2019 kaplan USMLE step 2 CK psychiatric

Defense Mechanisms Learning Objectives List the types of defense mechanisms and the situations in which they aremost likely to occur Describe the most common psychological and intelligen

USMLE ® Step 2 CK: Psychiatry, Epidemiology, Ethics, Patient Safety

Lecture Notes

2019

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Psychiatry

Memory: recent, remote, recent past, and immediate retention and recallConcentration and attention: serial sevens, ability to spell backwards

Defense Mechanisms

Learning Objectives

List the types of defense mechanisms and the situations in which they aremost likely to occur

Describe the most common psychological and intelligence tests and theirpurpose

Childhood Disorders

Learning Objectives

Describe the degrees of intellectual disability and expected level of functionList the different types of learning disorders

Describe the presentation of autism spectrum disorder

Describe the diagnosis and treatment of childhood disorders likely to

present to a psychiatrist, including attention deficit hyperactivity disorder,childhood conduct disorder, oppositional defiant disorder, childhood

Risk Factors/Etiology Associated genetic and chromosomal abnormalities

include inborn errors of metabolism (e.g., lipidoses, aminoacidurias, glycogenstorage diseases) and chromosomal abnormalities (e.g., cri du chat, Down,

fragile X syndromes) Associated intrauterine infections include rubella,

cytomegalovirus, and other viruses Intrauterine exposure to toxins and otherinsults such as alcohol, hypoxia, or malnutrition may be causal Postnatal causesinclude exposure to toxins and infection, poor prenatal care, postnatal exposure

to heavy metals, physical trauma, and social deprivation

Presenting Symptoms

Prevalence: 1% of the population Occurs at a 1.2:1 male-to-female ratio Mild ID (IQ 50–69): Attain academic skills to approximately the sixth-

grade level, often live independently in the community or with minimalsupervision, may have problems with impulse control and self-esteem, andmay have associated conduct disorder, substance-related disorder, or

Severe (IQ 20–35) and profound ID (IQ <20): Have little or no speech

and very limited abilities to manage self-care; require highly supervisedcare setting

adjustment

Differential Diagnosis Includes learning and communication disorders, sensory

impairment, autism spectrum disorder, borderline intellectual functioning (IQ70–100), and environmental deprivation

Definition Mood disorder that presents with at least a 2-week course of

symptoms that is a change from the patient’s previous level of functioning Musthave depressed mood or anhedonia (inability to enjoy oneself )

Risk Factors/Epidemiology Major depression is seen more frequently in

women due to several factors, such as hormonal differences, great stress, orsimply a bias in the diagnosis The typical age of onset is age 40 There is also ahigher incidence in those who have no close interpersonal relationships or aredivorced or separated Many studies have reported abnormalities in serotonin,

Differential Diagnosis

Medical disorders: hypothyroidism, Parkinson’s disease, dementia,

medications such as hypertensives, pseudodementia, tumors,

cerebrovascular accidents

Mental disorders: other mood disorders, substance disorders, and grief

Schizophrenia and Other Psychotic Disorders

Learning Objectives

List the diagnostic criteria and treatment approaches to schizophrenia andother psychotic disorders

Schizophrenia is more prevalent in low socioeconomic status groups, either as aresult of downward drift or social causation

Prevalence

General population 1% One schizophrenic parent 12%Monozygotic twin 47% Two schizophrenic parents 40%Dizygotic twin 12% First-degree relative 12%

Treatment Hospitalization is usually recommended for either stabilization or

safety of the patient If you decide to use medications, antipsychotic medicationsare most indicated to help control both positive and negative symptoms If noresponse, consider using clozapine after other medications have failed Thesuggested psychotherapy will be supportive psychotherapy with the primary aim

Anxiety Disorders

Learning Objectives

Describe the presentation, diagnostic criteria, and treatment approaches toanxiety disorders, including panic, phobic, obsessive-compulsive, acutestress, post-traumatic stress, and generalized anxiety disorders

Anxiety

Anxiety is a syndrome with psychologic and physiologic components

Psychologic components include worry that is difficult to control, hypervigilanceand restlessness, difficulty concentrating, and sleep disturbance Physiologiccomponents include autonomic hyperactivity and motor tension

Psychodynamic theory posits that anxiety occurs when instinctual drives are

thwarted Behavioral theory states that anxiety is a conditioned response to environmental stimuli originally paired with a feared situation Biologic theories

implicate various neurotransmitters (especially gammaaminobutyric acid

[GABA], norepinephrine, and serotonin) and various CNS structures (especiallyreticular activating system and limbic system)

