free - NINJA PRITE REVIEW 2016

LomaLindaDepartmentofPsychiatry’s
TheNinja’sGuidetoPRITE
2016Edition
TheBestPRITEReview…..EVER
Foreword
In2007,aragamuffingroupofinternsandresidentssetouttocreateahigh-yieldPRITEguide.Equippedwith
laptops,pencil-markedPRITEsfrom2001-2006,andenoughjunkfoodtofeedasmallcountry,the“Loma
LindaDepartmentofPsychiatryPRITESweatshop”wasstarted.Aftermultiplerevisionstotheguideoverthe
pastnineyears,TheNinja’sGuidetoPRITEcontinuestofocusonthemostimportantareastocramintoyour
braininthemonthprecedingPRITE.ItissuggestedthatgoingoveroldPRITEexamsisthebestpreparation
forPRITE.ThisguideprovidesacomprehensivesummaryofoldPRITEsinanattempttohelpwithamore
efficientreview.Otheritemsinthisguideincludeapsychopharmacologyreview,apsychotherapyreview,
andamiscellaneoustopicshigh-yieldreview.ThevariousNinjareviewscombineinformationfromthe
MassachusettsGeneralHospitalPsychiatryReview,SynopsisofPsychiatryandSynopsisof
PsychopharmacologybyKaplanandSadock,theAPAPsychiatryTextbookandotherexcellentsources.
Rememberthatthesematerialsarecopyrighted,sopleasedonotsellthisfreelearningtool.Withthese
tools,itismyhopethatyouwillcompletelyrockthePRITE.
BestofNinjaLuck,
MelissaPereau,MD
AssociatePsychiatryResidencyTrainingDirector
LomaLindaDepartmentofPsychiatry
LomaLindaUniversitySchoolofMedicine
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TableofContents
Foreword.....................................................................................................................................................2
TableofContents..........................................................................................................................3
ANINJA'SGUIDETOPSYCHOPHARMACOLOGY.........................................................................................8
Antipsychotics.........................................................................................................................................8
TypicalAntipsychotics.................................................................................................................................8
AtypicalAntipsychotics..............................................................................................................................10
MoodStabilizers....................................................................................................................................13
Lithium.......................................................................................................................................................13
ValproicAcid..............................................................................................................................................14
Carbamazepine(Tegretol).........................................................................................................................15
Oxcarbazepine(Trileptal)..........................................................................................................................16
Lamotrigine(Lamictal)...............................................................................................................................17
Gabapentin(Neurontin)............................................................................................................................17
Topiramate(Topamax)..............................................................................................................................18
Antidepressants.....................................................................................................................................18
TCAs...........................................................................................................................................................18
TetracyclicAntidepressants.......................................................................................................................20
MonoamineOxidaseInhibitors.................................................................................................................21
SelectiveSerotoninReuptakeInhibitors(SSRIs)........................................................................................22
SomeObservationsontheGenericMedicationsWeNowPrescribe.......................................................25
Bupropion(Wellbutrin,Zyban)..................................................................................................................26
Venlafaxine(Effexor)andDesvenlafaxine(Pristiq)...................................................................................27
Duloxetine(Cymbalta)...............................................................................................................................28
Anxiolytics.............................................................................................................................................28
Buspirone(Buspar)....................................................................................................................................28
Benzodiazepines........................................................................................................................................29
CognitiveEnhancers...............................................................................................................................31
MiscellaneousTopics.............................................................................................................................32
TreatmentofMedicationSideEffects.......................................................................................................32
TreatmentofOverdose.............................................................................................................................32
ANINJA’SGUIDETONEUROLOGY...............................................................................................33
Cortex....................................................................................................................................................33
AnatomyOverview....................................................................................................................................33
Pereau’s“CramtheBrainUsingtheMMSE”ReviewTool........................................................................34
HighYieldPRITEReview............................................................................................................................36
AnatomyOverview....................................................................................................................................38
Pereau’s“TheBrainstemasaFace”ReviewTool.....................................................................................39
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HighYieldPRITEReview............................................................................................................................41
ANINJA’SGUIDETOPSYCHOTHERAPY........................................................................................48
PsychoanalyticalPsychotherapy...............................................................................................................48
ExpressivePsychotherapy(“Insight-OrientedTherapy”)..........................................................................49
BriefPsychotherapy..................................................................................................................................49
InterpersonalTherapy...............................................................................................................................50
SupportivePsychotherapy........................................................................................................................50
BehavioralTherapy....................................................................................................................................51
Biofeedback...............................................................................................................................................51
CognitiveBehavioralTherapy....................................................................................................................51
GroupTherapy..........................................................................................................................................53
FamilyTherapy..........................................................................................................................................54
CouplesTherapy........................................................................................................................................55
ANINJA’SGUIDETOFREUD&OTHERSTUFF........................................................................................57
SigmundFreud.......................................................................................................................................57
InterpretationofDreams..........................................................................................................................57
TheTopographicalModeloftheMind......................................................................................................57
InstinctandDriveTheory..........................................................................................................................58
Pleasurevs.RealityPrinciples...................................................................................................................58
Narcissism..................................................................................................................................................58
TheStructuralTheoryoftheMind............................................................................................................58
DefenseMechanisms................................................................................................................................59
PsychosexualDevelopmentalStages........................................................................................................60
ErikErikson............................................................................................................................................62
Trustvs.Mistrust(0-18months,correlateswithOral).............................................................................62
Autonomyvs.ShameandDoubt(18months-3years,correlateswithAnal)...........................................62
Initiativevs.Guilt(3-5yearsold,correlateswithphallic).........................................................................62
Industryvs.Inferiority(5-13yearsold,correlateswithlatency)...............................................................63
Identityvs.RoleConfusion(13-21yearsold,correlateswithgenital)......................................................63
Intimacyvs.Isolation(21-40yearsold).....................................................................................................63
Generativityvs.Stagnation(40-60yearsold)...........................................................................................63
Integrityvs.Despair(60yearsolduntildeath).........................................................................................64
PathologicDevelopment........................................................................................................................64
Birthto18months....................................................................................................................................64
18monthsto3years.................................................................................................................................64
3to5years................................................................................................................................................65
5to13years..............................................................................................................................................65
13yearsto20s(Adolescence)...................................................................................................................65
20sto40s..................................................................................................................................................66
40sto60s..................................................................................................................................................66
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60stoEndofLife.......................................................................................................................................66
IntelligenceTests.......................................................................................................................................66
PersonalityAssessment.............................................................................................................................67
CognitiveTesting.......................................................................................................................................67
ChildandAdolescentPsychologicalAssessment......................................................................................68
Statistics................................................................................................................................................68
ANINJA’SGUIDETOSUBSTANCEUSEDISORDERS...................................................................................70
Overview................................................................................................................................................70
EtiologyofSubstanceUse.......................................................................................................................70
ScreeningforAddiction..........................................................................................................................70
MotivationalInterviewing.......................................................................................................................71
SubstanceUseDisorders........................................................................................................................71
Substance-InducedDisorders..................................................................................................................73
Substance/Medication-InducedMentalDisorders...................................................................................77
Alcohol-RelatedDisorders......................................................................................................................78
Caffeine-RelatedDisorders.....................................................................................................................83
Cannabis-RelatedDisorders....................................................................................................................84
Hallucinogen-RelatedDisorders..............................................................................................................86
Inhalant-RelatedDisorders.....................................................................................................................90
Opioid-RelatedDisorders........................................................................................................................92
Sedative,HypnoticorAnxiolytic-RelatedDisorders..................................................................................96
Stimulant-RelatedDisorders...................................................................................................................98
Tobacco-RelatedDisorders...................................................................................................................102
Miscellaneous......................................................................................................................................105
ANINJA’SGUIDETOPRITEQUESTIONS2016EDITION........................................................................108
Neurology.................................................................................................................................109
Amnesia................................................................................................................................................................109
BrainLesions........................................................................................................................................................109
Catatonia..............................................................................................................................................................113
CVA.......................................................................................................................................................................113
Delirium................................................................................................................................................................118
Dementia..............................................................................................................................................................120
Seizures................................................................................................................................................................124
EEG.......................................................................................................................................................................126
Endocrine.............................................................................................................................................................127
Headaches............................................................................................................................................................127
Huntington’sDisease...........................................................................................................................................129
Memory................................................................................................................................................................129
MultipleSclerosis.................................................................................................................................................130
Muscle/NeuronalDiseases/Lesions.....................................................................................................................131
Parkinson’sDisease..............................................................................................................................................134
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Spine.....................................................................................................................................................................135
TardiveDyskinesia................................................................................................................................................136
GeneralNeurology...............................................................................................................................................136
Neurotransmitters...............................................................................................................................................149
Radiology..............................................................................................................................................................150
Sleep.....................................................................................................................................................................150
AxisIDisorders.........................................................................................................................154
AcuteStressDisorder...........................................................................................................................................154
ADHD....................................................................................................................................................................154
AnxietyDisorders.................................................................................................................................................157
BipolarDisorder...................................................................................................................................................159
DelusionalDisorders............................................................................................................................................162
Depression...........................................................................................................................................................163
DissociativeDisorders..........................................................................................................................................168
EatingDisorders/BodyDysmorphicDisorder.......................................................................................................169
FactitiousDisorder...............................................................................................................................................171
ImpulseControlDisorder.....................................................................................................................................172
OCD......................................................................................................................................................................172
PanicDisorder......................................................................................................................................................174
Phobias.................................................................................................................................................................175
PTSD.....................................................................................................................................................................176
Schizophrenia/Psychosis......................................................................................................................................177
SomatoformDisorders.........................................................................................................................................181
Tourette’sDisorder..............................................................................................................................................182
PersonalityDisorders...........................................................................................................................................183
Alcohol.................................................................................................................................................................185
Substances...........................................................................................................................................................190
SomaticTreatments..................................................................................................................201
Anticonvulsants....................................................................................................................................................201
GeneralAntidepressants......................................................................................................................................203
MAOI....................................................................................................................................................................206
TCA.......................................................................................................................................................................207
SSRI.......................................................................................................................................................................208
Antipsychotics......................................................................................................................................................210
Anxiolytics/Benzodiazepines................................................................................................................................214
Lithium.................................................................................................................................................................216
Methadone...........................................................................................................................................................218
GeneralPsychopharmacology..............................................................................................................................219
PsychologicalTesting...........................................................................................................................................222
MSE......................................................................................................................................................................225
PsychologicalTheory............................................................................................................................................227
EriksonianStages.................................................................................................................................................230
PsychoanalysisandFreud....................................................................................................................................231
DefenseMechanisms...........................................................................................................................................232
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Therapy................................................................................................................................................................234
PsychodynamicTherapy.......................................................................................................................................240
CBT.......................................................................................................................................................................243
MaritalTherapy....................................................................................................................................................245
DialecticalBehavioralTherapy.............................................................................................................................246
FamilyTherapy.....................................................................................................................................................246
GroupTherapy.....................................................................................................................................................248
Hypnosis...............................................................................................................................................................249
InterpersonalTherapy..........................................................................................................................................250
SupportiveTherapy..............................................................................................................................................251
PsychosocialTherapies........................................................................................................................................251
TherapyTerms.....................................................................................................................................................252
Geriatrics..............................................................................................................................................................255
HIV/AIDS...............................................................................................................................................................257
ECT.......................................................................................................................................................................257
ChildhoodandDevelopment.....................................................................................................259
Attachment..........................................................................................................................................................259
Development........................................................................................................................................................261
ChildPsychiatry....................................................................................................................................................269
MentalRetardation..............................................................................................................................................270
PDD/Asperger’s/Autism.......................................................................................................................................271
ConditioningandLearning.........................................................................................................272
Conditioning.........................................................................................................................................................272
Learning................................................................................................................................................................274
ResearchandStatistics..............................................................................................................275
ResearchDesign...................................................................................................................................................275
Statistics...............................................................................................................................................................278
Genetics...............................................................................................................................................................280
Epidemiology........................................................................................................................................................283
Society......................................................................................................................................285
Culture..................................................................................................................................................................285
Spirituality............................................................................................................................................................287
Ethics....................................................................................................................................................................287
LegalandForensics..............................................................................................................................................290
CaseManagement...............................................................................................................................................294
ConsultandLiaison..............................................................................................................................................296
ViolenceandAbuse..............................................................................................................................................298
EmergencyPsychiatry..........................................................................................................................................299
Suicide..................................................................................................................................................................301
Bereavement........................................................................................................................................................302
Sexuality...............................................................................................................................................................304
Miscellaneous......................................................................................................................................................306
HistoryofPsychiatry............................................................................................................................................311
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ANINJA'SGUIDETOPSYCHOPHARMACOLOGY
Antipsychotics
TypicalAntipsychotics
Phenothiazinesarecompoundsderivedfromtheoriginalparentdrug,methyleneblue.Thischemicalisused
inhistologicstaining,analyticchemistry,andasanantimalarialmedication(asearlyas1891).DuringWW2
methyleneblue’suseasanantimalarialduetolackofaccessinthePacifictropicsandsideeffectsofturning
urinegreenandsclerablue.Theantihistaminepropertiesofmethylenebluewerefoundtobehelpfulas
anestheticagents.In1951,FrenchsurgeonLaboritaskedapharmaceuticalcompanytocreateaspecialized
phenothiazinetoreducepost-surgicalpsychosis.Thismedicationwaschlorpromazine.Shortlythereafter,the
medicationwasusedserendipitouslyinpsychiatricpatientstoreducepsychosis.Throughfurtherresearch
anddevelopment,asimilarstructure,imipraminewascreated.Thismedicationwasoneofthefirst
antidepressants.
Chlorpromazine
Imipramine
MethyleneBlue
Indications:schizophrenia(improvespositivesymptoms,mayworsennegativesymptoms),acutemania,
MDDwithpsychosis,hemiballismus,hiccups,Tourette’s.Highpotencyantipsychoticsarebetterusedin
patientswithpsychosisduetotumor/organiccauses.Astheydecreaseseizurethreshold,usewithcautionin
ETOHdetox.Lowpotencyantipsychoticsshouldbeavoidedintheelderlyandmedicallyillduetomultiple
anticholinergicandcardiacsideeffects.Avoidusein1sttrimester(especiallychlorpromazine);2ndand3rd
trimesteraresafer.Contraindicatedincardiacpatients,acuteangleglaucoma,andpatientswithahistoryof
TD.
MechanismofAction:blockadeofD2receptors
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•
•
•
Mesocortical/mesolimbic:diminishespsychosis
Tuberoinfundibular:increasesPRL(DAdecreasesPRL;DAblockadeincreasesPRL)
Nigrostriatal:basalgangliaandcaudate.MovementdisordersincludingEPS,PD,tremor
DrugInteractionsandP450:typicalsaremetabolizedby2D6and3A4,thusareincreasedinthepresenceof
Prozac,PaxilandLuvox.TheyarereducedbycoadministrationwithTegretol.Antacidsdecreasethe
absorptionoftypicals.Anticholinergicdeliriumispossibleinthepresenceofanticholinergicmedications,low
potencytypicalandTCAcoadministration.Typicalsincreasebloodconcentrationsofvalproicacid.Cigarettes
decreasebloodconcentrationsoftypical.Thus,ifapatientisstabilizedonaspecificdoseofatypicaland
quitssmokingthereisriskforEPSandothersideeffects.
OverviewofSideEffects:EPSandnon-EPS(anticholinergic,cardiac,sedation,etc).Highpotency
antipsychoticshavegreateraffinityforD2receptorsandhavelessspilloverintoothersystems(muscarinic,
cholinergic).Asaresult,themoreprevalentsymptomsarenigrostriatal.Theterm“extrapyramidal”refersto
motorsymptomsoutsideofthosefrommotorcortexmedullarypyramidsspinalcordmuscles.The
extrapyramidalsystemworkstomodulatemotorcontrolthroughthereticularformation,nigrostriatal
pathway,cerebellum,vestibularsystem,andanteriorhorncells.EPSinvolvesabnormalcoordinationof
movement,includingakathisia,akinesia,pseudoparkinsonsymptoms,andacutedystonia(musclespasms).
ExtrapyramidalSideEffects(MoreCommoninHighPotency)
•
•
•
•
•
Pseudoparkinson:bradykinesia,rigidity,maskedface,cogwheeling,tremor.Womenare2xmore
likely.Treatwithanticholinergics,Benadryl,oramantadine
Dystonia:musclespasmsofjaw,tongue,eyes.Laryngospasmspossible.Morecommoninyoung
males.TreatwithanticholinergicsorBenadryl
Akathisia:pacing,restlessness,describedasfeelingtheurgetomovearoundorhaving“crawling”
sensationunderskin.Treatedwithpropranolol,BZD,orclonidine
TardiveDyskinesia:occurabout6monthsafterinitiationofthemedication.Isrelatedtoincreased
sensitivitytoDAduetoreceptorchanges.Thusappearstobeclosertoamovementdisorderthat
occursduetoexcessDAdespitepresenceofDAblockingmedication.Presentswithabnormal
muscularjerkingoflimbs,trunkandperiorbital.Increaseswithstress.Morecommoninolder
females.Treatbydecreasingthemedicationordiscontinuing.AnticholinergicsworsenTD
NeurolepticMalignantSyndrome:fever,musclerigidity,autonomicsymptoms,increasedCPKand
acutementalstatuschange.Morecommoninmales.Canbelethal.Treatwithcooling,dantroleneor
bromocriptine,anddiscontinuetheincitingmedication
Non-EPSSideEffects(MoreCommoninLowPotency)
•
•
•
•
•
•
•
AlphaBlockade:orthostatichypotension
Anticholinergic:drymouth(treatwithsugarlessgum),constipation,sorethroat,urinaryretention
(treatwithbethanechol),blurredvision,confusion
Antihistamine:weightgainandsedation
Prolactin:sexualsideeffectslikeerectiledysfunction,priapism,increasedtimetoejaculation,
gynecomastia,impotence,andanorgasmia
Hepatic:jaundiceandelevatedLFTs(lessseverethanwithatypicals)
Cardiac:arrhythmiaandprolongedQTc
Agranulocytosis(monitorforfever,sorethroat)
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•
•
•
Epilepsyduetoloweredseizurethreshold
Skindiscolorationandphotosensitivityinchlorpromazine
Retinitispigmentosaandblindnessinthioridazine
Categories
•
•
•
HighPotency:fluphenazine(Prolixin),haloperidol(Haldol),thiothixine(Navane),trifluoperazine
(Stellazine)
MediumPotency:perfenazine(Trilafon),molindone(Moban),loxipine(Loxitane)
LowPotency:chlorpromazine(Thorazine),thioridazine(Mellaril)
ChoosingBetweenTypicals
•
•
•
•
•
•
•
•
Cardiacpatients:avoidlowpotency,especiallythioridazine(Mellaril)
Elderly:avoidlowpotencyduetoanticholinergicconfusion
Weightgain:molindone(Moban)andloxipine(Loxitane)havetheleastweightgain.Highpotency
haslessweightgain.P:Currentlymolindoneisoffthemarketduetolackofhighvolumeclinicaluse
Sexualsideeffects:mostcommoninthioridazine(Mellaril)
Sleep:chlorpromazineisasedatingtypicalandisagoodchoiceforaidingsleepinapatientwith
maniaorpsychosis
Mood:loxipine(Loxitane)hasmild5HTantagonism,makingitsimilartoatypical.Additionally,itis
metabolizedtotheTCAamoxepine.P:usefulwhenapatientcannotgetquetiapineoraripiprazole
duetocost.DAblockadeissimilartoquetiapineandthemoodcomponentislikearipiprazole.
Additionally,Stahlnotestheuseofloxipinefortheaugmentationofschizophreniamanagementwith
anatypicalantipsychotic.
Haloperidolhasadepotformulationthatlasts3-4weekstoensurecompliance.Fluphenazine
(Prolixin)hasadepotformulationthatlasts2weeks.P:alwaysdoanoraltestdosebeforegivinga
depotinjectionduetoriskofirreversibleEPSoncedepotisgiven.Consideravoidingfluphenazine
depotinmed-naïveyoungmuscularmalesduetoEPSrisk.
HaloperidolhasaliquidformulationtoaidineaseofadministrationandanIVformulation.Reminder
thatIVformulationsaremuchhigherpotencyduetolackoffirstpassintheliver.Thusstartwith
lowerdosesthanwoulduseinPOorevenIM(2-5mgIV).
AtypicalAntipsychotics
DuetotheprevalenceofEPSwithtypicalantipsychotics,theatypicalswerecreated.IfexcessiveDAblockade
leadstoEPS,thenlesssevereDAblockadewouldcauselessEPS.Thebestwayfoundtomodulatethe
amountofDAblockadewasthrough5HT.Normally,serotoninbindsto5HTreceptorsonDAneuronsand
inhibitsDArelease.Byblockingthese5HTreceptors,DAreleaseisnotinhibited.ThecombinationofDA
receptorblockadeplus5HTblockade(lessinhibition)leadstoanetincreaseinfreeDAcomparedwith
straightDAblockadeinthetypicals.Thus,theatypicalshavelessEPS.Additionally,theybettertreatthe
negativesymptomsofschizophreniathanthetypicalsdo.However,theatypicalsappeartohavemore
metabolicsideeffects(weightgain,diabetes)thanthetypicalsdoduetoeffectsonotherreceptors.
Additionally,theatypicalsmayhavemorelivereffectsandleukopeniathanthetypicalsdo.Themajorityof
theatypicalsarealsoapprovedbytheFDAfortreatingbipolarmaniaandmonotherapyforbipolardisorder.
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Clozapine
Quetiapine
Loxapine
Clozapine(derivedfromimipramine,adibenzazepine)isadibenzoxazepineOtherdibenzoxazepinesare
quetiapineandloxapine.Thesemedicationsallimprovemoodinadditiontopsychosis.
Risperidone(Risperdal):thefirstatypicaltobecomegeneric,thuslowercost.Inadditiontomaniaand
psychosis,itisapprovedforthetreatmentofaggressionandself-injuriousbehaviorinautisticchildren.Can
beusedinchildrenwithticdisorders(consideralsousinghaloperidol)orimpulsive/disruptivebehaviors.
Half-lifeis20hours;thusonce-dailydosingisfine.EquivalenttohaloperidolinD2bindingaffinitywithless
incidenceofEPSwhenkeptbelow6mgperday.Minimalalphaandmuscarinicaffinity.Hasanactive
metabolitethatisformedby2D6,thusinhibiting2D6(paroxetine,fluoxetine)leadstolessefficacyof
risperidone.HasmostPRLincreaseofallantipsychotics.WatchforpedaledemaandincreasedLFTs.Weight
gainis#3afterclozapineandolanzapine.Formulationincludespill,dissolvingMTabs,andRisperdalConsta
(depotpreparationlasting2weeks.Note:needoralrisperidonex3weeksafterstartConsta).P:usefulin
severeOCD,impulsecontrolissues,andbodydysmorphicsymptoms.
Paliperidone(Invega):theisolatedactivemetaboliteofrisperidone(i.e.,risperidoneisconvertedto
Paliperidoneinthelivernormally),whichmaybeabetterchoiceinhepaticallyimpairedpatients.Whileitis
consideredtohavelesssideeffectsthanrisperidone,paliperidonehasmoreQTcprolongationandrequires
lowerdosinginrenalimpairedpatients(asitisexcretedunchangedthroughthekidneys).Itexistsasan
immediatereleaseandadelayedreleasemedication(avoidingastricbypass)andalsooccursinadepot
formulation(Sustenna).Sustennarequiresnocontinuedoraldosingoncethedepotisgiven.Injectioninto
deltoidhasnearly30%higherplasmaconcentrationthatgluteal.Mostlikelyisa“metoo”drugwithnomajor
benefitoverrisperidone.
Olanzapine(Zyprexa):half-lifeaverages31hours,leadingtoonce-dailydosingisfine.Metabolizedby1A2,
thusfluvoxamine,cimetidine,andciprofloxacinincreaseolanzapineconcentrations(inhibitorsof1A2),while
carbamazepinereducesolanzapine.Weightgainandmetabolicsideeffectsarecommon(#2afterclozapine).
Canbeverysedatingandalcoholcoadministrationleadstoanincreasedolanzapineabsorptionby25%,
worseningsedation.Becomesgenericinlate2011.Formulationincludespill,dissolvingZydistabs,IM,and
depotRelprevv(injectionsq2-4weeks).
Quetiapine(Seroquel):half-lifeis7hours,thusBIDorTIDdosingisrecommended.WhileithaslessEPSthan
otheratypicals,itissedatingandhasweightgain.Isusedofflabelforthemanagementofanxiety,PTSDand
sleep.Hasorthostatichypotensioncommonly.HasanXRformulationwithequivalentbioavailability.Dilantin
increasesQuetiapine’sclearance5fold,thusconsiderhigherdosinginpatientsonDilantin.P:weightgain
appearstobesomewhatdosedependent.Ifusingitforsleep,onceexceeding200mgconsiderchangingto
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anothermedicationforsleep,likeTrazodone,VistarilorDoxepin.Additionally,becausetheweightgainis
metabolicinorigin,tellingthepatientthatthemedicationwillcauseweightgainduetoappetiteincrease
aloneisinaccurate.Itisimportanttohavethepatientmonitortheirweightwhileonmostoftheatypicals.
Ziprasidone(Geodon):half-lifeis5-10hours,thusBIDdosingneeded.Bioavailabilitydoubleswhentaken
withfood,preferablya500caloriemeal.Dueto5HT1AagonismandSSRI/SNRIproperties,ithassome
benefitintreatingoraugmentingdepressiontreatment.HaslessweightgainandEPSthanotheratypicals.
CommonsideeffectsincludesedationandQTcprolongation(morethanotheratypicals).ZiprasidonehasBID
dosingandexistsasacapsule(cannotbebrokeninhalf),liquid,andIM.P:whileziprasidoneisnotahighly
potentatypical,itisusefulintreatingMDDwithpsychosis.
Clozapine(Clozaril):likelythemosteffectiveantipsychotic.Half-lifeof12hours.Consideredtohavehigher
affinityforlimbicthanstriatalareas,comparedwithatypicals.Ismetabolizedprimarilyby1A2(increasedin
presenceoffluvoxamineorciprofloxacin).Sideeffectsincludeseveresedation,weightgain,sialorrhea,
agranulocytosis,QTcprolongation,andrequiresweeklyblooddrawsfor6monthstomonitortheANC.
DosingisheldifWBC<3000orgranulocytes<1500.Additionally,thismedicationisonlydispensedatcertain
pharmaciesandrequiresproofoflabstodispense.Thereisanationalclozapineregistrywhereallpatientson
themedicationarefollowedandtheirlabsreported.Inordertostartclozapine,thepatient’sinformation
mustbegiventotheregistryandpretreatmentlabsmustbenormal(lipids,CBCwithANC,Chem13and
EKG).Theriskofagranulocytosisis<1%inthefirstyearoftreatmentwithclozapine.TheriskofTDis
incrediblylowanditisthebesttreatmentforpsychosisthathasnotrespondedtootheragents.Itoccursin
pillanddissolvingtabletformulationsandisBIDdosing.Dosingstartsat25mgBIDandcanincreaseby25mg
perdaymaximum.Sialorrheamayrespondtoclonidine.Likerisperidone,isgeneric.P:lithiumcanbeusedto
raisetheANCinordertohelpwithclozapinetitration.Asimpledosingof600mgatnightofLicanhelp
improvetheANCenoughtostartorcontinueclozapine.
Aripiprazole(Abilify):unliketheotheratypicals,isaD2partialagonist,competingwithendogenousDA
(bothpostsynapticandpresynaptic)andbindslessrobustly.ThisisconsideredtobemodulationoftheDA
receptorratherthanblockade.ThenetresultisdiminishedDAactivityinthelimbicsystem(whichiselevated
inschizophrenia)andincreasedDAactivityinthefrontalandprefrontalareas(whichisconsideredlowin
schizophrenia).Inadditiontomaniaandpsychosis,itisindicatedforaugmentationofdepressiontreatment.
Thehalf-lifeisabout75hours;thusonce-dailydosingisfine.Metabolizedby3A4and2D6.Isastrong5HT2C
agonist(unliketheotheratypicals),whichmeanslessweightgain.Itisalsoastrong5HT-7antagonist,
improvingmood.Sideeffectsincludeakathisia,orthostatichypotension(alphablockade),nausea/GIeffects,
somnolenceorinsomnia.
Asenapine(Saphris):likeclozapine,hashigheraffinityforD3andD4receptorsthanD2receptors.Ithas
minimalanticholinergicsideeffects.Isassociatedwithakathisia,dizziness,sedation,andweightgain
(histamineaffinity).Metabolizedby1A2andisdosedBIDinasublingualformulation.Thepatientmaynot
eatordrinkfor10minutesafterdosing.Preliminarydrugcompanydatareportsresultsfrom1,500patients
butthereispaucityofpublisheddataonactualefficacy(themainpublishedstudyonlyevaluated174
patients).Thus,asenapinehasweightgain,sedation,mustbedosedsublingually,andisveryexpensive.
Thereislimitedpublisheddataontheefficacyonthismedicationascomparedwithotheratypicals.
Iloperidone(Fanapt):notstructurallyrelatedtoanyotheratypicals.HasmixedD2and5HT2antagonism
withlowaffinityforhistamineandmuscarinicreceptors.Metabolizedby2D6and3A4andthehalf-lifevaries
between18-37hoursbasedonthestrengthof2D6enzymes(longerhalf-lifeinpoormetabolizers).Avoidin
hepaticimpairment.ProlongsQTintervalasmuchasziprasidone.Itisalsoassociatedwithorthostatic
hypotension(alphablockade),dizziness,andsomnolence.Iloperidonehasminimalweightgain.PRLis
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increasedinover25%ofpatients.Duetoriskoforthostatichypotension,dosingmustbegradualover4days
inBIDscheduling.Consideringthatthismedicationwasfirstintrialsin1998andtookover10yearstobe
releasedaftermovingbetweenmultipledrugcompanies,likelyduetosubparefficacyresults.Thebottom
line:thismedicationissimilartoziprasidoneinQTcprolongationwithlessakathisiabutmoreweightgain.It
mustbetitratedslowlyduetoorthostatichypotensionandmanystudiesdonotshowittobeanybetter
thanexistingatypicals.
Lurasidone(Latuda):strongD2/5HT2antagonistwithminimalhistamineinteraction(thuslowweightgain).
Itdoeshavesedation,whichmayberelatedtostrong5HT-7antagonism(seebelow).Metabolizedby3A4.
Thereareonlyfour6-weektrialsofthismedicationsubmittedtotheFDA,thustheclinicaldataislimited.
OnestudysuggestedthatitupregulatesBDNFintheprefrontalcortex,suggestingthatthemedicationmay
be“pro-cognitive.”Hasonce-dailydosing,butmustbetakenwithfoodtobeabsorbed.Minimalweightgain,
noQTcissues.EPSisequivalenttootheratypicals.Furtherdataonlurasidoneefficacywillshowifthis
medicationisa“metoo”medication.
Anoteon5HT-7:someofthenewantipsychoticsareboasting5HT-7antagonism.Whilenotfully
understood,the5HT-7receptormaybeassociatedwithdepression.Medicationsthatblock5HT-7improve
depression.Additionally,theymayimprovehippocampus-mediatedactions,likememory.Manyofthe
atypicals(risperidone,ziprasidone)arepotent5HT-7antagonists.
MoodStabilizers
ThebasicmechanismofactionofthemoodstabilizersistoenhancetheactionsofGABAandreducethe
actionsofglutamate.Inthisway,bothseizuresandmoodswingsarecontrolled.Additionally,mood
stabilizerscanbeusedtoaidinthetreatmentofanxietyforsimilarreasons.Lithiumisthefirstknownmood
stabilizer,andismechanisticallydifferentfromtheothersinthatitdoesnotalsotreatseizures.
Regardinghistoricserendipity,lithiumwasfirstusedinthe1800sforthetreatmentofgout.Itwasknownto
helpdissolveurate,aparticleinitiallyblamedformaniaandpsychosis.Around1900lithiumwasabandoned
forthetreatmentofmaniaandwasnotrediscovereduntil1949byAustralianpsychiatristHenryCade.Due
tounderstandingthatdisorderssuchasthyrotoxicosiscouldbedetectedbymetabolitesinurine,Cade
examinedmanicpatients’urinefordetectableparticlesrelatedtomania.Hisstudyfocusedoninjecting
guineapigswithmanicpatienturinetoseeifbehavioraldisturbanceoccurred.Longstoryshort,theguinea
pigshewasinjectingwithmanicpatients’urinekeptdyingsohedecidedtoaddlithiumtotheurinetohelp
breakdownurate.Ultimatelyhediscoveredthatlithiumaloneledtocalmingofmania.
TheFDAdidnotapprovetheuseoflithiumforthetreatmentofmaniauntil1970.Strangely,inthe1930s-
50sifyouwantedtohaveaccesstolithium,itwasmosteasilyfoundasacommonreplacementfortablesalt
inpatientswithheartdiseaseORin7-UP.Seriously.Originallylabeledas“Bib-LabelLithiatedLemon-Lime
Soda,”7-UPcontaininglithiumwasmarketedspecificallyasahangovercure.
ValproicAcidwasfirstsynthesizedin1882fromvalerianasasolventfororganiccompoundthatwas
believedtobeinertmetabolically.Bythe1960sitwasdiscoveredthatmedicationsthathadlongbeen
consideredanticonvulsanthadnoabilitytopreventseizuresandthatthevalproicacidsolventhadbeenthe
activetreatment.
Lithium
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Indications:approvedforacuteandmaintenancetreatmentofmaniainadditiontoadjunctivetreatmentfor
depression.Itislessusefulinrapidcyclingormixedepisodesthanvalproicacid(VPA).Additionally,data
showsreductioninriskofsuicideinpatientstreatedwithlithium.Itcanbeusedinpregnancyandalthoughit
hasariskofEbstein’sabnormalitywhenusedinthefirsttrimester,thisriskisrelativelyminimal(general
population:1/20,000;Li:1/1,100,or0.1%).Thisriskreducesafterthefirsttrimesterandmustbeconsidered
againsta5%riskofneuraltubedefectwithVPAandtheriskofdangertothepatientandfetusifmania
continuesuntreated.Thusafterthefirsttrimester,lithiumisthemoodstabilizerofchoiceformaniain
pregnancy.
Profile:itdoesnotbindtoproteins,isnotmetabolized,andisexcretedinthekidneys.Half-lifeis18to24
hourswithsteadystatereachedinabout5days.Dosingshouldstartat300mgBIDorTIDandplasmatrough
drawnafter5daysofcontinuousdosing.Formulationincludesimmediatereleaselithiumcarbonate,450mg
extendedreleasetabs(Eskalith),andliquidlithiumcitrate.Therapeuticlevelaimsfor0.8-1.2andcanbe
dosedBIDorTID(oroncedailywithEskalith).Priortostartinglithium,baselineCBC,Chem13(including
renalfunction),TSH,EKGandHCGshouldbedone.
Sideeffects:includenausea/vomiting,sedation,weightgain,tremor(P:treatwithpropranolol),
hypothyroidism(15%female,4%male;P:iflithiumishelpful,consideruseoflevothyroxinetotreat
hypothyroidism),renaltubulardamage,bradycardia,AVblock,sexualdysfunction(duetoincreased5HT),
alopecia,acneandneurologicsymptomsincludingconfusion,coma,stupor,anddeathinthecaseoftoxicity.
Regardingrenalsymptoms,lithiumisassociatedwithNephrogenicDiabetesInsipiduswherelithium
antagonizestheeffectsofADHinthedistalkidney.Thesymptomsincludepolyuriaandpolydipsiaand
ultimaterenalfailureifnotresolved.Theprimarytreatmentisdiscontinuationoftreatmentoradditionof
HCTZ(thiazidediuretic).Thisiscounterintuitiveasthiazidesarediureticsandshouldincreasewaterloss.Itis
postulatedthatlithiumcausesthedistalkidneyaquaporinstobedownregulatedandlosesensitivitytoADH.
Thiazides,inadditiontoeffectsonNaintheproximalkidney,increaseexpressionofdistalaquaporins,thus
reversingtheeffectsoflithium(Loffingetal).BecauseHCTZdecreasesNAreabsorption,itultimatelyleadsto
increasedlithiumabsorption(apositiveion)andcanbeassociatedwithlithiumtoxicity.Thuslithium
coadministeredwithHCTZmustbedecreasedindose.
DrugInteractions:lithiumtoxicityismorecommoninthepresenceofNSAIDs,diuretics,ACE-Inhibitors,
hyponatremia,anddehydration.Treatlithiumtoxicitywithdialysis,gastriclavageorkayexalate,notcharcoal.
Caffeineisknowntodecreaselithiumbyenhancingitsrenalclearance(P:stoppingcaffeineleadstoworse
lithiumtremorfromhigherplasmaconcentration).LithiumcombinedwithSSRIscancauseserotonin
syndrome.
ValproicAcid
Indications:acutemania(includingrapidcyclingandmixedepisodes),maniasecondarytotraumaticbrain
injuryandorganicissues,aggressionandimpulsivity,migraines,generalepilepsy.P:lithiumisbetterat
treatingdepressionandsuicidalitywhileVPAisbetterattreatingmoresevereformsofBipolarDisorder.
Additionally,theelderlymaytolerateVPAbetterduetolesscognitiveandrenaleffects.
Profile:highlyproteinboundwithunbounddrugcrossingthebloodbrainbarrier.Half-lifeis10to16hours.
Metabolismisprimarilybyglucuronidationwithsomeoxidativemetabolism(producinganactivemetabolite)
andminimalP450metabolismonVPA.Valproicacid(Depakene)iscombinedwithasecondidentical
moleculeandNatoformdivalproexsodium(Depakote)whichisavailableasanentericcoatedtabletto
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minimizeGIsideeffects.Depakotealsoexistsin“sprinkle”formulation(itisneithercolorfulnortasty—a
totalletdown),aonce-dailyExtendedReleaseFormulation(withupto30%lessbioavailability),andIV
formulation.
Depakeneisavailableintabletandliquidformulation.DosingisgenerallyBIDorTIDandtroughlevelsare
drawn3daysaftercontinuousdosing.Therapeuticlevelsareconsideredbetween50-200fortheprevention
ofseizures,withmanysideeffectsstartingaftercrossing100.
ValproicAcid
DivalproexSodium
SideEffects:nausea/vomiting,pancreatitis,elevatedLFTs,liverfailure,tremor,sedation,neutropenia,
thrombocytopenia,hairloss,weightgain,polycysticovariansyndrome,neuraltubedefectinpregnancy.P:
overall,thelistofsideeffectsislongerandworsewithlithiumthanwithVPA.
Drug-DrugInteractions:proteinbounddrugsdisplaceVPA,makingitmoretoxic/crossBBBmorereadily.This
includesinteractionwithaspirin,carbamazepine,anddiazepam.LithiumplusVPAhasincreasedriskof
tremor.AntipsychoticsplusVPAhavemorecombinedsedation(thesameistrueforalcohol).RegardingVPA
andoxidationintheliver,VPAwillincreasecarbamazepine,diazepam,amitriptyline,andPhenobarbital.VPA
decreasesphenytoinanddesipramine.VPAmayaugmentanticoagulantsandshouldbemonitoredclosely.
FluoxetinemayincreaseVPAlevels.Mostimportantly,VPAdecreasesglucuronidationoflamotrigineleading
todoubledlevelsandhighriskforStevens-Johnsonsyndrome.
Carbamazepine(Tegretol)
Indications:structurallysimilartoimipramine,carbamazepine(CBZ)wasintendedinitiallyasan
antidepressant.Inthelate1960sitwasrecognizedastreatmentfortrigeminalneuralgiaandtemporallobe
epilepsy(complexpartialseizures).Isconsideredsecond-linetreatmentforacutemaniaafterlithiumand
VPA.Itcanalsobeusedinrefractorydepressionandtotreataggression.Itshouldbeavoidedinpregnancy
duetocraniofacialabnormalitiesandspinabifida.
Profile:theaveragehalf-lifeis26hoursanditisbetterabsorbedwithfood.CBZinduces(helps)P450enzyme
3A4.ThismeansthatanymedicationstakenwithCBZthatrequire3A4tobreakthemdownwillhave
decreaseddose.Example:warfarinisbrokendownby3A4.IftakenwithCBZ,3A4actionisincreasedand
warfarinisbrokendownmorethanexpected.Thiscanleadtolossofwarfarineffect(increasedblood
clotting—i.e.,bad).Additionally,CBZisalsobrokendownby3A4.WithchronicadministrationofCBZ,the
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half-lifediminishesto12hoursduetoinductionofitsownmetabolismby3A4(autoinduction).Thusafter35weeks,3A4breakdownofCBZincreases,requiringincreaseddosingandcanleadtounpredictableblood
levelsofCBZduringthistimeduetoautoinduction.Afterinitialprocessingintheliver,CBZhasanactive
epoxidemetabolitethatisthestrongerformofthemedication.Thisactivemetaboliteisassociatedwith
betteranticonvulsantpropertiesandlikelymoresideeffectsthanrelatedmedicationoxcarbazepine(see
nextsection).WhereaslithiumandVPAworktoincreaseGABAanddecreaseglutamate,CBZworksmoreon
inactivatingNachannelstostopdepolarization.Duetoirregularabsorption,CBZneedstobetakenTID,even
withfood.AnXRformulationexiststhatcanbetakenjustonceortwiceperday.Generallydosingstartsat
200mgBIDandincreasesby200mgevery2to3days.Thetargetdoseis1,200mgperdayandbloodlevels
areoftenunreliableduetotheepoxidemetabolitenotbeingthefocusofdrugmonitoring(detectsboth
parentandmetaboliteindiscriminately)andtheriskofautoinduction.
SideEffects:mildnausea,sedation,vertigo,diplopiaaremostcommonandaredosedependentwith
diminishingsideeffectsovertimeasthedrugdiminisheswithautoinduction.Weightgainisminimal.More
seriously,itcancauseaplasticanemiaoragranulocytosisthatisnotdosedependentin1/125,000.Benign
leukopeniaisseeninupto2%ofpatientsanddoesnotcorrelatewithmoreserioussideeffects.Monitorfor
fever,sorethroat,rash,petechiae,bruisingandeasybleeding.Additionally,CBZcancausehepatitiswith
elevatedLFTs.Upto15%ofpatientsonCBZdevelopabenignmaculopapularrashinthefirst3weeksof
treatment.TheconcernistheriskoftoxicepidermalnecrolysisandStevenJohnson’s,whichalsomay
presentwitharash.StoppingCBZremovestherashandinpatientswithsignificantresponsetothe
medicationmaybere-trialedonCBZaslongasrashwastheonlypresentingsymptom(nomalaise,oral
lesions,flusymptoms).CBZcancreatesymptomsoppositeoflithiumwithhyponatremiaandwaterloading
(similartoSIADH),butcannotcorrectabnormalitiesinlithiumuse.BeforestartingCBZ,CBC,Chem13
includingrenalfunction,andHCGareneeded.
Drug-DrugInteractions:duetoCYP3A4induction,itreducestheconcentrationsofmanydrugs,including
antipsychotics(haloperidol,clozapine,olanzapine,aripiprazole,quetiapine),TCAs(amitriptyline,
clomipramine,desipramine,doxepin,imipramine),benzodiazepines(alprazolam,clonazepam),seizure
meds/moodstabilizers(lamotrigine,VPA,phenytoin,ethosuximide)andothers(warfarin,Tylenol,
methadone,doxycycline,oralcontraceptives).Medicationsthatinhibit3A4causeCBZtoxicity,including
fluoxetine,fluvoxamine,cimetidine,verapamil,diltiazem,gemfibrozil,andgrapefruitjuice.CBZisdiminished
byphenytoinandETOH(3A4inducers).WhencombinedwithVPA,CBZisdisplacedfromplasmaproteins,
leadingtoincreasedriskoftoxicity.P:generally,ontests,whenaskedaboutCBZ,thecorrectansweristhatit
decreasesthedoseofwhatevermedicationadministeredwith.
Oxcarbazepine(Trileptal)
Indications:approvedfortreatmentofepilepsy,NovartispledguiltyinSeptember2010formarketing
oxcarbazepineforthetreatmentoftrigeminalneuralgiaandBipolarDisorderwithoutapprovalorsufficient
data.
Profile:unlikeCBZ,absorptionisrapidanddoesnotrequirefood.Theactivemetaboliteisamonohydroxide
withahalf-lifeof9hours.Intrials,dosingwasstartedat300mgatnightandincreasedtoatotalof1,200mg
perdayinBIDdosing.
SideEffects:sedation,nausea,dizziness,vertigoarecommon.DoesnothavetheserioussideeffectsofCBZ.
Hyponatremiacanoccurin3%ofpatientsandmustbemonitoredcloselyinitiallyasitmaynotpresentwith
symptomsandcanleadtoseizuresandconfusion.
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Drug-DrugInteractions:minimalcomparedwithCBZ.Mayinduce3A4mildly,thusavoiduseoforal
contraceptivesasprimaryformofbirthcontrol.PhenytoinandETOHwilldecreasethedoseof
oxcarbazepine.
Lamotrigine(Lamictal)
Indications:helpfulinreducingdepressiveepisodesinmaintenancetreatmentofBipolarDisorder,partial
epilepsyandLennox-Gastautseizures.OtherreportsusinglamotrigineforaggressioninRhett’sdisorder,
Alzheimer’sandinmentallyretardedpatients.Thereisnodatatoshowthatitcanmanageeitheracute
bipolardepressionormania.
Profile:initiallydevelopedasafolateantagonist(elevatedfolateinducesseizures),wasnotedtoblockNa
voltagechannelslikeCBZ/Trileptal.Additionally,itinhibits5HTreuptaketoincrease5HTconcentrations.
Half-lifeis25hoursandhas98%bioavailability.Lamotrigineismainlymetabolizedbyglucuronidationinthe
liver.Duetoavariedrateofabsorption,BIDdosingisrecommended.Noefficacyhasbeenseenindoses
above200mgforthetreatmentofbipolardisorder.Alone,itisdosed25mgadayfor2weeks,then50mga
dayfor2weeksthen100mgadaybyweek4.WhengivenwithCBZ(induces/decreaseslamotrigine),the
abovedosingscheduleisdoubled(i.e.startwith50mgperday).WhencoadministeredwithVPA(increases
lamotrigine),thedosingscheduleischangedto25mggiveneveryotherdayfor2weeks,then25mgperday
for2weeks,then50mgbyweekfourtoincreaseby25mgperweek.Lamotrigineexistsinanorally
dissolvingtablet(ODT)andinchewabletablets.
SideEffects:overalliswell-tolerated.Minimalsedationorweightgain.Milddizzinessandnauseaare
possible.Somedatashowsthattakinglamotrigineafter5pmleadstodisruptionofstage3sleep(restorative
sleepandwheremostparasomniasoccur).ThemainconcernisrashassociatedwithStevenJohnson’s
syndrome.About8%ofpatientsonlamotriginedevelopabenignmaculopapularrashwithinthefirst4
monthsoftreatment.Theriskofaseriousrashisabout0.08%.Despitethislowrate,thepresenceofany
rashshouldleadtodiscontinuationofthemedication.TreatmentwithconcomitantVPAandtreatmentin
patientsunderage16isassociatedwithhigherriskofseriousrash.
Drug-DrugInteractions:asmentioned,VPAincreaseslamotrigineconcentrationsandshouldbemonitored
closelyoravoided.CBZ,phenytoin,andPhenobarbitaldecreaselamotriginebyupto50%.Inthepresenceof
oralcontraceptives,lamotrigineitselfmaybedecreased,butnotthereverse.
Gabapentin(Neurontin)
Legal:discussionshouldbeginhere.Over90%ofprescribedNeurontinisoff-labeluse.Seriously.
Additionally,Pfizerwasfined$430MILLIONincriminalfinesrelatedtoillegalmarketingofthemedicationfor
off-labelusein2004.Afterpayingthat,continuedoff-labeluseandmarketingledtoaKaiserPermanente
suitforanadditional$141MILLIONinMarch,2010.Thus,gabapentinhasbeenmarketedforBipolar
Disorder,migraines,fibromyalgia,sleep,anxiety,diabeticneuropathy,andHIVneuropathy.TheFDAhasonly
everapprovedgabapentinforadd-ontherapyforthetreatmentofseizures.JustasidenoteaboutPfizer:in
September2009theUnitedStatesDepartmentofJusticeforcedPfizertopleadguiltytothelargestcriminal
penaltyeverimposedinAmericanhistory:$2.3BILLIONincivilandcriminalchargesforillegalmarketingof
fourmedications,includingGeodonandLyrica.
Indications:addontherapyfortreatmentofseizures.Otheroff-labelusesareabove.
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Profile:unboundbyproteinsandisnotappreciablymetabolized.Eliminatedrenally.IncreasesGABAand
5HT.Dosingisusuallystartedat100mgTIDandgraduallyincreasedforatotalof2,700mgperday.Existsas
capsules100,300,and400mgaswellas600and800mgtablets(usefulingastricbypass).Dosageis
decreasedinpatientswithimpairedrenalfunction.Bioavailabilitydiminishesby20%whengivenwith
antacids.
SideEffects:somnolence,ataxia,diplopia,anddizziness.Sideeffectsaredosedependent.
Pregabalin:has6xtheGABAbindingaffinityofgabapentin,isthefirstmedicationeverapprovedbytheFDA
specificallyforthetreatmentoffibromyalgia.Standarddosingis50mgBIDorTIDandcomesincapsulesor
strawberryflavoredsyrup.HastheabilitytopotentiatebenzodiazepinesandopiatesandisaScheduleV
drug.
Topiramate(Topamax)
Indications:antiepileptic,migraines,smokingcessation(especiallyinalcoholics),tremor,bulimiaandbinge
eating,somestudiesshowdecreasedself-mutilatorybehaviorinborderlinepersonalitydisorder,
managementofanxiety
Profile:isrenallyexcreted70%andneedstobedecreasedindoseinpatientswithrenalissues.Half-life24
hours.IncreasescerebralGABA.Dosingbeginsat25mgatbedtimeandgraduallyincreasestoBIDdosing.
SideEffects:paresthesia(P:especiallynumbnessandtinglinginfingertipsandperipheralextremities.
Sometimesimprovedbyqhsdosing),weightloss,sedation,dizziness,word-findingdifficulties(P:generally,
above100mgthisisseen.Patientscallit“dopamax”),lowersserumbicarbonatethroughcarbonic
anhydraseinhibition(causingcardiacarrhythmiasandrenalstonesin1.5%).
Drug-DrugInteractions:increasesphenytoinandVPAlevels.CBZandphenytoindecreasetopiramatelevels.
Avoidwithothermedicationsthatarecarbonicanhydraseinhibitors(acetazolamide/Diamox-glaucoma,
altitudesickness,pseudotumorcerebri).
Antidepressants
TCAs
Structurallyrelatedtothetypicalantipsychoticchlorpromazine,imipraminewasinitiallydesignedasa
medicationtomanageschizophrenia.However,itwasnotedthatthenewmedicationinexacerbatedmania
(upto25%ofpatientswithpre-existingBipolarDisorderwillhavemaniaorhypomaniawhenon
imipramine).Afterthiswasdiscovered,imipraminewasusedinthelate1950sasanantidepressant.Manyof
theTCAsarestructurallyrelatedtoimipramine,whichisinitiallyderivedfromtheantihistaminemethylene
blue.Theterm“tricyclic”and“tetracyclic”referstothe3and4ringsinthechemicalstructuresofthese
medications.
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TCAbasics:thethreeringedTCAsaredividedintotertiaryandsecondaryamines.Tertiaryamineshavehigh
affinityforblocking5HTreuptake.SecondaryamineshavehighaffinityforblockingNEreuptake.
Interestingly,tertiaryaminesaremetabolizedtosecondaryaminesintheliver.Thus,apersontakingthe
tertiaryTCAamitriptylineisgettingamedicationthatisstronglyserotonergicyetstillsomewhat
noradrenergic.Inthisway,theCAsserveasthefirstSNRIs.
Tertiary
Secondary
Clomipramine(Anafranil)
Amitriptyline(Elavil)→
Nortriptyline(Pamelor)
Trimipramine(Surmontil)
Imipramine(Tofranil)→
Desipramine(Norpramin)
Doxepin(Sinequan)
Protriptyline(Vivactil)
Indications:MDD(butaremorelikelytoinducemaniathanSSRIs),PanicDisorderwithAgoraphobia
(imipramineisbest),GeneralizedAnxietyDisorder(especiallyimipramineanddoxepin),OCD(clomipramine
isFDAapproved),andchronicpainandmigraine(amitriptylineisusedmostforthis).Imipraminecanbeused
totreatchildhoodenuresisbutduetoreportsofsuddendeathinchildrenandadolescents,TCAsshouldbe
avoidedinthispopulationifpossible.
Profiles:inadditiontoinhibitingreuptakeof5HTandNE,TCAscanantagonizemuscarinicacetylcholine,
histamine,andalpha1and2receptors.Additionally,NaandCachannelscanbeblocked,leadingtocardiac
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sideeffects.TCAsaremorelikelytocauseanticholinergicsideeffectsthanSSRIsbutarelesslikelytocause
sexualsideeffects,weightgain,andsleepdisturbancethanSSRIs.
•
•
•
•
•
•
Clomipramine:mostserotonergic
Amitriptyline:mostanticholinergicandalpha
Desipramine:mostnoradrenergic,lowanticholinergic
Nortriptyline:lowanticholinergic
Doxepin:mostantihistamine
Protriptyline:closesttonortriptylinebutmaybemorenoradrenergic
Pharmacokinetics:absorptioninsmallintestineisrapid.Half-livesvaryfrom10-70hourswithmostTCAs
abletobegivenonce-daily.Nortriptylineanddoxepinexistinliquidsolutions.
Metabolism:hepaticmetabolismfocusesprimarilyondemethylationandhydroxylation.ThetertiaryTCAs
aredemethylatedby2C19andotherenzymes,leadingtotheformationofsecondaryTCAs.Example:
clomipramine→desmethylclomipramine,asecondaryTCA.Inthecaseofamitriptylineandimipramine,they
areconvertedtothesecondaryTCAsnortriptylineanddesipramine.Secondaryaminesareactivecompounds
thatarehydroxylatedinthelivertoactivehydroxymetabolites.Duetothemultiplemetabolitesfloating
aroundandthehighvariabilityfrompersontoperson(think:differentenzymenumbersandfunctionality),
mostoftheTCAscannotbemeasuredinserumreliably.ThemainTCAsthatareassociatedwithareliable
serumlevelthatcorrelatestotherapeuticresponsearedesipramine,nortriptyline,andimipramine.P:For
nortriptyline,plasmalevelsbetween50-150aremoreeffectivethanlevelsbeloworabove.Thisiscalleda
curvilineartherapeuticwindow.Inthepresenceof2D6inhibitors,TCAscanraisetotoxiclevels(fluoxetine,
paroxetine,sertraline,cimetidine).
SideEffects:
•
•
•
•
•
•
CNS:deliriumduetoanticholinergicandantihistamineeffects,especiallywithamitriptyline.
Increasedriskofseizures,upto2%withclomipramine
Anticholinergic:drymouth,blurredvision,constipation,urinaryretention.Symptomsmaybe
reversedwithbethanechol.Amitriptylineandclomipraminearemostcommon.Avoidinnarrowangleglaucoma(isfineinchronicopen-angleglaucoma)
Antihistamine:doxepinismostpotent(butstilllessthanmirtazapineandolanzapine);
Cardiovascular:orthostatichypotensionduetoalpha1blockadeispresentwithmanyTCAs.Least
withnortriptyline.Asaclass,theTCAshavetypeIantiarrhythmicqualitieswithQTcprolongationand
shouldbeavoidedincardiacpatients
Hepatic:increasedLFTsareassociatedwithimipramineanddesipramine.Generallyassociatedwith
AST>>ALT.Acutehepatitiscanbefatalandmaybeseenin0.1%ofpatients
Overdose:deathoccursastheresultofcardiacarrhythmia.Afteracetaminophen,TCAsarethemost
lethalcauseofODintheUS,withamitriptylinedeathsexceedingtotalfatalitiesofallTCAscombined.
Today,ODonSSRIsis4.5xmorecommonthanTCAs.However,theratesofdeathsofSSRIsinOD(1.5
deaths/1,000OD)aremuchlowerthanTCAs(8.5deaths/1,000OD).
TetracyclicAntidepressants
SimilartotheTCAs,thetetracyclicsbindto5HTandNEtransporterstopreventreuptake.Amoxapineis
consideredbysometobeatricyclicantidepressantasitstructurallyhas3ringswithafourthringasaside
group.
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Amoxapine
Maprotiline
Amoxapine(Asendin):derivedfrommid-potencyantipsychotic,loxapine.Amoxapineincreases5HT,NE,and
blocksDA.ItistheonlyTCA/tetracyclicwithbothantidepressantandantipsychoticproperties.Hasanactive
metabolite.Half-lifeis8hours,buttheactivemetabolitehasahalf-lifeof>30hours.MayhaveTDandmay
havegreaterriskofseizuresthanotherTCAs.
Maprotiline(Ludiomil):greatlydiffersfromtheothersinthatitlacks5HTreuptakeinhibitionandprimarily
actstoinhibitNEreuptake.Isastrongantihistamine,thusissedating.Islessanticholinergicandalpha
blockingthanamitriptyline.Half-lifeis30--60hours.
MonoamineOxidaseInhibitors
Inthe1950sanantituberculosisdrug,isoniazid(INH),wasfoundtohaveantidepressantproperties.
Ultimately,INHshowedquickresistancetoactiveTBandisgenerallyusedinpreventionandaugmentation
oftreatmenttoday.Additionally,INHhasnoMAOinhibition.Isoniazidwasaltered(simpleadditionofNisopropylgroup)tocreateiproniazid(Euphozid)andapprovedforthetreatmentofdepressionin1958.This
medicationwasanMAOI,andwasthefirstantidepressantevermarketed,beatingimipraminenarrowly.
Threeyearslaterin1961itwasremovedfromthemarketduetohepatotoxicity.Thismedicationpavedthe
wayforotherMAOIswhichwereusedsteadilyuntiltheadventoftheSSRIs.Thesecond-linestatusofthe
MAOIscurrentlyisrelatedtosafetyandsideeffectprofile,notefficacy.Currently,MAOIsavailableinclude
phenelzine(Nardil),isocarboxazid(Marplan),tranylcypromine(Parnate),rasagiline(Azilect),moclobemide
(Manerix)andselegiline(Eldepryl).In2006,atransdermaldeliveryofselegilineforthetreatmentof
parkinsonismwasintroduced.
ReviewofMAO:theseenzymesarefoundontheoutermitochondrialmembranes,wheretheydegrade
monoamineneurotransmitters(NE,5HT,DA,Epi,Tyramine).MAOImedicationsactintheCNS,theGI
system,theliver,andthesympatheticnervoussystem.MAO-AbreaksdownNE,5HT,andEpinephrine.DA
andtyraminearebrokendownbyMAO-AandMAO-B.
Indications:MDD,somedatamayshowthatphenelzinemaybettertreatatypicaldepression(hypersomnia
andhyperphagia)thanTCAs,maytreatdepressioninBipolarDisorderbetterthanTCAswithless
hypomania/mania,anxiety,phobias,pain,migraines,depressionassociatedwithTBI.Tranylcyprominewas
includedintheSTAR*Dtrialsasaneffectiveoptionintreatment-resistantdepression.
Profile:phenelzine,tranylcypromine,andisocarboxazidhavehalf-livesrangingfrom2-3hoursbuthave
tissuehalf-liveswithlongertimes.TheyirreversiblyinactivateMAOIs,thustheeffectcanlastupto2weeks,
evenwithasingledose.MoclobemideisareversibleMAO-Ainhibitor,andhaslesssideeffectsandless
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21
dietaryrestrictions.ItisnotapprovedforuseintheUnitedStatesatthistime.Selegiline,phenelzine,and
tranylcyprominearestructurallyrelatedtoamphetamines,thushavestimulanteffectsinthebrain.
SideEffects:orthostatichypotension,insomnia,weightgain,paresthesia(possiblyfrompyridoxine
deficiency),andinductionofmania.WhenswitchingfromanirreversibleMAOItoanotherantidepressant,it
isimportanttogivea14-daywashoutperiodduetolossofMAO.
DietaryEffects:firstnotedasheadaches,seenmorecommonlyintranylcypromineandlessinphenelzine.
Tyramine,presentinmanyfoods,isusuallybrokendownbyMAO.InthepresenceofMAOIs,itisnotbroken
down,leadingtohypertensivecrisisandothersymptoms.Symptomsmayincludehypertension,sweating,
chills,headache,nausea,pyrexia,dilatedpupils,stiffneck,andrestlessness.Thiscanprogresstoalterationof
consciousness,fever,cerebralhemorrhage,anddeath(0.02%).TreatmentwithCachannelblocker,
nifedipine,ishelpful.Foodstoavoidincludecheese(exceptcreamcheese),favabeans,overripefruit,sherry,
sauerkraut,MSG,pickedfoods,redwine,andtousecaffeine,coffee,chocolate,tea,andbeerinmoderation.
Selegiline(Emsam,L-deprenyl,Eldepryl):anirreversibleMAO-BinhibitorusedprimarilytotreatParkinson’s
asanadjuncttoL-Dopatreatment.IntestinaltyramineinteractionswithMAO-BaremuchlessthanMAO-A
andasaresult,selegilinerequireslessfoodrestrictions.Sideeffectsofnauseaandlightheadednessare
minimal.DuetobeingmetabolizedtoL-methamphetamine,themedicationwillhaveapositiveUDS.In
additiontoaregulartablet,itexistsasanorallydissolvingtabandatransdermalpatchthatdeliversasteady
6mgper24hours,marketedunderthenameEMSAMforthetreatmentofdepression.Thetheorybehind
selegilinefordepressionisrelatedtostudiesfromthe1960swheretheD-isomerofselegiline(D-deprenyl)
showedstrongantidepressantpropertieswhenhighdosesofselegilinewereused.NEandDAincreaseswere
notedwiththeisomer.Inrecenttrialsusingoralselegilineforthetreatmentofdepression,requiredhigh
dosesledtoalossofselectivityforMAO-B,thushavingaffinityforMAO-BandintestinalMAO-A,leadingto
tyramineinteractions.ThetransdermalpatchwasastrategycreatedtobypasstheintestinalMAO-A
responsiblefortyraminereactions.Resultsforthetreatmentofdepressionwiththepatcharemixed,with
somestudiesshowingefficacyandsomeshowingnobenefitoverplacebo.
SelectiveSerotoninReuptakeInhibitors(SSRIs)
In1970,EliLillyandCompanybeganresearchon3-Phenoxy-3-phenylpropylamine,astructuresimilarto
diphenhydramine(knownatthetimetohavesomeantidepressantproperties).Overthenext2years,many
derivativesofthiscompoundwerecreating,ultimatelyleadingtothediscoveryoffluoxetine.Themedication
enteredthemarketin1986.Lillyresearcherspublishedapaperentitled“Prozac,thefirstselectiveserotonin
reuptakeinhibitorandanantidepressantdrug.”Forthenext20years,EliLillystronglymarketedProzacinto
popularcultureasthefirstSSRI.Inactuality,thefirstSSRIwaszimelidine(nowbannedforcausingGuillainBarresyndromeandothersometimesfatalsideeffects).Interestingly,fluvoxamineenteredthemarket2
yearspriortofluoxetine.Thus,“Prozac,thefirstSSRI”continuesinpublicknowledgedespitetheinaccuracy
(“Prozac,thefirstSSRImarketedintheUSA”wouldbeaccurate).
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22
Diphenhydramine(Benadryl)
Fluoxetine(Prozac)
Indications:MDD(allexceptfluvoxamineareapprovedbytheFDAforMDD),depressioninpregnancyand
postpartumdepression(over70%ofpatientswithMDDrelapseintodepressionupondiminishingor
discontinuingtheirSSRIduringpregnancy.Studiesfollowingchildrenexposedtofluoxetineinuteroshowno
relateddecreasesinIQ,language,orbehavioralissues),depressionintheelderly(P:avoidparoxetinedueto
anticholinergic),OCD(fluvoxamine,paroxetine,sertraline,andfluoxetineareFDAapproved.P:usehigher
dosesthanusedinMDD),panicdisorder(paroxetine,sertraline),PTSD,GAD,BulimiaNervosa(fluoxetine,
generallyover60mg),Anorexia(lessdropoutfromtreatmentandbettertreatmentofcomorbiddisorders
withfluoxetine),PremenstrualDysphoricDisorder(EliLillymarketedfluoxetineasSarafemintheearly1990s
asthepatentforProzacexpired.Literallypinkandpurplefluoxetinecapsulewithanewlogo.Intrials,
sertralineandfluoxetineworkequallywell).Inchildren,theFDAhasapprovedfluoxetineforthetreatment
ofdepressionandfluoxetine,fluvoxamine,andsertralineforthetreatmentofOCD.
BlackBox:in2004theFDAissuedablackboxwarningfortheuseofSSRIsinpatientsundertheageof24.
Thiswasbaseduponmeta-analysesthatshowedincreasedriskofsuicidalthoughtsandbehaviors,in
additiontoaggressionandhostilityinchildrentreatedwithSSRIs.Whilenotissuedinthetreatmentofthe
adults,theblackboxiswell-knowntomanypatientsandisasubjectofconcerninthegeneralpublic.All
depressedpatientsshouldbecloselymonitoredinthefirst1-2weeksofSSRItreatment.
Pharmacokinetics:seethesecondchartbelowforthehalf-livesofthevariousSSRIs.RegardingCYP
interaction,fluvoxaminehasthemostinteractionwith1A2,2C,and3Ainhibition(withminimal2D6
inhibition).Fluoxetineandparoxetinearethestrongest2D6inhibitors,withsertralinehavingmoderate
inhibition.
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23
Pharmacodynamics:citalopramandescitalopramarethemostselectiveinhibitorof5HTreuptake,having
littleinhibitionofDA,NE,histamine,orGABA.FluoxetineweaklyinhibitsNEreuptakeandbindsto5HT2C.
SertralineweaklyinhibitsNEandDAreuptake.Paroxetinehassignificantanticholinergicactivityathigher
doses.
DrugInteractions:2D6inhibitorswillslowthemetabolismofcarbamazepine,diazepam,phenytoin,and
antineoplasticagents.Sertralinemaydisplacewarfarinfromproteins,leadingtoincreasedPTT.Fluvoxamine
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24
increasesconcentrationsofmultipleBZD,warfarin,clozapine,carbamazepine,methadone,propranolol,and
diltiazem.Ithaslittleinteractionwithlorazepam.
SideEffects:
•
•
•
•
•
Sexualsideeffects:themostcommonsideeffectwithlong-termuseoftheSSRIs,withincidenceof
50-80%.Treatmentincludesdecreasingthedose,addingbupropion(increasesDA)orbuspirone
(antagonismof5HTviaautoreceptor),oruseofsildenafil.
GI:nausea,diarrhea,vomitingaremostcommonwithsertralineandfluvoxamine.Medicated
through5HT3.Paroxetineisassociatedwithconstipation(anticholinergic).Upto30%ofpatientson
SSRIwillgainweight,especiallywithparoxetine.
CNS:increasedanxiety(fluoxetine),insomnia(fluoxetine)andsedation(variedwithmanyofthe
SSRIs),emotionalblunting(feelingsofapathy,inabilitytocry,“zombie”effect),seizures(0.2%),and
EPS.
Hematologic:caninhibitplateletbinding,leadingtobruising(P:seencommonlywithsertraline)
Serotoninsyndrome:apotentiallyfatalconditioninvolvingdiarrhea,restlessness,agitation,
autonomicinstability,hyperthermia,myoclonus,rigidity,delirium,andcoma.P:onexaminations,
clinicallydistinguishingbetweenNMSandSerotoninSyndromegenerallycomesdowntomyoclonus
inSerotoninSyndrome.Treatmentisremovaloftheoffendingagents,nitroglycerine,dantrolene,
BZD,cooling,andpossiblyventilation.
PereauBasicsonSSRIs:duetothemajorityoftheSSRIsexistingingenericformulation(exception:
escitalopram),themedicationswecommonlyprescribetodaydonothavethesamesideeffectsandprofiles
oftheoriginalbrandmedications.AgenericmedicationisrequiredbytheFDAtohave70%bioavailabilityof
theoriginalbrandmedication.Thus,whenapatientswallowscitalopram,theamountofdrugintheserum
hastobe70%ofwhatwouldbepresenthadtheyswallowedCelexa.That’sit.Agenericmedicationdoesnot
havetobemadewiththesamematerials,isnotrequiredtohaveasimilarsideeffectprofile,andmaynot
havethesameefficacyduetothepossibilityof30%lessbioavailable.ImagineapatientstableonWellbutrin
XL300mg(maxdose).Afewyearslaterthemedicationbecomesgenericandthepatient’sinsurance
changestothegenericbudeprionXLduetolowercost.Theinsurancecompanyisnotrequiredtocontinueto
providethepatientwithWellbutrinXLbecausetheFDAhasapprovedthegenericbudeprionXLasequivalent
tothebrandmedication.Asaresult,thepatientnownotesthathefeelsmoredepressed(lossof30%ofhis
medication)despitemaxdoseofthemedication.Hehasterribleheadachesandirritabilitythatwerenever
presentontheoriginalmedication.Hecallshispsychiatristandsaysthathewantstogobackonthebrand
WellbutrinXL.Heisinformedthathisinsurancecompanywillnotpayforthemedicationasitnowhasa
genericformulationandthathecaninsteadpay$140amonthoutofpockettogetWellbutrinXL.Generics
suck.Butit’shardtoarguewith$4aprescription.
SomeObservationsontheGenericMedicationsWeNowPrescribe
Fluoxetine(originallyProzac):havenotedthatsomepatientsgettiredonthemedicationandbenefitfrom
pmdosing.Whileconsideredactivating,thegenericmaynotbe.Anothernoteisthateachbrandofgenerics
isdifferent;thesideeffectsofgenericfluoxetinecapsulesmadebyonecompanydifferfromanother
company.Islikelythesafestmedicationusedinpregnancywithasignificantamountofclinicaldatapresent.
Forbreastfeedingmothers,sertralinemaybeabetterchoicethanfluoxetine.
Citalopram(originallyCelexa):sexualsideeffectsaresevere.Theyappeartobedosedependentandmaybe
equaltoparoxetine.AnumberofpatientsgettiredonitsoIgenerallynowstartitatnight.Inadditionto
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25
hyponatremia,SIADHhasbeenseenanumberoftimeswithcitalopram.Headachessimilartogeneric
Wellbutrinarealsoseenwithcitalopram.Additionally,accordingtoareportfromtheFDA(8/24/11)
“Citalopramcausesdose-dependentQTintervalprolongation.Citalopramshouldnolongerbe
prescribedatdosesgreaterthan40mgperday”
Thislikelywillimpactprescriptionofthiscommonmedication.
Sertraline(originallyZoloft):commonlyhasbruisingandhairloss.Theoriginalmedicationwasoften
sedating,leadingtopmdosing.Thegenericoftenhastheoppositeeffect,withpatientsinitiallyexperiencing
feelingsofrestlessness,anxiety,andhypervigilance(whichareproblematicconsideringsertralineisusedfor
anxiety).Haveseenacouplecasesofbruxismwhichimproveswithbuspirone.SeenTorsadesand
neutropeniax1recentlywithsertraline.Sertralineisprobablythebestmedicationtousewhenbreastfeeding
asaminimalamountisexpressedinbreastmilk.
Paroxetine(originallyPaxil):Iavoidedthismedicationforalongtimeduetofearofweightgainandsexual
sideeffects.Nowthatthesideeffectsofcitalopramaremoreapparent,Iamlesshesitanttouseparoxetine
(amedicationthatmayhavebetterefficacythatcitalopram).Asassociatedwithpulmonaryhypertensionin
newbornswhenusedduringpregnancy.
Takehomepoint:whenyourpatientcomplainsofaSSRIsideeffect,believethem.Unlesstheyendorsethe
sideeffectof“MyrightindexfingerisnumbeveryotherThursday,”gowithit.Sideeffectsoftenresolve1014daysafterinitiationofthemedication.Iftheydonot,considermanagingthesideeffectsordiscontinuing
themedication.PuttinggenericSSRIsatnightseemstohaveafewlessnotedsideeffects.
VilazodoneHCL(Viibryd)
StructurallysimilartoTrazodone,thisisaselectiveserotoninreuptakeinhibitorinadditionto5HT1Aagonist
(likebuspirone).Thus,itissimilartocombiningcitalopram+buspirone.Thismedicationhaslesssexualside
effectsandweightgainthanotherSSRIs.Half-lifeis25hoursanddosingstartsat10mgtoincreaseby10mg
perweektoagoalof40mg.Discontinuationsymptomsmayoccurifstoppingquickly.Ismetabolizedby
CYP3A4.GIsideeffectsaremostcommon.TheremaybeQTcprolongationawellindosesatorabove80mg.
Thismaybea“metoo”medication;morestudiestofollow.
Bupropion(Wellbutrin,Zyban)
ApprovedbytheFDAandmarketedin1985(ayearbeforefluoxetine).Theoriginalrecommendeddosewas
400-600mg.Thisdosingwasassociatedwithariskofseizuresandresultedinthedrugbeingpulledfor3
yearsbeforebeingreintroducedwitharecommendedmaxdosageof450mg.In2007,inresponseto
multiplepatientreportsaboutthegenericBudeprionXLhavingmoresideeffectsandbeinglessefficacious
thatWellbutrinXL,theFDAconcludedthatthediscrepancywasdueto“naturalmoodvariation.”
Indications:MDDandseasonalaffectivedisorder,smokingcessation(underZybanbrandname,generally
usedincombinationwithnicotinesubstitutes),BMD(lesslikelytoprecipitatemaniainBMDIthanTCAsand
inBMDIIthanmostotherantidepressants),ADHD,cocainedetoxification(reducingcravings),hypoactive
sexualdesiredisorderduetoSSRIs.
Profile:availableinimmediatereleaseIR(BIDorTID),sustainedreleaseSR(usedBID),andextendedrelease
ER(oncedaily).Theactiveingredientisthesameineach.TheIRreachespeakconcentrationin2hours,SRin
3hoursandERin5hours.Thehalf-lifeis12hours.Mechanistically,bupropioninhibitsthereuptakeofDA
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andNE.IsmetabolizedtoactivemetabolitehydroxybupropionbyCYP2B6(inhibitedbyfluoxetine).
Hydroxybupropionitselfinhibits2D6.BupropionhasaffinityforDAtransporterswhilehydroxybupropionhas
moreselectiveaffinityforNEtransporters.BupropionmayhaveafalsepositiveUDSforamphetamines.
SideEffects:seizureriskis2%with600mgand0.1%with300-450mg(theSRandERatsamedoseshasrisk
of0.05%,equivalenttotheotherantidepressants).Sideeffectsmostcommonincludeheadache,insomnia,
drymouth,tremor,andnausea.Severeanxietyandpanicdisordercanbeworsenedbybupropion.Can
worsenpsychosisanddeliriumduetodopaminergicactivity.Haveseenseverepsychosiswithuseof
bupropioninpregnancy.
Mirtazapine(Remeron)
Atetracyclicantidepressantthatisbothserotonergicandnoradrenergicthroughamechanismdifferentfrom
serotoninreuptakeblockadeormonoamineoxidaseinhibition.
Mirtazapine
Indications:MDD(especiallywithinsomniaorweightloss),reductionofsideeffectsassociatedwith
chemotherapy,augmentationofantidepressanttherapy.
Profile:half-lifeof30hours.Clearanceisimpairedinhepaticimpairedpatientsby30%,inrenalimpaired
patientsby50%,andisimpairedintheelderly(by40%inmalesand10%infemales).Mechanistically,
mirtazapineworkstoincrease5HTatthe1Areceptor(themainsitefortheantidepressantactionsofmost
antidepressants).Itdoesthisbyblockingthe5HT2A,5HT2Cand5HT3receptors,resultinginallserotonin
beingdirectedtothe5HT1Areceptor.Asaresult,therearelesssexualandGIsideeffectsthanother
antidepressants.Additionally,itincreasesNEandDAtransmission(recall5HT2CnormallyinhibitsDA—think
atypicalantipsychoticmechanismofaction).Stronghistamineaffinitycausessedationandweightgain.There
isminimalanticholinergiceffect.Startingdoserangesfrom7.5to15mg.Increasingdoseabove30mgleads
tohigherNEeffectsandlesssedation.Metabolizedby2D6and3A4.
SideEffects:somnolenceoccursin>50%(worsenedbyalcoholorothersedatives),increasesappetiteand
cholesterol,reductionofANC(monitorforfever,chills,sorethroat),andagranulocytosis.
Venlafaxine(Effexor)andDesvenlafaxine(Pristiq)
Indications:MDD,GAD,PanicDisorder.Hasbeenusedfordiminishingsymptomsofmenopause,treating
chronicpain,anddualdiagnosisofMDDandcocainedependence.
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Profile:inhibitsreuptakeof5HTandNEwithoutmuchinteractionatothersites.Existsasimmediaterelease
IR(BIDdosing)andextendedreleaseXR(oncedaily).Duetoshorthalf-life,adiscontinuationsyndromemay
existifabruptlystopped.Metabolizedby2D6toactivemetabolitedesvenlafaxine(nowmarketedasPristiq).
Patientswithpoor2D6activitymayhavehighersideeffectprofile,leadingtotheisolationandmarketingof
themetaboliteastreatment(orsotheysay).TheIRismostassociatedwithnauseaandoftenisstartedin
lowdosesof37.5mgtwicedaily(useintheamandat1pmduetoriskofinsomniaiftakenatbedtime).As
doseincreases,affinityforNEtransporterincreases.Asaresult,HTNandanxietyaremoreassociatedwith
higherdosesofthemedication.WhentakenastheXR,themaximumdoseis375mg.Desvenlafaxinehasa
therapeuticdoseof50mg(whichhappenstobethestartingdose)withnosignificantdatatosupport
improvedefficacyof100mg.
SideEffects:nauseaandsexualdysfunctioninupto30%areserotonergicsideeffects.Whileappearing
anticholinergic,sideeffectsofheadache,insomnia,dizziness,constipation,sweating,andnervousnessare
duetoNEeffects.HTNoccurswithhigherdoses.Discontinuationsyndromeappearsasdizziness,insomnia,
nausea,anddiarrhea.
Duloxetine(Cymbalta)
Indications:MDDandNeuropathicpainassociatedwithdiabetes(firstdrugFDAapproved).Forthe
treatmentofstressincontinence,duloxetineincreasesthetoneoftheurethralsphincterandwillbe
marketedasYantreve(importanttoknowifyourpatientistakingYantreveakaduloxetine,especiallybefore
youstartthemonSSRIorSNRI).
Profile:similartovenlafaxine,buthasequalaffinityfor5HTandNEtransportersatalldoses.Thereislittle
datatoshowgreaterclinicalefficacyindosesabove60mgforthetreatmentofdepression.BIDdosingmay
reducesideeffectsseenwithonce-dailydosing.Startingdoseis20or30mg.
SideEffects:similartovenlafaxine,includingnausea,dizziness,constipation,insomnia,andsexual
dysfunction.LesslikelytocauseHTN.MayincreaseHgbA1cinlongtermtreatment.Potentiallyincreases
LFTs(especiallyinhepaticallycompromisedpatients).Discontinuationsyndromecanoccur.
Anxiolytics
Buspirone(Buspar)
Indications:GAD(notpanic,OCD,orsocialphobia).Mayreduceaggressionandhostilityinanxietybetter
thanBZD.LesseffectiveinmanagingsomaticsymptomsofanxietythanBZD.Canbeusedtotreatsexualside
effectsandbruxismcausedbySSRIs(throughinhibitionof5HT2andviaDAagonism).
Profile:half-life2-11hourssoisdosedTID.Hasanactivemetabolitethatis20%lesspotentbut30%more
concentratedinthebrainthantheparentcompound.Primarymechanismis5HT1Aagonist,helpingwith
anxiety(think:5HT2isactivating,5HT1iscalming).Dosingbeginsat5mgTIDandmaximumdoseis60mg.
Metabolizedby3A4.Grapefruitjuiceincreasesbuspironeconcentrations.
SideEffects:doesnotcauseweightgain,sedation,orsexualsideeffects(no5HT2orH1).Mainsideeffects
areheadache,nausea,anddizziness.Safeinoverdose(nodeathshavebeenreported)andtheestimated
lethaldoseis>300xtherecommendeddailydose.
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Benzodiazepines
Indications:GAD,Panic,acutemania,agitation,shorttermmanagementofinsomnia,anticonvulsant,
akathisia.Theycanbeusedfortheshorttermmanagementofanxietyandpanic(1-2weeks)whilealong
termagentisinitializing(SSRI).ChronicusemustbemonitoredcloselyandgenerallyBZDwithlonghalf-life
andgradualonsetofactionarelesslikelytobeabused.
Profile:anxiolyticpropertiesareduetomodulationofGABA.Allarelipid-soluble,allowingthemtocrossthe
bloodbrainbarrier.ThemostaddictiveBZDarehighlylipophilicwithashortonsetofaction(patientnotices
theeffectsquickly).Tolerancewithalprazolam,forexample,canoccurwithin1-2weeks.Seechartonnext
page.
SideEffects:sedation,ataxia,dizziness,respiratorydepressioninCOPDorsleepapnea,dependencetoBZD
(especiallywithrapidonset)andriskofwithdrawal,whichcanbefatalifnotmanaged.Mostrecentstudies
donotshowfetalcleft/palateabnormalitiesorcardiacmalformations.UseofBZDinthe3rdtrimestercan
resultinwithdrawalsymptoms,decreasedAPGARSandpoorfeedinginthenewborn.
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Generic
TRADE
Equivalent
Dose/
Class
Peak
Level/Absorb
Rate
Average* Active
Half-life
Metabolites
(hr)
Comments
InitialDose
UsualDose
Range
MaxDose
SHORTACTING:morereboundanxietyeffect&withdrawalreactions,bettersedative/hypnotic;preferredoverlongactinginelderly(less
accumulation)&patientswithliverdisorders(easiermetabolized).MOREADDICTIVE
Alprazolam
0.5mg
1-2
Medium
12
(9-20)
Minor
Oxidation
Anxiety,Panicattacks
XANAX
Lorazepam
1mg
3-Hydroxy
1-4
Medium
15
(8-24)
None
Conjugation
Anxiety,Preanesthetic;
15mg
3-Hydroxy
1-4
Medium
8
(3-25)
None
Conjugation
Anxiety,alcoholwithdrawal
0.5mg
0.5-2mg
potid
10mg
15-30mg
poqhs
120mg
10mg
3-Hydroxy
2-3
Medium
11
(3-25)
None
Conjugation
Sedative/hypnotic;noREM
suppression
RESTORIL
Triazolam
0.25-0.5mg
potid
10mg
SERAX
Temazepam
4-10mg
ATIVAN
Oxazepam
0.25mg
15mg
15-30mg
poqhs
60mg
0.25mg
Triazolo
1-2
Rapid
2
(1.5-5)
None
Conjugation
Sedative/hypnotic
HALCION
0.125mg
0.5mg
0.1250.25mg
poqhs
LONGACTING:lessreboundsymptoms;betterchoicewhentaperingoffofBZDs,LESSADDICTIVE
Chlordiazepoxide
25mg
2-Keto
1-4
Medium
100
Yes
Oxidation
Anxiety,preanesthetic,alcohol
withdrawal
LIBRIUM
Clonazepam
0.25mg
Nitro
1-4
Medium
34
(19-60)
5mg
2-Keto
1-2
Rapid
100
None
Oxidation&
Nitro
reduction
Anticonvulsant,panicattack;
RLS,neuralgia
25-50mg
potid
Yes
Oxidation
Anxiety,musclerelaxant,
seizures,alcoholwithdrawal
0.25mg
0.5-2mg
potid
10-20mg
VALIUM
Lorazepam
200-400mg
KLONOPIN
Diazepam
5mg
2mg
2-5mg
potid
40mg
15mg
2-Keto
DALMANE
0.5-1
Rapid
100
(40-250)
Yes
Oxidation
Sedative/hypnotic;can
accumulate
15mg
15-30mg
poqhs
60mg
Flumazenil:reversestheeffectsofBZDandcanbeusedincasesofOD.Usewithcautionasitmaycause
rapidsymptomsofBZDwithdrawal.
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CognitiveEnhancers
In1993,tacrine(Cognex)becamethefirstmedicationapprovedbytheFDAforthetreatmentofAlzheimer’s
Dementia.InitiallycreatedinMelbourne,AustraliaduringWW2,itsinitialfunctionwasasananaleptic
(stimulatesrespiratorymusclestoaidrecoveryfromanesthesia.Yeah,Ihadtolookthatoneup).Ultimately,
itwasfoundtoassistincognitioninAlzheimer’spatients.Ithassincebeenremovedfromthemarketdueto
livertoxicity,butitsmechanismofinhibitionofthebreakdownofacetylcholine(Ach)ledtocreationofother
cognitiveenhancers.
Longbeforetacrine,ancientGreektextsrefertothecommonsnowdropflower(Galanthusnivalis)being
usedtoreversepoisonsthatwereneurotoxic.Additionally,practitionersinEasterEuropeandSouthwest
Asiahavedocumenteduseoftheflowerfortreatmentofmyopathyandsensorydysfunction.Fromthe
Galanthusflowerandotherbotanicalproducts(likedaffodils),Bulgarianpharmacologistsinthe1950s
synthesizedgalantamine.Currently,galantaminecontinuestobeproducedfromacombinationoforganic
synthesistechniquesandcombinationwithnaturalresources(daffodilsfromWales,UK).
Indications:treatmentofmildtomoderatecognitiveimpairmentinAlzheimer’sDementia.Theyslowthe
progressionofmemorylossanddiminishapathy,depression,hallucinations,andmoodreactivity.Theymay
alsohelptodelaytheneedfornursinghomeplacement.Donepezilandrivastigminearealsousedin
Parkinson’sandLewyBodyDementiainadditiontobeingusedforcognitiveeffectsrelatedtotraumatic
braininjury.Useinvasculardementiamayproduceimprovementbutnotinallcases.
Profile:Alzheimer’sisduetodestructionandimpairedproductionofacetylcholine.Thecholinesterase
inhibitorsreversiblyinhibittheenzymesthatbreakdownAch,increasingsynapticconcentrationsofAch
especiallyinthehippocampusandcerebralcortex.BlockingthebreakdownofAchintheperipheryleadsto
nausea,diarrhea,vomiting,andcardiacabnormalitiesincludingbradycardia.Sideeffectsincludenausea,
diarrhea,vomiting,bradycardia,andsyncope.Avoidwithbethanecholandalsoavoidwithother
anticholinergicmedications(likeparoxetine).
Donepezil:hasahalf-lifeof70hoursintheelderlyandistakenoncedaily.Cirrhosisreducestheclearanceby
20%.DonepezilworksselectivelyintheCNSwithlessactivityintheperipheryoncholinesterases(lessGI
symptomsetc).Donepezilstartsat5mgqhswithamaximumdoseof10mg.Metabolizedby2D6and3A4.
Highlyproteinboundbutdoesnotdisplaceothermedications.Benefit:leastGIsideeffectsandmaybemore
effectivethangalantamineintreatmentofcognitivedisorders.
Rivastigmine:hasa1-hourhalf-life,butitremainsboundtocholinesterases,leadingtoeffectivedosefor10
hours.Rivastigminehasmoreperipheralactivityandinhibitsbothacetylcholinesteraseand
butyrylcholinesterase.Asaresult,ithasmoreGIandcardiaceffects.Rivastigminestartsat1.5mgBIDand
graduallyincreasesto3mgBIDgraduallyoverthecourseofamonth.Thecreationofarivastigminepatch
hasledtomoreeffectivetreatmentwithlessperipheraleffects.Unboundtoproteinsandhasminimaldrugdruginteractionsasitisnotmetabolizedintheliver.Benefit:patchgoodinpatientswithdifficulty
swallowingorwithquestionablecompliance.
Galantamine:isextractedfromdaffodilsandhasahalf-lifeof6hours.Sideeffectsareminimalandtransient.
Itisdosedat4mgBIDperdayfor4weeksandanysubsequentdoseincreasesshouldoccurat4-week
intervals.Maximumdoseis16mgBID.Metabolizedby2D6and3A4likedonepezil.Isanallostericagonistat
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thenicotinicreceptor,similartothewaythatBZDworkonGABAreceptors,inadditiontostoppingthe
breakdownofAch?Benefit:leastexpensiveofthecognitiveenhancerswithminimalsideeffects.
MiscellaneousTopics
TreatmentofMedicationSideEffects
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•
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TardiveDyskinesia:discontinuethemedication,someindicationforVitaminE
Akathisia:propranololorBZD
NMS:dantrolene,bromocriptine,coolingmeasures
Sexualsideeffects:changeSSRI,addbupropion,buspirone,sildenafil
Anticholinergicsideeffects:takewithfood(GI),sugarlessgumandpilocarpinemouthwash(dry
mouth),pilocarpineeyedrops(blurredvision),bethanechol(urinaryretention)
Orthostatichypotension:increasefluidintake,decreasecaffeine,increasesodiumifapprovedby
PMD,tedhose,considerchangingHTNmeds
TreatmentofOverdose
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•
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•
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•
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•
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BZD:emesis,lavage,charcoal,flumazenil
Bupropion:lavage,charcoal,prophylacticBZDtopreventseizures
Clozaril:charcoalandsorbitol
Antipsychotics:lavage,charcoal,norepinephrineforhypotension,monitorEKG
SSRI:lavage,charcoal,monitorEKG
Lithium:emesis,lavage,dialysis(nocharcoal),0.9%NaClifNadepletioncausedtoxicity
MAOI:emesis,lavage,charcoal,pressors,BZDtopreventseizures,phentolamineforhyperthermia,
AVOIDDEMEROL
TCAs:lavage,charcoal,telemetry,EKG,anti-arrhythmiamedications,BZDtopreventseizures
Thyroidhormones:emesis,lavage,charcoal,cholestyramine,propranolol
Opiates:naltrexone,monitorforrespiratorydepressionandmaintainairway
ETOH:bananabagforvolumeandnutrientdepletion,BZDtopreventseizure,maintainairway
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ANINJA’SGUIDETONEUROLOGY
Cortex
AnatomyOverview
FrontalLobes:primarymotorcortex(precentralgyrus),impulsecontrol/judgment(orbitofrontalcortex)
socialization,executivefunctioning,workingmemory,languageproduction(Broca’sArea)
ParietalLobes:primarysensorycortex(postcentralgyrus),knowledgeofnumbers,visuospatialprocessing,
R-Lorientation
TemporalLobes:primaryauditorycortex,containsthehippocampus(memory),Wernicke’sarea
(understandinglanguage),comprehension/naming,recognitionoffaces,visualprocessing
Occipital:primaryvisualcortex,lesionsleadtovisualfieldabnormalities
Cerebellum:sensoryperception,motorcoordination/learning,proprioception,equilibrium,posture
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BasalGanglia:composedofstriatum(putamen/caudate/nucaccumbens),globuspallidus,subthalamic
nucleus,andsubstantianigra.Isassociatedwithcoordinationofmovement.Motortractsgothroughthe
striatum.AbnormalitiesofBGincludePD,Tourette’s,CP,dystonia,OCD,andTD
Pereau’s“CramtheBrainUsingtheMMSE”ReviewTool
Ok,somostofusknowtheMiniMentalStatusExaminationbyheart.AstheMoCAbeginstotake
prevalence,thismaychange.Butforthetimebeing,let’scapturethatknowledgeoftheMMSEtoreview
partsofthebrain.EachquestionoftheMMSEisdesignedtotestadifferentregioninthebrain,including
cortexlocationsandbasalganglia.
Orientation:“PleasenametheYear,Season,Date,DayoftheWeek,andMonth,”and“Wherearewe:State,
City,Suburb,Hospital,Floor”
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•
FrontalLobe:canthepatientpayattentioninthisquestion?Cantheyreasonthroughthedate/day
oftheweekifitisnotreadilyintheirmind?HowmanytimesdoIaskthepatientthisquestionand
thenfranticallytrytorecallthedate?Ok,let’ssee…yesterdaywasthe11th,sotodayisthe12th.
Frontallobetotherescue!Medialprefrontalisassociatedwithorientationtoperson
TemporalLobe:doesthepatientrememberthedate,asinaretheystoringmemoryonadaytoday
basis?Thefrontallobe’sabilitytoreasonthatyesterdaywasthe11thsotodaymustbethe12this
onlydoableifyourememberwhatthedatewasyesterday.Doesthepatientrememberhowtheygot
totheroomtheyarespeakingtoyounowin?Thistestsspatialmemory
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Recall:Name3objects.“Canyourepeatthese3words?”“Inafewminutes,Iwillaskyoutorememberthe
words.”“Canyourepeatthe3wordsItoldyouearlier?”
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•
Immediaterecall(seconds):youhavejustaskedapatienttorepeatwords.First,theymusthavean
intactWernicke’sinTempo/Parietalareainordertocomprehendwhatyou’vejustasked(think:
parietal=understandwords).Second,thepatientmustbeabletoconnectwordcomprehensionwith
mechanicalreproductionofwords.TheArcuateFasciculusconnectsWernicke’s(comprehend)to
Broca’s(saythewords)inordertorepeatwords.Finally,Broca’sinthefrontallobehelpstoproduce
words(think:motorstripinfrontal=makewords)
Delayedrecall(2-3minutes):requireshippocampustoconvertimmediatememorytolongterm
memoryandmedialtemporallobetoactuallystorememory
Attention:“SpellWORLDbackwards”
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•
•
•
Prefrontal:canthepatientconcentratewhiledoinganunfamiliartask?
FrontalDorsolateral:workingmemory.Canthepatientrecallwhatletterswerealreadyused,and
whichonecomesnext?
InferiorParietal:spelling,language,syntax
Temporal:storageofhowtospellanything
Attention:Serial7s
•
•
•
•
Prefrontal:canthepatientconcentrateonadifficulttask,filteringoutdistractions?
FrontalDorsolateral:workingmemory.Canthepatientrecallwhatnumbershavebeenusedand
whichonescomenext?
LeftParietal:understandingofnumbers,math,andcalculation
Temporal:storageofwhatnumbersareandhowtheyrelatetoeachother
Naming:Showthepatient3objects“Canyounamethisobject?”
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•
LeftParietal:language,grammar
LeftTemporal:storageoflearnednames
Repetition:“Repeatnoifs,ands,orbuts”
•
SeeaboveImmediateRecall,involvesWernickeàArcuateàBroca
FollowCommand:Askthepatienttofollowa3stepcommand
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•
•
•
Frontal:attention,planning.Motorcortexcoordinatesmovement
Temporal:recallthe3commandsfromafewsecondsagotodotheminsequence
LeftParietal:right-leftorientation
BasalGanglia:additionalmotorcoordination,finemotorcoordination
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ReadingComprehension:“Closeyoureyes”
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Occipital:abilitytoread/seethewords
Leftparietal:wordrecognition,grammarsothatthewordsmakesenseandareacommand
Temporal:storageofwordslearnedpreviously
Writing:“Writeasentence”
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Occipital:abilitytoread/seewhatiswritten
Frontal:attention,motorcortexcoordinatesmovement
Leftparietal:words,grammar,syntax
Basalganglia:finemotorcoordination.Isthereatremor?
DesignCopy:“Copythisdesign”
•
•
Frontal:attention,planning.Motorcoordination
Rightparietal:construct,gestalt.Damageleadstohemineglect
Thus,knowingwhyeachquestionoftheMMSEisthereisausefulreviewofthefunctionsofthecortexand
basalganglia.Ratherthanjustrelyingoncramming,usingtheMMSEasareviewtoolcanserveasan
overviewforallregionscommonlytestedonPRITE.Additionally,useofClockDrawingcanbeasimilarreview
ofbrainregions.
HighYieldPRITEReview
Q:Apreviouslypleasantmotherbecomesprofaneandirresponsibleover6months.Whereisthelesion?
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A:FrontalLobe.Thefrontallobeisassociatedwithimpulsecontrol,judgment,sexualbehavior,socialization,
andmemory/languageproduction.Thispatienthasevidenceoffrontallobedysfunctionasevidencedbynew
onsetofsociallyunacceptablebehaviors.
Q:A62-year-oldmalewithDMspeaksinnonsense,saying“tharszingisphrumperzustalking.”Normal
intonationbutnobodyinthefamilycanunderstandhim.Hecannotfollowinstructions.Diagnosis?
A:Wernicke’sAphasia.Thepatienthasfluentaphasia(alsoknownasreceptiveaphasia)duetodamageto
Wernicke’sareainthesuperiortemporalgyrus.Thepatientcanproducenonsensicalwordswithproper
intonation,butcomprehensionisimpaired.Temporallobeisassociatedwithhearingandlanguage
comprehension.ThisisdifferentfromBroca’saphasia,whichisalsoknownasexpressive/non-fluentaphasia
duetodamagetotheinferiorfrontalregionofthebrain(usuallytheLside).Thefrontallobeisassociated
withmotorabilityandformingwords.Thesepatientscannotproducelanguagebuthavenormal
comprehension.ConductionaphasiaisproducedbydisruptionofthepathwaysconnectingBroca’sand
Wernicke’sareas,leadingtoapatientbeingabletorepeatphrasesdespiteintactcomprehensionand
languageability.
Q:60-year-oldmale(Rhanded)whofrequentlygetslost,andonlywritesontherighthalfofpaper.Whereis
thebrainlesion?
A:RightParietalLobe.ThisisanexampleofLeft-sidedhemi-neglect.Theparietallobesareassociatedwith
“deploymentofattention”ofthecontralateralspace.Thisisasensorydeficitthathaslackofattentionto
itemsintheleftvisualfield.Damageofrightparietallobeismorecommonlyassociatedwithhemineglect
thanleftparietallobes.
Q:A55-year-oldfemalepresentswithinabilitytowrite,calculateordoarithmetic,andinabilitytodistinguish
thedifferentfingersonherhands.Whereisthelesion?
A:LeftParietalLobe.Thisisanexampleof“Gerstmannsyndrome”andthecollectionofsymptomsindicate
abnormalitiesinleftparietallobe(dysgraphia,dyscalculia,fingeragnosia).
Q:A28-year-oldpatientpresentswithalossofvisioninthebilateraltemporalvisualfieldsandabnormalities
inprolactin.Whereisthelesion?
A:Pituitaryadenoma.Thislesioncompressestheopticchiasmleadingtobitemporalhemianopsia.In
addition,itleadstoabnormalprolactinlevels.
Q:A22-year-oldwithfever,headache,seizures,confusion,stupor,andcomaevolvingoverafewdays.EEG
haslateralizedhigh-voltagesharpwavesarisingintheLtemporalregion,withslowwavecomplexes
repeatingat2-3secondintervals.CTshowslow-densitylesioninLtemporallobe.Diagnosis?
A:HerpesSimplexEncephalitis.RetrogradetransmissionofHerpesvirusfromaperipheralsiteintotheCNS
alonganerveaxon.Canliedormantinthetrigeminal(CNV)ganglion.Targetsthetemporallobesofthe
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brain,leadingtoseizureswithhigh-voltagesharpwavesandslowwavecomplexes.Diagnosisismade
throughEEG,CT,andCSFPCRforherpessimplexDNAorCSFviralculture(CSFhaslymphocyticpleocytosis).
Treatmentincludesacyclovirandsupportivetreatment.
BrainstemandSpinalCord
AnatomyOverview
Midbrain(CNIII-V):upperpartofbrainstem,hasnucleifor
•
•
•
CNIII:oculomotor–eyemovementexceptSOandLRmuscles;E-W–autonomicfunctionslike
pupillarydilation
CNIV:trochlear–SOmusclewhichturnseyedown/in
CNV:trigeminalsensory–facialsensation
Pons(CNV-IX):middlebrainstem,hasnucleifor
•
•
CNV:trigeminalmotor–motorbranchesofmandibularnerveforbiting,chewing,swallowinghasBL
innervation,thusdeficitincentrallesionisrare
CNV:spinalsensory
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•
•
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•
CNVI:abducens–LRmusclelaterallymoveseye
CNVII:facial–facialmotor
CNVIII:vestibular–balance/equilibrium(Dysfunctionleadstovertigoandnystagmus);Cochlear–
hearing
Salivarynuclei:Inferiornucleus–IXforparasympatheticparotid;Superiornucleus–VIIfor
submandibular/sublingualsalivation
Medulla(CNIX-XII):lowestportionofbrainstem,isthelocationfordecussationofmotortractsand
dorsolateralcolumn(proprioception/finetouch).Nucleifor
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•
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SpinalCNV:sensory
SolitaryNucleus:VII–tastetoanterior2/3tongue;IX–tastetoposterior1/3tongueandinfofrom
carotidbaroreceptors/carotidbodychemoreceptors;X–sensationfromouterear
NucleusAmbiguous:motornucleusforIX,X,XI;IX–LMNforstylopharyngeus;X–larynx/pharynx;XI
–accessorynerveformovementofneckmuscles
HypoglossalNucleus:XII–movestongue
Pereau’s“TheBrainstemasaFace”ReviewTool
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ForthepurposeofquickreviewpriortoPRITE,simplifythecranialnerves&nucleitomatch3facialzones
•
•
•
Zone1:"Eyeballs."CNIII-V.Midbrainlesionscauseabnormalityineyemovement(CNIII)andface
sensation(V)
Zone2:"MiddleFace."CNV-IX.Ponslesionscauseabnormalitiesinfacialmovement(VII),chewing
(V),salivaproduction(IX),hearing/balance(VIII)
Zone3:"NeckStuff."CNIX-XII.Medullalesionsaffecttonguemovement(XII),taste(VII,IX)
swallowing(IX,X)andneckmovement(XI)
Whilenotperfectmodel(VIoutofplace,Vfacialsensationishigherthanexpected),thisisaquickwayto
isolatebrainstemlesionsinPRITEvignettes.Rememberthatthecerebellumhasconnectionsatalllevelsof
thebrainstem.Thus,ataxia/nystagmuscanoccurinanyZone
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HighYieldPRITEReview
Q:A35-year-oldfemalepresentswithunilateralhearingloss,unsteadiness,falls,headaches,mildfacial
weakness,andipsilaterallimbataxia.Whereisthelesion?
A:Cerebellopontineangle.Thepatienthasclearsymptomsofcerebellardysfunction(ipsilateralataxiais
specificforcerebellum).ThePonshasmultipleCNnuclei,includingthefacialnerve(facialweakness)and
vestibularnerve(unilateralhearingandbalance).Zone2:MiddleFace=Pons
Q:A48-year-oldwithhistoryofhypertensiondevelopsvertigo,nausea,vomiting,hiccups,left-sidedface
numbness,nystagmus,hoarseness,deficitsinpain/temperatureontherightsideofthebody,ataxiaofthe
limbs,staggeringgait,andfallstotheleft.Diagnosis?
A:LateralMedullaryStroke.AlsocalledWallenberg’sSyndromeandPosteriorInferiorCerebellarArtery
Syndrome.OcclusionofthePICAleadstolateralmedullaryinfarct.Thesymptomsinclude:contralateral
deficitsinpain/temperature(lateralspinthalamictract,whichcrossedearlyinspinalcord),ipsilateralloss
pain/temperaturetoface(trigeminalnucleus),dysphagia/hoarsenessanddiminishedgagreflex(Nucleus
Ambiguous:vagusandglossopharyngeal),vertigo/nystagmus(vestibular),ipsilateralHorner’s(descending
sympathetics),ipsilateralataxia,andhiccups.Zone3:NeckStuff=Medulla.WhileVIIIsymptomsarepresent,
theZone3symptomsindicatemedullaandwouldnotbeseeninponslesions.
Q:ApatientpresentswithpainbehindtheleftearprogressingtonumbnessoftheLface,tearingoftheL
eye,discomfortwithlowfrequencysounds,andLfacialweaknessonexam.Diagnosis?
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A:Bell’sPalsy.AbnormalityofCNVIIwithLMNparalysis,isrelatedtoLymediseaseandHerpesZoster.Thisis
isolatedVIIlesion.AZone2lesionwouldhaveissueswithchewing,saliva,hearing,etc.Inflammationofthe
facialnerveasitexitstheskullleadstosymptomsoffacialparalysis.Oftenthetrigeminalnervemaybe
involved,leadingtonumbness.TinnitusistheresultofinvolvementwithCNVIII.CNVIIhasbilateral
innervationoftheforehead(2nerveinnervationforeachsideoftheforehead).InUMNlesions,theforehead
maybesparedduetothisBLinnervation.However,inLMNconditions(Bell’s)theforeheadisaffecteddueto
theBLinnervationgetsinflamedgoingthroughthecanal.Treatmentissteroidsortreatmentofunderlying
Herpes.
Q:A38-year-oldwithseverelysensitive,lancinatingpainonthecheek,lastingafewseconds,andistriggered
bylighttouchontheface.Diagnosis?
A:TrigeminalNeuralgia.AlsocalledTicdoloureux.Neuropathicdisorderofthetrigeminalnerve(CNV)that
causesintensepainintheeyes,lips,nose,scalp,forehead,andjaws.Associatedwithhighratesofsuicide
duetosignificantpain.SuspectedcauseissuperiorcerebellararterycompressingCNVnearitsconnection
withthepons.PerPRITE,treatmentiscitedtobecarbamazepineorgabapentin.
Q:A48-year-oldpresentswithunsteady,lurching,broad-basedgait,appendicularataxiainLEonly,and
normaleyemovement.Henotedprogressivelegweaknessandclumsinessoverthepastyear.Diagnosis?
A:AlcoholicCerebellarDegeneration.IrreversiblealcoholtoxicityinPurkinjecells,relatedtoglutamate
abnormalitiesandpossiblynutritionaldeficiency.Presentswithtremor,unsteadygait,andtruncalataxia.
PredominantintheLE.Irreversible,evenafterETOHisstopped.Symptomsevolvefromweekstomonths.On
MRIthereiscerebellarshrinkage.Thalamusandperiaqueductalgraymatterareintact,andcognitionis
normal(vs.Wernicke’sEncephalopathy).Treatmentincludeimprovednutrition,thiamine,andcessationof
alcohol.
Q:A62-year-oldpresentswithparalysisofeyemovement,ataxia,andglobalconfusion.Healsohasshort
termmemoryimpairment.Diagnosis?
A:Wernicke’sEncephalopathy.Severesyndromeduetochronicalcoholism,precipitatedbythiamine
deficiency.Damageiscausedtothemammillarybodies,medialthalamicnuclei,andperiaqueductalareas.
Clinicaltriadincludeconfusion,truncalataxia/gaitimbalance,andopthalmoplegia(extraocularparalysisof
CN,especiallyCNVI).MRIshowsabnormalhyperdensityofmammillarybodiesandperiaqueductalgrey
matter.CanprogresstoKorsakoff’sSyndrome(anterograde/retrogradeamnesia,confabulation,andapathy)
andcoma/death.Treatmentisthiaminereplacement.DONOTadministerglucosebeforethiamine,leadsto
celldeathbyprovidingsubstratesforbiologicpathwayswithoutsufficientcoenzymes(thiamine).IV
thiamine/nutritionalreplacementisneededaswellassupportivecare.Mainstayoftreatmentiscessationof
ETOHuse.
Q:A65-year-oldmalewith6-monthsofepisodicconfusion,disorientation,VHofchildrenplayinginhis
room,noAH,andisnormalbetweenepisodes.Exam:normallanguage/memory,difficultywithtrailstestand
serialsubtractions,andsymmetricrigidity/bradykinesia.MRI,labs,UDS,andCSFarenormal.Diagnosis?
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A:LewyBodyDementia:overlapsAlzheimer’sDementiaandPD.Triadofabnormalproteinaceous
cytoplasmicinclusions(Lewybodies),abnormalDAneuronsinsubstantianigra(likePD),andlossofAchproducingneuronsinBasalNucleusofMeynart(likeAlzDementia)leadtotheclassicsymptomsofVH,
Parkinson’sfeatures,andcognitivedeficits.Treatmentincludesuseofcholinesteraseinhibitors.
Q:A36-year-oldmaleprogressiveinvoluntary,irregularmovementsofallfourextremities,bradykinesia,
unsteadygait,maskedfacies,gradualinabilitytochew/talk,cognitivedifficulties,andsignificantchangein
personality,includingdepression,agitation,andimpulsivity.Thepatienthasrelativeswhohadpresented
withsimilarsymptoms.Diagnosis?
A:Huntington’sDisease.Autosomaldominantdisorderwithtrinucleotide(CAG)repeatleadingtoneuronal
celldeath.OnPRITE,thisvignetteoftenshowsasignificantlyatrophiedcrosssectionofthebrain.Themore
CAGrepeats,theearliertheonsetofthedisorder,thuseachsuccessivegenerationdevelopsthedisease
earlier(calledanticipation).Hallmarksofthediseaseincludesymptomsduetodegenerationofthebasal
ganglia/striatum/caudate(chorea,unsteadygait,bradykinesia,inabilitytochew/swallow)andsymptomsdue
tofrontallobedegeneration(deficitsincognition,executivefunctioning,abstractthinking,memoryand
psychologicalsymptomslikeagitation,depression,impulsivity,hypersexuality,compulsion).Suicideis
commoninthesepatients.Genetictestingcandetectthetrinucleotiderepeat,helpingfamilyplanning.
Mainstayoftreatmentincludeshaloperidolandotherhighpotencyantipsychotics(perPRITE),andother
symptomatictreatment.
Q;A54-year-oldpatientpresentswithshufflinggaitandinvoluntaryacceleration,posturalinstability,
festination,andtruncalrigidity.Hehastremoratrestthatdecreaseswithvoluntarymovement,cogwheeling
rigidity,drooling/dysphagia,andmaskedfacies.Diagnosis?
A:Parkinson’sDisease.IncreasedactivityinthesubthalamicnucleusandGPleadstoDAinhibitionand
movementdisorder.Symptomsincludebradykinesia,tremorthatdecreaseswithvoluntarymovement,
rigidity/cogwheeling,shufflinggait,dystonia,festinatingspeech(rapid,soft,poorly-intelligible),drooling(due
toinfrequentswallowing),dysphagia,fatigue,maskedface,andmoodsymptomslikedepression.Treatment
isLevodopa,adopamineagonist.IntheeventofthedevelopmentofVHonLevodopa,decreasethedose.
Anothertreatmentisdeepbrainelectrodestimulationinsubthalamicnucleus.
Q:A35-year-oldmaleawakensfrequentlyinmiddleofnightwithsevereheadacheslasting1-2hours.
Headachesaresopainfulthatthepatientisafraidtogotosleep.LocatedaroundLeyeandassociatedwith
lacrimation,ptosis,andmitosis.Diagnosis?
A:ClusterHeadaches.Vascularheadacheswithintensepaincausedbydilationofbloodvesselsleadingto
pressureonTrigeminalnerve.MaybeassociatedwithHorner’ssyndrome(sympatheticchainlesion,leading
todeficiencyofsympathetictone:ptosis,lacrimation,miosis,rhinorrhea,andsweatingonaffectedsideof
face).TreatmentwithNSAIDsisrarelyhelpful.Mainstayoftreatmentaretriptans(abortive)orcooling
measures(coldshower,breathingcoldair).ThereissomesupportfortheuseofTopamaxorLithiumfor
treatment,inadditiontoCachannelblockersorsteroids.
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Q:A22-year-oldfemalehasgained70lbs.inthepastyearandnowpresentswithdailysevereheadaches
sometimesassociatedwithgrayingoutofvision.Papilledemaispresentonexam.Diagnosis?
A:PseudotumorCerebri.Associatedwithincreasedintracranialpressure,andincreasedopeningpressureon
LP.Thisleadstosignificantheadachesandpapilledema/visualproblemsthatcaneventuallycauseblindness.
TheCSFcompositionandneuroimagingarenormal.Treatmentisweightloss,therapeuticLP,andTopamax
(inhibitscarbonicanhydraseleadingtodecreasedCSFproductionandloweringofintracranialpressure.Itis
alsohelpfulinweightloss).
Q:A23-year-oldsafterrecoveringfromaflu-likeillness,developstinglingparesthesiainthelower
extremities,followedseveraldayslaterbyprogressiveweaknessR>L.Examshowsdecreasedsensationat
T10topinprick,3/5weaknessofLE(weakeronR),kneeandanklejerksarehyperactiveandthereis+BL
Babinski.Patienthasdifficultywalkingandhasabroadbasedstiff-leggedgait.Hasurinaryincontinence.
Diagnosis?
A:TransverseMyelitis.Inflammatoryprocessofthegray/whitematterofspinalcordleadingtoaxonal
demyelination.MaybeaforerunnerofMSorimmune-mediatedreactiontoavirus.Longtractsareaffected
first(LE).Sensationisaffected.Cervicalinvolvementcanleadtorespiratoryparalysis;Thoraciclesionscan
producespasticparaplegia;andLumbarlesionsleadtocombinationUMN/LMNsymptoms.Symptoms
generallypresentrapidly,firstwithsensorysymptomsandprogresstospasticity.Hyperactivereflex/+
BabinskiisUMN.CSFhaselevatedproteinduetodemyelinationandmononuclearcells.Diagnosisismade
withMRIdetectinglesions.Treatmentissteroidstodecreaseswellingandcompression.
Q:A28-year-oldwithdiplopia,isolatedLeyenystagmuswhenlookingL,inabilitytoadducttheReye.She
hassymptomsofdepressionandhistoryofepisodicdysarthria/dysphagia.Hasrecentdecreasedsensationin
thearms,unsteadygait,andproblemswithbalance.CSFshowselevatedprotein,oligoclonalbands,and
nucleatedcells.Diagnosis?
A:MultipleSclerosis.Chronic,demyelinatingdiseaseaffectingtheCNS.Canleadtoachangeinsensation,
visualproblems,muscleweakness,depressionandproblemswithgait/balance.Transversemyelitisisa
forerunner.InternuclearopthalmoplegiaisaproblemwiththecommunicationbetweenCNIII(moveseyes
medially)andCNVI(moveseyelaterally).InINO,thereisinabilityforbotheyestotracktogether(when
lookingtotheL,theLeyeabductsproperlywithLRmuscle[CNVI],butReyedoesnotadductdueto
abnormalMRmuscleinnervation[CNIII]).Thisleadstonystagmus.DiagnosisisobtainedthroughMRI
detectionofdemyelinatinglesions.Treatmentissteroids(acuteexacerbation)andinterferons,inadditionto
newermedicationsthatstimulateTcellstofightinflammation(Copaxone).Courseisrelapsing/remitting,
withexacerbationscausedbyinfections(commoncold,URI),heat,pregnancy,andemotionalstress.
Q:PatientpresentswithspasmsofLEwhilesleeping.Hasstiff-leggedgait,adductslegswhilewalking,
increasedLEtone/spasticcatch,hyperactivekneejerksandanklejerkclonus.IncreasedRombergsway.
