Melman Psych

A 12-year-old boy develops a new-onset tic shortly after a sore throat. What is the most likely diagnosis?

Diagnosis: PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Key features:

• Follows Group A Streptococcus infection

• Can present with:

  • Tics

  • OCD symptoms

  • ADHD-like symptoms

Helpful test:

• Anti-streptolysin O (ASO) titer (evidence of recent streptococcal infection)

Buzzword: New-onset tic/OCD after strep throat → think PANDAS

A 7-year-old girl has facial grimacing for 5 months. She has no vocal tics, neurologic deficits, or psychiatric symptoms. What is the next best step in management?

Answer: Schedule follow-up in 3 months (watchful waiting)

Diagnosis: Provisional Tic Disorder (formerly Transient Tic Disorder)

Diagnostic criteria:

• Motor and/or vocal tics

• Duration <1 year

• Onset before age 18

Key facts:

• Common age: 7–12 years

• Occurs in ~20% of children

• Most resolve spontaneously

Management: Observation and reassurance unless symptoms become severe or persistent.

A 65-year-old man receives IV methylprednisolone for temporal arteritis and soon develops confusion and visual hallucinations. What is the most likely diagnosis?

Diagnosis: Corticosteroid-induced psychotic disorder

Clinical features:

• Hallucinations

• Delusions

• Mania

• Confusion/agitation

High-yield point:

• Can occur even after short-term or high-dose glucocorticoid exposure.

• NBME may test this after a single treatment course.

Buzzword: New psychosis after steroid administration → glucocorticoid psychosis

An 8-year-old boy has had eye-blinking, facial grimacing, and throat-clearing for 1 year. What is the most appropriate pharmacologic treatment?

Diagnosis: Tourette Syndrome

• Multiple motor tics + ≥1 vocal tic

• Duration >1 year

• Onset before age 18

Pharmacologic treatment:

• Risperidone (commonly tested NBME answer)

Other treatment options:

• Alpha-2 agonists (clonidine, guanfacine)

• Behavioral therapy (CBIT/CBT)

High-yield: Tourette syndrome requiring medication → risperidone is a classic shelf/NBME answer.

An 82-year-old man develops acute confusion while taking multiple medications. Which medications should be suspected and discontinued?

Most likely cause: Medication-induced delirium due to anticholinergic drugs

Common NBME answers:

• Diphenhydramine (1st-generation H1 blocker)

• Amitriptyline

• Doxepin

• Desipramine (TCAs)

High-yield: In an elderly patient with new confusion, always review the medication list for drugs with anticholinergic properties.

Which medication classes commonly have anticholinergic, anti-α1-adrenergic, and anti-H1 histaminergic effects?

Three high-yield classes:

• Tricyclic antidepressants (TCAs)

• First-generation H1 antihistamines (e.g., diphenhydramine)

• Second-generation (atypical) antipsychotics (to varying degrees)

Shared adverse-effect triad:

• Anticholinergic: dry mouth, urinary retention, constipation, confusion

• Anti-α1: orthostatic hypotension

• Anti-H1: sedation

What are the anticholinergic effects of medications?

Think of the opposite of DUMBBELSS.

DUMBBELSS (cholinergic):

• Diarrhea

• Urination

• Miosis

• Bradycardia

• Bronchoconstriction

• Excitation

• Lacrimation

• Salivation

• Sweating

Anticholinergic effects:

• Constipation

• Urinary retention

• Mydriasis

• Tachycardia

• Dry mouth (xerostomia)

• Dry eyes (xerophthalmia)

• Anhidrosis

• Confusion/delirium (especially in elderly)

Buzzword: "Hot as a hare, dry as a bone, blind as a bat, red as a beet, mad as a hatter."

What does anti-α1-adrenergic activity cause?

Mechanism:

• α1 receptors normally mediate arteriolar vasoconstriction

• Blocking α1 receptors → vasodilation

Clinical effects:

• Orthostatic hypotension

• Dizziness

• Syncope (fainting)

Common culprits:

• TCAs

• Many atypical antipsychotics

What are the effects of H1 histamine receptor blockade?

