2019 kaplan USMLE step 2 CK psychiatric

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USMLE®Step2CK:Psychiatry,
Epidemiology,Ethics,PatientSafety
LectureNotes

2019

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USMLE®isajointprogramoftheFederationofStateMedicalBoards(FSMB)
andtheNationalBoardofMedicalExaminers(NBME),neitherofwhich
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containedinthisbook.
©2018byKaplan,Inc.
PublishedbyKaplanMedical,adivisionofKaplan,Inc.
750ThirdAvenue
NewYork,NY10017
AllrightsreservedunderInternationalandPan-AmericanCopyright

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Editors
Psychiatry
AlinaGonzalez-Mayo,MD
Psychiatrist
Dept.ofVeteran’sAdministration
BayPines,FL

PatientSafetyandQualityImprovement
TedA.James,MD,MS,FACS
Chief,BreastSurgicalOncology
ViceChair,AcademicAffairs
DepartmentofSurgery
BethIsraelDeaconessMedicalCenter
HarvardMedicalSchool
Boston,MA

Theeditorswouldliketoacknowledge
BrandonPeplinski,MPH,MDandKarenReimers,MDfortheir
contributions.

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Wewanttohearwhatyouthink.WhatdoyoulikeornotlikeabouttheNotes?
Pleaseemailusat

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PartI

Psychiatry

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1

MentalStatusExamination
LearningObjectives
Listthestepsrequiredtoperformamentalstatusexamination
Thementalstatusexaminationisusedtodescribetheclinician’sobservations
andimpressionsofthepatientduringtheinterview.Inconjunctionwiththe
historyofthepatient,itisthebestwaytomakeanaccuratediagnosis.
GeneralDescription
Appearance:grooming,poise,clothes,bodytype(disheveled,neat,
childlike,etc.)
Behavior:quantitativeandqualitativeaspectsofthepatient’smotor
behavior(restless,tics,etc.)

Attitudetowardtheexaminer:(cooperative,frank,andseductive)
MoodandAffect
Mood:emotionsperceivedbythepatient(depressed,anxious,angry,etc.)
Affect:patient’spresentemotionalresponsiveness(blunted,flat,labile,
etc.)
Appropriateness:inreferencetothecontextofthesubject(appropriateor
inappropriate)
Speech:physicalcharacteristicsofspeech(relevant,coherent,fluent,etc.)
Perceptualdisturbances:experiencedinreferencetoselfortheenvironment
(hallucinations,illusions)
Hallucinations:falsesensoryperceptionswithoutastimulus:auditory
(psychoticdisorders),visual(drugs,organicdiseases),tactile(cocaine

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intoxication,alcoholwithdrawal),olfactory(seizures)
Illusions:sensorymisperceptionwithastimulus
Thought
Formofthought:wayinwhichapersonthinks(flightofideas,loose
associations,tangentiality,circumstantiality,etc.)
Contentofthought:whatthepersonisactuallythinkingabout(delusions,
paranoia,andsuicidalideas)
SensoriumandCognition
Alertnessandlevelofconsciousness(awake,cloudingofconsciousness,
etc.)
Orientation:time,place,andperson
Memory:recent,remote,recentpast,andimmediateretentionandrecall
Concentrationandattention:serialsevens,abilitytospellbackwards.
Capacitytoreadandwrite:Askpatienttoreadasentenceandperformwhat
itsays.

Visuospatialability:copyafigure
Abstractthinking:similaritiesandproverbinterpretation
Fundofinformationandknowledge:calculatingability,namepast
presidents
ImpulseControl:estimatedfromhistoryorbehaviorduringtheinterview
JudgmentandInsight:abilitytoactappropriatelyandself-reflect
Reliability:physician’simpressionsofthepatient’sabilitytoaccuratelyassess
hissituation

InterviewingTechniques
Open-EndedQuestions:Allowthepatienttospeakinhisownwordsasmuch
aspossible.
“Canyoudescribeyourpain?”