Diagnosis?
A:CervicalSpondylosis.Spinaldeformitywhentwovertebraecompressanerveroot,resultinginsensory
andmotordeficit.Thisleadstocervicalpathologyandradicularsigns(LMN).Overtime,thespinalcordmay
becompressed,leadingtohyperreflexia,andotherUMNsymptoms.Mayfeel“electricshocks”goingdown
arms/legs.DiagnosisisthroughMRI.Treatmentissymptomaticorsurgical.Distinguishedfromtransverse
myelitisbycourse(TMisrapidonset),CSF(TMhaselevatedprotein)andMRI(spondylosishascompression).
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Q:A32-year-oldpatientrecoversfromaGIviralinfection,andnowpresentswithnewonsetlowerlimb
weakness,areflexiainlowerlimbs,graduallyleadingtoflaccidparalysis,anddecreasedsensation.All
symptomshavestartedina“stocking-glove”pattern,ascendingupthebody.Nerveconductionstudies
showslowedconductionvelocityandconductionblock.Diagnosis?
A:Guillain-BarreSyndrome.AlsocalledAcuteInflammatoryPolyneuropathy.Oftenprecededbyaninfection
thattriggersandautoimmuneresponseagainstperipheralnervemyelin.ThesymptomsarepurelyLMN,with
paresthesiasintheLEthatascendtoarmsandevendiaphragm.LMNsignsalsoincludeareflexiaandsensory
loss.Theautonomicsystemcanbeeffectedbyorthostatichypotension,andrarelyareCNinvolved,leading
toBLfacialweakness.CSFhaselevatedproteins,withoutanincreasedcellcount.EMGandNCSshowslowed
conductionduetolossofmyelin.Treatmentincludesplasmapheresis,andtreatmentwithimmunoglobulins.
Q:A43-year-oldmalehasgradualprogressiveweaknessover3-4months,atrophyofextremitymuscles,
briskreflexes,plantarreflexesareextensor,spasticity,fasciculations,fibrillations,positivesharpwaveson
EMG,anddysarthria.Diagnosis?
A:AmyotrophicLateralSclerosis.Aprogressive,fatalneurodegenerativediseaseinvolvingtheanteriorhorn
cells,leadingtobothUMN(increasedreflexes,Babinski,clonus)andLMNsymptoms(atrophy,
fasciculations).Sensationisnormal.AffectLMNinthebrainstem(particularlymedulla—nucambiguous,and
hypoglossalnucleus)leadingtodysarthriaanddysphagia.EMGismosthelpfuldiagnostictest,withactive
fibrillationsandchangesaffectingonlythemotornervefibers.SensorynervesNOTaffected(vs.TMand
spondylosis).Mostpatientsdiewithin4yearsandtreatmentispurelysymptomatic
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Q:A85-year-oldwithgaitabnormality,slowmovement,asymmetricUErigidity,anddifficultyinvoluntary
verticalupward/downwardgaze.Improvedslightlywithlevodopa.Laterthepatienthasinvoluntaryvisual
saccades,anddifficultywithhorizontal/verticalgaze.Occulocephalicreflexisnormal.Diagnosis?
A:ProgressiveSupranuclearPalsy.AtypicalParkinsonianmovementdisorder.Itaffectsgaitandbalance
generallyfirst,withprogressivedegeneration.Themostobvioussignisparalysisofverticalgaze.Thereare
associatedmoodandbehavioralsymptomsinadditiontoprogressivedementia.Treatmentiscurrently
symptomatic.
Q:A52-year-oldwithinsidiousonsetofblurredvision,diplopiax1day,ptosis,6thnervepalsy,unreactive
pupils,hoarsevoice,dysarthria,weakneckmuscles,andincreasedamplitudewithrepetitivenerve
stimulationonEMG.Diagnosis?
A:Botulism.Aparalyticillnesscausedbythenervetoxin,botulin.ItpreventsthepresynapticreleaseofAch
anddisablesbothmuscarinicandnicotinicreceptors.Presentswithmotorparalysis(nicotinic)and
autonomicsymptoms(muscarinic)ofconstipation,blurredvision(dilatedpupils—MGhasnormalpupils),dry
mouth,nausea,andvomiting.Respiratoryfailurecanbelethal.Diagnosisisbytestingbloodorstoolfor
toxin.Treatmentismainlysupportive.
Q:A43-year-oldpresentswithprogressiveweaknessofextremities,mildptosis,drymouth,impotence,and
reducedreflexes.NCSshowsincrementalresponsetorepetitivenervestimulation.Diagnosis?
A:LambertEatonSyndrome.Progressiveweaknessastheresultofantibodiesdirectedagainstpresynaptic
Cachannels,preventingthereleaseofAch.Hasbothmotorweaknessandautonomicsymptoms,like
Botulism.However,facialmusclesanddiaphragmarerarelyaffected.Reducedreflexes(notseeninMG).
Maybeassociatedwithsmallcelllungcancer,andapproximately50%ofLEhasidentifiablemalignancy.
DiagnosisthroughchestX-ray(lungmalignancy),serumantibodiestoCachannels,andincrementalresponse
ofmusclefiberstorepeatedstimulation(MG=decremental).Treatmentisfocusedonunderlyingmalignancy
andsteroids.
Q:A20-year-oldwithoccasionaldoublevisionwhenlookingtotheRandnormalacuityineacheyealone.L
ptosisanddifficultykeepingtheLeyeadducted.Pupilsareroundandreactive,speechisnasalandneck
flexorsareweak.Noparesisorreflexabnormalities.Diagnosis?
A:MyastheniaGravis.AutoimmunedisordercausedbyIgGantibodiestothepostsynapticAchreceptor,
inhibitingstimulationofAch.AdequateAchisreleased,(vs.botulismandLE),butthepost-synapticgatesare
blocked.Thefirstsymptomstodevelopareocular(3rdnervepalsysymptomsofptosisandinabilityto
adduct)orbulbar(dysarthria,dysphagia).Later,extremitiesdevelopweakness,proximal>distal.Doesnot
affectmuscarinic(autonomics)sothepupilisNOTaffected(vs.LEandBotulism).Fatigabilityisahallmark,
andsymptomsareworselaterinthedayandafterexertion.Diagnosiscanbemadebytensiontest(AchesteraseinhibitorincreasestheavailableAch,showingtemporaryimprovement),EMG(repetitive
stimulationcausesdecrementalresponse),andAchreceptorantibodiesinserum.Treatmentincludes
anticholinesterasemedications,thymectomy(associatedwiththymusabnormality,85%ofpatientshave
improvementafterthisprocedure),andsteroids.AcutemanagementofMyasthenicCrisisincludes
plasmapheresisandairwayprotection.
Q:A23-year-oldwithpersistentnumbnessoftheLhand,decreasedsensationinthe4th/5thdigits(palmar
dorsal),weakfingeradduction/abductionespeciallyinthe5thdigit.Cause?
A:UlnarNerveEntrapmentattheElbow.CubitalTunnelSyndromeoccurswhentheulnarnerveis
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entrappedalongtheouteredgeoftheelbow.Compressionleadstoulnarnervesymptoms,including
weaknessofabduction/adductionoffingersandsensorydeficitin4th/5thdigits,whichisthenormal
distributionoftheulnarnerve.Generally,alteringsleepingpositionswillrelievesymptoms.
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ANINJA’SGUIDETOPSYCHOTHERAPY
Disclaimer:Thistherapyguideisnotdesignedtobeacomprehensivereviewofpsychotherapy.Thepurpose
ofthisguideistointroduceyoutotermsassociatedwithvarioustherapiestohelpwithPRITEmultiplechoicequestions.Notallofthisishigh-yield,butitmayhelpfillinanygapsinyourtherapyeducationto
date.Ifnothingelse,youmaylearncommontermsthatgotogetherinPRITE(CBT:automaticnegative
thoughts,Psychodynamic:transference,MelanieKlein:objectrelations)topickuppoints.Thismaterialisa
summaryfromKaplanandSadoktextsandtheMassGeneralPsychiatryReview.
First,anoverviewofthespectrumoftechniquesusedintherapy,frommorepsychoanalytictomore
supportive:
InterpretationàConfrontationàClarificationàEncouragetoelaborateàEmpathicvalidationà
Advice/PraiseàAffirmation
MorePsychoanalytic:
•
•
•
Interpretation:bringingtheunconsciousthoughtstothesurface(conscious)
Confrontation:openlyaddressingsuppressionthroughconfrontingthepatient
Clarification:reformulation,“Sodoyoumeantosay….”
MoreSupportive:
•
•
•
•
Encouragetoelaborate:requestmoreinformation
Empathicvalidation:“Thatmustbereallyhardforyou”
Advice/Praise:therapistgivesconcreteadviceordirectpraisetothepatient
Affirmation:“uh-huh,”“Isee”
ThespectrumgoesfromMostPsychoanalytic(“couchtherapy”)toMostSupportive,withInterpretation
beingmorepsychoanalyticandAffirmationbeingprimarilysupportive.Psychoanalytictherapytendstohave
moreneutralinteractionsbetweenthetherapistandpatient(praise,advice,andvalidationarenotgenerally
psychoanalytictechniques),whilemoresupportiveformsoftherapyusemorepraiseandencouragementin
therapy.
PsychoanalyticalPsychotherapy
Overview:BasedonFreudiantraditionofuncoveringunconsciousaspectsofapatient’smentallife.Focuses
onunconsciousconflicts,repressedfeelings,familyissuesfromearlyinapatient’slife,anddifficultywith
currentrelationships.Occur5-6xperweekx1hourfor3-5years.
Therapist:maynotbevisibletothepatient,sometimesacouchisused,andthetherapistremainsneutral.
Patient:mustbeverymotivated,goodfrustrationtolerance,andhaveminimalpathology
Goals/Techniques:resolveinternalconflictandsymptomreliefthroughexaminationoftransferenceasa
meansofunlockingunconscious.Closeattentionispaidto:
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•
•
•
•
Transference:thepatient’sunconsciousredirectionoffeelingsfromthepasttowardtherapist.
Unconsciously,“Heythistherapistremindsmeofmyoverbearingmother.”
Countertransference:thetherapist’sunconsciousassociationoffeelingsfromthepastdirectedat
thepatient.Unconsciously,“Hey,thispatientremindsmeofmyjerkex-husband.”
Resistance:unconsciousandconsciousforceswithinapatientthatresisttreatment.Ex:patient
repeatedlycomestosessionslateduetounconsciouslyresistingtreatment
FreeAssociation:undirectedexpressionofconsciousthoughtsandfeelingsasanattemptto“tap
into”theunconscious.Basically,saythefirstthingthatcomestoyourmind,asitmayberelatedto
unconsciousstuff.
FourSubtypesofpsychoanalytictherapy(HighYieldPRITEFamousPeopleassociations):
1. ClassicalPsychotherapy:Freud
2. Egopsychology:AnnaFreud
3. Objectsrelationspsychotherapy:MelanieKlein(Objectrelationsarerelatedtodrives;“ego
splitting;”infant-motherrelationships;“depressive/paranoid/schizoidpositions”)andDonald
Winnicott(transitionalobject;“goodenoughmother”)
4. Self-psychology:HeinzKohut(“mirroring;”stuffonnarcissism)
ExpressivePsychotherapy(“Insight-OrientedTherapy”)
Overview:samegoalsandtechniquesusedinPsychodynamictherapywithafewdifferences.Occur3x/week
for30-50minutes
Therapist:face-to-faceinteraction,modifiedneutrality
Patient:cantoleratefrustration,hasintactrealitytesting,goodimpulsecontrol,andongoingsignificant
emotionalsuffering
Goals/Techniques:focusesonacurrentinterpersonaltransferenceinanattempttoreorganizepersonality,
resolveconsciousconflict,andincreaseinsightintointerpersonalevents.Improveobjectrelations.Uses
“hereandnow”interpretation,confront/clarification.Mayusemedications(asopposedtoPsychodynamic
psychotherapy,whichgenerallydoesn’tusemeds).
BriefPsychotherapy
Overview:Mainfocusisonbrevity(limited#ofsessionsunderstoodatthebeginning),patientselection
(rigidcriteria),aspecifictreatmentfocus(onespecificthingtobeworkedon/resolved),andhighlevelsof
therapistactivity.
FamousPRITEPeople:FranzAlexanderfirststartedtoaltertraditionalpsychodynamictherapybyshortening
sessions,decreasingfrequency,andothermeasurestodevelopmodernshort-termtherapy.Otherpeople
involvedinconceptualizingthisformoftherapywereMann,Malan,Sifneos.
EssentialFeaturesofBriefTherapy:Patientsselectedwithspecificinclusioncriteria(moderateemotional
distress,desireforrelief,aspecificproblemtoworkon,functional,abilitytocommittotreatment)and
exclusioncriteria(nopsychosis,substanceabuse,orriskofself-harm).Limitedto12-20hourlongsessions,
afterwhichtherapyisterminated
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Therapist:mustkeeptreatmentfocusedandmovingforwardastherearepre-establishedlimited#of
sessions.Sessionsbeginwithsummaryoflastsession,andrestatingfocus.Homeworkisgiven.Clarificationis
important.Transferencemustbequicklyidentifiedandworkedthrough.
Patient:seeaboveexclusionandinclusioncriteria.Mainly,thepatientmusthaveaspecificareatoworkon
(loss,conflict)andunderstandthat#ofsessionsislimited.
Goals/Techniques:fourcommonfociarelosses,beingoutofstepwithexpecteddevelopmentalstage,
interpersonalconflicts,andsymptomreduction.Brieftherapyworksontransferenceissues,exploresspecific
pasttrauma,reestablishesdefensemechanisms,andresolutionofwhatinitiallybroughtthepatientto
therapy.Threephasesoftherapy:
1. Initialphase:(evaluationthrusession3)evaluatesthepatient,selectsfocus,andestablishedworking
alliance
2. Middlephase:(session4-9)wherepatientstartstoworrytherewon’tbeenoughtimeintreatment,
issuesofseparationandaloneness,feelsworseduringthisphase
3. Terminationphase:(sessions8-16)patientacceptstreatmentending,discussterminationoftherapy
relationship.
InterpersonalTherapy
Overview:developedbyKlerman,utilizedbyHarryStackSullivan,itisabrieftherapythataddresses
relationshipsinthe“hereandnow.”Primarilyusedtotreatdepression.Occursfor12-16weekswithmonthly
maintenancethereafter.
Patient:mostcommonlytreatsMDD
Goal/Techniques:Interpersonaltherapyworkstoimproveinterpersonalcommunication,clarifyfeelings,and
providereassurance.Maybecombinedwithmedicationmanagement.Improveinterpersonalskillsby
examining4problemareas:
•
•
•
•
Unresolvedgrief:facilitategrievingprocess
Socialroledisputes:makeplanofactiontosolveinterpersonalroledisputes(conflictwithco-worker,
spouse,etc)
Socialroletransitions:mournandacceptthelossofanoldrole(demotioninjob,childrenmoveout
ofhome)andearnself-esteeminmasteringanewrole.
Interpersonaldeficits:learntoestablishhealthyrelationshipsanddecreasesocialisolation
SupportivePsychotherapy
Overview:Usuallybrief,withanactivefocusonhelpingthepatientdealwithalifecrisis.Especiallyeffective
foracutegriefreactions.Occurs1x/weekfor30-50minutes,canlastmonths
Therapist:face-to-facewithpatient,non-neutral,providesadvice,sympathy,andsupportwhilereinforcing
thepatient’sstrengths.
Patient:maybeundergoingalifecrisis,poorrealitytesting,lowleveloffrustrationtolerance,impaired
objectrelations,poorimpulsecontrol,mayhaveegodeficits.Thesepatientsaregenerallylessfunctional
thatpatientparticipatingintheotherabovetypesoftherapy.
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Goals/Techniques:formatherapeuticalliance,focusonconsciousexternalevents(noanalysisof
transference),reintegrationofcopingskills,andstrengthendefenses.Usesrealitytesting,advice,empathy,
andcognitiverestructuring.
BehavioralTherapy
Overview:focusesonreducingovertbehaviorsthataresymptomsofmentalillness.
Usesconditioningandmodeling.DevelopedbyJohnWatson.
TypesofBehavioralTherapy:
•
•
•
•
•
SystematicDesensitization(Wolpe):counterconditioningtodecreasemaladaptiveanxiety.Workson
decreasingresponsetoanxiety-provokingstimuli.Treatsphobias.Ex:patienthasfearofheights.
Makeahierarchyofleastfearedtomostfeared.Thinkaboutlessfearedanduserelaxation
techniques(mentalimagery,relaxingmusclesanddecreasingautonomicresponses)todesensitize
selftofear/anxiety.Nowgouponthehierarchy(increasedanxiety-provoking)andrepeattheabove
todesensitizegraduallyupthehierarchy.
Flooding:Similartosystematicdesensitizationinthatastimulusispresentedandthegoalisto
desensitizeoneselftofear/anxiety.However,nohierarchy,norelaxationtechniques,andhasin-vivo
exposure(actuallypresentedwithrealfearratherthanimaginingit).Ex:patientfearofheights,goto
topofhighestbuildingandsitthereuntilfearsubsides.
EMDR:saccadiceyemovementsusedtotreatPTSD
Positivereinforcement:usinga“tokeneconomy”torewardpatientsfordesiredbehavior.Gooduse
inSchizophrenics.Canalsobeusedinaddicts,similartomethadonemaintenance,whereabstinence
fromillicitdrugsleadstopositivereinforcementwithmethadone.
DialecticalBehavioralTherapy:treatsBPD/personalitydisordersusingcombinationof
supportive/cognitive/behavioraltechniques.Workstoimproveinterpersonalskills,anddecrease
self-destructivebehaviors.Addressesambivalence,increasesmotivation,seekstonotreinforce
maladaptivebehaviors,learnnewskills,andrestructurethepatient’senvironment.Useshomework,
advice,andconfrontation.
Biofeedback
Overview:DesignedbyMillertoassumevoluntarycontroloftheautonomicnervoussystemandother
biologicsystemsusingoperantconditioning.
Conditionstreated:includeReynaud’s,tensionHA,migraines,TMJ,epilepsy,asthma,arrhythmias,fecal
incontinence,HTN,andmanyothers.
Methods:usesEMG,skintemperature,BP,andothermeasurementstomonitorphysiologicstates.The
patientusesrelaxationtechniquestoself-modifyautonomicfunctionstoproduceresolutionofmultiple
symptoms.
CognitiveBehavioralTherapy
Overview:focusesontheinterplayofmaladaptivethoughts,feelings,andbehaviorsthatcausemental
disorders.Basically,maladaptivethoughtsandfeelingsleadtounhealthybehaviors.CBTcombinescognitive
therapy(identifyingandchallengingunderlyingcognitiveerrors)withbehavioraltherapy(removing
unwantedbehaviors).Occursoverthecourseof15-20weeks
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Therapist:thegoalistoteachthepatienttobecometheirowntherapistthroughaseriesofassignments,
homework,andcloseinteractionbetweentherapistandpatient
Patient:CBTisproventohelpwithpatientswithMDD,BMD,PanicDisorder,SocialAnxietyDisorder,GAD,
OCD,Phobias,EDO,PsychoticDisorders,andSubstanceAbuse.
Goals:identifyandalter“cognitivedistortions”thatmaintainsymptoms.Thecognitivetriadis:
1. negativeselfperception
2. patientseestheworldasanegativeplace
3. patientexpectsfailureandhardship.
CBTstrivestoidentifynegative“automaticthoughts”thataregeneratedby“cognitivedistortions.”Example:
patientbelievesheistoofattohavefriends.Thisisanautomaticnegativethoughtthatistheresultofa
maladaptivecognitivedistortion/error.
Techniques:3maincomponents
1. Didactics:teachthepatientabouttheirmentaldisorder,thecognitivetriad,theirfaultylogic,and
cognitivedistortions
2. Cognitivetechniques:elicitautomaticthoughts,testlogicofautomaticthoughts,identifycognitive
distortion,testvalidityofcognitivedistortion.Ex:afterherboyfriendbreaksupwithher,apatient
believesnobodywilleverloveher(automaticnegativethought).Therapiststatesthiscognitive
distortionis“overgeneralization”andisuntruethatNOBODYwilleverlovethepatient.Thenthe
patientworkstodisprovethedistortion(testvalidity)
3. Behavioraltechniques:varioushomeworkwithactivitiestoimproveself-relianceandfindnew
healthywaystocope(replacingsubstances,suicidality,eatingdisorderswithexercise,art,etc)
TechniquesforSpecificDisorders
•
•
•
•
•
•
MDD:provideseducation(informationalintervention),activityscheduling(behavioralmodification
ofanhedoniaandPMR),cognitiverestructuring(challengenegativeviewsofself),andproblem
solving(assertivenesstraining)
BMD:stressmanagement,monitoringmoodtoearlydetectdestabilization,improvingregularityof
circadiansystemthroughhealthybehaviors(exercise,diets,etc),problem-solvingskillstoimprove
compliancewithcare
PanicDisorder:educationtostopthe“fear-of-fear”cycleandstopcatastrophicmisinterpretations(“I
amhavingaheartattack”),cognitiverestructuring(decreasenegativityandcatastrophizing),
interoceptiveexposure(exposuretophysiologicsymptomsofanxietythroughrunninginplaceor
hyperventilating,similartodesensitization),desensitization,relaxationtraining
SocialAnxietyDisorder:education,cognitiverestructuring(monitoringand“catching”thoughtsthat
precipitateanxiety.Ex:“AllthesepeoplethinkI’manidiot.”),exposureintervention(desensitization
exercises),socialskillstraining,andsomeinteroceptiveexposures(asusedinpanicd/o)
GAD:education,cognitiveinterventions(examinecognitivedistortionsandnegativity),imaginal
exposuretoworries,relaxationtechniques
OCD:education,exposureandresponseprevention(desensitizationandflooding),cognitive
interventionstohelpbreakintrusivethoughts/ritualisticbehaviors
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•
•
•
•
•
•
•
PTSD:education,cognitiveinterventionstochallengeperpetualfearofdanger,imaginalexposure
(narratetrauma,extinguishextremeemotionalresponse,learntofeelsafe),desensitizationin-vivo,
relaxationtechniques
Phobias:exposureinterventions,participantmodeling(therapistexemplifiesabehavior[touchinga
snake]andencouragespatienttocopythebehavior)
BulimiaNervosa:education(includinghealtheducation),self-monitoringandreportingEDO
behaviors,stimulus-control(decreasingtriggers[ex:don’teatinmallwithallskinnyfriends]),
cognitiverestructuringbodyimageandchallengingnegativethoughtsaboutbody,problem-solving
(findnewwaystocopewithstressorsratherthanbinge/purge)
AnorexiaNervosa:positiveandnegativereinforcementproceduresinitiallytoprotecthealthand
decreasehospitalization/decompensation.AlsousetheabovetechniquesforBulimia
Substanceabuse:motivationalinterviewing,functionalanalysis(examinefunctionbeforevs.after
substanceabuse),self-monitoring,cognitiveinterventionstochallenge“allornothing”thoughts(“I
hadonedrink,Iblewit,Imightaswellcontinue”)andotherdysfunctionalthinking,problem-solving
(identifynewmeansofcopingwithstressors),andcontingencymanagement(contracts,positive
reinforcement)
PsychoticDisorders:education,cognitiveinterventionstopromotemedicationcompliance,social
skillstraining,stressmanagement
Personalitydisorders(needlongertreatmentCBTthanAxisId/o):emotionalregulation(identify,
tolerateandmodifyemotions),reductionoftherapy-interferingbehaviors(resistance),challenge
cognitivedistortions,stressmanagementandproblem-solving(newcopingskillsratherthan
unhealthymechanisms)
GroupTherapy
Overview:grouptherapyofferstheopportunityforpurposefullycreated,closelyobserved,andskillfully
guidedinterpersonalinteractioninacollectionofpatientsbroughttogetherbyaleaderforashared
therapeuticgoal.
Therapist:plansandorganizesgroupafteridentifyingspecificgoalsofthegroup.
Patients:patientsselectedforagroupbasedonneeds/diagnosis/goalsofgroup.ActiveSI,manic,psychotic,
andemotionallysadomasochisticindividualsarecontraindicated.Groupsneedtobesomewhat
homogeneousinegodevelopmentforpsychodynamicgroups.
Goals:Re-establishpre-morbidlevelsoffunctioninginpeoplewithacutedistress,supporttargeted
populations(medicalillnesslikecancer,ormentalillnesssupportgroups),providerelieffortargetsymptoms
(ex:eatingdisorders),encourageandstimulatecharacterchange(helpsidentifymalignantcharacterdeficits
inapatientthroughgroupreflection,andtopromotehealthychange).
TherapeuticFactorsinGroupTherapy(PRITEquestionsinpast):
•
•
•
•
•
Abreaction:unearthrepressedemotions,andrelivethemtoincreaseinsight
Acceptance:feelingofbeingacceptedbythegroup,absenceofcensureanddifferenceofopinionis
tolerated.
Altruism:onememberhelpsanother,helpstoestablishcohesion
Cohesion:groupisworkingtogetherforacommongoal.
Contagion:expressionofanemotioninonememberelicitstheexpressionofemotioninanother
member
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•
CorrectiveFamilialExperience:groupre-createsfamilyoforiginforonemembertohelpthemwork
throughoriginalconflict
• Empathy:groupmembercanputhimselfinthepsychologicalframeworkofanothermemberand
understandthethinking,feeling,andbehavior.
• Imitation:emulationormodelingofone’sbehaviorafteranotherperson
• Inspiration:impartingasenseofoptimismtogroupmembers
• RealityTesting:person’sabilitytoevaluatetheworldoutsideofthemselvesandperceivereality
accurately
• Universalization:theideathatanindividualisnotalonewiththeirproblems
• Ventilation:expressionofsuppressedfeelings,ideas,oreventstogroupmemberstoamelioratea
senseofshameorguilt(akaselfdisclosure)
TypesofGroupTherapy:
•
•
•
•
Supportive:weeklyovermonths,shareduniversaldilemmas,helpsadapttoenvironment.
UniversalizationandRealityTesting
Psychodynamic:1-3x/weekforyears,forneuroticdisorders,workonpresent/pastlifesituations,
focusoninterpretunconsciousconflicttochallengedefensesandreduceshame.Catharsis,Reality
testing,ExamineTransference
CBT:weeklyupto6months,phobiasorcompulsionstreated,worksoncognitivedistortionsto
relievespecificpsychiatricsymptoms.Reinforcement,Cohesion,Conditioning
Inpatient:dailygroupswithrapidturnoverofpatients,heterogeneousgroups,emphasisonthe
“hereandnow,”problemsolving,educationontreatment.EmpathyandRealityTesting
FamilyTherapy
Overview:seekstoresolvefamilyconflict,meetsfamilymembers’individualneeds,establishhealthyrole
relationships,copewithdestructiveforcesinsideandoutsidethefamily,andintegratethefamilyinto
society.Occursweeklyfor1-2hours.Familymaypresentwithasinglefamilymemberidentifiedasthe
“problem”butthedynamicislikelymuchmorecomplexthanthat.
Goals:alterinteractionsandimprovefunctionalityofthefamilyasaunitofindividuals.Bringtolighthidden
patternsandunderstandthepurposeofthesepatterns.
Techniques:collectathoroughhistory,includingafamilylifechronologyinthefirst2sessions.Understand
howtheparentsoperatefrommodelsfromtheirownparents/families.Onetechniqueusedis“reframing”
(ex:“Thischildisimpossible,”canbechangedto“Thischildistryingtodistractyoufromanunhappy
marriage).
TypesofFamilyTherapy:
•
•
Behavioral/CBT:coreconceptsarefunctionalanalysis,sociallearning,andcommunication.Goalsare
toresolveproblemsbyimprovingcommunicationandproblem-solvingskillswhilebalancingchange
vs.acceptance.Thisisthe#1empiricallysupportedfamily/couplestherapy
BowenFamilySystems:coreconceptsaredifferentiationofself,triangulation,familyemotional
system,andsiblingorder.Goalsaretoincreasefamilymemberdifferentiation,decrease
triangulation,andmanageanxiety.Usesgenograms
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•
•
•
•
•
•
•
Experimental/Humanistic:coreconceptsareattachmenttheoryand“psychotherapyoftheabsurd”
(seriously).Goalsarecreativity,increasingself-esteemandfosteringcohesionthroughwacky
activitieslikefamilysculpture.Mayhave2therapists
MilanSystem:coreconceptsareneutrality,circularinteractionbetweenfamilyandtherapists,
familiesgetstuckinpatternsofinteraction,solutionsresidewiththefamily,notthetherapist,“longtermbrieftherapy”(longsessionwithamonthbetweensessions).Goalsareunmaskingthe“family
game,”changingmaladaptivepatterns.Techniquesincludetherapistteambehindaone-waymirror,
“hypothesizing,”“counterparadoxicalinterventions”(intentionallyengageinunwantedbehaviorsto
increaseinsight),and“circularquestions”designedtoimproveempathy(“Whatdoyouthink
concernsyourwifemostaboutyourillness”).Thisissuperfamousfamilytherapyandsometimes
getstested
Narrative:coreconceptsarenarrativestoriesofthefamilysystemdesignedtomakeothers
understandthedynamic,understandingthefamilysysteminthecontextofanarrativestory.Goals
arecreationofnewer,moreusefullifestories,externalizeproblemsratherthanblamingsingle
membersforproblems,enhancecommunicationthroughtherapeuticletters
Psychodynamic:coreconceptsareprojectiveidentification(projectingyourundesirable
characteristicsontoanotherperson),splitting,scapegoating,andchangeoccursthroughconscious
insightintounconsciousprocesses.Goalsincludeincreasinginsight/empathy,disentangle
interlockingpathologies,identifytransferencewithinthefamilydynamic,andchallengeresistance.
Creationofa“holdingenvironment.”
Psychoeducational:coreconceptsareexpressedemotion,engagementwiththefamily,education
workshops,andrehabilitation.Goalsincludeimprovingsocialskillsandcommunications,problemsolving,relapseprevention.Thisisthe#1familybasedtherapyforfamilieswithamemberwith
schizophreniaoranothermajorpsychiatricdisorder
Structural:coreconceptsareboundaries,familyhierarchy,coalition/alliance,and
engagement/enmeshment.Goalsareimprovingflexibility/adaptability,findingabalancebetween
connectednessanddifferentiation,andhomeworkbasedproblemsolving
Strategic:coreconceptsarepower/control,familylifecycletransitions,rolechanges,adaptingto
change.Believeindividualcannotchangeuntilthesystemthatsustainsthemchanges.Goalsare
problem-solvingwithidentificationof“exceptiontotherules,”addressdoublebinds,disrupting
sequencesofbehaviorthatperpetuateproblems,“paradoxicaldirectives.”
CouplesTherapy
Overview:focusesonthepatternofinteractionsbetweentwopeoplewhiletakingintoaccountthe
individualhistoryofeachmember.
BasicPrinciples:monitorforprojectiveidentificationandre-enactmentofchildhoodattachmentissueswith
spouse.Acouple’srelationshiphasalifecyclecontext,withinthecontextofchangesintheindividualand
changesinthefamily.Lifecycleimpliesthattransitionfromonelifecycletoanotherhasthehighestriskfor
divorceandconflict(midlifecrisis,aging,etc).Communicationskillsareessential.Contraindicatedincasesof
domesticviolence,psychosis,orwhendivorcesisactivelybeingsoughtout.
TheInterview:componentsshouldincludeevaluationofeachpartner’smotivationtoparticipatein
treatment,providingasafeenvironmentinthefirstsession,identifyingeachmember’sviewofwhatthe
problemis,assessingforinfidelity,andidentifythebiggestsourcesofconflict.
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Goals:alleviatedistress,promotewell-beingasaunit,problem-solving,promoteaccountabilityand
responsibility.
TreatmentInterventions:interpretationofunconsciousprocesses,communicationskillstraining(including
learningactivelisteningskillsandlearningtofightconstructivelywithspecificrules),roleplaying(role
reversaltoincreaseempathy),andparadoxicalinterventions(reversepsychologystuffwhereatherapisttells
memberNOTtochange,leadingtochange).
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ANINJA’SGUIDETOFREUD&OTHERSTUFF
SigmundFreud
Associatedwiththetermsresistance,transference,countertransference,parapraxes(“Freudianslips”),
abreaction(recoveringrepressedfeelingstoremovesymptoms),catharsis,repression(hidingdistressing
materialintheunconscious)andmanymore.
InterpretationofDreams
Basedonthepremisethatdreamsareunconsciouswishes(potentiallychildhoodwishes)thatarenot
accessibleinwakinglife.ThefollowingtermsaresometimesseenonPRITE,requestingadefinition.
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Twolayersindreams:manifestlayeriswhatisremembered/recalledofdream;latentlayeristhe
unconsciouswishthatisnotrecalled
Condensation:severalunconsciousimpulsesareattachedtoonemanifestdreamimage(example,a
manwithafacemadeofbreadplayingatrumpetmaybethedreamer’sfearofmenconsuming
creativeinstincts…orsomethinglikethat)
Displacement:intensitytowardanobjectisredirectedtoamoreneutral/acceptableobject
(example:dreamerunconsciouslywantstokilltheirmother;inthedreamtheywanttokillan
unknownfemalestranger[moreacceptableobject])
Projection:dreamer’sunacceptablewishesareputontoanotherpersoninthedream(example:
dreamerwantstorobabank,indreamtheyareconcernedabouttheirbrother’sdesiretoroba
bank)
Symbolicrepresentation:innocentsymbolrepresentsacomplexsetoffeelings(example:dreamer
seesapuppy,whichactuallyrepresentstheirfeelingsofvulnerabilityandfearofbeing
castrated/neutered….orsomethinglikethat)
Primaryprocess:theaboveincoherentesotericcharacteristicsofthemanifestlayer(nonsensical
dreamaspectsthatarerecalled)
Secondaryrevision:rationalportionsofdreamsthatresemblewakinglife(dreamsactingout
work/homescenarios,beingoncall,etc)
TheTopographicalModeloftheMind
Basedonprinciplethatthemindisdividedintolayers.Freudusedthistheorytoidentifytheworkingsofthe
consciousandunconsciousmind.
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Conscious:ideas/thoughtsareintheconsciousminddueto“psychicenergy”(attentioncathexis),
whichpushesthesethoughtsintotheconsciousforefront
Preconscious:thisistheareawherethoughtsareheldbeforebeingpushedintotheconsciousmind.
Unacceptableunconsciouswishesheldheremaybepushedintoconsciousnessbypsychicenergy
Unconscious:theareaoftheprimaryprocess(seeabovedefinition)thatisincoherentand
representswishfulfillment.Memoriesareseparatefromwords,andpsychotherapyhelpstoattach
wordstounconsciousthoughtsandbringthemtotheconsciousmind
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InstinctandDriveTheory
Afterdevelopingthetopographicalmodelofthemind,Freudbegantoconsiderinstincttheory.Instinct
referstoapatternofgeneticallyderivedbehaviorthatisindependentoflearning.Theinstincthas4basic
characteristics:thesource(partofbodyfromwhichinstinctarises),theimpetus(intensityofinstinct),the
aim(generallyanactiontowarddecreasingtension),andtheobject/targetoftheinstinct.Specifictypesof
instinctarelibido,ego,andaggression.
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LibidoInstinct:sexual/pleasuredrives
EgoInstinct:non-sexualinstincts/drives
Aggression:dualinstincttheoryreferstothebalancebetweenlibidoandaggression,where
aggressionaimstodestroy
Pleasurevs.RealityPrinciples
ThePleasureprincipleisthathumansavoidpainandseekpleasure.TheRealityprincipleisthatwhich
delays/postponesthepleasureprinciplewhenitisnotappropriate.TheRealityprincipleisgenerallylearned.
Narcissism
Basicprincipleisthattheperson’slibidoisinvestedintheegoratherthaninotherpersons.Therecanbea
lossofrealitytestingandgrandiosity.Freudregardedhomosexualityasanarcissisticformofobjectchoice,
whenapersonfallsinlovewithanidealizedversionofthemselvesprojectedontosomeoneelse.
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Primarynarcissism:afterbirththeneonateiscompletelynarcissistic,withalllibidoinvestedin
meetingtheirownneeds.Theadditionofthemotherfigureleadstowithdrawalofthelibidofrom
selfandredirectedontotheexternalobject(mom).Thisisobjectattachment.
Secondarynarcissism:ifafterobjectattachmentoccurswiththemother,thereisalatertrauma,the
libidoiswithdrawnfromthemother(object)andreinvestedintheperson’sego.It’saregression.
TheStructuralTheoryoftheMind
Freudmovedfromthetopographicalmodelofthemindtothestructuraltheoryofthemind,whichfocused
ontheego,id,andsuperego.
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Id:unorganizedinstinctualdrivesthatarepartoftheprimaryprocess(seeabove).Occurs
unconsciously
Ego:spansallthreeareasofthemind(conscious,preconscious,andunconscious).Itisresponsible
forlogic/abstraction(conscious),defensemechanisms(unconscious),perception,contactwith
reality,anddelay/modificationofdrives(tomakethemsociallyacceptable).Theegohelpstomodify
theid,whichsometimesleadstoconflict
Superego:establishesandmaintainsthemoralconscience,basedonvaluesinternalizedfrom
parents.Proscribeswhatapersonshouldnotdo
FunctionsoftheEgo
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Controlsinstinctualdrives:mediatesbetweentheidandtheexternalworldanddelaysdrivesis
sociallyunacceptable
Judgment:anticipatestheconsequencesofactions
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•
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Relationtoreality:mediatesbetweeninternalworldandexternalworld.Developsasenseofreality
(distinguishinsidebodyvs.outsidebody),realitytesting(distinguishbetweenfantasyandreality),
andadaptationtoreality(adapttochange)
Objectrelations:developingsatisfyingrelationshipsstemsfromearlyinteractionswithparentsand
otherearlysignificantfigure.
DefenseMechanisms
TheseareverycommononPRITE,andbasicallyaregroupedfromthemostprimitive(likeprojection)tomost
mature(likesublimation).
Narcissistic(MostPrimitive)
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Denial:abolishesexternalreality(“Idon’thavecancer”)
Distortion:reshapesrealitytosuitinternalneeds(delusions,hallucinations)
Projection:endowingyourfeelingsontosomeoneelse(“Whyismomsoangrytoday?”whenreally
YOUareangry).Canincludeparanoiddelusionsanddelusionaldisorders,whichputsone’sfeelings
ontoothers(“Theywanttoharmme”)
Immature
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Actingout:givingintoanimpulsetorelievetension(burningdownahouse)
Blocking:inhibitingorblockingthoughts,pushingthemintotheunconscious.Blockingthoughtscan
leadtoincreasedtension
Hypochondriasis:overemphasizingillness,isaregressiontoavoidguiltandresponsibility
Introjection:internalizinganobject’squality.Anexampleisidentificationwithanaggressor
(internalization)leadingtobeliefthattheaggressionisunderone’scontrol.(“Poorthief,heprobably
reallyneedsacar.LookhowbenevolentIam”)
Passiveaggressivebehavior:indirectaggressionthatisnotovert(likeprocrastinationthatmakes
someoneelsesuffer)
Regression:returntoalessdevelopedphase(“Iwantmyteddybear”)
Schizoidfantasy:autisticretreattoavoidconflict.Repelsothersandavoidintimacy
Somatization:transformconsciousorunconsciousconflictintobodysensations/symptomstoavoid
dealingwithit.(Kidwithstomachpainontestdays)
Neurotic
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Controlling:obsessivemanagementofexternalenvironmenttodecreaseanxietyandresolveconflict
Displacement:shiftemotionfromoneobjecttoanother(baddayatwork,gohomeandyellatyour
spouse)
Externalization:generalizedprojectionwheretheentireworld/externalenvironmentisattributed
withpersonalelements(feelingangry,“Thewholeworldisanangryplace!”“Thisjobisso
uncaring!”)
Inhibition:renounceegofunctionstodecreaseanxiety
Intellectualization:useintellecttoavoidanemotional/affectiveexperience(getcancer,spendall
yourtimeoninternetlearningaboutittoavoidemotionallyexperiencinghavingcancer)
Isolation:separateanideafromanaffect(“isolationofaffect”PRITEquestionhasapatientwho
blanklytellstherapistthat,asachild,hisdadkickedapuppytodeath.Noaffectintellingstory)
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Rationalization:usingrationalexplanationstojustifyanunacceptablebehaviororbelief(“I’m
allowedtotakestacksofnapkinshomefromMcDonald’sbecausethey’lljustthrowthemaway
anyway”)
• Disassociation:modifyone’scharacter/identitytoavoidemotionaldistress.(“dissociativefugue”is
whenapersongoesplaces/doesthingsbutretainsnomemoryandappearsconfusedafterwards.
Disassociationisoftenusedbypatientswithborderlinepersonalitydisorder,andisanumbingof
sensoriuminresponsetotrauma)
• Reactionformation:unacceptableimpulse/emotionisconvertedtoanacceptableimpulse(youhate
yourneighborbecausetheyarenoisyatallhoursofthenight,butthishatredfeels
unacceptable/elicitsguilt.Asaresult,yougogiveyourneighborapresenteventhoughtyouhate
them)
• Repression:putanundesirablethought/feelingintotheunconscioustoavoiddealingwithit.Thisis
differentfromsuppression,whichconsciouslyavoidsthethought(Repression:forgetting
(unconscious)arapeattheageof5.Suppression:choosingnottothinkabouttherapethat
happenedatage5).Repressionissimilartothoughtblocking,exceptnotensionisobservedwith
repression
• Equalization:makinganeutralobjectsexualtodecreaseanxietyrelatedtoaprohibitedimpulse(No
clue.Havefunwiththatone….)
MatureDefenses
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Altruism:providingagratifyingservicetoothersforthevicariousexperience(volunteeringtoraise
moneyforcancermakesyoufeelallwarmandfuzzyinside)
Anticipation:anticipatefuturediscomfort(comingupwitharealisticback-upplanforproblemsin
thefuture,likeanearthquakesafetykitinthegarage)
Asceticism:gratificationthroughlimitationandrenunciation
Humor:usinghumortotolerateterribleexperience.Thisdefensemechanismactuallyfocusesonthe
experience(“Well,nowthatI’velostbothmylegs,I’llsaveloadsofmoneyonshoes.”)
Sublimation:impulsegratificationbyconvertingsociallyunacceptableimpulsestoacceptableactions
(gardening,painting).Feelings/impulsesareacknowledgedandmodified
Suppression:consciouslypostponingdiscomfort(onechildincaraccident,ratherthanfirstrushingto
ER,suppressesfearandcallstheotherkidsathometomakesuretheyaresafeandcaredfor,then
goestoER)
PsychosexualDevelopmentalStages
Basically,theseareFreudianDevelopmentalstagesthatoftenaretestedonPRITE.Thegoalistoprogress
throughthesestageslinearly,confrontingpathologyspecifictoeachstage,leadingtoresolutionof
conflict/pathologyandmovingontothenextstageinlife.Failingtoresolvepathologyleadstoincomplete
passagethrougheachstage,andthepersonwillcontinuetostrugglewithunresolvedissuesfromprevious
stages.Example:Apersonwhodoesnotresolvetheissuesofovercontrolvs.undercontrolintheanalstage
(age1-3years)willforeverstrugglewithautonomyissuesandbalanceofcontrol(makingthem“anal
retentive”andovercontrolling).Therapyseekstofindtheseunresolvedissuesandbringresolutiontowards
bettermentalhealth.Whilesometheoryseemsabitweird(penisenvy,castrationfears),theoverall
principleofworkingthroughunresolvedearly-lifeissuesisreasonable.ThesestagescorrelatewithEriksonian
Stages(discussednext).
Oral(0-18months):conceptsofthirst,hunger,andsatiation.Libido(oraleroticism)vs.Aggression(oral
sadism,biting,devouring,anddestroying).
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Goal:developtrustanddependenceandgratifylibidowithoutconflictwithaggression.
Pathology:narcissism,pessimism,dependenceonobjects/peopleforself-esteem,envy,jealousy
Resolutionofthisstage:learntogiveandreceivewithoutexcessivedependency/envyandbuild
trust/self-reliance.
Commondefensemechanisms:projectionanddenialinearlyoral,displacementand“turnagainst
self”inlateroral.
Anal(1-3yearsold):conceptsofcontrol(overanalsphincter),increasingaggressivedrives,andtheshift
fromapassive/dependentphase(oral)toanactivephase.
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Goal:separation,individualization,maintainingabalancebetweenovercontrol/undercontrol.
Relatedtoautonomy/independencewithagoodbalanceofcontrolvs.shame/self-doubtduetolack
ofcontrol.
Pathology:overcontrolleadstobeingoverlyneat/orderly,stubborn,andwillful.Lossofcontrolleads
tomessiness,ambivalence,anddefiance.Obsessive-compulsiveneurosispathologydevelopsinthis
stage.
Resolution:autonomy,initiativewithoutguilt,self-determiningbehaviorswithoutshameanddoubt.
Commondefensemechanisms:undoing,reactionformation,regression,andisolation.
UrethralTransitionStage(betweenanalandphallicstages):releasevs.retention.Thereisthepotentialfor
regressioninthistransitionfromanalstage(balanceofcontrol,autonomy)movingontophallicstage.
Regressiveenuresiscanoccurhere.
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Pathology:competitiveness/ambition,feminineshameduetolackofstrongurinestream
(seriously…)
Resolution:prideandself-competence,setsthestageforgenderidentity.
Phallic(3-5yearsold):sexualinterest,stimulation,andexcitement.Unconsciousoedipalissues(boy’s
competitionwithfatherforthemother’slove)andcastrationanxiety.
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Goals:genderidentity,overcomeoedipalissuesfororganizationofcharacter.
Pathology:neurosis,castrationanxietyinmales,penisenvyinfemales,abnormaldevelopmentof
humancharacter.
Resolution:abilitytomaintaincuriositywithoutembarrassment,initiationwithoutguilt,sexual
identity,regulationofdriveimpulses,generatesuperegobasedonidentificationwithparentofthe
samesex.
Commondefensemechanisms:Intellectualizationvs.repression
Latency(5/6-11/13yearsold):developmentofthesuperegointhephallicstageleadstoinstinctcontrol.In
latency,thelibidogetssublimated(directedintosociallyacceptablebehaviors).Starttoplayandlearnwhile
fightingovercontrolandobsessions.
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Goals:finishtheworkstartedinthephallicstagebyfurtherintegratingoedipalidentificationand
consolidatingsexroles.DevelopEgoandbegintomasterskills.
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Pathology:Issuesofcontrol(likeinanalstage),withproblemswithovercontrol/undercontrol.
Overcontrolleadstoclosure/stuntingofpersonalitydevelopment.Undercontrolleadstonot
focusingonlearninginthisstage.
Resolution:integratingpsychosexualdevelopment,masteringtasks/objects,becomingautonomous,
andlearningtotakeinitiative.
Commondefensemechanisms:sublimation.
Genital(11/13-Adulthood):physicalmaturity,hormonaldevelopment,increasingdrives.Thereisastruggle
againstregressionandthisstagemayreopenallconflictsinpreviousstages,leadingtotheneedtore-resolve
them.
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Goals:separatefromdependenceonparents,developmatureobjectrelations,developadultroles,
andacceptculturalvalues.
Pathology:reopening/reworkingpreviousdevelopmentandpotentialforregression;previous
unsuccessfulresolutionleadstopathologyinadulthood.
Resolution:reintegrationandresolutionofpreviouslyunresolvedconflictsleadstomaturationof
personalityandcapacityforself-realization.
ErikErikson
AdaptedsomeofFreud’stheoriesofdevelopmenttoformulateatheoryofdevelopmentthatcoversthe
entirespanofthelifecycle,frominfancyandchildhoodthrougholdageandsenescence.Epigenetic
principle:developmentoccursinsequential,clearlydefinedstages,andthateachstagemustbesatisfactorily
resolvedfordevelopmenttoproceedsmoothly.Avirtueisassociatedwitheachstage.
“Ifeverythinggoesbacktochildhood,theneverythingissomebodyelse’sfaultandtaking
responsibilityforoneselfisundermined."
Trustvs.Mistrust(0-18months,correlateswithOral)
Startingtotakeintheworldandlearntrustbasedonqualitymaternalrelationship.“Takingandholdingonto
things.”
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Defensemechanisms:projectionandintrojection
Virtue:hope
Pathology:schizophrenia(aggravatedcrisisduetofailingtodevelophope),depression(feeling
empty,nogood),addictionsissues
Autonomyvs.ShameandDoubt(18months-3years,correlateswithAnal)
Developingasenseofjusticeandmaintainingabalancebetweengoodwill/cooperativenessandwillfulness.
Self-certainvs.self-conscious.Regulatethewill.Willtobeoneselfvs.self-doubt.“Holdingonandlettinggo.”
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Virtue:will
Pathology:persecutoryparanoia(stuckbetweentrust/autonomouswillandmistrust/doubt),OCPD
(conflictwithholdon/letgo,leadingtodoubt>autonomyandaharshconscience),impulsivity.
Initiativevs.Guilt(3-5yearsold,correlateswithphallic)
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Exploration,conquest,curiosity,competitive,aggressive,preoccupationwithgenitals.Competewithsame
sexparent,jealousy,andrivalry.Failureleadstoguilt.Roleanticipationvs.roleinhibition.Thesuperegois
developedtoregulateinitiative.Oedipalimpulseisovercomeandthechildcanthencompeteintheoutside
worldandlearntoleadanactiveadultlife.“Beingonthemake.”
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Virtue:purpose
Pathology:overcompensationfortheconflictbetweeninitiativeandguilt.Thiscancauseconversion
disorder,inhibition,paranoia,andpsychosomaticillnesses.
Industryvs.Inferiority(5-13yearsold,correlateswithlatency)
Learningnewskills,pride,workethic,anddiligence.Identifywithteachers.Learntofindroleinsociety.Task
identificationvs.senseoffutility.
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Virtue:competence
Pathology:failuretocompletepreviousstagesleadstomistrust/pessimism,imbalancebetween
overcontrol/undercontrol,poordevelopmentofthesuperegoandguilt.Ifthereisnodevelopment
oftrust/balanceofcontrol/creationofsuperego,thechildwillnotintegratewellintosociety.In
addition,theywillnotlearnnewskillsandbecomecompetent.Thisallleadstocreativeinhibition
andconformity.
Identityvs.RoleConfusion(13-21yearsold,correlateswithgenital)
Puberty,compareselfwithothersandcarehowothersperceivethem,cliques.Failureleadstoidentity
diffusionandroleconfusion.Intoleranceofindividualdifferencesisthewaytheyouthwardsoffasenseof
theirownidentityloss.Fallinginloveservestoclarifyone’ssenseofidentityprojectingyouridentityonto
anotherperson.
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Virtue:fidelity,sustainingloyaltiestoothersdespitecontradictionofvaluesystems(accepting
peopleforwhotheyare).
Pathology:roleconfusionensueswhenthepersoncannotformulateasenseofidentity.Thisresults
indelinquency,gender-relatedidentitydisorders,andborderlinepsychoticepisodes.
Intimacyvs.Isolation(21-40yearsold)
Looksatthevirtueoflovewithinabalancedidentity.Intimacyistiedtofidelity,tomakecompromiseandto
self-sacrifice.Egolossoccurswhenbecomingclosertoothers;thereactionmaybetobecomedetachedand
self-absorbed.
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Virtue:love
Pathology:isolationanddetachedstates,includingschizoidpersonalitydisorder.
Generativityvs.Stagnation(40-60yearsold)
Establishingandguidingthenextgeneration,notjustspecificallyyourownoffspring.Personhasalready
learnedtoformintimaterelationships,andthisstageservestobroadensocialscopetoincludegroups,
organizationsandsociety.Importanceoffeelingneeded.Failureofgenerativityleadstostagnation,
escapisms(alcoholandothersexualinfidelity),andmid-lifecrisis.
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Virtue:care
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Pathology:alcoholism,divorce,witheringofleadershiproles/destructionofcompanies,premature
invalidism.
Integrityvs.Despair(60yearsolduntildeath)
Acceptingresponsibilityforone’sownlife,holdingontointegrity,anda“detachedyetactiveconcernwith
life.”
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Virtue:wisdom
Pathology:failingtoattainintegrityleadstobecomingdeeplydisgustedwiththeexternalworldand
contemptuousofpersonsandinstitutions.Disgustsmasksthefearofdeathandasenseofdespair
that“timeisnowtooshortfortheattempttostartanotherlifeandtryoutalternateroutesto
integrity.”
“Healthychildrenwillnotfearlifeiftheireldershaveintegrityenoughnottofeardeath.”ErikErikson
PathologicDevelopment
InbothFreudandErikson’sdevelopmentaltheoriesoneconceptiscentral:failuretoresolveconflictand
maturethrougheachstageleadstosignificantresidualpathology.Plainlystated,ifyoudon’tresolvethebad
stuffineachstage,youwillgoontothenextstagewithunresolvedbaggageandcontinuethroughlifewith
thatbaggage.Apersonwhodoesnotresolveoral/trust/mistruststageswillhavealifelongstrugglewith
dependence,trust,hopelessnessandmentalpathology.Thissectionisnothigh-yieldforPRITE,butitisvery
usefulforprovidinggoodcareforyourpatients,understandingtherootsofpathology,andmakingakickass
bio-psycho-social-spiritualformulationfororalexaminationsinresidency.
Birthto18months
Freud:Oralstage(feeding,nutrition,needs,narcissism,objectrelations),trust/give/receive.
Erikson:Trustvs.Mistrust(takingandholdingontothings),HOPE,projection
Pathology:Impairedtrustleadstomistrust.Associatedconditions:
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Separationininfancyleadstodepression,hopelessness,dysthymia
Projection(defensemechanismassociatedwiththisstage)leadstosocialmistrust,paranoia,
delusionaldisorders,schizoidpersonalitydisorder,andparanoidschizophrenia.
Socialmistrustleadstooraldependencyandsubstanceabuseduetothefeelingsofemptinessand
hunger.
Feelingstarvedandemptyalsoleadstothrillseekingbehaviors
18monthsto3years
Freud:Analstage(controlofsphincters),balancebetweenovercontrol/undercontrol,individualization
Erikson:Autonomyvs.ShameandDoubt(holdingonvs.lettinggo),independenceandthedevelopmentof
will
Pathology:developswhenshameanddoubtdominateautonomy
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Doubt>autonomyleadstoobsessivepersonality
Shame>autonomyleadstofeelingdirty,delinquentbehaviorandparanoiaaboutcontrol
Rigoroustoilettrainingleadstoexcessivecleanlinessandcompulsions
Overcontrolleadstoobsessions/compulsions,willfulnessandanalretention
Undercontrolcausesambivalence,messiness,andsadomasochism
Mistrust(inearlierstage)PLUSshameanddoubtleadstopersecutorydelusions
Refusaltobecontrolledcausesimpulsivity
3to5years
Freud:phallicstage(issuesofoedipalconflict,genderidentity,penisenvy/castrationanxiety),identification
withparentsleadingtothedevelopmentofsuperegotoregulatedrives.
Erikson:Initiativevs.Guilt(expedition,competitionwithparent),conscience,purpose,childlearnsvalues
andrecognizestheexternalworld,guiltsecondarytodrivesvs.initiative.
Pathology:guiltrelatedtoimpulsesanddesiresleadstosymptomformation.
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Guiltleadstoanxietydisorders,phobias,sexualinhibition(duetofearofpunishment)
Punishmentforimpulsesleadstoconversiondisorderduetooedipalwishes,andsexual
inhibition/impotence
Fearofnotfulfillingone’spurposeleadstopsychosomaticdisease
5to13years
Freud:Latencystage(superegodevelopedinphallicstagenowcontrols/regulatesdesiresandwishes),sexual
identity,learning,masteryofskills
Erikson:Industryvs.Inferiority(learnskills,begintoestablishidentity),competence,integrationintosociety
Pathology:developmentofinferiorityduetoproblemscompletinggoals
•
Workinhibition,feelinginadequate,compensatorydriveformoney/power/prestigelaterin
adulthoodattheexpenseofintimacy(laterstagessufferduetoincompletionofthisstage)
13yearsto20s(Adolescence)
Freud:Genitalstage(maturation,reworkingconflict),separation/independence,emphasisisonreworking
unresolvedissuesfromthepreviousstages.
Erikson:Identityvs.RoleConfusion(puberty,egoidentity),roles,fidelitytooneself.
Pathology:identityconfusion
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Lossofidentitythroughoveridentificationwithothersandformulationofcliques
Ifunabletoleavethehome,theremaybeprolongeddependence
Roleconfusionleadstoconductdisorder,genderidentitydisorder,anddisruptivebehavior
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20sto40s
Freud’slastsagewasthegenitalstage,whichfocusedoncontinuingtoworkthroughpreviousconflict
throughoutadulthood.TheremainingdiscussionondevelopmentofpsychopathologywillfocusonErikson.
Erikson:Intimacyvs.Isolation(maintainingidentitywhileestablishingintimacy),sacrifice/compromise,love.
Pathology:theinabilitytotakerisks,capacitytoloveandisolationleadstoschizoidpersonalitydisorder
40sto60s
Erikson:Generativityvs.Stagnation(guidingthenextgeneration),triballeaders,caring,newlyachieved
personalintimacywithsocialgroups,knowledgeandskills.
Pathology:developswhenapersoncannotgenerateofskillsandshareknowledgewiththenextgeneration
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Stagnationleadsto“escapism”intoalcohol/substances,infidelityandmid-lifecrisis
Societysuffers,thepatientsuffers,leadingtodepressionanddisappointment
Contemplationofpastfailures,currentproblems,andlosinghopeforthefuture.
60stoEndofLife
Erikson:Integrityvs.Despair(acceptthelifecycleandtheproximityofdeath),healthydetachmentand
wisdom
Pathology:theknowledgethattimehasrunout,nogenerativity,andinabilitytoacceptlife
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Decliningphysicalhealthleadstoanxiety,psychosomaticillness,hypochondriaanddepression.
Lackinggenerativityandacceptanceoftenleadstosuicide
NeuropsychologicTesting
ThisisahighlytestedareaonPRITE.Examplesarequestionsaskingyoutochoosethe“projectivetest”or
willgiveyouthenameofthetestandaskyouitsfunction.Reliabilityreferstotheabilitytoreproducethe
testresults.Validityshowsifatestcanaccuratelytestwhatitissupposedto.
TypesofTests:
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Objective:typicallypencil-and-papertestswithspecificquestionsthatcanyieldnumericscorestobe
analyzed.AnexampleistheMMPI.
Projective:ambiguousstimulithatthepatientrespondstoandtheresponseistheninterpreted.An
exampleistheRorschachtest.P:projectivetests“detectthepresenceofsubtlepsychoticthought
processes.”
IntelligenceTests
TheIQtestwasintroducedin1905byAlfredBinet.Theintelligencequotient(IQ)istheratioofmental
age/chronologicalage,whichismultipliedby100.AnIQof100wouldimplythatyourmentalage(thinking
ability)matchesyourchronologicalage(howoldyouare).TheaverageIQis100.
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WechslerAdultIntelligenceScales(WAIS)isthemostwidelyusedintelligencetest.Thelatestrevisionisthe
WAIS-III.ItusesverbalIQ(previouslylearnedfactualinfo)andperformanceIQ(visuospatial/visuomotor
skills).AnIQof90-100isnormal,50-70ismildMR,andbelow20isprofoundMR.P:theWAIShashigh
reliabilityandtheWAIS-IIvocabularytestmoststronglycorrelateswithpre-morbidfunctioninginapatient
withearlydementia.
PersonalityAssessment
ObjectiveTests
•
•
•
MMPI:uses10scalesinaconfigurationalapproach(seeanicelittlegraphbasedonresponsesin10
categories)to“identifymajorareasofpsychopathologicfunctioning”andmeasurestest-taking
attitudesduringtheexamination(candetectmalingering,answeringquestionsfalsely,etc.It’ssuper
cool).
MillionClinicalMultiaxialInventory:testwithbriefadministrationtimeandcorrelateswellwith
DSM-III.PerPRITE,itisthetest“themosthelpfulinconfirmingapersonalitydisorder.”
StructuredClinicalDiagnosticAssessments:theseareteststhatgiveanumericalscoretoshow
severityofaparticularillness.IncludesHamiltonRatingScaleforDepression,Yale-BrownObsessiveCompulsiveScale(YBOCS),andtheSCID.TheBeckDepressionInventory,P:“mostappropriatebrief
screeninginstrumentthatapatientcanfilloutaloneataphysician’sofficetoscreenfordepression.”
ProjectiveTests
•
•
•
•
•
RorschachTest:setof10inkblotsareastimulusforassociations,halfareblackandwhite,theyare
showninaparticularorder,andreactiontimesarerecorded.Interpretationofresponsesrequiresan
experiencedclinician.Itisthemostwidelyusedprojectivetest
ThematicApperceptionTest(TAT):P:“atestinwhichapatientisshownpicturesofsituationsand
askedtodescribewhatisgoingonineachpicture”(anexampleisawomanseatedonacouch
lookingupatanolderman).P:Italsoservesto“infermotivationalaspectsofbehavior”
SentenceCompletionTest(SCT):hassentencestemsthatthepatientcompletes(“SometimesI
wish,”“Mygreatestfearis”)
Word-AssociationTechnique:createdbyJung,patientispresentedwithawordandmustgivethe
firstwordthatcomestomind.Thisissimilartofreeassociationandbringsunconscioustoconscious.
Draw-a-PersonTest:firstusedtotestintelligenceinchildren,thepatientdrawsaperson(showsa
representationoftheexpressionoftheself)
CognitiveTesting
ExecutiveFunctioning
•
WisconsinCardSortingTest(WCST):assesses“abstractreasoningandflexibilityinproblemsolving”
perPRITE.Cardsaresortedintogroups(color,suit)thatthepatientisnotawareof,withthegoalof
learningthegroupsthroughtrialanderror
• TrailMakingTest:patientconnectslettersandnumberstogetherinsequentialordertotest
concentrationandexecutivefunctioning
VisuomotorCoordination
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•
BenderGestaltTest:testsvisuomotorcoordinationbycopyingdesignsonpaper.Hastwophases,
firstwiththepatientallowedtocopythedesignwiththeoriginaldesigninfrontofthem,andthena
memorytestingportionwheretheoriginaldesignisremovedandthepatientmustcopythedesign
fromvisualmemory.Helpsscreenfororganicdysfunction.P:determinesneuropsychologic
impairment.
ReceptiveandExpressiveLanguage
•
•
TokenTest:examinespatient’sabilitytocomprehendverbalinstructions,grammaticalcomplexity,
andattentionspan
BostonNamingTest:examinesverbalconfrontationandnaming.P:“discriminatescognitive
difficultiesinAlzheimer’sdiseasefromthoseindepression.”
TestBatteries
•
Halstead-ReitanBatteryofNeuropsychologicalTests:determinesneuropsychologicimpairment,is
composedof10separatetestthatfunctiontodifferentiatebraindamagedpatientsfromthosewho
areneurologicallyintact.Schizophrenicsfunctionsimilartochronicbraindamagedpatients.
ChildandAdolescentPsychologicalAssessment
Intelligence
•
WechslerIntelligenceScaleforChildren-III(WISC-III):WAIS-IIIcanbemodifiedforchildrenages5-15
intheWISC-III.P:isclosesttotheoriginalStanfordBinet.Forpreschoolers,thereistheWechsler
PreschoolandPrimaryScaleofIntelligence-Revised(WPPSI-R).
Achievement
•
Woodcock-JohnsonPsychoeducationalBattery-Revised(W-J):scoresreadingandmathematics,
writtenlanguage,andothermeasuresofacademicachievement.P:thistesthelpstomore
specificallyidentifylearningdisabilitywithchildrenthathaveotherwisenormalIQ.
• WideRangeAchievementTest-3(WRAT-3):screenfordeficitsinreading,spellingandmath.P:thisis
ausefultesttoscreenacademicperformance.
AdaptiveBehavior
•
VinelandAdaptiveBehavioralScales:evaluatesadaptivebehavior,communicationskills,livingskills,
socialization,andmotordomains.Canbemodifiedtotestthosewithvisualandhearing
impairments.
Statistics
HerearesomebasicstatisticsthatwillbehelpfulforPRITEquestions.PleasealsorefertotheNinja’sGuide
toPRITEQuestionsforallstatisticsquestionsusedsince2001.
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•
•
•
•
•
•
•
•
•
•
•
CohortStudies:followawell-definedpopulationoveralongperiodoftime(longitudinal),oftenwill
seeatvariousintervals(2y,3y,15y,20y,etc).
RetrospectiveStudies:looksatpastdata/events
CrossSectionalStudies:looksforinformationaboutprevalenceofacertaindiseaseinapopulation
ClinicalTrials:somepatientsaretreatedandcomparedwithacontrolpopulationwhoarenot
receivingtreatment.Randomassignment.
Cross-over:astudywheretheplacebogroupeventuallygetstreatmentandthegrouppreviously
treatedgetsplacebo.Thiscandecreasestudybias.
ANOVA:analysisofvariancethatcompares2ormoregroups
ChiSquared:evaluatestherelativefrequency/proportionofeventsinawelldefinedpopulation
Zscore:deviationofthescorefromthegroupmean.TheunitsofaZ-scorearestandarddeviations
(ex:2standarddeviationsabovethemean)
Ttest:compares2setsofobservations
Type1error:rejectingthenullhypothesis(statesthereisNOdifferencebetweenthethingsbeing
observed)falsely.Thisisstatingthatthenullhypothesisisfalse,andthatthereISadifference
betweentwothingswhenthereisn’t.
Type2error:keepingafalsenullhypothesis,whenthereISadifferencebetween2groups.
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ANINJA’SGUIDETOSUBSTANCEUSEDISORDERS
Overview
Substanceusedisordersareprevalentamongpatientsinallclinicalsettings.Regardlessofmedicalspecialty,
aclinicianshouldbeabletorecognizethesignsandsymptomsofsubstanceusedisorders,whilekeepingin
mindpossibleunderlyingemergentconditions(withdrawal,delirium,seizures,etc.).Thereishighcomorbiditybetweensubstanceusedisordersandotherpsychiatricdisordersandmedicalconditions.
Empathicandnon-judgmentalcareforpatientswithsubstanceusedisordersleadstoasignificantdecrease
inmorbidityandmortality.Substancerelateddisordersarebrokendownintotwocategories:Substance
UseDisordersandSubstance-InducedDisorders.
EtiologyofSubstanceUse
Multifactorial,including:
Psychodynamic(substanceusetotreatdepression/escapereality)
Behavioral(positivereinforcement)
Genetic(twinstudies,adoptionstudies)
Neurochemical(abnormalreceptor/neurotransmittersleadingtosubstancemodulationof
neurochemistry;rewardpathwaysinvolvingdopamine(DA)inthenucleusaccumbensandventral
tegmentalarea)
Comorbidity
•
•
•
•
•
•
•
AntisocialPersonalitydisorder
Depression/Mooddisorder,Anxietydisorders,Schizophrenia
Suicide:peoplewhoabusesubstancesare25xmorelikelytodiebysuicidethanthegeneral
population.15%ofalcoholicshavebeenreportedtocommitsuicide
ScreeningforAddiction
Wheninterviewingapatient,askabouteachchemicalfromthestandpointoftheleastlikelydrugtocause
denialtothemostlikelydrugtocausedenial.Example:prescriptionmeds(BZDs),thentobacco,thenEtOH,
thenillicitdrugs.
CAGEQuestions(EtOHScreening)
1.
2.
3.
4.
HaveyoueverfelttheneedtoCutdownonyouruseofEtOH?
HavepeopleAnnoyedyoubycriticizingyouruseofEtOH?
HaveyoueverfeltbadorGuiltyaboutyouruseofEtOH?
Haveyoueverhadadrinkinthemorningtosteadyyournervesorgetridofahangover(Eyeopener)?
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Each“yes”answerisscored1point.One“yes”raisessuspicionofanEtOHuseproblem;morethanone
“yes”isastrongindicationthataproblemexists.
AbbreviateCAGE:
1. Haveyoueverusedasubstancemorethanyouintended?
2. Haveyoueverfelttheneedtocutdown?
Yestobothis80%sensitiveandspecific.
Alwaysobtainahistoryofconsequencesofsubstanceuse.Theseincludemedical,legal,occupational,
family/relationships,andemotionalconsequencesofuse.Thisallowsyoutofindobjectivemarkersof
problematicusedespitethepatient’sdenial.*IfapatienthasahistoryofDUI,they’reprobablyNOTjusta
socialdrinker.
MotivationalInterviewing
Thisisaformofinterviewingtohelpmaximizethepatient’sintrinsicdesiretochange.Example:“Currently
youmotivationtoquitsmokingisata4/10.Whatwouldittaketogetittoa5/10?Whatarethe
advantages/disadvantagesofsmokingforyou?”Thestagesofchangeinclude:
•
•
•
•
•
Precontemplation:patientdoesnotintendtochangebehaviorintheforeseeablefuture.Apatient
atthisstagemaybeunawareoronlyvaguelyawareofhis/herproblem
Contemplation:patientisawareoftheproblemandisseriouslyconsideringchangingbehaviorbut
doesnotmakeacommitmenttotakeaction.Patientsatthisstageoftenfeelambivalentaboutthe
senseoflosstheymayfeeldespitetheperceivedgainofovercomingtheirproblem
Planning/Preparation:patientintendstotakeactionwithinthenext30daysandhastakensome
stepstowardtreatment.Thisstagecombinesintentionandbehavioralcriteria(suchasmakingsmall
modificationstobehaviorthatsignaladecisiontochange)
Action:patientchangesbehaviorandcommitsaconsiderableamountoftimeandenergyto
overcomingtheproblem.Thisstagelastsfromthetimeoftheinitialactionto6months
Maintenance:thepatientcontinuestomeetthegoalssetupintheplanning/actionstageanduses
copingskillstoavoidrelapse
SubstanceUseDisorders
Anessentialfeatureisaclusterofcognitive,behavioral,andphysiologicalsymptomsthatoccurduetoa
substancedespiteconsequences.Ingeneral,thediagnosisofsubstanceusedisorderrequiresthepresence
ofatleast2criteriaovera12monthperiodoftime.Theseverityofthedisorderisdeterminedbythe
numberofdiagnosticcriteriapresent.Forallsubstances,theDSM5criteriaforsubstanceusedisordercanbe
groupedintoimpairedcontrol,socialimpairment,riskyuse,andpharmacologicalcriteria.Ingeneral,the
substanceusecriteriaareorganizedassuch:
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•
•
•
•
ImpairedControl
1. Theindividualtakesthesubstanceinlargeramountsoroveralongerperiodoftime
thanintended
2. Theindividualexpressesapersistentdesiretocutdownorregulatethesubstance
useormayhavemultipleunsuccessfulattemptstodecreaseordiscontinueuse
3. Individualspendsagreatdealoftimeobtaining,using,orrecoveringfromtheeffects
ofasubstance
4. Cravingismanifestedbyanintensedesireorurgeforthedrugatanytimebutis
morelikelyinanenvironmentwherethedrugwaspreviouslyobtainedorused
(classicalconditioning)
SocialImpairment
1. Recurrentsubstanceuseleadstofailuretofulfillmajorroleobligationsatwork,
school,orhome
2. Continueduseofthesubstancedespitesocialorinterpersonalproblemscausedby
useofthesubstance
3. Importantsocial,occupational,orrecreationalactivitiesaregivenuporreduceddue
tosubstanceuse
RiskyUse
1. Recurrentsubstanceuseinsituationsthatarephysicallyhazardous
2. Continuedusedespiteknowledgeofhavingapersistentorrecurrentphysicalor
psychologicalproblemcausedbyorexacerbatedbythesubstance
PharmacologicalCriteria
1. Tolerance:requiresamarkedlyincreaseddoseofthesubstancetogetthedesired
effectorthereisamarkedlyreducedeffectwhentheusualdoseisconsumed
2. Withdrawal:asyndromethatoccurswhenbloodortissueconcentrationsofa
substancedeclineinanindividualwhohadmaintainedprolongedheavyuseofthe
substance.Theindividualmayconsumethesubstancetoremovewithdrawal
symptoms
3. Note:appropriatemedicaltreatmentwithaprescribedmedication(opiates,
stimulants,etc)oftenleadstorequiringmoremedicationtogeteffectorwithdrawal
upondiscontinuation.Thisisnotcountedindiagnosingasubstanceusedisorder.
Thereisnormal,expectedpharmacologicaltoleranceandwithdrawalwithmany
commonlyprescribedmedications,leadingtoerroneousdiagnosisof“addiction”
whenthesearetheonlysymptomspresent.Iftoleranceandwithdrawalaretheonly
symptomspresent,adiagnosisofsubstanceusedisorderisnotmade
Severityofthesubstanceuseisdeterminedbythenumberofsymptomspresent.Forindividualswith2-3of
theabovesymptoms,itisconsideredmildsubstanceuse.Moderatesubstanceusediagnosedinthepresence
of4-5symptoms,andseveresubstanceuseisdiagnosedinthepresenceof6ormoreoftheabove
symptoms.
Thediagnosisofasubstanceusedisorderiscodedbythespecificsubstance.Thus,youwouldnotdiagnosea
patientwith“BenzodiazepineUseDisorder,Moderate.”Instead,thediagnosiswouldbe“Moderate
AlprazolamUseDisorder.”Thewordaddictionisnotused,withthefocusonthemoreneutralterm
substanceusedisordertoeliminatenegativeconnotation.
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Substance-InducedDisorders
Thiscategoryincludesintoxication,withdrawal,andothersubstanceormedication-inducedmentaldisorders
(suchasasubstancecausingpsychosisordepression).
SubstanceIntoxication
Criteriaarespecifictosubstance,aseachsubstancehasitsownintoxicationprofile.Themostcommon
behavioralchangesincludedisturbanceinperception,wakefulness,thinking,attention,judgment,
psychomotorbehavior,andinterpersonalbehavior.Short-termintoxicationcanpresentverydifferentlythan
long-term,chronicintoxication.Forexample,acuteuseofcocaineleadstooutgoing,gregariousbehavior.
Dailyusecanactuallycauseirritabilityandsocialwithdrawal.Thepresenceofphysiologicalsymptomsalone
maynotmeetcriteriaforintoxication.Forexample,ifthepersonhasmethamphetamine-induced
tachycardia,butthatistheonlysymptompresent,itwouldnotbeconsideredintoxication.Substance
intoxicationcanbepresentinindividualswhodonototherwisemeetcriteriaforasubstanceusedisorder
(i.e.,persongetsdrunkoncebutdoesnototherwisehavecriteriaforAlcoholUseDisorder).Thebasiccriteria
forintoxicationareasfollows:
A. Areversible,substance-specificsyndromeduetotherecentingestionofasubstance
B. Duringorshortlyafterusingasubstance,therearephysiologicaleffectsofthesubstanceon
theCNS,causingproblematicbehaviororpsychologicalchanges
C. Thesymptomsarenotduetoanothermedicalconditionormentaldisorder
Routesofadministrationthatproducemorerapidandefficientabsorptionintotheblood(smoking,snorting,
injecting)tendtohavemoreintenseintoxicationandahigherlikelihoodofanescalatingpatternof
substanceuseleadingtowithdrawal.Rapidly-actingsubstancesaremorelikelythanslower-acting
substancestoproduceimmediateintoxication.
Drugsthatarehighpotency,haverapidonsetofaction,arelipohilic,andhaveashorthalf-lifehavethe
greatestliabilityforabuse.
SubstanceWithdrawal
Likeintoxication,thepresenceofphysiologicwithdrawalalonedoesnotmeanthatasubstanceusedisorder
mustbediagnosed.However,unlikeintoxication,thepresenceofwithdrawalisusuallyassociatedwitha
substanceusedisorder.Mostindividualswithwithdrawalhaveanurgetore-administerthesubstanceto
reducethesymptoms.Thebasiccriteriaforintoxicationareasfollows:
A. Thedevelopmentofasubstance-specificbehavioralchange,withphysiologicalandcognitive
components,duetocessationorreductionofsubstanceusethatwaspreviouslyheavyand
prolonged
B. Syndromecausessignificantdistressorimpairmentinsocialoroccupationalfunctioning
C. Thesymptomsarenotduetoanothermedicalconditionormentaldisorder
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Short-actingsubstancestendtohavehigherpotentialfordevelopmentofwithdrawalthandolong-acting
substances.However,longer-actingsubstancestendtohavealongerdurationofwithdrawal(daysor
weeks).Thelongerthedurationofaction,thelongerthetimebetweendrugcessationandonsetof
withdrawalsymptomsandtheoveralldurationofwithdrawalislonger.Example:discontinuingclonazepam
(longhalf-life,longdurationofaction)maynothaveinitiationofwithdrawalsymptomsfor1-2daysafter
stoppinguse,andthesymptomsofwithdrawalmayremainpresentforaweekorlonger.
Intoxicationandwithdrawaldiagnosesarecodedbythenameofthespecificsubstance.Thus,aperson
intoxicatedwithmethamphetaminewouldnotbediagnosed“StimulantIntoxication,”butwouldbe
diagnosed“MethamphetamineIntoxication.”Apersonwithdrawingfromdiazepamwouldnotbediagnosed
“BenzodiazepineWithdrawal,”butwouldbediagnosed“DiazepamWithdrawal.”TheICD10codingsystemin
2014willrequirewithdrawaldiagnosestobeassociatedwithaSubstanceUseDisorder,showingthe
associationbetweenwithdrawalandlikelysubstanceuseproblems.
ReviewofIntoxicationandWithdrawal
Intoxication
A)
B)
C)
D)
Recentingestionofthesubstance.
Maladaptivebehavioral/psychologicalchangesafteringestion.
Listofdrug-specificintoxicationsymptoms(seechartbelow).
SymptomsareNOTduetoamedicalconditionormentaldisorder.
Withdrawal
A)
B)
C)
D)
Cessation/reductionofthesubstanceinaheavyuser.
Listofdrug-specificwithdrawalsymptoms(seechartbelow).
Causessignificantdistressinsocial/work/importantareasoffunctioning.
SymptomsareNOTduetoamedicalconditionormentaldisorder
OverviewofSubstanceIntoxication/WithdrawalSymptoms
Drug
Alcohol
Amphetamine,
Intoxication
1.Clinicalsignificantdysfunctionalbehavior:
•
Disinhibition
•
Agitation/Aggression
•
MoodLability
•
ImpairedJudgment
2.Oneormoreofthefollowing:
•
SlurredSpeech
•
Incoordination
•
UnsteadyGait
•
Nystagmus
•
Memory/AttentionImpairment
•
↓edConsciousness(stupor/coma)
Severe:Hypotension,Hypothermia,DepressedGagReflex
1.Clinicallysignificantdysfunctionalbehaviororperceptualabnormality:
Withdrawal
1.Twoormoreofthefollowing:
•
AutonomicHyperactivity
(Sweating,Tachycardia,HTN)
•
TremorofTongue,Eyelids,or
OutstretchedHands(asterixis)
•
Insomnia
•
Nausea/Vomiting
•
TransientVisual,Tactile,or
AuditoryHallucinations,or
Illusions
•
PsychomotorAgitation
•
Anxiety
•
Generalizedtonic-clonic
seizures
2.CANBELETHAL
1.Dysphoricmood+twoofthefollowing:
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Cocaine,andother
Stimulants
Caffeine
•
Euphoria&Sensationof↑edEnergy
•
Hypervigilance
•
Changedsociability
•
Abusive/Aggressive
•
MoodLability
•
RepetitiveStereotypedBehaviors
•
ImpairedJudgment
2.Twoormoreofthefollowing:
•
Tachycardia
•
PupillaryDilatation
•
HTN
•
Sweating/Chills
•
Nausea/Vomiting
•
WeightLoss(2/2↓edAppetite)
•
PsychomotorAgitation
•
MuscularWeakness
•
ChestPain,Arrhythmias
•
RespiratoryDepression
•
Seizures,Dystonias,Dyskinesias
•
Confusion,Coma
Fiveormoreofthefollowing:
•
Restlessness/Anxiety
•
Excitement
•
Insomnia
•
FlushedFace
•
Diuresis
•
GIDisturbance
•
MuscleTwitching
•
RamblingFlowofThoughtandSpeech
•
TachycardiaorCardiacArrhythmias(PVCs)
•
PeriodsofInexhaustibility
•
PsychomotorAgitation
Thereisnorecognizednicotineintoxicationstate.
Tobacco
•
•
•
•
•
LethargyandFatigue
Vivid,DisturbingDreams
Insomnia/Hypersomnia
IncreasedAppetite
Psychomotor
Retardation/Agitation
Threein24hours:
•
Headache
•
MarkedFatigueandDrowsiness
•
MarkedAnxietyorDepression
•
Nausea/Vomitingormuscle
aches
Fourormorewithin24hoursofstopping:
•
Dysphoric/DepressedMood
•
Insomnia
•
Irritability/Frustration/Anger
•
Anxiety
•
DifficultyConcentrating
•
Restlessness
•
↑edAppetite/WeightGain
Drug
Cannabinoids
Intoxication
1.Clinicallysignificantdysfunctionalbehaviororperceptualabnormality:
•
Euphoria&Disinhibition
•
AnxietyorAgitation
•
TemporalSlowing(i.e.FeelslikeTimePassesSlowly)
•
ImpairedJudgment
•
Socialwithdrawal
2.Twoormoreofthefollowing:
•
ConjunctivalInjection
•
IncreasedAppetite(“Munchies”)
•
DryMouth
•
Tachycardia
Withdrawal
Afterdailyuseforafewmonths,hasthree
ormorewithinthefirstweekafter
stopping:
•
Anger/Irritability
•
Anxiety
•
Insomnia
•
DecreasedAppetite
•
Restlessness
•
Depressedmood
•
One:tremor,sweating,fever,
chills,headache,abdominalpain
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Hallucinogens
Inhalants&
VolatileSolvents
1.Clinicallysignificantdysfunctionalbehaviororperceptualabnormality:
•
Anxiety
•
Ideasofreference
•
Fearofllosingone’smind
•
Paranoid
•
Impairedjudgment
Perceptualchangesdespitewakefulnessandalertness
2.Twoormoreofthefollowing:
•
PupilsDilated
•
Tachycardia
•
Sweating/Chills
•
Palpitations
•
BlurredVision
•
Tremors
•
Incoordination
Thereisnorecognizedhallucinogen
withdrawalstate.
1.Clinicallysignificantdysfunctionalbehavior:
•
Apathy&Lethargy
•
Argumentativeness/Abusiveness/Aggression
•
ImpairedJudgment,Attention,andMemory
2.Twoormoreofthefollowing:
•
Dizziness
•
Nystagmus
•
Incoordination
•
SlurredSpeech
•
UnsteadyGait
•
Lethargy
•
DepressedReflexes
•
PsychomotorRetardation
•
Tremor
•
GeneralizedMuscleWeakness
•
Diplopia
•
StupororComa
•
Euphoria
Severe:Hypotension,Hypothermia,DepressedGagReflex
Thereisnorecognizedsolvent/inhalant
withdrawalstate.
Intoxication
1.Clinicallysignificantdysfunctionalbehavior:
•
InitialEuphoriaFollowedbyApathy&Sedation
•
PsychomotorRetardationorAgitation
•
ImpairedJudgment
2.PupillaryConstrictionANDoneofthefollowing:
•
DrowsinessorComa
•
SlurredSpeech
•
ImpairmentinAttentionorMemory
Severe:RespiratoryDepression,Hypoxia,Hypotension,Hypothermia.In
SEVEREOD,AnoxiaLeadstoDILATEDPupils.
Withdrawal
Occursaftercessationinheavyopiateuse
oradministrationofopioidantagonist
Threeormoreofthefollowing:
•
DysphoricMood
•
Nausea/Vomiting
•
MuscleAches
•
LacrimationorRhinorrhea(“The
Sniffles”)
•
PupillaryDilation
•
Piloerection(“ColdTurkey”)
•
Sweating
•
Diarrhea
•
Yawning
•
Fever
•
Insomnia
MayPresentWithTachycardiaandHTN.
ThereisnorecognizedPCPwithdrawal
state.
Drug
Opiates
Phencyclidine
(PCP)
1.Clinicallysignificantdysfunctionalbehavior:
•
Belligerence/Assaultive
•
Impulsivity/Unpredictability
•
PsychomotorAgitation
•
ImpairedJudgment
2.TwoorMoreoftheFollowing:
•
Vertical/HorizontalNystagmus
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Sedatives,
Hypnoticsand
Anxiolytics
(BZDs,
Barbuturates)
•
HTN/Tachycardia
•
NumbnessorDiminishedResponsivenesstoPain
•
Ataxia
•
Dysarthria
•
MuscleRigidity
•
Hyperacusis
•
SeizuresorComa
1.Clinicallysignificantdysfunctionalbehavior:
•
Abusiveness/Aggression
•
MoodLability
•
Impairedjudgment
2.Oneormoreofthefollowing:
•
SlurredSpeech
•
Incoordination
•
UnsteadyGait
•
Nystagmus
•
ImpairmentinAttentionorMemory
•
↓edLevelofConsciousness(Stupor/Coma)
Servere:Hypotension,Hypothermia,DecreasedGagReflex
Twoormoreofthefollowing:
•
AutonomicHyperactivity
(Sweating,↑edHR,HTN)
•
TremorofTongue,Eyelids,or
OutstretchedHands(Asterixis)
•
Insomnia
•
Nausea/Vomiting
•
TransientVisual,Tactile,or
AuditoryHallucinations/
Illusions
•
PsychomotorAgitation
•
Anxiety
•
GrandMalSeizures
CanBeLETHAL
Substance/Medication-InducedMentalDisorders
Toreview,Substance-InducedDisordersincludeintoxication,withdrawal,andthedevelopmentofspecific
mentaldisordersduetothepresenceofthesubstanceormedication.TheSubstance-InducedMental
Disordersarepotentiallysevere,usuallytemporary(butcanpersist)CNSsyndromesthatdevelopduetothe
influenceofsubstances,medications,ortoxins.AsopposedtotheSubstanceUseDisorders,whichare
attributedto10classesofdrugs/medications,theSubstance/Medication-InducedDisorderscanbedueto
manydifferentagents,includingmedicinesandtoxins.Anexampleofthisispsychosisduetotheuseof
corticosteroidstotreatCrohn’sDisease.Whenduetodruguse,Substance-inducedmentaldisordersusually
developwithinthecontextofintoxicationorwithdrawal.Theconditionisusuallytemporaryandlikelyto
disappearwithinonemonthaftercessationofacutedrugintoxication/withdrawalorwithinonemonthafter
stoppingtheoffendingmedication.Thebasiccriteriaareasfollows:
A. Thedisorderrepresentsaclinicallysignificantsymptomaticpresentationofarelevantmental
disorder(depression,psychosis)
B. Thereisevidencefromhistory,physicalexam,orlabfindingsofboth:
1. Disorderdevelopedwithin1monthofsubstanceintoxicationorwithdrawal,or
takingamedication;and
2. Theinvolvedsubstance/medicationiscapableofproducingthementaldisorder
C. Thedisorderisnotbetterexplainedbyanindependentmentaldisorder.Evidenceofan
independentmentaldisordercouldinclude:
1. Mentaldisorderprecededtheonsetofintoxication/withdrawalorexposuretothe
medication;or
2. Thefullmentaldisorderpersistedforatleast1monthafterthecessationofthe
acuteintoxication/withdrawalfromthesubstanceormedication.Thisdoesnotapply
tohallucinogensorsubstance-inducedneurocognitivedisorders(likeWernicke’s
Encephalopathy)thatpersistbeyondcessationofacuteintoxication/withdrawal
D. Disorderisnotexclusivelypartofdelirium
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E. Disordercausesclinicallysignificantdistressorimpairmentinsocial,occupational,orother
importantareasoffunctioning
Sedatingmedicationsaremorelikelytoproduceprominentandclinicallysignificantdepressivedisorders
duringintoxication,followedbyanxietysymptomsinwithdrawal.Intoxicationwithstimulantstendstobe
associatedwithpsychoticdisordersandanxietydisorders,withsubstance-induceddepressivedisordersin
withdrawal.Ifdeliriumispresent,otherpsychiatricsyndromesshouldnotbediagnosed(likesubstanceinducedpsychosis).
Alcohol-RelatedDisorders
Epidemiology
•
•
•
•
•
•
•
LifetimeEtOHUseDisorderis10%forwomenand20%formen
Commoncausesofdeathincludesuicide,cancer,heartdisease,andhepaticdisease
Drunkendriversareinvolvedin55%ofallautofatalitiesand75%offatalitiesinlate-evening
accidents
EtOHuseisassociatedwith50%ofallhomicidesand75%ofallsuicides.
Reduceslifeexpectancyby10years
Alcohol-relateddisordersoccuracrossallsocioeconomicclasses
o WhiteshavehighestrateofEtOHuse
o Men>Women2:1
o Associatedwithhigherlevelofeducation(contrastwithillicitdruguse)
60-80%ofEtOHUseDisorderinpatientswillbemissedbytheirPMD
Comorbidity
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•
•
•
AntisocialPersonalityDisorder
MoodDisorders
AnxietyDisorders
Suicide
Etiology
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•
•
•
ChildhoodHistory:ADHD,ConductDisorder,andotherpersonalitydisorderspredisposetoEtOHrelateddisorders
Sociocultural:dormitories/militarybasesleadtoexcessivedrinking.Somecultures(Asians,
conservativereligions)aremorerestrained
Behavioral/Learning:parentaldrinkinghabitsmaypredispose.Positivereinforcement(euphoria)
associatedwithEtOHencouragesuse
Genetics:closefamilymembershavefourfoldincreasedrisk.Identicaltwinshigherriskthanfraternal
twins.Adopted-awaychildrenofalcoholicparentsstillhavefourfoldhigherrisk
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EffectsofAlcohol
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Absorption:10%instomach,90%insmallintestine
Metabolism:90%oxidizedinliver.Bodymetabolizes~1drinkanhour(1drink=12oz.beer=5oz.
wine=1.5oz.80-proofliquor)
Neurochemistry:enhancesGABA,ACh,5-HT;inhibitsGlutamate
Gender:womentypicallyaremoreaffectedbyEtOHthanmen.Theaveragewomantypicallyhasa
smallerbodysize,lessbloodvolume,andmorebodyfat.Asbodyfathaslesswater,thereisless
waterforEtOHtodilutein;thereforeahigherbloodalcoholcontent(BAC)isachieved.Womenalso
havedecreasedesophagealandgastricoxidationofEtOHandlessEtOHdehydrogenase.Thus,they
metabolizeEtOHmoreslowly
Behavior:aBAC0.4-0.5willleadtosevereneurologicaldepression,resultingincoma.HigherBACs
leadtorespiratorydepressionanddeath
Sleep:decreasesREM/Stage4sleepandleadstosleepfragmentation
Physical:liver,GI,heart,lipids,cancer,possibledeathifcombinedwithsedatives
AlcoholEquivalents
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•
•
•
Onedrink=a12oz.beer,4oz.wine,or1¼oz.of80-proofliquor
Astandardbeeris4-9%EtOH,whichis8-18proof(%x2=proof).Liquortypicallyhas40%EtOH(i.e.
80proof)
1drinkis0.02-0.025%BAC;thelegallimitis0.08%BAC.1drinkismetabolizedeachhour,thusBAC
dropsby0.02%eachhour
At0.05%BACthereisexhilarationanddecreasedinhibition/judgment;0.10%hasslurredspeechand
staggeringgait;0.3%hasconfusionanddecreasedreflexes;0.4%hasstupor/LOC;0.5%hascoma;
0.6%leadstorespiratoryparalysisanddeath
DiagnosticMarkers
GGT>35isasensitivemarkerforheavydrinking,andoftenisthefirstabnormalmarker.Atleast70%
ofindividualswithanelevatedGGTarepersistentheavydrinkers(8ormoredrinksdaily)
• ElevatedMCVistheresultoftoxiceffectofalcoholonerythropoiesis.However,itisapoormethod
ofmonitoringduetothelonghalf-lifeofredbloodcells
• ElevatedLFTsaretheresultoftoxicinjurytotheliverasaconsequenceofheavydrinking
AlcoholUseDisorder
•
ThediagnosisofAlcoholUseDisorderismadebyapplyingthecriteriapresentedonpage5totheuseof
alcohol.Thesymptomsmustbepresentfor12months,withaminimumof2criteriapresenttodiagnose
MildAlcoholUseDisorder.Specifiersforremissionexist,withearlyremissionbeingatleast3monthswithno
symptomsbutnotyet12monthsinsobriety.Sustainedremissioniswhennocriteriahavebeenmetin12
months.Cravingsmaybepresentduringthistimeaslongastheyaretheonlysymptompresent.Thusa
personmaybeconsideredinremissionwiththepresenceofcravingsstillthere(asubstanceusedisorder
criteria).Anotherspecifierisifthepatientisinacontrolledenvironment(soberliving,jail,lockedunit).
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AlcoholIntoxication
Afteringestionofalcohol,thereisclinicallysignificantdysfunctionalbehavior:
• Disinhibition
• Agitation/Aggression
• MoodLability
• ImpairedJudgment
Oneormoreofthefollowing:
• SlurredSpeech
• Incoordination
• UnsteadyGait
• Nystagmus
• Memory/AttentionImpairment
• DiminishedConsciousness(stupor/coma)
Severe:Hypotension,Hypothermia,DepressedGagReflex
AlcoholWithdrawal
Aftercessationofalcoholusethathasbeenheavyandprolonged,therearetwoormoreofthefollowing:
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•
•
•
•
•
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AutonomicHyperactivity(Sweating,Tachycardia,HTN)
TremorofTongue,Eyelids,orOutstretchedHands(asterixis)
Insomnia
Nausea/Vomiting
TransientVisual,Tactile,orAuditoryHallucinations,orIllusions
PsychomotorAgitation
Anxiety
Generalizedtonic-clonicseizures
Spectrumofwithdrawal:6-8hours=tremor/autonomicsymptoms,8-12hours=hallucinations,12-24hours
=seizures,72hours–1week=DeliriumTremens(DTs).
Complications
•
•
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WithdrawalSeizures:stereotyped,tonic-clonicseizures.
o Treatment:BZDs–includingChlordiazepoxide(Librium)POtaperoranotherlong-actingBZD
(e.g.Diazepam)orIVLorazepam.Inpatientswithliverdamage,aBZDwithoutactive
metabolites(lorazepam)ispreferred.
DeliriumTremens:deliriumoccurringwithin1weekofabstinence.
o Symptoms:rapid-onset,cloudingconsciousness,insomnia,disturbanceofcognitionPLUS
autonomichyperactivity,hallucinations(usuallytactile),andpsychomotoractivity
fluctuation.Canbefatal.
o Treatment:preventwithBZDs(ChlordiazepoxidePOq4hrsorLorazepamIV).Avoid
antipsychotics(loweredseizurethreshold)ifpossible
LethalWithdrawal:BothEtOHandBZD/Barbituratewithdrawalcanleadtoseizuresanddeath.
Gettingagoodhistoryisthemostimportantfirststepinpreventingthesecomplications.Findout
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theaveragedailyquantityconsumedandthetimeoftheirlastdrink,asthiswillhelpdeterminethe
riskofseizures/complicatedwithdrawal
o Treatment:usetheseizurepreventionmeasuresaboveaswellasobtainoptimalfluidand
electrolytebalance.Patientsmayrequiremedicalinpatient/ICUadmissionifsevere
Wernicke’sEncephalopathy:secondarytothiaminedeficiency(acofactorforenzymesinvolvedin
axonalconduction).Lesionsareseeninthemammillarybodies.Symptoms:ataxia,dizziness,
confusion,nystagmus/gazepalsy
o Treatment:thiamine(PO/IV),alwaysgivenbeforeadministeringglucose
Korsakoff’sSyndrome:chronicamnesticsyndromefollowinguntreatedWernicke’sEncephalopathy.
Symptoms:anterogradememoryloss(difficultyformingnewmemories)withconfabulation(madeupmemoriestofillthegaps).Fewpatientsrecover
ElevatedBiomarkers:macrocytosis(2/2folatedeficiency),↑edGGT,↑edASTandALT(AST:ALTratio
of2:1),↑edcarbohydratedeficienttransferrin(CDT)
FetalAlcoholSyndrome(FAS):inhibitionofintrauterinegrowth.Symptoms:microcephaly,
craniofacialmalformations(thinupperlipwithnophiltrum),limbandheartdefects.Shortadult
statureandadultmaladaptivebehaviorsarealsoassociatedwithFAS
Prognosis
GoodPrognosticIndicators:
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•
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Absenceofpre-existingAntisocialPersonalityDisorder
Lifestability:havingajob,healthyfamilyrelationships,andnolegalproblems
Fullcourserehabilitationprogram(2-4weeksminimum)
Treatment
Thelong-termgoalsoftreatmentarethesameforallsubstanceusedisorders:abstinence,relapse
prevention,andrehabilitation.
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•
InpatientDetoxification:preventseizures(useBZDs)andlessenwithdrawalsymptoms(ß-blockers
andclonidinetreatautonomichyperactivity;antipsychoticstreatdeliriumagitation,andaggression)
Post-DetoxificationOutpatientTreatment:intensiveoutpatientcarewithfrequentvisitsordayhospitaltreatmentinearlyphases.Multiplestudiesshowthatgoodaftercarefollowinginpatient
treatmentisassociatedwiththelowestratesofrelapse
MedicationManagement
MosttreatmentfocusesondecreasingcravingforEtOHthroughmodulationofneurotransmitters(DA,
Glutamate)andreceptors(NMDA,Opioid).TreatmentmayalsodecreasereinforcementofEtOHthrough
inhibitionofrewardpathways.
•
Naltrexone:competitiveantagonistatthemuandkappaopioidreceptors.POorDepotformulation.
Decreasescravingsandblocksdopaminerewardpathways,therebydecreasingreinforcingeffectsof
use(i.e.useislessenjoyable)
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SideEffects:nausea(10%),headache(7%),dizziness(4%),insomnia(3%),anxiety(2%),and
sleepiness(2%).Serioussideeffectsincludehepatotoxicity(rare).CheckLFTsbefore
initiating
Acamprosate:blocksglutamateNMDAreceptorsandactivatesGABA-Areceptors.EtOHisinhibitory
andchronicuseleadstoupregulationofNMDAreceptors.WithdrawalofEtOHleadstoglutamate
excitation(i.e.seizures,tachycardia,etc).ByblockingNMDAreceptors,acamprosatedecreasesthe
sign/symptomsofwithdrawalaswellasdecreasingglutamate-drivencravings
o SideEffects:mainlyGIinnature
Disulfiram:inhibitsacetaldehydedehydrogenaseleadingtoincreasedacetaldehydeafter
consumptionofEtOH.Theincreasedacetaldehydeleadstosymptomsofpalpitations,flushing,
nausea,vomiting,andheadache.Itisanaversivetreatment
o SideEffects:seeabove.Raresymptomsofcardiotoxicity,MI,pulmonarydysfunction,and
hepatotoxicity.Contraindicatedinpatientsonmetronidazole(whichhasdisulfiramlikeeffects)orpatientswithcardiovascular,pulmonary,orhepaticdiseaseorwithchronicrenal
failure.CheckLFTsbeforeinitiating
Anticonvulsants:inhibitionofmesocorticolimbicDAreleaseleadingtodecreasedcraving.
Topiramatehasbeststudiestodate
o SideEffectsoftopiramate:dizziness,somnolence,cognitiveslowing,andweightloss.Rare
sideeffectsincludemetabolicacidosisandrenalstones.Becarefulwithdrug-drug
interactions
SSRIs:mayreducecomorbidpsychiatricsymptoms(anxiety/depression)thatinfluencedrinking
behavior
o
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PsychosocialTreatments
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MotivationalInterviewingtechniquesareuseful(seeabovesectioninMotivationInterviewing)
CBT:aimedatimprovingself-controlthroughgoalsetting,rewards,andlearningalternatecoping
strategies.Usesproblemsolvinginsteadofusingavoidanceasacopingstrategy
BehavioralTherapies:combinationdisulfiramandbehavioraladherenceprogram(EtOH-freesocial
environments,communityreinforcement,etc)
Self-HelpGroupsand12-StepTreatment:AAisa“spiritualbutnonreligiousprogramrequiringbelief
insomethingbeyondoneself”thatprovidestoolstomaintainsobriety.Toolsincludethe12steps,
groupidentification,andmutualhelp.MultiplestudiesshowgoodsupportforAAasviabletreatment
MaritalandFamilyTherapy
Al-Anon(friendsandfamilyofalcoholics),Alateen(teensofalcoholics),andAdultChildrenof
Alcoholicsallhelpfamilymembersbyteachingtoavoidenablingbehaviorsandimproveself-care
Thebesttreatmenthasbeenshowntobeacombinationoftherapy/supportgroupsandmedication
management.
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Caffeine-RelatedDisorders
Epidemiology
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Estimated85%ofadultsinUSAconsumecaffeineregularly
Isthemostwidelyusedbehaviorallyactivedrugintheworld
Averageconsumptionis200mg/day,with20-30%consuming>500mg/day(1cup=100-150mg)
About2/3rdsofthosewhoconsumelargeamountsofcaffeinedailyalsousesedativeandhypnotic
drugsforsleepandanxiety
Neuropharmacology
Caffeineisamethylxanthinethathastimetopeakconcentrationin30-60minutes
Readilycrossestheblood-brainbarrier
Half-lifeis4-6hours
AntagonizesadenosinereceptorsleadingtoanincreaseincAMP
Athigherconcentrations,caffeinemayactivatedopaminergicandnoradrenergicneurons
DifferentialDiagnosisofCaffeineIntoxication
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GeneralizedAnxietyDisorder,PainDisorderwith/withoutAgoraphobia,BipolarTypeII,ADHD,
Cocaine/Amphetamineabuse,Hyperthyroidism,Pheochromocytoma,andSleepDisorders.
ThereisnoCaffeineUseDisorder,onlyintoxicationandwithdrawalinadditiontoCaffeine-InducedDisorders.
CaffeineIntoxication
Recentconsumptionofcaffeine(usually>250mg)andfiveormoreofthefollowing:
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•
•
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Restlessness/Anxiety
Excitement
Insomnia
Flushedface
Diuresis
GIdisturbance
Muscletwitching
Ramblingflowofthoughtandspeech
Tachycardiaorcardiacarrhythmias(PVCs)
Periodsofinexhaustibility
Psychomotoragitation
Consumptionof>1gramleadstoramblingspeech,confusion,cardiacarrhythmias,agitation,tinnitus,and
mildvisualhallucinations(lightflashes).
Consumptionof>10gramsleadstogeneralizedtonic-clonicseizures,respiratoryfailure,anddeath.
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CaffeineWithdrawal
Afterprolongeddailyuseofcaffeine,abruptcessation/reductioninuseleadstothreeormoreofthe
followingin24hours:
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Headache
Markedfatigueordrowsiness
Dysphoricmood,depressedmood,orirritability
Flu-likesymptoms(nausea/vomiting,musclepain)
Withdrawaloccurswithin12-24hoursafterlastdose,symptomspeakbetween24-48hours,andresolve
within1week.
Complications
• Possiblecardiacarrhythmiasinthosewithpre-existingcardiacdisease
• Increasedriskofgastriculcersduetoincreasedgastricacidsecretion
Treatment
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MedicationManagement:analgesics(NSAIDs)forheadachesandmuscleaches.RarelyBZDsareused
forwithdrawalanxiety
TaperingCaffeineUsage:patientskeepdailyfooddiarynotingallformsofcaffeineaswellas
quantity.Thepatientandphysiciancanthenworkonataperingscheduleforconsumption,witha
10%decreaseeveryfewdays.Beveragesubstitutionisrecommended.Thediaryismaintainedto
trackprogress.“ColdTurkey”isNOTrecommendedduetopossiblewithdrawalsymptoms,as50%of
userswillhaveheadacheandothersymptoms
Cannabis-RelatedDisorders
Epidemiology
•
•
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•
Worldwide,cannabisisthemostcommonlyusedillicitdrug
AccordingtotheNationalHouseholdSurveyofDrugAbuse,thelifetimeprevalenceofcannabisuse
increaseswithagegroupupuntilage34,thedecreasesgradually.Betweentheagesof18-21,25%
hadusedinthepastyearand14%inthepastmonth
Males>Females(2:1)inthose26yearsandolder
Whites>Blacks>>Hispanics(under35yearsold)
Neuropharmacology
•
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•
IndianhempplantCannabisSativaisanherbknowninCentralAsiaandChinaforatleast4,000years
Hempiscut,dried,chopped,androlledintocigarettescalledjoints
Commonnamesaremarijuana,grass,pot,weed,tea,sticky-icky,andMaryJane
Containsthepsychoactivesubstance∆9-tetrahyrdocannibinol(∆9-THC),whichismostpotentinthe
floweringtopsoftheplantorfromthedriedresinexudatesfromtheleaves(hash,hashish)
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Activemetaboliteis11-hydroxy-∆9-THC,whichbindstoacannabinoidGiprotein-linkedreceptor(Gi=
inhibitorGprotein)thatinhibitsadenylylcyclaseandaffectsGABAneurons
Thecannabinoidreceptorismosthighlyconcentratedinthebasalganglia,hippocampus,cerebellum,
andcortex(lowerconcentrationsthanothers).Thecannabinoidreceptorisnotfoundinthe
brainstem,thusmarijuanahasminimaleffectsonrespiratoryandcardiacfunction
Whensmoked,euphoriaoccursinminutes,peaksat30minutes,andlasts2-4hours
ClinicalFeatures
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Mostcommoneffectsaredilationofconjunctivalbloodvessels(“redeye”),mildtachycardia,dry
mouth,andincreasedappetite(“munchies”)
Themostseriousadverseeffectischronicrespiratorydiseaseinheavychronicusersdueto
inhalationofcarcinogenichydrocarbons(samecompoundsintobacco)
Canprecipitatepsychosisandisassociatedwithanearlierageoffirstonsetofschizophreniainmales
(6.9yearsearlierthaninnon-cannabisusers)
Pregnancy:negativeeffectsonfetalgrowth,behavioral/cognitive/academicdifficulties,impulsivity,
andinattentionnotedaswell.Childhoodlearningdeficitsasaresultofin-uteroexposure
Highcomorbidityofothersubstanceuse,including>50%meetingcriteriaforAlcoholUseDisorder
CannabisUseDisorder
AswithotherSubstanceUseDisorders,cannabisusemustbeassociatedwithatleast2symptomsof
substanceuseovera12monthperiodoftime.Functionally,thedisorderisassociatedwithamotivational
syndrome,manifestedbychroniclowmotivationandreductioningoal-directedactivity.
CannabisIntoxication
During,orshortlyafteruse,thereisclinicallysignificantdysfunctionalbehaviororpsychologicalchanges:
• Impairedmotorcoordination
• Euphoria
• Anxiety
• Sensationofslowedtime
• Impairedjudgment
• Socialwithdrawal
Twoormorewithin2hours:
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ConjunctivalInjection
IncreasedAppetite(“Munchies”)
DryMouth
Tachycardia
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CannabisWithdrawal
Cessationofusethathasbeenheavyandprolonged(dailyorneardailyovermonths)withthreeormore
within1weekofstoppinguse:
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Irritability,angeroraggression
Nervousnessoranxiety
Insomnia
Decreasedappetiteorweightloss
Restlessness
Depressedmood
Atleastoneofthefollowingcausingsignificantdiscomfort:abdominalpain,tremors,sweating,
fever,chills,orheadache
NewtotheDSM5istheunderstandingthatdailyorneardailyuseofTHCovermonthscancause
withdrawal.Thisisafactorcontributingtodifficultyinquittinguse.Between50-95%ofheavyusershave
reportedwithdrawalsymptoms.Onsetofwithdrawalisinthefirst24-72hoursandmaylastupto2weeks.
Treatment
Thelong-termgoalsoftreatmentarethesameforallsubstanceusedisorders:abstinence,relapse
prevention,andrehabilitation.
TreatmentSetting:outpatientsetting,eitherindividuallyoringroups.
Alwaysmonitorforanunderlyingdepression(leadingtoTHCuse)thatmayrequiretreatmentwith
antidepressants.
PsychosocialTreatments
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Therapieswiththebestresultscombinemotivationaltherapywithcopingskillsdevelopmentto
promoteabstinenceandpreventrelapse.
Giventhelackofusefulpharmacotherapyandhighrelapserates(67%by6monthsinonestudy),
additionalgrouptherapyandotherbehavioralinterventionsarerecommendedtodecreasetherate
ofrelapse.
Hallucinogen-RelatedDisorders
DSM5separateshallucinogendisordersinto“PCP”and“Other”whichincludeLSD,mescaline,andothers.
Phencyclidine(PCP)
Epidemiology
•
PrevalenceofPCPuseisunknown.Onlyabout2.5%ofthepopulationhasreportedusingPCP.Males
makeup75%ofusers
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Phencyclidine(PCP),alsoknownas“angeldust,”isadissociativeanestheticthatisnolongerusedfor
anesthesiaduetodisorientation,agitation,andhallucinationsonawakening
Relatedcompound,Ketamine(“specialK”),isstillusedintheUSasananesthetic
Similareffectsashallucinogens,includingLSD
Easytosynthesizeandinexpensivetobuyonthestreets.HighestuseisinWashington,D.C.where
PCPaccountsfor18%ofallsubstance-relateddeaths
Neuropharmacology
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Soldascrystallinepowder,paste,liquid,ordrugsoakedpaper,andisoftenanadditiveincannabis
cigarettes.Cansmoke,snort,oruseIV.EffectsofsmokedPCPoccurin5minutesandplateauin30
minutes.Half-lifeis20hours
PrimaryeffectisNMDAantagonistatglutamatereceptors.AlsoaffectsDAneuronsinventral
tegmentalareatothecerebralcortexandlimbicarea
Detectedintheurineupto8daysafteringestion
Nowithdrawalsyndromerecognized
PCPUseDisorder
AproblematicpatternofPCPuseasmanifestedby2criteriaforsubstanceuseover12months.Withdrawal
symptomsarenotrecognizedforPCP,sothiscriterionwouldnotapplytowardthediagnosis.Consequences
ofuseincludephysicalevidenceofinjuries,suchasaccidents,fights,andfalls.Chronicuseisassociatedwith
memory,speechandcognitivedeficits.
PCPIntoxication
RecentuseofPCPorsimilarsubstanceleadingtoclinicallysignificantproblematicbehavioralchanges
developedduringorshortlyafteruse:
• Belligerence/assaultiveness
• Impulsivity/unpredictability
• Psychomotoragitation
• Impairedjudgment
Twoormorewithinonehour(lessifsnorted,smoked,orusedIV):
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Verticalorhorizontalnystagmus
HTNortachycardia
Numbnessordiminishedresponsivenesstopain
Ataxia
Dyarthria
Musclerigidity
Hyperacusis
Seizuresorcoma
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Treatment
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ForacutePCPintoxication,treatmentissymptomatic.DONOTattempttotalkthepatientdown.
ThismayleadtosignificantpersonalinjuryasthePCP-intoxicatedpatientmaybeagitatedor
confused,andwhencombinedwithincreasedstrengthandpoorresponsetophysicalpain,makes
foraverydangeroussituation
Treatacutepsychosis/agitationwithantipsychoticsandBZDs
Treatmedicalabnormalitiesasnecessary(includingcommonphysicalinjuriesthepatienthas
sustainedwhileintoxicated),monitorBP,temperature,andmuscleactivity.Respiratorydepression
mayoccur,monitorclosely
Ammoniumchlorideintheearlystage,andcranberryjuiceorascorbicacidlateronarehelpfulin
acidifyingthepatient’surine,leadingtoimprovedeliminationofthedrug
Patientmayneedinpatientpsychiatrichospitalizationaftermedicalclearanceduetopersisting
psychosis
Hallucinogens
Ofallsubstanceusedisorders,isoneoftherarest
Mostcommoninyoungwhitemales(whites:blacks=2:1)
Highestusein26-34y/o(15.5%ofthisagegrouphaveusedatleastonce)
WesternUS>EasternUS
Lessmorbidityandmortalitythanothersubstances(1%substance-relatedERvisitsvs.40%for
cocaine)
Neuropharmacology
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Schedule1Drugs:manyarenaturallyoccurringinmushrooms(psilocybin),cactus(mescaline),and
otherplants.LysergicAcidDiethylamide(LSD)wasfirstsynthesizedin1938
Actontheserotoninsystem,possiblyasapartialagonistonpost-synapticreceptors
Onsetofactionwithinanhour,peaksin2-4hoursandcanlastupto12hours
Rapidtolerancethatreversesquickly.Nophysicalwithdrawal
ClinicalFeatures
Sympathomimeticsymptomsincludetachycardia,tremors,HTN,hyperthermia,blurredvision,and
mydriasis.DeathcanoccurduetoHTN,hyperthermia,andphysicalinjuryduetoimpairedjudgment
• Synesthesia:colorsheardorsoundsseen.Canhavevisualandauditoryhallucinations,intense
emotionallability,introspectivereflection,andheightenedsuggestibility
HallucinogenUseDisorder
•
Aproblematicpatternofhallucinogenuseasmanifestedby2criteriaforsubstanceusewithin12months.
WithdrawalsymptomsarenotrecognizedforPCP,sothiscriterionwouldnotapplytowardthediagnosis.
Consequencesofuseinclude
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HallucinogenIntoxication
1.During,orshortlyafterhallucinogenusethereisclinicallysignificantbehaviororpsychologicalchanges:
Anxietyandfearfulness
ParanoidIdeation
Ideasofreference
Fearoflosingone’smind
Moodlability
Depersonalization/Derealization
2.Perceptualchangesinastateoffullwakefulnessandalertnessthatdevelopduringorshortlyafteruse
(mayincludeauditory,visual,ortactilehallucinations,illusions,orsynesthesia)
•
•
•
•
•
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3.Twoormoreofthefollowing:
•
•
•
•
•
•
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Pupilsdilated
Tachycardia
Sweating/Chills
Palpitations
Blurredvision
Tremor
Incoordination
Hallucinogen-RelatedDisorders
•
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HallucinogenPersistingPerceptionDisorder:followingcessationoftheuseofahallucinogen,the
personre-experiencesoneormoreoftheperceptualsymptomsthatwereexperienceswhile
intoxicatedwiththehallucinogen.Mayincludegeometrichallucinations,falseperceptionof
movementintheperiphery,trailsofimages,halosaroundobjects,andpositiveafterimages.These
“flashbacks”areexperiencedbyupto4%ofusers.Flashbacksarespontaneous,transitory
recurrencesofthesubstance-inducedexperiencelastingsecondstominutes,likelydueto
hallucinogenstorageinfatwithmetabolizationatalatertime.Canbetriggeredbystress,
EtOH/drugs,orsensorydeprivation(monotonousdriving)
Hallucinogen-InducedPsychoticDisorder:a“badtrip”withacutepanicandpsychosis.
