Borderline Personality Disorder: Diagnosis, Prevalence, and Treatment, Exams of Medicine

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Exam Bank for PMHNP Boards | Questions and Answers 100% Verified What is true of interprofessionality? - ANSWER - All health professionals have individual professional competencies What is the significance of an experimental p-value of 0.05 - ANSWER - There is a 5% chance of a similar result occurring by chance alone What percentage of children with oppositional defiance disorder will develop conduct disorder? - ANSWER - 30% In the DSM-5, selective mutism is now considered what type of disorder? - ANSWER - anxiety disorder Symptoms of selective mutism must persist for at least - ANSWER - 1 month Common competencies - ANSWER - overlap more than one health care professional, although not necessarily all health care professionals, and are competencies expected of all health care professionals Complementary competencies - ANSWER - enhance the qualities of other professions in provision of care Collaborative competencies - ANSWER - those that each individual profession must possess to work with others, including those who practice within different specialties within a profession. Interpersonal collaboration is _______ centered - ANSWER - patient Cognitive therapy is recommended for patients that have - ANSWER - negative cognitive distortions irrational beliefs faulty conceptions Humanistic Therapy focuses on assisting patients with - ANSWER - self-actualization and self-directed growth Behavioral Therapy focuses on - ANSWER - changing maladaptive behaviors through the use of behavioral modification techniques Existential therapy is for - ANSWER - reflection on life confronting self 120 who got diarrhea ate lettuce. 80 with diarrhea did not eat lettuce. 40 without diarrhea ate lettuce. 160 without diarrhea ate lettuce. What is the odds ratio of eating lettuce and developing diarrhea? - ANSWER - 6 ((120X160)/(80x40)) The New Freedom Commission on Mental Health (NFCMH) released a report that suggested - ANSWER - implementation a national campaign to reduce the stigma of seeking care Focusing on promoting recovery and building resilience The efficacy of mental health treatments was found to be well documented in - ANSWER - influential report issued by US Surgeon General in 1999 State of high negative emotion and pessimism - ANSWER - neuroticism Commonly known as an optimistic outlook on life They are are outgoing, like social interaction, respond to external rewards, have more active dopamine networks, and are responsive to positive reinforcement. - ANSWER - Extraversion (high levels protect from psychiatric illness) Introverts are more likely to be _______ motivated and more likely to respond to _______ reinforcement - ANSWER - internally negative (more likely to interact with internal motivation/self-image) Interpersonal trait of cooperation, easy going nature. Tend to have smooth relationships often at the expense of self-assertion - ANSWER - Agreeableness Associated with self-control and a focused, organized approach to life. Are achievement-oriented goal setters who can delay immediate gratification to obtain their long term desired outcome. They are considered responsible, reliable, and dependable. - ANSWER - conscientiousness In behavioral couples therapy, the initial sessions are spent doing a functional analysis of behavior (FAB). What is true about FAB? - ANSWER - FAB is concerned only with observable stimuli connected to operant behavior FAB is based on operant conditioning (identifying antecedent stimuli, operant behaviors, and consequent stimuli) The goal of FAB is modifying willful operant behavior Gestalt theory deals with _____, not _____ - ANSWER - perceptual psychology behavior Medication that can delay ejaculation in patients with premature ejaculation - ANSWER - Paroxetine (and other SSRIs) (others include: Topical anesthetic Mood disorder Cognitive dysfunction Dementia Psychosis Hallucinations What type of therapy is most useful in depressed HIV positive outpatients? - ANSWER - Interpersonal psychotherapy What type of therapy is most useful in patients with borderline personality disorder? - ANSWER - Dialectical behavioral therapy The NP is caring for a patient dying of lymphoma. The pt's wife states that the pt has been mismanaged and that another practitioner must be assigned to the patient for him to improve. This NP suspects that this individual is in which stage of grief according to Elizabeth Kugler-Ross? - ANSWER - Bargaining Involves resisting or refusing to remember information that has been supplied - ANSWER - Denial Pica and spoon shaped nails are associated with - ANSWER - Iron-deficiency anemia (microcytic) 2 common causes of microcytic anemia - ANSWER - iron deficiency anemia of inflammation/chronic disease (TB, HIV, endocarditis, RA, Chrohn's DM, kidney disease, CA) (Other causes: lead toxicity, alcohol/drug use, zinc excess (copper deficiency)) Initial symptoms of B12 deficiency - ANSWER - Generalized weakness Paresthesias Possible ataxia Late symptoms of B12 deficiency - ANSWER - Memory impairment Depressed mood 5 P's of Vitamin B12 deficiency - ANSWER - Pancytopenia (Peripheral and Posterior spinal cord) neuropathy Pyramidal tract signs Papillary atrophy of tongue (atrophic glossitis) 2 causes of megaloblastic macrocytic anemias - ANSWER - Vitamin B12 deficiency Folate deficiency What neurotransmitter is thought to play the most significant role in social phobia? - ANSWER - dopamine What neurotransmitter is thought to mediate social interest, gregariousness, confidence and sensitivity to rejection? - ANSWER - dopamine According to Gonzalez-Jaimes and Turnbull-Plaza (2003, which type of therapy with psychocorporal, cognitive, and neurolinguistic components and a holistic focus is significantly more effective in patients diagnosed with adjustment disorder? - ANSWER - mirror psychotherapy The ________ is part of the treatment to encourage a patient to accept his physical condition - ANSWER - mirror Discussing medical diagnoses and the reaction to it, as well as treatment modalities - ANSWER - medical conversation Therapy that emphasizes personal responsibility, focusing on the individual's experience at the present moment, the therapist-patient relationship, the context of the person's life, and adjustments people make as a result of their overall situation - ANSWER - Gestalt Therapy PANDAs is associated with _________ infections and results in _______ symptoms - ANSWER - Group A beta-hemolytic strep OCD After camping trip, pt began to have a petechial rash on her legs/trunk, parts of which are turning dark red and purple, temp 102.8, HR 1115, BP 88/50, mm pain, neck stiffness, severe HA. What is the dx? - ANSWER - meningococcemia 1 mg of Xanax = _____ mg of Ativan - ANSWER - 2 1mg of Xanax = ____mg of phenobarbital - ANSWER - 30 1mg Xanax = ____ mg of Clonazepam (Klonopin) - ANSWER - 1 1mg Xanax = ____ mg of chlordiazepoxide (Librium) - ANSWER - 25 1mg of Xanax = ____ mg of diazepam (Valium) - ANSWER - 10 Pt wanting something immediate and non-addictive for breakthrough anxiety - ANSWER - Hydroxyzine How long do GAD symptoms need to occur to make the diagnosis? - ANSWER - 6 months First lab test to check for Sjogren's - ANSWER - Anti-nuclear antibody tests To diagnose Cyclothymic disorder, it must be present for _______ in adults - ANSWER - 2 years To diagnose Cyclothymic disorder, it must be present for _______ in pediatrics - ANSWER - 1 year 4 physiological disturbances that may explain some of the symptoms of panic - ANSWER - impaired lactate metabolism abnormality of locus coeruleus (Ser, NE, GABA, Dop, cholecystokinin) carbon dioxide hypersensitivity (hyperventilation) A 45-year-old man presents to the ER for "panic attack". He appears agitated, confused, and dizzy. He became more agitated and combative with staff upon further questioning. He states he was prescribed Xanax 0.5mg 3x daily by outpatient psychiatrist. His vitals are WNL. What is most likely his dx - ANSWER - Benzodiazepine intoxication Anxiety, tremors, nightmares, insomnia, anorexia, nausea, vomiting, hypotension, seizures, delirium and hyperprexia are sx of. ______ which can result in _______ - ANSWER - Benzodiazepine withdrawal (serious medical complications including death) Confusion, AH, VH following a period of insomnia can be a sx of - ANSWER - withdrawal delirium Female patients with PTSD commonly have this comorbid diagnoses - ANSWER - Major depressive disorder (50%) Percentage of people with PTSD who have alcohol use disorder - ANSWER - male 50% female 27% Percentage of people with PTSD who have simple or social phobias - ANSWER - 30% both male and female Percentage of people with PTSD who have persistent depressive disorder ( previously dysthymia) - ANSWER - 20% for both male and female Treatment plan for OCD - ANSWER - SSRI or Clomipramine Psychotherapy Normal Rinne test is for this nerve - ANSWER - CN VIII What ethnic groups are at higher risk for social phobia - ANSWER - Native American In what Tanner's stage will a male's pubic hair look more like an adult, but will not cover as much area. Where penis will thicken, testes and scrotum continue to grow. - ANSWER - IV Brain structure R/T development of GAD - ANSWER - Amygdala What circumstance(s) are often correlated to the onset of panic disorder - ANSWER - separation from family serious illness of friend/family accident major relationship loss/change abusing substances postpartum Lifetime prevalence of anxiety disorders in the US - ANSWER - 25-35% (18% prevalence) Buspar needs ______ to have similar efficacy to benzodiazepines - ANSWER - 4 weeks How many panic symptoms must be present for diagnoses. - ANSWER - 4 Part of Brain responsible for smell - ANSWER - Limbic Part of brain (lobe) responsible for visual functions - ANSWER - Occipital Part of brain (lobe) responsible for sensory integration and somatosensory function - ANSWER - Parietal Part of brain (lobe) responsible for executive function, social conduct, judgement, and some motor function - ANSWER - Frontal Occasional crossing of eyes is not normal after the infant is older than ___________ - ANSWER - 2 months If strabismus is left untreated, what may result? - ANSWER - ambylopia (affected eye decrease in vision) What would be the normal testosterone level of a Tanner V male - ANSWER - 265-800 ng/dl Bactrim is contraindicated in - ANSWER - Glucose-6-phosphatase deficiency Folate deficiency anemia patients with significant hepatic impairment pregnant patiens Pt has severe headache behind right eye with eye pain and tearing, sees halos around light fixtures. C/o N/V. R pupil fixed more oval than round, mid-dilated and cloudy. What might be happening - ANSWER - Acute angle closure glaucoma (Emergency) What STD is not reportable in all 50 states - ANSWER - HPV Romberg test is a test of - ANSWER - balance A child will recognize faces and smile appropriately at familiar faces by age ____ - ANSWER - 3 A typical _____ can count up to 20 with minimal assistance of an older child or parent - ANSWER - 4 year old A typical _____ can run/walk up and down the stairs - ANSWER - 21 month old A typical _____ is beginning to acquire language skills - ANSWER - 14 month old What herbal supplement is effective for a pt with an adjustment disorder with anxiety according to RCT - ANSWER - Kava Kava What herbal supplement is effective for somatoform disorders according to RCT - ANSWER - St. John's Wort Recurrent spontaneous episodic vertigo, hearing loss. Must have aural fullness or tinnitis on one size to make