PSYCHIATRY

STEP 1 REVIEW
F E B R U A RY 2 8 , 2 0 1 1
 APPROACH TO QUESTIONS

• Underline/count/highlight EACH
SYMPTOM

• Make note of the DURATION of the

symptoms being described

• Rule out MEDICAL causes

 FREQUENTLY TESTED PSYCHOLOGY
CONCEPTS

• “White Coat Syndrome” Classical

Conditioning
• when a natural response (increase in BP) is
elicited by a conditioned stimulus (white coat)

• Transference
• Patient projects feelings about another person onto
psychiatrist

• Countertransference
• Doctor projects feeling about another person onto patient
 EGO DEFENSES
• GUARANTEE – you will be asked at least 1 question about this
• Immature…
• Acting Out
• Dissociation – can result in multiple personality disorder
• Denial – common when someone first hears of a diagnosis
• Displacement – mother towards child
• Fixation
• Identification
• Isolation of affect
• Projection
• Rationalization – logical reasoning to explain events
• Reaction formation – think opposite
• Regression
• Repression – NOT voluntary (vs suppression)
• Splitting – borderline personality disorder; think extremes
 EGO DEFENSES (CONT’D)

• Mature…
• Altruism
• Humor
• Sublimation
• Suppression - VOLUNTARY
 CHILD NEGLECT

• Any question that hints towards child neglect

and/or abuse…

REPORT to local child

protective services!!
 CHILDHOOD/EARLY-ONSET

• ADHD = limited attention; poor impulse

control
• Before age 7
• two settings
• Decreased frontal lobe volumes
• Tx = methylphenidate, amphetamines,
atomoxetine

• Conduct Disorder = behaviors that violate

social norms
• If > 18y/o = antisocial personality disorder
 CHILDHOOD/EARLY-ONSET

• Oppositional Defiant Disorder = defiant

behavior towards authority figures

• Tourette Syndrome = motor and vocal tics

• > 1 year
• Onset < 18 y/o
• Associated with OCD
• Tx = antipsychotics (haldol)
• D2 receptor blockers
 PERVASIVE DEVELOPMENTAL
• Autism = repetitive behaviors, poor social
interactions, language impairment
• Tx = behavioral and supportive therapy

• Asperger’s Disorder
• Normal intelligence; no language impairment

• Rett’s Disorder
• X-linked; mostly girls
• Normal until 4 y/o and then regress;
handwringing
 AMNESIA

• Retrograde
• Don’t remember events that occured before the
insult

• Anterograde
• No new memory

• Korsakof
• Anterograde caused by THIAMINE deficiency
• Destruction of mamillary bodies
• Alcoholics; confabulation
 DELIRIUM VS. DEMENTIA

DELIRIUM DEMENTIA
• Waxing and waning • No change in level of
level of consciousness consciousness
• Acute onset • Gradual
• Reversible • Irreversible
• Hallucinations, • Behavioral/personality
illusions, changes
misperceptions • Normal EEG
• Abnormal EEG • Caused by: Alzheimer’s,
hemorrhage, HIV, Pick’s,
CJD
 SCHIZOPHRENIA

• 2 or more of the following symptoms…

• Delusions – fixed, false belief
• Hallucinations – perception in the absence of a
stimulus
• Disorganized Speech
• Disorganized or Catatonic Behavior
• “Negative Symptoms” – flat affect, social
withdrawl, lack of motivation, lack of speech
• Symptoms must be present for > 6 months
• if < 1 month = brief psychotic disorder
• If 1 – 6 months = schizophreniform disorder
 BIPOLAR DISORDER

• Presence of at least one manic or hypomanic

episode
• The depression will occur eventually if it hasn’t
already
• Mania = 3 or more of the following sympotms
• Distractability
• Irresponsibility
• Grandiosity
• Flight of ideas
• Increased goal-directed activity
• Decreased need for sleep
• Talkativeness (pressures speech)
 BIPOLAR DISORDER (CONT’D)

• Hypomania
• Less severe form of mania that does not cause
impairment
• No psychosis; no hospitalization

• Treatment = mood stabilizers

• Lithium, valproic acid, carbamazepine

• Cyclothymic Disorder
• Duration of 2 years
 MAJOR DEPRESSIVE DISORDER

• 5 or more of the following symptoms

• Change in sleep habits
• Loss of interest
• Feeling of guilt
• Decreased energy
• Inability to concentrate
• Change in appetite
• Psychomotor retardation or agitation
• Suicidal thoughts
• Symptoms must be present for 2 weeks
• 1st line treatment = SSRI
• Dysthymia = milder form; lasting 2 years
 ATYPICAL DEPRESSION