Somatoform disorders are characterized by the presentation of physicalsymptoms with no medical explanation The symptoms are severe enough tointerfere with one’s ability to function in social or occupational activities

Dissociation is the fragmentation or separation of aspects of consciousness,including memory, identity, and perception Some degree of dissociation isalways present; however, if an individual’s consciousness becomes too

fragmented, it may pathologically interfere with the sense of self and ability toadapt Presenting complaints and findings of dissociative disorders includeamnesia, personality change, erratic behavior, odd inner experiences (e.g.,flashbacks, déjà vu), and confusion

on one’s emotional strength and coping skills

Prevalence Extremely common; all age groups

Onset is typically within 3 months of the initial presence of the stressor, and itlasts ≤6 months once the stressor is resolved If the stressor continues and newways of coping are not developed, it can become chronic

substance

Withdrawal: substance-specific behavioral, cognitive, and/or physiologic

change due to the cessation or reduction in heavy or prolonged substanceuse

Mental status examination: includes signs of substance-induced disorders Physical examination: includes signs of substance use

Coma

At higher levels, death may occur due to respiratorydepression

Table I-11-2 Substances of Abuse

Substance

Signs and Symptoms of Intoxication

Treatment of Intoxication

Signs and Symptoms of Withdrawal

1 Alcohol

1 Talkativeness,sullenness,gregariousness,moodiness, etc

1 Mechanicalventilation, ifsevere

1 Tremors,hallucinations,seizures,

deliriumtremens

1 Amphetamines,

cocaine

1 Euphoria,hypervigilance,autonomichyperactivity,weight loss,papillarydilatation,perceptualdisturbances

1 Short-term useof

antipsychotics,benzodiazepines,vitamin C topromoteexcretion inurine, anti-hypertensives

1 Anxiety,tremulousness,headache,increasedappetite,depression,risk of suicide

1 Anabolic

steroids

1 Irritability,aggression,mood changes,psychosis, heartproblems, liverproblems, etc

1 Symptomatic,abstinence

1 Depression,risk of suicide

1 Bath salts

1 Headache,palpitations,hallucinations,paranoia,violence,increased heartrate and bloodpressure

1 Supportive,benzodiazepines 1 Unknown

1 Benzodiazepines

1 Inappropriatesexual oraggressivebehavior,impairment inmemory orconcentration

1 Flumazenil

1 Autonomichyperactivity,tremors,insomnia,seizures,anxiety

1 Cannabis

1 Impaired motorcoordination,slowed sense oftime, socialwithdrawal,conjunctivalinjection,increasedappetite, drymouth,tachycardia

1 None 1 None

1 Ecstasy

1 Euphoria, mildpsychedelia,hyponatremia,seizures, death,rhabdomyolysis,increased heartrate, bloodpressure, andtemperature

1 Cyproheptadine,benzodiazepines,dantrolene

1 Unknown

1 Hallucinogens

1 Ideas ofreference,perceptualdisturbances,impairedjudgment,dissociativesymptoms,pupillarydilatation,tremors,incoordination

1 Supportivecounseling(talking down),antipsychotics,benzodiazepines

1 None

1 Belligerence,

1 Inhalants

apathy,assaultiveness,impaired

judgment,blurred vision,stupor or coma

1 Antipsychotics ifdelirious oragitated

1 None

1 Opiates

1 Apathy,dysphoria,papillaryconstriction,drowsiness,slurred speech,impairment inmemory, coma

or death

1 Naloxone

1 Fever, chills,lacrimation,runny nose,abdominalcramps,musclespasms,insomnia,yawning

1 Phencyclidine

(PCP)

1 Belligerence,assaultiveness,psychomotoragitation,nystagmus,hypertension,seizures, coma,hyperacusis

1 Talking down,benzodiazepines,antipsychotics

1 None

Impulse Control Disorders

Learning Objectives

Describe the presentation of intermittent explosive disorder, kleptomania,pyromania, gambling disorder, and trichotillomania

Describe the treatment approaches for impulse control disorders

Impulse Control

In impulse control disorders, patients are unable to resist a negative impulse.Before the act they have increased anxiety and after the act they feel a reduction

in anxiety Impulse control is mediated by the serotonergic system

Eating Disorders

Learning Objectives

List the diagnostic criteria for anorexia nervosa, bulimia nervosa, and bingeeating disorder