Treatment
Treatmentfocusesonabstainingfromhallucinogenuse,treatmentofsymptoms,reducehospital/ERvisits,
development,preservationofsocialrelationships,andtreatingco-morbidillnesses(Alcoholism,depression,
etc).
•
•
•
Providesupportivecarefortheremainderoftheintoxication.UseBZDsforacuteanxietyifnecessary
TreatmentofHallucinogenPersistingPerceptionDisorder(flashbacks)includesBZDsor
anticonvulsanttherapy.Unfortunately,thereisnocompletelysuccessfultreatment
o AvoidEtOH,caffeine,orotherdrugsthatmayprecipitateflashbacks
Treatpsychosiswithshort-termantipsychotics,withthemainstayoftreatmentbeingprevention
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Inhalant-RelatedDisorders
Epidemiology
Easilyavailable,legal,andinexpensive.Highlyusedbyadolescentsandthepoor
About10%of13year-oldAmericanshaveusedatleastonce
Highestuseinadolescents(onestudyshowedthatatleast18%ofhighschoolseniorshadusedat
leastonce)
• 20%ofusersdevelopInhalantUseDisorder
• WhitesmorecommonthanblacksorHispanics
• Malesaccountfor80%ofuse
• Only1%ofallsubstance-relateddeathsandlessthan0.5%ofsubstance-relatedERvisits
• AssociatedwithanincreasedlikelihoodofConductDisorderandAntisocialPersonalityDisorder
Neuropharmacology
•
•
•
•
•
•
•
•
•
•
•
Includessolvents,glues,adhesives,aerosolpropellants,paintthinners,andfuels.Specificexamples
include:gasoline,varnishremover,lighterfluid,airplaneglue/superglue,rubbercement,cleaning
fluid,spraypaint,andshoeconditioners
Activechemicalsincludetoluenes,propanes,ethylenes,andhalogenatedhydrocarbons.
Usedwithatube,can,plasticbag,oraninhalantsoakedragthroughwhichtheusercaninhalethe
fumesthroughthenoseormouth(“huffing”)
TolerancecandevelopbutthereisnoDSM5recognizedwithdrawaldisorder
Rapidlyabsorbedthroughthelungsanddeliveredtothebrain.Effectsappearwithin5minutesand
last30minutesuptohoursbasedonthesubstance/dose
BloodconcentrationincreasedwhencombinedwithEtOH
One-fifthisexcretedunchangedbythelungs,therestismetabolizedintheliver.Detectableinthe
bloodfor4-10hours
AdditiveeffectswithotherCNSdepressants(EtOH,BZDs)
o MAOmaybethroughenhancingtheGABAsystem
InhalantUseDisorder
Aproblematicpatternofuseofahydrocarbon-basedinhalantsubstancemeetingatleast2criteriafor
substanceusewithin12months.Nowithdrawalisrecognized,andthisisremovedfromthesubstanceuse
criteria.Consequencesincludetoxicity,arrhythmia,andfatality.
InhalantIntoxication
Recentshort-term,high-doseexposuretoaninhalantcausingclinicallysignificantproblematicbehavioralor
psychologicalchangesduringorshortlyafteruse:
•
•
Apathy&lethargy
Argumentativeness/Abusiveness/Aggression
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Moodlability
Impairedjudgment,attention,andmemory
Twoormore:
•
•
• Dizziness
• Nystagmus
• Incoordination
• Slurredspeech
• Unsteadygait
• Lethargy
• Depressedreflexes
• Psychomotorretardation
• Tremor
• Generalizedmuscleweakness
• Diplopia
• Stupororcoma
• Euphoria
Severe:Hypotension,Hypothermia,DepressedGagReflex
Inhalant-RelatedDisorders
InhalantIntoxicationInducedDelirium:behavioraldisturbanceduetohypoxiaorinteractionswith
othersubstances.Treatment:short-termantipsychoticsforagitation.AvoidBZDs,whichcanworsen
respiratorydepression
• Inhalant-InducedPersistingDementia:duetoprolongedhypoxia,inhalantneurotoxicity,orheavy
metals(i.e.lead)usesininhalants.Dementiaispermanent
• Inhalant-InducedMoodDisorder,PsychoticDisorder,andAnxietyDisorder
AdverseEffectsofInhalants
•
•
•
•
•
•
•
Short-TermSymptoms:pulmonary/cardiovascular(chestpain,bronchospasm),GI(N/V,
hematemesis),andneurological(peripheralneuritis,headache,andleadencephalopathy)
Irreversiblehepaticorrenaldamage(includingRTA)
o Permanentmuscledamageassociatedwithrhabdomyolysiscanalsocauserenaldamageas
wellaslong-termmotorimpairment
Organicsolventsarecombinedwithcopper,zinc,andheavymetals,whichcanleadtobrainatrophy,
temporallobeepilepsy,loweredIQ,andEEGchangesifingested
CongenitalanddevelopmentalabnormalitiesthatresembleFetalAlcoholSyndromeifinhalantsare
usedduringpregnancy
Ifapatientisabruptlystartledduringintoxication,cardiacarrestanddeathcanoccur
Deathisduetorespiratorydepression,cardiacarrhythmias,asphyxiation,aspirationofvomitus,or
accidentalinjury
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Treatment
•
•
•
Medicallytreatcoma,bronchospasm,laryngospasm,cardiacarrhythmias,trauma,orburns.Provide
reassurance,quietsupport,andattentiontovitalsigns/LOC
Mayrequirepsychiatrichospitalizationifinhalant-inducedpsychosisissevere.Treatwithshort-term
antipsychotics.Sedativesmayaggravatethepsychosis.Monitorforanxiety,depression,andSI
Streetoutreachandextensivesocialservicesupportfortheseverelydeteriorated/homeless.Family
supportiscrucial
Opioid-RelatedDisorders
Overview
•
•
•
•
•
•
Opioidshavebeenusedfor3,500years,andin1806morphinewasfirstisolated.Heroinisthemost
abusedopioidindevelopedcountries
Derivedfromtheopiumpoppy,Papavarsomniferum
Syntheticopioidsincludemeperidine(Demerol),methadone,andpropoxyphene(Darvocet)
Lifetimeprevalenceofheroinuseis1%,male-to-femaleuseis3:1,andaheroinhabitcancost
hundredsofdollarsperday,leadingtocriminalactivitiesandprostitution.Thisaccountsformuchof
thespreadofHIV(prostitutionandIVheroinuse)
90%ofpatientswithopioiddependencehaveanadditionalpsychiatricdisorder,mostcommonly
MDD,ETOHaddiction,antisocialPD,andanxietydisorders
15%ofopioiddependentpatientsattemptsuicideatleastonce
Neuropharmacology
•
•
•
•
•
•
Primaryeffectsareonopioidreceptors:μ-opioidreceptorsmediate/regulateanalgesia,respiratory
depression,constipation,anddependence;κ-opioidreceptorsareassociatedwithanalgesia,diuresis
andsedation;δ-opioidreceptorsmaybeassociatedwithanalgesia
Endogenousopioidsinthebrainincludeenkephalinsandendorphins,involvedinneuronal
transmissionandpainsuppression
Theaddictiverewardingpropertiesoftheopioidsaremediatedthroughtheactivationoftheventral
tegmentalareawithDAneuronsprojectingtothecortexandlimbicsystem
Heroinisthemostcommonlyabusedopioidandismorepotentandlipidsolublethanmorphine.
Crossestheblood-brainbarrierfasterandhasmorerapidonsetofactionthanmorphine
Opioidscanbetakenorally,snortedintra-nasally,andinjectedIV
Detectedintheurinefor12-36hours.Fentanylisnotdetectedintheurine
ToleranceandDependence
•
•
Long-termuseofopioidsresultsinchangesinthenumberandsensitivityofopioidreceptors,which
leadtosomeoftheeffectsoftolerance/withdrawal
Long-termuseisassociatedwithincreasedsensitivityoftheDA,cholinergic,andserotonergic
systems
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•
Theprimarymediatorofwithdrawalisopioideffectonnoradrenergicneurons.Short-termuse
decreasesnoradrenergicneuronsinthelocusceruleus(LC),whilelong-termuseleadstogene
alterationandincreasedLCexcitabilitybyNE.ToleranceforopioidsresultsfromthisincreasedLC
excitability.Withdrawalofopioidsleadstoreboundhyperactivity/increasedNE
Etiology
•
•
Psychosocialfactors:childrenofdivorcedparentsorsingleparentsareathigherriskfordependence
Biological/Geneticfactors:monozygotictwins>dizygotictwins
OpioidUseDisorder
Aproblematicpatternofopioiduseleadingtomeetingatleast2ofthesubstanceusecriteriawithin12
months.Recallthatthediagnosiscannotbemetiftheonlycriteriapresentaretoleranceandwithdrawal
withinthecontextofbeingmedicallyprescribed.Consequencesofuseincludemultiplemedical
comorbidities,increasedriskforsuicideandassociationwithcriminalactivity.
OpioidIntoxication
Duringorshortlyafterusethereisclinicallysignificantproblematicbehaviororpsychologicalchanges:
• Initialeuphoriafollowedbyapathyandsedation
• Disinhibition
• Psychomotorretardation
• Impairedjudgment
Pupillaryconstriction(ordilationaftersevereoverdose)ANDoneofthefollowing:
• Drowsinessorcoma
• Slurredspeech
• Impairmentinattentionormemory
Severe:respiratorydepression,hypoxia,hypotension,andhypothermia.InsevereODanoxialeadsto
DILATEDpupils.
OpioidWithdrawal
1.Presenceofeither:cessation/reductioninheavyandprolongeduseORadministrationofanopioid
antagonistafteraperiodofopiateuse
2.Threeormore:
•
•
•
•
•
•
•
•
Dysphoricmood
Nausea/vomiting
Muscleaches
Lacrimationorrhinorrhea
Pupillarydilation,piloerection,orsweating
Diarrhea
Yawning
Fever
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• Insomnia
Withdrawalofmorphineandheroinoccurswithin6-8hours,andsubsideswithin7-10days.Thekeypointis
thatwhileopiateoverdoseorintoxicationcanbefatal,withdrawalisrarelyfatal(asopposedtoEtOHand
BZDwithdrawal,whichcanbefatal).
AdverseEffects
Mostcommonandmostseriousadverseeffectispotentialtransmissionofhepatitis,bacterial
endocarditis,tuberculosis,andHIVthroughcontaminatedneedles
• Combiningmeperidine(Demerol)andMAOIscanproducecoma,seizures,anddeath
• Chronicabscessesfromsubcutaneousinjections(“skinpopping”)andvisibleneedletrackscanbe
notedonphysicalexamination
• Deathfromopioidoverdoseoccursthroughrespiratorydepressioninthebrainstem.Consider
opioidoverdosewithclinicaltriadofrespiratorydepression,pinpointpupils,andcoma
• Pregnancy:malnutrition/vitamindeficiency,HIV/sexuallytransmitteddiseases,HTN,pre-eclampsia,
miscarriage,prematureruptureofmembranes,lowbirthweight,prematurity,stillbirth,neonatal
dependenceonopioids(50%),andSIDS.Buprenorphineandmethadonearepreferredtreatmentin
pregnantwomenwithopioiddependence
TreatmentandRehabilitation
•
TreatmentofOverdose
Maintainandadequateairway.Mechanicallyventilateuntilnaloxone,aspecificopioidantagonist,
canbeadministered.Monitorvitalsignsandstabilizebeforeconsideringtreatmentofopioid
dependence/rehabilitation
TreatmentSettings
•
Fivesettings:inpatienthospital,outpatientclinics,opioidtreatmentprograms,self-helpprograms,and
therapeuticcommunities
•
•
•
•
•
Inpatienthospitalization:afteroverdose,inpatientmedicalhospitalizationisrequiredfor
stabilization.Reversalofopioideffectsthroughtheshort-actingopioidantagonistnaloxoneis
needed,andtreatmentofwithdrawalcanbedoneinamedicalsettingoraninpatientpsychiatric
hospital
Outpatientclinics:mayusegrouppracticesandmedicationmanagementforthetreatmentofopioid
dependence
Opioidtreatmentprograms:includemethadonemaintenanceclinicsthatoperateunderspecial
federalandstateregulations.Theseprogramscanbehighlyeffective.Arecoveringheroinaddict
mustberegisteredwiththeDEAinatreatmentprogramtoreceiveopioids
Self-helpprograms:NarcoticsAnonymousiseffectiveintreatingdependence,especiallywhen
combinedwithmedicationmanagementandothertreatmentsettings
Therapeuticcommunities(likeasoberlivinghome)participateinarigidprogramwithother
substanceusers
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MedicationManagement
Managementofwithdrawalissymptomatic,includinguseofclonidine(centralα2-adrenergicagonist
decreasesNEbystimulatingautoreceptors),anti-nauseamedications,NSAIDSforanalgesia,musclerelaxants,andshort-termBZDs(foranxietyandinsomnia).Methadoneandbuprenorphineand
highlyeffectiveintreatingsymptomsofwithdrawal
• MethadoneandLAAM:botharescheduleIIfullmuagonists.LAAMisstructurallyrelatedto
methadonebuthaslongerdurationofaction(takenofftheUSmarketduetocardiacarrhythmias).
Methadoneiscurrentlyonlyavailablethroughspeciallylicensedopioidtreatmentprogramsthatare
heavilyregulated.Goalsoftreatmentare:suppresswithdrawal,decreasecraving,blocksillicit
opioids,stoppingillicitopioiduse,andenlistthepatientinprogramdesignedtopromote
rehabilitation.Sideeffectsincludeconstipation,sweating,andsexualdifficulties.Thebenefits
includereductioninthespreadofHIVthroughIVdruguse,gainfulemployment/lesscriminal
activity,andproducesminimaleuphoriaordepression.Thedisadvantagesarecontinued
dependenceonacontrollednarcotic
• Buprenorphine:partialµ-agonist/κ-antagonistthathashigherbindingaffinityforµ-receptorsthan
illicitopioids/fullagonists(knocksillicitopioidsoff).Itislessaddictiveduetolessagonist/partial
agonisteffect(painmanagementwithouteuphoriaorrespiratorydistress)andentersthe
bloodstreammoreslowlythanotheragonists.Goodsublingualbioavailability.Treatsopioid
withdrawalandchronicpainmanagement.However,itcanstillbeabusedifinjected.Asaresult,
combinationwithnaloxone(opiateantagonist)leadstolessabusepotential(naloxonehasbetter
parenteralbioavailability.Ifthedrugisinjectedtoabuse,naloxoneblocksthereceptor).
• Naltrexone:opioidantagonistsimilartonaloxonewithlongerdurationofaction(72hours).
Blockingopioidagonisteffects,particularlyeuphoria,naltrexonediscourages/deconditions
substance-seekingbehavior.Similartodisulfram,thismedicationisusedtotreatdependence,not
withdrawal.Sideeffectsincludedysphoria,anxiety,GIdistress,andinhigherdoses,elevatedLFTs
PsychosocialTreatments
•
Allclinicaltrialsforpsychosocialinterventionshavetakenplaceinprogramsthatalsoprovideopioidagonist
maintenance(likemethadone)oropioidantagonists(likenaloxoneornaltrexone).Therapyalonemaynot
beaviableoptionfortreatment.
•
•
•
•
CBT:helpfulinpatientswithMDDorotherco-morbidpsychiatricissues.Inaddition,mayreduce
high-riskHIVbehaviorsanddecreasecriminalbehaviors
Behavioraltherapies:usesreinforcers/rewards(commonlymethadone)contingentonabstinence.
Canenhanceadherencewithnaltrexone
Familytherapyenhancestreatmentadherence
Self-helpgroupsand12-step-orientedtherapies:NarcoticsAnonymousisbeneficialbyproviding
peersupport,decreasingsubstance-abusingpeers,providingaccountability,confrontingdenial,and
interveningearlyinpreventingrelapse
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Sedative,HypnoticorAnxiolytic-RelatedDisorders
Overview
IncludesBZDs,barbiturates,methaqualone(Qualudes),andmeprobamate.Thesedrugsareantiepileptics,muscle-relaxants,anesthetics,andareadditivetotheeffectsofEtOH
• Sedativesaredrugsthatreducetensionandinducementaltranquility,synonymouswithanxiolytics
(i.e.theyreduceanxiety).Hypnoticsaredrugsusedtoinducesleep.However,atvarieddoses
sedativescanproducesleepandhypnoticscanproducetranquility
• BZDs:rapidonsetisassociatedwiththemostaddictionpotential
o Long-Acting:diazepam(rapidonset),clonazepam,flurazepam,chlordiazepoxide
o Short-Acting:lorazepam(rapidonset),oxazepam,temazepam
o Ultra-ShortActing:alprazolam(rapidonset)andtriazolam
• Barbiturates:beforeintroductionofBZDs,barbiturateswerefrequentlyprescribed,butarehighly
abusedandaremuchmorelethalthanBZDsduetorespiratorydepression,especiallywhen
combinedwithEtOH
o Long-Acting:phenobarbital(acommonanti-epileptic)andbarbital
o Intermediate-Acting:amobarbital(Amytal)useinthe“Amytalinterview”toaidinconversion
reactions,andtodifferentiatethestuporofdepression,schizophrenia,andstructuralbrain
lesions
o Short-Acting:secobarbital(“reds”)andpentobarbital(Nembutal,“yellowjackets”).Inthe
“PentobarbitalChallengeTest,”atestdoseofpentobarbitalisgivenorallytodeterminethe
extentofbarbituratetoleranceinordertoadequatelytreatwithdrawal
o Maybetakenorally(commoninmiddleaged/middleclassandprescribedbyFamilyMDfor
insomniaoranxiety)orIV(moresevereformofabuse,usuallyinyoungadults,with
increasedratesofHIV,cellulitis,andinfection).TheIVformhasarapidandprofound
tolerance/dependenceinadditiontoseverewithdrawal
Epidemiology
•
•
•
Thehighestprevalenceofsedativeabuseisinthe26-34yearoldagegroup
Femaletomaleratiois3:1,whitetoblackis2:1
Neuropharmacology
•
•
•
AllhaveprimaryeffectsonGABAtypeAreceptors,actingtoallostericallystrengthentheGABA
signal.Thisleadstomoreinfluxofnegativelychargedchloride,inhibitingneurons.Theoveralleffect
iscalming
ToleranceisunderstoodthroughchronicGABAstimulationonGABA-Areceptors,leadingtoless
sensitivity/lesschlorideinfluxinthepresenceofthedrug.This“downregulationofreceptor
response”isnotduetodecreasedreceptornumberordecreasedaffinityforGABA.Itappearstobe
duetodecreasedefficiencyofcouplingwiththechloridechannel,leadingtotolerance
Maybedetectedintheurineupto1weeklaterinlongeractingmedications
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Sedative,Hypnotic,orAnxiolyticUseDisorder
Aproblematicpatternofsedative,hypnotic,oranxiolyticuse,meetingatleast2criteriaforsubstanceuse
overa12monthperiod.Recallthatthediagnosiscannotbemetiftheonlycriteriapresentaretoleranceand
withdrawalwithinthecontextofbeingmedicallyprescribed.
Sedative,Hypnotic,orAnxiolyticIntoxication
Duringorshortlyafterusethereisclinicallysignificantmaladaptivebehaviororpsychologicalchanges:
• Abusiveness/Aggression
• Moodlability
• Impairedjudgment
Oneormore:
• Slurredspeech
• Incoordination
• Unsteadygait
• Nystagmus
• Impairmentinattentionormemory
• Diminishedlevelofconsciousness(Stupor/Coma)
Servere:Hypotension,Hypothermia,DecreasedGagReflex
Clinically,thesyndromeofintoxicationisindistinguishablefromEtOHintoxication.
Sedative,Hypnotic,orAnxiolyticWithdrawal
Aftercessationofprolongeduse,therearetwoormore:
•
•
•
•
•
•
•
•
Autonomichyperactivity(Sweating,tachycardia,HTN)
Tremoroftongue,eyelids,oroutstretchedhands(asterixis)
Insomnia
Nausea/vomiting
Transientvisual,tactile,orauditoryhallucinations/illusions
Psychomotoragitation
Anxiety
Grandmalseizures
CanbeLETHAL,justlikeEtOHwithdrawal
BZDwithdrawaloccurswithinthefirst3daysofcessation,withseizuresdevelopingonthe2ndor3rdday.
Shorteractingsubstanceshaveonsetofwithdrawalsooner.Forbarbiturates,thesymptomsofwithdrawal
usuallydon’toccuruntil2-3daysaftercessation(orwithlongeractingdrugs,upto5-6dayslater).
AssociatedDisorders
•
Deliriumpresentswithintoxicationorwithdrawal,andcanbeindistinguishablefromDTsinEtOH
withdrawal(morecommoninbarbituratewithdrawal)
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PsychoticDisordersaremorecommoninwithdrawalfrombarbituratesthanBZDs,andmaybe
undistinguishablefromEtOH-relatedDTs
• Sedativesandhypnoticscaninducemooddisorders,anxietydisorders,sleepdisorders,andsexual
dysfunction
Treatment
•
Overdose
•
•
•
Treatmentfocusesongastriclavage,activatedcharcoal,andmonitoringvitals/CNSactivity.ODmay
requiremechanicalventilationduetorespiratorydistress
BZDs:muchsaferinODthanbarbituratesduetominimalrespiratorydepressioninBZDs.Ifcombined
withEtOH,thereissignificantlyincreasedriskforlethality.Lethaldoseis200:1.Treatwithflumazenil
(BZDantagonist)intheER
Barbiturates:highlylethalinoverdoseduetorespiratorydepression.LikeBZDs,haveadditivelethal
effectswithEtOHorothersedative-hypnotics.Lethaldoseis3:1to30:1
Withdrawal
•
•
BZDs:topreventseizures,thedoseshouldbegraduallyreduced.Detoxificationgenerallyoccursin
aninpatientsetting,switchingtoalong-actingBZDforwithdrawalandgraduallytaperingoff.
Symptomsofwithdrawalaretreatedwithclonidine,andthereissomedatatosuggest
carbamazepinemaybeusefulintreatingsymptomsofwithdrawal
Barbiturates:withdrawalcanbehighlylethal,requiringinpatienthospitalization.Apentobarbital
challengetestisdonetoascertainthestartingdoseofbarbituratesrequiredfordetoxification.Longactingbarbiturates,likePhenobarbital,areusedfordetoxification.Taperingoffismuchmore
gradualthanwithBZDs
PsychosocialTreatments
•
•
•
•
Outpatienttreatmentprogramsfocusonrehabilitationinasafeenvironment,utilizingCBT,
behavioraltherapies,grouptherapies,andself-helpgroups
Treatanyunderlyingpsychiatricdisorders(SSRIsfordepression,anxiety,panicdisorder,etc)
Familysupportandeducationareimportant
PMDneedstobeactivelyinvolvedinthetreatmentplan,as“MDshopping”iscommonamongthese
patients,leadingtorelapse
Stimulant-RelatedDisorders
PharmacologicalPreparations
•
MajoramphetaminesinUSA:dextroamphetamine(Dexedrine),methamphetamine,mixed
detroamphetamine-methamphetaminesalt(Adderall,Ritalin),anddesigneramphetamineslike
MDMA(“ecstasy”)
o Nicknamesincludeice,crystalmeth,meth,andspeed
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o Canbesmoked,snorted,ingested,orinjected
• Cocaine:consumedascocaleaves,snortedorsmokedascocainehydrochloride,orconvertedintoan
alkaloidthrough“freebasing”tomakecrackcocainetosmoke
Epidemiology
•
•
•
Highestuseisinpersons18-25and26-34
Males>Females(2:1)
Allracesandsocioeconomicgroupsareaffectedequally
Comorbidity
•
•
AnxietyDisorders,ADHD,andAntisocialPersonalityDisorderoftenprecedeuse.Oftenmood
disordersandEtOHdependencearetheresultofresultofstimulantabuse
Commonlyassociatedpsychiatricdisordersinclude:MDD(>30%ofcocaineusers),Cyclothymia
(20%),BipolarDisorder,AnxietyDisorders,andAntisocialPersonalityDisorder
Neuropharmacology:Amphetamines
•
•
•
•
Rapidlyabsorbedandrapidonsetofaction(1hourorally,immediatelywhenintravenously)
Primaryeffectsareproducedthroughpresynapticreleaseofcatecholamines(DA),especiallyinthe
limbicandcerebralcortex,whichinfluencetherewardpathways.Thisdiffersfromcocaine,which
inhibitsthereuptakeofDA
MDMAandotherdesigneramphetaminescausereleaseofcatecholaminesANDserotonin(leading
tohallucinations)
Detectedintheurine1-3days,withhairsamplesabletodetectuseforupto90days
Neuropharmacology:Cocaine
AlkaloidderivedfromtheSouthAmericanshrubErythroxylonCoca.Itwasfirstusedasananesthetic
in1880(currentlyusedstillinENTsurgeries).WasusedbySigmundFreudandwidelyusedasa
“cure-all”until1914whenitsaddictivepropertieswererecognized
• Mostcommonmethodofuseis“snorting”(i.e.intra-nasally).OthermethodsincludeIVorsmoking
(“freebasing”).Freebasingmixesstreetcocainewithpurecocainealkaloid(freebase)toincrease
effect.Crackisasmokedfreebaseformofcocaineandishighlyaddictive
• CompetitiveblockadeofDAreuptake,therebyincreasingDAinsynapticcleftandincreasedD1/D2
receptoractivation
• AlsohaseffectsonNorepinephrine,Serotonin,cerebralbloodflow,andcerebralglucoseuse
• Behavioralaffectsarefeltimmediatelyandlast30-60minutes,requiringrepeateddosingfor
continuedintoxication.Canstayinurine1-3days,andupto12daysindailychronicusers
StimulantUseDisorder
•
Apatternofamphetamine-typesubstance,cocaine,orotherstimulantusemeetingatleast2criteriafor
substanceusewithinthepast12months.
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StimulantIntoxication
Duringorshortlyafterusethereareclinicallysignificantproblematicbehavioralorpsychologicalchanges:
• Euphoria&sensationofincreasedenergy
• Hypervigilance
• Increasedsociability
• Abusive/Aggressivebehavior
• Moodlability
• Repetitivestereotypedbehaviors
• Interpersonalsensitivity
• Impairedjudgment
Twoormore:
•
•
•
•
•
•
•
•
•
Tachycardiaorbradycardia
Pupillarydilatation
HTN
Sweating/Chills
Nausea/Vomiting
Weightloss
Psychomotoragitationorretardation
Muscularweakness,chestpain,arrhythmias,orrespiratorydepression
Seizures,dystonia,dyskinesia,confusion,orcoma
StimulantWithdrawal
Aftercessation/reductionofuse,thereisdysphoricmoodplusatleasttwoofthefollowingwithinafew
hourstoseveraldays:
•
•
•
•
•
Lethargyandfatigue
Vivid,disturbingdreams
Insomnia/Hypersomnia
Increasedappetite
Psychomotorretardationoragitation
Withdrawalpeaksin2-4daysandisusuallyresolvedby1week.Themostseriouswithdrawalsymptomis
depressionbecauseitcanleadtosuicidalideation.
AdverseEffectsofStimulantUse
•
•
•
Common:nasalcongestion/ulceration/bleeding/perforationofnasalsepta(snorting),damage
bronchialpassages(smoking),infection/embolism/HIV(IVuse),acutedystonia,tics,andmigraines
Two-thirdsofacutetoxiceventsoccurwithinonehourofintoxication,withmajorcomplications
beingcerebrovascular,epileptic,andcardiac
Cerebrovascular:nonhemorrhagiccerebralinfarctionmostcommon,TIA,andspinalcord
hemorrhages
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Seizures:occurin3-8%ofcocaine-relatedERvisits.Cocaineisthe#1abusedsubstanceassociated
withseizures,amphetaminesis#2.Partialcomplexstatusepilepticusisseen
• Cardiac:MIandarrhythmias.Long-termuseisassociatedwithcardiomyopathy
• Pregnancy:withamphetaminesandcocaine,riskoflowbirthweight,smallheadcircumference,
prematuredelivery,growthretardation,fetaldemise,andabruptioplacentae.Withcocaineinutero
specifically,seeCNSirritabilityinthenewbornwithdecreasedIGandattentionspandeficits
• IVUse:HIV,hepatitisB/C,lungabscess,endocarditis,andnecrotizingangiitis.
• Stimulant-InducedPsychoticDisorder:paranoia,hallucinations,hypersexuality,hyperactivity,and
confusion.CanbedistinguishedfromschizophreniainthatinamphetaminepsychosishasNOalogia,
flatteningofaffect,disorganizedthinking(i.e.looseassociations).Treatment:shorttermuseof
antipsychoticslikehaloperidoloratypicalantipsychotics
Treatment
•
Thelong-termgoalsoftreatmentarethesameforallsubstanceusedisorders:abstinence,relapse
prevention,andrehabilitation.
•
TreatmentSetting:oncemedicallycleared,inpatienttreatmentisrarelyneeded.Mostpatientscan
betreatedeffectivelyinanintensiveoutpatientprogram.Foracutepsychotic/agitatedpatients,
inpatientcaremaybenecessarytomonitorforsafetyandprovideshort-termtreatmentwith
antipsychotics
PsychosocialTreatments
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•
•
MultiplestudiesshowthatCBTisoneofthemosteffectivetreatmentmodalities
Familytherapyisanessentialcomponentoftreatment,focusingontheconsequencesofthe
patient’suseandgoalsforahealthyfuture.Itempowersfamiliestohelptheaddictpreventrelapse
ParticipationinNA,CocaineAnonymous,orother12-stephelpgroupspredictslessstimulant
use/relapse
MedicationManagement
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•
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Treatintoxicationsymptomatically:α-blockersbeforeß-blockerstopreventunopposedαactivity,
BZDsforagitation,antipsychoticsforseverepsychosis
Studiesfortreatmentofcocainedependence:buprenorphine(opiatepartialagonist),topiramate,
baclofen(GABABagonist),tiagabine(GABAreuptakeinhibitor).Allofthesemedicationshavesome
datatoshowefficacyintreatmentofcocainedependence/withdrawal
Bupropion(decreasesDAreuptake)hasbeenusedafteramphetaminewithdrawaltoreduce
dysphoriaandproducefeelingsofwell-being
Treatingunderlyingpsychiatricconditionsthatcontributetostimulantuseisalsoimportant
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Tobacco-RelatedDisorders
Epidemiology
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WHOestimates1billionsmokersworldwide;25%ofAmericanssmoke.Tobaccokillsmorethan3
millionpeopleayear
Tobaccoisthemostcommonformofnicotine.Tobaccocanbefoundincigarettes,cigars,pipes,
snuff,andchewingtobacco
Over75%ofsmokershavetriedtoquit,andabout40%attempttoquiteachyear.Inattemptingto
quit,only30%canremainabstinentforeven2days
About20%ofthepopulationdevelopsnicotinedependenceatsomepoint,makingitthemost
prevalentpsychiatricdisorder
Women=Men
Moreprevalentinlowersocioeconomicgroups,thelowereducated,andinminorities
70%ofpatientswithBipolarDisorderand90%ofschizophrenicssmoke.Inpatientswith
schizophrenia,nicotinecanreducetheirextraordinarysensitivitytooutsidesensorystimuliand
increasetheirconcentration
Associatedwith25%ofalldeathsintheUnitedStates.Deathsoccurfrombronchitis/emphysema,
cerebrovasculardisease,cardiovasculardisease,andalmostallcasesofCOPDandlungcancer.
Chewingtobaccoandcigarsareassociatedwithoropharyngealcancer
Secondhandsmokeincreasestheriskofheartdiseaseandcancerby30%
Dependenceisenhancedbystrongsocialfactorsthatencouragesmokingandtheeffectsoftobacco
companyadvertising.Somestudiessuggestageneticpredispositiontowardnicotinedependence
Neuropharmacology
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Nicotineactsasanagonistatthenicotinicsubtypeofacethycholine(ACh)receptors.Itactivatesthe
DApathwayprojectingfromtheventraltegmentalareatothecerebralcortexandthelimbicsystem
(i.e.thesameareasinvolvedincocaine/amphetaminedependence),resultinginpositivereinforcing
andaddictiveproperties
InadditiontoactivatingtheDArewardsystem,nicotinecausesincreasedconcentrationsofNE,
epinephrine,vasopressin,ß-endorphin,ACTH,andcortisol.ThisresultsinCNSstimulation
25%oftheinhalednicotinereachesthebloodstreamandbrainwithin15seconds.Thehalf-lifeof
nicotineis2hours
TobaccoUseDisorder
Aproblematicpatternoftobaccouse,meetingatleast2criteriaofsubstanceusewithin12months.Thereis
norecognizedintoxicationstatefortobacco.
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TobaccoWithdrawal
Afterdailyuseoftobaccoforatleastseveralweeks,within24hoursofreducingorceasingusethereareat
leastfourofthefollowing:
• Dysphoric/depressedMood
• Insomnia
• Irritability/frustration/anger
• Anxiety
• Difficultyconcentrating
• Restlessness
• IncreasedAppetite/weightgain
CancauseslowingofEEGactivity,decreasedcortisol,decreasedcatecholaminelevels,andadeclinein
metabolicrate.Heartratedecreasesby5-12BPMinthefirstfewdaysafterstoppingsmoking.Weightmay
increaseanaverageof4-7lbsaftercessation.Mayhaveincreasedcravingsforsugaryfoods.
Withdrawalsymptomspeak24-48hoursaftercessationandmaycontinuefor4weeks.Hungerandcraving
fortobaccocanlastupto6monthsinsomepatients.
AdverseEffects
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•
•
•
Adverseeffectsafterwithdrawal:
o BenzopyrenesintobacconormallyinhibitthehepaticP450CYP1A2system.Medications
metabolizedbythissystem(includingclozapine,haloperidol,BZDs,TCAs,andpropranolol)
willincreasesubstantiallyaftersmokingcessation.Monitorformedicationtoxicityafter
quittingsmoking
o Smokingincreasescaffeinemetabolism,thussmokingcessationincreasescaffeinelevelsby
50-60%,increasingriskforcaffeinetoxicity.Reducingcaffeineintakewhenquittingsmoking
mayberecommended
Nicotinetoxicity:inlowdoses,thesignsandsymptomsoftoxicityincludenausea,vomiting,pallor,
weakness,abdominalpain,diarrhea,dizziness,HA,HTN,tachycardia,tremorandcoldsweats.High
dosesofnicotineaffectconcentrationandcanleadtoconfusion
NicotineisassociatedwithdecreasedREMsleep
Smokingduringpregnancyisassociatedwithincreasedincidenceoflowbirthweightbabiesand
newbornswithpersistentpulmonaryhypertension.Quittingsmokingbyhethirdtrimesterreduces
riskoflowbirthweightbabiestoequalnonsmokers
Assessment
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Assessmentofdegreeofdependenceisveryimportant,ashighly-dependentindividualsaremore
likelytoneedmoreintensivetherapy,especiallypharmacotherapy
FagerstromTestforNicotineDependence:widelyusedassessmenttoolwithprovenreliability/
validity.Canpredictwhichsmokersarelikelytoquitsmokingandwhichmaybenefitfromnicotine
replacementtherapy(NRT).Questionsinclude:cigarettes/day,morningsmoking,howsoonafter
awakeninghavefirstcigarette,difficultytorefrainfromsmokinginplaceswhereitisforbidden,
smokingwhenill/bedridden.Morningsmokingandsmokingrightafterawakeningareknowntobe
highlyassociatedwithdifficultyquitting
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•
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Indicatorsofuse:nicotinelevelsinblood/urine/saliva(detectableforfewhours),cotinine
(metaboliteofnicotine)detectableforupto7days,carbonmonoxidelevel(measuredbybreath)
reflectssmokingoverlastfewhoursandisusefultoverifycessationinpatientsusingNRT)
Assesspreviouscausesofrelapsetohelppreventfuturerelapse
Treatment
•
Generalapproachtotreatment:
a. Establishingandmaintainingatherapeuticalliance.Thisisachronicrelapsingdisorderwith
mostsmokersrequiring5-7attemptsbeforequittingforgood.Mostpatientsarenotawareof
this,andareeasilydemoralizedbyrelapse.Goodtherapeuticallianceisessentialinencouraging
thepatienttowardabstinence,usingandnon-judgmentalandempathicapproach
b. Increasingreadinessandmotivationforsmokingcessation.Enhancingmotivationanddealing
withanticipatedbarrierstocessationareimportant,especiallyinambivalentpatients.Stages-ofchangeapproachesandmotivationalenhancementmodels(seeMotivationalinterviewing)help
toenhanceapatient’smotivationandchallengeambivalence.Lookingatthepatient’s
consequencesofuse(healthissues,socialpressures,andspecialsituations[pregnancy,living
withachildwithasthma])cansometimesmotivatesmokerstoquit.DuringMDvisits,frequent
revisitingoftheseissuesandevaluatingthebenefitsofquittingisassociatedwithincreased
readinesstoquit
c. Overcomingbarrierstosmokingcessation.Addressingthepatient’sfearsrelatedtoquitting
(weightgain,fearofwithdrawal,fearoffailure)isimportant.Mayneedtodetermineother
smokingcohabitatingfamilymembers’willingnesstoquit,asthismaybeabarriertothe
patient’ssmokingcessation
d. Elicitingpatientpreferencesabouttreatment.Includesdiscussingmethodoftreatment(NRT,
variouspsychosocialtherapies,etc)
e. Determiningtimingofsmokingcessation.Besttimingiswhenpatientispsychiatricallystable,no
urgentproblems,andnorecentchangesinmedications.Smoking-relatedillnessmaynecessitate
moreimmediatecessation
f. Determiningwhethercessationwillbeabruptorgradual.Mostdatashowsnodifference
betweenabruptvs.gradualcessation
g. Settingaquittingdate.Evenifusinggradualquitapproach,adateforcompletecessationofuse
isrecommended.Ifpatientisnotreadytosetaquitdate,frequentrevisitingtheissueon
subsequentvisitsishelpful
h. Developingaplanofpsychosocialandpharmacologictreatment.Frequentbrieffollow-upafter
thequitdateisrecommended,especiallytoidentifysymptomsofwithdrawal,andmonitorfor
exacerbationofpsychiatricsymptoms
i. Providingeducationandenhancingadherence.Keypointsincludeinformingpatientsthatmost
smokerstrytoquitmultipletimesbeforesucceeding,remainingabstinentfor3monthsis
associatedwithlowratesofrelapse,andeducationonwithdrawalsymptoms.Weightgaincan
bepreventedthroughphysicalactivityandhealthierdietchoices.DiminishingETOHintakeis
recommendedasitisariskofrelapse.Praiseshouldbeprovidedevenafterarelapseforany
timeremainedabstinent
j. Determiningapproachesforpatientswhodonotrespondtoinitialtreatment.Afterarelapseitis
importanttodetermineiftreatmentwasappropriateandadequatelyimplemented.Ifso,then
rescreeningthepatientforco-occurringdisorders(othersubstanceuseorpsychiatricdisorders)
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isindicated.MayrequiretrialofdifferentNRTifinitialtreatmentinadequate.Ifstressfullife
eventleadtorelapse,therapymaybeindicated
MedicationManagement
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Nicotinereplacementtherapies(NRT):5currentFDAapprovedarepatch,gum,lozenge(theseare
OTC),nasalspray,andinhaler(prescription).Optimaldurationisvariable,somepatientsstayon
theseagentsfor>6months.TheeasiestNRTtoadheretomaybethepatch,startedathighdose21
mg.Patientswhosmoke<15cigarettes/daymaybenefitfromintermediatepatch(11or14mg).
Durationofpatchtherapyshouldbe6-12weeks.Withtheuseofgum/lozenges,scheduleddosing
withgradualtaperingoffover6-12weeksismosteffective.Combinationwithbupropionor
psychosocialtherapiesmayimproveoutcome
Bupropion:sustainedreleasebupropionisafirst-linetreatmentforsmokingcessation.Doublesquit
rates,andusewithNRThasevenhigherratesofsuccess.Increasedinastep-wisetitrationover3-4
dayswithatargetof300mg/day.MechanismofactionisthroughdecreasingreuptakeofDA
(reward/seekingsystem)andnon-competitiveinhibitionofnicotinicacetylcholinereceptors
(interfereswithaddictiveactionsofnicotine).Sideeffectsincludejitteriness,insomnia,andGI
symptoms.Avoidinpatientswithhistoryofseizuresoraneatingdisorder(duetohigherriskof
seizures)
Nortriptyline:second-linetreatmentthathassupportivedataintheeventtheabovetreatmentsare
ineffective.However,canbetoxicinoverdose,usewithcaution
Clonidine:α2-adrenergicagonistattheNEautoreceptordecreasessympathetictoneinlocus
ceruleustoabatewithdrawalsymptoms.Second-linetherapy
Otheragents:acupuncture,naltrexone,buspirone,MAOIs,andSSRIsmaybeofsomeuse,but
efficacyisnotwellestablished
PsychosocialTreatments
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Socialsupportisarecommendedtreatmentforsmokingcessation
Behavioraltherapiessubstitutehealthybehaviors(walking,exercising)forsmoking
Brieftherapieswithmotivationalapproachesarehelpful
CBTarehelpfulforsmokerswithco-morbidpsychiatricdisordersorETOH/substanceabuse.May
alsohelpwithweightconcerns
Self-helpmaterialsandsupportgroupscanaidsmokingcessation
Miscellaneous
AnabolicSteroidAbuse
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Includestestosteroneandsyntheticanaloguesoftestosteronethatpossessanabolic(musclebuilding)andandrogenic(masculinizing)effects.Thesedrugsareusedillegallytoenhancephysical
performanceandincreasemusclebulk
Neuropharmacology:oraltestosteroneismetabolizedintheGImucosaandliver,leadingto
decreasedbioavailability.Syntheticandrogensarelessextensivelymetabolized
Mayinitiallyinduceeuphoriaandhyperactivity.However,overtime,canleadtoincreased
aggression(“roidrage”),irritability,anxiety,anddepression
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•
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Whenusersstoptaking,theycanbecomedepressedandover-concernedabouttheirphysical
appearance,evenwhennochangecanbeobjectivelyseen
AdverseEffects:
o Anabolicsteroidsleadtorapidenhancementofmusclebulk,butalsohaveacne,premature
balding,yellowingoftheskin/eyes,gynecomastia,decreasedsizeoftesticles/prostate,and
stuntedgrowthinadolescents.Womenusingsteroidsdevelopadeepervoice,shrinking
breasts,clitoralenlargement,andirregularmenses.AlsocausesabnormalLFTs,decreased
HDL/increasedLDL,decreasedspermatogenesis,andmaycauseMI/cerebrovasculardisease
o DHEAandandrostenedioneareOTCadrenalandrogenfoodsupplements.Theyaresteroid
precursorsandarenotedtocauseincreasedphysicalandpsychologicalwell-being.Theirside
effectsaresimilartoanabolicsteroids
Illicit“ClubDrugs”
Ecstasy(MDMA=methylene-dioxy-methamphetamine
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Syntheticmethamphetaminepopularatclubsand“Rave”parties.Somestudiessuggestthatitleads
topermanentserotonindepletioninthebrain
Intoxication:euphoria,hyper-verbal,lossofinhibition,hypersexuality,bruxism,alteredvisual
perception
Adverseeffects:hyperthermia,dehydration,CHF,pulmonaryedema,andreporteddeaths.Theuser
willoverexertthemselves,unawareofdehydrationandhyperthermia,leadingtosignificant
morbidityandmortality
Rohypnol(Flunitrazepam)
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ABZD,alsoknownas“roofies,”the“daterapedrug.”
Usedbydissolvingthepillintoabeverage,Rohypnolcausessedation,amnesia,musclerelaxation,
andaslowingofpsychomotorresponses.Sedationoccurs20-30minutesafteradministrationand
lastsforseveralhours.Commonlyusedtocommitsexualassault,however,currentlyGHBismore
widelyusedforthispurpose
GHB(Gamma-hydroxy-butyrate)
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•
•
CombinesGBL(asolventinfloorcleaningproducts,nailpolish,andsuperglueremovers)withNaOH
orKOH.Itisaclearliquidthatiseasilymixedintobeverages
Intoxication:euphoria,increasedenergy,hyper-verbal,increasedsocialization,disinhibition,
hypersexuality,musclerelaxation,andlossofcoordinationduetolossofmuscletone.Otherside
effectsincludenausea/vomiting,amnesia,poorconcentration,lossofgagreflex,andevendeath
Canalsobeusedasasedativeandhasanabolicbodybuildingeffects.Commonlyusedasadaterape
drug
CommonlyAbusedOver-the-CounterMedications
Dextromethorphan(DM)
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D-isomerofthecodeineanaloglevorphanol(centralacting,however,isnotananalgesic)usedto
suppresscough
• Presentinmanycough/coldformulations,specificallyRobitussinDMandCoricidinHBP(which
contains3xmoreDMthanRobitussin)
• Commonlyabusedbyteensforthe“high”ofheightenedawareness,dizziness,visualhallucinations,
alteredperceptionoftimeanddrowsiness.DMisveryinexpensiveandeasytoacquire.Patientswith
ahistoryofEtOHorsubstanceabuseissuesshouldbemonitoredforDMabuse
• SymptomsofOD:HTN,tachycardia,hallucinations,slurredspeech,sedation,seizures,dilatedpupils,
temporaryblindness,severeflushing,coma,anddeath
Coricidin
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•
•
•
Cough/coldpreparationsthatcontainanantihistamine(Chlorpheneramine),adecongestant(like
pseudoephedrine),and/oracoughsuppressant(DM)
CoricidinD,containingpseudoephedrine,ishighlyabusedduetotheeaseofconverting
pseudoephedrinetomethamphetamine.Anyproductscontainingpseudoephedrinearenowclosely
monitoredandnewdecongestantswithlessaddictivepropertiesarebeingmanufactured.
Pseudoephedrineisacentralnervoussystemstimulant,whichcanproducesymptomsofshakiness,
HTN,andtachycardia
Coricidincomesinpillformulation,makingingestionoflargequantitiesofDMeasierthandrinking
multiplebottlesofRobitussintogetthesameeffect
UrineDrugScreen
Drug
EtOH
Amphetamines
Barbiturates
BZDs
Cannabis
Cocaine
Codeine/Morphine
Heroin/Methadone
PCP
LengthofTimeinUrine
1drinkmetabolized/hour
2days
1day(short-acting),3weeks(long-acting)
3days,longerwithlong-actingagents
3daysto4weeks(chronicuse)
6-8hours,metabolitesstay2-4days
2days
2-3days
8days
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ANINJA’SGUIDETOPRITEQUESTIONS2016EDITION
ByMelissaPereau
Thankyoutoallwhohavecontributedto“ANinjaGuidetoPRITE”since2007
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•
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Classof2008:AndyHayton,BryanWick,LuciaCheng,TaoYan,MelissaPereau
Classof2009:SerinaSrikureja,KatieRoman
Classof2010:TimothyLee,ChristoffLeRoux,AimeeEllison,DamanBrar
Classof2011:NickMahaffey,TaujaiWilliams,NabiLatif,CarolinaOsorio
Classof2012:FrankRandall,SerafinLalas
Classof2013:ClaudiaCarmona,JosephLiu
Classof2015:DarcyTrenkle,JaredGorsuch
Classof2016:PiotrPelc,JDLii,MartinWu
Classof2017:MelissaUrquhart,ShannonRemick,LauraObit,RachelNguyen,RebeccaWhite,Tagbo
Arene
Classof2018:JamianReed,MaryellenEller,BrentWillard,TanyaJosic,MohsinRajani,PharezRolle
Classof2019:RajivJohnson,AaronHeffner,NeilAbidi,AndrewDornan,SamAlthauser,RayekNafiz
Classof2020:HansVonWalter,AaronGilmore
Aspecialthankstothe“LomaLindaSPEROMedicalStudentSweatshop”:
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•
•
Classof2015:LisaKim,AnthonyBui,DebbieChoi,JessicaCvetko,JoshuaGoh,RachelHuso,Joy
Jones,AllysonOshiro,MichaelSigsworth
Classof2016:MarkArd,StudentProjectLeader.CaseyHarms,EricMcDonald,JacksonBrammer,
JeyoonJung,AmyAppleby
Classof2017:BiancaRebolledo,StudentProjectLeader.JoEverett,AprilSchindler,EdwinDeKock,
ShelbyTanguay,MoniqueHarrison,CalebHo-a-shoo
ThisguidecontainsallPRITEquestionsfrom2001-2015.Itisdividedintosectionsbasedonrelevanceand
furthercategorizedbyfrequencyofquestions.Ifaquestionhasbeenfeaturedmorethanonce,a(#x)
appearsattheendofthequestion.Thus,aquestionwith(4x)meansthequestionhasbeenfeaturedin4
PRITEexams.Allquestionsthatweredisputedorhavemorethanoneacceptedanswerhavebeendeleted.
Whilethequestionsaresummaries,theanswersaretheactualanswersfromthePRITEexams.Therefore,
someofthesedonotmakegoodflashcards(e.g.Question:Ariskfactorforchildabuse?Answer:Financial
stress).Theseshouldbereadthrough,especiallytheoneswithmultipliers,forexposureandprimingof
recall.
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Neurology
Amnesia
Whatcharacterizesthememorylossinpatientswithdissociativeamnesia?(2x)
EPISODIC
Amnesiaprecededbyepigastricsensation/fearareassocwelectricalabnorm
where?
TEMPORALLOBE
Memorylosspatternindissociativeamnesia
OCCURSFORADISCRETEPERIODOFTIME
Amnesiacharacterizedbylossofmemoryofevents,occurafteronsetofetiologic
conditionoragent
ANTEROGRADE
Whatpsychoactivedrugproducesamnesia?
ALCOHOL
Ptw/strangebehavioranswersappropriatelywfluentspeechbutnoabilityto
retainnewinfo.Episodelasts6hrsthenbacktonormal.Norecollectionofevents. TRANSIENTGLOBALAMNESIA
Dx?
A61yowithmemoryproblemthatstartedabout2hrspriortoEDpresentation,
unabletorememberrecentevents,anxiousandfrustrated
Transientglobalamnesia
Ptreportshearingvoicesofsomeonenotpresent;stopsmoving,staresblankly,
repetitivelypicksatclothing,doesnotrespondtoQs/commandsxseveralmin.The COMPLEXPARTIALSEIZURE
confusionresolvesafter15minsbutpthasnorecollectionofevents.Likelywhat?
55y/optBIBfamilyafterepisodeofamnesia/bewildermentlastingseveralhrs.
CVA
ruledout.Ptkeepsaskingwhatishappening.Whatmedtoadministeratthis
point?
OBSERVATIONWITHNOPHARMACOLOGICAL
INTERVENTION
Whichofthefollowingdiagnosesinvolvesasenseoflossofidentity,often
DISSOCIATIVEFUGUE
followingatraumaticexperienceandassociatedwithinabilitytorecallone'spast?
Contralaterallegweaknesswithsparingofthefaceandarms.Urinaryincontinence
ANTERIORCEREBRALARTERY
andabulia.Whereisthelesion?
BrainLesions
80-yoptwithHTH,HLDdevelopssudden-onsetdifficultyspeakingand
understandingwrittenwords.Whereisthelesion?
Corpuscallosum
Visualprobleminpituitarytumorcompressingopticchiasm(10x)
BITEMPORALHEMIANOPSIA
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60y/oright-handedM,gettinglost,onlywritesonrighthalfofpaper.Left-sided
RIGHTPARIETALLOBE
hemi-neglect.Whereisthelesion?(8x)
66y/oc/ofrequentfalls,several-monthhxofanxiety,unwillingnesstoleave
home.Onexam,mildimpairmentofverticalgazeonsmoothpursuit/saccades,
mildaxialrigidity&minimalrigidityofupperextremities,alongwmildslowness
PROGRESSIVESUPRANUCLEARPALSY
ofmovementonfingertapping,handopening&wristopposition.Posturenml.
Gaittentative/awkward,butw/oshuffling,ataxia,tremor.Ptisslowinarising
fromachair.Mostlikelydx:(6x)
65y/optfellseveraltimespast6mos.MSEnml.Smoothpursuit,saccadic
movementsimpaired.Worsewverticalgaze.FullROMwdollheadmaneuver.
Mildsymmetricrigidity/bradykinesia,notremor.MRI/CSF/labsunremarkable.
Dx?(4x)
PROGRESSIVESUPRANUCLEARPALSY
26y/owHA,clumsinessofrighthandxweeks.Struggleswrapidalternating
movementsofRhand,overtintentiontremorwfinger-to-nose,mildlydysmetric CEREBELLUM
finger-tapping.CNsnml,nopapilledema.DamagetowhatisseenonMRI?(3x)
9y/oFhas3monthh/oseeminglyunprovokedboutsoflaughter.Worsewhen
not
sleepingwell.Ptdoesnotfeelhappyduringtheseepisodes.Started
menstruating
6monthsago,andatTannerstage4.Dx?(2x)
HYPOTHALAMICHAMARTOMA
5y/owith4monthhistoryofmorningHA,vomiting,andrecentproblemswith
gait,falls,anddiplopia:(2x)
MEDULLOBLASTOMA
75yopatientevaluatedforprogressivegaiturineincontinenceandcognitive
decline.Afterremovalofcsf,thereisimprovementingaitandbalance.What
wouldCTshow?
ENLARGEMENTOFTHEFRONTALHORNS
70y/optdevelopsconfusion,lethargy,andgeneralizedtonic-clonicseizure.Lab
revealsserumsodiumof95mEq/L.Thisismostlikelyacomplicationofexcessively CENTRALPONTINEMYELINOLYSIS
rapidcorrectionofwhichmetabolicproblem?
Whichlesioncausesbilateralcoarsenystagmusworseningwithvisualfixationand
BRAINSTEM
presentwithhorizontalandverticalgaze?
32y/opt1-monthhxofworseningheadaches,episodicmoodswingsand
occasionalhallucinationswithvisual,tactileandauditorycontent.CTheadreveals TEMPORALLOBE
tumorwhere:
Syndromecharacterizedbyfluentspeech,preservedcomprehension,inabilityto
repeat,w/oassociatedsigns.Locationoflesioninthebrain?
SUPRAMARGINALGYRUSORINSULA
AcuteonsetofhemiballismusofLUE&LLE.MRIismostlikelytoshowlesion
locatedwhere?
SUBTHALAMICNUCLEUS
43y/onewlyAIDSpthasincreasingsocialwithdrawalandirritabilityoverseveral
weeks.Can’trememberphonenumber,unabletodochores,appearsdistracted.
PROGRESSIVEMULTIFOCALLEUKOENCEPHALITIS
Mildrighthemiparesis,leftlimbataxia,andbilateralvisualfielddefects.LP:normal
cellcounts,protein,andglucose.T2Scanisshown.Whatisthediagnosis:
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Unconsciousnesscanbeinducedbyasmallareaofdamagewhere?
RETICULARFORMATION
PtwhowasadmittedtotheERafteraMVAreceivesIVdextrose5%toprovide
accessforadministrationofparenteralmeds.Later,ptexperiencesconfusion,
oculomotorparalysis,anddysarthria.Symptomswerelikelycausedby:
WERNICKE’SENCEPHALOPATHY
Ptreportsheadachesandperipheralvisualloss.Visualfielddefectsinvolvingthe
temporalfieldsofbotheyesaredetected.AnMRIscanislikelytoreveal?
AMASSINTHESELLATURCICA
A35yoFpatienthasdiscoidlupuswhichhaslongbeencontrolledwithastable
doseoforalprednisone.Sheabruptlydevelopsincreasedfatigue,inflamedjoints,
anddiffusemyalgias.Ptalsoexhibitsdepressedmoodandcognitiveimpairment.
Shehasnopriorpsychiatrichistoryandnofocalneurologicalsigns.Whichofthe
followingisthemostlikelyetiology?
DISEASEINDUCEDCEREBRITIS
AC&LpsychiatristseesasickpatientwithAMS.Haspersecutorydelusionsand
AH/VH.Malarrashandproteinuria,fever,pancytopeniapresent.Whatiscause LUPUSCEREBRITIS
ofAMS?
25y/optreportsdoublevisionandsomedifficultywithbalance.Onrightlateral
gaze,thereisweaknessoftheleftmedialrectus,withnystagmusoftherighteye.
MULTIPLESCLEROSIS
Onleftlateralgaze,thereisweaknessoftherightmedialrectus,withnystagmusof
thelefteye.Thereisalsomildfingertonoseataxiaontheright.Dx:
52y/oMpresentswithachiefcomplaintofgaitdifficulties.Onexam:mild
dysarthria,verymildfingertonoseataxiaandminimalheeltoshinataxia.
Rombergtest:negative,butveryunsteadywhilewalkingandwalkswithabroadCEREBELLARVERMISATROPHY
based,lurchinggait.Theplantarreflexesareflexor.Imagingstudiesaremostlikely
todemonstrate:
Theclinicalsyndromeassociatewithocclusionofthecorticalbranchofthe
posteriorcerebralarterywouldresultinwhichofthefollowing?
HOMONYMOUSHEMIANOPIAWITHALEXIAWITHOUT
AGRAPHIA
34y/oMisreferredforpsychiatricevaluation5yearsaftersustainingaheadinjury
atwork.Priortotheaccident,hewasastable,happilymarriedman.Sincethe
accident,hehasbeendescribedasoverlytalkativeandrestless.Hiswifedivorced
himbecausehewasactingirresponsibly,whichalsoresultedinterminationfrom FRONTALLOBE
hisjob.Psychometrictestingrevealsthatthemanhasaverageintelligenceandno
detectablememorydeficits.Pt’sclinicalpresentationismostconsistentwith
damagetowhichothefollowingbrainareas?
yostartskindergarten,parentsreportchildismoreemotionallyreactiveand
regressionathome.Teachersayskidisnormalatschool.Whatfactorlikely
accountsforchangenotedbyparents?
NORMATIVERESPONSETOSTRESSASSOCIATEDWITH
THESCHOOLTRANSITION
Whichcancerhasthehighestlikelihoodofgoingtobrain?
LUNG
Whichhormoneissecretedinfunctionalpituitaryadenoma:
PROLACTIN
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CT&MRIshowventriculomegalyareoutofproportiontosulcalatrophy.Thisis
suggestiveofwhatdiagnosis?
NORMALPRESSUREHYDROCEPHALUS
20y/owith1-yearh/obitemporalheadaches,polydipsia,polyuria,andbulimia
plus
2-monthh/oemotionaloutbursts,aggression,andtransientconfusion.Neuro
examnormal.WhatwillMRIofbrainshow?
HYPOTHALAMICTUMOR
Previouslypleasantmombecomesprofaneandirresponsibleover6months.Most
FRONTALLOBE
likelyapathologyin:
Unilateralhearingloss,vertigo,unsteadiness,falls,headaches,mildfacial
weaknessandipsilaterallimbataxiaismostcommonlyassociatedwithtumorsin
whatlocations?
CEREBELLOPONTINEANGLE
38y/oFwithmusclespasmoftheproximallimbsandtrunk,lumbarlordosiswhile
walking,w/oEMGabnormalityandwithserumantiglutamicacidantibodiesis
STIFF-PERSONSYNDROME
sufferingfrom:
Apituitarytumorthatprotrudesthroughthediaphragmaticsellaismostlikelyto
cause?
BITEMPORALHEMIANOPSIA
Conductionaphasiaoftenoccursasaresultofdamagetowhichstructure?
ARCUATEFASCICULUS
70y/odevelopsflaccidparalysisfollowingseverewaterintoxication.He
developsdysphagiaanddysarthriawithoutothercranialnerveinvolvement.
CENTRALPONTINEMYELINOLYSIS
Sensoryexamislimitedbutgrosslynormal,DTR’saresymmetric,andcognitionis
intact.Likelydx:(X2)
MRIfindingforwomanwithmemorydecline,urinaryincontinence,andtrouble
walking
DILATIONOFVENTRICLES
Ptdrawsclockwithhemiagnosia.Whereisthestroke?
PARIETALLOBE
Effortful,nonfluentspeechwithdecreasedspeechoutput
ANTERIORFRONTALGYRUS
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A43y/opatientwithnewlydiagnosedAIDShasincreasedirritability,can’t
rememberphonenumbers.Mildrighthemiparesis,leftataxiaandvisualfield
defectsapparent.LPisnormal.MRIabove.Whatisdiagnosis?
Progressivemultifocalleukoencephalitis
A50yoBIBEDforSAbybeinginaclosedgaragewiththecarsrunningfor
severalhours.CTbrain2weekslaterwouldshow
Lesioninglobuspallibus
Catatonia
Whichtermdescribesstateofimmobilitythatisconstantlymaintained?(Ability
ofacatatonicpttoholdthesameposition)(2x)
CATALEPSY
52y/owithh/ounipolardepressionisbroughttoEDwithafirstepisodeof
catatonia.Ptisonnomeds,UDSisneg.Furtherw/ushouldinitiallyfocusonwhat
factor?
METABOLICDISORDERS
Amonginpatients,availabledataindicatesthatcatatoniamostfrequentlyoccursas
MAJORDEPRESSIVEDISORDER
afeatureofwhatillness?
21y/orecentlydiagnosedwithschizophreniabecomeslargelymuteand
occasionallyrepeatswordsinaparrot-likemanner.Thisisasubtypeof
schizophreniacalled:
CATATONIC
Symptomsthatmaydominatepictureofmooddisorderswcatatonia?
EXCESSIVEPURPOSELESSMOTORACTIVITYNOT
INFLUENCEDBYEXTERNALSTIMULI
CVA
62y/oMw/DMisnotmakingsense,saying“tharszingisphrumperzustalking”.
Normalintonationbutnooneinthefamilycanunderstandit.Heverbally
WERNICKE’SAPHASIA
respondstoQswsimilarutterancesbutfailstosuccessfullyexecuteany
instruction.(8x)
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66y/owithHTNdevelopsvertigo,diplopia,nausea,vomiting,hiccups,Lface
numbness,nystagmus,hoarseness,ataxiaoflimbs,staggeringgait,andtendency LATERALMEDULLARYSTROKE
tofalltotheleft.Dx?(8x)
ChronicA-fibdevelopsaphasiaandRhemiparesisatnoon.ERexamnotes
weaknessofRextremitiesandseveredysfluentaphasia,butCTat1:30PMhas
noacutelesion.Mostappropriatetreatment:(4x)
TPA
Rapidonsetofrightfacialweakness,leftlimbweakness,diplopia:(2x)
BRAINSTEMINFARCTION
Alifethreateningcomplicationofcerebellarhemorrhageis:(2x)
ACUTEHYDROCEPHALUS
A72yopatienthadanembolicinfarctinthemiddlecerebralarteryterritory.ECG
showsnostructuralabnormalities.Dopplerstudiesoftheneckarteriesreveal
lessthan50%occlusiononbothcarotidarteries.AnEKGrevealsAFib.Whichof ANTICOAGULATIONWITHWARFARIN
thefollowingstrategieshasthebestlikelihoodofreducingrecurrentstrokesin
thispatient?(2x)
Youngadultgained70lbsinlastyearc/odailysevereheadachessometimes
assocwithgrayingoutofvision.Papilledemapresent.CTandMRIbrainno
abnormalitiesbutventriclessmallerthanusual.Goaloftreatmentinthiscase:
(2x)
PREVENTBLINDNESS
68y/optw/hypertensiondevelopsrapidlyprogressingrightarmandleg
weakness,withdeviationoftheeyestotheleft.Within30minutesoftheonset
ofthisdeficit,ptbecameincreasinglysleepy.Twohoursaftertheonset,the
patientbecameunresponsive.Onexam:denserighthemiplegia,eyesdeviatedto LEFTPUTAMINALHEMORRHAGE
theleft,pupils:equalandreactive,arightfacialweaknesstogrimaceelicitedby
noxiousstimuli.Coughandgagreflexes:present.WhichCTfindingismostlikely?
(2x)
Superiorhomonymousquadranticdefectsinthevisualfieldsresultfromlesions
towhichofthefollowingstructures?(2x)
TEMPORALOPTICRADIATIONS
78y/opthadanischemicstrokethatlefthimwitharesidualmildhemiplegia.Pt
appearedtobeunawarethattherewasaproblemofweaknessontonesideof
thisbody.Whenaskedtoraisetheweakarm,thepatientraisedhisnormalarm.
Whenthefailuretoraisetheparalyzedarmwaspointedouttopt,headmitted
RIGHTPARIETALLOBE
thatthearmwasslightlyweak.Healsoneglectsthesideofthebodywhen
dressingandgrooming.Ptdidnotshaveonesideofhisface,haddifficulty
puttingashirtonwhenitwasturnedinsideout.Areaofbrainlikelyaffectedby
stroke?(2x)
Apthasmultiplestokelikesymptomsofshortdurationoverseveraldays.And
hasnewonsetsymptomsforthelast90minutes.CTscanshowsnoevidenceof
strokeorhemorrhage.Whatistheappropriatetreatment?(2x)
INTRAVENOUSTHROMBOLYTICAGENTS
MRIscanofheadrevealsaninfarctindistributionofleftanteriorcerebralartery.
WEAKNESSOFCONTRALATERALFOOTANDLEG
Ptmostlikelyexhibits:(2x)
Puresensorydeficitextendingtomidlineandinvolvingface,arm,trunk,andleg
causedbylacunarinfarctwhere?
LATERALTHALAMUS
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HeadCTw/lens-shapedhyperdensity
EPIDURALHEMATOMA
50y/optrecentlybeganhavingVHofchildrenplaying.VHarefullyformed,
colorfulandvivid,butwithnosound.Ptisnotscaredordisturbed,butrather
amused.Onexam,normallanguage,memory,cranialnerves,noweaknessor
involuntarymovement,nosensorydeficits.DTR:symmetric.CSF/UDSnml.
POSTERIORCEREBRALARTERYISCHEMIA
124.Bilaterallowerextremityweakness,abulia,mutism,urinaryincontinence
aremostlikelytoresultfromocclusionofwhichofthefollowingarteries?
Anteriorcerebral
Right-sidepalsywithequalinvolvementoftheface,armandlegcombinedwith
thirdnervepalsyismostlikelyduetoocclusionofabranchofwhichartery?
POSTERIORCEREBRAL
Hemisensorylossfollowedbypainandhyperpathiainvolvingallmodalitiesand
reachingthemidlineoftrunkandheadismostconsistentwithischemiainthe
distributionofwhichofthefollowingarteries?
POSTERIORCEREBRAL
Whatisthemostcommonmanifestationofacuteneurosyphillis?
STROKE
65y/optwakesupwithright-sidedhemiparesisandmotoraphasia.Ptis
immediatelybroughttotheemergencydepartmentandanevaluationis
completedwithin1hour.Neurologicalexam:noadditionalabnormalities.HeadCT ASPIRIN
w/ocontrast:noadditionalabnormalities.Whichistheappropriatenextstepin
management?
65y/opthasastrokewhichcauseshimtofall.Onexam,weaknessoftherightleg,
withonlyminorweaknessoftherighthand,noweaknessoftheface,nosensory
LEFTANTERIORCEREBRALARTERY
deficit.Speechisnotaffected,butptseemsunusuallyquietandpassive.The
strokemostlikelyinvolvesthe:
58y/oMh/oHTN,cigsmokingandsuddeninabilitytospeak.FacedroopingonR
anddraggingRleg.InERexaminedwithin40minsofonset:Aphasic,unableto
understandorrepeatverbalcommands.Unintelligiblesoundsforspeech.Alertbut THROMBOEMBOLICSTROKEOFLEFTMCA
appearsfrustrated.Rhemiplegiawitharmandfaceweakerthanleg.CThead:no
hemorrhage.Pathologytypeandarea:
Abuliareferstoimpairmentinabilityto:
SPONTANEOUSLYMOVEANDSPEAK
Suddenonsetvertigo/nausea,hoarseness/dysphagia,rightsidedfacenumbness,
diminishedgagreflexonright,decreasedpinprickandtemperaturesensationon
left:
RIGHTMEDULLARYINFARCTION
65y/odiabeticptpresentstoEDc/oacuteLsidedweakness,deviationofgazeto
R,Lhemiplegiaandhemisensorydeficit,andLhomonymoushemianopsia.12hrs
later,ptisunconscious,Lpupilenlargedandunreactive.CTwillshowwhat?
RMCAINFARCTW/EDEMAANDUNCALHERNIATION
Ptwithacuteonsetvertigo,whatwillsuggestRlateralmedullaryinfarct?
RIGHTFACIALLOSSOFTOUCHANDTEMPERATURE
SENSATION
46y/oMw/doublevision+painReye.Exam:ptosisReyelid,inabilitytoelevate
oradductReye+Rpupillarydilation.Thisiscausedby:
POST.COMMUNICATINGARTERYANEURYSM
Aphasiaw/effortfulfragmented,non-fluent,telegraphicspeech,isseeninalesion
POSTERIORFRONTALLOBE
where?
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39y/optwithhxofmultiplemiscarriagesdevelopsanacuteleftsidedhemiparesis.
Workuprevealselevatedanticardiolipintitersandnootherriskfactorsforstroke. PLASMAPHERESIS
Appropriateinterventionatthispointis?
Abnormalelevatedmetabolicfindingsassociatedwithincreasedriskofstrokein
patientsunder50
PLASMAHOMOCYSTEINE
70y/optwashospitalizedbecauseofamiddlecerebralarterystroke.The
psychiatristwasaskedtoevaluatethept.Thepthasnon-fluentaphasia.Which
mostlikelycharacterizedthept’sinteractionwiththepsychiatrist?
THEPTWASABLETOFOLLOWTHEVERBALREQUEST,
“CLOSEYOUREYES.”
Acuteonsetofdensesensorimotordeficitinthecontralateralfaceandarm,with
milderinvolvementofthelowerextremity,associatedwithgazedeviationtoward SUPERIORDIVISIONOFTHEMCA
theoppositesideofthedeficit,likelyindicatesocclusionof:
Weaknessofextensionatkneeinvolvesalesioninwhichnerve?
FEMORAL
CTscanwithoccipitalandintraventricularhyper-intensities:
PARENCHYMALHEMORRHAGE
WhichmedhassecondarypreventionagainstembolicstrokeinptswithA-fib?
ORALWARFARIN
Asopposedtostrokescausedbyarterialembolismorthrombosis,thosecausedby
ASSOCIATEDWITHSEIZURESATONSET
cerebralveinorvenoussinusthrombosisare:
Atrophyofrighttemporallobeoncrosssectionassociatedwithocclusionof:
MIDDLECEREBRALARTERY
Lossofabilitytoexecutepreviouslylearnedmotoractivities(whichisnotthe
resultofdemonstrableweakness,ataxiaorsensoryloss)isassociatedwithlesions LEFTPARIETALCORTEX
of?
58y/os/pCABG–anomiaforfingersandbodyparts,errorsinvolvingrightand
left,inabilitytowritethoughts/takenotes/makecalculations.Fluentspeechand
excellentcomprehension
LEFTMEDIALTEMPORALSTROKE
Visualdisturbancesassociatedwithocclusionoftherightposteriorcerebralartery? LEFTHOMONYMOUSHEMIANOPSIA
65y/ow/HTNcollapsed.InEDisstuporous,Rhemiparesis+hemisensorydeficit,
eyesdeviatetoL.CTwouldshowintraparenchymalhemorrhagein:
LEFTBASALGANGLIA
Lowerfacialweaknessw/relativesparingofforehead,strokein?
INTERNALCAPSULE
Higherfrequency&greaterseverityofdepressionassociatedw/cortical&
subcorticalstrokes:
LEFTANTERIORFRONTAL
68y/optisdepressedfollowingahipsurgery.Ptiswithdrawn,looksblank,shows
dysarthria,weakness,PMR,hyperreflexia,andhastroubleswallowing.MRIofthe PERIVENTRICULARWHITEMATTERDEMYELINATION
headwillshow:
Prognosisofacuteinflammatorydemyelinatingpolyneuropathyispoorestifthe
diseaseprocessinvolveswhichofthefollowing?
PROXIMALAXON
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PtwithHTNdevelopspainlessvisionlossinthelefteye.Exam:blindnessinLeye
andafferentpupillarydefectontheleft.MRI:severalT2hyperintensitiesinthe
whitematterperiventricularly.Nocorpuscallosumlesions.Noenhancementwith
gadolinium.Dx?
ISCHEMICOPTICNEUROPATHY
63y/owithnewonsetaphasiaandRhemiparesis,2daysagohadmilder/similar
symptomsthatresolvedin30minutes,yesterdayhadsimilarepisodex45minutes. INTRAVENOUSTHROMBOLYTICAGENTS
CurrentSxstarted1.5hrsago.CTshowsnostrokeorhemorrhage.Tx?
Prosopagnosiais:
INABILITYTORECOGNIZEFACES
57y/odiabeticpt=w/HTNc/oseveralepisodesofvisualloss,“curtainfalling”over
hisLeye,transientspeechandlanguagedisturbance,andmildRhemiparesisthat EXTRACRANIALLEFTINTERNALCAROTIDSTENOSIS
lasted2hrs.Suggestspresenceofwhat?
Headinjury,LOC->lucidintervalxhours->rapidprogressingcoma.Hemorrhage? EPIDURAL
5daysafterCABGa47y/oMisdisorientedtotimeandplace.Heidentifieshis
rightandleftbutnotthatoftheexaminers.Candrawsquareandcirclebutnota
clock.Thisis:
DYSPRAXIA
PtinEDwithsuddenHAandcollapsing,somelethargy.Examshowsrigidneck,no
CTHEAD
papilledema,nofocalCNormotorsigns.Theinitialtestshouldbe?
Poststrokedepressionin80yopt(Rhanded)isassocwcognitiveimpairments
that:
CORRELATEWITHLEFTHEMISPHERICINVOLVEMENT
Fluentspeechwpreservedcomprehension,inabilitytorepeatstatementsis
consistentwithwhattypeofaphasia?
CONDUCTION
NormalRombergw/eyesopenbutlosesbalancewitheyesclosed.Whereisthe
abnormality?
CEREBELLARVERMIS
65y/ow/hxofHTN,Meniere’swithsuddenvertigo,N/V,worsewithhead
movement,Rbeatingnystagmusonlateralgaze,fingertonosetestingisataxic,
poorbalanceanddysarthria.Dx?
CEREBELLARINFARCT
66y/oMinEDw/suddenoccipitalHA,dizziness,vertigo,N/V,unabletostand,
mildlethargy,slurredspeech.Exam:smallreactivepupils,gazedeviatedtotheR,
nystagmus,w/occasionalocularbobbing,Rfacialweakness,decreasedRcorneal
reflex,truncalataxia,b/lhyperreflexia,b/lBabinski.Dx?
CEREBELLARHEMORRHAGE
MotorspeechparadigmactivationtaskonfMRI–hyperactivityinrighttemporal
lobe.Damageiswhere?
CALCARINEFISSURE
Inabilitytorecognizeobjectsbytouch:
ASTEREOGNOSIS
Inmanagingacuteischemicstroke,administerthiswithin48hrsofonsetofstroke
ASPIRIN
forbeneficialeffectinreducingriskofrecurrentstroke,disabilityanddeath:
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70y/optw/attacksof“whirlingsensations”w/n/v,diplopia,dysarthria,tinglingof
lips.Occursseveraltimesdailyfor1minute,severethatptcollapsesandis
VERTEBROBASILARINSUFFICIENCY
immobilizedwhensymptomsstart.Noresiduals/s,notinnitus,hearing
impairment,ALOCorassociationwithanyparticularactivity.Dx?
ComponentoftypeAbehaviormostreliableriskfactorforCAD
HOSTILITY
Vascularlesionmostcharacteristicofsuddensevereheadache,vomiting,collapse,
relativepreservationofconsciousness,fewornolateralizingneurologicalsigns,
SUBARACHNOIDHEMORRHAGE
andneckstiffness:
HeadCTdemonstrateswhichdx(grainypicturewithdiffusespecklinginposterior
region,unilateral)
SUBARACHNOIDHEMORRHAGE
Ptw/suddenonsetofLhemiparesis,Lhomonymoushemianopsia,tendencyto
gazetoright,andneglectleftsidedstimuliaredeficitsmostlikelyresultof
occlusionof:
RIGHTMIDDLECEREBRALARTERY
70y/oFsuddenonsetparalysisRfootandleg.Rarmandhandslightlyaffected.
Noaphasiaorvisualfielddeficit.Overweeksfoundwithlossofbladdercontrol,
abuliaandlackofspontaneity.Whichvasculararea:
ANTERIORCEREBRALARTERY(LEFT)
70yroldhospitalizedduetoMCAstroke,psycheval,pthasnon-fluentaphasia,
whatcharacterizesptsinteractionwithpsychiatrist?
theptwasabletofollowthecommandtocloseyour
eyes
Ptsinalockedinstatefollowingbasilararteryocclusiontypicallyretainwhat
movement?
eyelidsandverticalgaze
Delirium
72w/recentbehavior/memoryproblems.Disrobing,notsleeping,irritable.
Waxingandwaningconsciousness.Dx?(8x)
DELIRIUM
79y/optw/decreasingmentalstateover3weekshasanexaggeratedstartle
responsewithviolentmyoclonusthatiselicitedbyturningontheroomlights,
speakingloudly,ortouchingthepatient.Myoclonicjerksoccurspontaneously,
ataxia,EEG:sharpwaves.Dx:(5x)
SUBACUTESPONGIFORMENCEPHALOPATHY
52y/optw/hxofdepression&HTNhospitalized,beingevaluatedbypsych
resident.HisfamilyreportshehadsevereHA&“hasnotbeenhimself”for10
days.Onexam,pthaspooreyecontactandisinattentive,muttering,pickingat
his
clothes,occasionallydozingoffalthoughitismidday.Dx:(4x)
DELIRIUM
Mildconfusion,lethargy,thirst,polydipsia:(2x)
HYPONATREMIA
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Multifocalmyoclonusinacomatosepatientindicates:(2x)
METABOLICENCEPHALOPATHY
70y/owithmildAlzheimer’sliveswithfamilyandprescribedSSRIfordepression.
AlsohasHTN,adultonsetDM,andRA,whicharestable.Theptdevelopsacute
ELECTROLYTES
confusionbutnoothermedorpsychsymptomswhichtestshouldbeordered
first?(2x)
Whattestismosthelpfultodistinguishdementiavsdelirium
EEG
Alcoholicp/w2daysconfusion,AH/VH,disorientation,distractibility,withfever,
tachycardia,andtremor.EEGshowslow-voltagefastwavessuperimposedonslow DELIRIUMA/WETOHWITHDRAWAL
waves.Long-termolanzapinetreatmentforschizoaffectived/o.Dx?
MostcommonEEGfindinginmetabolicencephalopathy?(questionrequires
assigningdiagnosistoEEG)
GENERALIZEDSLOWING
Twodaysafterbowelsurgery,53y/oisdelirious.Correctlydrawsasquarewhen
asked,butthencontinuestodrawsquareswhenaskedtodrawothershapes.MSE PERSEVERATION
wouldreveal:
75y/oFptis8dayss/ptotalhipreplacementandhasdelirium.Herdiazepamand
doxepinwerediscontinuedjustpriortosurgery.Sheisgettingmeperidineforpain,
diphenhydramineforsleepandarenewedprescriptionfordoxepin.Herconfusion
islikelyduetowhichofthefollowing:medicationtoxicity,diazepamWDRL,
electrolyteimbalance,atypicaldepression,UTI.
MEDICATIONTOXICITY,DIAZEPAMWITHDRAWAL,
ELECTROLYTEIMBALANCE,ATYPICALDEPRESSION,OR
UTI.
(ALLOFTHEABOVE)
PtwithICUpsychosismostlikelyhaswhatcondition?
DELIRIUM
Bestrecommendationforptwithdelirium?Minimizecontactwithfamilymembers
orlimitsleepmedstodiphenhydramine,ormaximizestaffcontinuityassignedto MAXIMIZESTAFFCONTINUITYASSIGNEDTOPT
pt?
DeliriuminHIVpatientstreatedwithwhatparenteralagent?
LOWDOSEOFAHIGH-POTENCYANTIPSYCHOTIC
A34yopatientisbeingtreatedformalariaafterreturningfromatriptoKenya.
Thepatienthasahistoryofschizoaffectivedisorderwhichhasbeenwellcontrolled
formorethanadecadewithacomboofRisperdalandLithium.Theptisgivena
UNCOMMONSEOFTHEANTIMALARIALTREATMENT
singledoseofmefloquine,howeverafter1weekthepatientreportsfeeling
anxious.ThisescalatesoverthenextweektoPMAandpersecutorydelusions.The
mostlikelycauseofthept’spsychoticsymptomsis:
Cancerpatientonchemoisdisorientedandagitated.AfebrileVSS.Negneuro
exam.Poorattention,cogimpairment.Heldforobservation.CTneg,EEGdiffuse
slowing.Treatwith:
HALDOL
70y/o+HIVheroinabuseristreatedwithLopinavirandRitonavirandfluoxetine
forMDD.HepCwasdxandtreated2monthsago.Sincethenptismoreirritable,
insomnia,anddiarrhea.Why?
DRUG-DRUGINTERACTION
Aconsultisrequestedforapatientonamedicalwardwhoisagitatedand
hallucinating.Ptappearstobeflushedandhotwithdryskin,mydriasis,arapid
pulseanddiminishedbowelsounds.Whatisyourfirstrecommendation?
D/CANTICHOLINERGICDRUGS
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Suggestsdeliriumratherthandementia:
CLOUDINGOFCONSCIOUSNESS
85y/onursinghomeptw/hxofdementiabeingmoreconfusedandscreaming
“fire”
wheneverthelightnexttothebedisturnedon.Nextstep?
URINALYSIS
Ptw/hxofCPSpresentedtoEDwithhightemp,tachycardia,dilatedandpoorly
reactivepupils,VH,agitation,constipation,anddryskin.Dx:
ANTICHOLINERGICDELIRIUM
Whichofthefollowingisthemostcommonpsychiatricpresentationfollowinga
stroke?
Thismajorsymptomofdeliriummayrequirethattheptreceivepharmacological
treatment:
57y/owAMSoverseveralhours,followedbyabruptreturntonormal.No
recollection,patientobservedtobeconfused,oriented.Ptkeepsaskingsame
question,otherwiseneuroexamnormal,noweakness,lossofbalance,speech
impairment.Whatistypicalofthiscondition?
Doctorexamines81-year-oldpttwicedaily,midmorningandlateafternoon.
Comparingthetwoassessments,whatfindingssuggestthatthepatientis
delirious?
Depression
INSOMNIA
Recurrentepisodesrare
Logical,coherentspeechonfirstexam,disorganized
speechonsecond
Dementia
65y/oMwith6moh/oconfusionepisodes,disorientation,VHsofchildren
playinginhisroom.Hallucinatedimagesarefullyformed,colorful,vividandpt
haslittleinsightintotheirnature.NoAH.Wifesaysheisnormalbetween
episodes.Exam:Normallanguage,memory,moddiffwithtrailstest,milddiff
withserialsubtractions,mildsymmetricrigidityandbradykinesia.BrainMRI
unremarkable.CSF,routinelabsandUDSnormal.Diagnosis:(7x)
LEWYBODYDEMENTIA
WhichisalimitationoftheMMSE?(7x)
MAYFAILTODETECTVERYMILDCOGNITIVE
IMPAIRMENT
Whencombinedwithfunctionalneuroimaging,whichofthefollowing
biomarkersismostlikelytoidentifythosegeriatricptswithmildcognitive
impairmentmostatriskfordevelopingAlzheimer’sdisease?(6x)
E-4APOLIPOPROTEINEALLELE
Whichofthefollowingisthemostspecificfactorfordistinguishingdeliriumfrom
FLUCTUATINGAROUSAL
dementiaoftheAlzheimertype?(2x)
72yoearlydementia.Paranoid+VH.Lightheaded+socialinappropriate.Risperdal
LEWY-BODYDEMENTIA
.25x2days->confusion/sedation/rigidity.dx?
Inadditiontoorientation,attention,calculation,languageandregistration,what
othercognitivedomaindoesthemmsetest?
Whatisbeingassessedwhenpatientisaskedtorepeatwords"Apple,table,
penny"?
RECALL
Registration
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Pictureoftaustainingforptwithprogressivedementia.Dx?
ALZHEIMER'S
80y/owithVHandworseninggait,episodicconfusion,disturbedsleep,fightingin
sleep,bilateralrigidity,maskedfacies.Levodopa/carbidopaimprovedmovement DEMENTIAWITHLEWYBODIES
temporarily.Diagnosis?
80yop/winsidiousforgetfulnessf/bprogressivelanguageimpairment2yrlater
withdifficultyusingcommontools/appliances.Dx?
WhatmedicineinterfereswithefficacyofDonepezil?
Alzheimer’sDisease
OXYBUTYNIN
Aptwhohasbeenreceivingdialysistxforyearshasbecomemoredisoriented,has
memoryloss.Physicalexamnormal,nursingstaffreportthatpthasbeguntohave
DIALYSISDEMENTIA
seizures.Bloodlabtestingshowsnoobviousetiology,neurodiagnosticsshowno
suggestivefindings.Whatmostlikelyaccountsforthispresentation?
Whichtestcorrelatesmoststronglywithpre-morbidfunctioninginptw/early
dementia:
WECHSLERADULTINTELLIGENCESCALEIVVOCABULARY
TEST(WAIS-IV)
71Y/Onursinghomeresidentwithsx:Parkinsoniangait,prominentdelusions,
fluctuatingattention,visualhallucinations,sensitivitytoEPSeffectsof
antipsychoticmeds.Dx?
DEMENTIAWITHLEWYBODIES
FTDwithmutationinchromosome17isassocwithabnormalintraneuronal
depositionofwhichprotein?
TAU
NeuropsychologicaltestmostusefulintheearlydiagnosisofAlzheimerdisease:
10-ITEMWORDLISTLEARNINGTASK.
Adocmeetswithaptandfamilytodiscusstreatmentofpt’smildAlzheimer’s
disease.Therearenootherneurologicalorpsychiatricsymptomsorfindings.The
mostappropriatecourseofactionwouldbeto:
BEGINCHOLINESTERASEINHIBITORTREATMENT
74y/o,right-handedpatientpresentswithsignificantmemoryloss,expressive
aphasia,andleftplantarextensorresponse.Themostlikelydiagnosisis:
VASCULARDEMENTIA
SxmostlikelyrelatedtoexcessiveuseofvitaminB12
BURNINGSENSATIONS
60y/oFwith10monthhxofapathyanddepressionhashyperchromicmacrocytic
VITAMINB12LEVEL
anemia.Besttesttoordernext:
EarliestevidenceofcelllossinptswithAlzheimer’sDztypicallyoccursinwhichof
thefollowingareasofthebrain?
ENTORHINALCORTEX
AptwithEtOH-dependencepresenttoEDwithconfusion,ataxia,nystagmusand
ophthalmologist.Highdosesofwhichofthefollowingvitaminscouldhave
preventedthissyndrome?
VITAMINB1
MedicationhelpfulinearlyHIVdementiabutispotentiallytoxiclaterinthe
disease?
METHYLPHENIDATE
74y/oFsuspicious,poorADLs,personalitychanges,mostlikelydx:
PICK’SDISEASE
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80y/optw/nopriorpsychhx,moreforgetful,havingdifficultywithADLs.
However,ptisabletoconductroutinesocialactivitiessothatcasualacquaintances ALZHEIMERDEMENTIA
don’tnoticeabnormalities.Whatisthedx?
Safestheterocyclicantidepressantfor78y/owdepression,agitation&dementia
is:
NORTRIPTYLINE
WhatcognitiveenhancerisanNMDAreceptorantagonist?
MEMANTINE
Neuronaldamagefromexcitotoxicitysecondarytoglutamatesensitivity.Treat
with:
MEMANTINE
Acamprosateworksthroughwhichneurotransmittersystem?
GLUTAMATE
NeurofibrillarytanglesinAlzheimer’sarecomposedof:
HYPERPHOSPHORYLATEDTAUPROTEINS
80y/oAlzheimer’swithincreasinglycombativebehavior.Familywantstokeepat
home.Givewhatmedication?
HALDOL
Dementiacharacterizedbypersonalitychange,attentiondeficit,impulsivity,affect
lability,indifference,perseveration,andlossofexecutivefunction.Assoc.with
FRONTALLOBE
dysfunctioninwhatareaofthebrain?
Binswangerdiseasehaspseudobulbarstate,gaitdisorder,AND:
DEMENTIA
80y/optwithAlzheimer’sisbroughtinforincreasinglycombativebehavior.
Daughterwouldliketokeeptheptathomeifpossible.Whatinterventionswould
bemosthelpfulinthissituation?
ASSESSINGFORCAREGIVERBURNOUT
EarlystageHIVtypeIassociateddementiaascomparedtoearlyonsetdementia
haswhichofthefollowingdeficits?
DECREASEDPROCESSINGSPEED
Whichmedshavebestresultsfortreatingagitationindementia?
ANTIPSYCHOTICS
Clockdrawingtestisquicklyadministeredandsensitivescreenforwhichd/o?
ALZHEIMER’SDZ
Amyloidprecursorproteininwhatcognitivedisorder?
ALZHEIMER’SDZ
Mostcommoncauseofdementiainpts>65yrsofage:
ALZHEIMER’SDZ
Individualsover40yowithDown’ssyndromefrequentlydevelop:
ALZHEIMER’SDZ
CharacteristicMRIscanfindinginAlzheimerdisease:
REDUCEDHIPPOCAMPALVOLUMES.
Knownriskfactorsfordementia:
AGE,FAMHX,FEMALE,DOWN’SSYNDROME
NeuronalenzymethatisthetargetofdrugstotreatAlzheimer’si.e.galantamine
andrivastigmine
ACETYLCHOLINESTERASE
Ptwithvasculardementiatypicallyhasneuropathologicalchangesassocwith:
BASALGANGLIA
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An82-yopthasfalls,opthalmoplegia,parkinsonismandprogressivedementia.
Autopsyshows:
Taupositiveneurofibrillarytangles
83yoptwithmildHTNcomesinwithnewonsetheadacheandlefthemiparesis.
MRIshowsrightparietallobehemorrhage,smalloccipitalhemorrhageand
AMYLOIDANGIOPATHY
evidenceofprevioushemorrhageinrighttemporalandleftparietalregions.What
islikelyetiologyforthesefindings?
65y/oisbroughttotheEDwithdisorientationandmildagitation,andis
experiencingvividVHofseveralchildrenplayinginsidethehouse.Twosimilar
episodesinthepast,normalinbetweenepisodes.Normallanguageandmemory, DEMENTIAWITHLEWYBODIES
normalCN,mildsymmetricrigidityandbradykinesia,nodeficits.MRI,drugscreen,
CSFnormal:
Amedthatismostlikelytoslowtheprogressionofvasculardementia:
ASPIRIN
BestrationaleforusingcholinesteraseinhibitorsinptswithAlzheimer:
TOREDUCENEUROPSYCHSYMPTOMS
HIV+ptw/memoryloss,inattention,lackofmotivation,&poorcoordination.
NormalLP.CTscanshowsatrophy.MRIshowsdiffuse&confluentwhitematter
changesinT2,w/oanymasseffectorgadoliniumenhancement.Dx?
HIV-ASSOCIATEDDEMENTIA
Themostimportanttoolforevaluationofearlyandmoderatedementia:
MMSE
A62yoptisreferredforcomplaintsofmemoryproblems.Thepatientreports
feelingmoreforgetfulandgivesexamplesof“losingmykeys,handbag,or
forgettingthenamesofaquaintances.”Theptdeniesanyotherneurocognitive
symptoms.Familymembersconfirmthepatient’sreport,andfeelthatthishas
beenagradualchangeoverthelastyear.Familymembersreportthattheptisa
HASACEILINGEFFECTFORWELL-EDUCATEDPERSONS
formerhxprofessorwhocontinuestoenjoyintellectualactivitiesandtheyneedto
prepareifthepatientisgoingtolosethesecapabilitiesasaresultofdementia.The
standardMMSEwouldbearelativelyinsensitiveinstrumentforthispatient
because:
65y/optbroughtinbyfamilyforgradualonsetandveryslowprogressionof
mentalconfusionwithrespecttoplaceandtime,anomia,slownessof
comprehension,neglectofpersonalhygieneandgrooming,apathy,andalterations
FRONTOTEMPORALDEMENTIAORALZHEIMER
ofpersonalityandbehavior,impairmentofgaitanduprightstance,andprominent
DEMENTIA
graspandsuckreflexes.Dx?Theclockdrawingtestisaquicklyadministeredand
sensitivescreen
for:
65y/ohighschoolgradhasaMMSEscoreof23,thisscorewouldsuggestwhichof
DEMENTIA,MILDCOGNITIVEIMPAIRMENT
thefollowing:
Overcourseofseveralmonth46yoptwnopastpsychhxbecomesemotionally
labile/irritable.Ptundergoespersonalitychanges,isobservedtolaugh
inappropriatelywhenneighborkidstauntstraycat.Within2yrsptisconvincedall FRONTOTEMPORALDEMENTIA
foodhasgerms.Memoryispreserved.Ptisnolongerabletowork/live
independently.Neuropsychtestingshowsimpairedlanguage/attn.
Dementiaratherthandepressioninregardstomemoryhas…
NAMINGDEFICITS(RATHERTHANIMPAIRED
NONVERBALINTELLIGENCE)
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BilatlossofneuronsintheCA1segmentofthehippocampusisthemostcommon
ALZHEIMERDEMENTIA
histologicfindinginpatientswith:
65yoptlivesalone,increasinglyforgetfuloverthepastyear,lifelongdifficulty
recallingnamesofacquaintances,nowhasdifficultywithphonecallsand
rememberingappts.livesindependently,drives,preparesmeals,MSEwithdelayed AMNESTICMILDCOGNITIVEIMPAIRMENT
recallof4words,otherwisenormal.Ptupsetbydifficultyandisnotdepressed.
symptomsmostconsistentwith…?
Mostcommongeneticabnormalityleadingtointellectualdisability
DOWN’SSYNDROME
PatientisAlzheimer’sdementiainclinic.Patient’sdaughterisfrustratedwith
havingtocareforhermothermoreandisconsideringremovingherfromher
churchgroupbecauseofit.Whatisthemostinitialresponsebythepsychiatrist?
TELLHERTOCONTINUEGOINGTOHERCHURCHGROUP
Brainoffootballplayerwhodiedbysuicidehasfindingstypicalofchronic
traumaticencephalopathy,whatismosttypicalpathologyforthisbehavior?
TAUPATHY
PETscanshowsbitemporoparietalhypoperfusioninearlystagesofwhich
dementia?
Alzheimer
54yroldptdiesfromrapidlyprogressingdementiaassociatedwithmyoclonus,
whatismostlikelyfindingatautopsy?
microvacuolationofgliaandneuronaldendrites
Seizures
16y/optbroughttopsychiatrist’sattnafterhavingsinglegrandmalsz.Pt’s
parentshavenotedonoccasionpthassuddenjerksofentirebody,resultingin
droppingobjects.EEG:rare4-6HZirregularpolyspike/wavebursts.Diagnosis?
(9x)
JUVENILEMYOCLONICEPILEPSY
8y/ohasepisodesofstaringintospaceandthenblinkingforafewseconds.EEG
willshow?(7x)
3CYCLESPERSECONDSPIKEANDWAVEACTIVITY
40y/ohasepisodesofflailingofthearmsandtonicposturesdescribedas
“fencing.”EEGconfirmsseizure.Whichseizuretype?(4x)
FRONTALLOBE
10y/ochildfreqepisodesbrieflapsesofconsciousnesswithoutpremonitorysxs.
Lasts2-10seconds,followedbyimmediateandfullresumptionofconsciousness
ABSENCE
withoutawarenessofwhathashappened.Theseictalepisodesmostlikely
causedbywhatkindszs?(4x)
1stseizurewithfocalonsetandsecondarygeneralizationina58y/optislikely
theconsequenceofwhat?(2x)
GLIOBLASTOMAMULTIFORME
Whatisthediagnosticvalueoftransientparesisoraphasiaafteraseizure?(2x)
LOCALIZESTHEFOCUSOFSEIZURE
6yochildw/briefepisodesofstaringandfast,rhythmicblinding.Besttreatment?
VALPROICACIDETHOSUXIMIDE
40yonew-onsetszb/lthrashingmovement.Whatsuggestsnon-epilepticcause?
FOLLOWINGCOMMANDS
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Whichofthefollowingbestdescribesthecharacteristicsofthenormaladultalpha
INTERMITTENTANDPOSTERIORDOMINANT
rhythmseenonanEEGrecording?
Whichofthefollowingsurgicalprocedurescanbeusedinthetreatmentof
epilepsyrefractorytomeds?
ELECTRICALSTIMULATIONOFTHEVAGUSNERVE
19y/oFhasboutsofmotoragitation,oftenfollowedbyintense,seemingly
meaninglesswriting;alsomoodlability,tactile&olfactoryhallucinations.During
theinterview,patientabruptlystopspayingattentionandbeginsrapidlypacing
aroundtheroom.Whatshouldbethenextstep?
WAIT15MINS,THENOBTAINPROLACTINLEVEL
A73yoMptisseenforfollowuptreatmentforaseizuredisorder.Onexamination
theptisfoundtohavegumhypertrophy,cerebellarataxiaandhirsutism.Whichof PHENYTOIN/DILANTIN
thefollowingmedicationisthepttaking(mostlikely)?
Ptw/h/oDepressionandwell--controlledepilepsyrespondedtobupropionafter
failingonseveralantidepressants.Pthadnottriedimipramine,nortriptyline,
duloxetine,andselegiline.NoSzhaveoccurredonbupropion100mgBID.
CONTINUEBUPROPION
Insurancerecommendschangingmedduetoreducedszthresholdwithbupropion.
Whatisappropriateresponsefrompsychiatrist?
MostserioussideeffectofrTMS
SEIZURES
Whichprocedureconfirmsthediagnosisofnon-epilepticseizures?Videotelemetry
EEGVIDEOTELEMETRY
orEEGbetweenepisodes?
Antiepilepticforjuvenilemyoclonicepilepsy:
VALPROICACID
Complexpartialseizuresaredifferentiatedfromsimplepartialseizuresby:
SIMPLESEIZURESHAVENOLOSSOFCONSCIOUSNESS
BUTHAVEALTEREDRESPONSIVENESSTOOUTSIDE
STIMULI.
Convulsiveepisodewithleftwardeyedeviation,toniccontractureofleftside.
Postictally,eyesdeviatetorightw/hemiparesisofleftside
SEIZUREFOCUSRIGHTFRONTALREGION
28y/oFw/HA,hyperventilates,asynchronoustonic-clonicsz,noLOCduringSz:
PSYCHOGENICSEIZURE
Inyoungptw/epilepsy,Txdepressionw/:
PROZAC
Whyistherearelativelyhighrateofsuicideinepileptics?
COMORBIDPSYCHIATRICDISORDERS
Lackofprolactinelevationafterszssuggestswhatkindofszs:
NON-EPILEPTIC
32y/owithpartialcomplexseizuresrefractorytotreatment,pictureofMRIshown.
MESIALTEMPORALSCLEROSIS
(picture)
Drug-addictedhealthcareprofessionalexperiencesseizurethatisnotawithdrawal
MEPERIDINE
phenomenon.Cause?
Complexpartialepilepsyaurahaswhatsymptom?
LIPSMACKING
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Head&eyesdeviatetorightandrightarmextendsimmediatelybeforea
generalizedtonic-clonicseizure.Seizurefocus:
LEFTCEREBRALHEMISPHERE
Gustatoryspecialsensoryseizures(auras)localizewhere?
INSULARCORTEX
Whichofthefollowingsurgicalprocedurescanbeusedinthetreatmentof
epilepsyrefractorytomedication?
ELECTRICALSTIMULATIONOFTHEVAGUSNERVE
Ptw/episodesofalteredbehaviorlasting1-2minutes.Duringepisodesptmakes
chewingmovements.Pthasnorecollection.MRIisnormal.Dx?
COMPLEXPARTIALSEIZURES
28y/ofemalereferredtopsychd/trecentonsetepisodesofalteredbehavior
lasting1to2minutes.Husbandnotesifoccurswhencookingptwillplacethe
cleansilverwarebackindishwasher.Alsonotesshedoesdrawingmovementsheis COMPLEXPARTIALSEIZURES
unabletointerrupt.Pthasnorecollectionoftheevents.MRIscanisnormal.
Diagnosis?
32PtreportsAHofsomeonenotpresent,thenstopsmoving,staresblankly,
repetitivelypicksclothing,anddoesnotrespondforseveralminutes.Symptoms
Complexpartial
resolveafter15minbutpthasnorecollectionofevents.Thisrepresentswhattype
ofseizure?
16y/optw/newonsettonicclonicseizures.Ptreportshavingjerkymovements
whichcausehimtodropobjects.EEGshowspolyspikepattern.Whichantiepileptic VALPROICACID
medication?
15y/optw/partialcomplexseizuresw/secondarygeneralization,mental
retardation,andadenomasebaceum.Dx?
TUBEROUSSCLEROSIS
Whatisthemedicationforadequateinitialtreatmentofabsenceseizuresin
children?
VALPROICACID
Gelasticseizuresarea/wwhichbrainfoci?
Hypothalamus
EEG
EEGthatrevealsposterioralphaandanteriorbetaactivityismostlikelytohave
beenobtainedfromwhom?(4x)
ARELAXEDADULTWITHEYESCLOSED
TheEEGfindingof4-6hzirregularpolyspikeactivityinapatientwithgeneralized
JUVENILEMYOCLONIC
seizuresischaracteristicofwhichofthefollowingformsofepilepsy?(2x)
3dayss/pcardiacarrestandCPR,73y/omaniscomatose.Hiseyesareopenbut
hedoesnotfixandfollowwithhiseyes.Doll’seyeselicitsfullhorizontaleye
BURSTSUPPRESSIONPATTERN
movements.Hisspontaneouslimbmovementsaresymmetrical.Reflexes:mildly
hyperactive.TheEEGshows?(2x)
AnincreaseinbetafrequencyduringanawakeEEGiscausedbywhattypeof
medication?
SEDATIVES
WhatEEGfindingsareexpectedinacomatoseptwithhepaticencephalopathy? Triphasicwaves
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Endocrine
28y/owithemotionallabilityandimpulsivity.LFT’selevated.Closerelativehad
similarsxanddiedat30y/ofromhepaticfailure.Whichbloodlevelwouldbe
diagnostic?(3x)
CERULOPLASMIN
25yoptwseveralyearcognitivedecline,dysarthria,dysphagia,andslow
movements.Hashandtremorwhichincreasesinamplitudeonarmextension.Also
CERULOPLASMIN
hashepaticdiseaseofunknownetiology.Ocularexamrevealsgoldenbrownring
aroundcornea.Canconfirmdiagnosiswbloodtestfor?
73y/oMw/onsetoffatigue,weightgain,constipation,coldintolerance,
depressedmood.Whichorganiccausedneedstoberuledout?
THYROID
Physicalfindingassociatedwithhypothyroidism:
SLOWRELAXATIONOFDEEPTENDONREFLEXES
Forwhichpatientwouldorderingaserumceruloplasminbeindicated?
AYOUNGADULTMALEWITHNEWONSETEMOTIONAL
LABILITYANDMOVEMENTDISORDER
Ptwithbipolardisorderwhohasbeenonlithiumfor2yearsdevelopsrapidcycling.
THYROIDFUNCTIONTEST
Whatlabprocedureshouldbeperformed?
32y/os/pthyroidectomypresentsc/ofrequentpanicattack,progressivecognitive
inefficiency,perceptualdisturbances,severemusclecramps,andcarpopedal
HYPOPARATHYROIDISM
spasm.PE:alopeciaandabsentDTR.Dx?
55yop/wdepression,fatigue,wtgain,&somnolencex1mo.HxMI3moago
(VTach),onamiodarone,HCTZ,&metformin.Management?
Irregularasymmetricsmall(1-2mm)pupilswhichreactstoaccommodationbut
nottolight.
TSH&T4level
Diabeticautonomicneuropathy
Headaches
35y/oMawakensfrequentlymiddleofnightwithsevereHAs,whichsometimes
occursnightlyandlastsapprox1-2hrs,soseverethatptisafraidtogotosleep,
CLUSTERHEADACHES
locatedaroundLeyeandassocwithlacrimation,ptosis,&miosis.Likelydxis:
(12x)
YoungptwithnewonsetsevereHAsassocwithperiodsofvisualobscuration.
Neuroexamisnormalexceptforpapilledema.MRI:normalandshowsnomass
effect.Nexttest?(7x)
LUMBARPUNCTURETOMEASUREPRESSURE
Abortivetreatmentofcommonmigrainesisbestachievedw/whichmedication?
RIZATRIPTAN
(6x)
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WhichofthefollowingischaracteristicofpostlumbarpunctureHA?(4x)
HAWORSEW/SITTINGUPRIGHT
25y/ohasHAandvomiting.Painisdullandinoccipitalregion,worsewhenlying
down.+severepapilledemab/l.LPshowsopeningpressureof80w/normalCSF
SAGITTALSINUSTHROMBOSIS
chemistry,and120RBC’sinlasttube.D-dimer,FDPinbloodareelevated.CT
normal.(3x)
24yomwithnocturnalHAresultinginearlyamwaking.ROS+rhinorrhea,nostril
blockingandipsilateraleyetearingandfacialswelling.HApersists45-60min.
CLUSTERHA
Likelydx:(2x)
35y/oreportsepisodesofflashinglightstravelingslowlyfromLtoRintheleft
visualfield,symptomspersistingforabout30minutes,followedbydifficulty
expressingselfandconcentrating.Afterabout30minutes,theseneurologic
symptomsseemtosubside,andptdevelopsapoundingheadacheassociated
withnausea.BothphysicalexamandMRIarenormal.(2x)
MIGRAINEWITHAURA
30y/owithintermittentHAs,eachattacklastingapprox1hour.Attacksw/
sharp,stabbingpainaroundeye,tearing,andnasalcongestion.Mosteffective
abortivetreatment?(2x)
OXYGEN
Theeffectivetreatmentforacutemigraine:(2x)
SUMATRIPTAN
25y/ow/VH–similartothewavydistortionsproducedbyheatrisingfromasphalt
–affectingthewholeofbothvisualfields,+vertigo,dysarthria,tinglinginboth
BASILARMIGRAINE
handsandfeetandaroundbothsidesofmouthfollowedbyoccipitalheadache.
Mostlikelydx:
Pharmacologicmechanismsoftopiramateinclude:inhibitionoffiringofvoltage-
dependentsodiumchannels,antagonismofkainitebindingtothealpha-amino-3-
hydroxy-5-methyl-4-isoxazolepropionicacid(AMPA)receptor&potentiationat
whichreceptor?
GABA-A
28y/oFreportsepisodesofsevereHAswnausea/vomiting.HAscanbe
incapacitating,oftenprecededbyflashesoflightintherightvisualfield.During
TOPIRAMATE
headache,ptsometimeshasdifficultyexpressingherself.Whichmedwouldbethe
appropriatetopreventtheseepisodes?
26y/oFw/3-dayhxofseverecontinuousnon-throbbingheadache,hasnot
improvedonNSAID,hasmildbilateralpapilledema.AheadCTwandw/ocontrast SAGITTALSINUSTHROMBOSIS
isshown.
Ptc/oseveredullandconstantheadachenotassociatedwithN&V.+visionlossin
lefteye.+painandstiffnessoflimbs.MRIshowsperiventricularwhitematter
hyperintensitiesonT2.Elevatedsedrate.Nextstep?
HIGHDOSEPREDNISONE
Abortivetreatmentofcommonmigraine:
RIZATRIPTAN
35ptisevaluatedforheadachesyndromecharacterizedbyparoxysmsofsharp
painaroundtheeyesandsideoftheheadlasting5minandhappening10x/day.
PROPRANOLOL
Headachesareaccompaniedbyrhinorrheaandconjunctivalerythema.Whichmed
ismostlikelytogiverelief?
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68yowithdullR-sidednon-throbbingHA’sworseatnightandwithprolonged
chewing.Bestinitialtx?
Prednisone
Huntington’sDisease
42y/oMwithagraduallyprogressivecognitivedeficitalsodevelopsjerking
movementsoftheextremities,head,andtrunk.Imagingshowsatrophyofthe
caudatenucleibilaterally.Pt’sfatherhadasimilarillnessthatstartedatage50.
Whichofthefollowingtestsismostlikelytoconfirmthediagnosis?(6x)
DNAANALYSISFORCAGREPEATS
WhatMRIfindingwouldmostspecificallyindicateadiagnosisofHuntington’s
Disease?(5x)
CAUDATEHEADATROPHY
TreatmentofHuntington’schorea(3x)
HALOPERIDOL
98y/oMinER,unconsciousafterchoking,hadprogressiveneurocondition
presentedinhisearly30’swinvoluntaryirregularmovementsofallextremities
&facebutafter15yrcourseevolvedintorigid,akineticconditionwdiff
swallowing,speaking.Alsoprogressivedementia&fulltimecare.After
HUNTINGTON’SDISEASE
obstructionwasrelievedptremainedunconscious,hadcardiacarrest&died.PM
examshowedgeneralizedbrainatrophy.(Pathologypictureshowingbrain
atrophy).Dx:(3x)
35y/optw/2yrhxofcognitivedeterioration,difficultyatwork,andirritability.
Exam:restlessw/slow,writhingmovementsinmostmusclegroupsandfrequent
HUNTINGTON’SDISEASE
blinking.Pt’sfatherandpaternalgrandpahadsimilarsxanddiedintheir50s.Dx:
(2x)
Ptw/depression,3yrhxofchangeinpersonality,irritability,impulsive
outbursts,
&eccentricorinappropriatesocialinteractions.Hesubsequentlylosthisjob&is
HUNTINGTON’SDISEASE
nowwithdrawn&fidgety.Pthasincreasedeyeblinking,markedtongue
impersistence,mildbradykinesia,akinesia&mildhyperreflexiaw/oclonus.The
pt’sdaddiedofseveredementiaat55.Dx?(2x)
Dzw/trinucleotiderepeatexpansion
HUNTINGTON’S
TreatmentforHuntington’sdisease:
HIGHPOTENCYANTIPSYCHOTICS
Huntington’sdiseaseetiogeneisclassifiedasapolymorphismduetowhat
property?
THEREGIONHASMANYALLELESDIFFERINGINTHE
NUMBEROFGACREPEATS
Memory
Roleofthehippocampusandparahippocampalgyrus?(4x)
DECLARATIVEMEMORY(FACTS)
Exampleofdeclarativememory(2x)
RETENTIONANDRECALLOFFACTS
Confabulationis:
UNCONSCIOUSFILLINGINOFMEMORYGAPS
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45y/owithnystagmusandataxia,shorttermmemorylossandbelieveswifeis
possessedbydemons.Mostappropriatetreatment?
THIAMINE
Aconsciousmemorythatcoversforanothermemorythatistoopainfultoholdin
theconsciousnessis:
SCREENMEMORY
Inptswithpronounceddefectsinrecentmemory,remotememoryis:
OFTENDEFICIENTONCLOSEEXAMINATIONEVEN
WHENITSEEMSWELLPRESERVED
“Myfatherwasveryinvolvedinmylife.Iremembergoingtofootballgamesinthe
MEDIALTEMPORALLOBE
snowwithhim”isanexampleofmemoryassociatedwithwhatpartofthebrain?
Workingmemoryrequiresprefrontalcortex,dorsalthalamusandwhatotherarea
HIPPOCAMPUS
ofthebraintofunction?
Askingaptwhattheptateforbreakfastyesterdaytests:
RECENTMEMORY
Questiontoevaluateimmediaterecall?
CANYOUREPEATTHESESIXNUMBERS?
Askingpttoremember3thingsandrepeattheminafewminutesistesting:
SHORT-TERMMEMORY
MultipleSclerosis
WhichisthemostreliablefindingfromCSFanalysisforaptwithmultiple
sclerosisinthechronicprogressivephaseofthedz?(2x)
PRESENCEOFOLIGOCLONALBANDS
WhatconditionisaforerunnerofMS?(2x)
TRANSVERSEMYELITIS
Acuteonsetoffever,sorethroat,diplopia,&dysarthria.Examrevealsan
inflamedthroat,leftadductornervepalsyw/impairmentofverticalpursuit,
diffusehyperreflexiaw/bilateralclonus,lowerextspasticity,&mildright
hemiparesis.CTisuninformative.Spinalfluidhasproteinof24,10mononuclear
cells,andglucoseof70.Dx?(2x)
MULTIPLESCLEROSIS
Ptw/acuteonsetofpainanddecreasedvisionintheReye.Colorslookfaded
whenviewedthroughtheReye.Onexam,hasaRafferentpupillarydefectanda
MULTIPLESCLEROSIS
swollenrightopticdisc.Ptspontaneouslyrecoversoverthenext6wks.Likelyto
developlater:(3x)
25y/optwithdiplopia,difficultywithbalance.OnRlateralgaze,weaknessofL
medialrectuswithnystagmusofReye.OnLlateralgaze,weaknessofRmedial
rectuswithnystagmusofLeye.Mildfingertonoseataxia.Whatisthemost
likelydx?(2x)
MULTIPLESCLEROSIS
Diagnosisof32yowomanw/vertigoandINO
MULTIPLESCLEROSIS
TheMRIofthebrainofa35yowomanwnewonsetLarmandLlegnumbnessis
shown.
MULTIPLESCLEROSIS
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Muscle/NeuronalDiseases/Lesions
Myastheniagravisassociatedw/whichEMGfinding?(6x)
DECREASEDAMPLITUDEWITHREPETITIVEMOTOR
NERVESTIMULATION
37y/otruckdriverwnumbnessofLhand,incseverityinpast2yrs.Reduced
pinpricksensationonLlittle/ringfingers,atrophyofhypothenarmuscle.(6x)
ULNARNERVELESION
Whichofthefollowingwouldbeseeninelectrophysiologictestingofpatients
withmyastheniagravis?(3x)
DECREMENTALRESPONSETOREPETITIVE
STIMULATION
Mechanismofactionofbotulinumtoxinatneuromuscularjunction:(3x)
INHIBITIONOFACETYLCHOLINEFROMPRESYNAPTIC
TERMINALS
Myastheniagraviscanbediagnosedin80-90%ofcasesbyidentificationofserum
ACETYLCHOLINERECEPTORS
antibodiesagainstwhat?(3x)
During2ndtrimester,apregnant38y/oFhasnumbnessinbothhands,
particularlythumb,forefinger,middlefingerbilaterally.Dorsalpartofhand
unaffected.Armsacheinthemorningfromshoulderstohands.Diagnosis:(3x)
MEDIANNEUROPATHYATTHEWRIST
30y/odevelopspainbehindleftear.Thefollowingdayptcomplainsof
numbnessontheLsideoftheface,tearingfromLeye,anddiscomfortwithlow
frequencysounds.ExamshowsLfacialweakness,butnosensorydeficit.Likely
diagnosis:(2x)
IDIOPATHICBELL’SPALSY
OnemonthafteraMVA,a21y/ocopersistentpainintheleftshoulderandarm,
withsharppainradiatingintotheleftthumb.Examshowsweaknessofthe
C-6RADICULOPATHY
biceps.Thebicepsreflexontheleftisabsent.Themostlikelydiagnosisis?(2x)
Ptc/oprogressiveweaknessofseveraldays.Exam+forgeneralizedweakness
andabsentreflexes.Nerveconductionstudiesshowslowingofvelocities.Dx?
