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High Yield Psych

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					High Yield Psych - covers MOST of the lecture stuff we should need to know.


Module 1     Kiefer

1) Determining what kind of psychiatric disorder this patient suffers from:
AXIS 1: Psychiatric disorder axis (eg. depressed, manic, psychotic, anxious)
AXIS 2 : personality disorder axis. (Often deferred if you don’ t know) eg. Borderline disorder
AXIS 3: medical problems and comorbidities. Eg. Patient who has schizophrenia but also has high blood
         pressure, stroke or diabetes
AXIS 4: what kind of functional impairment the person has. Eg. “Academic problems” due to ADHD-
         problems in school and primary support if parents aren’t helpful.
AXIS 5: Severity of person’s disorder. Higher number is less severe, lower number is more severe. Out of 100.


2)
     DSM content generated by Task Forces
     Attempts toward congruence with ICD-10
     Categorical classification system incorporating bio-psycho-social elements and research to date (removal
       of “organic”)***
However in lecture, she stated to know that “attempts towards congruence are being made with ICD-9”…whereas
her PPT refers to ICD-10. (Not sure which is correct).

3) Know that DSM doesn’t address underlying causation of a disease (nor does it cover etiology or treatment of
the disease). Ie. It does not address why the disease is occurring or what is causing the disease. It ONLY
classifies the disease.

4) V-codes are included under Axis-I


Farrell

1) When dealing with patients:
    Establish relationship ***
    Identify positive and negative feelings that occur during the interview
    Differential diagnosis
    Treatment plan

Establishing a relationship is the most important; if they don’t want to come in you have no patient.


2)a) You don’t have to do a mental status exam all the time (eg. Depends on problem). HE DOES MENTAL
STATUS EXAM EVERY SINGLE TIME SINCE HE’S A PSYCHIATRIST**** So, as a psychiatrist, always
do a mental status exam. As any other type of doctor, use your discretion as to when to do a mental status exam.

b) ***Mental Status is neither sensitive nor specific (but it is all we have).**** Eg. Can’t do a mental status
exam and say “pt has phobias of speech and has schizophrenia”, etc.

3) 51-50- you can hold the patient in the hospital for 72 hours against their will
                  must be a danger to themselves- I’m going to kill myself
                  danger to others- I’m going to kill him
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                      gravely disabled- the McDonalds test


BUT, if they do not have a psychiatric diagnosis, you can not hold them on a 51-50
                           so if no psychiatric diagnosis—none of the above apply
If they do not have a psychiatric diagnosis, THE ANSWER IS “NONE OF THE ABOVE‖.****


4) Risk Factors of suicide***** KNOW THESE.
       Intoxicated and claim you are going kill yourself.
       Family history of depression or suicide
       Anxiety is a big deal when it comes to suicide
       Previous suicide attempts – half ass attempts still count.


Module 2: Murad

In general, if the patient can function you are not likely to treat. Always rule out other med conditions before
diagnosing schizophrenia. Goal of treatment for schizophrenia is to: improve functioning, (no cure is available)

Questions he gave:

1. DSM-IV criteria for schizophrenia includes all of the following EXCEPT?
      ―D is wrong‖. Answer has to do with knowing Duration > 6 months to diagnose schizophrenia

2. Hallucinations can be from any of the 5 senses. Olfactory, visual, auditory. The most common is
auditory, but it is not 100%. Visual hallucinations is also a clue that it is a physiological problem. Organic
problems have visual hallucinations eg. Pink elephants with Alcohol withdrawl = (visual hallucination).
SO, IF PATIENT PRESENTS ONLY WITH VISUAL HALLUCINATIONS, LOOK FOR A
PHYSIOLOGICAL CAUSE.

ANSWER: Most common form of schizophrenic hallucinations is AUDITORY

Negative symptoms of schizo include all of the following except:
A – tactile
B – Auditory
C – visual
D – olfactory
E - Gustatory


3. Negative symptoms of schizophrenia include all of the following EXCEPT? B correct. Answer = Loose
association- common symptom but it is not negative. They have associated things that don’t make a lot of
sense to us.

   Criteria of ** Negative symptoms ** associated with schizophrenia:
           (flat affect / anergia / withdrawal / anhedonia)
           Represent a deficit of normal functioning



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Neg symptoms of schizo include all of the following except
      A flattened affect
      (B) loose associations
      C anergia
      D anhedonia
      E loss of spontaneity

4. Bleuler’s 4 A’s (negative symptoms of schizophrenia)
           – Autism = psychotic symptoms
           – Ambivalence- mixed feelings about things
           – Affect (flattened)- restricted expression
           – A-volition – don’t have interest in doing anything

Question about Bleuler’s 4A’s. Pick one that does not belong. B is correct answer.
      Agitation and automation are NOT one of the four.



