Psychiatry Test 1 (Packrat) – Flashcards
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History & Physical/Psychiatry/Behavioral Medicine Which of the following historical factors differentiates post-traumatic stress disorder from acute stress disorder? Answers A. The inability of the person to recall an important aspect of the event. B. Avoidance of stimuli that invokes recollections of the event. C. A belief that their future has been foreshortened because of the event. D. The presence of sleep disorder.
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Explanations (u) A. See C for explanation. (u) B. See C for explanation. (c) C. Post-traumatic stress disorder and acute stress disorder have many of the same characteristics. A sense of a foreshortened future, such as not expecting a normal life span or a career due to the trauma, distinguishes post-traumatic stress disorder from an acute stress disorder. The other answers are common to both disorders. (u) D. See C for explanation.
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History & Physical/Psychiatry/Behavioral Medicine A patient with obsessive-compulsive disorder would most likely have which of the following findings? Answers A. Raw, red hands B. Priapism C. Memory impairment D. Abdominal pain
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Explanations (c) A. Common manifestations of obsessive-compulsive disorder include phobias of germ and contaminants, which results in frequent hand washing leading to chafe and reddened hands. The other answers are inconsistent with obsessive-compulsive disorder. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
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Diagnosis/Psychiatry/Behavioral Medicine A 53 year-old man with a history of hypertension is being treated with atenolol (Tenormin). He currently presents complaining of chronic fatigue, insomnia, decreased appetite, and difficulty concentrating for the past 3 weeks. His wife also notes that he no longer goes bowling with his friends and has lost interest in any sexual intimacy. Physical examination is unremarkable. Which of the following is the most likely diagnosis? Answers A. major depression B. dysthymic disorder C. atypical depression D. drug-induced depression
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Explanations (c) A. Diagnostic criteria for a major depressive disorder include a loss of pleasure in usual activities, vegetative or physical changes (poor appetite, loss of energy), and cognitive changes such as difficulty in concentrating. (u) B. A dysthymic disorder is a chronic depressive disorder whose symptoms are milder, but longer lasting (> 2 years) than those in a major depressive episode. (u) C. Atypical depression is characterized by hypersomnia, overeating, lethargy, and rejection sensitivity, which are not present in this case. (u) D. While beta-blockers may cause fatigue and sleep disturbances, they do not cause a depressive disorder.
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Clinical Intervention/Psychiatry/Behavioral Medicine The most important initial component of evaluating a patient with depressive illness is Answers A. assessment of suicidal risk. B. assessment of memory function. C. determination of the presence of hallucinations. D. determination of the degree of intellectual impairment.
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Explanations (c) A. Two-thirds of all depressed patients contemplate suicide, and 10 to 15% commit suicide. (u) B. Assessment of memory function and degree of intellectual impairment is important during the evaluation of the depressed patient, as both may be impaired in over 95% of patients. These, however, are not the most important. (u) C. Hallucinations are not a symptom of depression. (u) D. See B for explanation.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following antipsychotic medications is associated with significant agranulocytosis but not with extrapyramidal side effects? Answers A. Clozapine (Clozaril) B. Haloperidol (Haldol) C. Chlorpromazine (Thorazine) D. Fluphenazine (Prolixin)
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Explanations (c) A. Clozapine is referred as an "atypical" antipsychotic agent. It can cause agranulocytosis and should be monitored with weekly CBC. This is not a first line treatment drug. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
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192. Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following is effective in the long-term treatment of panic attacks? Answers A. Triazolam (Halcion) B. Propranolol (Inderal) C. Lorazepam (Ativan) D. Fluoxetine (Prozac)
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Explanations (u) A. Triazolam is a benzodiazepine used for sleep. (u) B. Propranolol blocks the peripheral symptoms associated with panic attacks (palpitations, tremors). It is not effective for treating the underlying disorder. (u) C. Lorazepam may be used for urgent treatment of panic disorders, but should not be used for long-term treatment. (c) D. SSRI's, such as fluoxetine, are the initial drugs of choice for the long-term treatment of panic disorders.