Primary adverse effect: Sedation

Common medications:

• Diphenhydramine

• Doxylamine

• Many TCAs

• Several atypical antipsychotics

High-yield: H1 blockade = sleepy patient.

An 8-year-old boy develops visual hallucinations after taking an over-the-counter cold medication. What is the most likely diagnosis?

Diagnosis: Medication-induced delirium

Common culprits:

• Diphenhydramine → anticholinergic toxicity

• Dextromethorphan → hallucinations at high doses

Buzzword: Child + OTC cold medicine + hallucinations = medication-induced delirium.

An 82-year-old man with urinary hesitancy and a weak urinary stream is taking amitriptyline. What is the next best step?

Answer: Discontinue amitriptyline.

Why?

• Amitriptyline has strong anticholinergic effects

• Antimuscarinic activity worsens:

  • Urinary retention

  • BPH symptoms

NBME pearl: Medication-induced urinary retention → stop the offending drug before adding another medication.

A 25-year-old man recently started a new psychiatric medication and now feels hot and has dry skin and dry mouth. What is the most likely cause?

Diagnosis: Anticholinergic toxicity

Likely culprit: Tricyclic antidepressant (TCA)

Classic findings:

• Hot

• Dry

• Flushed

• Mydriasis

• Tachycardia

• Urinary retention

• Constipation

• Delirium

Buzzword: "Hot and dry" after starting a psych medication → think TCA anticholinergic effects.

A 35-year-old woman develops acute insomnia after learning that a close family member has breast cancer. What is the most appropriate medication?

Answer: Clonazepam (short-term only)

High-yield points:

• Benzodiazepines are appropriate for acute, situational insomnia

• Avoid chronic use due to:

  • Dependence

  • Tolerance

  • Withdrawal

  • Cognitive impairment

NBME pearl: Acute stress + short-term insomnia → short course of a benzodiazepine may be appropriate; do not prescribe long term.

A 35-year-old man develops acute insomnia after a recent divorce. Which medication is most appropriate?

Answer: Zolpidem

Why?

• Appropriate for short-term treatment of acute insomnia.

• Used for situational/stress-related insomnia.

Other options:

• Benzodiazepines (e.g., clonazepam, temazepam) can also be used short term.

• SSRIs are not effective for immediate relief of insomnia.

NBME pearl: Acute insomnia → benzodiazepine or non-benzodiazepine hypnotic (zolpidem).

A 52-year-old woman has an 8-week history of rapidly progressive dementia, confusion, and myoclonus. What is the diagnosis?

Diagnosis: Creutzfeldt-Jakob disease (CJD)

Classic features:

• Rapidly progressive dementia

• Myoclonus

• Behavioral changes

• Ataxia

Cause: Prion disease

Buzzword: Rapid dementia + myoclonus = CJD

A 65-year-old man has visual hallucinations, parkinsonism, fluctuating cognition, and gradual cognitive decline. What is the diagnosis?

Diagnosis: Lewy Body Dementia

Classic triad:

• Visual hallucinations

• Parkinsonism

• Fluctuating cognition

Pathology:

• α-Synuclein Lewy bodies

NBME pearl: Hallucinations occur early, unlike in Alzheimer's disease.

A 65-year-old man begins pulling down his pants in front of guests and has become apathetic with personality changes. What is the diagnosis?

à frontotemporal

dementia (Pick disease) à characterized by apathy, disinhibition, personality change.

A patient has parkinsonism with prominent axial dystonia and early postural instability. What is the diagnosis?

Diagnosis: Progressive Supranuclear Palsy (PSP)

Key findings:

• Parkinsonism

• Axial rigidity/dystonia

• Early falls

• Vertical gaze palsy (classic)

NBME pearl: Parkinsonism + vertical gaze palsy = PSP.

A patient has urinary incontinence, gait instability, cognitive impairment, and parkinsonian features. What is the diagnosis?

Diagnosis: Normal Pressure Hydrocephalus (NPH)

Classic triad ("Wet, Wobbly, Wacky"):

• Wet → urinary incontinence

• Wobbly → gait apraxia/ataxia

• Wacky → dementia

Additional finding:

• Parkinsonism can occur.

