100+ Free ABPN C-L Psychiatry Practice Questions

Psychiatric Aspects of Medical Illness

Cancer distress/depression (psychostimulants — methylphenidate for fatigue; avoid paroxetine/fluoxetine with tamoxifen — CYP2D6), HIV/HAND, post-stroke depression (SSRIs) and pseudobulbar affect (dextromethorphan-quinidine), Parkinson disease psychosis (pimavanserin; avoid typical APs), DLB (severe antipsychotic hypersensitivity — quetiapine or clozapine only), MS, epilepsy (avoid bupropion/clozapine/chlorpromazine which lower seizure threshold; carbamazepine/valproate/lamotrigine mood-stabilizing), diabetes (SSRIs OK bidirectionally), post-MI depression (sertraline — SADHART trial), CKD/dialysis (sertraline safer than citalopram QTc), COPD, chronic pain, fibromyalgia (duloxetine, milnacipran, pregabalin FDA-approved).

Delirium

CAM diagnostic algorithm — feature 1 (acute onset + fluctuating course) PLUS feature 2 (inattention) PLUS either feature 3 (disorganized thinking) OR feature 4 (altered level of consciousness). Hyperactive vs hypoactive (most common and under-recognized) vs mixed. Reversible causes: infection, medications (anticholinergics, benzos, opioids, steroids), electrolytes (hyponatremia, hypercalcemia), hypoxia, alcohol/BZD withdrawal, hepatic/uremic encephalopathy, thyroid/adrenal. Non-pharmacologic interventions first (reorientation, sleep hygiene, early mobility, sensory aids). Low-dose haloperidol 0.5-2 mg IV/IM/PO; quetiapine in PD/DLB; avoid benzos EXCEPT alcohol/BZD withdrawal. MIND-USA (NEJM 2018) showed neither haloperidol nor ziprasidone improved ICU delirium outcomes. Dexmedetomidine in ventilated patients. Terminal delirium.

Decisional Capacity & Ethics

Four components of decision-making capacity — (1) understand the information, (2) appreciate the situation and its consequences, (3) reason about treatment options, (4) communicate a consistent choice. Capacity is a CLINICAL assessment for a SPECIFIC decision at a specific time; competency is a LEGAL determination. Sliding scale — higher threshold for higher-risk decisions. Aid to Capacity Evaluation (ACE). Surrogate decision-making hierarchy varies by state. Tarasoff duty to protect, mandated reporting for abuse, boundary crossings vs violations, involuntary commitment criteria, guardianship.

Drug Interactions & Medical Comorbidities

SSRI bleeding risk (platelet serotonin depletion; added risk with NSAIDs and anticoagulants). QTc prolongation — citalopram max 40 mg adults, 20 mg age >60 or hepatic impairment; ziprasidone; IV haloperidol (torsades de pointes). SIADH/hyponatremia with SSRIs (especially elderly). Serotonin syndrome vs NMS differentiation. MAOI washout 14 days (5 weeks for fluoxetine due to norfluoxetine half-life).

Somatic Symptom & Functional Disorders

DSM-5-TR somatic symptom disorder (distressing somatic symptoms PLUS excessive thoughts/feelings/behaviors — NOT about whether symptoms are medically explained). Illness anxiety disorder (formerly hypochondriasis — minimal somatic symptoms). Functional neurologic/conversion disorder (Hoover sign, entrainment, typically after psychological stressor). Factitious disorder self-imposed vs imposed on another (FDIA — Munchausen by proxy). Functional abdominal pain, chronic fatigue syndrome/ME.

Perinatal Psychiatry

Antidepressants in pregnancy — sertraline and fluoxetine generally preferred; AVOID paroxetine in 1st trimester (cardiac malformation risk); neonatal SSRI discontinuation syndrome; PPHN risk late pregnancy. Breastfeeding — sertraline first-line. Postpartum blues (self-limited) vs postpartum depression vs postpartum psychosis (PSYCHIATRIC EMERGENCY — bipolar onset risk, inpatient, mood stabilizer). Bipolar in pregnancy — lithium Ebstein anomaly risk reassessed LOWER than classic 1:1,000-1:2,000 teaching; valproate teratogen (spina bifida) AVOID; lamotrigine preferred; carbamazepine neural tube defects. Brexanolone IV 60-hour infusion; zuranolone 14-day oral course (approved 2023). Peripartum onset specifier.

