Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) Behavioral Health, Psychiatry, and the Nervous System Syllabus

How do adjustment disorder, acute stress disorder, and PTSD differ in stressor and timing?

Adjustment disorder: emotional/behavioral symptoms within 3 months of an identifiable (not necessarily life-threatening) stressor, resolving within 6 months of stressor end. Acute stress disorder and PTSD require a trauma involving threatened death/serious injury/sexual violence; ASD lasts <1 month, PTSD >1 month.

What are the DSM-5 criteria for Schizophrenia?

>=2 of 5 symptoms for a significant portion of 1 month (at least one being delusions, hallucinations, or disorganized speech), plus disorganized behavior or negative symptoms, with continuous disturbance/functional decline for >=6 months total.

How are schizophreniform disorder, brief psychotic disorder, and schizophrenia distinguished by duration?

Brief psychotic disorder: symptoms 1 day to <1 month with full return to baseline. Schizophreniform: 1-6 months. Schizophrenia: >=6 months (including prodromal/residual phases, with >=1 month of active symptoms).

What distinguishes schizoaffective disorder from a mood disorder with psychotic features?

Schizoaffective disorder requires >=2 weeks of delusions/hallucinations in the ABSENCE of a major mood episode, with mood episodes present for the majority of the illness. In mood disorder with psychotic features, psychosis occurs ONLY during mood episodes.

Compare positive and negative symptoms of schizophrenia and their treatment response.

Positive symptoms (hallucinations, delusions, disorganized speech/behavior) respond well to antipsychotics, especially first-generation (D2 blockade). Negative symptoms (flat affect, alogia, avolition, anhedonia, asociality) respond poorly; second-generation agents and clozapine are somewhat more effective.

What is delusional disorder?

One or more delusions for >=1 month without other active-phase schizophrenia symptoms, with functioning not markedly impaired and behavior not obviously bizarre. Subtypes include erotomanic, grandiose, jealous, persecutory, and somatic.

How is delirium distinguished from dementia (major neurocognitive disorder)?

Delirium: acute onset, fluctuating course, impaired attention/consciousness, often reversible, with an underlying medical cause (infection, drugs, metabolic). Dementia: gradual onset, progressive, stable level of consciousness/attention (early), usually irreversible memory/cognitive decline.

What are the distinguishing features of Alzheimer disease neurocognitive disorder?

Gradual, progressive memory impairment (recent memory first), with cortical atrophy and beta-amyloid plaques and neurofibrillary (tau) tangles. Treatment: cholinesterase inhibitors (donepezil, rivastigmine, galantamine) and the NMDA antagonist memantine for moderate-severe disease.

How does vascular neurocognitive disorder typically present compared to Alzheimer disease?

Vascular dementia shows a stepwise, abrupt decline correlating with cerebrovascular events, with focal neurologic signs and a history of vascular risk factors, versus the smooth, gradual decline of Alzheimer disease.

What clinical features differentiate dementia with Lewy bodies from other dementias?

Lewy body dementia features fluctuating cognition, recurrent well-formed visual hallucinations, spontaneous parkinsonism, REM sleep behavior disorder, and severe sensitivity to antipsychotics. Cognitive decline often precedes or coincides with motor symptoms (versus Parkinson disease dementia where motor symptoms precede by >1 year).

What characterizes frontotemporal (Pick) neurocognitive disorder?

Early personality/behavioral changes (disinhibition, apathy, loss of empathy) and/or language deficits, with relatively preserved memory early. Onset is often younger (<65). Associated with tau (Pick bodies) or TDP-43 inclusions and frontal/temporal atrophy.

List the DSM-5 cluster A personality disorders and their key features.

Cluster A ('weird/odd'): Paranoid (pervasive distrust/suspicion), Schizoid (detachment, restricted emotion, no desire for relationships), Schizotypal (eccentric behavior, magical thinking, ideas of reference, odd perceptions).

List the DSM-5 cluster B personality disorders and their key features.

Cluster B ('wild/dramatic'): Antisocial (disregard for/violation of others' rights, age >=18 with conduct disorder before 15), Borderline (instability of affect, relationships, self-image; impulsivity; splitting; self-harm), Histrionic (excessive emotionality, attention-seeking), Narcissistic (grandiosity, need for admiration, lack of empathy).

List the DSM-5 cluster C personality disorders and their key features.

Cluster C ('worried/anxious'): Avoidant (social inhibition, feelings of inadequacy, hypersensitivity to rejection but desires relationships), Dependent (excessive need to be cared for, submissive/clinging), Obsessive-compulsive (preoccupation with order, perfectionism, control).

What is the evidence-based first-line treatment for borderline personality disorder?

Dialectical behavior therapy (DBT) is the first-line and best-supported treatment. Psychotherapy is the mainstay; medications are adjunctive for specific symptoms (e.g., mood lability, impulsivity).

Differentiate somatic symptom disorder, illness anxiety disorder, conversion disorder, and factitious disorder.

