Uworld Psych

Help rejecters

They believe that no treatment will help and appear to not want to improve. These patients are frustrating and can leave the physician feeling angry and manipulated. The understandable tendency to want to refer this patient to another provider or specialist should be avoided.

These patients often have underlying depression but will refuse referral to a psychiatrist. They are needy for attention and unconsciously wish to remain symptomatic so that they can continue to see a physician. The best approach is to empathize with these patients and attempt to engage them in a collaborative plan in which there is mutual agreement about realistic treatment approaches and limited expectations. Sharing frustration over disappointing outcomes and focusing on alleviation of symptoms rather than a cure is often helpful.

Alcohol

The incidental findings of abnormal liver enzymes and macrocytosis in this patient suggest that her symptoms are most likely due to alcohol use. This patient's history of gastroesophageal reflux disease, hypertension, and tremor on examination are also consistent with this clinical picture. She does not have significant depressive symptoms or a history of anxiety suggestive of a primary psychiatric disorder. As in this case, patients with chronic alcohol use frequently present in primary care with sleep disturbance and anxiety symptoms due to mild withdrawal. Patients may use alcohol to help fall asleep, but as the blood alcohol level drops, central nervous system hyperarousal occurs and results in awakenings. Many patients with chronic alcohol use develop persistent difficulties in both falling and staying asleep.

Several biomarkers used in screening for unhealthy alcohol use include an aspartate aminotransferase:alanine aminotransferase ratio of at least 2:1, elevated gamma-glutamyl transpeptidase, macrocytosis, pancytopenia, and increased carbohydrate-deficient transferrin.

This patient's alcohol use might have started as an adjustment reaction to her children leaving home. However, her persistent symptoms and abnormal laboratory findings suggest that chronic alcohol dependence has developed and is causing her current insomnia and anxiety. It is also important to note that adjustment disorders should not be diagnosed when criteria are met for another specific disorder.

Suicide

This patient is severely depressed and has active suicidal ideation with a plan to hang himself. He has access to lethal means and unclear ability to refrain from acting on suicidal thoughts. Due to his high risk of self-harm, confidentiality should be broken and the parents informed. The patient should be hospitalized immediately (on an involuntarily basis if necessary) so that he can be closely monitored and placed on suicide precautions if needed.

Parents of adolescent patients should always be notified when the patient is a risk to self or others or when starting psychotropic medication. If this patient is not suicidal and simply wants to discuss his depression or obtain psychotherapy referrals, his request for confidentiality should be respected.

Delusions

The best approach to the psychotic patient with no insight is a nonjudgmental stance that acknowledges the patient's experience and perspective without endorsing specific delusions or hallucinations. After a physician-patient relationship is established and the patient's psychosis begins to improve, it may be appropriate to assist the patient in distinguishing psychotic thoughts from reality.

normal aging

Normal age-related changes, as seen in this patient, should not impair daily functioning (eg, self-care, finances, medication management). This helps distinguish normal aging from mild neurocognitive disorder (NCD). In mild NCD, there is a modest but notable decline in cognitive function (eg, complex attention, executive function, learning and memory, language, perceptual-motor, social cognition). Capacity for independence in everyday activities is generally preserved but takes greater effort, time, and/or compensatory strategies. Major NCD (dementia) involves significant cognitive decline and clearly impaired functioning that necessitates assistance in everyday activities.

Normal Stress Response vs Adjustment

• normal stress response: pt exhibits no impairment of social and occupational functioning

• Adjustment with depressed mood: depressive symptoms develop within 3 months of the onset of an identifiable stressor and cause marked distress out of proportion to the stressor, but the full criteria for major depressive disorder are not met. Adjustment disorder requires that symptoms cause clear impairment in social and occupational functioning, which this patient does not demonstrate (still performs at work, enjoys socializing).

Psychosis Hospitalization

The legal standards specifying the criteria for civil commitment vary by state, but they generally require the presence of a mental illness, danger to self or others, and/or grave disability (inability to care for self due to mental illness).

Admit vs Hold in ER

• Holding patients overnight is reasonable in situations in which they will likely be better able to communicate the next day (eg, no longer intoxicated with alcohol or drugs)

• Admit patient if their treatment plan is unlikely to change acutely (suicidal)

Smoking Cessation

Nicotine replacement therapy (NRT, patch, gum), varenicline, and bupropion.

OTC med psychosis

This previously well child has been receiving medication for his cough and cold for the past 36 hours, and hisacute onset of hallucinations is most likely due to a medication side effect. Many over-the-counter cold preparations contain antihistamines (eg, diphenhydramine, doxylamine) that decrease nasal discharge but also have anticholinergic properties that can cause confusion and hallucinations.

Antisocial vs Narcissitic

• both: exaggerated sense of self importance and lack empathy (eg, thinks ordinary work is beneath him, quits job without realistic plans for getting another)

• difference: antisocial has more aggression, physical violence

Therapies

Fund of Knowledge

asking question average adult would know.,

Concrete Thinking

Patients who present with concrete thinking have lost the ability to form abstract concepts, such as metaphors, and focus instead on actual things and facts. Concrete thinking is the norm in children and is seen in cognitive disorders (mental retardation, dementia) and schizophrenia.