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1. Which factor is considered to be the most critical indicator of disability in patients with
first episode schizophrenia (FES)?
a. Sub-optimal treatment
b. Delayed remission
c. Relapse *
d. Poor follow up
Trans: Relapse is the most critical driver of disability, risk very high without medication
2. Liebermans study on early and effective treatment of FES suggested minimizing this
complication:
a. Suicide or attempted suicide
b. Neurological deterioration *
c. Relapse/hospitalization
d. Co-morbid illness progression
Trans: Liebermans study: Neurologic deterioration 3% of cortical mass, relapsing devastating
and costly
3. Whilst Palmers study showed that early and effective treatment of FES would lessen this
unwanted sequela
a. Suicide or attempted suicide *
b. Neurologic deterioration
c. Relapse/hospitalization
d. Co-morbid illness progression
Trans: Palmer: Suicide/suicide attempt
4. A patient with an initial FES and who later relapses two times would usually take how
many weeks to remit?
a. 7
b. 14
c. 20
d. 24 *
Trans: 24 weeks (3 relapses)
5. On the contrary, a well-treated patient with FES would take only how many days, on
average, to achieve remission?
a. 7 days
b. 14 days
c. 21 days
d. 28 days *
6. A patient with FES who succumbs to a first relapse would take this length of time in
days, on average to gain remission
a. 28 days *
b. 36 days
c. 50 days
d. 70 days
7. How many percent of patient with FES undergo remission within the mean time of 10
weeks?
a. 60%
b. 70%
c. 80% *
d. 90%
8.
a.
b.
c.
d.
As shown in Kapurs study, this remission rate is directly linked to the patients
Early treatment
Effective treatment
Both a and b
Drug resistance *
12. How many percent of patients with FES achieve both positive and negative symptoms
remission?
a. 20%
b. 30% *
c. 40%
d. 50%
Trans: Schizophrenia 1
30% of patients with FES achieve both positive and negative symptoms
13. This remission percentage, from the Early Psychosis Prevention Center (EPSS) involved
more than 650 patients followed up for
a. 12 weeks
b. 24 months
c. 3 years
d. 7 years *
Trans: Schizophrenia 1
(EPPIC) study (Henry, et al. 2010): 29% of 651 FES patients, followed up for 7 years had both
positive and negative symptom remission. (Henry, et al. 2010)
14. How many percent of patients with FES achieved functional and symptomatic recovery?
a. 10%
b. 15% *
c. 22%
d. 26%
Trans: Schizophrenia 1
22/15 percent of patients with FES achieve functional and both functional and symptomatic
recovery
15. Marilou, 21, single, overweight, the youngest of four children of middle class parents
with high EE, breaks down with a FES. She was well until 6 weeks PTC when she broke
off with her 35-year-old boyfriend when she found out he was married, with 3 children.
Her parents are livid. In your MSE, you note the auditory hallucination, anhedonia,
avolition and effective incongruity to be quite prominent. She complains early morning
awakening, loss of interest, and loss of appetite. No suicidal ideas elicited. Her sensorium
is intact. You observe also that she is verbally abusive to her parents, but not to you. She
even calms down upon your suggestion. First thing first: what would you do?
a. Ask the patient if she wants to take to you without her parents *
b. Request parents to leave and wait outside to be called later
c. Best to keep it as it is to observe more family dynamics
d. Ask the parents if they want to talk to you first
16. The patient eventually agreed to be confined. PE, lab tests, including chest x-ray, drug
assay and pregnancy test were all negative. Your branded drug of choice would be:
a. Seroquel *
b. Zyprexa
c. Serenace
d. Thorazine
Trans: Schizophrenia 1
Quetiapine, aripiprazole, and risperidone are good choices (Crespo-Facoro 2011)
17. This drug that you correctly chose has a common side effect like
a. Galactorrhea
b. Weight gain *
c. Sedation
d. EPS
Trans: Schizophrenia 1
High risk for weight gain and metabolic side effects: Olanzapine, Quetiapine (Patel, et al. 2009)
18. You start Marilou with this medication with this dose
a. Seroquel 50mg HS
b. Zyprexa 2.5mg HS *
c. Serenace 1.0mg HS
d. Thorazine 50mg HS
Reference: Quetiapine (Seroquel): In schizophrenia a target of 400 mg a day is desired and in
mania and bipolar depression 800 mg and 300 mg respectively are desired. It has become evident
that the target dose can be achieved rapidly and that some patients benefit from doses of as much
as 1,200 to 1,600 mg a day. Quetiapine in doses of 25 to 300 mg at night has been used for
insomnia.