dx. - ANSWER - Meniere's Disease ADPIE stands for - ANSWER - Assessment Diagnosis Planning Implementation Evaluation If diagnosed with an adjustment disorder, which dx is most guarded: that of an adult or that of an adolescent? - ANSWER - adolescent (more likely to develop major psychiatric illness) Gastrointestinal lithium toxicity symptoms can overlap with - ANSWER - normal side effects (N/V) What is FDA approved for suicidality in schizophrenia - ANSWER - Clozapine Clozapine can cause this CBC abnormality - ANSWER - leukopenia (agranulocytosis) What is the dependent variable of a study examining the effects of a certain medication on hypertension? - ANSWER - Blood pressure What is the independent variable of a study examining the effects of a certain medication on hypertension? - ANSWER - Medication Effect of a variable that is not controlled - ANSWER - Confounding effect Type of error that results in the way the experiment is conducted, often due to the expectations of the researcher - ANSWER - Bias Pharmacological treatment of alcohol use disorder - ANSWER - Start Naltrexone at 25mg PO daily (1-hour observation for rxn). Naltrexone maintenance dose is usually 50mg PO q day or 380mg IM q 4 weeks Naltrexone side effects - ANSWER - Elevated LFTs Mild dysthymia GI upset Resembles GABA and is possibly an NMDA antagonist - ANSWER - Acamprosate Aldehyde dehydrogenase inhibitor - ANSWER - Disulfiram (Antabuse) Modest efficacy, may work better in combination with Naltrexone for alcohol use disorder - ANSWER - Acamprosate No convincing efficacy found for use of this Alcohol Use Disorder pharmacological treatment - ANSWER - Disulfiram (Antabuse) Most commonly reported side effect of ECT - ANSWER - Retrograde amnesia Neurodevelopmental disorder of biological origin that manifests in learning difficulties and problems in acquiring academic skills markedly below age level and manifested in the early years for at least 6 months that is not attributed to intellectual disabilities, development disorders or neurological or motor disorders - ANSWER - Specific Learning Disorder Specific Learning Disorders can be specified as impairment in - ANSWER - Reading Written Expression Mathematics The MOST important component when developing evidence based guidelines - ANSWER - An evidence review How does botox improve depression? - ANSWER - Reducing frown lines when injected into glabellar region What is a precursor for antisocial personality disorder - ANSWER - conduct disorder List of Cluster B personality disorders - ANSWER - antisocial borderline histrionic narcissistic List the cluster A personality disorders - ANSWER - paranoid schizoid schizotypal List of Cluster C personality disorders - ANSWER - avoidant dependent obsessive-compulsive pervasive pattern of excessive emotionality and attention seeking beginning in early adulthood and present in a variety of contexts - ANSWER - Histrionic Personality Disorder A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness must last at least _______ for Oppositional Defiant Disorder diagnosis - ANSWER - 6 months Oppositional defiant disorder does not include: - ANSWER - aggression toward people or animals destruction of property pattern of theft or deceit Recurrent behavioral outburst representing a failure to control aggressive impulses. - ANSWER - Intermittent Explosive Disorder In Intermittent Explosive disorder, physical aggression does not result in - ANSWER - damage or destruction to property physical injury to animals or other individuals Kubler-Ross's stages of grief - ANSWER - denial anger bargaining depression/sadness acceptance Symptoms can be associated with another medical condition - ANSWER - Somatic symptom disorder Somatic symptom disorder symptoms persist for - ANSWER - >6 months Despite frequent doctors visits and tests, this pt is rarely reassured and can feel that his/her medical care is insufficient - ANSWER - Somatic symptom disorder In order to meet DSM V criteria for somatic symptom disorder, in addition to somatic symptoms, pts must have - ANSWER - maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms. The Mental Health Party Act (1996) provides - ANSWER - equal lifetime and annual limits for mental health care as compared to physical health care. The zoster vaccination is recommended for _____ - ANSWER - adults over the age of 60 The pneumococcal vaccination is recommended for _______ - ANSWER - adults over the age of 65 The Tdap vaccination is recommended _________ - ANSWER - every 10 years Understanding the objective reality of a situation coupled with the motivation and emotional impetus to master the situation or change behavior is: - ANSWER - true insight Form of thinking that is logical, organized, reality oriented, and influenced by the demands of the environment - ANSWER - second process thinking What percentage of the population meets the criteria for 1 or more personality disorders? - ANSWER - 15% Study on daily exercise improving sleep quality in seniors. What is the dependent variable - ANSWER - Sleep quality The federal law that allows parents to provide insurance coverage for their children up to age 26 is - ANSWER - Affordable Care Act (ACA) Pedophiles attracted to female victims usually prefer females of what age? - ANSWER - 8-10 years old What is true of appropriation bills? - ANSWER - They provide for spending authority for a single fiscal year What bills establish laws or programs and although they recommend dollar amounts in some cases, do not allocate the funds or guarantee funds for the program - ANSWER - Authorization bills What bills usually originate in the House of Representatives and provide spending authority for a single fiscal year - ANSWER - Appropriation Bills Provide additional funding for projects as needed thought the current fiscal years - ANSWER - Supplemental appropriations Authorization bills are funded by - ANSWER - Appropriation Bills What is required for entry to practice as a Nurse Practitioner - ANSWER - Competency in nine content domains The NP is caring for a 16 year old who is depressed with suicidal ideation. The pt asked the nurse NOT to tell her parents. The most appropriate intervention for the nurse to do is: - ANSWER - Talk to parents and pt together to help the family discuss the pt's depression According to Mahler, which of the following stages of infant development is disrupted in children who develop borderline personality disorder - ANSWER - Rapproachment According to Mahler, which of the following stages of development was disrupted int children who developed narcissistic personality disorder - ANSWER - Symbiotic phase Phase during first weeks of life, characterized by total detachment and self-absorption, infant spends most of his or her time sleeping - ANSWER - Autistic stage When does the symbiotic phase occur - ANSWER - about 5 months of age According to Mahler, separation-individuation has 3 stages - ANSWER - Hatching (5-9 months) Practicing (9-16 months) Rapproachment (15-24 months) Phase where infant explores the outside world but requires that the mother is present and able to support the child appropriately and emotionally in completing the task? - ANSWER - Rapprochment (15-24 months) Phase in which infant develops the physical ability to separate from mother - ANSWER - Practicing (9-16 months) Disturbance of the rapprochement subphrase is associated with - ANSWER - persistent longing for and dread of fusion with object that is thought to be secondary to aggression or withdrawal in the mother. Thought to contribute to the development of borderline personality disorder. Phase in which infant shows increased interest in outside world - ANSWER - Hatching Stage where infant recognizes his or her mother but lacks a sense of individuality - ANSWER - symbiotic intense bouts of difficult-to-control anger transient paranoia or dissociation Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation - ANSWER - Avoidant Pervasive pattern of detachment from social relationships and a restricted range of expression - ANSWER - Schizoid Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent - ANSWER - Paranoid Pervasive pattern of social and interpersonal discomfort with, and reduced capacity for, close relationships as well as cognitive or perceptual distortions and eccentricities - ANSWER - Schizotypical Pervasive pattern of grandiosity, need for admiration, and lack of empathy - ANSWER - Narcissistic Pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation - ANSWER - Dependent The prevalence of borderline personality disorder in primary care - ANSWER - 6% The prevalence of borderline personality disorder in the general population - ANSWER - 1.5-5.9% What best determines the effectiveness of an educational intervention? - ANSWER - Pt's behavior modification and compliance rates After suffering the loss of a child, more than 50% of parent couples go through the following - ANSWER - Divorce Rubbing against non-consenting people - ANSWER - frotteurism Fantasies about watching unsuspecting individuals undressed or in sexual activity - ANSWER - voyeurism Use of non-living objects for sexual stimulation - ANSWER - fettishism Exposing one's genitals to strangers - ANSWER - exhibitionism Besides therapy in Borderline Personality Disorder, impulse behavioral dyscontrol symptoms that present serious risk to patient are treated by adding - ANSWER - an antipsychotic to an SSRI In borderline personality disorder, cognitive-perceptual symptoms respond best to - ANSWER - low dose antipsychotics Impulsive-behavioral dyscontrol symptoms in borderline personality disorder - ANSWER - aggression self-mutilation reckless spending promiscuity substance abuse Affective dysregulation in borderline personality disorder is treated with - ANSWER - SSRI or venlafaxine For histrionic personality disorder, which type of therapy helps them focus on their unconscious motivations for being unable to commit to a stable and meaningful relationship, and instead seeking out disappointing partners - ANSWER - psychodynamic Temporal lobe abnormalities and differences in the corpus callous and thalamic nuclei have been identified on MRI studies of patients with which condition - ANSWER - schizotypical personality disorder Schizotypical personality disorder can be differentiated from schizophrenia by the absence of - ANSWER - psychotis Prevalence of schizotypical personality - ANSWER - 3% (more cases occur in biological relatives with schizophrenia) Affective aggression can be treated with which medication? - ANSWER - Lithium Which personality disorder is often present with pts with anorexia-nervosa who restrict rather than binge-purge - ANSWER - Obsessive-compulsive A type of identification that is seen often in borderline personality disorder pts - ANSWER - projective identification 3 steps of projective identification - ANSWER - 1. pt assigns component of self to another individual 2. pt manipulates this individual into integrating this component into his or her consciousness 3. process leads to increased feeling of closeness between parties Analyst's emotional response to pt - ANSWER - countertransference When pt tends to identify aspects as either completely good or completely bad about a person - ANSWER - Splitting Mental process that gives rise to lack of connection in the pt's thoughts, memory, and sense of identity - ANSWER - Dissociation Substance that is found in lower concentrations in the CSF of impulsive, violent individuals - ANSWER - 5-HIAA In addition to an assessment of pathological personality traits, alternate model in Section III of the DSM-5 requires an assessment