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Closed-EndedQuestions:Askforspecificinformationwithoutallowing
optionsinanswering.
“Areyouhearingvoices?”
Facilitation:Helpthepatientcontinuebyprovidingverbalandnonverbalcues.
“Yes,pleasecontinue.”
Confrontation:Pointsomethingouttothepatient.
“Youseemveryupsettoday.”
Leading:Providetheanswerinthequestion.
“Arethevoicestellingyoutohurtyourself?”

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2

DefenseMechanisms
LearningObjectives
Listthetypesofdefensemechanismsandthesituationsinwhichtheyare
mostlikelytooccur
Describethemostcommonpsychologicalandintelligencetestsandtheir
purpose
Id:Drives(instincts)presentatbirth.The2mostimportantdrivesaresexand
aggression.
Ego:Defensemechanisms,judgment,relationshiptoreality,object
relationships,developedshortlyafterbirth
Superego:Conscience,empathy,andmoralityareformedduringlatencyperiod,
rightvs.wrong

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3

ChildhoodDisorders
LearningObjectives
Describethedegreesofintellectualdisabilityandexpectedleveloffunction
Listthedifferenttypesoflearningdisorders
Describethepresentationofautismspectrumdisorder
Describethediagnosisandtreatmentofchildhooddisorderslikelyto
presenttoapsychiatrist,includingattentiondeficithyperactivitydisorder,
childhoodconductdisorder,oppositionaldefiantdisorder,childhood
anxiety,andTourettesyndrome
Listtheapproachestotreatingchildhoodenuresis

IntellectualDisability(ID)
Definition.Formerlycalledmentalretardation.Significantlysubaverage

intellectualfunction(IQ<70),asmeasuredbyavarietyofIQtests.Mustbe
accompaniedbyconcurrentimpairmentinadaptingtodemandsofschool,work,
social,andotherenvironments.Onsetisage<18.
RiskFactors/Etiology.Associatedgeneticandchromosomalabnormalities
includeinbornerrorsofmetabolism(e.g.,lipidoses,aminoacidurias,glycogen
storagediseases)andchromosomalabnormalities(e.g.,criduchat,Down,
fragileXsyndromes).Associatedintrauterineinfectionsincluderubella,
cytomegalovirus,andotherviruses.Intrauterineexposuretotoxinsandother
insultssuchasalcohol,hypoxia,ormalnutritionmaybecausal.Postnatalcauses
includeexposuretotoxinsandinfection,poorprenatalcare,postnatalexposure
toheavymetals,physicaltrauma,andsocialdeprivation.
PresentingSymptoms

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Prevalence:1%ofthepopulation.Occursata1.2:1male-to-femaleratio.
MildID(IQ50–69):Attainacademicskillstoapproximatelythesixthgradelevel,oftenliveindependentlyinthecommunityorwithminimal
supervision,mayhaveproblemswithimpulsecontrolandself-esteem,and
mayhaveassociatedconductdisorder,substance-relateddisorder,or
attentiondeficithyperactivitydisorder.
ModerateID(IQ35–50):Attainacademicskillstosecond-gradelevel,
maybeabletomanageactivitiesofdailyliving,workinsheltered
workshops,liveinresidentialcommunitysettings;havesignificant
problemsconformingtosocialnorms(thosewithDown’ssyndromeareat
highriskforearlydevelopmentofAlzheimer’s).
Severe(IQ20–35)andprofoundID(IQ<20):Havelittleornospeech
andverylimitedabilitiestomanageself-care;requirehighlysupervised
caresetting.
PhysicalExamination.Evidenceofunderlyingdisorderorinjury.
DiagnosticTests.Amniocentesis:Mayrevealchromosomalabnormalities

associatedwithIDinhigh-riskpregnancies(motherage>35).
Treatment.Primarypreventionincludesgeneticcounseling,goodprenatalcare,
andsafeenvironments.Treatmentofassociatedgeneralmedicalconditionsmay
improveoveralllevelofcognitiveandadaptivefunction.Specialeducation
techniquesmayimproveultimateleveloffunction.Behavioralguidanceand
attentiontopromotingself-esteemmayimprovelong-termemotional
adjustment.
DifferentialDiagnosis.Includeslearningandcommunicationdisorders,sensory
impairment,autismspectrumdisorder,borderlineintellectualfunctioning(IQ
70–100),andenvironmentaldeprivation.

