REVIEW 3 SOMATIZATION AND RELATED DISORDERS SOMATIZATION AND RELATED DISORDERS

SOMATIZATION

▸ Psychological problems or concerns that are converted into and communicated as physical distress

▸ is either Conscious or Unconscious

▸ Physical Illness is Real SOMATIZATION AND RELATED DISORDERS - SSD

SOMATIC SYMPTOM DISORDER

A. One or more somatic symptoms that are distressing or result in significant disruption of daily life

B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following

1. Disproportionate and persistent thoughts about the seriousness or one’s symptoms

2. Persistently high level of anxiety about health or symptoms

3. Excessive time and energy devoted to these symptoms or health concerns

C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months) SOMATIZATION AND RELATED DISORDERS - SSD

TREATMENT

▸ Regular office visits with the same physician

▸ Psychotherapy

▸ Validate the patient’s feelings/experience of symptoms SOMATIZATION AND RELATED DISORDERS - ILLNESS ANXIETY DISORDER

ILLNESS ANXIETY DISORDER

A. Formerly hypochondriasis

B. Preoccupation with having or acquiring a serious illness

C. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (strong FH), the preoccupation is clearly excessive or disproportionate

D. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status (preoccupation with idea one is sick)

E. The individual performs excessive health-related behaviors (checking body) or exhibits maladaptive avoidance (avoids doctors)

F. Illness preoccupation present for at least 6 months

G. Illness preoccupation not better explained by another mental disorder SOMATIZATION AND RELATED DISORDERS - ILLNESS ANXIETY DISORDER

TREATMENT

▸ Cognitive Behavioral Therapy

▸ Medication

▸ SSRI (may help) SOMATIZATION AND RELATED DISORDERS - CONVERSION

CONVERSION DISORDER “FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER”

A. One or more symptoms of altered voluntary motor or sensory function

B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions

C. The symptoms or deficit is not better explained by another medical or mental disorder

D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

E. Primary Gain SOMATIZATION AND RELATED DISORDERS - CONVERSION

TREATMENT

▸ Psychotherapy

▸ Medications

▸ Treating comorbid anxiety and

▸ Physical therapy SOMATIZATION AND RELATED DISORDERS - FACTITIOUS DISORDER

FACTITIOUS DISORDER (IMPOSED ON SELF)

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception

B. Individual presents to others as ill, impaired, or injured

C. Deceptive behavior is evident even in the absence of obvious external rewards

D. Behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

E. Secondary Gain SOMATIZATION AND RELATED DISORDERS - FACTITIOUS DISORDER

FACTITIOUS DISORDER (IMPOSED ON ANOTHER)

A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception

B. Individual presents another individual (victim) to others as ill, impaired, or injured

C. Deceptive behavior is evident even in the absence of obvious external rewards

D. Behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder

E. Secondary Gain DEFENSE MECHANISMS DEFENSE MECHANISMS

BECOMING A SELF

▸ Mimicry: imitation of another’s behavior

▸ Introjection: a loved or hated person, or part of a person, is incorporated into one’s self, but retains the identify of the original person

▸ Identification: taking over of attitudes and behaviors of significant others, and experiencing those attributes as part of one’s own identity DEFENSE MECHANISMS

IMMATURE DEFENSES

▸ Repression ▸ Intellectualization

▸ Denial ▸ Isolation

▸ Displacement ▸ Splitting

▸ Reaction Formation ▸ Projective Identification

▸ Projection

▸ Rationalization DEFENSE MECHANISMS - IMMATURE

REPRESSION ▸ Involuntarily withholding an idea of feeling from conscious awareness

▸ A 20-year-old does not remember going to counseling during his parents’ divorce 10 years earlier.

DISPLACEMENT ▸ Redirection of emotions or impulses from original subject to a neutral, more acceptable, substitute

▸ A teacher is yelled at by the principal. Instead of confronting the principal directly, the teacher goes home and criticizes her husband’s dinner selection. DEFENSE MECHANISMS - IMMATURE

REACTION FORMATION ▸ Replacing a warded-off idea or feeling by an (unconsciously derived) emphasis on its opposite

▸ A patient with sexual thoughts and fantasies enters a monastery

PROJECTION ▸ Attributing to others one’s own unacceptable impulses, thoughts, and desires

▸ A patient with sexual thoughts and fantasies enters a monastery DEFENSE MECHANISMS - IMMATURE

RATIONALIZATION ▸ Proclaiming logical, socially approved reasons for our past, present, or proposed behavior.

▸ After getting fired, the patient explains that “the job was not important anyway”

INTELLECTUALIZATION ▸ Using facts and logic to emotionally distance oneself from a stressful situation

▸ In therapy, a patient who has cancer only focuses on the survival rates of their particular cancer. DEFENSE MECHANISMS - IMMATURE

ISOLATION ▸ Separating feelings from ideas and events

▸ A patient describes a murder in graphic detail without any emotional content.

SPLITTING ▸ Perceiving oneself or others as either all good or all bad, rather than experiencing ambivalently (good and bad)

▸ A patient praises the doctors for being the best on the inpatient unit, and states that the outpatient providers are horrible, the worst. DEFENSE MECHANISMS - IMMATURE

PROJECTIVE IDENTIFICATION ▸ A person induces, by projection, their own feelings in another person, and that person unknowingly acts out those feelings.

▸ A friend is upset because they believe that they have put on weight, and projects those feelings onto you asking, “Have you put on weight?” After this comment you become concerned about your own weight and start believing you have put on weight (when in fact you have not). DEFENSE MECHANISMS

MATURE DEFENSES

▸ Suppression

▸ Sublimation

▸ Humor

▸ Altruism DEFENSE MECHANISMS - MATURE

SUPPRESSION ▸ A deliberate, conscious effort to control and conceal disturbing thoughts, feelings or acts.

▸ A student who is worried about a championship game, consciously chooses to not worry about it until it is time to play.

SUBLIMATION ▸ Diverting basic drives or impulses into socially appropriate channels.

▸ A frustrated medical student channels his anger and negative emotions into sporting events and home improvement projects. DEFENSE MECHANISMS - MATURE

HUMOR ▸ Seeing the funny side of situations as a means of diffusing negative affects such as anxiety.

▸ A medical student who found out they failed the Step exam, texts friend meme to alleviate the stress and anxiety of the situation. ALTRUISM ▸ Taking a negative experience and turning it into a socially positive one.

▸ A patient who has been in a deadly motor vehicle accident as a teen, spends many days advocating for safe driving amongst high school students. PERSONALITY DISORDERS PERSONALITY DISORDERS

ATTACHMENT TYPES

▸ Secure Attachment

▸ Insecure - Ambivalent Attachment

▸ Not engaged in caregiver, angry and cannot use the contact to comfort during the reunion

▸ Inconsistent caregiver

▸ Insecure - Avoidant Attachment

▸ Not engaged in the caregiver, the reunion is not effective

▸ Insecure - Disorganized Attachment

▸ Uncertain, disorganized response to caregiver leaving (ambivalent extreme) PERSONALITY DISORDERS

PERSONALITY DISORDER

▸ Personality patterns that are so inflexible and pervasive that they become maladaptive and cause significant impairment in function or subjective pain and distress

▸ Onset: Adolescence

▸ Course: Persistent through Adulthood

▸ Clusters

▸ A: odd or eccentric

▸ B: dramatic, emotional, erratic

▸ C: anxious or fearful PERSONALITY DISORDERS

CLUSTER A “WEIRD” - ACCUSATORY, ALOOF, AWKWARD

▸ Paranoid (Accusatory)

▸ Pervasive distrust, suspiciousness and unwarranted tendency to interpret people’s actions as deliberately demeaning or threatening.

▸ Schizoid (Aloof)

▸ Pervasive pattern of detachment from social relationships and a restricted range of emotional experience and expression.

▸ Schizotypal (Awkward)

▸ Pervasive pattern of detachment from social and interpersonal deficits as well as cognitive or perceptual distortions and eccentricities of behavior.