of which category or a personality disorder diagnosis - ANSWER - level of impairment in personality functioning A diagnosis of a personality disorder who require at least a level _______ impairment - ANSWER - 2 ("moderate") What is the prevalence of obsessive-compulsive personality disorder in the general population - ANSWER - 5-10% Which personality disorder's criteria includes magical thinking - ANSWER - Schizotypical Females with _________ have a virilized clitoris - ANSWER - Congenital adrenal hyperplasia (CAH) A higher degree of ________ has been reported in individuals with CAH, which correlates to the degree of virilization - ANSWER - homosexuality A 2-year old girl with 21-hydroxylase deficiency undergoes genitoplasty. Which statement is true concerning her condition - ANSWER - There is a correlation between virilization degree and gender dysmorphia What is the prevalence of paranoid personality disorder among psychiatric patients? - ANSWER - 10-30% Gender identity usually begins to form by this age - ANSWER - 2 Anti-hypertensive effects on sexuality - ANSWER - impaired vaginal lubrication and erectile dysfunction d/t antiadrenergic effects Spironolactone effects on sexuality - ANSWER - decreased desire secondary to decreased testosterone Estrogen effects on sexuality - ANSWER - decreased desire secondary to decreased testosterone Steroid effects on sexuality - ANSWER - decreased desire secondary to decreased testosterone What is contraindicated in the treatment of aggressive personality changes due to epilepsy - ANSWER - antipsychotics females that have this are usually infertile have low estrogen levels but do not have higher levels of homosexuality - ANSWER - Turner syndrome(45XO) females with this are typically indistinguishable from other females except they are slightly taller and have increased learning difficulties and low-normal intelligence - ANSWER - Triple X syndrome 46XY with complete androgen insensitivity have - ANSWER - female gender identity equivalent of 46XX individuals Congenital adrenal hyperplasia is associated with increased prenatal - ANSWER - androgen exposure 5-alpha-reductase deficiency is associated with - ANSWER - higher rates of homosexuality in affected females a cause of pseudohermaphroditism Gender identity is generally set by age ____ and very difficult to change - ANSWER - 3 First line agents for treating impulsivity and aggression in personality disordered patients - ANSWER - SSRIs Explain what the following Pyramid Tract Signs result from: spasticity weakness slowing of rapid alternating movements hyper-reflexia Babinski sign - ANSWER - Vitamin B12 deficiency The only TCA levels that can be reliably followed are for - ANSWER - desipramine imipramine nortriptyline A transgender male is sexually attracted to men/masculinity. What is his sexual orientation? - ANSWER - Androphilic A transgender male is sexually attracted to females/femininity. What is his sexual attraction? - ANSWER - Gynephilic A transgender female is sexually attracted to females/femininity. What is her sexual attraction? - ANSWER - Gynephilic A transgender female is sexually attracted to men/masculinity. What is her sexual attraction? - ANSWER - Androphilic Attraction that is combination of androphilia and gynephilia - ANSWER - Ambiphilia Asexual is synonymous with - ANSWER - analophilic Part D of criteria for illness anxiety disorder - ANSWER - performs excessive health- related behaviors or exhibits maladaptive avoidance Physical symptoms are less prominent, while anxiety era preoccupation with having or acquiring a serious medical condition is the core complaint - ANSWER - Illness anxiety disorder In illness anxiety disorder somatic symptoms are - ANSWER - not present or are mild in intensity In illness anxiety disorder, illness preoccupation has to be present for at least _____ months - ANSWER - 6 Prevalence of illness anxiety disorder - ANSWER - 1-5% What are the FDA-approved medications for personality disorders? - ANSWER - There are none Pts with borderline personality disorder and psychotic disorders are particularly likely to have experienced - ANSWER - victimization as a child and/or adult Repeated changes in caregivers, history of neglect, avoidance of social interactions, and resistance to comforting from others is a sign of - ANSWER - reactive attachment disorder indiscriminate sociability and lack of selectivity in authority figures - ANSWER - Disinhibited social engagement disorder Symptoms present for _______ are more consistent with PTSD rather than Acute Stress Disorder - ANSWER - greater than 1 month Estimated lifetime prevalence of PTSD is - ANSWER - 7.8% What ethnic group of combat veterans experience a higher rate of PTSD - ANSWER - Latino especially Puerto Rican PTSD rates among Native Americans are _____ the national average - ANSWER - 3x higher What disorder is often comorbid with body dysmorphic disorder - ANSWER - social phobia Recovering completely within _______ is characteristic of a conversion disorder - ANSWER - 24 hours For pediatrics with conversion disorder (psychogenic seizure), what might be found in this patient's history - ANSWER - She argued with her parents earlier that day over a bad report card Conversions disorders do not show - ANSWER - pain symptoms What is the typical course of illness anxiety disorder - ANSWER - Onset in early adulthood has a chronic waxing/waning course Which medications have the strongest evidence for treatment of PTSD - ANSWER - Paroxetine Sertaline (Venlafaxine also approved by FDA) Pts with this disorder often exhibit emotional blunting that is sometimes referred to as "la belle indifference" - ANSWER - conversion disorder Pts with ________ PTSD typically show a more robust clinical response to SSRIs - ANSWER - non-combat In treating pts with histrionic personality disorder, which therapy type is useful for addressing provocative and attention seeking behavior? - ANSWER - Group therapy (pt may be unaware of behavior and it could help them if others point them out) What term represents a stable and realistic sense of self? - ANSWER - Self-system means of interpreting social situations and understanding the relational motives and actions of others - ANSWER - social system the capacity to observe the self as it relates to others - ANSWER - self-in-relation system What percentage of patients with neurological problems have conversion symptoms? - ANSWER - 1-3% Body dysmorphic disorder is associated with what risk factor and family history - ANSWER - Childhood neglect OCD sweating sleeplessness numbness dizziness rapid shifts in emotion depression anxiety - ANSWER - Hallucinogen intoxication A 30-year-old female presents to the ED with severe anxiety, palpitations, restlessness, and irritability. She reports no previous history of these symptoms. Her BP is 160/100, pulse is 115 beats/min, temperature 98 degree F, and pupils are dilated What condition explains her symptoms - ANSWER - cocaine intoxication Which statement differentiates the actions of cocaine and amphetamines - ANSWER - Cocaine prevents dopamine reuptake but amphetamines both slow dopamine reuptake and induces dopamine release In the COMBINE trial for alcohol dependent patients acamprosate faired ____ compared to various combinations of naltrexone and combined behavioral intervention - ANSWER - poorly For Alcohol dependent patients, the COMBINE trial found that - ANSWER - any combination of therapies including CBT, naltrexone, or both performed better than any combinations that did not include these interventions Buprenorphine is a ______ at mu receptors and binds with ______ - ANSWER - partial agonist high affinity (20x stronger per gram weight of morphine) This is resistant to cases of overdose to reversal by naloxone - ANSWER - buprenorphine d/t high binding affinity DSM-5 requires ____ of 9 criteria to be met for persistent and recurrent maladaptive gambling behavior - ANSWER - 4 What drug should be administered to address patient's aggression on PCP - ANSWER - Benzodiazepines What medications should be avoided d/t risk of hyperthermia, lower the seizure threshold, cause dystonia, or induce dysrhythmias when pt is intoxicated with PCP - ANSWER - haldol chlorpromazine Which of the following is not a feature of kleptomania - ANSWER - individual feels great pleasure and excitement leading to the theft (usually individual feels tension) Chronic alcohol use disorder reflects an _______ personality - ANSWER - oral- dependent Excessive alcohol use is associated with ________ traits such as - ANSWER - oral dependence and depression Men are more than _____ as likely as women to develop chronic alcohol use disorder - ANSWER - 2x Delirium tremens usually develops _____ from the person's last drink, with an average durage of _____ - ANSWER - 2-4 days <1 week This type of head bleed presents with headaches and confusion - ANSWER - subdural Most common approach to managing urges to shoplift - ANSWER - commit a self- imposed ban on shopping A 16 year old attended a rave with her friends. She presents with HTN, hyperthermia, and clinical examination indicates brisk reflexes. What conditions is her presentation consistent with - ANSWER - Serotonin Syndrome (likely from MDMA (ecstasy)) What is the rationale behind avoiding the use of restraints in someone intoxicated on PCP - ANSWER - Incidence of rhabdomyolysis in patients with PCP intoxication and physical restraints is much higher than baseline but can occur with PCP alone. With heavy cocaine use, patients can experience - ANSWER - a shower of lights in their central vision, as well as visual hallucinations of black dots on their skin and in the environment (coke bugs) What is a symptom of amphetamine withdrawal - ANSWER - fatigue vivid bad dreams insomnia/hypersomnia increased appetite psychomotor agitation/retardation A 29 year old male with yawning, perspiration, runny nose, dilated pupils, muscle twitching, no abdominal tenderness. Which drug is responsible for these withdrawal symptoms - ANSWER - Heroin The death rate among opioid abusers is ____ greater than the non-using population - ANSWER - 20x Sweating, flushing, sleep disturbances, hallucinations, seizures, and mild mental status changes are early symptoms of - ANSWER - alcohol withdrawal 8-10 hours after last drink LSD is derived from which of the following - ANSWER - Ergot fungus Cocaine is derived from the leaves of the plant - ANSWER - erythroxylon coca A 22 yo F with cystic fibrosis (CF) presents with fatigue, dysphoria, and depression. She stopped taking her meds and is wearing a baby pacifier on her necklace. Why is the pacifier significant in this pt with possible CF exacerbation? - ANSWER - MDMA (ecstasy) withdrawal baby pacifiers are used at "raves" to combat - ANSWER - bruxism (teeth grinding) while on MDMA Ganja is obtained from - ANSWER - flowering tops THC 6-20% Marijuana is obtained from - ANSWER - leaves/flowers Bhang is obtained from - ANSWER - dried marijuana leaves (1-3% THC) Hashish is obtained from - ANSWER - resin (THC 6-20%) In DSM-5 how many of the 11 criteria for substance use disorder must be present to meet "severe" subclassifications? - ANSWER - 6 In DSM-5 how many of the 11 criteria for substance use disorder must be present to meet "mild" subclassifications? - ANSWER - 2-3 In DSM-5 how many of the 11 criteria for substance use disorder must be present to meet "moderate" subclassifications? - ANSWER - 4-5 Sx of this type of intoxication are conjunctival infection, dry mouth and increased appetite - ANSWER - Cannabis intoxication What is the preferred benzodiazepine for treating withdrawal