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FIRST AID USMLE STEP 1: PSYCHIATRY 2025 WITH
VERIFIED ANSWERS
Transference? - ANSWER- Patient projects feelings about formative or other important persons onto physician. Countertransference? - ANSWER- Doctor projects feelings about formative or other important persons onto patient. What is the central goal of Freudian psychoanalysis? - ANSWER- Make patient aware of what is hidden in his/her unconsciousness. Primal urges (food, sex, aggression)
- "Drives" instinct
- Entirely subconcious - ANSWER-ID Mediator between primal urges and behavior accepted in reality - ANSWER- ego Moral values, conscience, can lead to self-blame and attacks on ego - ANSWER- super ego Thoughts and behaviors voluntary or involuntary that are used to resolve conflict and prevent undesirable feelings ( anxiety depression) - ANSWER- EGO Defenses 12 y/o girl dies her hair purple after her parents ground her - ANSWER- Acting out Ego Defense: Acting Out - ANSWER-Unacceptable feelings and thoughts are expressed through actions. Tantrums Temporary drastic change in personality, memory, consciousness or motor behavior to avoid emotional stress. - ANSWER- Dissociation Extreme forms of Dissociation can result in - ANSWER- Extreme forms can result in dissociative identiy disorder (multiple personality disorder). A patient with cancer schedules a full 40 hour work week despite her Oncologist telling her that she is going to be very fatigued and sick during treatment - ANSWER-Denial Denial - ANSWER- Avoidance of awareness of some painful reality.
Process whereby avoided ideas and feelings are transferred to some NEUTRAL PERSON or OBJECT - ANSWER- Displacement Mother places blame on child because she is angry with husband. Ego Defense: Fixation - ANSWER- Partially remaining at a more childish level of development vs. regression. Men fixating on sports games. Ego Defense: Identification - ANSWER- Modeling behavior after another person who is more powerful (though not necessarily admired*). Abused child identifies himself/herself as an abuser. Ego Defense: Isolation of affect - ANSWER- Separation of feelings from ideas and events. Describing murder in graphic detail with no emotional response. Ego Defense: Projection - ANSWER- An unacceptable internal impulse is attributed to an external source. A man who wants another woman thinks his wife is cheating on him. Ego Defense: Rationalization - ANSWER- Proclaiming logical regions for actions actually performed for other reasons; usually to avoid self blame. After getting fired, claiming that the job was not important anyway. Ego Defense: Reaction formation - ANSWER- Process whereby a warded-off idea or feeling is replaced by an unconsciously derived emphasis on its opposite. Patient with libidinous thoughts enters a monastery. Ego Defense: Regression - ANSWER- Turning back the maturational clock and going back to earlier modes of dealing with the world. Seen in children under stress (bedwetting) and in patients on dialysis (crying) Ego Defense: Repression - ANSWER-Involuntary witholding an idea or feeling from consciousness awareness. Not remembering a conflictual or traumatic experience.
Abuser- Usually female and the primary caregiver 3000 deaths/ year in the United States Sexual Abuse Evidence, Abuser, Epidemiology - ANSWER- Evidence- Genital/ Anal Trauma, STDs, UTIs Abuser- known to victim, usually male Peak incidence 9-12 years of age. Child Neglect - ANSWER- Failure to provide a child with adequate food, shelter, supervision, education, and/or affection. Most common form of child maltreatment. Evidence: poor hygiene, malnutrition, withdrawal, impaired social/ emotional development, failure to thrive. As with child abuse, child neglect must be reported to local child protective services. Anaclitic Depression (Hospitalism) - ANSWER-Depression in an infant attributable to continued separation from caregiver. Infant becomesw withdrawn and unresponsive. Reversible, but prolonged separation can result in failure to thrive or otehr developmental disturbances (Delayed speech) Regression in Children - ANSWER-Children regress to younger patterns of behavior under conditions of stress such as a physical illness, punishment, birth of a new sibling, or fatigue (bedwetting in a previously toilet-trained child when hospitalized). What are the Childhood and Early Onset Disorders? - ANSWER- ADHD Conduct Disorder Opposition Defiant Disorder Tourette's Syndrome Separation Anxiety Disorder What happens in ADHD? Associated with? Treatment - ANSWER- Limited attention span and poor impulse control. Onset before age 7. Characterized by hyperactivity, motor impairment, and emotional lability. Normal intelligence but commonly coexists with difficulty in school. May continue into adulthood in as many as 50% of individuals.
