NBME PSYCH Form 4 - Answers & Explanations

Updated: Nov 16, 2019

1) Lorazepam (alcoholic cant sleep) • Alcohol withdrawal symptoms should be managed with benzodiazepines • Lorazepam, Oxazepam, and Temazepam are the benzos that should be used in those with liver disease (chronic alcoholism) due to minimal first-pass metabolism

2) Dissociative disorder

• This patient has depersonalization/derealization disorder

• Acute stress (accident at construction site) → detachment from one’s own thoughts, actions, or environment; patients often seem like they’re in a fog or spaced out and in their own world

• Personal information collected from interpreter makes the diagnosis of dissociative amnesia unlikely

3) Substance-induced psychotic disorder

• This patient is using stimulants (eg, amphetamine, methylphenidate) to study → psychosis

4) Increased amylase activity • Recurrent vomiting → parodic gland enlargement/inflammation → ↑ Amylase

5) Major depressive disorder

• Post-partum depression

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

• Bipolar or major depression with psychotic features have psychotic symptoms occurring exclusively during mood episodes (this patient is still having psychotic features even though his mania has resolved after hospitalization)

7) Mini-Mental State Examination • This depressed geriatric patient that recently developed symptoms of dementia likely has pseudo-dementia, however it is imperative to rule out organic causes of dementia with an MMSE due to his old age • Neuropsychiatric testing would be a better choice (MMSE is now proprietary)

8) Discontinue haloperidol and begin risperidone • This patient is experiencing Tardive dyskinesia • This patient has attempted suicide twice, and therefore is not a candidate for drug cessation • Second generation antipsychotics are less likely to cause EPS than first generation antipsychotics (eg, haloperidol)

9) Psychiatric evaluation

• Long standing condition (over 7 years) that is situational (exams) → origin of problem is psychiatric

• Thyroid disease would present with additional symptoms and would be more pervasive (not just during exams)

10) Increased serum cortisol concentration

• MDD is associated with hyperactivity of the HPA axis → ↑ cortisol

• MDD patients may have an atypical (failure to suppress) dexamethasone suppression test

11) Specific phobia • Marked anxiety about a specific object or situation for >6 months

• Tx: CBT with exposure

12) Sertraline • OCD tx: SSRI and CBT (venlafaxine and clomipramine are second line)

13) Adjustment disorder with depressed mood • Identifiable stressor causing marked distress and significant functional impairment with onset within 3 months of stressor

14) Performance anxiety • Nocturnal/early morning erections = cause of sexual dysfunction is psychological

15) Ethylene glycol toxicity

• Ethylene glycol (antifreeze) → glycoaldehyde (toxic) → glycolate (anion gap) → calcium oxalate → kidney stones

• Methanol (moonshine) → formaldehyde (toxic) → formate → blindness

• Ethanol → acetaldehyde (toxic) → acetate (non-toxic)

16) Cholinergic • Alzheimer disease → ↓ ACh • Tx: AChE inhibitor (eg, donepezil, rivastigmine, galantamine) → ↑ ACh

17) EEG • This child is likely having seizures and should be evaluated with an EEG

• “Spit” = drooling, “blood” = from biting tongue, “takes his power” = loss of consciousness

18) Marijuana intoxication • Dry oral mucosa, injected conjunctive, tachycardia, HTN • Always rule out substance or medical related disorder before diagnosing a psychiatric condition

19) Admit to the psychiatric unit involuntarily • This patient is actively suicidal (recent attempt) and should be admitted to the psychiatric unit regardless of his refusal

20) Substantia nigra • MPTP induced Parkinsonism • MPTP (synthetic potent analog of meperidine (demerol)) is toxic to the substantial nigra

21) Schizophrenia • Delusion: Dementors searching for him to turn him into an alien

• Hallucination: Dementors look him in the eyes • Disorganized speech/thinking: Thought process not 100% linear

• Disorganized behavior: Disheveled appearance • Negative symptoms: Lives alone, no friends, poor eye contact

22) Adverse effect of prochlorperazine • The anti-emetic agent prochlorperazine has additional antipsychotic effects (by blocking D2 receptors) and may cause EPS

• Tx: β-blockers or benzos

23) Mood disorder due to a general medical condition

• This patient has OSA (obstructive sleep apnea)

24) Adjustment disorder with depressed mood • Distress with functional impairment within 3 months of a stressor

• MDD requires symptoms for ≥ 2 weeks

25) Cognitive behavior therapy • This patient has a specific phobia (heights & elevators)