Treatment: Ventriculoperitoneal shunt

What causes urinary incontinence in normal pressure hydrocephalus?

Mechanism: Failure of cortical inhibition of the pontine micturition (voiding) reflex.

Result:

• Urgency

• Urinary incontinence

Which brain structure undergoes degeneration in Huntington disease?

Answer: Caudate nucleus (early)

Pathology:

• Degeneration of the caudate and putamen

• Loss of GABAergic neurons

Clinical features:

• Chorea

• Psychiatric symptoms

• Dementia

Buzzword: Huntington → caudate atrophy

A 22-year-old man develops hyperorality, hyperphagia, docility, and hypersexual behavior. What is the diagnosis?

Diagnosis: Klüver-Bucy syndrome

Cause:

• Bilateral amygdala lesions

Classic findings:

• Hyperorality

• Hyperphagia

• Hypersexuality

• Docility

• Visual agnosia

What is the most common cause of Klüver-Bucy syndrome?

Answer: Herpes simplex virus (HSV-1) encephalitis

Mechanism:

• Bilateral temporal lobe destruction

• Bilateral amygdala damage

Buzzword: HSV encephalitis → Klüver-Bucy syndrome

A patient with Down syndrome develops early memory loss. Which brain structure is primarily affected?

Answer: Nucleus basalis of Meynert

Key facts:

• Located in the basal forebrain

• Rich in cholinergic neurons

• Degenerates in Alzheimer's disease

High-yield: Down syndrome → early-onset Alzheimer's disease.

Which brain structure is the primary source of norepinephrine?

Answer: Locus coeruleus

Location:

• Pons

Produces:

• Norepinephrine

Mnemonic: Blue (coeruleus) = blue mood = norepinephrine

Which brain structure contains the highest concentration of serotonergic neurons?

Answer: Raphe nuclei

Location:

• Midline brainstem (medial reticular formation)

Produces:

• Serotonin (5-HT)

Mnemonic: Raphe = serotonin

What is the first-line pharmacologic treatment for Alzheimer's disease?

First-line:

• Acetylcholinesterase inhibitors

  • Donepezil

  • Rivastigmine

  • Galantamine

Mechanism:

• Increase central cholinergic activity

Moderate-to-severe disease:

• Add memantine

• NMDA (glutamate) receptor antagonist

What is the mechanism of action of donepezil, rivastigmine, and galantamine?

Mechanism:

• Acetylcholinesterase inhibition

Effect:

• Increases acetylcholine in the CNS

• Improves cognition in Alzheimer's disease

High-yield: Alzheimer's = cholinergic deficit

A 74-year-old man has an MMSE score of 22/30, depressed mood, weight loss, poor eye contact, and cognitive complaints. What is the diagnosis and treatment?

Diagnosis: Pseudodementia (depression presenting as cognitive impairment)

Treatment:

• SSRI (e.g., sertraline)

Do NOT treat with:

• Donepezil (unless true Alzheimer's disease is present)

How to distinguish from Alzheimer's:

• Pseudodementia: prominent depressive symptoms, patients emphasize memory problems, cognition often improves with antidepressant treatment.

• Alzheimer's disease: gradual cognitive decline, patients may minimize deficits, progressive despite reassurance.

How can you differentiate pseudodementia from true dementia on the NBME?

Pseudodementia (Depression)

• Low mood

• Poor eye contact

• Tearfulness

• Weight loss or gain

• Apathy

• Complains about memory problems

• Performs poorly on cognitive testing due to lack of effort, but can improve with encouragement

True Dementia

• Progressive cognitive decline

• Usually tries hard on cognitive testing

• Deficits persist despite prompting

NBME pearl: Depressed patients appear apathetic during the MMSE, whereas patients with dementia generally make a genuine effort.

How do you distinguish normal aging from Alzheimer's disease on the NBME?

Normal Aging

• Patient recognizes and worries about memory lapses.

• Examples:

  • "I keep forgetting why I walked into a room."

  • "I accidentally left the stove on."

Alzheimer's Disease

• Patient often lacks insight into deficits.

