptoms that interfere with quality of life in whom the offending medication cannot be safely discontinued, we suggest a trial of levodopa. Amantadine and anticholinergics are also reasonable options. Electroconvulsive therapy (ECT) may be an option in patients with a concurrent indication such as refractory depression.

How do you treat antipsychotic-induced Parkinsonism?

The preferred treatment for hallucinogen intoxication is talking down the patient; during this process, guides can reassure patients that the symptoms are drug induced, that they are not going crazy, and that the symptoms will resolve shortly. In the most severe cases, dopaminergic antagonists-for example, haloperidol (Haldol}----or benzodiazepines-for example, diazepam (Valium}-can be used for a limited time.

How do you treat hallucinogen intoxication?

He'll first try Haldol or Abilify. If that's ineffective, then try Zyprexa. If that doesn't work then Clozaril. HOWEVER, residency is a time to learn. So prescribe all the antipsychotics you want and learn what works best. Then master that antipsychotic and become very proficient with it

How does Dr. McEvoy usually prescribe antipsychotics?

You will need to lower the starting dose by around half.

How does Renal and/or hepatic impairment effect diazepam does?

This observation led to the use of left vagal nerve stimulation (VNS) using an electronic device implanted in the skin, similar to a cardiac pacemaker. Preliminary studies have shown that a number of patients with chronic, recurrent major depressive disorder went into remission when treated with VNS. The mechanism of action of VNS to account for improvement is unknown. The vagus nerve connects to the enteric nervous system and, when stimulated, may cause release of peptides that act as neurotransmitters.

How does Vagal nerve stimulation treat depression?

Genetic studies, brain imaging, and neurocognitive and pharmacological studies in adults with ADHD have replicated findings demonstrated in children with ADHD. In attention and impulsivity are key findings (e.g., difficulty in organizing and complet ing work, inability to concentrate, increased distractibility, and sudden decision-making without thought of the consequences). These symptoms are described as A LIFE LONG PROBLEM GENERALLY (should have school problems) not as episodic events. T/t: stimulants are the only FDA approved drugs

How does adult ADHD differ from childhood ADHD based on studies and imaging? What are the prevailing C/F? What is the treatment?

It is a skeletal muscle relaxant so it can relieve rigidity

How does dantrolene help treat neuroleptic malignant syndrome?

Renal Impairment • Drug should be used with caution Hepatic Impairment • Should begin with lower starting dose (0.5-0.75 mg/day in 2 or 3 divided doses) Cardiac Impairment • Benzodiazepines have been used to treat anxiety associated with acute myocardial infarction

How does renal, cardiac, and hepatic impairment affect Xanax dosing?

Renal and cardiac impairment - no change Hepatic impairment - contraindicated (it's hepatotoxic)

How does renal, cardiac, hepatic impairment affect Depakote dosing?

Renal Impairment • No dose adjustment necessary • Not removed by hemodialysis • Intramuscular formulation should be used with caution Hepatic Impairment • No dose adjustment necessary Cardiac Impairment • Ziprasidone is contraindicated in patients with a known history of QTc prolongation, recent acute myocardial infarction, and uncompensated heart failure • Should be used with caution in other cases of cardiac impairment because of risk of orthostatic hypotension

How does renal, hepatic, and cardiac impairment affect Geodon dosing?

Renal Impairment • Lamotrigine is renally excreted, so the maintenance dose may need to be lowered • Can be removed by hemodialysis; patients receiving hemodialysis may require supplemental doses of lamotrigine Hepatic Impairment • Dose adjustment not necessary in mild impairment • Initial, escalation, and maintenance doses should be reduced by 25% in patients with moderate and severe liver impairment without ascites and 50% in patients with severe liver impairment with ascites Cardiac Impairment • Clinical experience is limited • Drug should be used with caution

How does renal, hepatic, and cardiac impairment affect Lamotrigine dose?

Renal impairment - no issues Hepatic impairment - may need to lower dose (oral and IM form) and if there's liver disease, check LFTs a few times in a year Cardiac impairment - use with caution bc of risk of orthostatic hypotension

How does renal, hepatic, and cardiac impairment affect Olanzapine?

Consequently, potential suicide victims are likely to be male, unmarried, unemployed, socially isolated, and living alone-perhaps in a single room. After discharge from their last hospitalization, they may experience a new adversity or return to ongoing difficulties. As a result, they become dejected, experience feelings of helplessness and hopelessness, reach a depressed state, and have, and eventually act on, suicidal ideas. Only a small percentage committed suicide because of hallucinated instructions or a need to escape persecutory delusions

How does schizophrenia result in suicide?

Sleep restriction therapy requires patients to limit the amount of time they spend in bed to an amount equal to their average total sleep time. In order to accomplish this, the clinician works with the patient to (1) estab- lish a fixed wake time and (2) decrease sleep opportunity by limiting the subject's time in bed (TIB) to an amount that equals their average total sleep time (TST) as ascertained by baseline sleep diary measures. The stan- dard form of this therapy recommends that the restriction be no less than 4.5 hours. Once a target amount of time in bed is set, the patient's bedtime is delayed to later in the night so that the TIB and average TST are the same. Initially, this intervention results in mild to moderate sleep loss. This con- trolled form of sleep deprivation (partial sleep deprivation) usually corre- sponds to a decrease in sleep latency and wake after sleep onset time. Thus, during the acute phase of treatment, patients get less sleep, but they sleep in a more consolidated fashion (i.e., they fall asleep more quickly and stay asleep for longer periods of time). As sleep efficiency increases, patients are instructed to gradually increase the amount of time they spend in bed. Upward titration is accomplished in 15-minute increments; given sleep diary data that shows that for the prior week the patient's sleep was effi- cient (90% or more of the time spent in bed was spent asleep [TST/TIB]).

How does sleep restriction therapy for insomnia work?

The longer the half life, the less frequently it needs to be given in a day. For example, Olanzapine has a half life of at least 21 hrs so it can be dosed QD, but Haldol has a half life of at least 12 hrs so it would be reasonable to dose it BID

How does the half life of a drug influence the drug schedule

Tolerance can start to decrease as quickly as one week since the last dose. This is medically relevant bc patients who are abstinent could OD if they relapse and use the same amount they once did

How fast does tolerance to opioids disappear?

VERY IMPORTANT The goal of treatment in bipolar disorder is SUSTAINED REMISSION. Remission is actually possible in bipolar unlike schizophrenia and if achieved, these people can live normal lives. Greater number of episodes make it harder to achieve sustained remission and the episodes cause a number of other issues, ex. Substance use, uninhibited behavior leading to financial, occupational, physical health, familial/social problems. It's crucial to identify bipolar patients early on so they can be started on prophylactic treatment once the episode is controlled so that they can live full lives. Prophylactic of choice is LITHIUM

How important is prophylactic treatment after a first manic episode?

It is most often used to separate temporal lobe seizures from pseudoseizures and to distinguish dementia from pseudodementia caused by depression.

How is EEG used in clinical psychiatry?

1. Infection 2. NMS 3. Pulmonary embolism Catatonia results in a hypercoagulable state, due to a number of reasons. Risk factors include immobility, hypercoagulable state, induced by stress hormones, hypercoagulability caused by antipsychotics. What has been seen in a few case reports is that pulmonary embolism usually develops two weeks into catatonia. As catatonia improves, the patient become more mobile and this dislodges the thrombi in the leg. PE can be prevented by quickly resolving catatonia with benzos an ECT. IT IS ALSO IMPORTANT TO LOOK FOR ANY SIZE DISCREPANCY IN PATIENT'S LOWER EXTREMITIES WITH MEASURING TAPE. SINCE THEY CANNOT VOICE DISCOMFORT. There is some thought behind starting low-dose anticoagulant.

How is catatonia deadly? Explain why the last one occurs and what can be done to prevent it.

As one between equals. The clinician is the expert in understanding and treating psychological problems and the client is the expert on herself. Both need to work together.

How is the therapeutic relationship in CBT viewed?

Eight days

How long after taking PCP can still be found in the urine?

30-60 days because the absorption rate is slow

How long do you continue Haldol PO after starting Haldol Dec and why?

2 weeks

How long does a patient need to have psychotic symptoms in the absence of mood symptoms to be diagnosed with SCAD?

At least 1 month

How long does a person have to be exposed to dopamine receptor blocking agents to develop traduce dyskinesia?

Like other antidepressants, Remeron can take up to 2 to 4 weeks before a therapeutic effect on depression is noticed. However, it's actions on insomnia and anxiety can start shortly after initiation of dose, most likely due to its antihistaminic effect.

How long does it take for Remeron to act on depressive symptoms, insomnia, and anxiety?

Some benefit should be felt after the following number of weeks: GAD - around six weeks PTSD - around eight weeks OCD - 10 to 12 weeks This is significant because these medications should start exerting there effect in 2-4 weeks when treating depression

How long does it take for SSRIs/SNRIs to exert their effect when treating the various anxiety disorders?

20 units/hr

How long does it take for alcohol to metabolize?

1 week

How long does it take for clozapine levels to come back from the lab?

It can start within a week but onset can take longer

How long does it take for duloxetine to start reducing neuropathic pain?

A few weeks

How long does it take to feel the effects of Trileptal when treating acute mania?

Up to six weeks

How long does somebody have to take Wellbutrin if they're taking it for smoking cessation?

Before considering a patient a poor responder to a particular drug, it is important to assure that they received an adequate trial of the medication. A 4- to 6-week trial on an adequate dose of an antipsychotic represents a reasonable trial for most patients. Patients who demonstrate even a mild amount of improvement during this period may continue to improve at a steady rate for 3 to 6 months

How long should a patient be on an antipsychotic before you consider them to be a poor responder?

At least two years

How long should you continue antidepressant treatment in a patient who has had multiple episodes of depression?

At least 6 months or the length of the previous episode, whichever is greater

How long should you maintain antidepressant therapy after remission of symptoms?

Some immediate relief with first dosing is common; can take several weeks with daily dosing for maximal therapeutic benefit

How long until BZDs usually work?

At least 2

How many antipsychotics need to be tried before starting clozapine?

1/3

How many patients do not respond to the first antidepressant that is prescribed?

Around 100 mg Max is 400 mg/day The amount varies per person but some reports suggest as low as 250 mg but other reports indicate greater than 800 mg

How much caffeine is in an average cup of coffee? What's the max amount a person can have in one day? How much is needed to cause psychosis?

Don't tell them anything about the patient without the patient's consent. When family calls, do nothing bring up material that the patient has shared but rather listen to the unlit from the family member

How much info should you give to patient's family when they call?

Although it's been taught that Lithium can cause serious side effects and a narrow therapeutic margin must be maintained, the side effects are more benign than presumed. Whenever side effects occur, it would be wise to first reduce the dose of Lithium as it has been found to be effective at serum levels of 0.4-0.5. Also it would be wise to treat the side effects rather than to discontinue lithium if they persist despite dose reduction (ex. For Tremors give beta blockers, for hypothyroidism, give thyroid hormone supplementation, for nephrogenic DI give amiloride). Also when it comes to renal toxicity, if you start to see Cr rise (above 1.2) and GFR rise, first reduce dose rather than just discontinue. And remember that these renal toxic effects are not unique to lithium, they can also be seen with anticonvulsants VERY IMPORTANT TO GIVE PATIENTS WHO NEED LITHIUM LITHIUM AS IT IS SO BENEFICIAL. CONTROL SIDE EFFECTS OR REDUCE THE DOSE IN THE EVENT AE OCCURS RATHER THAN D/CING LITHIUM

How serious are lithium side effects and how can the be managed?

✽ QTc prolongation fears are often exaggerated and not justified since QTc prolongation with ziprasidone is not dose- related and few drugs have any potential to increase ziprasidone's plasma levels ✽ Efficacy may be underestimated since ziprasidone is mostly under-dosed (<120 mg/day) in clinical practice

How serious is QTc prolongation side effect of Geodon?

Take lithium with food to prevent nausea. Honestly tell people to take every med with food Lithium is a salt in water so take it with water and stay hydrated. If losing lots of water through diarrhea or vomiting, REPLACE IT

How should a person take lithium? How does water intake affect it?

For the augmentation of SSRI treatment in MDD, the most robust evidence is available for atypical antipsychotics, particularly aripiprazole and quetiapine extended-release. However, the serious adverse effects of atypical antipsychotics make it prudent to consider other agents for first-line augmentation therapy; agents should be chosen on the basis of best practice and medical evidence. Supplements, while not traditionally considered augmentation options, have fewer adverse effects and have a growing evidence base supporting their use. Other options include mirtazapine or referrals for neuromodulation. T3, bupropion, and buspirone are fair options, if one keeps in mind that placebo-controlled evidence of their efficacy with SSRIs is limited. The role of topiramate, lamotrigine, pindolol, pramipexole, and sex hormones is unclear, given the evidence at this time. Data indicate that stimulants do not have a role in augmentation. It makes sense to use lithium only after other agents have failed because of associated long-term risks. Newer options, such as ketamine-based compounds and tDCS, show promise for augmentation, but they would benefit from more rigorous trials before widespread clinical use.

How should you augment SSRI treatment or MDD based on article McEvoy sent?

Instead of framing it as the problem, look at it as a SOLUTION to an underlying problem.

How should you frame suicidal thoughts?

The available antidepressants do not differ in overall efficacy, speed of response, or long-term effectiveness. Antidepressants, however, do differ in their pharmacology, drug-drug interactions, short- and long term side effects, likelihood of discontinuation symptoms, and ease of dose adjustment.

How should you pick an antidepressant?

Taper it. Rapid discontinuation increases risk of relapse in bipolar disorder

How should you stop Depakote?

Taper gradually over 1-2 weeks

How should you stop and taper antidepressants?

Any method works. There are no reported problems with stopping Olanzapine suddenly. You can gradually reduce Zyprexa then start new one, suddenly stop zyprexa and start a new one, partial overlap, full overlap

How should you switch/cross-taper from Olanzapine to another antipsychotic?

Explain to the patient that you will read the names of 3 to 5 objects, and practice them with the patient until the patient can repeat them perfectly. Then ask the patient to store the names while you do other tasks, and clarify that you will later ask for the names again. At least 5 minutes later ask the patient to retrieve the names from memory

How should you test delayed recall per Dr. McEvoy?

Start at 25 mg and increase by 25 every 2 days until you hit 400. Titrating it faster or with larger doses could increase risk of myocarditis

How should you titrate Clozaril?

Use either lithium or Depakote. Try to avoid antipsychotics due to their side effects. Lithium reduced mania a bit more

How should you treat mania in elderly bipolar patients?

Dissociative disorders

Hypnosis can treat what psychiatric disorder?

According to DSM-IV, somatization disorder has a specified number and type of somatic symptoms, whereas hypochondriasis is characterized by abnormal attitudes and beliefs about illness [16]. The criteria for hypochondriasis mention bodily symptoms but do not indicate what these might be. NOTECARD

Hypochondriasis vs. somatization disorder

Word knowledge

I'm normal aging, which of the following cognitive abilities is the last to show decline? A. Perceptual speed B. Inductive reasoning C. Numberical ability D. Spatial orientation E. Word knowledge

IEP - This is a more intensive plan that provides individualized special education and related services to meet a child's unique needs - In order to qualify for an IEP, a child must have one of the 13 disabilities listed in IDEA (ex. ADHD, learning disabilities, autism) and that disability must affect the child's educational performance and/or ability to learn from the general education curriculum. The child must need specialized instruction to make progress in school. 504 plan - This appears to be a step below IEP, and provide services and changes to the learning environment to enable students to learn alongside their peers - In order to qualify, a child has to have a disability, any disability, and that disability must interfere with a child's ability to learn in the general education classroom

IEP versus 504 plan

Parietal lobe

IQ is mostly a function of which brain lobe?

Methylphenidate

If a catatonic patient does not respond to Ativan or Ativan is contraindicated, what can you give instead?

Recent meta-analysis of clinical trials found only 4% of depression patients who did not show symptom improvement after two weeks went on to achieve remission. This suggests that if your patients haven't shown any improvement after two weeks on a specific anti-depressant the chances of achieving remission are very low. Ideally, you should reassess a patient 2 weeks after their initial visit to see if they're responding (can tell them to message you after two weeks if they're not improving). If they're showing partial improvement at 2 weeks, continue at the dose and reassess but if there's no improvement at 2 weeks, TITRATE. TITRATE EVERY 2 WEEKS IF NEEDED.

If a patient does not show symptom improvement after being on an antidepressant for at least two weeks, what is the likelihood that they will achieve remission? What is the significance of this finding?

Depakote It takes longer to taper Lamictal

If a patient is on Depakote and Lamictal and you need to stop one for whatever reason, which one should you?

Stimulants (for hyperactive/inattentive) and alpha adrenergic agonist (impulsivity) together from the beginning

If a patient presents with very severe ADHD, how will you treat them?

They may be Bipolar. Antidepressants do not relieve bipolar depression alone but ketamine does

If a person has tried so many antidepressants and nothing helps except ketamine, what could that indicate?

Lamotrigine Really good at preventing relapse of Bipolar depression and to a lesser degree mania *according to Dr. McEvoy. Different people may practice differently. Some may choose to start Depakote. But Depakote has its own problems (hepatotoxic, teratogenic, pancreas AE)

If despite treatment of bipolar with lithium and an anticonvulsant, mania or depression persists, what can you give next?

Understanding clients' difficulties and how to treat them. This is an ongoing process that develops with each session. It's a working hypothesis of how the clients' particular problems can be understood in terms of the cognitive behavioral model. Rather than seeing the client solely as a collection of symptoms, it helps the clinician to think clearly about the reason for, and the relationships among, these symptoms. It's like putting together a jigsaw puzzle Also, this is done in collaboration with the client. The clinician should present their hypothesis and give the client the chance to give their input.

In CBT, what is case conceptualizstion?

Amygdala and prefrontal cortex

In Neuroimaging studies of bipolar disorder, decreased functional connectivity is seen between which structures?

It involves the use of very short pulses of magnetic energy to stimulate nerve cells in the brain.

In a nutshell how does TMS work?

Brainstem: autonomic processes, processes that occur reflexively like breathing and heart rate Cerebellum: balance and coordination of movement

In a nutshell, what does the brainstem and cerebellum do?

E

In a patient receiving long-term opioid therapy for management of chronic pain, which of the following is most indicative of opioid addiction? A. Reporting increased pain overtime B. Exhibiting signs of physical dependence C. Needing increasing doses for pain relief D. Developing withdrawal symptoms upon cessation of use E. Administering opioids by alternative routes are prescribed

Anti-depressant

In addition to benzodiazepines, which of the following classes of medications is most highly associated with the falls in patients older than 60? A. Diuretics B. Narcotics C. Beta blockers D. Antipsychotics E. Anti-depressants

Tracking clinic patients in a registry

In an integrated setting with primary care and mental health, which if the following would be a population-based technique used to provide collaborative care? A. Tracking clinic patients in a registry B. Having a care plan for each patient in the clinic C. Using evidence-based mental health treatments D. Ensuring good communication between primary care and mental health E. Having a mental health provider see patients when they are symptomatic

PTSD

In children with cancer, inadequate prophylaxis of pain and stress during difficult procedures, such as bone marrow biopsies is most likely to result in what condition?

Depressed mood OR Loss of interest or pleasure

In order to diagnose MDD, which one of two symptoms has to be present?

Often deficient on close exam even when it seems well preserved

In patients who show pronounced defects in recent memory, remote memory is what?

Amygdala

In social cognitive neuroscience and the study of social decision-making and bias, functional MRI has been used to show that the brain area consistently activated by subliminal presentation of emotional faces is the what?

Offending others

In some Japanese and Korean cultures, rather than an intense fear of embarrassing oneself socially, social phobia symptoms my instead manifest with an intense fear of: A. Underachieving B. Offending others C. Being overweight D. Remaining unmarried E. Having no male children

Finding by the jury

In states that permit the insanity defense in criminal cases, the determination that an individual lacks the state of mind required for committing a crime is determined by white?

Tobacco use disorder

In the United States, what is the number one preventable cause of death?

Week after menses

In the criteria for premenstrual dysphoric disorder, Symptoms are typically absent during which part of the menstrual cycle?

Acknowledging the interviewer's experience of frustration and inquiring if patient feels similarly

In the initial interview with a patient who has schizophrenia, feelings of confusion and frustration may be evoked in the interviewer when the patient becomes silent. What response represents the best approach to establish rapport?

Dementia with aggression Behavioral symptoms in children and adolescents

In what areas in terms of aggression is Risperidone often preferred?

Narcolepsy

In what condition do you see sleep onset REM?

Adolescents

In which one of the following groups has suicide increased dramatically over the past 40+ years? A. Geriatrics B. Married men C. Married women D. Adolescents E. Chronic alcoholics

It can cause bradycardia and falls. When an elderly patient is at risk of these and a patient has polypharmacy, consider discontinuing Donepezil. Other drugs can be given for dementia (like Memantine) and it would be more risky to discontinue them (Memantine discontinuation can result in agitation)

Is Donepezil safe in elderly populations?

Increased expression of serotonin reuptake transporters

Inflammatory, cytokines mediate depression through what neurophysiological change?

Interpersonal therapy

Intentionally assigning the sick role to a patient which serves to give the patient the permission and responsibility in order to recover, is a tenet of which of the following forms of psychotherapy?

Elementary

Interests in secrets, collecting, and participating in organized games is characteristic of which age group?

Intuniv = Guanfacine ER

Intuniv vs. Tenex

No, other psychotherapies have efficacy comparable to CBT

Is CBT superior to other psychotherapies in treating depression?

Overdose • Rare fatalities have been reported; serotonin syndrome, sedation, vomiting seizures, coma, change in blood pressure

Is Cymbalta OD fatal?

Cymbalta

Is Cymbalta or Effexor preferred for neuropathic pain?

Marijuana use does increase dopaminergic activity in the brain acutely. However chronic use actually reduces the release of dopamine. Therefore, acute is more likely to result in psychosis (especially if it's laced with something, ie Spice)

Is acute or chronic marijuana use more likely to result in psychosis?

It can be lethal. There are higher rates of death from overdust than the facts and then with SSRIs. Possible symptoms include sedation, convulsions, rapid heartbeat.

Is an overdose on venlafaxine dangerous? What are the manifestations?

Cocaine

Is cocaine or amphetamines more commonly associated with seizures?

Complete or partial hospitalization may be required to achieve abstinence in order to remove patients from triggering social settings and give them the opportunity to focus on therap

Is hospitalization required for stimulant related disorders?

Very important to address insomnia. According to Dr McCall, insomnia has been associated with worsening many psych symptoms, even increasing risk of SI. Getting a good nights rest consistently helps a lot. Always ask about sleep!!!

Is insomnia a really important symptom to address?

No, it's really lethal Symptoms include sedation, disorientation, memory impairment, rapid heartbeat

Is mirtazapine overdose fail? What are the symptoms of overdose?

Gradual

Is the onset of childhood-onset schizophrenia more gradual or sudden?

That depends If they have a substance use disorder, there is an increased risk but without one the risk is the same as a person without a mental disorder. Also the violence that does occur is more likely to occur in their own homes against family and friends

Is there an increased risk of violence from patients with mental disorder recently discharged from hospitals?

Yes, it is a possible movement disorder side effect Causes (secondary to many drugs) 1. SSRIs 2. Lithium 3. TCAs 4. Antiepileptics (ESPECIALLY VALPROATE) 5. Antipsychotics Either stop the offending agent, alter dose, or switch to another drug. Propranolol may be useful

Is tremor a side effect psych meds? If so, name the ones that can cause it and how would you manage it

Unilateral

Is unilateral electrode placement or bilateral associated with less cognitive impairment after ECT?

PCP MOA- antagonist at the NMDA subtype of glutamate receptors Half-lives - PCP: 20 hrs - Ketamine: 2 hrs

Ketamine is closely related to what drug? What are these two compounds MOA and half-lives?

Tetrahydrobiopterin (BH4)

L-methylfolate may be an effective augmentation agent for depression, because it increases production of serotonin, norepinephrine, and dopamine by increasing formation of what?

• Benign rash (approximately 10%) • Sedation, blurred or double vision, dizziness, ataxia, headache, tremor, insomnia, poor coordination, fatigue • Nausea, vomiting, dyspepsia, abdominal pain, constipation, rhinitis • Rare serious rash (risk may be greater in pediatric patients but still rare) • Rare multi-organ failure associated with Stevens-Johnson syndrome, toxic epidermal necrolysis, or drug hypersensitivity syndrome Sedation and weight gain are uncommon!! May actually be one of the best tolerated mood stabilizers with little weight gain or sedation

Lamotrigine AE?

Leptin - decreased appetite, inhibits hunger Ghrelin - increases appetite and food intake

Leptin versus Ghrelin

There are low levels of serotonin metabolite, 5-HIAA in the CSF Low levels of 5-HIAA in the CSF predict future shicidal behavior

Levels of what neurochemical are abnormal in patients with suicidal behavior? Can it be used to predict future suicidal behavior?

NOTECARDS

List the different types of memory

Atomoxetine and Reboxetine

List the selective norepinephrine reuptake inhibitors (NRIs)

Uric acid

Lithium can cause a decrease in which substance's blood levels?

Lithium carbonate: generic version Eskalith: brand name Eskalith CR: controlled-release of Eskalith. Less side effects but also lower peak plasma levels

Lithium carbonate vs Eskalith vs Eskalith CR

1. Sedation 2. Weight gain 3. Acne, rash, alopecia 4. Diarrhea, nausea 5. Ataxia, dysarthria, tremors 6. Nephrogenic DI (polyuria, polydipsia) 7. Hypothyroidism

Lithium side effects?

Lithium is more likely to result in fine tremors. Antipsychotics result in more course tremors. PS, think of what you saw with Dr. McCall during ECT elective.

Lithium vs antipsychotic induced tremors

Tangentiality: Replies to questions are off-point or totally irrelevant. Derailment (loosening of associations): spontaneous speech with marked impairments in topic maintenance

Loose associations vs. tangentiality

Hyponatremia

MDMA use is most typically associated with which electrolyte abnormality?

Dopamine agonists

MOA of stimulant medications?

E

Maintenance of wakefulness is dependent on which of the following areas of the brain? A. Oral Pontine B. Midbrain tegmentum C. Posterior hypothalamus. D. Anterior cingulate parietal cortex E. Ascending reticular activating system

The prevalence rates between males and females are comparable for bipolar disorder

Male versus female prevalence rates for bipolar disorder

PCP

Marijuana is commonly tainted with what hallucinogen?

Google image search

Methdone vs suboxone

NOTECARDS

Mild vs moderate vs severe vs profound intellectual disability

Mirtazapine has antihistamine, α2-blocker, and antiserotonergic activity.[8][81] It is specifically a potent antagonist or inverse agonist of the α2A-, α2B-, and α2C-adrenergic receptors, the serotonin 5-HT2A, 5-HT2C, and the histamine H1 receptor.[8][81] Unlike many other antidepressants, it does not inhibit the reuptake of serotonin, norepinephrine, or dopamine,[8][81] nor does it inhibit monoamine oxidase.[82] Similarly, mirtazapine has weak or no activity as an anticholinergic or blocker of sodium or calcium channels, in contrast to most TCAs.[8][75][81] In accordance, it has better tolerability and low toxicity in overdose.

Mirtazapine MOA?

Studies of novelty seeking indicate that persons with high exploratory tendencies have diminished expression of a specific class of dopamine receptors, D2 receptors, in ventral midbrain dopamine neurons. These individuals also have enhanced dopamine responses to novel stimuli compared to individuals with low novelty seeking.

Novelty seeking has been associated with what in terms of Dopamine receptors? What is the possible significance of this?

Anxiety disorders

OCD is most commonly comorbid with what type of disorders?