▸ Magical Thinking PERSONALITY DISORDERS

CLUSTER B “WILD” - BEST, BAD, BORDERLINE, FLAMBOYANT

▸ Narcissistic (Best)

▸ Pervasive pattern of grandiosity, in fantasy or behavior, need for admiration and lack of self-esteem

▸ Antisocial (Bad)

▸ Pervasive pattern of disregard for and violation of the rights of others occurring since age 15 in someone at least 18 (criminals)

▸ Borderline

▸ Pervasive pattern of instability of affect, interpersonal relationships, and self-image, and marked

▸ Histrionic (flamBoyant)

▸ Pervasive pattern of excessive emotionality and attention seeking PERSONALITY DISORDERS

CLUSTER C “WORRIED” - COWARDLY, CLINGY, COMPULSIVE

▸ Avoidant (Cowardly)

▸ Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

▸ Dependent (Clingy)

▸ Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation

▸ Obsessive (Compulsive)

▸ Pervasive pattern of preoccupation with orderliness, perfectionism and mental and interpersonal control at the expense of flexibility, openness, and efficiency CHILD PSYCHIATRY CHILD PSYCHIATRY

CHILD PSYCHIATRY ▸ Children are NOT Small Adults

▸ Development

▸ Neurologic (prefrontal cortex fully developed at 25)

▸ Metabolic (body fat and metabolism (medications))

▸ Environment

▸ Confidentiality

▸ Young Children: Parent present

▸ Adolescents: information is private (not shared with parents)

▸ Breach: suicidal, homicidal, substance abuse

▸ Always report neglect and abuse CHILD PSYCHIATRY - DEPRESSION AND ANXIETY

DEPRESSION & ANXIETY IN CHILDREN & ADOLESCENTS

▸ Depression

▸ Presentation: irritable mood > depressed mood

▸ Treatment:

▸ Include family, school, etc.

▸ CBT

▸ Medications: SSRIs have Black Box Warning for increasing risk of suicide in individuals under age 25

▸ Acute Anxiety ()

▸ NOT treated with CHILD PSYCHIATRY - LEARNING AND INTELLECTUAL DISABILITIES

INTELLECTUAL DISABILITY AND LEARNING DISABILITY

▸ Intellectual Disability

▸ Deficits in Intellectual or Adaptive Functioning

▸ Reasoning, problem solving, planning, abstract thinking, judgment, academic learning, learning from experience, conceptual, social and practical domains

▸ Learning Disability

▸ Specific Deficits in Reading, Writing, or Mathematics

▸ May occur in isolation or in combination CHILD PSYCHIATRY - ASD

AUTISM SPECTRUM DISORDER (ASD) DSM5 A. Persistent deficits in social communication and social interaction across multiple contexts

1. Social-emotional reciprocity

2. Non-verbal communication

3. Impairment in developing, maintaining, and understanding relationships

B. Restricted, repetitive patterns of behavior, interests, or activities manifested as the following:

4. Stereotyped/repetitive motor activity/speech

5. Inflexible adherence to routines, sameness

6. Highly restricted, fixated interests

7. Hyper-/hypo-reactivity to sensory input

C. Symptoms present in early development

D. Persistent and significant impairment

E. Not better explained by intellectual disability or global developmental delay

‣ Specify Level, Impairment, Related Condition or Factor, Catatonia

ASD LEVELS OF IMPAIRMENT Level 3: Most Severe

▸ Social communication severely impaired, so inflexible that functioning is impaired in all areas of life

▸ Substantial Support Required

Level 2:

▸ Social communication limited, behavior is inflexible enough to be observed by bystander

▸ Support Required

Level 1: Least Severe

▸ Social communication awkward, inflexibility more limited to switching between activities and organizing/planning

▸ Support May be Required AUTISM

OTHER KEY FEATURES OF ASD

▸ Ridged Routines

▸ Interest in a part of an object, not the whole object

▸ Watching a scene over and over

▸ Not a complete show or series

▸ Textural Sensitivities

▸ Tight clothing

▸ Indifference to Pain or Temperature AUTISM

SOCIAL COMMUNICATION DISORDER

▸ Persistent difficulties in the social use of verbal and nonverbal communication, including:

▸ Communication for Social Purposes

▸ Contextual Changes

▸ Following / Cues for Conversing

▸ Making Inferences

▸ No history of restricted, repetitive behavior AUTISM

THERAPY BASED TREATMENT ▸ Social Treatments:

▸ Speech and Language Therapy, OT, and Social Skills Training

▸ Special Education (IEPs, integrated vs. inclusion, dedicated schools)

▸ Caregiver Supports

▸ Psychological Treatment:

▸ Applied Behavior

▸ “Simple” Rewards / Consequences

▸ Parent Training

▸ CBT AUTISM

MEDICATION BASED TREATMENT

▸ (Risperdal) and (Abilify)

▸ Approved for “Irritability associated with Autistic Disorder”

▸ Anecdotal data for other antipsychotics, anti-manic agents, SSRIs, , alpha-2 agonists,

▸ Benzodiazepines and anticholinergic medications often disinhibiting CHILD PSYCHIATRY - ADHD

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

A. Persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development

1. Inattention Symptoms (more than 6 if patient is before age 16, or more than 5 if patient is above the age of 17)

2. Hyperactivity - Impulsivity Symptoms (more than 6 if patient is before age 16, or more than 5 if patient is above the age of 17)

B. Several symptoms were present before age 12.

C. Symptoms present in multiple settings (school, home, places of worship, etc).

D. Normal intelligence, but commonly coexists with difficulties, reduced functionality in school, work, home. CHILD PSYCHIATRY - ADHD

INATTENTION SYMPTOMS OF ADHD

▸ Fails close attention to details

▸ Makes careless mistakes

▸ Trouble focusing on tasks or play activities

▸ Does not listen when spoken to

▸ Trouble organizing

▸ Easily distracted

▸ Forgetful in daily activities (loses things)

▸ Difficulty following through on instructions

▸ Difficulty finishing work (home, school, work)

▸ Reluctant to do tasks that require increased effort over longer time CHILD PSYCHIATRY - ADHD

HYPERACTIVITY AND IMPULSIVITY SYMPTOMS OF ADHD

▸ Fidgets, taps hands or feet, squirms in seat

▸ Leaves seat often when should be seated

▸ Runs or climbs when not appropriate

▸ Unable to play or take part in activities quietly

▸ Driven by a motor

▸ Talks excessively

▸ Trouble waiting turn

▸ Blurts out answer

▸ Intrudes and interrupts others CHILD PSYCHIATRY - ADHD

ATTENTION DEFICIT HYPERACTIVITY DISORDER

▸ Specifiers

▸ Combined Type: symptoms of both inattention and hyperactivity-impulsivity for the past 6 months (most cases)

▸ Predominantly Inattentive Type: symptoms of inattention, without hyperactivity-impulsivity present for the past 6 months

▸ Predominantly Hyperactive - Impulsive Type: symptoms of hyperactivity-impulsivity but not inattention present for the past 6 months CHILD PSYCHIATRY - ADHD

IMPAIRMENT IN ADHD

▸ Children

▸ Academic Limitations, Peer Relationship Difficulty, and Increased Injury

▸ Adolescents

▸ Low Self Esteem, Risk Taking Behaviors, Work Impairment, and Delinquency

▸ Adults

▸ Motor Vehicle Accidents, Legal Problems, Occupational Difficulty CHILD PSYCHIATRY - ADHD

TREATMENT IN ADHD

▸ Medications

▸ Stimulants (eg, , )

▸ Side Effects: appetite suppression, growth delay, sleep disturbances, increased HR and BP, headaches, anxiety, and GI discomfort

▸ Non-stimulants (atomoxetine, guanfacine, )

▸ CBT / Behavioral Management

▸ Parent / Child Education

▸ School Programming and Supports CHILD PSYCHIATRY - AGGRESSION

NORMAL DEVIANCE

▸ All children are oppositional (hungry, tired, stressed, or upset)

▸ May argue, talk back, disobey, and defy parents, teachers, and other adults

▸ Oppositional behavior is often a normal component in the development of 2-3 years olds and early adolescents

▸ Uncooperative and hostile behavior becomes serious when it is frequent, consistent, and stands out in comparison to other children of the same age CHILD PSYCHIATRY - ODD

OPPOSITIONAL DEFIANT DISORDER (ODD)