Olanzapine (Zyprexa): A starting daily dose of 5 to 10 mg is recommended. After 1 week, the
dosage can be raised to 10 mg a day. Given the long half-life, 1 week must be allowed to achieve
each new steady-state blood level. Dosages in clinical use ranges vary, with 5 to 20 mg a day
being most commonly used, but 30 to 40 mg a day being needed in treatment-resistant patients.
Remember! First episode patient needs the lowest end of dosing; rapid increase of dose not
advised. (Buchanan, et al. 2010)
19. The initial dose goes up gradually and in about a week, your daily dose should be around
a. Seroquel 300mg
b. Zyprexa 10mg *
c. Serenace 5mg
d. Thorazine 100mg
20. At this time and at this dose, Marilou is now stabilized. You have dealt with, quite
effectively, too, the parental high EE, the married lover, who in Marilous view is now
history. So, you have done very well indeed. Thats the easy part. Now comes the hard
phase of treatment: how to prevent Marilou from having another episode. This is best
achieved by
a. maintained control to parental high EE
b. drug adherence for a least 6 months *
c. making sure no more married lovers
d. A and C only
21. An interesting question comes from the father, who fancied himself to be brillant:
Doctor, what are the chances that Marilou wont have another episode, even without
maintenance drug? You would say
a. 5-10%
b. 10-15%
c. 15-20% *
d. 20-25%
Trans: Without meds, only 15-20% dont relapse (Alvarez-Jimenez, et al. 2011) or never
experience a second episode (poor functional recovery)
22. After 3 months, Marilou comes back to you with a second episode, this time, the features
of schizophrenia are, fortunately, less pronounced. The most likely cause of this relapse,
even without taking the history is (are)
a. drug adherence
b. resurgence of parental high EE
c. return to her lover
d. all of the above
23. She tells you she stopped the drug after 6 weeks because of feeling somewhat sleepy after
waking up which soon subsides. She also confides that the real reason why she stopped
the drug was the constant harangues by her parents not to take the medicine anymore
because she was now normal what would you do?
a. lower the dose of the medicine to make it less sedating
b. change the medicine to a less sedating type
c. resume the same medicine, same dose *
d. give the medicine to the parents
24. The medicine that you correctly gave Marilou does not usually cause EPS. But one of
these branded drugs can cause EPS at a certain total daily dose.
a. Ability at 2.5mg
b. Riseperidal at 6mg
c. Lexapro 10mg (escitalopram)
d. Zoloft 50mg (sertraline)
25. There is one drug listed down that can also cause high prolactin levels, causing some
embarrassing side effects like gynaecomastia in men. This generic drug is
a. Quetiapine
b. Aripiprazole
c. Riseperidone *
d. Olanzapiine
Trans: Risperidone and Haloperidol: hyperprolactinemia (Malik, et al. 2001)
26. It's a good thing you didn't choose the branded drug that can easily cause weight gain.
Remember that Marilou is somewhat overweight. Avoid giving this medicine to patient
like Marilou
a. Seroquel (Quetiapine)
b. Zyprexa (Olanzapine) *
c. Abilify (Apripazole)
d. Risperdal (Risperidone)
Trans: Olanzapine (not much for quetiapine) not generally recommended because of weight
gain and risk of metabolic syndrome (Buchanan, et al. 2010). Note: Pero all of these can
cause weight gain.
27. Because of the unfortunate relapse of Marilou, it is more crucial for her and particularly
her parents to make sure she continues with the same drug, at the same dose. Everybody
agrees to this proposal of yours. You have to tell them again, especially the parents, that
is Marilous medication is again discontinued, the likelihood of relapse within one year is
a. 50%
b. 60%
c. 70% *
d. 80%
Trans: If medication is stopped, 70% relapse within 1 year; 90% relapse after 2 years.
(Wunderink, et al. 2007)
28. And if by some chance theyre not impressed with the figure that you cited, many ne
theyd be impressed when you say relapse rate within 2 years is
a. just under 85%
b. just under 90%
c. 90% *
d. 95%
Trans: If medication is stopped, 70% relapse within 1 year; 90% relapse after 2 years.
