NBME PSYCH Form 3 - Answers & Explanations

Updated: Feb 25, 2020

1) Nucleus basalis of Meynert • Nucleus basalis of Meynert produces acetycholine; destruction → ↓ ACh → Alzheimer disease • Amygdaloid nucleus: Kluver-bucy syndrome • Caudate nucleus: Huntington disease • Medial geniculate nucleus: Auditory pathway • Red nucleus: mostly vestigial in mammals; crawling in human babies

• Substantia nigra: Parkinson disease • Subthalamic nucleus: Hemiballismus

2) Caudate nucleus

• Caudate & Putamen destruction → ↓ ACh and GABA → Huntington disease

• Amygdaloid nucleus: Kluver-bucy syndrome • Medial geniculate nucleus: Auditory pathway • Nucleus basalis of Meynert: Alzheimer disease • Red nucleus: mostly vestigial in mammals; crawling in human babies

• Substantia nigra: Parkinson disease • Subthalamic nucleus: Hemiballismus

3) Delirium due to anticholinergic medication • Certain antiparkinson drugs (eg, benztropine, trihexyphenidyl) curb excess cholinergic activity → side effects of dry mouth, flushed skin, tachycardia, etc.

4) PCP intoxication • PCP intoxication presents with violent behavior, dissociation, hallucinations, amnesia, ataxia, and nystagmus • Benzodiazepines treat severe psychomotor agitation

5) Reassure the father that this is normal development • Weight unchanged from the previous year, normal growth and development

6) Schizoaffective disorder • Delusions or hallucinations for ≥ 2 weeks in the absence of prominent mood symptoms

7) Borderline personality disorder

• Often have a history of childhood trauma (eg, physical/sexual abuse or neglect) → insecure attachment, unstable relationships, and fear of abandonment

• Cluster B personality disorders have a high rate of self-mutilation and suicide

8) Fragile site on the X chromosome • High forehead, large everted ears, prominent jaw, low IQ = Fragile X syndrome

• Fragile sites are discontinuity of staining in the region of the trinucleotide repeat on the long arm of the X chromosome (a diagnostic lab artifact)

9) Quetiapine

• This patient has Parkinson psychosis • Tx: Quetiapine or clozapine (lowest propensity to cause EPS)

10) Corticosteroid-induced psychotic disorder • Glucocorticoids, particularly at high doses, are often implicated in new-onset psychotic symptoms

11) Contact child protective services • Children who are victims of physical abuse often avoid eye contact on physical exam

12) Enlarged lateral and third ventricles on CT scan of the head • CT scans of patients with schizophrenia often show ventriculomegaly (particularly the lateral cerebral ventricles) and diffuse cortical atrophy

13) Obtain a rectal temperature under supervision • Temp of 107.6 F raises suspicion for factitious disorder

14) Conduct disorder • Repetitive and pervasive behavior that violates the basic rights of others or societal norms (eg, destruction of property)

15) Creutzfeldt-Jakob disease • Rapidly progressive dementia (weeks to months) • Periodic sharp waves on EEG • ↑ 14-3-3 protein in CSF

16) Discontinue clozapine therapy • Clozapine may lead to agranulocytosis (non-dose related) and seizures (dose related) • This patients leukocyte count is < 3000 and he has flu-like symptoms

17) Major depressive disorder • MDD has an atypical presentation with physical symptoms (eg, headache) in the elderly

• Sadness

• Guilt

• Weight loss

• Fatigue

• Psychomotor retardation (slowing of physical and/or emotional reactions, including speech and affect)

• Somatization and illness anxiety disorders require 6 months to diagnose (she has only been experiencing her headaches for 4 weeks)

18) Valproic acid • Valproic acid block box warning: hepatotoxicity, pancreatitis, fetal abnormalities

19) Drug-drug interaction • Switching from most antidepressants to a MAOI requires a 2-week washout; Fluoxetine, an SSRI, has a relatively long half-life and requires a 5 week washout

• Excess serotonin → serotonin syndrome

20) Discontinue desipramine therapy • TCA may cause prolonged QT • Tx: Stop medication and give NaHCO3 (prevents arrhythmia)

21) Alcohol use

• This patient drinks ‘several’ alcoholic beverages before sex and has ↑ GGT

• Alcohol is a depressant that can make it difficult to achieve erections or reach an orgasm

22) Propranolol

• The tremors in this patients hand are of 1 month duration which doesn’t indicate any anxiety disorder

• This patient likely has essential tremor (patients often self medicate with alcohol which decreases tremor amplitude, hence this patients alcohol abuse)

• Nonselective beta-blockers (eg, propranolol) are the treatment of choice

23) Lorazepam • This patient has a specific phobia • 1st-line tx: CBT with exposure; short-acting benzodiazepines are helpful if therapy is unavailable or insufficient time

24) Amitriptyline

• TCA are contraindicated in the elderly due to anticholinergic and antihistamine effects

• Hydrophilic β-blockers don’t cross the BBB and therefore don’t cause psychosis; Lipophilic β-blockers (eg, propranolol, nadolol) cross the BBB and therefore can cause psychosis and depression

25) Polysomnography • Polysomnography showing reduced REM sleep latency will diagnosis narcolepsy

26) Zolpidem • Psychotherapy is the first line therapy for Adjustment disorder (SSRIs aren’t given)

• Nonbenzodiazepine hypnotics (eg, zolpidem) can be given to treat insomnia

27) Buspirone

• Generalized anxiety disorder: excessive and persistent worry about multiple issues for ≥ 6 months

• First-line tx: CBT + SSRI/SNRI

• Second-line tx: Buspirone and benzodiazepines

28) Alcohol dependence • Drinks vodka in the morning, ‘eye-opener' = ⊕ CAGE questions • Must rule out any substance or medical related mood disorders before diagnosing a psychiatric condition (eg, Adjustment disorder)

29) Schizotypal • Cluster A personality disorder; genetic association with schizophrenia • Eccentric appearance, odd thoughts, beliefs, perceptions and behavior

30) Electroconvulsive therapy • ECT is appropriate for severely depressed geriatric patients who require rapid intervention • Antidepressants + antipsychotics would take too long to be effective

31) Post-traumatic stress disorder • Nightmares, functional impairment, psychological trauma, and detachment for > 1 month • Tx: Trauma focused CBT + SSRI/SNRI

32) Major depressive disorder • Diagnosis can’t be Adjustment disorder because this patient meets 5/9 criteria for MDD • Crying spells, sad mood = depressed • Poor concentration • Fatigue and lethargy = low energy • Not interested in socializing = anhedonia • 20lb weight gain = appetite/weight change

33) Alcohol • Gait disturbance is characteristic of alcohol intoxication

• Normal vitals rule out cocaine or amphetamine use

34) Drug reaction • Neuroleptic malignant syndrome: Fever, Muscle rigidity, Abnormal vitals, ↑ CK

35) Fetal alcohol syndrome • Facial abnormalities in FAS: long smooth philtrum, thin vermillion border, small palpebral fissures

36) Risperidone • Tourette syndrome - onset before age 18 • Tx: Antipsychotics, Tetrabenazine, Alpha-2-agonists (eg, guanfacine, clonidine)

37) “Have you been feeling like just giving up?” • Sense of hopelessness requires further investigation/questioning

38) Psychiatric assessment • This patient has a normal physical exam and has completed a battery of tests without any abnormalities (possible somatic symptom disorder)

39) Obsessive-compulsive disorder

• Ego-dystonic (behavior inconsistent with one’s own beliefs and attitude)