(2x)
ACUTEPOLYNEUROPATHY
65yoptwithprogressiveweakness,worsewhensquattingandstandingfroma
chair.C/odecreasedstrengthinrighthand.Onexam,prominentweaknessofthe
quadricepsbilaterallyandonoppositionofthethumbintherighthand.Atrophy
MYOTONICDYSTROPHY
offoremanmuscleswithnormalDTRs.Nootherweaknessnotedonexam.
Sensoryexamnormal.ROSnegative.LabsshownormalCKandnegforantitransferRNAsynthaseantibodies(Jo1).Whatisthemostlikelydx?(2x)
Whatchemoagentismostcommonlyassocwithdistalsensorypolyneuropathy?
CISPLATIN
(2x)
Ptpresentswithpersonalitychanges,cognitivedifficulties,affectivelability,and
olfactoryandgustatoryhallucinations.Themostlikelymedicalcauseofthis
HERPESSIMPLEXVIRUS(HSV)INFECTION
presentationis:(2x)
ConductionblockinNCSindicateswhat?
FOCALDEMYLENATION
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Polyneuropathycanbecausedbyeitherdeficiencyorextremeexcessofwhichof
thefollowingBvitamins?
45yopwgradualprogressiveweaknessfor3-4moinLUE,atrophyinRUEintrinsic
mm,andbriskreflexesandextensorplantarresponses.EMGwithwidespread
fasciulations,fibrillations,and+sharpwaves.Dx?
57y/oofficeworkerwnumbnessin4th/5thdigitofrighthand,whichwakes
patientinmiddleofnight.Nerveconductionstudyfindingmostlikelytoexplain
syndrome?
VITAMINB6
ALS
SLOWEDCONDUCTIONVELOCITYACROSSTHEELBOW
INTHEULNARNERVE
45y/oreportslowerbackpainalongw/painandnumbnessinRlegandfootw/
difficultywalkingx4wks.Exam:limitedduetobackpain,footdroponrightside.
Nerveconductionstudies:normalmotorandsensoryinleg.EMG:decreased
L-5RADICULOPATHY
recruitmentandspontaneousactivityinrighttibialisanteriorandtibialisposterior
muscles.Otherwisenormal.Dx:
A54yoptcomplainsofintermittentdoublevisionthathasworsenedoverthelast
3wks.Thept’scoworkeralsonotedthatattimesthepatienthada“droopiness”of
theeyelidsasifsleepy.Examinationrevealsbilateralptosis,mildesotropia,and
doublevisiononlyaftertheptisaskedtomaintainanupwardgazefor2minutes. EDROPHONIUMTEST
Thereisnodysarthria,butamild4/5weaknessisfoundintheproximalarm
musclesbilaterally.Whatismostappropriatetesttoperformnexttoestablishthe
diagnosis?
Whichofthefollowingantibioticsismostlikelytocauseorprecipitateacute
myasthenia?
CIPROFLOXACIN
15y/ohashxofseizuresbeginningattheageof9years,followedbyprolonged
motororsensorydeficitslastingdaystoweeks.Thepatternoftheseizuresandthe MITOCHONDRIALENCEPHALOMYOPATHY,LACTIC
focaldeficitshaschangedovertime.Theptalsohashemicranialheadaches.No
ACIDOSISANDSTROKE.
familyhxofsimilarsymptoms.Mostlikelydiagnosis?
Ahyperextensionlesionoftheshoulderresultinginweaknessofabduction,
internalrotation,flexion,andadductionoftheextendedarmmostlikelyincludes
whichnerveroots?
C5,C6
55y/oMpresentsw/hxofweaknessandclumsiness.Symptomsbeganseveral
monthsearlierwithdifficultybuttoninghisclothes,gettingthecarkeysinthe
ignition,andperformingotherfinemotortasks.Henoticedthatthemusclesinhis
armandforearmtwitchedunderthesurface,andcrampedeasily.Overthepast
ANTERIORHORNOFTHESPINALCORD,MEDIAL
fewmonthshisarmshavecontinuedtoweakenandlosemusclemass.Onexam,
BRAINSTEM,ANDPREROLANDICCORTEX
hehasdiffusewastingandweaknessofBUE,fasciculations,slightspasticityon
armsandlegs,andhyperreflexiawithextensorplantarresponses.Sensory,
coordination,andCNexamsarenormal.Theunderlyingpathologicalprocess
affectsneuronalbodiesinwhichofthefollowingstructures?
13y/oMwtroublekeepingupwP.E.class.Onexam:symmetricweaknessinlegs/
arms,worseinproximalmuscles,mostprominentinquadriceps/hamstrings.Both
X-LINKED
calvesenlarged,painfulwexercise.Serumcreatinekinaselevelis13,000.Muscle
bxrevealsabnormalitiesindystrophinproteinstaining.Patternofinheritanceis?
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Neoplasmsofthethymusareassociatedwith:
MYASTHENIAGRAVIS
Hyperkalemicperiodicparalysisischaracterizedbyepisodesofgeneralized
weaknessoffairlyrapidonset.ItisalsoassociatedwithariseinserumK,with
SODIUMCHANNELINACTIVATION
weaknesstypicallyappearingafteraperiodofrestfollowingexercise.Whichofthe
followingmoleculardeficitsunderliesthisdisease?
Ptwashitfrombehindwhiledriving&awokew/painradiatingintohisleftankle.
Weaknessofplantarflexionanddecreasedanklejerk.Straightlegraisingreveals
painbeyond45degreesonleft.Dx?
S-1RADICULOPATHY
Myastheniagravisptwithmildrespiratoryinfectiondevelopssevererespiratory
fatigue,restlessness,anddiaphoresis.Ptappearsanxiousandtremulous.Tx?
MECHANICALVENTILATION
Ptc/oleftfootslappingfloorwhenhewalks.Hehastostephightoavoidtripping.
Weaknessofdorsiflexionofleftfoot,w/smallareaofnumbnessinthedorsumof PERONEALNERVEPALSY
theleftfoot.Normalankleandkneejerks,andhamstringreflexes.Dx?
Alesioninwhatstructureisassociatedwithptosis,lackofsweatingonsameside
oftheface,andconjunctivalinjection?
SUPERIORCERVICALGANGLION
Whichofthefollowingisthemosteffectivetreatmentofspasmodictorticollis?
BOTULINUMTOXIN
50y/ootherwisehealthyptwhoisasecretarynoticescrampingandstiffeningof
handsonlywhilewriting,stiffnessceaseswhenptstopswriting.Occasionally
handswilltremor.WhichofthefollowingIsmosteffectivetherapy
BOTULINUMTOXIN
Rneckpain,usuallyrotatingnecktoleft.Correctedbytouchingchin.SpasmofR
SCMonPE.Treatment?
BOTOX
70Y/Optwithconfusion,lethargy,fever.DxofencephalitisismadeafterCSF
analysis.WhatclinicalfeaturesuggestsWestNilevirus?
MONOPARESIS
55y/optc/oofmildmuscularachesandstiffnessforwhichsteroidtreatmentwas
previouslygiven.Hxofhypercholesterolemiaandhypertriglyceridemia,andwas
STATIN-INDUCEDMYELOPATHY
treatedwithatorvastatinandgemfibrozilwithapositiveresponse.Serumcreatine
kinaselevelisslightlyelevated.Whichofthefollowingisthemostlikelydiagnosis?
A63y/optwithinsidiousonsetofneckpain,progressivelimbweakness,falls,and
urinaryincontinence.Onexam,pthasdecreasedneckROM,milddistaland
proximallimbweakness,briskDTRswithankleclonus,andupgoingplantar
CERVICALMYELOPATHY
reflexes.Increasemuscletoneinlegs.Restofexamisnormal.Whatismostlikely
dx?
A25yroldptdevelopsprogressivehearingloss,hasacousticneuromasandcaféau
NEUROFIBROMATOSISTYPE2
laitspots,diagnosis?
Gaitpatterninwhichonesideofpelvisisdroppedisassociatedwithwhich
neurologicalcondition?
MUSCULARDYSTROPHY
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Parkinson’sDisease
Parkinson’sDiseasetreatedw/levodopa.Visualhallucinations.
Recommendations?(5x)
REDUCEDOSEOFLEVODOPA
MedicationusefulinmanagementoforthostatichypotensioninParkinson’s(3x) FLUDROCORTISONE
Gaitconsistingof:posturalinstability,festination,&truncalrigidity.Lewybodies
PARKINSON’SDISEASE
visualized.Alsowithinvoluntaryaccelerationisseeninwhatcondition?(3x)
Pictureshowingsubstantianigrachanges,whatneurologicaldiseasewouldbe
expected?
PARKINSON'SDISEASE
Thenewonsetofpathologicalgambling,increasedlibido,andhypersexualityina
PRAMIPEXOLE
patientwithParkinsondiseaseislikelytobesecondaryto:(3x)
80yomaleevaluatedforgaitimbalanceandfalls.wifeexplainsthathekicksand
screamswhilesleeping,hereportsdreamsofbeingchased.Ptlikelyhas/will
develop?
PARKINSON'SDISEASE
67y/orecentlyretiredptwithParkinsons,nootherpsychhx,hastaken
Pramipexoleforseveralyearswithoutcognitivedecline.Pthassincestarted
gamblingexcessively.Ptdoesnotdrinkoruseillicitsubstances.Whatisthemost
likelycause?
USEOFDOPAMINERGICAGENTS
MostappropriateinitialtxforidiopathicParkinsondzinan81y/opt
CARBIDOPA/LEVODOPA
66y/oc/ofrequentfalls,mildaxialandLUErigidity,mildslownessoffinger
tapping,handopening,andwristopposition(allworseonleft),normalposture,
slowgaitwithshortsteps,doesnotswingleftarm,slowrisingfromchair.Whatis
thedx?
PARKINSON’SDISEASE
ImplantationofdeepbrainstimulationelectrodesisaneffectivetxforParkinson’s.
SUBTHALAMICNUCLEUS
Optimallocationforelectrodes?
Deepbrainstimulationinwhichbrainstructureisausefultreatmentforprimary
generalizeddystonia?
GLOBUSPALLIDUS
MotordysfunctioninParkinson’sassociatedwith:
INCREASEDACTIVITYINSUBTHALAMICNUCLEUSAND
PARSINTERNAOFGLOBUSPALLIDUS
CharacteristicsofParkinson’stremor
BEINGINHIBITEDWITHVOLITIONALMOVEMENT
ClinicalsyndromethatismostcommonlycomorbidwithParkinson’sdisease:
DEPRESSION
TypicalofIdiopathicParkinson’sdisease,ratherthananotherParkinsonian
syndrome:(x2)
ASYMMETRICALONSETANDPROGRESSIONOF
MOTORSYMPTOMS.
Ptw/Parkinson’sdiseaseexperiencesvisualhallucinationsonlevodopa/carbidopa
QUETIAPINE
therapy.Whichmedwouldbethemostappropriateintervention:
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Spine
26y/optw/suddenonsetbackpain.SpasmsinRparaspinalmusclesinthe
lumbarregion.StraightlegraisingontheRislimitedbysharppainat45degrees.
ORDERMRISCANOFTHELUMBARSPINE
AnklejerkonLisdiminished.Nomuscleweakness,nosensorydeficit.Nextstep?
(3x)
Contralaterallossofpainandtempsensationwithmotorparalysisand
proprioceptionlossontheother.Dx?(2x)
BROWN-SEQUARDSYNDROME(HEMISECTION)
Subacutecombineddegenerationoftheposteriorcolumnofthespinalcordis
associatedwithadeficiencyof:(2x)
VITAMINB12DEFICIENCY
T2MRIfigureinptwithcervicalmyelopathy.Mostconsistentwithwhatdx?
DEGENERATIVECERVICALSPONDYLOSIS
New-onsetbackpainaftershoveling–leftparaspinalmusclespasm,negative
straightlegraise,reflexessymmetric,noweakness,nosensorydeficit.
Management?
CONSERVATIVE(BEDREST)WITHNSAIDS
50y/oMw/acuteneckpainradiatingdownLarm,gaitproblems,urinary
incontinence.Whattestshouldbeordered?
MRIOFCSPINETOR/OCORDCOMPRESSION
23y/oCaucasianFinofficeforf/uafteranERvisit2daysearlierforsudden
diplopia,Rlegweaknessandshaking,difficultyw/speechwhichresolvedaftera
fewhours.Pthadfever103.1FandwastxforUTI.Currentexam:normalCN&
PROTEIN:50mg,+OLIGOCLONALBANDS,NUCLEATED
sensory,minimalRlegweakness,briskDTRandmusculocutaneousreflexes
CELLS:10
throughout,andequivocalplantarreflexonL.Rtoeisdowngoing.Hxofseveral
episodesoftransientneurologicaldeficitsthatresolvedspontaneouslyafterafew
days.Herspinalfluidismostlikelytoshowwhat?
68y/ow/paininbuttockswhilewalking,shootingdownlegs,w/weaknessand
numbness.Relievedbysitting,painpersistswithstanding.Dx?
LUMBARSPINALSTENOSIS
Whereisthelesionwhenapictureofafemalepatientwithptosisisshown?
SUPERIORCERVICALGANGLION
55y/oMwithchangesinhisvoice,orthostatichypotensionandoneimmobile
vocalcordoninspectionsuffersfrom:
SHY-DRAGERSYNDROME
Ayoungptw/afewdaysofprogressiveweaknessandnumbnessofbothlegsand
feetafterrecoveringfromaflu-likeillness.Exam:weaknessandlossofsensation
toallsensorymodalitiesbelowthemiddleofthethorax.DTR:briskeronthelower
ACUTETRANSVERSEMYELITIS
extremities,plantarreflexesareextensor.Pthashadseveralepisodesofurinary
incontinence.Otherneuroexamandvital:normal.LP:23mononuclearcells,
proteinlevel:37mg/dl,andnormalglucose.Dx:
28y/ococaineusercomplainsofLBP,numbnessinbothlegsandfeet,thighs,
buttocks,abdomen,andsaysRlegisweakandclumsy,Llegistired.Hasurinary
incontinenceanddifficultywalking.Decreasedlighttouch,pinprick,and
temperature.Normalvibrationandproprioception.DTRishardtoelicit.Muscle
toneisnormal.DecreasedstrengthinB/LLEbutworseonright.Diagnosis?
ANTERIORSPINALARTERYINFARCTION
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Fallfromaladderwithpersistentbackpainandinabilitytovoid.B/llegweakness,
CAUDAEQUINACOMPRESSION
decreasedpinprickinsacralandperianalarea.Dx?
35-yearoldptwithnewonsetofnumbnessandtinglinginthelegs.Thept
complainsofaband-likesensationaroundthemidchestandreportsepisodesof
urinaryincontinence.Whichofthefollowingtestsshouldbeorderednext?
MRIOFTHESPINE
Fluctuatingachingpaininlowerback,buttocks,andsciaticdistributionelicitedby
standingorwalking,andrelievedbysittingwithnumbnessinasimilardistribution, Spinalstenosis
lossofanklereflexes:whatdx?
TardiveDyskinesia
Thesinglemostconsistentlydocumentedandsignificantriskfactorinthe
epidemiologyoftardivedyskinesiais?
ADVANCEDAGE
RiskfactorforTD
PRESENCEOFMOODDISORDER
TDin63y/ow/endstagerenalfailure.Culprit:
METOCLOPRAMIDE
Whichgenderhasahigherriskfortardivedyskinesia(TD)?
FEMALE
GeneralNeurology
36y/optwpainbehindLearprogressingtonumbnessofLsideofface,tearing
ofL
eye,discomfortwlowfrequencysounds,leftfacialweaknessonexam.Dx?(9x)
IDIOPATHICBELL’SPALSY
Fever,HA,seizures,confusion,stupor,andcoma,evolvingoverseveraldays.EEG
withlateralizedhigh-voltagesharpwavesarisingintheLtemporalregionwslow HERPESSIMPLEXENCEPHALITIS
waverepeatingat2-3secintervals.CTlow-densitylesioninLtemporallobe.(8x)
SevereoccipitalHA,BLpapilledemaandnootherabnormalities.Chronicacne
treatedwithisotretinoin.Lumbarpunctureelevatedopeningpressurewithno
cells,62mg/dlglucose,and22mg/dlprotein.CTisnormal.(7x)
PSEUDOTUMORCEREBRI
TreatmentofTrigeminalNeuralgia:(6x)
GABAPENTIN(BUTMOSTEFFECTIVEIS
CARBAMAZEPINE)
22y/owithpainintherighthandthatradiatesintotheforearmandbicep
muscle.Paresthesiasinthepalmofthehand,thumb,index,middleringfinger.
Sensorysystemsintheringfingersplittheringerfingerlongitudinally.Dx?(6x)
MEDIANNERVEENTRAPMENTATTHEWRIST
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StiffnessoflegswhilewalkingandspasmsofLEwhilesleeping.Stiffleggedgait,
adductslegswhilewalking.IncreasedLEtone/spasticcatch,hyperactiveknee
jerks,anklejerkclonus.IncreasedRombergsway.(5x)
CERVICALSPONDYLOSIS
Atrophyoftheintrinsicmusclesoftherightarmandforearm.Reflexesare
generallybrisk,plantarreflexesareextensor.Electrophysiologyshows
widespreadfasciculations,fibrillationandsharpwaves,normalsensation,muscle AMYOTROPHICLATERALSCLEROSIS
spasticity.
PositivesharpwavesonEMG.(5x)
79y/optwithadeterioratingmentalstateovera3-weekperiodhasan
exaggeratedstartleresponsewithviolentmyoclonusthatiselicitedbyturning
ontheroomlights,speakingloudly,ortouchingthept.Myoclonicjerksarealso
seen.Diagnosis:(5x)
SPONGIFORMENCEPHALOPATHY
54y/opthasseveraldaysoflowgradefever,malaiseandseverepainintheright
sideoftheribcage.Examinationrevealsanerythematousrashwithclustersof
tensevesicles,withclearcontent,onabeltdistributionfromthefrontofthe
VARICELLAZOSTERVIRUS
chesttothebackunderthenipple,limitedtotherightside.Likelycausalviral
agent?(4x)
PersistentnumbnessintheLhand,decreasedsensationin4th/5thdigits
(palmar/dorsal),weakfingerabduction/adductionespecially5thdigit:(4x)
ULNARNERVEENTRAPMENTATTHEELBOW
Rightneckpain,tendstorotatenecktoleft–touchingthechinprevents
deviation
–prominentrightSCMspasm.Tx?(4x)
BOTULINUMTOXIN
54y/opthasseveraldaysoflowgradefever,malaiseandseverepainintheright
sideoftheribcage.Examinationrevealsanerythematousrashwithclustersof
tensevesicles,withclearcontent,onabeltdistributionfromthefrontofthe
VARICELLAZOSTERVIRUS
chesttothebackunderthenipple,limitedtotherightside.Likelycausalviral
agent?(4x)
17y/opthasaninsidiousonsetofunusualbehaviorandargumentativeness.
Exam,themouthisheldslightlyopen.Pthasmilddysarthriaandhoarseness,
generalizedslowness,rigidity,andamildrestingtremoroftheleftarmandhead.
URINARYCOPPEREXCRETION
ruleoutdrugand/oralcoholabuse.Liverfunctiontestsshowelevated
transaminases.AnincreaseinwhichlaboratorytestismostlikelytoconfirmDx?
(4x)
Progressiveweaknessoverseveraldays–absentreflexesworseinlower
extremities–slowconductionvelocity,conductionblockA54-year-oldpatient
hadaviralupperrespiratoryinfection2weeksagoandnowpresentswitha3dayepisodeofprogressive,symmetricweaknessinthelegs,andtinglinginthe
toesandfingers.Onexam,Achillesandpatellardeeptendonreflexesare
diminished.Nerveconductionstudiesdemonstratedecreasedconduction
velocityanddecreasedamplitudeofactionpotentials.ThemostlikelyDx:(4x)
ACUTEINFLAMMATORYDEMYELINATING
POLYNEUROPATHY
14y/optafterademandingphysicaltestbecomesextremelyweakandunableto
stand.PEispositivefordepressedDTR’s.Labs:K=2.8.Hxofsimilarepisodesafter
PERIODICPARALYSIS
strenuousexercises.EKG:minimallyprolongedPR,QRS,QTinterval.Fatherand
grandfatherhadsimilarepisodes.Dx?(3x)
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Severespasmsandrigidityoflimbsintermittentlyandlatermore
persistent/continuous:(2x)
ANTIGLUTAMICANDANTIDECARBOXYLASE
ANTIBODIES(anti-GAD)antibodies
Ptwithhxofherpessimplexandseizured/oundergoingEEGmonitoringthat
recordednoepilepticactivityduring,afterandbeforeaconfusedstatewherein
ptsuddenlyawokefrightened.Thenextdayptwithbaselinedemeanorhasno
memoryaboutthatepisode.(2x)
AMNESTICDISORDER
Gaitabnormality,slowmovement,asymmetricUErigidity.Difficultyinvoluntary
verticalupward/downwardgaze.Slowness/rigidityimprovedslightlywith
PROGRESSIVESUPRANUCLEARPALSY
levodopa.Laterhasproblemswithhorizontal&verticalgaze.Oculocephalic
reflexesnormal.Involuntarysaccades.(2x)
Ptc/ounpleasantachinganddrawingsensationsincalvesandthighsassociated
withacrawlingfeeling,forcinghimtomovelegs,bringingtransientrelief.Sxs
worsenedbyfatigue.Examnl.Bestmedtx?(2x)
PERGOLIDE(FORRESTLESSLEGSYNDROME)
Themostcommonpossiblecauseofaposteriorcerebralarteryinfarctin36y/oF
ORALCONTRACEPTIVES
withhxofmigraine:(2x)
BenignintracranialHTNetiology:(2x)
HYPERVITAMINOSISA
AnIVmethuserdevelopsseverebackpain,followedafterseveraldaysby
bilaterallowerextremityweakness/sensoryloss,bladderincontinence,low
gradefever,tendernesstopercussionoverthe2ndand3rdlumbarvertebrae,
paraparesisandlossofsensationtolighttouchandpinprickinbothlegs,
buttocks&sacralregion.(3x)
SPINALEPIDURALABSCESS
Ptw/episodesofsevere,intermittent,lancinatingpaininvolvingtheposterior
tongueandpharynx,w/radiationtodeepearstructures.Triggedbyswallowing
ofcoldliquidsandtalking.Workup:normal.Dx?(2x)
GLOSSOPHARYNGEALNEURALGIA
Ptpresentswithaslowlyprogressivegaitdisorder,followedbyimpairmentof
mentalfunction,andsphinctericincontinence.Nopapilledemaorheadachesare NORMALPRESSUREHYDROCEPHALUS
reported.Likelydiagnosis?(3x)
FirstlinetreatmentofvocalticsinTourettesyndrome:(2x)
ALPHA2ADRENERGICAGONIST
WhichdrugfortheTxofparkinsonismhasbeenassociatedwithsuddensleep
attacks?(2x)
ROPINIROLE
Weaknessinlimbs2weeksafteraviralgastroenteritis.WeaknessinUE/LE,
absentDTRs.Spinalfluidshowsnocellsandelevatedprotein.EMGshowsslow
conductionvelocity,prolongeddistalmotorlatency,andconductionblock.(2x)
ACUTEINFLAMMATORYPOLYNEUROPATHY
PtwithseveraldaysoffeverandsevereheadachespresentstoEDb/o
generalizedseizure.Ptisconfusedandsomnolent.Alsoreportedtohavebeen
irritableandhasc/ofoulsmells.T2MRIdisplayed(hyperintensityofleft
temporal):(2x)
HERPESENCEPHALITIS
Themostcommoncomplicationoftemporalarteritisiscausedbyocclusionof
the:(2x)
OPHTHALMICARTERY
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Tremorwithafrequencyofaround3Hz,irregularamplitude,mostevident
towardstheendofreachingmovements:(2x)
CEREBELLARTUMOR
Chiropracticadjustmentsareaknownprecipitantforwhichofthefollowing
acuteconditions?(2x)
VERTEBRALARTERYDISSECTION
HistologyconsistentwithJakob-Creutzfeldtdisease
CYTOSOLICVACUOLATIONOFNEURONSANDGLIA
WITHPRIONINCLUSIONS
22yofemaleishospitalizedwithparanoia,hallucinations,abdominalpainworse
withperiods,physicalexamshowsreducedstrengthinupperandlower
PORPHOPBILINOGEN
extremitiesandreducedtendonreflexes.Whichofthefollowinglabvaluesislikely
tobeelevatedandexplainhersymptoms?
Dxforptw/new-onsetsz,multiplesubQnodules,frecklingofaxilla?
NFTYPEI
Lesionsinmammalarybodieswillproducewhatsymptom?
AMNESIA,CONFABULATION,LACKOFINSIGHT
Whatisthefirststeptomangerestlesslegsyndrome?
CHECKFORIRONDEFICIENCY
DxforIVdruguserw/severebackpain,BLEweakness,LE/buttock/sacralsensory
loss,bladderincontinence,fever,TTPoversecond/thirdvertebrae.
SPINALEPIDURALABSCESS
25y/optc/osevereHAandvomiting.Painisdullandmostlyinoccipitalregion.
Exam:b/lseverepapilledema,otherwiseWNL.LP:openingpressure:200mmH2O, PSEUDOTUMORCEREBRI
nocells,62mg/dlglucose,31mg/dlprotein.CT:normal.Dx?
55yoptcomplainsofnumbnessin4th/5thdigitRhand.Sxsworsewhenptspeaks
NERVECONDUCTIONSTUDIES
onphone,awakenswparesthesiasinsamefingers.Testtoconfirmthedx?
A66yocomplainsoffrequentfalls.ONexam,thepthasdifficultywithupward
gaze,andhassevereaxialrigiditywhichislessapparentinupperorlower
extremities.Thereismildslownessofmovementonfingertapping,handopening
andwristoppositionandthepatient’sfingersacquirecrampedpastureswiththe
effortofthetask.Thept’sneckpostureisextended.Gaitissomewhatslow,with
shortsteps,andTheptisslowwhenarisingfromachair.Whatismostlikely
diagnosis?
Whichofthefollowingismostlikelytoreducepaininpostherpeticneuralgia
45y/oM,withrecurrentepisodesofLOCwhilewearingashirtwithatightcollar,
hasfeelingoffaintnessaccompaniedbypallor,followedbycollapseandLOC,and
severalsecondslaterbyafewbilateraljerksofthearmsandlegs.Entireepisode
lastedlessthanoneminute.Mostlikelyexplanation?
PROGRESSIVESUPRANUCLEARPALSY
Capsaicin
CAROTIDSINUSSYNCOPE
Dxfor68yoc/ofalls.PEshowsuprightrigidposture,stiffgait,extendedknees,and
PROGRESSIVESUPRANUCLEARPALSY
pivotingwhileturning.
Theimagebelowrepresentsadiplopiaevaluationusingtheredglasstechnique.A
redglassisplacedoverthept’srighteyeandalightisflashedatadistanceof1
meter.Theimagesaredescribedfromtheperspectiveoftheptwhenlookingto
RIGHTMEDIALRECTUS
the6cardinaldirections.Theseresultsaremostconsistentwithpalsyinwhichof
thefollowingintrinsicmuscles?
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75y/owithhxofextensivetobaccosmokingpresentswithsubacuteprogressive
ataxicd/ooverseveralmonths.MRIbrainisunremarkable.CSFshowsmild
pleocytosis.Foundpositiveforanti-Yoantibody.Whattestshouldbeordered
next?
CTCHEST
MostcommonsolidtumoroftheCNSinkids
NEUROBLASTOMA
2yearsafterMVAwithrear-endcollision,ptdevelopsBUEweaknesswithsome
musclewasting,lossofDTRsinarms,lossofsensationtopainandtempin
neck/arms/shoulders,intactsensationtotouch.Mostlikelycause?(X2)
SYRINGOMYELIA
PtwithchronicmusclewastinginbothUE,lossoflighttouch,pain,and
temperaturesensationinshoulders,upperarms,andback,andpainful
paresthesiasoverthesamedistribution,diagnosis?
SYRINGOMYELIA
Etiologyofmeningitisassocwithfever,HA,CSFpleocytosiswithlymphocyte
predominance,slightlyelevatedCSFprotein,andnormalCSFglucose
COXSACKIEVIRUS
Wordthatptmakesupis…
NEOLOGISM
Thetermforabnormallyslowspeechseenindepression
BRADYLALIA
5y/opresentsw/suddenonsetofslurredspeechandgaitdifficulty.Examshows
truncalataxiaandnystagmus,milddysarthriaandextensorplantarresponses.
Recenth/omeasles.MRI,UA,bloodworkunremarkable.Dx?
ACUTECEREBELLITIS
Termforburningdysesthesiawithshock-likeparoxysms:
NEUROPATHIC
Adultonsetopsoclonus-myoclonus-ataxiaisassociatedwithwhichformofcancer? BREASTCARCINOMA
Patientreportsthatanidentical-appearingimpostorhasreplacedhisfather.What
CAPGRASSYNDROME
isthenameofthisdelusion?
28y/owithacuteurinaryincontinenceandunsteadygait.Alsoreports1weekh/o
numbnessprogressingfrombothfeetuptoabdomen.Lighttouch,temperature,
andpinprickarereducedbelowthemid-thoracicregion.Vibrationandposition
ACUTETRANSVERSEMYELITIS
sensationinbothfeetareabsent.Musclebulkandtonearenormal.Strengthin
BLEarereduced,R>L.BriskDTRsinBLEwith+Babinski’s.What’stheDx?
33y/owithinsomnia,fatigue,nervousness,irritability,anddepressedmood.Has
scalydermatitisinsun-exposedareas,apathy,andmildmemoryimpairment.
Whichvitaminisptdeficientin?
NIACIN
Whichfindingwouldyouexpectifsomeoneisdiagnosedwithulnarneuropathyat LOSSOFSENSATIONINTHEFOURTHANDFIFTHDIGIT
theelbow?
ANDWEAKNESSOFINTRINSICHANDMUSCLES
Inhibitorsofenzymecatechol-O-methyltransferaseareusedinParkinsondisease
toaddresswhichdisease-associateproblem?
WEARINGOFFOFLEVODOPAEFFECT
43y/optw/memorylossx8monthsassociatedwithabdpain,wtloss,joint
CEREBROSPINALFLUIDWITHPAS+CELLSINFECTED
distention/pain,fever,lymphadenopathy,hyperpigmentationofskin,decrease
WITHTROPHERYMA
hemoglobin,andfatinstool.Whichtestresultislikelytobefoundinthispatient?
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BlockingRPCA(posteriorcerebralartery)causeswhichvisualdisturbance?
LEFTHOMONYMOUSHEMIANOPSIA
72y/opthadalacunarinfarctinthemiddlecerebralarteryterritory.Echois
normal.Dopplerstudiesofneckarteriesreveallessthan50%occlusiononboth
carotidarteries.EKGisnormal.Thebeststrategiestoreducerecurrentstroke:
ANTIPLATELETTHERAPYWITHASPIRINAND
DIPYRIDAMOLE
60y/optw/progressiveproximalarmandlegweakness,elevatedcreatinekinase
SMALL,SHORTDURINGMOTORUNITONNEEDLEEXAM
level.MDsuspectsamyopathyandordersEMG.WhichfindingsonEMG:
76y/optcomplainsofbilateral,severe,persistentheadachew/lossofvisionand
scalptenderness,andstiffnessofproximalmusculature.Sedimentationrate:
96mm/hr.Whichdiagnosticprocedure:
BIOPSY
OpiatesinhibitCampdependentproteinphosphorylationin:
LOCUSCERULEUS
Themostfrequencycauseofsimultaneous,bilateralfacialnervepalsies
BORRELIABURGDORFERI
45y/optw/weaknessofhipsandthighs,andlesserextenttheshoulderandneck.
Alsoextremelydifficulttorisefromasquattingorkneelingposition,Nomuscle
POLYMYOSITIS
pain.Notender.DTR:normal.Dx:
15y/optfelltothegroundafterbeinghitintheheadwhileplayingsoccer.Ptdid
notloseconsciousness,butwasconfusedforfollowing20min.Thenextday,pt
reportedaheadacheandirritable,neuroexamnormal.Bestrecommendationto
familyabout
pt:
SHOULDBEEXAMINEDIN2WKSBEFORERESUMING
PLAY
Adislocationofshoulderjointresultinginweaknessofabductionofarm,wasting
ofdeltoidmuscleandslightimpairmentofsensationonthelateralaspectof
shoulder,involveswhichnerves:
AXILLARY
2y/ochildw/hxofupperrespiratoryinfections,mostlikely:
HAEMOPHILUSINFLUENZA
Unilateraldistalweaknessinonelimb,oftenassociatedw/musclewastinginthe
samedistribution,themostcommonDx:
AMYOTROPHICLATERALSCLEROSIS(ALS)
52y/optwithEtOHdependencepresentwithseveraldaysofsevereheadache,
nausea,andlowgradefever.Physicalexamrevealsmilddisorientation,nuchal
rigidity,andmildspasticityinthelowerextremities.AheadCTisunrevealing.LP:
55/mm3leukocytes(mostlylymphocytes),45mg/dlglucose,protein:43mg/dl,
andpresenceofoccasionalgrampositivesphericalcells.Themostlikelycausative
organismis:
CRYPTOCOCCUSNEOFORMANS
49y/optwithETOHdependenceisbroughttotheEDwithaone-weekhistoryof
malaise,headache,diplopia,lethargyandconfusion.Onexamination,thepthasa
tempof38.2C,stiffneck,medicaldeviationoftherighteyewithimpaired
TUBERCULOUS
abductionandhoarseness.CSF:114leukocytes,predominantlymonocytes,a
proteinof
132mg/dl,andglucoseof29mg/dl.Likelytypeofmeningitis:
ClosedTBI,initiallynoLOC,then20minuteslaterLOC.Patientrecoversin5
minutes.
VASOVAGALSYNCOPALATTACK
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Ptwho5daysagoexperiencedarupturedaneurysmlocatedintheleftmiddle
cerebralarterydevelopsafluctuatingaphasiaandhemiparesiswithnosignificant
headaches.Underlyingevent:
VASOSPASM
45y/opthasrecurrentepisodesofLOC.Adetaileddescriptionbyfamily:pt
reportingafeelingoffaintnessaccompaniedbypallor,followedbycollapseand
LOC,andseveralsecondslaterbyafewbilateraljerksofthearmsandlegs.Priorto CARDIACSYNCOPE
recovery,thept’sfaceandchestareflushed.Noprecipitatingfactorsare
identified.Whichofthefollowingisthemostlikelyexplanation:
SevereoccipitalHA,BLpapilledemaandvomiting.Juststartedbirthcontrolpills.
Lumbarpunctureelevatedopeningpressurewithnocells,62mg/dlglucose,and
31mg/dlprotein,RBC400.CTisnormal.
SAGITTALSINUSTHROMBOSIS
Previouslyreliable,conscientiousmanbecomesincreasinglyprofane,irascible,
irresponsibleover6months.Sxssuggesttumormostlikelytobefoundwhere?
FRONTALLOBE
Conditionmostlikelytoaccountforthepresenceofcognitiveimpairmentinapt
withuntreatedHepC(HCV)infectionandnormalammonialevelwhoisHIVsero-
negative:
HCVINFECTIONOFBRAIN
Ptc/opainwhenwalkingthatradiatesfromlowerbackandissevereinthecalves.
Painrelievedbystoppingforacoupleofminutes,thenresuming.Nosensoryor
VASCULAREVALUATIONOFLOWEREXTREMITIES
motordeficits.TestmostlikelytoyieldDx?
Akineticmutismcanresultfrombilateralinfarctionsofwhichofthefollowing
structures:
ANTERIORCINGULATEGYRUS
Whichofthefollowingisthemosteffectivetreatmentofblepharospasm?(x2)
BOTULINUMTOXIN
AconditionwithincreasedfrequencyinptswithHIVonlongtermHAART:
HEPATOTOXICITY
Viralagentsfrequentlyassociatedwithidiopathicunilateralfacialnervepalsy:
HERPESSIMPLEX
62yoprogressivepersonalitychanges,hasdullemotions,lackofinitiative,and
apathy.Anautopsyislikelytoshowatrophyof…?
FRONTALLOBE
Weaknessofopponensofthumbandadductionof4th,5thdigit,decreased
sensationin4th,5thdigitsextendingintopalmandendingatcreaseofwrist,
causedby:
ULNARNERVELESION
Severelysensitive,lancinatingpainonthecheek
TRIGEMINALNEURALGIA
52y/owrecurrentstabbingpainoverrightcheekandjawforcinghimtofrown.
Stoppedshavingorbrushingteethd/tfearofpain.Episodeslastlessthan1
minute.Onlyexamabnormalityispainuponrepeatedtouchingofpt’sface.Most
likelyexplanationofsymptoms?
TRIGEMINALNEURALGIA
23y/odevelopstinglingparesthesiasinthelowerextremities,followedseveral
dayslaterbyprogressiveweakness,R>L.PEshowssensorylevelatT10topinprick,
TRANSVERSEMYELITIS
+3/5weaknessofLE,slightlyweakeronR.Kneeandanklejerksarehyperactive,
b/lcongenit.Pthasdifficultywalkingwithbroad-based,stiff-leggedgait.Dx?
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Severejabbingpain,lastsfewseconds,triggeredbylighttouchonface
TICDOULOUREUX
Irregular,unequal,smallpupilsnonreactive,donotdilate,butdoconstrictto
accommodation:
SYPHILIS
Mostcommonsymptominnarcoleptics:
SLEEPATTACKS
49y/owithgradualhearingloss.AtuningforkusedduringtheWebertestreveals
afailuretolateralize,andthewoman’sperceptionofairconductionisbetterthan
SENSORINEURALHEARINGLOSS(b/l)
thatofboneconduction.Shehastroublediscriminatingwords“fat”“cat”“mat”.
Dx?
65y/oMtroublefallingasleep2/2unpleasantachinganddrawingsensationsin
calvesandthighs.Alsocreepingandcrawlingsensationsinlegs.Urgetomovelegs
RESTLESSLEGSYNDROME
canbesuppressedvoluntarilyforshortwhilebutisultimatelyirresistible.Most
likelyDxis:
Tremordecreasingwithvolitionalmovementsandappearsprimarilyinanattitude
RESTINGTREMOR
ofrepose:
Mucosallesionthathealsandthenpthaspainintrigeminalnervearea
POST-HERPETICNEURALGIA
Unilateralfootdropwithsteppagegaitindicates:
PERONEALNERVECOMPRESSION
49y/ow/DM2presentswithsevereburningofsolesoffeetandinsomniab/cthe
touchofthesheetagainstthefeetispainful.Examshowsdecreasedsensationto
PERIPHERALNEUROPATHY
pinandtouchuptoankle,50%reductioninvibratorysenseatankleandimpaired
proprioceptionattoes.Anklejerksareabsent,butkneejerkspresent.Dx?
Resting,non-intentionaltremor
PARKINSON’SDISEASE
25y/oFwithLeyepainwhichincreaseswithmovingtheeye.Diminishedacuityin
Leye,pupilsconstrictwellwithlightonReye,butonlyconstrictweaklywithlight OPTICNEURITIS
onLeye.Dx?
75y/oWWIIveteranw/gradualonsetforgetfulness,intellectualdeterioration,
fast/slurredspeech,gaitimpaired,CTwithnormalatrophy.LP:35WBCs(most
lymph),protein110,increasedgammaglobulin.Dx?
NEUROSYPHILIS
Briefepisodesofsuddenlossofmuscletone,withintenseemotionare
characteristicof:
NARCOLEPSY
Termforsudden,irrepressibleshock-likecontractionofamuscletriggeredbyan
eventinCNS?
MYOCLONUS
20y/ooccasionaldoublevisionwhenlookingtoRandnormalacuityineacheye
alone.LptosisanddifficultykeepingLeyeadducted.Pupilsroundandreactive.
Speechnasalandneckflexorsweak.Noparesisorreflexabnormalitiesin
extremities.Dx?
MYASTHENIAGRAVIS
Firststepinthemanagementofacutemyastheniccrisis:
MECHANICALVENTILATION
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Diagnosticvalueassocw(+)transientparesisofarm/aphasiaafterepileptic
seizure:
HELPSLOCALIZETHEFOCUS
Triptandrugsshouldnotbegiveninabortivetreatmentofmigraineinptswith:
CAD
Femalewithvertigoanddiplopia,whenlookslefthasisolatedLeyenystagmus,
andcannotadductReye.Dx?
MULTIPLESCLEROSIS
41y/ochronicfatigue,cognitiveimpairment,reducedperceptualmotorspeed,
pooreffortmaintenance,andirritability(MRI:hyperintensityinfrontallobeand
whatlookslikeafingerprotrusion)
MULTIPLESCLEROSIS
Horner’ssyndromeischaracterizedby?
MIOSIS,PTOSIS,ANDANHIDROSISOFFOREHEAD
A57yoptdevelopsdroopingoftheReyelidfollowingmildnecktrauma.The
patient’sneurologicalexamisremarkableforasymmetricpupils,smallerontheR,
HORNER’SSYNDROME
mildeyelidptosisanddecreasedsweatingovertheRface.Thesefindingsare
consistentwithwhichofthefollowing?
DMptwithcreepingparesthesiasandburningpaininLanterolateralthigh.DTRs
normal,noweakness.Dx?
MERALGIAPARESTHETICA
Recurrentdeafness,tinnitusthenvertigo:
MENIERE’SDISEASE
Hippocampalatrophyhasbeenidentifiedinallofthefollowingdisorders:
MDD,ALZHEIMER’SDISEASE,PTSD.(NOTDISSOCIATIVE
AMNESIA)
Pts/psurgerydevelopsweaknessandwastingofsmallmusclesofthehandand
sensorylossoftheulnarborderofthehandandinnerforearm.Dx?
LOWERBRACHIALPLEXUSPARALYSIS
Ptwithdoublevisionwhenlookingtotheleftshowshereyesonprimarygaze.On
leftgazetherighteyefailstoadductandthereisnystagmusinthelefteye.On
INTERNUCLEAROPHTHALMOPLEGIA
rightgazeandverticalgazetheeyesmovenormally.Dx?
Whichmedicationreducesaccumulationofplaquesanddisabilityinpt’swith
relapsingremittingMS?
INTERFERONBETA-1A
3monthprogressivelimbweaknessL>R,problemsswallowing.NormalCN,
weaknessinneckextensormuscles,indistalandproximalmuscles(quadriceps,
feetdorsalflexors,extensorpollicislongus)andinwrist/fingerflexors.DTRs
normal.Motortone/coordination/gaitnormal.ElevatedCK.
INCLUSIONBODYMYOSITIS
Spinalfluidofpatientw/acuteinflammatorypolyneuropathyshows:
HIGHPROTEIN,NORMALCELLCOUNT
49y/optdevelopsseizuredisorderthatisdifficulttocontrol.CSFshows
lymphocyticpleocytosisandmanyRBC’s.MRI:T2hyperintensityintheLeft
temporallobe,withgadoliniumenhancementinthisareainT1weightedimage.
EEG:periodicdischarges.Dx?
HERPESSIMPLEXENCEPHALITIS
ProteinmutationassociatedwithAlzheimerdiseaseinpeopleyoungerthan60yo
AMYLOIDPRECURSOR
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Hyperkalemicperiodicparalysisandparamyotoniacongenitalareduetomutations
SODIUM
inthegeneforwhichofthefollowingionchannels?
Rightshoulderweaknessoninitialabductionandexternalrotationofthearmat
theshoulderjoint,aftercarryingsandbags.Affectnerve:
SUPRASCAPULAR
MentalstatuschangesafterCABG,fluentspeechandexcellentcomprehension,
inabilitytonamefingersandbodyparts,rightandleftorientationerrorsinability
towritedownthoughtsandcalculation,butwithgoodreadingcomprehension:
ANEMBOLICSTROKEAFFECTINGLEFTANGULARGYRUS
ReducesSxsduringacuteexacerbationofMS:
METHYLPREDNISONE
MirtazapinemediatesincreasedreleaseofNEandandserotoninthroughwhat
mechanism?
ALPHA-2ADRENERGICBLOCKADE
Youngadultw/headachebehindleftear.2dayslatertwistingofface.Impaired
tastesensation.Paralysisofforehead,lowerfaceonleft,incompleteclosureofleft GADOLINIUMENHANCEMENTOFLEFTFACIALNERVE
eyew/blinking.Nosensorydeficitorothercranialnervedeficit.MRIshows:
Electrophysiologicsignsofdenervation:
FIBRILLATIONANDPOSITIVESHARPWAVES
Shakinghands,increasedwhenusinghands/writing/volitionalactivities.Stress
worsens,wineimproves.Isfamilial.DX:
ESSENTIALTREMOR
Mostcommoncauseofasepticmeningitis:
ENTERICVIRUS
Whatdoesthecerebellumdointhehumanadultbrain?
DIVERSEROLESINMOVEMENT,BEHAVIOR,AND
LEARNING
25y/oMw7monthsdepression,forgetfulness,weightloss,insomnia,painful
tinglinginbothfeet+incoordination.InvoluntarychoreicmovementsofB/LUE,
apathetic,monosyllabic.Labsnormal.EEG:milddiffuseslowing.CT/MRInml.
Duringadmissiondevelopssevereakineticmutism,seizures,dies.Brainautopsy
shows:
DIFFUSEAMYLOIDPLAQUES,SPONGIFORMNEURONAL
DEGENERATION,ANDSEVEREASTROGLIOSIS
55y/ow/DMandHTNdevelopsRperiorbitalpainanddiplopia.Exam:paralysisof
DIABETIC6THNERVEPALSY
abductionofReye.
OrbitalpainwithLeyeparalysisofadductionandelevationoftheeyebutnormal
pupilfunction.Dx?
DIABETIC3RDNERVEPALSY
25y/optwithpaininLperiorbitalregion,followedbyblurringthenlossofvisionin
lefteye.ExamnormalbutnoreactionwhenlightshoneonLeye.Thisisconsistent DEMYELINATINGLESIONOFLEFTOPTICNERVE
with:
Seeninelectrophysiologictestinginmyastheniagravis
DECREMENTALRESPONSETOREPETITIVESTIMULATION
Involuntarysetofflowingjerkymovementsinmultiplejointsdescribe:
CHOREA
34y/optwpersistentnumbnessinthumb/forefinger/middlefinger/palmin4th
mopregnancy.Painradiatestoforearm,clumsiness&weaknesswholdingobjects. CARPALTUNNELSYNDROME
Dx?
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53y/ow/insidiousonsetofblurredvision,diplopiax1day,ptosis,CN6palsy,
unreactivepupils,hoarsevoice,dysarthria,weakneckmuscles.EMG-incampwith BOTULISM
repetitivenervestimulation.Dx?
Dxfor45yowomanw/pins&needlesfeelinginhandatnightanduponawakening CARPALTUNNELSYNDROME
5y/ocannotmaintaineyesopen,attemptstolookatperson/objectresultsintonic
eyelidclosure.Canwatchtelevisionw/odifficulty.ExtraocularmovementsNML.
BLEPHAROSPASM
Dx?
AdultLPwithopeningpressure190,protein110,glucose27,leukocytes5,000.Dx? BACTERIALMENINGITIS
75y/oM,Koreanwarveteran,withgradualdevelopmentofforgetfulnessand
cognitivedeterioration,presentswithveryfast/slurredspeechandimpairedgait.
AheadCTshowssomegeneralizedatrophy,unusualforhisage.TheLPshow35
NEUROSYPHILIS
WBC,lymphocytosisandtheproteinlevelis110mg/Dlandelevatedgamma
globulin.Dx:
Inabilitytocarryoutmotoractivitesonverbalcommanddespiteintact
comprehension&motorfunctionindicates?
APRAXIA
55y/optw/hxofweaknessandclumsinessxseveralmonths.Difficultyw/fine
motortasks.Armmusclestwitchandcrampeasily,weakening,atrophy.Sensory,
coordination,cranialnerveexamswnl.Underlyingillnessaffectsneuronalbodies
where?
ANTERIORHORNOFSPINALCORD,MEDIALBRAINSTEM
ANDCORTEX
Youngptrecoveringfromflu-likeillnessw/progressiveweaknessandnumbnessof
legsandfeet.Weaknessandnumbnessbelowmiddleofthorax.IncreasedLE
ACUTETRANSVERSEMYELITIS
DTR’s,extensorplantarreflexes.Urinaryincontinence.LP23mononuclearcells,
proteinlevel37,nmlglucose
Essentialcriterionfordeclarationofbraindeathpriortoorgandonationrequires? APOSITIVEAPNEATEST
41y/optw/ofamilyh/ocorticocerebellardegenerationpresentswith3-month
h/oataxiaofgait/limbs,dysarthria,andprogressivenystagmus.MRIandCSF
normal.1)Antibodypanelwithpresenceof?2)Whattypeoftumorislikely
present?
1)ANTI-YO
2)OVARIANCARCINOMA
TheusualtargetforDeepBrainStimulationinEssentialTremor:
VENTRALINTERMEDIATETHALAMUS
72-year-oldptpresentswithsubacuteonsetofprogressiveataxiaofgaitandlimbs.
Labtestingrevealsthepresenceofananti-Yoantibodyinserum.Whichofthe
CTSCANOFTHECHEST,ABDOMEN,ANDPELVIS
followingtestsshouldbeorderednext?
62y/optevaluatedforfrequentfallsw/olossofconsciousness.Ptwrigidity,
hallucinations.Threeepisodesofhallucinationsresolvedw/osequelae.Cause?
RISPERIDONE
Chronicperipheralneuropathyofinsidiousonset,symmetric,moreprominent
distallyinlimbs,legsmorethanarmsaffected,slowlyprogressive,withgreater
sensorythanmotorinvolvement,withinvolvementofperipheralsympathetic
nerves,andvariablelossofDTR,ismostlikelycausedbyagent:
ALCOHOL
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AmedicationtotreatMSisanintegrinantagonistthatprimarilyactsbyblocking
lymphocytesandmonocytesadhesiontotheendothelialcells:
NATALIZUMAB
Delayedneurologicaldeteriorationfollowingcarbonmonoxide-inducedcomais
mostlikelymanifestedby:
PARKINSONISM
Autosomalrecessivetrinucleotiderepeatexpansionisthemolecularetiologyof:
FRIEDRICHATAXIA
Distinguishingabsenceseizuresfrompartialcomplexseizures:
LACKOFPOSTICTALMANIFESTATIONS
Oneyearafterachievingmethamphetamineabstinence,thesecravingwillmost
likely:
DECREASEININTENSITY
Ptrecoveringfromsurgeryofanintracranialhemorrhage2/2arterialaneurysm,
developsasuddenonsetofheadache,vomitingandprogressivedeclineof
consciousness.Pupilsaremiotic,andabducensmusclesareweakbilaterally.
Etiology:
ACUTEHYDROCEPHALUS
50y/omanwacutonsetofnickpainradiatingdownleftarm,progressinggait
difficulty,urinaryincontinence.Whichtestshouldbeadministeredimmediately?
MRIofheadtoexcludedxofacutehydrocephalus
Neurotransmittermaintainsconsistentlevelswithage:
SEROTONIN
Whichneurotransmittersarereducedinquantity,uptakeandturnoveris
spasticity?
GLYCINE&GABA
ThecognitiveenhancementassociatedwithexperimentalD-cycloserinetreatment
inpt’swithschizophreniahasbeenattributedtoenhancementofNMDAreceptor GLYCINE
activitybywhichofthefollowingneurotransmitters?
Medicationforrestlesslegsyndrome:
RestlessLegssyndrome2/2medication
LocationofcharacteristiclesionsseeninCTscansofptwithcarbonmonoxide
poisoningassociatedcomas?
BROMOCRIPTINE
Antidepressants
GLOBUSPALLIDUS
Acuteonsetofleftfacialweaknessinvolvingtheforehead&perioralmusculature.
Onsetoffacialweaknesswasprecededbypaininleftearandmastoid,andby
BELL’SPALSY
sensationofdiscomfortintheleftearw/loudnoisesorlowpitchsounds.Dx?
Ptc/oinabilitytositstillanddescribesfeelinganinnertension.Examnotesptis
constantlyshiftingbodyandlegs.Pacedhallcontinuously.Receivedacourseof
neurolepticsuntilrecently.Dx?
AKATHISIA
Electrodiagnostictestfindingmostindicativeofademyelinatingneuropathic
process?
CONDUCTIONBLOCK
Ptdisplaysspasticgaitinwhichlegsarestiff,feetscrapeagainstfloor,andlegs
circumductwhicheachstep.Reflexesareincreasedandplantarresponsesare
extensorbilaterally.Dx?
CERVICALSPONDYLOSIS
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Causativeagentofprogressivemultifocalleukoencephalopathy(PML):
JCVIRUS
Ptpresentwithprogressiveweaknessofleftupperextremity,followedbytheright
upperextremity.+Musclewastingofbilateralarms.Upperandlowerextreflexes
AMYOTROPHICLATERALSCLEROSIS
increased,andplantarresponseareextensor.Normalnerveconductionstudies.
EMG:fibrillationsinarmandlegmuscles.Dx?
Ptc/ohearinglossonrightside.Whentuningforkheldatvertexofskull,pthears
soundbetterontheright.Whenforkisheldinfrontofthept’sears,ptreports
hearingitbetterontheleft.Dx?
CONDUCTIVEHEARINGLOSSONTHERIGHT
Pthassevereposturaltremorofupperextremitiesanddystonicposturingofthe
hands.Ptvoiceismildlydysarthric.Eyeshaveagoldenbrownlimbicring.Deep
tendonreflexesaremarkedlyincreased.ElevatedLFT’s.Dx?
WILSON’SDISEASE
14y/o@summercampdevelopssevereheadacheandfever,drowsiness,stiffness
ofneckonpassiveforwardflexion,petechialrashandskinpallor.Spinaltapreveals
MENINGOCOCCUS
openingpressure200mmH20,84%neutrophils(7,000nucleatedcells),glucose
levelof128mg/dl,andproteinlevelof33mg/dl.Mostlikelycausativeagent?
Transcutaneouselectricalnervestimulation(TENS)
FORPERIPHERALNEURALGIA
2monthsafterseverebraininjury,ptopenstheeyesforprolongedperiodsbut
remainsinattentive,doesnotspeak,andshowsnosignsofawarenessofthe
environmentorinnerneed.Ptiscapableofsomerudimentarybehaviorssuchas
MINIMALLYCONSCIOUSSTATE
followingasimplecommand,gesturing,orproducingsinglewordsorbriefphrases,
alwaysinaninconsistentwayfromoneexamtoanother.Whichofthefollowingis
themostaccuratedescriptionofthept’scondition?
Abundanthyperpigmentationspotspresentatbirthwithcutaneousand
subcutaneoustumorsappearingduringearlyandlatechildhoodandhamartomas
oftheirisarediagnosticofamutationinwhichgene?
NF-1(NEUROFIBROMATOSIS-IGENE)
Whywouldbrains>65yearsoldorahistoryofalcoholismmoresusceptibleto
chronicsubduralhematoma?
CORTICALATROPHY(LONGERDISTANCEFORBRIDGING
VEINSTOBEDAMAGED)
WhichofthefollowingtestsisrecommendedbytheAmericanAcademyof
Neurologytoestablishthediagnosisofbraindeath?
APNEATEST
26-year-oldobeseptpresentstoERwithsevereheadache.Ptisotherwisehealthy
anddoesnottakeanymeds.HeadCTandbrainMRIareunrevealing.Theonly
IDIOPATHICINTRACRANIALHYPERTENSION
findingonexamisshowninthefundoscopicimagesbelow(blurredopticdisk).
Whatisdiagnosis?
Apatientwithdaytimesleepiness,frequentnaps.Sleepstudiesshowsthatpt
entersREMwithin5minutesandwakesfrequentlyatnight.Whichtreatmentis
appropriate?
MODAFINILGIVENDOSEINTHEMORNING
ProgressiveLEstiffness&hyperreflexia(ankleclonus)withextensorplantar
responsesanddecreasedlight-touch&vibration/proprioceptioninb/lstocking
pattern?
Cobalamindeficiency
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106.Immunocompromisedpatientwithconfusionandmildheadache,b/l
papilledemaandcerebellarataxia.CSFstainshowspleocytosis,inc.protein,low
glucose?Indiainkstainshownbelow.Whatisdiagnosis?
Cryptococcus
119.Whichoffollowingisinvariablythefirstmanifestationofneurosyphilis?
Meningitis
Neurotransmitters
DAreleaseinwhatstructurerepresentscommonfinaleventassocwreinforcing
NUCLEUSACCUMBENS
effectsofopiates,cocaine,amphetamines,nicotine,PCP,andalcohol?(3x)
Principalmechanismofterminationofsynapticactivityofdopamineinprefrontal
cortex?
DIFFUSION
Wherearethemajorclustersofcellbodiescontainingserotonininbrain?
RAPHENUCLEUSINTHEBRAINSTEM
Aderivativeofwhichofthefollowingvitaminsisanecessarycofactorforthe
functionoftheenzymeglutamicaciddecarboxylase?
PYRIDOXINE
Whichofthefollowingneurohormonesisknowntomodulateimmunefunction,
hasanalgesicproperties,isderivedfromtheserotoninmolecule,andisapotent
antioxidantandfree-radicalscavenger?
MELATONIN
Whatneurotransmittershasbeenassociatedwithanxiety?
NOREPINEPHRINE
Positiveallostericmodulatorsofneurotransmitter-gated,multimericionchannels
dowhat?
INCREASEPROBABLILITYOFOPENINGINPRESENCEOF
ALIGAND
Asubstanceofabusewithpowerfulreinforcingeffect:
COCAINE
Whichofthefollowingistheprimarymechanismthroughwhichamphetamine
secrettheirstimulanteffect?
RELEASEOFCATECHOLAMIMES
NeurotransmitterthatchangesintheCSFofptswithIED:
SEROTONIN
Whatareaofthebodyhasthemostserotonin?
GITRACT
EEGfindingsinStageII(N2)sleep
K-COMPLEXESANDSLEEPSPINDLES
Neurotransmitterassocw/reward&reinforcementinnicotinedependence
DOPAMINE
25y/optwithsevereheadache,visualloss,vomiting,bilateralbabinski,andthen
becomesdrowsy:
EPENDYMOMAOFTHEFOURTHVENTRICLE
Whichneurotransmitterispredominantlyinhibitory?
GLYCINE
Inaddiction,dopaminergicneuronsprojecttonucleusaccumbens.Cellbodiesof
theseneuronsresideinwhichareaofbrain?
VentralTegmentalArea
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Radiology
WhichisanadvantageforCTheadvsMRI?
DIAGNOSINGACUTEEPIDURALHEMORRHAGE
GadoliniumcontrastinMRIscansismostspecificallyusefulfordiagnosingpatients
BLOODBRAINBARRIER
withdiseasesaffectingwhichofthefollowingstructures?
CTispreferableoverMRIinwhichsituation?
70Y/OFEMALEWHOFELLATHOMEANDNOWHAS
DEPRESSEDLEVELOFCONSCIOUSNESS
Neuroimagingthatmeasuresneuronalglucosemetabolism
PETSCAN
CTscanisbetterthanMRIforwhat?
DIFFERENTIATINGHEMORRHAGINGFROMEDEMA
65y/ohasfirstgeneralizedtonic-clonicSzseenbyspouseandtheyhavebeen
confusedandlethargicsince.Episodebeganw/repetitiveshakingofrightarm.
Bloodtestsunremarkableandnohxofotherrecentsymptoms,trauma,or
metabolicdisorders.Whatstudywilllikelyrevealcause?
BRAINMRI
WhatdoesfunctionalMRImeasure?
DETECTSBLOODFLOW
50y/optisintheEDforacuteonsetofneckpainradiatingdowntheleftarm,
progressivegaitdifficulty,andurinaryincontinence.Thistestshouldbe
administeredimmediately:
MRISCANOFTHECERVICALSPINETOEXCLUDEA
DIAGNOSISOFSPINALCORDCOMPRESSION.
Sleep
5y/owithscreaming/cryingfornoreasonabout1hourafterfallingasleep.Sits
upinbedwitheyesopen,trembling,sweating,mothercannotgainhisattention
SLEEPTERROR
for5minutes.Nonewstressors.Boyhasnomemoryoftheevent.PEnormal.
Dx?(4x)
Paralysiswhenawakening,lastsseveralminutes.Cansee/hearbutcannotmove
duringepisodes.Disappearsspontaneouslyorwhencalledbyhiswife.No
SLEEPPARALYSIS
hallucinations,nightmares,daytimesleepinessorh/ofalls.Neuroexamnormal
(4x)
Whatsleepstageisthemostimportantinrestoringthealteredfunctionsthat
resultfromprolongedsleepdeprivation?(3x)
STAGE4,NON-RAPIDEYEMOVEMENT
Medicalstudentasksforsomethingtohelpw/oattentionandalertness.Takinga
2-weekboardreviewcourseandstrugglestokeepupw/thepace.Sleeping
DYSSOMNIANOS
4hrs/night.Usuallysleeps8hr/night.Dx?(2x)
Age-relatedsleeppatternchange(2x)
GREATERWAKEFULNESSINTERMIXEDWITHSLEEP
Whataspectofsleepisincreasedinolderadults?(2x)
DURATIONOFAWAKENINGS
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WhatmedicationisbestfordecreasingnightmaresinPTSDpts?(2x)
PRAZOSIN
A35yorecurrentepisodesofawakeningduringsleepwakingupwithapanicked
screamandsweating,racingHR.cantremember,daytimedrowsinessaffecting
functioning,EEGnormal.Whatisthediagnosis?
SLEEPTERRORS
MosteffectivetreatmentforOSA
POSITIVEPRESSURETHERAPY
REMsleepisfirstevidentatwhichstageofdevelopment?
INUTERO
Ptworkingovertimedevelopsfrighteningnocturnalepisodescharacterizedby
semi-wakefulnessandinabilitytomove,accompaniedbythesensethatan
intruderispresent.Theptdeniesdaytimesleepattacksorsuddenlossofmotor
control.Bestinitialtx?
GETTINGSUFFICIENTSLEEP
Apatientreportsfeeling“irritable”withinabilitytosleepmorethananhourat
nightoneweekafterreceiving80mgprednisonedailyforapoisonivyrash.
BEGINTOGRADUALLYTAPERTHEPATIENTOFFOFTHE
PREDNISONE
MosteffectivetreatmentforREMsleepbehaviordisorders.
CLONAZEPAM
Whichofthefollowingaspectsofsleepisincreasedinolderadults?
SUBJECTIVEQUALITY
MDDhaswhatsleepabnormality?
SHORTENEDREMLATENCY,DECREASEDSTAGE4SLEEP,
INCREASEDAWAKENINGSINTHESECONDHALFOFTHE
NIGHT
REMsleepbehaviordisorderassociatedwithwhichpathology:
PARKINSON’SDISEASE
Involuntaryjerkingoflegswhilefallingasleep,notuncomfortable,stopswith
fallingasleep
NORMALPHENOMENON,NONPATHOLOGICAL
Predominantlynon-REMsleepproblem:
ENURESIS
Sinusoidalwavesat9-11HzonEEGis:
DEEPSLEEP
Mostcommonexplanationgivenbyindividuals>65yearsfordifficultymaintaining
NOCTURIA
sleep?
Whichofthefollowingisacharacteristicschangeonpolysomnogramassociated
withmajordepression?
SHORTREMLATENCY
67y/owithMDDdoingwellonSSRIbutcontinuestohaveinsomniaandsleepiness
BREATHING-RELATEDSLEEPDISORDER
duringday.Snoresloudly,morningheadaches,andnightsweats.Dx?
Whichofthefollowingmeasuresofrapideyemovement(REM)istypicallyreduced
SLEEPONSETTOREMONSET
inMDD?
AccordingtoDSM5,Lengthoftimeofsleepdifficultyfordiagnosisofinsomnia
3months
InsomniasecondarytodepressionwillmoreconsistentlyaffectREMsleepinwhich
REDUCEDLATENCYTOREMSLEEP
ofthefollowingways?
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17y/oMexperiencesa2monthperiodoflowenergy,drowsinesswithincreased
sleepdurationupto18hoursormoreaday.TheEEGshowsthatNREMandREM
cyclesarenormal,exceptforincreaseddurationofsleep.Mostlikelydiagnosis:
KLEIN-LEVINSYNDROME
Pts>65y/owchronicinsomniaaremostlikelytohavewhichpsychcomorbidity?
ALCOHOLABUSE
35y/optwithchronicinsomniahassleeptest,itshowsptfellasleepin10min,
slept
7hrswith90%efficiencywithfewawakenings.Ptreportsittook1hrtofallasleep
PARADOXICALINSOMNIA
withfrequentnighttimeawakeningsandlessthan2hrsofsleep.Medicaland
psychworkupneg.Whatexplainsdifferentbetweensleeplabfindingsandpt
report?
EEGcharacteristicofREMstageofsleep:
LOWVOLTAGEMIXEDFREQUENCYACTIVITYONEEG
Ptc/o6monthsofdifficultyfallingasleep.Despiteattemptstogotobedat
11:00pm,theptisunabletosleepbefore4:00am.Shethensleepswithout
interruptionbutcannotawakebefore11:00am.Thisresultsinproblemswith
tardinessatwork.Ptendorsesdaytimefatiguebutdenieschangesinmood,
appetiteorinterest.Dx?
CIRCADIANRHYTHMSLEEPDISORDER
Somnambulismduringchildhoodisassociatedwithwhichofthefollowingstages
ofsleepmeasuredbyanEEG?
STAGEIV
Nightterrorstypicallyappearwheninlife?
CHILDHOOD
42y/oanesthesiologistwithrepeatedepisodesoffallingasleepintheOR,mild
depression,irritabilityandmildcognitivetroubles.UDSisnegative.Hegained
substantialweightin18months,whichheattributestopooreatinghabits.Most
likelyDx:
BREATHING-RELATEDSLEEPD/O
REMsleepbehaviordisorderiscommonlyassociatedwithabnormalinclusions
containingwhichofthefollowingproteins?(2X)
SYNUCLEIN
Acharacteristicofnon-REMsleep?
DECREASEDRECALLOFDREAMACTIVITY
Whichmedicationismosteffectiveinthetreatmentofcataplexy?
CLOMIPRAMINE(TCAs2/2TOINCNE)
51y/optw/dysthymicdisorderhasrespondedwelltocitalopram.However,thept
continuestocomplainofmorningheadaches,anxietyanddaytimefatigue.The
psychiatristprescribesclonazepamandtheptimmediatelyreportsprofound
SLEEPAPNEA
daytimesedation.Thedifferentialdx,inadditiontoadirectsedativeeffectofthe
drug,shouldinclude:
Ptp/wcomplaintsofexcessivedaytimesleepiness,morningheadaches,and
OBSTRUCTIVESLEEPAPNEA
excessivenighttimesweating.Symptomsareconsistentwithwhichsleepdisorder?
Whichofthefollowingischaracteristicofsleepinindividualsovertheageof65,as
INCREASEDFRAGMENTATION
comparedtothatofyoungadults?
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Ptreportsinsomnia,frequentnighttimeawakenings,andexcessivedaytime
sleepiness.Sleepstudyrevealsbrieflowerexternaljerkswithbriefrepeated
arousals.Ptisunawareofthesemovements.Whichdxismostconsistentwithpt
presentation?
PERIODICLIMBMOVEMENTS
Aptpresentswithahxofirresistibleepisodicsleepinessthatisaccompaniedbya
vivid,dreamlikestateattheonsetofanepisode.Whichofthefollowingadditional SLEEPPARALYSIS
sleepsymptomsarelikelytobepresent?
10yoboyprimarynocutrnalenuresis,isdrydurringday,nourgency,frequency,
dysuria.Fatherhadsameatage12.Nootherissues,wantstostopbedwettingto
gotocamp.Whatisthenextstep?
TrialofDDAVP
Whichmedicationforinsomniaismostlikelytocauseamnesticcognitive
impairment?
TEMAZEPAM
17yowithincreasedsleepdurationto18hours,lethargyandcognitiveslowing.
SleepEEGisnormal.
KLINE-LEVINSYNDROME
Theevidencesuggeststhataftercompletingtreatmentforinsomnia,longterm
outcomesarebetteramongpatientswithwhichmedication/theray?
CBT
EEGbiofeedbackmoreeffectivethanprogressivemusclerelaxationintreating?
INSOMNIA
35y/owdailyheadachesoverlastseveralweekslastinganhour.Sharp,severe,
boringpainintorighteye.Anotherelementofthisheadache?
OccursduringREM
TreatmentforRLS
Pramipexole
65yop/wpillow-punching(xseveralmonths)inhissleepwithsuddenawakening
fromdreamsinvolvingpursuitbyassailants.Dx?
REMbehaviord/o
16yroldhearsmusicandhisnameatnight,duringwhichofthefollowingstagesof
N1
sleepifhypnagogichallucinations?
PhysiologicchangesduringREMsleep
IncreasedHeartRate,increasedeyemovements,
decreasedmuscletone
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AxisIDisorders
AcuteStressDisorder
32y/ow/nopsychiatrichistorybroughttoERwith2daysofmemoryloss,
insomnia,poorappetite,anddifficultyperformingdailyroutines.Subjectivesense
ofnumbing,detachment,andanxiety.Oneweekearlierptwitnessedherchild
ACUTESTRESSDISORDER
beingfatallyinjuredinamotorvehicleaccident.Alllabsandscansnormal.Dx?
(4x)
Whatsymptomismorelikelytooccurinacutestressd/othaninPTSD?
REDUCTIONINAWARENESSOFSURROUNDINGS
Importantdeterminantfactortowhetheranindividualwhowasexposedtotrauma
SEVERITYANDPROXIMITYOFTRAUMA
willdevelopPTSD?
Acutestressd/odifferentiatedfromPTSDby
DURATIONOFSYMPTOMS
29y/optreportshavingbeenrobbedatknifepointalmostamonthago.Ptescaped
unharmed,buthasbeenexperiencingasenseofunreality,detachment,and
ACUTESTRESSDISORDER
dampenedemotionsthatisinterspersedwithperiodsofintensephysiological
arousal.Thesesymptomsarecausingdifficultiesatwork.ThemostlikelyDx?
ADHD
7y/ochildBIBparentsreporthe’sbeenhyperactivesinceage4,talksconstantly,
interrupts,hastroublesittingstilltodohomework,willnotplayquietlyoutdoors. TEACHERREPORT
WhatelsedoyouneedtomaketheDxofADHD?(4x)
StudiesshoweffectiveinterventionforchildrenwithADHDistoinvolvetheir
parentsinwhatpartofTx?(4x)
BEHAVIORALMANAGEMENT
ChildwADHDineffectiveTxwithmethylphenidate.Nextstepinmanagement:(4x) DEXTROAMPHETAMINE
ChildwADHDnotrespondtomethylphenidateIR.Whatmedtotrynext(3x)
MIXEDAMPHETAMINESALTS
WhataspectofADHDismostlikelytoimproveaschildrenage?(3x)
HYPERACTIVITY
Atomoxetine’sprincipalmechanismofactionexertsatherapeuticactionbecause ISASELECTIVENOREPINEPHRINEREUPTAKE
it:(2x)
INHIBITOR.
AtomoxetineismostlikelytobeconsideredasinitialtreatmentinADHDin
adolescentswith:(2x)
SUBSTANCEUSED/O
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ThemultimodalTxstudyofchildrenw/ADHDexaminedthecomparative
responsesover14monthsofchildrentomedicationandintensepsychosocial
interventions.Whatdidthefindingsofthestudyrevealw/respecttoADHD
symptomchanges?(2x)
MEDICATIONMANAGEMENTISSUPERIORTO
COMMUNITYCARETREATMENT
WhichperinatalfactorisspecificallyassociatedwithdevelopmentofADHD?
MATERNALTOBACCOUSEPRENATALLY
ThecomponentofADHDthatismostlikelytoremaininadulthood:
INATTENTION
WhichDSM-Vdiagnosisrequiressymptomstobepresentin2ormoresettings?
ATTENTION-DEFICITHYPERACTIVITYDISORDER(ADHD)
CurrentthinkingaboutrelationshipbetweenADHDinchildrenandadults:
SIGNIFICANTNUMBEROFCHILDRENWILLGOONTO
BECOMEADULTSWITHADHD
8y/oboyw/ADHD,oppositionaldefiantdisorder,andchronicmotorticdisorder
hasworseningofhisticsonagooddoseofastimulantthatseemstocontrolhis
ADHD.Howdoyoumanagethisfurtherintryingtoimprovethetics?
MONITORTHETICSONLY
WhichcomorbiddiagnosisofchildhoodADHDworsenstheprognosisinto
adolescenceandadulthoodtothegreatestdegree?
CONDUCTDISORDER
32y/ow/ADHDmixedtypeaschild.AsadultstillhasSx.Tx:
METHYLPHENIDATE
Whichmedwouldyouprescribefor20y/ocollegestudentbeingworriedoverhis
grades?Hecomplainsthathehasnotbeenabletofocusonstudyingandthathis
mindwandersfrequentlyduringclasses.Hisenergylevelislow.Hesleepswelland
hisappetiteisgood.Historyindicateshewastreatedwithstimulantssincesecond
grade.
METHYLPHENIDATE
10yowADHDandaggressiveoutburstisstartedonamoderatedoseofastimulant.
ADHDsymptomshaveimproved,butaggressionhasnot.Inadditiontobehavioral MAXIMIZEDOSAGEOFLONGACTINGSTIMULANT
intervention,whatisthenextbeststeptomanageboththeADHDandaggression?
WhichpsychiatricdisorderiscomorbidwithADHD?
DISRUPTIVEBEHAVIORDISORDERS
Whichofthefollowingsideeffectscanresultfromstimulantmedicationtreatment
andwarrantsimmediatediscontinuationofthemedicationandareassessmentof
thetreatmentplan?
HALLUCINATIONS
AbnormalLFTswouldbemostcommonlyassociatedw/whatmedicationusedto
treatADHDinchildren/adol?
PEMOLINE
ADHDcomorbiddisorder
DEPRESSION
Theseempiricalnon-stimulantmedshaveempiricalsupporttotreatADHD:
CLONIDINE,BUPROPION,IMIPRAMINE,ATOMOXETINE
WhatprocedureisnecessarytodiagnosechildhoodADHD?
CLINICALINTERVIEWOFPARENTSANDCHILD
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Parentsbringtheir10yochildforanevalduetoconcernsaboutchild’sreported
difficultypayingattentioninaclassandcompletingassignmentsintheexpected
time.Parentsreportthatthechildhastroublestayingontaskwhiledoing
homeworkandtheyareconcernedthatthechildhasanattentiondisorder.Atthe RATINGDISCREPANCIESBYDIFFERENTOBSERVERSARE
completionoftheeval,thepsychiatristrequeststhatbothaparentandateacherfill COMMONINCLINICALPRACTICE.
outaratingscale.Theparentratingsfallintotheclinicalrangebuttheteacher’s
ratingsdonotmeetcriteriaforaclinicalproblem.Howshouldthepsychiatrist
accountforthedifferencesinobservedratings?
AntidepressantforADHD
BUPROPION
THEEQUIVALENCEOFCOMBINEDMETHYLPHENIDATE
WithrespecttoADHDsymptoms,the1999multimodaltreatmentstudyofchildren
ANDPSYCHOSOCIALTREATMENTCOMPAREDTO
withADHDwasmostnotablefordemonstratingwhichofthefollowing?
MEDICATIONALONE
Whichofthefollowinginstrumentsismosthelpfulintheassessmentofchildren
suspectedofhavingADHD?
CONNERSTEACHERRATINGSCALE
WhatmedusedforADHDhasbeenassociatedwithliverdamage?
ATOMOXETINE(STRATTERA)
11y/owithreadingdisability.Mostlikelycomorbiddx:
ADHD
DescribestherelationshipofstimulanttreatmentofchildrenwithADHDandthe
emergenceand/orpresenceofticd/o:
TREATMENTWITHSTIMULANTSHASBEENSHOWNTO
REDUCETICSINCHILDRENWITHCOMORBIDADHDAND
TICD/O.
WhatDSM-IV-TRdisorderrequiressymptomstobepresentintwoormoresettings? ADHD
12yocomesinforworseningattention,impulsive,andhyperactive.Heissnoring
andhardtowakeintheAM.Centraladiposity,broadbasedneckandenlarged
tonsils.examisunremarkable.InchildwithADHDandsleepproblems,whatisthe
mostaccurateaboutADHDandsleepinthispatient?
CORRECTINGTHEUNDERLYINGSLEEPDISORDERCAN
IMPROVEADHDSYMPTOMS
5y/oisevaluatedforADHD.Parentscomplainthatthechildhasmultiplesymptoms
ofhyperactivity,impulsivity,inattention,anddistractibility.Parentsalsobring
CHILDRENWITHADHDCANPRESENTWITHBRIEF
teacherfeedbackreportsthatconfirmthesesymptomsandstatechildisfailing
PERIODSOFHEIGHTENEDFOCUSANDCALM,
academicallyandhavingsocialproblems.InpsychMDofficechildisquiet,calmand
ESPECIALLYINASTRUCTUREDSETTING.
cooperative,andveryengaging.Thedifferenceinclinicalpresentationfromparent
andschoolreportsismostlikelybecause:
Failinggrades,poororganization,spendingsprees,spontaneoustripsditchingclass,
ADHD
fidgety,euthymic.Nochangeinsleep,appetite,noanhedonia.Dx?
WhencomparedtotheothersubtypesofADHD,childrenwiththeinattentive
subtypehavehigherratesofanxietyandsomaticcomplaintsand
LEARNINGDISORDERS
Evidencebasedtherapytreatmentforticdisorderinchildren
HABITREVERSALTHERAPY
DSM5priorageofpresentationADHDsymptoms
IncreasedrateofcomorbiditywithADHD?
12yo
AnxietyorOppositionaldefiant
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3010yroldchild,3yrhxofinvoluntarymovementsandvocalizations,symptoms
waxandwanebutneverdisappeared,childisawareofsymptomsandonlymildly
distressed,academicperformanceisbelowaverage,whatistheco-occurring
disordermostlikelycausingthisfunctionalimpairmentatschool?
ADHD
WhatdistinguishesADHDinchildrenvsadults?
Hyperactivity
AnxietyDisorders
Whichofthefollowingstrategiesexemplifiesuseofreciprocalinhibitionbyapatient Rehearsingmentalimagesofpleasurableexperiences
toattenuateanxiety?
whileattendingtheparty
Adiagnosticfeatureofpanicattackis:(2x)
DEREALIZATION
Whichofthefollowingistheinitialtreatmentofchoiceformildanxietydisorders
PSYCHOTHERAPYALONE
inchildren?(2x)
Thekeydistinctioninthedifferentialdiagnosisofsocialphobiaversus
agoraphobiais:(2x)
NATUREOFTHEFEAREDOBJECT
Besttherapyforpatientwithillnessanxietydisorder
CBT
DifferentialDxofanxietyintheERtypicallyincludes:
PULMONARYEMBOLISM
Theparentofa43y/optdied5yearsagofrompancreaticcancer.4yearsago
patientbeganfeelingfullaftereatinglargefattymeals,fearingitwaspancreatic
cancer.Constantlyweighshimselfsothatheisnotlosingweight.Nowavoids
goingtodoctortoavoidbeingdiagnosedwithcancer.Nootherpsychiatric
symptoms.Whatisdiagnosis?
Illnessanxietydisorder
Treatmentforsevereperformanceanxiety
PROPRANOLOL
36y/owithseveralepisodesofpalpitations,sweating,trembling,SOB.Work
sufferingduetoanxiety.InitialTxregimen:
PAROXETINEANDCBT
WhichofthefollowingagentshasbeenshowntoaugmenttheeffectsofCBTon
anxietydisorders?
D-CYCLOSERINE
A28yoptpresentswitha1yearhistoryofagoraphobia.Theptisabletodriveto
thelocaldrugstore,butonlywithconsiderablepre-travelapprehension.Theptwill
venturealonenofurtherthenwithin~5milesofhome.Personalhistoryofpanic
attacksordepressionisdenied,althoughfamilyhistoryispositivefordepression
andalcoholism.Thepthashadnoprevioustreatment.Thebestinitialtreatment,
andonethatoffersthebestlong-termprognosisforthispatientis?
SSRIandBZD
Weightloss,3-monthhxofanxiety,milddepression,&insomnia,thin,elevatedHR,
HYPERTHYROIDISM
lowBP,mildtremor
Prevalenceofseparationanxietyd/oandGADinchildrenfollowswhatpatternwith GADINCREASESWITHAGEWHILESEPARATIONANXIETY
regardtoage?
DECREASESWITHAGE
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28y/optpresentsw/1yrhxofagoraphobia.Ptisabletodrivetothelocaldrug
store,butonlywithconsiderablepre-travelapprehension.Ptwillventurealoneno
furtherthanwithinapproximately5milesofhome.Personalhistoryofpanicattacks
CBT,INCLUDINGEXPOSURE
ordepressionisdenied,althoughfamilyhistoryispositivefordepressionand
alcoholism.Pthashadnoprevioustreatment.Thebestinitialtreatment,andone
thatoffersthebestlong-termprognosisforthisptis:
14y/optwithalong-standingh/oofperfectionismhasrecentlydevelopedafearof
talkinginclassafterforgettingherlinesinaschoolplay.Ptsays,“Idon’tliketalking
SOCIALPHOBIA
tootherkids”andpracticesreadingaloudoverandoverso“IrememberwhatIam
saying.”Dx:
Ptpresentswithchappedandreddenedhands.Uponquestioning,ptadmitsto
washingthehandsmanytimesadaybecause“Iworkinahospitalcafeteriaandam SPECIFICPHOBIA
intenselyafraidofcontractingaflesh-eatingbacterialinfection.”ThemostlikelyDx:
InsomeJapaneseandKoreancultures,ratherthananintensefearofembarrassing
oneselfsocially,socialphobiasymptomsmayinsteadmanifestwithintensefearof
what?
OFFENDINGOTHERS
Whichofthefollowingisacommonmedicalcauseofanxietyinaptdyingofcancer? POORLYCONTROLLEDPAIN
Ptswithbloodphobiahave2stageresponsewhenexposedtostimulus.Firstis
increasedanxietyandelevatedBP.2ndresponse?
HYPOTENSION
6y/ochildgenerallyhealthythrowsafiteverytimefamilygoeshiking.Exposureto
snakeononehikeledchildtobecomeloud,agitated.Nowchildhasintensedistress SPECIFICPHOBIA
whenhiking,pleadstostaywithparentsatalltimes.Dx?
18y/orestless,feelsmindgoingblank,poorconcentration,irritability,insomnia,
fatigue>1yr,usedtobegoodstudentupuntil2-3yrsago,nosubstanceuse
GAD
CorefeatureofGAD
EXCESSIVEWORRYING
PtwithOCDresistanttoenteringtreatmentisacandidatefor:
MOTIVATIONALINTERVIEWING
35y/otruckdriverdiagnosedw/GAD.Doesnotwantmedthatcausessleepiness:
BUSPAR
EpisodicOCDwithvariableseverityofSxs,independentofTx,ismorecommonin:
BIPOLARMOODDISORDER
WhichTCAhasconsistentlybeenfoundtobeusefulinlongtermtreatmentand
relapsepreventionofOCD?
CLOMIPRAMINE
TheChild-AdolescentAnxietyMultimodalStudy(CAMS)comparedsertraline,CBT,
andcombinationtherapyinchildren/adolescentswithmoderate/severeGAD,SAD,
andSocialPhobia.Primaryfindings?
COMBINATIONTREATMENTSUPERIORTO
MONOTHERAPY
PsychMDwasconsultedforanxietyanddepression.Ptreportsseverepainand
indicatesthatdoctorsrefusetoprescribeenoughmedicationtocontrolpain.A
factorimportantforpsychiatristtoconsider:
ACUTEPAINISOFTENUNDERTREATED,ANDPOORPAIN
MANAGEMENTCANCONTRIBUTETOANXIETYAND
DEPRESSION.
Ptwithleukemiaunderwentmarrowtransplant.Psychconsulted.Ptmoreanxious
ADJUSTMENTDISORDERWITHANXIETY
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andfearfulaboutleavinghospital.Havingtroublesleeping.MSEunremarkable.Dx?
7y/ogirldislikesgoingtoherfriend’shouse,preferringherfriendscometoher
home.Shehasrecentlyhadastomachacheinthemorningbeforeattendingschool
andsometimescriesuncontrollablyifhermotherinsistssheattends.Teachers
reportsafterhermomleavesheusuallysettlesdownanddoesacademicallywell.
Dx?
SEPARATIONANXIETYDISORDER
Diagnoseachildwhopersistentlyrefusestoattendschoolorsleepinbedalone,
complainingofsomaticsymptomswithnophysiologicalorigin?
SEPARATIONANXIETY
Whichofthefollowingisamanifestationofunresolvedgriefinaschool-agechild
whohasexperiencethelossofasibling?
SEPARATIONANXIETYFROMPARENTS
A45yroldpt,terminatedtreatmentwithpreviousPCP"becausehedidn’ttakemy
concernsseriously."Ptbelieveshehasdreadedillnessandstomachcancer,denies
allsymptomsandlabsarenormal,diagnosis?
ILLNESSANXIETYDISORDER
Generalizedanxietydisorderischaracterizedbyexcessiveworryingalongwithwhat
BEINGEASILYFATIGUEDANDFEELINGKEYEDUP
combinationofsymptoms?
Childhooddisorderwithgreatestgeneticassociationforadultonsetpanicattacks?
separationanxietydisorder
EEG-biofeedbacktrainingisefficaciousforwhatd/o?
GAD
8yop/w“alwaysworried”andfearinggettinglostorbeingkidnapped,frequently
insistingonsleepinginparent’sroom(doeswellacademically&interactswithcircle Separationanxietydisorder
offriends,butfrequentlyc/oHAandvisitingschoolnurseofficetocallparent)
A19-yocollegestudentcomplainsof“difficultyconcentratingandmymindgoing
blankwhenItrytostudy.”Shefeelsrestless,keyedupandworriesexcessively.DoesGeneralizedanxietydisorder
notusesubstances.
55yroldHispanicAmericanbroughttopsychiatristbyfamily,spellsofuncontrollable
shouting,crying,trembling,insomnia,ptfeelschestheatgoinguptohead,ptand ANXIETYDISORDER
familybelieveptissufferingataquedenervios,ptmeetscriteriafor?
9yrwithbehavioralproblemsfor4yrs,athomeandschool,irritability,anger,verbal
outbursts,waspreviouslysocial,askedtoleaveteams,uncooperativewithparents, anxiety
whichdisorderwillhehavebythetimehereachedyoungadulthood?
BipolarDisorder
Whatpredictsbipolarityinadolescentwithdepression?(2x)
PSYCHOTICSYMPTOMS
40y/ow/6kids:insomnia,poorappetite,dizziness/nausea,thinkshusbandis
poisoningher.Despiteallclassesofmedsmarkedfluctuationsfromsadnessto
euphoria5xduringtheyear.Dx?(2x)
BIPOLARW/RAPIDCYCLING
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24-year-oldw/1monthincreasingfatigue,difficultyfallingasleep,poormotivation,
andtroublepayingattentioninnightschool.Nopersonalorfamilyhxofdepression.
RxMirtazapine15mgqhs.Aftertwodoses,ptbecomeseuphoric,hyperactive,
SUBSTANCE-INDUCEDBIPOLARDISORDER
talkative,andfullofcreativeideas.Ptstoodonachairatnightschoolandoffered
heartycongratulationstoteacherforcontributingtopt’scertainfuturesuccess.
Mostlikelydx?
Lamotrigineiseffectivetreatmentforwhatmooddisorder?
BIPOLARDEPRESSION
Whichmedistreatmentofchoiceforbipolarwithrapidcycling?
VALPROATE
Psychiatrististreatingptwithbipolardisorderwhoseconditionisrelativelystable,
recentlyreportsfeelingdepressed.Thepsychiatristisconsideringadding
lamotrigine,howeverisconcerneditmayinteractwithptscurrentmeds.Which
medicationinteractionispsychiatristconcernedabout?
VALPROATE
Manicepisodewhileoncarbamazepine.Goodresponsein2wks.4wksrecurrence. AUTOINDUCTIONOFEPOXIDEPATHWAY
Whatismosteffectiveandrapidintreatmentofmania?
COMBINEDANTIPSYCHOTICMEDICATIONWITH
LITHIUMORVALPROATE
Bipolarptw/2hospitalizationsformaniatakinglithium
NEEDSLIFETIMELITHIUMTREATMENT
First-degreerelativesofpatientwithBMDIIhaveahigherincidenceofwhat
disorder?
MDD
Whatdrugisgoodforacutemania?
LITHIUM
Thenaturalcourseofanuntreatedmanicepisodelastsapproximatelywhatlength
oftime?
3MONTHS
Whichofthefollowingbaselinelevelsshouldbeassessedpriortostartinglithium
treatment?
TSH
Thepresenceofadverselifeeventshasbeenassociatedwithprecipitationofwhich
DEPRESSIVEEPISODE
ofthefollowingaspectsofbipolardisorder?
AccordingtotheAACAPPracticeParameters,diagnosisofbipolardisorder,typeIin ADISTINCTPERIODOFABNORMALMOODAND
childrenrequireswhichofthefollowing?
EPISODICSYMPTOMS
Onecontroversyaboutpediatricbipolardisorderiswhethersevereirritabilityand
emotionaldysregulationare:
PREDICTIVEOFCLASSICBIPOLARDISORDERIN
ADULTHOOD
32y/ow/diarrheax2wks,isanxious,andnotorientedtodate/timeofday.Taking
“somedrug”forBMDandpatientdoubledherdoseamonthagowhenshefeltshe LITHIUM
wasn’tgettingbetterfastenough.WhatmedcausedtheseSx?
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42y/optwithepisodesoffeeling“sadanddown”accompaniedbydecreased
energy/interestinactivities.Ptestimatestheseepisodesoccurredatleastfourtimes
inhislife,lasting2-3weeksatatime.Duringepisodes,spendsmostofthetimein
bed.Mostrecentepisodeofsxended1weekago.Sincethen,ptreportsfeeling
BIPOLARIIDISORDER
energeticand“ontopoftheworld.”Henowsleepsonly1-2hoursanight,wakes
feelingrefreshed.Friendsremarkptseemsflighty,butptnotesnodeleteriouseffect
ofthemoodchangeandfindsthathisproductivityatworkisthebestithasever
been.MostlikelyDx:
29y/optisadmittedtothehospitalwitha1weekhistoryofeuphoria,insomnia,
pressuredspeech,andgrandiosity.PthasdelusionsofbeingmonitoredbytheFBI,
andthestaffobservesptrespondingtounseenothers.Inadditiontothese
symptoms,whatisrequiredfordiagnosisofSCHIZOAFFECTIVEdisorder?
PresenceofPSYCHOTICSYMPTOMSforatleast2
WEEKSintheABSENCEofMOODSYMPTOMS
WhichmedhasFDAapprovalfortxofmaniainchildren12yearsofageorolder?
LITHIUM
27y/optw/BMDI,hasbeenstabilizedasanoutptonemonthfollowinga
hospitalization,andisnowreceivingweeklymedmanagementandsupportive
CALLTHEPTTOEXPRESSCONCERNANDFINDOUTWHY
psychotherapy.Pthasbeeneuthymicforthepast2wks,buttodaydoesnotshow
THEPTDIDNOTMAKETHEAPPOINTMENT
upforascheduledappointment.Themostappropriateresponsebythepsychiatrist
is?
BMDIIwithrapidcyclinghavehigherprevalenceofwhatendocrinologic
dysfunction?
HYPOTHYROIDISM
Thisisariskfactorfortherapidcyclingformofbipolardisorder
FEMALESEX
WhatsymptomsareseeninamanicepisodebutnotinMDE?
FLIGHTOFIDEAS
Suggestunderlyingbipolarin27y/oFwhopresentsw/firstmajordepressive
episode:
FAMILYHXOFBIPOLAR
Txofacutemaniaw/lithium.Whatisthebestadjunctiveagent?
ECT
Bipolarw/4+manicepisodes/yrfor3yrs.Treatmentofchoice?
CARBAMAZEPINE,1200mgDAILY
DSM-IVdefinesh/omajordepressionplushxofmixedmanicanddepressive
episodeas:
BIPOALRDISORDER,TYPEI
Unlikeadultswithbipolardisorder,prepubertalchildrenwithbipolardisorderare
believedtohave:
PREDOMINANTLYCHRONICMIXEDMANICSTATES
HxofMDD,irritable,restless,distractible,insomnia,poorappetite,guilt,impulsive
spending
BIPOLARD/O,MIXED
Postpartumpsychosisisoftenassociatedwithwhichofthefollowingdisorders?
(x2)
BIPOLAR
Maleandfemaleprevalenceratesarecomparableforwhichofthefollowing
disorders?
BIPOLARDISORDER
Medicationthatincreasesserumleveloflamictal?
VALPROATE
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DelusionalDisorders
80yomaletellsPCPhethinkshiswifeof55yearsishavinganaffair,wifeandtwo
middleagedchildrendisagree.Ptacknowledgesnoclearevidenceofhisbelief.Ptis
DELUSIONALDISORDER
healthy,nopsychhistory,nohallucinations,cognitivetestingisnormalforage.
Whatishismostlikelydiagnosis?
Termforunreasonableandsustainedbeliefthatpatientacknowledgesmaynotbe
truewhenchallenged
OVERVALUEDIDEA
Lengthoftimecriteriafordelusionald/o
ONEMONTH
Bodydysmorphicd/ovs.Delusionald/osomatictype:
INTENSITYWWHICHPTINSISTSONPERCEIVEDBODY
DEFICITS
Complaintsofskininfectionwithinsects,negativemedicalw/u:
DELUSIONALD/O,SOMATICTYPE
Normalmale,exceptthatheisparanoidaboutwifecheatingonhim:
DELUSIONALD/O
26yoptthinkshisbrowbridgeistooprominentandlookslikeaneanderthal.
PhysicianfindsbrowbridgeprominentbutWNL.Ptwantsplasticsurgeryconsult.
Whatbestdescribesthept’sbelief?
OVERVALUEDIDEA
Erotomaniareferstowhichofthefollowingconditions?
DELUSIONSOFASECRETLOVER
Isolatederotomaniaisaformofwhat?
DELUSIONALD/O
Ptscomplainofhavinglostnotonlypossessions,status,andstrength,butalso
heart,blood,andintestinesufferfromwhichofthefollowingsyndromes?
COTARD
PtbelievesheistheSonofGod.ThisSxiscalled:
DELUSION
Immediateinterventionincaseofaptwithparanoiddelusionandideaofreference:
ASKINGFORDETAILSOFPERCEPTIONTHATLEDTOTHIS
DISTRESSINGDISCOVERY.
Themostimportantriskfactorfordevelopingpostpartumpsychosis:
PREVIOUSPOSTPARTUMPSYCHOSIS
Ptreportsthecontinuingsuspicionthatthespouseiscommittingadultery,but
acknowledgesthepossibilityofbeingwrongsincethereisnoevidencetosupport OVERVALUEDIDEA
thept’sbelief:(x2)
20yoJapaneseAmericanpatientpresentofcomplainingofpersonalbodyodorthat SOCIALPHOBIA,BODYDYSMORPHICDISORDER,
isoffensivetootherpeople.ThisismostoftencomparedtothisDSMdiagnosis?
DELUSIONALDISORDER(SOMATICTYPE)
Apatientwithsomaticdelusionaldisorderrefusingtoseeapsychiatristbutseesa
SUGGESTTHATTHEDERMATOLOGISTASKABOUT
dermatologistregularly.Whatshouldthepsychiatristrecommendthedermatologist
DRUGUSE
do?
Beliefthattelevisionissendingyouspecialmessages
Delusionofreference
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A20y/ofemalepatientreportsmensesstopped4monthsagoandshe’s
pregnant.Reportsmorningsicknessandvomiting,biggerbreasts.Pregnancytest PSEUDOCYESIS
negative,ultrasoundnegative,stillthinksshe’spregnant.What’sthediagnosis
Depression
Whichisassociatedw/worsenedretrogradeamnesiaduringECT?(5x)
BILATERALELECTRODEPLACEMENT
Inlearnedhelplessnessmodel,thebehavioraldeficitsinanimalsexposedto
uncontrollablestressisreversedby?(4x)
ANTIDEPRESSANTS
65y/ohadMDDbutwastreatedw/CBTtoremission.Usuallyhas1glassofwine
w/dinner.Samelevelofdrinkingformanyyears.Familyh/odementiainboth
parents.Advice?(3x)
CONTINUETHEALCOHOLASLONGASTHEPATTERN
OFUSEDOESNOTCHANGE
Whichd/oistreatedw/lighttherapy?(3x)
SEASONALAFFECTIVEDISORDER
79y/oasksforevalforSTD.Upsetandguiltyaboutanaffair.Spousesaysaffair
happenedmanyyearsago.Ptissadbutnotconfused.Dx?(2x)
MAJORDEPRESSIONWITHPSYCHOSIS
WhichdepressivesymptomisamelancholicfeaturespecifierinDSM-IV?(2x)
LACKOFPLEASURE
60y/ow/depressivesyndromehasmemoryproblems.Incorrectondate,messes
upserialsevens,spellsbackwards,butslowly.After4wksoftrazodone,both
PSEUDODEMENTIA
moodandcognitionareimproved.Dx?(2x)
Depressionincreasesriskofmortalityfromwhatdisease?(2x)
ISCHEMICHEARTDISEASE
HepatitisCtreatmentwithinterferoncancausewhatpsychiatricsymptom?(3x)
DEPRESSION
50y/oPTw/depressionbelievesthatheisresponsibleforthedestructionofthe
world.Thisisanexampleof:(2x)
MOOD-CONGRUENTDELUSION
Insteadofdepressedmood,childrenwMDDmayprimarilyshow:(2x)
IRRITABILITY
Whatmedicationmaycausemoodd/oinptsbeingtreatedformelanoma?Also
worsensfatigueandcognitiveinefficiency:(2x)
INTERFERON
Thetreatmentforadolescentswithdepressionstudyrecommendedwhichofthe
followingtreatmentsforpatientswithmoderatetoseveredepression?(2x)
FLUOXETINEANDCBT
Depression,accordingtoBeck’smodelisamanifestationof:(2x)
DISTORTEDNEGATIVETHOUGHTS(COGNITIVE
DISTORTIONS)
Whichofthefollowingcharacteristicsisconsideredparticularlylikelytobefound
INTERPERSONALREJECTIONSENSITIVITY
inpatientswithMDDwithatypicalfeatures?(2x)
34y/oFpresents“unabletoreachherpotential”wmoodswitchesfrequently
(daytoday,sometimeswithinoneday)frommildlytomoderately.Depressedto
happyinthemorning.Noepisodesmeetingcriteriaformania.Hxsuggestsmost
likelyDx?(2x)
CYCLOTHYMICDISORDER
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Melancholiaischaracterizedas(2x):
ANHEDONIA
ThemostcommonreasonthatpeoplediscontinuetheuseofSSRI:(2x)
GISIDEEFFECTS
AccordingtoJointCommission,whatisprimaryriskfactorforcompletedsuicidesin
Increasethedose
medicallyhospitalizedpts?
Firstlinerxforptwithdilatedcardiomyopathywhoisdepressedandhasnorelief
withfluoxetine.Ptdoesnotwantsideeffects
BUPROPION
Theoryofkindlingofdepressiveepisodesissupportedbywhatphenomenain
some?
RECURRENTWITHOUTASTRESSOR
47yooverweightfemaleoncelexawsexualsideeffects.Whatmedtoswitchto?
BUPROPION
Ptwithlowmood,middleinsomnia,impairedconcentrationandmemoryx3mons,
onsetshortlyafteradultchildwasconvictedwithfelonyandimprisonedx10years. ADJUSTMENTD/OWITHDEPRESSEDMOOD
MostlikelyDx?
Bonemarrowtransplantforleukemia.Moreanxious,fearfulthanhewasbefore
transplant.Troublesleeping,fearfulaboutleavinghospital.Whatisdx?
ADJUSTMENTD/OWITHANXIETY
BluntedresponsetoTRHstimulationtestcorrelateswith…
DEPRESSION
Mostcommonpsychd/othatoccursinptss/porgantransplant
MAJORDEPRESSION
ThemooddisturbanceofPMDDischaracterizedby…
ITCANBEASSEVEREASINMDD
Definingfeatureofmoodinatypicaldepression
REACTIVE
27y/oF,1weekpostpartum,hassuddenemotionaloutbursts;notsad,wantsthe
baby.What’sgoingon?
MATERNITYBLUES
WhichdietarysupplementhasdemonstratedsomeefficacyinTxofdepression?
S-ADENOSYL-L-METHIONINE(SAME)
Thebestdescribesdataonsuicideriskfrommeta-analysisofclinicalstudiesof
depressedchildrenandadoltreatedw.SSRI:
MOREYOUTHAPPEARTOFAVORABLYRESPONDTO
MEDSTHANSPONTANEOUSLYREPORTSUCIDALITY
Learnedhelplessnessisamodelfor:
DEPRESSION
Learnedhelplessnessisbasedonprinciplesof:
CLASSICALCONDITIONING
ImplantationofDBSelectrodeshasbeenshowntoleadtoremissioninabouthalfof
patientswithtreatment-refractorydepression.Toobtainthiseffect,theelectrodeis SUBGENUALCINGULATECORTEX
placedinthe:
Whatdisorderismostlikelytobecomorbidinptswtrichotillomania?
MOODDISORDER
Importantdistinctionbetweendepressivesymptomsinptswithcancerascompared
USUALLYMAINTAININTACTSELF-ESTEEM
tothosepatientswithdepressionbutnocanceristhatthepatientswcancer?
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WHOstudyin1990,whatisthe2ndworldwideleadingsourceofyearsofhealthy
lifelosttoprematuredeath/disability(#1isischemicheartdisease):
UNIPOLARMAJORDEPRESSION
17y/owithdepressedmood,lowselfesteemandpoorconcentrationpossiblyhas
dysthymia.WhichfeaturewouldsupporttheDx?
SYMPTOMS>1YEAR
10y/ochildwith2-monthh/oirritability,inattention,sleepdisturbance,and
withdrawal.Childattemptedtoruninfrontofacar.Nofamilyh/opsychiatricd/o.
Onexamination,noeyecontactandhaspsychomotoragitation.Whatmed?
SSRI
Comparedtoolderadolescentswithdepression,8-12year-oldsw/depressionmost
SOMATICCOMPLAINTS
oftenshowwhat?
27y/oMseeninEDc/oinsomnia,hopelessness,anorexia,decreasedconcentration
for2weeksandisnowacutelysuicidal.PthashxofETOHusedailyforthepast3
SIMD
months.ThemostlikelyDx?
First-lineTxfor9y/ow/depression
SERTARALINE
65y/omorbidlyobeseptwithnewonsetofdepressionendorsesfatigueand
hypersomnia.HeisnotonmedsandhasnoPMH.Whattest?
POLYSOMNOGRAPHY
First-lineTxforadolescentsw/majordepression
FLUOXETINE
40y/oMreportslonghxofcontinuousdysphoriaandinsomnia(dysthymia).
Recentlyhefeelsworseandreportspoorenergy,hopelessnessandSI.Dx:
DOUBLEDEPRESSION
Dxfor40yomalew/mildchronicdysphoria,insomnia,fatigue,andlessenedjob
performance,nowwithdespondency,tearfulness,lackofenergy,skippingwork,
hopelessness,psychomotoragitation,andSI
DOUBLEDEPRESSION
StrongestpredictorinptfollowingMI(everstrongerthanEF):
DEPRESSION
PtwOCDstartedon100mgsertraline,at4weekf/uincreasedto150mgb/ono
response.Week10,ptreportednoimprovement.Nextstep?
INCREASESERTRALINETO200MG
59y/oERphysicianwithalcoholproblemanddepressedmood,lesstoleranttoday
RECOMMENDRELIEFFROMTHENIGHTSHIFT
andnightshift.InadditiontoabstinencefromETOH,whatisnextstep?
WomenathighestriskofMDDduring:
REPRODUCTIVEYEARS
Mw/HTNandMI,hasstressorsanddepression,Tx?
RELAXATIONTRAINING
Pancreaticcancerpatientjustdiagnosed,tellsnurseshewisheshewasdead.Distant
withpsychiatrist.SeveralmonthhxofdepressiveSx’s,nosupportsystem.“Theonly PLACEONSUICIDEPRECAUTIONS
familyathomeismygun”
Aneffectiveantidepressantfordepressionw/atypicalfeaturesis:
PHENELZINE
Childmusthavedepressedorirritablemoodforwhatlengthoftimeinorderto
meetcriteriafordysthymicdo?
ONEYEAR
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Dexamethasonesuppressiontestfordiagnosingmooddisorders:
NOTUSEFULINROUTINECLINICALPRACTICE
61y/owithleftfrontallobedamagesecondarytocerebrovascularaccidentmaybe
predisposedtowhichpsychiatricsyndrome?
MDD
9y/ow/increasedirritabilityandaggressionfor3mons.Usedtobeeasygoing.
Gradesdropping.Noinsomniaorpoorappetite.AHofvoicetellinghimheisbad.
MostlikelyDx:
MDD
60y/ow/depression&paranoiatreatedwith50mgZoloftand6mgrisperidone.On
followupptc/oslowthinking&excessivesalvation.OnPEmaskedfacesand
LOWERDOSEOFANTIPSYCHOTICMEDS
cogwheelrigiditypresent.Moodandparanoiahavegreatlyimproved.Whatisthe
nextstep?
Whatisacharacteristicofatypicaldepression?
LEADENPARALYSIS
77y/oFwhosehusbanddied6wksago,complainsaboutthelengthoftimeittook
forhertodress.Shesoundsirritable,looksfatigued.“Ican’tacceptheisgone….I
shouldhavebeenabletosavehim”.Shesays“Whentherealdarknessdescendson HAVINGTHOUGHTSOFSUICIDE.
mespeciallyinthemiddleofthenightIdon’twanttocallanyone.”Whatismore
indicativeofMDDratherthanuncomplicatedbereavement:
Cognitivetriadofdepression:negativeself-perception,experiencetheworldasself-
EXPECTATIONOFCONTINUEDFAILURE
defeating,AND?
Whyisl-methylfolatepreferabletofolateinadjunctivetxofdepression?
IncreasetransferacrossBBB
Whataugmentationstrategiesfortreatment-refractorydepressionhasshownthe
highestefficacyandreplicability?
ELECTROCONVULSIVETHERAPY(ECT)
Txforworseningdepression,severeweightloss,dehydration,catatonia.
ELECTROCONVULSIVETHERAPY(ECT)
MostcommonlylimitstheuseofECT:
COGNITIVEIMPAIRMENT
Whichofthefollowingmedicationsshouldbestoppedorreducedbeforestartinga
LITHIUM
patientonECT?
Whichdiseaseismostlikelytopresentaspaindisorder
DEPRESSION
Ptw/unipolardepressionhashad3recurrenceofdepressioneachseparatedby1
yr,aftersuccessfultreatmentw/imipramine200mgqd.Whichprophylactic
treatmentshouldberecommended:
CONTINUEIMIPRAMINE200MGX5YRS
Suicidalthoughts,constantworrying,feelsdepressed,guilt,lacksenergy,
hypersomnia,feelsineffectiveatwork.Tx?
CONSIDERTXW/ANTIDEPRESSANT
ProphylacticTreatmentforaptwithseveredelusionaldepressionfollowingacourse COMBINATIONOFANTIPSYCHOTICSAND
ofECTincludeswhat?
ANTIDEPRESSANTS
Presence/severityofdepressiveTxinMSiscorrelatedwith:
CEREBRALINVOLVEMENT
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29y/oMh/orecurrentdepression&1.5PPDsmoking.Medication?
BUPROPION
8daysafterhipsurgerya75y/opthasepisodesofdisorientation,sleeplessness,
andcryingespeciallyatnight.Alsolittlefrogsinherroom.Inmidmorningsheisok.
WasDxw/MDDseveralmonthsagoandtakingdoxepin25mgtidanddiazepam5 ATYPICALDEPRESSIVEDISORDER
mgtidwered/cbeforesurgery.Currentlyonmeperidine,diphenhydramine.The
recentconfusionisNOTcausedby:
Researchontheuseofpsychostimulantstotreatptsw/secondarydepressive
symptomsinmedicalsettingsuggest:
WHENTREATEDWITHTHESEAGENTS,PTMAYENGAGE
INREHABILITATIONSOONER.
PsychMD.Consultedfordepressionafteranabortion.Ptreportssheisrelieved
abouttheabortionb/cshewasinabusiverelationship,notemotionally/financially
preparedtohavechild.Psychmustbeawarethat:
STRONGESTPREDICTOROFDEPRESSIONAFTER
ELECTIVEABORTIONISHISTORYOFPRE-PREGNANCY
DEPRESSION
21y/oFhospitalizedforexcessivebleedingfollowingelectivefirsttrimester
abortion.Ptreportshavinganxietyaboutbleeding,butisrelievedaboutabortion.Pt
HXOFPRE-PREGNANCYDEPRESSION
reportsthatbaby’sfatherisabusivebutdoesnotwanttoleavehim.Whatisthe
strongestpredictorofdepression?
Pthaspartialresectionofbowel.Hasnotresumedambulationdespite
encouragement.Pthaslowmood,poorsleep,andanhedonia.Dx?
PSYCHOLOGICALFACTORSAFFECTINGGENERAL
MEDICALCONDITION
6y/opresentswitha3yrshxofdisruptivebehaviorsathomeandschool.Parents
reporthehasdifficultypayingattentionandcompletingtasks.Recentlypthasb/c
DEPRESSION
moreoppositionalandangrywithadultsandpeers.Heoftenstates,“Iamnogood.”
Whatcomorbidconditionismostlikelyexplanationforthechildrecentbehaviors?
50y/optisbeingtreatedforsadness,anorexia,poorenergy,anddifficulty
concentrating.Fluoxetine20mgisprescribedandtheptachievesfullremission.
Laterptadmitsthatshehadvisualandauditoryhallucinations.Thisimprovedwith
treatmentandptcurrentlydeniesanyhallucinations.Dx?
MDDWITHPSYCHOTICFEATURES
25y/optreportsexperiencingintenseperiodsofprofoundtirednessoverthepast
2-
3weeks.Duringtheseperiodsshehasincreasedneedforsleepandspendmuchof MDDWITHATYPICALFEATURES
dayinbed.Ptalsoreportsincreasedappetite.Theseepisodesoftenoccurinsetting
ofinterpersonaldiscord.Dx?
AccordingtotheWorldHealthOrganization,whatisthenumberonepsychiatric
causeoflossofyearsofhealthylifeasmeasuredbydisability-adjustedlifeyearsfor UNIPOLARMAJORDEPRESSION
individualsbetweenagesof15and40years?
Ptisinitiatinglighttherapyforseasonaldepression.Whatstatementaccurately
representswhatisknownaboutthetype,dose,andtimingofeffectivetreatment?
MORNINGLIGHTTREATMENTAPPEARSTOBEMORE
EFFECTIVETHANMID-AFTERNOONEXPOSURE.
WhichantidepressantisLEASTLIKELYtoproducesexualdysfunction?
BUPROPION
CharacterizesdepressioninptwithMS:
RESPONDSTOANTIDEPRESSANTS
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PtpresentstoEDwith5-dayhxofN/V,diarrhea,HRof90,BP150/92,andtemp
100,sweating,tremor,hyperreflexiaanddistractibility,normallabsanandCThead, TRAMADOL
andyearsofFluoxetineuse.Oneweekagoanewmedisstarted:
35y/optpresentswithseveredepressionwithepisodesofanxietyfor9months
thathavebecomesobadhecannolongerleavethehouse,hassevereweightloss,
hyperpigmentationofexposedskin,andcoldtolerance.Dx?
ADDISON’SDISEASE
Howmanysymptom-freeweeksmustbebetweentwoepisodesofdepressionfor
themtobeconsideredseparateandthereforerecurrentaccordingtoDSM-IV?
8SYMPTOM-FREEWEEKS
Whichofthefollowingfunctionsismostlikelytonormalizeinan80y/opt
successfullytreatedfordepression?
IIFORMATIONPROCESSINGSPEED
19y/optpresentsforevaluationofdepression.Ptreportsagenerallyverylow
mood,althoughitbrightensupbrieflywhensomethinggoodhappens.Ptreports
feelingbestinthemorning.Pthasbeensleepingandeatingmorethanusual,and
complainsoffeelingsofheavinessintheextremities.Ptreportsalwaysbeingvery
sensitivetoperceivedrejectionbyothers.Trialswithtwoselectiveserotonin
reuptakeinhibitors(SSRIs)havefailed.Whichofthefollowingtreatmentsmaybe
particularlyeffectiveforthispt?
TRANYLCYPROMINE
Inptswithrecurrentdepression,successfultreatmentwithantidepressantsshould
befollowedbywhichtreatmentstrategy?
CONTINUINGANTIDEPRESSANTSATTHESAMEDOSAGE
35y/oFptpresentstothephysiciancomplainingofdecreasedinterestinsexual
activityanddifficultybecomingarousedbyherspouseoverthelast3months.Upon
furtherquestioning,thepatientalsoreportsanhedonia,difficultysleeping,fatigue,
SYMPTOMOFAMAJORDEPRESSIVEEPISODE
anddecreasedappetiteoverthesametimeperiod.Medicalhistoryandworkupare
otherwiseunremarkable,andptisnotcurrentlytakinganymedications.According
totheDSM-IV-TR,pt’sdecreasedinterestinsexismostlikelyassocwwhich?
Patientwithdepressiononadmission.Whichriskfactorsuggestsneedfor
maintenancepsychotherapy?(2X)
3ORMOREEPISODESOFDEPRESSIONINALIFETIME
A/wimprovedoutcomeinlate-lifedepression?
Familyhistoryofdepression
DissociativeDisorders
Focusedattention,alteredconsciousnessusuallyseeninptswdissociativeD/O
(2x)
TRANCE
Thissymptomisessentialtosupportadiagnosisofdissociativeidentitydisorder
(2x)
EXTENSIVEINABILITYTORECALLPERSONAL
INFORMATION
Ptbroughttoedbyfamilybecauseofconcernforptsabilitytorecognizethemsince
TBIonemonthago.PthadLOCaftertrauma.TendernessandswellingoverL
DISSOCIATIVEAMNESIA
temporalarea.Neuroexamnormal.Ptknowsownname,butunabletoidentify
familymembersoreventsrelatedtofamily.Whatisdiagnosis?