• Family members are usually more concerned than the patient.

NBME pearl: If the patient is complaining about their own memory, the answer is usually normal aging, not Alzheimer's disease.

What are common reversible causes of cognitive decline?

Always rule out:

• Hypothyroidism

• Vitamin B12 deficiency

• Neurosyphilis

• Neuroborreliosis (Lyme disease)

Mnemonic: Think "THy B-Ly S"

• THy = Thyroid

• B = B12

• Ly = Lyme

• S = Syphilis

A 53-year-old man has depression, hypercholesterolemia, mildly elevated AST, bradycardia, and a BMI of 25. What is the diagnosis, next step, and treatment?

Diagnosis: Hypothyroidism

Next step:

• Check serum TSH

Treatment:

• Levothyroxine (T4)

Associated findings:

• Depression/dysthymia

• Hyperlipidemia

• Bradycardia

• Mild transaminitis

Buzzword: Depression + high cholesterol + bradycardia = hypothyroidism

A 48-year-old woman has elevated cholesterol, bradycardia, proximal muscle weakness, and elevated CK. What is the diagnosis?

Diagnosis: Hypothyroidism

Mechanism:

• Hypothyroid myopathy

Findings:

• Proximal muscle weakness

• Elevated creatine kinase (CK)

• Bradycardia

• Hyperlipidemia

Next step:

• Check serum TSH

An 81-year-old woman appears depressed after the death of her husband. What is the next best step in management?

Answer: Assess suicide risk.

NBME pearl: Whenever depression is suspected, suicide assessment is the first priority, even in elderly patients.

An elderly patient with memory decline has already been assessed for suicide risk. What is the next step?

Answer: Perform a Mini-Mental State Examination (MMSE).

Purpose:

• Assess cognitive impairment

• Screen for dementia

An 81-year-old woman has memory decline, an MMSE score of 25/30, depression, no suicidal ideation, and nonacute neurologic deficits. What is the next best step?

Answer: Check serum vitamin B12.

Why?

• B12 deficiency is a reversible cause of cognitive decline.

• Neurologic deficits suggest subacute combined degeneration (SCD).

NBME pearl: Cognitive symptoms + neurologic findings → always consider B12 deficiency.

Which spinal cord tracts are affected in subacute combined degeneration due to vitamin B12 deficiency?

Affected tracts:

• Lateral corticospinal tract

• Dorsal columns

• Spinocerebellar tracts

Spared tract:

• Spinothalamic tract

Mnemonic: BCD

• Balance → Spinocerebellar

• Corticospinal

• Dorsal columns

A patient develops depression several weeks after starting medications for heart failure with reduced ejection fraction. Which medication is the most likely cause?

Answer: Beta-blocker

High-yield adverse effects:

• Depression

• Fatigue

• Sexual dysfunction

• Bradycardia

NBME pearl: New depression after starting HF medications → think beta-blockerAnswer: Beta-blocker

High-yield adverse effects:

• Depression

• Fatigue

• Sexual dysfunction

• Bradycardia

NBME pearl: New depression after starting HF medications → think beta-blocker

At what age does nocturnal enuresis become pathologic?

Answer: After 5 years of age.

Definition:

• Repeated nighttime urinary incontinence in a child ≥5 years old.

Remember:

• Bedwetting before age 5 is considered developmentally normal.

A 75-year-old man has recurrent episodes of loss of consciousness with tonic-clonic movements. He becomes pale and diaphoretic before the episode and has a history of myocardial infarction. What is the diagnosis?

Diagnosis: Convulsive syncope

Key clues:

• Pallor

• Diaphoresis

• Cardiac history

• Brief tonic-clonic movements due to cerebral hypoperfusion

NBME pearl: Convulsive movements do not always indicate epilepsy. Cardiac syncope can produce brief seizure-like activity.

What is the underlying mechanism of narcolepsy?

Answer: Deficiency of orexin (hypocretin)

Produced by:

• Lateral hypothalamus

Results in:

• Excessive daytime sleepiness

• Cataplexy

• Sleep paralysis

• Hypnagogic hallucinations

How is narcolepsy diagnosed?