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4

Depressive,Bipolar,andRelated
Disorders
LearningObjectives
Listthediagnosticcriteriaandtreatmentapproachesformajormood
disorders,includingmajordepressive,bipolar,cyclothymic,andpersistent
depressivedisorders
Describethepresentationofmooddisordersrelatedtotriggering
phenomenon,includingseasonalpattern,grief,peri/postpartum,and
death/dying

MajorDepressiveDisorder(Major
Depression)
A70-year-oldwomanwasrecentlyadmittedafterhersoninformedthedoctor
thatshehadbeendoingverypoorlyoverthepastfewmonths.Thepatient
reportsa30-poundweightloss,decreasedconcentration,feelingsofhelplessness

andhopelessness,decreasedenergy,depressedmood,anddecreasedsleep.
Definition.Mooddisorderthatpresentswithatleasta2-weekcourseof
symptomsthatisachangefromthepatient’spreviousleveloffunctioning.Must
havedepressedmoodoranhedonia(inabilitytoenjoyoneself).
RiskFactors/Epidemiology.Majordepressionisseenmorefrequentlyin
womenduetoseveralfactors,suchashormonaldifferences,greatstress,or
simplyabiasinthediagnosis.Thetypicalageofonsetisage40.Thereisalsoa
higherincidenceinthosewhohavenocloseinterpersonalrelationshipsorare
divorcedorseparated.Manystudieshavereportedabnormalitiesinserotonin,

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norepinephrine,anddopamine.Otherriskfactorsincludefamilyhistory,
exposuretostressors,andbehavioralreasons,suchaslearnedhelplessness.
PresentingSymptoms
Depressedmoodmostoftheday
Anhedoniaduringmostoftheday
Significantweightloss(>5%ofbodyweight)
Insomnia
Psychomotoragitationorretardation
Fatigueorlossofenergynearlyeveryday
Feelingsofworthlessnessorguilt
Diminishedabilitytoconcentrate
Recurrentthoughtsaboutdeath
PhysicalExamination.Usuallywithinnormallimits;however,mayfind
evidenceofpsychomotorretardation,suchasstoopedposture,slowingof
movements,slowedspeech,etc.Mayalsofindevidenceofcognitive
impairment,suchasdecreasedconcentrationandforgetfulness.
Mayalsoinclude:
Psychoticfeatures:worseprognosis

Atypicalfeatures:increasedweight,appetite,andsleep
Treatment.Mustfirstsecurethesafetyofthepatient,giventhatsuicideissuch
ahighrisk.Pharmacotherapyincludesantidepressantmedicationssuchas
SSRIs.Tricyclicantidepressants(TCAs),ormonoamineoxidaseinhibitors
(MAOIs).Electroconvulsivetherapy(ECT)maybeindicatedifpatientis
suicidalorintoleranttomedications.Individualpsychotherapyisindicatedto
helpthepatientdealwithconflicts,senseofloss,etc.Anotherformoftherapyis
cognitivetherapy,whichwillchangethepatient’sdistortedthoughtsaboutself,
future,world,etc.
DifferentialDiagnosis
Medicaldisorders:hypothyroidism,Parkinson’sdisease,dementia,
medicationssuchashypertensives,pseudodementia,tumors,
cerebrovascularaccidents

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Mentaldisorders:othermooddisorders,substancedisorders,andgrief

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5

SchizophreniaandOtherPsychotic
Disorders
LearningObjectives
Listthediagnosticcriteriaandtreatmentapproachestoschizophreniaand
otherpsychoticdisorders