5. Kurt Schneider
          First rank symptoms
                  • Thought diffusion
                  • Thought insertion
                  • Voices arguing / commenting
                  • No longer considered specific to Schizophrenia
                  •
Q: What were scheider’s first rank symptoms for diagnosing schizophrenia? The only correct choice is
***thought insertion***.

6. Regarding the dopamine hypothesis of schizophrenia, all of the following are correct EXCEPT?
Answer: B. decreased DA activity is the core deficit in schizophrenia.

Reason: In schizophrenia, DA activity is actually increased (that is why we use a dopamine blocker). It is
not only based on evidence of amphetamine.

7. Clozapine (clozaril) is an excellent antipsychotic because it: ANSWER = B
A- has a low risk of agranulocytosis
B. It produces very little or no EPS side effects.
C – starts working immediately

(It is the prototypical atypical antipsychotic). Not used as a first line drug because of its problems with
agranulocytosis and its propensity for seizure disorder and constipation. $$$$ and weekly CBC.

8. Schizophrenic patients are at higher risk of mortality due to all of the following EXCEPT?

A. increased cig smoking (increases the metabolism of anti-psychotic Rxs  incr dose  toxicity)
B. incr. sensitivity to Rx SE
C. obesity
D. diabetes
E. hypertriglyceridemia

ANSWER B. no difference in sensitivity to drug side effect than the general population.
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Increased smoking helps eliminate the drugs. This leads to less antipsychotic effect, making you increased the
dose so patient may become toxic.
Obesity risk since they are on tranquilizers.
High preponderance of diabetes with newer Zyprexa and Clozaril.

9. Which of the following are effective first line treatments for schizophrenia?
ANSWER B. Zyprexa (Zydis).

   A.     anti-depressant medication
   B.     Zydis (Zypreza, Olanzapine)
   C.     Clozapine
   D.     ECT (last resort)
   E.     EBT alone


IF they had depression as well it wouldn’t be wrong to give them an antidepressant. But for this question, the
ANSWER is B. Zydis.
Haldol or Zyprexa (Zydis) both just as effective for pure schizophrenic. Zydis is atypical and it can be used as
first line. Clozaril side effects are too dangerous to be used 1st line, 3rd or 4th. ECT (electroconvulsive therapy) is
last resort. CBT (cognitive behavioral therapy) does not treat the biochemical component.

10. The difference between schizophrenia and schizophreniform disorder is?
ANSWER B. He says the time frame answer is right (even though it isn’t). Brief psychotic disorder <1 month,
schizophreniform disorder 1-6 mos, schizophrenia >6 mos.

    Schizophreniform
         ** Same as SCP but duration is less (1 – 6 months)
                SCP symptoms are greater than 6 months ***

His answer: B: the total duration for schizopheniform can be not longer than 1 month.

Farrell

1) ***Supportive Therapy is NOT insight oriented
    the patient does not need to gain insight to their problems. Just do what allows the patient to be functional.
      Eg. Tell pt NOT to tell people on the bus they hear god in their head talking to them.

2)Interpersonal Therapy: Know it is great for studies. It is very researchable. Eg. Test whether Prozac is
better than psychoanalysis. Can do a double blind placebo controlled study on this! (As opposed to
psychotherapy in which it’s impossible to do a double blind study on.) Interpersonal therapy is usually designed
by pharmacologists, and is very structured.


Module 3: Murad

1) Physiology of the aging brain includes all of the following except:
 Answer = B. Decreased Gaba activity

Reason is because you will NOT see decreased Gaba receptor activity. You WILL see INCREASED Gaba
receptor activity.
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2) All of the following are true about dementia EXCEPT:
A- can occur at any age
B - ANSWER B: only occurs in pts older than 40
C-Slow onset in evolution
D alzheimers type II
E in Alzheimers 2 or more areas must be effected

3) With regards to deliurm, select the best answer:
A-has a fluctuating course
B-cognitive deficits appear suddenly and disappear just as quickly
C-prevelence of hospitalized patients is 10-30%
D-the mini-mental status exam may be normal in as many as 1/3 of patients
E -ANSWER: ALL OF THE ABOVE ARE CORRECT


4) All of the following are TRUE about alzheimers disease EXCEPT:

B- It can be reliably predicted by CT scan. (it can’t always be reliably predicted by CT; its a diagnosis of
exclusion)


5) All of the following are true about pseudodementia EXCEPT

A- Dementia symptomas are present but they are due to depression
B- Dementia symptoms have a gradual onset (False because it can look like a delirium, [there is acute onset])
C- Dementia and depression commonly occur together
D- Dementia’s signs and symptoms resolve with the depression treatment.