Gold standard:

• Overnight polysomnography followed by a Multiple Sleep Latency Test (MSLT)

NBME answer: Polysomnography

What is cataplexy?

Definition:

• Sudden loss of muscle tone triggered by strong emotions (especially laughter)

Consciousness is preserved.

Seen in:

• Narcolepsy

What are the polysomnography findings in narcolepsy?

Sleep latency: ↓ (fall asleep quickly)

REM latency: ↓ (enter REM rapidly)

High-yield: Narcolepsy = early REM onset

How do simple and complex focal seizures differ?

Simple focal seizure

• No loss of consciousness

Complex focal seizure

• Loss of awareness/consciousness

• Patient may stare blankly and be unaware of surroundings

NBME pearl: Staring with impaired awareness = complex focal seizure.

How do focal (partial) and generalized seizures differ?

Focal (partial):

• Begin in one cerebral hemisphere

• May remain focal or generalize

Generalized:

• Involve both cerebral hemispheres from onset

• • Usually associated with loss of consciousness

A patient starts tranylcypromine one week after stopping fluoxetine and develops a temperature of 105°F, tachycardia, and tachypnea. What is the diagnosis?

Diagnosis: Serotonin syndrome

Common causes:

• SSRI + MAOI

• SSRI + St. John's wort

• Multiple serotonergic medications

Classic findings:

• Hyperthermia

• Autonomic instability

• Hyperreflexia

• Clonus

• Agitation

NBME pearl: Think drug-drug interaction.

What is the treatment for serotonin syndrome?

Answer:

• Stop serotonergic agents

• Supportive care

• • Cyproheptadine (serotonin receptor antagonist)

How do serotonin syndrome and carcinoid syndrome differ?

Serotonin Syndrome

Cause

• Drug interaction

Symptoms

• Hyperthermia

• Tachycardia

• Tachypnea

• Hyperreflexia

• Clonus

Carcinoid Syndrome

Cause

• Serotonin-secreting neuroendocrine tumor

Symptoms

• Flushing

• Diarrhea

• Bronchospasm

• Abdominal pain

NBME pearl: High fever → serotonin syndrome; flushing + diarrhea → carcinoid syndrome.

How is carcinoid syndrome diagnosed and treated?

Diagnosis

• Urinary 5-HIAA

Treatment

• OctreotideA patient has felt emotionally numb and occasionally has sleep disturbances for two years after witnessing a terrorist attack. What is the next best step?

A patient has felt emotionally numb and occasionally has sleep disturbances for two years after witnessing a terrorist attack. What is the next best step?

Answer: Provide education about the range of normal reactions to trauma.

NBME pearl: Psychoeducation and supportive care are appropriate unless symptoms require more intensive intervention.

A patient with Parkinson disease develops paranoid delusions and hallucinations. What is the diagnosis and treatment?

Diagnosis: Parkinson disease psychosis

Treatment

• Quetiapine (NBME favorite)

• Clozapine is another option

• Pimavanserin is commonly used clinically

Avoid: Typical antipsychotics (worsen parkinsonism)

A man survives a plane crash and, two weeks later, repeatedly awakens reliving the event. What is the diagnosis?

Diagnosis: Acute Stress Disorder

Duration

• <1 month

Treatment

• Trauma-focused CBT

Remember:

• PTSD = symptoms >1 month

A 6-year-old boy has primary nocturnal enuresis. What is the stepwise management?

Management (NBME order):

1. Behavioral interventions

   • Reduce stressors

   • Provide reassurance and parental support

2. Positive reinforcement (star chart/reward system)

3. Enuresis alarm

4. Medications (only if refractory)

   • Desmopressin

   • Imipramine

NBME pearl: If a behavioral option is listed, it is almost always the correct first step.

What is the NBME treatment hierarchy for primary nocturnal enuresis?

Step	Management
1	Behavioral interventions (reduce stress, reassure family)
2	Positive reinforcement (star chart)
3	Enuresis alarm
4	Desmopressin or imipramine (refractory cases only)

Avoid as first-line:

• Water restriction after 5 PM

• Immediate medication therapy

High-yield: Behavior → Reward → Alarm → Medication

A patient expresses suicidal intent with a plan. What is the next best step?