Schizophrenia
Definition.Schizophreniaisathoughtdisorderthatimpairsjudgment,behavior,

andabilitytointerpretreality.Symptomsmustbepresentforatleast6monthsto
beabletomakeadiagnosis.
RiskFactors/Etiology.Menhaveanearlieronset,usuallyatage15–25.Many
theorieshaveevolvedregardingthecauseofschizophrenia.
Schizophreniahasbeenassociatedwithhighlevelsofdopamineand
abnormalitiesinserotonin.
Becausethereisanincreaseinthenumberofschizophrenicsborninthe
winterandearlyspring,manybelieveitmaybeviralinorigin.
Schizophreniaismoreprevalentinlowsocioeconomicstatusgroups,eitherasa
resultofdownwarddriftorsocialcausation.
Prevalence
Generalpopulation...........1%
Monozygotictwin...........47%
Dizygotictwin.................12%

Oneschizophrenicparent................12%
Twoschizophrenicparents..............40%
First-degreerelative..........................12%

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Second-degreerelative..................5–6%
PhysicalandPsychiatricPresentingSymptoms
Hallucinations(mostlyauditory)
Delusions(mostlybizarre)
Disorganizedspeechorbehavior
Catatonicbehavior
Negativesymptoms
Socialand/oroccupationaldysfunction
Physicalexamusuallyunremarkable,butmayfindsaccadiceye

movements,hypervigilance,etc.
BrainImagingFindings
CT:lateralandthirdventricularenlargement,reductionincortical
volume(associatedwiththepresenceofnegativesymptoms,
neuropsychiatricimpairment,increasedneurologicsigns,andpoor
premorbidadjustment)
MRI:increasedcerebralventricles
PET:hypoactivityofthefrontallobesandhyperactivityofthebasal
gangliarelativetothecerebralcortex
PsychologicTests
IQtests:WillscoreloweronallIQtests,maybeduetolowintelligenceat
theonsetortodeteriorationasaresultofthedisease
Neuropsychologic:Testsusuallyareconsistentwithbilateralfrontaland
temporallobedysfunction,includingdeficitsinattention,retentiontime,
andproblem-solvingability.
Personality:maygiveabnormalfindings,suchasbizarreideations,etc.
Treatment.Hospitalizationisusuallyrecommendedforeitherstabilizationor
safetyofthepatient.Ifyoudecidetousemedications,antipsychoticmedications
aremostindicatedtohelpcontrolbothpositiveandnegativesymptoms.Ifno
response,considerusingclozapineafterothermedicationshavefailed.The
suggestedpsychotherapywillbesupportivepsychotherapywiththeprimaryaim

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ofhavingthepatientunderstandthatthetherapististrustworthyandhasan
understandingofthepatient,nomatterhowbizarre.
DifferentialDiagnosis
Substance-induced:Psychostimulants,hallucinogens,alcoholhallucinosis,
barbituratewithdrawal,etc.Considerurinedrugscreentoruleout.
Epilepsy:temporallobeepilepsy

Otherpsychoticdisorders:schizoaffective,schizophreniform,brief
reactivepsychosis,delusionaldisorder
Malingeringandfactitiousdisorder:mustassesswhetherthepatientisin
controlofthesymptomsandwhetherthereisanobviousgain
Mooddisorders:Lookatdurationofmoodsymptoms;thesetendtobe
briefinschizophrenia.
Medical:HIV,steroids,tumors,CVAs,etc.Needmedicalwork-uptorule
out.
Personalitydisorders:Schizotypal,schizoid,andborderlinepersonality
disordershavethemostsimilarsymptoms.Mustlookatdurationof
symptomsaswellaspatient’sleveloffunctioning.

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6

AnxietyDisorders
LearningObjectives
Describethepresentation,diagnosticcriteria,andtreatmentapproachesto
anxietydisorders,includingpanic,phobic,obsessive-compulsive,acute
stress,post-traumaticstress,andgeneralizedanxietydisorders

Anxiety
Anxietyisasyndromewithpsychologicandphysiologiccomponents.
Psychologiccomponentsincludeworrythatisdifficulttocontrol,hypervigilance
andrestlessness,difficultyconcentrating,andsleepdisturbance.Physiologic
componentsincludeautonomichyperactivityandmotortension.
Psychodynamictheorypositsthatanxietyoccurswheninstinctualdrivesare
thwarted.Behavioraltheorystatesthatanxietyisaconditionedresponseto
environmentalstimulioriginallypairedwithafearedsituation.Biologictheories

implicatevariousneurotransmitters(especiallygammaaminobutyricacid
[GABA],norepinephrine,andserotonin)andvariousCNSstructures(especially
reticularactivatingsystemandlimbicsystem).