Somatic symptom disorder: >=1 distressing somatic symptom with excessive thoughts/behaviors about it (>=6 months). Illness anxiety disorder: preoccupation with having/acquiring serious illness with minimal/no somatic symptoms. Conversion (functional neurological): neurologic symptoms incompatible with disease. Factitious: intentional falsification of illness to assume the sick role (no external reward).

How is malingering distinguished from factitious disorder?

Malingering is intentional production/feigning of symptoms motivated by EXTERNAL incentives (money, avoiding work/legal duty, obtaining drugs) and is not a psychiatric disorder. Factitious disorder involves feigning to assume the sick role with NO external reward (internal motivation).

Differentiate anorexia nervosa from bulimia nervosa.

Anorexia: restriction leading to significantly low body weight, intense fear of weight gain, distorted body image. Bulimia: recurrent binge eating with compensatory behaviors (vomiting, laxatives, exercise) at least weekly for 3 months, typically with normal or above-normal weight.

What are the major medical complications and refeeding risk in anorexia nervosa?

Complications include amenorrhea, osteoporosis, bradycardia/arrhythmias, lanugo, hypotension, and electrolyte abnormalities. Refeeding syndrome causes hypophosphatemia, hypokalemia, hypomagnesemia, and cardiac failure; refeed slowly with electrolyte monitoring and phosphate repletion.

What is the first-line pharmacotherapy for bulimia nervosa, and which drug is contraindicated?

Fluoxetine (an SSRI) is first-line and FDA-approved for bulimia. Bupropion is CONTRAINDICATED in eating disorders due to increased seizure risk.

What characterizes narcolepsy and its core neurochemical deficit?

Excessive daytime sleepiness with sudden sleep attacks, often with cataplexy (sudden loss of muscle tone triggered by emotion), hypnagogic/hypnopompic hallucinations, and sleep paralysis. Caused by loss of hypothalamic orexin (hypocretin) neurons. Treated with stimulants/modafinil and sodium oxybate for cataplexy.

What defines obstructive sleep apnea and its first-line treatment?

Repetitive upper airway collapse during sleep causing apneas/hypopneas, loud snoring, daytime sleepiness, and morning headaches; risk factors include obesity and large neck circumference. Diagnosed by polysomnography (AHI). First-line treatment is CPAP plus weight loss.

What are the DSM-5 criteria for Alcohol Use Disorder severity?

A problematic pattern of alcohol use with >=2 of 11 criteria within 12 months (impaired control, social impairment, risky use, tolerance, withdrawal). Severity: mild = 2-3 criteria, moderate = 4-5, severe = >=6.

Describe the timeline and management of alcohol withdrawal, including delirium tremens.

Tremor/anxiety/autonomic symptoms at 6-24 hrs; withdrawal seizures at 12-48 hrs; alcoholic hallucinosis 12-24 hrs; delirium tremens (DTs) at 48-96 hrs with confusion, agitation, fever, tachycardia (can be fatal). Treatment: benzodiazepines (first-line), thiamine before glucose, and supportive care.

What medications are FDA-approved for maintenance treatment of Alcohol Use Disorder?

Naltrexone (opioid antagonist, reduces craving/reward; avoid with opioid use), acamprosate (modulates glutamate; good for those with hepatic disease/abstinent patients), and disulfiram (aversive aldehyde dehydrogenase inhibitor causing flushing/nausea with alcohol).

What is the presentation of opioid overdose and its antidote?

Opioid overdose: respiratory depression, pinpoint (miotic) pupils, decreased consciousness, decreased bowel sounds/constipation. Antidote is naloxone, an opioid antagonist; may precipitate acute withdrawal in dependent patients.

What are the medications for opioid use disorder maintenance therapy?

Methadone (full mu-opioid agonist, dispensed in licensed programs), buprenorphine (partial agonist, often combined with naloxone as Suboxone with a ceiling effect/lower overdose risk), and naltrexone (antagonist, requires opioid abstinence before starting).

What are the features of stimulant (cocaine/amphetamine) intoxication and withdrawal?

Intoxication: euphoria, dilated (mydriatic) pupils, tachycardia, hypertension, hyperthermia, agitation/psychosis, and risk of MI/stroke/seizures. Withdrawal: 'crash' with hypersomnia, increased appetite, dysphoria, fatigue, and intense craving (no major life-threatening physiologic withdrawal). Management is largely supportive; benzodiazepines for agitation.

What is the recommended screening for depression and alcohol use in primary care (USPSTF/SBIRT)?

USPSTF recommends screening all adults for depression (e.g., PHQ-9) and for unhealthy alcohol use, with systems in place for diagnosis and treatment. SBIRT (Screening, Brief Intervention, Referral to Treatment) is the evidence-based framework for substance use, often using the AUDIT or CAGE questionnaire.

What is motivational interviewing and when is it used?

A patient-centered, collaborative counseling style that explores and resolves ambivalence to elicit behavior change, using open questions, affirmations, reflective listening, and summaries (OARS). It is especially effective for substance use and other behavior-change interventions and aligns with the stages-of-change model.