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Scientific Concepts/Psychiatry/Behavioral Medicine Phenothiazines exert their antipsychotic effects by blocking Answers A. alpha-adrenergic receptors. B. dopamine receptors. C. histamine receptors. D. serotonin receptors.
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Explanations (u) A. Phenothiazine blockage of alpha-adrenergic and histamine receptors lead to orthostatic hypotension, sedation, and anticholinergic effects. (c) B. Blockage of the dopamine receptors in the mesolimbic areas of the brain is responsible for the antipsychotic effects of the phenothiazines; blockage of the dopamine receptors in the nigrostriatal areas lead to the motor side effects, such as dystonia and akathisia. (u) C. See A for explanation. (u) D. Phenothiazines do not block serotonin receptors.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine A 36 year-old man has a 30 pack-year history of smoking cigarettes and wants to quit. He is otherwise healthy at this time. Which of the following drugs would be appropriate for him? A. Amitriptyline (Elavil) B. Bupropion (Wellbutrin) C. Fluoxetine (Prozac) D. Venlafaxine (Effexor)
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Explanations (u) A. See B for explanation. (c) B. The only two approved drugs for aiding smoking cessation are nicotine and bupropion. (u) C. See B for explanation. (u) D. See B for explanation.
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History & Physical/Psychiatry/Behavioral Medicine The DSM-IV classifies mental disorders by using five axes in completing the process. Axis III is used to identify which of the following? A. Clinical disorders and other conditions that may be the focus of clinical attention B. Any physical disorder or general medical condition that is present in addition to the mental disorder C. The psychosocial and environmental problems that have had a significant contribution to the development or exacerbation of the disorder D. Personality disorders and/or mental retardation
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Explanations (u) A. Axis I identifies clinical disorders and other conditions that may be the focus of clinical attention. (c) B. Axis III identifies any physical disorder or general medical condition that is present in addition to the mental disorder. (u) C. Axis IV identifies the psychosocial and environmental problems having a significant contribution to the disorder. (u) D. Axis II identifies personality disorders and mental retardation.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following dietary substances interact with monoamine oxidase-inhibitor antidepressant drugs? A. Lysine B. Glycine C. Tyramine D. Phenylalanine
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Explanations (u) A. Lysine, glycine, and phenylalanine are not known to interact with MAO inhibitors. (u) B. See A for explanation. (c) C. Monoamine oxidase inhibitors are associated with serious food/drug and drug/drug interactions. Patient must restrict intake of foods having a high tyramine content to avoid serious reactions. Tyramine is a precursor to norepinephrine. (u) D. See A for explanation.
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Scientific Concepts/Psychiatry/Behavioral Medicine Which of the following medications used in the management of anxiety has a delayed onset of action? A. buspirone (BuSpar) B. diphenhydramine (Benadryl) C. lorazepam (Ativan) D. butalbital (Fiorinal)
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Explanations (c) A. Buspirone takes several days to weeks for it to have clinical activity. (u) B. Diphenhydramine works as a histamine blocker and will cause sedation immediately because of its anticholinergic effects. (u) C. Lorazepam is an anxiolytic medication that has an immediate onset of activity. (u) D. Butalbital is a short to intermediate-acting barbiturate that has immediate activity.
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Clinical Intervention/Psychiatry/Behavioral Medicine A 26 year-old female arrives in the emergency department with friends who say she was standing in front of her church, dressed in a white bathrobe, claiming to be the Virgin Mary and handing out $100 bills to all passers-by. Her friends noted that she had been depressed lately, but now seems completely euphoric. She had a similar episode two years ago. Which of the following is the most appropriate treatment? A. Inpatient olanzapine (Zyprexa) therapy B. Inpatient electroconvulsive therapy C. Outpatient paroxetine (Paxil) therapy D. Outpatient psychotherapy
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Explanations (c) A. Treatment of the manic phase is usually done in the hospital to protect patients from behaviors associated with grandiosity (spending inordinate amounts of money, making embarrassing speeches, etc.). Lithium, valproate, and olanzapine are considered effective in the manic stage; the depressive stage is treated with antidepressants. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
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Diagnosis/Psychiatry/Behavioral Medicine A 54 year-old patient has acute onset of palpitations, tremulousness, profuse sweating, shortness of breath, and numbness and tingling of the extremities. Physical examination reveals a pulse of 104 beats/min and regular, respiratory rate of 30/min, blood pressure of 160/95 mm Hg. Arterial blood gases reveal a low pCO2. ECG shows no acute changes. The most likely diagnosis is A. anxiety neurosis. B. atrial fibrillation. C. depressive neurosis. D. myocardial infarction.
