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USMLE Step 2 (Fach) / Psychiatry (Lektion)

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• Neurotransmitters of sleep SAND Serotonin: ↑ sleep- Drugs: Melatonin, tryptophan ACh: ↑ dreams Norepinephrine:- ↑ Dreams- ↓ Wakes Dopamine:- ↑ Wakes- Drugs: Antipsychotics (sleep more), bromocriptine (arousal) GABA:- ↓ Stage 4- ↓ Sleep latency- Drugs: Benzos Ethanol: ↓ REMBarbiturates: REM rebound
• REM sleep behavior disorder REM sleep arousal disorder (patient remembers the dream) Epidemiology:- Sex: ♂ > ♀- Usually in older patients (> 50 years) Risk factors: associated with narcolepsy, psychiatric medications, and neurodegenerative disorders Clinical features:- Physically acting out dreams during sleep (sometimes leading to injury to self or others)- Alert and orientated after awakening- Occor in the latter part of the night Treatment:- Remove dangerous objects from the bedroom to reduce risk of self-injury- If applicable, discontinue causative medications- Benzodiazepines (e.g., clonazepam)- Melatonin analogs
• Nightmare disorder REM sleep arousal disorder (patient remembers the dream) Epidemiology- Prevalence: up to 2% of adults, most common in early adulthood- Sex: ♀ > ♂ Risk factors: post-traumatic stress disorder (PTSD) Clinical features:- Recurrent frightening dreams during the second half of sleep cycle (middle of the night or early in the morning)- Patient remembers the dream after awakening- Causes functional impairment or distress Treatment:- Reassurance if the disorder is mild- Imagery rehearsal therapy: involves modifying a recurrent nightmare by writing it down and rehearsing new endings that make nightmares less frightening when they occur again- Antidepressants if associated with PTSD
• Age-related sleep changes - Decrease in total sleep time - Decreased time spent in deep sleep and REM sleep - Increased sleep latency - More frequent nighttime awakenings→ Likely multifactorial: due to nocturia, pain, and/or less time spent in deeper stages of sleep - Advanced circadian rhythms resulting in earlier bedtimes and thus morning awakenings Older patients are at increased risk for certain sleep disorders (e.g., obstructive sleep apnea) and should be screened accordingly!
• Paraphilias Pedophilia: Sexual focus on children.- Often male adult → female child Exhibitionism: Exposing genitals to strangers Voyeurism: Observing private activities of unaware victims Frotteurism: Touching, rubbing, or a nonconsenting person Fetishism: Inanimate objects Masochism: Being humiliated or force to suffer Sadism: Inflicting humiliation or pain on others Transvestic disorder: Sexually aroused by cross dressing
• Therapy Cognitive-behavioral therapy- Indications: Depression, generalized anxiety disorder, PTSD, panic disorder, OCD, eating disorders, negative thought patterns- Features: → Combines cognitive & behavioral therapy→ Challenges maladaptive cognitions→ Targets avoidance with behavioral techniques (relaxation, exposure, behavior modification) Interpersonal psychotherapy:- Indications: Depression- Features: Links symptoms to current relationship conflicts & interpersonal skill deficits Supportive psychotherapy:- Indications: Lower funcitoning, psychotic disorders, patients in crisis- Features:→ Maintains hope; provides encouragement→ Reinforces coping skills, adaptive defenses Psychodynamic psychotherapy:- Indications: Higher functioning, personality disorders- Features:→ Builds insight into unconscious conflicts & past relationships→ Uses transference→ Breaks down maladaptive defenses Motivational interviewing- Indications: Substance use disorders- Features:→ Nonjudgmental; acknowledges ambivalence & resistance→ Enhances intrinsic motivation to change Dialectical behavioral therapy:- Indications: Borderline personality disorder- Features:→ Improves emotion regulation, distress tolerance, mindfulness→ Decreases self harm; builds skills Biofeedback:- Indications: Prominent physical symptoms; pain disorders- Features: Improves control over physiological reactions to emotional stressors
• Inhalant abuse Inhalants: Glue, toluene, nitrous oxide ("whip-its"), amyl nitrate ("poppers"), spray paings Epidemiology:- Boys age 14-17 Acute intoxication:- Brief transient euphoria- Loss of consciousness- Immediate effects that typically last 15-45 minutes Diagnostics:- Dermatitis ("glue sniffer's rash"): Seen around mouth or nostrils- ↑ Liver function tests- Chronic abuse of nitrous oxide is associated with vitamin B12 deficiency
