DHA Mental Health & Psychiatry Flashcards

A 34-year-old woman presents with a 6-month history of recurrent, intrusive thoughts that she might harm her infant son, despite having no desire or intention to do so. She performs elaborate checking rituals to ensure his safety and is deeply distressed by these thoughts. She has no history of violence. What is the most appropriate initial pharmacotherapy?

Answer: High-dose SSRI (e.g., fluvoxamine 200–300 mg/day)

Intrusive thoughts of harming loved ones without intent are ego-dystonic obsessions characteristic of OCD. High-dose SSRIs are the first-line pharmacotherapy for OCD — doses required are typically higher than those used for depression (e.g., fluvoxamine up to 300 mg/day, fluoxetine up to 80 mg/day). Low-dose antipsychotics are used as augmentation, not monotherapy. Benzodiazepines and mood stabilizers are not indicated as primary treatments for OCD.

A 28-year-old male is admitted following his third manic episode. He is allergic to carbamazepine. He has a history of rapid cycling (more than 4 episodes per year) and has failed adequate trials of lithium and valproate. Which agent has the strongest evidence as an adjunctive or alternative mood stabilizer specifically for rapid-cycling bipolar disorder in this scenario?

Answer: Lamotrigine

Lamotrigine has evidence specifically for the depressive phase and as prophylaxis in rapid-cycling bipolar disorder, particularly for bipolar II. While quetiapine and olanzapine are effective for acute mania, lamotrigine is distinctively studied for the rapid-cycling subtype as an alternative when lithium and valproate fail. Gabapentin lacks robust evidence as a mood stabilizer despite being an anticonvulsant.

A 45-year-old woman on clozapine for treatment-resistant schizophrenia develops a fasting glucose of 11.8 mmol/L, a BMI of 32, and a new-onset seizure. Her clozapine level is 820 ng/mL (therapeutic: 350–600 ng/mL). What is the MOST appropriate next step regarding her antipsychotic management?

Answer: Reduce the clozapine dose and add valproate for seizure prophylaxis

A supratherapeutic clozapine level (820 ng/mL vs. therapeutic 350–600 ng/mL) is a known risk factor for clozapine-induced seizures. The correct approach is to reduce the clozapine dose to bring the level into the therapeutic range. Valproate is the preferred adjunct for clozapine-induced seizures as it also has mood-stabilizing properties, though it can increase clozapine levels requiring further monitoring. Abrupt discontinuation risks rebound psychosis. Simply adding metformin without addressing the supratherapeutic level is inadequate. Switching to olanzapine may not be necessary if the level can be corrected.

During a psychiatric interview, a 22-year-old patient describes his thoughts as feeling 'inserted' into his mind by an external force and believes his actions are being controlled by a government satellite. These experiences represent which first-rank symptoms of schizophrenia, respectively?

Answer: Thought insertion and made actions (delusions of control)

Kurt Schneider's first-rank symptoms include: thought insertion (thoughts placed into the mind by an external agency), thought withdrawal (thoughts removed from the mind), thought broadcasting (thoughts transmitted to others), and passivity phenomena — 'made' feelings, impulses, and actions (the patient's own experiences felt as controlled externally). The patient describes thought insertion and made actions (delusions of control). These are Schneiderian first-rank symptoms highly specific to schizophrenia, though not pathognomonic.

A 38-year-old man with a known personality disorder is admitted after a serious suicide attempt following perceived abandonment by a close friend. He has a history of intense unstable relationships, chronic emptiness, identity disturbance, and impulsive self-harm. He is calm and cooperative on day 2 of admission. What is the MOST evidence-based long-term psychotherapeutic intervention for this patient?

Answer: Dialectical Behavior Therapy (DBT)

The clinical picture is consistent with Borderline Personality Disorder (BPD) — unstable relationships, identity disturbance, impulsivity, abandonment fears, and self-harm. Dialectical Behavior Therapy (DBT), developed by Marsha Linehan, is the most robustly evidence-based psychotherapy for BPD, specifically shown to reduce suicidality, self-harm, and hospitalizations. CPT is evidence-based for PTSD, not BPD. Supportive psychotherapy alone lacks the structure needed. Psychodynamic approaches (e.g., MBT) also have evidence for BPD but DBT has the strongest and most replicated evidence base.

A 67-year-old retired engineer presents with a 2-year progressive history of visuospatial difficulties, recurrent complex visual hallucinations of people and animals (which he recognizes as not real), fluctuating cognition day to day, and REM sleep behavior disorder documented on polysomnography. Cognitive testing reveals impairment. What is the MOST likely diagnosis, and what class of medication must be used with extreme caution due to risk of severe neuroleptic sensitivity?

Answer: Dementia with Lewy Bodies (DLB); conventional (typical) antipsychotics

The four core clinical features of Dementia with Lewy Bodies (DLB) are: (1) fluctuating cognition, (2) recurrent visual hallucinations that are typically well-formed, (3) REM sleep behavior disorder (RBD), and (4) parkinsonism. This patient meets three core features plus RBD, consistent with probable DLB. Critically, patients with DLB can have severe, potentially fatal neuroleptic sensitivity reactions to conventional (typical) antipsychotics (e.g., haloperidol), including irreversible parkinsonism, reduced consciousness, and death. Even some atypical antipsychotics carry risk. Clinicians must avoid typical antipsychotics in this population.