Psychiatric comorbidity burden is greater

OCD with childhood Onset differs from adult onset in which of the following ways? A. Symptom burden is less B. Psychiatric, bit of a burden is greater C. Persistence of OCD later in life is less likely D. Compulsions without obsessions are less common

My trick instead is to break the symptoms down into three clusters: (a) the heart, (b) breathlessness, and (c) fear. To remember them, I visualize a panicking patient clutching his chest (heart cluster), hyperventilating (breathlessness cluster), and shaking with fear (fear cluster). Finally, I imagine him screaming out, "Three-five-five! Three-five-five!"- presumably as a way of distracting himself from the panic attack. The numbers refer to the number of criteria in each cluster: The heart cluster has three criteria, and the other two clusters have five each. I admit that this all sounds hokey, but believe me, you'll never forget the criteria if you do it! Heart Cluster: Three I think of symptoms that often accompany a heart attack: Palpitations Chest pain Nausea Breathlessness Cluster: Five I think of symptoms associated with hyperventilation, which include dizziness, light-headedness, tingling of the extremities or lips (paresthesias), and chills or hot flashes: Shortness of breath Choking sensation Dizziness Paresthesias Chills or hot flashes Fear Cluster: Five 1 associate shaking and sweating with fear. To remember derealization, think of it as a way of psychologically escaping panic. Fear of dying Fear of going crazy Shaking Sweating Derealization or depersonalization Patient must have 4 out of the 13 symptoms to meet criteria

Mnemonic for assessing panic attack (disorder)

Washing and Straightening Make Clean Houses: 1. Washing 2. Straightening (ordering rituals) 3. Mental rituals (e.g., magical words, numbers) 4. Checking 5. Hoarding (in DSM-5, there is now a separate "hoarding disorder")

Mnemonic to remember common symptom seen in OCD

Mnemonic: I DESPAIRR 1. Identity disturbance "Have you generally been pretty clear about what your goals are in life and what sort of person you are, or do you have trouble knowing who (Say patients name.) is?" REST ON NOTECARD

Mnemonic to remember for Borderline PD and associated questions to ask

PTSD patient Remembers Atrocious Nuclear Attacks: 1. Reexperiencing the trauma via intrusive memories, flashbacks, or nightmares (one of which is required for diagnosis) 2. Avoidance of stimuli associated with trauma 3. Negative alterations in cognitions and mood (e.g, amnesia for the trauma, negative beliefs about oneself or the world, irrationally blaming oneself for the trauma, negative emotional state, restricted interests and activities, detachment, and inability to have positive emotions; (two required for diagnosis) 4. Arousal increase, such as insomnia, irritability, hyper vigilance, start response, reckless behavior, and poor concentration (to require for diagnosis)

Mnemonic to remember when assessing PTSD

The first part of the diagnosis of GAD is easy: The patient has worried excessively about something for 6 months. The hard part is remembering the six anxiety symptoms, three of which must be present. The following mnemonic is based on the idea that Macbeth had GAD before and after killing King Duncan: Macbeth Frets Constantly Regarding Illicit Sins: 1. Muscle tension 2. Fatigue 3. Concentration problems 4. Restlessness, feeling on edge 5. Irritability 6. Sleep problems If this elaborate acronym isn't to your liking, an alternative is imagining what you would experience if you were constantly worrying about something or other. You'd have insomnia, leading to daytime fatigue. Fatigue in turn would cause irritability and problems concentrating, and constant worry would cause muscle tension and restlessness.

Mnemonic to remember when assessing generalized anxiety disorder

D1 receptor agonism

Molecular targets for improving cognition in schizophrenia have shown promise via what mechanism?

Metabolic encephalopathy

Multifocal myoclonus in a comatose patient most likely indicate what?

NOTECARDS

NREM vs REM sleep behavior disorders

LSD Mescaline Psilocybin (mushrooms) Ayahuasca Dimethyltryptamine (DMT) PCP Ketamine Ibogaine Nutmeg and mace LSD MOA- partial agonist at postsynaptic serotonin receptors

Name hallucinogens. Most of these have the same MOA as the first hallucinogen listed. What is it's MOA?

Selegiline Rasagiline

Name irreversible MAO-B inhibitors

Zoloft and Celexa Bupropion. Venlafaxine, like other SNRIs, increases HR and BP and can cause QTc prolongation

Name the preferred SSRIs in heart disease? Bupropion or venlafaxine in heart disease and why?

Dendritic spines

Neural plasticity is largely mediated through the capacity to rapidly change in number and morphology of what structure?

Conversion disorder

Of the following disorders, which one has the best prognosis? A. Somatic symptom disorder B. Body dysmorphic disorder C. Somatic symptom disorder with predominant pain D. Illness anxiety disorder E. Conversion disorder (functional neurological symptom disorder)

Antagonist of dopamine 2 receptors (reduces positive symptoms is psychosis and stabilizes affective symptoms) and antagonist of serotonin 2A receptors (enhances dopamine release in certain brain regions and thus reduces motor side effects and possibly improves cognitive and affective symptoms)

Olanzapine MOA?

Orbitofrontal cortex (OFC)

One of the most consistent and specific findings among anatomical volumetric studies has been the association between increased trait aggression and reduced volume of what?

Pathognomonic- complex blocking phenomenon (experience sensory overload, becoming more difficult to process their world. They become more anxious and experience motor dysfunction like aphasia. Mind goes blank and they may stop sensing the world to a significant degree. Eventually come out if it) Bad prognostic factor- disturbance in visual perception Very important to ask about "Mind going blank" or abnormal visual perceptions

Out of all the possible deficits schizophrenics can experience, which one is more pathognomonic for it and which one is a bad prognostic symptom?

Oxcarbazepine seems to have the same mechanism of therapeutic action as carbamazepine but with fewer side effects ✽ Specifically, risk of leukopenia, aplastic anemia, agranulocytosis, elevated liver enzymes, or Stevens-Johnson syndrome and serious rash associated with carbamazepine does not seem to be associated with oxcarbazepine

Oxcarbazepine vs carbamazepine?

Depakote Usually within 3 months

PCOS can be caused by which psychotropic? How long does it take for PCOS to develop after starting this drug?

Early childhood

Parental loss due to an external cause (suicide, homicide, or accident) during childhood, most elevates the risk for depression of the young adult when the loss occurs at what age? A. Early childhood. B. Middle childhood. C. Early teen years. D. Late teen years.

D

Parents of a 16-year-old are concerned that their child prefers using text messaging and online social media to communicate with peers. They have discovered text messages to and from romantic partners, and visits to sexual health-related websites. The family is from a higher socioeconomic stratum, and the adolescent has thus far met normal developmental milestones. Which of the following is the most likely consequence of this adolescent's reliance on electronic forms of communication? A. Decreased risk of depression and anxiety B. Greatly increased risk of sexual predation C. Delay in Individuation and identity formation D. Continued socialization within the current peer group E. Gradual disenchantment with online friendships in late adolescence

Panic disorder Vagal maneuvers will mitigate PSVT

Paroxysmal supraventricular tachycardia can be confused with what psych diagnosis? How can you differentiate!

PHP stands for partial hospitalization programming. ASAM defines PHP as care that is delivered at a minimum of five hours a day, five days a week for a duration of two weeks to a whole month. The purpose of PHP is to replicate what an inpatient stay delivers in terms of treatment but in an outpatient setting. A person needing the PHP level of care has a SUD that is severe enough that work needs to be put on hold for a period of time while the individual focuses on their treatment and changing aspects of their life. Where the PHP level of care is more intensive, it is less intensive than an inpatient level of care as it affords the individual the ability to live in their residence. IOP stands for intensive outpatient programming. According to the American Society for Addiction Medicine (ASAM), an IOP level of care is set at a minimum of three hours a day, three days a week for a duration of up to two months. This type of treatment is for those who have a handle on their addiction enough to maintain some semblance of daily life. An IOP is a step down from PHP or rehab. IOP affords those with SUD the opportunity to continue to work while they also treat their SUD.

Partial hospitalization program vs Intensive outpatient program

Fava beans

Patient's taking monomine oxidance inhibitors should use caution when consuming which of the following: A. Milk B. Grapefruit C. Fava beans D. Leafy vegetables E. Decaffeinate coffee

Calcium

Patients taking lithium are more likely to show elevated levels of which serum electrolyte independent of renal function?

Risperdal It is not affected by smoking

Patients who smoke tobacco heavily can markedly reduce levels of psychotropic medications they are taking. Which one of the following medications is not affected by tobacco smoking in this way? A. Clozapine B. Olanzapine C. Haloperidol D. Risperidone E. Amitriptyline

Decreased serotonin levels

Patients with intermittent explosive disorder may have what change in cerebrospinal fluid?

Depressed Patients Sound Anxious, So Claim Psychiatrists: 1. Depression and other mood disorders 2. Psychotic disorders 3. Substance use disorders 4. Anxiety disorders 5. Somatic disorders 6. Cognitive disorders 7. Personality disorders

Pneumonic for the seven major diagnostic categories in the DSM-5

E

Police officers bring a criminal suspect to the ER for evaluation and request notification when the individual is ready for discharge from the hospital. According to HIPAA regulations regarding such disclosure, which of the following statements is true? A. A court order is required B. Criminal charges must be filed or pending C. The police must make the request in writing D. The patient must be informed of the disclosure E. The disclosure can be made without the patient's consent

Vitamin B6

Polyneuropathy can be caused by either deficiency or extreme excess of which B vitamin?

Bipolar

Postpartum psychosis is often associated with which disorder?

Amygdala

Potentially threatening objects produce a startle response before a person becomes consciously aware of them. This process is due to direct connections of the thalamus with what structure?

Higher weight-adjusted doses of medication

Prepuberal children differ from adolescents and adults with regard to dosing of liver-metabolized medications. Which of the following strategies is the best approach when treating children? A. Higher absolute doses of medication B. Lower absolute doses of medication C. Higher weight-adjusted doses of medication D. Lower weight-adjusted doses of medication

Panic disorder: better to prescribe as scheduled instead of PRN (won't act as fast as needed) Performance anxiety: prescribe as PRN because they can plan to take it before the performance

Prescribing beta blockers for panic disorder vs performance anxiety

Somryst

Prescription app for insomnia

Proximal axon

Prognosis of acute inflammatory demyelinating polyneuropathy is poorest if the disease process involves what structure?

Organizational culture MBA thing

Proponents of which theory agree that social norms, expectations, meaning and perceptions are key to understanding individual behavior in institution and institutional effectiveness?

Adenosine receptor

Prostaglandin D2 helps regulate sleep-wake cycle by increasing extracellular levels or what?

Atypical antipsychotics

Several controlled trials have shown that adding which of the following classes of medication to a SSRI is an effective augmentation strategy for the treatment of PTSD? A. Antihistamines B. Anticholinergics C. Benzodiazepines D. Atypical antipsychotics E. MAOIs

1. Every time you come, PDMP will be checked and if I see you doctor shopping, then no more BZDs 2. Random drug screens 3. No tolerance for losing BZD bottle. You will get the medication at specific intervals and no deviations

What does McEvoy tell people he prescribes BZDs to?

Pseudo- a fake memory, such as a spurious recollection of events that never took place, as opposed to a memory that is merely inaccurate. See also confabulation; false memory; recovered memory Screen- a memory of a childhood experience, usually trivial in nature, that unconsciously serves the purpose of concealing or screening out, or is a conflation of, an associated experience of a more significant and perhaps traumatic nature. Also called cover memory; replacement memory. False memory- false memory is a recollection that seems real in your mind but is fabricated in part or in whole. An example of a false memory is believing you started the washing machine before you left for work, only to come home and find you didn't.

Pseudo memory vs. Screen memory vs. False memory?

DHEA (dehydroepiandrosterone)

Psychological stress increases cortisol synthesis and release, and prolonged, increased cortisol levels have been associated with adverse psychiatric outcomes. Stress also affects the release of other hormones. An increase of which of the following hormones is correlated with decreased PTSD severity, most likely due to the hormones anti-glucocorticoid properties? A. Prolactin B. DHEA C. TSH D. CRH E. ACTH

Nervousness

Puerto Rican and other Latin American patients are more likely than those from other western cultures to report their depression as what?

REM latency - the time from the sleep onset to the first epoch of REM sleep REM density - a measure of the frequency of rapid eye movements during REM sleep

REM latency vs REM density

In utero

REM sleep is first evident at which stage of development?

1. Depressive disorders (80%) 2. Schizophrenia (10%) 3. Dementia and delirium (5%)

Rank the psychiatric illnesses most likely to result in suicide?

Younger people are more likely to experience EPS

Relation of age with EPS incidence?

NOTES

Repression vs suppression defense mechanism

Similar to Zyprexa Blocks Dopamine D2 receptors reducing positive symptoms of psychosis and stabilizing affective symptoms Blocks Serotonin 2A receptors, causing enhancement of dopamine release in certain brain regions and thus reducing motor side effects and possibly improving cognitive and affective symptoms

Risperidone MOA?

1. Nausea, constipation, abd pain, weight gain 2. Tachycardia 3. Hyperprolactinemia, sexual AE 4. EPS 5. Dizziness, insomnia, anxiety, sedation 6. Orthostatic hypotension

Risperidone side effects?

In recent years, clonidine, the prototype of alpha 2 agonists has been used as an analgosedative in intensive care both in ventilated and spontaneously breathing patients.12,14 The first reported use of clonidine for sympathetic overactivity on the ICU was for the treatment of autonomic dysfunction in tetanus in 198922 [Table 1]. It plays a significant role in the treatment of a variety of conditions such as hypertension, delirious syndromes and withdrawal syndromes (opioid, alcohol and nicotine addiction).23-32 It is also used as an agent to facilitate weaning from long-term mechanical ventilation and in the prevention of resistance to opioids and benzodiazepines

Role of Clonidine in the ICU?

Often a preferred augmenting agent in Bipolar depression or treatment-resistant unipolar depression

Role of Olanzapine in depression?

They are co-agonists

Role of glycine and glutamate at the NMDA receptor?

REM sleep behavior disorder

SSRIs can precipitate what type of sleep disorder?

Sensitization: non-associative learning process through which repeated exposure to a stimulus results in the progressive amplification (increased strength) of the reaction to the stimulus Panic: specific psychological vulnerability of people to interpret normal physical sensations in a catastrophic way

Sensitization vs panic

Go with Benadryl. The doses you give Seroquel at for insomnia have similar effects as Benadryl but also more side effects, ie metabolic side effects

Seroquel vs Benadryl for insomnia?

Normative response to stress associated with the school transition

Shortly after a five-year-old child enters kindergarten, the child's parents report to the pediatrician that their child seems more emotionally reactive at home, displaying some regressive behavior, and being more demanding of parental attention. The child's teacher describes no behavioral or academic concerns. What most likely accounts for the change noted by the parents?

Dr. Rosenquist usually doesn't do this. Evidence indicates that concomitant use of lithium and ECT may increase the risk of cognitive deficits, encephalopathy, and spontaneous seizures, although this has been disputed.

Should lithium be discontinued prior to ECT?

A common clinical mistake is to unquestioningly believe a depressed patient who states that a previous trial of antidepressant medications did not work. Such statements may be false, and they require confirmation from another source. Psychiatrists should not view patients' misinformation as an intentional fabrication; the admission of any hopeful information may be impossible for a person in a depressed state of mind.

Should you always believe a depressed patient when they say a certain antidepressant did not work previously?

Technically no but it wouldn't be a bad idea since many immune disorders are associated with psych symptoms. Plus it's an extra $20

Should you always order CRP and ANA with routine labs for every patient presenting with psych issues?

COGENTIN is not recommended for use in patients with tardive dyskinesia. Prescribing of anticholinergic medications such as benztropine (Cogentin) not only increases the risk of developing TD, but can make existing TD worse

Should you give Cogentin to a patient with Tardive Dyskinesia?

Do not give to patients with acute suicidality! If they attempt to OD on lithium, it can be fatal. Lithium is good for chronic suicidal thoughts however

Should you give lithium to every suicidal patient?

No! Wellbutrin lowers seizure threshold and alcohol withdrawal can cause seizures

Should you give/continue Wellbutrin to a patient in alcohol withdrawal?

Straterra - Reduced appetite, abd discomfort, dizziness, irritability - Increased BP and HR Alpha-agonists (clonidine and guanfacine) - Somnolence, fatigue, abd pain, headache - Decreased BP and HR

Side effects of nonstimulants for ADHD?

1. Common side effects: headaches, stomachache, nausea, insomnia, reduced appetite 2. Rebound effect: become mildly irritable and appear to be slightly hyperactive for a brief period when the medication wears off 3. Growth suppression - During periods of use, methylphenidate is associated with slightly decreased rates of growth, and if used over many years continuously without any drug holidays growth suppression of about several centimeters has been noted. When given "drug holidays" on weekends or summers, children tend to eat more and also make up the growth

Side effects of stimulants? What role does a drug holiday play?

The psychotic symptoms themselves are often categorized as either mood congruent, that is, in harmony with the mood disorder ("I deserve to be punished because I am so bad"), or mood incongruent, not in harmony with the mood disorder. Patients with mood disorder with mood-congruent psychoses have a psychotic type of mood disorder; however, patients with mood disorder with mood-incongruent psychotic symptoms may have schizoaffective disorder or schizophrenia

Significant of mood-congruent psychotic features in depression against mood-incongruent psychotic features in depression?

Frontal and occipital lobes

Sleep spindles density most markedly decreases from middle-age into old age in which regions of the brain?

The difference between agoraphobia and social anxiety disorder is that a person with agoraphobia fears having an anxiety attack or losing control in specific situations while a person with social anxiety disorder worries about experiencing embarrassment or judgment in social situations.

Social phobia versus agoraphobia

In DSM-IV, somatization disorder, or hypochondriasis, was used to diagnose patients who worried excessively about multiple somatic symptoms--which were medically unexplained. DSM-5 has abolished somatization disorder, substituting two different diagnoses, which differ in subtle ways: Somatic symptom disorder (SSD) refers to people who have actual somatic symptoms (which may or may not be caused by an established medical problem) but who are so excessively preoccupied with the symptoms that they have problems functioning Illness anxiety disorder refers to people who do not actually have somatic symptoms but who are extremely worried that they have an illness-in the absence of any medical evidence that they do

Somatization disorder vs hypochondriasis vs somatic symptom disorder vs illness anxiety disorder per DSM

GHB Inhalants Kratom LSD DXM (bath salts)

Some drugs that may not show up on UDS

Hippocampal formation

Successful, global cognitive performance with aging has most consistently been positively associated with the size of what brain structure?

Defense mechanisms

Supportive psychotherapy classically involve supporting and excepting the patient's what?

Notable Side Effects • Blurred vision, constipation, urinary retention, increased appetite, dry mouth, nausea, diarrhea, heartburn, unusual taste in mouth, weight gain • Fatigue, weakness, dizziness, sedation. headache, anxiety, nervousness, restlessness • Sexual dysfunction, sweating Life-Threatening or Dangerous Side Effects • Paralytic ileus, hyperthermia (CAs + anticholinergic agents) • Lowered seizure threshold and rare seizures • Orthostatic hypotension, sudden death, arrhythmias, tachycardia • QTc prolongation • Hepatic failure, extrapyramidal symptoms • Increased intraocular pressure • Rare induction of mania • Rare activation of suicidal ideation and behavior (suicidality) (short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo beyond age 24) CCC: antiCholinergic, Cardiotoxic, Convulsions

TCA AE?

Tricyclic antidepressants act on approximately five different neurotransmitter pathways to achieve their effects. They block the reuptake of serotonin and norepinephrine in presynaptic terminals, which leads to increased concentration of these neurotransmitters in the synaptic cleft

TCA MOA?

5 weeks

THE minimum recommended washout period for fluoxetine prior to starting a MOA inhibitor is how many weeks?

Bioequivalence

The FDA requires the pharmaceutical companies to demonstrate that a generic drug is not significantly different from the parent compound in which of the following ways? A. Cost B. Efficacy C. Ingredients D. Bioequivalence E. Side effects

Stroke

The FDA specifically warns that antipsychotic medications prescribed for dementia related behavioral disturbances are associated with increased risk of death and what other comorbidity? A. Stroke B. Diabetes C. Cataracts D. Liver failure E. Myocardial infarction

The pathway connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain. The ventral striatum includes the nucleus accumbens and the olfactory tubercle.

The Mesolimbic pathway connects what areas?

Sleep problems

The Study of Women's Health Across the Nation compared women ages 42 to 52 years with persistent or recurrent depressive symptoms to those with a single depressive episode. Which of the following risk factors, distinguished those with persistent disease? A. Obesity B. Marital status C. Sleep problems D. Menopausal status E. Childhood maltreatment.

Language

The ability of preschool children to regulate their emotions is strongly enhanced by the development of what?

Fusiform gyrus

The area of the brain primarily responsible for face recognition is located in the what?

Recommend a trial of DDAVP

The psychiatrist evaluates a 10-year-old boy with a history of primary nocturnal in Eurices. He enjoyed during the day with no urgency, frequency, or dyspiora. The patient's father report that he had the same problem until he was 12 years old. The patient is otherwise healthy but wants to stop bedwetting because he's planning to go to an overnight camp. The next step is to: A. Order a urinalysis B. Order a bladder voiding study C. Recommend a trial of DDAVP D. Recommend a trial of imipramine E. Order projective psychological testing

Haldol

The chores associated with Huntington's disease responds well to what drug?

Orientation

The clock-drawing task tests all of the following except: A. Attention B. Visuospatial C. Planning D. Orientation E. Executive function

Glycine

The cognitive enhancement associated with experimental d-cycloserine treatment in patients with schizophrenia has been attributed to enhancement of NMDA receptor activity by which neurotransmitter?

Obsessive compulsive

The psychiatrist who is assessing a patient's suitability for psychotherapy notes that the patient prominently uses the defense of isolation of affect and intellectualization. The patient's description of many life events appears to involve reaction formation. Which of the following personality traits is most likely to characterize this patient? A. Schizoid B. Paranoid C. Histrionic D. Narcissistic E. Obsessive-compulsive

Loss of cortical volume in the parietal cortex

The cortical synaptic remodeling characteristic of normal adolescence is also believed to be associated with what neurobiological change?

Preferential loss of excitatory synapses

The cortical synaptic, remodeling characteristic of normal adolescence is also believed to be associated with what neurobiological change?

Personality disorders

The decreased late life prevalence of which of the following disorders is explained by typical psychosocial maturation? A. Anxiety disorders B. Personality disorders C. Depressive disorders D. Substance use disorders E. Somatic symptom and related disorders

Depression

The dietary supplement, S-adenosyl-1-methionine (SAMe) has demonstrated some efficacy in treating what?

Entorhinal Cortex This is an area of the brain's allocortex, located in the medial temporal lobe, whose functions include being a widespread network hub for memory, navigation, and the perception of time. It is the main interface between the hippocampus and neo cortex.

The earliest evidence of cell loss in patients with Alzheimer disease typically occurs in which area of the brain? What is the function of this area?

The brief form focuses on reducing symptoms without addressing underlying conflicts

The goals of brief psychodynamic therapy as compared to long term psychodynamic therapy differ how?

Psychotic disorders

The most common mental disorders of patients over 65 years of age include all of the following EXCEPT: Depressive disorders, cognitive disorders, phobias, alcohol use disorders, psychotic disorders

Alcoholic neuropathy

The most frequent neurological complication of chronic alcohol abuse is: A.Wernicke's encephalopathy B. Alcoholic cerebellar degeneration C. Alcoholic neuropathy D. Marchiafava-Bignami disease E. Alcoholic dementia

Three months

The natural course of an untreated manic episode last approximately what length of time?

Response inhibition

The neural circuit that connects the anterolateral orbitofrontal cortex, anterior part of the putamen and thalamus is involved in which of the following cognitive functions? A. Working memory B. Response inhibition C. Affective processing D. Default mode processing E. Developing emotional salience

Fiduciary duty

The obligation to act in the patient's best interests is known as: A. Beneficence B. Fiduciary duty C. Nonmalfeasance D. Altruism E.Parens patriae

Privilege Privilege refers to the psychiatrist's right to maintain a patient's secrecy or confidentiality even in the face of a subpoena. This implies that the right of privilege belongs to the patient, not the psychiatrist, and therefore the patient can waive the right. There are many exceptions to medical privilege, and many physicians are not aware that they do not legally enjoy the same privilege that exists between husband and wife, priest and parishioner, and a client and an attorney.

The psychiatrist's right to maintain a patient's secrecy in the face of a subpoena is known as: A. Privilege B. Confidentiality C. Communication rights D. Private rights E. Clinical responsibility Explain the answer

Tyrosine hydroxylase

The rate-limiting enzyme in the dopamine synthetic pathway is: A. DOPA decarboxylase B. Tyrosine hydroxylase C. Dopamine B-hydroxylase D. Phenylethanolamine N-methyltransferase (PNMT) E. Catechol-O-methyltransferase

Valproate

The risk of teratogenic neural tube defects is greatest for the offspring of mothers taking which of the following anti-convulsant? A. Phenytoin B. Lamotrigine C. Valproate D. Levetiracetam E. Carbamazepine

Nonverbal learning disability Nonverbal learning disabilities (NVLD) is a term that refers to challenges with a specific group of skills. These skills aren't language-based like reading and writing are. They're nonverbal skills, and they include motor, visual-spatial, and social skills. NVLD isn't an official diagnosis. But the challenges are real and can have an impact on learning and on working. They also make social interaction very hard. People with these difficulties often have strong verbal skills. But they may not know when someone's being sarcastic. They may talk a lot, but not share in a socially appropriate way. There's also a physical aspect. People with NVLD often have problems with coordination. These are lifelong struggles, but they aren't related to intelligence. With support, people may improve these skills and learn social strategies that can help. Still, they're often misunderstood and judged, and they may have a hard time fitting in.

There appears to be a strong correlation of Asperger disorder with which learning profile? Describe this learning profile

Carbamazepine

There is a strong association between HLA-B*1502 allele and Steven Johnson syndrome in individuals of Asian dissent who are treated with which agent?

Schizophrenia

There is robust evidence from epidemiological studies that offspring of older fathers have an increased risk of what?

Retrograde ejaculation

Thioridazine is most often associated with which one of the following side effects? A. Hematuria B. Delayed orgasm C. Retrograde ejaculation D. Priapism E. Hypospadias

1. OCD (only TCA with proven efficacy in OCD) 2. Treatment resistant depression (one of the most favored TCA for treating treatment resistant depression) 3. Cataplexy

Uses of Clomipramine?

Mania: 1200-1500 mg/day Migraine: 500-1000 mg/day

Usual dosage range for Depakote?

Hyperventilation

Though many symptoms can be associated with a panic attack, the cardinal symptom that appears to be central to the pathophysiology of the syndrome is what?

The cerebral hemispheres are further subdivided into four major lobes: the occipital, towards the back of the brain; the parietal, just above the ear; the temporal, just behind the forehead temples; and the frontal, resting above the eyes at the very front of the cortex. Generally, when neuroscientists talk about the lobes, they are doing so to denote a general anatomical location of brain activity. But these areas can also tell us a bit about function. - The occipital lobe is mainly responsible for processing and interpreting visual information. It's the seat of the primary visual cortex. - The temporal lobe is the major processing center of sound (including language) and some forms of memory. - The parietal lobe is the home of the somatosensory cortex, the area of the brain responsible for processing sensation and touch information, as well as some aspects of spatial processing. - The frontal lobe is the most complex part of the human brain—the bit that separates us from our primate cousins, so to speak. This, the largest brain lobe, is responsible for executive function, with a hand in reasoning, decision-making, sensory integration, planning, and execution of movement.

To a layman, where would you point out the location of the 4 lobes of the brain? What are the basic functions of these lobes?

C

To be eligible for special education services a student must require specific interventions in order to make progress in school, and meet which of the following criteria? A. Have failed at least one grade B. Be under a psychiatrist's care C. Have a documented disability D. Require pharmacologic treatment E. I felt all other less restrictive alternatives

ADHD OCD

Tourette's syndrome is usually associated with what other psychiatric manifestations?