patient with chronic alcohol use disorder and a history of liver disease - ANSWER - Oxazepam MRI in Korsakoff's syndrome shows the following 6 areas of involvement - ANSWER - midbrain pons hypothalamus thalamus mammillary bodies cerebellum What vitamin is deficient in Wernicke's encephalopathy and Korsakoff's syndrome - ANSWER - Vitamin B1 Icterus - ANSWER - jaundice According to a recent study, the volumes of which brain structures are significantly smaller in patients with dissociative identity disorder versus healthy subjects? - ANSWER - Hippocampus and amygdala In using the Structured Interview of Reported Symptoms (SIRS) test, when would a patient be considered to be malingering? - ANSWER - They score in the definitive range in 1 primary subscale or probable range in 3 sub scales A 48 year old pt admitted with profuse sweating, diarrhea, abdominal cramps, vomiting, yawning, muscle aches, restlessness, and insomnia for 1 day. Physical exam reveals BP 155/105 mmHg and a temp of 100 degrees F. The patient is cold with muscle twitches and dilated pupils. She is highly motivated to detoxify. Which medication is the best choice for detox? - ANSWER - Methadone Which of the following is useful in treating the autonomic effects of opiate withdrawal - ANSWER - Clonidine Which of the following is useful for treating hyperthermia in opiate withdrawal - ANSWER - cold blankets ice packs Which of the following is useful for treating seizures in cocaine overdose - ANSWER - benzodiazepine Which of the following is useful for treating malignant hypertension in cocaine overdose - ANSWER - IV phentolamine Which 2 medications are useful for treating agitation in cocaine overdose? - ANSWER - lorazepam haloperidol What is the most common type of psychiatric condition in an emergency room - ANSWER - Substance-related disorders "You have been through so much recently but you remain certain that alcohol is not a problem for you" This is an example of a - ANSWER - reflective statement "What do you feel about all this?" is an example of - ANSWER - open-ended question "You have done a phenomenal job staying sober in the past." is an example of - ANSWER - affirmation "let me see if I understand you. It sounds like you've been trying to stop using for some time but are on the fence right now about stopping. Is that about right?" is an example of - ANSWER - Summary Statement OARS stands for - ANSWER - Open-ended questions Affirmations Reflective listening Summaries 4 core techniques for motivational interviewing include - ANSWER - expression of empathy rolling with the resistance developing discrepancy supporting self-efficacy Successful malingerers are more likely to have which characteristic compared to unsuccessful maligerers - ANSWER - They are more likely to report fewer symptoms Pt got Tdap 10 years ago, what is she due for - ANSWER - Td booster Which type of group treatment affects the largest number of substance abuse patients - ANSWER - self-help groups inability to recall autobiographical information and apparently purposeful travel associated with amnesia. Onset sudden, memory loss may be refractory - ANSWER - dissociative amnesia with dissociative fugue Pt often feel detached from their body, as if they are watching from outside their body. There is no associated amnesia or change in personality or identity - ANSWER - Depersonalization/derealization disorder Temporary episode of memory loss which can not be associated with a neurological cause. there is no associated change in identity. Onset is sudden, and the person is unable to recall who they are, how they got there, or what they were doing - ANSWER - Transient global amnesia Factitious disorder involves - ANSWER - deceptively reporting false symptoms to assume the "sick role" Dangerous dose of methadone may present as - ANSWER - drowsiness motor impairment mitosis nausea Safest initial methadone dose - ANSWER - 10-20mg given in single dose A dose of ____ methadone can be given if withdrawal symptoms persist an hour after the initial dose - ANSWER - 5mg Piloerection - ANSWER - goose bumps On withdrawal for methadone, signs of insomnia, fatigue, irritability and anxiety may last for - ANSWER - weeks to months Typical methadone maintenance dose - ANSWER - 60-100mg daily The most difficult period is when tapering methadone maintenance at doses - ANSWER - <25mg Which of the following disorders does not fall into the category of somatic symptom and related disorders? - ANSWER - Somatization disorder Examples of Somatic symptom and related disorders - ANSWER - somatic symptom disorder illness anxiety disorder conversion disorder factitious disorder Approximately which percentage of patients with chronic alcohol use disorder have at least 2 parents with chronic alcohol use disorder - ANSWER - 30% Earlier symptoms of GHB withdrawal - ANSWER - Anxiety Insomnia Tremor confusion nausea vomiting Early symptoms of MDMA withdrawal - ANSWER - Fatigue dysphoria depression with loss of appetite trouble concentrating Although results vary based on age, gender and drinking pattern of patient, which 2 biomarkers will provide NP up to 90% sensitivity for heavy, chronic alcohol usage? - ANSWER - Glutamyltransferase (GGT) & carbohydrate deficient transferrin (CDT) Blood test that detects heavy alcohol use (5+ or more drinks a day) over the past two weeks - ANSWER - CDT Carbamazepine __________ causing theophylline_______ - ANSWER - induces CYP450 to clear faster (need higher dose) Phenytoin ________ CYP450 causing theophylline to ________ - ANSWER - induces clear faster (need higher dose) After stopping diazepam in pt who is a chronic user - ANSWER - Monitor patient for a week (withdrawal seizures occur about 5-7 days after drug is stopped) Ideally should be gradually tapered at max rate of 10% per day. You will not see any signs of withdrawal of diazepam until - ANSWER - 5-7 days due to long half-life Which of the following statements is correct concerning clozapine - ANSWER - TD is not commonly associated with clozapine compared to other antipsychotics Agranulacytosis is the most significant adverse effect of - ANSWER - clozapine If agranulocytosis occurs in a pt on clozapine, it will more likely happen - ANSWER - in first 6 months of tx to woman Ashkenazi Jewish descent to those of advanced age ______ of patients on dosage of _______ of clozapine will have seizures - ANSWER - 4-6% >600mg/day SSRI's and coagulation - ANSWER - increase risk of bleeding d/t interactions with serotonergic receptors on platelets What SSRI's are most likely to have gastrointestinal side effects - ANSWER - sertraline fluvoxamine CNS activation (anxiety, restlessness, tremor, and insomnia) occur most commonly with this SSRI - ANSWER - fluoxetine SIADH commonly occurs with this SSRI - ANSWER - fluoxetine Sedation occurs most commonly with this SSRI - ANSWER - paroxetine Which of the following statements is true regarding Gabapentin? - ANSWER - It does not interact with anticonvulsants Somnolence and dizziness are the common side effects and may lead to discontinuation How does trazodone cause activation of the CNS? - ANSWER - Metabolite activity as well as inhibition of serotonin reuptake in presynaptic receptors What is correct regarding methylphenidate (MPH) - ANSWER - patients on transdermal MPH require lower doses than oral extended-release (transdermal does not make first pass in liver) The ratio of transdermal MPH to oral extended release MPH is - ANSWER - 10:15mg MPH is currently manufactured as a mixture of - ANSWER - d and l-threo enantiomers (d-threo = active form ) Clozapine -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - High High No Quetiapine -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - Low High Low Haloperidol -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - Low Low High Olanzapine -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - Low Mid Low Risperidal (Risperidone) -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - Low Low Low Ziprasidone (Geodon) -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - Low Low Low Aripiprazole (Abilify) -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - Low Low Low Paliperidone (Invega) -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - Low Low Low Chlorpromazine (Thorazine) -Anticholinergic Effect -Sedation -Extrapyramidal Effects - ANSWER - High High Low What is the mechanism of action of memantine - ANSWER - NMDA receptor antagonist (blocks excessive stimulation of glutamate receptors but does not affect normal transmitter activity) Which of the following classes of antidepressant drugs includes mirtazapine - ANSWER - Tetracyclic antidepressants (noradrenergic and specific serotonergic antidepressant (NaSSA) Mechanism of action of Mirtazapine - ANSWER - blocks presynaptic alpha-2 andrenergic receptor -> 5-HT-1A activation and increased dopamine release Which FDA established category indicates a potential risk of a drug to cause birth defects in pregancy because there are no adequate and well-controlled studies to show the drug to cause birth defects in pregnant women? - ANSWER - Category B It measures a person's emotional functioning - ANSWER - Rorschach test ("inkblot" test) Which of the following statements about lithium-induced hypothyroidism is correct - ANSWER - occurs more commonly in woman Hypothyroidism is not a contraindication for - ANSWER - lithium treatment (can be treated with levothyroxine) Hypothyroidism in pt receiving lithium is associated with - ANSWER - rapid cycling increased risk of developing depression Blood tests with lithium - ANSWER - Thyroid function test (TFT) at least once in the first 6 months of treatment BMP (renal function) every 3 months After first 6 months, LFT, TFT q 6-12 months Lithium induced hypothyroidism generally occurs within the first - ANSWER - 6-18 months Half life of this hypnotic is 1-3 hours - ANSWER - ramelton Half life of this hypnotic is 1-2 hours - ANSWER - zaleplon Half life of these hypnotics is 2-4 hours - ANSWER - triazolam zolpidem Antidepressant medication with significant anticholinergic side effects do not need to be avoided in patients with which comorbidity - ANSWER - constipation (can be managed by bulk-forming laxatives and hydration) CYP450 substrate of Alprazolam - ANSWER - 3A4 CYP450 substrate of Citalopram - ANSWER - 2D6 CYP450 substrate of Codeine - ANSWER - 2D6 CYP450 substrate of Caffeine - ANSWER - 1A2 Acute alcohol consumption _______ CYP450, but chronic use leads to __________ CYP450 - ANSWER - inhibits induces (break down faster - sub therapeutic level) Monitoring of liver function tests every 6-12 months is required with which of the following mood stabilizers - ANSWER - valproic acid Side effects of carbamazepine - ANSWER - sedation dizziness fatigue nausea ataxia agranulocytosis aplastic anemia side effects of lithium - ANSWER - Tremor polyuria polydipsia weight gain cognitive slowing hypothyroidism decreased creatinine clearance Side effects of lamotrigine - ANSWER - benign rash in 10% of people Steven's Johnson syndrome in <1% Withdrawal syndrome following abrupt discontinuation of TCA results from - ANSWER - cholinergic rebound Quinidine and TCA both - ANSWER - prolong QT intervals Adverse effects of TCA overdose - ANSWER - severe sedation hypotension anticholinergic delirium Although lorazepam has a relatively short half life, it exerts sustained action via which mechanism - ANSWER - lower lipophilicity Being less _______ produces clinical effects more slowly, but may provide more sustained relief, as the drug comes out of the brain slowly - ANSWER - lipophilic Gabapentin