Module 4 - Chau
-very few hints given

Generalized anxiety disorder = often use SSRI*****- selective serotonin reuptake inhibitor (Prozac, paxil,
zolof). Takes 2-4 weeks for SSRI meds to work so you can use benzodiazapines in the mean time.

DDx: of the Anxiety disorders

  i)     Panic Disorders and Agorophobia
  • Recurrent discrete attacks of anxiety
  • Accompanied by somatic symptoms
         – Palpitations, parenthesis, hyperventilation, diaphoresis, chest pain, dizziness, tremor, dyspnea
  • Condition is accompanied by agoraphobia (fear of a situation eg. Driving, crowded places)
DDx: 4 symptoms (increased hrt rate, chest pain, etc.) must reach a maximum within 10 minutes

   ii) Social Phobia
   • Persistent and Exaggerated fear of humiliation or embarrassment in social or performance situations
       leading to high level of distress.

   iii)       Specific Phobia
          -scared/phobia to one thing. Eg. Snakes
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   iv)       OCD – obsessive compulsive disorder
         -unwanted and senseless but irresistible
         -obsession unrealistic but irresistible
         -interfere with functioning eg. Anxiety related to being contaminated by germs.
                 Common obsessions = contamination, symmetry/exactness
                 Common compulsions = wash hands, cleaning

   v)        PTSD – post traumatic stress disorder
         -Diagnosis:
   •     traumatic event
   •     event persistently reexperienced
   •     avoidance of stimuli associated with the trauma
   •     Persistent symptoms of increased arousal
   •     Duration of the disturbance is more than 1 month
   •     The disturbance causes clinically significant effects in social, occupational or other important areas of
         functioning.

   vi)      GAD – generalized anxiety disorder
               -Chronic excessive worry about multiple symptoms life circumstances with:
            Restlessness, fatigue, decreased concentration, irritability, change in sleep, at least for 6 months, and
            causes significant distress

Murad - Modules 5 and 6 Questions given:

ALL ANSWERS FOR THE FOLLOWING 8 QUESTIONS ARE ―B‖

1) The main difference between OCD and OCPD is?
A- in OCD repetitive behaviors like hand-washing are considered an obsession
B- in OCPD pts typically do not have obsessions
C- in OCPD pts have preoccupation w/ orderliness
D- in OCPD the person attempts to suppress or neutralize their intrusive thoughts

2) Obsessions are defined as
A- A preoccupation with details and order
B- recurrent or persistent thought that causes marked anxiety
C- a behavioral or mental act aimed at preventing some dreaded event
D- None of the above

3) All are criteria for OCPD except (original question said “OCD”, but should have been “OCPD”)
A- A pervasive pattern of preoccupation with orderliness and perfectionism
B- prominent thoughts or images that are not simply excessive worries about real life
C- preoccupation w/ rules, lists, order, or organization
D- Adoption of a miserly spending style

4) Typical SSx of OCD include all of the following except
A- Obsessions are considered aversive mental images, thoughts or impulses
B- the pt is unable to recognize that their behavior is absurd
C- feelings of dread and urgency
D- Complications are willed responses directed at reducing adverse thoughts

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1) Regarding OCD please select the best answer-
A- Tricoltillomania is seen in OCD
B- 50% of patients with OCD have co-morbid major depression
C- OCD is more prominent in adolescents
D- vocal motor tics are a rare finding

2)Select the best initial treatment choice for OCD
A- Psychotherapy with exposure and response prevention
B- Luvox 100mg/d combined with CBT
C- SSRI to treat underlying depression
D- MAOI plus Risperadal 3mg hs

3) Somatoform disorders include all the following except?
A- conversion disorder
B- malingering
C. Body dimorphic d/o
D. hydrochondriasis

4) Which of the following is criteria used in conversion disorder?
A- 4 pain symptoms in 4 diff sites
B- symptoms are not intentionally used or feigned
C. Duration of >6 months
D. Pain is a prominent syndrome




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Module 7 (Personality Disorders)– Singer Chang
-no hints given

A. Odd/                                    B. Dramatic/                       C. Anxious/
Eccentric                                  Erratic                            Fearful