Psychodynamic psychotherapy A form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. Psychodynamic psychotherapy relies on the interpersonal relationship between client and therapist more than other forms of depth psychology

Transference interpretations and clarification to develop insight and resolve conflict are among the techniques used in what type of therapy? Describe this therapy

NOTECARDS

Treatment algorithm for catatonia

Notable Side Effects ✽ Sedation, dizziness, headache, ataxia, nystagmus, abnormal gait, confusion, nervousness, fatigue ✽ Nausea, vomiting, abdominal pain, dyspepsia • Diplopia, vertigo, abnormal vision ✽ Rash - maybe weight gain

Trileptal AE?

B

Uncontrollable excessive talking, as seen in mania, is also known as: A. Alexithymia B. Logorrhea C. Echolalia D. Flight of ideas E. Stilted speech

Predominantly chronic mixed manic states

Unlike adults with bipolar disorder, prepubertal children with bipolar disorder are believe to have what?

It is associated with neonatal adaptation syndrome Multiple studies have demonstrated an increased risk of poor neonatal adaptation associated with exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants in late pregnancy. Results in the literature consistently indicate that about 25%-30% of infants exposed to SSRIs late in pregnancy manifest symptoms of poor neonatal adaptation. The most commonly observed symptoms include jitteriness, restlessness, increased muscle tone, and rapid breathing. These symptoms are transient, resolving spontaneously with no specific medical intervention.

Untreated depression in pregnancy is associated with poor maternal and infant outcomes, including pregnancy complications, preterm birth, and behavioral problems in the child. What does current evidence show about SSRI use in pregnancy? A. Causes oral cleft defects B. Is associated with fetal demise C. Is associated with neonatal adaptation syndrome D. Should be used at lower doses later in pregnancy E. Is associated with poor cognitive outcomes for the child Provide more details on the answer.

B The practice described in the question is called "fee splitting" and is considered unethical. As a physician you cannot receive financial compensation for referring patients to other doctors, nor can you pay for such referrals. Such an arrangement puts the doctor's interests (the financial incentive to refer) over the best interests of the patient and leads to inappropriate referrals.

Upon graduation from residency, you start a new practice in your home town. You go to a local internist and a local psychologist and tell them that for every patient they refer you, you will pay them $100. This arrangement is: A. Ethical because people need doctors and you need patients B. Unethical because it puts the doctor's interests ahead of the patient's C. Ethical because all parties involved benefit in some way D. Ethical because the referring clinician is fairly compensated for the referral E. Unethical because the primary care physician should know how to treat depression and should not need to refer to you

Cannabis Studies have shown that cannabis use is associated with development of psychosis. Others have assessed whether cannabis use (especially during adolescence) is a significant risk factor for developing schizophrenia later in life. Ferguson et al (2013) reported that individuals with cannabis use disorder at the ages of 18 and 21 had significantly higher rates of psychosis when compared to non-cannabis using participants (Fergusson et al., 2003), and Arseneault et al., (2002) found that adolescents using cannabis at the age of 15 were more likely to develop a schizophreniform disorder by the age of 26 when compared to non-using adolescents, even when controlling for prior psychotic symptoms Lastly, Schubar and colleagues demonstrated that cannabis use at the age of 12 was associated with a nearly 5-fold increase in odds of being hospitalized for psychosis later in life (2011). As discussed below, these studies raise the question of whether adolescent cannabis use can interfere with adolescent brain development, leading to an increased risk of schizophrenia (Rais et al., 2008). Not sure if the other drugs and their effect have been studied in adolescents

Use of which of the following substances in adolescence has been associated with the subsequent development of schizophrenia? A. LSD B. Cocaine C. Cannabis D. Methamphetamine E. PCP

Usual Dosage Range • Bupropion: 225-450 mg in 3 divided doses (maximum single dose 150 mg) • Bupropion SR: 200-450 mg in 2 divided doses (maximum single dose 200 mg) • Bupropion XL: 150-450 mg once daily (maximum single dose 450 mg) • Bupropion hydrobromide: 174-522 mg once daily (maximum single dose 522 mg)

Usual dosage range for bupropion

- Schizophrenia and mania: 15-30 mg/day - Augmenting SSRIs/SNRIs in depression: 2-10 mg/day - Abilify Maintena: 300-400 mg/28 days - Aristada: 441 mg, 662 mg, 882 mg/month OR 882 mg/6 weeks

Usual dosing range of Aripiprazole?

10-30 mg/day Initial: 5-10 mg/day

Usual dosing range of Olanzapine? What's the initial dose?

It is and SSRI and it also has partial agonist activity on serotonin receptors

Vilazodone MOA

A

Violent or aggressive behavior is associated with: A. Decreased levels of 5-HIAA in spinal fluid B. Decreased growth hormone response to insulin-induced hypoglycemia C. Abnormal dexamethasone suppression test D. Decreased response to corticotrophin-releasing hormone stimulation test E. Decreased response to thyrotropin-releasing hormone suppression test

Moderate to severe binge eating disorder

Vyvanse is FDA approved to treat what type of eating disorder?

>5%

Weight increase by how much after using a second generation antipsychotic for one month indicates increased risk of developing metabolic syndrome?

Prozac Could be stopped without a taper

What SSRI can be stopped without a long taper?

Fluvoxamine

What SSRI increases clozapine levels by inhibiting Cytochrome P450 enzyme?

Liver disease: Celexa or Lexapro. However, SSRIs as a whole are not very hepatotoxic so you don't really need to switch from one SSRI to another Renal disease: Zoloft

What SSRI should you give in liver disease? In renal disease?

Explain to them that mental health has genetic implications and that since they are suffering mental health disorders there is a chance that their children could also experience mental health disorders in the future. Explain to them that one mental health disorders are recognized early and are treated with the most effective treatment aggressively in the initial. The response rate and chances of remission are highest. Encourage them to monitor their children for mental health symptoms and to possibly provide early intervention's, i.e. by setting up appointments with psychiatrist or getting them to see a therapist.

What advice should you give to your patients that have newborns, entrance, and/or children?

Liothyronine

What agent is the best choice to augment an SSRI for a 58-year-old female patient with depression and pronounced psychomotor retardation?

Prozac

What antidepressant is preferred for bulimia?

Prozac - pregnancy Zoloft - breastfeeding (less likely to cross into milk) But if a patient is stable on Zoloft, no need to change to Prozac during pregnancy

What antidepressants are preferred in pregnancy and breastfeeding?

Abilify

What antipsychotic is approved for treatment of Tourette's disorder in children?

Zyprexa

What antipsychotic is most effective for drug induced psychosis

1. Geodon 2. Latuda 3. Viibryd (Vilazodone): an antidepressant

What antipsychotics need to be given with food?

Disruptive behavior disorders are a group of behavioral problems. They are called "disruptive" because affected children literally disrupt the people and activities around them (including at home, at school and with peers). The most common types of disruptive behavior disorder are oppositional defiant disorder (ODD) and conduct disorder. Children with oppositional defiant disorder display a persistent pattern of angry outbursts, arguments and disobedience. While this behavior is usually directed at authority figures, like parents and teachers, it can also target siblings, classmates and other children. Conduct disorder is a far more serious condition that can involve cruelty to animals and people, other violent behaviors and criminal activity.

What are disruptive behavior disorders?

"Was it your idea to come to? If not, whose idea was it? Do you believe that person's concerns have any merit/validity/truth to them? Do you have any nervous/mental problems?"

What are good first questions to ask a new patient per Dr. McEvoy?

Probing questions: "Do you like to be the center of attention? (Yes.) When you feel an emotion, do you keep it inside or do you express it? (Express it.)"

What are good probing questions for Histrionic PD?

CT and MRI The most consistent abnormality observed in the depressive disorders is increased frequency of abnormal hyperintensities in subcortical regions, such as periventricular regions, the basal ganglia, and the thalamus. More common in bipolar I disorder and among elderly adults, these hyperintensities appear to reflect the deleterious neuro degenerative effects of recurrent affective episodes. Ventricular enlargement, cortical atrophy, and sulcal widening also have been reported in some studies. Some depressed patients also may have reduced hippocampal or caudate nucleus volumes, or both, suggesting more focal defects in relevant neurobehavioral systems PET The most widely replicated positron emission tomography (PET) finding in depression is decreased anterior brain metabolism, which is generally more pronounced on the left side. From a different vantage point, depression may be associated with a relative increase in nondominant hemispheric activity. Furthermore, a reversal of hypofrontality occurs after shifts from depression into hypomania, such that greater left hemisphere reductions are seen in depression compared with greater right hemisphere reductions in mania. Other studies have observed more specific reductions of reduced cerebral blood flow or metabolism, or both, in the dopaminergically innervated tracts of the mesocortical and mesolimbic systems in depression. Again, evidence suggests that antidepressants at least partially normalize these changes. In addition to a global reduction of anterior cerebral metabolism, increased glucose metabolism has been observed in several limbic regions, particularly among patients with relatively severe recurrent depression and a family history of mood disorder. During episodes of depression, increased glucose metabolism is correlated with intrusive ruminations

What are CT, MRI, and PET scan findings in mood disorders?

Jean Piaget's theory of cognitive development suggests that children move through four different stages of mental development. His theory focuses not only on understanding how children acquire knowledge, but also on understanding the nature of intelligence.1 Piaget's stages are: Sensorimotor stage: birth to 2 years Preoperational stage: ages 2 to 7 Concrete operational stage: ages 7 to 11 Formal operational stage: ages 12 and up Piaget believed that children take an active role in the learning process, acting much like little scientists as they perform experiments, make observations, and learn about the world. As kids interact with the world around them, they continually add new knowledge, build upon existing knowledge, and adapt previously held ideas to accommodate new information. He proposed intelligence is something that grows and develops through a series of stages. Older children do not just think more quickly than younger children, he suggested. Instead, there are both qualitative and quantitative differences between the thinking of young children versus older children. Based on his observations, he concluded that children were not less intelligent than adults, they simply think differently. The Sensorimotor Stage Ages: Birth to 2 Years Major Characteristics and Developmental Changes: - The infant knows the world through their movements and sensations - Children learn about the world through basic actions such as sucking, grasping, looking, and listening - Infants learn that things continue to exist even though they cannot be seen (object permanence) - They are separate beings from the people and objects around them - They realize that their actions can cause things to happen in the world around them The Preoperational Stage Ages: 2 to 7 Years Major Characteristics and Developmental Changes: - Children begin to think symbolically and learn to use words and pictures to represent objects. - Children at this stage tend to be egocentric and struggle to see things from the perspective of others. - While they are getting better with language and thinking, they still tend to think about things in very concrete terms. The Concrete Operational Stage Ages: 7 to 11 Years Major Characteristics and Developmental Changes - During this stage, children begin to thinking logically about concrete events - They begin to understand the concept of conservation; that the amount of liquid in a short, wide cup is equal to that in a tall, skinny glass, for example - Their thinking becomes more logical and organized, but still very concrete - Children begin using inductive logic, or reasoning from specific information to a general principle The Formal Operational Stage Ages: 12 and Up Major Characteristics and Developmental Changes: - At this stage, the adolescent or young adult begins to think abstractly and reason about hypothetical problems - Abstract thought emerges - Teens begin to think more about moral, philosophical, ethical, social, and political issues that require theoretical and abstract reasoning - Begin to use deductive logic, or reasoning from a general principle to specific information

What are Piaget's stages of cognitive development?

When time is truly of the essence, you can begin with a direct question: "Have you ever had an eating disorder, such as anorexia or bulimia?" However, if you have the sense that your patient may be particularly ashamed of a suspected eating disorder, a too blunt approach might endanger the therapeutic alliance. In these cases, you can approach the issue more indirectly: "Have you ever thought you were overweight?" If the answer is "no," it is unlikely that your patient has an either anorexia or bulimia. If the answer is yes, ask: A) If you suspect anorexia: 1. "Have you ever dieted?" 2. "Have you ever weighed much less than people thought you should weigh? What was your lowest weight? And what is your height?" 3. "Did you think you were overweight at your lowest weight?" 4. "Were you afraid of gaining weight?" B) If you suspect Bulimia or Binge Eating Disorder: 1. "Have you ever felt like your eating was out of control? Do you have eating binges when you eat a large amount of food than you should and feel like you can't stop eating?" 2. "After you've binged, have you ever gotten rid of the food in some way, such as vomiting or taking laxatives?" 3. "At the most, how often were you binging and purging? Once a day? Twice a day? More?"

What are a good series of questions to ask for eating disorders?

1. Acute and prophylactic antimanic and prophylactic antidepressant effects in Bipolar 2. Acute and prophylactic effects in unipolar depression (even a small dose of Lithium can have some benefit in unipolar depression) 3. Antisuicidal effects, even in minute levels in drinking water 4. May reduce risk of dementia and has positive effects on cognition 5. Increases length of telomeres which is necessary for maintaining both physical and psychiatric health 6. Decreases incidence of some medical illnesses (seizures, ALS, dementia NOS, MI) 7. Enhances efficacy of multiple psychotropic drugs VERY IMPORTANT TO GIVE PATIENTS WHO NEED LITHIUM LITHIUM AS IT IS SO BENEFICIAL. CONTROL SIDE EFFECTS OR REDUCE THE DOSE IN THE EVENT AE OCCURS RATHER THAN D/CING LITHIUM

What are all the benefits of Lithium?

Oral, intervenous, liquid oral, rectal

What are all the formulations of diazepam?

A. Medical - Neurological disorders: nonconvulsive status epilepticus, head trauma - Infections: encephalitis - Metabolic disturbances: hepatic encephalopathy, hyponatremia, hypercalcemia B. Medications - Corticosteroids - Immunosuppressants - Antipsychotics (ex. Neuroleptic agents) C. Primary mental disorder - Advanced primary mood or psychotic illnesses

What are all the possible causes of Catatonia?

- Dry mouth - Blurry vision - Dry skin/reduced sweating - Tachycardia - Bowel obstruction - Bladder obstruction - Memory and other cognitive problems Always ask about dry mouth and blurry vision bc these occur at lower doses before the other more serious ones develop. If present, reduce/stop anticholinergic

What are anticholinergic AE? Which ones should you always ask for and why?

Cardiac risks and abnormalities

What are contraindications of stimulants?

Do you often find yourself getting frustrated because other people don't meet your standards? (Yes.) What are your ambitions for yourself? (Will be unrealistically high.)

What are good probing questions for Narcissistic PD?

Elevated HPA activity and thyroid dysfunction Elevated HPA activity is characterized by elevated cortisol (urinary, plasma, salivary levels) and no suppression of cortisol during dexamethasone suppression test Thyroid dysfunction is characterized by elevated basal TSH or an increased TSH response to TRH infusion. The dexamethasone suppression test normalizes with effective treatment but not the TSH TRH test

What are hormonal changes that are seen in depression. Which ones usually normalize with effective treatment

Ictal- looks crazy. Really rapid, sharp waves, waves from different leads cross over each other Inter-ictal- continuous spike-wave discharges (60% of patients)

What are ictal and inter-ictal EEG findings?

An idea of reference—sometimes called a delusion of reference—is the false belief that irrelevant occurrences or details in the world relate directly to oneself

What are ideas of references?

Thyroid and adrenal function tests bc both of these endocrine disorders can appear as depression

What are important lab tests that need to be ordered in MDD?

Naltrexone - LFT Acamprosate - RFT

What are labs you have to check before starting Naltrexone and/or Acamprosate?

Learning disabilities may be defined in practical, medical and legal terms. The common theme in all three definitions is that a learning disability is a disorder in one or more basic psychological processes that may manifest itself as an imperfect ability in certain areas of learning, such as reading, written expression, or mathematics. The term "learning disabilities", sometimes referred to as specific learning disabilities, is an umbrella term that covers a range of neurologically based disorders in learning and various degrees of severity of such disorders. Predecessor terms include: minimal brain damage and minimal brain dysfunction. Broadly speaking, these disorders involve difficulty in one or more, but not uniformly in all, basic psychological processes: (1) input (auditory and visual perception), (2) integration (sequencing, abstraction, and organization), (3) memory (working, short term, and long term memory), (4) output (expressive language), and (5) motor (fine and gross motor). Learning disabilities vary from individual to individual and may present in a variety of ways. Learning disabilities may manifest as difficulty: (1) processing information by visual and auditory, means, which may impact upon reading, spelling, writing, and understanding or using language, (2) prioritizing, organizing, doing mathematics, and following instructions, (3) storing or retrieving information from short or long term memory, (4) using spoken language, and (5) clumsiness or difficulty with handwriting. Learning disabilities are not emotional disturbances, intellectual disabilities, or sensory impairments. They are not caused by inadequate parenting or lack of educational opportunity.

What are learning disabilities?

- Lithium - G-CSF (expensive) - Steroids (Dr. McEvoy suggests giving 5-10 mg one day before labs need to be drawn to increase neutrophils. Dr. Sharma did this for up to 1-2 yrs and the patient was able to maintain his neutrophils)

What are medications that can be given if a patient on clozapine develops neutropenia or agranulocytosis?

SSRIs, N-acetylcysteine, and/or Naltrexone

What are possible treatments for excoriation disorder?

- Age - Duration of treatment with antipsychotics - Treatment with a conventional antipsychotic - Treatment with anticholinergics (interesting bc they're used to treat other EPSE) - Presence of EPS and akathisia - Substance abuse

What are risk factors for the development of tardive dyskinesia?

1. Sedation, dizziness, weight gain 2. Dry mouth, constipation, dyspepsia 3. Peripheral edema 4. Joint/back/chest/extremity pain, abnormal gait, ecchymosis 5. Tachycardia 6. Orthostatic hypotension 7. Increased risk of DM and dyslipidemia 8. Rare AE: DKA, DRESS, NMS, seizures

What are side effects of Olanzapine

It's associated with premature loss of deep (slow-wave) sleep and an increase in nocturnal arousal (characterized by increase in nocturnal awakenings, reduction in total sleep time, increased phased REM sleep, and increase core body temperature). Some do like deficits if slow-wave sleep

What are sleep changes seen in depression? Do they persist after recovery?

Oversedation, impaired recall, agitation When you give a patient midazolam or really any other benzodiazepine for agitation, you risk causing impaired recall. When these patients arise, they can experience confusion and an inability to recollect the preceding events thus increasing their anxiety and precipitating or worsening the associated agitation.

What are some common side effects of midazolam? What is the significance of these side effects?

Was it your idea to come here? Whose idea was it? Why do they think you need to be here?

What are some effective intro questions to assess insight?

There are no pathognomonic laboratory findings in catatonia. The laboratory evaluation should be used to rule out an underlying medical condition. Appropriate medical tests may include complete blood counts, electrolytes, brain imaging, and electroencephalography (if seizures are suspected). In addition, serum creatinine phosphokinase, white blood cell count, and serum transaminases should be checked because the results of laboratory tests are elevated in patients with neuroleptic malignant syndrome.

What are some lab tests to order in catatonia?

1. Poor spatial precision - Records the post-synaptic electrical activity of large groups of neurons. Difficult to pinpoint EEG to a precise location. 2. Records activity of neurons in cortex but has limited ability to accurately record from structures at a deeper level

What are some limitations of EEG?

1. Problems with impulse control: may increase risk of impulsive behavior. Be careful in people with impulse control issues (lots of bipolar patients potentially) 2. Use with caution in patients with conditions predisposing to hypotension (dehydration, overheating)

What are some precautions/warnings for Aripiprazole?

1. Hallucinations (alcoholic hallucinosis after withdrawal) 2. DT 3. Alcohol-induced mood disorders 4. Alcohol-induced anxiety disorder The first two usually occur during withdrawal so treat it like you'd treat alcohol withdrawal (BZDs, fluids, nutritional support, multivitamins especially thiamine) The last two tend to resolve once patients stop drinking. Improvement is noted a few weeks - month after cessation. Antidepressant may be given for mood disorders if no improvement is seen after 4 weeks

What are some psychiatric disorders alcohol use can cause? How should you treat them?

All domains of cognition are affected but some areas more so than others: 1. Verbal and visuospatial memory 2. Attention 3. Executive function (planning, problem solving, organizing, time-management) 4. Speed of processing Almost everyone with schizophrenia has cognitive dysfunction to some degree. They can appear in the presence or absence of positive and negative symptoms. They can first appear around age 6-7. Antipsychotics are not effective at treating them. The cognitive symptoms are the strongest predictor of functional outcome (employment, independent living, quality of life)

What are some schizophrenia cognitive symptoms? How common are they? How do they affect patients functionally?

Cardiac drugs, antihypertensives, sedatives, hypnotics, antipsychotics, antiepileptics, antiparkinsonian drugs, analgesics, antibacterials, and antineoplastics, and illicit drugs are all commonly associated with depressive symptoms.

What are some substances that can cause substance-induced depression?

Notecards (last section)

What are some supplements that can be used to augment treatment of depression?

Mirtazapine Bupropion Topiramate Methylphenidate There are some studies to suggest these drugs can help achieve abstinence but nothing definitive yet. Therapy is the strongest treatment

What are some treatments that can be used to treat methamphetamine use disorder?

1. When you have a panic attack, does it come out of the blue, or do you pretty much know what's going to cause it? - Remember that to meet criteria for panic disorder, the panic attacks have to be unexpected (i.e., out of the blue). Otherwise, panic attacks may signify social phobia, if the trigger is a social situation; PTSD, if the trigger is a flashback; agoraphobia, if the trigger is a hard-to-escape place; or a specific phobia with a variety of possible triggers. 2. Has one of these attacks ever woken you up at night? 3. Do you remember when you had your first panic attack? - These two questions will increase the specificity of your exploration. If a patient is awakened at night by panic, its very likely a true, unexpected panic attack. (Some clinicians would also wonder about a history of sexual abuse.) In addition, people with true panic disorders often distinctly remember their first panic attack.

What are specific questions for panic disorder?

The cortex is gathered and pleated into a unique configuration. The outer bump in each pleat is called the gyrus, while the groove inside each fold is called the sulcus. No two human brains are folded in the exact same way. Yet, several of these folds are large and pronounced enough to have their own names. For example, the lateral sulcus, the inner fold that separates the temporal lobe from the frontal lobe, and its neighbor, the temporal gyrus, house the primary auditory cortex, the area of the brain that processes sound information. Wernicke's Area, that important language region, also can be found on the temporal gyrus. References to gyri and sulci can help pinpoint more specific locations on a particular lobe of the cortex.

What are sulci and gyri? What is the significant sulcus that separates the frontal and temporal lobe?

1. NMDA 2. AMPA 3. Kainate

What are the 3 classes of glutamate receptors?

There are three major criteria for intellectual disability: significant limitations in intellectual functioning, significant limitations in adaptive behavior, and onset before the age of 18.

What are the 3 main diagnostic criteria for intellectual disability?

- Affect flattening or blunting - Alogia - Avolition/apathy - Anhedonia/Asociality - Attentional impairment

What are the 5 A's of schizophrenia negative symptoms

Elisabeth Kübler-Ross developed a comprehensive paradigm to classify the stages of a person's reactions to impending death. Stage 1 is that of shock and denial. Upon learning the news that they are dying, people are initially in a state of shock and may deny that the diagnosis is correct. Stage 2 is that of anger. During this stage patients get frustrated, angry, and irritable about their condition. They often ask: "Why me?" They typically undergo a lot of self-blame about their illness. Stage 3 is that of bargaining. Patients may try to negotiate or bargain with doctors, friends, family, and even God to alleviate their illness in exchange for good deeds or fulfillment of certain pledges. Stage 4 is that of depression. During this stage, patients demonstrate frank signs and symptoms of depression, including hopelessness, suicidal ideation, social withdrawal, and sleep problems. If the symptoms are severe enough to qualify as an MDD, the patient should be treated with an antidepressant. Stage 5 is that of acceptance. Patients acknowledge and come to terms with the inevitability of their death during this stage. Patients can begin to talk about facing the unknown without fear and with reso

What are the 5 stages of grief?

Bilateral triphasic waves

What are the EEG findings in hyperammonemia?

There are NO absolute contraindication for ECT! THE FOLLOWING PATIENTS ARE AT HIGHER RISK: - Those with space occupying lesion in the CNS - Those with increased ICP - Those at risk for cerebral bleed - Those who have had a recent MI - Those with uncontrolled hypertension

What are the absolute contraindications to ECT? Patients with what conditions are at higher risk during ECT?

Potential Advantages • Some cases of psychosis and bipolar disorder refractory to treatment with other antipsychotics ✽ Patients concerned about gaining weight and patients who are already obese or overweight ✽ Patients with diabetes ✽ Patients with dyslipidemia (especially elevated triglycerides) • Patients requiring rapid relief of symptoms (intramuscular injection) • Patients switching from intramuscular ziprasidone to an oral preparation Potential Disadvantages • Patients noncompliant with twice daily dosing ✽ Patients noncompliant with dosing with food

What are the advantages and disadvantages of Geodon?

Methadone maintenance has several advantages. First, it frees persons with opioid dependence from using injectable heroin and, thus, reduces the chance of spreading HIV through contaminated needles. Second, methadone produces minimal euphoria and rarely causes drowsiness or depression when taken for a long time. Third, methadone allows patients to engage in gainful employment instead of criminal activity. The major disadvantage of methadone use is that patients remain dependent on a narcotic.

What are the advantages and disadvantages of methadone?

It is a compost containing both valproic acid and sodium valproate. Aka divalproex sodium. Sodium valproate is the sodium salt of valproic acid. Depakene is either valproic acid or sodium valproate

What does Depakote consist of? What is Depakene?

Potential Advantages • Patients with retarded depression • Patients with atypical depression • Patients with comorbid anxiety • Patients with depression may have higher remission rates on SNRIs than on SSRis • Depressed patients with somatic symptoms, fatigue, and pain • Patients who do not respond or remit on treatment with SSRIs Potential Disadvantages • Patients sensitive to nausea (nausea less common with XR) • Patients with borderline or uncontrolled hypertension • Patients with cardiac disease

What are the advantages and disadvantages of venlafaxine?

1. Stupor (i .e., no psychomotor activity; not actively relating to environment) 2. Catalepsy (i .e., passive induction of a posture held against gravity) 3. Waxy flexibil ity (i .e., sl ight, even resistance to position ing by examiner) 4. Mutism (i .e., no, or very little, verbal response to instructions or external stimuli) 5. Negativism (i .e., opposition or no response to instructions or external stimuli) 6. Posturing (i .e., spontaneous and active maintenance of a posture against gravity) 7. Mannerism (i .e., odd, circumstantial caricature of normal actions) 8. Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements) 9. Agitation, not influenced by external stimuli 1 0. Grimacing 11. Echolalia (i .e., mimicking another's speech) 1 2 . Echopraxia (i .e., mimicking another's movement) 3 or more are needed to diagnose catatonia

What are the behavioral changes characteristic of catatonia?

1. Agranulocytosis 2. Seizures 3. Myocarditis and cardiomyopathy 4. Orthostatic hypotension 5. Increased mortality in elderly patients with dementia

What are the black box warnings for Clozapine?

Mood and psychotic disorders and some general medical disorders (ex. Renal disease, thyroid disease, DM, Parkinson's, encephalitis) and medications (some antipsychotics can actually worsen it especially if they block dopamine receptors)

What are the causes of catatonia?