What is serotonin syndrome and how is it managed?

A potentially life-threatening syndrome from excess serotonergic activity (often SSRI + MAOI, or serotonergic drug combinations) with the triad of mental status changes, autonomic instability (hyperthermia, tachycardia), and neuromuscular hyperactivity (clonus, hyperreflexia, especially lower extremities). Treatment: stop offending agents, supportive care, and cyproheptadine.

What is the mechanism and key adverse effects of SSRIs?

SSRIs block presynaptic serotonin reuptake (SERT). Adverse effects: GI upset, sexual dysfunction, insomnia, initial increase in anxiety, hyponatremia (SIADH, especially elderly), and a discontinuation syndrome if stopped abruptly. They carry a black-box warning for increased suicidality in patients <25.

Compare bupropion, mirtazapine, and SNRIs as antidepressants.

Bupropion (NDRI): no sexual dysfunction/weight gain, helps smoking cessation, but lowers seizure threshold (avoid in eating disorders/seizures). Mirtazapine (alpha-2 antagonist): causes sedation and weight gain (useful for insomnia/poor appetite). SNRIs (venlafaxine, duloxetine): also treat neuropathic pain; venlafaxine can raise blood pressure.

What dietary and drug precaution is critical with MAOIs?

MAOIs require avoidance of tyramine-rich foods (aged cheese, cured meats, wine) to prevent hypertensive crisis, and they must not be combined with serotonergic drugs (SSRIs, meperidine) due to serotonin syndrome risk. A washout period (typically 2 weeks; 5 weeks for fluoxetine) is needed when switching.

What are the therapeutic monitoring requirements and toxicity signs of lithium?

Narrow therapeutic index (~0.6-1.2 mEq/L; toxicity >1.5). Monitor levels, renal function, and thyroid function. Toxicity: tremor, ataxia, confusion, seizures. Chronic effects: nephrogenic diabetes insipidus, hypothyroidism, Ebstein anomaly (teratogen). NSAIDs, thiazides, and ACE inhibitors raise lithium levels.

Compare valproate, carbamazepine, and lamotrigine as mood stabilizers.

Valproate: effective for mania/mixed/rapid cycling; risks hepatotoxicity, pancreatitis, thrombocytopenia, weight gain, and neural tube defects (teratogen). Carbamazepine: risk of agranulocytosis, SIADH, Stevens-Johnson syndrome, and CYP induction. Lamotrigine: best for bipolar depression maintenance; risk of Stevens-Johnson syndrome, so titrate slowly.

Compare first-generation (typical) and second-generation (atypical) antipsychotics.

Typicals (haloperidol, fluphenazine) are potent D2 blockers, controlling positive symptoms but causing more extrapyramidal symptoms and hyperprolactinemia. Atypicals (risperidone, olanzapine, quetiapine) block D2 and 5-HT2A, treat negative symptoms somewhat better, with fewer EPS but more metabolic side effects (weight gain, diabetes, dyslipidemia).

What are the extrapyramidal side effects of antipsychotics and their time course?

Acute dystonia (hours-days: muscle spasm/torticollis, treat with anticholinergics/diphenhydramine), akathisia (days-weeks: restlessness, treat with beta-blocker/lowering dose), parkinsonism (weeks-months: bradykinesia/rigidity/tremor), and tardive dyskinesia (months-years: involuntary orofacial movements, often irreversible; treat with VMAT2 inhibitors).

What is neuroleptic malignant syndrome and how is it managed?

A life-threatening reaction to antipsychotics (dopamine blockade) with FEVER (hyperthermia), Encephalopathy (altered mental status), Vitals instability (autonomic), Elevated CK/enzymes, and Rigidity ('lead-pipe'). Treatment: stop the antipsychotic, supportive cooling/hydration, and dantrolene or bromocriptine/dopamine agonists.

What are the unique indication and monitoring requirements of clozapine?

Clozapine is reserved for treatment-resistant schizophrenia and reduces suicidality; it is the most effective antipsychotic. It requires regular ANC monitoring due to agranulocytosis risk, and carries risks of myocarditis, seizures (dose-related), metabolic effects, and severe constipation/ileus.

What is cognitive behavioral therapy (CBT) and what conditions is it used for?

CBT is a structured, time-limited, goal-oriented therapy that identifies and restructures maladaptive thoughts (cognitive distortions) and behaviors. It is first-line/highly effective for depression, anxiety disorders, OCD (with ERP), PTSD, insomnia, and many others, often combined with medication.

Differentiate the major psychotherapeutic modalities: psychodynamic, interpersonal, dialectical behavior, and supportive therapy.

Psychodynamic: explores unconscious conflicts and past experiences/transference. Interpersonal (IPT): focuses on current relationships and role transitions to relieve depression. DBT: combines CBT with mindfulness/distress tolerance/emotion regulation for borderline PD and self-harm. Supportive: bolsters existing coping mechanisms and provides reassurance.