Schizoid                                   Histrionic                          Avoidant
Lack of desire to relate, withdrawn from   Dramatic, flamboyant, theatrical. -avoid relationships despite wanting
emotional interactions, little energy.     Need for attention, Provides        them. Fears of rejection are
Slow/monotonous. Out of touch with         entertainment. Female.              overpowering. Low self-esteem.
body and info given to Dr. may be          Exaggerate emotions, doesn’t        -May avoid Tx due to
limited or lack important details. Flat    think things thru.                  embarrassement, uncomfort and
affect.                                    Seductive, manipulative             may filter info to avoid rejection
Paranoid                                   Antisocial                          Dependent
Eg. Movie “Falling Down”: Michael          Eg. Leonardo Di Caprio in           Eg. Bill Murray: “What about
Douglas when sitting in traffic. Thinks    “catch me if you can”: he steals Bob”. Very dependent on Dr.
the whole world is out to get him.         a plane while police chase him. -incapable of making simple
Eg. Gollum talking to himself, thinking    -criminal personality               decisions w/o input. Fear of
everyones out to get him.                  -No guilt/regret except getting abandonment, desperation and
On guard, mistrust of medical system,      caught                              neediness.
perceives others as hostile.               -think people are there to be used -Overly compliant and reliant on Dr
                                           -do well in prison (structure)
                                           -grandiosse, use doctor, referred
                                           by court, treat early
Schizotypal                                Borderline                          Obsessive-Compulsive
Eg. Willi Wonka from Charlie and the       -“you’re the best Dr. ever”: only -perfectionism to maintain sense of
Cholcolate factory. Eccentric,             sees black and white! Sues Dr’s. control
suspicious thinking, desire for            -Most extreme personality           -Rigid/inflexible thinking; black &
relationships, but anxious/mistrustful.    -fears abandonment/rejection        white thinking (“If I’m not perfect,
Magical thinking, strange dress, odd       -feels misunderstood; -> rage       I’m a total failure”)
collections                                -splitting: all or nothing thinking -detail and work orientated (but
                                                                               doesn’t accomplish much).
                                                                               -Opposite to Histrionic (shows little
                                                                               or controlled emotion).
                                           Narcissistic
                                           Eg. King of Rome in “Gladiator”
                                           -excessive grandiosity, only their
                                           needs are important, want to be
                                           idealized, inflated self image
                                           -doesn’t want you to see they
                                           feel inadequate or ashamed
                                           -only see Dr’s who are “worthy”
                                           and Dr. who “makes extra time”




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Module 8 – Kieffer
No hints given

Module 9 – Kieffer - “easy questions”

1) Know that the following are grouped under IMPULSE CONTROL DISORDERS
•Intermittent Explosive Disorder
•Kleptomania
•Pyromania
•Pathological Gambling
•Trichotillomania
Binge-Eating/Purging Types are more likely to exhibit other impulse-control problems: These are grouped
under impulse control disorders too

   •   2) ADHD
   •    Most common psychiatric problem in children
   •   Serious consequences can result if untreated
   •   23% of ADHD children develop antisocial personality disorder
   •   30% of ADHD teens fail to complete high school


Module 10 – Chau

1) Case: Female wearing latex glove obsessed about germs. Obsessed about not getting meds from pharmacy
(due to contamination). Suffers from OCD.
Tx = SSRI’s (serotonin re-uptake inhibitor); use prozac, zoloft, selexa or paxil
Note: SSRI’s can be used to treat OCD, depression and anxiety disorders.
                          So, if pt is depressed and/or has anxiety, think SSRI’s for Tx.

       Wellbutrin is NOT an SSRI. Efexa is Not an SSRI either.


2)Mood disorders diagnosis: Made when an individual develops significant functional impairment as a
result of mood disturbance.

3) Drugs info:
Know anticonvulsants: dilantin, tegratol,
Psychostimulants (to Tx ADHD) : ritalin, ritalin SOR, amantodate, aderol.

4)Medications that sedate (antidepressants): triazedone, ramerone.
Nonsedating: effexa, wellbutrin, prozac

5) Atypical antidepressants/neuroleptics/antipsychotics/mood stabilizer: respenol, cyprexa, also approved for
mood disorder may be used to tread mood disorder. You can’t treat bipolar disorder with them?!?? I think

6) Benzodiaepines used for agitation as needed. Ativan, lorezapam; short acting (4-6 hours). Longer acting is
valium, zantax.

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7) Case: Pt depressed, anxious, irritable, has nightmares. DDx: depression, anxiety disorder, bipolar disorder
(because of irritability).

8) Case: PTSD: symptoms: nightmare, flashback, history of trauma in the past (molested, raped, war).

9)Case: Postpartum depression: SSx = difficulty sleeping, not wanting to be around child, withdrawn.
Recommendations: antidepressants, therapy. Ask is she is breast feeding still before giving drugs.

10) Some depression may be involved in bipolar. Know what manic and depressive disorders are like.




Exam: 65 Q’s total
Clinicians: 47 Q’s (including 2 of Martin’s…presumably from his 1st lec)
Text and case studies: 18 Q’s

In general for test, etiology is not as important as Identification and correct treatment.


1 text Q Martin discussed: Continuity of Care. Ch 16. Know main pts of Ch. – different levels of care for
young people with mental problems. Know how country organizes care for these patients.




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