• Marchiafava-Bignami disease Definition: degeneration and necrosis of the corpus callosum, almost exclusively as a result of malnutrition due to chronic alcohol use Clinical features: varying symptoms such as- Behavioral changes- Intellectual difficulties and dementia- Epileptic seizures
• Childhood-onset fluency disorder Stuttering
• Speech sound disorder Articulation disorder
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• Stages of change model Precontemplation: Not ready to change; patient does not acknowledge negative consequences- Encourage patient to evaluate consequences of current behavior- Explain & personalize the risk- Recommending action is premature Contemplation: Thinking of changing; patient acknowledges consequences but is ambivalent- Encourage evaluation of pros & cons of behavior change- Promote new, positive behaviors Preparation: Ready to change; patient decides to change- Encourage small initial steps- Reinforce positive-outcome expectations Action: Making change; patient makes specific, overt changes- Help identify appropriate change strategies & enlist social support- Promote self-efficacy for dealing wth obstacles Maintenance: Changes integrated into patient's life; focus on relapse prevention- Follow-up support; reinforce intrinsic rewards- Develop relapse prevention strategies Identification: Behavior is automatic; changes incorporated into sense of self- Praise changes
• TCA overdose Clinical presentation:- CNS: Mental status changes (e.g., drowsiness, delirium, coma), seizures, respiratory depression- Cardiovascular: Sinus tachycardia, hypotension, prolonged PR/QRS/QT intervals, arrhythmias- Anticholinergic: Dry mouth, blurred vision, dilated pupils, urinary retention, flushing, hyperthermia Management:- Supplemental oxygen, intubation- IV fluids- Activated charcoal for patients within 2 hours of ingestion - IV sodium bicarbinate for cardiac arrhythmia (elevated pH and extracellular sodium concentrations → ↓ TCA binding; leaves sodium channels more active)
• Psychodynamic psychotherapy Indications: anxiety disorders Duration: weekly sessions for 6 months to years Main objectives:- Focuses on changing current behaviors, feelings, and thoughts by analyzing past experiences- Aims to reveal the unconscious mind- Therapist aims to keep their own personality neutral
• Interpersonal therapy Indications: depressive disorders Duration: weekly sessions for 12-16 weeks Main objectives:- Focuses on understanding problematic interpersonal relationships (e.g., unresolved grief or conflicts) and/or life situations (e.g., change in jobs, geographical move)- Aims to enable better control over mood and behavior
• Behavioral therapy Indicatons:- Obsessive-compulsive disorders- Phobias Duration: brief; usually combined with cognitive-behavioral therapy Techniques:- Based on learning theoretical alternatives to maladaptive behavior- Classical conditioning: a response evoked by a certain stimulus (e.g., ringing a bell at meal time provokes salivation in dogs- Operant conditioning: learned behavior following positive or negative reinforcement (e.g., opening the front door when the doorbell rings because a guest is expected) and likewise decrease in behavior following positive or negative punishment (e.g., prison sentence following a crime may cause a decrease in crime)- Systematic desensitization: increasing the level of exposure to anxiety-provoking stimuli while performing relaxation techniques- Flooding and implosion: exposing a patient to real (flooding) or imagined (implosion) anxiety-provoking simuli until th epatient achieves complete relaxation in that situation- Biofeedback: providing physiological information to patients to improve relaxation- Token economy: rewarding positive behaviors- Aversion therapy: using a nonrewarding stimulus to demote negative behaviors
• Motivational interviewing Indications:- Substance abuse disorders- Depressive disorders Duraion: 2-4 sessions Main objectives:- Showing support for optimism and self-efficacy- Avoiding arguments between the interviewer and client→ Involves adjusting to client's resistance→ Avoiding direct confrontation- Focuses on showing empathy through reflective listening