The core features of BPD are instability of interpersonal relationships, self-image, affect, and marked impulsivity. A useful model organizes features of the disorder into three dimensions [47]: ●Impaired relatedness - Unstable relationships with others, identity disturbance, and chronic emptiness ●Affective dysregulation - Affective lability, excessive anger, and efforts to avoid abandonment ●Behavior dysregulation - Impulsivity, suicidality, and self-injurious behavior Interpersonal difficulties — Patients with BPD usually have stormy relationships, especially with people to whom patients are close [56]. At one moment, a friend or romantic partner may be viewed not only as a trusted confidant but as an ideal, almost perfect person, and then this same individual can suddenly be seen as cruel, betraying, very limited, and damaged. When the idealized person is present and supportive, the patient feels strong and solid. However, if the support person leaves (or is unable to meet the patient's needs), even for a limited time, or if the patient thinks that the support person is about to leave, the patient can immediately become angry, demeaning, demanding, depressed, hopeless, and suicidal. Patients tend to view others as all good or all bad, a phenomenon that has been labeled "splitting" [57]. Rigidly classifying other people as good or bad can lead the patient to shift between extreme points of view and to selectively attend to information in a way that confirms his or her current opinion. This tendency to "split" can impact treatment. (See "Psychotherapy for borderline personality disorder".) Patients with BPD often interpret neutral events, words, or faces as "negative" [58,59]. Thus, the patient is prone to misinterpret relatively minor disagreements or adverse events as a sign that the caretaker wants to terminate the relationship. The patient often reacts with anger or threats of self-harm, which can alienate the support person, who then may really want to end the relationship. This heightened sensitivity to actual or perceived rejection most likely is what leads to patients often feeling more comfortable or secure with a "transitional object," such as a pet or stuffed animal, than with other people. Affective instability — Patients can experience repeated and marked mood changes throughout the course of a single day, with moment to moment fluctuations often triggered by environmental stressors. Periods of euthymia can alternate with intense, episodic dysphoria that includes depression, anxiety, and irritability. Angry outbursts triggered by dissatisfaction with a caregiver are often followed by feelings of shame, guilt, and worthlessness. Impulsivity — Impetuous and self-damaging behavior is common and can take many forms. Patients abuse substances, binge eat, engage in unsafe sex, spend money irresponsibly, and drive recklessly. In addition, patients can suddenly quit a job that they need or end a relationship that has the potential to last, thereby sabotaging their own success. Impulsivity can also manifest with immature and regressive behavior and often takes the form of sexually acting out. (See 'Nonsuicidal self-injury' below.)

What are the clinical features of Borderline Personality Disorder?

SOCIAL HISTORY FAMILY OF ORIGIN Where did you grow up? Tell me about your parents: What kind of work has your father done? What kind of person is your father? What kind of work has your mother done? What kind of person is your mother? Tell me about your brothers and sisters: Do you all stay in touch? Describe: Do you have any family local? Do you see then regularly? EDUCATION/EMPLOYMENT How far along in school have you gone? Tell me about your school experience: What subjects did you enjoy? What subjects gave you trouble? What sort of work have you done? Tell me about the best job you have had: Tell me about the worst job you have had: PERSONAL RELATIONSHIPS Tell me about your friends: How often do you get to see your friends? What do you do with your friends? Tell me about dating, romantic relationships: Are you in a romantic relationship now? Do you have children? Tell me about your children: SUBSTANCE USE Tell me about your use of alcohol and/or drugs: Do you smoke cigarettes? Details: Have you smoked cigarettes in the past? Details: Do you drink alcohol? Details: In the past? Do you smoke, or otherwise ingest, marijuana? Details: In the past? Do you use other drugs? Details In the past? CRIMINAL JUSTICE Have you ever been arrested? Details: Have you ever been imprisoned/jailed? Details: Are you on probation? Details: In the past?

What are the components of a social history per Dr. McEvoy?

Please tell me about your mother. Did she have any mental or nervous problems? If Y, detailed description of reported feelings, actions and behaviors, and consequences such as hospitalization or incarceration, treatments and effect thereof: Did she smoke cigarettes? ...drink alcohol? ...use drugs? If Y, detailed description of use, extent, and consequences: Please tell me about your father. Did he have any mental or nervous problems? If Y, details and consequences: Did he smoke cigarettes? ...drink alcohol? ...use drugs? If Y, details and consequences: Please tell me about your brothers and sisters (how many? ...ask about each individually): Any mental or nervous problems? Any substance use? Please tell me about your children. Any mental or nervous problems? Any substance use? Please tell me about your aunts and uncles Any mental or nervous problems? ...substance use? Please tell me about your grandparents Any mental or nervous problems? ...substance use? Please tell me about your grandchildren Any mental or nervous problems? ...substance use? Any other relatives (e.g. cousins) with mental problems or substance use? Has anyone (blood kin) in your family been incarcerated/jailed/imprisoned? If Y, details: Has anyone in your family been violent/harmed other people/cruel to animals? If Y, details: Have there been "odd/unusual/eccentric" members of your family? If Y, details: Did anyone in your family die young? ...under 40 years old? If yes, details

What are the components of family history per Dr. McEvoy?

Ventral tegmental area - A group of neurons located close to the midline on the floor of the midbrain. The VTA is the origin of the dopaminergic cell bodies of the mesocorticolimbic dopamine system and other dopamine pathways; it is widely implicated in the drug and natural reward circuitry of the brain. The VTA plays an important role in a number of processes, including reward cognition (motivational salience, associative learning, and positively-valenced emotions) and orgasm,[2] among others, as well as several psychiatric disorders Nucleus Accumbens - A region in the basal forebrain rostral to the preoptic area of the hypothalamus.[1] The nucleus accumbens and the olfactory tubercle collectively form the ventral striatum. The ventral striatum and dorsal striatum collectively form the striatum, which is the main component of the basal ganglia.[2] The dopaminergic neurons of the mesolimbic pathway project onto the GABAergic medium spiny neurons of the nucleus accumbens and olfactory tubercle. - As a whole, the nucleus accumbens has a significant role in the cognitive processing of motivation, aversion, reward (i.e., incentive salience, pleasure, and positive reinforcement), and reinforcement learning (e.g., Pavlovian-instrumental transfer);[4][7][8][9][10] hence, it has a significant role in addiction. Locus ceruleus - A nucleus in the pons of the brainstem involved with physiological responses to stress and panic. It is a part of the reticular activating system. - The principal site for brain synthesis of norepinephrine (noradrenaline). The locus coeruleus and the areas of the body affected by the norepinephrine it produces are described collectively as the locus coeruleus-noradrenergic system or LC-NA system.

What are the components of the brain reward circuitry and what effect do illicit drugs have on them. Briefly describe these areas?

Components: insula and the anterior mesial frontal cortex It is devoted to the recognition of affective behavior

What are the components of the limbic mirror system? What is this system responsible for?

1. Elevated waist circumference (≥ 88 cm for women; ≥ 102 cm for men) 2. Elevated triglycerides (≥ 150 mg/dL) or drug treatment for elevated triglycerides 3. Low HDL cholesterol (< 40 mg/dL for men; < 50 mg/dL for women) or drug treatment for low HDL 4. Elevated blood pressure (systolic ≥ 130 mm Hg or diastolic≥ 85 mm Hg) or hypertensive drug treatment 5. Elevated fasting glucose (≥ 100 mg/dL) or drug treatment for elevated glucose

What are the diagnostic features for metabolic syndrome?

1. Taking an antidepressant with a short half life. 2. Taking addresses for more than eight weeks. 3. Taking high doses of an antidepressant. 4. If anxiety symptoms develop at the start of antidepressant therapy. 5. If also taking other centrally acting medications, such as antihypertensives, antihistamines, antipsychotics. 6. Children and adolescents. 7. Younger patience. 8. If withdrawal symptoms have an experience before.

What are the factors for developing withdrawal symptoms after discontinuing an antidepressant?

Medication - Beta blockers - Gabapentin - SSRIs - BZDs Therapy - CBT - Exposure Exercise He doesn't like antihistaminics or Benadryl because of anticholinergic side effects

What are the general treatment guidelines for anxiety disorders based on McEvoy?

Paranoid delusions and hallucinations

What are the hallmark features of stimulant induced psychosis?

1. Premotivation 2. Motivation 3. Preparation 4. Action 5. Maintenance

What are the levels of change that an addictive brain has to go through in order to achieve abstinence?

Dialectical Behavior Therapy (DBT) is a type of Cognitive Behavioral Therapy (CBT). The main goals of DBT are to teach people how to live in the moment, regulate their emotions, develop and maintain healthy relationships, and cope with distress. You might remember back in June when we wrote about a communication strategy called DEAR MAN. This is a DBT strategy aimed at helping people set boundaries and ask for what they need in a healthy and balanced way. DBT was developed in the late 1990s by Dr. Marsha Linehan and colleagues with the goal of treating Borderline Personality Disorder (BDP). Since that time, DBT has been found to successfully treat many different mental health problems, especially those that primarily reflect a difficulty regulating emotions such as ADHD, Bipolar Disorder, Eating Disorders, Major Depression, and Generalized Anxiety Disorder. The "D" in DBT stands for dialectic. A dialectic is rooted in the idea that everything is made up of opposites and that change occurs when there is a dialogue between the opposing ends. The process makes three assumptions: All things are interconnected. Change is constant and inevitable. Opposites can be integrated to get closer to the truth. All of the above information is important in order to ground the basics of DBT. But, what can we take away from this reading that can help us in our everyday lives? By understanding dialectics, you start to see that there is more than one way to solve a problem and that two seemingly opposite ideas can be true at the same time. The simple summary of a dialectic in DBT is to remember the power of AND. Let's take a look at the way simply swapping out the word "but" for "and" can make a difference: I messed up, but I can try to make it right → I messed up AND I can try to make it right. I am disappointed in you, but I still love you → I am disappointed in you AND I still love you. I understand your point, but I am allowed to disagree with you → I understand your point AND I am allowed to disagree with you. I am doing the best I can, but I can try harder → I am doing the best I can AND I can try harder.

What are the main goals of DBT (explained to the layperson). What does the D in DBT mean?

The limbic system is composed of four main parts: the hypothalamus, the amygdala, the thalamus, and the hippocampus. There are several other structures that may be involved in the limbic system as well, but scientists have not reached a unanimous consensus on them. Remember them with the mnemonic: HAT Hippo The limbic system sits just on top of the brainstem Look up 3D limbic system

What are the main parts of the limbic system and where are they located?

MDD Smoking cessation

What are the most common indications for Wellbutrin?

The most serious potential adverse effects of cannabis use are those caused by inhaling the same carcinogenic hydrocarbons present in conventional tobacco, and some data indicate that heavy cannabis users are at risk for chronic respiratory disease and lung cancer.

What are the most serious AE of cannabis?

Potential Advantages • Bipolar depression • Some cases of psychosis and bipolar disorder refractory to treatment with other antipsychotics ✽ Patients with Parkinson's disease who need an antipsychotic or mood stabilizer ✽ Patients with Lewy body dementia who need an antipsychotic or mood stabilizer Potential Disadvantages • Patients requiring rapid onset of action • Patients who have difficulty tolerating sedation

What are the potential advantages and disadvantages of Seroquel?

Potential Advantages • Rapid onset of action • Less sedation than some other benzodiazepines • Availability of an XR formulation with longer duration of action Potential Disadvantages • Euphoria may lead to abuse • Abuse especially risky in past or present substance abusers

What are the potential advantages and disadvantages of Xanax?

Citalopram/Escitalopram Sertraline Venlafaxine/desvenlafaxine Duloxetine Mirtazapine Bupropion

What are the preferred SSRIs in geriatrics?

The evidence that exists for lithium augmentation of SSRIs is more sobering. Studies by Fava and colleagues3,4 showed no benefit of this augmentation compared with simply increasing the dose of the primary antidepressant. Additional factors to review when considering lithium augmentation are adverse effects, potential toxicity, and need for serum monitoring. Notably, in STAR*D, when lithium augmentation was compared with thyroid hormone augmentation, the two approaches were equally efficacious, but lithium had a higher adverse-effect burden

What are the results of studies examining lithium as an augmenting agent of SSRIs?

1. Sublingual: taken twice a day and not given orally because of poor bioavailability. Side effects include oral hypoesthesia and dysgeusia 2. Transdermal patch: first transdermal antipsychotic that avoids side effects of sublingual and offers a novel way to deliver an antipsychotic

What are the routes of administration of Asenapine? What are some interesting features of these routes?

Honestly none, and rarely cause a sexual dysfunction

What are the sexual side effects of mirtazapine?

1. Dizziness 2. Insomnia (interesting bc most antipsychotics cause sedation) 3. Akathisia (interesting bc most SGAs do not cause EPS) 4. Activation (potential use for negative symptoms?) 5. N/V 6. Orthostatic hypotension 7. Constipation 8. Headache Rarely causes sedation and weight gain

What are the side effects of Aripiprazole?

Mnemonic to remember when to check serum levels of certain drugs 1. Valproic 3 days after start 2. Tegretal 4 days after 3. Lithium 5 days after But this is not set, plus or minus a day most likely. So you can just do it 4 days after for all of them

What does VTL345 mean?

• Nausea, diarrhea, decreased appetite, dry mouth, constipation • Insomnia, sedation, dizziness • Sexual dysfunction (men: abnormal ejaculation/orgasm, impotence, decreased libido: women: abnormal orgasm) • Sweating • Increase in blood pressure (up to 2 mm Hg) • Urinary retention Weight gain is unusual and sedation can happen

What are the side effects of Cymbalta? How common is sedation and weight gain?

✽ Some patients may experience activating side effects at very low to low doses • Dizziness, extrapyramidal symptoms, sedation, dystonia at high doses • Nausea, dry mouth • Asthenia, skin rash • Rare tardive dyskinesia (much reduced risk compared to conventional antipsychotics) • Orthostatic hypotension and QTc PROLONGATION (one of the highest risks) Weight gain is unusual and sedation can occur (just not like other meds)

What are the side effects of Geodon?

1. EPS 2. Neuroleptic-induced deficit syndrome 3. Galactorrhea, amenorrhea 4. Dizziness, sedation (not unusual) 5. Dry mouth, constipation, urinary retention, blurred vision 6. Decreased sweating 7. Hypotension, tachycardia, hypertension 8. Weight gain (not unusual) Rare/life threatening ones: NMS, seizures, jaundice, agranulocytosis, leukopenia

What are the side effects of Haldol

The most common complaint after TMS is mild headaches. Otherwise, it is regarded as safe and without enduring side effects. There are no reported lasting neurological, cognitive, or cardiovascular AE as a result of TMS.

What are the side effects of TMS?

1. Dry mouth, constipation, nausea, weight loss, anorexia, myalgia 2. Insomnia, dizziness, headache, agitation, anxiety, tremor, abdominal pain, tinnitus 3. Sweating, rash 4. Hypertension 5. Rare seizures (higher incidents for immediate-release than for sustained-release)

What are the side effects of Wellbutrin?

1. Adverse cognitive effects (ex. Memory loss) 2. Psychomotor effects (falls, fractures, road traffic crashes) 3. Daytime fatigue 4. Tolerance 5. Addiction

What are the side effects of Z drugs (zolpidem, zaleplon, eszopiclone)?

Notable Side Effects • Most side effects increase with higher doses, at least transiently • Headache, nervousness, insomnia, sedation • Nausea, diarrhea, decreased appetite • Sexual dysfunction (abnormal ejaculation/ orgasm, impotence) • Asthenia, sweating • SIADH (syndrome of inappropriate antidiuretic hormone secretion) • Hyponatremia • Dose-dependent increase in blood pressure Weight gain is unusual and sedation is not uncommon

What are the side effects of venlafaxine? How common is sedation and weight gain?

1. Stupor 2. Excited - constant purposeless agitation and excitation. Extremely hyperactive and may have delusions and hallucinations

What are the subtypes of catatonia?

Subtypes of catatonia are based upon the specific nature of the movement disturbance and other associated features [1]. The three principal forms in order of incidence are: ●Retarded - Mutism, inhibited movement, posturing, rigidity, negativism, and staring ●Malignant - Fever, autonomic instability (labile or elevated blood pressure, tachycardia, tachypnea, and diaphoresis), delirium, and rigidity ●Excited - Excessive and purposeless motor activity, restlessness, stereotypy, impulsivity, frenzy, agitation, and combativeness

What are the subtypes of catatonia?

Remember the mnemonic capital FINISH Flu-like symptoms (lethargic, fatigue, headache, achiness, sweating) Insomnia (with vivid dreams or nightmares) Nausea (sometimes vomiting) Imbalance (dizziness, vertigo, light-headedness) Sensory disturbances ("burning," "tingling," "electric-like" or "shock-like" sensations) Hyperarousal (anxiety, irritability, agitation, aggression, mania, jerkiness)

What are the symptoms of SSRI discontinuation syndrome?

1. Positive symptoms 2. Violent/aggressive behavior Can worsen negative and cognitive symptoms at higher levels

What are the symptoms of psychosis primarily treated by Haloperidol?

Depakote: 60-120 Lithium: 0.6-1.2 Clozapine: 250-350 Lithium is the most important to check bc if it's narrow therapeutic range. Always check it 4-5 days after starting or changing the dose. Depakote is next in line to check but not as important. Clozapine doesn't really have to be checked (maybe for cheeking or if they're not responding)

What are the target range levels for Depakote, Lithium, and Clozapine? Which one is most important to check?

Bowlby and Robertson identified three essential stages of separation response among children. The first stage is that of protest. The child protests the mother's departure by crying, calling out, and searching for her. The second stage is despair and pain. The child loses faith that the mother will return. The third stage is detachment and denial of affection to the mother figure upon her return. These phases are noted universally in children who go through separation by loss of parents to death, through divorce, or by going off to boarding school.

What are the three stages of separation according to Bowlby and Robertson?

1. Intervention - AKA confrontation - Goal is to break through feelings of denial and help the patient recognize the adverse consequences likely to occur if the disorder is not treated. - It is the persistence rather than exceptional interpersonal skills that usually gets results. A single intervention is rarely sufficient. Most alcoholic persons need a series of reminders of how alcohol contributed to each developing crisis before they seriously consider abstinence as a long-term option. 2. Detoxification - Rest, adequate nutrition, multiple vitamins, BZDs 3. Rehabilitation - Counseling - Medications - AA

What are the three steps in treating an alcoholic?

1. Trail making test. 2. Wisconsin card sorting test.

What are the two best test to test executive function?

A) Stimulants 1. Methylphenidate (Ritalin, Concerta, Metadate, Methylin, Daytrana patch) 2. Dextroamphetamine (Dexedrine) 3. Combined Dextroamphetamine/amphetamine salts (Adderall) 4. Dexmethylphenidate (Focalin) 5. Lisdexamfetamine (Vyvanse) B) Non-stimulants 1. Atomoxetine (Strattera) 2. Alpha-adrenergic agonists - Clonidine (Catapres, Kapvay) - Guanfacine (Intuniv, Tenex) 3. Buproprion (Wellbutrin) FDA approved: all except Wellbutrin All of them can be given once 6 years of age except Adderall (not Adderall XR) and Dexedrine which can be given at 3 years

What are the two distinct classes of medications for ADHD? Which ones are FDA approved? At what age are they FDA approved for and what are the two exceptions?

1. Behavioral approach -Examining maladaptive learned behaviors that were learned through classical and operant conditioning 2. Cognitive approach - Examining how clients perceive various events that occur in their life and his this interpretation affects their behaviors and emotions

What are the two main approaches in CBT?

Pure malingering - faking symptoms Partial malingering - exaggerating symptoms False imputation - symptoms exist but give a false history (ex. They slipped and sprained their ankle at home but said it happened at work)

What are the types of malingering?

IV and IM

What are the various formulations of midazolam?

It improves overall cognition Minimal side effects, most common being nausea

What are two major benefits of Trintillex to keep in mind?

1. Lie down, intending to go to sleep only when sleepy. 2. Avoid any behavior in the bed or bedroom, other than sleep or sexual activity. 3. Leave the bedroom, if awake for more than 15 minutes. 4. Return to the bed only when sleepy. 5. Keep a fixed wake time seven days a week, irrespective of the amount of sleep obtained. Items three and four are repeated as needed. In an effort to avoid clock-watching behavior, encourage patient to leave the bedroom as soon as they feel "clearly awake" or experience annoyance and irritation over the fact that they are awake.

What are typical stimulus control therapy instructions for people with insomnia?

Amygdala and hypothalamus

What areas are connected by the Stria terminalis?

Addenbrookes cognitive exam

What assessment can be used to help diagnose frontotemporal dementia?

60 - 100 mg

What average dose of methadone yields the best result in decreasing illicit opioid use?

1. Orbitofrontal cortex 2. Anterior cingulate cortex 3. Head of the caudate nucleus

What brain regions play a role in OCD?

Bupropion, as long as no seizure history

What can be used to treat depression in chronic meth use?

Washington D.C.

What city has the highest PCP use in USA?

Frontotemporal dementia is more likely to show defects in language and Visuospatial functioning. Alzheimer's is more likely to show memory defects

What cognitive symptoms are usually affected in frontotemporal dementia? How does this differ from Alzheimer's?

Impulsivity

What component of ADHD are alpha adrenergic agonists typically used to treat?

In summary, patients with chronic schizophre- nia in this study discontinued their antipsychotic study medications at a high rate, indicating sub- stantial limitations in the effectiveness of the drugs. Within this limited range of effectiveness, olanza- pine appeared to be more effective than the other drugs studied, and there were no significant dif- ferences in effectiveness between the conventional drug perphenazine and the other second-genera- tion drugs. There were no significant differences among the drugs in the time until discontinuation of treatment owing to intolerable side effects. How- ever, olanzapine was associated with greater weight gain and increases in glycosylated hemoglobin, cholesterol, and triglycerides, changes that may have serious implications with respect to medical comor- bidity such as the development of the metabolic syndrome. How clinicians, patients, families, and policymakers evaluate the trade-offs between effi- cacy and side effects, as well as drug prices, will de- termine future patterns of use.

What did the CATIE trial conclude?

Patients in Finland were started on clozapine and 11 years later there was a reduction in all-cause mortality, suicidality, and cardiovascular side effects. Interesting because clozapine is up there with Olanzapine in terms of CVS side effects. It would be interesting to see the results of this study if they continued it for another 20-30 years

What did the FIN11 study conclude?

Overall, the study findings indicate that patients who do not achieve remission or response after several weeks of citalopram treatment could achieve those outcomes by the end of 14 weeks.[1] The STAR*D researchers state that their data "suggest that a patient with persistent depression can get well after trying several treatment strategies, but his or her odds of beating the depression diminish as additional treatment strategies are needed."[4] With failed treatment at a higher step, the chances of remission were smaller - and this decrease was particularly significant after level two.[1] For those who did achieve full remission, there was a decreased chance of relapse at 12-month (naturalistic) follow-up compared to those patients who only responded.[1] Although the study found no clear-cut "winner", it does provide guidance on how to start therapy and how to proceed if initial treatment fails. https://www.researchgate.net/profile/Madhukar-Trivedi-2/publication/5614758/figure/fig1/AS:601675022737438@1520461912842/figure-fig1.png

What did the STAR D trial conclude?

Narcolepsy

What disorder is associated with hypocretin deficiency?

Delayed ejaculation

What disorder is associated with the loss of fast conducting peripheral sensory nerves and decreased sex steroid secretion that accompanies aging?

Mental health case managers work intimately with their patients to develop treatment plans that are properly targeted at the patient's needs. This involves a thorough assessment of the patient's psychosocial triggers, strengths, and personal needs. ... Planning for crises and helping clients develop coping mechanisms.

What do case managers do?

Thalamus - Serves as a relay station for information coming to your brain about what you see, taste, touch and hear. All these sensations travel to by nerves to the thalamus first then the thalamus sends then sensations to the appropriate brain location. Associates sensations with emotions Amygdala - aka aggression center; Associates with emotions, particularly fear and anxiety. When stimulated is associated with anger/violence and fear/anxiety. When destroyed, it causes hyperorality, hypersexuality, disinhibited behavior Hippocampus - converts short term to long term memory. If destroyed, you cannot form new memories but long term memories remain Hypothalamus - Monitors body temperature, intake of food and liquid, sleep, and releases hormones that affect each of these body functions. Regulates autonomic nervous system

What do the 4 main parts of the limbic system do?

Schizophrenia and Bipolar disorder

What does Asenapine treat?

Sorry suggest that patient's with depression have difficulties shifting out of the default mode network when doing specific tasks, I E the default mode is over active.

What does studies suggest about the default mode ICN in patients with depression?

Recognition, immediate and intermediate recall

What does the Wisconsin Card Sorting Task most accurately measure?

Identified patient (IP) is a clinical term often heard in family therapy discussion. It describes one family member in a dysfunctional family who expresses the family's authentic inner conflicts. Usually, the "designated patient" expresses their physical symptoms unconsciously, unaware they are making overt dysfunctional family dynamics that have been covert and which no one can talk about at home. Occasionally, the identified patient is partly conscious of why and how they have become the focus of concern in the family system.

What does the concept of identified patient in therapy refer to?

There is limited evidence supporting the role of spirituality in abstinence

What does the evidence suggest about the role of spirituality in abstinence in alcoholics who attend AA?

Propranolol It has been shown to help control psychosis when given with Clozapine

What drug can be added when Clozapine alone is ineffective?

Latuda Seroquel Symbyax Vraylar Caplyta

What drugs are FDA approved for treatment of Bipolar depression?

1. Dopamine receptor blockers 2. SSRIs 3. Antiepileptics 4. Cocaine 5. Abilify

What drugs cause akathisia?

Anticholinergics and BZD Do not give these/dc them

What drugs should you check for in a delirium patient?

It increases precision

What effect do crossover studies have on precision?

Narcotics can reduce the serum testosterone levels by acting on the hypothalamus-pituitary axis, thereby suppressing the release of gonadotrophins [10]. Low testosterone levels can affect pain control leading to hyperalgesia, mood impairment, fatigue, and depression.

What effect do opioids have on testosterone?

They actually make anxiety worse. Best treatment is CBT

What effect doe BZDs have on anxiety over the long-term? What is the most effective way to treat anxiety?

It can improve these symptoms because of its partial agonist effect on dopamine receptors. By stimulating dopamine receptors in frontal lobe it can improve focusing/concentration. This effect should be considered when selecting antipsychotics. Can opt to give Abilify LAI to higher functioning schizophrenics (think of Tyson and schizophrenic patients in online computer classes).

What effect does Abilify have on focusing/concentration?

It reduces the levels. Can use it to treat hyperprolactinemia/galactorrhea caused by other antipsychotics. Usual dose: 1-5 mg/day

What effect does Aripiprazole have in Prolactin?

It can worsen hallucinations. May have to discontinue Concerta and start something else if hallucinations present/getting worse

What effect does Concerta have on hallucinations?

You should give half the Lamictal dosage you would normally give if Depakote is also being given bc it doubles the levels of Lamictal by decreasing metabolism

What effect does Depakote have on Lamictal dosage?

Long half life = longer time needed to reach steady stare and to wash out of body

What effect does a long half life have on steady state time and wash out time

It can decrease it

What effect does caffeine have on lithium levels?

Individuals with major depression exhibit about 8 to 10% reduction in hippocampal size bilaterally

What effect does major depression have on the volume of hippocampi?

It can increase appetite and weight gain. Out of all the SSRIs, it is most likely to do this

What effect does paroxetine have on appetite and weight?

Approximately 60 percent of patients with depressive disorders exhibit significant but transient benefits from total sleep deprivation. The positive results are typically reversed by the next night of sleep. Several strategies have been used in an attempt to achieve a more sustained response to sleep deprivation.

What effect does sleep deprivation have on depression?

Hypothyroid

What endocrine abnormality is rapid-cycling bipolar disorder associated with?

Mixed manic/depressed episode

What factor is thought to predict a poor response to lithium treatment for patients with Bipolar disorder?

Frontotemporal Dementia

What form of dementia has been associated with ALS?

Supportive psychotherapy

What form of psychotherapy is most likely to describe a therapeutic goal as improving ego functioning and self-esteem?

Genetic deletion of Chromosome 22q11.2

What genetic mechanism is involved in the development of velocardiofacial syndrome (DiGeorge Syndrome)?

De novo mutations

What genetic mechanism, can best account for the high prevalence of diseases, such as schizophrenia, autism and intellectual disability, despite the fact that these illnesses are associated with a marked reduction fertility?

Rapid eye movement (REM) sleep behavior disorder is a sleep disorder in which you physically act out vivid, often unpleasant dreams with vocal sounds and sudden, often violent arm and leg movements during REM sleep — sometimes called dream-enacting behavior. The onset of REM sleep behavior disorder is often gradual and it can get worse with time. REM sleep behavior disorder may be associated with other neurological conditions, such as Lewy body dementia (also called dementia with Lewy bodies), Parkinson's disease or multiple system atrophy. Treatment: melatonin first then Klonopin

What is REM sleep behavior disorder and how do you treat it?

