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NBME PSYCH Form 1 - Answers & Explanations

Updated: Feb 19, 2020

1) Circadian rhythm sleep disorder

• This patient is unable to sleep and wake at the time required for normal work and social needs

• These patients will have normal sleep, energy and functioning when they can set their own sleep cycle

2) Down syndrome • Epicanthal folds, cardiac murmur, developmental delay

3) Substance-induced mood disorder • Must rule out any substance or medical related mood disorder before diagnosing a psychiatric condition • Central acting beta-blockers (eg, propranolol, nadolol) can cause depression and psychosis

4) Admit the patient to the psychiatric unit • When someone is a danger to themselves or others they should be admitted

5) Focal spikes localized to the temporal lobe • Complex partial seizure most commonly arise from the temporal lobe, which is confirmed by smelling burnt rubber and hissing noise - spikes on EEG localize the seizure activity

• Burst suppression pattern = patients with inactivated brain (eg, coma)

• Hypsarrhythmia = infantile spasms

• Diffuse 3-Hz spike and slow wave activity = absence seizures

• Triphasic wave = toxic metabolic encephalopathy

6) Add bupropion to the medication regimen • Buproprion is an atypical antidepressant that has favorable sexual side effects and will help with this patients weight gain

7) Explain the risk of illness recurrence without medication • This patients bipolar disorder has been well controlled with his medication, and the importance of maintaining this should be explained

8) Social phobia • Social anxiety disorder, performance type: anxiety restricted to public speaking

• Fear of embarrassment or judgement is a classic sign of social phobia

9) Decreased concentration of 5-hydroxyindoleacetic acid in cerebrospinal fluid analysis

• The neurotransmitters that are decreased in depression include dopamine, norepinephrine, and serotonin

• Delayed REM sleep on nighttime polysomnography is seen in delayed phase sleep disorder

• Enlarged lateral ventricles is seen in schizophrenia

• Increased sensitivity to lactate infusion is seen in generalized anxiety disorder

10) Clonazepam • For mild agitation and anxiety, give a benzodiazepine • For agitation and psychosis you’d normally give an antipsychotic, but this patient has a prolonged QT interval, so Ziprasidone is contraindicated

11) Reassurance

• Sleep changes in elderly: ↓ REM sleep time, ↑ REM latency, ↓ stage N3 (non-REM sleep)

• This patient is experiencing normal age related changes

12) Reassurance that this is normal behavior

• Enuresis is normal until age 5 • Encopresis is normal until age 4

13) Recommend alcohol rehabilitation

• This patient does not believe he has a drinking problem, but has cut back on the amount he drinks - therefore he’s in the action phase, not the pre-contemplation phase

• Disulfiram is given to patients who are not actively drinking and are highly motivated to quit

• Clonidine is given in alcohol withdrawal, but should not be given to a patient that is actively drinking

• This patient has cirrhosis, so the only benzodiazepines that should be used are lorazepam, oxazepam, and temazapam due to minimal first-pass metabolism

14) Opioid

• Opioid intoxication → respiratory and CNS depression, pupillary constriction

15) Symmetric enlargement of the ventricles • CT scans of patients with schizophrenia often show ventriculomegaly (particularly the lateral cerebral ventricles) and diffuse cortical atrophy

16) Surreptitious administration of insulin • Oral hypoglycemic agents stimulate production of endogenous insulin (↑ insulin & ↑ C-peptide)

17) Discuss normal pubertal development

• Absence of 2° pubertal development is normal in girls ≤ 14, and boys ≤ 15

18) Switch from haloperidol to aripiprazole

• First generation antipsychotics treat positive symptoms only

• Second generation antipsychotics treat positive and negative symptoms

• Second generation antipsychotics are less likely to cause EPS than 1st generation antipsychotics (eg, haloperidol)

• This patients negative symptoms (blunted affect) remain untreated

19) Maintain the current dosage of sertraline and schedule weekly follow-up examinations for the next month

• SSRIs take 4-6 weeks to work - if there is no improvement at that time, then the dose can be titrated accordingly

• This patient has a mild-moderate risk for suicide - not enough to hospitalize, but they should be monitored closely outpatient (weekly examinations)

• Black box warning: patients age 18-24 have a slightly increased risk of becoming suicidal when initiating antidepressant treatment

20) Administer additional diazepam • The benefit of preventing death from alcohol withdrawal far outweighs the possible respiratory depression from benzodiazepines, especially since she is already intubated

21) Restless legs syndrome • Worse at night and at rest, Relieved by movement • Associated with iron deficiency → this patients fatigue

22) Brief psychotic disorder • Presence of ≥1 psychotic symptom (eg, paranoia, auditory hallucinations) with a sudden onset and full remission in 1 month

23) Administration of morphine

• Management of acute pain is similar in all patients regardless of substance abuse history

• This patient is about to undergo wound debridement and suturing - they require a stronger analgesic than ibuprofen

24) Acute intermittent porphyria

• Presents with the 5 P’s

• Painful abdomen • Port wine colored urine • Polyneuropathy • Psychological disturbances • Precipitated by drugs (eg, alcohol)

