Now, That’s What I Call High Yield: Psychiatry

  • /Reviewed by: Amy Rontal, MD
  • Psychiatry! Finally a topic with information that might be condensed into a single high-yield treatise!

    But don’t tell that to the psychiatrists. The information needed to get through Step 1 is much less than what’s necessary to be a psychiatrist. No matter what your chosen field, you will definitely need a basic understanding of depression, suicidality, personality disorders, and psychiatric medications. You will definitely need to know all of these to rock Step 1!

    Before we begin, a brief word of caution. Some students see the psych section as “not real medicine” and choose to put less effort into it. While some of the work in this discipline might feel more like a vocabulary test, you get the same amount of points for correctly identifying countertransference as you do for calculating a FENa and identifying a cause of kidney injury. Give this material its due credit and requisite focus. Without further ado, let’s begin.

    High-Yield Psychology for Step 1

    1. Ego defenses (7): There are 15+ ways that the our egos try to make us feel better about the state of affairs. See above; a lot of this is like a vocabulary test. Do your best to learn all of these, but if forced to triage, internalize splitting, rationalization, dissociation, denial, repression, and projection.

    2. Childhood disorders (6.5): Children are not immune from psychiatric diagnoses. ADHD is quite common, self-explanatory, and is treated with stimulants like methylphenidate.

    Autism spectrum disorder, NOT CAUSED BY VACCINES, is hallmarked by repetitive behaviors and poor social interactions. Children in question stems might be fixated on car wheels instead of the car as a whole.

    Conduct disorder labels a kid who is a bad seed, more or less a childhood criminal. On his or her 18th birthday, conduct disorder becomes antisocial personality disorder. Oppositional defiant disorder is also a common testable one. Be on the lookout for rebelling against authority both at school (teachers) and at home (parents).

    3. Schizophrenia (9): This is the prototypical psychiatric disease. Look for both positive (delusions, hallucinations) and negative (social withdrawal, lack of self-care) symptoms. You will certainly be tested on teasing out schizophrenia proper (6+ months duration) from a brief psychotic disorder, which lasts less than 1 month, and schizophreniform disorder, which lasts 1-6 months. When schizophrenia is combined with a mood disorder like depression or bipolar, you’ve got schizoaffective disorder.

    4. Major Depressive Disorder (8.5): With a prevalence of almost 10% in the US population, depression is certainly a disease you will be tested on. Always be on the lookout for 5 of the 9 SIGECAPS symptoms.

    Your first-line choice in treatment is an SSRI +/- CBT. Many options exist if SSRIs are ineffective or if their side effects are intolerable. Often, in the heavily-afflicted 18-35 year old demographic, sexual dysfunction is a deal breaker, and other treatment modalities like bupropion are better options.

    5. Personality disorders (7): Whether they are diagnosed by a psychiatrist or not, in all likelihood, you have met somebody out in the real world who is suffering from a personality disorder. Maybe it’s that uncle who keeps to himself, doesn’t really acknowledge the family, and has always taken jobs where he doesn’t have to interact with others.

    Or your coworker from the grocery store who could hold down a job and was enjoyable to be around but wholeheartedly believed she was married to the ghost of Jim Morrison (true story).

    Personality disorders are so hard to address because the afflicted patient is not aware of the problem, cannot recognize anything as being wrong, and has no desire to change. Keep this in mind when choosing between personality disorders, and similar conditions in which the patient does indeed recognize their behavior as not fitting in with social norms. As an example, a patient with obsessive-compulsive disorder doesn’t want to wash their hands 4 times before setting the table, and realizes this is a bizarre behavior. A patient with obsessive compulsive personality disorder might have similar behaviors, but would not see anything wrong with them.

    6. Intoxications/Withdrawal Syndromes (9): Being able to recognize intoxication and withdrawal from drugs of abuse is one of the cornerstones of psychiatry and also has a huge role in the emergency department.

    Remember, withdrawing from a GABA-ergic drug like alcohol or benzos can leave you for dead; other withdrawals are more unpleasant than deadly. Always consider cocaine use in a young, “healthy” patient with a cardiac condition like a STEMI.

    As a general rule, stimulants will increase sympathetic activity when in use, and leave a person in a low-energy state when withdrawing. Depressants slow things down when being taken, and sympathetic overdrive kicks in during withdrawal.

    7. Antipsychotics (7.5): You can 100% expect to see antipsychotics on Step 1. There are very many to internalize, so a framework is necessary.

    Separate your typical antipsychotics (prototype = haloperidol, a D2 receptor blocker, work mostly on positive symptoms) from your atypicals (risperidone, quetiapine, olanzapine, aripiprazole, etc., which work on both positive and negative symptoms).

    While remembering every nuance here is a near-impossibility, try to hang onto one major side effect for each one, as this is what makes them testable. For instance, think of olanzapine causing weight gain, risperidone causing elevated prolactin, and clozapine causing bone marrow suppression. Understanding the continuum of extrapyramidal symptoms from acute dystonia all the way to tardive dyskinesia is also crucial.

    8. Antidepressants (10): There are numerous drug classes to choose from when treating depression. Start with an SSRI, and remember these versatile drugs have applications to other maladies like panic disorder, PTSD, and OCD. Also, give them time, up to 2 months, to take effect. A classic question stem is a patient coming in at 2 weeks after initiation of an SSRI, not feeling much effect. Exercise patience.

    Other classes include serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants, both of which have application to chronic pain. As far as atypical choices, bupropion leads the pack for lack of sexual side effects, mirtazapine stimulates appetite, and trazodone makes you sleepy and causes priapism.

    Are you intimidated by these countless pharmacologic therapies and their laundry list of side-effects? It’s great that patients have options if one drug doesn’t agree with them, but tough on test takers who need to remember 30 drugs instead of 3. As above, hang onto the most common or most particular side effect for these medications, as that’s what really sets them apart and will be tested.

    Now go PSYCH yourself up for some studying. You got this…

     

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