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Wheneverthecultureofwesternmedhasbeenafocusofinquiryby
anthropologists,whatdiagnosishasbeenseenasacultureboundsyndromein
northAmerica?
DISSOCIATIVEIDENTITYD/O
Ptwmemorylapses,talkslikeadultattimes&likeascaredchildatothertimes.Dx? DISSOCIATIVEIDENTITYD/O
Psychiatristasks,“Doyoufindthingsinyourpossessionthatyoucannotexplain?”
Tryingtoelicit:
DISSOCIATION
Detachmentofemotionalcomponentfromperception
DEREALIZATION
Ptswithdissociativeidentitydisorderarealsomostlikelytomeetthediagnostic
criteriaforwhichofthefollowingdisorders?
PTSD
20y/oinMVA,noinjuries–speakssoftly,feelscalm,dimvision,mechanical
movements,feelsdetached:
DEPERSONALIZATION
Depersonalizationisclassifiedasdisturbanceofwhichofthefollowing?
PERCEPTION
44y/optreportshxofrepeatedepisodesofself-mutilationandsuddenchangesin
relationships.Afterseveralmonthsofpsychotherapy,theptspeaksinunusual
accent,isirritable,andhaslittleawarenessofin-sessiondiscussions.PsychMDhas DISSOCIATIVEIDENTITYD/O
pastrecordsthatstatepthasbeenDxwithborderlinepersonalitydisorderandhasa
sexualtraumahistory.Dx?
Ptsthat“cut”asaformofself-mutilationtypically:
CLAIMTOFEELNOPAIN
Newlymarried22-year-oldptisstronglyencouragedbyhusbandtoseekevaldueto
abruptchangesinpt’sattitudesandbehaviors.Ptdeniesawarenessofthis,butdoes
acknowledge“missingtime”thatmadeherfeellikeherlifeis“scatteredonthefloor
ofafilmeditor’sstudioafterpieceswerecutandtheendssplicedbacktogether.” DISSOCIATIVEIDENTITYD/O
Oldgfofhusbandhasthreatenedtofilecharges2/2hostiletelephonemessages
thathavebeentracedtopt’sphone.Ptdeniesmemoryofmakingcalls.Whatisthe
d/o?
45y/optwlungcanceranddepression.Physicalandemotionalsymptomsare
stable,ptworriesthat"familyalwaysseemsonedgewme."Familymeetingshows
childrenfearlosingfather,frustratedthatlivesseem"onhold".Daughterfeelsshe
can'tinvitefriendsoveroutoffearof"stressingherfather."Fatherfeelsguilty
aboutthisbutdoespreferquietenvironment.Beststrategicsystemicapproachto
problem?
Taskfamilywithcomingupwpracticalschedule
EatingDisorders/BodyDysmorphicDisorder
Episodesofunrestrainedeatingw/ocompensatorybehaviorsofbulimia.Dx?(5x) BINGE-EATINGDISORDER
Metabolicabnormalitycommonlyfoundwanorexianervosa/purgingsubtype?
(4x)
DECREASEDSERUMPOTASSIUM
Dehydratedbulimicw/BP100/60andorthostasisHR60.Statlabtest:(3x)
POTASSIUM
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ComplicationofanorexianervosaLEASTlikelytoresolveafterrestoringweightis?
OSTEOPOROSIS
(2x)
Adiagnosisofanorexianervosarequiresthatthepatienthasmaintainedaweight
85%
belowwhatpercentageofaminimallynormalweightforageandheight?(2x)
Ptwithsignificantmedicalhxadmittedtoinpatientpsychunit.Labsshow:lowK
andCl,elevatedHCO3andamylase,andnormallipase.Dx:(2x)
BULIMIANERVOSA,PURGINGTYPE
TheproposedDxofbingeeatingd/odiffersfrombulimianervosainthatptsw/
bingeeatingd/o:
USUALLYDONOTMAINTAINANORMALWEIGHT
Duringtheacuteinitialrefeedingphaseoftxforptw/severeanorexianervosa,
whichismosthelpfulfocusofpsychotherapeuticinterventionswiththept?
COACHING,SUPPORT,ANDPOSITIVEBEHAVIORAL
REINFORCEMENT
Whichofthefollowingmedshasbeenextensivelystudiedandfoundtobeeffective,
FLUOXETINE
incombinationwithCBT,intxofbulimianervosa?
23y/optw/excessivepreoccupationwithbodyshape.Ptisinnoapparent
distress,butadmitstobingeeatingepisodesfollowedbypurgingtwiceweeklyfor BULIMIANERVOSA
past6months,Bodyweight:normal.Dx:(x2)
Abdominalpain,diarrhea,hypokalemia,weightloss,steatorrhea,skinpigmentation.
PHENOLPHTHALEIN
Possiblelaxativeabuse.Measure:
Patientwithanorexianervosaisadmittedtoinpatientunitandhasbeguntreatment
withhighcaloricoralfeedings;2daysafteradmissionanEKGshowsventricular
PHOSPHATE
tachycardia.Whichtestswouldbestdeterminesthelikelycauseofarrhythmia?
Theprimaryfocusofbehaviortherapyinthetreatmentofanorexianervosaisto:
RESTOREWEIGHT
Bulimiaiscomorbidwith:
MDD
Frequentlyamedicalsx/signinptswithanorexia:
REPRODUCTIVEHORMONEDYSFUNCTION
Duringtheacuteinitialrefeedingphaseoftreatmentforapatientwithsevere
anorexianervosa,whichofthefollowingisthemosthelpfulfocusof
psychotherapeuticinterventionswiththepatient?
COACHING,SUPPORT,ANDPOSITIVEBEHAVIORAL
REINFORCEMENT
Whatelectrolyteabnormalityismostseeninbulimics?
HYPOCHLOREMICALKALOSISWITHHYPOKALEMIA
32y/optrevealsalong-standingpreoccupationwiththeshapeofhermothand
teeth,thoughshesaysthatherfriendsandspousehaveassuredherthather
feelingsareinappropriate.Ptreportsthatsheoftenspendsanhourcleaningher
teeth,sothattheabnormalitywillbelessnoticeable.Attimessheavoidssocial
contact,fearingthatpeoplewillsilentlycriticizetheappearanceofhermouth.She
hasnootherobsessionsoncleaningrituals.Bestdxforpt’slong-standing
preoccupation?
BODYDYSMORPHICDISORDER
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Aplasticsurgeonasksthepsychiatristtoevaluatea15yoptwhoisrequesting
rhinoplasty.Thesurgeoniswillingtoperformtheoperationbutisconcernedbythe
pt’syoungage.Theptiswithherparents.Theptexplains“Ibrokemynoseplaying
hockey2yearsagoandithasbotheredmeeversince”Onexam,hernoseis
noticeableasymmetrical.Patientshowsnoobviouspsychologicaldistressotherthan ANIMPROVEMENTINQUALITYOFLIFE
concernforherappearance.Ptstates“Ijustwanttolooknormalagain”.Parents
reportchildhashadpoorselfesteemsincetheinjuryandtheyarehopingthe
operationwillhelpherselfconfidence.Whichofthefollowingisthemostlikely
psychologicaloutcomeforthisptfollowingcosmeticsurgery?
25-year-oldptwithnopreviouspsychhistoryhasanewpreoccupationwith
imagineddefectsinappearance,whichisacauseofexcessiveconcern.Thepthasa
FLUOXETINE
normalmedicalworkupand,otherthanthedistressoverappearance,theptdoes
nothaveotherpsychsx.Whichofthefollowingmedsismostappropriate?
Inovercomingtheresistancetotreatmentoftenencounteredwithpatientswho
haveanorexianervosa,whatisitmostusefulforthepsychiatristtoemphasize?
EMPHASIZEHOWTREATMENTWILLALLOWTHE
PATIENTTOFOCUSENERGYONOTHERMATTERS.
Bulimiaanddepression.Contraindicated:
BUPROPION
Enlargedparotidglandsinaptbeingtreatedforanorexianervosawouldsuggest
whichofthefollowing?(2x)
SELF-INDUCEDVOMITING
Whattestfindingsareassociatedwithanorexiaandbulimia?
BRADYCARDIA,AMENORRHEA,HYPOKALEMIA,AND
ELEVATEDSERUMAMYLASE
Bulimianervosapresentsinwhichpersonalityd/o?
BORDERLINE
Whichenzymescanbeincreasedinserumofpt’swithbulimia?
AMYLASE
At30yearsafterpresentationfortreatment,mortalityratesforanorexianervosa
are:
0.20%
Labfindinginptwithbingeingandpurgingbx:
QTANDTWAVECHANGES
WhatisassociatedwithflatteningofTwavesanddevelopmentofUwavesonEKG? purgingbehavior
Psychotherapythathasbeenshowntobeeffectiveinbulimianervosa:
CBT
Whatmedhasshownsomeefficacyinreducingbinging+purginginbulimia
nervosa?(x2)
FLUOXETINE
WhichSSRIusedtotreatdiscontinuationsyndromecausedbySSRItermination?
FLUOXETINE
FactitiousDisorder
Whatfactordifferentiatesmalingeringfromfactitiousdisorder?(2x)
HAVINGEXTERNALINCENTIVE
Whatconditionshowsmotivationtoassumethesickrole?(2x)
FACTITIOUSDISORDER
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Centralcharacteristicoffactitiousdisorder
THEREISMOTIVATIONTOASSUMETHESICKROLE
Psychiatristisevaluatingfrequentliar.Pt’sliesaregrandioseandextreme.Pt
appearstobelievethestories.Thisiscalled:
PSEUDOLOGIAFANTASTICA
25y/oprisonerclaimingtobedepressedishospitalizedafterheswallowedsome
razorblades.Razorbladeswerecarefullywrappedwithsurgicaltapebefore
swallowing.Confesseshewantedsometimeoutofprison.Dx?
FACTITIOUSDISORDER
Incontrasttoptswithfactitiousdisorder,ptswithmalingeringarecharacterizedby
MOTIVATIONFORSECONDARYGAIN.
having:
Ptcomplainingofaninabilitytomovehisarm.Ptisbecomingenragedathiswife
and,onseveraloccasions,fearedhemightstrikeher.Shortlyafteroneargument,
hisarmbecamelimp.Dx:
PRIMARYGAIN
PsychMDisaskedtorecommendtreatmentinterventionsfora16y/optwitha
presumptivediagnosisofconversiondisorder.Whichoftheffismostlikelytobe
bothacceptedbytheptandresultinfunctionalimprovement:
REHABILITATIVETREATMENT
24y/oMseeninEDwithchestpainclaimstohavearareconnectivetissued/oand
saidherequiredarecenthearttransplantduetoaortadissection.Heprovidesthe
FACTITIOUSD/O(MALINGERERSUSUALLYAVOID
MDwithalistofimmunosuppressivemedsandrequeststhatatransesophageal
INVASIVETESTS)
echobedone.Hehasnosternotomyscarandoutsiderecordsindicatehisstoryis
false.Isthislikelyfactitiousd/oormalingering?
Hallucinationsinpatientswithconversiondisorderarecharacterizedby?
HAVINGACHILDISH,FANTASTICQUALITY
Whatkeyfactordistinguishesfactiousdisorderfrommalingering
MOTIVATIONTOBEIDENTIFIEDASILL
ImpulseControlDisorder
AccordingtoDSM-IV-TR,compulsiveskinpickingwouldbe:
IMPULSECONTROLD/ONOS
Comorbidconditionw/pathologicalgambling
MAJORDEPRESSION
Whatisaverycommonimpulsecontrold/oNOS?
PATHOLOGICGAMBLING
Pathologicalgamblingisincludedinwhatgrouping:
IMPULSECONTROLD/O
Ptishoarding,homefilledwithfilth,acknowledgesissheiskeepalotofthings
(hoarding)
HoardingDO
OCD
AgeneticsusceptibilityforOCDissuggestedbyevidencethatthereisafamilial
linkwith(4x)
TICDISORDERS
PrincipalbehavioraltechniqueforOCD(2x)
EXPOSURE&RESPONSEPREVENTION
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25y/owithOCDdiagnosed2yearsagoislikelytobenefitfromwhatmedicine(in
CLOMIPRAMINE
additiontopsychotherapy)?(2x)
HxofOCD,Zoloftonlypartiallyeffective.Next:
TRYANOTHERSSRI
Whatisaneffectivetreatmentforobsessivecompulsivedisorder?
ESCITALOPRAM
Anteriorcapsulotomyand/orcingulotomyareindicatedanddemonstratedeffective
OCD
forptswithwhatsevereincapacitatingdisorder?
Whichconditionisleastlikelytorespondtohypnosis?
OCD
Persistentlyintrusiveinappropriateidea,thought,impulse,orimagethatcauses
markeddistressis
OBSESSION
Obsessive-compulsivesymptomsarecharacterizedbywhichdefensemechanism?
ISOLATIONANDUNDOING
40y/optcomplainsofrepetitive,continuoushand-washingthroughoutdaytothe
pointofchaffingskin.Ptdeniesfearofgermsoranyobsessivethoughts,cannot
explaincontinuouswashing.Dx?
OCD
A20yearoldmaleptpresentstohisphysicianforaphysicalexaminationbecause
he
isworriedthathemayhavecontractedaninfectiousdisease.Hestatesthathis
worryisinterferingwithhisabilitytocompleteworkassignments.Hestatesthathe
CAUDATE
countsto100repetitivelyinordertodistracthimselffromthisworry.Hehasno
priormedicalorpsychiatrichistory.Hedoesnotabusesubstancesandisnot
involvedinanyrelationships.Whichofthefollowingregionsofthept’sbrainismost
likelytoshowincreasedactivityonPETscan?
ChildOCD.WhichcomorbiddiagnosisisassociatedwithpoorresponsetoSSRI?
TICDISORDER
PsychMDasksapatient,“aretherethingsyoumustdoinaparticularwayor
order?”
whichthisquestion,psychMDistryingtoelicit?
COMPULSIONS
WhichofthefollowingistheinitialtreatmentofchoiceforchildrenwithOCD?
CBTALONE
WhatinfectiousagentcanexacerbateorcauseinitialmanifestationofOCDin
children?
GROUPABETA-HEMOLYTICSTREPTOCOCCUS
Manobsessesaboutkillinghisg/f.Insteadofkilling,pickshisfacew/apin.
Medication:
FLUVOXAMINE
Ptwithcontaminationfearsandhandwashingritualsistreatedwithresponse
preventioncombinedwith:
EXPOSURETHERAPY
WhatisthemostcommonpatternofobsessionsinptswithOCD?
CONTAMINATION
Repetitivebehaviorsthattheptfeelscompelledtoperformritualistically,while
recognizingtheirrationalityandabsurdityofthebehaviors,describes:
COMPULSIONS
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35Mw/severeOCD,failedmultiplemeds,CBTandECT,whatnext?
CINGULOTOMY
WhatconditionisfrequentlyassociatedwithOCD?
TOURETTESYNDROME
PtpresentstoPMDthinkinghehascontractedinfectiousdisease.Constant
worrying,interfereswithwork,repetitivelycountsto100todistractfromworry.No CAUDATE
drugorpasthxofpsych/med.WhatsectiononPETwillhaveincreasedactivity?
Whatprincipalbehaviortechniqueisusedinthetreatmentofptsw/OCD?
EXPOSUREANDRESPONSEPREVENTION
Whatstatementreflectscurrentthinkingaboutneurologicalproceduresfor
intractableOCD?
ATPRESENT,THEREISLITTLEEVIDENCETOSUGGEST
THATANYONEPROCEDUREISSUPERIORTOANOTHER.
PediatricAutoimmuneDisorderAssociatedwithStreptococcus(PANDAS)is
associatedwithwhatdisorder?
OCD
Childrenwithpediatricautoimmuneneuropsychiatricdisordersassociatedwith
streptococcalinfection(PANDAS)oftenmanifest:
CHOREIFORMMOVEMENTSandOCDSYMPTOMS
PanicDisorder
Respiratoryillnessismostclearlyariskfactorfordevelopingwhichanxiety
disorder?(2x)
PANICDISORDER
Whatistheprinciplegoalofthecognitive-behavioraltherapyofpanicd/o?
USINGRESTRUCTUREDINTERPRETATIONOF
DISTURBINGSENSATIONS
DiffdiagnosisofptpresentsatEDwithpanicd/o:
PULMONARYEMBOLISM
HyperthyroidismshouldberuledoutaspartoftheDDxofwhatpsychiatricd/o
PANICD/O
Whichclinicalfeaturedistinguishespanicdisorderfrompheochromocytoma?
ANTICIPATORYANXIETY(inpanicd/o)
Panicattackreachespeakin
AFEWMINUTES
Presenceofwhatdisorderputsachildatgreatestriskfordevelopingpanicdisorder
SEPARATIONANXIETYDISORDER
asanadult?
Childhoodphysicalandsexualabuseincreasestheriskforwhichanxietydo?
PANICDISORDER
Thoughmanysymptomscanbeassociatedwithapanicattack,thecardinal
symptomthatappearstobecentraltothepathophysiologyofthesyndromeis:
HYPERVENTILATION
PsychMDintheEDevaluatesa67y/optw/h/odepressionwhoc/opanicattacks
sincethedeathofherspouse1monthago.Pthasfrequentepisodesofacute-onset
palpitations,chesttightness,nausea,shortnessofbreath,andintenseanxiety
lastingseveralminutes,withnospecifictriggers.Thismorningitwokeherupfrom EKG
hersleep.Exam:overweight,pale,anxiousappearing,andmildlydiaphoretic.HerBP
is
140/90,pulse106.Mostappropriatenextstepinmanagement?
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ptwpanicdisorderfailed2SSRItrials.Whichmedshouldbeusednext?
IMIPRAMINE
32yoh/opanicdisorder,phobias,numerousfailedtrialsofandtidepressants.On
clonazepam0.5mgbidwithgoodresponse.1molaterresponsestillgoodbutnotas
INCREASETO1.5MGPERDAY
good.Doseincrto1mgbid,on3rdvisitptreportssomelossofbenefitagain.What
istheappropriatecourseofaction?
Comparedtopharmacotherapy,advantageofCBTintxofpanicdisorderis
LOWERRATEOFRELAPSEFOLLOWINGD/COF
TREATMENT
Onceitbecomeseffective,pharmacologicaltxofptswithpanicd/oshouldgenerally
8-12MONTHS
continueforwhatlengthoftime?
Thisstatementbestcharacterizescurrentinformationontherecommendedinitial
treatmentofpsychotherapyorpharmacotherapyforaptwithpanicdisorder:
THEREAREINSUFFICIENTDATATOCHOOSEONE
TREATMENTOVERANOTHER,ORCOMBINATIONOVER
MONOTHERAPY
42y/osurgeonexperiencedintensestomachcrampsandpalpitationswhenunable
toimmediatelyfindtherightinstrumentwhenperforminganappendectomy.The
surgeonwasextremelyalarmedbythisandbegantoworryaboutthesymptoms
AGORAPHOBIAWITHOUTPANIC
recurring.ThesurgeonthentradedallEDcallssoastoavoidthesesituations,began
toavoidothercrowdedandnoisyenvironments,andavoidedavarietyofsocialand
professionalsettings.Likelydiagnosis:
Adiagnosisofpanicd/orequireswhichofthefollowing?
ATLEASTSOMEANXIETYATTACKSTHATARE
UNPROVOKED
10montholdchilddistressedwhenparentsleavehimwiththebabysitter.The
parentssaygoodbyeandleavequicklywithoutdisplayofaffection.Whatismost
likelytoobservedlaterinlife?
INCREASEDCLINGINGANDAVOIDANTBEHAVIOR
TOWARDSBEHAVIOR
First-linetreatmentofpanicdisorder?
FLUOXETINE
Phobias
Ptreportshavingafearofdrivingandexperiencesfeelingofpanic,SOB,heart
racing,sweating,andclamminesswhenanticipatingadrivedownstreetroads.Pt
acknowledgesgoingoutofthewaytoavoidthissituation.PtdeniedsimilarSxin
othersettings.Dx:
SPECIFICPHOBIA
Thecaseof“LittleHans”ledFreudtodevelopapsychologicaltheoryofthe
formationofwhichofthefollowingsymptoms?
PHOBIA
Diagnosisforchildw/behavioralinhibition
SOCIALPHOBIA
First-linetreatmentinpanicattacks:
FLUOXETINE
10y/oisseeninoutptclinicw/hxofextremefearofusingthebathroomatschool.
Hestatestobeafraidthatotherchildrenwilllaughiftheyhearorsmellhiminthe SOCIALPHOBIA
bathroom.Dx?
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Avoidsinterpersonalsituationsduetoanxietyandpanicattacks
SOCIALPHOBIA
28y/oMepisodicanxiety,palpitations,flushing,shaking,chesttightness.Mostlyat
SOCIALPHOBIA
workorw/groupoffriends.Embarrassed,afraidtogotowork,avoidingpeople:
Principalaimoftreatmentofchildwithschoolphobiais:
RETURNCHILDTOSCHOOL
42y/opthashadchronicabdominalpain,constipationandnauseaforthepast
14months.Extensivemedicalwork-uphasrevealednoorganiccause,butthept
insiststhatthesearesymptomsofaseriousdisease.Mostlikelydiagnosis:
HYPOCHONDRIASISWITHPOORINSIGHT
Mosteffectiveapproachinbehavioraltreatmentofphobias:
IN-VIVOEXPOSURE
Thismedicationiscommonlyusedinsocialphobiaassociatedwithperformance
situations,shortlybeforeexposuretoaphobicstimulus?
ATENOLOL
Theparentsofan18y/oadolwhoisoverweightnoticethattheirchildisavoiding
highcaloricfoods,suchasmeatandpasta.Whentheparentsinquireaboutthis,the
teensays,“Iamafraidofeating.”Theevaluatingpsychiatristaskswhentheeating
behaviorchanged,andtheteenreportshavinghadanepisodeofpanicwhich
SPECIFICPHOBIA
occurredwhileeatingandwasaccompaniedbychokingfeelings.Afearofchoking
whileeatingandawishtoavoidfoodsthatmightcausechokingdeveloped.The
teendeniesotherepisodesofpanic.Dx?
Parentsof18yroldfindchildavoidinghighcaloriefoodsduetofearofeating,andpt
linksthefeartoandepisodeofpanicthatoccurredwhileeatingaccompaniedby
SPECIFICPHOBIA
choking,deniesotherepisodesofpanic,diagnosis?
PTSD
12y/odisclosedtocounselorhxofsexualabusebyrelative.Reportmadeto
authorities.Duringeval,ptreportsanxiety/inabilitytoconcentrateduetothinking
PTSD
aboutevent/irritability/sleepproblems/cryingfrequently.Gradesfellsignificantly
afterabusebegan&relationshipssuffered.Dx?(5x)
40y/ohashyperarousalafterseeingbadMVA.Hasnightmares,avoidsfreeways,
isolatingathome.Therapyonlymoderatelyhelpful.Whichmedication?(3x)
WhichofthefollowingisthebestuseofhypnosisinapatientwithchronicPTSD
withseveredissociativesymptomsduetochildhoodabuse?
28y/ograduatestudentBIBwifeandreportsachangeinhisbehaviorsincehe
witnessedafatalmotorvehiclecollision3wksago.Ptfeltfeelingofhelpless,
horrifiedattimeofaccident.Nowptfeelslike“hisspiritleaveshisbody.”Andfeels
numbanddetached,anddreamsaboutevents.Dx:
SERTRALINE
Learningtogainvolitionalcontroloverdissociation
ACUTESTRESS
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A28yopatientpresentstotheEDafterexperiencingasexualassault1weekearlier.
Althoughthepatientcannotrecallallaspectsoftheevent,sheremembersfeeling
helpless,detached,andasifhersurroundingswerenotrealduringtheassault.For
thepastweekthepthashasdifficultysleepingduetonightmaresabouttheassault ACUTESTRESSDISORDER
andhasnotbeenabletotalkabouttheeventwithanyofherfriends.Sheisalso
experiencingintermittentepisodesofpalpitations,SOB,dizziness,andnausea
throughouttheday.Dx?
HowwouldasocialbiologistdescribeadaptivebenefitofPTSD?
HYPERVIGILANCEALLOWSFORQUICKSENSINGOFREAL
THREATS
ApatientpresentstotheEDafterwitnessingatragicMVAinwhichtheywitnesseda
death.Whatsymptompresentimmediatelyfollowingtheeventincreasesthe
DISSOCIATION
individual’sriskofdevelopingPTSD?
WhatsymptomcommonlydevelopsrelativelylateinchildrenwithPTSD?
SENSEOFFORESHORTENEDFUTURE
Whichofthefollowingisthebestpredictorofwhetherornotapatientwho
sustainedasignificanttraumawilldevelopearlyPTSDmorbidity?
THENATUREANDSEVERITYOFTHETRAUMA
Sxforapt2monthsaftertraumaticexperience:
INCREASEDAROUSALANDINTRUSIVETHOUGHTS
AddingwhichclassofmedicationtoanSSRIisaneffectiveaugmentationfor
treatmentofPTSD?
ATYPICALANTIPSYCHOTICS
Studentpresentsforpsychevalwithcontinuedanxiety,hyperalertness,flashbacks,
andsocialavoidanceafterbarelyescapinganattacker1monthago.These
4WEEKS
symptomsareexpectedtolastnolongerthan___?
Howtoprovepatientnotcriminallyresponsibleforattackingneighbor’shousein
middleofnightwithshotgunafterhearingimaginarygunfire.
Flashbackpreventedpatientfromunderstanding
wrongfulnessofhisact.
Schizophrenia/Psychosis
Schneiderianfirst-ranksymptomofschizophrenia:(3x)
HEARINGVOICESANDARGUINGABOUTONESELF
Whatfactorisagoodprognosticindicatorinschizophrenia?(2x)
FEMALEGENDER
Successfulpsychosocialinterventionsinschizophrenics:(2x)
ASSERTIVECOMMUNITYTREATMENT
16y/oboytreatedasoutpatientforSchizophreniaafterrecentinpatientfirst
break.Parentsconcernedre:anhedonia,withdrawn.Nopsychosis.Goalof
outpatienteval:(2x)
ADDRESSPT’SFEELINGSOFDEPRESSIONANDSCREEN
FORSI
19y/optreportedhearingavoicethattalkedaboutwhatptwasthinking.Thept’s
speechhasanormalrateandrhythm,butsaysthingssuchas,“Itiswhite,very
ALOGIA
white.Iknow.Thingsarethatway.Theyare.Iam.”(Povertyofspeechand
content)Thisspeechisanexampleof:(2x)
Subtypeofschizophrenialesssevereandstartsolder:(2x)
PARANOID
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Late-onsetschizophreniaismorecommoninmenorwomen?(2x)
WOMEN
Schizophrenicwithpoorresponseto3trialsofantipsychoticmeds,nextstep?(2x) CROSSOVERTOCLOZAPINE
Dysprosodyisanabnormalityof(2x)
SPEECH
PtwithCPShospitalized6xinthepastyear,hxofnonadherecetotreatment,
difficultymaintaininghousing,andmultmedprobs–whichtreatmentmost
appropriateforthispatient?(3x)
ASSERTIVECOMMUNITYTREATMENT
75y/omalebroughtinbyfamilyforpsycheval,familyreportsnopastpsych
history,hasgottensuspicious,withdrawn,hostile.Talkstoself,talksaboutbeing
controlledbyaliens,believesaliensareputtingthoughtsinhishead.28/30on
MOCA,MRIshowsage-relatedchanges.Diagnosis?
OnlyonecriterionisnecessaryforDxofschizophreniaifthereporteddelusionis:
SCHIZOPHRENIA
BIZARRE
23y/optw/nopreviouspsychhxBIBfamily.Parentsreportsthatpthasstopped
seeingfriendsforthelast6months,isafraidwhencarspassbyonthestreet,seems
SCHIZOPHRENIA
tobetalkingtoselfandtelevision.Ptalsohasunusualmovementsofarmsattimes,
flapandwaveontheirownaccord.Whatisthediagnosis?
Whichofthefollowingisanon-DSMtermforthecategoryofschizophreniawhen
thedxisbasedsolelyondeficitornegativesymptoms?
SIMPLESCHIZOPHRENIA
Whichofthefollowingstatementscharacterizeslate-onsetschizophrenia?
OCCURSMOREFREQUENTLYINWOMENTHANMEN
Assessingwhetheraschizophreniccriminaldefendantmaymeetstandardfor
insanitydefense,whatdoyouask?
“WHATWERETHEVOICESSAYINGTOYOUATTHETIME
OFTHECRIME?”
Whichdifferentiatesdeterioratived/ofromschizophrenia?
ABSENCEOFPROMINENTPOSITIVESYMPTOMS
Schizophreniawithonsetinchildhoodisdifferentfromadult-onsetbecause…
ITISMORELIKELYTOHAVEAGRADUALONSET
Thoughrecentresearchhasdemonstratedthatthebluntedemotionalexpressionin
schizophreniadoesnotimplythatapatientisanhedonic,individualswith
SOCIALINTERACTIONS
schizophreniadoexperiencelossofinterestorpleasureassociatedwith?
Focusforoutpatientpsychotherapeuticgroupsforschizophrenia?
SOCIALSKILLSDEVELOPMENT
WhichTxmodalitiesprovidescareforseriouslymentalillptsincommunityviaa
multidisciplinaryTxteam:
ASSERTIVECOMMUNITYTREATMENT
24y/optw/hxofepilepsysincechildhoodhasseveralseizuresinrapidsuccession.
FollowingSzs,ptdevelopedparanoiaandhallucination,butresolvedoveramatter
ofdays.Dx:
INTERICTALPSYCHOSIS
Whencomparedwithadult-onsetschizophrenia,childrenwithschizophreniahave: SIMILARDEFICITSINATTENTION,LEARNINGAND
(x2)
ABSTRACTION
NoadditionalcriterionAsymptomsarerequiredforthedxofschizophreniaifthept
HALLUCINATIONSOF2ORMOREPEOPLECONVERSING
haswhichofthefollowingsymptoms:
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44y/optwithschizophreniaisadmittedtoaninpatientpsychiatricunit.After
severaldayspthasmuscletremor,ataxia,twitching,diarrhea,restlessness,
vomiting,polyuria,andstupor.Dx?
WATERINTOXICATION
Whatisanegativesxofschizophrenia?
SOCIALINATTENTIVENESS
20y/oavoidseveryonebutparents.Stoppedgoingtoschool.Feelseveryone
watchinghim.Alwaysquiet,sitsathomedoingnothing,mumblestoself,some
bizarremovements,flataffect.Deniesdepressionorsubstanceuse.
SCHIZOPHRENIFORM
Characterizesschizophrenicsthatsmoke
REQUIREMORENEUROLEPTICMEDS
29y/o1wkeuphoria,insomnia,pressuredspeech,grandiose.Delusions,AH.Need
whatelseforDxschizoaffectived/o
PSYCHOTICSX’SX2WKSINABSENSEOFMOOD
SYMPTOMS
Mostcloselycorrelatesw/socialfxinschizophrenics:
NEGATIVESYMPTOMS
55y/optw/hxofETOHdependencereportshearingvoicesforthepast6weeks.Pt
reportsthatthelastepisodeofETOHintoxicationwas1monthprior,withmoderate
drinkingsincethattime.Thereisnopriorhxofpsychosis.Onexam,ptisalertand
ALCOHOLINDUCEDPSYCHOTICDISORDER
oriented.Onlaboratoryevaluation,pthasaGGTof54,anMCVof110,andan
AST/ALTratioof2.1.themostlikelycauseofthispt’shallucinationsis:
Healthy37y/oFbusinessexeclearnsthatherbrotheriskilledinaMVAandis
decapitated.Threedaysafterthefuneral,shespotsamandrivingacarjustlikeher
brothersandisnowconvincedheisnotdead.Shebelievessheisthevictimofa
conspiracyinwhichothersaremanipulatingherintolosinghermindonorderto
takeoverherbusiness.Shehearsabuzzingnoiseonherphoneatworkandbelieves BRIEFPSYCHOTICDISORDER
herlineistapped.Athome,shethinksthelightinherneighbor’swindowisasign
thatsheisundersurveillance.Shecallsthepoliceandbegsthatactionbetaken.A
monthaftertreatment,hersymptomsaregoneandwithin3monthsshehas
returnedtonormalfunction.Thediagnosisis:
45y/oFptwithvaguecomplaintsof“notfeelinggood,”notsleepingwellX1
month.Ptdisclosesfear/anxietyover“weirdthingshappeningtome,”including
believingthatsomepersonalpossessionsaremysteriouslymissingoraltered.Pt
aware“thisallsoundscrazy,”butcannothelpfeelingfrightenedthat“someoneis
messingwithmymind,maybemyex-husband.”Ptcalledpoliceseveraltimes,but
OBTAINAGENERALMEDICAL/NEUROLOGICAL
theyneverfoundanythingsuspicious.Pthadbeenasuccessfulinsuranceagent,and WORKUP
expressesworrythathisdistressisdistractingandmaynegativelyaffectwork
performance,whichcouldresultinjobloss.Deniespastpsychiatrichx,exceptfor
feelingdepressedforseveralmonthsafterthedivorceafewyearsago=resolved
withouttreatment.Whichcourseofactionwouldbestclarifythediagnosis?
Whichmedicalconditionislikelytoincludepsychosisinthesymptomcomplex?
SYSTEMICLUPUSERYTHEMATOSUS
A35yoFpatienthasdiscoidlupuswhichhaslongbeencontrolledwithastable
doseoforalprednisone.Sheabruptlydevelopsincreasedfatigue,inflamedjoints,
anddiffusemyalgias.Ptalsoexhibitsdepressedmoodandcognitiveimpairment.
Shehasnopriorpsychiatrichistoryandnofocalneurologicalsigns.Whichofthe
followingisthemostlikelyetiology?
DISEASEINDUCEDCEREBRITIS
MCcomplicationofcorticosteroidtherapy?
Mooddisorder
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PositiveSxsofschizophrenia:
PARANOIA,AH,THOUGHTINSERTION,DELUSIONS
AnegativeSxofschizophrenia:
BLUNTEDAFFECT
Communicationd/oassocw/neurologicalandpsychd/o
MUTISM
28Fptmute,rigid,catatonic.Notonmeds.WhatTx?
LORAZEPAM
Whatconditioninpatientswithschizophrenicorschizophreniformpsychosisis
associatedwithpoorprognosis?
INITIALONSETDURINGADOLESCENCE
Mostcommoneyetrackingmovementabnormalityinptswithschizophrenia?
INAPPROPRIATESACCADES(saccadicintrusions)
NoadditionalcriterionAsymptomsarerequiredforthediagnosisofschizophreniaif
HALLUCINATIONSOF2ORMOREVOICESCONVERSING
thepatienthaswhichsymptom?
Whatisthetermforsenselessrepetitioninschizophrenics?
ECHOLALIA
Whatisassociatedwithpoorprognosisinschizophrenics?
EARLYAGEOFONSET,NEGATIVESYMPTOMS,LACKOF
PRECIPITATINGFACTORS
Schizophreniformdisorderdiffersfromschizophreniaprimarilyin
DURATION
Whatarethecharacteristicsofchildhood-onsetschizophrenia?
CHRONICCOURSE,UNFAVORABLEPROGNOSIS,
HALLUCINATIONS,DELUSIONS
35yoptstabilizedonmethadonemaintenancetx5yrsisBIBfamilytoEDbcptis
lethargic/confused.Duringassessmentptbecomesobtunded/respdepression.
Familyreportsptrecentlybegannewmed.Whichmedislikelyresponsible?
CARBAMAZEPINE
Schizophreniconhaldol10developsacuteEPS.Cause?
CESSATIONOFSMOKING
Schizophrenicstabilizedonhaldol10.ReturnofpsychoticSx’safterstartingmedfor
CARBAMAZEPINE
anothercondition.Cause?
Identical-appearingimpostorhasreplacedDad:
CAPGRA’SSYNDROME
SchizophrenicwithVH,restlessness,markedthirst,agitation,elevatedtemperature,
ANTICHOLINERGICINTOXICATION
dilatedpupils,dryskin.Dx?
Notalikelycharacteristicofchildhood-onsetschizophrenia:
ACUTEONSET
Whatfactorisassociatedwithabetterlong-termprognosisinptswschizophrenia? ONSETAFTER35YEARSOFAGE
Goodprognosticfeatureinschizophrenia
ACUTEONSET
Moleculartargetsforimprovingcognitioninschizophreniahaveshownpromisevia
D1RECEPTORAGONISM
whichofthefollowingmechanisms?
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Whichofthefollowingantipsychoticmedsismostlikelytobeeffectiveinptswith
refractoryschizophreniawhohavefailedtoimprovewithotherantipsychotics?
CLOZAPINE
(2X)
Schizophrenicstopstakingantipsychotic.Statesthatnothingiswrong.Whatisthis
behavior?
A22y/optisbroughttotheEDbyfamilymemberswhoreportunusualbehavior
thathasworsenedoverafewweeks.Disorganizedanddifficulttointerview–
stating“Theworldisending!Youmustrepentnow!”Patientisactively
respondingtounseenothersandaccusesfamilyofbeing“devils”.Nofamily
historyandnopriorpsychhistoryforpt.Behaviorbegantwomonthsagofollow
gradfromcollege.Whatisdx
Schizophrenicpatientbecomingcatatonicwithwaxyflexibility.Whichisthemost
appropriatemedication?
Whichofthefollowingismorecommoninpatientsexperiencingafirstepisode
psychoticdepressionatoldagecomparedtoyoungerage?
POORINSIGHT
Schizophreniformdisorder
LORAZEPAM
NIHILISTICDELUSIONS
SomatoformDisorders
32y/ocannotmovetherightleg.Examdoesnotfindacause.Dxislikelytobe
conversiond/oifwhichofthefollowingisfound?(6x)
SYMPTOMSNOTINTENTIONALLYPRODUCED
Preoccupationandfearofhavingcontractedseriousdiseasebasedon
misinterpretationofbodilysxsdespitemedicalevalandreassurance.(3x)
HYPOCHONDRIASIS
25y/oreferredbyplasticsurgeon,claimsthatpartofherfaceisswollen.(2x)
BODYDYSMORPHICDISORDER
Evokedpotentialtestingmaybeusefulintheevalofwhichcondition?
PSYCHOGENICBLINDNESS
IntheUS,ptsmeetingthediagnosticcriteriaforneurasthenicoftenmeetcriteriafor
somatoformdisorderdepressionedisorderandwhichofhefollowingcategoriesof ANXIETY
disorders?
Psychconsultedre:43y/owhoc/o“lumpinthroat,”headaches,bloating,backpain,
diarrhea,chestpain,painfulurination,sexualindifference;complaintsdoNOT
SCHEDULEREGULARVISITSWITHAPHYSICALEXAM
matchobjectivefindingsfromdxworkup.Whatshouldberecommendedtopt’s
PCP?
Multiplicityofcomplaints,multipleorgansystems
SOMATIZATIOND/O
Whatiscommonlyassociatedwithconversiond/o?
LOWINTELLIGENCE
40-year-oldcannotspeakafterascreamingargumentwithspouse.Patientwrites,“I
havebeentryingtospeak,butcannotmakeasinglesound.”Throatexamisnormal. CONVERSIONDISORDER
Thereisanoccasionalloudcough.Diagnosis?
Somaticsx/complaint,negativemedicalworkup,negativepsycheval
LOOKAGAINFORORGANICETIOLOGY
Mainclinicalfactorofhypochondriasisvs.somatizationd/o?
FEAROFHAVINGADISEASE
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Hallucinationsinptwithconversiond/oarecharacterizedas:
HAVINGCHILDISH,FANTASTICQUALITY
Primaryfocusofptwithhypochondriasis:
DISEASE
Thepresenceofwhichofthefollowingwouldsuggestthatapatienthas
somatizationdisorderratherthanageneralmedicalcondition?
COMPLAINTSINVOLVINGMULTIPLEORGANSYSTEMS
Characterizedmainlybycognitiveratherthanperceptualpreoccupation
HYPOCHONDRIASIS
Psychiatristisaskedtoseeageneralmedicalinpatientforreportedhypochondriasis.
MEDICALCONDITION
Whichofthefollowingisthemostimportantdifferentialdiagnosticconsideration?
Ptisevaluatedforunilaterallowerextremityweaknesswithnoapparentphysiologic THEREISARISKTHATRELEVANTNEUROLOGICILLNESS
explanation.
WILLBEIDENTIFIEDINTHEFUTURE.
Apatienthasperiodicpelvicpainforpasttwoyears.Hadlaparoscopy,diagnosed
withendometriosis,startedoralcontraceptivesandanalgesicswithsomerelief,
stillhassymptoms.Thepatientreportsworrythatshewillquitjobduetopain.
Callsdoctoreveryfewdaystoaskwhethernewtxshouldbeconsideredorshe
mayhavecancer?.Whatisdiagnosis:
Somaticsymptomsdisorder
18y/optpresentswithanacuteonsetofblindnessafterwitnessingthemurderofa
SYMPTOMSWILLFULLYRESOLVEINAMATTEROFDAYS
closefriend.Neurologicalexaminationisinconsistentwithlossofvisionbut
ORWEEKS.
otherwiseunremarkable.Whatismostprobableoutcomeforthispt?
24y/optw/suddenonsetstumblingandpaininlegs,negativeneuroworkup–saw
acounselorpreviouslyforprotractedgriefafterfather’sdeath–increasedconflict CONVERSIOND/O
withhusband.Dx?
Neurasthenia,anacceptedconditioninEuropeandAsia,correspondstowhichof
thefollowinginDSM-IV-TR?
UNDIFFERENTIATEDSOMATOFORMDISORDER
Whatisthekeyelementforsuccessfulmanagementofsomatoformdisorders?
ENSURINGREGULARFOLLOWUPFROMPCP
Tourette’sDisorder
WhatsymptomsaremostcommonlyassociatedwithTourette’ssyndrome?
OBSESSIONSANDCOMPULSIONS
PathologicfindingsinbrainofTourette’s?
NOABNORMALITY
WhatantipsychoticmedicationishelpfulintreatingTourette’s?
HALOPERIDOL
WhichmedishelpfulinTouretteSyndromewhocan’ttolerateclonidine?
GUANFACINE
Guanfacine’sprimaryeffectisthroughwhatmechanismofaction?
Presynapticalpha2adrenergicreceptoractivation
Nameforticscomprisedofobscenegestures
COPROPRAXIA
OneoftheearliestsxofTourette’s:
EYE-BLINKINGANDHEADJERKING
Initialapproachforchildwithnew-onsetticdisorder
CLINICALMONITORING
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Whatmediseffectiveintxofmotor/vocalticsassociatedwTourettesyndrome
refractorytotxwithantipsychoticsandalphaadrenergicagonists?(x2)
TETRABENAZINE
Comorbidconditionw/Tourette’sinkids:
ADHD
Ticseveritybeginstodecreaseduringwhichageperiod?
PsychotherapytechniqueforchildrenwithTourette’ssyndrome.
ADOLESCENCE
Habitreversal
PersonalityDisorders
Whichtesttoconfirmpersonalitydisorder?
MillonClinicalMultiaxialInventory(MCMI-III)
Personalityd/owchronicfeelingsofemptiness,transientpsychoticsx,mood
swings,tumultuousrelationships,self-mutilation,poorself-image,impulsivity?
(5x)
BORDERLINE
WhichisatargetofDBTinolderadultsthatisnototherwiseincludedinthe
standardDBTprotocol?(3x)
EMOTIONALCONSTRICTION
Whatpersonalityd/oisassociatedwithtransientpsychoticsymptoms(2x)
BORDERLINE
Whichdisorderhasgreatestco-incidenceofalcoholabuseanddependence?(2x)
ANTISOCIALPERSONALITYDISORDER
Personalityd/oshouldbeconsideredinddxofcyclothymicd/o?(2x)
HISTRIONIC
Whatpersonalitydisorderresultsindisplaysofrapidlyshiftingandshallow
expressionofemotionsinpatients?(3x)
HISTRIONIC
Ptswithwhichpersonalityd/oseesthemselvessociallyinept,personally
unappealing,orinferiortoothers?(2x)
AVOIDANT
Ptprominentlyusesthedefensesofisolationofaffect&intellectualization.
Descriptionoflifeeventsappearstoinvolvereactionformation.Whatpersonality OBSESSIVE-COMPULSIVE
traitismostlikelytocharacterizethispt?(2x)
Anotherpsychiatristreferstoaptbysayingthisptis“special”andneedreally
goodtreatment.Youneedtobecarefulwiththeptto:(2x)
ANTICIPATETHEPOTENTIALFORSPLITTINGBETWEEN
THEREFERRINGMDANDYOURSELF.
AvoidantPDdiffersfromSchizoidPDby:(2x)
DESIREFORSOCIALRELATIONS
WhicharethedimensionsoftheFiveFactorModelofPersonality?
NEUROTICISM,EXTRAVERSION,OPENNESS,
AGREEABLENESS,CONSCIENTIOUSNESS
Whichsymptomisassociatedwithschizophreniaspectrumdisorders(clusterA
personalitydisorders)
SOCIALWITHDRAWAL
Whichpersonalitydisorderismostassociatedwithalcoholism?
ANTISOCIAL
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Whichinterventionishelpfulindealingwithaborderlineptonamedicalward?
SETTINGLIMITSWITHTHEPTONTHESTRUCTUREOF
THEMEDICALCARE
Extremelydemandingpatientrepeatedlycallspsychiatrist’sofficeandberatesstaff
SETLIMITSWITHTHEPATIENT
inoffensiveterms.Whichstepshouldthepsychiatristtakefirst?
Usefulinfotoconfirmdiagnosisofantisocialpersonalityd/o(APD)in20y/opatient? SCHOOLCOUNSELINGRECORDS
Interpersonalexploitativenessisadiagnosticfeatureof(2x):
NARCISSISTICPERSONALITYDISORDER
29y/oFw/moodswings-moodchangesveryrapidly,sometimeswithout
prompting,fromelationtodepressionorintenseanger.Thesemoodslastminutes
tohours.Herhistoryissignificantforpromiscuity,spendingsprees,tumultuous
relationships,unstableself-image,andoccasionaluseofcocaine.Hxofabrief
BORDERLINEPERSONALITYD/O
periodofparanoiaandAH?Duringandemotionalbreak-upwithherlastboyfriend,
whichremittedaftera2-dayadmissiontothepsychunit.WhenaskedaboutSI,she
reportsthatitisalwaysinhermindandthat,wheneversheisunderstress,shecuts
herarmswithasharpbladetorelieveastrongfeelingofemptiness.MostlikelyDx?
Personwithcovertobstructionism,procrastination,stubbornness,andinefficiency
maybeclassifiedassufferingfromwhichpersonalityd/ooutsideofcurrentDSM
classification?
PASSIVE-AGGRESSIVE
40y/oMemotionaldetachment,littleinterestinsex,noclosefriends.AxisIIDx?
SCHIZOIDPD
Commonsymptomsofparanoidpersonalitydisorder
PREOCCUPATIONW/UNJUSTIFIEDDOUBTSOF
LOYALTY/TRUSTWORTHINESSOFFRIENDS/ASSOCIATES
Underlyingdynamicofmuchofthebehaviorofptswithparanoidpersonalityd/o:
ADEVELOPMENTALFAILURETOACHIEVEOBJECT
CONSTANCY
20y/oMwithpoorperformanceincollege,beforewasverygoodstudentexceptfor
notbeingabletofinishassignedprojectsatcollege.Classmateshavedescribed
bizarrebehavior,suchascountingloudlyorrepeatingwordssilently.Hedoesnot
OBSESSIVECOMPULSIVEPERSONALITYDISORDER
wanttofollowothersrulesbuthisowns,hebelievesnobodyunderstandshimand
areagainsthim.
Ptwithbodydysmorphicd/omayhavewhatpersonalityd/o?
NARCISSISTIC
Whichpersonalitydisorderischaracterizedbyastyleofspeechthatisexcessively
impressionisticandlackingindetail?
HISTRIONIC
40y/ohandsurgeonhascomeintoconflictwiththehospitaladmin.Thoughthe
hospitalwentoutofitswaytorecruitthissurgeon,hehasfeltconsistently
betrayedandhasaccusedtheadministrationoftryingtoexploithimbyexpecting
thatheshouldtakemorecalls,thoughthishasneverbeenstated.ThedoctorPARANOIDPERSONALITYDISORDER
hospitalrelationshipdeterioratedfurtherwhenpeerreviewraisedaquestion
aboutoneofthesurgeon’scases.Thesurgeonbelievesthatnoneofhiscomplaints
havebeensatisfactorilyresolved.Hehasbecomemoreunforgivingandisolated:
(2x)
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Ptbecomespanickyanddistressedeverytimepsychiatristgoesonvacation,this
patternismostlikelyacharacteristicof:
DEPENDENTPERSONALITY
Ptwithhistrionicpersonalityd/ostormsinhispsychodynamicsessionandafew
minuteslate,clearlyinrage.Heexpresseshopelessnessanddeclaresvehemently
thathemustdivorcehiswife.Nextbestintervention:
ENCOURAGETHEPTTOREFLECTMOREONWHATHAS
HAPPENEDTOTRIGGERSUCHPAINFULFEELINGS.
22y/oborderlinesplittinginpatientstaff.Youshould:
EDUCATESTAFFABOUTSPLITTING
DDxofhistrionicpersonalitydisorderincludeswhatotherpersonalityd/o?
DEPENDENTPERSONALITYDISORDER
Whichpersonalityd/oshouldbeinthedifdxofagoraphobia:
DEPENDENTPERSONALITYDISORDER
23y/oMw/Borderline.Hadfightw/g/fnowpsychotic,cutting,AHw/commandto
BRIEFINPATIENTHOSPITALIZATION
harmself.Whatlevelofcare:
Ptsw/thispersonalityd/omostlikelytohave1stdegreerelativeswithdepression
BORDERLINE
AccordingtoDSM-IV-TR,whatpersonalitydisorderinadultsrequiresevidenceof
anotherspecificpsychiatricdiagnosispriortoage15?
ANTISOCIAL
Ptrepeatedlybecomesdistressedafterwhatseems,eventothept,tobeminor
disappointments.Ptalsoseemstosufferfromextremenarcissisticvulnerability.A
therapistutilizingself-psychologywouldbemostlikelytointerpretthisasdueto?
ALACKOFDEVELOPMENTALLYAPPROPRIATE
EMPATHICCAREGIVERS.
DBThasbeenshowntobeeffectiveinthetreatmentofwhatpersonalitydisorder?
BORDERLINE
Whatpersonalitydisordersshouldbethemainconsiderationindifferentialdxof
schizotypalpersonalitydisorder?
AVOIDANT
16-year-oldadolescentisbeingevaluatedforpossibleschizophrenia.Afamily
historyofwhichofthefollowingpersonalityd/oismoststronglyassociatedwith
thisdx?
SCHIZOTYPAL
25y/ohospitalizedforappy.Ptreportsbeing"botheredbysurgeon'saura".Lives
alone,noclosefriends,getsonwebsitesaboutaurasandcrystalwork.Pt'smother
affirmshe's"alwaysbeenthisway."Whichpersonalitydisorder?
SCHIZOTYPAL
DBTpatientarriveslatewithrecentrelapseondrugsandcuttingaftermarital
fight.Highestpriorityofsessionshouldfocusonwhat?
SelfInjuriousBehavior
Alcohol
Ptwhois2monthssoberondisulfiram,whatlabstudiesshouldbedoneatbaseline
Transaminases
andafter2monthsoftreatment?
Unsteadygait,appendicularataxiainLEonlyandnormaleyemovement.Walks
withlurchingbroad-basedgait.(8x)
CEREBELLARDEGENERATION(ALCOHOLIC)
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Ptw/oaddictionandsocialanxietyd/odiscussestheirpainfulexperienceof
anxietyduringtheirfirstAAmeeting.Whatreplyisconsistentwith12-step
facilitationtherapy?(7x)
Usingcashonlyd/tsubstantialdiscomfortwhilewritingchecksorsigningcredit
cardreceiptsinthepresenseofothers(becauseofmessyhandwriting)?
“YOUDIDTHEMOSTIMPORTANTTHING,YOUWENT
TOTHEMEETING.ITWILLGETEASIER.”
Socialanxietydisorder
WhatdoesCAGEstandfor?(7x)
CUTDOWN,ANNOYED,GUILTY,EYEOPENER
FetalAlcoholSyndromeisassociatedwith:(5x)
FACIALDYSMORPHISMS,POSTNATALGROWTH
RETARDATION,INTRAUTERINEGROWTH
RETARDATIONANDLEARNINGDIFFICULTIES.
Evalofwhichlabtestismostspecificforchronicheavyalcoholconsumption?(5x)
%CDT(PERCENTCARBOHYDRATEDEFICIENT
TRANSFERRING)
50y/owithalcoholdepatEDforconfusion,oculomotordisturbances,ataxia,and
THIAMINE
dysarthria.Givewhichmedfirst?(5x)
WhatisthefunctionofAl-anon?(2x)
HELPSRELATIVESCOPEWITHALCOHOLICSDRINKING
Evidencethatalcoholismishereditary?(2x)
ADOPTEDSIBLINGS
Labparameteroftenelevatedinpatientswithalcoholdependence?(2x)
MEANCORPUSCULARVOLUME
AlcoholichallucinosisversusDT:alcoholichallucinosisincludeswhat?(3x)
ACLEARSENSORIUM
Thebestwaytoaskadolescentaboutalcoholabuse?(2x)
HAVEYOUEVERRIDDENINACARDRIVENBY
SOMEONEINCLUDINGYOURSELF,WHOWASHIGHOR
HADBEENUSINGALCOHOLORDRUGS?
44y/optwETOHdependence/cirrhosisinquiringaboutmedtostopdrinking.Ptis
disappointedindrinkingbehaviorbutotherwiseshowslittleevidenceofamood
ACAMPROSATE
D/O.Whichmedshashismostfavorablerisk/benefitprofileforETOHcessation?
(2x)
AlcoholicondisulfiramreportsEtOHcravings.Whatdrugwilllikelydecrease
these?(3x)
NALTREXONE
Whichmedreducesacetaldehydedehydrogenasefunction?(2x)
DISULFIRAM
Characteristicofalcohol-inducedblackouts(2x)
ANTEROGRADEAMNESIAFORATIMEWHILEHEAVILY
INTOXICATEDBUTAWAKE
Aftergastricbypasssurgery,continuedabuseofwhatsubstancecanbemorelife
threateningthanbeforesurgery?
Alcohol
Typicalfeatureofepilepticactivityinalcoholicptwithseizure12hafterEtOH
cessation
MULTIPLEEPISODES
Molecularmechanismofethanolcausesintoxication?
NMDAANTAGONISMANDGABAAGONISM
Alcoholwithdrawalsymptomspeakinhowlong?
48HOURS
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Activatingwhatreceptorcausesalcohol’santi-anxiety,motorimpairing,and
sedative-hypnoticeffects?
GABA-A
ComparedtoEtOHdependenceinyoungpts,EtOHdependenceinpts>65yois:
LESSCOMMON
BestcharacterizestheroleofspiritualityinabstinenceinalcoholicswhoattendAA?
THEREISLIMITEDEVIDENCESUPPORTINGTHEROLEOF
SPIRITUALLTYINABSTINENCE
Mostcommonsubstanceofabuseinadolescents:
ALCOHOL
40yofemalepresentswithnewonsetparanoiddelusionaswellasAHandVH,no
SI.DenieshxofmaniaorMDD.PthasprevioushospitaladmissionforMDDand
anxietysymptomsandhadtakencitalopram,sertralineandquetiapinebutwasnon- ALCOHOL-INDUCEDMOODDISORDER
compliant.Hxrevealschronicalcoholusewigheavydrinkingoneweekago.Whatis
themostlikelycauseofherparanoia?
WhatisaSEcommontobothnaltrexoneanddisulfiram?
ELEVATEDLIVERENZYMES
72y/owchronichepatitisinEDfortreatmentofongoingalcoholwithdrawal.
Hospitalprotocolistousechlordiazepoxide,butpsychsuggestlorazepambecause
METABOLIZEDTHROUGHGLUCURONIDECONJUGATION
ElectrolyteimbalancecommoninchronicheavyEtOHuse?
HYPOMAGNESEMIAANDHYPOPHOSPHATEMIA
PsychiatristrecommendsAAtoptwhoabusesalcohol,butptreluctant.Nextstep?
RECOMMENDPATIENTSPEAKTOACURRENTAA
MEMBER
Dysfunctionalprocessinsystemictherapyillustratedbymothertelling15yosonto
confronthisfatherabouthisexcessivedrinking.
Triangulation
Whichisthemostsensitiveandspecificlabtestforidentifyingheavydrinkingand
monitoringTx?
CARBOHYDRATEDEFICIENTTRANSFERASE(CDT)
Womendifferfrommenindrinkingbehaviorandindevelopmentandeffectsof
alcoholused/o,comparedw/men,women:
HAVEAFASTERPROGRESSIONFROMFIRSTDRINKTO
ALCOHOLDEP
MostclearlypredictiveofalcoholabstinenceforalcoholicswhoattendAAmeeting: OBTAININGASPONSOR
Coreprincipleofmotivationalinterviewingthatisusedtotreataddictivebehaviors: DEVELOPDISCREPANCY
Exampleofaharmreductiontechniqueusedinpeoplewithopioiddependence:
NEEDLEEXCHANGE
50y/optwETOHdependenceadmittedtoEDforconfusion,oculomotordeficits,
ataxia,anddysarthria.Thefirststepinacutemanagementofthispt’scondition:
ADMINISTRATIONOFTHIAMINE
Canalcoholfumesatwork(brewery)causeaptondisulfiramheadaches?
YES
Sixthcranialnervepalsyisassociatedwithwhichalcohol-relatedsyndrome?
WERNICKE’SENCEPHALOPATHY
InERfollowingMVA,receivesIVdextrose5%.Experiencesconfusion,oculomotor
paralysis,anddysarthria:
WERNICKE’SENCEPHALOPATHY
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Testsfordetectingexcessivedrinking
TRIGLYCERIDES,MCV,SGGT,SGOT
Patternofdrinkinginwomenalcoholics(asopposedtomales):
SOLITARYDRINKING
Non-specifichematologicalmarkerforheavydrinking
MCV
ComplicationofheavyEtOHlikelytopersistbeyondfirstweekofwithdrawal?
SLEEPFRAGMENTATION
Ptwithalonghistoryofsubstanceabuseisadmittedtothehospitalforshortnessof
breath.Theptisfoundtohavemultiplegranulomasinbothlungs;abiopsyreveals METHYLPHENIDATE
thepresenceoftalcwithinthegranulomas.Ptmostlikelyabusingwhatsubstance?
32y/optwcocainedependenceprescribeddesipraminebyanotherMDfor
withdrawal-assocdepression.Psychiatristshouldwarnptofwhatadverseeffects
thatmightresultfromaninteractionbetweendesipramineandcocaine?
HYPERTENSION
Whatistheprincipleproblemwithdisulfiraminthetreatmentofalcoholics?
PTCANSTOPTAKINGITANDRESUMEDRINKING
VerballyandphysicallyaggressiveafterasmallamountofETOH.Dx?
PATHOLOGICALINTOXICATION
Wernicke’sdiseasetriad:
OPHTHALMOPLEGIA,ATAXIA,GLOBALCONFUSION
DrinkingETOHwhiletakingdisulfirammostlikelytoproducewhatsx
NAUSEAANDVOMITING
EqualdoseofalcoholcorrectedforbodyweightleadtohigherBALinwomanthan
me.Why?
LOWERLEVELSOFALCOHOLDEHYDROGENASEIN
GASTRICMUCOSA
Avoidwhichdruginaptintoxicatedwithalcoholorasedativedrug?
LORAZEPAM
CharacteristicofCloninger’stype1alcoholism:
LATEONSET
Individualpsychotherapyforalcoholicsmosteffectivewhenfocusingon
INTERACTIONSWITHPEOPLE
<ostseriouscomplicationforaptwhoingestsEtOHwhileondisulfiram
HYPOTENSION
Alcoholic,AHon&offalcohol,extremeagitation.Duringwithdrawalgivebenzoand HALDOL
WhatisdecreasedwithheavyETOHintake
GLUCOSE
41y/optinEDw/bloodalcohollevelof0.425.Ptisstuporous,thepulseis75,BPis
110/70.UDSisnegative.Whatistheimmediateconcern?
RESPIRATORYFAILURE
Alcoholintoxicationcauseswhatsleepabnormalities?
FRAGMENTATIONOFSTAGE4SLEEP
Characteristicoffemaleasopposedtomalealcoholics:
FASTERPROGRESSIONOFDISORDER
60y/oalcoholicwith4dayh/ounstructured,maligningAHandclearsensorium.Dx? ETOH-INDUCEDPSYCHOTICD/O
ComorbiddisorderinmenwithPTSD
ETOHABUSE/DEPENDENCE
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Whatisasideeffectofbothnaltrexoneanddisulfiram?
ELEVATEDLFTs
LFTafter8weeksisrequiredinptswithalcoholdependencetreated:
NALTREXONEANDDISULFIRAM
25y/opthasbeenDxw/ETOHdependence.PthasneitherhadETOHtodrinknor
metanyofthecriteriaforalcoholdependenceinthepast6months.Whatremission EARLYFULLREMISSION
specifierswouldapplytotheDxofETOHdependence?
Duringtreatmentofalcoholdependence,thepsychiatristworkswithapatienton
planningforemergenciesanddrinkrefusalskills.Thisisusingwhattherapeutic
mentality?
CBT
IndividualswhoconsumeETOHatnightusuallydevelop:
DECREASEDSLEEPLATENCY
Incomparisontomen,womenwhoabuseETOHaremorelikelytoalsohave…
AXISIDIAGNOSIS
Anidiosyncratic,physiologicrxntoEtOHincludingrash,nausea,tachycardia,and
hypotensionoccursinwhatethnicgroup?
ASIANS
AlcoholabuseinmencommonlyassocwwhatcomorbidmentalD/O
ANTISOCIALPERSONALITY
Priorityoftreatment:Maritalproblems,Depression,vs.Alcoholism.
ALCOHOLISMDETOXANDABSTINENCE
Typicaldurationforalcoholdetoxusingbenzodiazepinewithdrawal?
3TO5DAYS
Whatisonedisadvantageofusingshorterhalf-lifebenzodiazepinesinthetreatment
INCREASEDLIKELIHOODOFGRANDMALSEIZURES
ofalcoholwithdrawal?
Ptsover65y/owhoexperiencechronicinsomniaaremostlikelytohavewhat
comorbidpsychconditions
ALCOHOLABUSE
PrimarycharacteristicofWernickeencephalopathy
ACUTEONSET
Inptswithself-injuriousbxandSI,thedecisiontoadmittotheinpatientunitwould
RECENTALCOHOLABUSE
bestronglysupportedbyhxof:
TheroleofthesponsorinAAcharacterizedby:
ANAAMEMBERWHOPROVIDES1:1GUIDANCEIN
WORKINGTHEAAPROGRAM.
84y/optwhxofchronicalcoholism&amnesiawillneed,inadditiontoabstinence,
ENSURINGAGOODNUTRITIOUSDIET
thefollowinginterventiontopreventaprogressiontoalcohol-relateddementia:
Disadvantageofusingshorterhalf-lifebenzodiazepinesinthetxofEtOH
withdrawal:
INCREASEDLIKELIHOODOFGRANDMALSEIZURES
55y/optpresentsfordetoxafteralcoholbinge.Ptreports“mildliverdisease.”Labs
CHLORDIAZEPOXIDE
revealALTis80andAST70.Whatwouldbethepreferredagentfordetox?
Drugofabusethatdoesnotdependonspecificneuronalmembranebindingsites:
ALCOHOL
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54y/optwithgastriculcerundergoesemergentsurgeryand30hrspost-op
becomesconfused,agitatedandrespondstointernalstimuliandsuffersa
generalizedtonic-clonicseizure:Dx:
DELIRIUMTREMENS
44yoMfoundwanderingaimlessly,broughtintoED,BPis200/132,HR112and
regular.Ptisbelligerent,pickinghisskin,feelslikeinsectscrawlingonhisskin.
Orientedonlytoname,tremulous,isdiaphoretic,dilatedpupils,palmarerythema,
andspiderangiomataonchest.Whatexplainshissymptoms?
DELIRIUMTREMENS
Naltrexoneisclassifiedas?(Mechanismofaction)
OPIATEANTAGONIST
42yroldptevalfordepression,drinks3drinks/night,>3onweekends,ptreports
readinesstoquitas"3/10",whatisthemosthelpfulresponseformotivational
interviewing?
WHYA3ANDNOTA0
Substantiallyincreaserateofsustainedabstinencea/wDisulfiramuse?
Involvepatient’spartnerinmedicationadministration
Substances
84yoptgoestoEDwithfever,drymouth,visualhallucinations.Isfound
tachycardia,restless,toxicityofwhatmedicationmostlikelycausedsymptoms?
Caffeineresultsindopaminergicactivity,where?
Benztropine
AdenosineReceptor
23y/oinERafteraparty.Dehydration,dilatedpupils,HTN,elevatedCPK.Which
drugdidhetake?(7x)
MDMA
35y/optinEDpresentswhypoventilation,bluelips,pinpointpupils,crackleson
lungauscultation,mildarrhythmiaonEKG.Mostlikelydrugofabuse:(4x)
CODEINE
AfterOD,pthasfever,confusion,tachycardia,drymouth,urinaryretention,
dilatedandunresponsivepupils.Whichmedicationwouldtreatthis?
(Anticholinergictoxicity)(4x)
PHYSOSTIGMINE
Astateofgeneralfatigue,hypersomnolence,anddepressionmaybeseenduring
COCAINE
apatient’swithdrawalfrom:(4x)
WhatisthemuopioidpartialagonistapprovedbytheFDAforthetreatmentof
patientswithopioiddependence?Administeredsublingually:(3x)
BUPRENORPHINE
PtpresentstoEDc/oringinginears,abdominalpain,andisfoundtohavemild
metabolicacidosis.Overdoseofwhatsubstance?(4x)
ASPIRIN
AfterCannabisingestion(inchronicuse)itcanbedetectedinurinehowlong?(3x) ONEMONTH
Mostcommonlyabusedsubstanceamongpatientswithschizophrenia?(2x)
NICOTINE
Thefirstsymptomreportedbypatientswithemergingamphetaminepsychosisis:
PARANOIDIDEATION
(2x)
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Motivationalinterviewingoftenusedaspartofthetreatmentofwhich
conditions?(2x)
SUBSTANCEABUSE
ThelargenumberofCB1cannabinoidreceptorsfoundinthehippocampusbest
explainscannabis’negativeeffectson:(2x)
SHORTTERMMEMORY
Acutecaffeinewithdrawalsymptomsinclude:(2x)
HEADACHE
WhatisNOTlikelytobeaneffectiveinterventionforaphysicianwithasubstance OBSERVINGTHEPATIENTUNTILHE/SHEBECOMES
abuseproblem?(2x)
MOTIVATEDTOSEEKTREATMENT
Whichdrugcauseseuphoria,afeelinglike“flyingabovethedancefloor,”social
withdrawal,nystagmus?(2x)
KETAMINE
Whatdoesthepentobarbitalchallengetestdo?(2x)
ESTIMATESTHESTARTINGDOSEOFPENTOBARBITAL
USEDFORBARBITURATEDETOXIFICATION
Personwhosmokesapackofcig/daystopssmokingandhasneedforcigafter
everymeal.Thisis…(2x)
ENVIRONMENTALTRIGGER
Tachycardia,HTN,excessiveperspiration,pupilsdilatedincollegestudentafter
attendingaparty.Drug?(2x)
COCAINE
Whatdrugisusedtotreatautonomicsxsassociatedwithheroinwithdrawal?(2x) CLONIDINE
Ptconfused,disoriented,drymouth,dilatedunresponsivepupils.Likelyingested:
BENZTROPINE
(2x)
Motivationalinterviewingofpatientswithaddictivedisordersaddresseswhat?
(2x)
AMBIVALENCEABOUTBECOMINGDRUGFREE
MaximumdurationofPCPintheurine:(2x)
8DAYS
Whileintoxicatedwithapsychomimeticdrug,ayoungmanreports“seeing
sounds”and“patternsofcolorslikefireworksorcoloredflames”associatedwith
realauditorystimuli.Whatbestdescribesthistypeofsensoryexperience?(2x)
SYNESTHESIA
Whichofthefollowingareasofthebrainismostassociatedwiththereward
effectsofcocaine?(2x)
NUCLEUSACCUMBENS
Tachycardia,dilatedpupils,hypervigilance,anger,HTN,psychoticsxs,andchills.
UDSshows?(2x)
AMPHETAMINES
Maximumtimecocainemetabolitesdetectableinurine?(2x)
4DAYS
Ptwhobecameaddictedtocodeinehasalongh/omultiplerelapses.Pthas
completeda2wksdetoxand2wksfollowingthat,isabouttostartacourt
mandatedmaintenanceonnaltrexone.Priortostartingthemaintenancetherapy, NALOXONE
psychiatristshouldcheckforresidualphysicaldependencebyadministeringwhat?
(2x)
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Whatshouldleadaprovidertoincreaseconcernforpatienthavingasubstance
usedisorder?
HxofmisusingotherdrugsorEtOH
40y/odentistisreferredforevaluationbystaffmemberswhoareconcerned
abouthiserraticbehavior,stayingexcessivelylateattheofficeandproblemswith
NITROUSOXIDE
dexterityintreatingpts.Hecomplainsofnumbnessandweaknessoflimbs,lossof
dexterity,andlossofbalance.Whichdrugsisthedentistmostlikelyabusing?(2x)
A25yearoldbodybuildercomestoedwitheuphoria,peripheralvisionlossand
hallucinations.
GHB
ptstatestheseoccurredafteringestingaliquidnutritionalsupplementanhourago.
UDSandBALarenegative.Whatdidheingest?
21-year-oldmaleatEDisagitated,believescomputersareflashingmessagesat
him,andsays“Ineedmyknifetoprotectmyself.”WhichsubstanceonUDS?(2x)
AMPHETAMINES
Bestdescribestheinterventiongoalassociatedwithcontemplationstageof
substanceabusetreatmentusingmotivationalenhancementtherapy:(2x)
ACKNOWLEDGEAMBIVALENCEANDEVOKEREASONS
TOCHANGE
NeurotoxicityassociatedwithMDMAisassociatedwithdeficitsinneuronsthat
producewhichofthefollowingneurotransmitters?(2x)
SEROTONIN
Whattermbestdescribesbuprenorphine’sactionatthemuopioidreceptor?(2x) PARTIALAGONIST
18y/optinERw/acloudedsensorium,agitationandhyperactivity,mild
paranoia,pressuredspeech,andeuphoric,thoughlabilemood.Onexam:HTN,
tachycardia,andverticalnystagmus.Themostlikelyused?(2x)
PHENCYCLIDINE(PCP)
Flumazenilisusedtotreat:(2x)
BENZOINTOXICATION
17y/optisbroughttotheERbyfriendswhoreportthatheingestedadrug2
hoursearlier.Pt’sbehaviorafterthedrugingestionasrelaxedandtranquilbut
talkative.Soonafter,theptc/odrowsiness,dizziness,andnausea.Onexam,pt
hasamimpairedbutlabilelevelofconsciousness.Thedrugscreenisnegativefor GAMMA-HYDROXYBUTYRATE(GHB)
benzodiapzepines,barbiturates,andopioids.PsychMDalertsEDtothepossibility
ofimminentrespiratorydifficulty.Whatdrugmostlikelycausedthiscondition?
(2x)
Substancefoundinseveralover-the-countersymptomcoldremediesandis
abusedtoproduceadissociativefeeling:(2x)
DEXTROMETHORPHAN
Psychotherapyforaddictionutilizesadisease-modelapproachandemphasizes
acceptanceofthediseaseandsurrendertohelpbeyondoneself:(2x)
12-STEPFACILITATION
Drugofabuseassociatedwithsxsofbruxism,anorexia,diaphoresis,decreased
abilitytoorgasm,andhotflashes:(2x)
MDMA/ECSTASY
Healthcareprofessionalhasseizureasaresultofdrugaddiction,seizureisnotfrom
Meperidine
withdrawal.Whatsubstancearetheyusing?
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22y/optwithsuddenonsetanxiety,SOB,palpitations,dizziness,lightheadedness,
andsweatypalms2xdays.Paranoid,fearscollegepolicewillknowparticipatedin
weekend“hash-bashfestival.”Whatisdiagnosis?
CANNABIS-INDUCEDANXIETYDISORDER
Whatisthemostefficacioustreatmentoftobacco-usedisorder?
Verenicline
Heavysmokingwilllikelyaffectthedosingofwhichofthefollowingmedications?
OLANZAPINE
Guydrinks12-15cupsofcoffeeaday,Hasinsomniaandheadachesrelievedby
drinkingcoffee.Irritableandpoorconcentrationifhedoesn’tdrinkcoffee.Howto Cutcaffeineby25%weekly
treat?
Aneonatehastransienthyperreflexia,irritability,andtremorsfollowedbyaperiod
ofdepressedinteractivebehaviorandpoorresponsetoenvironmentalstimuli.
OLANZEPINE
Whatdidthechildsmotheruse?
Psychotherapyforalcoholismthattargetsptambivalence
MOTIVATIONAL-ENHANCEMENTTHERAPY
Smokingcessationstrategywithhighestsuccessrate
BUPROPIONPLUSGROUPTHERAPY
Howmanyhoursafteringestiondoamphetaminesreachpeaklevels?
2HOURS
Otherthannicotinereplacementtherapies,evidencemoststronglysupportstheuse
VERENICLINE
ofwhichofthefollowingagentsforsmokingcessation?
Whatisthemechofactionofverniclineinthetreatmentoftobaccousedisorders?
BLOCKSREINFORCINGEFFECTOFNICOTINE
Molecularmechanismofketamine?
ANTAGONISTATNMDARECEPTORS
Whichdiagnosisisassociatedwiththehighestriskofpersontopersonviolence?
ALCOHOLUSEDISORDER
Urinetoxicologyinaptonbupropionmayproduceafalse-positivescreeningtestfor
AMPHETAMINE
whichsubstances?
ThepsychiatristasksptwEtOHdependencetoratereadinesstoquitdrinkingon
scaleof1-10.Whenptresponds“3,”psychiatristasks,“Whya3insteadofa1?”The MOTIVATIONALENHANCEMENTTHERAPY
psychiatristisusingwhichofthefollowingmodalities?
19yocollegestudentatEDatepostagestampsizedLSD,nowdistressed,beggingfor
ADMINISTRATIONOF20MGDIAZEPAM
help,saysthingsaren'tright.Whatisthetreatment?
A24yoptwhoisintoxicatedwithPCPpresentstotheED.Theptisverbally
aggressive,threateningtostaff,andactivelyhallucinating.Pt’sbehaviorhas
ADMINISTERHALDOL5MGIM
escalateddespiteredirectionandplacementinaquietseclusionroom.Whichofthe
followingisthebesttreatmentformanagingthispatient’sacutepresentation?
Needleexchangeisanexampleofwhattypeofreductionstrategies?
HARM
LSDmayleadtoperceptionofdiffcolorswhenhearingvariousmusicaltones.
Phenomenon?
SYNESTHESIA
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Ptpresentshighlyanxiouswithseizures,Has,emotionallability,irritability,dizziness,
andconfusion.MRIrevealsmultiplesubcorticaldemyelinatinglesions.Themost
TOLUENE
likelysxisexposuretowhichofthefollowingsubstances?
A32yoptpresentstoEDwithacuteonsetparanoia,AHandhypervigilance.On
examptistachycardic,HTNandhasPMAandanxiety.NopastpsychhxorPMH.
URINETOXICOLOGY
ROSis+intermittentsubsternalCP.WhichtestismosthelpfulindevelopingaDDX?
Chronicrxopioiduseaffectswhichhormone?
TESTOSTERONE
NopregnantpremenopausalptinEDhasgalactorrhea,elevatedprolactinlevel,pt
deniesseizuresorantipsychoticmeds.Whatconditioncouldexplainthis?
COCAINEWITHDRAWAL
Ptwhoisdependentoncannabishadaperiodofcancellingapptsfrequentlybutis
nowshowingupconsistentlyandacknowledgesthatthenegativecostsofmarijuana
CONTEMPLATION
outweightheanxiolyticeffectandiscommittingtoalteringhisuse.Ptisatwhich
stageofchange?
17y/oreceivingcounselingforschooltruancy.Studentunderstandtruancyisnota
desirablebehaviorandisdiscusseswaystoimproveschoolattendance.Whatstage PREPARATION
ofchangeisstudentin?
Dosefor2ppdsmoker?
42mg/day.
Asmokerstates"Ineedtoquit,butI'mnotreadyyet."Whatistheptsstageof
change?
CONTEMPLATION
Theclassofmedswithgreatestprevalenceforprescriptiondrugabuse
PAINRELIEVERS
Whatisreasonthatopioidantagonistnaloxonecanbeco-administeredwith
buprenorphinesublinguallywithnoadverseeffect?
POORSUBLINGUALABSORPTIONOFNALOXONE
Ataminimum,statephysicianhealthprogramsprovidewhichservicestoimpaired
physician?
STRUCTUREDMONITORINGPROGRAM
Coreprincipleofmotivationalinterviewingwhenusedtotreataddictivedisorder:
DEVELOPDISCREPANCY
Stimulant-inducedcravingfordrugsofabuseismostfrequentlymediatedbywhich
GLUTAMATE
neurochemicals?
Withdrawalfromwhichsubcanconstitutealife-threateningmedicalemergency?
SEDATIVE-HYPNOTICS
Whichofthefollowingisusuallythefirststepintreatingadolescentswithsubstance ENGAGINGTHEPTANDFAMILYINSTEPSTODIMINISH
abusedisorders?
DRUG-SEEKINGBEHAVIOR
Apersonwhosmokesapackofcigarettesperdaystopssmokingandexperiences
theneedforacigaretteaftereverymeal.Exampleof:
ANENVIRONMENTALTRIGGER
Whichofthefollowingshouldleadapsychiatristtobeconcernedabout
benzodiazepineabuseordependence?
HISTORYOFABUSEOFOTHERDRUGSORALCOHOL.
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Whichofthefollowingdiagnosticcriteriahelpstoestablishadiagnosisofsubstance
RECURRENTUNSUCCESSFULEFFORTSTOCONTROLUSE
dependenceratherthansubstanceabuse?
MosteffectiveinitialtreatmentforptswithPCPintoxication:
URINEACIDIFICATION
17y/optinERafterreportingrecentcocaineusetoateacher.Ptisagitated,hyper-
aroused,andunabletoconcentrateontheinterview.Ptdeniesfrankhallucinations,
LORAZEPAM2mg
butappearsverydistractibleandfrightened.Onexam:HRof100withNSR.The
mostappropriateinterventionwouldbetogivewhichmed?
21y/optpresentstotheEDafterusingmarijuanaforthefirsttime.Theptreports
poundingheart,sweating,fearofdyingandshaking.Themostappropriatenextstep LORAZEPAM
toadminister:
45y/optw/hxofMDDrecentlyhadCitalopramtwofold,withadditionof
Trazodone
100mg/nightforsleep.Tendayslater,ptpresentstoEDwithsevererestlessness,
nausea,vomiting,anddiarrhea.Serumtoxnegative.Onexam,ptconfused,mildly
agitated,febrileto100.8,andtachyto108.Neuroexam=nystagmus,B/L
hyperreflexia,andankleclonus.Tonewithoutrigidity.Inadditiontostoppingall
meds&startingsupportivecare,whatmedshouldbegiven?
LORAZEPAM
Theimmediatephaseofamphetaminewithdrawalischaracterizedbydysphoriaand
anhedoniaaswellaseuphoricrecallofdruguseandcravingforthedrug.The
2-4MONTHS
anhedoniaanddysphoriaareusuallymuchimprovedinwhichofthefollowingtime
frames?
Whichofthefollowingsubstancesismostlikelytocauseapatienttodevelop
persistentdementiawithlong-termuse?
Bestinitialtreatmentofacutepsychosissymptoms2/2inhalantsuse,best
INHALANTS
Watchfulwaiting
21y/optatEDafterhavingnausea,sweating,andhematemesis,alsoreportsrecent
headachesandnumbnessintheextremities.CTshowsgeneralizedbrainatrophy,
INHALANTS
labsshowrenaltubularacidosisandCPKof3120.Consistentwithchronicuseof?
Medusedasstandardtreatmentofopioiddetox:
CLONIDINE
23y/optisadmittedtothehospwithrhabdomyolysisandrenalfailure.On
examination,ptisnotedtohaveataxiaandperipheralneuropathy.Following
treatmentofthept’sacutemedicalproblems,itbecomesapparentthatthepthas
dementia.MRI:cerebellaratrophyanddiffusewhitematterchanges.Whichlong
standingsubstanceofabuse:
TOLUENE
Amuscularmalepatientpresentstoanoutpatientpsychiatriccliniccomplainingof
discomfortinpublicplacesandexcessiveirritability.Thoughwarmoutside,the
patientisdressedinheavy,baggyclothes,makinghimappearbiggerthanheis.
ANABOLIC-ANDROGENICSTEROIDABUSE
Thepatient’sbeliefthatheisshrinkinggreatlydistresseshim.Whichofthe
followingisthemostlikelydiagnosisforthepatient?(2x)
WhichofthefollowingsubjectiveeffectsisthebasisoftheappealofMDMA?
CONNECTEDNESSTOOTHERS
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20y/omalecollegestudentwhoisaweightlifterandstarplayeronthefootball
team,isbroughttotheEDbyroomatesbecauseoftheirconcernregardingthept’s
increasedirritabilityandaggressivenessoverthelastseveralweeks,including
threatstoharmparticularclassmates.Theroommatesreportthatthepatienthas
beenexercisinginthegymmorefrequentlythaNusual.Theydonotthinkhehas
beendrinkingalcoholexcessively,usingcannabisorotherillicitsubstancesandhe
hasneverdonesointhepast.
ANABOLICSTEROIDUSE
Whatisperceptualabnormalityinwhichhallucinogenicdrugscausemovingobjects
TRAILING
toappearasaseriesofdiscreteanddiscontinuousimages?
Medicalspecialtywithhighestrateofsubstanceused/o:
EMERGENCYMEDICINE
Mostoftenabusedhallucinogensassociatedwith:
TOLERANCETOEUPHORICEFFECTS
WhattechniquemaybedangerousinmanagingpatientwithPCPintoxication?
TALKINGTHEPATIENTDOWN
Forpolysubstancedependenceneedcriteriafor:
SUBSTANCESASAGROUP,BUTNOTFORANY
PARTICULARSUBSTANCE
Howshouldbuprenorphineandthebuprenorphine/naloxonecombobe
administered?
SUBLINGUALLY
Prolongedingestionofhighdosespyridoxinecauses:
SUBACUTESENSORYNEUROPATHY
Mostcommoncauseoforganicparanoidsymptom
STIMULANTABUSE
Formication,agitation,stereotypicaloralmovements,&paranoia?
Stimulantintoxication
Physostigmineisusefulintreatingtoxicsyndromefromoverdosewith:
SCOPOLAMINE
Whichdxcriteriahelpstoestablishdxofsubstancedependencevs.abuse?
RECURRENTUNSUCCESSFULEFFORTSTOCONTROLUSE
15y/optisfoundunresponsivebyparentsafterptreturnsfromaparty,friend
confirmsptusedheroin.Whataresigns?
PUPILLARYCONSTRICTION
Withdrawalsymptomsinchronicheroinuserspeakafterwhatperiodoftime
36HOURS
Naltrexonepreventsrelapseofopioiddependencymosteffectivelyinwhichgroup? PHYSICIANS
Ataxia,nystagmus,muscularrigidity,normalorsmallpupilssuggestsintoxication
withwhat?
PCP
Txofptsw/substanceabusewhohaveacutepain
PATIENT-CONTROLLEDANAGESIA
AbstinencecomplianceincreaseswithrandomUDS.Thisisexof:
PARTIALREINFORCEMENT
Apost-oppt’swasreceiving75mgIMmeperidine.Afterswitchingtomeperidine
THELOWERPOTENCYOFPOMEPERIDINECOMPARED
100mgpoptreportsinadequatepainrelief.Shehasnopastpsychandabuseissues.
TOIM
Thisisdueto:
UDSperformedonptwhoeatspoppyseedbagelsmayyieldfalse(+)for?
OPIATES
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Mechanismresponsiblefortheeuphoriceffectsofmethamphetamine:
DOPAMINERELEASEINTHENUCLEUSACCUMBENS
Atwhatreceptorsdoesphencyclidine’smajoractionoccur?
N-METHYL-D-ASPARTATEACID(NMDA)
Checkforresidualphysicaldependenceofopiatesbyadministering:
NALOXONE
Pttook20tabs500mgacetaminophentabs6hoursago.Ptis52kg,pulse96,BP
135/65.PtalertandinNAD.Serumacetaminophenlevelis60Ug/ml.Liverfxntest
areminimallyelevated.Mostappropriateaction?
N-ACETYL-CYSTEINE
Causeslong-terminhibitionofnewserotoninsynthesisanddecreaseinserotonin
terminaldensity:
METHYLENEDIOXYMETHAMPHETAMINE(MDMA)
Labtogetpriortostartingnaltrexone
LFT’s
9y/ochildwapathy,decreasedappetite,irritability,dizziness,confusion,ataxia,and
HA.Recentlymovedtoolderhouseinanindustrialcity.Whichlabtesthelpfulfor
LEADSERUMLEVELS
dx?
Dissociativecompound,senseoffragmentationanddetachmentduringintoxication KETAMINE
PtrecentlyemigratedfromEastAfricapresentstoestablishcareatahealthcenter.
Ptdeniesuseofalcohol,tobacco,orcommonstreetdrugs,howevernotesthat,
priortoimmigrating,heroutinelychewedleavesofalocalplanttoimprove
KHAT
concentrationandhelphimstayawakewhileworkinglonghours.Whichplantdidpt
mostlikelyuse?
Commoncauseofacutecerebellarataxiainadults:
INTOXICATIONWITHANTIEPILEPTICS
Abruptwithdrawalofnicotineisfollowedbywhatsymptom?
INSOMNIA
Whatsubstancecancausedementiaw/long-termuse?
INHALANTS
16y/oadolescentwithburnstotheface2/2playingwithaspraypaintcanthat
ignited.GradesdroppedfromA’stoF’s.Themotherisconcernedabouthearing
problems.Nootherhealthproblems.Dx?
INHALANTABUSE
15year-oldptisbroughttoERbyfriendsduetoaggressionandimpairedjudgment
whileintoxicated.Onexamthepthasamildtremor,nystagmus,slurredspeech,
INHALANTS
unsteadygaitandhypoactivedeeptendonreflexes.Theptcomplainsofdizziness
andappearsuncoordinated.Whichofthefollowingsubstancesdidtheptuse?
13yoptisreportedbyparentstobesleepyduringtheday,outofit,dazed,
decreasedappetite,nauseated,redeyes,runnynose,redsoresaround
mouth.Whichsubstanceisplayingarole?
AEROSOLINHALANTS
Whatsymptomsofnicotinewithdrawalmaypersistinapatientforupto6mos?
INCREASEDAPPETITE
Intreatmentofrecoveringaddict,rehearsalstrategieshelpwithwhat?
IDENTIFYINGINTERNALHIGH-RISKRELAPSEFACTORS
Speedball
HEROINANDCOCAINE
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MiosisduetoODon:
HEROIN
PtintheEDisinwithdrawalfromasubstance.Symptomsincludemuscleaches,
lacrimation,yawning,anddiarrhea.Whatsubstancewithdrawn?
HEROIN
Methadoneprescriptioninheroindependenceiscalledwhatkindofstrategy?
HARMREDUCTION
Needleexchangeisanexampleofwhattypesofreductionstrategies?
HARMREDUCTION
Apatheticandnervous,seeshalos,flashesofcolor,recentETOHandLSD,
unemployed,neverhospitalized.Dx?
HALLUCINOGENPERSISTINGPERCEPTIOND/O
Recoveringaddictinrelapsepreventiontherapy,andhasmanyriskfactors.Rather
thandevelopingacopingstrategyforeachriskfactor,dowhat?
FOCUSONSKILLTRAINING,COGNITIVEREFRAMING,
ANDLIFESTYLEINTERVENTIONS
OpioidNOTdetectedinstandardUDS:
FENTANYL
Whatsubstanceisonlydetectedinurinefor7-12hoursafteringestion?
ETOH
Useoflevomethadylacetatehydrochloride(LAAM)formanagementofptw/opioid
ELIMINATIONOFNEEDTOTAKEHOMEDOSES
dependenceallowsfor:
Whatistheadvantageofbuprenorphinecomparedtomethadonetaperin
detoxificationfromopiatedependence?
LESSRISKOFRESPIRATORYSUPPRESSION
Innicotinedependence,neurotransmittermostassociatedw/rewardand
reinforcementis:
DOPAMINE
ODonsleepingpill.Hotskin,blurryvision,urinaryretention,drymucous
membranes,tachycardia,decreasedbowelsounds.Whatisthepill?
DIPHENHYDRAMINE
35y/optw/hypoventilates,bluelips,pinpointpupils,cracklesonlungexam,and
mildarrhythmiaonEKG.Intoxicatedwith:
CODEINE
2dayss/phospitalizationdysphoric,fatigued,hypersomnic,vividdreams,
requestingdoubleportions:
COCAINE
Whatsubstanceisacommoncauseofflashbacks?
CANNABIS
Useofwhichsubstanceinadolescenceisassociatedwithdevelopmentof
schizophrenia?
CANNABIS
Acuteanxiety,restless,flushed,irritable,nauseous,worseahlersandinsomnia–
attributeseverythingstressatwork
CAFFEINEINTOXICATION
Hasintoxicationsyndromebutnotasubstanceofabuse
CAFFEINE
LSDandmescalineshowagonistatwhichofthereceptors?
5HT2A
Themostcommonmoodalteringsubstanceworldwide:
CAFFEINE
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Whatmedisnotusedintxofopioidmaintenanceandrelapseprevention?
Patientinsustainedopioidremissionisnow10wkpregnant,howtomanage?
BUPROPION(NALTREXONE,METHADONE,
BUPRENORPHINEANDCLONIDINEAREUSED)
Continuemethadonecurrentdose
Phenobarbitaltolerancetestishelpfulindetoxfromwhat?
BENZODIAZEPINES
Anursew/24hrhxofanxietyandinsomniahasageneralizedtonic-clonicseizure.
Dx?
LORAZEPAMWITHDRAWAL
35y/oEDphysicianisreferredforpsychiatricevaluationbyEDmedicaldirectorwho
hasnotedrecentchangesinthephysicianincludingramblingspeech,psychomotor
agitation,aflushedandexcitedappearance,andrestlessdemeanor.Oneval,
physiciancomplainsofhavingtoworkexcessiveanddifferentshiftsduetoseveral CAFFEINEINTOXICATION
membersofthegroupbeingoutonvacationorsick.Physicianalsocomplainsof
palpitations.Thephysicianadmitstousingalcoholtoinitiatesleepandmore
caffeinetostayalert.Dx?
Howlongafteringestionisamphetaminedetectableinurine?
1-2DAYS
AbenzodiazepinereliablyabsorbedwhenadministeredPOorIM:
LORAZEPAM
20y/optw/acuteonsetbelligerence,distortionofbodyimage,depersonalization,
andcloudysensoriumfollowingingestionofastreetdrug.Horizontalnystagmus,
ataxia,andslurredspeech,pupilsnotdilated.Management:
ADMINISTERAMMONIUMCHLORIDE
Whatisacharacteristicofhallucinogens?
ADDICTIVECRAVINGISMINIMAL
Contraindicationtotheuseofclonidineinmanagingopiatewithdrawal:
AORTICINSUFFICIENCY
Conjunctivalinjectioninapatientwithasubstanceusedisorderismostsuggestive
of:
CANNABISINTOXICATION
Drugofabusethatexertsiteffectsprimarilythoughserotoninreleaseandreuptake
METHYLENEDIOXYMETHAMPHETAMINE(MDMA)
inhibition:
Developingaplanformanagingafuturelapseorrelapseofaddictiveillnessismost
HELPLIMITTHEEXTENTANDLENGTHOFDRUGUSE
likelyto:
Phenomenaismosttypicalofhallucinogenuse?
ILLUSIONS
Sideeffectcommontobothnaltrexoneanddisulfiram:
ELEVATEDLIVERENZYMES
Themostcommonacuteeffectofrecreationalketamineuse:
DISSOCIATION
Inrelapsepreventiontherapy,teachingarecoveringptw/anaddictionthatrelapse
WARNINGSIGNSPRECEDESUBSTANCEUSE
isaprocessratherthananeventconveyswhat?
Duetotheincreasedriskofstrokeandsuddendeath,theU.S.FDAhasdetermined
thatwhatsubstanceisunsafewhenusedincombinationwithephedra?
CAFFEINE
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Reducingtheintensityofanaddict’sreactiontoenvironmentalremindersofdrug
useisagoalofwhatintervention?
CUEEXPOSURETREATMENT
Havingapt’sfriendorspousemonitordisulfiramadministrationandreporttothe
treatingpsychMDisanexampleof:
NETWORKTHERAPY
Follow-upstudiesontheDrugAbuseResistanceEducation(DARE)programfor
elementarystudentshavereportedwhatfinding?
SMALLTONON-MEASURABLEDECREASESIN
SUBSTANCEUSEBYPARTICIPANTS
Whatdrugismostappropriateinemergencytreatmentofanticholinergictoxicity?
HALOPERIDOL
17yoptbroughttoEDafterreportingrecentcocaineusetoteacher.InEDptis
agitated,hyperaroused,unabletoconcentrateoninterview.Ptdenies
hallucinations,howeverappearsverydistractible,frightened.Physicalexamshows
HR100,normalrhythm.Whatismostappropriateinterventiontogive?
LORAZEPAM2MG
Emergencymanagementofptwphencyclidine(PCP)toxicityshouldinclude?
HALDOL,BENZODIAZEPINES,CLOSESUPERVISIONAND
RELATIVELYDARK,QUIETSURROUNDINGS.
AcetylcysteineisTxofchoiceforODof:
ACETAMINOPHEN
Riskofhepatotoxicitywillpeakinhowmanyhoursafteracetaminophenoverdose? 72to96HOURS
Formication,agitation,stereotypicaloralmovementsandparanoiaaresxof
intoxicationwithwhichofthefollowingsubstances?Intherewardpathways
implicatedintheneurobiologyofaddiction,dopaminergicneuronsprojecttothe
nucleusaccumbens.Thecellbodiesoftheseneuronsresideinwhatareaofbrain?
VENTRALTEGMENTALAREA
An18y/optpresentstotheEmergencyDeptwithacloudedsensorium,agitation,
hyperactivity,mildparanoia,pressuredspeechandeuphoricthoughlabilemood.
PhysicalexamnotableforHTN,tachycardiaandverticalnystagmus.Cause?
PCP
Inlong-termopioidtherapyformanagementofchronicpain,thesignmost
indicativeofaddictionis?
ADMINISTRATIONBYNON-PRESCRIBEDROUTES
26yopresentstoEDduetoPMR,slurredspeech,constrictedpupils.Intoxicated
with...?
OPIODS
Ptarrestedforposessionofcocaine,spends2daysinjail,aftermissingappswith
subsabusecounselor.Interventionisreferredtoas…?
DRUGCOURT
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SomaticTreatments
Anticonvulsants
Clinicallysignificantincreaseinlamotrigineconcentrationmayoccurifco-
administeredwith:(6x)
VALPROICACID
CarbamazepineshouldbeD/C’ediftheabsoluteneutrophilcountisbelow:(2x)
3,000
25y/optreceiveshaldolanddevelopslaryngospasm:Tx?(2x)
BENZTROPINE
Ptw/treatment-resistantmaniaandh/orapidcyclingisbeingtreatedw/
carbamazepineandthyroxine.Afteraddingclozapinetheptisclinicallystabilized. D/CCARBAMAZEPINE
Thept’smostrecentWBCisbelow3,000.Intervention?(2x)
Whichofthefollowinganticonvulsantsmaybeassociatedwithkidneystones?(2x) TOPIRAMATE
Ptwithtreatmentresistant,rapidcyclingbipolardisorderwhorecentlystarted
lamotriginedevelopsarashontheface.Ptadmitstoamildsorethroatandthinks DISCONTINUELAMOTRIGINEANDCOMETOTHE
hemayhaveafever.Whichofthefollowingisthebestrecommendationforthe
APPROPRIATEER
psychiatristtomaketothept?(2x)
Whichmeddecreasestheefficacyoforalcontraceptive?(2x)
OXCARBAZEPINE
TeratogeniceffectofbothVPAandcarbamazepine:(3x)
NEURALTUBEDEFECTS
Drugprophylacticfortreatmentofmigraines:(2x)
VALPROATEandTOPIRAMATE
Interactionbetweenvalproicacidandlamotriginethatcausesseverederm
reactions?
VALPROICACIDINHIBITSGLUCONURONIDATION
Whichmedwouldallowforlargerdailyreductioninbenzotaperfrom
supratherapeuticrange?
Valproate
Mosteffectivemedmosteffectiveformigraineprophylaxis
TOPIRAMATE
Acuteonsetofhematuriaandlumbago?Sideeffectofwhichanticonvulsant?
Topiramate
Whichofthefollowingagentshasbeenshowntomoderateweightgaininsomepts
METFORMIN
treatedw/valproateandatypicalantipsychotic?
PttakingcarbamazepineforBMDpresentswithweaknessandpallor.The
psychiatristnotesthepresenceofanon-blanchingrashonthepatient’sarms.The
mostimmediatelabtesttoorderis:
CBC
Adequateasamonotherapyforjuvenilemyoclonicepilepsy:
VALPROATE
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Fetalexposuretovalproateduringpregnancyincreasesriskof:
NEURALTUBEDEFECTS
CoarseningoffacialfeaturesandhirsuitismareSEofwhatmed?
VALPROATE
Adequateformonotherapygeneralizedtonicclonicszs:
VALPROATE
8y/oDxw/Bipolard/oisabouttostartvalproicacid.Whatneedstobemonitored
frequently?
LIVERFUNCTION
Whichantibioticmaysignificantlyraisecarbamazepinelevelsandprecipitateheart
block?
ERYTHROMYCIN
Sideeffectmorefrequentincarbamazepinethanlithium
DIZZINESS
Hairloss+weightgainareSEofwhichanticonvulsant
DIVALPROEXSODIUM
Lancinatingfacepain,triggeredbyminorsensorystimuli,besttreatedinitiallywith: CARBAMAZEPINE
InducerandsubstrateofCYP3a4(iemayrequiredoseincreaseafterseveralweeks
tomaintainsteadystate)
Carbamazepine
Whichdrugusedinthetreatmentofpatientswithepilepsyisassocw
hyponatremia?
CARBAMAZEPINE
Whichofthefollowingbaselinelabsshouldbeobtainedforptbeingtreatedwith
valproate?
LIVERFUNCTIONTESTS
Whatmedicationstrategiesismosteffectiveandrapidinthetreatmentofsevere
bipolarillness,manicphase?
ANTIPSYCHOTICMEDICATION+LITHIUMOR
VALPROATE
Associatedwithneuraltubedefectinfirsttrimesterofpregnancy:
VALPROATE
Whichofthefollowingmedsisassociatedwithbenignmaculopapularrashin
approximately10-15%ofpt’swithinthefirst3weeksoftreatment?
CARBAMAZEPINE
WhatuniquebindingpropertyofAbilify(Aripiprazole)distinguishesitfromother
antipsychotics?
PARTIALAGONISTACTIVITYATD2RECEPTORS
Howdoesabilifyreverseneurolepticinducedhyperprolactinemia?
PartialD2agonist
Afterpsychiatristaddsnewmed,ptturnsbrightredw/sunburnlikerash,similarto
LAMOTRIGINE
SJS.Whichmedcausedthis?
WhatCBCvalueismostimportanttofollowwhenonDepakote?
platelets
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GeneralAntidepressants
27y/odepressedpatienttreatedwithSSRIandtranylcypromine(andwith5-
hydroxytryptophan)nowpresentswithVH,mildconfusion,myoclonicjerks,
diaphoretic,flushing,restless:(6x)
SEROTONINSYNDROME
WhichantidepressantmedismostlikelytocauseHTN?(5x)
VENLAFAXINE
Whichantidepressantmedisbesttominimizeriskoforthostasisinan84y/o?(4x) NORTRIPTYLINE
Antidepressantpreferredfor>65y/oforwhichbloodlevelsareclinicallyuseful
(3x)
DESIPRAMINE
62y/optwithhxchestpainhasanddepression,onemonthagostartedon
paroxetine,presentswithnewonsetoflethargyandheadache,lowNaandBUN,
normalK,andCrof0.4.Nexttest:(2x)
URINEOSMOLALITY
38y/otakingimipramine300mgqdayforrecurrentMDD.After3weeks,moodis
improved,buthasdifficultypassingurineandmilderectiledysfunction.
Appropriateaction?(2x)
BETHANECHOL25MGTID
Antidepressantlesslikelytocausesexualdysfunction:(2x)
BUPROPION
WhichisamuscarinicSEofantidepressants?(2x)
URINARYRETENTION
30y/opthasbeentreatedforunreasonablefearofeatinginpublicplaces,feeling
ofembarrassmentinpublicplaces,andangeroverthepossibilityofbeing
scrutinized.Pthasnotrespondedtohighdosesofparoxetine,citalopram,
PHENELZINE
buspirone,andalprazolam,eachofthemadministeredfor4-6wks.Whichmeds
wouldbeappropriatefornext?(2x)
Whatmedscouldbehelpfulinthetreatmentofdepressioninpersonsoverthe
ageof65becauseitdoesnotproduceorthostatichypotension:(2x)
BUPROPION
Whatantidepressanthasplasmalevelthatcorrelateswiththerapeuticresponse?
(3x)
IMIPRAMINE
62y/optwithhxchestpainhasanddepression,onemonthagostartedon
paroxetine,presentswithnewonsetoflethargyandheadache,lowNaandBUN,
normalK,andCrof0.4.Nexttest:(2x)
URINEOSMOLALITY
Whichofthefollowingantidepressantmedsisconsideredtobethemosteffective
PAROXETINE
inthetxofprematureejaculation?(x2)
WhichSSRIisrecommendedforpostpartummothersbreastfeeding?
A34-yoptwithepilepsyhascontrolledseizuresbutdevelopsdepression.Whichis
themostappropriatedepressionmed?
SERTRALINE
SERTRALINE
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Pton2mgrisperdalisstartedonProzac20mgtotreatcomorbiddepressive
InhibitionofCYP2D6
symptoms.Ptthendevelopsacutesystolicreaction.Whichmechanismresponsible?
70yowdepressionplusconfusionx2wkfollowingthestartoffluoxetine.An
adverseeffectissuspectedbutneuroexamnormal.Whatevaluationwouldbemost UREAANDELECTROLYTES
usefultoconfirmsuspicionofanadverseeffect?
Rareoccurrencesofpriapismaremostfrequentlyassociatedwith:
TRAZODONE
WhatisthebestreasonforpreferringtheuseofSSRIantidepressantsoverTCAsin
txofptsw/depressionwhoare>65yo?
LESSLIKELYTOCAUSEORTHOSTATICHYPOTENSION
ApsychiatristwishedtostartaninpatientonaTCAbuttheptisreluctantdueto
hearingthesedrugsmaycausedrymouth,constipation,blurredvisionandurinary
retention.WhatTCAwouldhavetheleastsideeffects?
DESIPRAMINE
25yoCFstartedondesipramine50mgQday.SEofconstipation,drymouth,visual
POORMETABOLISMOFCYTOCHROMEP450
difficulties,tremorandagitatedfeeling.Notonanyothermedications.Bloodlevelis
SUBSTRATES
400ng/ml.Mostlikelycause?
WhichsideeffectoccurslessfrequentlyinptstreatedwithmirtazapinevsSSRIs?
DIARRHEA
Mirtazapineisanantagonistatwhichreceptor?
ALPHA-2-ADRENERGIC
46y/oFptpresentswincreasingdysphoria,progressivelyincreasedfrequency
withwhichshewashesherhandstothepointofexcoriation,doserangefor
effectiveTx:(x2)
FLUVOXAMINE200-300MGDAILY
Dermatologistasksforpsychconsulton38y/opt.5yearsagoptbeganhaving
concernsofperceivedskinirregularityshecalls“bumps.”Overtimeincreasingly
moredifficultforhertoignore“bumps”andpicksatthem.Severaldermatologists
havebeenunabletoconvinceptitisnotadermatologicalissue.Asidefromthisno
evidenceofothermoodorthoughtd/o.First-linetreatmentforpt?
FLUVOXAMINE
Theriskofincreasedpsychosisforptswithpsychoticdisorderswhotakebupropion
DOPAMINE
isattributabletoenhancementof:
Thesideeffectsofsedationandweightgainareassociatedwithmirtazepine’s
antagonismofwhichofthefollowingreceptors?
H1
Pttakingvenlafaxineformonthsstopsabruptlyandcallspsychiatrist3dayslater
withnausea,insomnia,muscleaches,anxiety,dizziness,andtransient“electric
shock”sensations.Themostlikelycause:
ANTIDEPRESSANTWITHDRAWAL
58y/optisstartedoncitalopram20mgforMDD.After3wksptreportssome
improvementinvegetativesxsbutremainsdysphoric.Whatisthenextstep?
CONTINUECITALOPRAMATTHEPRESENTDOSEWITH
NOADDITIONALMED
Antidepressantw/shortesteliminationhalf-life:
TRAZODONE
Phenylethylamineantidepressantthattargetsserotoninandnorepinephrine
reuptakeinhibition
VENLAFAXINE
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Whatpharmacologicaltreatmentshouldbeusedforlong-terminsomniainptswith
TRAZODONE
dementiaover65yearsofage?
Keyelementinemergencytreatmentofptwserotoninsyndrome,beyondstopping
SUPPORTINGVITALFUNCTIONS
offendingagentis:
Mirtazepine(vsotherantidepressants)haslowincidenceofwhatsideeffect?
SEXUALSIDEEFFECTS
OrthostatichypotensionisleastlikelytooccurasaS/Ewithwhatantidepressants?
SERTRALINE.NORTRIPTYLINE,IMIPRAMINE,
AMITRIPTYLINE,TRAZODONE◊ORTHOSTATIC
HYPOTENSION
Whichantidepressanthasactivemetabolitesthatextenditseffectivehalf-life?
SERTRALINE
50y/ofiremanbecameclinicallydepressedaftersustainingamyocardialinfarction.
SERTRALINE
Whatisanappropriatemedicationtoprescribe?
MDDpatientwithgoodresponsetovenlafaxinepresentswithdysphoria,agitation,
SEROTONINDISCONTINUATIONSYNDROME
nausea,poorbalanceafterrunningoutofmedication.Causeofsx?
EffectiveforOCD
PAROXETINE,PHENELZINE,FLUVOXAMINE,
CLOMIPRAMINE(NOTBUPROPION)
Receptorblockedbyantidepressants->blurredvision
MUSCARINIC
Whichantidepressanthasstrongesthistamine-Raffinity?
MIRTAZAPINE
45y/optw/firstepisodeMDD,onPaxilandinsight-orientedtherapy,but
depressionworsensovermonths.TakesPaxilonlyoccasionally,asheisworried
aboutbecomingdependentonit(afriendwasaddictedtoValium).Best
intervention?
EDUCATEPATIENTONTHEDIFFERENCESBETWEEN
ANTIDEPRESSANTS,LIKEPAXIL,ANDBENZODIAZEPINES,
LIKEVALIUM.
WhatantidepressantincreasesREMsleep?
BUPROPION
WhatantidepressanthasanFDApregnancyuseBrating?
BUPROPION
Antidepressantwithlowriskofweightgain
BUPROPION
40y/optexperienceddelirium,tremor,diaphoresis,rigidity,hyperpyrexia,and
myoclonusinmakingthetransitionfromtheuseofclomipraminetophenelzine.Pt
ismostlikelyexperiencing:
SEROTONINSYNDROME
AntidepressantthatcausesParkinson’ssx:
AMOXAPINE
Wptsover65wMDD,BupropionhaswhatadvantageoverSSRIs?
FEWERDRUGINTERACTIONS
Trazodonerequireslargerdosestobeusedasanantidepressantduetolower
potencyaffinitytowhichreceptor?
SEROTONICTRANSPORTER
Restlessness,myoclonus,hyperreflexia,diaphoresis,shivering,tremor,and
confusionarecompatiblewithwhichdiagnosis?
SEROTONINSYNDROME
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ApsychiatryconsultisplacedregardingapatientwithSI.HistoryofBipolar
disorderandadmittedforVREbacteremia.BPof171/95,tempof100.9.Has
tremors,hyperreflexia,myoclonicjerks,notorientedatall,hasvisual
hallucinations.Medsincludelinezolid,lithium,sertraline,Risperdal.Whatis
diagnosis?
SEROTONINSYNDROME
MAOI
Whichofthefollowingopioidshasapotentiallylethalinteractionwith
monoamineoxidaseinhibitors(MAOIs)?(4x)
MEPERIDINE
45y/oFptonphenelzineforMDD,takesOTCmedicationforcoldsxanddevelops
PSEUDOEPHEDRINE
hypertensivecrisis.WhichOTCmedicationwouldmostlikelycausethis?(3x)
MinimumrecommendedwashoutperiodforfluoxetinepriortostartingMAOI(2x) 5WEEKS
TreatmentforpatientswithMAOIrelatedhypertensivecrisisintheERmay
involvetheadministrationofwhichofthefollowingmeds?(2x)
PHENTOLAMINE
WhichmediscomparativesafetyduringTxw/MAOI?
FENTANYL
Fatalreactionshaveoccurredwhenmonoamineoxidaseinhibitors(MAOIs)are
combinedwithwhichofthefollowingmedications?
FENTANYL
2wkwaitingperiodrecommendedwhenswitchingfromphenelzineto
tranylcyprominebecause:
TRANYLCYPROMINEISANAMPHETAMINEDERIVATIVE
PtstakingMAOIsshouldusecautionwhenconsumingwhat?
FAVABEANS
WhichmedisirreversibleMAO-Binhibitor?
SELEGILINE
Whatdrughasbeenknowntocausehypertensivecrisis?
PHENELZINE
2wkswashoutofwhichmedisneededbeforestartingfluoxetine
PHENELZINE
MAOIleastlikelytocausedrug-foodinteractionintherapeuticantidepressantdoses MOCLOBEMIDE
PttakingphenelzineistreatedinEDforchestpain.Whiletreated,ptdevelops
hyperreflexia,HTN,goesintocoma.Whichmedismostlikelycause?
MEPERIDINE(DEMEROL)
At10mgselegilinedoesnotrequiredietaryrestrictionb/c
MAO-BISNOTINVOLVEDWITHINTESTINALTYRAMINE
REACTION
MostfrequentsideeffectofMAOI’s
HYPOTENSION
WhichofthefollowingisanegativepredictorresponsetotreatmentwithETinpts
withMDD?
BORDERLINEPERSONALITYDISORDER
42y/optwithhxofHTNtreatedwithHCTZandlisinoprilpresentsforf/uofsevere
melancholicandvegetativedepression.Thepatient,whileadherenttoallmed
regimens,hasfailedmultiplecombosofantidepressantsandiscurrentlyona
ITISANIRREVERSIBLEMAO-A&MAO-BINHIBITORAND
CANONLYBESTARTED5WEEKSAFTERDISCONTINUING
FLUOXETINETODECREASERISKOFSEROTONIN
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regimenthatincludesfluoxetine.Thepsychiatristplanstodiscontinuefluoxetine
andstartselegiline.Themostimportantconsiderationtobemadebeforestarting?
SYNDROME
MAOIsaffectcatecholaminesbydirectlyretarding:
DEACTIVATION
Ptw/MDDhasbeenunresponsivetopriortrialswithaTCAandSSRIs.Pthas1st
BEGINTXWITHPHENELZINE
degreerightbundlebranchblockandpoorlycontrolledHTN.Ptw/noSI.Nextstep?
WhatinhibitorofmonoamineoxidaseisalsousefulinthetreatmentofParkinson’s
disease?
SELEGILINE
TCA
Whatdrughasacurvilineartherapeuticwindow?(6x)
NORTRIPTYLINE
WhatdrugisusefulintheRxofurinaryretentionsecondarytoTCAtherapy(5x)
BETHANECHOL
AfteranODonAmitriptyline,whattestisneeded?(4x)
EKG
MostfrequentcauseofdeathfollowingTCAoverdose:(2x)
ARRHYTHMIA
OptimalstrategyinmaintenancetxwithTCAforpatientwithrecurrentMDD(2x)
FULLDOSEANTIDEPRESSANTTHERAPY
MonitorTCAoverdoseusing(2x)
EKG
Bloodlevelsfortherapeuticandpotentiallytoxiceffectscanroutinelybeassessed
forwhichmed?
NORTRIPTYLINE
Suddendeathinchildrentakingwhichmedication?
TRICYCLICS
IncreasedPR,QRS,orQTonEKG:
TRICYCLICS
Psychiatristplanstoaddnortriptylineasadjuncttofluoxetine.Heshouldproceed
how?
STARTNORTRIPTYLINEATLOWERTHANNORMALDOSE
ThebesttimetoobtainECGinthetreatmentofchildrenwithTCA:
BEFORETREATMENT,FORALLCHILDREN,TOESTABLISH
BASELINE
ThisisaneffectivepharmacologictreatmentforsymptomsofOCD?
CLOMIPRAMINE
Whichantidepressantissuccessfullyusedtotreatpainsyndromes?
AMITRIPTYLINE
NortriptylineistheactivemetaboliteofwhichofthefollowingTCAs?
AMITRIPTYLINE
Whichtricyclicantidepressanthasthemostpotentantihistaminiceffect?
DOXEPIN
WhichTCAshouldbeavoidedinptsw/Parkinson’s?
AMOXAPINE
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Drymouth,blurredvision,constipation,urinaryretention.S/Eofwhat
psychotropic?
AMITRIPTYLINE
DoNOTuseinptw/narrow-angleglaucoma
AMITRIPTYLINE
85y/optw/hxofHTNandCOPDreportsfeelingdepressed.Thepthasanepisode
ofdepression20yrsago,whichwassuccessfullytreatedwithnortriptyline.Thept’s
HTNiscurrentlywellmanagedwithhydrocholorothiazide.Thephysicianprescribes PT’SADVANCEDAGE
nortriptyline25mgqday.After1wk,theptcallsandreportsfeelingnobetter.What
wouldbeanappropriatereasontoobtainanortriptylinelevel?