• Tx: CBT with exposure

26) Reassure the patient that his sleep pattern is normal for his age

• Sleep changes in elderly: ↓ REM sleep time, ↑ REM latency, ↓ N3

27) Phentolamine

• Hypertensive crisis (tyramine displaces neurotransmitters (eg, NE) in the synaptic cleft → ↑ sympathetic stimulation)

• Phentolamine is a nonselective α-blocker that is giving to patients on MAO inhibitors that eat tyramine-contains foods

28) Normal, Normal • This teenage boy is developing normally, both physically and socially

29) Bipolar disorder • This patients grandiosity, impulsivity, talkativeness, flight of ideas and increased goal directed activity are consistent with a manic episode • Presence of psychotic features (“god is talking to me”) makes this a manic (not hypomanic) episode • This patients presentation is episodic (previous similar episodes)

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

• Sleep disturbances • Anhedonia: stopped going out with friends • Guilt: blames self • Fatigue and energy loss • Concentration problems • ↓ appetite and weight loss

31) Decreased serum albumin concentration

• Anorexia → malnutrition → ↓ albumin → ↓ oncotic pressure → edema

• Low albumin denotes low synthetic capacity of the liver secondary to malnourishment

32) Cocaine abuse

• “Sometimes she appears withdrawn/lethargic and other times appears energetic” is consistent with substance abuse

• Dilated pupils (without nystagmus), impulsivity, delusion = cocaine abuse (she’s a financial analyst...)

33) Increased sensitivity of the dopamine receptors • Tardive dyskinesia develops in the meeting of prolonged exposure to dopamine-blocking agents, which is thought to result in the up regulation and super- sensitivity of dopamine receptors

34) Fetal alcohol syndrome • Epicanthal folds, small palpebral fissures, low nasal bridge, smooth philtrum, thin vermillion border • Single palmar crease is sensitive but not specific for Down syndrome

35) REM sleep behavior disorder

• Paralysis that normally occurs during REM sleep is incomplete pr absent, allowing the person to ‘act out’ their dreams

• In older patients, REM sleep behavior disorder may be a sign of neurodegeneration (eg, Parkinson disease)

36) Discontinue doxepin

• TCA toxicity → Coma, Convulsions, Cardiotoxicity (arrhythmia), prolonged QT interval

• Tx: ECG, NaHCO3

37) Vitamin B1 (thiamine)

• Wernicke-Korsakoff syndrome → confusion, ataxia, nystagmus, ophthalmoplegia, memory loss

38) Decreased REM latency • Narcolepsy sleep changes: ↓ sleep latency, ↓ REM latency, ↓ sleep efficiency

39) Lorazepam • Catatonia: immobility, mutism, waxy flexibility • Tx: benzodiazepines (lorazepam), ECT

40) Marijuana intoxication • Injected conjunctive, tachycardia, HTN, slow reaction time, hallucination • Always rule out substance or medical related disorder before diagnosing a psychiatric condition

41) Trisomy of an autosomal chromosome • Trisomy 21 (down syndrome): Epicanthal folds, up slanting palpebral fissures, low-set small ears, flat facial profile, furrowed tongue

42) Lithium

• NSAIDS → ↓ renal clearance → ↑ lithium levels → toxicity

43) Age-appropriate behavior

• Between ages 6-11 (concrete operational stage), kids begin to understand that death is irreversible

• This child has no functional impairment (she continues to excel academically and participate in sports)

44) Cognitive behavioral therapy • This patient has panic disorder


45) Focal white matter lesions

• Intermittent blurred vision, focal neurologic changes, and paresthesia affecting a woman in her 30s is concerning for Multiple sclerosis

• Brain imaging would show Periventricular plaques and Multiple white matter lesions disseminated in time & space

46) Generalized anxiety disorder

• Excessive and persistent worry about multiple issues for ≥6 months with significant distress or impairment

• First-line tx: CBT + SSRI/SNRI

47) No treatment is indicated • This patient with normal pulses and DTRs is likely malingering (secondary gain: temporarily leaving jail)

48) “How would you feel about entering the hospital?” • A suicidal patient should be admitted to a psychiatric unit (ideally voluntarily, but involuntarily if the patient refuses)

49) Propranolol

• Performance only social anxiety disorder

• Tx: β-blockers or benzodiazepines

• This patient should receive a β-blocker (benzos may cause drowsiness, which isn’t ideal when giving a presentation)

50) Lorazepam • Performance only social anxiety disorder • Tx: β-blockers or benzodiazepines • This patient should receive a Benzo (β-blockers are contraindicated in asthma)

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