Answer: Involuntary psychiatric hospitalization.

Priority:

• Ensure patient safety before psychotherapy or medications.

NBME pearl: Active suicidal ideation with intent or plan = hospitalize.

A patient requires involuntary psychiatric hospitalization for acute suicidality. How should you begin the conversation?

Best response:

"How would you feel about entering the hospital?"

Why?

• Uses a collaborative, empathetic approach while arranging hospitalization.

• You do not need the patient's permission if involuntary admission is indicated.

A 10-year-old boy from a rural Asian community has episodes that his family describes as "possession." He occasionally spits up blood afterward. His parents are supportive. What is the next best diagnostic step?

Answer: Electroencephalography (EEG)

Why?

• Episodes likely represent seizures.

• Blood may result from tongue or cheek biting during a seizure.

NBME pearl: Respect cultural beliefs while appropriately evaluating for a medical cause.

Why is child protective services not the correct answer in a child whose family believes seizure episodes are due to possession?

Because:

• The family is caring and appropriately seeking medical attention.

• Cultural beliefs do not equal child abuse or neglect.

Next step:

• Evaluate medically (EEG) while remaining culturally sensitive.

NBME pearl: Choose the answer that demonstrates cultural competence without overlooking serious medical conditions.

A 33-year-old man becomes mute and unresponsive two days after being robbed at gunpoint. What is the diagnosis and treatment?

Diagnosis: Catatonia precipitated by psychological trauma

First-line treatment:

• Lorazepam

If refractory:

• Electroconvulsive therapy (ECT)

High-yield: Mutism, immobility, and unresponsiveness after a traumatic event → catatonia.

A 39-year-old woman has excessive worry about work, marriage, finances, and her children for over 6 months without depressive or psychotic symptoms. What is the diagnosis?

Diagnosis: Generalized Anxiety Disorder (GAD)

Diagnostic criteria:

• Excessive anxiety/worry

• Multiple life domains

• >6 months

• Difficult to control

• No better explanation (e.g., MDD, psychosis)

Buzzword: Generalized worry for >6 months

What is the first-line treatment for Generalized Anxiety Disorder (GAD)?

First-line:

• Cognitive behavioral therapy (CBT)

• SSRI (e.g., sertraline, escitalopram)

Second-line:

• Buspirone

Mechanism of buspirone:

• 5-HT1A (serotonin) receptor partial agonist

NBME pearl: Buspirone is commonly tested but is not first-line.

A college student has declining grades and depressed mood for 3 months after breaking up with her boyfriend. She sleeps normally and has no appetite changes or psychotic symptoms. What is the diagnosis?

Diagnosis: Adjustment Disorder

Features:

• Identifiable stressor

• Emotional or behavioral symptoms

• Functional impairment

• Does not meet criteria for another psychiatric disorder

• main thing- withitn 3 months of event

High-yield: Stressor + impairment without MDD = Adjustment disorder

An elderly patient with severe depression refuses to eat and has catatonia. What is the next best step?

Answer: Electroconvulsive therapy (ECT)

Major indications for ECT

• Catatonia

• Refusal to eat or drink

• Imminent suicide risk

• Pregnancy

• Psychotic depression

• Treatment-resistant depression

• Previous good response

When should you diagnose Adjustment Disorder instead of Major Depressive Disorder?

Adjustment Disorder

• Triggered by an identifiable stressor

• Functional impairment

• Does not meet full criteria for MDD

Major Depressive Disorder

• Meets ≥5 SIGECAPS criteria

• • Symptoms independent of a normal stress response

A patient develops calcium oxalate kidney stones and high-anion-gap metabolic acidosis after ingesting a toxic alcohol. What is the diagnosis?

Diagnosis: Ethylene glycol poisoning

Classic findings

• Calcium oxalate crystals

• High AG metabolic acidosis

• Tachypnea (respiratory compensation)

Mnemonic: Ethylene glycol = "stones"

An adolescent is found sluggish with normal pupils and vital signs after inhaling a substance. What is the most likely toxin?