32y/optw/hxoftreatmentresistantdepressionwasbroughttoERafteroverdose
onimipramine.Ptreportedwantingtodie,butthenchangedhermindandthen
calledforhelp.Pt’sregularpsychMDhadrecentlyaddedimipraminetothept’s
partiallyeffectiveregimenoffluoxetine80mgqday.Ptisafebrile,BPis100/58and
INSISTONFURTHERCARDIACMONITORINGINEITHER
HRis96andregular.Ptisvagueaboutthedetailoftheattempt,butreportsno
THEEDORICU
longerfeelingsuicidal.Medicalresidentrecommendsadmissiontoapsychunit.
RequestforaTCAbloodlevelandEKGaredeferred.Medicalresidentassertsthat
thept’scombinedimipramineanddesipraminelevelof750ng/mlisnotinthe
cardiotoxicrange.WhatisthebestcourseofactionforthepsychMDtotake?
50yoreferredtopsychfollowingnegativemedicalworkupofabdpain.Ptappears
depressedandinconstantpain.Whatisthepreferredpsychintervention?
Whatcausesthecardiactoxicityofimipramineinoverdose?
OrthostatichypotensionassociatedwithTCA’siscausedbyblockadeofwhat
receptor?
STARTLOWDOSEIMIPRAMINE
BLOCKADEOFVOLTAGE-GATEDSODIUMCHANNELS
ALPHA-1-ADRENERGIC
80yroldptwithMDDhastriedSSRIsandSNRIswithnoimprovement,wantstostart
TCA,nocardiachxandEKGisnormal,whichmedicationismostappropriatedueto Desipramine
thesideeffectprofile?
SSRI
WhichSSRIhasmildanticholinergicactivityduetosomeaffinityatthemuscarinic
PAROXETINE
receptors?(3x)
FluoxetineshouldNOTbeprescribedwithwhat?(2x)
PHENELZINE
21y/optexperiencesabriefmanicepisodeafterstartinganSSRI.TheptmeetsDx
SUBSTANCE-INDUCEDMOODDISORDER
criteriaforwhatdisorder?(2x)
Serotonergicantidepressantsareappropriatetreatmentfordepressionin54y/o
ptwithrecentcoronaryarterybypassgraftsurgerybecausethey:(2x)
INHIBITPLATELETFUNCTIONING
WhichSSRIhasthegreatestpotentialfordiscontinuationsyndromewithmissed
doses?
PAROXETINE
SSRIwithshortesthalflife
FLUVOXAMINE
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Ptw/hxofMDDhasbeentakingFluoxetine40mgPOQDayforoneyearsince
achievingremissionofthirddepressiveepisode.Ptwantstostopmedication
becauseofsexualsideeffectsresponsivetoSildenafil100mgPRN.Whatshould
psychiatristrecommendtopt?
CONTINUETHEFLUOXETINEASLONGASITISEFFECTIVE
Whichofthefollowinghasthelongestmeanhalf-life:citalopram,paroxetine,
venlafaxine,fluvoxamine,trazodone?
CITALOPRAM
InstudiesthatcompareSSRIantidepressantswithTCAs,whichofthefollowingis
thebestdocumentedadvantageofSSRIsoverTCAs?
LOWERDROPOUTRATESDUETOSIDEEFFECT
TheSSRImostlikelytocausediscontinuationsyndrome:
PAROXETINE
MosttypicalSEoffluoxetine:
NERVOUSNESS,RESTLESSNESS,ANDANXIETY
DiscontinuationsyndromeassociatedwithSSRIconsistsof:
MALAISE,NAUSEA,PARESTHESIAS,DIZZINESS,MOOD
SYMPTOMS,ANDHEADACHE
WhichisacommonsideeffectleadingtodiscontinuationofSSRI’searlyin
treatment?
GIDISTRESS
WhichofthefollowingSSRIshaslongesthalf-life?
FLUOXETINE
BlackboxwarningonSSRIswithregardtochildrenandadolescents:
SUICIDALIDEATION
Whichofthefollowingwouldrepresentaconcernifadministeredconcomitantly
withaSSRI?
HYPERICUMPERFORATUM
WhichoftheSSRIantidepressantshasthelongestmeanhalf-life?
CITALOPRAM
SSRIw/noormildinhibitionofmajorP450isoenzymesof1A2,2C9,2C19,2D6,3A4 CITALOPRAM
Africanamericanstendtohavehigheractivityofwhichofthefollowingcytochrome
3A4
p450enzymes?
Increasespaxilconcentration:
CIMETIDINE
WhatisasleepdisturbancelikelytooccurafterinitiatingatrialofanSSRI?
BRUXISM
Whichofthefollowingmedshasthelowestlikelihoodofdiscontinuationsymptoms
FLUOXETINE
ifthemedicationisabruptlystopped?
45y/optwhoisingoodphysicalhealthreportsincreasedfatigue,decreased
appetite,andaninabilitytotakepleasureinusualactivities.Ptisbegunon
fluoxetine20mg/day,andpt’smoodimprovesoverthecourseof2weeks.However,
BEGINPROPRANOLOL10MGTID
ptnownotesanewonsetofanxietysymptoms,includingrestlessnessinthearms
andlegs.Ptisobservedtofidgetandseemsunabletositstillfortheexam.
Neurologicalexam:unremarkable.WhichcoursesofTxwouldbemostappropriate?
Whatmedhassomeevidenceofeffectivenessinbothpsychotic/nonpsychotic
subtypesofbodydysmorphicdisorder?
FLUOXETINE
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ThisSSRIisusedtotreatthediscontinuationsyndromecausedbyterminationof
otherSSRI’s:
FLUOXETINE
50y/ofiremanbecameclinicallydepressedaftersustainingamyocardialinfarction.
SERTRALINE
Mostappropriatemedicationtoprescribe:
PtwhorespondedinthepasttoSSRIsrequestsadrugfromthisclasswhen
subsequentlyseenforanotherepisodeofdepression.However,ptreportsconcerns
thatwhenthepreviousmedicationwastapered,ptexperiencedfatigue,insomnia, FLUOXETINE
abdominaldistress,flu-likesymptoms,anddizziness.Whatmedswouldbe
appropriateforthispt?
Whatmedismostpotentinhibitorofthenorepinephrinetransporter?
PAROXETINE
36y/optc/odysphoria,insomnia,fatigue,poorconcentration.Ptisstartedon
sertraline50mg,increasedto100mgin2weeks.2monthsafterdoseincrease,pt
reportsmoodgreatlyimproved.However,ptnotesnewonsetofsxofdelayed
ejaculation,frequentlytopointofanorgasmia.Hebelievesthisbeganalmost
immediatelyafterdoseincrease.Firststepinmanagementofproblemwouldbe?
DECREASETHESERTRALINEDOSAGETO50MG/DAY
CytochromeP450(CYP450)subenzyme,inhibitedby______,increasesTCAlevels
____
FLUOXETINE,2D6
SSRIswiththegreatestpotentialforslowingorblockingmetabolismofother
medications?
LUVOX
FalsepositiveurinetoxicologyscreenforBenzodiazepam?
SERTRALINE
Antipsychotics
60y/oon6mgrisperidone,50mgsertraline.Slowedthinking,drooling,cog-
wheeling,maskedfacies.Mood/paranoiaimprovedonmeds.Whattodo?(4x)
DECREASEDOSEOFTHEANTIPSYCHOTIC
Howdoantipsychoticmedselevateprolactin(PRL)?(4x)
PRLISUNDERTONICINHIBITORYCONTROLBY
DOPAMINE
25y/opthospitalizedforanacutepsychoticbreak,beginstocomplainof
thickenedspeech.Physicalexamrevealseyesdeviatedtotheupperright,
grimacing,andposturingofthearms.Theonlymedstakenwerehaldoland
clonazepam.Themosthelpfultreatmentatthispointwouldbe:(3x)
DIPHENHYDRAMINE
Periodicallyassessneurolepticsideeffectsusing?(italsoshowspt’sawarenessof
AIMS
sideeffects)(2x)
Afteraninjectionwithhaldol,apatientappearstremulous,dystonic,confused,
andhasafeverof38.8degreesC.Whichofthefollowingwouldbeanessential
partofthediagnosticworkupforthispatient?(2x)
CSFEVALUATION
Whichmedreducestheacutesxofneurolepticinducedakathisia?(2x)
BETABLOCKERS(PROPRANOLOL,ATENOLOL)
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Apatienthasaseizuresecondarytoasupratherapeuticlevelofclozapine.What
changesinapatient’slifecouldaccountforthisfinding?(2x)
SMOKINGCESSATION
Inadditiontolifesupport,whichclassofmedstoconsiderforthetreatmentof
neurolepticmalignantsyndrome?(2x)
DOPAMINEAGONISTS(bromocriptine)
WhatdidtheClinicalAntipsychoticTrialsofInterventionEffectiveness(CATIE)
demonstrateabouteffectivenessof2ndgen.antipsychoticsfortxof
schizophrenia?(2x)
SECONDGEN.ANTIPSYCHOTICSWERENOMORE
EFFECTIVETHANFIRSTGENERATIONS
A75yowithbaselinedementiaadmittedfornewonsetconfusion,disorientedto
timeandplace,workupnegative,startedonHaldol.After3daysptismuch
improvedandminimallysomnolencebutstilldisoriented,whatisthenext
pharmacologicaltreatmentapproach
D/CHALDOL
47yoptpresentswithfever,confusion,andtremorandfoundtobetachyand
diaphoretic.Clonuseasilyelicitedonexam.Ptsuspectedtohaveserotonin
syndrome,istakingCelexaandLithium.Whatadditionalmedicationmayhave
contributedtosyndrome?
ST.JOHN’SWORT
Whichantipsychoticmedisassocwithdecreasedpsychoticsxs,decreased
substanceuse,andincreasedabstinenceinptswithschizophreniaandaddictive
d/o?
CLOZAPINE
Superiorefficacyforatypicalantipsychoticsovertypicalantipsychoticsinthe
treatmentofpsychosishasbeenconsistentlydemonstratedinwhatmedications?
CLOZAPINE
36y/oFptw/schizophreniahasbeentreatedw/olanzapineisdiscoveredprolactin
ORDERAPREGNANCYTEST
level:354ng/ml(normal:3-30).Thefirstactionis:
Previousdualantipsychoticfailure.ToleratingClozapine200mgforamonth.What
shouldbenextstepinmedicationmanagement?
ContinueClozapinebyItself
WhichantipsychoticmedhasthelargestnumberofstudiessupportingitsuseforTx
RISPERIDONE
ofexplosivenessandreactiveangerinyouth?
Antipsychoticdrugadrenergiceffectcausingorthostatichypotension
Α1-BLOCKADE
WhichmedhasincreasedriskofhyperglycemiaandDM?
OLANZAPINE
Autonomicinstability,nonfocalneurologicalsigns,andelevatedtempassociated
withwhichelevatedlabvalue?
CREATININEPHOSPHOKINASE(CPK)
Whichatypicalantipsychoticcausesleastweightgain?
ZIPRASIDONE
Whathematologicalfindingnecessitatesimmediatedcofclozaril?
WBC2000-3000,GRANULOCYTES1000-1500
Withtheuseof2ndgenantipsychotics,alphareceptorantagonismisassociated
withwhatsideeffects?
TACHYCARDIA
Retinalpigmentationfromlong-termTxwith:
THIORIDAZINE
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MechanismbywhichrisperidonecauseverylittleEPSdespitebindingw/high
affinitytoadopaminergicD2receptor
SEROTONERGIC5HT2ANTAGONISM
Whatisamajorsideeffectofclozapine?
SEIZURES
Ptonmethadonemaintenancestartedtakingarefluxdrugandnowissedated.
Whatmedwasrecentlyadded?
CIMETIDINE
55y/opsychiatricallyhospitalizedptwithchronicschizophreniastabilizedon
Clozapine.Twoweeksafterd/cptp/wimpendingsignsofpsychoticrelapse.
RESUMPTIONOFHEAVYSMOKING
Assumingptadherencetomedsandnegativeserum/urinetoxscreens,whatismost
likelyexplanationforrelapse?
Mostcommonsideeffectwithclozapinetxis
SEDATION
Antipsychoticassociatedwithdevelopmentofcataracts
QUETIAPINE
Blockadeofdopaminereceptorsintuberoinfundibulartractsresultsinbreast
PROLACTIN
enlargement,galactorrhea,impotence,andamenorrhea.Mechanismisincreaseof:
Recentschizophrenicmedadjustment,nowwithfever,diaphoresis,stiffness,
tachycardia,confusion.Dx?
NEUROLEPTICMALIGNANTSYNDROME
Apatientwhoisprescribedahigh-doseoffluphenazinedevelopsafeverof103F,
tachycardiaandAMS.Whichtestismostlikelytobehelpful?
CREATINEKINASE
IVHaldolrelatedtorsadesdepointesisassociatedwithwhat?
LOWMAGNESIUMLEVELS
WhichofthefollowingwouldbeofmostconcernafterinitiatingtreatmentwithIV
haldolforan82y/optwithdelirium?
PROLONGEDQTCINTERVAL
Whichofthefollowingagentsismostlikelytobehelpfulinthetreatmentofvisual
hallucinationsandpsychosisassociatedwithadvancedParkinson’sdisease?
QUETIAPINE
Aleadinghypothesisastowhyatypicalantipsychoticmedicationsarelesslikelythan
typicalneurolepticagentstocauseEPSisbasedonewhichofthefollowing
RAPIDDISSOCIATIONFROMD2RECEPTORS
propertiesofatypicalantipsychotics?
35y/optisstartedonatrialofclozapinefortreatment-refractoryschizoaffective
disorder.Duringtheinitialmedicationtitration,ptcomplainsofsedationand
orthostatichypotensionaswellasflu-likesymptoms,butseemssymptomatically
improved.Howeverafteradoseincreasefrom150to200mg,ptdevelopsafeverto
MYOCARDITIS
102degrees,tachycardiato130bpm,andanacutemetalstatuschange.CXR,urine
studies,andbloodcultureareunremarkable.ACBCrevealsaWBCof11.4,withan
elevatedeosinophilpercentof7%.Whichknowntoxicriskofclozapineisthemost
likelyDx?
A30yow.5yohxofSchizophrenia,priorfailedHaldolandRisperidonetrial,
despiteadherenttomedscontinuestohaveseverepsychoticsymptoms.Med
recommendationatthistimeis..
30yoonClozapinefortreatmentresistantschizophreniapresentingwithdyspnea,
orthostatichypotensionandHR130bpm.ElevatedEosinophil,EKGwithnonspecificTwavechanges.Furthermostlikelytesttoguidetreatment
CLOZAPINE
TROPONINLEVEL
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WhatlabfindingismosttypicallyassociatedwithNMS?
INCREASEDCREATINEKINASELEVELS
Appropriatemanagementofneurolepticmalignantsyndrome:
HYDRATIONANDCOOLING
Antipsychoticsareassociatedwithwhat?
DYSTONIA,POIKILOTHERMY,LIPIDSOLUBILITY,AND
LOWERSEIZURETHRESHOLD
ThesesymptomsmakeadiagnosisofNMSmorelikelythanotherneurologicaland
FEVERANDSEVEREMUSCLERIGIDITY
generalmedicalconditions:(x2)
Whichofthefollowingeffectsisthebasisfordantrolene’sefficacyinthetreatment
SKELETALMUSCLERELAXANT
ofneurolepticmalignantsyndrome(akanms)?
32y/optwithhxofschizoaffectived/ostableonclozapineisadmittedtointernal
medicineserviceforasevereGIviralinfection.Ptisconfused,slow,appearsvisibly
illandtired.Ptc/ostiffnessandthereissomerigiditytothemovements.What
shouldberecommended?
DISCONTINUECLOZAPINE
Whichantipsychotichasleasteffectonprolactin?
CLOZAPINE
Reducesthesuiciderateinadultswithschizophrenia:
CLOZAPINE
AslowtitrationofClozapineisrequiredtodecreasetheriskof:
SEIZURES
WhichneuroleptichastheweakestaffinityforthedopamineD2-likereceptor?
CLOZAPINE
Clozapineclearancedecreasedby
CIMETIDINE
Whichmediscontra-indicatedwithclozapine?
CARBAMAZEPINE
Whatisthetreatmentofacutedystonia?
BENZTROPINE
Schizophreniconhaldol5mgpresentstoED"unabletosee."Appearsdistressed,
writhingandmoaning.States"I'munabletostoplookingup."Whatisthebest
treatment?
ADMINISTERBENZTROPINE1MGIVNOW
Whatmanifestationsisthemostcommonsideeffectofconventionalantipsychotic
meds?
AKATHISIA
Whatantipsychoticmedicationwouldbethebestchoicetoavoidmotorsymptoms
CLOZAPINE
inParkinson’sdisease?
Antipsychoticdrugselevateprolactinduetowhat?
PROLACTINISUNDERTONICINHIBITORYCONTROLBY
DOPAMINE
Ptdevelopsfeelingsofrestlessness,aninabilitytorelax,jitteriness,pacing,and
rapidalternationofsittingandstandingshortlyafterbeingstartedonalowdoseof
ATENOLOL
haloperidol.Additionofwhatmedicationswouldbemosteffectiveinmanaging
thesesymptoms?
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60y/optw/depressionandparanoiaisbeingtreatedwith50mgofsertralineand
6mgofresperidone.Atf/uappointment,ptc/oslowedthinkingandexcessive
salivation.Onexam,theptexhibitsamaskedfaciesandcogwheelrigidity.Mood
andparanoiahavesignificantlyimproved.ThenextstepforthepsychMD?
LOWERTHEDOSEOFTHEANTIPSYCHOTICMEDICATION
Thetherapeuticeffectof2ndgenerationantipsychoticsonnegativesymptomsof
schizophreniaisthoughttoberelatedtotheinductionofexpressioninwhatareaof PREFRONTALCORTEX
thebrain?
PsychMDordersquetiapine50mgforan82y/onursinghomeptw/dementia
whohasbecomeseverelyagitated.Soonafter,thepsychiatristreceivesacallfrom
ATYPICALANTIPSYCHOTICSINCREASEMORTALITY;
afamilymemberwhoisconcernedaboutthe“blackbox”warningsassociated
THISMUSTBEBALANCEDAGAINSTANYPOTENTIAL
withantipsychoticsintheelderly.Whichofthefollowingisthemostaccurate
BENEFIT
informationthepsychiatristcouldgivethefamilymemberregardingthepotential
safetyrisksofthismedication?(x2)
Whichofthefollowingmedicationsismostlikelytoprecipitateamanicswitchina
patientwithbipolarIdisorder
Correlationofplasmadrugconcentrationwiththeclinicaleffectivenessisbest
establishedforwhichantipsychotics?
Acutelypsychoticptstartedonrisperdal2mgqhs.Increasedto3mgBIDovernext
fewdays.Ptbecomesincreasinglyagitated,restless,unabletostoppacing.Most
appropriateintervention?
6yearoldwithautismspectrumisreferredtopsychiatristforirritability,
aggression,andhittingself.ChildhasnotrespondedtoRisperdal.Whichhasthe
mostevidenceformanagingirritabilityandaggression?
DESIPRAMINE
CLOZAPINEANDHALOPERIDOL
ADDPROPRANOLOL10MGTID
ARIPIPRAZOLE
Anxiolytics/Benzodiazepines
Whatpsychotropiccancauseadecreaseinbenzoplasmalevels?(6x)
CARBAMAZEPINE
Ptw/h/obipolarpresentswimmobility,posturing,echopraxia.Firstlinetx?(5x)
LORAZEPAM
Whichbenzoaccumulateswithrepeatedadministration,shouldbeavoidedin
chronicrenalfailure,andmostlikelytoaccumulatewithrepeateddosing?(3x)
DIAZEPAM
Ifprescriptionbenzoisnecessaryforapatientw/severehepaticdysfunction
whichofthefollowingismostappropriatechoicetoavoidelevatedserumlevels.
(2x)
LORAZEPAM
Whichofthefollowingmedicationswouldbepreferableforuseinananxious
patientwithpulmonarydisease?(2x)
BUSPIRONE
WhichbenzoisreliablyabsorbedgivenIM?(2x)
LORAZEPAM
Whichofthefollowingreversestheeffectsofbenzodiazepines?(2X)
FLUMAZENIL
Buspironeisthoughttoexertanxiolyticeffectsprimarilyduetoitsactionsatwhich
receptor?
5HT-1A
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Benzohalf-life<6hrs
TRIAZOLAM
Pharmacokineticpropertymostrelatedtorelativeabusepotentialofbenzos
TIMETOONSETOFACTION
75y/optwithcirrhosisshouldbegivenwhichofthefollowingmeds:
TEMAZEPAM
Whichbenzodiazepineismetabolizedthroughglucuronidation(phaseII
metabolism)
intheliver?
LORAZEPAM
BenzodiazepamabsorbedPOorIM
LORAZEPAM
Benzow/oactivemetabolites
LORAZEPAM
Longesthalf-lifeamongstalprazolam,flurazepam,lorazepam,temazepamand
triazolam
FLURAZEPAM(DALMANE)USEDFORINSOMNIA
Mostcommonsideeffectofbenzos
DROWSINESS
Whichofthefollowingbenzoshasanactivemetabolite?
CHLORDIAZEPOXIDE
Whichofthefollowingsleepchangesisproducedbyallbenzos?
DECREASEINREM
Alcoholuseisassociatedwithwhatchangesinsleep?
DECREASEDREMSLEEP
Breakthroughpanicanxietyinapatienttreatedwithshort-actingbenzodiazepines
canbemanagedbyswitchingthepttowhatmedication?
CLONAZEPAM
75y/opthasdevelopedtolerancetoclonazepamovermanyyears,nowtaking5mg
SLOWLYWITHDRAWTHEPT’SCLONAZEPAMAND
clonazepamatnightbutstillwithpoorsleep.Ptdeniesanymoodoranxiety
REEVALUATE
symptoms,nodrugproblems.Nextstep:
Ptsonchronicbenzosdevelop:
AMNESIA
Benzothatwouldbethesafesttoprescribefora70y/opt:
LORAZEPAM
22y/optsuffersatraumaticbraininjuryfollowingaskiingaccident,andisadmitted
toaninpatientrehabilitationfacility.There,pthasfrequentepisodesofsudden
angerandaggressiondirectedtowardstaff.Onpsychiatricevaluation,ptisawareof
theseepisodes,saying,“Ican’thelpit,Ijustseered.”Ptdeniessymptomsof
PROPRANOLOL
depressionoranxiety,andthereisnoevidenceofacuteconfusiononexamination.
Therehabilitationstaffreportthatallbehavioralstrategieshavefailed,andthatpt’s
outburstsareintimidatingthestaff.Whichofthefollowingmedicationshasthebest
evidenceforefficacy?
Treatmentofcatatonia(hallucinationswithmutismandunusualposturing)
Ativan
35yopatientpresentswithfrequentpanicattacks,whichbeginwithfeelingsof
dread,sweating,shaking,fearofdoomanddeathlasting20min.Which
medicationprovidesimmediaterelief
LORAZEPAM
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Lithium
Treatmentofchoiceforlithiumintoxicationwhomanifestsimpaired
consciousness,neuromuscularirritability,andseizuresis(10x)
HEMODIALYSIS
SerumLilevelscanincreasesignificantlywhengivenwwhichHTNmed?(3x)
HCTZ
Whichmedisthoughttohaveaprotectiveeffectindependentofitsmood-
stabilizingeffectagainstsuicideriskinptswmooddisorder?(4x)
LITHIUM
32y/oFptw/BMDhasbeentreatedwithlithium.Ptrevealstoherpsychiatrist
thatsheisnowpregnant.Attemptstodclithiuminthepasthaveledtorelapsesof
thept’sdisorder,withsevereassociatedmorbidity.Atrialofanantipsychoticin
CONTINUELITHIUM
thepastresultedinNMS,andpthassincerefusedtousethem.Whichofthe
followingwouldbethebestoptionfortreatmentduringthepregnancy?(3x)
62y/oFwbipolard/odevelopsalteredmentalstatus,dysarthria,ataxiainhosp INDOMETHACINCOMPETESWITHLITHIUMFOR
aftermedsareaddedinhospitaltoherlithium.Whatmedicationcouldcausethis? EXCRETIONANDCAUSESLITHIUMTOXICITY
(2x)
SYMPTOMS
Lithiumexposureinfirsttrimesterofpregnancyincreasesriskofcongenital
abnormalitiesinwhichorgan?(2x)
HEART
Lithiumcanberemovedviahemodialysisbecause?(2x)
HASNOMETABOLITES
Stable,steadystateLithiumlevelsaregenerallyobtainedwithin:(2x)
4-5DAYS
Whichofthefollowingfactorsisapredictorofapoorresponsetolithium?(2x)
RAPIDCYCLING
Whatfactoristhoughttopredictapoorresponsetolithiumtreatmentforptswith
MIXEDMANIC/DEPRESSEDEPISODE
bipolardisorder?(2x)
Psoriasisexacerbatedby:(3x)
LITHIUM
LiinducedpolyuriatxwithleasteffectonLilevel?
AMILORIDE
Lithium-inducedtremorisusuallyreducedbywhichmed?
PROPRANOLOL
Whichofthefollowingmedicationswasfirstusedasatreatmentforgoutandlater
promotedbyjohncadefortreatmentofunstablemood?
LITHIUM
Medicationmostlikelytocausecognitivesideeffects,evenseizures,iftakenat
sametimeasECT?
LITHIUM
ThiscardiovasculardisturbanceismostcommonforLithium:
BENIGNTWAVECHANGES.
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A32yoFcomestotheEDwithCCof2weeksofdiarrhea.Onexamsheisanxious
andtremulousandisnotorientedtodateortimeoftheday.Shestatessheistaking
“somedrug”forBipolardisorderandaddsthatshestarteddoublingherdosea
LITHIUM
monthagobecauseshe“wasn’tgettingbetterfastenough.”Shedeniesuseof
drugs/ETOH.Whichmedicationwouldmostlikelycausethesymptomsdescribed?
AptwhowaspreviouslystableonLithiumpresentswithsymptomsoftoxicityafter
theirPMDstartsthemonaHTNmedicine.Whichofthefollowingistheisthemost REDUCEDRENALCLEARANCE
likelymechanismofinteractionbetweenthelithiumandtheHTNmedication?
Whatlabtestshouldbeconductedpriortoinitiationoflithiumtx?
TSH
Lithiumserumlevelsshouldbemonitoredbyevaluating:
TROUGHLEVELS12HOURSAFTERLASTDOSE
Whichmedcandecreasedserumconcentrationoflithium
AMINOPHYLLINE
BMDTxwithLix2yearsdevelopsrapidcycling.Whatlabtestshouldbedone?
THYROIDFUNCTIONTESTS
SEoftoxicserumlithiumlevels
STDEPRESSION,QTCPROLONGATION,ATAXIA,
TREMOR,DYSARTHRIA,NEPHROTOXICSX,STATUS
EPILEPTICUS
24y/oFin2ndtrimesternowmanicw/nopsychoticfx’s.Hxof1episodeofmania,
RESTARTLITHIUM
diagnosedbipolarI.D/Clithiumwhenshedecidedtohavekids.WillingtobeginTx.
Lithiuminducedtremorisusuallyreducedbywhichofthefollowingmeds?
PROPRANOLOL
BipolarptonlithiumandZoloftfor3yrs.Level0.8.Moredepressedandfatigued,
lowenergylevel.IncreasingZoloftineffective.Nextstep:
OBTAINTSHLEVEL
Themostcommoncauseofseverepolyuriawithlithiumis:
NEPHROGENICDIABETESINSIPIDUS
Whiletakinglithiumpatientsshould:
MAINTAINSODIUMINTAKE
ApsychotropicwithsamepharmacokineticpropertiesinAsianAmericansandWhite
LITHIUM
Americans
Administrationofactivatedcharcoalisineffectiveinoverdoseof:
LITHIUM
ACNSstructurethatislikelytosufferpermanentdamagefollowinglithiumtoxicity: CEREBELLUM
Interferesw/clearanceoflithium
IBUPROFEN
CardiaceffectsoflithiumresemblewhatonEKG
HYPOKALEMIA(LOWTWAVES)
Predictorofpositiveresponsetolithiumprophylaxis
HISTORYOFGOODINTER-EPISODEFUNCTION
Inpatientsonlithium,whattypeofthyroiddysfunctioncanoccur?
HIGHPREVALENCEOFTHEPRODUCTIONOFTHYROID
AUTOANTIBODIES
Intakeofthisincreaseslithiumlevels
FLUOXETINE
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Ptwhohasbeentreatedwithlithiumforbipolarshowsagoodresponsein
stabilizationofmood,butreportsfeelingdull,slow,andunabletoconcentrate.
Lithiumsideeffect?
ABSOLUTELY!
57y/optw/hxofbipolardisorderhasbeenstableonlithiumfor10years,with
averagelevelof0.8mEq/L.PtnowpresentstoERc/ofeelingnauseous.Ptisnoticed
tobetremulousandtohaveanunstablegait.Shewasrecentlyprescribeda
REDUCEDRENALCLEARANCE
medicationforHTN.Lithiumlevelisfoundtobe1.5mEq/L.Itisassumedthatthis
increasedlevelisduetoaninteractionbetweenthelithiumandthenew
medication.Whatisthemostlikelymechanismforthisinteraction?
Whichofthefollowinglaboratorytestsisessentialpriortoprescribinglithium?
BUNANDCREATININE
55y/optwithguilt,anhedonia,insomnia,andsadmoodhasbeentreatedfor10
wkswithfluoxetine60mgqam.Hismoodandappetitehaveimproved,thoughhe
stillhasdifficultieswithconcentration,hopelessness,andtearfulness.Hedeniesa
h/omanicorpsychoticsymptoms.Themedicationmostlikelytoaugmentthe
antidepressanteffectofhiscurrentregimenwouldbe:
LITHIUM
Ptonlithiumandpaxil.Lithiumisineffectivedespiteatherapeuticlevel.Whatdo
youdo?
DISCONTINUEPAXIL
Whichnervoussystemstructureislikelytosufferpermanentdamagefromlithium
OD?
CEREBELLUM
Lithiumcanraisewhatserumelectrolyte?
calcium
Methadone
22y/oheroindependentfemalediscoverssheispregnantandwantstodetox.
Whatwaywouldyourecommend?(4x)
METHADONEMAINTENANCEUNTILDELIVERYTHEN
DETOXIFICATION
Whatavgdoserangeofmethadoneyieldsbestresultsindecreasingillicituse?(3x) 60-100MG
Ptinmethadonetxearnsnumberoftake-homedosesbasedoncompliancewith
attendanceandparticipationingroups.Whatkindofinterventionisthis?(2x)
CONTINGENCYMANAGEMENT
Pregnantptdependentonheroinpresentsfortreatment,wantstodowhat’sbest METHADONEMAINTENANCEFORTHEDURATIONOF
forbaby.Whatissafesttreatmentforbothmotherandunbornbaby?(2x)
THEPREGNANCY
Medthathaspotentialtodecreasemethadonebloodlevel:(2x)
CARBAMAZEPINE
Federaleligibilityrequirementsformaintenancetreatmentwithmethadonespecify
thatanindividualmusthavebeendependentonopioidsforatleastwhatlengthof 1YEAR
time?
Adolattendsa“pharmparty”,takes2methadonetabs,laterfoundtohave
decreasedrespirationsandisrushedtotheED.Whichmedcouldcausean
interactionwhichcouldcausethisresponse?
SERTRALINE
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FactormostpredictiveofeffectivemethadoneTx
TOTALDAILYDOSE
Whichofthefollowingproducesbestoutcomeintermsofdrugconsumptionand
criminalbehaviorforheroin-dependents?
MAINTAININGOFMETHADONE
28y/optonmethadonemaintenancetherapydevelopsworseninganxietyandflu-
likesymptomssinceswitchedfromvalproatetocarbamazepineforseizurecontrol2 INCREASETHEMETHADONEDOSE
weeksago.Whatshouldbethenextstepinmanagement?
20y/optw/cancerpainisonamethadonemaintenanceprogram.Stafffeels
GIVEPTMOREOPIOIDMEDTOACHIEVEADEQUATE
requestforadditionalnarcoticsrepresentdrug-seekingbehavior.Recommendation? PAINCONTROLB/COFPT’STOLERANCE
Duetoitsrateoforalabsorption,whatmostenhancestheeuphoriaproducedby
benzodiazepineswithmethodone?
DIAZEPAM
Drug-druginteractionsinptstakingHIVmedsareparticularlyproblematicwith
whichmedication:
METHADONE
Whatisthelowestdoseofmethadonethatsuppressesopioiddrughungerand
inducesacrosstoleranceofillicitopiates?
80-120mg
GeneralPsychopharmacology
FDArequiresthatgenericsnotbesignificantlydifferentfromtheparent
compoundsinwhatway?(5x)
BIOEQUIVALENCE
Twoantidepressantsaretestedaloneandasacombotreatmentagainstawaitlist
controlgroupinptswithtreatmentresistantMDD.Bothmedsarefoundtohavea
TWOTREATMENTSMAINEFFECTSANDAN
significanttherapeuticeffectindividually,andthecombotreatmentismore
INTERACTIONEFFECT
efficaciousthanthesummedeffectsofeachmedgivenalone.Whathasbeen
demonstrated?(2x)
First-linetreatmentforrestlesslegsyndrome(2x)
PRAMIPEXOLE
Firstpasseffectreferstowhichofthefollowingaspectsofamed’smetabolism?
(2x)
PRESYSTEMICELIMINATION
WhichisanNMDAreceptorantagonist?(2x)
MEMANTINE
Psychiatristiscalledtoevalaptonamedicalfloorwhohasdevelopedacute
dysarthriaw/protrudingtongueandtorticollis.Whichmedissuspect?(2x)
METOCLOPRAMIDE
Ptwithflashbacks,nightmares,andinsomniar/tsexualtraumaisimproving
slightlywithZoloftbutstillhavingnightmares,nextstepinmgmt.?
Inptsw/recurrentdepression,successfulTxwithantidepressantsshouldbe
followedbywhichTxstrategies?
Prazosin
CONTANTIDEPRESSANTATSAMEDOSE
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TheuseofflumazenilfortreatingbenzoODislimitedby…
THERISKOFINDUCINGWITHDRAWALSEIZURESIN
BENZO-DEPENDENTPTS
Inadditiontobenzos,whichclassofmedsisassocwithfallsinptsolderthan60?
ANTIDEPRESSANTS
Thepotencyofmedicationreferstowhichofthefollowingpropertiesofa
medication?
RELATIVEDOSEREQUIREDTOACHIEVEACERTAIN
EFFEC
60yoptwithchronicschizophreniatakescogentinforneurolepticinduced
parkinsonnowhasincreasedurineretentionandconfusion.Whatmedicationwould AMANTADINE
bethebestalternativefortreatingthispatient’scondition?
PtwithmultiplepastmedtrialsreportingextensiveSEswiththosemedshasbeen
startedonfluoxetineandnowreportsseveresweating.Pt’sdepressionandanxiety
ADDTERAZOSINTOPT’SMEDREGIMEN
havesignificantlyimprovedon10mgdailybutptreports“mybeddingisdrenched
everydaywhenIwakeup”.Mostappropriatenextcourseofaction?
Mosteffectivetxfor“writer’scramp”(focaldystoniaassocw/writing)
BOTULINUMTOXIN
Mostofthebody’sserotoninislocatedwhere?
GITRACT
Commonsideeffectofacetylcholinesteraseinhibitors
DIARRHEA
Diphenhydramine’sabilitytotreatacutedystoniaisduetoactiononwhich
receptor?
MUSCARINIC-1
28y/owithBMDIIwantstousephototherapyfordepressiveSxtreatmentinwinter. CANBEUSEDBUTREQUIRESVIGILANCEANDCAREFUL
Whatshouldyouadvise?
TITRATIONOFDOSE
Mirtazapine’ssideeffectsofsedationandweightgainarecausedbybindingto
whichreceptors?
HISTAMINE
WhichmedisusedtotreathepCviralinfectionandisassociatedwithdepression,
anxiety,andcognitiveimpairment?
INTERFERON-ALPHA
Inptswhosurreptitiouslyuseexcesssulfonylurea,whichofthefollowingsubstances
TOLBUTAMIDE
canbeadministeredtor/opossibleinsulinoma?
Concurrentuseofphenelzineandmeperidinecancausehypermetabolicreaction
secondarytowhat?
INDIRECTPHARMACODYNAMICEFFECTSATA
COMMONBIOACTIVESITE
WhichofthefollowingmedicationsinhibitstheenzymeETOHacetaldehyde
dehydrogenase?
DISULFIRAM
Buprenorphine’sadvantagesoverclonidine,inthemanagementofpatientswith
opioidwithdrawal,includebettercontrolofwhichofthefollowingsymptoms?
CRAVINGS
Theeffectsofcaffeineonwhichofthefollowingresultsinincreaseddopaminergic
activity?
ADENOSINERECEPTOR
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Therapeuticindexisarelativemeasureofwhichofthefollowingcharacteristicsofa
SAFETY
medication?
WhichofthefollowingagentsusedtotreatpatientswithAlzheimersdiseasehasa
mechanismofactionrelatedtoanantiglutaminergicmechanism?
MEMANTINE
FreeRBCsprotoporphyrintestinthescreeningforintoxifiicationwith:
LEAD
Whatisthemostcommonreasonptsdiscontinuevalproate?
WEIGHTGAIN
Asafemedforthefetusofpregnantwomanduringagitationofamanicepisode:
HALDOL
Pharmacokineticfactorthatdeclinesw/aging?
GLOMERULARFILTRATIONRATE
Patients>65y/oaremoresensitivetopsychmeds.Whatphysiologicchangeoccurs
DECREASEDPHASE1OXIDATION
withaging?
AgitatedptgetsrapidtranquilizationinED.UsingoralconcentrateinsteadofIMor
IV
haswhatadvantage?
DECREASEDFEELINGSOFHELPLESSNESS
Psychoticptgivenhaldol,acutelaryngospasm.Inadditiontointubation,give:
COGENTIN
Differenceintherateandextenttowhichabrandnamevsagenericdrugbecomes
BIOEQUIVALENCE
availabletothesiteofaction,giventhesamedoseandcondition,ismeasuredas:
Ptonmethadonescreenpositiveforalcohol,achieveabstinenceofalcoholby
coadministeringwhatwithmethadone?
Disulfram
SchizophrenicOD’donantipsychotics,hasEPSandurinaryretention.Tx?
AMANTADINE
Amantadineisconsideredeffectiveintreatingptswhohavewhichsideeffectsof
antipsychotics?
PARKINSONISM
Whichmedreducestheacutesymptomsofneuroleptic-inducedakathisia?
PROPRANOLOL
Whatherbal(phytomedicinal)isusedasahypnotic?
VALERIAN
TheFDArequiresthatpharmaceuticalcompaniesdemonstratethatagenericdrugis
BIOEQUIVALENCE
notsignificantlydifferentfromtheparentcompoundinwhichway?
Thetherapeuticindexofadrugreferstothe:
RELATIVEMEASUREOFDOSINGTOXICITYTOSAFETY
Whatistheunderlyingmechanismofactionofsildenafilinerectiledysfunction?
ENHANCEMENTOFNITRICOXIDE
Initialpsychiatricinterventionfor50-year-oldmarriedmanwithEDduringsexbut
normalmasturbatoryability,otherwisegoodmarriage,andnormalevaluationby
PCP?
ASKPTTOBRINGWIFETODISCUSSBEHAVIORAL
EXERCISES
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Whatsubstanceisassociatedwithariskofbleedingwhentakenwithanti-platelet
drugsorwarfarin?
GINGKOBILOBA
Clonidinemechanismofaction:
ALPHA-2AGONIST
42y/opthasprimaryinsomnia.Ptcomplainsofdifficultyfallingasleep,butthen
sleepsthroughthenight.Whichofthefollowingwouldbethebestmedicationto
prescribeforthisptafteraddressingsleepissues:
ZALEPLON
CombineduseofLithiumandSSRIisknowntoincreasetheriskofwhichofthe
followingconditions?
SEIZURES
28y/optwantstostopsmokingwiththehelpofanicotinereplacementproduct.Pt
planstohaveorthodontiawithinthenext2months;haspsoriasis;andhasmultiple
NICOTINELOZENGES
environmentalallergiesthatoftencausenasalstuffiness,sorethroats,anditchy,
wateryeyes.Nicotinereplacementbest?
Prepubertalchildrendifferfromadolescentsandadultswithregardstodosingof
livermetabolizedmedicationrequiring?
35yearoldwomanreportshistoryofrecurrentdepressionalwaysbeginningin
fall/earlywinterandremitbyspring.Sheistryingtobecomepregnant,what’s
besttx?
HIGHERWEIGHTADJUSTEDDOSESOFMEDICATION
LIGHTTHERAPY
PsychologicalTesting
Whattestwouldbeconsideredmostusefultospecificallyevaluateconcept
formation,reasoning,andexecutivefunctioning?(4x)
WISCONSINCARDSORTINGTEST(WCST)
Mostappropriatebriefscreeninginstrumentthataptcanfillbyhim/herselfat
physician’sofficetoscreenfordepressionis(3x)
BECKDEPRESSIONINVENTORY
Whichtestisanobjectivemeasureofpersonalityinadultsandishelpfulin
confirmingdiagnosisofpersonalitydisorder?(3x)
MILLONCLINICALMULTIAXIALINVENTORY(MCMI)
Whichofthefollowingtestswouldbeconsideredmostusefultospecifically
evaluateconceptformationwithsetshifting?(2x)
WISCONSINCARDSORTINGTEST(WCST)
MMPIdoeswhat?(2x)
IDENTIFIESMAJORAREASOFPSYCHOPATHOLOGIC
FUNCTIONING
15y/optw/physicalcomplaints,decreasedappetite,irritability,thoughtsof
death,anhedonia.WhichmedisFDA-approvedforfirstlinetx?(2x)
ESCITALOPRAM
Wisconsincardsortingtest(WCST)assesses(2x)
ABSTRACTREASONINGANDFLEXIBILITYINPROBLEM
SOLVING
Anappropriatepurposeforprojectivetestingisto:(2x)
DETECTINGTHEPRESENCEOFSUBLEPSYCHOTIC
THOUGHTPROCESSES
Whatpsychologicaltestdeterminesneuropsychologicimpairment?(2x)
HALSTEAD-REITANBATTERY
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Abroad-basedratingscaleforpsychiatricsymptomsinchildren?(2x)
CHILDBEHAVIORCHECKLIST(CBCL)
Whatpsychologicaltestsmeasuretest-takingattitudesattimeofexam(2x)
MMPI(MINNESOTAMULTIPHASICPERSONALITY
INVENTORY)VALIDITYSCALE
Whatmostseriouslythreatenstheexternalvalidityofaresearchstudy?(2x)
ASTUDYPOPULATIONTHATISNOTREPRESENTATIVE
OFTHEPOPULATIONTOBETREATED
Whatisthemostcommonbiologicalcauseofprenatalneurotoxicitylinkedtothe
developmentofintellectualdisability(mentalretardation)?
ALCOHOLEXPOSURE
Mostspecifictestforassessingexecutivefunctioning?x2
WISCONSINCARDSORTINGTEST(WCST)
Whatneuropsychtestreliesoninhibitionoftheoverlearnedbehaviorstoassess
executivefunctioning?
STROOPCOLORWORDTEST
PtistakingMMPI-2intentionallyendorsesitemsthatreflectsocialdesirability.
Whichscalestocatchthispatternofitemendorsement?
LIESCALE
Researcherdevelopingtestforworkingmemoryinschizophrenics.Inadditionto
measuringimmediatememory,whatelseshouldtestmeasure?
ATTENTION
SomeonetakingtheContinuousPerformanceTest(CPT)isaskedtopressakey
wheneveranyletterexcept“X”isdisplayedonthescreen.Theletter“F”isdisplayed ATTENTION
andthepatientfailstopressakey.Mostlikelyaproblemwith…
Whyistherelimitedvalueofserialsevensasatestofconcentration?
SUCCESSFULPERFORMANCEREQUIRESARITHMETIC
SKILL
Nameoftestwhereptistoldtonamethecolorsinwhichthewordsareprinted
ratherthanreadingthewordsthemselves
STROOPCOLORWORDTEST
Whattestrequiresrapidandefficientintegrationofattention,visualscanning,and
cognitivesequencing?
TRAIL-MAKINGTESTTMT
WheninterpretingIQtestresults,whatindicatesneedforfurtherassessment?
VERBALSCORESIGNIFICANTLYHIGHERTHAN
NONVERBALSCORE
IQscoresgenerallyconsideredtobestablebeginningat:
7YEARSOLD
Toobtainadditionalaboutunconsciousdrivesandpsychodynamicprocesses,which
THEMATICAPPRERCEPTIONTEST(TAT)
testwouldbemosthelpful?
Whichofthefollowingtestsisusedforassessmentofexpressivelanguage?
BOSTONNAMINGTEST
TesttodiscriminatecognitivedifficultiesinAlzheimer’sfromthoseindepression
BOSTONNAMINGTEST
TestforanxietythatdoesnotincludeQsaboutphysicalsxsuchastachycardiaand
diaphoresiswouldbeconsideredlackinginwhat?
CONTENTVALIDITY
Thisisconsideredasanunstructuredpsychologicaltest:
RORSCHACHINKBLOT
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Psychiatristwishestoassessapt’spremorbidintellectualfunctioning.Whichofthe READINGSUBSETOFTHEWIDERANGEACHIEVEMENT
followingtestswouldbebestforthispurpose?
TEST
Awarenessofownsymptomsratedby:
GLOBALASSESSMENTSCALE
Whichofthefollowingisthebesttestforgeneralassessmentofapatient’s
psychiatricsymptompatterns?
SYMPTOMCHECKLIST-90-REVISED(scl-90)
Measuresattention,concentration,andfreedomfromdistractibility:
WECHSLERADULTINTELLIGENCESCALE(WAIS)
Whichofthefollowingstatementsspecificallytestsconcentration?
SAYTHELETTERSOFTHEALPHABETBACKWARDS
STARTINGWITH“Z”
Judgmentbyexpertsthatitemsonatest“makessense”isanexample
FACEVALIDITY
Bender-Gestaltdiagramsassesses:
NEUROPSYCHOLOGICALIMPAIRMENT
Whichtestassessesabilitytoattendtoataskwhileinhibitinginterferingstimuli?
STROOPCOLORWORDTEST
Whatwouldbeausefulscreeningtesttoevaluatean8y/ochild’sacademic
performance?
WIDERANGEACHIEVEMENTTEST(WRAT)
Whatdoestheclockdrawingtasktest?
ATTENTION,VISUOSPATIAL,PLANNING,EXECUTIVE
FUNCTION(NOTorientation)
PtscoresonrevisedWechsleradultintelligencescale(WAIS-R)subtestsforpicture
arrangementandblockdesignareverylowcomparedtoscoresonothersubtests.
Mostsuggestiveof:
LESIONINNONDOMINANTHEMISPHERE
Testtoassessintelligencein4y/o?
STANFORD-BINET
Stanford-Binetmostsimilarto
WECHSLERINTELLIGENCESCALEFORCHILDREN–III
Whichassessmentinstrumentbestmeasurescognitivefunctioningina4yearold
child?
WECHSLERPRESCHOOLANDPRIMARYSCALEOF
INTELLIGENCE-REVISEDWPPSI-R
Testmorespecifictoidentifyspecificlearningdisabilityinchildw/fullscaleIQof93 WOODCOCK-JOHNSONPSYCHO-EDUCATIONAL
onWISC-III
BATTERY–REVISED
25y/oMscoresinMMPIareallnormalexceptforelevatedscoresonthe
depressionandpsychastheniascales.Thissuggests:
HASDEPRESSIONWITHANXIETYANDOTHERNEUROTIC
SYMPTOMS
Objectivepsychologicaltest
MMPI
Measurestest-takingattitudes
MMPI
Thematicapperceptiontestisusedfor
INTERFERINGMOTIVATIONALASPECTSOFBEHAVIOR
Whatpsychtestswouldbeconsideredthemostunstructured?
RORSCHACHINKBLOT
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Whichtestscanbeusedforprojectivepersonalitytesting?
RORSCHACH,DRAWAPERSON,THEMATIC
APPERCEPTION(NOTMMPI)
WhichisaProjectiveAssessmenttest:
THEMATICAPPERCEPTIONTEST(TAT)
Thepersonalitytestinwhichaptisshownpicturesofsituationsandaskedto
describewhatishappeningineachpictureis:
THEMATICAPPERCEPTIONTEST(TAT)
Thistoolbestmeasuresthedegreeofself-careinchildrenwithMR:
VINELANDADAPTIVEBEHAVIORSCALE
8yochildrecentlyhadWechslerIntelligenceScaleforChildren(WISC-IV)and
receivedfullscaleIQof60.Whichadditionaltestswoulddetermineifchildmeets
criteriaforintellectualdisability(mentalretardation)?
VINELANDADAPTIVEBEHAVIORSCALES,2NDEDITION
(VABS-II)
Apsychologicaltestthatdemonstrateshighreliability:
WECHSLERADULTINTELLIGENCESCALE(WAIS)
Testcorrelatesmoststronglywpremorbidfcninptwearlydementia
WECHSLERADULTINTELLIGENCESCALEIIVOCABULARY
TEST
AknownlimitationoftheMinnesotaMultiphasicPersonalityInventory?
NORMSDONOTACCOUNTFOROUTCOMESBASEDON
RELIGIONANDRACE
Computerassistedcontinuousperformancetestingisusedtoassesswhat?
ATTENTION
Neuropsychologicaltestthatspecificallyevaluatesimpairmentsinfrontallobe
functioninadults?
WISCONSINCARDSORTINGTASK(WCST)
Onwhattestwouldperseverativeerrorbeconsideredaspecificoutcomeofclinical
WISCONSINCARDSORTINGTEST(WCST)
relevance?
75y/optpresentswithsymptomsofdementia.Especiallypoorperformanceon
whichofthefollowingneuropsychologicaltestsmightsuggestaDxofvascular
dementiaratherthanAlzheimer’sdementia?
Anappropriatepurposeforprojectivetestingisto:
Whichofthefollowingisaptself-reportedquestionnaire?
Patientisshownapictureofapersonstandingnexttowindowandisaskedto
describewhathappened.Whattest?
WISCONSINCARDSORTINGTEST(WCST)
Detectthepresenceofsubtlepsychoticthought
processes
BECKANXIETYINVENTORY
THEMATICAPPERCEPTIONTEST(TAT)
MSE
Questiontoaskwhenevaluatingforimmediaterecall(3x)
CANYOUREPEATTHESESIXNUMBERS?
Termforthoughtsconnectedbysound/wordsratherthanbytheirmeaningandis
CLANGASSOCIATION
classifiedasanimpairmentinthoughtprocess:(3x)
Whattaskisusefulinevaluatingapt’sabilitytoconcentrate?(2x)
PERFORMINGSERIAL7’S
WhichareaofMSEreliesprimarilyonpatientreport?
MOOD
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PsychMDaskedpt“whatwouldyoudoifyoulostyourprescription?”Thisquestion
JUDGMENT
primarilyassesses:
Whenpsychiatristasksaboutmania,ptresponds,“thatsoundsexactlylikemy
cousin,”andproceedstotelllongstoryaboutcousinbutdoesn’tanswerthe
psychiatrist’srequest.Thisisanexampleof:
TANGENTIALITY
Biologicalconsequencesofpsychologicalstressaffectwhichmechanism?
NEURO-IMMUNO-ENDOCRINEFUNCTION
“WhenIhearthenews,thenewscasteristalkingaboutme.”Thisrepresents?
IDEASOFREFERENCE
Disharmonybetweenfeelingtoneandspeechcontent
INAPPROPRIATE
Psychiatristasks“Howmanyquartersarein$15?”,examiningwhatability
COGNITION
Whichofthefollowingisthemostsignificantproblemwiththeuseoftheglobal
assessmentoffunctioningscale?
ITCONFOUNDSSYMPTOMSANDFUNCTIONING
Povertyofspeechandpovertyofcontentareaspectsofwhichofthefollowing
conditions?
ALOGIA
Whichofthefollowingrepresentsadisorderofthecontentofthought?
OBSESSIONS
Askingapatienttoreciteaseriesofnumbersinreverseorderisastandardtestof:
CONCENTRATION
Thedifferencebetweenanideaofreferenceandadelusionofreferenceisthatthe
HELDWITHLESSCONVICTION
formeris:
Aprofoundbreakdowninboththelogicalconnectionbetweenideasandtheoverall
DERAILMENT
senseofgoal-directednessofspeechiscalled:
Thepurposeofaskingapttostartat100andcountbackwardsby7’sistomeasure
CONCENTRATION
whichofthefollowing?
Aptwithchronicmotorandvocalticsmakesrecurrentobscenegestureswhichare
intrusiveandnotrelatedtotheconversationoranystimuliintheenvironment.The COPROPRAXIA
gesturesarebestdescribedas:
Adisorderofcontentofthought
PARANOIA
OnMSE,thoughtprocesswithlackofgoaldirectedness,excessivedetails,and
difficultywithclosuredescribesathoughtpatternof:
CIRCUMSTANTIALITY
Askingapt,“whichonedoesnotbelonginthefollowinggroup:13pennies,apiggy
bank,andacow?”isatestofwhichdomain:
ABSTRACTREASONING
Askingthepatient“howareanappleandanorangealike?”assesseswhichofthe
followingcognitivefunctions?
ABSTRACTREASONING
Askingapatienttointerpretthephrase“Don’tcryoverspilledmilk”testswhat?
ABSTRACTTHINKING
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Aptreports,“undercoveragentsareallthere,andthey’regonnakillme.”Pt’s
commentisbestdescribedas:
ADELUSION
Ptisnonsensicalbutisrhyming.Whatisthiscalled?
CLANGASSOCIATION
Askingptwhattheywoulddoinahypotheticalsituationistestingwhat?
JUDGMENT
DisorderofwhatelementofMSEisevidencedbypatientrepeatedlyreferringback
totheanswertoapreviousquestion?
THOUGHTPROCESS
Elderlyptwithprofoundapathy,howdoyoudistinguishdepressionfromexecutive
CLOCKDRAWING
dysfunction?
“It’sverynicetoreadyou”
Paraphasia
PsychologicalTheory
Psychicdeterminismis(2x)
BEHAVIORSRESULTFROMUNCONSCIOUSMIXOF
DRIVES,DEFENSES,OBJECTRELATIONSHIPS,SELFDISTURBANCES
Mostimportantprotectivefactordeterminingpreschoolchild’sreactionto
disaster(2x)
PARENTALFUNCTIONING
Riskfactorinfluencingpsychologicaloutcomeofchildfollowingdeathofparent:
(2x)
PRIORCONFLICTUALRELATIONSHIPBETWEENCHILD
ANDDECEASEDPARENT
Piaget’scontributiontodevelopmentwasatheoryexplainingwhatphenomenon? HOWINDIVIDUALSLEARNANDUNDERSTANDTHE
(2x)
WORLD
8y/oboysees2bottleswsameamountofliquid.Thecontentofoneispouredin
shorterwiderglassandtheothertoalongernarrowglass.Whenaskedwhichhas CONSERVATION
moreliquidhesaysit’sthesame.AccordingtoPiagetheisexhibiting:(2x)
Bestdescribestheroleoftheobservingego:
MOBILIZESDEFENSEMECHANISMSINRESPONSETO
SIGNALANXIETY
Accordingtothetheoryofself-psychology,amajorcauseofmentalillnessis:
ABSENCEOFAGE-SPECIFICMIRRORINGRESPONSES
Accordingtopsychoanalytictheory,thetermprimaryprocessthinkingrefersto
mentalactivityexemplifiedby?
UNCONSCIOUSTHOUGHTSTHATDONOTMAINTAIN
LOGICALCONNECTIONS
Acentralpremiseofobjectrelationstheory:
THEMINDISINHABITEDBYMENTALREPRESENTATIONS
OFSELFANDOTHERS
Psychologicalfunctionofamedication
ACTSASACONTAINERFORTHEPATIENT’SPROJECTED
ANXIETIESABOUTBEINGDEFECTIVE
Accordingtosociobiologictheory,whattermdescribesbehaviorsatthelevelofthe
ALTRUISM
individualthatmaximizefitnessatthelevelofthegene?
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OttoKernberg’smodelfortxofpatientswithnarcissisticpersonalitydisorderdiffers INTEGRATINGIDEALIZATIONANDTRUSTWITHRAGE
fromthatofKohutinthatinKernberg’smodel,thegoalsofpsychotherapyinclude: ANDCONTEMPT
Asconceptualizedbyself-psychology,whichofthefollowingisthemostproblematic
SHAME
reactionapatientcanhavewhenattemptingtofulfillaself-objectneed?
AccordingtoAaronBeck,theprimarydefectindepressioninvolveswhichofthe
following?
COGNITIVEDISTORTION
Piagetinterestedin:
HOWACHILDARRIVESATANSWERS
Intermsofthenormalfunctioningofthepersonality,AnnaFreud’scontributions
wereintherealmof:
DEFENSEMECHANISMS
Secureattachmentinaninfantisassociatedwithwhichofthefollowingoutcomes? EMOTIONALANDSOCIALCOMPETENCE
Whichofthefollowingdescribescorenarcissisticcharacterpathologyaccordingto
Kernberg’smodel?
AFUSIONOFTHEIDEALSELF,THEIDEALOBJECT,AND
THEREALSELFRESULTINGINTHEDEVALUATIONOF
OTHERS
3y/ogirlhurtsherselfw/atricycle.Thenshehitthetricycleandasks,“Whydidyou
ANIMISM
hurtme?”Whichthoughtprocessdoesthisbehaviorexemplify?
Experimentalsubjectswereaskedtomakeajudgmentbutgaveawronganswerin
spiteofknowingtherightonebecausetheydidn’twanttodisagreewithresponses CONFORMITY
ofotherparticipants.Thisphenomenonis:
Resilientindividualswhodowellindevelopmentalcoursethroughlifedespitebeing
HAVINGTHEABILITYTOFIND,USEANDINTERNALIZE
athighriskfornegativeoutcomesarethoughttobeprotectedinadulthoodmost
SOCIALSUPPORTS
by:
Accordingtotheoriesofinfantsocialization,successfulattachmentmostlikely
promotessurvivalthroughwhichofthefollowing?
CREATINGABONDSOTHATTHEADULTWILLPROTECT
THEINFANTFROMDANGER
AccordingtoC.G.Jung,animarefersto:
MAN’SUNDERDEVELOPEDFEMININITY
29y/ocomplainsaboutmistreatmentfromboyfriend.Proudofgenerousnaturebut
complainshowlittleshegetsback.Therapistfindsithardtomakeherself-reflective MASOCHISM
aboutherroleinthis,getsfrustratedandfatigued.Patientdisplays:
Childdancesformother&basksingleamofmother’seyes.Accordingtoself-
psychology,experiencing:
MIRRORING
Earlybehavioristtheorypromotedwhat
OBJECTIVEPSYCHOLOGICALRESEARCH
Whattermdescribestherolethatothersperformfortheindividualinregardto
mirroring,idealizing,andtwinshipneeds?
SELF-OBJECT
Thefundamentaldevelopmentalneedofallpersonsformirroring,validation,and
affirmationiscentraltowhichpsychoanalytictheory?
SELFPSYCHOLOGY
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66y/osentthreateningletterstothepresident,thinksCIAisfollowinghim.Wife
similarconvictions,dependentonhusband,passive
SHAREDPSYCHOTICDISORDER
Activitylevel,regularity,approach-withdrawaltonewsituations,adaptability,
persistenceareexamplesof:
TEMPERAMENTALVARIABLES
Kohut’stheoryofpersonalityisbasedon?
THEINDIVIDUAL’SNEEDFOREMPATHICINTERACTION
WITHSELF-OBJECTS
Theoristintroducedtheconceptsofintroversionandextroversion:
CARLJUNG
TherapyinterventionmostfrequentlyassocwKohut’sself-psychology:
EMPATHICVALIDATION
CartesiandualismfromthetheoriesofRenéDescartesrefersto
POTENTIALOFHUMANNATUREFORBOTHGOODAND
EVIL
Studiesinwhichmonkeysareraisedinvaryingdegreesofisolationhavebeen
importantincontributingtowhattheoriesofhumandevelopment?
THESIGNIFICANCEOFATTACHMENT
Whichoffollowingstatementsidentifieswhatbothtraditionalhealingandmodern
psychotherapeuticpracticesmayhaveincommon:
THETHERAPISTHELPSTHEPATIENTEXPERIENCEAN
EMERGINGSENSEOFLEARNINGANDMASTERYOVER
THEPROBLEM
WhatisachievedinPiaget’sstageofconcreteoperations?
CONSERVATION
4y/ochildupsetwhenicecreammelts.10y/oputsitinfreezerandtellshimitwill
beok.4y/oinsistsitisruined.Piaget’sconceptofthisis:
CONSERVATION(ALSOREVERSIBILITY)
AnimisticthinkingischaracteristicofwhichofPiaget’sstagesofcognitive
development?
PREOPERATIONALTHOUGHT
AccordingtoKohlberg,moraljudgmentmadebyolderschool-agechildrenarebased
PLEASINGTHOSEINAUTHORITY
largelyonwhichofthefollowing?
Achildwithautismisplacedinatherapeuticfosterhomewhereaconsistent
responseismadetoagivenactionwiththegoalofimprovingthechild'sfunctioning. BEHAVIORISM
Thistechniquederivesfromwhichofthefollowinglearningtheories?
Masturbationinadultsasviewedbycontemporarypsychiatryisbestdescribedas:
PSYCHOPATHOLOGICALONLYIFITISCOMPULSIVE
Normalautism,symbiosis,differentiation,andpracticingareamongthe
developmentalsubphasesofseparationandindividuationproposedbywhat
theorist?
MARGARETMAHLER
AccordingtoKohlberg,thehighestlevelofmoralreasoningisbasedon
considerationof
UNIVERSALETHICALPRINCIPLES
Winnicott’snotionofcapacitytobealoneinpresenceofanotherpersonpertainsto: MAINTENANCEOFONE’SIDENTITYAMONGSTOTHERS
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PerPiaget,Conservationistheabilitytodowhat?
UNDERSTANDTHATOBJECTSORQUANTITIESREMAIN
THESAMEDESPITEACHANGEINPHYSICAL
APPEARANCE
WithrespecttoRotter’ssociallearningtheory,whichofthefollowingstatements
bestdescribeshavinganinternallocusofcontrol?
BEHAVIORISSHAPEDBYANINDIVIDUAL’S
EXPECTATIONTHATITWILLREALIZEAVALUEDGOAL.
Unconsciousthoughtsthatdonotmaintainlogicalconnections
ACCORDINGTOPSYCHOANALYTICTHEORY,THETERM
PRIMARYPROCESSTHINKINGREFERSTOMENTAL
ACTIVITYEXEMPLIFIEDBYWHICHOFTHEFOLLOWING?
WhichisafirstranksymptomaccordingtoKurtSchneider?
VOICESARGUING
Duringtherapy,therapistcoughswhilepatientisspeaking.Ptangrilystates,"ifyou
disagreewithmejusttellme,butdon'tbeapassiveaggressivejerk!"Therapist
interpretsthatptisconsistentlytreatingthetherapistlikeaggressor.Whichbest
describesthistherapymodality?
TRANSFERENCEFOCUSEDPSYCHOTHERAPY
AccordingtoWinnicott,sufficientattunementandresponsivenesstoachild'sneeds
allowingthechildtobecomeawareofhisowndrivesisreferredtoas?
good-enoughparent?
EriksonianStages
AccordingtoErikson,person>65wsenseofsatisfactionthatlifewasproductive/
worthwhilehassuccessfullymanagedpsychosocialtaskofdeveloping:(4x)
INTEGRITY
AccordingtoErikson,achildwhostrivestobecompetentbylearningnewskills,
takingprideinresultsiswhichstage?(AlsocorrelatedwiththeFreudianstageof
latency)(3x)
INDUSTRYVSINFERIORITY
Erikson’spsychosocialstageinwhichapersoninvestenergyintoestablishing,
caringfor,andguidinginthenextgeneration?(2x)
GENERATIVITYVSSTAGNATION
Eriksontheorizedthatasuccessfuldevelopmentaltaskinthe40-60y/ogroupis
to?(3x)
FEELUSEFULTOSOCIETYTHROUGHBEHAVIORSTHAT
PROTECTFUTUREGENERATIONS
AccordingtoErikson,thepredominantemotionalissueinnormal,school-aged
childrenis:(2x)
PERSONALWORTHANDCOMPETENCE
10y/optreportshecollectsbaseballcards.Childisexcitedb/cheisonlyonein
hispeergroupwhoownsseveralcards.AccordingtoErickson,what
developmentaltaskaremostrelevantforthischild?(2x)
INDUSTRYVS.INFERIORITY
Achievingsenseofself-controlandfreewill,strugglingbetweencooperationand
willfulness(Erikson)
AUTONOMYVS.SHAMEANDDOUBT
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A23yoptbeganpsychotherapyduetofeelingsofinadequacyanddepressioninthe
contextofworkinginacoffeeshopsincegraduatingfromcollegeanddeferring
medicalschoolacceptance.Thepthasbeenhavingconflictswithparentsoverhis
IDENTITY
ambivalenceinbecomingaphysician.Whichofthefollowingisthemostlikely
developmentaltaskwithwhichtheptisstruggling?
Compulsions&obsessionsarerelatedtodevelopmentdisturbanceduringwhichof
Erikson’spsychosocialstages?
AUTONOMYVSSHAMEANDDOUBT
Eriksonianphasecorrespondw/Freud’sanalphase
AUTONOMYVS.SHAMEANDDOUBT
Eriksoniantaskduringage40-60is?
Generativityvs.Stagnation
PsychoanalysisandFreud
Freud’spsychologicaltheoryofdevelopment(2x)
DRIVETHEORY
Inwhatdevelopmentalperioddoesachildseehe/sheisachildofhis/herparents&
thatparentshavearelationshiptoeachothernotsolelyrelatedtotheirrolesas
PHALLIC
parents?
AccordingtoFreud,whatisadreamthatisrememberedonwakening?
MANIFESTDREAM
Classicalpsychoanalytictheorysayspleasureanadultmighttakeincontrolling
ANALRETENTIVE
others/makingorderofchaosrelatestowhichpsychosexualstageofdevelopment?
Accordingtocontemporarypsychoanalytictheory,frombirthto18months,children BIOLOGICALPROCESSESANDBODILYSENSATIONS
experienceanemerging“self”asaresultofwhatevent?
COMETOHAVEAPSYCHOLOGICALMEANING
Whatisthecombinationofseveralunconsciousimpulses,wishes,orfeelingsthat
areattachedtoasingledreamimage?
CONDENSATION
MelanieKleindifferedfromFreudinheremphasisonwhatfactor?
EARLYOBJECTRELATIONS
Freudsaysdepressionisangerturnedinwardagainstselfdueto:
IDENTIFICATIONWITHTHELOSTOBJECT
Freudsaysthatboysresolveoedipalcomplexby:
IDENTIFYINGWITHFATHERS
Whatdevelopmentalperioddoesthechildrealizehe/sheisthechildofhis/her
parentsandthechild’sparentshavearelationshipwithoneanother?
LATENT
Freudbelievedpthadfantasiesofincestwithopposite-sexparentscoupledwith
feelingsofjealousytowardthesame-sexparentduringwhichstage:
PHALLIC
AccordingtoFreud,whichpsychosexualstageisassociatedwithaprimaryerotic
focusonthegenitalareaandunconsciousfantasiesofsexualinvolvementwiththe
opposite-sexparent?
PHALLIC
Whichegodefenseisseenwhenanadolescentbelittlesparentsinordertodefend
againstregressivepulltowardchildhood?
REVERSALOFAFFECT
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Thismodeldividesthemindintoconscious,preconscious,andunconscious?
TOPOGRAPHICAL
Ptabletorecallhisaddressafterbeingpromptedtodoso.AccordingtoSigmund
Freud,thisinformationisstoredatwhatlevelofthetopographicmodel?
PRECONSCIOUS
Explorationoftransferenceneededforreparativeemotionalexperience
psychotherapeutictreatment?
PSYCHOANALYTICPSYCHOTHERAPY
Tendencyforgroupstoarriveatmoreextremedecisionsthanforindividualgroup
membersalone
GROUPPOLARIZATION
DefenseMechanisms
Handwashingritualsaremostrelatedtowhatdefensemechanism?(4x)
UNDOING
Adefensemechanismcharacterizedbyaselfofobjectrepresentationthatis
disavowedbyplacingitintosomeoneelse,andinducingthelatterto
unconsciouslyidentifywiththeself/objectrepresentation:(4x)
PROJECTIVEIDENTIFICATION
Youngmanrecountshowhisfatherkickedhispuppytodeath,noemotionwhen
tellingthetherapistthisdespitetherapist’supsetresponse.Defensemech?(3x)
ISOLATIONOFAFFECT
Semiconsciouslydivertingattentionfromaconflictinordertominimize
discomfortisanexampleofwhatdefensemechanism?(3x)
SUPPRESSION
Whichdefensemechanismmostrelevanttoetiologyofdelusionaldisorders(like
paranoia)accordingtopsychodynamictheory:(2x)
PROJECTION
Aparentwhojustlearnedthatherchildhasbeeninjuredandtakentothe
hospital,arrangesforaneighbortocareforherotherchildrenandthenrushedto
SUPPRESSION
thehospital.Whatdefensemechanismdidtheparentusetohandleherownfear?
(2x)
Defensemechanism:atransientreturntoearlierbehaviorscharacteristicofearlier
stageofdevelopmentinresponsetostress/conflict,despiteoverallmaturation
REGRESSION
(2x)
Accordingtopsychoanalytictheory,feelingsofpersecutionaremostreflectiveof
whichofthefollowingdefensemechanisms?
PROJECTION
Defensemechanismthatinvolvesinternalizingthequalitiesofanobject?
INTROJECTION
Patientwithmurderousimpulsestowardsaneighborgivestheneighborabouquet
offlowers.Thisisanexampleof:
REACTIONFORMATION
Coupleintherapyreviewargumentatfamilyreunion,husbandtoldhissister-in-law
thathiswifewassuperiortoherineveryway,thewifeexpresseddisapproval,
TURNINGAGAINSTSELF
husbandbecamequietandlaterfelldownaflightofstairs.Whatdefense
mechanismisthis?
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ManagementofpatientindenialimmediatelyafterMI:
SUPPORTINGTHEPATIENT,UNLESSDENIALINTERFERES
WITHCARE
Perpsychoanalytictheory,unacceptableaffectsandimpulsesarecommonly
gratifiedinsociallyacceptablewaysthrough:
SUBLIMATION
30y/ointherapystruggleswithfeelingsofambivalenceaboutmom.Momnowhas SETASIDEANIGHTOFTHEWEEKTOHAVEDINNER
metastaticBrCA.Ifthepatientusesanticipationasadefensemechanism,shemight: WITHMOMTODISCUSSMOM’SRXNTODIAGNOSIS
MajorpsychologicaldefensemechanismthatdeterminestheformandqualityofOC
REACTIONFORMATION
symptomis
Onegroupmemberalternatesbetweenbeingthe“scapegoat”forthegrouporthe
“spokesman”forthegroup.Theseeventsareagroupversionofwhat?
PROJECTIVEIDENTIFICATION
Whenaskedaboutacoworkerafterarecentconflict,apatientstates“Iharbornoill
feelingstowardhim,buthetrulyhatesme.”Theisexampleofwhichdefense
PROJECTION
mechanism?
Disassociationiswhattypeofdefensemechanism?
NEUROTICDEFENSE
Ptisannoyedbyfamily’sexpressionofconcernforhiscondition,saying,“whatthey
DEVALUING
aresayingisallinthetalk.”Whatdefensemechanismisthis?
7y/ostatesheknowsDaddied,butwhydidn’thecometothebirthdayparty?
Defensemechanism:
DENIAL
InVaillant’smodeloflifespandevelopment,whatisclassifiedasamaturedefense
mechanism:
HUMOR
Pt’swifestateshedrinksalmosteverynight.Ptstatesheneverdrinkstoexcess,
neverdrinksoutsidethehome,neverneedsaneyeopener,anddrinkingdoesnot
affecthisworkperformance.Thisisanexampleofwhichdefensemechanism?
DENIAL
Supportivepsychotherapyclassicallyinvolvessupportingandacceptingthe
patient’s:
DEFENSEMECHANISMS
Achildisjealousoftheoldersibling’saccomplishmentandbecomeslessjealous
whenhe(thepatient)accomplishessomething.Whichdefensemechanismisthis?
SUBLIMINATION
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Therapy
32y/oFwmixedanxiety/depressionworkingwellinsupportive-expressive
psychotherapyonceweeklyforpast3months.Focusonissuesrelatedto
childhoodneglect/abusesheexperienced,howtheseimpactcurrentrelationships.
Inonesession,silent/tearful.Withencouragementfromtherapist,reportsher18APOLOGIZEANDACKNOWLEDGETHATTHESILENCE
month-olddaughterhospitalizedwmeningitis;sheisupset,worried.Therapist
HADFELTHURTFULTOTHEPATIENT
listenssilently.Ptleavessessionearly,missesnextsession.Followingtime,sheis
angry,accusestherapistofbeinguncaring/insensitivefornotexpressingconcern
aboutherchild/empathizingwherdistress.Therapist’simmediateresponse
shouldbe?(2x)
BusinessexecutivehospitalizedforbleedingulcerrepeatedlyargueswithawelllikedheadnurseandthreatenstoleaveAMA.BestactionforC&Lpsychiatristis:
(2x)
LISTENTOPT’SCOMPLAINTSACKNOWLEDGEHIS
DISCOMFORTWITHTHEPASSIVEPOSITIONTHATHEIS
UNACCUSTOMEDTO
Commonthemeinpsychotherapyintheelderly:(2x)
LOSS
Psychresidentdislikesalcoholicptsandavoidsworkingwiththem.Indiscussing
theproblem,saysthatptsarehopelessandunmotivatedandshecan’tempathize COUNTERTRANSFERENCE
withthem.Exampleof?(2x)
Asopposedtolong-termpsychotherapy,time-limitedtherapymorelikelyto:(2x) SELECTCENTRALISSUEASFOCUS
Intreatinganolderptwithdepressionwhoisasuccessfulexecutive,heoffersyou
sometipsoninvesting.Whatdoyoudo?Doyouaccepttheofferasawayto
THELATTER
validatethepatient’ssuccessORexplorethept’smeaningsandfeelingsaboutthe
offerORaccepttheinformationbutdonotactonit?(2x)
Forthetreatmentofptswithcompulsivesexualbehavior,thebestresultshave
beenseenwithwhichofthefollowingapproaches?(2x)
TWELVESTEPGROUPS
Twomostpowerfulpredictorsofoutcomeinanyformofpsychotherapyare:(2x)
EMPATHYANDTHERAPEUTICALLIANCE
25y/osingleAfrican-Americanman,whoisafirstyearlawstudentatanivy
leagueschool,seekspsychotherapyforwhathecalls“academicparalysis.”Heis
fallingbehindashespendsmoretimebroodingabouttheracialand
socioeconomicdifferencesbetweenhimselfandhisclassmates.Hefeels
comfortablewithhisAfricanAmericanpsychiatristandspeaksopenlyabouther
racialslightsthatheexperienceseveryday.Themostimportantgoalofdynamic
psychotherapywiththisptisto:(2x)
USETHESHAREDETHNICBACKGROUNDTOOFFER
INSIGHTTOEXPLAINHOWTHEPT’SALIENATIONMAY
BEROOTEDINSOMETHINGMORETHANHISCURRENT
SITUATION
Thefactormostconsistentlyassociatedwiththerapyoutcomeinpsychotherapy
research:(3x)
STRENGTHOFTHERAPEUTICALLIANCE
Couplestherapy,husbandcomplainsthatMDwifeworkstoolonghours,shesays
shestayslatetomakesureeverythingis“right”checkingandrecheckingherwork.
UNDOING
Notesthatonceinhighschoolshewishedherstraight-Abrotherdeadandlaterhe
diedonhuntingtrip.Hercheckingbehaviorisanexampleof:(2x)
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Thebestresponsetoaptwhoreportsafixedfalsebeliefthathisneighboris
poisoninghisdogandsittingalldayatthewindowmonitoringis:(2X)
A16-yohighschoolstudentisplacedonacademicprobation.Whatispriorityin
structuralfamilytherapy?
EMPATHIZEWITHTHEPT,BUTAVOIDDIRECT
CONFRONTATIONABOUTTHEDELUSION
HELPINGTHEPARENTSDEFINEEXPECTATIONS
Oninitialpsycheval,pttellsdraboutrecentinfidelity,wantstomakeamendswith
spouse,whatresponsewouldgetadditionalinfofrompt?
TELLMEMOREABOUTHOWTHISSTARTED?
ParentsofchildwithADHDandODD.Theywanttoknowpsychotherapeutic
approacheshowtoproceedwithkid
FINDOUTWHATKIDDOLIKESANDMAKEABEHAVIOR
REWARDPROGRAMFORYOURCHILDATHOMEAND
SCHOOL
Psychiatrist’smindwandersduringsessions,whatshouldthepsychiatristdo?
EXAMINEINNERTHOUGHTSANDFEELINGS
36y/optisbeginningpsychodynamicpsychotherapyfortxoflong-standing
EXPLORETHEPROCESSDURINGTHESESSIONTHAT
problemsofinabilitytoestablishsatisfyingongoingrelationships.Ptexpressesmuch
MIGHTBEINTERFERINGWITHTHEESTABLISHMENTOF
skepticismthat“talkingaboutmypast”willhelp.Themostappropriateresponseof
THETHERAPEUTICALLIANCE
therapistis:
Inthecontextofthepsychodynamicpsychotherapy,theterm“frame”refersto
whichofthefollowingaspectsoftherapy?
HOWITISORGANIZEDINTERMSOFBOUNDARIESAND
CONSISTENTDEFININGRULES
Whattheoryisthebasisofmentalization-basedtherapy?
BOWLBY’SATTACHMENTTHEORY
Whichofthefollowingapproachesislikelytoobtainthemostaccurateinformation FAMILYCOPINGSTRATEGIESINRESPONSETOPAST
onthefactorsinfluencingafamily’sleveloffunctioning
STRESSORS
Duringtheinitialinterviewofacouplepresentingfortherapyitishelpfultopoint
outthatthefocusoftherapyisprimarilyonthe:
RELATIONSHIPPROBLEM
Duringinitialpsychinterview,pttearfullydiscussespainfulendingofromantic
relationship.WhatshouldDr.saytoestablishtherapeuticalliance?
ITSOUNDSLIKETHISHASBEENVERYDIFFICULTFOR
YOU.
HOWAREYOUCOPING?
Fpsychiatristhasbeentreatinga32y/omarriedFptwweeklyindividual
psychotherapyfordepressivesx,ambivalenceaboutmarriage.Therapyprogressing
well.Ptjustlearnedsheispregnant,exploresconflictedfeelingsaboutterminating
pregnancyandherfearsthatunplannedpregnancywouldtrapherinmarriage.
“YOUFELTIWASIMPOSINGAMORALJUDGMENT
Uncharacteristically,psychiatristspeaksstronglytoptaboutreasonsnottomak
ONTOYOU,AND,APPROPRIATELY,YOUOBJECTED.”
suchachoice.Ptrespondsbysaying“youarenotgoingtomakemefeelguiltyabout
this!”Whatstatementwouldbemostappropriatefortherapisttomakein
response?
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Ptw/BMDwhohasbeenmakingprogressinlong-termpsychodynamic
psychotherapyenterssessionobviouslydistraught.Afterlisteningtoscattered
seeminglyunimportantdetailsofrecentdailylife,therapistasksifptisavoiding
somethingtoouncomfortabletotalkabout.Ptrespondswintenseanger/distress.“I “IAMGOINGTONEEDAMOMENTTOTHINKABOUT
justheardyouaregettingadivorce,Iamsickaboutit.HereIamcountingonyouto WHATYOU’VESAIDANDAREFEELINGBEFOREICAN
helpmesortoutmychaoticlifeandmessed-uprelationships,andyoucan’teven
RESPOND.”
keepyourownmarriagetogether!Whatareyou,somekindofhypocrite?IthinkI
shouldleaveandfindsomeonewhoknowswhatthey’redoing!”Bestresponsefor
thetherapisttomake?
Themotivationalenhancementtherapymodelforaddictiontreatmentemphasizes
whichofthefollowingfactors?
THEROLEOFAMBIVALENCEINCHANGE
8yroldevaluatedforasthma,foundtohaveADHDsymptoms,putonstimulant,
behavioralproblemscontinue,senttopsychiatristandpsychologist,thisisan
exampleofwhatlevelofcollaborativecare?
SHARED(INTEGRATED)CARE
Whichofthefollowingpsychotherapeutictechniquesisbasedonthecoreprinciples
ofexpressingempathy,developingdiscrepancy,avoidingarguments,rollingwith
MOTIVATIONALENHANCEMENTTHERAPY
resistanceandself-efficacy?
9yofbib-parentsforoutptevaluationduetobehaviordifficultiesathome.Port
daughter"explodes"whenshedoesn'tgetherway.Bossywithfriend.Oninterview,
SENDTHEPTHOMEWITHPARENTS
childiscalm,cooperativeandinteractive,deniesSI/HIandstates"sometimesIjust
getmad."Whatisthemostappropriatelevelofcare?
9yofbib-parentsforoutptevaluationduetobehaviordifficultiesathome.Port
daughter"explodes"whenshedoesn'tgetherway.Bossywithfriend.Oninterview,
childiscalm,cooperativeandinteractive,deniesSI/HIandstates"sometimesIjust EXPLOREREASONSFORPARENTALDIFFERENCES
getmad."Atafollowupinterviewthephysicianlearnstheoutburstsarerelatedto
parentaldisputes.Whatisthenexttreatmentstep?
9y/ofemalebib-parentsforoutptevaluationduetobehaviordifficultiesathome.
Reportsdaughter"explodes"whenshedoesn'tgetherway.Bossywithfriend.On
interview,childiscalm,cooperativeandinteractive,deniesSI/HIandstates,
"sometimesIjustgetmad."Whichisthemostappropriateinitialdiagnosticstep?
OBTAINATEACHERREPORT
Whichofthefollowingprinciplesismostcommonlyendorsedinparent
managementtrainingprogramsfortreatmentofoppositionaldefiantdisorder?
PARENTALATTENTIONFORPROSOCIALBEHAVIOR
Animportantcounter-transferenceissueinaninterethnicpsychotherapeutic
relationshipis:
DENIALOFDIFFERENCES
Whichofthefollowingisthemostaccurateinformationontheuseofbiofeedback
forhypertension?
ITISEFFECTIVEFORHYPERTENSION,HOWEVER,ITIS
LESSEFFECTIVETHANMEDICATION
Anewptaskstherapist,“areyouChristian?”Whatisbestresponse?
“AREYOUCONCERNEDTHATIFWEARENOTOFTHE
SAMERELIGION,IWON’TBEABLETOTREATYOU
PROPERLY?’
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Exchangeduringinitialinterviewafterpt’sformertherapistclosedhispractice:pt
expressesconcernaboutnewtherapistbeingtooyoung/inexperienced,statesshe
doubtsnewtherapistcanprovideanynewinsights.Bestresponsetofurthergoalof
gettingtoknowpt,establishwhethertherapywnewtherapistwouldbe
appropriate
“ITCANBEVERYHARDTOSTARTOVERWITHANEW
THERAPIST.HOWHAVEYOUBEENFEELINGABOUT
HAVINGTOENDYOURTREATMENTWITHDR.
BROWN?”
Treatingamucholderptwhoasksabouttherapist’sage.Bestresponse:
“MAYBEYOU’RECONCERNEDABOUTWHETHERIAM
EXPERIENCEDENOUGHTOTREATYOU?”
Intensive,short-termdynamicpsychotherapyiscontraindicatedforwhatcondition? ACUTEEXACERBATIONOFCHRONICSCHIZOPHRENIA
Ptseeingnewpsychotherapistweeklyx3wkshesitantlycomplainedaboutbeing
abletooverhearmuchofwhatptintheprecedingsessionwassaying.Ptassured
therapistthathehadtriednottolistenandhadleftthewaitingroomtowait
outsideuntiltheotherpthadleft.Whichisbestresponse?
APOLOGIZEFORTHELACKOFPRIVACYANDINDICATE
THATFURTHERMEASURES,SUCHASMUSICSYSTEMIN
THEWAITINGROOM,WILLBEUTILIZED
MDseespsychiatristwincreasingsenseofdislikeforablaming,externalizingptwho
COUNTERTRANSFERENCE
pitsfamilymembersagainsttheMD.WhatshouldpsychiatristdiscusswMD?
Ptisseenbypsychiatristbecausehasbeendepressedfor1yrsincehewasfiredin
spiteofhavinganotherjob.Thepsychiatristtellsthept:menoftenfeelthattheyare
CUTOFFBYTHEPREMATUREOFFERINGOF
notallowedanyfailuresbutIcantellthatyouhavemovedonfromthissuccessfully
REASSURANCE
andhavenoreasonstodwellinit.Theptthenwithdraws.Themostlikelycauseof
ptresponseisthathefelt:
Beginningphaseoftherapywchildwhowasincestvictimshouldfirstfocuson
what?
DEALINGWITHPRIORBETRAYALANDESTABLISHING
TRUSTWITHTHETHERAPIST
5y/oenactsfightbetweentwodolls.Whatshouldtherapistdo?
DESCRIBETHEDOLL’SAFFECTWITHOUTATTRIBUTING
ANGERTOTHECHILD
Severalmonthsofweeklyindividualpsychotx—womanwMDD,panicd/odescribes
repressedmemoriesofsexualabusebystepfather.Therapistneutral,explorespt’s DOCUMENTCAREFULLYTHEUNFOLDINGPROCESSAND
experience.Ptreportsincreasingconvictiondespitesisterinsistingitwasimpossible. OBTAINSUPERVISION
Planstpgetlawyerifparentsdonotadmit&apologize.Whichisbestapproach?
50y/oMhospitalizedfordepressionandmelancholia.Firstfewtherapysession
shouldfocuson:
EDUCATEPATIENTONNATUREOFILLNESSAND
TREATMENT
Aptwithh/olifelongdepression&failedrelationshipscomplains(veryangry)(after
EMPATHIZEWITHTHEPT’SFEARSOFTRUSTAND
severalweeksoftherapy)thatsheisexpectedtotrusttheDr.withoutevenknowing
FEELINGOFBEINGATADISADVANTAGE
anythingabouthim(credentialsorpersonally)whatshouldtheDrsay?
62y/owithlungcancer,weightloss,fatigue,andpersistentcough.Patrefusesto
acceptDxofcancerandstateswill“getoverthisinfection.”Ptrefusesallfurther
testingandasksforantibioticsto“recoverinpeace.”C&Lpsychiatrist’sroleis:
EVALUATEPT’SCOPINGSTYLEANDHELPTHEMEDICAL
TEAMSEETHEPT’SRESPONSESINTHECONTEXTOF
HERUNIQUEPERSONALITYANDLIFECIRCUMSTANCES
Youngfemalestartingcognitivetherapywithafemaleresidentasksforahug.
Residentshouldfirst
EXPLAINWHYPHYSICALCONTACTISAVOIDED
C&Lpsychiatristusesalltherapeuticapproachesexcept:
EXPLORATORYPSYCHODYNAMIC
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PtrecurrentlygoestoEDbecauseofseverechestpain.Hasbeenw/uforeverything
andalltestarenormal.Hestatesthatsomethingneedstobedoneto“fix”hispain.
EXPLOREPT’SFEELINGSABOUTFATHER’SDEATH
Psychconsultisplaced.MSEandneuroisnormal.Pasthxrevealshisfatherdiedof
lungCA.Nextinterventionaspsychiatristis:
Psychiatrististreatinganolderptwhoisasuccessfulexecutive.Ptfeelsgratefulfor
EXPLOREPT’SMEANINGSANDFEELINGSABOUTTHE
thehelpw/hisdepressionandofferssometipsoninvestingtothepsychiatrist.
OFFER
Whatisthemostappropriateactionatthispointfromthepsychiatrist?
Fatherisdying.Ptisnotadrinker,butwentfrombartobardrinkingdad’sfavorite
drink.Barsaresimilartothosedadusedtogoto.Bestinterpretationofthis
behavior:
IDENTIFICATIONWITHORINCORPORATIONOF
PATIENT’SFATHER
Femalepsychresidentsaysptsawresidentintownoverweekend.Followedher
around.Thoughtshecouldlatershopatsamestoresandeatatsamerestaurantsas
INTERPRETPT’SLONGINGTOIDENTIFYWTHE
hergreatlyadmiredtherapist.Nothingwronginpt’sbxormaterialsuggestingsheis
PSYCHIATRIST
dangerous.Ptapologizesconvincingly,sayswillnotdoagain.Hopestherapistwill
notfireher.Whatisnextbeststep?
Whatifptaskswhetheryou’restillintrainingduringintakeinterview?
INFORMTHELEVELOFTRAINING
Midwaythroughpsychotherapysession,apsychiatrist’smindwandersdespite
repeatedrefocus.Bestimmediateaction:
EXAMINEOWNINNERFEELINGSABOUTTHEPATIENT
Thefirst-linetreatmentforretentiveencopresis:
BIOFEEDBACK
Ptseestherapistandmakesthreatsandbecomesagitated.Therapistfeelsuneasy,
thenextstepisto:
INTERRUPTINTERVIEWTOGETHELP
Useofmedswithpsychodynamicpsychotherapyoptimalwhen:
MEANINGSANDEFFECTSOFMEDSINTEGRATEDINTO
PT’SUNDERSTANDING
Whathasbeenshowntobeanevidence-basedtreatmentforindividualswith
conductd/o?
MULTISYSTEMICTHERAPY
Youngptintherapyreturnstoschool,announcestotherapistthathecanpass
classes,willgraduate.Bestresponse:
OFFERINGCONGRATULATIONS
Beginningtherapistfeelsgreatempathyfordepressedptfailstomaintainsufficient
OVERIDENTIFICATIONWITHPATIENT
distancetoobserveself-destructivepatterns.Toavoidthispayattentionto:
40y/oeatsandsleepstoomuch,cravessweets,poorconcentration,irritable,
constantconflictswithhusband.States“Ialwaysfeelbetterinspring.”Whatisthe
treatment?
PHOTOTHERAPY
Childhashigh-activitymotorlevel.Teachershould
PROVIDEBRIEFERRANDSTODOWHENTHECHILDIS
PARTICULARLYRESTLESS
Socialskillstrainingforthosewithpersistentmentalillnessisanessentialpartof:
PSYCHIATRICREHABILITATION
Whichpsychotherapyusestransferenceinterpretationsandclarificationtodevelop
PSYCHODYNAMICPSYCHOTHERAPY
insightandresolveconflict?
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Therapistisworkingwfamilyofschizophrenic.Strategiesincludeinformingabout
illness,socialsupport,managementguidelines.Therapistencouragescalmproblem
PSYCHOEDUCATIONAL
solvingapproach/facilitatesstressandstigmareductionwhenpossible.Which
modelistherapistusing?
Biofeedbackusuallyhelpsptswithwhichsyndrome?
RAYNAUD’SSYNDROME
Whichofthefollowingisaneffectivetreatmentformild-to-moderatelysevere
idiopathicRaynaud’sdisease?
THERMALBIOFEEDBACK
WhatinterventionsareconsistentwthetheoreticalassumptionsofcrisisTx?
REASSURANCE,BRIEFHOSPITALIZATION,
PSYCHODYNAMICINSIGHT,TREATMENTWITH
PSYCHOTROPICMEDICATIONS(NOTFOCUSINGON
PASTRELATIONSHIPS)
Duringlastsessionofsuccessfulpsychodynamicpsychotherapy,ptwarmly
expressesgratitudeforeverything,sayingthatthehelpthetherapisthasgivenhas
madeabigdifference.Appropriateresponse?
RESPONDBYSAYINGYOUTOOHAVEENJOYEDTHE
WORK
98.Schizophrenicwmemorylossandslowedthinking,stableonclozapine,with
poorresponsetohalloo,zyprexa,geodonandabillify.Whatcouldimprovethept’s
symptoms
COGNITIVEREMEDIATIONTHERAPY
Whichisaboundaryviolation?
•Investinginapt’sbusiness
•Treatingthetownpharmacistinsmallruraltown
•Acceptingpt’sholidaygiftofhand-madescarf
•Seeingoneptatreducedfeeandchargingothersmore
•Discussingapt’ssexualfeelingstowardthepsychiatristinsession
INVESTINGINAPT’SBUSINESS
12y/oFnotattendingschoolforfearhermommaydieinaccident.Management?
RETURNINGTHEGIRLTOHERCURRENTCLASSROOM
Afterattendingseveralsessionsofindividualpsychotherapyforanxietyand
depression,24y/oMrevealedhishomosexualitytohisheterosexualmale
SEEKCONSULTATIONTODISCUSS
psychiatrist.Therapistrealizesheisuncomfortablewhenptexpresseslongingsfora
COUNTERTRANSFERENCEISSUES
male.Therapistalsotendstooveremphasizeanymaterialthatmightrepresentpt’s
heterosexualwishes.Thenextbeststepforthepsychiatristwouldbeto:
Ptw/mildMRinprogramdesignedtodevelopnewbehaviorsbymodeling/
reinforcement,thenpracticethem.
SOCIALSKILLSTRAINING
Therapistpreoccupiedw/patient.Acknowledgesthisbutunabletoshakefeeling
TALKTOSUPERVISOR
15y/omalebibparents,doesnotwanttospeakwithpsych
THANKHIMFORCOMINGINANDASKHIMIFHE’DLIKE
TOBESEENALONEORWITHHISPARENTS
WhatwasmostimportantfactorindeterminingtxoutcomesinNationalInstituteof
THERAPEUTICALLIANCE
MentalHealthTreatmentofDepressionCollaborativeResearchProgram(1996)?
Couplehassoughtcouples’therapyduetochronicepisodicfighting.Solution
focusedtherapistmightmakewhichintervention?
BETWEENNOW&NEXTTIME,IWANTEACHOFYOUTO
THINKABOUTWHATTHETWOOFYOUAREDOING
DIFFERENTLYINTIMESOFNOTARGUING
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Intervieww/aptw/schizophreniaevokesfeelingsofconfusionandfrustrationin
ACKNOWLEDGINGTHEINTERVIEWER’SFRUSTRATION
theinterviewerwhentheptbecomessilent.Whatresponsebythetherapistwould
ANDINQUIRINGIFTHEPTFEELSSIMILARLY
bethebestapproachtoestablishingrapport?
Clinicalcircumstancethatbestwarrantsconsiderationofpsychotherapyasthesole PREGNANCY,LACTATION,ORWISHTOBECOME
treatmentformildtomoderatedepression:
PREGNANT
Whatrepresentsmajorgoalofpsychotherapyasconceptualizedbyself-psychology?
IMPROVINGTHEABILITYTOUSETHEAPPROPRIATE
AFFIRMINGRESPONSESFROMOTHERS
Incasesofrecoveredmemory,theroleofthetherapististo:
DEMONSTRATEEMPATHYFORTHEPATIENTWITHOUT
ENDORSEMENTOFTHEMEMORY
24y/optwtetraplegiaafterMVAshowingnosignsofgrieforacknowledgementof
poorprognosis,nosignificantdepressive/anxiousSx.Whatpsychintervention
SUPPORTBUTDONOTCONFRONTTHEPTABOUTTHE
preferred?Whatpsychotherapeuticschoolofthoughtemphasizeshowapthas
MEDICALREALITIESEGOPSYCHOLOGY
managedfeelingsofenvy/ragewparticularemphasisondefensemechanisms?
Insplittreatment,theroleoftheprescribingpsychiatristis?
EVALUATETHEPTSNEEDSFORMEDICATIONSWHILE
MAINTAININGREGULARCONTACTWITHTHE
THERAPIST
Psychotherapyresearchshowswhichofthefollowingpracticesinatherapeutic
relationshipismostsupportiveforimprovingoutcomes?
collectingfeedbackfromtheptaboutthetreatment
PsychodynamicTherapy
“Deficitmodel”ofpsychologicalillnessinpsychodynamicpsychotxdefines
psychopathologyas:(2x)
WEAKENEDORABSENTPSYCHICSTRUCTURES
43y/oMsuccessfulexecgoestopsychiatristb/cwifethreatenedtoleaveifhe
doesn’tchange.Doesn’tunderstandwife’scomplaintsthatheisperfectionist,
THEDIFFICULTYOFDEMONSTRATINGTOTHEPTTHAT
demanding,controlling,unavailable.Hebelievesheisjustagoodman.Informing HISEGOSYNTONICTRAITSAREMALADAPTIVE
optimalinitialtxplan,considerationsforchoiceoftherapyshouldinclude:(2x)
Txformedstudentw/chronicanxietyandsenseofinadequacy?
BRIEFPSYCHODYNAMICTHERAPY
Ininitialpsychinterview,ptfrustratedthathislastpsychiatristhadbriefvisits&
“justgavemeanotherpilleverytime.”Interviewingpsychiatristresponds“soyou
CLARIFICATION
wouldlikeyourpsychiatristtolisten&understandyoubeforeadjustingyourmeds.”
Ptreceivingweeklybriefpsychodynamicpsychotx.2monthsintotxpt
acknowledgesbeingawareofmaladaptivebehaviors,reportsnowbeingableto
removehimselffromsituationsthatfrustratehim.Thept’saccountisreflectiveof
whichofthefollowingelementsofbriefpsychodynamicpsychotherapy?
DISCREPANCY
WhenpracticingDavanloo’sshort-termdynamicpsychotx,onemustconsistently…
CLARIFYANDRELENTLESSLYCONFRONTTHEPT’S
DEFENSES
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25y/oFneveronadateafter6moofpsychodynamicpsychotherapy.Beganto
strugglew/positivefeelingsaboutMtherapistthatshefindshardtoaccept.Atthe
sametimeshestartstodate.Therapistbelievesitistransference.Therapistsaid
APRACTICAL/SUPPORTIVEAPPROACH
nothing,hebelievedaninterpretationmightinterferew/positivelearning
experience.Thisisexampleof:
Whichofthefollowingcharacteristicsiscommontoallbriefdynamic
psychotherapies?
PRACTICALWORKINGTHROUGHOFCONFLICTBY
TRANSFERENCEINTERPRETATION
Determinesifpthasegostrengthfortherapy
ASSESSMENTOFQUALITYOFRELATIONSHIPS
Whichofthefollowingmodelsdividethemindintoconscious,thepreconscious,and
TOPOGRAPHICAL
theunconscious?
Goalsofbriefpsychodynamicpsychotherapycomparedtolong-termpsychodynamic
DISCUSSIONOFTRANSFERENCEINTHELATTER
psychotherapydifferhow
Primaryinterventioninhighlyexpressivepsychotherapy:
INTERPRETATION
Psychiatristtellspt“Youtoldmeyourfeelingsarehurtwhenspousedoesn’tpay
attentiontoyou.IthinkyoumayalsobesayingIhurtyourfeelingsduringlast
sessionwhenIdidn’tletyoufinishbeforeendingsession.”Whatinterview
techniqueisthis?
INTERPRETATION
Ptisoftentardy.Supervisorwarnsnottobelate.Pthasanxietyaboutlosingjob.
Whenfatherdiesheleavestownw/otellingsupervisor.Againgivenwarning.Next
dayatraincauseshimtobelate.Intherapy,theoverlappingofmultiplepotential
causesfortardinessisanexampleofwhat?
OVERDETERMINATION
Thistreatmentgoalismostspecifictopsychoanalyticpsychotherapy:x2
BRINGINGUNCONSCIOUSCONFLICTINTO
AWARENESS.
A3yochildhasbeenexpressingangryfeelingsaboutthearrivalofanewsibling.
Thechildhasasecureattachmenttoparentsaswellasgrandparentswhovisit
frequently.Duringonesuchvisit,duringwhichthegrandparentsspendtimeholding TURNINGAGAINSTTHESELFASADEFENSEAGAINST
thenewbaby,thechildbeginstobangtheheadrhythmicallyagainstatable.
INTOLERABLEANGER.
Accordingtopsychoanalytictheory,thisbehaviorisunderstoodaswhichofthe
following?
38y/optindynamicpsychotherapyfordepressionsayssheislesbianandis
SUGGESTTHATCONJOINTTHERAPYWITHTHEPATIENT
dissatisfiedwithherotherwisegoodrelationshipwithherpartnerof7yrsb/cshe
ANDHERPARTNERMIGHTBEAPRODUCTIVEWAYTO
wantsachildandherpartnerdoesnot.Shethinksaboutleavingtherelationshipbut
EXPLORETHISCOMPLICATEDISSUE
thismakesherfeelsadnessandasenseofloss.Whatisbestintervention?
Whatbestdescribescurrentpsychoanalyticthinkingaboutthesourceof
countertransferencephenomenainthetherapist
THETHERAPISTSTOTALEMOTIONALREACTIONTOTHE
PATIENT
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32y/oF,divorced3times,seesamalepsychiatrist,sayingsheneedstherapy
becausesheisparalyzedaboutchoosingacareer.Pthasstartedandstopped
collegetwice,heldseveralwaitressandclerkjobs.Shehopedthetherapistcouldtell
herwhatjobtopursue.Intheinitialinterviewsheasksthetherapisttosendbills
TRYTOGETADVICEBUTTHENBEANGRYATTHE
directlytoherfather,whomanageshermoneybecauseshehasdifficultymanaging
THERAPISTFORGIVINGIT
billsandcreditcards.Sheexplainedshehastoliveathometosavemoney,but
hatesthisbecauseshefrequentlyfightsbitterlywherfatherwhoalwayswantsto
controlher.Transferenceissuethattherapistshouldexpecttobecentralthemein
therapyis:
“Deficitmodel”ofpsychologicalillnessinpsychodynamicpsychotherapydefine
psychopathologyas:
WEAKENEDORABSENTPSYCHICSTRUCTURES
Inpsychodynamictx,interpretationoftransference&resistanceuntilinsightfully
integratediscalled:
WORKINGTHROUGH
33y/optinlongtermpsychodynamicpsychotherapyforseveralmonthsis
chronicallylateforsessions.Therapistsuggeststhatthismayberesistance.Thept
says“oh,don’ttakeitpersonally,Iamthiswaywitheveryone”.Thisresponsecan
bebestunderstoodas:
ANUNINTENDEDCONFIRMATIONOFTHEPROBABLE
CORESIGNIFICANCEOFTHISBEHAVIOR.
Ptreenactstherapeuticrelationship
TRANSFERENCE
Studiesshowthatshort-termpsychodynamicpsychodynamic(STPP)psychotherapy
issuperiortosupportivetherapyinthetreatmentofcomplicatedgriefforcertain
MATUREOBJECTRELATIONS
pts.WhichofthefollowingptcharacteristicspredictsabetterresponsetoSTPPthan
supportivetherapy?
WhileassessingforDV,examinersaystopt/spouse,“Thetensionthatbuildsup
betweenyoumustbeincrediblystressful.It’snotunusualthatpeoplewhoare
stressedoutcanhavetroublecontrollingthemselvesorcandothingstheydidn’t
intend,likescreamingatorevenhittingtheirpartner.Hasanythinglikethat
happenedtoyou?”Whichtechniqueisthis?
NORMALIZATION
Youngfemaleinpsychodynamicpsychotxadmittedtoseeingtheresident
downtownlastweekend,followedhimaround,thinkingshecouldlatershopatthe
INTERPRETPATIENT’SLONGINGTOIDENTIFYWITHTHE
samestoresandeatatsameplacesashergreatlyadmiredtherapist.Ptnot
THERAPIST.
dangerous,convincinglyapologized,statedthatshewouldneverrepeatthis
behaviorandhopedtherapistwouldnot“fire”her.Nextsteptherapistshouldtake?
Ptinpsychodynamicpsychotherapyrepeatedlyasksthetherapistpersonal
questions.Thetherapistconsistentlyexploresthereasonsforthepatient’sasking, “IKNOWTHISCANSEEMVERYFRUSTRATING,BUTTHE
andsometimestheseexplorationsarefruitful.Regardless,theptpersistsinpressing FOCUSOFTHETHERAPYSHOULDBEONYOU”.
for“realanswers”.Thetherapistresponseatthispointiswhat?
Ptrepeatedlyredirectingdiscussionbytalkingaboutirrelevanttopicsisexampleof: RESISTANCE
Incontextofpsychodynamicpsychotx,“frame”referstowhataspectoftherapy?
HOWITISORGANIZEDINTERMSOFBOUNDARIESAND
CONSISTENTDEFININGRULES.
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60y/osuccessfulbusinessmanhasstartedpsychodynamicpsychotherapywitha
youngmaletherapistinoneearlysession,theptbeginsbysaying,“beforeweget
started,Iwanttoletyouknowaboutapotentiallylucrativeinvestment
opportunity.”Thisstatementisbestrepresents:
ANATTEMPTBYPT,PROBABLYUNCONSCIOUSLY,TO
SEDUCEANDTESTTHERAPIST.
CBT
Animportanttechniqueorgoalofcognitivetherapyis?(x2)
ELICITINGANDTESTINGAUTOMATICTHOUGHTS
CBTforptswithOCDinvolvesgraduallyexposingthepttoafearedstimulusand
preventingtheritualizedresponse.Overtime,thisresultsindecreasedanxietyto HABITUATIONELICITINGANDTESTINGAUTOMATIC
thestimulusdemonstratingwhichofthefollowingAnimportanttechniqueorgoal THOUGHTS
ofcognitivetherapyis:(2x)
WhichofthefollowingisaprincipalgoalofCBTforpanicd/o?
USINGRESTRUCTUREDINTERPRETATIONOF
DISTURBINGSENSATIONS
GoalofCBTforchronicpaintxis
IMPROVEFUNCTIONINGDESPITEPAIN
WhatisfirstlinetxforPTSDinchildrenandadolescents?
CBT
42Mbecomesdepressedafterdiscoveringhiswifeishavinganaffair.Ptdescribes
angerathiswife,avoidstalkingtoher.Admitstofeelingthatthewife’sactionsare
hisfault,thatheisafailureasahusband.Theptnotesthathehasbeguntodwell
onhispastfailedrelationships,aswellasthedivorceofhisparents.PtbeginsCBT
fordepression.Mostappropriatetargetforthistypeoftherapyinthispt?
ASSUMPTIONSOFPERSONALFAILURERESULTING
FROMTHISCRISIS
Identifyingnewrouteshomefromworkforalcoholicpatientisexampleofwhich
typeoftherapy?
CBT
Mostcommonlyusedcognitivetherapytechniquetouncover&modifyautomatic
negativethoughts
SOCRATICQUESTIONING
Whichofthefollowingischaracteristicofbothinterpersonalpsychotherapy,CBT?
HASAHEREANDNOWFOCUS
MostappropriaterationaleforusinghumorinCBT
HELPINGTOCREATEANEWPERSPECTIVEON
OTHERWISEDISTORTEDCOGNITIONS
Collegestudenttellspsychiatrist“IhadanexamtodayandI’msureIfailedit.NowI “LET’SMAKELISTSOFTHEEVIDENCEFORANDAGAINST
willnevergraduatefromcollege”.WhichresponseisconsistentwithCBT?
YOUFAILINGOUTOFCOLLEGE”
Fromcognitive-behavioralperspective,whichismostresponsibleformajor
depression?
FEELINGSOFDEVALUATION
InCBT,askpatienttokeeplogforeachhourandratesenseofmasteryandpleasure
ACTIVITYMONITORING
experienced.Whatisthis?
Primaryfocusofacognitivetherapyapproachtosuicidalbehavior:
ADDRESSINGALLORNOTHINGBELIEFSANDHELPING
PTLEARNPROBLEMSOLVING
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Programmedpractice,orexposuretherapy,isanindicatedtreatmentforwhat
disorder?
AGORAPHOBIA
PtwithdepressionbeingtreatedwithCBTtellspsychiatristaboutwakingupand
beingworriedaboutwork.Pthasbigprojectthatisdueintwoweeksandishalf
done,butptissureworkwillnotbefinishedontime.Exampleofwhichcognitive
error?
CATASTROPHIZING
Pthasseverestressandconflictatwork,therapistidentifiestheproblemof
maladaptiveresponsesbasedonrigidthoughtschemasanddecidestotarget
CBT
automaticnegativethoughtsthroughrealitycheckingandguidedassociation.What
typeoftherapyisthis?
Flooding,gradedexposure,andparticipantmodeling:
CONFRONTATIONOFANXIETY-PROVOKING
EXPERIENCES
Ptwithmultiplesocialfearsisterrifiedofpublicspeaking.Asthenextstepin
treatment,thetherapistarrangesforthepttogive15minutestalktoclinicalstaff.
Thisisanexampleof:
FLOODING
Cognitivetherapywasdevelopedby:
AARONBECK
Exposureandfloodingtogetherwithresponsepreventionaretechniquesof
behavioraltherapyaimedatwhichofthefollowing?
HASTENINGTHEEXTINCTIONOFACONDITIONEDFEAR
ORANXIETYRESPONSE
ElementscommontobothCBTandeyemovementdesensitizationandreprocessing CONTROLLEDEXPOSURETOTRAUMARELATED
inthetreatmentofpatientswithPTSDinclude:
TRIGGERS
Ptwfearofheights.Ptinstructedtovisualizecrossingabridge.Whatisthe
therapeutictechnique?
IMAGINALEXPOSURE
Whichpsychotherapeutictechniqueismostclearlyindicatedfortreatmentof
simplephobia?
EXPOSURETHERAPY
Takeagoraphobictocrowdedplaceandstaythereuntilanxietydissipates
FLOODING
TheLEASTutilizedapproachusedincognitivetherapyinptw/substance
dependence
INTERPRETATIONOFINTERACTIONALPROCESS
ACBTtherapistworkswithatherapist,amongstotherthings,toidentifyand
correct:
OVERGENERALIZATION
Incognitivetherapy,“selectiveabstraction”iswhat?
PATIENT’SFOCUSONADETAILTAKENOUTOFCONTEXT
ANDCONCEPTUALIZESAEXPERIENCEBASEDONTHIS
ELEMENT
Cognitiveerror:whenaskedabouthisday,ptreplies,“Iwaslateforworkb/cI
misplacedmykeys”then,“Ididn’tspeakupinthestaffmtg.”
SELECTIVEABSTRACTION
Thecognitiveerrorofarbitraryinferenceisbasedon:
DRAWINGACONCLUSIONDESPITETHEABSENCEOF
EVIDENCEORDESPITEEVIDENCETOTHECONTRARY
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42y/optb/cdepressedafterdiscoveringhiswifeishavinganaffair.Ptdescribes
angerathiswifeandavoidstalkingtoher.Headmitstofeelinghiswife’sactionsare
ASSUMPTIONSOFPERSONALFAILURERESULTING
hisfaultandthatheisafailureasahusband.Ptnoteshehasbeguntodwellonpast
FROMTHISCRISIS
failedrelationshipsandthedivorceofhisparents.HebeginsCBT.Themost
appropriatetargetforthistypeoftherapywouldbethept’s:
Thebehavioraltherapytechniqueinwhichaptisexposedtoprogressivelygreater
fearinducingsituationsisreferredtoas:
SYSTEMATICDESENSITIZATION
Behavioraltherapywrelaxationtraining/hierarchyconstruction/visualimagery?
SYSTEMATICDESENSITIZATION
Allofthefollowingarestrategiesforchangeincognitivetherapy:
USINGREATTRIBUTION,DEVELOPINGALTERNATIVES,
QUESTIONINGTHEEVIDENCE,FANTASIZING
CONSEQUENCES.(NOTEMPLOYINGINTERPRETATION)
Meta-analysissuggestswhichofthefollowingforpsychotherapytotreat
depression?
OTHERPSYCHOTHERAPIESHAVEEFFICACY
COMPARABLETOCBT
Duringpsychotherapy,patientdescribessituationwhereroommateleftthe
apartmentafterreceivingacall.Patientrecalls“imbeingleftoutagain”.This
AUTOMATICTHOUGHTS
MaritalTherapy
WhichTxiscontraindicatedininitialtreatmentofptexperiencingdomestic
violence?(4x)
CONJOINTMARITALTHERAPY
Whenconductingmaritaltherapywithacouplewhobegintotalkaboutdivorce,
whatshouldthepsychiatrist’sstancebe?(2x)
FOCUSONTHECOUPLE’SRESPONSIBILITYTODECIDE
THEFUTUREOFTHEIRRELATIONSHIP
Womanisunabletoachieveorgasmwithherpartner.Treatment=directed
masturbation+?
COUPLESTHERAPY
DEMONSTRATINGCONFLICTSARISINGFROMEACH
Thebasisforself-psychologicalstrategyinmaritaltherapyisbestindicatedbywhat? SPOUSE’SNEEDTOHAVEHIS/HERNEEDSMETBY
OTHER
Couplestherapy:whatisthegoalofacceptancework?
EACHPARTNERTAUGHTTOUNDERSTANDOTHER’S
POSITION&RELEASESTRUGGLETOCHANGEHIMOR
HER
Inasession,acoupleseemsblissfullycontentwhenhappybutenragedwhen
frustratedbytheother.Theyalternatebetweenover-idealizinganddevaluingthe
other.Thisisanexampleof?
SPLITTING
Duringinitialevalofanindividualforcouple’stherapy,itismostcriticaltoask
about:
DOMESTICVIOLENCE
28yohomosexualMreportsbeingvictimofdomesticviolenceandhasnotreported.
LISTENTOPT’SCONCERNSANDEXPLORETHEM
Whatisthebestresponseforthepsychiatristtomake?
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Duringaninitialofficeevaluation,thepttellsthepsychiatrist,“myspousetoldmeI
hadtobeevaluated.”Whichofthefollowingwouldbethemostempathic
“HOWDOYOUFEELABOUTTHAT?”
response?
Anewpsychotherapypatientarrivesforafirstappointment,accompaniedbythe
“CERTAINLY,IFTHATISYOURWISH,BUTI’DALSOLIKE
spouse.Theptasksifthespousecanbepresentduringtheinterview.Whichofthe
TOSPEAKWITHYOURPRIVATELYATSOMEPOINT.”
followingisthemostappropriateimmediateresponsebythepsychiatrist?
Couplesdissatisfiedwitheachotherandprogressingtowarddivorcehaswhichof
thefollowing?
Couplestherapyiscontraindicatedinwhichofthefollowingsituations?