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Explanations (c) A. Anxiety is characterized by short-lived, recurrent, unpredictable episodes of intense anxiety accompanied by marked physiological manifestations. (u) B. Atrial fibrillation would not account for abnormal respiratory rate or blood gases, and the pulse would be irregular. (u) C. Depressive neurosis may be associated with somatic complaints, but it is not manifested by an acute, abrupt onset of them. (u) D. Even though the patient manifests some signs of a myocardial infarction (sweating and numbness), the ECG is normal.
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Health Maintenance/Psychiatry/Behavioral Medicine A 28 year-old male patient is being treated for depression and has been taking paroxetine (Paxil) for the past two and a half months with a marked improvement in symptoms. The patient reports problems with sexual functioning which he believes is related to the medication. Which of the following is an immediate concern with abrupt discontinuation of the medication? A. increased risk of suicide B. diminished sexual functioning C. risk of drug withdrawal symptoms D. worsened depressive symptoms
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Explanations (u) A. Abrupt discontinuation of an SSRI in a patient who is relatively asymptomatic does not increase the risk of suicide. (u) B. Abrupt discontinuation may improve sexual functioning after the medication has cleared. (c) C. The greatest risk of abrupt withdrawal of short acting SSRIs is a withdrawal syndrome or withdrawal delirium which represents cholinergic rebound. (u) D. Approximately 50% of patients with a first episode of depression are at risk for relapse at some time during their lifetime; however, relapse is not an immediate risk of abrupt discontinuation.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine A 33 year-old hypertensive patient presents with increasing feelings of worthlessness and hopelessness over the past several months. Other symptoms include frequent crying episodes, loss of appetite, weight loss, insomnia with daytime sleepiness, and thoughts of suicide without any specific plans in place at this time. Which of the following would be the most appropriate first-line medication for this patient? A. amitriptyline (Elavil) B. bupropion (Wellbutrin) C. fluoxetine (Prozac) D. phenelzine (Nardil)
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Explanations (u) A. Tricyclic antidepressants, such as amitriptyline, are third-line drugs for treating major depression, and are reserved for complicated and/or unresponsive cases. (u) B. Bupropion is a second-line drug for treating major depression and should be avoided in patients with hypertension. (c) C. Selective serotonin reuptake inhibitors are the drugs of first choice for treating major depression. (u) D. Phenelzine, a monoamine oxidase inhibitor, is reserved for treatment failures with supervision by a psychiatrist.