The left hemisphere appears to seek logic and cohesiveness in its responses. It does not appear to be concerned with being factual or correct, but only with giving a coherent story. It generally doesn't admit that it doesn't know something, and it will "make up" an answer if needed. For example, in the hemineglect disconnection syndrome resulting from damage to the right hemisphere, the undamaged left hemisphere generates the story that the paralyzed hand belongs to someone else. In contrast, the right hemisphere séems concerned with accurate details and has difficulties dealing with inconsisten- cies. Unfortunately, this hemisphere does not have a direct language module, so it tends to express itself through emotions and feelings. These differences between the two hemispheres may contribute to the observation that strokes involving the ante- rior left hemisphere are more commonly associated with depression than lesions of the right hemisphere. When the left side is damaged, the right hemisphere recog nizes there is a problem and becomes "worried," expressing its concerns through negative emotions, In the presence of similarly placed anterior lesions of the right hemisphere, the left hemisphere typically has no problem going about its business, but it is not held in check by the emotional control imposed by the right hemisphere. This may result in the development of manic-like (or impulsive) behaviors in some cases.

What happens if a patient has a stroke involving the left vs right hemisphere in terms of mood?

It won't exert an antidepressant effect. At lower doses it's more likely to endure euphoria and anxiolysis. Effective dose when given IV, is usually 0.5 mg/kg and intranasally is 84 mg. Those companies that sell ketamine online are often dosed too low.

What happens if ketamine is dosed too low in the treatment of depression?

• If patient stops taking lamotrigine for 5 days or more it may be necessary to restart the drug with the initial dose titration, as rashes have been reported on reexposure

What happens to the dose schedule If a patient misses their Lamotrigine dose?

Results are inconsistent. You do not necessarily need years of experience to have good outcomes. This is why therapeutic alliance is so important.

What he research revealed about the relationship between years of experience and CBT outcomes?

NOTES

What impairments are you likely to see at different blood alcohol concentrations?

Group A beta hemolytic strep

What infectious agent has been associated with either an initial manifestation or an exacerbation of OCD in children?

Framing helps set boundaries and defines consistent rules in respect to the relationship between the patient and therapist. It refers to the environment and relationship which enables the patient to be open about their life with the therapist.

What is "framing/frame" in psychodynamic psychotherapy?

ACT consists of one multidisciplinary team (e.g., case manager, psychiatrist, nurse, general physicians). The team has a fixed caseload of patients and delivers all services when and where needed by the patient, 24 hours a day, 7 days a week. This is mobile and intensive intervention that provides treatment, rehabilitation, and support activities. These include home delivery of medications, monitoring of mental and physi cal health, in vivo social skills, and frequent contact with family members. There is a high staff-to-patient ratio (1:12). ACT programs can effectively decrease the risk of rehospitalization for persons with schizophrenia, but they are labor-intensive and expensive programs to administer.

What is ACT?

A term used to describe cognitive, motor and behavioral neurological impairments that are unrelated to opportunistic infections. These impairments significantly impair activities of daily living, resulting in decreased independence.

What is AIDS dementia complex?

A type of depression that is pathognomonically characterized by mood reactivity (improved mood in response to positive events) along with weight gain, hypersomnia, increased appetite, heavy sensation in limbs, interpersonal rejection sensitivity

What is Atypical depression?

The association venlafaxine-mirtazapine is currently known as California Rocket Fuel (CRF). Studies show advantage in terms of efficacy and rapid control of depressive symptoms compared to other associations. Venlafaxine is a selective serotonin-noradrenalin reuptake inhibitor and mirtazapine is a noradrenergic-specific serotonergic antidepressant: the result is a potent noradrenergic and serotonergic effect. Studies say that CRF should be performed only for drug-resistant depression; however, there are case reports of its use as a first line treatment, in selected patients. Patients with insomnia and weight loss may benefit from CRF as a first line option.

What is California Rocket Fuel?

EEG slowing is when the Hz (frequency) of the waves are slow. It is seen in decreased consciousness (sleep). Some waves are naturally slower than others (ex theta and delta vs beta and alpha). However when present while awake it could indicate encephalopathy. Rule of thumb for when patient is awake, at least 8 Hz beginning at age 8 years

What is EEG slowing and what does it indicate?

Early Psychosis Intervention Clinic These are clinics for patients experiencing first episode psychosis that along with medication management provide therapy, social, and cognitive support. They strive to maintain medication adherence, reduce rehospitalization and healthcare costs, and improve overall functioning and mortality in patients experiencing first break psychosis

What is EPIC?

Lithium 450 mg, Zyprexa 20 mg QHS, Depakote ER 1000 mg QHS and Ativan PO or IM PRN He'll continue this inpatient to stabilize them and then at outpatient follow-up Zyprexa and Depakote can be stopped and Abilify added if needed

What is McEvoy's go to cocktail for bipolar agitated patients in an inpatient setting?

Lithium + Abilify +/- Lamictal He sticks with low doses of these meds because there are less side effects. He says it's acceptable to have lithium level at 0.4-0.6 Lithium 450 mg + Abilify 5 mg However, he gets up to Lamictal 200 mg QD

What is McEvoy's med combination for Bipolar disorder? What are the doses?

Construct validity is "the degree to which a test measures what it claims, or purports, to be measuring." IE the ability of a depression screen to detect depression

What is construct validity?

It's a quick, 3-min test that can be used to detect cognitive impairment. Can be used as a "cognitive vital sign." It has two components, a 3-item recall memory test and a simply scored clock drawing test. Positive results warrant further testing

What is mini-cog test?

It is an offshoot of Freud's psychoanalytic theory, forms much of the foundation of contemporary psychoanalysis as the first large psychoanalytic movement recognizing empathy as an essential aspect of the therapeutic process of addressing human development and growth. Self psychology theory, which rejects Freudian ideology of the role sexual drives play in organization of the psyche, focuses on the development of empathy toward the person in treatment and the exploration of fundamental components of healthy development and growth. Therapists may use self psychology theory in part to help people consider how their early experiences may contribute to the formation of their sense of self.

What is Self Psychology?

It's a synthetic cannabinoid. It's use has increased lately. It may lace natural marijuana. It cannot be detected on UDS

What is Spice? Can you detect it on UDS?

A selective dual orexin receptor antagonist. It treats insomnia. It is not as intense as BZD or ambien so if a patient is on one of those two and you make them take Suvorexant, they'll say it doesn't work.

What is Suvorexant? How does it compare to the other drugs in the treatment of the condition it was made for?

Olanzapine-Fluoxetine combination It can treat Bipolar depression and treatment-resistant depression

What is Symbyax?

Transcutaneous electrical nerve stimulation (TENS) therapy involves the use of low-voltage electric currents to treat pain. A small device delivers the current at or near nerves. TENS therapy blocks or changes your perception of pain. Transcutaneous electrical nerve stimulation (TENS) is a therapy that uses low voltage electrical current to provide pain relief. A TENS unit consists of a battery-powered device that delivers electrical impulses through electrodes placed on the surface of your skin. The electrodes are placed at or near nerves where the pain is located or at trigger points. Indications - Osteoarthritis - Fibromyalgia - Tendinitis - Bursitis - Labor pain. - Low back pain. - Chronic pelvic pain. - Diabetic neuropathy - Peripheral artery disease

What is Transcutaneous electrical nerve stimulation (TENS) and what does it treat?

Increased mortality in elderly patients with dementia-related psychosis. Causes of death varied but most were due to either CVS (ex. HF, sudden death) or infections (ex. PNA)

What is a black box warming for antipsychotics?

Unlike the stimulants, Strattera carries with it a black box warning for potential increases in suicidal thoughts or behaviors and requires children with ADHD to be monitored for these symptoms, similarly to children who are administered antidepressants.

What is a black box warning for Straterra?

SSRIs, with the exception of fluoxetine, may increase the risk of SI and behaviors. Therefore, they should not be used to treat MDD in adolescents

What is a black box warning for antidepressants

Sertraline

What is a good first choice when starting treatment for moderate to severe major depression in adults?

The amount of weight patient again in the first few months of starting medication. If they do not gain or only gain a minimum amount, then future risk of metabolic side effects is low. Some patients can gain up to 40 lbs in the first month

What is a good predictor of metabolic side effects from SGA?

"Have people often disappointed you in your life?When something has gone really wrong in your life, such as losing a job or getting rejected, have you often done something to hurt yourself, such as cutting yourself or overdosing?"

What is a good probing question for Borderline PD?

"Have you ever had a period of a week or so when you felt so happy and energetic that you didn't need to sleep and your friends told you that you were talking too fast or that you were behaving differently and strangely?"

What is a good screening question for bipolar disorder?

"A panic attack is a sudden rush of fear and nervousness in which your heart pounds, you get short of breath, and you're afraid you're going to lose control or even die. Has that ever happened to you?"

What is a good screening question for panic disorder?

"Do you tend to worry a lot about your health?"

What is a good screening question to ask for somatic symptom disorder and/or illness anxiety disorder?

Psychedelic drugs act in serotinergic, dopaminergic, and noradrenergic receptors. Their psychedelic effect primarily stems from their activity on 5-HT2A receptors. However, they also act on 5-HT2B receptors. For many years, it has been known that drugs with potent 5-HT2B agonist activity induce valvular heart disease in humans. No studies have yet directly addressed the concern that chronic administration of psychedelic drugs, as might occur with microdosing, might induce clinically significant valvular heart disease. Until definitive studies are performed, people must use caution when using psychedelic drugs and MDMA chronically

What is a medical concern of long-term use of psychedelic drugs, including MDMA?

EEG It shows diffuse slowing. This isn't specific but further bolsters your diagnosis of delirium

What is a nonspecific test you can order to help diagnose delirium?

Because one of its side effects is urinary retention it should not be given to people with urologic disorders, prostate disorders (I. e. Older men) It's approved in many countries for stress urinary incontinence.

What is a potential GU disadvantage of Cymbalta and how is this feature of Cymbalta used as an advantage?

There is a risk for increased irritability, moodiness, and hyper activity when both are given together. Manage this by decreasing the dose of the stimulant.

What is a potential complication when treating ADHD with stimulants and EEG biofeedback? How do you manage this complication?

Returning the child to school

What is a principal aim in the treatment of a child with school phobia?

A psychological test in which words, images, or situations are presented to a person and the responses analyzed for the unconscious expression of elements of personality that they reveal.

What is a projective test?

It can cause serotonin syndrome. The likelihood of this happening, when given alone is low, but if patients are taking SSRIs, for example, the risk is increased.

What is a psychiatric side effect of Linezolid?

For a quick and dirty measure of intelligence quotient (1Q), you can give the easy-to-remember Wilson Rapid Approximate Intelligence Test (Wilson 1967) (Table 21.4). Start with 2 x 48 as a screening test. If the patient can calculate this, she's very unlikely to be in the borderline or retarded range, and you can end the testing. Patients who can't calculate 2 × 24 are likely to meet IQ criteria for mental retardation and should definitely be referred for formal neuropsychological testing. The usual caveat regarding educational level applies: You should only give this test to patients who have completed high school.

What is a quick way to measure intelligence during a mental status examination?

The McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) is a 10-item, self-report screening measure for BPD. A score of seven or higher indicates possible BPD and that further assessment is needed to determine if someone actually has BPD.

What is a screening psychometric for borderline personality disorder? How do you score it?

An abreaction is an emotional, unconscious reaction that you have in response to a stimulus that brings back a painful situation you have experienced before. It may be an event that you remember, or it may be something that suddenly pops into your consciousness when having the abreaction.

What is abreaction? How is it different from catharsis?

Inability to spontaneously move and speak. Absence of willpower or an inability to act decisively

What is abulia?

An inability to describe one's emotions or mood

What is alexithymia?

E Alogia is a lack of speech that results from a mental deficiency or dementia.

What is alogia? A. Poverty of movement B. Poverty of emotion C. Poverty of speech only D. Poverty of thought content only E. Poverty of speech and thought content

The overvalued idea, first described by Wernicke, refers to a solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer's life.

What is an overvalued idea?

Anaclitic depression is a term used to describe the transient depressed state of infants after their sep- aration from a mothering figure. It can occur after sudden or prolong separation and otherwise normally attached infant

What is anaclinic depression?

Animistic thinking is a mode of thinking which involves attributing life to an inanimate object. Piaget determined that stages of animism are age related. As the child becomes progressively older he is less animistic and more objectively logical in his thinking. Animism is the belief that inanimate objects are capable of actions and have lifelike qualities. An example could be a child believing that the sidewalk was mad and made them fall down, or that the stars twinkle in the sky because they are happy.

What is animistic thinking?

Patients are indecisive

What is another way diminished concentration manifests in MDD?

The dose could be too low. There's not enough in their blood

What is another way to look at a patient not experiencing side effects to medications?

Antisocial personality disorder is an inability to conform to the social norms that ordinarily govern many aspects of a person's adolescent and adult behavior. Although characterized by continual antisocial or criminal acts, the disorder is not synonymous with criminality. DSM-5 Diagnostic Criteria for Antisocial Personality Disorder A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following: 1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. 3. lmpulsivity or failure to plan ahead. 4. Irritabil ity and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for safety of self or others. 6. Consistent irresponsibil ity, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. B. The individual is at least age 18 years. C. There is evidence of conduct disorder with onset before age 1 5 years. D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

What is antisocial personality disorder?

Arbitrary inference is "the process of forming an interpretation of a situation, event, or experience when there is no factual evidence to support the conclusion or where the conclusion is contrary to the evidence"

What is arbitrary inference?

Ataque de nervios (Spanish pronunciation: [aˈtake ðe ˈneɾβjos], also known as "Puerto Rican syndrome"[1]) is a psychological syndrome that was initially discovered in the United States, among Spanish-speaking people from the Caribbean, although commonly identified among cultures of Latino descent Ataque de nervios translates into English as "attack of nerves",[2] Ataque de nervios can be referred to as culturally influenced syndrome classified by a specific pattern of symptoms, rather than being a general term for feeling nervous.[3] The term ataque de nervios may also refer to an idiom of distress that includes any "fit"-like paroxysm of emotionality and may be used to refer to an episode of loss of control in response to an intense stressor.[3] The condition appears in Appendix I of the revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a culture-bound syndrome.[4][5] Despite comparisons to panic attacks, investigators have identified ataque de nervios as a separate syndrome with measured differences in anxiety sensitivity, and types of attacks. Marlene Steinberg, an Associate Research Scientist at Yale University stated that because it is similar to Multiple Personality Disorder, some Hispanics may be misdiagnosed with an ataque de nervios syndrome instead. Reported symptoms of Ataque de nervios syndrome may include partial loss of consciousness, convulsive movements of psychogenic origin, assaultive hyperactivity, childlike regressed behavior, and/or psychosis, and may also include impulsive suicidal or homicidal acts, as well as uncontrollable screaming or shouting, crying, trembling, sensations of heat rising in the chest and head, dissociative experiences, and verbal or physical aggression. The cause of these symptoms can not be specifically defined but is usually associated with the memory or repression of a stressful event. These stressful events can be related, but is not limited to the particular geographical relocation of one's family, childhood sexual trauma, or dissociative experiences.

What is ataque de nervios?

A anorexia in which all other criteria for anorexia are met, except that despite significant weight loss, the individual's weight is still within or above the normal range

What is atypical anorexia?

Serotonin 1A partial agonist 30 mg in a day

What is buspirone's mechanism of action? At what does it usually start exerting its effect?

Deals with the whether the assessment, content and composition is appropriate given what is being measured (e.g. Does the test reflect the knowledge/skills required to do a job or demonstrate that one grasps the course material). For example, is there an appropriate representation of questions from each topic area on the assessment that reflects the curriculum that is being taught?

What is content validity of a test?

Content validity refers to the extent to which the items on a test are fairly representative of the entire domain the test seeks to measure

What is content validity?

Contingency Management is often called motivational incentives, the prize method, or the carrot and stick method. The Contingency Management (CM) approach, sometimes also referred to as "motivational incentives," is based on the principle of operant conditioning - that behavior is shaped by its consequences.

What is contingency management?

A therapeutic, covert conditioning procedure in which the client pictures a role model, imagines behaving as this person might, and then visualizes specific favorable consequences of the behavior.

What is covert modeling?

Covert sensitization is a form of behavior therapy in which an undesirable behavior is paired with an unpleasant image in order to eliminate that behavior.

What is covert sensitization?

A mental health crisis is defined as any non-life-threatening situation in which people experience an intensive behavioral, emotional, or psychiatric response triggered by a precipitating event and whose behavior puts them at risk of hurting themselves or others and/or prevents them from being able to care for themselves or function effectively in the community. It is important to recognize that addressing problems before physical safety becomes an issue is an important step in the successful management of patients experiencing a mental health crisis before it becomes a mental health emergency, which can be life-threatening. Most often mental health emergencies involve the threat of suicide or acting on a suicide threat. Other emergencies may involve a threat of harm to another individual. Mental health crisis intervention refers to methods that offer immediate, short-term help to individuals who are experiencing an event that is producing emotional, mental, physical, and behavioral distress or problems. Mental health crises are usually temporary, short-lived, and last approximately one month. The length of crisis intervention may range from one session to an average of four weeks, and session lengths may range from 20 minutes to more than two hours. Crisis intervention is appropriate for all ages and can take place in a range of settings.

What is crisis intervention in mental health? What is a mental health crisis vs emergency?

Dialysis dementia is a unique neurologic complication of renal failure associated with chronic dialysis. While many questions remain about the pathophysiology of the disease, aluminum toxicity is probably the major factor in the pathogenesis of the dementia.

What is dialysis dementia and what is the cause?

Double depression is a complication of a psychiatric illness called dysthymic disorder, or dysthymia. Dysthymia is a chronic, depressed mood accompanied by just one or two other symptoms of clinical depression (such as low energy or low self-esteem) that lasts at least two years in adults (or one year in kids). This low, dark mood -- sometimes described as a "veil of sadness" -- occurs nearly every day and can sometimes persist for many years. Some people may have this mood disorder for 10 to 20 years or even more before seeking treatment. Over time, more than half of people with dysthymia experience worsening symptoms that lead to the onset of a full syndrome of major depression superimposed on their dysthymic disorder, resulting in what is known as double depression.

What is double depression?

Emotional safety means that partners feel comfortable with being authentic, sharing thoughts, feelings, and ideas, and expressing issues without fear of being put down, shut down, ridiculed, criticized, or told to be, act, or feel different. Important to determine limits of emotional safety during the initial engagement phase

What is emotional safety? During what phase of group psychotherapy is it important to determine its limits?

A theory that predicts and explains how people within a family system interact, and how interactions inside the family system are different from those outside of it. Family systems theory can be simplified to just to hypotheses. The first is that the family is an AUTONOMOUS system. Family systems have rule-based, boundary making processes that generate and maintain the family. These processes are distinct to the family system, occur across time, and remain relatively stable. The second is that the family is an ADAPTABLE system. The family system response to stress from inside and outside of the system by making changes to its rule-based, boundary making processes. The goal of these adaptations is to help the family maintain autonomy.

What is family systems theory? And what two hypotheses is this theory based on?

Orgasmic disorder is lack of or delay in sexual climax (orgasm) even though sexual stimulation is sufficient and the woman is sexually aroused mentally and emotionally. Women may not have an orgasm if lovemaking ends too soon, there is not enough foreplay, or they are afraid of losing control or letting go.

What is female orgasmic disorder?

Gabapentin has no direct GABAergic action and does not block GABA uptake or metabolism. Gabapentin appears to inhibit the action of α2δ-1 subunits, thus decreasing the density of pre-synaptic voltage-gated calcium channels and subsequent release of excitatory neurotransmitters.

What is gabapentin's mechanism of action?

Kin selection is the evolutionary strategy that favours the reproductive success of an organism's relatives, even at a cost to the organism's own survival and reproduction.

What is kin selection?

Melancholia is one of the oldest terms used in psychiatry, dating back to Hippocrates in the 4th century to describe the dark mood of depression. It is still used to refer to a depression characterized by severe anhedonia, early morning awakening, weight loss, and profound feelings of guilt (often over trivial events). It is not uncommon for patients who are melancholic to have suicidal ideation. Melancholia is associated with changes in the autonomic nervous system (hyperactive) and in endocrine functions (abnormal HPA)

What is melancholia?

Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically.

What is mentalization?

The primary goal of MET is to help individuals overcome their ambivalence or resistance to behavior change. MET focuses on increasing intrinsic motivation by raising awareness of a problem, adjusting any self-defeating thoughts regarding the problem, and increasing confidence in one's ability to change. Instead of identifying a problem and telling a person in therapy what to do about it, the therapist encourages a person in therapy to make self-motivating statements that display a clear understanding of the problem and a resolve to change. MET is based on five motivational principles that are designed to guide the therapist's work with an individual in therapy: Express empathy: Therapists create a supportive environment in order to help an individual feel accepted and respected, and they engage in reflective listening rather than direct confrontation. The therapist will listen to what an individual is saying and then reflect it back, with slight but deliberate modifications. The modifications both let the individual know that the therapist has heard and understood and encourage the individual to elaborate. Develop discrepancy: In MET, the therapist directs attention toward the discrepancy between an individual's desired state of being and that individual's actual state of being. This discrepancy may help aid in recognizing the ways that current behaviors hinder one from achieving goals, and it can also provide a strong incentive for behavior change. Avoid argumentation: A therapist will avoid attacking an individual or an individual's behavior, as this is thought to result in defensiveness and resistance. Other, gentler methods are used to raise awareness of any problems, and any statements regarding a need for change should come from the individual, not the therapist. Roll with resistance: Instead of directly confronting any resistance on the part of the individual, the therapist tries to defuse it, often through reflective listening or by simply going along with what an individual is saying. This approach may seem counterintuitive, but it decreases the odds of further defensiveness and may make it more likely that an individual will remain in therapy and benefit from other aspects of the intervention. Support self-efficacy: One's motivation to change typically depends not only on the reasons for modifying behavior but also on the belief that one is able to perform the tasks required for change. One aspect of a therapist's role is to help individuals become aware of their ability to successfully undertake the actions needed for change.

What is motivational enhancement therapy? What are it's five principles?

The minimum amount of energy needed to observe the contraction of the thumb

What is motor threshold in TMS?

Multisystemic therapy is an intense, family-focused and community-based treatment program for juveniles with serious criminal offenses who are possibly abusing substances. It is also a therapy strategy to teach their families how to foster their success in recovery.

What is multisystemic therapy?

It's a paradoxical reaction where the patient gets worse in response to therapist interpretations that are accurate and appropriate

What is negative therapeutic reaction in psychodynamic psychotherapy?

Object relations theory is centered on our internal relationships with others. ... Objects refer to people or physical items that come to symbolically represent either a person or part of a person. Object relations, then, are our internalized relationships to those people. Object relations theory is that branch of psychodynamic thought that focuses on relationships being more crucial to personality development than are individual drives and abilities

What is object relations theory?

Orthostatic hypotension

What is one AE of Thorazine IM to be aware of?

Sodium A life-threatening side effect is hyponatremia

What is one electrolyte that you might consider monitoring when administering Trileptal?

Thyroid supplementation is frequently necessary during long-term treatment of bipolar disorder. Many patients treated with lithium develop hypothyroidism, and many patients with bipolar disorder have idiopathic thyroid dysfunction. T 3 (25 to 50 µg per day), because of its short half-life, is often recommended for acute augmentation strategies, but T 4 is frequently used for long-term maintenance. In some centers, hypermetabolic doses of thyroid hormone are used. Data indicate improvement in both manic and depressive phases with hypermetabolic T 4-augmenting strategies.

What is one hormonal therapy to consider in bipolar disorder?

Steroids

What is one medication to always look for when a patient develops new-onset psychosis?

Teratogenic effects. Take birth control

What is one warning you should give to women starting on Depakote?

Operant conditioning, sometimes referred to as instrumental conditioning, is a method of learning that employs rewards and punishments for behavior. Through operant conditioning, an association is made between a behavior and a consequence (whether negative or positive) for that behavior. Notecard pic for 4 types

What is operant conditioning and what are the 4 types?

Increased sensitivity to pakin with chronic opioid use. Ex. Patients will process pain that is usually 2/10 as 6/10. Something to remember in opioid users when having to provide pain relief

What is opioid-induced hyperalgesia?

A therapeutic technique in which a client is directed by the therapist to continue undesired symptomatic behavior, and even increase it, to show that the client has voluntary control over it.

What is paradoxical intervention in therapy?

It is a condition or phenomenon involving distorted memory or confusions of fact and fantasy, such as confabulation or déjà vu.

What is paramnesia?

A paraphasia is the production of an unintended sound within a word, or of a whole word or phrase. It can be the substitution of one sound for another sound, using the wrong word, or transposing sounds within a long word.

What is paraphrasia?

Freudian slip; a faulty act of purposeful behavior. It is an error in speech, memory, or physical action that occurs due to the interference of an unconscious subdued wish or internal train of thought.

What is parapraxis?

Paratonia: inability to relax muscles during muscle tone assessment Seen in catatonia Types - Gegenhalten (oppositional paratonia): occurs when subjects involuntarily resist passive movements - Mitgehen (facilitatory paratonia): occurs when subjects involuntarily assist passive movements

What is paratonia? Where do you see it and what are the two types?

A severe, sometimes disabling extension of premenstrual syndrome. Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that includes physical and behavioral symptoms that usually resolve with the onset of menstruation. PMDD causes extreme mood shifts that can disrupt work and damage relationships. Symptoms include extreme sadness, hopelessness, irritability, or anger, plus common premenstrual syndrome symptoms such as breast tenderness and bloating. Treatment: SSRIs

What is premenstrual dysphoric disorder and what is the best evidence based treatment for it?

Norepinephrine

What is produced when dopamine hydroxylase modifies dopamine?

Hypnosis

Which of the following therapies for IBS has demonstrated high efficacy in controlled trials? A. Hypnosis B. Surgical resection C. Tincture of morphine D. Supportive psychotherapy E. Progressive muscle relaxation

●As originally described, progressive supranuclear palsy (PSP) is characterized by progressive supranuclear ophthalmoplegia, gait disorder and postural instability, dysarthria, dysphagia, rigidity, and frontal cognitive disturbance. PSP is now recognized to encompass a number of phenotypic variants. The two most common are Richardson syndrome (the classic form of PSP) and PSP-parkinsonism. (See 'Historical background' above.) ●PSP is the most common degenerative form of atypical parkinsonism. The mean age of onset for PSP is approximately 65 years. No cases of PSP have been reported in patients younger than age 40 years. (See 'Epidemiology' above.) ●With the most common "classic" phenotype of PSP, known as Richardson syndrome (PSP-RS), the most frequent initial feature is a disturbance of gait resulting in falls. Supranuclear ophthalmoparesis or plegia is the hallmark of PSP but may come on later. An important earlier manifestation is slowing of vertical saccades (also difficulty with voluntary vertical gaze then eventually with horizontal gaze too). Dysarthria, dysphagia, rigidity, frontal cognitive abnormalities, and sleep disturbances are additional common clinical features. PSP with predominant parkinsonism (PSP-P) is characterized by asymmetric onset of limb symptoms, tremor, and a moderate initial therapeutic response to levodopa. It may be confused with idiopathic Parkinson disease. (See 'Clinical characteristics' above and 'Variant phenotypes' above.) ●The radiologic hummingbird sign (also called the penguin silhouette sign) results from the prominent midbrain atrophy in PSP with a relatively preserved pons, resembling a hummingbird or penguin in silhouette on midsagittal MRI of the brain (image 1). (See 'Neuroimaging' above.) The core clinical features include postural instability, oculomotor deficits, especially vertical gaze palsy, akinesia/parkinsonism, and frontal lobe impairments, including speech and language problems and behavioral change.

What is progressive supranuclear palsy?

Symptoms of anxiety, insomnia, and mild autonomic overactivity are likely to continue for 2 to 6 months after the acute withdrawal has disappeared.

