SMLE Psychiatry Syllabus

What is the first-line mood stabilizer and gold-standard treatment for Bipolar I Disorder?

Lithium. It is first-line for acute mania and maintenance, and is notable for reducing suicide risk in bipolar disorder.

What is the therapeutic serum level range for lithium in maintenance versus acute mania?

Maintenance: approximately $0.6$–$1.0\ \text{mEq/L}$. Acute mania: up to about $1.0$–$1.2\ \text{mEq/L}$. Toxicity generally occurs above $1.5\ \text{mEq/L}$.

List the early and severe signs of lithium toxicity.

Early: coarse tremor, nausea, vomiting, diarrhea, slurred speech, ataxia. Severe (>$2.0\ \text{mEq/L}$): confusion, seizures, arrhythmias, coma. Severe toxicity is treated with hemodialysis.

Which organs require baseline and periodic monitoring during lithium therapy?

Thyroid (TSH — lithium causes hypothyroidism) and kidneys (renal function/creatinine — nephrogenic diabetes insipidus). Also monitor serum lithium levels and, in some, ECG/pregnancy status.

What congenital malformation is associated with lithium use in pregnancy?

Ebstein's anomaly — a cardiac malformation of the tricuspid valve, associated with first-trimester lithium exposure.

Which anticonvulsant is preferred for rapid-cycling and mixed bipolar states, and what are its key toxicities?

Valproate (valproic acid). Toxicities include hepatotoxicity, pancreatitis, thrombocytopenia, weight gain, and teratogenicity (neural tube defects). It is contraindicated in pregnancy.

Which mood stabilizer is most effective for the depressive phase / maintenance of bipolar depression, and what dangerous rash can it cause?

Lamotrigine. It requires slow dose titration to reduce the risk of Stevens-Johnson syndrome / toxic epidermal necrolysis.

Why should antidepressant monotherapy be avoided in Bipolar Disorder?

Antidepressants can precipitate a manic/hypomanic switch or induce rapid cycling. Bipolar depression should be treated with a mood stabilizer and/or an atypical antipsychotic (e.g., quetiapine, lurasidone), not an SSRI alone.

Define Cyclothymic Disorder.

At least 2 years (1 year in children/adolescents) of numerous periods of hypomanic and depressive symptoms that do NOT meet full criteria for hypomania or a major depressive episode, without a symptom-free period longer than 2 months.

What is the definition of a rapid-cycling bipolar course?

At least 4 mood episodes (depressive, manic, or hypomanic) within a 12-month period. It is associated with a poorer prognosis and is more common in women.

What atypical antipsychotics are commonly used as first-line agents for acute mania?

Olanzapine, risperidone, quetiapine, and aripiprazole. They may be used alone or in combination with lithium or valproate, and act faster than lithium for acute agitation.

Why must valproate and carbamazepine be avoided in pregnancy?

Both are teratogenic: valproate causes neural tube defects (e.g., spina bifida) and lowers IQ; carbamazepine also causes neural tube defects. Lamotrigine or, cautiously, other agents are preferred if a mood stabilizer is needed.

What drug interaction concern exists with carbamazepine as a mood stabilizer?

Carbamazepine is a potent CYP450 (CYP3A4) inducer that autoinduces its own metabolism and lowers levels of other drugs (e.g., oral contraceptives). Key toxicities: agranulocytosis, aplastic anemia, hyponatremia (SIADH), and Stevens-Johnson syndrome.

What is the DSM-5 core criterion and minimum duration for Generalized Anxiety Disorder (GAD)?

Excessive anxiety and worry occurring more days than not for at least 6 months, about multiple events/activities, that is difficult to control.

How many of the 6 associated physical/cognitive symptoms are required to diagnose GAD in adults?

At least 3 of 6 symptoms: restlessness/feeling on edge, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. (Only 1 symptom is required in children.)

What are the first-line pharmacologic treatments for Generalized Anxiety Disorder?