• Hypersomnia
• Overeating that leads to weight gain
• Mood reactivity

• Treatment = MAO Inhibitors

 POSTPARTUM BLUES

• Benign

• Lasts up to 10 days postpartum

• Tx = watchful waiting

• If there is anhedonia, then postpartum depression

 PANIC DISORDER

• Presence of panic attacks

• A discrete time period (around 10 mins long) in which at
least 4 of the following are experienced
• Palpitations
• Paresthesia
• Abdominal discomfort
• Nausea
• Intense fear of dying
• Light-headedness
• Chest pain
• Chills
• Choking
• Sweating
• Shaking
• Shortness of breath
• Associated with hyperventilation and decreased pCO2
 PTSD

• Traumatic event must have involved actual or

threatened death and/or harm
• Symptoms include…
• Nightmares
• Flashbacks
• Intense fear
• Helplessness
• Easily startled
• Symptoms must be present for at least 1
month; and it must be 1 month after the
event
• if 2 days – 1 month = acute stress disorder
GENERALIZED ANXIETY DISORDER

• Uncontrollable anxiety/worrying that is

UNRELATED to anything
• If RELATED to something, then it is a specific phobia

• Lasting at least 6 months

 MALINGERING VS. FACTITIOUS
FACTITIOUS
MALINGERING DISORDER
• Consciously fakes a • Consciously creates
disorder symptoms
• Seeking secondary • seeking primary gain
gain • Willingness to receive
• Avoids treatment treatment
• “Munchausen’s
syndrome”
• “by proxy” when illness
in a child is caused by
caregiver
 SOMATOFORM DISORDERS

• Physical symptoms without a physical cause

• Unconsciously driven
• Somatization disorder
• At least 4 pain, 2 GI, 1 sexual and 1
pseudoneurologic complain over a period of years
• Conversion disorder
• Motor or sensory symptoms following an acute
stressor
• Hypochondriasis
• Body dysmorphic disorder
• Pain disorder
CLUSTER A PERSONALITY DISORDERS

• Think “weird”

• Paranoid

• Schizoid
• Socially isolated and withdrawn
• Content about the above
• Limited emotional expression

• Schizotypal
• Eccentric
• Magical thinking
• Odd beliefs
CLUSTER B PERSONALITY DISORDERS
• Think “wild”
• Antisocial
• Criminality
• REMEMBER….if < 18y/o = conduct disorder
• Borderline
• Unstable mood; impulsivity
• Unstable relationships
• Self-mutilating
• REMEMBER…splitting
• Histrionic
• Attention seeking
• Narcissistic
• grandiose thinking; lacks empathy
CLUSTER C PERSONALITY DISORDERS

• Think “worried”

• Avoidant
• Socially inhibited but desires relationships

• Obsessive compulsive
• Preoccupation with perfectionism

• Dependent
• Excessive need to be taken care of
 EATING DISORDERS
ANOREXIA
NERVOSA BULIMIA
• Excessive dieting • Binge eating with
• Fear of gaining weight purging
• Decreased bone • Parotitis
density • Enamel erosion
• Amenorrhea (from loss • Hand calluses
of pulsatile secretion • “Russell’s sign”
of GnRH from
hypothalamus)
• Decreased LH, FSH,
estradiol
 SUBSTANCE ABUSE

• Alcohol…
• Serum GGT is a sensitive indicator of alcohol use
• Tx for overdose = naltrexone, disulfiram
• Tx for withdrawl/DT = benzodiazepines
• Opiods (morphine, heroin, methadone)…
• Overdose leads to pinpoint pupils
• Tx for overdose = naloxone, naltrexone
• Tx for withdrawl = methadone
• Barbiturates…
• Overdose can cause respiratory depression
• Benzodiazepines…
• Tx for overdose = flumazenil
 SUBSTANCE ABUSE (CONT’D)

• Amphetamines…
• Overdose causes pupillary dilation
• Cocaine…
• Tx of overdose = benzodiazepines
• Nicotine…
• Tx of withdrawl = bupropion/varenicline
• PCP…
• Overdose leads to: belligerence
(aggressiveness), nystagmus and homicidality
• LSD…
• Overdose leads to: hallucinations, flashbacks
 ANTIPSYCHOTICS

• Typical = haloperidol + “azines” (ex:

thioridazine)
• Block dopamine D2 receptors
• Used to treat: positive symptoms of schizophrenia,
psychosis, acute mania, Tourette’s
• Toxicity…
• Hyperprolactinemia that can lead to galactorrhea and
amenorrhea
• NMS – fever, muscle rigidity, unstable vitals; tx = dantrolene
• Tardive dyskinesia – oral/facial movements from long-
term use
• Atypical = olanzapine, clozapine, risperidone
• Used to treat: positive AND NEGATIVE symptoms of
schizophrenia
• Toxicity…
 LITHIUM