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History & Physical/Psychiatry/Behavioral Medicine A patient with obsessive compulsive disorder would most likely have which of the following findings? A. Raw, red hands B. Priapism C. Memory impairment D. Abdominal pain
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Explanations (c) A. Common manifestations of obsessive compulsive disorder include phobias of germ and contaminants which results in frequent handwashing leading to chafed and reddened hands. The other answers are inconsistent with obsessive compulsive disorder. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
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Diagnosis/Psychiatry/Behavioral Medicine A 63 year-old retired engineer presents with one month of difficulty sleeping. He has a hard time staying asleep and says he is just restless. He also states that he has been more forgetful and can't pay attention very well. He lives with his wife. He denies fever, chills, recent trauma, or difficulty walking. When asked about the specifics of his symptoms, he repeatedly replies, "I don't know," without really trying. He states his wife thinks he just sits around the house all day since he retired. His neurological exam is unremarkable, except for some mild psychomotor retardation. Which of the following is the most likely diagnosis? A. Dementia B. Delirium C. Depression D. Dissociative disorder
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Explanations (u) A. Dementia is a deterioration of selective mental functions including progressive loss of impulse control and an attempt to cover up mental deficiencies. (u) B. Delirium has a rapid onset of symptoms, mental status fluctuations. Anxiety and irritability are common. (c) C. Depression often presents with difficulty thinking and concentrating, lessened sleep, and withdrawal from activities. (u) D. Dissociative disorder is associated with inability to recall important personal information usually of traumatic nature that is too extensive to be explained by ordinary forgetfulness.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine A 36 year-old patient presents requesting something to help him sleep. He reports that he has always had a problem sleeping, admits to feeling nervous most days for the last 2 years, and that he has always been "uptight" and a "worry wart." During the previous eight months he has frequently felt tense, shaky, sweaty, with palpitations and frequent headaches. He reports being irritable with his 5 year-old son. Which of the following is the best treatment option for this patient? A. Alprazolam (Xanax) B. Haloperidol (Haldol) C. Paroxetine (Paxil) D. Diphenhydramine (Benadryl)
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Explanations (u) A. Benzodiazapines should not be used in generalized anxiety disorder (GAD) as they only help symptoms short- term and should not be used long-term. (u) B. Antipsychotic medications are not useful in generalized anxiety disorder. (c) C. SSRI's, specifically Paxil, are the mainstay for treatment of generalized anxiety disorder. (u) D. Antihistamines are not useful in the treatment of generalized anxiety disorder.
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Diagnosis/Psychiatry/Behavioral Medicine A patient presents with an episode of an expansive, elevated mood during which she cleaned excessively without sleeping. Which of the following is the most likely diagnosis? A. Major depressive disorder B. Bipolar disorder C. Schizoaffective disorder D. Dysthymic disorder
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Explanations (u) A. Criteria for major depressive disorder do not include elevated expansive moods. (c) B. Bipolar disorder is characterized by episodic mood shifts from depression to manic type moods which is often rapid with depression lasting longer than manic episodes. Bipolar disorder may initially present with a manic episode. (u) C. Schizoaffective disorder presents with a mood disorder and characteristics of schizophrenia. (u) D. Dysthymia has no elevated moods or manic type behaviors.
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Clinical Intervention/Psychiatry/Behavioral Medicine A patient is started on a new antipsychotic medication for his disorder. Three days later he develops altered consciousness, lead-pipe rigidity, diaphoresis and catatonia. Vital signs reveal respiratory rate of 20, temperature of 105.6 degrees F, and pulse oximetry of 95% room air. Which of the following would be the most appropriate initial intervention in this patient? A. Immediate oral SSRI's and Benadryl B. Supportive care with fluids and antipyretics C. IV antibiotics and naloxone D. Intubation and mechanical ventilation
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Explanations (u) A. See B for explanation. (c) B. Neuroleptic malignant syndrome is characterized by extrapyramidal signs, blood pressure changes, altered consciousness, hyperpyrexia, muscle rigidity, dysarthria, cardiovascular instability, fever, pulmonary congestion and diaphoresis. Controlling fever and fluid support are the best initial management. With a normal pulse oximetry mechanical ventilation is not indicated. (u) C. See B for explanation. (u) D. See B for explanation.