▸ Children characterized by “negative, hostile, and defiant” behaviors occurring more frequently than is typically observed in children of comparable age and developmental level

▸ Behavior is categorized as:

▸ Angry/Irritable Mood

▸ Argumentative/Defiant Behavior

▸ Vindictiveness CHILD PSYCHIATRY - ODD

OPPOSITIONAL DEFIANT DISORDER (ODD)

▸ Serious TEMPER TANTRUMS involving threats of suicide and destruction of property when denied something they want

▸ Emergency Room Evaluations

▸ Comorbid with ADHD and Mood Disorders

▸ Substance Abuse Problems as Adults CHILD PSYCHIATRY - ODD

TREATMENT

▸ Behavioral Interventions

▸ Parent Training

▸ Individual Coping Skills for Child

▸ Medications (comorbid ADHD)

▸ Stimulants

▸ Alpha- Agents

▸ Clonidine

▸ Guanfacine CHILD PSYCHIATRY - CONDUCT DISORDER

CONDUCT DISORDER

▸ Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

▸ Behaviors characterized as:

▸ Aggression to People and Animals

▸ Destruction of Property

▸ Deceitfulness or Theft

▸ Serious Violations of Rules

▸ Specify if with “limited prosocial emotions”

▸ Must be present to later diagnose with Antisocial Personality Disorder at age 18 CHILD PSYCHIATRY - CONDUCT DISORDER

CONDUCT DISORDER ONSET

▸ Childhood Onset:

▸ Show at least one symptoms characteristic of conduct disorder prior to age 10 years

▸ Adolescent Onset:

▸ Show no symptom characteristic of conduct disorder prior to age 10 years

▸ Unspecified Onset:

▸ Criteria of a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptoms was before or after age 10 years CHILD PSYCHIATRY - CONDUCT DISORDER

TREATMENT

▸ Behavioral Interventions

▸ Parent Training

▸ Multi-Systemic Therapy (MST)

▸ Medications (Comorbid Disorders or Aggression)

▸ ADHD: Stimulants and Alpha-Agonists

▸ Aggression: Antipsychotics (Risperidone) and Lithium CHILD PSYCHIATRY - DMDD

DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD)

▸ Severe Recurrent Temper Outbursts (verbal or behavioral)

▸ Grossly out of proportion in intensity or duration to situation or provocation

▸ Inconsistent with developmental level

▸ Persistently irritable or angry most of the day

▸ Seen by others (parents, teachers, and peers)

▸ 3 or more times per week CHILD PSYCHIATRY - DMDD

TREATMENT

▸ No FDA approved medications for DMDD

▸ Individualized Therapy/Medications to account for other comorbidities or primary presenting problems

▸ Behavioral Interventions

▸ ADHD, or Aggression Medication FORENSIC PSYCHIATRY FORENSIC PSYCHIATRY

FORENSIC PSYCHIATRY

▸ Psychiatry and the legal system cross paths

▸ Evaluations

▸ Reports

▸ Testifying in court

▸ Managing psychiatric conditions in jails/prisons FORENSIC PSYCHIATRY

COMPETENCY

▸ Legal Term

▸ Ability to work with lawyer, understand the facts of the case, and the proceedings of court

▸ Psychiatrists/Psychologists evaluate and state findings to the court

▸ Judge makes final decision

▸ If found incompetent

▸ Court case on hold

▸ Psychiatric hospital for restoration

▸ Once competent the defendant returns to jail/prison and case resumed FORENSIC PSYCHIATRY

CIVIL COMMITMENT

▸ Involuntary Hospitalization

▸ Based on Dangerousness

▸ Criteria:

▸ Presence of Mental Illness

▸ Dangerousness (self, others, disabled, restrictiveness)

▸ Treatment (is there one?) FORENSIC PSYCHIATRY

RIGHT TO REFUSE TREATMENT

▸ Treatment Over Objection

▸ Varies by State

▸ Arguments for Both Sides

▸ Emergencies

▸ Provide Treatment (even if objection) FORENSIC PSYCHIATRY

VIOLENCE RISK

▸ History of Violence Prediction of Future Violence

▸ Young Males of Lower SES and IQ

▸ History of Substance Use

▸ Instability of home, employment, education

▸ Command hallucinations (harm self or others) FORENSIC PSYCHIATRY

DANGEROUSNESS TO SELF

▸ Sex (Male)

▸ Age (Teen or Elderly)

▸ Depression ▸ Previous Attempt

▸ or Drug Use

▸ Rational Thinking Loss

▸ Sickness (Medical)

▸ Organized Plan

▸ No Spouse

▸ Social Support Lacking FORENSIC PSYCHIATRY

CONFIDENTIALITY

▸ Medically ethical obligation to protect patient privacy and autonomy

▸ Exceptions to confidentiality (circumstances to breach confidentiality)

▸ Infectious disease

▸ Tarasoff: threaten to harm a third party (duty to warn/protect)

▸ Child and/or Elder abuse

▸ Impaired Automobile drivers

▸ Suicidal/Homicidal patient FORENSIC PSYCHIATRY

INFORMED CONSENT

▸ Discussion of Pertinent Information

▸ Facts about Intervention, Benefits, Risks, and Alternatives

▸ Patient Agrees with Plan, Free from Coercion

▸ Exceptions

▸ Patient Lacks Capacity

▸ Emergency

▸ Therapeutic Privilege: disclosure of information could cause harm or undermine informed decision-making

▸ Waiver by Patient FORENSIC PSYCHIATRY

MALPRACTICE

▸ The 4 D’s: Dereliction of Duty Directly causing Damages

▸ Physician’s Duty to Patient

▸ Physician Breaches Duty (Dereliction)

▸ Damage Results

▸ Dereliction Directly causes Damage PSYCHOTHERAPY PSYCHOTHERAPY

EGO, SUPER-EGO, AND ID

ID (pleasure principle)

‣ Instinctual drives

▸ Needs, wants, impulses, desires

▸ Unconscious

Ego (reality principle)

▸ Modifies the id to conform with external expectations

▸ Decision making

▸ Defense mechanisms

Super-Ego (inner critic)

▸ Morality

▸ Control id’s impulses

▸ Strive for perfection PSYCHOTHERAPY

THERAPY AND WEAKENED EGO FUNCTIONS

‣ In times of crisis, the patient “borrows” ego function from the therapist

‣ Patient internalizes new way of the thinking and behaving in order to strengthen their own ego function

‣ New ways of regulating self-esteem

‣ New ways of relating to others

‣ Learning more flexibility and adaptive coping skills PSYCHOTHERAPY

PSYCHODYNAMIC THERAPY

▸ To understand the origins of dysfunctional behaviors whose motivations are outside conscious awareness (unconscious) and are derived from experiences or beliefs from the past

▸ Uncover: make patient aware of the unconscious

▸ Confrontation: draw attention

▸ Clarification: note pattern (no hypothesis)

▸ Interpretation: note pattern with hypothesis and link to past

▸ Support: support patient through the uncovering PSYCHOTHERAPY

THERAPEUTIC RELATIONSHIP

▸ Patient learns about themself and their relationships with others via their interaction with the therapist

▸ Transference: patient’s feelings about the therapist which affect how they will interact with the therapist

▸ Countertransference: the therapist’s feelings, reaction, or response to the patient which affects how they will interact with the patient PSYCHOTHERAPY

SUPPORTIVE PSYCHOTHERAPY

▸ To help patient maintain or re-establish best possible level of function (here and now)

▸ Therapeutic Relationship for Stability

▸ Problem Solving, Role-Playing, and Education

▸ Achievement may take a short time for patients in crisis, or may be life-long for patients with chronic severe mental illness PSYCHOTHERAPY

COGNITIVE BEHAVIORAL THERAPY

▸ Identifying maladaptive patterns of thinking and behaving

▸ Hypothesis Testing and Alternative Generating / Testing

▸ Homework (target behaviors, thoughts and feelings)

▸ Challenging these patterns in order to change the way a person thinks and behaves

▸ Goal: improving overall function

▸ Using Behavior (more control over) to modulate Feelings (less control over) PSYCHOTHERAPY

EXPOSURE AND RESPONSE PREVENTION

▸ Gradual Exposure to Anxiety Provoking Situation

▸ Concomitant Use of Relaxation Techniques

▸ Goal: Extinction of Unwanted Behavior PRACTICE QUESTIONS PSYCHOTHERAPY

QUESTION 1.

