Past CMS Psych Things to Remember

Form 5

• Catatonia is associated with schizophrenia

  • Think about the psychosis becoming so overwhelming it starts to affect the body as well; this can manifest as motor disturbances, rigidity, or extreme withdrawal from the environment.

• If someone wants to stop taking quetiapine due to sedation, switch them to aripiprazole

  • Aripiprazole best relieves sedation compared to other antipsychotics; however, it may also have a lower risk of extrapyramidal symptoms and can be advantageous for patients who require mood stabilization.

• Use atypical antipsychotics initially, but ziprasidone should be used before clozapine

  • Ziprasidone is safer than clozapine; however, it is crucial to monitor patients for potential cardiac side effects, such as prolonged QT interval.

• Schizophrenia produces decline in attention, working memory, and executive function

  • Think about how because of how messed up the brain is from the delusions and hallucinations, it won’t function properly

• Multiple episodes of palpitations and feeling like you’re going to die is panic disorder

  • In this specific case, the panic attacks started before a very stressful event, so the main thing is the panic attacks being recurrent

• Intrusive thoughts that produce anxiety with excessive actions are OCD

  • In this case, she has the obsession that she might have sexually abused her daughter; that is an intrusive thought; the compulsion is to check her daughter to relieve that obsession

• Atypical depression can show situational improvement in mood

  • Mood improves in atypical depression when good things happen; the patient’s mood is improving when the good thing of the physician’s warm and supportive manner is happening

• Acute mania should be treated with atypical antipsychotics because they are also inherently mood stabilizers

  • Think about acute mania being dangerous psychosis; in a situation like this, you need to treat like you would psychosis; utilizing atypical antipsychotics promptly to stabilize the patient's mood and prevent further escalation of symptoms.

• If someone has MDD and is showing signs of nutritional compromise, they need to be admitted inpatient

  • Nutritional compromise is very dangerous as it can lead to further deterioration of mental health and physical well-being, requiring immediate intervention and close monitoring to ensure proper recovery.

• A big feature of mania is rapid speech

  • Mania is the mind racing at the speed of light; when the mind races, so does the speech

• Vomiting can also be seen with anorexia; anorexia is different from bulimia in that there will be low BMI

  • Anorexics hate eating, so their BMI will be low; whereas those with bulimia may maintain a normal weight due to their cycles of binging and purging.

• Narrow philtrum and thin upper lip with intellectual disability is fetal alcohol syndrome

  • You know alcohol is teratogenic; it’s the upper lip that’s the giveaway here

• Impulsivity is a big feature in ADHD and you can also see brisk reflexes; need to confirm with teacher ratings

  • Think about being so hyperactive you act on impulse, without thinking

• Serotonin is low with antisocial personality disorder

  • Serotonin is responsible for controlling our mood, which is based on emotion (joy, sadness); think about how no serotonin means no emotion

• Emotional disregulation within 3 months of a stressor is adjustment disorder

  • Not being able to handle a stressful event properly means you can’t adjust to life changes

• Adjustment disorder includes anxiety because of a stressor

  • A stressor is something active that causes worry, like a breast cancer diagnosis or moving away from home

• If someone is being treated with methadone and needs opioids for pain control, keep their methadone and add a patient-controlled analgesia schedule

  • Methadone will continue to treat the withdrawal of opioid use disorder, so you don’t want to discontinue that, but it won’t be enough for the acute pain; let the patient control the analgesia specific for their pain

• Moderate to severe alcohol use disorder can be treated with naltrexone

  • Naltrexone reduces the cravings

• Blurry vision (optic neuritis), periventricular white matter plaques, memory impairment = multiple sclerosis

  • Multiple sclerosis is demyelinating to the optic nerve and brain

• Alzheimer’s shows mutations in Tau protein

• Caffeine withdrawal can cause severe diffuse headaches

  • Think about how caffeine is stimulating to the body so when you’re off of it, your blood vessels are stimulated even though the body isn’t, resulting in headaches

• Restless leg syndrome gets treated with dopamine agonists (-ole)

  • Restless legs are dysfunctional movements from low dopamine, so having dopamine can control those movements

• Acute dystonia gets treated with anticholinergics like diphenhydramine

  • Dystonia is acetylcholine mediated because it’s dysfunctional muscle contraction, which is why an anticholinergic is used