Answer: Butane (inhalant intoxication)

NBME pearl: Inhalant abuse is common in adolescents.

A 14-year-old develops progressive ataxia and cognitive decline. Which substance is the most likely cause?

Answer: Glue (chronic inhalant abuse)

Why not alcohol?

• Chronic alcohol-induced cerebellar degeneration is uncommon in adolescents.

A young man develops violent behavior and horizontal nystagmus after taking an illicit drug. Which drug is responsible?

Answer: PCP

Classic findings

• Nystagmus

• Violence/bellicosity

• Analgesia

• Hypertension

• Psychosis

Mnemonic: PCP = "People Can't behave Peacefully."

A patient develops mutism and constricted pupils after drug use. Which drug is the NBME testing?

Answer: PCP

NBME pearl: Although uncommon clinically, the NBME has tested PCP presenting with mutism.

A patient has decreased cerebral blood flow due to drug-induced vasoconstriction. Which drug is responsible?

Answer: Cocaine

Mechanism

• Potent vasoconstriction

Also causes

• Coronary vasospasm

• Placental abruption

• • Ischemic stroke

A teenager has injected conjunctivae, paranoia, and recent drug use. What is the diagnosis and treatment?

Diagnosis: Marijuana intoxication

Treatment

• Observation

• Supportive care

What is the first-line treatment for Obsessive-Compulsive Disorder (OCD)?

Treatment

• CBT (Exposure and Response Prevention)

• • SSRI (e.g., sertraline, fluoxetine)

A patient has hallucinations for 6 weeks and manic symptoms for 4 weeks. What is the diagnosis?

Diagnosis: Schizoaffective Disorder

Diagnostic feature

• • ≥2 weeks of psychotic symptoms without mood symptoms

A patient currently has only psychotic symptoms but is ultimately diagnosed with schizoaffective disorder. Why?

Patients with schizoaffective disorder may be evaluated during the psychosis-only phase.

Diagnosis requires:

• At least 2 weeks of psychosis without mood symptoms

• Mood episodes present during most of the illness

How do Brief Psychotic Disorder, Schizophreniform Disorder, and Schizophrenia differ?

Disorder	Duration
Brief Psychotic Disorder	<1 month
Schizophreniform	1–6 months
Schizophrenia	>6 months

High-yield: The time course determines the diagnosis.

What brain imaging finding is classically associated with schizophrenia?

Answer:

• Enlarged lateral ventricles

• Enlarged third ventricle

Reflects:

• • Cerebral atrophy

What finding most strongly suggests a primary psychotic disorder on the NBME?

Answer: Auditory hallucinations

Remember:

• Auditory hallucinations → schizophrenia/psychosis

• Visual hallucinations → think drugs, delirium, dementia, or neurologic disease

What are the SIGECAPS criteria for Major Depressive Disorder?

Need ≥5 symptoms for ≥2 weeks, including depressed mood or anhedonia.

SIGECAPS

• Sleep changes

• Interest loss

• Guilt

• Energy loss

• Concentration impairment

• Appetite changes

• Psychomotor changes

• Suicidal ideation

How do Bipolar I and Bipolar II differ?

Bipolar I

• At least one manic episode

• Often hospitalization

• Marked social/occupational impairment

• Risky behaviors

Bipolar II

• Hypomania + major depression

• No hospitalization for mania

• Less severe functional impairment

What are the first-line mood stabilizers for bipolar disorder?

First-line

• Lithium

• • Valproic acid

What are the major adverse effects of lithium and valproic acid?

Lithium

• Ebstein anomaly

• Hypothyroidism

• Tremor

• Nephrogenic diabetes insipidus

Valproic acid

• Neural tube defects

• Hepatotoxicity

• Pancreatitis

• • Thrombocytopenia

How do cyclothymia and dysthymia differ?

Cyclothymia

• 2 years
  

• Alternating hypomanic and depressive symptoms

• Never meets criteria for bipolar disorder or MDD

Persistent Depressive Disorder (Dysthymia)

• 2 years
  

• Chronic depressed mood

• Never meets criteria for major depressive episodes

When is the diagnosis Delusional Disorder?