What is protracted withdrawal?

Another term for classical conditioning

What is respondent conditioning?

What is separation anxiety disorder in children? Separation anxiety disorder (SAD) is a type of mental health problem. A child with SAD worries a lot about being apart from family members or other close people. The child has a fear of being lost from their family or of something bad occurring to a family member if he or she is not with the person. All children and teens feel some anxiety. It is a normal part of growing up. Separation anxiety is normal in very young children. Nearly all children between the ages of 18 months and 3 years old have separation anxiety and are clingy to some degree. But the symptoms of SAD are more severe. A child must have symptoms of SAD for at least 4 weeks for the problem to be diagnosed as SAD. A child with SAD has worries and fears about being apart from home or family that are not right for his or her age. What causes separation anxiety disorder in a child? Experts believe SAD is caused by both biological and environmental factors. A child may inherit a tendency to be anxious. An imbalance of 2 chemicals in the brain (norepinephrine and serotonin) most likely plays a part. A child can also learn anxiety and fear from family members and others. A traumatic event may also cause SAD. Which children are at risk for separation anxiety disorder? SAD happens equally in males and females. But children who have parents with an anxiety disorder are more likely to have SAD.

What is separation anxiety disorder in children? What causes it and who is at greater risk?

Shaping, or behavior-shaping, is a variant of operant conditioning. Instead of waiting for a subject to exhibit a desired behavior, any behavior leading to the target behavior is rewarded. ... In other words, the subject behavior is shaped, or molded, into the desired form. Rather than reinforcing a single desired response, as in straight operant conditioning, shaping reinforces a series of responses that are progressively closer to the end goal. This process is also referred to as behavior shaping or the method of successive approximations.

What is shaping in terms of conditioning?

State-dependent learning is the facilitated recall of information in the same internal state or environment in which the information was originally obtained. An example of this is when someone learns a behavior when intoxicated with a drug. Without the drug he or she cannot recall the behavior. When the drug is given to him or her again, he or she remembers the behavior

What is state-dependent learning?

A. Two (or more) of the followi ng, each present for a sign ificant portion of time duri ng a 1 -month period (or less if successful ly treated). At least one of these must be (1 ), (2), or (3): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorgan ized or catatonic behavior 5. Negative symptoms (i .e., diminished emotional expression or avol ition). B. For a sign ificant portion of the time since the onset of the disturbance, level of functioning in one or more major areas of functioning, such as work, interpersonal relations, or self-care, is markedly below the level achieved before the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C. Continuous signs of the disturbance persist for at least 6 months. Th is 6-month period must include at least 1 month of symptoms (or less if successfu lly treated) that meet Criterion A (i .e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms l isted in Criterion A present in an attenuated form (e.g., odd bel iefs, unusual perceptual experiences). D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either (1 ) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if promi nent delusions or hal lucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfu lly treated).

What is the DSM 5 diagnostic criteria for schizophrenia?

QTc prolongation. Don't give more that 20 mg for citalopram and 10 mg for escitalopram

What is the FDA warning against citalopram/escitalopram in the elderly? How do you address this?

The Halstead-Reitan neuropsychological test battery (HRNB) is a compilation of neuropsychological tests designed to evaluate the functioning of the brain and nervous system in individuals aged 15 years and older.

What is the Halstead-Reitan battery?

It's a dopamine 2 receptor blocker (reduces positive symptoms) and serotonin 2A receptor blocker (enhances dopamine release and possibly improves cognitive and affective symptoms) like Zyprexa

What is the MOA of Ziprasidone?

It blocks the NMDA type of glutamate receptors on GABA neurons which blocks the release of GABA. This disinhibits the release of glutamate which will bind to AMPA receptors to produce excitatory/antidepressant responce

What is the MOA of ketamine?

Clear and convincing evidence

What is the minimal degree of legal certainty that is constitutionally required for an involuntary mental health commitment? Up to individual states Beyond a reasonable doubt Clear and convincing evidence Preponderance of the evidence Likelihood of dangerous behavior

The Minnesota Multiphasic Personality Inventory (MMPI) is the most widely used and researched clinical assessment tool used by mental health professionals to help diagnose mental health disorders. Originally developed in the late 1930s, the test has been revised and updated several times to improve accuracy and validity. The MMPI-2 consists of 567 true-false questions and takes approximately 60 to 90 minutes to complete, while the MMPI-2-RF has 338 true-false questions, taking 35 to 50 minutes to finish. It can help diagnose mental health disorders and conditions based on where you fall on 10 scales (ex of scales: hypochondriasis, depression, hysteria, masculinity-femininity, schizophrenia, paranoia) Known limitation: does nothing account for outcomes based on race and religion

What is the Minnesota Multiphasic Personality Inventory and what is a known limitation?

A PEth blood test measures the level of phosphatidylethanol, a direct alcohol biomarker which is found in human blood following alcohol consumption. Phosphatidylethanols are abnormal phospholipids formed in the presence of ethanol (more commonly known as alcohol). For men, it appears that a daily consumption averaging ~2.5 standard drinks of alcohol a day (35 g/day) could produce a positive (>20 ng/mL) laboratory PEth finding. For women, a positive PEth (>0.20 ng/mL) might be produced by the consumption of 1.5-2 standard drinks (21-28 g/day) a day.

What is the PEth blood test?

NOTECARD

What is the SCOFF questionnaire?

The Trail Making Test is a neuropsychological test of visual attention and task switching. It consists of two parts in which the subject is instructed to connect a set of 25 dots as quickly as possible while still maintaining accuracy. The TMT measures attention, visual screening ability and processing speed, and is a good measure of overall cognitive functioning. Part A is a good measure of rote memory. Part B is generally quite sensitive to executive functioning since the test requires multiple abilities to complete it.

What is the Trail-Making test?

Dopaminergic pathways are involved in many things, motor function, reward processing and motivation, and salience. There's a hypothesis that in schizophrenia, there is an aberrant salience mechanism resulting in over-attribution of meaning and motivational value to irrelevant environmental events. This could explain delusions but doesn't explain positive, negative, and cognitive symptoms

What is the aberrant salience hypothesis of schizophrenia?

Insomnia A lot of alcoholics drink alcohol before bed to aid in sleep so they depend on it to fall asleep

What is the biggest risk factor for relapse on alcohol?

There is no evidence to suggest that rapid cycling is a heritable phenomenon in bipolar disorder. It is therefore likely to be a result of external factors, such as stress or medications

What is the cause of rapid cycling in bipolar?

Classic triad: - mental confusion - Ophthalmoplegia - Gait ataxia Autopsy findings: Microhemorrhages in the periventricular gray matter, particularly around the aqueduct, and third and fourth ventricles

What is the classic triad for Wernicke's encephalopathy? What do you find on autopsy?

It's a treatment strategy that provides mental health care to patients through their PCP. A behavioral care manager is present at the PCP office and the manager will meet the patient and address their mental health needs. The manager will then discuss the patient with the psychiatric consult who will suggest evidence based therapy (meds, therapy, social support, all the above). The PCP would then provide that therapy (ex. Prescribe meds) or involve others to provide therapy (ex. Psychologists). For the most part, the psychiatric consult never meets the patient but can. This model allows a psychiatrist to "see" so many more patients. For example, in an 8-hour workday a psychiatric may see 10-16 patients. But w psych consult working with care managers who manage 50-80 patients each can provide care to hundreds more patients. Also, through telepsych, mental health care can expand to rural areas

What is the collaborative care model and how can it be used to expand mental health care coverage?

Each part of the brain's intricate configuration works together to govern perception, processing, and behavior—and help us make sense of the world around us. Important regions of the brain are strongly connected to one another through circuits, or tracts of networked neurons that help those regions communicate with one another with ease. Neuroscientists are learning that to understand brain function they need to look beyond functional segregation, or the localization of a particular function to a single area. Rather, today, researchers are focusing their investigations on these important connections, using new techniques to follow critical circuits to better understand how groups of different brain areas work together to determine human behavior. This intricate pattern of connections is called "the connectome."

What is the connectome?

A daily dose of 20 to 80 mg suffices to stabilize a patient, although daily doses of up to 120 mg have been used. The duration of action for methadone exceeds 24 hours; thus, once-daily dosing is adequate

What is the daily dose of Methadone? What's its duration of action and how many times is it given in a day?

It is an intrinsic connectivity network (ICN), A core neural system, that processes largely internal information, including memories, emotions, and overall state of well-being. It is most active when a person isn't focusing on a particular task and when other parts of the brain are "resting" Is the first neural system to be affected in Alzheimer's disease

What is the default system/network in the brain and in what disease is it the first system to be affected?

Catatonia is a clinical syndrome characterized by striking behavioral abnormalities that may include motoric immobility or excitement, profound negativism, or echolalia (mimicry of speech) or echopraxia (mimicry of movement). A diagnosis of catatonic disorder due to a general medical condition can be made if there is evidence that the condition is due to the physiological effects of a general medical condition. The diagnosis is not made if the catatonia is better explained by a primary mental disorder, such as schizophrenia or psychotic depression, or if catatonic symptoms occur exclusively within the course of delirium.

What is the definition of catatonia?

Definitions vary, and they do not include a resistance to psychological therapies, but it can be defined as an inadequate response in which there is less than 50% reduction in depressive symptoms following treatment with at least one anti-depressant medication

What is the definition of treatment resistant depression?

Formulary prescriptions are medications that are on a preferred drug list. A preferred drug list or formulary helps provide access to quality, affordable, prescription drug benefits. Drugs chosen for the formulary have gone through an extensive review process. This process is structured so that there are internal and external physicians and pharmacists offering clinical input about the medications under consideration. The drugs listed on the preferred drug list either represent an important therapeutic advance, or are clinically equivalent and possibly more cost-effective than other drugs not on the preferred drug list. Drugs that are usually considered non-formulary are ones that are not as cost effective and that usually have generic equivalents available.

What is the difference between formulary and non-formulary brand name prescriptions?

10-20 hrs

What is the elimination half life of Lorazepam?

The principle of veracity, or truth telling, requires that healthcare providers be honest in their interactions with patients.

What is the ethical principle of veracity?

1. Methylphenidate 2. Dextroamphetamine OR Dextroamphetamine/amphetamine salt combo

What is the first choice stimulant, second choice stimulant for ADHD?

Luria's Test ("fist-edge-palm" test or Luria Sequence) is a task that requires a patient to imitate three hand motions performed by a clinician. Luria's test is part of the Frontal Assessment Battery (FAB) battery of tests. Luria's test assesses for frontal lobe (i.e. - executive) dysfunction or damage, as patients will often have difficulty with fine motor skills and sequencing motor skills. Specifically, it is designed to assess different aspects of executive function, including execution of a learned motor program, inhibitory control, attentional flexibility, working memory, and motor planning.

What is the fist-edge-Palm test?

To teach clients the skills they need to become their own therapist.

What is the general goal of CBT?

The general rule about the onset and duration of withdrawal symptoms is that substances with short durations of action tend to produce short, intense withdrawal syndromes and substances with long durations of action produce prolonged, but mild, withdrawal syndromes. An exception to the rule, narcotic antagonist-precipitated withdrawal after long-acting opioid dependence can be severe.

What is the general rule of thumb about the onset and duration of withdrawal symptoms in relation to the duration of action of the substances?

The CNS macroscopic waste clearance system. It removed soluble proteins and metabolites from CNS via a unique paravascular tunnel system ultimately into the lymphatic system. It is most active during sleep. Therefore, it has been proposed that a fundamental function of sleep is to establish a stare for this system to efficiently clear the CNS of waste produced throughout the wakeful period. Hence, sleep disturbance disrupts this system allowing waste to accumulate. Abnormalities in the glymphatic system have been associated with neuro dysfunction and disorders (Alzheimer's, TBI, stroke, etc)

What is the glymphatic system?

Symptom REMISSION not just symptom reduction

What is the goal of pharmacotherapy in depression?

Aripiprazole - 75 hrs Olanzapine - 21-54 hrs Haloperidol - 12-38 hrs Depakote - 9-16 hrs Risperidone - 20-24 hrs Ziprasidone - 6.6 hrs

What is the half life of Aripiprazole, Olanzapine, Haloperidol, Depakote, Risperidone, Ziprasidone

Half life: 30-40 hrs Less likely to experience withdrawal and easier to taper

What is the half life of Clonazepam and what is the clinical significance?

20 to 50 hours

What is the half life of Diazepam?

6-7 hrs

What is the half life of Seroquel?

Least - Desipramine Most - Amitriptyline - Imipramine - Trimipramine - Doxepin

What is the least anticholinergic TCA? What are the most anticholinergic TCAs?

0.08 (80)

What is the legal BAL?

Competent" or "competency" means mental ability to stand trial. A person is mentally competent to stand trial if he or she is able to understand the character and consequences of the proceedings against him or her and is able properly to assist in his or her defense

What is the legal definition of competent to stand trial?

The limbic system is a set of structures in the brain that deal with emotions and memory. It regulates autonomic or endocrine function in response to emotional stimuli and also is involved in reinforcing behavior.

What is the limbic system?

80 to 120 mg

What is the lowest dose of methadone that is generally considered to suppress opioid drug hunger and induce a cross tolerance blockade of illicit opiates?

The intense craving for the drug

What is the major hurdle to overcome in the treatment of cocaine-related disorders?

Depends on the person. Some get an average of 8-12 cycles of treatment 3x/week and then go to maintenance for a few months. Some may go longer (one patient was getting ECT once/week for 2 years)

What is the max number of ECT treatments a person can get?

1500 mg QHS

What is the maximum dose of gabapentin for insomnia per Dr. McCall?

The exact mechanism of action is unknown. But what is seen is that ECT decelerates neural activity, especially in the frontal and temporal lobes, i.e. increased delta and theta wave activity

What is the mechanism of action of ECT?

Acts as a use-dependent blocker of voltage-sensitive sodium channels

What is the mechanism of action of Lamotrigine?

They are synthetic neurosteroids that act like the neurosteroid, allopregnanolone. Allopregnanolone is a metabolite of progesterone. It's levels decrease after pregnancy and some studies suggest low levels of this neurosteroid may play a role in postpartum depression. It is an antidepressant through its positive allosteric GABAa receptor modulation. What's unique about these drugs is that patients start to feel less depressed by day 3. Brexanolone is IV while Zuranolone is given PO

What is the mechanism of action of drugs like Brexanolone and Zuranolone? What is the main difference between them?

Minimum required to start: 1.5 If ANC drops below 1, then stop clozapine, consult Heme and monitor. Resume once it's >1

What is the minimum ANC needed before starting Clozapine? At what point do you stop Clozapine and initiate treatment based on ANC?

Their design is better suited to provide information about efficacy rather than effectiveness

What is the most clinically significant critique of the use of randomized controlled studies as the gold standard level of evidence?

Dissociation

What is the most common acute effect of recreational ketamine use?

Generalized anxiety disorder

What is the most common comorbid diagnosis in children with separation anxiety disorder?

Separating from loved ones

What is the most common fear expressed by adults leaving home to enter hospice?

G.I. side effects

What is the most common reason that patient discontinue the use of SSRIs early and treatment?

Depression

What is the most commonly seen psychiatric symptom in patients with hepatitis C treated with interferon?

CBT-I It has been proven to be more effective and have longer lasting effects then medications. It also avoids the side and dependency that medications cause

What is the most effective treatment for insomnia?

Naltrexone injection/Vivitrol plus Wellbutrin

What is the most effective treatment for stimulant use disorder?

Risperidone

What is the most frequently used antipsychotic in children and adolescents?

HR!!! If the HR is above 90 and someone has a significant BAL or a history of alcohol use, Camino considers this to be withdrawal unless proven otherwise. No one should have a resting HR above 90. He would recommend starting Valium 10 mg TID or even QID

What is the most important symptom of CIWA that needs to be corrected with scheduled BZD even if every other component of CIWA is normal (per Camino)?

K channel blockade

What is the most likely mechanism for QTc interval prolongation related to antipsychotic medication?

Essential tremor

What is the most prevalent movement disorder in persons 70 years or older?

Early morning awakening

What is the most typical effect of depression on nocturnal sleep? A. Decreased total sleep time B. Initial insomnia C. Middle insomnia D. Early morning awakening E. Sleep-wake cycle reversal

A situation in which a patient develops side effects or symptoms that can occur with a drug or other therapy just because the patient believes they may occur.

What is the nocebo effect?

Narcolepsy

What is the only approved use of GHB?

Ziprasidone (Geodon)

What is the only atypical antipsychotic that inhibits serotonin and norepinephrine reuptake?

A major neuronal loop circuit of the limbic system. The classical Papez circuit is the neural loop goes through from hippocampal formation to mammillary body (MB) in the hypothalamus to anterior nucleus of the thalamus (AN) to cingulate gyrus/part of the parahippocampal gyrus (PHG) and back to the hippocampal formation. This loop provided for interaction among the neocortex, limbic structures and hypothalamus, and originally proposed that their interconnections might be the anatomical substrate of central emotion and emotional experience. The Papez circuit is now known to be more involved in the consolidation of declarative memory. It functions primarily in the cortical control of emotion and memory storage and contains centers that regulate aversion and gratification.

What is the papez circuit and what does it do?

16-25%

What is the prevalence of Alzheimer's disease in people over the age of 85 years?

Divert offenders with mental illness away from incarceration

What is the primary purpose of mental health court?

Diffusion away from the synaptic cleft

What is the principal mechanism of termination of the synaptic activity of dopamine in the prefrontal cortex?

Rapid cycling is a pattern of frequent, distinct episodes in bipolar disorder. In rapid cycling, a person with the disorder experiences four or more episodes of mania or depression in one year.

What is the rapid cycling in bipolar disorder with rapid cycling?

The absorption rate from the injection site. The absorption rate is usually slower than the elimination rate.

What is the rate-limiting step for plasma drug levels for LAI?

40-120 mg/day in divided doses

What is the recommended dosage range for propranolol when treating anxiety disorders?

5-8 weeks

What is the recommended washout period for fluoxetine when discontinuing it and starting a new antidepressant?

In general, dopamine seems to promote aggression, whereas norepinephrine, serotonin, and GABA seem to inhibit

What is the relationship between dopamine, norepinephrine, serotonin, GABA and aggression?

LBW is associated with an increased risk of a number of mental illnesses (depression, OCD, ADHD, schizophrenia). Babies born LBW also are at greater risk of developing DM and metabolic syndrome. Theory is that they are programmed to take more glucose and pack it on because of the LBW to make up for it. Therefore these patients are at greater risk of developing metabolic side effects from antipsychotics.

What is the significance of low birth weight in psychiatry?

15-40% Offspring of schizophrenic parents can experience deficits in motor, cognitive, behavioral, and social functioning. These deficits are nonspecific but their presence reflects an increased risk of developing mental illness. Being aware of this possibility and searching for this deficits is important because certain steps could be taken if identified, such as environmental enhancing and programs to improve functioning in social and cognitive domain, etc

What risk do offspring of parents with schizophrenia have of developing psychotic or other psychiatric disorders? What effect does having a familial high risk status (I.e. parent with schizophrenia) have on a child and how is this clinically relevant?

Creutzfeldt-Jakob disease (CJD) is a fatal, neurodegenerative, rapidly progressive dementia (RPD) caused by the accumulation of misfolded prion protein, PrPSc.1,2 Neuronal cell death in CJD occurs at an accelerated rate compared to other neurodegenerative conditions (e.g., Alzheimer disease [AD] or Parkinson disease [PD]). It has become increasingly evident that sleep dysfunction commonly accompanies chronic neuro-degenerative conditions and may predate the onset of cardinal symptoms of these disorders by several years.3-6 For example, rapid eye movement (REM) sleep behavior disorder (RBD) may precede the development of a synucleinopathy by decades,7-10 and reduced sleep efficiency is seen in patients with preclinical AD.11 Furthermore, increasing evidence shows that sleep disruption can accelerate neurodegenerative processes including toxic protein aggregation in preclinical models, and increases the risk of developing symptomatic AD.

What is the significance of sleep disorders in neurodegenerative diseases?

Recent studies indicate that the amygdala also has direct chemo-sensing properties of its own and uses acid-sensing ion channels (ASICs) to detect changes in brain carbon dioxide levels or acid-base balance. Thus, the amygdala can do its own direct sensory processing; in turn, this can generate rapid emotional responses, including fear. This may be one of the reasons why changes in respiration (hyperventilation) are so closely intertwined with emotions

What is the significance of the amygdala having acid-sensing ion channels?

The Stroop Color and Word Test (SCWT) is a neuropsychological test extensively used to assess the ability to inhibit cognitive interference that occurs when the processing of a specific stimulus feature impedes the simultaneous processing of a second stimulus attribute, well-known as the Stroop Effect. Ex. Instructing a patient to name the colors in which the series of words are printed, rather than reading the words themselves

What is the stroop test?

NOTES

What is the treatment of tardive dyskinesia?

Usual Dosage Range • 100-200 mg/day How to Dose • Initial 25 mg/day increase over 2 weeks to 100 mg/day; maximum dose generally 250 mg/day

What is the usual dosage range and how do you does Clomipramine?

Usual Dosage Range • Seizures: dependent on individual response of patient, up to 20 mg/day • Panic: 0.5-2 mg/day either as divided doses or once at bedtime • Panic - 1 mg/day; start at 0.25 mg divided into 2 doses, raise to 1 mg after 3 days; dose either twice daily or once at bedtime; maximum dose generally 4 mg/day Clonazepam is generalkybdosed half the dosage of Xanax

What is the usual dosage range and how do you dose Clonazeoam?

Usual Dosage Range • Oral: 2-6 mg/day in divided doses, largest dose at bedtime • Injection: 4 mg administered slowly How to Dose • Oral: initial 2-3 mg/day in 2-3 doses; increase as needed, starting with evening dose; maximum generally 10 mg/day • Injection: initial 4 mg administered slowly; after 10-15 minutes may administer again

What is the usual dosage range and how do you dose Lorazepam?

Usual Dosage Range • 1,200-2,400 mg/day • Monotherapy for seizures or bipolar disorder: initial 600 mg/day in 2 doses; increase every 3 days by 300 mg/day; maximum dose generally 2,400 mg/day

What is the usual dosage range and how do you dose Trileptal?

For bipolar: 100-200 mg/day

What is the usual dosage range for Lamotrigine?

Adults: 2-8 mg QD Kids: 0.5 - 2 mg QD IM: 12.5-50 mg q2 weeks In adults, usually start at 1mg QD and increase by 1 mg per day

What is the usual dosage range for Risperjdone in adults, children and IM? How do you increase the dose in adults?

Usual Dosage Range • 400-800 mg/day in 1 (quetiapine XR) or 2 (quetiapine) doses for schizophrenia • 400-800 mg/day in 1 (quetiapine XR) or 2 (quetiapine) doses for bipolar mania • 300 mg once daily for bipolar depression Higher doses generally achieve greater response for manic or psychotic symptoms • In contrast, some patients with bipolar depression may respond well to doses less than 300 mg/day and as little as 25 mg/day

What is the usual dosage range for Seroquel? Are higher doses or lower doses needed for psychosis, mania, and depression?

4-40 mg/day in divided doses

What is the usual dosage range for oral diazepam?

DOSING AND USE Usual Dosage Range • Depression: 75-225 mg/day, once daily (extended-release) or divided into 2-3 doses (immediate-release) • GAD: 150-225 mg/day How to Dose • Initial dose 37.5 mg once daily (extended- release) or 25-50 mg divided into 2-3 doses (immediate-release) for a week, if tolerated; increase daily dose generally no faster than 75 mg every 4 days until desired efficacy is reached; maximum dose generally 375 mg/day • Usually try doses at 75 mg increments for a few weeks prior to incrementing by an additional 75 mg

What is the usual dosage range for venlafaxine and how do you dose it?

Usual Dosage Range • Anxiety: alprazolam IR: 1-4 mg/day • Panic: alprazolam IR: 5-6 mg/day • Panic: alprazolam XR: 3-6 mg/day How to Dose • For anxiety, alprazolam IR should be started at 0.75-1.5 mg/day divided into 3 doses; increase dose every 3-4 days until desired efficacy is reached; maximum dose generally 4 mg/day • For panic, alprazolam IR should be started at 1.5 mg/day divided into 3 doses; increase 1 mg or less every 3-4 days until desired efficacy is reached, increasing by smaller amounts for dosage over 4 mg/ day; may require as much as 10 mg/day for desired efficacy in difficult cases • For panic, alprazolam XR should be started at 0.5-1 mg/day once daily in the morning; dose may be increased by 1 mg/day every 3-4 days until desired efficacy is reached; maximum dose generally 10 mg/day. XR formulation only needs to be taken once or twice daily. Some severely ill patients may require 8 mg/day or more

What is the usual dosage range or Xanax and how do you dose it?

First give Donepezil (5 mg then 10 mg which is the max) then you can add Memantine to augment

What is the usual medication course for Alzheimer's?

The therapeutic index (TI; also referred to as therapeutic ratio) is a quantitative measurement of the relative safety of a drug. It is a comparison of the amount of a therapeutic agent that causes the therapeutic effect to the amount that causes toxicity

What is therapeutic index of a drug?

D-cycloserine

Which agent has been shown to augment the effects of CBT on anxiety disorders?

Sertraline

Which antidepressant has pharmacologically active metabolites that extend its effective half-life?

Therapeutic privilege refers to the decision of a healthcare practitioner to withhold information from a patient when there is a justified belief that disclosure may cause serious mental or physical harm to them.[1] As of 2022, this defence is permissible in countries such as Australia, Canada, England, Netherlands and Wales as an exception to the standard consent process.[2] Despite this, there are very limited cases in which therapeutic privilege has been upheld.[2] This is mainly due to the complex ethical and legal ramifications in withholding information from a patient and how to define someone as being at sufficient risk to fall into this category wherein therapeutic privilege should prevail. Another challenge in enacting therapeutic privilege is the consideration of other professionals involved in patient care, such as where there is a multidisciplinary care team.[3] However, in withholding information, there is also a denial of patient autonomy

What is therapeutic privilege?

Thought insertion is defined by the ICD-10 as feeling as if one's thoughts are not one's own, but rather belong to someone else and have been inserted into one's mind. Thought broadcasting is the belief that others can hear or are aware of an individual's thoughts.

What is thought insertion? What is thought broadcasting?

Transient global amnesia is a sudden, temporary episode of memory loss that can't be attributed to a more common neurological condition, such as epilepsy or stroke. During an episode of transient global amnesia, your recall of recent events simply vanishes, so you can't remember where you are or how you got there.

What is transient global amnesia?

The trough level is the lowest concentration in the patient's bloodstream, therefore, the specimen should be collected just prior to administration of the drug. The peak level is the highest concentration of a drug in the patient's bloodstream.

What is trough level of a drug (I.e. get VPA trough levels)?

Clinical monitoring

What is typically the initial recommended approach for a child with new onset tick disorder?

Vyvanse (lisdexamfetamine dimesylate) is a pro-drug of dextroamphetamine, which requires intestinal metabolism in order to reach its active form. Vyvanse is approved by the U.S. Food and Drug Administration (FDA) for children 6 years and older. Vyvanse, inactive until it is metabolized, is a less likely agent to have risks of abuse or overdose. It has side effects and efficacy similar to the other forms of amphetamines used in the treatment of ADHD.

What is unique about Vyvavse pharmacologically?

1. Generalized anxiety disorder (IR) 2. Panic disorder (IR and XR)

What is xanax commonly prescribed for?

Haloperidol It would make it worse

What medication is contraindicated in Lewy Body dementia? Why?

Prozac

What medication is effective at treating self-injurious behavior?

Benzodiazepines (Ativan)

What medication is used to manage agitation due to bath salts?

Methylphenidate

What medication is useful in early HIV-associated dementia but potentially toxic later in the disease?

Prozac (titrate it quickly. Some doctors go as high as 120 mg)

What medicine can be given to hypersexual children?

OCD

What mental disorder is equally common in men and women?

Amygdala - hypothalamus - periaqueductal gray

What neural pathway has been most consistently found to mediate reactive aggression?