• Mood stabilizer used in the treatment of bipolar

disorder
• Many side effects…
• ADH antagonist characteristics so can cause
nephrogenic diabetes insipidus
• HYPOthyroidism
• Tremors
• Teratogenic
 ANTIDEPRESSANTS
• TCAs = end in “pramine” or “triptyline”
• Also used for the treatment of fibromyalgia
• Anticholinergic side effects
• Toxicity…Convulsions, Coma, Cardiotoxicity
• SSRIs = fluoxetine, paroxetine, sertraline, citalopram
• Can cause sexual dysfunction
• Serotonin Syndrome
• Hyperthermia, muscle rigidity, cardiovascular collapse,
flushing, diarrhea, seizures
• tx. = cyproheptadine
• SNRIs = venlafaxine, duloxetine
• MAO inhibitors = phenelzine, selegiline
• Hypertensive crisis with tyramine ingestion (wine and
cheese)
 ATYPICAL ANTIDEPRESSANTS

• Bupropion
• Can cause seizures

• Mirtazapine

• Maprotiline

• Trazodone
• Used for insomnia
• Can cause men to have a prolonged erection
(priapism)
 KNOW YOUR TRANSMITTERS

• Anxiety
• Decreased: NE, GABA, serotonin
• Depression
• Decreased: NE, serotonin, dopamine
• Alzheimer’s
• Decreased: ACh
• Huntington’s Disease
• Decreased: GABA, Ach
• Schizophrenia
• Increased: dopamine
• Parkinson’s
• Decreased: dopamine
• Increased ACh
PRACTICE QUESTIONS
A 24-yeal-old man with chronic schizophrenia is
brought to the emergency room after his parents
found him in his bed and were unable to
communicate with him. On examination, the man
is confused and disoriented. He has severe muscle
rigidity and a temperature of 103F. His BP is
elevated and he has a leukocytosis. Which of the
following is the best first step in the pharmacologic
treatment of this man?

A – haloperidol
B – lorazepam
C – dantrolene
D – benztropine
E – lithium
A 19-year-old man is brought to the physician by
his parents after he called them from college,
terrified that the mafia was after him. He is
convinced that the mafia has put cameras in his
dormitory room. He occasionally hears the voices
of two men talking when no one is around. His
roommate states that for the past 2 months he
has been increasingly withdrawn and suspicious.
What is the most likely diagnosis?

A – delusional disorder
B – schizoaffective disorder
C – schizophreniform disorder
D – schizophrenia
E – PCP intoxication
A 27-year-old woman has been feeling blue for
the past 2 weeks. She has little energy and has
trouble concentrating. She states that 6 weeks
ago she had been feeling very good, with lots of
energy and no need for sleep. She says that this
pattern ahs been occurring for at least the past
3 years, though the episodes have never been
so severe that she couldn’t work. What is the
most likely diagnosis?

A – borderline personality disorder

B – seasonal affective disorder
C – cyclothymic disorder
D – major depression, recurrent
E – bipolar disorder
A 13-year-old girl grunts and clears her throat
several times in an hour, and her conversation
is often interrupted by random shouting. She
also performs idiosyncratic, complex motor
activities. She can prevent these movements
for brief periods of time, with effort. Which of
the following is the most appropriate treatment
for this disorder?

A – psychotherapy
B – lorazepam
C – methylphenidate
D – haloperidol
E – imipramine
A 26-year-old woman comes to the psychiatrist
with a 1-month history of severe anxiety. The
patient states that 1 month ago she was as
“normal, laid-back person”. Since that time she
rates her anxiety an 8 on a scale of 1 to 10, and
also notes she is afraid to leave the house
unless she checks that the door is locked at
least 5 times. Which of the following medical
conditions could commonly cause this kind of
symptom presentation?

A – hyperglycemia
B – Crohn’s disease
C – hyperparathyroidism
D – fibromyalgia
E – peptic ulcer disease
A 20-year-old woman comes to her primary care
doctor with multiple symptoms which are present
across several organ systems. She has seen five
doctors in the past 3 months and has had 6
surgeries since the age of 18. What is the most
likely diagnosis?

A – somatization disorder
B – conversion disorder
C – hypochondriasis
D – body dysmorphic disorder
E – pain disorder
A young librarian has been exceedingly shy and
fearful of people since childhood. She longs to
make friends, but even casual social interactions
cause her a great deal of shame and anxiety. She
has never been to a party, and she has requested
to work in the least active section of her library,
even though this means lower pay. She cannot
look at her rare customers without blushing, and
she is convinced that they see her as incompetent
and clumsy. Which of the following personality
disorders is most likely?

A – schizotypal
B – avoidant
C – dependent
D – schizoid
Three policemen, with difficulty, drag an agitated
and very combative young man into an
emergency room. Once there, he is restrained
because he reacts with rage and tries to hit
anyone who approaches him. When it is finally
safe to approach him, the resident on call notices
that the patient has very prominent vertical
nystagmus. Shortly thereafter, the patient has a
generalized seizure. Which of the following
substances of abuse is most likely to produce this
presentation?

A – amphetamine
B – PCP
C – cocaine
D – meperidine