Besttreatmentforgenito-pelvicpain/penetrationdisorder
EXPRESSIONOFCONTEMPTANDSTONEWALLING
DURINGINTERACTIONS
UNEQUALMOTIVATION
DILATIONWITHGRADUATEDSIZEDVAGINAL
DILATORS
DialecticalBehavioralTherapy
WhenDBTisusedtotreatpatientswithborderline,theworddialecticalrefersto
treatmentstrategiesthatfocuson:(2x)
SEARCHINGFORASYNTHESISBETWEENSEEMINGLY
CONTRADICTORYIDEAS
Dialecticalbehaviortherapyisutilizedfor:
BORDERLINEPERSONALITYD/O
Whichtypeoftherapyhasindividualsessionstoanalyzeself-destructive
cognitions/feelings/actions,andgroupsessionswithskillstrainingtoimprove
relationshipsanddecreaseimpulsivity?
DIALECTICALBEHAVIORALTHERAPY
AccordingtoDBTtheory,whichskillshouldbetaughttoptsfirst&regularly
practicedinordertofacilitatelearningofotherskills?
MINDFULNESS
PurposeofDBTtodiminishwhat?
PARASUICIDALTHOUGHTS
IntheindividualcomponentofDBT,atherapistspendtimein:
NURTURINGTHEPTANDREQUIRINGPTTOHELP
HERSELF
FamilyTherapy
11y/oboyhasfrequentepisodesofulcerativecolitisrequiringfrequent
hospitalization.Whileinthehospital,motherneverleaveshissideandresponds
toquestionsforhim,oftenreferringtodiseaseas“ourdisease.”Accordingto
Minuchin’stheoryoffamilyinteractions,thisis:(3x)
ENMESHED
Whatbestillustratesadoublebindinafamily?(x3)
BETTY’SPARENTSENCOURAGECOLLEGE,BUT
COMPLAINTHATEXPENSESWILLBEAHARDSHIPFOR
THEFAMILY
familypsychoeducationprogramsforpsychoticdisordersreducesymptomseverity
andrelapseriskbyreversingwhat?
FAMILYMEMBERSEXPRESSCRITICISM,HOSTILITYAND
BLAMETOWARDSTHEPATIENT
Thisbestdescribesthetechniqueofreframinginfamilytherapy:
NEGATIVELYEXPRESSEDFEELINGORBEHAVIORSARE
EXPRESSEDINPOSTIVETERMS
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Structuralmodeloffamilytherapycharacterizesfamilyas
COMPLEXSYSTEMCOMPRISEDOFALLIANCESAND
RIVALRIES
Whattypeofgrouptherapyisbasedontheunitfunctioningtomaintainitsown
homeostasisofinteracting?
FAMILYGROUPTHERAPY
Accordingtostrategicandstructuralfamilytherapies–underlyingbasisforanalysis OBSERVABLEANDREPORTEDFAMILYBEHAVIOR
ofsymptomsinchildren,parents,andfamilies
SEQUENCES
Whatisanimportanttechniqueofstructuralfamilytherapy?
OBSERVINGTHERELATIVEINFLUENCEOFEACHFAMILY
MEMBERONTHEOUTCOMEOFANACTIVITY
Whichpracticeiscommontoallcoupleandfamilytherapiesandcontributestoa
therapeuticoutcome?
CONCEPTUALIZINGDIFFICULTIESINRELATIONALTERMS
Therapistvalidatesfamily’sstrengths/resourcesindealingwpt’sschizophreniaatbiENGAGEMENT
weeklyfamilymeeting.Whatstageoffamilypsychoeducationalmodelisthis?
Accordingtobothstrategicandstructuralfamilytherapies,whichofthefollowingis
OBSERVABLEANDREPORTEDFAMILYBEHAVIOR
theunderlyingbasisforanalysisofsymptomsanddysfunctioninchildren,parents,
SEQUENCES
andfamilies?
12yoarguingwhissingleparentmother.Motherthreatensconsequencesandchild
runstograndmotherwhothenscoldsmotherforbeingtooharsh.Familydynamicis TRIANGULATION
reflectiveof?
Theconceptoftheidentifiedpatientintherapyrefersto:
ONEFAMILYMEMBERWHOHASBEENLABELEDTHE
PROBLEMBYTHEFAMILY
Whattypeoffamilytherapyusesparadoxicaldirectives,suchasprescribingthe
symptomorbehavioralsequence?
STRATEGIC
Inwhattypeoffamilytherapyaretheconceptsoffamilyhierarchies,boundaries,
coalitions,andalliancesseenascoreconcepts?
STRUCTURAL
Contraindicationtofamilytherapy
STRONGRELIGIOUSORCULTUREBELIEFSAGAINST
OUTSIDEINTERVENTION
Infamilytherapy,apreviouslydistantcouplebeginstocommunicatemore
frequentlyandintimately.Afterthishappenedthedaughterwhousedtobecloseto
TRIANGULATION
mom,andhasbecomelesssoasaconsequenceofabovetherapychanges,ismore
hostiletofather.Thisbehavioriscalled:
Ptw/schizophreniahasrecentlybeendischargedfromthehospitalafterafirst
psychoticepisode.Family-orientedtherapygoalsshouldinclude?
Duringfamilymeetingfor75yoptadmittedforMI,howtoaddressfamily
unwillingtoparticipateindiscussion?
EDUCATINGTHEFAMILYABOUTTHEPATIENT’SILLNESS
ANDPROVIDINGSUPPORTFORIMMEDIATEPROBLEMS
Identifytheinabilityorunwillingnesstodiscussasone
ofthefamily’sproblems
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Accordingtostructuralfamilytherapy,whatistheindicatorofnormalfamily
functioning?
WELLDEFINEDBOUNDARYBETWEENPARENTSAND
CHILDRENTHATPERSEVERESAUTHORITYAND
FACILITATESOPENCOMMUNICATION
GroupTherapy
Majortaskofagrouptherapyduringinitialengagementphaseis:(2x)
DETERMININGLIMITSOFEMOTIONALSAFETY
Whatisamajortherapeuticgoalofself-helpgroups?(2x)
OVERCOMINGMALADAPTIVEBEHAVIORS
Whichcharacteristicsofself-helpgroupsdistinguishesthemfromtraditional
psychotherapygroups?
GOALS/OBJECTIVESDON’TADDRESSINTRAGROUP
DYNAMICS
Whichisamajortherapeuticgoalofself-helpgroups?
OVERCOMINGMALADAPTIVEBEHAVIORS
Inagroupwhohasmetfor6therapysessions,onepthasspokenatsignificant
lengthforpast4sessionsaboutirrelevantissues&groupmembershaverallied
againsthim.Whattherapeuticmechanismingrouppsychotxisbeingundermined?
COHESIVENESS
Whichstageofgroupdevelopmenthasbeenmetwhenmembersarelessafraidof
revealingindividualdifferencessotheycanparticipateinexperientiallearning?
NORMING
Thegrouptherapistnoticesthatparticipantsinapsychotherapygroupexperience
self-disclosure.Whichstageofgroupdevelopmentdoesthisdemonstrate?
STORMING
Atherapistplanstocreateanewoutptpsychotherapygroupshouldexcludefrom
groupparticipationPtw/?
ANTISOCIALPERSONALITYDISORDER
Psychiatristwhousesnetworktherapytotreatpatientswithaddictivedisordersis
functioningas:
ATEAMLEADER
Ptwithschizoidpersonalitydisorderhaselaboratefantasyrelationshipsbuthasno
realfriends.Mosthelpfultherapytoassistptinformingsatisfyinginterpersonal
relationships?
GROUPTHERAPY
Whichfactormostlikelyimpedescohesionindailygrouptherapyonlockedadult
generalpsychiatryunits?
PATIENTTURNOVER
Intermsofgroupdynamics,theconfirmationofrealitybycomparingone’sown
conceptualizationswiththoseofothergroupmembersandtherebycorrecting
interpersonaldistortionsisknownaswhat?
CONSENSUALVALIDATION
Inthestructuralmodeloffamilytherapy,thefamilyisviewedasa:
SINGLE,INTERRELATEDSYSTEMWITHANEMPHASISON
BOUNDARIESBETWEENTHEGENERATIONS.
Thetherapist’sinitialtasksinstartingsupportivegrouptherapyaredecidingthe
logisticsoforganizingplannedmeetingsandselectingpatientswhocanparticipate
ingroupwork.Whichofthefollowingwouldbetheappropriateactionforthe
therapisttotakenext?
CREATEANDMAINTAINATHERAPEUTICENVIRONMENT
KEEPINGINMINDTHECULTUREOFTHEGROUP
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Initialtasksinstartingsupportivegrouptherapyaredecidinglogisticsandselecting
patients.Nextstep:
CREATEANDMAINTAINTHERAPEUTICENVIRONMENT
KEEPINGINMINDCULTUREOFTHEGROUP
Stageofgroupdevelopmentwherememberstestingnorms,competingw/each
other,seekingautonomy
DIFFERENTIATION
Excludeapatientfromaweeklyoutpatientgrouptreatmentgroupif:
TENDENCYTOASSUMEDEVIANTROLE
Differentiationstageofgroupdevelopmentisbestcharacterizedbywhatdynamic:
TESTINGANDCOMPETITION
Psychosocialtherapythathasshownefficacyinsomestudiesinimprovercancer
survivalrates:
GROUPTHERAPYWITHOTHERCANCERPATIENTS
Whatisthetherapeuticfactoroftreatingbulimicsingrouptherapytoopenly
disclosepersonalattitudestowardbodyimageandgivedetailedexperienceswith
binging/purging?
UNIVERSALITY
Hypnosis
WhathasdemonstratedefficacyforIBS?(4x)
HYPNOSIS
Whichofthefollowingdiagnosesisassociatedwithhighhypnotizabilitypotential?
DISSOCIATIVEDISORDER
(2x)
Hypnotizabilitymoststronglypredictedby
CAPACITYFORIMAGINATION
Whichofthefollowinghypnotictechniquesisusedformostpts?
ENCOURAGINGTHEPTTOUSEINNERRESOURCESFOR
ADAPTIVECOPINGSTRATEGIES
Abilitytogetsocaughtupinanexperiencethatonelosesawarenessof
surroundings
HYPNOTIZABILITY
Whatstatementsregardinghypnosisiscorrect
HYPNOTIZABILITYISAMEASURABLETRAIT
Whenusedasatxfollowingatraumaticevent,hypnosishasbeenfoundto:
SAFELYDECREASEPAINANDSTRESSINTHOSEWHO
AREHYPNOTIZABLE
Absorption,dissociation,andsuggestibilityconvergeduring:
HYPNOTICCONCENTRATION
Hypnosiswouldbecontraindicatedinthetreatmentofpatientswith:
PARANOIA
32y/optisconsideringacourseofhypnosistohelpquitsmoking,butvoices
concerns.Ptexpressesworryaboutpotentialharmofhypnosisifnotdoneproperly. ATRANCEPROCEDUREISBENIGNANDREVERSIBLEBY
WhatwouldbethebestinitialresponseforthepsychMDtomaketoptregarding CALMREASSURANCE
thisconcern?
Duringahypnosissessionaptreportsreducedawarenessofsoundsandother
distractionsintherapist’soffice.Ptreportisreflectiveofwhichofthefollowing
componentsofhypnoticconcentration
ABSORPTION
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Mostimportantguidelinere:hypnosis
HypnosishasbestevidenceofefficacyfortreatmentofGIdisorder
RECORDONVIDEOTAPE
IrritablebowelSyndrome
InterpersonalTherapy
Whichinterviewtechniqueisillustratedbyvalidatingapatient’sinappropriateED
visit(eg.superficialwristlaceration)butalsotransitioningtotheiremotional
needs?
Confrontation
Inthemiddlephaseofinterpersonalpsychotherapy(IPT),thetherapistfocuseson
IPTMIDDLEPHASE:CURRENTRELATIONSHIPS
thepatient’s:(4x)
Psychotherapywhereptsrealisticallyevaluatetheirinteractionswothers&
therapistoffersdirectadvice/helpsptsmakedecisions/ignorestransference
issues.(2x)
INTERPERSONALPSYCHOTHERAPY(IPT)
InptwithMDDandsocialphobiatheIPTtargetssocialisolationby(2x):
WORKINGWITHTHEPTTOHELPINCREASESOCIAL
CONTACTS,STRENGTHENTHECURRENT
RELATIONSHIPS.
Interpersonalsocialrhythmtherapyinbipolarfocusesonwhat?
LIFESTYLEREGULARITY
Comprehensivelyresearchedtherapyformoodd/o’s
INTERPERSONALPSYCHOTHERAPY
IPTofadultsw/depressionbeginsw/assessmentofpt’sadjustmenttostressfullife
QUALITYOFSOCIALCONNECTIONS
events,roletransitionsanddisputes,and:
Therapeuticfocusontheonpt’scurrentsocialfunctioningismostcharacteristicof: INTERPERSONALPSYCHOTHERAPY
26y/optwithdepressedmoodanddissatisfactionwithlife,feelingisolatedand
havingfewfriendswhoisnotunderunduestressandhistoricallycopeswellwith
personalproblemswouldbenefitfromwhattypeofpsychotherapy?
INTERPERSONALTHERAPY
Duringtheinitialphaseofinterpersonalpsychotherapy(ITP),whatproblemisthe
therapistmostlikelytoidentifyfortherapeuticfocuswiththepatient?
IPTINITIALPHASE:ROLETRANSITION
AtreatmentmodalityexplicitlyemphasizesgivingptsaformalpsychDxand
assigningthemsickrole.
INTERPERSONALTHERAPY
75y/opthasbeguntoexperienceinsomniaandfatigueafterthedeathofher
husband.Shedescribesfeeling“downinthedumps”.Shewaspreviouslyactivewith
manyfriendsandsocialoutlets.PsychMDdecidesthattreatmentshouldfocuson
INTERPERSONALTHERAPY
pt’sgriefastheprimaryprobleminordertoaidmourningandfacilitatept’s
reintroductionintooutsideactivitiesandrelationships.Whatmodeof
psychotherapywouldbestaddressthesegoalsoftreatment?
Intentionallyassigningthesickroletoaptwhichservestogivetheptthe
permissionandresponsibilityinordertorecoverisatenetofwhichformof
psychotherapy?
INTERPERSONALTHERAPY
MorelikelytobethefocusofInterpersonalPsychotherapy:
ROLETRANSITIONS
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SupportiveTherapy
Mostlikelyrepresentsanacceptableboundarycrossingbyatherapistasopposed RECEIVINGCOOKIESASANEXPRESSIONOF
toaboundaryviolation:(2x)
GRATITUDEBYAPTNEARTERMINATION.
Whichbestdefinesgoalsofsupportivepsychotherapy?(2x)
STABILIZEPT’SFUNCTIONING,STRENGTHENPT
DEFENSES
Whichpsychotherapywouldtherapistbeinclinedtogratifypts’dependencyneeds? SUPPORTIVE
Whichbestdefinesgoalsofsupportivepsychotherapy?
IMPROVEMENTOFREALITYTESTINGAND
REESTABLISHMENTOFTHEUSUALLEVELOF
FUNCTIONING
AftermildMI70y/oseenbypsychiatristfordepression.Seenforpsychotherapy,
givenSSRI.Describesfearofimminentdeath.Psychiatristtellshimcardiologistis
excellent,heisreceivingbestcare.Whatillustratessupportivetherapy:
REASSURANCE
Supportivetherapydiffersfrompsychoanalytictherapyinthatthetherapistwhois
conductingsupportivetherapydoeswhat?
REINFORCESEGODEFENSES
Ontheexpressive-supportspectrumoftherapeuticinterventions,whichis
consideredthemostsupportivetherapyintervention:
ADVISING
Animportanttechniqueinsupportivetherapyis…
WORKINGPRIMARILYINTHEPRESENT
35youninjuredinanaccidentbutwitnesseddeathsofco-workers.Thefollowing
dayreportsemotionalnumbness,intrussiveimages,inabilitytosleepsincethe
accident.Mostappropriateintervention
“Iunderstandwhythatfelt***”isanexampleofwhichtypeofpsychodynamic
psychotherapyintervention?
Normalizingstressreactionandmobilizingrelational
supports.
Empathicvalidation
PsychosocialTherapies
Mostlikelytobeenhancedbythestrategiesofputtingtheptatease,findingthe
pt’spainandexpressingcompassion,evaluationpt’sinsight,andshowing
expertise:(4x)
RAPPORT
Whichpsychosocialtherapiesforptsw/schizophreniahasbeenshowedtoreduce
FAMILYPSYCHOEDUCATIONALTHERAPY
relapserates?(3x)
Motherof2schoolagedkidsdiesunexpectedly.Whatwithimprovepsychological
outcomeforthechildren?
Ensuringavailabilityofpsychosocialsupports
Thetreatmentgoalofpsychoeducationinmultifamilygrouptxthatisintendedto
assistfamilytocopew/stressesoflivingw/psychoticorseveremoodd/opt.
PROVIDINGKNOWLEDGEANDDIRECTGUIDANCE
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A45y/owithdysthymicd/oisundergoingacourseofbriefdynamicpsychotherapy.
Inthe2ndsession,ptdiscusseshowhisfatherwasneveravailabletohim.Later,
whenthetherapisthastocancelanappointmentduetounforeseentrip,thept
INTERPRETTHISTRANSFERENTIALRESPONSEAND
becomesirritatedandwondersaloudwhetherheshouldcontinuesessionwiththe INVITETHEPTTODISCUSSITFURTHER
therapist.Whichofthefollowingwouldbethemostappropriateresponseforthe
psychiatristtomaketothept’sirritation?
Ptw/hxofEtOHdependenceBIBwife,whostatesthatpt’slongtermuseofETOH
hasresultedinmaritalseparationandpersistentunemployment.Prrefusestostop
drinking.PsychMDasksptabouthisperspectiveregardinghisuseofETOH,pt
PRECONTEMPLATION
responds,“Itmaybeaproblem.”PsychMDsuggestsTxandptsays,”Iwillthink
aboutit.”Accordingtothestagesofchangemodel,whichstage?
DBTisuniqueamongcommonlyemployedpsychotherapyinencouragingjudicious
usebyptsbywhich?
TELEPHONECONSULTATION
Ptsadlyreportsreceivingacollegerejectionletter,andthendisparaginglypredicts
thatalltheothercollegesappliedtowillrejecthimaswell.Thisisanexampleof:
OVERGENERALIZATIONANDALL-OR-NONETHINKING
PtwithPTSDwhowillhavethemostfavorableprognosisinCBTinvolvingexposure
therapy:
VICTIMOFARANDOMVIOLENTASSAULT
Accordingtoameta-analysispublishedin2008includingpatientswithpersonality
disorder,multiplementaldisordersandchronicmentaldisorder,whichofthe
followingpsychotherapieswasconsideredmosteffectiveinimprovingoverall
outcome,targetproblems,andpersonalityfunctioning?
LONG-TERMPSYCHODYNAMICPSYCHOTHERAPY;CBT;
DBT;FAMILYTHERAPY
Negativetherapeuticreactioninpsychodynamicpsychotherapyreferstowhat
Patientgetswoesinresponsetotherapist
interpretationsthatareaccurateandappropriate
TherapyTerms
139.Afeelingofbeingoutsideoneselfordetached
Depersonalization
Aperson’sinabilityordifficultytodescribeorbeawareofemotionsormoodis
called:(4x)
ALEXITHYMIA
Therapeuticempathyisbestdescribedasthetherapist’sabilityto:(2x)
GRASPPT’SINNEREXPERIENCEFROMPT’S
PERSPECTIVE
Therapeutictechniquewheretherapistinstructsthepatienttoholdontoa
symptom:(2x)
PARADOXICALINTERVENTION
Ahighlymotivatedpatientinpsychodynamicpsychotherapyfindsthathehas
nothingtosay,whichisanexampleof:(2x)
RESISTANCE
Catharsisis:(2x)
VERBALEXPRESSIONOFSUPPRESSEDTRAUMATIC
EXPERIENCESANDFEELINGS
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Ptinindividualpsychotxdescribeshatredfora“mean,unfair”boss.Thistimept
adds,“butactually,Ihaveheardmybosstalkingtoothersintheoffice,andhe
MENTALIZATION
seemsprettymuchok–evenhisvoicesoundssodifferentfromthewayIhearhim
inmyhead!”AccordingtoFonagy,ptisdemonstratingwhichmentalactivity?(2x)
Ptwhohaddifficultchildhoodcallstherapistmother’snameandquicklycorrects
error.Whatisthisanexampleof?
Parapraxis
Primaryprocessthinkingischaracterizedas…
MENTATIONFOCUSEDONDRIVESANDWISH
FULFILLMENT
Psychiatristandpatientmovefromthedayroomtoaninterviewroomwherethey
havemetonseveraloccasion.Thepatientstates,“theroomlooksweirdand
differenttoday;itdoesn’tfeelright.”Thisstatementisanexampleof:
DEREALIZATION
Ptenterspsychotherapybecauseofproblemsinhisrelationshipwithhiswife.
Duringthesessions,pttalksabouthisfamilyoforigin,hisboss,andhisproblemsat
RESISTANCE
work,butneverdiscussesdetailsabouthiswife.Thisisanexampleofwhichofthe
following?
Withoutevidentdistress,ptcalmlyreportstothepsychiatrist,“SinceIwaslast
here,mysignificantotherdumpedme.”Thedoctorrespondsbypointingoutthe
CONFRONTATION
discrepancybetweenthept’saffectandthecontentdescribed.Thisresponseisan
exampleof:(2x)
Theextenttowhichaninstrumentrepresentstheconstructbeingmeasuredis
referredtoaswhattypeofvalidity?
CONTENT
Ptwithdepressionrecountstothepsychiatristeventsofthelastweekanddescries
manyunpleasantexperiences,concernsaboutthesadnessofsomefriends,anda
reluctancetoreadthenewspaperbecause“allthenewsisbad.”Incognitive
SELECTIVEATTENTIONBIAS
psychology,whichofthefollowingformulationsbestaccountsforthispatient’s
presentation?
19y/optexpressesthebeliefthatshefailedarecentmidtermexamdespite
studyingagreatdealforthetest.Thepatientisconvincedthatthismeansshewill
losescholarshipmoneyandwillneedtodropoutofcollege.Thepatientisan
CATASTROPHICTHINKING
excellentstudentwhoispronetoexcessiveworrying.Herbeliefthatsheisgoingto
havetodropoutofcollegebecauseshedidpoorlyonthemidtermexamisan
exampleofwhichofthefollowingtypesofdistortion?
Principleofconfrontation:
“ITHINKYOU’DRATHERTALKABOUTYOURJOBTHAN
FACETHESADNESSYOUFELTINOURLASTSESSION”
Exampleofempathiccomment
“YOUMUSTFEELTERRIBLERIGHTNOW.”
Commonexperienceofbecomingsocaughtupinamoviethatoneignoresthe
environmentisexampleofwhatcomponentofhypnoticprocess?
ABSORPTION
Ptingrouptherapycallsanotherpatientathometoobjecttosomethingsaidin
session
ACTINGOUT
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Inpsychotherapyaptstatesthathestillfeelsdevaluedbycriticismoffather.
EMPATHICVALIDATION
Therapistcomment:Itmusthurtwhenyouaretreatedthatway.Thisisexampleof:
Psychiatristbehaviorofraisingeyebrows,leaningtowardspt,saying“Uh-huh”
FACILITATION
ReplaceduseofhypnosisbyFreud:
FREEASSOCIATION
Attributionprocessesaredefinedprimarilyasindividual:
CAUSALEXPLANATIONSOFEVENTSANDPERSONAL
EXPERIENCES
Menninger’striangleofinsightprovidesaframeworkforidentifyinglinksbetween
thepatient’scurrentinterpersonalrelationships,early-lifeinteractionswithfamily
WORKINGTHROUGH
membersorotherimportantcaregivers,andthetransferentialrelationshipwiththe
therapist.Whatisthisprocess?
Therapytechniqueofprescribingapre-existingsxbehaviorinrelationshiptherapy
PARADOXICALINTENT
Whatismostlikelytobeenhancedbystrategiesofputtingtheptatease,finding
RAPPORT
thept’spainandexpressingcompassion,evaluatinginsight,andshowingexpertise?
Redirectingdiscussionbytalkingaboutirrelevantstuff
RESISTANCE
Asetoffeelingsthatapatientreenactsinthetherapeuticrelationshiparecalled:
TRANSFERENCE
Acoupleintherapyforrelationshipdifficultiesthatarerelatedinparttoone
partner’sfrequentnaggingoftheother.Thetherapistrecommendsthatthenagging
partnerintentionallynagtheotherpartnerthreetimesaday,regardlessofwhether PARADOXICALINTENT
thereisanurgetodosoornot.Thistechniqueofprescribingthesymptomisan
exampleof:
Duringaclinicalinterview,thephysicianrecapitulateswhatthepthassaidsofar
andsaystopt“IjustwanttomakesurethatI’vegoteverythingrightuptothis
point”.Thisisanexampleof:
SUMMATION
Thedoctorandpatientrelationshipisdescribedasfiduciaryrelationis:
BASEDONTRUST
“Whenyoumentionedyoursibling’sproblem,yourvoicecrackedand,fora
moment,IthoughtIheardangerinyourvoice.”Whichinterviewingtechniquedoes FACILITATION,REFLECTION
psychiatristusehere?
Duringagrouptherapysessionfemaleptdescribespastexperiencesofsexualabuse
byherfather.Ptstatesthatattimesshefeelsdepressedandhopeless,andhas
intensethoughtsofkillingherself.Anotherptinthegroupsstates,“Ifeelthesame CONTAGION
way,andI’vefeltlikethisforalongtime.”Secondpt’sadmissionisreflectiveof
whichofthefollowingtherapeuticfactorsingrouptherapy?
Thepurposeofreflectivestatementsduringpatientinterviewisfor
ISTOENSUREWHATTHEPATIENTSAIDIS
UNDERSTOOD
Thoughtprocesswherethepointisnotconveyeddirectlyorcompletely.
Circumstantial
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Geriatrics
65y/ow/h/oasthmapresentsfortreatmentofessentialtremor.Whichforfirstline?(4x)
PRIMIDONE
91y/ohospiceptw/cachexia,endstagedementia,andrenalimpairmenthas
stoppedeatinganddrinking.Whatcomfortmeasurewouldbemostappropriate? FREQUENTSMALLSIPSOFWATER
(3x)
75y/optwithADstartedonquetiapine12.5mgbidforagitation>according
OmnibusBudgetReconciliationAct,theMDmust:(2x)
ATTEMPTTODECREASEORSTOPTHEMEDDOSEAT
LEASTEVERY3MONTHS.
Whichmetabolicchangesischaracteristicofnormalaging?
CREATINECLEARANCEDECLINES
80y/optwithAlzheimerdementiawholiveswithadaughterisbroughtinfor
evaluationofincreasinglycombativebehavior.Thedaughterwouldliketokeepthe ASSESSINGFORCAREGIVERBURNOUT
ptathomeifpossible.Whatinterventionwouldbemosthelpfulinthissituation?
Pts>65yearswbipolardisorderdifferfromyoungerptswsamedx—how?
MOREMIXEDEPISODES
Psychevalof82y/oFwithmemoryloss(mostlyworkingmemory):shefrequently
callsforhelpwithbathroombutwillurinateonherself(stafffeelptisdoingthisto
SCHEDULEREGULARVOIDING,INDEPENDENTOFPT
getbackatthem).Ptfrustratedwithstaffbecauseshefeelsthesuddenneedtovoid
REQUESTS,ANDSUFFICIENTLYFREQUENTTO
withoutmuchwarningandwishesthestaffwouldarrivesoonerbecauseshe’s
ELIMINATETHEACCIDENTS
embarrassedaboutthis.MSEsignificantonlyformodmemoryloss,labsarenormal.
Whichbehavioralinterventionshouldbeattemptedwithpt?
Whatpharmacokineticpropertyremainsmoststablewithage
Absorption
Neurocognitivefunctionsmostlikelytoshowdeclineinpeopleover65yearsofage? INFORMATIONPROCESSINGSPEED
Whichisimportantwhenworkingw/familymemberswhoarecaregiverstopts
w/dementia?
•Thereneedsonlybeonecaregiveratatime
•Griefworkw/famnotnecessarybeforept.dies
•Allfamtoequallysharecaregivingresponsibility
•Workw/famshouldenhanceeffectivenessofcaretopt.
•FamshouldexploreSNFoptionsassoonasptisdiagnosed
WORKW/FAMILYSHOULDENHANCEEFFECTIVENESS
OFCARETOPT
WhatjustifiesusingValproatemorecommonlythatlithiumforBMDinpts>age65?
CHANGESINRENALCLEARANCEMAKESLITHIUM
DOSINGPROBLEMATIC
Mostprevalentmovementd/ointhoseover70y/o?
ESSENTIALTREMOR
77y/optw/hxofBMD,stablew/bupropion300mgandvalproicacid1000mg
Qday.Ptreportsfeelinglessmotivatedthanusualatwork,abletoconcentrate,but
B12ANDHOMOCYSTEINELEVEL
takinglongertofinishtasks.Deniedsadness.HTNiswellcontrolled.MMSEscore
26/30.Pthasmasterdegree.Themostappropriateworkup:
68y/optw/hxofschizophreniasinceearlyadulthoodandmaintainedforyrson
thioridazine.Onexam:pt’stonguefrequentlyretractsonitslongitudinalaxisand
GRADUALLYD/CTHIORIDAZINEANDSTARTLOWDOSE
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movesinlateraldirections.Nootherfindings.Whentonguemovementsarepointed RISPERIDONE
out,ptreportsbeingunawareofmakingthem.WhatrecommendationforbestTx:
Whatcharacterizesexecutiveabilitiesinhealthyindividuals>65?
SHOWNOSIGNIFICANTCHANGE
Whatcharacteristicisassociatedwithbetteradaptationinindividuals>65?
UNCRITICALACCEPTANCEOFIDEAS
WhichisNOTcommoninpatients>65:depression,cogd/o,phobias,ETOHd/o,
psychoticd/o
PSYCHOTICD/O
Whatcausesofdecreasedvisioninolderadultsischaracterizedbyaninabilityto
focusonanobjectasaresultofretinaldamage
MACULARDEGENERATION
Malesexualityintheseventhdecadeischaracterizedbywhichofthefollowing?
NOCHANGEINSEXDRIVE
Whichcontrollingforhealthstatus,whichofthefollowingbestdescribesthe
relationshipbetweenretirementandsubsequentmortalityrisk?
NOINCREASEINMORTALITYRISK
Whichofthefollowingisthemostpowerfulpredictoroffallinginolderadults?
USEOFSEDATIVEMEDICATIONS
Ptswlate-lifedepressioncomparedwearlyonsetdepressionmorelikelytoreport: PSYCHOTICSXS
Ptsover65y/oarelesslikelytotoleratehigherdosesofantipsychoticsdueto:
DECREASEDHEPATICMETABOLISM
First-linemedforinsomniain78y/optwithdementia:
ZOLPIDEM
78y/optwithAlzheimer’sdementialivingwithspouseanddaughter,startingto
accusethespouseofinfidelity.Onevaluation,heassertsthatthespouseis
ARRANGEFORREGULAREVALUATIONSOFTHEPTAND
unfaithful.Heisalertandactscongeniallywiththespouse,heisondonepezil.Labs REASSURETHEFAMILY.
andmedicalworkupisunrevealingofanydisorderoutsideofdementia.Next?
Familyof75y/optisconcernedabouthissafetyb/chehasbeenforgettingtoturn
offstove.PsychMDsuspectsanevolvingcognitived/o.Whatismostlikelytobethe INABILITYTORECALL3WORDSAFTERA3MINDELAY
earliestimpairmenttooccurinthept?
Changesw/sleepassociatedwithaging:
DELTAWAVEAMPLITUDEDECREASESAND
PROPORTIONALLYLESSTIMEISSPENTINSTAGE3AND
4
Whencomparedtoyoungeradults,anxietydisordersinadultsoverage65have:
LESSCOMORBIDITYWITHALCOHOLABUSE
Medicarepaysforhospicecarewhenaphysiciandeclaresthatapatienthasa
maximumlifeexpectancyofhowlong?
6MONTHS
80y/optwithAlzheimer’sdementiawholiveswiththedaughterisbroughtinfor
evaluationofincreasinglycombativebehavior.Thedaughterwouldliketokeepthe
ASSESSINGFORCAREGIVERBURNOUT
ptathome,ifpossible.Whichofthefollowinginterventionswouldbemosthelpful
inthissituation?
Innormalaging,lastcognitiveabilitiestodecline
Wordknowledge
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HIV/AIDS
EndstageAIDSwithworseningfinemotormovement,fluency,andvisualspatial
coordination,Dx?(2x)
AIDSDEMENTIACOMPLEX
HIVseropositiveptw/psychoticsymptomshasanabsoluteneutrophilcountof
950cells/mm3.Ptisonzidovudine,lamivudine,andritonavir.Whatantipsychotic CLOZAPINE
wouldbecontraindicated?(2x)
34y/optw/hxofmemoryimpairmentdiesofunknowncauseforautopsy.
Pathologicalexam:diffuseandmultifocalrarefactionofcerebralwhitematter
accompaniedbyscantyperivascularinfiltratesoflymphocytesandclustersofafew HIV-ASSOCIATEDDEMENTIA
foamymacrophages,microglialnodules,andmultinucleatedgiantcells.Mostlikely
Dx:
Whenisapsychiatristpermittedtonotifya3rdpartyidentifiedtobeatriskfor
contractingHIVfromapatient
WHENPATIENTWAIDSUNWILLING/UNABLETOTAKE
AUTONOMY-PRESERVINGPRECAUTIONSLIKE
ABSTINENCE
AIDSpatientwithmemoryproblems,Rhemiparesis,Llimbataxia,BLvisualfield
deficits,andnormalCSF.MRIT2scanshowed.
PROGRESSIVEMULTIFOCALLEUKOENCEPHALITIS
AIDSandprogressivehemiparesisandRhomonymousvisualfielddeficitassocw
patchywhitematterlesionsonMRIwithnormalroutineCSF.
PROGRESSIVEMULTIFOCALLEUCOENCEPHALOPATHY
Gaycoupleseekstherapy.OnehasHIV,oneisnegative.HIVnegativefeelsbetrayed MEDIANDURATIONOFASYMPTOMATICSTAGESOFHIV
andbelievesHIVpositivepartnerwasunfaithful.Whatshouldtherapistsay?
INFECTIONINTHEUSIS10YEARS
MostfrequentrouteforHIVtransmissioninteenagegirls
HETEROSEXUALCONTACT
WhatisapoorprognosticsignforHIV?
DEMENTIA
AIDSpt,progressiveweaknessofextremitiesoverweeks.Distalsensorydeficitfor
pinprickandvibration.Slownerveconduction,butEMGshowsnodenervation
CHRONICINFLAMMATORYDEMYELINATING
POLYRADICULONEUROPATHY
InconsideringsafesexpracticesforavoidingHIVinfection,oralsexisbest
characterizedby:
CANRARELYTRANSMITVIRUS
PrevalenceofAIDSincreasedafterdiscoveryofAZT,bestexplanation?
moreptswerelivinglonger
ECT
47y/optwacutemaniaisunresponsivetopharmacotx.Pt’scurrentmedregimen
includeslithium,divalproex,clonazepam,olanzapine,bupropion.ECTisbegun,pt
LITHIUM
iscontinuedonpreviousmedregimen.After2ECTtx,ptbecomesdelirious.
Cause?(x3)
WhatmedicalconditionhashighestrelativeriskforadverseeventwithECT?
Congestiveheartfailure
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PtwithMDD4-wksintosertraline200mgtrialwithoutimprovement.Duloxetine
90mgaddedforanadditional6weeksfollowedby4-weeksonphenelzine90mg.Pt ECT
conttobedepressed.Whatwouldbethemostdefinitivetreatment:
WhatisassociatedwithamarkedlyincreasedriskofcomplicationsfromECT?
COPD
Theabilityofmagneticseizuretherapytotargetspecificbrainregionsimplicatedin
FEWERCOGNITIVESIDEEFFECTS
depressiongivesitwhatpotentialadvantage,comparedwithtraditionalECT:
58y/owithMDDisgettingECT,developsdenseretrogradeamnesiaafter3rd
treatment.Howcanthisbeameliorated?
INCREASINGTHEINTERVALBETWEENECTTREATMENTS
PthasnotrespondedtoadequatetrialsofSSRI,SNRI,TCA,MAOI,butfeels
improvedwith8treatmentsofECT.Whatnext?
CONTINUEMAINTENANCEECTFORATLEAST10WEEKS
TranscranialmagneticstimulationforTxofdepressiontargetswhichbrainregions? PREFRONTALCORTEX
WhichmedshouldbeheldbeforeECT?
LITHIUM
WhatbarbiturateisusedinECTtoproducealightcoma?
METHOHEXITAL
Greatestriskofdeathw/ECT:
RECENTMI
Indicationfortreatingamanicw/ECT:
DANGEROUSLEVELSOFEXHAUSTION
ECThasincreasedcomplicationsinpatientswithwhatmedicalcondition?
COPD
ECTisleastlikelytobeeffectiveforpatientswhohave?
CHRONICSCHIZOPHRENIA
WhatconditionisarelativecontraindicationtoECT?
CARDIACARRYTHMIA
Ptw/hxofmelancholicdepressionisseverelydehydrated,emaciated,and
catatonic.Hebeganwithdrawing,talkingaboutdeath,stoppedeatinganddrinking
andlost20lbs.Txofchoice?
ELECTROCONVULSIVETHERAPY(ECT)
Uponadmissiontothehospitalan85yearoldmanisseverelyemaciated,
dehydrated,andcatatonic,andhaslost20lbs.Hehasa35-yearhistoryof
melancholicdepression.4weeksagohebeganwithdrawingfromrelatives,talking
constantlytalkingaboutdeathandstoppedeatingordrinkingunlesspromptedby
hisdaughterinsistently.Priortoexhibitingthesesymptomsthepatientwas
medicallystableandreportedlyhealthy.Whatistheappropriatetherapyoncethe
patientismedicallystabilized?
ELECTROCONVULSIVETHERAPY(ECT)
A70y/opatientpresentswithseverepsychoticdepression.Patientstopped
eatingandspeaksverylittle.Failedmultiplemedtrials.What’snext?
ECT
PsychMDiscounselingaptaboutrisksandbenefitsofECT.Whatstatement
correctlydescribestheriskofcognitiveimpairment?
HIGHDOSEUNILATERALELECTRODEREPLACEMENTIS
ASSOCIATEDWITHLESSCOGNITIVEIMPAIRMENT.
Medthatisassocwprolongedseizures/confusionalstateduringECT:
LITHIUM
WhichmedicationshouldbediscontinuedpriortoECT?
BUPROPION
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CorrelatesofapositiveresponsetoECTincludewhichofthefollowing?
INCREASEDECT-INDUCEDFRONTALDELTAACTIVITY
MostimportantpotentialsideeffectofECTtodiscusswith78yopatient(2x)
COGNITIVEDYSFUNCTION
TMSadvantagesoverECT
Lackofanesthesia
ChildhoodandDevelopment
Attachment
Adult’spatternsofinteractingwithotherspredictedbywhataccordingtoobject
relationsandattachmenttheory
capacitytoperceiveandthinkabouttheintentionsof
others
WhichneurotransmittersystemisthelasttomatureintheCNSofchildrenand
adolescents?(2x)
CHOLINERGIC
The“strangesituation”inchilddevelopmentisusedtoassesstheinfant’sin
attachmenttheory:(2x)
SECURITYOFATTACHMENT
Infantsaremorelikelytohaveinsecureattachmentwithpoorchildcareifprimary
caretakersarealso:
UNRESPONSIVETOTHEIRINFANT’SNEEDS
Keycharacteristicofpreschoolerswhoaresecurelyattached
TRUSTANDRECIPROCITY
Whathasbeenfoundregardinginfants’attachmenttotheirparents?
STRENGTHOFINFANT’SATTACHMENTISAFUNCTION
ONLYOFTHEAMTOFINTERACTIONWITHTHEPRIMARY
PARENT
Whatstatementaboutinfant/parentinteractionsissupportedbyintegrationof
clinical/experimentalobservationsinearlychilddevelopment?
INFANTSAREBORNWITHSOPHISTICATEDPERCEPTUAL
ABILITIESTHATFACILITATEATTACHMENT
Atwhatdevelopmentalstageduekidsfirstexhibitabilitytorecognizetheir
PRE-SCHOOLAGE
thoughtsandfeelingsaretheirown,andthatothersmaythinkandfeeldifferently?
Startingaroundage3years,childrenspontaneouslyuselanguageinwhichofthe
followingways?
DESCRIBEPASTEVENTS
Comparedtopreschool-agechildren,aschool-agechildwithnormallanguage
developmentwilldemonstratewhatability?
CONSTRUCTINGSENTENCESWITHMULTIPLECLAUSES
WhichofthefollowingtermswasdevelopedbyReneSpitztodescribeacommon
outcomefollowingsuddenorprolongedseparationofotherwisenormallyattached ANACLITICDEPRESSION
infants?
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18m/oisvulnerabletoseparationandconstantlyconcernedaboutmother’sactual
RAPPROCHEMENT
location.ThisisrepresentativeofMahler’sstageof:
2y/odoesnotwanttoletgoofwoolblanketandresistsgoinganywherewithoutit.
TRANSITIONALOBJECT
Attachmenttypeis:
Preschoolchildrenwithimaginaryfriendsare:
FAIRLYNORMAL
Afemalechildperformsadanceforhermotherandbasksinthegleamofher
mother’seyes.Accordingtoself-psychology,thechildishavinganexperienceof:
MIRRORING
Whichofthefollowinginfantandtoddlertemperamentalstyleshasbeenshownto
havethegreatestassociationwiththeeventualonsetofanxietysymptomsin
INHIBITED
childhood?
Theparentsofa3y/ochildareconcernedbecauseshehasnotbegunspeak
intelligently.Thechild’shearingisnormal.Doctor’sresponse:
EXPRESSSOMECONCERNSBCMOSTCHILDRENTHIS
AGECANEFFECTIVELYMAKETHEMSELVES
UNDERSTOOD.
5y/ochildwithbehavioralproblemsinschool,inandoutoffostercareforthefirst
2yearsoflife.Friendlyandaffectionatewithothersevenwithstrangers.Parents
REACTIVEATTACHMENTDISORDER
don’tfeel“close”tothechildanddoesn’tseemtohaveenduringfriendships.
Diagnosis:
4yoraisedinMultplefosterhomes,minimallysmiles,doesnotseekcomfort
ReactiveAttachmentDO
Childhood-onsetschizophreniatypicallyhaveacoursedescribedas:
CHRONICANDUNREMITTING
Abilityofaninfanttoutilizesymbolicrepresentationatage18monthsallowsfor:
USINGLANGUAGEPROFICIENTLY
ChildholdstoytelephonetofaceandspeakstoDaddy.Thisbehavioriscalled?
SYMBOLICREPRESENTATION
Inpreschool-agechildrenisolatedhallucinationsarecommonwith:
ANXIETY
Apreschoolermisseshislong-termnannywhohasrecentlymovedaway.Tohelp
thischild,theparentsshould:(2x)
SHOWTHECHILDPICTURESOFTHENANNY
Toddlersoothedatnightbyinnermemoryofsecurerelationshipwithmother.
Calledwhat(inattachmenttheory):
OBJECTCONSTANCY
18montholdshowsamarkedawarenessofvulnerabilitytoseparationandseems
tobeconstantlyconcernedaboutthemother’sactuallocationisexhibitingMahler’s OBJECTCONSTANCY
stageof?
ThetermrapprochementinMahler’sdevelopmentaltheoryreferstothe:
RECONCILIATIONFOLLOWINGABRIEFATTACHMENT
RUPTUREBETWEENTODDLERSANDPARENTS
FinalphaseofMahler’sseparation—abilitytomaintainpositiveemotional
attachmentinfaceoffrustration
OBJECTCONSTANCY
Followingabriefseparationfromtheparents,asecurelyattachedtoddlerismost
likelytodowhichofthefollowing:
SEEKCONTACTEAGERLY
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Whichoffollowingparentaltasksbecomesimportantduringtoddlerhood?
LimitSetting
Development
7y/owithtempertantrums,refusestogotoschool.Stomachachesand
headachesonschooldays.Nightmaresaboutbeingkidnapped,fearsparentswill
die.Dx?(4x)
SEPARATIONANXIETYD/O
Anexampleofparallelplay:(2x)
A2YOCHILDSITSNEARANOTHERTODDLERWITHA
TRUCKANDPICKUPACAR.
14y/ofromjuvenilehall,gettingaggressive.Longh/obehaviorproblemsbutno
EVALUATETHEPATIENTFORADDITIONAL
psychormedicalhx.Inadditiontodiagnosingbehaviorproblem,whatisfirststep
PSYCHOPATHOLOGY
forpsychiatrist?(2x)
Whichagesofchildrenareinterestedinsecrets,collecting,andparticipatingin
organizedgames?(2x)
ELEMENTARYSCHOOL
Childargueswithmom,isangryandrude.Hasnotroubleatschoolandcompletes
OPPOSITIONALDEFIANTDISORDER
schoolwork.Dx?(2x)
Coregenderidentityistypicallyestablishedbywhatage?(2x)
3YEARS
Parentsreport3y/ohasnotbeguntotalk.Sincebirthchildhasbeendistractible.
Alsoreportchildseemstohaveproblemempathizingwithsiblings.Whatquestion “HASYOURCHILD’SHEARINGBEENTESTED?”
shouldthePsychMDaskfirst?(2x)
2y/oclingstomotherwhenintroducedtoanewchild,refusingtojoininplay
during1stvisit.On2ndvisit,childplaysbehindmother,andon3rdvisit,she
seemstocontinueherusualactivitieswhilewarilyeyeingthenewchild.What
temperamentaltraitsorconstellationsbestdescribesthischild’sbehavior?(2x)
SLOW-TO-WARM-UP
Childrendemonstrateapreferenceforthehumanvoiceandspeechoverother
soundsatwhatage?(2x)
BIRTH
AccordingtoFreud,whichofthefollowingisconsideredtobethemostsalient
featureofnormalpsychosexualdevelopmentinchildrenbetween1-3yearsof
age?
CHILD-PARENTSTRUGGLESABOUTTHENEEDTODELAY
GRATIFICATIONOFDESIRES
A4yohasdevelopedwhatlanguageskills?
STORY-TELLINGUSINGWORDS
Two4-yroldsplaying,onemakesloudnoise,theotherdoesnotwanttoplayany
more.Why?
PLAYPRODUCEDEXCESSIVEANXIETYFORCHILD
Whichofthefollowingparentbehaviorismostimportanttotoddlerslanguage
development?
ENGAGINGINFREQUENTCONVERSATIONAND
THINKINGALOUD
10-montholdinfantbecomesdistressedwhenparentsleavechildw/babysitter
withoutaffection.Whichsubsequentbehaviorpatternislikely?
CLINGYANDAVOIDANTTOWARDPARENTS
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Thefatherofa3½yearoldboywhoattendspreschoolreportsthatonseveral
occasionstheboyhascomeintothebathroomwhilethefatherisintheshower
interestedinobservinghisfather’sgenitalsaskingonce“whyisitsofat?”This
behaviormostlikelyisanindicationof?
NORMALPRESCHOOLAGESEXUALINTEREST
Pretendplay,basedonabilitytosymbolize,typicallyappearsatwhichofthe
followingstagesofdevelopment?
TODDLERHOOD
Whichgroupchildrenareatgreatestriskfordeathresultingfromchildabuse?
BIRTHTO3Y/OOLD
Cognitivestrategyoftypicallydevelopingschool-agechildreninresponsetotheir
environment?
GRADUALLYINTEGRATINGTHESENEWEXPERIENCES
INTOPRE-EXISTINGMENTALCONSTRUCTS
Whichofthefollowingischaracteristicofpreadolescentchildren’sphysicalgrowth?
THEGROWTHRATEFORBOYSLAGSBEHINDTHE
GROWTHRATEFORGIRLS
A5yearoldchildwhosemotherwasinaminorcaraccidentbelievesheis
responsibleforcausingtheaccidentbecauseheyelled“Ihateyou”inprotestwhen
AGEAPPROPRIATEEGOCENTICTHINKING
hismotherlefthimwithababysitteranhourearlier.Thisbeliefrepresentswhichof
thefollowing?
ChildwIQof68willlikelyhaveadjustmentissuesandstruggleswwhich
developmentalstage?
ADOLESCENCE
77.7yoMwagressionwasreferredbyschoolforevalafterIQof68discovered.Pt
wastemperamentallyinhibitedandavoidantasaninfant,difficultyinteractingw
peersandpreoccupationwithtrainsatage2.Nostereotypesortic.Whichaspeect
ofthispresentationismostindicativeofautismspectrumdisorder?
SYMPTOMSPRESENTBEFOREAGE3
2.5y/oobservesmothertakeanapplefromtherefrigerator,motherbrieflyturns
backtothechildandbeingseating,whenmotherturnstowardchildheanimatedly
AWARENESSOFBEINGASEPARATESELF
grabsfortheappleandsay,“myapple,notMommy’s.”Thisbehaviorisbest
describedaswhichdevelopmentalachievements?
Adolescentwhowaspreviouslygettingalongwithparentsisnowbecomingmore
resistanttoparentalcontrolandinsistentaboutmakinghisowndecisionsabout
AWISHTOSEVERTHEPARENT-CHILDRELATIONSHIP
dailylife.Feelingirritatedwithparentsandguiltyafterminorarguments.Feelingsof
guiltarelikelyexplainedby?
Achildwithtempertantrumsathomebeginstohavebettercontroloverher
outburstsfollowingwhichinterventionbyparents?
HADNEGATIVEREINFORCEMENTOFTHETANTRUMS
REMOVED
Theparentsofatoddlerareconcernedaboutarentincreaseinthefrequency,
intensityanddurationofthechild'stempertantrums.Theparentsreportthatthe
toddlergetsonthefloor,kicksandscreamswhentheysetlimits.Thechild'shealth EXPLORETHEPARENTS’CONCERNSABOUTSEEMINGLY
anddevelopmentalhistoryisunremarkable.FMHxsignificantformooddisorders
NORMALBEHAVIOR
andADHDandODD.Whichofthefollowingwouldbemostappropriateasnext
step?
Apatientrepeatedlybecomesdistressedafterwhatseems,eventothept,tobe
minordisappointments.Thepatientalsoseemstosufferfromextremenarcissistic
vulnerability.Atherapistutilizingself-psychologywouldbemostlikelytointerpret
thisduetowhichofthefollowingfactors?
ALACKOFDEVELOPMENTALLYAPPROPRIATEEMPATHY
FROMCAREGIVERS
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AccordingtoWinnicott,whichisanessentialcomponentofparentinginfants?
BEINGSENSITIVETOTHECHILD’SINSTINCTFOR
EXPLORATIONANDGROWTH
Thetemperamentaltraitofharmavoidanceisassociatedwithpolymorphismson
whichcandidategenes?
SEROTONINTRANSPORTER
WhichcomponentofADHDmostlikelytoremainuntiladulthood?
Inattention
In8-11y/okids,whichmoralskillisthe1stonetofullydevelop?
INTERNALIZATIONOFPARENTALVALUES
7y/oreferredforpsychevalduetolearningprobs.Mosthelpfulinfowouldbe
family’sapproachtoandhx
READINGWITHTHECHILD
Ariskfactorforchildabuse:
FINANCIALSTRESS
Whichofthefollowingisariskfactorforchildabuse?
PRESENCEOFASTEP-PARENT
Themostcommonlearningdisabilityfoundinschool-agechildren
READINGDISORDER
Whatismostcommonlearning/communicationD/Oinkidsreceivingspecialed?
READINGDISORDER
A4thgradechildisfallingbehindpeers.ChildhasIQof92,butlowerthanexpected
scoresonachievetestsandadaptivefunctioning.Teacherreportschildvoices
LEARNINGDISABILITY
understandingofmaterial,butstruggleswithhomework,whatischild’sdiagnosis?
Achildw/selectivemutismismostlikelytohavedifficultiesinwhicharea?
ATSCHOOL
A5year-oldbilingualchildhasprogressiverefusaltospeakinpublic,beingvery
BEHAVIORALTREATMENTTOINCREASETHECHILD’S
talkativeathomeandrefusingtospeakthroughoutthedayinhiskindergarten
TOLERANCEFORSPEAKINGINPUBLIC
class.Heisdiagnosedwithselectivemutism.Whatistheappropriateintervention?
Whatisconsideredtobethedeycomponentunderlyingthesyxofselective
mutism?
AVOIDANTBEHAVIOR
17½y/optmentionsdrinking“afewbeers”atpartiesandsmokingTHC
“sometimeswithfriends.”Theadolisdoingwellinschool.Hasclosefriendsandhas TYPICALADOLESCENTBEHAVIOR
nosignificantconflictsathome.Adol’suseofsubstanceisbestcharacterizedas:
4½y/ochildinsiststhereisasmallmonkeywhosharesthechild’sroom.Hetalksto
monkey,asksotherstoconversewithmonkeyandinsiststhatmonkeyhaveaseat BEHAVIORTYPICALFORPRESCHOOLERS
atdinnertable.Parentsaskiftheyshouldbeconcerned,bestresponse:
Adifficultchild,accordingtoThomasandchess’scategoriesoftemperament,
expectwhatcharacteristics?
INTENSEEXPRESSIONOFMOOD
Accordingtoneuroimagingstudiesofadol,theprefrontalcortexatthisage:
PREFRONTALCORTEXDEVELOPSLATERTHANOTHER
AREASOFBRAIN
Capacitytoinhibitbehavioralresponsesimprovesovercourseofadolescencemost
MATURATIONOFPREFRONTALCORTEX
likelybecauseof
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Pretendplayinpreschool-agedependsuponchildren’sincreasingabilityinwhich
skills
USEOFONEOBJECTTOREPRESENTANOTHER
Whentoddlerattributesasymbolicmeaningtostuffedanimal(e.g.teddybear),
imbuingitwiththequalityofbeingalive,thisisreferredtoas:
ANIMISM
The“falsebelief”testofyoungchildrenusestwodollsinaninteractionwhereby
onedollhidesamarbleinfrontofaseconddoll,andthenmovesmarblewhile
seconddollleavesthescene.Theseconddollre-enterssceneandchildsubjectis
thenaskedwherethisdollbelievesmarbletobe.Thistestisusedtoassess:
THEORYOFMIND
4y/ochildisadministeredthe“falsebeliefstask”inwhichtwodollsactoutascene,
wherebyonedollswitchesthelocationofamarblefromonesitetoanother,while
theotherdollleavesthesceneoftheaction.Whentheotherdollreturnstolookfor THEORYOFMIND
themarble,thechildcorrectlypointsoutthatitwilllookintheoriginallocation.
Thisresponsedemonstratesthechildisshowingevidenceof:
Whichofthefollowingstatementsbestdescribesthecurrentconceptualizationof
familythatinformsfamilysystemtheoriesandtreatmentapproaches?
FUNCTIONINGFAMILIESTENDTOHAVECERTAIN
SHAREDCHARACTERISTICATTRIBUTESRATHERTHAN
COMMONSTRUCTURES
Kohut’stheoryofpersonalityisbasedon:
THEINDIVIDUAL’SNEEDFOREMPATHICINTERACTIONS
WITHSELF-OBJECTS.
Thebirthofanewsiblingisassociatedwiththerecurrenceoftoiletingaccidentsina
NORMALREGRESSION
3y/owhohaspreviouslybeensuccessfullytrained:
81.AccordingtoWinnicott’stheoryofthedevelopmentofaninfant’sassertiveness
ENCOURAGESSPONTANEITYWHILEPROTECTINGTHE
andsenseofcompetencewhatbestdescribesthecriticalfunctionoftheholding
CHILDFROMHARM
environment?
Atwhatagedochildrenbegintoguidetheiractionsinambiguoussituationsusing
cuesfromthemother’sfacialexpressionorinhertoneofvoice?
12MONTHS
Winnicottdefinedhisconceptofholdingenvironmentasthe:
SAFECONTEXTPROVIDEDBYCONSISTENTAND
RELIABLEPARENTING
Maturationofbasalganglia/corticalmotorcircuitsismostcloselyassocw
developmentof:
SOCIALSMILE
3½y/ogirlhasincreasinglybecomeinterestedindressingupinhermother’s
clothesandshoes,withincreasedremarksaboutbeingagirl.Itwouldbemost
BASEDONMATERNALMODELINGANDBEHAVIOR
consistentwithasociallearningtheoryexplanationofpsychosexualdevelopment
tosaythatherbehavioris(x2):
Fatherisconcernedabout6y/osonbecausechildisrubbinggenitalswhilein
bathtub.Thishasnotoccurredatschoolorinpublic.Explanationofbehavior?
NORMALBEHAVIOR.
Aschildrenprogressthroughschoolagedevelopment,theybeginto
RECOGNIZEETHNICANDRACIALSTEREOTYPES
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Afterastrangersays“hello,”a12-month-oldchildturnsandlooksathismother
beforeresponding.Whenthemothersmilesandnodsherhead,theinfantlaughs
andsmilesinresponsetothestranger:
SOCIALREFERENCING
Theformationofsmallpeergroupswhosharevalues,speechpatterns,and
mannersisfirstseenaroundwhatage?
8YEARS
Aninfantwhoengagesinaninteractivegameofpeek-a-boomostclosely
demonstratestheconceptofwhichcognitiveability?(2x)
OBJECTPERMANENCE
Achild’sparentsareveryconcernedthattheir4y/osonstillwetshimselfseveral
timesaweek.Thechild’sbrotherswerepottytrainedwhentheywere3and3.5
yearsold.Thereisnoevidenceofdevelopmentaldelayandthechild’spediatrician
hasfoundnothingunusual.Whichwouldbemostappropriateintervention?
REASSURANCEANDMONITORING
4½y/ochild,playingaloneathomewithsometoycars,isobservedbyparentsto
bespeakingoutloudwhileplaying,excitedlymakingcommentssuchas,“let’sgoso
NORMATIVEASPECTOFPRESCHOOLPLAY
fastthatthemonsterwillnevercatchus.”Thistypeofspeechmostlikely
represents:
Achildwithcancerachievesremissionafterundergoingextensiveandmultiple
treatments.Twoyearslater,thechilddevelopsarecurrenceofthecancerthatis
unresponsivetotreatment.Thechildsays,“I’mdying.Ijustwanttobeathome
14YEARSOLD
withmymom,mydad,andmysister.”Atwhatagewouldthechildmostlikelybeto
havethisresponsetothissituation?
Childrenshouldplaytogetherwithsocialinteractionandroleplayingbywhatage?
4Y/O
Eriksontheorizedthatasuccessfuldevelopmentaltaskinthe40-60y/ogroupisto:
FEELUSEFULTOSOCIETYTHROUGHBEHAVIORSTHAT
PROTECTFUTUREGENERATIONS.
Sexplayfrom8-13y/oindicativeof:
TYPICALCHILDREN
AccordingtoKohlberg’stheoryofmoraldevelopment,a9y/ochildwouldbe
expectedtoreachthedecisionthatanactioniswrongbasedonwhichofthe
followingcriteria:
RECOGNIZEETHNICANDRACIALSTEREOTYPES
Anexampleofparallelplay:(2x)
A2YOCHILDSITSNEARANOTHERTODDLERWITHA
TRUCKANDPICKUPACAR.
Ayoungchildtriestodeterminehowmanyseatingarrangementstherearefora
TYPICALAPPROACHFORTHISSTAGEOFCONCRETE
familyof5aroundatable.Thechildusesnosystemandspendshourstryingtofind
OPERATIONS
alloptionsrandomlyandincompletely.Thisapproachsuggests:
Onsetofpubertyinboysbeginswith:
TESTICULARENLARGEMENT
Adoptedchildrenwhohaveabiologicalparentwithalcoholdependenceareat
increasedriskofdevelopingalcoholdependencewhencomparedtotheiradoptive
siblings.Thisisevidenceforwhichofthefollowingmodelsofsubstanceabuse?
DISEASEMODEL
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4y/ogirldevelopednormallyinthe1st18monthsoflife,butafterwardsdeveloped
deceleratedheadgrowth,lossofpurposefulhandmovements,midlineupper
RETTDISORDER
extremitystereotypies(e.g.hand-wringing),severepsychomotorretardationand
socialwithdrawal:
Whicheventprecipitatesmidlifecrisis?
RECOGNITIONOFUNATTAINABLEGOALS
IntheUS,whichofthefollowingisthemostcommonprecipitantofPTSDinchildren
INTRAFAMILIALVIOLENCE
andadolescents?
7month-oldisnotcrawling.Pediatricianisunconcerned.Childisalert,responsive,
sitsnormally,showsgoodresponsetotoys/stimuli.Psychiatristshouldtellfamily:
REASSURANCEANDPROVIDEREADINGMATERIALS
5y/oadoptedatage4nowhuggingstrangers,ageappropriatevocabulary,doesn’t
REACTIVEATTACHMENTD/O
respondwelltolimits,easilyfrustrated.
3y/owithdiminishedappetite,slowspeechdevelopment,poorsocialinteractions;
parentsaredetachedfromhim.After2weeksinhospitalisimprovingandfriendly REACTIVEATTACHMENTD/O
withstaffmembers.Dx?
20-monthchildrepeatedlyreturnstohermomwhenplayingw/other2-y/o
children.Thisis:
RAPPROCHEMENT
Askachild,“Whatmakesatraingo?”Hereplies,“Thesmokemakesitgo.”Thisis:
PRE-OPERATIONALTHINKING
Learningtriangularrelationships
OEDIPALSTAGE
Thedevelopmentoffullposturalcontrolinchildrenby4yrsoldcorrelates
neuroanatomicallywiththedevelopmentalmaturityofwhat?
MYELINATIONOFCEREBELLARFIBERS
Therapidlearningdemonstratedbychildrenduringtheschool-ageyearsis
paralleledneurodevelopmentallybywhichofthefollowingbrainprocesses?
INCREASEINWHITEMATTER
A10yochildremainssadandangryabouthisparent’sdivorcebutnolonger
believesthathecausedtheseparation.Thiscognitivechangeisexampleofwhat
mechanism?
DECENTRATION
Psychiatristisevaluatinga5y/ochildinkindergarten.Childdoeswellwithpuzzles
andotherperformanceactivities.Teacherreportsthatthechildhasalimited
vocabularyandimmaturegrammarincomparisontotheotherchildren.Child
interactswellwithotherchildren.Thechildalsoseemstohavesometrouble
understandingquestions.Child'shearingandvisionarenormal.Explanation?
MIXEDRECEPTIVE&EXPRESSIVELANGUAGED/O
Stageofdevelopmentassociatedw/settingupclubs,makingrules
LATENCY
Abilityofpreschoolchildrentoregulateemotionsismoststronglyenhancedbythe
LANGUAGE
developmentof:
AccordingtoThomas&Chess’categoriesoftemperament,thedifficultchildshows
INTENSEEXPRESSIONSOFMOOD
whatcharacteristics?
Signofpyromania
FEELINGRELIEFONSETTINGAFIRE
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Todefinelearningdisability,lookfordiscrepancybetween:
INTELLECTUALPOTENTIALANDPERFORMANCE
Integrationofclinicalandexperimentalobservationsinearlychildhood
developmentsupportswhatstatementaboutinfant/parentinteractions?
INFANTSAREBORNWITHSOPHISTICATEDPERCEPTUAL
ABILITIESTHATFACILITATEATTACHMENT
Incombowgrowthhormone(GH),whatisrequiredtoinitiateadolescentgrowth
spurt?
GONADALHORMONES
Showntobecriticaltothedevelopmentofmaternal-infantbondinginanimals:
OXYTOCIN
AcompoundthatincreasesmusclemassbyincreasingepisodicsecretionofGH:
GAMMAHYDROXYLBUTYRATE
Socialreferencingisgenerallyevidentatage:
12MONTHS
3y/oapproachesacrossingstreet,looksatmother’sexpressiontodecideifitis
safetocross.Thisisanexampleof:(2X)
SOCIALREFERENCING
6y/ow/4wkintenseeye-blinkingandlippursing.Waxandwane,increasewith
stress.FamilyHxofticd/o.Firststep:
EXPLAINTOFAMILYMAYBETRANSIENT
2y/oMhasbeenpreoccupiedwithasmallblanketforseveralmonths,carriesitw/
EXPLAINTHISISNORMALANDCHILDWILLEVENTUALLY
himeverywhereandbecomesupsetifanyonetriestotakeitaway.Herefusedto
GIVEITUPONHISOWN.
stayw/ababy-sitteruntilitwasretrieved.Thepsychiatristshould:
Achild’sunderstandingofdeath,attitudes,andresponsesatapreoperationalstage
EXPECTINGTHEDEADRELATIVETOWAKEUP
ofcognitivedevelopmentinclude:
Adolescentwithacongenitalphysicaldeformityismostvulnerabletoemotional
disturbanceduringwhatperiodofdevelopment?
EARLYADOLESCENCE(11-13Y/O)
Apreschoolerpresentstopsychiatristafterbeingplacedonpsychotropicmedbya
PCP.Parentsnotethatsincemedwasstarted,childhasshownirritability,skin
DEXTROAMPHETAMINE
picking,decreasedappetite,socialwithdrawal,insomnia.Whichmedischildtaking?
6y/oatschoolcriesformom,otherkidsstartcrying:
CONTAGION
Myelinationiscompletedinwhatdevelopmentalstages?
CHILDHOOD
Thefirstsignofpubertyinafemaleismostcommonly?
BREASTBUDS
9y/oisevaluatedforbedwettingseveraltimesaweek.Childhasneverbeen
completelydry.WhichTxmodalityislikelytobemosteffective?
BELLANDPAD
Normallossof25-40%ofneuronsinfetalbraininthe2ndhalfofgestationiscalled: APOPTOSIS
Whatisthemechanismforregulatingcellproductionandeliminationof
inappropriateaxonalconnectionsinthedevelopingbrain?
APOPTOSIS
DifferentialDxina6y/owithdailyfecalsoilingincludes:
ANALSTENOSIS,HYPOTHYROIDISM,HIRSCHSPRUNG’S
DZ,SMOOTHMUSCLEDZ
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Thestageoflifeinwhichconsolidationofapersonallyacceptablesexualidentity
generallyoccursiscalled?
ADOLESCENCE
Developmentalstageinwhichbrainisexperiencingpruningofhalfofitssynaptic
connections,adeclineinglucoseandoxygenmetabolismanddecreaseinEEG
amplitude:
ADOLESCENCE
INcontrasttoattachment,“bonding”isassociatedwith
Thenatureofaparent’srelationshiptoaninfant
Thecapacitytosetreasonablegoalsforone'sselfandtoacceptone'simperfections
ADOLESCENCE
andotherslimitationsistypicallyfirstrealizedduringwhichdevelopmentalstage?
AggressivebehaviorinpreschoolerswotherwiseNMLdevelopmentusuallydueto: LIMITEDVERBALABILITIES
Vocabularygrowthandpre-literacylanguageskillsinpreschoolersappeartobe
mostassociatedwith:
AMOUNTOFTALKDIRECTEDTOTHECHILD
Achildrecentlybecomesadeptatrunningandjumping,inusingapincergrasp,and
6YEARSOLD
knowingthedayandyearismostlikelytobeatwhatage?
Processbywhichchildrenmodifyexistingschemastoadapttonewexperiencesis:
ACCOMMODATION
Cognitivedevelopmentaltasksofadolescenceincludeacquiringthecapacityfor:
MORECOMPLEXUNDERSTANDINGOFCAUSALITY&
MULTILEVELREALITIES
Theageatwhichchildrentypicallyfirstusesentencesof2ormorewordsis:
24MONTHS
Earliestageinfantlikestolookmoreatstronglypatternedshapeslikefaces?
1WK
Whatagecaninfantrecognizemothersfaceasdistinctfromotherfaces?
1MONTH
Thecorticalsynapticremodelingcharacteristicofnormaladolescenceisalso
believedtobeassociatedwithwhatneurobiologicalchange?
PREFERENTIALLOSSOFEXCITATORYSYNAPSES
Theprimarypsychologicaltaskofschool-agechildrenisachieving:
COMPETENCE
13y/omaletellspsychMD“I’mtiredofbeingtheshortestboyinmyclass.”Pt
reportsmanyofthegirlsaretallerthanheis.Bothoftheparentsaretall.Whatis
themostappropriateinitialapproachforthepsychiatristtotake?
REVIEWWITHTHEPTTHETYPICALCOURSEOFPUBERTY
INMALES
5y/ochildexperiencesdeathofgrandmother.Childasks,“WhencanItalkto
Grandmaagain?”Thisreflectsanincompleteunderstandingofwhatconceptof
death?
IRREVERSIBILITY
Rapideyemovement(REM)sleepisfirstevidencedatwhichstageofdevelopment? INUTERO
Accordingtoclassicalpsychoanalytictheory,whatfactorprimarilyaccountsforthe UTILIZATIONOFDEFENSEMECHANISMSTOAVOID
polarizationofsamesexpeergroups?
SEXUALIMPULSES
Themostimportantfeatureofpostnatalbraindevelopmentisanincreaseinwhat? NUMBEROFDENDRITICANDAXONALPROCESSES
Whatcharacteristicpresentina2y/oismostlikelytopersistintoadultlife?
INHIBITION
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3y/oboywantstoplaywithhismom,butsheistiredanditisnaptime.What
explanationwouldhebestunderstand?
“IT’SNAPTIMENOW.”
Whichofthefollowingisthemosteffectiveevidence-basedtreatmentof
oppositionaldefiantdisorder(ODD):
PARENTMANAGEMENTTRAINING
A10yochildpresentswithexplosiveoutburstsathomewhenaskedtocomplete
tasksorwhentoldno.Thesebehaviorsarenotpresentwhileplayingwithsiblings.
Whichofthefollowingtreatmentshasthelargestbodyofevidencesupportingits
usetotreatthiscondition?
PARENTMANAGEMENTTRAINING
Infantwhoengagesinaninteractivegameofpeek-a-boomostcloselydemonstrates
OBJECTPERMANENCE
theconceptofwhichofthefollowingcognitiveabilities?
Parentsofa16y/oboydiscoverhe’sbeenvisitingadultsexsites,spendingupto
1hreveryfewwkslookingatnakedwomenandheterosexualsexualactivities.Boy
DEVELOPMENTALLYAPPROPRIATECURIOSITY
likesseveralfemaleclassmatesbutisshyandspendsmostofhistimewithamixed
gendergroupoffriends.Whatistheexplanationofhisinterestinthesesites?
Childengagedwithimaginativeplaywiththerapist,statesdollhouseonfire,
therapistpretendstocall911,childsaysit’snotactuallyafireit’sjustpretend,what PRE-OPERATIONALTOCONCRETEOPERATIONALSTAGE
transitioninPiaget'smodelofcognitivedevelopmentisthischilddemonstrating?
Ayounggirlsays“Iamgoingtostayagirlnomatterwhat,evenifIwearblueor
haveshorthair”.Whatcapacitydoesthisdemonstrate?
Longtermemotionalwellbeingofachildfollowingdivorcedependsmostupon
whichpost-divorcefactor?
Genderconstancy
Cessationofconflictbetweenparents
Phaseofchilddevelopment(MelanieKlein)wheretheyareabletointegrategood&
Depressiveposition
badelementsofcaregiverintooneunified‘object’
AccordingtoVygotsky,objectsandinteractionalexperiencesshouldbewithin
theinfant’s…
Zoneofproximaldevelopment
ChildPsychiatry
Longitudinalstudieshasshowedthatobesityinlaterchildhood,adoland
adulthoodcanbepredictedmostcommonlybypresenceofwhichpsychiatricd/o DEPRESSIVE
inchildhoodandadol?(2x)
Primaryadvantageoftreatingchildhoodenuresiswithbehavioralmethodsvs
desmopressin(2x)
LOWERRATESOFRELAPSE
Whichconcernsisthemostcommonreasonforreferralofchildrenandadol(6-16
DISRUPTIVEBEHAVIOR
y/o)tomentalhealthprofessionals?(2x)
Whichtypeofchildmaltreatmentismostprevalent?(2x)
NEGLECT
Whencomparedtoadol,8-12y/ochildrenwithdepressionmostoftenshow
whichsymptom?(2x)
SOMATICCOMPLAINTS
Mostdistinguishableaspectofchildhoodseparationanxietyd/owhencompared FEARTHATSOMETHINGBADWILLHAPPENTOTHEM
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tootherchildhoodanxietydisorders(2x)
ORTHEIRPRIMARYCARETAKER
MostcommonlyreportedSEofstimulantsinkids(2x)
APPETITESUPPRESSIONANDSLEEPDISTURBANCES
8y/owithpersistentdelayedsleeponsetdespitegoodsleephygiene,givenno
indicationofbroaderpsychopathology,whichmedhasbestevidencetotreatthis MELATONIN
problemandrestorenormalcircadianrhythm?(2x)
AnassociationhasbeenreportedinadolwithBPDbetweenserotonin
dysregulation,suicidalbehavior,aggressionand…(2x)
AACAPDiagnosisofBipolarIinchildrenrequires?
IMPULSIVITY
Adistinctperioidofabnormalmoodandepisodic
symptoms
Dxfor9yoboyw/irritabilityandaggression,failinggrades,andhearingavoice
sayingheisbad.
MDD
7yochildw/emotionaloutburstsatschoolandstomachaches,reluctance,and
complainingatschooltime,butwell-behavedathome,withoutstressors.Next
step?
PERMISSIONTOSPEAKWITHTEACHER
Melatoninagonistsareusefulintreatingwhichtypeofsleepdisorder?
SLEEPPHASEDELAY
Followingdivorce,whichbehaviorsinnon-residentialfathercontributesmost
positivelytochild’sfuturementalhealth?
Whichofthefollowingistheleadingcauseofchildmaltreatmentfatalities?
Whichofthefollowingisanexampleofsemanticmemoryinachild?
Whenaskedtodescribewhyasame-age,same-sexpeerisa“bestfriend,”an11-
year-oldchildismostlikelytocitewhichofthefollowingasmostimportant?
Winnicottdefinedtheconceptofholdingenvironmentasthe:
Traditionalparentingsuchashelpingwithhomework
orcelebratingholidaystogether
HEADINJURIES
RememberingthatthetownparadeoccurseveryJuly
4th
FEELINGCAREDABOUTBYTHEOTHERCHILD
Safecontextprovidedbyconsistentandreliable
parenting
MentalRetardation
Personw/MRwhoachieves1stgradeeducationfitswhichdiagnosticclassification? MODERATEMENTALRETARDATION
6y/ochildin1stgradeisdoingverypoorly.WISC-RIQscoreis60.Comparedwith
otherchildrenhisagehehassig.impairmentinsocialskill,dressing,language,and
feeding.WhatistheDx?
MILDMENTALRETARDATION
MedicationsforTxofaggressioninanindividualw/MR
LITHIUM,THIORIDAZINE,HALDOL,PROPANOLOL(NOT
CLONAZEPAM)
10y/oIQ69.FindingsthatwouldconfirmDxofMR?
DEFICITSINSELF-CAREANDSOCIALSKILLS
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Thenon-geneticcauseofmentalretardationintheUSis:
FETALALCOHOLSYNDROME
Achildwithmod-sevmentalretardationwakesfrequentlyatnight,clapsat
inappropriatetimes,andhasboutsofparoxysmallaughter.Syndrome?
ANGELMAN’SSYNDROME
AnindividualwithafullscaleIQof65couldbeexpectedtoplateauatwhatlevelof
6THGRADE
academicfunctioning?
17y/optwithIQ65andcommensuratedeficienciesinactivitiesofdailyliving,
communication,andmotorskillscanbeexpectedtofunctiononwhichacademic
level?
SIXTHGRADE
PDD/Asperger’s/Autism
StrongcorrelationbetweenAsperger’sand?(7x)
NONVERBALLEARNINGDISABILITY
Whatismostimportantwhentryingtodifferentiatebetweenautismand
Asperger’s?(6x)
LANGUAGEDEVELOPMENT
Whichofthefollowingisseenmostfrequentlyasacomorbidconditioninchildren
MENTALRETARDATION
withautism?(6x)
Pharmacologicaltreatmentinautismspectrumdisorderismostlikelytohavea
positiveeffecton?(4x)
AGGRESSIVENESS
WhichisasymptomofautisticdisorderbutNOTofAsperger’s?
DELAYOFSPOKENLANGUAGEORCOMMUNICATIVE
GESTURES
ThemostcommondeficitunderlyingreadingdisorderinEnglish-speakingchildrenis
PHONOLOGICALFUNCTIONING
deficitin:
7y/oMw/poorsocialskills,cognitive,butlanguagewnl.Dx
ASPERGER’SSYNDROME
Thelong-termoutcomeinautismismostcloselycorrelatedwith?
LANGUAGEDEVELOPMENT
Mostusefulinstrumenttoassessanon-verbal3-year-oldchildwhoplaysalonein
thecorner,stacking/unstackingblocks?
AUTISMDIAGNOSTICOBSERVATIONSCHEDULE(ADOS)
8y/oboyhasmarkedsocialdelay,difficultymaintainingrelationshipsd/todd
interpersonalstyle,preoccupiedwithsmallelectronicdevices,talksonandonabout
them,andexcludesotherageappropriateinterests,hasdifficultyw/transitioning ASPERGER’SSYNDROME
fromoneactivitytoanother,haspooreyecontact,andoblivioustopersonalspace.
DX?
AbnormalityinwhatdomainsisthemostimportantinestablishingtheDxofautistic
INTERPERSONALRELATIONS
do?
3y/onotspeakingintelligibly.Normalhearing.Parentsworriedaboutautism.
EXPRESSSOMECONCERNTOPARENTS
Decreasedattentiontosocialcuesismostcommonamongchildrenwith:(2x)
AUTISM
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Whichofthefollowingisapositiveprognosticpredictorofoveralloutcomefor
childrenwithautism?
MCSpeech/Languageabnormalityinautismspectrumdisorder
COMMUNICATIVESPEECHBYAGE5
ImpairedProsody
8y/oisevaluatedduetoproblemsatschool.Child’svocabularyisnormalandhis
conversationfocusesonvideogames.Hehassocialdifficultiesduetoinsistingon
directingplayw/peersandbeingverycontrolling.Heb/cagitatedanddisruptive
PERVASIVEDEVELOPMENTALDISORDERNOS
whenasubstituteteacherispresentandifthereareevensmallchangesinhisdaily
routine.Dx?
Autismspectrumdisordersinchildrenandadolescentsaremosthighlycomorbid
withwhichofthefollowingtypesofdisorder?
ANXIETY
Riskthatasubsequentchildwillbeautisticinafamilywithoneautisticchildis:
5%
4y/ochildisbroughtinforanevaluation.Thechildwaslap_otonicasaninfantand
nowisdemonstratingdevelopmentaldelays,foragingforfood,andhavingmany
PRADER-WILLISYNDROME
tempertantrums.Whichofthefollowingisthemostlikelydiagnosis?
105.Achildwithintellectualdisabilityisfreeofseizuresbutdevelopsepilepsyin
adolescence.Patternofonsetisoftenseenwith?
AutismSpectrumDisorder
ConditioningandLearning
Conditioning
A10-yochildisafraidofdogsandhasexposuretherapytothepointwherehecan Giventhenonclinicalsetting,thereactionisimpossible
tolerateasmalldog.Aweeklater,heencountersalargedog.Whatishisresponse? topredict
Accordingtooperantconditioning,behaviordecreasesinfrequencyif(4x)
INCOMPATIBLEWITHAPOSITIVELYREINFORCED
BEHAVIOR
Behavioralfrequencyalteredbyapplicationofpositiveandnegativeconsequences
OPERANTCONDITIONING
(2x)
Learningfromconsequencesofone’sactions(2x)
OPERANTCONDITIONING
Exampleoflearnedhelplessnessisachildwhostopsallattemptstoimproveafter
FAILINGNOMATTERHOWHARDTHECHILDTRIES.
beingpunishedforfailingorfailingnomatterhowhardthechildtries?(2x)
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Aformoflearnedfearinwhichapersonoranexperimentalanimallearnsto
respondstronglynotonlytoaharmfulstimulus,butalsotoasub-threshold
stimulus,refersto:(2x)
SENSITIZATION
Ptwithcocaineaddictionexperiencescravingsforcocainewheneverpassingbya
“crackhouse”.Thisreactionexemplifies:(2x)
CLASSICALCONDITIONING
Accordingtoclassicalconditioning,whatwouldbestunpairtheconditionedstimulus
HAVEPATIENTREPEATEDLYLISTENTOTHESONGIN
fromtheunconditionedstimulusforapatientwhofirstgotdrunkwhenacertain
THEABSENCEOFALCOHOL
songplayedontheradioandnowhascravingswheneverhehearsthatsong?
Inbehavioralpsychology,extinctionisdefinedas:
WEAKENINGOFCONDITIONEDRESPONSEDUETO
WITHDRAWALOFSTIMULUS
Childisshownaratanddoesnotreact.Thenshowchildratwaloudnoise.After
severalpairingofratandnoise,thechildthenbecomesfearfulwhenjustrat
presented.InPavlovianconditioning,whatistheconditionedstimulusinthiscase?
THERAT
Inbiofeedback,theautonomicnervoussystemcancomeundervoluntarycontrol
throughwhichoffollowingmechanisms?
OPERANTCONDITIONING
Patientw/ADHDistreatedwithstimulantsandbiofeedback.Lateinthecourseof
biofeedback,theptexhibitsincreasedirritability,moodiness,andhyperactivity.Best DECREASEDOSEOFSTIMULANT
response?
Repeatedpresentationofaconditionedstimuluswithoutbeingpairedwithits
unconditionedstimuluswillresultinwhat?
PARTIALREINFORCEMENT
PtwhowasinfrighteningMVA,consultspsychiatristforfearsofdriving,madecar
travelimpossible.Behaviorinterventionisplanned:psychiatriswillrideintraffic
withptandremainwptuntilphysicalsignsoffeardiminished.Whatlearningtx?
CLASSICALCONDITIONING
InOperantConditioning,apartialorintermittentreinforcementscheduleresultsin:
MAINTAININGABEHAVIORTHATISRESISTANTTO
EXTINCTION.
Reinforcingbehaviorwrewardeverythirdtimeabehaviorisdoneiscalled:
FIXEDRATIO
Learnedhelplessnessmodelfor
DEPRESSION
Systematicdesensitizationisderivedfrom
CLASSICALCONDITIONINGTHEORY
PtatemeatloafthenhadasevereGIvirus;developsastrongaversiontomeatloaf. CLASSICALCONDITIONING
Cocainecravingtriggeredbysightofcrackhouseisexofwhattypeoflearning?
CLASSICALCONDITIONING
IVheroinuseruponseeingtheneedleduringablooddrawdevelopsintensecraving
CLASSICALCONDITIONING
isanexampleof:
Anoperantconditioningreinforcementschedulethatisusedincasinoslotmachines
VARIABLE-RATIO
andmayplayaroleinthedevelopmentofpathologicalgambling:
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AsresultofaMVAaptfeelingpanicbeforehavetodriveandhasbeguntoavoidit.
DIRECTCONDITIONING
Exampleofmechanismoffeardevelopment:
Ptundergoingchemotherapy.Commonlybecomesnauseatedandvomitsinwaiting
CLASSICALCONDITIONING
roompriortothetreatment.Reactionisexof?
Whattypeofreinforcementismosteffectiveformaintainingbehaviorthatis
resistanttoextinction?
PARTIAL
Ifaresponseinhibitorytoanxietyoccursinthepresenceofanxiety-evokingstimuli,
RECIPROCALINHIBITION
itweakenstheconnectionbetweenthestimuliandtheanxiety.Thisiscalled:
A79yroldmanseekstherapyfollowingstressduetouncontrolledonlineshopping,
patientbeginstounderstandhoweachpurchaseimprovedmoodandimproved
OPERANTCONDITIONING
loneliness,thisbestexplainswhatlearningtheory?
Learning
10y/ochildlearnedtocleanhisroomwithoutbeingasked.Theparentsachieved
thisbyreinforcingthisbehaviorwithaone-dollarbilleverythirdtimethechild
cleanedtheroomwithoutbeingasked.Thistypeofreinforcementscheduleis
knownas:(4x)
FIXED-RATIO
22y/oexperiencesaearthquake(7.0)duringaseminar.Inthemonthsthatfollow
hedevelopsfearfulreactiontosuddenorloudnoises.Ptavoidsclassesinthe
AVERSIVECONDITIONING
samebuildingthattheseminarwasin.Whatisthemechanismofthebehavior?
(2x)
Childwhofearsbikeridingbecomeslessfearfulafterwatchingotherchildren
havingfunwhilebikeriding.Whichlearningprinciple?(2x)
IMPRINTING
Cognitive-behavioralexplanationoftrichotillomaniasuggestshairpullingreducesan
NEGATIVEREINFORCEMENT
uncomfortabletensionthatthechildisexperiencing.Whatisthisanexampleof?
Theevolutionofaddictionfromanimpulsivetoacompulsiveactischaracterizedby
NEGATIVEREINFORCEMENT
theincreasingimportanceofwhichofthefollowingfactors?
Whatlearningpatternisdemonstratedbyapatient(w/panicdisordera/wpublic
places)leavinganareawhenpanicattackbegins,andexperiencingcessationofsx?
Negativereinforcement
Worseningtempertantrumsin3y/o.Firstoccurredingrocerystoreandchildwas
quietedwithcandy.Thetantrumswouldoccurathomeandwouldescalateuntil
TANTRUMSWILLINCREASETHENDECREASE
givencandy.Psychiatristtellsparentsnottogivecandyduringatantrumunderany
circumstances.Outcome?
Amedicalstudenttakesamphetaminestostayawakewhilestudyingforanexam.
Whenshetakestheexamwithoutanymedication,shefindsthatshehasmuch
STATE-DEPENDENTLEARNING
greaterdifficultythanusualrememberingthematerial.Whatisthisanexampleof?
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Imitatingone'svaluedmentorwhileperformingpsychotherapyisanexampleof
whattypeoflearning?
SOCIALLEARNING
Formoflearnedfearinwhichapersonorananimallearnstorespondmorestrongly
SENSITIZATION
toanotherwiseinnocuousstimulusis:
Achildpracticesviolintopreventparentsnagging,whatdoesthisdescribe?
NEGATIVEREINFORCEMENT
Amothergivesan8y/oa"timeout"forfivemininthebedroombecauseofhis
misbehavior.Thisisanexampleofwhatbehavioraltechnique?
PUNISHMENT
Inlearningtheory,thepresentationofanaversivestimulusthatiscontingentupon
theoccurrenceofaparticularresponseisknownas:
PUNISHMENT
Childwhofearsbikeridingbecomeslessfearfulafterwatchingotherchildrenhaving
MODELING
funwhilebikeriding.Whichlearningprincipal?
Theoperantprocedureinwhichadesirablebehaviorpatternislearnedbythe
successivereinforcementofapproximationstothatbehavioriscalled:
SHAPING
30y/omorbidlyobeseptrefusestochangeeatingandexercisehabits,“I’llworry
aboutmyhealthwhenIam65.”Onemonthlaterhisfather,alsoobese,diesofa
myocardialinfarction.Thenowobviousdisparitybetweenpt’scurrentbehaviorand COGNITIVEDISSONANCE
knowledgeofthecircumstancessurroundinghisfather'sdeathisanexampleof
whichlearningtheoryprocess?
40y/optexperiencesrecurrentpanicattacksusuallyinpublicplaces.Theptleaves
theareawheneverapanicattackbeginsandthenthepanicSxstop.This
demonstrateswhichofthefollowingtypesoflearningpatterns?
NEGATIVEREINFORCEMENT
Ptreceives$20fornegativedrugtest,butlockedoutofrewardafterapositivetest
contingencymanagement
until3negativetests,thisisanexampleofwhichbehavioraltechnique?
ResearchandStatistics
ResearchDesign
Whatresearchstudyexaminesagroupstudiedoveraprolongedtimeperiod?(6x) COHORT
Whichstatisticalmethodattemptstoaddresstheeffectsofparticipantsdropping
LASTOBSERVATIONCARRIEDFORWARD
outofastudypriortocompletion?(5x)
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Agroupofresearchersstudiedthetemperamentofagroupofchildrenatage3
months,2years,5years,and20yearstodeterminerelationshipsbetweeninitial
temperamentalcharacteristicsofchildrenwhoeventuallyhadpsychiatric
problems.Thisisanexampleofwhattypeofstudy?(2x)
COHORT
Whichofthefollowingisthemajornegativeaspectofcrossoverdesignsfor
researchstudies?(2x)
RESIDUALEFFECTS
Whichofthefollowingtypesofstudiesisbestsuitedtodetermineprevalence?
(2x)
CROSSSECTIONAL
Examinerelationshipbetweenexposureandeffectbycomparingpatientswith
effecttopatientswithouteffect,assessingforpriorexposure.Typeofstudy?
CASE-CONTROL
WhatistypeIIerror?
FINDINGANTIDEPRESSANTINEFFECTIVEWHENITIS
ACTUALLYEFFECTIVE
Whatresearchdesignwouldbethemostappropriateinestablishingacausal
relationshipbetweenchildhoodvaccinationandonsetofautism?
COHORT
Studyreportsdifferencethatturnsouttobebychance
TYPEIERROR
Researchintothecomplexityofhealthcaresystemsanddistributionofresourcesis
bestcarriedoutinwhichfashion?
NATURALISTICSTUDY
Researcherswishtostudyagroupofstudentswhowereexposedtoaterrorist
attackinwhichsomeoftheirclassmateswerekilled,andcomparethestudentsto
otherstudentswhohadnotundergonesuchatrauma.Forthestudytobe
consideredquasi-experimental,whichofthefollowingrequirementsmustbemet?
BASELINEDATAMUSTHAVEBEENCOLLECTEDBEFORE
THEEVENT
CompanyXdevelopsnewmedicationfordepression.Althoughtheinitialtrials
revealonlymodes,statisticallyinsignificantmoodbenefits,theresearchteam
decidestoanalyzethedrug’seffectsinsubgroups.Bysubgroupingthesubjectpool
ANARTIFACTOFMULTIPLEANALYSES
into20subgroups,theresearchersfindstatisticallysignificantmoodbenefitsfor
men/womenwbirthdaysintheearlyfall.Conclusionthatcanbedrawnfromfinding
isthatitis:
Aresearcherdevelopsanewquestionnaireonthesubjectoftraumaticstress.
Whichofthefollowingactionswouldbemostappropriatetotestthemeasure’s
contentvalidity?
ASKTRAUMAEXPERTSTOEVALUATEITSRELEVANCE
ANDCOMPLETENESS
Intheanalysisofresultsofthenationalcomorbiditystudy(1994),anonresponse
adjustmentweightwasincluded.Thisinclusionwasimportantforwhatreason?
NONRESPONDERSWEREFOUNDTOHAVEHIGHER
RATESOFILLNESS
Researchsuggeststhatthefrequencyofalcoholisminlesbiansascomparedto
COHORTPHENOMENONRELATEDTOSOCIOCULTURAL
heterosexualwomenwasgreateronlyinlesbiansover55yearsofage.Whichofthe
ISSUES
followingisconsideredtobethebestexplanationforthisfinding?
Examiningrelationshipbetweenexposuretopsychotropicduringpregnancyand
Epstein’sanomalybetweenwomenwithEpstein’sanomalyandagroupofwomen
whohadbabiesw/othisanomalyisanexampleof
CASECONTROLSTUDY
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Acase-controlstudywouldbeappropriateinansweringanepidemiologicalquestion
INCIDENCEOFTHEDISEASEISLOW
whenthe:
Whichstudybestaddressestherelativeinfluencesofheritabilityandenvironment? TWINADOPTIONSTUDIES
Whydon’ttwinadoptionstudieshavemethodologicallimitations?
ADOPTEESARENOTAREPRESENTATIVEPOPULATION
SAMPLE.
Whatischaracteristicoftheplaceboeffect?
THEPLACEBOEFFECTISGREATERWHENTHEPT
KNOWSTHEDOCTOR.
Findingscanbereplicated
RELIABILITY
Testmeasureswhatitissupposedtomeasure(x2)
VALIDITY
Resultsarecombinedfromanumberofstudiesofsimilardesign.Anoverall
estimateoftheeffectofavariableismadewhichincorporatestheinformation
providedbyallthestudies.Theprocedureistermed?
META-ANALYSIS
Apsychiatristemployedbyaninstitutionwantstouseptdataforresearchlater.
Howcanshegettheprogressnotes?
KEEPHEROWNSEPARATERECORDS
Acase-controlstudycanappropriatelyansweranepidemiologicalquestionwhen
the:
INCIDENCEOFDISEASEISLOW
Comparedtothosedescribedas“lowreactive”inKagan’slongitudinalstudyof
childhoodinhibition,childrendescribedas“highreactive”atage4monthswere
characterizedby:
HIGHERRATESOFSOCIALANXIETYATAGE13
SmallpilotstudymeasureschangesinMMSEscorestocomparetheefficacyoftwo
ENROLLMORESUBJECTSTOOBTAINALARGERSAMPLE
medsforthetreatmentofAlzheimer’s.Datasaysthere’sdifferencebetweenmeds,
SIZE
butnotstatisticallysignificant.Whatdoyouneedtodotoclarify?
Thepurposeofdesigningstudytousethedoubleblindmethodisto:
ELIMINATEBIASDUETOEXAMINEREXPECTATIONS
Clinicaltrial:2studymedsin8hospitals.20receivedrug1inhospitalsA,B,C,D,
while
20receivedrug2inhospitalsE,F,G,H.Drug1isprovenandindicatedtreatment.
Whichcriticalconfounderbiasestheresults?
DRUGASSIGNMENTDEPENDSONPARTICIPANT’S
HOSPITAL.
Aclinicaltrialwillassesstheimpactoftwoatypicalantipsychoticmedsonglucose
intolerance.Halfoftheparticipantswillstartondrug1andthenbetreatedwith
drug2,whiletheotherhalfwillstartonDrug2thendrug1.Whattypeof
experimentaldesign?
CROSSOVERDESIGN
Psychiatristisdevelopinganewquestionnaireabouttraumaticstress.Whichof
followingactionswouldbemostappropriatetotestthemeasure’sconstruct
validity?
COMPARETHESCOREOFHURRICANESURVIVORSTO
THOSEWITHNOPRIORTRAUMA
Poweranalysisisastatisticalmethodusedto:
ESTIMATETHESAMPLESIZEREQUIREDTODETECT
STATISTICALEFFECTOFADEFINEDSIZEFORTWOOR
MOREPREDICTORS.
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Acrossoverdesignisavariationof:
DOUBLE-BLIND
Adoptionresearchinonemethodtodelineategeneticversusenvironmental
influencesonphenotype.Thelimitationofthisapproach:
ADOPTEESARENOTREPRESENTATIVESAMPLEAND
ADOPTIVEANDBIOLOGICALPARENTSMAYRESEMBLE
ONEANOTHER.
Typeofstudydesignsmostlikelytoeliminatethebiasofknowingwhattreatmentis
DOUBLE-BLIND
giventothept:
TheinfanttemperamentstudiesofKaganandcolleaguesfoundstrongcorrelation
betweenearlybehavioralinhibitionandsubsequentdevelopmentofd/o’sinthe
areaof:
ANXIETY
Typeofstudytodeterminerelationshipbetweenriskfactoranddevelopmentof
disease
COHORTSTUDY
Recentmeta-analyseshavesuggestedwhatwithregardtotheuseof
psychotherapytotreatdepression?
OTHERPSYCHOTHERAPIESHAVEEFFICACY
COMPARABLETOCBT
Whatresearchdesignbestclarifiestheroleofenvironmentinbehavioralgenetics?
ADOPTIONSTUDY
Twinstudiesofpatientswithschizophreniahaveconsistentlyidentifiedsubstantial
proportionsofmonozygotictwinpairsthatarediscordantfortheillness.Themost
likelyexplanationis:
A“TWO-HIT”MODELOFPATHOGENESISEXISTSIN
WHICHPREDISPOSINGENVIRONMENTALFACTORS
COMBINEWITHGENETICRISKS
Thereliabilityofanassessmentinstrument,suchasdiagnosticinterview,refersto
theabilityofaninstrumentto:
YIELDCONSISTENTRESULTSWHENUSEDBYDIFFERENT
EXAMINERSORATDIFFERENTTIMES.
Aresearcherdevelopsanewquestionnaireabouttraumaticstress.?ostappropriate COMPARETHESCORESWITHTHOSEOBTAINEDUSING
totestthemeasure’scriterionvalidity?
HAMILTONANXIETYRATINGSCALE(HAM-A)
Thepurposeofdesigningastudytousethedouble-blindmethodisto:
ELIMINATEBIASDUETOEXAMINEREXPECTATIONS
Whatisthemethodforestimatingsamplesizerequiredtodetectstatisticaleffects
ofdefinedsizeforvariableswithwell-knownvariancesisreferredtoaswhichofthe POWER
followingtypesofanalysis?
Whatreliesonstatisticalreview/interpretationofmultiplestudyresults?
META-ANALYSIS
ResearcherisreviewingaquestionnairetoscreenforMDD,noticesthatthe
questionnairehasnoQspertainingtodepressedmoodbuthasafewQspertaining
tospendingsprees.Whatformofvalidityismostaffected?
CONTENT
Statistics
Groupsofptsw/MDD,dysthymicd/o,andadjustmentd/oweregivenmood
scales.Inordertocomparethemeansofscoresofthesethreegroups,most
appropriatestatisticalmethodsis:(3x)
ANALYSISOFVARIANCE
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Whatisusedtoreportthedeviationofavaluefromitsgroupmean,expressedin
standarddeviationunits?(2x)
ZSCORE
5y/oboybecomesrestless,impulsive,anddifficulttomanagewhennotgiven
sufficientexercise.Teachergiveshimincreasedmotoractivity,andhisbehavior
improves.Thisisanexampleof:(2x)
GOODNESSOFFIT
Whichstatisticmeasuresmagnitudeofdifferencebetweentwointervention
groups?
EFFECTSIZE
Tenptsaregivendailydosesofasingleantidepressantuntiltheirmoodbecomes
euthymic.Eightptsrespondto1mg,oneptrespondsto5mg,andoneptresponds
MEDIAN
to10mg.Thebestreflectstheskeweddistributionofeffectivedoseinthisgroupof
pts?
WhichresearchorstatisticalmethodologieswereusedtodeveloptheDSM-IV-TR?
DATARE-ANALYSESANDFIELDTRIALS
Thevalidityofanassessmentinstrumentrefersto:
EXTENTTOWHICHITMEASURESWHATITINTENDSTO
MEASURE.
Whattermsbestdefinesthedegreeofspreadofscoresaboutthemean?
STANDARDDEVIATION
Aratinginstrumentissaidtohavehighreliabilitywhenwhichofthefollowing
propertiesisdemonstrated:(x2)
RATINGSARESIMILARAMONGDIFFERENTRATERS.
Thisdescribesthestatisticalconceptofpointprevalence:
THEPROPORTIONOFAPOPULATIONWITHASPECIFIC
DISEASEATONESPECIFICTIME.
Personestimatingusefulnessoftxstudywillusenumberneededtotreatstatisticto
representnumberofptswhoneedtobetreatedtoproduceoneadditionalgood
INVERSEOFTHEABSOLUTERISKREDUCTION
outcomebeyondthatobtainablewcontrolforcomparisoncondition.NNTformula?
Aresidentperformsaresearchstudyutilizingalloftheoutpatientswithany
psychiatricdisorder,whoweretreatedduringthefirst2monthsoftheresident’s
outpatientexperience.Theresidentdiscoversthatofthe47patientsdiagnosedwith THEPOINTPREVALENCEOFOCDIS6/47
anypsychiatricdisorder,sixmeetthecriteriaforOCD.Whichofthefollowing
statisticbestdefinesthisinfo?
Atestthatdetects98%ofthepeoplewhohaveadisease,butalsoprovidesafalse
positiveresultformanyofthepeoplewithoutthedisease,wouldhavea:
HIGHSENSITIVITYANDLOWSPECIFICITY
Methodforestimatingsamplesizerequiredtodetectstatisticaleffectsofdefined
sizeforvariableswwell-knownvariancesisreferredtoaswhichtypeofanalysis?
POWER
Astatisticaltermthatreferstotheproportionofptswiththeconditioninquestion
thatatestaccuratelydetects:
SENSITIVITY
Amethodformakingapredictionbasedonobservabledatainordertoassessthe
valveoftheonevariableinrelationtoanotheris
REGRESSIONANALYSIS
Whatstatisticalmeasureshouldbeusedtodeterminehow2independentvariables
REGRESSIONANALYSIS
affectthefrequencyoftheoccurrencerateofanevent?
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Statisticalconceptofpowerisdefinedasthe
PROBABILITYOFREJECTINGNULLHYPOTHESISWHENIT
SHOULDHAVEBEENREJECTED
Aresearcherwantstocompareanewatypicalantipsychoticmedicationtothe
alreadyexistingatypicalantipsychotics.Theresearcherwantstoconductthestudy
EFFECTIVENESS
inroutineclinicalsituationsratherthanusinghighlyselectedsubjects.Whichofthe
followingstudydesignswouldbethemostappropriate?
Aneffectivenessstudydiffersfromanefficacystudybyincludingwhat?
Realworldconditions
Assumingthereisnosignificantdifferencebtwn2randomsamplesofpopulationis: NULLHYPOTHESIS
Measureofcentraltendencythatmightbestbeusedtoanalyzeanoutcome
measurewithsignificantlyskeweddistributionofitsvalues?
MEDIAN
Inaskeweddistributionthisisameasureofcentraltendencyandmovesfurthest
awayfromthemodeinthedirectionofskewness:
MEAN
Specificityis:
IDENTIFYINGTHE#OFPTWITHOUTTHECONDITION
WHOHAVEANEGTESTRESULT
Anewscreeningtestcorrectlyclassifiesearlymildimpairmentin75%and
correctlyclassifiesnormalmentationin85%.Whatdoes85%referto?
Specificity
Testdetects98%ofpeoplew/disease,butalsohighfalsepositiverate
HIGHSENSITIVITY,LOWSPECIFICITY
Whichisusedtoevaluatetherelativefrequenciesorproportionsofeventsin2
populationsthatfallintowelldefinedcategories
CHI-SQUARE
An80y/optpresentswithsuddenonsetseizures,hallucinationsandaggressive
behavior.ApreliminaryCTscanofheaddoesnotshowabnormalities.Thept’s
familywantstoknowwhatisthelikelihoodthatthepthasnochangesinhisbrain
giventheCTscan.Whichofthefollowingconceptswouldneedtobeusedto
respondtothefamily’sconcernsabouttheCTscanresults?
NEGATIVEPREDICTIVEVALUE
Investigatorswishtomaximizetheprobabilityofcorrectlyrejectingthenull
hypothesis.Thisprobabilityisreferredtoas:
1MINUSBETA
Genetics
Developmentaldisabilityassocwtriplerepeatgeneticabnormality(4x)
FRAGILEXSYNDROME
13y/owdevelopmentaldelay,stereotypedbehaviors,impairedsocial
interactions,hyperactivebehavior,largeantevertedears,hyperextensiblejoints,
macroorchidism.Dx?(3x)
FRAGILEXSYNDROME
27y/oFhasmultiplebrownpopularlesionsontheface,neck,shouldersthathave
developedoveryears.Hasb/lhearingloss,b/llimbandgaitataxis.MRIw/
NF-2(NEUROFIBROMATOSIS2GENE)
gadoliniumshownontestandhasb/lenhancingmasses.Ptisacarrierofa
mutationinwhichgene?(3x)
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Childpresentsw/moderateintellectualdisability,deficitsinvisual-spatial
processing,highlevelsofanxiety,aphobia,andishighlysociable.Whichgenetic
d/o?(2x)
MICRODELETIONONCHROMOSOME7q11.23
(WILLIAMSSYNDROME)
Metachromaticleukodystrophyassociatedw/mutationingeneforwhich
enzyme?(2x)
ARYLSULFATASE
Apoptosisofcorticalneuronsdiffersfromnecrosisinthatit:(2x)
INVOLVESEXPRESSIONOFSPECIFICGENES
40y/oMdevelopedgraduallyprogressivedementiaandabnormalinvoluntary
movements.Olderbrotherandfatherhavesimilarillness.BestDx.test(2x)
EXCESSCAGTRIPLETSINDNAANALYSIS
Geneticanticipationrefersto:(2x)
EARLIERONSETORWORSENINGOFILLNESSWITH
EACHSUCCEEDINGGENERATIONINAPEDIGREE(WITH
EACHTRANSMISSIONOFUNSTABLEDNA)
Adolptswithvelcardiofacialsyndrome(chromosome22q11deletionsyndrome)are
SCHIZOPHRENIA
atsubstantiallyincreasedriskfordevelopingwhichpsychoticd/o?
Karyotypingisamethodofgeneticanalysischaracterizedbywhichtechniques?
ANALYZINGCHROMOSOMALSTRUCTURES
Whataregeneticpolymorphisms?
VARIANTDNASEQUENCESPREVALENTIN>1%OFA
POPULATION
Alogarithmicodds(LOD)scoreforagenerepresentswhat?
THEMOSTLIKELYRECOMBINATIONFREQUENCY
BETWEENTWOLOCIFROMPEDIGREEDATA
Familialamyotrophiclateralsclerosisgenemutation:
SUPEROXIDEDISMUTASE(SOD)
Bilinealinheritancetypicallyreflectswhichofthefollowingevolutionarypopulation
ASSORTATIVEMATING
geneticfeatures?
Term“endophenotype”referstowhatphenomenainbehavioralgenetics?
ALTERNATEEXPRESSEDFORMSRELATEDTOADISEASE
Whichofthefollowingpremisesiscentraltothesociobiologictheoryofinclusive
fitness?
THEKEYUNITOFSELECTIONISACTUALLYGENES
RATHERTHANINDIVIDUALS
4y/ochildthatwashypotonicasaninfantisnowdemonstratingdevelopmental
delays,foragingforfoodandhavingmanytempertantrums.DX?(x4)
PRADER-WILLISYNDROME
Skintumors,abundantcaféaulaitspots,Lischnodulesonirisisdiagnosticof
mutationonwhichgene:
NF-1(NEUROFIBROMATOSIS-1GENE)
Whichisthemostcommonmitochondrialdisorder(of4listed)?
MITOCHONDRIALENCEPHALOPATHY,MYOPATHY,
LACTICACIDOSIS,ANDSTROKE-LIKEEPISODES(MELAS)
Whichisseenin90–100%ofptw/narcolepsy(genetics)
HLA-DR2
Mostcommoninheritedmentalretardation:
FRAGILEX
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Mutationsinthegenethatcodesfortheparkinsonproteinaremostcommonly
associatedwithwhichparkinsonism?
EARLY-ONSETPARKINSON’SDISEASE
Adrenogenitalsyndrome,Downsyndrome,Hurler’ssyndrome,Tay-Sachsdisease
andphenylketonuriaallcausementalretardation.WhichonedoesNOThave
autosomalrecessiveinheritancepattern?
DOWNSYNDROME
Whatneurologicalsyndromesistheresultoftrisomy21?
DOWNSYNDROME
Processofgeneexpression
DNATRANSCRIBEDTOMRNAANDPRODUCES
PROTEINS
IndividualscarryinginactiveallelesoftheCYP2Agenehaveincreasedconiinelevels
TOBACCO
perunitofdrugingestedandarerelativelyprotectedfromaddictionto:
Geneticd/oassociatedwithincreasedriskforschizophrenia:
VELOCARDIOFACIAL
Psychcomorbiditiesinindividualswmentalretardationvsgeneralpopulation:
SAMETYPESOFPSYCHOPATHOLOGY
Strongestgeneticcontribution
CYCLOTHYMICDISORDER
Geneticlinkagestudiesinvestigateswhatinmedico-psychiatricresearch:
CO-SEGREGATIONOFGENESDURINGMEIOSIS
Whatispartofroutineworkupofchildwithmentalretardationbutwithout
dysmorphicfeaturesorneurologicalfindings?
CHROMOSOMALANALYSIS
PatternofinheritanceinWilson’sdisease
AUTOSOMALRECESSIVE
PatternofinheritanceinHuntington’sdisease
AUTOSOMALDOMINANT
Karyotypingisamethodofgeneticanalysischaracterizedbywhichtechnique
ANALYZINGCHROMOSOMALSTRUCTURES
Polymerasechainreaction(PCR)usedingeneticlinkagestudiesinvolves:
AMPLIFICATIONOFMICROSATELLITEMARKERS
WhatconditionsassociatedwMRhaveanautosomalrecessiveinheritancepattern?
ADRENOGENITALSYNDROME,HURLER’S,TAY-SACHS,
PHENYLKETONURIA
4y/odoesnotrun/climb,falls,hasiliopsoas/quadriceps/glutealweakness,
enlargementofcalveswithfirm,“rubbery”consistency,decreasedDTRsandnormal 1)SMALL,SHORT-LASTINGMOTORUNITPOTENTIALS
sensation.Widebasedstanceandwalkswaddling.Whenrisingfromtheground,
WITHINCREASEDRECRUITMENT
usesafour-pointpositionthroughfullextensionofallfourextremities.Hasfamily
2)DYSTROPHIN
h/osimilarsxinmales.1)EMGreveals?2)Geneticmutationinwhatprotein?
14y/ogirlpresentswithdelayedonsetofpuberty,shortstatus,andahistoryof
cardiacabnormalitiesandhypertension.Shehaspoorsocialskills.Psychological
assessmentrevealsanormalverbalIQandabelow-normalperformanceIQ.Which
ofthefollowingisthemostlikelydx?
TURNERSYNDROME
TheSuralnervebiopsyofaptwcharcot-marie-toothtype1isshown(image),exam
DUPLICATIONOFTHEPERIPHERALMYELINPROTEIN
showsdiminishedLEDTRsanddeformatiesoffeetBL.Thesedeformatiesaretypical
GENE
ofwhichmolecularabnormality?
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Increaseriskforpsychopathologyinoffspring?
Havingbiorelativeswithpsychiatricillness
Epidemiology
THEDEVELOPMENTOFOPERATIONALIZED
ScientificdevelopmentthatmadeNIMHepidemiologicalcatchmentsareastudies
DIAGNOSTICCRITERIAANDSTANDARDIZED
possible(9x)
INSTRUMENTS
AccordingtoNIMHEpidemiologicCatchmentAreaProgram’sreportsonethnicity EQUALAMONGASIANS,HISPANICS,AFRICAN&preventionofmentaldisorders,thelifetimeratesofAPDare:(5x)
AMERICANS,ANDWHITES.
Whichofthefollowingactionsismostimportantforpreventingsuicidein
adolescence?
MAKEITAGUNFREEHOME
Leadingcauseofneuropsychiatricdisabilityworldwide
UNIPOLARMAJORDEPRESSION
Whatpsychiatricillnessistheleadingcauseofdisabilityinpersons15-44y?
MDD
Ptswithunipolardepressiondifferepidemiologicallyfromptswithbipolard/oin
whatway?
THEDISCREPANCYBETWEENMALEFEMALELIFETIME
PREVALENCERATESISGREATER.
Whatisanexampleofsecondaryprevention?
SCREENINGFORDEPRESSION.
IntheInstituteofMedicineclassificationsystemdevelopedtoclarifydifferent
aspectsofprevention,thecategoryof“indicatedinterventions”referstowhichof
thefollowing?
INTERVENTIONSTHATFOCUSONHIGH-RISK
INDIVIDUALSTOENHANCERESILIENCEANDPREVENT
ONSETOFTHEILLNESS
Checkfastinglipidpanelsbeforestartingtreatmentbeforeatypicalantipsychotics.
WhichhealthqualityimplementedaccordingtotheaimsoftheInstituteof
Medicine?
SAFETY
Whichofthefollowingprobabilitiesmostaccuratelydescribesthelikelihoodof
patientswithschizophreniacommittinghomicidecomparedwiththegeneral
population?
EQUALLIKELIHOOD
Whichofthefollowingfactorsismostcloselyassociatedwithchildabuseand
neglect?
HOUSEHOLDPOVERTY
Aphysicianisdisciplinedbyahospitalatwhichhepracticesforissuesrelatedtocar
providedtoapt.ifthedisciplinaryactionlastsmorethan30days,thehospitalmust NATIONALPRACTITIONERDATABANK
reportthephysiciantowhichoffollowing:
Aphysicianwhoistestifyingasanexpertincourtisdifferentfromaregularor“fact”
PROFESSIONALOPINIONS
witnessinthattheexpertisallowedtotestifyaboutwhichofthefollowing?
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Apsychiatristwhoseptisinvolvedinawork-relatedlawsuitreceivesasubpoenato
producetheptsrecordsofpsychiatrictreatmentandtotestifyaboutthetreatment
isacourtoflaw.Uponspeakingwiththeattorneywhoissuedthesubpoenaand
FACTWITNESS
whoeraresenttheopposingparty,thepsychiatrististold"youwillnotbeaskedto
renderanindependentopinionrelatedtolegalquestions."Whichbestdescribesthe
psychiatrist’srole.
Whichofthefollowingisthemostcommonmethodofcompletedsuicideinfemale
FIREARMS
childrenandadolescents?
IntheUS,whatisthemostcommonmethodofcompletedsuicide?
SHOOTINGONESELF
Theconceptoflifetimeprevalencereferstothenumberofpersons:
MEASUREDATAPOINTINTIME,WHOHADAD/OAT
SOMEPOINTDURINGTHEIRLIVES.
Afindingregardingepidemiologyofnicotineuse:
YOUNGADULTSREPORTTHEHIGHESTRATESOF
SMOKING
Socioeconomicstatusiscorrelatedtoriskformentalillness,suchasthosewhoare
disadvantagedbysocialclassaremorelikelytodevelopamentald/o.research
showsthatthiscorrelationisaccountedformainlybygreater:
VULNERABILITYTOTHEIMPACTOFSTRESSFULLIFE.
Thenumberofindividualswithad/oataspecifictime
POINTPREVALENCE
WhichpopulationhashighestprevalenceofSchizophrenia?
MONOZYGOTICTWINOFSCHIZOPHRENICPT
Whencomparedtoyoungeragegroups,theprevalenceestimatesofMDDin
personsolderthan65yearsare:
LOWERINBOTHMENANDWOMAN
Prevalenceofpsychoticdisordersafterage65is:
LOWERINBOTHMEN&WOMEN
Whatsomatoformd/ohasmale=female?
HYPOCHONDRIASIS
Whatdistinguisheshypochondriasisfromdelusionald/o,somatictype?
INSIGHT
Leadingcauseofdeathfor15-24y/oAfricanAmericanmales?
HOMICIDE
Whatbestcharacterizesthecurrentexplanationforgroupdifferencesinprevalence
FACTORSTHATPROMOTEVULNERABILITYTOSTRESS
ofpsychiatricillness?
Pastyearsannualprevalencemuchhigherthanannualincidence
DISEASEISCHRONIC
AccordingtotheWHO,theworld'sgreatestcauseofmortality,illhealthand
sufferingiswhat?