A 27 year old man with a history of panic disorder and GAD is brought to the ED after being found unconscious in his room by his parents. He is lethargic and can barely be aroused. He nods “yes” when asked if he has taken any pill. His parents are sure the only pills in the house are those prescribed by his psychiatrist. His vital signs are normal, and his pupils are dilated to 2mm and normally reactive. His blood level is 100mg/dL. UTOX is pending. All of a sudden, his breathing slows and his oxygen saturation drops significantly. What should the physician give to treat this patient’s condition?

A. Benztropine

B. Flucytosine

C. Flumazenil

D. Naloxone

E. Naltrexone PSYCHOTHERAPY

QUESTION 1.

A 27 year old man with a history of panic disorder and GAD is brought to the ED after being found unconscious in his room by his parents. He is lethargic and can barely be aroused. He nods “yes” when asked if he has taken any pill. His parents are sure the only pills in the house are those prescribed by his psychiatrist. His vital signs are normal, and his pupils are dilated to 2mm and normally reactive. His blood alcohol level is 100mg/dL. UTOX is pending. All of a sudden, his breathing slows and his oxygen saturation drops significantly. What should the physician give to treat this patient’s condition?

A. Benztropine

B. Flucytosine

C. Flumazenil

D. Naloxone

E. Naltrexone PSYCHOTHERAPY

QUESTION 1.

The correct answer is C. This patient is exhibiting symptoms of CNS depression that cannot be explained by his blood alcohol level alone. It is reasonable, based on his psychiatric diagnoses, to think he may have ingested a BZD along with the alcohol resulting in a synergistic effect. To reverse the effect of the , the drug of choice is Flumazenil, a competitive GABA antagonist.

Answer A is incorrect. Benztropine is a centrally acting anticholinergic agent that acts as an acetylcholine . It is used to treat Parkinsonism as well as EPS and dystonic reactions. It is not used to treat benzodiazepine overdose.

Answer B is incorrect. Flucytosine is a potent antifungal.

Answer D is incorrect. Naloxone is used to reverse overdose.

Answer E is incorrect. Naltrexone, an opioid receptor antagonist, is used to treat opiate addiction. PSYCHOTHERAPY

QUESTION 2.

A 22 year old man presents to his PMD with complaints of . He was recently honorably discharged from the army after finishing an 18 month tour of duty in Iraq. He states that the insomnia began about seven months ago after a fierce night-time battle. He reports having nightmares and flashbacks of the battle and is easily startled by loud noises. Which of the following pharmacologic agents, along with psychotherapy, would be most appropriate to treat this patient’s condition?

A.

B.

C.

D.

E. PSYCHOTHERAPY

QUESTION 2.

A 22 year old man presents to his PMD with complaints of insomnia. He was recently honorably discharged from the army after finishing an 18 month tour of duty in Iraq. He states that the insomnia began about seven months ago after a fierce night-time battle. He reports having nightmares and flashbacks of the battle and is easily startled by loud noises. Which of the following pharmacologic agents, along with psychotherapy, would be most appropriate to treat this patient’s condition?

A. Buspirone

B. Carbamazepine

C. Fluoxetine

D. Propranolol

E. Trazodone PSYCHOTHERAPY

QUESTION 2.

The correct answer is C. This patient meets the criteria for diagnosis of PTSD. He has experienced an event that involved actual death of or threatened death to self or others; the traumatic event is persistently re- experienced through nightmares and flashbacks; he suffers from insomnia; and he has an exaggerated startle response. In PTSD, symptoms are present for longer than one month, whereas in acute stress disorder, symptoms last between two days and one month. SSRI such as Fluoxetine are first-line medications for the treatment of PTSD.

Answer A is incorrect. Buspirone is a partial agonist at the 5-HT1S receptor that is commonly used as an alternative to BZD in the treatment of GAD. Although its onset of action is slower than that of BZD, it does not potentiate the CNS depression of alcohol, and has little potential for abuse and addiction.

Answer B is incorrect. Carbamazepine is an anticonvulsant medication that also can be used as a mood stabilizer in bipolar mood disorder.

Answer D is incorrect. Propranolol is a nonspecific b-blocker. It is useful in the treatment of panic disorder and simple phobia.

Answer E is incorrect. Trazodone is a heterocyclic with sedative qualities that is used in the treatment of depression complicated by insomnia. It works by inhibiting reuptake, but also acts as a partial serotonin agonist. PSYCHOTHERAPY

QUESTION 3.

A 42 year old man presents to the local crisis center requesting alcohol detoxification. He has a 20 year history of heavy drinking, with the longest period of abstinence being four months. His last drink was two nights ago, and he now complains of discomfort and anxiety. Physical exam reveals course tremors, facial flushing, palmar erythema, and spider angiomas. His BP is 145/95, pulse is 115/min, and temperature is 38.3 C (100.9 F). Thiamine is administered. Which of the following drugs is indicated for the treatment of this patient’s condition?

A.

B. Disulfiram

C.

D. Methadone

E. Naltrexone PSYCHOTHERAPY

QUESTION 3.

A 42 year old man presents to the local crisis center requesting alcohol detoxification. He has a 20 year history of heavy drinking, with the longest period of abstinence being four months. His last drink was two nights ago, and he now complains of discomfort and anxiety. Physical exam reveals course tremors, facial flushing, palmar erythema, and spider angiomas. His BP is 145/95, pulse is 115/min, and temperature is 38.3 C (100.9 F). Thiamine is administered. Which of the following drugs is indicated for the treatment of this patient’s condition?

A. Chlordiazepoxide

B. Disulfiram

C. Haloperidol

D. Methadone

E. Naltrexone PSYCHOTHERAPY

QUESTION 3.

The correct answer is A. This patient is showing signs of alcohol withdrawal, manifested by tachycardia, fever, nausea, vomiting, tremors, and , and is at risk for delirium tremens. DT is an extreme and life- threatening form of withdrawal characterized by perceptual disturbances and confusion. IV BZD, such as chlordiazepoxide, are indicated in the treatment of both mild withdrawal and delirium tremens. Chlordiazepoxide is a long-acting benzodiazepine that works via stimulation of GABA receptors. Other drugs in the same class include , , and , each of which could be used in this scenario.

Answer B is incorrect. Disulfiram inhibits acetaldehyde dehydrogenase, which causes accumulation of acetaldehyde with ingestion of alcohol. This buildup of alcohol byproducts leads to extremely unpleasant adverse effects, including flushing, headache, diaphoresis, nausea, and vomitting. This drug is given to alcoholics to help them maintain sobriety.

Answer C is incorrect. Haloperidol is a . It can be used in patients withdrawing from alcohol who suffer psychotic symptoms such as hallucinations.

Answer D is incorrect. Methadone is a potent, long-acting opioid agonist used in the treatment of opioid addiction. This patient is an alcoholic and does not require a methadone taper.

Answer E is incorrect. Naltrexone is an opioid antagonist used to help maintain opioid sobriety. It also is used to help prevent alcohol relapses in alcohol dependence. PSYCHOTHERAPY

QUESTION 4.

A 24-year-old woman is brought to the emergency department by ambulance after she is found collapsed and unresponsive on the street. It is not known how long she was lying on the street. Physical examination reveals constricted pupils and a heart rate of 55. Administration of which of the following drugs would be most appropriate?

A. Chlordiazepoxide

B. Flumazenil

C. Fomepizole

D. N - acetylcysteine

E. Naloxone

F. Naltrexone

G. Phenobarbital PSYCHOTHERAPY

QUESTION 4.

A 24-year-old woman is brought to the emergency department by ambulance after she is found collapsed and unresponsive on the street. It is not known how long she was lying on the street. Physical examination reveals constricted pupils and a heart rate of 55. Administration of which of the following drugs would be most appropriate?

A. Chlordiazepoxide

B. Flumazenil

C. Fomepizole

D. N - acetylcysteine

E. Naloxone

F. Naltrexone

G. Phenobarbital PSYCHOTHERAPY

QUESTION 4.