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Diagnostic Studies/Psychiatry/Behavioral Medicine A 52 year-old female complains of bouts of anxiety and depression, the latter very deep but short lived (<24 hours). She states "I often feel like I am going to jump out of my skin". Her periods have become less frequent over the past 6 months. She denies suicidal ideations. She is not sleeping through the night. Which of the following the most appropriate next step in this patient? A. Check a follicle-stimulating hormone level B. Start a tricyclic antidepressant C. Refer her to a psychiatrist D. Endometrial biopsy
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Explanations (c) A. An FSH level should be assessed in this patient to evaluate for menopause as a cause for her psychiatric symptoms. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. Endometrial biopsy is indicated in a perimenopausal female with menorrhagia.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine A 25 year-old female presents to the emergency department after she collapsed at work. Medical history is significant for a mood disorder that causes her to have "wild mood swings and reckless behavior" according to her husband. She was diagnosed a year ago and since has been treated with several medications. Her symptoms today consist of nausea, vomiting, fatigue, tremor, and hyperreflexia. Lab results show an elevated BUN and creatinine, low sodium and elevated drug levels. All other results are normal. Which of the following medications is most likely the cause of her symptoms? A. Lithium (Lithobid) B. Lorazepam (Ativan) C. Carbamazepine (Tegretol) D. Risperidone (Risperdal)
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Explanations (c) A. Any sodium loss results in increased lithium levels. Signs and symptoms include vomiting and diarrhea which exacerbate the problem. Tremors, muscle weakness, confusion, vertigo, ataxia, hyperreflexia, rigidity, seizures, and coma may also be present. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following classes of antidepressants is associated with anticholinergic side effects, including cardiac dysrhythmias, dry mouth, sedation, and orthostatic hypotension? A. Selective serotonin reuptake inhibitors B. Monoamine oxidase inhibitors C. Tricyclic antidepressants D. Atypical antidepressants
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Explanations (u) A. SSRI's do not generally cause anticholinergic side effects. (u) B. MAOI's mainly cause orthostatic hypotension and sympthomimetic effects. (c) C. TCA's have well known anticholinergic effects. (u) D. Atypical antidepressants do not cause anticholinergic side effects.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine Which of the following is the treatment of choice for benzodiazepine intoxication? A. Flumazenil (Romazicon) B. Naloxone (Narcan) C. Chlordiazepoxide (Librium) D. Clonidine (Catapres)
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Explanations (c) A. Flumazenil is the treatment of choice for benzodiazepine intoxication. (u) B. Naloxone is used for the treatment of opioid intoxication and withdrawal. (u) C. Chlordiazepoxide is used for alcohol detoxification. (u) D. Clonidine is an alpha blocker that is often used for withdrawal from opioids, alcohol, benzodiazepines, or nicotine.
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Diagnostic Studies/Psychiatry/Behavioral Medicine What laboratory test must be monitored frequently in patients who are taking clozapine (Clozaril)? A. Thyroid stimulation hormone B. White blood cell count C. Platelet count D. Aspartate aminotransferase
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Explanations (u) A. See B for explanation. (c) B. Leukopenia, granulocytopenia, and agranulocytosis occur in approximately 1% of patients on this medication, clozapine should not be dispensed without proof of monitoring. (u) C. See B for explanation. (u) D. See B for explanation.
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Diagnosis/Psychiatry/Behavioral Medicine A 32 year-old female presents to the office with the complaint of worry which she can not control for the last six months. She tells you that she has symptoms at least four times per week consisting of sleep disturbances, difficulty concentrating and irritability. What is the most likely diagnosis? A. Panic disorder B. Generalized anxiety disorder C. Posttraumatic stress disorder D. Obsessive-compulsive disorder
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Explanations (u) A. Panic disorder typically involves certain situations or phobias rather than generalized symptoms. (c) B. A patient needs to have symptoms for more days than not for six months or more, need 3 of 6 symptoms to diagnose generalized anxiety disorder. (u) C. Posttraumatic stress disorder is characterized by development of symptoms after exposure to traumatic events. (u) D. In obsessive-compulsive disorder patients have symptoms of intrusive thoughts, rituals, preoccupations, and compulsions.