Associated with decreased frontal lobe volumes. Treatment: Methylphenidate (Ritalin), Amphetamines (Dexedrine), Atomoxetine (nonstimulant SNRI) Conduct Disorder? After 18 years, what is this diagnosed as? - ANSWER- Repetitive and pervasive behavior violating social norms (physical aggression, destruction of property, theft). Diagnosed as antisocial personality disorder after 18. Oppositional Defiant Disorder - ANSWER- Enduring pattern of hostile, defiant behavior toward authority figures in the absence of serious violations of social norms. Tourette's Syndrome. Lifetime prevalence? Associated with? Onset at? Treatment - ANSWER-Characterized by sudden, rapid, recurrent nonrhythmic stereotyped motor movements or vocalizations (tics) that persist for greater than 1 year. Lifetime prevalence of 0.1-1.0% in the general population. Coprolalia (obscence speech) found in only 20% of patients. Associated with OCD. Onset at < 18 years of age. Treatment: Antipsychotics (Haloperidol) Separation Anxiety Disorder. Common onset? - ANSWER-Overwhelming fear of separation form home or loss of attachment figure. May lead to factitious physical complaints to avoid going to school. Common onset from 7-9 years of age. What are the pervasive developmental disorders? - ANSWER-Autistic Disorders, Aspergers, Rette's disorder, Childhood disintegrative disorder Autistic Disorder, More common in? Treatment? - ANSWER- Severe language impairment and poor social interactions. Greater focus on objects than on people. Characterized by repetitive behavior and usually below-normal intelligence. Rarely, may have unusual abilities (savants). More common in boys. Treatment: Behavioral and supportive therapy to improve communication and social skills Asperger's Disorder - ANSWER- A milder form of autism. Characterized by all-absorbing
Common causes of loss of orientation include: alcohol, drugs, fluids/ electrolyte imbalance, head trauma, hypoglycemia, nutritional deficiencies. Order of loss: 1st- time, 2nd- place, last- person. What are the four types of amnesia? - ANSWER- Retrograde, Anterograde, Korsakoff's Amnesia, Dissociative Amnesia Retrograde Amnesia- - ANSWER- Inability to remember things that occurred before a CNS insult Anterograde Amnesia - ANSWER- Inability to remember things that occurred after a CNS insult (no new memories) Korsakoff's Amnesia. Seen in what populations? Associated with? - ANSWER-Classic anterograde amnesia caused by thiamine deficiency. Leads to bilateral destruction of mamilary bodies. May also lead to some retrograde amnesia. Seen in alcoholics and associated with confabulations Dissociative amnesia - ANSWER- Inability to recall important personal information, usually subsequent to severe trauma or stress. Delirium. What do you want to check for? Hows the EEG look? - ANSWER- Waxing and Waning Level of consciousness with acute onset. Rapid decrease in attention span and level of arousal. Characterized by acute changes in mental status, disorganized thinking, hallucinations (often visual), illusions, misperceptions, disturbance in sleep-wake cycle, cognitive dysfunction. Most common psychiatric illness on medical and surgical floors. Abnormal EEG Check for drugs with anticholinergic effects. Often reversible. Dementia. Hows the EEG look? Causes? - ANSWER-Gradual decrease in cognition with no change in level of consciousness. Characterized by memory deficits, aphasia, apraxia, agnosia, loss of abstract thought, behavioral/ personality changes, impaired judgment. Patient is alert.