overdose is associated with - ANSWER - sedation ataxia diplopia Which one more commonly causes weight gain: gabapentin or valproic acid - ANSWER - valproic acid Adverse effect of Topiramate - ANSWER - kidney stone formation (especially after CYP450 activity inhibited d/t acute alcohol ingestion) St. John's wort effect on Topiramate - ANSWER - increases clearance d/t induced CYP450 activity What medications can cause a hypertensive crisis when used with MAOI? - ANSWER - meperidine epinephrine local anesthetics (containing sympathomimetics) decongestants Pt on clozaril and is concerned that PCP prescribed pt this for her psoriasis - ANSWER - methotrexate (inc risk leukopenia) What antidepressant has the greatest evidence of beneficial effects in patients with depressed mood and eating disorders? - ANSWER - Fluoxetine In CATIE, patients were assigned to treatment with - ANSWER - olanzapine perphenzine quetiapine risperidone or (later) ziprasidone A 55 year old F takes metoprolol to control her HTN. She has toenail fungus and decides to take her husband's Rx for terbinafine. What is the most likely outcome - ANSWER - hypotension (unRx med is 2D6 potent inhibitor leading to elevated levels of the HTN med) Specific Gravity 1.045 indicates - ANSWER - fluid volume deficit dehydration SIADH CHF Acidosis Prerenal failure By what age is the process of absorption and transportation of drugs comparable between children and adults - ANSWER - 4 months ECT deliberately induces what type of phenomenon - ANSWER - generalized tonic- clonic seizures What are 2 common side effects of fluoxetine - ANSWER - diarrhea cramps All women of childbearing age treated with valproic acid should also receive which of the following vitamin supplements - ANSWER - Folate (B-9) Which of the following medications has the most evidence in its effectiveness for treating drug induced psychosis in patients with Parkinson's disease - ANSWER - Clozapine hypersecretion bronchoconstriction GI tract hypermotility decreased intraoccular pressure Priapism is associated with which drug - ANSWER - trazodone At 45mg mirtazapine, what can happen? - ANSWER - increased serum cholesterol inducing cases of acute pancreatitis and diabetic ketoacidosis. Mood stabilizers like lithium in pregnancy - ANSWER - stopped until 2nd trimester to avoid the time of highest teratogenic risk. In neonates, high potency antipsychotics - ANSWER - are least likely to cause anticholinergic, antihistaminic, or hypotensive effects (unlike low potency medications) What medication has the most evidence supporting its use in bipolar disorder and schizophrenia in pregnant women - ANSWER - haloperidol effective and safe treatment for severe mania in pregnancy - ANSWER - ECT Neonates can show signs of extrapyramidal side effects when - ANSWER - a high potency antipsychotic is used near term When switching from an SSRI or SNRI to an MAOI, which of the following medications requires a 5-6 washout period? - ANSWER - Fluoxetine Besides Fluoxetine, all other SSRI, SNRIs, and TCAs require a standard ___________ washout period when switching to an MAOI - ANSWER - 2 week What medication demonstrates histaminergic mechanism in addition to increasing dopamine binding to the dopamine transporter to increase wakefulness - ANSWER - modafinil Modafinil increases activity in the - ANSWER - tuberomammilary nucleus stratum cingulate cortex (at higher doses) Humans with narcolepsy have decreased levels of - ANSWER - histamine in the CSF Modafinil ________ to the dopamine transporter - ANSWER - weakly binds (inhibiting reuptake of dopamine) Dopaminergic mechanisms that are affected by traditional stimulants, such as amphetamine, are not thought to account for the ___________ induced by modafinil - ANSWER - wakefulness What is the mechanism of action of topiramate? - ANSWER - inhibits sodium channels enhances GABA-a receptors antagonizes kainite and AMPA (glutamate) receptors Carbamazepine mechanism of action - ANSWER - Inhibits voltage-gated sodium channel activation (doesn't block pores). inhibits pre-synaptic sodium channels Depakote mechanism of action - ANSWER - increases GABA Lamotrigine mechanism of action - ANSWER - inhibits glutamate inhibits voltage-gated sodium channels centrally acting, reversible acetylcholinesterase inhibitor used in tx of Alzheimer's dementia - ANSWER - Donepezil (Aricept) Why is Donepezil contraindicated in sick sinus syndrome? - ANSWER - Can cause heart block and symptomatic bradycardia Flushing is caused by - ANSWER - excessive dilation of cutaneous arteries caused by muscarinic blockade (eg atropine) Rash is less common in these drugs, but patients on these 2 drugs are at risk for Steven's Johnson syndrome - ANSWER - oxcarbamazepine carbamazepine A low ______ value can occur in isolation with oxcarbazepine - ANSWER - T4 What mood stabilizer is associated with aplastic anemia and other blood dycrasias in 1 in 10,000-150,000 treated pts? - ANSWER - Oxcarbazepine Carbamazepine overdose is associated with - ANSWER - high grade AV block CNS depression Oxcarbazepine overdose is associated with - ANSWER - CNS depression Adjuvant therapy in acute mania to treat hyperkinesis, agitation and insomnia - ANSWER - benzodiazepine Pt's with hx of ADHD in childhood may be at particular risk for medication induced agitation with this medication - ANSWER - benzodiazepine What is the initial medication dosage for treatment of uncomplicated depression: sertraline ____ - ANSWER - 50mg (increase q 2 weeks to max 200) What is the initial medication dosage for treatment of uncomplicated depression: Fluoxetine ______ - ANSWER - 10mg (maintain for 3 weeks, max benefit at 20-40mg) Typical maintenance dose of fluvoxamine - ANSWER - 100-200mg/day (short half life) Typical maintenance dose of fluoxetine is - ANSWER - 20-40mg/day Doses of fluoxetine ______ have more side effects and have not been effective - ANSWER - >=60mg A maximum of ______ is recommended for initial treatment with paroxetine - ANSWER - 50mg Which of the following findings is expected in a patient who is an ultra-rapid metabolizer - ANSWER - High urinary concentration of the drug's metabolite Low plasma concentration of the drug Which statement correctly describes the inducer/inhibitor pharmacology of sertraline and tramadol when a patient is taking both medications? - ANSWER - Sertraline at 200mg is a potent inhibitor of 2D6 and increases levels of tramadol (increased risk seizures) Inhibitors reduce the metabolism of ______ leading to elevated levels of ___________ - ANSWER - medications/substrates medications/substrates To have lower levels of tramadol, a patient must take a CYP2D6 _______ - ANSWER - inducer What medications selectively inhibit the reuptake of both serotonin and norepinephrine - ANSWER - SNRIs: duloxetine venlafaxine desvenlafaxine Antidepressant with relatively weak reuptake inhibitor of dopamine and norepinephrine - ANSWER - Bupoprion Noradrenergic and specific serotonergic antidepressant (NaSSA) that acts by antagonizing the adrenergic alpha-2 autoreceptors and alpha2-heteroreceptors, as well as by blocking 5-HT2 and 5-HT3 receptors - ANSWER - mirtazapine Mechanism of action of ramelteon (Rozerem) - ANSWER - melatonin MT1 and MT2 receptor agonist Substrates affected by St. John's wort include - ANSWER - amprazolam amlodipine atorvastatin diazepam cyclosporine serotinergic meds Cruciferous vegetables induces the metabolism of _________ - ANSWER - 1A2 Increasing consumption of cruciferous vegetable would _________ clozapine levels - ANSWER - lower (need higher dose to decrease risk for psychosis) For the ER form of divalproex sodium, what is the correct dosing adjustment compared with regular formula - ANSWER - increase ER dose by 15% What is an appropriate loading dose of valproic acid for a hospitalized patient with significant manic symptoms? - ANSWER - 20-30mg/kg Ventricular arrhythmia and seizures can be the result from ______ overdose - ANSWER - TCA Cardiac conduction defects are most severe with ______ overdose - ANSWER - desipramine TCAs are structurally similar to - ANSWER - class I arrhythmias (20% proarrythmic & 20% with preexisting conduction disturbances have cardiac complications when taking) Tyramine-containing foods should be avoided in pts treated with - ANSWER - MAOI Stevens-Johnson syndrome is associated with - ANSWER - Lamictal (Lamotrigine) SIADH, leading to hyponatremia, has been associated with - ANSWER - carbamazepine (Tegretol) Primary consideration when dosing fluoxetine for 9 year old boy - ANSWER - height and weight Adult values for the cytochrome 450 enzymes are generally achieved by what age? - ANSWER - 1 years old Psychotropic medications are not generally prescribed to children under the age of - ANSWER - 5 years Fluoxetine is FDA-approved in the treatment of depression for what ages - ANSWER - ages 8 years and older Monitor ADHD patients on stimulants for - ANSWER - palpitations syncope CP vital signs including high blood pressure What supplement can cause easy bruising? - ANSWER - Ginkgo biloba Gingko biloba should be avoid with - ANSWER - antiplatelet and anticoagulant medications Supplement contraindicated when taking warfarin - ANSWER - gingko biloba Anti-inflammatory and immune enhancing supplement with no known drug interactions - ANSWER - Echinacea purpurea Another name for garlic - ANSWER - Allium sativum Why should garlic be used cautiously with warfarin? - ANSWER - anti-platelet effects Which SSRI has been associated with hyponatremia and SIADH, particularly in elderly females - ANSWER - sertraline Appropriate ED treatment for panic disorder - ANSWER - benzodiazepine Recurrent episodes with at least four of the following symptoms: --trembling, diaphoresis, nausea --CP/palpations/dyspnea/choking sensation --intense anxiety/fear of dying or losing control --derealization --depersonalization --dizziness --paresthesias --anxiety about additional attacks --avoidance behavior - ANSWER - panic disorder First line tx of panic disorder - ANSWER - SSRI (fluoxetine, paroxetine, sertraline) or SNRI (venlafaxine) MAO-B inhibitor with FDA indication for depression, Parkinson's disease and major depression - ANSWER - selegiline pheochromocytoma - ANSWER - a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine It is associated with episodes of tachycardia, HA, diaphoresis, and paroxysmal or sustained HTN SSRI-induced sexual dysfunction occurs in - ANSWER - men mostly (tends not to dissipate with ongoing tx but does dissipate on dc tx) L-carnitine is effective in the treatment of methamphetamine toxicity via which mechanism - ANSWER - preventing formation of free radicals and peroxynitrite in neurons decreases free radicals in the neuron needed to transport long-chain fatty acids into the mitochondria for fatty acid oxidation Which cytochrome P450 enzyme is predominantly present at but levels fall quickly and are undetectable in most adults? - ANSWER - 3A7 Last P450 cytochrome to develop - ANSWER - 1A2 P450 enzymes present in newborns at very low concentration but surge quickly to about 20-30% of adult values within the first week of life - ANSWER - 3A4 2D6 2C9/19 Erythromycin _______ the metabolism of drugs - ANSWER - decreases (inhibits) sick-faces.com/g is a mnemonic to remember - ANSWER - inhibitors list drugs on the sick-faces.com/g mnemonic of inhibitors - ANSWER - sodium valproate isoniazid cimetidine ketoconazole fluconazole alcohol binge chloramphenicol erythromycin sulfonamides ciprofloxacin omeprazole metronidazole grapefruit juice smoking, griseofulvin and carbamazepine are all - ANSWER - inducer What birth defect has