DEPRESSIONANDSUICIDE
TherateofillicitdrugusageinhighschoolishighestamongwhichgroupsinUSA?
CAUCASIANAMERICANS
Highestprevalencepsychd/o?
ANXIETYDISORDERS
WhatisprevalenceofAlzheimer’sin>85y/o?
16-25%
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LifetimeprevalencerateforETOHabuseanddependence
15%
Lifetimeprevalenceofschizophrenia
1%
RiskfactormostpredictiveofapthavingemergentSI:
PERVASIVEINSOMNIA
Assessmentinstrumentusedinepidemiologystudyreliessolelyonsubjectsreport:
GENERALHEALTHQUESTIONAIRE
Intimatepartnerviolenceismostcommoninwhichofthefollowingdemographics? LOWINCOMEFAMILIES
Society
Culture
24y/oColombian-Americanisconcernedabouthowtomaintainhisparent’s
culturalheritageafterhemarriesaCaucasian.Whichtypeofacculturativestress INTEGRATION
ishedealingwith?(4x)
ImmigrantstoUSexperiencestress&demoralizationmostduringwhichperiod?
Howisethnicitydefined?(2x)
Duringfirst1-3yrincountry
GROUPOFINDIVIDUALSSHARINGSENSEOFCOMMON
IDENTITY,COMMONANCESTRY,SHAREDBELIEFS,&HX
20y/owesterntrainedpsychiatristofnorthernEuropeandescenthasbeenasked
totreata40y/oHindupatientwhoemigratedtotheUS2yearsago.Thepatient
presentswithcomplaintsofweakness,fatigue,headaches,insomnia,
palpitations,anddecreasedappetite.Thepatientalsoreportsa5lbweightloss ASKTHEPATIENTWHATHEBELIEVESEXPLAINSTHE
overthelastmonth,dysphoricmoodwithintermittentanxiety,andsuicidal
SYMPTOMS
ideation.Inadditiontoassessingthepatient’slevelofsuicidality,itwouldbe
appropriateforthepsychiatristtodowhichofthefollowingwhenbeginning
treatment?(2x)
22yoMptcomplainsoffatigue,abdpain,weightlossandbelievescausedby
nocturnalemissionsofsemen.Whatispt’sethnicbackground?
SoutheastAsian
Acculturationoutcomeassociatedwithhighriskforsuicide,substanceabuse,and
alcoholism
LACKINGSTRONGALLEGIANCETONATIVECULTURE,ANDNOT
INCORPORATINGHOSTCULTURE
Pt’sfamilybelievesdepressionis2/2santeriacurse.Duringassessment,psych
shouldfocuson...
LEARNINGFROMPTANDFAMILYWHATTHEYBELIEVETHE
COURSEOFTHISILLNESSISEXPECTEDTOBE
Racial/ethnicgroupwithhighestrateofsuicide?(x2)
NATIVEAMERICANS
Socialpsychologicalstudyoftheviewofselfinsomewesterncultureshas
delineateddifferencesfromthedefinitionofselfinmanynon-westerncultures.
Whatbestdescribesthebasisforpositiveself-esteeminthosenon-western
cultures?(2x)
POSITIVECONTRIBUTIONSTOTHEGROUPANDHARMONIOUS
RELATIONS
Whichofthefollowingpsychologicaltestshasbeenvalidatedforadolescents,
elderlyandethnicminoritygroups,andisrecommendedfortheassessmentof
psychologicalfunctioninginpatientsfromdiversecultures?
MINNESOTAMULTIPHASICPERSONALITYINVENTORY(MMPI-2)
PuertoRicanandotherLatinAmericanptsaremorelikelythanthosefromwestern
NERVOUSNESS
culturetoreporttheirdepressionaswhat?
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14y/oNativeAmericangirlwithvisionsofelderspiritswhoappearandgiveher
advice.Parentsfeelvisionsaregiftbutareworriedaboutthechild’s
preoccupationsinterferingwithschoolwork.Noh/omentald/oorsubstance
abuse.Treatmentgoal:
WORKONPROBLEMSINSCHOOL
Genderisbestunderstoodasreferringto:
WAYSINWHICHCULTURESDIFFERENTIATEROLESBASEDONSEX
AnaccuratestatementregardingassessmentforculturalID:
INFLUENCEDBYONE’SDEGREEOFACCULTURATION
30y/oMDwhohasemigratedfromChinatotheUScontinuestotakepridein
familyrecipes,buthasrecentlyembracedAmericanballroomdancing.This
representswhichofthefollowing:
ACCULTURATION
Acculturationoutcomesassociatedwithpt’shighriskforsuicide,substanceabuse, LACKINGSTRONGALLEGIANCETONATIVECULTUREANDNOT
andalcoholism:
INCORPORATINGHOSTCULTURE
TheculturallyandLinguisticallyAppropriateServices(CLAS)federalstandardsfor
healthcareorganizationsrequiretheorganizationsto:
HAVEPT-RELATEDMATERIALSAVAILABLEINTHEPT’SNATIVE
LANGUAGES.
AJapanesefamilywhorecentlymovedfromJapanbringstheir6yochildforan
evaluation.Theyexpressconcernsthatthechildappearsdepressed,isreluctantto
gotoschool,andisfearfulthatharmwillbefalltheparents.Duringtheevaluation CULTURALNORM
itisnotedthatthechildsleepsinthesameroomastheparents.Whichofthe
followingisthemostlikelyexplanationofthissleepingarrangement?
14y/oNativeAmericanIndiangirlbroughttomentalhealthcenterb/cshehas
visionsofspirits.Tellspsychiatristspiritsareelderswhoappear,giveheradvice.No
hxsubstanceabuse/mentaldisorder.Interviewwparentsrevealstheyare
DEALINGWITHHERSCHOOLPROBLEMS
traditional
&feeldaughter’svisionsareagift.Buttheyareworriedaboutschoolwork,which
hasdeterioratedb/cshehasbeenpreoccupiedwithspirits.Txshouldfocuson:
Psychiatristevaluatesrecentimmigrantwithcomplaintof“alterednerves”Clinical
interpreterfrompt’sculturalbackgroundexplainsthatculturallythenervous
HISPANICAMERICAN
systemisbelievedtobealteredbystressfullifeevents.Whatculturalgroupdoes
ptmostlikelybelongto?
Whatmostaccuratelydescribesscientificunderstandingoftheconceptofrace?
SOCIOPOLITICALDESIGNATIONASSIGNINGINDIVIDUALSTOA
PARTICULARGROUPTHATHASMEANINGDERIVEDFROM
PREVAILINGSOCIETALATTITUDES
Raceisbasedonphysicalcharacteristicswhereasethnicity
incorporatesmultiplefactors
Howis“race”differentthan“ethnicity”?
AmericanpsychiatristsoverdxinAfricanAmericanpatientswmood/psychoticsx? SCHIZOPHRENIA
Whichofthefollowingisacomponentofthepsychiatrist’sformalcultural
formulationofapt’sdisorder:
THEPT’SEXPLANATIONOFTHEILLNESS
Culture-boundsyndromeinCaribbeanandstatesborderingGulfofMexico–
anxiety,GIdistress,weakness,fearofbeingpoisoned,attributedtowitchcraft
ROOTWORK
Familyresponsetoamemberwataquedenervioswouldmostlikelybetodo
what?
RALLYTOSUPPORTRELATIVEBYREMOVINGSTRESSORS
Whichisthemostsignificantdisadvantageofusingafamilymemberasinterpreter
PTMAYCENSORCOMMENTSTOKEEPINFOFROMTHEFAMILY
forapatientwhodoesnotspeakthepsychiatrist’slanguage?
MostcommoncomplaintinsoutheastAsianswhoaredxw/mentaldisorderis:
MULTIPLESOMATICSYMPTOMS
50y/oCambodianwomanwith2kidssufferedcatastrophictraumafromthePol
PotregimeinCambodia(rape,abuse,watchedfamilystarve,escapedrefugee
GROUPTHERAPYOFPEOPLEOFTHEPATIENT’SOWN
campwith
BACKGROUNDWHOSHARETHESAMEEXPERIENCE
2kids).HasPTSD/MDDsxthatareincreasedwhenhernowgrowndaughterdates
manpatientdoesn’tlike.Needssupportivetherapy,antidepressant,AND?
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Acrossallcultures,whatstressfullifechangesiscorrelatedwithgreatestincrease
indeathandillnessinthesubsequent2years?
DEATHOFASPOUSE
CultureboundinindustrializedcountriesperDSMIV
BULIMIA
Whatculture-boundsyndromeswouldbeDxforaptwithofinsomnia,HAs,
anorexia,fears,despair,diarrhea,&anger?
ATAQUEDENERVIOS
PuertoRicanandotherLatinAmericanptsaremorelikelythanthosefromother
westernculturestoreportdepressionas:
NERVOUSNESS
29y/orecentimmigrantfromChinabelieveshispenisisshrinking;concernedhe
mightdieoncehispenisretractsintohisabdomen.1)Whattypeofd/oisthis?2)
Whatisbesttreatment?
1)CULTURE-BOUNDSYNDROME
2)SUPPORTIVETHERAPY
Whichdemographicsindicatebothacommonancestryandasharedsenseof
identity,beliefandhistory?
ETHNICITY(NOTRELIGION)
FirsteditionoftheDSMtoexcludehomosexualityasadiagnosis:
DSM-III-R(1987)
14yonativeAmericanp/wvisionsofspiritswhoareeldersgivingadvice(nohx
substanceabuseormentald/o)andwithparentswhoencouragehervisionsas
beingagift.Wheretofocustreatment(assumingacademicdecline)?
Dealingwithherschoolproblems
Spirituality
47y/oFw/increasedpreoccupationwithquestioningherlifelongaffiliationwith
herchurchandhasbeenspendingtimevisitingotherchurches.Concernedsheis
RELIGIOUSORSPIRITUALPROBLEM
losingherfaith,feelsguiltyandanxious.NoSI,MSEnormal,stateswouldnever
actagainsthermoralbeliefs.Dx?(3x)
Researchshowsdissociativesymptomsmostcommonlyrepresentwhat
worldwide?
NORMALPARTOFRELIGIOUS/RITUALEVENT
WhatDSM-IVdiagnosisislikelyfor41y/omanwithincreasingsenseofconflict
aboutchanginghisbeliefsfromwork-orientedtofaith-oriented.Nopastorpresent RELIGIOUSANDSPIRITUALPROBLEM
psychsymptoms,stablevocationalhx.
48y/owithchronicsadnessandnorelationshipssincehusbanddied12yearsago.
Normalgrieving,noDSM-IVcriteriaford/o,hassuccessfulcareerandclosefriends.
PARTOFABELIEFSYSTEMENDORSEDBYHERRELIGION
Stateshasconversationswithherdeadhusbandandhetalkstoher.Believesin
heaven.Likelyclassificationoftheseexperiencesis:
Ethics
Routinelyinformingptsaboutconfidentialitylimitsisex.Ofwhatethicalskill?
(6x)
Psychiatristblogsas“Dr.Empathy.”Whyunprofessional?
On-callresidentevaluatesnewpatientwithbaddementia.Realizespatientwas
oneoftheresident’sformerprofessorsandmentors.Residentistheonly
psychiatristontheunit.Attendingiscalledandtellsresidentthehospitaldoesn’t
havearelevantpolicy.What’stheoptimalwaytohandlethis?
BUILDINGETHICALSAFEGUARDSINTOWORK
Thepsychiatristshouldmakehisorheridentityandcredentials
clear
Finishtheevaluationandprovideanyurgenttreatmentbut
insistonatransferofcareassoonaspossible
Whatethicalprincipleprovidesthemostappropriatebasisforpsychiatric
interventioninamentallyincompetentpatient?(5x)
BENEFICENCE
Inethics,beneficenceis:(5x)
APPLYINGONE’SABILITIESSOLELYFORTHEPATIENT’SWELLBEING.PHYSICIANACTSPATERNALISTIC
Differencebetweenaboundaryviolationandboundarycrossingis?(4x)
BOUNDARYVIOLATIONSARECHARACTERISTICALLY
EXPLOITATIVE
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Fptintwice-weeklypsychodynamicpsychotxwmaletherapistforthelastyear
beginstodiscusssexualfantasiesaboutthetherapist.Thetherapistfeels
flatteredbythesexualinterestofthispatientandnoteshisownfeelingsof
attractionto
her.Themostappropriatenextstepforthetherapististo:(3x)
SEEKCONSULTATIONWITHACOLLEAGUE
“Firstdonoharm”referstowhichofthefollowingprinciples:(3x)
NONMALEFICENCE
Afamousentertainercommentspubliclyabouthavingproblemscuttingdownon
ETOHusedespiteknowingnegativeeffectsonfamilymembers.Well-known
UNETHICALBECAUSETHEPSYCHIATRISTHASNOTEXAMINED
psychiatrist,nevermettheentertainer,goesonanewsprogramandsaysthat
THEENTERTAINER
theentertainerismostlikelyexperiencingETOHabuse.Whatexplainsethicsof
MD?(2x)
WhatreflectsopinionofAPAonpracticeofchargingaptforamissed
appointment(2x)
SUPPORTSITIFITISCONTRACTEDWITHTHEPATIENT
APArulere:psychiatristdatingsiblingofcurrentpt
SHOULDBEAVOIDEDWITHANY3RDPARTY
Researchcoordinatorrequestsspouseofpatienttoparticipateinstudyashealthy
control.Whichfeatureofinformedconsentispotentiallybeingviolated?
VOLUNTARISM
MostethicalresponseandreasonwhenpatientsendstherapistaFacebookfriend
DECLINE;DISRUPTSBOUNDARIESOFTHERAPEUTICFRAME
request
Whatcharacterizesthenatureofboundarycrossingsindoctor-ptrelationship?
SHOULDBEASSESSEDACCORDINGTOCLINICALSITUATION
AgitatedmanicptevalinED,resistedvoluntarypsychhospitalization.Psychiatrist
said,“Youcancomeinvoluntarily&choosewhenyouwillbedischarged,orI’ll
involuntarilyhospitalizeyousoyouhavenosayinhowlongyoustayinthe
hospital”.PthadnoSI/HI.Whydoespsychiatrist’sdecisionnotmeetstandardof
care?
THEPSYCHIATRIST’SUSEOFCOERCIONINVALIDATEDINFORMED
CONSENT
APAaddressedethicsofsexualrelationshipsbetweenpsychiatrists&ptsbystating
NOTPERMISSIBLETOHAVEASEXUALRELATIONSHIPWITHA
CURRENTORFORMERPATIENT
Mostappropriatetimetodiscussadvancedirectiveswithapt
WHENTHEPTISCOMPETENT
Ethicalstandardsdictatethatthepsychiatristshoulddowhatinchildcustody
evals?
INTERVIEWALLPARTIESTOTHELITIGATION
Commonancestry+asharedsenseofidentity,beliefs,andhistory
ETHNICITY
PsychMDwishestochargeptsforappointmentsthattheydonotkeep.According
ETHICALIFPTISSPECIFICNOTIFIEDINADVANCE
tocodeofethicsofAPA,suchapolicyis:
PsychMDisapproachedatsocialgatheringbyaneighborwhoseeksadviceabout
recentSxofdepressionandanxietythatneighborhasexperiencedsincebeing
firedfromwork.Whichactionwouldconstituteestablishmentofdoctor-pt
relationship?
ADVISINGNEIGHBORTOSTARTCBTWONEOFSEVERAL
PROVIDERS
Psychiatristjudgespatientundermanagedcareplanwillneedcombined
psychopharmandpsychotherapyfor>1yr.Knowsthathealthplanstopspaying
after20visits.Mostethicaltotellpatient:
PATIENTMAYNEEDMORETXTHANINSURANCECOVERS
Aninternalmedicineresidentwhoisaskedbytheresidencyprogramtotakea
leaveofabsenceduetoerracticbehaviormustundergoapsychiatricassessment
beforereturningtoclinicalduties.Whichofthefollowingstatementsbest
describestheobligationoftheexaminingpsychiatrist?
STATECLEARLYTOPTPRIORTOEVALUATIONTHEPURPOSEOF
THEEVALUATIONANDTHATTHEINFORMATIONMAYBE
TRANSMITTEDTOTHERESIDENCYPROGRAM
AccordingtoAPA,itisunethicalforapsychiatristto:
PARTICIPATEINLEGALLYAUTHORIZEDEXECUTION
FactthatparticipantsdidNOTreceiveavailableindicatedtreatmentinthe
Tuskegee
Syphilisstudyisanethicalviolationofjustice,beneficenceornon-malfeasance?
NON-MALEFICENCE
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Psychiatristwarns24y/opt-ifptdoesnotsignintoahospitalvoluntarily,the
patientwillbeinvoluntarilycommitted.Thisapproachviolatesthespiritof:
INFORMEDCONSENT
“Primumnonocere”(firstdonoharm)referstowhichcoreethicalprinciple?
NONMALEFICENCE
Apsychiatristwishestochargepatientsforappointmentsthattheydonotkeep.
AccordingtothecodeofethicsoftheAPA,suchpolicyis:
ETHICALIFTHEPTISSPECIFICALLYNOTIFIEDINADVANCE
Psychiatristdeterminesthatfullyinformingaptoftxriskswouldnegativelyimpact
pt’shealth/welfare&documentsrationalefortxthepatientwithoutinformingthe THERAPEUTICPRIVILEGE
patientofalltherisks.Thispsychiatristisintendingtousewhichofthefollowing?
Forcingmedonptdirectlychallengeswhichofthefollowing?
AUTONOMY
Providingptswithanunderstandingoftheirdisordersandoptionsfortreatmentis
AUTONOMY
honoringwhichofthefollowingprinciplesofethics:
AdolescentwithrecentSAisabouttobedischargedfromhospital.Theparents
refusearequesttoremovefirearmsfromthehouse,stating,“Ineedfirearmsto
protectmyfamilyandIwillmakesuretheyaresecured.”Whichethicalprinciple
CONFLICTSwiththepsychiatristmakingaCPSreport?
AUTONOMY
Failingtoobtaininformedconsentdefieswhichprincipleofethics?
autonomy
Itisethicalforapsychiatristtobillptforamissedappointmentif:
IFPAYMENTFORMISSEDAPPTFALLSINCONTRACTUAL
AGREEMENT.
Thethreecomponentofinformedconsentinclude:thepresentationof
information,thevoluntarinessofconsentonthepartofpt,and:
MENTALCOMPETENCE
Watson’sexperimentwith“LittleAlbert”demonstratedthatan11y/ochild,who
previouslyshownnophobicresponsetoastimulus,learnedtofearthestimulus
afteritwasrepeatedlypairedwithaloudnoise.Thiswouldbeunethicalb/o
violationof:(2x)
NONMALEFICIENCE
Ptwhoispoorbuttalentedasksifhecanbarterforservices.Youlikethept’s
ITISNOTRECOMMENDEDASITMAYCOMPROMISETREATMENT
product.Whatdescribesthenatureofthisproposaltoacceptgoodsinlieuoffees BOUNDARIES
Psychiatristwishestochargeptsforappointmentsthattheydonotkeep.
ETHICALIFTHEPATIENTISSPECIFICALLYNOTIFIEDINADVANCE
AccordingtocodeofethicsoftheAmericanpsychiatricassociationsuchapolicyis:
PtqualifiesforECT,butdoesnotwanthisdoctotellhimtherisks.Heisa“chronic
DOCUMENTTHEPT’SKNOWINGANDVOLUNTARYWAIVERAND
worrier”andfearshearingtheriskswillmakehimanxious,perhapstothepointof
PROCEEDWITHTREATMENT
refusingtreatment,whichhebelievesheneeds.Whatisthebestresponse?
Insurancecompanytellspsychiatristtoswitchgenericdrug.Youknowalternatives CONTACTINSURANCEANDASKFORNONFORMULARY
maybegoodtoo.Whatdoyoudo?
APPROVAL
Psychiatristcallsptathome;wifeaskshowptisdoing.Whatprinciplegoverns
response?
CONFIDENTIALITY
Howshouldapsychiatristhandleaninterviewaboutthemisbehaviorofa
prominentgovernmentemployee?
COMMENTONHUMANBEHAVIORGENERALLY,BUTREFUSETO
OFFEROPINIONSABOUTTHESPECIFICPERSON
Sonof70y/optcallspsychMDtoreportshismomhasb/cdepressedinlast6
months,butptdeniesbeingsadandrefusestoseepsychMD.Sonmentionsthat
hewillbringmothertotheappointmentunderthepretenseofhavingherback
painchecked.MostappropriateresponsefrompsychMDwouldbeto:
TRYTODISSUADETHESONFROMUSINGDECEPTION
Gag-ruleclausesinsomemanagedcareplansmayprohibitdocsenrolledintheir
plansfromtakingwhichaction?
ADVISINGPTSABOUTTREATMENTSNOTCOVEREDBYHMO
ThepsychMDwhoreleasedmedicalrecordsandaudiotapesofthetreatmentof
thepoetAnneSextontotheauthorwhowaswritingabiographyafterherdeath
couldhavebeencriticizedforviolatingwhatprinciple?
CONFIDENTIALITY
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PsychMDistreatingachildwhoseparentsaredivorced.Underwhatcircumstance
isitethicallyacceptableforthepsychiatristtohavearomanticrelationshipwith
UNDERNOCIRCUMSTANCES
thechild’sparent?
Aptsuffersasaresultofthept’spsychiatristgoingonvacationw/oproviding
coverage.Thepsychiatrist’sproblematicbehaviorviolateswhichofthefollowing
ethicalprinciples?
FIDELITY
Theeffortsofpsychiatriststoachieve“parity”legislationformentalillnesscanbest
JUSTICE
beseenasillustratingwhichofthefollowingmoralprinciples?
Paternalismcanbejustifiedbywhichofthefollowingbasicethicalprinciples
(x2):
BENEFICENCE
Asuicidal18y/optwholiveswithhisparentsisevaluatedintheED.The
psychiatristwarnstheptthatifhedoesnotsigninvoluntarilyforinpttx,the
HEWASCOERCEDINTOGIVINGCONSENT
psychiatristwillinvoluntarilyhospitalizethept.Theptconsentstoinptcare.The
ptinthissituationhasnotgivenvalidinformedconsentbecause:(x2)
Ifathirdpartyissupervisingatherapycase,theresidentshouldinformthepatient
thathiscasewillbediscussed…Apsychiatristandspouseareattendingaconcert. INFORMWALKBYWITHOUTINDICATINGKNOWINGTHE
Duringintermission,thepsychiatristseesthattheywillcrosspathsinthelobby
PATIENTFROM,UNLESSTHEBEGINNINGPATIENTINITIATES
withoneofthepsychiatrist’spatients.Whichofthefollowingwouldbethemost CONTACT.
appropriateconductforthepsychiatristinthissituation?
Psychiatristprescribesmedicationtoapsychotherapyptofanothermentalhealth
psychiatristretainsfullresponsibilityfortheptscare
professional,whatishisliabilityinthistreatmentarrangement?
Ptwithhistoryofbipolardisorderhospitalized2weeksagoformaniaandSI.
Improvedbut2daysbeforebeingallowedhomevisit,patientstopsallmeds.
Doctorstatesifpatientrefusesmeds,cannotgohomeforvisit.Patientrelents
andacceptsmedsafterhearingthis.Fromethicalstandpoint,responsefrom
doctorcanbeconsidered:
Coercivebutacceptableifthedoctorbelievednon-adherence
wouldcausesignificantharm
LegalandForensics
requestmomprovidedcopyofdivorcedecreetoconfirm
Motherof8yowantsADHDeval,kids’parentsaredivorced,momreportsshehas
custodystatus
primarycustody,willnotsignROIforchild’sdad,whatisthenextstep?
Mentalcompetencyofanelderlypatientisdeterminedby:(7x)
JUDICIALHEARING
Testamentarycapacityreferstoperson’sabilityto(4x)
MAKEAWILL
Whatisprimaryroleofpsychiatricexpertwitness(4x)
RENDEROPINIONBASEDONSCIENTIFICKNOWLEDGE
Childcustodydeterminationsinmostjurisdictionsaremadeusingwhat
principle?(4x)
THEBESTINTERESTOFTHECHILD
Sufficienttoestablishthatapersonisincompetenttostandtrial(3x)
FAILURETOUNDERSTANDTHECHARGESONEISFACING
Pt’sspousecallsthepatient’spsychiatristtoaskaboutchangesinthepatient’s
medication.Whichofthefollowingwouldbeanappropriateinitialresponsefor
thepsychiatristtomake?(2x)
INFORMTHESPOUSETHATTHEPATIENT’SCONSENTIS
REQUIREDTODISCUSSTREATMENT
Whenevaluatingforcompetencetoproceedinacriminalmatter,thepsychiatric
CURRENTMENTALFUNCTIONING
evaluatorshouldfocusonwhichaspectofthedefendant?(2x)
Whatismostimportanttoevaluate“competence”?(2x)
“WHATDOYOUTHINKWILLHAPPENIFYOUDON’T
UNDERTAKETHISTREATMENT?”
WhichislistedonPresident’sNewFreedomCommissiononMentalHealth
(2003?)(2x)
ADDRESSINGMENTALHEALTHASVIGOROUSLYASPHYSICAL
HEALTH
Medicationcanbeadministeredwithoutapatient’sconsentunderwhichofthe
followingcircumstances?(2x)
ANEMERGENCYSITUATIONEXISTSANDCANBEDOCUMENTED
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Inmalpracticesuitsagainstpsychiatrists,themostcommonallegation?(2x)
INCORRECTTREATMENT
Whatisthelegalprocessthatasksthecourttoimmediatelyevaluateifapthas
beenhospitalizedw/odueprocessoflaw?(2x)
WRITOFHABEASCORPUS
Whatdocumentationwilllegallyprotectapsychiatrist,ifptdiesbysuicide?(2x)
DETERMINETHELEGALINSANITYSTANDARDTOBEUSED
Whatstandardofproofappliestocivilinvoluntarypsychcommitment?
Clearandconvincingevidence
Whatentitymandatespublicschoolsprovideeducationalservicesforchildrenwith
Federalgovernment
disabilities?
Whatisanunethicalfeearrangementforaforensicpsychiatrist?
PERCENTAGEOFPLAINTIFFSAWARD
Conditionheldtostrictestlegalconfidentialitystandard?
SUBSTANCEABUSE
Mostethicalactionwhenpsychiatristreceivessubpoenaforrecordspertainingto
patientarrestedforsellingmarijuana
OPPOSESUBPOENADUETOLACKOFPTCONSENT
Dementiaptwithdurablepowerofattorney,decisionsneedtobemadeby?
ASSIGNEDDECISIONMAKER
Individualw/schizophreniaarrestedafterbreakingintogrocerystorewouldbe
foundincompetenttostandtrialifs/he:
BELIEVESALLLAWYERSAREDEMONSANDREFUSESTOSPEAKTO
THEM
Ptarrestedforposessionofcocaine,spends2daysinjail,aftermissingappswith
subsabusecounselor.Interventionisreferredtoas…?
DRUGCOURT
Rogersv.commissioner(1983)isalegalcasethataddressedtherighttorefuse
antipsychoticmedsinnon-emergencysituations.Basedonthisruling,pts
previouslyadjudicatedasincompetentmaynotrefusemedsinwhichsituation?
THEREISACOURT-APPROVEDSUBSTITUTEDJUDGMENTTXPLAN
Inordertobejudgedcompetenttostandtrial,adefendantmustbeabletoconsult AFACTUALANDRATIONALUNDERSTANDINGOFPROCEEDINGS
withthelawyerw/areasonabledegreeofrationalunderstandandpossesswhat? AGAINSTHIM/HER
Patientthreatenscriminalbehaviortowardpropertyofanother.Legalobligationof
NONE
psychiatrist?
Whatsituationrequiresthepsychiatristtostepoutofusualtxrelationshipto
protecttheptorothersfromharm?
CHILDABUSE
Constitutionalandcommonlawdictateprisonersmustreceivecareatthelevelor
TREATMENTMUSTBEPROVIDEDTOTHOSEWHOARE
abovecaretheywouldreceiveiftheywereinthecommunity.This“necessaries”
PREVENTEDFROMSEEKINGTHEIROWNMEDICALCARE
doctrineisjustifiedbywhichofthefollowingprinciples?
Ptattemptedsuicideduringacrisiswhichwasworsenedbypt’sfeelingsabout
beingunabletoreachvacationingpsychiatristwhodidnotprovidecoverage.What ABANDONMENT
isthepsychiatrist’svulnerability?
Whendocumentingsuicideriskassessment,keystrategyistodiscuss…
WHYTHEPSYCHIATRISTREJECTEDALTERNATIVEWAYSOF
RESPONDING
Whichofthefollowingisthemostcommonreasonformalpracticeclaims?
INCORRECTTREATMENT
Psychiatristprovidespsychotherapyto22y/optwholivesw/parentsanddxw/
anxietyanddepression.Ptreportsthefatherthrew13y/osiblingacrosstheroom. TELLPTTHATTHEPSYCHIATRISTMUSTREPORTTHEABUSETO
Sibwasnotinjured.Multiplesimilarepisodes.Whatisappropriateresponseforthe CHILDPROTECTIVESERVICES.
psychiatrist?
Appropriatesubstanceabusetreatmentintheclinicalsettinghasbeenaddressed
inlandmarklegalcases.Whatistheconsensus?
ITISAMONGTHERIGHTSGRANTEDASITISCONSIDEREDA
PSYCHIATRICDISORDER
Whichtoolscanbeusedwhenapersonwishestoassignasurrogatetomake
healthcaredecisionsduringfutureperiodsofmentalincapacity?
ADVANCEDIRECTIVE
Ptwhosuffersfromaseriousmentald/oisadefendantinacriminalmatter.Even
ifptunderstandsthenatureandobjectivesofcourtproceedings,ptmaybefound BEINGUNABLETOASSISTATTORNEYINTHEDEFENCES
notcompetenttostandtrialunder:
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Themostaccuratelydescribestheprimaryfunctionofamentalhealthcourt:
DIRECTSMENTALLYILLDEFENDANTSTOTXRATHERTHAN
PUNISHMENT
Whichcharacterizesthedefendant’scompetencytostandtrialincriminal
proceedings?
ISPRESUMEDUNLESSTHEISSUEISRAISED
WhichshouldraisePsychMD’sindexofsuspicionformalingeringincasesof
litigationinwhichfinancialcompensationisatissue?
VAGUELYDEFINEDSYMPTOMS
CriterionforacovereddisabilityunderAmericanswithDisabilitiesAct:
SUBSTANTIALLYLIMITSONEORMOREMAJORLIFEACTIVITIES
Whatdeterminesdisability?
IMPAIRMENTAFFECTSABILITYTOMEETPERSONAL,SOCIAL,OR
OCCUPATIONALNEEDS
Ptgettingpsychexamtodeterminesuitabilityforajobmustbeinformed:
EXAMISNOTCONFIDENTIAL
Indeterminingthedisclosureofpsychiatrictreatmentinformationincourt,which
ofthefollowingindividualsisconsideredtoholdprivilege:
PATIENT
Psychiatristagreestoprescribemedicationtoaptwhoreceivesongoing
PSYCHIATRISTRETAINSFULLRESPONSIBILITYFORTHEPATIENT’S
psychotherapyfromanothermentalhealthprofessional.Whatisthepsychiatrist’s
CARE
liabilityinthistreatmentarrangement?
PthasintractableOCD,withprofoundmorbidity,andconsidersbrainsurgery.The THEINFORMATIONMOSTPATIENTSWOULDWANTTOKNOW.
surgeonmustdisclosethisinordertoobtainavalidinformedconsent:
(REALLY?)
Apsychconsultationisrequestedforapatientwhomthemedicalteambelievesis
manufacturingsymptomsofanillness.Whichofthefollowingfactorswouldbe
FINANCIALINCENTIVEFORILLNESS
mostconsistentwithadiagnosisofmalingering?
Whichofthefollowingpatientswouldautomaticallybeconsideredaslackingthe
capacitytogiveinformedconsentformedicalprocedures?
APATIENTWITHALZHEIMER’SDEMENTIAWHOHASASTATE
DESIGNATEDGUARDIAN
PatientrefusingIVantibiotics,whatisareasonhewouldnothavecapacitytodo
this?
DOESNOTUNDERSTANDCONSEQUENCESOFREFUSING
TREATMENT
Alawsuitchargesthatapsychiatricfacilityprematurelydischargedapatientwho
wasnotapprovedforfurtherstaybythemanagedcarecompany.Thefinallegal
responsibilitygenerallyfallstothe:
PSYCHIATRIST
Mostimportantfindingforapsychiatristtoconsiderindisabilitydetermination:
DEGREEOFFUNCTIONALIMPAIRMENT
Aresidentisdischargingapatientandnotesasignificantomissionintheresident’s
WRITEANADDENDUMTOTHEPROGRESSNOTEWITHTHE
last,handwrittenprogressnote.Whichofthefollowingisthebestcourseof
CURRENTDATE
action?
Inforensicpsychiatry,theterm“standardofcare”referstotheuseoftreatments
thatare:
USEDBYAVERAGEREASONABLEPRACTITIONERS
Inevaluatingapatient’scompetencetoconsenttoamedicaltreatment,the
degreeofstrictnesswithwhichtheexaminingpsychiatristconsidersthequestionis THERISK-BENEFITRATIOOFTHETREATEMENT
mostaffectedbywhichofthefollowingfactors?
InformedconsentisNOTrequiredinwhichofthefollowingforensicevaluations?
COMPETENCYTOSTANDTRIAL
Unethicalfeearrangementforforensicpsychiatrist:
PERCENTAGEOFPLAINTIFF’SAWARD
Whatdocumentationwilllegallyprotectapsychiatrist,ifptdiesbysuicide?
ANSUICIDERISKASSESSMENTANDPROTECTIVEFACTORS.
Severalstatesestablishedthattheverdictguiltybutmentallyilltobeanoption
whenadefendantpleadsnotguiltybyreasonofinsanitybecause:
WHENCOMPAREDTOGUILTY,GUILTYBUTMENTALLYILLIS
INTENDEDTOENSUREACCESSTOTREATMENTBUTIS
ESSENTIALLYSIMILAR
Inevaluatingthesanityofacriminaldefendant,theforensicpsychiatristshould
focusoncurrentstateofmind,orstateofmindattimeofoffense?
STATEOFMINDATTIMEOFOFFENSE
Therulethatfindspeoplenotguiltybyreasonofinsanityduetomentalillnessthat
impairedtheirknowledgeofthenaturequalityandconsequencesoftheiractions M’NAGHTENRULE
ortheywereincapableofrealizingthattheseactswerewrongiscalledwhat?
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Thecriminaldefendanttellsthepsychiatristdoingaforensiceval“Iknowthat
killingmyfatherwasillegal.”However,thedefendantdelusionallybelievedthat
APPRECIATETHEWRONGFULNESSOFHISCONDUCT
thefatherwasbeingtorturedbydemonsandkillinghimwasthemoralthingtodo.
Thedefendantisunabletodowhat?
Atthebeginningofaradiotalkshowapsychiatriststatesheisnotenteringintoa
doctor-patientrelationshipwithanyofthecallers.Herebyhedoesnothave_____ DUTY
towardsapatientincaseofamalpracticesuit.
Apatientrequestsanalternativetxfordepression.Hispsychiatristdoesnot
practicethistxhimselfbutrefersthepttoonewhodoes.In6mothepthas
complicationsfromthetxandsuesthe1stpsychiatristformalpractice.Which
elementofmalpracticeismissinginthiscase?
DUTY
Bestprotectionagainstmalpracticelawsuit:
MAINTAININGGOODDOCTOR-PTRELATIONSHIP
Standardofcarereferstotreatmentsthatare
USEDBYAVERAGEREASONABLEPRACTITIONERS
Lawsuitsagainstpsychiatristmostfrequentlyarisefromissuesconcerning:
SUICIDEATTEMPTS
Thefourbasicelementsthatmustbeproveninordertosustainaclaimof
malpracticeagainstaphysicianincludeadutyofcareowedtothepatient,
negligence,causation,andwhat?
HARMTOTHEPATIENT
Bestdefenseforagainstmedicalmalpractice?
Patient’sconfidentialityafterdeath
Patientdidnotsufferabadoutcome.
USUALLYMUSTBEMAINTAINED
Collegestudentintherapy,theDeancallstherapistrequestinginfoaboutthe
REFUSETHEDEAN’SREQUESTFORINFORMATION
student’stherapyduetorecentreportsfromadormsupervisor.Therapistshould:
Medicalresidentconsultspsychiatrybecausea38y/oFptrefuseddialysis
WILLASSESSPT’SCOMPETENCYTOMAKEONE’SOWNMEDICAL
secondaryto“antisocialpersonality”andtheresidentwantsyoutoconvinceherto
DECISION
stayfortreatment.Youransweris:
Themostrelevantissueforageriatricorforensicpsychiatristincaseswerethe
financesofanelderlyareindisputebetweenpartnerandchildrenis:
WHETHERTHEELDERLYHASAMENTALDISORDERAND
WHETHERISADEQUATELYTREATED
WHENTHEREISREASONTOBELIEVETHATTHEPATIENTLACKS
Whenshouldaschizophrenicadmittedtoamedicalhospitalforevaluationofchest THEABILITYTOUNDERSTAND,APPRECIATE,ORREASON
painhaveaformalassessmentofdecision-makingcapacity?
LOGICALLYWITHTHEINFORELEVANTTOHEALTHCARE
DECISIONS
Themostappropriatetimeforaphysiciantodiscussanadvancedirectivewithapt
WHENTHEPTISCOMPETENT
is
Themostappropriatetimetodiscussadvancedirectiveis:
ATTHETIMEOFADMISSIONTOTHEHOSPITAL
Ifptisincompetenttomakedecisionandhasdurablepowerofattorney,
treatmentrecommendationswillhavetoapprovedbythe:
ASSIGNEDDECISIONMAKER
Pt’sdementiaprogressedtothepointthatthept’sdrivingisaffected.Inaddition
totalkingtopt,theMDshould:
CONSULTSTATELAWABOUTOBLIGATIONSFORREPORTINGTHE
PT’SCONDITION.
78y/ow/deterioratingpersonalhygiene,significantweightloss.Signsvoluntary
admissionformbutlaterforgetsdoingthis.Potentiallyresectablemassesinlung
andbrainrequiringfurtherconsentforsurgicalandoncologicaltreatment.
Consentsbutcannotexplainreasonforsurgery.Legally,psychiatristshould:
URGENTLYREQUESTPROBATECOURTAPPOINTGUARDIANWITH
POWERTOMAKETREATMENTDECISIONS
GuardianofaptwithMRwithmedication-refractoryepilepsyinsiststhatthept
shouldhaveepilepsysurgery.Neurosurgeonbelievestheseizurefocuscanbe
resected,butthere’sa>50%chanceofRUEparalysiswhichoutweighspotential
benefitfromfreedomfromseizures.Guardianinsistsonsurgery.Whichdescribes
physicianresponsibilityinthiscase?
SHOULDPERFORMTHESURGERYONLYUNDERCOURTORDER
Whatcharacterizesthemajorityofdefendantswithpsychiatricdisorderswhoare
foundunfittostandtrial?
THEYCANREGAINFITNESSINLESSTHAN90DAYS
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Anattorneyrequestspsychiatricconsultationwhenhisdefendantwantstheworst
PROBABLYMEETSCRITERIAFORFINDINGOFINCOMPETENCETO
possibleoutcomefromthetrialbecausehefeelshedeservestheworst
PROCEED
punishmentpossible.Whatdirectionshouldyoutakeforthiscase?
Whatdistinguishesforensicfromgeneralpsychevaluation?
Maintenanceofconfidentiality
USSupremeCourtDecisionWashingtonvHarper1990,therighttorefuse
treatmentislimitedforprisoninmatesbecause:
PRISONSECURITYCONCERNSOUTWEIGHINDIVIDUAL
AUTONOMYINTERESTS
Informedconsentrequires:presentationofinformation,voluntaryconsentfrom
patient,and:
MENTALCOMPETENCE
Ptw/severeGIdiseaserequestsasurgicalprocedurewithquestionableefficacy
andarelativelyhighriskofnegativeeffects.Levelofcompetencyapsychiatrist
wouldrequiretofindptcompetenttomaketreatmentdecision?
RATIONALCONSIDERATIONOFALTERNATIVES
16y/osaysshethinkshemaybepregnantbutdoesnotwanttoinvolveher
parents.Whatshouldguidethepsychiatrist’sactions?
THEPATIENT’SABILITYTOGIVECONSENTWILLVARYFROM
STATETOSTATETOSTATE
Ptswhoarecommittedtopsychiatrictreatmentinstitutionsinmoststatesare
presumedto:
BECOMPETENTTOMAKETHEIROWNDECISIONS
Bothmenseraandactsreusearerequiredforwhichofthefollowing?
CONVICTIONOFACRIME
Duringanevaluationforcompetencytostandtrial,adefendanttellsthecourt-
appointedforensicpsychiatristaboutbeinginvolvedinanunsolvedcrime.The
psychiatristshoulddowhat?
AVOIDADETAILEDDESCRIPTIONOFTHEDEFENDANT’SPAST
OFFENSEHISTORY
Constitutionalandcommonlawdictatethatmentalhealthcareprovidedto
prisonersbeatorabovethelevelofservicesthatshouldbeavailabletothemif
theywereinthecommunity.The“necessaries”doctrineisjustifiedbywhat
principle?
TREATMENTMUSTBEPROVIDEDTOTHOSEWHOARE
PREVENTEDFROMSEEKINGTHEIROWNMEDICALCARE.
Ptconsumedalargeamountofalcoholanddischargedafirearm,woundinga
neighbor.Ptremembernothingoftheincident.Whatistrueaboutthept’s
criminalresponsibilitypertheinsanitydefense?
VOLUNTARYINTOXICATIONDOESNOTEXCUSETHECRIMINAL
BEHAVIOR
Whatisthefirststepwhendeterminingwhetherornotacriminaldefendantisnot
DETERMINETHELEGALINSANITYSTANDARDTOBEUSED.
guiltybyreasonofinsanity?
WhatriskmanagementstrategyfordealingwithaptwithSIismostlikelytobe
rejectedasinvalidinasubsequentmalpracticelawsuit?
A“NO-HARM”ORSUICIDEPREVENTIONCONTRACTBETWEEN
THEPTANDTHETHERAPIST.
Ptw/severedepressionisinterviewedforenrollmentinanexperimentaltrial.Pt
PRESENTINFORMATIONSEVERALTIMESUSINGDIFFERENT
hasfailedmultiplemedicationsandseveralcoursesofECT.Theptiscompetentbut
METHODSANDFEEDBACKTESTING
clearlydistressedatthetimeofconsentfortreatment.Nextstep?
Murdertrial,defendantstates“IthinkmurderiswrongbutkillingaspyfromMars
whoistryingtostealthesecretoflifeisright.”Thisposesaproblemforwhattype M’NAUGHTENRULE
ofevaluationofcriminalresponsibility?
TheNationalPractitionerDatabankcontainsreportsaboutwhichofthefollowing
typesofphysicianproblems?
MALPRACTICESETTLEMENTSWHERENOWRONGWAS
ADMITTED
Adementedpatientwhoisdrivingproblematically.Whatdoyoudo?
CONSULTSTATELAWABOUTREPORTING
Toprovemedicalmalpractice,theplaintiffmustestablishduty,dereliction,
damagesanddirectcausationbywhatpartofproof
PREPONDERANCEOFEVIDENCE
Whichstatementapatientisincompetenttostandtrial?
“Iamawizardandthereforehavediplomaticimmunity”
CaseManagement
Bestindicationforresidentialtreatmentofsubstanceabuse?(3x)
FAILURETOMAINTAINABSTINENCEAFTERTREATMENTIN
INPATIENTSETTINGS
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29y/oschizophrenicfrequentERvisitsandhospitalizations.Hallucinating,
agitated,notviolentorsuicidal,cooperative.Ranoutofmedsafewdaysago.
Hadbeendoingwellonolanzapineforseveralmonthsandwasdoingfairlywell
instructuredlivingenvironment.DeniescommandAH.Whatshouldthenext
interventionherebe?(3x)
CONTACTCASEMANAGERTOVERIFYENVIRONMENTAL
SUPPORT
PatientwithMDD;psychiatristprescribesantidepressant,psychologistprovides
interpersonaltherapy.Whoisresponsible&accountableforwhat?(2x)
PSYCHIATRISTISRESPONSIBLE&ACCOUNTABLEFORALL
TREATMENT;PSYCHOLOGISTJUSTFORPSYCHOTHERAPY
Describethepsychiatricassertivecommunitytreatmentcasemanagement
model:(2x)
INTERDISCIPLINARYTEAM,SERVICESINSITU,HIGH
STAFF/PATIENTRATIO,ANDINTENSIVEOUTPATIENTRESEARCH
Mostcommonfactorincasesofterminationofparentalright:(2x)
NEGLECTBYTHEPARENT
29y/oMptwithhxofCPS8xhospitalizationin14months,stoppedhismedsand
isunabletotakecareofhimself,becomesparanoidandstaysonthestreet,
eatingoutofgarbagecansandhisfamilyisunabletosupporthimanymore.The ASSERTIVECOMMUNITYTREATMENT
mostappropriateinterventiontodecreasethispt’sriskoffuturehospitalizations:
(2x)
Aspartofcomprehensivepainmanagementteamforptwhxofnarcoticabuse,a
RESOLVECONFLICTSBETWEENTHEPATIENTANDTHE
consultingpsychiatristmayappropriatelybeaskedtodowhichofthefollowing?
TREATMENTTEAM
(2x)
Ptconsultspsychiatristb/cformerpsychiatristhasretired&ptwishesto
continueTxwantidepressants.Theptisseeingacounselorforweekly
psychotherapyandplanstocontinue.ThepsychiatristsevalconfirmstheDxof
MDDandpsychiatristfeelsthatcontinuingthept‘santidepressantisindicated.
Nextstep?(2x)
ESTABLISHACLEARUNDERSTANDINGOFTHEDIVISIONOF
RESPONSIBILITIESBETWEENPSYCHIATRISTANDCOUNSELOR
PthasphonedtheEDcomplainingofhallucinationsthatcommandthepttokill
others.Psychiatrist’sfirstaction:
OBTAINPHONENUMBER,ADDRESSOFPATIENT
Whatare“leastrestrictivealternatives”forpatientswithseriousmentalillnesses?
TREATMENTSHOULDOCCURINASETTINGTHATINTERFERES
MINIMALLYWITHTHEPATIENT’SCIVILRIGHTS
Pthaspsychotherapist.Ptreferredtopsychiatristwhoprescribesmedication.
Psychiatrist’sresponsibilitytopt
TOFOLLOWUPBYSEEINGPTATAPPROPRIATESCHEDULED
INTERVALSANDBYCOMMUNICATINGREGULARLYW/
PSYCHOLOGISTABOUTPT’SCLINICALSTATUSANDTXPLAN
Finallegalresponsibilityfallson
PSYCHIATRIST
80y/optwasadmittedtoanursinghome,anemployeeofthefacilitynotifiedthe
ptaboutthestate’slawsonadvancedirectives.Duringthatsession,thepatient
THELIVINGWILL
mostlikelyreceivedinformationaboutwhichofthefollowingissues:
29y/oseverelydepressedwithSI.Threatenstokillhiswifeanddaughterto“take
themwithme.”Legalresponsibility:
NOTIFYTHEWIFE
Howdoyouresolveamixeddecisionforamongstaffandfamilyofadyingpatient MEETSEPARATELYWITHFAMILYANDSTAFFTOEXPRESSISSUES
(continueTxvsletdie):
OFPOLARIZATION
Goalsofinitialdialoguew/docrequestingconsultexcept;
MAKINGSUREFAMILYISNOTPRESENT
Majorissuewithmaintainingseverelymentallyillincommunity
INSUFFICIENTRESOURCES
Basicconceptofcommunitypsychiatry
CONTINUITYOFCARE
Initialstepwhenchildisreferredforevaluation:
CONSENTFOREVALFROMGUARDIAN
Publicmentalhealthclinicianswhofollowpatientsthroughallphasesoftreatment CASEMANAGERS
Managedcareorg.asksMDtod/captwhostillrequireshospitalization.MD
should:
CONTINUEADMISSIONASLONGASMEDICALLYNECESSARY
Principalgoalofwraparoundservices:
PREVENTHOSPITALIZATIONORRESIDENTIALPLACEMENTS
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FORMALMENTALHEALTHSERVICESANDINFORMAL
COMMUNITYSUPPORT
Essentialelementofwraparoundtreatment
31y/opostpartumFdistressedbyfantasiesofsmotheringbaby,tearfullydescribes
feelingoverwhelmedbytheburdenofthechildcare.ShedeniesSI/HI,but
describesfeelingsomeevilexternalforcetakingherbabyaway.Requestsoutpt
INVOLUNTARYADMISSION
psychf/u&refusesvoluntaryadmission>herhusbandsayseverythingisfine.Next
step:
PtisadmittedtoICU.Ptcancommunicatebutisdeemedincompetent.Whichof
thefollowingadvancedirectivesshouldbeusedtoinformthehospitalstaffofpt
wishes?
LIVINGWILL
Howtomanagetelephoneconversationwithlabilepatientwhoendedrelationship
withboyfriendandishavingSIwithplan,butiswillingtostaywithfamilyand
Next-dayoutpatientf/uwithpsychiatrist
allowsyoutospeakwithfamily?
50yroldptdivorcedandlaidofffromworkpresentstoEDwithSIwithplantoOD
ontylenol,lackssocialsupportandhasimpulsivehistory,disposition?
Inpatienthospitalization
rd
24yohomelesswithSIrequestshospitalization.Thisis3 visitinspanof2
weeks.Ptisorganized,coherent.Whenaskedwhatwouldbedifferentwiththis
hospitalization,attacksthedoctor.Bestnextstepofaction?
Calllawenforcement
ConsultandLiaison
Whatresponsewouldbebasedonapurelylaisonalmodelofpsychosomatic
medicinegiveforaptwhomaybedepressed?
ADVISETHETEAMONHOWTOPROPERLYDIAGNOSE
DEPRESSION
21y/optishospitalizedw/4wkhxofprogressiveparanoia,irritability,confusion
andsleepdisturbance.PsychMDelicitspthxofviralillnessprecedingtheonsetof
DELIRIUMSECONDARYTOVIRALENCEPHALITIS
psychiatricSxandmentalstatuschanges.Nofamilypsychhx.Benadrylmarkedly
makeSxworsened.Dx:
Biologicalconsequencesofpsychologicalstressaredocumentedtoaffect…
ALTERATIONOFNEURO-IMMUNO-ENDOCRINEFUNCTION
22y/optpresentstopsychfortreatmentof“internetaddiction.”Ptnoticeda
patternofincreasingtimepentontheinternet,needforbettercomputer
equipment,andfeelingsofangeranddysphoriawhenunabletoaccessthe
Internet.Explainconceptsoftoleranceandwithdrawalinthissyndrome?
BOTHTOLERANCEANDWITHDRAWALTOINTERNETUSECAN
DEVELOP
Whichcancertreatmentmaybefollowedbyasubcorticaldementiaduetoa
leukoencephalopathywithonsetafter6monthspost-treatment?
WHOLEBRAINRADIATION
WhichSxismostcommoninptswithSLE?
DEPRESSIONAND/ORCOGNITIVEDYSFUNCTION
C&Lpsychsees58y/owidowedptmedicinewantstodischarged/tnegworkupfor
abdpainandnausea.Ptrefusestoreturnhometoadultkidsbecausethefoodthey SCHEDULEMEETINGWITHTHEMEDICALTEAM,PATIENT,AND
preparearemakinghersickandcausinghersxs.MSEunremarkableandnopast
FAMILY
psychhx.Nextstep?
45y/owithRhemiparesis,CTshowsLinternalcapsuleischemicchangesextending
toadjacentbasalganglia+oldlacunarinjuryofRcaudatehead.LP–65wbcs
PCN
(mostlylymphocytes),78protein,63glucose,+regainantibodies.Tx?
PtwhorecentlydeliveredababyBIBtoER,Ptisagitated,labile,anddemandingto
leavebecauseshesaidherbabyisbeingpoisoned.Thisconditionisconsidereda
INFANTICIDE
psychemergencybecauseofitsassociatedw/?
35y/optw/severedepressionwithepisodesofanxietyforpast9months.Pthas
severeweightloss,hyperpigmentationofexposedskin,andcoldintolerance.Dx:
ADDISIONDISEASE
15y/optw/hxofatypicalseizuresthatincludepsychomotorattacksand
generalizedmotorepisodes.Ptdoespoorlyinschool.Examrevealsskinlesion,no
otherabnormalities.Amutationofwhichgene?
TSC-1(TUBEROUSSCLEROSISGENE1)
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Themostcommonpsychiatricsymptomassociatedwithpheochromocytoma?
PANICATTACKS
Psychiatristseesfamilyofaptwhoisinvegetativestate.Allstaff,exceptone
nurse,&alloffamily,exceptoneadultchild,believeitis“timetoletgo.”Butnurse MEETSEPARATELYWITHFAMILYANDSTAFFTOEXPLORETHEIR
&adultchildclaimsignsofrecognizing&respondingtothemdespiteallofthe
ISSUESWITHPOLARIZATION
evidenceofcorticalbraindeath.Mostappropriatenextstep?
PsychMDtestsamedicalptwithgo/no-gotestinwhichpsychMDaskspttotap
thetableonceifPsychMDtapsitonce,butnottotapthetableifpsychMDtapsit EXECUTIVEFUNCTIONING
twice.PsychMDisscreeningfordeficitsin?
Whichpersonalityd/oismostcommonlyfoundinptsw/severefactitiousd/o?
BORDERLINEPERSONALITY
Mostcommonpsychiatricpresentationfollowingastroke?
DEPRESSION
61y/optpresentstoEDwithfamilywhoreportthattheptunabletoremember
recentevents.Memoryproblemsstarted2hoursprior;cognitivelyintactbefore
episode.Ptisalert,anxious,frustrated:“WhyamIinthehospital?”Dx:
TRANSIENTGLOBALAMNESIA
Onthewaytoairportforvacation,58yoFbeginstobehaveinverystrangeway.
Husbandnoticeswhenhetalkstohersheanswersappropriatelywfluentspeech
butseemstohavenoabilitytoretainanynewinformation.Sherepeatedlyasks
TRANSIENTGLOBALAMNESIA
wheretheyaregoing,evenafterhehastoldhermanytimes.Theepisodelastsfor
bout6hours.Thefollowingdaysheisbacktonormalbuthasnorecollectionofthe
priordayevents.Thisepisodeismostconsistwithadiagnosisof:
C&Lpsychiatristseesa20y/optwithcancerpainonmethadonemaintenance
program.Thestafffeelsthatthept’srequestforadditionalnarcoticsrepresent
drug-seekingbehavior.Mostappropriaterecommendation:
THEPTSHOULDBEGIVENMOREOPIOIDMEDICATIONTO
ACHIEVEADEQUATEPAINCONTROLBECAUSEOFTHEPT’S
TOLERANCE.
Thisisarelativecontraindicationforinterferontreatmentinpt’swithHepatitisC:
(2x)
DEPRESSIONWITHSUICIDALIDEATION
PsychMDsees62y/optwhohasbeenhospitalizedafteranacuteMIbecausestaff
reportthat“theptisdrivinguscrazy.”Thenursescomplainthatptisconstantly
requestinginfoabouthisconditionandtreatment,andwillrefusetestsand
ANSWERTHEPT’SQUESTIONSANDACTIVELYINVOLVETHEPTIN
medicationsifhefeelstheexplanationsarenotsufficient.Oninterviewptadmits
ALLPORTIONSOFHISTREATMENT
that“Iamaperfectionist”butisproudofthisfact,sayingthatitis“thesecretof
mysuccess.”Ptisawareofthestaff’sfrustration,butfeelshisrequestsfor
informationarereasonable.ThebestadvicetotheTxteam?
25y/oprisonerwhoclaimstobedepressedishospitalizedafterheswallowed
somerazorblades.Therazorbladesarefoundtohavebeencarefullywrappedin
surgicaltapebeforetheptswallowedthem.Later,theptconfessesheswallowed
thebladesbecausehewantedsometimeoutofprison:
MALINGERING
Psychevalrequestedonmanagementof32y/optadmittedbyinternalmedicine
fortxofseveregastrointestinalviralinfection—dehydration,nausea,vomiting,
fever.Pthashxschizoaffectivedisorder,controlledwstabledosesofclozapine
overthepastyear.Staffconcernedthatptmightbedelusional/hallucinating,aspt DISCONTINUECLOZAPINE
hasappearedsomewhatconfused/inattentive.Onexam,ptisorientedtoperson,
placebutnottime.Ptsomewhatslow,appearsvisiblyill/tired.Ptcomplainsof
stiffness,thereissomerigiditytomovements.Psychrecommendation?
PsychMDisaskedtoevaluatea37y/oFwhocomplainsofchronicvulvarpain.This
painisaccompaniedbyaburningsensationwhichislocalizedtothevestibular
region.Pt’shusbandreportsa12-monthlackofanysexualintercoursewithpt.on
psychiatriceval,theptexpressesambivalenceaboutthelackofintimacywithher
husband,andappearssomewhatannoyedathimfornotunderstandinghow
INITIATENORTRIPTYLINEANDSLOWLYTITRATE.
painfulsexhasbecome.Ptdeniesdepressionoranxiety,butadmitstofrustration
aboutthepain.Thegynecologistreportsthatafullphysicalandlaboratoryworkup
isremarkableexceptforpaininthevestibulewhichcanbeelicitedwithtouch.
Whichwouldbethemostreasonableintervention?
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Whichofthefollowingistheprincipalserviceprovidedbytheliaisoncomponentof TEACHINGPSYCOSOCIALASPECTSOFMEDICALCARETOOTHER
consultation-liaisonpsychiatry?
HEALTHCAREWORKERS
Aneffectiveconsultation-liaisonpsychiatryprograminamedicalhospitalwillresult
IMPROVEDTREATMENTCOMPLIANCE
inwhichofthefollowing?
58yopatientwithbreastcancerontheC&Lservice,recentlyputonpalliativelevel
anddevelopsdepression.SheishopelessbutdeniesSI.Whatisthemost
VALIDATETHEPATIENT’SFEELINGS
appropriateresponse?
A40-year-oldptishospitalizedforevaloffever,weightlossandataxia.Psychiatric
consultationisrequestedasthepatientseemsdepressed,andafamilymember
reportsthatthepthasbeenexhibitingprogressivememorylossoverthelast
HIV
severalmonths.Whichofthefollowinglabtestsmayhelpexplainthepatient’s
presentation?
85yopatientwithhxofdementiaadmittedforagitationbecomesmoreconfused
andangry.Whatlabshouldyouget?
UA
41yodrunkmalewhoisstuporoushasapulseof75andBPof110/70.Whatisthe
RESPIRATORYFAILURE
mostimmediateclinicalconcern?
Consultantevaluatespatientforcapacity.Patientrefusingmeds,procedures,
yellsatnurses,orderstakeoutintohospital,threatenslawsuitsifdemandsnot
met.Patientaccusesdoctorofbeingabusive,screamsatdoctor,whenaskedfor
explanationofbehavior“you’rejustanotherpersonheretoabuseme!”Best
responseandadviceformedicalteamis?
AneffectiveroleofC&Lpsychiatristconsultingonamanipulative,entitledpatient?
“thepatientisadifficultpatienttoworkwith.Let’stalkabout
waystomanagethepatient’sbehavior?”
MODELINGANAPPROACHOFAPPEALINGTOTHEPATIENT’S
ENTITLEMENT
ViolenceandAbuse
Whichofthefollowingsituationalandenvironmentalfactorsismostclearly
associatedw/increasedinpatientassaults?(6x)
CHANGEOFSHIFT
PregnantwomeninvolvedinaDVrelationshipgetstruckwheremostcommonly?
ABDOMEN
(5x)
23y/oadmittedininpatientunitw/Dxacutepsychoticd/oafterthreateningto
beatuphismother(withwhomhelives).Agreedtovoluntaryadmit,but2days
IFTHEPATIENTCONTINUESTOTHREATENHISMOTHER
laterdemandstosignoutAMA.Whatjustifiesinvoluntaryhospitalizationinthis
pt?(2x)
PthasbeensexuallyassaultedisintheERimmediatelyafterthetrauma.
PSYCHOSOCIALINTERVENTIONSTOESTABLISHSAFETYFROM
InitiationofwhichofthefollowingismostlikelytobehelpfulinpreventinglongFURTHERTRAUMA
termpsychiatricsequelae?(2x)
Whichofthefollowingcaregivercharacteristicsisthestrongestpredictivefactor
ALCOHOLABUSE
forelderabuse?(2x)
20y/optisbroughttoERbyfriendwhoisconcernedaboutpt’spotentialfor
assaultiveness.Whichfeatureismostindicativeofthisrisk?
Childabuseresultsinsmallersizeofwhichareaofthebrain?
VIOLENCETOOTHERS
Hippocampus
Psychd/oinviolentpeople
SUBSTANCERELATEDD/O
Whichofthefollowingisthemostcommonpsychiatricdiagnosisassociatedwith
violentacts?
SUBSTANCEUSEDISORDERS
Oneofthemostcommonpsychd/ofoundinindividualswhocommitviolence
againstothers(evenmorethanIED,BMD,MDD,CPS):
SUBSTANCERELATEDD/O
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MptBIBtoEDbypoliceafterhethreateningtokillhiswifeandadmitsthathas
thoughtsofharminghisspouseeversincelearningofherinfidelity,saying“Iwant
hertohurtlikeIdonow.”Theptdoesn’tdisplaydelusionsandmoodproblems.He REFERPTBACKTOLAWENFORCEMENT
admitstodrinkingoccasionally,butinthelastweekandpriortoviolence.Next
step:
DutyasoutlinedbyTarasoff
PROTECTTHEPOTENTIALVICTIMOFADANGEROUSPATIENT
Bestpredictoroffutureviolentbehavioris:
PASTVIOLENTBEHAVIOR
WhatdoesNOTpredictviolence?
NON-VIOLENTCRIMINALACTIVITY
Whatistherelationshipofviolencetomentald/o?
MENTALD/OHEIGHTENSRISKINSOME,DECREASESRISKIN
OTHERS
Homicideandhomicidalbehaviorsaremostoftenrelatedtowhatfactors?
EMOTIONSNOTASSOCIATEDWITHMENTALILLNESS
Drugleasteffectiveasadjunctivetxofchronicviolentbehavior
DIAZEPAM
70y/opresentswithfearfulness,angerandagitationaftermovinginwithadult
child.Onfirstvisitptisresignedandtimidduringexam.Whichismostconsistent
withpt’sbehaviors?
PSYCHOLOGICALABUSE
18y/oFinED,justraped.Immediateintervention:
PROVIDESUPPORTANDALLOWTOVENT
Characteristicofwomenwithincreasedriskofbattery
PREGNANCY
Femaleshavecomparableratestomalesfor:
DOMESTICVIOLENCE
20y/optbrings2y/ochildtoERwithmultiplebruises.Mothersayshefelldown
stairs.Motherhashealingblackeyeandcutlip.Sayssheslippedoniceandhit
ADMITCHILDFORCAREANDPROTECTIONDESPITEMOTHER’S
head.X-rayofchild'sarmshowhairlinefxandhealingcallous.Whatactionshould OBJECTIONS
psychiatristtakefirst?
Afindingthatshouldraiseaconcernforchildabuse?
SYMMETRICALBRUISINGINA24-MONTH-OLD
PtconfidestothepsychMDthatthept’sspousehasbeenphysicallyabusingthe
pt.Inallcases,thepsychMDshoulddowhatbeforetheptleavesoffice?
DETERMINEWHETHERTHEPATIENTISINPRESENTDANGER
WhatisthefirstpriorityinERmanagementofarapevictim?
ESTABLISHINGPSYCHOLOGICALSAFETY
27y/oangry,agitatedptisadmittedtotheER.Heisevaluatedduringinitial
interviewasnon-psychoticandhighriskforimminentviolence.Herefuses
medication.Whatwouldbethemostappropriateinterventionatthistime?
USEEXTERNALRESTRAINTWITHCALMREASSURANCE.
16y/ocaughtforshopliftingjeans.Nohxofstealing,jeansnothersize.Pt
frightened,remorseful,insomnia,failinggrades,avoidingfriends.Raped2months ACRYFORHELP
earlier,familyinsistedshenottellanyone.Understandstealingas:
42yroldfemalewithdepression,Spanishspeaking,usuallyseenbypsychiatrist
withinterpreter,butthistimebilingualhusbandwillserveasinterpreter,
psychiatristseesunexplainedinjuriesandsuspectsabusebyhusband,atnext
appointmentptcomeswithclosebilingualfriendandrequestsfriendtojoin
session,ptsayshusbandisparkingcarandwillbeinshortly,whatwouldbethe
bestapproachtoclarifytoclarifysuspicionsofabuse?
Occurrenceofsexualabuseorinappropriatesexualexposureisindicatedby?
(x2)
BEGINSESSIONWITPT,INTERPRETER,ANDPTSFRIENDWHILE
HAVINGTHEHUSBANDREMAINOUTSIDE
Pretendingtohaveintercoursewithastuffedanimal
EmergencyPsychiatry
24yoptcomestoedwithwristcuts.ptreportshavingnointentiontodiebut
wantedtofeelthings.Admitstootherselfharmbehaviorswhenstressed.
Admissiontopsychhospitalwouldbemostsupportedbywhatinthepatients
history?
RECENTALCOHOLABUSE
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25y/oFisbroughttoERafterbeingseverelybeatenbyherBF.Followingmedical
stabilization,firststepinanacutepsychologicalinterventionis:
HELPHERRECOGNIZETHATIMMEDIATEDANGERHASPASSED
ANDSHEISINASAFEPALCE
14y/obroughttoEDaftertellingmomthatshehadbeenrapedbystepdad.On
psycheval,ptreportsfeeling“okay”anddeniesacutedistress.Ptiscalmduring
interviewandappearsgenerallyunaffectedbyrecenttrauma.Onfurther
questioning,ptappearsconfusedandbelievessheisatafriend’shouse.Whichis
thepreferableintervention?
EMPLOYGROUNDINGSTRATEGIESTOORIENTPT
22y/obroughttoEDbyroommatewhofoundhimunconsciouswithasuicide
note.Temp100.9,BP100/60,P124,RR8,warmanddryskin,dilatedpupilsand
TCA
reactivetolight,bowelsoundsdecreased,EKGwithsinustachyandQTCof589,no
obvioustrauma.OnwhichdidptOD?
GivingcharcoalisanineffectivetreatmentforptwhoOD’don:
LITHIUM
PatientcomestoEDconfused,lethargic,flushing,diaphoretic,andrestless.
Recentlystartedfluoxetinebutdoesn’trecallnamesofotherpsychotropicshe’s
taking.Tempis101.5,BP110/62,hastremorandmyoclonus.What’scausinghis
symptoms?
SEROTONINSYNDROME
25y/opresentstoEDc/ochestpain,SOB,andanxietybutappearsNADandcalmly
answersquestions.Ptreportsh/opanicattacks,requestingalprazolambyname,
andreports“Iusuallyneedaprescriptionforatleast2mg4xperdaytogetrelief”. SUBSTANCEABUSE
Whenaskedtodescribe1stpanicattack,ptstates,“Ican’trememberwhenthey
startedorthefrequency”.Whichd/oislikelypresent?
PtinEDfortreatmentofOD–wasfound4hrsagoafteringesting10coldmed
PT’SSERUMN-ACETYL-P-AMINOPHENOL(APAP)LEVELOVER
packsof650mgTylenol,antihistamine,andalpha1agonistdecongestant.Ptispale
TIME
andvomiting.HowdoyoudecidewhethertouseN-acetylcysteineasanantidote?
InER,whichsymptomsmoststronglysuggestageneralmedicalcondition?
CLOUDEDSENSORIUM
PttakingtranylcypromineforatypicaldepressioncalledPsychMD,reportsHA,
vomiting,chills,palpationsoveroneday.Ptasksifhecontinuemedduringillness.
Inadditiontodirectingpttostopmed,emergentTxwould1stincludewhatmed?
NIFEDIPINE
Patientwithlonghistoryoftreatmentresistantdepressiononphenelzine
complainingofsweating,palpitations,andheadache.BP=210/118.Recently
tookOTCmedicinetotreatURI.Whatisthemostappropriateintervention?
NIFEDIPINE
AnintoxicatedptinERthrowsafoodtrayatsecurityguard,norespondtoverbal
redirectionandrefusedtotakemedsbypo.Ptisnowpacing,cursingand
threateningto“hurtsomeone”.Themostappropriatemeds:
LORAZEPAM2MGIM,REPEATEDIN45MINIFNORESPONSE
Themostvalidcriticismofrelyingonano-harmcontracttodetermineapt’s
suicidepotential:
ITLACKSANYSIGNIFICANTEMPIRICALEVIDENCETOSUPPORT
ITSUS
Homicideandhomicidalbehaviorsaremostoftenrelatedtowhichofthefollowing
EMOTIONSNOTASSOCIATEDWITHMENTALILLNESS.
factors?
InhelpingavictimofrapeintheED,thefirstintervention?
RESTOREASENSEOFSAFETYWITHTHEPATIENT
35y/optwithhxofopioidandalcoholdependencepresentstotheemergency
departmentcomplainingoftremlousness,anxiety,nauseaandvomiting.Usedlarge
METHADONE
amountsofheroinandalcoholthedayprior.Initialpreferredmedicationforopioid
withdrawal?
27y/ouninsuredptwashospitalizedinanintensivecareunitafteranearlethalOD
whichfollowedtheendingofalong-termrelationship.Ptismedicallyreadyfor
INPATIENTHOSPITALIZATION
discharge,butisambivalentaboutfollow-uppsychcare,noncommittalwhenasked
aboutregretfulfeelingsforsurviving.Bestapproach?
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25y/optisbroughttotheEDwithasuddenonsetofseverespasmsoftheneck
andeyesdeviatedupandtotheright.Thepthashadaviralillnesswithnausea
andvomitingandwasgivenprochlorperazineyesterday.Whichofthefollowing
medswouldbemostappropriatetoprescribeforthispatient?
DIPHENHYDRAMINE
28y/owomanwhoisat33weeksgestationandhasahistoryofbipolardisorderis
broughttotheemergencydepartmentbyfamilymembersbecauseshewas
runningaroundtheneighborhoodloudlyproclaiming,“IamthemotherofChrist.”
Theptisinrestraints,yelling,spitting,disorganized,andtangential,withrapid
HALOPERIDOL
speech.Familymembersreportthattheptwasstableonvalproate,but
discontinuedthemedicationwhenshelearnedshewaspregnant.Which
medicationtogiveacutelyforthispt?
50y/optwithmyastheniagravisanda3-dayhxofcough,low-gradefeverand
chills,presentswithgreatdifficultybreathing.Theptappearstiredandanxious,
andthept’sskinisclammyandsweaty.Initialmanagement?
MECHANICALVENTILATION
WhenevaluatingapatientintheEDforriskofdangerousnesstoothers,thebest
AHISTORYOFVIOLENTBEHAVIOR
predictoroffutureviolentbehavioris(x2):
AdultmalepresentstoclinicwithbrokenhandduetofirsttimeDVtowardhis
same-agespouse.Bestresponsebypsychiatrist?
TELLTHEPATIENTTHATVIOLENCEISHISRESPONSIBILITYANDHE
NEEDSTOSTOPIT
Suicide
Whichd/oisthemostcommonamongptswhocompletesuicide:(4x)
MOOD
Noharmcontractbetweenpatientsandcliniciansare?(2x)
UNHELPFULINMAKINGDECISIONS
Rateofcompletedsuicidehighestforadultmaleswhen?(2x)
OLDERTHAN65
Consistentpredictoroffuturesuicidalbehavior(2x)
PRIORATTEMPTS
Mostcommonmethodforcompletedsuicidesinadolescents(2x)
FIREARMS
AccordingtoJointCommission,whatisprimaryriskfactorforcompletedsuicides
inmedicallyhospitalizedpts?
lackofproperassessmentforsuiciderisk
Baseduponlongitudinalstudies,whichriskfactorscorrelatedw/suicidemorethan
HISTORYOFPRIORATTEMPTSANDHOPELESSNESS
oneyearafterinitialassessment?
Inthecognitivetherapymodel,whichofthefollowingismostassociatedwith
suiciderisk?
HOPELESSNESS
Whichisaconsistentlyidentifiedriskfactorforsuicidethatisuniquetoadultswith
AGELESSTHAN35YEARS
schizophreniacomparedtothegeneralpopulation?
Whichofthefollowingfactorscarriesthehigheststandardizedmortalityrationfor
HISTORYOFPRIORSUICIDEATTEMPTS
suicide
Highestrateofsuicideassociatedwith
HAVINGREADYACCESSTOFIREARMS
Basedonepidemiologicalstudiesfrom1994-2004,whichgroupshashighest
suicidecompletionrate?
CAUCASIANAMERICANMENINTHEIR60S
Indocumentingsuiciderisk-assessment,keyriskmanagementstrategyistodiscuss WHYTHEPSYCHIATRISTREJECTEDALTERNATIVEWAYSOF
whatfactorsintherecord?
RESPONDING
Ptwithwhichmedicalconditionmostlikelytocommitsuicide?
SYMPTOMATICHIVINFECTION
Theleadingcauseofdeathamonggunbuyersinthefirstyearaftertheweapon
waspurchasedis:
SUICIDE
WhatpsychiatricsymptomdoesnotrequirepharmacologictreatmentintheER?
SUICIDALITY
Alongw/depressionmostcommoncomorbiddisorderinphysiciansuicideis
SUBSTANCEDEPENDENCE
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Preventingadolescentsuicide:
REMOVEFIREARMS
23y/optpresentstoEDbyambulanceforSI.Pthasalcoholodorandslurred
speech.HeendorsesSIbuthisplanisincomprehensible.Nextstep:
OBSERVEANDEVALUATEWHENHEISSOBER.
Mostcommontimeforptw/schizophreniatoattemptsuicideisduring
RECOVERYPHASEOFTHEILLNESS
Whatfactorsismosthighlycorrelatedwithcompletedsuicideinadolescentmales? PREVIOUSSUICIDEATTEMPT
Whichcommonlyprecipitatessuicideintheelderly?
LOSS
Mostpowerfulstatisticalriskfactorforcompletedandattemptedsuicide
HAVINGAPSYCHILLNESS
MostcommonmethodofcommittingsuicideforwomenintheUSis:
FIREARMS
15y/optdepressed+suicidalhasanalcoholicfather.Priord/cfromhospitalthe
nextstepshouldbe:
ENSURETHATANYLETHALMEANSAREUNAVAILABLEATHOME
1993–highestrateofsuicidein75-84y/oagegroup:
CAUCASIAN-AMERICANMALES
Ptwithwhichdxaremostlikelytoengageinparasuicidalbehaviors?
BORDERLINED/O
WhenistherehighestriskofsuicideinMDDpatientsrecentlydc’dfromhospital?
0-3MONTHSAFTERDC
Interminalcancerpatientswhoultimatelydiebysuicide,whichoneofthe
followingcomplaintsismostfrequentlyreported?
SEVEREUNCONTROLLEDPAIN
PsychMDintheERevaluatesa27y/optwithnopastpsychiatrichistorywho
presentswithSIfollowinganaltercationw/herboyfriend.ThepsychMDmakesa
diagnosisofadjustmentdisorderwithmixedemotionalfeatures.Whatisinitially
mostappropriateforthepsychMDtorecommendforthispt?
CRISISINTERVENTION
Whatconditionhasbeenshowntoincreasetheriskofsuicidetothegreatest
degreeinpersonswithdepression?
PAINSYNDROMES
Whatfactormaybeprotectiveinassessingapt’sriskforsuicide?
STRICTRELIGIOUSFAITH
Whatdiagnosis,consideredintheabsenceofothercomorbidities,isestimatedto
putoneathighestlifetimeriskforsuicide?
BIPOLARDISORDER
PsychiatristtoevalptwithbipolarDOwhoisexhibitingthreateningbehaviorwhile
inptonCCUforcardiacischemia.Ptwasincarceratedforassaultingandofficer,
disturbingthepeaceandfirearmsviolations.Ptverballythreatenstotrackdown
INFORMPOLICETHATPTISINPOTENTIALDANGER
hisex-girlfriendand“teachheralessonshe’llneverforget.”Psychiatristhaslegal
responsibilityto…
Afteraptassaultsaroommateonapsychinptunitthetxteamdecidestohavept
DUTYTOOTHERHOSPITALIZEDPTS
arrestedandtransferredtojail.Decisionisbasedon…?
50y/optpresentstotheERvoicingsuicidalthoughts.Theptstatestheintentto
killhimselfwithaguninthewoodsbehindhishouse.Bestcourseofactionisto:
ADMITTHEPTTOTHEHOSPITALFORFURTHERASSESSMENT
ANDCARE.
ACaucasianptwithwhatriskfactorshasthehighestriskforcompletedsuicidein
the
US?
AGEGREATERTHAN85YEARS
Prevalencerateofsuicideingeneraladolescentpopulation?
10%
Bereavement
62y/orequestsantidepressant.Spousedied6wksago.Cryingspells,decreased
appetite,poorsleep.Continuestoseefriends,noSI.FamHxofdepression,no
priordepressiveepisodes(2x)
BEREAVEMENT;ASSUREPATIENTOFNOPATHOLOGY
Mostlikelytoincreaseriskofimpairmentafterbereavementin80y/o
SIGNIFDEPRESSIVESXSSHORTLYAFTERTHELOSS
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Normalbereavementinprepubertalchildren
WISHTOUNITEW/DEADLOVEDONE
5y/ochildseveralmonthafterthathelosthismotherinaMVAreportsthathis
motheriswatchinghimfromskyeverydayisandexampleof:
NORMALGRIEF
8yow/nohxofemotionaldisturbancep/wseparationanxiety&over-concern
forhealthofsurvivingparent.
Age-typicalpresentationofnormalbereavement
Foradult,deathoflovedonebyviolentmeansaffectsgrievingprocessinwhat
way?
EARLYBEREAVEMENTISSIMILAR,HOWEVER,DYSPHORIA
PERSISTSFORPROLONGEDPERIOD
Afatherwantstoknowifheshouldallowhis5y/ochildtoattendthefuneralof
hermother.Thechildexpressesadesiretogo.Tohelpthechildthroughthe
funeral,itwillbeimportanttodowhichofthefollowing?
HAVESOMEONEFAMILIARACCOMPANYTHECHILD
62y/optpresentstopsychiatristrequestingmedfordepression.Detailedhx
revealspt’sspouseof35yearsdiedsuddenly6wksago.Sincethen,ptcomplains
offrequentcryingspells,decreasedappetitewithoutweightloss,andpoorsleep
duetomiddleofthenightawakening.Ptcontinuestoattendsocialengagements
withfriendsanddeniesSI.Pthasfamilyhxofdepression,nohxofdepressive
episodeinpast.Dx:
BEREAVEMENT
Whatfactorisnecessarytoconsiderwhendecidingifapatient’sgriefisdefinedas
CROSS-CULTURALGRIEFPRACTICES
normalorabnormal?
Whatsymptombestdifferentiatechronictraumaticgrieffromuncomplicated
bereavement?
PERSISTENTAVOIDANTOFDEATHREMINDERS
Ptisengagedininterpersonalpsychotherapyfordepression.Inthefirstseveral
sessions,thepatientandtherapistidentifyunresolvedgriefafterthedeathofthe
FINDINGNEWACTIVITIESANDRELATIONSHIPSTOOFFSETTHE
patient’smotherastheproblemarea,andrelatethesefeelingstothepatient’s
PATIENT’SLOSS
currentdepression.Whichofthefollowingwillbethefocusofthemiddlephaseof
treatment?
5y/ohasbeenenureticaftermotherdiedinanMVA4daysagoandkeepssaying,
THECHILDANDSIBLINGSHOULDBOTHBEALLOWEDTOATTEND
"Mommywillcomehomesoon."Thefatherwondersifthechildrenshouldattend
IFTHEYWANTTOGO.
thefuneral.Whatisyourrecommendation?
WhichsymptomwouldindicateMDDratherthanjustbereavement:Poorappetite
andsleep,hearingthevoiceofthelovedone,feelingsofguiltorthoughtsof
THOUGHTSOFSUICIDE
suicide?
Whichofthefollowingfactorshasthemostevidencetosupportitsprotective
effectinbereavementfollowingthelossofaspouse?
QUALITYOFSOCIALSUPPORTOFTHEBEREAVED
30y/optrecentlyDxw/Hodgkin’sdzconstantlystates,“Whyme?”Accordingto
ElizabethKubler-Ross,thepatient’sreactionisconsistentwithwhatphases?
SHOCKANDDENIAL
Whatisasymptomofnormalbereavementina<5y/ochildafterthedeathofa
parent?
REGRESSIONINBOWELANDBLADDERCONTROL
4monthsagothewifeofaptdiedandptblameshimselfforherdeath.Nextstep: REASSURANCE
60y/olostspouse2wksago–sadnesscomesandgoes
NORMALGRIEF
65y/optinitiallydiagnosedwbereavement.DurationofsxtodxMDD?
2MONTHS
58y/ohaveweek’sh/ointensefeelingsofsorrowandbitternessonly6mosafter
wife’sdeath.“Wewouldhavebeenmarried30yrsthismonth.”Hisdaughter
confirmedhisleveloffunctioningonlytookadipaweekago.Moderatediff
sleepingandpoorappetiteonlyassocSxs.NoSI.Physicalexamnormal.Dx:
DELAYEDGRIEF
1-monthpostdeathoflovedone.Whatwouldsuggestapathologicalgriefrxn?
CONT.FEELINGSOFWORTHLESSNESS
Riskfactorthatcanadverselyinfluencepsychoutcomeofchildafterdeathof
parent
CONFLICTUALRELATIONSHIPW/DECEASEDPARENT
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6y/ogirlhospforsurgerytorepairfracturesustainedinMVAinwhichmotherwas
injured&brotherdied.Shereportsseeingherbrotherinherroomsinceaccident, BEREAVEMENT
MSEisnml.ReceivingVicodin&Benadryl.Whatexplainsptseeingbrother?
10y/oMs/pMVAsustainedburnandcrushinjuriestoRfoot4daysago,doesnot
remembertheaccidentbutneverlostconsciousness,keepsaskingforhismother
ASAP
whowaskilledintheaccidentandhavingnightmarescryingout“Daddyhelp
Mommy.”Whenshouldthechildbetoldabouthismother’sdeath?
45y/ostillgrievingformother3yearsafterherdeath.Statesshefeelshermother
hoveringoverherandseesmotheratnight.Friendsareconcerned.Patienthas
ANTIDEPRESSANTMEDICATIONANDPSYCHOTHERAPY
normaljobfunction,cleanshouse,endorsesanhedonia.Tx?
AccordingtoHolmes&Rahe,whatlifeeventisassocwhigheststress/disruption?
DEATHOFASPOUSE
Risksofcomplicatedbereavement:
1)AMBIVALENTRELATIONSHIPTODECEASED;
2)SIMULTANEOUSGRIEVINGFORMULTIPLEDEATHS;
3)PRE-EXISTINGLOWSELF-ESTEEM&INSECURITY;
4)RECURRENTMAJORDEPRESSION
65y/optwMDDhasdiedbysuicide.Pthadreceivedtxfromsamepsychiatristx5
CONCENTRATEONADDRESSINGTHEFEELINGSOFTHESPOUSE
yrs.Psychiatristcontactsthept'sspouse.Bestwaytocommunicatethis?
Whichofthefollowingispredictiveofbetteradaptationinbereavement?
FINDINGMEANINGINLOSS
Sexuality
Txofprematureejaculation(MEN)andpremenstrualdysphoricd/o(WOMEN):
(3x)
FLUOXETINE
25y/oMpthasnotedsexualarousalandevenattainederectionswhilerubbing
upagainstunsuspectingwomenonsubway.(2x)
FROTTEURISM
Ptdissatisfiedwmarriage,nosexinayeardespitehusband’sefforts,whenever
husbandtriestokisshershebecomesdisgusted,uncomfortable,anxious.Avoids
SEXUALAVERSIONDISORDER
sexbyneglectingpersonalhygiene.Inabilitytobecomearousedbyhusband
whichwasokinthepast,masturbatestoorgasm.Dx?(2x)
Whathormonelevelsurgesduringorgasm?
Oxytocin
Malephysicianrepeatedlyaccusedbyadultfemaleptsofsittingoppositethemon
hisstoolduringeyeexam,opposingkneesalternating,insuchamannerthatone FROTTEURISM
ofpts’kneestouchesphysician’scrotch.Iftrue,thisisanexampleof
Cross-dressingforthepurposeofsexualexcitementiscalled:
TRANSVESTICFETISHISM
Txfirstlinetootherwisehealthy34y/omanforprematureejaculation?
TRAININGINBEHAVIORALTECHNIQUESTODELAYEJACULATION
Recurrent,intensesexuallyarousingfantasies,urges,orbehaviorsincludingthe
useofnonlivingobjectsaremaindxfeatureofwhatd/o
FETISHISM
Psychiatrististreating23yoFwlifelonginabilitytomaintainadequatelubrication-
swellingresponseofsexualexcitementuntilcompletionofintercourse.Ptonno
SENSATEFOCUSEXERCISE
meds,doesn’tusedrugs/EtOH,hasnoothermedconditions.Mosteffectivetx?
Acoupleinpsychotherapyduetosexualdysfunctionisencouragedtoexplore
eachother’sbodiesexceptforbreastandgenitals.Whattechniqueisthis?
SENSATEFOCUSING
Whatstatementdescribesprinciplesoftxofptwsexualdysfunction?
THOROUGHMEDEVALANDTREATMENTOFANYMEDICALD/O
SHOULDBEPERFORMEDBEFOREENTERINGTHERAPY
26-year-oldfemalewithintenseburningpainwithintercourseforseveralweeks
causinghertotenseupduringpenetration.Mostappropriateaction?
REFERFORCOMPREHENSIVEGYNEXAM
25y/oMw/prematureejaculationrefusesmeds.Tx?
SQUEEZETECHNIQUE
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65y/oMwimpotence,diabetes,AFib.Psychiatristrecommendssildenafil.What
doyoutellthept?1)impotenceisduetoDM.2)erectiledysfunctionparallels
diabeticcomplications.3)sildenafilworksformajorityofpatientswDM.
SILDENAFILWORKSFORTHEMAJORITYOFPATIENTSWITH
DIABETES.
65y/optwMDDc/oanorgasmiaafterstartingtxwfluoxetine.Howtotx?
SILDENAFIL
Masturbationinadultsasviewedbycontemporarypsychiatryisbestdescribedas: PSYCHOPATHOLOGICALONLYIFITISCOMPULSIVE.
Substanceusefulformaleerectiledysfunctionwhenadministeredeither
transurethrallyorbyintracarvernosalinjection?
ALPROSTADIL
Retrospectiveinterviewswithhomosexualadultshaveestablishedthat,forthe
majority,theirsexualorientationwasself-recognizedatwhatage?
SCHOOLAGE
Transienthomosexual/heterosexualexperiencesinheterosexual/homosexual
adolescentsrespectivelyarebestunderstoodas?
NORMALEXPERIMENTATIONINSEXUALIDENTITY
Reluctancetodiscusssexissuesortakesexhistory:
PHYSICIAN'SOWNANXIETY
Sildenafilinhibitswhichenzyme?
PHOSPHODIESTERASE5
Ptusesoralsexassolesourceofsexualgratification,refusingcoitus.Diagnosis?
PARTIALISM
Psychiatristconductingindependentmedicalexamforindividual’semployerto
determinefitnesstoreturntoworkaftermedsuspensionduetosupervisory
complaintsoferraticbehavior/lapsesinjudgment.Despitehavingbeeninformed
thatresultsofexamarenotconfidential/willresultinreporttoemployer,
individualrevealsbeinghomosexual,butnothaving“comeout.”Bestwayto
handlethis?
OMITMATERIALUNLESSITISDIRECTLYRELATEDTOTHE
REPORTEDWORKPROBLEMS
Pttellsdoctor:“Ifeellikeawomantrappedinman’sbody.”Mostlikelydx:
GENDERIDENTITYDISORDER
ApatientisadmittedtoinpatientpsychunitwithSIhasmalegenitalsandbreast
implants.Alwaysidentifiedasawomanandissuicidalbecausetheycan’t
GENDERDYSPHORIA
becomeawoman.Whatisthediagnosis?
Chronicdiseasecausingprogressiveerectilefailure:
DIABETES
35y/oFreportsbeinghappilymarriedrespondswelltofluoxetinefordepression.
Onfollow-up,complainsofanorgasmia.MosthelpfulTx?
CYPROHEPTADINE
New-onsetErectileDysfunctiondespitesatisfactorysexlifew/wife.Preoccupied
w/
job,arguingmore.Normalpasthistory.Tx:
COUPLESTHERAPY(INSTEADOFSOMATICTHERAPY)
Explainspsychosexualininfantsandchildren,pairedwithrighthypothesis
COGNITIVEDEVELOPMENT–SEXUALBEHAVIORDETERMINEDBY
SELF-IMAGEANDGENDERIDENTITY
Whatdopamineagonisthasbeenusedtotreatptswitherectiledysfunction?
APOMORPHINE
Theprevalentmalesexuald/ois:
PREMATUREEJACULATION
Exogenoustestosteronemaybeusefulintreatingwhatmalesexualdisorder?
HYPOACTIVESEXUALDESIRE
Thepatternofaperson’sbiologicalsexualcharacteristicsisknownas:
SEXUALIDENTITY
Notadiagnosticcriteriaforgenderidentitydisorder:
PERSISTENTFANTASIESOFSEXUALACTIVITYWITHMEMBERSOF
THESAMESEX
Medicationtotreathypoactivesexualdesired/owhoarenotdepressed:
BUPROPION
Homosexualcouplew/sexualdysfunction.Consider:
POSSIBILITYOFLINKBETWEENPROBLEMSOFSUBSTANCEABUSE
&ACCEPTANCEOFSEXUALORIENTATION
Masturbationwithavibratorisusedfortreatmentofwhichsexualdysfunction?
FEMALEORGASMICDISORDER
Medicationeffectiveforlowsexualdesireinpostmenopausalwomen
TESTOSTERONE
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Whatdoesa15yoboymasturbateto?
Explicitsexualacts
55yroldmanreportsbeinggayhiswholelife,duringwhichphaseofhislifeheis
expectedtohaveexperiencedhisfirstsexualattractiontowardsasamesex
partner?
earlyadolescence
Miscellaneous
AmultidisciplinaryteamisroundingonaMODpatientwhohasnotbeen
progressingduetolimitedparticipationinphysicaltherapy.Internistbelievesthisis
Ensurethatteammembersmakeexplicittheirneedforhelpand
duetodepressionandwantstotransferpatienttopsychunit.Psychiatristbelieves
valueforotheropinions
patientisdeliriousandneedsfurtherworkup.Whichofthefollowingwouldmake
itmostlikelythatotherteammemberswouldspeakupandshareopinions?
Childp/wwrithingmovementsoflimbandheadturningfollowingasorethroat?
Post-streptococcussequelae
Harmreductioninterventionaltechniqueforthosewopioiddependence?
Needleexchange
AlcoholiccomestoEDwithdaysofmalaise.Flexionoftheneckworsenspain.Pt
hasBLVInervepalsy.Spinalfluidanalysisshowsprotein233,glucose25,and135
nucleatedcells(43%PMN,47%lymphocytes).Likelyetiology?
WHOprioritizationofwhathascausedimprovedlifespaninlow&middleincomecountries?
MycobacteriumTB
Trainnon-specialistproviderstoidentifyandtreatmental
illness
72y/olegallyblindpt(2/2maculardegeneration)withVHandw/oanyother
psychotic,cognitiveandmoodd/o.(2x)
CHARLESBONNETSYNDROME
Adoptiveparentsofachildwhosebirthmotherdiedfromsuicideareasking
aboutthechild’srelativeriskforfuturesuicidalbehavior.Bestresponse?(2x)
THECHILD’SRISKOFCOMPLETEDSUICIDEISELEVATED
RELATIVETOOTHERADOPTEES
18y/oMptisbroughttotheERw/suddenonsetofanxiety.Ptreportssuddenly
experiencingapoundingheartbeat,SOB,chestpain,andpalpitationslasting1hr.
PAROXYSMALATRIALTACHYCARDIA
Onexampulseis200andbloodpressureis90/60.Ptisinstructedtoperforma
Valsalvamaneuverandheimproves.Diagnosis?(2x)
1stethicaldirectivedevelopedafterWorldWarIItoprotecthumansubjectsin
researchwascalled:(2x)
NIMHfoundedduringperiodofTherapeuticoptimism
NUREMBERGCODE
TreatmentofsoldiersduringWorldwarII
Thepsychiatricassessmentofachildoradolescentshouldalwaysinclude:(2x)
PARENTALINTERVIEW
Whatsignifiestheabilitytoshiftbackandforthbetweengeneralconceptsand
specificexamples?(2x)
ABSTRACTREASONING
Treatmentforapathywithoutaccompanyingdepression,whichalsohasbeen
knowntoprecipitateaticdisorder:(2x)
METHYLPHENIDATE
Twowksafterbeginningastrictdiet,a24y/opatienthasabdominalandlimb
pain.Heisanxious,paleandtachycardiaonexam.Unabletoorientandseemsto ACUTEINTERMITTENTPORPHYRIA
berespondingtohallucinations.Thishappenedinthepast.Dx?(2x)
72y/olegallyblindpt(2/2maculardegeneration)withVHandw/oanyother
psychotic,cognitiveandmoodd/o.(2x)
CHARLESBONNETSYNDROME
TreatmentwiththiscanmaskB12deficiencybynormalizingmacrocyticanemia
FOLICACID
Remindingpatientstogetflushots:typeofprevention?
PRIMARYPREVENTION
Whenusinganinterpreterduringtheinterviewofanimmigrantpatient,whatis
mostimportant?
USINGYOUINSTEADOFHEORSHE
Psychoeducationprovidedafterthefirsthospitalizationofnewdiagnosed
schizophreniawouldincludeteachingthefamily,patientwhat?
IMPORTANCEOFTAKINGMEDS
Absolutecontraindicationtosildenafil
SUBLINGUALNITROGLYCERIN
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Impairedphysicianfailstoobtain/benefitfromtreatmentmayrequireevalfrom
administrativepsychiatrist.whatisdifferentaboutadministrationalpsychiatrist
comparedtotypicalpsychiatrist?
NOTBOUNDBYUSUALPARAMETERSOFCONFIDENTIALITY
Goalofwrap-aroundservicesofC&A
PREVENTHOSPITALIZATIONORRESIDUALPLACEMENT
Whatisthemostsignificantchallengetotheclinicalapplicationoftheanalytic
theoryoflibidinalstagedevelopment?(2x)
STAGESAREMOREFLUIDANDLESSSTRICTLYSEQUENTIALTHAN
THETHEORYSUGGESTS
ImmanuelKantcontributedwhichdevelopmentofpsychiatry?
PHILOSOPHICALFOUNDATIONSFORCLINICALETHICS
32y/optwithhxoftreatment-resistantdepressionpresentstoEDBIB-familyafter
ODonimipramine.Ptswallowedpills,changedhermindandaskedforhelp.Pt's
outptpsychiatristhadrecentlyaddedImipraminetotheptsfluoxetine80mgdaily.
Ptisafebrile,BP100/58,HR96andregular.Ptisvagueregardingsuicideattempt TRANSFERPTTOAPSYCHUNITFORINVOLUNTARYDETENTION
andstatesshenolongerwantstodie.EDwantstoadmittopsych,psychstatesthe
ODattemptwasnotlethalandnotcardiotoxicperpt’sreportofhowmanypills
shetook.Whatisthebestcourseofactionforthepsychiatristtofollow?
Screeningbloodtestina72yoptadmittedforbehavioraloutbursts,progressive
cognitivedeclineandataxiarevealapositiveserumvdrl.Familymemberscannot
eliminatethepossibilitythattheptwasexposedtosyphilis.Thepthashada
historyofallergicreactiontopenicillin.Whichofthefollowingisthemost
appropriatenextstep?
OBTAINCSFFORFT-ABS
80y/optwithbipolard/ostableonLithiumforyears,recentlygotstartedona
new
THIAZIDEDIURETIC
med.Theptnowhastremulousness,dystonia,hyperreflexia,ataxia,andconfusion.
Whichmedmightbecontributingtopt’spresentation
A45yomanbelieveshehasgastriccancer,andreportsindigestionandreflux.The
patientfindshimselfsodistressedwiththisthoughtthathehasbeenhaving
REFERFORFURTHERMEDICALEVALUATION
problemsathomeandatwork.Whichofthefollowingwouldbethemost
reasonablestrategyforapsychiatristtoconsiderwhentreatingthispatient?
Gestationalinsufficiencyofwhichhormonehasbeenassociatedwithdevelopment
of
THYROID
severeintellectualdisability?
Mostcommoncauseofbraintumorina65yr-oldM?
METASTATICLUNGCARCINOMA
36Fwitheasyfatigue,weightloss,cravingsalt,nausea,hyperpigmentation,and
musclecramps.Ptnotedtohaveamoddepressedmoodandappearsapathetic.
Dx?
ADRENALCORTICALINSUFFICIENCY
Long-termnursinghomecareintheU.S.isprimarilyfundedbywhatentity?
MEDICAID
CNSresponsestofearstimuliaremediatedchieflythrough?
CENTRALNUCLEUSOFAMYGDALA
28y/ofemalewsorethroat,muscle/jointpain,HAs,poormemory,poorsleep.
Takes
1daytophysicallyrecoverafternormalexertion.Flu6monthsago.Nofamily
historyofdepression.NoSI.Diagnosis:
CHRONICFATIGUESYNDROME
IgGelevatedinCSFandserumismostconsistentwithwhichillness?
SARCOIDOSIS
35y/ofemalefailedseveralantidepressanttrialsforMDD,referredtospecialty
mood
ECCHYMOSES
clinic.Clinicianobservesobesity,acne,andhirsuitism.Whatfindingwouldincrease
suspicionforCushingsyndrome?
Infectiousneuropsychiatricd/o,characterizedbypsychosisandabnormalgait,that
wasoncetreatedwithmalaria-inducedfeverandaccountedforup20%ofptsin
SYPHILIS
mentalasylumsuntil1940s:
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Trackingptsatisfactionforaccreditingagenciesischaracterizedaswhichtypesof
administrativeactivity?
CONTQUALITYIMPROVEMENT
Forptswholackdecision-makingcapacity,physicianshaveabeneficence-based
obligationtodowhichofthefollowing?
•Hospitalizept
•Applyforcourt-orderedtx
•Designateptasfullcode
•Seekdecision-makingsurrogates
•Delivertxinpt’sbestinterests
DELIVERTXINPT’SBESTINTERESTS
TheTuskegeesyphilisstudyviolatedcurrentethicalprinciplesofresearchinthe
selectionofparticipantsand…
RISK:BENEFITRATIOFORPARTICIPATINGINTHESTUDY
A75y/omanandhis72y/owifepresentrequestingmaritaltherapy.Theydescribe
increasingconflictbeginningaboutadecadeagowhenthewifebeganrefusing
sexualactivity.Husbandexplainsthathestilldesiresanintimaterelationshipandis
frustratedandhurt.Thewifeexplainsthataftermenopauseshecouldnot
SEXEDUCATION
understandherhusband’sdesire.Shesuggestshefind"someyoungerwoman."He
isinsultedbecausehedoesnotwanttostrayfrommarriage.Theinitialtreatment
approachshouldfocuson:
PhilippePinel’sATreatiseonInsanitydescribedanewapproachtotreatingthe
institutionalizedmentallyillthatfocusedongeneratingatherapeuticenvironment.
MORALTREATMENT
Ptswerepersuadedtofollowadailyschedulethatincludededucationand
occupationalactivities.Thisapproachwastermedwhichofthefollowing?
Psychiatristvoicemailmessagewhileonvacationshouldclarifyhowtomanage
urgentbutnotemergentclinicalmatter
Callthearrangedclinicalcoverage
MelanieKleindifferedfromFreudinheremphasison:
EARLYOBJECTRELATIONS
Whichisparaamnesia?
DEJAVU
Dysfunctionofwhichisspecificallyimplicatedinthepathophysiologyof
narcolepsy?
HYPOCRETIN
19yoptatedw/lossofvisionw/oothersyx.H/osevererecurrentabdpain.1yago
pthadepisodeoflhemiparesis.Inrecentwkspthadepisodesoftransientvisual
blurring/lossspontaneouslyresolved.Physicalshowsblcorticalblindness,mild
SICKLECELLDISEASE
pronationoflue,mildblspasticity,hyperreflexia,extensorplantarresponsesbl.No
sensorychanges.Dx?(cerebralangioandmriimagesnotincluded)
AccordingtoAPAguidelines,sexualrelationshipswithptsare
NOTALLOWEDWITHCURRENTORFORMERPTS
Barriertobroaderuseoftelepsychiatry
PSYCHIATRISTSHAVEBEENRELUCTANTTOUSETHISMODEOF
CAREPROVISION
AccordingtoAPAguidelines,whatistheplaceofexpertopinioninevidence-based
RANKSASEVIDENCECOMPARABLETOCASESTUDIES
medicine?
Whatisaneologism?
PATIENTMAKESUPAWORD
In“splittreatment,”theroleoftheprescribingpsychiatrististo:
EVALUATEPT’SNEEDFORMED&PRESCRIBEACCORDINGLY
WHILEMAINTAININGREGULARCONTACTWTHERAPIST.
10y/ogirlw/hepBisevaluatedforpersistentdifficultyw/schoolworksince1st
grade.Oftenlooseshomework,seemsnottolistentoparentsorteachers.If
neededtreatmentwhatwillyougive?
METHYLPHENIDATE
Initialpharmacologicaltherapyforchildwithhighenergy,impulsivity,ashortfuse
METHYLPHENIDATE
whenfrustrated,frequentangryoutbursts,andcarelesshomeworkmistakes.
Stockholmsyndromeisdefinedas:
DEVELOPMENTINHOSTAGESOFPOSITIVEEMOTIONALFEELINGS
TOWARDCAPTORS
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WhichSxscommoninptafteranabolicsteroiddiscontinuation?
DEPRESSION
WhichofthefollowingstatementsreflectstheAPApositionstatementon
reparativeconversiontherapyforgayandlesbianindividuals?
ITISCONSIDEREDUNETHICALBECAUSEHOMOSEXUALITYISNOT
CONSIDEREDAMENTALDISORDERANDHARMOFTENCOMES
FROMSUCHTREATMENT
Empiricalstudiesofthediagnosticpsychiatricinterviewprocesshavesuggested
thatthemostcomprehensiveandaccurateinformationiselicitedbywhichofthe
followingapproaches?
FOCUSEDINTERVIEWING,ELICITINGDETAILSOFTHECHIEF
COMPLAINTANDTHENANINVENTORYOFSYMPTOMS
Whichofthefollowinginstrumentswouldbemostappropriatetomeasurethe
intensityofpaininyoungchildren?
FACESSCALE
PsychMDisattendingaseminarwhenacolleaguestates,“Iheardyouaretreating
“YOUKNOW,FORCONFIDENTIALITYPURPOSESICAN’TREVEAL
Mr.X.Iamsogladtohearit,becauseIknowhe’sbeenhavingalotoftroubleandI
WHOISEEORDON’TSEE.”
amsurethatyoucanhelphimalot.”Mostappropriateresponse?
PsychMDwhoisconductingindividualpsychotherapywithapt,andfamilytherapy
AVOIDINGDUALRELATIONSHIPS.
withtheptandfamilyisatrisktoviolatetheethicalguideline:
PsychMDacceptsagiftfromapharmaceuticalcompanythatmakesan
THEGIFTCONTRIBUTESTOTHEPSYCHIATRIST’SEDUCATIONOR
antidepressantmedication.Thisisconsideredethicalunderwhichofthefollowing
CAREOFPATIENTS
circumstances?
IntheUS,mostneedsofdependentelderlypatientsarefulfilledbywhichofthe
followingindividualsoragencies?
ADULTCHILDREN
Whichofthefollowingisthemostcommonreasonforpsychiatricconsultreferral
ingeneralmedicalandsurgicalpatients?
DEPRESSION
Themostprominentlobbyingandsupportorganizationforfamiliesofpeoplewith
NATIONALALLIANCEFORTHEMENTALLYILL(NAMI)
severepsychiatricdisordersisthe:
Nephrologistsmostcommonlyrequestpsychconsultonpatientswithendstage
renaldiseaseforwhichofthefollowingconditions?
NONCOMPLIANCE
Whichofthefollowingfamilialeffectsfalselyinflatesestimatesofheritability?
SHAREDDEVELOPMENTALENVIRONMENT
Aresidentisaskedbyhisprogramtotakealeaveofabsenceduetoerratic
behaviorandmustundergoapsychiatricevaluationbeforereturning.What
statementbestdescribestheobligationoftheexaminingpsychiatricMD?
STATECLEARLYTOPTPRIORTOEVALUATIONTHEPURPOSEOF
THEEVALUATIONANDTHATTHEINFORMATIONMAYBE
TRANSMITTEDTORESIDENCYPROGRAM.
Psychiatristwhodoesnotnormallytakephonecallsduringtherapysessionshasan
emergencycallputthrough30minutesintoa50minutesessionwithapt.The
OFFERTORESCHEDULETHEPT’SSESSION,ANDNOTCHARGE
psychiatristapologizes,explainsthatitisanemergencythatcannotwait,andasks
FORTHISONETHATWASINTERRUPTED.
thepttositinthewaitingroomuntilthecallisfinished,whichturnsouttobe15
mins.Nextstep:
Unmarriednulliparouswomanparticipatesactivelyinrearingofhersiblings.
KINSELECTION
AccordingtoDarwiniantheory,suchaltruisticbehaviorexplainedbywhatconcept?
WhichofthefollowingdidKurtSchneiderconsidertobeafirst-ranksymptomof
schizophrenia?
VOICESARGUING
Ptreceivingapsychiatricexaminationtodeterminesuitabilityforajobmustbe
informedthat:
EXAMINATIONISNOTCONFIDENTIAL
Recurrent,intensesexuallyarousingfantasies,urges,orbehaviors,includingthe
useofnonlivingobjects,arethemaindiagnosticfeatureofwhichdisorder?
FETISHISM
Apreviouslyhealthy65yopatientpresentstoapsychiatristwithnew-onsetAH.
Thepsychiatricevaluationofthispatientshouldinitiallyfocusonuncovering:
ANUNDERLYINGMEDICALCONDITION
Whichofthefollowingmostaccuratelydescribesanimportantcharacteristicof
friendshipsduringmidlife?(x2)
ARELESSDEPENDENTONBEINGCLOSEINAGE
GeneticsyndromeconsideredtobeaneurodevelopmentalmodelforAlzheimer
disease?
DOWNSYNDROME
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Whatoverdosecausesringingintheear,abdominalpainandmetabolicacidosis?
ASPIRIN
Whichofthefollowingabnormalelevatedmetabolicfindingshasbeenassociated
withincreasedriskofstrokeinptsundertheageof50?
PLASMAHOMOCYSTEINE
Ptisadmittedtothehospitalforrenaltransplantrejection.Priortothis,thepthad
beendoingwellsincethetransplantoneyearagotheptreportscompliancewith
theimmunosuppressiveregimen,butbloodlevelsofcyclosporinearelow;
SERTRALINE/NORTRIPTYLINE/VALIRANAOFFICINALIS/S-
previously,thecyclosporinelevelswerewithinthetherapeuticrange.Thept
ADENOSINYLMETHINONINE(ALLOFTHEABOVE)
reportsrecentlystartingonapilltotreatdepressionandanxiety,butdeniesany
othermedicationchangesornewhealthconditions.Whichistheptmostlikely
taking?
Whichofthefollowingtherapisttechniquesaremorecommonlyemployedin
grouptherapycomparedtoindividualpsychotherapies
TRANSPARENCNYANDSELFDISCLOSURE
Self-disclosurebytherapistmaybeappropriateinordertodowhat?
MODELAPPROPRIATEBEHAVIORANDFOSTER
THERAPEUTICALLIANCE
Followingtheinitiationofpost-transplantmedications,aptwhowashospitalized
forakidneytransplantbecametremulousandhighlyanxious,hadtroublespeaking
CYCLOSPORINE
andshowedsignsofpsychosiswithhallucinations.Whichofthefollowing
medicationsismostlikelytohavecausedthechangeinthepatient’sstatus?
Terminallyillcancerpatientswhoexperienceconcernsabouta“baddeath”are
mosttypicallyworriedaboutdyinghow?
INPAIN
60-year-oldptwithliverdzpresentswithconfusion.Onexampthasasterixisof
handsandhaselevatedserumammonialevel.EEGislikelytoshow:
BILATERALTRIPHASICWAVES
Apsychisaskedtoseeageneralmedicalinptforreportedhypochondriasis.Which
MEDICALCONDITION
ofthefollowingisthemostimportantdifferentialdiagnosticconsideration?
Recommendedprocedureforpatienthandoffbetweenresidents?
INCLUDESSUMMARYOFTREATMENTCOURSEANDRISK
ASSESSMENT
65-yearoldptwithhxofMDD,hyponatremiaandlethargyisinneedofananti-
hypertensivemed.Whichofthefollowingwouldbethesafestmedtotrygiventhe ATENOLOL
pt’shistory?
Whichofthefollowingisthecorestrategywheninitiatingtreatmentofhostilept
ACKNOWLEDGE&VALIDATETHEPATIENT’SAFFECT
17yoisabletocompleteADLsbyhimselfbutrequiressomesupervision.Livesin
grouphome,empliotedasgrocerystoregreeterundersupervisionofanother
employee,academicskillsofa2ndgrader.whichclassificationbestrepresentsthe
levelofintellectualdisability
Associationb/wBetablockeranddepression
NOASSOCIATIONSUPPORTED
ChangesinCSFinptswithIED
DECREASED5HTLEVELS
Frequentepisodesoffallingasleepduringdailyactivityisassociatedwithwhichlab
DECREASEDCSFHYPOCRETIN
finding
Bipolarpatientstableonlithiumdevelopstremors,confusion,dysarthriaand
elevatedlithium.Whatmedicationcancausethis?
Patientinsupportivepsychotherapyrequestingfriendshipoftreatingpsychiatrist
viapersonalfacebook
Beststrategytomaximizethenumberofcontributionfromseveralresidentsthat
wanttocontributetobuypizzafortheirmeeting
THIAZIDEDIURETIC
Discussboundaries
Arrangeameetingthatincludesallclubmemberstodiscuss
thisplan
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HistoryofPsychiatry
Whonotedthatmajormentalillnesseshavedifferentcoursesandoutcomes;
Andalsodifferentiatedbetweendementiapraecoxandmanic-depressiveillness? EMILKRAEPELIN
(5x)
PhineasGage,whohadanironbarshotthroughhisskullinanexplosionin1848
andsubsequentlyshowedprofoundchangesinbehavior,isstillofinteresttoday MODERATE
becauseofitsimplicationsfor(4x)
Whichindividualcoinedtheterm“schizophrenia”andintroducedtheterms
“ambivalence”and“autism”?(3x)
EUGENEBLEULER
Whocharacterizedmentalillnessbasedupontheinteractionofthefourhumors?
HIPPOCRATES
(2x)
Explicitdxcriteria&multiaxialsystemwereintroducedinwhatDSMedition?
(2x)
DSM-III
9y/ochildbangshishandonsofttoy,settingupsteadyrhythm&smilingw
pleasure.Motherfallsintohisrhythm&says“Kaaa-bam,kaaa-bam,”with“bam”
ATTUNEMENT
fallingonthestroke&“kaaa”accompanyingupswingofthearm.Thisisexample
of:(2x)
TheapproachtodiagnosisthathasbeentakenincurrenteditionsoftheDSMis
consideredtogrowfromandbeclosesttothatofwhom?
EMILKRAEPELIN
Whenpublishedin1980,DSM-IIIrepresentedasignificantdeparturefromearlier
editionsofDSMincludingtheintroductionofwhichofthefollowing?
•Prototypicaldescriptions
•Dimensionalclassification
•Descriptivediagnosticcriteria
•Broaddefinitionofschizophrenia
DESCRIPTIVEDIAGNOSTICCRITERIA
WhodevelopedMoralTreatment?
PHILLIPEPINEL
Developedinterpersonaltheoryofpsychiatry
HARRYSTACKSULLIVAN
Whocoinedtheterm"contactcomfort"anddemonstratedthatnewbornRhesus
monkeysseparatedfromtheirmotherschosecontactcomfortoverfoodand
water?
HARRYHARLOW
DSMIIIdiagnosticliabilitywasachievedbystandardizing
DIAGNOSTICCRITERIA
In1935DrBobSmithasurgeonwalcoholismmetandwashelpedbyanindividual
seekingsupportforabstinenceformEtOHwhiletravelingforbusiness.Thesetwo BILLWILSON
areconsideredthefoundersofAlcoholicsAnonymous.Whoistheotherperson?
Whichindividualarticulatedatheoryofpsychosocialdevelopmentalphases
accordingtoapredeterminedsequence?
ERIKERIKSON
Whoestablishedthatlearningproduceschangesattheneuronallevel,inturn
facilitatedbyalterationsingeneexpression:
ERICKANDEL
Atherapistconceptualizespatients’depressionasrelatedtoguiltathavingacted
harmfullytowardlovedones.Whichtheoristmostlikelyinfluencedthistherapist:
MELANIEKLEIN
AccordingtoKlein,apersonwhoiscomfortableaccepting“thegoodwiththebad”
DEPRESSIVE
inrelationshipshasreachedwhichofthefollowingpositions?
AnnaFreud’scontributiontochilddevelopmentbasedonconceptualizing:
DEVELOPMENTALLINESIN6AREASOFADAPTIVEFUNCTIONING
DSMIIcalledDysthymicdisorderaswhat?
DEPRESSIVENEUROSIS
Caregiver’sattemptstounderscorechild’sfeelingstate(Stern)
ATTUNEMENT
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Whichofthefollowingmajorworldeventsimmediatelyprecededandhelpedto
shapethecontentofDSM-I?
WORLDWARII
Whomonitorsphysicianswithsubstanceabuseissues?
STATEMEDICALBOARDANDSTATEPHYSICIANHEALTH
PROGRAMS
Ptreportsassassinsenterroom,rapeandthreatenhereverynight.Reports"police "WELL,FROMWHATYOUARETELLINGMEITSOUNDS
thinkI'mmakingitup,youbelievemeright?"Whatismostappropriateresponse? TERRIFYING"
TheFeighnercriteriainitiatedaparadigmshiftinAmericanpsychiatry'sapproach
todiagnosingmentalillnessbecause?
APPLIEDOPERATIONALCRITERIATOPSYCHIATRICDISORDERS
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