Psychiatry is covered on both the RITE® exam and the neurology boards, so it is important to stay up-to-date on the basics of psychiatry. The level of knowledge required as a neurologist in the realm of psychiatry is somewhat limited. You should be able to identify common psychiatric disorders, understand the first-line treatment, and know the side effects of medications. Here you will find the high-yield psychiatry material you should know, and a practice quiz at the end!
Authors: Kyle Rodenbach MD, Brian Hanrahan MD
Chapter Multimedia Content
Table of Contents
- Differentiate between volitional and non-volitional Disorders.
- Identify major depressive disorder, dysthymia, bereavement, and bipolar disease.
- Differentiate between different Cluster B personality disorders.
- Understand basic panic disorders.
- Be able to identify psychotropic drugs, their mechanism of action, and adverse side effects.
Note: DSM updates are always fair game although they do not always adhere to that. The level of knowledge required is not extensive and not above the level you learned for your USMLE Step 1.
Volitional and non-volitional psychiatric diseases
- In an effort to assume the sick role, patients will intentionally produce symptoms in the absence of external incentives. Patients place value on the emotional comfort that comes from being cared for, and may not have insight into their actions.
- Common comorbidities: Borderline personality disorder, antisocial personality disorder, and history of trauma (sexual, verbal, and/or emotional).
- The performance of certain behaviors for external secondary gain.
- Example: Patient with opioid addiction complains of abdominal pain in order to receive pain medication.
- Presents with motor or sensory dysfunction that causes significant distress to the patient that can’t be explained by any neurological/medical disorder.
- Onset is often preceded by conflicts, abuse, or other stressors but is not required for diagnosis.
- Symptoms are produced subconsciously and not intentionally.
- Example: A patient whose mother just passed away who now can no longer walk. Her examination shows no effort with individual muscle strength testing and she has negative imaging/diagnostic studies. Additionally, the patient will withdraw to pain when pinched on the leg.
Somatic symptom disorder/somatoform disorder
- Presents before the age of 30 years with recurrent and multiple somatic complaints not due to any physical disorder.
- Diagnosis (each of the following must be met, based on DSM-IV criteria):
- Four pain symptoms
- Two gastrointestinal symptoms
- One sexual symptom
- At least one symptom or deficit suggesting a neurologic condition not limited to pain (pseudo-neurologic)
- Dissociate disorders present with a disruption of normally integrated functions of consciousness, environmental perception, memory, and identity.
Dissociative identity disorder (multiple personality disorder)
- The patient will present with two or more distinct personalities.
- Etiology usually related to a severe physical and/or sexual abuse event(s) in childhood.
- The patient will present with detachment or estrangement from one’s own body or the environment.
- Cotard delusion: Patients who have the belief that they are dead. Can also be seen with schizophrenia and major depression with psychotic features.
- Presents will present in a new geographic location with amnesia and possibly a new identity. Can be associated with traumatic circumstances
Depression and related diseases
Major depressive disorder (MDD)
- Symptoms: SIGECAPS (Sleep, loss of interest, guilt, loss of energy, loss of concentration, appetite/weight changes, psychomotor retardation, suicidal ideations).
- Symptoms need to be longer than 2 weeks.
- Associated with low serotonin levels in the brain.
- If someone makes a vague suicidal statement during history gathering, it is important to try to ascertain intent and degree of risk.
- Suicide risk factors: Severe depression, widowed/divorced, male gender, age over 45, white ethnicity, past suicide attempts.
- Neurologic diseases with a higher risk of depression and suicide include Parkinson’s disease, epilepsy, Huntington’s disease, and multiple sclerosis.
- Electroconvulsive therapy (ECT) should be considered in patients with medically refractory MDD or those who are pregnant due to the teratogenic effects of psychotropic medications.
- Contraindications include a recent stroke or myocardial infarction, increased intracranial pressure, and having an intracranial space-occupying lesion.