25) Separation anxiety disorder • Persistent anxiety with separation and excessive worry about losing major attachment figures for ≥4 weeks

26) Dopamine • Blockade of the nigrostriatal dopamine pathway is responsible for EPS in patients taking antipsychotics

27) Psychotherapy • Psychotherapy is the treatment of choice for adjustment disorder

28) Adjustment disorder • Onset within 3 months of a non-life threatening stressor • Poor test performance = functional impairment • For bereavement, someone has to have died (according to the DSM-5)

29) Begin parent management training • Child is behaved in daycare, at the doctors office, and with her grandmother

• Tantrums are most likely due to parental interactions

30) Major depressive disorder • This patient presents with 5/9 SIG E CAPS

• “Withdrawn” = anhedonia • “-15lb” = appetite/weight loss

• “sad” = depressed mood • “poor energy” = fatigue • “decreased sleep” = insomnia

• Common to develop MDD in chronic diseases

31) Anorexia nervosa • Excessive dieting, exercising, or binge eating/purging with BMI <18.5 (adults) or <5th percentile (children/adolescents)

32) Lewy body dementia

Parkinsonism, Hallucination, Dementia (LEWY has a PHD)

33) Conversion disorder • Loss of sensory or motor function following an acute stressor La belle indifference = patient is aware but indifferent toward symptoms

34) Decrease the dosage of carbidopa-levodopa

• The psychotic symptoms of Parkinson’s disease may be treated with dose reduction of antiparkinson agents and/or low potency antipsychotics (eg, quetiapine)

• In the elderly (this patient is 87) it is better to remove medications rather than adding more if it will lead to the sam result

35) Panic disorder

• Recurrent and unexpected attacks + >1 month of preoccupation with the attacks

• Preoccupation with unexplained symptoms overlaps with somatic symptom disorder, but the abrupt onset of physical symptoms that resolve quickly is more consistent with panic disorder

• Tx: SSRI or SNRI + CBT

36) Child abuse • Forceful twisting of a limb → spiral fractures = child abuse

• Demineralization occurs with all bony injuries

37) Decreased binding of dopamine at the postsynaptic receptor

• Haloperidol is a typical antipsychotic that blocks dopamine D2 receptors

38) Serotonin

• Fluoxetine (SSRI) → ↑ serotonin in the synoptic cleft

• Tramadol inhibits the re-uptake of NE and serotonin

• Fluoxetine + Tramadol → Serotonin Syndrome

39) Begin escitalopram therapy • This patient has MDD - 5/9 SIG E CAPS:

• Not sleeping = insomnia

• Avoids social activities = anhedonia

• Tired = ↓ energy

• Wight loss = appetite/weight changes

• Not remembering like he used to = ↓ concentration or psychomotor retardation • SSRI is first line pharmacotherapy for MDD

40) Generalized anxiety disorder • Excessive anxiety/worry for ≥ 6 months with significant distress or impairment • Muscle tension, sleep disturbance, irritability, difficulty concentrating, and fatigue are common associated symptoms

41) Amphetamine intoxication • Paranoia, tachycardia, hyperreflexia, rapid speech, agitation

42) Hallucinogen intoxication • Perceptual distortion (visual), anxiety, paranoia, negative urine toxicology (LSD isn’t included on a standard drug test)

43) Amenorrhea • Anorexia nervosa → ↓ GnRH → ↓ LH, FSH → ↓ estrogen → amenorrhea, bone loss

44) Ziprasidone

• Antipsychotics are the first-line pharmacotherapy for patients with acute psychosis

• Second-generation is usually preferred due to less EPS side effects

45) Clomipramine • Tx of OCD: CBT + SSRI; clomipramine and venlafaxine are second line

46) Obsessive-compulsive disorder • This patients disorder is ego-dystonic (behavior inconsistent with one’s own beliefs and attitude) making OCD the most likely diagnosis • Tx: CBT + SSRI (clomipramine and venlafaxine are second line)

47) Caudate atrophy

• Trinucleotide repeat diseases often show anticipation (earlier onset of disease in succeeding generations) - this patients symptoms began when she was 47 years old and it began in her father when he was 56 years old

• This patient has Huntington disease which often presents wit chorea, aggression, depression and dementia

• Imaging of the brain in Huntington disease will show atrophy of the caudate nucleus and putamen with ex-vacuo ventriculomegaly

48) Dissociative fugue • Dissociative amnesia is an inability to recall important personal information • Dissociative fugue is a subtype of dissociative amnesia characterized by travel or wandering

49) Conduct disorder

• Repetitive and pervasive behavior that violates the basic rights of others or societal norms (eg, aggression to people and animals, destruction of property, theft)

• The kid killed his cat with no remorse...

50) Delusional disorder

• Fixed, persistent, false belief system lasting >1 month with otherwise normal functioning

• Schizophrenia/Schizophreniform requires greater functional impairment and other psychotic symptoms (eg, hallucinations, disorganization, negative symptoms)

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