The correct answer is E. This patient has signs indicating opioid overdose: she is comatose with miosis and bradycardia. Naloxone, an opioid antagonist given intravenously, should quickly reverse the effects of the overdose.

Answer A is incorrect. Chlordiazepoxide is a long-acting BZD used in the management of alcohol withdrawal. Though patients with alcohol intoxication can become unresponsive, alcohol tends to cause pupillary dilation, not constriction as seen with this patient.

Answer B is incorrect. Flumazenil is an antagonist at BZD receptors and is used to reverse benzodiazepine intoxication.

Answer C is incorrect. Fomepizole is an inhibitor of alcohol dehydrogenase, and is used to prevent the conversion of ethylene glycol and methanol to the toxic substances oxalic acid and formic acid, respectively. Thus it is mainly used as an antidote for methanol or ethylene glycol poisoning. There is no evidence that this patient ingested methanol or ethylene glycol.

Answer D is incorrect. N-acetylcysteine is used in cases of acetaminophen poisoning.

Answer F is incorrect. Naltrexone, like naloxone, is an opioid receptor antagonist; however, it is not indicated for reversal of acute opioid overdose. Naltrexone is more commonly used to treat alcohol and opioid dependence.

Answer G is incorrect. Phenobarbital is a long-acting useful in patients with seizure disorders. PSYCHOTHERAPY

QUESTION 5.

After several failed trials of various antipsychotic drugs, a 46-year-old woman is switched to a new medication for her schizophrenia. However, a few weeks later, she develops pneumonia. A complete blood count is ordered and reveals a significantly reduced number of neutrophils, basophils, and eosinophils. Which of the following agents is the most likely cause of this clinical picture?

A.

B.

C. Haloperidol

D. Risperidone

E. PSYCHOTHERAPY

QUESTION 5.

After several failed trials of various antipsychotic drugs, a 46-year-old woman is switched to a new medication for her schizophrenia. However, a few weeks later, she develops pneumonia. A complete blood count is ordered and reveals a significantly reduced number of neutrophils, basophils, and eosinophils. Which of the following agents is the most likely cause of this clinical picture?

A. Chlorpromazine

B. Clozapine

C. Haloperidol

D. Risperidone

E. Thioridazine PSYCHOTHERAPY

QUESTION 5.

The correct answer is B. Clozapine is an used to treat schizophrenia that is refractory to traditional therapy. The most dangerous adverse effect of clozapine is bone marrow suppression, specifically agranulocytosis. This necessitates frequent monitoring of the WBC count for all patients who are started on this drug. A sudden increase in infections or bouts of illness in a patient on clozapine should raise concern about the development of agranulocytosis. If laboratory tests indicate this is the case, the drug must be discontinued immediately and the patient should be monitored carefully.

Answer A is incorrect. Chlorpromazine, a traditional antipsychotic, has an adverse-effect profile similar to that of haloperidol. Agranulocytosis can occur with its use, but occurs much more commonly as an adverse effect of clozapine.

Answer C is incorrect. Haloperidol is a traditional antipsychotic that acts by blocking receptors and is not associated with agranulocytosis.

Answer D is incorrect. Risperidone, another atypical antipsychotic agent, has a mechanism of action similar to that of clozapine. It does not, however, produce the adverse effect of agranulocytosis.

Answer E is incorrect. Thioridazine is a traditional antipsychotic that has an adverse-effect profile similar to that of haloperidol and chlorpromazine. Although agranulocytosis is possible, it is much less frequent than with clozapine. PSYCHOTHERAPY

QUESTION 6.

A 60-year-old AAM has been reclusive, rarely leaving his home for the past 40 years. His family describes him as an emotionally cold person with few friends. Growing up, he preferred solitary activities like reading to engaging in activities with others. Members of his church have delivered groceries to his front door once a week for the past 20 years, but he never opens the door to greet them. Which of the following is the most likely diagnosis?

A. Avoidant Personality Disorder

B. Paranoid Personality Disorder

C. Schizoid Personality Disorder

D. Schizophrenia

E. Schizophreniform Disorder

F. Schizotypal Personality Disorder PSYCHOTHERAPY

QUESTION 6.

A 60-year-old AAM has been reclusive, rarely leaving his home for the past 40 years. His family describes him as an emotionally cold person with few friends. Growing up, he preferred solitary activities like reading to engaging in activities with others. Members of his church have delivered groceries to his front door once a week for the past 20 years, but he never opens the door to greet them. Which of the following is the most likely diagnosis?

A. Avoidant Personality Disorder

B. Paranoid Personality Disorder

C. Schizoid Personality Disorder

D. Schizophrenia

E. Schizophreniform Disorder

F. Schizotypal Personality Disorder PSYCHOTHERAPY

QUESTION 6.

The correct answer is C. This man has schizoid personality disorder, marked by a lifelong pattern of social withdrawal. Patients with this disorder experience discomfort with human interaction, so they avoid close relationships, and engage in solitary activities. These patients often are viewed as eccentric, isolated, lonely, and emotionally cold.

Answer A is incorrect. Avoidant patients are like schizoid patients in their pervasive pattern of social inhibition. However, they do desire companionship; an intense fear of rejection leads to avoiding any situation where there is a perceived risk of rejection.

Answer B is incorrect. Patients with paranoid personality disorder tend to be more socially engaged than those with schizoid personality disorder, even though they have a lifelong history of suspiciousness and mistrust of other people.

Answer D is incorrect. Patients with schizophrenia exhibit a formal thought disorder with hallucinations, or delusional thinking. In contrast, patients with schizoid personality disorder have intact reality testing.

Answer E is incorrect. Schizophreniform disorder is identical to schizophrenia except that symptoms last for at least one month but less than six months.

Answer F is incorrect. Schizotypal and schizoid personality disorder are rather similar, but the former is distinguished in that these patients tend to be more similar to schizophrenics. Patients with schizotypal disorder are strikingly odd, with peculiar notions, ideas of reference, illusions, magical thinking, and derealization. PSYCHOTHERAPY

QUESTION 7.

A 27-year-old man is brought to the emergency department by ambulance. Paramedics report that he was found sitting on the sidewalk speaking as though engaged in a heated argument, but nobody else was around. They say that the patient appeared to be in distress and that he was quite disheveled. The man is evaluated by a psychiatrist, admitted to the hospital, and started on a medication to treat his symptoms. Two days later a medical student notices that the patient has painful spasms in his neck muscles. Which of the following is the most appropriate treatment for this man’s condition?

A. Benztropine

B. Dantrolene

C. Diazepam

D.

E. PSYCHOTHERAPY

QUESTION 7.

A 27-year-old man is brought to the emergency department by ambulance. Paramedics report that he was found sitting on the sidewalk speaking as though engaged in a heated argument, but nobody else was around. They say that the patient appeared to be in distress and that he was quite disheveled. The man is evaluated by a psychiatrist, admitted to the hospital, and started on a medication to treat his symptoms. Two days later a medical student notices that the patient has painful spasms in his neck muscles. Which of the following is the most appropriate treatment for this man’s condition?

A. Benztropine

B. Dantrolene

C. Diazepam

D. Fluphenazine

E. Prochlorperazine PSYCHOTHERAPY

QUESTION 7.

The correct answer is A. The patient has classic signs of schizophrenia and was likely given haloperidol, a typical antipsychotic agent that acts by blocking dopamine receptors. Haloperidol has a high affinity for the D2- dopaminergic receptor. The patient is experiencing an acute dystonic reaction soon after receiving the medication. The painful muscle spasm of the neck is known as torticollis. This acute EPS is the result of unopposed cholinergic activity in the CNS following blockade of dopaminergic transmission. The treatment for this adverse effect is initiation of an anticholinergic agent such as benztropine.

Answer B is incorrect. Dantrolene is effective in the treatment of NMS. Dantrolene acts by preventing the release of calcium from the endoplasmic reticulum.

Answer C is incorrect. Diazepam can be used as a , a sedative, an anticonvulsant, and a muscle relaxant. As a muscle relaxant, diazepam is used to treat chorea, an involuntary abnormal movement disorder or dyskinesia that is a hallmark of Huntington disease.