Risk Factors/Etiology Biologic factors are suggested by higher concordance

for illness in monozygotic twins and the fact that amenorrhea may precede

abnormal eating behavior Psychologic risk factors include emotional conflictsconcerning family control and sexuality A cultural risk factor may be an

Great concern with appearance Significant amount of time spent examiningand denigrating self for perceived signs of excess weight

Denial of emaciated conditions

With binge-eating/purging: self-induced vomiting; laxative and diureticabuse

Diagnostic Tests

Signs of malnutrition: normochromic, normocytic anemia, elevated liver

enzymes, abnormal electrolytes, low estrogen and testosterone levels, sinusbradycardia, reduced brain mass, and abnormal EEG

Signs of purging: metabolic alkalosis, hypochloremia, and hypokalemia

caused by emesis; metabolic acidosis caused by laxative abuse

Treatment Initial treatment should be correction of significant physiologic

consequences of starvation with hospitalization if necessary Behavioral therapyshould be initiated, with rewards or punishments based on absolute weight, not

on eating behaviors Family therapy designed to reduce conflicts about control

by parents is often helpful Antidepressants may play a limited role in treatmentwhen comorbid depression is present

Differential Diagnosis Major rule-outs are bulimia nervosa, general medical

conditions that cause weight loss, major depressive disorder, schizophrenia,

OCD, and body dysmorphic disorder.

adapting to stress, failure to achieve goals, chronic unhappiness, low self-esteem

Treatment Psychotherapy is the mainstay of treatment Intensive and long-term

psychodynamic and cognitive therapy are treatments of choice for most PDs.Use of mood stabilizers and antidepressants is sometimes useful for Cluster BPDs

A 57-year-old man living in a condominium complex constantly accuses hisneighbors of plotting to avoid payment of their share of maintenance He writesangry letters to other owners and has initiated several lawsuits He lives aloneand does not socialize

Schizoid PD: Detachment and restricted emotionality Individuals are

emotionally distant They are disinterested in others and indifferent to praise orcriticism Associated features include social drifting and dysphoria

A 24-year-old man lives alone and works nights as a security guard He ignoresinvitations from coworkers to socialize and has no outside interests

Schizotypal PD: Discomfort with social relationships; thought distortion; eccentricity Individuals are socially isolated and uncomfortable with others.

Unlike Schizoid PD, they have peculiar patterns of thinking, including ideas ofreference and persecution, odd preoccupations, and odd speech and affect DSM-

5 includes this PD in both psychotic disorders and personality disorders

A 30-year-old man is completely preoccupied with the study and the brewing ofherbal teas He associates many peculiar powers with such infusions and saysthat plants bring him extra luck He spends all of his time alone, often takingsolitary walks in the wilderness for days at a time, collecting plants for teas He

Cluster B

Histrionic PD Usually characterized by colorful, exaggerated behavior and

excitable, shallow expression of emotions; uses physical appearance to drawattention to self; sexually seductive; and is uncomfortable in situations where he

or she is not the center of attention

A 30-year-old woman presents to the doctor’s office dressed in a sexually

seductive manner and insists that the doctor comment on her appearance Whenthe doctor refuses to do so, she becomes upset

Borderline PD Usually characterized by an unstable affect, mood swings,

marked impulsivity, unstable relationships, recurrent suicidal behaviors, chronicfeelings of emptiness or boredom, identity disturbance, and inappropriate anger

If stressed, may become psychotic Main defense mechanism is splitting

A 20-year-old nurse was recently admitted after reporting auditory

hallucinations, which have occurred during the last few days She reports

marriage difficulties and believes her husband is to blame for the problem Shehas several scars on her wrists and has a history of substance abuse

Antisocial PD Usually characterized by continuous antisocial or criminal acts,

inability to conform to social rules, impulsivity, disregard for the rights of others,aggressiveness, lack of remorse, and deceitfulness These have occurred sincethe age of 15, and the individual is at least 18 years of age

A 22-year-old man was recently arrested after he set his mother’s house on fire

He has had numerous problems with the law, which started at an early age when

he was sent to a juvenile detention center for his behavior at both home andschool He lacks remorse for setting the fire and expresses a desire that his

mother would have died in the fire

Narcissistic PD Usually characterized by a sense of self-importance,

grandiosity, and preoccupation with fantasies of success This person believes he

is special, requires excessive admiration, reacts with rage when criticized, lacksempathy, is envious of others, and is interpersonally exploitative