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Clinical Intervention/Psychiatry/Behavioral Medicine A 35 year-old male patient comes back to the office for a follow-up visit. He remarks that after 5 weeks on fluoxetine (Prozac) 20 mg per day, he still feels depressed but he denies suicidal ideations. What should you do to help this patient? A. Switch to tricyclic antidepressant B. Increase the dose of fluoxetine C. Switch the patient to divalproex (Depakote) D. Admit the patient to the behavioral health unit
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Explanations (u) A. Tricyclics are second line in the treatment of depression. (c) B. An antidepressant should be raised to the recommended level and maintained at that level for 4-5 weeks, this patient was on too low of a dose. (u) C. Divalproex is a drug that is used to treat seizures and bipolar disorder. (u) D. This patient denies suicidal ideations, and is not in need of an admission to the behavioral health unit.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine You are treating a patient for her first episode of major depression. She has no medical problems and there is no family history of psychiatric disorders. In addition to psychotherapy, which class of drugs should be your first choice for the treatment of this patient? A. Monamine oxidase inhibitors (MAOIs) B. Tricyclic antidepressants (TCAs) C. Selective serotonin reuptake inhibitors (SSRIs) D. Serotonin dopamine antagonists (SDAs)
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Explanations (u) A. MAOIs should not be first choice in the treatment of this patient because of the concern for potentially lethal hypertension and the need for a restrictive diet. (u) B. Although, TCAs are effective in the treatment of depression, they are not considered first line and have a significant risk of death with overdose. (c) C. SSRIs are the first line treatment for depression because of ease of use, safety, and broad spectrum of treatment. (u) D. SDAs or atypical antidepressants are not first line treatment for depression.
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Diagnostic Studies/Psychiatry/Behavioral Medicine What laboratory test should be followed routinely every six to twelve months in patients taking lithium? A. Complete blood count B. Calcium C. Potassium D. Thyroid stimulating hormone
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Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Lithium induces hypothyroidism because of the decrease in concentration of circulating thyroid hormones.
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Health Maintenance/Psychiatry/Behavioral Medicine Who is the most likely adult to sexually abuse a child? A. School teacher B. Friend of the family C. Scout leader D. Family member
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Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation (c) D. Adults within the immediate or extended family perpetrate the most child sexual abuse, usually this is a trusted member of the family.
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History & Physical/Psychiatry/Behavioral Medicine On performing a mental status examination you notice that the patient tends to repeat words and phrases out of context to your questions. This type of thought disorder is defined as which of the following? A. Flight of ideas B. Perseveration C. Circumstantiality D. Derailment
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Explanations (u) A. With flight of ideas, thoughts move from one topic to another with rapid speech. (c) B. Definition of perseveration is the persistent repetition of words or concepts in the process of speaking. This is often seen in cognitive disorders, schizophrenia, and other mental illness. (u) C. Circumstantiality includes much detail, but information is not relevant. (u) D. Derailment is speech with loose associations and sentences that do not make sense.
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Clinical Therapeutics/Psychiatry/Behavioral Medicine Higher doses of SSRIs are usually required in which of the following conditions? A. Obsessive-compulsive disorders B. Depression C. Manic depression D. Panic disorder
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Explanations (c) A. Higher doses of SSRIs are needed in the treatment of OCD for a beneficial effect. (u) B. Although patients with depression may occasionally need to have an increase in the SSRI dosage, higher doses are not needed for beneficial effect. (u) C. Patients who are bipolar will often have worsening of their manic symptoms with the use of SSRIs. (u) D. SSRIs are good drugs to treat patients with panic disorder, however, these patients are particularly sensitive to the activating effects of SSRIs, so they should be started initially at small dosages and titrated up slowly.
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Diagnostic Studies/Psychiatry/Behavioral Medicine What laboratory test should be closely monitored in patients on long-term lithium treatment for bipolar disorder? A. ALT B. Calcium C. Lipase D. TSH
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Explanations (u) A. See D for explanation. (u) B. See D for explanation. (u) C. See D for explanation. (c) D. Patients with bipolar disorder and those on long term lithium therapy are prone to hypothyroidism severe enough to require treatment. Liver and pancreatic complications are not a common concern. Electrolyte/renal issues can arise with poor fluid intake and severe vomiting and diarrhea, calcium does not require routine monitoring.
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Diagnostic Studies/Psychiatry/Behavioral Medicine A 25 year-old female presents with signs and symptoms of depression. She does not have any other known medical problems. What diagnostic study is indicated in the initial evaluation of this patient? A. Thyroid stimulating hormone (TSH) B. Prolactin C. Growth hormone (GH) D. Cortisol
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Explanations (c) A. Patients who are presenting with symptoms of depression should be evaluated with a TSH because 10 percent of patients evaluated for depression have previously undetected thyroid dysfunction. (u) B. See A for explanation. (u) C. See A for explanation. (u) D. See A for explanation.