Answer D is incorrect. Fluphenazine, like haloperidol, can induce potent D2-dopaminergic receptor blockade. It is a high-potency typical antipsychotics. Administration of fluphenazine will likely exacerbate this patient’s symptoms rather than alleviate them.

Answer E is incorrect. Prochlorperazine is a typical antipsychotic agent with potent antidopaminergic effects. It can also be used to treat nausea because of its weak anticholinergic and antihistaminic effects. PSYCHOTHERAPY

QUESTION 8.

A 19-year-old man is brought to the emergency department by his friends after suffering a seizure. He is sweating, paranoid, tachycardic, and his pupils are dilated. His friends say that he has a history of using illicit drugs. What is the mechanism of action of the drug that is causing the patient’s symptoms?

A. Blocks NMDA receptors

B. Increases GABA activity by increasing the duration of chloride channel opening

C. Prevents reuptake of , dopamine, and serotonin by presynaptic pumps

D. Prevents the fusion of the presynaptic visible with the presynaptic surface membrane

E. Prevents the uptake of acetylcholine at cholinergic synapses PSYCHOTHERAPY

QUESTION 8.

A 19-year-old man is brought to the emergency department by his friends after suffering a seizure. He is sweating, paranoid, tachycardic, and his pupils are dilated. His friends say that he has a history of using illicit drugs. What is the mechanism of action of the drug that is causing the patient’s symptoms?

A. Blocks NMDA receptors

B. Increases GABA activity by increasing the duration of chloride channel opening

C. Prevents reuptake of norepinephrine, dopamine, and serotonin by presynaptic pumps

D. Prevents the fusion of the presynaptic visible with the presynaptic surface membrane

E. Prevents the uptake of acetylcholine at cholinergic synapses PSYCHOTHERAPY

QUESTION 8.

The correct answer is C. The patient’s symptoms are caused by cocaine. Cocaine prevents the reuptake of norepinephrine, dopamine, and serotonin by presynaptic transporter pumps in the central and peripheral nervous systems.

Answer A is incorrect. PCP causes aggressive and impulsive behavior, nystagmus, and tachycardia. It acts as an NMDA receptor antagonist.

Answer B is incorrect. cause respiratory depression and act by increasing GABA activity by increasing the duration of chloride channel opening.

Answer D is incorrect. Selegiline is a MAO B inhibitor that is used to treat Parkinson disease by decreasing the breakdown of dopamine. It has no role in the treatment of schizophrenia. Adverse effects of selegiline include gastrointestinal (GI) upset, nausea, heartburn, and dry mouth.

Answer E is incorrect. Cocaine works on noradrenergic neurons; it does not work on cholinergic neurons. PSYCHOTHERAPY

QUESTION 9.

A 45-year-old man who has received long-term treatment for schizophrenia recently has been displaying involuntary facial movements that include lateral deviations of the jaw and “fly catching” motions of the tongue. Which of the following agents is the most likely cause of his involuntary movements?

A. Clozapine

B. Fluphenazine

C. Lithium

D. Selegiline

E. PSYCHOTHERAPY

QUESTION 9.

A 45-year-old man who has received long-term treatment for schizophrenia recently has been displaying involuntary facial movements that include lateral deviations of the jaw and “fly catching” motions of the tongue. Which of the following agents is the most likely cause of his involuntary movements?

A. Clozapine

B. Fluphenazine

C. Lithium

D. Selegiline

E. Ziprasidone PSYCHOTHERAPY

QUESTION 9.

The correct answer is B. This patient is displaying signs of tardive dyskinesia, a complication of long-term antipsychotic use thought to be the result of increased dopamine receptor synthesis in response to long- term receptor blockade by antipsychotics. This complication is encountered more commonly with use of older, typical antipsychotic medications such as fluphenazine and haloperidol.

Answer A is incorrect. Clozapine, an atypical antipsychotic that has a relatively low risk of inducing tardive dyskinesia. The most concerning adverse effect of clozapine is agranulocytosis, which can be fatal if left untreated.

Answer C is incorrect. Lithium is a mood stabilizer that is used primarily to treat episodes of mania in patients with bipolar disorder. Adverse effects of lithium include nephrogenic diabetes insipidus, nausea, anorexia, and mild diarrhea.

Answer D is incorrect. Selegiline is a MAO B inhibitor that is used to treat Parkinson disease by decreasing the breakdown of dopamine. It has no role in the treatment of schizophrenia. Adverse effects of selegiline include gastrointestinal (GI) upset, nausea, heartburn, and dry mouth.

Answer E is incorrect. Ziprasidone is an atypical antipsychotic and has a lower incidence of tardive dyskinesia when compared to typical antipsychotics. More often than other atypical antipsychotics, it has been associated with QT prolongation and the risk of malignant ventricular arrhythmias. PSYCHOTHERAPY

QUESTION 10.

A 28-year-old man who has been experiencing delusions, hallucinations, and thought disorders for the past six months now begins to display flattening affect, lack of motivation, and social withdrawal. Which of the following agents would address his newest symptoms?

A.

B. Haloperidol

C. Lithium

D. Fluphenazine

E. PSYCHOTHERAPY

QUESTION 10.

A 28-year-old man who has been experiencing delusions, hallucinations, and thought disorders for the past six months now begins to display flattening affect, lack of motivation, and social withdrawal. Which of the following agents would address his newest symptoms?

A. Olanzapine

B. Haloperidol

C. Lithium

D. Fluphenazine

E. Phenelzine PSYCHOTHERAPY

QUESTION 10.

The correct answer is A. Olanzapine is an atypical antipsychotic that blocks both serotonin and dopamine receptors. Drugs in this class are noted for their ability to treat both positive symptoms of schizophrenia (ie, hallucinations and delusions) and negative symptoms (ie, blunted affect and social withdrawal). With the onset of negative symptoms, addition of an atypical antipsychotic such as olanzapine, can effectively treat both positive and negative symptoms of this disorder.

Answer B is incorrect. Haloperidol, another typical agent, would be less effective at mitigating the patient’s negative symptoms compared to olanzapine.

Answer C is incorrect. Lithium is a mood stabilizer that is used to treat the acute manic phases of bipolar disorder. It is not used in the treatment of schizophrenia.

Answer D is incorrect. Fluphenazine is a typical antipsychotic that blocks only dopamine receptors. Agents in this class are more effective at mitigating positive symptoms of schizophrenia, but are less effective at relieving the negative symptoms .

Answer E is incorrect. Phenelzine, a MAO inhibitor, is used to treat depression in patients who are unresponsive to TCA or who experience concomitant anxiety. Such agents are not used to treat schizophrenia. PSYCHOTHERAPY

QUESTION 11.

A 35-year-old man with depression has been treated with medication for the past seven years. Recently he began seeing a new psychiatrist who suggested changing this medication to a newer class of that has proven effective for many of her patients. Two weeks later he presents to the ED because of flushing, diarrhea, sweating, and muscle rigidity. During the physical examination, he admits that he was a bit suspicious of the new medication he was given to treat his depression since he was told he no longer needed to avoid certain foods. He decided to use both medicines just to “make sure” the new one was working. Which of the following medications did the new doctor most likely prescribe for this patient?

A. Lithium

B.

C. Phenelzine

D.

E. Trazodone PSYCHOTHERAPY

QUESTION 11.

A 35-year-old man with depression has been treated with medication for the past seven years. Recently he began seeing a new psychiatrist who suggested changing this medication to a newer class of antidepressants that has proven effective for many of her patients. Two weeks later he presents to the ED because of flushing, diarrhea, sweating, and muscle rigidity. During the physical examination, he admits that he was a bit suspicious of the new medication he was given to treat his depression since he was told he no longer needed to avoid certain foods. He decided to use both medicines just to “make sure” the new one was working. Which of the following medications did the new doctor most likely prescribe for this patient?

A. Lithium

B. Nortriptyline

C. Phenelzine

D. Sertraline

E. Trazodone PSYCHOTHERAPY

QUESTION 11.

The correct answer is D. This patient has likely been taking a MAO inhibitor for the past seven years since he was told he had to avoid certain foods. Sertraline is a SSRI that can lead to serotonin syndrome when taken in conjunction with MAO inhibitors. Serotonin syndrome is the result of excess serotonin in the nervous system and is characterized by AMS, autonomic changes (eg, fever, diaphoresis, tachycardia), and neuromuscular changes (eg, tremor or rigidity).