There are four brain regions in the regulation of normal emotions: the prefrontal cortex (PFC), the anterior cingulate, the hippocampus, and the amygdala. The PFC is viewed as the structure that holds representations of goals and appropriate responses to obtain these goals. The anterior cingulate cortex (ACC) is thought to serve as the point of integration of attentional and emotional inputs. Two subdivisions have been identified: an affective subdivision in the rostral and ventral regions of the ACC and a cognitive subdivision involving the dorsal ACC. The hippocampus is most clearly involved in various forms of learning and memory, including fear conditioning, as well as inhibitory regulation of the HPA axis activity. The amygdala appears to be a crucial way station for processing novel stimuli of emotional significance and coordinating or organizing cortical responses. NOTECARD PIC

What neuroanatomical regions regulate normal emotions and how?

Adolescence: 60-85% Adulthood: up to 60%

What percentage of children diagnosed with ADHD continue to meet criteria in adolescence? In adulthood?

57-98%!!! Majority of them lack insight. They may be polite and take medicines but deep down a lot of them don't think they have any issue. Those who have insight take longer to become med non-adherent.

What percentage of schizophrenic patients usually lack insight? What is the significance of insight in relation to medication non-adherence?

Shorter half-lives

What pharmacokinetic trait in SSRIs is associated with discontinuation symptoms when abruptly stopped?

Self psychology

What psychodynamic theory emphasizes the need to receive empathy from parents or similarly important figures in order to develop one's own sense of worth?

Risperidone Although it is most commonly used, other studies suggest it may not be the best (placebo groups had better outcomes vs Risperidone, Haldol)

What psychotropic is most commonly used for behavioral problems in children and patients with intellectual disability?

Lithium Valproic acid

What psychotropic(s) can worsen/trigger psoriasis?

Lithium Clozapine

What psychotropics reduce suicidality?

In contrast to most other substances of abuse with identified receptor targets-such as the N-methyl-D-aspartate (NMDA) receptor of phencyclidine (PCP)-no single molecular target has been identified as the mediator for the effects of alcohol.

What receptor does alcohol act on?

There is an inverse relationship Therefore, Remeron binds more effectively to histamine receptors at lower doses. At higher doses it is less effective. It is helpful as a sleep aid most at 15 mg QHS

What relationship does the dose of Remeron have with its affinity to histamine receptors?

They should not play any role!!!!!! They are not useful. They increase suicidal behaviors, they're ineffective inBipolar, and can worsen prognosis. Although there are some meds marketed towards Bipolar (Olanzapine-Fluoxetine), better to avoid them

What role do antidepressants play in Bipolar?

Two studies showed that monotherapy with methylphenidate outperformed antidepressants for the treatment of depression in TBI. And improve depressive symptoms, daytime, sleepiness, and cognitive function.

What role do stimulants play in depression and TBI?

It has been shown to improve neurocognition. Should be considered in patients with TBI

What role does Amantadine play in TBI?

It can reduce aggressive behavior (lower doses) and self-injurious behavior (high doses). It also reduces hospital stay duration and rehospitalization. Studies have shown this. It seems to be more effective than Risperidone for ID patients (another notecard) Usually given 200-350 mg QD for around 3 months. If no response, d/c

What role does Clozapine have in intellectually disability patients?

It can be used to treat combativeness. It lowers testosterone. It also is an ERBB4 receptor inhibitor. Neurobiological studies have identified an enhanced NRG1-ERBB4 signaling as a risk pathway for schizophrenia so this may make this drug helpful in treating schizophrenia

What role does Spironolactone have in psychiatry?

It can be given to combat stimulant induced weight loss. Cyproheptadine can be prescribed to increase appetite.

What role does cyproheptadine play it ADHD?

SSRI

What should be your first choice when managing a demented patient with agitation?

LITHIUM There are so many benefits as listed in other cards. Avoid giving Depakote in women of child-bearing age bc of teratogenic effects. However you may feel need to give Depakote first since it's faster acting. If giving to a woman make sure you tell her about teratogenic effect so she knows to tell her doctor if she gets pregnant

What should be your mood stabilizer of choice between Lithium and Depakote?

If they understand what death means and the finality of it

What should you clarify with a child who has SI?

• Consider switching to another agent or adding an appropriate augmenting agent (such as Gabapentin or Pregabalin; not generally rational to combine with another BZD) • Consider psychotherapy, especially cognitive behavioral psychotherapy • Consider presence of concomitant substance abuse • Consider presence of alprazolam abuse • Consider another diagnosis, such as a comorbid medical condition

What should you do if BZD isn't working to control anxiety?

You should switch to another antidepressant. As you know, patient should experience some improvement around two weeks and definitely by 3-4 weeks. If they show no improvement at all at 3-4 weeks, switched to another antidepressant. If they start showing some improvement by 3-4 weeks, continue the same anti-depressant for 6-9 months at full treatment dose

What should you do if a patient's depression is not showing any improvement after 3-4 weeks on an anti-depressant? What if they show some improvement at 3-4 weeks?

Straterra, more effective at treating ADHD and associated behaviors in this population

What stimulant is useful in autism?

Dextromethorphan

What substance found in several OTC symptom cold remedies is abused to produce a dissociative feeling?

Reduced energy (97%) Trouble sleeping (80%)

What symptom is prevent in 97% of depressed patients? In 80%?

Video telemetry

What test confirms the diagnosis of nonepileptic seizure?

Multiple sleep latency test

What test is most useful in the diagnosis of narcolepsy?

1. CBC w/ diff: for ANC and agranulocytosis 2. EKG: to check QTc (should be done ideally before every antipsychotic) 3. Weight, HbA1c, Lipids: for metabolic syndrome (should be done ideally before every antipsychotic, especially 2nd gen) 4. Troponin, CK, ESR/CRP: for myocarditis (according to Surya, Troponin is the only one that needs to be ordered) 1. CBC w/diff: 1x/week for 6 months then 1x/2 weeks for 6 months then 1x/month for the rest of the time they're on it 2. Troponin +/- CRP (Surya says no): 1x/ week in first month 3. Dr. Surya: Clozapine level every 2 weeks the first 4 weeks

What tests should you order before starting Clozapine and why? What tests need to be ordered routinely after starting clozapine?

Klonopin

What the is the drug of choice for treating withdrawal from Xanax?

TSH and free T4

What thyroid studies do you check for mood disorder?

CBT

What treatment has the best evidence for Managing Illness anxiety disorder?

Evoked potentials If there was true blindness you wouldn't see a response.

What type of EEG monitoring is most likely to aid in differentiating psychogenic from true blindness?

Malignant catatonia The other types try BZD first

What type of catatonia requires ECT as first line therapy?

Positive symptoms Negative symptoms are not improved

What type of schizophrenia symptoms are most improved with ECT?

https://www.neeuro.com/wp-content/uploads/1eeg.png Notecard GBAT-D (gamma, beta, alpha, theta, delta)

What types of waves will you see on EEG and what are their significance?

1. Folic acid 1 mg PO QD 2. Thiamine 500 mg IV daily x 3 doses then 100 mg PO QD 3. Multivitamin PO QD

What vitamins should you prescribe when Treating a patient inpatient for alcohol withdrawal?

Mirtazapine and Bupropion (have favorable effects on slow-wave sleep and REM)

Which antidepressant have the most favorable effects on sleep architecture?

Atypical- MAOIs, SSRIs, Wellbutrin Melancholia - antidepressant with dual action in both serotonergic and noradrenergic receptors (Effexor)

Which antidepressants should be used for MDD with atypical features? Melancholia?

Erikson maintained that personality develops in a predetermined order through eight stages of psychosocial development, from infancy to adulthood. During each stage, the person experiences a psychosocial crisis which could have a positive or negative outcome for personality development. For Erikson (1958, 1963), these crises are of a psychosocial nature because they involve psychological needs of the individual (i.e., psycho) conflicting with the needs of society (i.e., social). According to the theory, successful completion of each stage results in a healthy personality and the acquisition of basic virtues. Basic virtues are characteristic strengths which the ego can use to resolve subsequent crises. Failure to successfully complete a stage can result in a reduced ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved successfully at a later time. https://www.psychologynoteshq.com/wp-content/uploads/2019/05/erikerikson-01.jpg

What was Erik Erikson's theory of psychosocial development?

Twenty percent of Kagan's 4-month-old infant subjects were labeled high reactive, "a behavioral profile marked by vigorous motor activity and crying to unfamiliar experiences." And 40 percent were labeled low reactive because they showed the opposite behaviors. Both temperaments are modest predictors of future personalities, depending on how children responded to their environments. (Another 40 percent belonged to neither group.) "The high-reactive infants are biased to become children who are timid, shy, and cautious in unfamiliar situations. This is a personality trait known as inhibited," said Kagan. "The low reactives are biased to develop into outgoing, spontaneous, fearless children — uninhibited."

What were Jerome Kagan's findings on the temperaments of infants?

Reduction in circulating levels of GABA

What what changes have been noted in the circulating levels of GABA in depressive disorder?

A drug that is chemically similar to an existing drug with an expiring patent rather than a genuine advance in treatment

What's a me-too drug?

Hydroxyzine first then Seroquel

What's a treatment algorithm for anxiety in the hospital (mine own)?

Give methylphenidate Patients with pseudodementia will become less depressed, more active, and their dementia symptoms will improve

What's an old trick that Geri-psych doctors do to distinguish pseudodementia from true dementia?

Cocaine

What's more addictive, cocaine or amphetamines?

A standard dose is 2mg q4-6 hrs (IV first 24-28 hrs) But some patients may require titration to as much as 30 mg daily especially in cases with malignant features

What's the max amount of Ativan a catatonic patient can receive!

40 mg

What's the max amount of Geodon IM you can give in one day?

40 mg (10 mg every 2 hrs or 20 mg every 4 hrs) Should not be administered for more than 3 consecutive days

What's the max amount of Geodon IM you can give in one day? For how many days can you administer scheduled Geodon IM?

300 mg

What's the max amount of Haldol Dec than can be injected in one sitting

400 mg q4-6 hrs

What's the max amount of Thorazine you can give PRN?

Usual Dosage Range • Schizophrenia: 40-200 mg/day (in divided doses) orally • Bipolar disorder: 80-160 mg/day (in divided doses) orally • 10-20 mg intramuscularly

What's the usual dosage range for Geodon?

LOOK FOR MANIC/HYPOMANIC EPISODES Important to do this because the treatment is different and the sooner you catch bipolar the sooner you can start treatment and greater chance there is to achieve sustained remission. Obtained through an MDQ, ask them about family history of bipolar/manic/weird or problematic symptoms matching mania, talk to collateral about patient and possible mania, ask about prior dysphoric response to antidepressants

When a patient presents with depression, what is one thing to always look for and how?

Boundary crossing

When a psychiatrist graciously accepts flowers from a paranoid patient, thereby helping the patient feel more relaxed in the treatment setting and more willing to discuss symptoms, this demonstrates which of the following behaviors? A. Social skills training B. Empathic reflection C. Boundary crossing D. Behavioral activation E. Therapeutic mirroring

During their reproductive years

When are women at the highest risk for major depression?

Besides asking about alcohol, tobacco, and illicit substances (THC, cocaine, meth, etc) also ask about prescription pills

When asking about substance use in a psych history, what is one important group to always remember to discuss?

Less comorbidity

When compared to younger adults, do anxiety disorders in adults over age 65 show more or less comorbidity with alcohol abuse

Dorsolateral prefrontal cortex

Which area of the frontal cortex is most consistently activated during shifting of cognitive sets in the Wisconsin Card Sorting Test?

1. Chronic, biological brain illnesses The Psychotic, Depressive, Manic-Depressive, Anxiety, Attention-Deficit, and Eating Disorders are chronic, biological, strongly-inherited brain illnesses. They are similar to hypertension or diabetes mellitus conceptually, but localized in the brain. 2. Organic mental disorders The Organic Mental Disorders (e.g. delirium, brain injury from trauma or vascular accident, dementia) reflect coarse damage/dysfunction or deterioration of brain tissue . 3. Personality disorders The Personality Disorders are long-term, rigid patterns (traits) of internal experience (thinking of self and others) and external behavior (self-control/impulsiveness) that impair social/occupational functioning and relationships

When developing a working diagnosis, what are the three broad categories to consider per Dr. McEvoy?

Per Dr. Dexter's experience, they tend to develop a day or two after the reported timelines

When do Alcohol withdrawal symptoms generally appear in patients according to Dr. Dexter?

The behavioral symptoms of autism spectrum disorder (ASD) often appear early in development. Many children show symptoms of autism by 12 months to 18 months of age or earlier. Doctors look at the child's developmental history and behavior to make a diagnosis. ASD can sometimes be detected at 18 months of age or younger. By age 2, a diagnosis by an experienced professional can be considered reliable. However, many children do not receive a final diagnosis until much older.

When do the symptoms of autism generally appear? At what age is autism usually diagnosed at?

Unless adverse events prevent it, the dosage of an antidepressant should be raised to the maximum recommended level and maintained at that level for at least 4 or 5 weeks before a drug trial is considered unsuccessful.

When do you consider a drug trial with an antidepressant unsuccessful?

Haldol: 4-6 weeks Other 4 LAI (prolixin, risperdal, invega, Abilify): 2-3 weeks

When do you stop giving PO meds after starting LAI?

When the symptoms start improving or when you hit 400 mg QD. Once hitting 400, observe them for 4-6 weeks then make further adjustments if necessary

When do you stop up titrating Clozapine?

6 months

When do you usually stop an antipsychotic given to stabilize mood disorder?

Clouded sensorium

When evaluating a patient in the emergency department, which of the following symptoms most strongly suggest a general medical condition? Anergia, irritability Clouded sensorium Psycho motor agitation auditory hallucinations

EKG (QTc) Increased risk of torsades de pointes (more than with PO/IM)

When giving Haldol IV what is one thing to pay extra attention to?

No! Doses should be held only for respiratory depression due to oversedation and not for sedation alone as the regularity of dosing is important for full lysis

When giving a Ativan to catatonic patient, should Ativan beheld if the patient is overly sedated?

First 2 years of life

When is cortical synaptic density at its highest?

2-3 weeks after initiation. Be on the look out for symptoms (they're vague: headaches, fever, diarrhea)

When is myocarditis due to Clozaril most likely to occur? (the danger period)

1. Panic disorder 2. Agoraphobia 3 GAD Social anxiety disorder 5. Specific phobia 6. OCD 7. PTSD

When screening for anxiety disorders, what diagnoses are you looking for?

If conventional antipsychotics are being prescribed, clinicians may consider prescribing prophylactic anti-Parkinson medications for patients who are likely to experience disturbing extrapyramidal side effects. These include patients who have a history of extrapyramidal side effect sensitivity and those who are being treated with relatively high doses of high-potency drugs. Prophylactic anti-Parkinson medications may also be indicated when high-potency drugs are prescribed for young men who tend to have an increased vulnerability for developing dystonias

When should you give prophylactic anti-Parkinson medicines for patients on antipsychotics?

If in order to achieve max therapeutic benefit the patient requires a dose that causes EPSE, start an anticholinergic May not be a good idea to give it prophylactically because patients may not even develop EPSE and you also have to be aware of anticholinergic AE

When should you start an anticholinergic in a patient on an antipsychotic? Should it be given prophylaxtically?

Lithium

When used as a therapeutic dose/level during pregnancy, the dose of which of the following medications should be reduced in the immediate postpartum period to minimize the risk of adverse drug effect? A. Lithium B. Lamotrigine C. Carbamazepine D. Topiramate E. Valproate

Treatment of OCD. It's given usually when other SSRIs are unable to treat OCD

When would you use Fluvoxamine?

Mania Epilepsy Parasomnias People who are at risk for falls

Where are my stimulus control therapy for insomnia might be contraindicated?

Hypothalamus

Where is orexin produced?

Dalmane (Flurazepam) It has a metabolite that is much longer lasting giving it a half life of 47-100 hrs. It's primarily used in insomnia for only a few weeks

Which BZD has the longest half life?

Diazepam

Which BZD is most likely to accumulate with repeated administration?

Selegeline (Eldepryl) Increased dopamine by inhibiting MOA

Which Monoamine Oxidase Inhibitor can treat Parkinsonism and why?

Fluoxetine, which has the longest half-life of the SSRIs, appears to produce the fewest withdrawal symptoms, while paroxetine, which has the shortest half-life, produces the most pronounced discontinuation effects.

Which SSRI has the longest half-life? The shortest? What's the significance if this?

Fluvoxamine, at 12 to 13 hours

Which SSRI has the shortest half life and how long is that half life?

Clomipramine (Anafranil)

Which TCA has consistently found to be useful in the long-term treatment and relapse prevention of OCD?

In imaging studies, the sgACC has emerged as a key node, with increased activity in the sgACC and amygdala correlating with the severity of active depressive symptoms, In contrast, changes in vIPFC and lateral orbital cortex correlate negatively with depression severity. Imaging studies have also found that hippocampal changes are prominent in MDD. Antidepressant medications and deep brain stimulation targeted to sgACC appear to diminish overactivity in sgACC and amygdala, while psychotherapeutic interventions (interpersonal therapy and CBT) appear to increase activity in the vlPFC, orbital cortex and anterior insular cortex

Which areas have emerged as key nodes in major depressive disorder based on imaging studies? How do the various treatments for depression affect these key nodes?

Lorazepam, oxazepam, temazepam (LOT) All benzodiazepines are metabolize by the liver. Some are just metabolized by different pathways that are less dependent on global liver function. These three drugs or metabolized mostly by glucuronide conjugation. These drugs do not have active metabolites after hepatic conjugation and therefore have minimally affected half lives in patients with liver disease.

Which benzodiazepines are metabolized by glucourindation? What is the significance?

Motor cortex

Which develops first, motor or sensory cortex?

Anxiety and oppositional defiant disorder

Which disorders are most frequently comorbid in school age children with ADHD, combined presentation?

In treating Parkinson's disease with dopaminergic agonists, such as pramipexole, ropinirole, pergolide, rotigotine, apomorphine, or bromocriptine, it has been observed that a significant number of patients develop impulse-control disorders, such as compulsive shopping, pathological gambling, or hypersexuality.

Which dopaminergic agonists have been observed to cause impulse-control disorders like compulsive shopping, pathological gambling, or hypersexuality

D Disorders of smooth visual pursuit and disinhibition of saccadic eye movements are commonly found in patients with schizophrenia. This has been proposed by some as a trait marker for schizophrenia because it is found regardless of medication use and is also present in first-degree relatives. It is thought that the eye movement disorders are the function of pathology in the frontal lobes.

Which eye findings are common in schizophrenia? A. Failure of adduction B. Failure of accommodation C. Pupillary dilatation D. Abnormal smooth pursuit and saccades E. Weakness of the third cranial nerve

Bupropion, has the least sexual side effects out of all antidepressants.

Which has least sexual side effects? Bupropion or Mirtazapine?

Absorption

Which if the following Physiologic measures affecting Farocco kinetics remains the most stable in individuals over the age of 65 years when compared to younger people? A. Absorption B. Gastric emptying C. Hepatic circulation D. Volume of distribution E. Glomerular filtration rate

A

Which if the following is a core feature of practicing mindfulness? A. Experiencing internal and external stimuli non-judgmentally B. Learning to systematically relax muscles through the body C. Noticing thoughts and discovering which ones are maladaptive D. Practicing regulating the breath ti induce a parasympathetic state E. Increasing focus by continually bringing attention back to a chosen point D. E.

Imipramine

Which if the following, when added to lithium for treatment resistant bipolar depression is the least likely to induce rapid cycling or a mixed state? A. Bupropion B. Duloxetine C. Imipramine D. Venlafaxine E. Desipramine

Steroids Tacrolimus Cyclosporine

Which immunosuppressive agents I have been known to cause psychosis?

Tetrabenazine (Xenazine)

Which medication has been shown to be effective in the treatment of motor and vocal tics associated with Tourette's syndrome refractory to treatment with antipsychotics and alpha adrenergic agonist?

Imipramine (sometimes used to treat symptoms of hyperactivity and impulsivity in patients with attention deficit hyperactivity disorder when traditional medications are ineffective)

Which medication used to treat ADHD has been associated with liver damage?

Wisconsin Card Sorting Task

Which neuropsychological test specifically evaluated impairments in frontal lobe functions in adults?

Glutamate

Which neurotransmitter effects, when dysfunctional, has been shown to most comprehensively replicate the core symptoms of schizophrenia?

Dopamine

Which neurotransmitter is thought to play a key role in fine-tuning working memory function in the dorsolateral prefrontal cortex?

Dopaminergic

Which neurotransmitter system facilitate sexual arousal?

Serotonergic

Which neurotransmitter system most directly regulates impulsive or affective aggression?

Dopamine

Which of neurotransmitter is thought to play a key role in fine-tuning working memory function in the dorsolateral prefrontal cortex?

Impaired prosody

Which of the following abnormalities of speech or language is a patient with autism spectrum disorder most likely to demonstrate? A. Dyslexia B. Aphasia C. Impaired prosody D. Pressured speech E. Problematic enunciation

A

Which of the following actions by a psychiatrist is an example of a boundary violation? A. Conducting a session after hours in a local coffee bar B. Communicating with the patient's family without permission

Oxcarbazepine

Which of the following agents has the weakest evidence base to support its use in the treatment of manic episodes associated with bipolar disorder? A. Quetiapine B. Risperdal C. Depakote D. Oxcarbazepine E. Carbamazepine

Lithium

Which of the following agents is most likely to cause seizure activity of greater than three minutes following ECT administration? A. Lithium B. Propranolol C. Fluoxetine D. Fluvoxamine E. Hydroxyzine

75

Which of the following ages do adult males have the highest rates for completed suicide? A. 30 B. 45 C. 60 D. 75

Stimulants - methylphenidate, dextroamphetamine

Which psychotropics can cause Reynaud's?

Nortriptyline TCAs are known to cause orthostatic hypotension. Nortriptyline is least likely out of all of them to do that

Which of the following antidepressant medication's would be the best choice to minimize the risk of orthostasis in an 80-year-old patient? A. Doxepin B. Amitriptyline C. Desipramine D. Imipramine E. Nortriptyline

Paroxetine

Which of the following antidepressant medications is considered to be most effective in the treatment of premature ejaculation? A. Citalopram B. Clomipramine C. Fluvoxamine D. Paroxetine E. Sertraline

Imipramine

Which of the following antidepressants' plasma levels correlates with therapeutic response? A. Trazodone B. Imipramine C. Amoxapine D. Trimipramine E. Clomipramine

Dorsolateral prefrontal cortex

Which of the following areas of the brain is most likely to be active when trying to remember a phone number long enough to make a phone call? A. Amygdala B. Hippocampus C. Parahippocampal gyrus D. Dorsolateral prefrontal cortex E. Ventromedial prefrontal cortex

Hyperactivity

Which of the following aspects of ADHD is most likely to improve as children age? A. Impulsivity B. Hyperactivity C. Inattention D. Peer relationships E. Academic difficulties

Clinical interview with parents and child

Which of the following assessment procedures is required to make the diagnosis do childhood ADHD? A. Classroom observation of the child B. Clinical interview with the parents and child

Longitudinal follow up

Which of the following assessment strategies is most reliable in differentiating bipolar from unipolar depression in a patient presenting with an index depressive episode? A. Family history B. Longitudinal follow up. C. Young mania rating scale. D. Mood disorder questionnaire E. Hamilton, depression rating scale.

Fentanyl

Which of the following can be prescribed with comparative safety during treatment with monoamine oxidase inhibitor's? A. Amitriptyline B. Tramadol C. Meperidine D. Fentanyl E. Dextromethorphan

C

Which of the following changes is associated with normal aging? A. 10% loss of hippocampal volume per year B. Diffuse cerebral atherosclerosis in fine arterioles C. Loose aggregates of amorphous material with amyloid D. Widespread neurofibrillary tangles in the frontal and temporal cortex

Psychomotor disturbance

Which of the following characteristics of major depression is indicative of a greater overall severely? A. Fatigue B. Insomnia C. Weight gain D. Somatic complaints E. Psychomotor disturbance

Inhibition

Which of the following characteristics present in a 2 year old is most likely to persist into adult life? A. Irritability B. Inhibition C. Attentiveness D. High level activity

Separation anxiety disorder

Which of the following childhood disorders has the greatest genetic association with the development of adult onset panic attacks? A. Social anxiety disorder B. Major depressive disorder C. Separation anxiety disorder D. OCD E. ADHD

Conduct disorder

Which of the following comorbid diagnosis of childhood ADHD worse as the prognosis into adolescence and adulthood to the greatest degree? A. Contact disorder B. Tourette's syndrome C. MDD D. GAD E. Expressive language disorder

Disruptive behaviors

Which of the following concerns is the most common reason for referral of children and adolescents, 6 to 16 years of age, to mental health professionals? Mood Anxiety Development Substance use Disruptive behavior

Substance-abuse

Which of the following conditions is held to a stricter confidentiality standard by Federal law? A. Suicidality B. Homicidality C. Substance-abuse D. Psychotic disorders E. Treatment with ECT

Carbamazepine

Which of the following decreases BZD plasma levels? Carbamazepine Fluoxetine Cimetidine Disulfiram

Bipolar disorder

Which of the following diagnoses, considered in the absence of other comorbidities, is estimated to put one at highest lifetime risk for suicide? A. Schizophrenia B. Panic disorder C. Bipolar disorder D. Substance dependence E. Borderline PD

Brief psychiatric rating scale

Which of the following diagnostic assessments is administered with a clinical interview rather than self report? A. Minnesota Multiphasic Personality Inventory B. Symptom checklist - 90 C. Brief symptom inventory D. Millon clinical multiaxial inventory E. Brief psychiatric rating scale

Antisocial

Which of the following disorders carries with it the greatest co-incidence of alcohol abuse and dependence? A. Antisocial PD B. OCPD C. PTSD D. GAD

Anorexia nervosa

Which of the following disorders has significant treatment literature support of the use of structural family therapy? A. Selective mutism B. Conduct disorder. C. Anorexia nervosa. D. Social anxiety disorder. E. Social communication disorder.

Mental retardation

Which of the following disorders occurs most frequently in patients with autistic disorder? A. Epilepsy B. Schizophrenia C. Tuberous sclerosis D. Tourette's syndrome E. Mental retardation

D

Which of the following factors has the most evidence to support it's protective a fact in bereavement following the loss of a spouse? A. Intelligence of the bereaved B. Quality of the couples relationship C. Length of the couples relationship D. Quality of social support of the bereaved E. Capacity for psychological mindedness of the bereaved

Family history of depression

Which of the following factors is associated with improved outcome in late life depression? A. Male gender B. Introverted personality C. Family history of depression D. History of cardiovascular disease E. Presence of major adverse life events

Growth hormone

Which of the following hormones is released during sleep, but likely doesn't have a circadian pattern? A. Melatonin B. Cortisol C. Prolactin D. Oxytocin E. Growth hormone

Hirsutism

Which of the following symptoms is considered to be an irreversible effect of chronic anabolic steroid use? A. Infertility B. Hirsutism C. Impotence D. Gynecomastia E. Testicular atrophy

D

Which of the following hypnotic techniques is used for most patients? A. Using persuasion to change the patient's behavioral responses B. Provided the patient with specific directions from an authoritative source C. Using metaphors to enhance the patient's understanding of symptoms D. Encouraging the patient to use inner resources for adaptive coping strategies

Arcuate

Which of the following hypothalamus nuclei is key to the integration of neural and nutrient signals with hormonal signals for the small intestine, pancreas, liver, adipose tissue, and brainstem? A. Arcuate B. Posterior C. Paraventricular D. Anterior hypothalamic E. Dorsomedial hypothalamic

B

Which of the following is a disadvantage if the use of shorter half-life BZD in the treatment of alcohol withdrawal A. Increased likelihood of oversedation B. Increased likelihood of grand mal seizures C. Increased likelihood of protracted abstinence syndrome D. Less effectiveness milligram for milligram E. The presence of active metabolites

C

Which of the following is a limitation of the mini mental status exam? A. Low interrater reliability B. Useful only as a screen for dementia C. May fail to detect very mild cognitive impairment D. Serial use is an unreliable measure of cognitive decline

C

Which of the following is a major goal of the initial phase of interpersonal psychotherapy? A. Modifying the patient's expectations of family and friends B. Encourage the patient to reconnect with family and friends C. Collecting information about the patient's significant relationships D. Educating the patient about personality and communication styles E. Making connections between the patient's symptoms and interpersonal events

Conners' Continuous performance test

Which of the following is a neuropsychological test of sustained attention? A. Differential ability skills. B. Wisconsin card sorting test. C. Rey-Osterreith complex figure test. D. Connors continuous performance test. E. Delis-Kaplan executive function system.