• Family therapy Indications:- Schizophrenia- Eating disorders (e.g., anorexia) Duration: months to years Techniques:- Identifies family dysfunctions and individual's problems that affect the entire family- Aim to reduce conflict and help accommodate each other within a family unit- Addresses to permeable (e.g., allowing child to smoke cigarettes) or too rigid (e.g., not allowing any social contact outside of the family) boundaries
• Substance abuse - Gamma-hydroxybutyric acid (GHB) Action: Direct agonist of GABA receptors (similar to benzodiazepines) Street names: liquid ecstasy (unrelated to MDMA) Clinical features: intoxication- Lightheadedness and loss of consciousness; may induce amnesia for the time of intoxication.- Vegetative symptoms: perspiration, agitation, nausea- Bruxism- Dehydration- In low doses: intensification of experience, well-being, increased desire to make contact Withdrawal:- CNS stimulation: irritability, insomnia, hallucinations, delirium- Autonomic instability: tachycardia, hypertension- Gastrointestinal complaints: diarrhea, abdominal pain- Tremor, increased muscle tone Treatment: Supportive
• Suicidality Age:- Peak incidence: 45-64 years- Incidence significantly increases after age 20 with another significant increase after age 45- Sex: ♂ > ♀Suicides are more common in men, suicide attempts are more common in women!  The biggest risk factors for suicidal behavior are:- Previous suicide attempt(s)- Other psychiatric disorders (e.g., major depressive disorder, alcohol or substance abuse, psychotic symptoms, history of aggressive behavior)- Other chronic and/or serious diseases (e.g., cancer or chronic pain)- Age > 45 years- Male sex- Possession of firearms- Social factors: unemployment, no spouse, poor social support/few social contacts, early loss of a parent Acute management:- Imminent risk of suicidal behavior (suicidal ideation, intent and concrete plan)→ Immediately reduce the risk, actively prevent the patient from suicidal behavior and assure the patient's safety.→ Hospitalization (even against the patients will If both clear suicidal ideation and concrete plan/intent are present) → Remove objects from the patient's environment that could be used in a suicide attempt.→ Do not leave the patient alone or even with his family.- Elevated risk of suicidal behavior (suicidal ideation and intent but no concrete plan)→ Involve the family of the patient and inquire about the patient's psychological and social situation (e.g., history of suicidal ideation, access to firearms, social connections).→ Take measures to increase the patient's social contacts and interaction with medical professionals. Long-term management:- Treat underlying psychiatric disorders.→ Lithium is an especially effective mood stabilizer in suicidal patients with depression. → If possible, avoid treatment with tricyclic antidepressants, MAO-inhibitors, and venlafaxine since these medications may easily cause lethal overdoses. 
• Substance abuse – Caustic liquids Products containing lye (e.g., potassium hydroxide, sodium hydroxide) or acid (e.g., hydrogen fluoride, zinc chloride), used as drain or toilet bowl cleaners or rust removers Clinical features:- Abdominal pain, nausea, vomiting- Chest pain, dyspnea- Oral pain, odynophagia, heavy salivation- Dysphagia Management:- Secure airways, oxygenation, monitoring, fluid resuscitation- Removal of contaminated clothes- Endoscopy in first 12–24 hours to evaluate severity of injury- Ocular exposure: Eye irrigation with topical anesthetics Complications (ingestion): gastric outlet obstruction, esophageal perforation, esophageal strictures, esophageal cancer
• Tics Vocal tics- Throat clearing- Grunting- Lip smacking- Barking- Sniffing- Coprolalia: uttering obscene or socially inappropriate words or phrases- Echolalia: repeating vocalizations of others Motor tics:- Facial grimacing- Blinking- Shoulder shrugging- Head jerking- Jumping- Twisting the body- Echopraxia: repeating movements of others
• Prognostic factors in schizophrenia Good: - Later onset- Female sex- Acute onset with precipitant- Predominantly positive symptoms- No family history- Short duration of active symptoms Poor:- Onset in childhood or adolescence- Male sex- Gradual onset (prodrome), no precipitant- Predominantly negative symptoms- Family history of psychotic illness- Long duration of untreated psychosis
• Female sexual interest/arousal disorder Sexual disorder in women characterized by lack of, or significantly reduced, sexual interest/arousal that is not better explained by another medical disorder, substance/medication-related issue, or a relationship problem.

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