Answer A is incorrect. Lithium is typically used to treat bipolar disorder. While lithium is considered an effective adjunctive therapy for depression in combination with a second therapy for depression is not recommended.

Answer B is incorrect. Nortriptyline is a TCA associated with the “3 Cs:” Convulsions, Coma, and Cardiotoxicity. TCAs primarily have anticholinergic adverse effects as well, including dry mouth, mydriasis, constipation, and urinary retention.

Answer C is incorrect. Phenelzine is an MAO inhibitor. There is no evidence that two MAO inhibitors lead to serotonin syndrome when taken together.

Answer E is incorrect. Trazodone is a heterocyclic associated with sedation, nausea, priapism, and postural . PSYCHOTHERAPY

QUESTION 12.

A 20-year-old man is seen by a physician for the third time in three months. At the first visit he was brought to the emergency department by his mother after swallowing toilet bowl cleaner. He told the doctor that he took the cleaning product to “cleanse his body from the aliens” that had “forced their entry” and “possessed” him. Today the patient appears unclean and disheveled, and his mother reports that he has become progressively withdrawn and expressionless. Four months ago the patient witnessed the gruesome death of his father in a drive-by shooting incident. Prior to this incident, he had a normal and healthy life. Which of the following is the most likely diagnosis?

A. Factitious Disorder

B. Schizophreniform Disorder

C. Schizophrenia

D. Schizoaffective Disorder

E. Shared Delusional Disorder PSYCHOTHERAPY

QUESTION 12.

A 20-year-old man is seen by a physician for the third time in three months. At the first visit he was brought to the emergency department by his mother after swallowing toilet bowl cleaner. He told the doctor that he took the cleaning product to “cleanse his body from the aliens” that had “forced their entry” and “possessed” him. Today the patient appears unclean and disheveled, and his mother reports that he has become progressively withdrawn and expressionless. Four months ago the patient witnessed the gruesome death of his father in a drive-by shooting incident. Prior to this incident, he had a normal and healthy life. Which of the following is the most likely diagnosis?

A. Factitious Disorder

B. Schizophreniform Disorder

C. Schizophrenia

D. Schizoaffective Disorder

E. Shared Delusional Disorder PSYCHOTHERAPY

QUESTION 12.

The correct answer is B. Over the course of two visits, the patient has exhibited psychotic and residual symptoms characteristic of schizophrenia and related disorders. A diagnosis of schizophrenia, however, requires active phase (“positive”) symptoms, and may include “negative” ones as well, over a period of >6 months. In this case, the patient’s symptoms have lasted <4 months, and were potentially incited by a traumatic event and its repercussions. In this patient, symptoms with a duration of >1 month but <6 months yield a diagnosis of schizophreniform disorder.

Answer A is incorrect. There is no evidence that either the patient or his mother is actively seeking the attention of medical personnel.

Answer C is incorrect. Explicit in the diagnosis of schizophrenia is the presence of “positive” and (but not always) “negative” symptoms of >6 months’ duration.

Answer D is incorrect. The diagnosis of a schizoaffective disorder requires the symptoms of schizophrenia (often both “positive” and “negative” symptoms) as well as those of a mood disorder (ie, depression, mania).

Answer E is incorrect. Shared delusions are those transmitted from one person to another in a parent-to- child or spouse-to-spouse relationship. There is no evidence presented that the patient’s mother shares the false beliefs of her son. PSYCHOTHERAPY

QUESTION 13.

A 23-year-old man is brought to the ED because his friends heard him say that he was talking to president Kennedy about a secret spy mission in the Soviet Union. He appears quite anxious, agitated, and restless. Physical examination reveals dilated pupils. His pulse is 80/min and his is 120/80 mm Hg. What is the most likely cause of his symptoms?

A. Alcohol

B. Cocaine

C. Lysergic Acid Diethylamide

D. Marijuana

E. Phencyclidine PSYCHOTHERAPY

QUESTION 13.

A 23-year-old man is brought to the ED because his friends heard him say that he was talking to president Kennedy about a secret spy mission in the Soviet Union. He appears quite anxious, agitated, and restless. Physical examination reveals dilated pupils. His pulse is 80/min and his blood pressure is 120/80 mm Hg. What is the most likely cause of his symptoms?

A. Alcohol

B. Cocaine

C. Lysergic Acid Diethylamide

D. Marijuana

E. Phencyclidine PSYCHOTHERAPY

QUESTION 13.

The correct answer is C. This patient is experiencing hallucinations, delusions, and dilated pupils, but very few observable behavioral changes. These are symptoms consistent with lysergic acid diethylamide (LSD) abuse. LSD is a hallucinogenic drug that can cause marked anxiety, depression, nausea, weakness, and paresthesias.

Answer A is incorrect. Alcohol abuse is characterized by a general disinhibition, slurred speech, and ataxia. It does not usually cause patients to hallucinate or become delusional.

Answer B is incorrect. Cocaine can cause many of the symptoms this patient is experiencing. However, patients with recent cocaine use are usually hypertensive and tachycardic because of its effects.

Answer D is incorrect. Marijuana can cause many of the symptoms this patient is experiencing. However, patients with recent marijuana use usually have an increase in appetite and dry mouth as well.

Answer E is incorrect. PCP is a hallucinogenic drug that is often associated with belligerence and acting out impulsively. PSYCHOTHERAPY

QUESTION 14.

The parents of an 8-year-old boy bring him to see a psychiatrist because they are frustrated with his behavior. In the last two years he has become increasingly restless and moody, interrupts other children in the classroom, and often runs into the street without looking out for cars first. The psychiatrist prescribes a medication that works through which of the following mechanisms?

A. Increases release of norepinephrine

B. Inhibits acetylcholine activity

C. Inhibits reuptake of serotonin

D. Stimulates dopamine receptors

E. Stimulates serotonin receptors PSYCHOTHERAPY

QUESTION 14.

The parents of an 8-year-old boy bring him to see a psychiatrist because they are frustrated with his behavior. In the last two years he has become increasingly restless and moody, interrupts other children in the classroom, and often runs into the street without looking out for cars first. The psychiatrist prescribes a medication that works through which of the following mechanisms?

A. Increases release of norepinephrine

B. Inhibits acetylcholine activity

C. Inhibits reuptake of serotonin

D. Stimulates dopamine receptors

E. Stimulates serotonin receptors PSYCHOTHERAPY

QUESTION 14.

The correct answer is A. The boy exhibits the characteristic emotional lability and impulsivity seen in patients with ADHD. Methylphenidate is a first-line treatment for ADHD. It works similarly to by increasing the presynaptic release of norepinephrine.

Answer B is incorrect. Antimuscarinic drugs like benztropine can be used in conjunction with typical antipsychotics in the treatment of schizophrenia to alleviate EPS.

Answer C is incorrect. SSRIs can be used to treat depression, anxiety, and OCD.

Answer D is incorrect. Drugs that stimulate dopamine receptors are used in the treatment of Parkinson disease.

Answer E is incorrect. Buspirone is a serotonin receptor agonist that is used in the treatment of anxiety. PSYCHOTHERAPY

QUESTION 15.

A 15-year-old girl is brought to the ED by her mother after experiencing a first-time seizure. The thin-appearing girl has a heart rate of 55/min, signs suggestive of dehydration, and fine, velvety hair covering her arms and legs. The physician calculates her BMI to be 16.4. When the patient’s mother leaves the room for a moment, the patient admits to the physician that she has been feeling depressed recently and that for the past week she has been self medicating with normal daily doses of one of her friend’s antidepressant medications. What antidepressant is the patient most likely taking?

A.

B. Buproprion

C. Fluoxetine

D.

E. Selegiline PSYCHOTHERAPY

QUESTION 15.

A 15-year-old girl is brought to the ED by her mother after experiencing a first-time seizure. The thin-appearing girl has a heart rate of 55/min, signs suggestive of dehydration, and fine, velvety hair covering her arms and legs. The physician calculates her BMI to be 16.4. When the patient’s mother leaves the room for a moment, the patient admits to the physician that she has been feeling depressed recently and that for the past week she has been self medicating with normal daily doses of one of her friend’s antidepressant medications. What antidepressant is the patient most likely taking?