Features

• One fixed non-bizarre delusion

• No hallucinations

• No disorganized behavior

• Minimal functional impairment outside the delusion

Examples

• Believes coworkers are stealing from him

• Believes neighbors are spying on him

If the delusion is bizarre ("aliens implanted a chip") → think schizophrenia, not delusional disorder.

A patient with metastatic cancer says, "I just want to die." What is the most likely reason?

Answer: Inadequate pain control

NBME pearl: In patients with advanced cancer, optimize pain management before assuming major depression.

A patient with chronic pain says, "I'm realizing I'll be like this forever." What is the most appropriate physician response?

Answer:

"Have you been feeling like just giving up?"

Why?

• • Assess for suicidal ideation whenever hopelessness is expressed.

A patient has insomnia and uncomfortable leg sensations at night. What is the next best step?

Answer: Check serum iron and ferritin.

Why?

• • Restless Leg Syndrome is commonly associated with iron deficiency.

A patient has Restless Leg Syndrome and normal iron studies. What is the treatment?

Answer:

• Pramipexole

• Ropinirole

Mechanism

• • Dopamine (D2/D3) agonists

Patients with Restless Leg Syndrome are at increased risk for developing which neurologic disease?

Answer: Parkinson disease

Reason: Both involve dopaminergic dysfunction.

A patient loses consciousness while shaving. Tilt-table testing is normal. What is the diagnosis?

Answer: Carotid sinus hypersensitivity

Differentiate:

• Normal tilt-table → carotid sinus hypersensitivity

• • Positive tilt-table → vasovagal syncope

Fundoscopy shows hard exudates, cotton-wool spots, and scattered retinal hemorrhages. What is the diagnosis?

Answer: Diabetic retinopathy

Classic findings:

• Microaneurysms

• Dot-blot hemorrhages

• Hard exudates

• Cotton-wool spots

High-yield: These retinal findings in a patient with diabetes strongly suggest nonproliferative diabetic retinopathy.

Which non-antipsychotic medication can cause tardive dyskinesia?

Answer: Metoclopramide

Mechanism:

• Dopamine (D2) receptor antagonist

Other adverse effects:

• Tardive dyskinesia

• Hyperprolactinemia

• QT prolongation

• • Drug-induced parkinsonism

Which antidepressant has the highest risk of causing seizures?

Answer: Bupropion

Risk is increased in:

• Eating disorders

• Electrolyte abnormalities

• • History of seizures

What are the high-yield facts about bupropion?

Mechanism

• Norepinephrine and dopamine reuptake inhibitor (NDRI)

Uses

• Major depressive disorder

• Smoking cessation

Advantages

• Minimal sexual dysfunction

• Less weight gain than SSRIs

Contraindications

• Bulimia/anorexia nervosa

• Seizure disorders

• Significant electrolyte abnormalities

Mnemonic: Bupropion = "Boosts dopamine, Burns cigarettes, Brings seizures."

Which laboratory test is most suggestive of chronic or recent heavy alcohol use?

Answer: Elevated γ-glutamyl transferase (GGT)

High-yield: GGT is a sensitive marker of chronic alcohol consumption.

A patient sustains a frontal lobe injury in a motor vehicle accident. Which cognitive deficit is most likely?

Answer: Impaired conceptual planning (executive dysfunction)

Frontal lobe functions

• Planning

• Judgment

• Organization

• Personality

• • Executive function

A man who normally drinks 12 beers daily cuts down to 4 beers and develops tremulousness. What is the treatment?

Diagnosis: Alcohol withdrawal

Treatment

• Long-acting benzodiazepine

• Chlordiazepoxide (or diazepam)

A postoperative patient develops tremors, tachycardia, and hallucinations 2–3 days after surgery. What is the diagnosis?

Answer: Alcohol withdrawal (alcoholic hallucinosis/early delirium tremens)

Treatment

• • Benzodiazepines

A patient has an intense fear of flying. What is the diagnosis and treatment?

Diagnosis: Specific phobia

Treatment

• Exposure therapy (long-term)

• • Lorazepam or another benzodiazepine for acute situations (e.g., an upcoming flight)