Neurocognitive Disorders

Delirium vs dementia vs depression (pseudodementia — treat with SSRI). Alzheimer disease (MCI, donepezil/rivastigmine/galantamine for mild-moderate, memantine for moderate-severe; anti-amyloid lecanemab/donanemab with ARIA-E/H MRI monitoring). DLB — visual hallucinations, fluctuations, RBD, parkinsonism, SEVERE antipsychotic hypersensitivity (use quetiapine or clozapine cautiously). Frontotemporal (behavioral variant — disinhibition, apathy, hyperorality). Vascular (stepwise). CJD, NPH (wet, wobbly, wacky).

Catatonia, NMS & Serotonin Syndrome

Catatonia DSM-5-TR — 3 or more of 12 (stupor, waxy flexibility, mutism, negativism, posturing, mannerisms, stereotypies, echolalia, echopraxia, agitation, catalepsy, grimacing). Lorazepam 1-2 mg IV/IM challenge — dramatic response is both diagnostic and therapeutic. ECT if refractory. Malignant catatonia overlaps with NMS. AVOID antipsychotics (worsen catatonia). NMS — fever + rigidity + altered mental status + autonomic instability + elevated CK — stop antipsychotic, supportive care (IVF, cooling), dantrolene, bromocriptine; wait 2 weeks before atypical AP rechallenge. Serotonin syndrome — hyperreflexia + clonus (LE > UE) + hyperthermia + agitation + diaphoresis — stop offender, supportive, cyproheptadine 12 mg load then 2 mg q2h.

Substance Use in the Hospital

Alcohol withdrawal — CIWA-Ar, benzodiazepines (symptom-triggered preferred), thiamine BEFORE glucose to prevent Wernicke encephalopathy. Opioid withdrawal — COWS, buprenorphine or methadone, symptomatic (clonidine, loperamide, ondansetron). BZD withdrawal — long-acting taper. Hepatic encephalopathy — lactulose, rifaximin. Alcohol biomarkers — PEth (phosphatidylethanol), CDT (carbohydrate-deficient transferrin).

Psychiatric Emergencies

Acute agitation — verbal de-escalation FIRST; then IM olanzapine or ziprasidone or haloperidol +/- lorazepam; AVOID combining IM olanzapine + IM benzodiazepine (hypotension and respiratory depression); physical restraints last resort. Acute psychosis. Suicide and homicide risk assessment. Medical clearance workup. ED psychiatric boarding.

Pain Psychiatry

Nociceptive vs neuropathic pain. CDC 2022 opioid prescribing update (shared decision-making, MME monitoring, taper carefully). TCAs (amitriptyline, nortriptyline) and SNRIs (duloxetine, venlafaxine) for neuropathic pain. Gabapentinoids (pregabalin FDA-approved for postherpetic neuralgia, diabetic peripheral neuropathy, fibromyalgia; gabapentin). Chronic pain plus SUD. Pain catastrophizing. CBT for chronic pain.

Suicide in Medical Settings

C-SSRS (Columbia Suicide Severity Rating Scale), lethal means restriction (firearms, medications), medically hospitalized suicide risk (recent diagnosis, uncontrolled pain), safety planning, 1:1 sitter, involuntary commitment for imminent dangerousness.

Transplant Psychiatry

Pre-transplant psychosocial evaluation tools — SIPAT (Stanford Integrated Psychosocial Assessment for Transplantation), PACT (Psychosocial Assessment of Candidates for Transplantation), TERS (Transplant Evaluation Rating Scale). Adherence prediction. Substance use (6-month abstinence controversial for liver transplant). Post-transplant psychotropic adjustment with calcineurin inhibitors.

Adjustment, Grief & Psychological Reactions

Adjustment disorder vs MDD (does not meet full MDD criteria). DSM-5-TR prolonged grief disorder (>12 months adults, >6 months children). Existential distress. Demoralization syndrome. Anticipatory grief.

Neuroimaging in Psychiatry

Indications — first-episode psychosis with atypical features (late onset, neurologic signs), new focal neurologic deficit, catatonia of unknown etiology. MRI preferred over CT. Findings in dementia subtypes, white-matter lesions, stroke.