been associated with lithium use in pregnancy (only psychoactive drug associated with this) - ANSWER - Ebstein's anomaly PCOS is associate with ________ use in pregnancy - ANSWER - valproic acid Narcolepsy with cataplexy and excessive daytime sleepiness FDA approved treatment - ANSWER - sodium oxybate (Xyrem) CYPD6 inhibitor - ANSWER - bupropion citalopram duloxetine fluoxetine fluvoxamine paroxetine cimetedine doxepin haloperidol methadone CYP2D6 inducer - ANSWER - dexamethasone rifampacin CYP1A2 inhibitor - ANSWER - Fluvoxamine Paroxetine Amiodarone Fluroquinolones Cimetedine CYP1A2 inducers - ANSWER - insulin modafinil (also 3A4 inducer) omeprazole phenobarbital (also 3A4 inducer) rifampicin (also 3A4 inducer) CYP2B6 inhibitors - ANSWER - Ticlopidine CYPB6 inducers - ANSWER - Phenobarbital Rifampicin CYP2C8 inhibitors - ANSWER - gemfibrozil giltazones CYP2C8 inducers - ANSWER - 1. Carbamazepine (Tegretol) 2. Phenobarbitol 3. Phenytoin (Dilantin) 4. Rifampin (Rifadin) CYP2C9 inhibitors - ANSWER - Amiodarone Fluconazole isonazid sulfa drugs trimethoprim CYPC19 inducers - ANSWER - Phenobarbital Rifampicin Bupoprion is a _______ substrate - ANSWER - 2D6 Methadone is a _______ substrate - ANSWER - 2D6 (and inhibitor) Fluoxetine is a ______ substrate - ANSWER - 2C9 2C19 2D6 and inhibitor (3A4 inhibitor) Phenytoin is a _______ substrate - ANSWER - 2C9 2C19 (3A4 inducer) Sertraline is a _______ substrate - ANSWER - 2C9 2C19 2D6 Fluoxetine is a _______ substrate - ANSWER - 2C9 2C19 2D6 and inhibitor (3A4 inhibitor) Fluvoxamine is a ______ substrate - ANSWER - 2C9 1A2 2C19 2D6 and inhibitor Amitriptyline is a _____ substrate - ANSWER - 1A2 2C19 Clozapine is a _____ substrate - ANSWER - 1A2 Duloxetine is a _____ substrate - ANSWER - 1A2 2D6 and inhibitor Haloperidal is a _____ substrate - ANSWER - 1A2 2D6 (and inhibitor) Imipramine is a _____ substrate - ANSWER - 1A2 2C19 Mirazapine is a _____ substrate - ANSWER - 1A2 2D6 Ondanseteron is a _____ substrate - ANSWER - 1A2 Warfarin is a _____ substrate - ANSWER - 1A2 2C9 Olanzepine is a _____ substrate - ANSWER - 1A2 2D6 Citalopram is a _______ substrate - ANSWER - 2C19 2D6 (and inhibitor) Diazepam is a _____ substrate - ANSWER - 2C19 escitalopram is a _____ substrate - ANSWER - 2C19 2D6 Paroxetine is a _______ substrate - ANSWER - 2D6 and inhibitor Amphetamine is a _________ substrate - ANSWER - 2D6 Atomoxetine is a _______ substrate - ANSWER - 2D6 Clomipramine is a _________ substrate - ANSWER - 2D6 Risperidal is a _____ substrate - ANSWER - 2D6 Venlafaxine is a _____ substrate - ANSWER - 2D6 Buspirone is a _______ substrate - ANSWER - 3A4 St. John's wort is a _______ inducer - ANSWER - 3A4 Oxcarbazepine and carbazepine are __________ inducers - ANSWER - 3A4 Grapefruit juice is a ______ inhibitor - ANSWER - 3A4 Clonazepam (Klonopin) is a ______ substrate - ANSWER - 3A4 Xanax is a ______ substrate - ANSWER - 3A4 Buprenorphine is a _______ substrate - ANSWER - 3A4 Topiramate is a ______ substrate - ANSWER - 3A4 Sildenafil (Viagra, Revatio) is a _____ substrate - ANSWER - 3A4 What mood stabilizer is more likely to cause renal insufficiency? - ANSWER - Lithium Indications: maintenance and propylaxis of bipolar - ANSWER - Lithium Risperidone Indications: mood stabilizer the augments antidepressant - ANSWER - Lithium Indications: schizoaffective (bipolar type) - ANSWER - Lithium Indications: Maintenance of bipolar II - ANSWER - Lamictal Indications: Partial seizures in adult and children - ANSWER - oxcarbazepine Indications: Lennox-Gaust syndrome seizures, partial seizures, tonic-clonic seizures, migraine prophylaxis - ANSWER - Topiramate St John's wort lowers the level of - ANSWER - Warfarin Digoxin Ginkgo Biloba contraindications - ANSWER - pt on antiplately or anticoagulant med Garlic should be used cautiously with - ANSWER - anti platelet and anticlotting medications After dc of benzodiazepine, rebound insomnia is likely to happen. What's the next step in mgmt? - ANSWER - Start sedative antihistamine What medications should be used with caution or avoided with ECT? - ANSWER - theophylline (can prolong seizure and status epileptics) hypoglycemics Beta blockers (can cause systole) Lidocaine (reduce seizure induction) Lithium (can prolong seizure and confusion) What med if given with ECT can prolong seizure and confusion? - ANSWER - Lithium What med if given with ECT can cause systole? - ANSWER - Beta blockers What med if given with ECT can reduce seizure induction - ANSWER - Lidocaine Alopecia is transient when taking valproic acid and can be treated with - ANSWER - a multivitamin containing zinc and selenium Side effects of valproic acid are more frequent with ____________ than with other preparations - ANSWER - divalproex sodium Carbamazepine and fluoxetine interaction - ANSWER - Increased carbamazepine levels Carbamazepine and lithium interaction - ANSWER - increased risk of neurotoxicity Carbamazepine and oral contraceptive (OBC) interaction - ANSWER - decreased levels of OBC Carbamazepine and valproic acid interaction - ANSWER - increased carbamazepine levels decreased valproic acid levels Is phenytoin an inducer or inhibitor? - ANSWER - inducer Is Valproic acid an inducer or inhibitor? - ANSWER - inhibitor Is ciprofloxacin an inducer or inhibitor? - ANSWER - inhibitor Is ketoconazole an inducer or inhibitor? - ANSWER - inhibitor Indications: Schizophrenia - ANSWER - Quetiapine Aripiprazole Risperidone Paliperidone Olanzapine Clozapine Asenapine Lurasidone Ziprasidone Lloperidone Indications: Acute psychosis - ANSWER - Ziprasidone Indications: agitation - ANSWER - Ziprasidone Olanzapine Aripiprazole Indications: schizoaffective - ANSWER - Clozapine Paliperidone Indications: Autism (5-16 years) - ANSWER - Risperidone Aripiprazole (all ages) Antipsychotics FDA indicated for bipolar disorder - ANSWER - Ziprasidone Olanzapine Risperidone Quetiapine Aripiprazole Which antipsychotic should you avoid in patients with a significant cardiac history? - ANSWER - (due to increased QTc) Lloperidone Ziprasidone Patients tend to lose weight (no significant increase in lipids or glucose) when treated with this antipsychotic long term - ANSWER - Lurasidone Antipsychotic that is category B for pregnancy, little prolactin increase - ANSWER - Lurasidone What antipsychotic is related to mirtazapine and likely has antidepressant properties? - ANSWER - Asenapine What antipsychotic has the notable side effect of metabolic syndrome and diabetic ketoacidosis? - ANSWER - Olanzapine What antipsychotic has the notable side effect of dose-related hyperprolactinemia? - ANSWER - Risperidone What antipsychotic has the notable side effects of metabolic syndrome and cataracts (in animal studies) - ANSWER - Quetiapine What antipsychotic has no increase in prolactin? - ANSWER - Quetiapine What antipsychotic has a black box warning of suicide in children - ANSWER - Aripiprazole What antipsychotic is most likely to cause akathisia and can be activating at low doses - ANSWER - aripiprazole What antipsychotic is preferred in Parkinson's and Lewy body demential due to low EPS - ANSWER - Quetiapine Nalmefene Cognitive affects of taking benzodiazepines are greatest in _____ - ANSWER - elderly (especially at risk is pts with delirium and dementia) Initial side effects of benzodiazepines can persist and worsen in pts - ANSWER - with liver disease taking longer-acting agents (diazepam) What antidepressants significantly increase dopamine? - ANSWER - Phenelzine Selegiline (Bupropion is slight) Which antidepressants significantly increase NE? - ANSWER - Desipramine Amitriptyline Buproprion Duloxetine Phenelzine Selegiline Which antidepressants increase does not increase DA or 5-HT but increases NE? - ANSWER - Desipramine Which antidepressants increase NE and 5-HT, but not DA - ANSWER - Amitriptyline Duloxetine Effexor Which antidepressants increase NE, 5HT and DA - ANSWER - Phenelzine Selegiline _____ of every _____ black or white persons may have an exaggerated response to beta-blockers due to a polymorphism in CYP450 enzymes - ANSWER - 1 15 Sialorrhea - ANSWER - excessive salivation Sialorrhea is associated with side effects of - ANSWER - Clozapine (31-48%) Clozapine has a boxed warning concerning - ANSWER - AGRANULOCYTOSIS (severe neutropenia is associated with significant risk of serious infection or death) orthostatic hypotension bradycardia syncope (more likely to occur during initiation of tx and titration of dose) Baseline ANC must be at least ___________ before initiation of Clozapine tx - ANSWER - 1500 Due to _________ clozapine is available only under a Risk Evaluation Mitigation Strategy (REMS) program. - ANSWER - risk of severe neutropenia (ANC<500) Acute alcohol ingestion _______ the rate of drug metabolism - ANSWER - lowers (inhibits) Acute alcohol ingestion causes benzodiazepine level to - ANSWER - increase Hypnotic drug of choice for pt with insomnia who wants to take it in the middle of the night without causing significant grogginess in the morning - ANSWER - Zalepon Half life of Zalepon - ANSWER - 1-2 hours What is the mechanism of action of galantamine? - ANSWER - competitive inhibitor of acetylcholinesterase According to the Lilly Worldwide Pharmacovigilance Safety Database, what is the rate of spontaneous abortion in olanzapine exposed pregnancy? - ANSWER - 13% (falls within range of normal historic control rates) Exposure during gestation to this medication can cause arrhythmias, polyhydramnios, nephrogenic diabetes insidious, and "floppy infant syndrome" - ANSWER - LIthium Desvenlafaxine is ________ protein bound with ____ likelihood of displacing tightly protein-bound medication like phenytoin and warfarin - ANSWER - weakly reduced The SNRIs have an ______ onset of action compared to SSRIs due to _________ - ANSWER - earlier rapid down-regulation of beta-adrenergic receptor-coupled cAMP Do stimulants cause an increase in tics - ANSWER - no (can worsen for a short interval, then go back to baseline) Most prescription and nonprescription medications can be used safely with _________ - ANSWER - stimulants (MAOI formally contraindicated but can be used with caution in tx resistant cases) Excessive caffeine intake with stimulants may _________ the effectiveness of the stimulant - ANSWER - decrease (increase sleep problems) Use of stimulants with anticonvulsants may require - ANSWER - dosage adjustment and blood levels of both medication due to decreased effects of anticonvulsants SSRI associated with the greatest weight gain - ANSWER - Paroxetine Amiloride is used to treat which side effect of lithium - ANSWER - Renal side effects TCA for OCD - ANSWER - Clomipramine Induction of a seizure with ECT occurs when an applied electrical stimulus causes which of the following? - ANSWER - Depolarization of cell membranes of neurons in brain synchronously A 14 year old boy is dced on carbamazepine after an admission for acute mania. About 4 weeks later, he is again acutely manic despite having been initially stabilized on carbamazepine. What is the likely cause of this medication failure? - ANSWER - Autoinduction transcription up regulation of genes involved in its own metabolism - ANSWER - Autoinduction How long does auto induction of carbamazepine take - ANSWER - 3-5 weeks (after ignition of a fixed dose when taken consistently) Meds that can increase serum concentration of 3A4 temporarily (but ultimately act as an inhibitor) - ANSWER - Cimetidine Erythromycin Grapefruit juice Vagus nerve stimulation is FDA approved for - ANSWER - epilepsy treatment resistant depression it involves surgical implantation of a device in the carotid sheath - ANSWER - vagus nerve stimulation Adding ginseng to lithium can cause - ANSWER - irritability, insomnia and mania Adding ginseng to neuroleptics or phenelzine can cause - ANSWER - irritability, insomnia and mania What adverse reaction is associated with mirtazapine use? - ANSWER - Agranulocytosis (1/1000) Mirtazapine ______ nausea and vomiting due to ________ - ANSWER - improves 5-HT3 receptor blockade Urinary ______ can occur with mirtazapine - ANSWER - frequency Lifestyle risk factors for elevated Lithium level - ANSWER - Salt-restricting diets dehydration high heat poor PO intake Lithium levels should be checked _____ after an increase or any time prior to an increase - ANSWER - 5 days (sooner in acute mania) Target level for Lithium in tx of mania - ANSWER - 0.8-1.0 meq/L Fewer lithium side effects (but more manic episodes) are seen in this level - ANSWER - 0.4-0.6meq/L In stable patients on chronic lithium treatment, levels should be drawn every ______ and renal/thryoid function every ______ - ANSWER - 6 months 6-12 months When taking lithium, renal function should be evaluated every ______ months during the first 6 months of treatment - ANSWER - 2-3 months Sexual side effects from antipsychotics are due to - ANSWER - alpha-2 receptors Long term effects of typical antipsychotics - ANSWER - weight gain photosensitivity sexual side effects hyperprolactinemia TD is associated with all _______ and occurs at a rate of approximately _______ per year - ANSWER - typical antipsychotics 5% Whta is the most effective treatment for major depression? - ANSWER - ECT Valproate competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Anything that blocks either _______ or ________ will increase lamotrigine levels - ANSWER - (UGT) 1A4 or 2B7 Depakote competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Tamoxifen (Novadex) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Imipramine competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Amitriptyline (Elavil) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Doxepin competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Nicotine competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Olanzapine competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Promethazine (Phenergen) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Meperidine (Demerol) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Clozapine (Clozaril) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Clorpromazine (Thorazine) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Androsterone and Testosterone competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Progestins (progesterone) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Diphenhydramine (Benadryl) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Asenapine (Saphris) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 1A4 Atorvastatin (Lipitor) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 buprenorphine/naloxone competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Ibuprofen (Advil, Motrin) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Fenofibrate (Tricor) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Oxycodone/APAP (Percocet) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Hydromorphone (Dilaudid) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Methadone competes with lamotrigine at _______________ - ANSWER - glucuronidation site (2B7) Tacrolimus (Prograf) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Codeine competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Temazepam (Restoril) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Valproic Acid (Depakote) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Simvastatin (Zocor) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 carvediolol (Coreg) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Cyclosporine competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Lorazepam (Ativan) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Oxazepam (Serax) competes with lamotrigine at _______________ - ANSWER - glucuronidation site 2B7 Benzodiazepines that undergo glucuronide conjugation 2B7 (not via the cytochrome p450 system) - ANSWER - Oxazepam Temazepam Lorazepam Another name for Thorazine - ANSWER - Clorpromazine Another name for Tegretol - ANSWER - Carbamazepine Another name for Valproate - ANSWER - Depakote Another name for Depakote - ANSWER - Valproate Sodium Valproic Acid Divalproex Sodium Another name for Valproic Acid - ANSWER - Valproate Sodium Depakote Divalproex Sodium Another name for Oxcarbazepine - ANSWER - Trileptal Another name for Trileptal - ANSWER - Oxcarbazepine Another name for Luvox - ANSWER - Fluvoxamine Another name for Fluvoxamine - ANSWER - Luvox Another name for Prozac - ANSWER - Fluoxetine Another name for Fluoxetine - ANSWER - Prozac Another name for Sertaline - ANSWER - Zoloft Another name for Zoloft - ANSWER - Sertraline Another name for Paroxetine - ANSWER - Paxil Another name for Paxil - ANSWER - Paroxetine Another name for Lexapro - ANSWER - Escitalopram Another name for Citalopram - ANSWER - Celexa Another name for Celexa - ANSWER - Citalopram Another name for Escitalopram - ANSWER - Lexapro Another name for Cymbalta - ANSWER - Duloxetine Another name for Duloxetine - ANSWER - Cymbalta Another name for Effexor - ANSWER - Venlafaxine Another name for Venlafaxine - ANSWER - Effexor Another name for Pristiq - ANSWER - Desvenlafaxine Another name for Desvenlafaxine - ANSWER - Pristiq Pt's meds include lisinopril, atorvastatin, bupropion, ibuprofen. Which medication is responsible for his insomnia? - ANSWER - Bupropion Bupropion is also known as - ANSWER - Wellbutrin Wellbutrin is also known as - ANSWER - Bupropion What SSRI is known to cause activation and insomnia - ANSWER - Fluoxetine There are no _________ for ECT - ANSWER - ABSOLUTE contraindications Space-occupying intercerebrayl lesion has traditionally been considered a ______ - ANSWER - contraindication of ECT since ECT increases intracerebral pressure, however slow growing meningiomas without mass effect and other similar lesions do not present a high risk While caution needs to be applied weighing risks and benefits, ECT has been safely administered (after appropriate subspecialty consultation) to pts with a hx of - ANSWER - brain surgery deep brain stimulators cardiac pacemakers AICD vagus nerve stimulator seizures space occupying intracerebral lesions ADHD patients may have side effects from stimulants that represent - ANSWER - manifestation or exacerbation of comorbid disorder (ie GAD) Side effect of treatment Antihistamine _______ is used to increase appetite - ANSWER - Cyproheptadine Medications to treat sleep problems associated with stimulant use - ANSWER - Melatonin Clonidine Diphenhydramine Trazodone Mirtazapine Hyperparathyroidism is associated with which medication - ANSWER - Lithium hyperparathyroidism - ANSWER - excessive levels of parathyroid hormone Ketoconazole is ______ of the ______ enzyme - ANSWER - inhibitor 3A4 Cannabinoids is a _______ of the ______ enzyme - ANSWER - inhibitor 3A4 Phenytoin, Carbamazepine, and St John's wort have this in common - ANSWER - 3A4 inducer Ketoconazole, amiodarone, and erythromycin have this in common - ANSWER - 3A4 inhibitor Regarding ECT treatment for depression in adolescents, which of the following statements is correct - ANSWER - response to ECT is similar in adolescents and adults Before ECT is used on an adolescent - ANSWER - 2 child and adolescent psychiatrists who are not the primary caregivers for the adolescent should be consulted and agree that it is indicated Which antidepressant is least likely to cause significant drug-drug interactions in the elderly - ANSWER - Venlafaxine (most SSRIs cause some inhibition of the 2D6 enzyme which leads to increased plasma level of other drugs (ie antiarrhythmics, benztropine, TCA, many antipsychotics) A 26 year old F with dx of bipolar on lithium presents to ED with marked tremor, ataxia, and confusion after a suspected suicide attempt less than an hour before admission. Her lithium level is 2.1. Over the next half hour, the pt becomes increasingly confused and then unresponsive, what is the next step in management? - ANSWER - Alert nephrology for emergent hemodialysis Which medication has been helpful in women with stress incontinence - ANSWER - Duloxetine Another name for Lurasidone - ANSWER - Latuda Another name for Latuda - ANSWER - Lurasidone Indicated for bipolar depression - ANSWER - Latuda (Lurasidone) What medication given in combination with Latuda may cause orthostatic hypotension - ANSWER - beta blocker When someone is on continuation maintenance ECT, the need should be reviewed by practitioner and patient at least - ANSWER - twice a year Consent for continuation maintenance ECT should be reobtained at least every - ANSWER - 6 months What needs to be reevaluated every 6 months with continuation maintenance ECT - ANSWER - need/indication anesthetic/medical complications cognitive tests (presence of persistent memory deficits weighed against anticipated benefits) Even in patients who do not have a hx of diabetes, a possible side effect of olanzapine - ANSWER - Diabetic ketoacidosis Hyperosmolar nonketotic coma What is considered a side effect of antipsychotics and is treated by beta blockers (propranolol) - ANSWER - Akathisia Nefazodone is a potent ________ of CYP 450 - ANSWER - inhibitor Medication can be used as an antidote to SSRI induced impotence - ANSWER - Nefazodone Unlike other antidepressants, this medication enhances rapid eye movement (REM) and may increase restful sleep in some patients - ANSWER - Nefazodone This antidepressant medication is not usually given first line for depression or at all anymore due to risk of liver failure (need to do liver function tests) - ANSWER - Nefazodone Haldol should be avoided in - ANSWER - pregnant women (d/t risk for birth defects) Common reasons for inadequate response to antidepressants include - ANSWER - inadequate dosing pt non-compliance misdiagnosis substance abuse (especially ETOH) Dc medications too quickly/early Young female brought to ED after being found in coma next to empty bottle of Vicodin. She is unresponsive. Medication that is indicated in management - ANSWER - Naloxone Naloxone is also called - ANSWER - Narcan Narcan is also called - ANSWER - Nalaxone Flumazenil is also called - ANSWER - Romazicon Naltrexone is also called - ANSWER - ReVia Which MAOI antidepressant has the lowest incidence of sexual dysfunction? - ANSWER - Tranylcypromine Which MAOIs have a high incidence of sexual dysfunction - ANSWER - Isocarboxazid Phenelzine Tranylcypromine is also known as - ANSWER - Parnate (MAOI) Isocarboxazid is also known as - ANSWER - Marplan (MAOI) Phenelzine is also known as - ANSWER - Nardil (MAOI) The 2015 Beers criteria contains a strong recommendation against using SSRI in combination with other __________ in older adults based on moderate evidence for __________ - ANSWER - CNS acting medications increased fall and fx risk Memantine is also known as - ANSWER - Namenda Memantine mechanism of action - ANSWER - NMDA receptor antagonist Potent allosteric potentiating ligand of human nicotinic acetylcholine receptors - ANSWER - Galantamine Galantamine is also known as - ANSWER - Razadyne an acetylcholinesterase inhibitor that inhibits both butyrlcholinesterase and acetylcholinesterase - ANSWER - Rivastigmine Selectively inhibits acetylcholinesterase unlike Rivastigmine - ANSWER - Donepezil Donepezil is also known as - ANSWER - Aricept Precursor to the neurotransmitters dopamine, norepinephrine and