ADHD
What 2 categories of symptoms are used to diagnose ADHD? What is an important caveat to diagnosis?
Inattention and Hyperactivity
Caveats:
Must be persistent (>6 months), lead to impairment in multiple settings. Symptoms must be present before age 12
What is the most common comorbidity in patients with autism?
What is the most common first presentation?
ADHD (50-70%)
Also Seizures (30%), intellectual disabilities (~33%)
Most common presentation is speech delay.
What's the difference between Alcohol Use Disorder and Addiction to Alcohol?
AUD - Impaired ability to control ETOH use and it leads to problems in their life. They crave alcohol, and tolerance/withdrawal are common but unnecessary for diagnosis
Alcohol Addiction by definition will cause withdrawal.
What are the 2 necessary components in diagnosis of Major Depressive disorder? How long does this need to last?
Many different presentations but needs to include Depressed mood and anhedonia for at least 2 weeks.
What's the difference between Bipolar I, II, and cyclothymic disorder?
Bipolar I: Mania (episode lasts >1week), with or without depression
Bipolar II: Episodes of depression and hypomania (no delusions or hallucinations) lasting at least 4 days.
Cyclothymic: symptoms of hypomania/depression that do not meet criteria for hypomania or MDD, occurs steadily for 2+ years.
Your patient is a 11 year old male who has been diagnosed with ADHD. When you are discussing treatment options with the parents, what is first line? What about if they say there is a history of substance abuse in the family?
First line is stimulants (Adderall, Vyvanse)
If hx of substance abuse concerns, use Strattera (SNRI), but Vyvanse also has a lower abuse potential.
Give an example of a matching OCD pattern and a non-matching OCD pattern
Non-matching: fear of cancer (obsession) needing to tap each doorknob 3 times.
____ causes miosis and _____ causes mydriasis
Opiates cause miosis and stimulants cause mydriasis
A patient reveals that he is feeling very depressed due to his heavy smoking habits and unsuccessful efforts to quit. He has started to feel like he isn't doing his normal hobbies, and has started sleeping into the afternoon a lot more. What would be the best treatment in this scenario?
Mirtazapine
Bupropion
ECT
Buspirone
Bupropion (Wellbutrin): DNRI that is often used for smoking cessation. You wouldn't want to give Mirtazapine due to sedative side effects since the patient is already hypersomnic.
Buspirone is for GAD, ECT is for refractory depression/anxiety/schizophrenia
What is first line for maintenance treatment of Bipolar I disorder? Which medications should always be avoided?
Mood stabilizers (Lithium, Depakote) are first line, antipsychotics are second line. SSRI/SNRI should always be avoided due to risk of inducing manic episodes.
Which of the following medications does NOT need a taper?
A: Methylphenidates
B: Amphetamines
C: Atomoxetine (Strattera)
D: Buproprion (Wellbutrin)
Which should we avoid in patients with Hx of Schizophrenia/Bipolar I?
A & B
Also A & B
In relation to diagnostic criteria for Autism, Which of these is false?
A) Deficits in non-verbal communication (eg. body language/pointing)
B)Symptoms can arise later in development
C) No reaction to pain
D) repetitive movements
B.
Symptoms must be present early in development for diagnosis.
What medication is used to treat cannabis hyperemesis syndrome?
A) Zofran
B) Phenergan
C) Haldol
D) Benztropine
Haldol
What is a necessary symptom to have in order to diagnose Panic Disorder?
A)Palpitations/Tachycardia
B)Nocturnal Attacks
C)Uncued Attacks
D)1+ Attack every 3 months
What is acute rescue treatment? Maintenance?
C) Uncued Attacks
Acute treatment: Fast acting beta blocker (propranolol), Benzodiazepine, Hydroxyzine
Maintenance: SSRI/SNRI
In the show Breaking Bad, Walter White fakes a mental illness to cover up being kidnapped by pretending he dissociated and woke up naked in a gas station. In the aftermath, he reports he doesn't remember anything about the last 3 days, saying that he completely blacked out. What kind of dissociative disorder did he fake?
A) Depersonalization Episode
B) Localized Dissociative Amnesia
C) Selective Dissociative Amnesia
D) Generalized Dissociative Amnesia
B) Localized Dissociative Amnesia. He also faked a fugue state, traveling to another location, but this is more associated with Generalized Dissociative Amnesia.
What somatic disorder do you have to rule out in children before diagnosing ADHD?
Hearing impairment
What is the best prognostic factor for a patient with OCD?
Good insight into their diagnosis and that their beliefs are irrational/excessive
What are the maintenance treatment options for moderate/severe AUD? What are the indications for one medication vs another?
Psychosocial counseling + Medication
Naltrexone is an opioid antagonist - will reduce cravings
If patient is on opioids or has elevated LFTs, use Acamprosate (not well understood mechanism but not able to be abused)
A 45-year-old female presents to your clinic saying that she has felt fatigued, irritable, and restless for the past 10 months. She says she often worries about her finances, kids, and health. On physical exam, she appears nervous and keeps tapping her feet. Her labs are unrevealing. Which of the following is the best first-line treatment for the patient’s most likely diagnosis?
A. Haloperidol
B. Amitriptyline
C. Chlordiazepoxide
D. Paroxetine
E. Quetiapine
D) Paroxetine
A 35-year-old man with bipolar disorder, most recent episode mixed, comes to the clinic for routine follow-up examination. His condition has been difficult to control and has required treatment with multiple medications during the past two years. The patient says his mood has been stable with his current regimen, but for the past three months, he has had tremor primarily affecting his hands. Which of the following medications is the most likely cause of this patient's tremor?
(A) Carbamazepine
(B) Gabapentin
(C) Lamotrigine
(D) Lithium carbonate
(E) Topiramate
D) Lithium carbonate
You have a patient who has been diagnosed with ADHD and is pregnant. Her symptoms are moderately severe, and she is interested in trying medication, if it's safe. What patient education do you give?
Stimulants (Amphetamines/Methylphenidates) are Category C for pregnancy (risk unknown). It is a shared decision, potentially switching to an SNRI. However, they are NOT recommended during lactation, as they can pass to baby via milk. Use Strattera or Venlafaxine
What are some physical exam findings you might find in a child with autism?
They may display:
repetitive behaviors, avoidance of eye contact, signs of cognitive disability, altered gait, hyper-reaction to stimuli, macrocephaly.
However, physical exam is often normal in patients with ASD.
What type of substances should we ask about in atypical cardiac patients (eg. heart attack at 40)
Stimulants (eg. methamphetamine or cocaine)
What is used as treatment for stimulant use disorder?
A 50-year-old woman who has been treated with sertraline for major depressive disorder for more than two years comes to the office because she has had weakness, cold intolerance, constipation, and weight gain during the past six months. Physical examination shows dry, coarse skin as well as bradycardia, hypothermia, and swelling of the hands and feet. Which of the following laboratory studies is the most appropriate to determine the diagnosis?
(A) Liver function testing
(B) Measurement of serum electrolyte levels
(C) Measurement of serum estrogen level
(D) Measurement of serum sertraline level
(E) Measurement of serum thyroid-stimulating hormone level
E) Measurement of serum TSH
What are labs to monitor while your patient is on Lithium?
Bonus: What chronic adverse effects can lithium cause?
CBC (blood dyscrasia)
CMP (LFTs - transaminitis)
Vit D (Osteoporosis)
Weight (weight gain)
Amylase & Lipase (Pancreatitis)
Chronic AEs: Hypothyroidism, nephrogenic DI, arrhythmias