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7

SomaticSymptomandRelated
Disorders
LearningObjectives
Differentiateconversiondisorder,factitiousdisorder,andmalingering
Answerquestionsaboutsomaticsymptom,illnessanxiety,andbody
dysmorphicdisorders

SomatoformDisorders
Somatoformdisordersarecharacterizedbythepresentationofphysical
symptomswithnomedicalexplanation.Thesymptomsaresevereenoughto
interferewithone’sabilitytofunctioninsocialoroccupationalactivities.

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8

NeurocognitiveDisorders
LearningObjectives
Differentiatedelirium,dementia,andpsychosis
Listthecausesofdeliriumanddescribethediagnosticwork-up
Defineneurocognitivedisorderandmildneurocognitivedisorder

NeurocognitiveDisorders
Cognitionincludesmemory,language,orientation,judgment,problemsolving,
interpersonalrelationships,andperformanceofactions.Cognitivedisordershave
problemsintheseareasaswellasbehavioralsymptoms.
Definition.Characterizedbythesyndromesofdelirium,neurocognitive
disorder,andamnesia,whicharecausedbygeneralmedicalconditions,
substances,orboth.
RiskFactors/Etiology.Veryyoungoradvancedage,debilitation,presenceof
specificgeneralmedicalconditions,sustainedorexcessiveexposuretoavariety
ofsubstances.
PresentingSymptoms(KeySymptoms)
Memoryimpairment,especiallyrecentmemory
Aphasia:failureoflanguagefunction
Apraxia:failureofabilitytoexecutecomplexmotorbehaviors
Agnosia:failuretorecognizeoridentifypeopleorobjects
Disturbancesinexecutivefunction:impairmentintheabilitytothink
abstractlyandplansuchactivitiesasorganizing,shopping,andmaintaining
ahome

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9

DissociativeDisorders
LearningObjectives
Definedepersonalizationandderealization
Describethepresentationofdissociativeamnesiawithandwithoutfugue
Recognizedissociativeidentitydisorder

Dissociation

Dissociationisthefragmentationorseparationofaspectsofconsciousness,
includingmemory,identity,andperception.Somedegreeofdissociationis
alwayspresent;however,ifanindividual’sconsciousnessbecomestoo
fragmented,itmaypathologicallyinterferewiththesenseofselfandabilityto
adapt.Presentingcomplaintsandfindingsofdissociativedisordersinclude
amnesia,personalitychange,erraticbehavior,oddinnerexperiences(e.g.,
flashbacks,déjàvu),andconfusion.

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10

AdjustmentDisorders
LearningObjectives
Recognizeanddescribetreatmentapproachestoadjustmentdisorders

AdjustmentDisorders
Adjustmentdisordersaremaladaptivereactionstoanidentifiablepsychosocial
stressor.Theyarecausedbyenvironmentalstressorshavinganeffecton
functioning.Theriskthatastressorwillcauseanadjustmentdisorderdepends
onone’semotionalstrengthandcopingskills.
Prevalence.Extremelycommon;allagegroups
Onsetistypicallywithin3monthsoftheinitialpresenceofthestressor,andit
lasts≤6monthsoncethestressorisresolved.Ifthestressorcontinuesandnew
waysofcopingarenotdeveloped,itcanbecomechronic.
KeySymptoms.Complaintsofoverwhelminganxiety,depression,oremotional
turmoilassociatedwithspecificstressors
AssociatedProblems.Socialandoccupationalperformancedeteriorate;erratic
orwithdrawnbehavior
Treatment.Removeoramelioratethestressor.

Briefpsychotherapytoimprovecopingskills
Pharmacotherapy:Anxiolyticorantidepressantmedicationsareusedto
amelioratesymptomsiftherapyisnoteffective.

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