• Alcohol abuse with amnesia means Korsakoff syndrome

  • It goes Wernicke encephalopathy first with head issues like ophthalmoplegia then progresses to Korsakoff, with the memory and psychosis issues

• Cognitive impairment does not rule out discussion of preferences for care; regardless of cognitive status, you should still discuss preferences for care

  • You would still want to talk to them about their care just to see if they understand it;

Form 6

• The best way to handle delivering bad news is to schedule a follow up appointment

  • By scheduling a follow up appointment, you can allow the patient to discuss their emotions and feelings; it’s not dismissive to tell them to schedule a follow up, rather it can give them time to process and come back more receptive

• Worrying more often than not and not being able to sleep because of worries for more than 6 months is GAD and is best treated with CBT and SSRIs

  • Knowing your anxieties, you know it’s best to talk to someone; worries definitely have kept you awake and in this case, it’s the worry that’s causing this patient to sleep poorly

• In times of opioid overdose, respiration will be really low; need to correct that first before anything else

  • Respiratory failure will kill you

• Alcohol and valproic acid cause pancreatitis, but if alcohol consumption is below the limit for issues, think more about valproic acid

  • Remember 3:7 and 4:14 rule for alcohol consumption

• Hospice care is all about providing comfort; in terms of pain control, keep them comfortable by keeping them on their regimen and adding short-acting opioids

  • Keep them comfortable and focus on controlling their pain

• When lithium causes nephrogenic DI, if there isn’t severe hypernatremia, encourage them to keep drinking water

  • Lithium isn’t causing major problems and is treating the symptoms well; best thing to do is prevent hypernatremia by keep drinking water

• Female orgasmic disorder is when it’s not possible for orgasm due to stress and previous trauma

  • You could think about it like PTSD but not having the symptoms for it; instead, the individual experiences a significant dysfunction in their sexual response due to underlying psychological factors.

• Parkinson’s treatment includes dopamine agonists but opens the door for psychosis; best to decrease the carbidopa-levodopa

  • Think about how severe the symptoms are and evaluate which is worse; if the side effects are worse than the main symptoms the medication is trying to treat, decrease the medication; conversely, if the main symptoms are more severe and affect daily functioning, it may be necessary to adjust the treatment plan or consider alternative therapies that manage both the symptoms and side effects more effectively.

• With delirium, there’s fluctuations in mood and is acute

• Huntington’s is a genetic disorder, so genetic testing is better than MRI

Form 7

• A stressor causes disproportionate distress that takes over

  • In this case, the patient couldn’t sleep, he couldn’t feel good; that’s what it’s like when it takes over, and you’ve also felt that way too before

• Teens believe they are invulnerable to consequences (“this won’t happen to me”)

  • One of your coaches when you were a teen had to tell all of us “it’s funny until it happens to you” because of this exact thinking of invulnerability

• Meperidine is an opioid that will lead to delirium

  • Meperidine is a drug you’ll have to walk on eggshells for; have some degree of suspicion when meperidine is involved

• If there’s sexual dysfunction and gynecomastia, it’s because of hyperprolactinemia from dopamine antagonists

  • Gynecomastia involves hyperprolactinemia

• If you get to know about snoring and falling asleep during the day, think about OSA and get polysomnography

  • Loud snoring can interrupt normal sleep, causing sleep when there shouldn’t be; aggression also happens due to not having proper sleep

• Pressured speech, intense eye contact, impulsive behavior like buying a bunch of things are characteristic of hypomania

  • Hypomania is still relatively high energy but it’s not very intense; if it’s intense, it’ll be really clear of how controlling it is; it often results in unpredictable and erratic behavior that disrupts daily functioning.

• Loud and rapid speech is a characteristic sign of acute mania; other signs that help determine acute mania include grandiose self-image and irresponsibility

  • In this case, the patient said “I can show you a good time” and tried to come onto the doctor; that’s a grandiose self-image; she was also loud

• Delirium is acute change in mental status, including hallucinations

  • Think about those military shows you used to watch and how sleep deprivation made all those soldiers delirious; in that moment, remember how altered their mental status was

• Delusions are the only thing to exist in delusional disorder; there’s no hallucinations or mood changes

  • Try to see what they’re spending the most space talking about; if they’re honing in on a delusion without anything else, think delusional disorder