SSRIs and SNRIs (e.g., venlafaxine, duloxetine) are first-line. Cognitive behavioral therapy (CBT) is the first-line psychotherapy and can be combined with medication.

What is the role and mechanism of buspirone in treating GAD?

Buspirone is a 5-HT1A partial agonist used for chronic GAD. It is non-sedating, non-addictive, has no abuse potential, and does not cause withdrawal, but takes 1-2 weeks to work. It does not treat acute anxiety attacks.

Why are benzodiazepines not preferred for long-term management of GAD?

Risk of tolerance, dependence, abuse, withdrawal, sedation, and cognitive impairment. They are reserved for short-term or acute use (e.g., bridging until an SSRI takes effect).

What is the mechanism of action of benzodiazepines?

They bind the GABA-A receptor and increase the frequency of chloride channel opening, enhancing GABA's inhibitory effect. (Barbiturates increase the duration of channel opening.)

What medication reverses benzodiazepine overdose, and what is its main risk?

Flumazenil, a GABA-A benzodiazepine receptor antagonist. Its main risk is precipitating seizures/withdrawal in benzodiazepine-dependent patients.

How do the pharmacokinetics of short-acting versus long-acting benzodiazepines affect their clinical use?

Short-acting (e.g., alprazolam, lorazepam, midazolam) have higher abuse/withdrawal potential and shorter effect. Long-acting (e.g., diazepam, chlordiazepoxide, clonazepam) have smoother withdrawal and are used in alcohol detox. Lorazepam/oxazepam/temazepam ('LOT') are safest in liver disease.

What are the DSM-5 criteria for a Panic Attack (number and timing of symptoms)?

An abrupt surge of intense fear/discomfort that peaks within minutes, with at least 4 of 13 physical/cognitive symptoms (e.g., palpitations, sweating, trembling, shortness of breath, chest pain, choking, nausea, dizziness, chills/heat, paresthesias, derealization, fear of losing control, fear of dying).

What distinguishes Panic Disorder from isolated panic attacks per DSM-5?

Panic Disorder requires recurrent unexpected panic attacks PLUS at least 1 month of persistent worry about additional attacks or maladaptive behavioral change (e.g., avoidance) related to the attacks.

What are the first-line treatments for Panic Disorder?

SSRIs/SNRIs plus cognitive behavioral therapy (CBT). Benzodiazepines may be used short-term for acute/breakthrough attacks while awaiting SSRI onset.

What is agoraphobia and how does it relate to Panic Disorder?

Agoraphobia is marked fear/avoidance of at least 2 situations (public transport, open spaces, enclosed spaces, crowds/lines, being outside home alone) where escape may be difficult. It is a separate DSM-5 diagnosis that frequently co-occurs with Panic Disorder.

How is the peak/timing of a panic attack used to differentiate it from other anxiety states?

A panic attack reaches peak intensity within minutes (typically about 10 minutes) and then subsides, whereas GAD involves persistent, chronic worry lasting months without discrete peaks.

What medical conditions should be excluded in a patient presenting with panic-attack-like symptoms?

Hyperthyroidism, cardiac arrhythmia/MI, pheochromocytoma, hypoglycemia, asthma/pulmonary embolism, and substance use/withdrawal (caffeine, stimulants, alcohol). Panic disorder is a diagnosis of exclusion.

Compare the typical time course of GAD versus Panic Disorder.

GAD: chronic, persistent, generalized worry present most days for at least 6 months with no discrete attacks. Panic Disorder: recurrent, sudden, discrete episodes of intense fear peaking within minutes, with anticipatory anxiety between attacks.

What is the SSRI discontinuation syndrome and which SSRI is most/least associated with it?

Flu-like symptoms, dizziness, insomnia, nausea, and 'brain zaps' after abrupt cessation. Most associated with short-half-life paroxetine; least associated with long-half-life fluoxetine, which self-tapers. Doses should be tapered.