C

Which of the following is a predisposing vulnerability factor in PTSD? A. Male gender B. Schizotypal traits C. Recent excessive use of alcohol D. Perception of internal locus of control E. Obsessive-compulsive personality traits

Metacognitive therapy

Which of the following is a psychosocial treatment for schizophrenia that focuses on social awareness and basic mental processes, with the aim of helping patients understand their own intellectual capacities, strengths, and limitations? A. Major role therapy B. Social skills training C. Metacognitive therapy D. Psychodynamic therapy E. Assertive community therapy

Lesion volume

Which of the following is associated with an increased risk of depression in patients with multiple sclerosis? A. Older age B. Female sex C. Type of deficit D. Lesion volume E. Family history of depression

C

Which of the following is characteristic of sleep EEG changes in major depressive disorder? A. Decreased wakefulness B. Decreased REM density C. Decreased REM latency D. Increased slow wave sleep E. Excess theta wave activity over the occipital scalp

Borderline intellectual functioning

Which of the following is considered to be the key component underlying the symptoms of selective mutism? A. Avoidant behavior B. Phonological disorder C. Oppositional behavior D. Expressive language delay E. Borderline intellectual functioning

CBT

Which of the following is most commonly used in sex offender treatment programs? A. Supportive psychotherapy B. Interpersonal psychotherapy C. CBT D. Psychodynamic psychotherapy E. Motivation enhancement therapy

E

Which of the following is most likely to reduce psychotic symptoms in patients with Parkinson disease without worsening motor symptoms? A. Quetiapine B. Mirtazapine C. Aripiprazole D. Rivastigmine E. Pimavanserin

C

Which of the following is most suggestive of psychogenic blindness? A. Abnormal color vision only B. Loss of vision in only the hemifield C. Ocular jerk movement with optokinetic drunk D. Normal direct and consensual response to light E. Normal brain MRI scan

Intellectual disability

Which of the following is seen most frequently as a comorbid condition in children with autism? A. Selective mutism B. Intellectual disability (mental retardation) C. Early onset schizophrenia D. OCD E. ADHD

Rapid does escalation

Which of the following is the greatest risk factor for developing akathisia? A. Male sex B. Younger age. C. Rapid dose escalation. D. Lower potency agents. E. Preponderance of positive symptoms.

42 mg/d

Which of the following is the most appropriate dose of nicotine patches to give a patient smokes 40 cigarettes per day? A. 7 mg/d B. 14 mg/d C. 21 mg/d D. 28 mg/d E. 42 mg/d

Mood disorder

Which of the following is the most common psychiatric complication of corticosteroid therapy? A. Dementia B. Delirium C. Psychosis D. Anxiety E. Mood disorder

Panic attacks

Which of the following is the most common psychiatric symptoms associated with pheochromocytoma? A. Mania B. Psychosis C. Depression D. Panic attacks E. Social withdrawal

C

Which of the following is the most common type of dissociative amnesia? A) Failure to recall the new events as they occur B) Total loss of memory from ones on personal history C) Failure to recall events during a particular period of time D) Inability to recall some but not all events during a particular time E) In ability to recall info in a certain category

Testosterone

Which of the following is the most effective treatment for low sexual desire in postmenopausal women? Fluoxetine Testosterone Mirtazapine Nortriptyline Sildenafil

Autism

Which of the following is the most highly heritable of all mental disorders: A. Bipolar disorder B. Autism spectrum disorder C. MDD D. GAD E. OCD

Caregiver with alcohol abuse

Which of the following is the most predictive factor for elder abuse? A. Patient with psychosocial stressors B. Patient with substance abuse C. Patient with psychiatric illness D. Caregiver with psychiatric illness E. Caregiver with alcohol abuse

D

Which of the following is the most significant barrier to accessing mental health services in school-based health centers? A. Lower quality of care B. Stricter referral process C. Health insurance restrictions D. Concerns about confidentiality E. Limited access to appointments

Sleep onset to REM onset

Which of the following measures of REM is typically reduced in major depressive disorder? A. Total density of REM B. Total time in REM sleep C. Sleep onset to REM onset D. Duration of the first REM period E. Average interval between REM periods

Congestive heart failure

Which of the following medical conditions is considered to present the highest relative risk for adverse events associated with ECT? A. Congestive heart failure B. Multiple sclerosis C. Hydrocephalus D. Pregnancy E. Asthma

Corticosteroids

Which of the following medication classes is most likely to exacerbate physiological tremor? A. Barbiturates B. Corticosteroids C. Benzodiazepines D. Calcium channel blockers E. Beta adrenergic antagonist

Escitalopram

Which of the following medication's is least likely to cause treatment emergent, medication induced sexual dysfunction? A. Duloxetine B. Escitalopram C. Paroxetine D. Sertraline E. Venlafaxine

Temazepam

Which of the following medications commonly used to treat insomnia is most likely to cause amnestic cognitive impairment? A. Trazodone B. Benadryl C. Lunesta D. Temazepam

Fluoxetine (Prozac)

Which of the following medications has the greatest potential to contribute to the development of galactorrhea in a patient on Risperdal? A. Fluvoxamine B. Gabapentin C. Lorazepam D. Nefazodone E. Fluoxetine

Dopamine

Which of the following medications is most likely to precipitate a manic switch in a patient with bipolar I disorder? A. Sertraline B. Phenelzine C. Bupropion D. Mirtazapine E. Dopamine

Valproic acid

Which of the following medications would be the best choice to allow for a larger daily reduction in benzodiazepines during a taper from a supratherapeutic dosage? A. Valproic acid B. Topiramate C. Flumazenil D. Naltrexone E. Seroquel

Paroxetine Both paroxetine and venlafaxine inhibit serotonin AND norepinephrine transporters but paroxetine I guess is better at blocking NET

Which of the following meds is the most potent inhibitor of norepinephrine transporter? A. Citalopram B. Fluoxetine C. Paroxetine D. Sertraline E. Venlafaxine

Breach of duty causing harm

Which of the following must be established in a medical malpractice case for a plaintiff to prevail? A. Malicious intent. B. Physical harm to the patient. C. Breach of duty causing harm. D. Deviation from standard of care.

B

Which of the following neuroimaging technologies is most useful in studying connectivity pathways in the brain? A. EEG B. Diffusion tensor imaging C. Magnetoencephalography D. PET scan E. SPECT scan

Cholinergic

Which of the following neurotransmitter systems is the last to mature in the CNS of children and adolescents? A. Noradrenergic B. Dopaminergic C. Serotoninergic D. Cholinergic

Limit setting

Which of the following parental tasks first becomes especially important during Tolerhood? A. Attachment B. Nurturance C. Limit setting D. Stimulation E. Instruction

D

Which of the following perinatal factors specifically associated with the development of ADHD? A. Macrocephaly at birth B. Advanced maternal age C. Thimerosal exposure in utero D. Maternal tobacco use prenatally

Illusions

Which of the following phenomena is most typical of hallucinogen use? A. Illusions B. Hallucinations C. Depersonalization

Decreased hepatic blood flow

Which of the following physiologic changes that affect drug pharmacokinetics is commonly seen in older adults A. Increase protein binding. B. Increased total body water. C. Decrease hepatic blood flow. D. Decreased gastric transit time. E. Decreased hepatic glucuronidation

B

Which of the following practices is common to all couple and family therapies and contributes to a therapeutic outcome? A. Assessing couple or family psychopathology B. Conceptualizing differences in relational terms C. Gauging level of object relatedness among couple or family members D. Formulating clinical problems in terms of boundaries, roles, and hierarchical decision-making E. Discerning how a patient's symptom represents a "solution" for a systemic problem

CBT

Which of the following psychosocial treatment modalities is most relevant and affective for the positive symptoms of schizophrenia? A. Social skills training B. Compliance therapy C. Cognitive remediation D. Supported employment E. CBT

Start an SSRI

Which of the following recommendations on the use of medication to treat sub threshold depressive symptoms in patients with cancer is best supported by current evidence? A. Administer a short acting stimulant B. Start an SSRI C. Use anticancer drugs at target the underlying neoplasm D. Delay pharmacological treatment until the patient meets full syndrome DSM 5 criteria

A

Which of the following scales is the easiest to use for an initial assessment of delirium in geriatric patients? A. Confusion Assessment Method B. Montreal Cognitive Assessment C. Mini-Mental Status Examination D. Geriatric Mental State Schedule E. Brief Psychietric Rating Scale

D

Which of the following statements about the brain's default mode network is accurate? A. Is activated by external stimuli B. Localize is primarily to the non-dominant hemisphere C. Uses much less energy than goal oriented brain activity D. Is involved in re-processing previously experienced stimuli

Last observation carried forward

Which of the following statistical methods attempts to address the effects of participants dropping out of a study prior to completion?

Use of care managers

Which of the following strategies has been most often linked to better outcomes in the treatment of depression in primary care settings? A. Patient education B. The use of care managers C. Continuing medical education D. Published treatment guidelines E. Depression screening measures

Supportive Supportive therapy is a form of psychotherapy that relies on the therapeutic alliance to alleviate symptoms, improve self-esteem, restore relation to reality, regulate impulses and negative thinking, and reinforce the ability to cope with life stressors and challenges.

Which of the following therapies is generally most appropriate for patients who have poor reality testing, primitive and immature defenses, inadequate affect regulation and/or poor impulse control? A. Supportive B. Interpersonal C. Psychoanalytic D. Short-term psychodynamic E. Acceptance and commitment Describe the correct answer

D Answer choice D describes pseudocyesis, which is listed in the DSM under "Other Specified Somatic Symptom and Related Disorders." It involves a false belief that one is pregnant, and it can involve physical signs associated with pregnancy, such as those described. However, the patient is not pregnant, and there is no endocrine disorder present to explain the findings. Other patients that fall under the heading of "Other Specified Somatic Symptom and Related Disorders" include those with other somatic symptoms that do not meet the time criteria for other diagnoses.

Which of the following would fall under the heading of "Other Specified Somatic Symptom and Related Disorders" A. A patient with pain in one or more areas that is thought to be significantly mediated by psychological factors B. A patient with a persisten belief that he or she has cancer despite reassurance by his or her physician that nothing it wrong C. A patient who develops a motor deficit following significant psychological stressors D. A patient who feels that she is pregnant and presents with amenorrhea, enlarged abdomen, and breast engorgement but a negative pregnancy test E. A patient who has medical complaints involving pain, gastrointestinal complaints, neurological complaints, and sexual complaints, but no medical explanation can be found for these symptoms

Abilify

Which of the medication has the most evidence for managing irritability and aggression and children with autism?

GABA-A

Which one of the GABA receptors is thought to be the site of action of the benzodiazepines? A. GABA-A B. GABA-B C. GABA-C D. GABA-D E. GABA-E

Acetylcholine

Which one of the following neurotransmitters localizes predominantly to the basal forebrain and is responsible for memory, attention, and executive functioning? A. Serotonin B. NE C. GABA D. Glycine E. Acetylcholine

Phenelzine is an MAOI and is not likely to worsen the movement disorder symptoms of Parkinson's dis-ease. The other four agents are antagonists of dopamine D2 receptors and can of course worsen symptoms of Parkinson's disease and cause drug-induced parkinsonism. The pathophysiology involves D2 receptor antagonism in the caudate. Patients who are elderly and female are at greatest risk for neurolep-tic-induced parkinsonism. More than half of patients exposed to neuroleptics on a long-term basis have been noted to develop this unwanted adverse effect. Amoxapine (Asendin) is a dibenzoxazepine tetracy-clic antidepressant that has strong D2-antagonistic properties because it is a chemical derivative of the neuroleptic loxapine (Loxitane). Because of its unique structure and chemical properties, amoxapine can also cause akathisia, dyskinesia, and, infrequently, neuroleptic malignant syndrome.

Which one of the following agents is least likely to exacerbate the extrapytamidal symptoms of Parkinson's disease? A. Аmoxapine B. Perphenazine C. Thorazine D. Fluphenazine E. Phenelzine Explain

D

Which one of the following agents is not potentially useful for the treatment of essential tremor? A. Lorazepam B. Primidone C. Propranolol D. Desipramine E. Botulinum toxin type A

Protriptyline Severe motor tics in Tourette's syndrome are best treated by neuroleptics, in particular haloperidol and pimozide. Protriptyline and the other antidepressants may be effective for associated obsessive compulsive symptoms, but these agents are not useful for treatment of tics.

Which one of the following agents would not be useful for the treatment of tics in Tourette's syndrome? A. Fluphenazine B. Molindone C. Botulinum toxin type A D. Haloperidol E. Protriptyline

Carbamazepine

Which one of the following anticonvulsant agent needs rapid dosage increases early in therapy owing to autoinduction of its own metabolism? A. Carbamazepine. B. Depakote. C. Phenytoin. D. Phenobarbital. E. Pimavanserin

D

Which one of the following antidepressants can be used as an antipruritic agent and for the treatment of gastric ulcer because of its potent histamine blockade? A. Trazodone B. Fluoxetine C. Vilazodone D. Amitriptyline E. Amoxapine

Paroxetine

Which one of the following antidepressants does not have strong sedative effect? A. Trazodone B. Paroxetine C. Doxepin D. Clomipramine E. Mirtazapine

E Patients with aneurysms, vascular malformations, or increased intracranial pressure are at greater risk during ECT because of increased blood flow during the induction of the seizure. This risk can be decreased by careful control of blood pressure during the seizure. Epilepsy and prior neuroleptic malignant syndrome are not problematic with the administration of ECT.

Which one of the following conditions involves increased risk in electroconvulsive shock therapy (ECT)? A. Pregnancy B. Hypopituitarism C. Uncontrolled epilepsy D. Neuroleptic malignant syndrome E. Cerebral aneurysm

Cigarette smoking, it decreases TCA concentration

Which one of the following does not increase tricyclic antidepressant concentrations? A. Clozapine B. Haloperidol C. Risperidone D. Cigarette smoking E. Methylphenidate

B To diagnose schizophrenia, active phase symproms must be present tor a l-month period only. It may be diagnosed if other symproms (ie, negative) are present over a 6 month period, but active phase symptoms may be present for at least 1 month of these 6 months

Which one of the following is not a DSM criterion for schizophrenia? A. Delusions B. Presence of active-phase symptoms for 6 months C. Hallucinations D. Disorganized speech E. Grossly disorganized or catatonic behavior

Nortriptyline, Desipramine

Which tricyclic antidepressants are less anticholinergic?

Catalepsy

While working on the ward of a state hospital, a psychiatrist comes across a patient with schizophrenia. The patient in one spot for extended periods of time without changing position. This phenomenon is best described as: A. Psychomotor retardation B. Catalepsy C. Cataplexy D. Catatonia E. Stereotypy

Less dopamine receptors

Why are elderly people more likely to develop EPS from antipsychotics?

Hypertension The tricyclic antidepressants have many cardiac side effects that are worsened in overdose. They act as type 1A antiarrhythmics. As such, they can terminate ventricular fibrillation and increase collateral blood supply to ischemic heart tissue. In overdose, they can be highlv cardiotoxic and will cause decreased myocardial contractility, tachycardia, hypotension, and increased myocardial irritability. Also important to note is that nortriptyline is unique for its therapeutic window. Blood levels should be brained, and the therapeutic range is 50 to 150 ng/mL. Levels above 150 ng/mL may reduce its efficacy

Which one of the following is not a side effect of treatment with tricyclic antidepressants? A. Termination of ventricular fibrillation B. Increased collateral blood supply to ischemic heart muscle C. Decreased contractility D. Tachycardia E. Hypertension EXPLAIN

B

Which one of the following is not seen in narcolepsy? A. Cataplexy B. Nighttime awakening C. Excessive daytime sleepiness D. Sleep paralysis •E. Hypnagogic hallucinations

E

Which one of the following is not true concerning cyclothymic disorder? A. It is similar to bipolar disorder but less severe B. Symptoms must be present for at least 2 years C. It is equally common in men and women D. Substance abuse is common in patients with cyclothymia E. There are often psychotic symptoms found in patients with cyclothymia

Daily functioning is markedly impaired

Which one of the following is not true of delusional disorder? A. It may involve nonbizarre delusions that could happen in real life B. It may involve tactile hallucinations C. The erotomanic type involves another person of higher social standing being in love with D. Daily functioning is markedly impaired E. The person's behavior is not markedly odd or bizarre

B It is more common in urban areas

Which one of the following is not true regarding schizophrenia? A. Lifetime prevalence is about 1% B. Prevalence is greater in rural than in urban areas C. The male-to-female ratio is 1:1 D. Onset is rare before age 10 years or after age 40 years E. There is a higher incidence of the disease in babies born in winter and early spring

E The opposite is true.

Which one of the following is not true regarding use of the tricyclic antidepressants? A. Owing to their ability to prolong cardiac conduction time, their use in patients with conduction defects is contraindicated B. These agents should be discontinued before elective surgery because they may cause hypertensive episodes durin surgery C. Some patients who experience orthostatic hypotension may respond to the use of fludrocortisone D. Myoclonic twitches and tremors of the tongue and upper extremities are common in some patients on tricyclics E. Amoxapine is the least likely of all the tricyclics to cause parkinsonian symptoms

C

Which one of the following is true regarding psychoanalytic psychotherapy? A. All of the patient's remarks should be taken at face value B. Most of what the patient says is unimportant C. Disclaimers often precede emotionally charged material and are important to note D. It is important to point out to the patient every instance in which he or she exhibits low self-esteem E. One should interpret the patient's resistance at each and every opportunity

Ramelteon (Rozerem) is a melatonin agonist and has a short half-life ranging from 1 to 2.5 hours. Ramelteon has an active metabolite, M-Il, that has a half-life of about 5 hours. Zolpidem (Ambien) has a half-life of about 2.5 hours, but the duration of action can range from 1 to 4.5 hours. Zolpidem has 10 active metabolite. Zaleplon (Sonata) is a benzodiazepine receptor agonist that has the shortest half-ife of all these agents at about 1 hour. It is therefore very useful for the treatment of middle insomnia. Eszopiclone (Lunesta) has the longest half-life of all these sleeping agents at about 6 hours. It is there-fore, at least theoretically, the one most likely to cause next-day drowsiness. Triazolam (Halcion) is a benzodiazepine sedative hypnotic agent with high potency and a short half-life ranging in duration from 2 to 4 hours

Which one of the following sleep-promoting agents has the longest half-life? A. Ramelteon B. Zolpidem C. Zaleplon D. Eszopiclone E. Triazolam Describe the half life of these agents.

D

Which one of the following statements is true regarding carbamazepine? A. Carbamazepine is approved in the United States for treatment of temporal lobe epilepsy and general epilepsy but not trigeminal neuralgia B. Carbamazepine is metabolized by the kidneys C. Carbamazepine can be associated with a transient increase in the white blood cell count D. Carbamazepine has been shown to be as effective as the benzodiazepines in some studies for management of alcohol withdrawal E. A benign pruritic rash occurs in 60% to 70% of patients treated with carbamazepine

Amygdala

Which one of the following structures is not part of Papez' circuit? A. Amygdala B. Mammillary body C. Fornix D. Cingulate gyrus E. Hippocampus

The safest choice of all the answers is of course ECT. There is no real contraindication to ECT in normal pregnancy. If the pregnancy is high risk or complicated, fetal monitoring can be carried out during the procedure. Haloperidol would be the next best choice and is of course a butyrophenone antipsychotic agent. Haloperidol can pass into breast milk, so mothers should not breastfeed if they are taking this drug. Haloperidol has been shown to cause teratogenicity in animals. Human studies are inadequate in this regard, and the beneft needs to outweigh the risk before the drug is given to a pregnant patient. The first trimester is the most vulnerable period of pregnancy for teratogenic fetal effects. Lithium is of course contraindicated in pregnancy because of the risk of Ebstein's anomaly of the tricuspid valves. The risk of Ebstein's anomaly is 1 in 1000. Lithium is also excreted into breast milk. Divalproex sodium is also dangerous in pregnancy because of the first-trimester risk of fetal spina bifida and neural tube defects in about 1% to 2% of those taking the drug in their first trimester. Folic acid supplementation (1 to 4 mg daily) taken during the first trimester of pregnancy reduces the risk of neural tube defects with divalproex sodium. Aripiprazole has not been well studied in pregnancy. There are animal studies that have revealed fetal abnormalities as a direct result of maternal exposure to aripiprazole. Another commonly tested fact with respect to psychiatric medications and pregnancy is that selective serotonin reup-take inhibitors (SSRIs), most notably paroxetine, can increase the risk of pulmonary hypertension in the infant.

Which one of the following therapies would be best suited to a bipolar patient in a manic episode during pregnancy? A. Haloperidol B. Lithium C. Aripiprazole D. Divalproex sodium E. Electroconvulsive therapy EXPLAIN!!!

CBT

Which psychosocial treatment modality is most relevant and effective for the positive symptoms of schizophrenia?

If you move, especially your head, that'll generate electrical activity which will produce waves (artifacts). Any movement can produce artifacts (myogenic and eye-movement artifacts)

Why are you not supposed to move during an EEG?

Because it has no metabolite

Why can lithium be effectively removed by hemodialysis?

Because they all block H1 receptors. This not only makes you sleepy but also affects the satiety center and thermogenesis. Short term, it blocks the receptor in the satiety center so you don't feel full and keep eating. Long term it affects thermogenesis by blocking the mechanism behind burning fat for heat. Weight gainers: - Paroxetine - Mirtazapine - Olanzapine - Clozapine - Seroquel Bupropion can cause weight loss

Why do antidepressants and mood stabilizers cause weight gain? Name some of the biggest meds in these categories that cause weight gain? Name the antidepressant that can make you lose weight?

More likely to be abused to experience a general relaxed feeling rather than fir the purpose of feeling high/euphoria

Why do people abuse BZDs?

One patient reported temporary hearing loss after TMS. Extensive study was conducted examining auditory threshold before an after four weeks of TMS and no changes were found. However as a general precaution, patient are advised to wear earplugs during the treatment.

Why do people wear earplugs when getting TMS?

PNA occurs when an infant gets exposed to SSRIs in utero during the third trimester. It's a transient condition that resolves within 2 weeks. Risk factors - High doses of SSRIs - SNRI monotherapy - Antidepressant med combinations - Paroxetine monotherapy Wellbutrin is less likely to result in PNA. It's also not associated with persistent pulmonary HTN (a rare complication of SSRI in utero exposure)

Why does PNA occur? What are the risk factors for developing poor neonatal adaptation syndrome? What is the risk if the mother is taking Wellbutrin?

The body has protective devices against inundation by alcohol. For example, if the concentration of alcohol in the stomach becomes too high, mucus is secreted and the pyloric valve closes. These actions slow the absorption and keep the alcohol from passing into the small intestine, where there are no significant restraints on absorption. Thus, a large amount of alcohol can remain unabsorbed in the stomach for hours. Furthermore, pylorospasm often results in nausea and vomiting.

Why does drinking too much alcohol result in vomiting?

It can cross the blood brain barrier

Why is I-methylfolate preferred over folate in the adjunctive treatment of depression?

Counter transference feelings represent some of the most clinically valuable material available to the interviewer. Whatever feelings the patient elicits in you are feelings the patient probably elicits in most other people she encounters in her life. Knowing this can give you powerful insight into the nature of her problems. Bottom line: when you feel a negative emotion toward your patient, don't act on it but rather analyze it ad possible connection to your patient psychopathology.

Why is countertransference useful diagnostically?

Traumatic brain injury can result in a large number of cognitive, personality, affective, behavioral, and other psychiatric manifestations. A lot of these occur much after the initial trauma. It's important to ask about head injury because TBI patients usually have many of these sequelae and it would be good to manage them all

Why is it important to always ask about head injury during an H&P?

Generally, AH are negative and hence, should be distressing. Also it's scary to start hearing voices. You'd expect people to be afraid of AH and not speak about it calmly. If they react calmly to voices it may not be real. Ex. Sleeping with a knife due to voices vs. I hear 3 voices that are good, bad, and neutral.

Why is it important to ask about a patient's reaction to AH?

While several popular books suggest these two sides of the brain are important to specific functions—that is, the right side of the brain is responsible for creativity while the left side handles your more analytical-type processing (sometimes referred to as "lateralization")—activity for most cognitive tasks is seen on both hemispheres. The exception is language. Two key areas involved in language—Broca's Area, responsible for language grammar and syntax, and Wernicke's Area, implicated in language content and meaning processing—reside on the left side of the brain for most.

Why is it incorrect to use terms like "Right brain" and "Left brain" ? What is the exception to this rule?

Less occurrence of AE with methylphenidate in comparison to amphetamines

Why is methylphenidate the first choice over amphetamines for children with ADHD?

There's an increased risk of hyponatremia (something that can already occur with SSRIs alone)

Why should you buy give Tramadol and SSRIs together?

Alcohol and BZDs

Withdrawal from which drugs can kill you?

Zoloft Prozac is more activating so it could worsen her anxiety. Zoloft is more calming in comparison. Also Zoloft is effective at reducing SH like Prozac

Would you give Prozac or Zoloft to a depressed, anxious 15 year old with SI who cuts and why?

4 mg PO Risperdal + 2 mg PO Ativan

X Risperdal + x Ativan = 5 mg IM Haldol + 2 mg IM Ativan

✽ Alprazolam XR may be less sedating than immediate-release alprazolam ✽ XR pills cannot be broken in half bc it would ruin their controlled release ✽ Alprazolam XR may be dosed less frequently than immediate-release alprazolam, and lead to less interdose breakthrough symptoms and less "clock- watching" in anxious patients ✽ Alprozolam XR generally has longer biological duration of action than clonazepam ✽ If clonazepam can be considered a "long- acting alprazolam-like anxiolytic," then alprazolam XR can be considered "an even longer-acting clonazepam-like anxiolytic" with the potential of improved tolerability features in terms of less euphoria, abuse, dependence, and withdrawal problems, but this has not been proven

Xanax XR vs IR

Elimination half-life 12-15 hours Clinical duration of action may be shorter than plasma half-life, leading to dosing more frequently than 2-3 times daily in some patients, especially for immediate release alprazolam

Xanax half-life and clinical importance?

How much water have you been drinking recently? The case presented in this question is a common description of water intoxication. Symptoms include tremor, ataxia, restlessness, diarrhea, vomiting, polyuria, and eventual stupor. This is a problem that can be found in up to 20% of patients with chronic schizophrenia. When found, these patients need close monitoring of their electrolytes, and in many cases must be water-restricted with close monitoring of their intake and output. The electrolyte disturbances that result from drinking enormous quantities of water can become serious medical issues and in some cases prompt medical hospitalization. Although the other questions could be useful in doing a thorough evaluation, the patient's symptoms and psychiatric diagnosis should suggest water intoxication.

You are on call and get paged to go see a schizophrenic patient in the inpatient unit. The patient has a tremor, is ataxic, and is restless. During the interview the patient vomits. The nurse tells you he has been having diarrhea and has been urinating very frequently. What question would be most useful to ask the patient? A. Can you count from 100 backward by 75? B. Where are you right now? C. Who is the current president? D. How much water have you been drinking recently? E. Are you HIV positive? What is the cause of these symptoms?

Seizures

You increase the risk of what if you prescribe Wellbutrin XL above 450 mg/day?