(Wunderink, et al. 2007)
29. Based on the sequential imaging studies, how many percent of grey matter is lost in
patients with FES who are not treated early and effectively?
a. 3% *
b. 4%
c. 5%
d. 6%
Trans - Schizophrenia 1
Neurological deterioration(Liebermann 2001) -by as muchas 3% of cortical mass
30. Marilou is again stabilized, albeit longer than the first episode. Youre rightfully
concerned that a second episode might be followed by a third episode. And if that
happens, you may be looking at the possibility of a treatment-resistant type of
schizophrenia (TRS). Just may be, you decide to do a more extensive assessment of
Marilous profile and try to discern the presence of harbingers of TRS. You check your
notes during the first episode and you notice some items that strongly reinforce your
concern, these include:
a. Negative and depressive symptoms *
b. Cognitive impairment
c. Substance abuse
d. Soft neurologic signs
Trans:Schizophrenia 2
WARNING: HARBINGERS OF TRS!!
Deficit syndrome
Cognitive impairment
Depression
Substance abuse
Physical illness
poor pre-morbid functioning
early onset
maleness
soft neurologic
31. You request for an MRI, some features if present may indicate possible TRS. Youre
hoping not to find any of the following:
a. fronto-temporal decrement in the grey matter
b. Enlarged ventricles
c. lacunar infarcts
d. A and B only *
Trans: Schizophrenia 2
Sequential imaging studies of progressive brain changes (enlarged ventricles, fronto-temporal
decrements in the grey matter) suggest possible TRS
32. Your worst fears are confirmed. The findings ran counter with her normal physical
findings and other negative test previously done. What would you do?
a. Wait for a third episode; she is stable, on medication, hopefully adherent
b. No time to waste; stop her current medicine, bring clozapine *
c. Repeated engagements with parents, to bring EE to low levels
d. A and C only
Trans: Schizophrenia 2
After failure from an atypical, switching to clozapine is better than a move to another atypical
33. In one of these engagements with Marilous parents, the father again, in a brilliant spark,
asks, Doctor, I read about something about clozapine. Do you think it's a good drug for
Marilou to take? Never to be caught flat-footed, you respond with aplomb,
a. Not at the moment, may be later, and make sure the EE stays los
b. Im actually thinking about Marilous, sooner than later
c. You mean now? Why not?
d. It's a very trickery drug to use, a double-edged sword * (Answer found on number 36)
34. Of course you know the depressing figures of TRS. In Kanes study of 305 TRS patients,
only this much percent responded to high dose haloperidol
a. less than 1
b. less than 2 *
c. more than 2
d. only 3
Trans: Schizophrenia 2
Only 5 of 305 (1.6%) TRS patients responded to high dose (60 mg) haloperidol after 6 weeks
35. These are multitudes of other depressing statistics on TRS. Numerous studies show the
following:
a. show benefit from drugs
b. 60% remain poor after 6 months
c. 30% on clozapine improve *
d. A and B only
Trans: Schizophrenia 2
Results: Clz 30% & Cpz4- 4% improved
36. Marilous mother takes it from the father and asks you in a manner that makes you feel
defensive, so whats tricky and double edged about clozapine, doctor? Or are they just
big words you love to utter? you keep your composure and with exquisite grace you
pronounce, clozapine...
a. Is the only antipsychotic with proven efficacy for TRS an possibly for FES too
b. Can produce agranulocytosis at little less than 0.8%
c. Can also provoke fits at about 1%
d. All of the above *
Trans: Schizophrenia 2
The ONLY antipsychotic with proven efficacy for TRS
Results: clozapine with lowest potential for EPS and highest rating for efficacy BUT
clozapine causes agranulocytosis
Seizures- 1% on less than 300 mg/day (Janicak, et al 2001); a gradual, low start helps prevent
fits
37. And youre nor finished, yet. Not after they got you started. You also proclaim in a
didactic way that clozapine
a. Based on PET scans, the mean and ceiling of D2 occupancy rate are 40/70%
b. Has a golden plasma level 250-300ng/ml
c. At a dose of 300mg gives a plasma level of 350ng/ml *
d. All of the above
Trans: Schizophrenia 2
REMEMBER: About 300 mg/day gives a plasma level of 350 ng/ml
38. Clozapine, on a golden plasma level at 300mg/day
a. Discriminates between responders and non-responders
b. Has 72% sensitivity
c. Has 70% specificity
d. All of the above *
Trans: Schizophrenia 2
REMEMBER: About 300 mg/day gives a plasma level of 350 ng/ml Discriminates between
responders and non-responders with 72% sensitivity, 70% specificity
39. Marilou, an interested spectator all the while, winks at you and gives you thumbs up. And
you wink back. this exchange of wink didn't go unnoticed by her parents. The father
remarks, so if clozapine is that good what are you waiting for? Are you waiting for
Godot? What woud be your retort?