Increased incidence with age. More often gradual onset. Normal EEG. Caused by alzheimer's disease, vascular thrombosis, hemmorhage ( may have acute/subacute onset), HIV, pick's disease, substance abuse, CJD USUALLY IRREVERSIBLE. Pseudodementia - ANSWER- In Elderly patients, depression may present like dementia. Hallucination - ANSWER- Perceptions in the absence of external sitmuli Illusion - ANSWER- Misinterpretation of actual external stimuli Delusions - ANSWER- False beliefs not shared with otehr members of a culture/ subculture that are firmly maintained in spite of obvious proof to the contrary. Loose associations - ANSWER- Disorders in the form of thought (the way ideas are tied together) Schizophrenia. Associated with? How long? Risk Factors - ANSWER-Periods of psychosis and disturbed behavior with a decline in functioning lasting > 6 months. Associated with increased dopaminergic activity and decreased dendritic branching Marijuana use is a risk factor for schizophrenia in teenagers. What does diagnosis of Schizophrenia require? - ANSWER- 2 or more of the following:
- Delusions
- Hallucinations
- Disorganized speech (loose associations)
- Disorganized or catatonic behavior
- Negative symptoms: Flat affect, social withdrawal, lack of motivation, lack of speech of thought How long does brief psychotic disorder last? - ANSWER- <1 month, usually stress related Schizophreniform Disorder - ANSWER- 1 - 6 months Schizoaffective Disorder - ANSWER- At least 2 weeks of stable mood with psychotic symptoms, plus a major depressive, manic, or mixed (both) episode Two subtypes: Bipolar or depressive
Leads to significant distress or impairment. Not the result of substance abuse or general medical conditions. Types of hallucinations and what they are common in? - ANSWER- Visual Hallucinations- common in delirium Auditory Hallucinations- common in schizophrenia Olfactory Hallucinations- often occurs as an aura of psychomotor epilsepy Gustatory- Rare Tactile Hallucination- Common in alchol withdrawal (formication- the sensation of ants crawling on one's skin). Also seen in cocaine abusers (cocaine bugs) Hypnagogic hallucinations - ANSWER- Occurs while going to sleep Hypnopompic hallucinations - ANSWER- Occur while waking from sleep (Pompous upon awakening) Manic Episode - ANSWER-Distinct period of abnormally and persistently elevate, expansive, or irritable mood lasting at least one week. Often disturbing to patients. Diagnosis requires 3 or more of the following: Distractilbility, Irresponsibility, Grandiosity, Flight of Ideas, Increase in goal-directed activity/ psychomotor agitation, decreased need for sleep, talkativeness or pressured speech Hypomanic Episode - ANSWER-Like manic disorder except mood disturbance is not severe enough to cause marked impairment in social/ and or occupational funcitoning or to neccessitate hospitalization. No psychotic features. Bipolar Disorder. Treatment - ANSWER-Defined by presence of at least 1 manic (Bipolar
- or hypomanic (bipolar II) episode. Depressive symptoms always occur eventually. Use of antidepressants can lead to increased mania. Patients mood and functoning usually return to normal between episodes. Engagement in pleasurable activities with painful consequences can be seen. High suicide risk. Treatment: high mood stabilizers (lithium, valproic acid, carbamazepine, atypical antipsychotics) Cyclothymic Disorder- - ANSWER- Milder form of bipolar disorder lasting at least 2 years
Major Depressive Episode - ANSWER-Characterized by at least 5 of the following 9 symptoms for 2 weeks (symptoms must include patient-reported depressed mood or anhedonia). 1. Sleep disturbance
- Loss of interest
- Guilt or feelings of worthlessness
- Loss of energy
- Loss of concentration
- Appetite/weight changes
- Psychomotor retardation or agitation
- Suicidal ideations
- Depressed mood Major Depressive Disorder - ANSWER- Recurrent; requires 2 or more major depressive episodes with a symptom free interval of 2 months. Lifetime prevalence of major depressive episode? - ANSWER- 5 - 10% males, 10-25% females Dysthymia - ANSWER- Milder form of depression lasting at least two years. Seasonal Affective Disorder - ANSWER- Associated with winter season, improves in response to full-spectrum light exposure. What does the sleep pattern of depressed patients look like? - ANSWER- Decreased slow-wave sleep Decreased REM latency Increased REM early in sleep cycle Increased total REM Repeated nighttime awakenings Early morning awakening (important screening question) Atypical Depression? Treatment? - ANSWER- Differs from classical forms of depression. Characterized by hypersomnia, hyperphagia, and mood reactivity (experience improves in response to positive events vs. persistent sadness). Associated with weight gain and sensitivity to rejection. Most common subtype of depression. Treatment: MAOIs/SSRI Electroconvulsive Therapy? Adverse effects? - ANSWER- Treatment option for major
intrussive thoughts, feelings, or sensations (obsessions)* that cause severe distress; relieved in part by performance of repetitive actions (compulsions). Ego DYStonic; behavior inconsistent with one's own beliefs and attitudes (vs. obsessive compulsive personality disorder; OCPD is ego SYNtonic). Associated with Tourette's disorder. Treatment: SSRIs, Clomipramine Post Traumatic Stress Disorder (PTSD) vs. Acute Stress Disorder? Treatement for PTSD - ANSWER-PTSD: Persistent reexperiencing of a previous traumatic event. May involve nightmares or flashbacks, intense fear, helplessness, or horror. Leads to avoidance of stimuli associated with the trauma and persistently increased arousal. - Disturbance lasts greater than a month with onset greater than 1 month after event and causes significant distress and/or impaired functioning.