epinephrine (collectively known as catecholamines) - ANSWER - L-DOPA 2 typical antiparkinsonian drugs that are ineffective in the tx of antipsychotic-induced Parkinsonism - ANSWER - Levodopa Selegiline antipsychotic-induced Parkinsonism medication that works for tx, but its effects tend to wear off - ANSWER - Amantadine Lithium is associated with risk of Ebstein's anomaly which is malformation of which structure - ANSWER - Tricuspid valve What is true regarding methylphenidate and amphetamine? - ANSWER - Both stimulants increase intrasynaptic levels of NE and Dopamine Through which receptor dose mirtazapine exert its effect - ANSWER - Alpha-2 adrenergic antagonism. What do oral contraceptives, reserpine, clonidine, ETOH, hydralazine, amantadine, benzodiazepines, and guanethidine have in common - ANSWER - can cause depression Reserpine (Serpasil) - ANSWER - peripherally-acting sympathetic antagonist used for HTN; depletes stores of catecholamines in neurons; decreases TPR and CO Guanethidine (Ismelin) - ANSWER - adrenergic neuron blocker can cause depression Loxapine (Loxitane) - ANSWER - typical tetracyclic antipsychotic with antidepressant properties It's active metabolite is amoxapine which is a secondary amine tricyclic antidepressant - ANSWER - Loxapine (Loxitane) Patients with atypical depression respond particularly well to this MAOI - ANSWER - Phenelzine (Nardil) What is the most appropriate medication for melancholic depression in the geriatric population? - ANSWER - Nortriptyline Nortriptyline is also called - ANSWER - Pamelor Which of the following is the safest short acting barbiturate that can be used as an induction for anesthesia? - ANSWER - Sodium thiopental What medication should be avoided in patient with hx of epilepsy and hyperlipidemia who wants to quit tobacco use? - ANSWER - Bupropion What is the best medication option for pt who wants to quit tobacco use who has a hx or seizures - ANSWER - Varenicline can be combined with NRT annually Which medication side effect is NOT associated with lithium or valproic acid - ANSWER - eosinophilic colitis Pancreatitis is a rare but potentially deadly side effect of - ANSWER - valproic acid Hepatic failure is associated with - ANSWER - valproic acid hyperparathyroidism and hyperglycemia have been associated with - ANSWER - Lithium Hyperplasia and ademomas of parathyroid glands have been associated with - ANSWER - Lithium Mechanism of action of varenicline - ANSWER - partial agonist of alpha4beta2 and full agonist of alpha7 mechanism of action of bupropion (Zyban) that helps with smoking cessation - ANSWER - partial agonist of alpha4beta2 and partial agonist of alpha7 mechanism of action of NRT that helps with smoking cessation - ANSWER - Full agonist at alpha4beta2 and full agonist at alpha7 Neuroleptics and antiemetic drugs such as metoclopramide are dopamine _____ - ANSWER - receptor antagonists Rifampicin is an __________ of CYP _______ - ANSWER - inducer 2D6 Clozapine leads to seizures in ____ of patients taking >=6--mg - ANSWER - 4% ___________ is most likely to cause seizures among typical antipsychotics - ANSWER - Chlorpromazine Which drug is effective in improving sexual dysfunction in men but when given with an antidepressant to counter its adverse sexual effects can be counterproductive because it is actually anxiogenic? - ANSWER - Yohimbine Can help reverse some sexual dysfunction caused by SSRIs at 4-12mg/day, but also can reverses the antidepressant or anti-obsessive effects of SSRIs - ANSWER - Cyproheptadine The use of _____ has been more effective than placebo in men with SSRI-induced sexual dysfunction - ANSWER - Sildenafil (Viagara) ______ Has been reported to increase overall sexual satisfaction in both men and women - ANSWER - Sildenafil (Viagara) Valproic acid is a CYP450 ________ - ANSWER - inhibitor What is NOT true regarding typical antipsychotic overdose - ANSWER - Dialysis is useful in treating it. (It is often lethal due to significant cardiovascular effects) What seizure medications are considered safe for use in breastfeeding mothers - ANSWER - Carbamazepine (Tegretol) Valproic Acid (Depakote) Phenytoin (Dilantin) Phenobarbital Primidone (Mysoline) If >______ %of the body surface area is involved it is termed Toxic Epidermal Necrolysis - ANSWER - >30 In it involves _______% of the skin surface area it is known as Steven-Johnson Syndrome (SJS) - ANSWER - <10 If it involves ______% of the skin surface area it is known as SJS-TEN - ANSWER - 10- 30 Mr Matthews presents for evaluation of this out-of-control aggressive impulses. Usually he is "a regular guy with decent temperament" but sometimes becomes disproportionately aggressive to a precipitating stress. Which of the following medications may worsen the symptoms of intermittent explosive disorder long term? - ANSWER - Diazepam _________ and ______ have been superior to placebo in reducing impulsive aggression in pts with intermittent explosive disorder - ANSWER - Fluoxetine Oxcarbamazepine ______ might help control explosive rage - ANSWER - Beta blockers Due to risk of neural tube defects in bipolar pts on lithium, carbamazepine or valproic acid maintenance, ___________ must be monitored, if elevated, ______ and _______ are needed to look for _______ - ANSWER - alpha-fetoprotein amniocentesis ultrasound spinal deformities Due to the risk for cardiac abnormalities in pts on lithium, valproic acid, or carbamazepine maintenance during pregnancy, _______ should be suggested at ________ weeks to rule out cardiac effects - ANSWER - high-resolution ultrasound 16-18 As a result of large fluid shifts during delivery, the bipolar medication levels of ______________ can become toxic so dose should be ______ and hydration should be ______. Discontinuation is not recommended due to _____ - ANSWER - lithium carbamazepine valproate lowered adequate 50% risk of postpartum relapse Buspirone mechanism of action - ANSWER - 5HT1A receptor partial agonist at postsynaptic receptors acts on postsynaptic receptors in hippocampus and cortex as partial agonist Mild-moderate presynaptic dopamine agonist at D2, D3, and D4 receptors Partial alpha-1 receptor agonist The DSM-5 now includes _____ separate criteria for intermittent explosive disorder _____ which have empirical support - ANSWER - 2 A1 - does not lead to destruction of property or physical injury A2- 3 outburst that involve injury or destruction within a year period In order to be diagnosed with intermittent explosive disorder, individual must be at least ____ old - ANSWER - 6 years What is true about Carbamazepine - ANSWER - It slows cardiac conduction and should be avoided in pts with high-grade AV block or sick sinus syndrome SSRI discontinuation syndrome symptoms usually resolve within - ANSWER - 2 weeks Common side effects of stimulant medications - ANSWER - Abdominal pain anorexia diminished appetite headache insomnia mood lability nausea nervousness vomiting What SNRI is associated with discontinuation syndrome - ANSWER - Venlafaxine Concurrent administration with which medication is likely to decrease levels of valproic acid? - ANSWER - Carbamazepine Phenytoin Primidone Buspirone primarily acts on which receptor - ANSWER - 5-HT1A Which medications (not yet FDA approved) can be used to treat kleptomania? - ANSWER - Fluoxetine Naltrexone Which of the following is characteristic of fetal phenytoin syndrome - ANSWER - Hypertelorism Hypertelorism - ANSWER - eyes spaced widely apart fetal valproate syndrome features - ANSWER - bifrontal narrowing midface hypoplasia broad nasal bridge short nose with anteverted nares epicanthic folds micrognathia shallow philtrum thin upper lip thick lower lip NSAID ______ Lithium clearance and can cause side effects such as ______ - ANSWER - decrease tremor What antidepressant is associated with significant sexual side effects and weight gain - ANSWER - Phenelzine Some patients on chronic lithium treatment may have gradually _______ - ANSWER - increased creatinine Development of hypothyroidism that is not responsive to thyroxine constitutes a valid reason to consider - ANSWER - discontinuation of lithium ECG effects common in LIthium - ANSWER - changes in depolarization phase worsening existing arrhythmias With most modern devices, the dosage of ECT is changed by varying which aspect - ANSWER - time of exposure to fixed current When drug is quickly metabolized to inactive metabolites, which of the following statements may be true of this patient - ANSWER - She is a poor metabolizer Donazepil is believed to improve - ANSWER - memory in neurocognitive disorder by increasing the amount of acetylcholine available in the synaptic cleft by inhibiting its breakdown by acetylcholinesterase. This inhibition is reversible. Barbituates ________ plasma TCA, _____ the antidepressant effects because of their induction of __________ and accelerated _______ - ANSWER - lower diminishes liver microsomal enzymes degradation of the TCA Barbiturates act on ______ receptors - ANSWER - GABA For gastrointestinal issues associated with Lithium use - ANSWER - change to longer- acting oral preparation or use lithium citrate syrup For lithium associated edema - ANSWER - administer spironolactone (25mg/day) and follow lithium levels closely For lithium tremor - ANSWER - administer propranolol (10-30mg TID) or primidone (25- 100mg/day) as second-line For lithium hypothyroidism treat with - ANSWER - thyroid hormone and continue lithium therapy When in the body is melatonin made - ANSWER - Pineal gland (Serotonin derivative) Hormones hypothalamus makes - ANSWER - TRH (thyrotropin releasing hormone) dopamine GHRH (growth hormone releasing hormone) SS (somatostatin) GnRH (gonadotropin releasing hormone) CRH (corticotropin releasing hormone) oxytocin vasopressin (ADH) The posterior pituitary stores and releases - ANSWER - oxytocin and vasopressin (ADH) The anterior pituitary makes - ANSWER - ACTH TSH FSH LH GH prolactin What pharmacological treatment is clinically supported for treating kleptomania - ANSWER - Lithium Which of the following medication has the least effect on the CYP-450 system: carbamazepine, valproate, levetiracetam, phenytoin, Lamictal - ANSWER - Levetiracetam Which of the following hypnotic agents is preferred for the elderly - ANSWER - Ramelteon What is the rate of malformation among fetuses exposed to SSRI medications - ANSWER - 2.6% (consistent with reports in general population) Studies suggest that TMS may be most useful for which symptom in schizophrenia? - ANSWER - Hallucinations Second generation drugs are more effective for treating ________ in schizophernia - ANSWER - negative symptoms Used for aggression and impulsivity in schizophrenics - ANSWER - Beta blockers Lithium ECT is most often used for ______ in schizophrenia - ANSWER - catatonia TMS is effective for _____ in OCD - ANSWER - impulsivity Second generation antipsychotic with high D2 blocking/binding - ANSWER - Risperidol Second generation antipsychotic with lower D2 blocking/binding - ANSWER - Clozapine Quetiapine Blockade of ______ or more of the D2 receptors is associated with increased EPS - ANSWER - 80% Lower D2 blockade of ______ % is safer and still clinically effective - ANSWER - 60- 70% Bupropion is an NDRI that should be avoided in patients with - ANSWER - anorexia nervosa hx of seizures heavy alcohol use Clomipramine is a TCA that _________ the seizure threshold - ANSWER - lowers What can cause phalangeal hypoplasia in 2.5kg baby girl whose mom has a past medical history of epilepsy - ANSWER - Phenytoin Short limbs and phalangeal hypoplasia - ANSWER - teratogenicity caused by phenytoin