a. Marilou is not a case of TRS
b. Her relapse was not due to drug failure per se, but due to parental misjudgement
c. Another relapse whilst on her medicine can be the optimal time for clozapine
d. All of the above *
40. Finally, you have convinced the inconvincible. Marilou is willing to continue her current
antipsychotic, at an effective and safe maintenance dose. Youve convinced her parents
the importance of long-term drug adherence, the need to give the medication time to
show its worth, not to mention their need to win over their own barrel of high EE. But its
still likely for another recurrence, for such is schizophrenia. If and when it happens again,
the most common culprit is
a. Discontinuation of medication *
b. Parental high EE
c. Another personal relationship loss
d. All of the above
Trans: If medications is stopped, there are 70/90% patients with relapse within 1 year
41. In the use of medications, this aspect of the drug must be very well studied by the
physician
a. Caloric value
b. Cost of medicine
c. Patients preference
d. Side effect profile *
Kaplan
Patients will frequently experience side effects of an antipsychotic before they experience
clinical improvement. Whereas a clinical response may be delayed for days or weeks after
drugs are started, side effects may begin almost immediately.
42. Drug switching depends on
a. Patients preference
b. Degree of benefit with initial treatment *
c. Prior treatment history
d. All of the above
Trans: If there is failure in the treatment with atypical
43. The pharmacologic treatment of bipolar disorder is divided into these phases
a. Acute and maintenance *
b. Depression and mania
c. Prodromal, subclinical and clinical
d. Current, recurrent remission
Trans: Pharmacologic treatment is divided into 2 phases: acute and maintenance.
44. Which of these goals in the treatment of mood disorder is the most urgent?
a. Provide food and shelter
b. Complete diagnostic evaluation
c. Patient safety *
d. Treatment plan
l
themes
56. The 3 types of short-term psychotherapy include the following EXCEPT
a. Cognitive therapy
b. Interpersonal therapy
c. Behavioral therapy
d. Family therapy *
79. 40 y/o F was brought to the hops with the ff sx: elevated mood, insomnia, agitation, flight
of ideas, and sexual indiscretion. She was observed in the past 4 days and hx revealed
feeling of worthlessness, fatigue, excess guilt in the past. Dx is:
a. Bipolar d/o I most recent episode
b. Bipolar I single manic episode
c. Bipolar II *
d. Major depressive d/o
Trans: Bipolar II presence of one or more MDD episodes (Insomnia), presence of hypomania
(elevated mood, agitation, flight of ideas, sexual indiscretion in 4 days)
80. The goal and greatest challenge in maintenance tx in bipolar d/o:
a. Prevent recurrence *
b. Sustain euthymia
c. Make sure there are no untoward effect
d. Ensure good sleep and calmness
Trans: Mood disorders Part2
Greatest challenge/goal for maintenance treatment is preventing recurrence
81. 25-year old male presented with irritability, grandiosity and recklessness. This is the first
time for the patient to experience these. No depression noted. What is the diagnosis?
a. Bipolar 1, single manic episode *
b. Bipolar 1, most recent hypomania
c. Bipolar 1, most recent episode
d. Bipolar 2
82. Luisa, 30 years old, was diagnosed with bipolar mood disorder. She has had recurring
episodes in the last 2-3 years. Among these drugs, the best choice is:
a. Fluoxetine
b. Haloperidol
c. Carbamazepine *
d. Lorazepam
83. Patient comes in obviously depressed. She has had a long standing problem with her
sister in law which is the reason for her separation with her husband. What is the best
psychotherapy?
a. Psychoanalytically oriented psychotherapy
b. Behavioral
c. Group
d. Interpersonal *
84. Patient complains of severe depression and suspiciousness of others. Patient also thinks
of not doing anything right at work and she might as well resign. The best therapy:
a. Behavioral
b. Family
c. Cognitive *
d. Group
85. Patient presented with psychomotor symptoms and agitation. Upon admission, noted to
have deep disturbance. Start with:
a. Lithium and paroxetine *
b. Risperidone and haloperidol
c.
d. Lamotrigine and sertraline
Trans: Mood Disorders 2
- Psychomotor agitation or retardation nearly every day: one of the symptoms of MDE
- SSRI (Paroxetine, Sertraline): used for MDE
- Lithium mood stabilizer used for bipolar disorders
- Lamotigrine- superior ACUTE + PROPHYLACTIC AD properties vs. ANTIMANIC
properties
Treatment of the Depression of Bipolar Mood Disorder:
As a general rule, we DO NOT want to give ADs for bipolar mood disorders depressive side.