- Treatment: Psychotherapy, SSRIs Acute Stress Disorder: Lasts between 2 days/1 month Generalized anxiety disorder (GAD)? Treatment? - ANSWER- Pattern of uncontrollable anxiety for at least 6 months that is unrelated to a specific person, situation, or event. Associated with sleep disturbance, fatigue, and difficulty concentrating. Treatment: Benzodiazepines, Buspirone, SSRIs Adjustment Disorder - ANSWER-Emotional symptoms (anxiety, depression) causing impairment following an identifiable psychosocial stressor (divorce, illness) and lasting less than 6 months. Greater than 6 months in presence of a chronic stressor. Malingering - ANSWER-Patient consciously fakes of claims to have a disorder in order to attain a specific secondary gain (avoiding work, obtaining drugs). Avoids treatment by medical personnel. Complaints cease after gain (vs. factitious disorder). Factitious Disorder - ANSWER-Patient consciously creates physical and/or psychological symptoms in order to assume sick role and to get medical attention (primary gain). Complaints DO NOT cease after gain (vs. malingering).
Manchausens Syndrome - ANSWER- Chronic Factitious Disorder with predominantly physical signs and symptoms. Characterized by a history of multiple hospital admissions and willingness to receive invasive procedures. Munchausen's Syndrome By Proxy - ANSWER- When illness in a child is caused by the caregiver. Motivation is to assume a sick role by proxy. Form of child abuse. Somatoform Disorders. More common in? - ANSWER-Category of disorders characterized by physical symptoms with no identifiable physical cause. Illness production and motivation are unconscious drives. Symptoms NOT INTETIONALLY produced or feigned. More common in women. What are the somatoform disorders? - ANSWER- Somatization Disorder Conversion Hypochondriasis Body Dysmorphic Disorder Pain Disorder Somatization Disorder - ANSWER- Variety of complaints in multiple organ systems (at least 4 pain, 2 GI, 1 sexual, 1 pseudoneurologic) over a period of years. Conversion - ANSWER- Motor or sensory symptoms, often following an acute stressor. Patient is aware but indifferent toward symptoms. Hypochondriasis - ANSWER- Preoccupation with and fear of having a serious illness despite medical evaluation and reassurance. Body Dysmorphic Disorder - ANSWER-Preoccupation with minor or imagined defect in appearance, leading to significant emotional distress or impaired functioning. Patients often repeatedly seek cosmetic surgery. Pain Disorder - ANSWER- Prolonged pain with no physiologic findings. Personality Trait - ANSWER-An enduring repetitive pattern or perceiving, relating to, and thinking about the environment and oneself that is exhibited in a wide range of important social and personal contexts. Personality Disorder - ANSWER-Inflexible, maladaptive, and pervasive pattern of behavior causing subjective distress and or impaired functioning. Person is usually not aware of problem. Stable by early adulthood and not usually diagnosed in children.
Males > Females Conduct disorder if less than 18 Histrionic - ANSWER- Cluster B Excessive emotionality and excitability, attention seeking, sexually provocative, overly concerned with appearance. Narcissistic - ANSWER- Cluster B Grandiosity, sense of entitlement, lacks empathy and requires excessive admiration, often demands the "best" and reacts to criticism with rage. Cluster C Description? - ANSWER- Anxious or fearful Genetic association with anxiety disorders. "Worried" (Cowardly, Compulsive, Clingy)
- Avoidant
- Obsessive compulsive
- Dependent Avoidant - ANSWER- Cluster C Hypersensitive to rejection, socially inhibited, timid, feelings of inadequacy, desires relationships with others (vs. schizoid). Obsessive Compulsive - ANSWER- Cluster C Preoccupation with order, perfectionism, and control. Ego SYNtonic; behavior consistent with one's own beliefs and attitudes (vs. OCD; OCD is ego DYStonic). Dependent - ANSWER- Cluster C Submissive and clinging, excessive need to be taken care of, low self-confidence. What is the schizophrenia time course? - ANSWER- <1 month: Brief psychotic disorder, usually stress related
1 - 6 months: Schizophreniform disorder > 6 months: Schizophrenia What is the progression of schizophrenia? - ANSWER-Schizoid --> Schizotypal (Schizoid + Odd thinking) --> Schizophrenic (Greater odd thinking than schizotypal) - > Schizoaffective (Schizophrenic psychotic symptoms + Bipolar or depressive mood disorder) Anorexia Nervosa - ANSWER- Excessive dieting +/- Purging Intense fear of gaining weight, body image distortion, and increased exercise leading to body weight less than 85% below ideal body weight. Associated with decreased bone density. Severe weight loss, metatarsal stress fractures, amenorrhea, anemia, and electrolyte disturbances. Seen primarily in adolescent girls. Commonly coexists with depression. Bulimia Nervosa - ANSWER- Binge eating +/- Purging Followed by self-induced vomiting or use of laxatives, diuretics, or emetics. Body weight often maintained within normal range. Associated with parotitis, enamel erosion, electrolyte disturbances, alkalosis, dorsal hand calluses from inducing vomiting (Russell's sign). Gender Identity Disorder - ANSWER-Strong persistent cross-gender identification. Characterized by persistent discomfort with one's sex causing significant distress and/or impaired functioning. Substance Dependence - ANSWER- Maladaptive patterns of substance use defined as 3 or more of the following signs in 1 year:
- Tolerance (need more to achieve same effect)
- Withdrawal
- Substance taken in larger amounts or over longer time than desired.