A. Amitriptyline

B. Buproprion

C. Fluoxetine

D. Mirtazapine

E. Selegiline PSYCHOTHERAPY

QUESTION 15. The correct answer is B. This patient has physical signs consistent with anorexia nervosa, most notably a low BMI, bradycardia, evidence of hypotension, fine body hair (called lanugo), and concomitant depression. The mainstay of therapy is a combination of CBT and SSRIs. Use of the antidepressant is contraindicated in patients with anorexia nervosa because it increases the risk of seizure in this population.

Answer A is incorrect. Amitriptyline is a TCA. TCAs, although effective, are not first-line therapy in the management of anorexia nervosa, given the potential for cardiac adverse effects in anorexic patients already suffering from bradycardia and electrolyte abnormalities. TCAs are not known to increase the risk of seizure in anorexic patients.

Answer C is incorrect. Fluoxetine is an SSRI most commonly used as an antidepressant. It has also been used to treat anorexia nervosa, although with questionable efficacy. SSRIs are not known to increase the risk of seizure in anorexic patients.

Answer D is incorrect. Mirtazapine in an atypical antidepressant that induces weight gain, which may be beneficial in patients with weight control issues, although this has not yet been studied rigorously. Mirtazapine is not known to increase the risk of seizure in anorexic patients.

Answer E is incorrect. Selegiline is a MAO inhibitor most commonly used as an antidepressant; it is not typically used to manage anorexia nervosa. MAO inhibitors are not known to increase the risk of seizure in anorexic patients. PSYCHOTHERAPY

QUESTION 16.

The image depicts a biochemical pathway occurring in the nervous system. An “X” marks the effect of a certain class of medications on this pathway. For which condition is this class of medications an effective first-line treatment?

A. Bipolar Disorder

B. Delirium Tremens

C. Dissociative Identity Disorder

D. Obsessive - Compulsive Disorder

E. Schizophrenia PSYCHOTHERAPY

QUESTION 16.

The image depicts a biochemical pathway occurring in the nervous system. An “X” marks the effect of a certain class of medications on this pathway. For which condition is this class of medications an effective first-line treatment?

A. Bipolar Disorder

B. Delirium Tremens

C. Dissociative Identity Disorder

D. Obsessive - Compulsive Disorder

E. Schizophrenia PSYCHOTHERAPY

QUESTION 16.

The correct answer is D. SSRIs block the reuptake of serotonin in presynaptic neurons; the result is an effective increase in serotonin within the synaptic space. SSRIs act at the “X” in the image by inhibiting the binding of serotonin to the serotonin transport protein (STP). SSRIs have demonstrated efficacy for numerous medical and psychiatric conditions, most notably depression, anxiety, OCD, and eating disorders.

Answer A is incorrect. SSRIs are not first-line treatment for bipolar disorder; a mood stabilizing agent (eg, lithium or valproic acid) would be the treatment of choice.

Answer B is incorrect. SSRIs are not first-line treatment for DT; a long-acting BZD (eg, chlordiazepoxide) would be the treatment of choice.

Answer C is incorrect. SSRIs are not first-line treatment for DID.

Answer E is incorrect. SSRIs are not first-line treatment for schizophrenia; an antipsychotic (eg, haloperidol or risperidone) would be the treatment of choice. PSYCHOTHERAPY

QUESTION 17.

An 18-year-old woman complains of weakness, fatigue, decreased appetite, and insomnia over the past month. She is no longer interested in her favorite activities, and has been unable to concentrate in school. She also reports feeling guilty about not hanging out with her friends even though they ask her out almost every weekend. As part of her treatment plan, her physician prescribes a medication. On a follow-up visit, she reports that her mood has improved, but she now feels that her face flushes more frequently and she is more sensitive to the hot weather outside. She is also worried that at times she feels like her heart is racing. On further questioning, she admits to some constipation. Which of the following drugs was most likely prescribed for this patient?

A. Amitriptyline

B. Clonazepam

C. Lithium

D. Sertraline

E. PSYCHOTHERAPY

QUESTION 17.

The correct answer is A. This patient is being treated for depression. Amitriptyline, a TCA, is as effective as the sSSRI, but often is not prescribed as a first-line agent because of its many adverse effects. These include sedation, a-blocking effects, and, most commonly, anticholinergic effects such as dry mouth, blurry vision, tachycardia, urinary retention, constipation, confusion, and dry, hot skin. These adverse effects can be remembered with the following: red as a beet (flushing), dry as a bone (anhidrosis), hot as a hare (overheating secondary to anhidrosis), blind as a bat (blurry vision), mad as a hatter (hallucinations or delirium), and full as a flask (urinary retention).

Answer B is incorrect. Clonazepam is a BZD sometimes prescribed as an at the initiation of anti- depressant therapy. The most commonly reported adverse effects are those associated with CNS depression, such as sedation or respiratory depression at higher doses.

Answer C is incorrect. Lithium is a mood stabilizer used to treat bipolar disorder. Adverse effects include CNS depression, dizziness, nephrogenic diabetes insipidus, edema, and hypothyroidism, as well as many others.

Answer D is incorrect. Sertraline and other SSRIs are associated with adverse effects related to CNS stimulation such as headache, anxiety, tremor, insomnia, anorexia, nausea, and vomiting. Weight gain and sexual dysfunction are also frequently reported with SSRI use.

Answer E is incorrect. Venlafaxine is a SNRI. It has adverse effects similar to those of SSRIs plus additional adverse effects due to the norepinephrine, such as dizziness and diaphoresis. PSYCHOTHERAPY

QUESTION 18.

A 20-year-old woman is brought to the emergency department by her roommate because she was “walking funny,” had difficulty breathing, and slurred her speech. She was recently diagnosed and given medication for panic disorder. Her blood pressure is 110/75 mm Hg, pulse is 58/min, and respiratory rate is 8/min. She is afebrile. Her mucous membranes are moist and pupil size is normal. Serum laboratory studies are negative for evidence of ethanol, organophosphate, or opioid ingestion. The agent that would be used to reverse the effects of the patient’s anxiety medication works by which of the following mechanisms?

A. Activating an enzyme responsible for the termination of a drug’s activation

B. Amplifying the effect of an endogenous neurotransmitter by inhibiting to break- down

C. Displacement of the drug from its binding site

D. Inhibiting the formation of a toxic metabolite

E. Inhibiting the storage of a neurotransmitter PSYCHOTHERAPY

QUESTION 18.

The correct answer is C. This patient has evidence of BZD intoxication. This is the most likely scenario given her recent diagnosis and treatment for panic disorder, in addition to the exclusion of other causes with similar presentations. Competitive antagonists work by displacing a drug from its binding site. Flumazenil is a competitive antagonist that can be used in the case of BZD overdose.

Answer A is incorrect. Pralidoxime, a cholinesterase regenerator, is indicated in cases of organophosphate poisoning. Organophosphates such as parathion and malathion are indirect-acting cholinomimetics that inhibit acetylcholinesterase by forming a very stable bond with it.

Answer B is incorrect. Physostigmine is an indirect-acting cholinomimetics that inhibits the action of acetylcholinesterase, thereby amplifying the effect of endogenous acetylcholine. It is indicated in cases of anticholinergic (but not tricyclic) poisoning, which would present with the classic picture described by the mnemonic “red as a beet, blind as a bat, mad as a hatter, dry as a bone, and hot as a hare.” One would expect fever, flushing, delirium, dry mucous membranes, and miosis on physical exam.

Answer D is incorrect. Ethanol is indicated in cases of toxic alcohol ingestion (eg, methanol or ethylene glycol). Toxic metabolites are formed when alcohol dehydrogenase metabolizes methanol or ethylene glycol. Ethanol works by inhibiting the formation of these harmful substances by competing for binding sites on alcohol dehydrogenase.

Answer E is incorrect. inhibits the storage of norepinephrine in adrenergic nerve terminals, thereby depleting the neuron of its stores. It has been classified as a postganglionic sympathetic nerve terminal blocker, and is rarely used as an antihypertensive medication.