Kaplan suggests that lithium may be a first-line antidepressant in treating the depression of
bipolar disorder. A MAOI may be added, but the patient should be monitored for the emergence
of manic symptoms
induce CYCLING, MANIA or HYPOMANIA
- AD use enhanced by MOOD STABILIZER in FIRST LINE treatment for a FIRST or
ISOLATED episode of Bipolar Depression. Ex. Olanzapine and Flouxetine effective
Many patients with Bipolar in DEPRESSED phase DO NOT RESPOND to AD (ex.
Lamotrigine or Low Dose Atypical Antipsychotic may be OK.)
86. Patient is experiencing suicidal thoughts, hopelessness, insomnia, decreased appetite and
anhedonia of 4 weeks duration. Hospitalization, psychotherapy and Escitalopram
initiated. Afterwards, behavior presented was elevated mood, recklessness and decreased
inhibitions. What could explain this behavior
a. This episode is transient.
b. Antidepressant induced manic episode *
c. Treatment too late
d. Psychotherapy induced
Trans: Mood Disorders 2
Disadvantages of SSRIs
o Lower remission rates than dual-acting agents
o Increase weight gain and sexual side effects
91. Dina, a 31-year old manager, climbs 14 flights of stairs everyday to reach her office
because she is terrified of the thought of riding the elevator. She has never had any bad
event occur inside an elevator but she has been afraid since childhood. What is the most
likely diagnosis?
a. Social phobia
b. Specific phobia
c. Generalized anxiety disorder
d. Agoraphobia *
Trans: Management of Anxiety Disorders1
Agoraphobia: Emotion Situational anxiety; Cognition Thoughts of collapsing and being left
helpless in public; Behavior - avoidance of panic-provoking situations; Somatic Symptoms
Physical sensations of panic; Associations strong association with panic disorder
92. What is the treatment for Dina?
a. Imipramine
b. Clonazepam *
c. Propanolol
d. Exposure therapy
Trans: Management of Anxiety Disorders2
Imipramine (Tricyclic Antidepressant) for panic disorders; Clonazepam (Benzodiazepine) drug of choice for Generalized Anxiety Disorder; Propranolol (Beta blockers) for PTSD;
Exposure therapy for specific phobic disorder
93. Yon-yon is a middle aged chronic worker who constantly worries about work, etc. What
is the likely diagnosis?
a. Social phobia
b. Specific phobia
c. Generalized anxiety disorder *
d. Agoraphobia
Trans: Management of Anxiety Disorders1
GAD: Emotion Anxiety; Cognition - Excessive, disproportionate, uncontrollable worry;
Behavior - Easily startled, on edge; Somatic symptoms multiple chronic aches, tension,
sweating, headache; Associations Depression
94. A new serotonin and dopamine antagonist approved for treatment of anxiety is:
a. Risperidone *
b. Olanzapine atypical antipsychotic
c. Quetiapine atypical antipyschotic along with an SSRI properties
d. Perphenazine typical antipyscotic for schizophrenia and mania of bipolar disorders
Risperidone belongs to the class of atypical antipsychotics.[1] It isa dopamine antagonist
possessing antiserotonergic, antiadrenergic and antihistaminergic properties. (wikipedia)
95. Major reservations in the use of benzodiazepines in anxiety disorders are the following
factors except:
a. Dependence
b. Abuse
c. High cost *
d. Cognitive impairment
Trans: management of anxiety disorders 1
Major reservations in the use of BZ: potential for dependence, cognitive impairment, and abuse
after long term use
96. The use of clonidine and propranolol is supported by the involvement of this theory in the
etiology of anxiety disorders:
a. Noradrenergic *
b. Dopaminergic
c. Serotonergic
d. GABAminergic
Trans management of anxiety disorders 1
Use of anti-adrenergic agents like clonidine and propanolol supports noradrenergic
hyperactivity
97. The efficacy of SSRI is due to the following characteristics except:
a. Efficacy
b. Low cost *
c. Safety ratings
d. Tolerability
Trans management of anxiety disorders 2
Advantages of SSRI: effective, safe, no physical abuse and effective on depression.
Disadvantages: possible increase in anxiety, reactivation syndrome, sexual side effects. I checked
the price of Paroxetine at MIMS it costs 1790 pesos.
98. Exposure to the phobic stimulus until the patient reaches a point at which s/he can no
longer face it is called:
a. Catharsis
b. Flooding
c. Abreaction
d. Aversion therapy *
99. Of all the tricyclic and tetracyclic drugs, this is the one best used for OCD:
a. Imipramine
b. Trimipramine
c. Clomipramine *
d. Buspirone