- Persistent desire or unsuccessful attempts to cut down.
- Significant energy spent obtaining, using, or recovering from substance.
- Important social, occupational, or recreational activities reduced because of substance abuse.
respiratory depression Treatment: Supportive (maintain respiration and BP) What happens in barbituate withdrawal? - ANSWER- Anxiety, seizures, delirium, life treatening cardiovascular collapse What happens in benzodiazepine intoxication? Treatment? - ANSWER- Greater safety margin, amnesia, ataxia, somnolence, minor respiratory depression. Additive effects with alcohol. Treatment: Flumazenil (competive GABA antagonist) What happens in benzodiazepine withdrawal? - ANSWER- Rebound anxiety, seizures, tremor, insomnia What drugs are depressants? - ANSWER- Alcohol Opiods Barbituates Benzodiazepines What drugs are stimulants? - ANSWER- Amphetamines Cocaine Caffeine Nicotine What drugs are hallucinogens? - ANSWER- PCP LSD Marijuana What does amphetamine intoxication cause? - ANSWER-Psychomotor agitation, impaired judgment, pupillary dilation, hypertension, tachycardia, euphoria, prolonged wakefulness and attention, cardiac arrhythmias, delusions, hallucinations, fever What does amphetamine withdrawal cause? - ANSWER-Post-use crash including depression, lethargy, headache, stomach cramps, hunger, hypersomnolence Cocaine Intoxication, Treatment? - ANSWER-Euphoria, psychomotor agitation, impaired jugment, tachycardia, pupillary dilation, hypertension, hallucinations (including tactile), aranoid ideations, angina, sudden cardiac death. Treat with a benzodiazepines
Cocaine Withdrawal - ANSWER- Post-use crash including severe depression and suicidality, hypersomnolence, fatigue, malaise, severe psychological craving Caffeine Intoxication - ANSWER- Restlessness, insomnia, Increased diuresis, muscle twitching, cardiac arrhythmias Caffeine withdrawal - ANSWER- Headache, lethargy, depression, weight gain Nicotine Intoxication - ANSWER- Restlessness, insomnia, anxiety, arrhythmias Nicotine Withdrawal. Treatment? - ANSWER- Irritability, headache, anxiety, weight grain, craving. Treatment: Buproprion, Varenicline PCP Intoxication - ANSWER- Belligerence, impulsiveness, fever, psychomotor agitation, vertical and horizontal nystagmus, tachycardia, ataxia, homicidality, psychosis, delirium PCP withdrawal - ANSWER- Depression, anxiety, irritability, restlessness, anergia, disturbances of thought and sleep LSD Intoxication (No withdrawal symptoms) - ANSWER- Marked anxiety or depression, delusions, visual hallucinations, flashbacks, pupillary dilation Marijuana Intoxication - ANSWER- Euphoria, anxiety, paranoid delusions, perception of slowed time, impaired judgment, social withdrawal, increased appetite, dry mouth, hallucinations Marijuana Withdrawal - ANSWER-Irritability, depression, insomnia, nausea, anorexia. Most symptoms peak in 48 hours and last 5-7 days. Can be detected in urine up to 1 month after use. Heroine Addiction. Users at increased risk for what? Treatment - ANSWER- Increased risk for hepatitis, abscesses, overdoses, hemorrhoids, AIDS, and right sided endocarditis. Look for track marks (needle sticks in veins). Symptoms of opiod intoxication (pinpoint pupils, respiratory depression, coma) Treatment: Naloxone, Naltrexone- competitively inhibits opiods, used in cases of overdose Methadone- long acting oral opiate, used for heroine detoxification of long term maintenenance
